A study of cardiovascular risk among depressed obese patients

Chitra Singh; Mohd Wasim; RK Solanki

doi:10.4103/jmhhb.jmhhb_19_18

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Year : 2020 | Volume : 25 | Issue : 1 | Page : 5-9

A study of cardiovascular risk among depressed obese patients

Chitra Singh, Mohd Wasim, RK Solanki
Department of Psychiatry, SMS Medical College, Jaipur, Rajasthan, India

Date of Submission	12-May-2018
Date of Acceptance	10-Aug-2019
Date of Web Publication	7-Oct-2020

Correspondence Address:
Mohd Wasim
Department of Psychiatry, SMS Medical College, Jaipur, Rajasthan
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jmhhb.jmhhb_19_18

Abstract

Background: Both depression and obesity are widespread problems with major public health implications. Depression and obesity are both associated with an increased risk of cardiovascular disease (CVD) and with marked impairments in the quality of life. Aim and Objective: The aim of the study is to assess the CVD risk and cardiovascular risk factors among depressed obese individuals. Materials and Methods: Fifty patients of depression whose body mass index (BMI) >30 kg/m² and diagnosed with ICD-10 criteria of depression were selected as study group and 30 healthy obese of BMI >30 kg/m² without depression were selected as the control group for the study. The participants were divided into two groups: obese patients with depression and healthy obese individuals without depression. Fasting venous blood sample was collected under aseptic condition to estimate fasting blood sugar, total cholesterol, and high - density lipoprotein cholesterol. Using standard mercury manometer at least two readings at 5 - min intervals, were taken to measure the blood pressure (BP) in the supine position. Both the groups were subjected to specially designed pro forma which included personal and sociodemographic details and Framingham risk assessment tool for assessing cardiovascular risk. The cardiovascular risk was assessed and compared using Framingham risk score assessment tool. Results and Conclusion: Mean age of depressed obese was 46.44 ± 10.44 years and healthy obese had 47.33 ± 10.53. Mean BMI of study group was 32.82 ± 2.53 and healthy obese had 31.76 ± 1.66. BMI was significantly associated with depression. Presence of depression in obese patients increases the chances of CVD risk. Presence of smoking, hypertension, and high cholesterol in patients with depression, increase the risk of CVD, which can be modified by healthy diet, regular exercise, and BP management with periodic blood investigation and regular medication.

Keywords: Cardiovascular risk, depression, obesity

How to cite this article:
Singh C, Wasim M, Solanki R K. A study of cardiovascular risk among depressed obese patients. J Mental Health Hum Behav 2020;25:5-9

How to cite this URL:
Singh C, Wasim M, Solanki R K. A study of cardiovascular risk among depressed obese patients. J Mental Health Hum Behav [serial online] 2020 [cited 2023 Mar 26];25:5-9. Available from: https://www.jmhhb.org/text.asp?2020/25/1/5/297412

Introduction

Both depression and obesity are widespread problems with major public health implications.^[1],[2] Depression and obesity are both associated with an increased risk of cardiovascular disease (CVD)^[3],[4],[5] and with marked impairments in the quality of life.^[6],[7] Obesity is a major public health concern that is widely prevalent across all age groups and cultures. The prevalence of obesity varies across the world. Indian studies showed 15%–37% prevalence of overweight/obesity among the adult population aged between 20 and 60 years.^[8],[9],[10] In general, obesity is defined on the basis of body mass index (BMI). Individuals with a BMI ≥30 kg/m² are considered obese.^[11] The association of obesity and abnormal lipid levels with physical illnesses such as hypertension (HTN), diabetes mellitus (DM), and CVD has been well documented.^[12],[13] Previous studies reported a positive association of obesity with mood disorders (depression), anxiety disorders, eating disorders, and personality disorders,^[14],[15] which in turn may contribute to the development of obesity itself. This bidirectional association of obesity and psychiatric disorders was observed in a few studies.^[16],[17] Depression is an independent risk factor for the development of CVDs. Depression also raises the risk for further diseases, such as DM or obesity, which themselves are associated with higher cardiovascular risk.^[18]

The equation of the Framingham 10-year risk for CVD, derived from the Framingham heart study, has been validated and widely used in different populations to predict the 10-year risk of CVD, including angina, myocardial infarction (MI), stroke, transient ischemic attack and peripheral artery disease.^[19]

Hence, this study was carried out to assess the cardiovascular risk and cardiovascular risk variables (age, smoking, DM, HTN, total cholesterol, high - density lipoprotein (HDL) cholesterol, and systolic blood pressure (SBP) among depressed obese patients and non-depressed obese individuals. The study was carried out to assess cardiovascular risk and cardiovascular risk factors among depressed obese individuals.

Selection criteria

Inclusion criteria for study group

Patient diagnosed with depression as per the criteria given in ICD-10
Age 30–60 belonging to either sex
Patients with BMI >30 kg/m² calculated by Quetelet Index (kg/m²).

Inclusion criteria for healthy group

Healthy obese individuals who had no past or present history of physical or psychiatric illness.

Exclusion criteria

Participants having a prior history of CVD including MI, stroke, and any complication of DM.

Materials and Methods

A cross-sectional study was carried out in the Department of Psychiatry, SMS medical college, Jaipur, India, after taking permission from the Ethical Committee of Institution. Informed consent was obtained from all the participants participating in the study. Fifty patients of depression whose BMI >30 kg/m² and diagnosed with ICD-10 criteria of depression were selected as study group and thirty number of healthy obese of BMI >30 kg/m² without depression were selected as the control group for study, matched on sociodemographic variables (direct standardization) from community, patient's relative, and hospital staff.

The participants were divided into two groups, obese patients with depression and healthy obese individuals without depression. Fasting venous blood sample was collected under aseptic condition to estimate fasting blood sugar, total cholesterol, and HDL cholesterol. Using standard mercury manometer at least two readings at 5 - min intervals, were taken to measure the BP in the supine position. If BP was found to be high (≥140/90), then a third reading after 30 min was obtained; the lowest of these readings was taken. All the patients' personal and sociodemographic details were recorded and cardiovascular risk was assessed and compared using Framingham risk score assessment tool.

Ten years cardiovascular disease risk calculation^{[19],[20],[21]}

Framingham risk score provides an estimate of the chances that a person will develop CVD over a specified period, usually 10-year. The score is estimated on the basis of age, gender, total cholesterol, HDL cholesterol, systolic arterial pressure, HTN, DM, and smoking habit. On the basis of the Framingham risk score, CVD risk is estimated in terms of percentage. Higher percentage score indicates higher risk and the percentage scores are categorized arbitrarily into as low risk (10%) and high risk (>10%).

Statistical analysis

Statistical analysis was done using IBM Statistical Package for Window, version 23 (IBM coperation, Chicago). Frequencies with percentages were calculated for nominal and ordinal variables and mean and standard deviation (SD) were calculated for continuous variables. Group differences were analyzed with the help of frequency distribution, Chi-square test, and t-test for comparisons.

Results

Mean age of depressed obese was 46.44 ± 10.44 years and healthy obese had 47.33 ± 10.53. Mean BMI of study group was 32.82 ± 2.53 and healthy obese had 31.76 ± 1.66 (range 30–40 kg/m²). Age was not statistically significant (t = 0.358, df = 78, P = 0.72), but BMI in both groups was statistically significant (t = 2.023, df = 78, P = 0.047) [Table 1].

Table 1: Mean and standard deviation of age and body mass index of studied groups

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[Table 2] shows sociodemographic variables of study groups, two-third were female (64% in study group and 66.66% in control group). Fifty-four percent depressed obese and 63.33% healthy obese are from the urban locality. Nearly 90% are married in both groups. Healthy group was matched on sociodemographic variables with the study group; therefore, no differences were found in sociodemographic variables statistically in both groups.

Table 2: Sociodemographic variable of studied group

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[Table 3] shows that 36% depressed obese and 26.66% healthy obese have very high/high CVD risk score. These values were not statistically significant (χ² = 0.745, df = 1, P = 0.388).

Table 3: Framingham score (cardiovascular disease risk in 10 years) of studied group

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[Table 4] shows the prevalence of various CVD risk factors in both groups. The most commonly present CVD risk factor was high total cholesterol, age followed by, HDL cholesterol, HTN, smoking, DM, and high SBP. Among various CVD factors smoking (χ² = 5.569, df = 1, P = 0.018) and HTN (χ² = 7.172, df = 1, P = 0.007) had statistically significant value.

Table 4: Cardiovascular disease risk factors of the studied group

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Discussion

In this study, mean BMI of study group was 32.82 (SD ± 2.53) and healthy obese had 31.76 (SD ± 1.66) (range 30–40 kg/m²). The difference in BMI in both the groups was significant. BMI was significantly associated with depression. In this study, the most commonly present CVD risk factors were age, high total cholesterol, HDL cholesterol, HTN, smoking, DM, and high SBP. Among various CVD risk factors, smoking and HTN were statistically significant.

Studies have reported a strong association of CVD risk factors with both obesity and depression and associated with numerous health complications, including HTN, coronary heart disease, and increased mortality.^[22] Psychological stress experienced by people suffering from major depressive disorder (MDD) can also cause deregulation in the sympathetic nervous system and hypothalamic–pituitary–adrenal (HPA) axis.^[23],[24] This, in turn, has a number of deleterious downstream effects, including the development of HTN, left ventricular hypertrophy,^[25] coronary vasoconstriction, endothelial dysfunction,^{[26],[27],[28]} platelet activation, and the production of pro-inflammatory cytokines.^[29],[30] The potential consequence of this is an elevated risk in ventricular arrhythmias^[31] and MI.^[32]

It is well established that there are number of behavioral and lifestyle factors, which are present in MDD patients that can increase the chance of developing CHD.^[33] These include increased rates of smoking, alcohol intake, physical inactivity, and obesity.^[34] Furthermore, some antidepressant may also increase cardiovascular risk. The possible findings of excessive smoking habits in obese patients with depression could be its use to elevate mood. Currently, there are several hypotheses that have been proposed to explain the high rates of smoking in people with depression and anxiety. The self-medication hypothesis postulates that individuals turn to smoking to alleviate their symptoms.^{[35],[36],[37]} The effect of smoking on depression and anxiety can be explained by the neurobiochemical response mechanism of nicotine and monoamine oxidase. First, smoking increases the amount of nicotine in the blood. Then, nicotine promotes corticosteroid, a hormone in the body, by stimulating the HPA axis and increases the manifestation of messenger RNA related to steroids in the cells of the cerebral amygdala, which is in charge of emotions and feelings.^[38] Sedentary lifestyles are responsible for obesity and HTN.

On a behavioral level, depression is often associated with an unhealthy lifestyle such as smoking and physical inactivity. In addition, depressed patients also have more difficulties to implement recommended behavioral change.^[18] The major depression is associated with a significantly higher number of cardiovascular risk factors in the presence or absence of heart disease.^[39] It has also been found that the increased cardiovascular risk among individuals with depression is multifactorial and requires several strategies toward cardiovascular risk reduction, tobacco cessation, and for increasing physical activity in people with depression.^[40]

Limitations

The present study was a cross-sectional study having small sample size. The effect of lifestyle factors, physical activity levels, and dietary factors were not assessed which can also affect CVD risk. The association between severity of depression and CVD risk was also not evaluated.

Conclusion

BMI is significantly associated with depression. Presence of depression in obese patients increases chance of CVD risk. Presence of smoking, HTN, and high cholesterol in patients with depression, increase the risk of CVD.

General recommendations

There are following recommendations after evaluating the results of our study:

The assessment of patients of depression should definitely include significant risk factors such as smoking, HTN, and high cholesterol which can further be assessed for cardiovascular risk.
The patients of depression with significant risk factors smoking, HTN, and high cholesterol should be advised as:

Quit smoking, advise nicotine substitutes if needed
Controlling BP by regular morning exercise, dietary modifications (salt <5 mg/day), and antihypertensive medicine, if required
The medication to reduce cholesterol with dietary modifications, e.g., increase roughage and fiber contents in diet.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006;3:e442.
2.	Murray CJ, Lopez AD. Alternative projections of mortality and disability by cause 1990-2020: Global burden of disease study. Lancet 1997;349:1498-504.
3.	Ferketich AK, Schwartzbaum JA, Frid DJ, Moeschberger ML. Depression as an antecedent to heart disease among women and men in the NHANES I study. National health and nutrition examination survey. Arch Intern Med 2000;160:1261-8.
4.	Grundy SM, Hansen B, Smith SC Jr., Cleeman JI, Kahn RA; American Heart Association, et al. Clinical management of metabolic syndrome: Report of the American Heart Association/National Heart, Lung, and Blood Institute/American Diabetes Association conference on scientific issues related to management. Circulation 2004;109:551-6.
5.	Nguyen NT, Nguyen XM, Wooldridge JB, Slone JA, Lane JS. Association of obesity with risk of coronary heart disease: Findings from the national health and nutrition examination survey, 1999-2006. Surg Obes Relat Dis 2010;6:465-9.
6.	Fontaine KR, Barofsky I. Obesity and health-related quality of life. Obes Rev 2001;2:173-82.
7.	Spitzer RL, Kroenke K, Linzer M, Hahn SR, Williams JB, deGruy FV 3^rd, et al. Health-related quality of life in primary care patients with mental disorders. Results from the PRIME-MD 1000 study. JAMA 1995;274:1511-7.
8.	Obesity Update; 2012. Available from: http://www.oecd.org/health. [Last accessed on 2014 Jan 29].
9.	Uthakalla VK, Kumar KJK, Jena, Sekhar KC, Tondare D, Chandra VD. Prevalence study of overweight and obesity among adults (20–60 years old) of urban field practice area of Osmania Medical College, Hyderabad. Indian J Public Res Dev 2012;3:250-3.
10.	National Family Health Survey 2005-2006 (NFHS-3) India Reports. Vol. 1. Available from: http://www.nfhsindia.org. [Last accessed on 2014 Apr 30].
11.	World Health Organization/International Association for the Study of Obesity Task force. The Asia Pacific Perspective: Redefining Obesity and its Treatment. Available from: http://www.idi.org.au/obesityreport.htm. [Last accessed on 2014 Jan 29].
12.	Reis JP, Loria CM, Lewis CE, Powell-Wiley TM, Wei GS, Carr JJ. Association between duration of overall and abdominal obesity beginning in young adulthood and coronary artery calcification in middle age. JAMA 2013;310:280-8.
13.	Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity. JAMA 1999;282:1523-9.
14.	Carpenter KM, Hasin DS, Allison DB, Faith MS. Relationships between obesity and DSM-IV major depressive disorder, suicide ideation, and suicide attempts: Results from a general population study. Am J Public Health 2000;90:251-7.
15.	Luppino FS, de Wit LM, Bouvy PF, Stijnen T, Cuijpers P, Penninx BW, et al. Overweight, obesity, and depression: A systematic review and meta-analysis of longitudinal studies. Arch Gen Psychiatry 2010;67:220-9.
16.	Roberts RE, Deleger S, Strawbridge WJ, Kaplan GA. Prospective association between obesity and depression: Evidence from the alameda county study. Int J Obes Relat Metab Disord 2003;27:514-21.
17.	Jorm AF, Korten AE, Christensen H, Jacomb PA, Rodgers B, Parslow RA. Association of obesity with anxiety, depression and emotional well-being: A community survey. Aust N Z J Public Health 2003;27:434-40.
18.	Kuehl LK, Penninx BW, Otte C. Depression: Risk factor for cardiovascular disease. Nervenarzt 2012;83:1379-84.
19.	D'Agostino RB Sr., Vasan RS, Pencina MJ, Wolf PA, Cobain M, Massaro JM, et al. General cardiovascular risk profile for use in primary care: The Framingham heart study. Circulation 2008;117:743-53.
20.	Wilson PW, D'Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation 1998;97:1837-47.
21.	D'Agostino RB, Russell MW, Huse DM, Ellison RC, Silbershatz H, Wilson PW, et al. Primary and subsequent coronary risk appraisal: New results from the Framingham study. Am Heart J 2000;139:272-81.
22.	Faith MS, Matz PE, Jorge MA. Obesity-depression associations in the population. J Psychosom Res 2002;53:935-42.
23.	Esler M, Turbott J, Schwarz R, Leonard P, Bobik A, Skews H, et al. The peripheral kinetics of norepinephrine in depressive illness. Arch Gen Psychiatry 1982;39:295-300.
24.	Veith RC, Lewis N, Linares OA, Barnes RF, Raskind MA, Villacres EC, et al. Sympathetic nervous system activity in major depression. Basal and desipramine-induced alterations in plasma norepinephrine kinetics. Arch Gen Psychiatry 1994;51:411-22.
25.	Schlaich MP, Kaye DM, Lambert E, Sommerville M, Socratous F, Esler MD. Relation between cardiac sympathetic activity and hypertensive left ventricular hypertrophy. Circulation 2003;108:560-5.
26.	Rubanyi GM. The role of endothelium in cardiovascular homeostasis and diseases. J Cardiovasc Pharmacol 1993;22 Suppl 4:S1-14.
27.	Ghiadoni L, Donald AE, Cropley M, Mullen MJ, Oakley G, Taylor M, et al. Mental stress induces transient endothelial dysfunction in humans. Circulation 2000;102:2473-8.
28.	Spieker LE, Hürlimann D, Ruschitzka F, Corti R, Enseleit F, Shaw S, et al. Mental stress induces prolonged endothelial dysfunction via endothelin-A receptors. Circulation 2002;105:2817-20.
29.	Brydon L, Edwards S, Jia H, Mohamed-Ali V, Zachary I, Martin JF, et al. Psychological stress activates interleukin-1beta gene expression in human mononuclear cells. Brain Behav Immun 2005;19:540-6.
30.	von Känel R, Kudielka BM, Preckel D, Hanebuth D, Fischer JE. Delayed response and lack of habituation in plasma interleukin-6 to acute mental stress in men. Brain Behav Immun 2006;20:40-8.
31.	Meredith IT, Broughton A, Jennings GL, Esler MD. Evidence of a selective increase in cardiac sympathetic activity in patients with sustained ventricular arrhythmias. N Engl J Med 1991;325:618-24.
32.	Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005;352:539-48.
33.	Joynt KE, Whellan DJ, O'Connor CM. Depression and cardiovascular disease: Mechanisms of interaction. Biol Psychiatry 2003;54:248-61.
34.	Stapelberg NJ, Neumann DL, Shum DH, McConnell H, Hamilton-Craig I. A topographical map of the causal network of mechanisms underlying the relationship between major depressive disorder and coronary heart disease. Aust N Z J Psychiatry 2011;45:351-69.
35.	Chaiton MO, Cohen JE, O'Loughlin J, Rehm J. A systematic review of longitudinal studies on the association between depression and smoking in adolescents. BMC Public Health 2009;9:356.
36.	Boden JM, Fergusson DM, Horwood LJ. Cigarette smoking and depression: Tests of causal linkages using a longitudinal birth cohort. Br J Psychiatry 2010;196:440-6.
37.	Taylor G, McNeill A, Girling A, Farley A, Lindson-Hawley N, Aveyard P, et al. Change in mental health after smoking cessation: Systematic review and meta-analysis. BMJ 2014;348:g1151.
38.	Haustein KO, Haffner S, Woodcock BG. A review of the pharmacological and psychopharmacological aspects of smoking and smoking cessation in psychiatric patients. Int J Clin Pharmacol Ther 2002;40:404-18.
39.	Katon WJ, Lin EH, Russo J, Von Korff M, Ciechanowski P, Simon G, et al. Cardiac risk factors in patients with diabetes mellitus and major depression. J Gen Intern Med 2004;19:1192-9.
40.	Bivanco-Lima D, Souza Santos ID, Vannucchi AM, Almeida Ribeiro MC. Cardiovascular risk in individuals with depression. Rev Assoc Med Bras (1992) 2013;59:298-304

Tables

[Table 1], [Table 2], [Table 3], [Table 4]

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