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NRI 12-413 – HSR&D Study

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NRI 12-413
Mindfulness Based Stress Reduction for Women at Risk for Cardiovascular Disease
Karen L. Saban PhD RN
Edward Hines Jr. VA Hospital, Hines, IL
Hines, IL
Funding Period: July 2013 - December 2017

BACKGROUND/RATIONALE:
Evidence demonstrates that chronic stress doubles the risk of myocardial infarction and contributes to proinflammatory processes implicated in coronary artery disease and stroke. Veterans who have experienced combat are at greater risk for cardiovascular disease (CVD) compared to noncombat Veterans and non-Veterans. However, previous research has focused primarily on male Veterans. Yet statistics reveal a startling number (81-92%) of women Veterans report at least one traumatic event sometime in their lives and women Veterans experience significant rates of prior life adversity such as sexual assault, physical violence, and combat exposure. Compelling evidence demonstrates a strong relationship between the breadth of prior life adversity, proinflammatory cytokines and stress-related inflammatory disease, such as CVD. Assisting women Veterans to reduce stress and develop coping strategies may improve psychological well-being and reduce CVD risk. Mindfulness Based Stress Reduction (MBSR) involves intensive training in mindfulness, which promotes positive adaptation to life stress. MBSR has been found to reduce symptoms of depression and improve quality of life in Veterans experiencing Post-Traumatic Stress Disorder (PTSD). Practitioners of MBSR gain increased awareness and insight into the relationship among their thoughts, emotions, and somatic reactivity which can facilitate change in conditioned patterns of emotional reaction. However, only minimal research and no randomized control trials (RCTs) have examined MBSR as an intervention for reducing CVD risk in women Veterans. Furthermore, previous studies have neither examined CVD risk objectively using a well-established CVD risk score nor measured endothelial dysfunction. Endothelial dysfunction is acknowledged to precede atherosclerosis and is a strong predictor of CVD. Furthermore, studies demonstrate that lifestyle changes, such exercise and yoga, can reverse endothelial dysfunction. However, no studies were found that considered endothelial function in relation to MBSR. Moreover, potential protective and risk factors, such as prior life adversity, social support, health behaviors, acculturation, and diurnal cortisol, posited to moderate the effect of psychological well-being and inflammation on MBSR have not been examined in this population.

OBJECTIVE(S):
The following specific aims were addressed: (1) Determine the extent to which training in MBSR (1) improves psychological well-being, (2) decreases inflammatory burden, and (3) reduces cardiovascular risk in women Veterans; and (2) Evaluate protective and risk factors posited to moderate the effect of MBSR on psychological well being, inflammatory burden and cardiovascular risk (inlcuding endothelial dysfunction) in women Veterans. Age, body mass index (BMI), menstrual status, medications, and socioeconomic status (SES) were evaluated as covariates.

METHODS:
Women Veterans between the ages of 18 and 70 years who had at least one cardiovascular disease (CVD) risk factors (as defined by Framingham CVD Risk Scale) were randomized into either an 8-week MBSR program or health education control program. We ran three cohorts per year.

FINDINGS/RESULTS:
Our targeted enrollment was 138 participants with an expected attrition rate of 25% resulting in a sample size of 110 (N=55 in the MBSR group and 55 in the attention control group). We enrolled 162 participants with 140 participants completing baseline testing. Of the women Veterans who completed baseline testing and attended at least one class (N=122, mean age=50.87), 57% reported high levels of perceived stress and 62% higher than average levels of anxiety at baseline. Participants were randomized into either the MBSR group (n=66) or the attention control group (n=56) and attended an average of 5.74 classes with 30% attending all 8 classes. Over 88% of participants indicated that they would recommend the MBSR program to others.

Controlling for age, education level and household income, participants in the MBSR reported significantly decreased levels of perceived stress (p=.05) and anxiety (p=.002) at the completion of the 8-wk program as compared to those in the attention control group.

Participants in the MBSR group also had lower diurnal salivary cortisol levels (as measured by area under the curve) at 6 months post intervention compared to participants in the attention control group (p=.013). There was an upward trend for serum IL-10 (anti-inflammatory cytokine) from baseline to completion (8 wk time point) for the MBSR group whereas IL-10 trended downwards for those in the control group. No differences were found among IL-6 or IFNG. No differences were found in relationship to CVD risk. Higher depressive symptoms were associated with lower levels of mindfulness.


IMPACT:
Findings suggest that women Veterans experience elevated levels of perceived stress and anxiety and that MBSR is effective in reducing perceived stress and anxiety as well as markers of inflammation. MBSR can be considered as a safe and effective option for women Veterans seeking to reduce their levels of anxiety and perceived stress. The MBSR program was well accepted by the participants with 88% of participants indicating that they would recommend the program to others.

PUBLICATIONS:

Journal Articles

  1. Saban KL, Mathews HL, Bryant FB, Tell D, Joyce C, DeVon HA, Witek Janusek L. Perceived discrimination is associated with the inflammatory response to acute laboratory stress in women at risk for cardiovascular disease. Brain, Behavior, and Immunity. 2018 Oct 1; 73:625-632.
  2. Levine GN, Lange RA, Bairey-Merz CN, Davidson RJ, Jamerson K, Mehta PK, Michos ED, Norris K, Ray IB, Saban KL, Shah T, Stein R, Smith SC, American Heart Association Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and Council on Hypertension. Meditation and Cardiovascular Risk Reduction: A Scientific Statement From the American Heart Association. Journal of the American Heart Association. 2017 Sep 28; 6(10).
Conference Presentations

  1. Saban KL, Matthews HL, Collins EG, Janusek L. Early Life Adversity, Depressive Symptoms, and Endothelial Dysfunction in Women Veterans. Poster session presented at: Psychoneuroimmunology Research Society Annual Meeting; 2014 May 29; Philadelphia, PA.


DRA: Cardiovascular Disease
DRE: Treatment - Comparative Effectiveness
Keywords: Cardiovascular Disease, Outcomes - Patient, Patient Preferences, Stress
MeSH Terms: none