Associations with stress: a cross-sectional comparison of

wellness in older adults

Shelby Benci, B.S.Chad Earl, B.S.

April Irvine, B.S.Julie Long, B.S.Nikki Nies, B.S.

Jessica Schiappa, B.S.

Mentor: Bonnie Beezhold, Ph.D.

Study background

• By 2050, 20% of the U.S. population will be over the age of 65 (Kobrosly, 2013)

•Older adults report higher stress levels than a healthy range (APA, 2012)

•Many older adults do not meet dietary guidelines for their age (Fakhouri, 2012)

•Aging is associated with increasing BMI and body fat (Flegal, 2012; Fakhouri, 2012; Kizer, 2011)

BackgroundResearch question: Do older adults living in a vowed religious community have less stress than those living in an independent retirement community?

•Vowed religious communities can positively impact health and lifestyle factorsoBlood pressure in nuns did not increase with age

(Timio, 1997)oLife expectancy higher than outside community

(Gouw, 1995)

Study objectives

(1) To explore relationships of various health and lifestyle factors that may impact stress and other wellness dimensions in older adults – physical, emotional, social, and spiritual; and,

(2) To compare these factors in different communal environments – the vowed religious community and an independent retirement community

Methods - Participants

• Sites – 4 vowed religious communities (n=35); 1 independent retirement community (n=32) • Total participants – 67 (41 females/26 males)

St. Procopius Abbey, Lisle

Sacred Heart Monastery, Lisle

Marmion Abbey, Aurora

Monarch Landing Community, Naperville

School Sisters of St. Francis of Christ the King, Lemont

Participants - Comparison of communities

• SimilaritiesoCommunaloNo financial strainoAccess to religious facilities

•DifferencesoVoluntary vs obligatory activitiesoCoed vs single gender

living environmentoCommunity involvement

and responsibility

Methods

Design and recruitment process•Cross sectional study design •Participant recruitment: convenience sample recruited at vowed religious sites and independent retirement community•Fliers posted, sign-up sheets

Jessica administered the wellness surveys.

Methods

Eligibility criteria •65 years and older•Live independently - function without significant physical or cognitive impairment•Willing to participate

April collected 24 hour recall data.

Methods

Wellness survey•Demographic questions•Lifestyle questions•Four embedded questionnaires:• Perceived Stress Scale-10• Geriatric Depression Scale-15• Spirituality Index of Well-

being• Multidimensional Scale of

Perceived Social Support Julie collected 24 hour food recall data.

Methods

Data collection process•Areas were segmented and

participants rotated to stations•Data collection was

exclusively performed by six team members on five Saturdays in five sites

Shelby measured blood pressure and heart rate.

Methods

Stations • Station 1:

Wellness survey• Station 2:

Blood pressure, pulse• Station 3:

Anthropometrics• Station 4:

Diet surveysNikki and Chad measured height, weight, waist circumference and percent body fat.

Results – Population characteristics by group

Variable N VRC IRCTest Stat

P value

Mean ± SE Mean ± SE

Age 67 78.91±1.50 79.28±1.34 542.51 .826

Gender (m/f) 67 15 / 20 11 / 21 0.52 .477

Degree/No3 Degree

67 4 / 31 15 / 17 10.32 .001

Activity Hrs4 59 29.79±5.11 4.00±0.78 194.51 .001

Social Support 67 63.77±2.94 68.06±2.68 461.51 .216

Spirituality 67 53.53±1.06 52.06±1.15 471.01 .262

1 Mann-Whitney U test statistic2 Chi-Square test statistic

3 Degree/No Degree Effect Size: φ = 1.59 4 Activity Hours Effect Size: r = 0.46

Results - Education

Results – Population characteristics by group

Variable N VRC IRCTestStat1

Pvalue

Mean ± SE Mean ± SE

Total exercise 32 46.79±17.85 29.50±3.18 89.5 .165

Body mass index (BMI)

65 28.80± 0.93 26.94±0.72 400.0 .095

Waist circumference 66 39.74± 1.14 40.13±3.69 465.5 .314

Muscle mass 62 55.86± 2.54 54.43±2.51 463.5 .811

Systolic blood pressure

67 128.37± 4.14 131.89±3.34 447.0 .156

Diastolic blood pressure

67 71.49± 2.62 70.63±1.82 495.5 .418

1 Mann-Whitney U test statistic

Results – Blood Pressure

Results – Reliability of scales

Cronbach’s Alpha Internal Consistency

Perceived Stress Scale-10 0.80 0.7 ≤ α ≤ 0.9; Good

Geriatric Depression Scale – 15

0.70 0.7 ≤ α ≤ 0.9; Good

Multidimensional Perceived Social Support Scale

0.97 α ≥ 0.9; Excellent

Spirituality Index ofWell-being Scale

0.90 α ≥ 0.9; Excellent

Background - StressResearch question: Does a more spiritual environment affect perceived stress in older adults, and are health and lifestyle factors associated with perceived stress?

•Americans report a mean stress level of 4.9 on 10-point scale where 1=little/no stress and 10=a great deal of stress (APA Stress in America, 2012)

• Stress is an altered state of homeostasis in response to mental or physical stressors (Het, 2012)

• Chronic stress can cause depression, anxiety, cardiovascular disease, weight gain and insulin resistance (Het, 2012)

Stress mechanisms

Sweis, 2012

Methods – Measuring stress

•Measured perceived stress using the 10-item Perceived Stress Scale (PSS)oExample question: In the last month, how often have you felt

that you were unable to control the important things in your life?

N Min Max Mean SE

PSS-10 61 1 24 10.84 0.69

Living Site N Mean SE

St. Procopius Abbey 6 7.17 1.68

Sacred Heart Monastery 8 15.63 1.03

Marmion Abbey 9 10.89 1.70

School Sisters of St. Francis of Christ the King

9 12.44 2.15

Monarch Landing 29 9.76 0.97

PSS national average for those 65 and older: 12.0

Results – Comparison by groupsH10: There is no difference in stress scores reported by the vowed religious community and the independent retirement community

Results – Comparison by groupsH10: There is no difference in stress scores reported by the vowed religious community and the independent retirement community

PSS-10Mean±SE

M-WStatistic

*P value

Vowed Religious Community

11.81 ± 0.97 362.0 .140

Independent Retirement Community

9.76 ± 0.97

Males 9.50 ± 0.97 346.5 .113

Females 11.83 ± 0.95*Actual PSS scores shown vs mean ranks.

Results – Associations with PSS-10 scoresH20: Perceived stress is not related to health and lifestyle factors in older adults

Variable Correlation (r) p valueSpirituality score -.444 .000

Depression score .374 .003

Sweets per day .328 .013

Muscle mass -.327 .014

Alcohol per week -.331 .009

Fiber -.271 .035

Vitamin B6 -.286 .027

Vitamin B12 -.269 .038

Vitamin D (IU) -.305 .018

Magnesium -.256 .048

Potassium -.287 .026

Results – Multivariate analysisH31: Certain health and lifestyle factors contribute to or predict perceived stress in older adults

VariableStandardized

β p value R2

Spirituality scores -.347 .002

Vitamin D (IU) -.271 .010

Sweets per day .216 .046

Muscle mass -.199 .080

Depression scores .189 .080

Alcohol per wk -.186 .083

Model total .505*

*Adjusted R square = .444

Discussion - Stress

• There was no difference in reported perceived stress in the vowed religious and independent retirement communities of older adults• Stress was not related to blood pressure in this

population• Spirituality was the biggest lifestyle predictor of lower

perceived stress in older adults, followed by vit DoA spiritual lifestyle is associated with less stress (Timio, 1997)

oLow vit D status is associated with depression, anxiety and low mental health related quality of life (Motsinger, 2012)

Background - Weekly alcohol intakeResearch question: Does alcohol intake per week impact stress and other health and lifestyle factors in older adults?

(USDA; Gallup 2012)

Weekly alcohol intake in U.S.

Older adults (55 & over) 3.9 drinks/wk

General population 4.2 drinks/wk

• Alcohol intake has a wide variety of health outcomes (Rehm, 2003)

• Regular light to moderate drinking may have cardioprotective effects (O’Keefe, 2007)

Methods – Measuring alcohol intakeResearch question: Does alcohol intake per week impact stress and other health and lifestyle factors in older adults?

•Measured alcohol intake by this question: “How many alcoholic beverages do you drink weekly?”o 1 beverage = 1 glass of wine, 1 beer, 1 cocktail

• 65/67 participants answered the question• Total mean intake was 1.72 drinks/wk

o Range was 0 – 7 drinks per week

Results - Comparison of groupsH10: There is no difference in weekly alcohol intake

between groups in the two living sites.

Alcohol servings/wk N Mean SEMW Test*

P value

Vowed Religious Community

34 1.11 .28 332.5 .0081

Independent Retirement Community

31 2.39 .39

Males 26 2.02 .37 379.5 .078Females 39 1.51 .33*Mann-Whitney U tests showing actual mean scores versus mean rank.1 Effect Size

Results - Associations with weekly alcohol intakeH20: Weekly alcohol intake is not related to stress or other health and lifestyle factors.

Variable N Correlation (r) P value

Total sample

Perceived Stress Scale 61 -.331 .009

Females only

Perceived Stress Scale 35 -.422 .011

Results- Comparison of groupsH30: Perceived stress scores (PSS-10) will not be different in levels of alcohol intake.

N

None – 1/2 drink/wk

1-2 drinks/wk

>2 drinks/wk

K-W Stat1

Pvalue

Mean ± SE Mean ± SE Mean ± SE

PSS-10 scores 61 13.36 ± 1.00 10.58 ± 1.24 7.41± 1.02 12.1 .0022

1 Kruskal-Wallis statistic; actual mean PSS scores shown versus mean ranks.=2 Mann-Whitney U tests.

Discussion

• Older adults in independent retirement communities are drinking more alcoholic beverages than the vowed religious communities

• Alcohol intake was associated with reporting less stress• Older adults drinking 2 or more alcoholic beverages/wk

reported less stress than those drinking none to ½ beverage/week. oDrinking less alcohol is related to higher levels of perceived

stress (Barrington, 2014)oDrinking in moderation is linked to better well-being than

abstinence (Lang, 2007)

Introduction – Sweets intakeResearch question: Does consuming sweets impact stress and other health and lifestyle factors in older adults?

• Recommendations for added sugars:oDietary Guidelines: reducing calories from added sugars (USDA &

USDHSS, 2010)oWHO - less than 10% of total energy intake per day (WHO, 2014)

•U.S. older adult population consumes 10.7%/11.2% (males/females) of its total calories from added sugar (Ervin & Ogden, 2013)

•Higher perceived stress levels associated with increased intake of sweets and decreased intake of fruits and vegetables (Mikolaiczyk, 2009)

Methods – Measuring sweets intake

• The number of sweets consumed per a day was measured with the following question:o How many times per day, on average, do you eat sweets, like

sugar-sweetened cake, cookies, candy, pie, or pastries? (1 serving)

• 63/67 participants answered the question

Results – Associations with sweets intake H11: Sweets intake is related to perceived stress and other health and lifestyle factors in older adults

Variable N Correlation (r) P value

PSS scores 57 .328 .013*

Iron (mg) 62 .448 .000*

Vit B1 (mg) 62 .371 .003*

Vit B2 (mg) 62 .269 .035

Soluble fiber 63 -.261 .039

Zinc 62 .260 .041

*Correlations entered into the multiple linear regression model.

Results – Associations with sweets intake H11: Sweets intake is related to perceived stress and other health and lifestyle factors in older adults

Variable Standardized β P value R2

PSS scores .373 .001

Iron (mg) .315 .012

Vit B1 (mg) .296 .020

Model total .373**Adjusted R square .337

Results – Comparison of groups H20: There is no difference in daily sweets intake between the two living sites

VRC IRCM-W

statistic1

P value

Mean ± SE Mean ± SE

Servings of sweets/day

1.29 ± 0.15 0.84 ± 0.14 345.5 .0262

1 Mann-Whitney U test; actual mean serving per day shown vs mean rank.2 Effect size r = .28.

Results – Comparison of groups H31: Perceived stress scores differ by level of daily sweets intake in older adults

Sweets per day N PSS-10K-W

statistic1 P valueMean ± SE

None 14 9.00 ± 1.04 7.9 .0202

1 serving per day 28 10.32 ± 1.00

2+ servings per day 15 14.20 ± 1.41

1Kruskal Wallis test; showing actual mean PSS-10 scores2Mann-Whitney U tests showed difference between groups 1 and 3 (effect size = .49) and groups 2 and 3 (effect size = .33)

Discussion

• Stress is linked with sweets intake in older adults• Those who consumed more sweets per day reported

higher perceived stress than those who consumed less sweetsoAssociation of added sugar and stress observed in older adults

studies (Barrington, 2014; Laugero, 2011)

•An increase in sweets intake is associated with intake of nutrients used in enrichment but displacement of foods with soluble fiber (Mikolaiczyk, 2009)

Background – DepressionResearch question: Does a more spiritual living environment reduce the risk of depression in older adults, and what health and lifestyle factors are associated with that risk?

• Prevalence: 5.5% of Americans ≥65 years (American Psychiatric Association, 2013)• DSM-V criteria includes mood and somatic symptoms• Biochemical, genetic, environmental including diet, and

psychological factors contribute to development; women report more depression than men

• Consequences: increased healthcare costs, visits to ER, poorer quality of life, suicide (Lamers, 2013)

Methods - Measuring depressionResearch question: Does a more spiritual living environment reduce the risk of depression in older adults, and what health and lifestyle factors are associated with that risk?

• Measured depressive symptoms with GDS-15 (Marc, 2008)

oScores of 15 questions were totaled

• 66/67 of our participants completed the scale

Substance Abuse and Mental Health Services Administration, 2012

Results – Comparison between groups H10: Older adults living in the vowed religious group will report less depression than those living in the independent retirement group.

N

GDS-15 Mean ± SE

M-W Statistic1 P value

Vowed Religious Community

34 2.12 ± 0.36 369.0 .0202

Independent Retirement Community

32 1.16 ± 0.27

1 Mann-Whitney U test; actual scores are shown vs ranks.2 Effect size .20

Results – Associations with GDS-15 scoresH21: Depressive symptoms reported by participants will be associated with health and lifestyle factors in older adults.

1 Religious / non-religious group.

Results – Multivariate analysisH31: Health and lifestyle factors will be predictors of depression in older adults.

VariableStandardized

βP

value R2

Perceived stress .295 .014

Social support -.196 .033

Living environment -.171 .044

Model total .210*

*Adjusted R squared = .169

Results – Associations with depressive symptoms

H40: Associations of health and lifestyle factors with depression scores will be significant in older adults.

Discussion

• The religious environment was not protective with regard to depression for older adults.

• Depressive symptoms were related to stress, lack of social support, and living environment in older adultso Individuals with more depressive symptoms exhibited more pro-

inflammatory cytokines and IL-6 levels (Fagundes, 2013)

o Older adults and lack of social support results in greater rates of depression (Aziz, 2013)

Background – Sleep

• Adequate sleep improves health, wellness, and quality of life.

• Consequences of sleep deficit: behavior patterns that negatively affect health and interpersonal relationships (Lui, 2013)

• Recommendation: 7-8 hours for adults and older adults (CDC, 2003)

• Prevalence: 7% adults (>65 yrs) report sufficient sleep (CDC, 2003)

• <7hrs negatively affects cognitive function, but >8 hours also increases disease risk (McKnight, 2014)

Methods – Measuring sleep hoursResearch question: Does living environment affect sleep in older adults, and is sleep duration related to other health and lifestyle factors in this population?

•Reported hours of sleep per night o“How many hours of sleep do you

typically get per night?”

(US Bureau Labor and Statistics, 2012)

Results – Comparison of groupsH10: There is no difference in reported hours of sleep per night between living groups.

Variable N Mean ± SE1 M-W Test Statistic1

P value

VRC 35 7.12 ± 0.16535.0 .749

IRC 32 6.98 ± 0.20

Males 26 7.17 ± 0.23458.5 .327 Females 41 6.98 ± 0.16

1Mann-Whitney U test; showing actual mean hours of sleep versus mean rank

Results – Associations with hours of sleep/night H21: Sleep hours per night is related to health and lifestyle factors in older adults.

Variable NCorrelation (r)with sleep hrs

Pvalue

Total sample

Iron (mg) intake 66 .360 .003

Males only

Moderate exercise/wk 21 -.464 .034

Mild exercise/wk 13 -.589 .034

Iron intake (mg) 26 .417 .034

Females only

Sweets intake/day 39 .374 . 019

Results – Comparison of groups H30: There are no differences in health or lifestyle factors between sleep levels in older adults.

Variable N<7

hours7-8

hours>8

hoursK-W Stat1

P value

Mean ± SE Mean ± SE Mean ± SE

Sweets/day 63 0.88±0.19 1.02±0.12 2.25±0.25 8.4 .0152

Iron (mg) 66 11.80±1.34 12.92±0.84 44.08±15.31 10.6 .0053

1Kruskal-Wallis statistic; actual mean hours of sleep shown versus mean ranks.2 Mann-Whitney U tests showed a difference between level 1 and 3; effect size = 0.603 Mann-Whitney U tests showed a difference between level 1 and 3; effect size = 0.61

Discussion

• There was no difference in the amount of sleep reported by gender or living site

• Older adults who slept more than 8 hrs consumed more sweets and iron than those who slept less than 7 hrs

• Hours of sleep was associated with exercise and iron in older men, and sweets intake in older women.o Too much sleep → disruption in traditional meal times and

increase in snacking (Kim, 2011; Sato-Mito, 2011)

Background – Physical health measures Research question: How is physical health impacted by stress and other lifestyle factors in older adults?

• Stress measures: blood pressure, heart rate, body mass index, body fat, waist circumference muscle mass o PSS scores associated with increased blood pressure and pulse

(Hawkley, 2006) o Highest mean scores of BMI, WC, BP, HR were from the

group with highest mean stress scores (Farag, 2008)

Methods – Measuring physical health measuresResearch question: How is physical health impacted by stress and other lifestyle factors in an older population?

• Blood pressure and heart rate were measured by the BpTRU BPM-200

• Waist circumference was taken at the umbilicus with standard measuring tape

• Weight and percent body fat were measured by Inbody 230

• Height was measured with a stadiometer

Results – Associations of physical health measuresH11: Physical health measures are associated with stress in older adults.

Variable NCorrelation (r)

with PSS-10P

value

Muscle mass 56 -.327 .014 Percent body fat 58 .160 .232 Heart rate 61 .051 .696 Body mass index 59 -.061 .647

Diastolic BP 61 -.188 .146 Systolic BP 61 -.042 .747 Waist circumference 60 .134 .308

Results – Associations of physical health measuresH21: Muscle mass was associated with lifestyle factors in older adults.

Variable NCorrelations (r)

with muscle massP

value

Age 56 -.295 .020

Percent body fat 56 -.280 .028

Activity hours 53 .291 .034

Vowed Religious Community

Independent Retirement

Community M-W Stat*

Pvalue

N Mean ± SE Mean ±SE

Heart rate 67 75.86±2.08 68.41±1.99 386.5 .0291

% body fat 64 38.55±1.68 33.26±1.74 345.5 .0251

*Mann-Whitney U tests showing actual mean scores versus mean rank1 Effect sizes for heart rate and body fat are .27 and .28, respectively.

Results – Comparison of groups H30: There is no difference in physical health measures between older adults in the two living sites.

Physical health measures by group

Variable N VRC IRCTestStat1

Pvalue

Mean ± SE Mean ± SE

Heart rate 67 75.86±2.08 68.41±1.99 386.5 .0291

Percent body fat 64 38.55±1.68 33.26±1.74 345.5 .0251

Waist circumference 66 39.74±1.14 40.13±3.69 465.5 .314 Muscle mass 62 55.86±2.54 54.43±2.51 463.5 .811

Systolic BP 67 128.37±4.14 131.89±3.34 447.0 .156 Diastolic BP 67 71.49±2.62 70.63±1.82 495.5 .418

1 Mann-Whitney U test statistic

Results – Associations of physical health measures H41: Percent body fat and heart rate are associated with lifestyle factors in older adults.

Variables N Correlations (r) P value

Percent body fat 64

Muscle mass (kg) 56 -.280 .028

Saturated fat (kcals) 64 -.279 .026

Calcium (mg) 63 -.282 .025

B vitamins (mg) 63 -.275 .029

Heart rate 67

Vitamin C (mg) 66 -.291 .018

Results – Comparison of groups H50: Perceived stress scores do not differ in older individuals with lower and higher muscle mass.

VariableMuscle mass

<54.3 kgMuscle mass

>54.4 kgM-W stat*

P value

Mean ± SE Mean ± SE

PSS-10 scores 9.96 ± 1.30 11.65 ± 1.00 307.5 .186

Discussion

• Lower muscle mass was associated with higher perceived stresso Negative body composition changes were associated with

stress (Farag, 2008)

• Percent body fat and heart rate were lower in the independent retirement community

o Majority of individuals were not highly stressed, but mean % BF and WC were in elevated risk ranges for chronic disease

o Age-related loss of muscle and increase of abdominal fat has been shown to increase risk of hypertension, diabetes, hypercholesterolemia, atherosclerosis, insulin resistance (Goh, 2010)

Study strengths

•Affluent control group → equalizer for groups• Equal number of participants in groups • Similar age range of groups, males and females • Conducted 24 hour recall • Properly trained research team obtained validated

anthropometric measurements• Examined a population where little evidence-based

research exists

Study limitations

• Cross sectional study design• Sample size was small• Self reported data: cannot be independently verified• Bias: selective memory (with 24 hour recall)•Data collection started during Lenten season

Study conclusions

• Compared to the independent retirement community, the vowed religious community had a lower level of wellness as indicated by our measures.

• Lower stress may be related to certain lifestyle practices in older adults, particularly greater spirituality, but also eating fewer sweets, more vitamin D foods, and responsible alcohol intake.

THANK YOU !

QUESTIONS ?