Prospective study of cardiorespiratory fitness and depressive symptoms in women and men

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Abstract

Most studies of the relationship between cardiorespiratory fitness (CRF) and depression have been limited to cross-sectional designs. The objective of this study was to follow individuals over time to examine whether those with higher levels of CRF have lower risk of developing depressive symptoms. Participants were 11,258 men and 3085 women enrolled in the Aerobics Center Longitudinal Study in Dallas, TX. All participants completed a maximal treadmill exercise test at baseline (1970–1995) and a follow-up health survey in 1990 and/or 1995. Individuals with a history of a mental disorder, cardiovascular disease, or cancer were excluded. CRF was quantified by exercise test duration, and categorized into age and sex-stratified groups as low (lowest 20%), moderate (middle 40%), or high (upper 40%). Depressive symptoms were assessed using the 20-item Center for Epidemiologic Studies Depression Scale (CES-D). Those who scored 16 or more on the CES-D were considered to have depressive symptoms. After an average of 12 years of follow-up, 282 women and 740 men reported depressive symptoms. After adjusting for age, baseline examination year, and survey response year, the odds of reporting depressive symptoms were 31% lower for men with moderate CRF (odds ratio, OR 0.69; 95% confidence interval, CI 0.56–0.85) and 51% lower for men with high CRF (OR 0.49, CI 0.39–0.60), compared to men with low CRF. Corresponding ORs for women were 0.56 (CI 0.40–0.80) and 0.46 (CI 0.32–0.65). Higher CRF is associated with lower risk of incident depressive symptoms independent of other clinical risk predictors.

Introduction

In any given year, depressive disorders affect about 18.8 million Americans, 9.5% of all adults (NIMH, 2006). The costs associated with depression for the year 2000 have been estimated at $83.1 billion (Greenberg et al., 2003). Depressive symptoms are associated with greater morbidity and mortality, less ability to function independently, and lower occupational performance (Penninx et al., 2001, Kouzis et al., 1995, Druss et al., 2000, Krishnan et al., 2002). There is also evidence suggesting that depression may increase the risks of developing Alzheimer’s disease and cognitive decline (Jorm, 2000, Green et al., 2003).

Many population-based studies have reported that physical activity may reduce the risk of developing depression (Farmer et al., 1988, Camacho et al., 1991, Paffenbarger et al., 1994, Kritz-Silverstein et al., 2001, Strawbridge et al., 2002, Wiles et al., 2007, Thirlaway and Benton, 1992, Galper et al., 2006, Tolmunen et al., 2006). Meta-analyses based on cross-sectional studies, longitudinal studies, and randomized clinical trials appear to confirm this association (Lawlor and Hopker, 2001, Dunn et al., 2001, Stathopoulou et al., 2006, Blumenthal et al.,1999). However, some studies have not found this effect (Lennox et al., 1990, Cooper-Patrick et al., 1997, Weyerer, 1992). The inconsistent findings of previous research may be due to: cross-sectional analyses or experimental designs with short term follow-up; selection biases associated with age, gender, or other non-representative sampling; nonstandardized measurement of depression; and the variety of ways in which physical activity has been measured, most commonly with self-reports (Hopko et al., 2008).

For the measure of depressive symptoms, we employed the validated and widely-used Center for Epidemiologic Studies Depression Scale (CES-D). Although the CES-D cannot diagnose depression, it is not diagnostic, the CES-D is a valid and reliable measure of depressive symptoms among adults in the general population (Beekman et al., 1997). We sought to overcome many of the limitations of previous research in the current study by examining the prospective relationship between cardiorespiratory fitness (CRF) and depressive symptoms. CRF is an objective and reproducible physiological measure that reflects functional influences of physical activity habits, genetics, and disease status. CRF has been found to be inversely associated with the risks of developing fatal and nonfatal chronic diseases (Bouchard et al., 2006, Blair et al., 1989, Blair et al., 1996, Sui et al., 2007). Less research has examined associations between CRF and emotional well being. To our knowledge, only three previous studies have investigated the association between symptoms of depression and CRF (Tolmunen et al., 2006, Galper et al., 2006, Thirlaway and Benton, 1992). One focused on middle-aged men, reporting that those with low CRF (measured by VO2max, maximal oxygen uptake) were more likely to have depressive symptoms (Tolmunen et al., 2006). The others included both women and men (Thirlaway and Benton, 1992, Galper et al., 2006). Thirlaway and Benton (1992) studied a group of relatively young subjects, the majority between ages 30 and 40, finding an inverse association between CRF and depressive symptoms. This result was found only for those who were physically inactive, however, not for those who were at least moderately active. More recently, in the Aerobics Center Longitudinal Study (ACLS), (Galper et al. (2006) also reported that CRF was inversely associated with depressive symptoms. All of these studies were limited by their cross-sectional designs. The present study will expand the earlier report from the ACLS, by examining the longitudinal association between CRF and depressive symptoms.

Section snippets

Study population

The ACLS is a prospective epidemiological study investigating health outcomes associated with physical activity and CRF at the Cooper Clinic, Dallas, TX (Blair et al., 1989, Blair et al., 1996, Sui et al., 2007). All patients had a baseline health examination. All patients included in this study had normal resting electrocardiograms (ECGs), and were able to complete an exercise stress test to at least 85% of their age-predicted maximal heart rate (defined as 220 minus age) during 1970–1995. The

Results

The mean baseline age of the study sample was 44.9 years (SD, 9.7); 22% were female. Baseline treadmill time ranged from 1.0 to 38.3 min, with a mean of 17.4 (SD, 5.4). Among the participants, the prevalence of low, moderate, and high CRF was 12.7% (1,816), 37.1% (5,317), and 50.3% (7,210), respectively. Time to follow-up averaged 12 years (range 1 to 25 years), with 174,554 total person-years of exposure. Among women, 9.1% reported depressive symptoms at follow-up (CES-D scores above 16). The

Principal findings

In longitudinal analyses, we found a sharply graded inverse dose-response relationship between CRF at baseline and depressive symptoms at follow-up, in both men and women. Participants with low CRF were at significantly greater risk of developing depressive symptoms, even after adjustment for age, baseline examination year, follow-up survey response year, smoking status, alcohol consumption, body mass index, hypertension, diabetes, and abnormal exercise ECG responses. The inverse association

Acknowledgements

We thank the Cooper Clinic physicians and technicians for collecting the baseline data, the Cooper Institute staff for data entry and data management, and Gaye Christmus for editorial assistance.

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