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Physical activity levels and Health-related quality of life in young Italian

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Physical activity levels and Health-related quality of life in young Italian population.

Myosotis Massidda1, Lucia Cugusi2, Alessandro Mathieu3

1
Department of Life and Environmental Sciences, University of Cagliari, ITALY.

2
Department of Medical Sciences, University of Cagliari, ITALY

3
Chair of Rheumatology II, Department of Medical Sciences, University of Cagliari, ITALY

Physical activity and health among young adult population.

This manuscript represents results of original work that have not been published elsewhere

(except as an abstract at the ACSM’s 2nd World Congress on Exercise is Medicine®. May 31-

June 4, 2011 - Denver, Colorado USA).

No external financial support was received for the study. There are not any conflict of interest

and any professional relationship between each authors and the companies or manufacturers

who will benefit from the results of the present study.

Acknowledgments

The authors would like to thank all the students and colleagues who participated in the study

and who assisted with data collection during the project.

Corresponding author: Myosotis Massidda, Department of Life and Environmental

Sciences, University of Cagliari, SS 554, Km 4.500 – 09042 Monserrato, Italy; e-mail:
myosotis.massidda@unica.it Tel.+39.070.6754154.

1
Abstract

Significant levels of physical activity (PA) have benefit in reducing chronic diseases in the

general adults, but little is known on the association between health-related quality of life

(HRQoL) and PA levels among young population. Aim. This study aims to investigate the

association between different levels of PA and HRQoL in a random sample of 155 Italian

University students (age range: 18-30). Methods. We used the short version of IPAQ and SF-

36 to assess PA levels and HRQoL, respectively. Differences in HRQoL scores between the

three IPAQ categories (low, moderate and high) were evaluated by the analysis of covariance

(with age and BMI as covariates). Forward stepwise multiple regression analysis was used to

determine the most predictive variables for a good HRQoL. Results. A significant

relationship between PA (Kcal/week and METs/week) and Physical Functioning, Role

Physical, General Health, and Physical Summary Component scores was observed in females,

while the Role Physical, and the Vitality were associated with PA in males. The amount of

PA (day/week, Kcal/week and METs/week) significantly predicted the HRQoL scores and the

variance explained by the function ranged from 5.75% to 14.24% for females and from

5.41% to 10.95% for males. The regular frequency of PA during the week was the most

important positive predictors for the highest scores in the most of HRQoL domains.

Conclusions. Our results confirm that the highest PA Levels was associated with more

favorable scores in HRQoL dimensions, also among young Italian population.

Keywords: Exercise, IPAQ, SF-36, Sport

2
Introduction

The impact of physical activity (PA) on health status has been mostly investigated by

objective outcomes1. Indeed, there are several scientific evidences on the role of exercise and

PA in reducing the risks of many health burdens for both healthy people and patients with

chronic disease2. More specifically, PA is reported to be associated with a 30-40% reduction

in risk of colon cancer and 20-30% reduction for breast cancer3, as well as with reduction of

sputum eosinophil and fractional exhaled nitric oxide in patients with moderate or severe

asthma4. PA is also associated with improving physical function and reduction disability in

patients with rheumatoid arthritis5,6. Moreover, exercise can prolong life and improve quality

of life, and it is associated with a lower risk to develop heart disease, stroke, diabetes, and

osteoporosis.

The American College of Sports Medicine (ACSM) and the Centers for Disease Control and

Prevention (CDC) have explicitly quantified the amounts and the intensities of PA that should

be accumulated for optimum health. During a week, adults are recommended to participate in

moderate-intensity aerobic physical activity (PA) for a minimum of 30 min on five days each

week or vigorous-intensity aerobic activity for a minimum of 20 min on three days each

week7.

Nevertheless, Häkkinen and colleagues8 reported that 41% of adults in the European Union

countries exert no moderate PA level during week, and Haskell and colleagues7 showed that

less than half (49.1%) of U.S. adults met the CDC/ACSM physical activity recommendations.

Besides of such data, recent studies showed that PA is also associated with elevated

psychological well-being and with improved health-related quality of life (HRQoL). The

relationship between physical fitness level and HRQoL has been reported in different cohorts

of aged and chronically illness individuals9-12 moreover, the few studies on the general adult

3
population suggested a positive effect of PA on both mental and physical component of

HRQoL13,14.

Despite a recent systematic review highlighted the public health importance of better

understanding the relation between PA and HRQoL in the general adult population15, little is

yet known on the association between HRQoL and PA levels in such a population1.

In addition, there is insufficient evidence regarding the relationship between PA levels and

HRQoL in the youngest adults8 and, to our knowledge, there are not studies on the association

between PA levels and HRQoL among young health Italian population.

The aim of the present study was to investigate the relationships between different levels of

PA (walking, moderate-intensity activity, vigorous-intensity activity) and HRQoL in a

population of males and females University students.

Materials and Methods

Participants.

The research was a cross-sectional survey. Students were selected from Bachelor’s and

Master's Degree Courses of the University of Cagliari (Italy) using a simple random sampling

technique by ballot. Using this process, one hundred fifty-tree students (Males=n.72;

Females=n.81) aged 22.66 ± 3.55 were recruited for the study. Subjects taking any kind of

medications or having any chronic disease or hypertension were prior to the study excluded.

Procedure

Participants were given a brief introduction to the purpose of the study, after which their

consent was sought and obtained. Ethical approval for this research was obtained from the

ethical committee of the University of Cagliari and it was performed in accordance with the

1975 Helsinki Declaration, as modified in 2000. All volunteers provided their written

informed consent before participation in the study. Each subject visited in two consecutive
4
days our laboratory. During the first visit, the International Physical Activity Questionnaire

(IPAQ)16 was completed. The second visit was used to assessed the HRQoL by means of the

SF-36 Health Survey17.

Body mass index (BMI) was calculated as weight (kg)/height (m2) according to the self-

reported weight and height. Age and body mass index (BMI) were recorded as continuous

variables.

PA measures

PA was assessed using the short version of IPAQ which records physical activity (PA) as

hours and additional minutes of participation during the past 7 days in activities rated

according to multiples of metabolic equivalents (METS). IPAQ assesses frequency and time

of walking (3.3 METS) and moderate (4.0 METS) and vigorous (8.0 METS) PA, appropriate

for categorization of individuals as meeting public health guidelines for sufficient regular

physical activity. IPAQ defines three categories of PA: "low" (physically inactive),

"moderate" and "high" levels of PA, in relation to health-related recommendations18. IPAQ

has acceptable measurement properties for monitoring population levels of physical activity

among 18- to 65- year-old adults in diverse settings16.

The total weekly PA levels, expressed as MET-minutes per week (MET•min•wk-1), was

calculated as duration x frequency per week x MET intensity, and it was the expression of the

summed of walking and moderate and vigorous PA for the week.

HRQoL measures

SF-36 Health Survey consist of 36 items, each one with various response alternatives that

provide a health status profile. The test explores eight dimensions: “physical functioning”

(PF), “role limitations due to physical problems” (RP), “body pain" (BP), "general health"

(GH), "vitality" (V), "social functioning" (SF), “role limitations due to emotional problems”,

(RE) and "mental health" (MH). Each subscale is linearly transformed into a 0 to 100 scale,
5
with higher scores representing better health status and functioning19. The eight scales form

two distinct higher-ordered clusters physical component summary (PCS) score and mental

component summary (MCS) score due to their common physical and mental health

variance20. Aplone and Mosconi17 studied the characteristics of reliability and validity of this

test in Italian population and found that the measures for internal reliability (Cronbach's

alpha) of the different categories ranged between 0.77 and 0.93, with a mean always above

the value of 0.70.

Data analysis

Statistical analyses were performed using STATISTICA software, version 7.0 (StatSoft, Inc.,

Tulsa, OK, USA). Mean and standard deviation (SD) are given as descriptive statistics. All

variables were checked for normal distribution by the Shapiro-Wilks test. Significant

differences between genders in PA levels and HRQoL scores were tested by the analysis of

variance with the Bonferroni’s post hoc test.

Differences in HRQoL scores between the three IPAQ (low, moderate and high) categories

were evaluated by the analysis of covariance (with age and BMI as covariates) with the

Bonferroni’s post hoc test.

Forward stepwise multiple regression analysis was used to determine the most predictive

variables for the highest value of HRQoL. Particularly, the relationships between different

intensity levels of PA (MET•min•wk) and weekly frequency of PA (day•wk), total weekly PA

(MET•min•wk), total Energy Expenditure (EE) (kcal•wk) and HRQoL were evaluated. In the

regression model, the types and frequencies of PA, age and BMI, and the total weekly EE

were used as independent variables and the scales of SF-36 as dependent variables.

Significant different were assumed when p<0.05.

Results
6
The physical characteristics, PA levels and HRQoL scores of the sample are shows in table 1.

*** Table 1 near here ***

The analysis of variance suggested that males were younger (F=4.524; df=1; p=0.03), taller

(F=144.329; df=1; p=0.01) and heavier (F=144.527; df=1; p=0.01) than females. Figure 1

shows the results of HRQoL items in both sexes. Females showed a significant lower scores

of GH (F=5.057; df=1; p=0.02), MH (F=5.240; df=1; p=0.02), and MCS (F=4.745; df=1;

p=0.03) domains than males.

*** Figure 1 near here ***

Figure 2 shows IPAQ outcomes in males and females. Significant differences between

genders were observed for the Vigorous activity (F=16.230; df=1; p=0.01) and for the Total

EE (kcal) during the week (F=6.377; df=1; p=0.01) that were higher in males than females.

*** Figure 2 near here ***

As far as PA categories, 7.40 % of females (age=23.1±2.3 yr; BMI=21.8±2.2) and 0% of

males were classified as physically inactive, 33.3% of females (age=23.3±3.7 yr;

BMI=19.8±2.8) and 20.8% of males (age=23.2±3.9 yr; BMI=22.5±2.2) were classified into

the Moderate and 59.2 % females (age=23.1±3.9 yr; BMI=20.8±2.3) and 79.1% males

(age=21.7±2.9 yr; BMI=22.4±1.9) into the High PA categories.

Tables 2 and 3 shows the HRQoL scores for each IPAQ category in females and males.

7
*** Tables 2 and 3 near here ***

For females, the results showed that PH score was lower in the inactive group (F=1.787;

df=16, p=0.03) with respect to other PA categories. No significant differences (p>0.05) was

found between PA categories and HRQoL scores in males, while there was a trend toward an

higher scores with the increasing of PA levels in both sexes.

Differences in scores between low and high PA female exercisers were found to be at least

five point in MH, MCS and PCS, and approximately over ten points in GH and SF. For

females, the multivariate model combining different levels and frequencies of PA

significantly predicted PH (model F=9.733, df=2, p=0.006), RP (model F=9.423, df=2,

p=0.002), GH (model F=4.822, df=1, p=0.031), and PCS (model F=5.012, df=2, p=0.008)

scores, and variance explained by the function ranged from 5.75% to 14.24%. For males, the

same multivariate model significantly predicted RP (model F=4.244, df=2, p=0.018) and VT

(model F=4.004, df=1, p=0.049) scores, and variance explained by the function ranged from

5.41% to 10.95%. The most influenced variable was the RP in both sexes, while the regular

frequency of PA during the week was the most important positive predictors for the highest

scores in the most of HRQoL domains in both sexes.

Discussion

Results of the present study showed that the highest PA Level was associated with more

favorable scores in the HRQoL dimensions. Our findings are in agreement with those of other

studies in which the higher levels of physical activity were associated with one or more

HRQoL dimensions, in both men and women13,21,22.

A significant differences in HRQoL and PA levels were observed between sexes. Males

showed an higher PA energy expenditure (kcal), more time spent during Vigorous activity
8
(PA) and an higher scores in GH, MH, and MCS domains with respect to those of females.

Previous studies demonstrated significant differences between genders in physical activity23

HRQoL24,25 and in the relationship between physical activity and HRQoL26.

Another interesting result of the present study was the relationship between PA levels and

HRQoL scores. In fact, HRQoL scores showed a consistent positive gradient from the

inactive group (Low PA) and moderate PA group to the high PA groups (except for bodily

pain and role emotional dimensions in women), suggesting a dose-response relationship.

Similar to our findings, other cross-sectional study conducted on adults from France1 reported

a positive trend of HRQoL scores across the four categories of leisure-time PA level. Also

Brown et al.21,27 described a bell-shaped dose-response curve with the best HRQoL scores

corresponding to a PA category compatible with public health recommendations.

However, our findings have some limitations due to the very few subjects classified as

physically inactive. In fact, only 7.40% of the females and none of the males fell in the low

PA categories and this point can partially explain the poor proportion of the variance

explained by the regression analysis, more specifically for males.

Previous studies showed that the proportion of the variance of the HRQoL scores explained

by the PA level ranged from 23.9% (SF-36 scale)13 to 35% (PF)28, and the differences in

scores between the lowest and the highest PA categories ranged from 1.7 points (PCS in

men)22 to 9 points (VT)1. Our study showed a great differences in HRQoL dimensions

between the lowest and highest PA categories in females, and a smaller differences between

the moderate and highest PA categories in both sexes. More specifically, the differences

ranged from 0.5 points (SF in men) and 10.8 points (SF in women) and a five points

difference is generally considered as clinically meaningful29.

In the present study we also found a negative gradient from the inactive group (Low PA) to

the high PA group for BP and RE in woman. Previous investigations suggested that, in
9
general, the relationship between higher doses of PA and benefits to health are not always

linear, due to the risk of overuse injuries30,31, upper respiratory tract infections32, detrimental

mental health among “exercise abuser” 33 that increases with the dose of physical activity.

Finally, the best predictor for the highest HRQoL scores was the frequency of PA in both

sexes. The subjects engaged in a regular PA during all the 7 days of week showed the greatest

HRQoL scores. Similar results was obtained in other study conducted in a group of subjects

(18-75 age) from Rhode Island13. The researchers showed that, with respect to mental health

functioning, the strongest differences appeared for those who engaged in regular exercise

behavior versus those who did not.

Conclusions

In conclusion, this is the first study that analyzed the relationships between PA levels and

HRQoL in health Italian young population.

Although the present study sample was mainly composed by physically active people, the

obtained results showed a significant relationship between PA and HRQoL in both sexes. The

males engaged more vigorous PA and had significantly higher GH, MH and MCS scores than

females.

On the basis of our results it is very important to plan public health interventions designed to

promote, increase or maintain a good physical activity levels in this type of population and

advise young people on the adverse health consequences of a sedentary lifestyle.

10
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Title of Tables

Table 1. Subjects’ physical characteristics, PA Levels and HRQoL scores.

Table 2. Females’ HRQoL scores for the three IPAQ (low, moderate and high) categories.

Table 3. Males’ HRQoL scores for the three IPAQ (low, moderate and high) categories.

15
 Title of Figures

Figure 1. HRQoL scores in males and female.

Figure 2. Type and total amount of PA (METs) during the week in males and females.

16

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