Understanding the role of depression and anxiety on cardiovascular disease risk, using structural equation modeling; the mediating effect of the Mediterranean diet and physical activity: the ATTICA study

Abstract Purpose To evaluate the mediating role of behavioral patterns, such as adherence to the Mediterranean diet and physical activity status, in the relationship between depression, anxiety, and the cardiovascular disease (CVD) risk score HellenicSCORE. Methods In the context of the ATTICA study, a cross-sectional survey, 453 men (45 ± 13 years) and 400 women (44 ± 18 years), with complete psychological evaluation were studied. Participants were without any evidence of cardiovascular or other chronic disease. Depression was assessed with the Zung Self-Rating Depression Scale and anxious state by the Spielberger State Anxiety Inventory Scale. Physical activity was assessed using the International Physical Activity Questionnaire and adherence to the Mediterranean diet was assessed by the MedDietScore. Structural equation modeling methodology was implemented in the statistical analysis. Results Five latent depression and anxiety factors were revealed and associated with CVD risk score through mediation of physical activity status and adherence to the Mediterranean diet with very good fit to the data (χ2 /df ratio = 2.34; root mean square error of approximation = 0.021; 90% confidence interval, 0.020–0.022; comparative fit index = 0.951). Significant total effect on CVD risk was found for the “anxiety–worry” latent factor, and this effect was through the inverse relationship of “anxiety–worry” with MedDietScore ( P = .002). Moreover, “positive feelings” latent construct was associated with lower CVD risk, and this seems to be through the higher adherence to the Mediterranean diet ( P = .01). Conclusions Adherence to the Mediterranean diet seems to mediate the unfavorable effect of depression and anxiety on CVD risk.