Associations of Depressive Symptoms With Diabetes,Chronic Kidney Disease,and Physical Activity in Later Life

Abstract

Objectives

Diabetes-related chronic kidney disease (CKD) is a common and clinically consequential multimorbidity cluster in later life. This study examined the associations of depressive symptoms (PHQ-9) with diabetes, CKD, coexisting diabetes-CKD, and physical activity (PA).

Methods

Data came from the 2011-2023 National Health and Nutrition Examination Survey (N = 13,610 adults aged ≥50). Linear regression models were used to answer the research questions.

Results

In models adjusting for sociodemographic factors and other chronic illnesses, diabetes (B = 0.38, SE = 0.14, p = .007) and coexisting diabetes-CKD (B = 0.58, SE = 0.17, p = .001) were associated with higher depressive symptoms, whereas meeting PA guidelines was associated with lower symptoms (B = −0.86, SE = 0.10, p < .001). The inverse association between PA and depressive symptoms was weaker among individuals with advanced CKD (p = .042).

Conclusions

These findings suggest that depressive symptoms and PA are closely linked in later life, highlighting the importance of supporting combined mental health and exercise interventions for older adults with complex chronic conditions.

Keywords

older adults diabetes chronic kidney disease depression physical activity

Introduction

Older adults are disproportionately affected by diabetes and chronic kidney disease (CKD). With prevalence estimates of 20.6% (95% CI = 17.8–23.8) among adults aged 45–64 years and 28.8% (95% CI = 24.0–34.0) among those aged ≥65 years (Centers for Disease Control and Prevention, 2026), diabetes is one of the most common chronic diseases among older adults in the United States. The risk of CKD (defined as estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m² or eGFR ≥60 ml/min/1.73 m² with urinary albumin-to-creatinine ratio (UACR) >30 mg/g) also increases with age. Our analysis of the 2011-2023 National Health and Nutrition Examination Survey (NHANES) found that the prevalence of CKD was 13.7% among adults aged 50–64 years and 35.2% among those aged ≥65 years. CKD is particularly common among individuals with diabetes—the overall prevalence of 43.5% in the type 2 diabetes population and 61.0% in those aged ≥65—due to the complex and mutually reinforcing pathophysiological connections between these conditions (Bailey et al., 2014; Kumar et al., 2023). The co-existence of diabetes and CKD is linked to a substantial increase in disease burden, cardiovascular complications, healthcare costs, unmet healthcare needs, and mortality (Birkeland et al., 2020; Fried et al., 2023; Ostrominski et al., 2023; Vijay et al., 2022).

Depressive symptoms are common in patients with diabetes and/or CKD, especially those in advanced stages of the disease (Adejumo et al., 2024; Cheng et al., 2025). The high prevalence of depression is understandable given the biopsychosocial stressors, including inflammation, vascular burden, and the strain of managing these conditions alongside other related comorbidities. Research has also suggested bidirectional relationships between depression and both diabetes and CKD, that is, unremitting and increasing depressive symptoms are associated with higher risks of developing and worsening these conditions (Burns et al., 2025; Han et al., 2025; Liu M. et al., 2022; Zhao, L. et al., 2026; Zheng et al., 2024).

Depression in older adults with chronic illnesses is a significant public health concern because it interferes with their self-management of these illnesses and is associated with poorer physical and cognitive functioning, reduced quality of life, and increased healthcare utilization and mortality (Alexandre et al., 2021; Chow et al., 2022; Lyu et al., 2023; Hoogendoorn et al., 2022; Zhou, X. et al., 2026). In older adults with diabetes, depression is also associated with poorer glycemic control and complications, accelerated disability progression, cognitive impairment, and higher risks of all-cause and cardiovascular mortality (Xu et al., 2025; Yang & Xing, 2024; Yoon, 2024; Zhang, Z. et al., 2025). Studies have documented similar adverse effects of depression among individuals with CKD (Chang et al., 2022; Zhao, J. et al., 2025; Zhou T. et al., 2024). Given the significant adverse effects of depression on older adults with diabetes and/or CKD, identifying strategies to alleviate depressive symptoms in this population is critically important.

One pathway through which depressive symptoms may be linked to poorer health outcomes in older adults with diabetes and/or CKD is its impact on physical activity (PA), a key health behavior recommended for the nonpharmacologic management of diabetes. PA has consistently been associated with a range of positive outcomes, including improved metabolic regulation, reduced inflammation, improved glycemic control, better cardiovascular health, and greater psychological well-being in diabetes (Al-Mhanna et al., 2024; Kanaley et al., 2022; Ribeiro et al., 2023; Shah et al., 2021) and CKD (Bishop et al., 2023; Gollie et al., 2024) patients. PA and depressive symptoms appear to influence each other in a mutually reinforcing manner. Prior research has shown that depressive symptoms are associated with lower levels of PA among older adults in general, whereas insufficient PA may, in turn, exacerbate depressive symptoms (Huang et al., 2025; Ramos-Jimenez et al., 2025; Wang et al., 2024; Zhang, S. et al., 2021). Among older adults with diabetes or CKD, the burden of chronic disease, such as fatigue and functional limitations, combined with depressive symptoms, may further reduce motivation and energy for PA, leading to lower activity levels (Lyu et al., 2023). Thus, depression may adversely influence health outcomes in patients with diabetes and/or CKD partly through reduced engagement in PA.

Despite these interrelationships, limited research has examined how depressive symptoms, comorbid diabetes and CKD, and engagement in physical activity intersect in later life. Diabetes-related CKD represents a common and clinically consequential multimorbidity cluster, yet little is known about how coexisting diabetes and CKD, together with engagement in PA, are associated with depressive symptom severity among older adults. In this study, using data from the 2011–2023 cycles of NHANES, we examined the associations of depressive symptoms with diabetes and/or CKD status and PA among adults aged ≥50. Specifically, we analyzed whether diabetes alone, CKD alone, and the co-existence of both conditions, as well as engagement in recommended levels of aerobic PA, were associated with depressive symptom severity.

Study hypotheses were as follows: (H1) compared with individuals without diabetes or CKD, those with diabetes alone, CKD alone (especially in advanced stages), and coexisting diabetes-CKD would report significantly higher depressive symptoms, with the highest levels among those with both conditions; (H2) individuals meeting the recommended PA guidelines would have significantly lower depressive symptoms than those not meeting the guidelines; and (H3) the association between engagement in recommended levels of PA and depressive symptom severity would vary across diabetes-CKD groups, potentially reflecting differences in disease burden. Covariates included sociodemographic variables and other comorbidities (cardiovascular disease, lung disease, and arthritis) common among older adults with diabetes and/or CKD. The findings of this study provide population-level evidence on the associations between depressive symptoms, chronic disease burden, and PA among older U.S. adults with diabetes and/or CKD. Understanding how depressive symptoms, multiple chronic conditions, and engagement in PA are interrelated in later life is critical for informing behavioral and psychosocial interventions in aging populations.

Methods

Data Source and Sample

The U.S. NHANES (https://wwwn.cdc.gov/nchs/nhanes/) is a biennial, nationally representative, and cross-sectional survey of the civilian, noninstitutionalized population, conducted to assess the population’s health and nutritional status by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention. Data are collected through in-home interviews, physical examinations, and laboratory assessments. Since data collection for the 2019–2020 cycle was not completed when NHANES suspended field operations in March 2020 due to the COVID-19 pandemic, the data collected during the time period were combined with data from the 2017–2018 cycle to form a nationally representative NHANES 2017-March 2020 pre-pandemic dataset, accompanied by appropriate survey weights.

The analytic sample in this study was restricted to adults aged ≥50 who completed the examination component and had available laboratory data required to define diabetes (glycohemoglobin (HbA1c) and fasting serum glucose) and CKD (serum creatinine-based eGFR and UACR). Figure 1 illustrates the sample selection process for the analytic samples derived from pooled NHANES 2011–2023 data.

Figure 1.

Sample selection flowchart for the analytic sample, NHANES 2011–2023

Measures

Depressive Symptoms

Depressive symptoms were measured with the Patient Health Questionnaire-9 (PHQ-9), a self-report depression module of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 rates each of the 9 DSM-IV criteria from “0” (not at all) to “3” (nearly every day), using the past 2 weeks as the time frame. The PHQ-9 was not administered to participants needing a proxy informant or interpreter due to the sensitive nature of the questions. In multivariable analyses, PHQ-9 was modeled as a continuous variable to retain information across the full symptom spectrum and avoid loss of statistical power. PHQ-9 scores >10 were used in sensitivity analyses, as they are commonly considered indicative of clinically significant depressive symptoms, with both sensitivity and specificity of 88% for detecting major depression (Kroenke et al., 2001).

Diabetes and Chronic Kidney Disease (CKD)

In NHANES, participants were classified as having diabetes if they met any of the following conditions: (1) self-reported provider diagnosis of diabetes, (2) HbA1c ≥ 6.5%, or (3) fasting serum glucose ≥126 mg/dl (≥7.0 mmol/L, ≥8 hours fasting). NHANES does not allow definitive differentiation between type 1 and type 2 diabetes. Although some misclassification is possible, the prevalence of type 1 diabetes among adults aged ≥50 is low, and findings are therefore most applicable to individuals with type 2 diabetes.

CKD was assessed using eGFR and albuminuria in accordance with the Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group clinical practice guidelines (KDIGO, 2024). eGFR was calculated from standardized serum creatinine measurements using the 2021 Chronic Kidney Disease Epidemiology Collboration (CKD-EPI) race-free equation (Charles et al., 2024) with the following categories: G1 (≥90 ml/min/1.73 m²), G2 (60–89 ml/min/1.73 m²), G3a (45–59 ml/min/1.73 m²), G3b (30–44 ml/min/1.73 m²), G4 (15–29 ml/min/1.73 m²), and G5 (<15 ml/min/1.73 m²). Albuminuria was assessed using the urine albumin-to-creatinine ratio (UACR) derived from spot urine samples and categorized according to KDIGO thresholds as A1 (<30 mg/g), A2 (30–299 mg/g), and A3 (≥300 mg/g). CKD was defined as eGFR <60 ml/min/1.73 m² (i.e., G3a through G5) or eGFR ≥60 ml/min/1.73 m² and a UACR ≥30 mg/g (i.e., A2 or A3). In this study, we grouped CKD into two categories: CKD stages 1–2 (eGFR ≥60 ml/min/1.73 m² and UACR ≥30 mg/g) and CKD stages 3–5 (eGFR <60 ml/min/1.73 m²). Based on diabetes and CKD stages, we created the following diabetes-CKD status groups: (1) no diabetes or CKD; (2) diabetes only (without CKD); (3) CKD stages 1–2 only (without diabetes); (4) CKD stages 3–5 only (without diabetes); and (5) coexisting diabetes-CKD (with CKD of any stage).

Physical Activity (PA)

In NHANES, PA was self-reported using the Global Physical Activity Questionnaire (He et al., 2022). Prior to the 2021–2023 cycle, NHANES collected the frequency, duration, and intensity (moderate or vigorous) of domain-specific activities (occupational, transportation, and leisure-time) during a typical week. Because the 2021–2023 cycle included only leisure-time activities, this study focused on leisure-time moderate- and vigorous-intensity PA (e.g., exercise, sports, or physically active hobbies). Current aerobic PA guidelines recommend at least 150 minutes/week of moderate-intensity activity, or 75 minutes/week of vigorous-intensity activity, or an equivalent combination. Weekly minutes of moderate- and vigorous-intensity activity were calculated by multiplying reported days per week by minutes per day. Consistent with federal guidelines, moderate-equivalent PA minutes were computed as minutes of moderate activity plus twice the minutes of vigorous activity. Participants were categorized as inactive (0 minutes/week), insufficiently active (<150 minutes/week), or meeting PA guidelines (≥150 minutes/week). Based on preliminary analyses, a binary variable indicating meeting versus not meeting PA guidelines was used in multivariable models.

Covariates

Covariates included both sociodemographic and comorbidity variables. These were chronological age, gender (female vs. male), race/ethnicity (non-Hispanic Whites, Black, Hispanic, and Asian/Other), level of education (college degree vs. no degree), ratio of monthly family income to the poverty line (≤185%, >185%, and refused/don’t know/missing (noted as missing)), marital status (married/living with a partner vs. not married/not living with a partner), cardiovascular disease (any heart disease or stroke), lung disease, and arthritis (yes = 1, no = 0 for each). Health insurance coverage and mental health professional visits were reported for descriptive purposes only.

Analysis

All analyses were conducted using Stata/MP version 19.5 (College Station, TX) with survey (svy) procedures to account for the complex NHANES sampling design, incorporating mobile examination component (MEC) sampling weights, strata, and primary sampling units. MEC weights were used because diabetes and CKD measurements were obtained during the mobile examination component. Sampling weights were recalculated and combined across the 2011–2023 NHANES cycles, in accordance with the NCHS analytic guidelines, to produce nationally representative estimates.

First, we used χ² tests and analysis of variance (ANOVA) to compare sociodemographic characteristics, comorbidities, depressive symptoms, and PA engagement across diabetes-CKD status groups: no diabetes or CKD, diabetes only, CKD stages 1–2 only, CKD stages 3–5 only, and coexisting diabetes-CKD.

Second, to test H1 and H2 (associations of depressive symptoms with diabetes-CKD status and PA), we fitted two linear regression models with the PHQ-9 score as the dependent variable. In Model 1, we adjusted for sociodemographic variables only. In Model 2, we additionally adjusted for comorbid conditions (cardiovascular disease, lung disease, and arthritis). Following Model 2, we conducted post-estimation pairwise comparisons of adjusted predictive margins to examine differences in depressive symptom severity across five diabetes-CKD status groups. Multicollinearity, using variance inflation factors >2.5 (Allison, 2012), was not a concern. Linear regression results were reported as unstandardized regression coefficients (B) and standard errors (SE).

Third, to test H3 (whether the association between depressive symptoms and PA differed across diabetes-CKD status groups), we fitted a linear regression model (Model 3) that included interaction terms between the diabetes-CKD status group and PA engagement. To facilitate interpretation of the interaction, we calculated adjusted predictive margins for each diabetes-CKD and PA group and generated margins plots to visualize differences in predicted PHQ-9 scores across groups.

For sensitivity analysis, we ran logistic regression for Models 2 and 3 with PHQ-9 ≥10 as the dependent variable, with the results reported as adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Statistical significance was set at p < .05.

Results

Characteristics of Older Adults by Diabetes-CKD Status Group

Table 1 shows that among individuals aged ≥50, 13.9% had diabetes without CKD, 13.4% had CKD without diabetes (5.8% with stage 1–2 CKD and 7.6% with stage 3–5 CKD), and 9.0% had coexisting diabetes-CKD. Those with CKD stages 3–5 only and those with coexisting diabetes-CKD were older than the other groups. The two CKD-only groups had higher proportions of women. The diabetes only and coexisting diabetes-CKD groups included higher proportions of Black and Hispanic individuals. The coexisting diabetes-CKD group had a lower proportion of individuals with a college education and a higher proportion with income <185% of the poverty line. The co-morbidity burden, especially cardiovascular diseases, was highest among those with coexisting diabetes-CKD, followed by those with CKD stages 3–5.

Table 1.

Characteristics among the 50+ age group by diabetes-CKD status

	No diabetes or CKD (0)	Diabetes only (1)	CKD stages 1–2 only (2)	CKD stages 3–5 only (3)	Coexisting diabetes & CKD (4)	P Among	P Among
N (%)	7,738 (63.7)	2,202 (13.9)	874 (5.8)	1,170 (7.6)	1,626 (9.0)	(0)-(4)	(1)-(4)
Age, M (SE)	61.9 (0.17)	63.3 (0.25)	65.5 (0.42)	72.2 (0.37)	67.7 (0.38)	<.001	<.001
Age group, %						<.001	<.001
50–64	65.2	58.6	49.4	19.8	37.1
65+	34.8	41.4	50.6	80.2	62.9
Female, %	54.0	44.3	56.2	63.5	46.8	<.001	<.001
Race/ethnicity, %						<.001	<.001
Non-Hispanic White	76.6	63.0	70.1	79.4	63.5
Black	7.2	11.9	12.5	12.9	14.8
Hispanic	9.5	15.6	8.9	3.9	11.8
Asian/other	6.7	9.5	8.5	3.8	9.9
Married/cohabiting, %	67.5	65.5	56.4	53.4	57.7	<.001	<.001
College degree, %	35.6	25.0	26.9	24.7	18.0	<.001	.007
Income to poverty ratio, %						<.001	.004
≤185% of the poverty line	25.0	33.5	32.7	33.4	40.7
>185% of the poverty line	68.0	59.2	61.5	59.8	51.4
Missing	7.0	7.3	5.8	6.7	7.9
Health insurance coverage, %	91.6	92.8	90.3	96.9	93.0	<.001	<.001
Saw a mental health professional, %	8.7	8.6	6.9	8.7	8.8	.763	.614
Cardiovascular disease, %	10.4	23.1	19.3	30.5	39.2	<.001	<.001
Lung disease, %	9.1	15.0	17.0	14.2	19.8	<.001	.040
Arthritis, %	42.6	50.1	47.3	57.7	53.5	<.001	<.001
PHQ-9, M (SE)	2.8 (0.07)	3.6 (0.13)	3.3 (0.22)	3.3 (0.14)	4.0 (0.15)	<.001	<.001
PHQ-9 ≥10, %	7.1	10.8	9.4	7.8	12.7	<.001	<.001
Leisure-time PA, %						<.001	<.001
Inactive	41.0	52.2	52.0	53.8	64.2
Insufficient	20.2	18.8	17.0	16.9	15.1
Meeting recommended PA guidelines	38.8	29.0	31.0	29.3	20.7

Note. P-values were calculated based on Pearson’s χ² tests for categorical variables and ANOVA for the PHQ-9 scores and denote the differences among groups.

Depressive symptoms were higher among the diabetes-only group and the coexisting diabetes-CKD group, with a little over 1 in 10 in each group showing clinically significant depressive symptom severity (PHQ-9 ≥10). Despite their higher depressive symptoms, these two groups did not differ from the other groups in mental health professional visits. The diabetes-only group and the coexisting diabetes-CKD group also had the lowest proportions of individuals meeting PA guidelines (29.0% and 20.7%, respectively). Almost two-thirds of those with coexisting diabetes-CKD were inactive, meaning they engaged in 0 minutes of PA.

Associations of Depressive Symptoms With Diabetes-CKD Status and PA: Multivariable Regression Results

Model 1 in Table 2 shows that, after adjusting for sociodemographic variables, diabetes only (B = 0.65, SE = 0.14, p < .001), CKD stages 3–5 only (B = 0.46, SE = 0.16, p < .001), and coexisting diabetes-CKD (B = 0.99, SE = 0.17, p < .001) were associated with higher depressive symptom (PHQ-9) scores than in the absence of either condition. Meeting PA guidelines was associated with a nearly 1-point lower PHQ-9 score (B = −0.98, SE = 0.10, p < .001).

Table 2.

Associations of depressive symptoms with diabetes-CKD status and meeting physical activity (PA) guidelines: Linear regression results

	Model 1			Model 2			Model 3 (interaction model)
	B (SE)	t	p	B (SE)	t	p	B (SE)	t	p
Diabetes-CKD status: Vs. no diabetes or CKD
Diabetes only	0.65 (0.14)	4.65	<.001	0.38 (0.14)	2.75	.007	0.44 (0.18)	2.43	.017
CKD stages 1–2 only	0.33 (0.20)	1.66	.101	0.19 (0.19)	0.98	.330	0.16 (0.25)	0.61	.541
CKD stages 3–5 only	0.46 (0.16)	2.89	.005	0.26 (0.16)	1.62	.109	0.09 (0.19)	0.48	.631
Coexisting diabetes and CKD	0.99 (0.17)	5.78	<.001	0.58 (0.17)	3.53	.001	0.55 (0.19)	2.81	.006
Meeting the PA guideline vs. not meeting	−0.98 (0.10)	−10.21	<.001	−0.86 (0.10)	−8.92	<.001	−0.89 (0.12)	−7.64	<.001
Diabetes-CKD status x PA: Vs. no diabetes or CKD & not meeting PA guideline
Diabetes only x meeting the PA guideline							−0.20 (0.27)	−0.75	.455
CKD stages 1–2 x meeting the PA guideline							0.10 (0.38)	0.25	.806
CKD stages 3–5 x meeting the PA guideline							0.55 (0.27)	2.07	.042
Coexisting diabetes and CKD x meeting the PA guideline							0.14 (0.30)	0.48	.633
Age	−0.04 (0.01)	−8.21	<.001	−0.06 (0.01)	−11.89	<.001	−0.06 (0.01)	−11.81	<.001
Female vs. male	0.80 (0.10)	7.96	<.001	0.69 (0.10)	7.04	<.001	0.69 (0.10)	7.05	<.001
Race/ethnicity: Non-Hispanic White
Black	−0.49 (0.13)	−3.72	<.001	−0.35 (0.12)	−2.81	.006	−0.35 (0.12)	−2.82	.006
Hispanic	−0.02 (0.13)	−0.13	.898	0.26 (0.12)	2.11	.038	0.26 (0.12)	2.08	.040
Asian/other	−0.21 (0.16)	−1.25	.215	−0.07 (0.15)	−0.49	.624	−0.08 (0.15)	−0.50	.621
Married/cohabiting vs. not married/cohabiting	−0.83 (0.12)	−6.65	<.001	−0.76 (0.13)	−6.04	<.001	−0.76 (0.13)	−6.00	<.001
College degree vs. no degree	−0.61 (0.10)	−5.81	<.001	−0.42 (0.10)	−4.19	<.001	−0.42 (0.10)	−4.17	<.001
Income: vs. ≤ 185% of the poverty line
>185% of the poverty line	−1.14 (0.14)	−8.27	<.001	−1.02 (0.13)	−7.65	<.001	−1.02 (0.13)	−7.68	<.001
Missing	−0.93 (0.16)	−5.79	<.001	−0.83 (0.15)	−5.39	<.001	−0.84 (0.16)	−5.41	<.001
Cardiovascular disease vs. no cardiovascular disease				1.07 (0.14)	7.67	<.001	1.08 (0.14)	7.68	<.001
Lung disease vs. no lung disease				1.15 (0.16)	7.34	<.001	1.16 (0.16)	7.34	<.001
Arthritis vs. no arthritis				1.29 (0.10)	13.52	<.001	1.29 (0.10)	13.55	<.001
	N = 13,610; population size = 95.2 million; design df = 87;			N = 14,105; population size = 98.2 million; design df = 87;			N = 14,105; population size = 98.2 million; design df = 87;
	F (14,74) = 54.64; p < .001; R² = 0.09			F (17,71) = 32.50; p < .001; R² = 0.13			F (21,67) = 50.38; p < .001; R² = 0.13

Note. Interaction terms represent the difference in the association between meeting PA guidelines and depressive symptom severity for each diabetes-CKD group relative to the reference group (no diabetes or CKD).

Model 2 shows that after additionally adjusting for other comorbidities, the association between diabetes and depressive symptoms attenuated but remained statistically significant (B = 0.38, SE = 0.14, p = .007). In contrast, CKD stages 3–5 were no longer significantly associated with PHQ-9 score. Coexisting diabetes-CKD remained associated with higher depressive symptoms, although the magnitude of the association was also reduced (B = 0.58, SE = 0.17, p = .001). Meeting PA guidelines remained significantly associated with lower depressive symptoms (B = −0.86, SE = 0.10, p < .001).

Post-estimation pairwise comparisons of adjusted predictive margins showed that the difference in depressive symptoms between individuals with coexisting diabetes-CKD and those with diabetes only was not statistically significant (contrast = 0.20, SE = 0.18, t = 1.10, p = .273). Similarly, none of the other pairwise comparisons among the diabetes-CKD status groups were statistically significant, indicating that the predicted PHQ-9 scores did not differ significantly among these disease groups after adjustment for covariates.

Model 3 in Table 2 includes interaction terms between diabetes-CKD status group and engagement in recommended PA, and shows that meeting PA guidelines was associated with lower depressive symptom severity in the reference group (no diabetes or CKD; B = −0.89, SE = 0.12, p < .001). A significant interaction was observed for CKD stages 3–5 (B = 0.55, SE = 0.27, p = .042), indicating that the inverse association between PA and depressive symptoms was weaker in this group, compared to the reference group. The interaction was not significant among participants with diabetes only, CKD stages 1–2 only, or coexisting diabetes-CKD.

Adjusted predictive margins (Figure 2) indicate that meeting PA guidelines was associated with lower predicted PHQ-9 scores across all groups; however, the difference between those meeting and not meeting PA guidelines was smaller among individuals with CKD stages 3–5 only.

Figure 2.

Adjusted predicted PHQ-9 scores by diabetes/CKD status among meeting PA guidelines

With respect to covariates in the fully adjusted model, older people, Black (vs. non-Hispanic White) individuals, married people, college-educated individuals, and those having income ≥185% of the poverty line had lower PHQ-9 scores, whereas females, Hispanic people, and those with cardiovascular disease, lung disease, or arthritis had higher PHQ-9 scores.

Sensitivity analyses with PHQ-9 ≥10 (yes vs. no) as the outcome yielded similar patterns of associations (Supplemental Table S1). In the fully adjusted model, coexisting diabetes-CKD was associated with higher odds of clinically significant depressive symptoms (OR = 1.36, 95% CI = 1.04–1.77). Diabetes alone showed a marginally significant association (OR = 1.26, 95% CI = 0.98–1.61). CKD alone was not significantly associated with the outcome. Meeting versus not meeting the PA guidelines was associated with significantly lower odds of PHQ-9 ≥10 (OR = 0.49, 95% CI = 0.39–0.63). In the model with interaction terms, the protective association of meeting PA guidelines was significantly attenuated among individuals with CKD stages 3–5 (interaction OR = 2.61, 95% CI = 1.30–5.22) and among those with coexisting diabetes-CKD (interaction OR = 2.10, 95% CI = 1.23–3.59), indicating that the inverse association between meeting PA guidelines and clinically significant depressive symptoms was weaker among individuals with advanced CKD and those with coexisting diabetes-CKD, compared with individuals without diabetes or CKD. The results of these analyses provide partial support for H1–H3.

Discussion

Using nationally representative data, we examined the associations of depressive symptoms with diabetes-CKD status and engagement in PA in U.S. adults aged ≥50. By simultaneously examining depression, diabetes, CKD severity, and PA, this study provides new population-level evidence of the interplay among mental health, chronic disease burden, and health behaviors in later life.

Descriptive data showed that, compared to those without diabetes and CKD, depressive symptoms were higher among the four diabetes-CKD status groups, with the highest symptom severity among those with co-existing diabetes and CKD. Also, significantly smaller proportions of individuals with diabetes and/or CKD were engaged in recommended PA levels, with the lowest proportion among those with co-existing diabetes and CKD. These patterns are consistent with prior research suggesting that mental health, chronic physical conditions, and health behaviors are closely interconnected in later life, such that comorbid diabetes and CKD may further increase vulnerability to depressive symptoms while also limiting engagement in protective behaviors such as PA (Egede & Ellis, 2010; Katon, 2011).

Multivariable regression results also showed that compared to individuals without diabetes and CKD, individuals with diabetes (regardless of CKD status) had higher depressive symptoms. These findings align with previous studies, summarized earlier, documenting an increased risk of depression among individuals living with diabetes, likely due to the cumulative burden of disease management, functional limitations, and concerns about long-term complications. Importantly, however, post-estimation comparisons indicated no statistically significant difference between diabetes alone and coexisting diabetes-CKD or CKD alone after adjusting for sociodemographic factors and other comorbidities. These findings do not indicate a clear gradient in depressive symptoms across diabetes-CKD combinations. Although coexisting health conditions may play a role, the study did not directly assess multimorbidity burden; therefore, this interpretation remains speculative. Future studies incorporating validated measures of multimorbidity and illness burden are needed to clarify these relationships. From a psychosocial perspective, this pattern may also reflect the cumulative burden of living with chronic illness in later life, where shared challenges such as symptom burden, treatment demands, and functional limitations may outweigh differences across specific disease combinations in shaping depressive symptom experiences.

Multivariable models further showed a consistent inverse relationship between depressive symptoms and meeting PA guidelines, even after adjusting for sociodemographic factors and other major comorbid conditions. Compared to individuals who did not meet the guidelines, those who met the guidelines had significantly lower PHQ-9 scores and lower odds of clinically significant depressive symptoms. However, the examination of interaction effects showed that the association was weaker among individuals with advanced CKD (stages 3–5) or co-existing diabetes-CKD, suggesting that the relationship between depressive symptoms and PA may be moderated by functional limitations and symptom severity associated with advanced disease. Since advanced CKD is often accompanied by fatigue, anemia, reduced physical endurance, and functional limitations (Karnabi et al., 2023), the psychological benefits typically associated with PA may be limited in this population. Nevertheless, prior research has shown PA’s positive effects on health outcomes, including kidney function and mortality (Hoshino et al., 2024; Rampersad et al., 2021).

The overall findings indicate that the inverse association between depressive symptoms and PA persists even among individuals with complex chronic conditions, providing further support for the importance of PA for mental health in later life among older adults with diabetes and/or CKD. Regular exercise among people, regardless of age, can reduce systemic inflammation and levels of pro-inflammatory cytokines, potentially alleviating depressive symptoms associated with inflammation; help in regulating circadian rhythms that are often disrupted in individuals with depression; and improve sleep patterns, thus improving mood and energy levels (Hossain et al., 2024; Vanderlinden et al., 2020).

Regular PA has also been shown to improve metabolic regulation and enhance neurobiological processes such as endorphin release and neurotrophic signaling (Chen and Nakagawa, 2023; Clemente-Suárez et al., 2024; Matei et al., 2023), all of which may contribute to improved mood and reduced depressive symptoms. In addition, engagement in PA has been shown to reduce cognitive decline among older adults with diabetes (Rabinowitz et al., 2023; Ren et al., 2025; Wang et al., 2025), reduce the risk of falls (Oh and Ylitalo, 2023), and enhance psychosocial resources such as self-efficacy, self-esteem, and life satisfaction (Toros et al., 2023). Engagement in PA may also reflect broader self-regulatory capacity and coping resources, which are often diminished in the presence of depressive symptoms. These benefits may be especially important for individuals with diabetes and/or CKD experiencing functional limitations and psychosocial stressors.

Our findings also point out that, consistent with prior research, sociodemographic factors and other major chronic conditions (e.g., cardiovascular disease, lung disease, and arthritis) are associated with depressive symptoms. The lower depressive symptoms among older people, Black individuals, married people, and those with a college education, and higher depressive symptoms in women and Hispanic older adults have been well documented in previous studies of general older adults (Liu and Lin, 2024; Mohebbi et al., 2019).

The study has the following limitations. First, the cross-sectional data preclude causal inference regarding the temporal ordering of depressive symptoms, diabetes-CKD status, and PA; the findings should be interpreted as reflecting associations rather than causal relationships. Second, self-reported PA may have been subject to recall or social desirability bias and misclassification of activity levels. Third, although we adjusted for a range of sociodemographic characteristics and major chronic conditions, residual confounding from unmeasured factors such as disease duration, medication use, pain severity, or functional limitations may remain. Fourth, CKD status was defined based on laboratory measurements from a single examination cycle, which may not fully capture CKD persistence over time. Fifth, CKD stages 3–5 were combined into a single category, which may have obscured important heterogeneity across advanced CKD stages, limiting the granularity of interpretation. Future studies with larger samples should examine stage-specific associations to better characterize potential differences across CKD severity.

Despite these limitations, the use of a large nationally representative sample and standardized measures strengthens the generalizability of the findings, with the following clinical and research implications. First, the high prevalence of depression, especially among older adults with diabetes and those with co-existing diabetes and CKD, underscores the importance of timely detection and management of depression among these older adults in both primary and specialty care settings. Second, all older adults with chronic conditions need support and guidance to engage in regular PA. Integrating mental health assessment with PA education and promotion is crucial, as depressive symptoms can impair individuals’ ability and motivation to initiate and sustain engagement in PA. The attenuated association observed among individuals with advanced CKD further suggests that tailored PA approaches may be needed for those with a greater disease burden. Promoting safe and accessible PA opportunities is an important strategy for supporting both the physical and mental health of older adults with chronic conditions. Third, these findings underscore the importance of addressing mental health and health promotion activities simultaneously in efforts to improve health outcomes among older adults with complex chronic conditions. Future research should also examine longitudinal relationships and intervention strategies to better understand how different types and intensities of PA could improve mental health outcomes among older adults with complex chronic conditions.

Supplemental Material

Supplemental Material - Associations of Depressive Symptoms With Diabetes, Chronic Kidney Disease, and Physical Activity in Later Life

Supplemental Material for Associations of Depressive Symptoms With Diabetes, Chronic Kidney Disease, and Physical Activity in Later Life by Namkee G. Choi, Emma Stanmore, and Elizabeth C. Lorenz in Journal of Aging and Health.

Footnotes

ORCID iD

Namkee G. Choi

Ethics Considerations

Ethical approval was not required for the study involving humans because the analysis of the de-identified secondary data was exempt from the human subjects ethics review requirement of the authors’ Institutional Review Boards.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors declare that financial support was received for the research and/or publication of this article. This research was supported by grant, P30AG066614, awarded to the Center on Aging and Population Sciences at The University of Texas at Austin by the National Institute on Aging. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data analyzed in this study are in the public domain and available at .

Supplemental Material

Supplemental Material for this article is available online.

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