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“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health
Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
Note: This article will be published in a forthcoming issue of
the Journal of Physical Activity & Health. This article appears
here in its accepted, peer-reviewed form, as it was provided by
the submitting author. It has not been copy edited, proofed, or
formatted by the publisher.
Section: Original Research
Article Title: Physical Activity: Does Environment Make a Difference for Tension, Stress,
Emotional Outlook, and Perceptions of Health Status?
Authors: Robin Puett1, Jane Teas2, Vanesa España-Romero3, Enrique Garcia Artero4, Duck-chul
Lee5, Meghan Baruth4, Xuemei Sui4, Jessica Montresor-López1, and Steven N. Blair4
Affiliations: 1Maryland Institute for Applied Environmental Health, University of Maryland,
College Park, MD. 2Thomas Cooper Library, University of South Carolina, Columbia, SC.
3MRC Epidemiology Unit, Institute of Public Health & Institute of Metabolic Science,
Cambridge, UK. 4Department of Exercise Science, University of South Carolina, Columbia, SC.
5Department of Kinesiology, Iowa State University, Ames, IA.
Running Head: Physical activity environment, stress and outlook
Journal: Journal of Physical Activity & Health
Acceptance Date: September 21, 2013
©2014 Human Kinetics, Inc.
DOI: http://dx.doi.org/10.1123/jpah.2012-0375
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health
Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
Title: Physical Activity: Does environment make a difference for tension, stress, emotional
outlook, and perceptions of health status?
Running Head: Physical activity environment, stress and outlook
Manuscript Type: Original research
Abstract word count: 200
Manuscript word count: 6,980 including tables, figures, acknowledgements, funding sources,
and references
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health
Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
Abstract
Background: The importance of physical activity for health is well-established. Questions
remain whether outdoor exercise additionally benefits overall mental and physical well-being.
Methods: Using cross-sectional data from the Aerobics Center Longitudinal Study, we
examined relationships of physical activity environment (PAE) with reported tension, stress,
emotional outlook, and health. Results: 11,649 participants were included. 18% exercised
indoors, 54% outdoors, and 28% in both. Participants who exercised partially or entirely
outdoors exercised more. In fully-adjusted models, for women combined PAE was protective for
worse emotional outlook (OR: 0.72; 95%CI: 0.52, 0.98). Combined PAE was also protective for
reported poor health (OR for women: 0.63; 95%CI: 0.44, 0.91; OR for men: 0.75; 95%CI: 0.61,
0.92). Amount of physical activity modified PAE relationships with outcomes. Combined and
outdoor PAE were more consistently protective for worse outcomes among high activity
participants. Regardless of PAE, better outcomes were observed in active versus inactive
participants. Conclusion: The current study suggests addition of outdoor PAE may be linked
with better stress management, outlook and health perceptions for more active populations,
whereas indoor PAE may be more important for low active populations. Further research
should examine the order of causation and whether type of outdoor PAE (e.g., urban, natural) is
important.
Keywords: exercise, outside, psychosocial, epidemiology
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health
Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
Introduction
The importance of physical activity for the prevention of cardiovascular disease, diabetes
and other health outcomes is well-established1. Psychosocial stress, emotional outlook, and
perceptions of overall health are important factors for chronic disease prevention and
prognosis1-3. Additionally, physical activity has been linked with emotional well-being and
resilience to psychosocial stress. Cross-sectional and longitudinal studies conducted in various
countries have shown associations between increases in physical activity and reductions in
depression, neuroticism, anxiety, hostility, and stress; as well as improvements in social
coherence and overall psychological health4-7. Intervention studies have also demonstrated the
importance of physical activity in providing psychological benefits (e.g., stress
reduction/resilience, lower depression) directly related to the prevention of and rehabilitation
from adverse cardiovascular and cancer outcomes8,9. A meta-analysis of 40 studies showed an
association between exercise training and anxiety reduction, with a stronger relationship
apparent among those with more stressful lifestyles10.
With the recognition of widespread physical inactivity and the growth of related adverse
chronic health outcomes, researchers have begun investigating the contribution of the built and
natural environment to these significant public health problems11-13. Lack of access to indoor
physical activity facilities, such as gyms and fitness centers; as well as limited opportunities for
outdoor exercise, including lack of sidewalks and distance to parks, have been related to
physical inactivity, obesity, and related chronic diseases (e.g., cardiovascular disease,
diabetes)14-16. Though studies in land use planning, health and psychology have shown human
preferences and benefits for exposure to greenspace 17-20, few studies have examined whether
the environment in which exercise occurs (physical activity environment) modifies the impact of
physical activity on well-being. The limited number of studies addressing this topic have been
difficult to compare as the populations, exposures, and outcomes examined have differed; and
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health
Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
many studies have focused on acute time periods or interventions with small study populations.
However, the majority of findings point to the added benefit of better psychological well-being
from outdoor physical activity environment, beyond the physical fitness achieved by indoor
physical activity 21-24.
To address the paucity of information on self-selected, regular physical activity
environment, we used cross-sectional data from a large population of adults enrolled in the
Aerobics Center Longitudinal Study (ACLS) to examine the relationship of physical activity
environment (indoor, outdoor, or a combination) with tension, stress, emotional outlook, and
perceptions of health status. A previously published study with this population has already
shown that emotional well-being was associated with cardiorespiratory fitness and regular
physical activity 6. Therefore, this population provided a valuable opportunity to use data
collected on routine, participant-selected physical activity to investigate the importance of
physical activity environment to tension, stress, emotional outlook and perceptions of health.
Methods
Study Population
The ACLS is a prospective study that has been described in detail elsewhere 25-27.
Briefly, it is a study of men and women over 20 years of age, who completed a baseline
examination at the Cooper Clinic, Dallas Texas. Data were collected via a questionnaire and a
clinical evaluation that included a physical examination, maximal exercise treadmill test, blood
chemistry analyses, anthropometry, and health histories. Participants were predominantly
Caucasian (>95%) and of middle and upper socioeconomic status (about 80% graduated from
college). Written informed consent was obtained from all participants, and the Institutional
Review Board at the Cooper Institute annually reviewed and approved the study protocol.
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health
Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
The present study included men and women from the ACLS with a medical examination
(using the earliest examination if more than one was completed) between 1987 and 2006
(N=28,439), who had complete data on the outcomes (N=22,084), exposures (N=14,291) and
covariates (N=11,649). Exposures (physical activity environment) were assessed by
questionnaire items asking the participant to consider the three months prior to questionnaire
completion and respond whether they had performed any of the following activities, as well as
their frequency, intensity and duration per week: 1) walked/jogged/ran on a treadmill or rode a
stationary cycle (categorized as indoor activity), 2) walked/jogged/ran or cycled outside
(categorized as outdoor activity), or 3) participated in both indoor and outdoor activities.
Participants who engaged in other types of physical activity (e.g., dancing or swimming) were
excluded because no information was provided regarding whether these activities occurred
inside or outside. In sensitivity analyses, we included participants who reported being inactive
(N=17,783), though the comparison of inactivity versus activity is further described in Galper et
al 6. The study was limited to participants who achieved at least 85% of their age-predicted
maximal heart rate (220 minus age in years) during the treadmill exercise test.
The outcomes for the current study were stress and emotional factors from the ACLS
medical history questionnaire. Specifically, we focused on specific individual questions
regarding overall tension and anxiety (five possible responses from no to very tense and
categorized for analysis as: no, slight or moderate tension versus high tension or very tense),
general presence or absence of stress and tension symptoms (irritability, headache, abdominal
discomfort, sleeplessness, fatigue and other and categorized for analysis as 1 or less compared
to more), stress management (three possible responses from not well to very well most of the
time and categorized as: not well most of the time versus fairly well and very well most of the
time) general emotional outlook (five possible responses from often very depressed to usually
very happy and optimistic and categorized as generally happy or usually very happy versus
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health
Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
happy and sad equally, generally sad, often very depressed), and overall health (four possible
responses from poor to excellent and categorized as excellent or good versus fair or poor) . For
the emotional outlook question, we used the same cut point as reported by Baruth et al 28. For
the remaining outcomes, given the lack of previously established cutpoints in the literature we
conducted descriptive statistics to evaluate the distribution and selected cut points which would
provide a large enough sample size for each category, as well as an obvious positive and
negative outcome.
Potential confounders and effect modifiers included information from the anthropometry
and the standard medical history questionnaire. Height and weight were measured on a
stadiometer and standard scale and were used to calculate body mass index (BMI) (weight in
kilograms/height in meters squared). Data on other covariates were collected via the
questionnaire, including: age; gender, total metabolic equivalent (MET)-minutes per week of
leisure-time physical activity; and history of cardiovascular disease, asthma, chronic obstructive
pulmonary disease (COPD), or joint leg problems (at least one of the following: chronic joint,
muscle, or low back pain, swollen or stiff joints, arthritis, gout). Given asthma, COPD, and
cardiovascular disease exacerbation have been associated with outdoor air pollutant exposures
as well as tension, outlook and overall health29-33, these variables were considered as
confounders. In addition, joint and leg problems may contribute to worse outlook and health as
well as deterring individuals from outdoor physical activity environments due to the challenges
of exercising on uneven surfaces34. Lastly, a question on the use of medication to relieve stress
was included (categorized as: seldom or almost never versus occasionally or frequently).
Statistical Analyses
Descriptive analyses summarized characteristics of participants, by gender and physical
activity environment. Multiple logistic regression was used to estimate odds ratios (ORs) and
95% confidence intervals (CIs) for the relationship of tension and anxiety, stress management,
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health
Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
symptoms of stress and tension, emotional outlook and overall health with physical activity
environment (indoor, outdoor, both). Multivariate analyses adjusted for age (years), BMI,
baseline examination year, cardiovascular diseases, asthma, chronic obstructive pulmonary
disease (history or not for each), leg/joint problems (chronic joint or muscle pain, low back pain,
swollen/stiff joints, arthritis or gout), and medication use to relieve stress. We conducted
analyses with additional adjustment for total MET-minutes/week of the five physical activity
variables, as total physical activity may confound the associations of physical activity
environment with tension, stress, emotional outlook and overall health perception. Potential
effect modification by amount of total physical activity was examined through statistical
significance of interaction terms and likelihood ratio tests. An additional sensitivity analysis
included participants who were inactive. Analyses were executed with SAS version 9.2 (Cary,
NC). All P values are 2-sided with an alpha level of 0.05.
Results
The current study included 11,649 ACLS participants. About 18% of participants
reported indoor physical activity environment only, 28% reported indoor and outdoor physical
activity environments and 54% exercised outdoors only. Table 1 shows descriptive
characteristics for participants stratified by physical activity environment. For the entire sample,
the mean age was about 46 years and BMI about 26 kg/m2. Total physical activity was the
greatest for participants reporting both indoor and outdoor physical activity environment (1441.6
MET-minutes per week) and the least for those with indoor only (684.0 MET-minutes per week).
Men represented about 74% of participants overall, but they composed a lower percentage of
participants reporting both indoor and outdoor physical activity environment (70.7%). Among the
three physical activity environments, percentages of participants with asthma and COPD were
similar. Less than 2% of participants in each physical activity environment reported previous
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health
Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
cardiovascular disease, but about half of participants in each physical activity environment
reported at least one joint or leg problem.
Percentages of stress and emotional factors by type of physical activity environment,
gender and amount of physical activity are displayed in Table 2. The majority of participants
reported no to moderate tension; managed their stress fairly well or very well; had few stress
symptoms; had a generally optimistic outlook; and perceived they were in good to excellent
health. Physical activity environment was significantly associated with overall health perception,
with the greatest percentage of participants reporting positive overall health perception in the
combined physical activity environment and the least in the indoor only group. Gender was
significantly associated with managing stress well, with men reporting fewer symptoms of stress
and/or tension and better emotional outlook. Participants with physical activity of at least 500
MET minutes per week reported lower tension and better stress management, emotional
outlook and overall health.
Table 3 shows the relationships of stress and outlook with physical activity environment
in fully adjusted models stratified by gender, for ACLS participants with complete data. Higher
odds ratios are indicative of worse outcomes. For example, women who reported both outdoor
and indoor physical activity environments and women with outdoor only were 15% and 11%,
respectively, less likely to report high or very high tension and anxiety compared with women
who reported indoor physical activity environment alone (referent group). However, the
associations were not statistically significant (respective 95%CIs: 0.65, 1.11 and 0.70, 1.14). For
tension and anxiety as well as for stress management, no significant differences by physical
activity environment were apparent for men or women, however ORs for combined and outdoor
only physical activity environments were protective against worse tension and stress
management compared with indoor only. No statistically significant differences were evident for
stress symptoms, but the results differed among men and women. For men, outdoor or
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health
Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
combined physical activity environment increased risks for higher stress symptomology, while
the same addition of outdoor physical activity environment was protective among women. A
combination of indoor and outdoor physical activity environment was significantly protective for
worse emotional outlook (OR: 0.72, 95%CI: 0.52, 0.98) among women and for worse perception
of overall health for both genders (male OR: 0.75, 95%CI: 0.61, 0.92; female OR: 0.63, 95%CI:
0.44, 0.91). Models adjusting for total physical activity were similar with a few exceptions. The
relationship between indoor and outdoor physical activity environment and overall health
perception among men and women attenuated to non-significance, and the increased risk of
worse perception of overall health associated with outdoor physical activity environment
increased to significance (OR: 1.24, 95%CI: 1.03,1.48).
Level of physical activity modified the relationship of physical activity environment with
tension, emotional outlook and overall health. Table 4 presents results stratified by gender and
level of physical activity. Notably, among men and women in the low total physical activity group
(<500 MET minutes per week), increased risks for worse tension, stress management,
emotional outlook and overall health are observed with outdoor exercise alone compared to
indoor exercise alone. However, outdoor physical activity environment appears protective
compared to indoors for worse outcomes among men and women in the high total physical
activity group. Among both men and women in the high physical activity group, outdoor and a
combined physical activity environment appear to be more consistently protective for higher
levels of tension and worse stress management, emotional outlook and overall health.
Finally, we compared the relationships of stress and outlook with activity in the three
physical activity environment categories (indoor, outdoor, and combination) to inactive
participants (N=6,134, 75% male). In fully adjusted models of participants with complete data,
stratified by gender, we found that exercise in any of the three environments was protective for
tension, stress management and symptoms, poor emotional outlook and poor overall health
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health
Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
perception compared to inactivity. Risks for poor emotional outlook (OR: 1.39, 95%CI:
1.06,1.82) and poor perceptions of overall health (OR: 1.96, 95%CI: 1.45,2.65) were
significantly higher among inactive women compared to women who exercised indoors alone
(referent physical activity environment). Among men, risks of greater stress symptomology (OR:
1.17, 95%CI: 1.03, 1.34), worse emotional outlook (OR: 1.12, 95%CI: 1.03,1.44) and overall
health (OR: 2.25, 95%CI: 1.90,2.66) were significantly greater among inactive men than for
those with indoor physical activity.
Discussion
To summarize our overall findings in one of the largest US studies conducted to date on
the relationship of routine, participant-selected physical activity environment with stress,
emotional outlook and overall health perception; a combination of outdoor and indoor or outdoor
physical activity environment alone, compared to indoor alone, suggested protection against
tension, stress, poor emotional outlook and poor overall health perception among women.
Relationships were weaker and less consistent for men. Outdoor physical activity environment
also appears more beneficial with respect to the outcomes examined for men and women who
are more active.
Though the combination of outdoor and indoor physical activity environment has not yet
been addressed by much of the literature, our findings are suggestive of a relation of positive
health perception, affect and tension levels with inclusion of outdoor physical activity in a
physical activity regimen, particularly among women and more active adults. This finding is
consistent with several studies which have reported benefits of outdoor physical activity
environment. However, direct comparability is limited due to differences between our
observational epidemiology study and previous research, much of which uses an intervention
design. In a review of eleven studies, Thompson Coon et al 24 reported that most found reduced
tension, depression and better energy for outdoor exercise compared to indoor exercise.
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health
Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
Intervention studies conducted among adults in the United Kingdom, Australia and Switzerland
reported lower tension, positive affect and psychological restoration (respectively) associated
with outdoor physical activity compared to indoor35,36. However, a series of intervention studies
among college students reported mixed results, with women reporting outdoor activity as most
enjoyable or satisfying but the least calming37,38, and no strong differences in tension for a trial
conducted among women38. One study of outdoor activity alone reported a significant linear
relationship between decline in anxiety and perception of a green exercise environment among
101 members of outdoor exercise groups39 suggesting perhaps that differences in the outdoor
environment in which the physical activity occurred (i.e. natural versus urban setting) may
partially explain the inconsistencies in these findings. Unfortunately, this level of detail was not
measured in the ACLS.
One of our strongest findings was a possible protective effect of combined physical
activity environment with respect to poor emotional outlook among women. Other studies have
also indicated improved affective states for outdoor compared to indoor physical activity
environment, but information regarding impact of combined physical activity environment is
sparse. A study of 35 physically active college women40 and a study of 34 young men and
women 41 found more positive affective states following an outdoor walk compared with an
indoor treadmill walk. Reduced depression and anger was observed among male athletes
following outdoor runs versus indoor runs35. Our findings differed in that we found no strong
differences with respect to emotional outlook between indoor and outdoor or a combination of
physical activity environments for men. Though our ORs for women were lower for depressed
mood (not statistically significant) for outdoor compared to indoor physical activity environment,
the strongest protection was from a combination of indoor and outdoor environments. The
emotional benefits of outdoor exercise environment among women were also supported by a
study of 19 physically active postmenopausal women who reported greater pleasure and delight
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health
Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
following outdoor walking and more frustration and worry after a treadmill walk42. However,
similar to most other studies on physical activity environment, the study did not address
combined physical activity environment as it was focused on understanding the acute impacts of
outdoor versus indoor physical activity environment on affect through an intervention trial.
In the current study, the amount of physical activity differed among physical activity
environment. For both men and women, the greatest MET-minutes per week of total physical
activity occurred in a combination of outdoor and indoor environments, whereas the least MET-
minutes per week occurred indoors. Some previous research has suggested more intense
physical activity occurs indoors, but physical activity outdoors is of longer duration. In a large
study of self-selected physical activity focusing on intensity and exercise duration, Dunton and
colleagues showed that vigorous intensity physical activity was more likely to occur indoors43.
But the mean duration of time was higher for physical activity outside among the 7,700 adults
who reported exercising the day prior to completing the American Time Use Survey. Longer
duration of outdoor exercise may be related to greater compatibility with personal preferences 36
and more satisfaction and enjoyment among participants38,44.
The amount of total physical activity also modified the relationship of physical activity
environment with several outcomes explored in this study. Outdoor and combined physical
activity environments appeared more consistently protective against tension and stress, poor
emotional outlook and poor overall health perception among more active individuals. Indoor and
combined activity environments showed potential for more benefit among less active individuals.
Adding to the findings of better emotional outlook for habitual physical activity reported by
Galper et al 6 in the same study population, we found for both men and women that each
physical activity environment was better than inactivity. Unfortunately the cross-sectional design
of this study prevents our ability to examine the chronological order of physical activity amount,
physical activity environment preference, and the outcomes we explored. Further research is
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health
Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
needed to understand, for example, whether a positive outlook and positive health perception
encourage higher amounts of physical activity outdoors or whether individuals who enjoy the
outdoors exercise longer which in turn elevates their mood and health perception.
Evidence from the literature supports a physiological basis for physical activity’s benefit
on stress and emotional outlook45-47, and exposure to natural settings has been shown to lower
stress and improve mood48-50. However, less is known regarding the biological mechanisms
through which outdoor exercise environment may influence stress and affect. For example,
some studies have shown improved physiological stress recovery associated with sensory
stimuli provided by natural environments compared with urban environments. Ulrich and
colleagues 51 have suggested that the parasympathetic nervous system may be influenced by
natural visual stimuli, and Alvarsson and co-authors52 suggested the sympathetic nervous
system may respond to sounds of nature. Other physiologic pathways may also be involved.
Given much of our vitamin D levels are obtained through sunlight exposure, perhaps vitamin D
plays a physiologic role, particularly as there is some evidence vitamin D deficiency is
associated with mood disorders, worse cognitive performance, mental health related quality of
life, chronic tension headaches and fatigue53-57. Many studies of outdoor versus indoor physical
activity environment have indirectly controlled for the influence of vitamin D. However, two
studies used more direct control by presenting participants with natural and urban scenes and
found physiological recovery and improved executive attention performance after a stressful
event were faster after views of natural settings20, suggesting health impacts of nature cannot
be fully explained through vitamin D exposure. Another potential explanation from the
psychological literature rises from Attention Restoration Theory, where directed attention,
integral to human effectiveness, can be restored through exposure to natural settings58. For
example, natural settings resonate with humans and provide a sense of extent or openness and
being away from stressful activities, which can reduce fatigued directed attention 58-60. A recently
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health
Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
published study61 provided additional support for the restoration theory. Systematic differences
were observed in EEG recordings between walkers' exposure to green space and urban
development.
To our knowledge, this is the largest study of the relationship self-selected physical
activity environment with stress, emotional outlook and overall health perception published to
date. However, limitations of generalizability to less affluent populations and to non-white
race/ethnicities should be noted. This study is a cross-sectional design with limitations inherent
to this type of design, including the inability to examine the order of causation in the
associations observed between physical activity environment and the outcomes of emotional
outlook and overall health perceptions. Individual questionnaire items were used to assess
tension, emotional outlook and overall health. Nonetheless, this study offers an important
opportunity to examine the relationships of tension, stress, emotional outlook, and perceived
health with routine, participant-selected physical activity environment compared to previous
intervention studies which were limited to acute measures of mental and physical well-being.
Similar to previous observational research43, we were unable to examine other factors, such as
climate or perceptions of safety, which have been associated with locational preferences for
exercise62-64. In addition, information on the greenness or aesthetics of the outdoor activity
environments or how the participants interacted with these environments (e.g., running with
headphones versus hearing natural sounds or traffic) was unavailable. Thus potential
confounding by these important factors could not be addressed. Lastly, we focused on
perceived outcomes, rather than physiological measures. Very few studies have explored
biomarker differences for indoor and outdoor exercise environments, with somewhat
inconsistent findings35, highlighting the need for additional research in this area.
In conclusion, the current study suggested that a combination of indoor and outdoor
physical activity environments as well as outdoor alone physical activity environment may be
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health
Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
linked with lower risks of self-reported stress, poor emotional outlook and poor overall
perceptions of health for women and individuals who have higher levels of physical activity.
Further research is needed to understand better the order of causation and any modification of
these associations by greenness or urbanicity of outdoor activity environment. Tension, stress,
emotional outlook and health perception were better compared to inactivity regardless of activity
environment; thus underscoring the importance of physical activity regardless of environment.
Acknowledgements:
We thank the Cooper Clinic physicians and technicians for collecting the data, and staff at the
Cooper Institute for data entry and data management.
Funding Sources:
This study was supported by the National Institutes of Health grants (AG06945, HL62508, and
R21DK088195), an unrestricted research grant from The Coca-Cola Company, and a
postdoctoral fellowship from the Spanish Ministry of Education (EX-1008-2010). The content is
solely the responsibility of the authors and does not necessarily represent the official views of
the National Institutes of Health.
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health
Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
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© 2014 Human Kinetics, Inc.
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“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health
Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
Figure 1.
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
Table 1 Baseline characteristics of all participants and according to type of physical activity environment
Type of Physical Activity
Characteristic Indoor Indoor and Outdoor Outdoor
(n=2107) (n=3221) (n=6321)
Mean (SD):
Age (years) 46.8 ± 9.1 46.0 ± 9.7 46.7 ± 9.4
BMI (kg/m2) 26.7 ± 4.5 26.0 ± 4.2 26.0 ± 4.0
Total Physical Activity (MET-min/week) 684.0 ± 544.0 1441.6 ± 1179.9 1056.6 ± 1135.0
Outdoor Walking (MET-min/week) -- 346.5 ± 411.4 355.6 ± 473.5
Outdoor Jogging/Running (MET-min/week) -- 357.6 ± 740.2 572.5 ± 979.3
Indoor Treadmill (MET-min/week) 417.7 ± 519.9 372.6 ± 488.9 --
Outdoor Bike (MET-min/week) -- 127.5 ± 536.5 128.5 ± 657.9
Indoor Cycle (MET-min/week) 266.3 ± 423.0 237.3 ± 442.8 --
Tension and Anxiety 2.9 + 0.9 2.9 +0 .9 2.9 + 0.8
Stress Management 2.3 + 0.6 2.3 + 0.6 2.3 + 0.6
Symptoms of Stress and/or Tension 1.1 +. 0.2 1.0 + 0.2 1.1 + 0.2
General Emotional Outlook 4.2 + 0.7 4.2 + 0.7 4.2 + 0.7
Overall Health 3.1 +0.6 3.2 + 0.6 3.2 + 0.7
Number (%):
Male* 1590 (75.5) 2278 (70.7) 4789 (75.8)
Low Total Physical Activity (<500 MET-min/week) 929 (44.1) 360 (11.2) 2129 (33.7)
Cardiovascular diseases* 27 (1.3) 42 (1.3) 49 (0.8)
Asthma 184 (8.7) 270 (8.4) 504 (8.0)
COPD 150 (7.1) 205 (6.4) 448 (7.1)
Leg/Joint Problems (>1) * 1092 (51.8) 1666 (51.7) 3051(48.3)
Medication Use for Stress*
Frequently 175(8.3) 290(9.0) 630(10.0)
Occasionally 271(12.9) 445(13.8) 838(13.3)
Seldom 308(14.6) 515(16.0) 842(13.3)
Almost Never 1353(64.2) 1971(61.2) 4011(63.5)
* Chi square test for differences pvalue<0.05
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
Table 2 Stress and emotional factors according to type of physical activity and gender
Indoor Indoor and Outdoor Males Females Low PA
High PA
Outdoor
(n=2107) (n=3221) (n=6321) (n=10296) (n=3744) (n=3408)
(n=8231)
Tension and Anxiety
No to moderate tension 1615 (76.7) 2487 (77.2) 4863 (76.9) 6643 (76.7) 2322 (77.2) 2560 (74.9)
6405 (77.8)
High and very tense 492 (23.4) 734 (22.8) 1458 (23.1) 2014 (23.3) 670 (22.4) 858 (25.1)
1826 (22.2)
P-value* 0.890 0.329
<0.001
Stress Management
Very well most of the time and 1967 (93.4) 3027 (94.0) 5936 (93.9) 8167 (94.3) 2763 (92.4) 3179 (93.0)
7751 (94.2)
fairly well most of the time
Not well most of the time 140 (6.6) 194 (6.0) 385 (6.1) 490 (5.7) 229 (7.7) 239 (7.0)
480 (5.8)
P-value* 0.604 <0.001
0.018
Symptoms of Stress and/or Tension
One or no symptoms of 1346 (63.9) 2017 (62.6) 4084 (64.6) 5840 (67.5) 1607 (53.7) 1997 (58.4)
5450 (66.2)
stress and/or tension
Two or more symptoms of stress 761 (36.1) 1204 (37.4) 2237 (35.4) 2817 (32.5) 1385 (46.3) 1421 (41.6)
2781 (33.8)
and/or tension
P-value* 0.160 <0.001
<0.001
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
General Emotional Outlook
Generally happy and usually very 1823 (86.5) 2832 (87.9) 5517 (87.3) 7618 (88.0) 2554 (85.4) 2927 (85.6)
7245 (88.0)
happy and optimistic
Often very depressed, generally, 284 (13.5) 389 (12.7) 804 (12.7) 1039 (12.0) 438 (14.6) 491 (14.4)
986 (12.0)
sad and happy and sad equal amounts
P-value* 0.320 <0.001
<0.001
Overall Health
Good and Excellent 1819 (86.3) 2895 (89.9) 5518 (87.3) 7577 (87.5) 2655 (88.7) 2780 (81.3)
7452 (90.5)
Fair and Poor 288 (13.7) 326 (10.1) 803 (12.7) 1080 (12.5) 337 (11.3) 638 (18.7)
779 (9.5)
P-value* <0.001 0.080
<0.001
*Chi-square p-value for differences between groups
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
Table 3 Odds ratios and 95% CI for stress and emotional factors stratified by gender*
Males Females
Tension and Anxiety
Indoor and Outdoor 0.97 (0.83, 1.14) 0.85 (0.65, 1.11)
Outdoor 0.99 (0.86, 1.13) 0.89 (0.70, 1.14)
Indoor 1.00 (Referent) 1.00 (Referent)
Stress Management
Indoor and Outdoor 0.89 (0.67, 1.18) 0.77 (0.52, 1.16)
Outdoor 0.96 (0.75, 1.23) 0.80 (0.55, 1.16)
Indoor 1.00 (Referent) 1.00 (Referent)
Symptoms of Stress and/or Tension
Indoor and Outdoor 1.05 (0.91, 1.21) 0.78 (0.58, 1.04)
Outdoor 1.05 (0.92, 1.20) 0.94 (0.72, 1.23)
Indoor 1.00 (Referent) 1.00 (Referent)
General Emotional Outlook
Indoor and Outdoor 0.93 (0.76, 1.13) 0.72 (0.52, 0.98)**
Outdoor 0.89 (0.75, 1.06) 0.93 (0.70, 1.23)
Indoor 1.00 (Referent) 1.00 (Referent)
Overall Health
Indoor and Outdoor 0.75 (0.61, 0.92)** 0.63 (0.44, 0.91)**
Outdoor 1.13 (0.95, 1.35) 0.95 (0.69, 1.30)
Indoor 1.00 (Referent) 1.00 (Referent)
*All models adjusted for age, body mass index, cardiovascular disease, asthma, chronic obstructive pulmonary disease, leg/joint problems,
medication use to relieve stress and emotional factors and baseline examination year.
** p value<0.05
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
Table 4 Odds ratios and 95% CI for stress and emotional factors stratified by gender and by low and high total physical activity (PA)*
Males Females
Low total PA High total PA Low total PA High total PA
Tension and Anxiety
Indoor and Outdoor 0.93 (0.65, 1.34) 0.92 (0.76, 1.11) 0.74 (0.42, 1.31) 0.91 (0.64,
1.28)
Outdoor 1.27 (1.02, 1.59)** 0.84 (0.70, 1.01) 1.02 (0.71, 1.45) 0.84 (0.59,
1.18) Indoor 1.00 (Referent) 1.00 (Referent) 1.00 (Referent) 1.00 (Referent)
Stress Management
Indoor and Outdoor 0.81 (0.42, 1.57) 0.85 (0.60, 1.19) 1.27 (0.50, 3.19) 0.51 (0.32,
0.82)**
Outdoor 1.18 (0.80, 1.73) 0.83 (0.60, 1.15) 1.73 (0.93, 3.20) 0.44 (0.27,
0.71)** Indoor 1.00 (Referent) 1.00 (Referent) 1.00 (Referent) 1.00 (Referent)
Symptoms of Stress and/or Tension
Indoor and Outdoor 0.91 (0.65, 1.29) 1.16 (0.97, 1.38) 0.59 (0.33, 1.07) 0.86 (0.60,
1.25) Outdoor 1.14 (0.92, 1.42) 1.05 (0.89, 1.24) 0.94 (0.62, 1.43) 0.96 (0.67,
1.37) Indoor 1.00 (Referent) 1.00 (Referent) 1.00 (Referent) 1.00 (Referent)
General Emotional Outlook
Indoor and Outdoor 1.07 (0.69, 1.64) 0.93 (0.73, 1.19) 0.58 (0.28, 1.22) 0.68 (0.46,
1.01)
Outdoor 1.04 (0.79, 1.36) 0.83 (0.65, 1.05) 1.03 (0.67, 1.57) 0.83 (0.57,
1.22) Indoor 1.00 (Referent) 1.00 (Referent) 1.00 (Referent) 1.00 (Referent)
Overall Health
Indoor and Outdoor 1.05 (0.69, 1.59) 0.74 (0.57, 0.96)** 0.64 (0.31, 1.30) 0.63 (0.39,
1.03) Outdoor 1.60 (1.23, 2.08)** 0.86 (0.67, 1.11) 1.24 (0.80, 1.91) 0.69 (0.43,
1.12) Indoor 1.00 (Referent) 1.00 (Referent) 1.00 (Referent) 1.00 (Referent)
“Physical Activity: Does Environment Make a Difference for Tension, Stress, Emotional Outlook, and Perceptions of Health Status?” by Puett R et al.
Journal of Physical Activity & Health
© 2014 Human Kinetics, Inc.
*All models adjusted for age, body mass index, cardiovascular disease, asthma, chronic obstructive pulmonary disease, leg/joint problems,
medication use to relieve stress and emotional factors and baseline examination year.
** p value<0.05
