Negative Mood is Associated with Sociobehavioral Factors Contributing to Cardiovascular Risk in an Immigrant Population

Background Immigrants to the United States, on average, accumulate cardiovascular risk after resettlement, including obesity. There is a need to co-create interventions to address these disparities, and mood may be an important mediating factor. Methods The Healthy Immigrant Community (HIC) study, set in southeast Minnesota, enrolled 475 adult participants in a weight loss intervention to reduce cardiovascular risk. Baseline questionnaires assessed mood, nutrition, physical activity, self-efficacy for healthy eating and physical activity, social support, and cohesion. A single-item mood rating of poor or fair was considered “negative”, while ratings of good, very good, or excellent were considered “positive”. Results A total of 449 HIC participants (268 Hispanic/Latino and 181 Somali) with complete baseline measures and were included in this analysis. Participants endorsing negative mood compared to those endorsing positive mood had lower scores for healthy eating (p = 0.02) and physical activity levels (p = 0.03), lower confidence in eating a healthy diet (p = 0.001), and felt less of a sense of belonging to their community (p = 0.01). Those endorsing negative mood also reported receiving less social support from their family and friends to eat healthy (p = < 0.001) and be physically active (p = 0.01), and less often accessed community resources for healthy eating (p = 0.001) and physical activity (p = < 0.01) compared to participants reporting positive mood. Conclusions Negative mood was associated with less healthy nutrition, lower confidence in eating healthy, sedentary lifestyle, and perceived lack of belonging to the community. Integrating mood management and self-efficacy strategies may enhance the effectiveness of lifestyle interventions among immigrants who report negative mood. ClinicalTrials.gov registration: NCT05136339; April 23, 2022


Introduction
Immigrants to the United States often experience structural barriers to healthful nutritional habits and physical activity that leads to accumulation of cardiovascular risk over time.[1][2][3] Common behaviors such as sedentary lifestyle and unhealthy nutrition, de ned as foods with low nutrient quality or limited fruit and vegetable intake, contribute to increased rates of obesity, cardiovascular disease, and chronic health conditions.[2,3] Our community-based participatory research (CBPR) team has engaged immigrant populations in southeast Minnesota in co-creating and implementing interventions to address this public health problem for several years.These interventions have included a family-based nutrition and physical activity intervention [4] and a pilot project examining the effectiveness of a social network weight loss intervention, [5] and a digital story telling intervention for adults with diabetes.[6] In our prior research to design cardiovascular risk reduction interventions with immigrant populations, we engaged Hispanic/Latino, Somali, and Sudanese immigrants to develop a home-based, high-contact intervention to improve nutrition and physical activity.[4] While the intervention was found to be feasible, post-intervention focus groups suggested involving friends and family to improve participation and target weight management.Overweight and obesity-related behaviors, normative beliefs, and intentions for control were often clustered by social networks.[4] Additionally, in a relatively small sample, our CBPR team previously found that negative mood was associated with reporting unhealthy nutritional and physical activity behaviors in both adolescent and adult immigrants.[7] Many other studies have also demonstrated a link between negative mood and poor health behaviors leading to cardiovascular disease and obesity.[8][9][10][11] In social cognitive theory, an individual's perceived self-e cacy determines the goals they set, the amount of effort expended to meet these goals, and how they respond to challenges or failures over time.[12,13] In turn, self-e cacy is concurrently affected by external sociocultural factors that may support or impede these goals and behaviors.[14] Thus, negative mood may lower one's self-e cacy for healthy behaviors, leading to overconsumption of unhealthy foods and resulting in a more sedentary and isolated lifestyle.
The present Healthy Immigrant Community (HIC) randomized study used a social cognitive theoretical framework to adapt our earlier Healthy Immigrant Families study to develop a social-network delivered weight loss intervention among Hispanic/Latino and Somali immigrant communities in southeast Minnesota.[15] The purpose of this sub-analysis was to examine the possible association between self-reported negative mood with dietary quality, physical activity, selfe cacy for healthy behaviors, and sociobehavioral factors (e.g., support from family and friends in healthy behaviors and sense of belonging to the community).

Setting and Participants
The HIC study (NCT0513633) was approved by our institution's Institutional Research Review Board and participants provided written informed consent.The study is set in Rochester, Minnesota, a metropolitan area in southeastern MN (2022 population estimate: 121,878), and an estimated 13.6% of persons in the city were born outside of the US (2017-2021).[16]Rochester Healthy Community Partnership (RHCP) started in 2004 with the goal of bringing together community-based organizations, community activists, and academic researchers to "improve the health of our community through CBPR, education, and civic engagement".[17] RHCP has provided extensive training programs to local groups, improved community-based healthcare screening and delivery programs, and established a robust, productive, and cross-disciplinary research and implementation infrastructure to support community priorities.[18] The current cross-sectional analysis is embedded within the RHCP Healthy Immigrant Community study, which is a randomized, waitlist-controlled trial to assess the effectiveness of a social network-informed, CBPR-derived health promotion weight loss intervention with Hispanic/Latino and Somali immigrant communities.The intervention consists of community-based mentoring, educational and motivational sessions, group activities, and the application of a community toolkit for healthy weight loss delivered by members of the immigrant populations, trained health promoters (HP), to their social networks.A total of 51 HPs (29 Hispanic/Latino, 22 Somali), and 475 of their social network members (mean social network group size = 8, range 5-12) were enrolled and randomized in the HIC study.
Eligibility for the HIC study included self-reported Hispanic/Latino or Somali ethnicity, age ≥ 18 years, willing to participate in all aspects of the study, and a member of a HP's social network.Exclusion criteria was pregnancy at the time of enrollment or having a medical condition or disability that would prevent adopting a physically active lifestyle.Demographic and survey measures (e.g., dietary quality, physical activity, quality of life) and biometric measurements (e.g., height, weight, blood pressure, glucose, cholesterol) were obtained at baseline by trained study staff and community volunteers.Individuals completing baseline measures were eligible for inclusion in the current analysis.

Primary Outcome Measures
Mood Item: The baseline survey included a one-question mood assessment item previously used by our research team: "How would you rate your mood over the past 7 days?"This question refers to things such as feeling sad, anxious, stressed, happy, etc.".[7,19] Based on community feedback, cartoon emoji faces were created to accompany textual mood descriptor response options on a ve-point Likert scale (poor; fair; good; very good; excellent).Emojis showing frowning (poor), neutral (good), and smiling (excellent) faces were placed over the text words.On analysis, responses of "poor" or "fair" were classi ed as having "negative mood" while responses of "good," "very good," or "excellent," were classi ed as having "positive mood."Dietary Quality and Intake Measurements: Nutritional behaviors were assessed using the Food Behavior Checklist, which is recommended for use among low-income and diverse communities.[20] Questions such as "Do you eat fruits or vegetables as snacks" and "Do you drink regular soda" were rated on a 4-point Likert scale (no; yes, sometimes; yes, often; yes, everyday).On analysis, the "often" and "everyday" categories were combined, and three variables were assessed (no; sometimes; often).Dietary quality and intake was also assessed by a 24-hour dietary recall using the Automated Self-Administered 24-hour Recall (ASA24) system, a National Cancer Institute web-based tool that enables multiple automated 24-hour recalls.[21] The recalls were performed using a computer under the supervision of study staff and with an interpreter, as needed.
The ASA24® can produce several scores but the overall measure of diet is the Healthy Eating Index (HEI).[22] The overall HEI score is comprised of 12 dietary components (e.g., total fruit, total vegetables, whole grains, dairy, total protein goods, empty calories) each with possible score from 0-10.The components are weighted equally, and the maximum overall HEI score is 100.Higher scores indicate dietary intakes in the recommended ranges.
Physical Activity Measurements: In the baseline survey, the short form of the International Physical Activity Questionnaire (IPAQ) was used to assess physical activity level.[23] Physical Activity is de ned for respondents as "any activity that increases your heart rate and makes you breathe harder some of the time," "Moderate" activity is de ned as "an activity that takes somewhat more physical effort and makes you breathe a little harder than normal," and "Vigorous" is described as taking "much more physical effort and makes you breathe a lot harder than normal."Respondents indicated how many days and minutes per day they did both moderate and vigorous physical activities over the last 7 days, how many days and minutes per day were spent walking for at least 10 minutes over the last 7 days, and how many hours and minutes were spent sitting on a weekday.
The IPAQ scoring criteria recommend three categories: Inactive, Minimally Active, and Health-Enhancing Physical Activity (HEPA) Active."Minimally Active" is de ned as "≥3 days of vigorous activity at least 20 minutes per day, or ≥ 5 days of moderate-intensity activity or walking at least 30 minutes per day, or ≥ 5 days of moderate or vigorous activity achieving a minimum of least 600 MET-min (multiples of the resting metabolic rate) per week."Because the "minimally active" criteria exceed public health recommendations, the categories "minimally active" and "HEPA Active" were combined on analysis and two variables were assessed (inactive; active).

Theory-based measures
Self-E cacy: The adapted Patient Centered Assessment and Counseling for Exercise plus Nutrition (PACE+) survey [24] was completed at baseline, which included items on perceived self-e cacy and social support for healthy eating and physical activity.Con dence in eating a healthy diet was rated as a percentage interval (0% = not at all con dent; 25%; 50% = somewhat con dent; 75%; 100% = very con dent).Con dence in participating in regular exercise or physical activity was rated with the same percentage interval.
Social Support: Family and friend support for healthy eating and physical activity was also measured.The items "How often in the last 30 days has your family or friends encouraged you to do physical activity?" and "How often in the last 30 days has your family or friends done physical activity with you?" were rated on a 5-point Likert scale (never; once in a while; sometimes; often; always).On analysis, "never/once in a while" and "often/always" were combined, and three variables were assessed (seldom; sometimes; often).The items "How often in the last 30 days has your family or friends encouraged you to eat healthy foods?" and "How often in the last 30 days has your family or friends eaten healthy meals with you?" were rated and combined for analysis in the same manner.
Social Cohesion: The "Social Cohesion" section of the baseline survey included the item "I feel a sense of belonging to my community".[25] Responses were provided on a 7-point Likert scale (strongly disagree; disagree; slightly disagree; neither agree nor disagree; slightly agree; agree; strongly agree).On analysis, the three "disagreement" categories and three "agreement" categories were combined, and three variables were assessed (disagree; neither agree nor disagree; agree).
Resource Access: Two items assessed the extent to which participants accessed existing community resources for physical activity and nutrition: "How often do you access community physical activity resources, places, or events to be physically active" and "How often do you access community nutrition resources to get healthy foods or to learn how to eat healthy".Responses were given on a 5-point Likert scale (never; once in a while; sometimes; often; always).On analysis, "never/once in a while" and "often/always" were combined and three variables were assessed (seldom; sometimes; often).

Data Analysis
Categorical variables classi ed by mood were analyzed using chi-square tests.Kruskal Wallis tests were used to analyze continuous variables by mood.Analyses were two-sided using 5% type I error rates and performed using SAS version 15.1 (SAS Institute Inc. Cary, NC, USA).No adjustments were needed due to the analysis containing only baseline data.

Results
Of the 475 enrolled study participants, 449 completed baseline mood measures and were included in this analysis.Of the 449 participants, 268 (60%) were Hispanic/Latino and 181 (40%) were Somali.Although missing in 88 (19%) respondents, only 38 (11%) reported that English is the language they most commonly speak at home (11% Hispanic/Latino, 10% Somali).
Of the 449 participants, 107 (24%) reported having negative mood within the past 7 days at baseline.Participants who reported having a negative mood were more often Hispanic/Latino (74%), female (68%), had no health insurance plan in the last 12 months (46%), or were younger age (mean = 41.3 years, IQR = 32-50 years; Table 1).Healthy Dietary Quality and Intake Table 2 shows the dietary results.Overall, who reported "no" or "sometimes" eating fruits or vegetables as snacks (p = < 0.001) and "often" drinking regular soda (p = 0.03) were more likely to report having negative mood.
However, among both Hispanic/Latino and Somali participants, only the item "Do you eat fruits or vegetables as snacks" was signi cantly associated with negative mood (p = < 0.01 and 0.04, respectively).A lower ASA24® HEI total score was also associated with negative mood for the sample overall (mean = 49.8 [IQR = 39.4-59] for negative mood vs. mean = 53.6 [IQR = 43-63.1]for positive mood; p = 0.02).

Physical Activity
Participants who were classi ed in the "inactive" category more often reported negative mood (39% vs 28%), and participants who were classi ed in the "minimally or HEPA active" category more often reported positive mood (72% vs 61%; p = 0.03).Somali participants who were classi ed in the "inactive" category more often reported negative mood (62% vs 28%), while those in the "minimally or HEPA active" category more often reported positive mood (72% vs 39%; p = 0.001), but there was no signi cant difference among Hispanic/Latino participants.

Theory-Based Measures
Table 3 shows results from the social cognitive theory-based measures of self-e cacy, social support, and social cohesion.Self-E cacy: For the sample overall, participants who reported being not at all or somewhat con dent in eating a healthy diet were more likely to report negative mood than those who reported being very con dent (p = 0.001).Among Hispanic/Latino participants, those who reported being not at all or somewhat con dent in eating a healthy diet were more likely to report negative mood (p = < 0.001), but there was no signi cant difference among Somali participants.
Social support: Overall, participants who reported "seldom" or "sometimes" having family or friends encourage them to eat healthy food in the last 30 days (p = < 0.001) or eat healthy meals with them in the last 30 days (p = < 0.001) were more likely to report having negative mood.Among Hispanic/Latino participants, those who reported "seldom" or "sometimes" having family or friends encourage them to eat healthy foods in the last 30 days (p = 0.01) or eating healthy meals with them in the last 30 days (p = 0.001) were more likely to report negative mood, but there was no signi cant difference among Somali participants.
Participants who reported "seldom" or "sometimes" having family or friends encourage them to do physical activity in the last 30 days were more likely to report negative mood (p = 0.01).Those who reported having family or friends only "seldom" actually do physical activities with them in the last 30 days also reported negative mood more often (p = < 0.001).Among both Hispanic/Latino and Somali participants, only the question on having family or friends do physical activity with them in the last 30 days and the response category of "seldom" was statistically signi cant (p = 0.01 and 0.05, respectively) in being associated with negative mood.
Social Cohesion and Resource Access: Participants who either "disagreed" or "neither agreed nor disagreed" with the statement "I feel a sense of belonging to my community" reported negative mood more often than participants with higher social cohesion ratings (p = 0.01).For the sample overall, those who "seldom" or "sometimes" access community resources to get healthy foods or learn to eat healthy or who "seldom" or "sometimes" access community physical activity resources (p = 0.003) reported negative mood more than participants who "often" access community resources.
For both Hispanic/Latino and Somali participants, the question "How often do you access community nutrition resources to get healthy foods or to learn how to eat healthy?" was signi cantly associated with negative mood.
Hispanic/Latino participants who reported "seldom" accessing community nutrition resources (p = 0.01) and Somali participants who reported "seldom" or "sometimes" accessing community nutrition resources (p = 0.03) were more likely to report negative mood.Additionally, Somali participants who responded "seldom" or "sometimes" to the question "How often do you access community physical activity resources, places, or events to be physically active?" more often reported negative mood (p 0.02), but there was no signi cant difference among Hispanic/Latino participants.

Discussion
This study assessed the baseline measures of Hispanic/Latino and Somali immigrants enrolled in a CBPR-derived weight loss intervention program to reduce cardiovascular risk.Self-reported negative mood was associated with several factors associated with cardiovascular disease including poor dietary quality, low physical activity levels, and a lack of perceived social support.These ndings con rm results from a prior smaller study by our research team, and extend the ndings to a larger adult immigrant population.[7] It is well-established that self-e cacy, or one's perceived ability to exert control over their behavior, and perceived social support are associated with future health behaviors.[26-28]In examining dietary quality, study participants classi ed as having negative mood reported eating fewer fruits and vegetables, drinking more regular soda, and had less healthy diets as measured by the 24-hour dietary recall (ASA24).They also reported lower con dence in eating healthfully compared to participants reporting a positive mood.Additionally, participants reporting a negative mood endorsed receiving less support for healthy eating (e.g., encouragement from family or friends to eat healthy food, frequency of family or friends eating healthy meals with them) compared to those reporting a positive mood.Given the signi cant relationship between self-e cacy and health behaviors, individuals reporting negative mood are likely to continue to have poor dietary quality and low physical activity behaviors in the future.[28,29] Similar results were found in the domain of physical activity.Study participants classi ed as having a negative mood were more likely to be physically inactive compared to those with a positive mood.Previous research has found that physical activity can bene t those with negative moods, and may offer protection from the development of depression.
[30] − [31] Participants in our study reporting negative mood also reported lower con dence in participating in regular exercise or physical activity, as well as receiving less encouragement from family or friends for physical activity and having family or friends do physical activity with them.This aligns with previous research that has found that friends and family who are obese may in uence the obesity rates of those around them, [32] and conversely, that membership in a sport or exercise group can be bene cial to both mood and physical activity.[33] Thus, interventions that seek to improve physical activity levels in immigrants reporting negative mood should address social support for, and selfcon dence in, being physically active.
Social support and social cohesion are associated with a range of positive health behaviors and outcomes.[34] In this study, participants classi ed as having negative mood also reported a lower sense of community belonging compared to participants with a positive mood.Those with negative mood were also less likely to report accessing community resources for healthy eating and physical activity.The nding that a lack of community belongingness is associated with a lower level of accessing community resources is in line with other research supporting the strong association between social support and positive health behaviors.[35] The results presented herein con rm prior ndings supporting an association between mood, healthy diet, and physical activity, and re ect the self-reported experiences of Hispanic/Latino and Somali immigrants prior to starting a healthy lifestyle intervention.The study has several limitations.The results are limited by measures of some health behaviors being self-reported, as it is possible that direct measurement of dietary quality and intake or physical activity level would yield different ndings.Additionally, as the measure for mood classi cation was a single item, it is possible that a more extensive assessment of mood may have classi ed participants differently.Furthermore, the US version of the ASA24 is available in Spanish, but Somali participants had some di culty reporting food intake due to cultural differences.
Participants were individuals in southeast Minnesota who self-enrolled in a weight loss intervention and may differ from the broader immigrant population.However, the large sample size and strong response rate likely provided results which can be used to inform future research.
In conclusion, in this baseline assessment in Hispanic/Latino and Somali immigrants, self-reporting a negative mood was associated with a less healthy diet, lower physical activity levels, and lower levels of con dence in eating a healthy diet and being active.Additionally, participants reporting negative mood had less of a sense of belonging to their communities and were less likely to access community resources for healthy eating or physical activity.While more research is needed in larger and other immigrant communities, our ndings suggest that health-improvement behavioral interventions may bene t from incorporating mood management and self-e cacy strategies as additional mechanisms to reduce cardiovascular risk and promote health equity.

Declarations
Ethics Approval: This study was performed in line with the principles of the Declaration of Helsinki.Approval was granted by the Mayo Clinic Institutional Review Board (October 19, 2021; #21-009339).
Consent to Participate: Informed consent was obtained from all individual participants included in this analysis.
Data Availability: The data that support the ndings of this study are available from the corresponding author, BNT, upon reasonable request.

Funding:
This work was supported by the National Institutes of Health: National Institute on Minority Health and Health Disparities (P50 MD017342), the Mayo Clinic Center for Clinical and Translational Science: National Center for Advancing Translational Science UL1 TR000135, and the Mayo Clinic O ce of Health Disparities Research.
Posted Date: March 12th, 2024 DOI: https://doi.org/10.21203/rs.3.rs-3934645/v1License:   This work is licensed under a Creative Commons Attribution 4.0 International License.Read Full License Additional Declarations: Competing interest reported.Author M. Clark declares IP on the Pheno-Diet: Individualized Lifestyle Intervention for Obesity Management Based on Obesity Phenotypes.No other authors have competing interests to declare.

Table 1
Healthy Immigrant Community participant characteristics by mood at baseline.

Table 2
Healthy nutrition and physical activity behaviors associated with mood at baseline.* ¥ Kruskal Wallis *Chi-Square ¥ Kruskal Wallis

Table 3
Self-e cacy, social support, social cohesion, and resource access associated with mood at baseline. *Chi-Square