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James McKinney, MD, MSc, Daniel J. Lithwick, MHA, Barbara N.

Morrison, BHK,
Hamed Nazzari, MD, PhD, Saul H. Isserow, MBBCh, Brett Heilbron, MB ChB,
Andrew D. Krahn, MD

The health benefits of


physical activity and
cardiorespiratory fitness
“Lack of activity destroys the good condition of every human being,
while movement and methodical physical exercise save it and
preserve it.”  — Plato (427–347 BC)

A
ABSTRACT: The benefits of physical diseases, it is imperative that we en- ncient philosophers and phy­
activity are plentiful and significant. courage regular physical exercise for sicians such as Plato and Hip­
High levels of physical activity and optimal health. The benefits of phys- pocrates believed in the rela­
cardiorespiratory fitness (referred ical activity exhibit a dose-response tionship between physical activity and
to simply as “fitness” in this article) relationship; the higher the amount health, and the lack of physical activity
are associated with lower all-cause of physical activity, the greater the and disease. However, by the mid-20th
and cardiovascular mortality. Fur- health benefits. However, the most century it was believed that physical
thermore, physical activity can re- unfit individuals have the potential activity might be harmful to health.
duce the development of chronic for the greatest reduction in risk, Moreover, the recommended treat­
diseases such as hypertension, dia- even with small increases in physi- ment of the time after myocardial in­
betes, stroke, and cancer. Addition- cal activity. Given the significant farction was complete bed rest. It was
ally, physical activity can promote health benefits afforded by physical not until landmark epidemiological
healthy cognitive and psychosocial activity, considerable efforts should studies in the 1950s that physical in­
function. An extensive effort to as- be made to promote this vital agent activity was associated with increased
certain the benefits from the current of health. risk of coronary heart disease (CHD).
Canadian physical activity guide- Dr Jeremy Morris examined the differ­
lines on all-cause mortality and sev- ences in CHD incidence between two
en chronic diseases suggests that groups of men working on London’s
the current recommendation for at double-decker buses: the drivers, who
least 150 minutes of moderate-to- were sedentary (sitting for more than
vigorous aerobic physical activity
per week in sessions of 10 minutes Dr McKinney is a fellow at UBC Hospital Isserow is co-founder and medical direc-
or more is associated with a 20% to and is completing a sports cardiology fel- tor of SportsCardiologyBC and director of
30% lower risk for premature all- lowship at SportsCardiologyBC. Mr Lith- cardiology services at both UBC Hospital
cause mortality and incidence of wick is a project and research coordinator and the Centre for Cardiovascular Health
many chronic diseases. Because the at SportsCardiologyBC and has completed at Vancouver General Hospital. Dr Heilbron
health benefits of activity have been a master’s degree in health administration is a cardiologist at SportsCardiologyBC and
established and physical inactivity at UBC. Ms Morrison is a project and re- a clinical assistant professor in the Division
is a modifiable risk factor central search coordinator at SportsCardiologyBC of Cardiology at UBC. Dr Krahn is a profes-
to the development of many chronic and is completing a master’s degree in ex- sor of medicine and head of the Division of
perimental medicine at UBC. Dr Nazzari is Cardiology at UBC.
This article has been peer reviewed. a resident in internal medicine at UBC. Dr

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The health benefits of physical activity and cardiorespiratory fitness

90% of their shifts), and the conduc­ Physical activity and activity patterns.
tors, who were physically active primary prevention of The relationship of fitness to all-
(climbing roughly 500 to 750 steps a all-cause mortality cause mortality was examined in the
day). Despite coming from similar so­ Contemporary studies have consis­ Aerobics Center Longitudinal Study4
cial classes, the physically active con­ tently demonstrated the inverse rela­ of 13 344 healthy people. The sub­
ductors had lower rates of CHD than tionship between physical activity jects included in the study had no
the physically inactive drivers (overall and rates for all­cause mortality and personal history of MI, hypertension,
annual incidence of 1.9/1000 for con­ cardiovascular death (CVD).2­4 Physi­ diabetes, or stroke, and no resting
ductors versus 2.7/1000 for drivers). cal activity is an important determi­ or stress­induced electrocardiogram
Furthermore, sudden cardiac death nant of cardiorespiratory fitness4 and (ECG) changes. They were required
(SCD) occurred less often in conduc­ fitness is related to physical activity to complete an exercise treadmill test
tors than drivers (0.5/1000 versus patterns.5 While physical activity can (ETT) to establish their fitness lev-
1.1/1000), and the conductors’ CHD be difficult to estimate, fitness can be el. After 8 years of follow­up, those
were more likely to manifest as angi­ assessed readily using the metabolic subjects in the lowest quintile of fit-
na than SCD. Similarly, it was shown equivalent task (MET) to provide an ness compared to those in the highest
that physically active postal work­ objective measure of a subject’s fit- quintile had a relative risk (RR) all­
ers had lower rates of incident CHD ness.4 (See Box for a definition of cause mortality rate of 3.44 for men
and SCD than their less active co­ MET and other fitness-related terms and 4.65 for women. Additionally,
workers.1 Based on these findings, used in this article.) Although deter­ the RR for CVD in the least fit men
Morris and colleagues postulated that minants of cardiorespiratory fitness and women compared with the most
physically active work offered a pro­ include age, sex, health status, and fit was 8.0. Even after adjusting for
tective effect, predominantly related genetics, the principal determinant age, cholesterol level, blood pressure,
to sudden cardiac death as a first man- is habitual physical activity lev­ smoking, fasting blood glucose, and
ifestation of disease. These observa­ els. Thus, cardiorespiratory fitness family history of CHD, the findings
tions were the first formal studies (referred to simply as “fitness” in this were consistent for men and women.
to link physical inactivity and heart article) can be used as an objective
disease. surrogate measure of recent physical How much physical activity
is enough?
The greatest reduction in all­cause
mortality occurs between the least
fit and the next-to-least fit group.3­5
Risk for chronic disease and

High Activity/fitness level In a study assessing both fitness and


at baseline
premature mortality

Health physical activity and the relationship


benefits to all­cause mortality, age­adjusted
Change in health status
with an increase in mortality decreased per quartile, with
physical activity/fitness a 41% reduction in death occurring
between the least fit and the next-to-
Low least fit quartiles.5 These findings sug-
gest that even small improvements in
fitness can translate into significant-
ly lower risk of all­cause mortality
Inactive/unfit Active/fit Highly trained
(Extreme activity/
and CVD.6 Efforts should be made
fitness) to target the least fit (the physically
Activity/fitness level
inactive) because slight increases in
activity can mean significant gains in
Figure 1. Dose-response relationship between physical activity/fitness and health status.
health status. A theoretical relation­
Estimates derived from prospective cohort studies are used here to show that a small change in ship between physical activity and the
physical activity/fitness in individuals who are physically inactive/unfit can lead to a significant
improvement in health status, including a reduction in the risk for chronic disease and premature risk for mortality and chronic disease
mortality. The dashed line represents the potential attenuation in health status seen in highly trained is shown in Figure 1 .7
endurance athletes. Adapted from Bredin and colleagues7 and used with permission.

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The health benefits of physical activity and cardiorespiratory fitness

What is the optimal amount of


45.0
physical activity?
Data from many prospective popula­ 40.0

Mean risk reduction (%)


tion studies suggest there is a graded 35.0
dose-response relationship between 30.0
physical activity/fitness and mortality 25.0
or disease state.4,3,8 In other words, the 20.0
greater the amount of physical activ­ 15.0
ity, the greater the health benefits. A 10.0
theoretical risk of excessive endur­ 5.0
ance exercise and the possibility of 0.0
a U-shaped curve ( Figure 1 ) is dis­ All- All- Cardio- Cardio- Stroke Hyper- Colon Breast Diabetes
cause cause vascular vascular tension cancer cancer (type 2)
cussed by Warburton and colleagues mortality: mortality: disease: disease:
physical statins physical statins
in Part 2 of this theme issue. To activity activity
examine whether low levels of physi­
cal activity (below the recommended Figure 2. Risk reduction for all-cause mortality and chronic disease seen in physically
weekly 150 minutes of moderate- active subjects.
intensity exercise) affect mortality, Mean estimates of risk reduction for statins and all-cause mortality and cardiovascular disease
a large prospective study considered from Taylor and colleagues,10 cancer mortality risk estimates from Cholesterol Treatment Trialists’
Collaboration,11 and remaining mean risk reduction estimates from Warburton and colleagues.8
the mortality of 416 175 individuals in
relation to five different activity vol­
umes: inactive, low, medium, high, or amount of 15 minutes, all-cause mor­ body of literature included in the study
very high activity.9 Participants in the tality was further reduced by 4% and suggests that the current requirement
low-volume activity group who exer­ all-cancer mortality was reduced by for at least 150 minutes of moderate-
cised for an average of 92 minutes per 1%.9 to-vigorous aerobic physical activity
week, or approximately 15 minutes a per week in sessions of 10 minutes
day, experienced a 14% reduced risk Physical activity and or longer (an energy expenditure of
of all-cause mortality and had a life risk reduction approximately 1000 kcal/week) is
expectancy 3 years longer than those An extensive effort to ascertain the associated with a 20% to 30% lower
in the inactive group. A graded ben­ benefits from the current Canadian risk for premature all-cause mortality
efit to exercise was also seen in this physical activity guidelines on all- and incidence of many chronic dis­
population: for every 15 minutes of cause mortality and seven chronic eases, with greater health benefits for
exercise added to the minimum daily diseases was published recently.8 The higher volumes and greater intensities

Box. Fitness-related terms

Cardiorespiratory fitness: The ability to One MET is defined as the amount of oxygen or Light-intensity physical activity: Has only
transport and use oxygen during prolonged, calories consumed while sitting quietly— minor effects on heart and breathing rates.
strenuous exercise or work. Reflects the 1 MET = 3.5 mL O2 per kg per minute or 1 kcal Measured as 1.6 to < 3 METs.
combined efficiency of the lungs, heart, (4.2 kJ) per kg per hour.
vascular system, and muscles in the transport Moderate-intensity physical activity:
and use of oxygen. Physical activity: Any bodily movement Increases heart and breathing rate to 50.0%
produced by skeletal muscles that results in to 70.0% of maximum. Energy requirement
Exercise: Structured and repetitive physical energy expenditure. By comparison, physical can usually be met by aerobic metabolism
activity designed to maintain or improve fitness depicts the capacity to achieve a using the body’s stores of glycogen and then
physical fitness. Often incorporates aerobic certain performance standard or trait. fats. Measured as 3 to < 6 METs.
activities that are rhythmic in nature and use
large muscle groups at moderate intensities Physical inactivity (or sedentary activity): Vigorous-intensity physical activity:
for 3 to 5 days per week for at least 10 minutes Involves no noticeable effort. Heart and Increases heart and breathing rates to
at a time (e.g., walking, bicycling, jogging). breathing rates are not raised perceptibly > 70.0% of their maximum. Anaerobic
above resting levels. Requires < 40.0% metabolism is needed to provide energy.
Metabolic equivalent task (MET): A measure maximum heart rate. Measured as 1.0 to 1.6 Measured as ≥ 6 METs.
of energy expended during physical activity. METs.

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The health benefits of physical activity and cardiorespiratory fitness

of activity (i.e., moderate or vigor­ mia and slightly reduce diabetic com­ Stroke
ous intensity rather than light inten­ plications, but cannot eliminate all the Stroke is the third leading cause of
sity).8 A summary of risk reduction adverse consequences and have had death in Canada, where 5.5% of all
in physically active subjects is shown limited success at reducing macrovas­ deaths are due to cerebrovascular dis­
in Figure 2 .8,10,11 cular complications.16 Since current eases. 17 Physically inactive people
have a significantly elevated stroke
risk (RR 1.60).18 In a systematic
review, high levels of physical activ­
ity were associated with a 31% risk
Efforts should be made to target the reduction. The reduced risk of stroke
is seen in both men and women, and
least fit (the physically inactive) because it appears that this benefit may be
slight increases in activity can mean present for both ischemic and hemor­
rhagic stroke.19
significant gains in health status.
Cancer
Cancer is now the leading cause of
death among Canadians, accounting
for 29.9% of all deaths (more than MI
Hypertension methods for treating diabetes remain and stroke combined).17 Population
Hypertension is the most common inadequate, prevention of the disease studies from the 1980s have identi­
risk factor for heart disease, stroke, is preferable.16 fied an increased risk of developing
and renal disease and has been identi­ A randomized controlled trial cancer among physically inactive
fied as a leading cause of mortality.12 sought to determine whether lifestyle people.4,20 In the NHANES I survey,
In a recent meta-analysis of 13 pro­ intervention or treatment with metfor­ physical inactivity was associated
spective cohort studies, high-level min would prevent or delay the onset with a relative risk of 1.8 for men and
recreational physical activity was of diabetes in patients with impaired 1.3 for women compared with their
associated with decreased risk of fasting glucose levels. Participants physically active counterparts.20 Mul­
developing hypertension when sub­ assigned to the intensive lifestyle tiple studies provide compelling evi­
jects were compared to a reference intervention were able to achieve dence that high physical fitness levels
group with low-level physical activity and maintain a reduction of at least are associated with a reduced risk of
(RR 0.81).13 In another meta-analysis 7% of initial body weight through a developing and dying from cancer. A
that included 30 studies involving healthy low-calorie, low-fat diet and recent meta-analysis confirmed that
patients with existing hypertension, to engage in moderate-intensity phys­ fitness is inversely related to cancer
aerobic endurance training was shown ical activity such as brisk walking for mortality: individuals with high car­
to reduce blood pressure by 6.9/4.9 at least 150 minutes per week. When diorespiratory fitness levels had a
mm Hg.14 compared with placebo, the lifestyle 45% reduced risk of total cancer mor­
intervention reduced the incidence of tality (RR 0.55) when compared with
Diabetes diabetes by 58% and the metformin their unfit peers, independent of adi­
Type 2 diabetes is a worldwide prob­ intervention reduced the incidence by posity.21
lem with significant health, social, 31%.16 This translates into a number Cancer, like CHD, is also pre­
and economic implications. Diabe­ needed to treat (NTT) of 7 for the life­ ventable to some extent and shares
tes results from a complex interplay style intervention and 14 for the met­ several common risk factors such as
of environmental and genetic com­ formin when attempting to prevent poor nutrition, obesity, inflammation,
ponents. There is strong evidence one case of diabetes over a 3-year and physical inactivity. Improve­
that such modifiable risk factors as period. Thus, physical activity repre­ ments in some of these risk factors
obesity and physical inactivity are sents a major public health opportuni­ with regular exercise might explain
the main nongenetic determinants of ty to reduce the cost of a major source the cancer mortality benefits seen
the disease.15 Current diabetes treat­ of morbidity. in meta-analyses.8 Physical activ­
ments can help control hyperglyce­ ity appears to affect all the stages of

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The health benefits of physical activity and cardiorespiratory fitness

carcinogenesis (initiation, promotion,


and progression), and it is likely that
Decreased
multiple mechanisms act synergisti­ estrogens and androgens
cally to reduce overall cancer risk.22 Improved immune
Some protective mechanisms that function
may attenuate cancer risk or promote
survival are shown in Figure 3 .22

Depression
Increased physical Reduced Decreased risk of
Depression is associated with poorer activity adiposity cancer
adherence to medical treatments and
reduced health-related quality of life,
as well as increased disability and
health care utilization.23 Furthermore, Decreased
depression is independently associ­ insulin and glucose
ated with increased cardiovascular Altered
morbidity and mortality, and is com­ adipocytokines
monly seen in patients with CHD.24 ( adiponectin , leptin,
inflammation)
In a meta-analysis examining the
effect of exercise in patients with
chronic disease, exercise significant­ Figure 3. Protective mechanisms of physical activity that may reduce cancer risk.
ly reduced depressive symptoms by Adapted from McTiernan.22
30%. The greatest reduction in depres­
sive symptoms occurred in patients tion in risk (35%).27 In addition to specific APOE e4 allele, the stron­
with higher baseline depressive symp­ reducing risk factors associated with gest known genetic risk factor for
toms and exercise-improved physical the incidence of vascular dementia, Alzheimer disease.31
function.23 A recent Cochrane review physical activity appears to increase An exciting aspect of the positive
found exercise to be effective at the production of neurotrophic fac­ relationship between physical activity
reducing depression symptoms when tors in the brain28 and can potentially and gray matter volume is that aero­
compared with psychological and mitigate against the loss of gray mat­ bic exercise interventions over a 6- to
pharmacological therapies.25 ter.29 High levels of physical fitness 12-month period appear to be suffi­
(as measured objectively by maximal cient for increasing volume.32 Further­
Cognitive function oxygen consumption) are associated more, in an intention-to-treat study of
The benefits of physical activity in with greater gray matter volume in older adults with memory impairment
maintaining cognitive function in old­ frontal and temporal lobes indepen­ who did not meet diagnostic critieria
er age and promoting healthy aging dent of age.30 There is a consistent for dementia, a short 24-week home-
have been well documented. In the association between higher levels based exercise program demonstrated
third decade of life the human brain of fitness and greater gray matter, a modest improvement in cognition.
starts to show a loss of gray matter and between physical activity and a Those subjects who did not receive
that is disproportionately large in the reduction in accelerated brain aging the exercise program had a decline
frontal, parietal, and temporal lobes or neuron loss. in cogntive function over the study
of the brain.26 Physical activity may also reduce period.33
In a meta-analysis of 33 816 non­ the risk for developing Alzhiemer dis­
demented subjects from 15 prospec­ ease. In a 21-year longitudinal study Physical inactivity—
tive cohorts, physical activity was that assessed individuals age 65 to 79, a modifiable risk factor
found to protect against cognitive twice-weekly leisure-time physical Physical inactivity is the fourth lead­
decline. The most fit subjects had a activity was associated with a reduced ing cause of death worldwide.34 It is
reduced risk of cognitive decline of risk of dementia and Alzheimer dis­ estimated that over a third of cancers
38%. Even low-to-moderate-level ease. This risk reduction was more and about 80.0% of heart disease,
exercise showed a significant reduc­ pronounced in individuals with a stroke, and type 2 diabetes could be

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The health benefits of physical activity and cardiorespiratory fitness

Table 1. Health outcomes and conditions Table 2. How physical activity improves social function. Physical inactivity
improved by physical activity. health outcomes: Proposed mechanisms. should be recognized and treated like
other modifiable risk factors.
• All-cause mortality • Improves fitness as measured by Extensive evidence shows an
• Cardiovascular disease mortality metabolic equivalent task values inverse relationship between physi­
• Cancer incidence (convincing data for • Decreases systemic vascular cal activity and mortality and the
breast and colon cancer) resistance
development of chronic disease: the
• Cancer mortality • Decreases sympathetic activity
greater the amount of physical activ­
• Type 2 diabetes • Decreases plasma renin activity
ity, the greater the benefits. As well,
• Hypertension (through primary • Helps maintain body weight
evidence confirms there is a graded
prevention and by lowering blood • Decreases waist circumference
pressure in patients with established dose-response relationship. The unfit
• Reduces percentage of body fat
hypertension) or the physically inactive can achieve
• Improves insulin resistance
• Stroke the largest health gains with slight
• Raises HDL cholesterol levels
• Osteoporosis increases in activity levels. Even
• Lowers LDL cholesterol levels
• Sarcopenia patients with established disease or
• Reduces systemic inflammation
• Depression
• Improves heart rate variability
cardiovascular risk factors can reduce
• Anxiety
• Improves endothelial function
their risk of premature mortality by
• Cognitive function
• Improves immune function
becoming physically active. The rec­
• Fear of falling
• Protects against gray matter loss
ommended weekly 150 minutes of
moderate-intensity aerobic activity
has been shown to prevent and pos­
prevented by eliminating behavioral only one-quarter (25.1%) of Cana­ itively moderate disease. The ben­
risk factors such as physical inactiv­ dians are moderately active.37 The efits of physical activity cannot be
ity, unhealthy diet, tobacco smoking, physical inactivity of Canadians has overstated, and encouraging physical
and alcohol use.35 In a study designed a significant economic impact, and in activity should remain an important
to examine the population attribut­ 2001 was estimated to be $5.3 billion health care policy objective.
able risk of physical inactivity on or 2.6% of total health care costs.18
death from diseases such as CHD, Among Canadians physical inactivity Competing interests
cancer, and diabetes, 6.0% to 10.0% is the most prevalent modifiable risk None declared.
of all deaths from noncommunicable factor,38 and improvements in fitness
disease worldwide were attributed to over time have been demonstrated References
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