Abstract
Study objective
Depression and education have associations with cardiovascular health. We hypothesized educational attainment would modify the association between depression and cardiovascular health.
Design
We used the Patient Health Questionnaire (PHQ), a validated instrument to categorize individuals as having minimal (0–4), moderate (5–9) or severe (≥10) depression. We employed the American Heart Association's Life's Simple 7 (LS7) comprised of known cardiovascular risk factors. In multivariable-adjusted analyses we related PHQ to cardiovascular health measured by LS7. We then evaluated the modification of the association between depression and cardiovascular health by educational attainment.
Participants
Individuals age ≥18 years participating in the National Health and Nutrition Examination Survey 2013–214 and 2015–16 cycles.
Main outcome measures
LS7, continuous (0–14) and categorized as poor (0–4), intermediate (5–9) or ideal (10–14).
Results
In total 8727 individuals (age 48 ± 17 years; 51% female sex; 70% white race; 14% < high school graduate; 32% ≥ college graduate) were included. Among those with mild depression, educational attainment greater than a high school degree or equivalent was significantly more likely to have higher LS7 scores than those without high school graduation. In participants with moderate depression, only those with college education or greater were more likely to have higher LS7 scores (odds ratio [OR] 3.49, 95% confidence interval [CI] 2.01–6.08). In those with severe depression, educational attainment did not modify LS7 scores.
Conclusions
Our findings suggest that educational attainment modifies the association between depression and cardiovascular health. This study provides insight on how social factors modify depression, a well-recognized contributor to cardiovascular health.
Keywords: Cardiovascular health, Education attainment, Major depressive disorder, Preventive health
Highlights
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Depression is well recognized as contributing to cardiovascular health (CVH).
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We examined how education modifies the relation of depression and CVH.
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In mild depression, higher education attenuated the effect of depression on CVH.
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When severe, education did not attenuate the effect of depression on CVH.
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Addressing depression as a part of CVH remains a priority.
1. Introduction
The American Heart Association developed “Life's Simple Seven” (LS7) to facilitate cardiovascular health assessment and easily identify fundamental, modifiable contributors to cardiovascular disease [1]. LS7 categorizes cardiovascular risk factors as poor, intermediate, or ideal health, utilizing a validated, cumulative score that has been related to cardiovascular disease outcomes [2], [3].
Major depressive disorder constitutes an additional, critical risk factor for worsened quality of life, morbidity, and mortality [4], [5]. Depression is one of the most common psychiatric diseases with a lifetime prevalence estimated as exceeding 20% [6]. While LS7 assesses modifiable health behaviors and biometric markers of health, the prognostic model does not account for depression or other mental health disorders [7], [8], [9], [10], [11], [12], [13]. Several population-based and nationally representative studies have demonstrated a graded relationship between depression and cardiovascular health [4], [14], [15], [16].
Likewise, educational attainment has been shown to have an association with cardiovascular health outcomes, particularly in developed countries where studies have identified association between higher educational attainment and healthier, longer life [17], [18], [19]. While socioeconomic factors like educational attainment do have a notable association with cardiovascular health, how such social risk factors exacerbate the relation between depression and cardiovascular health merits elucidation [5], [14], [19], [20], [21], [22]. In the current analysis, we aimed to determine the effect of educational attainment on the association between depression and cardiovascular health in a large, socially diverse, population-based study.
2. Methods
2.1. Cohort selection
The National Health and Nutrition Examination Survey (NHANES) assesses the health and nutritional status of US adults and children [23]. Every 2 years, a nationally representative sample is surveyed and asked detailed questions regarding their demographics and social information such as education, household income, nutritional intake and health-related information. A detailed physical exam, vital sign, and biometric laboratory assessment are conducted. The design and operational process of the NHANES survey and its approval by the National Center for Health Statistics Research Ethics Review Board have been previously described [24]. In our study, we assessed survey data conducted in the 2013–14 and 2015–16 examination cycles. Participants were included in this analysis if they were age ≥18 years and completed both the interview and medical examination components.
2.2. Measurement of cardiovascular health
Cardiovascular health metrics included 3 modifiable health behaviors (smoking, physical activity, health dietary scores) and 4 measured health factors (body mass index, total cholesterol, blood pressure, and plasma glycohemoglobin level). Supplementary Table 1 lists each metric and its categorization as poor, intermediate, or ideal using LS7 [25].
Smoking history, physical activity, and dietary patterns were self-reported. Participants reported current smoking status as current, former, or never smoker. Participants also reported frequency and duration of physical activity over the past 7 days. Calculated totals were used to categorize level of physical activity as poor, intermediate, or ideal based on time engaged in moderate and vigorous activity. Dietary scores were calculated based upon the total number of servings of fruit, vegetables, whole grains, sugar-sweetened beverages, and sodium intake over 24 h, as previously described [26]. NHANES reports each food item with a US Department of Agriculture food code and portion size [27]. Body mass index was calculated as weight in kilograms divided by height in meters squared.
Total cholesterol and glycohemoglobin (Hgb A1c) were measured with standardized laboratory techniques [23]. As only a subset of NHANES participants had fasting plasma glucose, we employed serum Hgb A1c as consistent with prior NHANES studies [28], [29], [30], [31]. Participants had three blood pressure readings taken over 5 min in a seated position, and the average of the three was used. Participants with a self-reported history of hyperlipidemia, hypertension, and/or diabetes were scored as “intermediate” if treated to goal, or “poor,” if not at goal as defined by American Heart Association and American College of Cardiology guidelines [32], [33], [34].
We calculated a summary LS7 score for each participant in accordance with the American Heart Association's categorization of each component as poor, intermediate, and ideal (Supplementary Table 1). Those metrics which were ideal received two points, those intermediate one point, and those deemed poor zero points, achieving a continuous score range from 0 to 14. We then categorized LS7 scores as poor (0–4), intermediate (5–9), or ideal (10–14) as defined by the development of LS7 [25], [35].
2.3. Depression
Depression was assessed using the Patient Health Questionnaire (PHQ-9), a validated, nine-item screening instrument designed to assess the frequency of depression symptoms over the past two weeks and correlated with depression severity [21]. Responses to each question include “not at all”, “several days”, “more than half the days” and “nearly every day” where 0, 1, 2 and 3 points are scored for each response. Continuous PHQ-9 scores were calculated by summing the points of each PHQ-9 question and categorizing into three levels: minimal (0–4), moderate (5–9), and severe (≥10).
2.4. Covariates
Demographic factors (age, sex, race/ethnicity), clinical covariates (history of cardiovascular disease or stroke), and social factors (educational attainment, poverty-income ratio), and health insurance status were obtained during the NHANES interview. Race/ethnicity was classified as non-Hispanic White, Mexican American, other Hispanic, non-Hispanic Black, non-Hispanic Asian, or other. Educational attainment was categorized as less than high school degree, high school degree or equivalent, some college, or college graduate. Poverty-income ratio was calculated using the Department of Health and Human Services' poverty guidelines to divide family income by the poverty threshold specific to family size [23]. Ratios less than one indicate a family income below the poverty level and ratios greater than or equal to one indicate family income at or above. To assess health insurance status, participants indicated their health insurance status.
2.5. Statistical analysis
We summarized continuous variables by their mean and standard deviations and categorical variables by their frequencies and proportions. Participants missing data for LS7, depression, and education were included in analyses and assumed to be not missing completely at random. We analyzed the frequency and proportion of each LS7 category across depression groups and used a chi-squared test to detect significant differences across the score distributions. Additionally, we plotted continuous LS7 scores (0–14) by depression group as cumulative proportions.
We used multivariable ordinal logistic regression to model associations between depression group (minimal, moderate, severe) and the outcome, LS7 category, across the lower ordered categories of LS7 (poor and intermediate). Covariates were assessed by percent agreement and changes in regression coefficients and C-statistics after inclusion. The proportional odds assumption was assessed with the Brant test (p > 0.05). Missing data for predictors were incorporated into analyses by specifying the ‘nomcar’ option in each model using the ‘proc surveylogisitic’ statements in SAS 9.4 (SAS Institute, Cary, NC). This option computes variance estimates by analyzing both missing and non-missing outcomes and treating the non-missing values as a domain or a subpopulation thereby increasing the standard errors of the point estimates.
Ordinal logistic regressions models are shown in Supplementary Table 2 and consisted of (1) depression group and education; (2) model 1 + the interaction term of depression group and education; (3) model 2 + age (per 5 years), sex, and race/ethnicity; (4) model 3 + history of cardiovascular disease or stroke; (5) model 4 + health insurance status and income-poverty ratio. Model 3 through 5 were used to assess for goodness-of-fit using the C-statistic. To further investigate the effect modification of education on the relation between depression group and LS7 category using model 3, the differences of the interaction terms least square means were calculated by adding an ‘lsmeans’ statement to the SAS ‘proc surveylogistic’ command. The Brant test was performed in Stata 16.1 [36]. For all analyses, a two-tailed p-value of ≤0.05 was considered significant. All analyses used the weighting and complex survey procedures as specified by the NHANES analytics protocol [37].
3. Results
The total cohort was 8727 participants with complete PHQ-9 and LS7 data, described as age 48.1 ± 16.7 years; 51.7% women; 69.5% non-Hispanic White; 13.8% with less than a high school education; 21.0% with high school degree or equivalent; and 33% with some college education. Most individuals (6522) scored 0–4, indicating minimal depression, while 782 scored ≥10. There were 2843 individuals categorized as having ideal cardiovascular health while 394 were categorized as poor. The distribution of PHQ scores across the cohort is summarized in Table 1.
Table 1.
Participant demographics for minimal, moderate and severe depression.
| All participants |
Minimal |
Moderate |
Severe |
|
|---|---|---|---|---|
| n = 8727 | n = 6522 | n = 1423 | n = 782 | |
| Age, years (mean, SD) | 48.2 (16.7) | 48.0 (16.7) | 49.0 (17.0) | 49.0 (16.3) |
| Male sex (n, %) | 4226 (48.6) | 3355 (51.8) | 576 (39.9) | 295 (35.8) |
| Race/ethnicity (n, %) | ||||
| Hispanic | 2364 (15.1) | 1764 (15.2) | 371 (14.9) | 229 (15.5) |
| NH Black | 1733 (10.7) | 1273 (10.2) | 313 (12.3) | 147 (11.6) |
| NH Asian | 858 (4.7) | 723 (5.2) | 103 (3.7) | 32 (2.2) |
| NH White | 3477 (69.5) | 2557 (69.4) | 584 (69.1) | 336 (70.7) |
| Education (n, %) | ||||
| Less than high school | 1810 (13.8) | 1213 (12.2) | 335 (16.8) | 262 (23.2) |
| High school or equivalent | 1881 (21.0) | 1366 (20.1) | 342 (23.8) | 173 (24.5) |
| Some college | 2574 (32.7) | 1903 (31.8) | 435 (35.6) | 236 (36.0) |
| College or greater | 2201 (32.4) | 1833 (35.9) | 275 (23.8) | 93 (16.3) |
| Previously diagnosed CVD or stroke (n, %) | 381 (3.5) | 227 (2.9) | 95 (5.4) | 59 (5.8) |
| Health insurance, yes (n, %) | 7020 (84.7) | 5301 (85.7) | 1113 (81.6) | 606 (80.8) |
| Income-poverty ratio (mean, SD) | 3.0 (1.6) | 3.2 (1.6) | 2.6 (1.6) | 2.1 (1.5) |
| Life's Simple 7 score category (n, %) | ||||
| Ideal | 2843 (36.1) | 2320 (39.1) | 389 (30.8) | 134 (18.1) |
| Intermediate | 5490 (60.1) | 3966 (58.0) | 949 (63.8) | 575 (72.9) |
| Poor | 394 (3.8) | 236 (2.9) | 85 (5.4) | 73 (9.0) |
Depression defined as minimal (PHQ scores 0–4), moderate (5–9) and severe (>10) depression.
Abbreviations: SD, standard deviation; NH, non Hispanic; HS, high school; GED, General Education Development; CVD, cardiovascular disease.
Significant differences in LS7 measures were found between those with severe and minimal depression with respect to physical activity, smoking, body mass index, levels, blood pressure and glycohemoglobin. There was no statistically significant difference between severe and minimal depression in diet and cholesterol levels. These data are seen in Table 2 which shows the distributions of ideal and poor cardiovascular health for each measure of the LS7 by depression category. Fig. 1 presents the cumulative proportion of LS7 scores by depression severity. The figure demonstrates the increased concentration of participants with moderate and severe depression at lower LS7 scores.
Table 2.
Characterization of ideal versus poor cardiovascular health for each Life's Simple 7 measure according to depression category (minimal or severe) in 8727 NHANES participants.
| Total |
Minimal |
Moderate |
Severe |
p-Value |
|
|---|---|---|---|---|---|
| n = 8727 | n = 6522 | n = 1423 | n = 782 | ||
| Overall Life's Simple 7 | <0.01 | ||||
| Ideal | 2843 (36.1) | 2320 (39.1) | 389 (30.8) | 134 (18.1) | |
| Poor | 394 (3.8) | 236 (2.9) | 85 (5.4) | 73 (9.0) | |
| Physical activity | <0.01 | ||||
| Ideal | 5247 (63.6) | 4053 (65.8) | 823 (59.7) | 371 (50.2) | |
| Poor | 2180 (21.7) | 1505 (19.8) | 388 (25.7) | 287 (31.8) | |
| Diet | 0.75 | ||||
| Ideal | 11 (0.2) | 8 (0.2) | 2 (0.2) | 1 (0.1) | |
| Poor | 6040 (69.9) | 4477 (69.7) | 997 (69.5) | 566 (72.1) | |
| Smoking | <0.01 | ||||
| Ideal | 6828 (78.8) | 5309 (82.2) | 1043 (73.4) | 476 (57.9) | |
| Poor | 1691 (18.6) | 1065 (15.4) | 350 (24.1) | 276 (38.2) | |
| Body mass index | <0.01 | ||||
| Ideal | 2421 (27.8) | 1902 (29.0) | 335 (23.7) | 184 (24.0) | |
| Poor | 3469 (39.5) | 2424 (37.3) | 643 (44.0) | 402 (51.9) | |
| Cholesterol | 0.06 | ||||
| Ideal | 5424 (60.8) | 4077 (61.2) | 874 (59.5) | 473 (60.0) | |
| Poor | 997 (12.1) | 710 (11.4) | 191 (14.7) | 96 (13.8) | |
| Blood pressure | 0.04 | ||||
| Ideal | 3876 (47.4) | 2952 (48.2) | 605 (45.3) | 319 (43.7) | |
| Poor | 1589 (15.6) | 1120 (14.8) | 301 (17.4) | 168 (18.8) | |
| Glycohemoglobin | <0.01 | ||||
| Ideal | 5245 (67.3) | 4027 (69.2) | 806 (62.9) | 412 (57.9) | |
| Poor | 1046 (9.0) | 705 (8.0) | 205 (11.4) | 136 (14.3) |
Fig. 1.
Association between cumulative Life’s Simple 7 scores and depression severity. The figure demonstrates the differences in cardiovascular health as measured by Life's Simple 7 across categories of depression.
Odds ratios are cumulated for both intermediate and ideal cardiovascular health. Estimates are presented by level of educational attainment, employing education less than high school as the referent. For individuals with minimal depression, those with a high school degree had 1.3-fold (95% CI 1.04–1.60) increase association of higher LS7 scores than those with less than high school education. Similarly, in participants with minimal depression, those with some college (OR 1.80, 95% CI 1.42–2.28) or college degree (OR 3.39, 95% CI 2.78–4.14) were significantly more associated with higher LS7 scores than those with less than high school education. In contrast, among those with moderate depression, only participants with college degree – the highest category of educational attainment – were associated with higher LS7 scores compared to participants with less than high school. Most importantly, in participants with severe depression, educational attainment was no longer associated with higher LS7 scores. Table 3 presents these multivariable-adjusted estimates of the likelihood of higher LS7 scores, and therefore overall better cardiovascular health, by depression category.
Table 3.
Association of depression (minimal, moderate, and severe) and likelihood of improved cardiovascular health by educational attainment, in reference to less than high school.
| Depression level | High school or equivalent |
Some college |
College degree |
|||
|---|---|---|---|---|---|---|
| OR | 95% CI | OR | 95% CI | OR | 95% CI | |
| Minimal | 1.29 | 1.04–1.60 | 1.80 | 1.42–2.28 | 3.39 | 2.78–4.14 |
| Moderate | 1.58 | 0.93–2.67 | 1.31 | 0.90–1.91 | 3.49 | 2.01–6.08 |
| Severe | 0.80 | 0.47–1.38 | 1.13 | 0.53–2.42 | 1.31 | 0.71–2.43 |
OR indicates odds ratio; CI, confidence interval. Estimates are adjusted for age, sex and race/ethnicity.
Fig. 2 graphically presents the relation of depression to cardiovascular health across educational categories, again employing less than high school educational attainment as the referent. The figure further demonstrates that education attainment has a significant effect on individuals with mild depression while educational attainment has no effect on cardiovascular health in individuals with severe depression.
Fig. 2.
Odds of higher cardiovascular health scores by depression as (PHQ-9 scores) and educational attainment. Higher educational attainment attenuates the effect of depression on cardiovascular health. Participants with at least college degree or greater in all depression groups are now associated with increased odds of higher cardiovascular health.
Abbreviations: HS, high school.
4. Discussion
We examined the relation between depression and cardiovascular health as measured by the American Heart Association's Life's Simple 7, or LS7, and its modification by educational attainment. The LS7 has become widely accepted as a summary measure to identify health metrics and behaviors, and thereby focus interventions to optimize cardiovascular health. Missing from the LS7, however, are (1) mental health, particularly depression, which is highly prevalent and has strong associations with cardiovascular health and outcomes, and (2) social factors such as educational attainment, which likewise have associations with health-related access and outcomes. In this analysis, foremost determined that educational attainment did not attenuate the relation of depression with cardiovascular health. Our findings have relevance to understanding the effect of education on the relation between depression and cardiovascular health.
Prior studies have established reciprocal associations between depression and cardiovascular health. In a large-sized, community-based sample of adults, symptoms of depression were associated with worse cardiovascular health [14]. The Aerobics Center Longitudinal Study found that those with ideal cardiovascular health were less likely to develop depressive symptoms. Notably, this cohort was approximately 80% men, and included primarily individuals of white race with high levels of education and income [15], [38]. A cross-sectional study conducted in China identified ideal cardiovascular health was associated with a lower prevalence of depression [16]. A prior analysis in NHANES spanning 2007–2014 also found an association between depression and poor cardiovascular health [4]. Our work extends these prior studies by examining the effect of educational attainment on the relation between depression and cardiovascular health. Our results show that educational attainment has a differential effect on the association of depression with cardiovascular health.
Historically, age, sex, family history, smoking, hypertension, diabetes, cholesterol, obesity and physical inactivity have been recognized as “traditional risk factors” for cardiovascular disease [39]. A growing body of evidence has demonstrated that depression may be a valuable predictor of cardiovascular health and thus should be a target for preventive strategies to reduce cardiovascular morbidity and mortality [40], [41]. Similarly, various social factors such as income level, educational ascertainment, health literacy, and access to high-value care play a complex role on our overall health [42], [43]. In particular, research has further demonstrated the significant associations of educational attainment with physical and cardiovascular health [43], [44], [45], [46], [47]. Education and depression have their own complicated relationship and association on cardiovascular health. We further examine these associations using effect modification with educational attainment. Our results suggest that educational attainment does modify the association between depression and cardiovascular health.
More specifically, our results suggest that higher educational attainment in those with mild and moderate depression is associated with better cardiovascular health. More importantly, our results suggest that higher educational attainment in those with severe depression is no longer associated with better cardiovascular health. We suggest that severe depression is a significant risk factor for poor cardiovascular health regardless of how much education an individual has attained. These results may be even further indication to ask about depression, regardless of education level. Further research can be done to evaluate other social resources and their effect on the relationship between depression and cardiovascular health.
Our study has several strengths. First, our study used a population-based sample that is designed as being nationally representative. Second, we employed a validated metric for cardiovascular health assessment, the LS7, which has been broadly adopted for cardiovascular risk measurement and has been demonstrated to predict mortality and cardiovascular disease risk and events [48]. We additionally recognize multiple limitations to our work. First, the cross-sectional design of NHANES precludes assessing the temporal association of depression with cardiovascular health. We note that prior literature has also examined if cardiovascular health is protective against depression. Our analysis is not able to preclude such a reciprocal association. Second, albeit designed as representative, NHANES does not enroll institutionalized individuals and may consequently be biased towards a healthier population. Third, like many community-based studies, NHANES uses self-report. As a result, measures such as physical activity, dietary history, and smoking – all integral to the LS7 – may be subject to recall or other bias, and we are not able to ascertain if depression has an effect on such potential bias. Fourth, we note that ideal diet habits were extremely rare in this cohort with 0.2% of the cohort having ideal dietary habits. We note this significant limitation to our study as there is a clear known association between poor diet alone and cardiovascular health. Therefore, we may have a cohort with worse cardiovascular overall than would be expected at a national level. Further research is may be indicated with an even more randomized demographic profile. Fifth, we are not able to exclude residual confounding due to unmeasured factors that affect depression and cardiovascular health. Finally, we note a limitation for the ‘n’ of the severe depression group which is significantly smaller than for minimal depression.
In conclusion, our results identify the varied effect of educational attainment on the association between depression and cardiovascular health. Our results suggest that in individuals with mild depression, higher levels of educational attainment are associated with higher LS7 scores. In contrast, such an association is not present in those with severe depression. Our results reinforce the importance of addressing depression, particularly when severe, regardless of social assets, resources or education, as part of cardiovascular assessment and prevention.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgments
Acknowledgements
None.
Sources of funding
None.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.ahjo.2021.100062.
Appendix A. Supplementary data
Supplementary tables
References
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