Vitamin A Consumption To Ease Depression In Heart Failure Patients
Overview
The study aimed to examine the link between vitamin A consumption and depression in patients with heart failure (HF). Utilizing data from the National Health and Nutrition Examination Survey (NHANES) spanning 2007 to 2020, researchers focused on vitamin A intake as the independent variable and depression as the dependent variable. A total of 999 HF patients were analyzed, with an average age of 66.19 years, of which 52.49% were male. Out of these, 197 patients exhibited signs of depression.
The findings revealed that a vitamin A intake of 731.38 mcg or more correlated with a reduced prevalence of depression, indicated by an odds ratio (OR) of 0.37 (95% confidence interval [CI]: 0.18–0.76). This association was further supported across various subgroups, including patients over 65 years old (OR = 0.16; 95% CI: 0.04–0.55), males (OR = 0.35; 95% CI: 0.14–0.86), those without hypertension (OR = 0.25; 95% CI: 0.11–0.58), without diabetes (OR = 0.30; 95% CI: 0.11–0.78), with hyperlipidemia (OR = 0.23; 95% CI: 0.09–0.64), and those with chronic kidney disease (CKD) (OR = 0.32; 95% CI: 0.13–0.80).
In conclusion, higher vitamin A intake appears to be associated with a lower likelihood of depression in patients with heart failure. These findings suggest that appropriate vitamin A supplementation could offer potential benefits for preventing depression in this population. However, further prospective studies on a larger scale are necessary to validate the impact of vitamin A on reducing depressive symptoms.
Introduction
Heart failure (HF) is a chronic and progressive disorder marked by the heart’s inability to pump enough blood to meet the body’s needs. In the United States alone, approximately 6.2 million adults aged 20 and older live with HF, with around one million new diagnoses each year, and the prevalence is on the rise. This condition poses significant health challenges globally, contributing to high rates of morbidity and mortality, as well as adversely affecting patients’ quality of life.
In addition to the physical limitations, many individuals with HF also suffer from psychological issues, particularly depression, which is prevalent in 9.7% to 45.5% of these patients. This co-morbidity can worsen HF outcomes, leading to increased hospitalizations, lower treatment adherence, diminished quality of life, and elevated mortality rates. The onset of depression in HF patients may be linked to inflammatory mediators, such as interleukin-1, interleukin-6, interleukin-10, and tumor necrosis factor.
Research indicates that diet plays a crucial role in reducing the risk of depression. Antioxidant therapies, including vitamin supplementation, have shown promise in managing depressive symptoms. Vitamin A, a fat-soluble micronutrient essential for various physiological processes such as vision and immune function, has been identified as having potential antidepressant properties. Studies suggest an inverse relationship between vitamin A intake and depression rates, with findings indicating that higher dietary intakes of vitamin A and beta-carotene are linked to lower depression prevalence. Additionally, decreased levels of retinoic acid, a metabolite of vitamin A, have been associated with increased depression risk in post-stroke patients, possibly due to its effects on neuroinflammation.
Patients with HF often exhibit insufficient vitamin A consumption, which coincides with a high incidence of depression. Although the connection between vitamin A intake and depression has been investigated in the general population, its specific impact on HF patients remains unclear. This study aims to examine the relationship between vitamin A intake and depression in individuals with HF, including further analysis across various subgroups.
Method
The National Health and Nutrition Examination Survey (NHANES) serves as a comprehensive, multi-stage, cross-sectional survey that aims to assess the health and nutritional status of both adults and children across the United States. This initiative, a key program of the National Center for Health Statistics (NCHS), utilizes a combination of interviews and physical examinations. Ethical approval for NHANES was granted by the NCHS Ethics Review Board, and informed consent was obtained from all participants. The study in question received a waiver for ethical approval from the Ethics Committee of the Third Affiliated Hospital of Changchun University of Traditional Chinese Medicine.
This cross-sectional analysis focused on heart failure (HF) patients using data extracted from the NHANES database spanning 2007 to 2020. Inclusion criteria for the study comprised individuals aged 18 and older diagnosed with HF, those with recorded information on vitamin A intake, and those assessed for depression. Patients were excluded if they lacked data regarding vitamin A consumption or depression evaluation. HF diagnosis was confirmed through a direct question regarding previous professional diagnoses of congestive heart failure.
Depression levels were evaluated using the Patient Health Questionnaire (PHQ-9), which is scored from 0 (not at all) to 3 (nearly every day) for each item. The total score ranges from 0 to 27, with scores of 10 or higher indicating clinically significant depression. The PHQ-9 has demonstrated a sensitivity and specificity of 88% when using this cut-off score, and the internal consistency in this study was measured with a Cronbach’s alpha of 0.852.
Vitamin A intake was assessed through 24-hour dietary recalls and dietary supplement information collected over the previous 30 days. Interviews for the 24-hour dietary recall were conducted in person by trained staff at Mobile Examination Centers (MEC). Participants reported their dietary supplement usage, including type, frequency, duration, and amount taken in the past month. The total vitamin A intake was calculated by aggregating dietary and supplemental sources and classified into four distinct levels.
To account for potential confounding variables, various demographic factors were assessed, including age, gender, race/ethnicity (including Mexican American, non-Hispanic Black, non-Hispanic White, other Hispanic, and other races), education level, marital status, and the family income-to-poverty ratio (PIR). Physical activity levels were determined using the ‘PAQ’ report, with weekly energy expenditure calculated based on the metabolic equivalent (MET) of activities reported.
The duration of heart failure was calculated by subtracting the age at which heart failure was diagnosed from the participant’s current age. Additionally, clinical indicators such as white blood cell count, hemoglobin levels, and assessments for hypertension (defined as systolic blood pressure ≥ 140 or diastolic blood pressure ≥ 90) and diabetes (with criteria based on HbA1c and fasting glucose levels) were included. Dyslipidemia was screened using total cholesterol, LDL-C, HDL-C, and triglycerides. Chronic kidney disease (CKD) was defined according to the KDIGO 2021 Guidelines, utilizing urinary albumin-to-creatinine ratios and estimated glomerular filtration rates (eGFR) calculated with the CKD-EPI equation. Data regarding medication usage were also collected, encompassing antihypertensives, hypoglycemics, lipid-lowering agents, anticoagulants, antiplatelet medications, psychotherapeutics, and cardiovascular drugs.
Statistical Analysis
Continuous variables were summarized using the mean and standard error (SE), with weighted t-tests applied to assess differences between two groups. Categorical variables were reported as counts and composition ratios [N (%)], employing chi-square tests for group comparisons. Missing data were addressed through the random forest chain equation multiple imputation method, as detailed in Table S1. Sensitivity analysis indicated no significant changes in data distribution pre- and post-imputation, supporting the validity of the imputation process (see Table S2). All analyses utilized sample weights derived from the SDMVPSU, SDMVSTRA, WTDRD1, and WTDRD1PP variables from the NHANES database. Potential covariates were identified through weighted univariate logistic regression models. The relationship between vitamin A intake and depression in patients with heart failure (HF) was examined using both weighted univariate and multivariate logistic regression models, presenting results with 95% confidence intervals (CIs) and odds ratios (ORs). Additionally, subgroup analyses by gender, age, and comorbidities further investigated this association. A two-sided p-value of less than 0.05 was considered statistically significant for all analyses, conducted using SAS 9.4 (SAS Institute Inc., Cary, NC, USA).
Result
The study included a total of 999 patients with heart failure (HF), excluding 292 individuals due to incomplete data regarding vitamin A intake (200 patients) and depression (92 patients). The mean age of the participants was 66.19 years, with 19.72% exhibiting depressive symptoms. Notable differences between the depressed and non-depressed groups were observed across various demographics and health-related factors, including age, race, education, marital status, poverty index ratio (PIR), body mass index (BMI), sleep disturbances, alcohol consumption, smoking habits, and the use of antihypertensive, psychotherapeutic, and cardiovascular medications (all P < 0.05).
The analysis revealed a significant association between vitamin A intake and depression among HF patients. Specifically, after adjusting for factors such as age, marital status, education, PIR, and medication use, an intake of vitamin A ≥731.38 mcg was correlated with a reduced incidence of depression (odds ratio [OR] = 0.37; 95% confidence interval [CI]: 0.18–0.76; P < 0.05). This association persisted even when a higher threshold for vitamin A intake was examined.
Subgroup analyses highlighted further associations based on age, gender, and comorbidities. For patients over 65 years, vitamin A intake levels of 463.53–731.38 mcg (OR = 0.27; 95% CI: 0.08–0.85) and levels exceeding 731.38 mcg (OR = 0.16; 95% CI: 0.04–0.55) were linked to lower depression rates. Additionally, male patients with vitamin A intake >731.38 mcg demonstrated decreased odds of depression (OR = 0.35; 95% CI: 0.14–0.86). Similar results were noted among patients without hypertension, where those with higher vitamin A intake (OR = 0.25; 95% CI: 0.11–0.58) also showed reduced depression prevalence.
Conclusion
The study explored the relationship between vitamin A intake and depression among heart failure (HF) patients in the United States, using a nationally representative sample. Results revealed that higher vitamin A consumption was linked to a reduced incidence of depression, particularly in individuals over 65, males, and those with co-existing conditions like hyperlipidemia or chronic kidney disease (CKD).
Prior research on the association between dietary vitamin A and depression has been limited, though a meta-analysis indicated a negative correlation. This study aligns with existing literature suggesting that vitamin A-rich diets could positively influence depressive symptoms. The findings also propose that increased self-care behaviors may contribute to higher vitamin A intake, subsequently leading to improved mental health outcomes.
The beneficial effects of vitamin A in reducing depression among HF patients can be attributed to several mechanisms. HF is associated with heightened oxidative stress and inflammation, factors closely linked to the development of depression. Vitamin A acts as an antioxidant, alleviating oxidative damage and diminishing inflammation by inhibiting pro-inflammatory cytokines. Furthermore, the vitamin plays a critical role in immune regulation; its modulation of immune responses could help mitigate chronic inflammation often observed in depressive states.
Additionally, vitamin A is involved in the regulation of hormones such as cortisol and thyroid hormones, both of which are connected to mood disorders. Chronic stress in HF patients can disrupt the hypothalamic-pituitary-adrenal (HPA) axis, leading to increased cortisol levels. Vitamin A has been shown to help maintain HPA axis homeostasis, potentially reducing the risk of depression.
The association was notably strong among HF patients over 65 years, males, and individuals with hyperlipidemia or CKD. Age-related neurodegenerative changes may make older adults more vulnerable to depression, but adequate vitamin A intake could slow this progression. Males consuming at least 731.38 mcg of vitamin A exhibited lower odds of depression compared to those with lower intake levels. This gender difference might stem from genetic factors influencing the dietary impacts on mood, although further research is warranted.
Moreover, the protective effect of vitamin A against depression was similarly observed in patients with hyperlipidemia or CKD, with higher intake correlating to reduced depressive symptoms. Given the inflammatory and oxidative stress linked to these conditions, vitamin A’s antioxidant and anti-inflammatory properties may play a crucial role in safeguarding mental health.
However, the study does have limitations. Self-care behaviors, such as medication adherence and dietary choices, could confound the relationship between vitamin A intake and depression. The assessment of vitamin A consumption relied on 24-hour dietary recalls, which may introduce recall bias. Additionally, the sample size for CKD and non-CKD subgroups was small, limiting statistical power. Future research should involve larger sample sizes and consider various factors contributing to self-care behaviors. Furthermore, the identification of clinically relevant depressive symptoms was based on a single instrument, though results remained consistent across different thresholds for the PHQ-9.
In conclusion, this study highlights that higher vitamin A intake is associated with a lower incidence of depression in HF patients, particularly among those aged over 65, males, and individuals with co-morbidities like hyperlipidemia or CKD. Monitoring and promoting adequate vitamin A intake in these patients may offer significant benefits for their mental health.
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