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Rev. Saúde Pública vol.46 n.1 São Paulo Feb. 2012
Asociación entre actividad física y calidad de vida en adultos
Gabrielle Cristine Moura Fernandes PucciI; Cassiano Ricardo RechI, II, III; Rogério César FerminoI, II; Rodrigo Siqueira ReisI, II
de Pesquisa em Atividade Física e Qualidade de Vida. Centro de Ciências
Biológicas e da Saúde. Pontifícia Universidade Católica
do Paraná. Curitiba, PR, Brasil
IIPrograma de Pós-Graduação em Educação Física. Universidade Federal do Paraná. Curitiba, PR, Brasil
IIIDepartamento de Educação Física. Curso de Educação Física. Universidade Estadual de Ponta Grossa. Ponta Grossa, PR, Brasil
To summarize and analyze evidences of the association between physical activity
and quality of life.
METHODS: Systematic literature review in three electronic databases -PubMed, Lilacs and SciELO- using the following descriptors: "physical activity," "motor activity," "exercise," "walking," "running," "physical fitness," "sport," "life style," "quality of life," "WHOQOL" and "SF." There were selected 38 studies published between 1980 and 2010 that used any instrument to measure physical activity and any version of the Medical Outcomes Study 36-Item Short-Form Health Survey or the World Health Organization Quality of Life to assess quality of life.
RESULTS: Most studies reviewed were cross-sectional (68%), 18% experimental, 8% prospective follow-up cohort and 5% mixed-design (cross-sectional and longitudinal). The most widely used questionnaire to assess quality of life was SF-36 (71%), and physical activity was self-reported in 82% of the studies reviewed. Higher level of physical activity was associated with better perception of quality of life in the elderly, apparently healthy adults and individuals with different clinical conditions.
CONCLUSIONS: There is a positive association between physical activity and quality of life that varies according to the domain analyzed.
Descriptors: Motor activity. Exercise. Quality of Life. Review.
Sintetizar y analizar las evidencias de la literatura sobre la asociación
entre actividad física y calidad de vida.
MÉTODOS: Revisión sistemática en las bases PubMed, Lilacs y SciELO con utilización de los descriptores "physical activity", "motor activity", "exercise", "walking", "running", "physical fitness", "sport", "life style", "quality of life", "WHOQOL", y "SF". Se seleccionaron 38 estudios publicados entre 1980 y 2010 que utilizaron algún instrumento de medida de la actividad física y con alguna versión de los cuestionarios Medical Outcomes Study 36-Item Short-Form Health Survey o World Health Organization Quality of Life para evaluar la calidad de vida.
RESULTADOS: La mayoría de los estudios presentó delineamiento transversal (68%), 18% fueron experimentales, 8% de acompañamiento prospectivo (cohorte) y 5% con delineamiento mixto (transversal y longitudinal). El cuestionario más utilizado para evaluar la calidad de vida fue el SF-36 (71%) y la actividad física fue auto reportada en 82% de los estudios. El mayor nivel de actividad física se asoció con la mejor percepción de calidad de vida en ancianos, adultos aparentemente saludables o en diferentes condiciones de salud.
CONCLUSIONES: La asociación entre actividad física y calidad de vida es positiva y varía de acuerdo con el dominio analizado.
Descriptores: Actividad Motora. Ejercicio. Calidad de Vida. Revisión.
Quality of life (QoL) is a multidimensional subjective construct41 that is hardly defined and systematized and thus of complex operationalization. QoL is conceptually defined as an individual's perception of his/her stand in life within a sociocultural context with regards to their goals, expectations, standards and concerns.52 It is related to personal well-being and includes several aspects such as health, leisure, personal satisfaction, habits, and lifestyle.30
The operationalization of QoL involves its measurement. Several instruments have been proposed to assess QoL in different populations,41 but most of them have been developed in high-income countries and adapted to other contexts.4,9,18 The instruments for overall assessment of QoL include the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36)50 and the World Health Organization Quality of Life-100 (WHOQOL-100),18 both available in abridged versions for use in specific population groups and/or domains. These instruments have enabled an increasing number of studies on the association between QoL and health behaviors such as diet, smoking and physical activity (PA).4,37
Regular PA increases QoL at different ages.4,19,26,31,39,51 Studies have investigated the association between PA and overall QoL, and the effects of PA on specific domains of QoL,4,37 and it has often been reported an association with the "physical" and "mental" domains.19,39,41,42,46,51
Evidence supports a positive association between PA and QoL, but the state of the art is not well established. The magnitude of this association is conflicting in different populations4,37 and inconsistent results have been found when instruments for measuring PA and QoL, as well as designs, were compared.4 A recent review study4 assessed the association between PA and perception of QoL in apparently healthy adults and, despite reporting a positive association, the authors stressed the importance of further exploring this same association in other age groups, health conditions and using more specific instruments to measure PA and QoL.4
The current study aimed to summarize and analyze evidence of the association between PA and perception of QoL in adults.
A systematic review was carried out in the electronic databases PubMed, Lilacs, and SciELO following the procedures described in the literature.23 There were selected studies that met the following inclusion criteria: report of the association or effect of PA on QoL; use of an instrument for measuring PA; use of any version of the SF or WHOQOL for assessing QoL; year of publication from 1980; adults (>18 years); empirical cross-sectional or longitudinal, randomized controlled, cohort or case-control studies; and studies published in English or Portuguese. Studies that did not report any instrument for the measurement of PA and/or failed to assess QoL using either SF or WHOQOL, review studies, opinion articles, letters to the editor, books or book chapters, and dissertations and theses were excluded.
The review was limited to QoL assessment instruments that are recommended by health organizations and have psychometric properties that have been widely studied in the literature. While this choice may limit the number of studies included, the analyses or evidence obtained are not affected.
The following English terms were searched in PubMed: "physical activity," "motor activity," "exercise," "walking," "running," "physical fitness," "sport," and "lifestyle." The following QoL terms were also searched: "quality of life," "WHOQOL," and "SF." The same descriptors in Portuguese were searched in the SciELO and Lilacs databases. Terms were combined using Boolean operators "AND" and "OR." The search was conducted between March and August 2010.
The Figure shows a flowchart of the search, selection, and related reasons for excluding references. Three researchers familiar with the methodology selected and evaluated the references.
There were identified general aspects of publication, methodological description, measurement instruments of PA and QoL, and main results. The researchers screened the studies separately and then compared their findings in a consensus meeting. Items that showed agreement between at least two researchers were considered adequate and were included in the description of results.
The results of experimental and cohort studies were analyzed for the percentage of agreement of evidence (Table 1). The agreement of the results was estimated by dividing the number of studies pointing towards an association by the number of studies reviewed and then the results were categorized. This procedure is used in reviews on PA and provides the level of agreement of the findings.40
Thirty-eight studies met the inclusion criteria (Table 2). They were published from 1998 and 92% were published from 2003 on. Most studies were conducted in North America (42%), Europe (21%), and Asia (18%).
Most (71%) investigated both female and male individuals, but 29% were limited to one gender, predominantly female (26%). Several different population groups were studied: 32% in the elderly and 24% in apparently healthy adults. The clinical conditions studied included heart disease (11%); overweight/obesity (5%); breast cancer (5%); hypertension (5%); diabetes, lung cancer, fibromyalgia, colon cancer, hepatitis C, liver transplantation and multiple sclerosis (3%).
The majority were cross-sectional studies (68%), seven were experimental (18%), three prospective cohort (8%) and two (5%) had a mixed design (cross-sectional and longitudinal).
The level of PA was self-reported in 82% of studies and general questions were asked in 21%. The International Physical Activity Questionnaire (11%) and Godin Leisure-Time Exercise were the most commonly used questionnaires (11%), a direct measure of PA was used in 16% (accelerometer and/or pedometer) and both measures of PA were used in 3%. About half of the studies reviewed (53%) investigated overall PA, 21% the leisure-time domain, 24% associated leisure-time PA with another domain, and the domain evaluated could not be identified in 3%.
The most widely used questionnaire to assess QoL was SF-36 (71%), followed by the SF-12 (13%), WHOQOL-BREF (11%), SF-8 (3%) and WHOQOL-OLD (3%).
Higher level of PA was associated with better perception of QoL in the elderly, apparently healthy adults and individuals with different health conditions (Table 3). Two studies found an inverse association between PA and any domain of QoL.8,27 Most studies examined the association between PA and overall QoL score. But as the instruments used were different, different domains of QoL were included.
The results of experimental and cohort studies were summarized (Table 4). There was no agreement of findings on the association between PA and QoL in the "social functioning," "bodily pain," and "social relations" domains.
The current review showed that most studies were published from 2003, indicating a recent interest in this area. There were few studies conducted in low- and middle-income countries such as Latin American countries. Since PA and perception of QoL are influenced by cultural, social and physical factors, this scarcity of studies prevents the generalization of results and comparisons of different contexts.20 This is true for Latin America as social inequalities are a major factor associated with people's health.11 The level of development of a country also seems to be related to PA patterns of their populations.16
Leisure-time was the most widely investigated domain of PA. It is the most commonly explored domain in the literature and it has consistently reported that it favors health promotion.21 Self-reported measures were most widely used. Specific questionnaires were developed for some studies but their psychometric properties were not reported.7,17,28,36
The SF-36 was the most commonly used QoL questionnaire, which corroborates previous reports in the literature.14 This can be attributed to longer experience using SF-36 since its was developed in the early 1990s50 while the WHOQOL was developed in the late 1990s.18 To increase the reliability of results, it was opted for establishing the use of SF and/or WHOQOL for the assessment of QoL as an inclusion criterion. In their literature review, Bize et al4 stressed the need for more accurately measuring PA and QoL.
Most cross-sectional studies showed a positive association between PA and QoL (Table 3). However, this study design does not allow to establishing a time association between cause (PA) and effect (QoL) and thus a causal relationship. Other variables can also affect this association: in addition to the levels of PA, self-efficacy can also influence health perception, fitness and vitality of individuals.4,51
The results of experimental and cohort studies (Table 4) show agreement of findings of a positive association between PA and SF domains including "physical functioning," "vitality," "mental health," "role-physical," "role-emotional," "general health" and "physical and mental components." This result may due to a greater number of studies using SF. Despite evidence showing an association between PA and QoL using WHOQOL, the results were inconclusive due to the small number of studies.
The domains "physical functioning," "vitality," and "mental health" showed higher agreement among the studies reviewed. These findings are corroborated in other studies showing greater association of these domains with PA regardless of the study design, population studied, age, gender or type of intervention.4,37,38,47 Despite the small number of studies, the results indicate a need to further explore the benefits of PA in the "social functioning," "social relations," and "bodily pain" domains of QoL, as well as to investigate physiological mechanisms and social and cultural factors involved.
Two studies had a mixed (longitudinal and cross-sectional) design28,51 with inconsistent results. In Wendel-Vos study,51 cross-sectional associations were not confirmed by longitudinal analyses. The cross-sectional analysis showed an association between leisure-time PA and the physical component of QoL, but the prospective analysis showed associations predominantly with the mental component. These inconsistencies may arise from methodological differences as the results may show a false association between PA and QoL because a causal relationship cannot be established in a cross-sectional analysis. In Lee et al28 study, the cross-sectional analyses showed that higher levels of PA were associated with better QoL in all domains of the mental component. After a three-year follow-up, the longitudinal analysis found that women who initiated or maintained PA had higher QoL scores. However, active women at baseline who discontinued PA had lower QoL scores. These results point to a transient effect of PA on QoL. Despite different results seen among the study designs, PA is associated with improved mental health in elderly women.28
It was not feasible to assess the quality of the studies reviewed using a common instrument for the studies had different designs and information on the methods used (e.g., cutoffs for PA; sample size; selection criteria; control for confounders, etc.) was not available. The application of a single instrument could produce inaccurate scores, which would lead to miscategorization of studies to the detriment of the quality of the findings. The review followed strict inclusion criteria and there were selected studies with any measure of level of PA and perception of QoL using SF or WHOQOL. This approach increase the strength of evidence of the associations found.
In conclusion, there is a positive association between PA and perception of QoL, which varies according to the domains of QoL assessed. Further studies should be encouraged to investigate the association between PA and the different domains of QoL, particularly in low- and middle-income countries in Latin America. Methodological issues such as design and quality of measurement of PA should be optimized.
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Correspondence: Received: 12/14/2010 The authors declare
no conflicts of interest.
Gabrielle Cristine Moura Fernandes Pucci
Pontifícia Universidade Católica do Paraná
Centro de Ciências Biológicas e da Saúde
Curso de Educação Física Grupo de Pesquisa em Atividade Física e Qualidade de Vida
R. Imaculada Conceição, 1.155 - Prado Velho
80215-901 - Curitiba, PR, Brasil
The authors declare no conflicts of interest.