The cyclic connection between physical and mental health: from local case study to the globe

Kelly Hemsley

BA (Hons) Sport, Coaching and Physical Education

Abstract

Higher Education (HE) students in England are more likely than other demographic to experience poor mental health. Through a case study approach focusing upon Nat, a 20-year-old HE student based in Cambridge, it will be argued that there is a clear cyclic relationship between physical and mental health. This relationship will be explored via environmental and social factors, and the ways in which outcomes are tested via physical, psychological and general procedures are critically evaluated. The need for a positive mindset, as well as testing health in a holistic manner, including evaluating happiness, rather than disorders, will be argued through the case of Nat. Following the case study, there is discussion of global trends, situating Nat within a wider context. In conclusion, is it argued that physical exercise impacts upon mental health, and that by considering wider factors that affect the undertaking of exercise, mental health crises may be better alleviated.

Introduction

This article will argue there is a cyclic connection between physical and mental health. The original contribution of this piece is to explore this connection in the contemporary socioeconomic climate in England via a case study approach, focusing on a full-time student, Nat, who also works part time. This is because England based HE students are one of the demographics most likely to face mental health illnesses when compared to others (Neves and Hillman, 2016). Based in Cambridge, the case study will explore the affects that the wider built environment (Baker et al., 2016; Thomson et al., 2001), and familial and social relationships (Bandura and Walters, 1977) have upon health outcomes in England. Ways of testing health will also be critically explored, looking at physical (Army, 2022; Brzycki, 1993; Royal Air Force, 2017; Royal Navy, 2022), psychological (Beck, 1961; Shrout et al., 2018,) and general health tests (Dalgleish et al., 2001; Heyward, 2010; NHS, 2019). It is argued that holistic health (Bouchard et al., 2012) and happiness (Argyle et al., 2014) testing is preferable to that which focuses primarily on deficits or disorders. Exploring the ‘invisible benefits’ of exercise (Ruby et al., 2011), the importance of a positive mindset and cyclic correlation of physical and mental health are outlined. The final part of the piece extrapolates from the study of Nat, and situates him within wider global trends (WHO, 2020). The piece concludes with some recommendations; namely, the importance of physical activity upon mental health to foster an ongoing virtuous cycle.

Demographic overview

Nat is a 20-year-old university student studying Criminology and Policing in Cambridge. He used to live with his mum, dad, and younger sister in a small village in Fenland, Cambridgeshire, but moved to student accommodation in Cambridge at 18 for university. Nat’s dad and sister are swimming coaches and the whole family is regularly physically active. His BMI is 26.2kg/m2 and his body type would be considered muscular. He grew up involved in swimming and football as well as taking part in school sports and activities such as cricket, rugby and athletics. He now only plays football once a week socially with friends. Nat attended a state school and came from a working-class family. He currently works a part-time job alongside his studies as a waiter at a local restaurant.

Psychological Factors Affecting Health, Fitness and Wellbeing

Depression and Anxiety

There are many psychological factors which can affect health, fitness and wellbeing, especially among university students. Psychological concerns can include stress, anxiety, depression and loneliness. Depression and anxiety are common among students which often leads to motivation, concentration and mood being negatively influenced (Andrews and Wilding, 2004). It is considered that most psychological disorders will start at university age, with depression being the first, later leading to the development of associated conditions such as anxiety (Ibrahim et al., 2013; Said et al., 2013).

Research conducted by Goodwin (2003) using 5877 adults aged 15 to 54 found an exposure-response relationship between regular levels of physical activity and mental disorders such as depression and anxiety. Ten Have et al. (2011) conducted research specifically into anxiety using 7076 adults aged 18 to 64 and found that those who were participating in physical activity for between one to three hours per week were 50% less likely to have an anxiety disorder compared to those who were deemed inactive. These research studies suggest that those who have psychological disorders are less likely to be active, which has been shown to lead to an increased risk of obesity, thus meaning a higher risk of developing cardiovascular diseases, musculoskeletal diseases, cancer, diabetes and many other health concerns (WHO, 2021). In a vicious circle, Dixon (2010) argues that those who have these health issues are more likely to be obese or develop obesity, meaning that their physical activity levels will have decreased. This in turn will cause major impacts upon mental health, and also physical health and quality of life. Considering all of the research presented, an assumption can be made that university students such as Nat will be likely to develop mental health issues, such as depression. This could cause a decrease or lack of participation in physical activity which is likely to lead to health concerns such as obesity, meaning that their health, fitness and wellbeing are all negatively affected.

Motivation

An individual’s psychological attitude, specifically motivation or a lack of motivation, has a statistically significant effect on their physical fitness and mental health. A lack of motivation can come from mental health issues such as depression, where side effects include factors such as a lack of motivation (Smith, 2013; Scarapicchia et al., 2014). This would suggest that university students who have been found to be more susceptible to developing mental health issues are likely to have a low level of motivation for taking part in physical activity. This, again, vicious circle, suggests that their fitness levels are likely to be low, leading to a higher risk of health concerns. Despite this, Brunet and Sabiston (2011) found that young adults (19-24 years old) have a higher level of intrinsic motivation for taking part in physical activity than older adults (25-65 years old) indicating that they have the potential for a healthy level of fitness and physical health. It is also important to consider how motivation and wellbeing are linked. Maslow’s hierarchy of needs is a theory of human motivation which suggests that basic needs such as food and safety needs must be met before psychological needs can be addressed or self-fulfillment realised (Maslow and Lewis, 1987). As Nat has a part-time job, it could suggest that he is financially stable, while he also has a healthy relationship with his family and friends, meaning that via Maslow’s hierarchy of needs, he has all his basic needs met, and one could assume that he has met some of his psychological needs. Using this data may imply that Nat’s motivation levels are potentially high enough to ensure his wellbeing is addressed.

Environmental Factors Affecting Health, Fitness and Wellbeing

Housing

Considering the lived environment, housing can be a challenging issue for university students. Linked to this, universities strongly suggest to students to not have part time jobs as university is a full-time commitment. However, due to a lack of income from employment, students often encounter financial difficulties. Some individuals, such as Nat, cannot afford to not have part-time jobs alongside their studies. As a result, they often run into additional pressure at university as they do not have as much time for their studies as those without a job. Individuals with less money, regardless of if they are a student or not, normally live in lower quality or overcrowded accommodation. These housing issues can often lead to negative thoughts regarding life in general, as well as future prospects. These issues may also exacerbate the possible development of existing mental health issues such as depression, anxiety and stress. Public Health England (2019) found that 19% of adults who live in poor housing conditions experience jeopardised mental health. Baker et al. (2016) also found that housing can cause health issues as those living in poor quality housing experience social disadvantage. Thomson et al. (2001) argues along similar lines, in that those who live in poor quality conditions are more likely to develop health concerns. Thomson et al. (2001) also found that by moving these individuals into accommodation with improved conditions, their overall health began to improve. This may suggest that for Nat, his health, fitness and wellbeing are being put at risk by his living situation.

Living Area

Taking into consideration the financial issues that university students often face, this may cause difficulties when accessing sports and fitness facilities such as gyms and sports clubs, as these are usually relatively expensive. Due to this, it is important to consider the area that an individual lives in and what it provides as an alternative to costly facilities, including nature and open spaces for exercise. Hunter et al. (2019) found that green spaces benefit individuals’ health and fitness and fosters socialization.

Living in an area that has a large amount of open green space promotes physical activity, especially for those who cannot afford the gym or sports clubs or lack a larger outdoor space at home. This is applicable to university students, such as Nat, as they often live in apartments that are small and do not allow for physical activity. Nat has no access to easy access to green space at his accommodation. However, Cambridge as a city has lots of green space, meaning that with spare time, and his commutes, he may be able to utilise the environment in an advantageous manner for his overall health.

Social Factors Affecting Health, Fitness and Wellbeing

Family and Friends

An individual’s family and friends can have a significant impact on their outlook and motivation towards being healthy, involved in physical activity and taking care of their wellbeing. Bandura’s social learning theory suggests that we learn through those who are deemed significant role models, which at a young age is often parents or siblings (Bandura and Walters, 1977). Considering this, if an individual’s family is dedicated to being healthy and both physically and mentally fit, then they are more likely to commit to ensure the same occurs for themselves. Bandura’s (1977) social learning theory may then explain why Nat was more involved in sport and physical activity when he was younger, as he observed his family being so. However, this may have changed as he has entered adulthood, as his family would have less of an effect upon his behaviour compared to before. Through one’s wider friendship network, those with more social connections are more likely to be involved in group physical activities or use physical activity as a way of socialising (Graham, 2013).

Time

In relation to time, we should consider an individual’s education and employment. Those who are full-time students with part-time jobs, such as Nat, will have little to no free time. They may decide to use this free time for other things such as visiting family or socialising with friends rather than taking part in physical activity or exercise. This could be because the individual feels as though that is more important for their personal wellbeing. Nat only takes part in planned exercise for an hour a week, which may be due to his busy schedule of university and work. Due to this lack of time, Nat is more likely to have a lower level of fitness han he could have otherwise, meaning that he is more at risk of physical and mental health concerns. However, the football that Nat takes part in is with friends, so he can use this time for socialising as well as exercising meaning that he may actually be able to gain some psychological benefits from this time (Graham, 2013).

Physical Fitness Testing

One way to measure an individual’s fitness levels is by evaluating their strength with the most common way of doing this being the use of the one rep max test. This is where the individual’s dynamic strength is tested by assessing the maximum load that they are able to lift for a single repetition of the major muscle groups (Brzycki, 1993). These exercises may include a bench press to test the strength of the individual’s chest and shoulder muscles while a squat or leg press may be used to test their leg and gluteal muscles strength. The one rep max test would be considered relevant to Nat as there are many research studies which report its reliability in adults over 18 years old (Seo et al., 2012; Ribeiro et al., 2014). As in the demographic overview it is suggested that Nat has a muscular body type, it may indicate that this test would be relevant in order to test the strength that the muscles can produce.

The one rep max test has major safety concerns as it requires the individual to lift heavy weights meaning a large amount of pressure on their muscles and bones which may lead to possible injury (Brzycki, 1993). This means that it is important to have an experienced coach involved when employing the test. Research conducted by Brookes and Craven (2011) found that while performing a one rep max test there was no significant relationship found between the weight being lifted and the individual’s heart rate which indicates their cardiovascular endurance fitness levels. Despite the test being relevant to the demographic, due to these factors, it is important to consider alternatives that can be used to assess individual’s physical fitness levels.

Another commonly used method of testing an individual’s fitness is the multistage fitness test which is used to give an indication of cardiovascular endurance and can be used to assess V02. This would be beneficial for Nat as he has been described as muscular, meaning that we could assume his strength is at a relatively good level thus indicating the importance of assessing other aspects of his fitness. The multistage fitness test is used, among others, in the British Military, suggesting that it is a clear indicator of an individual’s endurance due to the importance that the military holds on their employees fitness levels being beyond average (Royal Air Force, 2017; Army, 2022; Royal Navy, 2022).

Psychological Wellbeing Testing

The most common method used to test psychological wellbeing is through multiple-choice questionnaires, or with scaled answers alongside checklists (Eabon and Abrahamson, 2013). A questionnaire into mental health such as depression and anxiety may be the best choice for testing Nat’s psychological wellbeing, as per the observation above that students are one of the most common demographics to be affected by poor mental health.

A specific test is Beck’s depression inventory (1961) which uses four statements per question, and gives a score at the end to suggest the level of depression, if any, that the individual is experiencing. Although this test gives an idea of mental health, giving an indication of their wellbeing, being exposed to words with negative connotations shortly before the test has been shown to negatively impact the results (Shrout et al. 2018). This may give an inaccurate score on the tests and could lead to a possible incorrect diagnosis and treatment plans for the individual.

It would be useful to use other tests or methods of testing alongside this one when investigating mental wellbeing to give a clearer diagnosis (Lincoln et al., 2003). To mitigate against the limitations of the depression test previously discussed, an alternative way of measuring wellbeing could be through a happiness test. Michael Argyle and Peter Hills from Oxford Brookes University were able to form a happiness test which is now known as the Oxford Happiness Test (Argyle et al., 2014). The test is not as commonly used as Beck, as individuals cannot be ‘diagnosed’ with happiness owing to it not being a mental health concern.

General Health Testing

One method commonly used for health check-ups is the testing of blood pressure. Blood pressure can be taken in two ways;

1. Directly, which is invasive as it involves catheterization

2. Indirectly, which uses auscultation or oscillometry (Heyward, 2010).

Taking an individual’s blood pressure can give clear results linked to hypertension and hypotension (Tsumura et al., 2002; Dalgleish et al., 2001). Hypotension is when an individual has low blood pressure, which can often lead to feelings of faintness. However, it is not often treated as the effects are not detrimental (Dalgleish et al., 2001). On the other hand, hypertension is marked by an elevated blood pressure, which can cause an increased risk of serious health concerns such as heart attacks and strokes. However, it often involves no symptoms (asymptomatic), meaning that it is difficult to spot (NHS, 2019; Dalgleish et al., 2001). Roughly one third of adults in the UK have high blood pressure, and with it being difficult to diagnose without testing, can be life threatening (NHS, 2019). For this reason, it would be a relevant test for Nat as it could identify a possible risk to health issues.

Despite giving an indication of their health status, it is difficult to test an individual’s health with just one test or examination. Bouchard et al. (2012) suggests that statistics do not allow for a full overview of an individual’s health as it is a complex and multifunctional structure. Therefore, an alternative to this is the health assessment questionnaire which assesses five different aspects of health (Green et al., 2019). Sometimes known as the health status questionnaire, it explores existing medical conditions, characteristics that may cause an increased risk to health, occurring signs of health concerns, lifestyle behaviours that may indicate a positive or negative health and the results from a fitness test (Howley and Franks, 1997). This would be a holistic way of testing Nat’s general health as it explores many aspects, meaning that any health concerns would be identified while he is still young so that diagnosis and treatment could be provided at the stage of prevention, rather than cure.

The remainder of the piece will broaden in scope, extrapolating from the case study of Nat, to place him in a contemporary global context in relation to physical and mental health. This will be done by exploring research data from organisations such as the World Health Organisation (WHO).

The Benefits of Exercise on Public Health Improvement and Wellbeing

Walking is a simple yet highly effective form of exercise that is commonly overlooked. If promoted further, it could help the public to better meet recommended daily physical activity levels. The WHO recommends for adults to participate in around 150-300 minutes of moderately intense physical activity per week, or less if the physical activity is considered to be vigorous. However, at least 25% of the global population do not meet this recommendation (WHO, 2020).

The risk of cardiovascular disease is reduced by up to 30% for those who walk for at least 30 minutes a day when compared to those who are inactive (Stensel et al., 2022; Zheng et al. 2009). A meta-analysis of eight studies researching the same topic area conducted by Hamer and Chida (2008) found that walking as a form of commuting instead of driving or getting public transport results in an 11% reduction in cardiovascular disease risk. Further supporting evidence of this comes from research conducted by Gordon-Larsen et al. (2009) which suggested that men specifically were less likely to be at risk of cardiovascular disease if they used walking as a method of transport. If walking alone can make such a significant difference to the risk of health concerns such as cardiovascular disease, it suggests the majority of the population are able to make a small change which will allow for many life-changing health benefits.

Considering cardiovascular disease as a health concern alongside many others, the risk of health issues is intensified and often the result of being overweight or obese which stems from inactivity. The World Health Organisation states that the risk of death increases by up to 30% for those who are physically inactive (WHO, 2021) while 39% of adults worldwide are considered to be overweight (WHO, 2020). The Global BMI Mortality Collaboration supports this through their meta-analysis, which included 189 studies, to present the idea that there is a heightened risk of early death from being overweight (Angelantonio et al., 2016). Through exercise and eating healthily, creating a calorie deficit, weight loss will occur and therefore reduce the risk of health concerns that have been previously mentioned.

Linked to this, improvements to mental wellbeing and prevention of mental health concerns often come from physical activity and exercise as they provide benefits, which include the development of cognitive ability and the enhancement of mood (Mandolesi et al., 2018). Research conducted by Ruby et al. (2011) on the ‘invisible benefits of exercise’ found that people usually underestimate how much they enjoy exercise as they tend to focus on the tougher components of it rather than the enjoyable aspects. This may suggest that when the mindset is positive, exercise becomes more enjoyable, which is likely to induce positive thoughts, reducing the chances of negative mental health.

Research suggests that endurance is the best form of exercise for a positive mental health (Ruegsegger and Booth, 2018). In addition to this, Plante et al. (2006) found through their research study that exercise which is done outside provides more energising feelings, while exercising indoors is more relaxing. It is suggested that by making social and environmental changes when exercising, there will be more comfort and enjoyment which is likely to lead to increased mental health benefits (Plante at al., 2006). These factors all indicate that exercise results in an improvement in mental wellbeing.

Martinsen (1990) suggests that individuals who are diagnosed with a form of depression are often physically sedentary which leads to a lower level of fitness. Those with existing mental health are often advised to take part in some form of exercise in order to help them manage their mental health alongside cognitive-behavioural therapies, thereby reiterating a cyclic relationship. De Moor et al. (2006) found that regular exercise resulted in decreased symptoms relating to depression and anxiety as well as seeing higher levels of extroversion being portrayed. Craft and Perna (2004) note that exercise as a behavioural intervention is notably effective in alleviating symptoms of depression. Martinsen (1990) supports this as their research found that exercise has an anti-depressive effect on those involved. When exercise was used as a treatment for depressed patients, more than 50% continued with regular exercise after the programme had finished as they gained mental health benefits from it. This indicates that exercise can be used as a way of restoring and maintaining positive mental health.

Conclusion

To summarise, physical activity has been proven through numerous studies to have a largely positive effect on improving an individual’s overall health, multiple aspects of fitness and induce better psychological feelings. Health benefits include reducing the risk of cardiovascular disease, stroke, diabetes and cancer among many other health concerns. Regular physical activity can lead to improvements of muscular strength, muscular endurance, cardiovascular endurance and flexibility. In addition to these benefits, physical activity has been shown to have positive effects on individual psychological wellbeing and is it often used as a method of prevention or treatment for mental health concerns.

References

Andrews, B., & Wilding, J. M. (2004). The relation of depression and anxiety to life-stress and achievement in students. British journal of psychology, 95(4), 509-521.

Argyle, M., Hills, P., & Wright, S. (2014). Take the Oxford Happiness Questionnaire. The Guardian. https://www.theguardian.com/lifeandstyle/2014/nov/03/take-the-oxford-happinessquestionnaire

Army. (2022). Army Fitness Tests. Army. https://apply.army.mod.uk/how-to-join/can-ijoin/fitness/physical-entry-standards

Baker, E., Lester, L. H., Bentley, R., & Beer, A. (2016). Poor housing quality: Prevalence and health effects. Journal of Prevention & Intervention in the Community, 44(4), 219-232.

Bandura, A., & Walters, R. H. (1977). Social learning theory (Ed. 1). Prentice Hall: Englewood cliffs.

Bouchard, C., Blair, S. N., & Haskell, W. L. (2012). Physical activity and health (2nd ed.). Human Kinetics.

Brunet, J., & Sabiston, C. M. (2011). Exploring motivation for physical activity across the adult lifespan. Psychology of sport and exercise, 12(2), 99-105.

Brzycki, M. (1993). Strength testing—predicting a one-rep max from reps-to-fatigue. Journal of physical education, recreation & dance, 64(1), 88-90.

Craft, L. L., & Perna, F. M. (2004). The benefits of exercise for the clinically depressed. Primary care companion to the Journal of clinical psychiatry, 6(3), 104. doi: 10.4088/pcc.v06n0301

Dalgleish, J., Dollery, S., Frankham, H., Lifetime Health & Fitness (Firm), & Frankham, H. (2001). The health and fitness handbook. Pearson Education.

De Moor, M. H., Beem, A. L., Stubbe, J. H., Boomsma, D. I., & De Geus, E. J. (2006). Regular exercise, anxiety, depression and personality: a population-based study. Preventive medicine, 42(4), 273-279. https://doi.org/10.1016/j.ypmed.2005.12.002

Di Angelantonio, E., Bhupathiraju, S. N., Wormser, D., Gao, P., Kaptoge, S., De Gonzalez, A. B., Cairns, B. J., Jackson, C. L., Josh, G., Lewington, S., & Huxley, R. (2016). Body-mass index and all-cause mortality: individual-participant-data meta-analysis of 239 prospective studies in four continents. The Lancet, 388(10046), 776-786. https://doi.org/10.1016/S01406736(16)30175-1

Eabon, M. F. & Abrahamson, D. (2013). Understanding psychological testing and assessment. American Psychological Association. https://www.apa.org/topics/testing-assessmentmeasurement/understanding

Goodwin, R. D. (2003). Association between physical activity and mental disorders among adults in the United States. Preventive medicine, 36(6), 698-703.

Gordon-Larsen, P., Boone-Heinonen, J., Sidney, S., Sternfeld, B., Jacobs, D. R., & Lewis, C. E. (2009). Active commuting and cardiovascular disease risk: the CARDIA study. Archives of internal medicine, 169(13), 1216-1223.

Graham, L. (2013). “Socialising through Exercise Perhaps is a Gift from Heaven”: The Relevance of a Sport and Recreation Service to the Needs of International Students. International Journal of Sport & Society, 3(2).

Hamer, M., & Chida, Y. (2008). Active commuting and cardiovascular risk: a meta-analytic review. Preventive medicine, 46(1), 9-13. https://doi.org/10.1016/j.ypmed.2007.03.006

Heyward, V. H. (2010). Advanced fitness assessment and exercise prescription (6th ed.). Human Kinetics.

Howley, E. T., & Franks, B. D. (1997). Health fitness instructor’s handbook (3rd ed.). Human Kinetics.

Hunter, R. F., Cleland, C., Cleary, A., Droomers, M., Wheeler, B. W., Sinnett, D., Nieuwenhuijsen, M.J. & Braubach, M. (2019). Environmental, health, wellbeing, social and equity effects of urban green space interventions: A meta-narrative evidence synthesis. Environment international, 130, 104923.

Ibrahim, A. K., Kelly, S. J., Adams, C. E., & Glazebrook, C. (2013). A systematic review of studies of depression prevalence in university students. Journal of psychiatric research, 47(3), 391-400.

Lincoln, N. B., Nicholl, C. R., Flannaghan, T., Leonard, M., & Van der Gucht, E. (2003). The validity of questionnaire measures for assessing depression after stroke. Clinical Rehabilitation, 17(8), 840-846.

Mandolesi, L., Polverino, A., Montuori, S., Foti, F., Ferraioli, G., Sorrentino, P., & Sorrentino, G. (2018). Effects of physical exercise on cognitive functioning and wellbeing: biological and psychological benefits. Frontiers in psychology, 9, 509. https://doi.org/10.3389/fpsyg.2018.00509

Martinsen, E. W. (1990). Benefits of exercise for the treatment of depression. Sports Medicine, 9(6), 380-389. https://doi.org/10.2165/00007256-199009060-00006

Maslow, A. H. (1987). Motivation and personality. (3rd ed.; R. Frager, J. Fadiman, C. McReynolds, &. R. Cox, Eds.). Addison Wesley.

Neves, J. and Hillman, N. (2016). The 2016 Student Academic Experience Survey (Higher Education Policy Institute and Higher Education Academy). Available at: https://www.hepi.ac.uk/wp-content/uploads/2016/06/Student-Academic-Experience-Survey-2016.pdf.

Plante, T. G., Cage, C., Clements, S., & Stover, A. (2006). Psychological benefits of exercise paired with virtual reality: Outdoor exercise energizes whereas indoor virtual exercise relaxes. International Journal of Stress Management, 13(1), 108–117. https://doi.org/10.1037/1072-5245.13.1.108

Public Health England. (2019). Mental health: environmental factors. https://www.gov.uk/government/publications/better-mental-health-jsna-toolkit/2understanding-place#housing-and-homelessness

Ribeiro, A. S., do Nascimento, M. A., Salvador, E. P., Gurjão, A. L. D., Avelar, A., Ritti-Dias, R. M., Mayhew, J. L., & Cyrino, E. S. (2014). Reliability of one-repetition maximum test in untrained young adult men and women. Isokinetics and Exercise Science, 22(3), 175-182.

Royal Air Force. (2017). Action: preparing for application and training in the RAF. Royal Air Force. https://www.raf.mod.uk/recruitment/fitness-in-the-raf/fitness-test-training-plan

Royal Navy. (2022). Royal Marines Commando Stages and Standards. Royal Navy. https://www.royalnavy.mod.uk/careers/royal-marines/get-fit-to-join/stages-andstandards/royal-marines-commando/rmcpc

Ruby, M. B., Dunn, E. W., Perrino, A., Gillis, R., & Viel, S. (2011). The invisible benefits of exercise. Health Psychology, 30(1), 67. https://doi.org/10.1037/a0021859

Ruegsegger, G. N., & Booth, F. W. (2018). Health benefits of exercise. Cold Spring Harbor perspectives in medicine, 8(7). doi: 10.1101/cshperspect.a029694

Said, D., Kypri, K., & Bowman, J. (2013). Risk factors for mental disorder among university students in Australia: findings from a web-based cross-sectional survey. Social psychiatry and psychiatric epidemiology, 48(6), 935-944.

Scarapicchia, T. M., Sabiston, C. M., O’Loughlin, E., Brunet, J., Chaiton, M., & O’Loughlin, J. L. (2014). Physical activity motivation mediates the association between depression symptoms and moderate-to-vigorous physical activity. Preventive medicine, 66(1), 45-48.

Seo, D. I., Kim, E., Fahs, C. A., Rossow, L., Young, K., Ferguson, S. L., Sherk, V.D., Loenneke, J.P., Kim, D., & Lee, M.K. (2012). Reliability of the one-repetition maximum test based on muscle group and gender. Journal of sports science & medicine, 11(2), 221.

Shrout, P. E., Stadler, G., Lane, S. P., McClure, M. J., Jackson, G. L., Clavél, F. D., Iida, M., Gleason, M.E., Xu, J.H. & Bolger, N. (2018). Initial elevation bias in subjective reports. Proceedings of the National Academy of Sciences, 115(1), 15-23. https://doi.org/10.1073/pnas.1712277115

Smith, B. (2013). Depression and motivation. Phenomenology and the Cognitive Sciences, 12(4), 615-635.

Stensel, D. J., Hardman, A. E., & Gill, J. M. R. (Eds.). (2022). Physical activity and health: the evidence explained (3rd ed.). Routledge.

Ten Have, M., de Graaf, R., & Monshouwer, K. (2011). Physical exercise in adults and mental health status: findings from the Netherlands mental health survey and incidence study (NEMESIS). Journal of psychosomatic research, 71(5), 342-348.

Thomson, H., Petticrew, M., & Morrison, D. (2001). Health effects of housing improvement: systematic review of intervention studies. BMJ, 323(7306), 187-190.

Tsumura, K., Hayashi, T., Hamada, C., Endo, G., Fujii, S., & Okada, K. (2002). Blood pressure response after two-step exercise as a powerful predictor of hypertension: the Osaka Health Survey. Journal of hypertension, 20(8), 1507-1512.

World Health Organisation. (2020). Physical Activity. World Health Organisation. https://www.who.int/news-room/fact-sheets/detail/physical-activity

World Health Organisation. (2021). Obesity and Overweight. World Health Organisation. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight

Zheng, H., Orsini, N., Amin, J., Wolk, A., Nguyen, V. T. T., & Ehrlich, F. (2009). Quantifying the dose-response of walking in reducing coronary heart disease risk: meta-analysis. European journal of epidemiology, 24(4), 181-192.