Bie, R.A.

Koopmans, B.

Leusink, G.L.

Pop, V.J.M.

Pouwer, F.

van Rooij, E.S.J.

English

Tilburg University Repository

    Tilburg UniversityDepressive symptoms are associated with physical inactivity in patients with type 2diabetesKoopmans, B.; Pouwer, F.; Bie, R.A.; van Rooij, E.S.J.; Leusink, G.L.; Pop, V.J.M.Published in:Family PracticePublication date:2009Document VersionPublisher's PDF, also known as Version of recordLink to publication in Tilburg University Research PortalCitation for published version (APA):Koopmans, B., Pouwer, F., Bie, R. A., van Rooij, E. S. J., Leusink, G. L., & Pop, V. J. M. (2009). Depressivesymptoms are associated with physical inactivity in patients with type 2 diabetes: The DIAZOB primary carediabetes study. Family Practice, 26(3), 171-173.General rightsCopyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright ownersand it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights.            • Users may download and print one copy of any publication from the public portal for the purpose of private study or research.            • You may not further distribute the material or use it for any profit-making activity or commercial gain            • You may freely distribute the URL identifying the publication in the public portalTake down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Download date: 12. May. 2021 The Author 2009. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org.doi:10.1093/fampra/cmp016Depressive symptoms are associated with physicalinactivity in patients with type 2 diabetes. TheDIAZOB Primary Care Diabetes studyBerber Koopmansa, Francxois Pouwera, Robert A de Bieb, Elisabeth Svan Rooija, Geraline L Leusinkc and Victor J PopaKoopmans B, Pouwer F, de Bie RA, van Rooij ES, Leusink GL and Pop VJ. Depressive symptomsare associated with physical inactivity in patients with type 2 diabetes. The DIAZOB Primary CareDiabetes study. Family Practice 2009; Pages 1–3 of 3.Background. Depression is a common complication of type 2 diabetes, associated with poordisease outcomes such as impaired glycaemic control, cardiovascular disease and increasedmortality. The mechanisms behind these associations are unclear. Depression might contributeto poor disease outcomes through decreased physical activity.Objective. To test whether type 2 diabetes patients with elevated depression scores are moreoften physically inactive.Methods. Demographic features, clinical factors, level of physical inactivity and depressivesymptoms were assessed in 2646 primary care patients with type 2 diabetes. Sequential multiplelogistic regression analyses [odds ratio, 95% confidence interval (CI)] were performed to test theassociation between depressive symptoms and physical inactivity.Results. About 48% of the respondents were physically inactive. Elevated depressive symptomswere found in 14% of the respondents. After adjustment for potential confounders, the odds forbeing physically inactive were almost doubled in depressed patients with type 2 diabetes 1.74(95% CI 1.32–2.31).Conclusions. Presence of depressive symptoms almost doubles the likelihood of physical inac-tivity in patients with type 2 diabetes. Longitudinal studies are needed to investigate whetherphysical inactivity forms the link between depression and poor disease outcomes.Keywords. Depression, physical activity, type 2 diabetes.BackgroundIn a recent meta-analysis, the prevalence of depressionwas significantly higher in patients with type 2 diabetescompared to those without [18% versus 10%, odds ratio(OR) = 1.6, 95%, confidence interval (CI) 1.2–2.0].1 Therelationship between diabetes and depression is complexand probably bidirectional, and mechanisms linking bothconditions are still unclear.2,3 In prospective studies andmeta-analyses, depressive symptoms were associatedwith a range of adverse health outcomes including dis-ability,4 impaired glycaemic control,5 impaired quality oflife,6 morbidity7 and mortality8 in patients with diabetes.These poor health outcomes may be mediated throughphysical inactivity. Research concerning the associationbetween depression and physical inactivity in patientswith type 2 diabetes patients is scarce.9,10 Therefore, theaim of this study was to examine the association betweendepressive symptoms and physical inactivity in primarycare patients with type 2 diabetes.MethodsSubjectsThe current study was performed using baseline datafrom an ongoing diabetes management project inReceived 17 March 2008; Accepted 1 February 2009.aCentre of Research on Psychology in Somatic Diseases (CoRPS), Department of Medical Psychology, Tilburg University, Til-burg, The Netherlands, bCAPHRI School, Department of Epidemiology, Maastricht University, Maastricht, The Netherlandsand cDiagnostic Centre ‘s Hertogenbosch, ‘s Hertogenbosch, The Netherlands. Correspondence to Victor J Pop, Centre of Re-search on Psychology in Somatic Diseases (CoRPS), Department of Medical Psychology, Tilburg University, PO Box 90153,5000 LE Tilburg, The Netherlands; Email: v.j.m.pop@uvt.nl.Page 1 of 3 Family Practice Advance Access published March 25, 2009general practice called ‘DIAZOB’ (Diabetes CareZuidoost Brabant). In this project, the participantsare, apart from their regular three monthly diabetescontrol, annually assessed for biological, demographic,psychosocial and lifestyle factors. All 3300 patientswith type 2 diabetes from 100 GPs in the Eindhovenregion, The Netherlands, were asked by their nursepractitioner to join this project, during their regular di-abetes check-up. After exclusion of respondents whogave no informed consent and after excluding recordsdue to missing data, 2646 participants (80%) wereincluded in the final analysis.AssessmentsDemographic variables were assessed during a nurse-led interview. Glycated haemoglobin (HbA1c) levelsand body mass index (BMI) values were determinedat the regional primary care diagnostic institute.Physical inactivity. Physical inactivity was assessedduring a nurse-led interview. The nurse practitionerasked the patient how many hours per week onespends on ‘active’ physical activity (like e.g. walking,cycling, stair climbing, gardening, other than sports).Answer categories were as follows: ‘never’, ‘1–2hours’, ‘between 2 and 4 hours’, ‘between 4 and 6hours’ and ‘over 6 hours’ per week. Since nationalpublic health recommendations indicate moderatephysical activity for at least 30 minutes on preferablyall days of the week,11 respondents who said they werephysically active for 4 or less hours/week were labelled‘inactive’, the others as active.Depressive symptoms. Depressive symptoms werepatient reported and assessed using a validated Dutchversion of the Edinburgh Depression Scale.12–14 Thisis a 10-item self-rating scale in which each item isscored on a four-point Likert scale. Total scores rangefrom 0 to 30 points, with a score of over 11 points indi-cating elevated depressive symptoms.Statistical analysesAnalyses were conducted using the Statistical Packagefor the Social Sciences (SPSS) version 16. Sequentialmultiple logistic regression analyses (OR, 95% CI)were performed to assess the relative importance of de-pressive symptoms and potential confounders to physi-cal inactivity by entering the following sets ofindependent variables: (i) age, female sex, being single,low education; (ii) depressive symptoms; and (iii) BMI.ResultsThe sample was predominantly Caucasian (98%), witha roughly equal sex distribution. The average age was68 years, the average HbA1c level was 6.7% and theaverage BMI was 29.6. The majority of respondentshad a low level of education (62%) and lived witha partner (72%). About half (49%) of the respondentswere classified as physically inactive. Elevated depres-sive symptoms were found in 14% of all respondents.In Table 1, the results of the sequential multiple re-gression analyses are shown. In the final model, physi-cal inactivity was predicted by depressive symptoms(OR = 1.74), higher BMI (OR = 1.04), older age(OR = 1.02), female sex (OR = 1.27) and being single(OR = 1.32).ConclusionsSome 49% of the respondents were physically inactive.Similar to findings in the general population, physicalinactivity was related to older age, being female, beingwithout a partner and having a high BMI. The preva-lence of elevated depressive symptoms in the entiresample was 14%, which was 4% point lower than theprevalence reported in the meta-analysis by Ali et al.1Key finding of the present study is that participantswho reported elevated depressive symptoms hadTABLE 1 Sequential multiple logistic regression predicting physical inactivity by demographic features, depression and BMI (n = 2646)Model 1:demographics onlyModel 2: final model.Depressive symptomscorrected for demographicsModel 3: final model. Depressivesymptoms correctedfor demographics and BMII Demographic featuresAge 1.01 (1.00–1.02) 1.01 (1.00–1.02) 1.02 (1.01–1.03)Female sex 1.40 (1.15–1.70) 1.36 (1.12–1.65) 1.28 (1.04–1.55)Low education 1.05 (0.86–1.29) 1.09 (0.89–1.34) 1.11 (0.91–1.37)Being single 1.38 (1.10–1.71) 1.34 (1.07–1.66) 1.32 (1.06–1.65)II Depressive symptomsEDS score >11 1.73 (1.31–2.29) 1.74 (1.32–2.31)III BMIHigher BMI 1.04 (1.02–1.06)Goodness of fit [chi-square(d.f.), P-value]23.55 (8), 0.003 14.66 (8), 0.066 10.63 (8), 0.223Bold depicts that ORs are significant. EDS, Edinburgh Depression Scale.Family Practice—an international journalPage 2 of 3a 70% increased likelihood of being physically inactive.This finding corresponds with the results of two previ-ous studies in patients with type 2 diabetes9,10 or thegeneral population.15 Various key symptoms of depres-sion such as fatigue, lack of motivation, low self-esteem,having difficulty with problem solving and feelings ofhelplessness might explain why depressed patients aremore often physically inactive.15Strengths of our study are the large number of dia-betes patients included and the fact that the studysample was conducted in a representative sample ofprimary care diabetes patients.Some limitations need to be mentioned. Due to itscross-sectional design, no causal relationships can bedetermined between physical inactivity and depressivesymptoms. Another limitation involved the self-re-porting of physical activity. The single item by whichphysical activity was assessed was phrased in generalterms and did not include information about intensity,which may have caused bias towards overestimation.However, this may be compensated by the relativelystrict cut-off point used for physical activity.The findings of the current study show that depres-sion is common in patients with type 2 diabetes andthat depression is associated with physical inactivity.Other studies have shown that physical activity is asso-ciated with improved glycaemic control and decreasedcardiovascular risk and hence reduced morbidity andmortality in diabetes.16 It is therefore conceivable thatpatients with type 2 diabetes and co-morbid depressivesymptoms will benefit from tailored interventions ad-dressing their activity level, even more since it wasfound in other studies that physical activity interven-tions had long-term antidepressive effects.17,18 Longi-tudinal studies are now needed to test whetherdecreased physical activity is one of the factors thatlink depression with subsequent poor health outcomesin type 2 diabetes. Randomized studies are needed totest whether interventions that increased the level ofphysical activity have antidepressive effects in patientswith diabetes who suffer from co-morbid depression.DeclarationFunding: Zon-MW, The Netherlands Organization forHealth Research and Development.Ethical approval: None.Conflicts of interest: None.References1 Ali S, Stone MA, Peters JL, Davies MJ, Khunti K. The prevalenceof co-morbid depression in adults with Type 2 diabetes: a sys-tematic review and meta-analysis. Diabet Med 2006; 23:1165–1173.2 Golden SH, Lazo M, Carnethon M et al. Examining a bidirectionalassociation between depressive symptoms and diabetes. J AmMed Assoc 2008; 299: 2751–2759.3 Knol MJ, Heerdink ER, Egberts AC et al. Depressive symptoms insubjects with diagnosed and undiagnosed type 2 diabetes. Psy-chosom Med 2007; 69: 300–305.4 Von Korff M, Katon W, Lin EH et al. Potentially modifiable fac-tors associated with disability among people with diabetes.Psy-chosom Med 2005; 67: 233–240.5 Lustman PJ, Anderson RJ, Freedland KE, de Groot M, CarneyRM, Clouse RE. Depression and poor glycemic control:a meta-analytic review of the literature. Diabetes Care 2000;23: 934–942.6 Schram M, Baan CA, Pouwer F. Depression and quality of life inpatients with diabetes: a systematic review from the EuropeanDepression in Diabetes (EDID) Research Consortium. CurrDiabetes Rev 2009; in press.7 Black SA, Markides KS, Ray LA. Depression predicts increasedincidence of adverse health outcomes in older Mexican Amer-icans with type 2 diabetes. Diabetes Care 2003; 26: 2822–2828.8 Katon WJ, Rutter C, Simon G et al. The association of comorbiddepression with mortality in patients with type 2 diabetes. Di-abetes Care 2005; 28: 2668–2672.9 Lin EH, Katon W, Von Korff M et al. Relationship of depressionand diabetes self-care, medication adherence, and preventivecare. Diabetes Care 2004; 27: 2154–2160.10 Morrato EH, Hill JO, Wyatt HR, Ghushchyan V, Sullivan PW.Physical activity in U.S. adults with diabetes and at risk for de-veloping diabetes, 2003. Diabetes Care 2007; 30: 203–209.11 Kemper HCG, Ooijendijk WTM, Stiggelbout M. Consensus overde Nederlandse norm voor gezond bewegen. T Soc Geneesk2000; 78: 180–183.12 Cox JL, Holden JM, Sagovsky R. Detection of postnatal depres-sion. Development of the 10-item Edinburgh Postnatal De-pression Scale. Br J Psychiatry 1987; 150: 782–786.13 Cox JL, Chapman G, Murray D, Jones P. Validation of the Edin-burgh Postnatal Depression Scale (EPDS) in non-postnatalwomen. J Affect Disord 1996; 39: 185–189.14 Pop VJ, Komproe IH, van Son MJ. Characteristics of the Edin-burgh Post Natal Depression Scale in TheNetherlands. J AffectDisord 1992; 26: 105–110.15 Seime RJ, Vickers KS. The challenges of treating depression withexercise: from evidence to practice. Clin Psychol Sci Pract2006; 13: 194–197.16 Albright A, Franz M, Hornsby G et al. American College of SportsMedicine position stand. Exercise and type 2 diabetes.Med SciSports Exerc 2000; 32: 1345–1360.17 McAuley E, Blissmer B, Marquez DX, Jerome GJ, Kramer AF,Katula J. Social relations, physical activity, and well-being inolder adults. Prev Med 2000; 31: 608–617.18 Motl RW, Konopack JF, McAuley E, Elavsky S, Jerome GJ, Mar-quez DX. Depressive symptoms among older adults: long-termreduction after a physical activity intervention. J Behav Med2005; 28: 385–394.Page 3 of 3Depressive symptoms are associated with physical inactivity in patients with type 2 diabetes

Depressive symptoms are associated with physical inactivity in patients with type 2 diabetes:The DIAZOB primary care diabetes study

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Depressive symptoms are associated with physical inactivity in patients with type 2 diabetes:The DIAZOB primary care diabetes study

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