The Role of Anxiety in Metabolic Syndrome

Aline Sardinha; Antonio E Nardi

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

Five-year View

As MS seems to be due to the convergence of a variety of factors, such as genetic predisposition, chronic stress, negative emotion and unhealthy lifestyle habits, it is plausible to think that treatment and prevention strategies should address the modifiable factors. If genetic predisposition and stress triggered by modern society cannot be changed, emotional regulation and lifestyle habits should be focused upon.

However, adherence to long-term life-style changes is challenging. Motivational interviewing – a client-centered, directive counseling approach aimed at promoting motivation in patients to change certain behaviors – has been showed to be effective in promoting short-term lifestyle changes in cardiac rehabilitation patients,^[54] cancer survivors,^[55] childhood obesity^[56] and other health settings, meriting further investigation. Numerous cognitive and behavioral evidence-based techniques could also be potentially useful.^[57,58]

Interventions that modify psychological activation concomitantly to psychological symptoms such as biofeedback, relaxation and other psychophysiologic strategies have been studied and used in patients with elements of the MS, particularly diabetes and hypertension, being shown to effectively lower blood glucose and blood pressure.^[59]

Despite the important side effects reported by the inverse agonist for the CB1 medications, the ECS still seems to be the best candidate for successful pharmacological interventions. A recent study reuniting the metabolic effects of rimonabant in randomized controlled trials showed that, in all trials, there was a considerable reduction in bodyweight in subjects taking 20 mg of rimonabant daily. The lipidemic profile also improved in these patients, with levels of HDL increasing significantly while levels of triglycerides decreased in all trials. In all cases, prevalence of the MS decreased significantly. The metabolic changes observed were partly independent of the weight loss and could be attributed to the independent peripheral effect of the drug. It is likely that these important findings contribute to further efforts for the development of novel cannabinoid Type 1 receptor blockers with similar metabolic results but decreased prevalence of psychiatric adverse effects.^[60]

Additionally, physical activity is known to positively impact the prognoses of numerous chronic diseases, particularly cardiovascular problems.^[61] The prescription of exercise is particularly useful for preventing premature death from all causes, ischemic heart disease, stroke, hypertension, colon and breast cancer, Type 2 diabetes, MS, obesity, osteoporosis, sarcopenia, functional dependence and falls in the elderly, cognitive impairment, anxiety and depression. This benefit is observed in both sexes and increases with the volume or intensity of exercise.^[62] Regular exercising also seems to play an important role in mental health maintenance.^[63] As we have proposed elsewhere,^[64] it is plausible that regular exercise could be a useful and simple strategy to address psychological disorders and metabolic alterations simultaneously in both high-risk patients and the general population.

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Financial & competing interests disclosure
A grant was obtained for this review from the Brazilian Council for Scientific and Technological Development (CNPq) and National Institute for Translational Medicine (INCT-TM). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.

Table 1. Current evidence on the association of anxiety and depression and metabolic syndrome.
Study (year)	Sample	Outcome	Ref.
Cohen et al. (2010)	1024 stable CAD outpatients	Higher levels of depression were significantly associated with increased prevalence of MS	[16]
Holt et al. (2009)	2997 subjects	Depression increases risk for diabetes	[17]
Engum (2007)	37291 subjects	Diabetes could not be considered a predictor of depression or anxiety. The presence of depression and anxiety represented a significant risk for onset of Type 2 diabetes	[20]
Takeuchi et al. (2009)	1183 men	MS can predict the development of depression	[24]
Hildrum et al. (2009)	9571 subjects	No association of anxiety and depression with MS	[25]
Raikkonen et al. (2002)	425 women	Psychological risk factors, particularly anger, predicted the development of MS	[26]
Dunbar et al. (2008)	1690 subjects	Participants with MS with or without diabetes presented higher scores on depression scales than individuals without MS. No association was found with psychological distress or anxiety	[28]
Petrlova et al. (2004)	116 subjects	In MS patients, depression was approximately four-times more prevalent than in the general population	[29]
Bonnet et al. (2009)	840 hypertensive subjects with MS	In hypertensive subjects with MS, depressive symptoms were independently associated with unhealthy lifestyles	[30]
Skilton et al. (2007)	1598 subjects	MS was related to an increased prevalence of depression but not anxiety	[31]
Toker et al. (2008)	2355 men and 1525 women	Depression among women, but not men, was associated with a twofold increased risk of MS and elevated glucose levels	[32]
Nishnia et al. (2011)	1613 subjects	Depression was associated with MS and glucose abnormality in men	[33]
Vogelzangs et al. (2007)	2917 elderly patients	An association between depressive and MS symptoms was found in white but not in black participants. Anxiety symptoms were significantly associated with MS in men, but not in women	[34]
Herva et al. (2006)	5698 subjects	No clear association of MS with depression or anxiety	[45]
van Reedt Dortland et al. (2010)	1217 anxious and depressive patients	MS was associated with severity of depression and with tricyclic antidepressant use, but not with anxiety	[47]
Carroll et al. (2009)	4256 men	Generalized anxiety disorder, but not major depressive disorder, was associated with MS	[50]

CAD: Coronary artery disease; MS: Metabolic syndrome.

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The Role of Anxiety in Metabolic Syndrome

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