Fluent Essays

D ow nloaded from https://journals.lw w .com /jcnjournalby B hD M f5eP H K av1zE oum 1tQ fN 4a+kJLhE ZgbsIH o4X M i0hC yw C X 1A W nY Q p/IlQ rH D 3w xN ooC N zZviz210ugR W rvTQ fK hV fQ 9yD eD D fjU O kr7c= on 05/09/2018 Downloadedfromhttps://journals.lww.com/jcnjournalbyBhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3wxNooCNzZviz210ugRWrvTQfKhVfQ9yDeDDfjUOkr7c=on05/09/2018 Journal of Cardiovascular Nursing Vol. 33, No. 2, pp E15YE20 x Copyright B 2018 Wolters Kluwer Health, Inc. All rights reserved. Depressive Symptoms Moderate the Association Between Appetite and Health Status in Patients With Heart Failure Christina Andreae, RN; Anna Strömberg, PhD, RN; Misook L. Chung, PhD, RN; Carina Hjelm, PhD, RN; Kristofer Årestedt, PhD, RN Background: Decreased appetite and depressive symptoms are clinical problems in patients with heart failure. Both may result in impaired health status. Objective: The aims of this study were to investigate the association between appetite and health status in patients with heart failure and to explore whether depressive symptoms moderate this association. Methods: In this cross-sectional study, patients with heart failure (n = 186; mean age, 71 years), New York Heart Association class II to IV, participated. Data on appetite (Council of Nutrition Appetite Questionnaire), depressive symptoms (Patient Health Questionnaire-9), and health status (EQ-5D 3-level scale [EQ-5D-3L] descriptive system, EQ-5D-3L index, and EQ Visual Analog Scale) were collected by self-rating questionnaires. Pearson correlation was used to investigate the association between appetite and health status. Multiple regression was performed to examine whether depressive symptoms moderate the association between appetite and health status. Results: There was a significant association between appetite and health status for EQ-5D-3L descriptive system, mobility (P G .001), pain/ discomfort (P G .001), and anxiety/depression (P G .001). This association was also shown in EQ-5D-3L index (P G .001) and EQ Visual Analog Scale (P G .001). Simple slope analysis showed that the association between appetite and health status was only significant for patients without depressive symptoms (B = 0.32, t = 4.66, P G .001). Conclusions: Higher level of appetite was associated with better health status. In moderation analysis, the association was presented for patients without depressive symptoms. Decreased appetite is an important sign of poor health status. To improve health status, health professionals should have greater attention on appetite, as well on signs of depressive symptoms. KEY WORDS: appetite, association, depression, health status, heart failure, nutritional status Heart failure (HF) is a common chronic condi-tion worldwide, with a prevalence of 2% in the adult population, rising up to 10% to 20% among persons 70 years or older.1 Heart failure is a pro- gressive condition manifested by reduced cardiac pump function, which results in burdensome symptoms (ie, breathlessness, fatigue, and weakness) often leading to frequent hospitalizations.1 The 5-year mortality after diagnosis is estimated to be 50% or higher.2 Appetite, defined as the desire to eat,3 is often de- creased in elderly populations.4 Approximately 40% of individuals with HF have decreased appetite.5 De- crease of appetite contributes to a smaller energy intake, which increases the risk for developing malnutrition. This may lead to weakness and impaired functional capacity that adversely affect health status.1 Decreased appetite is also a major concern in health status mainte- nance for individuals with HF because most are older, with a mean age of approximately 68 years.6 Decreased appetite has been shown to have a negative impact on perceived health status and was a significant predictor E15 Christina Andreae, RN PhD Student, Division of Nursing Science, Department of Medical and Health Sciences, Linköping University, Sweden, and Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden. Anna Strömberg, PhD, RN Professor, Division of Nursing Science, Department of Medical and Health Sciences, and Department of Cardiology, Linköping University, Sweden, and Program in Nursing Science, University of California Irvine. Misook L. Chung, PhD, RN Professor, College of Nursing, University of Kentucky, Lexington. Carina Hjelm, PhD, RN Lecturer, Division of Nursing Science, Department of Medical and Health Sciences, Linköping University, Sweden. Kristofer Årestedt, PhD, RN Professor, Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden; Department of Research, Kalmar County Hospital, Kalmar Sweden; Division of Nursing Science, Department of Medical and Health Sciences, Linköping University, Sweden. This study was funded by the Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden; the Swedish Heart and Lung Foundation; King Gustaf V and Queen Victoria’s Freemason Foundation; and the Medical Research Council of Southeast Sweden. The authors have no conflicts of interest to disclose. Correspondence Christina Andreae, RN, Department of Medicine, Mälarsjukhuset, 63188 Eskilstuna, Sweden ([email protected]). DOI: 10.1097/JCN.0000000000000428 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. of mortality in hospitalized patients with various ill- nesses.7 We have also previously found that decreased appetite was associated with health status in patients with HF.5 Depressive symptoms are also a pivotal factor asso- ciated with poor health status in patients with HF; as many as 30% of individuals with HF experience depres- sive symptoms.8 Depressive symptoms have been shown to be a significant predictor of health status and mortality.9,10 Researchers also reported that decreased appetite is associated with increased depressive symp- toms in chronic conditions such as kidney diseases, as well as frail older adults.11,12 Although decreased appetite and depressive symptoms are common pro- blems in patients with HF and both may impair health status, the associations among appetite, depressive symp- toms, and health status are rarely investigated. There is limited research to determine whether depressive symptoms moderate the association between appe- tite and health status. Therefore, the specific aims of this study were (1) to investigate the association be- tween appetite and health status in patients with HF and (2) to examine whether depressive symptoms mod- erate this association. Methods Study Design, Sample, and Site This cross-sectional multicenter study was conducted bet- ween 2009 and 2012 at 3 outpatient HF clinics in Sweden. The inclusion criteria were patients who (1) had HF with 49% or less in ejection fraction, (2) had New York Heart Association classification (NYHA class) of II to IV, (3) were 18 years or older, and (4) were able to speak Swedish. Patients who had comorbidity of renal failure on dialysis or advanced cancer were excluded. The re- gional ethical review board in Linköping, Sweden, ap- proved the study (no. M222-08/T81-09). Procedures Consecutive patients who met the inclusion criteria were invited to participate in the study by HF nurses during a regular HF clinic visit. All patients gave written informed consent in accordance with the Declaration of Helsinki.13 Nurses who had clinical experience of HF care and were trained to collect data arranged 2 study visits. The first visit took place at the hospital, and the second took place at the patients’ home. All patients were asked to complete the survey at the hospital (clinical data) and at home (questionnaires). Measures Appetite Appetite was measured using the Council of Nutrition Appetite Questionnaire (CNAQ),14 which has been validated in patients with HF.15 It consists of 8 items assessing different aspects of appetite, including fullness, taste, food intake, nausea, and mood. All items have 5 response alternatives, ranging from 1 to 5. The total score ranges between 8 and 40, with lower scores indicating decrease appetite. The CNAQ score of 28 or less indicates decreased appetite with a significant risk of weight loss of at least 5% during a 6-month period.14 In this study, the CNAQ was treated as a continuous variable, and internal consistency was acceptable (Cronbach’s ! = .74). Health Status Health status was measured with the generic instrument EQ-5D 3-level scale (EQ-5D-3L). It consists of the EQ- 5D-3L descriptive system and the EQ Visual Analog Scale (EQ VAS). The EQ-5D-3L descriptive system includes 5 health dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each dimension is rated on a 3-point scale, ranging from 1 (‘‘no problems’’) to 3 (‘‘extreme problems’’). These di- mensions can be used to calculate a preference-based utility index, EQ-5D-3L index. The possible index values range between j0.59 and 1, where 1 indicates perfect health and a value less than 0 indicates a health state worse than death. The EQ VAS has 2 anchors: 0, ‘‘worst imaginable health state,’’ and 100, ‘‘best imag- inable health state.’’16,17 Depressive Symptoms The Patient Health Questionnaire (PHQ-9) was used to assess depressive symptoms. The scale includes 9 items, all rated on a 4-point Likert-type scale ranging from 0 (‘‘not at all’’) to 3 (‘‘nearly every day’’). The total score ranges between 0 and 27.18 In this study, PHQ-9 was used as a categorical variable; 0 to 4 indicate none to minimal depressive symptoms, and 5 to 27 indicate mild to severe depressive symptoms. The cut points can be used to discriminate individuals with and without major depression.18 The internal consistency in this study was considered acceptable (Cronbach’s ! = .80). Demographic and Clinical Data Collection Data on age, gender, and living situation were self- reported. Six-minute walk test was performed to assess functional capacity19 and HF symptoms according to NYHA classifications. Data Analyses Descriptive statistics including mean (SDs) or frequen- cies were used to describe demographic and clinical characteristics. Pearson #2 test and independent sample t test were used to test for differences in gender, age, and NYHA class between patients with and without depressive symptoms. For the first specific aim, we examined the association between appetite and health E16 Journal of Cardiovascular Nursing x March/April 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. status using Pearson correlation. For the second aim, multiple linear regression models in 3 blocks were conducted to examine the effect of the moderator, that is, depressive symptoms, on the association between appetite and health status. We entered appetite as a predictor variable (continuous) in block 1, depressive symptoms as a moderator variable (dichotomized, PHQ- 9 e 4 vs 9 4) in block 2, and a multiplicative interaction term between appetite and depressive symptoms in block 3. In block 4, age, gender, and NYHA class were entered as covariates. We used both the EQ-5D-3L in- dex and the EQ VAS as health status outcomes in the models. A moderation effect of depressive symptoms is identified when there is a statistical significance for the interaction term.20 By using a Web program, ModGraph,21 we obtained simple slopes of the asso- ciation between appetite and health status for 2 depres- sive symptom groups. Statistical analyses were conducted using IBM SPSS statistics 20.0 (IBM Corp, Armonk, New York) and Stata 14.1 (StataCorp LP, Collage Station, Texas). The level of statistical signif- icance was set to P G .05. According to recommenda- tions by Cohen,22 a sample size of 186 individuals is more than sufficient to identify a medium effect size for a regression model with 6 predictor variables (! = .05 and 1-" = 0.8). Results Patient Characteristics Of the 316 eligible patients, 59% (n = 186) participat- ed in this study. No significant differences between participants and nonparticipants were detected regard- ing gender (#2(1) = 0.31, P = .575) or age (t(314) = j1.41, P = .184). Demographic and clinical characteristics of patients are presented in Table 1. Of the patients, 38% re- ported appetite levels at risk for weigh loss (CNAQ e 28), and 41% had at least mild to severe depressive symptoms (PHQ-9 9 4). Patients with depressive symp- toms (ie, PHQ 9 4) were significantly more often women (P = .027) and had higher body mass index (P = .003) compared with those without depressive symptoms (PHQ-9 e 4). They also reported poorer health status measured with both EQ-5D-3L index (P G .001) and EQ VAS (P G .001). Associations Between Appetite and Health Status Patients with a higher level of appetite reported significantly better health status. This association was shown in 3 of 5 health dimensions of the EQ-5D-3L descriptive system: mobility (r = j0.26, P G .001), pain/discomfort (r = j0.31, P G .001), and anxiety/ depression (r = j0.24, P G .001). This association was also shown in the EQ-5D-3L index (r = 0.37, P G .001) and EQ VAS (r = 0.38, P G .001). Moderation Effect of Depressive Symptoms on the Association Between Appetite and Health Status When the EQ-5D-3L index was used as outcome (Table 2), appetite was a significant predictor of health status by explaining 14% of the total variance in block 1. When the moderator variable was added in block 2, both ap- petite and depressive symptoms significantly predicted health status, and depressive symptoms added 6% of the total variance. In block 3, the interaction term was significant by contributing additional 4% of the total variance. That indicates a significant moderation effect of depressive symptoms. When the model was adjusted for age, gender, and NYHA class in block 4, the in- teraction term remained significant. The final model TABLE 1 Comparison of Demographic and Clinical Characteristics Between Nondepressed and Depressed Patients Nondepressed (n = 109) Depressed (n = 77) P Age, mean (SD), y 71.5 (9.7) 69.6 (12.7) .239 a Male gender, n (%) .027 b Male 83 (63.8) 47 (36.2) Female 26 (46.4) 30 (53.6) Cohabitation, n (%) .461 b Yes 75 (60.5) 49 (39.5) No 34 (54.8) 28 (45.2) CNAQ, mean (SD) 29.9 (2.7) 27.1 (3.9) G.001a e28, increased risk for weight loss, n (%) 27 (38.0) 44 (62.0) 928, no increased risk for weight loss, n (%) 82 (71.3) 33 (28.7) EQ-5D-3L index, mean (SD) 0.79 (0.20) 0.62 (0.20) G.001a EQ VAS, mean (SD) 67.0 (16.2) 49.8 (16.8) G.001a Six-minute walking test, mean (SD), m 386.8 (145.6) 340.6 (138.1) .053 a NYHA class, n (%) .143 b II 71 (62.3) 43 (37.7) III 34 (56.7) 26 (43.3) IV 4 (33.3) 8 (66.7) LVEF, n (%) .548 b 40Y49 25 (53.2) 22 (46.8) 30Y39 44 (57.9) 32 (42.1) G30 40 (63.5) 23 (36.5) CCI, mean (SD) 1.8 (0.9) 2.0 (1.5) .237 a BMI, mean (SD), kg/m 2 27.8 (26.8) 31.1 (28.8) .003 a Abbreviations: BMI, body mass index; CCI, Charlson Comorbidity Index; CNAQ, Council on Nutrition Appetite Questionnaire; LVEF, left ventricle ejection fraction; NYHA class, New York Heart Association classification. aIndependent sample t test. bPearson #2 test. Appetite and Depressive Symptoms in HF E17 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. explained 29% of the total variance. The result implies that depressive symptoms moderated the association between appetite and health status even after age, gender, and NHYA class were controlled. The simple slope analysis (Figure) demonstrated that associa- tion between appetite and health status was significant for patients with no to minimal depressive symptoms (B = 0.32, t = 4.66, P G .001), but not for patients with mild to severe depressive symptoms (B = 0.01, t = 1.06, P = .290). When the EQ VAS was used as an outcome variable (Table 3), there was a significant association between appetite and health status in block 1, which explained 14% of the total variance. In block 2, both appetite and depressive symptoms were significantly associated with health status, which explained 25% of the total variance. However, there was no significant modera- tion effect of depressive symptoms on the association between appetite and health status because the inter- action term was not significant in block 2. Discussion The authors investigated the association between self- reported appetite and health status in patients with HF and whether depressive symptoms influenced this TABLE 2 The Association Between Appetite, Depressive Symptoms, and Health Status (EQ-5D 3-Level Index), Based on Multiple Linear Regression Analysis Predictor Variables B (SE) t Statistic P 95% CI for B Model Statistics Block 1 Appetite 0.023 (0.004) 5.481 .000 0.015Y0.032 F1,184 = 30.045, P = .000, R 2 = 0.140 Block 2 Appetite 0.017 (0.004) 3.702 .000 0.008Y0.025 Depressive symptoms j0.119 (0.032) j3.776 .000 j0.181 to j0.057 F2,183 = 23.234, P = .000, R 2 = 0.203 Block 3 Appetite 0.032 (0.007) 4.700 .000 0.018Y0.045 Depressive symptoms 0.643 (0.258) 2.492 .014 0.134Y1.151 Appetite � depressive symptoms j0.026 (0.009) j2.975 .003 j0.044 to j0.009 F3,182 = 19.105, P = .000, R2 = 0.239 Block 4 a Appetite 0.029 (0.007) 4.207 .000 0.016Y0.043 Depressive symptoms 0.649 (0.259) 2.506 .013 0.138Y1,161 Appetite � depressive symptoms j0.026 (0.009) j2.949 .004 j0.044 to j0.009 F7,178 = 10.394, P = .000, R2 = 0.290 Abbreviation: CI, confidence interval. a Adjusted for age, gender, and NYHA class. FIGURE. Moderation effects of depressive symptoms on appetite and health status. Patients (n = 186) were grouped into those with none to minimal depressive symptoms (n = 109) and those with mild to severe depressive symptoms (n = 77). E18 Journal of Cardiovascular Nursing x March/April 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. association. We found that a higher level of appetite was associated with better health status using 2 measures of health status (ie, EQ-5D-3L index and EQ VAS). Although there is limited study about the associa- tion between appetite and health status in patients with HF, our findings correspond with a study about frail elderly people23 and patients who were hospitalized.7 Lainscak et al7 found that patients with decreased appe- tite were more likely to report impaired health status in terms of physical mobility. This was also supported in the study by Landi et al23 who found that elderly per- sons with decreased appetite walked significantly slower when compared with those with no appetite problems. The mechanism behind this association could possibly be explained by the fact that decreased appetite con- tributes to insufficient nutritional intake, which in turn contributes to malnutrition and muscle weakness.24,25 Few studies have investigated the relationship be- tween appetite and depressive symptoms in the context of cardiovascular disease. It is therefore difficult to compare our results in similar populations. In psychol- ogy research, altered appetite is a cardinal symptom that can increase or decrease depending on the type of depressive disorder.26 Our findings showed that de- pressive symptoms moderated the association between appetite and health status. The simple slope analysis showed that the association between appetite and health status was significant for patients without de- pressive symptoms, but not for patients with depres- sive symptoms. This implies that interventions focused on improving appetite may not result in improved health status in patients with depressive symptoms unless their depressive symptoms are treated or de- creased. To the best of our knowledge, the moderation effect of depression on the association between appe- tite and health status has not been previously described. This knowledge has important clinical implications for improving health status in patients with HF. It is im- portant to identify and treat depressive symptoms as well when we target appetite. Altogether, our findings indicate that decreased appe- tite may be recognized as a sign of poor health status. In clinical practice, health professionals could measure ap- petite in patients with HF to identify patients at risk of developing malnutrition and impaired health status. Depressive symptoms moderated the association be- tween appetite and health status when health status was measured with the EQ-5D-3L index, but not with EQ VAS. This was unexpected because both are measures of health status. The discrepancies could be explained by the fact that EQ-5D-3L index and EQ VAS reflect different aspects of health status. The EQ-5D-3L index measures distinct health problems such as mobility, self- care, usual activities, pain/discomfort, and anxiety/ depression, whereas EQ VAS reflects the individual’s overall health status. It has been shown that the results of EQ-5D-3L index and EQ VAS differ. In EQ VAS, fewer people report improvements in health, whereas more report worsening in health compared with the EQ-5D-3L index. This discrepancy is also demon- strated in correlation analyses between the 2 mea- sures.27 Therefore, we suggest that both the EQ-5D- 3L index and EQ VAS be used to measure health status in further research. We would like to address some study limitations. This study had a cross-sectional design, and therefore, no causal conclusions can be drawn. The patients were recruited from outpatient HF clinics, which might make it difficult to generalize the findings to patients admitted to the hospital. Furthermore, the patients had TABLE 3 The Association Between Appetite, Depressive Symptoms, and Health Status (EQ Visual Analog Scale), Based on Multiple Linear Regression Analysis Predictor Variables B (SE) t Statistic P 95% CI for B Model Statistics Block 1 Appetite 1.981 (0.361) 5.491 .000 1.270Y2.693 F1,184 = 30.154, P = .000, R 2 = 0.141 Block 2 Appetite 1.207 (0.367) 3.285 .001 0.482Y1.931 Depressive symptoms j13.759 (2.598) j5.296 .000 j18.885 to j8.632 F2,183 = 31.314, P = .000, R 2 = 0.255 Block 3 Appetite 1.501 (0.579) 2.593 .010 0.359Y2.644 Depressive symptoms 0.461 (21.727) 0.021 .983 j42.409 to 43.331 Appetite � depressive symptoms j0.494 (0.750) j0.659 .511 j1.974 to 0.985 F3,182 = 20.957, P = .000, R2 = 0.257 Block 4 a Appetite 1.270 (0.565) 2.249 .026 0.156Y2.384 Depressive symptoms 2.715 (20.873) 0.130 .897 j38.475 to 43.905 Appetite � depressive symptoms j0.568 (0.718) j0.791 .430 j1.985 to 0.849 F7,178 = 14.695, P = .000, R2 = 0.366 Abbreviation: CI, confidence interval. a Adjusted for age, gender, and NYHA class. Appetite and Depressive Symptoms in HF E19 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. mild to moderate HF symptoms, which might limit the possibilities to generalize the findings to patients with severe HF, particularly among patients in NYHA class IV. Conclusions This study shows that appetite was associated with health status among patients with HF and this asso- ciation was only significant in patients without depres- sive symptoms due to the moderation effect of depressive symptoms on the association. A greater focus on appetite in clinical settings is of importance to pre- vent malnutrition and improve health status among pa- tients with HF. To improve health status, it is also of importance to identify and treat symptoms of depression. Acknowledgments The authors acknowledge all study participants, HF nurses, and administration staff for their assistance in completing this study. REFERENCES 1. 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Assessing the performance of the EQ-VAS in the NHS PROMs programme. Qual Life Res. 2014;23(3):977Y989. What’s New and Important h Increased appetite is associated with better health status compared with patients with decreased appetite. h Depressive symptoms have a negative impact on health status, regardless of appetite. E20 Journal of Cardiovascular Nursing x March/April 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. http://www.euroqol.org/about-eq-5d/publications/user-guide.html http://www.euroqol.org/about-eq-5d/publications/user-guide.html http://pavlov.psyc.vuw.ac.nz/paul-jose/modgraph/ http://pavlov.psyc.vuw.ac.nz/paul-jose/modgraph/