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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 (christina.andreae@dll.se).

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.

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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.

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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/

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