Boosting Connectedness Through Physical Activity

“Lifestyle medicine practitioners can help by developing a patient handout with local resources for physical activity and connectedness.”

In this issue of the journal, Merlo, Snellman, and Sugden adumbrate six domains of human connectedness, ¹ perhaps the most neglected of the lifestyle medicine pillars. This column is designed as a physical activity addendum to their insightful paper. For each connectedness domain, I provide a brief scientific rationale for linking physical activity and offer practical tips for lifestyle medicine practitioners, aiming to improve both the connectedness and physical activity pillars with a single intervention.

Happiness. Numerous studies have established that physical activity—across various levels of duration and intensity, and throughout life—can modulate levels of major neurotransmitters that affect mood and pleasure sensations. These neurotransmitters include dopamine, serotonin, norepinephrine, and endocannabinoids.^2,3 This is not to suggest that happiness can be reduced to an equation involving neurochemical concentrations. As Merlo and colleagues explain, the determinants of happiness are broad, and happiness per se is fundamentally subjective. It is important, therefore, to review studies which assess self-perceived happiness and life satisfaction. In such studies, physical activity is consistently associated with a significant positive effect. ⁴ Lifestyle medicine practitioners can improve their patients’ happiness by helping them discover physical activities that acutely boost mood and reduce stress. By developing a set of bedrock happiness exercises for hectic or taxing seasons of life, patients can slowly expand their repertoire of physical activities and find new ways to meet both the aerobic and muscle-strengthening components of the Physical Activity Guidelines for Americans. ⁵ The Office of Disease Prevention and Health Promotion within the U.S. Department of Health and Human Services offers an interactive activity planner that features a smorgasbord of activities. ⁶

Purpose in Life and Meaning-Making. Merlo and colleagues explore the rather momentous issue of how one finds purpose and meaning in life. In a recent issue of Public Health Reports, former U.S. Surgeon General Vivek Murthy shares an interesting anecdote from his childhood. As a middle schooler with low self-confidence, Murphy received a weight bench from his father. By gaining physical strength, his father explained, he would also develop mental fortitude. “In the decades since,” Murthy writes, “whenever I feel adrift, frustrated, or alone, I still find strength and peace in physical activity.” The Surgeon General used his personal story to advocate for physical activity as a corrective to the mental health crisis among children and adolescents in the United States. He argued that regular physical activity, and organized sports in particular, can help young people develop purposeful, emotionally stable lives. ⁷ Lifestyle medicine practitioners can be especially helpful in this regard through community advocacy—by encouraging their local schools to promote safe routes for active commuting to and from school, incorporating formal and informal physical education during the school day, and hosting after-school programs, such as Girls on the Run.

Empathy and Compassion. At first blush, it may seem absurd to suggest that physical activity could improve empathy and compassion. Indeed, the scientific basis for this relationship is not well-established. Nonetheless, based on the aforementioned effects of physical activity on quantitative levels of neurotransmitters and qualitative measures of happiness, it is not far-fetched to surmise such a relationship. An interesting trial was conducted on 92 women with multiple sclerosis. Compared to those in the control group, women randomized to either endurance training or coordinative exercise training achieved greater gains in empathy and emotional regulation at the conclusion of the 8-week trial. Although it is unwise to generalize results from one small trial in women with multiple sclerosis to the broader population, it is reasonable, as the authors conclude, to promote regular physical activity because it “is an easy and cost-effective intervention with virtually no side-effects and virtually no restrictions.” ⁸ Taking their cue, lifestyle medicine practitioners may want to prescribe physical activity to patients who struggle with empathy and compassion.

Social Connection and Community. One could certainly meet the Physical Activity Guidelines in complete isolation, but, of all the health-related behaviors, physical activity is particularly well-suited for fostering social connection and community. This is true across the lifespan. In children and adolescents, effective interventions targeting physical activity and social connection usually focus on play or time in nature. ⁹ In older adults, group exercise classes have been found to reduce loneliness and improve connectedness. ¹⁰ Lifestyle medicine practitioners can help by developing a patient handout with local resources for physical activity and connectedness. This handout might include the following: activity-friendly clubs proximate to the clinic, such as walking, hiking, or gardening clubs; local dance, yoga, or Pilates studios; and fitness centers that offer community experiences, such as group spin classes, open swim hours, or pickleball tournaments. One specific opportunity is called Walk with a Doc, which has chapters throughout the United States (https://walkwithadoc.org/join-a-walk/locations/); if none exists nearby, the engaged health care provide could start a new chapter. Those who provide geriatric care may want to work with their patients’ nursing or long-term care facilities to develop or host community exercise classes.

Nature. Cross-sectional studies consistently find that exposure to nature is associated with higher levels of physical activity. ¹¹ Moreover, a recent systematic review found that nature prescriptions improved step counts by approximately 900 steps per day. ¹² Merlo and colleagues acknowledge that “spending time in nature” may be difficult given “structural barriers, such as a lack of local parks and green spaces.” ¹ These barriers are real and should be addressed. But spending time in nature does not require proximity to a pristine wilderness or an expensive trip to a national park (although your columnist humbly submits that the grandest physical activity is a hike in Rocky Mountain National Park or Yosemite National Park). In fact, even a small inner-city park can promote physical activity among the local population. A fascinating community-based randomized trial in Philadelphia, described as a “vacant lot greening program,” found that turning vacant lots into pocket parks resulted in more physical activity among local residents, in addition to safety improvements (i.e., reduced vandalism and gun-associated crime). ¹³ Lifestyle medicine practitioners can help by supporting such initiatives in their communities and by prescribing time in nature.

Spirituality and Religion. In their catalog of spiritual practices, Merlo and colleagues suggest multiple endeavors that could also be categorized as light- or moderate-intensity physical activity, including yoga and reflective walks. The pursuits of spirituality and physical activity can also overlap based on the context or setting. For example, numerous physical activity intervention trials have been delivered within faith-based contexts. Although the quality of evidence is fairly low, these studies consistently demonstrate that participants in faith-based physical activity interventions experience objective and subjective improvements in physical fitness. ¹⁴ Lifestyle medicine practitioners can help by partnering with their own local church to develop physical activity programs, or by supporting the strategies and tactics for implementing physical activity programs in coordination with religious denominations and congregations as outlined in the National Physical Activity Plan Faith-Based Settings Sector. ¹⁵

Like a Michelin chef who enhances the flavor of one ingredient by adding another in just the right amount, the effective lifestyle practitioner finely calibrates the six lifestyle medicine pillars—uniquely so for each patient. To enhance connectedness, the most important intervention may be adding physical activity in just the right amount.