Health-promoting lifestyle in cardiac patients: The mediating role of cognitive flexibility in the relationship between intimate relationships and distress tolerance

Document Type : Original Article

Authors

1 Department of Psychology, Ra.C., Islamic Azad University, Rasht, Iran

2 Department of Psychology, Payame Noor University, Tehran, Iran

10.48305/arya.2025.45677.3105
Abstract
BACKGROUND: The present study aimed to determine the predictive model of health-promoting lifestyle in cardiovascular patients based on intimate relationships and distress tolerance, mediated by cognitive flexibility.
METHODS: The research design was a cross-sectional correlational study using structural equation modeling. The statistical population included cardiovascular patients in 2025 who referred to three specialized cardiology clinics for outpatient examination. A total of 265 individuals were selected as the sample using convenience sampling. Standard questionnaires for health-promoting behaviors (Walker et al.), social intimacy (Miller and Lefcourt), distress tolerance (Simons and Gaher), and cognitive flexibility (Dennis and Vander Wal) were used. Statistical data analysis was performed using the Pearson correlation coefficient and path analysis with bootstrap testing, employing AMOS 24 and SPSS 26 software. 
RESULTS: The results of path analysis and bootstrap testing showed that the proposed model had a good statistical fit (χ²/df = 2.94, RMSEA = 0.071, CFI = 0.939, GFI = 0.990). The indirect effect of intimate relationships on health-promoting lifestyle through cognitive flexibility (β = 0.1148, p = 0.001) and the indirect effect of distress tolerance on health-promoting lifestyle through cognitive flexibility (β = 0.0924, p = 0.001) were confirmed.
CONCLUSION: The structural model, with good fit, explained the mediating role of cognitive flexibility in the relationship between intimate relationships and distress tolerance with health-promoting lifestyle in cardiovascular patients. These findings provide an operational framework for psychotherapy interventions based on strengthening distress tolerance and interpersonal relationships to improve cardiovascular health.

Keywords


1. Afjeh-Dana E, Naserzadeh P, Moradi E, Hosseini N, Seifalian AM, Ashtari B. Stem Cell Differentiation into Cardiomyocytes: Current Methods and Emerging Approaches. Stem Cell Rev Rep. 2022 Dec;18(8):2566-92. https://doi.org/10.1007/s12015-021-10280-1
2. Mayo NL, Russell HA, Holt K, Williams GC. Implementation of a self-determination based clinical program to reduce cardiovascular disease risk. J Health Psychol. 2022 Nov;27(13):2898-908. https://doi.org/10.1177/13591053211068124
3. Netala VR, Teertam SK, Li H, Zhang Z. A Comprehensive Review of Cardiovascular Disease Management: Cardiac Biomarkers, Imaging Modalities, Pharmacotherapy, Surgical Interventions, and Herbal Remedies. Cells. 2024 Sep 1;13(17):1471. https://doi.org/10.3390/cells13171471
4. Liao W, Liu X, Kang N, Song Y, Yuchi Y, Hu Z, et al. Associations between healthy lifestyle score and health-related quality of life among Chinese rural adults: variations in age, sex, education level, and income. Qual Life Res. 2023 Jan;32(1):81-92. https://doi.org/10.1007/s11136-022-03229-5
5. Svenšek A, Štiglic G, Lorber M. Validation of a Slovenian version of the Healthy Lifestyle and Personal Control Questionnaire (HLPCQ) for use with patients in family medicine. BMC Public Health. 2025 May 14;25(1):1778. https://doi.org/10.1186/s12889-025-22945-4
6. Golaszewski NM, LaCroix AZ, Godino JG, Allison MA, Manson JE, King JJ, et al. Evaluation of Social Isolation, Loneliness, and Cardiovascular Disease Among Older Women in the US. JAMA Netw Open. 2022 Feb 1;5(2):e2146461. https://doi.org/10.1001/jamanetworkopen.2021.46461
7. Li Y. The study of psychology and intimate relationships. J Educ Educ Res. 2024;7(1): 146-8. https://doi.org/10.54097/nkgaz709
8. Smith TW. Intimate Relationships and Coronary Heart Disease: Implications for Risk, Prevention, and Patient Management. Curr Cardiol Rep. 2022 Jun;24(6):761-74. https://doi.org/10.1007/s11886-022-01695-4
9. Cornelius T, Birk JL, Edmondson D, Schwartz JE. Romantic Relationship Satisfaction and Ambulatory Blood Pressure During Social Interactions: Specificity or Spillover Effects? Ann Behav Med. 2019 Mar 1;53(3):223-31. https://doi.org/10.1093/abm/kay030
10. Yang Z, Liu C, He L, Zhao H, Jian J, Chen H, et al. Social isolation and loneliness increase the risk of coronary heart disease: Insights from a prospective cohort study. Soc Sci Med. 2025 Feb;366:117701. https://doi.org/10.1016/j.socscimed.2025.117701
11. Bouchard K, Gareau A, Greenman PS, Lalande K, Sztajerowska K, Tulloch H. What’s love got to do with it? Relationship quality appraisals and quality of life in couples facing cardiovascular disease. Health Psychol Behav Med. 2023 Jul 18;11(1):2237564. https://doi.org/10.1080/21642850.2023.2237564
12. Lopez MM, Naragon-Gainey K, Conway CC. Defining distress tolerance in a structural model of Big Five personality domains. J Pers. 2025 Jun;93(3):567-80. https://doi.org/10.1111/jopy.12952
13. Melli G, Chiorri C, Lebruto A, Drabik MJ, Puccetti C, Caccico L. Psychometric properties of the Italian version of the Distress Tolerance Scale (DTS). J Psychopathol Behav Assess. 2021;43:698-706. https://doi.org/10.1007/s10862-021-09876-1
14. Roohi R, Soltani AA, Zinedine Meimand Z, Razavi Nematollahi V. The Effect of Acceptance and Commitment Therapy (ACT) on Increasing the Self-Compassion, Distress Tolerance, and Emotion Regulation in Students with Social Anxiety Disorder. J Child Ment Health. 2019;6(3):173-87. http://dx.doi.org/10.29252/jcmh.6.3.16
15. Onyedibe MCC, Ibeagha PN, Onyishi IE. Distress tolerance moderates the relationship between anger experience and elevated blood pressure. S Afr J Psychol. 2020;50:39-53. https://doi.org/10.1177/0081246319832540
16. Asgari P, Bozorgi ZD. The effectiveness of healthy lifestyle training and existential therapy on distress tolerance, health concerns and blood pressure in elderly people with hypertension. Curr Psychol. 2023;42:13951-9. https://doi.org/10.1007/s12144-021-02647-x
17. Hahad O, Kerahrodi JG, Brähler E, Lieb K, Gilan D, Zahn D, et al. Psychological resilience, cardiovascular disease, and mortality - Insights from the German Gutenberg Health Study. J Psychosom Res. 2025 May;192:112116. https://doi.org/10.1016/j.jpsychores.2025.112116
18. Oosterhuis EJ, Slade K, May PJC, Nuttall HE. Toward an Understanding of Healthy Cognitive Aging: The Importance of Lifestyle in Cognitive Reserve and the Scaffolding Theory of Aging and Cognition. J Gerontol B Psychol Sci Soc Sci. 2023 May 11;78(5):777-88. https://doi.org/10.1093/geronb/gbac197
19. Uddin LQ. Cognitive and behavioural flexibility: neural mechanisms and clinical considerations. Nat Rev Neurosci. 2021 Mar;22(3):167-79. https://doi.org/10.1038/s41583-021-00428-w
20. Friedman NP, Robbins TW. The role of prefrontal cortex in cognitive control and executive function. Neuropsychopharmacology. 2022 Jan;47(1):72-89. https://doi.org/10.1038/s41386-021-01132-0
21. Mousavi SS, Nadri M, Amiri M, Radfar F, Farokhcheh M. The predictive role of psychological flexibility and cognitive emotion regulation strategies on depression, anxiety and stress in type 2 diabetic patients. Middle East J Disabil Stud. 2016;9.
22. Hohl K, Dolcos S. Measuring cognitive flexibility: A brief review of neuropsychological, self-report, and neuroscientific approaches. Front Hum Neurosci. 2024 Feb 19;18:1331960. https://doi.org/10.3389/fnhum.2024.1331960
23. Buechner BM, Clarkson JJ, Otto AS, Ainsworth G. Political ideology and cultural consumption: the role of flexibility in shaping liberal and conservative preferences for global-local experiences. J Assoc Consum Res. 2022;7:266-75. https://doi.org/10.1086/719582
24. Kline R. Data preparation and psychometrics review. Principles and practice of structural equation modeling 4th ed New York, NY: Guilford 2016: 64-96.
25. Walker SN, Sechrist KR, Pender NJ. The Health-Promoting Lifestyle Profile: development and psychometric characteristics. Nurs Res. 1987 Mar-Apr;36(2):76-81.
26. Rathnayake N, Alwis G, Lenora J, Lekamwasam S. Applicability of health promoting lifestyle profile-II for postmenopausal women in Sri Lanka; a validation study. Health Qual Life Outcomes. 2020 May 6;18(1):122. https://doi.org/10.1186/s12955-020-01371-7
27. Khajehnasiri F, Hokmabadi E, Lotfi M, Dabiran S, Khosravi S, Sharifi N. Study of health-promoting lifestyle and its effective factors in the employees of Tobacco Company. Iran J Health Educ Health Promot 2022; 10 (1) :70-79. http://dx.doi.org/10.52547/ijhehp.10.1.70
28. Miller RS, Lefcourt HM. The assessment of social intimacy. J Pers Assess. 1982 Oct;46(5):514-8. https://doi.org/10.1207/s15327752jpa4605_12
29. Manafi F, Dehshiri G. The role of family cohesion and adaptability and emotion regulation in predicting the social intimacy of female students. Rooyesh Ravanshenasi J. 2019;8:209-16.
30. Simons JS, Gaher RM. The Distress Tolerance Scale: development and validation of a self-report measure. Motiv Emot. 2005;29:83-102. https://doi.org/10.1007/s11031-005-7955-3
31. Barati H, Hasani F, Panah AG, Pooshneh K. The evaluation modeling distress tolerance based on unpleasant lifestyle with mediation of cognitive emotion regulation in women nurses hospital in during coronavirus disease. Q J Psychol Methods Models. 2022;13:31-42. https://dx.doi.org/10.30495/jpmm.2023.31160.3726
32. Dennis JP, Vander Wal JS. The cognitive flexibility inventory: Instrument development and estimates of reliability and validity. Cogn Ther Res. 2010;34:241-53. https://doi.org/10.1007/s10608-009-9276-4
33. Salehi H, Hosseinian S, Yazdi SM. The relationship between cognitive flexibility and successful marriage: the mediating role of cognitive emotion regulation. Rooyesh Ravanshenasi J. 2021;10:93-102.
34. Chin WW. The partial least squares approach to structural equation modeling. Modern methods for business research. Psychology Press, 1998, pp.295-336.
35. Raisi Nasehi S, Dehghani A, Moradi Manesh F, Haghayegh SA. Modeling structural relations of health promoting lifestyle based on sense of coherence, psychological flexibility and impulsivity with the mediating role of body dissatisfaction in cardiovascular disease patients with obesity. Med J Mashhad Univ Med Sci. 2020;62:2004-19. https://doi.org/10.22038/mjms.2020.18889
36. Kenneally LB, Milam AL, Paulson JF. Pathways to intimacy: the direct and indirect effects of cognitive flexibility and emotion dysregulation. Couple Fam Psychol Res Pract. 202314(2):22-137. https://doi.org/10.1037/cfp0000247
37. Amirpour B, Sadeghin R. The mediating role of cognitive flexibility in the relationship between existential anxiety and distress tolerance with corona disease anxiety among air defense soldiers. Mil Psychol. 2023;13:123-46.
38. Habibović M, Piera-Jimenez J, Wetzels M, Widdershoven JWGM, Soedamah-Muthu SS. Associations between behavioral flexibility and health behavior in cardiac patients in the Do CHANGE trials. Health Psychol. 2022 Oct;41(10):710-8. https://doi.org/10.1037/hea0001151
39. Rezaei SVK, Kakabraee K, Hosseini SS. The effectiveness of teaching emotion regulation skill based on dialectical behavioral therapy on psychological distress and cognitive flexibility cardiovascular patients. J Nurs Educ. 2019;7:31-40.
40. Milam AL, Judah MR. The association of emotion regulation with distress tolerance depends on a neural correlate of cognitive control. Biol Psychol. 2023 May;180:108571. https://doi.org/10.1016/j.biopsycho.2023.108571