Move it! It’s good for you! On the Influence of aerobic exercise training (AET) on disease symptoms, cardiovascular fitness, sleep, and depression in children and adolescents with Inflammatory Bowel Disease (IBD)

Laura maehlmann

 

By Laura Mählmann, Phd, Psychiatric Clinics of the University of Basel, Centre for Affective, Stress and Sleep Disorders, University of Basel, Basel, Switzerland and Maastricht Economic and Social Research Institute on Innovation and Technology (MERIT), Maastricht University
Laura.maehlmann@upkbs.ch

Serge Brand

 

Serge Brand, PD Phd, Psychiatric Clinics of the University of Basel, Centre for Affective, Stress and Sleep Disorders, University of Basel, Basel, Switzerland and Kermanshah University of Medical Sciences (KUMS), Psychiatry Department, Substance Abuse Prevention and Sleep Disorders Research Center, Kermanshah, Iran
Serge.Brand@upk.ch

 

For Citation: SITE4Society Brief No.14-2018
Related to Sustainable Development Goals (SDGs): #SDG3 (Good Health and Well Being) 
Country Focus: Switzerland, Developed and developing countries
SITE Focus:  Science, Technology, Engagement
Sub-disciplines of sciences/social sciences/humanities concerned: Psychology, Gastroenterology and Movement Science.
Based on the following articles:

  1. Mählmann L, Gerber M, Furlano RI, Legeret C, Kalak N, Holsboer-Trachsler E, Brand S: Psychological wellbeing and physical activity in children and adolescents with inflammatory bowel disease compared to healthy controls. BMC Gastroenterol 2017;17:160.
  2. Mählmann L, Gerber M, Furlano RI, Legeret C, Kalak N, Holsboer-Trachsler E, Brand S: Impaired objective and subjective sleep in children and adolescents with inflammatory bowel disease compared to healthy controls. Sleep Med 2017;39:25–31.
  3. Mählmann L, Gerber M, Furlano RI, Legeret C, Kalak N, Sadeghi Bahmani D, Holsboer-Trachsler E, Brand S: Aerobic exercise training in children and adolescents with inflammatory bowel disease: Influence on psychological functioning, sleep and physical performance. Eur Psychiatry 2017;41:125.
  4. Mählmann L, Gerber M, Legeret C, Köhler H, Kalak N, Holsboer-Trachsler E, Brand S, Furlano R: Favorable impact of chronic aerobic exercise training on disease symptoms in children and adolescents with inflammatory bowel disease. About to be submitted 2018.

 

Pic 1.jpgContext: Around one-quarter of individuals with Inflammatory Bowel Disease (IBD) are diagnosed in the first 20 years of life with increasing incidences. Children and adolescents with IBD report impairments in daily activities, social interaction, coping and sleep. A possible reason for this rising trend in IBD could be increased consumption of western diet which is rich in red meat, dairy products, processed and artificially sweetened foods, and salt, with minimal intake of fruits, vegetables, fish, legumes, and whole grains as well as insufficient physical activity – a lifestyle problem in many countries. Given the encouraging results of previous studies investigating the beneficial effect of physical activity in other chronic disease or among adults with IBD, the aim of the present study was to investigate possible beneficial effects of regular physical activity on psychological functioning, symptoms of depression, sleep and physical activity behaviour in paediatric patients with IBD.

Research Questions: What is the influence of aerobic exercise training or AET on inflammatory indices (C-reactive Protein (CRP) erythrocyte sedimentation rate (ESR), Thrombocytosis), cardiovascular fitness, depression and sleep among child and adolescent IBD patients?

Motivation for Research Questions: Today, there is a major lifestyle problem among many middle and upper-income households worldwide, where simple common sense habits such as regular exercise are absent. The problem is even more in Emerging and Developing countries due to lack of sports facilities, parks and competition at school for university entrance. However, if a clear relationship between aerobic exercise and ailments such as poor cardiorespiratory fitness, IBD, sleep problems, and depression can be established, then it would motivate parents, school and public authorities to ensure that children and youth engage in regular physical activity, as a means to prevent lifestyle diseases or to alleviate the individual burden of diseases such as IBD. At a macro-level, incentivizing physical activity would not only save governments expenditures on curative health programs, but also build human capital for economic growth and well-being.

Data and Methodology Used: 
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The study took place in 2015 at the Children’s Hospital in Basel, Switzerland (UKBB). 21 children and adolescents with IBD were compared to 23 gender- and age-matched healthy controls (HC). The IBD group was split into a “remission-group” (IBD-RE; n=14) and an “active disease group” (IBD-AD; n=7). The remission group is in a non-active state of the disease and is successfully drug-adjusted, while the latter group was still in an active state of the disease experiencing the full burden of the disease.

All participants completed an 8-week AET exergame intervention reaching 60-80% of maximum heart rate for 5 days per week, 30 min each time. At the start of the study and after 8 weeks, psychological functioning, depressive symptoms, subjective sleep and subjective PA were assessed with a questionnaire. Objective sleep was measured with an EEG at the children’s homes. Finally, all participants had to wear a fitbit step counting device on their wrist during the intervention time.

Main findings:

1. Comparison of children and adolescents with IBD and healthy control participants (Article 1): At the start of the investigation before any games were played, participants with IBD in an active state of the disease (IBD-AD) showed higher markers of inflammation including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) values, haemoglobin, and leukocyte values. IBD-AD had poorer psychological functioning, meaning lower scores on the depression scale, and they were less physically active, measured with a accelerometer counting the steps walked per day, compared to participants with IBD in remission (IBD-RE) and healthy controls (HC). No mean differences were found between IBD-RE and HC.

2. Association between inflammation and sleep (Article 2): Compared to HC and IBD-RE, IBD-AD patients showed impaired objective sleep patterns (e.g. more awakenings, longer sleep latency, and reduced deep sleep). Downward sloping linear relationships described the inverse correlation between higher chronic inflammation and more deep sleep. Nonlinear relationships described the relation between chronic inflammation and subjective sleep quality (inverse U-shaped) and between acute inflammation and sleep latency (U-shaped).

3. Impact of exercise on physical activity, psychological wellbeing and sleep of groups (Article 3):

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The 8-week physical activity intervention led to improved exercise capacity of all participants. Self-reported fitness and daily physical activity increased in IBD-AD, but not in IBD-RE and HC.

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No improvements were reported by IBD-RE and HC subjects for psychological functioning, depressive symptoms. The lack of impact of aerobic exercise training on psychological functioning and depressive symptoms is in marked contrast to many studies demonstrating a positive influence of structured exercise training on mental health. The following possible reasons may explain our findings: First, the majority of our sample of patients could be characterized as mentally healthy and consequently improvements were unlikely and high pretest values provided only limited scope for improvement. Second, as concluded from previous research, exercise needs to be sustained in the longer term to affect mental health. Therefore, it seems likely that only a prolonged period of exercising may lead to long-term benefits for mental health. Put another way, the intervention period of eight weeks might have been too short or at too low intensity. Third, self-perception of psychological functioning may have changed, but in ways too subtle to be captured by the questionnaires, which might have been inappropriate or too coarse-grained.

Regarding sleep, subjective sleep did not improve among the groups e.g. sleep efficiency, however, specific favorable sleep changes have been observed among objective sleep markers (according to EEG recordings), such as deep sleep increased, light sleep decreased in all groups and in the IBD-AD group the number of arousals after sleep onset also decreased.

4. Short and Medium term Impact of exercise on inflammation (Article 4):

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Finally, after a single bout of exercise inflammation markers (albumin, haemoglobin, erythorcytes, haematocrit, leukocytes) strongly increased in all three groups. Finally, after a long-term AET intervention, inflammation markers ESR, CRP and thrombocytes significantly decreased.

IBD AD IBD RE Healthy Control
Psychological functioning Small effect Small effect Small effect
Depressive symptoms Small effect Small effect Small effect
Subjective sleep Small effect Small effect Small effect
Objective sleep Large Effect Moderate Effect Small effect
Inflammation markers Large Effect Large Effect Large Effect

To conclude, our research clearly indicates that the role of lifestyle factors in IBD is crucial, and may affect treatment outcomes. Regular physical activity can reduce inflammation and improve. Therefore, moderate physical activity should be promoted as an adjuvant therapy in pediatric IBD for its various beneficial effects. This would contribute to the improvement of existing treatments and potential new treatment options through retrospective evaluation.

Policy Recommendations: 

1. Introduce psychological counselling of children and adolescents in an active state of IBD in addition to standard treatment schedules.

2. Include assessment of subjective sleep quality in the care of pediatric IBD patients as an additional indicator for study of sleep disturbances due to inflammation.

3. Even in households where children and adolescents cannot access sports programs or be provided accompaniment for the same, promote computer/phone based exercise games and moving activity (such as the exergames played in intervention). In all education institutes, starting from kindergarten to universities, physical activity should be encouraged. Especially for children and adolescents, it can be introduced several times a week as part of the educational curriculum to become embedded as a lifestyle norm. This would have clear socio-economic benefits, as our research confirms that moderate physical activity lowers inflammatory markers in children and adolescents with IBD in the long run, though they may spike them in the short run.

4. Moderate regular physical activity can be promoted as an adjuvant anti-inflammatory therapy in paediatric IBD.

Acknowledgements:

This study has been conducted together with the IBD study team and we would like to express our gratitude towards the entire team for this great collaborative work which led to the successful execution of this study: Corinne Légeret, PhD, Children’s University Hospital of Basel, Basel, Switzerland; Nadeem Kalak, PhD, Psychiatric Clinics of the University of Basel, Centre for Affective, Stress and Sleep Disorders, University of Basel, Basel, Switzerland; Markus Gerber, Prof., Department of Sport, Exercise and Health, Sport Science Section, University of Basel, Basel, Switzerland; Edith Holsboer-Trachsler, Prof., Psychiatric Clinics of the University of Basel, Centre for Affective, Stress and Sleep Disorders, University of Basel, Basel, Switzerland and Raoul Furlano, PD, PhD, Children’s University Hospital of Basel, Basel, Switzerland.

Further, we thank the Freiwillige Akademische Gesellschaft Basel (FAG, Basel, Switzerland) and the Forschungsfond of the Psychiatric Clinics of the University of Basel for financially supporting the project.