New Study Will Examine the Impact of Anxiety and Depression on Patient Engagement in Healthy Behaviors and Find Ways to Refine Effective TEAM-Red Intervention

UH Research & Education Institute

Jennifer Levin, PhD

Martha Sajatovic, MD

Jennifer Levin, PhD, Clinical Psychologist, Department of Psychiatry at University Hospitals and Professor of Psychiatry at Case Western Reserve University School of Medicine and Martha Sajatovic, MD, psychiatrist and the Willard Brown Chair in Neurological Outcomes at University Hospitals, Director of the Neurological and Behavioral Outcomes Center and Professor of Psychiatry and Neurology at Case Western Reserve University School of Medicine (CWRU) are using a $175,000 supplemental grant from the American Heart Association® Research Goes Red initiative to evaluate the impact of depression, anxiety and stress on diet quality and physical activity, exploring the relationship between mental health and adherence to healthy lifestyle behaviors among a community-representative group of women in Northeast Ohio.

The researchers will assess how psychological and social factors influence patient adherence to the Association’s Life’s Essential 8TM, key health factors and behaviors for improving and maintaining cardiovascular health. They will focus on how anxiety and depression affect healthy diet and exercise engagement in women with an elevated cardiovascular disease risk. They aim to enhance the current TEAM-Red self-management intervention by integrating physical and mental health to see if this can improve long-term patient outcomes.

“We are trying to look at psychosocial aspects that are potentially modifiable to figure out how they impact a woman’s ability to consistently engage in a healthy diet and physical exercise,” says Dr. Levin. “There are few interventions that integrate both physical and mental health. Our long-term goal is to help women choose healthy lifestyle behaviors when they are young, so they don’t end up with more risk factors and ultimately cardiovascular disease.”

Supplemental Study Aims to Expands TEAM-Red Study Findings

Building off promising results from prior Team-Red pilot studies, Drs. Levin and Sajatovic have developed a supplemental survey-based study to evaluate the impact of psychological distress, social support, and self-efficacy on engagement in recommended diets and physical activity.  They aim to recruit a broad sample of 150 women, aged 18 to 49, with at least one cardiovascular disease risk factor, such as a body mass index greater than or equal to 30, a current smoking habit, or high blood, cholesterol or sugar levels.

Study participants will complete a survey administered twice at two-month intervals by Evidation, an independent health and research platform. Their responses will shed light on health behaviors, including diet and exercise, mental health symptoms encompassing anxiety, depression, and perceived stress. The study’s resulting baseline data will be combined with an existing sample of 82 women to create a diverse, cross-sectional study sample of 232 women, allowing researchers to run more complex statistical models that examine the relationship between psychosocial variables.  

Findings from the supplemental study will provide more specific data and information on how to refine TEAM-Red. For instance, if anxiety is identified as a major factor in women not eating well or exercising, then the researchers will know they will need to address anxiety in the Team-Red intervention, which already integrates an evidence-based intervention for depression. The supplemental study also helps pave the way to eventually conduct a large randomized controlled trial to more definitively determine the effectiveness of TEAM-Red in helping women at risk of developing heart disease stay physically and emotionally healthy.

“Our ultimate goal is to scale up the TEAM-Red intervention to both improve health behaviors and depression, teach strategies to manage stress, and then maintain healthy behaviors over the long run,” says Dr. Levin.

The current TEAM-Red self-management approach is based on a TargetEd manAgeMent (TEAM) program initially developed by Co-investigator Sajatovic and tested as a secondary prevention program for Black men post-stroke. TEAM was then adapted and served as a template for TEAM-Red, a new intervention pilot tested in young, depressed Black women at risk for hypertension. The results of the original pilot study showed initial improvement in depression following the program, further improvement 3 months after the program, as well as early change in health behaviors, which began to plateau and drop off over time. This new survey study will further our understanding of how to modify and expand the reach of the TEAM-Red self-management program to yield sustainable heart-healthy behavior change in at-risk women.

Addressing a Major Health Issue by Preventing Heart Disease

Cardiovascular disease, the leading cause of death in the United States, is responsible for one in five female deaths, signaling the need to improve adherence to the American Heart Association’s Life’s Essential 8 steps for cardiovascular health, says Dr. Levin. The Association’s Life’s Essential 8 calls for being more physically active, quitting tobacco use, getting healthy sleep, maintaining a healthy diet and weight, controlling cholesterol, and managing blood sugar and blood pressure levels.

While there has been greater attention to the bidirectional relationship between mental and physical/cardiovascular health, the integration of mental health into lifestyle interventions to optimize overall health remains limited, says Dr. Levin.

As part of their supplemental study, Drs. Levin and Sajatovic will investigate the relationship between neighborhood-level social stress, as measured using a validated index based on census data, and perceived stress, diet quality and physical activity. They will also gauge if changes in levels of depression, anxiety and stress predict changes in diet and exercise, while controlling for social desirability bias. They will likewise test if social support and self-efficacy, the belief in one’s ability to carry out certain behaviors, help mitigate the adverse effects of distress on behavior. The researchers will apply structural equation modeling to assess how social determinants of health, psychological symptoms and protective factors interact to influence lifestyle behaviors.

The results of this survey study, combined with the outcomes from the TEAM-Red pilot trial, will inform necessary adaptations to the TEAM-Red program, ensuring that the psychosocial needs of high-risk women are met, enabling them to achieve and maintain lifestyle changes over time. Dr. Levin states, “With each research study, we add to our knowledge base with the ultimate goal of improving whole health for our patients.”