The Role of Anxiety in Metabolic Syndrome

Aline Sardinha; Antonio E Nardi


Expert Rev Endocrinol Metab. 2012;7(1):63-71. 

In This Article

Abstract and Introduction


Metabolic syndrome (MS) seems to be associated with both depression and increased cardiovascular risk. This article emphasizes the most relevant findings on the link between MS and psychological cardiovascular risk factors, focusing on the impact of anxiety. There is evidence for an association between psychological disorders and the development of MS, which could eventually increase cardiovascular risk. However, the coexistence of anxiety in MS patients seems to be a byproduct of anxiety–depression comorbidity, stress and negative health behaviors. Endocannabinoid receptors, and hypothalamic–pituitary–adrenal axis dysregulation and sympathetic hyperactivation are the most commonly mentioned plausible underlying pathways.


Psychological factors are known to play a role in cardiovascular risk by contributing significantly to the pathogenesis, development and aggravation of coronary artery disease (CAD).[1] This evidence is composed largely of data relating increased cardiovascular risk to five specific psychosocial domains: depression, anxiety, personality factors and character traits, social isolation and chronic life stress.[2] However, most research on the role of emotional disturbances in cardiovascular outcome has focused on depression. Earlier studies relating depression and CAD have highlighted the physiological mechanisms mediating this association, leading to the identification of shared genetic determinants, inflammation, blood clotting and vascular mechanisms as plausible explanatory hypotheses.[3] Subsequently, behavioral aspects started to be addressed, and an indirect association with increased cardiovascular risk through an unhealthy lifestyle linked to depression and stress (tobacco use, alcohol abuse, sedentarism, obesity, and so on) has been hypothesized.[4]

Until recently, evidence linking anxiety to cardiovascular risk was limited to demonstrations of elevated mortality rates among psychiatric patients with anxiety disorders.[5] Increasing evidence now links anxiety to cardiac events in the general population.[2] Additionally, anxiety seems to predict a greater risk of major adverse cardiac events in patients with stable CAD and to negatively influence the development and prognosis of CAD through hyperactivation of the autonomic nervous system.[6]

Metabolic syndrome (MS) is a construct that defines a closely related cluster of factors that increase the risk of CAD and diabetes mellitus Type 2. Although increasing research efforts have been allocated lately in the attempt to propose a universally accepted pathogenic mechanism and clearly define the diagnostic criteria,[7–11] there is still a lot of debate concerning these issues.[12] The most widely accepted definition currently was proposed by Alberti et al., in the Joint Interim Statement. This document proposes that the presence of three of the following criteria are needed for a diagnosis of MS: elevated waist circumference (according to population and country-specific definitions) triglycerides 150 mg/dl or greater; high-density lipoprotein (HDL)-cholesterol lower than 40 mg/dl in men and 50 mg/dl in women; blood pressure of 130/85 mmHg or greater and fasting glucose 100 mg/dl or greater. This definition highlights that there should be no obligatory component for MS but rather all individual components should be considered on cardiovascular risk prediction.[13]

Although the prevalence of MS varies depending on the criteria used,[14] consistent evidence show that over the last 20 years, the prevalence of MS has steadily increased in all populations worldwide.[15] Although the cause of the syndrome remains obscure, it is thought to result from a complex interaction between lifestyle, environmental and biological factors. The central relevance of this construct lies in its potential use for identifying patients presenting an elevated cardiovascular risk and promoting early preventive lifestyle modifications.

Recent studies on the association between MS and depression have reported conflicting findings, and little is known about the role played by anxiety. This study aimed to review the most relevant findings on the link between MS and psychological cardiovascular risk factors, focusing on the impact of anxiety.


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