Let's Get Physical - The impact of physical activity on wellbeing Mental Health Awareness Week 2013 - Mental Health Foundation
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Let’s Get Physical The impact of physical activity on wellbeing Mental Health Awareness Week 2013
Contents
04 Introduction
08 What is Wellbeing?
10 What is Physical Activity?
14 What impact does physical
activity have on wellbeing?
30 How does physical activity
impact on wellbeing?
34 Physical activity: getting
started and keeping up
the habit
44 Recomendations
45 Summary
46 References
Acknowledgements
This report was written by Dr Sarah
Edmunds, Hannah Biggs and Isabella
Goldie. Others who contributed to
this report include Dr Eva Cyhlarova,
Simon Lawton-Smith, Dr Andrew
McCulloch and Joanna Carson.
02 01
03
Introduction
It is impossible to read a newspaper or turn on
the television without hearing about the health
benefits of physical activity. The messages have Nietzsche
been clear that being active is important in terms
of managing weight and preventing chronic
illness (such as Type 2 diabetes).
“All truly great
thoughts are
conceived
while walking.”
Despite this growing interest in the role The primary aim of this report is to ask If we are going to change our attitude to Some people may prefer to participate
of physical activity in managing health that we reconsider the way that we physical activity then it needs to become in more regular and structured forms of
and reducing obesity, there has been view physical activity in the UK: from a natural and important part of our lives, physical activity such as going out for
relatively little corresponding change in a behaviour which we do because we not something else for us to find the a run or playing sport and these are, of
people’s activity levels. National surveys ‘have to’, ‘should do’ or ‘ought to do’ time to do. For some people this will course, great ways to enhance wellbeing
show that currently only one-third of the for our health, to something that we mean heading to the gym, but for others and mental health. There are so many
population meet UK physical activity feel improves our lives. In other words: it may include taking the stairs at the ways to become more active, indeed the
guidelines. In part, this may be a result to view physical activity ‘as a pleasure train station or department store (rather possibilities are limitless from gardening
of being told that we should increase and not a chore’. Furthermore we aim than the lift or escalator) and walking through to dancing or skateboarding.
our activity levels to ‘fix’ our health to make the case that physical activity or cycling to work or to the shops. For Deciding to become more active brings
deficits leaving us feeling negative is something that can protect mental children it will be more about play. As with it the potential to try lots of new
about ourselves and guilty when we do health. We are living in times where there our lives have become more sedentary, experiences and meet new people.
not do more. Within this report we aim seems so much to worry about. The many of us find we do not have to walk
to examine physical activity through a difficult financial climate, environmental much in our daily lives and even our jobs Regardless of what activity fits you best,
different lens and consider the role it challenges, welfare reform, terrorist have become more desk-based. Safety the evidence is clear that doing any
can play in enhancing our psychological threats, public health scares – the list is concerns about our children have also physical activity is better than doing
wellbeing and mental health. We aim endless and it can feel as though much meant that children do not go out to play none in terms of wellbeing and mental
to make the case that physical activity of life is outside of our individual control, as often as they did 20 or 30 years ago, health. So, getting started is the most
does not need to be a chore, but can leaving people feeling stressed and and gaming has become a key form of important thing. There will be many
instead be something that we do to unsure how to best to cope. However, entertainment and interaction for young reasons why we might want to put off
enhance wellbeing. Perhaps may even within this report we will make the case people. We now need to rethink our getting started; perhaps you have not
be something we might come to see as that taking steps to become more active relationship with physical activity and exercised in a while, do not know how
fun that we look forward to. is something that we personally can do find ways to do more each day. Many to get started or are worried about the
to help us deal with the stress brought forms of physical activity can be built into cost, but even small increases in levels
about by uncertainty and to feel positive our everyday lives and become part of of activity can make a real positive
about ourselves and our lives. our regular routine. In this way we can difference, bringing about a cycle of
regularly gain the wellbeing benefits of positive reinforcement and motivation
physical activity. to continue.
04 05
There is extensive research that shows that good social relationships and networks promote and are a protective factor for wellbeing and mental health. 06 07
What is Wellbeing?
The UK government recently defined wellbeing
as ‘a positive physical and social and mental
state’.1
This report focuses on mental wellbeing. The term ‘mental health problem’ is
Mental wellbeing includes factors often used to describe a difficulty with
such as individuals’ ability to develop our mental health that causes concern,
their potential, work productively and or interrupts our ability to go about our
creatively, build strong and positive daily lives in the way in which we would
relationships with others and contribute want. Mental illness refers to clinically
to their community’.2 p.1 It also involves identifiable illnesses or conditions that
areas of life such as feelings of affect our cognitive and emotional
satisfaction, optimism, self-esteem, having functioning. In recent years many
some control over one’s life, having a researchers have shifted from a focus on
purpose in life and a sense of belonging how to alleviate, or prevent, mental illness
and support.3 However, for someone and distress to a focus on promoting
to have sustainable wellbeing it is not mental wellbeing and positive mental
required that they feel good all of the time. health. This approach recognises that
Experiences of painful emotions such as
failure, disappointment and grief are part
mental wellbeing is more than simply the
absence of symptoms of a diagnosed Buddha
“To keep the body
of normal life. However, mental wellbeing mental illness. For example, a person may
is reduced when these emotions are very have a diagnosis of mental illness (e.g.
frequent, long lasting or very intense and bipolar disorder) but be living a fulfilling,
interfere with a person’s ability to function happy and productive life much of the
in good health is a
in their daily life. time.
One way to enhance our mental
wellbeing and protect our mental health
is through participating in physical activity.
duty…otherwise we
Physical activity has been shown to have
a strong and positive influence on mental
wellbeing and some mental illnesses.
In the remainder of the report the term
shall not be able to
‘wellbeing’ is used to mean ‘mental
wellbeing’.
keep our mind strong
and clear.”
08 09What is Physical Activity? Type
There are a huge number of different
types of physical activity. Walking is a
These different types of physical activity
can have a number of different physical
outcomes:
An all-encompassing definition of physical type of physical activity which many
people find practical and accessible; — Many types of physical activity
activity is ‘any bodily movement produced it can be done at low, moderate or
vigorous intensity. Other examples are
increase aerobic fitness, or stamina;
for example, running and cycling.
by skeletal muscles that requires energy dance, gardening, following keep fit
videos at home, badminton, martial arts
— Some types of physical activity
increase muscle strength; for
expenditure’.4 Here we explain some of the and rock climbing to name just a few. example, weight training, or using
resistance bands.
different aspects of physical activity which are — Some types of physical activity
increase flexibility and balance;
relevant to understanding the physical activity for example, yoga and stretching
exercises.
and wellbeing relationship. The different types of physical activity
are sometimes grouped under the
following headings:
— ‘Sport’ - structured and competitive
physical activity
— ‘Exercise’ - planned and purposive
physical activity to improve fitness,
health or performance
— ‘Play’ - unstructured physical activity,
done for fun and enjoyment
— ‘Daily physical activity’ – physical
activity which is done as part of one’s
Intensity daily routine.
Physical activity intensity varies along a
continuum from sedentary (physically Each of these four types of physical
inactive) to vigorous (high intensity activity can be done at both moderate
activity). and vigorous intensity depending on
what it is and how it is performed.
Moderate intensity physical activity sits
in-between sedentary and vigorous
intensity physical activity on the Dance, gardening,
continuum. It requires a reasonable
amount of effort and noticeably following keep fit
accelerates the heart rate and breathing
rate but you should be able to hold a videos at home,
conversation. Examples include brisk
walking, housework, gardening, dancing badminton, martial
and walking the dog.
arts and rock climbing
Vigorous intensity physical activity
requires a large amount of effort, causes are just a few examples
rapid breathing and a substantial
increase in heart rate, e.g. running, of physical activity.
aerobics, sports such as football or
hockey and walking or climbing briskly
up a hill. When taking part in vigorous
intensity physical activity it will be difficult
to talk without pausing for a breath every
few words.
10 11Danish Proverb
“Fresh air
impoverishes
the doctor.”
12 13What impact does physical 4.1. Positive Moods
The mood we are in has an impact
on how we experience day-to-day
A review of studies which have
investigated the impact of exercise
activity have on wellbeing? situations. As Thayer.5 p3 wrote:
“Even an unpleasant social situation
can be tolerable if our mood is positive.
interventions on positive moods has
shown that regular aerobic exercise
results in moderate increases in positive
Physical activity has a huge potential to enhance On the other hand, if we are in a bad moods.7 more specifically they found
wellbeing in our population. It is known that mood, an activity that usually is very
pleasant, one that otherwise gives
that exercise interventions increased
feelings of activation (how energised
even a short burst of 10 minutes brisk walking us great enjoyment, can be boring
and uninteresting. When our mood
a person feels) and pleasant feelings.
People who experienced lower energy
increases mental alertness, energy and positive is low, even the most positive events
become meaningless”.Therefore people
and more unpleasant feelings at
baseline showed greater increases in
mood states. generally try to regulate their moods
to be on the whole positive and use a
these factors. The review also found
that higher exercise frequency and
variety of strategies to do so. Example lower exercise intensity were associated
strategies are: eating a nice meal, with more pleasant feelings and higher
speaking to a good friend, watching activation. Overall the results indicated
comedy on TV, and going for a brisk that low intensity aerobic exercise, for
walk. 30–35 min, on 3–5 days per week for
10–12 weeks was optimal for improving
There is accumulating evidence that positive moods.
walking, and physical activity more
generally, can be an effective way to The impact of physical activity on day-
enhance positive moods. For example, to-day moods has been investigated
people with high levels of regular in more detail; people rated their mood
physical activity have been shown to immediately after periods of physical
have higher levels of positive emotions activity (e.g. going for a walk or doing
such as interest, excitement, enthusiasm housework) and periods of inactivity (e.g.
and alertness compared to people with reading a book or watching television).8
moderate and low levels of physical Participants reported feeling more
activity.6 content, more awake and calmer directly
after being physically active compared to
periods of inactivity. They also found that
the largest beneficial effect of physical
Participation in regular activity on mood (i.e. greatest change
in mood score) occurred when mood
physical activity can was initially low. An earlier study found
that walking for 10–15 minutes was
increase self-esteem and sufficient to have an impact on mood
states.9 Participants rated their energy
reduce stress and anxiety. levels and pleasant feelings as higher
Physical activity can help whilst walking compared to beforehand.
Following a 10–15 minute period of rest,
play a role in preventing participants’ moods returned towards
calmness and relaxation. These findings
mental health problems are encouraging as they suggest
physical activity could be used as a
and improve the quality of strategy to regulate mood during the
day; walking is practical to do in short
life of those experiencing bursts, available to most people and free.
it. For example, there is an Allowing people to choose their
preferred physical activity intensity
approximately 20–30% seems to lead to more favourable
changes in positive mood than imposed-
lower risk for depression intensity physical activity (e.g. walking at
one’s own pace rather than walking at
and dementia, for adults the pace set by an exercise instructor).10
participating in daily
physical activity.4
14 154.2 Stress Physical activity may offer an alternative
A recent survey published by the Mental approach to reducing or managing
Health Foundation 11 found that 59% stress. Cross-sectional studies on
of British adults felt their life was more adults who are employed have found
stressful than it was five years ago. 47% that highly active individuals tend to
of all survey respondents said they felt have lower stress rates compared
stressed every day and a further 24% to low active individuals.14, 15 Several
said they felt stressed every few days. mechanisms have been suggested
The Health and Social Care Information to explain how physical activity may
Centre 12 also recently published data reduce the harmful effects of stress.
which showed hospital admissions As summarised by Gerber and Puhse
for stress have risen by 7% in just 12 16
these include that physical activity
months, and the Health and Safety reduces arousal (i.e. enhances mood
Executive 13 recently published figures due to distraction from worries or
which indicate a rise in sick days due to biochemical changes) or increases
work-related stress. positive health behaviours during
periods of stress (i.e. decreased smoking
Stress causes the body to produce more and healthier eating habits). It has also
of the so-called ‘fight or flight’ chemicals been suggested that the higher levels
which prepare it for an emergency. of fitness brought about by physical
Adrenaline and noradrenaline raise activity result in a more efficient stress
blood pressure, and increase heart regulation (i.e. reduced secretion of
rate and perspiration. They can also hormones, lowered blood pressure)
reduce blood flow to the skin and or enhanced recovery from stress.
reduce stomach activity. The body These effects are referred to as stress-
produces cortisol which in turn causes buffering.
fat and sugar to be released into the
bloodstream (but also reduces the However, research testing the stress-
efficiency of the immune system). All buffering effect of physical activity
these changes are the body’s way of shows mixed results. A review of 31
making it easier to fight or run away. studies found 16 reported physical
Unfortunately these changes are less activity did have a stress-buffering
helpful for individuals stuck in a busy effect whereas 15 found it did not. 16
office or on an overcrowded train. They After considering the evidence from the
cannot fight and cannot run away. 31 studies in depth, the authors were
Because of this, they cannot use up confident to advertise physical activity Case study: Kim Since swapping the car for my bike I have
the chemicals their own bodies have as a stress-management strategy. I would like to highlight to people the noticed a marked improvement in my
produced to protect them. Over time Furthermore, they found that even enormous benefit of getting to work by foot energy levels and mood. I arrive at my
these chemicals and the changes they though physical activity may not always or bike! desk far more awake than if I’d been sat
produce can cause serious damage to reduce stress, there was no evidence
health. For example, people suffering that engaging in physical activity during in traffic, when I get home I have more
from stress may start to experience periods of high stress increased stress About a year ago my husband and I moved energy to pursue hobbies or go for a walk,
headaches, nausea and indigestion. levels, and that physical activity had house and ended up much closer to our whereas before I would fall onto the sofa
They may breathe more quickly, perspire direct health benefits. Further efforts are places of work. Since then we have both and hardly move until bed time! I have also
more, have palpitations or suffer from required to understand what dose and run or cycled to work. My husband has a made acquaintances from the number of
various aches and pains. Longer term intensity of physical activity is optimal for
stress can lead to feelings of strain, triggering stress-buffering effects and three mile journey and mine is seven miles. regular cyclists, postmen and dog walkers
worry, insomnia and exhaustion, and whether the effect is moderated by the Some people would consider this too far I see each morning and there is a real
increased risk for health problems such exercise environment. but it’s only a 40 minute cycle and, in rush community feeling among people who are
as heart attacks and strokes. hour traffic, the car journey can easily be travelling about without their cars in the
The Mental Health Foundation survey 11 half an hour. Luckily my office has a shower morning.
found that 18% of people found drinking so I can arrive at my desk fully refreshed.
alcohol helpful for stress and 10% found Another welcome side effect is that I tend
smoking helpful, while only 6% would to be eating healthily but am also able to
consider visiting a GP. This is worrying have extra snacks without worrying about
because in the long run alcohol and
smoking can make mental and physical putting on weight, as my cycling burns
health problems worse. hundreds of calories every day!
I hope more and more people will choose
to ditch their cars for their commutes...
if you are physically well, a journey of less
than two miles is often quicker by bike.
16
04 17
054.3 Self-esteem A review of 113 physical activity
Self-esteem is a key indicator of intervention studies 20 found three
psychological wellbeing. People with factors that influenced how much
high self-esteem tend to have high impact physical activity interventions
life satisfaction, resilience and greater have on a person’s self-esteem. The
achievement in education and work. On greatest gains in self-esteem occurred
the other hand low self-esteem tends to for people who initially had low self-
be associated with mental illness, anxiety esteem, those whose fitness increased
and hopelessness. during the intervention, and those who
were active on more days per week. All
Self-esteem can be defined as the types of physical activity were equally
sum of a person’s perceptions of their effective at increasing self-esteem.
competence in several areas of their Overall the researchers concluded
life; for example, academic, emotional, from their review that physical activity
social and physical areas.17 Of these interventions which aim to increase self-
areas the physical aspect of self-esteem esteem should include physical activity
(i.e. one’s competence regarding which is moderately demanding, and
stamina, strength, sport ability and body last for 12 weeks or more. As all types of
attractiveness) has been shown to have physical activity have been found to be
a strong influence on overall equally effective, people should choose
self-esteem.18 a type of physical activity based on what
they enjoy doing.
Physical activity is a behaviour which
has a strong influence on physical self- Another important factor to consider
esteem and a smaller but significant when using physical activity to enhance
influence on overall self-esteem. Studies self-esteem is that physical activity
have found that people who participate should provide opportunities to
in physical activity typically have greater experience feelings of accomplishment.
Case Study: Kelly physical and overall self-esteem. This Physical activity goals should be set
I’ve always been involved in sport and relationship has been found in children, so that they are achievable and result
exercise from a young age. Throughout all adolescents, young adults, adults and in feelings of success. For this to be
the endless doses of medication, group older people, and across both males and achieved the duration, type, intensity
females.19 and frequency of physical activity in any
therapy sessions, one-to-one chats with programme should be set in relation
professionals and general health related to an individual’s physical fitness and
interventions, exercise has been the one previous physical activity experience.
constant thing that has kept me feeling
sane and safe.
With all the ups and downs I’ve had in my
life, taking me through depression, alcohol
and drug abuse, anorexia, anxiety and
finally being diagnosed with bipolar in
2009, I’ve always found myself involved in
some form of exercise, whether it be playing
rugby, running or training in the gym. To
put it simply, exercise is the BEST form of Exercise really helps me to channel my
medication I have found to help me cope emotions and keep me focused. I’m
with mental illness. extremely grateful that I am able to exercise
to the extent I can, as mental illness can be
so utterly debilitating at times. From just
a bipolar point of view, if I’m feeling high,
exercise can help exhaust the nervous,
uncontrollable rush of energy I would
otherwise not know how to contain. If I’m
feeling low, the exercise can really enhance
my mood and alter my outlook on my day
as a whole.
18
04 19
054.4 Depression Researchers have also compared The majority of published trials which
Depression varies in severity from mild the effectiveness of physical activity have found a positive outcome for
to severe, and between 8% and 12% interventions with the effectiveness of physical activity in treating depression
of the British population experience medication and psychological therapy have used aerobic physical activity and
depression in any year.21 In recent years and found similar effects. Rimer et al.24 were supervised.26 Furthermore, all
prescription rates for antidepressant summarised the findings from three modes of physical activity and locations
medication have increased steeply. trials that compared exercise with (e.g. home or gym) were equally
However, antidepressants are not antidepressant medication, and reported effective, although it is noteworthy
equally effective for all people.22 and there was no significant difference in the here that outdoor locations were
many people are reluctant to take effect of the two treatment approaches not studied as these provide access
antidepressants for long periods, often on depression. They found six trials to sunlight and green open spaces.
due to their side effects, which can lead that compared exercise with cognitive Effective intervention programmes were
to non-compliance with medication or therapy and again the data showed no supervised but whether the supervisor
not seeking treatment. Psychological significant difference between the two was an exercise professional or from
therapies (e.g. cognitive behavioural interventions in terms of their impact some other professional background
therapy; CBT) have become more widely on depression. A further review of the did not have an impact on their
available but there are still waiting lists literature on exercise and depression effectiveness. Both group and individual
for free and low cost services. concluded that exercise is effective physical activity programmes were
when used independently and in found to be equally effective.
Physical activity can be an alternative combination with other treatments such
treatment approach for depression. as medication or CBT.26 Implications of the above studies
It can be used as a stand-alone are that meeting the recommended
treatment approach or in combination Researchers have also looked into public health guidelines for physical
with medication and/or psychological the question of what ‘dose’ of physical activity seems to offer greater benefits
therapy. It has very few side effects activity is most effective at alleviating compared to lower levels of physical
and does not have the stigma that the symptoms of depression. One activity. Individuals’ preferences about
some people perceive to be attached study compared four different ‘doses’ physical activity type (e.g. swimming,
to taking antidepressants or attending of aerobic physical activity and found dancing, football) can and should be
counselling. In addition physical activity a dose roughly equivalent to the public accommodated into physical activity
is available to all, has few costs attached health guidelines (see section 6) was programmes. Personal preferences
and is an empowering approach that can significantly more effective than a low of participants with regard to physical
support self-management. dose (less than public health guidelines) activity location and whether to be active
and a control condition in reducing in groups or individually should also
The evidence for the benefits of physical depression.27 A recent study compared be considered. Furthermore research
activity for depression is not universal different doses of physical activity for suggests that exercising at preferred
e.g. Chalder et al.23 but a recent review people whose depression had not intensity results in greater reductions in
of 30 randomised controlled trials 24 remitted after a course of antidepressant depression compared to exercising at
concluded that exercise improved medication.28 Again, a high dose of a prescribed intensity.29 In other words,
depressive symptoms in people with physical activity was more effective than when people are given choice and
a diagnosis of depression (including a low dose (28% and 15% remission control over the physical activity, they do
mild to severe clinical symptoms) respectively). report greater benefits to their mental
when compared with no treatment or health.
a control intervention (e.g. sedentary
social activity). A further review of
thirteen randomised trials looked the
effect of physical activity for people with
clinical depression only.25 The effect of
exercise on depression was significant
but weaker than in the above review
suggesting the effectiveness of physical Physical activity can be
activity as a treatment for depression
may vary according to the severity of the an alternative treatment
depression a person has.
approach for depression.
20 214.5 Anxiety A further review of 49 randomised 4.6 Dementia and Cognitive decline Cognitive decline
Anxiety symptoms vary from mild to controlled trials that have investigated in older people Researchers have investigated whether
severe. Feeling anxious is sometimes the effect of physical activity Improvements in healthcare have led to being physically active can reduce and
perfectly normal. However, people with interventions on anxiety in non-clinical increasing life expectancy and a growing even reverse cognitive decline which
generalised anxiety disorder find it hard and clinical populations found physical population of people over 65 years. occurs with aging in people without
to control their worries; their feelings activity significantly reduced anxiety Alongside this increase in life expectancy dementia. A review of 15 studies which
of anxiety are more constant and compared to no-treatment control has been a rise in the number of people had followed individuals over 1 to 12
often affect their daily life. Generalised groups.32 However, the majority of living with dementia and cognitive years found that being physically active
anxiety disorder affects about 1 in 20 the studies in this review included decline. The main symptom of dementia at the start of the study was a significant
adults in Britain.30 Other conditions participants with non-clinical levels of is memory loss; it is a progressive protective factor against developing
where anxiety is the main symptom anxiety. Analysis of the dose response disease which results in people cognitive decline during the follow up
include panic disorder, phobias and relationship between physical activity gradually becoming more impaired over period.39 People who participated in high
post-traumatic stress disorder. Anxiety and anxiety was limited by the fact that time. Despite encouraging research levels of physical activity at baseline
often occurs alongside depression, i.e. the majority of the physical activity developments, a cure for dementia has had a 38% lower risk of experiencing
people often experience both mental interventions reviewed has used the not yet been found. Cognitive decline cognitive decline than people who
health problems at the same time. same dose: aerobic exercise with also occurs with ageing in people who were sedentary. The protective effect
Treatments for anxiety include anxiolytic a frequency of 3–4 times per week. do not go on to develop dementia; of physical activity was similar (35%)
medication and psychological therapy. Further studies using a greater range for example, attention, memory and for people who participated in low to
Limitations to the use of medication and of physical activity types and intensities concentration decline and become moderate intensity physical activity
psychological therapy in the treatment are needed to understand this slower and less efficient. Although they compared to those who were sedentary.
of anxiety are similar to the limitations to relationship in more detail. are not as disabling as dementia, these The effect seemed to be stronger in
their use to treat depression. Also similar declines in cognitive functioning lead to women than in men.
to the treatment of depression, there is Less is known about the effect of decreased quality of life.
mounting evidence that physical activity exercise on specific severe types of However, although data from
is beneficial as a treatment for people anxiety, such as panic attacks, social Dementia observational cohort studies are
with both mild and severe (clinical) anxiety disorder, generalised anxiety Physical activity during the lifespan fairly strong with respect to physical
anxiety. disorder or post-traumatic stress seems to have a positive effect on activity reducing risk for cognitive
disorder. However, data do show cognition and a protective effect against decline, evidence from intervention
A review of 19 intervention studies, there are lower rates of clinical anxiety developing dementia.36 Evidence to trials is weaker. An expert panel
which had investigated the effect of amongst people who are active than date suggests that all types of physical recently concluded that although
physical activity on healthy adults, found people who are not 33 and intervention activity are equally beneficial. Higher there were some positive studies,
that increasing physical activity in this studies have shown exercise holds levels of physical activity seem to be there was insufficient evidence to
group resulted in reduced anxiety.31 promise for reducing symptoms of more protective than lower levels. It determine whether physical activity
Further analyses of these studies clinical anxiety. For example, one seems that physical activity needs to interventions improved cognition in
revealed that interventions were most study compared patients with various be performed at least twice a week older adults.40 Observational studies
effective when: participants engaged types of clinical anxiety who were and that three or more times a week tend to occur over longer time periods
in moderate or high intensity physical randomly assigned to CBT plus home- is probably more beneficial.37 The than intervention trials and the expert
activity; physical activity was supervised; based walking, or CBT plus additional impact of physical activity intensity is panel recommended that intervention
the intervention was delivered to education sessions.34 Patients in the less well understood. One study found studies lasting for one or more years
individuals (rather than group based); home-based walking group reported that the higher the intensity of physical should be run to see whether the results
and when participants were encouraged significantly greater reductions in activity the greater the protective effect; of long-term observational studies can
to continue exercising at a fitness centre anxiety, depression and stress following however, a more recent study found be replicated in these longer-duration
following the intervention (rather than at treatment compared to those receiving that moderate intensity physical activity intervention studies.
home). CBT without exercise. Several other had a protective effect, but very light
small scale studies have focused on intensity and vigorous intensity physical
a particular type of anxiety (e.g. panic activity did not.38
disorder or post-traumatic stress
disorder) and shown positive effects for For individuals who have developed
exercise in reducing anxiety symptoms dementia, physical activity has been
Physical activity during in these groups of patients.35 shown to be effective in delaying and
reducing the severity of symptoms.
the lifespan seems to For example, physical activity has been
have a positive effect on shown to improve cognition or slow its
deterioration, improve symptoms such
cognition and a protective as depression or agitation, and improve
physical functioning such as endurance,
effect against developing strength, balance, mobility, gait and
flexibility.36
dementia.
22 234.7 Physical activity and quality For people with severe mental health
of life for people with severe problems participating in physical
mental health problems activity may lead to improvements in
Physical activity has the potential to quality of life. A review of 16 studies
improve the quality of life of people with which included a physical activity
severe mental health problems, such intervention for people with severe
as schizophrenia and bipolar disorder, mental illness found physical activity
through improvements in physical can contribute to improved quality of life
and mental health. People with these through social interaction, meaningful
conditions have the same physical use of time, purposeful activity and
health needs as the general population, empowerment.42 Several studies have
but are more likely to be sedentary and focused specifically on people with
have high rates of obesity, confounded schizophrenia and a review of three
by the side effects of medication. such randomised controlled physical
Consequently, this group is at high activity interventions 43 found exercise
risk for chronic medical conditions improves negative symptoms of
associated with inactivity, such as schizophrenia compared to standard
cardiovascular disease, diabetes care. Yoga showed potential as a
and obesity.41 beneficial form of physical activity.
However, Bonsakseni and Lerdal 44
found no relationship between
physical activity and quality of life I currently go four days a week; on
for 18 hospitalised patients with Tuesday’s I do a sitting yoga class and the
severe mental illness. pensioners there really like it. It’s pretty easy
Physical activity levels in people with for me although everyone there does really
severe mental illness tend to be very well we are always happy when we leave.
low, and were described as hazardously On a Thursday it’s Tai Chi and I love it. Last
low following a recent survey.45 So, even Case Study: David week I even took the class in the teacher’s
small increases in physical activity could I have been attending Kingsgate, an activity absence which came very naturally to me
have important physical health benefits, centre, for nearly 10 years now and I don’t
as well as enhancing quality of life. after a decade of practise. I also play pool
know where I’d be without it. Kilburn Older every Friday which is very good for the spine
Voices (www.kove.org.uk) are also based and balance as you’re bending over to pot
there and I have appeared in their film about the balls.
wellbeing.
The centre is fantastic and I’ve made some
Ten years ago I had a nervous breakdown great friends there. The exercise really
and my doctor recommended the centre to helps with my general wellbeing, keeps
me and I’ve been going ever since. I’m very me in good spirits and I’m so grateful for
mobile and physically fit and, at the age of
Even small increases in 77 I definitely can’t complain!
what Mother Nature has given me – she’s
wonderful.
physical activity could
have important physical
health benefits, as well as
enhancing quality of life.
24 254.8 Negative effects of physical activity A challenging question in this area is
For the vast majority of people, physical how to distinguish healthy exercise
activity is beneficial for wellbeing and from exercise dependence. Seven
mental health, and these relationships diagnostic criteria have been suggested
have been described above. However, to assess exercise dependence: tolerance
physical activity can have a negative of increasing amounts of exercise;
effect for some individuals who withdrawal symptoms from not exercising;
participate in very high levels of physical lack of control over exercise; consistently
activity. doing more exercise than was intended;
spending a lot of time exercising; reduction
Overtraining can result in a range in other activities; and continuing to
of short-lived negative effects, such exercise despite physical, psychological
as fatigue, low mood and irritability. and interpersonal problems.48 The
Often this can be rectified by resting actual volume of exercise may be less
or changing exercise patterns, such as important than the motives underlying this
reducing intensity levels or altering the behaviour, and it has been suggested that
type of activity to one that uses different the likelihood of an addiction increases
muscle groups.46 However, overtraining for those who exercise with the goal
may reflect a more unhealthy of escaping unpleasant feelings 49 or
relationship with physical activity where transforming their appearance to improve
there is a shift from the person choosing self-esteem as compared to those who
to take part in physical activity as part of exercise with the goal of improving
a healthy lifestyle, to feeling compelled performance and fitness.
to take part even when the benefits are
outweighed by adverse consequences.47 However, the extent to which exercise
The problems that can emerge from dependence is an addictive behaviour
this compulsion include planning your in its own right or is secondary to other
life around exercise to the exclusion of disorders is a continuing debate.50 Eating
Case Study: Jamie other domains of daily life that previously disorders are the most common disorders
I was diagnosed with anxiety during a brought joy. to co-occur with exercise dependence,
difficult chapter in my life. I was drinking approximately 39–48% of people
heavily and the alcohol softened the anxiety suffering from an eating disorder also
suffer from exercise dependence, and
but when I allowed myself to soberly reflect there is strong evidence of a relationship
on my life, I was full of fear and experienced between exercise dependence and body
panic attacks. Due to my drinking I was not image concerns.51 An issue with this co-
eligible for any help and I convinced myself morbidity is that often only the eating
disorder is treated.52
that I didn’t need any. Four years after my
original diagnosis and the loss of my father
I attempted suicide and, while sitting in the
Accident & Emergency waiting room staring
down at a bandaged arm, I finally realised
The hardest part is taking those first few
steps, be it putting on a pair of running
Movement is medicine
myself. I was assigned a psychiatrist and
together we established that I had never
shoes or signing up to a sports club, but for creating change in
once you have done that you will never look
really faced anything. back. I am now running three times a week, a person’s physical,
I started running short distances which at
have signed up to run the High Wycombe emotional, and mental
marathon to raise money for the Mental
first were to distract me but I began to feel Health Foundation, and it is only 10 months states.
good when I added another half mile to my since I sat in that waiting room staring down
runs. It had been a long time since I had at my bandaged arm feeling completely
felt good without the intake of alcohol. The helpless.
anxiety was fading, and the more I pushed
myself the more I felt the depression lose I see no better way of doing this than with
its grip on me. Those short runs at the the easily accessible method that rewards
beginning of my recovery were to become you with endorphins, improves your
the foundations of who I am now. overall health and teaches you that you
do have control over your mind: exercise.
Use today as a time to achieve something
that challenges you, I have learnt that it
is the only rite of passage in to a brighter
tomorrow.
26 27There is accumulating evidence that walking, and physical activity more generally, can be an effective way to enhance positive moods. 028 029
How does physical activity 5.1 Physiological adaptations
Many people believe that the biological
explanation for experiencing enhanced
Despite there still being uncertainty as
to the biological reasons for enhanced
mood following exercise, there have
impact on wellbeing? mood and wellbeing following exercise is
that exercise causes the brain to release
endorphins. Endorphins are naturally
been recent advances in understanding
the impact of physical activity on overall
brain health. For example, it has been
The mechanisms underpinning the relationships produced chemicals which have similar shown that physical activity can improve
properties to heroin and morphine, brain plasticity, or the capacity of the
between physical activity, wellbeing and mental hence the term ‘endorphin high’ is brain to develop new neural pathways
health are complex and multifaceted. Physical sometimes used. In a recent review
paper Dishman and O’Connor 53 explain
and for new neurons to grow during
adulthood. This effect seems to be
activity influences numerous interconnected that this mechanism was first proposed
about 30 years ago, when research
particularly strong in the hippocampus
(an area of the brain involved in
systems. linked endorphins with disorders of
mood and personality. Further research
memory) and frontal cortex (involved in
movement, decision-making, problem
found changes in endorphin-receptors in solving, and planning). Increased brain
the brains of rats following exercise, and plasticity has been suggested as a
that in people endorphin levels increased mechanism by which physical activity
in the blood following exercise. However, enhances brain functioning, especially
no evidence was found for a direct link in later life, and protects against
between exercise-induced changes in neurodegenerative diseases, such as
mood and endorphin levels measured dementia. For an accessible and recent
in either the blood or the brain. The review of this area see Erickson et al.54
review concludes that the hypothesis
that endorphins are responsible for
the changes in moods during and after
exercise remains possible, but has been
perpetuated based on little evidence.
With developments in neuroscience
and increased understanding of how
the brain functions, it has become clear
that changes in states of mind (such
as the changes in mood that occur
following exercise) will involve complex
These systems act at: a interactions of many neural circuits
and the release and uptake of many
physiological level e.g. chemicals in the brain (e.g. acetylcholine
and dopamine).53 Advances in brain
influencing the release and imaging techniques are opening up new
avenues for exploration, and may soon
uptake of chemicals in the lead to a fuller understanding of the
brain and the development biological mechanisms underpinning
the relationship between exercise and
of new neural pathways; mood.
a psychological level
e.g. influencing feelings
of mastery; and a social
level e.g. influencing
social connections and
interpersonal relationships.
In this section we give a
brief overview of some key
mechanisms at each of
these three levels.
30 315.2 Improvements in sleep 5.3. Mastery experiences 5.4 Increased social interaction
The importance of sleep for At a psychological level, physical activity A further mechanism by which
mental wellbeing was highlighted can lead to greater feelings of mastery, physical activity has a positive impact
in a recent report by the Mental or the belief that one is able to influence on wellbeing and mental health is
Health Foundation.55 This report also his or her environment and bring about by providing opportunities for social
highlighted that up to one-third of the desired outcomes, which in turn leads contact and social interaction. Where
population may suffer from insomnia to greater wellbeing. For example, physical activity is done as part of a
(lack of sleep or poor quality sleep). completing an exercise session that group, or brings one into contact with
Insomnia can negatively affect mood, was previously thought impossible, or other people, there is an opportunity
energy and concentration levels, running a 5km race for the first time, for individuals to increase their social
relationships, and people’s ability to staymay enhance feelings of confidence and networks and make friends. There is
awake and function during the day. self-esteem. It has been suggested that extensive research that shows that
as exercisers become more confident good social relationships and networks
Physical activity may enhance sleep and gain mastery of their physical skills, promote and are a protective factor for
quality which in turn improves wellbeing. they may take this feeling of control
A recent survey collected objective and success into their everyday lives.59 Plato wellbeing and mental health.61
“The part can
physical activity data and responses to A controlled study with 19 women with This social relationship may come
questions on sleep from 3081 adults depression found that involvement in a from being part of a team (e.g. football,
and found that higher levels of physical 9-week exercise programme provided a rugby, volleyball) or taking part in an
activity were associated with fewer meaningful mastery experience through activity that requires more than one
never be well
reports of feeling overly sleepy during which confidence in their ability to person (salsa dancing, squash, fencing).
the day and less difficulty concentrating engage in a variety of coping responses It could also come from taking part in
when tired.56 was increased and level of depression physical activity that takes you to places
decreased.60 It has also been suggested where you meet others who are doing
Research with people who have that mastery experiences from exercise- the same physical activity, or have a
unless the
long-term difficulties with initiating related successes may counteract similar interest (dog walking, hill walking,
and maintaining sleep (chronic primary negative thinking styles of anxious paragliding).
insomnia) has found physical activity can individuals.35 Therefore it is suggested
be used as an intervention to enhance that physical activity interventions The wellbeing and mental health
whole is well.”
sleep quality and improve quality of life. emphasise opportunities for participants benefits of the social aspects of
A single session of 50 minutes moderate to experience mastery and success, and physical activity are applicable to all
intensity aerobic exercise was found to provide positive feedback. age groups throughout the life course.
reduce pre-sleep anxiety and improve They can be important in terms of
sleep in patients with chronic primary making friends, developing social skills
insomnia.57 A 6-month physical activity (such as negotiating, working as a
intervention (50 minutes moderate team, learning to deal with competition,
intensity exercise, 3 times per week) sharing etc.) and expanding social
resulted in improved sleep, greater networks. The social aspect can be of
quality of life and reduced negative a particular benefit to those who are
moods, such as tension, depression isolated, as building social relationships
and anger.58 can help people develop social skills
that they did not have before, which
can aid social inclusion by improving
people’s confidence and competence
in interacting with others. This can lead
to the development of friendships and
supportive peer relationships, which may
be particularly important for older people
given that about 3.8 million older people
in the UK live alone.
32 33Physical activity: getting started A little help from a friend
Social support for physical activity can
be very helpful for overcoming initial
Financially
When many people think about physical
activity they think of attending gyms or
and keeping up the habit apprehension about being active,
and it can also act as a motivator to
continue to be active. Having someone
sports that require equipment or kit that
can be expensive. Therefore, the belief
that being physically active is expensive
We know from national surveys that only 40% to accompany you to a first visit to can be prohibitive. However, there are
a new club or class, or when you are many types of physical activity that can
of men and 28% of women in the UK currently taking up a new activity for the first be virtually free, many of which can be
meet recommended physical activity guidelines time, can help overcome any fears
about trying something new. Having a
built into daily life. For example:
of moderate intensity activity for at least 150 friend with whom you exercise or who
encourages you to be active can add to
– Brisk walking to/from work or in lunch hour
– Outdoors gyms
minutes each week, which could be broken down the enjoyment of being active. So can
being a member of a club or an online
– Volunteering
– Football, rounders or Frisbee in the park
to 30 minutes five days a week.62 social network of people who are also
interested in the same form of physical
– Dancing at home
– Gardening, housework, walking the dog
activity or increasing their physical – Stair climbing
activity behaviour.
However, if you are interested in going
Fitting physical activity into your daily life to the gym or taking part in classes, local
Lack of time is a very common barrier councils or local authorities may have
to people taking up physical activity. schemes set up to offer discounts to
However, physical activity does not have access leisure facilities. Adult learning
to mean a two hour trip to a gym or other programmes through local councils
exercise facility. It can be incorporated often provide activities for a fraction of
into daily life by, for example, walking the price, as they run in terms and you
short trips rather than taking the car or buy a block of sessions.
6.1. Individuals The biggest gain in terms of health bus, walking up stairs rather than taking
Setting your own pace benefits from physical activity comes the lift or escalator. Some activities ‘Exercise on prescription’ schemes
One of the biggest barriers to being or from people who are inactive starting in the home, such as housework and are available in some areas. These are
becoming physically active for some to do some physical activity (even if this gardening, also count as moderate where GPs can refer patients to a free
people is the fear of failure. The thought is below the national physical activity intensity physical activity, depending exercise programme in the same way
of trying to incorporate 30 minutes of guidelines). So the most important on the intensity at which they are done. they refer patients for other forms of
physical activity into each day can be so thing is to get started at a level which Incorporating physical activity into one’s treatment, such as counselling. The
daunting to some people that they put feels comfortable and build up the day, rather than using an exercise facility, exercise programmes are generally run
it off and are not physically active at all. duration and intensity of physical activity has the added benefit of little financial by local gyms or exercise facilities. A
Organisations like the Royal College of gradually. For example, a short period cost. patient will receive an initial consultation
Psychiatrists recognise that the most (e.g. 10 minutes) of brisk walking each with an exercise professional, and a 10–
important thing is that people feel able day is one way to begin. Making physical activity accessible and 12 week exercise programme tailored to
to start being more physically active achievable for everyone their needs, plus continuing monitoring
regardless of the duration or intensity of Motivational theory and research has A common barrier for people being and support.
the physical activity in the first instance. shown that having choice and control physically active is a belief that it is not
over your physical activity (i.e. what type accessible financially, physically, or
of activity you do, how frequently and at geographically.
what intensity) is associated with greater
persistence and greater enjoyment of
the activity. In addition, feeling a sense
of competence as a result of physical
activity enhances motivation as does
feeling that physical activity offers the
Participation in physical
opportunity for meaningful relationships
with other people.
activity declines significantly
with age for both men and
women, and people in lower
socio-economic groups are
on average less active.
34 35Working with what you’ve got Body Image Geographical accessibility and Be active outdoors
Some people may also feel that physical Body image can act as a barrier to feeling safe Some research suggests that doing
activity is not accessible to them as participating in physical activity. People Other ways in which people may not physical activity in nature, i.e. an outdoor
they feel limited by a physical condition, who are anxious about how their find being physically active accessible ‘green’ environment, has greater positive
for example, asthma, heart conditions, body will look to others while they are is if they have to travel far to access effects on wellbeing compared to
diabetes or arthritis. However, it is widely exercising may avoid exercise as a facilities or services. This may have a physical activity in an indoor or outdoor
known that being physically active result. The fact that the body tends to be cost and time implication which may be built up ‘grey’ environment. A review
is important in helping people self- on show whilst exercising, e.g. through prohibitive. In addition, public transport of research found that compared
manage their condition and look after wearing tight fitting clothing, shorts, or networks may not be available, regular to exercising indoors, exercising in
their mental health. Guidance on how a swimming costume, heightens this or fit in with opening times of facilities natural environments was associated
to incorporate physical activity safely is anxiety. Anxiety about how others will or groups. Choosing to be physically with greater feelings of revitalisation
available from third sector organisations perceive one’s body is called ‘social active in your own neighbourhood can and positive engagement, decreases
dealing with specific physical conditions, physique anxiety’. In general greater be a solution to some of these barriers; in tension, confusion, anger, and
e.g. British Heart Foundation (www.bhf. social physique anxiety is associated however, not everyone may feel safe to depression, and increased energy.64
org.uk/heart-health/prevention/staying- with lower levels of physical activity. This do so, particularly in areas or high crime Greater satisfaction and enjoyment
active.aspx) and Diabetes UK (www. anxiety tends to be higher in women or after dark. It is possible to be active were reported following outdoor activity,
diabetes.org.uk/Guide-to-diabetes/ than in men and younger age groups.63 within the home (e.g. exercise DVDs etc.) along with a stronger intent to repeat
Healthy_lifestyle/Keeping_active), as but local authorities should consider the activity again at another time. The
well as from the NHS. Although it is likely to be hard to get how they can improve accessibility to interaction between being in nature and
started, participating in physical activity leisure facilities and spaces through being physically active seems to have
intervention programmes has been coordinated transport plans and synergistic positive effects.
shown to reduce social physique community safety initiatives (see section
anxiety.63 For women, attending a on policy makers p.40). Examples of organisations which
female only exercise class or a ladies promote outdoor physical activity
only swimming session may help to include:
overcome anxiety as a barrier to initially – Outdoor gyms where some gym
starting to exercise. Exercising with a equipment is provided in outside
companion can also help to reduce spaces for people to use for free e.g.
social physique anxiety and may be nationally through the Great Outdoor
particularly helpful during the first few Gym Company http://www.tgogc.com/
exercise sessions. The environment can and through some local authorities e.g.
influence how one feels too; gyms with outdoor gyms in Camden http://www.
mirrored walls tend to heighten anxiety, camden.gov.uk/ccm/content/leisure/
as does exercising near a window or sports-and-activities/outdoor-gyms.
other space where one feels ‘on show’. – Green gyms provide guided
CBT may also help through challenging environmentally focused physical
the unhelpful thinking patterns which are activity in the outdoors and can be
leading to the anxiety. found throughout the United Kingdom
http://www.tcv.org.uk/greengym/
find-green-gym. A national evaluation
of Green Gyms found that 100% of
participants agreed that taking part
in a Green Gym has had a positive
benefit on their mental health, as it
has boosted their self-esteem and
confidence through learning new skills
and completing tasks.
– Blue gyms encourage people to be
active in and around water outdoors
The interaction between e.g. canals, rivers, lakes and the sea.
Research is being undertaken into the
being in nature and being wellbeing benefits of doing so: http://
www.bluegym.org.uk
physically active seems to – National Trust volunteering in the
have synergistic positive outdoors: http://www.nationaltrust.org.
uk/get-involved/volunteer/
effects. – Branching Out – outdoor physical
activity for adults who use mental
health services within Greater Glasgow
and Clyde area http://www.forestry.
gov.uk/branchingout
36 37You can also read
