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With contributions from internationally renowned experts, Physical Activity and Mental Health presents research illustrating how the use of physical activity can enhance well-being and reduce the impact of potentially debilitating mental health conditions. Written for students, researchers, and professionals in exercise science, fitness, and health care fields, Physical Activity and Mental Health details the factors that influence the relationship between mental health and physical activity as well as the benefits of physical activity in dealing with mental illnesses such as Alzheimer’s disease, depression, schizophrenia, and addictive behaviors. Readers will learn how promotion of physical activity can lead to a greater sense of well-being or act as a medical intervention. Exercise readiness checklists, mental health checklists, and population-specific sample activity plans assist in creating and implementing exercise programs to meet the needs of patients or clients.
Physical Activity and Mental Health begins with an exploration of the brain systems that are affected by physical activity and how these affect mental well-being. The text continues with discussion of the following topics:
• An overview of physical activity guidelines and the challenges in measuring physical activity in a mental health context
• How physical activity promotes well-being across the life span and among socioeconomic statuses
• How physical activity and exercise can improve quality of life and recovery in people with a range of mental and physical health conditions
• An examination of exercise dependence, including its relationship with eating disorders and body dysmorphia and the negative impacts of excessive exercise on mental health
Learning features in each chapter assist both the student and practitioner in learning and referencing the information. A chapter outline and an editors’ introduction provide an overview of the structure and content. Key concepts cover important ideas and definitions. Evidence to Practice boxes review current knowledge and theory from a perspective of practical application. Each chapter concludes with a summary and list of references, and additional highlight boxes throughout the text accent important topics.
Physical Activity and Mental Health integrates theoretical and applied approaches with practical tips on exercise programs, measurement strategies, and methodological considerations. Balancing theory and practice, this resource assists students, researchers, and practitioners in understanding the links between physical activity, well-being, and mental health and how to apply this information for the benefit of patients and clients across a range of populations and conditions.
Part I: Introduction to Physical Activity and Mental Health
Chapter 1. Relationship Between Physical Activity and Mental Health
Angela Clow, PhD, and Sarah Edmunds, PhD
1. Science of Well-Being
2. Relationship Between Well-Being and Mental Health
3. Physical Activity as a Complex Behaviour
4. Biological Foundations of Effects of Physical Activity on Mental Health
5. Summary
6. References
Chapter 2. Physical Activity Guidelines and National Population-Based Actions
Fiona Bull, PhD, and Adrian Bauman, PhD
1. Population-Based Approach for Promoting Physical Activity
2. Physical Activity Guidelines
3. Development of the First National Physical Activity Guidelines
4. Current Best Practice in Developing Guidelines
5. Global, Regional and National Physical Activity Guidelines
6. Implementation and Influence of Physical Activity Guidelines
7. Summary
8. References
Chapter 3. Challenges in Measuring Physical Activity in the Context of Mental Health
Natalie Taylor, PhD
1. Types of Measurement Information
2. Factors That Affect Method Choice
3. Challenges in Measuring Physical Activity in a Mental Health Context
4. Available Methods for Measuring Physical Activity
5. Summary
6. References
Part II: Factors Influencing the Interaction Between Mental Health and Physical Activity
Chapter 4. Social Class Relationships in Physical Activity and Mental Health
Mark Hamer, PhD
1. Inequalities in Social Health
2. Social Class and Exercise
3. Nature Versus Nurture
4. SES Mechanisms Linking Physical Activity and Health
5. Public Health Interventions
6. Summary
7. References
Chapter 5. Physical Activity and Self-Esteem
Magnus Lindwall, PhD, and F. Hülya Aşçı, PhD
1. Multidimensional Hierarchical Model of Self-Concept
2. Physical Self
3. Global Self-Esteem and Physical Self-Esteem Across the Life Span
4. Causality of the Relationship Between Physical Activity and Self-Esteem
5. Biopsychosocial Model of the Relationship Between Exercise and Physical Self
6. Implications for Practitioners and Researchers
7. Summary
8. References
Chapter 6. Effects of Overtraining on Well-Being and Mental Health
John S. Raglin, PhD, Gregory Wilson, PED, and Goran Kenttä, PhD
1. Paradox of Increased Training and Decreased Performance
2. Signs and Symptoms of Overtraining Syndrome
3. Treatment of Overtraining Syndrome
4. Prevalence and Susceptibility in Athlete Samples
5. Early Detection Using Physiological Measures
6. Early Detection Using Psychological Measures
7. Summary
8. References
Chapter 7. Physical Functioning and Mental Health in Older Adults
Donald H. Paterson, PhD, and Juan M. Murias, PhD
1. Physical Activity and Mortality
2. Physical Activity, Functional Abilities, Independence and Well-Being Into Older Age
3. Physical Activity, Cognitive Function and Mental Health in Older Adults
4. Physical Activity Guidelines for Older Adults
5. Aerobic Exercise-Training Interventions
6. Strength-Training Interventions
7. Exercise-Training Interventions and Cognitive Function
8. Exercise Programmes for Older Adults
9. Summary
10. References
Chapter 8. Impact of Physical Activity on Mental Health in Long-Term Conditions
Sarah Edmunds, PhD, and Angela Clow, PhD
1. Long-Term Conditions and Mental Health Issues
2. Long-Term Conditions and Quality of Life
3. Long-Term Conditions and Physical Activity
4. Chronic Obstructive Pulmonary Disease
5. Diabetes
6. Cancer
7. Summary
8. References
Part III: Physical Activity and Mental Health Conditions
Chapter 9. Depression and Anxiety
Amanda Daley, PhD
1. Evidence Linking Depression and Exercise
2. Exercise and Postnatal Depression
3. Exercise and Antenatal Depression
4. Exercise and Anxiety
5. Exercise for Treating Depression and Anxiety
6. Exercise Versus Conventional Treatment for Depression and Anxiety
7. Promoting Exercise in the Treatment of Depression and Anxiety
8. Summary
9. References
Chapter 10. Dementia and Alzheimer’s Disease
Juan Tortosa Martinez, PhD
1. Risk Factors and Pathophysiology for Dementia and Alzheimer’s Disease
2. Need for Interventions
3. Physical Activity and the Prevention of Dementia and Alzheimer’s Disease
4. Exercise Conditions Effective at Delaying the Onset of Dementia
5. Mechanisms by Which Physical Activity May Affect Dementia
6. Physical Activity for Attenuating the Progression and Symptoms of Dementia and Alzheimer’s Disease
7. Physical Activity Interventions in Dementia and Alzheimer’s Disease
8. Summary
9. References
Chapter 11. Schizophrenia
Guy Faulkner, PhD, and Paul Gorczynski, MA
1. Schizophrenia and Physical Health
2. Self-Report Physical Activity Measures in Schizophrenic Populations
3. Factors That Influence Physical Activity in Schizophrenic Populations
4. Physical Activity Interventions in Schizophrenic Populations
5. Promoting Exercise in the Treatment of Schizophrenia
6. Summary
7. References
Chapter 12. Addictive Behaviour
Michael Ussher, PhD
1. Links Between Physical Activity and Addictive Behaviours
2. Mechanisms Underlying the Role of Physical Activity in Treatments for Addiction
3. Physical Activity Interventions for Addictive Behaviours
4. Designing a Physical Activity Programme for Individuals With Addictions
5. Summary
6. References
Chapter 13. Exercise Dependence, Eating Disorders, and Body Dysmorphia
Brian Cook, PhD and Heather Hausenblas, PhD
1. Exercise Dependence
2. Eating Disorders and Body Dysmorphia
3. Impact of Exercise Dependence on Well-Being and Health
4. Relationship Between Exercise Dependence and Eating Disorders
5. Models of Exercise Dependence and Eating Disorders
6. Exercise in Body Dysmorphia
7. Strategies for Minimizing the Risk of Exercise Dependence
8. Summary
9. References
Angela Clow, PhD, is a professor of psychophysiology in the department of psychology at the University of Westminster (London, United Kingdom). She also serves as the head of the department of psychology and leader of the psychophysiology and stress research group. Clow has garnered international acclaim for her research in the biological foundations of mental health. In 2002 she received the National Teaching Fellowship Award.
Sarah Edmunds, PhD, is a research fellow in the department of psychology at the University of Westminster. Edmunds is a BPS-chartered psychologist and HCPC-registered sport and exercise psychologist. She is well regarded as both a researcher and teacher in sport and exercise psychology.
As research partners, Clow and Edmunds combine their expertise in the areas of mental health and sport and exercise psychology to bring unique insight to the exploration of the connections between physical activity and mental health.
Available methods for measuring physical activity
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry.
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry. Most are moderately correlated at best. Each method has its own strengths and limitations. Due to the complexity of physical activity, outlined previously, researchers and practitioners need to consider what is most important for their purposes when deciding to use a particular technique. Although no one measurement tool can be singled out as the most appropriate, recommendations for the most useful and practical measurement tools can be made after considering factors such as context, type, duration, frequency and intensity of physical activity as well as the constraints under which the research or treatment programme is operating. These techniques are presented in order of increasing feasibility but decreasing validity. Table 3.2 at the end of this section summarises the key advantages and limitations of each measurement technique.
Doubly Labelled Water
Doubly labelled water (DLW, or free-living indirect calorimetry) is a method commonly used to increase the precision and accuracy of physical activity measurement. DLW, which measures EE over several (4-21) consecutive days in a free-living person under normal life conditions (Schoeller, 1988), is the most widely accepted gold standard method by which to measure EE (Aadahl & Jørgensen, 2003). DLW measures EE of free-living, unrestricted subjects using water labelled with stable isotopes of oxygen and hydrogen (Schoeller & van Santen, 1982). It calculates activity-related EE by combining measurement of total EE with basal metabolic rate. The utility of the DLW method in measuring total EE is demonstrated by its use in a variety of settings, including all age groups, premature infants, hospitalised patients, pregnant women and the elderly (Ainslie, Reilly & Westerterp, 2003). As such, researchers who use this method to assess the relationship between physical activity and other psychological variables or to detect changes in physical activity as a result of interventions can be confident that the results produced regarding EE are accurate. Schoeller (1988) fully describes the validation of the DLW method.
Despite its level of precision, the DLW method is not without disadvantages, which include high cost, limitations for assessing brief periods of EE (Ainslie, Reilly & Westerterp, 2003) and additional demands on participants in terms of time and tasks required. The cost and availability of isotopes and the requirement for analysis by isotope ratio mass spectrometer prohibit DLW from being widely used in studies of large populations. The use of this method among populations with more severe mental health problems may likely present a set of ethical issues. Furthermore, although this technique provides an accurate measure of total EE, it cannot provide information about patterns of physical activity in terms of type, frequency, duration, intensity or context. Consequently, such an approach would not be feasible in a large natural-field experiment or in a test of the effect of interventions on changes in physical activity in both healthy populations and populations that suffer from mental health problems. However, this gold standard measure is believed to offer the most precise estimate of EE and is often used to validate many other types of tools that assess physical activity.
Direct Observation
Direct observation, one of the most basic approaches for acquiring information about behaviours, provides information about how people exercise and play, how environments shape the activities individuals participate in and how people use specific facilities (e.g., parks, leisure facilities, walking or cycling paths). It can take place using basic observation methods, systematic forms or sophisticated technology (e.g., lasers). Direct observation often involves a trained observer who codes physical activity behaviours (e.g., sitting, walking, running) undertaken by participants over time in various settings (e.g., playground, park, home). A number of observation systems are available, such as SOPLAY (System for Observing Play and Leisure Activity in Youth), SOFIT (System for Observing Fitness Instruction Time), and the Systematic Pedestrian and Cycling Environmental Scan. The trained observer may either observe participants in person or review video media. Because it is time consuming, direct observation might be used only with small groups in specific settings (Dugdill & Stratton, 2007).
Advantages of direct observation include that self-report bias is eliminated, participants do not need to recall behaviour and the level of detail regarding behaviour patterns and context can be extremely accurate. Furthermore, practitioners may find some of these tools accessible. For example, clinical psychologists working with institutionalised individuals diagnosed with severe mental health conditions may find this type of measurement technique useful for assessing relationships between physical activity patterns or patterns of inactivity and specific mental illnesses because it can combine both context and behaviour to provide powerful data.
However, disadvantages include the time involved in recording and coding behaviour, the time involved in consolidating the plethora of data collected and the costs associated with training coders. Furthermore, the subjective bias of coders may lead to incorrect judgments about the intensities of specific activities, which would affect estimates of EE. As such, it would be important to consider whether information regarding patterns of behaviour combined with context or specific EE data are required to fulfill the aims of a research project or treatment programme.
Accelerometers
Motion sensors, such as pedometers and accelerometers, can be used to detect body movement and estimate physical activity (Spruijt-Metz et al., 2009). Accelerometers are devices that measure bodily movements in terms of acceleration. This measurement can then be used to estimate the intensity of physical activity, and therefore EE, over time (Burton et al., 2005; Chen & Basset, 2005). Accelerometers can measure human activity on vertical (uniaxial accelerometers), anterior - posterior and medial - lateral (triaxial accelerometers) planes. EE can then be then estimated from vector magnitude counts using a proprietary algorithm, which is a composite of counts from these planes of motion (Howe, Staudenmayer & Freedson, 2009). Accelerometers can be used repeatedly on numerous participants, are more accurate than pedometers and are less expensive (approximately £200 per device; ActiLife, 2009) than other objective methods such as DLW (approximately £200 per participant per procedure; Friedman & Johnson, 2002). However, they remain too expensive to use in studies that assess large numbers of people (Wood, 2000). Nevertheless, these devices are a more feasible and participant-friendly method of attempting to validate a self-report questionnaire than is DLW. They also provide the data necessary to allow researchers to distinguish between light, moderate and vigorous physical activity as well as between continuous and intermittent activity modes (Crouter, Clowers & Bassett, 2006). A recent review of accelerometers against DLW found ActiGraph (previously named CSA/MTI) models to be of the most valid types tested; they produce an average correlation of r = .57 (Plasqui & Westerterp, 2007). Limitations of accelerometers include the increased time required to analyse the large amount of data provided, participant burden of wearing the device, that they cannot be feasibly used to test large-scale interventions, and that they cannot provide information about the specific type of activity (e.g., playing football, going to the gym) or the context in which it is performed.
Some studies have attempted to validate accelerometers among populations diagnosed with mental health conditions. For example, Sharpe and colleagues (2006) conducted a study to assess the validity of the RT3 accelerometer against DLW in people with schizophrenia. They found that the accelerometer overpredicted energy expended on physical activity by an average of 148 kcal/day (standard deviation = 413 kcal/day); this varied from an underestimation of 614 kcal/day to an overestimation of 582 kcal/day. The authors suggested that the RT3 accelerometer is a poor tool for measuring activity EE in sedentary men with schizophrenia. As such, the results of studies that have used this measurement tool in mentally ill populations may be questionable. For example, the recent intervention study of Jerome and colleagues (2009) used the RT3 accelerometer to measure physical activity in persons with mental illness. The authors of this study concluded that participants were undertaking approximately 120 min/wk of moderate-intensity physical activity on average, which would equal approximately 70 kcal/day. Given that the results of the study by Sharpe and colleagues (2006) indicated that the RT3 accelerometer overpredicted EE, it is possible that the results found by Jerome and colleagues (2009) overestimate the amount of physical activity undertaken by participants. Consequently, this might affect the validity of the relationships found between physical activity and various mental health variables measured in this study. Sharpe and colleagues (2006) did, however, indicate that the RT3 appeared to be a valid measure of physical inactivity in men with schizophrenia. Therefore, it could be used for research or clinical purposes to quantify the contribution of sedentary behaviour to medical conditions associated with inactivity. Sharpe and colleagues (2006) also recommended that using the RT3 to validate questionnaires may not be appropriate until it is more robust.
Indirect Objective Measures
Indicators of the physiologic response to physical activity include heart rate and pulmonary gas exchange. Heart-rate monitoring is a promising measurement method because heart rate is a physiological parameter that correlates well with, and strongly predicts, EE (Strath et al., 2002). Most heart rate monitors include software that converts heart rate data into an estimate of EE. However, one of the limitations of heart rate monitoring is that training state and individual heart rate characteristics can affect the relationship between heart rate and oxygen consumption. Higher levels of accuracy can be obtained through a graded submaximal exercise test that calibrates participant heart rate to simultaneous oxygen consumption. This information allows for the construction of a calibration curve that estimates EE at moderate and strenuous levels of exercise. (A linear relationship exists between increasing heart rate and oxygen consumption; Freedson & Miller, 2000.) Measuring heart rate is a common method used to describe intensity and duration of physical activity and is a relatively inexpensive method of measuring EE. However, heart rate is affected by factors other than physical activity, such as emotional stress, temperature, humidity, dehydration, posture and illness (Ainslie, Reilly & Westerterp, 2003). These factors can influence heart rate without causing associated changes in oxygen consumption. Given the potentially increased fluctuations in emotions in individuals diagnosed with mental health conditions, this method may not be the most appropriate for obtaining accurate physical activity levels. Furthermore, the relationship between oxygen uptake and heart rate is weak at low levels of activity (Keim, Blanton & Kretsch, 2004). Evidence suggests that individuals suffering from mental health problems tend to perform less intensive physical activity than do members of the general population (e.g., Brown et al., 1999). Therefore, the heart rate method may not provide accurate information about the physical activity of mental health populations. Also, the heart rate method is unable to identify types of activity or the context in which physical activity is performed. Although heart rate is a physiological marker for physical activity and may provide a general picture of physical activity patterns, it may not be the best method available for obtaining an accurate estimate of EE.
Pedometers
Pedometers, which measure steps on a single axis as well as calories expended, are less expensive than some other types of motion sensors. As such, these devices are an attractive alternative to self-report in large observational or intervention studies. Public health campaigns have also promoted pedometers as a motivational tool for achieving the goal of 10,000 steps daily. A range of pedometers is available. The pedometer that is most suitable for a particular study may depend on factors such as the research question (outcome of interest), population, available funds, context and validity of the model. For example, when considering context, researchers or practitioners who wish to understand the types of physical activity being undertaken in a variety of settings would not gain this information using pedometers alone. When considering population, some pedometers are validated in healthy adults but not in other populations such as children, the elderly or those diagnosed with mental illness. Pedometers have demonstrated reduced accuracy in elderly populations because of the slow pace or shuffling nature with which elderly people walk (Cyarto, Myers & Tudor-Locke, 2004). Tudor-Locke and colleagues (2002) evaluated the validity of pedometers in a review of 25 studies and found a strong correlation between pedometer counts and accelerometer output (median of reported correlations is r = .86). However, evidence suggests that the validity of pedometers for measuring EE and distance in normal populations is questionable. The findings of a study testing the validity of 10 pedometers (Crouter et al., 2003) indicated that these devices overestimated distance at slower speeds and underestimated distance at faster speeds. Furthermore, in 8 of the pedometers tested, it was unclear whether the device was measuring gross EE (all the energy expended by an individual during a specific activity) or net EE (the energy expended by an individual during a specific activity minus the resting EE for the equivalent amount of time). The Yamax Digiwalker SW-200 was found to be the most reliable and accurate pedometer available (Crouter et al., 2003). This pedometer was used in a recent study by McKercher (2009) that assessed relationships between physical activity and depression in young adults. This study found that low levels of depression were significantly correlated with moderate levels of physical activity, as measured by the Yamax Digiwalker SW-200, among females. However, this device has not been validated in specific mental health populations, which may limit the validity of these results. It is important to validate physical activity devices among specific populations because patterns of physical activity in these populations may differ from those in the general population. For example, individuals with serious mental illness are significantly less active than the general population (Brown et al., 2004). As such, using a physical activity measure that has been validated with mental health populations in research on physical activity and mental health will increase the strength of the results produced.
Read more from Physical Activity and Mental Health edited by Angela Clow, Sarah Edmunds.
Coping with long-term physical health conditions
Approximately 30% of the European population has a long-term physical health condition. People with a long-term condition that is comorbid with a mental health problem have worse health outcomes than do people with either of these alone.
Key Concepts
- Approximately 30% of people with a long-term condition have a comorbid mental health condition.
- Physical activity is an important part of the management of physical and psychological well-being in people with long-term conditions.
- Pulmonary rehabilitation leads to reduced depression and anxiety and increased quality of life in people with chronic obstructive pulmonary disease. Further research is required to understand the optimal exercise dose; the interaction of exercise training, education and psychosocial support during pulmonary rehabilitation; and how to sustain changes in physical activity behaviour after pulmonary rehabilitation.
- Physical inactivity is associated with greater depression in people with type 2 diabetes. Further research is required to understand the causality of this relationship, although available data suggest that physical activity interventions reduce depression.
- Data that explore the relationship between physical activity and mental health in people with type 1 diabetes are limited.
- Physical activity has been shown to increase quality of life and reduce anxiety and depression in cancer survivors. Data suggest that supervised and group exercise are more beneficial than unsupervised and home-based exercise in this population.
Long-term conditions (LTCs) have been defined as "those conditions that cannot, at present, be cured, but can be controlled by medication and other therapies. The life of a person with an LTC is forever altered - there is no return to normal" (Department of Health, 2008, p. 10). LTCs include diabetes, arthritis, chronic obstructive pulmonary disease (COPD) and a number of cardiovascular diseases. In addition, conditions such as human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) and certain cancers that were not traditionally considered LTCs are increasingly being regarded as such (Naylor et al., 2012). Many mental health problems can themselves be considered LTCs. However, in this chapter the term long-term condition refers specifically to physical health conditions.
The World Health Organisation's (2011) report on the global burden of noncommunicable diseases (i.e., all previously mentioned LTCs except HIV and AIDS) found that noncommunicable diseases are by far the leading cause of mortality in the world and represent 63% of all deaths. The majority of these deaths are due to cardiovascular disease, diabetes, cancer and chronic respiratory disease. The highest occurrence of deaths from these diseases is in low- and middle-income countries, and the prevalence in these countries is predicted to increase substantially in the future. In Europe 29% of people aged 15 yr or older report a longstanding health problem (TNS Opinion, 2007), and the Office for National Statistics (2005) found that in England approximately 30% of the population (15.4 million people) has a LTC. As populations age, the burden of LTCs is projected to increase even further.
Long-Term Conditions and Mental Health Issues
People with LTCs are two to three times more likely than the general population to experience mental health problems. Depression and anxiety are the most frequently reported mental health problems in people with LTCs, but dementia, cognitive decline and some other conditions have also been reported (Naylor et al., 2012). Depression is two to three times more common in people with an LTC than in those with good physical health and occurs in approximately 20% of people with an LTC (National Collaborating Centre for Mental Health, 2010). Conservative estimates suggest that at least 30% of all people with an LTC also have a comorbid mental health problem of some kind (Cimpean & Drake, 2011). Research has shown that having a mental health problem along with an LTC has a stronger negative impact on quality of life and functional status than does either the number of LTCs or the severity of those conditions. For example, quality of life is lower in people with one LTC and depression than in people with two or more LTCs and no depression (Moussavi et al., 2007). Figure 8.1 shows the overlap between LTCs and mental health disorders.
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In addition to experiencing psychological distress, patients with an LTC and comorbid mental health problem experience poorer clinical outcomes compared with people with an LTC and no mental health problem (Moussavi et al., 2007). This is partly because self-management is necessary for effectively controlling LTCs, and poor mental health can result in poorer self-management. For example, it may lead to lack of motivation and energy to adhere to treatment plans or attend medical appointments (DiMatteo, Lepper & Croghan, 2000). From a financial perspective, comorbid mental health problems are typically associated with a 45% to 75% increase in care costs for a person with an LTC. These data are based on a wide range of LTCs and are observed after adjustment for severity of physical disease (Unützer et al., 2009; Welch et al., 2009).
Overlap between long-term conditions and mental health problems in England. Adapted, by permission, from C. Naylor et al., 2012, Long-term conditions and mental health: The cost of co-morbidities (London: The King's Fund and Centre for Mental Health).
Long-Term Conditions and Quality of Life
Quality of life is an individual's perception of their ability to function well on physical, mental and social levels. Quality of life can be measured in a reliable and valid manner using self-reported questionnaires, which can be categorised into three main groups: generic, disease specific and domain specific. Generic questionnaires measure quality of life in general terms, independent of the presence of any disease. Disease-specific questionnaires measure the consequences of a specific disease on quality of life. Domain-specific questionnaires focus on certain domains of quality of life (e.g., physical inabilities).
Where it is possible to manage but not cure a disease, such as in LTCs, measures of quality of life are frequently used to help determine the impact of treatment and disease. They help health professionals make informed judgements about whether treatment is appropriate and, where a choice of treatments exists, which might be the best option. Researchers frequently use these measures to assess the impact of a new intervention.
Long-Term Conditions and Physical Activity
Doctors have traditionally advised people with a range of LTCs to rest and not tire themselves out, and this advice persists in the lay psyche. For example, a recent Swedish survey found that the physical activity levels of people with diabetes, rheumatoid arthritis or COPD are lower than those of healthy controls; 73% of people with diabetes, 74% with rheumatoid arthritis and 84% with COPD reported low physical activity levels compared with 60% of controls (Arne et al., 2009). However, modern treatment of LTCs often includes promoting physical activity as part of a healthy lifestyle, and accumulating evidence shows the importance of physical activity in the management of both physical and psychological well-being for people with one or more LTCs. Regular contact between health professionals and people with LTCs provides opportunities for promoting physical activity in this group.
Each LTC presents its own challenges and benefits with regard to physical activity. The remainder of this chapter focusses in particular on the impact of physical activity on mental health and well-being in people with COPD, diabetes and cancer.
Chronic Obstructive Pulmonary Disease
COPD is characterised by airflow obstruction that is not fully reversible and usually progressive in the long term. It is predominantly caused by smoking. Symptoms include breathlessness (dyspnoea) on exertion, chronic cough, regular production of sputum and frequent winter bronchitis or wheeze. Exacerbation of symptoms often occurs in which the patient's symptoms rapidly worsen beyond normal day-to-day variations. Diagnosis relies on a combination of history, physical examination and confirmation of airflow obstruction using spirometry; no single test for COPD exists (National Institute for Health and Clinical Excellence, 2010). Severity of COPD is often classified using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria (I [mild], II [moderate], III [severe] and IV [very severe]) and index of body mass, airway obstruction, dyspnoea and exercise capacity (BODE).
The World Health Organisation has predicted that by 2020 COPD will be the third leading cause of death and fifth leading cause of disability in the world (Murray & Lopez, 1996, 1997). Mortality rates for men in the United Kingdom are at a plateau and mortality rates for women are steadily increasing (Soriano et al., 2000) most likely as a result of the uptake of smoking among women post-World War II. According to the chief medical officer in England, COPD accounts for more than £800 million in direct health care costs (Department of Health, 2005); more than one half of these costs relate to the provision of hospital care. COPD is among the most costly inpatient conditions that the National Health Service treats.
Read more from Physical Activity and Mental Health edited by Angela Clow, Sarah Edmunds.
Designing a physical activity program for individuals with addictions
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours.
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours. However, implementation of behavior change in this population can present practitioners with specific challenges. This section discusses the suggestions for designing effective interventions for those with addictions based on the evidence reviewed so far as well as practical considerations.
Exercise Type, Frequency and Intensity
Most studies have promoted moderate-intensity cardiovascular-type exercise such as brisk walking for use in those with addictive behaviours. Some work also incorporates more vigorous activities such as running. Because individuals with addictions are often extremely sedentary, a programme of moderate-intensity activity is likely to be acceptable and safe. However, a progression to more vigorous exercise may be beneficial. For example, the only study that found a long-term benefit of exercise for smoking cessation entailed 30 to 40 min of vigorous exercise 3 times/wk for 12 wk (Marcus et al., 1999). Similarly, the single study that showed a long-term impact of exercise on alcohol abstinence involved 1 h of progressively vigorous exercise 5 days/wk for 6 wk (Sinyor et al., 1982). None of the trials reviewed compared the effects of vigorous-intensity and moderate-intensity exercise on abstinence rates. Experimental studies have compared the effects of bouts of moderate-intensity and vigorous-intensity exercise and have shown that both intensities are effective in the short term for reducing tobacco-withdrawal symptoms (Taylor et al., 2007).
The intensity of activity that an individual is capable of depends on initial level of fitness, medical condition and stage of recovery from addiction. Careful medical screening is vital. For example, those addicted to amphetamine or cocaine are often undernourished, and problem drinkers often have weak muscles. Such individuals may require nutrition advice. Ultimately, individuals will have preferences regarding types of exercise, and programmes should be tailored to these preferences (Abrantes et al., 2011; Everson-Hock et al., 2010). Some individuals may prefer noncardiovascular types of exercise, which may also be beneficial. Resistance (i.e., weight) training, yoga and isometric exercise have all been successfully piloted as aids for smoking cessation and need to be tested in larger trials (Ussher, Taylor & Faulkner, 2012).
Regarding frequency and volume of exercise, the findings from Marcus and colleagues (2005) suggest that abstaining smokers need to accumulate at least 110 min/wk of moderate-intensity activity to maintain abstinence; supervised exercise on 2 or 3 days/wk may be necessary in order to achieve this. Shorter bouts of exercise can be used on an as-needed basis in response to cravings, and longer scheduled bouts can be used to maintain positive mood, manage stress and prevent cravings from arising. Research has not yet addressed the optimum dose of exercise for assisting alcohol and drug rehabilitation.
Exercise Supervision
The majority of intervention studies have employed group-based supervised exercise. In smokers, exercise counselling alone did not increase exercise levels sufficiently (Ussher et al., 2003), and all the interventions that showed a significant impact on long-term abstinence from alcohol or smoking entailed supervised exercise. Among novice exercisers, an element of supervised exercise may be useful to ensure initial adoption of regular exercise and to provide information about safe exercise (e.g., warm-up) and exercise intensities (e.g., using heart rate monitors). Counselling toward pursuing home-based exercise is also likely to be important for encouraging patients to maintain exercise levels after the initial exercise programme ends.
Stages of Addiction Treatment
Early recovery from drug and alcohol dependence is a major transition that affects close relationships and employment and involves numerous treatment sessions. An exercise programme needs to complement these changes. Most exercise interventions discussed in this chapter have required patients to alter their substance- or alcohol-misuse behaviour and exercise behaviour simultaneously, yet it is not clear whether this is optimal. For some individuals the challenge of changing two health behaviours simultaneously may be too demanding. Also, it is not clear whether involvement in physical activity increases the motivation to manage substance intake or vice versa.
Among smokers, exercise has often been introduced in the studies discussed several weeks before an attempt to quit, thereby allowing people to adjust to the demands of increased exercise before starting to quit. This also allows exercise to play a role in managing cravings during the crucial early days of abstinence, when relapse rates are highest. Empirical work is required to determine the relative benefits of initiating exercise at different points in the addiction-treatment process. During later stages of treatment exercise may be useful for preventing relapse (e.g., by promoting an exercise identity that is incompatible with drug use). Studies are also needed to determine whether exercise can be used to increase substance abstinence among those who are not motivated to attempt abstinence.
Integrating Exercise With Standard Addiction Treatments
Greater integration of addiction and exercise programmes may enhance abstinence rates. For instance, rather than just proposing exercise as a means for getting fitter and managing weight, the practitioner could present exercise more as a self-control strategy for managing withdrawal symptoms and a way to address psychological and physical harms caused by addiction. Exercise could be used more in combination with pharmaceutical interventions. Whereas pharmaceutical interventions focus on reducing withdrawal symptoms (e.g., NRT), exercise could ideally be used to provide an added effect in client-led management of addictive symptoms.
Perceived Barriers to Exercise
Individuals with addictions are likely to have specific barriers to exercise, and these need to be determined. In the general population, use of cognitive - behavioural techniques is effective for overcoming perceived barriers and increasing exercise adherence. Few addiction studies have included cognitive - behavioural counseling. Techniques such as self-monitoring (e.g., diaries), goal-setting and relapse-prevention planning are commonly used. Also, pedometers are now commonly used as a motivational tool. These and other motivational aids (e.g., financial incentives) need to be tested with exercise interventions in addicted populations.
Interventions for Different Subgroups
Exercise interventions need to be tested among addicted populations who might especially benefit from such interventions. Given the high prevalence of addictions among people with mental illness and the established benefits of regular physical activity for mental health, research that examines the role that physical activity may play in this population is needed (Arbour-Nicitopoulos et al., 2011).
Exercise interventions might be particularly appealing to adolescents, and controlled trials with young people are needed. Addicted individuals who are overweight may have a need for weight-control interventions such as exercise; no trial has yet focussed on this population. Additionally, surveys suggest that a nonpharmaceutical intervention such as exercise is likely to appeal to pregnant smokers (Ussher at al., 2008). Finally, sex needs to be considered when planning an appropriate intervention. Some evidence shows that women often prefer walking and aerobics, whereas men have more interest in sport, running and strength training.
Evidence to Practice
- Both moderate- and vigorous-intensity exercise have been shown to be effective for reducing tobacco-withdrawal symptoms and cravings.
- Progressing from light- and moderate-intensity exercise (e.g., brisk walking) to more vigorous-intensity exercise is advisable.
- Careful medical screening is required, especially among those with long-term alcohol or drug dependence (e.g., for malnutrition).
- Exercise interventions should be tailored to individual preferences.
- Abstaining smokers should accumulate at least 110 min/wk of moderate-intensity exercise.
- Interventions involving supervised exercise on 2 or 3 days/wk are likely to be necessary to be effective in treating addictive behaviours.
- Exercise can be performed on an as-needed basis for managing cravings or in scheduled bouts.
- If the exercise programme is to assist with early withdrawal symptoms, it ideally needs to begin before abstinence is attempted.
- Participating in physical activity encourages individuals to adopt an identity as an exerciser, which is incompatible with using addictive substances.
- Perceived barriers to exercise need to be identified and addressed using cognitive - behavioural techniques.
- The intervention needs to be adapted to various subgroups (e.g., according to sex, body weight and mental health).
Summary
Drug, alcohol and tobacco addictions are growing global problems. Exercise has many benefits for physical and psychological health, and evidence convincingly shows that exercise is effective for managing cravings and withdrawal symptoms, particularly in smokers. Regular exercise fosters a healthy lifestyle and exercise identity that is largely incompatible with addiction, and individuals undergoing rehabilitation for addiction express interest in exercising more. Exercise interventions are inexpensive, can be easily integrated with existing addiction treatments and have minimal side effects compared with pharmacological treatments. This chapter demonstrates that exercise is a highly plausible adjunctive treatment for addictive behaviour and that exercise programmes can be readily disseminated. However, limited evidence currently supports the benefits of exercise for helping smokers quit or helping those with drug or alcohol dependence abstain. This lack of evidence can partly be explained by the small number of large RCTs that have been conducted, lack of knowledge about effective doses of exercise and limited attention to methods for maximizing exercise adherence. This area of research is in its infancy, and further well-designed trials are needed.
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Physical activity guidelines
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits.
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits. National guidelines aimed at the whole population (as opposed to specific populations defined by a medical condition) focus on the optimal amount of activity to prevent disease and promote health and well-being. PAGs indicate the type (e.g., aerobic activity, strength training, weight bearing), frequency (e.g., 3 days/wk), duration (e.g., 30 min) and intensity (e.g., moderate, vigorous) (see figure 2.2) of physical activity to undertake and for what benefits. These detailed specifications reflect the latest science on the topic.
PAGs need to be updated periodically because evidence about the relationship between physical activity and health changes over time and knowledge grows. Some guidelines are more general in nature, whereas others provide very specific details; this usually reflects the state of knowledge at that time. Through a review and revision process, more specific details are added to PAGs when available. For example, in various national PAGs, guidelines relating to maintaining musculoskeletal strength have been revised over time and now include details on how much strength training is required for good health (World Health Organisation, 2010) and, specifically, for preventing falls and treating depression (Singh, Clements & Singh, 2001).
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The dose - response relationship: Increasing benefits from increasing amounts (expressed in frequency, duration and intensity) of activity. Reprinted, by permission, from I. Vuori, 1995, Terveysliikunta [Health and physical education]. UKK Institute for Health Promotion Research (Tampere, Finland).
National guidelines are an important component of a population-based approach to addressing any public health issue. First, such guidelines communicate a consensus on the scientific evidence of the importance of the issue. They describe the strength of the science in terms of the volume as well as the quality (determined based on the quality of study designs and research methods used) of the evidence. Communicating scientific consensus is important because it removes doubt and speculation about the validity of the health issue and its importance. This scientific consensus can also be used to advocate for resources and programmes. However, just because guidelines exist does not mean that everyone agrees about what the science says - far from it. However, these disagreements, or alternative interpretations of overall findings to date, are usually communicated in technical reports that accompany the publication of PAGs and are not fully accessible to the general public.
The process of developing PAGs usually involves leadership by a high-level institution. This adds credence to the message that the issue is important. For example, several national and international health agencies, such as the American Heart Association (Haskell et al., 2007), have developed guidelines on physical activity. National governments, usually the ministry of health, often lead the development process and endorse national PAGs. This endorsement is very useful because it specifies the government's position on physical activity and thereby provides the opportunity for interested parties such as charities and public health directors to leverage the government into supporting further action and funding for programmes and services aimed at increasing physical activity. This might include government endorsement of counselling and clinical services for inactive patients, as has been trialled in the United Kingdom (Bull & Milton, 2011). Government involvement and endorsement can also prevent policy inaction. The absence of an official position on physical activity can block funding and further development of a national population-based approach.
One important role of PAGs is to direct community-level actions aimed at increasing physical activity in the whole population. The details in PAGs about the type, frequency, duration and intensity of activities required for different age groups can provide clinicians, health care practitioners and others with direction on what types of programmes to provide and promote to patients and the wider community.
PAGs should drive and direct action not just at the level of individuals and service providers but also at all levels - national, regional and local - of government. If the national government endorses PAGs, ideally with multiparty political support, the government should be held accountable when levels of physical activity are not improving and can be expected to include physical activity promotion as part of ongoing disease-prevention and health-promotion strategies. The role of PAGs and national surveillance of risk factors is discussed in more detail later in this chapter.
Development of the First National Physical Activity Guidelines
Epidemiological studies of exercise and health were well advanced by the 1970s. The American College of Sports Medicine released the first set of recommendations in 1975 and released another set in 1980 (American College of Sports Medicine, 1975, 1980). These recommendations were predominantly directed at cardiorespiratory fitness and suggested that people undertake vigorous-intensity aerobic exercise 3 times/wk for 20 min each time. This was a practical interpretation of the exact recommendation from 1975, which suggested that people undertake 20 to 45 min of physical activity 3 to 5 days/wk at 70% to 90% of heart rate (i.e., vigorous intensity) (American College of Sports Medicine, 1975). The focus on aerobic exercise for increasing fitness continued to dominate and influence health messages about physical activity until the early 1990s. However, guidelines began to recommend moderate-intensity physical activity rather than vigorous-intensity activity, and by the mid-1990s the focus shifted from cardiorespiratory fitness to health benefits. This new position on physical activity was communicated in a landmark set of recommendations from the office of the U.S. surgeon general in the report "Physical Activity and Health" (U.S. Centers for Disease Control and Prevention, 1996).
In the mid-1990s, epidemiological evidence started to show that people with different health conditions require slightly different amounts of physical activity. Although the recommendation for 30 min of moderate-intensity activity on most days remained valid for preventing heart disease and diabetes, studies showed that slightly more physical activity was recommended for preventing cancer. Further, studies identified that the amount of activity required for weight loss or preventing weight gain was greater than that required to prevent chronic disease (Haskell et al., 2007). For example, the International Association for the Study of Obesity recommendations made a clear distinction between the minimum physical activity required for health benefits and the amount required for preventing weight gain. The recommendations state that "45 to 60 min (60-90 min for formerly obese individuals) of moderate-intensity physical activity daily is needed to prevent the transition to overweight or obesity" (Saris et al., 2003). Furthermore, research has now shown that the amount of physical activity required by young people differs from that of adults. The overall amount of physical activity recommended for children is twice that recommended for adults and is usually expressed as "at least 60 min/day" (Canadian Society for Exercise Physiology, 2011a; Saris et al., 2003).
These different recommendations make the development of PAGs complex. However, a core and consistent interpretation of the evidence is that 30 min of moderate-intensity physical activity on most days of the week is associated with maximum overall population benefit and the prevention of major noncommunicable diseases. This same dose has been expressed as "at least 150 min/wk of moderate-intensity activity" in the most recent global, U.S. and U.K recommendations (Department of Health, 2011b; U.S. Department of Health and Human Services, 2008a; World Health Organisation, 2010).
Current Best Practice in Developing Guidelines
Figure 2.3 illustrates the process of developing guidelines. The first step is establishing the need for guidelines. This need is often defined by policymakers, public health scientists, advocates and, sometimes, the community. Then a process for guideline development needs to be agreed on by interested parties, with actions planned in sequence and, ideally, a linkage between the PAG development process and other aspects of national or regional physical activity policy and strategy development (step 1 in figure 2.3). The next stage comprises reviewing the scientific evidence and creating an updated summary of what the research says and how this information differs from that in previous guidelines. A number of countries, notably Canada and, most recently, the United Kingdom and United States, have undertaken this process. Tremblay and colleagues (2010) extensively discuss this process with reference to the recent Canadian guidelines along with frameworks and a checklist for auditing data quality in the review stage.
Once the science has been reviewed, the next stage is developing communication messages based on the evidence and testing these messages with the target audience for acceptability, comprehension and usefulness. This step is part of developing a communications strategy for disseminating the evidence (stages 3 and 4 in figure 2.3). It requires resources for conducting the qualitative and quantitative research and the involvement of communications and media specialists in framing the messages correctly so that they will have optimal impact on the target populations. The final stages (stages 5-7 in figure 2.3) involve disseminating the message to the community, professional groups and other stakeholders. Historically, those developing PAGs have put considerable effort into the technical and scientific stages and have often neglected message development and communication. Frequently, only informal and unpaid communication channels are used after the launch of PAGs. Thus, a very important step in PAG development and dissemination is the final public health promotion component.
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Framework for developing physical activity guidelines. Adapted from Bauman et al. 2006.
Global, Regional and National Physical Activity Guidelines
Table 2.1 summarises the 2011 global PAGs and provides examples of regional (i.e., European and Western Pacific islands) and national guidelines. Quite a few countries in Europe have their own national PAGs, and many of these countries (e.g., Finland, Switzerland, the Netherlands, United Kingdom) have been engaged with implementing national population-based approaches for some time (Department of Health, 2011b; Ministry of Health, Welfare and Sport, 2011; Swiss Federal Office of Sports, 2006; UKK Institute, 2009). Other countries in Europe have officially or unofficially adopted the guidelines published by the U.S. Centers for Disease Control and Prevention in 1996 and the more recently updated 2008 version.
PAGs in other regions of the world are patchy. Australia (Department of Health and Ageing, 2005b) and New Zealand (Sport and Recreation New Zealand, 2005) have had national guidelines for some time. In Australia, guidelines exist for all ages, from young children (Department of Health and Ageing, 2004) to older adults (Department of Health and Ageing, 2005b), although all guidelines are more than 5 yr old and arguably are due for updating to reflect the latest science. Far fewer examples of PAGs exist in South America, Asia, the Middle East and Africa because physical activity promotion is relatively new in these regions. Countries in which national action on physical activity is beginning have often used the U.S. guidelines as an international benchmark. This has allowed the countries to develop an agenda of physical activity promotion without being hindered by the absence of PAGs. However, in some countries, adopting the PAGs of another country is not politically or culturally welcome or appropriate. Either these countries have developed their own PAGs (a recent example from the Middle East is Brunei; Ministry of Health, 2011) or very little physical activity promotion has occurred.
The absence of a set of official global guidelines did not hinder the World Health Organisation (WHO) from developing the Global Strategy on Diet, Physical Activity and Health in 2004 (World Health Organisation, 2004). Since the publication of the 2002 health report (World Health Organisation, 2002), the focus on the need for greater action to prevent noncommunicable disease and address mental health has increased. To address these issues, WHO commenced developing global guidelines in 2007. WHO launched the final global recommendations on physical activity in 2010 after a 2 yr process involving global and regional consultations (World Health Organisation, 2010). These global guidelines are now available for adoption and use by countries with no national PAGs. Because the guidelines are from WHO, the leading international health agency, the scientific quality and relevance of these guidelines are usually accepted.
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Treating depression and anxiety with exercise
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety.
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety. Information about these prescription parameters is scarce, but it is critical if exercise interventions are to be translated into clinical practice. Asking someone to do something without specifying what they should do or how they should do it would likely make it difficult for the individual to fully comply in a meaningful way. It is also possible that the prescription of exercise for depression and/or anxiety could be different, both in nature and content, than that required for general health benefits.
One trial that is particularly worthy of attention is the Depression Outcomes Study of Exercise (DOSE; Dunn et al., 2005), which attempted to provide evidence about the dose of exercise required to treat depression. In the DOSE study 80 participants were randomised to 1 of 4 exercise groups that varied in total energy expenditure (7 or 17.5 kcal·kg-1·wk-1) and frequency (3 or 5 days/wk) or to a flexibility-exercise placebo control for 12 wk. Exercise at a dose of 17.5 kcal·kg-1·wk-1 was effective in reducing depression regardless of frequency, whereas exercise at a dose of 7 kcal·kg-1·wk-1 yielded antidepressant effects that were comparable to those of the placebo treatment. The plausible biological reason for why a higher dose of exercise may be more effective than lower doses is that frequent and regular exercise should increase fitness levels such that physical discomfort decreases and exercise becomes a more pleasant and enjoyable experience as the conditioning process progresses. Indeed, findings from both the DOSE and TREAD trials in the United States have indicated that higher doses of exercise are more effective than are lower doses (as defined in the study).
Perraton and colleagues (2010) published a systematic review that attempted to summarise what is currently known about the prescription of exercise for depression. The review is useful because previous reviews of exercise and depression did not synthesise this information in a way that would help guide intervention development. This review included only trials that had reported exercise to be effective in reducing depression in order to analyse the specific dosage parameters and modes of exercise used in these successful trials.
The review found that the most common intensity, frequency and duration of aerobic exercise were 60% to 80% of maximum heart rate, 30 min/session and 3 days/wk over 8 wk. The volume of evidence supporting the use of aerobic exercise programmes to treat depression was greater than that supporting the use of anaerobic exercise programmes. No clear trend showed one mode of aerobic exercise to be the most effective, and a range of activity types appeared to be effective. This is encouraging given that one size does not fit all, and individuals can be encouraged to participate in whatever type of aerobic activity they prefer.
In terms of context of exercise, a number of common trends emerged. A variety of locations were effective in treating depression, although all trials that reported location took place indoors. Both group and individual interventions were effective. However, group exercise may have added benefit by providing social support, which can be pivotal for sustaining compliance and can contribute in its own right to lowering depression. Moreover, exercise might lower depression by several plausible mechanisms, one of which could be interrelations or connections with others (Bailey & McLaren, 2005). Many types of exercise can be performed with other people (depressed or not). Therefore, this exercise could provide social integration and an opportunity to interact with the social world as well as a setting in which to expand social networks and make friends (Stathi, Fox & McKenna, 2002).
Another unresolved question concerns the intensity of exercise at which a reduction in depression might occur. Callaghan and colleagues (2011) compared the effects of preferred intensity with those of prescribed intensity of group-based exercise for 12 sessions over 4 wk in 38 women aged 45 to 65 yr who were receiving treatment for depression from either primary or secondary care services. The preferred-intensity group reported significantly lower depression and higher self-esteem and quality-of-life scores than did the prescribed-exercise group and attended more sessions (66% versus 50%). Similar findings have been found in nondepressed populations (Daley & Maynard, 2003). Several theories, such as self-determination theory (Deci & Ryan, 1985), support the notion that giving people a choice and control over what they do, whether it be exercise or other activities, leads to better adherence and enjoyment of the activity, which in turn leads to enhanced psychological well-being. People experiencing depression are no exception.
Wipfli, Rethorst and Landers (2008) considered the relationship between dose of exercise and anxiety levels as part of their broader meta-analysis of the anxiolytic effect of exercise. The trend in the data from 12 RCTs showed that the effect size increased as exercise approached a dose of 12.5 kcal·kg-1·wk-1 (equates to slightly less than the dose recommended for public health) and then began to decrease as exercise dose increased. A combination of aerobic and anaerobic exercise appeared to be better than either type alone, and a frequency of 3 or 4 times/wk appeared more effective than more or less than this amount.
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Available methods for measuring physical activity
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry.
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry. Most are moderately correlated at best. Each method has its own strengths and limitations. Due to the complexity of physical activity, outlined previously, researchers and practitioners need to consider what is most important for their purposes when deciding to use a particular technique. Although no one measurement tool can be singled out as the most appropriate, recommendations for the most useful and practical measurement tools can be made after considering factors such as context, type, duration, frequency and intensity of physical activity as well as the constraints under which the research or treatment programme is operating. These techniques are presented in order of increasing feasibility but decreasing validity. Table 3.2 at the end of this section summarises the key advantages and limitations of each measurement technique.
Doubly Labelled Water
Doubly labelled water (DLW, or free-living indirect calorimetry) is a method commonly used to increase the precision and accuracy of physical activity measurement. DLW, which measures EE over several (4-21) consecutive days in a free-living person under normal life conditions (Schoeller, 1988), is the most widely accepted gold standard method by which to measure EE (Aadahl & Jørgensen, 2003). DLW measures EE of free-living, unrestricted subjects using water labelled with stable isotopes of oxygen and hydrogen (Schoeller & van Santen, 1982). It calculates activity-related EE by combining measurement of total EE with basal metabolic rate. The utility of the DLW method in measuring total EE is demonstrated by its use in a variety of settings, including all age groups, premature infants, hospitalised patients, pregnant women and the elderly (Ainslie, Reilly & Westerterp, 2003). As such, researchers who use this method to assess the relationship between physical activity and other psychological variables or to detect changes in physical activity as a result of interventions can be confident that the results produced regarding EE are accurate. Schoeller (1988) fully describes the validation of the DLW method.
Despite its level of precision, the DLW method is not without disadvantages, which include high cost, limitations for assessing brief periods of EE (Ainslie, Reilly & Westerterp, 2003) and additional demands on participants in terms of time and tasks required. The cost and availability of isotopes and the requirement for analysis by isotope ratio mass spectrometer prohibit DLW from being widely used in studies of large populations. The use of this method among populations with more severe mental health problems may likely present a set of ethical issues. Furthermore, although this technique provides an accurate measure of total EE, it cannot provide information about patterns of physical activity in terms of type, frequency, duration, intensity or context. Consequently, such an approach would not be feasible in a large natural-field experiment or in a test of the effect of interventions on changes in physical activity in both healthy populations and populations that suffer from mental health problems. However, this gold standard measure is believed to offer the most precise estimate of EE and is often used to validate many other types of tools that assess physical activity.
Direct Observation
Direct observation, one of the most basic approaches for acquiring information about behaviours, provides information about how people exercise and play, how environments shape the activities individuals participate in and how people use specific facilities (e.g., parks, leisure facilities, walking or cycling paths). It can take place using basic observation methods, systematic forms or sophisticated technology (e.g., lasers). Direct observation often involves a trained observer who codes physical activity behaviours (e.g., sitting, walking, running) undertaken by participants over time in various settings (e.g., playground, park, home). A number of observation systems are available, such as SOPLAY (System for Observing Play and Leisure Activity in Youth), SOFIT (System for Observing Fitness Instruction Time), and the Systematic Pedestrian and Cycling Environmental Scan. The trained observer may either observe participants in person or review video media. Because it is time consuming, direct observation might be used only with small groups in specific settings (Dugdill & Stratton, 2007).
Advantages of direct observation include that self-report bias is eliminated, participants do not need to recall behaviour and the level of detail regarding behaviour patterns and context can be extremely accurate. Furthermore, practitioners may find some of these tools accessible. For example, clinical psychologists working with institutionalised individuals diagnosed with severe mental health conditions may find this type of measurement technique useful for assessing relationships between physical activity patterns or patterns of inactivity and specific mental illnesses because it can combine both context and behaviour to provide powerful data.
However, disadvantages include the time involved in recording and coding behaviour, the time involved in consolidating the plethora of data collected and the costs associated with training coders. Furthermore, the subjective bias of coders may lead to incorrect judgments about the intensities of specific activities, which would affect estimates of EE. As such, it would be important to consider whether information regarding patterns of behaviour combined with context or specific EE data are required to fulfill the aims of a research project or treatment programme.
Accelerometers
Motion sensors, such as pedometers and accelerometers, can be used to detect body movement and estimate physical activity (Spruijt-Metz et al., 2009). Accelerometers are devices that measure bodily movements in terms of acceleration. This measurement can then be used to estimate the intensity of physical activity, and therefore EE, over time (Burton et al., 2005; Chen & Basset, 2005). Accelerometers can measure human activity on vertical (uniaxial accelerometers), anterior - posterior and medial - lateral (triaxial accelerometers) planes. EE can then be then estimated from vector magnitude counts using a proprietary algorithm, which is a composite of counts from these planes of motion (Howe, Staudenmayer & Freedson, 2009). Accelerometers can be used repeatedly on numerous participants, are more accurate than pedometers and are less expensive (approximately £200 per device; ActiLife, 2009) than other objective methods such as DLW (approximately £200 per participant per procedure; Friedman & Johnson, 2002). However, they remain too expensive to use in studies that assess large numbers of people (Wood, 2000). Nevertheless, these devices are a more feasible and participant-friendly method of attempting to validate a self-report questionnaire than is DLW. They also provide the data necessary to allow researchers to distinguish between light, moderate and vigorous physical activity as well as between continuous and intermittent activity modes (Crouter, Clowers & Bassett, 2006). A recent review of accelerometers against DLW found ActiGraph (previously named CSA/MTI) models to be of the most valid types tested; they produce an average correlation of r = .57 (Plasqui & Westerterp, 2007). Limitations of accelerometers include the increased time required to analyse the large amount of data provided, participant burden of wearing the device, that they cannot be feasibly used to test large-scale interventions, and that they cannot provide information about the specific type of activity (e.g., playing football, going to the gym) or the context in which it is performed.
Some studies have attempted to validate accelerometers among populations diagnosed with mental health conditions. For example, Sharpe and colleagues (2006) conducted a study to assess the validity of the RT3 accelerometer against DLW in people with schizophrenia. They found that the accelerometer overpredicted energy expended on physical activity by an average of 148 kcal/day (standard deviation = 413 kcal/day); this varied from an underestimation of 614 kcal/day to an overestimation of 582 kcal/day. The authors suggested that the RT3 accelerometer is a poor tool for measuring activity EE in sedentary men with schizophrenia. As such, the results of studies that have used this measurement tool in mentally ill populations may be questionable. For example, the recent intervention study of Jerome and colleagues (2009) used the RT3 accelerometer to measure physical activity in persons with mental illness. The authors of this study concluded that participants were undertaking approximately 120 min/wk of moderate-intensity physical activity on average, which would equal approximately 70 kcal/day. Given that the results of the study by Sharpe and colleagues (2006) indicated that the RT3 accelerometer overpredicted EE, it is possible that the results found by Jerome and colleagues (2009) overestimate the amount of physical activity undertaken by participants. Consequently, this might affect the validity of the relationships found between physical activity and various mental health variables measured in this study. Sharpe and colleagues (2006) did, however, indicate that the RT3 appeared to be a valid measure of physical inactivity in men with schizophrenia. Therefore, it could be used for research or clinical purposes to quantify the contribution of sedentary behaviour to medical conditions associated with inactivity. Sharpe and colleagues (2006) also recommended that using the RT3 to validate questionnaires may not be appropriate until it is more robust.
Indirect Objective Measures
Indicators of the physiologic response to physical activity include heart rate and pulmonary gas exchange. Heart-rate monitoring is a promising measurement method because heart rate is a physiological parameter that correlates well with, and strongly predicts, EE (Strath et al., 2002). Most heart rate monitors include software that converts heart rate data into an estimate of EE. However, one of the limitations of heart rate monitoring is that training state and individual heart rate characteristics can affect the relationship between heart rate and oxygen consumption. Higher levels of accuracy can be obtained through a graded submaximal exercise test that calibrates participant heart rate to simultaneous oxygen consumption. This information allows for the construction of a calibration curve that estimates EE at moderate and strenuous levels of exercise. (A linear relationship exists between increasing heart rate and oxygen consumption; Freedson & Miller, 2000.) Measuring heart rate is a common method used to describe intensity and duration of physical activity and is a relatively inexpensive method of measuring EE. However, heart rate is affected by factors other than physical activity, such as emotional stress, temperature, humidity, dehydration, posture and illness (Ainslie, Reilly & Westerterp, 2003). These factors can influence heart rate without causing associated changes in oxygen consumption. Given the potentially increased fluctuations in emotions in individuals diagnosed with mental health conditions, this method may not be the most appropriate for obtaining accurate physical activity levels. Furthermore, the relationship between oxygen uptake and heart rate is weak at low levels of activity (Keim, Blanton & Kretsch, 2004). Evidence suggests that individuals suffering from mental health problems tend to perform less intensive physical activity than do members of the general population (e.g., Brown et al., 1999). Therefore, the heart rate method may not provide accurate information about the physical activity of mental health populations. Also, the heart rate method is unable to identify types of activity or the context in which physical activity is performed. Although heart rate is a physiological marker for physical activity and may provide a general picture of physical activity patterns, it may not be the best method available for obtaining an accurate estimate of EE.
Pedometers
Pedometers, which measure steps on a single axis as well as calories expended, are less expensive than some other types of motion sensors. As such, these devices are an attractive alternative to self-report in large observational or intervention studies. Public health campaigns have also promoted pedometers as a motivational tool for achieving the goal of 10,000 steps daily. A range of pedometers is available. The pedometer that is most suitable for a particular study may depend on factors such as the research question (outcome of interest), population, available funds, context and validity of the model. For example, when considering context, researchers or practitioners who wish to understand the types of physical activity being undertaken in a variety of settings would not gain this information using pedometers alone. When considering population, some pedometers are validated in healthy adults but not in other populations such as children, the elderly or those diagnosed with mental illness. Pedometers have demonstrated reduced accuracy in elderly populations because of the slow pace or shuffling nature with which elderly people walk (Cyarto, Myers & Tudor-Locke, 2004). Tudor-Locke and colleagues (2002) evaluated the validity of pedometers in a review of 25 studies and found a strong correlation between pedometer counts and accelerometer output (median of reported correlations is r = .86). However, evidence suggests that the validity of pedometers for measuring EE and distance in normal populations is questionable. The findings of a study testing the validity of 10 pedometers (Crouter et al., 2003) indicated that these devices overestimated distance at slower speeds and underestimated distance at faster speeds. Furthermore, in 8 of the pedometers tested, it was unclear whether the device was measuring gross EE (all the energy expended by an individual during a specific activity) or net EE (the energy expended by an individual during a specific activity minus the resting EE for the equivalent amount of time). The Yamax Digiwalker SW-200 was found to be the most reliable and accurate pedometer available (Crouter et al., 2003). This pedometer was used in a recent study by McKercher (2009) that assessed relationships between physical activity and depression in young adults. This study found that low levels of depression were significantly correlated with moderate levels of physical activity, as measured by the Yamax Digiwalker SW-200, among females. However, this device has not been validated in specific mental health populations, which may limit the validity of these results. It is important to validate physical activity devices among specific populations because patterns of physical activity in these populations may differ from those in the general population. For example, individuals with serious mental illness are significantly less active than the general population (Brown et al., 2004). As such, using a physical activity measure that has been validated with mental health populations in research on physical activity and mental health will increase the strength of the results produced.
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Coping with long-term physical health conditions
Approximately 30% of the European population has a long-term physical health condition. People with a long-term condition that is comorbid with a mental health problem have worse health outcomes than do people with either of these alone.
Key Concepts
- Approximately 30% of people with a long-term condition have a comorbid mental health condition.
- Physical activity is an important part of the management of physical and psychological well-being in people with long-term conditions.
- Pulmonary rehabilitation leads to reduced depression and anxiety and increased quality of life in people with chronic obstructive pulmonary disease. Further research is required to understand the optimal exercise dose; the interaction of exercise training, education and psychosocial support during pulmonary rehabilitation; and how to sustain changes in physical activity behaviour after pulmonary rehabilitation.
- Physical inactivity is associated with greater depression in people with type 2 diabetes. Further research is required to understand the causality of this relationship, although available data suggest that physical activity interventions reduce depression.
- Data that explore the relationship between physical activity and mental health in people with type 1 diabetes are limited.
- Physical activity has been shown to increase quality of life and reduce anxiety and depression in cancer survivors. Data suggest that supervised and group exercise are more beneficial than unsupervised and home-based exercise in this population.
Long-term conditions (LTCs) have been defined as "those conditions that cannot, at present, be cured, but can be controlled by medication and other therapies. The life of a person with an LTC is forever altered - there is no return to normal" (Department of Health, 2008, p. 10). LTCs include diabetes, arthritis, chronic obstructive pulmonary disease (COPD) and a number of cardiovascular diseases. In addition, conditions such as human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) and certain cancers that were not traditionally considered LTCs are increasingly being regarded as such (Naylor et al., 2012). Many mental health problems can themselves be considered LTCs. However, in this chapter the term long-term condition refers specifically to physical health conditions.
The World Health Organisation's (2011) report on the global burden of noncommunicable diseases (i.e., all previously mentioned LTCs except HIV and AIDS) found that noncommunicable diseases are by far the leading cause of mortality in the world and represent 63% of all deaths. The majority of these deaths are due to cardiovascular disease, diabetes, cancer and chronic respiratory disease. The highest occurrence of deaths from these diseases is in low- and middle-income countries, and the prevalence in these countries is predicted to increase substantially in the future. In Europe 29% of people aged 15 yr or older report a longstanding health problem (TNS Opinion, 2007), and the Office for National Statistics (2005) found that in England approximately 30% of the population (15.4 million people) has a LTC. As populations age, the burden of LTCs is projected to increase even further.
Long-Term Conditions and Mental Health Issues
People with LTCs are two to three times more likely than the general population to experience mental health problems. Depression and anxiety are the most frequently reported mental health problems in people with LTCs, but dementia, cognitive decline and some other conditions have also been reported (Naylor et al., 2012). Depression is two to three times more common in people with an LTC than in those with good physical health and occurs in approximately 20% of people with an LTC (National Collaborating Centre for Mental Health, 2010). Conservative estimates suggest that at least 30% of all people with an LTC also have a comorbid mental health problem of some kind (Cimpean & Drake, 2011). Research has shown that having a mental health problem along with an LTC has a stronger negative impact on quality of life and functional status than does either the number of LTCs or the severity of those conditions. For example, quality of life is lower in people with one LTC and depression than in people with two or more LTCs and no depression (Moussavi et al., 2007). Figure 8.1 shows the overlap between LTCs and mental health disorders.
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In addition to experiencing psychological distress, patients with an LTC and comorbid mental health problem experience poorer clinical outcomes compared with people with an LTC and no mental health problem (Moussavi et al., 2007). This is partly because self-management is necessary for effectively controlling LTCs, and poor mental health can result in poorer self-management. For example, it may lead to lack of motivation and energy to adhere to treatment plans or attend medical appointments (DiMatteo, Lepper & Croghan, 2000). From a financial perspective, comorbid mental health problems are typically associated with a 45% to 75% increase in care costs for a person with an LTC. These data are based on a wide range of LTCs and are observed after adjustment for severity of physical disease (Unützer et al., 2009; Welch et al., 2009).
Overlap between long-term conditions and mental health problems in England. Adapted, by permission, from C. Naylor et al., 2012, Long-term conditions and mental health: The cost of co-morbidities (London: The King's Fund and Centre for Mental Health).
Long-Term Conditions and Quality of Life
Quality of life is an individual's perception of their ability to function well on physical, mental and social levels. Quality of life can be measured in a reliable and valid manner using self-reported questionnaires, which can be categorised into three main groups: generic, disease specific and domain specific. Generic questionnaires measure quality of life in general terms, independent of the presence of any disease. Disease-specific questionnaires measure the consequences of a specific disease on quality of life. Domain-specific questionnaires focus on certain domains of quality of life (e.g., physical inabilities).
Where it is possible to manage but not cure a disease, such as in LTCs, measures of quality of life are frequently used to help determine the impact of treatment and disease. They help health professionals make informed judgements about whether treatment is appropriate and, where a choice of treatments exists, which might be the best option. Researchers frequently use these measures to assess the impact of a new intervention.
Long-Term Conditions and Physical Activity
Doctors have traditionally advised people with a range of LTCs to rest and not tire themselves out, and this advice persists in the lay psyche. For example, a recent Swedish survey found that the physical activity levels of people with diabetes, rheumatoid arthritis or COPD are lower than those of healthy controls; 73% of people with diabetes, 74% with rheumatoid arthritis and 84% with COPD reported low physical activity levels compared with 60% of controls (Arne et al., 2009). However, modern treatment of LTCs often includes promoting physical activity as part of a healthy lifestyle, and accumulating evidence shows the importance of physical activity in the management of both physical and psychological well-being for people with one or more LTCs. Regular contact between health professionals and people with LTCs provides opportunities for promoting physical activity in this group.
Each LTC presents its own challenges and benefits with regard to physical activity. The remainder of this chapter focusses in particular on the impact of physical activity on mental health and well-being in people with COPD, diabetes and cancer.
Chronic Obstructive Pulmonary Disease
COPD is characterised by airflow obstruction that is not fully reversible and usually progressive in the long term. It is predominantly caused by smoking. Symptoms include breathlessness (dyspnoea) on exertion, chronic cough, regular production of sputum and frequent winter bronchitis or wheeze. Exacerbation of symptoms often occurs in which the patient's symptoms rapidly worsen beyond normal day-to-day variations. Diagnosis relies on a combination of history, physical examination and confirmation of airflow obstruction using spirometry; no single test for COPD exists (National Institute for Health and Clinical Excellence, 2010). Severity of COPD is often classified using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria (I [mild], II [moderate], III [severe] and IV [very severe]) and index of body mass, airway obstruction, dyspnoea and exercise capacity (BODE).
The World Health Organisation has predicted that by 2020 COPD will be the third leading cause of death and fifth leading cause of disability in the world (Murray & Lopez, 1996, 1997). Mortality rates for men in the United Kingdom are at a plateau and mortality rates for women are steadily increasing (Soriano et al., 2000) most likely as a result of the uptake of smoking among women post-World War II. According to the chief medical officer in England, COPD accounts for more than £800 million in direct health care costs (Department of Health, 2005); more than one half of these costs relate to the provision of hospital care. COPD is among the most costly inpatient conditions that the National Health Service treats.
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Designing a physical activity program for individuals with addictions
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours.
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours. However, implementation of behavior change in this population can present practitioners with specific challenges. This section discusses the suggestions for designing effective interventions for those with addictions based on the evidence reviewed so far as well as practical considerations.
Exercise Type, Frequency and Intensity
Most studies have promoted moderate-intensity cardiovascular-type exercise such as brisk walking for use in those with addictive behaviours. Some work also incorporates more vigorous activities such as running. Because individuals with addictions are often extremely sedentary, a programme of moderate-intensity activity is likely to be acceptable and safe. However, a progression to more vigorous exercise may be beneficial. For example, the only study that found a long-term benefit of exercise for smoking cessation entailed 30 to 40 min of vigorous exercise 3 times/wk for 12 wk (Marcus et al., 1999). Similarly, the single study that showed a long-term impact of exercise on alcohol abstinence involved 1 h of progressively vigorous exercise 5 days/wk for 6 wk (Sinyor et al., 1982). None of the trials reviewed compared the effects of vigorous-intensity and moderate-intensity exercise on abstinence rates. Experimental studies have compared the effects of bouts of moderate-intensity and vigorous-intensity exercise and have shown that both intensities are effective in the short term for reducing tobacco-withdrawal symptoms (Taylor et al., 2007).
The intensity of activity that an individual is capable of depends on initial level of fitness, medical condition and stage of recovery from addiction. Careful medical screening is vital. For example, those addicted to amphetamine or cocaine are often undernourished, and problem drinkers often have weak muscles. Such individuals may require nutrition advice. Ultimately, individuals will have preferences regarding types of exercise, and programmes should be tailored to these preferences (Abrantes et al., 2011; Everson-Hock et al., 2010). Some individuals may prefer noncardiovascular types of exercise, which may also be beneficial. Resistance (i.e., weight) training, yoga and isometric exercise have all been successfully piloted as aids for smoking cessation and need to be tested in larger trials (Ussher, Taylor & Faulkner, 2012).
Regarding frequency and volume of exercise, the findings from Marcus and colleagues (2005) suggest that abstaining smokers need to accumulate at least 110 min/wk of moderate-intensity activity to maintain abstinence; supervised exercise on 2 or 3 days/wk may be necessary in order to achieve this. Shorter bouts of exercise can be used on an as-needed basis in response to cravings, and longer scheduled bouts can be used to maintain positive mood, manage stress and prevent cravings from arising. Research has not yet addressed the optimum dose of exercise for assisting alcohol and drug rehabilitation.
Exercise Supervision
The majority of intervention studies have employed group-based supervised exercise. In smokers, exercise counselling alone did not increase exercise levels sufficiently (Ussher et al., 2003), and all the interventions that showed a significant impact on long-term abstinence from alcohol or smoking entailed supervised exercise. Among novice exercisers, an element of supervised exercise may be useful to ensure initial adoption of regular exercise and to provide information about safe exercise (e.g., warm-up) and exercise intensities (e.g., using heart rate monitors). Counselling toward pursuing home-based exercise is also likely to be important for encouraging patients to maintain exercise levels after the initial exercise programme ends.
Stages of Addiction Treatment
Early recovery from drug and alcohol dependence is a major transition that affects close relationships and employment and involves numerous treatment sessions. An exercise programme needs to complement these changes. Most exercise interventions discussed in this chapter have required patients to alter their substance- or alcohol-misuse behaviour and exercise behaviour simultaneously, yet it is not clear whether this is optimal. For some individuals the challenge of changing two health behaviours simultaneously may be too demanding. Also, it is not clear whether involvement in physical activity increases the motivation to manage substance intake or vice versa.
Among smokers, exercise has often been introduced in the studies discussed several weeks before an attempt to quit, thereby allowing people to adjust to the demands of increased exercise before starting to quit. This also allows exercise to play a role in managing cravings during the crucial early days of abstinence, when relapse rates are highest. Empirical work is required to determine the relative benefits of initiating exercise at different points in the addiction-treatment process. During later stages of treatment exercise may be useful for preventing relapse (e.g., by promoting an exercise identity that is incompatible with drug use). Studies are also needed to determine whether exercise can be used to increase substance abstinence among those who are not motivated to attempt abstinence.
Integrating Exercise With Standard Addiction Treatments
Greater integration of addiction and exercise programmes may enhance abstinence rates. For instance, rather than just proposing exercise as a means for getting fitter and managing weight, the practitioner could present exercise more as a self-control strategy for managing withdrawal symptoms and a way to address psychological and physical harms caused by addiction. Exercise could be used more in combination with pharmaceutical interventions. Whereas pharmaceutical interventions focus on reducing withdrawal symptoms (e.g., NRT), exercise could ideally be used to provide an added effect in client-led management of addictive symptoms.
Perceived Barriers to Exercise
Individuals with addictions are likely to have specific barriers to exercise, and these need to be determined. In the general population, use of cognitive - behavioural techniques is effective for overcoming perceived barriers and increasing exercise adherence. Few addiction studies have included cognitive - behavioural counseling. Techniques such as self-monitoring (e.g., diaries), goal-setting and relapse-prevention planning are commonly used. Also, pedometers are now commonly used as a motivational tool. These and other motivational aids (e.g., financial incentives) need to be tested with exercise interventions in addicted populations.
Interventions for Different Subgroups
Exercise interventions need to be tested among addicted populations who might especially benefit from such interventions. Given the high prevalence of addictions among people with mental illness and the established benefits of regular physical activity for mental health, research that examines the role that physical activity may play in this population is needed (Arbour-Nicitopoulos et al., 2011).
Exercise interventions might be particularly appealing to adolescents, and controlled trials with young people are needed. Addicted individuals who are overweight may have a need for weight-control interventions such as exercise; no trial has yet focussed on this population. Additionally, surveys suggest that a nonpharmaceutical intervention such as exercise is likely to appeal to pregnant smokers (Ussher at al., 2008). Finally, sex needs to be considered when planning an appropriate intervention. Some evidence shows that women often prefer walking and aerobics, whereas men have more interest in sport, running and strength training.
Evidence to Practice
- Both moderate- and vigorous-intensity exercise have been shown to be effective for reducing tobacco-withdrawal symptoms and cravings.
- Progressing from light- and moderate-intensity exercise (e.g., brisk walking) to more vigorous-intensity exercise is advisable.
- Careful medical screening is required, especially among those with long-term alcohol or drug dependence (e.g., for malnutrition).
- Exercise interventions should be tailored to individual preferences.
- Abstaining smokers should accumulate at least 110 min/wk of moderate-intensity exercise.
- Interventions involving supervised exercise on 2 or 3 days/wk are likely to be necessary to be effective in treating addictive behaviours.
- Exercise can be performed on an as-needed basis for managing cravings or in scheduled bouts.
- If the exercise programme is to assist with early withdrawal symptoms, it ideally needs to begin before abstinence is attempted.
- Participating in physical activity encourages individuals to adopt an identity as an exerciser, which is incompatible with using addictive substances.
- Perceived barriers to exercise need to be identified and addressed using cognitive - behavioural techniques.
- The intervention needs to be adapted to various subgroups (e.g., according to sex, body weight and mental health).
Summary
Drug, alcohol and tobacco addictions are growing global problems. Exercise has many benefits for physical and psychological health, and evidence convincingly shows that exercise is effective for managing cravings and withdrawal symptoms, particularly in smokers. Regular exercise fosters a healthy lifestyle and exercise identity that is largely incompatible with addiction, and individuals undergoing rehabilitation for addiction express interest in exercising more. Exercise interventions are inexpensive, can be easily integrated with existing addiction treatments and have minimal side effects compared with pharmacological treatments. This chapter demonstrates that exercise is a highly plausible adjunctive treatment for addictive behaviour and that exercise programmes can be readily disseminated. However, limited evidence currently supports the benefits of exercise for helping smokers quit or helping those with drug or alcohol dependence abstain. This lack of evidence can partly be explained by the small number of large RCTs that have been conducted, lack of knowledge about effective doses of exercise and limited attention to methods for maximizing exercise adherence. This area of research is in its infancy, and further well-designed trials are needed.
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Physical activity guidelines
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits.
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits. National guidelines aimed at the whole population (as opposed to specific populations defined by a medical condition) focus on the optimal amount of activity to prevent disease and promote health and well-being. PAGs indicate the type (e.g., aerobic activity, strength training, weight bearing), frequency (e.g., 3 days/wk), duration (e.g., 30 min) and intensity (e.g., moderate, vigorous) (see figure 2.2) of physical activity to undertake and for what benefits. These detailed specifications reflect the latest science on the topic.
PAGs need to be updated periodically because evidence about the relationship between physical activity and health changes over time and knowledge grows. Some guidelines are more general in nature, whereas others provide very specific details; this usually reflects the state of knowledge at that time. Through a review and revision process, more specific details are added to PAGs when available. For example, in various national PAGs, guidelines relating to maintaining musculoskeletal strength have been revised over time and now include details on how much strength training is required for good health (World Health Organisation, 2010) and, specifically, for preventing falls and treating depression (Singh, Clements & Singh, 2001).
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The dose - response relationship: Increasing benefits from increasing amounts (expressed in frequency, duration and intensity) of activity. Reprinted, by permission, from I. Vuori, 1995, Terveysliikunta [Health and physical education]. UKK Institute for Health Promotion Research (Tampere, Finland).
National guidelines are an important component of a population-based approach to addressing any public health issue. First, such guidelines communicate a consensus on the scientific evidence of the importance of the issue. They describe the strength of the science in terms of the volume as well as the quality (determined based on the quality of study designs and research methods used) of the evidence. Communicating scientific consensus is important because it removes doubt and speculation about the validity of the health issue and its importance. This scientific consensus can also be used to advocate for resources and programmes. However, just because guidelines exist does not mean that everyone agrees about what the science says - far from it. However, these disagreements, or alternative interpretations of overall findings to date, are usually communicated in technical reports that accompany the publication of PAGs and are not fully accessible to the general public.
The process of developing PAGs usually involves leadership by a high-level institution. This adds credence to the message that the issue is important. For example, several national and international health agencies, such as the American Heart Association (Haskell et al., 2007), have developed guidelines on physical activity. National governments, usually the ministry of health, often lead the development process and endorse national PAGs. This endorsement is very useful because it specifies the government's position on physical activity and thereby provides the opportunity for interested parties such as charities and public health directors to leverage the government into supporting further action and funding for programmes and services aimed at increasing physical activity. This might include government endorsement of counselling and clinical services for inactive patients, as has been trialled in the United Kingdom (Bull & Milton, 2011). Government involvement and endorsement can also prevent policy inaction. The absence of an official position on physical activity can block funding and further development of a national population-based approach.
One important role of PAGs is to direct community-level actions aimed at increasing physical activity in the whole population. The details in PAGs about the type, frequency, duration and intensity of activities required for different age groups can provide clinicians, health care practitioners and others with direction on what types of programmes to provide and promote to patients and the wider community.
PAGs should drive and direct action not just at the level of individuals and service providers but also at all levels - national, regional and local - of government. If the national government endorses PAGs, ideally with multiparty political support, the government should be held accountable when levels of physical activity are not improving and can be expected to include physical activity promotion as part of ongoing disease-prevention and health-promotion strategies. The role of PAGs and national surveillance of risk factors is discussed in more detail later in this chapter.
Development of the First National Physical Activity Guidelines
Epidemiological studies of exercise and health were well advanced by the 1970s. The American College of Sports Medicine released the first set of recommendations in 1975 and released another set in 1980 (American College of Sports Medicine, 1975, 1980). These recommendations were predominantly directed at cardiorespiratory fitness and suggested that people undertake vigorous-intensity aerobic exercise 3 times/wk for 20 min each time. This was a practical interpretation of the exact recommendation from 1975, which suggested that people undertake 20 to 45 min of physical activity 3 to 5 days/wk at 70% to 90% of heart rate (i.e., vigorous intensity) (American College of Sports Medicine, 1975). The focus on aerobic exercise for increasing fitness continued to dominate and influence health messages about physical activity until the early 1990s. However, guidelines began to recommend moderate-intensity physical activity rather than vigorous-intensity activity, and by the mid-1990s the focus shifted from cardiorespiratory fitness to health benefits. This new position on physical activity was communicated in a landmark set of recommendations from the office of the U.S. surgeon general in the report "Physical Activity and Health" (U.S. Centers for Disease Control and Prevention, 1996).
In the mid-1990s, epidemiological evidence started to show that people with different health conditions require slightly different amounts of physical activity. Although the recommendation for 30 min of moderate-intensity activity on most days remained valid for preventing heart disease and diabetes, studies showed that slightly more physical activity was recommended for preventing cancer. Further, studies identified that the amount of activity required for weight loss or preventing weight gain was greater than that required to prevent chronic disease (Haskell et al., 2007). For example, the International Association for the Study of Obesity recommendations made a clear distinction between the minimum physical activity required for health benefits and the amount required for preventing weight gain. The recommendations state that "45 to 60 min (60-90 min for formerly obese individuals) of moderate-intensity physical activity daily is needed to prevent the transition to overweight or obesity" (Saris et al., 2003). Furthermore, research has now shown that the amount of physical activity required by young people differs from that of adults. The overall amount of physical activity recommended for children is twice that recommended for adults and is usually expressed as "at least 60 min/day" (Canadian Society for Exercise Physiology, 2011a; Saris et al., 2003).
These different recommendations make the development of PAGs complex. However, a core and consistent interpretation of the evidence is that 30 min of moderate-intensity physical activity on most days of the week is associated with maximum overall population benefit and the prevention of major noncommunicable diseases. This same dose has been expressed as "at least 150 min/wk of moderate-intensity activity" in the most recent global, U.S. and U.K recommendations (Department of Health, 2011b; U.S. Department of Health and Human Services, 2008a; World Health Organisation, 2010).
Current Best Practice in Developing Guidelines
Figure 2.3 illustrates the process of developing guidelines. The first step is establishing the need for guidelines. This need is often defined by policymakers, public health scientists, advocates and, sometimes, the community. Then a process for guideline development needs to be agreed on by interested parties, with actions planned in sequence and, ideally, a linkage between the PAG development process and other aspects of national or regional physical activity policy and strategy development (step 1 in figure 2.3). The next stage comprises reviewing the scientific evidence and creating an updated summary of what the research says and how this information differs from that in previous guidelines. A number of countries, notably Canada and, most recently, the United Kingdom and United States, have undertaken this process. Tremblay and colleagues (2010) extensively discuss this process with reference to the recent Canadian guidelines along with frameworks and a checklist for auditing data quality in the review stage.
Once the science has been reviewed, the next stage is developing communication messages based on the evidence and testing these messages with the target audience for acceptability, comprehension and usefulness. This step is part of developing a communications strategy for disseminating the evidence (stages 3 and 4 in figure 2.3). It requires resources for conducting the qualitative and quantitative research and the involvement of communications and media specialists in framing the messages correctly so that they will have optimal impact on the target populations. The final stages (stages 5-7 in figure 2.3) involve disseminating the message to the community, professional groups and other stakeholders. Historically, those developing PAGs have put considerable effort into the technical and scientific stages and have often neglected message development and communication. Frequently, only informal and unpaid communication channels are used after the launch of PAGs. Thus, a very important step in PAG development and dissemination is the final public health promotion component.
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Framework for developing physical activity guidelines. Adapted from Bauman et al. 2006.
Global, Regional and National Physical Activity Guidelines
Table 2.1 summarises the 2011 global PAGs and provides examples of regional (i.e., European and Western Pacific islands) and national guidelines. Quite a few countries in Europe have their own national PAGs, and many of these countries (e.g., Finland, Switzerland, the Netherlands, United Kingdom) have been engaged with implementing national population-based approaches for some time (Department of Health, 2011b; Ministry of Health, Welfare and Sport, 2011; Swiss Federal Office of Sports, 2006; UKK Institute, 2009). Other countries in Europe have officially or unofficially adopted the guidelines published by the U.S. Centers for Disease Control and Prevention in 1996 and the more recently updated 2008 version.
PAGs in other regions of the world are patchy. Australia (Department of Health and Ageing, 2005b) and New Zealand (Sport and Recreation New Zealand, 2005) have had national guidelines for some time. In Australia, guidelines exist for all ages, from young children (Department of Health and Ageing, 2004) to older adults (Department of Health and Ageing, 2005b), although all guidelines are more than 5 yr old and arguably are due for updating to reflect the latest science. Far fewer examples of PAGs exist in South America, Asia, the Middle East and Africa because physical activity promotion is relatively new in these regions. Countries in which national action on physical activity is beginning have often used the U.S. guidelines as an international benchmark. This has allowed the countries to develop an agenda of physical activity promotion without being hindered by the absence of PAGs. However, in some countries, adopting the PAGs of another country is not politically or culturally welcome or appropriate. Either these countries have developed their own PAGs (a recent example from the Middle East is Brunei; Ministry of Health, 2011) or very little physical activity promotion has occurred.
The absence of a set of official global guidelines did not hinder the World Health Organisation (WHO) from developing the Global Strategy on Diet, Physical Activity and Health in 2004 (World Health Organisation, 2004). Since the publication of the 2002 health report (World Health Organisation, 2002), the focus on the need for greater action to prevent noncommunicable disease and address mental health has increased. To address these issues, WHO commenced developing global guidelines in 2007. WHO launched the final global recommendations on physical activity in 2010 after a 2 yr process involving global and regional consultations (World Health Organisation, 2010). These global guidelines are now available for adoption and use by countries with no national PAGs. Because the guidelines are from WHO, the leading international health agency, the scientific quality and relevance of these guidelines are usually accepted.
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Treating depression and anxiety with exercise
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety.
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety. Information about these prescription parameters is scarce, but it is critical if exercise interventions are to be translated into clinical practice. Asking someone to do something without specifying what they should do or how they should do it would likely make it difficult for the individual to fully comply in a meaningful way. It is also possible that the prescription of exercise for depression and/or anxiety could be different, both in nature and content, than that required for general health benefits.
One trial that is particularly worthy of attention is the Depression Outcomes Study of Exercise (DOSE; Dunn et al., 2005), which attempted to provide evidence about the dose of exercise required to treat depression. In the DOSE study 80 participants were randomised to 1 of 4 exercise groups that varied in total energy expenditure (7 or 17.5 kcal·kg-1·wk-1) and frequency (3 or 5 days/wk) or to a flexibility-exercise placebo control for 12 wk. Exercise at a dose of 17.5 kcal·kg-1·wk-1 was effective in reducing depression regardless of frequency, whereas exercise at a dose of 7 kcal·kg-1·wk-1 yielded antidepressant effects that were comparable to those of the placebo treatment. The plausible biological reason for why a higher dose of exercise may be more effective than lower doses is that frequent and regular exercise should increase fitness levels such that physical discomfort decreases and exercise becomes a more pleasant and enjoyable experience as the conditioning process progresses. Indeed, findings from both the DOSE and TREAD trials in the United States have indicated that higher doses of exercise are more effective than are lower doses (as defined in the study).
Perraton and colleagues (2010) published a systematic review that attempted to summarise what is currently known about the prescription of exercise for depression. The review is useful because previous reviews of exercise and depression did not synthesise this information in a way that would help guide intervention development. This review included only trials that had reported exercise to be effective in reducing depression in order to analyse the specific dosage parameters and modes of exercise used in these successful trials.
The review found that the most common intensity, frequency and duration of aerobic exercise were 60% to 80% of maximum heart rate, 30 min/session and 3 days/wk over 8 wk. The volume of evidence supporting the use of aerobic exercise programmes to treat depression was greater than that supporting the use of anaerobic exercise programmes. No clear trend showed one mode of aerobic exercise to be the most effective, and a range of activity types appeared to be effective. This is encouraging given that one size does not fit all, and individuals can be encouraged to participate in whatever type of aerobic activity they prefer.
In terms of context of exercise, a number of common trends emerged. A variety of locations were effective in treating depression, although all trials that reported location took place indoors. Both group and individual interventions were effective. However, group exercise may have added benefit by providing social support, which can be pivotal for sustaining compliance and can contribute in its own right to lowering depression. Moreover, exercise might lower depression by several plausible mechanisms, one of which could be interrelations or connections with others (Bailey & McLaren, 2005). Many types of exercise can be performed with other people (depressed or not). Therefore, this exercise could provide social integration and an opportunity to interact with the social world as well as a setting in which to expand social networks and make friends (Stathi, Fox & McKenna, 2002).
Another unresolved question concerns the intensity of exercise at which a reduction in depression might occur. Callaghan and colleagues (2011) compared the effects of preferred intensity with those of prescribed intensity of group-based exercise for 12 sessions over 4 wk in 38 women aged 45 to 65 yr who were receiving treatment for depression from either primary or secondary care services. The preferred-intensity group reported significantly lower depression and higher self-esteem and quality-of-life scores than did the prescribed-exercise group and attended more sessions (66% versus 50%). Similar findings have been found in nondepressed populations (Daley & Maynard, 2003). Several theories, such as self-determination theory (Deci & Ryan, 1985), support the notion that giving people a choice and control over what they do, whether it be exercise or other activities, leads to better adherence and enjoyment of the activity, which in turn leads to enhanced psychological well-being. People experiencing depression are no exception.
Wipfli, Rethorst and Landers (2008) considered the relationship between dose of exercise and anxiety levels as part of their broader meta-analysis of the anxiolytic effect of exercise. The trend in the data from 12 RCTs showed that the effect size increased as exercise approached a dose of 12.5 kcal·kg-1·wk-1 (equates to slightly less than the dose recommended for public health) and then began to decrease as exercise dose increased. A combination of aerobic and anaerobic exercise appeared to be better than either type alone, and a frequency of 3 or 4 times/wk appeared more effective than more or less than this amount.
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Available methods for measuring physical activity
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry.
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry. Most are moderately correlated at best. Each method has its own strengths and limitations. Due to the complexity of physical activity, outlined previously, researchers and practitioners need to consider what is most important for their purposes when deciding to use a particular technique. Although no one measurement tool can be singled out as the most appropriate, recommendations for the most useful and practical measurement tools can be made after considering factors such as context, type, duration, frequency and intensity of physical activity as well as the constraints under which the research or treatment programme is operating. These techniques are presented in order of increasing feasibility but decreasing validity. Table 3.2 at the end of this section summarises the key advantages and limitations of each measurement technique.
Doubly Labelled Water
Doubly labelled water (DLW, or free-living indirect calorimetry) is a method commonly used to increase the precision and accuracy of physical activity measurement. DLW, which measures EE over several (4-21) consecutive days in a free-living person under normal life conditions (Schoeller, 1988), is the most widely accepted gold standard method by which to measure EE (Aadahl & Jørgensen, 2003). DLW measures EE of free-living, unrestricted subjects using water labelled with stable isotopes of oxygen and hydrogen (Schoeller & van Santen, 1982). It calculates activity-related EE by combining measurement of total EE with basal metabolic rate. The utility of the DLW method in measuring total EE is demonstrated by its use in a variety of settings, including all age groups, premature infants, hospitalised patients, pregnant women and the elderly (Ainslie, Reilly & Westerterp, 2003). As such, researchers who use this method to assess the relationship between physical activity and other psychological variables or to detect changes in physical activity as a result of interventions can be confident that the results produced regarding EE are accurate. Schoeller (1988) fully describes the validation of the DLW method.
Despite its level of precision, the DLW method is not without disadvantages, which include high cost, limitations for assessing brief periods of EE (Ainslie, Reilly & Westerterp, 2003) and additional demands on participants in terms of time and tasks required. The cost and availability of isotopes and the requirement for analysis by isotope ratio mass spectrometer prohibit DLW from being widely used in studies of large populations. The use of this method among populations with more severe mental health problems may likely present a set of ethical issues. Furthermore, although this technique provides an accurate measure of total EE, it cannot provide information about patterns of physical activity in terms of type, frequency, duration, intensity or context. Consequently, such an approach would not be feasible in a large natural-field experiment or in a test of the effect of interventions on changes in physical activity in both healthy populations and populations that suffer from mental health problems. However, this gold standard measure is believed to offer the most precise estimate of EE and is often used to validate many other types of tools that assess physical activity.
Direct Observation
Direct observation, one of the most basic approaches for acquiring information about behaviours, provides information about how people exercise and play, how environments shape the activities individuals participate in and how people use specific facilities (e.g., parks, leisure facilities, walking or cycling paths). It can take place using basic observation methods, systematic forms or sophisticated technology (e.g., lasers). Direct observation often involves a trained observer who codes physical activity behaviours (e.g., sitting, walking, running) undertaken by participants over time in various settings (e.g., playground, park, home). A number of observation systems are available, such as SOPLAY (System for Observing Play and Leisure Activity in Youth), SOFIT (System for Observing Fitness Instruction Time), and the Systematic Pedestrian and Cycling Environmental Scan. The trained observer may either observe participants in person or review video media. Because it is time consuming, direct observation might be used only with small groups in specific settings (Dugdill & Stratton, 2007).
Advantages of direct observation include that self-report bias is eliminated, participants do not need to recall behaviour and the level of detail regarding behaviour patterns and context can be extremely accurate. Furthermore, practitioners may find some of these tools accessible. For example, clinical psychologists working with institutionalised individuals diagnosed with severe mental health conditions may find this type of measurement technique useful for assessing relationships between physical activity patterns or patterns of inactivity and specific mental illnesses because it can combine both context and behaviour to provide powerful data.
However, disadvantages include the time involved in recording and coding behaviour, the time involved in consolidating the plethora of data collected and the costs associated with training coders. Furthermore, the subjective bias of coders may lead to incorrect judgments about the intensities of specific activities, which would affect estimates of EE. As such, it would be important to consider whether information regarding patterns of behaviour combined with context or specific EE data are required to fulfill the aims of a research project or treatment programme.
Accelerometers
Motion sensors, such as pedometers and accelerometers, can be used to detect body movement and estimate physical activity (Spruijt-Metz et al., 2009). Accelerometers are devices that measure bodily movements in terms of acceleration. This measurement can then be used to estimate the intensity of physical activity, and therefore EE, over time (Burton et al., 2005; Chen & Basset, 2005). Accelerometers can measure human activity on vertical (uniaxial accelerometers), anterior - posterior and medial - lateral (triaxial accelerometers) planes. EE can then be then estimated from vector magnitude counts using a proprietary algorithm, which is a composite of counts from these planes of motion (Howe, Staudenmayer & Freedson, 2009). Accelerometers can be used repeatedly on numerous participants, are more accurate than pedometers and are less expensive (approximately £200 per device; ActiLife, 2009) than other objective methods such as DLW (approximately £200 per participant per procedure; Friedman & Johnson, 2002). However, they remain too expensive to use in studies that assess large numbers of people (Wood, 2000). Nevertheless, these devices are a more feasible and participant-friendly method of attempting to validate a self-report questionnaire than is DLW. They also provide the data necessary to allow researchers to distinguish between light, moderate and vigorous physical activity as well as between continuous and intermittent activity modes (Crouter, Clowers & Bassett, 2006). A recent review of accelerometers against DLW found ActiGraph (previously named CSA/MTI) models to be of the most valid types tested; they produce an average correlation of r = .57 (Plasqui & Westerterp, 2007). Limitations of accelerometers include the increased time required to analyse the large amount of data provided, participant burden of wearing the device, that they cannot be feasibly used to test large-scale interventions, and that they cannot provide information about the specific type of activity (e.g., playing football, going to the gym) or the context in which it is performed.
Some studies have attempted to validate accelerometers among populations diagnosed with mental health conditions. For example, Sharpe and colleagues (2006) conducted a study to assess the validity of the RT3 accelerometer against DLW in people with schizophrenia. They found that the accelerometer overpredicted energy expended on physical activity by an average of 148 kcal/day (standard deviation = 413 kcal/day); this varied from an underestimation of 614 kcal/day to an overestimation of 582 kcal/day. The authors suggested that the RT3 accelerometer is a poor tool for measuring activity EE in sedentary men with schizophrenia. As such, the results of studies that have used this measurement tool in mentally ill populations may be questionable. For example, the recent intervention study of Jerome and colleagues (2009) used the RT3 accelerometer to measure physical activity in persons with mental illness. The authors of this study concluded that participants were undertaking approximately 120 min/wk of moderate-intensity physical activity on average, which would equal approximately 70 kcal/day. Given that the results of the study by Sharpe and colleagues (2006) indicated that the RT3 accelerometer overpredicted EE, it is possible that the results found by Jerome and colleagues (2009) overestimate the amount of physical activity undertaken by participants. Consequently, this might affect the validity of the relationships found between physical activity and various mental health variables measured in this study. Sharpe and colleagues (2006) did, however, indicate that the RT3 appeared to be a valid measure of physical inactivity in men with schizophrenia. Therefore, it could be used for research or clinical purposes to quantify the contribution of sedentary behaviour to medical conditions associated with inactivity. Sharpe and colleagues (2006) also recommended that using the RT3 to validate questionnaires may not be appropriate until it is more robust.
Indirect Objective Measures
Indicators of the physiologic response to physical activity include heart rate and pulmonary gas exchange. Heart-rate monitoring is a promising measurement method because heart rate is a physiological parameter that correlates well with, and strongly predicts, EE (Strath et al., 2002). Most heart rate monitors include software that converts heart rate data into an estimate of EE. However, one of the limitations of heart rate monitoring is that training state and individual heart rate characteristics can affect the relationship between heart rate and oxygen consumption. Higher levels of accuracy can be obtained through a graded submaximal exercise test that calibrates participant heart rate to simultaneous oxygen consumption. This information allows for the construction of a calibration curve that estimates EE at moderate and strenuous levels of exercise. (A linear relationship exists between increasing heart rate and oxygen consumption; Freedson & Miller, 2000.) Measuring heart rate is a common method used to describe intensity and duration of physical activity and is a relatively inexpensive method of measuring EE. However, heart rate is affected by factors other than physical activity, such as emotional stress, temperature, humidity, dehydration, posture and illness (Ainslie, Reilly & Westerterp, 2003). These factors can influence heart rate without causing associated changes in oxygen consumption. Given the potentially increased fluctuations in emotions in individuals diagnosed with mental health conditions, this method may not be the most appropriate for obtaining accurate physical activity levels. Furthermore, the relationship between oxygen uptake and heart rate is weak at low levels of activity (Keim, Blanton & Kretsch, 2004). Evidence suggests that individuals suffering from mental health problems tend to perform less intensive physical activity than do members of the general population (e.g., Brown et al., 1999). Therefore, the heart rate method may not provide accurate information about the physical activity of mental health populations. Also, the heart rate method is unable to identify types of activity or the context in which physical activity is performed. Although heart rate is a physiological marker for physical activity and may provide a general picture of physical activity patterns, it may not be the best method available for obtaining an accurate estimate of EE.
Pedometers
Pedometers, which measure steps on a single axis as well as calories expended, are less expensive than some other types of motion sensors. As such, these devices are an attractive alternative to self-report in large observational or intervention studies. Public health campaigns have also promoted pedometers as a motivational tool for achieving the goal of 10,000 steps daily. A range of pedometers is available. The pedometer that is most suitable for a particular study may depend on factors such as the research question (outcome of interest), population, available funds, context and validity of the model. For example, when considering context, researchers or practitioners who wish to understand the types of physical activity being undertaken in a variety of settings would not gain this information using pedometers alone. When considering population, some pedometers are validated in healthy adults but not in other populations such as children, the elderly or those diagnosed with mental illness. Pedometers have demonstrated reduced accuracy in elderly populations because of the slow pace or shuffling nature with which elderly people walk (Cyarto, Myers & Tudor-Locke, 2004). Tudor-Locke and colleagues (2002) evaluated the validity of pedometers in a review of 25 studies and found a strong correlation between pedometer counts and accelerometer output (median of reported correlations is r = .86). However, evidence suggests that the validity of pedometers for measuring EE and distance in normal populations is questionable. The findings of a study testing the validity of 10 pedometers (Crouter et al., 2003) indicated that these devices overestimated distance at slower speeds and underestimated distance at faster speeds. Furthermore, in 8 of the pedometers tested, it was unclear whether the device was measuring gross EE (all the energy expended by an individual during a specific activity) or net EE (the energy expended by an individual during a specific activity minus the resting EE for the equivalent amount of time). The Yamax Digiwalker SW-200 was found to be the most reliable and accurate pedometer available (Crouter et al., 2003). This pedometer was used in a recent study by McKercher (2009) that assessed relationships between physical activity and depression in young adults. This study found that low levels of depression were significantly correlated with moderate levels of physical activity, as measured by the Yamax Digiwalker SW-200, among females. However, this device has not been validated in specific mental health populations, which may limit the validity of these results. It is important to validate physical activity devices among specific populations because patterns of physical activity in these populations may differ from those in the general population. For example, individuals with serious mental illness are significantly less active than the general population (Brown et al., 2004). As such, using a physical activity measure that has been validated with mental health populations in research on physical activity and mental health will increase the strength of the results produced.
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Coping with long-term physical health conditions
Approximately 30% of the European population has a long-term physical health condition. People with a long-term condition that is comorbid with a mental health problem have worse health outcomes than do people with either of these alone.
Key Concepts
- Approximately 30% of people with a long-term condition have a comorbid mental health condition.
- Physical activity is an important part of the management of physical and psychological well-being in people with long-term conditions.
- Pulmonary rehabilitation leads to reduced depression and anxiety and increased quality of life in people with chronic obstructive pulmonary disease. Further research is required to understand the optimal exercise dose; the interaction of exercise training, education and psychosocial support during pulmonary rehabilitation; and how to sustain changes in physical activity behaviour after pulmonary rehabilitation.
- Physical inactivity is associated with greater depression in people with type 2 diabetes. Further research is required to understand the causality of this relationship, although available data suggest that physical activity interventions reduce depression.
- Data that explore the relationship between physical activity and mental health in people with type 1 diabetes are limited.
- Physical activity has been shown to increase quality of life and reduce anxiety and depression in cancer survivors. Data suggest that supervised and group exercise are more beneficial than unsupervised and home-based exercise in this population.
Long-term conditions (LTCs) have been defined as "those conditions that cannot, at present, be cured, but can be controlled by medication and other therapies. The life of a person with an LTC is forever altered - there is no return to normal" (Department of Health, 2008, p. 10). LTCs include diabetes, arthritis, chronic obstructive pulmonary disease (COPD) and a number of cardiovascular diseases. In addition, conditions such as human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) and certain cancers that were not traditionally considered LTCs are increasingly being regarded as such (Naylor et al., 2012). Many mental health problems can themselves be considered LTCs. However, in this chapter the term long-term condition refers specifically to physical health conditions.
The World Health Organisation's (2011) report on the global burden of noncommunicable diseases (i.e., all previously mentioned LTCs except HIV and AIDS) found that noncommunicable diseases are by far the leading cause of mortality in the world and represent 63% of all deaths. The majority of these deaths are due to cardiovascular disease, diabetes, cancer and chronic respiratory disease. The highest occurrence of deaths from these diseases is in low- and middle-income countries, and the prevalence in these countries is predicted to increase substantially in the future. In Europe 29% of people aged 15 yr or older report a longstanding health problem (TNS Opinion, 2007), and the Office for National Statistics (2005) found that in England approximately 30% of the population (15.4 million people) has a LTC. As populations age, the burden of LTCs is projected to increase even further.
Long-Term Conditions and Mental Health Issues
People with LTCs are two to three times more likely than the general population to experience mental health problems. Depression and anxiety are the most frequently reported mental health problems in people with LTCs, but dementia, cognitive decline and some other conditions have also been reported (Naylor et al., 2012). Depression is two to three times more common in people with an LTC than in those with good physical health and occurs in approximately 20% of people with an LTC (National Collaborating Centre for Mental Health, 2010). Conservative estimates suggest that at least 30% of all people with an LTC also have a comorbid mental health problem of some kind (Cimpean & Drake, 2011). Research has shown that having a mental health problem along with an LTC has a stronger negative impact on quality of life and functional status than does either the number of LTCs or the severity of those conditions. For example, quality of life is lower in people with one LTC and depression than in people with two or more LTCs and no depression (Moussavi et al., 2007). Figure 8.1 shows the overlap between LTCs and mental health disorders.
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In addition to experiencing psychological distress, patients with an LTC and comorbid mental health problem experience poorer clinical outcomes compared with people with an LTC and no mental health problem (Moussavi et al., 2007). This is partly because self-management is necessary for effectively controlling LTCs, and poor mental health can result in poorer self-management. For example, it may lead to lack of motivation and energy to adhere to treatment plans or attend medical appointments (DiMatteo, Lepper & Croghan, 2000). From a financial perspective, comorbid mental health problems are typically associated with a 45% to 75% increase in care costs for a person with an LTC. These data are based on a wide range of LTCs and are observed after adjustment for severity of physical disease (Unützer et al., 2009; Welch et al., 2009).
Overlap between long-term conditions and mental health problems in England. Adapted, by permission, from C. Naylor et al., 2012, Long-term conditions and mental health: The cost of co-morbidities (London: The King's Fund and Centre for Mental Health).
Long-Term Conditions and Quality of Life
Quality of life is an individual's perception of their ability to function well on physical, mental and social levels. Quality of life can be measured in a reliable and valid manner using self-reported questionnaires, which can be categorised into three main groups: generic, disease specific and domain specific. Generic questionnaires measure quality of life in general terms, independent of the presence of any disease. Disease-specific questionnaires measure the consequences of a specific disease on quality of life. Domain-specific questionnaires focus on certain domains of quality of life (e.g., physical inabilities).
Where it is possible to manage but not cure a disease, such as in LTCs, measures of quality of life are frequently used to help determine the impact of treatment and disease. They help health professionals make informed judgements about whether treatment is appropriate and, where a choice of treatments exists, which might be the best option. Researchers frequently use these measures to assess the impact of a new intervention.
Long-Term Conditions and Physical Activity
Doctors have traditionally advised people with a range of LTCs to rest and not tire themselves out, and this advice persists in the lay psyche. For example, a recent Swedish survey found that the physical activity levels of people with diabetes, rheumatoid arthritis or COPD are lower than those of healthy controls; 73% of people with diabetes, 74% with rheumatoid arthritis and 84% with COPD reported low physical activity levels compared with 60% of controls (Arne et al., 2009). However, modern treatment of LTCs often includes promoting physical activity as part of a healthy lifestyle, and accumulating evidence shows the importance of physical activity in the management of both physical and psychological well-being for people with one or more LTCs. Regular contact between health professionals and people with LTCs provides opportunities for promoting physical activity in this group.
Each LTC presents its own challenges and benefits with regard to physical activity. The remainder of this chapter focusses in particular on the impact of physical activity on mental health and well-being in people with COPD, diabetes and cancer.
Chronic Obstructive Pulmonary Disease
COPD is characterised by airflow obstruction that is not fully reversible and usually progressive in the long term. It is predominantly caused by smoking. Symptoms include breathlessness (dyspnoea) on exertion, chronic cough, regular production of sputum and frequent winter bronchitis or wheeze. Exacerbation of symptoms often occurs in which the patient's symptoms rapidly worsen beyond normal day-to-day variations. Diagnosis relies on a combination of history, physical examination and confirmation of airflow obstruction using spirometry; no single test for COPD exists (National Institute for Health and Clinical Excellence, 2010). Severity of COPD is often classified using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria (I [mild], II [moderate], III [severe] and IV [very severe]) and index of body mass, airway obstruction, dyspnoea and exercise capacity (BODE).
The World Health Organisation has predicted that by 2020 COPD will be the third leading cause of death and fifth leading cause of disability in the world (Murray & Lopez, 1996, 1997). Mortality rates for men in the United Kingdom are at a plateau and mortality rates for women are steadily increasing (Soriano et al., 2000) most likely as a result of the uptake of smoking among women post-World War II. According to the chief medical officer in England, COPD accounts for more than £800 million in direct health care costs (Department of Health, 2005); more than one half of these costs relate to the provision of hospital care. COPD is among the most costly inpatient conditions that the National Health Service treats.
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Designing a physical activity program for individuals with addictions
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours.
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours. However, implementation of behavior change in this population can present practitioners with specific challenges. This section discusses the suggestions for designing effective interventions for those with addictions based on the evidence reviewed so far as well as practical considerations.
Exercise Type, Frequency and Intensity
Most studies have promoted moderate-intensity cardiovascular-type exercise such as brisk walking for use in those with addictive behaviours. Some work also incorporates more vigorous activities such as running. Because individuals with addictions are often extremely sedentary, a programme of moderate-intensity activity is likely to be acceptable and safe. However, a progression to more vigorous exercise may be beneficial. For example, the only study that found a long-term benefit of exercise for smoking cessation entailed 30 to 40 min of vigorous exercise 3 times/wk for 12 wk (Marcus et al., 1999). Similarly, the single study that showed a long-term impact of exercise on alcohol abstinence involved 1 h of progressively vigorous exercise 5 days/wk for 6 wk (Sinyor et al., 1982). None of the trials reviewed compared the effects of vigorous-intensity and moderate-intensity exercise on abstinence rates. Experimental studies have compared the effects of bouts of moderate-intensity and vigorous-intensity exercise and have shown that both intensities are effective in the short term for reducing tobacco-withdrawal symptoms (Taylor et al., 2007).
The intensity of activity that an individual is capable of depends on initial level of fitness, medical condition and stage of recovery from addiction. Careful medical screening is vital. For example, those addicted to amphetamine or cocaine are often undernourished, and problem drinkers often have weak muscles. Such individuals may require nutrition advice. Ultimately, individuals will have preferences regarding types of exercise, and programmes should be tailored to these preferences (Abrantes et al., 2011; Everson-Hock et al., 2010). Some individuals may prefer noncardiovascular types of exercise, which may also be beneficial. Resistance (i.e., weight) training, yoga and isometric exercise have all been successfully piloted as aids for smoking cessation and need to be tested in larger trials (Ussher, Taylor & Faulkner, 2012).
Regarding frequency and volume of exercise, the findings from Marcus and colleagues (2005) suggest that abstaining smokers need to accumulate at least 110 min/wk of moderate-intensity activity to maintain abstinence; supervised exercise on 2 or 3 days/wk may be necessary in order to achieve this. Shorter bouts of exercise can be used on an as-needed basis in response to cravings, and longer scheduled bouts can be used to maintain positive mood, manage stress and prevent cravings from arising. Research has not yet addressed the optimum dose of exercise for assisting alcohol and drug rehabilitation.
Exercise Supervision
The majority of intervention studies have employed group-based supervised exercise. In smokers, exercise counselling alone did not increase exercise levels sufficiently (Ussher et al., 2003), and all the interventions that showed a significant impact on long-term abstinence from alcohol or smoking entailed supervised exercise. Among novice exercisers, an element of supervised exercise may be useful to ensure initial adoption of regular exercise and to provide information about safe exercise (e.g., warm-up) and exercise intensities (e.g., using heart rate monitors). Counselling toward pursuing home-based exercise is also likely to be important for encouraging patients to maintain exercise levels after the initial exercise programme ends.
Stages of Addiction Treatment
Early recovery from drug and alcohol dependence is a major transition that affects close relationships and employment and involves numerous treatment sessions. An exercise programme needs to complement these changes. Most exercise interventions discussed in this chapter have required patients to alter their substance- or alcohol-misuse behaviour and exercise behaviour simultaneously, yet it is not clear whether this is optimal. For some individuals the challenge of changing two health behaviours simultaneously may be too demanding. Also, it is not clear whether involvement in physical activity increases the motivation to manage substance intake or vice versa.
Among smokers, exercise has often been introduced in the studies discussed several weeks before an attempt to quit, thereby allowing people to adjust to the demands of increased exercise before starting to quit. This also allows exercise to play a role in managing cravings during the crucial early days of abstinence, when relapse rates are highest. Empirical work is required to determine the relative benefits of initiating exercise at different points in the addiction-treatment process. During later stages of treatment exercise may be useful for preventing relapse (e.g., by promoting an exercise identity that is incompatible with drug use). Studies are also needed to determine whether exercise can be used to increase substance abstinence among those who are not motivated to attempt abstinence.
Integrating Exercise With Standard Addiction Treatments
Greater integration of addiction and exercise programmes may enhance abstinence rates. For instance, rather than just proposing exercise as a means for getting fitter and managing weight, the practitioner could present exercise more as a self-control strategy for managing withdrawal symptoms and a way to address psychological and physical harms caused by addiction. Exercise could be used more in combination with pharmaceutical interventions. Whereas pharmaceutical interventions focus on reducing withdrawal symptoms (e.g., NRT), exercise could ideally be used to provide an added effect in client-led management of addictive symptoms.
Perceived Barriers to Exercise
Individuals with addictions are likely to have specific barriers to exercise, and these need to be determined. In the general population, use of cognitive - behavioural techniques is effective for overcoming perceived barriers and increasing exercise adherence. Few addiction studies have included cognitive - behavioural counseling. Techniques such as self-monitoring (e.g., diaries), goal-setting and relapse-prevention planning are commonly used. Also, pedometers are now commonly used as a motivational tool. These and other motivational aids (e.g., financial incentives) need to be tested with exercise interventions in addicted populations.
Interventions for Different Subgroups
Exercise interventions need to be tested among addicted populations who might especially benefit from such interventions. Given the high prevalence of addictions among people with mental illness and the established benefits of regular physical activity for mental health, research that examines the role that physical activity may play in this population is needed (Arbour-Nicitopoulos et al., 2011).
Exercise interventions might be particularly appealing to adolescents, and controlled trials with young people are needed. Addicted individuals who are overweight may have a need for weight-control interventions such as exercise; no trial has yet focussed on this population. Additionally, surveys suggest that a nonpharmaceutical intervention such as exercise is likely to appeal to pregnant smokers (Ussher at al., 2008). Finally, sex needs to be considered when planning an appropriate intervention. Some evidence shows that women often prefer walking and aerobics, whereas men have more interest in sport, running and strength training.
Evidence to Practice
- Both moderate- and vigorous-intensity exercise have been shown to be effective for reducing tobacco-withdrawal symptoms and cravings.
- Progressing from light- and moderate-intensity exercise (e.g., brisk walking) to more vigorous-intensity exercise is advisable.
- Careful medical screening is required, especially among those with long-term alcohol or drug dependence (e.g., for malnutrition).
- Exercise interventions should be tailored to individual preferences.
- Abstaining smokers should accumulate at least 110 min/wk of moderate-intensity exercise.
- Interventions involving supervised exercise on 2 or 3 days/wk are likely to be necessary to be effective in treating addictive behaviours.
- Exercise can be performed on an as-needed basis for managing cravings or in scheduled bouts.
- If the exercise programme is to assist with early withdrawal symptoms, it ideally needs to begin before abstinence is attempted.
- Participating in physical activity encourages individuals to adopt an identity as an exerciser, which is incompatible with using addictive substances.
- Perceived barriers to exercise need to be identified and addressed using cognitive - behavioural techniques.
- The intervention needs to be adapted to various subgroups (e.g., according to sex, body weight and mental health).
Summary
Drug, alcohol and tobacco addictions are growing global problems. Exercise has many benefits for physical and psychological health, and evidence convincingly shows that exercise is effective for managing cravings and withdrawal symptoms, particularly in smokers. Regular exercise fosters a healthy lifestyle and exercise identity that is largely incompatible with addiction, and individuals undergoing rehabilitation for addiction express interest in exercising more. Exercise interventions are inexpensive, can be easily integrated with existing addiction treatments and have minimal side effects compared with pharmacological treatments. This chapter demonstrates that exercise is a highly plausible adjunctive treatment for addictive behaviour and that exercise programmes can be readily disseminated. However, limited evidence currently supports the benefits of exercise for helping smokers quit or helping those with drug or alcohol dependence abstain. This lack of evidence can partly be explained by the small number of large RCTs that have been conducted, lack of knowledge about effective doses of exercise and limited attention to methods for maximizing exercise adherence. This area of research is in its infancy, and further well-designed trials are needed.
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Physical activity guidelines
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits.
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits. National guidelines aimed at the whole population (as opposed to specific populations defined by a medical condition) focus on the optimal amount of activity to prevent disease and promote health and well-being. PAGs indicate the type (e.g., aerobic activity, strength training, weight bearing), frequency (e.g., 3 days/wk), duration (e.g., 30 min) and intensity (e.g., moderate, vigorous) (see figure 2.2) of physical activity to undertake and for what benefits. These detailed specifications reflect the latest science on the topic.
PAGs need to be updated periodically because evidence about the relationship between physical activity and health changes over time and knowledge grows. Some guidelines are more general in nature, whereas others provide very specific details; this usually reflects the state of knowledge at that time. Through a review and revision process, more specific details are added to PAGs when available. For example, in various national PAGs, guidelines relating to maintaining musculoskeletal strength have been revised over time and now include details on how much strength training is required for good health (World Health Organisation, 2010) and, specifically, for preventing falls and treating depression (Singh, Clements & Singh, 2001).
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The dose - response relationship: Increasing benefits from increasing amounts (expressed in frequency, duration and intensity) of activity. Reprinted, by permission, from I. Vuori, 1995, Terveysliikunta [Health and physical education]. UKK Institute for Health Promotion Research (Tampere, Finland).
National guidelines are an important component of a population-based approach to addressing any public health issue. First, such guidelines communicate a consensus on the scientific evidence of the importance of the issue. They describe the strength of the science in terms of the volume as well as the quality (determined based on the quality of study designs and research methods used) of the evidence. Communicating scientific consensus is important because it removes doubt and speculation about the validity of the health issue and its importance. This scientific consensus can also be used to advocate for resources and programmes. However, just because guidelines exist does not mean that everyone agrees about what the science says - far from it. However, these disagreements, or alternative interpretations of overall findings to date, are usually communicated in technical reports that accompany the publication of PAGs and are not fully accessible to the general public.
The process of developing PAGs usually involves leadership by a high-level institution. This adds credence to the message that the issue is important. For example, several national and international health agencies, such as the American Heart Association (Haskell et al., 2007), have developed guidelines on physical activity. National governments, usually the ministry of health, often lead the development process and endorse national PAGs. This endorsement is very useful because it specifies the government's position on physical activity and thereby provides the opportunity for interested parties such as charities and public health directors to leverage the government into supporting further action and funding for programmes and services aimed at increasing physical activity. This might include government endorsement of counselling and clinical services for inactive patients, as has been trialled in the United Kingdom (Bull & Milton, 2011). Government involvement and endorsement can also prevent policy inaction. The absence of an official position on physical activity can block funding and further development of a national population-based approach.
One important role of PAGs is to direct community-level actions aimed at increasing physical activity in the whole population. The details in PAGs about the type, frequency, duration and intensity of activities required for different age groups can provide clinicians, health care practitioners and others with direction on what types of programmes to provide and promote to patients and the wider community.
PAGs should drive and direct action not just at the level of individuals and service providers but also at all levels - national, regional and local - of government. If the national government endorses PAGs, ideally with multiparty political support, the government should be held accountable when levels of physical activity are not improving and can be expected to include physical activity promotion as part of ongoing disease-prevention and health-promotion strategies. The role of PAGs and national surveillance of risk factors is discussed in more detail later in this chapter.
Development of the First National Physical Activity Guidelines
Epidemiological studies of exercise and health were well advanced by the 1970s. The American College of Sports Medicine released the first set of recommendations in 1975 and released another set in 1980 (American College of Sports Medicine, 1975, 1980). These recommendations were predominantly directed at cardiorespiratory fitness and suggested that people undertake vigorous-intensity aerobic exercise 3 times/wk for 20 min each time. This was a practical interpretation of the exact recommendation from 1975, which suggested that people undertake 20 to 45 min of physical activity 3 to 5 days/wk at 70% to 90% of heart rate (i.e., vigorous intensity) (American College of Sports Medicine, 1975). The focus on aerobic exercise for increasing fitness continued to dominate and influence health messages about physical activity until the early 1990s. However, guidelines began to recommend moderate-intensity physical activity rather than vigorous-intensity activity, and by the mid-1990s the focus shifted from cardiorespiratory fitness to health benefits. This new position on physical activity was communicated in a landmark set of recommendations from the office of the U.S. surgeon general in the report "Physical Activity and Health" (U.S. Centers for Disease Control and Prevention, 1996).
In the mid-1990s, epidemiological evidence started to show that people with different health conditions require slightly different amounts of physical activity. Although the recommendation for 30 min of moderate-intensity activity on most days remained valid for preventing heart disease and diabetes, studies showed that slightly more physical activity was recommended for preventing cancer. Further, studies identified that the amount of activity required for weight loss or preventing weight gain was greater than that required to prevent chronic disease (Haskell et al., 2007). For example, the International Association for the Study of Obesity recommendations made a clear distinction between the minimum physical activity required for health benefits and the amount required for preventing weight gain. The recommendations state that "45 to 60 min (60-90 min for formerly obese individuals) of moderate-intensity physical activity daily is needed to prevent the transition to overweight or obesity" (Saris et al., 2003). Furthermore, research has now shown that the amount of physical activity required by young people differs from that of adults. The overall amount of physical activity recommended for children is twice that recommended for adults and is usually expressed as "at least 60 min/day" (Canadian Society for Exercise Physiology, 2011a; Saris et al., 2003).
These different recommendations make the development of PAGs complex. However, a core and consistent interpretation of the evidence is that 30 min of moderate-intensity physical activity on most days of the week is associated with maximum overall population benefit and the prevention of major noncommunicable diseases. This same dose has been expressed as "at least 150 min/wk of moderate-intensity activity" in the most recent global, U.S. and U.K recommendations (Department of Health, 2011b; U.S. Department of Health and Human Services, 2008a; World Health Organisation, 2010).
Current Best Practice in Developing Guidelines
Figure 2.3 illustrates the process of developing guidelines. The first step is establishing the need for guidelines. This need is often defined by policymakers, public health scientists, advocates and, sometimes, the community. Then a process for guideline development needs to be agreed on by interested parties, with actions planned in sequence and, ideally, a linkage between the PAG development process and other aspects of national or regional physical activity policy and strategy development (step 1 in figure 2.3). The next stage comprises reviewing the scientific evidence and creating an updated summary of what the research says and how this information differs from that in previous guidelines. A number of countries, notably Canada and, most recently, the United Kingdom and United States, have undertaken this process. Tremblay and colleagues (2010) extensively discuss this process with reference to the recent Canadian guidelines along with frameworks and a checklist for auditing data quality in the review stage.
Once the science has been reviewed, the next stage is developing communication messages based on the evidence and testing these messages with the target audience for acceptability, comprehension and usefulness. This step is part of developing a communications strategy for disseminating the evidence (stages 3 and 4 in figure 2.3). It requires resources for conducting the qualitative and quantitative research and the involvement of communications and media specialists in framing the messages correctly so that they will have optimal impact on the target populations. The final stages (stages 5-7 in figure 2.3) involve disseminating the message to the community, professional groups and other stakeholders. Historically, those developing PAGs have put considerable effort into the technical and scientific stages and have often neglected message development and communication. Frequently, only informal and unpaid communication channels are used after the launch of PAGs. Thus, a very important step in PAG development and dissemination is the final public health promotion component.
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Framework for developing physical activity guidelines. Adapted from Bauman et al. 2006.
Global, Regional and National Physical Activity Guidelines
Table 2.1 summarises the 2011 global PAGs and provides examples of regional (i.e., European and Western Pacific islands) and national guidelines. Quite a few countries in Europe have their own national PAGs, and many of these countries (e.g., Finland, Switzerland, the Netherlands, United Kingdom) have been engaged with implementing national population-based approaches for some time (Department of Health, 2011b; Ministry of Health, Welfare and Sport, 2011; Swiss Federal Office of Sports, 2006; UKK Institute, 2009). Other countries in Europe have officially or unofficially adopted the guidelines published by the U.S. Centers for Disease Control and Prevention in 1996 and the more recently updated 2008 version.
PAGs in other regions of the world are patchy. Australia (Department of Health and Ageing, 2005b) and New Zealand (Sport and Recreation New Zealand, 2005) have had national guidelines for some time. In Australia, guidelines exist for all ages, from young children (Department of Health and Ageing, 2004) to older adults (Department of Health and Ageing, 2005b), although all guidelines are more than 5 yr old and arguably are due for updating to reflect the latest science. Far fewer examples of PAGs exist in South America, Asia, the Middle East and Africa because physical activity promotion is relatively new in these regions. Countries in which national action on physical activity is beginning have often used the U.S. guidelines as an international benchmark. This has allowed the countries to develop an agenda of physical activity promotion without being hindered by the absence of PAGs. However, in some countries, adopting the PAGs of another country is not politically or culturally welcome or appropriate. Either these countries have developed their own PAGs (a recent example from the Middle East is Brunei; Ministry of Health, 2011) or very little physical activity promotion has occurred.
The absence of a set of official global guidelines did not hinder the World Health Organisation (WHO) from developing the Global Strategy on Diet, Physical Activity and Health in 2004 (World Health Organisation, 2004). Since the publication of the 2002 health report (World Health Organisation, 2002), the focus on the need for greater action to prevent noncommunicable disease and address mental health has increased. To address these issues, WHO commenced developing global guidelines in 2007. WHO launched the final global recommendations on physical activity in 2010 after a 2 yr process involving global and regional consultations (World Health Organisation, 2010). These global guidelines are now available for adoption and use by countries with no national PAGs. Because the guidelines are from WHO, the leading international health agency, the scientific quality and relevance of these guidelines are usually accepted.
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Treating depression and anxiety with exercise
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety.
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety. Information about these prescription parameters is scarce, but it is critical if exercise interventions are to be translated into clinical practice. Asking someone to do something without specifying what they should do or how they should do it would likely make it difficult for the individual to fully comply in a meaningful way. It is also possible that the prescription of exercise for depression and/or anxiety could be different, both in nature and content, than that required for general health benefits.
One trial that is particularly worthy of attention is the Depression Outcomes Study of Exercise (DOSE; Dunn et al., 2005), which attempted to provide evidence about the dose of exercise required to treat depression. In the DOSE study 80 participants were randomised to 1 of 4 exercise groups that varied in total energy expenditure (7 or 17.5 kcal·kg-1·wk-1) and frequency (3 or 5 days/wk) or to a flexibility-exercise placebo control for 12 wk. Exercise at a dose of 17.5 kcal·kg-1·wk-1 was effective in reducing depression regardless of frequency, whereas exercise at a dose of 7 kcal·kg-1·wk-1 yielded antidepressant effects that were comparable to those of the placebo treatment. The plausible biological reason for why a higher dose of exercise may be more effective than lower doses is that frequent and regular exercise should increase fitness levels such that physical discomfort decreases and exercise becomes a more pleasant and enjoyable experience as the conditioning process progresses. Indeed, findings from both the DOSE and TREAD trials in the United States have indicated that higher doses of exercise are more effective than are lower doses (as defined in the study).
Perraton and colleagues (2010) published a systematic review that attempted to summarise what is currently known about the prescription of exercise for depression. The review is useful because previous reviews of exercise and depression did not synthesise this information in a way that would help guide intervention development. This review included only trials that had reported exercise to be effective in reducing depression in order to analyse the specific dosage parameters and modes of exercise used in these successful trials.
The review found that the most common intensity, frequency and duration of aerobic exercise were 60% to 80% of maximum heart rate, 30 min/session and 3 days/wk over 8 wk. The volume of evidence supporting the use of aerobic exercise programmes to treat depression was greater than that supporting the use of anaerobic exercise programmes. No clear trend showed one mode of aerobic exercise to be the most effective, and a range of activity types appeared to be effective. This is encouraging given that one size does not fit all, and individuals can be encouraged to participate in whatever type of aerobic activity they prefer.
In terms of context of exercise, a number of common trends emerged. A variety of locations were effective in treating depression, although all trials that reported location took place indoors. Both group and individual interventions were effective. However, group exercise may have added benefit by providing social support, which can be pivotal for sustaining compliance and can contribute in its own right to lowering depression. Moreover, exercise might lower depression by several plausible mechanisms, one of which could be interrelations or connections with others (Bailey & McLaren, 2005). Many types of exercise can be performed with other people (depressed or not). Therefore, this exercise could provide social integration and an opportunity to interact with the social world as well as a setting in which to expand social networks and make friends (Stathi, Fox & McKenna, 2002).
Another unresolved question concerns the intensity of exercise at which a reduction in depression might occur. Callaghan and colleagues (2011) compared the effects of preferred intensity with those of prescribed intensity of group-based exercise for 12 sessions over 4 wk in 38 women aged 45 to 65 yr who were receiving treatment for depression from either primary or secondary care services. The preferred-intensity group reported significantly lower depression and higher self-esteem and quality-of-life scores than did the prescribed-exercise group and attended more sessions (66% versus 50%). Similar findings have been found in nondepressed populations (Daley & Maynard, 2003). Several theories, such as self-determination theory (Deci & Ryan, 1985), support the notion that giving people a choice and control over what they do, whether it be exercise or other activities, leads to better adherence and enjoyment of the activity, which in turn leads to enhanced psychological well-being. People experiencing depression are no exception.
Wipfli, Rethorst and Landers (2008) considered the relationship between dose of exercise and anxiety levels as part of their broader meta-analysis of the anxiolytic effect of exercise. The trend in the data from 12 RCTs showed that the effect size increased as exercise approached a dose of 12.5 kcal·kg-1·wk-1 (equates to slightly less than the dose recommended for public health) and then began to decrease as exercise dose increased. A combination of aerobic and anaerobic exercise appeared to be better than either type alone, and a frequency of 3 or 4 times/wk appeared more effective than more or less than this amount.
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Available methods for measuring physical activity
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry.
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry. Most are moderately correlated at best. Each method has its own strengths and limitations. Due to the complexity of physical activity, outlined previously, researchers and practitioners need to consider what is most important for their purposes when deciding to use a particular technique. Although no one measurement tool can be singled out as the most appropriate, recommendations for the most useful and practical measurement tools can be made after considering factors such as context, type, duration, frequency and intensity of physical activity as well as the constraints under which the research or treatment programme is operating. These techniques are presented in order of increasing feasibility but decreasing validity. Table 3.2 at the end of this section summarises the key advantages and limitations of each measurement technique.
Doubly Labelled Water
Doubly labelled water (DLW, or free-living indirect calorimetry) is a method commonly used to increase the precision and accuracy of physical activity measurement. DLW, which measures EE over several (4-21) consecutive days in a free-living person under normal life conditions (Schoeller, 1988), is the most widely accepted gold standard method by which to measure EE (Aadahl & Jørgensen, 2003). DLW measures EE of free-living, unrestricted subjects using water labelled with stable isotopes of oxygen and hydrogen (Schoeller & van Santen, 1982). It calculates activity-related EE by combining measurement of total EE with basal metabolic rate. The utility of the DLW method in measuring total EE is demonstrated by its use in a variety of settings, including all age groups, premature infants, hospitalised patients, pregnant women and the elderly (Ainslie, Reilly & Westerterp, 2003). As such, researchers who use this method to assess the relationship between physical activity and other psychological variables or to detect changes in physical activity as a result of interventions can be confident that the results produced regarding EE are accurate. Schoeller (1988) fully describes the validation of the DLW method.
Despite its level of precision, the DLW method is not without disadvantages, which include high cost, limitations for assessing brief periods of EE (Ainslie, Reilly & Westerterp, 2003) and additional demands on participants in terms of time and tasks required. The cost and availability of isotopes and the requirement for analysis by isotope ratio mass spectrometer prohibit DLW from being widely used in studies of large populations. The use of this method among populations with more severe mental health problems may likely present a set of ethical issues. Furthermore, although this technique provides an accurate measure of total EE, it cannot provide information about patterns of physical activity in terms of type, frequency, duration, intensity or context. Consequently, such an approach would not be feasible in a large natural-field experiment or in a test of the effect of interventions on changes in physical activity in both healthy populations and populations that suffer from mental health problems. However, this gold standard measure is believed to offer the most precise estimate of EE and is often used to validate many other types of tools that assess physical activity.
Direct Observation
Direct observation, one of the most basic approaches for acquiring information about behaviours, provides information about how people exercise and play, how environments shape the activities individuals participate in and how people use specific facilities (e.g., parks, leisure facilities, walking or cycling paths). It can take place using basic observation methods, systematic forms or sophisticated technology (e.g., lasers). Direct observation often involves a trained observer who codes physical activity behaviours (e.g., sitting, walking, running) undertaken by participants over time in various settings (e.g., playground, park, home). A number of observation systems are available, such as SOPLAY (System for Observing Play and Leisure Activity in Youth), SOFIT (System for Observing Fitness Instruction Time), and the Systematic Pedestrian and Cycling Environmental Scan. The trained observer may either observe participants in person or review video media. Because it is time consuming, direct observation might be used only with small groups in specific settings (Dugdill & Stratton, 2007).
Advantages of direct observation include that self-report bias is eliminated, participants do not need to recall behaviour and the level of detail regarding behaviour patterns and context can be extremely accurate. Furthermore, practitioners may find some of these tools accessible. For example, clinical psychologists working with institutionalised individuals diagnosed with severe mental health conditions may find this type of measurement technique useful for assessing relationships between physical activity patterns or patterns of inactivity and specific mental illnesses because it can combine both context and behaviour to provide powerful data.
However, disadvantages include the time involved in recording and coding behaviour, the time involved in consolidating the plethora of data collected and the costs associated with training coders. Furthermore, the subjective bias of coders may lead to incorrect judgments about the intensities of specific activities, which would affect estimates of EE. As such, it would be important to consider whether information regarding patterns of behaviour combined with context or specific EE data are required to fulfill the aims of a research project or treatment programme.
Accelerometers
Motion sensors, such as pedometers and accelerometers, can be used to detect body movement and estimate physical activity (Spruijt-Metz et al., 2009). Accelerometers are devices that measure bodily movements in terms of acceleration. This measurement can then be used to estimate the intensity of physical activity, and therefore EE, over time (Burton et al., 2005; Chen & Basset, 2005). Accelerometers can measure human activity on vertical (uniaxial accelerometers), anterior - posterior and medial - lateral (triaxial accelerometers) planes. EE can then be then estimated from vector magnitude counts using a proprietary algorithm, which is a composite of counts from these planes of motion (Howe, Staudenmayer & Freedson, 2009). Accelerometers can be used repeatedly on numerous participants, are more accurate than pedometers and are less expensive (approximately £200 per device; ActiLife, 2009) than other objective methods such as DLW (approximately £200 per participant per procedure; Friedman & Johnson, 2002). However, they remain too expensive to use in studies that assess large numbers of people (Wood, 2000). Nevertheless, these devices are a more feasible and participant-friendly method of attempting to validate a self-report questionnaire than is DLW. They also provide the data necessary to allow researchers to distinguish between light, moderate and vigorous physical activity as well as between continuous and intermittent activity modes (Crouter, Clowers & Bassett, 2006). A recent review of accelerometers against DLW found ActiGraph (previously named CSA/MTI) models to be of the most valid types tested; they produce an average correlation of r = .57 (Plasqui & Westerterp, 2007). Limitations of accelerometers include the increased time required to analyse the large amount of data provided, participant burden of wearing the device, that they cannot be feasibly used to test large-scale interventions, and that they cannot provide information about the specific type of activity (e.g., playing football, going to the gym) or the context in which it is performed.
Some studies have attempted to validate accelerometers among populations diagnosed with mental health conditions. For example, Sharpe and colleagues (2006) conducted a study to assess the validity of the RT3 accelerometer against DLW in people with schizophrenia. They found that the accelerometer overpredicted energy expended on physical activity by an average of 148 kcal/day (standard deviation = 413 kcal/day); this varied from an underestimation of 614 kcal/day to an overestimation of 582 kcal/day. The authors suggested that the RT3 accelerometer is a poor tool for measuring activity EE in sedentary men with schizophrenia. As such, the results of studies that have used this measurement tool in mentally ill populations may be questionable. For example, the recent intervention study of Jerome and colleagues (2009) used the RT3 accelerometer to measure physical activity in persons with mental illness. The authors of this study concluded that participants were undertaking approximately 120 min/wk of moderate-intensity physical activity on average, which would equal approximately 70 kcal/day. Given that the results of the study by Sharpe and colleagues (2006) indicated that the RT3 accelerometer overpredicted EE, it is possible that the results found by Jerome and colleagues (2009) overestimate the amount of physical activity undertaken by participants. Consequently, this might affect the validity of the relationships found between physical activity and various mental health variables measured in this study. Sharpe and colleagues (2006) did, however, indicate that the RT3 appeared to be a valid measure of physical inactivity in men with schizophrenia. Therefore, it could be used for research or clinical purposes to quantify the contribution of sedentary behaviour to medical conditions associated with inactivity. Sharpe and colleagues (2006) also recommended that using the RT3 to validate questionnaires may not be appropriate until it is more robust.
Indirect Objective Measures
Indicators of the physiologic response to physical activity include heart rate and pulmonary gas exchange. Heart-rate monitoring is a promising measurement method because heart rate is a physiological parameter that correlates well with, and strongly predicts, EE (Strath et al., 2002). Most heart rate monitors include software that converts heart rate data into an estimate of EE. However, one of the limitations of heart rate monitoring is that training state and individual heart rate characteristics can affect the relationship between heart rate and oxygen consumption. Higher levels of accuracy can be obtained through a graded submaximal exercise test that calibrates participant heart rate to simultaneous oxygen consumption. This information allows for the construction of a calibration curve that estimates EE at moderate and strenuous levels of exercise. (A linear relationship exists between increasing heart rate and oxygen consumption; Freedson & Miller, 2000.) Measuring heart rate is a common method used to describe intensity and duration of physical activity and is a relatively inexpensive method of measuring EE. However, heart rate is affected by factors other than physical activity, such as emotional stress, temperature, humidity, dehydration, posture and illness (Ainslie, Reilly & Westerterp, 2003). These factors can influence heart rate without causing associated changes in oxygen consumption. Given the potentially increased fluctuations in emotions in individuals diagnosed with mental health conditions, this method may not be the most appropriate for obtaining accurate physical activity levels. Furthermore, the relationship between oxygen uptake and heart rate is weak at low levels of activity (Keim, Blanton & Kretsch, 2004). Evidence suggests that individuals suffering from mental health problems tend to perform less intensive physical activity than do members of the general population (e.g., Brown et al., 1999). Therefore, the heart rate method may not provide accurate information about the physical activity of mental health populations. Also, the heart rate method is unable to identify types of activity or the context in which physical activity is performed. Although heart rate is a physiological marker for physical activity and may provide a general picture of physical activity patterns, it may not be the best method available for obtaining an accurate estimate of EE.
Pedometers
Pedometers, which measure steps on a single axis as well as calories expended, are less expensive than some other types of motion sensors. As such, these devices are an attractive alternative to self-report in large observational or intervention studies. Public health campaigns have also promoted pedometers as a motivational tool for achieving the goal of 10,000 steps daily. A range of pedometers is available. The pedometer that is most suitable for a particular study may depend on factors such as the research question (outcome of interest), population, available funds, context and validity of the model. For example, when considering context, researchers or practitioners who wish to understand the types of physical activity being undertaken in a variety of settings would not gain this information using pedometers alone. When considering population, some pedometers are validated in healthy adults but not in other populations such as children, the elderly or those diagnosed with mental illness. Pedometers have demonstrated reduced accuracy in elderly populations because of the slow pace or shuffling nature with which elderly people walk (Cyarto, Myers & Tudor-Locke, 2004). Tudor-Locke and colleagues (2002) evaluated the validity of pedometers in a review of 25 studies and found a strong correlation between pedometer counts and accelerometer output (median of reported correlations is r = .86). However, evidence suggests that the validity of pedometers for measuring EE and distance in normal populations is questionable. The findings of a study testing the validity of 10 pedometers (Crouter et al., 2003) indicated that these devices overestimated distance at slower speeds and underestimated distance at faster speeds. Furthermore, in 8 of the pedometers tested, it was unclear whether the device was measuring gross EE (all the energy expended by an individual during a specific activity) or net EE (the energy expended by an individual during a specific activity minus the resting EE for the equivalent amount of time). The Yamax Digiwalker SW-200 was found to be the most reliable and accurate pedometer available (Crouter et al., 2003). This pedometer was used in a recent study by McKercher (2009) that assessed relationships between physical activity and depression in young adults. This study found that low levels of depression were significantly correlated with moderate levels of physical activity, as measured by the Yamax Digiwalker SW-200, among females. However, this device has not been validated in specific mental health populations, which may limit the validity of these results. It is important to validate physical activity devices among specific populations because patterns of physical activity in these populations may differ from those in the general population. For example, individuals with serious mental illness are significantly less active than the general population (Brown et al., 2004). As such, using a physical activity measure that has been validated with mental health populations in research on physical activity and mental health will increase the strength of the results produced.
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Coping with long-term physical health conditions
Approximately 30% of the European population has a long-term physical health condition. People with a long-term condition that is comorbid with a mental health problem have worse health outcomes than do people with either of these alone.
Key Concepts
- Approximately 30% of people with a long-term condition have a comorbid mental health condition.
- Physical activity is an important part of the management of physical and psychological well-being in people with long-term conditions.
- Pulmonary rehabilitation leads to reduced depression and anxiety and increased quality of life in people with chronic obstructive pulmonary disease. Further research is required to understand the optimal exercise dose; the interaction of exercise training, education and psychosocial support during pulmonary rehabilitation; and how to sustain changes in physical activity behaviour after pulmonary rehabilitation.
- Physical inactivity is associated with greater depression in people with type 2 diabetes. Further research is required to understand the causality of this relationship, although available data suggest that physical activity interventions reduce depression.
- Data that explore the relationship between physical activity and mental health in people with type 1 diabetes are limited.
- Physical activity has been shown to increase quality of life and reduce anxiety and depression in cancer survivors. Data suggest that supervised and group exercise are more beneficial than unsupervised and home-based exercise in this population.
Long-term conditions (LTCs) have been defined as "those conditions that cannot, at present, be cured, but can be controlled by medication and other therapies. The life of a person with an LTC is forever altered - there is no return to normal" (Department of Health, 2008, p. 10). LTCs include diabetes, arthritis, chronic obstructive pulmonary disease (COPD) and a number of cardiovascular diseases. In addition, conditions such as human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) and certain cancers that were not traditionally considered LTCs are increasingly being regarded as such (Naylor et al., 2012). Many mental health problems can themselves be considered LTCs. However, in this chapter the term long-term condition refers specifically to physical health conditions.
The World Health Organisation's (2011) report on the global burden of noncommunicable diseases (i.e., all previously mentioned LTCs except HIV and AIDS) found that noncommunicable diseases are by far the leading cause of mortality in the world and represent 63% of all deaths. The majority of these deaths are due to cardiovascular disease, diabetes, cancer and chronic respiratory disease. The highest occurrence of deaths from these diseases is in low- and middle-income countries, and the prevalence in these countries is predicted to increase substantially in the future. In Europe 29% of people aged 15 yr or older report a longstanding health problem (TNS Opinion, 2007), and the Office for National Statistics (2005) found that in England approximately 30% of the population (15.4 million people) has a LTC. As populations age, the burden of LTCs is projected to increase even further.
Long-Term Conditions and Mental Health Issues
People with LTCs are two to three times more likely than the general population to experience mental health problems. Depression and anxiety are the most frequently reported mental health problems in people with LTCs, but dementia, cognitive decline and some other conditions have also been reported (Naylor et al., 2012). Depression is two to three times more common in people with an LTC than in those with good physical health and occurs in approximately 20% of people with an LTC (National Collaborating Centre for Mental Health, 2010). Conservative estimates suggest that at least 30% of all people with an LTC also have a comorbid mental health problem of some kind (Cimpean & Drake, 2011). Research has shown that having a mental health problem along with an LTC has a stronger negative impact on quality of life and functional status than does either the number of LTCs or the severity of those conditions. For example, quality of life is lower in people with one LTC and depression than in people with two or more LTCs and no depression (Moussavi et al., 2007). Figure 8.1 shows the overlap between LTCs and mental health disorders.
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In addition to experiencing psychological distress, patients with an LTC and comorbid mental health problem experience poorer clinical outcomes compared with people with an LTC and no mental health problem (Moussavi et al., 2007). This is partly because self-management is necessary for effectively controlling LTCs, and poor mental health can result in poorer self-management. For example, it may lead to lack of motivation and energy to adhere to treatment plans or attend medical appointments (DiMatteo, Lepper & Croghan, 2000). From a financial perspective, comorbid mental health problems are typically associated with a 45% to 75% increase in care costs for a person with an LTC. These data are based on a wide range of LTCs and are observed after adjustment for severity of physical disease (Unützer et al., 2009; Welch et al., 2009).
Overlap between long-term conditions and mental health problems in England. Adapted, by permission, from C. Naylor et al., 2012, Long-term conditions and mental health: The cost of co-morbidities (London: The King's Fund and Centre for Mental Health).
Long-Term Conditions and Quality of Life
Quality of life is an individual's perception of their ability to function well on physical, mental and social levels. Quality of life can be measured in a reliable and valid manner using self-reported questionnaires, which can be categorised into three main groups: generic, disease specific and domain specific. Generic questionnaires measure quality of life in general terms, independent of the presence of any disease. Disease-specific questionnaires measure the consequences of a specific disease on quality of life. Domain-specific questionnaires focus on certain domains of quality of life (e.g., physical inabilities).
Where it is possible to manage but not cure a disease, such as in LTCs, measures of quality of life are frequently used to help determine the impact of treatment and disease. They help health professionals make informed judgements about whether treatment is appropriate and, where a choice of treatments exists, which might be the best option. Researchers frequently use these measures to assess the impact of a new intervention.
Long-Term Conditions and Physical Activity
Doctors have traditionally advised people with a range of LTCs to rest and not tire themselves out, and this advice persists in the lay psyche. For example, a recent Swedish survey found that the physical activity levels of people with diabetes, rheumatoid arthritis or COPD are lower than those of healthy controls; 73% of people with diabetes, 74% with rheumatoid arthritis and 84% with COPD reported low physical activity levels compared with 60% of controls (Arne et al., 2009). However, modern treatment of LTCs often includes promoting physical activity as part of a healthy lifestyle, and accumulating evidence shows the importance of physical activity in the management of both physical and psychological well-being for people with one or more LTCs. Regular contact between health professionals and people with LTCs provides opportunities for promoting physical activity in this group.
Each LTC presents its own challenges and benefits with regard to physical activity. The remainder of this chapter focusses in particular on the impact of physical activity on mental health and well-being in people with COPD, diabetes and cancer.
Chronic Obstructive Pulmonary Disease
COPD is characterised by airflow obstruction that is not fully reversible and usually progressive in the long term. It is predominantly caused by smoking. Symptoms include breathlessness (dyspnoea) on exertion, chronic cough, regular production of sputum and frequent winter bronchitis or wheeze. Exacerbation of symptoms often occurs in which the patient's symptoms rapidly worsen beyond normal day-to-day variations. Diagnosis relies on a combination of history, physical examination and confirmation of airflow obstruction using spirometry; no single test for COPD exists (National Institute for Health and Clinical Excellence, 2010). Severity of COPD is often classified using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria (I [mild], II [moderate], III [severe] and IV [very severe]) and index of body mass, airway obstruction, dyspnoea and exercise capacity (BODE).
The World Health Organisation has predicted that by 2020 COPD will be the third leading cause of death and fifth leading cause of disability in the world (Murray & Lopez, 1996, 1997). Mortality rates for men in the United Kingdom are at a plateau and mortality rates for women are steadily increasing (Soriano et al., 2000) most likely as a result of the uptake of smoking among women post-World War II. According to the chief medical officer in England, COPD accounts for more than £800 million in direct health care costs (Department of Health, 2005); more than one half of these costs relate to the provision of hospital care. COPD is among the most costly inpatient conditions that the National Health Service treats.
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Designing a physical activity program for individuals with addictions
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours.
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours. However, implementation of behavior change in this population can present practitioners with specific challenges. This section discusses the suggestions for designing effective interventions for those with addictions based on the evidence reviewed so far as well as practical considerations.
Exercise Type, Frequency and Intensity
Most studies have promoted moderate-intensity cardiovascular-type exercise such as brisk walking for use in those with addictive behaviours. Some work also incorporates more vigorous activities such as running. Because individuals with addictions are often extremely sedentary, a programme of moderate-intensity activity is likely to be acceptable and safe. However, a progression to more vigorous exercise may be beneficial. For example, the only study that found a long-term benefit of exercise for smoking cessation entailed 30 to 40 min of vigorous exercise 3 times/wk for 12 wk (Marcus et al., 1999). Similarly, the single study that showed a long-term impact of exercise on alcohol abstinence involved 1 h of progressively vigorous exercise 5 days/wk for 6 wk (Sinyor et al., 1982). None of the trials reviewed compared the effects of vigorous-intensity and moderate-intensity exercise on abstinence rates. Experimental studies have compared the effects of bouts of moderate-intensity and vigorous-intensity exercise and have shown that both intensities are effective in the short term for reducing tobacco-withdrawal symptoms (Taylor et al., 2007).
The intensity of activity that an individual is capable of depends on initial level of fitness, medical condition and stage of recovery from addiction. Careful medical screening is vital. For example, those addicted to amphetamine or cocaine are often undernourished, and problem drinkers often have weak muscles. Such individuals may require nutrition advice. Ultimately, individuals will have preferences regarding types of exercise, and programmes should be tailored to these preferences (Abrantes et al., 2011; Everson-Hock et al., 2010). Some individuals may prefer noncardiovascular types of exercise, which may also be beneficial. Resistance (i.e., weight) training, yoga and isometric exercise have all been successfully piloted as aids for smoking cessation and need to be tested in larger trials (Ussher, Taylor & Faulkner, 2012).
Regarding frequency and volume of exercise, the findings from Marcus and colleagues (2005) suggest that abstaining smokers need to accumulate at least 110 min/wk of moderate-intensity activity to maintain abstinence; supervised exercise on 2 or 3 days/wk may be necessary in order to achieve this. Shorter bouts of exercise can be used on an as-needed basis in response to cravings, and longer scheduled bouts can be used to maintain positive mood, manage stress and prevent cravings from arising. Research has not yet addressed the optimum dose of exercise for assisting alcohol and drug rehabilitation.
Exercise Supervision
The majority of intervention studies have employed group-based supervised exercise. In smokers, exercise counselling alone did not increase exercise levels sufficiently (Ussher et al., 2003), and all the interventions that showed a significant impact on long-term abstinence from alcohol or smoking entailed supervised exercise. Among novice exercisers, an element of supervised exercise may be useful to ensure initial adoption of regular exercise and to provide information about safe exercise (e.g., warm-up) and exercise intensities (e.g., using heart rate monitors). Counselling toward pursuing home-based exercise is also likely to be important for encouraging patients to maintain exercise levels after the initial exercise programme ends.
Stages of Addiction Treatment
Early recovery from drug and alcohol dependence is a major transition that affects close relationships and employment and involves numerous treatment sessions. An exercise programme needs to complement these changes. Most exercise interventions discussed in this chapter have required patients to alter their substance- or alcohol-misuse behaviour and exercise behaviour simultaneously, yet it is not clear whether this is optimal. For some individuals the challenge of changing two health behaviours simultaneously may be too demanding. Also, it is not clear whether involvement in physical activity increases the motivation to manage substance intake or vice versa.
Among smokers, exercise has often been introduced in the studies discussed several weeks before an attempt to quit, thereby allowing people to adjust to the demands of increased exercise before starting to quit. This also allows exercise to play a role in managing cravings during the crucial early days of abstinence, when relapse rates are highest. Empirical work is required to determine the relative benefits of initiating exercise at different points in the addiction-treatment process. During later stages of treatment exercise may be useful for preventing relapse (e.g., by promoting an exercise identity that is incompatible with drug use). Studies are also needed to determine whether exercise can be used to increase substance abstinence among those who are not motivated to attempt abstinence.
Integrating Exercise With Standard Addiction Treatments
Greater integration of addiction and exercise programmes may enhance abstinence rates. For instance, rather than just proposing exercise as a means for getting fitter and managing weight, the practitioner could present exercise more as a self-control strategy for managing withdrawal symptoms and a way to address psychological and physical harms caused by addiction. Exercise could be used more in combination with pharmaceutical interventions. Whereas pharmaceutical interventions focus on reducing withdrawal symptoms (e.g., NRT), exercise could ideally be used to provide an added effect in client-led management of addictive symptoms.
Perceived Barriers to Exercise
Individuals with addictions are likely to have specific barriers to exercise, and these need to be determined. In the general population, use of cognitive - behavioural techniques is effective for overcoming perceived barriers and increasing exercise adherence. Few addiction studies have included cognitive - behavioural counseling. Techniques such as self-monitoring (e.g., diaries), goal-setting and relapse-prevention planning are commonly used. Also, pedometers are now commonly used as a motivational tool. These and other motivational aids (e.g., financial incentives) need to be tested with exercise interventions in addicted populations.
Interventions for Different Subgroups
Exercise interventions need to be tested among addicted populations who might especially benefit from such interventions. Given the high prevalence of addictions among people with mental illness and the established benefits of regular physical activity for mental health, research that examines the role that physical activity may play in this population is needed (Arbour-Nicitopoulos et al., 2011).
Exercise interventions might be particularly appealing to adolescents, and controlled trials with young people are needed. Addicted individuals who are overweight may have a need for weight-control interventions such as exercise; no trial has yet focussed on this population. Additionally, surveys suggest that a nonpharmaceutical intervention such as exercise is likely to appeal to pregnant smokers (Ussher at al., 2008). Finally, sex needs to be considered when planning an appropriate intervention. Some evidence shows that women often prefer walking and aerobics, whereas men have more interest in sport, running and strength training.
Evidence to Practice
- Both moderate- and vigorous-intensity exercise have been shown to be effective for reducing tobacco-withdrawal symptoms and cravings.
- Progressing from light- and moderate-intensity exercise (e.g., brisk walking) to more vigorous-intensity exercise is advisable.
- Careful medical screening is required, especially among those with long-term alcohol or drug dependence (e.g., for malnutrition).
- Exercise interventions should be tailored to individual preferences.
- Abstaining smokers should accumulate at least 110 min/wk of moderate-intensity exercise.
- Interventions involving supervised exercise on 2 or 3 days/wk are likely to be necessary to be effective in treating addictive behaviours.
- Exercise can be performed on an as-needed basis for managing cravings or in scheduled bouts.
- If the exercise programme is to assist with early withdrawal symptoms, it ideally needs to begin before abstinence is attempted.
- Participating in physical activity encourages individuals to adopt an identity as an exerciser, which is incompatible with using addictive substances.
- Perceived barriers to exercise need to be identified and addressed using cognitive - behavioural techniques.
- The intervention needs to be adapted to various subgroups (e.g., according to sex, body weight and mental health).
Summary
Drug, alcohol and tobacco addictions are growing global problems. Exercise has many benefits for physical and psychological health, and evidence convincingly shows that exercise is effective for managing cravings and withdrawal symptoms, particularly in smokers. Regular exercise fosters a healthy lifestyle and exercise identity that is largely incompatible with addiction, and individuals undergoing rehabilitation for addiction express interest in exercising more. Exercise interventions are inexpensive, can be easily integrated with existing addiction treatments and have minimal side effects compared with pharmacological treatments. This chapter demonstrates that exercise is a highly plausible adjunctive treatment for addictive behaviour and that exercise programmes can be readily disseminated. However, limited evidence currently supports the benefits of exercise for helping smokers quit or helping those with drug or alcohol dependence abstain. This lack of evidence can partly be explained by the small number of large RCTs that have been conducted, lack of knowledge about effective doses of exercise and limited attention to methods for maximizing exercise adherence. This area of research is in its infancy, and further well-designed trials are needed.
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Physical activity guidelines
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits.
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits. National guidelines aimed at the whole population (as opposed to specific populations defined by a medical condition) focus on the optimal amount of activity to prevent disease and promote health and well-being. PAGs indicate the type (e.g., aerobic activity, strength training, weight bearing), frequency (e.g., 3 days/wk), duration (e.g., 30 min) and intensity (e.g., moderate, vigorous) (see figure 2.2) of physical activity to undertake and for what benefits. These detailed specifications reflect the latest science on the topic.
PAGs need to be updated periodically because evidence about the relationship between physical activity and health changes over time and knowledge grows. Some guidelines are more general in nature, whereas others provide very specific details; this usually reflects the state of knowledge at that time. Through a review and revision process, more specific details are added to PAGs when available. For example, in various national PAGs, guidelines relating to maintaining musculoskeletal strength have been revised over time and now include details on how much strength training is required for good health (World Health Organisation, 2010) and, specifically, for preventing falls and treating depression (Singh, Clements & Singh, 2001).
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The dose - response relationship: Increasing benefits from increasing amounts (expressed in frequency, duration and intensity) of activity. Reprinted, by permission, from I. Vuori, 1995, Terveysliikunta [Health and physical education]. UKK Institute for Health Promotion Research (Tampere, Finland).
National guidelines are an important component of a population-based approach to addressing any public health issue. First, such guidelines communicate a consensus on the scientific evidence of the importance of the issue. They describe the strength of the science in terms of the volume as well as the quality (determined based on the quality of study designs and research methods used) of the evidence. Communicating scientific consensus is important because it removes doubt and speculation about the validity of the health issue and its importance. This scientific consensus can also be used to advocate for resources and programmes. However, just because guidelines exist does not mean that everyone agrees about what the science says - far from it. However, these disagreements, or alternative interpretations of overall findings to date, are usually communicated in technical reports that accompany the publication of PAGs and are not fully accessible to the general public.
The process of developing PAGs usually involves leadership by a high-level institution. This adds credence to the message that the issue is important. For example, several national and international health agencies, such as the American Heart Association (Haskell et al., 2007), have developed guidelines on physical activity. National governments, usually the ministry of health, often lead the development process and endorse national PAGs. This endorsement is very useful because it specifies the government's position on physical activity and thereby provides the opportunity for interested parties such as charities and public health directors to leverage the government into supporting further action and funding for programmes and services aimed at increasing physical activity. This might include government endorsement of counselling and clinical services for inactive patients, as has been trialled in the United Kingdom (Bull & Milton, 2011). Government involvement and endorsement can also prevent policy inaction. The absence of an official position on physical activity can block funding and further development of a national population-based approach.
One important role of PAGs is to direct community-level actions aimed at increasing physical activity in the whole population. The details in PAGs about the type, frequency, duration and intensity of activities required for different age groups can provide clinicians, health care practitioners and others with direction on what types of programmes to provide and promote to patients and the wider community.
PAGs should drive and direct action not just at the level of individuals and service providers but also at all levels - national, regional and local - of government. If the national government endorses PAGs, ideally with multiparty political support, the government should be held accountable when levels of physical activity are not improving and can be expected to include physical activity promotion as part of ongoing disease-prevention and health-promotion strategies. The role of PAGs and national surveillance of risk factors is discussed in more detail later in this chapter.
Development of the First National Physical Activity Guidelines
Epidemiological studies of exercise and health were well advanced by the 1970s. The American College of Sports Medicine released the first set of recommendations in 1975 and released another set in 1980 (American College of Sports Medicine, 1975, 1980). These recommendations were predominantly directed at cardiorespiratory fitness and suggested that people undertake vigorous-intensity aerobic exercise 3 times/wk for 20 min each time. This was a practical interpretation of the exact recommendation from 1975, which suggested that people undertake 20 to 45 min of physical activity 3 to 5 days/wk at 70% to 90% of heart rate (i.e., vigorous intensity) (American College of Sports Medicine, 1975). The focus on aerobic exercise for increasing fitness continued to dominate and influence health messages about physical activity until the early 1990s. However, guidelines began to recommend moderate-intensity physical activity rather than vigorous-intensity activity, and by the mid-1990s the focus shifted from cardiorespiratory fitness to health benefits. This new position on physical activity was communicated in a landmark set of recommendations from the office of the U.S. surgeon general in the report "Physical Activity and Health" (U.S. Centers for Disease Control and Prevention, 1996).
In the mid-1990s, epidemiological evidence started to show that people with different health conditions require slightly different amounts of physical activity. Although the recommendation for 30 min of moderate-intensity activity on most days remained valid for preventing heart disease and diabetes, studies showed that slightly more physical activity was recommended for preventing cancer. Further, studies identified that the amount of activity required for weight loss or preventing weight gain was greater than that required to prevent chronic disease (Haskell et al., 2007). For example, the International Association for the Study of Obesity recommendations made a clear distinction between the minimum physical activity required for health benefits and the amount required for preventing weight gain. The recommendations state that "45 to 60 min (60-90 min for formerly obese individuals) of moderate-intensity physical activity daily is needed to prevent the transition to overweight or obesity" (Saris et al., 2003). Furthermore, research has now shown that the amount of physical activity required by young people differs from that of adults. The overall amount of physical activity recommended for children is twice that recommended for adults and is usually expressed as "at least 60 min/day" (Canadian Society for Exercise Physiology, 2011a; Saris et al., 2003).
These different recommendations make the development of PAGs complex. However, a core and consistent interpretation of the evidence is that 30 min of moderate-intensity physical activity on most days of the week is associated with maximum overall population benefit and the prevention of major noncommunicable diseases. This same dose has been expressed as "at least 150 min/wk of moderate-intensity activity" in the most recent global, U.S. and U.K recommendations (Department of Health, 2011b; U.S. Department of Health and Human Services, 2008a; World Health Organisation, 2010).
Current Best Practice in Developing Guidelines
Figure 2.3 illustrates the process of developing guidelines. The first step is establishing the need for guidelines. This need is often defined by policymakers, public health scientists, advocates and, sometimes, the community. Then a process for guideline development needs to be agreed on by interested parties, with actions planned in sequence and, ideally, a linkage between the PAG development process and other aspects of national or regional physical activity policy and strategy development (step 1 in figure 2.3). The next stage comprises reviewing the scientific evidence and creating an updated summary of what the research says and how this information differs from that in previous guidelines. A number of countries, notably Canada and, most recently, the United Kingdom and United States, have undertaken this process. Tremblay and colleagues (2010) extensively discuss this process with reference to the recent Canadian guidelines along with frameworks and a checklist for auditing data quality in the review stage.
Once the science has been reviewed, the next stage is developing communication messages based on the evidence and testing these messages with the target audience for acceptability, comprehension and usefulness. This step is part of developing a communications strategy for disseminating the evidence (stages 3 and 4 in figure 2.3). It requires resources for conducting the qualitative and quantitative research and the involvement of communications and media specialists in framing the messages correctly so that they will have optimal impact on the target populations. The final stages (stages 5-7 in figure 2.3) involve disseminating the message to the community, professional groups and other stakeholders. Historically, those developing PAGs have put considerable effort into the technical and scientific stages and have often neglected message development and communication. Frequently, only informal and unpaid communication channels are used after the launch of PAGs. Thus, a very important step in PAG development and dissemination is the final public health promotion component.
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Framework for developing physical activity guidelines. Adapted from Bauman et al. 2006.
Global, Regional and National Physical Activity Guidelines
Table 2.1 summarises the 2011 global PAGs and provides examples of regional (i.e., European and Western Pacific islands) and national guidelines. Quite a few countries in Europe have their own national PAGs, and many of these countries (e.g., Finland, Switzerland, the Netherlands, United Kingdom) have been engaged with implementing national population-based approaches for some time (Department of Health, 2011b; Ministry of Health, Welfare and Sport, 2011; Swiss Federal Office of Sports, 2006; UKK Institute, 2009). Other countries in Europe have officially or unofficially adopted the guidelines published by the U.S. Centers for Disease Control and Prevention in 1996 and the more recently updated 2008 version.
PAGs in other regions of the world are patchy. Australia (Department of Health and Ageing, 2005b) and New Zealand (Sport and Recreation New Zealand, 2005) have had national guidelines for some time. In Australia, guidelines exist for all ages, from young children (Department of Health and Ageing, 2004) to older adults (Department of Health and Ageing, 2005b), although all guidelines are more than 5 yr old and arguably are due for updating to reflect the latest science. Far fewer examples of PAGs exist in South America, Asia, the Middle East and Africa because physical activity promotion is relatively new in these regions. Countries in which national action on physical activity is beginning have often used the U.S. guidelines as an international benchmark. This has allowed the countries to develop an agenda of physical activity promotion without being hindered by the absence of PAGs. However, in some countries, adopting the PAGs of another country is not politically or culturally welcome or appropriate. Either these countries have developed their own PAGs (a recent example from the Middle East is Brunei; Ministry of Health, 2011) or very little physical activity promotion has occurred.
The absence of a set of official global guidelines did not hinder the World Health Organisation (WHO) from developing the Global Strategy on Diet, Physical Activity and Health in 2004 (World Health Organisation, 2004). Since the publication of the 2002 health report (World Health Organisation, 2002), the focus on the need for greater action to prevent noncommunicable disease and address mental health has increased. To address these issues, WHO commenced developing global guidelines in 2007. WHO launched the final global recommendations on physical activity in 2010 after a 2 yr process involving global and regional consultations (World Health Organisation, 2010). These global guidelines are now available for adoption and use by countries with no national PAGs. Because the guidelines are from WHO, the leading international health agency, the scientific quality and relevance of these guidelines are usually accepted.
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Treating depression and anxiety with exercise
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety.
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety. Information about these prescription parameters is scarce, but it is critical if exercise interventions are to be translated into clinical practice. Asking someone to do something without specifying what they should do or how they should do it would likely make it difficult for the individual to fully comply in a meaningful way. It is also possible that the prescription of exercise for depression and/or anxiety could be different, both in nature and content, than that required for general health benefits.
One trial that is particularly worthy of attention is the Depression Outcomes Study of Exercise (DOSE; Dunn et al., 2005), which attempted to provide evidence about the dose of exercise required to treat depression. In the DOSE study 80 participants were randomised to 1 of 4 exercise groups that varied in total energy expenditure (7 or 17.5 kcal·kg-1·wk-1) and frequency (3 or 5 days/wk) or to a flexibility-exercise placebo control for 12 wk. Exercise at a dose of 17.5 kcal·kg-1·wk-1 was effective in reducing depression regardless of frequency, whereas exercise at a dose of 7 kcal·kg-1·wk-1 yielded antidepressant effects that were comparable to those of the placebo treatment. The plausible biological reason for why a higher dose of exercise may be more effective than lower doses is that frequent and regular exercise should increase fitness levels such that physical discomfort decreases and exercise becomes a more pleasant and enjoyable experience as the conditioning process progresses. Indeed, findings from both the DOSE and TREAD trials in the United States have indicated that higher doses of exercise are more effective than are lower doses (as defined in the study).
Perraton and colleagues (2010) published a systematic review that attempted to summarise what is currently known about the prescription of exercise for depression. The review is useful because previous reviews of exercise and depression did not synthesise this information in a way that would help guide intervention development. This review included only trials that had reported exercise to be effective in reducing depression in order to analyse the specific dosage parameters and modes of exercise used in these successful trials.
The review found that the most common intensity, frequency and duration of aerobic exercise were 60% to 80% of maximum heart rate, 30 min/session and 3 days/wk over 8 wk. The volume of evidence supporting the use of aerobic exercise programmes to treat depression was greater than that supporting the use of anaerobic exercise programmes. No clear trend showed one mode of aerobic exercise to be the most effective, and a range of activity types appeared to be effective. This is encouraging given that one size does not fit all, and individuals can be encouraged to participate in whatever type of aerobic activity they prefer.
In terms of context of exercise, a number of common trends emerged. A variety of locations were effective in treating depression, although all trials that reported location took place indoors. Both group and individual interventions were effective. However, group exercise may have added benefit by providing social support, which can be pivotal for sustaining compliance and can contribute in its own right to lowering depression. Moreover, exercise might lower depression by several plausible mechanisms, one of which could be interrelations or connections with others (Bailey & McLaren, 2005). Many types of exercise can be performed with other people (depressed or not). Therefore, this exercise could provide social integration and an opportunity to interact with the social world as well as a setting in which to expand social networks and make friends (Stathi, Fox & McKenna, 2002).
Another unresolved question concerns the intensity of exercise at which a reduction in depression might occur. Callaghan and colleagues (2011) compared the effects of preferred intensity with those of prescribed intensity of group-based exercise for 12 sessions over 4 wk in 38 women aged 45 to 65 yr who were receiving treatment for depression from either primary or secondary care services. The preferred-intensity group reported significantly lower depression and higher self-esteem and quality-of-life scores than did the prescribed-exercise group and attended more sessions (66% versus 50%). Similar findings have been found in nondepressed populations (Daley & Maynard, 2003). Several theories, such as self-determination theory (Deci & Ryan, 1985), support the notion that giving people a choice and control over what they do, whether it be exercise or other activities, leads to better adherence and enjoyment of the activity, which in turn leads to enhanced psychological well-being. People experiencing depression are no exception.
Wipfli, Rethorst and Landers (2008) considered the relationship between dose of exercise and anxiety levels as part of their broader meta-analysis of the anxiolytic effect of exercise. The trend in the data from 12 RCTs showed that the effect size increased as exercise approached a dose of 12.5 kcal·kg-1·wk-1 (equates to slightly less than the dose recommended for public health) and then began to decrease as exercise dose increased. A combination of aerobic and anaerobic exercise appeared to be better than either type alone, and a frequency of 3 or 4 times/wk appeared more effective than more or less than this amount.
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Available methods for measuring physical activity
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry.
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry. Most are moderately correlated at best. Each method has its own strengths and limitations. Due to the complexity of physical activity, outlined previously, researchers and practitioners need to consider what is most important for their purposes when deciding to use a particular technique. Although no one measurement tool can be singled out as the most appropriate, recommendations for the most useful and practical measurement tools can be made after considering factors such as context, type, duration, frequency and intensity of physical activity as well as the constraints under which the research or treatment programme is operating. These techniques are presented in order of increasing feasibility but decreasing validity. Table 3.2 at the end of this section summarises the key advantages and limitations of each measurement technique.
Doubly Labelled Water
Doubly labelled water (DLW, or free-living indirect calorimetry) is a method commonly used to increase the precision and accuracy of physical activity measurement. DLW, which measures EE over several (4-21) consecutive days in a free-living person under normal life conditions (Schoeller, 1988), is the most widely accepted gold standard method by which to measure EE (Aadahl & Jørgensen, 2003). DLW measures EE of free-living, unrestricted subjects using water labelled with stable isotopes of oxygen and hydrogen (Schoeller & van Santen, 1982). It calculates activity-related EE by combining measurement of total EE with basal metabolic rate. The utility of the DLW method in measuring total EE is demonstrated by its use in a variety of settings, including all age groups, premature infants, hospitalised patients, pregnant women and the elderly (Ainslie, Reilly & Westerterp, 2003). As such, researchers who use this method to assess the relationship between physical activity and other psychological variables or to detect changes in physical activity as a result of interventions can be confident that the results produced regarding EE are accurate. Schoeller (1988) fully describes the validation of the DLW method.
Despite its level of precision, the DLW method is not without disadvantages, which include high cost, limitations for assessing brief periods of EE (Ainslie, Reilly & Westerterp, 2003) and additional demands on participants in terms of time and tasks required. The cost and availability of isotopes and the requirement for analysis by isotope ratio mass spectrometer prohibit DLW from being widely used in studies of large populations. The use of this method among populations with more severe mental health problems may likely present a set of ethical issues. Furthermore, although this technique provides an accurate measure of total EE, it cannot provide information about patterns of physical activity in terms of type, frequency, duration, intensity or context. Consequently, such an approach would not be feasible in a large natural-field experiment or in a test of the effect of interventions on changes in physical activity in both healthy populations and populations that suffer from mental health problems. However, this gold standard measure is believed to offer the most precise estimate of EE and is often used to validate many other types of tools that assess physical activity.
Direct Observation
Direct observation, one of the most basic approaches for acquiring information about behaviours, provides information about how people exercise and play, how environments shape the activities individuals participate in and how people use specific facilities (e.g., parks, leisure facilities, walking or cycling paths). It can take place using basic observation methods, systematic forms or sophisticated technology (e.g., lasers). Direct observation often involves a trained observer who codes physical activity behaviours (e.g., sitting, walking, running) undertaken by participants over time in various settings (e.g., playground, park, home). A number of observation systems are available, such as SOPLAY (System for Observing Play and Leisure Activity in Youth), SOFIT (System for Observing Fitness Instruction Time), and the Systematic Pedestrian and Cycling Environmental Scan. The trained observer may either observe participants in person or review video media. Because it is time consuming, direct observation might be used only with small groups in specific settings (Dugdill & Stratton, 2007).
Advantages of direct observation include that self-report bias is eliminated, participants do not need to recall behaviour and the level of detail regarding behaviour patterns and context can be extremely accurate. Furthermore, practitioners may find some of these tools accessible. For example, clinical psychologists working with institutionalised individuals diagnosed with severe mental health conditions may find this type of measurement technique useful for assessing relationships between physical activity patterns or patterns of inactivity and specific mental illnesses because it can combine both context and behaviour to provide powerful data.
However, disadvantages include the time involved in recording and coding behaviour, the time involved in consolidating the plethora of data collected and the costs associated with training coders. Furthermore, the subjective bias of coders may lead to incorrect judgments about the intensities of specific activities, which would affect estimates of EE. As such, it would be important to consider whether information regarding patterns of behaviour combined with context or specific EE data are required to fulfill the aims of a research project or treatment programme.
Accelerometers
Motion sensors, such as pedometers and accelerometers, can be used to detect body movement and estimate physical activity (Spruijt-Metz et al., 2009). Accelerometers are devices that measure bodily movements in terms of acceleration. This measurement can then be used to estimate the intensity of physical activity, and therefore EE, over time (Burton et al., 2005; Chen & Basset, 2005). Accelerometers can measure human activity on vertical (uniaxial accelerometers), anterior - posterior and medial - lateral (triaxial accelerometers) planes. EE can then be then estimated from vector magnitude counts using a proprietary algorithm, which is a composite of counts from these planes of motion (Howe, Staudenmayer & Freedson, 2009). Accelerometers can be used repeatedly on numerous participants, are more accurate than pedometers and are less expensive (approximately £200 per device; ActiLife, 2009) than other objective methods such as DLW (approximately £200 per participant per procedure; Friedman & Johnson, 2002). However, they remain too expensive to use in studies that assess large numbers of people (Wood, 2000). Nevertheless, these devices are a more feasible and participant-friendly method of attempting to validate a self-report questionnaire than is DLW. They also provide the data necessary to allow researchers to distinguish between light, moderate and vigorous physical activity as well as between continuous and intermittent activity modes (Crouter, Clowers & Bassett, 2006). A recent review of accelerometers against DLW found ActiGraph (previously named CSA/MTI) models to be of the most valid types tested; they produce an average correlation of r = .57 (Plasqui & Westerterp, 2007). Limitations of accelerometers include the increased time required to analyse the large amount of data provided, participant burden of wearing the device, that they cannot be feasibly used to test large-scale interventions, and that they cannot provide information about the specific type of activity (e.g., playing football, going to the gym) or the context in which it is performed.
Some studies have attempted to validate accelerometers among populations diagnosed with mental health conditions. For example, Sharpe and colleagues (2006) conducted a study to assess the validity of the RT3 accelerometer against DLW in people with schizophrenia. They found that the accelerometer overpredicted energy expended on physical activity by an average of 148 kcal/day (standard deviation = 413 kcal/day); this varied from an underestimation of 614 kcal/day to an overestimation of 582 kcal/day. The authors suggested that the RT3 accelerometer is a poor tool for measuring activity EE in sedentary men with schizophrenia. As such, the results of studies that have used this measurement tool in mentally ill populations may be questionable. For example, the recent intervention study of Jerome and colleagues (2009) used the RT3 accelerometer to measure physical activity in persons with mental illness. The authors of this study concluded that participants were undertaking approximately 120 min/wk of moderate-intensity physical activity on average, which would equal approximately 70 kcal/day. Given that the results of the study by Sharpe and colleagues (2006) indicated that the RT3 accelerometer overpredicted EE, it is possible that the results found by Jerome and colleagues (2009) overestimate the amount of physical activity undertaken by participants. Consequently, this might affect the validity of the relationships found between physical activity and various mental health variables measured in this study. Sharpe and colleagues (2006) did, however, indicate that the RT3 appeared to be a valid measure of physical inactivity in men with schizophrenia. Therefore, it could be used for research or clinical purposes to quantify the contribution of sedentary behaviour to medical conditions associated with inactivity. Sharpe and colleagues (2006) also recommended that using the RT3 to validate questionnaires may not be appropriate until it is more robust.
Indirect Objective Measures
Indicators of the physiologic response to physical activity include heart rate and pulmonary gas exchange. Heart-rate monitoring is a promising measurement method because heart rate is a physiological parameter that correlates well with, and strongly predicts, EE (Strath et al., 2002). Most heart rate monitors include software that converts heart rate data into an estimate of EE. However, one of the limitations of heart rate monitoring is that training state and individual heart rate characteristics can affect the relationship between heart rate and oxygen consumption. Higher levels of accuracy can be obtained through a graded submaximal exercise test that calibrates participant heart rate to simultaneous oxygen consumption. This information allows for the construction of a calibration curve that estimates EE at moderate and strenuous levels of exercise. (A linear relationship exists between increasing heart rate and oxygen consumption; Freedson & Miller, 2000.) Measuring heart rate is a common method used to describe intensity and duration of physical activity and is a relatively inexpensive method of measuring EE. However, heart rate is affected by factors other than physical activity, such as emotional stress, temperature, humidity, dehydration, posture and illness (Ainslie, Reilly & Westerterp, 2003). These factors can influence heart rate without causing associated changes in oxygen consumption. Given the potentially increased fluctuations in emotions in individuals diagnosed with mental health conditions, this method may not be the most appropriate for obtaining accurate physical activity levels. Furthermore, the relationship between oxygen uptake and heart rate is weak at low levels of activity (Keim, Blanton & Kretsch, 2004). Evidence suggests that individuals suffering from mental health problems tend to perform less intensive physical activity than do members of the general population (e.g., Brown et al., 1999). Therefore, the heart rate method may not provide accurate information about the physical activity of mental health populations. Also, the heart rate method is unable to identify types of activity or the context in which physical activity is performed. Although heart rate is a physiological marker for physical activity and may provide a general picture of physical activity patterns, it may not be the best method available for obtaining an accurate estimate of EE.
Pedometers
Pedometers, which measure steps on a single axis as well as calories expended, are less expensive than some other types of motion sensors. As such, these devices are an attractive alternative to self-report in large observational or intervention studies. Public health campaigns have also promoted pedometers as a motivational tool for achieving the goal of 10,000 steps daily. A range of pedometers is available. The pedometer that is most suitable for a particular study may depend on factors such as the research question (outcome of interest), population, available funds, context and validity of the model. For example, when considering context, researchers or practitioners who wish to understand the types of physical activity being undertaken in a variety of settings would not gain this information using pedometers alone. When considering population, some pedometers are validated in healthy adults but not in other populations such as children, the elderly or those diagnosed with mental illness. Pedometers have demonstrated reduced accuracy in elderly populations because of the slow pace or shuffling nature with which elderly people walk (Cyarto, Myers & Tudor-Locke, 2004). Tudor-Locke and colleagues (2002) evaluated the validity of pedometers in a review of 25 studies and found a strong correlation between pedometer counts and accelerometer output (median of reported correlations is r = .86). However, evidence suggests that the validity of pedometers for measuring EE and distance in normal populations is questionable. The findings of a study testing the validity of 10 pedometers (Crouter et al., 2003) indicated that these devices overestimated distance at slower speeds and underestimated distance at faster speeds. Furthermore, in 8 of the pedometers tested, it was unclear whether the device was measuring gross EE (all the energy expended by an individual during a specific activity) or net EE (the energy expended by an individual during a specific activity minus the resting EE for the equivalent amount of time). The Yamax Digiwalker SW-200 was found to be the most reliable and accurate pedometer available (Crouter et al., 2003). This pedometer was used in a recent study by McKercher (2009) that assessed relationships between physical activity and depression in young adults. This study found that low levels of depression were significantly correlated with moderate levels of physical activity, as measured by the Yamax Digiwalker SW-200, among females. However, this device has not been validated in specific mental health populations, which may limit the validity of these results. It is important to validate physical activity devices among specific populations because patterns of physical activity in these populations may differ from those in the general population. For example, individuals with serious mental illness are significantly less active than the general population (Brown et al., 2004). As such, using a physical activity measure that has been validated with mental health populations in research on physical activity and mental health will increase the strength of the results produced.
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Coping with long-term physical health conditions
Approximately 30% of the European population has a long-term physical health condition. People with a long-term condition that is comorbid with a mental health problem have worse health outcomes than do people with either of these alone.
Key Concepts
- Approximately 30% of people with a long-term condition have a comorbid mental health condition.
- Physical activity is an important part of the management of physical and psychological well-being in people with long-term conditions.
- Pulmonary rehabilitation leads to reduced depression and anxiety and increased quality of life in people with chronic obstructive pulmonary disease. Further research is required to understand the optimal exercise dose; the interaction of exercise training, education and psychosocial support during pulmonary rehabilitation; and how to sustain changes in physical activity behaviour after pulmonary rehabilitation.
- Physical inactivity is associated with greater depression in people with type 2 diabetes. Further research is required to understand the causality of this relationship, although available data suggest that physical activity interventions reduce depression.
- Data that explore the relationship between physical activity and mental health in people with type 1 diabetes are limited.
- Physical activity has been shown to increase quality of life and reduce anxiety and depression in cancer survivors. Data suggest that supervised and group exercise are more beneficial than unsupervised and home-based exercise in this population.
Long-term conditions (LTCs) have been defined as "those conditions that cannot, at present, be cured, but can be controlled by medication and other therapies. The life of a person with an LTC is forever altered - there is no return to normal" (Department of Health, 2008, p. 10). LTCs include diabetes, arthritis, chronic obstructive pulmonary disease (COPD) and a number of cardiovascular diseases. In addition, conditions such as human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) and certain cancers that were not traditionally considered LTCs are increasingly being regarded as such (Naylor et al., 2012). Many mental health problems can themselves be considered LTCs. However, in this chapter the term long-term condition refers specifically to physical health conditions.
The World Health Organisation's (2011) report on the global burden of noncommunicable diseases (i.e., all previously mentioned LTCs except HIV and AIDS) found that noncommunicable diseases are by far the leading cause of mortality in the world and represent 63% of all deaths. The majority of these deaths are due to cardiovascular disease, diabetes, cancer and chronic respiratory disease. The highest occurrence of deaths from these diseases is in low- and middle-income countries, and the prevalence in these countries is predicted to increase substantially in the future. In Europe 29% of people aged 15 yr or older report a longstanding health problem (TNS Opinion, 2007), and the Office for National Statistics (2005) found that in England approximately 30% of the population (15.4 million people) has a LTC. As populations age, the burden of LTCs is projected to increase even further.
Long-Term Conditions and Mental Health Issues
People with LTCs are two to three times more likely than the general population to experience mental health problems. Depression and anxiety are the most frequently reported mental health problems in people with LTCs, but dementia, cognitive decline and some other conditions have also been reported (Naylor et al., 2012). Depression is two to three times more common in people with an LTC than in those with good physical health and occurs in approximately 20% of people with an LTC (National Collaborating Centre for Mental Health, 2010). Conservative estimates suggest that at least 30% of all people with an LTC also have a comorbid mental health problem of some kind (Cimpean & Drake, 2011). Research has shown that having a mental health problem along with an LTC has a stronger negative impact on quality of life and functional status than does either the number of LTCs or the severity of those conditions. For example, quality of life is lower in people with one LTC and depression than in people with two or more LTCs and no depression (Moussavi et al., 2007). Figure 8.1 shows the overlap between LTCs and mental health disorders.
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In addition to experiencing psychological distress, patients with an LTC and comorbid mental health problem experience poorer clinical outcomes compared with people with an LTC and no mental health problem (Moussavi et al., 2007). This is partly because self-management is necessary for effectively controlling LTCs, and poor mental health can result in poorer self-management. For example, it may lead to lack of motivation and energy to adhere to treatment plans or attend medical appointments (DiMatteo, Lepper & Croghan, 2000). From a financial perspective, comorbid mental health problems are typically associated with a 45% to 75% increase in care costs for a person with an LTC. These data are based on a wide range of LTCs and are observed after adjustment for severity of physical disease (Unützer et al., 2009; Welch et al., 2009).
Overlap between long-term conditions and mental health problems in England. Adapted, by permission, from C. Naylor et al., 2012, Long-term conditions and mental health: The cost of co-morbidities (London: The King's Fund and Centre for Mental Health).
Long-Term Conditions and Quality of Life
Quality of life is an individual's perception of their ability to function well on physical, mental and social levels. Quality of life can be measured in a reliable and valid manner using self-reported questionnaires, which can be categorised into three main groups: generic, disease specific and domain specific. Generic questionnaires measure quality of life in general terms, independent of the presence of any disease. Disease-specific questionnaires measure the consequences of a specific disease on quality of life. Domain-specific questionnaires focus on certain domains of quality of life (e.g., physical inabilities).
Where it is possible to manage but not cure a disease, such as in LTCs, measures of quality of life are frequently used to help determine the impact of treatment and disease. They help health professionals make informed judgements about whether treatment is appropriate and, where a choice of treatments exists, which might be the best option. Researchers frequently use these measures to assess the impact of a new intervention.
Long-Term Conditions and Physical Activity
Doctors have traditionally advised people with a range of LTCs to rest and not tire themselves out, and this advice persists in the lay psyche. For example, a recent Swedish survey found that the physical activity levels of people with diabetes, rheumatoid arthritis or COPD are lower than those of healthy controls; 73% of people with diabetes, 74% with rheumatoid arthritis and 84% with COPD reported low physical activity levels compared with 60% of controls (Arne et al., 2009). However, modern treatment of LTCs often includes promoting physical activity as part of a healthy lifestyle, and accumulating evidence shows the importance of physical activity in the management of both physical and psychological well-being for people with one or more LTCs. Regular contact between health professionals and people with LTCs provides opportunities for promoting physical activity in this group.
Each LTC presents its own challenges and benefits with regard to physical activity. The remainder of this chapter focusses in particular on the impact of physical activity on mental health and well-being in people with COPD, diabetes and cancer.
Chronic Obstructive Pulmonary Disease
COPD is characterised by airflow obstruction that is not fully reversible and usually progressive in the long term. It is predominantly caused by smoking. Symptoms include breathlessness (dyspnoea) on exertion, chronic cough, regular production of sputum and frequent winter bronchitis or wheeze. Exacerbation of symptoms often occurs in which the patient's symptoms rapidly worsen beyond normal day-to-day variations. Diagnosis relies on a combination of history, physical examination and confirmation of airflow obstruction using spirometry; no single test for COPD exists (National Institute for Health and Clinical Excellence, 2010). Severity of COPD is often classified using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria (I [mild], II [moderate], III [severe] and IV [very severe]) and index of body mass, airway obstruction, dyspnoea and exercise capacity (BODE).
The World Health Organisation has predicted that by 2020 COPD will be the third leading cause of death and fifth leading cause of disability in the world (Murray & Lopez, 1996, 1997). Mortality rates for men in the United Kingdom are at a plateau and mortality rates for women are steadily increasing (Soriano et al., 2000) most likely as a result of the uptake of smoking among women post-World War II. According to the chief medical officer in England, COPD accounts for more than £800 million in direct health care costs (Department of Health, 2005); more than one half of these costs relate to the provision of hospital care. COPD is among the most costly inpatient conditions that the National Health Service treats.
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Designing a physical activity program for individuals with addictions
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours.
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours. However, implementation of behavior change in this population can present practitioners with specific challenges. This section discusses the suggestions for designing effective interventions for those with addictions based on the evidence reviewed so far as well as practical considerations.
Exercise Type, Frequency and Intensity
Most studies have promoted moderate-intensity cardiovascular-type exercise such as brisk walking for use in those with addictive behaviours. Some work also incorporates more vigorous activities such as running. Because individuals with addictions are often extremely sedentary, a programme of moderate-intensity activity is likely to be acceptable and safe. However, a progression to more vigorous exercise may be beneficial. For example, the only study that found a long-term benefit of exercise for smoking cessation entailed 30 to 40 min of vigorous exercise 3 times/wk for 12 wk (Marcus et al., 1999). Similarly, the single study that showed a long-term impact of exercise on alcohol abstinence involved 1 h of progressively vigorous exercise 5 days/wk for 6 wk (Sinyor et al., 1982). None of the trials reviewed compared the effects of vigorous-intensity and moderate-intensity exercise on abstinence rates. Experimental studies have compared the effects of bouts of moderate-intensity and vigorous-intensity exercise and have shown that both intensities are effective in the short term for reducing tobacco-withdrawal symptoms (Taylor et al., 2007).
The intensity of activity that an individual is capable of depends on initial level of fitness, medical condition and stage of recovery from addiction. Careful medical screening is vital. For example, those addicted to amphetamine or cocaine are often undernourished, and problem drinkers often have weak muscles. Such individuals may require nutrition advice. Ultimately, individuals will have preferences regarding types of exercise, and programmes should be tailored to these preferences (Abrantes et al., 2011; Everson-Hock et al., 2010). Some individuals may prefer noncardiovascular types of exercise, which may also be beneficial. Resistance (i.e., weight) training, yoga and isometric exercise have all been successfully piloted as aids for smoking cessation and need to be tested in larger trials (Ussher, Taylor & Faulkner, 2012).
Regarding frequency and volume of exercise, the findings from Marcus and colleagues (2005) suggest that abstaining smokers need to accumulate at least 110 min/wk of moderate-intensity activity to maintain abstinence; supervised exercise on 2 or 3 days/wk may be necessary in order to achieve this. Shorter bouts of exercise can be used on an as-needed basis in response to cravings, and longer scheduled bouts can be used to maintain positive mood, manage stress and prevent cravings from arising. Research has not yet addressed the optimum dose of exercise for assisting alcohol and drug rehabilitation.
Exercise Supervision
The majority of intervention studies have employed group-based supervised exercise. In smokers, exercise counselling alone did not increase exercise levels sufficiently (Ussher et al., 2003), and all the interventions that showed a significant impact on long-term abstinence from alcohol or smoking entailed supervised exercise. Among novice exercisers, an element of supervised exercise may be useful to ensure initial adoption of regular exercise and to provide information about safe exercise (e.g., warm-up) and exercise intensities (e.g., using heart rate monitors). Counselling toward pursuing home-based exercise is also likely to be important for encouraging patients to maintain exercise levels after the initial exercise programme ends.
Stages of Addiction Treatment
Early recovery from drug and alcohol dependence is a major transition that affects close relationships and employment and involves numerous treatment sessions. An exercise programme needs to complement these changes. Most exercise interventions discussed in this chapter have required patients to alter their substance- or alcohol-misuse behaviour and exercise behaviour simultaneously, yet it is not clear whether this is optimal. For some individuals the challenge of changing two health behaviours simultaneously may be too demanding. Also, it is not clear whether involvement in physical activity increases the motivation to manage substance intake or vice versa.
Among smokers, exercise has often been introduced in the studies discussed several weeks before an attempt to quit, thereby allowing people to adjust to the demands of increased exercise before starting to quit. This also allows exercise to play a role in managing cravings during the crucial early days of abstinence, when relapse rates are highest. Empirical work is required to determine the relative benefits of initiating exercise at different points in the addiction-treatment process. During later stages of treatment exercise may be useful for preventing relapse (e.g., by promoting an exercise identity that is incompatible with drug use). Studies are also needed to determine whether exercise can be used to increase substance abstinence among those who are not motivated to attempt abstinence.
Integrating Exercise With Standard Addiction Treatments
Greater integration of addiction and exercise programmes may enhance abstinence rates. For instance, rather than just proposing exercise as a means for getting fitter and managing weight, the practitioner could present exercise more as a self-control strategy for managing withdrawal symptoms and a way to address psychological and physical harms caused by addiction. Exercise could be used more in combination with pharmaceutical interventions. Whereas pharmaceutical interventions focus on reducing withdrawal symptoms (e.g., NRT), exercise could ideally be used to provide an added effect in client-led management of addictive symptoms.
Perceived Barriers to Exercise
Individuals with addictions are likely to have specific barriers to exercise, and these need to be determined. In the general population, use of cognitive - behavioural techniques is effective for overcoming perceived barriers and increasing exercise adherence. Few addiction studies have included cognitive - behavioural counseling. Techniques such as self-monitoring (e.g., diaries), goal-setting and relapse-prevention planning are commonly used. Also, pedometers are now commonly used as a motivational tool. These and other motivational aids (e.g., financial incentives) need to be tested with exercise interventions in addicted populations.
Interventions for Different Subgroups
Exercise interventions need to be tested among addicted populations who might especially benefit from such interventions. Given the high prevalence of addictions among people with mental illness and the established benefits of regular physical activity for mental health, research that examines the role that physical activity may play in this population is needed (Arbour-Nicitopoulos et al., 2011).
Exercise interventions might be particularly appealing to adolescents, and controlled trials with young people are needed. Addicted individuals who are overweight may have a need for weight-control interventions such as exercise; no trial has yet focussed on this population. Additionally, surveys suggest that a nonpharmaceutical intervention such as exercise is likely to appeal to pregnant smokers (Ussher at al., 2008). Finally, sex needs to be considered when planning an appropriate intervention. Some evidence shows that women often prefer walking and aerobics, whereas men have more interest in sport, running and strength training.
Evidence to Practice
- Both moderate- and vigorous-intensity exercise have been shown to be effective for reducing tobacco-withdrawal symptoms and cravings.
- Progressing from light- and moderate-intensity exercise (e.g., brisk walking) to more vigorous-intensity exercise is advisable.
- Careful medical screening is required, especially among those with long-term alcohol or drug dependence (e.g., for malnutrition).
- Exercise interventions should be tailored to individual preferences.
- Abstaining smokers should accumulate at least 110 min/wk of moderate-intensity exercise.
- Interventions involving supervised exercise on 2 or 3 days/wk are likely to be necessary to be effective in treating addictive behaviours.
- Exercise can be performed on an as-needed basis for managing cravings or in scheduled bouts.
- If the exercise programme is to assist with early withdrawal symptoms, it ideally needs to begin before abstinence is attempted.
- Participating in physical activity encourages individuals to adopt an identity as an exerciser, which is incompatible with using addictive substances.
- Perceived barriers to exercise need to be identified and addressed using cognitive - behavioural techniques.
- The intervention needs to be adapted to various subgroups (e.g., according to sex, body weight and mental health).
Summary
Drug, alcohol and tobacco addictions are growing global problems. Exercise has many benefits for physical and psychological health, and evidence convincingly shows that exercise is effective for managing cravings and withdrawal symptoms, particularly in smokers. Regular exercise fosters a healthy lifestyle and exercise identity that is largely incompatible with addiction, and individuals undergoing rehabilitation for addiction express interest in exercising more. Exercise interventions are inexpensive, can be easily integrated with existing addiction treatments and have minimal side effects compared with pharmacological treatments. This chapter demonstrates that exercise is a highly plausible adjunctive treatment for addictive behaviour and that exercise programmes can be readily disseminated. However, limited evidence currently supports the benefits of exercise for helping smokers quit or helping those with drug or alcohol dependence abstain. This lack of evidence can partly be explained by the small number of large RCTs that have been conducted, lack of knowledge about effective doses of exercise and limited attention to methods for maximizing exercise adherence. This area of research is in its infancy, and further well-designed trials are needed.
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Physical activity guidelines
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits.
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits. National guidelines aimed at the whole population (as opposed to specific populations defined by a medical condition) focus on the optimal amount of activity to prevent disease and promote health and well-being. PAGs indicate the type (e.g., aerobic activity, strength training, weight bearing), frequency (e.g., 3 days/wk), duration (e.g., 30 min) and intensity (e.g., moderate, vigorous) (see figure 2.2) of physical activity to undertake and for what benefits. These detailed specifications reflect the latest science on the topic.
PAGs need to be updated periodically because evidence about the relationship between physical activity and health changes over time and knowledge grows. Some guidelines are more general in nature, whereas others provide very specific details; this usually reflects the state of knowledge at that time. Through a review and revision process, more specific details are added to PAGs when available. For example, in various national PAGs, guidelines relating to maintaining musculoskeletal strength have been revised over time and now include details on how much strength training is required for good health (World Health Organisation, 2010) and, specifically, for preventing falls and treating depression (Singh, Clements & Singh, 2001).
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The dose - response relationship: Increasing benefits from increasing amounts (expressed in frequency, duration and intensity) of activity. Reprinted, by permission, from I. Vuori, 1995, Terveysliikunta [Health and physical education]. UKK Institute for Health Promotion Research (Tampere, Finland).
National guidelines are an important component of a population-based approach to addressing any public health issue. First, such guidelines communicate a consensus on the scientific evidence of the importance of the issue. They describe the strength of the science in terms of the volume as well as the quality (determined based on the quality of study designs and research methods used) of the evidence. Communicating scientific consensus is important because it removes doubt and speculation about the validity of the health issue and its importance. This scientific consensus can also be used to advocate for resources and programmes. However, just because guidelines exist does not mean that everyone agrees about what the science says - far from it. However, these disagreements, or alternative interpretations of overall findings to date, are usually communicated in technical reports that accompany the publication of PAGs and are not fully accessible to the general public.
The process of developing PAGs usually involves leadership by a high-level institution. This adds credence to the message that the issue is important. For example, several national and international health agencies, such as the American Heart Association (Haskell et al., 2007), have developed guidelines on physical activity. National governments, usually the ministry of health, often lead the development process and endorse national PAGs. This endorsement is very useful because it specifies the government's position on physical activity and thereby provides the opportunity for interested parties such as charities and public health directors to leverage the government into supporting further action and funding for programmes and services aimed at increasing physical activity. This might include government endorsement of counselling and clinical services for inactive patients, as has been trialled in the United Kingdom (Bull & Milton, 2011). Government involvement and endorsement can also prevent policy inaction. The absence of an official position on physical activity can block funding and further development of a national population-based approach.
One important role of PAGs is to direct community-level actions aimed at increasing physical activity in the whole population. The details in PAGs about the type, frequency, duration and intensity of activities required for different age groups can provide clinicians, health care practitioners and others with direction on what types of programmes to provide and promote to patients and the wider community.
PAGs should drive and direct action not just at the level of individuals and service providers but also at all levels - national, regional and local - of government. If the national government endorses PAGs, ideally with multiparty political support, the government should be held accountable when levels of physical activity are not improving and can be expected to include physical activity promotion as part of ongoing disease-prevention and health-promotion strategies. The role of PAGs and national surveillance of risk factors is discussed in more detail later in this chapter.
Development of the First National Physical Activity Guidelines
Epidemiological studies of exercise and health were well advanced by the 1970s. The American College of Sports Medicine released the first set of recommendations in 1975 and released another set in 1980 (American College of Sports Medicine, 1975, 1980). These recommendations were predominantly directed at cardiorespiratory fitness and suggested that people undertake vigorous-intensity aerobic exercise 3 times/wk for 20 min each time. This was a practical interpretation of the exact recommendation from 1975, which suggested that people undertake 20 to 45 min of physical activity 3 to 5 days/wk at 70% to 90% of heart rate (i.e., vigorous intensity) (American College of Sports Medicine, 1975). The focus on aerobic exercise for increasing fitness continued to dominate and influence health messages about physical activity until the early 1990s. However, guidelines began to recommend moderate-intensity physical activity rather than vigorous-intensity activity, and by the mid-1990s the focus shifted from cardiorespiratory fitness to health benefits. This new position on physical activity was communicated in a landmark set of recommendations from the office of the U.S. surgeon general in the report "Physical Activity and Health" (U.S. Centers for Disease Control and Prevention, 1996).
In the mid-1990s, epidemiological evidence started to show that people with different health conditions require slightly different amounts of physical activity. Although the recommendation for 30 min of moderate-intensity activity on most days remained valid for preventing heart disease and diabetes, studies showed that slightly more physical activity was recommended for preventing cancer. Further, studies identified that the amount of activity required for weight loss or preventing weight gain was greater than that required to prevent chronic disease (Haskell et al., 2007). For example, the International Association for the Study of Obesity recommendations made a clear distinction between the minimum physical activity required for health benefits and the amount required for preventing weight gain. The recommendations state that "45 to 60 min (60-90 min for formerly obese individuals) of moderate-intensity physical activity daily is needed to prevent the transition to overweight or obesity" (Saris et al., 2003). Furthermore, research has now shown that the amount of physical activity required by young people differs from that of adults. The overall amount of physical activity recommended for children is twice that recommended for adults and is usually expressed as "at least 60 min/day" (Canadian Society for Exercise Physiology, 2011a; Saris et al., 2003).
These different recommendations make the development of PAGs complex. However, a core and consistent interpretation of the evidence is that 30 min of moderate-intensity physical activity on most days of the week is associated with maximum overall population benefit and the prevention of major noncommunicable diseases. This same dose has been expressed as "at least 150 min/wk of moderate-intensity activity" in the most recent global, U.S. and U.K recommendations (Department of Health, 2011b; U.S. Department of Health and Human Services, 2008a; World Health Organisation, 2010).
Current Best Practice in Developing Guidelines
Figure 2.3 illustrates the process of developing guidelines. The first step is establishing the need for guidelines. This need is often defined by policymakers, public health scientists, advocates and, sometimes, the community. Then a process for guideline development needs to be agreed on by interested parties, with actions planned in sequence and, ideally, a linkage between the PAG development process and other aspects of national or regional physical activity policy and strategy development (step 1 in figure 2.3). The next stage comprises reviewing the scientific evidence and creating an updated summary of what the research says and how this information differs from that in previous guidelines. A number of countries, notably Canada and, most recently, the United Kingdom and United States, have undertaken this process. Tremblay and colleagues (2010) extensively discuss this process with reference to the recent Canadian guidelines along with frameworks and a checklist for auditing data quality in the review stage.
Once the science has been reviewed, the next stage is developing communication messages based on the evidence and testing these messages with the target audience for acceptability, comprehension and usefulness. This step is part of developing a communications strategy for disseminating the evidence (stages 3 and 4 in figure 2.3). It requires resources for conducting the qualitative and quantitative research and the involvement of communications and media specialists in framing the messages correctly so that they will have optimal impact on the target populations. The final stages (stages 5-7 in figure 2.3) involve disseminating the message to the community, professional groups and other stakeholders. Historically, those developing PAGs have put considerable effort into the technical and scientific stages and have often neglected message development and communication. Frequently, only informal and unpaid communication channels are used after the launch of PAGs. Thus, a very important step in PAG development and dissemination is the final public health promotion component.
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Framework for developing physical activity guidelines. Adapted from Bauman et al. 2006.
Global, Regional and National Physical Activity Guidelines
Table 2.1 summarises the 2011 global PAGs and provides examples of regional (i.e., European and Western Pacific islands) and national guidelines. Quite a few countries in Europe have their own national PAGs, and many of these countries (e.g., Finland, Switzerland, the Netherlands, United Kingdom) have been engaged with implementing national population-based approaches for some time (Department of Health, 2011b; Ministry of Health, Welfare and Sport, 2011; Swiss Federal Office of Sports, 2006; UKK Institute, 2009). Other countries in Europe have officially or unofficially adopted the guidelines published by the U.S. Centers for Disease Control and Prevention in 1996 and the more recently updated 2008 version.
PAGs in other regions of the world are patchy. Australia (Department of Health and Ageing, 2005b) and New Zealand (Sport and Recreation New Zealand, 2005) have had national guidelines for some time. In Australia, guidelines exist for all ages, from young children (Department of Health and Ageing, 2004) to older adults (Department of Health and Ageing, 2005b), although all guidelines are more than 5 yr old and arguably are due for updating to reflect the latest science. Far fewer examples of PAGs exist in South America, Asia, the Middle East and Africa because physical activity promotion is relatively new in these regions. Countries in which national action on physical activity is beginning have often used the U.S. guidelines as an international benchmark. This has allowed the countries to develop an agenda of physical activity promotion without being hindered by the absence of PAGs. However, in some countries, adopting the PAGs of another country is not politically or culturally welcome or appropriate. Either these countries have developed their own PAGs (a recent example from the Middle East is Brunei; Ministry of Health, 2011) or very little physical activity promotion has occurred.
The absence of a set of official global guidelines did not hinder the World Health Organisation (WHO) from developing the Global Strategy on Diet, Physical Activity and Health in 2004 (World Health Organisation, 2004). Since the publication of the 2002 health report (World Health Organisation, 2002), the focus on the need for greater action to prevent noncommunicable disease and address mental health has increased. To address these issues, WHO commenced developing global guidelines in 2007. WHO launched the final global recommendations on physical activity in 2010 after a 2 yr process involving global and regional consultations (World Health Organisation, 2010). These global guidelines are now available for adoption and use by countries with no national PAGs. Because the guidelines are from WHO, the leading international health agency, the scientific quality and relevance of these guidelines are usually accepted.
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Treating depression and anxiety with exercise
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety.
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety. Information about these prescription parameters is scarce, but it is critical if exercise interventions are to be translated into clinical practice. Asking someone to do something without specifying what they should do or how they should do it would likely make it difficult for the individual to fully comply in a meaningful way. It is also possible that the prescription of exercise for depression and/or anxiety could be different, both in nature and content, than that required for general health benefits.
One trial that is particularly worthy of attention is the Depression Outcomes Study of Exercise (DOSE; Dunn et al., 2005), which attempted to provide evidence about the dose of exercise required to treat depression. In the DOSE study 80 participants were randomised to 1 of 4 exercise groups that varied in total energy expenditure (7 or 17.5 kcal·kg-1·wk-1) and frequency (3 or 5 days/wk) or to a flexibility-exercise placebo control for 12 wk. Exercise at a dose of 17.5 kcal·kg-1·wk-1 was effective in reducing depression regardless of frequency, whereas exercise at a dose of 7 kcal·kg-1·wk-1 yielded antidepressant effects that were comparable to those of the placebo treatment. The plausible biological reason for why a higher dose of exercise may be more effective than lower doses is that frequent and regular exercise should increase fitness levels such that physical discomfort decreases and exercise becomes a more pleasant and enjoyable experience as the conditioning process progresses. Indeed, findings from both the DOSE and TREAD trials in the United States have indicated that higher doses of exercise are more effective than are lower doses (as defined in the study).
Perraton and colleagues (2010) published a systematic review that attempted to summarise what is currently known about the prescription of exercise for depression. The review is useful because previous reviews of exercise and depression did not synthesise this information in a way that would help guide intervention development. This review included only trials that had reported exercise to be effective in reducing depression in order to analyse the specific dosage parameters and modes of exercise used in these successful trials.
The review found that the most common intensity, frequency and duration of aerobic exercise were 60% to 80% of maximum heart rate, 30 min/session and 3 days/wk over 8 wk. The volume of evidence supporting the use of aerobic exercise programmes to treat depression was greater than that supporting the use of anaerobic exercise programmes. No clear trend showed one mode of aerobic exercise to be the most effective, and a range of activity types appeared to be effective. This is encouraging given that one size does not fit all, and individuals can be encouraged to participate in whatever type of aerobic activity they prefer.
In terms of context of exercise, a number of common trends emerged. A variety of locations were effective in treating depression, although all trials that reported location took place indoors. Both group and individual interventions were effective. However, group exercise may have added benefit by providing social support, which can be pivotal for sustaining compliance and can contribute in its own right to lowering depression. Moreover, exercise might lower depression by several plausible mechanisms, one of which could be interrelations or connections with others (Bailey & McLaren, 2005). Many types of exercise can be performed with other people (depressed or not). Therefore, this exercise could provide social integration and an opportunity to interact with the social world as well as a setting in which to expand social networks and make friends (Stathi, Fox & McKenna, 2002).
Another unresolved question concerns the intensity of exercise at which a reduction in depression might occur. Callaghan and colleagues (2011) compared the effects of preferred intensity with those of prescribed intensity of group-based exercise for 12 sessions over 4 wk in 38 women aged 45 to 65 yr who were receiving treatment for depression from either primary or secondary care services. The preferred-intensity group reported significantly lower depression and higher self-esteem and quality-of-life scores than did the prescribed-exercise group and attended more sessions (66% versus 50%). Similar findings have been found in nondepressed populations (Daley & Maynard, 2003). Several theories, such as self-determination theory (Deci & Ryan, 1985), support the notion that giving people a choice and control over what they do, whether it be exercise or other activities, leads to better adherence and enjoyment of the activity, which in turn leads to enhanced psychological well-being. People experiencing depression are no exception.
Wipfli, Rethorst and Landers (2008) considered the relationship between dose of exercise and anxiety levels as part of their broader meta-analysis of the anxiolytic effect of exercise. The trend in the data from 12 RCTs showed that the effect size increased as exercise approached a dose of 12.5 kcal·kg-1·wk-1 (equates to slightly less than the dose recommended for public health) and then began to decrease as exercise dose increased. A combination of aerobic and anaerobic exercise appeared to be better than either type alone, and a frequency of 3 or 4 times/wk appeared more effective than more or less than this amount.
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Available methods for measuring physical activity
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry.
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry. Most are moderately correlated at best. Each method has its own strengths and limitations. Due to the complexity of physical activity, outlined previously, researchers and practitioners need to consider what is most important for their purposes when deciding to use a particular technique. Although no one measurement tool can be singled out as the most appropriate, recommendations for the most useful and practical measurement tools can be made after considering factors such as context, type, duration, frequency and intensity of physical activity as well as the constraints under which the research or treatment programme is operating. These techniques are presented in order of increasing feasibility but decreasing validity. Table 3.2 at the end of this section summarises the key advantages and limitations of each measurement technique.
Doubly Labelled Water
Doubly labelled water (DLW, or free-living indirect calorimetry) is a method commonly used to increase the precision and accuracy of physical activity measurement. DLW, which measures EE over several (4-21) consecutive days in a free-living person under normal life conditions (Schoeller, 1988), is the most widely accepted gold standard method by which to measure EE (Aadahl & Jørgensen, 2003). DLW measures EE of free-living, unrestricted subjects using water labelled with stable isotopes of oxygen and hydrogen (Schoeller & van Santen, 1982). It calculates activity-related EE by combining measurement of total EE with basal metabolic rate. The utility of the DLW method in measuring total EE is demonstrated by its use in a variety of settings, including all age groups, premature infants, hospitalised patients, pregnant women and the elderly (Ainslie, Reilly & Westerterp, 2003). As such, researchers who use this method to assess the relationship between physical activity and other psychological variables or to detect changes in physical activity as a result of interventions can be confident that the results produced regarding EE are accurate. Schoeller (1988) fully describes the validation of the DLW method.
Despite its level of precision, the DLW method is not without disadvantages, which include high cost, limitations for assessing brief periods of EE (Ainslie, Reilly & Westerterp, 2003) and additional demands on participants in terms of time and tasks required. The cost and availability of isotopes and the requirement for analysis by isotope ratio mass spectrometer prohibit DLW from being widely used in studies of large populations. The use of this method among populations with more severe mental health problems may likely present a set of ethical issues. Furthermore, although this technique provides an accurate measure of total EE, it cannot provide information about patterns of physical activity in terms of type, frequency, duration, intensity or context. Consequently, such an approach would not be feasible in a large natural-field experiment or in a test of the effect of interventions on changes in physical activity in both healthy populations and populations that suffer from mental health problems. However, this gold standard measure is believed to offer the most precise estimate of EE and is often used to validate many other types of tools that assess physical activity.
Direct Observation
Direct observation, one of the most basic approaches for acquiring information about behaviours, provides information about how people exercise and play, how environments shape the activities individuals participate in and how people use specific facilities (e.g., parks, leisure facilities, walking or cycling paths). It can take place using basic observation methods, systematic forms or sophisticated technology (e.g., lasers). Direct observation often involves a trained observer who codes physical activity behaviours (e.g., sitting, walking, running) undertaken by participants over time in various settings (e.g., playground, park, home). A number of observation systems are available, such as SOPLAY (System for Observing Play and Leisure Activity in Youth), SOFIT (System for Observing Fitness Instruction Time), and the Systematic Pedestrian and Cycling Environmental Scan. The trained observer may either observe participants in person or review video media. Because it is time consuming, direct observation might be used only with small groups in specific settings (Dugdill & Stratton, 2007).
Advantages of direct observation include that self-report bias is eliminated, participants do not need to recall behaviour and the level of detail regarding behaviour patterns and context can be extremely accurate. Furthermore, practitioners may find some of these tools accessible. For example, clinical psychologists working with institutionalised individuals diagnosed with severe mental health conditions may find this type of measurement technique useful for assessing relationships between physical activity patterns or patterns of inactivity and specific mental illnesses because it can combine both context and behaviour to provide powerful data.
However, disadvantages include the time involved in recording and coding behaviour, the time involved in consolidating the plethora of data collected and the costs associated with training coders. Furthermore, the subjective bias of coders may lead to incorrect judgments about the intensities of specific activities, which would affect estimates of EE. As such, it would be important to consider whether information regarding patterns of behaviour combined with context or specific EE data are required to fulfill the aims of a research project or treatment programme.
Accelerometers
Motion sensors, such as pedometers and accelerometers, can be used to detect body movement and estimate physical activity (Spruijt-Metz et al., 2009). Accelerometers are devices that measure bodily movements in terms of acceleration. This measurement can then be used to estimate the intensity of physical activity, and therefore EE, over time (Burton et al., 2005; Chen & Basset, 2005). Accelerometers can measure human activity on vertical (uniaxial accelerometers), anterior - posterior and medial - lateral (triaxial accelerometers) planes. EE can then be then estimated from vector magnitude counts using a proprietary algorithm, which is a composite of counts from these planes of motion (Howe, Staudenmayer & Freedson, 2009). Accelerometers can be used repeatedly on numerous participants, are more accurate than pedometers and are less expensive (approximately £200 per device; ActiLife, 2009) than other objective methods such as DLW (approximately £200 per participant per procedure; Friedman & Johnson, 2002). However, they remain too expensive to use in studies that assess large numbers of people (Wood, 2000). Nevertheless, these devices are a more feasible and participant-friendly method of attempting to validate a self-report questionnaire than is DLW. They also provide the data necessary to allow researchers to distinguish between light, moderate and vigorous physical activity as well as between continuous and intermittent activity modes (Crouter, Clowers & Bassett, 2006). A recent review of accelerometers against DLW found ActiGraph (previously named CSA/MTI) models to be of the most valid types tested; they produce an average correlation of r = .57 (Plasqui & Westerterp, 2007). Limitations of accelerometers include the increased time required to analyse the large amount of data provided, participant burden of wearing the device, that they cannot be feasibly used to test large-scale interventions, and that they cannot provide information about the specific type of activity (e.g., playing football, going to the gym) or the context in which it is performed.
Some studies have attempted to validate accelerometers among populations diagnosed with mental health conditions. For example, Sharpe and colleagues (2006) conducted a study to assess the validity of the RT3 accelerometer against DLW in people with schizophrenia. They found that the accelerometer overpredicted energy expended on physical activity by an average of 148 kcal/day (standard deviation = 413 kcal/day); this varied from an underestimation of 614 kcal/day to an overestimation of 582 kcal/day. The authors suggested that the RT3 accelerometer is a poor tool for measuring activity EE in sedentary men with schizophrenia. As such, the results of studies that have used this measurement tool in mentally ill populations may be questionable. For example, the recent intervention study of Jerome and colleagues (2009) used the RT3 accelerometer to measure physical activity in persons with mental illness. The authors of this study concluded that participants were undertaking approximately 120 min/wk of moderate-intensity physical activity on average, which would equal approximately 70 kcal/day. Given that the results of the study by Sharpe and colleagues (2006) indicated that the RT3 accelerometer overpredicted EE, it is possible that the results found by Jerome and colleagues (2009) overestimate the amount of physical activity undertaken by participants. Consequently, this might affect the validity of the relationships found between physical activity and various mental health variables measured in this study. Sharpe and colleagues (2006) did, however, indicate that the RT3 appeared to be a valid measure of physical inactivity in men with schizophrenia. Therefore, it could be used for research or clinical purposes to quantify the contribution of sedentary behaviour to medical conditions associated with inactivity. Sharpe and colleagues (2006) also recommended that using the RT3 to validate questionnaires may not be appropriate until it is more robust.
Indirect Objective Measures
Indicators of the physiologic response to physical activity include heart rate and pulmonary gas exchange. Heart-rate monitoring is a promising measurement method because heart rate is a physiological parameter that correlates well with, and strongly predicts, EE (Strath et al., 2002). Most heart rate monitors include software that converts heart rate data into an estimate of EE. However, one of the limitations of heart rate monitoring is that training state and individual heart rate characteristics can affect the relationship between heart rate and oxygen consumption. Higher levels of accuracy can be obtained through a graded submaximal exercise test that calibrates participant heart rate to simultaneous oxygen consumption. This information allows for the construction of a calibration curve that estimates EE at moderate and strenuous levels of exercise. (A linear relationship exists between increasing heart rate and oxygen consumption; Freedson & Miller, 2000.) Measuring heart rate is a common method used to describe intensity and duration of physical activity and is a relatively inexpensive method of measuring EE. However, heart rate is affected by factors other than physical activity, such as emotional stress, temperature, humidity, dehydration, posture and illness (Ainslie, Reilly & Westerterp, 2003). These factors can influence heart rate without causing associated changes in oxygen consumption. Given the potentially increased fluctuations in emotions in individuals diagnosed with mental health conditions, this method may not be the most appropriate for obtaining accurate physical activity levels. Furthermore, the relationship between oxygen uptake and heart rate is weak at low levels of activity (Keim, Blanton & Kretsch, 2004). Evidence suggests that individuals suffering from mental health problems tend to perform less intensive physical activity than do members of the general population (e.g., Brown et al., 1999). Therefore, the heart rate method may not provide accurate information about the physical activity of mental health populations. Also, the heart rate method is unable to identify types of activity or the context in which physical activity is performed. Although heart rate is a physiological marker for physical activity and may provide a general picture of physical activity patterns, it may not be the best method available for obtaining an accurate estimate of EE.
Pedometers
Pedometers, which measure steps on a single axis as well as calories expended, are less expensive than some other types of motion sensors. As such, these devices are an attractive alternative to self-report in large observational or intervention studies. Public health campaigns have also promoted pedometers as a motivational tool for achieving the goal of 10,000 steps daily. A range of pedometers is available. The pedometer that is most suitable for a particular study may depend on factors such as the research question (outcome of interest), population, available funds, context and validity of the model. For example, when considering context, researchers or practitioners who wish to understand the types of physical activity being undertaken in a variety of settings would not gain this information using pedometers alone. When considering population, some pedometers are validated in healthy adults but not in other populations such as children, the elderly or those diagnosed with mental illness. Pedometers have demonstrated reduced accuracy in elderly populations because of the slow pace or shuffling nature with which elderly people walk (Cyarto, Myers & Tudor-Locke, 2004). Tudor-Locke and colleagues (2002) evaluated the validity of pedometers in a review of 25 studies and found a strong correlation between pedometer counts and accelerometer output (median of reported correlations is r = .86). However, evidence suggests that the validity of pedometers for measuring EE and distance in normal populations is questionable. The findings of a study testing the validity of 10 pedometers (Crouter et al., 2003) indicated that these devices overestimated distance at slower speeds and underestimated distance at faster speeds. Furthermore, in 8 of the pedometers tested, it was unclear whether the device was measuring gross EE (all the energy expended by an individual during a specific activity) or net EE (the energy expended by an individual during a specific activity minus the resting EE for the equivalent amount of time). The Yamax Digiwalker SW-200 was found to be the most reliable and accurate pedometer available (Crouter et al., 2003). This pedometer was used in a recent study by McKercher (2009) that assessed relationships between physical activity and depression in young adults. This study found that low levels of depression were significantly correlated with moderate levels of physical activity, as measured by the Yamax Digiwalker SW-200, among females. However, this device has not been validated in specific mental health populations, which may limit the validity of these results. It is important to validate physical activity devices among specific populations because patterns of physical activity in these populations may differ from those in the general population. For example, individuals with serious mental illness are significantly less active than the general population (Brown et al., 2004). As such, using a physical activity measure that has been validated with mental health populations in research on physical activity and mental health will increase the strength of the results produced.
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Coping with long-term physical health conditions
Approximately 30% of the European population has a long-term physical health condition. People with a long-term condition that is comorbid with a mental health problem have worse health outcomes than do people with either of these alone.
Key Concepts
- Approximately 30% of people with a long-term condition have a comorbid mental health condition.
- Physical activity is an important part of the management of physical and psychological well-being in people with long-term conditions.
- Pulmonary rehabilitation leads to reduced depression and anxiety and increased quality of life in people with chronic obstructive pulmonary disease. Further research is required to understand the optimal exercise dose; the interaction of exercise training, education and psychosocial support during pulmonary rehabilitation; and how to sustain changes in physical activity behaviour after pulmonary rehabilitation.
- Physical inactivity is associated with greater depression in people with type 2 diabetes. Further research is required to understand the causality of this relationship, although available data suggest that physical activity interventions reduce depression.
- Data that explore the relationship between physical activity and mental health in people with type 1 diabetes are limited.
- Physical activity has been shown to increase quality of life and reduce anxiety and depression in cancer survivors. Data suggest that supervised and group exercise are more beneficial than unsupervised and home-based exercise in this population.
Long-term conditions (LTCs) have been defined as "those conditions that cannot, at present, be cured, but can be controlled by medication and other therapies. The life of a person with an LTC is forever altered - there is no return to normal" (Department of Health, 2008, p. 10). LTCs include diabetes, arthritis, chronic obstructive pulmonary disease (COPD) and a number of cardiovascular diseases. In addition, conditions such as human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) and certain cancers that were not traditionally considered LTCs are increasingly being regarded as such (Naylor et al., 2012). Many mental health problems can themselves be considered LTCs. However, in this chapter the term long-term condition refers specifically to physical health conditions.
The World Health Organisation's (2011) report on the global burden of noncommunicable diseases (i.e., all previously mentioned LTCs except HIV and AIDS) found that noncommunicable diseases are by far the leading cause of mortality in the world and represent 63% of all deaths. The majority of these deaths are due to cardiovascular disease, diabetes, cancer and chronic respiratory disease. The highest occurrence of deaths from these diseases is in low- and middle-income countries, and the prevalence in these countries is predicted to increase substantially in the future. In Europe 29% of people aged 15 yr or older report a longstanding health problem (TNS Opinion, 2007), and the Office for National Statistics (2005) found that in England approximately 30% of the population (15.4 million people) has a LTC. As populations age, the burden of LTCs is projected to increase even further.
Long-Term Conditions and Mental Health Issues
People with LTCs are two to three times more likely than the general population to experience mental health problems. Depression and anxiety are the most frequently reported mental health problems in people with LTCs, but dementia, cognitive decline and some other conditions have also been reported (Naylor et al., 2012). Depression is two to three times more common in people with an LTC than in those with good physical health and occurs in approximately 20% of people with an LTC (National Collaborating Centre for Mental Health, 2010). Conservative estimates suggest that at least 30% of all people with an LTC also have a comorbid mental health problem of some kind (Cimpean & Drake, 2011). Research has shown that having a mental health problem along with an LTC has a stronger negative impact on quality of life and functional status than does either the number of LTCs or the severity of those conditions. For example, quality of life is lower in people with one LTC and depression than in people with two or more LTCs and no depression (Moussavi et al., 2007). Figure 8.1 shows the overlap between LTCs and mental health disorders.
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In addition to experiencing psychological distress, patients with an LTC and comorbid mental health problem experience poorer clinical outcomes compared with people with an LTC and no mental health problem (Moussavi et al., 2007). This is partly because self-management is necessary for effectively controlling LTCs, and poor mental health can result in poorer self-management. For example, it may lead to lack of motivation and energy to adhere to treatment plans or attend medical appointments (DiMatteo, Lepper & Croghan, 2000). From a financial perspective, comorbid mental health problems are typically associated with a 45% to 75% increase in care costs for a person with an LTC. These data are based on a wide range of LTCs and are observed after adjustment for severity of physical disease (Unützer et al., 2009; Welch et al., 2009).
Overlap between long-term conditions and mental health problems in England. Adapted, by permission, from C. Naylor et al., 2012, Long-term conditions and mental health: The cost of co-morbidities (London: The King's Fund and Centre for Mental Health).
Long-Term Conditions and Quality of Life
Quality of life is an individual's perception of their ability to function well on physical, mental and social levels. Quality of life can be measured in a reliable and valid manner using self-reported questionnaires, which can be categorised into three main groups: generic, disease specific and domain specific. Generic questionnaires measure quality of life in general terms, independent of the presence of any disease. Disease-specific questionnaires measure the consequences of a specific disease on quality of life. Domain-specific questionnaires focus on certain domains of quality of life (e.g., physical inabilities).
Where it is possible to manage but not cure a disease, such as in LTCs, measures of quality of life are frequently used to help determine the impact of treatment and disease. They help health professionals make informed judgements about whether treatment is appropriate and, where a choice of treatments exists, which might be the best option. Researchers frequently use these measures to assess the impact of a new intervention.
Long-Term Conditions and Physical Activity
Doctors have traditionally advised people with a range of LTCs to rest and not tire themselves out, and this advice persists in the lay psyche. For example, a recent Swedish survey found that the physical activity levels of people with diabetes, rheumatoid arthritis or COPD are lower than those of healthy controls; 73% of people with diabetes, 74% with rheumatoid arthritis and 84% with COPD reported low physical activity levels compared with 60% of controls (Arne et al., 2009). However, modern treatment of LTCs often includes promoting physical activity as part of a healthy lifestyle, and accumulating evidence shows the importance of physical activity in the management of both physical and psychological well-being for people with one or more LTCs. Regular contact between health professionals and people with LTCs provides opportunities for promoting physical activity in this group.
Each LTC presents its own challenges and benefits with regard to physical activity. The remainder of this chapter focusses in particular on the impact of physical activity on mental health and well-being in people with COPD, diabetes and cancer.
Chronic Obstructive Pulmonary Disease
COPD is characterised by airflow obstruction that is not fully reversible and usually progressive in the long term. It is predominantly caused by smoking. Symptoms include breathlessness (dyspnoea) on exertion, chronic cough, regular production of sputum and frequent winter bronchitis or wheeze. Exacerbation of symptoms often occurs in which the patient's symptoms rapidly worsen beyond normal day-to-day variations. Diagnosis relies on a combination of history, physical examination and confirmation of airflow obstruction using spirometry; no single test for COPD exists (National Institute for Health and Clinical Excellence, 2010). Severity of COPD is often classified using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria (I [mild], II [moderate], III [severe] and IV [very severe]) and index of body mass, airway obstruction, dyspnoea and exercise capacity (BODE).
The World Health Organisation has predicted that by 2020 COPD will be the third leading cause of death and fifth leading cause of disability in the world (Murray & Lopez, 1996, 1997). Mortality rates for men in the United Kingdom are at a plateau and mortality rates for women are steadily increasing (Soriano et al., 2000) most likely as a result of the uptake of smoking among women post-World War II. According to the chief medical officer in England, COPD accounts for more than £800 million in direct health care costs (Department of Health, 2005); more than one half of these costs relate to the provision of hospital care. COPD is among the most costly inpatient conditions that the National Health Service treats.
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Designing a physical activity program for individuals with addictions
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours.
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours. However, implementation of behavior change in this population can present practitioners with specific challenges. This section discusses the suggestions for designing effective interventions for those with addictions based on the evidence reviewed so far as well as practical considerations.
Exercise Type, Frequency and Intensity
Most studies have promoted moderate-intensity cardiovascular-type exercise such as brisk walking for use in those with addictive behaviours. Some work also incorporates more vigorous activities such as running. Because individuals with addictions are often extremely sedentary, a programme of moderate-intensity activity is likely to be acceptable and safe. However, a progression to more vigorous exercise may be beneficial. For example, the only study that found a long-term benefit of exercise for smoking cessation entailed 30 to 40 min of vigorous exercise 3 times/wk for 12 wk (Marcus et al., 1999). Similarly, the single study that showed a long-term impact of exercise on alcohol abstinence involved 1 h of progressively vigorous exercise 5 days/wk for 6 wk (Sinyor et al., 1982). None of the trials reviewed compared the effects of vigorous-intensity and moderate-intensity exercise on abstinence rates. Experimental studies have compared the effects of bouts of moderate-intensity and vigorous-intensity exercise and have shown that both intensities are effective in the short term for reducing tobacco-withdrawal symptoms (Taylor et al., 2007).
The intensity of activity that an individual is capable of depends on initial level of fitness, medical condition and stage of recovery from addiction. Careful medical screening is vital. For example, those addicted to amphetamine or cocaine are often undernourished, and problem drinkers often have weak muscles. Such individuals may require nutrition advice. Ultimately, individuals will have preferences regarding types of exercise, and programmes should be tailored to these preferences (Abrantes et al., 2011; Everson-Hock et al., 2010). Some individuals may prefer noncardiovascular types of exercise, which may also be beneficial. Resistance (i.e., weight) training, yoga and isometric exercise have all been successfully piloted as aids for smoking cessation and need to be tested in larger trials (Ussher, Taylor & Faulkner, 2012).
Regarding frequency and volume of exercise, the findings from Marcus and colleagues (2005) suggest that abstaining smokers need to accumulate at least 110 min/wk of moderate-intensity activity to maintain abstinence; supervised exercise on 2 or 3 days/wk may be necessary in order to achieve this. Shorter bouts of exercise can be used on an as-needed basis in response to cravings, and longer scheduled bouts can be used to maintain positive mood, manage stress and prevent cravings from arising. Research has not yet addressed the optimum dose of exercise for assisting alcohol and drug rehabilitation.
Exercise Supervision
The majority of intervention studies have employed group-based supervised exercise. In smokers, exercise counselling alone did not increase exercise levels sufficiently (Ussher et al., 2003), and all the interventions that showed a significant impact on long-term abstinence from alcohol or smoking entailed supervised exercise. Among novice exercisers, an element of supervised exercise may be useful to ensure initial adoption of regular exercise and to provide information about safe exercise (e.g., warm-up) and exercise intensities (e.g., using heart rate monitors). Counselling toward pursuing home-based exercise is also likely to be important for encouraging patients to maintain exercise levels after the initial exercise programme ends.
Stages of Addiction Treatment
Early recovery from drug and alcohol dependence is a major transition that affects close relationships and employment and involves numerous treatment sessions. An exercise programme needs to complement these changes. Most exercise interventions discussed in this chapter have required patients to alter their substance- or alcohol-misuse behaviour and exercise behaviour simultaneously, yet it is not clear whether this is optimal. For some individuals the challenge of changing two health behaviours simultaneously may be too demanding. Also, it is not clear whether involvement in physical activity increases the motivation to manage substance intake or vice versa.
Among smokers, exercise has often been introduced in the studies discussed several weeks before an attempt to quit, thereby allowing people to adjust to the demands of increased exercise before starting to quit. This also allows exercise to play a role in managing cravings during the crucial early days of abstinence, when relapse rates are highest. Empirical work is required to determine the relative benefits of initiating exercise at different points in the addiction-treatment process. During later stages of treatment exercise may be useful for preventing relapse (e.g., by promoting an exercise identity that is incompatible with drug use). Studies are also needed to determine whether exercise can be used to increase substance abstinence among those who are not motivated to attempt abstinence.
Integrating Exercise With Standard Addiction Treatments
Greater integration of addiction and exercise programmes may enhance abstinence rates. For instance, rather than just proposing exercise as a means for getting fitter and managing weight, the practitioner could present exercise more as a self-control strategy for managing withdrawal symptoms and a way to address psychological and physical harms caused by addiction. Exercise could be used more in combination with pharmaceutical interventions. Whereas pharmaceutical interventions focus on reducing withdrawal symptoms (e.g., NRT), exercise could ideally be used to provide an added effect in client-led management of addictive symptoms.
Perceived Barriers to Exercise
Individuals with addictions are likely to have specific barriers to exercise, and these need to be determined. In the general population, use of cognitive - behavioural techniques is effective for overcoming perceived barriers and increasing exercise adherence. Few addiction studies have included cognitive - behavioural counseling. Techniques such as self-monitoring (e.g., diaries), goal-setting and relapse-prevention planning are commonly used. Also, pedometers are now commonly used as a motivational tool. These and other motivational aids (e.g., financial incentives) need to be tested with exercise interventions in addicted populations.
Interventions for Different Subgroups
Exercise interventions need to be tested among addicted populations who might especially benefit from such interventions. Given the high prevalence of addictions among people with mental illness and the established benefits of regular physical activity for mental health, research that examines the role that physical activity may play in this population is needed (Arbour-Nicitopoulos et al., 2011).
Exercise interventions might be particularly appealing to adolescents, and controlled trials with young people are needed. Addicted individuals who are overweight may have a need for weight-control interventions such as exercise; no trial has yet focussed on this population. Additionally, surveys suggest that a nonpharmaceutical intervention such as exercise is likely to appeal to pregnant smokers (Ussher at al., 2008). Finally, sex needs to be considered when planning an appropriate intervention. Some evidence shows that women often prefer walking and aerobics, whereas men have more interest in sport, running and strength training.
Evidence to Practice
- Both moderate- and vigorous-intensity exercise have been shown to be effective for reducing tobacco-withdrawal symptoms and cravings.
- Progressing from light- and moderate-intensity exercise (e.g., brisk walking) to more vigorous-intensity exercise is advisable.
- Careful medical screening is required, especially among those with long-term alcohol or drug dependence (e.g., for malnutrition).
- Exercise interventions should be tailored to individual preferences.
- Abstaining smokers should accumulate at least 110 min/wk of moderate-intensity exercise.
- Interventions involving supervised exercise on 2 or 3 days/wk are likely to be necessary to be effective in treating addictive behaviours.
- Exercise can be performed on an as-needed basis for managing cravings or in scheduled bouts.
- If the exercise programme is to assist with early withdrawal symptoms, it ideally needs to begin before abstinence is attempted.
- Participating in physical activity encourages individuals to adopt an identity as an exerciser, which is incompatible with using addictive substances.
- Perceived barriers to exercise need to be identified and addressed using cognitive - behavioural techniques.
- The intervention needs to be adapted to various subgroups (e.g., according to sex, body weight and mental health).
Summary
Drug, alcohol and tobacco addictions are growing global problems. Exercise has many benefits for physical and psychological health, and evidence convincingly shows that exercise is effective for managing cravings and withdrawal symptoms, particularly in smokers. Regular exercise fosters a healthy lifestyle and exercise identity that is largely incompatible with addiction, and individuals undergoing rehabilitation for addiction express interest in exercising more. Exercise interventions are inexpensive, can be easily integrated with existing addiction treatments and have minimal side effects compared with pharmacological treatments. This chapter demonstrates that exercise is a highly plausible adjunctive treatment for addictive behaviour and that exercise programmes can be readily disseminated. However, limited evidence currently supports the benefits of exercise for helping smokers quit or helping those with drug or alcohol dependence abstain. This lack of evidence can partly be explained by the small number of large RCTs that have been conducted, lack of knowledge about effective doses of exercise and limited attention to methods for maximizing exercise adherence. This area of research is in its infancy, and further well-designed trials are needed.
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Physical activity guidelines
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits.
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits. National guidelines aimed at the whole population (as opposed to specific populations defined by a medical condition) focus on the optimal amount of activity to prevent disease and promote health and well-being. PAGs indicate the type (e.g., aerobic activity, strength training, weight bearing), frequency (e.g., 3 days/wk), duration (e.g., 30 min) and intensity (e.g., moderate, vigorous) (see figure 2.2) of physical activity to undertake and for what benefits. These detailed specifications reflect the latest science on the topic.
PAGs need to be updated periodically because evidence about the relationship between physical activity and health changes over time and knowledge grows. Some guidelines are more general in nature, whereas others provide very specific details; this usually reflects the state of knowledge at that time. Through a review and revision process, more specific details are added to PAGs when available. For example, in various national PAGs, guidelines relating to maintaining musculoskeletal strength have been revised over time and now include details on how much strength training is required for good health (World Health Organisation, 2010) and, specifically, for preventing falls and treating depression (Singh, Clements & Singh, 2001).
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The dose - response relationship: Increasing benefits from increasing amounts (expressed in frequency, duration and intensity) of activity. Reprinted, by permission, from I. Vuori, 1995, Terveysliikunta [Health and physical education]. UKK Institute for Health Promotion Research (Tampere, Finland).
National guidelines are an important component of a population-based approach to addressing any public health issue. First, such guidelines communicate a consensus on the scientific evidence of the importance of the issue. They describe the strength of the science in terms of the volume as well as the quality (determined based on the quality of study designs and research methods used) of the evidence. Communicating scientific consensus is important because it removes doubt and speculation about the validity of the health issue and its importance. This scientific consensus can also be used to advocate for resources and programmes. However, just because guidelines exist does not mean that everyone agrees about what the science says - far from it. However, these disagreements, or alternative interpretations of overall findings to date, are usually communicated in technical reports that accompany the publication of PAGs and are not fully accessible to the general public.
The process of developing PAGs usually involves leadership by a high-level institution. This adds credence to the message that the issue is important. For example, several national and international health agencies, such as the American Heart Association (Haskell et al., 2007), have developed guidelines on physical activity. National governments, usually the ministry of health, often lead the development process and endorse national PAGs. This endorsement is very useful because it specifies the government's position on physical activity and thereby provides the opportunity for interested parties such as charities and public health directors to leverage the government into supporting further action and funding for programmes and services aimed at increasing physical activity. This might include government endorsement of counselling and clinical services for inactive patients, as has been trialled in the United Kingdom (Bull & Milton, 2011). Government involvement and endorsement can also prevent policy inaction. The absence of an official position on physical activity can block funding and further development of a national population-based approach.
One important role of PAGs is to direct community-level actions aimed at increasing physical activity in the whole population. The details in PAGs about the type, frequency, duration and intensity of activities required for different age groups can provide clinicians, health care practitioners and others with direction on what types of programmes to provide and promote to patients and the wider community.
PAGs should drive and direct action not just at the level of individuals and service providers but also at all levels - national, regional and local - of government. If the national government endorses PAGs, ideally with multiparty political support, the government should be held accountable when levels of physical activity are not improving and can be expected to include physical activity promotion as part of ongoing disease-prevention and health-promotion strategies. The role of PAGs and national surveillance of risk factors is discussed in more detail later in this chapter.
Development of the First National Physical Activity Guidelines
Epidemiological studies of exercise and health were well advanced by the 1970s. The American College of Sports Medicine released the first set of recommendations in 1975 and released another set in 1980 (American College of Sports Medicine, 1975, 1980). These recommendations were predominantly directed at cardiorespiratory fitness and suggested that people undertake vigorous-intensity aerobic exercise 3 times/wk for 20 min each time. This was a practical interpretation of the exact recommendation from 1975, which suggested that people undertake 20 to 45 min of physical activity 3 to 5 days/wk at 70% to 90% of heart rate (i.e., vigorous intensity) (American College of Sports Medicine, 1975). The focus on aerobic exercise for increasing fitness continued to dominate and influence health messages about physical activity until the early 1990s. However, guidelines began to recommend moderate-intensity physical activity rather than vigorous-intensity activity, and by the mid-1990s the focus shifted from cardiorespiratory fitness to health benefits. This new position on physical activity was communicated in a landmark set of recommendations from the office of the U.S. surgeon general in the report "Physical Activity and Health" (U.S. Centers for Disease Control and Prevention, 1996).
In the mid-1990s, epidemiological evidence started to show that people with different health conditions require slightly different amounts of physical activity. Although the recommendation for 30 min of moderate-intensity activity on most days remained valid for preventing heart disease and diabetes, studies showed that slightly more physical activity was recommended for preventing cancer. Further, studies identified that the amount of activity required for weight loss or preventing weight gain was greater than that required to prevent chronic disease (Haskell et al., 2007). For example, the International Association for the Study of Obesity recommendations made a clear distinction between the minimum physical activity required for health benefits and the amount required for preventing weight gain. The recommendations state that "45 to 60 min (60-90 min for formerly obese individuals) of moderate-intensity physical activity daily is needed to prevent the transition to overweight or obesity" (Saris et al., 2003). Furthermore, research has now shown that the amount of physical activity required by young people differs from that of adults. The overall amount of physical activity recommended for children is twice that recommended for adults and is usually expressed as "at least 60 min/day" (Canadian Society for Exercise Physiology, 2011a; Saris et al., 2003).
These different recommendations make the development of PAGs complex. However, a core and consistent interpretation of the evidence is that 30 min of moderate-intensity physical activity on most days of the week is associated with maximum overall population benefit and the prevention of major noncommunicable diseases. This same dose has been expressed as "at least 150 min/wk of moderate-intensity activity" in the most recent global, U.S. and U.K recommendations (Department of Health, 2011b; U.S. Department of Health and Human Services, 2008a; World Health Organisation, 2010).
Current Best Practice in Developing Guidelines
Figure 2.3 illustrates the process of developing guidelines. The first step is establishing the need for guidelines. This need is often defined by policymakers, public health scientists, advocates and, sometimes, the community. Then a process for guideline development needs to be agreed on by interested parties, with actions planned in sequence and, ideally, a linkage between the PAG development process and other aspects of national or regional physical activity policy and strategy development (step 1 in figure 2.3). The next stage comprises reviewing the scientific evidence and creating an updated summary of what the research says and how this information differs from that in previous guidelines. A number of countries, notably Canada and, most recently, the United Kingdom and United States, have undertaken this process. Tremblay and colleagues (2010) extensively discuss this process with reference to the recent Canadian guidelines along with frameworks and a checklist for auditing data quality in the review stage.
Once the science has been reviewed, the next stage is developing communication messages based on the evidence and testing these messages with the target audience for acceptability, comprehension and usefulness. This step is part of developing a communications strategy for disseminating the evidence (stages 3 and 4 in figure 2.3). It requires resources for conducting the qualitative and quantitative research and the involvement of communications and media specialists in framing the messages correctly so that they will have optimal impact on the target populations. The final stages (stages 5-7 in figure 2.3) involve disseminating the message to the community, professional groups and other stakeholders. Historically, those developing PAGs have put considerable effort into the technical and scientific stages and have often neglected message development and communication. Frequently, only informal and unpaid communication channels are used after the launch of PAGs. Thus, a very important step in PAG development and dissemination is the final public health promotion component.
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Framework for developing physical activity guidelines. Adapted from Bauman et al. 2006.
Global, Regional and National Physical Activity Guidelines
Table 2.1 summarises the 2011 global PAGs and provides examples of regional (i.e., European and Western Pacific islands) and national guidelines. Quite a few countries in Europe have their own national PAGs, and many of these countries (e.g., Finland, Switzerland, the Netherlands, United Kingdom) have been engaged with implementing national population-based approaches for some time (Department of Health, 2011b; Ministry of Health, Welfare and Sport, 2011; Swiss Federal Office of Sports, 2006; UKK Institute, 2009). Other countries in Europe have officially or unofficially adopted the guidelines published by the U.S. Centers for Disease Control and Prevention in 1996 and the more recently updated 2008 version.
PAGs in other regions of the world are patchy. Australia (Department of Health and Ageing, 2005b) and New Zealand (Sport and Recreation New Zealand, 2005) have had national guidelines for some time. In Australia, guidelines exist for all ages, from young children (Department of Health and Ageing, 2004) to older adults (Department of Health and Ageing, 2005b), although all guidelines are more than 5 yr old and arguably are due for updating to reflect the latest science. Far fewer examples of PAGs exist in South America, Asia, the Middle East and Africa because physical activity promotion is relatively new in these regions. Countries in which national action on physical activity is beginning have often used the U.S. guidelines as an international benchmark. This has allowed the countries to develop an agenda of physical activity promotion without being hindered by the absence of PAGs. However, in some countries, adopting the PAGs of another country is not politically or culturally welcome or appropriate. Either these countries have developed their own PAGs (a recent example from the Middle East is Brunei; Ministry of Health, 2011) or very little physical activity promotion has occurred.
The absence of a set of official global guidelines did not hinder the World Health Organisation (WHO) from developing the Global Strategy on Diet, Physical Activity and Health in 2004 (World Health Organisation, 2004). Since the publication of the 2002 health report (World Health Organisation, 2002), the focus on the need for greater action to prevent noncommunicable disease and address mental health has increased. To address these issues, WHO commenced developing global guidelines in 2007. WHO launched the final global recommendations on physical activity in 2010 after a 2 yr process involving global and regional consultations (World Health Organisation, 2010). These global guidelines are now available for adoption and use by countries with no national PAGs. Because the guidelines are from WHO, the leading international health agency, the scientific quality and relevance of these guidelines are usually accepted.
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Treating depression and anxiety with exercise
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety.
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety. Information about these prescription parameters is scarce, but it is critical if exercise interventions are to be translated into clinical practice. Asking someone to do something without specifying what they should do or how they should do it would likely make it difficult for the individual to fully comply in a meaningful way. It is also possible that the prescription of exercise for depression and/or anxiety could be different, both in nature and content, than that required for general health benefits.
One trial that is particularly worthy of attention is the Depression Outcomes Study of Exercise (DOSE; Dunn et al., 2005), which attempted to provide evidence about the dose of exercise required to treat depression. In the DOSE study 80 participants were randomised to 1 of 4 exercise groups that varied in total energy expenditure (7 or 17.5 kcal·kg-1·wk-1) and frequency (3 or 5 days/wk) or to a flexibility-exercise placebo control for 12 wk. Exercise at a dose of 17.5 kcal·kg-1·wk-1 was effective in reducing depression regardless of frequency, whereas exercise at a dose of 7 kcal·kg-1·wk-1 yielded antidepressant effects that were comparable to those of the placebo treatment. The plausible biological reason for why a higher dose of exercise may be more effective than lower doses is that frequent and regular exercise should increase fitness levels such that physical discomfort decreases and exercise becomes a more pleasant and enjoyable experience as the conditioning process progresses. Indeed, findings from both the DOSE and TREAD trials in the United States have indicated that higher doses of exercise are more effective than are lower doses (as defined in the study).
Perraton and colleagues (2010) published a systematic review that attempted to summarise what is currently known about the prescription of exercise for depression. The review is useful because previous reviews of exercise and depression did not synthesise this information in a way that would help guide intervention development. This review included only trials that had reported exercise to be effective in reducing depression in order to analyse the specific dosage parameters and modes of exercise used in these successful trials.
The review found that the most common intensity, frequency and duration of aerobic exercise were 60% to 80% of maximum heart rate, 30 min/session and 3 days/wk over 8 wk. The volume of evidence supporting the use of aerobic exercise programmes to treat depression was greater than that supporting the use of anaerobic exercise programmes. No clear trend showed one mode of aerobic exercise to be the most effective, and a range of activity types appeared to be effective. This is encouraging given that one size does not fit all, and individuals can be encouraged to participate in whatever type of aerobic activity they prefer.
In terms of context of exercise, a number of common trends emerged. A variety of locations were effective in treating depression, although all trials that reported location took place indoors. Both group and individual interventions were effective. However, group exercise may have added benefit by providing social support, which can be pivotal for sustaining compliance and can contribute in its own right to lowering depression. Moreover, exercise might lower depression by several plausible mechanisms, one of which could be interrelations or connections with others (Bailey & McLaren, 2005). Many types of exercise can be performed with other people (depressed or not). Therefore, this exercise could provide social integration and an opportunity to interact with the social world as well as a setting in which to expand social networks and make friends (Stathi, Fox & McKenna, 2002).
Another unresolved question concerns the intensity of exercise at which a reduction in depression might occur. Callaghan and colleagues (2011) compared the effects of preferred intensity with those of prescribed intensity of group-based exercise for 12 sessions over 4 wk in 38 women aged 45 to 65 yr who were receiving treatment for depression from either primary or secondary care services. The preferred-intensity group reported significantly lower depression and higher self-esteem and quality-of-life scores than did the prescribed-exercise group and attended more sessions (66% versus 50%). Similar findings have been found in nondepressed populations (Daley & Maynard, 2003). Several theories, such as self-determination theory (Deci & Ryan, 1985), support the notion that giving people a choice and control over what they do, whether it be exercise or other activities, leads to better adherence and enjoyment of the activity, which in turn leads to enhanced psychological well-being. People experiencing depression are no exception.
Wipfli, Rethorst and Landers (2008) considered the relationship between dose of exercise and anxiety levels as part of their broader meta-analysis of the anxiolytic effect of exercise. The trend in the data from 12 RCTs showed that the effect size increased as exercise approached a dose of 12.5 kcal·kg-1·wk-1 (equates to slightly less than the dose recommended for public health) and then began to decrease as exercise dose increased. A combination of aerobic and anaerobic exercise appeared to be better than either type alone, and a frequency of 3 or 4 times/wk appeared more effective than more or less than this amount.
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Available methods for measuring physical activity
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry.
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry. Most are moderately correlated at best. Each method has its own strengths and limitations. Due to the complexity of physical activity, outlined previously, researchers and practitioners need to consider what is most important for their purposes when deciding to use a particular technique. Although no one measurement tool can be singled out as the most appropriate, recommendations for the most useful and practical measurement tools can be made after considering factors such as context, type, duration, frequency and intensity of physical activity as well as the constraints under which the research or treatment programme is operating. These techniques are presented in order of increasing feasibility but decreasing validity. Table 3.2 at the end of this section summarises the key advantages and limitations of each measurement technique.
Doubly Labelled Water
Doubly labelled water (DLW, or free-living indirect calorimetry) is a method commonly used to increase the precision and accuracy of physical activity measurement. DLW, which measures EE over several (4-21) consecutive days in a free-living person under normal life conditions (Schoeller, 1988), is the most widely accepted gold standard method by which to measure EE (Aadahl & Jørgensen, 2003). DLW measures EE of free-living, unrestricted subjects using water labelled with stable isotopes of oxygen and hydrogen (Schoeller & van Santen, 1982). It calculates activity-related EE by combining measurement of total EE with basal metabolic rate. The utility of the DLW method in measuring total EE is demonstrated by its use in a variety of settings, including all age groups, premature infants, hospitalised patients, pregnant women and the elderly (Ainslie, Reilly & Westerterp, 2003). As such, researchers who use this method to assess the relationship between physical activity and other psychological variables or to detect changes in physical activity as a result of interventions can be confident that the results produced regarding EE are accurate. Schoeller (1988) fully describes the validation of the DLW method.
Despite its level of precision, the DLW method is not without disadvantages, which include high cost, limitations for assessing brief periods of EE (Ainslie, Reilly & Westerterp, 2003) and additional demands on participants in terms of time and tasks required. The cost and availability of isotopes and the requirement for analysis by isotope ratio mass spectrometer prohibit DLW from being widely used in studies of large populations. The use of this method among populations with more severe mental health problems may likely present a set of ethical issues. Furthermore, although this technique provides an accurate measure of total EE, it cannot provide information about patterns of physical activity in terms of type, frequency, duration, intensity or context. Consequently, such an approach would not be feasible in a large natural-field experiment or in a test of the effect of interventions on changes in physical activity in both healthy populations and populations that suffer from mental health problems. However, this gold standard measure is believed to offer the most precise estimate of EE and is often used to validate many other types of tools that assess physical activity.
Direct Observation
Direct observation, one of the most basic approaches for acquiring information about behaviours, provides information about how people exercise and play, how environments shape the activities individuals participate in and how people use specific facilities (e.g., parks, leisure facilities, walking or cycling paths). It can take place using basic observation methods, systematic forms or sophisticated technology (e.g., lasers). Direct observation often involves a trained observer who codes physical activity behaviours (e.g., sitting, walking, running) undertaken by participants over time in various settings (e.g., playground, park, home). A number of observation systems are available, such as SOPLAY (System for Observing Play and Leisure Activity in Youth), SOFIT (System for Observing Fitness Instruction Time), and the Systematic Pedestrian and Cycling Environmental Scan. The trained observer may either observe participants in person or review video media. Because it is time consuming, direct observation might be used only with small groups in specific settings (Dugdill & Stratton, 2007).
Advantages of direct observation include that self-report bias is eliminated, participants do not need to recall behaviour and the level of detail regarding behaviour patterns and context can be extremely accurate. Furthermore, practitioners may find some of these tools accessible. For example, clinical psychologists working with institutionalised individuals diagnosed with severe mental health conditions may find this type of measurement technique useful for assessing relationships between physical activity patterns or patterns of inactivity and specific mental illnesses because it can combine both context and behaviour to provide powerful data.
However, disadvantages include the time involved in recording and coding behaviour, the time involved in consolidating the plethora of data collected and the costs associated with training coders. Furthermore, the subjective bias of coders may lead to incorrect judgments about the intensities of specific activities, which would affect estimates of EE. As such, it would be important to consider whether information regarding patterns of behaviour combined with context or specific EE data are required to fulfill the aims of a research project or treatment programme.
Accelerometers
Motion sensors, such as pedometers and accelerometers, can be used to detect body movement and estimate physical activity (Spruijt-Metz et al., 2009). Accelerometers are devices that measure bodily movements in terms of acceleration. This measurement can then be used to estimate the intensity of physical activity, and therefore EE, over time (Burton et al., 2005; Chen & Basset, 2005). Accelerometers can measure human activity on vertical (uniaxial accelerometers), anterior - posterior and medial - lateral (triaxial accelerometers) planes. EE can then be then estimated from vector magnitude counts using a proprietary algorithm, which is a composite of counts from these planes of motion (Howe, Staudenmayer & Freedson, 2009). Accelerometers can be used repeatedly on numerous participants, are more accurate than pedometers and are less expensive (approximately £200 per device; ActiLife, 2009) than other objective methods such as DLW (approximately £200 per participant per procedure; Friedman & Johnson, 2002). However, they remain too expensive to use in studies that assess large numbers of people (Wood, 2000). Nevertheless, these devices are a more feasible and participant-friendly method of attempting to validate a self-report questionnaire than is DLW. They also provide the data necessary to allow researchers to distinguish between light, moderate and vigorous physical activity as well as between continuous and intermittent activity modes (Crouter, Clowers & Bassett, 2006). A recent review of accelerometers against DLW found ActiGraph (previously named CSA/MTI) models to be of the most valid types tested; they produce an average correlation of r = .57 (Plasqui & Westerterp, 2007). Limitations of accelerometers include the increased time required to analyse the large amount of data provided, participant burden of wearing the device, that they cannot be feasibly used to test large-scale interventions, and that they cannot provide information about the specific type of activity (e.g., playing football, going to the gym) or the context in which it is performed.
Some studies have attempted to validate accelerometers among populations diagnosed with mental health conditions. For example, Sharpe and colleagues (2006) conducted a study to assess the validity of the RT3 accelerometer against DLW in people with schizophrenia. They found that the accelerometer overpredicted energy expended on physical activity by an average of 148 kcal/day (standard deviation = 413 kcal/day); this varied from an underestimation of 614 kcal/day to an overestimation of 582 kcal/day. The authors suggested that the RT3 accelerometer is a poor tool for measuring activity EE in sedentary men with schizophrenia. As such, the results of studies that have used this measurement tool in mentally ill populations may be questionable. For example, the recent intervention study of Jerome and colleagues (2009) used the RT3 accelerometer to measure physical activity in persons with mental illness. The authors of this study concluded that participants were undertaking approximately 120 min/wk of moderate-intensity physical activity on average, which would equal approximately 70 kcal/day. Given that the results of the study by Sharpe and colleagues (2006) indicated that the RT3 accelerometer overpredicted EE, it is possible that the results found by Jerome and colleagues (2009) overestimate the amount of physical activity undertaken by participants. Consequently, this might affect the validity of the relationships found between physical activity and various mental health variables measured in this study. Sharpe and colleagues (2006) did, however, indicate that the RT3 appeared to be a valid measure of physical inactivity in men with schizophrenia. Therefore, it could be used for research or clinical purposes to quantify the contribution of sedentary behaviour to medical conditions associated with inactivity. Sharpe and colleagues (2006) also recommended that using the RT3 to validate questionnaires may not be appropriate until it is more robust.
Indirect Objective Measures
Indicators of the physiologic response to physical activity include heart rate and pulmonary gas exchange. Heart-rate monitoring is a promising measurement method because heart rate is a physiological parameter that correlates well with, and strongly predicts, EE (Strath et al., 2002). Most heart rate monitors include software that converts heart rate data into an estimate of EE. However, one of the limitations of heart rate monitoring is that training state and individual heart rate characteristics can affect the relationship between heart rate and oxygen consumption. Higher levels of accuracy can be obtained through a graded submaximal exercise test that calibrates participant heart rate to simultaneous oxygen consumption. This information allows for the construction of a calibration curve that estimates EE at moderate and strenuous levels of exercise. (A linear relationship exists between increasing heart rate and oxygen consumption; Freedson & Miller, 2000.) Measuring heart rate is a common method used to describe intensity and duration of physical activity and is a relatively inexpensive method of measuring EE. However, heart rate is affected by factors other than physical activity, such as emotional stress, temperature, humidity, dehydration, posture and illness (Ainslie, Reilly & Westerterp, 2003). These factors can influence heart rate without causing associated changes in oxygen consumption. Given the potentially increased fluctuations in emotions in individuals diagnosed with mental health conditions, this method may not be the most appropriate for obtaining accurate physical activity levels. Furthermore, the relationship between oxygen uptake and heart rate is weak at low levels of activity (Keim, Blanton & Kretsch, 2004). Evidence suggests that individuals suffering from mental health problems tend to perform less intensive physical activity than do members of the general population (e.g., Brown et al., 1999). Therefore, the heart rate method may not provide accurate information about the physical activity of mental health populations. Also, the heart rate method is unable to identify types of activity or the context in which physical activity is performed. Although heart rate is a physiological marker for physical activity and may provide a general picture of physical activity patterns, it may not be the best method available for obtaining an accurate estimate of EE.
Pedometers
Pedometers, which measure steps on a single axis as well as calories expended, are less expensive than some other types of motion sensors. As such, these devices are an attractive alternative to self-report in large observational or intervention studies. Public health campaigns have also promoted pedometers as a motivational tool for achieving the goal of 10,000 steps daily. A range of pedometers is available. The pedometer that is most suitable for a particular study may depend on factors such as the research question (outcome of interest), population, available funds, context and validity of the model. For example, when considering context, researchers or practitioners who wish to understand the types of physical activity being undertaken in a variety of settings would not gain this information using pedometers alone. When considering population, some pedometers are validated in healthy adults but not in other populations such as children, the elderly or those diagnosed with mental illness. Pedometers have demonstrated reduced accuracy in elderly populations because of the slow pace or shuffling nature with which elderly people walk (Cyarto, Myers & Tudor-Locke, 2004). Tudor-Locke and colleagues (2002) evaluated the validity of pedometers in a review of 25 studies and found a strong correlation between pedometer counts and accelerometer output (median of reported correlations is r = .86). However, evidence suggests that the validity of pedometers for measuring EE and distance in normal populations is questionable. The findings of a study testing the validity of 10 pedometers (Crouter et al., 2003) indicated that these devices overestimated distance at slower speeds and underestimated distance at faster speeds. Furthermore, in 8 of the pedometers tested, it was unclear whether the device was measuring gross EE (all the energy expended by an individual during a specific activity) or net EE (the energy expended by an individual during a specific activity minus the resting EE for the equivalent amount of time). The Yamax Digiwalker SW-200 was found to be the most reliable and accurate pedometer available (Crouter et al., 2003). This pedometer was used in a recent study by McKercher (2009) that assessed relationships between physical activity and depression in young adults. This study found that low levels of depression were significantly correlated with moderate levels of physical activity, as measured by the Yamax Digiwalker SW-200, among females. However, this device has not been validated in specific mental health populations, which may limit the validity of these results. It is important to validate physical activity devices among specific populations because patterns of physical activity in these populations may differ from those in the general population. For example, individuals with serious mental illness are significantly less active than the general population (Brown et al., 2004). As such, using a physical activity measure that has been validated with mental health populations in research on physical activity and mental health will increase the strength of the results produced.
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Coping with long-term physical health conditions
Approximately 30% of the European population has a long-term physical health condition. People with a long-term condition that is comorbid with a mental health problem have worse health outcomes than do people with either of these alone.
Key Concepts
- Approximately 30% of people with a long-term condition have a comorbid mental health condition.
- Physical activity is an important part of the management of physical and psychological well-being in people with long-term conditions.
- Pulmonary rehabilitation leads to reduced depression and anxiety and increased quality of life in people with chronic obstructive pulmonary disease. Further research is required to understand the optimal exercise dose; the interaction of exercise training, education and psychosocial support during pulmonary rehabilitation; and how to sustain changes in physical activity behaviour after pulmonary rehabilitation.
- Physical inactivity is associated with greater depression in people with type 2 diabetes. Further research is required to understand the causality of this relationship, although available data suggest that physical activity interventions reduce depression.
- Data that explore the relationship between physical activity and mental health in people with type 1 diabetes are limited.
- Physical activity has been shown to increase quality of life and reduce anxiety and depression in cancer survivors. Data suggest that supervised and group exercise are more beneficial than unsupervised and home-based exercise in this population.
Long-term conditions (LTCs) have been defined as "those conditions that cannot, at present, be cured, but can be controlled by medication and other therapies. The life of a person with an LTC is forever altered - there is no return to normal" (Department of Health, 2008, p. 10). LTCs include diabetes, arthritis, chronic obstructive pulmonary disease (COPD) and a number of cardiovascular diseases. In addition, conditions such as human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) and certain cancers that were not traditionally considered LTCs are increasingly being regarded as such (Naylor et al., 2012). Many mental health problems can themselves be considered LTCs. However, in this chapter the term long-term condition refers specifically to physical health conditions.
The World Health Organisation's (2011) report on the global burden of noncommunicable diseases (i.e., all previously mentioned LTCs except HIV and AIDS) found that noncommunicable diseases are by far the leading cause of mortality in the world and represent 63% of all deaths. The majority of these deaths are due to cardiovascular disease, diabetes, cancer and chronic respiratory disease. The highest occurrence of deaths from these diseases is in low- and middle-income countries, and the prevalence in these countries is predicted to increase substantially in the future. In Europe 29% of people aged 15 yr or older report a longstanding health problem (TNS Opinion, 2007), and the Office for National Statistics (2005) found that in England approximately 30% of the population (15.4 million people) has a LTC. As populations age, the burden of LTCs is projected to increase even further.
Long-Term Conditions and Mental Health Issues
People with LTCs are two to three times more likely than the general population to experience mental health problems. Depression and anxiety are the most frequently reported mental health problems in people with LTCs, but dementia, cognitive decline and some other conditions have also been reported (Naylor et al., 2012). Depression is two to three times more common in people with an LTC than in those with good physical health and occurs in approximately 20% of people with an LTC (National Collaborating Centre for Mental Health, 2010). Conservative estimates suggest that at least 30% of all people with an LTC also have a comorbid mental health problem of some kind (Cimpean & Drake, 2011). Research has shown that having a mental health problem along with an LTC has a stronger negative impact on quality of life and functional status than does either the number of LTCs or the severity of those conditions. For example, quality of life is lower in people with one LTC and depression than in people with two or more LTCs and no depression (Moussavi et al., 2007). Figure 8.1 shows the overlap between LTCs and mental health disorders.
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In addition to experiencing psychological distress, patients with an LTC and comorbid mental health problem experience poorer clinical outcomes compared with people with an LTC and no mental health problem (Moussavi et al., 2007). This is partly because self-management is necessary for effectively controlling LTCs, and poor mental health can result in poorer self-management. For example, it may lead to lack of motivation and energy to adhere to treatment plans or attend medical appointments (DiMatteo, Lepper & Croghan, 2000). From a financial perspective, comorbid mental health problems are typically associated with a 45% to 75% increase in care costs for a person with an LTC. These data are based on a wide range of LTCs and are observed after adjustment for severity of physical disease (Unützer et al., 2009; Welch et al., 2009).
Overlap between long-term conditions and mental health problems in England. Adapted, by permission, from C. Naylor et al., 2012, Long-term conditions and mental health: The cost of co-morbidities (London: The King's Fund and Centre for Mental Health).
Long-Term Conditions and Quality of Life
Quality of life is an individual's perception of their ability to function well on physical, mental and social levels. Quality of life can be measured in a reliable and valid manner using self-reported questionnaires, which can be categorised into three main groups: generic, disease specific and domain specific. Generic questionnaires measure quality of life in general terms, independent of the presence of any disease. Disease-specific questionnaires measure the consequences of a specific disease on quality of life. Domain-specific questionnaires focus on certain domains of quality of life (e.g., physical inabilities).
Where it is possible to manage but not cure a disease, such as in LTCs, measures of quality of life are frequently used to help determine the impact of treatment and disease. They help health professionals make informed judgements about whether treatment is appropriate and, where a choice of treatments exists, which might be the best option. Researchers frequently use these measures to assess the impact of a new intervention.
Long-Term Conditions and Physical Activity
Doctors have traditionally advised people with a range of LTCs to rest and not tire themselves out, and this advice persists in the lay psyche. For example, a recent Swedish survey found that the physical activity levels of people with diabetes, rheumatoid arthritis or COPD are lower than those of healthy controls; 73% of people with diabetes, 74% with rheumatoid arthritis and 84% with COPD reported low physical activity levels compared with 60% of controls (Arne et al., 2009). However, modern treatment of LTCs often includes promoting physical activity as part of a healthy lifestyle, and accumulating evidence shows the importance of physical activity in the management of both physical and psychological well-being for people with one or more LTCs. Regular contact between health professionals and people with LTCs provides opportunities for promoting physical activity in this group.
Each LTC presents its own challenges and benefits with regard to physical activity. The remainder of this chapter focusses in particular on the impact of physical activity on mental health and well-being in people with COPD, diabetes and cancer.
Chronic Obstructive Pulmonary Disease
COPD is characterised by airflow obstruction that is not fully reversible and usually progressive in the long term. It is predominantly caused by smoking. Symptoms include breathlessness (dyspnoea) on exertion, chronic cough, regular production of sputum and frequent winter bronchitis or wheeze. Exacerbation of symptoms often occurs in which the patient's symptoms rapidly worsen beyond normal day-to-day variations. Diagnosis relies on a combination of history, physical examination and confirmation of airflow obstruction using spirometry; no single test for COPD exists (National Institute for Health and Clinical Excellence, 2010). Severity of COPD is often classified using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria (I [mild], II [moderate], III [severe] and IV [very severe]) and index of body mass, airway obstruction, dyspnoea and exercise capacity (BODE).
The World Health Organisation has predicted that by 2020 COPD will be the third leading cause of death and fifth leading cause of disability in the world (Murray & Lopez, 1996, 1997). Mortality rates for men in the United Kingdom are at a plateau and mortality rates for women are steadily increasing (Soriano et al., 2000) most likely as a result of the uptake of smoking among women post-World War II. According to the chief medical officer in England, COPD accounts for more than £800 million in direct health care costs (Department of Health, 2005); more than one half of these costs relate to the provision of hospital care. COPD is among the most costly inpatient conditions that the National Health Service treats.
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Designing a physical activity program for individuals with addictions
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours.
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours. However, implementation of behavior change in this population can present practitioners with specific challenges. This section discusses the suggestions for designing effective interventions for those with addictions based on the evidence reviewed so far as well as practical considerations.
Exercise Type, Frequency and Intensity
Most studies have promoted moderate-intensity cardiovascular-type exercise such as brisk walking for use in those with addictive behaviours. Some work also incorporates more vigorous activities such as running. Because individuals with addictions are often extremely sedentary, a programme of moderate-intensity activity is likely to be acceptable and safe. However, a progression to more vigorous exercise may be beneficial. For example, the only study that found a long-term benefit of exercise for smoking cessation entailed 30 to 40 min of vigorous exercise 3 times/wk for 12 wk (Marcus et al., 1999). Similarly, the single study that showed a long-term impact of exercise on alcohol abstinence involved 1 h of progressively vigorous exercise 5 days/wk for 6 wk (Sinyor et al., 1982). None of the trials reviewed compared the effects of vigorous-intensity and moderate-intensity exercise on abstinence rates. Experimental studies have compared the effects of bouts of moderate-intensity and vigorous-intensity exercise and have shown that both intensities are effective in the short term for reducing tobacco-withdrawal symptoms (Taylor et al., 2007).
The intensity of activity that an individual is capable of depends on initial level of fitness, medical condition and stage of recovery from addiction. Careful medical screening is vital. For example, those addicted to amphetamine or cocaine are often undernourished, and problem drinkers often have weak muscles. Such individuals may require nutrition advice. Ultimately, individuals will have preferences regarding types of exercise, and programmes should be tailored to these preferences (Abrantes et al., 2011; Everson-Hock et al., 2010). Some individuals may prefer noncardiovascular types of exercise, which may also be beneficial. Resistance (i.e., weight) training, yoga and isometric exercise have all been successfully piloted as aids for smoking cessation and need to be tested in larger trials (Ussher, Taylor & Faulkner, 2012).
Regarding frequency and volume of exercise, the findings from Marcus and colleagues (2005) suggest that abstaining smokers need to accumulate at least 110 min/wk of moderate-intensity activity to maintain abstinence; supervised exercise on 2 or 3 days/wk may be necessary in order to achieve this. Shorter bouts of exercise can be used on an as-needed basis in response to cravings, and longer scheduled bouts can be used to maintain positive mood, manage stress and prevent cravings from arising. Research has not yet addressed the optimum dose of exercise for assisting alcohol and drug rehabilitation.
Exercise Supervision
The majority of intervention studies have employed group-based supervised exercise. In smokers, exercise counselling alone did not increase exercise levels sufficiently (Ussher et al., 2003), and all the interventions that showed a significant impact on long-term abstinence from alcohol or smoking entailed supervised exercise. Among novice exercisers, an element of supervised exercise may be useful to ensure initial adoption of regular exercise and to provide information about safe exercise (e.g., warm-up) and exercise intensities (e.g., using heart rate monitors). Counselling toward pursuing home-based exercise is also likely to be important for encouraging patients to maintain exercise levels after the initial exercise programme ends.
Stages of Addiction Treatment
Early recovery from drug and alcohol dependence is a major transition that affects close relationships and employment and involves numerous treatment sessions. An exercise programme needs to complement these changes. Most exercise interventions discussed in this chapter have required patients to alter their substance- or alcohol-misuse behaviour and exercise behaviour simultaneously, yet it is not clear whether this is optimal. For some individuals the challenge of changing two health behaviours simultaneously may be too demanding. Also, it is not clear whether involvement in physical activity increases the motivation to manage substance intake or vice versa.
Among smokers, exercise has often been introduced in the studies discussed several weeks before an attempt to quit, thereby allowing people to adjust to the demands of increased exercise before starting to quit. This also allows exercise to play a role in managing cravings during the crucial early days of abstinence, when relapse rates are highest. Empirical work is required to determine the relative benefits of initiating exercise at different points in the addiction-treatment process. During later stages of treatment exercise may be useful for preventing relapse (e.g., by promoting an exercise identity that is incompatible with drug use). Studies are also needed to determine whether exercise can be used to increase substance abstinence among those who are not motivated to attempt abstinence.
Integrating Exercise With Standard Addiction Treatments
Greater integration of addiction and exercise programmes may enhance abstinence rates. For instance, rather than just proposing exercise as a means for getting fitter and managing weight, the practitioner could present exercise more as a self-control strategy for managing withdrawal symptoms and a way to address psychological and physical harms caused by addiction. Exercise could be used more in combination with pharmaceutical interventions. Whereas pharmaceutical interventions focus on reducing withdrawal symptoms (e.g., NRT), exercise could ideally be used to provide an added effect in client-led management of addictive symptoms.
Perceived Barriers to Exercise
Individuals with addictions are likely to have specific barriers to exercise, and these need to be determined. In the general population, use of cognitive - behavioural techniques is effective for overcoming perceived barriers and increasing exercise adherence. Few addiction studies have included cognitive - behavioural counseling. Techniques such as self-monitoring (e.g., diaries), goal-setting and relapse-prevention planning are commonly used. Also, pedometers are now commonly used as a motivational tool. These and other motivational aids (e.g., financial incentives) need to be tested with exercise interventions in addicted populations.
Interventions for Different Subgroups
Exercise interventions need to be tested among addicted populations who might especially benefit from such interventions. Given the high prevalence of addictions among people with mental illness and the established benefits of regular physical activity for mental health, research that examines the role that physical activity may play in this population is needed (Arbour-Nicitopoulos et al., 2011).
Exercise interventions might be particularly appealing to adolescents, and controlled trials with young people are needed. Addicted individuals who are overweight may have a need for weight-control interventions such as exercise; no trial has yet focussed on this population. Additionally, surveys suggest that a nonpharmaceutical intervention such as exercise is likely to appeal to pregnant smokers (Ussher at al., 2008). Finally, sex needs to be considered when planning an appropriate intervention. Some evidence shows that women often prefer walking and aerobics, whereas men have more interest in sport, running and strength training.
Evidence to Practice
- Both moderate- and vigorous-intensity exercise have been shown to be effective for reducing tobacco-withdrawal symptoms and cravings.
- Progressing from light- and moderate-intensity exercise (e.g., brisk walking) to more vigorous-intensity exercise is advisable.
- Careful medical screening is required, especially among those with long-term alcohol or drug dependence (e.g., for malnutrition).
- Exercise interventions should be tailored to individual preferences.
- Abstaining smokers should accumulate at least 110 min/wk of moderate-intensity exercise.
- Interventions involving supervised exercise on 2 or 3 days/wk are likely to be necessary to be effective in treating addictive behaviours.
- Exercise can be performed on an as-needed basis for managing cravings or in scheduled bouts.
- If the exercise programme is to assist with early withdrawal symptoms, it ideally needs to begin before abstinence is attempted.
- Participating in physical activity encourages individuals to adopt an identity as an exerciser, which is incompatible with using addictive substances.
- Perceived barriers to exercise need to be identified and addressed using cognitive - behavioural techniques.
- The intervention needs to be adapted to various subgroups (e.g., according to sex, body weight and mental health).
Summary
Drug, alcohol and tobacco addictions are growing global problems. Exercise has many benefits for physical and psychological health, and evidence convincingly shows that exercise is effective for managing cravings and withdrawal symptoms, particularly in smokers. Regular exercise fosters a healthy lifestyle and exercise identity that is largely incompatible with addiction, and individuals undergoing rehabilitation for addiction express interest in exercising more. Exercise interventions are inexpensive, can be easily integrated with existing addiction treatments and have minimal side effects compared with pharmacological treatments. This chapter demonstrates that exercise is a highly plausible adjunctive treatment for addictive behaviour and that exercise programmes can be readily disseminated. However, limited evidence currently supports the benefits of exercise for helping smokers quit or helping those with drug or alcohol dependence abstain. This lack of evidence can partly be explained by the small number of large RCTs that have been conducted, lack of knowledge about effective doses of exercise and limited attention to methods for maximizing exercise adherence. This area of research is in its infancy, and further well-designed trials are needed.
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Physical activity guidelines
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits.
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits. National guidelines aimed at the whole population (as opposed to specific populations defined by a medical condition) focus on the optimal amount of activity to prevent disease and promote health and well-being. PAGs indicate the type (e.g., aerobic activity, strength training, weight bearing), frequency (e.g., 3 days/wk), duration (e.g., 30 min) and intensity (e.g., moderate, vigorous) (see figure 2.2) of physical activity to undertake and for what benefits. These detailed specifications reflect the latest science on the topic.
PAGs need to be updated periodically because evidence about the relationship between physical activity and health changes over time and knowledge grows. Some guidelines are more general in nature, whereas others provide very specific details; this usually reflects the state of knowledge at that time. Through a review and revision process, more specific details are added to PAGs when available. For example, in various national PAGs, guidelines relating to maintaining musculoskeletal strength have been revised over time and now include details on how much strength training is required for good health (World Health Organisation, 2010) and, specifically, for preventing falls and treating depression (Singh, Clements & Singh, 2001).
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The dose - response relationship: Increasing benefits from increasing amounts (expressed in frequency, duration and intensity) of activity. Reprinted, by permission, from I. Vuori, 1995, Terveysliikunta [Health and physical education]. UKK Institute for Health Promotion Research (Tampere, Finland).
National guidelines are an important component of a population-based approach to addressing any public health issue. First, such guidelines communicate a consensus on the scientific evidence of the importance of the issue. They describe the strength of the science in terms of the volume as well as the quality (determined based on the quality of study designs and research methods used) of the evidence. Communicating scientific consensus is important because it removes doubt and speculation about the validity of the health issue and its importance. This scientific consensus can also be used to advocate for resources and programmes. However, just because guidelines exist does not mean that everyone agrees about what the science says - far from it. However, these disagreements, or alternative interpretations of overall findings to date, are usually communicated in technical reports that accompany the publication of PAGs and are not fully accessible to the general public.
The process of developing PAGs usually involves leadership by a high-level institution. This adds credence to the message that the issue is important. For example, several national and international health agencies, such as the American Heart Association (Haskell et al., 2007), have developed guidelines on physical activity. National governments, usually the ministry of health, often lead the development process and endorse national PAGs. This endorsement is very useful because it specifies the government's position on physical activity and thereby provides the opportunity for interested parties such as charities and public health directors to leverage the government into supporting further action and funding for programmes and services aimed at increasing physical activity. This might include government endorsement of counselling and clinical services for inactive patients, as has been trialled in the United Kingdom (Bull & Milton, 2011). Government involvement and endorsement can also prevent policy inaction. The absence of an official position on physical activity can block funding and further development of a national population-based approach.
One important role of PAGs is to direct community-level actions aimed at increasing physical activity in the whole population. The details in PAGs about the type, frequency, duration and intensity of activities required for different age groups can provide clinicians, health care practitioners and others with direction on what types of programmes to provide and promote to patients and the wider community.
PAGs should drive and direct action not just at the level of individuals and service providers but also at all levels - national, regional and local - of government. If the national government endorses PAGs, ideally with multiparty political support, the government should be held accountable when levels of physical activity are not improving and can be expected to include physical activity promotion as part of ongoing disease-prevention and health-promotion strategies. The role of PAGs and national surveillance of risk factors is discussed in more detail later in this chapter.
Development of the First National Physical Activity Guidelines
Epidemiological studies of exercise and health were well advanced by the 1970s. The American College of Sports Medicine released the first set of recommendations in 1975 and released another set in 1980 (American College of Sports Medicine, 1975, 1980). These recommendations were predominantly directed at cardiorespiratory fitness and suggested that people undertake vigorous-intensity aerobic exercise 3 times/wk for 20 min each time. This was a practical interpretation of the exact recommendation from 1975, which suggested that people undertake 20 to 45 min of physical activity 3 to 5 days/wk at 70% to 90% of heart rate (i.e., vigorous intensity) (American College of Sports Medicine, 1975). The focus on aerobic exercise for increasing fitness continued to dominate and influence health messages about physical activity until the early 1990s. However, guidelines began to recommend moderate-intensity physical activity rather than vigorous-intensity activity, and by the mid-1990s the focus shifted from cardiorespiratory fitness to health benefits. This new position on physical activity was communicated in a landmark set of recommendations from the office of the U.S. surgeon general in the report "Physical Activity and Health" (U.S. Centers for Disease Control and Prevention, 1996).
In the mid-1990s, epidemiological evidence started to show that people with different health conditions require slightly different amounts of physical activity. Although the recommendation for 30 min of moderate-intensity activity on most days remained valid for preventing heart disease and diabetes, studies showed that slightly more physical activity was recommended for preventing cancer. Further, studies identified that the amount of activity required for weight loss or preventing weight gain was greater than that required to prevent chronic disease (Haskell et al., 2007). For example, the International Association for the Study of Obesity recommendations made a clear distinction between the minimum physical activity required for health benefits and the amount required for preventing weight gain. The recommendations state that "45 to 60 min (60-90 min for formerly obese individuals) of moderate-intensity physical activity daily is needed to prevent the transition to overweight or obesity" (Saris et al., 2003). Furthermore, research has now shown that the amount of physical activity required by young people differs from that of adults. The overall amount of physical activity recommended for children is twice that recommended for adults and is usually expressed as "at least 60 min/day" (Canadian Society for Exercise Physiology, 2011a; Saris et al., 2003).
These different recommendations make the development of PAGs complex. However, a core and consistent interpretation of the evidence is that 30 min of moderate-intensity physical activity on most days of the week is associated with maximum overall population benefit and the prevention of major noncommunicable diseases. This same dose has been expressed as "at least 150 min/wk of moderate-intensity activity" in the most recent global, U.S. and U.K recommendations (Department of Health, 2011b; U.S. Department of Health and Human Services, 2008a; World Health Organisation, 2010).
Current Best Practice in Developing Guidelines
Figure 2.3 illustrates the process of developing guidelines. The first step is establishing the need for guidelines. This need is often defined by policymakers, public health scientists, advocates and, sometimes, the community. Then a process for guideline development needs to be agreed on by interested parties, with actions planned in sequence and, ideally, a linkage between the PAG development process and other aspects of national or regional physical activity policy and strategy development (step 1 in figure 2.3). The next stage comprises reviewing the scientific evidence and creating an updated summary of what the research says and how this information differs from that in previous guidelines. A number of countries, notably Canada and, most recently, the United Kingdom and United States, have undertaken this process. Tremblay and colleagues (2010) extensively discuss this process with reference to the recent Canadian guidelines along with frameworks and a checklist for auditing data quality in the review stage.
Once the science has been reviewed, the next stage is developing communication messages based on the evidence and testing these messages with the target audience for acceptability, comprehension and usefulness. This step is part of developing a communications strategy for disseminating the evidence (stages 3 and 4 in figure 2.3). It requires resources for conducting the qualitative and quantitative research and the involvement of communications and media specialists in framing the messages correctly so that they will have optimal impact on the target populations. The final stages (stages 5-7 in figure 2.3) involve disseminating the message to the community, professional groups and other stakeholders. Historically, those developing PAGs have put considerable effort into the technical and scientific stages and have often neglected message development and communication. Frequently, only informal and unpaid communication channels are used after the launch of PAGs. Thus, a very important step in PAG development and dissemination is the final public health promotion component.
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Framework for developing physical activity guidelines. Adapted from Bauman et al. 2006.
Global, Regional and National Physical Activity Guidelines
Table 2.1 summarises the 2011 global PAGs and provides examples of regional (i.e., European and Western Pacific islands) and national guidelines. Quite a few countries in Europe have their own national PAGs, and many of these countries (e.g., Finland, Switzerland, the Netherlands, United Kingdom) have been engaged with implementing national population-based approaches for some time (Department of Health, 2011b; Ministry of Health, Welfare and Sport, 2011; Swiss Federal Office of Sports, 2006; UKK Institute, 2009). Other countries in Europe have officially or unofficially adopted the guidelines published by the U.S. Centers for Disease Control and Prevention in 1996 and the more recently updated 2008 version.
PAGs in other regions of the world are patchy. Australia (Department of Health and Ageing, 2005b) and New Zealand (Sport and Recreation New Zealand, 2005) have had national guidelines for some time. In Australia, guidelines exist for all ages, from young children (Department of Health and Ageing, 2004) to older adults (Department of Health and Ageing, 2005b), although all guidelines are more than 5 yr old and arguably are due for updating to reflect the latest science. Far fewer examples of PAGs exist in South America, Asia, the Middle East and Africa because physical activity promotion is relatively new in these regions. Countries in which national action on physical activity is beginning have often used the U.S. guidelines as an international benchmark. This has allowed the countries to develop an agenda of physical activity promotion without being hindered by the absence of PAGs. However, in some countries, adopting the PAGs of another country is not politically or culturally welcome or appropriate. Either these countries have developed their own PAGs (a recent example from the Middle East is Brunei; Ministry of Health, 2011) or very little physical activity promotion has occurred.
The absence of a set of official global guidelines did not hinder the World Health Organisation (WHO) from developing the Global Strategy on Diet, Physical Activity and Health in 2004 (World Health Organisation, 2004). Since the publication of the 2002 health report (World Health Organisation, 2002), the focus on the need for greater action to prevent noncommunicable disease and address mental health has increased. To address these issues, WHO commenced developing global guidelines in 2007. WHO launched the final global recommendations on physical activity in 2010 after a 2 yr process involving global and regional consultations (World Health Organisation, 2010). These global guidelines are now available for adoption and use by countries with no national PAGs. Because the guidelines are from WHO, the leading international health agency, the scientific quality and relevance of these guidelines are usually accepted.
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Treating depression and anxiety with exercise
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety.
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety. Information about these prescription parameters is scarce, but it is critical if exercise interventions are to be translated into clinical practice. Asking someone to do something without specifying what they should do or how they should do it would likely make it difficult for the individual to fully comply in a meaningful way. It is also possible that the prescription of exercise for depression and/or anxiety could be different, both in nature and content, than that required for general health benefits.
One trial that is particularly worthy of attention is the Depression Outcomes Study of Exercise (DOSE; Dunn et al., 2005), which attempted to provide evidence about the dose of exercise required to treat depression. In the DOSE study 80 participants were randomised to 1 of 4 exercise groups that varied in total energy expenditure (7 or 17.5 kcal·kg-1·wk-1) and frequency (3 or 5 days/wk) or to a flexibility-exercise placebo control for 12 wk. Exercise at a dose of 17.5 kcal·kg-1·wk-1 was effective in reducing depression regardless of frequency, whereas exercise at a dose of 7 kcal·kg-1·wk-1 yielded antidepressant effects that were comparable to those of the placebo treatment. The plausible biological reason for why a higher dose of exercise may be more effective than lower doses is that frequent and regular exercise should increase fitness levels such that physical discomfort decreases and exercise becomes a more pleasant and enjoyable experience as the conditioning process progresses. Indeed, findings from both the DOSE and TREAD trials in the United States have indicated that higher doses of exercise are more effective than are lower doses (as defined in the study).
Perraton and colleagues (2010) published a systematic review that attempted to summarise what is currently known about the prescription of exercise for depression. The review is useful because previous reviews of exercise and depression did not synthesise this information in a way that would help guide intervention development. This review included only trials that had reported exercise to be effective in reducing depression in order to analyse the specific dosage parameters and modes of exercise used in these successful trials.
The review found that the most common intensity, frequency and duration of aerobic exercise were 60% to 80% of maximum heart rate, 30 min/session and 3 days/wk over 8 wk. The volume of evidence supporting the use of aerobic exercise programmes to treat depression was greater than that supporting the use of anaerobic exercise programmes. No clear trend showed one mode of aerobic exercise to be the most effective, and a range of activity types appeared to be effective. This is encouraging given that one size does not fit all, and individuals can be encouraged to participate in whatever type of aerobic activity they prefer.
In terms of context of exercise, a number of common trends emerged. A variety of locations were effective in treating depression, although all trials that reported location took place indoors. Both group and individual interventions were effective. However, group exercise may have added benefit by providing social support, which can be pivotal for sustaining compliance and can contribute in its own right to lowering depression. Moreover, exercise might lower depression by several plausible mechanisms, one of which could be interrelations or connections with others (Bailey & McLaren, 2005). Many types of exercise can be performed with other people (depressed or not). Therefore, this exercise could provide social integration and an opportunity to interact with the social world as well as a setting in which to expand social networks and make friends (Stathi, Fox & McKenna, 2002).
Another unresolved question concerns the intensity of exercise at which a reduction in depression might occur. Callaghan and colleagues (2011) compared the effects of preferred intensity with those of prescribed intensity of group-based exercise for 12 sessions over 4 wk in 38 women aged 45 to 65 yr who were receiving treatment for depression from either primary or secondary care services. The preferred-intensity group reported significantly lower depression and higher self-esteem and quality-of-life scores than did the prescribed-exercise group and attended more sessions (66% versus 50%). Similar findings have been found in nondepressed populations (Daley & Maynard, 2003). Several theories, such as self-determination theory (Deci & Ryan, 1985), support the notion that giving people a choice and control over what they do, whether it be exercise or other activities, leads to better adherence and enjoyment of the activity, which in turn leads to enhanced psychological well-being. People experiencing depression are no exception.
Wipfli, Rethorst and Landers (2008) considered the relationship between dose of exercise and anxiety levels as part of their broader meta-analysis of the anxiolytic effect of exercise. The trend in the data from 12 RCTs showed that the effect size increased as exercise approached a dose of 12.5 kcal·kg-1·wk-1 (equates to slightly less than the dose recommended for public health) and then began to decrease as exercise dose increased. A combination of aerobic and anaerobic exercise appeared to be better than either type alone, and a frequency of 3 or 4 times/wk appeared more effective than more or less than this amount.
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Available methods for measuring physical activity
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry.
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry. Most are moderately correlated at best. Each method has its own strengths and limitations. Due to the complexity of physical activity, outlined previously, researchers and practitioners need to consider what is most important for their purposes when deciding to use a particular technique. Although no one measurement tool can be singled out as the most appropriate, recommendations for the most useful and practical measurement tools can be made after considering factors such as context, type, duration, frequency and intensity of physical activity as well as the constraints under which the research or treatment programme is operating. These techniques are presented in order of increasing feasibility but decreasing validity. Table 3.2 at the end of this section summarises the key advantages and limitations of each measurement technique.
Doubly Labelled Water
Doubly labelled water (DLW, or free-living indirect calorimetry) is a method commonly used to increase the precision and accuracy of physical activity measurement. DLW, which measures EE over several (4-21) consecutive days in a free-living person under normal life conditions (Schoeller, 1988), is the most widely accepted gold standard method by which to measure EE (Aadahl & Jørgensen, 2003). DLW measures EE of free-living, unrestricted subjects using water labelled with stable isotopes of oxygen and hydrogen (Schoeller & van Santen, 1982). It calculates activity-related EE by combining measurement of total EE with basal metabolic rate. The utility of the DLW method in measuring total EE is demonstrated by its use in a variety of settings, including all age groups, premature infants, hospitalised patients, pregnant women and the elderly (Ainslie, Reilly & Westerterp, 2003). As such, researchers who use this method to assess the relationship between physical activity and other psychological variables or to detect changes in physical activity as a result of interventions can be confident that the results produced regarding EE are accurate. Schoeller (1988) fully describes the validation of the DLW method.
Despite its level of precision, the DLW method is not without disadvantages, which include high cost, limitations for assessing brief periods of EE (Ainslie, Reilly & Westerterp, 2003) and additional demands on participants in terms of time and tasks required. The cost and availability of isotopes and the requirement for analysis by isotope ratio mass spectrometer prohibit DLW from being widely used in studies of large populations. The use of this method among populations with more severe mental health problems may likely present a set of ethical issues. Furthermore, although this technique provides an accurate measure of total EE, it cannot provide information about patterns of physical activity in terms of type, frequency, duration, intensity or context. Consequently, such an approach would not be feasible in a large natural-field experiment or in a test of the effect of interventions on changes in physical activity in both healthy populations and populations that suffer from mental health problems. However, this gold standard measure is believed to offer the most precise estimate of EE and is often used to validate many other types of tools that assess physical activity.
Direct Observation
Direct observation, one of the most basic approaches for acquiring information about behaviours, provides information about how people exercise and play, how environments shape the activities individuals participate in and how people use specific facilities (e.g., parks, leisure facilities, walking or cycling paths). It can take place using basic observation methods, systematic forms or sophisticated technology (e.g., lasers). Direct observation often involves a trained observer who codes physical activity behaviours (e.g., sitting, walking, running) undertaken by participants over time in various settings (e.g., playground, park, home). A number of observation systems are available, such as SOPLAY (System for Observing Play and Leisure Activity in Youth), SOFIT (System for Observing Fitness Instruction Time), and the Systematic Pedestrian and Cycling Environmental Scan. The trained observer may either observe participants in person or review video media. Because it is time consuming, direct observation might be used only with small groups in specific settings (Dugdill & Stratton, 2007).
Advantages of direct observation include that self-report bias is eliminated, participants do not need to recall behaviour and the level of detail regarding behaviour patterns and context can be extremely accurate. Furthermore, practitioners may find some of these tools accessible. For example, clinical psychologists working with institutionalised individuals diagnosed with severe mental health conditions may find this type of measurement technique useful for assessing relationships between physical activity patterns or patterns of inactivity and specific mental illnesses because it can combine both context and behaviour to provide powerful data.
However, disadvantages include the time involved in recording and coding behaviour, the time involved in consolidating the plethora of data collected and the costs associated with training coders. Furthermore, the subjective bias of coders may lead to incorrect judgments about the intensities of specific activities, which would affect estimates of EE. As such, it would be important to consider whether information regarding patterns of behaviour combined with context or specific EE data are required to fulfill the aims of a research project or treatment programme.
Accelerometers
Motion sensors, such as pedometers and accelerometers, can be used to detect body movement and estimate physical activity (Spruijt-Metz et al., 2009). Accelerometers are devices that measure bodily movements in terms of acceleration. This measurement can then be used to estimate the intensity of physical activity, and therefore EE, over time (Burton et al., 2005; Chen & Basset, 2005). Accelerometers can measure human activity on vertical (uniaxial accelerometers), anterior - posterior and medial - lateral (triaxial accelerometers) planes. EE can then be then estimated from vector magnitude counts using a proprietary algorithm, which is a composite of counts from these planes of motion (Howe, Staudenmayer & Freedson, 2009). Accelerometers can be used repeatedly on numerous participants, are more accurate than pedometers and are less expensive (approximately £200 per device; ActiLife, 2009) than other objective methods such as DLW (approximately £200 per participant per procedure; Friedman & Johnson, 2002). However, they remain too expensive to use in studies that assess large numbers of people (Wood, 2000). Nevertheless, these devices are a more feasible and participant-friendly method of attempting to validate a self-report questionnaire than is DLW. They also provide the data necessary to allow researchers to distinguish between light, moderate and vigorous physical activity as well as between continuous and intermittent activity modes (Crouter, Clowers & Bassett, 2006). A recent review of accelerometers against DLW found ActiGraph (previously named CSA/MTI) models to be of the most valid types tested; they produce an average correlation of r = .57 (Plasqui & Westerterp, 2007). Limitations of accelerometers include the increased time required to analyse the large amount of data provided, participant burden of wearing the device, that they cannot be feasibly used to test large-scale interventions, and that they cannot provide information about the specific type of activity (e.g., playing football, going to the gym) or the context in which it is performed.
Some studies have attempted to validate accelerometers among populations diagnosed with mental health conditions. For example, Sharpe and colleagues (2006) conducted a study to assess the validity of the RT3 accelerometer against DLW in people with schizophrenia. They found that the accelerometer overpredicted energy expended on physical activity by an average of 148 kcal/day (standard deviation = 413 kcal/day); this varied from an underestimation of 614 kcal/day to an overestimation of 582 kcal/day. The authors suggested that the RT3 accelerometer is a poor tool for measuring activity EE in sedentary men with schizophrenia. As such, the results of studies that have used this measurement tool in mentally ill populations may be questionable. For example, the recent intervention study of Jerome and colleagues (2009) used the RT3 accelerometer to measure physical activity in persons with mental illness. The authors of this study concluded that participants were undertaking approximately 120 min/wk of moderate-intensity physical activity on average, which would equal approximately 70 kcal/day. Given that the results of the study by Sharpe and colleagues (2006) indicated that the RT3 accelerometer overpredicted EE, it is possible that the results found by Jerome and colleagues (2009) overestimate the amount of physical activity undertaken by participants. Consequently, this might affect the validity of the relationships found between physical activity and various mental health variables measured in this study. Sharpe and colleagues (2006) did, however, indicate that the RT3 appeared to be a valid measure of physical inactivity in men with schizophrenia. Therefore, it could be used for research or clinical purposes to quantify the contribution of sedentary behaviour to medical conditions associated with inactivity. Sharpe and colleagues (2006) also recommended that using the RT3 to validate questionnaires may not be appropriate until it is more robust.
Indirect Objective Measures
Indicators of the physiologic response to physical activity include heart rate and pulmonary gas exchange. Heart-rate monitoring is a promising measurement method because heart rate is a physiological parameter that correlates well with, and strongly predicts, EE (Strath et al., 2002). Most heart rate monitors include software that converts heart rate data into an estimate of EE. However, one of the limitations of heart rate monitoring is that training state and individual heart rate characteristics can affect the relationship between heart rate and oxygen consumption. Higher levels of accuracy can be obtained through a graded submaximal exercise test that calibrates participant heart rate to simultaneous oxygen consumption. This information allows for the construction of a calibration curve that estimates EE at moderate and strenuous levels of exercise. (A linear relationship exists between increasing heart rate and oxygen consumption; Freedson & Miller, 2000.) Measuring heart rate is a common method used to describe intensity and duration of physical activity and is a relatively inexpensive method of measuring EE. However, heart rate is affected by factors other than physical activity, such as emotional stress, temperature, humidity, dehydration, posture and illness (Ainslie, Reilly & Westerterp, 2003). These factors can influence heart rate without causing associated changes in oxygen consumption. Given the potentially increased fluctuations in emotions in individuals diagnosed with mental health conditions, this method may not be the most appropriate for obtaining accurate physical activity levels. Furthermore, the relationship between oxygen uptake and heart rate is weak at low levels of activity (Keim, Blanton & Kretsch, 2004). Evidence suggests that individuals suffering from mental health problems tend to perform less intensive physical activity than do members of the general population (e.g., Brown et al., 1999). Therefore, the heart rate method may not provide accurate information about the physical activity of mental health populations. Also, the heart rate method is unable to identify types of activity or the context in which physical activity is performed. Although heart rate is a physiological marker for physical activity and may provide a general picture of physical activity patterns, it may not be the best method available for obtaining an accurate estimate of EE.
Pedometers
Pedometers, which measure steps on a single axis as well as calories expended, are less expensive than some other types of motion sensors. As such, these devices are an attractive alternative to self-report in large observational or intervention studies. Public health campaigns have also promoted pedometers as a motivational tool for achieving the goal of 10,000 steps daily. A range of pedometers is available. The pedometer that is most suitable for a particular study may depend on factors such as the research question (outcome of interest), population, available funds, context and validity of the model. For example, when considering context, researchers or practitioners who wish to understand the types of physical activity being undertaken in a variety of settings would not gain this information using pedometers alone. When considering population, some pedometers are validated in healthy adults but not in other populations such as children, the elderly or those diagnosed with mental illness. Pedometers have demonstrated reduced accuracy in elderly populations because of the slow pace or shuffling nature with which elderly people walk (Cyarto, Myers & Tudor-Locke, 2004). Tudor-Locke and colleagues (2002) evaluated the validity of pedometers in a review of 25 studies and found a strong correlation between pedometer counts and accelerometer output (median of reported correlations is r = .86). However, evidence suggests that the validity of pedometers for measuring EE and distance in normal populations is questionable. The findings of a study testing the validity of 10 pedometers (Crouter et al., 2003) indicated that these devices overestimated distance at slower speeds and underestimated distance at faster speeds. Furthermore, in 8 of the pedometers tested, it was unclear whether the device was measuring gross EE (all the energy expended by an individual during a specific activity) or net EE (the energy expended by an individual during a specific activity minus the resting EE for the equivalent amount of time). The Yamax Digiwalker SW-200 was found to be the most reliable and accurate pedometer available (Crouter et al., 2003). This pedometer was used in a recent study by McKercher (2009) that assessed relationships between physical activity and depression in young adults. This study found that low levels of depression were significantly correlated with moderate levels of physical activity, as measured by the Yamax Digiwalker SW-200, among females. However, this device has not been validated in specific mental health populations, which may limit the validity of these results. It is important to validate physical activity devices among specific populations because patterns of physical activity in these populations may differ from those in the general population. For example, individuals with serious mental illness are significantly less active than the general population (Brown et al., 2004). As such, using a physical activity measure that has been validated with mental health populations in research on physical activity and mental health will increase the strength of the results produced.
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Coping with long-term physical health conditions
Approximately 30% of the European population has a long-term physical health condition. People with a long-term condition that is comorbid with a mental health problem have worse health outcomes than do people with either of these alone.
Key Concepts
- Approximately 30% of people with a long-term condition have a comorbid mental health condition.
- Physical activity is an important part of the management of physical and psychological well-being in people with long-term conditions.
- Pulmonary rehabilitation leads to reduced depression and anxiety and increased quality of life in people with chronic obstructive pulmonary disease. Further research is required to understand the optimal exercise dose; the interaction of exercise training, education and psychosocial support during pulmonary rehabilitation; and how to sustain changes in physical activity behaviour after pulmonary rehabilitation.
- Physical inactivity is associated with greater depression in people with type 2 diabetes. Further research is required to understand the causality of this relationship, although available data suggest that physical activity interventions reduce depression.
- Data that explore the relationship between physical activity and mental health in people with type 1 diabetes are limited.
- Physical activity has been shown to increase quality of life and reduce anxiety and depression in cancer survivors. Data suggest that supervised and group exercise are more beneficial than unsupervised and home-based exercise in this population.
Long-term conditions (LTCs) have been defined as "those conditions that cannot, at present, be cured, but can be controlled by medication and other therapies. The life of a person with an LTC is forever altered - there is no return to normal" (Department of Health, 2008, p. 10). LTCs include diabetes, arthritis, chronic obstructive pulmonary disease (COPD) and a number of cardiovascular diseases. In addition, conditions such as human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) and certain cancers that were not traditionally considered LTCs are increasingly being regarded as such (Naylor et al., 2012). Many mental health problems can themselves be considered LTCs. However, in this chapter the term long-term condition refers specifically to physical health conditions.
The World Health Organisation's (2011) report on the global burden of noncommunicable diseases (i.e., all previously mentioned LTCs except HIV and AIDS) found that noncommunicable diseases are by far the leading cause of mortality in the world and represent 63% of all deaths. The majority of these deaths are due to cardiovascular disease, diabetes, cancer and chronic respiratory disease. The highest occurrence of deaths from these diseases is in low- and middle-income countries, and the prevalence in these countries is predicted to increase substantially in the future. In Europe 29% of people aged 15 yr or older report a longstanding health problem (TNS Opinion, 2007), and the Office for National Statistics (2005) found that in England approximately 30% of the population (15.4 million people) has a LTC. As populations age, the burden of LTCs is projected to increase even further.
Long-Term Conditions and Mental Health Issues
People with LTCs are two to three times more likely than the general population to experience mental health problems. Depression and anxiety are the most frequently reported mental health problems in people with LTCs, but dementia, cognitive decline and some other conditions have also been reported (Naylor et al., 2012). Depression is two to three times more common in people with an LTC than in those with good physical health and occurs in approximately 20% of people with an LTC (National Collaborating Centre for Mental Health, 2010). Conservative estimates suggest that at least 30% of all people with an LTC also have a comorbid mental health problem of some kind (Cimpean & Drake, 2011). Research has shown that having a mental health problem along with an LTC has a stronger negative impact on quality of life and functional status than does either the number of LTCs or the severity of those conditions. For example, quality of life is lower in people with one LTC and depression than in people with two or more LTCs and no depression (Moussavi et al., 2007). Figure 8.1 shows the overlap between LTCs and mental health disorders.
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In addition to experiencing psychological distress, patients with an LTC and comorbid mental health problem experience poorer clinical outcomes compared with people with an LTC and no mental health problem (Moussavi et al., 2007). This is partly because self-management is necessary for effectively controlling LTCs, and poor mental health can result in poorer self-management. For example, it may lead to lack of motivation and energy to adhere to treatment plans or attend medical appointments (DiMatteo, Lepper & Croghan, 2000). From a financial perspective, comorbid mental health problems are typically associated with a 45% to 75% increase in care costs for a person with an LTC. These data are based on a wide range of LTCs and are observed after adjustment for severity of physical disease (Unützer et al., 2009; Welch et al., 2009).
Overlap between long-term conditions and mental health problems in England. Adapted, by permission, from C. Naylor et al., 2012, Long-term conditions and mental health: The cost of co-morbidities (London: The King's Fund and Centre for Mental Health).
Long-Term Conditions and Quality of Life
Quality of life is an individual's perception of their ability to function well on physical, mental and social levels. Quality of life can be measured in a reliable and valid manner using self-reported questionnaires, which can be categorised into three main groups: generic, disease specific and domain specific. Generic questionnaires measure quality of life in general terms, independent of the presence of any disease. Disease-specific questionnaires measure the consequences of a specific disease on quality of life. Domain-specific questionnaires focus on certain domains of quality of life (e.g., physical inabilities).
Where it is possible to manage but not cure a disease, such as in LTCs, measures of quality of life are frequently used to help determine the impact of treatment and disease. They help health professionals make informed judgements about whether treatment is appropriate and, where a choice of treatments exists, which might be the best option. Researchers frequently use these measures to assess the impact of a new intervention.
Long-Term Conditions and Physical Activity
Doctors have traditionally advised people with a range of LTCs to rest and not tire themselves out, and this advice persists in the lay psyche. For example, a recent Swedish survey found that the physical activity levels of people with diabetes, rheumatoid arthritis or COPD are lower than those of healthy controls; 73% of people with diabetes, 74% with rheumatoid arthritis and 84% with COPD reported low physical activity levels compared with 60% of controls (Arne et al., 2009). However, modern treatment of LTCs often includes promoting physical activity as part of a healthy lifestyle, and accumulating evidence shows the importance of physical activity in the management of both physical and psychological well-being for people with one or more LTCs. Regular contact between health professionals and people with LTCs provides opportunities for promoting physical activity in this group.
Each LTC presents its own challenges and benefits with regard to physical activity. The remainder of this chapter focusses in particular on the impact of physical activity on mental health and well-being in people with COPD, diabetes and cancer.
Chronic Obstructive Pulmonary Disease
COPD is characterised by airflow obstruction that is not fully reversible and usually progressive in the long term. It is predominantly caused by smoking. Symptoms include breathlessness (dyspnoea) on exertion, chronic cough, regular production of sputum and frequent winter bronchitis or wheeze. Exacerbation of symptoms often occurs in which the patient's symptoms rapidly worsen beyond normal day-to-day variations. Diagnosis relies on a combination of history, physical examination and confirmation of airflow obstruction using spirometry; no single test for COPD exists (National Institute for Health and Clinical Excellence, 2010). Severity of COPD is often classified using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria (I [mild], II [moderate], III [severe] and IV [very severe]) and index of body mass, airway obstruction, dyspnoea and exercise capacity (BODE).
The World Health Organisation has predicted that by 2020 COPD will be the third leading cause of death and fifth leading cause of disability in the world (Murray & Lopez, 1996, 1997). Mortality rates for men in the United Kingdom are at a plateau and mortality rates for women are steadily increasing (Soriano et al., 2000) most likely as a result of the uptake of smoking among women post-World War II. According to the chief medical officer in England, COPD accounts for more than £800 million in direct health care costs (Department of Health, 2005); more than one half of these costs relate to the provision of hospital care. COPD is among the most costly inpatient conditions that the National Health Service treats.
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Designing a physical activity program for individuals with addictions
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours.
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours. However, implementation of behavior change in this population can present practitioners with specific challenges. This section discusses the suggestions for designing effective interventions for those with addictions based on the evidence reviewed so far as well as practical considerations.
Exercise Type, Frequency and Intensity
Most studies have promoted moderate-intensity cardiovascular-type exercise such as brisk walking for use in those with addictive behaviours. Some work also incorporates more vigorous activities such as running. Because individuals with addictions are often extremely sedentary, a programme of moderate-intensity activity is likely to be acceptable and safe. However, a progression to more vigorous exercise may be beneficial. For example, the only study that found a long-term benefit of exercise for smoking cessation entailed 30 to 40 min of vigorous exercise 3 times/wk for 12 wk (Marcus et al., 1999). Similarly, the single study that showed a long-term impact of exercise on alcohol abstinence involved 1 h of progressively vigorous exercise 5 days/wk for 6 wk (Sinyor et al., 1982). None of the trials reviewed compared the effects of vigorous-intensity and moderate-intensity exercise on abstinence rates. Experimental studies have compared the effects of bouts of moderate-intensity and vigorous-intensity exercise and have shown that both intensities are effective in the short term for reducing tobacco-withdrawal symptoms (Taylor et al., 2007).
The intensity of activity that an individual is capable of depends on initial level of fitness, medical condition and stage of recovery from addiction. Careful medical screening is vital. For example, those addicted to amphetamine or cocaine are often undernourished, and problem drinkers often have weak muscles. Such individuals may require nutrition advice. Ultimately, individuals will have preferences regarding types of exercise, and programmes should be tailored to these preferences (Abrantes et al., 2011; Everson-Hock et al., 2010). Some individuals may prefer noncardiovascular types of exercise, which may also be beneficial. Resistance (i.e., weight) training, yoga and isometric exercise have all been successfully piloted as aids for smoking cessation and need to be tested in larger trials (Ussher, Taylor & Faulkner, 2012).
Regarding frequency and volume of exercise, the findings from Marcus and colleagues (2005) suggest that abstaining smokers need to accumulate at least 110 min/wk of moderate-intensity activity to maintain abstinence; supervised exercise on 2 or 3 days/wk may be necessary in order to achieve this. Shorter bouts of exercise can be used on an as-needed basis in response to cravings, and longer scheduled bouts can be used to maintain positive mood, manage stress and prevent cravings from arising. Research has not yet addressed the optimum dose of exercise for assisting alcohol and drug rehabilitation.
Exercise Supervision
The majority of intervention studies have employed group-based supervised exercise. In smokers, exercise counselling alone did not increase exercise levels sufficiently (Ussher et al., 2003), and all the interventions that showed a significant impact on long-term abstinence from alcohol or smoking entailed supervised exercise. Among novice exercisers, an element of supervised exercise may be useful to ensure initial adoption of regular exercise and to provide information about safe exercise (e.g., warm-up) and exercise intensities (e.g., using heart rate monitors). Counselling toward pursuing home-based exercise is also likely to be important for encouraging patients to maintain exercise levels after the initial exercise programme ends.
Stages of Addiction Treatment
Early recovery from drug and alcohol dependence is a major transition that affects close relationships and employment and involves numerous treatment sessions. An exercise programme needs to complement these changes. Most exercise interventions discussed in this chapter have required patients to alter their substance- or alcohol-misuse behaviour and exercise behaviour simultaneously, yet it is not clear whether this is optimal. For some individuals the challenge of changing two health behaviours simultaneously may be too demanding. Also, it is not clear whether involvement in physical activity increases the motivation to manage substance intake or vice versa.
Among smokers, exercise has often been introduced in the studies discussed several weeks before an attempt to quit, thereby allowing people to adjust to the demands of increased exercise before starting to quit. This also allows exercise to play a role in managing cravings during the crucial early days of abstinence, when relapse rates are highest. Empirical work is required to determine the relative benefits of initiating exercise at different points in the addiction-treatment process. During later stages of treatment exercise may be useful for preventing relapse (e.g., by promoting an exercise identity that is incompatible with drug use). Studies are also needed to determine whether exercise can be used to increase substance abstinence among those who are not motivated to attempt abstinence.
Integrating Exercise With Standard Addiction Treatments
Greater integration of addiction and exercise programmes may enhance abstinence rates. For instance, rather than just proposing exercise as a means for getting fitter and managing weight, the practitioner could present exercise more as a self-control strategy for managing withdrawal symptoms and a way to address psychological and physical harms caused by addiction. Exercise could be used more in combination with pharmaceutical interventions. Whereas pharmaceutical interventions focus on reducing withdrawal symptoms (e.g., NRT), exercise could ideally be used to provide an added effect in client-led management of addictive symptoms.
Perceived Barriers to Exercise
Individuals with addictions are likely to have specific barriers to exercise, and these need to be determined. In the general population, use of cognitive - behavioural techniques is effective for overcoming perceived barriers and increasing exercise adherence. Few addiction studies have included cognitive - behavioural counseling. Techniques such as self-monitoring (e.g., diaries), goal-setting and relapse-prevention planning are commonly used. Also, pedometers are now commonly used as a motivational tool. These and other motivational aids (e.g., financial incentives) need to be tested with exercise interventions in addicted populations.
Interventions for Different Subgroups
Exercise interventions need to be tested among addicted populations who might especially benefit from such interventions. Given the high prevalence of addictions among people with mental illness and the established benefits of regular physical activity for mental health, research that examines the role that physical activity may play in this population is needed (Arbour-Nicitopoulos et al., 2011).
Exercise interventions might be particularly appealing to adolescents, and controlled trials with young people are needed. Addicted individuals who are overweight may have a need for weight-control interventions such as exercise; no trial has yet focussed on this population. Additionally, surveys suggest that a nonpharmaceutical intervention such as exercise is likely to appeal to pregnant smokers (Ussher at al., 2008). Finally, sex needs to be considered when planning an appropriate intervention. Some evidence shows that women often prefer walking and aerobics, whereas men have more interest in sport, running and strength training.
Evidence to Practice
- Both moderate- and vigorous-intensity exercise have been shown to be effective for reducing tobacco-withdrawal symptoms and cravings.
- Progressing from light- and moderate-intensity exercise (e.g., brisk walking) to more vigorous-intensity exercise is advisable.
- Careful medical screening is required, especially among those with long-term alcohol or drug dependence (e.g., for malnutrition).
- Exercise interventions should be tailored to individual preferences.
- Abstaining smokers should accumulate at least 110 min/wk of moderate-intensity exercise.
- Interventions involving supervised exercise on 2 or 3 days/wk are likely to be necessary to be effective in treating addictive behaviours.
- Exercise can be performed on an as-needed basis for managing cravings or in scheduled bouts.
- If the exercise programme is to assist with early withdrawal symptoms, it ideally needs to begin before abstinence is attempted.
- Participating in physical activity encourages individuals to adopt an identity as an exerciser, which is incompatible with using addictive substances.
- Perceived barriers to exercise need to be identified and addressed using cognitive - behavioural techniques.
- The intervention needs to be adapted to various subgroups (e.g., according to sex, body weight and mental health).
Summary
Drug, alcohol and tobacco addictions are growing global problems. Exercise has many benefits for physical and psychological health, and evidence convincingly shows that exercise is effective for managing cravings and withdrawal symptoms, particularly in smokers. Regular exercise fosters a healthy lifestyle and exercise identity that is largely incompatible with addiction, and individuals undergoing rehabilitation for addiction express interest in exercising more. Exercise interventions are inexpensive, can be easily integrated with existing addiction treatments and have minimal side effects compared with pharmacological treatments. This chapter demonstrates that exercise is a highly plausible adjunctive treatment for addictive behaviour and that exercise programmes can be readily disseminated. However, limited evidence currently supports the benefits of exercise for helping smokers quit or helping those with drug or alcohol dependence abstain. This lack of evidence can partly be explained by the small number of large RCTs that have been conducted, lack of knowledge about effective doses of exercise and limited attention to methods for maximizing exercise adherence. This area of research is in its infancy, and further well-designed trials are needed.
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Physical activity guidelines
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits.
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits. National guidelines aimed at the whole population (as opposed to specific populations defined by a medical condition) focus on the optimal amount of activity to prevent disease and promote health and well-being. PAGs indicate the type (e.g., aerobic activity, strength training, weight bearing), frequency (e.g., 3 days/wk), duration (e.g., 30 min) and intensity (e.g., moderate, vigorous) (see figure 2.2) of physical activity to undertake and for what benefits. These detailed specifications reflect the latest science on the topic.
PAGs need to be updated periodically because evidence about the relationship between physical activity and health changes over time and knowledge grows. Some guidelines are more general in nature, whereas others provide very specific details; this usually reflects the state of knowledge at that time. Through a review and revision process, more specific details are added to PAGs when available. For example, in various national PAGs, guidelines relating to maintaining musculoskeletal strength have been revised over time and now include details on how much strength training is required for good health (World Health Organisation, 2010) and, specifically, for preventing falls and treating depression (Singh, Clements & Singh, 2001).
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The dose - response relationship: Increasing benefits from increasing amounts (expressed in frequency, duration and intensity) of activity. Reprinted, by permission, from I. Vuori, 1995, Terveysliikunta [Health and physical education]. UKK Institute for Health Promotion Research (Tampere, Finland).
National guidelines are an important component of a population-based approach to addressing any public health issue. First, such guidelines communicate a consensus on the scientific evidence of the importance of the issue. They describe the strength of the science in terms of the volume as well as the quality (determined based on the quality of study designs and research methods used) of the evidence. Communicating scientific consensus is important because it removes doubt and speculation about the validity of the health issue and its importance. This scientific consensus can also be used to advocate for resources and programmes. However, just because guidelines exist does not mean that everyone agrees about what the science says - far from it. However, these disagreements, or alternative interpretations of overall findings to date, are usually communicated in technical reports that accompany the publication of PAGs and are not fully accessible to the general public.
The process of developing PAGs usually involves leadership by a high-level institution. This adds credence to the message that the issue is important. For example, several national and international health agencies, such as the American Heart Association (Haskell et al., 2007), have developed guidelines on physical activity. National governments, usually the ministry of health, often lead the development process and endorse national PAGs. This endorsement is very useful because it specifies the government's position on physical activity and thereby provides the opportunity for interested parties such as charities and public health directors to leverage the government into supporting further action and funding for programmes and services aimed at increasing physical activity. This might include government endorsement of counselling and clinical services for inactive patients, as has been trialled in the United Kingdom (Bull & Milton, 2011). Government involvement and endorsement can also prevent policy inaction. The absence of an official position on physical activity can block funding and further development of a national population-based approach.
One important role of PAGs is to direct community-level actions aimed at increasing physical activity in the whole population. The details in PAGs about the type, frequency, duration and intensity of activities required for different age groups can provide clinicians, health care practitioners and others with direction on what types of programmes to provide and promote to patients and the wider community.
PAGs should drive and direct action not just at the level of individuals and service providers but also at all levels - national, regional and local - of government. If the national government endorses PAGs, ideally with multiparty political support, the government should be held accountable when levels of physical activity are not improving and can be expected to include physical activity promotion as part of ongoing disease-prevention and health-promotion strategies. The role of PAGs and national surveillance of risk factors is discussed in more detail later in this chapter.
Development of the First National Physical Activity Guidelines
Epidemiological studies of exercise and health were well advanced by the 1970s. The American College of Sports Medicine released the first set of recommendations in 1975 and released another set in 1980 (American College of Sports Medicine, 1975, 1980). These recommendations were predominantly directed at cardiorespiratory fitness and suggested that people undertake vigorous-intensity aerobic exercise 3 times/wk for 20 min each time. This was a practical interpretation of the exact recommendation from 1975, which suggested that people undertake 20 to 45 min of physical activity 3 to 5 days/wk at 70% to 90% of heart rate (i.e., vigorous intensity) (American College of Sports Medicine, 1975). The focus on aerobic exercise for increasing fitness continued to dominate and influence health messages about physical activity until the early 1990s. However, guidelines began to recommend moderate-intensity physical activity rather than vigorous-intensity activity, and by the mid-1990s the focus shifted from cardiorespiratory fitness to health benefits. This new position on physical activity was communicated in a landmark set of recommendations from the office of the U.S. surgeon general in the report "Physical Activity and Health" (U.S. Centers for Disease Control and Prevention, 1996).
In the mid-1990s, epidemiological evidence started to show that people with different health conditions require slightly different amounts of physical activity. Although the recommendation for 30 min of moderate-intensity activity on most days remained valid for preventing heart disease and diabetes, studies showed that slightly more physical activity was recommended for preventing cancer. Further, studies identified that the amount of activity required for weight loss or preventing weight gain was greater than that required to prevent chronic disease (Haskell et al., 2007). For example, the International Association for the Study of Obesity recommendations made a clear distinction between the minimum physical activity required for health benefits and the amount required for preventing weight gain. The recommendations state that "45 to 60 min (60-90 min for formerly obese individuals) of moderate-intensity physical activity daily is needed to prevent the transition to overweight or obesity" (Saris et al., 2003). Furthermore, research has now shown that the amount of physical activity required by young people differs from that of adults. The overall amount of physical activity recommended for children is twice that recommended for adults and is usually expressed as "at least 60 min/day" (Canadian Society for Exercise Physiology, 2011a; Saris et al., 2003).
These different recommendations make the development of PAGs complex. However, a core and consistent interpretation of the evidence is that 30 min of moderate-intensity physical activity on most days of the week is associated with maximum overall population benefit and the prevention of major noncommunicable diseases. This same dose has been expressed as "at least 150 min/wk of moderate-intensity activity" in the most recent global, U.S. and U.K recommendations (Department of Health, 2011b; U.S. Department of Health and Human Services, 2008a; World Health Organisation, 2010).
Current Best Practice in Developing Guidelines
Figure 2.3 illustrates the process of developing guidelines. The first step is establishing the need for guidelines. This need is often defined by policymakers, public health scientists, advocates and, sometimes, the community. Then a process for guideline development needs to be agreed on by interested parties, with actions planned in sequence and, ideally, a linkage between the PAG development process and other aspects of national or regional physical activity policy and strategy development (step 1 in figure 2.3). The next stage comprises reviewing the scientific evidence and creating an updated summary of what the research says and how this information differs from that in previous guidelines. A number of countries, notably Canada and, most recently, the United Kingdom and United States, have undertaken this process. Tremblay and colleagues (2010) extensively discuss this process with reference to the recent Canadian guidelines along with frameworks and a checklist for auditing data quality in the review stage.
Once the science has been reviewed, the next stage is developing communication messages based on the evidence and testing these messages with the target audience for acceptability, comprehension and usefulness. This step is part of developing a communications strategy for disseminating the evidence (stages 3 and 4 in figure 2.3). It requires resources for conducting the qualitative and quantitative research and the involvement of communications and media specialists in framing the messages correctly so that they will have optimal impact on the target populations. The final stages (stages 5-7 in figure 2.3) involve disseminating the message to the community, professional groups and other stakeholders. Historically, those developing PAGs have put considerable effort into the technical and scientific stages and have often neglected message development and communication. Frequently, only informal and unpaid communication channels are used after the launch of PAGs. Thus, a very important step in PAG development and dissemination is the final public health promotion component.
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Framework for developing physical activity guidelines. Adapted from Bauman et al. 2006.
Global, Regional and National Physical Activity Guidelines
Table 2.1 summarises the 2011 global PAGs and provides examples of regional (i.e., European and Western Pacific islands) and national guidelines. Quite a few countries in Europe have their own national PAGs, and many of these countries (e.g., Finland, Switzerland, the Netherlands, United Kingdom) have been engaged with implementing national population-based approaches for some time (Department of Health, 2011b; Ministry of Health, Welfare and Sport, 2011; Swiss Federal Office of Sports, 2006; UKK Institute, 2009). Other countries in Europe have officially or unofficially adopted the guidelines published by the U.S. Centers for Disease Control and Prevention in 1996 and the more recently updated 2008 version.
PAGs in other regions of the world are patchy. Australia (Department of Health and Ageing, 2005b) and New Zealand (Sport and Recreation New Zealand, 2005) have had national guidelines for some time. In Australia, guidelines exist for all ages, from young children (Department of Health and Ageing, 2004) to older adults (Department of Health and Ageing, 2005b), although all guidelines are more than 5 yr old and arguably are due for updating to reflect the latest science. Far fewer examples of PAGs exist in South America, Asia, the Middle East and Africa because physical activity promotion is relatively new in these regions. Countries in which national action on physical activity is beginning have often used the U.S. guidelines as an international benchmark. This has allowed the countries to develop an agenda of physical activity promotion without being hindered by the absence of PAGs. However, in some countries, adopting the PAGs of another country is not politically or culturally welcome or appropriate. Either these countries have developed their own PAGs (a recent example from the Middle East is Brunei; Ministry of Health, 2011) or very little physical activity promotion has occurred.
The absence of a set of official global guidelines did not hinder the World Health Organisation (WHO) from developing the Global Strategy on Diet, Physical Activity and Health in 2004 (World Health Organisation, 2004). Since the publication of the 2002 health report (World Health Organisation, 2002), the focus on the need for greater action to prevent noncommunicable disease and address mental health has increased. To address these issues, WHO commenced developing global guidelines in 2007. WHO launched the final global recommendations on physical activity in 2010 after a 2 yr process involving global and regional consultations (World Health Organisation, 2010). These global guidelines are now available for adoption and use by countries with no national PAGs. Because the guidelines are from WHO, the leading international health agency, the scientific quality and relevance of these guidelines are usually accepted.
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Treating depression and anxiety with exercise
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety.
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety. Information about these prescription parameters is scarce, but it is critical if exercise interventions are to be translated into clinical practice. Asking someone to do something without specifying what they should do or how they should do it would likely make it difficult for the individual to fully comply in a meaningful way. It is also possible that the prescription of exercise for depression and/or anxiety could be different, both in nature and content, than that required for general health benefits.
One trial that is particularly worthy of attention is the Depression Outcomes Study of Exercise (DOSE; Dunn et al., 2005), which attempted to provide evidence about the dose of exercise required to treat depression. In the DOSE study 80 participants were randomised to 1 of 4 exercise groups that varied in total energy expenditure (7 or 17.5 kcal·kg-1·wk-1) and frequency (3 or 5 days/wk) or to a flexibility-exercise placebo control for 12 wk. Exercise at a dose of 17.5 kcal·kg-1·wk-1 was effective in reducing depression regardless of frequency, whereas exercise at a dose of 7 kcal·kg-1·wk-1 yielded antidepressant effects that were comparable to those of the placebo treatment. The plausible biological reason for why a higher dose of exercise may be more effective than lower doses is that frequent and regular exercise should increase fitness levels such that physical discomfort decreases and exercise becomes a more pleasant and enjoyable experience as the conditioning process progresses. Indeed, findings from both the DOSE and TREAD trials in the United States have indicated that higher doses of exercise are more effective than are lower doses (as defined in the study).
Perraton and colleagues (2010) published a systematic review that attempted to summarise what is currently known about the prescription of exercise for depression. The review is useful because previous reviews of exercise and depression did not synthesise this information in a way that would help guide intervention development. This review included only trials that had reported exercise to be effective in reducing depression in order to analyse the specific dosage parameters and modes of exercise used in these successful trials.
The review found that the most common intensity, frequency and duration of aerobic exercise were 60% to 80% of maximum heart rate, 30 min/session and 3 days/wk over 8 wk. The volume of evidence supporting the use of aerobic exercise programmes to treat depression was greater than that supporting the use of anaerobic exercise programmes. No clear trend showed one mode of aerobic exercise to be the most effective, and a range of activity types appeared to be effective. This is encouraging given that one size does not fit all, and individuals can be encouraged to participate in whatever type of aerobic activity they prefer.
In terms of context of exercise, a number of common trends emerged. A variety of locations were effective in treating depression, although all trials that reported location took place indoors. Both group and individual interventions were effective. However, group exercise may have added benefit by providing social support, which can be pivotal for sustaining compliance and can contribute in its own right to lowering depression. Moreover, exercise might lower depression by several plausible mechanisms, one of which could be interrelations or connections with others (Bailey & McLaren, 2005). Many types of exercise can be performed with other people (depressed or not). Therefore, this exercise could provide social integration and an opportunity to interact with the social world as well as a setting in which to expand social networks and make friends (Stathi, Fox & McKenna, 2002).
Another unresolved question concerns the intensity of exercise at which a reduction in depression might occur. Callaghan and colleagues (2011) compared the effects of preferred intensity with those of prescribed intensity of group-based exercise for 12 sessions over 4 wk in 38 women aged 45 to 65 yr who were receiving treatment for depression from either primary or secondary care services. The preferred-intensity group reported significantly lower depression and higher self-esteem and quality-of-life scores than did the prescribed-exercise group and attended more sessions (66% versus 50%). Similar findings have been found in nondepressed populations (Daley & Maynard, 2003). Several theories, such as self-determination theory (Deci & Ryan, 1985), support the notion that giving people a choice and control over what they do, whether it be exercise or other activities, leads to better adherence and enjoyment of the activity, which in turn leads to enhanced psychological well-being. People experiencing depression are no exception.
Wipfli, Rethorst and Landers (2008) considered the relationship between dose of exercise and anxiety levels as part of their broader meta-analysis of the anxiolytic effect of exercise. The trend in the data from 12 RCTs showed that the effect size increased as exercise approached a dose of 12.5 kcal·kg-1·wk-1 (equates to slightly less than the dose recommended for public health) and then began to decrease as exercise dose increased. A combination of aerobic and anaerobic exercise appeared to be better than either type alone, and a frequency of 3 or 4 times/wk appeared more effective than more or less than this amount.
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Available methods for measuring physical activity
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry.
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry. Most are moderately correlated at best. Each method has its own strengths and limitations. Due to the complexity of physical activity, outlined previously, researchers and practitioners need to consider what is most important for their purposes when deciding to use a particular technique. Although no one measurement tool can be singled out as the most appropriate, recommendations for the most useful and practical measurement tools can be made after considering factors such as context, type, duration, frequency and intensity of physical activity as well as the constraints under which the research or treatment programme is operating. These techniques are presented in order of increasing feasibility but decreasing validity. Table 3.2 at the end of this section summarises the key advantages and limitations of each measurement technique.
Doubly Labelled Water
Doubly labelled water (DLW, or free-living indirect calorimetry) is a method commonly used to increase the precision and accuracy of physical activity measurement. DLW, which measures EE over several (4-21) consecutive days in a free-living person under normal life conditions (Schoeller, 1988), is the most widely accepted gold standard method by which to measure EE (Aadahl & Jørgensen, 2003). DLW measures EE of free-living, unrestricted subjects using water labelled with stable isotopes of oxygen and hydrogen (Schoeller & van Santen, 1982). It calculates activity-related EE by combining measurement of total EE with basal metabolic rate. The utility of the DLW method in measuring total EE is demonstrated by its use in a variety of settings, including all age groups, premature infants, hospitalised patients, pregnant women and the elderly (Ainslie, Reilly & Westerterp, 2003). As such, researchers who use this method to assess the relationship between physical activity and other psychological variables or to detect changes in physical activity as a result of interventions can be confident that the results produced regarding EE are accurate. Schoeller (1988) fully describes the validation of the DLW method.
Despite its level of precision, the DLW method is not without disadvantages, which include high cost, limitations for assessing brief periods of EE (Ainslie, Reilly & Westerterp, 2003) and additional demands on participants in terms of time and tasks required. The cost and availability of isotopes and the requirement for analysis by isotope ratio mass spectrometer prohibit DLW from being widely used in studies of large populations. The use of this method among populations with more severe mental health problems may likely present a set of ethical issues. Furthermore, although this technique provides an accurate measure of total EE, it cannot provide information about patterns of physical activity in terms of type, frequency, duration, intensity or context. Consequently, such an approach would not be feasible in a large natural-field experiment or in a test of the effect of interventions on changes in physical activity in both healthy populations and populations that suffer from mental health problems. However, this gold standard measure is believed to offer the most precise estimate of EE and is often used to validate many other types of tools that assess physical activity.
Direct Observation
Direct observation, one of the most basic approaches for acquiring information about behaviours, provides information about how people exercise and play, how environments shape the activities individuals participate in and how people use specific facilities (e.g., parks, leisure facilities, walking or cycling paths). It can take place using basic observation methods, systematic forms or sophisticated technology (e.g., lasers). Direct observation often involves a trained observer who codes physical activity behaviours (e.g., sitting, walking, running) undertaken by participants over time in various settings (e.g., playground, park, home). A number of observation systems are available, such as SOPLAY (System for Observing Play and Leisure Activity in Youth), SOFIT (System for Observing Fitness Instruction Time), and the Systematic Pedestrian and Cycling Environmental Scan. The trained observer may either observe participants in person or review video media. Because it is time consuming, direct observation might be used only with small groups in specific settings (Dugdill & Stratton, 2007).
Advantages of direct observation include that self-report bias is eliminated, participants do not need to recall behaviour and the level of detail regarding behaviour patterns and context can be extremely accurate. Furthermore, practitioners may find some of these tools accessible. For example, clinical psychologists working with institutionalised individuals diagnosed with severe mental health conditions may find this type of measurement technique useful for assessing relationships between physical activity patterns or patterns of inactivity and specific mental illnesses because it can combine both context and behaviour to provide powerful data.
However, disadvantages include the time involved in recording and coding behaviour, the time involved in consolidating the plethora of data collected and the costs associated with training coders. Furthermore, the subjective bias of coders may lead to incorrect judgments about the intensities of specific activities, which would affect estimates of EE. As such, it would be important to consider whether information regarding patterns of behaviour combined with context or specific EE data are required to fulfill the aims of a research project or treatment programme.
Accelerometers
Motion sensors, such as pedometers and accelerometers, can be used to detect body movement and estimate physical activity (Spruijt-Metz et al., 2009). Accelerometers are devices that measure bodily movements in terms of acceleration. This measurement can then be used to estimate the intensity of physical activity, and therefore EE, over time (Burton et al., 2005; Chen & Basset, 2005). Accelerometers can measure human activity on vertical (uniaxial accelerometers), anterior - posterior and medial - lateral (triaxial accelerometers) planes. EE can then be then estimated from vector magnitude counts using a proprietary algorithm, which is a composite of counts from these planes of motion (Howe, Staudenmayer & Freedson, 2009). Accelerometers can be used repeatedly on numerous participants, are more accurate than pedometers and are less expensive (approximately £200 per device; ActiLife, 2009) than other objective methods such as DLW (approximately £200 per participant per procedure; Friedman & Johnson, 2002). However, they remain too expensive to use in studies that assess large numbers of people (Wood, 2000). Nevertheless, these devices are a more feasible and participant-friendly method of attempting to validate a self-report questionnaire than is DLW. They also provide the data necessary to allow researchers to distinguish between light, moderate and vigorous physical activity as well as between continuous and intermittent activity modes (Crouter, Clowers & Bassett, 2006). A recent review of accelerometers against DLW found ActiGraph (previously named CSA/MTI) models to be of the most valid types tested; they produce an average correlation of r = .57 (Plasqui & Westerterp, 2007). Limitations of accelerometers include the increased time required to analyse the large amount of data provided, participant burden of wearing the device, that they cannot be feasibly used to test large-scale interventions, and that they cannot provide information about the specific type of activity (e.g., playing football, going to the gym) or the context in which it is performed.
Some studies have attempted to validate accelerometers among populations diagnosed with mental health conditions. For example, Sharpe and colleagues (2006) conducted a study to assess the validity of the RT3 accelerometer against DLW in people with schizophrenia. They found that the accelerometer overpredicted energy expended on physical activity by an average of 148 kcal/day (standard deviation = 413 kcal/day); this varied from an underestimation of 614 kcal/day to an overestimation of 582 kcal/day. The authors suggested that the RT3 accelerometer is a poor tool for measuring activity EE in sedentary men with schizophrenia. As such, the results of studies that have used this measurement tool in mentally ill populations may be questionable. For example, the recent intervention study of Jerome and colleagues (2009) used the RT3 accelerometer to measure physical activity in persons with mental illness. The authors of this study concluded that participants were undertaking approximately 120 min/wk of moderate-intensity physical activity on average, which would equal approximately 70 kcal/day. Given that the results of the study by Sharpe and colleagues (2006) indicated that the RT3 accelerometer overpredicted EE, it is possible that the results found by Jerome and colleagues (2009) overestimate the amount of physical activity undertaken by participants. Consequently, this might affect the validity of the relationships found between physical activity and various mental health variables measured in this study. Sharpe and colleagues (2006) did, however, indicate that the RT3 appeared to be a valid measure of physical inactivity in men with schizophrenia. Therefore, it could be used for research or clinical purposes to quantify the contribution of sedentary behaviour to medical conditions associated with inactivity. Sharpe and colleagues (2006) also recommended that using the RT3 to validate questionnaires may not be appropriate until it is more robust.
Indirect Objective Measures
Indicators of the physiologic response to physical activity include heart rate and pulmonary gas exchange. Heart-rate monitoring is a promising measurement method because heart rate is a physiological parameter that correlates well with, and strongly predicts, EE (Strath et al., 2002). Most heart rate monitors include software that converts heart rate data into an estimate of EE. However, one of the limitations of heart rate monitoring is that training state and individual heart rate characteristics can affect the relationship between heart rate and oxygen consumption. Higher levels of accuracy can be obtained through a graded submaximal exercise test that calibrates participant heart rate to simultaneous oxygen consumption. This information allows for the construction of a calibration curve that estimates EE at moderate and strenuous levels of exercise. (A linear relationship exists between increasing heart rate and oxygen consumption; Freedson & Miller, 2000.) Measuring heart rate is a common method used to describe intensity and duration of physical activity and is a relatively inexpensive method of measuring EE. However, heart rate is affected by factors other than physical activity, such as emotional stress, temperature, humidity, dehydration, posture and illness (Ainslie, Reilly & Westerterp, 2003). These factors can influence heart rate without causing associated changes in oxygen consumption. Given the potentially increased fluctuations in emotions in individuals diagnosed with mental health conditions, this method may not be the most appropriate for obtaining accurate physical activity levels. Furthermore, the relationship between oxygen uptake and heart rate is weak at low levels of activity (Keim, Blanton & Kretsch, 2004). Evidence suggests that individuals suffering from mental health problems tend to perform less intensive physical activity than do members of the general population (e.g., Brown et al., 1999). Therefore, the heart rate method may not provide accurate information about the physical activity of mental health populations. Also, the heart rate method is unable to identify types of activity or the context in which physical activity is performed. Although heart rate is a physiological marker for physical activity and may provide a general picture of physical activity patterns, it may not be the best method available for obtaining an accurate estimate of EE.
Pedometers
Pedometers, which measure steps on a single axis as well as calories expended, are less expensive than some other types of motion sensors. As such, these devices are an attractive alternative to self-report in large observational or intervention studies. Public health campaigns have also promoted pedometers as a motivational tool for achieving the goal of 10,000 steps daily. A range of pedometers is available. The pedometer that is most suitable for a particular study may depend on factors such as the research question (outcome of interest), population, available funds, context and validity of the model. For example, when considering context, researchers or practitioners who wish to understand the types of physical activity being undertaken in a variety of settings would not gain this information using pedometers alone. When considering population, some pedometers are validated in healthy adults but not in other populations such as children, the elderly or those diagnosed with mental illness. Pedometers have demonstrated reduced accuracy in elderly populations because of the slow pace or shuffling nature with which elderly people walk (Cyarto, Myers & Tudor-Locke, 2004). Tudor-Locke and colleagues (2002) evaluated the validity of pedometers in a review of 25 studies and found a strong correlation between pedometer counts and accelerometer output (median of reported correlations is r = .86). However, evidence suggests that the validity of pedometers for measuring EE and distance in normal populations is questionable. The findings of a study testing the validity of 10 pedometers (Crouter et al., 2003) indicated that these devices overestimated distance at slower speeds and underestimated distance at faster speeds. Furthermore, in 8 of the pedometers tested, it was unclear whether the device was measuring gross EE (all the energy expended by an individual during a specific activity) or net EE (the energy expended by an individual during a specific activity minus the resting EE for the equivalent amount of time). The Yamax Digiwalker SW-200 was found to be the most reliable and accurate pedometer available (Crouter et al., 2003). This pedometer was used in a recent study by McKercher (2009) that assessed relationships between physical activity and depression in young adults. This study found that low levels of depression were significantly correlated with moderate levels of physical activity, as measured by the Yamax Digiwalker SW-200, among females. However, this device has not been validated in specific mental health populations, which may limit the validity of these results. It is important to validate physical activity devices among specific populations because patterns of physical activity in these populations may differ from those in the general population. For example, individuals with serious mental illness are significantly less active than the general population (Brown et al., 2004). As such, using a physical activity measure that has been validated with mental health populations in research on physical activity and mental health will increase the strength of the results produced.
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Coping with long-term physical health conditions
Approximately 30% of the European population has a long-term physical health condition. People with a long-term condition that is comorbid with a mental health problem have worse health outcomes than do people with either of these alone.
Key Concepts
- Approximately 30% of people with a long-term condition have a comorbid mental health condition.
- Physical activity is an important part of the management of physical and psychological well-being in people with long-term conditions.
- Pulmonary rehabilitation leads to reduced depression and anxiety and increased quality of life in people with chronic obstructive pulmonary disease. Further research is required to understand the optimal exercise dose; the interaction of exercise training, education and psychosocial support during pulmonary rehabilitation; and how to sustain changes in physical activity behaviour after pulmonary rehabilitation.
- Physical inactivity is associated with greater depression in people with type 2 diabetes. Further research is required to understand the causality of this relationship, although available data suggest that physical activity interventions reduce depression.
- Data that explore the relationship between physical activity and mental health in people with type 1 diabetes are limited.
- Physical activity has been shown to increase quality of life and reduce anxiety and depression in cancer survivors. Data suggest that supervised and group exercise are more beneficial than unsupervised and home-based exercise in this population.
Long-term conditions (LTCs) have been defined as "those conditions that cannot, at present, be cured, but can be controlled by medication and other therapies. The life of a person with an LTC is forever altered - there is no return to normal" (Department of Health, 2008, p. 10). LTCs include diabetes, arthritis, chronic obstructive pulmonary disease (COPD) and a number of cardiovascular diseases. In addition, conditions such as human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) and certain cancers that were not traditionally considered LTCs are increasingly being regarded as such (Naylor et al., 2012). Many mental health problems can themselves be considered LTCs. However, in this chapter the term long-term condition refers specifically to physical health conditions.
The World Health Organisation's (2011) report on the global burden of noncommunicable diseases (i.e., all previously mentioned LTCs except HIV and AIDS) found that noncommunicable diseases are by far the leading cause of mortality in the world and represent 63% of all deaths. The majority of these deaths are due to cardiovascular disease, diabetes, cancer and chronic respiratory disease. The highest occurrence of deaths from these diseases is in low- and middle-income countries, and the prevalence in these countries is predicted to increase substantially in the future. In Europe 29% of people aged 15 yr or older report a longstanding health problem (TNS Opinion, 2007), and the Office for National Statistics (2005) found that in England approximately 30% of the population (15.4 million people) has a LTC. As populations age, the burden of LTCs is projected to increase even further.
Long-Term Conditions and Mental Health Issues
People with LTCs are two to three times more likely than the general population to experience mental health problems. Depression and anxiety are the most frequently reported mental health problems in people with LTCs, but dementia, cognitive decline and some other conditions have also been reported (Naylor et al., 2012). Depression is two to three times more common in people with an LTC than in those with good physical health and occurs in approximately 20% of people with an LTC (National Collaborating Centre for Mental Health, 2010). Conservative estimates suggest that at least 30% of all people with an LTC also have a comorbid mental health problem of some kind (Cimpean & Drake, 2011). Research has shown that having a mental health problem along with an LTC has a stronger negative impact on quality of life and functional status than does either the number of LTCs or the severity of those conditions. For example, quality of life is lower in people with one LTC and depression than in people with two or more LTCs and no depression (Moussavi et al., 2007). Figure 8.1 shows the overlap between LTCs and mental health disorders.
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In addition to experiencing psychological distress, patients with an LTC and comorbid mental health problem experience poorer clinical outcomes compared with people with an LTC and no mental health problem (Moussavi et al., 2007). This is partly because self-management is necessary for effectively controlling LTCs, and poor mental health can result in poorer self-management. For example, it may lead to lack of motivation and energy to adhere to treatment plans or attend medical appointments (DiMatteo, Lepper & Croghan, 2000). From a financial perspective, comorbid mental health problems are typically associated with a 45% to 75% increase in care costs for a person with an LTC. These data are based on a wide range of LTCs and are observed after adjustment for severity of physical disease (Unützer et al., 2009; Welch et al., 2009).
Overlap between long-term conditions and mental health problems in England. Adapted, by permission, from C. Naylor et al., 2012, Long-term conditions and mental health: The cost of co-morbidities (London: The King's Fund and Centre for Mental Health).
Long-Term Conditions and Quality of Life
Quality of life is an individual's perception of their ability to function well on physical, mental and social levels. Quality of life can be measured in a reliable and valid manner using self-reported questionnaires, which can be categorised into three main groups: generic, disease specific and domain specific. Generic questionnaires measure quality of life in general terms, independent of the presence of any disease. Disease-specific questionnaires measure the consequences of a specific disease on quality of life. Domain-specific questionnaires focus on certain domains of quality of life (e.g., physical inabilities).
Where it is possible to manage but not cure a disease, such as in LTCs, measures of quality of life are frequently used to help determine the impact of treatment and disease. They help health professionals make informed judgements about whether treatment is appropriate and, where a choice of treatments exists, which might be the best option. Researchers frequently use these measures to assess the impact of a new intervention.
Long-Term Conditions and Physical Activity
Doctors have traditionally advised people with a range of LTCs to rest and not tire themselves out, and this advice persists in the lay psyche. For example, a recent Swedish survey found that the physical activity levels of people with diabetes, rheumatoid arthritis or COPD are lower than those of healthy controls; 73% of people with diabetes, 74% with rheumatoid arthritis and 84% with COPD reported low physical activity levels compared with 60% of controls (Arne et al., 2009). However, modern treatment of LTCs often includes promoting physical activity as part of a healthy lifestyle, and accumulating evidence shows the importance of physical activity in the management of both physical and psychological well-being for people with one or more LTCs. Regular contact between health professionals and people with LTCs provides opportunities for promoting physical activity in this group.
Each LTC presents its own challenges and benefits with regard to physical activity. The remainder of this chapter focusses in particular on the impact of physical activity on mental health and well-being in people with COPD, diabetes and cancer.
Chronic Obstructive Pulmonary Disease
COPD is characterised by airflow obstruction that is not fully reversible and usually progressive in the long term. It is predominantly caused by smoking. Symptoms include breathlessness (dyspnoea) on exertion, chronic cough, regular production of sputum and frequent winter bronchitis or wheeze. Exacerbation of symptoms often occurs in which the patient's symptoms rapidly worsen beyond normal day-to-day variations. Diagnosis relies on a combination of history, physical examination and confirmation of airflow obstruction using spirometry; no single test for COPD exists (National Institute for Health and Clinical Excellence, 2010). Severity of COPD is often classified using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria (I [mild], II [moderate], III [severe] and IV [very severe]) and index of body mass, airway obstruction, dyspnoea and exercise capacity (BODE).
The World Health Organisation has predicted that by 2020 COPD will be the third leading cause of death and fifth leading cause of disability in the world (Murray & Lopez, 1996, 1997). Mortality rates for men in the United Kingdom are at a plateau and mortality rates for women are steadily increasing (Soriano et al., 2000) most likely as a result of the uptake of smoking among women post-World War II. According to the chief medical officer in England, COPD accounts for more than £800 million in direct health care costs (Department of Health, 2005); more than one half of these costs relate to the provision of hospital care. COPD is among the most costly inpatient conditions that the National Health Service treats.
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Designing a physical activity program for individuals with addictions
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours.
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours. However, implementation of behavior change in this population can present practitioners with specific challenges. This section discusses the suggestions for designing effective interventions for those with addictions based on the evidence reviewed so far as well as practical considerations.
Exercise Type, Frequency and Intensity
Most studies have promoted moderate-intensity cardiovascular-type exercise such as brisk walking for use in those with addictive behaviours. Some work also incorporates more vigorous activities such as running. Because individuals with addictions are often extremely sedentary, a programme of moderate-intensity activity is likely to be acceptable and safe. However, a progression to more vigorous exercise may be beneficial. For example, the only study that found a long-term benefit of exercise for smoking cessation entailed 30 to 40 min of vigorous exercise 3 times/wk for 12 wk (Marcus et al., 1999). Similarly, the single study that showed a long-term impact of exercise on alcohol abstinence involved 1 h of progressively vigorous exercise 5 days/wk for 6 wk (Sinyor et al., 1982). None of the trials reviewed compared the effects of vigorous-intensity and moderate-intensity exercise on abstinence rates. Experimental studies have compared the effects of bouts of moderate-intensity and vigorous-intensity exercise and have shown that both intensities are effective in the short term for reducing tobacco-withdrawal symptoms (Taylor et al., 2007).
The intensity of activity that an individual is capable of depends on initial level of fitness, medical condition and stage of recovery from addiction. Careful medical screening is vital. For example, those addicted to amphetamine or cocaine are often undernourished, and problem drinkers often have weak muscles. Such individuals may require nutrition advice. Ultimately, individuals will have preferences regarding types of exercise, and programmes should be tailored to these preferences (Abrantes et al., 2011; Everson-Hock et al., 2010). Some individuals may prefer noncardiovascular types of exercise, which may also be beneficial. Resistance (i.e., weight) training, yoga and isometric exercise have all been successfully piloted as aids for smoking cessation and need to be tested in larger trials (Ussher, Taylor & Faulkner, 2012).
Regarding frequency and volume of exercise, the findings from Marcus and colleagues (2005) suggest that abstaining smokers need to accumulate at least 110 min/wk of moderate-intensity activity to maintain abstinence; supervised exercise on 2 or 3 days/wk may be necessary in order to achieve this. Shorter bouts of exercise can be used on an as-needed basis in response to cravings, and longer scheduled bouts can be used to maintain positive mood, manage stress and prevent cravings from arising. Research has not yet addressed the optimum dose of exercise for assisting alcohol and drug rehabilitation.
Exercise Supervision
The majority of intervention studies have employed group-based supervised exercise. In smokers, exercise counselling alone did not increase exercise levels sufficiently (Ussher et al., 2003), and all the interventions that showed a significant impact on long-term abstinence from alcohol or smoking entailed supervised exercise. Among novice exercisers, an element of supervised exercise may be useful to ensure initial adoption of regular exercise and to provide information about safe exercise (e.g., warm-up) and exercise intensities (e.g., using heart rate monitors). Counselling toward pursuing home-based exercise is also likely to be important for encouraging patients to maintain exercise levels after the initial exercise programme ends.
Stages of Addiction Treatment
Early recovery from drug and alcohol dependence is a major transition that affects close relationships and employment and involves numerous treatment sessions. An exercise programme needs to complement these changes. Most exercise interventions discussed in this chapter have required patients to alter their substance- or alcohol-misuse behaviour and exercise behaviour simultaneously, yet it is not clear whether this is optimal. For some individuals the challenge of changing two health behaviours simultaneously may be too demanding. Also, it is not clear whether involvement in physical activity increases the motivation to manage substance intake or vice versa.
Among smokers, exercise has often been introduced in the studies discussed several weeks before an attempt to quit, thereby allowing people to adjust to the demands of increased exercise before starting to quit. This also allows exercise to play a role in managing cravings during the crucial early days of abstinence, when relapse rates are highest. Empirical work is required to determine the relative benefits of initiating exercise at different points in the addiction-treatment process. During later stages of treatment exercise may be useful for preventing relapse (e.g., by promoting an exercise identity that is incompatible with drug use). Studies are also needed to determine whether exercise can be used to increase substance abstinence among those who are not motivated to attempt abstinence.
Integrating Exercise With Standard Addiction Treatments
Greater integration of addiction and exercise programmes may enhance abstinence rates. For instance, rather than just proposing exercise as a means for getting fitter and managing weight, the practitioner could present exercise more as a self-control strategy for managing withdrawal symptoms and a way to address psychological and physical harms caused by addiction. Exercise could be used more in combination with pharmaceutical interventions. Whereas pharmaceutical interventions focus on reducing withdrawal symptoms (e.g., NRT), exercise could ideally be used to provide an added effect in client-led management of addictive symptoms.
Perceived Barriers to Exercise
Individuals with addictions are likely to have specific barriers to exercise, and these need to be determined. In the general population, use of cognitive - behavioural techniques is effective for overcoming perceived barriers and increasing exercise adherence. Few addiction studies have included cognitive - behavioural counseling. Techniques such as self-monitoring (e.g., diaries), goal-setting and relapse-prevention planning are commonly used. Also, pedometers are now commonly used as a motivational tool. These and other motivational aids (e.g., financial incentives) need to be tested with exercise interventions in addicted populations.
Interventions for Different Subgroups
Exercise interventions need to be tested among addicted populations who might especially benefit from such interventions. Given the high prevalence of addictions among people with mental illness and the established benefits of regular physical activity for mental health, research that examines the role that physical activity may play in this population is needed (Arbour-Nicitopoulos et al., 2011).
Exercise interventions might be particularly appealing to adolescents, and controlled trials with young people are needed. Addicted individuals who are overweight may have a need for weight-control interventions such as exercise; no trial has yet focussed on this population. Additionally, surveys suggest that a nonpharmaceutical intervention such as exercise is likely to appeal to pregnant smokers (Ussher at al., 2008). Finally, sex needs to be considered when planning an appropriate intervention. Some evidence shows that women often prefer walking and aerobics, whereas men have more interest in sport, running and strength training.
Evidence to Practice
- Both moderate- and vigorous-intensity exercise have been shown to be effective for reducing tobacco-withdrawal symptoms and cravings.
- Progressing from light- and moderate-intensity exercise (e.g., brisk walking) to more vigorous-intensity exercise is advisable.
- Careful medical screening is required, especially among those with long-term alcohol or drug dependence (e.g., for malnutrition).
- Exercise interventions should be tailored to individual preferences.
- Abstaining smokers should accumulate at least 110 min/wk of moderate-intensity exercise.
- Interventions involving supervised exercise on 2 or 3 days/wk are likely to be necessary to be effective in treating addictive behaviours.
- Exercise can be performed on an as-needed basis for managing cravings or in scheduled bouts.
- If the exercise programme is to assist with early withdrawal symptoms, it ideally needs to begin before abstinence is attempted.
- Participating in physical activity encourages individuals to adopt an identity as an exerciser, which is incompatible with using addictive substances.
- Perceived barriers to exercise need to be identified and addressed using cognitive - behavioural techniques.
- The intervention needs to be adapted to various subgroups (e.g., according to sex, body weight and mental health).
Summary
Drug, alcohol and tobacco addictions are growing global problems. Exercise has many benefits for physical and psychological health, and evidence convincingly shows that exercise is effective for managing cravings and withdrawal symptoms, particularly in smokers. Regular exercise fosters a healthy lifestyle and exercise identity that is largely incompatible with addiction, and individuals undergoing rehabilitation for addiction express interest in exercising more. Exercise interventions are inexpensive, can be easily integrated with existing addiction treatments and have minimal side effects compared with pharmacological treatments. This chapter demonstrates that exercise is a highly plausible adjunctive treatment for addictive behaviour and that exercise programmes can be readily disseminated. However, limited evidence currently supports the benefits of exercise for helping smokers quit or helping those with drug or alcohol dependence abstain. This lack of evidence can partly be explained by the small number of large RCTs that have been conducted, lack of knowledge about effective doses of exercise and limited attention to methods for maximizing exercise adherence. This area of research is in its infancy, and further well-designed trials are needed.
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Physical activity guidelines
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits.
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits. National guidelines aimed at the whole population (as opposed to specific populations defined by a medical condition) focus on the optimal amount of activity to prevent disease and promote health and well-being. PAGs indicate the type (e.g., aerobic activity, strength training, weight bearing), frequency (e.g., 3 days/wk), duration (e.g., 30 min) and intensity (e.g., moderate, vigorous) (see figure 2.2) of physical activity to undertake and for what benefits. These detailed specifications reflect the latest science on the topic.
PAGs need to be updated periodically because evidence about the relationship between physical activity and health changes over time and knowledge grows. Some guidelines are more general in nature, whereas others provide very specific details; this usually reflects the state of knowledge at that time. Through a review and revision process, more specific details are added to PAGs when available. For example, in various national PAGs, guidelines relating to maintaining musculoskeletal strength have been revised over time and now include details on how much strength training is required for good health (World Health Organisation, 2010) and, specifically, for preventing falls and treating depression (Singh, Clements & Singh, 2001).
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The dose - response relationship: Increasing benefits from increasing amounts (expressed in frequency, duration and intensity) of activity. Reprinted, by permission, from I. Vuori, 1995, Terveysliikunta [Health and physical education]. UKK Institute for Health Promotion Research (Tampere, Finland).
National guidelines are an important component of a population-based approach to addressing any public health issue. First, such guidelines communicate a consensus on the scientific evidence of the importance of the issue. They describe the strength of the science in terms of the volume as well as the quality (determined based on the quality of study designs and research methods used) of the evidence. Communicating scientific consensus is important because it removes doubt and speculation about the validity of the health issue and its importance. This scientific consensus can also be used to advocate for resources and programmes. However, just because guidelines exist does not mean that everyone agrees about what the science says - far from it. However, these disagreements, or alternative interpretations of overall findings to date, are usually communicated in technical reports that accompany the publication of PAGs and are not fully accessible to the general public.
The process of developing PAGs usually involves leadership by a high-level institution. This adds credence to the message that the issue is important. For example, several national and international health agencies, such as the American Heart Association (Haskell et al., 2007), have developed guidelines on physical activity. National governments, usually the ministry of health, often lead the development process and endorse national PAGs. This endorsement is very useful because it specifies the government's position on physical activity and thereby provides the opportunity for interested parties such as charities and public health directors to leverage the government into supporting further action and funding for programmes and services aimed at increasing physical activity. This might include government endorsement of counselling and clinical services for inactive patients, as has been trialled in the United Kingdom (Bull & Milton, 2011). Government involvement and endorsement can also prevent policy inaction. The absence of an official position on physical activity can block funding and further development of a national population-based approach.
One important role of PAGs is to direct community-level actions aimed at increasing physical activity in the whole population. The details in PAGs about the type, frequency, duration and intensity of activities required for different age groups can provide clinicians, health care practitioners and others with direction on what types of programmes to provide and promote to patients and the wider community.
PAGs should drive and direct action not just at the level of individuals and service providers but also at all levels - national, regional and local - of government. If the national government endorses PAGs, ideally with multiparty political support, the government should be held accountable when levels of physical activity are not improving and can be expected to include physical activity promotion as part of ongoing disease-prevention and health-promotion strategies. The role of PAGs and national surveillance of risk factors is discussed in more detail later in this chapter.
Development of the First National Physical Activity Guidelines
Epidemiological studies of exercise and health were well advanced by the 1970s. The American College of Sports Medicine released the first set of recommendations in 1975 and released another set in 1980 (American College of Sports Medicine, 1975, 1980). These recommendations were predominantly directed at cardiorespiratory fitness and suggested that people undertake vigorous-intensity aerobic exercise 3 times/wk for 20 min each time. This was a practical interpretation of the exact recommendation from 1975, which suggested that people undertake 20 to 45 min of physical activity 3 to 5 days/wk at 70% to 90% of heart rate (i.e., vigorous intensity) (American College of Sports Medicine, 1975). The focus on aerobic exercise for increasing fitness continued to dominate and influence health messages about physical activity until the early 1990s. However, guidelines began to recommend moderate-intensity physical activity rather than vigorous-intensity activity, and by the mid-1990s the focus shifted from cardiorespiratory fitness to health benefits. This new position on physical activity was communicated in a landmark set of recommendations from the office of the U.S. surgeon general in the report "Physical Activity and Health" (U.S. Centers for Disease Control and Prevention, 1996).
In the mid-1990s, epidemiological evidence started to show that people with different health conditions require slightly different amounts of physical activity. Although the recommendation for 30 min of moderate-intensity activity on most days remained valid for preventing heart disease and diabetes, studies showed that slightly more physical activity was recommended for preventing cancer. Further, studies identified that the amount of activity required for weight loss or preventing weight gain was greater than that required to prevent chronic disease (Haskell et al., 2007). For example, the International Association for the Study of Obesity recommendations made a clear distinction between the minimum physical activity required for health benefits and the amount required for preventing weight gain. The recommendations state that "45 to 60 min (60-90 min for formerly obese individuals) of moderate-intensity physical activity daily is needed to prevent the transition to overweight or obesity" (Saris et al., 2003). Furthermore, research has now shown that the amount of physical activity required by young people differs from that of adults. The overall amount of physical activity recommended for children is twice that recommended for adults and is usually expressed as "at least 60 min/day" (Canadian Society for Exercise Physiology, 2011a; Saris et al., 2003).
These different recommendations make the development of PAGs complex. However, a core and consistent interpretation of the evidence is that 30 min of moderate-intensity physical activity on most days of the week is associated with maximum overall population benefit and the prevention of major noncommunicable diseases. This same dose has been expressed as "at least 150 min/wk of moderate-intensity activity" in the most recent global, U.S. and U.K recommendations (Department of Health, 2011b; U.S. Department of Health and Human Services, 2008a; World Health Organisation, 2010).
Current Best Practice in Developing Guidelines
Figure 2.3 illustrates the process of developing guidelines. The first step is establishing the need for guidelines. This need is often defined by policymakers, public health scientists, advocates and, sometimes, the community. Then a process for guideline development needs to be agreed on by interested parties, with actions planned in sequence and, ideally, a linkage between the PAG development process and other aspects of national or regional physical activity policy and strategy development (step 1 in figure 2.3). The next stage comprises reviewing the scientific evidence and creating an updated summary of what the research says and how this information differs from that in previous guidelines. A number of countries, notably Canada and, most recently, the United Kingdom and United States, have undertaken this process. Tremblay and colleagues (2010) extensively discuss this process with reference to the recent Canadian guidelines along with frameworks and a checklist for auditing data quality in the review stage.
Once the science has been reviewed, the next stage is developing communication messages based on the evidence and testing these messages with the target audience for acceptability, comprehension and usefulness. This step is part of developing a communications strategy for disseminating the evidence (stages 3 and 4 in figure 2.3). It requires resources for conducting the qualitative and quantitative research and the involvement of communications and media specialists in framing the messages correctly so that they will have optimal impact on the target populations. The final stages (stages 5-7 in figure 2.3) involve disseminating the message to the community, professional groups and other stakeholders. Historically, those developing PAGs have put considerable effort into the technical and scientific stages and have often neglected message development and communication. Frequently, only informal and unpaid communication channels are used after the launch of PAGs. Thus, a very important step in PAG development and dissemination is the final public health promotion component.
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Framework for developing physical activity guidelines. Adapted from Bauman et al. 2006.
Global, Regional and National Physical Activity Guidelines
Table 2.1 summarises the 2011 global PAGs and provides examples of regional (i.e., European and Western Pacific islands) and national guidelines. Quite a few countries in Europe have their own national PAGs, and many of these countries (e.g., Finland, Switzerland, the Netherlands, United Kingdom) have been engaged with implementing national population-based approaches for some time (Department of Health, 2011b; Ministry of Health, Welfare and Sport, 2011; Swiss Federal Office of Sports, 2006; UKK Institute, 2009). Other countries in Europe have officially or unofficially adopted the guidelines published by the U.S. Centers for Disease Control and Prevention in 1996 and the more recently updated 2008 version.
PAGs in other regions of the world are patchy. Australia (Department of Health and Ageing, 2005b) and New Zealand (Sport and Recreation New Zealand, 2005) have had national guidelines for some time. In Australia, guidelines exist for all ages, from young children (Department of Health and Ageing, 2004) to older adults (Department of Health and Ageing, 2005b), although all guidelines are more than 5 yr old and arguably are due for updating to reflect the latest science. Far fewer examples of PAGs exist in South America, Asia, the Middle East and Africa because physical activity promotion is relatively new in these regions. Countries in which national action on physical activity is beginning have often used the U.S. guidelines as an international benchmark. This has allowed the countries to develop an agenda of physical activity promotion without being hindered by the absence of PAGs. However, in some countries, adopting the PAGs of another country is not politically or culturally welcome or appropriate. Either these countries have developed their own PAGs (a recent example from the Middle East is Brunei; Ministry of Health, 2011) or very little physical activity promotion has occurred.
The absence of a set of official global guidelines did not hinder the World Health Organisation (WHO) from developing the Global Strategy on Diet, Physical Activity and Health in 2004 (World Health Organisation, 2004). Since the publication of the 2002 health report (World Health Organisation, 2002), the focus on the need for greater action to prevent noncommunicable disease and address mental health has increased. To address these issues, WHO commenced developing global guidelines in 2007. WHO launched the final global recommendations on physical activity in 2010 after a 2 yr process involving global and regional consultations (World Health Organisation, 2010). These global guidelines are now available for adoption and use by countries with no national PAGs. Because the guidelines are from WHO, the leading international health agency, the scientific quality and relevance of these guidelines are usually accepted.
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Treating depression and anxiety with exercise
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety.
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety. Information about these prescription parameters is scarce, but it is critical if exercise interventions are to be translated into clinical practice. Asking someone to do something without specifying what they should do or how they should do it would likely make it difficult for the individual to fully comply in a meaningful way. It is also possible that the prescription of exercise for depression and/or anxiety could be different, both in nature and content, than that required for general health benefits.
One trial that is particularly worthy of attention is the Depression Outcomes Study of Exercise (DOSE; Dunn et al., 2005), which attempted to provide evidence about the dose of exercise required to treat depression. In the DOSE study 80 participants were randomised to 1 of 4 exercise groups that varied in total energy expenditure (7 or 17.5 kcal·kg-1·wk-1) and frequency (3 or 5 days/wk) or to a flexibility-exercise placebo control for 12 wk. Exercise at a dose of 17.5 kcal·kg-1·wk-1 was effective in reducing depression regardless of frequency, whereas exercise at a dose of 7 kcal·kg-1·wk-1 yielded antidepressant effects that were comparable to those of the placebo treatment. The plausible biological reason for why a higher dose of exercise may be more effective than lower doses is that frequent and regular exercise should increase fitness levels such that physical discomfort decreases and exercise becomes a more pleasant and enjoyable experience as the conditioning process progresses. Indeed, findings from both the DOSE and TREAD trials in the United States have indicated that higher doses of exercise are more effective than are lower doses (as defined in the study).
Perraton and colleagues (2010) published a systematic review that attempted to summarise what is currently known about the prescription of exercise for depression. The review is useful because previous reviews of exercise and depression did not synthesise this information in a way that would help guide intervention development. This review included only trials that had reported exercise to be effective in reducing depression in order to analyse the specific dosage parameters and modes of exercise used in these successful trials.
The review found that the most common intensity, frequency and duration of aerobic exercise were 60% to 80% of maximum heart rate, 30 min/session and 3 days/wk over 8 wk. The volume of evidence supporting the use of aerobic exercise programmes to treat depression was greater than that supporting the use of anaerobic exercise programmes. No clear trend showed one mode of aerobic exercise to be the most effective, and a range of activity types appeared to be effective. This is encouraging given that one size does not fit all, and individuals can be encouraged to participate in whatever type of aerobic activity they prefer.
In terms of context of exercise, a number of common trends emerged. A variety of locations were effective in treating depression, although all trials that reported location took place indoors. Both group and individual interventions were effective. However, group exercise may have added benefit by providing social support, which can be pivotal for sustaining compliance and can contribute in its own right to lowering depression. Moreover, exercise might lower depression by several plausible mechanisms, one of which could be interrelations or connections with others (Bailey & McLaren, 2005). Many types of exercise can be performed with other people (depressed or not). Therefore, this exercise could provide social integration and an opportunity to interact with the social world as well as a setting in which to expand social networks and make friends (Stathi, Fox & McKenna, 2002).
Another unresolved question concerns the intensity of exercise at which a reduction in depression might occur. Callaghan and colleagues (2011) compared the effects of preferred intensity with those of prescribed intensity of group-based exercise for 12 sessions over 4 wk in 38 women aged 45 to 65 yr who were receiving treatment for depression from either primary or secondary care services. The preferred-intensity group reported significantly lower depression and higher self-esteem and quality-of-life scores than did the prescribed-exercise group and attended more sessions (66% versus 50%). Similar findings have been found in nondepressed populations (Daley & Maynard, 2003). Several theories, such as self-determination theory (Deci & Ryan, 1985), support the notion that giving people a choice and control over what they do, whether it be exercise or other activities, leads to better adherence and enjoyment of the activity, which in turn leads to enhanced psychological well-being. People experiencing depression are no exception.
Wipfli, Rethorst and Landers (2008) considered the relationship between dose of exercise and anxiety levels as part of their broader meta-analysis of the anxiolytic effect of exercise. The trend in the data from 12 RCTs showed that the effect size increased as exercise approached a dose of 12.5 kcal·kg-1·wk-1 (equates to slightly less than the dose recommended for public health) and then began to decrease as exercise dose increased. A combination of aerobic and anaerobic exercise appeared to be better than either type alone, and a frequency of 3 or 4 times/wk appeared more effective than more or less than this amount.
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Available methods for measuring physical activity
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry.
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry. Most are moderately correlated at best. Each method has its own strengths and limitations. Due to the complexity of physical activity, outlined previously, researchers and practitioners need to consider what is most important for their purposes when deciding to use a particular technique. Although no one measurement tool can be singled out as the most appropriate, recommendations for the most useful and practical measurement tools can be made after considering factors such as context, type, duration, frequency and intensity of physical activity as well as the constraints under which the research or treatment programme is operating. These techniques are presented in order of increasing feasibility but decreasing validity. Table 3.2 at the end of this section summarises the key advantages and limitations of each measurement technique.
Doubly Labelled Water
Doubly labelled water (DLW, or free-living indirect calorimetry) is a method commonly used to increase the precision and accuracy of physical activity measurement. DLW, which measures EE over several (4-21) consecutive days in a free-living person under normal life conditions (Schoeller, 1988), is the most widely accepted gold standard method by which to measure EE (Aadahl & Jørgensen, 2003). DLW measures EE of free-living, unrestricted subjects using water labelled with stable isotopes of oxygen and hydrogen (Schoeller & van Santen, 1982). It calculates activity-related EE by combining measurement of total EE with basal metabolic rate. The utility of the DLW method in measuring total EE is demonstrated by its use in a variety of settings, including all age groups, premature infants, hospitalised patients, pregnant women and the elderly (Ainslie, Reilly & Westerterp, 2003). As such, researchers who use this method to assess the relationship between physical activity and other psychological variables or to detect changes in physical activity as a result of interventions can be confident that the results produced regarding EE are accurate. Schoeller (1988) fully describes the validation of the DLW method.
Despite its level of precision, the DLW method is not without disadvantages, which include high cost, limitations for assessing brief periods of EE (Ainslie, Reilly & Westerterp, 2003) and additional demands on participants in terms of time and tasks required. The cost and availability of isotopes and the requirement for analysis by isotope ratio mass spectrometer prohibit DLW from being widely used in studies of large populations. The use of this method among populations with more severe mental health problems may likely present a set of ethical issues. Furthermore, although this technique provides an accurate measure of total EE, it cannot provide information about patterns of physical activity in terms of type, frequency, duration, intensity or context. Consequently, such an approach would not be feasible in a large natural-field experiment or in a test of the effect of interventions on changes in physical activity in both healthy populations and populations that suffer from mental health problems. However, this gold standard measure is believed to offer the most precise estimate of EE and is often used to validate many other types of tools that assess physical activity.
Direct Observation
Direct observation, one of the most basic approaches for acquiring information about behaviours, provides information about how people exercise and play, how environments shape the activities individuals participate in and how people use specific facilities (e.g., parks, leisure facilities, walking or cycling paths). It can take place using basic observation methods, systematic forms or sophisticated technology (e.g., lasers). Direct observation often involves a trained observer who codes physical activity behaviours (e.g., sitting, walking, running) undertaken by participants over time in various settings (e.g., playground, park, home). A number of observation systems are available, such as SOPLAY (System for Observing Play and Leisure Activity in Youth), SOFIT (System for Observing Fitness Instruction Time), and the Systematic Pedestrian and Cycling Environmental Scan. The trained observer may either observe participants in person or review video media. Because it is time consuming, direct observation might be used only with small groups in specific settings (Dugdill & Stratton, 2007).
Advantages of direct observation include that self-report bias is eliminated, participants do not need to recall behaviour and the level of detail regarding behaviour patterns and context can be extremely accurate. Furthermore, practitioners may find some of these tools accessible. For example, clinical psychologists working with institutionalised individuals diagnosed with severe mental health conditions may find this type of measurement technique useful for assessing relationships between physical activity patterns or patterns of inactivity and specific mental illnesses because it can combine both context and behaviour to provide powerful data.
However, disadvantages include the time involved in recording and coding behaviour, the time involved in consolidating the plethora of data collected and the costs associated with training coders. Furthermore, the subjective bias of coders may lead to incorrect judgments about the intensities of specific activities, which would affect estimates of EE. As such, it would be important to consider whether information regarding patterns of behaviour combined with context or specific EE data are required to fulfill the aims of a research project or treatment programme.
Accelerometers
Motion sensors, such as pedometers and accelerometers, can be used to detect body movement and estimate physical activity (Spruijt-Metz et al., 2009). Accelerometers are devices that measure bodily movements in terms of acceleration. This measurement can then be used to estimate the intensity of physical activity, and therefore EE, over time (Burton et al., 2005; Chen & Basset, 2005). Accelerometers can measure human activity on vertical (uniaxial accelerometers), anterior - posterior and medial - lateral (triaxial accelerometers) planes. EE can then be then estimated from vector magnitude counts using a proprietary algorithm, which is a composite of counts from these planes of motion (Howe, Staudenmayer & Freedson, 2009). Accelerometers can be used repeatedly on numerous participants, are more accurate than pedometers and are less expensive (approximately £200 per device; ActiLife, 2009) than other objective methods such as DLW (approximately £200 per participant per procedure; Friedman & Johnson, 2002). However, they remain too expensive to use in studies that assess large numbers of people (Wood, 2000). Nevertheless, these devices are a more feasible and participant-friendly method of attempting to validate a self-report questionnaire than is DLW. They also provide the data necessary to allow researchers to distinguish between light, moderate and vigorous physical activity as well as between continuous and intermittent activity modes (Crouter, Clowers & Bassett, 2006). A recent review of accelerometers against DLW found ActiGraph (previously named CSA/MTI) models to be of the most valid types tested; they produce an average correlation of r = .57 (Plasqui & Westerterp, 2007). Limitations of accelerometers include the increased time required to analyse the large amount of data provided, participant burden of wearing the device, that they cannot be feasibly used to test large-scale interventions, and that they cannot provide information about the specific type of activity (e.g., playing football, going to the gym) or the context in which it is performed.
Some studies have attempted to validate accelerometers among populations diagnosed with mental health conditions. For example, Sharpe and colleagues (2006) conducted a study to assess the validity of the RT3 accelerometer against DLW in people with schizophrenia. They found that the accelerometer overpredicted energy expended on physical activity by an average of 148 kcal/day (standard deviation = 413 kcal/day); this varied from an underestimation of 614 kcal/day to an overestimation of 582 kcal/day. The authors suggested that the RT3 accelerometer is a poor tool for measuring activity EE in sedentary men with schizophrenia. As such, the results of studies that have used this measurement tool in mentally ill populations may be questionable. For example, the recent intervention study of Jerome and colleagues (2009) used the RT3 accelerometer to measure physical activity in persons with mental illness. The authors of this study concluded that participants were undertaking approximately 120 min/wk of moderate-intensity physical activity on average, which would equal approximately 70 kcal/day. Given that the results of the study by Sharpe and colleagues (2006) indicated that the RT3 accelerometer overpredicted EE, it is possible that the results found by Jerome and colleagues (2009) overestimate the amount of physical activity undertaken by participants. Consequently, this might affect the validity of the relationships found between physical activity and various mental health variables measured in this study. Sharpe and colleagues (2006) did, however, indicate that the RT3 appeared to be a valid measure of physical inactivity in men with schizophrenia. Therefore, it could be used for research or clinical purposes to quantify the contribution of sedentary behaviour to medical conditions associated with inactivity. Sharpe and colleagues (2006) also recommended that using the RT3 to validate questionnaires may not be appropriate until it is more robust.
Indirect Objective Measures
Indicators of the physiologic response to physical activity include heart rate and pulmonary gas exchange. Heart-rate monitoring is a promising measurement method because heart rate is a physiological parameter that correlates well with, and strongly predicts, EE (Strath et al., 2002). Most heart rate monitors include software that converts heart rate data into an estimate of EE. However, one of the limitations of heart rate monitoring is that training state and individual heart rate characteristics can affect the relationship between heart rate and oxygen consumption. Higher levels of accuracy can be obtained through a graded submaximal exercise test that calibrates participant heart rate to simultaneous oxygen consumption. This information allows for the construction of a calibration curve that estimates EE at moderate and strenuous levels of exercise. (A linear relationship exists between increasing heart rate and oxygen consumption; Freedson & Miller, 2000.) Measuring heart rate is a common method used to describe intensity and duration of physical activity and is a relatively inexpensive method of measuring EE. However, heart rate is affected by factors other than physical activity, such as emotional stress, temperature, humidity, dehydration, posture and illness (Ainslie, Reilly & Westerterp, 2003). These factors can influence heart rate without causing associated changes in oxygen consumption. Given the potentially increased fluctuations in emotions in individuals diagnosed with mental health conditions, this method may not be the most appropriate for obtaining accurate physical activity levels. Furthermore, the relationship between oxygen uptake and heart rate is weak at low levels of activity (Keim, Blanton & Kretsch, 2004). Evidence suggests that individuals suffering from mental health problems tend to perform less intensive physical activity than do members of the general population (e.g., Brown et al., 1999). Therefore, the heart rate method may not provide accurate information about the physical activity of mental health populations. Also, the heart rate method is unable to identify types of activity or the context in which physical activity is performed. Although heart rate is a physiological marker for physical activity and may provide a general picture of physical activity patterns, it may not be the best method available for obtaining an accurate estimate of EE.
Pedometers
Pedometers, which measure steps on a single axis as well as calories expended, are less expensive than some other types of motion sensors. As such, these devices are an attractive alternative to self-report in large observational or intervention studies. Public health campaigns have also promoted pedometers as a motivational tool for achieving the goal of 10,000 steps daily. A range of pedometers is available. The pedometer that is most suitable for a particular study may depend on factors such as the research question (outcome of interest), population, available funds, context and validity of the model. For example, when considering context, researchers or practitioners who wish to understand the types of physical activity being undertaken in a variety of settings would not gain this information using pedometers alone. When considering population, some pedometers are validated in healthy adults but not in other populations such as children, the elderly or those diagnosed with mental illness. Pedometers have demonstrated reduced accuracy in elderly populations because of the slow pace or shuffling nature with which elderly people walk (Cyarto, Myers & Tudor-Locke, 2004). Tudor-Locke and colleagues (2002) evaluated the validity of pedometers in a review of 25 studies and found a strong correlation between pedometer counts and accelerometer output (median of reported correlations is r = .86). However, evidence suggests that the validity of pedometers for measuring EE and distance in normal populations is questionable. The findings of a study testing the validity of 10 pedometers (Crouter et al., 2003) indicated that these devices overestimated distance at slower speeds and underestimated distance at faster speeds. Furthermore, in 8 of the pedometers tested, it was unclear whether the device was measuring gross EE (all the energy expended by an individual during a specific activity) or net EE (the energy expended by an individual during a specific activity minus the resting EE for the equivalent amount of time). The Yamax Digiwalker SW-200 was found to be the most reliable and accurate pedometer available (Crouter et al., 2003). This pedometer was used in a recent study by McKercher (2009) that assessed relationships between physical activity and depression in young adults. This study found that low levels of depression were significantly correlated with moderate levels of physical activity, as measured by the Yamax Digiwalker SW-200, among females. However, this device has not been validated in specific mental health populations, which may limit the validity of these results. It is important to validate physical activity devices among specific populations because patterns of physical activity in these populations may differ from those in the general population. For example, individuals with serious mental illness are significantly less active than the general population (Brown et al., 2004). As such, using a physical activity measure that has been validated with mental health populations in research on physical activity and mental health will increase the strength of the results produced.
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Coping with long-term physical health conditions
Approximately 30% of the European population has a long-term physical health condition. People with a long-term condition that is comorbid with a mental health problem have worse health outcomes than do people with either of these alone.
Key Concepts
- Approximately 30% of people with a long-term condition have a comorbid mental health condition.
- Physical activity is an important part of the management of physical and psychological well-being in people with long-term conditions.
- Pulmonary rehabilitation leads to reduced depression and anxiety and increased quality of life in people with chronic obstructive pulmonary disease. Further research is required to understand the optimal exercise dose; the interaction of exercise training, education and psychosocial support during pulmonary rehabilitation; and how to sustain changes in physical activity behaviour after pulmonary rehabilitation.
- Physical inactivity is associated with greater depression in people with type 2 diabetes. Further research is required to understand the causality of this relationship, although available data suggest that physical activity interventions reduce depression.
- Data that explore the relationship between physical activity and mental health in people with type 1 diabetes are limited.
- Physical activity has been shown to increase quality of life and reduce anxiety and depression in cancer survivors. Data suggest that supervised and group exercise are more beneficial than unsupervised and home-based exercise in this population.
Long-term conditions (LTCs) have been defined as "those conditions that cannot, at present, be cured, but can be controlled by medication and other therapies. The life of a person with an LTC is forever altered - there is no return to normal" (Department of Health, 2008, p. 10). LTCs include diabetes, arthritis, chronic obstructive pulmonary disease (COPD) and a number of cardiovascular diseases. In addition, conditions such as human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) and certain cancers that were not traditionally considered LTCs are increasingly being regarded as such (Naylor et al., 2012). Many mental health problems can themselves be considered LTCs. However, in this chapter the term long-term condition refers specifically to physical health conditions.
The World Health Organisation's (2011) report on the global burden of noncommunicable diseases (i.e., all previously mentioned LTCs except HIV and AIDS) found that noncommunicable diseases are by far the leading cause of mortality in the world and represent 63% of all deaths. The majority of these deaths are due to cardiovascular disease, diabetes, cancer and chronic respiratory disease. The highest occurrence of deaths from these diseases is in low- and middle-income countries, and the prevalence in these countries is predicted to increase substantially in the future. In Europe 29% of people aged 15 yr or older report a longstanding health problem (TNS Opinion, 2007), and the Office for National Statistics (2005) found that in England approximately 30% of the population (15.4 million people) has a LTC. As populations age, the burden of LTCs is projected to increase even further.
Long-Term Conditions and Mental Health Issues
People with LTCs are two to three times more likely than the general population to experience mental health problems. Depression and anxiety are the most frequently reported mental health problems in people with LTCs, but dementia, cognitive decline and some other conditions have also been reported (Naylor et al., 2012). Depression is two to three times more common in people with an LTC than in those with good physical health and occurs in approximately 20% of people with an LTC (National Collaborating Centre for Mental Health, 2010). Conservative estimates suggest that at least 30% of all people with an LTC also have a comorbid mental health problem of some kind (Cimpean & Drake, 2011). Research has shown that having a mental health problem along with an LTC has a stronger negative impact on quality of life and functional status than does either the number of LTCs or the severity of those conditions. For example, quality of life is lower in people with one LTC and depression than in people with two or more LTCs and no depression (Moussavi et al., 2007). Figure 8.1 shows the overlap between LTCs and mental health disorders.
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In addition to experiencing psychological distress, patients with an LTC and comorbid mental health problem experience poorer clinical outcomes compared with people with an LTC and no mental health problem (Moussavi et al., 2007). This is partly because self-management is necessary for effectively controlling LTCs, and poor mental health can result in poorer self-management. For example, it may lead to lack of motivation and energy to adhere to treatment plans or attend medical appointments (DiMatteo, Lepper & Croghan, 2000). From a financial perspective, comorbid mental health problems are typically associated with a 45% to 75% increase in care costs for a person with an LTC. These data are based on a wide range of LTCs and are observed after adjustment for severity of physical disease (Unützer et al., 2009; Welch et al., 2009).
Overlap between long-term conditions and mental health problems in England. Adapted, by permission, from C. Naylor et al., 2012, Long-term conditions and mental health: The cost of co-morbidities (London: The King's Fund and Centre for Mental Health).
Long-Term Conditions and Quality of Life
Quality of life is an individual's perception of their ability to function well on physical, mental and social levels. Quality of life can be measured in a reliable and valid manner using self-reported questionnaires, which can be categorised into three main groups: generic, disease specific and domain specific. Generic questionnaires measure quality of life in general terms, independent of the presence of any disease. Disease-specific questionnaires measure the consequences of a specific disease on quality of life. Domain-specific questionnaires focus on certain domains of quality of life (e.g., physical inabilities).
Where it is possible to manage but not cure a disease, such as in LTCs, measures of quality of life are frequently used to help determine the impact of treatment and disease. They help health professionals make informed judgements about whether treatment is appropriate and, where a choice of treatments exists, which might be the best option. Researchers frequently use these measures to assess the impact of a new intervention.
Long-Term Conditions and Physical Activity
Doctors have traditionally advised people with a range of LTCs to rest and not tire themselves out, and this advice persists in the lay psyche. For example, a recent Swedish survey found that the physical activity levels of people with diabetes, rheumatoid arthritis or COPD are lower than those of healthy controls; 73% of people with diabetes, 74% with rheumatoid arthritis and 84% with COPD reported low physical activity levels compared with 60% of controls (Arne et al., 2009). However, modern treatment of LTCs often includes promoting physical activity as part of a healthy lifestyle, and accumulating evidence shows the importance of physical activity in the management of both physical and psychological well-being for people with one or more LTCs. Regular contact between health professionals and people with LTCs provides opportunities for promoting physical activity in this group.
Each LTC presents its own challenges and benefits with regard to physical activity. The remainder of this chapter focusses in particular on the impact of physical activity on mental health and well-being in people with COPD, diabetes and cancer.
Chronic Obstructive Pulmonary Disease
COPD is characterised by airflow obstruction that is not fully reversible and usually progressive in the long term. It is predominantly caused by smoking. Symptoms include breathlessness (dyspnoea) on exertion, chronic cough, regular production of sputum and frequent winter bronchitis or wheeze. Exacerbation of symptoms often occurs in which the patient's symptoms rapidly worsen beyond normal day-to-day variations. Diagnosis relies on a combination of history, physical examination and confirmation of airflow obstruction using spirometry; no single test for COPD exists (National Institute for Health and Clinical Excellence, 2010). Severity of COPD is often classified using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria (I [mild], II [moderate], III [severe] and IV [very severe]) and index of body mass, airway obstruction, dyspnoea and exercise capacity (BODE).
The World Health Organisation has predicted that by 2020 COPD will be the third leading cause of death and fifth leading cause of disability in the world (Murray & Lopez, 1996, 1997). Mortality rates for men in the United Kingdom are at a plateau and mortality rates for women are steadily increasing (Soriano et al., 2000) most likely as a result of the uptake of smoking among women post-World War II. According to the chief medical officer in England, COPD accounts for more than £800 million in direct health care costs (Department of Health, 2005); more than one half of these costs relate to the provision of hospital care. COPD is among the most costly inpatient conditions that the National Health Service treats.
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Designing a physical activity program for individuals with addictions
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours.
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours. However, implementation of behavior change in this population can present practitioners with specific challenges. This section discusses the suggestions for designing effective interventions for those with addictions based on the evidence reviewed so far as well as practical considerations.
Exercise Type, Frequency and Intensity
Most studies have promoted moderate-intensity cardiovascular-type exercise such as brisk walking for use in those with addictive behaviours. Some work also incorporates more vigorous activities such as running. Because individuals with addictions are often extremely sedentary, a programme of moderate-intensity activity is likely to be acceptable and safe. However, a progression to more vigorous exercise may be beneficial. For example, the only study that found a long-term benefit of exercise for smoking cessation entailed 30 to 40 min of vigorous exercise 3 times/wk for 12 wk (Marcus et al., 1999). Similarly, the single study that showed a long-term impact of exercise on alcohol abstinence involved 1 h of progressively vigorous exercise 5 days/wk for 6 wk (Sinyor et al., 1982). None of the trials reviewed compared the effects of vigorous-intensity and moderate-intensity exercise on abstinence rates. Experimental studies have compared the effects of bouts of moderate-intensity and vigorous-intensity exercise and have shown that both intensities are effective in the short term for reducing tobacco-withdrawal symptoms (Taylor et al., 2007).
The intensity of activity that an individual is capable of depends on initial level of fitness, medical condition and stage of recovery from addiction. Careful medical screening is vital. For example, those addicted to amphetamine or cocaine are often undernourished, and problem drinkers often have weak muscles. Such individuals may require nutrition advice. Ultimately, individuals will have preferences regarding types of exercise, and programmes should be tailored to these preferences (Abrantes et al., 2011; Everson-Hock et al., 2010). Some individuals may prefer noncardiovascular types of exercise, which may also be beneficial. Resistance (i.e., weight) training, yoga and isometric exercise have all been successfully piloted as aids for smoking cessation and need to be tested in larger trials (Ussher, Taylor & Faulkner, 2012).
Regarding frequency and volume of exercise, the findings from Marcus and colleagues (2005) suggest that abstaining smokers need to accumulate at least 110 min/wk of moderate-intensity activity to maintain abstinence; supervised exercise on 2 or 3 days/wk may be necessary in order to achieve this. Shorter bouts of exercise can be used on an as-needed basis in response to cravings, and longer scheduled bouts can be used to maintain positive mood, manage stress and prevent cravings from arising. Research has not yet addressed the optimum dose of exercise for assisting alcohol and drug rehabilitation.
Exercise Supervision
The majority of intervention studies have employed group-based supervised exercise. In smokers, exercise counselling alone did not increase exercise levels sufficiently (Ussher et al., 2003), and all the interventions that showed a significant impact on long-term abstinence from alcohol or smoking entailed supervised exercise. Among novice exercisers, an element of supervised exercise may be useful to ensure initial adoption of regular exercise and to provide information about safe exercise (e.g., warm-up) and exercise intensities (e.g., using heart rate monitors). Counselling toward pursuing home-based exercise is also likely to be important for encouraging patients to maintain exercise levels after the initial exercise programme ends.
Stages of Addiction Treatment
Early recovery from drug and alcohol dependence is a major transition that affects close relationships and employment and involves numerous treatment sessions. An exercise programme needs to complement these changes. Most exercise interventions discussed in this chapter have required patients to alter their substance- or alcohol-misuse behaviour and exercise behaviour simultaneously, yet it is not clear whether this is optimal. For some individuals the challenge of changing two health behaviours simultaneously may be too demanding. Also, it is not clear whether involvement in physical activity increases the motivation to manage substance intake or vice versa.
Among smokers, exercise has often been introduced in the studies discussed several weeks before an attempt to quit, thereby allowing people to adjust to the demands of increased exercise before starting to quit. This also allows exercise to play a role in managing cravings during the crucial early days of abstinence, when relapse rates are highest. Empirical work is required to determine the relative benefits of initiating exercise at different points in the addiction-treatment process. During later stages of treatment exercise may be useful for preventing relapse (e.g., by promoting an exercise identity that is incompatible with drug use). Studies are also needed to determine whether exercise can be used to increase substance abstinence among those who are not motivated to attempt abstinence.
Integrating Exercise With Standard Addiction Treatments
Greater integration of addiction and exercise programmes may enhance abstinence rates. For instance, rather than just proposing exercise as a means for getting fitter and managing weight, the practitioner could present exercise more as a self-control strategy for managing withdrawal symptoms and a way to address psychological and physical harms caused by addiction. Exercise could be used more in combination with pharmaceutical interventions. Whereas pharmaceutical interventions focus on reducing withdrawal symptoms (e.g., NRT), exercise could ideally be used to provide an added effect in client-led management of addictive symptoms.
Perceived Barriers to Exercise
Individuals with addictions are likely to have specific barriers to exercise, and these need to be determined. In the general population, use of cognitive - behavioural techniques is effective for overcoming perceived barriers and increasing exercise adherence. Few addiction studies have included cognitive - behavioural counseling. Techniques such as self-monitoring (e.g., diaries), goal-setting and relapse-prevention planning are commonly used. Also, pedometers are now commonly used as a motivational tool. These and other motivational aids (e.g., financial incentives) need to be tested with exercise interventions in addicted populations.
Interventions for Different Subgroups
Exercise interventions need to be tested among addicted populations who might especially benefit from such interventions. Given the high prevalence of addictions among people with mental illness and the established benefits of regular physical activity for mental health, research that examines the role that physical activity may play in this population is needed (Arbour-Nicitopoulos et al., 2011).
Exercise interventions might be particularly appealing to adolescents, and controlled trials with young people are needed. Addicted individuals who are overweight may have a need for weight-control interventions such as exercise; no trial has yet focussed on this population. Additionally, surveys suggest that a nonpharmaceutical intervention such as exercise is likely to appeal to pregnant smokers (Ussher at al., 2008). Finally, sex needs to be considered when planning an appropriate intervention. Some evidence shows that women often prefer walking and aerobics, whereas men have more interest in sport, running and strength training.
Evidence to Practice
- Both moderate- and vigorous-intensity exercise have been shown to be effective for reducing tobacco-withdrawal symptoms and cravings.
- Progressing from light- and moderate-intensity exercise (e.g., brisk walking) to more vigorous-intensity exercise is advisable.
- Careful medical screening is required, especially among those with long-term alcohol or drug dependence (e.g., for malnutrition).
- Exercise interventions should be tailored to individual preferences.
- Abstaining smokers should accumulate at least 110 min/wk of moderate-intensity exercise.
- Interventions involving supervised exercise on 2 or 3 days/wk are likely to be necessary to be effective in treating addictive behaviours.
- Exercise can be performed on an as-needed basis for managing cravings or in scheduled bouts.
- If the exercise programme is to assist with early withdrawal symptoms, it ideally needs to begin before abstinence is attempted.
- Participating in physical activity encourages individuals to adopt an identity as an exerciser, which is incompatible with using addictive substances.
- Perceived barriers to exercise need to be identified and addressed using cognitive - behavioural techniques.
- The intervention needs to be adapted to various subgroups (e.g., according to sex, body weight and mental health).
Summary
Drug, alcohol and tobacco addictions are growing global problems. Exercise has many benefits for physical and psychological health, and evidence convincingly shows that exercise is effective for managing cravings and withdrawal symptoms, particularly in smokers. Regular exercise fosters a healthy lifestyle and exercise identity that is largely incompatible with addiction, and individuals undergoing rehabilitation for addiction express interest in exercising more. Exercise interventions are inexpensive, can be easily integrated with existing addiction treatments and have minimal side effects compared with pharmacological treatments. This chapter demonstrates that exercise is a highly plausible adjunctive treatment for addictive behaviour and that exercise programmes can be readily disseminated. However, limited evidence currently supports the benefits of exercise for helping smokers quit or helping those with drug or alcohol dependence abstain. This lack of evidence can partly be explained by the small number of large RCTs that have been conducted, lack of knowledge about effective doses of exercise and limited attention to methods for maximizing exercise adherence. This area of research is in its infancy, and further well-designed trials are needed.
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Physical activity guidelines
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits.
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits. National guidelines aimed at the whole population (as opposed to specific populations defined by a medical condition) focus on the optimal amount of activity to prevent disease and promote health and well-being. PAGs indicate the type (e.g., aerobic activity, strength training, weight bearing), frequency (e.g., 3 days/wk), duration (e.g., 30 min) and intensity (e.g., moderate, vigorous) (see figure 2.2) of physical activity to undertake and for what benefits. These detailed specifications reflect the latest science on the topic.
PAGs need to be updated periodically because evidence about the relationship between physical activity and health changes over time and knowledge grows. Some guidelines are more general in nature, whereas others provide very specific details; this usually reflects the state of knowledge at that time. Through a review and revision process, more specific details are added to PAGs when available. For example, in various national PAGs, guidelines relating to maintaining musculoskeletal strength have been revised over time and now include details on how much strength training is required for good health (World Health Organisation, 2010) and, specifically, for preventing falls and treating depression (Singh, Clements & Singh, 2001).
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The dose - response relationship: Increasing benefits from increasing amounts (expressed in frequency, duration and intensity) of activity. Reprinted, by permission, from I. Vuori, 1995, Terveysliikunta [Health and physical education]. UKK Institute for Health Promotion Research (Tampere, Finland).
National guidelines are an important component of a population-based approach to addressing any public health issue. First, such guidelines communicate a consensus on the scientific evidence of the importance of the issue. They describe the strength of the science in terms of the volume as well as the quality (determined based on the quality of study designs and research methods used) of the evidence. Communicating scientific consensus is important because it removes doubt and speculation about the validity of the health issue and its importance. This scientific consensus can also be used to advocate for resources and programmes. However, just because guidelines exist does not mean that everyone agrees about what the science says - far from it. However, these disagreements, or alternative interpretations of overall findings to date, are usually communicated in technical reports that accompany the publication of PAGs and are not fully accessible to the general public.
The process of developing PAGs usually involves leadership by a high-level institution. This adds credence to the message that the issue is important. For example, several national and international health agencies, such as the American Heart Association (Haskell et al., 2007), have developed guidelines on physical activity. National governments, usually the ministry of health, often lead the development process and endorse national PAGs. This endorsement is very useful because it specifies the government's position on physical activity and thereby provides the opportunity for interested parties such as charities and public health directors to leverage the government into supporting further action and funding for programmes and services aimed at increasing physical activity. This might include government endorsement of counselling and clinical services for inactive patients, as has been trialled in the United Kingdom (Bull & Milton, 2011). Government involvement and endorsement can also prevent policy inaction. The absence of an official position on physical activity can block funding and further development of a national population-based approach.
One important role of PAGs is to direct community-level actions aimed at increasing physical activity in the whole population. The details in PAGs about the type, frequency, duration and intensity of activities required for different age groups can provide clinicians, health care practitioners and others with direction on what types of programmes to provide and promote to patients and the wider community.
PAGs should drive and direct action not just at the level of individuals and service providers but also at all levels - national, regional and local - of government. If the national government endorses PAGs, ideally with multiparty political support, the government should be held accountable when levels of physical activity are not improving and can be expected to include physical activity promotion as part of ongoing disease-prevention and health-promotion strategies. The role of PAGs and national surveillance of risk factors is discussed in more detail later in this chapter.
Development of the First National Physical Activity Guidelines
Epidemiological studies of exercise and health were well advanced by the 1970s. The American College of Sports Medicine released the first set of recommendations in 1975 and released another set in 1980 (American College of Sports Medicine, 1975, 1980). These recommendations were predominantly directed at cardiorespiratory fitness and suggested that people undertake vigorous-intensity aerobic exercise 3 times/wk for 20 min each time. This was a practical interpretation of the exact recommendation from 1975, which suggested that people undertake 20 to 45 min of physical activity 3 to 5 days/wk at 70% to 90% of heart rate (i.e., vigorous intensity) (American College of Sports Medicine, 1975). The focus on aerobic exercise for increasing fitness continued to dominate and influence health messages about physical activity until the early 1990s. However, guidelines began to recommend moderate-intensity physical activity rather than vigorous-intensity activity, and by the mid-1990s the focus shifted from cardiorespiratory fitness to health benefits. This new position on physical activity was communicated in a landmark set of recommendations from the office of the U.S. surgeon general in the report "Physical Activity and Health" (U.S. Centers for Disease Control and Prevention, 1996).
In the mid-1990s, epidemiological evidence started to show that people with different health conditions require slightly different amounts of physical activity. Although the recommendation for 30 min of moderate-intensity activity on most days remained valid for preventing heart disease and diabetes, studies showed that slightly more physical activity was recommended for preventing cancer. Further, studies identified that the amount of activity required for weight loss or preventing weight gain was greater than that required to prevent chronic disease (Haskell et al., 2007). For example, the International Association for the Study of Obesity recommendations made a clear distinction between the minimum physical activity required for health benefits and the amount required for preventing weight gain. The recommendations state that "45 to 60 min (60-90 min for formerly obese individuals) of moderate-intensity physical activity daily is needed to prevent the transition to overweight or obesity" (Saris et al., 2003). Furthermore, research has now shown that the amount of physical activity required by young people differs from that of adults. The overall amount of physical activity recommended for children is twice that recommended for adults and is usually expressed as "at least 60 min/day" (Canadian Society for Exercise Physiology, 2011a; Saris et al., 2003).
These different recommendations make the development of PAGs complex. However, a core and consistent interpretation of the evidence is that 30 min of moderate-intensity physical activity on most days of the week is associated with maximum overall population benefit and the prevention of major noncommunicable diseases. This same dose has been expressed as "at least 150 min/wk of moderate-intensity activity" in the most recent global, U.S. and U.K recommendations (Department of Health, 2011b; U.S. Department of Health and Human Services, 2008a; World Health Organisation, 2010).
Current Best Practice in Developing Guidelines
Figure 2.3 illustrates the process of developing guidelines. The first step is establishing the need for guidelines. This need is often defined by policymakers, public health scientists, advocates and, sometimes, the community. Then a process for guideline development needs to be agreed on by interested parties, with actions planned in sequence and, ideally, a linkage between the PAG development process and other aspects of national or regional physical activity policy and strategy development (step 1 in figure 2.3). The next stage comprises reviewing the scientific evidence and creating an updated summary of what the research says and how this information differs from that in previous guidelines. A number of countries, notably Canada and, most recently, the United Kingdom and United States, have undertaken this process. Tremblay and colleagues (2010) extensively discuss this process with reference to the recent Canadian guidelines along with frameworks and a checklist for auditing data quality in the review stage.
Once the science has been reviewed, the next stage is developing communication messages based on the evidence and testing these messages with the target audience for acceptability, comprehension and usefulness. This step is part of developing a communications strategy for disseminating the evidence (stages 3 and 4 in figure 2.3). It requires resources for conducting the qualitative and quantitative research and the involvement of communications and media specialists in framing the messages correctly so that they will have optimal impact on the target populations. The final stages (stages 5-7 in figure 2.3) involve disseminating the message to the community, professional groups and other stakeholders. Historically, those developing PAGs have put considerable effort into the technical and scientific stages and have often neglected message development and communication. Frequently, only informal and unpaid communication channels are used after the launch of PAGs. Thus, a very important step in PAG development and dissemination is the final public health promotion component.
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Framework for developing physical activity guidelines. Adapted from Bauman et al. 2006.
Global, Regional and National Physical Activity Guidelines
Table 2.1 summarises the 2011 global PAGs and provides examples of regional (i.e., European and Western Pacific islands) and national guidelines. Quite a few countries in Europe have their own national PAGs, and many of these countries (e.g., Finland, Switzerland, the Netherlands, United Kingdom) have been engaged with implementing national population-based approaches for some time (Department of Health, 2011b; Ministry of Health, Welfare and Sport, 2011; Swiss Federal Office of Sports, 2006; UKK Institute, 2009). Other countries in Europe have officially or unofficially adopted the guidelines published by the U.S. Centers for Disease Control and Prevention in 1996 and the more recently updated 2008 version.
PAGs in other regions of the world are patchy. Australia (Department of Health and Ageing, 2005b) and New Zealand (Sport and Recreation New Zealand, 2005) have had national guidelines for some time. In Australia, guidelines exist for all ages, from young children (Department of Health and Ageing, 2004) to older adults (Department of Health and Ageing, 2005b), although all guidelines are more than 5 yr old and arguably are due for updating to reflect the latest science. Far fewer examples of PAGs exist in South America, Asia, the Middle East and Africa because physical activity promotion is relatively new in these regions. Countries in which national action on physical activity is beginning have often used the U.S. guidelines as an international benchmark. This has allowed the countries to develop an agenda of physical activity promotion without being hindered by the absence of PAGs. However, in some countries, adopting the PAGs of another country is not politically or culturally welcome or appropriate. Either these countries have developed their own PAGs (a recent example from the Middle East is Brunei; Ministry of Health, 2011) or very little physical activity promotion has occurred.
The absence of a set of official global guidelines did not hinder the World Health Organisation (WHO) from developing the Global Strategy on Diet, Physical Activity and Health in 2004 (World Health Organisation, 2004). Since the publication of the 2002 health report (World Health Organisation, 2002), the focus on the need for greater action to prevent noncommunicable disease and address mental health has increased. To address these issues, WHO commenced developing global guidelines in 2007. WHO launched the final global recommendations on physical activity in 2010 after a 2 yr process involving global and regional consultations (World Health Organisation, 2010). These global guidelines are now available for adoption and use by countries with no national PAGs. Because the guidelines are from WHO, the leading international health agency, the scientific quality and relevance of these guidelines are usually accepted.
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Treating depression and anxiety with exercise
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety.
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety. Information about these prescription parameters is scarce, but it is critical if exercise interventions are to be translated into clinical practice. Asking someone to do something without specifying what they should do or how they should do it would likely make it difficult for the individual to fully comply in a meaningful way. It is also possible that the prescription of exercise for depression and/or anxiety could be different, both in nature and content, than that required for general health benefits.
One trial that is particularly worthy of attention is the Depression Outcomes Study of Exercise (DOSE; Dunn et al., 2005), which attempted to provide evidence about the dose of exercise required to treat depression. In the DOSE study 80 participants were randomised to 1 of 4 exercise groups that varied in total energy expenditure (7 or 17.5 kcal·kg-1·wk-1) and frequency (3 or 5 days/wk) or to a flexibility-exercise placebo control for 12 wk. Exercise at a dose of 17.5 kcal·kg-1·wk-1 was effective in reducing depression regardless of frequency, whereas exercise at a dose of 7 kcal·kg-1·wk-1 yielded antidepressant effects that were comparable to those of the placebo treatment. The plausible biological reason for why a higher dose of exercise may be more effective than lower doses is that frequent and regular exercise should increase fitness levels such that physical discomfort decreases and exercise becomes a more pleasant and enjoyable experience as the conditioning process progresses. Indeed, findings from both the DOSE and TREAD trials in the United States have indicated that higher doses of exercise are more effective than are lower doses (as defined in the study).
Perraton and colleagues (2010) published a systematic review that attempted to summarise what is currently known about the prescription of exercise for depression. The review is useful because previous reviews of exercise and depression did not synthesise this information in a way that would help guide intervention development. This review included only trials that had reported exercise to be effective in reducing depression in order to analyse the specific dosage parameters and modes of exercise used in these successful trials.
The review found that the most common intensity, frequency and duration of aerobic exercise were 60% to 80% of maximum heart rate, 30 min/session and 3 days/wk over 8 wk. The volume of evidence supporting the use of aerobic exercise programmes to treat depression was greater than that supporting the use of anaerobic exercise programmes. No clear trend showed one mode of aerobic exercise to be the most effective, and a range of activity types appeared to be effective. This is encouraging given that one size does not fit all, and individuals can be encouraged to participate in whatever type of aerobic activity they prefer.
In terms of context of exercise, a number of common trends emerged. A variety of locations were effective in treating depression, although all trials that reported location took place indoors. Both group and individual interventions were effective. However, group exercise may have added benefit by providing social support, which can be pivotal for sustaining compliance and can contribute in its own right to lowering depression. Moreover, exercise might lower depression by several plausible mechanisms, one of which could be interrelations or connections with others (Bailey & McLaren, 2005). Many types of exercise can be performed with other people (depressed or not). Therefore, this exercise could provide social integration and an opportunity to interact with the social world as well as a setting in which to expand social networks and make friends (Stathi, Fox & McKenna, 2002).
Another unresolved question concerns the intensity of exercise at which a reduction in depression might occur. Callaghan and colleagues (2011) compared the effects of preferred intensity with those of prescribed intensity of group-based exercise for 12 sessions over 4 wk in 38 women aged 45 to 65 yr who were receiving treatment for depression from either primary or secondary care services. The preferred-intensity group reported significantly lower depression and higher self-esteem and quality-of-life scores than did the prescribed-exercise group and attended more sessions (66% versus 50%). Similar findings have been found in nondepressed populations (Daley & Maynard, 2003). Several theories, such as self-determination theory (Deci & Ryan, 1985), support the notion that giving people a choice and control over what they do, whether it be exercise or other activities, leads to better adherence and enjoyment of the activity, which in turn leads to enhanced psychological well-being. People experiencing depression are no exception.
Wipfli, Rethorst and Landers (2008) considered the relationship between dose of exercise and anxiety levels as part of their broader meta-analysis of the anxiolytic effect of exercise. The trend in the data from 12 RCTs showed that the effect size increased as exercise approached a dose of 12.5 kcal·kg-1·wk-1 (equates to slightly less than the dose recommended for public health) and then began to decrease as exercise dose increased. A combination of aerobic and anaerobic exercise appeared to be better than either type alone, and a frequency of 3 or 4 times/wk appeared more effective than more or less than this amount.
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Available methods for measuring physical activity
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry.
A range of methods are used in the assessment of physical activity, including self-report, systematic observation, motion sensors, cardiorespiratory fitness and free-living indirect calorimetry. Most are moderately correlated at best. Each method has its own strengths and limitations. Due to the complexity of physical activity, outlined previously, researchers and practitioners need to consider what is most important for their purposes when deciding to use a particular technique. Although no one measurement tool can be singled out as the most appropriate, recommendations for the most useful and practical measurement tools can be made after considering factors such as context, type, duration, frequency and intensity of physical activity as well as the constraints under which the research or treatment programme is operating. These techniques are presented in order of increasing feasibility but decreasing validity. Table 3.2 at the end of this section summarises the key advantages and limitations of each measurement technique.
Doubly Labelled Water
Doubly labelled water (DLW, or free-living indirect calorimetry) is a method commonly used to increase the precision and accuracy of physical activity measurement. DLW, which measures EE over several (4-21) consecutive days in a free-living person under normal life conditions (Schoeller, 1988), is the most widely accepted gold standard method by which to measure EE (Aadahl & Jørgensen, 2003). DLW measures EE of free-living, unrestricted subjects using water labelled with stable isotopes of oxygen and hydrogen (Schoeller & van Santen, 1982). It calculates activity-related EE by combining measurement of total EE with basal metabolic rate. The utility of the DLW method in measuring total EE is demonstrated by its use in a variety of settings, including all age groups, premature infants, hospitalised patients, pregnant women and the elderly (Ainslie, Reilly & Westerterp, 2003). As such, researchers who use this method to assess the relationship between physical activity and other psychological variables or to detect changes in physical activity as a result of interventions can be confident that the results produced regarding EE are accurate. Schoeller (1988) fully describes the validation of the DLW method.
Despite its level of precision, the DLW method is not without disadvantages, which include high cost, limitations for assessing brief periods of EE (Ainslie, Reilly & Westerterp, 2003) and additional demands on participants in terms of time and tasks required. The cost and availability of isotopes and the requirement for analysis by isotope ratio mass spectrometer prohibit DLW from being widely used in studies of large populations. The use of this method among populations with more severe mental health problems may likely present a set of ethical issues. Furthermore, although this technique provides an accurate measure of total EE, it cannot provide information about patterns of physical activity in terms of type, frequency, duration, intensity or context. Consequently, such an approach would not be feasible in a large natural-field experiment or in a test of the effect of interventions on changes in physical activity in both healthy populations and populations that suffer from mental health problems. However, this gold standard measure is believed to offer the most precise estimate of EE and is often used to validate many other types of tools that assess physical activity.
Direct Observation
Direct observation, one of the most basic approaches for acquiring information about behaviours, provides information about how people exercise and play, how environments shape the activities individuals participate in and how people use specific facilities (e.g., parks, leisure facilities, walking or cycling paths). It can take place using basic observation methods, systematic forms or sophisticated technology (e.g., lasers). Direct observation often involves a trained observer who codes physical activity behaviours (e.g., sitting, walking, running) undertaken by participants over time in various settings (e.g., playground, park, home). A number of observation systems are available, such as SOPLAY (System for Observing Play and Leisure Activity in Youth), SOFIT (System for Observing Fitness Instruction Time), and the Systematic Pedestrian and Cycling Environmental Scan. The trained observer may either observe participants in person or review video media. Because it is time consuming, direct observation might be used only with small groups in specific settings (Dugdill & Stratton, 2007).
Advantages of direct observation include that self-report bias is eliminated, participants do not need to recall behaviour and the level of detail regarding behaviour patterns and context can be extremely accurate. Furthermore, practitioners may find some of these tools accessible. For example, clinical psychologists working with institutionalised individuals diagnosed with severe mental health conditions may find this type of measurement technique useful for assessing relationships between physical activity patterns or patterns of inactivity and specific mental illnesses because it can combine both context and behaviour to provide powerful data.
However, disadvantages include the time involved in recording and coding behaviour, the time involved in consolidating the plethora of data collected and the costs associated with training coders. Furthermore, the subjective bias of coders may lead to incorrect judgments about the intensities of specific activities, which would affect estimates of EE. As such, it would be important to consider whether information regarding patterns of behaviour combined with context or specific EE data are required to fulfill the aims of a research project or treatment programme.
Accelerometers
Motion sensors, such as pedometers and accelerometers, can be used to detect body movement and estimate physical activity (Spruijt-Metz et al., 2009). Accelerometers are devices that measure bodily movements in terms of acceleration. This measurement can then be used to estimate the intensity of physical activity, and therefore EE, over time (Burton et al., 2005; Chen & Basset, 2005). Accelerometers can measure human activity on vertical (uniaxial accelerometers), anterior - posterior and medial - lateral (triaxial accelerometers) planes. EE can then be then estimated from vector magnitude counts using a proprietary algorithm, which is a composite of counts from these planes of motion (Howe, Staudenmayer & Freedson, 2009). Accelerometers can be used repeatedly on numerous participants, are more accurate than pedometers and are less expensive (approximately £200 per device; ActiLife, 2009) than other objective methods such as DLW (approximately £200 per participant per procedure; Friedman & Johnson, 2002). However, they remain too expensive to use in studies that assess large numbers of people (Wood, 2000). Nevertheless, these devices are a more feasible and participant-friendly method of attempting to validate a self-report questionnaire than is DLW. They also provide the data necessary to allow researchers to distinguish between light, moderate and vigorous physical activity as well as between continuous and intermittent activity modes (Crouter, Clowers & Bassett, 2006). A recent review of accelerometers against DLW found ActiGraph (previously named CSA/MTI) models to be of the most valid types tested; they produce an average correlation of r = .57 (Plasqui & Westerterp, 2007). Limitations of accelerometers include the increased time required to analyse the large amount of data provided, participant burden of wearing the device, that they cannot be feasibly used to test large-scale interventions, and that they cannot provide information about the specific type of activity (e.g., playing football, going to the gym) or the context in which it is performed.
Some studies have attempted to validate accelerometers among populations diagnosed with mental health conditions. For example, Sharpe and colleagues (2006) conducted a study to assess the validity of the RT3 accelerometer against DLW in people with schizophrenia. They found that the accelerometer overpredicted energy expended on physical activity by an average of 148 kcal/day (standard deviation = 413 kcal/day); this varied from an underestimation of 614 kcal/day to an overestimation of 582 kcal/day. The authors suggested that the RT3 accelerometer is a poor tool for measuring activity EE in sedentary men with schizophrenia. As such, the results of studies that have used this measurement tool in mentally ill populations may be questionable. For example, the recent intervention study of Jerome and colleagues (2009) used the RT3 accelerometer to measure physical activity in persons with mental illness. The authors of this study concluded that participants were undertaking approximately 120 min/wk of moderate-intensity physical activity on average, which would equal approximately 70 kcal/day. Given that the results of the study by Sharpe and colleagues (2006) indicated that the RT3 accelerometer overpredicted EE, it is possible that the results found by Jerome and colleagues (2009) overestimate the amount of physical activity undertaken by participants. Consequently, this might affect the validity of the relationships found between physical activity and various mental health variables measured in this study. Sharpe and colleagues (2006) did, however, indicate that the RT3 appeared to be a valid measure of physical inactivity in men with schizophrenia. Therefore, it could be used for research or clinical purposes to quantify the contribution of sedentary behaviour to medical conditions associated with inactivity. Sharpe and colleagues (2006) also recommended that using the RT3 to validate questionnaires may not be appropriate until it is more robust.
Indirect Objective Measures
Indicators of the physiologic response to physical activity include heart rate and pulmonary gas exchange. Heart-rate monitoring is a promising measurement method because heart rate is a physiological parameter that correlates well with, and strongly predicts, EE (Strath et al., 2002). Most heart rate monitors include software that converts heart rate data into an estimate of EE. However, one of the limitations of heart rate monitoring is that training state and individual heart rate characteristics can affect the relationship between heart rate and oxygen consumption. Higher levels of accuracy can be obtained through a graded submaximal exercise test that calibrates participant heart rate to simultaneous oxygen consumption. This information allows for the construction of a calibration curve that estimates EE at moderate and strenuous levels of exercise. (A linear relationship exists between increasing heart rate and oxygen consumption; Freedson & Miller, 2000.) Measuring heart rate is a common method used to describe intensity and duration of physical activity and is a relatively inexpensive method of measuring EE. However, heart rate is affected by factors other than physical activity, such as emotional stress, temperature, humidity, dehydration, posture and illness (Ainslie, Reilly & Westerterp, 2003). These factors can influence heart rate without causing associated changes in oxygen consumption. Given the potentially increased fluctuations in emotions in individuals diagnosed with mental health conditions, this method may not be the most appropriate for obtaining accurate physical activity levels. Furthermore, the relationship between oxygen uptake and heart rate is weak at low levels of activity (Keim, Blanton & Kretsch, 2004). Evidence suggests that individuals suffering from mental health problems tend to perform less intensive physical activity than do members of the general population (e.g., Brown et al., 1999). Therefore, the heart rate method may not provide accurate information about the physical activity of mental health populations. Also, the heart rate method is unable to identify types of activity or the context in which physical activity is performed. Although heart rate is a physiological marker for physical activity and may provide a general picture of physical activity patterns, it may not be the best method available for obtaining an accurate estimate of EE.
Pedometers
Pedometers, which measure steps on a single axis as well as calories expended, are less expensive than some other types of motion sensors. As such, these devices are an attractive alternative to self-report in large observational or intervention studies. Public health campaigns have also promoted pedometers as a motivational tool for achieving the goal of 10,000 steps daily. A range of pedometers is available. The pedometer that is most suitable for a particular study may depend on factors such as the research question (outcome of interest), population, available funds, context and validity of the model. For example, when considering context, researchers or practitioners who wish to understand the types of physical activity being undertaken in a variety of settings would not gain this information using pedometers alone. When considering population, some pedometers are validated in healthy adults but not in other populations such as children, the elderly or those diagnosed with mental illness. Pedometers have demonstrated reduced accuracy in elderly populations because of the slow pace or shuffling nature with which elderly people walk (Cyarto, Myers & Tudor-Locke, 2004). Tudor-Locke and colleagues (2002) evaluated the validity of pedometers in a review of 25 studies and found a strong correlation between pedometer counts and accelerometer output (median of reported correlations is r = .86). However, evidence suggests that the validity of pedometers for measuring EE and distance in normal populations is questionable. The findings of a study testing the validity of 10 pedometers (Crouter et al., 2003) indicated that these devices overestimated distance at slower speeds and underestimated distance at faster speeds. Furthermore, in 8 of the pedometers tested, it was unclear whether the device was measuring gross EE (all the energy expended by an individual during a specific activity) or net EE (the energy expended by an individual during a specific activity minus the resting EE for the equivalent amount of time). The Yamax Digiwalker SW-200 was found to be the most reliable and accurate pedometer available (Crouter et al., 2003). This pedometer was used in a recent study by McKercher (2009) that assessed relationships between physical activity and depression in young adults. This study found that low levels of depression were significantly correlated with moderate levels of physical activity, as measured by the Yamax Digiwalker SW-200, among females. However, this device has not been validated in specific mental health populations, which may limit the validity of these results. It is important to validate physical activity devices among specific populations because patterns of physical activity in these populations may differ from those in the general population. For example, individuals with serious mental illness are significantly less active than the general population (Brown et al., 2004). As such, using a physical activity measure that has been validated with mental health populations in research on physical activity and mental health will increase the strength of the results produced.
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Coping with long-term physical health conditions
Approximately 30% of the European population has a long-term physical health condition. People with a long-term condition that is comorbid with a mental health problem have worse health outcomes than do people with either of these alone.
Key Concepts
- Approximately 30% of people with a long-term condition have a comorbid mental health condition.
- Physical activity is an important part of the management of physical and psychological well-being in people with long-term conditions.
- Pulmonary rehabilitation leads to reduced depression and anxiety and increased quality of life in people with chronic obstructive pulmonary disease. Further research is required to understand the optimal exercise dose; the interaction of exercise training, education and psychosocial support during pulmonary rehabilitation; and how to sustain changes in physical activity behaviour after pulmonary rehabilitation.
- Physical inactivity is associated with greater depression in people with type 2 diabetes. Further research is required to understand the causality of this relationship, although available data suggest that physical activity interventions reduce depression.
- Data that explore the relationship between physical activity and mental health in people with type 1 diabetes are limited.
- Physical activity has been shown to increase quality of life and reduce anxiety and depression in cancer survivors. Data suggest that supervised and group exercise are more beneficial than unsupervised and home-based exercise in this population.
Long-term conditions (LTCs) have been defined as "those conditions that cannot, at present, be cured, but can be controlled by medication and other therapies. The life of a person with an LTC is forever altered - there is no return to normal" (Department of Health, 2008, p. 10). LTCs include diabetes, arthritis, chronic obstructive pulmonary disease (COPD) and a number of cardiovascular diseases. In addition, conditions such as human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) and certain cancers that were not traditionally considered LTCs are increasingly being regarded as such (Naylor et al., 2012). Many mental health problems can themselves be considered LTCs. However, in this chapter the term long-term condition refers specifically to physical health conditions.
The World Health Organisation's (2011) report on the global burden of noncommunicable diseases (i.e., all previously mentioned LTCs except HIV and AIDS) found that noncommunicable diseases are by far the leading cause of mortality in the world and represent 63% of all deaths. The majority of these deaths are due to cardiovascular disease, diabetes, cancer and chronic respiratory disease. The highest occurrence of deaths from these diseases is in low- and middle-income countries, and the prevalence in these countries is predicted to increase substantially in the future. In Europe 29% of people aged 15 yr or older report a longstanding health problem (TNS Opinion, 2007), and the Office for National Statistics (2005) found that in England approximately 30% of the population (15.4 million people) has a LTC. As populations age, the burden of LTCs is projected to increase even further.
Long-Term Conditions and Mental Health Issues
People with LTCs are two to three times more likely than the general population to experience mental health problems. Depression and anxiety are the most frequently reported mental health problems in people with LTCs, but dementia, cognitive decline and some other conditions have also been reported (Naylor et al., 2012). Depression is two to three times more common in people with an LTC than in those with good physical health and occurs in approximately 20% of people with an LTC (National Collaborating Centre for Mental Health, 2010). Conservative estimates suggest that at least 30% of all people with an LTC also have a comorbid mental health problem of some kind (Cimpean & Drake, 2011). Research has shown that having a mental health problem along with an LTC has a stronger negative impact on quality of life and functional status than does either the number of LTCs or the severity of those conditions. For example, quality of life is lower in people with one LTC and depression than in people with two or more LTCs and no depression (Moussavi et al., 2007). Figure 8.1 shows the overlap between LTCs and mental health disorders.
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In addition to experiencing psychological distress, patients with an LTC and comorbid mental health problem experience poorer clinical outcomes compared with people with an LTC and no mental health problem (Moussavi et al., 2007). This is partly because self-management is necessary for effectively controlling LTCs, and poor mental health can result in poorer self-management. For example, it may lead to lack of motivation and energy to adhere to treatment plans or attend medical appointments (DiMatteo, Lepper & Croghan, 2000). From a financial perspective, comorbid mental health problems are typically associated with a 45% to 75% increase in care costs for a person with an LTC. These data are based on a wide range of LTCs and are observed after adjustment for severity of physical disease (Unützer et al., 2009; Welch et al., 2009).
Overlap between long-term conditions and mental health problems in England. Adapted, by permission, from C. Naylor et al., 2012, Long-term conditions and mental health: The cost of co-morbidities (London: The King's Fund and Centre for Mental Health).
Long-Term Conditions and Quality of Life
Quality of life is an individual's perception of their ability to function well on physical, mental and social levels. Quality of life can be measured in a reliable and valid manner using self-reported questionnaires, which can be categorised into three main groups: generic, disease specific and domain specific. Generic questionnaires measure quality of life in general terms, independent of the presence of any disease. Disease-specific questionnaires measure the consequences of a specific disease on quality of life. Domain-specific questionnaires focus on certain domains of quality of life (e.g., physical inabilities).
Where it is possible to manage but not cure a disease, such as in LTCs, measures of quality of life are frequently used to help determine the impact of treatment and disease. They help health professionals make informed judgements about whether treatment is appropriate and, where a choice of treatments exists, which might be the best option. Researchers frequently use these measures to assess the impact of a new intervention.
Long-Term Conditions and Physical Activity
Doctors have traditionally advised people with a range of LTCs to rest and not tire themselves out, and this advice persists in the lay psyche. For example, a recent Swedish survey found that the physical activity levels of people with diabetes, rheumatoid arthritis or COPD are lower than those of healthy controls; 73% of people with diabetes, 74% with rheumatoid arthritis and 84% with COPD reported low physical activity levels compared with 60% of controls (Arne et al., 2009). However, modern treatment of LTCs often includes promoting physical activity as part of a healthy lifestyle, and accumulating evidence shows the importance of physical activity in the management of both physical and psychological well-being for people with one or more LTCs. Regular contact between health professionals and people with LTCs provides opportunities for promoting physical activity in this group.
Each LTC presents its own challenges and benefits with regard to physical activity. The remainder of this chapter focusses in particular on the impact of physical activity on mental health and well-being in people with COPD, diabetes and cancer.
Chronic Obstructive Pulmonary Disease
COPD is characterised by airflow obstruction that is not fully reversible and usually progressive in the long term. It is predominantly caused by smoking. Symptoms include breathlessness (dyspnoea) on exertion, chronic cough, regular production of sputum and frequent winter bronchitis or wheeze. Exacerbation of symptoms often occurs in which the patient's symptoms rapidly worsen beyond normal day-to-day variations. Diagnosis relies on a combination of history, physical examination and confirmation of airflow obstruction using spirometry; no single test for COPD exists (National Institute for Health and Clinical Excellence, 2010). Severity of COPD is often classified using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria (I [mild], II [moderate], III [severe] and IV [very severe]) and index of body mass, airway obstruction, dyspnoea and exercise capacity (BODE).
The World Health Organisation has predicted that by 2020 COPD will be the third leading cause of death and fifth leading cause of disability in the world (Murray & Lopez, 1996, 1997). Mortality rates for men in the United Kingdom are at a plateau and mortality rates for women are steadily increasing (Soriano et al., 2000) most likely as a result of the uptake of smoking among women post-World War II. According to the chief medical officer in England, COPD accounts for more than £800 million in direct health care costs (Department of Health, 2005); more than one half of these costs relate to the provision of hospital care. COPD is among the most costly inpatient conditions that the National Health Service treats.
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Designing a physical activity program for individuals with addictions
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours.
The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours. However, implementation of behavior change in this population can present practitioners with specific challenges. This section discusses the suggestions for designing effective interventions for those with addictions based on the evidence reviewed so far as well as practical considerations.
Exercise Type, Frequency and Intensity
Most studies have promoted moderate-intensity cardiovascular-type exercise such as brisk walking for use in those with addictive behaviours. Some work also incorporates more vigorous activities such as running. Because individuals with addictions are often extremely sedentary, a programme of moderate-intensity activity is likely to be acceptable and safe. However, a progression to more vigorous exercise may be beneficial. For example, the only study that found a long-term benefit of exercise for smoking cessation entailed 30 to 40 min of vigorous exercise 3 times/wk for 12 wk (Marcus et al., 1999). Similarly, the single study that showed a long-term impact of exercise on alcohol abstinence involved 1 h of progressively vigorous exercise 5 days/wk for 6 wk (Sinyor et al., 1982). None of the trials reviewed compared the effects of vigorous-intensity and moderate-intensity exercise on abstinence rates. Experimental studies have compared the effects of bouts of moderate-intensity and vigorous-intensity exercise and have shown that both intensities are effective in the short term for reducing tobacco-withdrawal symptoms (Taylor et al., 2007).
The intensity of activity that an individual is capable of depends on initial level of fitness, medical condition and stage of recovery from addiction. Careful medical screening is vital. For example, those addicted to amphetamine or cocaine are often undernourished, and problem drinkers often have weak muscles. Such individuals may require nutrition advice. Ultimately, individuals will have preferences regarding types of exercise, and programmes should be tailored to these preferences (Abrantes et al., 2011; Everson-Hock et al., 2010). Some individuals may prefer noncardiovascular types of exercise, which may also be beneficial. Resistance (i.e., weight) training, yoga and isometric exercise have all been successfully piloted as aids for smoking cessation and need to be tested in larger trials (Ussher, Taylor & Faulkner, 2012).
Regarding frequency and volume of exercise, the findings from Marcus and colleagues (2005) suggest that abstaining smokers need to accumulate at least 110 min/wk of moderate-intensity activity to maintain abstinence; supervised exercise on 2 or 3 days/wk may be necessary in order to achieve this. Shorter bouts of exercise can be used on an as-needed basis in response to cravings, and longer scheduled bouts can be used to maintain positive mood, manage stress and prevent cravings from arising. Research has not yet addressed the optimum dose of exercise for assisting alcohol and drug rehabilitation.
Exercise Supervision
The majority of intervention studies have employed group-based supervised exercise. In smokers, exercise counselling alone did not increase exercise levels sufficiently (Ussher et al., 2003), and all the interventions that showed a significant impact on long-term abstinence from alcohol or smoking entailed supervised exercise. Among novice exercisers, an element of supervised exercise may be useful to ensure initial adoption of regular exercise and to provide information about safe exercise (e.g., warm-up) and exercise intensities (e.g., using heart rate monitors). Counselling toward pursuing home-based exercise is also likely to be important for encouraging patients to maintain exercise levels after the initial exercise programme ends.
Stages of Addiction Treatment
Early recovery from drug and alcohol dependence is a major transition that affects close relationships and employment and involves numerous treatment sessions. An exercise programme needs to complement these changes. Most exercise interventions discussed in this chapter have required patients to alter their substance- or alcohol-misuse behaviour and exercise behaviour simultaneously, yet it is not clear whether this is optimal. For some individuals the challenge of changing two health behaviours simultaneously may be too demanding. Also, it is not clear whether involvement in physical activity increases the motivation to manage substance intake or vice versa.
Among smokers, exercise has often been introduced in the studies discussed several weeks before an attempt to quit, thereby allowing people to adjust to the demands of increased exercise before starting to quit. This also allows exercise to play a role in managing cravings during the crucial early days of abstinence, when relapse rates are highest. Empirical work is required to determine the relative benefits of initiating exercise at different points in the addiction-treatment process. During later stages of treatment exercise may be useful for preventing relapse (e.g., by promoting an exercise identity that is incompatible with drug use). Studies are also needed to determine whether exercise can be used to increase substance abstinence among those who are not motivated to attempt abstinence.
Integrating Exercise With Standard Addiction Treatments
Greater integration of addiction and exercise programmes may enhance abstinence rates. For instance, rather than just proposing exercise as a means for getting fitter and managing weight, the practitioner could present exercise more as a self-control strategy for managing withdrawal symptoms and a way to address psychological and physical harms caused by addiction. Exercise could be used more in combination with pharmaceutical interventions. Whereas pharmaceutical interventions focus on reducing withdrawal symptoms (e.g., NRT), exercise could ideally be used to provide an added effect in client-led management of addictive symptoms.
Perceived Barriers to Exercise
Individuals with addictions are likely to have specific barriers to exercise, and these need to be determined. In the general population, use of cognitive - behavioural techniques is effective for overcoming perceived barriers and increasing exercise adherence. Few addiction studies have included cognitive - behavioural counseling. Techniques such as self-monitoring (e.g., diaries), goal-setting and relapse-prevention planning are commonly used. Also, pedometers are now commonly used as a motivational tool. These and other motivational aids (e.g., financial incentives) need to be tested with exercise interventions in addicted populations.
Interventions for Different Subgroups
Exercise interventions need to be tested among addicted populations who might especially benefit from such interventions. Given the high prevalence of addictions among people with mental illness and the established benefits of regular physical activity for mental health, research that examines the role that physical activity may play in this population is needed (Arbour-Nicitopoulos et al., 2011).
Exercise interventions might be particularly appealing to adolescents, and controlled trials with young people are needed. Addicted individuals who are overweight may have a need for weight-control interventions such as exercise; no trial has yet focussed on this population. Additionally, surveys suggest that a nonpharmaceutical intervention such as exercise is likely to appeal to pregnant smokers (Ussher at al., 2008). Finally, sex needs to be considered when planning an appropriate intervention. Some evidence shows that women often prefer walking and aerobics, whereas men have more interest in sport, running and strength training.
Evidence to Practice
- Both moderate- and vigorous-intensity exercise have been shown to be effective for reducing tobacco-withdrawal symptoms and cravings.
- Progressing from light- and moderate-intensity exercise (e.g., brisk walking) to more vigorous-intensity exercise is advisable.
- Careful medical screening is required, especially among those with long-term alcohol or drug dependence (e.g., for malnutrition).
- Exercise interventions should be tailored to individual preferences.
- Abstaining smokers should accumulate at least 110 min/wk of moderate-intensity exercise.
- Interventions involving supervised exercise on 2 or 3 days/wk are likely to be necessary to be effective in treating addictive behaviours.
- Exercise can be performed on an as-needed basis for managing cravings or in scheduled bouts.
- If the exercise programme is to assist with early withdrawal symptoms, it ideally needs to begin before abstinence is attempted.
- Participating in physical activity encourages individuals to adopt an identity as an exerciser, which is incompatible with using addictive substances.
- Perceived barriers to exercise need to be identified and addressed using cognitive - behavioural techniques.
- The intervention needs to be adapted to various subgroups (e.g., according to sex, body weight and mental health).
Summary
Drug, alcohol and tobacco addictions are growing global problems. Exercise has many benefits for physical and psychological health, and evidence convincingly shows that exercise is effective for managing cravings and withdrawal symptoms, particularly in smokers. Regular exercise fosters a healthy lifestyle and exercise identity that is largely incompatible with addiction, and individuals undergoing rehabilitation for addiction express interest in exercising more. Exercise interventions are inexpensive, can be easily integrated with existing addiction treatments and have minimal side effects compared with pharmacological treatments. This chapter demonstrates that exercise is a highly plausible adjunctive treatment for addictive behaviour and that exercise programmes can be readily disseminated. However, limited evidence currently supports the benefits of exercise for helping smokers quit or helping those with drug or alcohol dependence abstain. This lack of evidence can partly be explained by the small number of large RCTs that have been conducted, lack of knowledge about effective doses of exercise and limited attention to methods for maximizing exercise adherence. This area of research is in its infancy, and further well-designed trials are needed.
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Physical activity guidelines
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits.
PAGs are evidence-based summary statements on the health benefits of physical activity and represent a high level consensus on what the scientific evidence has demonstrated by describing, in a summary format, the "dose" of the behaviour required to gain the benefits. National guidelines aimed at the whole population (as opposed to specific populations defined by a medical condition) focus on the optimal amount of activity to prevent disease and promote health and well-being. PAGs indicate the type (e.g., aerobic activity, strength training, weight bearing), frequency (e.g., 3 days/wk), duration (e.g., 30 min) and intensity (e.g., moderate, vigorous) (see figure 2.2) of physical activity to undertake and for what benefits. These detailed specifications reflect the latest science on the topic.
PAGs need to be updated periodically because evidence about the relationship between physical activity and health changes over time and knowledge grows. Some guidelines are more general in nature, whereas others provide very specific details; this usually reflects the state of knowledge at that time. Through a review and revision process, more specific details are added to PAGs when available. For example, in various national PAGs, guidelines relating to maintaining musculoskeletal strength have been revised over time and now include details on how much strength training is required for good health (World Health Organisation, 2010) and, specifically, for preventing falls and treating depression (Singh, Clements & Singh, 2001).
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The dose - response relationship: Increasing benefits from increasing amounts (expressed in frequency, duration and intensity) of activity. Reprinted, by permission, from I. Vuori, 1995, Terveysliikunta [Health and physical education]. UKK Institute for Health Promotion Research (Tampere, Finland).
National guidelines are an important component of a population-based approach to addressing any public health issue. First, such guidelines communicate a consensus on the scientific evidence of the importance of the issue. They describe the strength of the science in terms of the volume as well as the quality (determined based on the quality of study designs and research methods used) of the evidence. Communicating scientific consensus is important because it removes doubt and speculation about the validity of the health issue and its importance. This scientific consensus can also be used to advocate for resources and programmes. However, just because guidelines exist does not mean that everyone agrees about what the science says - far from it. However, these disagreements, or alternative interpretations of overall findings to date, are usually communicated in technical reports that accompany the publication of PAGs and are not fully accessible to the general public.
The process of developing PAGs usually involves leadership by a high-level institution. This adds credence to the message that the issue is important. For example, several national and international health agencies, such as the American Heart Association (Haskell et al., 2007), have developed guidelines on physical activity. National governments, usually the ministry of health, often lead the development process and endorse national PAGs. This endorsement is very useful because it specifies the government's position on physical activity and thereby provides the opportunity for interested parties such as charities and public health directors to leverage the government into supporting further action and funding for programmes and services aimed at increasing physical activity. This might include government endorsement of counselling and clinical services for inactive patients, as has been trialled in the United Kingdom (Bull & Milton, 2011). Government involvement and endorsement can also prevent policy inaction. The absence of an official position on physical activity can block funding and further development of a national population-based approach.
One important role of PAGs is to direct community-level actions aimed at increasing physical activity in the whole population. The details in PAGs about the type, frequency, duration and intensity of activities required for different age groups can provide clinicians, health care practitioners and others with direction on what types of programmes to provide and promote to patients and the wider community.
PAGs should drive and direct action not just at the level of individuals and service providers but also at all levels - national, regional and local - of government. If the national government endorses PAGs, ideally with multiparty political support, the government should be held accountable when levels of physical activity are not improving and can be expected to include physical activity promotion as part of ongoing disease-prevention and health-promotion strategies. The role of PAGs and national surveillance of risk factors is discussed in more detail later in this chapter.
Development of the First National Physical Activity Guidelines
Epidemiological studies of exercise and health were well advanced by the 1970s. The American College of Sports Medicine released the first set of recommendations in 1975 and released another set in 1980 (American College of Sports Medicine, 1975, 1980). These recommendations were predominantly directed at cardiorespiratory fitness and suggested that people undertake vigorous-intensity aerobic exercise 3 times/wk for 20 min each time. This was a practical interpretation of the exact recommendation from 1975, which suggested that people undertake 20 to 45 min of physical activity 3 to 5 days/wk at 70% to 90% of heart rate (i.e., vigorous intensity) (American College of Sports Medicine, 1975). The focus on aerobic exercise for increasing fitness continued to dominate and influence health messages about physical activity until the early 1990s. However, guidelines began to recommend moderate-intensity physical activity rather than vigorous-intensity activity, and by the mid-1990s the focus shifted from cardiorespiratory fitness to health benefits. This new position on physical activity was communicated in a landmark set of recommendations from the office of the U.S. surgeon general in the report "Physical Activity and Health" (U.S. Centers for Disease Control and Prevention, 1996).
In the mid-1990s, epidemiological evidence started to show that people with different health conditions require slightly different amounts of physical activity. Although the recommendation for 30 min of moderate-intensity activity on most days remained valid for preventing heart disease and diabetes, studies showed that slightly more physical activity was recommended for preventing cancer. Further, studies identified that the amount of activity required for weight loss or preventing weight gain was greater than that required to prevent chronic disease (Haskell et al., 2007). For example, the International Association for the Study of Obesity recommendations made a clear distinction between the minimum physical activity required for health benefits and the amount required for preventing weight gain. The recommendations state that "45 to 60 min (60-90 min for formerly obese individuals) of moderate-intensity physical activity daily is needed to prevent the transition to overweight or obesity" (Saris et al., 2003). Furthermore, research has now shown that the amount of physical activity required by young people differs from that of adults. The overall amount of physical activity recommended for children is twice that recommended for adults and is usually expressed as "at least 60 min/day" (Canadian Society for Exercise Physiology, 2011a; Saris et al., 2003).
These different recommendations make the development of PAGs complex. However, a core and consistent interpretation of the evidence is that 30 min of moderate-intensity physical activity on most days of the week is associated with maximum overall population benefit and the prevention of major noncommunicable diseases. This same dose has been expressed as "at least 150 min/wk of moderate-intensity activity" in the most recent global, U.S. and U.K recommendations (Department of Health, 2011b; U.S. Department of Health and Human Services, 2008a; World Health Organisation, 2010).
Current Best Practice in Developing Guidelines
Figure 2.3 illustrates the process of developing guidelines. The first step is establishing the need for guidelines. This need is often defined by policymakers, public health scientists, advocates and, sometimes, the community. Then a process for guideline development needs to be agreed on by interested parties, with actions planned in sequence and, ideally, a linkage between the PAG development process and other aspects of national or regional physical activity policy and strategy development (step 1 in figure 2.3). The next stage comprises reviewing the scientific evidence and creating an updated summary of what the research says and how this information differs from that in previous guidelines. A number of countries, notably Canada and, most recently, the United Kingdom and United States, have undertaken this process. Tremblay and colleagues (2010) extensively discuss this process with reference to the recent Canadian guidelines along with frameworks and a checklist for auditing data quality in the review stage.
Once the science has been reviewed, the next stage is developing communication messages based on the evidence and testing these messages with the target audience for acceptability, comprehension and usefulness. This step is part of developing a communications strategy for disseminating the evidence (stages 3 and 4 in figure 2.3). It requires resources for conducting the qualitative and quantitative research and the involvement of communications and media specialists in framing the messages correctly so that they will have optimal impact on the target populations. The final stages (stages 5-7 in figure 2.3) involve disseminating the message to the community, professional groups and other stakeholders. Historically, those developing PAGs have put considerable effort into the technical and scientific stages and have often neglected message development and communication. Frequently, only informal and unpaid communication channels are used after the launch of PAGs. Thus, a very important step in PAG development and dissemination is the final public health promotion component.
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Framework for developing physical activity guidelines. Adapted from Bauman et al. 2006.
Global, Regional and National Physical Activity Guidelines
Table 2.1 summarises the 2011 global PAGs and provides examples of regional (i.e., European and Western Pacific islands) and national guidelines. Quite a few countries in Europe have their own national PAGs, and many of these countries (e.g., Finland, Switzerland, the Netherlands, United Kingdom) have been engaged with implementing national population-based approaches for some time (Department of Health, 2011b; Ministry of Health, Welfare and Sport, 2011; Swiss Federal Office of Sports, 2006; UKK Institute, 2009). Other countries in Europe have officially or unofficially adopted the guidelines published by the U.S. Centers for Disease Control and Prevention in 1996 and the more recently updated 2008 version.
PAGs in other regions of the world are patchy. Australia (Department of Health and Ageing, 2005b) and New Zealand (Sport and Recreation New Zealand, 2005) have had national guidelines for some time. In Australia, guidelines exist for all ages, from young children (Department of Health and Ageing, 2004) to older adults (Department of Health and Ageing, 2005b), although all guidelines are more than 5 yr old and arguably are due for updating to reflect the latest science. Far fewer examples of PAGs exist in South America, Asia, the Middle East and Africa because physical activity promotion is relatively new in these regions. Countries in which national action on physical activity is beginning have often used the U.S. guidelines as an international benchmark. This has allowed the countries to develop an agenda of physical activity promotion without being hindered by the absence of PAGs. However, in some countries, adopting the PAGs of another country is not politically or culturally welcome or appropriate. Either these countries have developed their own PAGs (a recent example from the Middle East is Brunei; Ministry of Health, 2011) or very little physical activity promotion has occurred.
The absence of a set of official global guidelines did not hinder the World Health Organisation (WHO) from developing the Global Strategy on Diet, Physical Activity and Health in 2004 (World Health Organisation, 2004). Since the publication of the 2002 health report (World Health Organisation, 2002), the focus on the need for greater action to prevent noncommunicable disease and address mental health has increased. To address these issues, WHO commenced developing global guidelines in 2007. WHO launched the final global recommendations on physical activity in 2010 after a 2 yr process involving global and regional consultations (World Health Organisation, 2010). These global guidelines are now available for adoption and use by countries with no national PAGs. Because the guidelines are from WHO, the leading international health agency, the scientific quality and relevance of these guidelines are usually accepted.
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Treating depression and anxiety with exercise
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety.
It is important to understand the dose, type and context of exercise that are necessary or ideal for effectively treating depression and anxiety. Information about these prescription parameters is scarce, but it is critical if exercise interventions are to be translated into clinical practice. Asking someone to do something without specifying what they should do or how they should do it would likely make it difficult for the individual to fully comply in a meaningful way. It is also possible that the prescription of exercise for depression and/or anxiety could be different, both in nature and content, than that required for general health benefits.
One trial that is particularly worthy of attention is the Depression Outcomes Study of Exercise (DOSE; Dunn et al., 2005), which attempted to provide evidence about the dose of exercise required to treat depression. In the DOSE study 80 participants were randomised to 1 of 4 exercise groups that varied in total energy expenditure (7 or 17.5 kcal·kg-1·wk-1) and frequency (3 or 5 days/wk) or to a flexibility-exercise placebo control for 12 wk. Exercise at a dose of 17.5 kcal·kg-1·wk-1 was effective in reducing depression regardless of frequency, whereas exercise at a dose of 7 kcal·kg-1·wk-1 yielded antidepressant effects that were comparable to those of the placebo treatment. The plausible biological reason for why a higher dose of exercise may be more effective than lower doses is that frequent and regular exercise should increase fitness levels such that physical discomfort decreases and exercise becomes a more pleasant and enjoyable experience as the conditioning process progresses. Indeed, findings from both the DOSE and TREAD trials in the United States have indicated that higher doses of exercise are more effective than are lower doses (as defined in the study).
Perraton and colleagues (2010) published a systematic review that attempted to summarise what is currently known about the prescription of exercise for depression. The review is useful because previous reviews of exercise and depression did not synthesise this information in a way that would help guide intervention development. This review included only trials that had reported exercise to be effective in reducing depression in order to analyse the specific dosage parameters and modes of exercise used in these successful trials.
The review found that the most common intensity, frequency and duration of aerobic exercise were 60% to 80% of maximum heart rate, 30 min/session and 3 days/wk over 8 wk. The volume of evidence supporting the use of aerobic exercise programmes to treat depression was greater than that supporting the use of anaerobic exercise programmes. No clear trend showed one mode of aerobic exercise to be the most effective, and a range of activity types appeared to be effective. This is encouraging given that one size does not fit all, and individuals can be encouraged to participate in whatever type of aerobic activity they prefer.
In terms of context of exercise, a number of common trends emerged. A variety of locations were effective in treating depression, although all trials that reported location took place indoors. Both group and individual interventions were effective. However, group exercise may have added benefit by providing social support, which can be pivotal for sustaining compliance and can contribute in its own right to lowering depression. Moreover, exercise might lower depression by several plausible mechanisms, one of which could be interrelations or connections with others (Bailey & McLaren, 2005). Many types of exercise can be performed with other people (depressed or not). Therefore, this exercise could provide social integration and an opportunity to interact with the social world as well as a setting in which to expand social networks and make friends (Stathi, Fox & McKenna, 2002).
Another unresolved question concerns the intensity of exercise at which a reduction in depression might occur. Callaghan and colleagues (2011) compared the effects of preferred intensity with those of prescribed intensity of group-based exercise for 12 sessions over 4 wk in 38 women aged 45 to 65 yr who were receiving treatment for depression from either primary or secondary care services. The preferred-intensity group reported significantly lower depression and higher self-esteem and quality-of-life scores than did the prescribed-exercise group and attended more sessions (66% versus 50%). Similar findings have been found in nondepressed populations (Daley & Maynard, 2003). Several theories, such as self-determination theory (Deci & Ryan, 1985), support the notion that giving people a choice and control over what they do, whether it be exercise or other activities, leads to better adherence and enjoyment of the activity, which in turn leads to enhanced psychological well-being. People experiencing depression are no exception.
Wipfli, Rethorst and Landers (2008) considered the relationship between dose of exercise and anxiety levels as part of their broader meta-analysis of the anxiolytic effect of exercise. The trend in the data from 12 RCTs showed that the effect size increased as exercise approached a dose of 12.5 kcal·kg-1·wk-1 (equates to slightly less than the dose recommended for public health) and then began to decrease as exercise dose increased. A combination of aerobic and anaerobic exercise appeared to be better than either type alone, and a frequency of 3 or 4 times/wk appeared more effective than more or less than this amount.
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