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Exercise is generally acknowledged to be important for weight control, strengthening bones and muscles and increased stamina. Nevertheless, the benefits of exercise transcend these common facts to many other aspects of health and wellness. Other reasons why you should exercise include a reduced the risk of disease, increased brain health, improved energy, sleep and sex and, in the end, a longer life.

Reduced Risk of Cardiovascular Disease

Exercise can be imperative in reducing your chance of developing cardiovascular disease, which includes atherosclerosis and hypertension. Physical activity increase the body's production of high-density lipoprotein and decreases triglycerides. Consequently, the risk of developing cardiovascular diseases decreases as your blood pressure lowers and cholesterol levels improve. Simultaneously, you will decrease the chances of having a stroke or heart attack as your blood flow and heart begin to work more efficiently.

Prevention of Diabetes

Additionally, exercise reduces the chance of developing diabetes and metabolic syndrome. Regular exercise not only prevents diabetes through weight control, but also through muscle activity, according to Harvard Medical School. Muscles that are worked regularly maintain receptiveness to insulin so that blood sugar is more effectively absorbed. As a result, exercise can both prevent and decrease the effects of diabetes, as a diabetic can also control their blood sugar with exercise.

Reduced Risk of Cancer Development and Reoccurance

Regular physical activity can reduce the risk of developing cancers, including breast, colon, endometrial and lung cancer, according to the Centers for Disease Control and Prevention. Moreover, cancer survivors and those undergoing cancer treatment also benefit from exercise. Cancer survivors who exercise experience a greater quality of life, as well as lower the chance of reoccurance, according to the National Cancer Institute, while the American College of Sports Medicine indicates that exercise during cancer treatment decreases fatigue and increases strength.

Improved Brain Function

According to the American Council on Exercise, physical activity affects the brain through stimulation of brain-pleasing neurotransmitters such as serotonin, dopamine and endorphins. Consequently, individuals that exercise tend to be less stressed and anxious and have a happier outlook. Additionally, symptoms of depression can be alleviated through regular exercise. Benefits for the brain also occur through improved cognitive functioning, as exercise helps improve thinking and learning. According to Harvard Medical School, the onset and development of certain cognitive impairments, such as dementia, can be reduced by exercise.

Energy, Sleep and Sex

Regular exercise helps your body function more efficiently through improved oxygen consumption, effective delivery of nutrients and a healthy cardiovascular system, resulting in increased energy, says MayoClinic.com. At the same time, individuals who exercise fall asleep more quickly and achieve a higher quality of sleep than those who do not exercise. Consequently, individuals begin to look and feel better -- and, by feeling and looking better through regular exercise, your sex life can be improved. Additionally, women who exercise regularly may experience greater arousal, while men maintain better erectile function.

Live Longer

The cumulative benefits of exercise add up to the most important conclusion of all: a longer life. According to the CDC, individuals that engage in seven hours of physical activity a week decrease the chances of dying early by 40 percent. However, seven hours a week is not the requirement to a long life, as exercising for at least 30 minutes a day may also decrease the chances of premature death. Any amount of exercise performed can improve the length and quality of your life.

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• MayoClinic.com: Exercise: 7 Benefits of Regular Physical Activity
• Centers for Disease Control: Physical Activity and Health
• Harvard Medical School: Why We Should Exercise--and Why We Don't
• American College of Sports Medicine: New Guidelines Strongly Recommend Exercise for Cancer Patients, Survivors
• American Council on Exercise: Exercise Provides Stress and Anxiety Relief
• Harvard Medical School: 10 Reasons to Work Your Body
• National Cancer Institute: Physical Activity and Cancer

Jennifer Carr, MSHE specializes in health and wellness, fitness, nutrition, alternative medicine and treatment for substance abuse. She has served as a health-care communicator and recovery coach, providing support and guidance for individuals going through treatment for addictions. Carr completed her Master of Science in health education at Arcadia University. She graduated from Villanova University with a Bachelor of Arts.

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2.7 Conclusion

Engaging in regular physical activity may produce improvements in an individual’s physical health, cognitive performance, and psychological well-being. Physical benefits include, but are not limited to, reduced risk for diseases, and improvements in physical functioning, fitness, and overall quality of life. Literature supports a link between exercise and cognitive benefits related to academic performance, brain function, and aging. Psychological benefits incurred from physical activity pertain to improvements in mood and self-esteem, and potential reductions in stress, anxiety, and depression. Strong scientific evidence indicates that adopting a physical activity regimen may positively impact health. However, individuals react differently to exercise and may face unique challenges and barriers when beginning and maintaining an exercise program. One may engage in behavioral modification strategies to enhance physical activity. Useful strategies include: identifying personally perceived barriers to physical activity, increasing self-efficacy, effectively setting goals, planning for setbacks, and self-monitoring progress.

A Guide to Physical Activity Copyright © 2019 by Eydie Kramer is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Aerobic exercise: top 10 reasons to get physical.

Regardless of age, weight or athletic ability, aerobic exercise is good for you. See why — then prepare yourself to get moving.

Regular aerobic activity, such as walking, bicycling or swimming, can help you live longer and healthier. Need motivation? See how aerobic exercise affects your heart, lungs and blood flow. Then get moving and start reaping the rewards.

How your body responds to aerobic exercise

During aerobic activity, you repeatedly move large muscles in your arms, legs and hips. You'll notice your body's responses quickly.

You'll breathe faster and more deeply. This maximizes the amount of oxygen in your blood. Your heart will beat faster, which increases blood flow to your muscles and back to your lungs.

Your small blood vessels (capillaries) will widen to deliver more oxygen to your muscles and carry away waste products, such as carbon dioxide and lactic acid.

Your body will even release endorphins, natural painkillers that promote an increased sense of well-being.

What aerobic exercise does for your health

No matter your age, weight or athletic ability, aerobic activity is good for you. Aerobic activity has many health benefits. As your body adapts to regular aerobic exercise, you'll get stronger and fitter.

Consider the following 10 ways that aerobic activity can help you feel better and enjoy life to the fullest.

Aerobic activity can help you:

1. Keep excess pounds at bay

Combined with a healthy diet, aerobic exercise helps you lose weight and keep it off.

2. Increase your stamina, fitness and strength

You may feel tired when you first start regular aerobic exercise. But over the long term, you'll enjoy increased stamina and reduced fatigue.

You can also gain increased heart and lung fitness and bone and muscle strength over time.

3. Ward off viral illnesses

Aerobic exercise activates your immune system in a good way. This may leave you less susceptible to viral illnesses, such as colds and the flu.

4. Reduce your health risks

Aerobic exercise reduces the risk of many conditions. These conditions include obesity, heart disease, high blood pressure, type 2 diabetes, metabolic syndrome, stroke and certain types of cancer.

Weight-bearing aerobic exercises, such as walking, help lower the risk of osteoporosis.

5. Manage chronic conditions

Aerobic exercise may help lower blood pressure and control blood sugar. It can reduce pain and improve function in people with arthritis. It can also improve the quality of life and fitness in people who've had cancer. If you have coronary artery disease, aerobic exercise may help you manage your condition.

6. Strengthen your heart

A stronger heart doesn't need to beat as fast. A stronger heart also pumps blood more efficiently, which improves blood flow to all parts of your body.

7. Keep your arteries clear

Aerobic exercise boosts your high-density lipoprotein (HDL), the "good," cholesterol, and lowers your low-density lipoprotein (LDL), the "bad," cholesterol. This may result in less buildup of plaques in your arteries.

8. Boost your mood

Aerobic exercise may ease the gloominess of depression, reduce the tension associated with anxiety and promote relaxation. It can improve your mental well-being and your self-esteem. It can also improve your sleep.

9. Stay active and independent as you age

Aerobic exercise keeps your muscles strong, which can help you maintain mobility as you get older. Exercise can also lower the risk of falls and injuries from falls in older adults. And it can improve your quality of life.

Aerobic exercise also keeps your mind sharp. Regular physical activity may help protect memory, reasoning, judgment and thinking skills (cognitive function) in older adults. It may also improve cognitive function in children and young adults. It can even help prevent the onset of dementia and improve cognition in people with dementia.

10. Live longer

Studies show that people who participate in regular aerobic exercise live longer than those who don't exercise regularly. They may also have a lower risk of dying of all causes, such as heart disease and certain cancers.

Take the first step

Ready to get more active? Great. Just remember to start with small steps. If you've been inactive for a long time or if you have a chronic health condition, get your doctor's OK before you start.

When you're ready to begin exercising, start slowly. You might walk five minutes in the morning and five minutes in the evening. Any physical activity is better than none at all.

The next day, add a few minutes to each walking session. Pick up the pace a bit, too. Soon, you could be walking briskly for at least 30 minutes a day, five days a week, and reaping all the benefits of regular aerobic activity. You can gain even more benefits if you exercise more. Also aim to sit less and move more during the day.

Short of time? Try a high-intensity interval training workout and enjoy a great workout with similar benefits as a standard aerobic workout in less time. In interval training, you alternate between short periods of intense activity and longer periods of less intense activity.

Other options for aerobic exercise could include cross-country skiing, aerobic dancing, swimming, stair climbing, bicycling, jogging, elliptical training or rowing.

If you have a condition that limits your ability to participate in aerobic activities, ask your health care provider about alternatives. If you have arthritis, for example, aquatic exercises may give you the benefits of aerobic activity without stressing your joints.

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• Peterson DM. The benefits and risks of aerobic exercise. https://www.uptodate.com/contents/search. Accessed Nov. 9, 2021.
• AskMayoExpert. Physical activity (adult). Mayo Clinic; 2021.
• Benefits of physical activity. Centers for Disease Control and Prevention. https://www.cdc.gov/physicalactivity/basics/pa-health/. Accessed Nov. 9, 2021.
• Endurance exercise (aerobic). American Heart Association. https://www.heart.org/en/healthy-living/fitness/fitness-basics/endurance-exercise-aerobic. Accessed Nov. 9, 2021.
• Systrom DM. Exercise physiology. https://www.uptodate.com/contents/search. Accessed Nov. 10, 2021.
• Physical Activity Guidelines for Americans. 2nd ed. U.S. Department of Health and Human Services. https://health.gov/our-work/physical-activity/current-guidelines. Accessed Nov. 10, 2021.
• Goldman L, et al., eds. Physical activity. In: Goldman-Cecil Medicine. 26th ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed Nov. 11, 2021.
• Seidu S, et al. The importance of physical activity in management of type 2 diabetes and COVID-19. Therapeutic Advances in Endocrinology and Metabolism. 2021; doi:10.1177/20420188211054686.
• Valenzuela PL, et al. Exercise benefits on Alzheimer's disease: State-of-the-science. Ageing Research Reviews. 2020; doi:10.1016/j.arr.2020.101108.

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• Research article
• Open access
• Published: 16 November 2020

Exercise/physical activity and health outcomes: an overview of Cochrane systematic reviews

• Pawel Posadzki 1 , 2 ,
• Dawid Pieper   ORCID: orcid.org/0000-0002-0715-5182 3 ,
• Ram Bajpai 4 ,
• Hubert Makaruk 5 ,
• Nadja Könsgen 3 ,
• Annika Lena Neuhaus 3 &
• Monika Semwal 6  

BMC Public Health volume  20 , Article number:  1724 ( 2020 ) Cite this article

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Sedentary lifestyle is a major risk factor for noncommunicable diseases such as cardiovascular diseases, cancer and diabetes. It has been estimated that approximately 3.2 million deaths each year are attributable to insufficient levels of physical activity. We evaluated the available evidence from Cochrane systematic reviews (CSRs) on the effectiveness of exercise/physical activity for various health outcomes.

Overview and meta-analysis. The Cochrane Library was searched from 01.01.2000 to issue 1, 2019. No language restrictions were imposed. Only CSRs of randomised controlled trials (RCTs) were included. Both healthy individuals, those at risk of a disease, and medically compromised patients of any age and gender were eligible. We evaluated any type of exercise or physical activity interventions; against any types of controls; and measuring any type of health-related outcome measures. The AMSTAR-2 tool for assessing the methodological quality of the included studies was utilised.

Hundred and fifty CSRs met the inclusion criteria. There were 54 different conditions. Majority of CSRs were of high methodological quality. Hundred and thirty CSRs employed meta-analytic techniques and 20 did not. Limitations for studies were the most common reasons for downgrading the quality of the evidence. Based on 10 CSRs and 187 RCTs with 27,671 participants, there was a 13% reduction in mortality rates risk ratio (RR) 0.87 [95% confidence intervals (CI) 0.78 to 0.96]; I 2  = 26.6%, [prediction interval (PI) 0.70, 1.07], median effect size (MES) = 0.93 [interquartile range (IQR) 0.81, 1.00]. Data from 15 CSRs and 408 RCTs with 32,984 participants showed a small improvement in quality of life (QOL) standardised mean difference (SMD) 0.18 [95% CI 0.08, 0.28]; I 2  = 74.3%; PI -0.18, 0.53], MES = 0.20 [IQR 0.07, 0.39]. Subgroup analyses by the type of condition showed that the magnitude of effect size was the largest among patients with mental health conditions.

There is a plethora of CSRs evaluating the effectiveness of physical activity/exercise. The evidence suggests that physical activity/exercise reduces mortality rates and improves QOL with minimal or no safety concerns.

Trial registration

Registered in PROSPERO ( CRD42019120295 ) on 10th January 2019.

Peer Review reports

The World Health Organization (WHO) defines physical activity “as any bodily movement produced by skeletal muscles that requires energy expenditure” [ 1 ]. Therefore, physical activity is not only limited to sports but also includes walking, running, swimming, gymnastics, dance, ball games, and martial arts, for example. In the last years, several organizations have published or updated their guidelines on physical activity. For example, the Physical Activity Guidelines for Americans, 2nd edition, provides information and guidance on the types and amounts of physical activity that provide substantial health benefits [ 2 ]. The evidence about the health benefits of regular physical activity is well established and so are the risks of sedentary behaviour [ 2 ]. Exercise is dose dependent, meaning that people who achieve cumulative levels several times higher than the current recommended minimum level have a significant reduction in the risk of breast cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke events [ 3 ]. Benefits of physical activity have been reported for numerous outcomes such as mortality [ 4 , 5 ], cognitive and physical decline [ 5 , 6 , 7 ], glycaemic control [ 8 , 9 ], pain and disability [ 10 , 11 ], muscle and bone strength [ 12 ], depressive symptoms [ 13 ], and functional mobility and well-being [ 14 , 15 ]. Overall benefits of exercise apply to all bodily systems including immunological [ 16 ], musculoskeletal [ 17 ], respiratory [ 18 ], and hormonal [ 19 ]. Specifically for the cardiovascular system, exercise increases fatty acid oxidation, cardiac output, vascular smooth muscle relaxation, endothelial nitric oxide synthase expression and nitric oxide availability, improves plasma lipid profiles [ 15 ] while at the same time reducing resting heart rate and blood pressure, aortic valve calcification, and vascular resistance [ 20 ].

However, the degree of all the above-highlighted benefits vary considerably depending on individual fitness levels, types of populations, age groups and the intensity of different physical activities/exercises [ 21 ]. The majority of guidelines in different countries recommend a goal of 150 min/week of moderate-intensity aerobic physical activity (or equivalent of 75 min of vigorous-intensity) [ 22 ] with differences for cardiovascular disease [ 23 ] or obesity prevention [ 24 ] or age groups [ 25 ].

There is a plethora of systematic reviews published by the Cochrane Library critically evaluating the effectiveness of physical activity/exercise for various health outcomes. Cochrane systematic reviews (CSRs) are known to be a source of high-quality evidence. Thus, it is not only timely but relevant to evaluate the current knowledge, and determine the quality of the evidence-base, and the magnitude of the effect sizes given the negative lifestyle changes and rising physical inactivity-related burden of diseases. This overview will identify the breadth and scope to which CSRs have appraised the evidence for exercise on health outcomes; and this will help in directing future guidelines and identifying current gaps in the literature.

The objectives of this research were to a. answer the following research questions: in children, adolescents and adults (both healthy and medically compromised) what are the effects (and adverse effects) of exercise/physical activity in improving various health outcomes (e.g., pain, function, quality of life) reported in CSRs; b. estimate the magnitude of the effects by pooling the results quantitatively; c. evaluate the strength and quality of the existing evidence; and d. create recommendations for future researchers, patients, and clinicians.

Our overview was registered with PROSPERO (CRD42019120295) on 10th January 2019. The Cochrane Handbook for Systematic Reviews of interventions and Preferred Reporting Items for Overviews of Reviews were adhered to while writing and reporting this overview [ 26 , 27 ].

Search strategy and selection criteria

We followed the practical guidance for conducting overviews of reviews of health care interventions [ 28 ] and searched the Cochrane Database of Systematic Reviews (CDSR), 2019, Issue 1, on the Cochrane Library for relevant papers using the search strategy: (health) and (exercise or activity or physical). The decision to seek CSRs only was based on three main aspects. First, high quality (CSRs are considered to be the ‘gold methodological standard’) [ 29 , 30 , 31 ]. Second, data saturation (enough high-quality evidence to reach meaningful conclusions based on CSRs only). Third, including non-CSRs would have heavily increased the issue of overlapping reviews (also affecting data robustness and credibility of conclusions). One reviewer carried out the searches. The study screening and selection process were performed independently by two reviewers. We imported all identified references into reference manager software EndNote (X8). Any disagreements were resolved by discussion between the authors with third overview author acting as an arbiter, if necessary.

We included CSRs of randomised controlled trials (RCTs) involving both healthy individuals and medically compromised patients of any age and gender. Only CSRs assessing exercise or physical activity as a stand-alone intervention were included. This included interventions that could initially be taught by a professional or involve ongoing supervision (the WHO definition). Complex interventions e.g., assessing both exercise/physical activity and behavioural changes were excluded if the health effects of the interventions could not have been attributed to exercise distinctly.

Any types of controls were admissible. Reviews evaluating any type of health-related outcome measures were deemed eligible. However, we excluded protocols or/and CSRs that have been withdrawn from the Cochrane Library as well as reviews with no included studies.

Data analysis

Three authors (HM, ALN, NK) independently extracted relevant information from all the included studies using a custom-made data collection form. The methodological quality of SRs included was independently evaluated by same reviewers using the AMSTAR-2 tool [ 32 ]. Any disagreements on data extraction or CSR quality were resolved by discussion. The entire dataset was validated by three authors (PP, MS, DP) and any discrepant opinions were settled through discussions.

The results of CSRs are presented in a narrative fashion using descriptive tables. Where feasible, we presented outcome measures across CSRs. Data from the subset of homogeneous outcomes were pooled quantitatively using the approach previously described by Bellou et al. and Posadzki et al. [ 33 , 34 ]. For mortality and quality of life (QOL) outcomes, the number of participants and RCTs involved in the meta-analysis, summary effect sizes [with 95% confidence intervals (CI)] using random-effects model were calculated. For binary outcomes, we considered relative risks (RRs) as surrogate measures of the corresponding odds ratio (OR) or risk ratio/hazard ratio (HR). To stabilise the variance and normalise the distributions, we transformed RRs into their natural logarithms before pooling the data (a variation was allowed, however, it did not change interpretation of results) [ 35 ]. The standard error (SE) of the natural logarithm of RR was derived from the corresponding CIs, which was either provided in the study or calculated with standard formulas [ 36 ]. Binary outcomes reported as risk difference (RD) were also meta-analysed if two more estimates were available. For continuous outcomes, we only meta-analysed estimates that were available as standardised mean difference (SMD), and estimates reported with mean differences (MD) for QOL were presented separately in a supplementary Table  9 . To estimate the overall effect size, each study was weighted by the reciprocal of its variance. Random-effects meta-analysis, using DerSimonian and Laird method [ 37 ] was applied to individual CSR estimates to obtain a pooled summary estimate for RR or SMD. The 95% prediction interval (PI) was also calculated (where ≥3 studies were available), which further accounts for between-study heterogeneity and estimates the uncertainty around the effect that would be anticipated in a new study evaluating that same association. I -squared statistic was used to measure between study heterogeneity; and its various thresholds (small, substantial and considerable) were interpreted considering the size and direction of effects and the p -value from Cochran’s Q test ( p  < 0.1 considered as significance) [ 38 ]. Wherever possible, we calculated the median effect size (with interquartile range [IQR]) of each CSR to interpret the direction and magnitude of the effect size. Sub-group analyses are planned for type and intensity of the intervention; age group; gender; type and/or severity of the condition, risk of bias in RCTs, and the overall quality of the evidence (Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria). To assess overlap we calculated the corrected covered area (CCA) [ 39 ]. All statistical analyses were conducted on Stata statistical software version 15.2 (StataCorp LLC, College Station, Texas, USA).

The searches generated 280 potentially relevant CRSs. After removing of duplicates and screening, a total of 150 CSRs met our eligibility criteria [ 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 , 133 , 134 , 135 , 136 , 137 , 138 , 139 , 140 , 141 , 142 , 143 , 144 , 145 , 146 , 147 , 148 , 149 , 150 , 151 , 152 , 153 , 154 , 155 , 156 , 157 , 158 , 159 , 160 , 161 , 162 , 163 , 164 , 165 , 166 , 167 , 168 , 169 , 170 , 171 , 172 , 173 , 174 , 175 , 176 , 177 , 178 , 179 , 180 , 181 , 182 , 183 , 184 , 185 , 186 , 187 , 188 , 189 ] (Fig.  1 ). Reviews were published between September 2002 and December 2018. A total of 130 CSRs employed meta-analytic techniques and 20 did not. The total number of RCTs in the CSRs amounted to 2888; with 485,110 participants (mean = 3234, SD = 13,272). The age ranged from 3 to 87 and gender distribution was inestimable. The main characteristics of included reviews are summarised in supplementary Table  1 . Supplementary Table  2 summarises the effects of physical activity/exercise on health outcomes. Conclusions from CSRs are listed in supplementary Table  3 . Adverse effects are listed in supplementary Table  4 . Supplementary Table  5 presents summary of withdrawals/non-adherence. The methodological quality of CSRs is presented in supplementary Table  6 . Supplementary Table  7 summarises studies assessed at low risk of bias (by the authors of CSRs). GRADE-ings of the review’s main comparison are listed in supplementary Table  8 .

Study selection process

There were 54 separate populations/conditions, considerable range of interventions and comparators, co-interventions, and outcome measures. For detailed description of interventions, please refer to the supplementary tables . Most commonly measured outcomes were - function 112 (75%), QOL 83 (55%), AEs 70 (47%), pain 41 (27%), mortality 28 (19%), strength 30 (20%), costs 47 (31%), disability 14 (9%), and mental health in 35 (23%) CSRs.

There was a 13% reduction in mortality rates risk ratio (RR) 0.87 [95% CI 0.78 to 0.96]; I 2  = 26.6%, [PI 0.70, 1.07], median effect size (MES) = 0.93 [interquartile range (IQR) 0.81, 1.00]; 10 CSRs, 187 RCTs, 27,671 participants) following exercise when compared with various controls (Table 1 ). This reduction was smaller in ‘other groups’ of patients when compared to cardiovascular diseases (CVD) patients - RR 0.97 [95% CI 0.65, 1.45] versus 0.85 [0.76, 0.96] respectively. The effects of exercise were not intensity or frequency dependent. Sessions more than 3 times per week exerted a smaller reduction in mortality as compared with sessions of less than 3 times per week RR 0.87 [95% CI 0.78, 0.98] versus 0.63 [0.39, 1.00]. Subgroup analyses by risk of bias (ROB) in RCTs showed that RCTs at low ROB exerted smaller reductions in mortality when compared to RCTs at an unclear or high ROB, RR 0.90 [95% CI 0.78, 1.02] versus 0.72 [0.42, 1.22] versus 0.86 [0.69, 1.06] respectively. CSRs with moderate quality of evidence (GRADE), showed slightly smaller reductions in mortality when compared with CSRs that relied on very low to low quality evidence RR 0.88 [95% CI 0.79, 0.98] versus 0.70 [0.47, 1.04].

Exercise also showed an improvement in QOL, standardised mean difference (SMD) 0.18 [95% CI 0.08, 0.28]; I 2  = 74.3%; PI -0.18, 0.53], MES = 0.20 [IQR 0.07, 0.39]; 15 CSRs, 408 RCTs, 32,984 participants) when compared with various controls (Table 2 ). These improvements were greater observed for health related QOL when compared to overall QOL SMD 0.30 [95% CI 0.21, 0.39] vs 0.06 [− 0.08, 0.20] respectively. Again, the effects of exercise were duration and frequency dependent. For instance, sessions of more than 90 mins exerted a greater improvement in QOL as compared with sessions up to 90 min SMD 0.24 [95% CI 0.11, 0.37] versus 0.22 [− 0.30, 0.74]. Subgroup analyses by the type of condition showed that the magnitude of effect was the largest among patients with mental health conditions, followed by CVD and cancer. Physical activity exerted negative effects on QOL in patients with respiratory conditions (2 CSRs, 20 RCTs with 601 patients; SMD -0.97 [95% CI -1.43, 0.57]; I 2  = 87.8%; MES = -0.46 [IQR-0.97, 0.05]). Subgroup analyses by risk of bias (ROB) in RCTs showed that RCTs at low or unclear ROB exerted greater improvements in QOL when compared to RCTs at a high ROB SMD 0.21 [95% CI 0.10, 0.31] versus 0.17 [0.03, 0.31]. Analogically, CSRs with moderate to high quality of evidence showed slightly greater improvements in QOL when compared with CSRs that relied on very low to low quality evidence SMD 0.19 [95% CI 0.05, 0.33] versus 0.15 [− 0.02, 0.32]. Please also see supplementary Table  9 more studies reporting QOL outcomes as mean difference (not quantitatively synthesised herein).

Adverse events (AEs) were reported in 100 (66.6%) CSRs; and not reported in 50 (33.3%). The number of AEs ranged from 0 to 84 in the CSRs. The number was inestimable in 83 (55.3%) CSRs. Ten (6.6%) reported no occurrence of AEs. Mild AEs were reported in 28 (18.6%) CSRs, moderate in 9 (6%) and serious/severe in 20 (13.3%). There were 10 deaths and in majority of instances, the causality was not attributed to exercise. For this outcome, we were unable to pool the data as effect sizes were too heterogeneous (Table 3 ).

In 38 CSRs, the total number of trials reporting withdrawals/non-adherence was inestimable. There were different ways of reporting it such as adherence or attrition (high in 23.3% of CSRs) as well as various effect estimates including %, range, total numbers, MD, RD, RR, OR, mean and SD. The overall pooled estimates are reported in Table 3 .

Of all 16 domains of the AMSTAR-2 tool, 1876 (78.1%) scored ‘yes’, 76 (3.1%) ‘partial yes’; 375 (15.6%) ‘no’, and ‘not applicable’ in 25 (1%) CSRs. Ninety-six CSRs (64%) were scored as ‘no’ on reporting sources of funding for the studies followed by 88 (58.6%) failing to explain the selection of study designs for inclusion. One CSR (0.6%) each were judged as ‘no’ for reporting any potential sources of conflict of interest, including any funding for conducting the review as well for performing study selection in duplicate.

In 102 (68%) CSRs, there was predominantly a high risk of bias in RCTs. In 9 (6%) studies, this was reported as a range, e.g., low or unclear or low to high. Two CSRs used different terminology i.e., moderate methodological quality; and the risk of bias was inestimable in one CSR. Sixteen (10.6%) CSRs did not identify any studies (RCTs) at low risk of random sequence generation, 28 (18.6%) allocation concealment, 28 (18.6%) performance bias, 84 (54%) detection bias, 35 (23.3%) attrition bias, 18 (12%) reporting bias, and 29 (19.3%) other bias.

In 114 (76%) CSRs, limitation of studies was the main reason for downgrading the quality of the evidence followed by imprecision in 98 (65.3%) and inconsistency in 68 (45.3%). Publication bias was the least frequent reason for downgrading in 26 (17.3%) CSRs. Ninety-one (60.7%) CSRs reached equivocal conclusions, 49 (32.7%) reviews reached positive conclusions and 10 (6.7%) reached negative conclusions (as judged by the authors of CSRs).

In this systematic review of CSRs, we found a large body of evidence on the beneficial effects of physical activity/exercise on health outcomes in a wide range of heterogeneous populations. Our data shows a 13% reduction in mortality rates among 27,671 participants, and a small improvement in QOL and health-related QOL following various modes of physical activity/exercises. This means that both healthy individuals and medically compromised patients can significantly improve function, physical and mental health; or reduce pain and disability by exercising more [ 190 ]. In line with previous findings [ 191 , 192 , 193 , 194 ], where a dose-specific reduction in mortality has been found, our data shows a greater reduction in mortality in studies with longer follow-up (> 12 months) as compared to those with shorter follow-up (< 12 months). Interestingly, we found a consistent pattern in the findings, the higher the quality of evidence and the lower the risk of bias in primary studies, the smaller reductions in mortality. This pattern is observational in nature and cannot be over-generalised; however this might mean less certainty in the estimates measured. Furthermore, we found that the magnitude of the effect size was the largest among patients with mental health conditions. A possible mechanism of action may involve elevated levels of brain-derived neurotrophic factor or beta-endorphins [ 195 ].

We found the issue of poor reporting or underreporting of adherence/withdrawals in over a quarter of CSRs (25.3%). This is crucial both for improving the accuracy of the estimates at the RCT level as well as maintaining high levels of physical activity and associated health benefits at the population level.

Even the most promising interventions are not entirely risk-free; and some minor AEs such as post-exercise pain and soreness or discomfort related to physical activity/exercise have been reported. These were typically transient; resolved within a few days; and comparable between exercise and various control groups. However worryingly, the issue of poor reporting or underreporting of AEs has been observed in one third of the CSRs. Transparent reporting of AEs is crucial for identifying patients at risk and mitigating any potential negative or unintended consequences of the interventions.

High risk of bias of the RCTs evaluated was evident in more than two thirds of the CSRs. For example, more than half of reviews identified high risk of detection bias as a major source of bias suggesting that lack of blinding is still an issue in trials of behavioural interventions. Other shortcomings included insufficiently described randomisation and allocation concealment methods and often poor outcome reporting. This highlights the methodological challenges in RCTs of exercise and the need to counterbalance those with the underlying aim of strengthening internal and external validity of these trials.

Overall, high risk of bias in the primary trials was the main reason for downgrading the quality of the evidence using the GRADE criteria. Imprecision was frequently an issue, meaning the effective sample size was often small; studies were underpowered to detect the between-group differences. Pooling too heterogeneous results often resulted in inconsistent findings and inability to draw any meaningful conclusions. Indirectness and publication bias were lesser common reasons for downgrading. However, with regards to the latter, the generally accepted minimum number of 10 studies needed for quantitatively estimate the funnel plot asymmetry was not present in 69 (46%) CSRs.

Strengths of this research are the inclusion of large number of ‘gold standard’ systematic reviews, robust screening, data extractions and critical methodological appraisal. Nevertheless, some weaknesses need to be highlighted when interpreting findings of this overview. For instance, some of these CSRs analysed the same primary studies (RCTs) but, arrived at slightly different conclusions. Using, the Pieper et al. [ 39 ] formula, the amount of overlap ranged from 0.01% for AEs to 0.2% for adherence, which indicates slight overlap. All CSRs are vulnerable to publication bias [ 196 ] - hence the conclusions generated by them may be false-positive. Also, exercise was sometimes part of a complex intervention; and the effects of physical activity could not be distinguished from co-interventions. Often there were confounding effects of diet, educational, behavioural or lifestyle interventions; selection, and measurement bias were inevitably inherited in this overview too. Also, including CSRs only might lead to selection bias; and excluding reviews published before 2000 might limit the overall completeness and applicability of the evidence. A future update should consider these limitations, and in particular also including non-CSRs.

Conclusions

Trialists must improve the quality of primary studies. At the same time, strict compliance with the reporting standards should be enforced. Authors of CSRs should better explain eligibility criteria and report sources of funding for the primary studies. There are still insufficient physical activity trends worldwide amongst all age groups; and scalable interventions aimed at increasing physical activity levels should be prioritized [ 197 ]. Hence, policymakers and practitioners need to design and implement comprehensive and coordinated strategies aimed at targeting physical activity programs/interventions, health promotion and disease prevention campaigns at local, regional, national, and international levels [ 198 ].

Availability of data and materials

Data sharing is not applicable to this article as no raw data were analysed during the current study. All information in this article is based on published systematic reviews.

Abbreviations

Adverse events

Cardiovascular diseases

Cochrane Database of Systematic Reviews

Cochrane systematic reviews

Confidence interval

Grading of Recommendations Assessment, Development and Evaluation

Hazard ratio

Interquartile range

Mean difference

Prediction interval

Quality of life

Randomised controlled trials

Relative risk

Risk difference

Risk of bias

Standard error

Standardised mean difference

World Health Organization

https://www.who.int/dietphysicalactivity/pa/en/ . (Accessed 8 June 2020).

Piercy KL, Troiano RP, Ballard RM, Carlson SA, Fulton JE, Galuska DA, George SM, Olson RD. The physical activity guidelines for AmericansPhysical activity guidelines for AmericansPhysical activity guidelines for Americans. Jama. 2018;320(19):2020–8.

PubMed   Google Scholar  

Kyu HH, Bachman VF, Alexander LT, Mumford JE, Afshin A, Estep K, Veerman JL, Delwiche K, Iannarone ML, Moyer ML, et al. Physical activity and risk of breast cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke events: systematic review and dose-response meta-analysis for the global burden of disease study 2013. BMJ. 2016;354:i3857.

PubMed   PubMed Central   Google Scholar  

Abell B, Glasziou P, Hoffmann T. The contribution of individual exercise training components to clinical outcomes in randomised controlled trials of cardiac rehabilitation: a systematic review and meta-regression. Sports Med Open. 2017;3(1):19.

Anderson D, Seib C, Rasmussen L. Can physical activity prevent physical and cognitive decline in postmenopausal women? A systematic review of the literature. Maturitas. 2014;79(1):14–33.

Barbaric M, Brooks E, Moore L, Cheifetz O. Effects of physical activity on cancer survival: a systematic review. Physiother Can. 2010;62(1):25–34.

Barlow PA, Otahal P, Schultz MG, Shing CM, Sharman JE. Low exercise blood pressure and risk of cardiovascular events and all-cause mortality: systematic review and meta-analysis. Atherosclerosis. 2014;237(1):13–22.

CAS   PubMed   Google Scholar  

Aljawarneh YM, Wardell DW, Wood GL, Rozmus CL. A systematic review of physical activity and exercise on physiological and biochemical outcomes in children and adolescents with type 1 diabetes. J Nurs Scholarsh. 2019.

Chastin SFM, De Craemer M, De Cocker K, Powell L, Van Cauwenberg J, Dall P, Hamer M, Stamatakis E. How does light-intensity physical activity associate with adult cardiometabolic health and mortality? Systematic review with meta-analysis of experimental and observational studies. Br J Sports Med. 2019;53(6):370–6.

Abdulla SY, Southerst D, Cote P, Shearer HM, Sutton D, Randhawa K, Varatharajan S, Wong JJ, Yu H, Marchand AA, et al. Is exercise effective for the management of subacromial impingement syndrome and other soft tissue injuries of the shoulder? A systematic review by the Ontario protocol for traffic injury management (OPTIMa) collaboration. Man Ther. 2015;20(5):646–56.

Alanazi MH, Parent EC, Dennett E. Effect of stabilization exercise on back pain, disability and quality of life in adults with scoliosis: a systematic review. Eur J Phys Rehabil Med. 2018;54(5):647–53.

Adsett JA, Mudge AM, Morris N, Kuys S, Paratz JD. Aquatic exercise training and stable heart failure: a systematic review and meta-analysis. Int J Cardiol. 2015;186:22–8.

Adamson BC, Ensari I, Motl RW. Effect of exercise on depressive symptoms in adults with neurologic disorders: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2015;96(7):1329–38.

Abdin S, Welch RK, Byron-Daniel J, Meyrick J. The effectiveness of physical activity interventions in improving well-being across office-based workplace settings: a systematic review. Public Health. 2018;160:70–6.

Albalawi H, Coulter E, Ghouri N, Paul L. The effectiveness of structured exercise in the south Asian population with type 2 diabetes: a systematic review. Phys Sportsmed. 2017;45(4):408–17.

Sellami M, Gasmi M, Denham J, Hayes LD, Stratton D, Padulo J, Bragazzi N. Effects of acute and chronic exercise on immunological parameters in the elderly aged: can physical activity counteract the effects of aging? Front Immunol. 2018;9:2187.

Hagen KB, Dagfinrud H, Moe RH, Østerås N, Kjeken I, Grotle M, Smedslund G. Exercise therapy for bone and muscle health: an overview of systematic reviews. BMC Med. 2012;10(1):167.

Burton DA, Stokes K, Hall GM. Physiological effects of exercise. Contin Educ Anaesth Crit Care Pain. 2004;4(6):185–8.

Google Scholar  

Kraemer WJ, Ratamess NA. Hormonal responses and adaptations to resistance exercise and training. Sports Med. 2005;35(4):339–61.

Nystoriak MA, Bhatnagar A. Cardiovascular effects and benefits of exercise. Front Cardiovasc Med. 2018;5:135.

CAS   PubMed   PubMed Central   Google Scholar  

Vina J, Sanchis-Gomar F, Martinez-Bello V, Gomez-Cabrera MC. Exercise acts as a drug; the pharmacological benefits of exercise. Br J Pharmacol. 2012;167(1):1–12.

Warburton DER, Bredin SSD. Health benefits of physical activity: a systematic review of current systematic reviews. Curr Opin Cardiol. 2017;32(5):541–56.

Excellence NIfHaC: Cardiovascular disease prevention public health guideline [PH25] Published date: June 2010. Available at: https://www.nice.org.uk/guidance/ph25/resources/cardiovascular-disease-prevention-pdf-1996238687173 .

Excellence NIfHaC: Obesity prevention clinical guideline [CG43] published date: December 2006 Last updated: March 2015. Available at: https://www.nice.org.uk/guidance/cg43/resources/obesity-prevention-pdf-975445344709 .

Excellence NIfHaC: Physical activity for children and young people public health guideline [PH17] Published date: January 2009. Available at: https://www.nice.org.uk/guidance/ph17/resources/physical-activity-for-children-and-young-people-pdf-1996181580229 .

Higgins J, Green S. Cochrane Handbook for Systematic Reviews of Interventions. Version 6 [updated September 2018] edition. Available from www.cochrane-handbook.org : The Cochrane Collaboration, 2011. 2011.

Bougioukas KI, Liakos A, Tsapas A, Ntzani E, Haidich A-B. Preferred reporting items for overviews of systematic reviews including harms checklist: a pilot tool to be used for balanced reporting of benefits and harms. J Clin Epidemiol. 2018;93:9–24.

Pollock M, Fernandes RM, Newton AS, Scott SD, Hartling L. The impact of different inclusion decisions on the comprehensiveness and complexity of overviews of reviews of healthcare interventions. Syst Rev. 2019;8(1):18.

Handoll H, Madhok R. Quality of Cochrane reviews. Another study found that most Cochrane reviews are of a good standard. BMJ. 2002;324(7336):545.

Petticrew M, Wilson P, Wright K, Song F. Quality of Cochrane reviews. Quality of Cochrane reviews is better than that of non-Cochrane reviews. BMJ. 2002;324(7336):545.

Shea B, Moher D, Graham I, Pham B, Tugwell P. A comparison of the quality of Cochrane reviews and systematic reviews published in paper-based journals. Eval Health Prof. 2002;25(1):116–29.

Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, Moher D, Tugwell P, Welch V, Kristjansson E, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017;358:j4008.

Posadzki PP, Bajpai R, Kyaw BM, Roberts NJ, Brzezinski A, Christopoulos GI, Divakar U, Bajpai S, Soljak M, Dunleavy G, et al. Melatonin and health: an umbrella review of health outcomes and biological mechanisms of action. BMC Med. 2018;16(1):18.

Bellou V, Belbasis L, Tzoulaki I, Evangelou E, Ioannidis JP. Environmental risk factors and Parkinson's disease: an umbrella review of meta-analyses. Parkinsonism Relat Disord. 2016;23:1–9.

Walter SD, Cook RJ. A comparison of several point estimators of the odds ratio in a single 2 x 2 contingency table. Biometrics. 1991;47(3):795–811.

Khan H, Sempos CT. Statistical methods in epidemiology. New York: Oxford University Press; 1989.

DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–88.

CAS   Google Scholar  

Higgins J, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editors. Cochrane Handbook for Systematic Reviews of Interventions version 6.0 (updated July 2019): Cochrane; 2019. Available from www.training.cochrane.org/handbook .

Pieper D, Antoine SL, Mathes T, Neugebauer EA, Eikermann M. Systematic review finds overlapping reviews were not mentioned in every other overview. J Clin Epidemiol. 2014;67(4):368–75.

Adeniyi FB, Young T. Weight loss interventions for chronic asthma. Cochrane Database Syst Rev. 2012;7.

Al-Khudairy L, Loveman E, Colquitt JL, Mead E, Johnson RE, Fraser H, Olajide J, Murphy M, Velho RM, O'Malley C, et al. Diet, physical activity and behavioural interventions for the treatment of overweight or obese adolescents aged 12 to 17 years. Cochrane Database Syst Rev. 2017;6.

Amorim Adegboye AR, Linne YM. Diet or exercise, or both, for weight reduction in women after childbirth. Cochrane Database Syst Rev. 2013;7.

Anderson L, Nguyen TT, Dall CH, Burgess L, Bridges C, Taylor RS. Exercise-based cardiac rehabilitation in heart transplant recipients. Cochrane Database Syst Rev. 2017;4.

Anderson L, Thompson DR, Oldridge N, Zwisler AD, Rees K, Martin N, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2016;1.

Andriolo RB, El Dib RP, Ramos L, Atallah Á, da Silva EMK. Aerobic exercise training programmes for improving physical and psychosocial health in adults with Down syndrome. Cochrane Database Syst Rev. 2010;5.

Araujo DN, Ribeiro CTD, Maciel ACC, Bruno SS, Fregonezi GAF, Dias FAL. Physical exercise for the treatment of non-ulcerated chronic venous insufficiency. Cochrane Database Syst Rev. 2016;12.

Ashworth NL, Chad KE, Harrison EL, Reeder BA, Marshall SC. Home versus center based physical activity programs in older adults. Cochrane Database Syst Rev. 2005;1.

Bartels EM, Juhl CB, Christensen R, Hagen KB, Danneskiold-Samsøe B, Dagfinrud H, Lund H. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev. 2016;3.

Beggs S, Foong YC, Le HCT, Noor D, Wood-Baker R, Walters JAE. Swimming training for asthma in children and adolescents aged 18 years and under. Cochrane Database Syst Rev. 2013;4.

Bergenthal N, Will A, Streckmann F, Wolkewitz KD, Monsef I, Engert A, Elter T, Skoetz N. Aerobic physical exercise for adult patients with haematological malignancies. Cochrane Database Syst Rev. 2014;11.

Bidonde J, Busch AJ, Schachter CL, Overend TJ, Kim SY, Góes SM, Boden C, Foulds HJA. Aerobic exercise training for adults with fibromyalgia. Cochrane Database Syst Rev. 2017;6.

Bidonde J, Busch AJ, van der Spuy I, Tupper S, Kim SY, Boden C. Whole body vibration exercise training for fibromyalgia. Cochrane Database Syst Rev. 2017;9.

Bidonde J, Busch AJ, Webber SC, Schachter CL, Danyliw A, Overend TJ, Richards RS, Rader T. Aquatic exercise training for fibromyalgia. Cochrane Database Syst Rev. 2014;10.

Braam KI, van der Torre P, Takken T, Veening MA, van Dulmen-den Broeder E, Kaspers GJL. Physical exercise training interventions for children and young adults during and after treatment for childhood cancer. Cochrane Database Syst Rev. 2016;3.

Bradt J, Shim M, Goodill SW. Dance/movement therapy for improving psychological and physical outcomes in cancer patients. Cochrane Database Syst Rev. 2015;1.

Broderick J, Crumlish N, Waugh A, Vancampfort D. Yoga versus non-standard care for schizophrenia. Cochrane Database Syst Rev. 2017;9.

Broderick J, Knowles A, Chadwick J, Vancampfort D. Yoga versus standard care for schizophrenia. Cochrane Database Syst Rev. 2015;10.

Broderick J, Vancampfort D. Yoga as part of a package of care versus standard care for schizophrenia. Cochrane Database Syst Rev. 2017;9.

Brown J, Ceysens G, Boulvain M. Exercise for pregnant women with gestational diabetes for improving maternal and fetal outcomes. Cochrane Database Syst Rev. 2017;6.

Busch AJ, Barber KA, Overend TJ, Peloso PMJ, Schachter CL. Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev. 2007;4.

Busch AJ, Webber SC, Richards RS, Bidonde J, Schachter CL, Schafer LA, Danyliw A, Sawant A, Dal Bello-Haas V, Rader T, et al. Resistance exercise training for fibromyalgia. Cochrane Database Syst Rev. 2013;12.

Cameron ID, Dyer SM, Panagoda CE, Murray GR, Hill KD, Cumming RG, Kerse N. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev. 2018;9.

Carson KV, Chandratilleke MG, Picot J, Brinn MP, Esterman AJ, Smith BJ. Physical training for asthma. Cochrane Database Syst Rev. 2013;9.

Carvalho APV, Vital FMR, Soares BGO. Exercise interventions for shoulder dysfunction in patients treated for head and neck cancer. Cochrane Database Syst Rev. 2012;4.

Cavalheri V, Granger C. Preoperative exercise training for patients with non-small cell lung cancer. Cochrane Database Syst Rev. 2017;6.

Cavalheri V, Tahirah F, Nonoyama ML, Jenkins S, Hill K. Exercise training undertaken by people within 12 months of lung resection for non-small cell lung cancer. Cochrane Database Syst Rev. 2013;7.

Ceysens G, Rouiller D, Boulvain M. Exercise for diabetic pregnant women. Cochrane Database Syst Rev. 2006;3.

Choi BKL, Verbeek JH, Tam WWS, Jiang JY. Exercises for prevention of recurrences of low-back pain. Cochrane Database Syst Rev. 2010;1.

Colquitt JL, Loveman E, O'Malley C, Azevedo LB, Mead E, Al-Khudairy L, Ells LJ, Metzendorf MI, Rees K. Diet, physical activity, and behavioural interventions for the treatment of overweight or obesity in preschool children up to the age of 6 years. Cochrane Database Syst Rev. 2016;3.

Connolly B, Salisbury L, O'Neill B, Geneen LJ, Douiri A, Grocott MPW, Hart N, Walsh TS, Blackwood B. Exercise rehabilitation following intensive care unit discharge for recovery from critical illness. Cochrane Database Syst Rev. 2015;6.

Cooney GM, Dwan K, Greig CA, Lawlor DA, Rimer J, Waugh FR, McMurdo M, Mead GE. Exercise for depression. Cochrane Database Syst Rev. 2013;9.

Corbetta D, Sirtori V, Castellini G, Moja L, Gatti R. Constraint-induced movement therapy for upper extremities in people with stroke. Cochrane Database Syst Rev. 2015;10.

Cramer H, Lauche R, Klose P, Lange S, Langhorst J, Dobos GJ. Yoga for improving health-related quality of life, mental health and cancer-related symptoms in women diagnosed with breast cancer. Cochrane Database Syst Rev. 2017;1.

Cramp F, Byron-Daniel J. Exercise for the management of cancer-related fatigue in adults. Cochrane Database Syst Rev. 2012;11.

Dal Bello-Haas V, Florence JM. Therapeutic exercise for people with amyotrophic lateral sclerosis or motor neuron disease. Cochrane Database Syst Rev. 2013;5.

Dale MT, McKeough ZJ, Troosters T, Bye P, Alison JA. Exercise training to improve exercise capacity and quality of life in people with non-malignant dust-related respiratory diseases. Cochrane Database Syst Rev. 2015;11.

Daley A, Stokes-Lampard H, Thomas A, MacArthur C. Exercise for vasomotor menopausal symptoms. Cochrane Database Syst Rev. 2014;11.

de Morton N, Keating JL, Jeffs K. Exercise for acutely hospitalised older medical patients. Cochrane Database Syst Rev. 2007;1.

Dobbins M, Husson H, DeCorby K, LaRocca RL. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18. Cochrane Database Syst Rev. 2013;2.

Doiron KA, Hoffmann TC, Beller EM. Early intervention (mobilization or active exercise) for critically ill adults in the intensive care unit. Cochrane Database Syst Rev. 2018;3.

Ekeland E, Heian F, Hagen KB, Abbott JM, Nordheim L. Exercise to improve self-esteem in children and young people. Cochrane Database Syst Rev. 2004;1.

Elbers RG, Verhoef J, van Wegen EEH, Berendse HW, Kwakkel G. Interventions for fatigue in Parkinson's disease. Cochrane Database Syst Rev. 2015;10.

Felbel S, Meerpohl JJ, Monsef I, Engert A, Skoetz N. Yoga in addition to standard care for patients with haematological malignancies. Cochrane Database Syst Rev. 2014;6.

Forbes D, Forbes SC, Blake CM, Thiessen EJ, Forbes S. Exercise programs for people with dementia. Cochrane Database Syst Rev. 2015;4.

Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2015;1.

Fransen M, McConnell S, Hernandez-Molina G, Reichenbach S. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. 2014;4.

Freitas DA, Holloway EA, Bruno SS, Chaves GSS, Fregonezi GAF, Mendonça K. Breathing exercises for adults with asthma. Cochrane Database Syst Rev. 2013;10.

Furmaniak AC, Menig M, Markes MH. Exercise for women receiving adjuvant therapy for breast cancer. Cochrane Database Syst Rev. 2016;9.

Giangregorio LM, MacIntyre NJ, Thabane L, Skidmore CJ, Papaioannou A. Exercise for improving outcomes after osteoporotic vertebral fracture. Cochrane Database Syst Rev. 2013;1.

Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012;9.

Gorczynski P, Faulkner G. Exercise therapy for schizophrenia. Cochrane Database Syst Rev. 2010;5.

Grande AJ, Keogh J, Hoffmann TC, Beller EM, Del Mar CB. Exercise versus no exercise for the occurrence, severity and duration of acute respiratory infections. Cochrane Database Syst Rev. 2015;6.

Grande AJ, Reid H, Thomas EE, Nunan D, Foster C. Exercise prior to influenza vaccination for limiting influenza incidence and its related complications in adults. Cochrane Database Syst Rev. 2016;8.

Grande AJ, Silva V, Andriolo BNG, Riera R, Parra SA, Peccin MS. Water-based exercise for adults with asthma. Cochrane Database Syst Rev. 2014;7.

Gross A, Kay TM, Paquin JP, Blanchette S, Lalonde P, Christie T, Dupont G, Graham N, Burnie SJ, Gelley G, et al. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2015;1.

Hageman D, Fokkenrood HJP, Gommans LNM, van den Houten MML, Teijink JAW. Supervised exercise therapy versus home-based exercise therapy versus walking advice for intermittent claudication. Cochrane Database Syst Rev. 2018;4.

Han A, Judd M, Welch V, Wu T, Tugwell P, Wells GA. Tai chi for treating rheumatoid arthritis. Cochrane Database Syst Rev. 2004;3.

Han S, Middleton P, Crowther CA. Exercise for pregnant women for preventing gestational diabetes mellitus. Cochrane Database Syst Rev. 2012;7.

Hartley L, Dyakova M, Holmes J, Clarke A, Lee MS, Ernst E, Rees K. Yoga for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2014;5.

Hartley L, Flowers N, Lee MS, Ernst E, Rees K. Tai chi for primary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2014;4.

Hartley L, Lee MS, Kwong JSW, Flowers N, Todkill D, Ernst E, Rees K. Qigong for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2015;6.

Hassett L, Moseley AM, Harmer AR. Fitness training for cardiorespiratory conditioning after traumatic brain injury. Cochrane Database Syst Rev. 2017;12.

Hayden J, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005;3.

Hay-Smith EJC, Herderschee R, Dumoulin C, Herbison GP. Comparisons of approaches to pelvic floor muscle training for urinary incontinence in women. Cochrane Database Syst Rev. 2011;12.

Heine M, van de Port I, Rietberg MB, van Wegen EEH, Kwakkel G. Exercise therapy for fatigue in multiple sclerosis. Cochrane Database Syst Rev. 2015;9.

Heiwe S, Jacobson SH. Exercise training for adults with chronic kidney disease. Cochrane Database Syst Rev. 2011;10.

Hemmingsen B, Gimenez-Perez G, Mauricio D, Roqué i Figuls M, Metzendorf MI, Richter B. Diet, physical activity or both for prevention or delay of type 2 diabetes mellitus and its associated complications in people at increased risk of developing type 2 diabetes mellitus. Cochrane Database Syst Rev. 2017;12.

Herbert RD, de Noronha M, Kamper SJ. Stretching to prevent or reduce muscle soreness after exercise. Cochrane Database Syst Rev. 2011;7.

Heymans MW, van Tulder MW, Esmail R, Bombardier C, Koes BW. Back schools for non-specific low-back pain. Cochrane Database Syst Rev. 2004;4.

Holland AE, Hill CJ, Jones AY, McDonald CF. Breathing exercises for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;10.

Howe TE, Rochester L, Neil F, Skelton DA, Ballinger C. Exercise for improving balance in older people. Cochrane Database Syst Rev. 2011;11.

Howe TE, Shea B, Dawson LJ, Downie F, Murray A, Ross C, Harbour RT, Caldwell LM, Creed G. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database Syst Rev. 2011;7.

Hurkmans E, van der Giesen FJ, Vliet Vlieland TPM, Schoones J, Van den Ende E. Dynamic exercise programs (aerobic capacity and/or muscle strength training) in patients with rheumatoid arthritis. Cochrane Database Syst Rev. 2009;4.

Hurley M, Dickson K, Hallett R, Grant R, Hauari H, Walsh N, Stansfield C, Oliver S. Exercise interventions and patient beliefs for people with hip, knee or hip and knee osteoarthritis: a mixed methods review. Cochrane Database Syst Rev. 2018;4.

Jones M, Harvey A, Marston L, O'Connell NE. Breathing exercises for dysfunctional breathing/hyperventilation syndrome in adults. Cochrane Database Syst Rev. 2013;5.

Katsura M, Kuriyama A, Takeshima T, Fukuhara S, Furukawa TA. Preoperative inspiratory muscle training for postoperative pulmonary complications in adults undergoing cardiac and major abdominal surgery. Cochrane Database Syst Rev. 2015;10.

Kendrick D, Kumar A, Carpenter H, Zijlstra GAR, Skelton DA, Cook JR, Stevens Z, Belcher CM, Haworth D, Gawler SJ, et al. Exercise for reducing fear of falling in older people living in the community. Cochrane Database Syst Rev. 2014;11.

Kramer MS, McDonald SW. Aerobic exercise for women during pregnancy. Cochrane Database Syst Rev. 2006;3.

Lahart IM, Metsios GS, Nevill AM, Carmichael AR. Physical activity for women with breast cancer after adjuvant therapy. Cochrane Database Syst Rev. 2018;1.

Lane R, Harwood A, Watson L, Leng GC. Exercise for intermittent claudication. Cochrane Database Syst Rev. 2017;12.

Larun L, Brurberg KG, Odgaard-Jensen J, Price JR. Exercise therapy for chronic fatigue syndrome. Cochrane Database Syst Rev. 2017;4.

Larun L, Nordheim LV, Ekeland E, Hagen KB, Heian F. Exercise in prevention and treatment of anxiety and depression among children and young people. Cochrane Database Syst Rev. 2006;3.

Lauret GJ, Fakhry F, Fokkenrood HJP, Hunink MGM, Teijink JAW, Spronk S. Modes of exercise training for intermittent claudication. Cochrane Database Syst Rev. 2014;7.

Lawrence M, Celestino Junior FT, Matozinho HHS, Govan L, Booth J, Beecher J. Yoga for stroke rehabilitation. Cochrane Database Syst Rev. 2017;12.

Lin CWC, Donkers NAJ, Refshauge KM, Beckenkamp PR, Khera K, Moseley AM. Rehabilitation for ankle fractures in adults. Cochrane Database Syst Rev. 2012;11.

Liu CJ, Latham NK. Progressive resistance strength training for improving physical function in older adults. Cochrane Database Syst Rev. 2009;3.

Long L, Anderson L, Dewhirst AM, He J, Bridges C, Gandhi M, Taylor RS. Exercise-based cardiac rehabilitation for adults with stable angina. Cochrane Database Syst Rev. 2018;2.

Loughney LA, West MA, Kemp GJ, Grocott MPW, Jack S. Exercise interventions for people undergoing multimodal cancer treatment that includes surgery. Cochrane Database Syst Rev. 2018;12.

Macedo LG, Saragiotto BT, Yamato TP, Costa LOP, Menezes Costa LC, Ostelo R, Maher CG. Motor control exercise for acute non-specific low back pain. Cochrane Database Syst Rev. 2016;2.

Macêdo TMF, Freitas DA, Chaves GSS, Holloway EA, Mendonça K. Breathing exercises for children with asthma. Cochrane Database Syst Rev. 2016;4.

Martin A, Booth JN, Laird Y, Sproule J, Reilly JJ, Saunders DH. Physical activity, diet and other behavioural interventions for improving cognition and school achievement in children and adolescents with obesity or overweight. Cochrane Database Syst Rev. 2018;3.

McKeough ZJ, Velloso M, Lima VP, Alison JA. Upper limb exercise training for COPD. Cochrane Database Syst Rev. 2016;11.

McNamara RJ, McKeough ZJ, McKenzie DK, Alison JA. Water-based exercise training for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2013;12.

McNeely ML, Campbell K, Ospina M, Rowe BH, Dabbs K, Klassen TP, Mackey J, Courneya K. Exercise interventions for upper-limb dysfunction due to breast cancer treatment. Cochrane Database Syst Rev. 2010;6.

Mead E, Brown T, Rees K, Azevedo LB, Whittaker V, Jones D, Olajide J, Mainardi GM, Corpeleijn E, O'Malley C, et al. Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years. Cochrane Database Syst Rev. 2017;6.

Meekums B, Karkou V, Nelson EA. Dance movement therapy for depression. Cochrane Database Syst Rev. 2015;2.

Meher S, Duley L. Exercise or other physical activity for preventing pre-eclampsia and its complications. Cochrane Database Syst Rev. 2006;2.

Mehrholz J, Kugler J, Pohl M. Water-based exercises for improving activities of daily living after stroke. Cochrane Database Syst Rev. 2011;1.

Mehrholz J, Kugler J, Pohl M. Locomotor training for walking after spinal cord injury. Cochrane Database Syst Rev. 2012;11.

Mehrholz J, Thomas S, Elsner B. Treadmill training and body weight support for walking after stroke. Cochrane Database Syst Rev. 2017;8.

Mishra SI, Scherer RW, Geigle PM, Berlanstein DR, Topaloglu O, Gotay CC, Snyder C. Exercise interventions on health-related quality of life for cancer survivors. Cochrane Database Syst Rev. 2012;8.

Mishra SI, Scherer RW, Snyder C, Geigle PM, Berlanstein DR, Topaloglu O. Exercise interventions on health-related quality of life for people with cancer during active treatment. Cochrane Database Syst Rev. 2012;8.

Montgomery P, Dennis JA. Physical exercise for sleep problems in adults aged 60+. Cochrane Database Syst Rev. 2002;4.

Morris NR, Kermeen FD, Holland AE. Exercise-based rehabilitation programmes for pulmonary hypertension. Cochrane Database Syst Rev. 2017;1.

Muktabhant B, Lawrie TA, Lumbiganon P, Laopaiboon M. Diet or exercise, or both, for preventing excessive weight gain in pregnancy. Cochrane Database Syst Rev. 2015;6.

Ngai SPC, Jones AYM, Tam WWS. Tai chi for chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev. 2016;6.

Norton C, Cody JD. Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults. Cochrane Database Syst Rev. 2012;7.

O'Brien K, Nixon S, Glazier R, Tynan AM. Progressive resistive exercise interventions for adults living with HIV/AIDS. Cochrane Database Syst Rev. 2004;4.

O'Brien K, Nixon S, Tynan AM, Glazier R. Aerobic exercise interventions for adults living with HIV/AIDS. Cochrane Database Syst Rev. 2010;8.

Østerås N, Kjeken I, Smedslund G, Moe RH, Slatkowsky-Christensen B, Uhlig T, Hagen KB. Exercise for hand osteoarthritis. Cochrane Database Syst Rev. 2017;1.

Page MJ, Green S, Kramer S, Johnston RV, McBain B, Chau M, Buchbinder R. Manual therapy and exercise for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. 2014;8.

Page MJ, Green S, McBain B, Surace SJ, Deitch J, Lyttle N, Mrocki MA, Buchbinder R. Manual therapy and exercise for rotator cuff disease. Cochrane Database Syst Rev. 2016;6.

Page MJ, O'Connor D, Pitt V, Massy-Westropp N. Exercise and mobilisation interventions for carpal tunnel syndrome. Cochrane Database Syst Rev. 2012;6.

Panebianco M, Sridharan K, Ramaratnam S. Yoga for epilepsy. Cochrane Database Syst Rev. 2017;10.

Perry A, Lee SH, Cotton S, Kennedy C. Therapeutic exercises for affecting post-treatment swallowing in people treated for advanced-stage head and neck cancers. Cochrane Database Syst Rev. 2016;8.

Radtke T, Nevitt SJ, Hebestreit H, Kriemler S. Physical exercise training for cystic fibrosis. Cochrane Database Syst Rev. 2017;11.

Regnaux JP, Lefevre-Colau MM, Trinquart L, Nguyen C, Boutron I, Brosseau L, Ravaud P. High-intensity versus low-intensity physical activity or exercise in people with hip or knee osteoarthritis. Cochrane Database Syst Rev. 2015;10.

Ren J, Xia J. Dance therapy for schizophrenia. Cochrane Database Syst Rev. 2013;10.

Rietberg MB, Brooks D, Uitdehaag BMJ, Kwakkel G. Exercise therapy for multiple sclerosis. Cochrane Database Syst Rev. 2005;1.

Risom SS, Zwisler AD, Johansen PP, Sibilitz KL, Lindschou J, Gluud C, Taylor RS, Svendsen JH, Berg SK. Exercise-based cardiac rehabilitation for adults with atrial fibrillation. Cochrane Database Syst Rev. 2017;2.

Romano M, Minozzi S, Bettany-Saltikov J, Zaina F, Chockalingam N, Kotwicki T, Maier-Hennes A, Negrini S. Exercises for adolescent idiopathic scoliosis. Cochrane Database Syst Rev. 2012;8.

Ryan JM, Cassidy EE, Noorduyn SG, O'Connell NE. Exercise interventions for cerebral palsy. Cochrane Database Syst Rev. 2017;6.

Saragiotto BT, Maher CG, Yamato TP, Costa LOP, Menezes Costa LC, Ostelo R, Macedo LG. Motor control exercise for chronic non-specific low-back pain. Cochrane Database Syst Rev. 2016;1.

Saunders DH, Sanderson M, Hayes S, Kilrane M, Greig CA, Brazzelli M, Mead GE. Physical fitness training for stroke patients. Cochrane Database Syst Rev. 2016;3.

Schulzke SM, Kaempfen S, Trachsel D, Patole SK. Physical activity programs for promoting bone mineralization and growth in preterm infants. Cochrane Database Syst Rev. 2014;4.

Seron P, Lanas F, Pardo Hernandez H, Bonfill Cosp X. Exercise for people with high cardiovascular risk. Cochrane Database Syst Rev. 2014;8.

Shaw KA, Gennat HC, O'Rourke P, Del Mar C. Exercise for overweight or obesity. Cochrane Database Syst Rev. 2006;4.

Shepherd E, Gomersall JC, Tieu J, Han S, Crowther CA, Middleton P. Combined diet and exercise interventions for preventing gestational diabetes mellitus. Cochrane Database Syst Rev. 2017;11.

Sibilitz KL, Berg SK, Tang LH, Risom SS, Gluud C, Lindschou J, Kober L, Hassager C, Taylor RS, Zwisler AD. Exercise-based cardiac rehabilitation for adults after heart valve surgery. Cochrane Database Syst Rev. 2016;3.

Silva IS, Fregonezi GAF, Dias FAL, Ribeiro CTD, Guerra RO, Ferreira GMH. Inspiratory muscle training for asthma. Cochrane Database Syst Rev. 2013;9.

States RA, Pappas E, Salem Y. Overground physical therapy gait training for chronic stroke patients with mobility deficits. Cochrane Database Syst Rev. 2009;3.

Strike K, Mulder K, Michael R. Exercise for haemophilia. Cochrane Database Syst Rev. 2016;12.

Takken T, Van Brussel M, Engelbert RH, van der Net JJ, Kuis W, Helders P. Exercise therapy in juvenile idiopathic arthritis. Cochrane Database Syst Rev. 2008;2.

Taylor RS, Sagar VA, Davies EJ, Briscoe S, Coats AJS, Dalal H, Lough F, Rees K, Singh SJ, Mordi IR. Exercise-based rehabilitation for heart failure. Cochrane Database Syst Rev. 2014;4.

Thomas D, Elliott EJ, Naughton GA. Exercise for type 2 diabetes mellitus. Cochrane Database Syst Rev. 2006;3.

Ussher MH, Taylor AH, Faulkner GEJ. Exercise interventions for smoking cessation. Cochrane Database Syst Rev. 2014;8.

Valentín-Gudiol M, Mattern-Baxter K, Girabent-Farrés M, Bagur-Calafat C, Hadders-Algra M, Angulo-Barroso RM. Treadmill interventions in children under six years of age at risk of neuromotor delay. Cochrane Database Syst Rev. 2017;7.

van der Heijden RA, Lankhorst NE, van Linschoten R, Bierma-Zeinstra SMA, van Middelkoop M. Exercise for treating patellofemoral pain syndrome. Cochrane Database Syst Rev. 2015;1.

Vloothuis JDM, Mulder M, Veerbeek JM, Konijnenbelt M, Visser-Meily JMA, Ket JCF, Kwakkel G, van Wegen EEH. Caregiver-mediated exercises for improving outcomes after stroke. Cochrane Database Syst Rev. 2016;12.

Voet NBM, van der Kooi EL. Riphagen, II, Lindeman E, van Engelen BGM, Geurts ACH: strength training and aerobic exercise training for muscle disease. Cochrane Database Syst Rev. 2013;7.

White CM, Pritchard J, Turner-Stokes L. Exercise for people with peripheral neuropathy. Cochrane Database Syst Rev. 2004;4.

Wieland LS, Skoetz N, Pilkington K, Vempati R, D'Adamo CR, Berman BM. Yoga treatment for chronic non-specific low back pain. Cochrane Database Syst Rev. 2017;1.

Williams AD, Bird ML, Hardcastle SGK, Kirschbaum M, Ogden KJ, Walters JAE. Exercise for reducing falls in people living with and beyond cancer. Cochrane Database Syst Rev. 2018;10.

Williams MA, Srikesavan C, Heine PJ, Bruce J, Brosseau L, Hoxey-Thomas N, Lamb SE. Exercise for rheumatoid arthritis of the hand. Cochrane Database Syst Rev. 2018;7.

Yamamoto S, Hotta K, Ota E, Matsunaga A, Mori R. Exercise-based cardiac rehabilitation for people with implantable ventricular assist devices. Cochrane Database Syst Rev. 2018;9.

Yamato TP, Maher CG, Saragiotto BT, Hancock MJ, Ostelo R, Cabral CMN, Menezes Costa LC, Costa LOP. Pilates for low back pain. Cochrane Database Syst Rev. 2015;7.

Yang ZY, Zhong HB, Mao C, Yuan JQ, Huang YF, Wu XY, Gao YM, Tang JL. Yoga for asthma. Cochrane Database Syst Rev. 2016;4.

Young J, Angevaren M, Rusted J, Tabet N. Aerobic exercise to improve cognitive function in older people without known cognitive impairment. Cochrane Database Syst Rev. 2015;4.

Zainuldin R, Mackey MG, Alison JA. Optimal intensity and type of leg exercise training for people with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2011;11.

Mok A, Khaw K-T, Luben R, Wareham N, Brage S. Physical activity trajectories and mortality: population based cohort study. Bmj. 2019;365:l2323.

Ekelund U, Brown WJ, Steene-Johannessen J, Fagerland MW, Owen N, Powell KE, Bauman AE, Lee IM. Do the associations of sedentary behaviour with cardiovascular disease mortality and cancer mortality differ by physical activity level? A systematic review and harmonised meta-analysis of data from 850 060 participants. Br J Sports Med. 2019;53(14):886–94. https://doi.org/10.1136/bjsports-2017-098963 . Epub 2018 Jul 10.

Article   PubMed   Google Scholar  

Ekelund U, Steene-Johannessen J, Brown WJ, Fagerland MW, Owen N, Powell KE, Bauman A, Lee IM. Does physical activity attenuate, or even eliminate, the detrimental association of sitting time with mortality? A harmonised meta-analysis of data from more than 1 million men and women. Lancet. 2016;388(10051):1302–10.

Lear SA, Hu W, Rangarajan S, Gasevic D, Leong D, Iqbal R, Casanova A, Swaminathan S, Anjana RM, Kumar R, et al. The effect of physical activity on mortality and cardiovascular disease in 130000 people from 17 high-income, middle-income, and low-income countries: the PURE study. Lancet. 2017;390(10113):2643–54.

Sattelmair J, Pertman J, Ding EL, Kohl HW 3rd, Haskell W, Lee IM. Dose response between physical activity and risk of coronary heart disease: a meta-analysis. Circulation. 2011;124(7):789–95.

Heyman E, Gamelin FX, Goekint M, Piscitelli F, Roelands B, Leclair E, Di Marzo V, Meeusen R. Intense exercise increases circulating endocannabinoid and BDNF levels in humans--possible implications for reward and depression. Psychoneuroendocrinology. 2012;37(6):844–51.

Horton R. Offline: the gravy train of systematic reviews. Lancet. 2019;394(10211):1790.

Guthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1.9 million participants. Lancet Glob Health. 2018;6(10):e1077–86.

Fletcher GF, Landolfo C, Niebauer J, Ozemek C, Arena R, Lavie CJ. Promoting physical activity and exercise: JACC health promotion series. J Am Coll Cardiol. 2018;72(14):1622–39.

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Additional file 1:.

Supplementary Table 1. Main characteristics of included Cochrane systematic reviews evaluating the effects of physical activity/exercise on health outcomes ( n  = 150). Supplementary Table 2. Additional information from Cochrane systematic reviews of the effects of physical activity/exercise on health outcomes ( n  = 150). Supplementary Table 3. Conclusions from Cochrane systematic reviews “quote”. Supplementary Table 4 . AEs reported in Cochrane systematic reviews. Supplementary Table 5. Summary of withdrawals/non-adherence. Supplementary Table 6. Methodological quality assessment of the included Cochrane reviews with AMSTAR-2. Supplementary Table 7. Number of studies assessed as low risk of bias per domain. Supplementary Table 8. GRADE for the review’s main comparison. Supplementary Table 9. Studies reporting quality of life outcomes as mean difference.

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Posadzki, P., Pieper, D., Bajpai, R. et al. Exercise/physical activity and health outcomes: an overview of Cochrane systematic reviews. BMC Public Health 20 , 1724 (2020). https://doi.org/10.1186/s12889-020-09855-3

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Physical inactivity is a modifiable risk factor (similar to dyslipidemia and hypertension) for a variety of chronic diseases, including cancer and cardiovascular disease. Exercise provides a clear health benefit, which serves in the primary and secondary prevention of these disease processes (the most important being a reduction in cardiovascular disease and premature death). The physiologic mechanisms for such a benefit occur at both a cellular and multisystem level. Prolonged periods of occupational or leisure-time sitting have adverse health effects independent of exercise performed before or after. Almost any form of physical activity (PA) is beneficial, whether part of a regular exercise program or as a series of intermittent, incidental, non-purposeful, lifestyle-embedded activity (causing non-exercise activity thermogenesis or NEAT). The health benefits of exercise appear to be dose-dependent. Physicians should recommend near daily exercise which includes at various times strength training, stretching, and aerobic activity in addition to emphasizing adjustments that allow for reduced sitting and increased activity during daily routines. Patients should understand that for optimal health, exercise is no longer optional.

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Introduction

Physical inactivity is a modifiable risk factor for cardiovascular disease, obesity, depression, cancer, diabetes mellitus, hypertension, and osteoporosis. Physical exercise reduces the risk of premature death and prolongs longevity, and is an important treatment modality in the primary and secondary prevention of the above disorders [ 1 ]. For most states in this country, less than half of the population meets CDC exercise recommendations [ 2 •]. The decline in physical activity (PA) occurs both at work and in leisure time, and may have at least partially contributed to the increase in obesity over the past 30 years. Low recreational physical activities have been associated with a threefold increase for major weight gain in men and a fourfold increase in women [ 3 ]. Surveys of PA across the lifecycle show that physical exercise peaks in the middle high-school age range and begins declining through high school and into adult life. A vicious cycle of decline occurs between inactivity and loss of skeletal muscle mass which accelerates with age. With avoidance of activity requiring effort, there is increased loss of exercise capacity. This loss causes the perception of effort associated with even sub-maximal work to worsen, as the anaerobic threshold decreases. The vicious cycle contributes to further inactivity and deterioration of physical function. The only treatment that can break the cycle is exercise.

Impact of Exercise on Aging

Exercise provides powerful health benefits for quality of life, physical function, and independent living throughout the life cycle. Exercise impedes the aging process and promotes longevity. Observational studies have shown that even in the presence of disease processes such as hypertension (HTN), chronic obstructive pulmonary disease (COPD), diabetes, smoking, high body mass index (BMI), and hypercholesterolemia, increasing PA has a dose-dependent effect in decreasing relative risk of death [ 4 ]. In a study of subjects over a 13-year time period, both baseline fitness, and improvement in physical fitness through exercise and PA was associated with significant increases in longevity [ 4 ]. Functional independence with advanced age relates to the overall level of physical fitness. Physical fitness is most affected by the status of the cardiorespiratory and vascular systems, as well as muscle function [ 5 •].

Garatachea et al. provide an excellent review of the effect of exercise on the physiologic changes associated with aging [ 5 •]. Exercise exerts its positive influence on both a cellular level and at the level of organ systems. At the cellular level, exercise helps reduce genomic instability, epigenetic alteration, loss of proteostasis, dysregulated nutrient sensing, cellular senescence, and altered intracellular communication that leads to inflammation. These effects alter the way the body performs transcellular signaling in the skeletal muscle, the turning on and off of genes through epigenetics, and the manner in which the system manages reactive oxygen species [ 5 •]. On a multisystem level, the benefits of exercise include improvement in brain, cardiovascular, lung, and muscle function, favorable alterations in body composition, and advantageous changes in metabolic responses. The report concludes by suggesting that in the future, pharmaceuticals should be designed which mimic the effects of exercise on the aging process [ 5 •].

Effect of Exercise on Treatment of Disease

Robert Butler from the National Institute on Aging has said that “If exercise could be put in a bottle, it would be the strongest medicine money could buy” [ 6 ]. Exercise helps prevent common chronic diseases (primary prevention), and often plays an important role in the treatment of these disease processes (secondary prevention). Specific benefits from exercise have been seen with cardiovascular disease, stroke, diabetes mellitus, depression, cancer, obesity, and osteoporosis [ 7 , 8 ]

Cardiovascular Disease

Increased levels of PA and physical fitness have a graded effect in reducing the risk of death from cardiovascular disease. The relative risk from all cause and cardiovascular disease mortality is reduced 20–35 % by exercise and PA [ 9 ]. In an observational study, subjects in the lowest quintile of exercise had a relative risk of 3.4 in men and 4.7 in women for death compared to those in the highest quintile [ 10 ]. An increase in activity-related energy expenditure by as little as 1000 kcal or 1 metabolic equivalent (MET)-hour of exercise per week has a mortality benefit of 20 % [ 11 ]. Physically inactive women have a 52 % increase in death, a cardiovascular disease-related death that is doubled, and a cancer-related death rate that is increased by 29 % [ 11 ]. These risks on mortality from inactivity are similar to other modifiable risk factors such as HTN, hypercholesterolemia, and obesity. In randomized controlled trials (RCT)s, exercise and PA are valuable for the secondary prevention of cardiovascular disease. Whereas in the past, traditional recommendations for patients with a heart attack included rest and physical inactivity. Newer information demonstrates that exercise actually attenuates or reverses risk of cardiovascular disease [ 12 ]. The benefit of exercise is seen in cardiac rehabilitation, where increasing PA reduces the risk of premature death following a myocardial infarction [ 12 ]. Added energy expenditure of 1600 kcal/week from exercise may halt the progression of heart disease and energy expenditure of >2200 kcal/week can lead to plaque reduction [ 13 ]. The minimum training recommendation for patients following myocardial infarction is to reach 45 % of their heart rate reserve through cardiac rehabilitation [ 12 , 13 ].

Multiple mechanisms have been identified whereby exercise reduces the risk of premature death [ 4 ]. Exercise affects body composition by decreasing abdominal adiposity and improving weight control. Exercise enhances lipid profiles by reducing serum triglyceride levels, raising HDL, and reducing the LDL/HDL ratio. In addition, a recent meta-analysis showed beneficial changes in lipoprotein subclasses associated with regular exercise including a reduction in small LDL-p and an increase in large LDL-p [ 14 ]. Exercise enhances hemodynamics by decreasing blood pressure, increasing cardiac function, and improving coronary blood flow. Autonomic tone is enhanced and shear stress-mediated endothelial function is improved. Exercise reduces systemic inflammation, as evidenced by reduced C-reactive protein (CRP) levels. Improved psychological well-being in response to exercise is associated with reduced stress, anxiety, and depression [ 4 ].

PA is inversely correlated with risk of incident stroke as shown in a large nurses’ health study [ 15 ]. Habitual exercise reduces risk of stroke by 40–50 % at the highest level of PA. Change in PA is protective against stroke as evidenced by the fact that an increase of 3.5 h of exercise or PA per week is associated with a 29 % reduction in ischemic stroke [ 15 ].

Diabetes Mellitus

Exercise is valuable in both the primary and secondary prevention of diabetes mellitus. Aerobic and resistant-type exercise reduces the likelihood of developing type-2 diabetes mellitus. For each 500 kcal of energy expended per week, there is an associated 6 % reduction in the likelihood of type-2 diabetes (which may be even greater with increasing BMI) [ 16 ]. In patients already diagnosed to have diabetes mellitus, walking 2 h per week is associated with a 39–54 % reduction in all-cause mortality from diabetes mellitus, and a 34–53 % reduction in mortality related to cardiovascular disease [ 17 ]. The benefit of exercise on glycemic control appears to be greater with resistance training than aerobic exercise. A meta-analysis of exercise and PA in diabetes showed that exercise reduces hemoglobin A1C by 0.66 %, an effect similar to intensive glucose-lowering pharmacologic therapy [ 18 ]. The mechanisms by which exercise benefits diabetes relate to the fact that exercise increases glycogen synthetase and hexokinase activity [ 4 ]. Exercise reduces GLUT-4 protein and messenger RNA expression and increases muscle capillary density, which helps improve glucose delivery to the muscle [ 4 ].

Increasing PA, either occupational or at leisure, has been shown to exert a primary preventative effect on two cancers—breast and colon cancer [ 19 ]. Moderate exercise of as little as 4–5 METs (equivalent to mowing the lawn or brisk walking), is required to achieve this effect [ 20 ]. Exercise is associated with a 20–30 % reduction in the incidence of breast cancer in women, and a 30–40 % reduction in the incidence of colon cancer in both men and women [ 20 ]. In those patients already diagnosed to have one of these cancers, exercise reduces the likelihood for cancer recurrence and reduces risk from cancer death by as much as 26–40 % [ 21 ]. PA improves quality of life and overall health status in cancer patients. The mechanisms by which exercise improves risk from cancer may relate to reduced fat stores, an increase in energy expenditure offsetting a high-fat diet, activity-related changes in sex hormone levels, improvement in immune function, and reduced generation of free oxygen radicals [ 4 ].

Osteoporosis

Exercise has a valuable effect in the primary prevention of osteoporosis. Routine PA minimizes age-related bone loss. Weight-bearing exercise (especially resistance exercise) increases bone density compared to low impact non-weight-bearing exercise. Exercise prevents 1 % of bone loss per year, an effect which is greater in post-menopausal than pre-menopausal women [ 22 ]. In RCTs, exercise reduces the risk and number of falls, as well as the risk of fracture [ 22 ]. Even in men, PA reduces the risk of fracture by 62 % over the age of 21 years [ 23 ]. Exercise is also valuable in the secondary prevention of osteoporosis. RCTs in the past have shown that exercise with resistance training increases bone density in older osteoporotic women by as much as 1.4 %, while agility training alone increases bone density by 0.5 % [ 24 ]. Stretching, which was used as sham control, was shown to have no effect on the expected decrease in bone density with age [ 24 ]. In a 12-year follow up of over 60,000 post-menopausal women, risk of hip fracture was lowered 6 % for each increase of three MET-hours per week of activity (the equivalent of walking three miles in 1 h) [ 25 ]. Active women with at least 24 met-hours of exercise per week had a 55 % lower risk of hip fracture than sedentary women with no other exercise. Walking at least 4 h per week was associated with a 41 % lower risk of hip fracture than walking less than one hour per week [ 25 ].

Exercise has a valuable therapeutic effect on the treatment on multiple types of depression, including dysthymic, seasonal, bipolar, post-natal, pre-menstrual, atypical, and major depression [ 26 ]. The value in treating depression comes from an innate anti-depressive effect from exercise. Combining exercise with psychotropic medications achieves better treatment results than the same medications alone [ 26 ]. Exercise is relatively inexpensive, safe, and has minimal side effects when done correctly. Exercise may help reduce the dose of anti-depressive medications required. Subjects are less likely to relapse with an active exercise program [ 26 ].

The patients with depression who are most likely to benefit from exercise include those with age <20 or >40 years, higher education, higher baseline physical status, females, untrained subjects, and those with mild to moderate depression [ 26 ]. There are a number of aspects of exercise that get the optimal results in treating depression including programs that are structured, individually tailored to the patient, low to moderate intensity, when it is used as an adjunct to medication therapy, and exercise that is a combination of aerobic or resistive training performed 3–4 times per week [ 26 ]. The mechanism of effect from exercise on depression occurs on a systemic level as well as a direct effect on central nervous system (CNS) function. Exercise appears to increase serotonin, ACTH, endorphins, and endocannabinoids within the CNS. On a systemic level, exercise increases norepinephrine and reduces cortisol, tumor necrosis factor (TNF), and interleukin-6 [ 26 ].

In a controversial article that appeared in Time magazine in 2009, the journalist John Cloud wrote about “The Myth of Exercise” and its effect on treating obesity [ 27 ]. The article suggested that exercise was not good for weight management in obesity. The author pointed out that exercise leads to increased appetite and intake of food and causes a decrease in non-exercise energy expenditure, and therefore that exercise was a poor strategy for weight loss [ 27 ]. A number of letters to the editor of Time magazine followed the publication of this article, including letters from the American Society for Sports Medicine, arguing that facts were misrepresented and that the article gave the wrong message about the health benefits of exercise.

A recent review by Swift clarified the role of exercise in managing or preventing obesity, and suggested that Cloud’s article was in fact an accurate portrayal of the facts [ 28 ]. The key issue of Swift’s review is that exercise without caloric restriction is unlikely to succeed in weight loss [ 28 ]. Increasing PA can prevent weight gain, but it requires 150–250 min per week of moderate to vigorous exercise or 1200–2000 kcal/week expended through exercise to accomplish this feat [ 29 ]. Aerobic exercise by itself is minimally helpful in promoting weight loss, successful in loss of only 0–2 kg total [ 29 ]. Extreme high-volume aerobic exercise can achieve significant weight loss, but this is usually unsustainable by most obese patients. Moderate intensity, surprisingly, is no different than vigorous intensity in achieving weight loss, unless subjects are matched for exercise duration. Resistance training by itself has no impact on weight loss, and aerobic training combined with resistant training has no greater effect than aerobic training alone. However, adding caloric restriction to aerobic training does result in successful weight loss of 9–13 kg, and higher intensity of exercise has the potential for even greater weight loss [ 29 ]. Some obese subjects do experience weight compensation in response to exercise, defined by the circumstances where less weight is lost than expected with the amount of exercise sustained, often a factor related to an increase in caloric intake [ 28 , 30 ]. This is more likely to occur in women performing 150 % of weekly recommendations (compared to women performing only 100 % or 50 % of weekly recommendations) [ 28 , 30 ]. Even if minimal or no weight loss occurs in response to exercise, obese subjects still benefit from the increase in PA due to increased cardiorespiratory fitness, glucose control, endothelial function, improvements in hyperlipidemia, quality of life, and a reduction in future weight gain [ 28 ].

Caloric restriction is better than exercise for significant weight loss initially, and the weight loss is not necessarily enhanced significantly by adding exercise [ 28 ], although exercise training plus caloric restriction does improve body composition by increasing fat loss and decreasing loss of lean body mass [ 31 ]. The greatest value of exercise in the management of obesity occurs not in the initial weight loss, but in the situation where obese patients have lost weight successfully and now require substantial PA to maintain that weight loss [ 28 ]. Interestingly, an “energy gap” has been identified as the difference in energy expenditure before and after weight loss [ 32 ]. The energy gap is estimated to be approximately 8 kcal per day per pound of weight lost. An energy gap, for example, of 40 lbs lost would be associated with 320 kcal of energy. Sustaining this weight loss successfully would require either a continued reduction in energy consumption by 320 kcal per day, or increasing activity-associated energy expenditure by the same amount [ 32 ]. Based on the Set Point theory, both biological and environmental pressures oppose the strategy of food restriction in keeping weight off, but the same effect does not occur with increased PA [ 32 ]. Therefore, while food restriction is the key to weight loss, PA is the key to successful maintenance of the weight lost [ 32 ]. The ACSM has identified that people who successfully maintain weight loss average at least 250 min of PA per week [ 29 ].

Low Back Pain

A 2016 systematic review and meta-analysis reviewed 23 randomized controlled trials evaluating the prevention of low back pain [ 33 ]. Over 30,000 patients were involved in these studies. Ultimately, the combination of exercise (varying regimens of abdominal strengthening, core stability, cardiovascular, and isometrics) plus education regarding prevention of low back pain was found to reduce the risk of low back pain as well as sick leave related to low back pain. Exercise alone was also found to have an impact but had a more short term effect (<12 months), thought to be due to cessation of exercise following the intervention. Other interventions, including back belts, insoles, and education alone were not found to have any impact [ 33 ].

Not All Exercise is Created Equal

Physical activity versus physical fitness.

The lay public tends to use the terms PA and physical fitness interchangeably, but subtle differences between the two exist. Physical fitness is a physiologic state of being with regard to daily living and/or sports performance [ 4 ]. Physical fitness is comprised of cardiovascular, musculoskeletal, body composition, and metabolic components [ 4 ]. Physical fitness is similar to PA, but is more predictive of health outcomes. For example, a high-fit versus a low-fit person is estimated to have a 50 % lower mortality [ 34 ]. Physical fitness, therefore, becomes a better measure of PA than self-reporting. From a public health standpoint, however, it is better and more productive to encourage the public to be physically active and not push the need to be physically fit. Eventually, increased activity should lead to physical fitness.

In the past, guidelines for optimal health seemed to have had a singular focus on aerobic fitness. But a new paradigm shift has occurred with the addition of the concept of musculoskeletal fitness [ 4 ]. In other words, health status can improve due to increased PA in the absence of changes in aerobic fitness. Regular PA can decrease risk factors from chronic disease and disability without changing cardiac output or oxidative potential, especially in the elderly [ 4 ]. The shift has been to focus on the health benefits of musculoskeletal fitness, which may be a critical factor in the functional threshold for dependence with the aging population. Loss of muscular fitness can result in loss of capacity for daily living, and a cycle of decline can ensue [ 4 ]. Improvement in musculoskeletal function can delay the onset of disability, dependence, and chronic disease [ 35 ]. Musculoskeletal fitness is associated with fewer functional limitations and a reduced incidence of cardiovascular disease, diabetes, degenerative joint disease, and coronary artery disease [ 35 ]. Therefore, resistance training that works all the major muscle groups (including legs, hips, back, abdomen, chest, shoulders, and arms) and flexibility exercise, which are necessary to achieve musculoskeletal fitness, are recommended to be done at least twice weekly, to complement aerobic fitness and optimize overall health status.

Adverse Health Risk from Sitting

In an effort to delineate those factors which contribute to the obesity epidemic, researchers are increasingly focused on the adverse health risk from prolonged sitting [ 36 •]. A newly recognized occupational hazard has evolved because of workers needing to sit at a computer screen throughout the workday. Each mean hour of sitting after a total mean of 7 h per day is associated with a 5 % increase in premature death [ 36 •]. More time sitting at work has been shown to correlate with more sitting in leisure time. Prolonged sitting while watching TV at home, for example, has adverse effects on mental health, well-being, and muscle strength. Long sedentary hours have been linked to a twofold increase in diabetes, a twofold increase in cardiovascular disease, a 13 % increase in the incidence of cancer, and a 17 % increase in mortality related to cancer [ 36 •]. It is estimated that the average worker in the USA and England spends 60–70 % of waking hours in a sedentary sitting position. The effect of sitting has been likened to the transmission of a car. Sitting for such a prolonged period is like putting a car in reverse, causing one’s overall health status to go in the wrong direction [ 36 •]. Approximately 20–30 % of the time is spent in light intensity activity, described as postural changes, standing and movement, or ambulation. For less than 5–10 % of waking hours, individuals spend in moderate to vigorous PA. The adverse effect of sitting on health status is independent of the exercise or PA done before or after [ 36 •]. In other words, no amount of PA later can overcome the negative health effects of prolonged sitting.

Changes in the workplace environment may be the key issue to minimizing the negative effects of prolonged sitting. Particularly, in the UK, recommendations and guidelines have been developed to avoid this health hazard [ 36 •]. Workers are encouraged to accumulate up to 2 h per day at work standing or performing light walking, with the goal to progress ultimately to 4 h per day. Workers should interrupt seat-based work with standing-based work. However, workers should avoid both prolonged periods of standing as well as prolonged periods of sitting. Adaptation of these guidelines may lead to musculoskeletal complaints and fatigue, which should be monitored by managers in the workplace. Such health promotion strategies should eventually extend from the workplace to the leisure time [ 36 •].

Non-Exercise Activity Thermogenesis

Non-exercise activity thermogenesis (NEAT) has been described as unstructured PA, energy expended unrelated to sleeping, eating, or sports exercise. NEAT is energy expended outside of purposeful exercise [ 37 ]. Surprisingly, this incidental, non-purposeful lifestyle-embedded PA can have tremendous health benefits. Three components of NEAT include body posture, ambulation, and all other movements (the most important of which may be fidgeting) [ 38 ]. Researchers involved in the study of obesity are finding that in some cases what delineates the lean subject from an obese one is a difference in NEAT, not exercise-associated activity thermogenesis [ 38 ]. Early experiments which helped identify NEAT came from studies where energy requirements were measured and all subjects were placed on a diet of 1000 cal over requirements [ 39 ]. Subjects were then videotaped, and in a blinded fashion designated as fidgeters or non-fidgeters. At the end of the trial, those patients who were designated as fidgeters failed to gain weight, while those identified to be non-fidgeters sustained significant weight gain. The increase in kilocalories of energy expenditure attributed to NEAT was inversely proportional to fat gain in pounds [ 39 ]. NEAT ranges from 15 % of total energy expenditure (TEE) in sedentary subjects to as much as 50 % of TEE in fidgeting physically active people [ 39 ]. Fidgeting has been shown in twin studies to be genetic, with an estimated >62 % heritability [ 40 ]. Simply standing or lightly ambulating can increase energy expenditure by an average of 350 kcal/day (range 269–477 kcal/day) [ 37 ]. NEAT tends to be greater in men than women, in obese subjects rather than lean, and in those with more education than those with less [ 38 , 39 ]. NEAT tends to be seasonal and overall, declines with age [ 39 ]. The concept of an energy gap is pertinent to NEAT. An average citizen in the USA has been shown to gain 1–2 lbs each year through their adult life. An energy gap of 100 kcal additional energy consumed each day would account for this weight gain [ 41 ]. NEAT can be an important contributor to TEE, such that increases in NEAT of as little as 100–150 kcal of activity per day could prevent such weight gain (by offsetting the energy gap) in the vast majority of people [ 41 ]. Recommendations now suggest that if you were not lucky enough to inherit fidgeting, you should “act like a fidgeter,” standing often, getting up from sitting, pacing, parking at the back of a parking lot, and taking stairs instead of elevators [ 40 ].

Continuous Versus Interval Exercise

Long bouts of continuous exercise as a strategy for weight loss or weight maintenance can be a contentious and challenging recommendation for the general public. Longer duration, continuous exercise may be difficult and not particularly enjoyable for patients and may not fit as well with work or home schedules. Research now has shown that interval exercise, which involves alternating short bouts of high-intensity exercise with lower-intensity exercise that allows for partial recovery, can match the health benefits of continuous exercise [ 42 ]. Studies in patients with class-1 obesity (BMI 30–34.9 kg/m 2 ), walking at a moderate level of intensity, randomized to two 15-min intervals of walking versus one 30-min interval, showed essentially the same improvements in overall health status [ 42 ]. Both intermittent and continuous exercise resulted in improvement of maximum oxygen consumption, body composition, and lipid profiles. In some categories, interval exercise even exceeded the benefit seen with continuous exercise (such as VLDL levels and percent fat lost) [ 42 ]. The value of these findings for intermittent exercise stems from three factors: there is less attrition with recommendations for interval exercise, time constraints, and short periods of interval exercising may allow for greater intensity of PA [ 42 ]. An additional study involving 28 sedentary overweight or obese men compared five 45- to 60-min sessions of continuous moderate intensity cycling per week for 6 weeks with three 20-min sessions of high-intensity interval exercise per week (for a total of 60 min) for 6 weeks. Similar improvements in cardio-metabolic risk factors including improved insulin sensitivity, cardiovascular fitness, and a reduction in blood lipids and body fat percentage were observed in the groups [ 43 ]. While cardiovascular fitness was improved to a greater extent in the continuous exercise group, this study, along with numerous other studies of interval exercise showing similar outcomes in different populations, are encouraging in that they show many of the same improvements in overall health with a substantially reduced time commitment [ 43 ]. This is especially relevant as lack of time is cited as the most common reason for not exercising by many. In addition, interval exercise can be easily adapted to an individual’s starting fitness level by adjusting either the duration or intensity (or both) of the high-intensity component of exercise. This may be especially beneficial for sedentary overweight or obese individuals who are new to exercise. In light of both the potential health and time saving benefits, interval exercise training appears to be an appealing and worthwhile exercise option in addition to, or instead of, continuous exercise. The good news for public health is that short walks on a subject’s lunch break or brief periods of activity before and after work all count, and the sum of their duration may have similar benefits to a single continuous interval of exercise of the same duration.

Success of Pedometers

The use of pedometers to increase PA was generated years ago in Japanese walking clubs. The rationalization for the pedometer was that the average stride was estimated to be 2.5 ft. Therefore, 2000 steps should approximately equal a mile, 10,000 equaling about 5 miles [ 44 ]. Based on this rationalization, PA can be classified as sedentary (<5000 steps per day), low active (5000 to 7500 steps), somewhat active (7500 to 10,000 steps), and active (>10,000 steps per day). Highly active physical exercise is associated with >12,500 steps per day [ 44 ]. This is an arbitrary categorization, however, and 10,000 steps per day may be too little for children or too much for the elderly. Weight loss using a pedometer without caloric restriction is associated with minimal to modest weight loss of <2 kg [ 44 ]. Health benefits associated with use of the pedometer may be limited to a reduction in blood pressure, with not much change in cholesterol, triglycerides, or fasting glucose [ 44 ].

Exercise in the Intensive Care Unit

Exercise is becoming increasingly important in one of the least expected circumstances, that of a critically ill patient in the intensive care unit (ICU). Researchers have found that exercising muscle increases the uptake of amino acid fuel and promotes greater protein synthesis [ 45 , 46 ]. Patients in the ICU on a ventilator in some centers are gotten out of bed and encouraged to walk with assistance in the hallway. Other centers have used a pedaling device, some of which can even be adapted for passive activity in a patient who is otherwise sedated and minimally responsive. Exercise in the critical care setting helps maintain muscular strength, reduces the risk for long-term neuromuscular weakness, shortens rehabilitation, and is more likely to result in the patient being discharged to their home [ 45 , 46 ].

Recommendations for Public Health

Similar to the Food Guide Pyramid designed by the USDA, an activity pyramid has been created to guide the public in strategies to increase flexibility, muscular strength, and aerobic capacity ( www.wellspan.org/media/3648/activitypyramid-2009.pdf ). Every day, subjects are encouraged to increase activity in leisure and at work. Three to five times per week, aerobic activity should occur, accumulating 150 min each week ( www.wellspan.org/media/3648/activitypyramid-2009.pdf ). Two to three times per week, muscular activity focusing on flexibility and strength training should be scheduled. Sitting more than 30 min at a time, watching TV, or staring at a computer screen should be minimized or reduced as much as possible ( www.wellspan.org/media/3648/activitypyramid-2009.pdf ).

Guidelines differentiate between moderate and vigorous intensity of PA. Moderate intensity is defined by a 3–5 MET level of effort, and includes activities that cause some increase in breathing and heart rate (such as walking 3–4 miles per hour, bicycling on level ground, light swimming, gardening, or mowing a lawn) [ 4 ]. Vigorous intensity is defined by ≥6 METs, and is exemplified by activities causing large increases in breathing, heart rate, and sweating. Such activities of vigorous intensity would include jogging or running at faster than a 10 min mile, aerobic dancing, competitive sports, heavy yard or construction work, brisk swimming, or fast bicycling [ 4 ].

The amount of PA needed to optimize health is not clear. The particular dose of exercise required to achieve benefits with regard to a particular disease process is difficult to ascertain. For cardiovascular disease, the intensity of PA is inversely and linearly associated with increased mortality, with the biggest effect seen as a reduction of premature death [ 47 ]. PA of >2000 kcal per week extends life by 1–2 years by age 80 [ 47 ]. An average energy expenditure of 1000 kcal per week is associated with a 20–30 % decrease in all-cause mortality. Beginning at a minimum of 1000 kcal per week, increasing benefits are seen with increasing energy expenditure, suggesting a dose-response gradient to the effect of exercise on cardiovascular health [ 47 ]. For diabetes mellitus, there is decreased risk from this disease process with PA of >5.5 METs for at least 40 min per week [ 48 ]. Walking 2 h per week decreases the risk of premature death from diabetes [ 48 ]. Moderate exercise defined by a >4.5 METs for 30–60 min per day reduces both the risk of colon cancer and breast cancer [ 19 ]. For women in particular, >7 h per week of moderate exercise has been shown to be successful in reducing risk of breast cancer (TI01). For osteoporosis, the dose-response gradient is less clear, with recommendations simply emphasizing that osteogenic adaptation is load-dependent and site-specific [ 4 ]. The Center for Disease Control (CDC), the American College of Sports Medicine, and the Healthy People 2010 recommendations provide guidelines for aerobic activity for public health purposes [ 49 ]. Adults should engage in PA of moderate intensity for at least 150 min per week or engage in PA of vigorous intensity for at least 75 min per week. Bouts of exercise may be broken up into smaller increments lasting at least 10 min [ 49 ].

Should Anyone Not be Exercising?

Jim Fixx was a celebrity journalist who helped contribute to the running craze seen in the 1980s in the USA. His sudden death from cardiovascular disease, while jogging, raised questions as to the need for medical evaluation prior to engaging in a program of increasing PA. Moderately strenuous PA may trigger ischemic events, particularly among sedentary people. There is an increased incidence of primary heart attack in high-intensity exercise. In competitive athletes, 80 % of deaths are caused by coronary artery disease. Some subjects do need to have their health risks assessed prior to engaging in an aggressive program.

The degree to which a person is evaluated prior to exercise depends on the presence or absence of cardiovascular disease risk factors and whether the exercise will be moderate or vigorous in intensity [ 50 ]. Subjects at low risk would be those who are young in age (<45 years for male, <55 years for female), are asymptomatic, and have ≤1 cardiovascular risk disease factors. These patients do not need a medical evaluation or stress test for moderate or even vigorous exercise. Subjects at moderate risk are older (men >45 years, women >55 years), or have ≥2 risk factors for cardiovascular disease. For moderate exercise, no medical evaluation may be needed, but these subjects should undergo a stress test. If exercise of vigorous intensity is planned, both a medical evaluation and a stress test should be performed. For those patients at high risk, however, defined by ≥1 sign or symptom of cardiovascular, pulmonary, or metabolic disease, both a full medical evaluation and stress test should be performed before any program is undertaken [ 50 ].

Specifically, those subjects who should not be exercising are those experiencing an acute myocardial infarction, subjects with unstable angina, systolic blood pressure >180, diastolic pressure >110 ml/Hg, uncontrolled diabetes mellitus, poorly controlled congestive heart failure, or thrombophlebitis [ 50 ].

While formal studies have shown that physician counseling is time-intensive and only minimally effective in changing behavior, physicians should no longer avoid the subject of recommendations for exercise as part of the healthcare they deliver to their patients. Physicians can begin by suggesting lifestyle changes such as climbing stairs at work, parking further away from the door on errands, walking regularly, and doing chores at home and in the yard. Clinicians should write on a prescription pad for the patient, specifying the type of exercise, duration, frequency, and intensity. The physician upon discharge from an office visit should determine plans for support and follow up to encourage success, manage obstacles, and prevent relapses. Clinicians should encourage their outpatients to involve community services such as physical therapy, mall-walking programs, school tracks, safe neighborhoods, the YMCA, and walk-a-thon’s.

Physicians should counsel that exercise is not an option. The exercise does not have to be continuous to be effective, and any physical activity counts. Patients should sit less, stand more, and plan their exercise activity at the beginning of each week. Subjects should be encouraged to find activities which they enjoy and involve others to maintain compliance. As Edward Stanley, the Earl of Derby in 1873 said, “Those who think they have not time for bodily exercise will sooner or later have to find time for illness” [ 51 ].

Papers of particular interest, published recently, have been highlighted as: • Of importance

Rezende LF, Rey Lopez JP, Matsudo VK, Luiz OD. Sedentary behavior and health outcomes among older adults: a systematic review. BMC Public Health. 2014;14(1):333.

Article   PubMed   PubMed Central   Google Scholar  

www.cdc.gov/nchs/fastats/exercise.htm . Accessed June 12, 2016. Center for Disease Control and Prevention statistics regarding current levels of PA in the United States and trends in physican recommendations to patients relevant to exercise.

Lee IM, Djoussé L, Sesso HD, Wang L, Buring JE. Physical activity and weight gain prevention. JAMA. 2010;303(12):1173–9.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. CMAJ. 2006;174(6):801–9.

Garatachea N, Pareja-Galeano H, Sanchis-Gomar F, Santos-Lozano A, Fiuza-Luces C, Morán M, et al. Exercise attenuates the major hallmarks of aging. Rejuvenation Res. 2015;18(1):57–89. Discussion regarding the exercise mediated attenuation of physical fitness and functional decline in aging.

"Working With Special Populations Sport Essay." UKessays.com. 11 2013. All Answers Ltd. 06 2016 < https://www.ukessays.com/essays/sports/working-with-special-populations-sport-essay.php?cref=1 >

Blumenthal JA, Babyak MA, Moore KA, Craighead WE, Herman S, Khatri P, et al. Effects of exercise training on older patients with major depression. Arch Intern Med. 1999;159(19):2349–56.

Article   CAS   PubMed   Google Scholar  

Byrne A, Byrne DG. The effect of exercise on depression, anxiety and other mood states: a review. J Psychosom Res. 1993;37(6):565–74.

Macera CA, Hootman JM, Sniezek JE. Major public health benefits of physical activity. Arthritis Rheum. 2003;49(1):122–8.

Article   PubMed   Google Scholar  

Blair SN, Kohl 3rd HW, Paffenbarger Jr RS, Clark DG, Cooper KH, Gibbons LW. Physical fitness and all-cause mortality. A prospective study of healthy men and women. JAMA. 1989;262(17):2395–401.

Hu FB, Willett WC, Li T, Stampfer MJ, Colditz GA, Manson JE. Adiposity as compared with physical activity in predicting mortality among women. N Engl J Med. 2004;351(26):2694–703.

Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004;116(10):682–92.

Hambrecht R, Niebauer J, Marburger C, Grunze M, Kälberer B, Hauer K, et al. Various intensities of leisure time physical activity in patients with coronary artery disease: effects on cardiorespiratory fitness and progression of coronary atherosclerotic lesions. J Am Coll Cardiol. 1993;22(2):468–77.

Sarzynski MA1, Burton J2, Rankinen T2, Blair SN3, Church TS2, Després JP4, et al. The effects of exercise on the lipoprotein subclass profile: a meta-analysis of 10 interventions. Atherosclerosis. 2015;243(2):364–72.

Hu FB, Stampfer MJ, Colditz GA, Ascherio A, Rexrode KM, Willett WC, et al. Physical activity and risk of stroke in women. JAMA. 2000;283(22):2961–7.

Helmrich SP, Ragland DR, Leung RW, Paffenbarger Jr RS. Physical activity and reduced occurrence of non-insulin-dependent diabetes mellitus. N Engl J Med. 1991;325(3):147–52.

Gregg EW, Gerzoff RB, Caspersen CJ, Williamson DF, Narayan KM. Relationship of walking to mortality among US adults with diabetes. Arch Intern Med. 2003;163(12):1440–7.

Boulé NG, Haddad E, Kenny GP, Wells GA, Sigal RJ. Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials. JAMA. 2001;286(10):1218–27.

Thune I, Furberg AS. Physical activity and cancer risk: dose-response and cancer, all sites and site-specific. Med Sci Sports Exerc. 2001;33(6 Suppl):S530–50. discussion S609-10.

Lee IM. Physical activity and cancer prevention—data from epidemiologic studies. Med Sci Sports Exerc. 2003;35(11):1823–7.

Holmes MD, Chen WY, Feskanich D, Kroenke CH, Colditz GA. Physical activity and survival after breast cancer diagnosis. JAMA. 2005;293(20):2479–86.

Wolff I, van Croonenborg JJ, Kemper HC, Kostense PJ, Twisk JW. The effect of exercise training programs on bone mass: a meta-analysis of published controlled trials in pre- and postmenopausal women. Osteoporos Int. 1999;9(1):1–12.

Kujala UM, Kaprio J, Kannus P, Sarna S, Koskenvuo M. Physical activity and osteoporotic hip fracture risk in men. Arch Intern Med. 2000;160(5):705–8.

Liu-Ambrose TY, Khan KM, Eng JJ, Heinonen A, McKay HA. Both resistance and agility training increase cortical bone density in 75- to 85-year-old women with low bone mass: a 6-month randomized controlled trial. J Clin Densitom. 2004;7(4):390–8.

Feskanich D, Willett W, Colditz G. Walking and leisure-time activity and risk of hip fracture in postmenopausal women. JAMA. 2002;288(18):2300–6.

Ranjbar E, Memari AH, Hafizi S, Shayestehfar M, Mirfazeli FS. Eshghi MA. J Sports Med. 2015;6(2):e24055.

Google Scholar  

Cloud J. Why exercise won’t make you thin. Time. 2009;174(6):49–51.

Swift DL, Johannsen NM, Lavie CJ, Earnest CP, Church TS. The role of exercise and physical activity in weight loss and maintenance. Prog Cardiovasc Dis. 2014;56(4):441–7.

Donnelly JE, Blair SN, Jakicic JM, Manore MM, Rankin JW, Smith BK. American College of Sports Medicine. American College of Sports Medicine Position Stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc. 2009;41(2):459–71.

Church TS, Martin CK, Thompson AM, Earnest CP, Mikus CR, Blair SN. Changes in weight, waist circumference and compensatory responses with different doses of exercise among sedentary, overweight postmenopausal women. PLoS One. 2009;4(2):e4515.

Miller CT, Fraser SF, Levinger I, Straznicky NE, Dixon JB, Reynolds J, et al. The effects of exercise training in addition to energy restriction on functional capacities and body composition in obese adults during weight loss: a systematic review. PLoS One. 2013;8(11):e81692.

Hill JO, Thompson H, Wyatt H. Weight maintenance: what’s missing? J Am Diet Assoc. 2005;105(5 Suppl 1):S63–6.

Steffens D, Maher CG, Pereira LS, Stevens ML, Oliveira VC, Chapple M, et al. Prevention of low back pain: a systematic review and meta-analysis. JAMA Intern Med. 2016;176(2):199–208.

Myers J, Kaykha A, George S, Abella J, Zaheer N, Lear S, et al. Fitness versus physical activity patterns in predicting mortality in men. Am J Med. 2004;117(12):912–8.

Warburton DE, Gledhill N, Quinney A. Musculoskeletal fitness and health. Can J Appl Physiol. 2001;26(2):217–37.

Buckley JP, Hedge A, Yates T, Copeland RJ, Loosemore M, Hamer M, et al. The sedentary office: an expert statement on the growing case for change towards better health and productivity. Br J Sports Med. 2015;49(21):1357–62. Expert consensus on techniques to combat increased periods of sitting and inactivity in the modern workplace.

Tremblay MS, Esliger DW, Tremblay A, Colley R. Incidental movement, lifestyle-embedded activity and sleep: new frontiers in physical activity assessment. Can J Public Health. 2007;98 Suppl 2:S208–17.

PubMed   Google Scholar  

McManus AM. Physical activity—a neat solution to an impending crisis. J Sports Sci Med. 2007;6(3):368–73.

PubMed   PubMed Central   Google Scholar  

Levine JA. Non-exercise activity thermogenesis (NEAT). Nutr Rev. 2004;62(7 Pt 2):S82–97.

Bouchard C, Tremblay A. Genetic influences on the response of body fat and fat distribution to positive and negative energy balances in human identical twins. J Nutr. 1997;127(5 Suppl):943S–7S.

CAS   PubMed   Google Scholar  

Hill JO, Wyatt HR, Reed GW, Peters JC. Obesity and the environment: where do we go from here? Science. 2003;299(5608):853–5.

Campbell L, Wallman K, Green D. The effects of intermittent exercise on physiological outcomes in an obese population: continuous versus interval walking. J Sports Sci Med. 2010;9(1):24–30.

Fisher G, Brown AW, Bohan Brown MM, Alcorn A, Noles C, Winwood L, et al. High intensity interval- vs moderate intensity-training for improving cardiometabolic health in overweight or obese males: a randomized controlled trial. PLoS One. 2015;10(10):e0138853.

Tudor-Locke C, Bassett Jr DR. How many steps/day are enough? Preliminary pedometer indices for public health. Sports Med. 2004;34(1):1–8.

Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36(8):2238–43.

Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373(9678):1874–82.

Paffenbarger Jr RS, Hyde RT, Wing AL, Hsieh CC. Physical activity, all-cause mortality, and longevity of college alumni. N Engl J Med. 1986;314(10):605–13.

Lynch J, Helmrich SP, Lakka TA, Kaplan GA, Cohen RD, Salonen R, et al. Moderately intense physical activities and high levels of cardiorespiratory fitness reduce the risk of non-insulin-dependent diabetes mellitus in middle-aged men. Arch Intern Med. 1996;156(12):1307–14.

U.S. Department of Health and Human Services. Healthy People 2010: Understanding and improving health. 2nd ed. Washington DC: US Government Printing Office; 2000.

Balady GJ, Weiner DA. Exercise testing for sports and the exercise prescription. Cardiol Clin. 1987;5(2):183–96.

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Miller, K.R., McClave, S.A., Jampolis, M.B. et al. The Health Benefits of Exercise and Physical Activity. Curr Nutr Rep 5 , 204–212 (2016). https://doi.org/10.1007/s13668-016-0175-5

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Published : 14 July 2016

Issue Date : September 2016

DOI : https://doi.org/10.1007/s13668-016-0175-5

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Importance of Body Exercise Essay

Introduction.

Physical exercise can be defined as any body activity that maintains body fitness and the entire body health status. It must be done for a number of reasons such as improving muscle strength and joint structures, improving energy levels and reducing the risk of heart diseases.

It also helps in naturally lowering or controlling blood pressure level, improving immune system, enhancing healthy weight maintenance, boosting the immune system as well as an excellent stress handler. Biological studies reveal that healthy exercise reduces levels of hydrocortisone. Physical exercise can be broadly categorized into three types based on the overall effects they can have in the body.

The first category is the flexibility; it involves exercises such as body stretching to improve the range of muscle and joints motion. The second category is anaerobic exercise; which includes cycling, swimming, and rope skipping, running or even walking that focus on increasing cardiovascular endurance. The third category is anaerobic exercise; which includes weight, functional and eccentric training or sprinting.

Physical exercise plays a tremendously role in reducing the risk of acquiring heart disorders such as heart attacks and stroke. These heart defects are most likely a factor in the reduction of human life expectancy. Healthy body exercise helps in strengthening the heart and lungs thus increasing the efficiency of the heart muscle.

It improves the heart’s pumping ability by regulating the blood and oxygen circulation in the body. Regular exercise enhances the heart muscle functionality and blood flow. It reduces the chances of developing blood clots, lowers heart resisting rate and relieves stress on one’s heart. Being fit before a surgery also helps in quick recovery from the operation.

Many recent studies have shown that exercise naturally lowers and control blood pressure. This helps in reducing the risk of developing high blood pressure (hypertension). Healthy exercise yields to a stable condition reducing the level of medication dose one can take when ill. Studies have also revealed that a healthy body exercise lowers the blood level of fats and unhealthy cholesterol, which may contribute to the hardening and contraction of the arteries.

This may render one vulnerable to heart attack or stroke. By reducing the chances of contracting illnesses caused by winter weather such as common colds, moderate body exercise have been shown to boost the immune system. Good exercise also helps improve the quality of sleep giving the body ample time to rest and rebuild its defenses.

Exercise helps in weight loss and maintenance by elevating the metabolism thus more calories are regularly burned. This catalyses the breakdown and utilization of fats for energy during any activity and can result to a reduction in the Body Mass Index to a height ratio.

This figure is vital in the prediction of risk for developing conditions such as obesity, type 2 diabetes, stroke and cancers. Regular body exercise has also been known to be an excellent stress handling by lifting the moods leaving one with something positive to focus attention on, reduce anxiety and provide a positive base to release stress.

For example, one can play football or run as a form of exercise and forget his stressful moments. This helps boost self-esteem and confidence providing a better ground to handle emotional stress. The mental benefits gained from exercising are of equal importance to the physical ones. Good exercise just makes one feel calm by bringing the overall feeling of quality life. It helps improve the physical appearance, body posture, and mental outlook of someone.

Healthy body exercise can also help improve muscle strength, joint functions and joint structures by boosting the strength of bones, muscles and tissues. Regular exercise makes the body adapt to these non-regular body activities leading to a gainful growth in strength. This enhances the one’s ability to perform daily chores more easily and conveniently.

Exercises that involve weight bearing such as running and long-distance walking is critically vital for women since it helps reduce the risk of osteoporosis (low-bone density) and body fractures. Studies have revealed that substantial exercise helps improve joint health for all people, especially arthritis patients by increasing the thickness of cartilage in the joints, thus protecting them against wear and tear. Healthy exercise may leave one tired in the early stages of an exercise program.

Gradual exercise helps one adapt to this new body requirement increasing the body aerobic requirement capacity, endurance and stigma. This helps one to improve the energy levels enhancing the ability to spend a day with less energy expenditure in performing the daily tasks.

Although it is essential to exercise as a daily body requirement, too much of this can sometimes be dangerous. Exercising without proper rest can lead to developing conditions such as stroke and other circulation problems leading to heart rhythm abnormalities. This is mostly experienced by athletes who train for large marathon events. It is advisable to consult a doctor before making a radical change from the current exercise routine to a new one to avoid inappropriate exercise activities.

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This Test Might Be the Best Way to Track Fitness and Longevity

VO2 max has become ubiquitous in fitness circles. But what does it measure and how important is it to know yours?

By Talya Minsberg

Talya Minsberg took a VO2 max test while reporting this story. She is already eager to see if it changes after she completes a marathon training cycle.

Fitness is full of numbers meant to help you become faster and stronger. There’s your mile run time, your resting heart rate and measures of strength and flexibility. But perhaps the gold standard is VO2 max.

A handful of years ago, the test — which tracks how much oxygen your body absorbs — was an obscure tool mainly used by elite athletes. Today, it’s touted by fitness professionals and wellness experts like Peter Attia as being a useful measure for all exercisers.

But getting an accurate number requires an expensive and exhausting lab evaluation. And estimates provided by wearable devices might not tell you much. So how useful is it to invest time and money in the full work-up , and how important is knowing your VO2 max?

For everyday people who want to be healthy and live a long time, the measurement is “the best piece of empirical information we have on health and longevity,” said Kate Baird, a clinical exercise physiologist and the coordinator of running and metabolic services at Hospital for Special Surgery in New York.

The key, she said, is acting on what the data tells you.

What is VO2 Max?

“VO2 max” is a two-digit number that expresses how effectively your body metabolizes oxygen. The measurement itself is the milliliters of oxygen consumed in a minute per kilogram of body weight.

As you exercise, your body needs ever more oxygen. The more you can efficiently consume, the more energy your muscles will have, increasing the time and intensity you can exercise. Generally speaking, someone with a higher VO2 max will be able to sustain a run or an aerobic activity at a given pace longer than someone with a lower VO2 max.

The test has participants exercise to exhaustion to measure that threshold, essentially measuring the size of someone’s internal aerobic engine.

Most VO2 max tests are conducted with a medical professional in a lab, with a specialized mask that measures the amounts of oxygen and carbon dioxide that are inhaled and exhaled. Participants then work out with the goal of reaching maximal aerobic capacity, or the point of complete exhaustion.

The same score might be considered high for one person and low for another, depending on their genetics, sex, age and body composition.

The test is difficult, which can be a turnoff for those who don’t want to push to their limits, and it costs a few hundred dollars, which is generally not covered by insurance.

What does it tell you about longevity and performance?

Studies have shown that a higher score is a strong predictor of longer life span .

Your VO2 max can decline by about 10 percent per decade starting at around 25 , but it is possible to increase or maintain it with activity. A 2021 study of 2,000 middle-aged men and women found that small amounts of activity could improve VO2 max. The more effort you put in, the higher the benefit; moderate to vigorous physical activity increased that number even more dramatically.

Testing your VO2 max annually can show you whether you are slowing that decline, Ms. Baird said. For serious athletes, proper rest and sustenance are also key for maintaining or improving your score. Measuring VO2 max before and after a few months of focused training can reveal if you are working out too hard or if you are fueling properly during your workouts, among other things, according to Luke Greenberg, a physical therapist and co-founder of MotivNY, a physical therapy and training studio.

What about VO2 max on wearables?

Not everyone can afford to spend their time and a few hundred dollars on a lab-based test. As a result, dozens of wearables have recently entered the market claiming to measure VO2 max with algorithms that use heart rate and GPS data to extrapolate the value.

Some worry that those estimates may not be accurate , but it’s difficult to assess their accuracy because the algorithms are not published, according to Dimitris Spathis, a researcher at the University of Cambridge.

In 2022, Dr. Spathis coauthored a study in which researchers developed a model to better predict VO2 max using data from 11,000 participants. He’s hopeful that most athletes will someday be able rely on wearables instead of paying for tests.

If you don’t have the time or interest to take a lab test or use a wearable device, Ms. Baird advises finding other ways of setting goals to increase your fitness. There’s a good chance that a VO2 max test would tell you information that you already know.

“The best predictor of performance is your performance,” she said. If you enjoy running, set a time or distance goal. If you are more sedentary and aiming to exercise more, start moving in a way that feels tolerable and safe, starting with a walk of as little as 10 to 15 minutes.

And above all, be patient.

“Every single person is going to respond differently to training based on their genes and other lifestyle factors,” Ms. Baird said. “It can take years to move your body in the direction you want to go.”

Talya Minsberg is a reporter covering fitness and wellness for The Times. More about Talya Minsberg

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What is aerobic exercise.

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            Aerobic exercise is vital to staying healthy and fit. The benefits that it offers are many, helping a person achieve physical and even emotional fitness. Aerobic literally means "with oxygen." Aerobic exercise includes any activity that uses large muscle groups and can be done continuously over a period of longer than five minutes. Aerobic exercise increases one's heart rate and expands the lungs. Promoting general fitness, aerobic exercise conditions one's cardiovascular and respiratory systems, as well as increases one's endurance. An aerobically-fit individual has more stamina, and thus can work longer and more vigorously than one who is not as fit. As exercise becomes more frequent, the endurance of a person escalates. Besides this, it has also been proven that it reduces stress, increases oxygen flow, strengthens nervous and immune systems, provides more energy, and gives one a sense of well-being. In order to maintain one's health, it is recommended to exercise five times a week, for at least thirty minutes. One's heart rate should be at sixty to ninety percent of an age-specific maximum heart rate in order to achieve fitness. One's daily schedule should include cardiovascular activity such as housework, gardening, walking, etc. Most doctors agree that walking is a great tool for fitness, as it can give a better workout than most gym machines. Also, it does not require equipment, and it has the least risk of injury than any other aerobic exercise. Another aerobic exercise, swimming, aids the joints, and is a balanced muscular workout that can promote relaxation. Cycling builds leg muscles. There is a numerous variety of aerobic activities that can suit nearly any person's goals and abilities. Aerobic exercise builds up an individual in strength, endurance, and well-being, and therefore should be a top priority for most people. .             

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The General Benefits of Aerobic Exercise Aerobic exercise is not only meant for maintaining physical appearances, but also to benefit our health. ... Aerobic exercise benefits are innumerable. ... Aerobic exercise reduces your risk of heart disease, vascular disease and diabetes. ... Aerobic exercise also improves the strength of your ligaments, bones, and tendons. ... We know we need to begin exercising and how you start or what you start with depends on many factors such as current fitness level, history of medical problems and what your fitness goals may be. ...

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• Front Neurosci

Relationship Between Exercise and Alzheimer’s Disease: A Narrative Literature Review

1 School of Physical Education, Huaqiao University, Quanzhou, China

2 Sport and Health Research Center, Huaqiao University, Quanzhou, China

Muh-Shi Lin

3 Department of Biotechnology and Animal Science, College of Bioresources, National Ilan University, Yilan, Taiwan

4 Division of Neurosurgery, Department of Surgery, Kuang Tien General Hospital, Taichung, Taiwan

5 Department of Biotechnology, College of Medical and Health Care, HungKuang University, Taichung, Taiwan

6 Department of Health Business Administration, College of Medical and Health Care, HungKuang University, Taichung, Taiwan

I-Shiang Tzeng

7 Department of Exercise and Health Promotion, College of Education, Chinese Culture University, Taipei, Taiwan

Associated Data

This narrative review aimed to summarize evidence regarding the responses to exercise among patients with preclinical Alzheimer’s disease (AD) and the effectiveness of long-term exercise interventions in improving cognitive function and neuropsychiatric symptoms. We performed a narrative review of existing literature on the effectiveness of long-term exercise interventions in improving cognitive function and neuropsychiatric symptoms in patients with AD. Patients with AD who presented with long-term exercise interventions appeared to have improved blood flow, increased hippocampal volume, and improved neurogenesis. Most prospective studies have proven that physical inactivity is one of the most common preventable risk factors for developing AD and that higher physical activity levels are associated with a reduced risk of AD development. Physical exercise seems to be effective in improving several neuropsychiatric symptoms of AD, notably cognitive function. Compared with medications, exercise has been shown to have fewer side effects and better adherence.

Alzheimer’s disease (AD) is a progressive neurodegenerative disorder characterized by memory loss and multiple cognitive disorders ( Reddy and Oliver, 2019 ). This symptom is the most frequent cause of neurogenesis. Individuals with AD develop progressive mild cognitive impairment (MCI), leading to the development of neuropsychiatric manifestations. Agitation and anxiousness are common complications in individuals diagnosed with AD. Other complications such as bladder and bowel problems, depression, infection, and head trauma or broken bones are the main cause of imbalance and incoordination in these patients ( Higuera, 2016 ).

Alzheimer’s disease is associated with common causes of dementia and is estimated to account for 60–80% of these cases ( Alzheimer’s Association [AA], 2016 ). Aging can be treated as the greatest risk factor for AD progression. About 81% of AD patients are aged over 75 years as estimated by the Alzheimer’s Association [AA], 2016 ). The diagnosis and treatment of AD involves many challenges. Studies have shown that drug combinations are effective and that there is no efficient treatment for patients diagnosed with preclinical AD or MCI. With respect to the definition of MCI, it is regarded as a syndrome of cognitive decline that is higher than the expectation of the age of individual and level of education without significantly obstructing with daily living activities. Notably, it develops into AD during 5 years in over half of the MCI patients ( Gauthier et al., 2006 ). Based on the possibility of side effects of drugs, people are very interested in the non-pharmacological treatment of AD ( Raggi et al., 2017 ).

Inconsistent benefits of treatments, comprising cognitive training and cognitive stimulation, have been reported. There is an intension to prevent and treat AD, MCI, and dementia via regular exercise ( Laurin et al., 2001 ; Lindsay et al., 2002 ; Andel et al., 2008 ). This article aims to review important studies with this scope and consider the association of exercise and AD in patients.

Overview of Alzheimer’s Disease

Alzheimer’s disease is a chronic neurodegenerative disease in which pathological features include changes in the brain structure and function ( Scheltens et al., 2016 ). The consequences have a significant impact on individual lives and societal costs ( World Health Organization [WHO] and Alzheimer’s Disease International [ADI], 2012 ). The emotions derived from the disease, changes in neurocognition, and physical disability are common and also lower the quality of life considerably, e.g., higher dependence on people and reduction of functioning mobility ( Glenthøj et al., 2017 ). Additionally, the prevalence rate of depressive symptoms in AD patients was 10 times higher than that in the normal population ( Lee and Lyketsos, 2003 ; Strober and Arnett, 2009 ). Approximately 747,000 (15%) Canadians aged over 65 years were affected by a particular form of person cognitive impairment or dementia in 2011 ( Alzheimer Society of Canada [ASC], 2011 ). Around 60–70% of people have AD ( World Health Organization [WHO] and Alzheimer’s Disease International [ADI], 2012 ). Commensurate statistics from United States estimate that nearly one in eight among the aged have AD ( Alzheimer’s Association [AA], 2012 ). Therefore the annual cost for treatment is as high as $600 billion ( World Health Organization [WHO] and Alzheimer’s Disease International [ADI], 2012 ). The care cost is estimated to grow to around $20 trillion for American AD patients if the present trend is unchanged for the next 40 years ( Alzheimer’s Society [AS], 2010 ). Psychosocial care takers still need to take on the burden of AD-related disease even though the economic cost has been cut back in Canada ( Herrmann et al., 2010 ). The age-standardized death rate (per 100,000 people) of the aged in Ontario remains stable ( Statistics Canada, 2011 ). The results show that women’s death rate are higher than men. It seems older people (over 65 years of age) represent number of AD patients’ growth was more than other age groups. Early identification and management of AD is a challenging task but a public health priority.

Diagnosis and Treatment

Diagnosis is mostly clinical and commonly includes the patient’s main care doctor. Acquiring good medical, family medical, and neuropsychiatric history is essential. If necessary, neuropsychological test and serologic tests for biomarkers can bolster the diagnosis. Other causes of dementia are ruled out by routine laboratory test with whole blood cell counts, metabolome comparison, thyroid stimulating hormone, vitamin B-12, folate, and MRI. These are regarded as part of the routine diagnostic examination.

In accordance with the definition of National Institute on Aging in 2011, AD is characterized by three progressive and overlapping stages of deterioration, including preclinical AD, MCI, and Dementia ( Sperling et al., 2011 ). In the early phase of the disease, most of the symptoms may be misinterpreted as ordinary changes in behavior, attention, and forgetfulness ( Burns and Illiffe, 2009 ). The intricacies and gradualness of the symptoms have led to some people classifying the features as “syndromes.”

The only way to obtain a definitive diagnosis of AD is through autopsy and an accurate examination of the brain tissue ( Caroli and Frisoni, 2009 ). However, physician diagnosis can reach relatively high accuracy in a clinical setting because serum or cerebrospinal fluid biomarkers have been proven to provide high diagnostic accuracy, accounting for 85–90% for sensitivity and specificity ( Jack et al., 2010 ; Scheltens et al., 2016 ). Thus the diagnostic accuracy is as high as 90%.

Factors associated with the clinical analysis of AD cases are particular medical history and physical examination to determine the family history of dementia and changes in behavior, mood, and motor performance and to rule out other explanations so that physicians can oversee, treat, and arrange supporting services ( Burns and Illiffe, 2009 ).

Risk Factors

Age is the biggest risk factor for AD. There is a possible minor risk (less than 1%) owing to gene mutation, mutant amyloid precursor proteins, among patients account 40–65% with AD may also accompany APOE-e4 genetic variant ( Mahley et al., 2006 ; Alzheimer’s Association [AA], 2016 ). Family history can be another risk factor for AD; it can also be influenced by cardiovascular disease, low education level, social factors, and cognitive involvement, as well as traumatic brain injury prior to MCI ( Alzheimer’s Association [AA], 2016 ). The evidence also shows that chronic disease risk factors (such as physical inactivity, diabetes, smoking, abdominal obesity, and high cholesterol) ( Purnell et al., 2009 ; Li et al., 2011 ) may increase the risk of developing AD, whereas social participation and low saturated fat/high fiber vegetable diet can reduce the risk of developing AD ( Alzheimer’s Association [AA], 2012 ).

It is unclear whether this relationship is dependent on the dose; it seems that there is reduced risk with higher levels of physical activity ( Yaffe et al., 2001 ). This may be vital in patients with risk factors or early progression MCI. Exercise seems to have potential benefits for people diagnosed with AD. However, the management of AD is still challenging. Drug treatment is limited to date. Three most common classes of drugs include: acetylcholinesterase inhibitors for behavioral symptoms; N-methyl D-aspartate antagonists to treat cognitive decline and slow progression of AD; and antipsychotics (not recommended) ( National Institute of Aging [NIA], 2008 ). Other complementary treatments such as group-based social procedures (e.g., art and music) and cognitive and emotional orientation treatments (e.g., psychotherapy, validation, recall, etc.) have been used and have varied ineffectiveness ( Olazarán et al., 2010 ; Ballard et al., 2011 ).

Neurophysiology

One of the most vital and majestic organs in an organism is the brain which can be categorized under the CNS. A human brain contains approximately 98% of the body’s neural tissue ( Martini et al., 2011 ). It consists of over 100 billion nerves that are connected to one another through long protoplasmic fibers named axons ( Hendrickson, 2004 ). These fibers carry signal pulses to different parts of the brain and body targeting specific recipient cells. The main function of the brain is to conduct, consolidate, and control different organs of the body physiologically. Brain coordinates and controls most of the sensory system, social behavior, muscle movements and synchronized body functions such as heart and respiratory rate, blood pressure, fluid balance, and body temperature. The brain is the cradle of mood, emotion, cognition, memory, motor, and different forms of learning.

Exercise could be a strategy to prevent or postpone the aging brain from decline in cognition ( Barnes, 2015 ). Thus, a great amount of effort and research have undertaken to understand the physiology of aging brain, which is changed or tempered by exercise ( Marks et al., 2011 ; Burzynska et al., 2014 ; Bullock et al., 2018 ). Exercise may cause effects on three areas of the brain: vascular physiology, hippocampal volumes, and neurogenesis ( Barnes, 2015 ). With advancing age, blood flow to the brain is negatively influenced and is related to cognition ( Barnes, 2015 ). It is shown that moderate-intensity exercise causes intense augmentation of blood flow to the brain, also the cerebral blood flow increment is found in participants trained by exercise than participants who were seated for a long period ( Bailey et al., 2013 ). A randomized trial with 12-week-long exercise training showed that the cerebral blood flow is higher in the anterior cingulate cortex ( Chapman et al., 2013 ). In AD, hippocampal circuits that are considered as relatively significant for episodic-like memory are affected initially. Higher volume of the hippocampus is related to improved cognition. Over a year of mild-to-moderate exercise seems to protect against shriveling hippocampal volume ( Duzel et al., 2016 ). Hippocampal volume variation was also associated with improved heart health ( Duzel et al., 2016 ). Physical exercise can improve cognitive ability and is associated with a boost in the hippocampal volume as shown by Erickson et al. (2009) . Currently, it has been assessed that AD is caused by neuropathological and physiological factors. The current drug treatment for AD is aimed at an advanced stage, where severe morbidity, mortality and the burden on caregivers may increase. For the early stages of AD and general dementia prevention, exercise seems to be a useful way to treat and prevent it ( Tabei et al., 2018 ).

Physical Activity and Alzheimer’s Disease

Prospective studies have shown that physical activity can reduce the likelihood of dementia and AD, even at mild to moderate intensity ( Yaffe et al., 2001 ; Erickson et al., 2009 ; Hamer and Chida, 2009 ; Smith et al., 2010 ; Barnes and Yaffe, 2011 ; Sattler et al., 2011 ; Buchman et al., 2012 ; Norton et al., 2014 ). Exercise could help diminish the occurrence of dementia and AD so that it has been cited as a possible lifestyle intervention. Some previous studies have proof to support this hypothesis. A study measured that 54% of AD risk factors may be avertible ( Barnes and Yaffe, 2011 ). Another study estimated the demographic risk of global AD, which can be attributed to seven potentially adjustable risk factors by using the relative risks of existing meta-analyses ( Norton et al., 2014 ). The lack of physical activity was the highest attributable risk that they found. In a systematic review that collated evidence from 163,000 non-psychotic participants and compared highest physical activity category to the participants with least relative risk of dementia ( Hamer and Chida, 2009 ). They also found that the risk of dementia and AD can be lowered by 28% and 45% with physical activity. A systematic review of randomized controlled trials observing the connection of exercise and cognitive performance between 1966 and 2009 was completed by Smith et al. (2010) . They chose research that had ample influence, supervised aerobic exercise programs and control groups. They showed improvement in attention and processing speed in the exercise group, executive function and memory improvement. Inconsistency of the impact on working memory was seen. The duration of exercise or intensity seems to be essential for the benefit. As mentioned earlier, the hippocampus of dementia patients gets decayed. Erickson et al. (2009) observed the relation between exercise and hippocampus because exercise effectively reduces cortical decay in the elderly. They noticed that among 165 non-demented elderly people, active individuals had higher levels of health, larger hippocampus, and better spatial memory by using MRI. The benefits of exercise for diminishing cognitive degeneration and dementia have been demonstrated by population-based prospective studies. A 14-year time course German population study showed a lower risk of MCI and AD in participants with regular physical activity and better performance in the neuropsychological tests ( Sattler et al., 2011 ). Another prospective trial examined the hypothesis that objectively measuring daily activities could forecast the incidence rate in AD and MCI ( Buchman et al., 2012 ). Participants wore wrist activity recorders to observe their overall physical activity instead of relying on questionnaires, which self-reported in this study. It was determined that levels of daily overall activity were associated with incidence of global cognitive decline and AD, at 4 years of follow-up. A significant reduction in AD risk was associated with higher levels of physical activity. Besides, a prospective study of more than 8 years showed that women who walked more had less cognitive decline during the entire study period ( Yaffe et al., 2001 ). A Cochrane review examined how aerobic activity affected mentally healthy older adults. The objective was to assess whether heart health affects the impact of physical activity on cognition ( Forbes et al., 2015 ). With this intention, they included trials that have demonstrated an increase in cardiovascular health through a test for VO2max. Their findings did not show any evidence of the benefits of exercise in cognition and the research they studied had a moderate to high risk of bias ( Forbes et al., 2015 ). It has to be considered that their comments exclude studies where exercise interventions do not add cardiovascular health (i.e., mild aerobic exercise), weightlifting or stretching. Studies that performed a test for VO2max or other tests for heart health were included. We found that comments may be useful for a specific individual subgroup, but should be cautious in interpretation. In addition, other systematic reviews and meta-analyses show that exercise has significant improvements and benefits in cognition ( Farina et al., 2014 ).

Exercise as Treament for Alzheimer’s Disease

Although several studies have shown that exercise has a potential benefit in declined cognition, are there any evidences to prove that exercise is good for people with AD? Some of the previous studies have limitations associated with randomization and surveillance in the group with treatment. There are also relatively few large-scale studies focusing on Alzheimer’s patients.

A randomized, controlled trial was designed to tackle these issues by evaluating whether exercise programs could impact the decline in activities of daily living (ADL) in AD patients ( Rolland et al., 2007 ). With an hour of training twice a week in aerobic exercise, strength level, balance skill and flexibility as intervention for 1 year, they found that ADL was slower than the non-active group. However, there was no effect on behavioral disorders, depression or nutritional scores. Another study attempted to compare the effects of drug and exercise on AD and MCI ( Ströhle et al., 2015 ). The study allowed for including exercise or pharmacological intervention as the treatment group. For AD, exercise had a medium to strong pooled effect size, with a small effect on MCI. Treatment with a cholinesterase inhibitor in the meantime had a consequent slight effect on the perception in AD but had no effect on MCI. Note that the drug withdrawal rate is very high, but the exercise group has a much lower rate of discontinuation. In addition, systematic reviews and meta-analyses display improvement in dementia, reduced neuropsychiatric symptoms, and slight decline in ADL ( Hamer and Chida, 2009 ; Smith et al., 2010 ; Forbes et al., 2015 ). In a large systematic review, exercise had less side effects and superior compliance than medications ( Ströhle et al., 2015 ). Exercise also has intrinsic benefits for cardiovascular health and personal health. It is difficult to suggest specific exercises for AD patients or for prevention of AD based on the available evidence. These studies including the various types of exercises are established based on the duration of intervention. Nelson et al. (2007) believe the American Sports Medicine Association and the American Heart Association’s recommendations can be used to comprehensively treat the elderly. These suggestions are also more likely to cover most of the support activities needed to identify potential benefits.

A randomized controlled trial examined aerobic exercise programs with moderate to high-intensity on mild AD patients ( Hoffmann et al., 2016 ). Training for 60 min was performed three times a week for 16 weeks, but there was no benefit for cognitive ability; however, the score on neuropsychiatric symptoms significantly improved. This study is indeed related to subjects that follow the training program. A general problem is that most people use intentional treatment models in their studies. During longer intervention studies, you are more likely to see compliance disruptions throughout the process. This makes the duration of intervention support for observation questionable. A 3-month randomized study looked at supervised exercise program three times a week ( Chapman et al., 2013 ). Through the training interval, they found immediate and delayed memory improvements. In the anterior cingulate area, the exercise group also showed a cerebral blood flow while resting. Unfortunately, we may not be able to compare findings of AD patients to adults with normal cognition. Another minor study of eight people with MCI observed an exercise intervention for 9-months and a training during 2, 3-months ( Sacco et al., 2016 ). Their cognitive performance improved, but their influence weakened after disrupting the training. A Cochrane review investigated the effects of exercise on Alzheimer’s patients ( Forbes et al., 2015 ). Their meta-analysis showed no clear evidence that exercise is beneficial for cognitive function. However, they did get the ability to perform ADL from the exercises. It should be noted that the results and studies found by the reviewers comprised diverse data and lack of quality owing to insufficient evidence. They suggest more qualified trials to assess various dementias of different types with severity, which will help to improve the quality of evidence for reviews ( Forbes et al., 2015 ). Finally, a few systematic reviews and accompanying analyzed results showed a favorable effect on AD patients receiving exercise programs based on six randomized controlled trials ( Farina et al., 2014 ). Farina, Rusted, and Tabet show a downturn in a declining rate of cognition and a positive impact on global cognitive function ( Farina et al., 2014 ).

Limitations

The study was conducted under narrative review approach. There are several limitations of this research. First, hypothesis was set as board overview of a topic-related research area. Second, search method depends on non-predefined protocol based which may involve subjective selection bias. Third, inclusion criteria of studies for review also rely on researchers’ experiences. Finally, search media usually via PubMed or Medline. In the meantime, extracted studies with non-protocol based may partially grade objectively by anecdotal resources for their quality.

To present the core information of this review, we constructed a Supplementary Table S1 has brief summary extracted from aforementioned references (except citations from specific associations and monograph). Systematic reviews and meta-analyses indicate the benefits of physical activity based on large-scale prospective trials. Unfortunately, many of these comments and studies have been plagued by methodological problems and noted the heterogeneity of the population.

In the next few decades, AD will be a huge challenge for the country in the field of medicine. Moreover, there are still much to learn despite a lot of rigorous and large-scale research. More high quality randomized trials are needed to really determine if AD can be prevented and treated by exercise.

Author Contributions

QM and I-ST proposed the research idea, wrote the background and conclusion, and contributed to the literature review. M-SL supported the literature review, helped to revise the manuscript and provided clinical suggestions. I-ST prepared the manuscript for submission. All authors read and approved the final manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding. Huaqiao University’s Academic Project Supported by the Fundamental Research Funds for the Central Universities (19SKGC-QT06) for this study.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fnins.2020.00131/full#supplementary-material

• Alzheimer Society of Canada [ASC] (2011). Available at: https://alz-journals.onlinelibrary.wiley.com/doi/abs/10.1016/j.jalz.2012.02.001 (accessed August 27, 2019). [ Google Scholar ]
• Alzheimer’s Association [AA] (2012). Alzheimer’s disease facts and figures. Alzheimers Dement. 8 131–168. [ PubMed ] [ Google Scholar ]
• Alzheimer’s Association [AA] (2016). Alzheimer’s disease facts and figures. Alzheimers Dement. 12 459–509. 10.1016/j.jalz.2016.03.001 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Alzheimer’s Society [AS] (2010). Changing the Trajectory of Alzheimer’s Disease: A National Imperative. Available at: www.alz.org/trajectory (accessed August 22, 2019). [ Google Scholar ]
• Andel R., Crowe M., Pedersen N. L., Fratiglioni L., Johansson B., Gatz M. (2008). Physical exercise at midlife and risk of dementia three decades later: a population-based study of Swedish twins. J. Gerontol. A Biol. Sci. Med. Sci. 63 62–66. 10.1093/gerona/63.1.62 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Bailey D. M., Marley C. J., Brugniaux J. V., Hodson D., New K. J., Ogoh S., et al. (2013). Elevated aerobic fitness sustained throughout the adult lifespan is associated with improved cerebral hemodynamics. Stroke 44 3235–3238. 10.1161/STROKEAHA.113.002589 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ballard C., Khan Z., Clack H., Corbett A. (2011). Nonpharmacological treatment of Alzheimer disease. Can. J. Psychiatry 56 589–595. 10.1177/070674371105601004 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Barnes D. E., Yaffe K. (2011). The projected effect of risk factor reduction on Alzheimer’s disease prevalence. Lancet Neurol. 10 819–828. 10.1016/S1474-4422(11)70072-2 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Barnes J. N. (2015). Exercise, cognitive function, and aging. Adv. Physiol. Educ. 39 55–62. 10.1152/advan.00101.2014 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Buchman A. S., Boyle P. A., Yu L., Shah R. C., Wilson R. S., Bennett D. A. (2012). Total daily physical activity and the risk of AD and cognitive decline in older adults. Neurology 78 1323–1329. 10.1212/WNL.0b013e3182535d35 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Bullock A. M., Mizzi A. L., Kovacevic A., Heisz J. J. (2018). The Association of aging and aerobic fitness with memory. Front. Aging Neurosci. 10 : 63 . 10.3389/fnagi.2018.00063 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Burns A., Illiffe S. (2009). Alzheimer’s disease. BMJ 338 : b158 10.2236/bmj.b158 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Burzynska A. Z., Chaddock-Heyman L., Voss M. W., Wong C. N., Gothe N. P., Olson E. A., et al. (2014). Physical activity and cardiorespiratory fitness are beneficial for white matter in low-fit older adults. PLoS One 9 : e107413 . 10.1371/journal.pone.0107413 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Caroli A., Frisoni G. B. (2009). Quantitative evaluation of Alzheimer’s disease. Expert Rev. Med. Devices 6 569–588. [ PubMed ] [ Google Scholar ]
• Chapman S. B., Aslan S., Spence J. S., DeFina L. F., Keebler M. W., Didehbani N., et al. (2013). Shorter term aerobic exercise improves brain, cognition, and cardiovascular fitness in aging. Front. Aging Neurosci. 5 : 75 . 10.3389/fnagi.2013.00075 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Duzel E., Van Praag H., Sendtner M. (2016). Can physical exercise in old age improve memory and hippocampal function? Brain 139 662–673. 10.1093/brain/awv407 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Erickson K. I., Prakash R. S., Voss M. W., Chaddock L., Hu L., Morris K. S., et al. (2009). Aerobic fitness is associated with hippocampal volume in elderly humans. Hippocampus 19 1030–1039. 10.1002/hipo.20547 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Farina N., Rusted J., Tabet N. (2014). The effect of exercise interventions on cognitive outcome in Alzheimer’s disease: a systematic review. Int. Psychogeriatr. 26 9–18. 10.1017/s1041610213001385 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Forbes D., Forbes S. C., Blake C. M., Thiessen E. J., Forbes S. (2015). Exercise programs for people with dementia. Cochrane Database Syst. Rev. 1–77. 10.1002/14651858.CD006489.pub4 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Gauthier S., Reisberg B., Zaudig M., Petersen R. C., Ritchie K., Broich K., et al. (2006). Mild cognitive impairment. Lancet 367 1262–1270. [ PubMed ] [ Google Scholar ]
• Glenthøj L. B., Jepsen J. R., Hjorthøj C., Bak N., Kristensen T. D., Wenneberg C., et al. (2017). Negative symptoms mediate the relationship between neurocognition and function in individuals at ultrahigh risk for psychosis. Acta Psychiatr. Scand. 135 250–258. 10.1111/acps.12682 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hamer M., Chida Y. (2009). Physical activity and risk of neurodegenerative disease: a systematic review of prospective evidence. Psychol. Med. 39 3–11. 10.1017/S0033291708003681 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hendrickson R. (2004). The Facts on File Encyclopedia of Word and Phrase Origins , 3rd Edn New York, NY: Checkmark Books, 822. [ Google Scholar ]
• Herrmann N., Tam D. Y., Balshaw R., Sambrook R., Lesnikova N., Lanctôt K. L., et al. (2010). The relation between disease severity and cost of caring for patients with Alzheimer disease in Canada. Can. J. Psychiatry 55 768–775. 10.1177/070674371005501204 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Higuera V. (2016). Complications of Alzheimer’s Disease (AD). Available at: https://www.healthline.com/health/alzheimers-disease-complications (accessed September 10, 2019). [ Google Scholar ]
• Hoffmann K., Sobol N. A., Frederiksen K. S., Beyer N., Vogel A., Vestergaard K., et al. (2016). Moderate-to-high intensity physical exercise in patients with Alzheimer’s disease: a randomized controlled trial. J. Alzheimers Dis. 50 443–453. [ PubMed ] [ Google Scholar ]
• Jack C. R., Knopman D. S., Jagust W. J., Shaw L. M., Aisen P. S., Weiner M. W., et al. (2010). Hypothetical model of dynamic biomarkers of the Alzheimer’s pathological cascade. Lancet Neurol. 9 119–128. 10.1016/s1474-4422(09)70299-6 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Laurin D., Verreault R., Lindsay J., MacPherson K., Rockwood K. (2001). Physical activity and risk of cognitive impairment and dementia in elderly persons. Arch. Neurol. 58 498–504. [ PubMed ] [ Google Scholar ]
• Lee H. B., Lyketsos C. G. (2003). Depression in Alzheimer’s disease: heterogeneity and related issues. Biol. Psychiatry 54 353–362. 10.1016/s0006-3223(03)00543-2 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Li J., Wang Y. J., Zhang M., Xu Z. Q., Gao C. Y., Fang C. Q., et al. (2011). Vascular risk factors promote conversion from mild cognitive impairment to Alzheimer disease. Neurology 76 1485–1491. 10.1212/WNL.0b013e318217e7a4 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Lindsay J., Laurin D., Verreault R., Hébert R., Helliwell B., Hill G. B., et al. (2002). Risk factors for Alzheimer’s disease: a prospective analysis from the Canadian study of health and aging. Am. J. Epidemiol. 156 445–453. 10.1093/aje/kwf074 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mahley R. W., Weisgraber K. H., Huang Y. (2006). Apolipoprotein E4: a causative factor and therapeutic target in neuropathology, including Alzheimer’s disease. Proc. Natl. Acad. Sci. U.S.A. 103 5644–5651. 10.1073/pnas.0600549103 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Marks B. L., Katz L. M., Styner M., Smith J. K. (2011). Aerobic fitness and obesity: relationship to cerebral white matter integrity in the brain of active and sedentary older adults. Br. J. Sports Med. 45 1208–1215. 10.1136/bjsm.2009.068114 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Martini F. H., Nath J. L., Bartholomew E. F. (2011). Fundamentals of Anatomy & Physiology , 9th Edn San Francisco, CA: Benjamin-Cummings Publishing Company, 1114. [ Google Scholar ]
• National Institute of Aging [NIA] (2008). Alzheimer’s Disease Medications Fact Sheet. Available at: http://www.nia.nih.gov/alzheimers/publication/alzheimers-disease-medications-fact-sheet (accessed July 16, 2019). [ Google Scholar ]
• Nelson M. E., Rejeski W. J., Blair S. N., Duncan P. W., Judge J. O., King A. C., et al. (2007). Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Med. Sci. Sports Exerc. 39 1435–1445. 10.1249/mss.0b013e3180616aa2 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Norton S., Matthews F. E., Barnes D. E., Yaffe K., Brayne C. (2014). Potential for primary prevention of Alzheimer’s disease: an analysis of population-based data. Lancet Neurol. 13 788–794. 10.1016/S1474-4422(14)70136-X [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Olazarán J., Reisberg B., Clare L., Cruz I., Peña-Casanova J., Ser T. D., et al. (2010). Nonpharmacological therapies in Alzheimer’s disease: a systematic review of efficacy. Dement. Geriatr. Cogn. Disord. 30 161–178. [ PubMed ] [ Google Scholar ]
• Purnell C., Gao S., Callahan C. M., Hendrie H. C. (2009). Cardiovascular risk factors and incident Alzheimer disease: a systematic review of the literature. Alzheimer Dis. Assoc. Disord. 23 1–10. 10.1097/WAD.0b013e318187541c [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Raggi A., Tasca D., Ferri R. (2017). A brief essay on non-pharmacological treatment of Alzheimer’s disease. Rev. Neurosci. 28 587–597. 10.1515/revneuro-2017-0002 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Reddy P. H., Oliver D. M. (2019). Amyloid beta and phosphorylated Tau-induced defective autophagy and mitophagy in Alzheimer’s disease. Cells 8 : 488 . 10.3390/cells8050488 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Rolland Y., Pillard F., Klapouszczak A., Reynish E., Thomas D., Andrieu S., et al. (2007). Exercise program for nursing home residents with Alzheimer’s disease: a 1-year randomized, controlled trial. J. Am. Geriatr. Soc. 55 158–165. 10.1111/j.1532-5415.2007.01035.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Sacco G., Caillaud C., Ben Sadoun G., Robert P., David R., Brisswalter J. (2016). Exercise plus cognitive performance over and above exercise alone in subjects with mild cognitive impairment. J. Alzheimers Dis. 50 19–25. 10.3233/JAD-150194 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Sattler C., Erickson K. I., Toro P., Schröder J. (2011). Physical fitness as a protective factor for cognitive impairment in a prospective population-based study in Germany. J. Alzheimers Dis. 26 709–718. 10.3233/JAD-2011-110548 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Scheltens P., Blennow K., Breteler M. M., Strooper B. D., Frisoni G. B., Salloway S., et al. (2016). Alzheimer’s disease. Lancet 388 505–517. [ PubMed ] [ Google Scholar ]
• Smith P. J., Blumenthal J. A., Hoffman B. M., Cooper H., Strauman T. A., Welsh-Bohmer K., et al. (2010). Aerobic exercise and neurocognitive performance: a meta-analytic review of randomized controlled trials. Psychosom. Med. 72 239–252. 10.1097/PSY.0b013e3181d14633 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Sperling R. A., Aisen P. S., Beckett L. A., Bennett D. A., Craft S., Fagan A. M., et al. (2011). Toward defining the preclinical stages of Alzheimer’s disease: recommendations from the National Institute on Aging and the Alzheimer’s Association workgroup. Alzheimers Dement. 7 280–292. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Statistics Canada (2011). Deaths and Mortality Rate, by Selected Grouped Causes and Sex, Canada, Provinces and Territories, Annual. CANSIM (Database) . Ottawa, ON: Statistics Canada. [ Google Scholar ]
• Strober L. B., Arnett P. A. (2009). Assessment of depression in three medically ill, elderly populations: Alzheimer’s disease, Parkinson’s disease, and stroke. Clin. Neuropsychol. 23 205–230. 10.1080/13854040802003299 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ströhle A., Schmidt D. K., Schultz F., Fricke N., Staden T., Hellweg R., et al. (2015). Drug and exercise treatment of Alzheimer disease and mild cognitive impairment: a systematic review and meta-analysis of effects on cognition in randomized controlled trials. Am. J. Geriatr. Psychiatry 23 1234–1249. 10.1016/j.jagp.2015.07.007 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Tabei K. I., Satoh M., Ogawa J. I., Tokita T., Nakaguchi N., Nakao K., et al. (2018). Cognitive function and brain atrophy predict non-pharmacological efficacy in dementia: the mihama-kiho scan project2. Front. Aging Neurosci. 10 : 87 . 10.3389/fnagi.2018.00087 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• World Health Organization [WHO] and Alzheimer’s Disease International [ADI] (2012). Dementia: A Public Health Priority. Geneva: World Health Organization. [ Google Scholar ]
• Yaffe K., Barnes D., Nevitt M., Lui L. Y., Covinsky K. (2001). A prospective study of physical activity and cognitive decline in elderly women: women who walk. Arch. Intern. Med. 161 1703–1708. [ PubMed ] [ Google Scholar ]