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Zarza-Rebollo JA, López-Isac E, Rivera M, Gómez-Hernández L, Pérez-Gutiérrez AM, Molina E. The relationship between BDNF and physical activity on depression. Prog Neuropsychopharmacol Biol Psychiatry 2024; 134:111033. [PMID: 38788892 DOI: 10.1016/j.pnpbp.2024.111033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 05/15/2024] [Accepted: 05/21/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND/OBJECTIVE Major depressive disorder (MDD) is one of the leading causes of disease burden and disability worldwide. Brain-derived neurotrophic factor (BDNF) seems to have an important role in the molecular mechanisms underlying MDD aetiology, given its implication in regulating neuronal plasticity. There is evidence that physical activity (PA) improves depressive symptoms, with a key role of BDNF in this effect. We aim to perform a systematic review examining the relationship between the BDNF Val66Met polymorphism and the BDNF protein, PA and MDD. METHODS Both observational and experimental design original articles or systematic reviews were selected, according to the PRISMA statement. RESULTS Six studies evaluated the Val66Met polymorphism, suggesting a greater impact of physical activity on depression depending on the Val66Met genotype. More discordant findings were observed among the 13 studies assessing BDNF levels with acute or chronic exercise interventions, mainly due to the high heterogeneity found among intervention designs, limited sample size, and potential bias. CONCLUSIONS Overall, there is cumulative evidence supporting the potential role of BDNF in the interaction between PA and MDD. However, this review highlights the need for further research with more homogeneous and standardised criteria, and pinpoints important confounding factors that must be considered in future studies to provide robust conclusions.
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Affiliation(s)
- Juan Antonio Zarza-Rebollo
- Department of Biochemistry and Molecular Biology II, Faculty of Pharmacy, University of Granada, 18071 Granada, Spain; Institute of Neurosciences, Biomedical Research Centre, University of Granada, 18016 Granada, Spain; Instituto de Investigación Biosanitaria (ibs.GRANADA), 18071 Granada, Spain
| | - Elena López-Isac
- Department of Biochemistry and Molecular Biology II, Faculty of Pharmacy, University of Granada, 18071 Granada, Spain; Institute of Neurosciences, Biomedical Research Centre, University of Granada, 18016 Granada, Spain; Instituto de Investigación Biosanitaria (ibs.GRANADA), 18071 Granada, Spain
| | - Margarita Rivera
- Department of Biochemistry and Molecular Biology II, Faculty of Pharmacy, University of Granada, 18071 Granada, Spain; Institute of Neurosciences, Biomedical Research Centre, University of Granada, 18016 Granada, Spain; Instituto de Investigación Biosanitaria (ibs.GRANADA), 18071 Granada, Spain.
| | - Laura Gómez-Hernández
- Institute of Neurosciences, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
| | - Ana M Pérez-Gutiérrez
- Department of Biochemistry and Molecular Biology II, Faculty of Pharmacy, University of Granada, 18071 Granada, Spain; Institute of Neurosciences, Biomedical Research Centre, University of Granada, 18016 Granada, Spain; Instituto de Investigación Biosanitaria (ibs.GRANADA), 18071 Granada, Spain
| | - Esther Molina
- Institute of Neurosciences, Biomedical Research Centre, University of Granada, 18016 Granada, Spain; Instituto de Investigación Biosanitaria (ibs.GRANADA), 18071 Granada, Spain; Department of Nursing, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain
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Rossi C, Amato A, Alesi M, Alioto A, Schiera G, Drid P, Messina G, Pagliaro A, Di Liegro I, Proia P. Hormonal and psychological influences on performance anxiety in adolescent female volleyball players: a multi-approach study. PeerJ 2024; 12:e16617. [PMID: 38390388 PMCID: PMC10883150 DOI: 10.7717/peerj.16617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 11/15/2023] [Indexed: 02/24/2024] Open
Abstract
Background The neuroendocrine system has important implications for affiliation behavior among humans and can be used to assess the correlation between social relationships, stress, and health. This can be influenced by social closeness; this aspect is the closeness towards another individual or a group of individuals such as a sports team. Sports performance anxiety is considered an unpleasant emotional reaction composed of physiological, cognitive, affective, and behavioral components. This motivates us to learn about the process that can influence the outcome of competition. Hormones and genetics would seem to influence outcome and performance. In this regard, many studies have focused on the exercise response as a function of ovarian hormones and it has been observed that progesterone is a hormone that plays a key role in reducing anxiety, and thus stress, in humans and other animals. On the other hand, high cortisol concentrations are known to contribute to increased anxiety levels. However, the salivary alpha-amylase (sAA) enzyme has been suggested as marker of acute stress than cortisol. Genetics also seem to influence anxiety and stress management as in the case of brain-derived neurotrophic factor (BDNF) and striatal dopamine transporter (DAT). Therefore, the study aims to investigate social closeness, as a measure of sports team cohesion that can influence athletes' performance results, and its ability to influence the secretion of hormones, such as progesterone and cortisol, that affect the management of sports anxiety while also taking into account genetic background during a volleyball match. Methods Twenty-six female volleyball players who volunteered participated in this study (mean ± SD: age, 12.07 ± 0.7 years), and played in the final of the provincial volleyball championship in Palermo. All girls were during the ovarian cycle, in detail between the follicular and early ovulatory phases. Results The results showed a significant decrease in salivary cortisol only in the winning group (p < 0.039). In fact, whilst in the latter the pre-match level was 7.7 ng/ml and then decreased to 4.5 ng/ml after the match, in the losers group change was not statistically significant (7.8 ng/ml vs 6.6 ng/ml pre- and post-match). As to the sAA concentration, the winning team showed a statistically significant variation between pre- and post-match than the losers (166.01 ± 250 U/ml vs 291.59 ± 241 U/ml) (p = 0.01). Conclusion Analyzing the results of the SAS-2 psychological test it is highlighted that, on average, the loser group was more anxious than the winning group, and this contributed to the final result. In conclusion, there is strong evidence supporting the state of the art that many factors can affect performance anxiety and thus the performance itself.
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Affiliation(s)
- Carlo Rossi
- Sport and Exercise Sciences Research Unit, University of Palermo, Palermo, Italy
- Research and Innovation, Centro Medico di Fisioterapia “Villa Sarina”, Trapani, Italy
| | - Alessandra Amato
- Department of Biomedical and Biotechnological Sciences, Section of Anatomy, Histology and Movement Science, School of Medicine, University of Catania, Catania, Italy
| | - Marianna Alesi
- Department of Psychology, Educational Sciences and Human Movement, University of Palermo, Palermo, Italy
| | - Anna Alioto
- Sport and Exercise Sciences Research Unit, University of Palermo, Palermo, Italy
| | - Gabriella Schiera
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies (STEBICEF), University of Palermo, Palermo, Italy
| | - Patrik Drid
- Faculty of Sport and Physical Education, University of Novi Sad, Novi Sad, Serbia
| | - Giulia Messina
- Sport and Exercise Sciences Research Unit, University of Palermo, Palermo, Italy
| | - Andrea Pagliaro
- Sport and Exercise Sciences Research Unit, University of Palermo, Palermo, Italy
| | - Italia Di Liegro
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Patrizia Proia
- Sport and Exercise Sciences Research Unit, University of Palermo, Palermo, Italy
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Gujral S, Burns M, Erickson KI, Rofey D, Peiffer JJ, Laws SM, Brown B. Dose-response effects of exercise on mental health in community-dwelling older adults: Exploration of genetic moderators. Int J Clin Health Psychol 2024; 24:100443. [PMID: 38304020 PMCID: PMC10831729 DOI: 10.1016/j.ijchp.2024.100443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/15/2024] [Indexed: 02/03/2024] Open
Abstract
Background/Objective (1) Examine the role of exercise intensity on mental health symptoms in a community-based sample of older adults. (2) Explore the moderating role of genetic variation in brain-derived neurotrophic factor (BDNF) and apolipoprotein E (APOE) on the effects of exercise on mental health symptoms. Method This study is a secondary analysis of a three-arm randomized controlled trial, comparing the effects of 6 months of high-intensity aerobic training vs. moderate-intensity aerobic training vs. a no-contact control group on mental health symptoms assessed using the Depression, Anxiety, and Stress Scale (DASS). The BDNF Val66Met polymorphism and APOE ε4 carrier status were explored as genetic moderators of exercise effects on mental health symptoms. Results The exercise intervention did not influence mental health symptoms. The BDNF Val66Met polymorphism did not moderate intervention effects on mental health symptoms. APOE ε4 carrier status moderated the effect of intervention group on perceived stress over 6 months, such that APOE ε4 carriers, but not non-carriers, in the high-intensity aerobic training group showed a decline in perceived stress over 6 months. Conclusions APOE ε4 carrier status may modify the benefits of high-intensity exercise on perceived stress such that APOE ε4 carriers show a greater decline in stress as a result of exercise relative to non-APOE ε4 carriers.
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Affiliation(s)
- Swathi Gujral
- School of Medicine, Department of Psychiatry, University of Pittsburgh, 3501 Forbes Ave Suite 520-17, Pittsburgh, PA 15213, USA
| | - Marcia Burns
- Department of Psychology, Indianapolis University, 402 North Blackford Street, LD 124, Indianapolis, IN 46202, USA
| | - Kirk I Erickson
- AdventHealth Research Institute, Neuroscience, Orlando, FL 32804, USA
- Department of Psychology, University of Pittsburgh, USA
| | - Dana Rofey
- School of Medicine, Department of Psychiatry, University of Pittsburgh, 3501 Forbes Ave Suite 520-17, Pittsburgh, PA 15213, USA
| | - Jeremiah J Peiffer
- Centre for Healthy Ageing, Health Futures Institute, Murdoch University, Murdoch Western, Australia
| | - Simon M. Laws
- Centre for Precision Health, Edith Cowan University, Joondalup, Western Australia, Australia
- Collaborative Genomics and Translation Group, School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
- Curtin Medical School, Curtin University, Bentley, Western Australia, Australia
| | - Belinda Brown
- Centre for Healthy Ageing, Health Futures Institute, Murdoch University, Murdoch Western, Australia
- Centre for Precision Health, Edith Cowan University, Joondalup, Western Australia, Australia
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Antolasic EJ, Jaehne EJ, van den Buuse M. Interaction of Brain-derived Neurotrophic Factor, Exercise, and Fear Extinction: Implications for Post-traumatic Stress Disorder. Curr Neuropharmacol 2024; 22:543-556. [PMID: 37491857 PMCID: PMC10845100 DOI: 10.2174/1570159x21666230724101321] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/16/2023] [Accepted: 02/23/2023] [Indexed: 07/27/2023] Open
Abstract
Brain-Derived Neurotrophic Factor (BDNF) plays an important role in brain development, neural plasticity, and learning and memory. The Val66Met single-nucleotide polymorphism is a common genetic variant that results in deficient activity-dependent release of BDNF. This polymorphism and its impact on fear conditioning and extinction, as well as on symptoms of post-traumatic stress disorder (PTSD), have been of increasing research interest over the last two decades. More recently, it has been demonstrated that regular physical activity may ameliorate impairments in fear extinction and alleviate symptoms in individuals with PTSD via an action on BDNF levels and that there are differential responses to exercise between the Val66Met genotypes. This narrative literature review first describes the theoretical underpinnings of the development and persistence of intrusive and hypervigilance symptoms commonly seen in PTSD and their treatment. It then discusses recent literature on the involvement of BDNF and the Val66Met polymorphism in fear conditioning and extinction and its involvement in PTSD diagnosis and severity. Finally, it investigates research on the impact of physical activity on BDNF secretion, the differences between the Val66Met genotypes, and the effect on fear extinction learning and memory and symptoms of PTSD.
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Affiliation(s)
- Emily J. Antolasic
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Emily J. Jaehne
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
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Ren J, Xiao H. Exercise Intervention for Alzheimer's Disease: Unraveling Neurobiological Mechanisms and Assessing Effects. Life (Basel) 2023; 13:2285. [PMID: 38137886 PMCID: PMC10744739 DOI: 10.3390/life13122285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 11/26/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023] Open
Abstract
Alzheimer's disease (AD) is a progressive neurodegenerative disease and a major cause of age-related dementia, characterized by cognitive dysfunction and memory impairment. The underlying causes include the accumulation of beta-amyloid protein (Aβ) in the brain, abnormal phosphorylation, and aggregation of tau protein within nerve cells, as well as neuronal damage and death. Currently, there is no cure for AD with drug therapy. Non-pharmacological interventions such as exercise have been widely used to treat AD, but the specific molecular and biological mechanisms are not well understood. In this narrative review, we integrate the biology of AD and summarize the knowledge of the molecular, neural, and physiological mechanisms underlying exercise-induced improvements in AD progression. We discuss various exercise interventions used in AD and show that exercise directly or indirectly affects the brain by regulating crosstalk mechanisms between peripheral organs and the brain, including "bone-brain crosstalk", "muscle-brain crosstalk", and "gut-brain crosstalk". We also summarize the potential role of artificial intelligence and neuroimaging technologies in exercise interventions for AD. We emphasize that moderate-intensity, regular, long-term exercise may improve the progression of Alzheimer's disease through various molecular and biological pathways, with multimodal exercise providing greater benefits. Through in-depth exploration of the molecular and biological mechanisms and effects of exercise interventions in improving AD progression, this review aims to contribute to the existing knowledge base and provide insights into new therapeutic strategies for managing AD.
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Affiliation(s)
- Jianchang Ren
- Institute of Sport and Health, Guangdong Provincial Kay Laboratory of Development and Education for Special Needs Child, Lingnan Normal University, Zhanjiang 524037, China
- Institute of Sport and Health, South China Normal University, Guangzhou 510631, China
| | - Haili Xiao
- Institute of Sport and Health, Lingnan Normal University, Zhanjiang 524037, China;
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Li S, Wang X, Wang P, Qiu S, Xin X, Wang J, Zhao J, Zhou X. Correlation of exercise participation, behavioral inhibition and activation systems, and depressive symptoms in college students. Sci Rep 2023; 13:16460. [PMID: 37777582 PMCID: PMC10542367 DOI: 10.1038/s41598-023-43765-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/28/2023] [Indexed: 10/02/2023] Open
Abstract
To clarify the pathways and effects of the behavioral inhibition and activation systems in the relationship between exercise participation and depressive symptoms among college students. A cross-sectional research design was employed to survey 2606 college students using physical activity questionnaires, the Behavioral Inhibition/Activation Systems Scale, and the Beck Depression Inventory. Data were analyzed using methods including one-way ANOVA, independent sample t-tests, non-parametric tests, chi-square tests, correlation analysis, and structural equation modeling. Depressive symptoms were significantly negatively correlated with exercise participation (r = - 0.107, P < 0.001), reward responsiveness (r = - 0.201, P < 0.001), drive (r = - 0.289, P < 0.001), and fun seeking (r = - 0.102, P < 0.001), and positively correlated with behavioral inhibition (r = 0.084, P < 0.001). Exercise participation was positively correlated with reward responsiveness (r = 0.067, P = 0.001), drive (r = 0.085, P < 0.001), and fun seeking (r = 0.063, P = 0.001). Exercise participation had a significant direct effect (B = - 0.079, 95% CI - 0.116 to - 0.043) and total effect (B = - 0.107, 95% CI - 0.148 to - 0.069) on depressive symptoms. The mediating effects of drive (B = - 0.028, 95% CI - 0.043 to - 0.016) and fun seeking (B = 0.005, 95% CI - 0.001 to 0.011) were significant. The more college students engage in exercise, the lower their depressive symptom scores. Drive and fun seeking mediate the relationship between college students' exercise participation and depressive symptoms. Encouraging exercise participation among college students and enhancing their sensitivity to behavioral activation strategies and reward information may have a significant role in preventing and alleviating depressive symptoms.
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Affiliation(s)
- Shufan Li
- Shanghai University of Sport, Shanghai, China
| | - Xing Wang
- Shanghai University of Sport, Shanghai, China
| | - Peng Wang
- Shanghai University of Sport, Shanghai, China
| | - Shali Qiu
- Shanghai University of Sport, Shanghai, China
| | - Xin Xin
- Shanghai University of Sport, Shanghai, China
| | - Jing Wang
- School of Physical Education and Health, Shanghai Lixin University of Accounting and Finance, No.2800 Wenxiang Road, Songjiang District, Shanghai, China
| | - Jinlei Zhao
- School of Physical Education and Health, Shanghai Lixin University of Accounting and Finance, No.2800 Wenxiang Road, Songjiang District, Shanghai, China
| | - Xiaojing Zhou
- School of Physical Education and Health, Shanghai Lixin University of Accounting and Finance, No.2800 Wenxiang Road, Songjiang District, Shanghai, China.
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Ren J, Xiao H. Exercise for Mental Well-Being: Exploring Neurobiological Advances and Intervention Effects in Depression. Life (Basel) 2023; 13:1505. [PMID: 37511879 PMCID: PMC10381534 DOI: 10.3390/life13071505] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 07/30/2023] Open
Abstract
Depression is a common mental disorder in which patients often experience feelings of sadness, fatigue, loss of interest, and pleasure. Exercise is a widely used intervention for managing depression, but the specific molecular mechanisms underlying its antidepressant effect are unclear. In this narrative review, we aim to synthesize current knowledge on the molecular, neural, and physiological mechanisms through which exercise exerts its antidepressant effect and discuss the various exercise interventions used for managing depression. We conducted a narrative review of the literature on the topic of exercise and depression. Our review suggests that exercise impacts peripheral tryptophan metabolism, central inflammation, and brain-derived neurotrophic factors through the peroxisome proliferator-activated receptor γ activating factor 1α (PGC-1α) in skeletal muscles. The uncarboxylated osteocalcin facilitates "bone-brain crosstalk", and exercise corrects atypical expression of brain-gut peptides, modulates cytokine production and neurotransmitter release, and regulates inflammatory pathways and microRNA expression. Aerobic exercise is recommended at frequencies of 3 to 5 times per week with medium to high intensity. Here we highlight the significant potential of exercise therapy in managing depression, supported by the molecular, neural, and physiological mechanisms underlying its antidepressant effect. Understanding the molecular pathways and neural mechanisms involved in exercise's antidepressant effect opens new avenues for developing novel therapies for managing depression.
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Affiliation(s)
- Jianchang Ren
- Institute of Sport and Health, Guangdong Provincial Kay Laboratory of Development and Education for Special Needs Children, Lingnan Normal University, Zhanjiang 524037, China
| | - Haili Xiao
- Institute of Sport and Health, Guangdong Provincial Kay Laboratory of Development and Education for Special Needs Children, Lingnan Normal University, Zhanjiang 524037, China
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Wang Y, Li O, Li N, Sha Z, Zhao Z, Xu J. Association between the BDNF Val66Met polymorphism and major depressive disorder: a systematic review and meta-analysis. Front Psychiatry 2023; 14:1143833. [PMID: 37415688 PMCID: PMC10321516 DOI: 10.3389/fpsyt.2023.1143833] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 06/01/2023] [Indexed: 07/08/2023] Open
Abstract
Study objectives This meta-analysis analytically reviewed recent studies concerning the potential associations between the brain-derived neurotrophic factor (BDNF) Val66Met polymorphism and susceptibility to major depressive disorder (MDD), with subgroup analyses for race and age. Methods Relevant case-control studies were systematically searched for in PubMed, Embase, the Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang, and Sinomed databases. A total of 24 studies were finally identified to have reported outcomes including alleles, dominant genes, recessive genes, homozygosity, and heterozygosity. Subgroup meta-analyses were performed based on participant age and ethnicity. Publication bias was represented by funnel plots. All meta-analyses of the randomized controlled trials included for evaluation were performed using RevMan5.3 software. Results The findings revealed no significant association between BDNF Val66Met polymorphism and MDD. However, the Met allele was found to be associated with genetic susceptibility to MDD among white populations on subgroup analysis (OR = 1.25, 95% CI: 1.05-1.48, P = 0.01). In the genetic model, dominant (OR = 1.40, 95% CI: 1.18-1.66, P = 0.0001), recessive (OR = 1.70, 95% CI: 1.05-2.78, P = 0.03), and homozygous (OR = 1.77, 95% CI: 1.08-2.88, P = 0.02) genes were all associated with MDD. Conclusions Despite the outcome limitations, this meta-analysis confirmed that the BDNF Val66Met polymorphism is a susceptibility factor for MDD in white populations.
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Zeng B, Yue Y, Liu T, Ahn H, Li C. The Influence of the BDNF Val66Met Variant on the Association Between Physical Activity/Grip Strength and Depressive Symptoms in Persons With Diabetes. Clin Nurs Res 2022; 31:1462-1471. [PMID: 36168703 DOI: 10.1177/10547738221119343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The rs6265 in the brain-derived neurotrophic factor (BDNF) is associated with depression in people with diabetes. Both physical activity (PA) and grip strength are negatively associated with depression. We conducted cross-sectional analyses of the wave 10 survey data for a nationally representative sample of 1,051 diabetes participants of the Health and Retirement Study. Both greater PA (β = -.15) and stronger grip strength (β = -.02) were independently associated with depression. Although the interaction between BDNF rs6265 and PA on depressive symptoms was not significant, the negative PA-depression association was stronger among female non-Met carriers (β = -.19) and male Met carriers (β = -.14). Meanwhile, grip strength was associated with depression only in Met carriers (β = -.04), and similar association was observed in both males and females. In conclusion, female non-Met carriers and male Met carriers may benefit from PA.
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Affiliation(s)
- Bin Zeng
- Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, China
| | - Yan Yue
- Hospital of Chengdu University of Traditional Chinese Medicine, China
| | - Tingting Liu
- Florida State University College of Nursing, Tallahassee, USA
| | - Hyochol Ahn
- Florida State University College of Nursing, Tallahassee, USA
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