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The Effects of Stress on Physical Activity and Exercise - Sports Medicine

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Background Psychological stress and physical activity (PA) are believed to be reciprocally related; however, most research examining the relationship between these constructs is devoted to the study of exercise and/or PA as an instrument to mitigate distress. Objective The aim of this paper was to review the literature investigating the influence of stress on indicators of PA and exercise. Methods A systematic search of Web of Science, PubMed, and SPORTDiscus was employed to find all relevant studies focusing on human participants. Search terms included “stress”, “exercise”, and “physical activity”. A rating scale (0–9) modified for this study was utilized to assess the quality of all studies with multiple time points. Results The literature search found 168 studies that examined the influence of stress on PA. Studies varied widely in their theoretical orientation and included perceived stress, distress, life events, job strain, role strain, and work–family conflict but not lifetime cumulative adversity. To more clearly address the question, prospective studies (n = 55) were considered for further review, the majority of which indicated that psychological stress predicts less PA (behavioral inhibition) and/or exercise or more sedentary behavior (76.4 %). Both objective (i.e., life events) and subjective (i.e., distress) measures of stress related to reduced PA. Prospective studies investigating the effects of objective markers of stress nearly all agreed (six of seven studies) that stress has a negative effect on PA. This was true for research examining (a) PA at periods of objectively varying levels of stress (i.e., final examinations vs. a control time point) and (b) chronically stressed populations (e.g., caregivers, parents of children with a cancer diagnosis) that were less likely to be active than controls over time. Studies examining older adults (>50 years), cohorts with both men and women, and larger sample sizes (n > 100) were more likely to show an inverse association. 85.7 % of higher-quality prospective research (≥7 on a 9-point scale) showed the same trend. Interestingly, some prospective studies (18.2 %) report evidence that PA was positively impacted by stress (behavioral activation). This should not be surprising as some individuals utilize exercise to cope with stress. Several other factors may moderate stress and PA relationships, such as stages of change for exercise. Habitually active individuals exercise more in the face of stress, and those in beginning stages exercise less. Consequently, stress may have a differential impact on exercise adoption, maintenance, and relapse. Preliminary evidence suggests that combining stress management programming with exercise interventions may allay stress-related reductions in PA, though rigorous testing of these techniques has yet to be produced. Conclusions Overall, the majority of the literature finds that the experience of stress impairs efforts to be physically active. Future work should center on the development of a theory explaining the mechanisms underlying the multifarious influences of stress on PA behaviors.

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. Author manuscript; available in PMC: 2015 Jan 1.

Abstract

Background

Psychological stress and physical activity (PA) are believed to be reciprocally related; however, most research examining the relationship between these constructs is devoted to the study of exercise and/or PA as an instrument to mitigate distress.

Objective

The aim of this paper was to review the literature investigating the influence of stress on indicators of PA and exercise.

Methods

A systematic search of Web of Science, Pub-Med, and SPORTDiscus was employed to find all relevant studies focusing on human participants. Search terms included "stress", "exercise", and "physical activity". A rating scale (0-9) modified for this study was utilized to assess the quality of all studies with multiple time points.

Results

The literature search found 168 studies that examined the influence of stress on PA. Studies varied widely in their theoretical orientation and included perceived stress, distress, life events, job strain, role strain, and work-family conflict but not lifetime cumulative adversity. To more clearly address the question, prospective studies ( n = 55) were considered for further review, the majority of which indicated that psychological stress predicts less PA (behavioral inhibition) and/or exercise or more sedentary behavior (76.4 %). Both objective (i.e., life events) and subjective (i.e., distress) measures of stress related to reduced PA. Prospective studies investigating the effects of objective markers of stress nearly all agreed (six of seven studies) that stress has a negative effect on PA. This was true for research examining (a) PA at periods of objectively varying levels of stress (i.e., final examinations vs. a control time point) and (b) chronically stressed populations (e.g., caregivers, parents of children with a cancer diagnosis) that were less likely to be active than controls over time. Studies examining older adults (>50 years), cohorts with both men and women, and larger sample sizes ( n > 100) were more likely to show an inverse association. 85.7 % of higher-quality prospective research (≥7 on a 9-point scale) showed the same trend. Interestingly, some prospective studies (18.2 %) report evidence that PA was positively impacted by stress (behavioral activation). This should not be surprising as some individuals utilize exercise to cope with stress. Several other factors may moderate stress and PA relationships, such as stages of change for exercise. Habitually active individuals exercise more in the face of stress, and those in beginning stages exercise less. Consequently, stress may have a differential impact on exercise adoption, maintenance, and relapse. Preliminary evidence suggests that combining stress management programming with exercise interventions may allay stress-related reductions in PA, though rigorous testing of these techniques has yet to be produced.

Conclusions

Overall, the majority of the literature finds that the experience of stress impairs efforts to be physically active. Future work should center on the development of a theory explaining the mechanisms underlying the multifarious influences of stress on PA behaviors.

1 Introduction

1.4 Understanding Physical Activity (PA)

In contrast to the apparently debilitating effects of unremitting psychological stress, PA appears to have a salubrious effect on many health outcomes. PA is "any bodily movement produced by skeletal muscles that results in energy expenditure [ 58] above resting (basal) levels [ 59]. PA broadly encompasses exercise, sports, and physical activities done as part of daily living, occupation, leisure, and active transportation" [ 60]. Also implicit in this definition is that PA is a physical stressor, though not necessarily an uncomfortable one. Exercise is a behavioral subset of PA and is defined as "Physical activity that is planned, structured, and repetitive and has as a final or intermediate objective the improvement or maintenance of physical fitness" [ 58]. Dissimilarly, sedentarianism is "activity that involves little or no movement or PA, having an energy expenditure of about 1-1.5 metabolic equivalents (METs). Examples are sitting, watching television, playing video games, and using a computer" [ 61]. These definitions connote that PA behaviors are specific to a person, situation, and context. Also, they suggest that these concepts are quantified in terms of mode, frequency, duration, and intensity [ 60].

1.5 Beneficial Effects of PA/Exercise on Psychological Stress

When the PA and stress relationship is explored, it has typically been within the perspective of improving mental health outcomes via exercise [ 62]. As suggested earlier, those who exercise have lesser rates of depression, negative affectivity, and anxiety [ 10, 11]. Indeed, PA and exercise have been demonstrated to promote positive changes in one's mental health and ability to cope with stressful encounters [ 19, 63, 64]. Moreover, exercise interventions appear to improve one's depression status [ 65, 66].

2 Methods

2.1 Search for Publications

A search was conducted in Web of Science, SPORTDiscus and PubMed for relevant literature. The search terms utilized were "stress", "exercise", and "physical activity". This yielded a large number of returns. Consequently, the search was narrowed by selecting options in each database. When possible, articles were eliminated for irrelevant fields (e.g., engineering, chemical science, etc), unoriginal data (e.g., review articles, corrections, editorials, magazine articles), non-human subjects, and text not reported in the English language. Starting with Web of Science, titles and abstracts of articles were reviewed by one of the authors (MSK) for relevance with date in descending order. To speed the search, titles containing "stress test", "oxidative stress", "stress fracture", "stress incontinence", or "urinary stress" were automatically disqualified. Abstracts were also reviewed for relevance and scanned to make sure that PA was the outcome variable of interest and stress variables were the predictors. Case-control studies that investigated PA in stressed populations were retained. After this process was completed for the first database, the inspection of results for SPORTDiscus ensued. Articles were further eliminated if they were duplicated in Web of Science. This resulted in a very small collection of additional articles. With the additional fact that the initial results from PubMed were very large, the search date range was shortened to the years 2000-2012. These returns were searched for relevance as before. Finally, all article reference lists were examined for pertinent reports. The last search for articles via database was in July 2012 (see Fig. 1).

Fig. 1.

Flow chart of literature review for the effects of stress on physical activity

2.2 Study Quality Assessment

Prospective studies ( n = 55) were assessed for risk of bias with a quality assessment rating scale modeled after Rhodes and colleagues [ 162]. As with this former study, this instrument was developed to assess risk of bias as defined by the Cochrane Collaboration [ 163]. The quality scale comprised nine questions answered with a "yes" or "no" response (e.g., Did the study include a control group comparison? Was an objective measure of physical activity/inactivity used?). Low risk of bias (high quality) was deemed for studies with a score of 7-9, moderate quality and risk of bias for studies with scores between 5 and 6, and high risk of bias (low quality) for studies with a score of 4 or below (see Electronic Supplementary Material, Appendix 1).

3 Results

3.1 The Effects of Psychological Stress on PA/Exercise: State of the Literature

The search yielded a total of 168 papers interested in the impact of stress on PA. Five studies were published in the 1980s, 37 in the 1990s, 86 in the 2000s, and 40 from 2010 to July 2012 (see Fig. 2). The first evidence in the scientific literature of the link between mental stress and PA was reported in the early 1980s [ 164] (refer to Gardell et al. [ 165] for an earlier study reported in Swedish). Research at this time addressed the impact of stress on a host of health-promoting and -degrading behaviors, including alcohol use, smoking, dietary practices, and PA [ 164, 166- 168], in particular in relation to their role as risk factors for cardiovascular disease. This early work was epidemiological in nature, typically cross-sectional, employing very large sample sizes [ 164, 169, 170]. Furthermore, the population of focus frequently was middle-aged adults in occupational settings [ 169, 170].

Fig. 2.

Yearly distribution of publications ( n = 168) examining the association of stress and physical activity/exercise from 1984 to 2012

The majority of studies identified by the literature review supported the hypothesis that stress has an impact, whether negative or positive, on PA behaviors ( n = 134, 79.8 %). However, the literature is not entirely in agreement with regards to the valence of the association. The majority of studies ( n = 123, 72.8 %) provide evidence that psychological stress predicts lesser PA or exercise. Nevertheless, correlations of stress and exercise in studies supporting the association typically find no relationship greater than -0.28 to -0.42 [ 89, 143, 202- 204]. Conversely, 29 (17.2 %) studies provide evidence of an increase in PA with stress. As might be apparent, some papers reported evidence indicating (a) an association in both a positive and negative direction; and (b) that some indicators of stress and PA were not associated, but others were in either a positive or inverse direction (see Table 1).

Table 1.

n

Inverse associationb

No associationc

Positive associationd

n

%

n

%

n

%

Studies over a single time point

Retrospectivee

5

5

100.0

0

0.0

1

20.0

Studies with multiple time points

Prospective-non-objective stresse f

48

36

75.0

7

14.6

10

20.8

Prospective-objective stressf

7

6

85.7

1

14.3

0

0.0

All studiese

3.2 Supporting Evidence for an Inverse Relationship Between Stress and PA

3.2.1 Cross-Sectional, Retrospective, and Qualitative Studies

Studies conducted over a single time point (cross-sectional, qualitative, and retrospective, n = 114) have established an association between stress and PA. While two-thirds (67.0 %) of cross-sectional studies reported a negative association of stress with exercise, qualitative and retrospective (where respondents self-assess changes in PA) studies unanimously find evidence of an inverse association. These studies were typically of lower quality, with the exception of one study which reported that nearly 30 % of college students who were sufficiently active in high school did not attain this level of PA when transitioning to college [ 180] (see Electronic Supplementary Material, Appendix 2 for more details).

Stress has been inversely related to exercise and PA behavior most frequently for employee populations (22 studies) [ 83, 194, 205- 224], but also for individuals in community fitness programs [ 225], those with heart disease [ 147, 226], pregnant women [ 174] and those in national probability samples [ 227, 228]. When examining specific age groups, it is apparent that the results replicate for college-aged and young adults [ 180, 202, 203, 229- 231], middle-aged adults [ 143, 167, 232, 233], and the elderly [ 195, 234- 237], but no cross-sectional data exist for children and only qualitative data exist for adolescents [ 171]. The relationship has been found for both genders, although several studies found that men were more vulnerable than women [ 194, 229, 237, 238], while other studies observed the opposite trend [ 202, 239, 240]. Stress also was related to lesser PA in several minority populations [ 177, 195, 198, 219, 241], and ethnicity/race may interact with stress on PA [ 207, 242]. However, there appears to be no moderating effect of age or education [ 196]. The associations appear to be true for reports of exercise [ 243- 245], PA measures [ 202, 203], sedentary behavior/inactivity [ 170, 195, 197, 209, 230, 246, 247] and days of sports participation [ 171, 248], but little data exist for energy expenditure [ 249]. Stress is linked to low levels of PA in chronically stressed populations, such as military spouses [ 196], cancer survivors and those in treatment [ 182, 243, 250], low-income and first-time mothers [ 172, 173, 251], medical school students [ 229, 252] and caregivers [ 239, 240, 253- 257]. Several case-control studies have demonstrated that stressed populations, such as caregivers and parents of children with cancer, have lower PA and exercise behavior than matched control groups [ 239, 240, 254, 255, 258].

3.2.2 Prospective Studies

Directionality of the stress and PA association is evidenced by many prospective studies in which a time-lagged effect may be assessed ( n = 55) (see Table 2). The majority of these studies ( n = 35; 63.6 %) were rated as high quality, meaning that they were more likely to use validated instruments, control comparisons, appropriate statistical methods, and theoretical frameworks. Some studies, however, were of moderate ( n = 19) to low ( n = 1) quality (see Electronic Supplementary Material, Appendix 1). Many studies conducted in naturalistic settings have found evidence that stress is associated with facets of PA at a later time point [ 17, 20, 79, 181, 210, 245, 259- 272]. For instance, in an employee population from a large food processing plant in Texas, USA, Lutz et al. [ 20] found that perceived stress predicted leisure time PA 2 months later. Furthermore, this association was greater than the cross-lagged relationship of exercise at time 1 on perceived stress at time 2. Likewise, in a random sample of Danish adults, those who were high in stress were 2.63 times more likely to be classified as inactive at baseline and 90 % more likely to become inactive a decade later [ 270]. Burton et al. [ 263] found that those low in emotional stress were more likely to initiate brisk PA at least three times a week than those high in stress (35.8 vs. 14.6 %). In this same study, low-stress individuals were also more likely to maintain PA over a 4-year period (69 vs. 36.4 %). On the other hand, a few studies have found no support whatsoever of a relationship [ 79, 145, 191, 273- 277] or evidence for a positive association of stress and PA [ 17, 188, 259, 261, 262, 264, 267, 269, 278- 280] (see below for more details).

Table 2.

Study

Sample

Participants
(n)

Theoretical
framework
or model

Study design

Stress measure(s)

PA measure(s); data transformation

Significant findings, associations, ESs

QR

Allard et al.
2011, [ 259]

3,224

6

Bell and Lee
2006, [ 260]

853

Life
transitions

Perceived Stress Q for
Young Women
Transitions Q

Age stopping full-time education was associated
with higher stress (partial r ² = 0.02,
p < 0.001) and less PA ( p < 0.001,
η ² = 0.028)
Age starting full-time work was associated with
lower PA ( p values <0.001, η ² = 0.036)
Other transitions not related to PA
Note: no analysis to predict PA from perceived
stress

7

364

Major life
events

Prospective
8 months
Two time points

Life Events Survey

DUR of 14 different activities >1×/week
Measured at both time points

Life event stress at BL and not correlated with
exercise at time 1 or time 2 ( r = −0.03 to
−0.04)
No other analysis available

6

7,281

Events checklist (no
validation reported)

Life events and transitions strongly associated
with activity status at follow-up
Inactivity predicted by marriage (OR = 1.46,
95 % CI 1.27-1.68), having a first baby
(OR = 2.27, 95 % CI 1.90-2.59), having
another baby (OR = 2.06, 95 % CI
1.70-2.51), all p < 0.0001
Beginning work (OR = 1.15, 95 % CI
1.03-1.20, p = 0.010).
Becoming a single parent (OR = 1.32, 95 % CI
1.04-1.67, p = 0.020)
Return to study related to LESS inactivity
(OR = 0.77, 95 % CI 0.63-0.94, p = 0.009)
Changing work related to LESS inactivity
(OR = 0.82, 95 % CI 0.74-0.90, p < 0.0001)

7

Brown et al.,
2009 [ 262]

22,595

Norbeck Life Event Q
(modified)

Life events and transitions associated with
activity status at follow-up. Associations
varied by age-cohort (see paper for details)
Transitions associated with decreasing PA (all
p < 0.001): getting married (OR = 1.27, 95 %
CI 1.10-1.46), childbirth (OR = 1.67, 95 % CI
1.43-1.95), illness (OR = 2.23, 95 % CI
1.83-2.71), surgery (OR = 1.55, 95 % CI
1.28-1.88), moving to an institution
(OR = 1.97, 95 % CI 1.05-3.67)
Transitions associated with increasing PA:
retirement (OR = 1.52, 95 % CI 1.22-1.88,
p < 0.001), harassment at work (OR = 1.49,
95 % CI 1.14-1.95, p < 0.01)
Transitions associated with increasing PA
( p values <0.05): beginning a new personal
relationship (OR = 1.23, 95 % CI 1.01-1.50),
changing work conditions (OR = 1.24, 95 %
CI 1.04-1.48), major personal achievement
(OR = 1.29, 95 % CI 1.07-1.56), death of a
spouse/partner (OR = 1.55, 95 % CI
1.01-2.37), decreased income (OR = 1.20,
95 % CI 1.04-1.38)

7

274

Theory of
Planned
Behavior

Spielberger Job Stress
Survey

No main effect of occupational stress on PA
measures
r = −0.10 (composite score) to −0.11 (binary
score)
Occupational stress did inversely relate to PBC
to exercise ( r = −0.16), thus relating to
exercise intention and exercise behavior

7

Burton et al.,
1999 [ 263]

2,507

Behavior
change
model

GHQ-12 (emotional
distress)

There is a relationship of emotional distress
measured at the last wave and PA
Distress did not predict initiation of PA
Moderate distress predicted maintenance of
activity status over 4-year lapse of time
(OR = 0.43, 95 % CI 0.28-0.67). Severe
distress did not predict maintenance, however
Low emotional stress, 35.8 % initiate activity,
69 % maintain; medium emotional stress,
18.0 % initiate activity, 40 % maintain; high
emotional stress, 14.6 % initiate activity,
36.4 % maintain (Table 3 of study)

6

Burton et al.,
2010 [ 273]

16

Resiliency

Stress subscale from
DASS-21

Stress level improved pre-post ( p = 0.013)
Pedometer steps and PA survey data did not
improve pre-post

6

Castro et al.,
2002 [ 145]

100

Exercise adherence
Program retention
Motivational Readiness for PA

7

Survivors of colorectal
cancer
M + W

978

Health stress;
stressed
population

Continuous cognitive threat appraisal predicted
inactive PA (OR = 0.95, 95 % CI 0.9,1.0) and
insufficiently active PA (OR = 0.96, 95 % CI
0.9, 1.0). Overall model ( p = 0.031)
Previous anxiety predicts increase in low levels
of PA (<2 h/week) (OR = 1.11, 95 % CI
1.05-1.19, p = 0.004)
No evidence that the distress and PA association
changed over time
Depression and cognitive threat did not predict
increases in PA

7

274

None

Perceived Stress Q-30
Beck Depression and
Anxiety Inventories

BL perceived stress inversely associated with PA
at 3 time points: (BL, r = −0.16, p = 0.01;
1-year PA, r = −0.18, p = 0.003; 2-year PA,
r = −0.17, p = 0.007)
Similar pattern of results for anxiety and
depression
Stress did not independently predict PA at any
time point when depression, self-efficacy, stage
of change, and other factors were modeled
Depression predicted PA at BL ( p = 0.03)
Stress did not alter the gender-PA relationship

7

Dobkin et al.,
2005 [ 291]

39

Behavior
change
theories

WSI

Average mins of weekly stretching

Stress at BL and during the treatment were the
best predictors of poor maintenance of
stretching
Every 1 SD increase in BL stress related to a
−28.29 min change in stretching at 4, 5, and
6 months ( p < 0.05)
Every 1 SD increase in stress change over
3 months was related to a decline in stretching
(−38.58 min) in months 4, 5, and 6 ( p < 0.01)
Stress did not impact weekly changes in any
outcome

7

Dobkin et al.,
2006 [ 289]

39

Behavior
change
theories

WSI

Daily exercise log recording exercise type,
FREQ, DUR, and intensity. Energy
expenditure calculated

Over 12 weeks, participants with higher BL
stress reduced their aerobic exercise
participation at faster rates ( p = 0.02) Every
1 SD increase in stress resulted in a change of
−3.19 min of aerobic exercise and −11.33
kcals of energy expenditure
With interactions included in the model, stress
did not impact initial participation in the
aerobic exercise program
Those with higher BL stress decreased energy
expenditure at a higher rate ( p = 0.02)

7

Dougall et al.,
2011 [ 286]

149

Life
transition

PSS-4

Main effect of stress on fitness center use ( β =
−0.10, SE = 0.05, p < 0.05) but not vigorous
exercise or intention to exercise
Participants with high stress in the later stages of
change had more PA intention than those in
earlier stages of change ( p < 0.02)
3-way interaction for stress, intervention
response, and time ( p = 0.05). At the end of
the semester, responders low in stress had
higher PA
3-way interaction between stress, time, and stage
of change ( p = 0.09). Those in the later stages
of change for exercise and low in stress had
higher fitness center use initially

8

Dunton et al.,
2009 [ 265]

23

None

Only 10 % of the sample reported a stressful
event
Stress events did not predict PA ( r = 0.09)
NA (subjective stress) did predict MVPA (HLM
COEFF = −0.09, robust SE = 0.02,
p < 0.001)
Within-person variance explained by NA was
0.5 %, and for stress events was 0.8 %

6

Grace et al.,
2006 [ 274]

243 (201
non-
pregnant)

Role strain

Work-Family Spillover
Scale

HPLP-II (8-items for PA)

Levels of PA did not vary across groups and did
not change across the pregnancy and
postpartum period; however, a trend was
observed for decreased inactivity during
maternity leave
Negative work-to-family spillover and negative
family-to-work spillover was not associated
with PA at BL ( r = −0.07 to 0.03, NS) or at
the last time point ( r = −0.14 to 0.22, NS) in
either the maternity group or the comparison
group
When returning to work (final assessment), PA
was related to positive work-to-family
spillover

8

Griffin et al.,
1993 [ 191]

79

None

PSS related to exercise at start of semester
( r = −0.22, p < 0.05), but not at the end of
the semester ( r = −0.14)
No association between academic demands,
academic stress, hassles, or negative affect
with exercise
Exercise declined from low stress time of
semester to finals; however, this was NS. Early
semester: mean = 14.78, SD = 5.19; finals:
mean = 14.64, SD = 5.78
Among subjects who experienced an increase in
demands from early semester until finals,
exercise decreased (but NS)
Early semester: mean = 14.98, SD = 5.27;
finals: mean = 14.36, SD = 5.57
Among subjects who experienced an increase in
demands the week before finals (vs. early
semester), exercise decreased (but NS). Early
semester: mean = 15.15, SD = 5.19; finals:
mean = 14.94, SD = 5.37
Exercise increased for those whose academic
demands remained the same or declined during
finals (NS)
When controlling for BL exercise, academic
demands at finals and the week before finals
did not predict exercise at the second time
point

7

University employees
M + W
Age not reported

338

None

Prospective
Intervention
(20 weeks)

1 item from Wellness
Q, re.: stress at home
(not validated)

Binary respondent classification: exercise
program starters vs. non-starters

6

Hull et al.,
2010 [ 266]

638

Life
transition

Cohabitation, marriage,
parenthood
transitions

Marriage does not impact PA in young adults
Compared with those who stayed with the same
number of children over the 2-year period,
having a child (PA change = −3.7, SD = 6.0,
p = 0.01), having a first child (−3.9,
SD = 5.6, p = 0.02), and having a subsequent
child (−3.5, SD = 6.4, p = 0.02) is associated
with a reduction in PA

8

Johnson-
Kozlow
et al., 2004
[ 279]

338

Life events

Life Experiences
Survey

7-day PA recall
Data expressed as kcal/kg/week

44 % of sample was inactive at BL
No direct relationship, but stress by time
interaction was significant ( p = 0.015)
M with higher stress at 1 year had greater
exercise in the exercise intervention group
( p = 0.008)
In the control condition, M with low stress
tended to be more physically active at 1 year
No relationship between stress and PA was
observed for W

8

Jones et al.,
2007 [ 267]

422

Job strain

Daily negative affect had an inverse relationship
with exercise for M ( p = 0.001) but not for W
For M, job demand had an effect on daily
exercise ( β = −0.48, SE = 0.13, t = −1.98,
p = 0.049). M in low-demand jobs showed
greater reductions in PA than M in high-
demand jobs
There was an interaction with negative affect
( β= 0.22, SE = 0.06, t = 2.37, p = 0.02).
Negative affect also interacted with job control
( β= −0.18, SE = 0.05, t = −2.51,
p = 0.01). When combined with NA, high job
control can result in less exercise
Long work hours were associated with less
exercise for W but not for M

7

87

Tense-
energy
model

Stress-Energy Scale

Exercise diary (sessions per week)
Concentration on Qigong (1-10 scale, 1 item)
Exercise intention

Exercise sessions negatively correlated with
stress ( r = −0.22, p < 0.05, 1-tailed test), but
there was no correlation of stress with exercise
intention ( r = 0.07) or concentration ( r =
−0.16)
Stress predicted exercise session ( R ² = 0.03)

8

38,883

None

PTSD Checklist-
Civilian Version
(evaluated twice)

Those with new-onset of PTSD symptoms are
less likely to engage in moderate activity at
"active" level (OR = 0.71, 95 % CI
0.60-0.84); less likely to engage in vigorous
activity at "slightly active" (OR = 0.66, 95 %
CI 0.49-0.89), "active" (OR = 0.58, 95 % CI
0.49-0.70), and "very active" (OR = 0.59,
95 % CI 0.46-0.76) levels; more likely to be
unable to engage in strength training
(OR = 2.06, 95 % CI 1.45-2.93)

6

Lutz et al.,
2007 [ 20]

203

None

PSS-10

Godin Leisure Time Exercise Q
PA recalled over the previous month
FREQ of strenuous exercise used for analyses

In SEM analysis: (a) the stress-to-exercise model
provided the best fit and was significantly
different than the stability model; (b) stress and
PA were not concurrently related at time 1 but
were concurrently related at time 2; (c) stress at
time 1 significantly predicted exercise at time 2
( r = −0.16; path COEFF = −0.13), but
exercise at time 1 did not predict stress at time
2 ( r = −0.03; path COEFF = −0.02)

7

Lutz et al.,
2010 [ 17]

95

None

WSI-2 scales used:
stress FREQ and
stress intensity

No main effects of stress events or stress
intensity on exercise mins per session
When exercise stages were run as dichotomous
variables, the maintenance stage was a
significant moderator of the stress event and
exercise duration relationship ( β = 0.52,
SE = 0.11, t(79) = 4.56, p < 0.001). Similar
relationship found for exercise frequency
( β = 0.04, SE = 0.01, t(79) = 4.12,
p < 0.001) and exercise intensity ( β = 0.04,
SE = 0.01, t(75) = 2.69, p < 0.001)
When exercise stages were run as dichotomous
variables, the maintenance stage was a
significant moderator of the stress intensity and
exercise duration relationship ( β = 0.18,
SE = 0.04, t(79) = 5.00, p < 0.001). Similar
relationship found for exercise frequency
( β = 0.012, SE = 0.003, t(79) = −2.265,
p < 0.05) and exercise intensity ( β = 0.01,
SE = 0.004, t(75) = 1.89, p < 0.062)

6

5,388 (time
1); 2,595
(time 2)

None

Reeder Stress Inventory
(summary score, 1-8)

1-item survey for sedentary behavior (h/week)
Binary respondent classification: "sedentary"
defined as <3 h/week

At first screening, stress related to more
sedentary behavior ( p = 0.005). 26 % of high-
stress group was sedentary vs. 19 % of low-
stress group
Sum of stress at time 1 and 2 and change in stress
from time 1 to 2 not related to sedentary
behavior at time 2

5

Miller et al.,
2004 [ 275]

83

None

Paffenberger Activity Scale (1993)
Data analyzed as mins of intense PA

Daily (cumulative) stress ratings were not
associated with health behaviors, including
mins of intense PA ( r = −0.04)

6

Moen et al.,
2011 [ 284]

659

Job strain

Negative work-home
spillover
Psychological distress

Average FREQ of exercise/week over last
4 weeks

Results Only Work Environment program
resulted in no changes in distress vs. control
Negative work-home spillover was related to
distress ( p < 0.001)
Those in control group decrease more in exercise
overtime ( p < 0.05). Thus, stress management
program may help to attenuate decline in PA
behavior
Effect mediated by reductions in negative work-
home spillover ( p < 0.05)

8

57: 30 exam
stress; 27
control

Self-
regulation
model

No difference between groups in exercise
behavior at BL
Those in exam stress group reported a decline in
all exercise FREQ ( df = 1, 26, F = 71.39,
p < 0.001), DUR ( df = 1, 26, F = 35.71,
p < 0.001), and reported ease ( df = 1, 26,
F = 31.24, p<0.001) during exam period. No
means reported
The control group did not change exercise
behaviors pre to post
No relationship between change in perceived
stress (PSS) or emotional distress (GHQ) and
the change in exercise behavior. However,
residuals of changes in PSS and GHQ were
related to residuals of changes in exercise
behavior

8

422

Diathesis-
stress
perspective

Prospective
Diary study
4 weeks

2-item exercise survey
Daily exercise participation: binary response
(yes/no)

Hassles inversely related to exercise participation
over time (COEFF = −0.055, SE = 0.022,
p = 0.013, 95 % CI 0.907-0.988)
Participants with average ( β = −0.064, t =
−2.417, p < 0.05) or high ( β = −0.149,
t = −3.93, p < 0.001) levels of order (a facet
of conscientiousness) exercised more on days
when they experienced daily hassles

6

Payne et al.,
2002 [ 332]

213

Open-ended question for exercise type and DUR:
"What types of exercise did you do today and
how long did you devote to each?"
Exercise defined as "taking part in purposeful
activity which is often structured and pursued
for health and fitness benefits"
Data run as continuous and dichotomous
Psychological predictors of exercise intention
also collected (intention, PBC, attitudes,
norms, etc.)

No correlation between exercise behavior and
work barriers (including work stress; r =
−0.08), job demands ( r = −0.11), and job
control ( r = 0.08)
Those with increased work demands have greater
failure in ability to fulfill their exercise
intentions (succeeded, M = 3.63, SD = 0.64;
failed, M = 3.95, SD = 0.57; F (1,
147) = 7.87, p < 0.01, ES = 0.50)
Intentions were not associated with job strain
Job demands moderated the relationship between
self-efficacy and the probability of being an
exercise intender who actually exercised
(OR = 0.93, 95 % CI 0.87-0.99)
People in high-strain jobs have less exercise self-
efficacy, PBC, and did less exercise at follow-
up (however, they did not intend to do any less
exercise)

7

Payne et al.,
2005 [ 333]

286

No direct effect of job demands ( r = −0.11) or
job control ( r = −0.03) on exercise behavior
Intention, job demands, and job control
interacted but only explained 1 % more of the
variance in exercise behavior
Job demands and control affected exercise
indirectly by lowering perceptions of perceived
behavior control over exercise
Job demands did not moderate the intention/
behavior relationship for exercise

7

Payne et al.,
2010 [ 281]

42

No main effect of job demands
Demands moderated the intention/exercise
relationship (COEFF = −0.10, SE = 0.01,
p < 0.01, OR = 1.04, 95 % CI 1.01-1.06)
Anxiety and depression had no main effect on
exercise and did not moderate intention-
behavior relationships
Note: daily planning intervention backfired
(people in no intervention group were more
likely to exercise)

7

73

None

DASS-21

6

Rod et al.,
2009 [ 270]

7,066

Allostasis

Item inquiring about level of LTPA
Binary respondent classification: active vs.
inactive

Those with medium (OR = 1.19, 95 % CI
1.07-1.32) or high (OR = 2.63; 95 % CI
2.25-3.08) levels of stress were more likely to
be physically inactive at BL. 12 % of the low-
stress group was inactive vs. 26 % of the high-
stress group
Those stressed were more likely to become
physically inactive during follow-up than the
low-stress group (OR = 1.90; 95 % CI
1.41-2.55)
Those in the high-stress group were not more
likely than the low-stress group to become
active (OR = 0.78, 95 % CI 0.48-1.14).
Authors state "There were no differences in
the proportions of inactive persons who
became active during follow-up according to
stress"

5

350

Stressed
population

PSS-11 (Swedish
version)

Exercise decreased from pre-pregnancy to week
20 ( p < 0.001). There was no change from
week 20 to week 32
Stress at week 12 correlated with exercise at
week 20 ( r = −0.20, p < 0.05) but not week
32 ( r = −0.07)
Contemporaneous correlation of stress and
exercise at week 32 was significant ( r =
−0.11, p < 0.05)
SEM analysis found significant path from stress
at week 12 to exercise at week 20 ( β = −0.20)

7

25

None

Experimental
Laboratory
stressor (Trier
Social Stress
Test) vs.
neutral
control
Crossover
design (order
randomized
on 2 separate
days)

Significant main effect of stress condition: lesser
energy expenditure ( df = 1, 23, F = 14.97,
p < 0.001) and exercise minutes ( df = 1, 23,
F = 7.61, p < 0.001). No means for main
effect reported
Subjects reduced their PA by 21 % on the stress
condition day
Changes in perceived stress were not correlated
with changes in exercise behavior ( r = −0.19,
p > 0.35)
Children with high stress reactivity had a greater
decline than children with low reactivity

8

Undergraduate students
M + W
Mean age 20.11 years

54 (only 17
analyzed)

None

1-item survey: DUR of exercise (min)

Note: analysis of stress and exercise was
exploratory
17 participants reported exercising the night
before each urine sample was collected
There was a decrease in exercise DUR from the
pre-test (mean = 61.18, SE = 11.94) to the
post-test (mean = 30.88, SE = 7.74), F (1,
16) = 5.67, p = 0.03, η ² = 0.26. Cohen's
d = 0.62
Results suggest that students reduced their
exercise during the midterm exam period

6

Smith et al.,
2005 [ 186]

98

Stressed
population

Case control
Prospective
Cancer
diagnosis vs.
no diagnosis
3 months
PA measured
twice
(2 weeks
after
diagnosis and
3 months
later)

PSS-14
Recent Life Changes Q
POMS

Overall, the stressed group reported less PA than
the control group F (1, 94 = 43.38,
p < 0.0001).
Parents of cancer patients reported only
400-500 kcal/week of PA vs.
1,400-1,500 kcal/week in parents of healthy
children
Group × time interaction significant F (1,
94 = 6.04, p < 0.05). Parents of cancer
patients increased their PA over time
( t (48) = −2.50, p = 0.01), but parents of
healthy children did not change
ES at time 1 = 1.71; ES at time 2 = 1.13
A group × time interaction was significant for
TV viewing F (1, 94 = 5.84, p = 0.01).
Parents of children with an illness watched
more TV at time 1 but the groups were the
same at time 2

9

Smith et al.,
2008 [ 272]

3,411

Job control subscale of
Kasarek Job Content
Q
Wheaton Stress Q (18-
item): personal,
environmental,
financial stress
Composite International
Diagnostic Interview
(distress; University
of Michigan revision)
Household income
adequacy

Those in the lowest quartile of job control had
the greatest level of psychological distress
Low job control measured in 1994 predicted PA
in 1996 wave ( β = −0.065, t = −3.284,
p = 0.001) even when adjusted for many
covariates (e.g., BMI, gender, health, back
pain, education, etc.)
In model comparing all stress exposures, low job
control ( β = −0.052, t = −2.52, p = 0.012)
and high environmental stress ( β = −0.07,
t = − 2.58, p = 0.010) predicted PA
Relationships of (a) job control and
(b) environmental stress with self-rated health
was mediated by PA ( p values = 0.026 and
0.024, respectively)

6

78

Job stress
Self-
regulation

Time pressure and role ambiguity did not relate
to indices of sport and PA participation
Situational constraints inversely related to LTPA
(estimate = −0.159, SE = 0.076, t = −2.106,
p < 0.05)
Sedentary (low-effort) activities positively
related to situational constraints
(estimate = 0.253, SE = 0.111, t = 2.275,
p < 0.05)
Hours worked inversely related to sedentary
(low-effort) activities (estimate = −0.098,
SE = 0.039, t = −2.513, p < 0.05)

7

Urizar et al.,
2005 [ 89]

68

Exercise
barriers

Maternal stress FREQ did not decrease with
intervention ( p = 0.06). Also, impact/intensity
of stress and PSS did not change over
intervention
Increased PA from BL to 10 weeks was
associated with decrease in maternal stress
( r = −0.42, p < 0.01), but maternal stress
frequency over 10 weeks not related to class
attendance ( r = 0.01, p = 0.97)
Higher maternal stress frequency at BL related to
less class attendance ( β = −0.18, SE = 0.09,
p = 0.05)
Higher impact/intensity of maternal stress at BL
related to 10-week PA (β = −0.76,
SE = 0.30, p = 0.01)
Perceived stress was not associated with PA or
program adherence

8

165 (80
caregivers)

Stressed
population

Caregivers were more depressed ( p < 0.001) and
reported more hassles ( p < 0.01) than the
control group
Caregivers had less PA than controls at both time
points ( p < 0.05)
At time 1 among subjects without cancer,
caregivers (mean = 1.2; SD = 0.74) had less
PA than non-caregivers (mean =1.5;
SD = 0.75; ES = 0.41)
At time 2 among subjects without cancer,
caregivers (mean = 0.9; SD = 0.71) had less
PA than non-caregivers (mean = 1.3;
SD = 0.74; ES = 0.57)

8

Studies employing diary techniques have found that exercise behavior changes in days [ 269, 281, 282] and weeks when experiencing stressful events [ 17, 188, 189] and subjective stressful states [ 265]. Jones et al. [ 267] found this was true for negative affectivity, but job strain was related to greater PA over a 4-week period. Mixed results were also discovered by Lutz et al. [ 17] who followed a group of 95 young women over a 6-week period. In this study, less-experienced exercisers held steady or declined in self-reported exercise frequency, intensity, and duration during weeks of greater life event stress frequency and impact. Stetson and colleagues [ 189] utilized the same measure of life events (the Weekly Stress Inventory [ 283]) and compared periods of low versus high stress among middle-aged women. They found an effect of stress frequency but not stress impact on exercise duration (effect size [ES] = 0.14) while stress impact influenced the number of planned exercise sessions that were missed (ES = 0.22). In a study with a similar data analytic approach, Steptoe et al. [ 188] found that exercise frequency and duration of both moderate/vigorous and low-intensity exercise decreased between two low-stress and two high-stress weeks; however, this was not statistically significant ( d values = 0.16-0.25). Unfortunately, this study suffered from high attrition, which may have masked any significant results as stressed individuals tend to dropout at higher rates.

Finally, intervention studies targeting stress [ 284] or exercise/health behaviors [ 89, 124, 204, 281, 285- 287] have found inverse associations between stress and indicators of PA over time. For instance, Urizar et al. [ 89] found that PA changes over a 10-week period were moderately correlated with maternal stressors over the same period ( r = -0.42). In a particularly interesting study, Dougall and colleagues [ 286] were granted permission to access records of students' use of a university fitness center. The frequency of these visits was related inversely to stress levels. Some interventions, however, have found no association [ 145, 273, 276, 277] or that higher stress relates to greater PA [ 279]. Improvements in exercise readiness over time are compromised by the experience of stress [ 124]. Whether stress has a stronger association with adoption or continued participation of an exercise routine/PA programming is undetermined [ 184, 278, 288]. Indeed, both subjective stress and life events negatively affect adherence to exercise programming [ 89, 184, 204, 287, 289, 290] and intervention attrition [ 145], but not all studies agree with this assessment [ 145, 276]. Post-intervention PA maintenance may be affected to a greater degree by the experience of stress [ 184, 291]. In an underpowered investigation, Williams and Lord found a trend in this direction, which was not significant [ 277].

3.2.3 Prospective Evidence of Changes in PA Behaviors During Objective Conditions of Stress

In rare instances, prospective studies have employed designs to compare a period of objective stress (i.e., final examinations) with a less stressful period [ 185, 187, 191, 192], to compare a stressed and non-stressed population over time [ 186, 190], or to manipulate a laboratory stressor compared to a control condition [ 193]. These studies were typically of high quality (rating ≥7), with one exception [ 185] (see Table 2). Of these seven studies, six discovered a statistically significant effect of stress on exercise and/or PA.

Final examinations are naturalistic stressors which have been studied opportunistically to assess temporal associations of stress and PA behaviors. Examinations are also objectively stressful, typically endure over a longer time frame (as opposed to a discrete conflict) and provide greater ecological validity than laboratory-induced stressors. Oaten and Cheng [ 192] and Steptoe et al. [ 187] assessed students during a baseline period near the beginning of a semester and also during final examinations. Control groups were assessed at the end of the semester but not during examinations. Both studies found declines in duration of exercise/PA compared to controls, but Oaten and Cheng [ 192] also found declines in exercise frequency and the perceived ease of exercise. Final examinations are not uniformly stressful over an entire examination period. In an attempt to capture the most stressful point of this time frame, Sherman et al. [ 185] measured exercise in a group of 17 students 14 days before their most stressful final examination (as determined by self-rating of anticipated strain). Their exploratory analysis found that exercise decreased on the day of the examination compared with 14 days earlier ( d = 0.62; η ² = 0.23). In a less rigorous design, Griffin et al. [ 191] found that exercise decreased for those college students experiencing increased demands during examination stress; however, the changes were not significant. Nevertheless, there was a significant correlation between stress and exercise at baseline. The lack of a significant finding at the second time point may be related to the fact that this study was confounded by a high dropout rate.

Two longitudinal, case-control studies agree that stress has an influence on PA. Smith et al. [ 186] found that parents of a child who had just received a cancer diagnosis reported lower weekly PA and more television viewing post-diagnosis than parents of a healthy child (approximately a 1,000 kcal difference). The size of the effect post-diagnosis was 1.71 (Cohen's d) and 3 months later was 1.13, indicating a large effect. Vitaliano et al. [ 190], studying caregivers and matched controls both with and without a cancer diagnosis, found that caregivers were higher in stress indicators, as expected, and also lower in reported exercise frequency at two time points. When comparing the caregivers and controls without cancer, the effect sizes (Cohen's d) were 0.41 and 0.57.

The study by Roemmich et al. [ 193] is exceptional in that it identified that a single, acute interpersonal stressor causes reductions in PA. Children participated in two experimental conditions, the order of which was randomized within subjects. The experimental condition was a strong interpersonal stressor, where the child prepared and delivered a videotaped speech on a social topic. The control condition was a passive reading activity. After each condition, children were provided the opportunity to be active on a cycle ergometer or remain sedentary. Results indicated that after the stressor condition, both energy expenditure and total exercise minutes decreased. In fact, PA decreased by 21 % during the stress condition; however, changes in perceived stress were not related to changes in exercise behavior ( r = -0.19). Furthermore, those children who had high autonomic stress reactivity had even greater reductions in these exercise variables. Altogether, these results indicate that acute and transient life stressors have a negative impact on PA in humans.

3.2.4 Factors that may Influence Prospective Associations Between PA and Stress

The relationship of PA and stress may vary based on several factors. Therefore, results were further broken down by gender, age, sample size, study quality, and whether the study focused specifically on clinical populations or cohorts of employees. Levels of these factors with >80 % of studies finding evidence of an inverse association were deemed as more likely to be negatively affected by stress. Per this cutoff, studies examining older adults (>50 years; 80.0 %), cohorts with men and women and larger sample sizes ( n > 100; 82.1 %), as well as studies of higher quality (≥7 on a 9-point scale; 85.7 %) were more likely to show an inverse association. Other factors, such as whether a study's subject pool comprised employees or a clinical population, did not clearly differentiate the literature (see Electronic Supplementary Material, Appendix 3).

3.4 Evidence that Stress may Increase PA

Speaking to the point of positive influences of stress, 29 studies found that stress predicts an increase in PA behavior [ 3, 17, 81, 164, 168, 171, 172, 175, 183, 251, 253, 254, 256, 259, 262, 264, 267, 269, 278- 280, 313- 320], ten of which were prospective (see above). Other studies found trends in this direction [ 169, 191]. Lutz et al. [ 17] found that this was only the case for habituated exercisers. Brown et al. [ 262] found that some life events were associated with increased PA, including distressing harassment, beginning a new close personal relationship, retirement, changing work conditions, major personal achievement, death of a spouse/partner, and income reduction. Seigel et al. [ 183] reports that in a random sample of young Swedish women, 22.0 % were likely to increase PA, 60.1 % were likely to be unaffected, and only about 16.5 % of respondents were likely to decrease PA with the experience of stress.

3.5 Life Transitions, Major Events, and Trauma

A substantial portion of the literature focused on specific events, life transitions, or distinct experiences of trauma. As noted above [ 262], some life experiences result in enhancement of PA behavior. Nevertheless, this same study found that exercise declines for women for some types of events, including the birth of one's first or second baby or grandchild, having a child with a serious illness or disability, beginning work outside the home, major personal illness or injury, major surgery, or moving into an institution [ 262]. Death of a spouse was deleterious for PA in older women [ 204]. Transitioning from high school to college or leaving college and entering the workforce full-time is also predictive of a decline in PA [ 180, 260, 321]. Fan et al. [ 200] found that being a victim of violence, harassment, or other threats was not related to PA. This is contradicted by evidence that exercise behavior substantially declined for New Yorkers after the trauma of the 9/11 attacks [ 181]. In contrast, the experience of Hurricane Katrina in the USA has been associated with heightened levels of PA [ 313].

4 Discussion

4.1 Summary

The majority of the literature finds an inverse association of stress and PA behaviors. The current search uncovered 168 studies reported in the English language exploring these relationships in humans. This demonstrates a high level of interest in the topic for the last two decades, with an apparent acceleration in research production in the area. The literature provided ample support for an association between stress and PA (79.8 %), and of the studies identified, 72.8 % supported the hypotheses that higher stress is associated with lesser exercise and/or PA. Prospective studies with objective markers of stress, one indicator of study quality, nearly unanimously agreed (six of seven studies, 85.7 %) with this conclusion. Studies examining older adults (>50 years), cohorts with men and women, and larger sample sizes ( n > 100) as well as studies of higher quality (≥7 on a 9-point scale) were more likely to show an inverse association. Other factors, such as whether a study's subject pool comprised employees or a clinical population, did not clearly differentiate the literature finding inverse relationships between stress and PA and the literature finding a null association. Interestingly, 17.2 % of prospective studies found evidence that stress was predictive of greater PA and exercise behavior, and qualitative studies were particularly equivocal in regards to the valence of the association. While these findings cannot be labeled definitively as anomalies, it is clear that stress exerts a generally negative influence on PA.

As might be expected, not all studies found an association between stress and PA. However, several studies suggest that the association may be indirect or masked by factors that moderate the relationship, such as exercise stage of change [ 17, 332, 333]. For instance, Lutz et al. [ 17] found that that women in the habit of exercising, in other words, at a higher stage of change, exercised more during times of stress. Conversely, infrequent exercisers were less active during periods of strain. This finding was supported by Seigel et al. [ 183], who found that young women who increased activity with stress were more avid exercisers. One's stage of change for exercise, however, is not itself related to indicators of stress [ 243, 334]. Budden and Sagarin [ 210] found no association between exercise and occupational stress, but did find that stress related to perceived behavioral control for exercise, which in turn predicted exercise intention. Intention was predictive of actual exercise behavior. Payne et al. [ 333] found a similar pattern of results in a group of 286 British employees. Clearly, the influence of stress varies by individual attributes, which in some cases may obscure simple associations between stress and PA.

4.2 Clinical Implications

Stress interferes with the engagement of activity for the majority of people, which has important theoretical, practical, and clinical significance for professionals in the health and exercise fields. This is especially true given that the experience of stress (a) is widely prevalent; (b) has repercussions for a wide range of health issues; and (c) is reported as a growing problem in developed countries around the globe [ 18]. On the second assertion, it is well-known that a link exists between stress and the development of depression, cardiovascular disease, and many other health endpoints [ 50]. Convincing evidence is emerging that such links are moderated by PA [ 49, 53], with some data indicating that the connection is contingent on changes to this behavior [ 212]. With all of these facts in mind, health policies should include provisions for integrated prevention and treatment of chronic stress and its behavioral and medical sequela. Before this progress can materialize, however, the well-identified associations between stress and health-promoting behavior must be more recognized within the community of PA researchers, practitioners, and other advocates.

At this time, action must be taken to advance PA interventions by interweaving effective stress management techniques. Simply arousing knowledge of stress is not sufficient [ 335]. First, practitioners should measure objective and subjective measures of stress for each individual. This effort will help to identify those at risk for the effects of stress. Working with an interdisciplinary team, such as psychologists and therapists, will help to promote careful interpretation of these data and will provide the resources to more carefully attune to the client's stressors and associated constrains, barriers, and needs [ 336]. Furthermore, practitioners should be mindful of stress vulnerability across stages of change and refine prescriptions accordingly to magnify adherence and to prevent relapse and dropout [ 184, 189]. For people contemplating a new exercise regimen, stress may interfere with attempts to initiate PA, and this may translate to an inability to reach healthful levels of exercise [ 184, 189]. On the other hand, those habituated to exercise exhibit resilience in the face of stress [ 17, 183]. In addition to exercise habits, it is worthwhile to identify individuals' coping style. Some people use exercise to deal with stress (exercise approach) while others become distracted and succumb to the lure of less healthful behaviors (exercise avoidance). This emphasizes further that prescriptions should be tailored to the individual [ 60]. Stress differentially impacts various populations and interventions must be modified accordingly [ 232, 337]. As an example, Urizar et al. [ 89] suggests that specific coping strategies should be addressed for mothers based on family constraints, including social support, problem solving, reframing cognitions, and strategies to balance motherhood with the need to care for oneself. Relapse prevention counseling is an example of a technique that incorporates stress management [ 331, 338] and is a recommended intervention for stressed populations [ 184].

4.4 Significance of Literature Finding a Positive Association Between Stress and PA

Findings that stress may elicit increases in PA behavior should not be considered happenstance and may explain studies with null findings [ 17]. Castro and associates [ 145] found that women who were anxious at baseline had better adherence to an exercise program over 12 months, and a similar result was found for colorectal cancer patients [ 264]. Johnson-Kozlow et al. [ 279] implemented an exercise intervention for a group of students in which stress management was a central feature. It should not be surprising then that with burgeoning stress men increased PA in this study. Health behaviors, such as exercise or recreational park use, may actually improve after a major life event, such as the death of a spouse with Alzheimer's, simply because barriers for behavior are removed [ 374, 375]. Moreover, such observations are consistent with theories that predict changes in behavior in either direction with stress [ 183, 330, 376, 377]. For instance, resiliency researchers have long stressed that adversity may spur some individuals to higher levels of functioning [ 376, 377]. Seigel et al. [ 183] suggests a nomenclature for these disparate responses, referring to increased PA with stress as behavioral activation and weakened PA as behavioral inhibition, responses that appear to vary by traits of the individual. The rebound hypothesis of stress and PA proposed by Griffin et al. [ 191] posits that stress can result in a degraded PA response followed within days or weeks by a compensatory uptick in PA. Specifically, these researchers speculate that people may overdo healthy behaviors, such as exercise, to compensate for poor attention to health during the stressful period.

These issues decry the general lack of understanding of the relationship between coping with stress and PA. Exercise behavior declines on days when individuals use more emotion-focused coping [ 201], but in general the use of positive coping behaviors is related to greater PA [ 250, 300]. The general coping style of the individual may account for these differences, as people with rigid coping styles tend to increase PA behavior with increased stress [ 280], although this finding is challenged by other data [ 150]. Moos and Schaefer [ 388] state that "Among self-efficacious individuals, engaging in PA can be described as a task-oriented way of dealing with stressful events using a behavioral-approach coping style. Alternatively, engaging in PA may be used to avoid life stressors among less self-efficacious individuals." This suggests that exercise may serve to both deal with and steer away from stress, and the strategy utilized may vary by one's self-efficacy for exercise. This may be particularly salient for those who are exercise dependent [ 389, 390] and for those who compensate for stress-induced overeating by exercising [ 183, 391- 393]. These phenomena add an extra layer of complexity to any analysis of stress and exercise and may account for weak relationships observed by many studies.

4.5 Limitations of the Literature: Methodological Considerations

Several limitations in the stress literature have been discerned by this review, particularly as identified by the quality assessment rating (Electronic Supplementary Material, Appendix 1). The most obvious is the limited amount of experimental evidence. The use of control groups should be utilized, as changes in PA are frequently due to other factors, such as a change in seasons [ 331, 394]. Examination and holiday stressors coincide with more averse weather in many latitudes, which is perhaps the greatest limitation in this area of research. Cross-sectional studies cannot provide indication of the direction of influence. Does stress impact exercise directly, or do inactive individuals self-select more stressful environments [ 170]? Such a possibility implies that other factors may be responsible for the association. Nevertheless, more than 50 studies in this review utilized a prospective design, which allays some concern.

Apart from issues of design, there are also issues with measurement. First, stress may impact the recall of exercise behavior as opposed to exercise behavior itself, with activity being over- or understated [ 395]. Objective measures of PA, therefore, are greatly needed, and only a few cross-sectional studies have employed such markers [ 249, 258]. Furthermore, most subjective measures do not capture the full complexity of the behavior, including occupational and commuting activity [ 308]. To illustrate this point, Fredman et al. [ 254] found that caregivers have greater self-reported total PA than non-caregivers but lower leisure time PA. Moreover, many papers do not inquire about exercise intensity, although it is equivocal as to whether intensity is impacted to the same degree as frequency or duration [ 17, 229, 241, 251]. It is possible that an individual may shift intensity as the priority for fitness, typically achieved with greater exercise effort, gives way to a greater emphasis on stress management [ 173]. When athletes are specifically asked what mental factors prevent them from giving 100 % effort in practice, they typically list life events, school demands, and other stressors [ 396]. Lastly, it is unfortunate that nearly 50 % of prospective studies did not utilize pre-tested PA/exercise measures, with some relying on simple dichotomous measures of exercise behavior [ 210, 219, 263].

Sample characteristics are germane to the study of stress. It is frequently difficult to recruit truly stressed subjects for research studies, which results in a response or selection bias [ 400]. Consequently, a constrained range or low level of stress scores (i.e., not enough variability in stress) may obscure any true effect [ 191, 275, 303]. Those who drop out of studies tend to have higher stress and anxiety, which could also mask any potential effects [ 188]. Several studies finding an inverse trend of a stress-PA association have been underpowered [ 277], while others are overpowered, detecting trivial associations [ 260, 268, 270, 272, 316]. Studies with large samples of inactive participants (or conversely all active subjects) may not have enough variability in exercise measures to detect an effect [ 273].

Finally, it should be noted that this review has limitations. Only three databases were searched. Moreover, the search in PubMed was truncated and did not extend before the year 2000. However, these are not likely substantive issues considering (a) the numerous studies discovered; (b) the retrieval of few unique investigations in successive database searches; and (c) the linear distribution of papers across time ( Fig. 2). Additionally, this is the first review of its kind; therefore, this analysis adds considerable insight into an area that has produced a large quantity of data. Despite this abundance, the current body of work has not been featured well in reviews summarizing psychosocial influences on PA, necessitating the current report [ 153- 160].

4.6 Future Directions

Possibilities abound for future research in this area. Currently, evidence demonstrating the efficacy of an exercise-stress management intervention is scant. Nevertheless, initial reports are promising [ 192]. Interventions could be optimized if stress-PA relationships could be titrated. For instance, Oman and King [ 184] discerned that an increase in major life events, specifically from three to four, did not result in a proportional decline in exercise adherence. This type of research represents an important area of future inquiry and could be coordinated to additionally identify the factors that potentially protect one from, or make one vulnerable to, the effects of stress. Risk factors might include race/ethnicity, family background or individual characteristics, such as lifetime adversity and disadvantaged experiences [ 34, 35]. These latter two constructs are also indicators of stress, which serve as a reminder that stress instrumentation could be enhanced in future research by incorporating a lifespan perspective. Triangulating self-report measures with participant interviews and corroborating evidence from persons close to study participants would provide a strong advancement to stress measurement [ 401].

Apart from one experiment [ 193], there has been a lack of studies manipulating stress to assess the effect of such experiences on PA behaviors. It must be noted, however, that experimental exposure to stress is difficult, if not unethical, to implement. Measuring PA opportunistically during periods of objectively rated low and high stress, such as final examinations or other naturalistic stressors, provides stronger evidence [ 185, 187, 192]. The model demonstrated by Stults-Kolehmainen and Bartholomew [ 29], in which populations are screened for both very low and very high levels of chronic perceived stress, is an example of a quasi-experimental design that could be employed. Ecological Momentary Assessment (EMA) is one technique to measure stress and PA in real time, resulting in less vulnerability to stress-related failures in the recall of behavior and emotion [ 154, 265, 402]. Prospective studies should sample more frequently to minimize the effects of stress on memory and cognition, factors that in themselves may moderate the stress and exercise relationship [ 403].

5 Conclusion

This review is the only manuscript, to the best of our knowledge, that has attempted to synthesize the diverse literature on the association of stress and PA/exercise in the reverse direction of influence. This emerging focus stands in contrast to the vast number of studies that have almost exclusively emphasized the anxiolytic and anti-depressant effects of exercise. The current analysis concludes that stress and PA are associated in a temporal manner. More specifically, the experience of stress influences PA, and the great majority of studies indicate an inverse relationship between these constructs. In other words, stress impedes individuals' efforts to be more physically active, just as it negatively influences other health behaviors, such as smoking, alcohol, and drug use. Interestingly, a smaller number of studies suggest a positive association between stress and PA. While seemingly contradictory, these data are consistent with theories that predict changes in behavior in either direction with stress. The utility of exercise as a coping or stress management technique is notable and may explain this finding. Resiliency research suggests that some individuals thrive under conditions of stress; therefore, future research is needed to understand why some individuals are immune to changes in PA in the face of stress while others become inactive. Few studies employ rigorous experimental designs, which would strengthen this area of inquiry. Nevertheless, available prospective data is of moderate to high quality. Data identifying moderators of the relationship between stress and exercise would help to improve the design of interventions targeted towards at-risk populations, such as older adults. Future empirical research in this area could be guided by a theory of stress and PA, which is lacking at this time.

Supplementary Material

Acknowledgments

National Institute of Health grants UL1-DE019586 and PL1-DA024859 supported the preparation of this manuscript. The authors would like to extend appreciation to the late Rafer Lutz, Ph.D. for his thorough and thoughtful critiques of this manuscript just before his passing in 2012. Dr. Lutz's work made a special contribution to advances in this literature.

Footnotes

Electronic supplementary material The online version of this article (doi:10.1007/s40279-013-0090-5) contains supplementary material, which is available to authorized users.

The authors declare no conflict of interest.

References

Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials

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The Effects of Stress on Physical Activity and Exercise

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Psychological stress and physical activity (PA) are believed to be reciprocally related; however, most research examining the relationship between these constructs is devoted to the study of exercise and/or PA as an instrument to mitigate distress. ...

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Find out about the major food groups and how to balance them for a healthy diet.

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An Evidence-based Look at the Effects of Diet on Health

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Diet is a daily activity that has a dramatic impact on health. There is much confusion in society, including among medical professionals, about what constitutes a healthy diet. Many reviews focus on one aspect of healthy dietary practices, but few…

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In the news

Media coverage of health and science topics

NPR News

Bad Diets Are Responsible For More Deaths Than Smoking, Global Study Finds

by Allison Aubrey

Some 11 million deaths annually are linked to diet-related diseases like diabetes and heart disease, a study finds. Researchers say that makes diet the leading risk factor for deaths around the world.

Read more at NPR News

Behind the headlines

Research findings and data from the National Library of Medicine

Also of interest

Additional recent and related news

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News: Bad Diets Are Responsible For More... (NPR News) - Behind the headlines - NLM

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(NPR News) Bad Diets Are Responsible For More Deaths Than Smoking, Global Study Finds. Associated research findings from the National Library of Medicine.

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The Broken Plate 2022 report

The influential 2022 Broken Plate report published today by The Food Foundation reveals as never before the dangerous impact of negative trends in the nation's diet and the urgent need for a major overhaul of our food system.

The report highlights the wide range of damaging effects caused by poor nutrition and the absence of a coherent UK food policy, leading to problems which include stunted growth in our children and record-breaking levels of amputations linked to the complications of obesity.

The Broken Plate presents the strongest arguments so far for a change in the nation's food policies to give everyone in the UK access to a healthy diet that avoids further damage to global climate and environment.
Its authoritative research presents a bleak picture of the consequences of our broken food system:

On current trends more than 80% of children born in 2022 who survive to the age of 65 will be overweight or obese. At least one in 20 of them will already have died.

Obesity in children has risen by 50% in the past year alone. Children with obesity are more likely to grow up to have diet-related disease. Obesity adversely affects ability to learn in school, self-esteem and physical and mental health.

Poor nutrition is causing stunted growth. British five-year-olds are shorter than five-year-old populations of our European neighbours with significant height variation between poor and wealthy areas within this country.

Life-limiting amputations caused by the complications of diabetes linked to obesity have reached record levels, tragically impacting the quality of life of affected individuals and placing a huge burden on our healthcare system and the wider economy.

Healthy nutritious food is nearly three times more expensive than obesogenic unhealthy products, with more healthy foods costing an average of £8.51 for 1,000 calories compared to just £3.25 for 1,000 calories of less healthy foods. Between 2021 and 2022 healthier foods became even more expensive, increasing in price by an average of 5.1% compared with 2.5% for the least healthy foods.

Excess weight costs the UK approximately £74 billion every year in direct NHS costs, lost workforce productivity and reduced life expectancy. It is one of the main factors in the 20-year gap in healthy life expectancy between the richest and poorest members of society.

One in five households would have to spend almost half their disposable income on food to achieve the government-recommended healthy diet, leaving little money for energy and other household bills. By contrast, the wealthiest fifth of the population would need to spend just 11% of their disposable income.

Sustainable alternative milks made from ingredients such as oats and soya, cost up to £1.79 per litre compared to £1 for cows' milk. They are 60% more expensive than dairy milk even though they on average create less than a third of the greenhouse gas emissions of dairy milk and use little more than half the water to produce.

Sandwiches with plant-based fillings cost £3.25 on average compared with £3.00 for meat and £2.85 for fish.

About a third (32%) of all food and soft drink advertising is still invested in promoting unhealthy foods compared with 1% spent on fruit and vegetable promotion. A further 39% is spent on brand advertising, much of which is associated with less healthy products.

Fast food retailers gravitate to areas of poverty: 31% of food retailers in the most deprived areas are fast food outlets compared with 22% in the least deprived areas. As fast-food consumption is closely linked with increased risk of obesity, it is likely that this higher availability of fast food is a contributing factor to socio-economic health inequalities.

Only one in four state schools in England is known to be meeting school food nutritional requirements, despite calls for the Government to mandate an accreditation scheme so that compliance with standards can be more regularly checked in all schools. Childhood is a critical time for development and suboptimal nutrition can have irreversible lifelong implications.

Breakfast cereals and yogurts are foods that parents often give their children in the belief they are relatively healthy, but only 7% of breakfast cereals and 4% of yogurts marketed for children are low in sugar. Some breakfast cereals and yoghurts supply almost the entire recommended daily allowance (RDA) of sugar in one portion: Kellogg's Froot Loops Marshmallows 17.0g (89% of a 4-6-year-old's maximum recommended intake); Nestlé Smarties Vanilla Flavour Yogurt 16.5g (87% of a 4-6 year old's maximum recommended intake).

Unless there is action to halt the upward trend, emissions from the food system will be four times higher by 2050 than the level needed for the UK to meet its net zero target.

The Broken Plate report shows more clearly than ever, the need for regulation to create structural change in our food system if we are going to provide a healthy future for our population.

Anna Taylor, Executive Director of The Food Foundation, said: "This report provides the strongest evidence to date of the worsening crisis affecting our food system and the health of the UK population. It is vital that the incoming prime minister takes urgent action to address the issues raised by the National Food Strategy with the development of a new plan for primary legislation."

Laura Sandys CBE, Chair of Trustees at The Food Foundation, said: "The nation's health is worse than it's been for generations and we're now suffering the double whammy of the COVID impact plus massive inflation. We need action on unsafe food (like we had on cigarettes) to protect the whole population. We cannot condemn the next generation to more stunted growth, diabetes or amputations."

Catherine Dennison, Welfare Programme Head at the Nuffield Foundation, said: "The cost of living crisis is putting additional pressure on families with low incomes who were already struggling to afford a healthy diet. The Broken Plate provides stark evidence of how dietary inequalities in the UK are impacting on people's health. We support The Food Foundation's call for a comprehensive policy and practice response from government and industry if we are to improve people's health and well-being, including for the youngest children in our society."

Dr Max Davie, Health Improvement Officer, Royal College of Paediatrics and Institute of Child Health, said: "As prices continue to rise nationally, there is an ever-growing nutritional gap between high and low-income families. Healthy foods are nearly three times more expensive than less healthy foods per calorie. We call on the Government to ensure that all members of our society, including the most vulnerable, have the means to access healthy affordable foods. We must act now to build a healthier and more sustainable future for our children."

Dr Dolly Theis, of the MRC Epidemiology Unit & Centre for Diet and Activity Research (CEDAR) at Cambridge University, said: "This major Food Foundation report shows that our food system is completely broken. Unhealthy food is cheap, aggressively marketed and makes people sick. Although we have had almost 700 government obesity policies in England to date, very few have led to any action. The government must stop this cycle and ensure it implements all policy proposals, including those put forward in the latest obesity strategy published in 2020."

Jo Hannan, Fusion21 Foundation Manager, said: "We hope this latest report will help to pave the way for positive change, making healthy eating accessible for all and benefiting individuals and families across the country."

The Broken Plate report is funded by the Nuffield Foundation and improvements to the methodology for assessing the 'Affordability of a Healthy Diet' metric have been made possible by the Fusion21 Foundation.

We are also grateful for the contribution of these collaborators: Eating Better, Action on Sugar, Nielsen, Resolution Foundation, CEDAR and Feat at the MRC Epidemiology Unit University of Cambridge, Food DB at the University of Oxford, Soil Association, and the London School of Hygiene and Tropical Medicine.

Available for Interview

Anna Taylor, Executive Director of Food Foundation

Shona Goudie, Project Lead, The Broken Plate
Notes to Editor
Please contact:

Lois Rogers 07770 350822 / [email protected]

Jo Ralling - 07770 500858 / [email protected]

Social Media

Twitter: @Food_Foundation

#BrokenPlate2022
About The Food Foundation
The Food Foundation is a charity working to influence food policy and business practice, shaping a sustainable food system which makes healthy diets affordable and accessible for all. We work in partnership with researchers, campaigners, community bodies, industry, investors, government and citizens to galvanise the UK's diverse agents of change, using surprising and inventive ideas to drive fundamental shifts in our food system. These efforts are based on the continual re-evaluation of opportunities for action, building and synthesising strong evidence, convening powerful coalitions, harnessing citizens' voices and delivering impactful communications.

Registered Charity Number 1187611
About The Broken Plate
In February 2019, The Food Foundation published its first annual flagship report. The Broken Plate presented 10 vital signs revealing the health of our food system, its impact on our lives, and the remedies we must pursue. The first report showed that the UK's food system has led the country into a national health crisis, with children and households on low incomes suffering the severest health consequences. Each year The Food Foundation publishes a new edition of The Broken Plate, providing updated statistics for ten key metrics, new commentary on the direction of travel and proposals for change inspired by emerging evidence.

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Major report highlights impact of Britain's disastrous food policy

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The Broken Plate is the Food Foundation's flagship annual report showing the state of the food system and the huge challenges we face in ensuring everyone in the UK can afford and access a healthy and sustainable diet.

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The world is changing even faster than ever and has modified people's lives [ 1, 2]. Although globalization is an opportunity to develop technology, food, industry, health care advances and transport, it has changed people's work, leisure, behaviours, and choices. These factors have also determined an increase in the prevalence of non-communicable diseases such as cardiovascular disease, diabetes, chronic respiratory disease, mental disorders and some cancers that appear across ages. Most of them are considered in the articles of this Special Issue. Noncommunicable diseases are attributed to 41 million deaths per year worldwide [ 3, 4]. All these diseases are multifactorial, and lifestyle plays a fundamental role in their development; modifiable behaviours, such as diet and exercise, interact with their prevention and treatment [ 4]. Indeed, 1.8 million annual deaths have been attributed to excess salt/sodium intake; more than half of these 1.5 million have been attributable to alcohol use, and 830,000 deaths annually to insufficient physical activity [ 3]. However, although we have indications that the combination of factors is important, the question of how the beneficial effect of the interplay between exercise and diet can be enhanced is less well studied, probably due to greater methodological difficulty in study design and control. Therefore, this Special Issue addresses a complex and scientifically challenging topic. The studies featured in this Special Issue include research exploring the important interaction between diet and exercise across ages and different diseases, with a focus on the potential benefits and challenges.

From childhood to adolescence, this is a crucial period for establishing healthy lifestyle habits that can last a lifetime. Research has shown a healthy diet and regular physical activity in childhood can reduce the risk of chronic disease later in life [ 5, 6, 7]. A healthy diet, considered a diet rich in fruits, vegetables, whole grains, plant proteins, and dairy products, provides the essential nutrients needed for growth and development. However, achieving a healthy diet and regular exercise in childhood can be challenging, given the prevalence of unhealthy food consumption and sedentary lifestyles characterized by long periods of screen time. Some of the first large-scale studies associating dietary and movement behavioural patterns established a relationship between low levels of physical activity and sedentary behaviours with high sugared drinks and salted and sweetened snacks at pre-school ages [ 8] and then in children and adolescents [ 9, 10]. This relationship increases the risk of developing obesity and other cardiovascular diseases, which may decrease the quality of life in this younger population. In this Special Issue, in the PASOS study, it is shown that a Mediterranean diet with higher fitness status can be related to higher levels of health-related quality of life, independent of the body mass index [ 11]. Therefore, these results highlight the importance of promoting healthy lifestyles to ensure the subject's well-being, including an individual's social, mental, and physical dimensions [ 12]. In this sense, combined interventions of nutrition and physical activity are the most promising [ 13, 14, 15].

Given the increased autonomy and independence of adolescents and young adults, the transition to this developmental stage is often accompanied by changes in diet and physical activity. It has been known for some years that this includes the increased consumption of unhealthy foods and a decrease in physical activity [ 16]. Peer pressure, busy schedules, and competing demands can make it difficult to prioritize healthy habits. These changes can lead to weight gain, obesity, and a higher risk of cardiovascular diseases later in life. It has been reported that more than one-third of people up to the age of sixteen in the European Union reported having a chronic health problem in 2021 [ 17]. Nonetheless, their desire to be independent makes them a target population to develop strategies that can improve their skills and healthy habits to be maintained in adulthood. In this regard, there is one article in this Special Issue that attempts to decrease cardiovascular diseases risk factors though an exercise and diet strategy [ 18]. Tang et al. performed a caloric restriction and rope-skipping program to improve cardiometabolic health in young adults [ 18]. They found that caloric restriction and both caloric restriction and rope skipping were effective in reducing body weight and obesity; however, only both together decreased the inflammation markers and metabolic profile. Thus, combining exercise and diet is a better strategy for cardiovascular prevention. Likewise, it is important to maintain this type of strategy over time to prevent the development of chronic conditions.

Maintaining caloric restriction could be difficult over time and in some specific cases. In this sense, the article in the framework of the BALANCE program focuses on the whole diet, recommending healthier dietary patterns to prevent the development of new cardiovascular events [ 11]. They observed an improvement in the dietary patterns with higher intakes of fruits and vegetables and a decrease in salted and sugared ultra-processed foods after an intervention. However, they did not observe a physical activity interaction between them. Further studies considering both dietary patterns and physical activity as lifestyle patterns are of interest, as a combination of them could probably increase benefits for health. In any case, it is essential to know how these main modifiable factors interact so that they can be considered in the field of nutrition or exercise, and exercise and dietary prescription can be more individualized, precise, and, therefore, efficient.

The evidence to date suggests that healthy dietary patterns reduce the risk of major diet-related chronic diseases, such as type 2 diabetes, cardiovascular disease and some cancers [ 7]. The study of dietary patterns has the difficulty of isolating unique foods or nutrients; however, this Special Issue includes an epidemiological article focusing on the prevalence of cancer and its relationship with coffee consumption and physical activity interaction [ 19]. They observed a lower odds ratio for most cancers in coffee consumers, probably due to their bioactive compounds but also higher odds of cancer in those with higher levels of physical activity. It is important that these results are interpreted with care and are adequately explained, as they can lead to misleading messages in the population. There are many advances and evidence of the independent benefits of exercise in different types of cancer [ 20]; the hypothesis remains that with adequate diet and physical exercise, cancer can be prevented, and treatment and recovery periods can be faced with greater guarantees. In fact, in this study [ 19], it has been speculated that this habit is achieved after the progression of the disease, as they are more conscious of their benefits. However, more research is needed as it seems the combined effect of both lifestyles may improve health, as a positive interaction was found between thyroid cancer and coffee consumers and physical activity practitioners [ 19].

As has been mentioned, evaluating single dietary components is complex. For this reason, during the last few years, analyses of dietary patterns and, more specifically, the Mediterranean diet have increased. The Mediterranean diet has been widely related to health outcomes [ 21]. It is considered in three of the nine articles in this Special Issue for different populations [ 22, 23, 24]. It is closely related to the quality of life in healthy school children [ 23], and moreover, it has also been related to self-perceptions of health in older adults [ 24]. Conde-Pipó et al. observed that a better physical self-concept was related to higher levels of Mediterranean diet adherence and higher levels of physical activity [ 24]. Furthermore, it is concerning that with age, there is a loss of these healthy patterns that are important for maintaining good health in older adults. Aging leads to physiological changes that compromise the independence of a person, increasing the risk of disease and leading to a high risk of falls and disability that could be aggravated if a person does not maintain healthy habits [ 25].

In this regard, aging is associated with multimorbidity. Metabolic syndrome components are abdominal obesity, hyperglycemia, high blood pressure, high levels of triglycerides and low levels of high-density lipoproteins cholesterol. Two studies in this Special Issue evaluate this pathology. Subías-Perie et al. indicates that a prevalence of around 30-40% do not observe a relationship between this condition and frailty [ 26]. However, they observed a low prevalence of abdominal obesity and hypertension in active participants, suggesting the beneficial effect of physical activity in the progression of this pathology [ 26]. Although individuals may experience health conditions as they age, Conde-Pipó et al. observed that older adults with metabolic syndrome had a higher health-related quality of life (HRQL) if they had better physical function [ 22]. Moreover, physical activity is not only important for the physical component of health but also for mental health. In this sense, the article written by Huang et al. describes the mediator effect of physical activity on reducing inflammation which has been associated with obesity and also depression [ 27].

Finally, taking into consideration polypharmacy, which is usually taken by older adults due to their multimorbidity, Navarrete-Villanueva et al. conducted a study to examine the relationship between obesity, fitness, and drug consumption [ 28]. The researchers categorized participants into different groups based on their obesity and fitness status. They found that those who were fitter with a lower fat mass consumed fewer drugs compared to those who had obesity or were less fit. This suggests that maintaining a healthy lifestyle and a balanced diet may lead to lower dependence on drugs. Apart from overall health and well-being benefits, these results also suggest an important step toward tools that can improve and make countries' public health and health systems more sustainable.

To sum up, this Special Issue highlights how a healthy diet and regular exercise are essential for optimal health across a lifespan. The interaction between diet and exercise may have significant implications for health outcomes, including a reduced risk of cardiovascular and cancer diseases [ 18, 19]. They improve mental health and well-being as well as maintaining physical function and independence at an older age [ 22, 24, 27]. However, achieving a healthy diet and regular exercise can be challenging, given the competing demands of modern life and age-related changes in health. Future research is needed for a better understanding of the interaction between diet and exercise on human health across lifespans and to develop individualized, precise, and, therefore, efficient interventions to promote healthy habits which can ensure adherence and maximize beneficial effects.

Author Contributions

Conceptualization, A.M., G.V.-R. and A.G.-C.; investigation, A.M., L.A.M., J.A.C., G.V.-R. and A.G.-C.; writing-original draft preparation, A.M.; writing-review and editing, L.A.M., J.A.C., G.V.-R. and A.G.-C.; supervision, G.V.-R. and A.G.-C. All authors have read and agreed to the published version of the manuscript.

Conflicts of Interest

The authors declare no conflict of interest.

Funding Statement

This research received no external funding.

References

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Effects of Diet-Exercise Interaction on Human Health across a Lifespan

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The world is changing even faster than ever and has modified people's lives [ 1, 2]. Although globalization is an opportunity to develop technology, food, industry, health care advances and transport, it has changed people's work, leisure, behaviours, and choices.

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Exercise and Healthy Living - NEW TOPIC 

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Exercise and Healthy Living - NEW TOPIC 

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Good morning everyone,

Today we were to begin looking at a new topic within our EHL unit, 'Exercise referral' - as this task was highly practical, this session will take place next Friday instead.

Today you have been tasked with completing a task which will indicate where your current level of knowledge is on this specific topic. I have attached the document you are required to complete, it is also uploaded to 'assignments' on canvas under the name of 'Starting Point Assessment – NEW TOPIC - Lifestyle & Exercise Referral' (canvas link attached)

Ensure you do not use google for this task, this is for me to understand your current level of knowledge. It is not being formally graded and will not impact your unit grade. We will go through this as a class at the start of next weeks session.

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Training for Fitness – Worksheet 1 - Fitness Programming

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Lesson Case Studies to Create CANVA Resource from.

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Lesson Case Studies to Create CANVA Resource from.