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Culture Documents
doi:10.1093/qjmed/hcg041
Review
QJM
Physical activity: the evidence of benefit in the prevention
of coronary heart disease
Introduction
Over the past 40 years, evidence has accumulated Endothelial function is improved, leading to
on the role of physical activity in preventing and better flow–mediated dilatation. In addition, the
treating coronary heart disease (CHD). The findings diameter and dilatory capacity of coronary arteries
are consistent and show that sedentary people have are increased, as is collateral formation. Regular
about twice the risk of developing or dying from exercise also has effects on the tendency of blood
CHD, compared to active people. The evidence is to clot. Changes include reduced platelet aggrega-
compelling and has established physical inactivity tion and increased fibrinolytic activity, possibly
as one of the major modifiable risk factors for CHD. resulting from lower levels of plasminogen activator
A recent analysis suggests that 37% of deaths from inhibitor-1. In addition, regular physical activity
CHD are attributable to physical inactivity; this is lowers inflammatory factors such as plasma fibrino-
second only to raised blood cholesterol.1 Despite gen concentrations, C-reactive protein and white
this, few doctors appear to realize the extent of the cell count.
benefits of regular exercise, nor are they aware of Metabolic adaptations include stimulation of
current recommendations relating to it.2 This article lipid oxidation during activity and in post-exercise
reviews the evidence for, and mechanisms by recovery.4 There are alterations in the transport of
which physical activity confers benefit, as well as blood lipids, with a higher ratio of high-density
the main health messages and ways in which lipoprotein (HDL) to low-density lipoprotein (LDL)
people can be helped to become more active. and increased lipoprotein lipase activity, which
Throughout the paper, physical activity means increases the use of circulating triglycerides as fuel
all activity at work and leisure, including sport. and increases their clearance even at rest. Activa-
Exercise means formal training-type activities, tion of this enzyme also speeds up the conversion
which can also include sport. of the VLDL to HDL. Finally, regular exercise
improves the sensitivity of liver, skeletal muscle
and adipose tissue to the actions of insulin. Con-
sequently, there are decreases in fasting insulin
Physiological benefits of exercise levels and the insulin response to glucose, asso-
The benefits of regular exercise include3 improve- ciated with increases in the disposal rate for
ment in myocardial contraction and its electrical glucose.5
stability, and an increase in stroke volume at rest Given these highly favourable changes, it is
and during exercise, leading to a higher maximal important to determine the level of exercise at
cardiac output. Heart rate is decreased at rest, and which these are manifest in a reduction of risk
at any given level of submaximal cardiac output. factors and overall risk of CHD.
Address correspondence to Professor Sir C.F. George, British Heart Foundation, 14 Fitzhardinge Street, London
W1H 6DH
ß Association of Physicians 2003
246 V. Press et al.
The evidence that vigorous activity in moderate or moderately vigorous activities had a
50% reduction in risk, compared to those who were
prevents CHD inactive.11 There was no threshold for benefit, with
Vigorous activity is variously defined as expending rates of first heart attack declining with increasing
more than 6 mets or a minimum of 7.5 kilocal/min physical activity until the moderately vigorous
or working at a minimum of 70% of maximum level. Men with pre-existing CHD showed a similar
heart rate or 70% of VO2max.6,7 inverse association up to moderate levels of activity.
Numerous studies have confirmed the benefits of There was no additional benefit seen in those
vigorous activity in reducing risk from CHD. The participating in vigorous activity.
Study of British Civil Servants by Morris et al. was Another 4-year follow-up study, beginning in
1992 and involving 4311 of the original BRHS men
than those walking longer distances. The findings with increasing total energy expenditure rather than
were consistent even after adjustment for age and duration of exercise. Men accumulating the same
other risk factors. total energy expenditure, whether it be through one
The Nurses Health Study, a large prospective longer episode or several shorter sessions experi-
study of female nurses in the US, collected detailed enced the same reduction in CHD risk. Total energy
information on physical activity from 72 488 expenditure consistently predicted a decreased risk
women aged 40–65 in 1986 and free from diag- of CHD, whether it was through walking, stair
nosed CVD or cancer. After a follow-up period of climbing or other recreational or sporting activities.16
8 years, researchers examined associations between
total physical activity, walking and vigorous exer-
cise and the incidence of coronary events.14 There
and an estimated further 2% have undiagnosed Several studies have pointed towards those over-
diabetes.17 The evidence demonstrates that physical weight but fit having lower risks than those who are
activity can have a significant role to play in the normal weight and unfit, suggesting that activity
prevention and management of type 2 diabetes, may offset some of the health risks associated with
particularly in people who are obese or have obesity. A recent review summarizing the epidemio-
impaired glucose tolerance.20–23 logical evidence suggests that the health risks of
For example, the Nurses Health Study examined obesity are largely controlled if a person is physically
the relationship between total physical activity and active and physically fit.28 Unfit men have been
risk of diabetes and compared the benefits of shown to carry a higher risk of all-cause mortality,
vigorous activity and walking.24 The study looked irrespective of waist circumference.29
at 70 102 women aged 40–65 and free from dia-
25% of women meet the current guidelines of research has identified common features of success-
30 min moderate activity on five or more days of ful physical activity interventions.37 These are: (i)
the week suggested by the Government.32 Over home-based programmes (not necessarily activities
one-third of adults are currently sedentary, that is based at home, but activities that could be carried
undertake less than one occasion of 30 min moder- out from the home, such as walking); (ii) unsuper-
ate activity a week.32 Physical activity declines vised informal exercise; (iii) frequent profes-
rapidly with age, such that only 17% of men and sional contact; and (iv) moderate intensity activity,
12% of women in the 65–74-year age group meet particularly walking.
the current guidelines.32 Primary health care seems an obvious setting to
encourage individuals to be more physically active.
Professionals should see the promotion of physical
27. Prentice AM, Jebb SA. Obesity in Britain: gluttony or sloth? 38. Donaldson LJ. Sport and exercise: the public health
Br Med J 1995; 311:437–9. challenge. Br J Sports Med 2000; 34:409–15.
28. Welk GJ, Blair SN. President’s Council on Physical Fitness, 39. Morris JN. Exercise in the prevention of coronary heart
Sports. Physical activity protects against the health risks of disease: today’s best buy in public health. Med Sci Sports
obesity. Research Digest 2000; 3:1–7. Exerc 1994; 26:807–14.
29. Lee CD, Blair SN, Jackson AS. Cardiorespiratory fitness, 40. Morris JN, Hardman AE. Walking to health. Sports Med
body composition and all-cause and cardiovascular 1997; 23:306–32.
disease mortality in men. Am J Clin Nutr 1999; 41. National Health Service. Exercise Referral Systems: A
69:373–80. National Quality Assurance Framework. London,
30. Stefanick ML, Wood PD. Physical activity, lipid and Department of Health, 2001.
lipoprotein metabolism, and lipid transport. In Bouchard C, wwww.doh.gov.uk/exercisereferralsx,
Shephard RJ, Stephens T, eds. Physical Activity, Fitness and or contact the NHS Response Line on: 0800 555777.