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ITAMAR LEVINGER,1 STEVE SELIG,1 CRAIG GOODMAN,1 GEORGE JERUMS,2 ANDREW STEWART,3 3 AND DAVID L. HARE
1 2
Institute for Sport, Exercise and Active Living, School of Sport and Exercise Science, Victoria University, Melbourne, Australia; Department of Endocrinology, University of Melbourne, Austin Health, Melbourne, Australia; and 3Department of Cardiology, University of Melbourne, Austin Health, Melbourne, Australia
ABSTRACT
Levinger, I, Selig, S, Goodman, C, Jerums, G, Stewart, A, and Hare, DL. Resistance training improves depressive symptoms in individuals at high risk for type 2 diabetes. J Strength Cond Res 25(8): 23282333, 2011Depression is more prevalent in obese individuals and those with diabetes, compared to the general population. This study examined the effect of resistance training on depressed mood in individuals with high (HiMF, n $ 2) and low (LoMF, n # 1) numbers of risk factors for metabolic syndrome and type 2 diabetes. The primary hypothesis was that resistance training would signicantly reduce depressed mood, as measured by the Cardiac Depression Scale (CDS), in individuals with HiMF. Fifty-ve middle-aged volunteers (50.8 6 0.9 years, mean 6 SEM) from the general community participated in the study. After initial allocation to HiMF or LoMF, participants were randomly allocated to 4 groups, HiMF training (HiMFT), HiMF control (HiMFC), LoMF training (LoMFT), and LoMF control (LoMFC). Participants underwent resistance training involving major muscle groups on 3 dwk21 for 10 weeks. Before and after interventions (training or control), participants completed the CDS to assess change in the level of depressed mood. Following resistance training, the CDS score of the HiMFT group was reduced by 214.8 6 4.9 points on the CDS, a signicant improvement in comparison to both baseline (p = 0.01) and HiMFC (p = 0.049) values. No signicant change was observed for LoMFT. In the HiMF group only, the percent change in relative muscle strength was correlated with the D change in CDS; r = 20.46, p = 0.008. Resistance exercise training programs that consist 7 exercises for the major muscle groups at both low-moderate and
moderate-high intensities appear to alleviate depressed mood in individuals with clusters of metabolic risk factors.
INTRODUCTION
Address correspondence to Dr. Itamar Levinger, itamar.levinger@vu. edu.au. 25(8)/23282333 Journal of Strength and Conditioning Research 2011 National Strength and Conditioning Association
he prevalence of obesity and its associated conditions, such as hypertension, dyslipidemia, and insulin resistance, has proliferated worldwide over the past 2 decades (16). Increases in metabolic risk prole can lead to metabolic syndrome, type II diabetes mellitus (T2DM), and cardiovascular disease (CVD). Obesity and metabolic risk factors may not only have physiological and metabolic consequences (17) but may also have psychological effects (5). Depression is more prevalent in obese individuals (11) and patients with diabetes (1), compared to in the general population. Depression may also be a major risk factor for obesity and its related complications (such as T2DM) because it may lead to behavioral changes such as reduced physical activity and increased energy intake (24). In addition, in people with chronic physical illness, depression is associated with increased health care use and increased functional disability and work absence, compared to in individuals with chronic physical illness without depression (23). Finally, individuals with T2DM who also suffer from depression have an increased risk for developing diabetic complications(1). Questionnaires to quantify depression (such as the Beck Depression Inventory) have commonly been developed for psychiatric populations, but they produce skewed score distributions in other populations (2). The cardiac depression scale (CDS) was specically developed, originally in cardiac patients, to assess the wide range of depressed moods seen in nonpsychiatric populations, to encompass adjustment disorder with depressed mood and minor depression and major depression on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition classication (9). Because many obese and middle-aged individuals have
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a person who was not involved in the study, using sealed envelopes) to 1 of 4 groups: HiMF training (HiMFT, men = 8, women = 5), HiMF nonexercise control (HiMFC, men = 10, women = 5), LoMF training (LoMFT, men = 3, women = 8), and LoMF nonexercise control (LoMFC, men = 4, women = 9). Randomization was stratied according to sex. Participants were on a range of medications including beta-blockers (n = 2), calcium channel blockers (n = 2), angiotensinconverting enzyme inhibitors (n = 4), diuretics (n = 1), statins (n = 2), metformin (n = 1), and hormone replacement therapy (n = 6). Participants were excluded if they had documented incidence of cardiac disease or they were involved in regular physical activity in the previous 6 months. Participants were given written and verbal information on the nature of the study including the experimental risks and then signed an informed consent document before the investigation. The investigation was approved by the Victoria University and Austin Health Human Research Ethics Committees.
Procedures
METHODS
Experimental Approach to the Problem
Participants with varying numbers of metabolic risk factors were allocated to HiMF and LoMF groups, and then these 2 groups were each randomly allotted to either the exercise training or nonexercise control group. Levels of depressive symptoms were analyzed before and after the 10 weeks of interventions of either exercise or nonexercise group for both HiMF and LoMF.
Subjects
Assessment of the Number of Metabolic Risk Factors. The method of assessing the number of metabolic risk factors has been described previously (12). In brief, plasma glucose, triglyceride, and high-density lipoprotein levels were analyzed (SYNCHRON LX System/Lxi725, Beckman Coulter Inc, Carlsbad, CA, USA) after a 12-hour fast. Blood pressure was measured using a mercury sphygmomanometer after participants had rested in a seated position for 15 minutes. Systolic and diastolic blood pressures were recorded to the nearest 2 mm Hg. Waist circumference was measured with a steel tape and taken as the smallest circumference between the iliac crest and the lower border of the ribs. Cardiac Depression Scale. The CDS contains 26 items on a Likert scale from 1 to 7, 4 items being reverse scored, and a higher score indicating a more severe depressed mood (9). The CDS has excellent receiver operating characteristics with an area under the curve of 0.94 for any depression and 0.96 for major depression (20). Although originally developed in cardiac patients, it measures core aspects of depression (e.g., depressed mood, anhedonia, and sleep disturbance) measured by commonly used depression scales such as the Beck Depression Inventory, Hospital Anxiety Depression Scale, and the Center for Epidemiologic Studies Depression Scale (22). In addition to measurement of the severity of core depressive symptoms, it measures hopelessness-related cognitions associated with depression in persons adjusting to a chronic illness such as diabetes. The CDS has been shown to be a sensitive, reliable, and responsive tool for assessing changes in depression in both English speaking (3) and non-English speaking populations (25). Questionnaires were administered by a single investigator. The internal construct validity of the CDS in this population was tested in all 55 participants, at baseline. The testretest reliability of the CDS was assessed in the 28 participants randomly allocated to the nonexercise controls. The external CDS validity was conrmed using the generic Short Form
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A total of 55 (men = 28, women = 27) untrained middle-aged individuals (50.8 6 0.9 years, range = 4069 years; mean 6 SEM) took part in the study. Participants anthropometric measurements were as follows: height = 168.7 6 1.3 cm (range = 152186 cm), mass = 79.4 6 2.3 kg (range = 40116 kg), body mass index = 27.7 6 0.7 kgm22 (range = 1740 kgm22), and waist circumference = 92.2 6 1.9 cm (range = 59121 cm). Participants with 2 or more metabolic risk factors, according to the International Diabetes Federation criteria (IDF) (28), were classied as having HiMF and those with one or no metabolic risk factors were classied as having a low number of metabolic risk factors (LoMF). The rationale for the HiMF group allocation is that individuals with 2 or more risk factors are at a high risk of developing metabolic syndrome and T2DM (19). The IDF criteria include the following: waist circumference $94 cm for men and $80 cm for women, triglycerides $1.7 mmolL21, highdensity lipoprotein ,1.03 mmolL21 for men and ,1.29 mmolL21 for women, systolic blood pressure $ 130 mm Hg or diastolic blood pressure $ 85 mm Hg (or hypertensive medications) and fasting blood glucose level $5.6 mmolL21. As described previously (12), after the allocation into HiMF and LoMF groups, participants were randomly allocated (by
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dependent variable was the change (D) from pre-to-post in the CDS score, the xed factor (independent variable) was the intervention group (training or control), and the covariate was the baseline (pretraining) score. The relationship between the change in CDS and the change in muscle strength was assessed using Spearman correlation with gender as a covariate. The relationship between the CDS and the SF-36 was assessed using Spearman correlation between the total CDS score, separately with both the physical and mental dimensions of the SF-36. The baseline data of the 55 participants were used for the internal construct validity for the CDS in this particular population using standard methods as used by Birks et al. (3). Cronbachs a was calculated using the 26 individual items of each CDS questionnaire. Test retest reliability was assessed by comparing the total CDS score at baseline and the score after 10 weeks for the 28 participants who were randomly allocated to the control group. These values were compared using Spearman correlation, intraclass correlation coefcient (ICC), and BlandAltman plots (4). Data are reported as mean 6 SEM, and all statistical analyses were conducted at the 95% level of signicance.
RESULTS
Validity and Reliability of the Cardiac Depression Scale
Training data were analyzed for the 52 participants who completed the study. Multivariate analysis of variance was used to examine the differences in anthropometric and metabolic risk factors after the allocation to groups, that is, HiMFT vs. HiMFC and LoMFT vs. LoMFC (Table 1). Oneway analysis of covariance (ANCOVA) was used to examine the effect of training on the CDS score as the HiMFT group had a signicant higher CDS score at baseline. The
The internal reliability of the CDS score (n = 28) was high, with Cronbachs a = 0.84. The testretest reliability was satisfactory with a Spearman correlation = 0.77 (p , 0.01) and ICC = 0.84. BlandAltman plots revealed a mean and SEM of difference, between repeat CDS scores, of 2.1 6 3.3. A signicant correlation was found between the CDS scores and the physical (r = 20.78, p , 0.01) and mental (r = 20.69, p , 0.01) health dimensions of the SF-36. In addition, the distribution of scores in the CDS demonstrated greater normality, compared to the physical and mental health dimensions of the SF-36 (Figure 1).
TABLE 1. Baseline comparisons between HiMFT vs. HiMFC and LoMFT vs. LoMFC (n = 52).* Variable Sex (M/W) Age (y) Height (cm) Weight (kg) Waist (cm) HiMFT 8/5 51.5 6 2.0 168.6 6 3.2 88.6 6 3.4 102.3 6 2.7 HiMFC 10/5 52.3 6 1.5 170.9 6 2.3 88.3 6 2.3 99.0 6 2.7 p 0.74 0.56 0.94 0.40 LoMFT 3/8 51.2 6 167.0 6 66.4 6 79.9 6 1.5 3.2 3.3 2.6 LoMFC 4/9 48.5 6 2.1 166.4 6 2.3 67.8 6 3.5 81.3 6 2.3 p 0.32 0.88 0.79 0.71
*HiMFT = high number of metabolic risk factor training group; HiMFC = high number of metabolic risk factor control group; LoMFT = low number of metabolic risk factor training group; LoMFC = low number of metabolic risk factor control group. Values are given as mean 6 SEM.
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Figure 1. Distribution of scores on the Cardiac Depression Scale (CDS) and physical and mental dimensions of the generic Short Form 36 (SF-36; n = 55).
Baseline
Participants anthropometric characteristics are shown in Table 1. At baseline, there were no signicant depression score differences between LoMFC and LoMFT (67.9 6 6.2 vs. 65.5 6 7.2, respectively, p = 0.78). By chance, the HiMFT group had higher depression scores at baseline, compared to the HiMFC group (82.6 6 5.9 vs. 62.9 6 4.6, p = 0.01). There was also a trend toward higher depression scores in the HiMFT group, compared to in the LoMFT group (p = 0.07).
Adherence to Training
(1 from the HiMFT group and 1 from the LoMFT group) or because of work-related reasons (1 person from the HiMFT group). The adherence to training was high in both training groups (HiMFT = 88%, and LoMFT = 96%).
The Effect of Training on Cardiac Depression Scale
Three participants from the training groups (1 from the LoMFT group and 2 from the HiMFT group) did not complete the study, and their data were excluded from the training analyses. These 3 individuals did not complete the study because of medical reasons not related to the study
After training, the depression score for HiMFT was reduced (improved) by 14.8 6 4.9 points on the CDS, which was a signicant improvement compared to both baseline (p = 0.01) and the HiMFC (p = 0.049) values (Figure 2). No signicant change was observed for the LoMFT or LoMFC group (all p . 0.05) (Figure 2). As reported previously (12), muscle strength improved for both HiMFT training groups (by 25%, p , 0.01) and the LoMFT (by 23.7%, p , 0.01), compared to their controls. In the HiMF group only, the percent change in absolute muscle strength and relative muscle strength (total muscle strength/body mass) was correlated with the D change in the CDS score (r = 20.045, p = 0.009, and r = 20.46, p = 0.008, respectively).
DISCUSSION
The main nding of this study is that RT may alleviate depression in individuals at high risk of developing T2DM and CVD. It also conrms that the CDS is a robust measure of depressed mood in this population. It is widely reported that exercise training (6) can improve QoL in middle-aged and elderly individuals. It has also been reported that both aerobic (18) and resistance (12) training regimens can improve QoL in individuals at high risk of developing T2DM and CVD. Previous studies have shown that exercise can improve depression in elderly individuals with major or minor depression (21). There are, however, limited data with regard to the effect of RT on symptoms of depression in middle-aged individuals at a high risk for developing T2DM
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Figure 2. The effects of resistance exercise training (RT) on Cardiac Depression Scale (CDS) score of individuals with a high number of metabolic risk factor training group (HiMF) and a low number of metabolic risk factor training group (LoMF) (mean 6 SEM, n = 52). *p = 0.01 compared to baseline, #p = 0.049 compared to control.
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PRACTICAL APPLICATIONS
Resistance exercise training appears to alleviate depressed mood in individuals who have multiple numbers of metabolic risk factors associated with T2DM and CVD. Implications from this study are that RT programs consisting of both low moderate and moderatehigh intensities can have positive effects on the depressive mood of people with clusters of metabolic risk factors. Furthermore, based on the data that we presented here, we recommend the following: lowmoderate intensity training of 68 exercises covering all major muscle groups with 23 sets of 1520 repetitions each and at approximately 5065% of 1RM; and moderatehigh intensity training consisting of the same exercises with 23 sets of 815 repetitions, up to 85% of 1RM. In summary, RT is a simple and effective method to improve depressed mood in this population and should form an important part of the exercise training regimens for people at a high risk of developing T2DM and CVD.
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