**3. Type 2 diabetes mellitus and mental disorder**

Beyond the physical and social well-being implications, patients with T2D are more likely to experience mental health problem. Among the mental disorders, depression and anxiety are the most common in those patients, which can lead to unfavorable influences on metabolic control and micro- and macrovascular complications compared to those with diabetes alone [53].

Depression is a medical condition in which the affected patient experience a feeling of sadness, lack of motivation, and change in thinking which lasts for more than 2 consecutive weeks, and it can lead to a decrease in the performance of the activities of daily living [54].

Individuals with T2D have a doubled risk to be diagnosed with depression than in the general population. The concurrent presence of both these disorders has a negative effect on the quality of life, loss of productivity, and absence at work, a higher risk for mortality and to develop the long-term micro- and macrovascular complication of diabetes compared with those patients without depression [55]. Besides that, those patients are associated with a poor glycemic control and poor adherence to healthy lifestyles [56].

Although it is well documented that patients with T2D are more likely to experience depression, the mechanisms underlying this association is poorly understood. It is pointed out that psychological factors such as the burden of life and relatedevents of the disease predispose the patient to depression. On the other side, there is a potential biological evidence that is emphasized in three aspects: (i) hyperglycemia, due to the high intracellular glucose level on the brain, it can activate polyol pathway that induces an oxidative stress and formation of advanced glycation end products, and both of them can lead to a neuronal damage; (ii) microvascular dysfunction, involved in an increased cerebrovascular damage, those injury can affect the frontal and subcortical regions of the brain that regulate mood state; and (iii) low-grade inflammation, with less evidence linked to depressive symptoms but is associated with chronic disease and predispose to cardiovascular complications [55]. On the other side, diabetes duration is viewed as a mediator for depressive symptoms. These symptoms tend to elevate immediately following diagnosis and decrease and increases again after several years. The duration of diabetes less than 10 years and bigger than 30 years is associated with increased depressive symptoms, while that between 10 and 30 years is remaining low [56].

It can be classified on (i) major depression, when the presence of depressive mood and anhedonia (reduced positive affect) for 2 weeks is accompanied by at last five symptoms such as depressed mood, uncontrolled weight for no apparent reason, lack of motivation, psychomotor disorder, loss of energy or increased fatigue, alteration in sleep, difficulty thinking and thoughts of dead or suicide; (ii) minor depression, which is similar to major depression, but the patient has few than five symptoms; and (iii) dysthymia, when the patient experiences an acute depressive mood for most of the day which persists for at least 2 years. However, at least two of the following symptoms should be present: changes in appetite, low self-esteem, sleep alteration, difficulty thinking, discouragement, and loss of energy or increased fatigue [57].

The nine-item patient health questionnaire is a valid and reliable screaming tool frequently used for the diagnosis of depression. It is an easy and brief self-report questionnaire and can be used in patient with T2D. It consists of nine questions based in the depressive symptoms with score of "0" (not at all) to "3" (nearly every day). It calculated a total score, and it ranges from 0 to 27. A cutoff score of 10–14, 15–19, and 20–27 indicates moderate, moderately severe, and severe depression, respectively [58].

Referring to anxiety, it is defined as a subjective feeling of fear, worry, and discomfort, for no reason at all or derived from anticipation of something [59]. Results from a recent meta-analysis support scientifically evidence that people with T2DM exhibit an increased likelihood of having anxiety disorder and anxiety symptoms than people without diabetes, and on the other side, it is associated with poor glycemic control and increased diabetes complications [53]. Those patients can experience physiologic sensation such as tachycardia, dizziness, sweating, headaches, and gastrointestinal disorder and also avoid places, people, and events. The diagnosis of the disease may induce anxiety because the patient has to adopt a severe lifestyle change in function of the disease treatment with a daily management of diabetes and worry of the long-term micro- and macrovascular complication [53]. It is common to diagnose anxiety using self-report symptom scales, mainly the Spielberger Trait Anxiety Questionnaire, the general health questionnaire for anxiety subscale, Hospital Anxiety and Depression Scale for anxiety (HADS), and Hopkins symptom checklist [59].

It is important to note that the idea that physical exercise has positive effects on depression and anxiety of patients with T2D in some cases is not unanimous. For instance, results from a systematic review of intervention studies [60] concluded that the evidences of physical exercise on psychological outcomes are conflicting. In this review, aerobic exercise shows to improve symptoms of anxiety. Significant difference in depression was found only in resistance training. For quality of life, among 6 studies (478 participants examined), only 2 reported significant effect of aerobic training compared to control group. Previous studies examined (361 participants), a mixed effect of resistance training on the mental domain of the SF-36 and SF-12 questionnaire was found. The authors stand out that heterogeneity of the studies was reflected on the mixed results found [60]. On the other side, a randomized controlled trial of 218 inactive patients with T2D found that no exercise was superior to resistance or combined exercise of 22 weeks, three times per week for improving mental health status [61]. Against the mixed evidence of physical exercise to improve mental health in T2D, it is necessary for future studies to confirm some findings. The literature showed that physical activity can mitigate mental disorder in active patient with T2D [15], and in this sense, an important benefit of physical activity or physical exercise for mental health on those patients could be speculated.

For these patients, it is expressly recommended to perform at least 150 min of aerobic exercise of moderate-to-vigorous intensity and at least 2 sessions of resistance exercise. The compliance with these recommendations may have a positive

**75**

*Effects of Physical Exercise on the Quality of Life of Type 2 Diabetes Patients*

impact on the physical functioning and may improve or maintain their health status [62]. In addition to the specific benefits, aerobic and resistance training seems to be synergic, and available evidence recommends combining both form of trainings to confer great improvements for people with T2D. In this sense, the effects of combined physical exercise program in those patients (aerobic-resistance exercise performed 60-min, 3 days/week for 12 weeks) was examined and reported significant effects in several domains of quality of life in the exercise group (mental health, +40%). The authors emphasize the importance of combining aerobic exercise with strength training in the clinical care of people with T2D [63]. In another study, the effect of three types of treatments in people with T2DM for 24 months was evaluated: (PE) physical exercise with a combined program, n = 59; (M) medication with metformin, n = 30; (PE + M) combination of physical exercise and medication, n = 195. The "PE" group trained three times a week, the "M" used 850 mg of metformin twice a week, and in "PE + M" they combined the two treatments. The physical exercise program consisted in a combination of aerobic, resistance, flexibility, and balance trainings which is performed for 60 min. After the study period, the "PE" and "PE + M" groups improved mood states and better perceived of physical and mental domains of quality of life in comparison with the

This scientific evidence presented above reinforces the preponderant role that physical exercise plays as medicine in treatment of different pathologies, especially T2D. However, faced with the growing interest in using physical exercise as a nonpharmacological treatment for psychological changes, further research is needed to

and Armando Raimundo1,2

1 Department of Sport and Health, University of Évora, Évora, Portugal

2 Comprehensive Health Research Centre (CHRC), University of Évora, Portugal

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

determine the type and dose response in this population.

Authors have no conflict of interest to disclose.

*DOI: http://dx.doi.org/10.5772/intechopen.87110*

"M" group [64].

**Conflict of interest**

**Author details**

Pablo Tomas-Carus1,2\*, Nilton Leite1

\*Address all correspondence to: ptc@uevora.pt

provided the original work is properly cited.

#### *Effects of Physical Exercise on the Quality of Life of Type 2 Diabetes Patients DOI: http://dx.doi.org/10.5772/intechopen.87110*

impact on the physical functioning and may improve or maintain their health status [62]. In addition to the specific benefits, aerobic and resistance training seems to be synergic, and available evidence recommends combining both form of trainings to confer great improvements for people with T2D. In this sense, the effects of combined physical exercise program in those patients (aerobic-resistance exercise performed 60-min, 3 days/week for 12 weeks) was examined and reported significant effects in several domains of quality of life in the exercise group (mental health, +40%). The authors emphasize the importance of combining aerobic exercise with strength training in the clinical care of people with T2D [63]. In another study, the effect of three types of treatments in people with T2DM for 24 months was evaluated: (PE) physical exercise with a combined program, n = 59; (M) medication with metformin, n = 30; (PE + M) combination of physical exercise and medication, n = 195. The "PE" group trained three times a week, the "M" used 850 mg of metformin twice a week, and in "PE + M" they combined the two treatments. The physical exercise program consisted in a combination of aerobic, resistance, flexibility, and balance trainings which is performed for 60 min. After the study period, the "PE" and "PE + M" groups improved mood states and better perceived of physical and mental domains of quality of life in comparison with the "M" group [64].

This scientific evidence presented above reinforces the preponderant role that physical exercise plays as medicine in treatment of different pathologies, especially T2D. However, faced with the growing interest in using physical exercise as a nonpharmacological treatment for psychological changes, further research is needed to determine the type and dose response in this population.
