561820 research-article2014
SJP0010.1177/1403494814561820Self-rated Health and Physical ActivityE. Engberg et al.
Scandinavian Journal of Public Health, 2015; 43: 190–196
Original Article
Associations of physical activity with self-rated health and well-being in middle-aged Finnish men
Elina Engberg1,2, Helena Liira3, Katriina Kukkonen-Harjula4, Svetlana From3, Hannu Kautiainen3,5, Kaisu Pitkälä3 & Heikki Tikkanen1,2,6 1Department
of Sports and Exercise Medicine, Institute of Clinical Medicine, University of Helsinki, Helsinki, Finland, for Sports and Exercise Medicine, Clinic for Sports and Exercise Medicine, Helsinki, Finland, 3Department of General Practice and Helsinki University Central Hospital, Unit of Primary Health Care, University of Helsinki, Helsinki, Finland, 4UKK Institute for Health Promotion Research, Tampere, Finland, 5Unit of Primary Health Care, Kuopio University Hospital, Kuopio, Finland, and 6Institute of Biomedicine, School of Medicine, University of Eastern Finland, Kuopio, Finland 2Foundation
Abstract Aims: We examined the associations of physical activity (PA) frequency with self-rated health (SRH), self-rated well-being (SRW) and depressive symptoms, in middle-aged men in Finland. Methods: The cross-sectional study comprised 665 men (mean age 41 ± 3 SD years; body mass index (BMI) 26.8 ± 4.2 SD kg/m2), who had completed the screening questionnaire of an intervention for men with cardiovascular risk factors. Their weekly frequency of PA was assessed by a questionnaire, SRH and SRW by visual analog scales (VAS), and depressive symptoms by the Patient Health Questionnaire-2 (PHQ-2). Results: The mean SRH ± SD (range of scale 0–100) by PA frequency categories was 56.2 ± 18.5 for PA sometimes or never, 63.8 ± 16.2 for PA about 1–2 times/week, and 71.1 ± 15.5 for PA at least 3 times/week. The mean SRW ± SD (range of scale 0–100) was 59.0 ± 20.4, 65.6 ± 17.6, and 68.9 ± 17.1, respectively. The mean PHQ-2 score ± SD (range of scale 0–6) by PA categories was 1.83 ± 1.40 for PA sometimes or never, 1.68 ± 1.28 for PA about 1–2 times/week, and 1.60 ± 1.31 for the PA at least 3 times/week group. SRH and SRW improved linearly with increasing PA frequency (both p < 0.001), and the results remained similar after adjustment for BMI, education and smoking status. No association existed between PA frequency and PHQ-2. Conclusions: More frequent PA was linearly associated with better SRH and SRW, but not with depressive symptoms that were measured by a brief depression screening tool. Key Words: Depression, Finland, health, middle-aged men, physical activity, self-rated health, well-being
Introduction Physical inactivity and mental illnesses are global public health problems. Physical inactivity is closely related to increasing levels of non-communicable diseases such as cardiovascular diseases, obesity, diabetes, cancer and depression [1]; whereas neuropsychiatric conditions, largely depression, are estimated to be among the most important conditions affecting people’s overall disability-adjusted life-years and the years lived with disability in all regions [2]. Cross-sectional associations between higher levels of physical activity (PA) and reduced incidence rates in depression and anxiety disorders have been reported [3]. Furthermore, results of
longitudinal studies indicate that PA can prevent future depression [4]; and that exercise training seems to improve depressive symptoms in people with a diagnosis of depression, although the results of existing randomized controlled trials need to be interpreted cautiously [5]. In population studies, depressive symptoms are assessed by longer, self-administered depression scales; whereas primary care often relies on short depression screening tools, e.g. the Patient Health Questionnaire-2 (PHQ-2). To the best of our knowledge, no previous study has examined the associations between PA and PHQ-2.
Correspondence: Elina Engberg, University of Helsinki, Paasikivenkatu 4, Helsinki, FI-00250, Finland. E-mail: [email protected] (Accepted 6 November 2014) © 2014 the Nordic Societies of Public Health DOI: 10.1177/1403494814561820
Associations of physical activity with self-rated health and well-being in middle-aged Finnish men 191 Perceived or self-rated health (SRH) has been shown to be a strong predictor of morbidity [6] and mortality [7]. According to a meta-analysis, the association between worse SRH and mortality persists even after adjustment for key covariates, such as comorbidity [7]. Various biomarkers, including several laboratory values and blood pressure, show a graded relationship with SRH. Accordingly, it has been interpreted that SRH has a biologic basis and it can serve as a sensitive barometer of physiologic states [8]. SRH has been assessed using different wording of questions, types of scales and response options, but it is often ascertained with a single item. Previous cross-sectional studies reported associations between higher levels of PA and better SRH in their population samples [9–11], and a longitudinal study by Froom et al. [12] showed that a lack of regular leisure sports activity predicts poorer SRH after 9 years, in male workers. Commonly-used objective indicators of wellbeing, such as a lack of diseases and good education, fail to take into account human perception, which is fundamental in determining and understanding an individual’s well-being. Subjective well-being has been assessed with various questionnaires on feelings, experiences and the evaluation of one’s life as a whole [13]. Although SRH assessed by a single item is one of the most widely-used indicators of health status, little attention has been paid to assessing selfrated well-being (SRW) by a simple measure in health and PA research. Sjögren et al.[14] reported that a cluster randomized controlled trial of a workplace exercise intervention increased the subjective physical well-being in middle-aged men and women, while psychosocial functioning or general well-being (consisting of life satisfaction and the meaning of life) measured by visual rating scales of 0–100 did not change. The purpose of this study was to examine the associations of PA with SRH, SRW and depressive symptoms, as assessed by simple measures in middle-aged men. Methods In this cross-sectional study, we report on selected baseline data for the ‘Man 40’ study. The Man 40 project includes health checks and an exercise intervention, conducted in Kirkkonummi primary care in cooperation with the University of Helsinki, Finland. Kirkkonummi is a municipality of 36,000 inhabitants situated close to Helsinki. The study protocol was approved by the Coordinating Ethics Committee at Helsinki University Hospital on 8 June 2009 (ref: 4/13/03/00/09), and the trial registration number is
ISRCTN80672011. The protocol is described in greater detail elsewhere [15]. Recruitment Men aged 35–45 years at increased risk for atherosclerotic cardiovascular diseases (ASCVDs) and with low levels of PA were searched for in the Man 40 study, in three ways: 1) By invitation letter to the 40-year-old male age cohort in the community; 2) By identifying eligible men in the community healthcare services (targeted opportunistic screening); and 3) By providing information on the project in the media and on the internet. Men were invited to complete an online health and lifestyle questionnaire, including questions on date of birth, height, weight, education, smoking, nutrition, dental care, medication for blood pressure and cholesterol, PA, SRH, SRW and symptoms of depression. In this cross-sectional study, all men who completed the online screening questionnaire were included in the analyses, and no further exclusion criteria were applied. Middle-aged men living in Kirkkonummi were eligible to complete the screening questionnaire. Measures Physical activity. We assessed physical activity (PA) by asking about the weekly frequency of PA bouts lasting at least 30 minutes, and inducing sweating and breathlessness, i.e. bouts of at least moderate intensity. Answer options were: never, sometimes, about 1–2 times a week, and 3 times a week or more. The responses were categorized into three groups for statistical analyses: ‘Very low’ (PA frequency sometimes or never), ‘Low’ (PA frequency about 1–2 times/week), and ‘Moderate’ (PA frequency at least 3 times/week). Self-rated health and self-rated well-being. Self-rated health (SRH) was assessed by the answer to a single item: ‘How do you regard your general health at the moment?’ and self-rated well-being (SRW) by the single item: ‘How do you regard your general wellbeing at the moment?’ Participants answered using a horizontal visual analog scale (VAS). On the scale, 0 represents the worst possible situation and 100 the best possible situation, with participants indicating a point on the line between these extremes that best reflected their situation.
192 E. Engberg et al. Depressive symptoms. Depressive symptoms were assessed by the Patient Health Questionnaire-2 (PHQ-2), which is validated for the detection of depression among adults in primary care [16]. The PHQ-2 consists of two items that deal with loss of interest and depressed mood. The PHQ-2 score ranges from 0–6, with 6 indicating the most symptoms. A score of ≥ 3 is shown to have a sensitivity of 83% and a specificity of 92%, for major depression [16]. The PHQ-2 can be used as a first step in screening for depression in primary care; the cut-point score of ≥ 3 identifies any possible clinically-significant depression and should prompt further assessment of the patient. Statistical analyses Descriptive statistics are presented as means and standard deviations (SDs), or frequencies and percentages (%). Statistical analyses were performed using Stata statistical software, release 11.0 (StataCorp, College Station, TX, USA) and IBM SPSS statistics version 20. Linearity between the SRH, SRW, PHQ-2 score and PA categories were analyzed using a bootstrap-type analysis of variance (ANOVA). The bootstrap method is useful when the theoretical distribution of the test statistic is unknown or in the case of violation of assumptions. The models were adjusted for the following covariates: body mass index (BMI), education (categorized into four groups) and current smoking status (yes/no). We analyzed differences in SRH, SRW and PHQ-2 score by the PA frequency categories (Very low, Low and Moderate) with the Mann-Whitney U-test. Statistical significance was set at p < 0.05. Results Between the years 2008 and 2011, the study invitation letter was sent to 946 men aged 40 years, 320 (33.8%) of whom completed the online screening questionnaire. These respondents comprised 122 of the 313 men born in 1969; 110 of the 330 men born in 1970 and 88 of the 303 men born in 1971. In addition, 345 men recruited through primary care services and the media completed the online screening questionnaire. Thus, a total of 665 men were included in this crosssectional study. The mean age of the men was 41 ± 3 SD years (range: 34–49 years), and their mean BMI was 26.8 ± 4.2 kg/m2 (range: 17.0–52.6 kg/m2). Table I presents the characteristics of the men. The participants were divided into three categories, according to their weekly frequency of PA. Of the 665 participants, 176 (26.5%) fell into the category ‘Very low’, 299 (45%) into the category ‘Low’, and 190 (28.6%) into the category ‘Moderate’.
Table I. Characteristics of the participants (n = 629–665, depending on the variable). Characteristic
Mean ± SD or frequency (%)a
Age (yrs) Height (cm) Weight (kg) BMI (kg/m2) Waist circumference (cm) Current smokers Education Primary Secondary Bachelor’s degree or equivalent Master’s degree or beyond Physical activity groupsb Sometimes or Never About 1–2 times/week ≥ 3 times/week Self-rated health (scale 0–100) Self-rated well-being (scale 0–100) PHQ-2 score (scale 0–6) PHQ-2 score ≥ 3
41 ± 3 180 ± 7 87 ± 15 27 ± 4 98 ± 13 155 (23.3) 46 (6.9) 248 (37.3) 177 (26.6) 194 (29.2) 176 (26.5) 299 (45.0) 190 (28.6) 63.9 ± 17.5 64.8 ± 18.6 1.70 ± 1.32 169 (25.4)
aValues
are shown as mean ± SD or frequency and proportion (%). activity frequency: at least 30 min. cm: centimeters; kg: kilogram; m: meters; min: minutes; PHQ-2: Patient Health Questionnaire-2; SD: standard deviation; yrs: years bPhysical
The mean SRH (± SD) by PA frequency category was 56.2 ± 18.5 (Very low), 63.8 ± 16.2 (Low), and 71.1 ± 15.5 (Moderate). The mean SRW was 59.0 ± 20.4; 65.6 ± 17.6 and 68.9 ± 17.1, respectively. The mean PHQ-2 score (± SD) by PA category was 1.83 ± 1.40 (Very low), 1.68 ± 1.28 (Low) and 1.60 ± 1.31 (Moderate); and the proportion of participants having a PHQ-2 score ≥ 3 was 30%, 24% and 25%, respectively. With increasing PA, both SRH and SRW increased linearly (both p < 0.001), as seen in Figure 1 and Figure 2. The model was adjusted for possible confounding variables: BMI, education and smoking status. Furthermore, the Mann-Whitney U-test revealed significant differences in SRH between the PA categories Very low and Low, Very low and Moderate, and Low and Moderate (all p < 0.001). Similarly, the difference in SRW was significant between the PA categories Very low and Low (p = 0.002), Very low and Moderate (p < 0.001), and Low and Moderate (p = 0.028). The linearity between increasing PA frequency and decreasing PHQ-2 score (Figure 3) did not reach statistical significance (p = 0.40). Discussion In this cross-sectional study, we examined the associations of PA frequency with SRH, SRW and depressive
Associations of physical activity with self-rated health and well-being in middle-aged Finnish men 193
Figure 1. Self-rated health (a VAS value) according to weekly physical activity (PA) frequency categories. Values are shown as means with 95%CI. Adjusted for BMI, education and smoking. P-value from a Bootstrap-type ANOVA. ANOVA: analysis of variance; BMI: body mass index; CI: confidence interval; PA: physical activity; VAS value: a visual analog scale value
symptoms in middle-aged men. SRH and SRW improved linearly with increasing PA frequency, but no association existed between PA and depressive symptoms. The results are in line with previous studies reporting associations between higher levels of leisure PA and better SRH in the general population [9–11] and in male employees aged 50–59 years [17]. A linear trend between SRH and PA has been observed in adolescents [18]. In addition, dose-response relationships between higher PA levels and better SRH [19,20], and between higher levels of cardiorespiratory fitness (CRF) and better SRH are found among both men and women [19]. A positive association between good SRH and a combined score for a better PA level and muscle strength has been shown [21], and a longitudinal study by Froom et al. [12] reports that a lack of regular leisure sports activity predicts poorer SRH in men after a 9-year follow-up. PA was assessed in more detail in these studies than in ours.
Figure 2. Self-rated well-being (a VAS value) according to weekly physical activity (PA) frequency categories. Values are shown as means with 95%CI. Adjusted for BMI, education and smoking. P-value from a Bootstrap-type ANOVA. ANOVA: analysis of variance; BMI: body mass index; CI: confidence interval; PA: physical activity; VAS value: a visual analog scale value
This study showed for the first time a positive linear relationship between PA frequency and SRW, as assessed by a single item. Previously, both PA during leisure and CRF were demonstrated to be positively associated with general well-being, as assessed by the General Well-being Schedule (GWB), which covers such constructs as energy level, satisfaction, freedom from worry, and self-control [22]. Another study reports that leisure PA and CRF are inversely associated with hopelessness, as assessed by two questions each with five response alternatives, in men aged 42–60 years [23]. In addition, higher levels of PA and shorter duration of daily sitting are shown to be independently associated with excellent SRH and quality of life, the latter two measured with single questions in middle-aged and older men and women [24]. In a longitudinal study by Wang et al. [25], PA was associated with self-reported happiness, as assessed by a single item after 2 and 4 years, in 7745 men and women.
194 E. Engberg et al.
Figure 3. The Patient Health Questionnaire-2 (PHQ-2) score, according to weekly physical activity (PA) frequency categories. Values are shown as means with 95%CI, adjusted for BMI, education and smoking. P-value from Bootstrap-type ANOVA. ANOVA: analysis of variance; BMI: body mass index; CI: confidence interval; PA: physical activity; PHQ-2: Patient Health Questionnaire 2
In our study of middle-aged men, we found no relationship between PA frequency and depressive symptoms. Likewise, in a study by Tolmunen et al. [26], self-reported PA was not associated with elevated depressive symptoms in middle-aged men [26], but an association was found for low CRF. Conversely to our results, others describe an association of higher levels of PA with lowered depressive symptoms [9,27]; and a dose-response relationship between increased PA and decreased depressive symptomatology, as assessed by the Center for Epidemiological Studies Scale for Depression (CES-D) [22]. Limitations and strengths Our study sample consisted of all middle-aged men who had completed the screening questionnaire of a health promotion trial aimed at men aged 35–45 years, who are at increased risk for ASCVDs and have low levels of PA. The study participants were
recruited by an invitation letter to 40-year-old males in the community, by identifying eligible men in community care services, and by providing information about the project in the local media and on the internet. Nearly half of the study sample (48%) was comprised of the 40-year-old men of the community, and the rest were recruited through community care services and the media. Thus, this study’s findings cannot be generalized to all middle-aged Finnish men. According to the annual Health Behavior and Health among the Finnish Adult Population study, conducted in 2011, altogether 43.7% of men aged 35–44 years performed leisure-time physical exercise lasting at least 30 minutes, 3 times a week or more [28]; whereas the corresponding figure in our study was 28.6%. This comparison suggests that among the men in our study, the PA frequency level is lower than in the general Finnish middle-aged male population. This may be partly due to the two recruitment methods (through primary care and the media) that were aimed at men with low levels of PA. Our study was cross-sectional; thus, no causal conclusions can be drawn. Several psychological and physiological mechanisms have been proposed to explain the effect of PA on mental well-being. The main psychological hypotheses are related to distraction, self-efficacy, and social interaction; and the main physiological hypotheses are based on studies on monoamines and endorphins. However, no consensus exists regarding the relative role of these mechanisms in explaining the association between PA and mood improvement. A model in which psychological and biological factors interact and vary according to the characteristics of each individual and environmental stimuli is probable [29]. Furthermore, mental health and subjective wellbeing may affect the likelihood of undertaking PA; the association between PA and mental health is shown to be bidirectional [27]. Because the online questionnaire used in our study did not include questions about all possible confounding factors (e.g. work conditions, life situation and income), the use of confounding factors was limited. Another limitation was that the PA, health status, well-being and depressive symptoms were self-reported, which may bias findings. Moreover, PA, SRH, SRW and depressive symptoms were assessed by simple measures. Using single items and short questionnaires facilitates the study of large populations and multiple lifestyles. A brief questionnaire such as the PHQ-2 is a useful and time-saving tool in screening for depression in primary care, but it may not be sufficiently sensitive to detect differences in levels of depressive symptoms, to such a degree that associations with PA frequency, also assessed with a simple measure, could be found.
Associations of physical activity with self-rated health and well-being in middle-aged Finnish men 195 We assessed SRH and SRW by a VAS of 0–100, whereas most of the previous studies examining relationships between PA and SRH assessed SRH by a Likert item with two to five response levels; however, a previous longitudinal study by Froom et al. [12] used a VAS of 1–10 and found that a lack of regular leisure sports activity predicts poorer SRH. Furthermore, they reported that assessing SRH by the VAS correlated with a 5-point scale measurement of SRH; and also predicted mortality and risk factors, such as blood pressure, BMI and blood glucose concentrations. Another study shows that a single VAS and previously-validated single Likert items measuring the same psychosocial constructs were highly correlated, e.g. the respondents who scored high on the VAS for SRH also tended to score high on the corresponding Likert item [30]. The advantages of assessing subjective well-being with VAS, relative to Likert scales, are that VAS may allow greater sensitivity in determining subjective well-being, because there is a broader range of possible scores. In addition, VAS is easy to administer and low in terms of respondent burden. To the best of our knowledge, this is the first study to examine the associations between PA and SRW, as assessed by a single item, and between PA and the PHQ-2. Consequently, our results contribute to the literature on the relationship between PA and subjective well-being, specifically among middle-aged men. Conclusions Our results suggest that more frequent PA is linearly associated with better SRH and SRW, but not with depressive symptoms, as measured by a brief depression-screening tool in middle-aged men. Intervention studies are needed to examine whether increasing PA can improve SRH and SRW in working-aged populations; and whether these mediate the effects on morbidity. Conflict of interest The authors declare there are no conflicts of interest. Funding This work (‘Man 40’ project) was supported by the Municipality of Kirkkonummi, Finland, and the Fit for Life Program, a national program aimed at creating permanent sport services targeted to adults in Finland (a grant). The PhD work of author Engberg was supported by Tekes, The Finnish Funding Agency for Technology and Innovation (grant number 40043/07);
the Juho Vainio Foundation; Urheiluopistosäätiö [Sports Institute Foundation]; the University of Helsinki Medicine Fund; and the Ministry of Education and Culture of Finland. References [1] US Department of Health and Human Services (USDHHS). 2008 Physical activity guidelines for Americans, http://www. health.gov/Paguidelines/ (2008, accessed 11 August 2014). [2] World Health Organization (WHO). World health report 2003: Shaping the future. Geneva: WHO, 2003. [3] Ströhle A. Physical activity, exercise, depression and anxiety disorders. J Neural Transm 2009;116:777–84. [4] Mammen G and Faulkner G. Physical activity and the prevention of depression: A systematic review of prospective studies. Am J Prev Med 2013;45:649–57. [5] Cooney GM, Dwan K, Greig CA, et al. Exercise for depression. Cochrane Database Syst Rev 2013;9:CD004366. [6] Latham K and Peek CW. Self-rated health and morbidity onset among late midlife US adults. J Gerontol B Psychol Sci Soc Sci 2013;68:107–16. [7] DeSalvo KB, Bloser N, Reynolds K, et al. Mortality prediction with a single general self-rated health question. A metaanalysis. J Gen Intern Med 2006;21:267–75. [8] Jylhä M, Volpato S and Guralnik JM. Self-rated health showed a graded association with frequently used biomarkers in a large population sample. J Clin Epidemiol 2006;59:465–71. [9] Hassmén P, Koivula N and Uutela A. Physical exercise and psychological well-being: A population study in Finland. Prev Med 2000;30:17–25. [10] Södergren M, Sundquist J, Johansson SE, et al. Physical activity, exercise and self-rated health: A population-based study from Sweden. BMC Public Health 2008;8:352. DOI: 10.1186/1471–2458–8–352. [11] Kaleta D, Makowiec-Dabrowska T, Dziankowska-Zaborszczyk E, et al. Physical activity and self-perceived health status. Int J Occup Med Environ Health 2006;19:61–9. [12] Froom P, Melamed S, Triber I, et al. Predicting self-reported health: The CORDIS study. Prev Med 2004;39:419–23. [13] Kashdan T. The assessment of subjective well-being (issues raised by the Oxford happiness questionnaire). Personality Individ Diff 2004;36:1225–32. [14] Sjögren T, Nissinen KJ, Järvenpää SK, et al. Effects of a physical exercise intervention on subjective physical wellbeing, psychosocial functioning and general well-being among office workers: A cluster randomized-controlled cross-over design. Scand J Med Sci Sports 2006;16:381–90. [15] From S, Liira H, Leppävuori J, et al. Effectiveness of exercise intervention and health promotion on cardiovascular risk factors in middle-aged men. A protocol of a randomized controlled trial. BMC Public Health 2013;13:125. DOI: 10.1186/1471–2458–13–125. [16] Kroenke K, Spitzer RL and Williams JB. The Patient Health Questionnaire-2: Validity of a two-item depression screener. Med Care 2003;41:1284–92. [17] Okano G, Miyake H and Mori M. Leisure time physical activity as a determinant of self-perceived health and fitness in middle-aged male employees. J Occup Health 2003;45:286–92. [18] Galán I, Boix R, Medrano MJ, et al. Physical activity and self-reported health status among adolescents: A cross-sectional population-based study. BMJ Open 2013;3:e002644. DOI: 10.1136/bmjopen-2013–002644. [19] Eriksen L, Curtis T, Gronbaek M, et al. The association between physical activity, cardiorespiratory fitness and selfrated health. Prev Med 2013;57:900–2.
196 E. Engberg et al. [20] Galán I, Meseguer CM, Herruzo R, et al. Self-rated health according to amount, intensity and duration of leisure time physical activity. Prev Med 2010;51:378–83. [21] Hansen AW, Beyer N, Flensborg-Madsen T, et al. Muscle strength and physical activity are associated with selfrated health in an adult Danish population. Prev Med 2013;57:792–8. [22] Galper DI, Trivedi MH, Barlow CE, et al. Inverse association between physical inactivity and mental health in men and women. Med Sci Sports Exerc 2006;38:173–8. [23] Valtonen M, Laaksonen DE, Laukkanen J, et al. Leisuretime physical activity, cardiorespiratory fitness and feelings of hopelessness in men. BMC Public Health 2009;9:204. DOI: 10.1186/1471–2458–9–204. [24] Rosenkranz RR, Duncan MJ, Rosenkranz SK, et al. Active lifestyles related to excellent self-rated health and quality of life: Cross-sectional findings from 194,545 participants in The 45 and Up Study. BMC Public Health 2013;13:1071. DOI: 10.1186/1471–2458–13–1071. [25] Wang F, Orpana HM, Morrison H, et al. Long-term association between leisure-time physical activity and changes in
[26] [27]
[28]
[29] [30]
happiness: Analysis of the Prospective National Population Health Survey. Am J Epidemiol 2012;176:1095–100. Tolmunen T, Laukkanen JA, Hintikka J, et al. Low maximal oxygen uptake is associated with elevated depressive symptoms in middle-aged men. Eur J Epidemiol 2006;21:701–6. Azevedo Da Silva M, Singh-Manoux A, Brunner EJ, et al. Bidirectional association between physical activity and symptoms of anxiety and depression: The Whitehall II study. Eur J Epidemiol 2012;27:537–46. Helakorpi S, Holstila A, Virtanen S, et al. Health behaviour and health among the Finnish adult population, Spring 2011. Report for the National Institute for Health and Welfare (THL). Report no. 45, 2012. Helsinki: THL. www.julkari.fi/bitstream/ handle/10024/90839/URN_ISBN_978–952–245–566–6. pdf?sequence=1 (2012, accessed 11 August 2014). Peluso MA and Guerra de Andrade LH. Physical activity and mental health: The association between exercise and mood. Clinics (Sao Paulo) 2005;60:61–70. Hasson D and Arnetz BB. Validation and findings comparing VAS vs. Likert scales for psychosocial measurements. Int Electron J Health Educ 2005;8:178–92.
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SJP0010.1177/1403494814561820Self-rated Health and Physical ActivityE. Engberg et al.
Scandinavian Journal of Public Health, 2015; 43: 190–196
Original Article
Associations of physical activity with self-rated health and well-being in middle-aged Finnish men
Elina Engberg1,2, Helena Liira3, Katriina Kukkonen-Harjula4, Svetlana From3, Hannu Kautiainen3,5, Kaisu Pitkälä3 & Heikki Tikkanen1,2,6 1Department
of Sports and Exercise Medicine, Institute of Clinical Medicine, University of Helsinki, Helsinki, Finland, for Sports and Exercise Medicine, Clinic for Sports and Exercise Medicine, Helsinki, Finland, 3Department of General Practice and Helsinki University Central Hospital, Unit of Primary Health Care, University of Helsinki, Helsinki, Finland, 4UKK Institute for Health Promotion Research, Tampere, Finland, 5Unit of Primary Health Care, Kuopio University Hospital, Kuopio, Finland, and 6Institute of Biomedicine, School of Medicine, University of Eastern Finland, Kuopio, Finland 2Foundation
Abstract Aims: We examined the associations of physical activity (PA) frequency with self-rated health (SRH), self-rated well-being (SRW) and depressive symptoms, in middle-aged men in Finland. Methods: The cross-sectional study comprised 665 men (mean age 41 ± 3 SD years; body mass index (BMI) 26.8 ± 4.2 SD kg/m2), who had completed the screening questionnaire of an intervention for men with cardiovascular risk factors. Their weekly frequency of PA was assessed by a questionnaire, SRH and SRW by visual analog scales (VAS), and depressive symptoms by the Patient Health Questionnaire-2 (PHQ-2). Results: The mean SRH ± SD (range of scale 0–100) by PA frequency categories was 56.2 ± 18.5 for PA sometimes or never, 63.8 ± 16.2 for PA about 1–2 times/week, and 71.1 ± 15.5 for PA at least 3 times/week. The mean SRW ± SD (range of scale 0–100) was 59.0 ± 20.4, 65.6 ± 17.6, and 68.9 ± 17.1, respectively. The mean PHQ-2 score ± SD (range of scale 0–6) by PA categories was 1.83 ± 1.40 for PA sometimes or never, 1.68 ± 1.28 for PA about 1–2 times/week, and 1.60 ± 1.31 for the PA at least 3 times/week group. SRH and SRW improved linearly with increasing PA frequency (both p < 0.001), and the results remained similar after adjustment for BMI, education and smoking status. No association existed between PA frequency and PHQ-2. Conclusions: More frequent PA was linearly associated with better SRH and SRW, but not with depressive symptoms that were measured by a brief depression screening tool. Key Words: Depression, Finland, health, middle-aged men, physical activity, self-rated health, well-being
Introduction Physical inactivity and mental illnesses are global public health problems. Physical inactivity is closely related to increasing levels of non-communicable diseases such as cardiovascular diseases, obesity, diabetes, cancer and depression [1]; whereas neuropsychiatric conditions, largely depression, are estimated to be among the most important conditions affecting people’s overall disability-adjusted life-years and the years lived with disability in all regions [2]. Cross-sectional associations between higher levels of physical activity (PA) and reduced incidence rates in depression and anxiety disorders have been reported [3]. Furthermore, results of
longitudinal studies indicate that PA can prevent future depression [4]; and that exercise training seems to improve depressive symptoms in people with a diagnosis of depression, although the results of existing randomized controlled trials need to be interpreted cautiously [5]. In population studies, depressive symptoms are assessed by longer, self-administered depression scales; whereas primary care often relies on short depression screening tools, e.g. the Patient Health Questionnaire-2 (PHQ-2). To the best of our knowledge, no previous study has examined the associations between PA and PHQ-2.
Correspondence: Elina Engberg, University of Helsinki, Paasikivenkatu 4, Helsinki, FI-00250, Finland. E-mail: [email protected] (Accepted 6 November 2014) © 2014 the Nordic Societies of Public Health DOI: 10.1177/1403494814561820
Associations of physical activity with self-rated health and well-being in middle-aged Finnish men 191 Perceived or self-rated health (SRH) has been shown to be a strong predictor of morbidity [6] and mortality [7]. According to a meta-analysis, the association between worse SRH and mortality persists even after adjustment for key covariates, such as comorbidity [7]. Various biomarkers, including several laboratory values and blood pressure, show a graded relationship with SRH. Accordingly, it has been interpreted that SRH has a biologic basis and it can serve as a sensitive barometer of physiologic states [8]. SRH has been assessed using different wording of questions, types of scales and response options, but it is often ascertained with a single item. Previous cross-sectional studies reported associations between higher levels of PA and better SRH in their population samples [9–11], and a longitudinal study by Froom et al. [12] showed that a lack of regular leisure sports activity predicts poorer SRH after 9 years, in male workers. Commonly-used objective indicators of wellbeing, such as a lack of diseases and good education, fail to take into account human perception, which is fundamental in determining and understanding an individual’s well-being. Subjective well-being has been assessed with various questionnaires on feelings, experiences and the evaluation of one’s life as a whole [13]. Although SRH assessed by a single item is one of the most widely-used indicators of health status, little attention has been paid to assessing selfrated well-being (SRW) by a simple measure in health and PA research. Sjögren et al.[14] reported that a cluster randomized controlled trial of a workplace exercise intervention increased the subjective physical well-being in middle-aged men and women, while psychosocial functioning or general well-being (consisting of life satisfaction and the meaning of life) measured by visual rating scales of 0–100 did not change. The purpose of this study was to examine the associations of PA with SRH, SRW and depressive symptoms, as assessed by simple measures in middle-aged men. Methods In this cross-sectional study, we report on selected baseline data for the ‘Man 40’ study. The Man 40 project includes health checks and an exercise intervention, conducted in Kirkkonummi primary care in cooperation with the University of Helsinki, Finland. Kirkkonummi is a municipality of 36,000 inhabitants situated close to Helsinki. The study protocol was approved by the Coordinating Ethics Committee at Helsinki University Hospital on 8 June 2009 (ref: 4/13/03/00/09), and the trial registration number is
ISRCTN80672011. The protocol is described in greater detail elsewhere [15]. Recruitment Men aged 35–45 years at increased risk for atherosclerotic cardiovascular diseases (ASCVDs) and with low levels of PA were searched for in the Man 40 study, in three ways: 1) By invitation letter to the 40-year-old male age cohort in the community; 2) By identifying eligible men in the community healthcare services (targeted opportunistic screening); and 3) By providing information on the project in the media and on the internet. Men were invited to complete an online health and lifestyle questionnaire, including questions on date of birth, height, weight, education, smoking, nutrition, dental care, medication for blood pressure and cholesterol, PA, SRH, SRW and symptoms of depression. In this cross-sectional study, all men who completed the online screening questionnaire were included in the analyses, and no further exclusion criteria were applied. Middle-aged men living in Kirkkonummi were eligible to complete the screening questionnaire. Measures Physical activity. We assessed physical activity (PA) by asking about the weekly frequency of PA bouts lasting at least 30 minutes, and inducing sweating and breathlessness, i.e. bouts of at least moderate intensity. Answer options were: never, sometimes, about 1–2 times a week, and 3 times a week or more. The responses were categorized into three groups for statistical analyses: ‘Very low’ (PA frequency sometimes or never), ‘Low’ (PA frequency about 1–2 times/week), and ‘Moderate’ (PA frequency at least 3 times/week). Self-rated health and self-rated well-being. Self-rated health (SRH) was assessed by the answer to a single item: ‘How do you regard your general health at the moment?’ and self-rated well-being (SRW) by the single item: ‘How do you regard your general wellbeing at the moment?’ Participants answered using a horizontal visual analog scale (VAS). On the scale, 0 represents the worst possible situation and 100 the best possible situation, with participants indicating a point on the line between these extremes that best reflected their situation.
192 E. Engberg et al. Depressive symptoms. Depressive symptoms were assessed by the Patient Health Questionnaire-2 (PHQ-2), which is validated for the detection of depression among adults in primary care [16]. The PHQ-2 consists of two items that deal with loss of interest and depressed mood. The PHQ-2 score ranges from 0–6, with 6 indicating the most symptoms. A score of ≥ 3 is shown to have a sensitivity of 83% and a specificity of 92%, for major depression [16]. The PHQ-2 can be used as a first step in screening for depression in primary care; the cut-point score of ≥ 3 identifies any possible clinically-significant depression and should prompt further assessment of the patient. Statistical analyses Descriptive statistics are presented as means and standard deviations (SDs), or frequencies and percentages (%). Statistical analyses were performed using Stata statistical software, release 11.0 (StataCorp, College Station, TX, USA) and IBM SPSS statistics version 20. Linearity between the SRH, SRW, PHQ-2 score and PA categories were analyzed using a bootstrap-type analysis of variance (ANOVA). The bootstrap method is useful when the theoretical distribution of the test statistic is unknown or in the case of violation of assumptions. The models were adjusted for the following covariates: body mass index (BMI), education (categorized into four groups) and current smoking status (yes/no). We analyzed differences in SRH, SRW and PHQ-2 score by the PA frequency categories (Very low, Low and Moderate) with the Mann-Whitney U-test. Statistical significance was set at p < 0.05. Results Between the years 2008 and 2011, the study invitation letter was sent to 946 men aged 40 years, 320 (33.8%) of whom completed the online screening questionnaire. These respondents comprised 122 of the 313 men born in 1969; 110 of the 330 men born in 1970 and 88 of the 303 men born in 1971. In addition, 345 men recruited through primary care services and the media completed the online screening questionnaire. Thus, a total of 665 men were included in this crosssectional study. The mean age of the men was 41 ± 3 SD years (range: 34–49 years), and their mean BMI was 26.8 ± 4.2 kg/m2 (range: 17.0–52.6 kg/m2). Table I presents the characteristics of the men. The participants were divided into three categories, according to their weekly frequency of PA. Of the 665 participants, 176 (26.5%) fell into the category ‘Very low’, 299 (45%) into the category ‘Low’, and 190 (28.6%) into the category ‘Moderate’.
Table I. Characteristics of the participants (n = 629–665, depending on the variable). Characteristic
Mean ± SD or frequency (%)a
Age (yrs) Height (cm) Weight (kg) BMI (kg/m2) Waist circumference (cm) Current smokers Education Primary Secondary Bachelor’s degree or equivalent Master’s degree or beyond Physical activity groupsb Sometimes or Never About 1–2 times/week ≥ 3 times/week Self-rated health (scale 0–100) Self-rated well-being (scale 0–100) PHQ-2 score (scale 0–6) PHQ-2 score ≥ 3
41 ± 3 180 ± 7 87 ± 15 27 ± 4 98 ± 13 155 (23.3) 46 (6.9) 248 (37.3) 177 (26.6) 194 (29.2) 176 (26.5) 299 (45.0) 190 (28.6) 63.9 ± 17.5 64.8 ± 18.6 1.70 ± 1.32 169 (25.4)
aValues
are shown as mean ± SD or frequency and proportion (%). activity frequency: at least 30 min. cm: centimeters; kg: kilogram; m: meters; min: minutes; PHQ-2: Patient Health Questionnaire-2; SD: standard deviation; yrs: years bPhysical
The mean SRH (± SD) by PA frequency category was 56.2 ± 18.5 (Very low), 63.8 ± 16.2 (Low), and 71.1 ± 15.5 (Moderate). The mean SRW was 59.0 ± 20.4; 65.6 ± 17.6 and 68.9 ± 17.1, respectively. The mean PHQ-2 score (± SD) by PA category was 1.83 ± 1.40 (Very low), 1.68 ± 1.28 (Low) and 1.60 ± 1.31 (Moderate); and the proportion of participants having a PHQ-2 score ≥ 3 was 30%, 24% and 25%, respectively. With increasing PA, both SRH and SRW increased linearly (both p < 0.001), as seen in Figure 1 and Figure 2. The model was adjusted for possible confounding variables: BMI, education and smoking status. Furthermore, the Mann-Whitney U-test revealed significant differences in SRH between the PA categories Very low and Low, Very low and Moderate, and Low and Moderate (all p < 0.001). Similarly, the difference in SRW was significant between the PA categories Very low and Low (p = 0.002), Very low and Moderate (p < 0.001), and Low and Moderate (p = 0.028). The linearity between increasing PA frequency and decreasing PHQ-2 score (Figure 3) did not reach statistical significance (p = 0.40). Discussion In this cross-sectional study, we examined the associations of PA frequency with SRH, SRW and depressive
Associations of physical activity with self-rated health and well-being in middle-aged Finnish men 193
Figure 1. Self-rated health (a VAS value) according to weekly physical activity (PA) frequency categories. Values are shown as means with 95%CI. Adjusted for BMI, education and smoking. P-value from a Bootstrap-type ANOVA. ANOVA: analysis of variance; BMI: body mass index; CI: confidence interval; PA: physical activity; VAS value: a visual analog scale value
symptoms in middle-aged men. SRH and SRW improved linearly with increasing PA frequency, but no association existed between PA and depressive symptoms. The results are in line with previous studies reporting associations between higher levels of leisure PA and better SRH in the general population [9–11] and in male employees aged 50–59 years [17]. A linear trend between SRH and PA has been observed in adolescents [18]. In addition, dose-response relationships between higher PA levels and better SRH [19,20], and between higher levels of cardiorespiratory fitness (CRF) and better SRH are found among both men and women [19]. A positive association between good SRH and a combined score for a better PA level and muscle strength has been shown [21], and a longitudinal study by Froom et al. [12] reports that a lack of regular leisure sports activity predicts poorer SRH in men after a 9-year follow-up. PA was assessed in more detail in these studies than in ours.
Figure 2. Self-rated well-being (a VAS value) according to weekly physical activity (PA) frequency categories. Values are shown as means with 95%CI. Adjusted for BMI, education and smoking. P-value from a Bootstrap-type ANOVA. ANOVA: analysis of variance; BMI: body mass index; CI: confidence interval; PA: physical activity; VAS value: a visual analog scale value
This study showed for the first time a positive linear relationship between PA frequency and SRW, as assessed by a single item. Previously, both PA during leisure and CRF were demonstrated to be positively associated with general well-being, as assessed by the General Well-being Schedule (GWB), which covers such constructs as energy level, satisfaction, freedom from worry, and self-control [22]. Another study reports that leisure PA and CRF are inversely associated with hopelessness, as assessed by two questions each with five response alternatives, in men aged 42–60 years [23]. In addition, higher levels of PA and shorter duration of daily sitting are shown to be independently associated with excellent SRH and quality of life, the latter two measured with single questions in middle-aged and older men and women [24]. In a longitudinal study by Wang et al. [25], PA was associated with self-reported happiness, as assessed by a single item after 2 and 4 years, in 7745 men and women.
194 E. Engberg et al.
Figure 3. The Patient Health Questionnaire-2 (PHQ-2) score, according to weekly physical activity (PA) frequency categories. Values are shown as means with 95%CI, adjusted for BMI, education and smoking. P-value from Bootstrap-type ANOVA. ANOVA: analysis of variance; BMI: body mass index; CI: confidence interval; PA: physical activity; PHQ-2: Patient Health Questionnaire 2
In our study of middle-aged men, we found no relationship between PA frequency and depressive symptoms. Likewise, in a study by Tolmunen et al. [26], self-reported PA was not associated with elevated depressive symptoms in middle-aged men [26], but an association was found for low CRF. Conversely to our results, others describe an association of higher levels of PA with lowered depressive symptoms [9,27]; and a dose-response relationship between increased PA and decreased depressive symptomatology, as assessed by the Center for Epidemiological Studies Scale for Depression (CES-D) [22]. Limitations and strengths Our study sample consisted of all middle-aged men who had completed the screening questionnaire of a health promotion trial aimed at men aged 35–45 years, who are at increased risk for ASCVDs and have low levels of PA. The study participants were
recruited by an invitation letter to 40-year-old males in the community, by identifying eligible men in community care services, and by providing information about the project in the local media and on the internet. Nearly half of the study sample (48%) was comprised of the 40-year-old men of the community, and the rest were recruited through community care services and the media. Thus, this study’s findings cannot be generalized to all middle-aged Finnish men. According to the annual Health Behavior and Health among the Finnish Adult Population study, conducted in 2011, altogether 43.7% of men aged 35–44 years performed leisure-time physical exercise lasting at least 30 minutes, 3 times a week or more [28]; whereas the corresponding figure in our study was 28.6%. This comparison suggests that among the men in our study, the PA frequency level is lower than in the general Finnish middle-aged male population. This may be partly due to the two recruitment methods (through primary care and the media) that were aimed at men with low levels of PA. Our study was cross-sectional; thus, no causal conclusions can be drawn. Several psychological and physiological mechanisms have been proposed to explain the effect of PA on mental well-being. The main psychological hypotheses are related to distraction, self-efficacy, and social interaction; and the main physiological hypotheses are based on studies on monoamines and endorphins. However, no consensus exists regarding the relative role of these mechanisms in explaining the association between PA and mood improvement. A model in which psychological and biological factors interact and vary according to the characteristics of each individual and environmental stimuli is probable [29]. Furthermore, mental health and subjective wellbeing may affect the likelihood of undertaking PA; the association between PA and mental health is shown to be bidirectional [27]. Because the online questionnaire used in our study did not include questions about all possible confounding factors (e.g. work conditions, life situation and income), the use of confounding factors was limited. Another limitation was that the PA, health status, well-being and depressive symptoms were self-reported, which may bias findings. Moreover, PA, SRH, SRW and depressive symptoms were assessed by simple measures. Using single items and short questionnaires facilitates the study of large populations and multiple lifestyles. A brief questionnaire such as the PHQ-2 is a useful and time-saving tool in screening for depression in primary care, but it may not be sufficiently sensitive to detect differences in levels of depressive symptoms, to such a degree that associations with PA frequency, also assessed with a simple measure, could be found.
Associations of physical activity with self-rated health and well-being in middle-aged Finnish men 195 We assessed SRH and SRW by a VAS of 0–100, whereas most of the previous studies examining relationships between PA and SRH assessed SRH by a Likert item with two to five response levels; however, a previous longitudinal study by Froom et al. [12] used a VAS of 1–10 and found that a lack of regular leisure sports activity predicts poorer SRH. Furthermore, they reported that assessing SRH by the VAS correlated with a 5-point scale measurement of SRH; and also predicted mortality and risk factors, such as blood pressure, BMI and blood glucose concentrations. Another study shows that a single VAS and previously-validated single Likert items measuring the same psychosocial constructs were highly correlated, e.g. the respondents who scored high on the VAS for SRH also tended to score high on the corresponding Likert item [30]. The advantages of assessing subjective well-being with VAS, relative to Likert scales, are that VAS may allow greater sensitivity in determining subjective well-being, because there is a broader range of possible scores. In addition, VAS is easy to administer and low in terms of respondent burden. To the best of our knowledge, this is the first study to examine the associations between PA and SRW, as assessed by a single item, and between PA and the PHQ-2. Consequently, our results contribute to the literature on the relationship between PA and subjective well-being, specifically among middle-aged men. Conclusions Our results suggest that more frequent PA is linearly associated with better SRH and SRW, but not with depressive symptoms, as measured by a brief depression-screening tool in middle-aged men. Intervention studies are needed to examine whether increasing PA can improve SRH and SRW in working-aged populations; and whether these mediate the effects on morbidity. Conflict of interest The authors declare there are no conflicts of interest. Funding This work (‘Man 40’ project) was supported by the Municipality of Kirkkonummi, Finland, and the Fit for Life Program, a national program aimed at creating permanent sport services targeted to adults in Finland (a grant). The PhD work of author Engberg was supported by Tekes, The Finnish Funding Agency for Technology and Innovation (grant number 40043/07);
the Juho Vainio Foundation; Urheiluopistosäätiö [Sports Institute Foundation]; the University of Helsinki Medicine Fund; and the Ministry of Education and Culture of Finland. References [1] US Department of Health and Human Services (USDHHS). 2008 Physical activity guidelines for Americans, http://www. health.gov/Paguidelines/ (2008, accessed 11 August 2014). [2] World Health Organization (WHO). World health report 2003: Shaping the future. Geneva: WHO, 2003. [3] Ströhle A. Physical activity, exercise, depression and anxiety disorders. J Neural Transm 2009;116:777–84. [4] Mammen G and Faulkner G. Physical activity and the prevention of depression: A systematic review of prospective studies. Am J Prev Med 2013;45:649–57. [5] Cooney GM, Dwan K, Greig CA, et al. Exercise for depression. Cochrane Database Syst Rev 2013;9:CD004366. [6] Latham K and Peek CW. Self-rated health and morbidity onset among late midlife US adults. J Gerontol B Psychol Sci Soc Sci 2013;68:107–16. [7] DeSalvo KB, Bloser N, Reynolds K, et al. Mortality prediction with a single general self-rated health question. A metaanalysis. J Gen Intern Med 2006;21:267–75. [8] Jylhä M, Volpato S and Guralnik JM. Self-rated health showed a graded association with frequently used biomarkers in a large population sample. J Clin Epidemiol 2006;59:465–71. [9] Hassmén P, Koivula N and Uutela A. Physical exercise and psychological well-being: A population study in Finland. Prev Med 2000;30:17–25. [10] Södergren M, Sundquist J, Johansson SE, et al. Physical activity, exercise and self-rated health: A population-based study from Sweden. BMC Public Health 2008;8:352. DOI: 10.1186/1471–2458–8–352. [11] Kaleta D, Makowiec-Dabrowska T, Dziankowska-Zaborszczyk E, et al. Physical activity and self-perceived health status. Int J Occup Med Environ Health 2006;19:61–9. [12] Froom P, Melamed S, Triber I, et al. Predicting self-reported health: The CORDIS study. Prev Med 2004;39:419–23. [13] Kashdan T. The assessment of subjective well-being (issues raised by the Oxford happiness questionnaire). Personality Individ Diff 2004;36:1225–32. [14] Sjögren T, Nissinen KJ, Järvenpää SK, et al. Effects of a physical exercise intervention on subjective physical wellbeing, psychosocial functioning and general well-being among office workers: A cluster randomized-controlled cross-over design. Scand J Med Sci Sports 2006;16:381–90. [15] From S, Liira H, Leppävuori J, et al. Effectiveness of exercise intervention and health promotion on cardiovascular risk factors in middle-aged men. A protocol of a randomized controlled trial. BMC Public Health 2013;13:125. DOI: 10.1186/1471–2458–13–125. [16] Kroenke K, Spitzer RL and Williams JB. The Patient Health Questionnaire-2: Validity of a two-item depression screener. Med Care 2003;41:1284–92. [17] Okano G, Miyake H and Mori M. Leisure time physical activity as a determinant of self-perceived health and fitness in middle-aged male employees. J Occup Health 2003;45:286–92. [18] Galán I, Boix R, Medrano MJ, et al. Physical activity and self-reported health status among adolescents: A cross-sectional population-based study. BMJ Open 2013;3:e002644. DOI: 10.1136/bmjopen-2013–002644. [19] Eriksen L, Curtis T, Gronbaek M, et al. The association between physical activity, cardiorespiratory fitness and selfrated health. Prev Med 2013;57:900–2.
196 E. Engberg et al. [20] Galán I, Meseguer CM, Herruzo R, et al. Self-rated health according to amount, intensity and duration of leisure time physical activity. Prev Med 2010;51:378–83. [21] Hansen AW, Beyer N, Flensborg-Madsen T, et al. Muscle strength and physical activity are associated with selfrated health in an adult Danish population. Prev Med 2013;57:792–8. [22] Galper DI, Trivedi MH, Barlow CE, et al. Inverse association between physical inactivity and mental health in men and women. Med Sci Sports Exerc 2006;38:173–8. [23] Valtonen M, Laaksonen DE, Laukkanen J, et al. Leisuretime physical activity, cardiorespiratory fitness and feelings of hopelessness in men. BMC Public Health 2009;9:204. DOI: 10.1186/1471–2458–9–204. [24] Rosenkranz RR, Duncan MJ, Rosenkranz SK, et al. Active lifestyles related to excellent self-rated health and quality of life: Cross-sectional findings from 194,545 participants in The 45 and Up Study. BMC Public Health 2013;13:1071. DOI: 10.1186/1471–2458–13–1071. [25] Wang F, Orpana HM, Morrison H, et al. Long-term association between leisure-time physical activity and changes in
[26] [27]
[28]
[29] [30]
happiness: Analysis of the Prospective National Population Health Survey. Am J Epidemiol 2012;176:1095–100. Tolmunen T, Laukkanen JA, Hintikka J, et al. Low maximal oxygen uptake is associated with elevated depressive symptoms in middle-aged men. Eur J Epidemiol 2006;21:701–6. Azevedo Da Silva M, Singh-Manoux A, Brunner EJ, et al. Bidirectional association between physical activity and symptoms of anxiety and depression: The Whitehall II study. Eur J Epidemiol 2012;27:537–46. Helakorpi S, Holstila A, Virtanen S, et al. Health behaviour and health among the Finnish adult population, Spring 2011. Report for the National Institute for Health and Welfare (THL). Report no. 45, 2012. Helsinki: THL. www.julkari.fi/bitstream/ handle/10024/90839/URN_ISBN_978–952–245–566–6. pdf?sequence=1 (2012, accessed 11 August 2014). Peluso MA and Guerra de Andrade LH. Physical activity and mental health: The association between exercise and mood. Clinics (Sao Paulo) 2005;60:61–70. Hasson D and Arnetz BB. Validation and findings comparing VAS vs. Likert scales for psychosocial measurements. Int Electron J Health Educ 2005;8:178–92.
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