Mental Health’s Link to CVD Risk
By Carrie Dennett, MPH, RDN
Today’s Dietitian
Vol. 26 No. 2 P. 16
How Similar Nutrition and Lifestyle Interventions May Help Body and Mind
Humans are complex, and part of that complexity comes from the interplay of mind and body. On any given day, someone may notice how mental stress leads to muscle tension or how happiness makes them feel buoyant. But mind-body interactions go deeper, with research uncovering connections between mental health and heart health and how diet influences both.
A 2021 scientific statement from the American Heart Association says that clinicians traditionally have focused on specific physical conditions rather than the patient as a whole, and that includes giving less attention to psychological health and how that can contribute to physical health and disease. “However, there is now an increasing appreciation of how psychological health can contribute not only in a negative way to cardiovascular disease (CVD) but also in a positive way to better cardiovascular health and reduced cardiovascular risk,” the authors wrote.1
The statement outlined negative and positive psychological health traits. Negative traits include stress—as well as work-related stress—anxiety and depression, PTSD, social isolation and loneliness, pessimism, and anger and hostility. Positive traits include happiness, positive affect, emotional vitality, optimism, a sense of purpose, gratitude, psychological well-being, and mindfulness.1
“I can’t talk to my patients about their cardiovascular health without addressing their mental health,” said Erin Michos, MD, MHS, director of women’s cardiovascular health research at The Johns Hopkins University School of Medicine in Baltimore, while presenting at the annual meeting of the Food & Nutrition Conference & Expo in Denver in October.
In this article, Today’s Dietitian explores the association between decreased mental health and cardiovascular health and the impact optimal nutrition has on both.
Poor Mental Health, Poor Cardiovascular Health?
A 2020 study coauthored by Michos found that among patients admitted to the hospital with acute myocardial infarction (MI) from 2008 to 2017, the prevalence of people with mental health disorders—especially anxiety disorder and major depression—had increased. The percentage of patients with depression increased from 4.7% to 7.4%, while the percentage of patients with anxiety disorder increased from 3.2% to 8.9%.2 A 2022 study Michos also coauthored found that 30-day hospital readmission rates for MI were higher among patients with mental health disorders.3
Major depressive disorder and bipolar disorder in youth are considered moderate risk factors for early onset of CVD.4 A small 2014 study found that among post-MI patients younger than age 60, higher levels of depressive symptoms—both cognitive (sadness, guilty feelings, pessimism, sense of failure) and somatic (poor sleep, fatigue, low appetite)—were associated with an increased risk of developing myocardial ischemia (lack of blood flow from the coronary arteries to the heart) following mental stress.5
Being optimistic—expecting that good things will happen for you in the future—and having a purpose in life are both linked to better survival from CVD. A 2006 study found that elderly men with high optimism were 50% less likely than those with low optimism to die from a cardiovascular event.6 Similarly, 2001 results from the Veterans Affairs Normative Aging Study, which followed 1,306 healthy subjects for 10 years, found that those who spoke about life pessimistically were 56% more likely to experience angina and 55% more likely to experience a hard cardiac event such as MI or death compared with subjects who spoke with optimism.7 A 2022 systematic review and meta-analysis found that optimism was associated with a 13% lower risk of all-cause mortality and a 41% lower risk of CVD.8 A 2009 study using data from 1,238 community-dwelling older adults enrolled in the Rush Memory and Aging Project or the Minority Aging Research Study found that, after five years of follow-up, those with a high sense of purpose were 57% less likely to die than those with a low sense of purpose.9
Having positive social connections also may be important for cardiovascular health. “Those who are more socially isolated have more cardiovascular risk,” Michos says, citing a 2023 UK study that followed 18,509 people with diabetes for more than 10 years and found that loneliness was associated with a 20% increased risk of CVD.10 That makes it a bigger risk factor than depression and some “traditional” risk factors, such as high blood pressure and high blood sugar, smoking, low physical activity, and poor diet.
Psychological traits can influence cardiovascular health directly. Michos offered stress as an example. “Not all stress is bad. Stress is what helps us meet deadlines, but chronic stress can change some processes in the body.” Chronic stress—as well as anxiety, depression, anger, and negative outlook—can activate the hypothalamic-pituitary-adrenal axis and cause the autonomic nervous system to become dysregulated. These changes can then trigger the release of stress hormones, elevate heart rate and blood pressure, increase inflammation, stiffen the arteries, increase the risk of blood clots, and constrict blood vessels on the heart’s surface.1
In a 2017 study, researchers followed 293 people (without known CVD or cancer) after they had levels of activity in their amygdala (a brain region involved in stress) assessed after receiving a PET/CT scan. Patients who had increased amygdalar activity were 59% more likely to experience a CVD event during the median follow up of 3.7 years than were those with normal amygdalar activity.11
Connecting the Dots
Assessing the relationship between chronic stress, poor mental health, CVD, and observed psychological or behavioral traits sometimes is a chicken-or-the-egg scenario. A 2019 study found that people who slept less than six hours or more than nine hours per night were more likely to have a heart attack.12 Michos says this may be because short or long sleepers are more likely to be struggling with depression, other mental health concerns, or a chronic physical illness. In other words, is it the sleep pattern affecting the heart, or is a physical or mental illness affecting both sleep and the heart? For example, a 2021 study found that veteran women with PTSD had a 44% increased risk of cardiovascular death, possibly because trauma to the brain leads to mental disorders and CVD.13
A 2022 study presented two models that may explain the links between PTSD and CVD. One views PTSD as a mental health disorder that elicits stress-related physiological, psychological, and behavioral responses, which can then cause atherosclerosis. The second model characterizes PTSD as a systemic disorder that includes biological risk factor components, which can cause atherosclerosis directly—or indirectly through physiological or behavioral responses or via intermediate conditions such as hypertension, substance use disorder, or depression. Regardless of the pathway, atherosclerosis can go on to cause coronary heart disease and stroke.14
Such evidence and other research demonstrate that chronic stress and poor mental health can contribute to heart disease indirectly by affecting how patients take care of themselves. For example, some people may have adverse coping mechanisms such as smoking, overuse of alcohol, stress eating, not taking medication as prescribed, and not seeking preventive health care. On the flip side, positive psychological health is linked to lower blood pressure and better blood glucose control, as well as several beneficial behaviors—smoking cessation, increased physical activity, heart healthy eating, taking medications as prescribed, and keeping up with preventive health screenings.1 Social factors also may be at play.
The authors of the 2017 study that looked at amygdalar activity and CVD risk published a similar study in 2019; this one found that increased amygdalar activity is a connection between socioeconomic disparities and major adverse cardiac events such as cardiac death, MI, unstable angina, stroke, or heart failure. Specifically, lower neighborhood median income was associated with higher amygdalar activity. The authors note that lower socioeconomic status has been associated with both greater psychosocial stress and systemic inflammation, which in turn are linked with higher risk of cancer and CVD—two diseases correlated with low socioeconomic status.15 A person’s socioeconomic status is one example of social determinants of health, the conditions within the environment where people are born and live that affect health, functioning, and quality-of-life outcomes and risks.16
Kristina Petersen, an associate professor of nutritional sciences at Penn State University who copresented with Michos, says it’s important for dietitians to understand social determinants of health and factor them into their assessments. “Social determinants of health can be barriers or enablers to behavior change. If dietitians have information about a patient’s or client’s social context and reality, they will be able to better tailor MNT to suit the holistic needs of the person.”
Nutrition Interventions
Because mental health and cardiovascular health are intertwined, a nutrition intervention designed for heart health or general health should incorporate what’s known about how diet affects the brain and the heart. Petersen refers to research observing that a healthful dietary pattern that includes higher intakes of healthful food groups—fish, fruits, vegetables, whole grains, pulses, nuts and seeds, and soyfoods—is associated with a lower risk of depression, while an unhealthful “Western” dietary pattern containing higher amounts of meat, refined grains, fast food, and “junk” food is associated with an increased risk of depression.17
She also cites a 2022 systematic review and meta-analysis of 17 observational studies that found an association between increased intake of ultraprocessed food and greater risk of depression and anxiety,18 as well as associations between adherence to a Mediterranean-style diet and reduced risk of depression.19 But is it possible that social determinants of health may muddy those observations—that people with low socioeconomic status may consume more ultraprocessed foods due to accessibility and affordabilty, while people with a higher socioeconomic status may have the time and food budget to eat in a Mediterranean way and have better access to quality medical and mental health care?
Petersen says that most of the analyses examining the association between ultraprocessed foods and mental health disorders adjusted for certain socioeconomic status-related variables, such as income and education, but other factors typically weren’t considered, including food insecurity. “A few clinical trials have been conducted that show benefits of a Mediterranean diet, suggesting this may be a causal relationship,” Petersen says. “However, it’s important to acknowledge that a person’s ability to follow a healthful diet such as the Mediterranean diet will be influenced by social determinants of health.”
Recent evidence for a causal relationship comes from a 2019 systematic review and meta-analysis of dietary intervention studies that found that dietary interventions significantly reduced symptoms of depression, and in studies where most participants were female, dietary interventions decreased symptoms of anxiety.20 The 12-week SMILES (Supporting the Modification of lifestyle In Lowered Emotional States) randomized controlled trial found that structured dietary support focused on improving diet quality using a modified Mediterranean diet improved depressive symptoms better than social support,21 while the AMMEND (A Mediterranean Diet in MEN with Depression) randomized controlled trial found that a Mediterranean diet intervention improved symptoms in young men with moderate to severe clinical depression compared with a control group that received befriending therapy.22
“We know that diet quality at every life stage does affect health and wellbeing,” Petersen says. A poor diet, along with impaired sleep and reduced physical activity, are associated with major depressive disorder in what may be a bidirectional relationship.23 However, at least 150 minutes of moderate intensity physical activity per week can help buffer against stress, anxiety, and depression while directly benefiting heart health. Petersen says a healthful eating pattern is associated with a lower risk of depression, possibly because the vitamins, minerals, phytochemicals, fiber, and healthful fats have positive effects on the gut microbiota while helping to reduce levels of stress hormones, inflammation, and oxidative stress in the body.24
Petersen coauthored a 2021 study on the role of diet and nutrition in the prevention and management of depression and anxiety, also known as nutritional psychiatry.25 Despite a growing evidence base that relies less on observational research—which can’t determine whether poor diet and lifestyle contribute to depression and anxiety or vice versa—Petersen says more evidence about the efficacy of dietary intervention as an adjunctive therapy is needed. “Once the evidence is there for nutrition psychiatry to become more mainstream, insurance reimbursement will be needed, and mental health clinicians will need to refer patients,” she says. “Ultimately, there likely will need to be data to support the cost effectiveness and improvement in prognosis beyond what can be achieved with pharmacological or psychiatric therapy alone.” A 2022 review stated in its conclusion that dietitians should be aware of this growing evidence base, especially in relation to highly prevalent mental disorders.26
In broad strokes, dietary patterns that support mental health are aligned with those that bolster cardiovascular health. The healthy dietary patterns recommended in the Dietary Guidelines for Americans—which include a Mediterranean-style pattern—also are associated with reduced risk of CVD.27 American Heart Association recommendations for improving cardiovascular health and primary prevention of CVD are based on a diet rich in vegetables, fruits, whole grains, healthy sources of protein—such as pulses (beans and lentils), nuts, fish and seafood, low-fat or nonfat dairy products, and lean cuts of poultry or meat—and liquid plant oils.28,29 The diet limits refined grains, tropical oils, animal fats, processed meats, and foods and beverages with added sodium and sugars. It also keeps alcohol to moderate levels while recommending that people who don’t currently drink continue to abstain.
Lifestyle Interventions
While a nutrient-rich diet is important for physical and mental health, healthful lifestyle habits are too. Michos says that while many clinicians may not feel equipped to have substantial discussions about mental health, they can recommend exercise, meditation, or other self-care habits that can have both mental health and cardiovascular benefits.1 Dietitians also can discuss sleep habits with their clients and patients, ask what activities they do to relax and recharge, and find out if they’re keeping up with preventive and follow-up health care. Moreover, dietitians can include screening for psychological wellbeing in their assessments.
“Nutrition problems can be related to a person’s psychological wellbeing, therefore including a brief—one or two questions—assessment of wellbeing can help dietitians with the nutrition diagnosis and determining the nutritional intervention,” Petersen says. “For example, excessive intake may be related to high levels of stress and using food as a coping strategy.”
A few potential questions to ask patients include the following1:
• “How often do you experience pleasure or happiness in your life?” (Assesses positive affect)
• “How do you think things will go with your health going forward?” (Assesses optimism)
• “Do you ever feel grateful about your health/other things in your life?” (Assesses gratitude)
The American Heart Association offers information on managing and finding relief from stress, as well as more information on the links between stress, mental health, and heart health at heart. org/stress. Michos says that some stressors are difficult to modify because they may be related to factors such as socioeconomic status, discrimination, or living in an unsafe neighborhood. “I think too much blame is placed on the individual when they’re in a toxic environment, but having tools to buffer stress is still important,” Michos says. In addition to sleep, physical activity, and a nutritious diet, patients can build personal resilience against stress by learning healthful ways to cope, bonding with family and friends, practicing mindfulness, engaging in genuine laughter, reframing setbacks as opportunities, and cultivating gratitude (perhaps with a gratitude journal).30 Michos says self-compassion also is key. “I think we’re harder on ourselves than others are.”
— Carrie Dennett, MPH, RDN, is the nutrition columnist for The Seattle Times, owner of Nutrition By Carrie, and author of Healthy for Your Life: A Non-Diet Approach to Optimal Well-Being.
References
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