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 of the 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 poli- ticians 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 d Blair 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 on 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~s local primary c x e health centre who not only smoked (in his consulting room!), but recon-r-

mended that all one reallv needed in respect of p h y ~ l c a l activity was 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 rgu l~r , moderate intensity physical activity on most davs of cht. week (Dep~rtmerit of Health 2004; Department of' Health and Human Serviczs 2nd Centers for Disease Control and prevention 1996; Pate et a!. 1995). In addition, rccunin~end~~ions can 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 I -

f eel-good f ~ c tor'-the psychological benefits that pcoplc derive from physical ~ c t l v i q . Our current undrrscandlng of the mcihanisrns underlying the beneficial effects oiphysical activiv is presented, challrn;ing sonlr widely held views. A brief

142 1 STUART J.H. BIDDLE AND PANTELEIMON EKKEKAKIS

exarnination of ~ h z hctors underlying why some people are physically nctive while others are not is follow-ed by a section on successful interventions a t both an indi- vidual 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 body 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 in 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 at 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

The five-phase behavioural epidenliology framework advocated by Sallis and Owen (1 999) is a useful way of viewing various processes in the understanding of physical activity and healrh. Behavioural epidemiology cor~siden the 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~rnecvork has five main phases.

1 To establish t l ie link b e t w c e n plrysiial nctivity at ld 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/ i fykysical nctiviiy.This remains a

problematic area. Large-scale sun-erllanae of population trends i ~ l e v i tably 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-BEll jG 1 143

pcdon~etrrs. are usrful E u t do no t necessarily give all of the inf'ornlation rcquircd, such as in rewiq- or rype of actimty or the setting in arhich jctiviv

took place. Un td we have berrer meaures of thc bsh~biour itself-i.r. phx,sical aztivit)l-the field will mug$ to progress in man): respects.

3 'A, idc~~rrq j~ fac tors that are ~~ssociated with diJ;rc~t ICI~CIS qf p hysiccll dctivity. Given the

evidence supporting the beneficin1 effects of physicdl dctivity on health, i t 15

tr-rlportant to identify f ~ c t o r s t h ~ r might be associated with the adoption 2nd malntsnance of the beha~iour.This area is referred to as the study ofLcorrelaces'

or 'determinants' of physical aztivity.The term correlater is now preferred in order to avnid the arsunlption oCcausal links. much of the evidence a t this stage is not able 10 support causahty.

4 771 evaluatr in t t . r~~ent ions deskned to promofr ph~lsicrll activity. 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 TI trirnslateJti,ldin~s from 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~vincing evidence, but may include a monitoring and evduatiun element to test the eficacy of such an i~ltervention before refining future interventions-The whole process then becomes iterative. Drawing on the behaviourd epidemiology framework, this chapter will consider the psychologic~l benetits 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 e 4).

The feel-good factor: what psychological benefits do people derive from physical activity?

The ps);chological effects asso~.iared with physical ~ctiviry have been the topic of numerous scientific studies, conducted m ~ i n l y since 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 ~ s yalt -fie1 ,?ood " ' (Fox 1999: p. 4 13. it;ll~ss in the origind). How-ever.

although the conceptual and rnethodologjc~l soph~stication of the studies has irlcre~sed over the years. not all reviewers hare rt.,~chcd a sinlilarly definitive con-

clusion. Skeptics have argued that. in many CJsCs. . ; t~ten~rnts about the psychological h~rlefits of physical activiry serin to '~nticipate mther than reflect the accumulation

of strong evidence' (Salmon 200 1, p. 36).

144 1 STUART J.H. alDDLE A K D DANTELEIMON EKKEKAKS

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 L 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 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 caus~I link between physica1 activity and reduced clinically defined depression. This is the first time

such a statemerit has been made.' In contrast, Lawlor and Hopker (200 1, p. 1) found that 'the effectiveness of exercise in reducing symptoms of depressiorl cannot be

determined because of a lack of good 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 that , nlthough, if taken

together, the extant studies seem to suggest that regular physical activity can reduce 1 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 1 i

n~odality for 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. pharmaco-

'

and ~sychothcr~py) and 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 sub- stantinl 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 l participation in

physical activity (e.g. for months or years) and those associated with sin+ bouts of activity.

Psychological effects of habitual physical activity

The 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 ohe l l -b r ing be tween groups differing in

PHYStCALLY ACTIVE LIFESTYLES AND WELL-BEING 1 145

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 i ~ n in anxiety Landers and Petruzzello 7994; O'Connor et a1 2001); Petruzzello et a/. 1991; Taylor 2000

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - - - , , , .. ,

Reduction in depression . . . . . . . . . . . . .

Brosse etal. 2002; Craft and Landers 1998: Mutr~e 2000: OrNeal eta/, 2000 , - . . . . . . . . . . . .

improved mood slates . . . . . . . . .

Arent etal. 2000; Biddle 2000 . . . . . . . . . . . - - , , ,

Enhanced health-related quality of Serger 2004; Berger and Mot1 2001. Re~esk! et a/. 1996. Releskr and life in the elderly and various pallent Mlhalka 2001 populations . ,

~mproved-physical and general Fox 2000a. 6: Sonstroem 1997 sell-worth

. , - - - , , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

lrnproved deep . . . . . . . . . . . . . . . . . . . . . ,- - . . . . . . . . . . . . . . . . .

Kubitz et at. 1996. Youngstedt 2000; Youngstedt et a/. 1997

Reduced reacttv~ly to psychosoc~al Oishman and Jackson 2000. Sothmann et a/. 1996 stressors

... ... . . . . . ...

lmprwed cogn~tive funct~on ~n all Colcombe and Krarner 2003; Etnier et al 1997 populations, includtng older adults

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 conceptud- izations of well-being as a multifaceted construct, the beneficial effects of physical activity are clearly not restricted to one outcome var~able but, instead, appear to be broad (Landers and Arent 200 1 ; McAuley and Katula 1 998). 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, i t 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.

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. self- reports of pain, physical seIf-efficacy, or satisfaction with physical function) are not necessarilv correlated and do n o t ncccssarily show the same time-course in

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 4

-3

that, based on the assumption that the 'active ingrebent' in physical activity inter-

ventions is the derobic training, used control groups involving nctn-aerobic activities, i such ar stretching and toning (strength training), have shown that reductions in

4 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 j or the participants' perception that they are actively taking control of their mental 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 1 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 the 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 1 147

initial 16-week treatment period, those rvho had been assigned to the exercise

g were more likely to have partly or fully recovered after 6 months than those 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 ~ersonal mastery 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'. I t has been shown that the expectation of psychological benefits 6om physical activity can sigrhcantly influ- ence the outcome (Desharnais et at. 1993). Babyak et al. (2000) also commented on 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 no 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~lducted in 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 well- designed 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

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 con- ceptual and methodological. One 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 y and 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 111ost zxpericnrially 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~lisms or 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~ts after 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

at 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 affect- ive changes not in terms of distinct states but rather in terms of broad hmensiom, such as those comprising the circumplex model o € f lect , 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 physio- logical steady state (i.e, a continuous rise in heart rate, oxygen uptake, and lactic acid concentration) and a multitude of physiologicd adjustments as t he 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 participa- tion (McAuley 199 1).

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. This 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 1 151

(-) mecnve 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-1 0' 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~vated unpleasant 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~ll lest {see text for additional information). (Plotted with data from Ekkekakis et at. (2000) and Hall et al. (2002).)

state anxiety (Bahrke and Morgan 3 978). Given that these three tasks had no sirmlar- ities 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 dec t ive 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 inir i~l ly, to high-activation pleasant state (e.g. energy, excitement) and

seden tq or relaxing activities leading to a low-activation pleasant state (t.g, calmness,

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 explana tian, 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 environ- me& 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 con-

sequences of its w-ell-established effects on physical fitness, including cardiorespirat- ory 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 ~ t is being sought is the mechanism by which i t 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 on the receiving neuron. Using

= L ' ~ S I C A L L Y ACTI'JE LIFESTYLES AND WEt i -6EI?:S 153 !

Ecruhnicjut.s such as microdi~iysis. which 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 ~ r i ~ of this 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~zcl h ~ l f of the 1970s and anecdotal reports of what became knon-n as the 'runner's high' phenomenon. Eager journalists (and some ~verzealous scienti5ts) hstily made the connec~ion that 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- no means yielded an

u r ~ e ~ ~ i i v o c a l answer (Hoffmann 1947). What 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 11 r-rlited. if any, centrd ~Eects and do not 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 s trenuous levels of exercise intensity. Furthermore, descending opioidergic neurons, o r i g i n ~ t ~ n g primarily in the periaqueductal grey and ~ctivated by h jsh levels of stress. c d n rzyulntc: the tlow of' bodily sensory cues

that ascend the spirlal surd ~ n d eI1tt.r cIzz brnin.

Finallv. J recently proposed I ~ y p o t h t ' s ~ ~ IS J ~ I I ~ ~ L I ~t esplairting the changing dective

responses to i n c r c a s i n ~ Irvels ~ 7 f phv~ic 'dl dc'tivlty irltensity (Ekkekakis 2003). According to this hypothrsis. atfictivt. rt.sponst.5 co ~ h y ~ i z a l activiw art: shaped by evolution and are the product of the ~.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~tive jnduzncr of chzse tcvo factors on affect is hypothes- ized 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 t i e s 2nd the latter gaining dor-rlinmce at high and near-rnaxinl,ll inttnsitics. This llyplschesis also has s o m e

irr~pIicutio r l s for irlterventions aimed a t con~rolJing sonlc u~ lp l easa l~ t responses to

p h ~ s i c d ~ctiviry. p~rticularly anlong bzginncr csrrciscrc.Accorhng to thc h-~pothtsi~. ~o~grtitivt. teil~mques, such as attentiond dissocintion, iog~lltive rekanling. 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 he 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 sympathetic- adrenorned~l lar~ (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 increas-

ing 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 relation- ship 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 end- products 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 phys- ically active and fit individuals buffer the harmful eflkcts of stress (Jonsdottir 2000;

PHYSICALLY ACTIVE LIFESTYLES AN0 WELL-BEING ( 155

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~ysical activity reduces anxiety and depression, improves quality of life, and enhances immunocompetence in 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 determi nantslcorrelates 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 educ~tion and socio-cconomic status, but negatively associated with non-White echrlicity and 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~loting physical 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

- , , , , , , - - - - - - - . . , . . ... , , , , . .. ,,,. . . , , , , , . . . . , , . . ... ... . , , . ,

Typ~cally, guidelines for ~ d u l t s are to parricipate in 30 r~linutes of moderate intensify physical activity on mos: (,5) days of the wzck, that is 150 min/wet.k (Departr~lent of H e a l t h 2004; Pate et dl. 1995).

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.

One 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) decision- making 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). One 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 an approach is likely to lead to feelings of higher well-being.

Finally, decision-making theories have recently been favoured, and the transtheor- eticd 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 lppl l td to smoking cessation ( P r o c h ~ s k ~ 2nd DiClcrnrnrc 1 &)51) . It incorporatvs cognitive, bzhavioural. and cemporal aspects of changing >,ha~iour. The TT1M appiied to physlcal activity zor~siscs of 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 j , and self-efficaq.The stage of change is the time di~.nension along which ><]:~t.io ur change occurs. The stdges are:

+ Crecontemplation: no incentinn to start physical jCtivitv on a regular basis;

+ ion templation: in tending to start physical ~ i t i c - i t v on 3 regular b ~ s i s , usuaIly

within the n t s t h months;

4 peprat ion: immediate intention (within the next 30 days) and corrmitment to

ih~ng-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.The processes 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 e 2001), probably due to individu~l preferences.

Social and environmental correlates

Social support appears to be associated with physical activity 111 ~ciults and 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 mdy be vital in

detrrminlng 1vhztht.r people return for future sessions (Ntuurnanis and BiJdle 1999). Evidence suggests tha t the most positive climate wili be when the exercise

leader encouragt-s cooperation and reward5 effort over compar~tive performance. The ~nfluenct of 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 d has a ' h e ~ l t h y school' policy 2nd positive adult role

models. although many of rhrw likely influences lack robust supporting data. In ~ddi t ion. i t is not clear to 11 hat extent the social settins influetlc-es positive mood during or afrer exerciw.

Environmrnr,~I correlates 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.ntal variables

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 fol- low horn the identification of correlates or determinants. One reason is chat effect-

ive 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

Longcr- term health 'A

Physical activity - be haviour

T

Modifiable drtrrminana

outcoma. e.g. reduced

risk of CHD,

diabetes,

better mental h e ~ l t h

Sh ort-ad

medlurn- tr rrn

oucsonlcs, e.g. body

composirion,

fceling of well-being

Fig. 6.2 A conceptual framework showing links between an intervent~on, determ~nants/correlates, and phys~cal act~vity behaviours and outcomes. CHD = Coronary heart disease. (Adapted from Kahn et at. 2002.)

]ikt!::. LO be k-;..: ,o n:o7:rnC .. ,I 2 7 : - a : ~ ! ; r ~ c ~ , p l ~ f ~ r ro i o n t r m p l ~ t i ~ ~ . Sonlrclmes it is 4 3

jljlble KO ~k!i~-~: S L ~ C ~ tr..Ccj i:i :;::er~.-e;ltion in j n d l Sroups. i , ,

p L , p ~ l , ~ r irlterventivn c c r r i n ~ is t h ~ t of pr1ril;lrv health c n x (PHC). Giyrn the inlportnncc attached to ~ c l ~ - i c e kcnl hr,llth care profession.lls. and GPs jn p a r ~ i ~ ~ l . ! ~ ,

, l j Lt-t.11 a5 t h e r e g ~ i ~ l r i t ) : .\x-jrh n-hrch many visi: rhe i r PHC f ~ r i l ~ t ~ , i t seems

~ p p r o ~ r i ~ t t ' sttting 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 . 4 Som studies in pr im~ry care thar halve focused o n

i;;lproving heilldl behal~iour in gsnzral and not J ust physicd ,~ctlvl?. For example,

S ~ ~ F I O ~ p [ d l . (1999) report-.c! on a larse-scale trial of t he us? of b e h a v i o u r ~ l l ~

orltntcd counselling (or primarl: i J r e p~t ients a t increased risk of coronary heart

Jlsease. The ~n~ervent ion group received counselling from the practice nurse who llad been trained in an approach b ~ s z d on cilz TThT. At both 4 and 12 months, the inrzrl-ention group. in comparison to che control group. h ~ d a F3~iour;lbIt reduction in cigarette smoking, reduction in fat intakt. ~ n d increassd physical activlr);.

TIIIIF s t~ ldy demonstrated t h ~ t phvsicul activity, and other h e ~ l t h behaviours, can be influenced by a counselling approach in the primary care setting. B rne 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 ~ l . 2003). Physical ~ctivity of older adults in Finland has also been shown ro be scrondy xsocl;-ltt.d with opportunist~c advice slyen by health care professionals (tjirk-ensalo ct n l . 2003).

Project PACE (physicj,ln-baszd asssssmcn: and counselling fo r exercise), irl t he USA. has a lso used the TTM tn dcsign short interventions deljvered by GPs (Pdcrrck et ai. 1994). The in t r rvenr~on consisted of brief (3-5 minutes) counst.lling with each p ~ t i r n t where pros and cons, self-e!tic.~cy. 2nd likt.1)- processes (?trare_~ies)

might be .~sscsszd and discussed. T h e counselling focuseJ on he benetits and

barriers to increasing ;liti~ity, self'-eCiic;1cj-, 21ld gaining ,:ncial support <or increasing actix-ltv. The i cr~tcgier differed 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) and ,I ra~ldamized ~ n n t m l l e d trid

s ho\c-cd t h ; ~ r t ! ~ u PACE i n r e r ~ ~ r ~ t i o n s did incrt.,ljc p hysic~l ,~ct iv i ty . particularly

kvnlking ( C ~ l i ~ s et dl. 199(1j.

T\vo major r r v i ~ = \ ~ s of intt.rvrntions aimed ~t PHC or relate'! wttings Jre now available. Riddoch ct ill. (1908) iozated 35 papers from the UK.Tlley concluded

that ' the ~n~joritqr of studlrs report sonle h r m of improvtr~lent in sither ph)*sical act ic iry or related measures. Hen-t-ever. the size of rht. effect ~s generallv small, and there is no redl consistency acroqj studies' (p. 23).

Althotlgh tlot restricted to prim;lry health curel Simons-hIorto t l er a!. (1 9481, 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 d secondary

prcvrntion. Long-~crnl ~ i 5 i r i arc: more likely wlth cuntirlfiing intervention and

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 a l . (2002) also reviewed what 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~licabllity across &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 interven- tions 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 of walking or ski paths in the winter. Construcred environment factors might include inter- ventions 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) in 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 the 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 Fig. 6.3 Sta~r climbing before (baseline), durrng (poster). and after ( I 2 weeks) a poster ~ntervention enc~uraging stair use In favour of escalator use

Baseline Poster 12. Weeks (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 dur-

ing 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 relation- ship 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 socio- economic 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 con- sequences with huge personal, societal, and economic costs (McGinnis 1992). However, another focus is to show that physical activity has many health benefits- in 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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Stuart J.H. B~ddle is 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~dent of 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~mon Ekkekak~s IS 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~cal act~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 l t and adherenc~.

The Science of Well-Being

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