Helping Our Patients To Feel Good About Physical Activity
Kristina Sandstedt, MS, CDE, Clinical Exercise Physiologist

As diabetes educators we are fully aware of the benefits of physical activity and its role in blood glucose control. However, suggesting or incorporating physical activity into ones self-management plan on the basis of blood glucose control alone unfortunately may not be enough to motivate our patients to engage in long term regular physical activity.

Although healthcare professionals are cognizant of the physiological benefits of physical activity, we may fail to educate our patients on the psychological benefits as we help the patient develop their individual self-management plan. Through such education, we may not only be able to further motivate our patients, but also ameliorate psychological difficulties that are comorbid with diabetes.

These psychological difficulties may include depression, anxiety or other forms of disturbed mood. In fact, the Washington University School of Medicine in St. Louis, Missouri found that the incidence of depression among people with diabetes is twice as high compared to individuals who do not have diabetes.

How exactly does physical activity effect the psychological state and what are the mechanisms responsible for the improvement? More importantly, how much physical activity is needed?

Supportive evidence on the role of physical activity in improved mental health has come from both Physiologists and Psychologists.

At Duke University’s Medical Center, researchers recruited 156 men and women, age 50 and older, that suffered from major depression. One group was instructed to briskly walk or jog 30 minutes, three days a week. Another group took the antidepressant Zoloft, and the third group exercised and took the medication.

In spite of the fact that the patients receiving the medication began to respond sooner than the exercise-only folks at the end of four months all three groups were markedly better. This proved support for the notion that regular workouts were an effective treatment.

The big question, however, for us as diabetes educators was, would the patients relapse? The researchers checked back six months after the study concluded and found that only 8% of the exercise only group were experiencing symptoms of depression. This was compared to 31% of the subjects taking Zoloft in combination with exercise and 38% in the Zoloft only. This finding supports the theory that physical activity has a therapeutic benefit, especially when continued over time.

There is a rather large volume of research investigating the link between physical activity and enhanced mood. The most commonly studied mood has been state anxiety, defined as situational bouts of worry accompanied by physiological arousal. Recent evidence indicates that acute bouts of aerobic physical activity are associate with improved psychological mood (Martinsen, Raglin, Hoffart & Friis, 1998; McAuley & Butki, 1998; Treasure & Newberry, 1998; Turner, Rejeski & Brawley, 1997). Resistance training activity has also been associated with improved mood (Bartholomew & Linder, 1998).

Other variables that have been investigated in relation to improved mood with physical activity are gender, type of physical activity and intensity. Berger et al found that gender was not observed to be a significant main or interaction effect in their investigation. Researchers Cox, Thomas and Davis (1999) studied the effect of physical activity and type of exercise on state anxiety and found no significant main effect or interaction to be associated with the type of activity performed.

With regard to the intensity of the physical activity, researchers have reported that moderate intensity generally demonstrates the best results in terms of maximizing positive mood (Focht & Koltyn, 1999; Treasure & Newberry, 1998; Tuson, Sinyor & Pelletier, 1995). Specifically, physical activity bouts of 10-20 minutes in length are effective in increasing perceptions of positive well being and decreasing perception of distress (Rudolph & Butiki, 1998).

Moderate intensity activity on a cycle ergometer leads to an increase in positive feeling states and a decrease in negative feeling states compared to a high intensity exercise group (Treasure & Newbery, 1998).

How exactly does physical activity effect mood? The exact mechanisms are
still unknown, however prevalent theories fall into two categories, physiological and
psychological.

Physiological mechanisms that have been researched include the cerebral lateralization hypothesis and the central catecholamine response. The cerebral lateralization hypothesis in its simplest form, proposes that increased cardiovascular arousal associated with physical activity may differentially influence the degree of alpha activation in the two hemispheres of the cerebrum (Hatfield & Landers, 1987; Hatfield, 1991). The central catecholamine response suggests that the role of neuroendocrine responses, particularly catecholamine secretion, to acute and chronic activity serve as a mediating factor of mood alteration.

The psychological mechanisms include the opponent process and the time-out hypothesis. The opponent-process theory, according to Hatfield (1991), suggests that engagement in any stressful activity is followed by an opposing, or pleasant, affective state upon cessation of the stressor. Moreover, with long term adaptation to the stressor (in this case physical activity), the negative experience (e.g. the perception of fatigue to a given activity stimulus) becomes reduced, while the opponent experience becomes increasingly positive. The time out hypothesis simply suggests that taking time out of your schedule and doing something for yourself (e.g. physical activity)
can help to increase your positive mood. According to this theory, physical activity should be viewed as an enjoyable reward rather than punishment.

Most studies focusing on physical activity and improved mood have required their subjects to perform ~30 minutes of aerobic activity three or more times per week at a moderate intensity. Brisk walking is a wonderful and effective form of physical activity and more importantly the patient should be encouraged to perform physical activities they like. However, improved mood was also found for those performing resistance-training activities.

When educating the patient about physical activity and the psychological benefits, emphasize the fact that when people start to feel overwhelmed, stressed, depressed or anxious, physical activity is usually the first thing to be abandoned. Discuss how that particular behavior of abandonment carries over into other areas of diabetes care, e.g. compliance with monitoring blood glucose levels, medication and meal planning.

Finally and more importantly, educating our patients about the psychological benefits of physical activity can prove to be an effective strategy in helping them maintain compliance with this important aspect of their self-management plan.

 

Kristina Sandstedt, MS, CDE received her Masters of Science degree from the University of Montana-Missoula. She is certified as an Exercise Specialist through the American College of Sports Medicine and recently received her Certified Diabetes Educator designation. She is currently the Diabetes Education Program Coordinator for the ADA recognized program at Boone Hospital Center in Columbia, Missouri.

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