A Prospective Study of Ideal Cardiovascular Health and Depressive ...

Psychosomatics 2013:54:525–535

& 2013 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

A Prospective Study of Ideal Cardiovascular Health and Depressive Symptoms Vanesa España-Romero, Ph.D., Enrique G Artero, Ph.D., Duck-chul Lee, Ph.D., Xuemei Sui, M.D., Ph.D., Meghan Baruth, Ph.D., Jonatan R Ruiz, Ph.D., Russell R. Pate, Ph.D., Steven N. Blair, P.E.D.

Background: Ideal cardiovascular health is a new construct defined by the American Heart Association as part of its 2020 Impact Goal. Objective: The purpose of this study was to examine whether the simultaneous presence of ideal cardiovascular health behaviors and factors could reduce the odds of developing depressive symptoms. Methods: Participants from the Aerobics Center Longitudinal Study, who did not have any mental disorder/condition at baseline, were examined between 1987 and 1998, and they were followed up for a mean period of 6.1 years. Ideal cardiovascular health behaviors (never smoking, body mass index o25 kg/ m2, physical activity at goal, and appropriate diet consistent with guideline recommendations) and factors (total cholesterol o200 mg/dL, blood pressure o120/ 80 mm Hg, and fasting blood glucose o100 mg/dL) were measured at baseline. Depressive symptoms were assessed using the 10-item Center for Epidemiologic

Studies Depression Scale in 1990, 1995, or 1999. Results: Of the 5110 participants, 641 reported depressive symptoms. Participants meeting 3–4 or 5–7 ideal cardiovascular health components had 28% (odds ratio ¼ 0.72; 95% confidence interval 0.59–0.87) and 36% (odds ratio ¼ 0.64; confidence interval 0.50–0.82) decreased odds of depressive symptoms, respectively, when compared with those meeting 0–2 ideal components. Ideal behaviors were associated with lower odds of depressive symptoms in participants meeting 2 or 3–4 ideal behaviors, compared with those meeting 0–1 (odds ratio ¼ 0.81; confidence interval 0.67–0.98 and odds ratio ¼ 0.72; confidence interval 0.57–0.91). Ideal factors were not associated with depressive symptoms. Conclusion: Ideal cardiovascular health components, especially health behaviors, present an inverse relationship with depressive symptoms. (Psychosomatics 2013; 54:525–535)

INTRODUCTION Depressive symptoms and major depression are common, affecting about 121 million people worldwide.1 In the United States, depressive symptoms affect approximately 18.8 million adults or about 9.5% of the population aged 18 and older.2 Cost-of-illness studies indicate that depression is associated with substantial economic burden.3,4 Depressive symptoms are associated with greater morbidity and mortality, less ability to function independently, and lower occupational performance.5–8 Psychosomatics 54:6, November/December 2013

Received February 27, 2013; revised June 17, 2013; accepted June 18, 2013. From Department of Exercise Science, University of South Carolina, Columbia, SC; MRC Epidemiology Unit, University of Cambridge, Cambridge, UK; Department of Kinesiology, Iowa State University, Iowa; Department of Physical Education and Sport, Faculty of Sport Sciences, University of Granada, Spain; Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC. Send correspondence and reprint requests to Vanesa España-Romero, Ph.D., MRC Epidemiology Unit, University of Cambridge, Institute of Metabolic Science, Box 285 Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK; e-mail: [email protected] & 2013 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

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Cardiovascular Health and Depression Ideal cardiovascular health is a construct defined by the American Heart Association (AHA) as part of its 2020 Impact Goal, defined by the simultaneous presence of health behaviors (never smoking, body mass index [BMI] o25 kg/m2, physical activity at goal levels, and pursuit of a diet consistent with current guideline recommendations) and health factors (untreated total cholesterol o200 mg/dL, untreated blood pressure o120/80 mm Hg, and fasting blood glucose o100 mg/dL).9 This definition is a strategy of the AHA to “improve cardiovascular health of all Americans by 20% and reduce cardiovascular disease (CVD) and stroke deaths by 20%.”9 Depression has long been recognized as a risk factor for the development of CVD.10–14 In a survey of 245,404 adults from 60 countries, patients with depression reported worse overall health than those with asthma, diabetes, arthritis, or CVD alone.15 A recent study suggested that the relationship between depression and cardiovascular events may be modifiable with behavioral interventions.13 If the measurable construct defined by the AHA proves to be useful in reducing the odds of depressive symptoms, a substantial proportion of CVD events originated by depression could plausibly be prevented. The purpose of this study is to examine whether the presence of ideal cardiovascular health is associated with reduced odds of developing depressive symptoms in adults enrolled in the Aerobics Center Longitudinal Study (ACLS). METHODS Study Population The ACLS is a prospective epidemiologic study investigating health outcomes associated with physical activity and cardiorespiratory fitness at the Cooper Clinic, Dallas, TX.5,16 All participants included in this study had a baseline health examination, normal resting electrocardiograms, and a BMI ≥18.5 kg/m2. Those who reported having previously been diagnosed with a mental disorder/condition—such as depression, anxiety, thoughts of suicide, nervous breakdown, or the need for psychiatric counseling—were excluded from the analysis. We also excluded individuals with a history of myocardial infarction, stroke, or cancer, because these diseases might be related to depression. The baseline examination took place between 1987 526


and 1998. The final analysis included 5110 individuals (aged 20–83 years; 20.4% women) who met the aforementioned criteria and responded to at least 1 mail-back health survey in 1990, 1995, and 1999. Most participants were Caucasian, relatively well-educated, and from middle to upper socioeconomic strata. The participants were told the purpose of the study and they provided their written informed consent to participate. The study protocol was approved annually by the Cooper Institute's institutional review board. Baseline Examination Clinical examinations were completed after a 12-hour fast and were conducted by trained clinical personnel. The details of the examination have been described elsewhere.16 Briefly, information pertaining to personal and family health histories, personal health habits, and demographic information was obtained from standardized medical history questionnaires. Height and weight were measured using a standard clinical scale and stadiometer. BMI was calculated as weight in kilograms divided by height in meters squared (kg/m2). The fasting blood samples were analyzed for lipids and glucose using automated bioassays in accordance with the Centers for Disease Control and Prevention's Lipid Standardization Program. Resting blood pressure was measured after a brief period of quiet sitting, specifically as the first and fifth Korotkoff sounds using standard auscultation methods. Two or more readings separated by 2 minutes were averaged. If the first 2 readings differed by more than 5 mm Hg, additional readings were obtained and averaged. Standardized Cooper Clinic questionnaires were used to determine smoking habits (never, former, or current smoker), alcohol intake (drinks per week; correcting for alcohol content, where 1 unit of alcohol was defined at 12 oz of beer, 5 oz of wine, and 1.5 oz of hard liquor), physician-diagnosed mental disorders, physical activity, and family history of CVD. Physical Activity Leisure-time or recreational physical activity during the past 3 months was assessed using a previously validated self-report questionnaire.17 Physical activity categories were created based on responses to participation in the following 10 specific activities: walking, Psychosomatics 54:6, November/December 2013

España-Romero et al. jogging, running, treadmill exercise, cycling, stationary cycling, swimming, racquet sports, aerobic dance, and other sports-related activities (e.g., basketball). The frequency (number of workouts per week) and duration (minutes of workout per session) spent in each activity were also collected. The intensities of activities were estimated via speed-specific or activityspecific metabolic equivalent (MET) values from the Compendium of Physical Activities.18 To calculate the total volume of physical activity, the MET value for a given speed or activity was multiplied by the frequency and the duration and then summed over all activities resulting in total MET-min/wk of physical activity. All participants were classified into 3 categories based on the 2008 Physical Activity Guidelines: inactive (0 MET-min/wk), insufficient (1–499 MET-min/wk), and recommended (≥500 MET-min/wk).19 Five hundred MET-minutes per week is equivalent to 150 min/wk of moderate-intensity activity or 75 min/wk of vigorous-intensity activity.19

Diet Information The 3-day diet record methods used in the ACLS have been described elsewhere.20 Briefly, participants recorded their food intake on 2 weekdays and 1 weekend day. They were provided with written instructions on how to accurately describe foods and estimates portion sizes. They kept an ongoing, real-time, written record of foods consumed during and between meals and reported portion sizes in common household measures. Registered dieticians at the Cooper Clinic coded and analyzed the diet records using the Cooper Clinic Nutrition and Exercise Evaluation system. TABLE 1.

We categorized achievement of the AHA diet goals as follows: 4.5 or more servings per day of fruits and vegetables; 2 or more 3.5-oz servings per week of fish, shellfish, or other seafood; 3 or more servings per day of whole grains; and less than 1500 mg/d of sodium.9 AHA Ideal Cardiovascular Health Using the AHA definitions of ideal cardiovascular health, we classified the level of each cardiovascular health metric at baseline as ideal, intermediate, or poor9 (Table 1). For ideal levels of total cholesterol, blood pressure, and glucose, the AHA definition does not include achievement of ideal levels through medication use. This information is not available in the ACLS, so ideal levels of these factors additionally required no previous physician diagnosis of hypercholesterolemia (for total cholesterol), hypertension (for blood pressure), or diabetes or use of insulin (for fasting plasma glucose). From a total of 7 metrics, we grouped participants into 3 categories according to the number of ideal metrics: 0–2, 3–4, and 5–7. Those participants meeting the fewest ideal metrics (0–2) were considered as the reference group to analyze the association between ideal cardiovascular health and depressive symptoms. The categories of cardiovascular health selected represent a relatively even distribution with the prevalence of participants meeting the different numbers of metrics (approximately 40%, 40%, and 20% for 0–2, 3–4, and 5–7 components, respectively). Similar categories have been used in other studies.21–23 Depressive Symptoms Depressive symptoms were evaluated using the short version of the Center for Epidemiological

Definition of Poor, Intermediate, and Ideal Cardiovascular Health for Each Metric in the Aerobics Center Longitudinal Study

Goal/Metric

Poor

Intermediate

Ideal

Smoking Body mass index (kg/m2) Physical activity (MET-min/wk) Healthy diet score Total cholesterol (mg/dL) Blood pressure (mm Hg) Fasting plasma glucose (mg/dL)

Current ≥30 0 0–1 Components ≥240 SBP ≥ 140 or DBP ≥ 90 ≥126

Former 25–29.9 1–499 2 Components 200–239 SBP 120–139 or DBP 80–89 100–125

Never 18.5–25 ≥500 3–4 Components o200* o120/o80† o100‡

DBP ¼ diastolic blood pressure; MET ¼ metabolic equivalent; SBP ¼ systolic blood pressure. n

† ‡

Plus no previous physician diagnosis of hypercholesterolemia. Plus no previous physician diagnosis of hypertension. Plus no previous physician diagnosis of diabetes or use of insulin.

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Cardiovascular Health and Depression Studies-Depression Scale (CES-D).24 The CES-D is a self-reported measure of depressive symptoms experienced during the previous week. Although the CESD is not a diagnostic instrument, it is a valid, reliable, and widely used tool for screening and detecting depressive symptoms, particularly in epidemiologic studies.5,14,25,26 The scale consists of 10 items. The questions focus on mood (5 items), irritability (1 item), energy (2 items), concentration (1 item), and sleep (1 item). The items are scored on a 4-point scale ranging from 0 (rarely or none of the time [o1 day]) to 3 (most or all of the time [5–7 days]). Total scores range from 0 to 30, with a higher score indicating a higher burden of depressive symptoms. We used a cutoff of CES-D score of 8 and higher to indicate the presence of depressive symptoms.25 All participants completed the CES-D as part of a mail-back survey in 1990 (2073 participants), 1995 (2076 participants), and1999 (3435 participants). In participants who replied to more than 1 survey, we used the last one if they reported no depressive symptoms (CES-D score o 8), and the first one for those who reported depressive symptoms (CES-D score ≥ 8). All individuals included in this analysis completed at least 1 mail-back survey, 1462 (28.6%) completed 2 surveys, and 821 (16.1%) completed all 3. The aggregate survey response rate across these 3 survey periods was about 65%. Nonresponses bias is a concern in epidemiologic surveillance. This issue has been investigated in the ACLS.27 Baseline health histories and clinical measures were similar between responders and nonresponders and between early and late responders.27 Statistical Analyses Descriptive analyses summarized baseline characteristics of the participants based on gender and the presence of depressive symptoms developed during follow-up. The mean levels of continuous variables were compared using standard t-tests, while chi-square tests compared the distribution of categoric variable values. Linear regression analyses were used to examine the association between the number of ideal cardiovascular health components (as well as behaviors and factors separately) and the depressive symptom score. Furthermore, logistic regressions were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for depressive symptoms across categories of each ideal behavior/factor, total number of 528


ideal behaviors and factors combined, total number of ideal behaviors only, and total number of ideal factors only. Multivariate analyses included age (years), sex, baseline examination year, and heavy alcohol intake (present or not). When exploring the role of each ideal component, secondary analyses also adjusted for the presence/absence of the rest of the ideal components. No significant effect modification by sex was observed using interaction terms in the logistic regression models, thus we presented the results of pooled analyses. To account for differences in survey response patterns among study participants, and for the possibility that external events may have differentially affected the responses to the CES-D during the 3 survey periods, we created dummy variables that indicated whether the outcome measurement was from 1990, 1995, or 1999. Incidence rates were calculated by dividing the number of individuals reporting elevated levels of depressive symptoms by the population at risk. Data analyses were performed using PWSA statistical package version 18.0 (SPSS Inc., Chicago, IL). All p values are 2-sided with an α level of 0.05. RESULTS During an average follow-up of 6.1 years (range 1–12 years), 641 participants reported having depressive symptoms. Baseline characteristics of participants according to gender and depressive symptoms are shown in Table 2. Participants with depressive symptoms (CES-D score ≥ 8) were significantly younger and less active (p o 0.001). The proportion of participants meeting the 2008 Physical Activity guidelines (≥500 MET-min/wk) was 60.7% and 65.8% among those with and without depressive symptoms, respectively. The prevalence of participants meeting different numbers of components of ideal cardiovascular health is represented in the Figure. Approximately 4% of the participants had 0 of the 7 ideal components, approximately 52% had o4, and only 0.3% had all 7 ideal cardiovascular health components. Only 5.2% of the population met the ideal diet criteria, having at least 3 of 4 AHA dietary metrics. The individual dietary components met most often were fruit and vegetable intake (72.8%) and fish consumption (44.4%), whereas whole grain consumption (12.0%) and sodium consumption (0.6%) were met least often (data not shown). For the rest of the health components, the prevalences Psychosomatics 54:6, November/December 2013

España-Romero et al. TABLE 2.

Baseline Characteristics of Participants According to Gender and Depressive Symptoms at Follow-up, Aerobics Center Longitudinal Study 1987–1998

Characteristic, Mean ⫾ SD

Gender

Depressive Symptom Score (CES-D Score)

Men (N ¼ 4068) Women (N ¼ 1042) p

o8 (N ¼ 4469)

Age (y) 47.6 26.2 Body mass index (kg/m2) Total cholesterol (mg/dL) 208.5 Fasting plasma glucose (mg/dL) 100.1 Blood pressure (mm Hg) Systolic 121.8 Diastolic 81.4 Physical Activity (MET-min/wk) 1239.7 Fruits and Vegetables (servings per day) 6.2 Fish (ounces per day) 1.3 Whole grains (servings per day) 1.6 Sodium (mg/d) 4075.3 Characteristics, n (%) Current smokers Heavy drinkersn Hypercholesterolemia† Diabetes mellitus‡ Hypertension§

450 407 1237 107 1203

⫾ ⫾ ⫾ ⫾

9.8 3.7 39.2 15.0

⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾

13.0 113.8 ⫾ 14.5 9.2 76.0 ⫾ 9.6 1361.8 1255.1 ⫾ 1706.8 2.8 6.1 ⫾ 2.7 1.5 0.9 ⫾ 1.2 1.6 1.4 ⫾ 1.2 1166.1 3185.3 ⫾ 917.9

(11.1) (10.0) (30.4) (2.6) (29.6)

47.1 23.3 202.6 95.6

43 133 257 30 167

⫾ ⫾ ⫾ ⫾

10.4 4.0 39.7 19.0

(4.1) (12.8) (24.7) (2.9) (16)

0.167 o0.001 o0.001 o0.001

47.7 25.6 207.3 99.3

⫾ ⫾ ⫾ ⫾

9.9 3.9 39.3 16.1

≥8 (N ¼ 641) 46.1 25.8 207.5 98.6

⫾ ⫾ ⫾ ⫾

10.2 4.0 40.1 15.5

p o0.001 0.169 0.903 0.326

o0.001 120.2 ⫾ 13.9 119.5 ⫾ 12.6 o0.001 80.2 ⫾ 9.6 80.4 ⫾ 9.3 0.757 1263.4 ⫾ 1456.8 1099.1 ⫾ 1297.1 0.236 6.2 ⫾ 2.7 6.2 ⫾ 3.1 o0.001 1.2 ⫾ 1.5 1.1 ⫾ 1.3 o0.001 1.6 ⫾ 1.5 1.5 ⫾ 1.4 o0.001 3886.3 ⫾ 1169.1 3946.7 ⫾ 1222.2

0.218 0.686 0.007 0.847 0.012 0.443 0.224

o0.001 0.010 o0.001 0.362 o0.001

0.060 0.230 0.178 0.545 0.340

418 481 1292 120 1188

(9.4) (10.8) (28.9) (2.7) (26.6)

75 59 202 17 182

(11.7) (9.2) (31.5) (2.7) (28.4)

CES-D ¼ Center for Epidemiological Studies—Depression Scale; MET ¼ metabolic equivalent; SD ¼ standard deviation. n

Defined as 414 and 7 drinks/wk for men and women, respectively. Defined as a total cholesterol concentration of ≥240 mg/dL or a history of physician diagnosis. ‡ Defined as a fasting plasma glucose concentration of ≥126 mg/dL, previous physician-diagnosed diabetes, or use of insulin. § Defined as resting blood pressure ≥140/90 mm Hg or previous physician-diagnosed hypertension. †

of participants meeting the ideal level were (in ascending order): blood pressure, 30.4%; total cholesterol, 41.6%; BMI, 48.9%; smoking, 56.7%; fasting plasma glucose, 60.2%; and physical activity, 65.1%. The proportion of participants reporting depressive symptoms (CES-D scores ≥ 8) in the different mail-back surveys was 7.0%, 10.5%, and 8.7% in 1990, 1995, and 1999, respectively. Table 3 shows ORs for depressive symptoms (CES-D score ≥ 8) by each component of ideal cardiovascular health and their associated 95% CIs, adjusted for age, sex, baseline examination year, survey response year, and alcohol consumption (414 and 7 drinks/week for men and woman, respectively, or no consumption). Among the 7 individual components, smoking, BMI, physical activity and diet were inversely associated with the odds of depressive symptoms. Participants who never smoked and former smokers had significantly decreased odds of depressive symptoms in comparison with current smokers (OR¼ 0.75; CI 0.57–0.99 and OR ¼ 0.73; CI 0.55– 0.98, respectively). Normal weight individuals had Psychosomatics 54:6, November/December 2013

significantly decreased odds of depressive symptoms in comparison with obese participants (OR ¼ 0.68; CI 0.52–0.88). Those with a physical activity level ≥500 MET-min/wk had decreased odds of depressive symptoms in comparison with inactive individuals (OR ¼ 0.78; CI 0.63–0.95). Finally, those meeting 3–4 dietary components had decreased odds of depressive symptoms in comparison with those meeting 0–1 dietary components (OR ¼ 0.58, CI 0.37–0.92). However, when the independent association of each ideal cardiovascular health component was investigated (i.e., adjusting for the other components), only meeting 3–4 ideal dietary components was associated with decreased odd of depressive symptoms (OR ¼ 0.63, CI 0.40–0.99; supplementary Table 1). In the linear regression analyses, the number of ideal cardiovascular health components was inversely associated with the depressive symptom score (β ¼ 0.091, p o 0.001) after adjusting for age, sex, baseline examination year, survey response year, and alcohol consumption. The association between the number of ideal cardiovascular health components and depressive www.psychosomaticsjournal.org

529

Cardiovascular Health and Depression FIGURE.

Prevalence of Participants Meeting Different Numbers of Ideal Cardiovascular Health Components.

symptoms score was also analyzed separately for behaviors (smoking, BMI, physical activity, and diet) and factors (total cholesterol, blood pressure, and glucose). A higher number of ideal behaviors was associated with a lower depressive symptom score (β ¼ 0.078; p o 0.001), after adjusting for ideal factors. No association was found when the number of ideal factors was adjusted by number of ideal behaviors (β ¼ 0.028, p ¼ 0.126). Table 4 shows the number of cases where respondents reported depressive symptoms (CES-D score ≥ 8) at follow-up (events), the number of participants, the incidence rate of depressive symptoms, and the ORs and 95% CIs for depressive symptoms by number of components of ideal cardiovascular health. After adjusting for age, sex, baseline examination year, survey response year, and alcohol consumption, participants meeting 3–4 and 5–7 ideal components had 28% (OR ¼ 0.72, CI 0.59–0.87) and 36% (OR ¼ 0.64, CI 0.50–0.82) decreased odds of depressive symptoms, respectively, compared with those meeting 0–2 ideal components. The association between ideal cardiovascular health and odds of depressive symptoms was also analyzed separately by number of behaviors and factors (Table 4). We observed that a combination of 2 ideal behaviors decreased the odds of depressive symptoms by 19% (OR ¼ 0.81, CI 0.67–0.98) and 3–4 ideal behaviors decreased 530


them by 28% (OR ¼ 0.72, CI 0.57–0.91) compared with 0–1 ideal behaviors. No association was found when analyzing the number of ideal factors. We examined the sensitivity of the 8 cutoffs (CES-D score ≥ 8) using also the CES-D cutoff of 10 (CES-D score ≥ 10) to indicate the presence of depressive symptoms. The results did not change (data not shown). DISCUSSION The main finding of this study was that meeting a higher number of ideal cardiovascular health components was associated with a lower depressive symptoms score in adults. Furthermore, having at least 3 of the 7 ideal cardiovascular health components established by the AHA was associated with 28% decreased odds of depressive symptoms compared with those meeting 2 or fewer components. The odds of depressive symptoms was even further reduced among those with a higher number of components, as individuals having 5–7 components of ideal cardiovascular health had 36% decreased odds of developing depressive symptoms. We also found that meeting a higher number of ideal cardiovascular health behaviors (never smoking, ideal BMI, physical activity at goals, and healthy diet) was associated with a decreased odds of developing depressive symptoms, while meeting Psychosomatics 54:6, November/December 2013

España-Romero et al. TABLE 3.

Odds Ratio (OR) and 95% Confidence Intervals (CI) for Depressive Symptoms (CESD ≥ 8) by Components of Ideal Cardiovascular Health OR

95% CI

p For Linear Trend

Smoking Current smoker Former Never

1.00 0.73 0.75

Referent 0.55–0.98 0.57–0.99

0.087

Body mass index ≥30 kg/m2 25.0–29.9 kg/m2 18.5–24.9 kg/m2

1.00 0.78 0.68

Referent 0.60–1.02 0.52–0.88

0.015

Physical activity 0 MET-min/wk 1–499 MET-min/wk ≥500 MET-min/wk

1.00 1.12 0.78

Referent 0.85–1.47 0.63–0.95

0.003

Diet (no. of components) 0–1 2 3–4

1.00 0.93 0.58

Referent 0.78–1.11 0.37–0.92

0.061

Total cholesterol ≥240 mg/dL 200–239 mg/dL o200 mg/dL*

1.00 0.97 0.80

Referent 0.77–1.22 0.64–1.01

0.081

1.00 0.87 0.81

Referent 0.70–1.09 0.64–1.04

0.238

1.00 1.04 1.02

Referent 0.56–1.93 0.55–1.88

Blood pressure SBP ≥ 140 or DBP ≥ 90 mm Hg SBP 120–139 or DBP 80–89 mm Hg o120/o80 mm Hg† Glucose ≥126 mg/dL 100–125 mg/dL o100 mg/dL‡

0.969

DBP ¼ diastolic blood pressure; SBP ¼ systolic blood pressure. All models adjusted for age, sex, baseline examination year, survey response year, and alcohol consumption (414 and 7 drinks/wk for men and women, respectively, or no consumption). n

† ‡

Plus no previous physician-diagnosed hypercholesterolemia. Plus no previous physician-diagnosed hypertension. Plus no previous physician-diagnosed diabetes or use of insulin.

ideal cardiovascular health factors (total cholesterol o200 mg/dL, blood pressure o120/o80 mm Hg, and fasting plasma glucose o100 mg/dL) was not. In line with our results, several studies have examined individual modifiable components and their relationship with depressive symptoms.28–35 Physical activity has long been suggested as a behavior that has an inverse association with depressive symptoms not only in young and middle-aged people,31,32 but also in older men and women.33 Regarding BMI, it is becoming more evident that there may be a direct relationship with depressive symptoms.29,30 Petry et al. studied 41,654 participants and found that obesity was associated with significantly increased odds of major Psychosomatics 54:6, November/December 2013

depression compared with normal weight individuals.29 Similar direct associations have been suggested between smoking and depressive symptoms,34,35 as well as some nutritional factors and the risk of developing depressive symptoms.28 In agreement with Sanchez-Villegas et al., only in those participants who met 3–4 dietary components an association was found with depressive symptoms when all 7-components of ideal cardiovascular health were taken into account as confounders.28 Further, recent studies also suggest that health behaviors may play an important role in mediating the relationship between depressive symptoms and risk of cardiovascular events.13,14 Whooley et al. studied 1017 www.psychosomaticsjournal.org

531

Cardiovascular Health and Depression TABLE 4.

Odds Ratios and 95% Confidence Intervals for Depressive Symptoms (CESD ≥8) by Number of Components of Ideal Cardiovascular Health No. of Events (No. of Participants)

Incidence Rate (%)

OR

95% CI

All 7 components 0–2 Ideal Components 3–4 Ideal Components 5–7 Ideal Components p for linear trend

264 (1892) 257 (2214) 120 (1004)

14.0 11.6 12.0

1.00 0.72 0.64

Referent 0.59–0.87 0.50–0.82 o0.001

Behaviors† 0–1 Ideal behaviors 2 Ideal behaviors 3–4 Ideal behaviors p For linear trend

274 (1997) 225 (1888) 142 (1225)

13.7 11.9 11.6

1.00 0.81 0.72

Referent 0.67–0.98 0.57–0.91 0.013

Factors‡ 0–1 Ideal factors 2 Ideal factors 3 Ideal factors p For linear trend

386 (2998) 174 (1495) 81 (617)

12.9 11.6 13.1

1.00 0.84 0.89

Referent 0.67–1.03 0.67–1.18 0.231

*

CI ¼ confidence interval; OR ¼ odds ratio. n Adjusted for age, sex, baseline examination year, survey response year, and alcohol consumption (414 and 7 drinks/wk for men and women, respectively, or no consumption). † Adjusted for the aforementioned factors plus hypercholesterolemia, hypertension, and diabetes (present or none for each). ‡ Adjusted for those in * plus current smoking, body mass index, physical activity (MET-min/wk), and number of ideal diet components.

outpatients with stable coronary heart disease and found that participants with baseline depressive symptoms had a 50% greater rate of subsequent cardiovascular events than participants without depressive symptoms. However, the association between depressive symptoms and cardiovascular events was no longer significant after additional adjustment for physical activity and other health behaviors.13 Win et al. also showed that physical inactivity accounts for a significant proportion (approximately 25%) of the increased cardiovascular mortality risk because of depressive symptoms in adults older than 65 years.14 Smoking, physical activity, and dietary lifestyle changes have already been suggested as targets for the prevention and treatment of CVDs in patients with depressive symptoms.36 The health factors analyzed in this study (total cholesterol, blood pressure, and fasting plasma glucose) and their relationship with depression have been habitually examined in the opposite direction.11,37–39 Studies have shown an association between the presence of depressive symptoms and an increased risk of developing coronary artery diseases,11 diabetes,37,38 and hypertension.39 However, few studies have examined the relationship between the health 532


factors examined in this study and the risk of developing depressive symptoms. We only found 1 meta-analysis evaluating the association between total, high-, and low-density cholesterol as risk factors for developing depressive symptoms. 40 In contraposition to our results, the authors concluded that there was an inverse connection between total cholesterol and depression (d ¼ 0.29). However, in the same line of this study, the results for high- and low-density cholesterol were inconclusive.40 In our study, we did not find any association between meeting a higher number of ideal cardiovascular health factors and the risk of developing depressive symptoms. Given that ideal cardiovascular health is a relatively new construct, only Kronish et al., studied all these behaviors and factors and their relationship with depressive symptoms in a cross-sectional study of 20,093 participants ≥ 45 years of age enrolled in the REGARDS study.26 They found that depressive symptoms were associated with worse level on both behavioral and factors components.26 Therefore, this new construct that was initially defined to improve cardiovascular health and reduce CVD and stroke deaths, may also be useful to prevent initial stages of Psychosomatics 54:6, November/December 2013

España-Romero et al. depression.9 From a public health perspective, this is of vital importance since the World Health Organization highlighted the detrimental effects of depression on medical illness as 1 of its 10 most important global public health issues.13,41 Some particular considerations of the ACLS must be acknowledged. The main strengths of this study include the large number of participants (N ¼ 5110), the prospective study design, and the mean extensive follow-up ( 6 years). Additionally, this study included objective measures for BMI, blood pressure, glucose, and cholesterol. Moreover, the extensive baseline examination allowed for the collection of multiple exposures and confounders. Finally, we excluded individuals with cancer, CVD, or a selfreport of having had a physician diagnosis of any mental disorder at baseline, reducing the likelihood of residual confounding. However, there are also some limitations that need to be considered when interpreting the data. First, the homogeneity of the ACLS population on sociodemographic factors deserves comment. The participants were mainly white and of middle to upper socioeconomic status. Although this enhances the internal validity of our findings by reducing the degree of confounding by these factors, our findings may not generalize well to the general population. However, the ACLS study group is similar in many respects to other cohorts that have provided important information on disease prevention.42,43 Second, depressive symptoms were not measured at baseline, and therefore it cannot be assumed that ideal cardiovascular health definition predicts clinically significant depressive symptoms. Moreover, we did not use clinical diagnostic criteria to diagnose depression. Some of the study participants who were classified as having depressive symptoms might not have qualified for the diagnosis of clinical depression. It is also possible that a CES-D cutoff of ≥8 may be too low; in which case, our outcome variable would misclassify some individuals as false positives. Although there is no widely accepted “optimal” cutoff score for the CES-D,44 the cutoff of ≥8 used in this study has been used in earlier reports.14,38 Additional analyses were conducted with a cutoff of ≥10 to define depressive symptoms and the results did not materially change (data not shown). Furthermore, it would have been interesting to consider the confounding effect of specific items of the CES-D questionnaire, such as those related to energy. Participants with worse health Psychosomatics 54:6, November/December 2013

behaviors may have worse energy, independently of depression. Third, some of the variables used in this study were self-reported, such as physical activity and diet. Although there is bias associated with selfreported measures, it was minimized by using standardized procedures and validated questionnaires. Compared with the original ideal cardiovascular health construct, diet and smoking status were slightly modified in this study. We had insufficient information to include sugar-sweetened beverages among the dietary components, and we did not have data on the length of time since former smokers had quit. Fourth, it should be noted that some of these ideal factors may not be realistic (e.g., sodium consumption was met by 0.6% of the individuals) and it may be problematic regarding their use. Finally, the findings of our study may also be affected by unmeasured factors associated with cardiovascular health and depressive symptoms at the same time, although it seems unlikely that such factors would explain all of the observed association. We do not have sufficient information on medication use, treatments, menopausal status, or pregnancy status to include these factors in our analysis. Such information should be included in future studies, to expand on the findings reported here. In conclusion, the ideal cardiovascular health definition established by the AHA, especially health behaviors, presents an inverse relationship with depressive symptoms. Meeting a higher number of ideal cardiovascular health components seems to be associated with lower odds of developing depressive symptoms. This relation is significant in the case of cardiovascular health behaviors (smoking, BMI, physical activity, and diet), but not for cardiovascular health factors (total cholesterol, blood pressure, and fasting plasma glucose). Acknowledgements: The authors thank the Cooper Clinic physicians and technicians for collecting the baseline data, and staff at the Cooper Institute for data entry and data management. This study was supported by National Institutes of Health Grants AG06945, HL62508, and DK088195, and in part by an unrestricted research grant from the Coca-Cola Company. This work was also supported by Spanish Ministry of Education (EX-2009-0899, EX-2010-1008, and RYC2010-05957). Disclosure: All authors declare no support from any organization for the submitted work, no financial www.psychosomaticsjournal.org

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Cardiovascular Health and Depression relationships with any organizations that might have an interest in the submitted work, and no other relationships or activities that could appear to have influenced the submitted work. The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.

APPENDIX A. SUPPLEMENTARY INFORMATION Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10. 1016/j.psym.2013.06.016.

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