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http://cpx.sagepub.com/ Possible Mechanisms Explaining the Association Between Physical Activity and Mental Health: Findings From the 2001 Dutch Health Behaviour in School-Aged Children Survey
Karin Monshouwer, Margreet ten Have, Mireille van Poppel, Han Kemper and Wilma Vollebergh Clinical Psychological Science 2013 1: 67 originally published online 7 September 2012 DOI: 10.1177/2167702612450485 The online version of this article can be found at: http://cpx.sagepub.com/content/1/1/67

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Brief Empirical Report

Possible Mechanisms Explaining the Association Between Physical Activity and Mental Health: Findings From the 2001 Dutch Health Behaviour in School-Aged Children Survey
Karin Monshouwer1,3, Margreet ten Have1, Mireille van Poppel2, Han Kemper2, and Wilma Vollebergh3
1

Clinical Psychological Science 1(1) 6774 The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2167702612450485 http://cpx.sagepub.com

Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands; 2Department of Public and Occupational Health, EMGO+ Institute, Amsterdam, The Netherlands; and 3Department of Social Sciences, University of Utrecht, Utrecht, The Netherlands

Abstract More physical activity is associated with fewer mental health problems among adolescents, but the underlying mechanisms are not clear. The aim of this article is to investigate whether the association between physical activity and mental health is mediated by body-weight perception (self-image) or the social aspects of participation in organized sports (social interaction). Data from 7,304 adolescents were drawn from the Dutch Health Behaviour in School-Aged Children survey. Logistic regression analyses showed that, compared with respondents who were physically active, inactive respondents were at higher risk for both internalizing (odds ratio [OR] = 1.52, p < .001) and externalizing (OR = 1.34, p < .05) problems. The inclusion of bodyweight perception and sports-club membership variables reduced the strength of the association to an OR of 1.35 (p < .05) for internalizing problems and an OR of 1.20 (p = .132) for externalizing problems. This study found some support for the self-image and social interaction hypotheses and thereby confirms the importance of the psychological and sociological aspects of physical activity. Keywords physical activity, adolescence, internalizing and externalizing problem behaviors
Received 1/12/12; Revision accepted 3/30/12

Although still limited in number, empirical studies among adolescents have consistently shown associations between physical activity and mental health. Adolescents who are physically inactive tend to have higher levels of internalizing problems such as depression and anxiety (Kirkcaldy, Shephard, & Siefen, 2002; Motl, Birnbaum, Kubik, & Dishman, 2004; Sanders, Field, Diego, & Kaplan, 2000; Thorlindsson, Vilhjalmsson, & Valgeirsson, 1990) and lower rates of emotional well-being (Steptoe & Butler, 1996) compared with those who are physically active. Physical activity has been shown to be effective in the treatment of depression, although to our knowledge these studies were performed only in the adult population (Craft & Landers, 1988; Wayne, Kiernan, & King, 2003). It has been suggested that participation in sports prevents adolescents from showing externalizing behavioral problems such as delinquency, aggression, and substance use (Chen et al., 2004; Collingwood, Sunderlin, Reynolds, &

Kohl, 2000; Duncan, Duncan, Strycker, & Chaumeton, 2002; Nelson & Gordon-Larsen, 2006). Physical activity is used also as a rehabilitative and preventive intervention for youth with behavioral problems (Wilson & Lipsey, 2000). However, researchers studying associations between physical activity and externalizing problems have reached ambiguous conclusions. For example, the authors of a New Zealand study (Begg, Langley, Moffitt, & Marshall, 1996) concluded that high levels of physical activity were a risk factor rather than a protective factor for delinquent behavior, but not among participants who were involved in team sports.

Corresponding Author: Karin Monshouwer, Trimbos Institute, Netherlands Institute of Mental Health and Addiction, P.O. Box, 725, 3500 AS, Utrecht, The Netherlands E-mail: kmonshouwer@trimbos.nl

68 Although associations between physical activity and mental health, especially internalizing problems, seem to be established, much is still unclear with regard to the mechanisms underlying these associations. The relationship could be direct (i.e., through the physiological effects of physical exercise; Bjornebekk, Math, & Bren, 2005; Dishman et al., 2006), but the psychological and sociological processes of exercise also have been suggested as having effects on mental health (Paluska & Schwenk, 2000). In this study, we aim to extend the understanding of the link between physical activity and mental health by investigating two hypotheses put forward in previous studies: the self-image hypothesis and the social interaction hypothesis (Kirkcaldy et al., 2002; Paluska & Schwenk, 2000). The self-image hypothesis suggests that the positive association between physical activity and mental health is (partly) due to the favorable effects of physical activity on body weight and body structure, resulting in more positive feedback from peer groups, which in turn improves an adolescents selfimage, thereby resulting in better mental health (Kirkcaldy et al., 2002). Studies testing this mechanism are lacking, but support can be found in two types of studies: those reporting that higher levels of physical activity are associated with a more positive body image (Hausenblas & Fallon, 2006) and those reporting that a more positive body image is associated with better mental health (Stice, Hayward, Cameron, Killen, & Taylor, 2000; Ter Bogt et al., 2006). Most of the latter studies have focused on internalizing problems; however, body image dissatisfaction (Jurich & Andrews, 1984; Ter Bogt et al., 2006) and being overweight (Hasler et al., 2004) have been found to be related to externalizing problem behavior as well. The social interaction hypothesis suggests that it is not the physical activity itself but the social aspects of physical activitythat is, the social relationships and mutual support among team membersthat contribute to the positive effects on mental health (Vilhjalmsson & Thorlindsson, 1992). This hypothesis is one of the underlying assumptions of wilderness challenge programs for delinquent youth: The positive effects of these programs are partly attributed to positive group interaction and cooperation. It is suggested that these effects lead to improvements in interpersonal skills that transfer to situations outside the program and thereby reduce the risk for delinquent behavior. Although these psychological and sociological mechanisms are frequently put forward in the literature, little work has been carried out to test these mechanisms. In this study, we further investigate the hypothesized mechanisms in empirical data. For actual testing of the hypotheses, longitudinal data are a prerequisite; however, the results of this study can substantiate the need for longitudinal data. This information will enable a more informed decision on whether to continue research into these mechanisms in studies with a longitudinal design. Two hypotheses were investigated: First, guided by the theory on the effects of physical activity on self-image, it was expected that the association between physical activity and mental health would be mediated by body-weight perception. Second, based on the social interaction hypothesis, it was

Monshouwer et al. expected that the association between physical activity and mental health would be (partially) explained by the increased involvement in organized sports among the physically active respondents. These hypotheses were investigated in a large (N = 7,304) representative sample of primary and secondary school students (11 to 16 years old) using standard validated instruments for the measurement of physical activity (Prochaska, Sallis, & Long, 2001) and mental health problems (Achenbach, 1991), while taking the effect of confounders into account. All analyses were performed separately for internalizing and externalizing behavior problems.

Method Sample
This study was conducted as part of the World Health Organization cross-national study Health Behaviour in School-Aged Children (HBSC), which addresses health, health behaviors, and their social context in children and adolescents in Europe and North America (Currie et al., 2004). In accordance with HBSC guidelines, a two-stage random-sampling procedure was used (Currie, Samdal, Boyce, & Smith, 2001). First, schools were stratified according to level of urbanization and were drawn proportionally by the number of the corresponding urbanization level. Second, for secondary education, one class from each grade (Years 1, 2, 3, and 4) was selected randomly from a list of all classes provided by every participating school. In schools for primary education, all classes of the last grade (Grade 8) were selected (usually one class per school). Within classes, all students were drawn as a single cluster. This procedure resulted in a sample of 1,826 pupils in the 8th grade of primary education and 5,730 pupils in the first 4 years of secondary education (a total of 7,556 students). Because of the small number of respondents in the 10- (0.3%), 17- (1.8%), and 18-year (0.3%) age groups, only the 11- to 16-year-olds were included in the analyses (7,304 students). The response rate for primary and secondary schools was 60% (71 out of 119) and 45% (66 out of 146), respectively. Reasons offered for nonresponse included lack of time or conflicts with other research occurring at that time. Response and nonresponse schools did not differ with regard to urbanization level and school size. Response was high: On average, only 5% of the students were not reached, mainly due to illness. To make it possible to generalize the results to the total school-going population, a weighting procedure was applied. Poststratification weights were calculated by comparing sample distributions and known population distributions of gender, school level, grade, and level of urbanization (the national statistics were obtained from Statistics Netherlands).

Data collection
All data were collected by means of questionnaires, which were distributed in classes and administered by the teachers (at four schools by a research assistant) during a lesson (usually

Physical Activity and Mental Health 50 min). When introducing the questionnaire, teachers emphasized the respondents anonymity. Collecting all questionnaires in one envelope and sealing the envelope in the presence of the respondents further ensured anonymity. activity are running, brisk walking, rollerblading, skateboarding, biking, dancing, swimming, soccer, basketball, football and surfing (Prochaska et al., 2001).

69

Measures
Mental health was measured using the Youth Self-Report (YSR; Achenbach, 1991). The YSR is designed to be completed by adolescents (11 to 18 years old) and has been shown to have good reliability and validity (Achenbach, 1991). It has been translated and validated for Dutch use (Verhulst, Van der Ende, & Koot, 1997). The YSR contains 101 problem items (0, not true; 1, somewhat true; 2, very true or often true, on the basis of the preceding 6 months). The YSR can be scored by the total problem score (sum of all scores) and on the following eight subscales, divided into three groups: withdrawn, somatic complaints, and anxious/depressed (internalizing problems); delinquent and aggressive behavior (externalizing problems); social problems, thought problems, and attention problems (the latter three are not part of either the internalizing or externalizing scale). For this study, only the internalizing and externalizing scales were used. Problem scores on the YSR internalizing and externalizing syndrome scales were computed using the cutoff points of the YSR manual (Verhulst et al., 1997), taking scores above the normative cutoff point as indicative for the presence of borderline or clinical emotional or behavioral problems. A dichotomous variable was created for the internalizing and externalizing problem scales: Respondents exceeding the borderline or clinical score of the YSR problem scale were categorized as 1 (index category), and those not meeting the borderline score were coded as 0 (reference category). Physical activity was measured using the moderate-tovigorous physical activity (MVPA) screening measure developed by Prochaska et al. (2001). This measure is consistent with current international recommendations for youth to accumulate 60 min of MVPA on most days of the week (Sallis & Patrick, 1994). The reliability (intraclass correlation coefficient = 0.77; k value to assess reliability for correct classification of respondents as meeting or not meeting guidelines = 61%) and validity (a correlation of r = .40, p < .01, with accelerometer data) showed that the MVPA is a reasonable method for assessing participation in overall physical activity and for assessing achievement based on current guidelines (Prochaska et al., 2001). The measure consists of two questions that refer to two time frames (the past week and a usual week) and gather information on the number of days that adolescents undertake physical activity of at least moderate intensity for a minimum of 60 min. The questions are preceded by the following definition of physical activity: Physical activity is any activity that increases your heart rate and makes you get out of breath some of the time. Physical activity can be done in sports, playing with friends, or going to school. Some examples of physical

The question used in the HBSC survey was slightly modified in that it allowed the inclusion of physical activity within the school timetable. For analyses, the average of the past and usual week (r = .84) was computed and recoded into three categories (norm-active, semiactive, and inactive). Current Dutch guidelines recommend 60 min of moderate activity on all days of the week and also 2 days of vigorous exercise to enhance or maintain physical fitness (Kemper, Ooijendijk, & Stiggelbout, 2000), whereas international guidelines recommend 60 min of moderate or greater intensity activity on 5 days of the week (Prochaska et al., 2001). It was decided to follow the international guidelines and categorize those respondents scoring an average of 5 or more days of 60 min of MVPA as norm-active. As this study explored the relationship between mental health and different levels of physical activity, we also defined semiactive and inactive groups. Respondents scoring between 2 and 4.5 days were categorized as semiactive, and those scoring between 0 and 1.5 days were categorized as inactive. This categorization resulted in group sizes that allow adequate statistical analyses (norm-active n = 3,938, semiactive n = 3,355, and inactive n = 964). Body-weight perception was assessed with the following question: What do you think of your own body? It is . . .? Response categories on a 5-point Likert-type scale ranged from far too thin to far too heavy. The responses far too thin and too thin were compressed into one category, as were far too heavy and too heavy, resulting in a three-category variable (with the third category, good, serving as the reference category). Current sports-club membership was assessed in a separate question. Respondents answering yes were categorised as 1 (index category), and those answering no were coded as 0 (reference category). The selection of the confounder set included in the multivariate models was based on the outcomes of other studies (e.g., Begg et al., 1996; Collingwood et al., 2000) and the results of earlier research using the same data set, showing a significant association between sociodemographic and family factors and mental health problems (Vollebergh et al., 2006). Analyses were performed to assess which factors were related to both physical activity and mental health problems and therefore were confounding factors in the association between physical activity and mental health. This procedure resulted in the following factors: age (in years), gender (female or male), household composition (living with both biological parents: no or yes), urbanization level (four levels), and socioeconomic status (SES; low, medium, or high). The SES of children was measured using the Family Affluence Scale (Currie, Elton, Todd, & Platt, 1997). This scale is a validated measure of material affluence, assessed using four questions concerning

70 the presence of material goods in the family: number of cars, student having a bedroom of his or her own, number of computers, and number of times the family goes on holiday. In accordance with the HBSC protocol (Currie et al., 2001), the answers were recoded into the earlier cited three categories. The variables ethnic status (ethnic minority student: no or yes) and job status of both mother and father (unemployed: no or yes) were associated with mental health problems but not with physical activity levels and therefore were not included as confounding factors in the multivariate models.

Monshouwer et al. added to the second model. This stepwise approach gives information on changes in the strength of the associations between physical activity and mental health. A decrease in the strength of the association between physical activity and mental health from Model 1 to Model 2 indicates that body-weight perception has a mediating role. A further decrease in this association when adding membership in a sports club indicates that part of the association between physical activity and mental health is due to the favorable aspects of being a member of a sports club and the higher percentage of sports club involvement among those who are more physically active. All analyses were carried out with Stata Version 7.0 (Stata Corporation, 2001).

Data analysis
To obtain correct 95% confidence intervals and p values in a weighted and clustered sample, robust standard errors were obtained (Skinner, Holt, & Smith, 1989). Univariate analyses explored the relationships between (a) level of physical activity, body-weight perception, and membership in a sports club, on the one hand, and mental health, on the other, and (b) level of physical activity, on the one hand, and body-weight perception and membership in a sports club, on the other. Multivariate logistic regression analyses, resulting in odds ratios (ORs), were performed to assess (a) the independent association between physical activity and mental health and (b) the mediating role of body-weight perception and the explanatory role of sports-club membership. These research questions were investigated in three models. First, physical activity, bodyweight perception, and sports-club membership were separately associated with problem behavior while the effect of confounding variables (age, gender, SES, urbanization level, and household composition) was controlled. In a second model, both physical activity and body-weight perception were included. In a third step, membership in a sports club was

Results
The descriptive results in Table 1 show that the prevalence of internalizing and externalizing problems is highest in the inactive group. For example, 28% of the respondents in the inactive group reported internalizing problems; this percentage was much lower in the norm-active (19%) and semiactive (20%) groups. Mental health problems were more prevalent among respondents who found themselves too thin or too heavy, compared with those who rated their body weight as good. Finally, respondents who were members of a sports club reported fewer problems than those who were not. Table 2 shows that the percentage of respondents considering themselves to be too heavy is lowest in the norm-active group (30%) and highest among the inactive respondents (40%), with the semiactive group scoring in between (37%). As expected, respondents who were meeting the physical activity guidelines were more often members of a sports club than were inactive respondents (69% vs. 37%). Membership

Table 1. Mental Health Status by Physical Activity Level, Body Weight Perception, and Membership in a Sports Club (in %) Mental health status No problems (n = 4,268) Physical activity level Norm-active (reference; n = 2,859) Semiactive (n = 3,355) Inactive (n = 964) Body-weight perception Good (reference; n = 3,615) Too thin (n = 1,103) Too heavy (n = 2,462) Member of a sports club Yes (n = 4,530) No (n = 2,773) 70.8 69.7 59.4a 75.9 67.6a 58.6a 71.3 62.9a Internalizing problems (n = 1,279) 18.9 19.8 27.9 14.7 22.2a 28.5a 18.7 24.7 Externalizing problems (n = 1,139) 17.2 17.7 23.7 13.9 18.1a 24.7a 16.6 22.0a

Note: Horizontal percentages do not add to 100 because respondents can report both internalizing and externalizing problems. a Significant difference with the reference category; that is, 95% confidence intervals do not overlap.

Physical Activity and Mental Health

Table 2. Body Weight Perception and Membership in a Sports Club by Physical Activity Level (in %) Body-weight perception Good (n = 3,615) 53.7 49.0 43.9 Too thin (n = 1,103) 16.6 14.0 16.5 Too heavy (n = 2,462) 29.7 36.9a 39.6a Member of a sports club Yes (n = 4,530) 68.8 63.8 36.6a No (n = 2,773) 31.2 36.2 63.4a

71

Physical activity level Norm-active (reference; n = 2,659) Semiactive (n = 3,355) Inactive (n = 964)
a

Significant difference with the reference category (norm-active); that is, 95% confidence intervals do not overlap.

in a sports club was slightly lower in the semiactive group (64%) than in the norm-active group but was still much higher than in the inactive group. The results of three separate analyses (Table 3) showed that physical activity, body-weight perception, and membership in a sports club (Model 1) were all significantly associated with mental health problems (while controlling for confounding factors). In comparison with respondents in the norm-active reference category, physically inactive respondents had a significantly higher risk for internalizing (OR = 1.52) and externalizing (OR = 1.34) problem behavior. No significant differences were observed between the semiactive and the norm-active groups. Perceiving oneself as too thin or, especially, too heavy was associated with a higher risk for internalizing and externalizing behavior (ORs ranging from 1.30 to 2.28). Respondents who were members of a sports club were at lower risk for mental health problems (OR = 0.78). To assess the mediating effect of body-weight perception, physical activity and body-weight perception were simultaneously included in Model 2. This resulted in a slight decrease in the strength of the associations between physical activity and mental health, but associations with both internalizing and externalizing problems remained significant. In the next step (Model 3), sports-club membership was added to the model. Again, the strength of the associations between physical activity and mental health was reduced, and, thus, the association between physical activity and externalizing problems lost significance. The third model further showed that members of a sports club were at slightly lower risk for mental health problems (both internalizing and externalizing) than those who were not, even when the level of physical activity was controlled for.

Discussion
This study shows that the indirect effects of body-weight perception and participation in organized sports explain part of the association between physical activity, on the one hand, and externalizing and internalizing problems, on the other hand. Thus, although the effects were small, this study provides a

degree of empirical support for both the social interaction and the self-image hypotheses. Although the association between physical activity and internalizing problems was reduced after inclusion of the body-weight perception variable, the effect was small, indicating that the mediating role of body-weight perception in this sample is modest at best. This seems to be due primarily to the weak association between physical activity and body-weight perception, as, in line with other studies (Ter Bogt et al., 2006), the association between body-weight perception and internalizing problems appeared to be rather strong. The weak association between physical activity and body-weight perception could indicate that the lower threshold for the norm-active group was not high enough in this study to influence bodyweight perception. However, additional analyses showed that increasing the threshold to 7 days of MVPA only slightly changed the association with body-weight perception. These results are in keeping with a recent meta-analysis on body image and exercise that concluded that effect sizes in correlational studies were small, especially among younger age groups (Hausenblas & Fallon, 2006). Studies have indicated that the psychological response to physical activity may be influenced by the mode of exercise. For example, results of a study among British schoolgirls concluded that a 6-week aerobic dance intervention was significantly more effective in improving body image than was the regular physical education program (Burgess, Grogan, & Burwitz, 2006). The authors assumed that this effect was (partly) due to the more supportive environment (i.e., noncompetitive and nonthreatening) of the aerobic dance program. Unfortunately information on the mode and context of the physical activity was not available in this study. The descriptive results (Table 1) indicated that internalizing problems were more prevalent among respondents reporting that they were not a member of a sports club. However, inclusion of this variable in the logistic model only slightly decreased the strength of the association between physical activity and internalizing problems. Thus, sports-club membership seems to have a limited role in explaining the association between physical activity and internalizing problems.

72
Table 3. Association Between Physical Activity, Body-Weight Perception (BWP), Membership in a Sports Club, and Mental Health Problems Internalizing problems Variable Physical activity Norm-active Semiactive Inactive BWP Good Too thin Too heavy Member of a sports club Physical activity Norm-active Semiactive Inactive BWP Good Too thin Too heavy Physical activity Norm-active Semiactive Inactive BWP Good Too thin Too heavy Member of a sports club OR 95% CI Model 1 1 1.04 1.52** 1 1.61** 2.28** 0.78** 1 1.00 1.34** 1 1.30* 1.91** 0.78** p Externalizing problems OR 95% CI p

Monshouwer et al.

0.901.20 1.251.86

.582 .000

0.861.16 1.071.69

.970 .011

1.351.92 1.982.62 0.680.90 Model 2

.000 .000 .001

1.061.60 1.632.27 0.670.91

.012 .000 .001

1 1.01 1.42** 1 1.61** 2.25**

0.881.17 1.161.74

.881 .001

1 0.95 1.26* 1 1.30* 1.88**

0.821.11 1.001.60

.513 .049

1.351.92 1.952.59 Model 3

.000 .000

1.061.60 1.592.22

.012 .000

1 1.00 1.35** 1 1.60** 2.24** 0.84*

0.871.16 1.091.67

.950 .006

1 0.95 1.20 1 1.29* 1.87** 0.84*

0.811.10 0.951.52

.470 .132

1.341.91 1.942.58 0.730.98

.000 .000 .028

1.051.59 1.582.21 0.720.98

.015 .000 .031

Note: Model 1 shows the results of three separate analyses on (a) physical activity, (b) BWP, and (c) membership in a sports club, while controlling for the influence of all confounders (age, gender, socioeconomic status, urbanization level, and household composition). Model 2 includes physical activity and BWP, while controlling for the influence of all confounders. Model 3 adds membership to a sports club to Model 2. The p values indicate a significant difference with the reference category. OR = odds ratio. *p < .05. **p < .01.

Nevertheless, our study indicates that sports-club membership itself is associated with internalizing problems independently of the level of physical activity and body-weight perception. An Icelandic study (Vilhjalmsson & Thorlindsson, 1992) also found sport participation in clubs and groups to be negatively related to anxiety, depression, and psychophysiological symptoms; however, the association disappeared when exercise intensity was controlled for. Finally, as both body-weight perception and membership in a sports club did not fully explain the association between physical activity and internalizing problems, other mechanisms, including the direct physiological effects of the physical exercise itself (Bjornebekk et al., 2005; Dishman et al., 2006), are probably also at work.

This study showed that physical activity was significantly associated with externalizing problems. However, when bodyweight perception and membership in a sports club were accounted for, this association disappeared. Thus, these findings seem to support both the body image and the social interaction hypotheses. However, it should be noted that the initial association (i.e., while accounting for demographics, but not for body-weight perception and sports-club membership) was not very strong, which means that relatively small effects already lead to insignificance. It seems likely that both the type of physical activity and its context are very important, as they are for internalizing problems. This might also explain the conflicting results of studies on the association between externalizing problems and physical

Physical Activity and Mental Health activity (Begg et al., 1996; Wilson & Lipsey, 2000). For example, it is suggested that antisocial behaviors are reduced because physical activities are often supervised or structured (Duncan et al., 2002). However, supervision and structuring are not intrinsic elements of physical activity. The same argument applies to the supposed mechanism of positive group interaction and cooperation (Wilson & Lipsey, 2000). Whether this positive group interaction and cooperation exist seems highly dependent on, for example, the type of sport, the atmosphere among participants, and the attitude of the coach. It is likely that these aspects differ between an individual sport like weight training and a team sport like volleyball. In many studies, as in this one, information on type and context of physical activity is lacking. This study has several strengths; it is among the few projects investigating the possible mechanism that explains the association between physical activity and mental health in adolescence. This was done using a large representative population survey, while applying instruments validated for the measurement of both physical activity and mental health (including both internalizing and externalizing problems) among adolescents. However, the study has a number of limitations, which should be considered when interpreting the results. First, this study uses cross-sectional data and therefore does not provide definite evidence of the causal structure of relationships between physical activity, body-weight perception, and mental health. For example, the association between physical activity and internalizing problems might occur at least partly because of selection processes, with those who are distressed being less likely to be physically active. Furthermore, although we corrected the analyses for a range of potential confounding factors, we cannot rule out the possibility that the observed associations are due to other characteristics associated with both physical activity and mental health. Second, the reliability of self-reports of physical activity levels among adolescents is problematic (Welk, Corbin, & Dale, 2000). However, the MVPA measure has proven to be among the most reliable and valid self-report instruments for physical activity and adequate for answering research questions as formulated in the present study. Third, this study did assess whether respondents were members of a sports club; however, detailed information on the type of physical activity, the context, and the amount of time spent on individual or organized sports was not available. In conclusion, the findings of this study indicate that bodyweight perception and participation in organized sports mediate the association between physical activity and mental health problems. Although their role appears to be modest at best, this study confirms the importance of the psychological and sociological aspects of physical activity in explaining the association with mental health. Future longitudinal studies, including more detailed information on type and context of physical activity, are needed to obtain a better understanding of the direction of the association and the particular characteristics of physical activity that are relevant to mental health.

73 This type of information is important to advance the use of physical activity as an effective instrument in the prevention and treatment of mental health problems in adolescence. Declaration of Conflicting Interests
The authors declared that they had no conflicts of interest with respect to their authorship or the publication of this article.

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