Professional Documents
Culture Documents
Morrison, BHK,
Hamed Nazzari, MD, PhD, Saul H. Isserow, MBBCh, Brett Heilbron, MB ChB,
Andrew D. Krahn, MD
A
ABSTRACT: The benefits of physical diseases, it is imperative that we en- ncient philosophers and phy
activity are plentiful and significant. courage regular physical exercise for sicians such as Plato and Hip
High levels of physical activity and optimal health. The benefits of phys- pocrates believed in the rela
cardiorespiratory fitness (referred ical activity exhibit a dose-response tionship between physical activity and
to simply as “fitness” in this article) relationship; the higher the amount health, and the lack of physical activity
are associated with lower all-cause of physical activity, the greater the and disease. However, by the mid-20th
and cardiovascular mortality. Fur- health benefits. However, the most century it was believed that physical
thermore, physical activity can re- unfit individuals have the potential activity might be harmful to health.
duce the development of chronic for the greatest reduction in risk, Moreover, the recommended treat
diseases such as hypertension, dia- even with small increases in physi- ment of the time after myocardial in
betes, stroke, and cancer. Addition- cal activity. Given the significant farction was complete bed rest. It was
ally, physical activity can promote health benefits afforded by physical not until landmark epidemiological
healthy cognitive and psychosocial activity, considerable efforts should studies in the 1950s that physical in
function. An extensive effort to as- be made to promote this vital agent activity was associated with increased
certain the benefits from the current of health. risk of coronary heart disease (CHD).
Canadian physical activity guide- Dr Jeremy Morris examined the differ
lines on all-cause mortality and sev- ences in CHD incidence between two
en chronic diseases suggests that groups of men working on London’s
the current recommendation for at double-decker buses: the drivers, who
least 150 minutes of moderate-to- were sedentary (sitting for more than
vigorous aerobic physical activity
per week in sessions of 10 minutes Dr McKinney is a fellow at UBC Hospital Isserow is co-founder and medical direc-
or more is associated with a 20% to and is completing a sports cardiology fel- tor of SportsCardiologyBC and director of
30% lower risk for premature all- lowship at SportsCardiologyBC. Mr Lith- cardiology services at both UBC Hospital
cause mortality and incidence of wick is a project and research coordinator and the Centre for Cardiovascular Health
many chronic diseases. Because the at SportsCardiologyBC and has completed at Vancouver General Hospital. Dr Heilbron
health benefits of activity have been a master’s degree in health administration is a cardiologist at SportsCardiologyBC and
established and physical inactivity at UBC. Ms Morrison is a project and re- a clinical assistant professor in the Division
is a modifiable risk factor central search coordinator at SportsCardiologyBC of Cardiology at UBC. Dr Krahn is a profes-
to the development of many chronic and is completing a master’s degree in ex- sor of medicine and head of the Division of
perimental medicine at UBC. Dr Nazzari is Cardiology at UBC.
This article has been peer reviewed. a resident in internal medicine at UBC. Dr
90% of their shifts), and the conduc Physical activity and activity patterns.
tors, who were physically active primary prevention of The relationship of fitness to all-
(climbing roughly 500 to 750 steps a all-cause mortality cause mortality was examined in the
day). Despite coming from similar so Contemporary studies have consis Aerobics Center Longitudinal Study4
cial classes, the physically active con tently demonstrated the inverse rela of 13 344 healthy people. The sub
ductors had lower rates of CHD than tionship between physical activity jects included in the study had no
the physically inactive drivers (overall and rates for allcause mortality and personal history of MI, hypertension,
annual incidence of 1.9/1000 for con cardiovascular death (CVD).24 Physi diabetes, or stroke, and no resting
ductors versus 2.7/1000 for drivers). cal activity is an important determi or stressinduced electrocardiogram
Furthermore, sudden cardiac death nant of cardiorespiratory fitness4 and (ECG) changes. They were required
(SCD) occurred less often in conduc fitness is related to physical activity to complete an exercise treadmill test
tors than drivers (0.5/1000 versus patterns.5 While physical activity can (ETT) to establish their fitness lev-
1.1/1000), and the conductors’ CHD be difficult to estimate, fitness can be el. After 8 years of followup, those
were more likely to manifest as angi assessed readily using the metabolic subjects in the lowest quintile of fit-
na than SCD. Similarly, it was shown equivalent task (MET) to provide an ness compared to those in the highest
that physically active postal work objective measure of a subject’s fit- quintile had a relative risk (RR) all
ers had lower rates of incident CHD ness.4 (See Box for a definition of cause mortality rate of 3.44 for men
and SCD than their less active co MET and other fitness-related terms and 4.65 for women. Additionally,
workers.1 Based on these findings, used in this article.) Although deter the RR for CVD in the least fit men
Morris and colleagues postulated that minants of cardiorespiratory fitness and women compared with the most
physically active work offered a pro include age, sex, health status, and fit was 8.0. Even after adjusting for
tective effect, predominantly related genetics, the principal determinant age, cholesterol level, blood pressure,
to sudden cardiac death as a first man- is habitual physical activity lev smoking, fasting blood glucose, and
ifestation of disease. These observa els. Thus, cardiorespiratory fitness family history of CHD, the findings
tions were the first formal studies (referred to simply as “fitness” in this were consistent for men and women.
to link physical inactivity and heart article) can be used as an objective
disease. surrogate measure of recent physical How much physical activity
is enough?
The greatest reduction in allcause
mortality occurs between the least
fit and the next-to-least fit group.35
Risk for chronic disease and
Cardiorespiratory fitness: The ability to One MET is defined as the amount of oxygen or Light-intensity physical activity: Has only
transport and use oxygen during prolonged, calories consumed while sitting quietly— minor effects on heart and breathing rates.
strenuous exercise or work. Reflects the 1 MET = 3.5 mL O2 per kg per minute or 1 kcal Measured as 1.6 to < 3 METs.
combined efficiency of the lungs, heart, (4.2 kJ) per kg per hour.
vascular system, and muscles in the transport Moderate-intensity physical activity:
and use of oxygen. Physical activity: Any bodily movement Increases heart and breathing rate to 50.0%
produced by skeletal muscles that results in to 70.0% of maximum. Energy requirement
Exercise: Structured and repetitive physical energy expenditure. By comparison, physical can usually be met by aerobic metabolism
activity designed to maintain or improve fitness depicts the capacity to achieve a using the body’s stores of glycogen and then
physical fitness. Often incorporates aerobic certain performance standard or trait. fats. Measured as 3 to < 6 METs.
activities that are rhythmic in nature and use
large muscle groups at moderate intensities Physical inactivity (or sedentary activity): Vigorous-intensity physical activity:
for 3 to 5 days per week for at least 10 minutes Involves no noticeable effort. Heart and Increases heart and breathing rates to
at a time (e.g., walking, bicycling, jogging). breathing rates are not raised perceptibly > 70.0% of their maximum. Anaerobic
above resting levels. Requires < 40.0% metabolism is needed to provide energy.
Metabolic equivalent task (MET): A measure maximum heart rate. Measured as 1.0 to 1.6 Measured as ≥ 6 METs.
of energy expended during physical activity. METs.
of activity (i.e., moderate or vigor mia and slightly reduce diabetic com Stroke
ous intensity rather than light inten plications, but cannot eliminate all the Stroke is the third leading cause of
sity).8 A summary of risk reduction adverse consequences and have had death in Canada, where 5.5% of all
in physically active subjects is shown limited success at reducing macrovas deaths are due to cerebrovascular dis
in Figure 2 .8,10,11 cular complications.16 Since current eases. 17 Physically inactive people
have a significantly elevated stroke
risk (RR 1.60).18 In a systematic
review, high levels of physical activ
ity were associated with a 31% risk
Efforts should be made to target the reduction. The reduced risk of stroke
is seen in both men and women, and
least fit (the physically inactive) because it appears that this benefit may be
slight increases in activity can mean present for both ischemic and hemor
rhagic stroke.19
significant gains in health status.
Cancer
Cancer is now the leading cause of
death among Canadians, accounting
for 29.9% of all deaths (more than MI
Hypertension methods for treating diabetes remain and stroke combined).17 Population
Hypertension is the most common inadequate, prevention of the disease studies from the 1980s have identi
risk factor for heart disease, stroke, is preferable.16 fied an increased risk of developing
and renal disease and has been identi A randomized controlled trial cancer among physically inactive
fied as a leading cause of mortality.12 sought to determine whether lifestyle people.4,20 In the NHANES I survey,
In a recent meta-analysis of 13 pro intervention or treatment with metfor physical inactivity was associated
spective cohort studies, high-level min would prevent or delay the onset with a relative risk of 1.8 for men and
recreational physical activity was of diabetes in patients with impaired 1.3 for women compared with their
associated with decreased risk of fasting glucose levels. Participants physically active counterparts.20 Mul
developing hypertension when sub assigned to the intensive lifestyle tiple studies provide compelling evi
jects were compared to a reference intervention were able to achieve dence that high physical fitness levels
group with low-level physical activity and maintain a reduction of at least are associated with a reduced risk of
(RR 0.81).13 In another meta-analysis 7% of initial body weight through a developing and dying from cancer. A
that included 30 studies involving healthy low-calorie, low-fat diet and recent meta-analysis confirmed that
patients with existing hypertension, to engage in moderate-intensity phys fitness is inversely related to cancer
aerobic endurance training was shown ical activity such as brisk walking for mortality: individuals with high car
to reduce blood pressure by 6.9/4.9 at least 150 minutes per week. When diorespiratory fitness levels had a
mm Hg.14 compared with placebo, the lifestyle 45% reduced risk of total cancer mor
intervention reduced the incidence of tality (RR 0.55) when compared with
Diabetes diabetes by 58% and the metformin their unfit peers, independent of adi
Type 2 diabetes is a worldwide prob intervention reduced the incidence by posity.21
lem with significant health, social, 31%.16 This translates into a number Cancer, like CHD, is also pre
and economic implications. Diabe needed to treat (NTT) of 7 for the life ventable to some extent and shares
tes results from a complex interplay style intervention and 14 for the met several common risk factors such as
of environmental and genetic com formin when attempting to prevent poor nutrition, obesity, inflammation,
ponents. There is strong evidence one case of diabetes over a 3-year and physical inactivity. Improve
that such modifiable risk factors as period. Thus, physical activity repre ments in some of these risk factors
obesity and physical inactivity are sents a major public health opportuni with regular exercise might explain
the main nongenetic determinants of ty to reduce the cost of a major source the cancer mortality benefits seen
the disease.15 Current diabetes treat of morbidity. in meta-analyses.8 Physical activ
ments can help control hyperglyce ity appears to affect all the stages of
Depression
Increased physical Reduced Decreased risk of
Depression is associated with poorer activity adiposity cancer
adherence to medical treatments and
reduced health-related quality of life,
as well as increased disability and
health care utilization.23 Furthermore, Decreased
depression is independently associ insulin and glucose
ated with increased cardiovascular Altered
morbidity and mortality, and is com adipocytokines
monly seen in patients with CHD.24 ( adiponectin , leptin,
inflammation)
In a meta-analysis examining the
effect of exercise in patients with
chronic disease, exercise significant Figure 3. Protective mechanisms of physical activity that may reduce cancer risk.
ly reduced depressive symptoms by Adapted from McTiernan.22
30%. The greatest reduction in depres
sive symptoms occurred in patients tion in risk (35%).27 In addition to specific APOE e4 allele, the stron
with higher baseline depressive symp reducing risk factors associated with gest known genetic risk factor for
toms and exercise-improved physical the incidence of vascular dementia, Alzheimer disease.31
function.23 A recent Cochrane review physical activity appears to increase An exciting aspect of the positive
found exercise to be effective at the production of neurotrophic fac relationship between physical activity
reducing depression symptoms when tors in the brain28 and can potentially and gray matter volume is that aero
compared with psychological and mitigate against the loss of gray mat bic exercise interventions over a 6- to
pharmacological therapies.25 ter.29 High levels of physical fitness 12-month period appear to be suffi
(as measured objectively by maximal cient for increasing volume.32 Further
Cognitive function oxygen consumption) are associated more, in an intention-to-treat study of
The benefits of physical activity in with greater gray matter volume in older adults with memory impairment
maintaining cognitive function in old frontal and temporal lobes indepen who did not meet diagnostic critieria
er age and promoting healthy aging dent of age.30 There is a consistent for dementia, a short 24-week home-
have been well documented. In the association between higher levels based exercise program demonstrated
third decade of life the human brain of fitness and greater gray matter, a modest improvement in cognition.
starts to show a loss of gray matter and between physical activity and a Those subjects who did not receive
that is disproportionately large in the reduction in accelerated brain aging the exercise program had a decline
frontal, parietal, and temporal lobes or neuron loss. in cogntive function over the study
of the brain.26 Physical activity may also reduce period.33
In a meta-analysis of 33 816 non the risk for developing Alzhiemer dis
demented subjects from 15 prospec ease. In a 21-year longitudinal study Physical inactivity—
tive cohorts, physical activity was that assessed individuals age 65 to 79, a modifiable risk factor
found to protect against cognitive twice-weekly leisure-time physical Physical inactivity is the fourth lead
decline. The most fit subjects had a activity was associated with a reduced ing cause of death worldwide.34 It is
reduced risk of cognitive decline of risk of dementia and Alzheimer dis estimated that over a third of cancers
38%. Even low-to-moderate-level ease. This risk reduction was more and about 80.0% of heart disease,
exercise showed a significant reduc pronounced in individuals with a stroke, and type 2 diabetes could be
Table 1. Health outcomes and conditions Table 2. How physical activity improves social function. Physical inactivity
improved by physical activity. health outcomes: Proposed mechanisms. should be recognized and treated like
other modifiable risk factors.
• All-cause mortality • Improves fitness as measured by Extensive evidence shows an
• Cardiovascular disease mortality metabolic equivalent task values inverse relationship between physi
• Cancer incidence (convincing data for • Decreases systemic vascular cal activity and mortality and the
breast and colon cancer) resistance
development of chronic disease: the
• Cancer mortality • Decreases sympathetic activity
greater the amount of physical activ
• Type 2 diabetes • Decreases plasma renin activity
ity, the greater the benefits. As well,
• Hypertension (through primary • Helps maintain body weight
evidence confirms there is a graded
prevention and by lowering blood • Decreases waist circumference
pressure in patients with established dose-response relationship. The unfit
• Reduces percentage of body fat
hypertension) or the physically inactive can achieve
• Improves insulin resistance
• Stroke the largest health gains with slight
• Raises HDL cholesterol levels
• Osteoporosis increases in activity levels. Even
• Lowers LDL cholesterol levels
• Sarcopenia patients with established disease or
• Reduces systemic inflammation
• Depression
• Improves heart rate variability
cardiovascular risk factors can reduce
• Anxiety
• Improves endothelial function
their risk of premature mortality by
• Cognitive function
• Improves immune function
becoming physically active. The rec
• Fear of falling
• Protects against gray matter loss
ommended weekly 150 minutes of
moderate-intensity aerobic activity
has been shown to prevent and pos
prevented by eliminating behavioral only one-quarter (25.1%) of Cana itively moderate disease. The ben
risk factors such as physical inactiv dians are moderately active.37 The efits of physical activity cannot be
ity, unhealthy diet, tobacco smoking, physical inactivity of Canadians has overstated, and encouraging physical
and alcohol use.35 In a study designed a significant economic impact, and in activity should remain an important
to examine the population attribut 2001 was estimated to be $5.3 billion health care policy objective.
able risk of physical inactivity on or 2.6% of total health care costs.18
death from diseases such as CHD, Among Canadians physical inactivity Competing interests
cancer, and diabetes, 6.0% to 10.0% is the most prevalent modifiable risk None declared.
of all deaths from noncommunicable factor,38 and improvements in fitness
disease worldwide were attributed to over time have been demonstrated References
physical inactivity.36 Specifically, in to improve prognosis and longevity.2 1. Morris JN, Heady JA, Raffle P, et al. Coro-
Canada 5.6% of CHD, 7.0% of dia Health outcomes and conditions that nary heart disease and physical activity of
betes, 9.2% of breast cancer, 10.0% are improved by physical activity and work. Lancet 1953;265(6796):1053-1057.
of colon cancer, and 9.1% of all-cause the proposed mechanisms they are 2. Blair SN, Kohl HW, Barlow CE, et al.
mortality were attributed to physical improved by are shown in Table 1 Changes in physical fitness and all-cause
inactivity. 36 These results suggest and Table 2 . mortality. A prospective study of healthy
that 6.0% of the burden of noncom and unhealthy men. JAMA 1995;273:
municable disease worldwide could Conclusions 1093-1098.
be eliminated if all inactive people Physical inactivity is central to the de 3. Myers J, Prakash M, Froelicher V, et al.
become active. Furthermore, the pub velopment of many chronic diseases Exercise capacity and mortality among
lic health burden of physical inactiv that pose a major threat to our health men referred for exercise testing. N Engl
ity is similar in magnitude to that of and survival. The physically inactive J Med 2002;346:793-801.
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was estimated that physical inactiv disease and all-cause mortality. Not Physical fitness and all-cause mortality. A
ity contributed to 9.0% of premature only can a physically active lifestyle prospective study of healthy men and
mortality or more than 5.3 million of reduce mortality and prevent many women. JAMA 1989;262:2395-2401.
the 57.0 million deaths worldwide.36 chronic diseases such as hypertension, 5. Myers J, Kaykha A, George S, et al. Fit-
In Canada nearly half the population diabetes, stroke, and cancer, it can pro ness versus physical activity patterns in
(47.8%) is physically inactive and mote healthy cognitive and psycho predicting mortality in men. Am J Med