Katie Becofsky

A Prospective Study of Fitness, Fatness, and Depressive Symptoms

Being overweight or obese might be a risk factor for developing depression. It is also possible that low cardiorespiratory fitness, rather than overweight or obesity, is the better predictor of depressive symptom onset. Adults in the Aerobics Center Longitudinal Study (Dallas, Texas) underwent fitness and fatness assessments between 1979 and 1998 and later completed a questionnaire about depressive symptoms in 1990, 1995, or 1999. Separate logistic regression models were used to test the associations between 3 fatness measures (body mass index, waist circumference, and percentage of body fat) and the onset of depressive symptoms. Analyses were repeated using fitness as the predictor variable. Additional analyses were performed to study the joint association of fatness and fitness with the onset of depressive symptoms. After controlling for fitness, no measure of fatness was associated with the onset of depressive symptoms. In joint analyses, low fitness was more strongly associated with the onset of elevated depressive symptoms than was fatness, regardless of the measure of fatness used. Overall, results from the present study suggest that low fitness is more strongly associated with the onset of elevated depressive symptoms than is fatness. To reduce the risk of developing depression, individuals should be encouraged to improve their fitness regardless of body fatness.

Public perceptions about risk and protective factors for cognitive health and impairment: a review of the literature.

BACKGROUND Preventing and/or delaying cognitive impairment is a public health priority. To increase awareness of and participation in behaviors that may help maintain cognitive function or reduce risk of impairment, we need to understand public perceptions about risk and protective factors. METHODS We conducted a scoping review of studies examining the publics perceptions about risk and protective factors related to cognitive health and impairment published since the 2007 National Public Health Road Map to Maintaining Cognitive Health. RESULTS A search of five databases yielded 1,115 documents published between June 2007 and December 2013. Initial review of abstracts identified 90 potentially eligible studies. After full-article review, 30 met inclusion criteria; four additional articles identified in reference lists also met inclusion criteria. Of the 34, 16 studies addressed Alzheimers disease (AD) specifically, 15 dementia broadly, 5 mild to moderate cognitive impairment, and 8 normal functioning, with some content overlap. Across studies, respondents reported genetics (n = 14 studies), older age (n = 8), stress (n = 7), brain/head injury (n = 6), and mental illness/brain disease (n = 6) as perceived risk factors for AD and dementia. Protective factors most commonly identified for maintaining cognitive health were intellectual/mental stimulation (n = 13), physical activity (n = 12), healthy diet (n = 10), and social/leisure activities (n = 10). CONCLUSIONS Studies identified genetics and older age as key perceived risk factors more so than behaviors such as smoking. Individuals perceived that numerous lifestyle factors (e.g. intellectual stimulation, physical activity) could protect against cognitive impairment, AD, and/or dementia. Results can inform national and international education efforts about AD and other dementias.

Physical functioning, perceived disability, and depressive symptoms in adults with arthritis.

This study investigated how physical functioning and perceived disability are related to depressive symptoms in adults with arthritis (n = 401). Participants self-reported depressive symptoms and disability. Objective measures of physical functioning included the 30-second chair stand test, 6-minute walk test, gait speed, balance, grip strength, and the seated reach test. Separate quantile regression models tested associations between each functional measure and depressive symptoms, controlling for age, gender, race, BMI, self-reported health status, and arthritis medication use. The association between perceived disability and depressive symptoms was also tested. Participants averaged 56.3 ± 10.7 years; 85.8% were women; 64.3% were white. Lower distance in the 6-minute walk test, fewer chair stands, slower gait speed, and greater perceived disability were associated with greater depressive symptoms in unadjusted models (Ps < 0.05). Fewer chair stands and greater perceived disability were associated with more depressive symptoms in adjusted models (Ps < 0.05). Balance, grip strength, and seated reach were not related to depressive symptoms. The perception of being disabled was more strongly associated with depressive symptoms than reduced physical functioning. To reduce the risk of depression in arthritic populations, it may be critical to not only address physical symptoms but also to emphasize coping skills and arthritis self-efficacy.

Influence of the Source of Social Support and Size of Social Network on All-Cause Mortality

OBJECTIVE To examine associations between relative, friend, and partner support, as well as size and source of weekly social network, and mortality risk in the Aerobics Center Longitudinal Study. PATIENTS AND METHODS In a mail-back survey completed between January 1, 1990, and December 31, 1990, adult participants in the Aerobics Center Longitudinal Study (N=12,709) answered questions on whether they received social support from relatives, friends, and spouse/partner (yes or no for each) and on the number of friends and relatives they had contact with at least once per week. Participants were followed until December 31, 2003, or until the date of death. Cox proportional hazards regression analyses evaluated the strength of the associations, controlling for covariates. RESULTS Participants (3220 [25%] women) averaged 53.0 ± 11.3 years of age at baseline. During a median follow-up of 13.5 years, 1139 deaths occurred. Receiving social support from relatives reduced mortality risk by 19% (hazard ratio [HR], 0.81; 95% CI, 0.68-0.95). Receiving spousal/partner support also reduced mortality risk by 19% (HR, 0.81; 95% CI, 0.66-0.99). Receiving social support from friends was not associated with mortality risk (HR, 0.90; 95% CI, 0.75-1.09); however, participants reporting social contact with 6 or 7 friends on a weekly basis had a 24% lower mortality risk than did those in contact with 0 or 1 friend (HR, 0.76; 95% CI, 0.58-0.98). Contact with 2 to 5 or 8 or more friends was not associated with mortality risk, nor was the number of weekly contacts with relatives. CONCLUSION Receiving social support from ones spouse/partner and relatives and maintaining weekly social interaction with 6 to 7 friends reduced mortality risk. Such data may inform interventions to improve long-term survival.

Psychosocial Mediators of Two Community-Based Physical Activity Programs

BackgroundPrevious findings are inconclusive regarding the mediators of physical activity behavior change.PurposeTo test self-efficacy and social support as mediators of Active Choices, a telephone-delivered physical activity intervention, and Active Living Every Day, a group-based physical activity intervention, implemented with midlife and older adults in community settings.MethodsMacKinnons product of coefficients was used to examine social support and self-efficacy as mediators of change in physical activity. The proportion of the total effect mediated was calculated. Each model controlled for age, gender, race (white vs. non-white), body mass index (BMI), and education (high school graduate or less vs. at least some college).ResultsIncreases in self-efficacy mediated increases in physical activity among Active Choices (n = 709) and Active Living Every Day (n = 849) participants. For Active Living Every Day, increases in social support also mediated increases in physical activity in single mediator models.ConclusionsIncreasing self-efficacy and social support may help increase physical activity levels in older adults.

Baseline predictors of physical activity in a sample of adults with arthritis participating in a self-directed exercise program.

OBJECTIVES To examine baseline predictors of moderate-to-vigorous intensity physical activity (MVPA) at the 12-week follow-up in a sample of adults with arthritis participating in a self-directed, multicomponent exercise program. STUDY DESIGN Pretest-posttest. Analyses were limited to those randomized to the exercise intervention. METHODS Participants (n = 152) completed a survey assessing demographic, health-related, and arthritis-related factors, and completed anthropometric and functional measurements at baseline. Self-reported MVPA was assessed at baseline and 12 weeks. Participants were classified as engaging in ≥2.5 or <2.5 h/week of MVPA at the 12-week follow-up. Baseline demographic, health-related, arthritis-related, and functional factors were examined as predictors of engaging in ≥2.5 h of MVPA. RESULTS At the 12-week follow-up, 66.5% (n = 101) of participants engaged in ≥2.5 h/week of MVPA. Those with a higher body mass index, more days with poor physical health, a greater number of health conditions, self-reported hypertension, self-reported high cholesterol, and greater pain and stiffness were less likely to engage in ≥2.5 h of MVPA at the 12-week follow-up; those with greater arthritis self-efficacy and better performance on the 6 minute walk test were more likely. None of the other factors examined were associated with MVPA. CONCLUSIONS This study uncovered health-related, arthritis-related, and functional factors associated with MVPA that may help guide intervention strategies. Participants with less severe symptoms, better functional performance and fewer comorbidities at baseline were more likely to achieve the recommended MVPA level at 12 weeks; therefore self-directed PA interventions may be best suited for those with relatively good health status despite arthritis, while those with worse symptoms and health status may benefit more from other intervention delivery modalities such as structured, individualized programs where additional support for managing arthritis symptoms and comorbidity can be addressed.

A Randomized Controlled Trial of a Behavioral Weight Loss Program for Human Immunodeficiency Virus–Infected Patients

Obesity compounds the negative health effects of human immunodeficiency virus (HIV) infection. We conducted the first randomized trial of behavioral weight loss for HIV-infected patients (n = 40). Participants randomized to an Internet behavioral weight loss program had greater 12-week weight loss (mean, 4.4 ± 5.4 kg vs 1.0 ± 3.3 kg; P = .02) and improvements in quality of life than controls. Clinical Trials Registration NCT02421406.

Obesity prevalence and related risk of comorbidities among HIV+ patients attending a New England ambulatory centre

Human immunodeficiency virus infection and obesity are pro‐inflammatory conditions that, when occurring together, may pose a synergistic risk for diabetes and cardiovascular disease.

In reply—Association of Social Support Source and Size of Social Support Network With All-Cause Mortality in a National Prospective Cohort

To the Editor: We read with great interest the recent study on the influence of social support source and size of social network on all-cause mortality by Becofsky et al published in the July 2015 issue of Mayo Clinic Proceedings. Using data from the Aerobics Center Longitudinal Study (mean age of participants, 53.0 years) located in Dallas, Texas, they examined the association of the size of social network (number of friends) and source of social support (spouse/partner, relatives, friends, and overall relationships) with all-cause mortality. They found that those receiving emotional support from relatives or spouse/partner had a 19% lower risk of all-cause mortality; those reporting contact with 6 to 7 friends weekly (vs 0-1) had a 24% lower risk of dying. These findings, and those of other investigators, underscore the importance of initiating and maintaining social support. As a supportive effort to complement the findings of Becofsky et al, we examined the association of sources of social support and size of social network with all-cause mortality in a nationally representative sample, with emphasis on older adults (aged 60 years and older) and a comprehensive evaluation of sources of social support, uncommon in this literature.

Becofsky et al. Respond to “Misclassifying Fitness and Depression”

We appreciate Dr. Mukamals thoughtful commentary (1) on our paper (2). We are in agreement with Dr. Mukamal on a number of points, but wish to re-affirm and clarify our stance on others. In his commentary, Dr. Mukamal says, “To some degree, this [fit versus fat] debate is poorly suited to epidemiologic inquiry” (1, p. 321). He stresses that it is difficult to ascertain repeated, quality measurements of fitness in epidemiologic studies. This point speaks to the importance of our paper and others published on the topic using data from the Aerobics Center Longitudinal Study cohort (3–6), from which “reasonable measures of both fitness and fatness” are available, as Dr. Mukamal notes (1, p. 322). In speaking of fitness and fatness, Dr. Mukamal notes that “their strong interrelationships raise legitimate questions about the clinical utility of trying to parse their separate roles too finely” (1, p. 321). Perhaps in terms of clinical utility, his statement is sound; if obese patients begin exercising and lose weight, it is unnecessary to pick apart which physiological adaptations are responsible for the numerous downstream health benefits. From a messaging perspective, though, we believe it is critical to understand which factor, low fitness or high fatness, is a stronger predictor of negative health outcomes. As many persons struggling with weight management can attest, being active does not always translate to weight loss. Alternatively, underactive persons in the “normal” range of body mass index should not be made to believe that “skinny” means “healthy” because of a cultural and clinical emphasis on weight loss. If fitness is a better predictor of negative health outcomes than is fatness (as has been shown repeatedly (7)), clinicians and public health professionals alike have a responsibility to emphasize that leading an active lifestyle is more important than having a body mass index in the “normal” range. Dr. Mukamals critique of our study focuses on the possibility that responses to 2 items from the Center for Epidemiologic Studies Depression Scale (“inability to ‘get going’” and “the feeling that everything is an effort”) might have been influenced by lack of fitness. We explicitly acknowledged this possibility in the limitations section of our paper. We also would like to stress that fatigue and loss of energy are core symptoms of depression and that it would be inappropriate to claim that “unfit” participants endorsing these items are doing so because of their fitness level rather than their mental health status. Further, these questions could be interpreted by participants as referring to a lack of motivation or concentration, in other words, a psychological “inability to get going” and “feeling that everything is an effort” rather than physical fatigue. As Dr. Mukamal points out, depression is complex and multidimensional. It is also prevalent and debilitating. We cannot shy away from studying modifiable risk factors, such as cardiorespiratory fitness and fatness, simply because they might overlap with a few of the many possible symptoms of depression. Dr. Mukamal mentions that, when possible, subscales of larger instruments might be helpful in studying relationships among specific aspects of complex diseases. We agree but recognize that many epidemiologists interested in the fitness-depression relationship might not have this option. In these cases, the overlap between the exposure (fitness) and the composite outcome variable should always be acknowledged and considered (as in our article), but it should not be viewed as damning. These variables are clearly separate entities, and understanding their relationship has important implications for public health.