The association of Aerobic and Muscle-Strengthening Physical

Activities with Mental Well-being among Young Adults: Considering

Fitness as Mediators, Gender as Moderators, and other 24-h
movements as covariates

Denny Agustiningsih1, Retna Siwi Padmawati2, Dicky Moch Rizal1, Rahmaningsih Mara
Sabirin1, Meida Sofyana1, Jajar Setiawan1, Merrinda Agustina2, Fahmi Baiquni2, Rakhmat Ari
Wibowo1*
1
Department of Physiology, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah
Mada, Indonesia
2
Department of Health Behaviour, Environment, and Social Medicine, and Centre of Health
Behaviour and Promotion, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah
Mada, Yogyakarta, Indonesia

* Correspondence:
Rakhmat Ari Wibowo
rakhmatari@mail.ugm.ac.id

Keywords: Hand Strength, Movement, Oxygen Consumption, Sedentary Behavior, Sleep,

Universities. (Min.5-Max. 8)

Abstract

Abundant evidence showed the independent benefits of aerobic physical activities and muscle-
strengthening activities on mental well-being. However, studies investigating the interaction between
two types of physical activities on mental health are scarce. In addition, other 24-hour movement
behaviors, including sitting time and sleep behaviors, as well as health-related fitness as intermediate
outcomes of physical activities, which could also influence mental health, were also infrequently
considered. Moreover, sex-difference in the effect of physical activities suggested including gender
as a moderator. This study aimed to conduct mediation and moderation analysis to investigate the
association between aerobic and muscle-strengthening physical activities and mental health among
young adults by considering other 24h movement behaviors, gender, and health-related fitness.

Using cross-sectional data of 221 young adults joining a physical activity intervention at a University
at Yogyakarta, Indonesia, aerobic physical activities and sitting time, muscle strengthening activities,
sleep behavior, and mental well-being were measured using Indonesian Physical Activity, Sedentary
Behaviour, and Sleep Questionnaire, Indonesian version of Muscle-Strengthening Exercise
Questionnaire, Pittsburgh Sleep Quality Index Indonesian Short Version, and Warwick-Edinburgh
Mental Wellbeing Scale Indonesian version. Mediation and moderation analyses were conducted
using Process Macro model 8 on SPSS 25 to investigate the association of aerobic or muscle-
strengthening activities on mental well-being, with gender as moderator, V̇ O2max was predicted
using the Six Minute Walk Test, Handgrip strength was measured using Camry EH101
24-hour movement behavior mental well-being

dynamometer, and muscle mass was measured using Omron HBF-375 as mediators, and each
reference type of activities, sitting time, and sleep behavior as covariates.

Weekly volume of muscle-strengthening activities had a direct association with mental well-being
among males with an effect of 0.00049 (95% Confidence Interval 0.00001 to 0.00096) without
mediation effect from health-related fitness. In contrast, the weekly volume of moderate-vigorous
aerobic activities had a fully-mediated association with mental well-being among females by
V̇ O2max with an indirect effect of 0.00004 (95% Confidence Interval 0.00001 to 0.00010).

Findings suggest that increasing participation in muscle-strengthening activities among young male
adults and increasing participation in moderate-vigorous aerobic activities, which could particularly
increase V̇ O2max among young female adults, should be considered to improve their mental well-
being.

1 Introduction

Evidence showed increased trends in the global burden of mental disorders in the last decades,
resulting in an increase of disability-adjusted life-years (DALYs) from 80.8 million in 1990 to 125.3
million in 2019 [1]. Across all age groups, the number of DALYs caused by mental disorders
increased during youth, including young adults, before reaching its peak until the 34 years age group
[1]. In Indonesia, mental health problems among young adults are highly prevalent accounting for
25% of disease burden [2]. The high prevalence of mental health problems among young adults could
disturb their transition into adulthood since poor mental health is associated with poor academic and
workplace performance [3,4,5].

Mental wellbeing, conceptualized as more than the absence of mental problems as well as
encompassing hedonic and eudaimonic state, is beneficial for a broad range of health outcomes and
associated with better educational and occupational outcomes [4,5,6,7]. While mental wellbeing may
be related to mental problems, these two concepts should be viewed separately resulting in four
states: struggling (high mental problems and high mental wellbeing), floundering (high mental
problems and low mental wellbeing), languishing (low mental problems and low mental wellbeing),
and flourishing (low mental problems and high mental wellbeing) [8]. In addition to high prevalence
of mental problems, there is also high prevalence of low mental wellbeing among young adults
ranging from 40.3% to 65.3%, particularly during the COVID-19 pandemic [9,10]. Therefore,
research is also required to investigate factors associated not only with mental problems but also with
mental wellbeing among young adults.
Mechanisms on aerobic physical activity influencing mental health through dopamine and
hippocampus function are well documented [11,12]. Evidence on benefits of aerobic physical activity
in either promoting mental wellbeing or reducing mental health problems are also adequately
explored [13-22]. Growing evidence also showed that muscle strengthening physical activity were
independently negatively associated with mental health problems, such as depression and anxiety
[23-26]. On the perspective of 24 hour movement, growing interest also examined the role of
sedentary behavior and sleep habits on mental health problems and mental wellbeing [27-32]. While
the findings are inconclusive, available evidence indicates that sedentary behavior negatively
correlated with mental wellbeing and positively associated with mental health problems,
independence from the effect of aerobic physical activity [27-30]. Sleep habits, including sleep
duration and sleep quality, which is interconnected with the other 24 hour movement behavior, is also
associated with mental health problems [31,32]. However, the majority of studies did not

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comprehensively consider the interdependence among all 24 hour movement behavior with mental
health, particularly mental wellbeing.

Moreover, health-related fitness, including cardiorespiratory fitness, muscle strength, body mass
index (BMI) and body composition, which can be outcomes of both aerobic and muscle
strengthening physical activities, are also associated with mental health outcomes (33,34,35,36).
Therefore, it could mediate the association between physical activity and mental health outcomes.
While several studies showing physical activity and fitness could be separate independent risk factor
of health outcomes, particularly cardiovascular disease, and health-related fitness could mediate the
effect of physical activity on health outcomes, most previous studies did not take into consideration
the mediation effect of fitness on the association between physical activity and mental health
outcomes. In addition, studies examining the association between physical activity and mental
wellbeing are not as abundant as studies on mental health problems. Moreover, gender could also
moderates the association between physical activity and mental wellbeing[35,37]. Therefore, our
study aimed to examine the association between physical activity and mental well being among
young adults in Indonesia by considering health-related fitness as mediator, gender as moderator, and
other 24 hour movement behavior as covariates.

2 Materials and Methods

2.1 Study design and setting

We conducted a secondary analysis in a cross sectional study based on baseline data obtained from
university students joining a pilot lifestyle intervention “Health and Wellness Festival 2022” at
Universitas Gadjah Mada, a public university in Yogyakarta, Indonesia. A convenient sampling was
conducted on September 3rd to 16th, 2022 among 412 students who joined in this intervention.
Participants who agreed to participate were given an online questionnaire on the day they participated
on fitness measurement which they can choose either on September 17 or September 18, 2022.
Participants younger than 18 years old or older than 25 years old at the time of baseline data
collection were excluded participants younger than 18 years old had different recommended physical
activity level and did not have the right to provide consent or participants older than 25 years old had
different categories of health-related fitness level [38,39,40]. A sample size of 414 subjects was
required to detect the mediated effect of cardiorespiratory fitness on the association between physical
activity and mental wellbeing with size of the α and β path of 0.36 and 0.20 respectively(41,35,42).
However, the present study did not reach the minimum sample size because of the limited number of
participants in the primary studies. This study was approved by the Medical and Health Research
Ethics Committee, Faculty of Medicine, Public Health and Nursing (KE/…..) and all subjects
provided written informed consent. We reported our current study following the strengthening the
reporting of observational studies in epidemiology (STROBE) statement and A Guideline for
Reporting Mediation Analyses of Randomized Trials and Observational Studies (AGReMA)
reporting guideline (43,44). The study protocol was retrospectively registered on thaiclinicalregistry.

2.2 Measurements
Demographics including sex, age, study subject were self-reported by participants using an online
questionnaire. Participants also reported their weekly duration and intensity of moderate and vigorous
physical activity (MVPA), daily sitting time duration during weekdays and weekend days using the
Indonesian Physical Activity Sedentary Behaviour and Sleep Habits (I-PASS) questionnaire [42],
their weekly duration, intensity, and type of muscle strengthening exercise using the Muscle
Strengthening Exercise Questionnaire (MSEQ) Indonesian version [45], sleep latency, sleep duration,

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sleep efficiency, sleep disturbances, and daytime dysfunction using the brief Pittsburgh Sleep Quality
Index (PSQI) Indonesian version [46,47]. All of the questionnaires used in this present study were
valid and reliable to be used in the young adult population [42,45,47]. Participants’ mental well-
being was measured using the shortened Warwick–Edinburgh Mental Well-being Scale (WEMWBS)
which has been translated and validated in Bahasa Indonesia [48,49]. Independent trained volunteer
measured participants height using a wall-mounted stadiometer, weight, muscle mass percentage, and
body fat percentage using OMRON HBF-375 body impedance analyzer (Omron Healthcare Ltd,
Lake Forest, IL) which a similar model has a good validity (r=.942) and reliability (r=.933 to .993)
to measure fat free mass in typical measurement condition in population, muscle strength using
CAMRY EH101 (Sensun Weighing Apparatus Group Ltd, Guangdong, China) which has reliability
and validity of r=.94 and 0.815 to 0.854 intraclass correlation coefficient, respectively [50,51,52],
and predicted V̇ O2max using the six minute walk test (6MWT).

Aerobic physical activity and sedentary behavior were retrieved from six questions in the IPASS
questionnaire asking for frequency and duration of moderate intensity and high intensity aerobic
physical activity as well as daily duration of sitting time during weekdays and weekend days.
Aerobic physical activity were calculated into weekly metabolic equivalent(MET). Minutes
moderate-vigorous physical activity (MVPA) and sedentary behavior was calculated into average
daily hour of sitting time based on the I-PASS scoring guideline (42). Data was also cleaned using
the I-PASS scoring guideline [42]. Six hundred MET.minutes/week MVPA was categorized as met
with the aerobic physical activity guideline and sitting time was categorized based on an 8 hour
threshold [39,53]. Weekly total volume (MET.minutes/week) of muscle strengthening physical
activities was calculated from the MSEQ Indonesian version asking for day, duration, and intensity
of weight-machine, free weight, body weight and holistic muscle strengthening exercise. Subjects
participating in muscle-strengthening physical activities for at least twice a week were categorized as
met with muscle-strengthening physical activity guideline [39]. Sleep behavior was examined using a
global PSQI index calculated from sleep latency, sleep duration, sleep efficiency, sleep disturbances,
and daytime dysfunction retrieved from 13 questions in the brief PSQI Indonesian version. Subjects
having at least 5 PSQI score were categorized as having bad sleep habits [46]. Mental well-being was
measured. The sum of participants’ response in seven items of the shortened WEMWBS was used to
their mental well-being. The score of 7.00 to 17.99, 18.00 to 24.99 and 25.00 to 35.00 was scored as
low, moderate, and high mental well-being, respectively [48].

The six minutes walk test was conducted on 15 meters track using standardized procedure, then the
predicted V̇ O2max were calculated using Mantarri’s equation which have a good accuracy for
predicting V̇ O2max compared to graded maximal exercise test with standard error of estimate of 3.5
ml/kg.min to 3.6 ml/kg.min (54). Z-score of predicted V̇ O2max were calculated across gender groups
[55,56]. Grip strength were measured thrice using in a standing position with 90-degree-flexed-elbow
and shoulder in adduction and neutral position The highest grip strength were used to calculate
relative maximal handgrip strength by dividing it with body mass index [57-60].

An average height was calculated based on two measurements using standardized procedure.
Standardized procedures were conducted twice to measure average weight, average body fat
percentage, and average muscle mass percentage of the subjects. Z-score of relative maximal
handgrip, body fat percentage, and muscle mass percentage were calculated across age and gender
groups based on the Camry instruction manual [56]. All participants were instructed to abstain from
vigorous physical activity and heavy meals at least two hours before the test and to empty his bladder
before the test. All the procedures were conducted in the morning (8 am to 12 am).

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2.3 Statistical analysis

We presented descriptive characteristics of our study sample as median and interquartile range (IQR)
for continuous variables which were not normally distributed, or frequencies and percentages for
categorical variables. Percentile bootstrapping with 10.000 samples linear regression analysis were
conducted using the Hayes’ PROCESS macro model 9 for SPSS (Armonk, New York) to examine if
the association between aerobic physical activity and muscle-strengthening physical activity with
mental well-being was mediated by health-related fitness components, including V̇ O2max z-score,
relative maximal handgrip strength z-score, and body fat percentage z-score and moderated by
gender (Figure 1). The model examines direct effect (c) that indicates the direct change in
WEMWBS score for each METs.minutes/week change in either muscle strengthening physical
activity or moderate-vigorous aerobic physical activity and five indirect effect (a1 x b1, a2 x b2, a3 x
b3, a4 x b4, a5 x b5) that indicates the change in WEMWBS score for each METs.minutes/week
change in these two type of physical activities that were mediated by z-score of predicted V̇ O2max,
z-score of relative maximal handgrip strength and z-score of body fat percentage. Crude and adjusted
analysis by adding volume of another type of physical activity, PSQI index and average daily hour of
sitting time.

Figure 1. Causal directed acyclic graph representing moderated-mediation analysis of association

between (A) muscle-strengthening physical activity with mental well-being and (B) moderate-
vigorous aerobic physical activity with mental wellbeing
MSPA = Muscle-Strengthening Physical Activity
MVPA = Moderate-Vigorous Aerobic Physical Activity
MW = Mental Well-being
CRF = Cardiorespiratory Fitness
MS = Muscle Strength
BFP = Body Fat Percentage
MM = Muscle Mass Percentage
BMI = Body Mass Index
SLEEP = Sleep Quality and Quantity

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SB = Sedentary Behavior

3 Results

Among 412 participants of the Health and Fitness Festival, 257 undergraduate students agreed to
participate in the study and filled the questionnaire. Ninety percent of them (235) attended the health
and fitness examination but 4 of them had absolute contraindication for fitness measurement,
resulting in a total of 231 study subjects. After excluding 5 missing data and 5 invalid data, a total of
221 subjects were finally included in the analysis (Figure 2). Table 1 descriptively presents the
characteristics of our study subjects. Majority of our subjects were female (64.7%), had moderate-
high mental well-being scores (96.4%) and excess body weight (50.7%. Majority of them studied
health sciences (82.8%) and lived in off-campus private accommodation (61.5%).

Potentially eligible
(n=412)
Excluded
Did not give consent to participate
(n=155)

Examined for eligibility

(n=257)
Excluded
Did not attend fitness examination
(n=22)
Had musculoskeletal problems
contraindicated to fitness
examination
(n=6)

Confirmed eligible
(n=231)
Excluded
Missing data (n=5)
Invalid data (n=5)

Included in the analysis

(n=221)

Figure 2. Study flow diagram

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Median (IQR) / n (%)

Age 19 (1)

Gender
Male
Female

BMI
Underweight 20 (9%)
Normal weight 89 (40.3%)
Overweight 44 (19.9%)
Obese 68 (30.8%)

Study subject
Health science 183 (82.8%)
Non-health natural science 26 (11.8%)
Social and humanity science 12 (5.4%)

Living arrangement
Living with parents 29 (13.1%)
On-campus accommodation 56 (25.3%)
Off-campus private accommodation 136 (61.5%)

Adherence to 24-hour movement behavior

guideline
Met with the aerobic physical activity guideline 113 (51.1%)
Did not meet with the aerobic physical activity 108 (48.9%)
guideline
Meet with the muscle-strengthening physical 70 (31.7%)
activity guideline
Did not met with the muscle-strengthening 151 (68.3%)
physical activity guideline
Sitting for up to 8 hours a day 169 (76.5%)
Sitting for more than 8 hours a day 52 (23.5%)
Having PSQI score less than 88 (39.8%)
Having PSQI score at least 133 (60.2%)

Mental wellbeing
Low 8 (3.6%)
Moderate 105 (47.5%)
High 108 (48.9%)

Table 1. Participant characteristics

The R2 of the unadjusted model showed that either muscle strengthening physical activity and
moderate-vigorous aerobic physical activity explains 9.9% and 10.1%, respectively, of variances in
mental well-being. After adjusting covariates, muscle strengthening physical activity and moderate-

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vigorous aerobic physical activity explains 11.4% and 11.2%, respectively, of variances in mental
well-being. Therefore, adjusted models were used in explaining the mediation-moderation analysis.

Figure 3. (A) Direct and indirect effects of muscle-strengthening physical activity on mental well-
being mediated by health-related fitness, (B) Direct and indirect effects of moderate-vigorous aerobic
physical activity on mental well-being mediated by health-related fitness.

MSPA = Muscle-Strengthening Physical Activity

MVPA = Moderate-Vigorous Aerobic Physical Activity
MW = Mental Well-being
CRF = Cardiorespiratory Fitness
MS = Muscle Strength
BFP = Body Fat Percentage
MM = Muscle Mass Percentage
BMI = Body Mass Index
SLEEP = Sleep Quality and Quantity
SB = Sedentary Behavior
The results of the adjusted models (Figure 3) showed a statistically significant direct effect of muscle
strengthening physical activities on mental well-being among male (β= 0.00049, 95% CI 0.00001 to
0.00096, t 2.0292, p 0.043) but not among female (β=-0.00043 95% CI -0.00206 to 0.00119 t -0.5253
p 0.599). It could be seen that approximately 510 minutes of 4 MET muscle-strengthening physical
activity per week was directly associated with an increase of 1 point mental well-being score among
male students. There was neither mediation effect of cardiorespiratory fitness, muscle strength, body
fat percentage nor muscle mass percentage on the association between muscle-strengthening physical
activity and mental well-being. On the other hand, there was no direct effect of moderate-vigorous
physical activity on mental well-being scores shown from the adjusted model either among male or
female students. The association between moderate-vigorous physical activity on mental well-being
was fully-mediated by cardiorespiratory fitness z-score, particularly among females with an indirect
effect of 0.00004 (95% CI 0.00001 to 0.00010). Neither z-score of muscle strength, muscle mass
percentage nor body fat percentage was found to have a mediation effect on the association between
moderate-vigorous physical activity and mental-wellbeing score both among male and female.

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4 Discussion

Our underpowered study showed that muscle-strengthening physical activity has a direct effect on
mental well-being score among male students and cardiorespiratory fitness fully-mediated the
association between moderate-vigorous physical activity among female students. Among males, the
mediation effect of any health-related fitness did not emerge. BMI, body fat percentage, muscle mass
percentage, and muscle strength were not found to have a mediation effect among females.
Therefore, policies and interventions could prioritize any muscle-strengthening physical activity
promotion for males and any aerobic physical activity promotion which effectively enhance
cardiorespiratory fitness for females to improve mental health among young adults.

Our research that did not find mediating effects of health-related fitness, particularly among male, on
the association between muscle-strengthening physical activity and mental well-being could indicate
that there would be socio psychological factors rather than physical health-related fitness that have a
greater mediator effect among male. Several studies showed that muscle-strengthening physical
activity increases body image [61], self-esteem [62], perceived confidence of physical capability
[63], and self-attentiveness [64]. A qualitative study also suggested that participation in resistance
training could also increase social interaction which then could lead to a higher mental well-being
[65]. This might be explained by the opportunity of social interaction during a session of muscle
strengthening physical activity since there were several rests between sets of exercise. This also
explained the need for long duration of muscle-strengthening physical activity to improve mental
well-being score since session duration is longer than muscle contraction duration in a session of
muscle-strengthening exercise. It should be noted that the majority of studies regarding psychological
and social factors related to muscle-strengthening physical activity were conducted among older
adults. Therefore, further studies exploring the effect of resistance training on social and
psychological factors mediating well-being among young adults were warranted.

The role of cardiorespiratory fitness in fully-mediating the association of aerobic physical activity
and mental well-being among females could be explained by the sex-difference in the brain-derived
neurotrophic factor (BDNF) adaptation to the aerobic training. BDNF was postulated as one of
molecules contributing to the regulation of neural plasticity which are important for mental well-
being [66,67]. Strong evidence showed that BDNF is one of the biomarkers which is increased by
chronic aerobic training, but not by resistance training [68]. While increased cardiorespiratory fitness
was also a result of aerobic training adaptation, positive correlation between cardiorespiratory fitness
and BDNF was only found among females [69]. Therefore, female young adults have an advantage in
aerobic effectiveness on mental well-being through cardiorespiratory fitness improvement which
could be associated with BDNF level improvement.

Our study also explained previous findings suggesting participation in certain kinds of aerobic
physical activity, particularly water-based physical activity, resulted in a stronger association with a
higher mental well-being than in other kinds of aerobic physical activities [70]. Water-based exercise
could result in a higher cardiorespiratory fitness improvement than land-based physical activity,
probably through greater improvement in lung function among certain populations [71,72]. While
further study is warranted to establish this relationship, policy makers and stakeholders could
consider providing opportunities for water-based physical activity for young adults, particularly
females, to increase their mental well-being.

While our study comprehensively examined interrelationship between 24-hours movement and
mental well-being among young adults, several null findings in our study should be interpreted with

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cautions. Several health-related fitness which were not found to be mediating the association between
physical activity and mental health could have a lower effect size than the other variables having a
statistically significant effect. Further sufficiently powered studies were required. In addition, our
models could not explain approximately 89% of variance in mental well-being among young adults.
Personal traits and environmental factors, in addition to biological, psychological and social factors,
should be considered in future studies [73,74].

5 Conclusion

Our study comprehensively clarified two types of physical activity in the perspective of 24 hour
movement behavior as correlates and health-related fitness as mediators of mental well-being among
young adults. Since muscle-strengthening physical activities had a direct effect on mental well-being
on male and cardiorespiratory fitness fully-mediated the association between aerobic physical activity
and mental well-being on male, stakeholders and policymakers should consider to prioritize
promotion of muscle strengthening physical activity among male and aerobic physical activity which
effectively improve cardiorespiratory fitness, such as water-based physical activity, among female to
optimize their mental well-being.

6 Conflict of Interest

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as representing a potential conflict of interest must be disclosed. If no such relationship exists,
authors will be asked to confirm the following statement:
The authors declare that the research was conducted in the absence of any commercial or financial
relationships that could be construed as a potential conflict of interest.

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9 Acknowledgments

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that aided the efforts of the authors.

10 Reference styles

The following formatting styles are meant as a guide, as long as the full citation is complete and
clear, Frontiers referencing style will be applied during typesetting.

10.1 Harvard Referencing Style (Author-Date)

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