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2
Physical Activity, Health Promotion, and
Chronic Disease Prevention
The scope of effects of physical activity in health promotion and
chronic disease prevention is broad, and the workshop devoted two ses-
sions to the topic as it relates to the general population. This chapter ad-
dresses four major topics:
• Cardiovascular disease (CVD), all-cause mortality, and cancer
• Bone, joint, and muscle health and performance
• Mental and neurological health
• Diabetes and other metabolic disorders
Brief coverage of mechanisms of action in diabetes and of physical activ-
ity and cognition appears under the discussion section, followed by
points raised by participants during the group discussion.
CARDIOVASCULAR DISEASE, ALL-CAUSE
MORTALITY, AND CANCER
Presenter: Steven N. Blair
Dr. Blair’s presentation began with a historical overview of the topic
and the identification of exposure assessment issues, followed by a dis-
cussion of physical activity and the relationships among CVD, all-cause
mortality, and cancer. As the volume of evidence is very large and time
was limited, Dr. Blair selected data pertaining to different populations to
illustrate these relationships.
17
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18 PHYSICAL ACTIVITY WORKSHOP
Background
Historical Overview
Although Hippocrates and Galen recognized the benefits of physical
activity, the beginning of exercise science occurred in the twentieth cen-
tury. In the early 1920s, August Krogh and A.V. Hill won separate Nobel
Prizes in physiology and medicine for work related to physical activity.
A study of London transport workers (Morris et al., 1953) showed much
lower rates of coronary occlusion and of death from heart attack among
the physically active conductors than among the sedentary drivers. Based
on these results, Morris and colleagues formulated the hypothesis that
vigorous physical activity helps protect against coronary heart disease
(CHD). A study of the relationship of physical activity at work to CHD
deaths among longshoremen (Paffenbarger and Hale, 1975) provided
further strong evidence of the benefits of physical activity.
Exposure Assessment Issues
Self-reported questionnaires have provided valuable evidence of re-
lationships between physical activity and disease outcomes. Nonetheless,
some of them have led to a large amount of misclassification. Misclassi-
fication, in turn, has led to an underestimation of the observed effect. The
objective assessment of physical activity levels, such as the use of accel-
erometers or specific fitness tests, is expected to provide stronger evi-
dence of the effects of physical activity or inactivity on various health
outcomes.
Physical Activity, Fitness, and
Cardiovascular Disease
Figure 2-1 illustrates the results obtained from a study of CVD death
rates for women and men by fitness category (obtained using an objec-
tive test of fitness). Steep inverse gradients occur across the fitness cate-
gories. Especially notable is the very large difference in CVD death rates
between the low fit and the moderately fit group. That is, one need only
achieve the moderately fit category to derive considerable benefit.
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HEALTH PROMOTION AND DISEASE PREVENTION
16
14
Deaths/10,000 person years
12
Fitness Group
10
Low
8 Mod
High
6
4
2
0
Women Men
FIGURE 2-1 Cardiovascular death rates by fitness groups and sex. Death rates
are adjusted for age, examination year, and other risk factors. The Aerobic Cen-
ter Longitudinal Study (ACLS) objective test of fitness was used to classify fit-
ness groups.
SOURCE: Blair et al. (1996). Reprinted, with permission, from JAMA
276(3):205–210. Copyright ©1996 American Medical Association.
The measurement of inactivity or sedentary behavior may be another
useful approach to examining the relationship of physical activity to
CVD. For example, Manson and colleagues (2002) showed an increase
in the multivariate-adjusted relative risk of CVD with an increase in the
number of hours per day spent sitting.
Work by Hambrecht and colleagues (2004) shows that, among indi-
viduals with documented coronary artery disease, the group randomly
assigned to exercise (20 minutes per day on a cycle ergometer and a 60-
minute group aerobic exercise class once per week) had greater event-
free survival and exercise capacity than the group assigned to standard
treatment and angioplasty.
Unpublished data from the Aerobics Center Longitudinal Study
(LaMonte et al., 2005b) show that for both men and women, a greater
fitness level is associated with decreasing rates of CVD deaths, CHD
events, or CHD deaths. Fitness was assessed by a maximal exercise test
on a treadmill and was categorized by the highest level of metabolic
equivalent (MET) expenditure. In a multivariate analysis, the reduction
of risk per MET was approximately 10 to 15 percent for the various end
points in both women and men.
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20 PHYSICAL ACTIVITY WORKSHOP
A very recent report from the Nurse’s Health Study (Whang et al.,
2006), using self-reported data, shows a substantial decrease in the age-
adjusted hazard ratio for sudden cardiac death among women who spend
more than 3.9 hours per week in moderate to vigorous physical activity.
This is one of the first reports to show a relationship between physical
activity and a lower risk of sudden cardiac death in women. Evidence is
accumulating that coronary artery calcium is an indicator of subclinical
CHD among men and women (LaMonte et al., 2005c). A study of 710
asymptomatic men with a coronary artery calcium score of greater than
100 found a very large reduction in the relative risk of CHD events for
those having an exercise tolerance of 10 or more METS (Lamonte et al.,
2006).
Barlow and colleagues (2006) reported on the risk of incident hyper-
tension among healthy women by fitness group. After adjusting for age
and other relevant factors, the risk of developing hypertension was mark-
edly decreased for women in the moderate fitness group and even further
decreased for women in the high fitness group. Earlier work had demon-
strated this relationship among men.
All-Cause Mortality
Physical activity has been associated with a decreased risk of death
in various population groups. A prospective study of 17,265 men and
13,375 women ages 20–93 years in Copenhagen found a substantial de-
crease in the risk of death among those who spent 3 hours per week
commuting to work by bicycle compared to those who did not commute
by bicycle (Andersen et al., 2000). Among the men and women ages 60
years and older, the multivariate-adjusted relative risk for all-cause mor-
tality decreased substantially by fitness level. Among men, the death rate
for those ages 80 years or older in the high fitness group was lower than
that for the least fit men ages 60 to 69 years (Blair and Wei, 2000).
Among men, the relative risk for all-cause and CVD mortality is
consistently lower for the fit when compared to the unfit across body fat
categories (Lee et al., 1999). In other words, being moderately fit is asso-
ciated with a substantially greater chance of survival even among those
with 25 percent of their body weight as fat. Similarly, among men with
metabolic syndrome, those in the moderate and high cardiorespiratory
fitness groups have increasingly lower all-cause mortality than do the
less fit men (Katzmarzyk et al., 2004).
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HEALTH PROMOTION AND DISEASE PREVENTION
The length of time required to complete a 400-meter walk—a differ-
ent kind of objective fitness test—is a predictor of mortality, CVD, and
mobility disability among women and men ages 70 to 79 years at base-
line (Newman et al., 2006). Differences in energy expenditure measured
with doubly labeled water methods produce similar results (Manini et al.,
2006).
Measuring physical activity level by accelerometer, Garg and col-
leagues (2006) found than men and women with peripheral artery disease
had decreasing multivariate-adjusted rates of all-cause mortality with
increasing levels of physical activity.
Findings in a paper by Erikssen and colleagues (1998) are consistent
with those of a number of other papers reporting decreasing multivariate-
adjusted relative risk of mortality with improvements in cardiorespiratory
fitness. Changing one’s fitness level affects mortality risk. These obser-
vations strengthen the causal inference for the effect of physical activity
in lowering the risk of death.
Physical Activity, Fitness, and Cancer
The body of literature on physical activity and cancer is smaller than
that discussed above, but it is growing. Three examples of relevant study
results follow:
• Women diagnosed with breast cancer had a lower multivariate-
adjusted relative risk of death and of recurrence if they obtained
at least 3 MET-hours of activity per week than if they had a
lower exercise level (Holmes et al., 2005).
• In a study of men with gastric cancer in Japan, the least fit one-
fourth of the group (tested by cycle odometer) were much more
likely to die of gastric cancer than was the more fit group (Sa-
wada et. al., 2003).
• Farrell and colleagues (2006) report that the inverse association
of cardiorespiratory fitness with cancer mortality remains after
adjustment for the percentage of body fat.
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22 PHYSICAL ACTIVITY WORKSHOP
Concluding Remarks
We have and are accumulating a very large amount of evidence on
the effects of physical activity and fitness on a variety of health out-
comes. For nearly every health outcome examined and in nearly every
subgroup of the population, physical activity provides benefits. Dr. Blair
expressed the view that there is a sufficient evidence base for under-
standing the benefits of physical activity and chronic disease prevention,
and he suggested that the U.S. Department of Health and Human Ser-
vices move forward with a process for developing physical activity
guidelines for Americans.
BONE, JOINT, AND MUSCLE HEALTH
AND PERFORMANCE
Presenter: Wendy M. Kohrt
In addressing the role of physical activity in bone, joint, and muscle
health and performance, Dr. Kohrt focused on bone mineral content
(BMC)—the amount of mineral at a particular skeletal site, such as the
femoral neck, lumbar spine, or total body; bone mineral density
(BMD)—the value determined by dividing the bone mineral content by
the area of a scanned region; osteoporotic fracture risk, osteoarthritis, and
muscle mass and function (quality). Performance related to mobility and
functional abilities was covered by Dr. Fielding. (See Chapter 6, Physical
Activity and Special Considerations for Older Adults.)
Bone Health
Many studies show positive effects of either a physically active life-
style or exercise interventions on intermediate markers of bone health,
such as BMC and BMD. The evidence regarding the effects of physical
activity on the risk of osteoporosis comes from randomized controlled
trials of exercise intervention, meta-analyses of those trials, trials of the
effects of immobilization and unloading, observational studies, and oth-
ers. The intensity of the exercise appears to be a key determinant of the
osteogenic response.
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HEALTH PROMOTION AND DISEASE PREVENTION
Intervention Studies
A meta-analysis from the Cochrane database involved 18 exercise in-
tervention trials involving more than 1,400 postmenopausal women
(Bonaiuti et al., 2002). Results were reported as mean differences be-
tween the exercise and the control groups and the change in BMD in per-
centile units. Any type of exercise showed a benefit (approximately a 1.8
percent increase on lumbar spine BMD, and walking benefited both
spine and hip BMD).
A slightly larger meta-analysis by Wallace and Cumming (2000)
found that impact exercise had significant benefits among postmeno-
pausal women on both lumbar spine and femoral neck BMD. Nonimpact
exercise (primarily weight lifting) benefited lumbar spine BMD in post-
menopausal women. Essentially the same results were found in studies
involving premenopausal women. Randomized controlled trials of exer-
cise interventions in men and children generally have shown benefits on
BMD, but they have not yet been included in meta-analyses.
Observational Studies
Physical activity and risk of fracture The question remains about
whether an increase in BMD—along with balance, mobility, and muscle
strength—decreases the risk of fractures. No randomized controlled trials
are available, but some prospective observational studies provide useful
data about physical activity and hip fracture risk. The report by
Feskanich et al. (2002) from the Nurses’ Health Study of more than
60,000 women serves as a good example. The physical activity data are
self-reported. The incidence of hip fracture was collected for a 12-year
period. The women with the highest level of activity measured in MET-
hours per week had about a 50 percent relative risk reduction in hip frac-
ture. Similarly, as walking time increased, hip fracture risk decreased;
those who walked more briskly appeared to gain more benefit. The
women who became less active over a 6-year period had a statistically
significant increase in risk for hip fracture.
Effects of unloading or reduced loading Extreme conditions of
physical inactivity or reduced mechanical loading (such as limb immobi-
lization, bed rest, microgravity) cause rapid and profound bone loss. The
likelihood for full recovery of mineral is low. A meta-analysis of the ef-
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24 PHYSICAL ACTIVITY WORKSHOP
fects of bed rest (Law et al., 1991) suggests that 3 weeks of bed rest dou-
bles the risk for hip fractures during the subsequent 10 years. A study by
van der Poest et al. (1999) compared the BMD of a person’s fractured
tibia to that of the healthy tibia for 5 years after the fracture. The 8-week
period of unloading subsequent to the fracture resulted in a substantially
lower BMD in the injured limb even 5 years after the fracture.
Data Limitations
Little evidence is available on dose–response with respect to how the
type, frequency, duration, and/or intensity of exercise affects bone. Be-
cause the duration of follow-up in intervention studies has been quite
short, little is known about the extent to which the benefits of the inter-
ventions are retained. Bone strength (e.g., resistance to fracture) cannot
be measured directly in humans, and there is a paucity of information on
the relationship between BMD and bone strength. Therefore, the effects
of physical activity on BMD may not accurately reflect the effects on
resistance to fracture.
Animal Studies
On the other hand, a study conducted in rats showed that loading
causes small changes in BMC and BMD that resulted in very large in-
creases in bone strength (Turner and Robling, 2003), as illustrated in
Figure 2-2. Thus evidence in animals suggests that physical activity or
mechanical loading probably affects the skeleton in a way that translates
into large gains in bone strength.
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HEALTH PROMOTION AND DISEASE PREVENTION
Nonloaded
2,000 80
Loaded
5%
94%
1,500 60
7%
64%
BMC and BD
Fu and U
1,000 40
500 20
0 0
BMC BMD FU U
2
(mg) (mJ)
(mg/cm ) (N)
FIGURE 2-2 Effects of mechanical loading on bone mineral content, bone min-
eral density, ultimate force (the maximum amount of force supported before
failure), and energy to fail (the amount of energy absorbed by the bone before
failure).
NOTE: BMC = bone mineral content, BMD = bone mineral density, FU = ulti-
mate force, N = newtons, U = energy to fail, and mJ = millijoules.
SOURCE: Adapted from Turner and Robling (2003). Reprinted with permission
from Exerc Sport Sci Rev.
Possible Mechanisms by Which Physical Activity Reduces Risk
for Osteoporotic Fracture
Four mechanisms may explain the beneficial effects of physical ac-
tivity in reducing the risk of osteoporotic fracture. Physical activity
1. Increases bone mineral accrual during maturation
2. Attenuates the rate of bone mineral loss during aging
3. Enhances bone strength
4. Reduces the risk of falls by improving muscle strength, flexibil-
ity, coordination, and balance
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26 PHYSICAL ACTIVITY WORKSHOP
Summary of Effects of Physical Activity on Bone
Moderate to strong evidence indicates that physical activity plays an
important role in optimizing bone health during the developmental years;
but the long-term effects of benefit are not well known, and dose–
response information is lacking. In adulthood, moderate to strong evi-
dence from observational studies suggests that physical activity helps
prevent fractures, and randomized controlled trials indicate benefits of
physical activity on such useful biomarkers as BMD. The effects of ex-
treme disuse are very deleterious. Dose–response data are lacking.
Joint Health
Very little information is available about the pathogenesis of os-
teoarthritis (OA) and about a role for physical activity in the primary
prevention of the disease. Scant evidence is available for a direct relation
of physical activity (especially vigorous activity) and articular volume in
children (Jones et al., 2003). Systematic reviews, however, indicate that
exercise has benefits in the management of OA. Roddy et al. (2005) ex-
amined the evidence base for the role of exercise in the management of
hip and knee OA and differentiated research-based evidence from expert
opinion. Their literature base included 57 intervention trials of exercise
for knee OA, 9 intervention trials of exercise for hip OA, and 3 system-
atic reviews of exercise for knee or hip OA. When they summarized the
evidence, they rated it to be very high for the exercise benefits for people
with knee OA. In particular, after pooling all the trials and minimizing
the variability, the effect sizes range from 0.3 to 0.5 for the effect of ex-
ercise on pain. In contrast, they found very little evidence to support a
benefit for individuals with hip OA. The amount of evidence also was
very low for the type of exercise to recommend, contraindications for
exercise, the relationship of exercise to the progression of the OA, and
several other propositions. As with bone health, dose–response data are
lacking.
Muscle Health
In contrast with bone health and joint health, muscle health is not di-
rectly linked with a chronic disease. A few chronic diseases, however,
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HEALTH PROMOTION AND DISEASE PREVENTION
are associated with low muscle mass or impaired muscle function. These
include osteoporosis, in which there is a direct association between mus-
cle mass and bone mass; type 2 diabetes mellitus, in which the muscle is
resistant to insulin-mediated glucose uptake; and congestive heart failure
(CHF), in which there is skeletal muscle mitochondrial dysfunction. The
abnormal muscle in CHF may be a result rather than a cause of the dis-
ease, whereas low muscle mass and insulin resistance in muscle may be
contributing factors to the etiology of osteoporosis and type 2 diabetes
mellitus, respectively.
Physical Activity and Muscle Mass
A wealth of evidence indicates that high-intensity resistance exercise
induces muscle hypertrophy and that this adaptive response is retained
into very old age. Aerobic exercise has little or no anabolic effect on
muscle, although disuse causes muscle atrophy. Aerobic fitness does not
appear to have any impact on fat-free mass, whereas strength training
enhances muscle mass and strength. Using fat-free mass as a surrogate
for muscle mass, Holloszy and Kohrt (1995) showed that fat-free mass is
preserved until approximately the age of 50 years. Thereafter, a decline
occurs, which becomes steeper with advancing age. Combining those
data with data from Hawkins et al. (2001) shows the following: (1) men
and women who maintain very vigorous levels of endurance or aerobic
activity have fat-free mass levels that are comparable to those of seden-
tary individuals, and (2) the trajectory of change in fat-free mass over
time appears to be quite similar in athletes and sedentary individuals.
Similarly, Kyle et al. (2004) showed that fat-free mass, estimated with
bioelectrical impedance, is essentially the same in sedentary and physi-
cally active men and women.
Physical Activity and Muscle Quality
Dr. Kohrt identified the following characteristics of muscle quality:
• Specific torque (Newton-meters per square centimeter)
• Fatigue resistance
• Metabolic function (e.g., insulin resistance)
• Inflammatory state
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