Relationship between anxiety, depressive symptoms and compulsive overeating disorder in patients with cardiovascular diseases

ABSTRACT Objectives: to identify the presence of compulsive overeating disorder in patients with cardiovascular diseases and to verify its relation with sociodemographic, clinical variables and the presence of anxiety and depressive symptoms. Method: cross-sectional, correlational study with a sample of 111 patients with cardiovascular diseases. The presence of anxiety and depressive symptoms was assessed by the Hospital Anxiety and Depression Scale instrument and compulsive overeating disorder was assessed through a likert instrument called the Periodic Eating Disorder Scale (Binge Eating Scale). Results: there was a predominance of patients without compulsive overeating disorder (n=91, 82%), followed by moderated compulsive overeating (n=15, 13.5%) and severe (n=5, 4.5%) associating to high levels of body mass index (p=0.010) and the presence of anxiety (p=0.017). Conclusion: Compulsive overeating disorder was present in 18% of the patients, being associated with body mass index and anxiety, suggesting that health professionals should pay attention to the comprehensive evaluation of patients with cardiovascular diseases. Important results emerged from this study, emphasizing the need to implement programs to improve the patients’ mental and physical health in both primary and specialized care services.


Recent statistics from the American Heart
Association have shown that cardiovascular diseases (CVD) continue to lead the most common causes of mortality in the world. In 2013, they accounted for about 17.3 million of a total of 54 million deaths or 31.5% of all global deaths, with most, about 80%, occurring in low-and middle-income countries, including Brazil. Although mortality rates from these causes have declined, it is estimated that by 2030, 43.9% of the adult population in the United States should have some of its clinical forms (1) .
The cardiovascular diseases can, mostly, be prevented by combating traditional risk factors such as smoking, sedentarism, obesity, hypertension, inadequate diet and dyslipidemia (1) . In addition, recent studies have pointed out that psychological factors, such as emotional states of anxiety and depression, are also associated with the presence of these affections and, therefore, should be considered in their clinical management (1)(2)(3) .
A large cohort in the United Kingdom, recently, demonstrated that depression was prospectively associated with heart, cerebrovascular and peripheral diseases (2) . Similarly, the American Heart Association has assembled several evidences on the effect of anxiety, depressive symptoms, and other negative emotional states that act independently on the onset and worsening of cardiovascular diseases such as stroke and acute myocardial infarction (1) .
In addition to the symptoms of anxiety, depression, stress, sadness and anger, which are conditions frequently associated with these diseases, compulsive overeating can also be a coping strategy used to soften or solve everyday problems, providing a sense of pleasure (4) . This behavior characterized by the ingestion of high amounts of food in a delimited period, accompanied by sensation of loss of control is denominated compulsive overeating disorder (5)(6) . To characterize the diagnosis, these events should occur at least two days per week in the last six months, associated with some loss of control characteristics and not accompanied by compensatory behaviors directed towards weight loss (5,7) .
Compulsive overeating comprises at least two elements: the subjective (feeling of loss of control) and the objective (amount of food consumption). An example of a situation that can trigger this disorder is the stress, with consequent cortisol release, which takes action stimulating food intake and weight gain (8) .
In the United States, a representative sample of adults from the National Health and Wellness Survey was recruited into an online panel to respond to an Internet survey regarding issues to assess compulsive eating behaviors. Out of the total of 22,397 interviewees, 344 reported criteria that met the diagnosis of compulsive overeating. The compulsive overeating frequency occurred, on average, in more than two or three days per week, with duration lasting 12 months and was characterized as severe symptoms (9) .
Clinically, compulsive overeating has often been associated with metabolic deficits and clinical conditions predisposing to the onset of cardiovascular diseases, such as obesity, dyslipidemia, and diabetes.
The evidences suggest that this disorder, along with other eating disorders, may affect about 40% of people with type 2 diabetes mellitus, compromising the metabolic control and raising the risk of vascular complications (10) . However, individuals with compulsive overeating had a higher risk, expected in 10 years, of developing cardiovascular diseases, based on the Framingham risk score (11) .
Despite consistent evidence, this eating disorder is not investigated or evaluated effectively by professionals working in direct care. A study with patients diagnosed with heart failure revealed that problems of emotional origin are not adequately identified by health professionals, pointing to some probable reasons for this situation, such as difficulty for patients to reveal their emotional state, because of the fear of being labeled as mental illnesses carriers and the assistance given by professionals guided by the biomedical model, whose attention is mainly focused on the pathology and treatment (3) .
A recent study that aimed to investigate the knowledge and attitudes of Australian health professionals regarding compulsive overeating disorder, concluded that the professionals were reluctant to diagnose this disorder and the obesity as comorbid conditions. In addition, the knowledge of the physical complications associated with compulsive overeating came out as limited (12) . The presence of anxiety and depressive symptoms was evaluated by the Hospital Anxiety and Depression Scale (HADS) (13) , in its Portuguese validated version (14) .
The scale has 14 items (seven for the evaluation of anxious symptoms and seven for depressive symptoms), evaluated on a scale from zero to three points, with scores varying from zero to 21 points. Higher values indicate high symptomatology of anxiety and depression (14) .
The ECAP has 16 items and was developed specifically for the evaluation of obese individuals (15) , contemplating aspects related to the behavioral characteristics (e.g. amount of food that was consumed), emotional and cognitive. Each item has three to four possible answers, with values from zero (absence) to three (maximum severity), which must be selected according to the response that represents the individual. The score ranges from zero to 46 points.
The individuals are classified according to the following scores: ≤17 = absence of compulsive overeating; 18 to 26 = moderate compulsive overeating; ≥27 = severe compulsive overeating.
As for its psychometric properties, ECAP presented internal consistency, measured by the Cronbach's Alpha, of 0.85, considered moderately high (15) .
The ECAP was translated and adapted into the Portuguese language in 2001 and it was considered adequate for clinical use (16) .    patients admitted to a cardiovascular rehabilitation unit in Croatia (4) , 16% in a sample of 5175 obese adults who sought for a weight reduction program (18) and 12.2% in a sample of patients with type 2 diabetes mellitus (19) .
A multi-centered study conducted by professionals from several countries with the objective to assess the epidemiological situation of compulsive overeating worldwide, through data from the World Health Organization, showed that its prevalence might range from 0.2% (Romania) to 4.7% (Brazil) in the population and that this percentage may increase in females, with a high body mass index, aged from 18 and 29 years old and that have musculoskeletal diseases, chronic pain, diabetes, hypertension, ulcers and headache . The prevalence of compulsive overeating in hypertensive patients was 1.8% and in patients with heart diseases was 0.9% (6) .
In our sample, the prevalence of compulsive overeating was high (18%) when compared to the general population of Brazil (4.7%) (6) . Compulsive overeating may have been influenced by the increased anxiety and emotional distress of these people in dealing with the condition of having a chronic disease.
We also emphasize that our sample was consisted of overweight and obese patients, whose rates tend to be higher.  (20) .
Another cross-sectional study, which used data from The authors also showed that physicians only focus on the treatment of comorbidities such as diabetes, obesity, cardiovascular diseases, dyslipidemias, not considering the possible association of these conditions with compulsive overeating, therefore, reaching incomplete therapeutic results (26) .

Another relevant finding that deserves attention
is the prevalence of increasing compulsive overeating at early ages. Results from a meta-analysis indicated that compulsive overeating was prevalent in more than a quarter of overweight and obese children and adolescents (27) , clearly demonstrating that preventive actions should be initiated as early as in childhood, so as to prevent future negative outcomes and to achieve positive impacts on morbimortality rates.
Similarly to our study, other studies have found an association between compulsive overeating and BMI elevation (28)(29) . Obesity has multiple etiologies and the emotional factors seem to play a relevant role in its genesis. Conflicts and feelings of loneliness were significantly associated with eating disorders, mainly to compulsive overeating disorder, in severe obese patients (29) .
Although it is clear that there is a strongly positive association between binge eating and high BMI (18,22) , there are divergent findings in the literature adjusting for body mass index (28) .
On the other hand, the prevalence of compulsive overeating was associated with higher risk of hypertension, hypertriglyceridemia, decreased HDL, insulin resistance and metabolic syndrome, apparently mediated by increased BMI, among participants in the Framingham Heart Study with compulsive overeating. The eating disorder was strongly associated, independently, with hyperglycemia alone. In addition, these individuals had more visceral, subcutaneous and hepatic fat (11) .
A recent study reinforced the idea that compulsive overeating does not seem to be independently related to cardiometabolic risk factors, and this connection is mediated by the elevation of BMI (18) . It is worth noting that although the mechanisms associated with elevated cardiovascular risk in patients with compulsive overeating remain unclear, the literature is consistent on the clinical relevance of screening and treating this disorder to reduce the risk of developing obesity and cardiovascular disease (11,18) .
Our results also evidenced the presence of anxiety as a factor that influences compulsive overeating, corroborating results of other studies (4,30) . In a review of the literature, it was found that anxiety is an important factor in the development and maintenance of compulsive overeating, supported by a set of previous researches that illustrate not only a high simultaneity between these disorders, but also the ways in which anxiety might play a unique role in the genesis of compulsive overeating (31) .
Several other evidences point to the importance of emotional deficits and stressors in the development of compulsive overeating, which may explain, in part, the association of this variable with anxiety. Recent models of rats submitted to various episodes of stress, developed compulsive overeating and hyperphagia, completely imitating the behavioral and metabolic characteristics of human compulsive overeating (8) .
In addition, subjects with binge eating reported greater psychological deficits when compared to obese and normal weight controls (32) , suggesting emotional Although our study found no association between depression and compulsive overeating, we emphasize the positive correlation between anxiety and depressive symptoms, corroborating the literature regarding the close relationship between these variables (33)