Association between cardiovascular health and self-reported depression: 2019 National Health SurveyAbstract
The aim is to analyze the association between the ideal cardiovascular health score and the self-reported diagnosis of depression in Brazilian adults. Cross-sectional study, with 57,898 Brazilian adults from the 2019 National Health Survey. Presence of self-reported depression. Exposures: behavioral scores (BMI, smoking, diet, physical activity, ideal if ≥3 ideal factors), biological (smoking, dyslipidemia, hypertension and diabetes, ideal if ≥3 ideal factors) and cardiovascular health (all factors, ideal if ≥4 ideal factors), based on the score proposed by the American Heart Association. They were categorized as poor/intermediate or ideal. Associations were tested using logistic regression models adjusted for sociodemographic characteristics. The prevalence of depression was 11.1%. All scores classified as ideal were inversely associated with depression after adjustments for sociodemographic variables (Ideal behavioral score: OR: 0.58 [95%CI: 0.48-0.70], ideal biological score: OR: 0.48 [95%CI: 0.43-0.53] and ideal cardiovascular health: OR: 0.53 [95%CI: 0.48-0.59]). The ideal cardiovascular health score was inversely associated with the self-reported diagnosis of depression among Brazilian adults.
Key words:
Depression; Cardiovascular diseases; Risk Factors for Heart Disease; Epidemiological Surveys
Resumo
O objetivo é analisar a associação entre o escore de saúde cardiovascular ideal e o diagnóstico autorreferido de depressão em adultos brasileiros. Estudo transversal, com 57.898 adultos brasileiros da Pesquisa Nacional de Saúde de 2019. Presença de depressão autorreferida. Exposições: escores comportamental (IMC, tabagismo, dieta, atividade física, ideal se ≥3 fatores ideais), biológico (tabagismo, dislipidemia, hipertensão e diabetes, ideal se ≥3 fatores ideais) e saúde cardiovascular (todos os fatores, ideal se ≥4 fatores ideais), com base no escore proposto pela American Heart Association. Foram categorizados em ruim/intermediário ou ideal. As associações foram testadas por meio de modelos de regressão logística ajustados por características sociodemográficas. A prevalência de depressão foi de 11,1%. Todos os escores classificados como ideais foram inversamente associados à depressão após ajustes por variáveis sociodemográficas (Escore comportamental ideal: OR: 0,58 [IC95%: 0,48-0,70], biológico ideal: OR: 0,48 [IC95%: 0,43-0,53] e cardiovascular ideal: OR: 0,53 [IC95%: 0,48-0,59]). O escore de saúde cardiovascular ideal associou-se inversamente ao diagnóstico autorreferido de depressão entre adultos brasileiros.
Palavras-chave:
Depressão; Doenças Cardiovasculares; Fatores de Risco de Doenças Cardíacas; Inquéritos Epidemiológicos
Resumen
El objetivo es analizar la asociación entre el puntaje ideal de salud cardiovascular y el diagnóstico auto-reportado de depresión en adultos brasileños. Estudio transversal con 57.898 adultos brasileños de la Encuesta Nacional de Salud de 2019. Presencia de depresión autoreportada. Exposiciones: puntajes conductuales (IMC, tabaquismo, dieta, actividad física, ideal si ≥3 factores ideales), biológicas (tabaquismo, dislipidemia, hipertensión y diabetes, ideal si ≥3 factores ideales) y salud cardiovascular (todos los factores, ideal si ≥4 factores ideales), basado en la puntuación propuesta por la American Heart Association. Fueron categorizados como pobres/intermedios o ideales. Las asociaciones se probaron utilizando modelos de regresión logística ajustados por características sociodemográficas. La prevalencia de depresión fue de 11,1%. Todos los puntajes clasificados como ideales se asociaron inversamente con la depresión tras los ajustes por variables sociodemográficas (puntaje conductual ideal: OR: 0,58 [IC95 %: 0,48-0,70], puntaje biológico ideal: OR: 0,48 [IC95 %: 0,43-0,53] y salud cardiovascular ideal: OR: 0,53 [IC95 %: 0,48-0,59]). El puntaje de salud cardiovascular ideal se asoció inversamente con el diagnóstico autoinformado de depresión entre los adultos brasileños.
Palabras clave:
Depresión; Enfermedades cardiovasculares; Factores de riesgo de enfermedades cardíacas; Encuestas epidemiológicas
Introduction
In Brazil, it is estimated that depressive disorders affect around 16.3 million people1. According to the World Health Organization (WHO), the number of cases of depression increased by 18% between 2005 and 20152. This condition is considered a preventable multifactorial disorder characterized by sadness or irritability, disinterest or displeasure, cognitive difficulties, feelings of guilt or low self-esteem, sleep or appetite disorders and recurrent ideas of death3, which can be occasional or last for days, months or years2.
Depression is a public health problem due to its high prevalence, repercussions on general health and its psychosocial impact4. In 2019, depressive disorders led to a global total of more than 125 million years lived with disability (YLD), making it the thirteenth leading cause of disability-adjusted life years (DALYs)5.
Global spending equivalent to lost productivity due to anxiety and depression costs the global economy US$ 1 trillion and is estimated to rise to approximately US$ 6 trillion by 20306. People with mental disorders have poor physical health and are therefore at greater risk of developing physical illnesses, such as cardiometabolic diseases, obesity, diabetes7, heart disease and oncological problems8,9. This, places a high social and economic burden on individuals, families, governments and society.
Previous studies have revealed a bidirectional association between cardiovascular disease (CVD) and depression10,11. Depression is a risk factor for cardiovascular mortality and morbidity, both in the healthy population and in those with established cardiovascular diseases12,13, and cardiac morbidity is a risk factor for depression14. The correlation between these diseases can be explained by the increase in inflammatory markers14,15, since inflammation is a component present in both depression and cardiovascular diseases16. This is due to mental stress, a common feature between CVD and depression, which causes changes in the autonomic nervous system and contributes to inflammation12.
In 2010, the American Heart Association (AHA) proposed a cardiovascular health score to reduce morbidity and mortality from CVD. The score includes 7 protective factors for cardiovascular health, behavioral factors (not smoking, physical activity, having a Body Mass Index (BMI) below 25 kg/m² and adequate nutrition) and biological factors (not having hypertension and having adequate glycaemia and cholesterol levels). The AHA considers the presence of these factors to be a metric of ideal cardiovascular health status17.
Some studies show that physical activity18,19, good nutrition20, controlled blood pressure21,22, controlled glycaemia23 and not taking nicotine24 reduce symptoms of anxiety and depression. On the other hand, the presence of depression is independently associated with poor cardiovascular health25-27.
Data from the Longitudinal Study of Adult Health (Elsa-Brazil) showed that the risk of depression is tripled in the presence of poor cardiovascular health10, considering the score proposed by the AHA17. However, there are few publications relating this score to the occurrence of depression. It should also be emphasized that there is a need for publications on this association in a representative sample of the Brazilian population.
Based on the above, the aim of this study was to assess the association between the ideal cardiovascular health score and self-reported diagnosis of depression in Brazilian adults, using data from the 2019 National Health Survey.
Methods
This is a cross-sectional study using data from the National Health Survey (PNS) 2019, carried out by the Ministry of Health in partnership with the Brazilian Institute of Geography and Statistics (IBGE). The PNS is a national household-based survey containing a questionnaire divided into three parts: firstly, focused on the characteristics of the household, secondly, all the residents of the household and thirdly, one resident of each selected household aged 15 or over. To calculate the sample size of the PNS, the average values, variances and effects of the sampling plan were considered, and a non-response rate of 20% was assumed. More detailed information on the PNS can be found in a specific publication28.
For the analyses in this study, data from individuals aged 18 and over were analyzed, with the presence of self-reported depression (no/yes) as the outcome and ideal cardiovascular health as the exposure. Of the 90,846 residents selected, pregnant participants, those who did not know they were pregnant, individuals aged <18 years and those who did not have complete information on all the variables that make up this study were excluded.
Ideal cardiovascular health was analyzed as proposed by the American Heart Association (AHA)17, based on three self-reported scores: 1) behavioral score (BMI, smoking, diet, physical activity [PA]); 2) biological score (smoking, dyslipidemia, hypertension and diabetes), where in this study the behavioral and biological scores were considered ideal in the presence of 3 or more factors and poor/intermediate in the presence of less than 3 factors; and 3) cardiovascular health score, made up of the 7 factors (BMI, smoking, diet, physical activity, dyslipidemia, hypertension and diabetes). In this study, the presence of 4 or more factors was considered ideal cardiovascular health. This cut-off point has previously been associated with cardiovascular protection and a reduction in the incidence of coronary heart disease29,30. It should be noted that, in accordance with AHA guidelines, the variable smoking was included in both the behavioral score and the biological score, due to the importance of not smoking or quitting this habit for health promotion and the prevention of cardiovascular diseases17. Thus, the variables that are part of the scores were classified as poor/intermediate or ideal. The self-reported cardiovascular health score was validated in relation to that measured for the Brazilian population in a previous study31.
The presence of depression was self-reported using the question: “Has a doctor or mental health professional (such as a psychiatrist or psychologist) ever diagnosed you with depression?”. Hypertension, diabetes and cholesterol were assessed using the questions: “Has any doctor ever diagnosed you with hypertension (high blood pressure)?”; “Has any doctor ever diagnosed you with diabetes?” and “Has any doctor ever diagnosed you with high cholesterol?”, with “no” being considered the ideal answer for all questions.
Diet was assessed based on four criteria: 5 portions of fruit, vegetables and legumes (FLV) 5 times a week; consumption of fish 2 times a week; no soft drinks and less than 5g of salt a day32, with the presence of all 4 factors being ideal. As the PNS 2019 does not estimate the exact amount of salt consumption in the Brazilian population, the following question was adapted: “Considering freshly prepared food and processed food, do you think your salt consumption is:”, with those who answered “very high” and “high” being considered to consume more than 5g of salt per day, and those who answered “adequate”, “low” and “very low” being considered to consume less than 5g.
In terms of physical activity, individuals who performed at least 150 minutes of moderate PA per week or at least 75 minutes of vigorous PA per week were considered ideal33. The ideal BMI was considered to be less than or equal to 25 kg/m²34, based on self-reported weight and height, as proposed by the AHA17.
Smoking was assessed using the following questions: “Do you currently smoke any tobacco products?” and “Have you smoked any tobacco products in the past?”. Individuals who did not currently smoke and who reported never having smoked in the past were considered to be in the ideal category.
Bivariate analyses of the association between behavioral, biological and cardiovascular scores, as well as the factors that make them up, and self-reported depression were carried out using the chi-square test, considering a significance level of 5%. Associations between cardiovascular health scores and depression were tested using logistic regression models adjusted for gender, age, race/color, education and marital status. These adjustment variables were considered because they were associated with both the exposure (cardiovascular health) and the outcome (depression), according to previous studies35-45, and according to the analyses in this study. In the final model, scores with a p-value of <0.05 were considered associated. All the analyses were carried out using Stata software version 12.0 and sample and post-stratification weights were considered.
The PNS project was approved by the National Research Ethics Committee (process No. 3.529.376, dated August 23, 2019) and all interviewees signed an Informed Consent Form agreeing to take part in the research at the time of the interview.
Results
In this study, data from 57. 898 individuals were analyzed. 52.5% (95%CI: 51.8-53.2) were female, 59.0% (95%CI: 58.2-59.8) were aged 18-49, 47.1% (95%CI: 46.3-48) were white, 40.2% (95%CI: 39.5-41) reported that high school was the highest level of education they had attended and 48.8% (95%CI: 48.08-49.7) were married (data not shown).
Of the Brazilian adults, 8.70% of men and 10% of women had the ideal behavioral score. Regarding the biological score, 78.80% of men and 76.70% of women were classified as ideal. As for the cardiovascular score, 65.00% of men and 64.00% of women were classified as ideal. These results, as well as a description of the components of the scores by gender, are described in Table 1, also considering stratification by age group.
The prevalence of depression was 16.18% (95%CI: 15.42-16.98) in women and 5.49% (95%CI: 5.03-5.99) in men, 9.80% (95%CI: 9.15-10.41) in individuals aged 18-49, 13.20% (95%CI: 12.09-14.37) aged 50-59 and 12.90% (95%CI: 11.98-13.90) aged 60 or over. These and other prevalences of depression by sociodemographic characteristics are described in Table 2.
The prevalence of depression was higher in the poor/intermediate categories for all scores. The prevalence of depression was higher in individuals with a score in the poor/intermediate category, with 15.27% (95%CI: 14.43-16.14) in the cardiovascular health score, while 8.77% (95%CI: 8.26-9.31) were classified in the ideal category. In the behavioral score, 11.51% (95%CI: 11.01-12.02) prevalence of depression was observed in the poor/intermediate category and 7.2% (95%CI: 6.12-8.46) in the ideal category. In the biological score, 17.51% (95%CI: 16.36-18.72) had depression in the poor/intermediate category and 9.27% (95%CI: 8.8-9.76) in the ideal category (Table 2).
Having ideal cardiovascular health scores was found to be inversely associated with self-reported diagnosis of depression among Brazilian adults in the unadjusted logistic regression models. Furthermore, statistical significance was maintained after adjusting for sociodemographic variables (Model 1), with the following OR values for self-reported depression: 0.53 (95%CI: 0.48-0.59) for ideal vs. intermediate/poor cardiovascular score, 0.58 (95%CI: 0.48-0.70) for ideal vs. intermediate/poor behavioral score and 0.48 (95%CI: 0.43-0.54) for ideal vs. intermediate/poor biological score (Table 3).
Discussion
The study showed that having ideal cardiovascular health was inversely associated with a self-reported diagnosis of depression, compared to having intermediate/poor cardiovascular health. This relationship was significant for both the biological, behavioral and cardiovascular health components, and was maintained even after adjusting for sociodemographic variables.
In relation to the variables that make up the cardiovascular health score and the analysis of the association with the diagnosis of depression, it is known that some studies have already shown the effects of physical exercise in the prevention and treatment of depression46,47, as well as the effects of good nutrition20, controlled blood pressure24,25 and controlled blood glucose26. The components of the cardiovascular health score showed direct and significant associations between unhealthy behaviors (smoking, physical inactivity) and a diagnosis of depression48, corroborating the findings of this study.
There is evidence that there is a bidirectional association between CVD and depression. The association of these disorders arises because of a series of shared factors; biological and behavioral mechanisms and risk factors10,14. Individuals with CVD are two to three times more likely to develop depression49, and individuals with depression are more likely to develop CVD49,50.
Although there are few studies on the mechanisms involved in the cardiovascular health score and the development of depression, there are studies on the mechanisms of isolated score variables and the predisposition to develop depression18,20-24,51. One study showed that a lower intake of FV is related to depressive symptoms52, due to the influence of minerals, vitamins, amino acids, phytochemicals and antioxidant compounds, which in low concentrations interfere with inflammatory markers, oxidative stress and arterial stiffness53.
In this study, consumption of the ideal diet was low in relation to 2 important indicators, FVG and fish, which showed low prevalence (7.23% and 24.44%, respectively) (data not shown). For this reason, public policies are needed to enable greater access to healthy food and thus promote the fight against chronic non-communicable diseases (CNCDs) and contribute to achieving sustainable development goals54.
It should be noted that the ideal cardiovascular health score, made up of potential protective factors for cardiovascular diseases, and the inverse association with depression found in this study, is consistent with national and international evidence10,25,30. A prospective study of 732 Finnish female employees who were not initially depressed assessed ideal cardiovascular health metrics by means of physical examination and laboratory tests, medical history and self-assessment, and showed a higher risk of depressive symptoms in those with poor/intermediate cardiovascular health25.
In Dallas, Texas, another prospective epidemiological study was carried out between 1987 and 1998 with 5,510 participants in the Aerobics Center Longitudinal Study. The authors concluded that the ideal components of cardiovascular health show an inverse relationship with depressive symptoms, which was significant in the case of cardiovascular health behaviors, but not for cardiovascular health factors such as total cholesterol, blood pressure and fasting glycemia30.
Additionally, in agreement with the findings of this study, Elsa-Brasil, a multicenter cohort study of 15,105 active or retired civil servants aged 35 to 74, showed that poor cardiovascular health precedes the development of depression. In addition, adults without a diagnosis of depression were followed up for an average of 3 years and 8 months, and it was found that poor cardiovascular health tripled the risk of depression10.
It should be noted that depression is one of the conditions that contributes most to the global burden of mental health-related diseases in the world55, despite its underdiagnosis56. Due to its high prevalence, repercussions on general health and psychosocial impact, it constitutes a serious public health problem57.
Nowadays, the prevalence of unhealthy lifestyle habits and depressive symptoms may be higher than in the present study. In addition to changes in lifestyles, in terms of tobacco and alcohol consumption, diet and physical activity during the period of social restriction resulting from the COVID-19 pandemic, studies point to an increase in feelings of sadness, anxiety and nervousness, as well as sleep-related problems49,58. In the first year of the pandemic alone, anxiety and depression increased by more than 25%32.
In Brazil, the Unified Health System (SUS) serves around 190 million people, 71% of whom receive their healthcare exclusively through the public network59. Primary Health Care (PHC), the first level of the Health Care Network and the citizen’s preferred gateway to SUS health services, is a privileged space for welcoming the individual and working on actions to prevent and control mental disorders, aimed at health promotion and protection, disease prevention, diagnosis and treatment and rehabilitation actions in the individual and collective spheres60. Despite this, there is a large gap between the need for treatment of mental disorders and the provision of care56.
Mental health is not dissociated from general health, so recognizing that mental health demands are present in various complaints reported by users of health services is fundamental61. It should be emphasized that encouraging lifestyle changes and reducing risk factors are useful interventions for preventing mental health problems and this should be agreed between users and health professionals18,20-24, always based on the principle of equity and the leading role of the individual involved in their health production process.
Among the limitations of the study, as it is a self-report survey, the results are subject to memory limitations and underdiagnosis of hypertension, diabetes and dyslipidemia, i.e. some of the interviewees are unaware of the disease and do not mention the diagnosis62. Likewise, it is inferred that the prevalence of self-reported diagnosis of depression by the participants may be underestimated, as it is a limited indicator for estimating the prevalence of depression in the population, which should preferably be measured using a standardized and validated diagnostic instrument or clinical assessment55.
In addition, in the 2019 PNS, salt consumption was not measured using the sodium/creatinine ratio in a casual urine sample, but through the participant’s self-report, which may underestimate its prevalence; 80.59% reported consuming little salt, however, studies of laboratory data from the 2013 PNS estimated an average consumption of 9.34g of salt per day, in which 95% of the adult population had excessive salt consumption63.
In this study, when composing the cardiovascular health score, we used the ideal BMI cut-off point of <25 kg/m², as recommended by the AHA17 and used in national and international publications10,64. On the other hand, there is a clinical recommendation to consider a different cut-off point for the elderly, considering those with a BMI<27 kg/m² to be eutrophic, due to the fact that the body composition of the elderly is different from adults, associated with the aging process65,66. In a sensitivity analysis, in order to test the possible impact of a different cut-off point for elderly individuals in determining the cardiovascular health score and its relationship with depression, a cardiovascular health score was created considering an ideal BMI of less than 27 kg/m² for people aged 60 or over and less than 25 kg/m² for individuals under 60. We then tested the logistic regression model between this new cardiovascular health score and self-reported depression, obtaining an OR adjusted for sociodemographic variables of 0.56 (95%CI: 0.51-0.62) (data not shown). It should be noted that the adjusted OR, considering the ideal BMI below 25 kg/m² for the entire population, was 0.53 (95%CI: 0.48-0.59), as shown in this study. There was therefore a minimal difference in the ORs in terms of magnitude, maintaining the meaning and significance of the association. It was therefore decided to maintain the 25 kg/m² cut-off point for the general population to support the comparability of the findings with the literature.
This study makes progress by referring to a representative sample of the Brazilian population in assessing the association between cardiovascular health and self-reported depression. It also highlights the robustness and methodological rigor of the PNS, which configures the importance of these findings to emphasize public programs and policies aimed at comprehensive care for users of health services, which should include interprofessional actions aimed at the modifiable factors of the score.
Conclusion
The dimension of the ideal cardiovascular health score was inversely associated with the self-reported diagnosis of depression among Brazilian adults. In this context, we believe that the use of this score in the clinical practice of health professionals could help raise awareness of the importance of healthy lifestyle habits aimed at promoting health and preventing illnesses. In addition, the implementation of the score can contribute to comprehensive individual and collective health care, through interventions that promote the prevention of diseases and the investigation and screening of chronic conditions.
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