The Role of Anxiety in Metabolic Syndrome

Aline Sardinha; Antonio E Nardi


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

In This Article

MS & Depression

Research efforts to clarify the association between MS and depression have reported interesting outcomes. A cross-sectional study of 1024 outpatients with stable coronary CAD showed that higher levels of depression were significantly associated with increased prevalence of MS and that this could be explained by differences in socioeconomic status and health behaviors.[16] Data from Japan have added support for the idea that MS could predict the development of depression and that the strongest risk factor was waist circumference (odds ratio [OR]: 2.08; 95% CI 1.23–3.50).[24] Another cross-sectional study of 9571 participants in the Nord-Trøndelag Health Study (HUNT 2) found no relationship of anxiety and depression with MS.[25]

The direction of the causality of the relationship between MS and depression; however, remains unclear. A 7-year follow-up of 425 women found that psychological risk factors predicted the development of MS and that the association between anger and MS was reciprocal.[26] It is also possible that MS may predispose for depression, leading to a reciprocal association. A 7-year follow-up study of men and women reported that nondepressed women and men with MS at baseline were twice as likely to have depressive symptoms at follow-up (OR: 2.2, 95% CI: 1.1–4.5 for women; OR: 2.2, 95% CI: 0.8–5.9 for men) as compared with the nondepressed cohort members without MS at baseline.[27] In a review study conducted by Rosolová and Podlipný, depressive disorders were nearly twice as frequent in individuals with MS compared to individuals without MS (relative risk: 1.85; 95% CI: 1.11–3.10).[19] In three cross-sectional surveys completed in rural regions of Australia, participants with MS presented higher scores on depression scales than individuals without MS. These authors also found this association in MS patients without diabetes, indicating that the link between psychological factors and metabolic alterations is not necessarily mediated by the presence of diabetes. In this study, large waist circumference and low HDL-cholesterol showed significant and independent associations with depression.[28]

In another sample of subjects with MS, depression was approximately four-times more prevalent than in the general population. Depressed participants also showed higher heart rate and sympathetic nervous activity, larger waist circumference, lower HDL-cholesterol, higher triglycerides and higher BMI.[29] Among hypertensive subjects with MS, depressive symptoms along a continuum of severity were independently associated with multiple unhealthy lifestyles,[30] which adds to the hypothesis of psychological factors contributing to the development of metabolic disturbances through behavioral aspects.

It has also been hypothesized that gender-specific variables may mediate this relationship. In a sample of 1598 men and women at risk for cardiovascular disease, MS was related to an increased prevalence of depression but not anxiety, and a direct relationship was observed between the number of diagnostic criteria for MS and the severity of depression.[31] An Israeli study of 2355 men and 1525 women found that depression among women, but not men, was associated with a twofold increased risk of MS and with an elevated risk of having two of its five components: larger waist circumference (OR: 2.23) and elevated glucose levels (OR: 2.44). Among men, depression was associated with larger waist circumference only (OR: 1.77).[32] In urban Japanese men, depressive symptoms are considered to be associated with MS and, more specifically, glucose abnormality (OR: 1.24). No such association was found for Japanese women.[33]

In a community-based sample of 2917 older persons, the relationship between depressive symptoms and MS was found in white (OR: 1.11; 95% CI: 1.01–1.23) but not in black (OR: 0.97; 95% CI: 0.86–1.11) participants.[34] These findings suggest that the association between depression and metabolic abnormalities can be mediated by other variables in specific populations and they highlight the relevance of understanding the roles played by gender, ethnicity and age when designing interventions.

It is also likely that adaptations to environmental changes play a role in the dramatic increase in the prevalence of cardiometabolic risk factors such as obesity, hypertension, Type 2 diabetes, dyslipidemias and the MS in industrialized countries. With improvements in economic situation in developing countries, increasing prevalences of obesity and MS are seen in adults and children.[35]

Another important psychological factor that could increase psychological distress, anxiety and related MS in underdeveloping countries is stress related to coping with the challenges posed by urbanization. A study conducted with urban black Africans in South Africa saw coping disability and anxiety-related symptoms in relation to MS.[36,37] Results from China showed that the prevalence of MS was 9.9-times higher in Chinese farmers that migrated to a big city (23.8%) and 6.3-times higher in Chinese individuals from an urban environment (15.2%) than in Chinese farmers (2.4%). The authors attribute the high prevalence of MS to a change in lifestyle associated with urbanization.[38] Research carried out in India pointed to a nutrition transition due to rapid urbanization, combining a decreasing intake of coarse cereals and vegetables, increasing intake of meat products and salt, with declining levels of physical activity, that have resulted in escalating levels of obesity, MS and coronary heart disease.[39]


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