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Jsc201506 2328.2333

RESISTANCE TRAINING IMPROVES DEPRESSIVESYMPTOMS IN INDIVIDUALS AT HIGH RISK FORTYPE 2 DIABETES ITAMAR LEVINGER,1 STEVE SELIG,1 CRAIG GOODMAN,1 GEORGE JERUMS,2 ANDREW STEWART,3 1Institute for Sport, Exercise and Active Living, School of Sport and Exercise Science, Victoria University, Melbourne, Australia;2Department of Endocrinology, University of Melbourne, Austin Health, Melbourne, Australia; and 3Department of Cardiology,University of Melbourne, Austin Health, Melbourne, Australia moderate-high intensities appear to alleviate depressed mood Levinger, I, Selig, S, Goodman, C, Jerums, G, Stewart, A, and in individuals with clusters of metabolic risk factors.
Hare, DL. Resistance training improves depressive symptoms KEY WORDS cardiac depression scale, depressed mood, in individuals at high risk for type 2 diabetes. J Strength Cond Res 25(8): 2328–2333, 2011—Depression 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 The prevalence of obesity and its associated conditions, such as hypertension, dyslipidemia,and insulin resistance, has proliferated worldwide syndrome and type 2 diabetes. The primary hypothesis was that over the past 2 decades (16). Increases in metabolic resistance training would significantly reduce depressed mood, risk profile can lead to metabolic syndrome, type II diabetes as measured by the Cardiac Depression Scale (CDS), in mellitus (T2DM), and cardiovascular disease (CVD). Obesity individuals with HiMF. Fifty-five middle-aged volunteers (50.8 6 and metabolic risk factors may not only have physiological 0.9 years, mean 6 SEM) from the general community and metabolic consequences (17) but may also have participated in the study. After initial allocation to HiMF or psychological effects (5). Depression is more prevalent in LoMF, participants were randomly allocated to 4 groups, HiMF obese individuals (11) and patients with diabetes (1),compared to in the general population. Depression may training (HiMFT), HiMF control (HiMFC), LoMF training also be a major risk factor for obesity and its related (LoMFT), and LoMF control (LoMFC). Participants underwent complications (such as T2DM) because it may lead to resistance training involving major muscle groups on 3 dÁwk21 behavioral changes such as reduced physical activity and for 10 weeks. Before and after interventions (training or increased energy intake (24). In addition, in people with control), participants completed the CDS to assess change in chronic physical illness, depression is associated with the level of depressed mood. Following resistance training, the increased health care use and increased functional disability CDS score of the HiMFT group was reduced by 214.8 6 4.9 and work absence, compared to in individuals with chronic points on the CDS, a significant improvement in comparison to physical illness without depression (23). Finally, individuals both baseline (p = 0.01) and HiMFC (p = 0.049) values. No with T2DM who also suffer from depression have an significant change was observed for LoMFT. In the HiMF group increased risk for developing diabetic complications(1).
only, the percent change in relative muscle strength was Questionnaires to quantify depression (such as the Beck correlated with the D change in CDS; r = 20.46, p = 0.008.
Depression Inventory) have commonly been developed forpsychiatric populations, but they produce skewed score Resistance exercise training programs that consist 7 exercises distributions in other populations (2). The cardiac depression for the major muscle groups at both low-moderate and scale (CDS) was specifically developed, originally in cardiacpatients, to assess the wide range of depressed moods seen in Address correspondence to Dr. Itamar Levinger, [email protected]
nonpsychiatric populations, to encompass ‘‘adjustment disorder with depressed mood’’ and ‘‘minor depression’’ and ‘‘major depression’’ on the Diagnostic and StatisticalManual of Mental Disorders, Fourth Edition classification (9).
Journal of Strength and Conditioning ResearchÓ 2011 National Strength and Conditioning Association Because many obese and middle-aged individuals have Journal of Strength and Conditioning Research Copyright National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited.
al of Strength and Conditioning ResearchTM | www.nsca-jscr.org mildly elevated levels of depressed mood, the CDS was a person who was not involved in the study, using sealed thought to be a potentially suitable tool for assessing envelopes) to 1 of 4 groups: HiMF training (HiMFT, men = 8, depression in the range found in these individuals who are women = 5), HiMF nonexercise control (HiMFC, men = 10, at high risk for developing T2DM and CVD.
women = 5), LoMF training (LoMFT, men = 3, women = 8), Lifestyle modifications are considered as important and LoMF nonexercise control (LoMFC, men = 4, women = 9).
interventions for obese individuals and those with metabolic Randomization was stratified according to sex. Participants risk factors for T2DM and CVD. Interventions including diet were on a range of medications including beta-blockers with behavioral modifications (10), aerobic exercise training (n = 2), calcium channel blockers (n = 2), angiotensin- (18), and resistance exercise training (RT) (12) have been converting enzyme inhibitors (n = 4), diuretics (n = 1), statins shown to improve quality of life (QoL) in obese populations (n = 2), metformin (n = 1), and hormone replacement and those with metabolic risk factors for T2DM and CVD. In therapy (n = 6). Participants were excluded if they had addition, Fox (8) has suggested that exercise may be useful in documented incidence of cardiac disease or they were the treatment of depression. As such, the aim of this study involved in regular physical activity in the previous 6 months.
was to determine whether RT reduces the level of depressed Participants were given written and verbal information on the mood in middle-aged individuals with risk factors for nature of the study including the experimental risks and then developing T2DM and CVD. To our knowledge, no study signed an informed consent document before the investigation.
has examined the effect of RT on the depressed mood of The investigation was approved by the Victoria University and people with a cluster of metabolic risk factors. The primary Austin Health Human Research Ethics Committees.
hypothesis was that RT would significantly reduce depressed mood, as measured by the CDS, in individuals with high Assessment of the Number of Metabolic Risk Factors. The method numbers of metabolic risk factors (HiMF).
of assessing the number of metabolic risk factors has been described previously (12). In brief, plasma glucose, tri-glyceride, and high-density lipoprotein levels were analyzed Experimental Approach to the ProblemParticipants with varying numbers of metabolic risk factors (SYNCHRON LXÒ System/Lxi725, Beckman Coulter Inc, were allocated to HiMF and LoMF groups, and then these Carlsbad, CA, USA) after a 12-hour fast. Blood pressure was 2 groups were each randomly allotted to either the exercise measured using a mercury sphygmomanometer after partic- training or nonexercise control group. Levels of depressive ipants had rested in a seated position for 15 minutes. Systolic symptoms were analyzed before and after the 10 weeks of and diastolic blood pressures were recorded to the nearest 2 interventions of either exercise or nonexercise group for both mm Hg. Waist circumference was measured with a steel tape and taken as the smallest circumference between the iliaccrest and the lower border of the ribs.
SubjectsA total of 55 (men = 28, women = 27) untrained middle-aged Cardiac Depression Scale. The CDS contains 26 items on a Likert individuals (50.8 6 0.9 years, range = 40–69 years; mean 6 scale from 1 to 7, 4 items being reverse scored, and a higher score SEM) took part in the study. Participants’ anthropometric indicating a more severe depressed mood (9). The CDS has measurements were as follows: height = 168.7 6 1.3 cm excellent receiver operating characteristics with an area under (range = 152–186 cm), mass = 79.4 6 2.3 kg (range = 40–116 the curve of 0.94 for any depression and 0.96 for major kg), body mass index = 27.7 6 0.7 kgÁm22 (range = 17–40 depression (20). Although originally developed in cardiac kgÁm22), and waist circumference = 92.2 6 1.9 cm (range = patients, it measures core aspects of depression (e.g., depressed 59–121 cm). Participants with 2 or more metabolic risk mood, anhedonia, and sleep disturbance) measured by factors, according to the International Diabetes Federation commonly used depression scales such as the Beck Depression criteria (IDF) (28), were classified as having HiMF and those Inventory, Hospital Anxiety Depression Scale, and the Center with one or no metabolic risk factors were classified as having for Epidemiologic Studies Depression Scale (22). In addition to a low number of metabolic risk factors (LoMF). The measurement of the severity of core depressive symptoms, it rationale for the HiMF group allocation is that individuals measures hopelessness-related cognitions associated with de- with 2 or more risk factors are at a high risk of developing pression in persons adjusting to a chronic illness such as metabolic syndrome and T2DM (19). The IDF criteria diabetes. The CDS has been shown to be a sensitive, reliable, include the following: waist circumference $94 cm for men and responsive tool for assessing changes in depression in both and $80 cm for women, triglycerides $1.7 mmolÁL21, high- English speaking (3) and non-English speaking populations (25).
density lipoprotein ,1.03 mmolÁL21 for men and ,1.29 Questionnaires were administered by a single investigator.
mmolÁL21 for women, systolic blood pressure $ 130 mm Hg The internal construct validity of the CDS in this population or diastolic blood pressure $ 85 mm Hg (or hypertensive was tested in all 55 participants, at baseline. The test–retest medications) and fasting blood glucose level $5.6 mmolÁL21.
reliability of the CDS was assessed in the 28 participants As described previously (12), after the allocation into HiMF randomly allocated to the nonexercise controls. The external and LoMF groups, participants were randomly allocated (by CDS validity was confirmed using the generic Short Form VOLUME 25 | NUMBER 8 | AUGUST 2011 | 2329 Copyright National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited.
36 (SF-36) Health Survey, which is although not designed to dependent variable was the change (D) from pre-to-post in measure depression, includes dimensions that reflect the CDS score, the fixed factor (independent variable) was depressed mood. The SF-36 contains 36 items comprising the intervention group (training or control), and the covariate 8 subscales. Four subscales evaluate the physical health was the baseline (pretraining) score. The relationship dimension. The remaining 4 subscales constitute the mental between the change in CDS and the change in muscle health dimension (15,26). A higher score represents a higher strength was assessed using Spearman correlation with level of function and health-related QoL.
The relationship between the CDS and the SF-36 was Resistance Training Protocol. The training protocol was as assessed using Spearman correlation between the total CDS described by Levinger et al. (12). In brief, the RT was score, separately with both the physical and mental conducted 3 dÁwk21 for 10 weeks. Training included dimensions of the SF-36. The baseline data of the 55 7 exercises: chest press, leg press, lateral pull-down, triceps participants were used for the internal construct validity for pushdown, knee extension, seated row, and biceps curl.
the CDS in this particular population using standard methods Training intensity was determined according to the as used by Birks et al. (3). Cronbach’s a was calculated using 1 repetition maximum (1RM) method. This method has the 26 individual items of each CDS questionnaire. Test– been shown to have high reliability for assessing muscle retest reliability was assessed by comparing the total CDS strength (13). In the first week, training consisted of 2 sets score at baseline and the score after 10 weeks for the 28 of 15–20 repetitions at 40–50% of the 1RM for that participants who were randomly allocated to the control particular exercise. From weeks 2–10, participants per- group. These values were compared using Spearman formed 3 sets of 8–20 repetitions at 50–85% 1RM for each correlation, intraclass correlation coefficient (ICC), and exercise. The wide range of repetitions is because of the stages of progression, 15–20 repetitions in week 2, 12–15 Data are reported as mean 6 SEM, and all statistical repetitions during weeks 3–6, and 8–12 repetitions during analyses were conducted at the 95% level of significance.
weeks 7–10. At each session, weights were adjustedaccording to the capacity of the individual, with weightsincreased if the participant was able to achieve the maximum number of prescribed range of repetitions for Validity and Reliability of the Cardiac Depression Scale that week and decreased if the minimum number of range The internal reliability of the CDS score (n = 28) was high, of repetitions was not able to be achieved.
with Cronbach’s a = 0.84. The test–retest reliability was satisfactory with a Spearman correlation = 0.77 (p , 0.01) Training data were analyzed for the 52 participants who and ICC = 0.84. Bland–Altman plots revealed a mean and completed the study. Multivariate analysis of variance was SEM of difference, between repeat CDS scores, of 2.1 6 3.3.
used to examine the differences in anthropometric and A significant correlation was found between the CDS metabolic risk factors after the allocation to groups, that is, scores and the physical (r = 20.78, p , 0.01) and mental HiMFT vs. HiMFC and LoMFT vs. LoMFC (Table 1). One- (r = 20.69, p , 0.01) health dimensions of the SF-36. In way analysis of covariance (ANCOVA) was used to examine addition, the distribution of scores in the CDS demonstrated the effect of training on the CDS score as the HiMFT group greater normality, compared to the physical and mental had a significant higher CDS score at baseline. The health dimensions of the SF-36 (Figure 1).
TABLE 1. Baseline comparisons between HiMFT vs. HiMFC and LoMFT vs. LoMFC (n = 52).*† *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.
Journal of Strength and Conditioning Research Copyright National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited.
al of Strength and Conditioning ResearchTM | www.nsca-jscr.org 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).
(1 from the HiMFT group and 1 from the LoMFT group) or Participants’ anthropometric characteristics are shown in because of work-related reasons (1 person from the HiMFT Table 1. At baseline, there were no significant depression group). The adherence to training was high in both training score differences between LoMFC and LoMFT (67.9 6 6.2 groups (HiMFT = 88%, and LoMFT = 96%).
vs. 65.5 6 7.2, respectively, p = 0.78). By chance, the HiMFT The Effect of Training on Cardiac Depression Scale group had higher depression scores at baseline, compared to After training, the depression score for HiMFT was reduced the HiMFC group (82.6 6 5.9 vs. 62.9 6 4.6, p = 0.01). There (improved) by 14.8 6 4.9 points on the CDS, which was was also a trend toward higher depression scores in the a significant improvement compared to both baseline (p = HiMFT group, compared to in the LoMFT group (p = 0.07).
0.01) and the HiMFC (p = 0.049) values (Figure 2). No significant change was observed for the LoMFT or LoMFC Three participants from the training groups (1 from the group (all p . 0.05) (Figure 2). As reported previously (12), LoMFT group and 2 from the HiMFT group) did not muscle strength improved for both HiMFT training groups complete the study, and their data were excluded from (by 25%, p , 0.01) and the LoMFT (by 23.7%, p , 0.01), the training analyses. These 3 individuals did not complete the compared to their controls. In the HiMF group only, the study because of medical reasons not related to the study percent change in absolute muscle strength and relativemuscle strength (total muscle strength/body mass) wascorrelated with the D change in the CDS score (r = 20.045,p = 0.009, and r = 20.46, p = 0.008, respectively).
The main finding of this study is that RT may alleviatedepression in individuals at high risk of developing T2DMand CVD. It also confirms that the CDS is a robust measure ofdepressed mood in this population.
It is widely reported that exercise training (6) can improve QoL in middle-aged and elderly individuals. It has also beenreported that both aerobic (18) and resistance (12) trainingregimens can improve QoL in individuals at high risk of Figure 2. The effects of resistance exercise training (RT) on Cardiac developing T2DM and CVD. Previous studies have shown that Depression Scale (CDS) score of individuals with a high number of exercise can improve depression in elderly individuals with metabolic risk factor training group (HiMF) and a low number of metabolic major or minor depression (21). There are, however, limited risk factor training group (LoMF) (mean 6 SEM, n = 52). *p = 0.01compared to baseline, #p = 0.049 compared to control.
data with regard to the effect of RT on symptoms of depressionin middle-aged individuals at a high risk for developing T2DM VOLUME 25 | NUMBER 8 | AUGUST 2011 | 2331 Copyright National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited.
and CVD. We hypothesized that RT can improve depressive of 55 participants, 28 were men and 27 were women. The symptoms in this clinical population. We found that short-term allocation to HiMF or LoMF groups was based on RT improved depressive mood in the experimental cohort. The objective IDF criteria, and participants were randomly implication is that depression in these clinical populations may allocated and stratified according to sex to ensure near be alleviated by the application of RT, commencing at moderate equal numbers of men and women in each study subgroup intensity and progressing over several weeks to include high- (i.e., LoMFC and LoMFT and HiMFC and HiMFT, Table 1).
intensity training. Further studies are needed to investigate the (b) Despite the randomization, HiMFT had higher de- sustainability of these early benefits. Previously, we have shown pression scores at baseline, compared to HiMFC. We have that, in this population, RT can improve muscle strength, stratified the randomization to sex and used ANCOVA to functional capacity, and self-perceived QoL (12) without take the higher baseline depression severity score into changing metabolic risk factors such as fasting glucose levels, consideration. However, it is recommended that future lipid profile, blood pressure, and waist circumference (14). This studies stratify the randomization to groups according to suggests that the improvement in the depression score for the baseline depression scores and not only sex. (c) We did not HiMFT group occurred independent of changes to metabolic assess the long-term effect of RT on depressive symptoms risk profiles. This also shows that the CDS is sensitive to and as such future studies should include a follow-up measure exercise training–induced changes in depression. It is important to identify for how long the benefits of RT on depressive to note that no change was observed in the depression score for the LoMFT group, compared to baseline and LoMFC. The In conclusion, RT programs that consist of 7–8 exercises for different effects of exercise on HiMFT and LoMFT may be the major muscle groups at both low-moderate and related to higher depression scores for HiMFT at baseline. This moderate-high intensities appear to alleviate the depressed suggests that it is more difficult to improve depression score in mood in individuals who have multiple numbers of metabolic individuals with relatively lower scores of depression or that risk factors associated with T2DM and CVD. The CDS, as a longer or more intense training protocol may be needed to a measure of depressed mood, is a responsive tool for improve depression scores in individuals with LoMF. It is assessing exercise intervention in these individuals.
unlikely that the improvement in the depression score in theHiMFT group was simply because of ‘‘regression toward the mean,’’ as (a) this bias phenomenon is of more relevance in Resistance exercise training appears to alleviate depressed nonrandomized studies (27), (b) we have used ANCOVA mood in individuals who have multiple numbers of metabolic analysis to take the higher baseline score under consideration in risk factors associated with T2DM and CVD. Implications the statistical analysis and (c) the percent changes in absolute from this study are that RT programs consisting of both low– muscle strength and relative muscle strength were correlated moderate and moderate–high intensities can have positive with the D change in CDS in the HiMF group only. This effects on the depressive mood of people with clusters of suggests that the improvement in CDS score was related to the metabolic risk factors. Furthermore, based on the data that we increase in muscle strength as a result of the training.
presented here, we recommend the following: low–moderate Depression, especially mild depression, is more common in intensity training of 6–8 exercises covering all major muscle middle-aged individuals and those with metabolic risk factors groups with 2–3 sets of 15–20 repetitions each and at or CVD, compared to the general population (7). As such, to approximately 50–65% of 1RM; and moderate–high intensity identify and to treat individuals with depression, it is training consisting of the same exercises with 2–3 sets of 8–15 important to have a valid, reliable, sensitive, and simple tool repetitions, up to 85% of 1RM. In summary, RT is a simple and for assessing depression. The results from this study indicate effective method to improve depressed mood in this that, although designed for patients with overt cardiac population and should form an important part of the exercise disease, the CDS would appear to be a valid and reliable tool training regimens for people at a high risk of developing for middle-aged individuals without overt cardiac disease.
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