To examine the association between the Life's Essential 8 (LE8) cardiovascular health index and depressive symptoms among older adults in Mexico.
Materials and methodsThis cross-sectional study analysed data from 700 adults aged ≥55 years (59% women) participating in the Mexican Health and Aging Study (MHAS) and the Mex-Cog ancillary study (2015–2016). LE8 comprises eight components – food insecurity, physical activity, smoking, sleep, body mass index, blood lipids, blood glucose, and blood pressure – each scored from 0 to 100 and classified as low (0–49), moderate (50–79), or high (80–100) cardiovascular health. Depressive symptoms were assessed using the 9-item Center for Epidemiologic Studies Depression Scale (CES-D), with scores ≥5 indicating probable depression. Binary and multinomial logistic regression models estimated associations, adjusting for age, sex, education, comorbidities, alcohol consumption, and socioeconomic status.
ResultsFor depressive symptom burden (CES-D score), compared with the high cardiovascular health group, individuals in the low cardiovascular health group had significantly higher odds of depressive symptoms (OR 2.84; 95% CI 1.62–4.99). Relative to the moderate cardiovascular health group, the low cardiovascular health group also showed increased odds (OR 2.47; 95% CI 1.71–3.58). For probable depression (CES-D ≥5), the low cardiovascular health group exhibited higher odds compared with both the high cardiovascular health group (OR 3.47; 95% CI 1.57–7.70) and moderate cardiovascular health groups (OR 2.74; 95% CI 1.76–4.28).
ConclusionsPoor cardiovascular health, reflected by lower LE8 scores, was independently associated with greater odds of depressive symptoms in older Mexican adults. These findings support the potential utility of LE8 as a practical framework for identifying individuals with a higher burden of depressive symptoms and warrant further longitudinal investigation.
Population aging is a global phenomenon, currently affecting approximately 9% of the world's population aged ≥65 years, a proportion projected to increase to 16% by 2050 according to the United Nations.1 Aging results from complex interactions among psychosocial, environmental, and sociodemographic factors and is frequently accompanied by chronic diseases and functional decline.2 Cardiovascular diseases (CVDs) remain the leading causes of disability and mortality worldwide, accounting for 42.5% of all deaths in Europe in 2019, and are strongly linked to other disabling conditions, including dementia and depression.3
Depression is highly prevalent in later life and is associated with reduced quality of life, increased comorbidity burden, and higher mortality risk. Growing evidence supports a bidirectional relationship between cardiovascular and mental health, with recent studies demonstrating close links between cardiovascular health and depressive outcomes.4 In this context, the American Heart Association introduced Life's Essential 8 (LE8), a comprehensive framework incorporating diet quality, physical activity, smoking, sleep, body mass index, blood lipids, blood glucose, and blood pressure to promote optimal cardiovascular health.6
Beyond cardiovascular outcomes, lower LE8 scores have been associated with cognitive impairment, neurodegenerative diseases, biological aging, and non-cardiovascular mortality.7,8 In Latin America, where the prevalence of both cardiovascular disease and depression is rapidly increasing, understanding these interconnections is critical. Therefore, this study aimed to examine the association between LE8 and depressive symptoms among Mexican adults aged ≥55 years.5
Materials and methodsStudy design and populationThis secondary analysis used data from the Mexican Health and Aging Study (MHAS) and its ancillary Mexican Cognitive Aging Study (Mex-Cog). The MHAS is a nationally representative, longitudinal cohort of adults aged ≥50 years designed to investigate the social, economic, and health determinants of aging in Mexico.9 Initiated in 2001, the MHAS has completed five follow-up waves, with the most recent conducted in 2021. Data are collected through structured, face-to-face interviews at the individual and household levels, capturing comprehensive information on sociodemographic characteristics, health conditions, health behaviors, and functional status. Mex-Cog is a subcohort of the MHAS that focuses on detailed physical and biological assessments. It includes participants aged ≥55 years residing in eight randomly selected Mexican states. Data collection for Mex-Cog was conducted by trained interviewers from the National Institute of Public Health, who followed standardized protocols to obtain anthropometric measurements and blood samples.
The 2015 MHAS wave included 14,749 participants, from whom Mex-Cog randomly selected 2265 individuals. Of these, biomarker data were available for 752 participants. To address missing body mass index (BMI) values, imputed BMI data provided by the MHAS were used (Supplementary Table S1). After excluding participants with incomplete data on key variables, a final analytic sample of 700 individuals from the 2015–2016 MHAS and Mex-Cog waves was included in the present analysis (Supplementary Fig. S1).
Measurement of Life's Essential 8Cardiovascular health was assessed using the American Heart Association's Life's Essential 8 (LE8) framework,5 which evaluates eight modifiable components: diet quality, physical activity, nicotine exposure, sleep duration, body mass index, blood lipids, blood glucose, and blood pressure. Each component was scored on a scale from 0 to 100, with higher scores reflecting more favorable health status. The overall LE8 score was calculated as the mean of the eight component scores. Detailed scoring procedures for each LE8 component are provided in Supplementary Table S1.
Measurement of depressive symptomsDepressive symptoms were the primary outcome and were assessed using the nine-item abbreviated version of the Centre for Epidemiologic Studies Depression Scale (CES-D), administered as part of the MHAS. Participants responded yes or no to each item based on their experiences during the previous week. Positively worded items were reverse-coded, resulting in total scores ranging from 0 to 9, with higher scores indicating greater depressive symptom burden.10 Two depression-related outcomes were examined: (1) depressive symptom burden, assessed using the CES-D score (range 0–9), and (2) probable clinical depression, defined using a cutoff score of ≥5. This threshold has previously been shown to have acceptable sensitivity (80.7%) and specificity (68.7%) in older adult populations.10
CovariatesAll regression models were adjusted for relevant sociodemographic and health-related covariates, including age, sex, and years of education. Multimorbidity was defined as the presence of at least one of seven self-reported physician-diagnosed conditions: hypertension, diabetes, cancer, chronic respiratory disease, myocardial infarction, stroke, and arthritis. Alcohol consumption was classified based on current drinking status. Socioeconomic position was assessed using household net worth, a comprehensive indicator of long-term economic resources.
Statistical analysisDifferences between the MHAS population and the analytic subsample were assessed using the Kruskal–Wallis test for continuous variables. Comparisons across Life's Essential 8 (LE8) categories were performed using one-way analysis of variance (ANOVA), while ordinal and categorical variables were analysed using the χ2 test. Two depression-related outcomes were examined: (1) depressive symptom burden, assessed using the CES-D score (range 0–9), and (2) probable clinical depression, defined as a CES-D score ≥5. Multinomial logistic regression models were used to examine the association between LE8 categories and depressive symptom burden (CES-D score 0–9). Binary logistic regression models were used to assess the association between cardiovascular health categories and probable clinical depression (CES-D ≥5).10 For both outcomes, unadjusted models were first estimated, followed by adjusted models including age, sex, education, comorbidities, alcohol consumption, and socioeconomic status. All analyses were performed using STATA version 14.2. Statistical significance was defined as a two-sided p-value of <0.05.
ResultsIn our sample of 700 participants, the mean age was 67.7 years (8.55) and 410 (58.6%) were female. Descriptive data demonstrated that when stratifying by cardiovascular health categories (high, moderate, and low), significant differences were observed in the prevalence of multimorbidity (p<0.001), the presence of five or more CES-D symptoms (p<0.001), and sex, with a higher proportion of females in certain groups (p=0.045), Table 1.
Characteristics of the sample.
| Variables | MHAS reference population(n=14,749) | Study sample(n=700) | LE8 cardiovascular health categories | p-Value* | ||
|---|---|---|---|---|---|---|
| High | Moderate | Low | ||||
| Age (years), mean (SD) | 66.13 (10.62) | 67.74 (8.55) | 67.52 (2.7) | 68.11 (8.6) | 66.22 (8.07) | 0.105 |
| Female, n (%) | 8618 (58.44) | 410 (58.6) | 30 (50) | 300 (57.5) | 80 (67.8) | 0.045 |
| Education (years), mean (SD) | 5.76 (4.75) | 5.34 (4.53) | 4.97 (4.89) | 5.44 (4.64) | 5.11 (3.80) | 0.498 |
| Multimorbidity (2+ illnesses), n (%) | 4545 (31.1) | 238 (34) | 7 (11.67) | 160 (30.65) | 71 (60.17) | <0.001 |
| Alcohol consumption, n (%) | 3378 (22.91) | 171 (24.43) | 16 (26.7) | 128 (24.52) | 27 (22.88) | 0.853 |
| Net assets, mean (SD)** | 81,600 (194,500) | 86,500 (184,800) | 74,400 (108,800) | 90,400 (201,000) | 75,500 (133,800) | 0.899 |
| Married, n (%) | 9841 (66.74) | 473 (67.57) | 44 (73.33) | 354 (67.82) | 75 (63.56) | 0.409 |
| CES-D (0–9 points), mean (SD) | 3.33 (2.64) | 3.14 (2.563) | 2.417 (2.028) | 2.918 (2.496) | 4.492 (2.666) | <0.001 |
| ≥5 CES-D symptoms, n (%) | 4253 (30.9) | 197 (28.1) | 11 (18.3) | 127 (24.3) | 59 (50.0) | <0.001 |
Group differences were assessed using the Kruskal–Wallis test for continuous variables.
Net assets were originally reported in Mexican pesos and converted to US dollars using the 2016 annual average exchange rate (1 MXN=0.05364 USD). According to American Heart Association criteria (5), participants were categorized into three cardiovascular health groups: high cardiovascular health (scores 80–100), moderate cardiovascular health (scores 50–79), and low cardiovascular health (scores 0–49).
Absolute risk differences in depressive symptoms were greatest for participants in the low cardiovascular health group, with a 31.7% higher prevalence compared with the high cardiovascular health group (95% CI: 18.3–45.0). Participants in the moderate group had a smaller, non-significant difference of 6.0% compared with the high LE8 group (95% CI: −4.5–16.5). In the adjusted models, the probability of having a higher CES-D score and of presenting five or more CES-D symptoms was significantly higher in the low cardiovascular health group than in the other groups (CES-D score: OR=2.84, 95% CI: 1.62–4.99, p<0.001; five or more CES-D symptoms: OR=3.47, 95% CI: 1.57–7.70, p=0.002) (Fig. 1). Similarly, compared with the moderate health group, the low cardiovascular health group had higher odds of depressive symptoms (adjusted CES-D score: OR=2.47, 95% CI: 1.71–3.58, p<0.001; five or more CES-D symptoms: OR=2.74, 95% CI: 1.76–4.28, p<0.001). No significant differences were observed between the moderate and high LE8 groups.
Forest plot displaying odds ratios (ORs) for depressive symptoms by comparing LE8 cardiovascular health categories. Higher cardiovascular health categories were associated with significantly lower odds of depressive symptoms in both the CES-D scale (0–9) and +5-point analyses (probable clinical depression) when comparing LE8 risk groups.
Our findings suggest that cardiovascular health measured with the LE8 is associated with depressive symptoms in older Mexican adults. Cardiovascular health has already been associated with mental health outcomes such as cognitive impairment and depression.11 The link between cardiovascular health and depression is bidirectional, driven by behavioral and lifestyle factors.11 Sedentary behavior, poor diet, and smoking can elevate proinflammatory mediators, worsening depressive symptoms and promoting vascular damage, which in turn affects brain circuits and contributes to both the development and progression of depression.12 Individuals with the healthiest lifestyles have up to a 67% lower risk of depression, and both physical inactivity and smoking are independently associated with higher depression prevalence.13–15
This study has some limitations; its cross-sectional design did not allow for causal inference or incidence calculation. Several LE8 components were adapted using MHAS-derived proxy measures due to data limitations: diet was represented by food insecurity, physical activity by self-reported regular exercise or hard work, and sleep by difficulty falling asleep rather than sleep duration. Although these proxies align conceptually with LE8 domains, they may not fully capture the original constructs, and potential measurement bias should be considered (Supplementary Table S1). Furthermore, multimorbidity varied significantly across cardiovascular health categories (p<0.001), with a markedly higher burden in the lowest group, suggesting potential residual confounding despite adjustment. Additionally, the distribution of participants across LE8 categories was uneven, with a relatively small number in the high cardiovascular health group. This imbalance may have affected the stability and precision of estimates, particularly for comparisons involving this group. Finally, the use of a lower, culturally validated CES-D cut-off may have captured milder depressive symptoms, potentially inflating prevalence estimates.
Our study has key strengths, notably the use of nationally representative data from a nationally representative Latin American sample. In a population where obesity, sedentary lifestyles, poor diets, and underdiagnosed depression are prevalent, our findings provide further insight and contribute needed evidence on this understudied topic. Even though these results may not generalize to other Latin American populations, due to regional variations in diet, comorbidities and socioeconomic factors, this study demonstrates a significant association between poor cardiovascular health, as measured by LE8, and increased odds of depressive symptoms in older Mexican adults. Individuals in the lowest LE8 category had more than threefold higher odds of exhibiting clinically significant depressive symptoms compared to those in the highest category. These findings underscore the relevance of LE8 not only as a cardiovascular risk assessment tool but also as a practical proxy for identifying individuals with a higher prevalence of depression in later life. Given its ease of use and integration with routine clinical data, LE8 may help identify individuals with a greater burden of depressive symptoms, especially in under-resourced settings such as our population. Implementing LE8-based evaluations in aging populations could help identify associations with depression. Further longitudinal research is warranted to explore causal pathways and validate LE8 across diverse populations.
Ethics declarations and disseminationThe study was approved by the Institutional Review Boards of the University of Texas Medical Branch, the Instituto Nacional de Estadística y Geografía, and the Secretaría de Salud Pública of Mexico. This study adhered to the ethical principles of the Declaration of Helsinki. All participants provided written informed consent in accordance with the Good Clinical Practice guidelines before enrolment.
Conflict of interestThe authors declare no potential conflicts of interest.
The authors report no declarations of interest.
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