Dance, Hearts and Well-being
There is a clear link between lifestyle factors, health and well-being. Lifestyle factors include things like our diet, whether we smoke or drink, how much sleep we get, how sociable we are and how much physical exercise we do. In this chapter I’m going to look at the relationship between our health and well-being as it relates to the physical exercise we get from dance. I’m going to ask whether dancing is better than other forms of physical exercise for our health and well-being, whether dancing might prevent some forms of ill health and whether dancing provides a universal benefit.
In 2014 a new way of handling health care budgets was introduced in the UK. The Personal Health Budget (PHB) is an amount of money given to individuals that enables them to directly purchase the healthcare they need, based around an agreed health plan. So, for example, if a person has obesity, and an agreed health plan based around weight reduction, they can either buy “traditional” healthcare, such as paying to see a dietician, or they can buy “different” healthcare, such as paying to join an online diet service, or they can use their personal heath budget to buy “radical” healthcare, such as attending dance lessons (Vogel, 2012). If people are to use PHB’s to purchase what might be considered “radical” healthcare, such as dance-based interventions, there needs to be evidence that such interventions are effective, and not a waste of public money. Within this context it is worth noting that Lauren Vogel (2012), in a news article on the use of dance lessons on PHB’s reports a case where a personal health budget was shut down because people were spending their budgets on, amongst other things, pole dancing.
There is clear evidence that engaging in physical activity can lead to extraordinary physical health benefits. For example, regular and moderate physical activity has been shown to reduce the risk of coronary heart disease, and among people with type 2 diabetes physical activity can reduce the risk of related medical complications. The consequences of physical inactivity are also very important as they are related to the incidence of cancer and mortality in some cancer populations (Penedo & Dahn, 2005). With regards to cardiovascular disease a study by Wessel et al. (2004) into the relationship between physical fitness and coronary artery disease, and cardiovascular events, in 906 women found that lower self-rated scores on physical fitness were associated with higher prevalence of coronary heart disease risk factors (which include risk factors associated with high blood pressure and cholesterol, diabetes and prediabetes) and coronary artery disease, as observed through coronary angiograms which is a test of the main arteries that supply the heart with blood and oxygen. There seems little doubt that physical exercise is good for our heart and well-being.
The intensity of different physical activities is measured in units called METs. A MET is an estimate of the metabolic equivalent intensity level of performing a certain physical activity. Different physical activities require a different level of physical intensity. For example, resting (sitting quietly in a chair doing nothing) requires very little physical intensity and so has a MET score of 1. MET scores for different activities are calculated as multiples of the resting MET. So, fast running requires a lot of physical intensity and requires eighteen times more intensity than resting, and therefore has a MET of 18 (the highest MET). All other physical activities come somewhere between 1 and 18. So, the fast chopping of a tree with an axe has a MET of 17, boxing in a ring has a MET of 12, general bike riding has a MET of 8 and sexual activity has a MET somewhere between 1 and 1.5. It is worth noting that even the most active and vigorous sexual activity is less MET intensive than playing croquet, which has a MET of 2.5. Wessel et al. (2004) observed a relationship between the MET intensity of physical activity and the risk of major adverse cardiovascular events (such as heart attacks and death) in their sample of women. They report that for every 1 MET increase in the physical activity undertaken there was an 8% decrease in risk of major adverse cardiovascular events approximately four years later.
But what about dancing? Is it a form of physical exercise that provides enough activity to lead to significant changes in health and well-being? MET intensity levels for different types of dance range from 3 to 10, which means dancing is more intensive than playing croquet and as intensive as taking part in track and field sports, such as steeplechase and hurdles. MET values for a range of activities are listed in Ainsworth et al. (2000) and examples related to dance are shown below. The average METS for dance and dance related activities is 5.8 (excluding hatha yoga).
Dance & Health: Experimental Evidence
Flores (1995) set up a project called Dance for Health. The aim of the project was to see if attending a series of regular dance classes would help to reduce the BMI and resting heart rate of young children. Flores points out that sedentary lifestyles and being overweight are contributors to the development of cardiovascular disease in later life. The link between aerobic fitness, BMI and cardiovascular disease risk factors in adolescents has been reported by Eisenmann et al. (2005). In a study of over 700 children between the ages of 9 and eighteen, Eisenmann et al. found that those who had the highest aerobic fitness and a low BMI showed the best cardiovascular disease risk factor profile, whereas those who had the lowest aerobic fitness and a high BMI showed the worst cardiovascular disease risk factor profile. The profile of cardiovascular disease risk factors was generated by measuring lipids and lipidproteins (triglyceride, high-density lipoprotein cholesterol, total cholesterol, low-density lipoprotein cholesterol); Blood pressure (resting systolic and diastolic and mean arterial pressure); Plasma glucose (fasting plasma glucose concentrations). Eisenmann et al. (2005) also found that within fatness categories (for those people who were either high or low in BMI) aerobic fitness levels were associated with better cardiovascular disease risk factor profiles. In other words, even for those with a high BMI, higher levels of aerobic fitness are associated with reduced cardiovascular disease risk profile.
Within this theoretical context Flores sought to test whether engaging in 36 moderate to high intensity aerobic dance session over a 12 week period would lead to a decrease in BMI and an increase in aerobic fitness (as measured by changes in resting heart rate). Flores tested a sample of 81 seventh grade students in the USA (mean age 12.6 years) using a between groups, repeated measures, design she allocated some of the students to an dance group and the other students to a normal physical activity control group. Flores reports her data separately for boys and girls. For the girls, taking part in 36 dance sessions led to greater positive changes (reductions) in both resting heart rate and BMI than were observed for the girls in the control group. However, no statistically significant changes were observed in the boys who took part in the dance sessions. For girls, at least, increased engagement with dance (at MET intensity 7) might be an appropriate primary prevention activity, which could help reduce cardiovascular disease risk factors. A “primary prevention” program is the first level of health care, which is designed to promote health and prevent the occurrence of disease. It seems from the study carried out by Flores that dance can play a significant role in promoting healthy behaviours and reducing cardiovascular disease risk factors in young girls.
A similar pattern of findings, concerning the differential benefits of dance for girls and boys, was obtained by Quinn et al. (2007). 348 children aged between 11 and 14 years took part in ten weeks of creative dance. The children took a series of physiological assessments before and after the 10-week programme of dance. Quin et al. found that for the girls in the sample there were significant increases in lung function (forced expiratory volume and functional vital capacity) and in aerobic fitness (20 meter shuttle run test) but there were no significant changes in the scores for the boys. It is worth noting that the girls in the sample were more positive about the dance programme than the boys.
The locus of the sex differences in observed in these studies is unclear. We do not know whether the boys engaged with the dance program as fully as the girls, or whether the MET intensity of the classes was insufficient to give the boys a full aerobic workout. It might, conceivably, be the case that boys do not attain health benefits from recreational dance due to differences in their physiological make up, or it might be the case that boys’ attitudes to dance somehow interact with the physical benefits of dance.
However, it appears to be the case that in at least one study of young men (17-19 year olds), who engaged in 24 dance sessions over an 8-week period, there was a significant increase in aerobic capacity. The study was carried out by Adiputra et al. (1996) using Balinese dance. Balinese dance is a traditional form of dance, used for both religious and artistic expression among the people of Bali, Indonesia. Adiputra et al. divided a group of young men into two groups, a dance group and a control (no-dance) group and then took measures of maximum aerobic capacity (VO2max) eight weeks apart. The researchers found that VO2max scores increased significantly for those who took part in the dance sessions and, unsurprisingly, found no change in the no-dance group. This suggests that using a dance-based intervention in a group of young men can increase aerobic capacity.
It is interesting that there are differences in outcome between the studies of Flores (1995), Quinn et al. (2007) and Adiputra et al. (1996) with respect to teenage boys aerobic response to different forms of dance. Whereas Flores, who used Hip Hop dance, and Quinn et al. who used creative dance found no positive effect of dance on young men’s aerobic fitness, Adiputra et al.’s use of traditional dance did find a positive effect of dance on aerobic capacity. One of the major differences between these forms of dance is that Balinese dance is both culturally and religiously important and perhaps the importance of the dance form to the participants influenced how they engaged with dance sessions. It is an open question whether asking them to engage in 24 sessions of Hip Hop or creative dance would have led to similar changes in aerobic capacity.
Regardless of the anomalous findings associated with boys, dance and cardiovascular fitness, there is a consistency in the literature which shows that for young people dancing has a positive effect on cardiovascular function and this has the potential to improve health. In addition to the studies already cited positive effects of dance on cardiovascular fitness/function have also been reported by Blackman et al. (1988) in a small group of sixteen 14-15 year old girls, by Viscki-Stalec et al. (2007) in a larger sample of two hundred and twenty girls aged between 16-18 year and by Mavradis et al. (2004) in a sample of 6-7 year old children. For a systematic review of this area see Burkhardt & Brennan (2012).
All of the studies examined so far have looked at the effect of dance on the cardiovascular system of relatively healthy young people. If some forms of dance satisfy those conditions that are required to lead to healthy changes in the cardiovascular system then dance might help those people who have chronic heart failure or in those with age-related reductions in cardiac function.
It is widely reported that coronary heart disease (CHD) is the primary cause of death for both men and women in the United States of America (National Heart, Lung and Blood Institute) and in the United Kingdom (National Health Service). Although CHD is more common in men than in women, the risk of developing CHD increases with age for both sexes (see Jousilahti et al. 1999). Engaging in recreational dance has consistently been shown to reduce CHD risk factors in groups of older women.
David Hopkins and his colleagues carried out a study, which shows that dancing can significantly improve cardiorespiratory endurance. Hopkins et al. (1999) recruited 65 women between the ages of 57 and 77 to take part in low-impact aerobic dance classes. Half the women were assigned to a dance group where they took part in three dance sessions per week for 12 weeks. The other women were told that they could join the dance group in 12 weeks time and in the meantime they were to continue with their daily activities as normal. Hopkins et al. therefore had an active dance group and a sedentary waiting group. All the women took part in tests of cardiorespiratory endurance, physical flexibility, physical strength/endurance, body agility, motor control & coordination and balance at the beginning of the study and 12 weeks later.
Over the 12-week period clear differences emerged between the active dance group and the sedentary waiting group. For those women in the active dance group there were positive (and significant) changes in their functional fitness measures. They had improved cardiorespiratory endurance, such that they became faster at walking the half-mile walk test, there was an improvement in their strength and endurance, they became more flexible and agile and they showed improvements in their balance. The sedentary waiting group on the other hand saw significant negative changes in their functional fitness measures. Their cardiorespiratory endurance was reduced by 4%, their body agility reduced by 3% and their motor control/coordination deteriorated by 6%. Hopkins et al. conclude that “Without intervention, it appears that sedentary elderly women continue to decline in functional fitness.” (p. 191). This study suggests that low-impact aerobic dance sessions can improve cardiorespiratory endurance in sedentary older women.
Two further studies have shown a link between engagement with recreational dance and cardiopulmonary performance. In one study, carried out in Hong Kong by Hui et al., 94 Chinese women (and three men) between the ages of 60 and 75, either took part in two low-impact aerobic dance classes per week for 12 weeks or they waited for the same period of time. This study was very similar in terms of design to Hopkins et al. (1999) described above. Hui et al. took measures before and after the 12 weeks of dancing or waiting to dance and they report that for those people who were allocated to the dance group there was a greater positive change in resting heart rate, walking speed, dynamic balance and mobility, lower limb endurance and in perceptions of general health than in the waiting group.
In the second study, carried out in Turkey by Eyigor et al. (2009), 40 women over the age of 65 were allocated to either a Turkish Folkloric dance-based exercise programme or to a control group. Those women in the control group were asked to continue their normal physical activities. Those women in the Turkish Folkloric dance-based exercise group attended three dance classes per week for eight weeks. Eyigor et al. took a range of measures before and after the eight week intervention and found that for those in the Turkish Folkloric dance-based exercise group there were similar significant improvements in walking speed, lower limb endurance and in perceptions of general health as were reported by Hui et al. (2009). Those people in the control group showed no such improvements. In fact, for those in the control group there was a significant negative change in their perception of general health.
These studies show a convergence of findings on the effect of different types of recreational dance on cardiorespiratory and general health in older women. It seems that several weeks of regular dancing is good for the heart. However, these studies raise many important questions, such as, how much dance is necessary to lead to significant changes in health. We know that three 50-minute sessions per week over 8 weeks is effective, but what is the minimum dose of dance that we can take and still derive a significant benefit? Di Blasio, De Sanctis, Gallina & Ripari (2009) suggest that a single 90-minute session of Caribbean dance has a sufficient impact on metabolic and cardiocirculatory systems to potentially improve health. We clearly need more research before we can prescribe a recommended dance dosage. Some other important questions concern how long the positive effects of dance last and whether men can derive a benefit from engaging in recreational dance too.
None of the studies that we’ve looked at so far have examined how long the positive effects of dance participation last post treatment. Research in the field of osteoarthritis and a physiotherapy-based individual exercise program has shown that the positive effects of intervention, which are seen at the end of a twelve-week treatment period, decline over time during the next twelve- and twenty-four weeks and the positive effects finally disappear altogether (see van Baar et al, 2001) and similar reductions in the positive effects observed after a 16 week cardiovascular or resistance exercise programme in older adults were seen ten weeks after the completion of the study (see Sforzo et al., 1995).
Within the context of cardiovascular risk and dance Kim et al. (2003) carried out a study which looked at the effect of a health promotion programme (which included a programme of Korean traditional dance movements). Kim et al. examined changes in cardiovascular risk factors, health behaviours and life satisfaction in 21 institutionalised women between the ages of 67 and 89. The women were monitored before and after they took part in the study, which lasted for three months, and again 3 months after the conclusion of the study. Kim et al. report follow up data which shows that for some measures the effect of the health promotion programme persist beyond the termination of the programme. For cardiovascular risk factors the women started with a low-to-moderate total risk score of 20.1 at pre-test. This reduced significantly (to 16.8) immediately after the health promotion programme and remained significantly lower than pre-test three months later (at 18.1). It is not entirely clear why a health promotion programme including elements of Korean traditional dance should lead to a longer-term benefit, beyond the end of the treatment programme. Perhaps it is because the participants in Kim et al.’s study were institutionalised and as such were encouraged to continue with some form of social dance once the formal programme had ended, or perhaps the participants enjoyed the dancing and carried on by themselves. We cannot know whether the participants stopped dancing at the end of the programme and as such we cannot be certain for how long such effects last in the absence of a dance programme.
Most of the older published research on the relationship between CHD risk and dance has been carried out on women. However, there have been two studies on the effects of dance-based exercise on adults with chronic heart failure. Belardinelli et al. (2008) compared waltz dancing with traditional exercise training (exercise bike or treadmill) and a control group on a sample of 109 men and 21 women, and found that after 8 weeks of dance or exercise there were significant improvements in a range of measures associated with cardiopulmonary exercise testing (such as the maximum rate of oxygen consumption, peak heart rate and systolic blood pressure). No such changes were observed in the control group. The finding of Belardinelli et al. suggest that dance is as good a form of exercise for this population as traditional exercise.
One of the major problems with traditional forms of exercise concerns adherence and drop out rates. The proverb “The road to hell is paved with good intentions” sums up adherence to exercise classes and drop rates rather well. The proverb means that people may have good intentions to do something, but ultimately they fail to take action. This is seen most starkly in unused gym memberships. In 2011 the UK consumer organisation WHICH? published the findings of research on its website which suggests that people in the UK are wasting about £37,000,000 per year on unused gym memberships. People are clearly motivated to join a gym and attend regularly but, the report agues, despite buying all the gear they soon stop attending. Nevertheless, they let the monthly fees continue to be paid, presumably because they intend to return.
A study carried out in Greece by Antonia Kaltsatou and her colleagues compared, among other things, cardiopulmonary exercise testing and motivation in a group of 51 men with chronic heart failure (such as coronary artery disease, hypertension, valvuvar heart disease or arrhythmia). The men were divided randomly into three groups: Group A was a Greek traditional dance group, Group B was an exercise group and Group C was a sedentary control group. Those men in Groups A and B took part in eight months of exercise and were tested at baseline and again at the end of the exercise programme (8 months later). Kaltsatou et al. (2014) report similar findings to Belardinelli et al. (2008) with regards to peak oxygen consumption, such that following the dance and exercise programme there were significant increases in VO2Peak but there was no such increase in the control group. In addition, Kaltsatou et al. also observed an increase in self-perceptions of general health in those men who were in either of the dance or exercise groups. This finding is consistent with similar patterns of data observed by both Eyigor et al. (2009) and Hui et al. (2009), who both examined cohorts of female participants.
One of the unique findings of Kaltsatou et al.’s study was that levels of intrinsic motivation were higher following 8 months of Greek traditional dance than they were following 8 months of exercise or being sedentary. Intrinsic motivation is a measure of the evaluated subjective experiences of taking part in the activity and it includes dimensions for enjoyment/interest, effort/importance, perceived competence and pressure/tension. Kaltsatou et al. observed increases in intrinsic motivation but only in those men who took part in the dance sessions. These men showed a significant in a score of total intrinsic motivation and also in increases in the constituent elements of enjoyment/interest, effort/importance and perceived competence. There was no change in pressure/tension. These findings also echo participants attendance rates for the different forms of exercise. The average attendance for the men in the dance group was 96.3%, the average attendance for those in the exercise group was just 91.5%.
It seems, therefore, that taking part in dance-based activities provides the same physical benefits as regular exercise but that it delivers these benefits in a more efficient way because men feel more motivated to attend the classes over a long period of time. Of course, Kaltsatou et al.’s study used traditional Greek dance with cohorts of older Greek men and it remains to be seen whether similar health-related benefits would be observed in the same male population if other forms of dance were used or whether the use of traditional forms of dance might be as beneficial to older men in other parts of the world.