Chapter 6
Physically active lifestyles and
well-being
Stuart J.H. Biddle and Panteleimon Ekkekakis
Fen7 da)-s go past without reference in the mass mrda to (unlhealthy lifestyles in
rllodern society. Diseases o f t h e age that are most often mentioned and have an
,wociation with physical inactivity include obesity, habetes, heart disease, and some
cancers. Indeed, obesity seems to be a current health issue most worrying politicians and health professionals, and lack of physical activity ki a key dement of the
Pnergy imbalance that is causing current obesity trends (Bouchard 2000; Bouchard
~ n Blair
d
1999). However, the beneficial effects of physical activity go far beyond
healthy weight management-The 'magic pdl' of physicaI activity is powerful, with
effects demonstrated o n nnrnerou s health outcomes. including puritive mental
health (Dishman et 01. 2(104). Indeed, physical activity research pioneer, Professor
Jeremy Morris, once referred to physical activity JS 'today's best buy for public
health' (Morris 1993).Nt.verche1ess. it was only in 1983 that one of the present
~ u t h o r s(SJHB) was referred to a General Pr,lctitioner (GP) at h ~ slocal primary
c x e health centre who not only smoked (in his consulting room!), but recon-rmended that all one reallv needed in respect of p h y ~ l c a lactivity w a s a grne of
rugby a t the weekend! Fortunately ;,we have come some wav since then and now
have strong advocacy documents prornotlng the importance of r r g u l ~ rmoderate
,
intensity physical activity o n most davs of cht. week (Dep~rtmeritof Health 2004;
Department of' Health and Human Serviczs 2nd Centers for Disease Control and
prevention 1996; Pate et a!. 1995). In addition, r c c u n i n ~ e n d ~ ~ i ocan
n s be tailored to
individual needs, such as those of young people, adults, older adults. ur those wlth
certain medical conditions (Department of Hedth 2004).
In this chapter, we review the evidence that phvsical nctivit): can contribute to
positive weU-being as well ~s prevent or ameliorate diseasz.We examine the so-called
f eel-good f ~tor'-the
c
psychological benefits that pcoplc derive from physical
~ c t l v i qO
. u r current undrrscandlng of the mcihanisrns underlying the beneficial
effects oiphysical activiv is presented, challrn;ing sonlr widely held views.A brief
I
142
1
STUART J.H. BIDDLE AND PANTELEIMON EKKEKAKIS
exarnination of ~ h hctors
z
underlying why some people are physically nctive while
others are not is follow-ed by a section on successful interventions a t both an individual and a societal level. We conclude that, despite the long history of research
in his field, there remain some exciting challcngcs in establishing how physical
activity exerts its enhancing effects on well-being and in using this knowledge to
develop intenen tions that would raise levels of p hysical activity and well-being in
the population at large.
Defining key terms
Typically, phvsical activity includes movement of the b o d y produced by the
skeletal muscles that results in energy expenditure (Caspersen e t QI. 1985).This
over-arching category can include any form of movement but, for the purposes
of health enhancement, we tend to be more interested i n murc sross motor
movements such as waking, cycling, lifiing, or large or prolonged do-it- yourself
(Dm)
activities.
Physical activity can include others types of movement, such as structured exercise
and sport. Exercise involves 'planned, structured and repe titivr bodily movement'
(Caspersen et al. 1985, p. 127), often with the objective of fitness maintenance or
improvement. An example would be exercising on a treadmill a t a htness club.
Sport, on the other hand, is physical activity that is rule-governed,structured, and
competitive and involves gross motor movement characterized by physical strategy,
prowess, and chance (Rejeski and Brawley 1988), such as golf or tennis. Not all
forms of physical activity are necessarily healthy and this may depend on the nature
of [he activity. how ic is performed, arid the characteristics of the individual.
However, within rhe normal bounds of safety and appropriate advice, physical
activity can have major health benefits.
Behavioural epidemiology framework
T h e five-phase behavioural epidenliology framework advocated by Sallis and
O w e n (1 999) is a useful way of viewing various processes in the understanding of
physical activity and healrh. Behavioural epidemiology cor~sidenthe link between
behaviours and health and disease, such as why some people are physically active
and others are not. In relation to physicill activity, this fi~rnecvorkhas five main
phases.
1 To establish tlie link b e t w c e n plrysiial nctivity a t l d heulth.This is now well
documenrrd tbr marly diversc conditiolls as well as well-being (Eouchard et a/.
1994; Dishman et nI. 2004).
2 To iievrlop rnethild-Jor the accurtltc asse<.irnen/ ifykysical nctiviiy.This remains a
problematic area. Large-scale sun-erllanae of population trends i ~ l e vtably
i
rclies
on seIf-report, n method that is fraught with validiry and reliability problems.
Recent 'objective' methods, such as movement sensors, heart rate monitors, or
'
PHYSICALLY ACTIVE LIFESTYLES i - N O WELL-BElljG
1
pcdon~etrrs.are usrful E u t do n o t necessarily give all of the inf'ornlation
rcquircd, such as i n r e w i q - or rype of actimty or the setting in arhich jctiviv
took place. U n t d we have berrer meaures of thc b s h ~ b i o u ritself-i.r. phx,sical
aztivit)l-the field will mug$ to progress in man): respects.
3 'A, idc~~rrqj~factors
that are ~~ssociated
with diJ;rc~t ICI~CISqf p hysiccll dctivity. Given the
evidence supporting the beneficin1 effects of physicdl dctivity on health, i t 15
tr-rlportant t o identify f ~ c t o r st h ~ might
r
be associated with the adoption 2nd
malntsnance of the beha~iour.Thisarea is referred to as the study ofLcorrelaces'
or 'determinants' of physical aztivity.The term correlater is n o w preferred in
order to avnid t h e arsunlption oCcausal links. much of the evidence a t this
stage is not able 10 support causahty.
4 771evaluatr intt.r~~entions
deskned to promofr ph~lsicrllactivity. Once J variable is
identified as a correlate of physical activity (e.g, self-eficacy), then intrn:entions
can manipulate this variable to test if it is. it1 fat t, a determinant. The nunlber of
intervention studies in physical activity is increasing (Kahn et a!. 2002).
j T I trirnslateJti,ldin~sfrom rtscrirclr itzto practice. lf interventions work,it is appropriate
to translate such findings into ecologically valid 'real-world' settings.
I t is important to realize thdt the above sequence is not linear. For example,
measures of physical activity are developed and refined alongside tests of outcomes,
and often community projects are established prior to iot~vincingevidence, but
may include a monitoring and evduatiun element to test the eficacy of such an
i~lterventionbefore refining future interventions-The whole process then becomes
iterative. Drawing on the behaviourd epidemiology framework, this chapter will
consider the psychologic~lbenetits of physical activity (phase 2 of the framework),
the correlates of physical activity (phase 31, and interventions designed tcl enhance
physical activity levels (p h ~ s e4).
The feel-good factor: what psychological benefits
do people derive from physical activity?
The ps);chological effects asso~.iaredwith physical ~ctiviryhave been the topic of
numerous scientific studies, conducted m ~ i n l ysince the early 1 9711s. The g t n z r ~ l
concIusion frnnl this research is that physical activity can enhance the participants'
sense of well-being. '4s described in a recent litemture rev1s\x7,'both survey and
experimental research . . . provide support for the \\-ell publicized rtatement that
"exercise m a k ~ syalt -fie1 ,?ood ' (Fox 1999: p. 4 13. it;ll~ssin the origind). How-ever.
although the conceptual and rnethodologjc~lsoph~sticationof the studies has
irlcre~sedover the years. not all reviewers hare rt.,~chcda sinlilarly definitive conclusion. Skeptics have argued that. in many CJsCs. . ; t ~ t e n ~ r nabout
ts
the psychological
h~rlefitsof physical activiry serin to '~nticipatemther than reflect the accumulation
of strong evidence' (Salmon 200 1, p. 36).
"
143
144
1 STUART
J.H. alDDLE A K D DANTELEIMON E K K E K A K S
The controversy has been persisting for many years. Over 2 decades ago, bascd
on a few* preliminary studies, Morgan ( 2 98 1, p. 306) asserted that 'the "feeling
better" sensation that accompanies regular physical activity is so obvious that it is
one of the few universally accepted benefits of exercise.' Yet, at about the same
time, Hughes's (1984, p. 76) arsessrnent w s that 'the enthusiastic support of exrrcise
L
to improve mental health has a limited empirical basis and lacks a well-tested
rationale.' More recently, a similar contrast is evident in the conclusions reached
by different reviewers evaluating the research on the effects of habitual physical
activity on depression. Biddle et al. (2000, p. 155) stated that 'overall, the evidence is
strong enough for us to conclude chat there is support for a c a u s ~ link
I
between
physica1 activity and reduced clinically defined depression. This is the first time
such a statemerit has been made.' In contrast, Lawlor and Hopker (2001,p. 1)found
that 'the effectiveness of exercise in reducing symptoms ofdepressiorl cannot be
determined because of a lack ofgood quality research on clinical populations with
1
adequate follow up.' Others, characterizing Lawlor and Hopker's conclusion as
'a bit harsh' (Brosse e t 21. 2002, p. 754). acknowledge t h a t , nlthough, if taken
together, the extant studies seem to suggest that regular physical activity can reduce 1
depression, the literamre std contains a very small number of high-qualty clinical 4
rials and, consequently, the quantity and quality of the evidence could not yet
satisfy the most stringent of criteria, such as those established for evaluating the
effectiveness of prescription drugs.
Despite the conflicting views, the appeal of physical activity as an intervention
n~odalityfor enhancing psychological well-being is such that the research will
surely continue. In a n era of rising mental health care costs, physical activity is a i
potentially viable alternative or adjunct to traditional forms of therapy (i-e.pharmacoand ~ s y c h o t h c r ~ p yand
) is inexpensive a n d free of serious side-effects. Moreover,
physical activity has some added advantages that other interventions cannot claim.
First, besldes being poterltiaUy effective AS a therapeutic mod~lity,physical activity
also seems to have great potential value as a preventive rnodalitv amorig hralthy
individuals. Second, besides its psychological effects, physical activity also has substantinl beneficla1 effrctc nn physical health-and
these are supported by a much
more extensive and robust evidence base! In the following paragraphs, u-e provide
a brief summary of the research on the psychological effects of physical nctivity,
separating them into the efl>uts of physical fitnebs o r l ~ d b i t u a lparticipation in
physical activity (e.g. for months o r years) and those associated with sin+ bouts
1
1
i
'
of activity.
Psychological effects of habitual physical activity
T h e effects of habitua! physic31 activity on various aspects of well-being have
been examined in numerous studies. These include both cross-scctiotlal studies
(i.e. exami riing differences in aspects o h e l l - b r i n g b e t w e e n groups differing in
PHYStCALLY ACTIVE LIFESTYLES AND WELL-BEING
Table 6.1 Benefits of regular, long-term physical activrty for various aspects of well-being, with
references to representative literature reviews
p
-
Benefit for dl-being
Selected n k ~ e n c e s
~ ~ d u c l ini ~anxiety
n
Landers and Petruzzello 7994;O'Connor et a1 2001);Petruzzello et a/. 1991;
Taylor 2000
--
.
. . . . . . . .
Reduction in depression
-
,
.
improved mood slates
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
Arent etal. 2000; Biddle 2000
.
.
. . . . . . . . . . . . - --
.
.
.
.
.
.
.
.
.
...........
Serger 2004; Berger and Mot1 2001. Re~esk!et a/. 1996. Releskr and
Mlhalka 2001
~mproved-physicaland general
sell-worth
Fox 2000a. 6:Sonstroem 1997
,
-
-
-
,
,
,
. . . . . . . . . . . .
.
Enhanced health-related quality of
life in the elderly and various pallent
populations
. ,
.
, , , ..
Brosse etal. 2002; Craft and Landers 1998: Mutr~e2000:OrNealeta/,2000
. . . . . . . . . . . . . . . . .
--
,,,
. . . . . . . . . . . . . . . .
Kubitz et at. 1996. Youngstedt 2000;. Youngstedt
et a/. 1997
. . . . . . . . . . . . . . . . . . . .
,-.................
Oishman and Jackson 2000. Sothmann et a/. 1996
Reduced reacttv~lyto psychosoc~al
lrnproved deep
stressors
...
...
lmprwed cogn~tivefunct~on~nall
populations, includtng older adults
.
.
.
.
.
...
Colcombe and Krarner 2003; Etnier et al 1997
habitual levels of activity or levels of physical fitness) and experimental studies
(1.e. examining the effects of weeks or months of participation). With so many
studies whose methodological approaches are quite diverse and none of which can
be characterized as definitive, this topic has also been the subject of many reviews,
including meta-analytic reviews.These reviews have generally concluded that
physical activity is associated with reduced anxiety, reduced depression, improved
mood states, enhanced health-related quality of life in the elderly and various
patient populations, improved physical and general self-worth, improved sleep,
reduced reactivity to psychosocial stressors, and improved cognitive function in all
populations including older adults (for references, see Table 6.1).
Collectively, these findings suggest that individuals who are physically active,
besides lowering their risk of premature death or chronic disease and physical
disability. s houId experience a sense of psychological well-being. The following
adhtional conclusions can also be drawn. First, consistent with common conceptudizations of well-being as a multifaceted construct, the beneficial effects of physical
activity are clearly not restricted to one outcome var~ablebut, instead, appear to be
broad (Landers and Arent 200 1; McAuley and Katula 1998). Second, the beneficial
effects of physical activity on the various aspects of welI-being appear to extend to
both genders and all age groups.Third, these benefits tend to be larger with Ionger
interventions and for those individuals whose mental health is more compromised
at baseline. Having said this, it is important to clarify that individuals without
compromised mental health also receive significant benefits, albeit of smaller
magnitude, given their narrower available margin for improvement. Fourth, the
beneficial effects on well-being are not fully accounted for by the beneficial effects
of physical activity on o bjeccive nlsasures of physical fitness or physical function.
1 145
146
1 STUART J.H. BIDOLE AND PANTELEIMON EKKEKAKIS
For example, research on health-related quality of life, particularly among older
adults, has demonstrated that 'objective' (e.g. the ability to walk certain distances,
climb a flight of stairs, or maintain balance) and 'subjective' measures (cg. selfreports of pain, physical seIf-efficacy, or satisfaction with physical function) are not
necessarilv correlated and do n o t ncccssarily show t h e same time-course i n
response to physical activity interventions. Other studies have consistently shown
that there is no association between activity-induced increases in physical fitness
and improvements in anxiety and depression. Collectively, these findings suggest
that cognitive self-appraisals of activity-related effects, which may or may not be
entirely congruent with actual physical gains, constitute an important mechanism
by which physical ncdvity influences quality of life and well-being. Fifth, studies
that, based on the assumption that the 'active ingrebent' in physical activity interventions is the derobic training, used control groups involving nctn-aerobic activities,
such ar stretching and toning (strength training), have shown that reductions in
anxiety and depression were similar, regardless of the aerobic or non-aerobic nature
of the activity.These findings clearly point to alternative explanations, including
the possibdity that these psychoIogical benefits are influenced by social interactions
or the participants' perception that they are actively taking control of their mental
:
;
{
4
-3
i
'
4
.{
j
1
and physical health.
Although, as noted earlier, most literature reviews have concluded that habitual physical activity entails substantial benefits for various aspects of well-being, the
research picture is complicated, so it is necessary to examine the Gndings from a
4
critical standpoint. As a case in point, consider the arguably most complete study of 1
the eEects of physical activity on depression (Blurnenthd ei a/. 1999).In this study, I
156 men and women, 50 years of age or older, who had been diagnosed with
major depressive disorder, were randomly assigned to one of three 16-week treament
conht~ons:.( 1) exercise (3 sessions per week, lascing for 1 5 minutes each, at 7&85%
of heart rate reserve); (2) antidepressant mehcation (using thc popular serotonin
rruptake inhibitor sertraline hydrochloride or zoloftTM);
or (3) a combination
of thc excrcisc and antidepressant creaments.The drop-out rates at the end of the
16-week period were not significantly different between the three groups (26%,
1394, and 20% for groups 1 , 2 , and 3, respectively). At the end of'the treatment
period,both clinician-rated and self-reported levels of depression were reduced
compared to baseline, with no significant differences between the groups. A similar
result was also found for anxiety, self-esteem, life satisfaction, and dysfunctional
atti tudcs. At the I 0-month folIow-up (6 months after the conclusion of treatment),
self-reporred depression scores were also not different across t h e three groups.
However, based on DSM-IV criteria and clinician ratings (a Hamilton Rating
Scale score hrghcr than 71, the participants in the exercise group had a lower rate of
depression (30%) than those in the medication (5296) and combined-treatment
groups (55%). Furthermore, of the participants who were in remission after the
PHYSICALLY ACTIVE LIFESTYLES AND WELL-BEING
initial 16-week treatment period, those rvho had been assigned to the exercise
were more likely to have partly or fully recovered after 6 months than those
g
in the medication and combined-treatment groups (Babyak et al. 2000).The
authors discussed these findings stating that exercise helps participants develop 'a
sense of ~ersonalmastery and positive self-regard', whereas the exclusive reliance
oll or the inclusion of medication 'may undermine this benefit by prioritising
an alternative, less self-confirming attribution for one's improved condition'
Pabyak et al. 2000, p. 636).
On the one hand, t h study overcame several of the methodological shortcomings
of earlier studies, having an adequate sample size, including both men and women,
and exanlining inhviduals who were depressed at baseline rather than a converlience
sample. Furthermore, the study involved reasonably Iong treatment and follow-up
periods, two comparison conditions, and more than one standard measure of the
main outcome \miable (i.e. both self-reports and clinician ratings of depression).
Findy, as Lawlor and Hopker (2001) noted in their review, the Blurnenthal et al.
(1999) study did involve an 'intention to treat' analysis. thus accounting for the
possible biasing effects of the less-than-perfect adherence and often substantial
drop-out rates commonly associated with exercise and medication interventions.
On the other hand, h study could not address other persistent problems, some
of which seem to be unavoidable (Morgan 1997). First, there was a selection bias,
since the participants were all volunteers who responded to advertisements for
a research study of'exrrcise therapy for depression'. It has been shown that the
expectation of psychological benefits 6om physical activity can sigrhcantly influence the outcome (Desharnais et at. 1993). Babyak et al. (2000) also commented
o n the possible presence of an 'anti-medication' bias among some participants.
Perhaps associated with volunteerisni, the participants were also highly educated
and physically healthy. Furthermore, the possibility of 'spontaneous recovery'
cannot be excluded since there was n o no-treatment control condition.The reason
for this is that there can be no true 'placebo' exercise intervention, leaving only
control conditions that are of questionable meaningfulness (e.g.wait list), since they
fail to control for expectancy. Moreover, since the exercise was co~lductedin a
group environment, it is possible that the bene6cial effects of exercise were partly
or fully mediated by the factor of social interaction. Finally, there is no way to fully
account for treatment cross-overs that can take place during the follow-up period
( e .g. participants opting to switch or discontinue treatments) .These limitations,
which are clearly not trivial, underscore the fact that even large, costly, and welldesigned studies that produce seemingly robust results supporting the beneficial
role of physical activity should be viewed cautiously.
In addition to the continued efforts to design methodologically stronger
randomized clinicd trials. research is also being conducted on several other fionts.
O n e important area of research deals with the delineation of the shape of the
1
147
148
1
STUART J.H. BIDOLE AND PANTELEIMON EKKEKAKIS
relationship between the 'dose' of physical activity (i-e.frequency, session duration,
intensity) and the psychoIogcaI response. In the case of depression and anxiety, which
are the most intensely studied ourconles of habitual physical activity, the current
conclusion is that 'there is little evidence for dose-response effects, though this is
largely because of a lack o f studes rather than a lack of evidence' P u n n et al. 2001,
p. 5587).
Psychological effects of single bouts of physical activity
Finding that people report 'feeling better' after they participate in a session of
physical activity: regardless of h o w this 'feel-better' effect is operationally d e h e d
and largely regardless of the characteristics of the physical activity stimulus and the
participants, are remarkably robust. The most common methodological approach
in his line of research has been the assessment of psychological states, using
multi-item inventories, before and &er a bout of physical activity and some control
condition, typically a sedentary one ( e . g . reading an article or participating in an
arts and crafts class). Compared to these control conditions, physical activity has
consistently been shown to be associated with reductions in state anxiety and
improvements in various mood states, such as decreases in tension and depression
and increases in vigour (Landers and Arent 200 1;Tuson and Sinyor 1993;Yeung
1996).The publication of studies that follow this basic paradigm (and produce
similar, positive results) has continued unabated for over 3 decades, having generated
a literature that now contains literally hundreds of reports.
As was the case with research examining the effects of habitual physical activity,
studies on the effects of single sessions of activity also have limitations, both conceptual and methodological. O n e example is the fact that the afore~nentiorled
operational definitions of the 'feel-better' effect (i.c. mainly self-reports of state
a ~ e t and
y nkovd states) wcre chosen not because these had heen demonstrated to
be the only or the strongest changes associated with physical activity but rather due
to the fact that these could be assessed by available self-report measures when this
research got under way (i.e. in the early 2 970s). Consequently, even though rhe
positive changes in these variables have been replicated in numerous studies, it
remains unclear if these are the only or thc 111ostzxpericnrially salient changes that
occur in response to physical activicy under various conditions.
Another consequence is that very little attention was paid over the years to
hstinctions between the various constructs that fall under the affective umbrella,
such as prototypical emotions, moods, and core affect (Ekkekakis and Pctruzzello
2000; Russell 2003), yet these distinctions are clearly irnpormnt. Elrrutiurls, such as
state anxiety or pride. and moods, such as irritability or cheerfulness, rely on
cognitive appraisals, whereas core affect, such ss tension or calmness, could emanate
from the body in a direct, cognitivrly unrneciiated fashion.These differences imply
PHYSICALLY ACTIVE LIFESTYLES AND WELL-BEING
1 149
that not all facets of the response to a session of physical activity are necessarily
subject to the same mecha~lismsor k e l y to follow a unified pattern.
Furthermore, as a consequence of using standard self-report measures of state
anxiety and mood stares that contain a relatively large number of items (wicdy
between 20 and 65 each), change in the outcome variables was assessed from
before to various tinlz poir~tsafter the termination of the activity. Logically, this
pactice would make sense only if the trajectory of change during the
were linear. However, it has become clear that, in many cases, the changes
are nonlinear, particularly as the intensity of the activity increases or the duration
progresses (e.g. consisting of a curvilinear decline during the activity, followed by
an instantaneous rebound after the end).Thus, a pre-to-post assessment protocol
would clearly misrepresent the changes that take place in the interim.
An important consequence of failing to recognize that such dynamic changes
might occur has been the inability to iden* a consistent pattern of doseresponse
effects. Despite the fact that, as anyone with any physical activity experience can
attest, different intensities and/or durations of physical activity will likely lead a
participant to experience a gamut of experientially different responses, possibly
including both pleasant and unpIeasant ones, 30 years of research have failed to
provide reliable evidence for such an effect (Ekkekakis and Petruzzello 1999).
Finally, contrary to the assumption that all or most individuals would respond to
physical activity in the same direction (presumably, with changes toward a more
pleasant state), i t has become apparent that, under certain conditions, it is possible
for some participants to respond with changes toward pleasure and others with
changes toward displeasure. For example, a study involving cycling for 30 minutes
a t 60% of the participants' maximal capacity, showed that approximately half
reported feeling progressively better and half reported feeling progressively worse
(Van Landuyt et a/. 2000).Nevertheless, given the enormous multitude of interacting
influences on affective responses (e-g.physicd and social condtions, exercise intensity
and duration, and the physioIogica1 and psychoIogica1 traits of the participants), the
proportions of individuals who respond positively and negatively under various
conditions remain extremely diEcult to prcdct .
As these and other limitations became apparent, nlore recent studies have started
to investigate the affective changes associated with single sessions of physical activity
using a new conceptual and methodological platform. The primary characteristics
of this new approach have been: (1) the conceptuhzation and assessment of affective changes not in terms of distinct states but rather in terms of broad hmensiom,
such as those comprising the circumplex model o € flect, namely pleasurdspleasure
and activation (Ekkekalus and Petruzzello 1999,2002);('2)the repeated assessments
of these dimensions both during and after the sessions of activity; and (3) the
examination of individual patterns of change. These studies have produced the first
150
1 STUART J.H. BDDLE AND PANTELEIMON EKKEKAKlS
reliable evidence of a specific relationship between the intensity of physical activity
and affective responses, showing that the let-el of intensity corresponding to the
transition from aerobic to anaerobic metabolism appears to be the 'turning point'
toward displeasure during physical activity (Acevedo ~r al. 2003; Bixby et 'ni. 200 1 ;
Ekkekakis et ~1.2004;Hdu et al. 2002).Ths is an important physiological landmark,
since the metabolic resources that are available to anaerobic metabolism are limited
and exceeding the point of transition entails the inability to maintain a physiological steady state (i.e, a continuous rise in heart rate, oxygen uptake, and lactic acid
concentration) and a multitude of physiologicd adjustments as t h e body approaches
fatigue and exhaustion. Below this transition. affective changes tend to be mostly
pleasant. However, above this transition, there i s a gradual decrease in pleasure and,
ultimately, an increase in displeasure. However, once physical activity is stopped,
there is a rapid increase in self-raced pleasure, regardless of whether this response
represents a continuatio~of a positive trend or a rebound h m a negative crend during
the activity (Bixby e t al. 2001). Examples of affective responses to two physical
activity stimulr of markedly different intensities, one treadmiu walk at a self-chosen
pace (lasting 15 minutes) and a treadmill test involving gradual increases of the
speed and grade untd the point of volitional exhaustion (lasting 1 1.3 minutes), are
shown in Fig. 6.1 (see aption for more details).
Mechanisms underlying the psychological benefits of
physical activity
An important area of research in exercise psychology focuses on the mechanism(s)
by which physical activity benefits well-being. Establishing one or more plausible
mechanisms could help to show that the relationship between physical activity
and well-b ting goes beyond statistical association, providing evidence that physical
activity can, in fact, cause positive changes in well-being. Unfortunately, this research
has trahtionally been fiagrnentcd, reflecting dualistic thinking, with some researchers
seeking explanations in psychnlugical mechanisms, others seeking explanations in
physioIogica1 mechanisms, and virtually no eEorts aimed a t integrating the two.
As noted earlier, cognitive appraisals of agency, mastery, control, or self-efficacy
have long been theorized to underlie the bencf cia1 effects of physical activity on
various aspects of well-being. For example, studies designed to manipulate the
known sources of self-efficacy (i-e. prior accompIishments, vicarious experiences,
verbal persuasion, and physiological arousal) have shown congruent changes in
affective parameters, both in single sessions of activity and in long-term participation (McAuley 1991).
According to another psychological mechanistic hypothesis, physical activity can
enhance well-being by providing a distraction or a 'time-out' Gom daily hassles and
worries. T h i s explanation was based on a finding that exercise, meditation, and
qulet rest for equal periods of time were all accompanied by sirrlilar reductions in
PHYSICALLY ACTIVE LIFESTYLES AND WELL-BEING
(-) m e c n v e valence (+)
Fig. 6.1 Affective responses to two bouts of physical activity, plotted in circurnplex space, where
the horizontal dimension represents affectwe valence, ranging from displeasure (left) to pleasure
(right) and the vertical dlrnensron represents perceived activation, ranging from low (bottom) to
high (top). Both d~mens~ons
are assessed by self-ratings. 'Pre' indicates the beginning of each
activity, 'End' Indicates its end, and 'Post-10' indicates a time point 10 minutes after the end.
A 15 mlnute treadmill walk at a self-chosen pace on the treadmill results in an activated pleasant
state durrng and immediately after its completion, whereas a 10 minute seated recovery per~od
leads to a low-activation pleasant state. A treadmill test, lasting on average 11.3 minutes, during
which the speed and grade are gradually increased until the point of volitional exhaustion, leads
to a n act~vatedunpleasant state, whereas a subsequent cool-down and 10 minute seated recovery
perlod brjng about a return to a low-activation pleasant state. Notice that the ventilatory threshold
(indicated by VT), a marker of the transition from aerobic to anaerobic metabolism, appears to be
the turning point toward displeasure during the treadm~lllest {see text for additional information).
(Plotted with data from Ekkekakis et at. (2000) and Hall et al. (2002).)
anxiety (Bahrke and Morgan 3 978). Given that these three tasks had no sirmlarities other than givjng participants the opportunity for a break, researchers assumed
that this common ingredirnt was the key to reducing state anxiety. However, if the
assessment of the d e c t i v e outcomes is extended beyond the single variable of state
anxiety, it becomes clear that physical activity leads to affective responses that differ
substantially h n l those associated with sedentary tasks, with physical activity leadng,
a t least iniri~lly,to high-activation pleasant state (e.g. energy, excitement) and
s e d e n t q or relaxing activities leading to a low-activation pleasant state (t.g, calmness,
state
1
151
152
1 STUART J.H. BiDDLE AND PANTELElMDN EKKEKAKIS
sereniv).
Given this qualitative difference, the explanation that physical activity
leads to a n enhanced affective state simply because it provides a distraction from
worries becomes unlikely.
A third psychological explanation is that, given the fact that in most-studies
physical activity takes place in groups, physical activity can enhance the sense of
well-being by providing an opportunity for social interactions. Although this
explanation remains possible, it cannot be considered the only explanatian, primarily
because of studies that have shown positive affective responses to physicd activity
even if the activity takes place in social isolation and in the relatively dull environme& of a laboratory. Furthermore, stuches have shown that the presence of others
does not necessarily have a positive influence on affect, as individuals concerned
about their appearance may respond with increased anxiety when exercising in a
socid setting (Focht and Hausenblas 2003).
Of the physiological expIanations, perhaps the most intuitively appealing
proposes that the positive effects of physical activity on well-being are consequences of its w-ell-established effects on physical fitness, including cardiorespiratory endurance, strength, and flexibdity. Specikally, it is assumed that a physically
active individual will 'feel better' because he or she is able to do more things more
eEcicntly, avoid health problems (such as obesity or chronic debilitating &eases),
dnd, importantly, maintain these abilities into old age. This hypo thesis seems
particularly relevant to how physical activity benefits health-rebted quality of life.
How-ever, as noted earlier, several studies have failed to provide evidence of an
associa tion between objectively quantified physical gains, such as improvements
in endurance or strength, and changes in well-being. Therefore, what remains as a
viable explanation at this point is that the beneficial effects of physical activity on
w-&-bring might be mediated by the perceived, rather than the objective, physical
and physiological changes associated with physical activity participation.
T h e studies that have focused on brain mechanisms have usually taken one of
~ V O
approaches. In one, physical activity is viewed as an appetitive stinlulus (akin
to tasty food or addictive drugs) and, consequently, w h ~ is
t being sought is the
mechanism by which it is experienced as pleasant or rewarding. Studies that have
followed this approach have considered primarily brain areas known to be involved
in pleasure and reward, focusing particularly on the mesolimbic dopaminergic
pathway projecting horn the ventral tegrnental area of the nlidbrain to the nucleus
accunlbens. In the second approach, physical activity is viewed as an intervention
modaliry capable of correcting imbalances in brain neurotransmission commonly
associated with anxiety and depression, in a manner malogous to that of centrally
acting drugs. For example, modern antidepressant medications (serotonin-specific
reuptake inhibitors or SSRIs) work mainly by bloclung the rzuptake pumps that
collect serotonin from the synaptic cleft back into the releasing neuron, thus leaving
more serotonin available to attach to reztptors o n the receiving neuron. Using
= L ' ~ S I C A L L Y ACTI'JE LIFESTYLES AND W E t i - 6 E I ? : S
! 153
Ecruhnicjut.ssuch as microdi~iysis.w h i c h allnlt-s [he collection of extracellular tluid
from specific locatinns in the brain of free-hing animals, srudies have sho\vn that
esrrcise appzrrrs to have an effect similar co that of the SSKIs, raising the levels
(Metusen and De Mcirlzir 1993; hleeusen et al. 2001).
But perhaps the most \videI>. known mechanism for the 'feel-better' effects of
pIlvricnl activir; is the 'endorphin hypo thesis'; popularized through numerous press
reports over the vears.The ~ o p u l ~ofr this
i ~ hypothesis can be attributed to the
coj~~cidt.nt
tinlrng of several s~snts.First. the isolation of endogenous opioids ~ y a s
yuicHl- fvllowzd by the &scoverv that the level of these opioid substances is raist.d
huowing vigorous cxrrcise.Then. this happened to coincide with the developing
craze during the seco~zclh ~ l of
f the 1970s and anecdotal reports of what
became knon-n as the 'runner's high' phenomenon. Eager journalists (and some
~verzealousscienti5ts) hstily made the connec~ionthat the natural opioiris must be
for the 'high'. From a research standpoint, chis connection has proven
infinitely more difficult to make and the literature has bj- n o means yielded an
u r ~ e ~ ~ i i v oanswer
cal
(Hoffmann 1947).W h a t seems clear is ch;ir: pzrip herally
circul;lting opioids (beta-endorphin from the pituitary and beta-snksphalin from
the c hromaffin cells of the adrenal medulla) have 11r-rlited. if any, c e n t r d ~Eectsand
do n o t reflect the dynamics of brain opioid neurotransmission. On the other hand,
brain opioids, which can be experimentally manipulated by blockrr agerlcs such as
ndosone and naltreuone, mav have a role in exercise-associated affectwe responses.
Even if their role is not to directly induce pleasure. central opioids have been
shown to have an attenuating effect on card-rovascrllar and respiratory responses to
sxeriiw. Through that, the); can potentially suppress symptoms associated with
perceived exertion (e.g. heart rate, blood pressure, ventilation), which is, in turn,
closely linked to affect at strenuous levels of exercise intensity. Furthermore,
descending opioidergic neurons, o r i g i n ~ t ~ nprimarily
g
in the periaqueductal grey
and ~ctivatedby h jsh levels of stress. c d n rzyulntc: the tlow of' bodily sensory cues
that ascend the spirlal surd ~ n eI1tt.r
d
cIzz brnin.
Finallv. J recently proposed I ~ y p o t h t ' sIS~J~~ I I ~~t~ esplairting
LI
the changing dective
responses to i n c r c a s i n ~Irvels ~ 7 phv~ic'dl
f
dc'tivlty irltensity (Ekkekakis 2003).
According to this hypothrsis. atfictivt. rt.sponst.5 co ~ h y ~ i z activiw
al
art: shaped by
evolution and are the product of t h e ~.onrinuc~us
interaction of social-cognirive
factors (such as physic31 self-tficacy) and interoc-epcive h t o r s (such as respiratory
and nluscular cues).Tht. rel~tivejnduzncr of chzse tcvo factors on affect is hypothesized to change systematically as a filnction of the intensity of the activity with the
former being dominant at low and mid-range i ~ ~ c r r ~ s i t2nd
i e s the latter gaining
dor-rlinmce at high and near-rnaxinl,ll inttnsitics. This llyplschesis also has s o m e
irr~pIicutiorls for irlterventions aimed a t con~rolJingsonlc u ~ l p l e a s a l ~responses
t
to
p h ~ s i c d~ctiviry.p~rticularlyanlong bzginncr csrrciscrc.Accorhng to thc h-~pothtsi~.
~o~grtitivt.
teil~mques,such as attentiond dissocintion, iog~lltiverekanling. or boosting
154
1
STUART J.H. BlDDLE AND PANTELEIMON EKKEKAKlS
self-efficaq, can only be expected to be effective when the intensity of the activity
presents an appreciable but not yet overwhelming challenge but noc when it
reaches high or near-mAmal levels.
Expanding the focus: the psychosomatic benefits
Although the vast majority of research on the health benefits of physical activity
has been conducted along either physiologicrrl or psychological lines, some studies
have taken A more interdisciplinary approach by examining health and well-being
from a psychosomatic perspective. The influence of psychosocial factors in the
pathogenesis of t h e two leading causes of death in Western societies, namely,
coronary heart disease (Krantz and McCeney 2002; Rozanski et a/. 1999) and
cancer (Kiecolt-Glaser and Glaser 1999), is fairly weU established. Ir is also well
established that the two psychoneuroendocrine systems, namely, the sympathetica d r e n o r n e d ~ l l a r(SAM)
~
axis and the hypothalamic-pituitary-adrenocortical
(HPA) axis, are the main mediators in the relationship between psychosocial stress
and pathogenesis (Chrousos 3998; Chrousos and Gold 1998;Tsigos and Chrousos
2002).
Unlike pharmacological and psyc hotherapeutic interventions, p hysicd activity
appeats to offer the unique advantage of being able to produce beneficial changes
in both the psychosocial variables (by reducing depression and anxiety and increasing perceived control) and the neuroendocrine variables (by producing a more
adaptive pattern of hormonal responses to stressors). Therefore, two lines of
research have emerged, one focusing on physical activity-induced changes in
neuroendocrirls and cardovascular responses to psycho so cia^ stressors (Sothnlann
et a/. 1996) and one focusing on physical activity-induced changes in the relationship between psychosocial stress and immune function (Hong 2000; Laperritre
ei aE. 1994;Perna et al. 1997).The starting point for both of these lines of research is
the numerous findings in the Iast 15 years that physical activity offers significant
protection from mortality associated with cardovascular disease and various types
of cancer.The question is whether part of this beneficial egect is due so physical
activity-] nduced changes in how stress impacts the pa thogenesis and progression of
these diseases.
Conceptually, based on studies focusing on neuroendocrine responses to exercise
stirnub among trained and untrained individuals, physical activity and 6 tness should
be associated with a n adaptive overall pattern of responses to stressors. Such a
pattern would consist of an attenuated elevation of catecholamine levels (the endproducts of the SAM axis) and a rapid return to baseline, reduced basal leveis and
stress-induced responses of cortisol (the end-product of the HPA axis), and an
enhanced production of endogenous opioid peptides.These changes, if [hey
manifested themselves in response to daily psychosocial stressors, could help physically active and fit individuals buffer the harmful eflkcts of stress (Jonsdottir 2000;
PHYSICALLY ACTIVE LIFESTYLES A N 0 WELL-BEING
LaPerriere et al. 1994; Pema et al. 1997).Yet,research has once again shown that the
complexity of these relationships is far greater than one might have expected. For
example, cortisol does not always have an immunosuppressive effect (McEwen
et a!. 1997).Opioids do not always have an irnrnunoenhancing effect (Risdahl et
1998).And physical training does not necessarily lead to an attenuated cortisol
(Chennaoui ct aI. 2002; Droste et al. 2003) or catechotarnine (Peronnet and Szabo
1993) response to psychosocial stressors. Nevertheless, the hypothesis that part
of the efTectiveness of physical activity for reducing mortality from cardiovascular
disease and cancer is due to its effects on stress rnechdnisms remains viable and
certainly warrants additional research. A prominent example is a series of studies
showing that pl~ysicalactivity reduces anxiety and depression, improves quality of
life, and enhances immunocompetence i n individuals suffering from HIV
(LaPerriere et al. 1990; Rojas et al. 2003; Stringer e t al. 1998).
Physical activity: why we do or don-
a hnitarnental question concerning many health behaviours-and
physicrrl activity
is no different-is why people do or do not participate. If physical activity is so
'good for you', yet a clear majority of the adult population fail to meet current
guidelines of healthy physical activity,' it is important to understand the key correlates
of an active lifestyle.
Key determinantslcorrelates
Researchers interested in factors associated with physical activity have typically
categorized such 'correlates' o r 'determinants' into personal or demographic,
psychological, social, and environmental factors ( S A s el a / . 2000;Trost er rll. 2002).
Personalldemographic correlates
There are consistent positive trends for leisure-time physical activity in adults to be
associated with rnale gender and higher levels of e d u c ~ t i o nand socio-cconomic
status, but negatively associated with non-White echrlicity a n d age (Trost at al.
2003, with s i d a r mends in youth. Such gender differences are highly reproducible
and one of the most consistent findings in the literature. Pror~lotingphysical activity
in girls seems a particular challenge, although trials with adults suggest that more
women than men show interest in takrng part (Mutrie et (11.2002).
Psychological correlates
Psychological correlates of physical activity have been studied quite extensively.
There are two main types of studies: those using descriptive approaches whereby
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Typ~cally,guidelines for ~ d u l t sare to parricipate in 30 r~linutesof moderate intensify physical
activity on mos: (,5) days of the wzck, that is 150 min/wet.k (Departr~lentof H e a l t h 2004; Pate
et dl. 1995).
(
155
156
1
STUART J.H. BIDDLE AND PANTELEIMON EKKEKAKIS
psychologicaI variables are assessed alongside physical activity and those that use a
theoreclcal model. The latter enable us to build knowledge and understanding of
how and why people might be motivated or not ('amotivated') to adopt and/or
maintain a physically active lifestyle. Descriptive studies can be helpful in developing
more explanatory research designs.
O n e intuitively obvious motive is enjoyment. Those who are active tend to
report higher levels of enjoyment than those who participate less. However, this
may mask a number of issues. First, enjoyment can cover many things. Some may
report enjoyment because of the social aspects of participating, others for reasons of
positive well-being. In addition, research suggests that people exercise less for
intrinsic fun,but more for the satisfaction in meeting valued goals, such as weight
control, feeling better, or social connectedness (Chatzisarantis et al. 2003).
The development of exercise psychology as a thriving research field has led to
the proliferation of theories borrowed from other areas of psychology (Biddlr: and
Mutrie 2001). In particular, theories tested in social and health psychology have
been utilized.To help make sense of the different approaches, it is useful to view
theories as falling into four categories-There are theories focused on: (1) belie6 and
attitudes; (2) perceptionr of competence; (3),perceptiorls of control; and (4) decisionmaking processes.Nthough these &visions are not always clear-cut, they may help
readers better organize the field piddle and Nigg 2000).
BelieUattitude theories test the links between belie&,attitudes, intentions, and
physical activity, such as the theory o € planned behaviuur. Evidence shows that
intentions are predicted best by attitudes and perceived behavloural control, and
rather less so by subjective (social) norms (Hagger et a). 2002). However, research
tends to show that intentions are far from perfect predictors of behaviour, and one
could argue that greater emphasis is needed on how to translate intentions into
behaviour. Competence-based theories focus on perceptions of competence and
confidence as a prime driver of behaviour, such as in self-efficacy approaches
(Bandura 1997; McAuley and Blissmer 2000). Early attempts in exercise psychology
favoured theories of perceived control, such as locus of control (Rotter 1966).
These yielded small effects or were inadequately tested so researchers searched for
other control-related constructs piddle 1999;Biddlc and Mutrie 2001). O n e that
has been popular is the self-determination theory advocated by Deci, Ryan, and
colleagues (Deci and Flaste 1995; Deci and Ryan 1985; Ryan and Deci 2000~1,b;
Wdhams et al. 2000) and applied to physical activity by others (Chatzisarantis ~r al.
2003). Research shows that motivation for physical activity is likely to be more
robust lf it involves greater choice and self-deterninatioc rather than external control.
In addition, such a n approach is likely to lead to feelings of higher well-being.
Finally, decision-making theories have recently been favoured, and the transtheoreticd model (TTM) of behaviour change has grown in popularity (Marshall and
Biddle 200 1). The TTM was developed as a comprehensive model of behaviour
;i,,lllse 2nd was irlitiauy lpplltd to smoking cessation ( P r o c h ~ s k2nd
~ DiClcrnrnrc
cognitive, bzhavioural. and cemporal aspects of changing
>,ha~iour.The TT1M appiied to physlcal activity zor~siscsof the stages of change,
[lie p r o i e s x s ot'chulge. decisional balance (weighing up the pros and cons of
r l l ~ r l y e jand
,
self-efficaq.The stage of change is the time di~.nensionalong which
><]:~t.io
ur change occurs. The stdges are:
1 & ) 5 1 )It
. incorporatvs
+
Crecontemplation:no incentinn to start physical jCtivitv on a regular basis;
+
ion templation: in tending to start physical ~ i t i c - i t vo n
within the n t s t h months;
4
3
regular b ~ s i s usuaIly
,
p e p r a t i o n : immediate intention (within the next 30 days) and corrmitment to
i h ~ n g - e(sometimes along with small behavioural c hangts. such as obtaining
membership a t a fitness club) ;
+ ncrion: engaging in regular physical activity but for less than 6 months;
maintenance: engaging in regular physical activity for some time (more than
h months).
The processes of change are the strategies used to progress along the stagrs of
sh~nge.Theprocesses are dvided into cogmtive ( d h n g ) and behaviounl strategies.
For example, people might seek information on physical activlty and mood
enhancement (cognitive strategy) or post a note on the refrigerator door to remind
them to walk that day (behavioural strategy).We found that both types of straregizs
tend to be used throughout the change cycle (Marshall and B ~ d d 2001),
e
probably
due to individu~lpreferences.
Social and environmental correlates
Social support appears to be associated with physical activity 111 ~ciultsand youth.
Troft et d.'s (2002)reviexv suggested that social support &om friends/peers and f d v /
spouse was particulnrly important. In addition, the influence of one's GP (family
physician) plays a role. particularly for adults. as may the teacher or trainer in group
exercise wrsions.The 'motivational climate' created by such 3 leader m d y be vital in
detrrminlng 1vhztht.r people return for future sessions (Ntuurnanis and BiJdle
1999). Evidence suggests that the most positive climate wili be when the exercise
leader encouragt-s cooperation and reward5 effort over compar~tiveperformance.
The ~nfluenctof school settings and local me& may also help or hindcr activity.
For example, physical activity may be Illore likely in a school that encourages staff
and pupils to be active ~ n has
d a ' h e ~ l t h yschool' policy 2nd positive adult role
models. although many of rhrw likely influences lack robust supporting data. In
~ddition.i t is not clear to 11 hat extent the social settins influetlc-es positive mood
during o r afrer exerciw.
Environmrnr,~Icorrelates o f phvsical nstivits: h a w on]): bcen studied q u i t e
recentlv.Tr05t c~ t-rl.'s (2002) revre\% showed that 11 new- envrrolln~c.ntalvariables
158
/
STUART J.H. BlDDLE AND PANTELEIMON EKKEKAKIS
had been studied since a review of correlates published in 1999.There was weak or
inixed support for an association of most variables wirh physical activity. A recent
review of environmental correlates of walking in adults (Owen et al. 2004) found
18 studies. From these, it was concluded that walking was associated with aesthetic
attributes; convenience of facihties. such as trails; accessibility of destinations, such
as shops: and perceptions of tr&c and busy roads. However, the authors concluded
that the current evidence is 'promising, although at this stage limited' (p. 73). I t is
likely that facilities, incluhng open spaces and parks, are only part of a solution to
increase physical activity levels. 0 ther [actors include previous experiences of
physical activity and current level of fitness.
Interventions: what works?
The behavioural epidemiological b e w o r k suggests that interventions should follow horn the identification of correlates or determinants. One reason is chat effective interventions are the result of manipulating an J changing the antecedent of
behaviour as a precursor to actual behaviour change. This is illustrated in Fig. 6.2.
Interventions, however, can occur at several levels, incluhng the individual, group,
and community. Interventions at societal or national level can also be identified,
such as governmental policy initiatives (Bull et al. 2004).
Individual-level interventions typically involve advice-giving, such as by your
family doctor (GP), or through counselling for be haviour change. These strategies
might be based on theTTM with the aim to 'tailor'strategies and advice to fit the
individual's stage of decision-making. For example, it would seem unnecessary to
give much educational information about the benefits of physical activity to those
loolung to move from the action to the mintenance stage, whereas such a strategy
'A
Physical activity
be haviour
-
Sh ort-ad
medlurntr rrn
oucsonlcs,
e.g. body
T
Modifiable
drtrrminana
Longcrterm health
outcoma.
e.g. reduced
risk of
CHD,
composirion,
diabetes,
fceling
of well-being
better mental
he~lth
Fig. 6.2 A conceptual framework showing links between an intervent~on,determ~nants/correlates,
and phys~calact~vitybehaviours and outcomes. CHD = Coronary heart disease. (Adapted from
Kahn et at. 2002.)
k-;..: ,o n:o7:rnC.. ,I 2 7 : - a : ~ ! ; r ~ c ~ , p l ~ ro
f ~ ri o n t r m p l ~ t iSonlrclmes
~~.
it is
jljlble KO ~ k ! i ~S- ~
L :~ tr..Ccj
C, ,~
i:i:;::er~.-e;ltion in j n d l Sroups.
i
p L , p ~ l , ~irlterventivn
r
c c r r i n ~is t h ~ of
t pr1ril;lrv health c n x (PHC). Giyrn the
inlportnncc attached to ~ c l ~ - i kcnl
c e hr,llth care profession.lls. and GPs jn p a r ~ i ~ ~ l . ! ~ ,
, l j Lt-t.11a5 t h e r e g ~ i ~ l r i t.\x-jrh
) : n-hrch many visi: r h e i r PHC f ~ r i l ~it tseems
~,
~ p p r o ~ r i ~sttting
tt'
in xvh!z?. co test the t.ffectrventsss of inciii-idually oriented
courlst.lling ~pproacht.5.
There are Izssons to be l e a r ~ t . 4Som studies in prim~rycare thar halve focused o n
i;;lproving heilldl behal~iourin gsnzral and not J ust physicd ,~ctlvl?. For example,
S ~ ~ F pI[ dOl . ~(1999) report-.c! on a larse-scale trial of t h e us? of b e h a v i o u r ~ l l ~
orltntcd counselling (or primarl: i J r e p ~ t i e n t sa t increased risk of coronary heart
Jlsease. The ~ n ~ e r v e n t i ogroup
n
received counselling from the practice nurse who
llad been trained in an approach b ~ s z don cilz TThT. At both 4 and 12 months, the
inrzrl-ention group. in comparison t o che control group. h ~ ad F3~iour;lbItreduction
i n cigarette smoking, reduction in fat intakt. ~ n increassd
d
physical activlr);.
TIIIIFs t ~ l d ydemonstrated t h ~ phvsicul
t
activity, and other h e ~ l t hbehaviours, can be
influenced by a counselling approach in the primary care setting. B r n e t i c i d
changes in physical activity h a w a130 been notrd in a similar trial i n Nexv Zedand
(Elley ei L ~2003).
l.
Physical ~ctivityof older adults in Finland has also been shown
ro be scrondy xsocl;-ltt.d with opportunist~cadvice slyen by health care professionals
(tjirk-ensalo ct nl. 2003).
Project PACE (physicj,ln-baszd asssssmcn: and counselling f o r exercise), irl t h e
USA. has also used the TTM t n dcsign short interventions deljvered by GPs
(Pdcrrck et ai. 1994).The i n t r r v e n r ~ o nconsisted of brief (3-5 minutes) counst.lling
with each p ~ t i r n where
t
pros and cons, self-e!tic.~cy.2nd likt.1)- processes (?trare_~ies)
might be .~sscsszdand discussed. T h e counselling focuseJ o n he benetits and
barriers to increasing ;liti~ity,self'-eCiic;1cj-,21ld gaining ,:ncial support <or increasing
actix-ltv. The i cr~tcgierdiffered dzpending or1 the stage of t.s<rcise behaviour of
each patient; thus the inter\-ention n-,IS
stage-n~atched.Phvsici,lns themselves find
thc PACE tools acceptable (Long c.t (11. 1 996) a n d ,I ra~ldamized~ n n t m l l e dtrid
s ho\c-cd t h ; ~ rt ! ~ u PACE i n r e r ~ ~ r ~ t i did
o n s incrt.,ljc p hysic~l, ~ c t i v i t yparticularly
.
kvnlking ( C ~ l i et
~ sdl. 199(1j.
T\vo major r r v i ~ = \of
~ sintt.rvrntions aimed ~t PHC or relate'! wttings Jre now
available. Riddoch ct ill. (1908) iozated 35 papers from t h e UK.Tlley concluded
that ' t h e ~n~joritqr
of studlrs report sonle h r m of improvtr~lentin sither ph)*sical
acticiry or related measures. Hen-t-ever. the size of rht. effect ~s generallv small, and
there is n o redl consistency acroqj studies' (p.23).
Althotlgh tlot restricted to prim;lry health curel Simons-hIorto t l er a!. (19481, in
their review of interventions in he;llrh cure settings, co tlcluded thar 'interventions
in health care sertinss can incrrnst. physical a c t i v i ~for both prinlar). ~ n secondary
d
prcvrntion. Long-~crnl~ i 5 i r arc:
i more likely wlth cuntirlfiing intervention and
]ikt!::.
4
3
LO
be
180
(
STUART J.H BlDDLE AND PAkTELEIMON EKKEKAKIS
multiple intervention components such as supervised exercise, provision of
equipment, and behavioral approaches' (p. 4 13).
Kahn el al. (2002) also reviewed w h a t they called 'individually adapted'
programmes. The interventions were often delivered by people through outlets
such as phone or mail. Reviewing 18 such studies, they concluded that there was
strong evidence for effectiveness and good ap~licabllityacross &verse settings and
populations. They located some evidence for econornk effectiveness but warned
that successfd interventions of this type require careful planning, well-trained s t a ,
and adequate resources.
Perhaps somewhat surprisingly given their p r d e in the media, personal trainers.
have been poorly studied as a motivational tool.This m y be due to their probably
small influence at the level of
health. Few can afford such intense interventions and they remain a marginal strategy for population health gains.
Sociaknvironmental interventions
Ecological models of health suggest that behaviour i s determined by multiple
influences, including individual,social, and environmental factors (S&s and Owen
2002).To date, most interventions target the individual or social (e.g. community
walking groups) level. However, more recently, interest has grown in the potential
of eKective interventions at the level of the environment (Owen et aE. 2000). Sallis
et a!. (1998) suggest chat environmental interventions might include those aimed
at both the natural and consrructed environment. The former might include
providing additional indoor facilities for physical activity in places where the
weather may preclude or inhibit participation outside, or the lighting ofwalking
or ski paths in the winter. Construcred environment factors might include interventions aimed at the transport infrastructure, suburban environments for waking,
the workplace, or specialized f~cllities.
One of the most successful environmental interventions is the placing of signs
in public places to encourage stair climbing (Kahn e t al. 2002). O n e example is
the study by Blarney et al. (1995) i n which they aimed to discover if Scottish
commuters would respond to motivational signs eilcouraging them to 'Stay
healthy, save time, use the stairs'.The s i p s were placed in a Glasgow city centre
underground station where stairs (30 steps) and escalators were adjacent. Eight
observation weeks were split into four stages: a 1-week baseline; a 3-week period
when t h e sign was present; a 2-week period inlnlediately after t h e sign was
removed; and two I-week follow-ups, during the fourth and twelfth weeks after
the intervention. Observers recorded the number of adults using the escalators and
stairs and categorized them by gendzr.Those carrying luggage or with pushchairs
were excluded. A comparisorl was made between the baseline week stair use and
each of the seven subsequent observation weeks.
n
Baseline
Poster
12. Weeks
Fig. 6.3 Sta~rclimbing before
(baseline), durrng (poster).
and after ( I 2 weeks) a poster
~nterventionenc~uragingstair
use In favour of escalator use
(data from Blarney et at. 1995j.
S t i r use during the I -week baseline period was around 8%.This increased to the
order of 15-17% during the 3 weeks that the sign was present (Fig. 6.3). Stair use
jigniflcantly increased after the signs were in place and continued to increase during the three intervention weeks.A sudden decrease in stair use occurred once the
sign was removed. At the 12-week follow-up, stair use remained significantly
higher than at baseline. There is, however, an obvious downward trend suggesting a
possible eventual return to baseline 1evels.The results do show, however, that
a motivational sign positively influenced stair use, and similar studies have shown
supportive findings (Kerr et a/. 2001).
Future directions for research
Great progress has been made in the past few years in the field of exercise psychology.
However, inevitably there remain a number of significant research issues that
require attention. Thzsc include the following.
1 Larger and better desiped trials are required to investigate the effects of physical
activiq- on various inhces of psychologicd well-being.
3 There must be continued efforts to improve on the methodologies adopted
for such trials, including controlling for expectancy effects and other 1ikt.l~
influencing factors.
3 Further efforts are required to delineate likely mechanisms of thc 'feel good
effcct' of physical activity and integrating psychoIogica1 with somatic-based
mechanisms.
4 More evidence is required on the effects of physical activity on the psychological
well-being of children and adolescents.
5 More needs to be known about whether there is a dose-response reIationship
between physicid activity and psychologicd well-being. For example, the relationship between intensity of exercise and psychological effects needs further
exploration, and other characteristics of exercise, such as type. frequency, and
duration, are also understuhed.
6 Research needs to advance undetstanding of how physical activity-induced
changes can enhance our ability to combat harmful effects of psychosocial
stress.
7 Research must continue to study the diverse individual differences reported
in psychological responses to exercise.
8 Aspects of well-being, such as health-related quality of lik, happiness, and
optimism, have been understudied by exercise psychologists.
9 Exercise psychology has been dominated by research concerning correlates of
participation and needs to devote more energies to the study of interventions
concerning participation.
10 Less is known about environmental correlates of physical activity and how
they might interact with other potentially influencing factors, such as socioeconomic status or physical fitness.
1 2 Interventions need wider evaluation, such as in respect to cost-effectiveness.
Summary and conclusions
Physical activity is a significant health behaviour requiring serious research and
public policy attention. Lack of physical activity has major public health consequences with huge personal, societal, and economic costs (McGinnis 1992).
However, another focus is to show that physical activity has many health benefitsin other words, it is health-enhLrrlritzg as well as disease-preventing. In a book
on well-being it is important to recogmze this. As a result, in t h s chapter, we have
outlined the important psychological coilsequences of physical activity, what
factors might be associated with physical activity participation, and how physical
activity levels can be changed. Emphasis needs to continue to be placed on the
importance of p hysicdy active lifestyles for the health and well-being of society.
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Youngstedt, S.D., O'Connor, PI., and Dishman, R.K. (1997). The effects of acute exercise on
sleep: 3 quantitative synthesis. Sleep 20,203-14.
Stuart J.H. B~ddleis professor 06 exercise and sport psychology and head of the School of Sport
and Exercrse Sciences at Loughborough Univers~ty,UK. Stuart is the past pres~dentof the
European Federation of Sport Psychology, founding editor of Psychology of Spofr and Exercise,
and author of a number of books in the field.
Pantele~monEkkekak~sIS an ass~stan:professor of exercise psychology in the De~;ls:ment of
Health and Human Pyrformance at Iowa State University, USA. His research examrnes affective
responses to phys~calact~vity,lnc!uding :he tra~t,social-cognitive, and physroloaic?l factors that
influence them and :he ~m~lrcatrons
of these responses for w l o v ~ e r land
t
adherenc~.
The Science of
Well-Being
Edited by
Felicia A.Huppert
Department of Psychiatry
University of Cambridge
Nick Baylis
Department of Social and Deveiopmental Psychology
University of Cambridge
and
Barry Keverne
Department of Zoology
University of Cambridge
Contributions originating from
Philosophical Transactions of
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