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The mediating role of healthy behaviors and self-perceived health in the relationship between eating behaviors and comorbidity in adults

Archives of Public Health volume 82, Article number: 203 (2024) Cite this article

Abstract

Background

There is limited information on how healthy behaviors and individual health perceptions mediate the relationship between eating behaviors and noncommunicable diseases in adults. This study aimed to evaluate the mediating role of these factors in the relationship between eating behaviors and comorbidity in U.S. adults.

Methods

A cross-sectional predictive study using data from 5,247 adults from the Health Information National Trends Survey (HINTS) 5, cycle 3 (2019) was conducted. Structural equation modeling (SEM) was used to assess the mediating effect.

Results

The model showed good fit (χ2/df = 1.22, CFI = 971, TLI = 959, RMSEA = 0.050, SRMR = 0.036). It was found that self-perceived health totally mediated the relationship between eating behaviors and comorbidities (β = − 0.026, p < .001). Additionally, healthy behaviors and self-perceived health together mediated the relationship between eating behaviors and comorbidities (β = − 0.025, p < .001). A direct relationship was also observed between healthy behaviors and comorbidities, mediated by self-perceived health (β = − 0.103, p < .001).

Conclusion

The study concludes that eating behaviors are significantly related to comorbidities through the mediation of healthy behaviors and self-perceived health.

Peer Review reports

Text box 1. Contributions to the literature

• Limited research has explored how self-perceived health mediates the relationship between eating behaviors and comorbidity.

• This study highlights the co-mediation of healthy behaviors and self-perceived health, showing the need for comprehensive public health approaches.

• Healthy behavior independently reduces comorbidity risk, reinforcing the importance of promoting physical activity and lifestyle changes.

Introduction

Chronic diseases and comorbidities are becoming an increasingly significant problem in the adult population [1]. Factors such as diet and health behaviors play a significant role in the development and progression of these conditions [2]. Although it is recognized that unhealthy eating habits are directly related to the onset of various chronic diseases [3], the impact of other factors, such as healthy behaviors and self-perceived health status, on this relationship has not been fully explored. Healthy behaviors, such as regular physical activity and reduced tobacco and alcohol consumption, may mediate the relationship between eating habits and comorbidity, influencing long-term health outcomes [4, 5]. In addition, self-perceived health, or how individuals subjectively assess their own state of well-being, may be a key determinant in the adoption of preventive behaviors and the management of chronic diseases [6].

Comorbidity

Comorbidity is defined as the simultaneous presence of two or more chronic diseases in an individual [1]. For example, it is common to find cases in which an individual suffering from diabetes also has high blood pressure or cardiovascular disease [1, 7]. The increase in chronic diseases and comorbidity has become one of the most important problems for healthcare systems worldwide [8]. More specifically, the presence of comorbidity is an area of concern in the United States adult population [9]. According to the most recent epidemiological data, it is estimated that approximately 45% of adults in the United States, which equates to about 133 million individuals, suffer from at least one chronic disease [10]. These chronic diseases cover a wide range of long-term conditions, such as diabetes, arterial hypertension, cardiovascular disease, obesity, different types of cancer, among others [4]. These health conditions not only represent a significant burden for the affected individuals, but also generate enormous economic and social costs for the healthcare system and society in general [8].

Comorbidities represent a significant public health challenge, as they have the potential to exacerbate the overall health status and well-being of individuals, further complicating the clinical picture [2]. In addition to representing a deterioration in the quality of life of those affected, these comorbidities amplify the overall burden of disease, leading to an increase in the demand for and complexity of medical treatment [11, 12]. This scenario underscores the importance of a thorough and detailed understanding of the interrelationship between health-related behaviors, individual perception of one’s own health status, and the emergence of comorbidity in the U.S. adult population. With a clearer understanding of these dynamics, strategies and policies can be designed and implemented that not only address the treatment of existing comorbidity, but also promote preventive actions and foster a culture of health and wellness in the population [12].

Eating behaviors

Healthy eating behaviors play a key role in the prevention and management of chronic diseases and comorbidity in the adult population [13]. Understanding the relationship between diet and comorbidity is especially significant, given that unhealthy diets represent a modifiable risk factor for most chronic conditions, either as individual diseases or in combination with other comorbidities [14]. It is essential to keep in mind that the association between diet and risk of comorbidity is a process that develops over time, in contrast to an acute exposure that occurs in a single day or multiple short-term exposures [15]. Most research studies examining the relationship between diet and chronic disease risk are based on prospective cohort studies in humans [16,17,18]. These studies assess the participants’ habitual diet at the beginning of the study (i.e., at entry into the cohort) and, in some cases, follow-up is also performed at various points over several years. For example, a prospective cohort study involving 63,805 participants suggests that following healthy dietary patterns, such as the Mediterranean diet or the DASH diet, was associated with a lower risk of chronic disease mortality in women [19]. Moreover, another similar study found that following healthy diets was associated with a significant reduction in the risk of developing type 2 diabetes [16]. In addition, a cohort study conducted among Seventh-day Adventists showed that following a vegetarian diet is associated with a lower risk of chronic diseases, such as type 2 diabetes, cardiovascular disease, and some types of cancer; additionally, vegetarians were found to have lower body mass indexes and longer life expectancy compared to non-vegetarians [17].

Dietary behaviors and their influence on public health have been the subject of increasing interest in scientific research. Specifically, there is evidence to suggest that certain dietary behaviors, particularly those that favor a high consumption of meat and dairy products, are intrinsically linked to the development of noncommunicable diseases and an increase in overall mortality [18]. This relationship is especially noticeable in the U.S. context, where the incidence of chronic conditions has experienced an alarming increase [10]. It has been proposed that this increase in chronic diseases is closely related to the predominance of the typical Western diet [20]. This dietary pattern is characterized by a deficiency in the consumption of fruits and vegetables, together with a marked preference for foods rich in fat and sodium. In addition, the quantity of portions, the high caloric content, and an excessive intake of sugars, particularly added sugars, are notable [21]. To put this problem in context, these added sugars constitute 13% of the total daily caloric intake, and, within this percentage, almost half comes from sugar-sweetened beverages [22]. Additionally, other popular products, such as cookies, cakes, and various candies, represent significant sources of these added sugars [20].

However, the unhealthy nutritional profile of the Western diet does not end there; in fact, it is also known for its high content of saturated and trans fats [23]. Beyond simply contributing to a high caloric intake, these fats have a detrimental impact on the individual’s lipid profile, by raising low-density lipoprotein levels. These alterations can lay the foundations for the development of cardiovascular diseases, which represent one of the main causes of morbidity and mortality in the western context. Therefore, the identification and modification of these dietary patterns is imperative for the promotion of optimal public health and prevention of comorbidity.

Healthy behaviors

Some healthy behaviors, such as regular physical activity, reduction of tobacco and alcohol consumption, among others, may play an important role in the relationship between dietary intake and comorbidity by influencing risk factors and underlying physiological mechanisms [24,25,26]. Evidence from cross-sectional and longitudinal studies suggests that physical activity plays a fundamental role in energy balance, macronutrients (fat balance), and body composition (overweight/obesity) [27], which have been associated with chronic diseases in the general population [25, 28]. Poor dietary habits can influence caloric intake from fats, whereas combining physical exercise with a high-fat diet might enhance fat oxidation in comparison to a sedentary lifestyle [29]. Physical activity can counteract the negative effects of poor diet on energy balance, body weight, cardiovascular health, glucose metabolism, and insulin sensitivity [30, 31]. These are important risk factors in the development of diseases such as type 2 diabetes, cardiovascular disease, and metabolic syndrome [30].

On the other hand, reducing tobacco consumption could have a direct and positive impact on eating behaviors, and thus on the onset of comorbidity. Several studies have shown that tobacco consumption can influence eating habits, leading to increased appetite and preference for foods rich in fats and sugars, and decreased satiety [32, 33]. For example, findings from a systematic review revealed that smoking may be associated with changes in eating patterns, such as lower consumption of fruits and vegetables and higher consumption of foods rich in fats and sugars, which, in turn, may negatively impact body weight [33]. This is congruent with another study that found that cigarette smoking is associated with increased cravings for foods high in fat and sugars, as well as increased consumption of these foods [33]. Smokers may have greater difficulty in addressing and resisting cravings for unhealthy foods. These changes in eating behaviors because of tobacco use may increase the risk of developing comorbidity [32]. Therefore, it is important to consider these behaviors as mediating factors in the relationship between eating habits and comorbidity and to address them as an integral part of interventions to prevent and treat these chronic diseases.

Self-perceived health

Self-perceived health refers to an individual’s subjective assessment of his own state of health; it is not based solely on objective aspects of health, such as the results of medical tests or diagnoses, but also considers personal experience and each individual’s interpretation of his or her own state of physical, mental, and social health [34]. This perception can influence an individual’s behavior in the context of lifestyle choices and health care seeking [5]. Specifically, self-perceived health may impact the relationship between eating habits and comorbidity. In fact, when individuals have a positive perception of their health, they are more likely to adopt and maintain healthy eating habits [6], which in turn reduces the risk of developing comorbidity. In contrast, a negative self-perception of health may lead to a greater tendency toward unhealthy eating habits, which increases the risk of comorbidity [2]. Therefore, it is important to consider self-perceived health as a key factor in the promotion of healthy eating habits and the prevention of comorbidity.

Aim and hypothesis of the study

There is evidence that dietary habits can influence the onset and development of chronic diseases and comorbidity, however, a deeper understanding of how this relationship occurs is required. Consequently, in the current study, we sought to investigate the mediating role of healthy behaviors and self-perceived health in this relationship, i.e., how these variables may influence the association between eating habits and the presence of comorbidity. Understanding these mechanisms is particularly important for designing and promoting nutrition education and healthy lifestyle interventions and campaigns, which can contribute to improving the health and well-being of individuals. That said, the following hypotheses were proposed in the present study (Fig. 1): H1) Self-perceived health has a significant mediating effect on the relationship of eating behaviors to comorbidity; H2) Self-perceived health and healthy behaviors has a significant mediating effect on the relationship of eating behaviors to comorbidity; H3) Healthy behaviors has a significant mediating effect on the relationship of eating behaviors with comorbidity; finally, H4) Self-perceived health has a significant mediating effect on the relationship of healthy behaviors with comorbidity.

Fig. 1
figure 1

Sequential mediation models illustrating the relationship between eating behaviors, healthy behaviors, perceived health, and comorbidity in adults. Data from HINTS 5, Cycle 3 (2019), United States

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Materials and methods

Design

This study uses a cross-sectional design with a predictive approach, employing Structural Equation Modeling (SEM) [35]. This analysis is from secondary data pertaining to Cycle 3 of the Health Information National Trends Survey (HINTS) 5, conducted by the National Cancer Institute (NCI) in 2019. This survey is nationally representative in the United States and aims to examine how the general population uses information related to cancer risk. HINTS uses a mail sampling methodology that has been implemented since 2011. The sample design follows a two-stage process, where a random sample of addresses is first selected from a database, and then one adult is chosen from each sampled household [36]. Participants were sent a self-administered questionnaire by mail, covering a wide range of topics related to health communication, mental health, risk behaviors, and respondent characteristics [36].

Participants

The population considered was adults over 18 years of age residing in the United States collected through address sampling in the first stage and the selection of one adult from each sampled household in the second stage to culminate in an original data set consisting of 5,247 participants (Table 1).

Table 1 Sociodemographic Characteristics of Participants from the HINTS 5, cycle 3 (2019), United States (N = 5,247)
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Variables

The variables used in this study are part of Cycle 3 of HINTS 5, developed by the NCI. This survey consists of multiple items covering a wide range of health-related topics, such as healthy behaviors, self-perceived health, eating habits, presence of comorbidities, among others. For the current study, items corresponding to the following key variables were selected: “Healthy behaviors,” “Self-perceived health,” “Eating behaviors,” and “Comorbidity,” which are described below.

Healthy behaviors

Information was collected on healthier lifestyle behaviors, including fruit and vegetable intake, tobacco use, and physical activity [37]. The following questions were used to find out the consumption of fruits and vegetables: “Approximately how many cups of fruit (including 100% pure fruit juice) do you eat or drink each day?” and “Approximately how many cups of vegetables (including 100% pure vegetable juice) do you eat or drink each day?“. With a response from 0 (none) to 6 (4 cups or more). Tobacco use was assessed by the following question, “How often do you smoke cigarettes now?” and the response items were from 1 (every day) to 3 (never), which were reversed for the analysis of this research: 1 (never) to 3 (every day). Physical activity was measured by the following item: “On the days that you do any physical activity or exercise of at least moderate intensity, how long are you typically doing these activities?”, the response was not restricted to specific ranges, participants had to provide the number of minutes of exercise they perform each day. It was evident that items related to nutrition, physical activity, and smoking were considered in other studies [38, 39]. In addition, this study presented as evidence of reliability an omega coefficient of 0.617.

Self-perceived health

The variable consists of a single question: “In general, would you say your health is.“. Responses ranged from 1 (excellent) to 5 (poor). For this research, the traditional order of the scale was inverted, with the configuration of 1 (poor) and 5 (excellent), This modification was made to reflect a positive perception of health in the study. The relevance of this item was also considered in other studies [40, 41].

Eating behaviors

The variable consisted of 4 items. The first item comprises the following: “Thinking about the last time you ordered food in a fast food or sit-down restaurant; did you notice calorie information listed next to the food on the menu or menu board?”. The other three questions started with the previous premise of: “Thinking about the last time you noticed calorie information on the menu or menu board, how did the calorie information cause you to change what you planned to order?, and then specifically select the questions: “I ordered something with fewer calories”, “I ordered less food”, and “I ordered smaller portions”. All responses were dichotomous 0 (No) and 1 (Yes). These items have been previously considered in other studies [42, 43]. The eating behavior variable presents an omega coefficient of 0.842.

Comorbidity

Diabetes, hypertension, cardiovascular disease, and cancer were measured with the following questions: “Has a doctor or other health care professional ever told you that you had diabetes or high blood sugar?”; “Has any doctor or other health professional ever told you that you have hypertension or high blood pressure?”; “Have you ever been told by a doctor or other health care professional that you had a heart condition, such as a heart attack, angina, or congestive heart failure?”; “Have you ever been diagnosed with cancer?“. Binary responses were recoded to 0 (No) and 1 (Yes). The use of comorbidity-related questions was noted in another study [44].

Data analysis

Initially, we accessed the database, which is available on the NIH website free of charge. Subsequently, the open-source statistical software JAMOVI (version 2.3.26) was used to carry out the descriptive analysis, considering parameters such as mean and standard deviation, both for manifest and latent variables. Then, Structural Equation Modeling (SEM) was used to represent the direct and indirect effects of the suggested statistical mediation model. Given that the multivariate data presented nonparametric data and considering the sample size, we chose to use the Unweighted Least Squares (ULS) estimator.

We also considered the overall fit based on several indices, such as the comparative fit index (CFI), the Tucker-Lewis index (TLI), the Standardized Root Mean Square Residual (SRMR), the Root Mean Square Error of Approximation (RMSEA) together with the 95% Confidence Interval (CI), and the lower and upper limits. In addition, the Bootstrap method with 1,500 resampling samples was used to calculate the bias-adjusted 95% confidence interval, following the proposal of Efron and Tibshirani [45].

In SEM, mediation analysis allows us to examine the process in which an intermediate or mediating variable is involved between the predictor variable and the dependent variable, where the mediating variable exerts an indirect effect on the latter [46]. This analysis is characterized by two types of main mediation, where the total mediation of the mediating variable responds explanatorily to the existing association between the independent and dependent variable, in addition, the direct effect of the independent variable becomes non-significant (p > .05). Regarding partial mediation, both the direct and indirect effects can reach significance, although the mediating variable explains part of the relationship between the two variables.

In addition, within the context of the study of the mediating role, it is possible to identify a sequential mediation analysis. This analytical approach involves examining a series of mediating variables, whereby one mediating variable influences another mediating variable before the latter finally affects the dependent variable. This methodology proves to be advantageous in cases where a succession of sequential mediation processes is suspected to play a role in the causal connection between the variables under investigation [47].

Finally, the coefficient of determination (R2) was used to indicate the percentage of variability in the regressions. The minimum range (R2 = 0.4) was established [48].

Results

The descriptive statistics are shown in Table 2, where it is observed that the healthy behaviors variable has a higher mean (M = 167.83 and SD = 296.77). In this particular case, the distribution of the variable was found to conform to that of a normal distribution. This was because the skewness and kurtosis values are within the range of ± 1.5 [49]. In addition, it was found that there is a direct correlation with statistical significance for each of the variables, with the magnitude of the effect ranging from slight (0.10 to 0.30) and strong (0.50 and above) [50].

Table 2 Descriptive statistics and correlations among study variables: data from the HINTS 5, cycle 3 (2019), United States
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Table 3 presents the results of the direct and indirect effects analysis of the proposed model, which are considered acceptable because their fit indices are within the predetermined parameters (χ2/df = 1.22, CFI = 971, TLI = 959, RMSEA [95% CI] = 0.050 [0.046, 0.055], and SRMR = 0.036). In this sense, four indirect routes were found, where the first three routes exhibit total mediation, which refers to the statistical significance of the indirect effect (p < .05) while the direct effect was not significant (p = .21). The first pathway is constituted as follows: eating behavior-self-perceived health-comorbidity (β = − 0.026, p < .001). The second pathway: eating behavior-healthy behaviors-self-perceived health-comorbidity (β = − 0.025, p < .001). The third pathway: eating behavior-healthy behaviors-comorbidity (β = − 0.029, p < .001). Finally, the fourth pathway is characterized as partial mediation: healthy behaviors-self-perceived health-comorbidity (β = . -103, p < .001) where both the direct and indirect effect are significant.

Table 3 Mediation analysis of the effects between eating behaviors, Healthy Behaviors, Self-Perceived Health, and Comorbidity: results from HINTS 5 cycle 3 (2019), United States
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Likewise, the R² statistic was used to assess predictability. The findings indicated that the self-perceived health model (R² = 0.092), the comorbidity model (R² = 0.169), and the healthy behaviors model (R² = 0.060) demonstrated a higher degree of variance explained compared to the parameter set (R²=. 04).

Discussion

The relationship between eating behaviors and comorbidity has been widely studied in the scientific literature, showing the direct impact of healthy eating on the health of individuals [16, 17, 19]. However, the underlying mechanisms that explain this relationship are not always straightforward and may be influenced by various intermediate factors. In this study, we focused on exploring the role of healthy behaviors and self-perceived health as mediators of this complex relationship in the U.S. adult population. The importance of understanding these mediators lies in their potential to inform nutritional and behavioral interventions in the public health setting.

In the context of the current study, the proposed model has proven to be adequate, providing a coherent framework for interpreting the data collected. This statement is supported by standard fit indices that are widely recognized in the scientific literature [47, 51, 52]. These indices, which range from goodness-of-fit measures to residual error indices, indicate that the model aligns closely with the observed data, suggesting that the relationships and structures postulated in the model effectively reflect inherent trends in the data set. The usefulness of these indices lies in their ability to provide an objective assessment of model fit, minimizing bias and allowing comparisons with other studies. In this regard, in the findings of the current study, four indirect routes were found.

In the present research, one hypothesis was posed for each pathway of analysis. In the first pathway, it was identified that self-perceived health acts as a total mediator in the relationship between eating behaviors and comorbidity. This finding suggests that how an individual perceives his or her own health status can significantly influence how his or her eating habits may affect the presence of multiple diseases simultaneously. This finding is consistent with previous studies that have highlighted the importance of self-perceived health in the context of healthy eating. For example, Kretschmer et al. [53] found a positive correlation between a better perception of health and healthy eating behaviors, highlighting the regular consumption of fruits and vegetables. Therefore, a positive perception of one’s own well-being and health status can translate into the adoption of healthy eating patterns. For their part, Park et al. [54] observed an association between a poorer perception of physical and mental health status with high intake of fast food and soft drinks and frequent skipping of breakfast, these results remained consistent even after considering potential confounding factors such as sex, school level, place of residence, socioeconomic status, and other dietary habits. According to recent studies, individuals who maintain an optimistic view of their health status tend to be more inclined toward beneficial and sustainable eating habits over time [6]. This trend, in the long term, contributes significantly to the reduction of risks associated with comorbidity [13]. On the other hand, those individuals who perceive their health negatively tend to fall more easily into less healthy eating patterns. This preference for unhealthy habits, as pointed out by some studies [2], may increase the risk of developing comorbidity [19]. Therefore, it becomes essential to recognize the importance of self-perceived health in strategies for health promotion and prevention of noncommunicable diseases. Addressing and improving this perception can be a valuable tool in motivating individuals to adopt eating habits that benefit overall well-being and reduce associated risks.

On the other hand, in the second pathway, an additional element stands out in the analysis, which is healthy behaviors. This pathway illustrates the complexity of the interactions between the study variables and how they can interrelate to affect the outcome in terms of comorbidity. Specifically, it was observed that not only self-perceived health has a mediating role, but healthy behaviors also play an important role in mediating between eating behaviors and comorbidity. That is, the dietary choices that individuals make, along with their healthy actions, can influence how they perceive their health, and this, in turn, can have a direct impact on the development or prevention of comorbidity. For example, healthy behaviors such as regular physical activity and reduction of tobacco and alcohol consumption could have a direct and positive impact on eating behaviors, impacting specifically on energy balance, body weight, cardiovascular health, glucose metabolism, and insulin sensitivity, which are important risk factors in the development of chronic diseases, such as type 2 diabetes, obesity, cardiovascular disease, and metabolic syndrome [30, 31, 55]. In concrete terms, one study found that smoking is associated with an increase in cravings for foods rich in saturated fats and sugars [56], which are associated with the risk of comorbidity [32]. It is worth noting that this chain of relationships highlights the importance of considering multiple factors when analyzing the impact of diet on health and that, therefore, the promotion of healthy eating habits must go hand in hand with the promotion of general healthy behaviors to achieve a significant impact on disease prevention.

Another relevant finding of the current study is that the third pathway omits self-perceived health, highlighting the mediating role of healthy behaviors in the relationship between eating behaviors and comorbidity. This aspect could indicate that the influence of eating behaviors on comorbidity does not necessarily depend on how individuals view themselves in terms of health, but more directly on their healthy behavior. It is possible that healthy behaviors, such as regular physical activity, reduction of alcohol and tobacco consumption, among other behaviors, have a direct and substantial influence on the reduction of comorbidity [57,58,59], regardless of how individuals rated their own health status. This observation is fundamental for public health interventions, as it highlights the importance of promoting healthy behaviors as a primary prevention strategy. Current research highlights the intrinsic importance of healthy behaviors in the relationship between eating behaviors and comorbidity, beyond how individuals perceive their own health status. These findings underscore the need for interventions that directly promote healthy behaviors in the population to address and reduce the risk of comorbidity.

Finally, for the last hypothesis, a relationship between healthy behaviors and comorbidity, mediated by self-perceived health, was identified. More specifically, it was observed that the relationship between healthy behaviors and comorbidity is not only direct, but also indirect, the latter being facilitated through self-perceived health. This pattern suggests that adopting healthy behaviors has a double benefit: on the one hand, it offers a direct protective effect against comorbidity, and, on the other hand, it improves the perception of health, which, in turn, may contribute to the prevention or reduction of comorbidity. This finding aligns with previous research that has highlighted the importance of self-perceived health in terms of clinical outcomes. For example, Yang et al. [60] found that compared to participants who reported good self-rated health, those who reported poor self-rated health had a higher prevalence of chronic diseases, such as hypertension, diabetes, and heart disease. Likewise, Barreto et al. [61] observed that individual perception of poor health is related to more chronic diseases. On the other hand, in relation to healthy behaviors, Manjunath et al. [5] found that healthy behaviors, such as healthy eating habits, regular physical activity, and reduced substance use, were linked to a more positive perception of health. In other words, practicing healthy behaviors can improve an individual’s perception of his or her own health, which, in turn, can influence the presence of comorbidity. Furthermore, in the current study, the findings evidence a negative relationship between healthy behaviors and comorbidity, meaning that as healthy behaviors increase, comorbidity tends to decrease. This supports the premise that the adoption and maintenance of healthy behaviors can serve as preventive tools in reducing the risk of comorbidity [30, 33]. This trend is consistent with the existing literature, where studies such as that of Li et al. [62] showed that the promotion of healthy habits has a positive impact on the prevention of chronic diseases. Therefore, the results of the present study not only validate previous findings, but also emphasize the importance of considering self-perceived health as an essential element when investigating the mechanisms underlying the relationship between healthy behaviors and comorbidity.

Limitations

It is essential to understand that, despite the robustness of our methodological design, there are intrinsic limitations that must be considered when interpreting the results. Although the current study is based on a sample that is representative of the U.S. population and has been carefully adjusted to reflect nationwide projections, it is important to approach the conclusions with caution for several reasons. First, the HINTS methodology is cross-sectional; this feature limits the ability to infer causalities between eating behaviors, health behaviors, self-perceived health, and comorbidity. Thus, although we identify important relationships, we cannot state with certainty that one variable directly causes changes in another. Second, reliance on information provided by participants was another important limitation; This reliance on self-reported data, especially in terms of memories associated with behaviors and health status may be subject to recall bias or the influence of social desirability. Thus, there is a possibility that what participants reported may not exactly match their actual behaviors and experiences. Finally, as we relied on self-reported comorbidity, there was no opportunity to cross-check these data with medical records or confirmed clinical diagnoses, which could lead to inaccuracies.

Clinical implications

One of the central findings of the current study is how self-perceived health mediates the relationship between eating behaviors and healthy behaviors with comorbidity. This finding suggests that an individual’s perception of his or her own health status may influence his or her lifestyle behavior and, in turn, his or her risk of developing comorbidity. From a clinical perspective, this underscores the importance of not only providing nutritional and general health education, but also working on improving the patient’s self-image and self-perception of health. It is important for health professionals to recognize and address these psychological and behavioral factors to optimize their clinical interventions. The study also highlights the fundamental role of healthy behaviors, beyond diet, in reducing the risk of comorbidity. The inclusion of physical activity routines and other healthy behaviors such as reducing tobacco and alcohol consumption can be as essential as maintaining a balanced diet. Clinical interventions, therefore, should be holistic, addressing not only diet but also other aspects of the patient’s lifestyle. The prominence of indirect pathways also suggests that there may be other mediators not identified in this study that influence the relationship between eating behaviors and comorbidity. This underscores the importance of continuing research to identify all relevant factors and thoroughly understand their interactions. The link between eating behaviors, self-perceived health, healthy behaviors, and comorbidity suggests that effective comorbidity management involves addressing both behaviors and perceptions. This is particularly relevant for conditions such as type 2 diabetes and cardiovascular disease, where diet and lifestyle play an important role [55, 58]. By recognizing and acting on the multiple factors that influence comorbidity, healthcare professionals will be better equipped to promote positive health outcomes and improve patients’ quality of life.

Conclusion

The proposed model is adequate and reflects a good fit to the data, as indicated by the standard fit indices. Essentially, self-perceived health was observed to act as a total mediator between eating behavior and comorbidity. In turn, a second pathway reveals the co-mediation of healthy behaviors and self-perceived health in the interaction between eating behaviors and comorbidity. Moreover, another relevant finding of the current study is that a third pathway shows that the healthy behaviors variable acts as a primary mediator, without the intervention of self-perceived health, in the relationship between dietary practices and comorbidity. Additionally, a relationship between healthy behaviors and comorbidity was identified, mediated by individual perception of health. Specifically, the relationship between healthy behaviors and comorbidity was found to be not only direct, but also indirect, the latter being facilitated through self-perceived health. Therefore, research in this field should continue to gain a deeper understanding of the factors linked to comorbidity in adults and the general population, and to determine strategies to adequately address this issue.

Data availability

All data used in this study are publicly available data from the National Cancer Institute and are available at http://hints.cancer.gov.

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Acknowledgements

The author(s) declare that they have not received the following financial support for the research, authorship, and/or publication of this article. However, the authors wish to thank Varisier Noel for their support during the manuscript writing process. Finally, we thank the developers and administrators of the HINTS - the National Cancer Institute. Moreover, it should be noted that this study does not reflect the views of the National Cancer Institute.

Funding

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. Funding for Open Access Charge: Universidad Señor de Sipán (Grant: 0195–2023/VRI-USS).

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Authors and Affiliations

  1. Áera de Investigación, Universidad César Vallejo, Lima, Perú

    Cristian Ramos-Vera

  2. Escuela de Psicología, Universidad Nacional de San Agustín de Arequipa, Arequipa, Perú

    Gleni Quispe-Callo

  3. Escuela de Posgrado, Universidad Femenina del Sagrado Corazón, Lima, Perú

    Miguel Basauri-Delgado

  4. Research Group for Nutrition and Lifestyle, Universidad Peruana Unión, Lima, Perú

    Yaquelin E. Calizaya-Milla

  5. Research Group for Nutrition and Healthy Behaviors, School of Medicine, Faculty of Health Sciences, Universidad Señor de Sipán, Carretera a Pimentel Km 5, Chiclayo, Lambayeque, 14001, Perú

    Christian Casas-Gálvez, Norma Del Carmen Gálvez-Díaz & Jacksaint Saintila

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  1. Cristian Ramos-Vera
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  7. Jacksaint Saintila
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Contributions

CR-V, GQ-C, and JS designed the study. MB-D, CC-G, and YEC-M performed literature searches and provided summaries of previous research studies. CR-V, GQ-C, and MB-D performed the statistical analysis and interpretation of the data. CR-V, NDCG-D, and YEC-M wrote the first draft of the article. All read and approved the final manuscript.

Corresponding author

Correspondence to Jacksaint Saintila.

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Ethics approval and consent to participate

The HINTS 5 survey was approved by the Institutional Review Board of Westat. HINTS was exempt from institutional review board (IRB) review by the NIH Office of Human Subjects. All procedures followed were conducted in accordance with the U.S. Federal Policy for the Protection of Human Subjects. All participants provided their written informed consent to participate in this study.

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Not Applicable.

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The authors declare no competing interests.

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Ramos-Vera, C., Quispe-Callo, G., Basauri-Delgado, M. et al. The mediating role of healthy behaviors and self-perceived health in the relationship between eating behaviors and comorbidity in adults. Arch Public Health 82, 203 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13690-024-01435-w

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Keywords

Archives of Public Health

ISSN: 2049-3258