RES E A R C H A R T I C L E Open Access
The forgotten guidelines: cross-sectional
analysis of participation in muscle
strengthening and balance & co-ordination
activities by adults and older adults in
Scotland
Tessa Strain
*
, Claire Fitzsimons, Paul Kelly and Nanette Mutrie
Abstract
Background: In 2011, the UK physical activity guidelines were updated to include recommendations for muscle
strengthening and balance & coordination (at least two sessions of relevant activities per week). However, monitoring
and p olicy efforts remain focussed on aerobic activity. This study aimed to assess differences by gender and age
in the a) p revalence of mu scle streng theni ng and balanc e & co-ordination guidelines, and b) participation in
guideline-specific activities.
Methods: The samp le for the muscle streng thening analys es was 10,488 adult (16–64 ye ars) and 3857 older adult
(≥65 years) 2012–2014 Scottish Health Survey responde nts. The balance & co- ordina tion analyses used only the
older adult responses. Differences by gender and (where possible) age in guideline prevalence and activity
participation were assess ed using logistic regression and t-tests.
Results: Thirty-o ne perc ent of men and 24 % of women met the muscle strengthening guid elin e, approx imately
half that of published figures for aerobic physical activity. Nineteen percent of older men and 1 2 % of older
women met the balance & co-ordination guidelines. The oldest age groups were less likely to meet both guidelines
compared to the youngest age groups. Differences by gender were only evident for muscle strengthening: more men
met the guidelines than women in all age groups, with the largest difference amongst 16–24 year olds (55 % men
compared with 40 % women). Participation in relevant activities differed by gender for both guidelines. ‘Workout at
gym’ was the most popular activity to improve muscle strength for men (18 % participated), while swimming was for
women (15 % participated). G olf was the most popular activity to impro ve balance & co-ordination for old er men
(11 % participated) and aerobics was for older women (6 % participated). Participation decreased in most muscle
strengthening activities for both men and women. One exception was golf, where participation levels were as
high amongst older men as in young er age groups, al though overall levels were low (3 % of all men).
Conclusions: Physical activity policy should aim to increase prevalence of these ‘forgotten’ guidelines, particularly
amongst young women (for muscle strengthening) and older age groups (both guidelines). Gender and age
participation differences should be considered when designing population-level interventions.
Keywords: Physical activity, Public health surveillance, Muscle strengthening, Balance, Co-ordination, Guidelines
* Correspondence: tessa.strain@ed.ac.uk
Physical Activity for Health Research Centre, Institute for Sport, Physical
Education and Health Sciences, St Leonard’s Land, The University of
Edinburgh, Holyrood Road, Edinburgh EH8 8AQ, UK
© The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Strain et al. BMC Public Health (2016) 16:1108
DOI 10.1186/s12889-016-3774-6
Background
Increasing physical activity (PA) levels is a health priority
in Scotland [1]. Progress is monitored by the proportion
of the population undertaking the recommended amount
of moderate and vigorous aerobic PA [2]. Until recently,
the Scottish PA guidelines for adults focused only on
aerobic activity. In 2011, the guidelines were updated
to include recommendations on muscle strengthening
(MS), balance & co-ordination (BC; for older adults
(≥65 ye ars) at risk of falls), and sedentary behaviour [3].
This paper focuses on MS and B C. The relevant add-
itional recommendations are:
Those over the age of 19 should undertake two
sessions of MS activities per week, and
Those over the age of 65 who are at risk of falls
should undertake two sessions of BC activities per
week [3 ].
(see Table 1 for a list of the activities that were
considered to improve MS and/or BC).
The inclusion of the MS guidelines for adults was in
response to the growing evidence base showing that
higher levels of muscle strength are associated with a re-
duced risk of premature mortality and cardiovascular
disease across all ages, independent of aerobic PA levels
[4–6]. There are also metabolic benefits to undertaking
regular MS activities, such as improved insulin action,
blood glucose control, and fat oxidation, all of which are
critical in the prevention and treatment of type 2 dia-
betes and metabo lic syndrome [7, 8]. There is tenta tive
evidence to suggest MS activities improve self-esteem
[9], and ameliorate symptoms of depression and anxiety
[10, 11].
In older adults, MS activities limit the age-related de-
cline in lean muscle mass (sarcopenia), help prevent
osteoporosis, maintain functional capacity and reduce
risk of falls [12–15]. Older adults may further reduce
their risk of falls by undertaking BC activities [16, 17].
Studies in New Ze aland and USA have found that
around one-third of community-dwelling older adults
fall each year [18, 19]. Considering the health and e co-
nomic burden related to falls is high [14], this issue
needs to be addressed.
In response to the additional guidelines, the Scottish
national surveillance questionnaire (the Scottish Health
Survey (SHeS)) was expanded so the MS activities of
adults and old er adults, and the BC activ ities of older
adults could be monitored annually [20]. Whilst the
SHeS records aerobic PA under the domains of walking,
housework, heavy manual/Do-it-yourself home mainten-
ance/gardening, occupational, and sport and exercise, des-
ignated MS and BC activities only appear within the sport
and exercise domain [20] (full list in Table 1). Therefore,
we use the terms MS and BC sport and exercise activities
in this paper.
So far, the SHeS annual reports have only published
descriptive statistics on the proportion of adults and
older adult s meeting the MS guidelines (27 % in 2012
[20]). There has been no statistical examination of the
differences by age and gender, nor any analysis as to
what MS sport and exercise activities adults an d older
adults undertake. There has been no analysis relating to
the BC guidelines. This paper addresses these omissions
by assessing whether there are any important and sta-
tistically significant differences by gender and (where
possible given available bases) age group in:
i) the MS and BC guideline prevalence (and the
proportions that undertaking no or insufficient
activities)
ii) the participation levels in specific MS and BC sport
and exercise activities.
This will provide a baseline from which progress can
be monitored, suggest which activities are important in
different sub-groups, and highlight sub-groups most in
need of policy focus and intervention.
Methods
Data source
We obtained the 2012-2013-2014 SHeS combined dataset
from the UK data archive on 17
th
December 2015 [21].
The SHeS uses a two-stage stratified clustered sampling
design to select households for participation in an
inter viewer-led computer a ssisted inter view . After
weighting, the data are nationally representative of the
population living in private households in S cotland in
2012, 2013, and 2014. Fu rther details on the sampling
design and sur vey methods are in the SH eS Te chnical
Report [22].
Measurement of muscle strengthening and balance &
co-ordination activities in the Scottish Health Survey
Adult respondents to the SHeS were asked to report the
frequency (in the 28 days prior to interview) and average
duration of any sport and exercise activities that they
undertook. Over 40 sport and exercise activities were
prompted and they were given the opportunity to report
any others (for further details see Corbett et al. (2013)
[23]). A panel of experts was convened to determine
whether the prompted sport and exercise activities could
count towards the MS and/or the B C guidelines [20].
Table 1 displays the three categories that they were al-
located to: a) definitely a MS/B C sport and exercise
activity, b) only a MS/B C sport and exercise activity if
the respondent confirms in a follow up question, c) not a
MS/BC sport and exercise activity. The follow up question
Strain et al. BMC Public Health (2016) 16:1108 Page 2 of 12
for MS activities was “During the past four weeks, was the
effort of (name of activity) usually enough to make your
muscles feel some tension, shake or feel warm?” There
was only one BC activity to require a follow-up question
(exercises). The follow-up question to this activity was
“Did these exercises involve you standing up and moving
about?” The construct validity of this method has not been
tested but we are unaware of any other validated method
of assessing prevalence meeting national MS or the BC
guidelines.
A respondent was deemed to have met the MS or the
BC guidelines if they reported undertaking an average of
≥2 sessions of MS or BC sport and exercise activities re-
spectively per week in the preceding 28 days. This is
based on the assumption that the sessions took place on
separate days. The UK PA guidelines do not specify a
recommended bout length for MS or BC activities [3]
and so the reported duration of activity was not taken
into account. We calculated the proportions (1) achiev-
ing or exceeding these guide lines, (2) participating in
some MS or BC sport and exercise activities but not suf-
ficiently to mee t the guidelines, or (3) not participating
in any MS or BC sport and exercise activities.
Finally, we calculated the proportions that reported
participating in each individual MS and BC sport and
exercise activity in 28 days prior to interview. For category
(b) activities where a follow up question was required to
confirm that the activity was relevant, respondents only
counted as participants if the answer was affirmative.
Sample characteristics
There were 10,509 adult (16– 64 years) and 3857 older
adult (≥65 years) respondents to the 2012, 2013 and
2014 SHeSs. These were analysed together for the MS
analyses. Those aged 16–18 were included in the ana-
lysis in line with UK health survey reporting although
the PA guidelines defines adults as 19–64 years [3]. Only
Table 1 Activities that are considered by the Scottish Health
Survey to improve muscle strength and/or balance & co-ordination
Activity
*
Muscle
strengthening
category
Balance &
co-ordination
category
Aerobics/Keep Fit/Gymanastics/Dance for
fitness
ba
Aquarobics/Aquafit/Exer cise class in water b a
Athletics a a
Badminton/Tennis b a
Basketball b a
Canoeing/Kayaking a a
Climbing a a
Cricket b a
Curling b a
Cycling b a
Dancing (any other type) b a
Exercises b b
Fishing/angling c c
Football/Rugby b a
Golf b a
Hill walking/Rambling b a
Hockey b a
Horse riding a a
Ice skating b a
Powerboating/Jet skiing c a
Lawn Bowls b a
Martial arts/Tai Chi b a
Netball b a
Rowing a c
Running/Jogging b c
Sailing/Windsurfing a a
Shinty b a
Skateboarding/inline skating c c
Skiing/Snowboarding a a
Snooker/Billiards/Pool c c
Squash b a
Subaqua c c
Surf/Body boarding b a
Swimming a c
Table tennis c a
Tenpin bowling b a
Table 1 Activities that are considered by the Scottish Health
Survey to improve muscle strength and/or balance & co-ordination
(Continued)
Volleyball b a
Waterskiing a a
Workout at gym/Weight Training/Exercise
bike
ba
Yoga/Pilates b a
*
The activities are listed as they are prompted in the Scottish Health Survey.
No further details are available as to exactly what the respondent was referring to
when they reported undertaking this activity
a) definitely a muscle strengthening and/or balance & co-ordination sport and
exercise activity
b) only a muscle strengthening and/or balance & co-ordination sport and
exercise activity if the respondent confirms in a follow up questio n (see text
for more details)
c) not a muscle strengthening and/or balance & co-ordination sport and
exercise activity
Strain et al. BMC Public Health (2016) 16:1108 Page 3 of 12
older adults were included in the BC analyses a s the
guideline only applies to this age group. It was not pos-
sible to identify those at risk of falls (the exact target
group for the recommendation) and so we have analysed
the data for all those over the age of 65.
Ten respondents were excluded from the MS analyses
and one from the BC analyses as they did not answer
the PA questions relating to sport and exercise. If there
were missing data for a specific MS or BC sport and ex-
ercise activity, the respondent was kept in the overall
analysis but that activity did not count towards the
weekly total. Twelve further respondents were excluded
from the MS analysis and one from the BC analysis as
they averaged over 3 sessions per day for the previous
28 days. We considered these individuals as extreme
outliers and not representative of normal populations.
The MS analyses by age group used 10-year groups in
line with standard health survey reporting; 5-year age
groups were used for the BC analyses to provide further
insight in the already restric ted age range. Table 2 shows
the unweig hted and weighted sample sizes for the age
and gender sub-groups (Table 2).
Statistical analyses
Analyses were carried out using STATA/SE v14.1 using
the ‘svyset’ commands to accou nt for the design effects
of the complex sampling strategy, following the recom-
mendations of Heeringa et al. (2010) [24].
Multiple log istic regressions were performed on the
proportions undertaking no, some, or sufficient MS or
BC sport and exercise activities with the predictors age
group, gender, and an interaction term. Significant dif-
ferences compared to the reference category (youngest
age group and males for the predictors respectively)
were identified through Wald tests for the regression
coefficient s.
T-tests were performed to assess gender differences in
the proportions taking part in the MS and BC sport and
exercise activities (if the overall proportion participating
was ≥1 %) using the ‘lincom’ command. Simple logistic
regressions were used to test the differences in the pro-
portions taking part in MS sport and exercise activities
by age group, stratified by gender. Regressions were only
undertaken if the activity featured in the top five for any
age category for that gender. This was not possible for the
BC sport and exercise activities as the sample sizes were
too small.
A conservative Bonferroni adjusted α-level of 0.0003
was used to account for the large number of compari-
sons being made (184 test statistics). However, our con-
clusions have taken into account overall trends in the
interpretation of the data and we comment only where
differences appear to be of practical importance. One
should be cautious interpreting these data based solely
on this cut-off for statistical significance and therefore
have provided the exact p-values and 95 % confidence
Table 2 The unweighted and weighted sample sizes for the age and gender sub-groups in the muscle strengthening and balance
& co-ordination analyses
Muscle strengthening analyses
Age group
16–24 25–34 35–44 45–54 55–64 65–74 75+ Total
Men
Unweighted 573 785 990 1165 1075 1063 669 6320
Weighted 970 1097 1101 1286 1071 812 535 6873
Women
Unweighted 701 1082 1326 1469 1322 1180 945 8025
Weighted 966 1153 1169 1359 1125 908 780 7459
Balance & co-ordination analyses
Age group
65–69 70–74 75–79 80–84 85+ Total
Men
Unweighted 618 445 325 207 137 1732
Weighted 487.3 325.2 260.1 160.2 114.6 1347
Women
Unweighted 679 500 437 301 207 2124
Weighted 522.9 384.5 361.3 245 173.4 1687
Note rows may not add up due to rounding
Strain et al. BMC Public Health (2016) 16:1108 Page 4 of 12
intervals for the regression analyses in the Additional
Tables (see Additional file 1).
Results
Muscle strength
The proportions of men and women in Scotland in
2012–14 meeting the MS guidelines were 31 and 24 %
respectively (Fig. 1, Additional file 1: Table S1). The pro-
portions were highest amongst the youngest age group
16–24 year olds (57 % of males and 38 % of females); all
other age groups were significantly less likely to meet
the guidelines. The proportions decreased with age with
the lowest amongst the over 75 s (9 % of men and 4 %
of women in this age group). Men were more likely to
meet the guidelines than women across all age groups,
with the exception 35–44 year olds where the statistically
significant interaction effect implied the 2 percentage
point difference between the genders is with the range of
variance.
The proportion doing some M S sport and exercise
activities but at an insufficient frequency (>0 but <2
sessions per week over pre vious 28 days) to meet the
guidelines ranged between 17 and 28 % for both genders
between the ages o f 16 and 54 years, bef ore dec lining
to 7 % for men and 5 % for women over 75 years. The
difference between the youngest and oldest age groups
was significant. Men were more likely to undertake
some MS sport and exercise activities than women in
the youngest age group (17 % for men and 28 % for
women aged 16–24 years). Although the only interaction
effect to meet our conservative α-level was for 55–64 year
olds (implying no effect of gender in this age group), the
difference between the genders was a maximum of two
percentage points in all other (non-reference category) age
groups.
The proportion undertaking no MS sport and exercise
activities per week increased with age from 26 % of men
and 34 % of women aged 16–24 to 84 % of men and 91 %
of women over 75 years. This was significantly higher for
those over the age of 35 compared with the youngest age
group. There were no significant effects of gender, or
interaction between gender and age group.
Figure 2 shows the participation levels (at least 1 ses-
sion in the previous 28 days) by gender for individual
MS sport and exercise activities that had an overall
prevalence ≥1 %. Men were more likely to participate in
Fig. 1 Levels of muscle strengthening sport and exercise activities, by age group and gender. Weighted n = 6873 men, n = 7459 women.
*significantly different from 16 to 24 year age group at p < 0.0003. †significantly different between genders at p < 0.0003. ‡significant interaction
between gender and age group at p < 0.0003
Strain et al. BMC Public Health (2016) 16:1108 Page 5 of 12