Association between grip strength and depression in Chinese older adults: A cross-sectional analysis from the China Health and Retirement Longitudinal Study

doi:10.21203/rs.3.rs-2484771/v1

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Association between grip strength and depression in Chinese older adults: A cross-sectional analysis from the China Health and Retirement Longitudinal Study

https://doi.org/10.21203/rs.3.rs-2484771/v1

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Background

An increasing evidence exists of an association between grip strength and depressive symptoms. Grip strength and depression are associated with hospitalization rates in the older adults. Our primary goal is to ascertain the relationship between grip strength and depression among adults aged 60 years and above. The following data are quoted from the China Health and Retirement Longitudinal Study(CHARLS).

Method

The quoted data were from wave 3 (2015) of the CHARLS, which included 4,689 older adults (aged ≥ 60 years). Depressive symptoms were assessed using the 10-term Center for Epidemiologic Studies Depression Scale (CES-D). Grip strength was measured in kilograms using a handheld dynamometer (WCS-100; Nantong, China). Multivariate logistic regression was used to estimate the relationship between hand grip strength and depression in the four models.

Results

Participants were community-dwelling older adults (N = 4,689; 79.0% females, 21.0% males) aged ≥ 60 years. Handgrip strength was negatively associated with depressive symptoms (P = 0.000) after adjusting for covariates. However, no significant correlation was noted between BMI, smoking, drinking, and depressive symptoms (P > 0.05).

Conclusion

Grip strength was negatively associated with depressive symptoms in a large sample of older adults in China. Future research is required to further explore the causal relationship between grip strength and depression and determine effective grip strength and depression interventions to improve the quality of life in older people.

depression

grip strength

older adults

Currently, approximately 350 million people worldwide suffer from depression [1, 2]. Particularly, older adult depression has become a major public health problem, which has a huge impact on health when coexisting with a chronic disease, such as coronary heart disease [3], diabetes, hypertension, cerebrovascular disease, cancer, chronic kidney disease, chronic obstructive pulmonary disease, and Parkinson’s disease. Such diseases have been shown to be associated with the incidence of depression and can influence prognosis and treatment [4–6]. According to a meta-analysis by Read et al., depression is two to three times more likely in people with multimorbidity than in people without multimorbidity or in those with no chronic physical condition [7]. Furthermore, depression increased the risk of suicide; decreased physical, cognitive, and social functioning; and increased self-neglect. Regardless of gender, age, and social environment, depressive symptoms exist in all cultures and animals, and recent studies have shown that the incidence of depression in females is always higher than that in males [8, 9]. Nearly 14% of people over the age of 55 years suffer from depression, 2% of which are major depression, and the prevalence increases with age. In addition, 10–15% of the older adults have significant clinical depression symptoms, even without severe depression [10]. Thus, identifying those at risk for depression and managing depression is necessary.

Grip strength is associated with overall muscle strength and functional and health outcomes, including weakness, falls, nutritional status, and mortality [11]. Grip strength is a simple and effective parameter that can reflect the overall muscle strength and is widely used in clinical practice [12]. Studies have found that weak grip strength can predict all-cause, cardiovascular, and other-cause mortality but not cancer mortality [11, 13, 14]. Moreover, some findings indicate that lower grip strength is associated with diabetes, hypertension, and depression [15–18]. Thus, grip strength is closely associated with physical activity, and studies have confirmed that participating in physical activity can reduce the risk of depression [19].

Several cross-sectional studies have found an inverse association between grip strength and depression [17, 20, 21]. However, the specific threshold of grip strength that contributes to depression symptoms has never been explored. In this study, the analysis was conducted separately for men and women to identify sex differences in grip strength.

This study aimed to examine the relationship between hand grip strength and depression among adults aged 60 years and older in a nationally representative sample.

2.1 Study population

Data were derived from The China Health and Retirement Longitudinal Study (CHARLS), which aims to collect high-quality micro-data representing families and individuals aged 45 years and over in China to analyze the aging population. The CHARLS National Baseline Survey was founded in 2011 and covers 150 county-level units, 450 village-level units, and 17,000 of the approximately 10,000 households. These samples were tracked every 2 to 3 years later.

The data of the 2015 CHARLS, which involved 20,967 individuals as a cross-sectional study, excluded 9,281 individuals who were under 60 years old and 912 who did not have sociodemographic information. A total of 729 participants who lost their CES-D scores, 1,659 who did not completed grip strength-related information, and 119 without weight or height coefficient were excluded. A total of 3,542 individuals were excluded because they had lost smoking information. Ultimately, 4,689 individuals were included in this study (Fig. 1).

2.2 Measures

Depressive symptoms were evaluated using the 10-item Short-Form Center for Epidemiological Studies Depression Scale (CES-D, Table 1), which is more efficient and increases the detection rate of depression [22, 23]. Some studies[23, 24] have proven that the 10-item CES-D has excellent performance and can be used as a screening instrument to identify major depression in older adults. The answers for CES-D were on a four-scale metric: “rarely or none of the time (< 1 day)” represents 0 points, “ some or a little of the time (1–2 days)” represents 1 point, “occasionally or a moderate amount of the time (3–4 days)” represents 2 points, and “ most or all of the time (5–7 days)” represents 3 points. Items 5 and 8 were reverse-scoring items in this scale. The total possible range of the 10-item CES-D scale is 0 to 30, with a score of 10 or more indicating significant depressive symptoms.

Grip strength (kg) of the dominant hand was assessed using a handheld dynamometer (WCS-100, Nantong, China). During the assessment, the participants were requested to stand, hold the dynamometer at a right angle, and squeeze the handle for a few seconds. Similar to previous studies, the mean of the two measurements was analyzed as a continuous variable[17]. However, it is worth mentioning that studies have shown consistent results irrespective of whether maximum or average values were used [25]. Grip strength scores were independently divided into quartiles [26] for both the sexes. We categorized the grip strength scores of ≤ 28.0, 28.0–32.75, 32.75–38.5, and > 38.5 kg as Q1, Q2, Q3, and Q4, respectively, for men. Similarly, GS scores of ≤ 18, 18–22, 22–26, and > 26 kg were categorized as Q1, Q2, Q3, and Q4, respectively, for women.

Potential confounders included sociodemographic (i.e., age, sex, and education), health behavioral factors (i.e., alcohol consumption and smoking), and health conditions (i.e., body mass index and chronic diseases). Body mass index (BMI) was calculated by dividing the body weight (kg) by height squared (m²). Participant's education levels were classified into four groups (i.e., <=6, 6–9, 9–12, and > 12 years). Marital status was categorized into two groups: married and unmarried (including people who are widowed, divorced, or never married). Participants were classified into one of three groups based on self-reported alcohol consumption: none, less than once a month, and more than once a month. We classified participants into two smoking groups: never smokers and current smokers. We divided participants into underweight (BMI < 18.5), normal weight (18.5 ≤ BMI < 25), overweight (25 ≤ BMI < 30), and obese (30 ≤ BMI) group. The study evaluated the number of chronic diseases, which include 14 chronic diseases (arthritis or rheumatism, and asthma, hypertension, dyslipidemia, diabetes, cancer, digestive disease, chronic lung diseases, liver disease, heart problems, stroke, kidney disease, psychiatric problems, and memory-related disease). The study divided "no chronic disease", "1 chronic disease", "2 chronic diseases ", "3, and more chronic diseases " into "0, 1, 2, and 3" groups, respectively.

2.3 Statistical analyses

Descriptive statistics were presented as frequencies and percentages for continuous and categorical variables, respectively. Mean differences in categorical variables were compared using Chi-square, and odds ratio of the prevalence of depressive symptoms in different grip strengths was estimated using binomial multivariate logistic regression adjusting for other covariates. Multivariable models were adjusted for covariates in a stepwise fashion: Model 1 was a univariate binary logistic regression analysis of the relationship of grip strength. Model 2 was based on Model 1 adjusting for the sociodemographic variables: age, sex, education level, marriage. Model 3 was based on Model 2 adjusting for the health behavior: drinking and smoking. Model 4 was based on Model 3 adjusting for the health conditions: chronic diseases and BMI. All odds ratios (OR) were recorded with a 95% confidence interval (CI). All analyses considered complex sampling weights using IBM SPSS Statistics 21.0.

Table 2 shows the characteristics of the study population. A total of 983 (21.0%) men and 3,706 (79.0%) women were analyzed, and 1,858 participants were considered as having depressive symptoms (14.3% for men and 85.7% for women), while 2,813 samples had no symptoms of depression. Approximately 90% of the participants were aged between 60 and 79 years, and 79.9% were married, 92.5%, non-smokers, and 79.2%, non-drinkers. The educational level of 2,525 (53.8%) people was primary school and 1,380 (29.4%), college education or above. Of the population, 23.6% is suffered from more than three chronic diseases. Finally, we found that grip strength and most covariates showed a significant difference between the depressive and no depressive symptoms groups (P< 0.05), except for the BMI group.

Table 3 shows the logistic regression analysis between grip strength and depressive symptoms with different sexes and four models. We found that different grip strengths have statistically significant differences with depressive symptoms. In Model 4 (adjustment for all covariates), We found that the Q2 segment had a lower risk of depressive symptoms compared with Q1 (P < 0.001, OR = 0.449, 95% CI: 0.296 to 0.679) in the male population. The grip strength in the Q3 segment has a lower risk of depression than that in Q1 (P < 0.01, OR = 0.497, 95% CI: 0.329 to 0.751). The grip strength in the Q4 segment also has a lower risk of depression than that in Q1 (P < 0.001, OR = 0.370, 95% CI: 0.236 to 0.582). Similar outcomes could be observed in the females. The risk of depression in the Q2 segment was 0.817 times that of Q1 (P < 0.05, OR = 0.817, 95% CI: 0.679 to 0.983). The grip strength in the Q3 segment has a lower risk of depression than that in Q1 (P < 0.05, OR = 0.818, 95% CI: 0.676 to 0.991). The grip strength in the Q4 segment has a lower risk of depression compared with Q1 (P < 0.001, OR = 0.700, 95% CI: 0.575 to 0.852). Grip strength was negatively correlated with depression in both the male and female populations, namely, grip strength is a protective factor for depression.

Table 4 shows the binomial logistic regression analysis of the relationship between grip strength and depressive symptoms adjusted by all covariates. Men aged 80 years and over has a lower risk of developing depression than those aged 60–69 years (P < 0.01, OR = 0.438, 95% CI: 0.248 to 0.722). Unmarried individuals (including divorced and widowed) have a 1.662-fold higher risk of depression than married ones (P < 0.05, OR = 1.662, 95% CI: 1.052 to 2.624). Furthermore, the risk of depression in college-educated participants was lower than the primary-educated individuals (P < 0.05, OR = 0.592, 95% CI: 0.386 to 0.907). Participants with depression with three or more chronic diseases have a higher risk of depressive symptoms than those without chronic diseases (P < 0.05, OR = 1.655, 95% CI: 1.090 to 2.512). We observed that the higher the age, the lower the risk of depression in the female population, while the more chronic diseases combined, the greater the risk of depression. Unmarried individuals (including divorce and widowed) are 1.305 times more likely to have depression than married ones (P < 0.01, OR = 1.305, 95% CI: 1.104 to 1.543). Ultimately, the research shows that depression was associated with most covariates except BMI, smoking, and alcohol consumption (P < 0.05).

In this study, we investigated the association between grip strength and depressive symptoms in a nationally representative cohort of older Chinese adults and distinguished the discrepancy between men and women. We found an inverse correlation between grip strength and depressive symptoms after adjusting many covariates (including sociodemographics, health conditions, and health behavior), which is consistent with the results of earlier studies[1, 17, 20, 27].

The study also observed that women presented higher levels of depressive symptoms than men (85.7% women vs. 14.3% men), which is in line with previous research [28].

However, our study showed that depression was not associated with BMI, which contradicts the findings of previous research. Zhi et al. (2016) showed that higher BMI categories were associated with a lower risk of depressive symptoms in older women [29]. A longitudinal study by Bruin et al. [30] in 2018 showed that depression was not associated with lifestyle factors, such as BMI, smoking, and drinking. This discrepancy may be explained by the sex and age of the participants.

Smoking status was not associated with depressive symptoms contrary to our hypothesis, and a cross-sectional study showed that current smoking was positively associated with depression in male and female adolescents [31]. The age difference between the two study populations possibly played a role in this discrepancy.

Regarding alcohol consumption, a meta-analysis suggested that the current state of the literature suggests a causal linkage between alcohol use disorders and major depression, such that increasing alcohol involvement increases the risk of depression [32]. We categorized participants into non-drinkers, less than once a month, and more than once a month in our study. These categories may not have predicted the course of depression. Investigating whether stopping or reducing alcohol use can lead to changes in the depression process is noteworthy in future studies.

Our study has several limitations. First, this is a cross-sectional study, which cannot determine causality, conclusions whether low grip strength was due to depressive symptoms could not be established. Second, depressive symptoms were diagnosed using the CED-10, which is not a diagnostic tool for depression. Third, men (21%) made up less of this study, whereas women (79%) made up the majority.

This study aimed to explore the relationship between grip strength and depression to prevent physical decline in the older adults and use physical and mental health strategies to improve and maintain their independent lives. Future research requires further probing of the causality between grip strength and depression, and determine effective grip strength and depression interventions.

CHARLS

China Health and Retirement Longitudinal Study

CES-D

Center for Epidemiological Studies Depression Scale

Ethics approval and consent to participate

Ethics approval for the study was granted by the Ethics Review Committee of Peking University, and all the participants provided signed informed consent at the time of participation. The study methodology was carried out in accordance with approved guidelines.All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Consent for publication

Not applicable.

Availability of data and materials

Data set from the China Health and Retirement Longitudinal Study (CHARLS)http://charls.pku.edu.cn/

Competing interests

The authors declare that they have no competing interests.

Funding

The authors received no financial support for the research, creation, or publication of this study.

Authors' contributions

HW designed the study, performed the experiments, analyzed the data, and wrote the manuscript; GQS prepared the manuscript; ZLX analyzed the data; JZ helped perform the analyses, participated in constructive discussions and contributed to the conception of the study; All authors read and approved the final manuscript.

Acknowledgments

We acknowledge all people involved in this study. Thanks to the National School of Development of Peking University and the China Social Science Survey Center of Peking University for providing CHARLS data.

Authors' information

¹Department of Respiratory and Critical Care Medicine, General Hospital of Western Theater Command, NO.270 Tianhui Road, Rongdu Avenue, Jinniu District, Chengdu, Sichuan Province 610083, P. R. China.

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Table 1. CES-D, 10-item version.

Question numbers	Items	Options
1	I was bothered by things that do not usually bother me.
2	I had trouble keeping my mind on what I was doing.
3	I felt depressed.
4	I felt everything I did was a effort.	1. Rarely or none of the time (<1 day).
5^a	I felt hopeful about the future.	2. Some or a little of the time (1–2 days).
6	I felt fearful.	3. Occasionally or a moderate amount of the time (3–4 days)
7	My sleep was restless.	3. Occasionally or a moderate amount of the time (3–4 days)
8^a	I was happy.	4. Most or all the time (5–7 days)
9	I felt lonely.
10	I could not get “going.”

^aItems 5 and 8 had been reverse scored before analysis.

Table 2. Distribution of overall study variables.

Variable

Total N =4689

Depressive symptoms^b

N =1858

No depressive

symptoms

N =2831

P Value^a

Grip strength

Sex

Male

Female

Sociodemographic variables

Sex

Age

Marriage

Education level

Health behavior

Smoking status

Drinking

Health condition

BMI^c (kg/m²)

Chronic disease

Grip strength grouping

Male

Female

60–69

70–79

80–

Married

Unmarried/widowed/divorced

＜6 years

6–9 years

9–12 years

＞12 years

Yes

None

Less than once a month

More than once a month

Underweight

Normal

Overweight

Obesity

≥3

251

246

240

963

938

902

903

983

3706

2922

1373

394

3745

944

2525

757

1380

4336

353

3716

306

667

281

2722

1413

273

1436

1172

976

1105

5.4

5.2

5.1

20.5

20.0

19.2

19.3

21.0

79.0

62.3

29.3

8.4

79.9

20.1

53.8

16.1

0.6

29.4

92.5

7.5

79.2

6.5

14.2

6.0

58.1

30.1

5.8

30.6

25.0

20.8

23.6

459

400

385

348

266

1592

1180

556

122

1430

428

1049

232

571

1751

107

1521

121

216

123

1059

561

115

478

434

407

539

5.2

3.1

3.4

2.6

24.7

21.5

20.7

18.7

14.3

85.7

63.5

29.9

6.6

77.0

23.0

56.5

12.5

0.3

30.7

94.2

5.8

81.9

6.5

11.6

6.6

57.0

30.2

6.2

25.7

23.4

21.9

29.0

154

188

183

192

504

538

517

555

717

2114

1742

817

212

2315

516

1476

525

809

2585

246

2195

185

451

158

1663

852

158

958

738

569

566

5.4

6.6

6.5

6.8

17.8

19.0

18.3

19.6

25.3

74.7

61.5

28.9

9.6

81.8

18.2

52.1

18.5

0.7

28.6

91.3

8.7

77.5

6.5

15.9

5.6

58.7

30.1

5.6

33.8

26.1

20.1

20.0

.000

0.001

.000

0.344

.000

^aChi-square test was used to calculate the P value to evaluate the association between depressive symptoms and exposure factors, depressive symptoms, and covariates.

^bDepressive symptom, based on CES-D 10 scores.

^cBMI, body mass index.

Table 3 and 4 are available in the Supplementary Files section.

No competing interests reported.

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Association between grip strength and depression in Chinese older adults: A cross-sectional analysis from the China Health and Retirement Longitudinal Study

Status:

Version 1

Abstract

Background

Method

Results

Conclusion

Figures

1. Introduction

2. Methods

2.1 Study population

2.2 Measures

2.3 Statistical analyses

3. Results

4. Discussion

5. Conclusion

List Of Abbreviations

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

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