Review article

Exercise: Should it matter to internal medicine?

Daniela Lucini
a,
, Massimo Pagani
a,b
a
Centro di ricerca Terapia Neurovegetativa e Medicina dell'esercizio, Dipartimento Scienze Cliniche, Universit degli Studi di Milano, Italy
b
U.O. Telemedicina e Medicina dello Sport, Ospedale Luigi Sacco, Milano, Italy
a r t i c l e i n f o
Available online xxxx
Keywords:
clinical prevention
cardiovascular risk
exercise
physical activity
life style
1. Introduction
A 71 year old man died unexpectedly. An extensive myocardial
infarction occurred while he was gardening in the rst day of his
vacation, and led him to sudden death shortly thereafter.
His daughter, a 45 year old woman who has always considered
herself healthy, refers to her Internist for advice: I'm worried. I know
that genetics is important in the development of myocardial
infarction my grandmother suffered for an ischemic heart disease
too, and she died due to congestive heart failure after two myocardial
infarctions. She and her son, my father, were treated for high blood
cholesterol level One week before he died he performed a blood
test: his total cholesterol was 277 mg/dl, HDL 46 mg/dl, and LDL
192 mg/dl, triglycerides were 196 mg/dl and fasting glucose 97 mg/dl.
His blood pressure was 150/90 mmHg, is it right? He was only
71 years old! His body weight was about 95 Kg, but he was tall, more
or less 1.88 m! Is there something that I may do in order to avoid the
same fate?
The Internist asks about her, medical history and life styles, performs
a physical assessment, prescribes blood and urine test analysis, and
other instrumental tests in order to assess any subclinical organdamage
(electrocardiogram, echocardiogram, determination of Intima Media
Thickness) [1] that might contribute to total cardiovascular risk. Blood
European Journal of Internal Medicine xxx (2011) xxxxxx
Source of support: ASI contract DCMC, PRIN 2007.
Corresponding author at: Centro Terapia Neurovevegetativa e Medicina dell'Eser-
cizio, Dipartimento Scienze Cliniche L. Sacco- Universit di Milano, Via G.B. Grassi, 74,
20157 Milano, Italy. Tel.: +39 02 39042802; fax: +39 02 50319823.
E-mail address: daniela.lucini@unimi.it (D. Lucini).
EJINME-02068; No of Pages 8
tests show: total cholesterol 228 mg/dl, HDL 83 mg/dl, LDL 127 mg/dl,
triglycerides 60 mg/dl, fasting glucose 91 mg/dl. Her blood pressure is
135/85 mm/Hg, BMI is 29 Kg/m
2
and waist circumference is 88 cm. Her
eating habits are regular and she is sedentary.
If we calculate cardiovascular risk factor using traditional
algorithms [24], as SCORE, we nd that the father would have had
a 10-year risk of fatal CVD of 10% (no surprise!) and the daughter a
risk lower than 1%! Considering also that the performed instrumental
tests did not suggest any subclinical organ damage, is the Internist
allowed to reassure his/her patient leaving her to her destiny
(whatever it will be) or could he/she do anything else?
To delve into every single cardiovascular component per se, allows
to nd room to improve her lifestyle and consequently her health
(see Table 1). BMI, waist circumference, cholesterol, blood pressure
values and physical activity levels need to be ameliorated. Lifestyle
changes, in particular to optimize body weight and to become
physically active, represent the answer to the woman's question and
should be prescribed. The goal of this approach [5,6] is not obviously
to determine nor the absolute, nor the relative risk to develop
cardiovascular diseases, but it is to concretize at individual level a
clinical preventive strategy. Generally Internists are used and have all
the requested tools (awareness, knowledge and skills) to help their
patients lose body weight and reduce cholesterol blood level
primarily prescribing ad hoc diet; is not always the same if they
have to counsel and even more prescribe physical exercise as therapy.
A fundamental goal of exercise prescription is to bring about a change
in personal health behavior including habitual physical activity [7]
and hence direct patients to initiate, maintain, or increase their level
of physical activity [8]. Scientic literature clearly shows that
counseling and prescribing regular exercise, in everyday clinical
practice, may be effective in helping patients to incorporate regular
exercises in their daily routines [811], obtaining clinical benets. The
essential is to know how to do it effectively, to have received effective
education and training in just how to do it so that it can work [8]. The
main foes may be: to underestimate the required skills, thinking that
simple good sense could be enough for a correct prescription; to
consider exercise prescription outside medical role; and to believe
that people cannot change physical activity habits [9,1215].
2. Benet of physical exercise in internal medicine
The concept of a benecial relationship between exercise and health
is as old as the writings of Hyppocrates (5th century BC) [16]. Eons of
interest and scientic investigations eventually followed through, and
the role of regular exercise in determining healthgrewof importance so
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doi:10.1016/j.ejim.2011.02.022
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Please cite this article as: Lucini D, Pagani M, Exercise: Should it matter to internal medicine? Eur J Intern Med (2011), doi:10.1016/j.
ejim.2011.02.022
much as to be proposed as therapy [17] at the end of Nineties and being
considered itself a real therapy ten years later when the scientic
community launched the slogan exercise is medicine [18,19] The
benets of regular exercise are evident both in secondary (preventing
the recurrence of clinical events in patients who have manifest clinical
diseases), in primary (preventing the rst occurrence of a clinical event
among individuals who are at risk) and primordial (avoiding the
development of riskfactors intherst place) prevention[5,7,8,18,20,21]
of many diseases (see Table 2) [2235]. Moreover regular exercise is
associated with longevity [3638], reduced risk of physical disability
and dependence [39], cognitive performance both in youth [40] and
adulthood [41] and reduced stress effects [17,42].
There is a strong correlation between regular physical exercise and
all-cause mortality [21,4345]. Cardiorespiratory tness (see Box 1)
may be considered the best quantitative predictor of all-cause mortality
and cardiovascular events in healthy men and women [46]; it means
that those individuals who maintain an active and t way of life live
longer and healthier than those who do not.
The risk of death from any cause in subjects whose exercise
activity was less than 5 Metabolic Equivalents (METs) was roughly
double than of subjects whose exercise capacity was more than
8 METs. The protective role of a higher exercise capacity is conrmed
even in the presence of other risks factors [43]. Importantly, the
largest reduction in mortality was observed between the least-t and
the next least-t category, i.e. those achieving 6 to 8 METs versus
those achieving b6 METs [21,43,45]. This data suggests that the goal of
exercise prescription is a realistic one; being not to transform a
sedentary man into an athlete, but only in a moderately active
individual.
The mechanisms underlying the relationship between regular
physical exercise and health are numerous and new evidences
suggesting new benets are constantly emerging. Regular exercise,
particularly aerobic [20,47,48] exercise (althoughrecent data suggest an
important role also of the resistance modality [49]), acts through many
pathways which affect cardiovascular risk factors. On the other hand, it
is associated with a better and longer life beyond what can be explained
only with improvement of cardiovascular health [44,50]. Many studies
show that the benets of regular exercise remained signicant even
after adjustment for the most common cardiovascular risk factors
[22,27,44] and could not be explained by genetic factors [51,52]. Fig. 1
reports main benecial effect of regular physical exercise
[21,23,26,27,40,46,48,5368].
Of particular interest is the relationship between exercise and
autonomic nervous system [54,6975]. Acute exercise enhances
Table 1
Cardiovascular health components.
Ideal values Patients values
Total cholesterol [mg/dI]
HDL cholesterol [mg/dI]
Triglycerides [mg/dI]
Fasting plasma glucose [mg/dI]
BMI [kg/m
2
]
Waist circumference [cm]
Arterial Pressure [mmHg]
Smoking
Physical activity min/wk
Healthy diet score [components]
<200 228
83
60
91
29
88
135/85
no
30 moderate intensity
4 components
<150
<100
<25
>150 moderate intensity or >75 vigorous intensity or
>150 moderate + vigorous
<120/<80
80
no
45 components
>50
_ _ _
_
Green light = optimal health; yellow light = intermediate health; red light = poor health (modied from [5]).
Table 2
Example of clinical conditions that may beneciate from regular exercise.
coronary heart diseases
chronic heart failure
hypertension
thromboembolic stroke
peripheral arterial diseases
metabolic syndrome
dyslipidemia
diabetes (type 2 and 1)
obesity
cancer (in particular colon and breast)
chronic obstructive pulmonary disease
osteoporosis
bone and joint diseases
anxiety
depression
dementia
Box 1
Maximal oxygen consumption (V
O2 max
) is the greatest amount
of oxygen a person can take in from inspired air while
performing dynamic exercise involving a large part of total
muscle mass [48]. It is considered the best measure of
cardiovascular fitness and exercise capacity. VO
2 max
repre-
sents the amount of oxygen transported and used in cellular
metabolism. It is convenient to express oxygen uptake in
multiples of sitting/resting requirements. One metabolic equiva-
lent (MET) is a unit of sitting/resting oxygen uptake 3.5 mL
of O
2
per kilogram of body weight per minute (standard 01).
VO
2 max
is influenced by age, sex, exercise habits, heredity, and
cardiovascular clinical status.
The ventilatory threshold is another measure of relative work
effort, and it represents the point at which ventilation abruptly
increases, despite linear increases in oxygen uptake and work
rate [48].
Aerobic exercise: exercise intense enough to lead to a significant
increase in muscle oxygen uptake.
Anaerobic exercise: intense exercise, necessarily of very short
duration, fueled by energy sources (glycolytic pathways) solely
within the contracting muscle that does not depend upon the
use of inhaled oxygen as an immediate energy source.
2 D. Lucini, M. Pagani / European Journal of Internal Medicine xxx (2011) xxxxxx
Please cite this article as: Lucini D, Pagani M, Exercise: Should it matter to internal medicine? Eur J Intern Med (2011), doi:10.1016/j.
ejim.2011.02.022
sympathetic activity and thus might increase the risk of cardiac events
on short term basis, particularly in those patients with known heart
disease [20,76,77]. Conversely aerobic training is associated with an
improvement of autonomic control of the circulation as suggested by
an increase of baroreex sensitivity and of indices of vagal activity in
patients with coronary artery disease [6971], hypertension [73,74],
diabetes [75] or in athletes [73,78].
3. Approaching patients to exercise
While the sport medicine physician generally works with subjects
used to the concept, benets and practical issues of exercise, and
willing to perform; the internist has to approach subjects who actually
do not (Fig. 2). Hence, in order to prescribe exercise successfully, it is
important not only to assess the patients' health status, in order to be
sure to prescribe a safe and efcacious exercise [20,48], but also to
motivate him/her to become physically active [8,79]. To maintain
physical activity behavior [9] becomes only a necessary second step.
Exercise is voluntary, tiring and time consuming, it may compete with
vocational responsibilities or other valued leisure-time interests [9];
then many subjects would like or dream to be physically active but
they are not performing. Many theoretical paradigms [9,79] were
invoked to disentangle this issue and to dene strategies useful to
help patient to overcome this impasse. Of particular appeal were
theories related to social learning paradigms [80] or social cognitive
models [81]: the former ones indicate as primary determinants of
behavior the expectancy-value that conceptualizes expected out-
comes and their perceived importance; while the latter ones
emphasize the importance of self-efcacy beliefs. From a more
concrete point of view, both theories suggest a principle of triadic
reciprocal causation, in which personal (e.g., cognitive and demo-
graphic), environmental (e.g.,social environments) and behavioral
(e.g., characteristics of physical activity, such as intensity) factors are
thought to be mutually inuential [82]. Also the transtheoretical
model [83], which includes 10 processes of change that are said to
drive peoples' progression through 5 stages of change (pre-contem-
plation, contemplation, preparation, action and maintenance), can
Fig. 1. Main benets of regular physical exercise. These apply particularly to aerobic exercise.
SPORT
EXERCISE
R
i
s
k
B
e
n
e
f
i
t
Resistance to change
low knowledge
Mental drive
high knowledge
Fig. 2. Schematic outline of the risk/benet balance of sport and exercise in the context
of life style changes. Note that in the athletic domain (SPORT) there is already a large
presence of willingness to engage in (strenuous) physical activity and knowledge of
how to do it, with an emphasis on competition. Conversely, in the patients' domain
(EXERCISE) physicians will have to manage resistance to change and lack of knowledge
of which physical activity should be best chosen to achieve health benets. Among less
recognized unfavorable social, cultural and environmental conditions we should also
consider the scarcity of focused resources, the diffuse non professionalism and
inaccurate information frequently provided by mass communication.
3 D. Lucini, M. Pagani / European Journal of Internal Medicine xxx (2011) xxxxxx
Please cite this article as: Lucini D, Pagani M, Exercise: Should it matter to internal medicine? Eur J Intern Med (2011), doi:10.1016/j.
ejim.2011.02.022
offer important suggestions to help patients to become physically
active.
To discuss with the patients about real benets that he/her may
get, about barriers and methods to overcome them, to set realist
exercise goals that make sense for him/her and are correct also from a
medical point of view, to clarify expectancies, to demonstrate that
exercise is a therapeutic/preventive tool synergistic with other more
traditional means such as drugs, represent and indispensable strategy
leading to a correct exercise prescription. The most recent ACSM
Clinician's Guide to exercise prescription [8] suggests that an effective
physician's counseling can be based on the three Ms: Mentioning
exercise on regular basis, at opportune times, when talking with
patients about a large variety of subjects; to be a Model for the patient
[84], speaking about personal exercise experience (benets, difcul-
ties and skills to overcome them, etc.); and Motivating patients. This
latter point is considered the most important step toward the
acquisition of behavior change; and it is dened by the ACSM Guide
[8] as a mental process that connects a thought or a feeling with an
action and requires that the patient takes (conscious) control of
the specic issues. The physician may play a Socratic, maieutic role,
guiding the patient through this process of choice (to dene why and
when to change behavior, to decide which kind of activity to engage
in, what goals to set, which skills are needed [79], etc.) offering not
only the possibility to realize it, but also the medical expertise
necessary to guarantee that the resulting behavior could actually be
therapeutic/preventive and tailored to patient's clinical condition,
without undue risks. Of particular importance may be the denition
of the main goal and the discussion about patients' expectations. If
the patient sets a too ambitious goal; or the dose of exercise he/she
can sustain is insufcient to reach it; or the goal considered by the
physician doing the exercise prescription is different from the
patient's one; the patient will relapse. A good example can be
provided by the patient's desire to signicantly lose weight. This goal
may be achieved only by high dose exercise, obtained increasing
markedly the intensity or duration of physical activity [9,25,29,85,86]
as compared to the amount of exercise usually prescribed [20] to
reduce cardiovascular, metabolic and all-cause mortality. It is highly
unlikely that a sedentary, overweight patient will sustain such a dose
of exercise; and the probability that he/she will drop out of an exercise
program, that should have been tailored in relation to his/her initial
level of cardiorespiratory tness and clinical condition is very high.
Consequently the patient will (erroneously) consider exercise
ineffective. Vice versa a good (albeit more gradual) counseling
process might show different benets (progressive increase in
cardiorespiratory tness, fatigue reduction while performing aerobic
exercise, etc.) and other tools, as change in diet behaviors that may
preserve patient's compliance, improve his/her clinical condition and
reach the initial goal. The rst result of a good motivating counseling
may be a mental immediate gratication that comes from taking
control, taking responsibility, realizing self-empowerment, and self-
efcacy, doing something new and different [8]. This may be the best
emotional milieu where a correct exercise prescription may lead to a
regular exercise behavior.
One of the simplest, practical methods to transform a general
discussion on exercise into a concrete patient's experience is, while
collecting medical history, to correctly estimate the dose of physical
activity performed and, hence, his/her exercise capacity. Obviously the
best way to determine the cardiorespiratory tness is to determine
VO
2max
by performing a cardiopulmonary test [20,48], but this is not
always possible for a variety of reasons (usually non-medical). The
simple quantication of the time spent every week walking (at least
10 min consecutive) or doing moderate or vigorous physical activities,
both for structured exercise and/or leisure-time physical activities,
could be a practical tool to verify if the patient performs enough (for
adult subjects: 150 min/week of moderate intensity or 75 min/
week vigorous intensity or 150 min/week moderate+vigorous)
physical activity, as indicated by the recent literature [5,29,47,87].
Moreover adhoc tables [47,88] may also be usedto estimate the amount
of accumulated METs. For instance if a subject walked at 3 mph on a at,
hard surface for 30 min, he would have accumulated about 99 MET min
of activity (3.3 MET30 min=99 MET min) [47]. Considering that light
exercise (e.g., walking slowly, household or occupational activities)
corresponds to less than 3 METs, moderate exercise (e.g., brisk walking,
dancing, bicycling on at, etc.) ranges from 3 to 6 METs and vigorous
exercise (e.g., jogging, running, swimming hard, etc.) corresponds more
than 6 METs, it is possible to estimate if the patient meets current
recommendation. The minimum goal should be in the range of 450 to
750 MET min wk
1
(for instance, moderate intensity aerobic physical
activity for a minimum of 30 min on 5 days each week, or vigorous
intensity aerobic physical activity for a minimum of 20 min on 3 days
every week) [47].
Collecting all the information necessary to estimate the dose of
physical activity requires a deep discussion with the patient regarding
his/her behavior; it requires to dene different level of activity
intensities, and to differentiate structured exercise from leisure-time
physical activities. This would be a good element of initial exercise
counseling. Moreover it could be useful also to complement
information on activity with parallel questions regarding the time
spent in sedentary behaviors, as ofce work, using personal computer
or other electronic devices, studying, watching TV, [8991] particu-
larly in childhood [25,73].
4. Exercise prescription
Considering the huge amount of evidence supporting that exercise
is benecial to health, international scientic communities [8,18,19]
indicate that it is both the role and the responsibility of a clinician to
prescribe exercise to patients who would benet from it, after a
tailored medical evaluation and, if the case [20,47], order pre-
exercising testing to determine the possible presence of health risks
when attempting regular exercise. Exercise prescription should be
developed with careful consideration of the individual's health status
(including medications), risk factor prole, behavioral characteristics,
personal goals and exercise preferences [7,20].
The components of exercise prescription follow a format similar
[8] to that of drug prescription: in this latter case the physician is used
to specify the name of the medication, strength or dose, frequency of
administration, route, rells and precautions; in exercise prescription
it is important to specify type, frequency, intensity and duration of
activity. Prescription for a sedentary patient begins at a minimal level,
then progresses to at least the minimum recommended level [7,20]
and nally may reach a level tailored to patient's needs, preferences
and characteristics in order to sustain and improve his/her health.
Exercise progression in an important part of the prescription, to
consider in addition to the denition of the prescribed dose of activity
[48].
ACSM and AHA Guidelines [20,47] recommend that to promote
and maintain health, all healthy adults aged 18 to 65 years need
moderate-intensity aerobic physical activity for a minimum of 30 min
on 5 days each week or vigorous-intensity aerobic physical activity for
a minimumof 20 min on 3 days each week. Combination of moderate-
and vigorous-intensity activity can be performed to meet this
recommendation [9,20,47]. In addition, every adult should perform
activities that maintain or increase muscular strength and endurance
for a minimumof 2 days each week [8,20,47,49]. Moreover, because of
the doseresponse relation between physical activity and health, to
exceed the minimum recommended amount of physical activity will
result in a further improvement of personal tness, reduction in risk
for chronic disease and disabilities [8,20,47]. Recommendation for
older subjects [92] is very similar to those for adults, although we
should emphasize some differences particularly related to recom-
mended intensity levels and the settled goals. However, the health
4 D. Lucini, M. Pagani / European Journal of Internal Medicine xxx (2011) xxxxxx
Please cite this article as: Lucini D, Pagani M, Exercise: Should it matter to internal medicine? Eur J Intern Med (2011), doi:10.1016/j.
ejim.2011.02.022
status, the presence of cardiovascular risk and the tness level, as
determinants, are sometimes more important than age.
Several recent studies [21,85,86,93] have clearly shown that high-
intensity aerobic interval training in healthy adults may prove more
benecial than traditional continuous exercise. This nding applies to
several metabolic, muscular and cardiovascular conditions. High-
intensity aerobic interval training consists in multiple short bouts
(usually 3 to 4 min in duration) of high-intensity activity (N85% of peak
oxygen uptake or peak heart rate) followed by approximately equal
periods of low-intensity activity. Of notable interest is the observation
[94] that this type of trainingseems to provide more benet also inheart
failure patients, even if this observation needs further conrmation in
consideration of the lesser safety of high-intensity exercise.
Type of exercise: much of the focus of exercise prescription is on
the cardiovascular (aerobic) component, being this one related to the
benets induced by exercise training both at moderate (safer and
easier to be performed) and at vigorous intensities. Nevertheless the
most recent guidelines recommend that patients include a resistance
training component [49] primarily for the increase in strength and in
muscle mass that may improve the individual's ability to become
more physically active, raise the basal metabolic rate and, especially in
older persons, improve quality of life.
Among aerobic activities, walking is the most common form of
physical activity that sedentary individuals can take on: it is familiar,
safe, cheap and it can easily be incorporated into daily life. However
many other types of aerobic activities may be chosen (see Table 3),
always considering patient's health status and his/her preferences.
Guidelines [8,20] recommend that patients choose more than one
activity that they enjoy to provide variety, to utilize different muscles,
to help prevent overuse injuries and to overcome weather barriers in
the case one activity (e.g. walking) should need to be performed
outside [8]. Moreover it is important that further to structured
exercise, patients consider to take advantage of every opportunity in
daily life in order to perform physical activity (e.g., take the stairs
instead of elevator, walk instead to drive, etc.) [9].
Intensity of exercise: (see Table 4) it represents the level of vigor at
which the activity is performed and may be dened by physiological
relative or absolute measures and by subjective measures. Absolute
intensity refers to the absolute expenditure of energy needed to
accomplish a given task and it is usually expressed in Metabolic
Equivalents (METs); one MET approximates the body's energy
requirements at complete rest, while 3.3 METs represent an exercise
intensity equivalent to 3.3 times the metabolic rate at rest. Relative
intensity refers to the percent of aerobic power utilized during
exercise and it is expressed as percent of VO
2max
. Considering the
(approximate) linear relationship between O
2
consumption and heart
rate [95], it is highly convenient in clinical setting to indicate the
exercise intensity using heart rate. The most accurate formulas [7,96]
consider the measured patient's basal and maximal heart rate
(Percent of HR
max
, heart rate reserve HRR) and are strongly preferable
in particular conditions, such as in cardiac patients or in patients
under medical treatment possibly affecting heart rate (e.g. beta
blockers). Other formulas consider standard (i.e. theoretical) values
and, even if easier to use, are less accurate (see Table 5). [8].
Depending on patient's clinical status, pharmacological treatment,
specic situation, the clinician will need to decide whether ease or
accuracy is more important. Subjective measures are the least
accurate measures of intensity, yet they are the easiest to obtain.
These measures have the advantage to be easily employed by the
patient during his/her exercise activity particularly if heart rate
monitoring devices are not available. The traditional subjective mea-
sure is represented by the Borg Rate of Perceived Exertion (RPE) [97]
Scale. This scale ranges froma minimumof 6 to a maximumof 20, and
it has been simplied [8] to a 10-point scale in which intensity
increases from a minimum (level 0) to a maximum (level 10). The
easiest (and less robust) subjective measure is the so called talk test
[8] that refers to the subject's capability to talk while performing
physical activity. Generally at moderate-intensity an individual is able
to talk but not to sing.
Duration of exercise: it refers to the length of time during which
the activity is performed. Generally bouts of exercise that last for at
least 10 min are added together to give a total time for a given day [8].
Guidelines [8,20,47] recommend a minimum of 30 min each day of
aerobic moderate-intensity activity that should preferably be per-
formed continuously. Old and/or unt patients may not sustain such
duration and in this case it is possible to start with 10 min bouts to be
repeated during the day until the set duration is achieved [98].
Frequency of exercise: it refers to the number of times the activity
is performed each week. Ideally exercise should be performed every
day, particularly if the chosen intensity is moderate; or in conditions
where more frequent training sessions of exercise are known to
produce greater benets such as in the case of glycemic control [27].
Dose of exercise: The term dose is used frequently in prescribing
physical activity, but it can be interpreted in several ways: as the total
amount of physical activity (i.e. total energy expended) or as its
intensity, duration, or frequency of activity [47]. Froma clinical point of
view, it is important to remember that the total amount of physical
activity is a combined function of its intensity, duration and frequency,
Table 3
Examples of type of physical activity (with associated intensity in METs) (modied from [8]).
Light b3 METs Moderate 36 METs VigorousN6 METs
Walking METs Walking METs Walking, jogging, running METs
Walking slowly 2

Walking (3.0 mph) 3.3

Walking at very, very brisk Pace (4.5 mph) 6.3

walking at very brisk pace (4 mph) 5.0

Jogging at 5 mph 8.0

Running at 7 mph 11.5

Household and occupation Household and occupation Household and occupation

Sitting, using computer 1.5 Cleaning-heavy 3.0 Shoveling sand, coal, etc. 7.0
Standing performing light work 2.02.5 Sweeping oors, vacuuming 3.03.5 Carrying heavy load such as bricks 7.5
Carrying and stacking wood 5.5
Leisure time and sports Leisure time and sports Leisure time and sports
Art and craft, playing cards 1.5 Basketball-shooting around 4.5 Basketball game 8.0
Fishing sitting 2.5 Bicycling-on at (1012 mph) 6.0 Bicycling on at: moderate Effort (1214 mph) 8.0
Playing most musical instruments 2.02.5 Dancing-ballroom slow 3.0 Skiing cross country slow (2.5 mph) 7.0
Dancing-ballroom fast 4.5 Soccer-casual 7.0
Swimming leisurely 6.0

Soccer-competitive 10.0
Volleyball noncompetitive 34 Swimming moderate-hard 811
On at, hard surface.

MET value can vary substantially from person to person during swimming as a result of different strokes and skills levels.
5 D. Lucini, M. Pagani / European Journal of Internal Medicine xxx (2011) xxxxxx
Please cite this article as: Lucini D, Pagani M, Exercise: Should it matter to internal medicine? Eur J Intern Med (2011), doi:10.1016/j.
ejim.2011.02.022
components that may be differently combined in the denition of the
progression of exercise [8,47].
Progression of exercise: there is a positive doseresponse
relationship between the amount of exercise performed and the
benets that are derived. Available data document that the minimum
amount of exercise necessary to obtain health benet is of 450750
METs min wk
1
, corresponding to about 1000 Kcal wk
1
[20,47,48].
How to combine intensity, frequency and duration in order to meet
this minimum goal, depends on patient's health status, tness level,
goals and preferences. The patient may reach the minimum
recommended level at the outset or he/she may need some time to
change the lifestyle, to nd time and mental room to engage in
exercise before realizing that exercise should be a regular activity of
day life [8]. A balance should be sought between giving patient time to
adjust and encouraging he/her to challenge him/herself to attain
goals. This progression can occur by increasing the duration, the
frequency, the intensity or a combination of these ones. There is no
single gold standard in setting the progression of these components;
the best option is to tailor the prescription according to patient's
characteristics. Recent ACSMguidelines [8,20] suggest in any case that
the patient should begins his/her programfor a duration that he/she is
condent with and that he/she can maintain at least 3 times per week
(frequency) at a low to moderate-intensity.
Resistance training: This aspect of physical activity is reempha-
sized by the American Heart Association that in a recent Scientic
Statement on Resistance Training [49] points out that prescribed and
supervised resistance training (RT) enhances muscular strength and
endurance, functional capacity and independence, and quality of life
while reducing disability in persons with and without cardiovascular
diseases. These benets may be obtained when the RT is performed
following safe modalities, tailored to individual's characteristics, with
particular attention to avoid high intensities and the Valsalva
maneuver (a forced expiration produced against a closed glottis)
[99]. In fact, excessive blood pressure elevations, produced by high
intensity RT, generally are not observed with low- to moderate-
intensity RT performed with correct breathing technique (exhaling
during the contraction or exertion phase of the lift and inhaling during
the relaxation phase) [99].
A key point at the initial stages of RT is to allow sufcient time for
musculoskeletal adaptation to occur and to become procient in the
practice of good techniques, thus reducing the likelihood of excessive
subsequent muscle soreness and injury. The initial resistance or
weight load should be set at a moderate level that permits one to
achieve the prescribed repetition range without straining [49]. It is
recommended that 810 repetitions be performed on 2 or more non-
consecutive days each week using the major muscle groups
[8,20,47,49]; this format may be modied according to individual's
improved tness and needs, considering that a lower repetition range
with a heavier weight may better optimize strength and power,
whereas a higher repetition range with a lighter weight may better
enhance muscular endurance; using weight loads that permit 8 to 15
repetitions will generally facilitate improvements in muscular
strength and endurance [49].
5. Conclusions
We can conclude saying that the evidence favoring the introduc-
tion of exercise into clinical practice is irrefutable. Consequently we
may agree with the statement that it should be considered now an
imperative of clinical prevention that all patients understand the risks
of a sedentary life and that exercise is important in treating and
preventing chronic diseases [18]. We believe that a synergistic
approach to exercise and sport (Fig. 2) might suggest a key role for
the internal medicine paradigm that takes advantage of its holistic
approach and capacity of governing multidisciplinary integration. In
the context of the numerous organizational and cultural changes that
will be necessary to achieve the goal of introducing exercise into
everyday clinical practice [6,9], we should consider the strategic role
of physicians' competence and acquisition of a role model in
supporting patients in their life style changes.
6. Learning points
Regular physical exercise is now considered a preventive and
therapeutic strategy for a wide array of chronic diseases. The
evidence favoring the introduction of exercise into clinical practice
is irrefutable.
It is both the role and the responsibility of a clinician to prescribe
exercise to patients who would benet from it, after a tailored
medical evaluation. If deemed necessary, clinician should order
appropriate pre-exercise tests to determine the possible presence of
health risks when attempting regular exercise.
In order to prescribe a safe and efcacious physical exercise
adequate competence and skills are needed.
All healthy adults aged 18 to 65 years need moderate-intensity
aerobic physical activity for a minimum of 30 min on 5 days each
week or vigorous-intensity aerobic physical activity for a minimum
Table 4
Measure of exercise intensity (Adapted from [48]).
Subjective measures Physiological/relative measures Absolute measure METS
Intensity Talk test Perceived exertion
(Borg scale)
%HRR VO
2Max
(%)
Maximal HR
(%)
Young
(2029 years)
Adults
(4064 years)
Olds
(6579 years)
Light Able to talk and/or sing b11 b39 b54 b4.7 b3.9 b3.1
Moderate Able to talk but not to sing 1213 4059 5569 4.87.1 45.9 3.24.7
Vigorous Difculty talking 1416 6084 7089 7.210.1 6.08.4 4.86.7
Very vigorous Great difculty talking 1719 85 90 10.2 8.5 6.8
Maximum

Unable to talk 20 100 100 12.0 10 8.0

METs = metabolic equivalent units; HRR = heart rate reserve;
Maximum values are mean values achieved during maximum exercise by healthy adults. Absolute intensity values are approximate mean values for men. Mean values for
women are; 1 to 2 METs lower than those for men.
Table 5
Nominal heart rate ranges for intensity exercise. (Adapted from [20]).
Age Low intensity
(b64% HR
Max
)
Moderate intensity
(b64%76% HR
Max
)
Vigorous intensity
(N76% HR
Max
)
HR
Max
20 b124 124147 N147 194
30 b120 120142 N142 187
40 b115 115137 N137 180
50 b111 111132 N132 173
60 b107 107127 N127 167
70 b102 102122 N122 160
80 b98 98117 N117 153
Reported ranges are calculated using the formula: [206.9(0.67age)] x% HR
Max
.
A simple, but less accurate, formula to calculate HR
Max
is (220age).
6 D. Lucini, M. Pagani / European Journal of Internal Medicine xxx (2011) xxxxxx
Please cite this article as: Lucini D, Pagani M, Exercise: Should it matter to internal medicine? Eur J Intern Med (2011), doi:10.1016/j.
ejim.2011.02.022
of 20 min on 3 days each week. Combination of moderate- and
vigorous-intensity activity can be performed to meet this recom-
mendation. In addition, every adult should perform activities that
maintain or increase muscular strength and endurance for a
minimum of 2 days each week.
For exercise prescription, it is important to specify type, frequency,
intensity and duration of activity. Prescription for a sedentary patient
begins at a minimal level, then progresses to at least the mini-
mum recommended level and nally may reach a level tailored to
patient's needs, preferences and characteristics in order to sustain
and improve his/her health prole.
7. Conict of interest
None.
References
[1] Mancia G, Laurent S, Agabiti-Rosei E, Ambrosioni E, Burnier M, Cauleld MJ, et al.
Reappraisal of European guidelines on hypertension management: a European
Society of hypertension task force document. J Hypertens 2009;27:212158.
[2] D'Agostino RB, Vasan RS, Pencina MJ, Wolf A, Cobain M, Massaro MJ, et al. General
cardiovascular risk prole for use in primary care the Framingham heart study.
Circulation 2008;117:74353.
[3] Grundy SM, Bazzarre T, Cleeman J, D'Agostino RB, Hill M, Houston-Miller N, et al.
Prevention Conference V beyond secondary prevention: identifying the high-
risk patient for primary prevention medical ofce assessment. Circulation
2000;101:1116.
[4] Graham I, Atar D, Borch-Johsen K, Boysen G, Burell G, Cifkova R, et al. European
guidelines on cardiovascular disease prevention in clinical practice: executive
summary Fourth Joint Task Force of the European Society of Cardiology and
other Societies on cardiovascular disease prevention in clinical practice (Consti-
tuted by representatives of nine societies and by invited experts). Eur J Cardiovasc
Prev Rehabil 2007;14:E1E40.
[5] Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, et al.
Dening and setting national goals for cardiovascular health promotion and
disease reduction. The American Heart Association's strategies impact goal
through 2020 and beyond. Circulation 2010;121:586613.
[6] Capewell S, Lloyd-Jones DM. Optimal cardiovascular prevention strategies for the
21st century. JAMA 2010;304:20578.
[7] ACSM'S guidelines for exercise and prescription. 7th Edition. Lippincott Williams &
Wilkins; 2005.
[8] Jonas S, Phillips EM. ACSM's exercise is medicine. Wolters Kluver Lippincott
Williams & Wilkins; 2009.
[9] Bess HM, Williams DM, Dubbert PM, Sallis JF, King AC, Yancey AK, et al. Physical
activity intervention study:what we know and what we need to know: a scientic
statement from the American Heart Association Council on Nutrition, physical
activity, and metabolism (Subcommittee on Physical Activity); Council on
Cardiovascular Disease in the Young; and the Interdisciplinary Working Group
on Quality of Care and Outcomes Research. Circulation 2006;114:273952.
[10] Manson JAE, Greenland P, Vanitallie TB. The escalating pandemics of obesity and
sedentary lifestyle a call to action for clinicians. Arch Int Med 2004;164:24958.
[11] Elley CR, Kerse N, Arroll B, Robinson E. Effectiveness of counseling in patients on
physical activity in general practice: cluster randomized controlled trial. BMJ
2003;326:7939.
[12] Murphy AW, Cupples ME, Smith SM, Byrne M, Byrne MC, Newell J. Effect of
tailored practice and patient care plans on secondary prevention on heart disease
in genral practice: cluster randomized controlled trial. BMJ 2009;339:b4220.
[13] Koelewijin-van Loon MS, van der Weijden T, van Steenkiste B, Ronda G, Winkens
B, Severens JL, et al. Involving patients in cardiovascular risk management with
nurse-led clinics: a cluster randomized controlled trial. CMAJ 2009;181:E26774.
[14] Stamatakis E, Weiler R. Prevention of cardiovascular disease: why do we neglect
the most potent intervention. Heart 2010;96:2612.
[15] Gupta K, Fan L. Doctors: ghting t or couch potatoes? Br J Sports Med 2009;43:1534.
[16] Jones WH. Hippocrates. Cambridge: Harvard University Press; 1952.
[17] Shephard RJ, Balady GJ. Exercise as cardiovascular therapy. Circulation 1999;99:
96372.
[18] Sallis RE. Exercise is medicine and physicians need to prescribe it. Br J Sports Med
2009;43:34.
[19] Exercise is medicine. www.exerciseismedicine.org.
[20] ACSM's guidelines for exercise testing and prescription. 8th Edition. Philadelphia
(PA): Lippincott Williams & Wilkins; 2009.
[21] Kokkinos P, Myers J. Exercise and physical activity clinical outcomes and
applications. Circulation 2010;122:163748.
[22] Yusuf S, Hawken S, unpuu S, Dans T, AvezumA, Lanas F, et al. Effect of potentially
modiable risk factors associated with myocardial infarction in 52 countries (the
INTERHEART study): case control study. Lancet 2004;364:93752.
[23] Pescatello LS, Franklin BA, Fagard R, Farquhar WB, Elley GA, Ray CA. American
College of Sports medicine position stand: exercise and hypertension. http://
www.acsm-msse.org/pt/pt-core/template/msse/media/034.pdf2006.
[24] Hu G, Nol C, Barengo NC, Tuomilehto J, Lakka TA, Nissinen A, et al. Relationship of
physical activity and body mass index to the risk of hypertension: a prospective
study in Finland. Hypertension 2004;43:2530.
[25] Farpour-Lambert NJ, Aggoun Y, Marchand LM, Martin XE, Herrmann FR, Beghetti
M. Physical activity reduces systemic blood pressure and improves early markers
of atherosclerosis in pre-pubertal obese children. J Am Coll Cardiol 2009;54:
2396406.
[26] Finucane FM, Sharp SJ, Purslow LR, Horton K, Horton J, Savage DB, et al. The effects
of aerobic exercise on metabolic risk, insulin sansitivity and intrahepatic lipid in
healthy older people from the Hertfordshire Cohort Study: a randomised
controlled trial. Diabetologia 2010;53:62431.
[27] Marwick T, Hordern MD, Miller T, Chyun DA, Bertoni AG, Blumenthal RS, et al. Exercise
training for type 2 diabetes mellitus impact on cardiovascular risk a scientic
statement from the American Heart Association. Circulation 2009;119:324462.
[28] Vuori IM. Doseresponse of physical activity and lowback pain, osteoarthritis, and
osteoporosis. Med Sci Sports Exerc 2001;33:S55186.
[29] I-Min Lee, Djouss L, Sesso HD, et al. Physical activity and weight gain prevention.
JAMA 2010;303:11739.
[30] Holmes MD, Chen WY, Feskanich D, Kroenke CH, Colditz GA. Physical activity and
survival after breast cancer diagnosis. JAMA 2005;293:2479.
[31] Slattery ML, Potier JC. Physical activity and colon cancer: confounding or
interaction? Med Sci Sports Exerc 2002;34:9139.
[32] Pedersen Bk, Saltin B. Evidence for prescribing exercise as therapy in chronic
disease. Scand J Med Sci Sports 2006;16:363.
[33] Garg PK, Kiang L, Tian L, Guralnik JM, Ferricci L, Criqui MH, et al. Physical activity
during daily life and functional decline in peripheral arterial disease. Circulation
2009;119:25160.
[34] Herring MP, O'Connor PJ, Dishman RK. The effect of exercise training on anxiety
symptoms among patients. Arch Int Med 2010;170:32131.
[35] Brosse AI, Sheets ES, Lett HS, Blumenthal JA. Exercise and the treatment of clinical
depression in adults: recent ndings an future directions. Sports Med 2002;32:
74160.
[36] Yates LB, Djouss L, Kurth T, Buring JE, Gaziano JM. Exceptional longevity in men.
Modiable factors associated with survival and function to age 90 years. Arch Int
Med 2008;168:28490.
[37] Sun Q, Townsend MK, Okerke OI, Franco OH, Hu FB, Grodstein F. Physical activity
at midlife in relation to successful survival in women at age 70 years or older. Arch
Int Med 2010;170:194201.
[38] Werner C, Frster T, Widmann T, Pss J, Roggia C, Hanhoun M, et al. Physical
exercise prevents cellular senescence in circulating leukocytes and in the vessel
wall. Circulation 2009;120:243847.
[39] Dechamps A, Diolez P, Thiaudiere E, Tulon A, Onifade C, Vuong T, et al. Effects of
exercise programs to prevent decline in health-related quality of life in highly
deconditioned institutionalized elderly persons. Arch Int Med 2010;170:1629.
[40] berg MAI, Pedersen NL, Torn K, Svartengren M, Bckstrand B, Johnsson T, et al.
Cardiovascular tness is associated with cognition in young adulthood. PNAS
2009;106:2090611.
[41] Etgen T, Sander D, Huntgeburth U, Poppert H, Frstl H, Bickel H. Physical activity
and incident cognitive impairment in elderly persons. Arch Int Med 2010;170:
18693.
[42] Phillips AC, Burns VE, Lord JM. Stress and exercise getting the balance right for
aging immunity. Exerc Sport Sci Rev 2007;35:359.
[43] Myers J, Prakash M, Froelicher VF, Partington S, Atwood JE. Exercise capaciy and
mortality among men referred for exercise testing. N Engl J Med 2002;346:
793801.
[44] Barengo NC, Hu G, Lakka TA, Pekkarinen H, Nissinen A, Tuomilehto J. Low physical
activity as a predictor for total and cardiovascular disease mortality in middle-
aged men and women in Finland. Eur Heart J 2004;25:220411.
[45] Kokkinos P, Myers J, Faselis C, Demosthenes B, Panagiotakos B, Doumas M, et al.
Exercise capacity and mortality in older men. A 20-year follow-up study.
Circulation 2010;122:7907.
[46] Kodama A, Kazumi S, Tanaka S, Maki M, Yachi Y, Asumi M, et al. Cardiorespiratory
tness as a quantitative predictor of all-cause mortality and cardiovascular events
in healthy men and womena meta analysis. JAMA 2009;301:202435.
[47] Haskell WL, Lee I-Min, Pate RR, Powel KE, Blair SN, Franklin BA, et al. Physical
activity and public health. Updated recommendation for adults fromthe American
College of Sports Medicine and the American Heart Association. Circulation
2007;116:108193.
[48] Fletcher G, Balady G, Amsterdam EA, Chaitman B, Eckel R, Fleg J, et al. Exercise
standards for testing and training a statement for healthcare professionals from
the American Heart Association. Circulation 2001;104:1694740.
[49] Williams MA, Haskell W, Ades PA, Amsterdam EA, Bittner V, Franklin BA, et al.
Resistance exercise in individuals with and without cardiovascular disease: 2007
update. Circulation 2007;116:57284.
[50] De Backer GG, De Bacquer D. Be physically active: the best buy in promoting heart
health. Eur Heart J 2004;25:21834.
[51] Kujala UM, Kaprio J, et al. Relationship of leisure-time physical activity and
mortality: the Finnish twin cohort. JAMA 1998;279:4404.
[52] Willet WC. Balancing life-style and genomics research for disease prevention.
Science 2002;296:695.
[53] Tall AR. Exercise to reduce cardiovascular risk how much is enough? N Engl J
Med 2002;347:15224.
[54] Pagani M, Somers VK, Furlan R, Dell'Orto S, Conway J, Baselli G, et al. Changes in
autonomic regulation induced by physical training in mild hypertension.
Hypertension 1988;12:60010.
7 D. Lucini, M. Pagani / European Journal of Internal Medicine xxx (2011) xxxxxx
Please cite this article as: Lucini D, Pagani M, Exercise: Should it matter to internal medicine? Eur J Intern Med (2011), doi:10.1016/j.
ejim.2011.02.022
[55] Blumenthal JA, Babyak MA, Hinderlitter A, Watkins LL, Craighead L, Lin Pao-Hwa,
et al. Effects of the DASH diet alone and in combination with exercise and weight
loss on blood pressure and cardiovascular biomarkers in men and women with
high blood pressure. Arch Int Med 2010;170:12635.
[56] Stratton JR, Chandler WL, Schwartz RS, et al. Effects of physical conditioning on
brinolytic variables and brinogen in young and old healthy adults. Circulation
1991;83:16927.
[57] Kestin AS, Elleis PA, Barnard MR, et al. Effects of strenous exercise on platelet
activation state and reactivity. Circulation 1993;88:150211.
[58] Abramson JL, Vaccarino V. Relationship between physical activity and inamma-
tion among apparently healthy middle-aged and older US adults. Arch Int Med
2002;162:128692.
[59] Hambrecht R, Wolf A, Gielen S, et al. Effects of exercise on coronary endothelial
function in patients with coronary artery disease. N Engl J Med 2000;342:45460.
[60] Kim SH, Lee SJ, Kang ES, Hurr KY, Lee HJ, Ahn CW, et al. Effects of lifestyle
modication on metabolic parameters and carotid intima-media thickness in
patients with type 2 diabetes mellitus. Metabolism 2006;55:10539.
[61] Oliveria SA, Christos PJ. The epidemiology of physical activity and cancer. Ann NY
Acad Sci 1997;833:7990.
[62] Smith JK, Dykes R, Douglas JE, et al. Long term exercise and atherogenic activity of
blood mononuclear cells in pesons at risk of developing ischemic heart disease.
JAMA 1999;218:17227.
[63] Albert MA, Glynn RJ, Ridker PM. Effect of physical activity on serum C-reactive
protein. Am J Cardiol 2004;93:2215.
[64] Ll Ji, Fu R. Responses of glutathione systemand antioxidant enzymes to exhaustive
exercise and hydroperoxide. J Appl Physiol 1992;72:54954.
[65] Colcombe SJ, et al. Cardiovascular tness, cortical plasticity, and aging. Proc Natl
Acad Sci U S A 2004;101:331621.
[66] Cotman CW, Berchtold NC, Christie LA. Exercise builds brain health: key roles of
growth factor cascades and inammation. Trends Neurosci 2007;30:46472.
[67] Schwarz AJ, Brasel JA, Hintz RL, Mohan S, Cooper DM. Acute effect of brief low and
high-intensity exercise on circulating insulin-like growth factor (GF) I, II, and IGF-
binding protein-3 andits proteolysis in young healthy men. J Clin Endocrinol
Metab 1996;81:34927.
[68] Davis CL, et al. Effects of aerobic exercise on overweight children's cognitive
functioning: a randomized controlled trial. Res Q Exerc Sport 2007;78:5109.
[69] La Rovere MT, Bigger JT, Marcus FI, Mortara A, Schwartz PJ. Baroreex sensitivity
and heart-rate variability in prediction of total cardiac mortality after myocardial
infarction: ATRAMI (Autonomic Tone and Reexes after Myocardial Infarction).
Lancet 1998;351:47884.
[70] Iellamo F, Legramante JM, Massaro M, Raimondi G, Galante A. Effects of a
residential exercise training on baroreex sensitivity and heart rate variability in
patients with coronary artery disease. A randomized controlled study. Circulation
2000;102:258892.
[71] Lucini D, Milani RV, Costantino G, Lavie CJ, Porta A, Pagani M. Effects of cardiac
rehabilitation and exercise training on autonomic regulation in patients with
coronary artery disease. Am Heart J 2002;143:97783.
[72] Pagani M, Lucini D. Can autonomic monitoring predict results in distance runners.
Am J Physiol Heart Circ Physiol 2009;296:17212.
[73] Genovesi S, Pieruzzi F, Giussani M, Tono V, Stella A, Porta A, et al. Analysis of heart
period and arterial pressure variability in childhood hypertension key role of
baroreex impairment. Hypertension 2009;51:128994.
[74] Pagani M, Pizzinelli P, Beltrami S, Massaro M, Lucini D, Iellamo F. Baroreex and
metaboreex control of cardiovascular system during exercise in space. Respir
Physiol Neurobiol 2009;169S:S425.
[75] Loimaala A, Huikuri HV, Kbi T, Rinne M, Nenonen A, Vuori I. Exercise training
improves baroreex sensitivity in type 2 diabetes. Diabetes 2003;52:183742.
[76] Braunwald E, Zipes DP, Libby P. Heart disease a text book of cardiovascular medicine.
6th edition edn. Phyladelphia, Pennsylvania: W.B.Saunders Company; 2001.
[77] Thompson PD, Franklin BA, Balady GJ, Blair SN, Corrado D, Estes MNA, et al.
Exercise and acute cardiovascular events. Placing the risks into perspective. A
scientic statement from the American Heart Association Council on nutrition,
physical activity, and metabolism and the Council on Clinical Cardiology.
Circulation 2007;115:235868.
[78] Iellamo F, Legramante JM, Pigozzi F, Spataro A, Norbiato G, Lucini D, et al.
Conversion from vagal to sympathetic predominance with strenuous training in
high-performance world class athletes. Circulation 2002;105:271924.
[79] Artinian NT, Fletcher GF, Mozaffarian D, Kris-Etherton P, Van Horn L, Lichtenstein
AH, et al. Interventions to promote physical activity and dietary lifestyle changes
for cardiovasculr risk factor reduction in adults a scientic statement from the
American Heart Association. Circulation 2010;122:40641.
[80] Rotter JB. Social learning and clinical psychology. New York, NY: Prentice-Hall;
1954.
[81] Bandura A. Self-efcacy: the exercise of control. NewYork, NY: WHFreeman & Co;
1997.
[82] Bandura A. Social foundation of thought and action: a social cognitive theory.
Englewood Cliffs, NJ: Prtentice-Hall; 1986.
[83] Prochaska J, Di Clemente C. Transtheoretical therapy, toward a more integrative
model of change. Psych Theory Res Pract 1982;19:27688.
[84] Beckman TJ. Prescribing exercise: is your physician's head in the game? Arch Int
Med 2004;164:20667.
[85] Slentz CA, Duscha BD, Johnson JL, Ketchum K, Aiken LB, Samsa GP, et al. Effects of
the amount of exercise on body weight, body composition, and measures of
central obesity. Arch Int Med 2004;164:319.
[86] Ades PA, Savage PD, Toth MJ, Harvey-Berino J, Schneider DJ, Bunn JY, et al. High-
calorie-expenditure exercise a new approach to cardiac rehabilitation for
overweight coronary patients. Circulation 2009;119:26718.
[87] Craig CL, Marshall AL, Sjstrm M, Bauman AE, Booth ML, Ainsworth BE, et al.
International physical activity questionnaire: 12-country reliability and validity.
Med Sci Sports Exerc 2003;35:138195.
[88] Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz AM, Strath SJ, et al.
Compendium of physical activities: an update of activity codes and MET
intensities. Med Sci Sports Exerc 2000;32:S498516.
[89] Beunza JJ, Martinez-Gonzalez MA, Ebrahim S, Bes-Rastrollo M, Nuez J, Martinez
JA, et al. Sedentary behaviors and the risk of incident hypertension. Am J
Hypertens 2007;20:115662.
[90] Laaksonen DE, Lakka H-M, Salonen JT, Niskanen L, Rauramaa R, Lakka TA. Low
levels of leisure-time physical activity and cardiorespiratory tness predict
development of the metabolic syndrome. Diabetes Care 2002;25:16128.
[91] Ferretti G, Pizzinelli P, Iellamo F, Aquilani S, Kenfack MA, Lador F, et al. Prolonged
head down bed rest-induced inactivity impairs tonic autonomic regulation while
sparing oscillatory cardiovascular rhythms in healthy humans. J Hypertens
2009;27:55161.
[92] Nelson ME, Rejeski JW, Blair SN, Duncan PW, Judge JO, King AC, et al. Physical
activity and public health in older adults recommendation from the American
College of Sport Medicine and the American Heart Association. Circulation
2007;116:1094105.
[93] Nemote K, Gen-no H, Masuki S, Okazaki K, Nose H. Effects of high intensity interval
walking training on physical rness and blood pressure in middle-aged and older
people. Mayo Clin Proc 2007;82:80311.
[94] Wisloff U, Stoylen A, Loennechen JP, Bruvold M, Rognmo O, Haram PM, et al.
Superior cardiovascular effect of aerobic interval training versus moderate
continuous training in heart failure patients: a randomized study. Circulation
2007;115:308694.
[95] Londeree BR, Ames SA. Trend analysis of the % VO2 max-HR regression. Med Sci
Sports 1976;8:1235.
[96] Karvonen M, Kentala K, Mustala O. The effects of training on heart rate: a
longitudinal study. Ann Med Exp Biol Fenn 1957;35:30715.
[97] Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc
1982;14:37781.
[98] Thompson PD, Buchner D, Pina IL, Balady GJ, Williams MA, Marcus BH, et al.
Exercise and physical activity in the prevention and treatment of atherosclerotic
cardiovascular disease: a statement from the Council on Clinical Cardiology
(Subcommittee on Exercise, Rehabilitation and Prevention) and the Council on
Nutrition, Physical Activity, and Metabolism (Subcommittee of Physical Activity).
Circulation 2003;107:310916.
[99] McCartney N. Acute responses to resistance training and safety. Med Sci Sports
Exerc 1999;31:317.
8 D. Lucini, M. Pagani / European Journal of Internal Medicine xxx (2011) xxxxxx
Please cite this article as: Lucini D, Pagani M, Exercise: Should it matter to internal medicine? Eur J Intern Med (2011), doi:10.1016/j.
ejim.2011.02.022