type d personality is characterized by both normal and stable personality traits , negative 
 affectivity ( na , tendency to experience negative emotions ) , and social inhibition ( si , 
 tendency to inhibit self - expression in social interaction)1 , 2 . with reference to type d 
 personality ,
the health condition of type d personality people is not six times better than 
 that of non - type d personality people through the study intended for chronic cardiac disease 
 patients3 , through the results of 
 studies intended for heart attack patients , reported that type d personality was highly 
 related to the onset of cardiovascular disease ( cvd ) prognosis , death rate and caused a 
 falling - off in quality of life4 .
negative emotions are associated with increased production of pro - inflammatory cytokines 
 including tumor necrosis factor - alpha ( tnf- ) and interleukin-6 ( il-6)5 , 6 .
episodic 
 psychological risk factors such as depression have been associated with poor prognosis in 
 cvd7 , 8 .
chronic psychological risk factors may also affect clinical 
 manifestations of heart disease9 , but 
 individual difference variables like personality traits have received little attention to 
 date in behavioral immunology research10 .
regular aerobic exercise reduces cvd risk factors and levels of oxidative stress and , has a 
 positive influence on lipoprotein metabolism11 .
personality type , unlike other psychological factors , is slowly 
 and stably formed from childhood through adulthood and is not easily changed , so 
 psychological factors of type d personality people are likely formed repeatedly over a 
 comparatively long period of time .
they think that it is needed to apply the long - term 
 exercise program over 12 weeks .
also , it was difficult that the results of studies was 
 applied because the main subjects of previous studies was patients with disease . 

furthermore , a previous study in patients with disease has investigated the relation between 
 type d personality and risk factors of cvd , but no previous study has shown type d 
 personality to be associated with increased cvd risk in healthy populations12 . therefore , the aim of this study was to research the association of type d personality with 
 cvd risk factors and psychology through comparison of the association of exercise 
 participation with cvd risk factors and psychological risk factors in women with type d 
 personality .
this study included 416 middle - aged women . all participants completed the 14-item type d 
 scale ( ds14 ) to assess type d personality .
the ds14 consists of two subscales , na and si , 
 both of which comprise 7 items . a standardized cut - off score  10 on both subscales
is used 
 to classify type d personality13 . in this 
 study , a korean version of
the cronbach s  was 0.82 for the na subscale and 0.80 for the si 
 subscale . based on self - reporting , subjects who had gone through menopause , drank alcohol , 
 smoked , or had been performing regular exercise for more than 6 months were excluded from 
 this study .
the sample size of this study was estimated prior to data collection by using a 
 power analysis method as previously suggested14 .
assuming a medium effect of 0.25 and an alpha level of 0.05 , 
 g*power 3.1 estimated that at least 8 participants were required .
the 48 participants were classified into one 
 out of four subgroups : type d+exercise ( n=12 ) , type d+non - exercise ( n=12 ) , non - type 
 d+exercise ( n=12 ) , non - type d+non - exercise ( n=10 ) .
two subjects refused to participate , and 
 so the final sample consisted of 46 participants .
characteristics of the participants are 
 shown in table 1table 1.characteristics of the subjectsvariablesgroupsmsdage ( years)type dexercise47.81.75non - exercise47.52.50non - type dexercise46.52.43non - exercise46.71.90height ( cm)type dexercise156.54.93non - exercise157.14.74non - type dexercise157.26.16non - exercise157.85.31weight ( kg)type dexercise69.29.99non - exercise66.88.00non - type dexercise66.44.00non - exercise66.83.73 .
social support , anxiety , depression , na , and si were chosen as psychosocial risk factors of 
 cvd15 , 16 . in the korean version of the social support scale , each item is 
 scored on a 4-point likert scale ranging from 0 to 317 .
we 
 investigated anxiety using the korean version of the spielberger state and trait anxiety 
 inventory ( stai - s ) .
the items of this scale are answered on a 4-point likert scale from 1 to 
 4 .
the self - rating depression scale12 is a short self - report scale designed to 
 measure depressive symptoms .
the questionnaire contains 20 items , and each item is scored on 
 a 4-point scale ranging from 0 to 3 .
spss for windows version 20.0 was used for statistical analysis , and p<0.05 was 
 considered statistically significant .
one - way anova was performed for verification of 
 differences between groups with regard to variables measured before the interventions . 

two - way repeated anova was performed to examine differences between type d personality and 
 non - type d personality after 10 months . in the case of a significant interaction effect 
 between the main effects
, the paired t - test was applied between groups by time , and for 
 comparison between groups by time , one - way anova and duncan s post hoc test were 
 performed .
the changes in body composition and psychosocial risk factors after exercise for 10 months 
 are shown in table 2table 2.the changes in body composition and psychosocial risk factors of cvdvariablesgroupsbeforeafterdifferenceduncanweight ( kg)type dexercise69.219.9963.099.626.12***non - exercise66.818.0066.698.220.12non - type dexercise66.434.0059.044.597.39***non - exercise66.893.7367.403.110.51percent fat ( % ) type dexercise38.025.0033.415.694.61***non - exercise37.474.3137.434.210.04non - type dexercise36.683.5233.343.683.34***non - exercise37.053.0337.123.250.07waist circumference ( cm)type dexercise95.147.0790.945.674.20non - exercise96.786.6297.306.840.52c < a < d , bnon - type dexercise90.436.5887.344.873.09non - exercise95.477.7495.688.030.21energy ( kcal)type dexercise1,947.10270.321,921.38251.801.32non - exercise1,934.54266.431,926.56273.230.41non - type dexercise1,927.43252.001,918.44317.120.47non - exercise1,929.50274.001,921.81306.200.40social support ( score)type dexercise35.589.5444.428.5924.85non - exercise40.7510.0039.427.833.26a , b < d , cnon - type dexercise47.5010.4551.508.638.42non - exercise48.608.2147.707.541.85anxiety ( score)type dexercise56.008.7647.676.6214.88non - exercise56.0812.4961.7513.2910.11c , d < a < bnon - type dexercise48.256.2841.083.7514.86non - exercise46.105.5345.607.291.08depression ( score)type dexercise56.258.2346.177.9317.92non - exercise55.6711.8061.5012.8010.47c < d , a < bnon - type dexercise46.837.6539.086.1116.55non - exercise47.105.3245.605.173.18negative affectivity ( score)type dexercise12.753.1711.422.0710.43non - exercise16.334.4816.424.250.55c , d < a < bnon - type dexercise4.923.654.753.523.46non - exercise5.403.275.603.533.70social inhibition ( score)type dexercise12.753.1111.332.3511.14non - exercise15.754.5916.174.472.67c , d < a < bnon - type dexercise4.503.454.333.263.78non - exercise4.402.554.602.884.55cvd risk ( n)type dexercise2.670.981.670.6537.45*non - exercise2.751.062.750.970.00c < a < d , bnon - type dexercise1.920.511.080.9043.75**non - exercise2.450.692.360.813.67meansd . * * * p<0.001 ; * * p<0.01 ; * p<0.05 ( paired t - test ) . a , type d+exercise 
 ( n=12 ) ; b , type d+non - exercise ( n=12 ) ; c , non - type d+exercise ( n=12 ) ; d , non - type 
 d+non - exercise ( n=10 ) . weight ( p=0.026 ) and percent body fat ( p=0.025 ) showed a significant 
 difference between times , and those of the exercise groups were significantly lower than 
 those of the non - exercise groups . social support showed a significant difference between 
 groups ( p<0.001 ) , and social support in the type d groups were lower than that in the 
 non - type d groups ; the levels of social support in the type d+exercise ( 44.428.59 score ) 
 and non - type d+exercise ( 51.508.63 score ) groups were significantly increased . waist 
 circumference ( p<0.001 ) showed a significant difference between groups , and those of the 
 exercise groups were significantly decreased compared with those of the non - exercise groups ; 
 that of the non - type d+exercise group ( 87.344.87  cm ) was significantly smaller than that of 
 the type d+exercise group ( 90.945.67  cm ) . meansd . * * * p<0.001 ; * * p<0.01 ; * p<0.05 ( paired t - test ) . a , type d+exercise 
 ( n=12 ) ; b , type d+non - exercise ( n=12 ) ; c , non - type d+exercise ( n=12 ) ; d , non - type 
 d+non - exercise ( n=10 ) anxiety and depression showed a significant interaction effect between groups ( p<0.001 ) 
 and for grouptime ( p=0.023 , p=0.010 respectively ) , and the scores for the type d groups 
 were significantly higher than those of the non - type d group in the post - test results ; those 
 for the exercise groups were significantly decreased compared with those of the non - exercise 
 groups . na and
si showed a significant difference between groups ( p<0.001 ) and were 
 significantly decreased in the type d+exercise group ( 11.422.07 and 11.332.35 , 
 respectively ) .
the average number of cvd risk factors in subjects showed a significant 
 difference between groups ( p<0.001 ) and times ( p=0.007 ) , and the numbers of cvd risk 
 factors were significantly decreased in the type d+exercise ( 1.670.65 ) and non - type 
 d+exercise ( 1.080.90 ) groups .
people with a type d personality have a temperament featuring a lack of positive emotions 
 and so have high self - esteem and high stress responses under certain circumstances18 .
it is easier for them to feel more 
 depressed than people with non - type d personality , and they tend to have a very low life 
 satisfaction4 .
apart from negative 
 emotions , social inhibition may also impact the immune system19 . in relation to health problems ,
type d personality is a factor 
 causing occurrence of cvd and poor prognosis4 , 19 . in a previous study ,
the heart rates of the heart rate recovery at one minute of rest 
 ( hrr-1)18 bpm group was significantly lower than that of the hrr-1>18 bpm group during 
 exercise , and most of the subjects had a type d personality ; it was also particularly 
 confirmed that they had high si tendencies20 .
but after a cardiac rehabilitation program for 12 weeks , maximum 
 aerobic exercise capacity , left ventricular ejection fraction , exhaustion time , and type d 
 character variables did not show significant differences between groups2 .
milani and lavie reported that as cvd patients can have low 
 cardiorespiratory function , the effect of exercise training for three months is 
 insufficient21 .
cvd patients have 
 various cvd risk factors , and they need more long - term exercise training rather than a 
 higher exercise intensity in order to reduce the cvd risk factors .
therefore , application of 
 the long - term exercise program conducted in this study is effective in improving cvd risk 
 factors22 . through studies on type d personality and the effects of exercise programs ,
the type d 
 personality score was found to decrease and quality of life was found to increase after a 
 cardiac rehabilitation program23 .
anxiety 
 and depression scores in people with type d personality decreased after a three - month 
 cardiac rehabilitation program3 .
after long - term exercise training in this study , the exercise groups showed decreased 
 degrees of anxiety and depression , while the non - exercise groups showed significant 
 increases .
therefore , we found that aerobic exercise and meditation were effective for 
 decreasing anxiety and depression .
depression and anxiety appear to be higher in individuals 
 with cvd than on those that are healthy , but it is ambiguous whether this is the result of 
 illness or the result of original personality traits .
however , as in the present study , 
 depression and anxiety in the general population can be interpreted as the results of 
 personality maladjustment unrelated to disease .
it has been suggested that a 
 dysregulated cytokine network is implicated in the pathophysiology of emotional distress in 
 coronary artery disease24 , 25 .
programs need to be developed that can raise the 
 awareness associated with dietary habits , care for health control behaviors , health - related 
 behaviors , the effort for health in diet , etc . , and to manage stress , motivators and 
 opportunities should be diversified that can strongly take advantage of sound programs such 
 as those incorporating various movements in daily life , singing classes , yoga , meditation , 
 etc .
the muscle output during 
 simultaneous contraction was larger than that of each individual muscle , suggesting that it 
 is easier to contract the la when the ta is contracted from the atandpoint of the kinetic 
 chain26 .
in addition , 
 the findings from the study results were somewhat limited by the small sample sizes for the 
 groups .
however , the present study has extended the existing research on type d personality 
 in several respects , including intervention and social support .
 [ purpose ] the aim of this study was to research the association of type d personality 
 with cvd risk factors and psychology through comparison of the association of exercise 
 participation with cvd risk factors and psychological risk factors in women with type d. 
 [ subjects ] this study included 416 middle - aged women . 
 all participants completed the 
 14-item type d scale ( ds14 ) to assess type d personality . 
 the ds14 consists of two 
 subscales , na and si , both of which comprise 7 items . 
 the research subjects were randomly 
 assigned to four groups : type d+exercise ( n=12 ) , type d+non - exercise ( n=12 ) , non - type 
 d+exercise ( n=12 ) , non - type d+non - exercise ( n=10 ) . 
 the study consisted of 46 participants . 
 
 [ methods ] an aerobic exercise program and meditation were conducted in parallel for 10 
 months . 
 stretching was performed for 10  min as a warm - up , and then walking and running 
 were performed on a treadmill at the hrmax 6070% level for 40  min ; this was done three 
 times a week . 
 blood samples were processed according to standard laboratory procedures . 
 
 the concentrations of tg and hdl - cholesterol were determined enzymatically on a clinical 
 chemistry analyzer . 
 blood glucose was measured by the hexokinase method . 
 [ results ] weight , 
 percent fat , social support , and waist circumference showed a significant difference 
 between times in the exercise groups , and the values were significantly lower than those 
 of the non - exercise groups . anxiety and 
 depression showed a significant interaction effect 
 between groups . 
 the average number of cvd risk factors in subjects showed a significant 
 difference between groups . 
 [ conclusion ] in conclusion , there were significant differences 
 between groups in terms of cvd risk factors and psychological risk factors in women with 
 type d personality . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION