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` SE REVIEW / SYNTHE

Evidence-informed physical activity guidelines for Canadian adults1
Darren E.R. Warburton, Peter T. Katzmarzyk, Ryan E. Rhodes, and Roy J. Shephard

Abstract: This review of the literature provides an update on the scientific biological and psychosocial bases for Canada’s physical activity guide for healthy active living, with particular reference to the effect of physical activity on the health of adults aged 20–55 years. Existing physical activity guidelines for adults from around the world are summarized briefly and compared with the Canadian guidelines. The descriptive epidemiology of physical activity and inactivity in Canada is presented, and the strength of the relationship between physical activity and specific health outcomes is evaluated, with particular emphasis on minimal and optimal physical activity requirements. Finally, areas requiring further investigation are highlighted. Summarizing the findings, Canadian and most international physical activity guidelines advocate moderate-intensity physical activity on most days of the week. Physical activity appears to reduce the risk for over 25 chronic conditions, in particular coronary heart disease, stroke, hypertension, breast cancer, colon cancer, type 2 diabetes, and osteoporosis. Current literature suggests that if the entire Canadian population followed current physical activity guidelines, approximately one third of deaths related to coronary heart disease, one quarter of deaths related to stroke and osteoporosis, 20% of deaths related to colon cancer, hypertension, and type 2 diabetes, and 14% of deaths related to breast cancer could be prevented. It also appears that the prevention of weight gain and the maintenance of weight loss require greater physical activity levels than current recommendations. Key words: active living, chronic disease, diabetes mellitus, dose–response relationships, health, hypertension, ischemic heart disease, mental health, metabolic syndrome, mortality, obesity, osteoporosis, preventive medicine. ` res e ´ tudes scientifiques sur les fondements biologiques et psychosociaux du ´ sume ´ : Cet article fait le tour des dernie Re ` re a ` l’effet de l’activite ´ phy´ physique canadien pour une vie active saine et porte une attention particulie Guide d’activite ´ des adultes a ˆ ge ´ s de 20 a ` 55 ans. Nous exposons brie ` vement les directives provenant d’un peu partout sique sur la sante ` re d’activite ´ physique a ` l’intention des adultes et nous les comparons aux directives canadiennes. dans le monde en matie ´ sentons l’e ´ pide ´ miologie descriptive de l’activite ´ physique et de l’inactivite ´ physique et nous analysons l’imporNous pre ´ physique et certaines re ´ percussions sur la sante ´ en mettant l’accent sur les quantite ´ s mitance de la relation entre l’activite ` cette fin. En conclusion, nous mentionnons des pistes de recherche particulie ` res. En bref, les nimale et optimale requises a ´ physique directives canadiennes et la plupart des directives issues des autres pays recommandent la pratique d’activite ´ mode ´ re ´ e presque tous les jours de la semaine. L’activite ´ physique diminue fort probablement le risque de soufd’intensite ´ re ´ brovasculaire, l’hypertension, frir de plus de 25 conditions chroniques, notamment la maladie coronarienne, l’accident ce ˆ lon, le diabe ` te de type 2 et l’oste ´ oporose. D’apre ` s les e ´ tudes recense ´ es, si la population le cancer du sein, le cancer du co ` re adhe ´ rait aux recommandations du Guide, on e ´ viterait environ un tiers des de ´ ce ` s associe ´s a ` la maladie canadienne entie ´ ce ` s associe ´s a ` l’accident ce ´ re ´ brovasculaire et a ` l’oste ´ oporose, un cinquie ` me des de ´ ce ` s assocoronarienne, un quart des de ´ s au cancer du co ˆ lon, a ` l’hypertension et au diabe ` te de type 2 et un septie ` me des de ´ ce ` s associe ´ s au cancer du sein. Il cie ´ vention du gain de poids et le maintien de la perte de poids exigent de plus gros efforts que ne l’insemble aussi que la pre diquent les recommandations actuelles. Received 1 April 2007. Accepted 30 May 2007. Published on the NRC Research Press Web site at apnm.nrc.ca on 14 November 2007. D.E. Warburton.2 Experimental Medicine Program, Unit II Osborne Centre, 6108 Thunderbird Blvd., Cardiovascular Physiology and Rehabilitation Laboratory, University of British Columbia, Vancouver, BC V6T 1Z3. P.T. Katzmarzyk. School of Kinesiology and Health Studies, Queen’s University, Kingston, ON K7L 3N6. R.E. Rhodes. School of Exercise Science, Physical and Health Education, University of Victoria, Victoria, BC V8P 5C2. R.J. Shephard. Faculty of Physical Education and Health, University of Toronto, Toronto, ON M5S 2W6.
1This

article is part of a supplement entitled Advancing physical activity measurement and guidelines in Canada: a scientific review and evidence-based foundation for the future of Canadian physical activity guidelines co-published by Applied Physiology, Nutrition, and Metabolism and the Canadian Journal of Public Health. It may be cited as Appl. Physiol. Nutr. Metab. 32(Suppl. 2E) or as Can. J. Public Health 98(Suppl. 2). 2Corresponding author (e-mail: darren.warburton@ubc.ca).
Appl. Physiol. Nutr. Metab. 32: S16–S68 (2007) doi:10.1139/H07-123

© NRC Canada 2007 / © Canadian Public Health Association 2007

Warburton et al.

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` te sucre ´ , relation dose–effet, sante ´ , hypertension, cardiopathie ische ´ mique, ´ s : vie active, maladie chronique, diabe Mots-cle ´ mentale, syndrome me ´ tabolique, mortalite ´ , obe ´ site ´ , oste ´ oporose, me ´ decine pre ´ ventive. sante ´ daction] [Traduit par la Re

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Introduction
Overwhelming evidence supports the importance of physical activity in the primary and secondary prevention of several chronic diseases (American College of Sports Medicine 1998a; Blair and Brodney 1999; Blair et al. 1989, 2001; Bouchard and Shephard 1994; Lee and Skerrett 2001; McAuley 1994; Paffenbarger et al. 1986a; Puett and Griffin 1994; Shephard 2001; Taylor et al. 2004; US Department of Health and Human Services 1991; Warburton et al. 2001a, 2001b, 2006a, 2006b). Seven chronic diseases in particular have been associated with physical inactivity: coronary heart disease (CHD), stroke, hypertension, breast cancer, colon cancer, type 2 diabetes mellitus (T2DM), and osteoporosis. Moreover, compelling evidence links physical inactivity to the development of obesity, sarcopenia, arthritis, physical disability, and several psychological disorders (Katzmarzyk and Janssen 2004; Warburton et al. 2006a, 2006b). In all, physical activity is thought to benefit over 25 chronic conditions (Bouchard et al. 1994). Canada has developed a series of physical activity guides designed for adults, children and youth, and older adults. The recommended guidelines have been widely promoted and adopted. However, much research has been completed since formulation of these guidelines (Figs. 1a and 1b). Accordingly, the primary goal of this review is to create an evidence-informed document evaluating current physical activity guidelines for adult Canadians and, where necessary, to recommend research informing revisions to the guidelines. Particular attention has been directed to literature (including high-quality systematic reviews and (or) metaanalyses of randomized controlled trials) on the role of physical inactivity in the prevention and treatment of CHD, stroke, hypertension, breast cancer, colon cancer, T2DM, obesity, and osteoporosis. The intent is not to replace current Canadian guidelines; rather, the review supports current guidelines or points to a need for improvements. The emphasis is on primary prevention, one particular focus being current literature on minimal and optimal levels of physical activity and fitness needed to control specific disease states. Because of the current high prevalence and the heavy economic and societal costs of obesity and CVD, the secondary and tertiary prevention of these conditions is also given brief consideration. 55 years (Health Canada and the Canadian Society for Exercise Physiology 1998a). This was followed by Canada’s physical activity guide to healthy active living for older adults (Health Canada and the Canadian Society for Exercise Physiology 1999), and Canada’s physical activity guide for children and Canada’s physical activity guide for youth (Health Canada and the Canadian Society for Exercise Physiology 2002a, 2002b). The adult guidelines are now approximately 8 years old, although still generally consistent with the current international viewpoint (Table 2). These recommendations have been endorsed by more than 65 Canadian national organizations, all provincial and territorial governments, and several international agencies. The central message is that 20–55-year-old adults should accumulate 60 min of daily physical activity or 30 min of moderate or vigorous exercise on at least 4 d/week:
Scientists say accumulate 60 minutes of physical activity every day to stay healthy or improve your health. As you progress to moderate activities you can cut down to 30 minutes, 4 days a week. Add-up your activities in periods of at least 10 minutes each. Start slowly. . . and build up (Health Canada and the Canadian Society for Exercise Physiology 1998a).

Current national and international guidelines for physical activity in adults
A variety of national and international guidelines and consensus statements have been developed around the health benefits of physical activity (Tables 1 and 2). Canada has played a leading role in these developments. In 1998, Health Canada and the Canadian Society for Exercise Physiology (CSEP) published Canada’s physical activity guide to healthy active living for adults between the ages of 20 and

The 60 min duration was advocated previously by the 1996 Surgeon General’s Report (United States Department of Health and Human Services 1996). The Canadian guidelines promoted the 60 min recommendation on the premise that most sedentary individuals would initially choose to perform light-intensity activities (such as easy walking and gardening). The wide range of activities required for various health outcomes was also acknowledged, with health benefits seen as developing across a continuum from light to vigorous effort (Warburton et al. 2006a, 2006b). Most international physical activity guidelines support the adoption of moderate-intensity physical activity on most days of the week. Often, an absolute intensity or energy expenditure (such as 3–6 METs) has been specified, based on tables that outline the metabolic costs of various activities, with specification of a total weekly requirement corresponding to a gross energy expenditure of 4.2 MJ (1000 kcal) (Warburton et al. 2006a). This particular dose was chosen mainly on the basis of epidemiological evidence showing associations between such energy expenditures and lower risks of all-cause mortality and incident CVD, colon and breast cancer, and T2DM (Helmrich et al. 1991; Lee and Paffenbarger 1994; Paffenbarger et al. 1986b; Sesso et al. 1998; Shephard 2001; Shephard and Futcher 1997). There are only minor differences in guidelines between countries and associations (Tables 1 and 2); however, a Canadian initiative to harmonize these guidelines would be welcome. Shephard (2001, 2003) emphasized that basing exercise prescriptions on absolute intensities of effort has limited value, particularly in diseased, middle-aged, and older individuals. An exercise intensity of 4 METs may be near max© NRC Canada 2007 / © Canadian Public Health Association 2007

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Appl. Physiol. Nutr. Metab. 32(Suppl. 2E), 2007 / Can. J. Public Health 98(Suppl. 2), 2007

Fig. 1. (a) Number of Medline hits with the keywords ‘‘health’’, ‘‘physical activity’’, and ‘‘exercise’’. (b) Number of Medline hits with the keywords ‘‘cardiovascular disease’’, ‘‘physical activity’’, and ‘‘exercise’’.
Number of Medline hits (all languages) 8000 7000 6000 5000 4000 3000 2000 1000 0 1980-1984 1985-1989 1990-1994 1995-1999 2000-2004

(A)

“Health” and “Physical Activity”

“Health” and “exercise”

900 800 700 600 500 400 300 200 100 0

(B)

1980-1984

1985-1989

1990-1994

1995-1999

2000-2004

“cardiovascular disease” and “physical activity” “cardiovascular disease” and “exercise”

imal effort for a frail elderly person, but is a very easy (and ineffective) prescription for a young and fit individual. MET values may also deviate from the standard figure because of inter-individual differences in the rate of task performance, fitness levels, skill, coordination, and economy of exercise; further moderating influences include heat, cold, wind, and altitude (American College of Sports Medicine 2000). Moreover, it is difficult to maintain an adequate training stimulus with a fixed absolute intensity of effort because of increases in personal fitness (Shephard 2001, 2003). One important advantage of the Canadian guidelines, highlighted in companion papers, is that recommended exercise intensities are based on relative rather than absolute effort (e.g., perceptions of effort, sweating, and vigorous breathing) (Health Canada and the Canadian Society for Exercise Physiology 1998b). Other resources created by CSEP provide exercise prescriptions based on objective measurements of heart rate (Table 3). Moderate-intensity effort (such as brisk walking) equates to approximately 40%–59% of heart rate reserve (Table 3). Such guidelines are consistent with recent recommendations from the American College of Sports Medicine (American College of Sports Medicine 1998b) and other authors (Howley 2001). The

Canadian guidelines also offer a menu of activity choices, emphasizing that the ‘‘time needed depends upon effort.’’ These recommendations have been effectively adopted and implemented by advanced health and fitness professionals (including CSEP-Certified Personal Trainers and CSEPCertified Exercise Physiologists, http://www.csep.ca) across Canada. They also have provided a strong template upon which to develop international guidelines. Inclusion of statements such as ‘‘Every little bit counts, but more is even better – everyone can do it!’’ reflects belief in a dose–response relationship between physical activity and health status; it is consistent with current international guidelines that acknowledge additional health benefits from greater energy expenditures. The accumulation of short bouts of exercise (10–15 min) throughout the day as a substitute for one prolonged exercise bout has found some recent advocates (American College of Sports Medicine 1998b; Gledhill 2001; Lee and Skerrett 2001). Literature supporting the minimal 10 min bout of exercise is lacking. Nonetheless, from the viewpoint of behavioural change, this paradigm shift may help previously sedentary individuals who would like to adopt a healthier lifestyle, but are unlikely to do so if it immediately involves prolonged vigorous exercise. The activities that adult Canadians elect during their leisure time follow this pattern (Table 4), and the new focus also seems attractive because recent evidence points to the greatest improvement in population health if sedentary individuals become physically active (Erikssen 2001). However, empirical evidence supporting this new approach is limited and this issue requires further investigation. The guidelines of many agencies and countries (including Canada) have supported the inclusion of activities to tax the musculoskeletal system (e.g., resistance and flexibility exercises) on at least 2 d/week. Canadian guidelines also advocate flexibility exercises on at least 4 d/week. This policy is supported by increasing evidence of a relationship between musculoskeletal fitness and health outcomes (Katzmarzyk and Craig 2002; Mason et al. 2007; Payne et al. 2000a, 2000b; Warburton et al. 2001a, 2001b, 2006a).

Number of Medline hits (all languages)

Descriptive epidemiology of physical inactivity
The importance of being physically active for health and well-being is accepted by much of the general population. Nevertheless, the majority of people in developed countries fail to meet even minimal requirements (Canadian Fitness and Lifestyle Research Institute 1998; Craig et al. 1999; Katzmarzyk et al. 2000). In the European Union, at least two thirds of those over the age of 15 years engage in less than 30 min of moderate-intensity physical activity each day (World Health Organization 2006), and this is also true for 60% of the global population. In Canada, some 54% of women and 48% of men are physically inactive (defined as expending <6.2 kJÁkg–1Ád–1; <1.5 kcalÁkg–1Ád–1) (Fig. 2). Indeed, the prevalence of physical inactivity is higher than for all other modifiable cardiovascular disease risk factors (Fig. 3). Various Canadian agencies have acknowledged the importance of increasing the physical activity of the population (Canadian Medical Association 2004; Federal–Provincial–
© NRC Canada 2007 / © Canadian Public Health Association 2007

Table 1. International physical activity guidelines for adults. Organization (reference) Title Guidelines

Year

Country

Warburton et al.

1975

USA

1980 and 1986

USA

Guidelines for graded exercise testing and prescription Guidelines for graded exercise testing and prescription

3–5 d/week for 20–45 min/d at 70%–90% of heart rate range 3–5 d/week for 15–60 min/d at 70%–85% of heart rate range

1991

USA

1995

USA

ACSM (American College of Sports Medicine 1975) ACSM (American College of Sports Medicine 1980, 1986) ACSM (American College of Sports Medicine 1991) CDC/ACSM (Pate et al. 1995)

3–5 d/week for 15–60 min/d at 60%–85% of heart rate range Adults should accumulate 30 min or more of moderateintensity physical activity on most, preferably all, days of the week.

1995

USA

NIH (National Institute of Health 1996)

Guidelines for graded exercise testing and prescription Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine NIH consensus development panel on physical activity and cardiovascular health

1996 Physical activity and health: a report from the Surgeon General

USA

Surgeon General (US Department of Health and Human Services 1996)

1998

Canada

Health Canada and CSEP (Health Canada and the Canadian Society for Exercise Physiology 1998a)

Canada’s physical activity guide to healthy active living

1999

Australia

Department of Health and Ageing (Australian Government 1999) ACSM (American College of Sports Medicine 2000)

The national physical activity guidelines for Australians

© NRC Canada 2007 / © Canadian Public Health Association 2007

2000

USA

ACSM’s guidelines for exercise testing and prescription

All individuals should engage in regular physical activity at a level appropriate to their capacity, needs, and interest. Children and adults should accumulate at least 30 min of moderate-intensity physical activity on most, and preferably all, days of the week. Individuals who currently meet these guidelines may achieve additional health benefits by becoming more physically active or including more vigorous activity. There should be greater utilization of cardiac rehabilitation programs that combine physical activity with other risk factor reduction. People of all ages should accumulate at least 30 min of moderate-intensity physical activity on most if not all days of the week. An increase in daily energy expenditure of approximately 150 kcal/d (or 1000 kcal/ week) is associated with significant health benefits. Health benefits can be achieved through intermittent, moderate intensity physical activity. Additional health benefits can be gained through greater amounts of physical activity. 20–55-year-old adults should accumulate 60 min of daily physical activity, or 30 min of moderate or vigorous exercise on at least 4 days a week. Time needed depends on effort. ‘‘Every little bit counts, but more is even better – everyone can do it!’’ Specific guidelines include: Endurance exercises performed 4–7 d/week; Flexibility exercises performed 4–7 d/week including gentle reaching, bending and stretching; Strength exercises performed 2–4 d/week. Adults should accumulate at least 30 min of moderateintensity physical activity on most, preferably all, days of the week and more vigorous activity will lead to greater health benefits. For health, 20 min/d, at 40%–85% heart rate range on most days of the week.

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Table 1 (concluded). Title Healthy people 2010 Guidelines Adults should engage in vigorous-intensity physical activity 3 or more days per week for 20 or more minutes per occasion.

Year 2000

Country USA

2000

Switzerland

Organization (reference) Healthy People Consortium (US Department of Health and Human Services 2000) Health-Enhancing Physical Activity (HEPA 2000) Recommendations of the Swiss Federal Office of Sports, the Swiss Federal Office of Public Health and the Network HEPA Switzerland The Filipino pyramid activity guide – adults

2000

Philippines

At least 30 min of moderate-intensity physical activity on most days of the week. This can be accomplished through 10 min bouts of exercise. Equivalent to an additional energy expenditure of 1000 kcal/week. 10 min a time, 30 min/d, 5 d/week

2001 Hillary Commission. 2001. Movement = health. National physical activity guidelines.

New Zealand

At least 30 min of moderate-intensity physical activity on most if not all days of the week. Vigorous exercise will lead to extra health and fitness benefits. For general health, at least 30 min of moderate-intensity exercise per day on 5 or more days of the week. These recommendations can be achieved by doing all of the activity in one session or through several shorter bouts of activity (10 min or more). For the prevention of obesity, 45–60 min of moderate-intensity exercise a day.

2004 At least five a week

UK

2006

European Union

The Philippine Association for the Study of Overweight and Obesity (Philippine Association for the Study of Overweight and Obesity 2000) Sport & Recreation New Zealand (SPARC) (Hillary Commission 2001) Department of Health, Physical Activity, Health Improvement and Prevention (Department of Health Physical Activity Health Improvement and Prevention 2004) WHO HEPA (World Health Organization 2006) Physical activity: a basic requirement for health

At least 30 min of moderate-intensity physical activity on most days of the week (equivalent to expending 150 kcal/d). More activity may be required for weight control. It is recommended that activities to improve musculoskeletal fitness be performed twice weekly.

Appl. Physiol. Nutr. Metab. 32(Suppl. 2E), 2007 / Can. J. Public Health 98(Suppl. 2), 2007

© NRC Canada 2007 / © Canadian Public Health Association 2007

Note: ACSM, American College of Sports Medicine; CDC, Centers for Disease Control; NIH, National Institute of Health.

People with mild hypertension should engage in 50–60 min of dynamic exercise of the lower extremities 3–4 times/week to reduce blood pressure. Persons of all ages should include physical activity in a comprehensive program of health promotion and disease prevention and should increase their habitual physical activity to a level appropriate to their capacities. for persons with high BP. days of the week. and interest. Physical activity messages promoting at least 30–45 min of moderate to vigorous activity on most days of the week should be included in primary prevention interventions for cancer. USA American College of Sports Medicine (Pescatello et al. training frequencies between 3 and 5 d/week are effective in reducing BP. Canada CHD Hypertension Canada Canadian Coalition for High Blood Pressure Prevention and Control. Large-muscle aerobic activities at 40%–70% heart rate reserve (RPE 11–14). 2–3 d/week (before or after aerobic or strength training). Example consensus statements surrounding the health benefits of physical activity. 20– 60 min/session (or multiple 8–10 exercises). 2004) Stroke Canada Hypertension Every US adult should accumulate 30 min or more of moderate-intensity physical activity on most. an exercise program that is primarily aerobic-based is recommended. 2–3 d/week. strength training consisting of 1–3 sets of 10–15 repetitions of 8–10 exercises using the major muscle groups. people who do not have hypertension should participate in regular exercise owing to the beneficial effects on blood pressure and the risk of CHD. the form of physical activity that is best suited to a given individual depends on that individual’s needs. The frequency. S21 . and goals. 2–3 d/week. exercise should be prescribed as an adjunct therapy for people who require pharmacologic therapy for hypertension. limitations. primary prevention must include a plan for a lifetime of appropriate physical activity. flexibility training. resistance training should serve as an adjunct to an aerobic-based program. needs. and the Heart and Stroke Foundation of Canada (Cleroux et al. the Laboratory Centre for Disease Control at Health Canada. The preferred general primary prevention recommendation is moderate-level physical activity performed consistently to accumulate 30 min or more over the course of most days of the week. holding each stretch for 10–30 s. coordination and balance activities. the greatest benefits can be seen at the lowest intensities. 1995) Lifestyle modifications to prevent and (or) treat hypertension should include 30–60 min of aerobic exercise on 4–7 d/week. The regular practice of moderate-intensity physical activity is an independent risk factor associated with a reduction in: all-cause and CHD mortality. and the maintenance of a healthy body mass. duration. 2005) Canadian Task Force on Preventative Health Care (Beaulieu 1994) CHD Canada Canada Population health promotion Cancer © NRC Canada 2007 / © Canadian Public Health Association 2007 USA Canadian Association of Cardiac Rehabilitation (Stone and Arthur 2005) Cancer Care Ontario (Friedenreich 2000) Centers for Disease Control and ACSM (Pate et al. incidence of CHD. 1999) Canadian Hypertension Society (Khan et al. preferably all. and intensity of the activity should be individualized to personal satisfaction as well as mode and progression. 3–7 d/week.Table 2. Every US adult should accumulate 30 min or more of moderate-intensity physical activity on most. preferably all days of the week. hypertension and T2DM. 1996) USA American Heart Association (Gordon et al. Ideally this activity should be done for at least 30 to 60 min four to six times weekly or 30 min on most days of the week. 2004) USA CVD American Heart Association (Fletcher 1997. Fletcher et al. Condition Hypertension Recommendation(s) Country Consensus panel Warburton et al. but there are additional benefits to physical activity of higher intensities.

Canada The European Network for the Promotion of HealthEnhancing Physical Activity (HEPA) (Cavill et al. is beneficial. 2007 / Can. all young people (5–18 years) should participate in physical activity of at least moderate intensity for one hour a day. 2006) Kino-Quebec (Thibaut 1999) Population health promotion Australia Population health promotion Population health promotion National Heart Foundation of Australia (Bauman et al. a greater volume of activity than advocated by these guidelines likely leads to greater benefits. it is likely that to prevent obesity. a given increase in physical activity has a greater effect for a sedentary or slightly active person than for an active person. but also increases the risk of injuries. higher levels of physical activity might be necessary for younger people to support optimal growth and development as well as reducing risk of CVD in later life. 2E). a larger volume of activity is likely needed to counter weight gain. Shelley and Ryden 2004) Canada Population health promotion Recommendation(s) Every adult should accumulate at least 30 min of moderate-intensity physical activity most and preferably every day of the week. 2007 © NRC Canada 2007 / © Canadian Public Health Association 2007 UK National Institute for Health and Clinical Excellence (health education authority) (Department of Health Physical Activity Health Improvement and Prevention 2004) Report from the Chief Medical Officer for England The more active a person is. Public Health 98(Suppl. any increase. Accumulate 60 min of physical activity every day to stay healthy or improve your health. in absolute terms. Physiol. activities that exceed the recommended amount of physical activity will bring about greater benefits. 2). Canada Population health promotion Health Canada and the Canadian Society for Exercise Physiology (Health Canada and the Canadian Society for Exercise Physiology 1998a) Health Canada/United States Centers for Disease Control and Prevention Conference (Shephard 2002) Switzerland Population health promotion The current guidelines of moderate-intensity physical activity on most days of the week (with the potential to use shorter bouts of exercise to accumulate the required dose) were sufficient to reduce the risk of premature mortality and multiple chronic diseases (including CVD and colon cancer). 32(Suppl. Nutr. a sedentary person can obtain major health benefits. exercises that tax the musculoskeletal system are required to attenuate age-related decreases in muscle mass and mobility. the total amount of physical activity seems to be more important than the intensity. so that lower intensity daily activity (such as walking) may confer similar benefits to higher intensity activity on fewer days of the week. Metab. there seems to be no level below which physical activity has no positive effect on health. this should be seen as a meaningful target and not a maximum. 4 d/week. by increasing physical activity (even slightly). 2001) Appl. Condition CVD Country European Union Consensus panel European Consensus (Shelley 2004.S22 Table 2 (continued). J. At least 30 min of moderate-intensity activity on most or all days of the week. At least 30 min of moderate physical activity 5 d/week (or more). however small. 45–60 min of moderate physical activity is needed every day of the week. . At least 30 min/d of moderate-intensity physical activity is recommended for women and men of all ages. As you progress to moderate activity you can decrease the time needed to 30 min. the better his or her health will be. the time needed for physical activity depends on effort.

additional health benefits can be gained through greater amounts of physical activity. Children and adults alike should set a goal of accumulating at least 30 min of moderate-intensity physical activity on most. and interest. if not all. 2002) Obesity Consensus Conference (Bouchard and Blair 1999) Report of the US Surgeon General on Physical Activity and Health (United States Department of Health and Human Services 1996) USA Hypertension Significant health benefits can be obtained by including a moderate amount of physical activity (e. or 45 min of playing volleyball) on most. needs. cardiovascular disease. colon cancer and breast cancer. et al. The 57th World Health Assembly (World Health Organization 2004) At least 30 min of regular. bones. and preferably. and of CHD. coronary heart disease. Evaluation. More activity may be required for weight control. For the primary prevention of hypertension it is recommended that people engage in regular aerobic activity 30 min/d on most days of the week. hypertension. moderate-intensity physical activity on most days reduces the risk of CVD and diabetes. physical activity and health. Muscle strengthening and balance training can reduce falls and increase functional status among older adults. P. those who currently meet these standards may derive additional health and fitness benefits by becoming more physically active or including more vigorous activity.K. cardiac rehabilitation programs that combine physical activity with reduction in other risk factors should be more widely used. all days of the week. Physical activity also improves mental health and is important for the health of muscles. and joints. for those with known CVD. physical activity reduces the risk of premature mortality in general. 30 min of brisk walking or raking leaves. S23 . and Treatment of High Blood Pressure (Chobanian et al.g. International Obesity USA Population health promotion National High Blood Pressure Program (Whelton. most Americans can improve their health and quality of life. Detection. 15 min of running. Country USA Consensus panel NIH (National Institute of Health 1996) USA Hypertension Recommendation(s) All Americans should engage in regular physical activity at a level appropriate to their capacity.. People who can maintain a regular regimen of activity that is of longer duration or of more vigorous intensity are likely to derive greater benefit. particularly those pertaining to CVDs and type II diabetes. CHD. through a modest increase in daily activity. colon cancer. most days of the week may result in an approximate systolic BP reduction of 4–9 mmHg. and diabetes mellitus in particular. Condition Cardiovascular health Warburton et al. days of the week. It is well established that regular physical activity has favorable effects on several of the comorbidities of obesity.Table 2 (concluded). © NRC Canada 2007 / © Canadian Public Health Association 2007 Note: CVD. 2003) World Health Organization—Global strategy on diet. Lifestyle modifications that include engaging in regular aerobic physical activity such as brisk walking at least 30 min/d. International Population health promotion The Seventh Report of the Joint National Committee on Prevention.

100 Fig.5 kcalÁkg–1Ád–1. *Fifteen-category RPE scale (6–20). There appears to have been an 11% increase in Canadian physical activity levels between the 1994–1995 National Population Health Survey and the 2002–2003 Canadian Community Health © NRC Canada 2007 / © Canadian Public Health Association 2007 . Public Health 98(Suppl. obesity was defined as a body mass index of >27. 2. and territorial Ministers responsible for sport and physical activity have advocated a 10% increase in physical activity levels in every jurisdiction by 2010 (Federal–Provincial–Territorial Conference of Ministers Responsible for Sport 2003). Relative intensities for aerobic exercise prescription (for activities lasting up to 60 min). Prevalence of traditional risk factors for cardiovascular disease in Canadian society according to gender. The prevalence of physical inactivity as a function of age in Canada. 60 Combined Men and Women Men Women 50 Prevalence of Physical Inactivity (%) Men Women 80 Prevalence (%) 40 30 60 20 40 10 20 0 Diabetes Hypertension Inactivity Smoking Obesity Alcohol Risk Factor 0 20-24 25-44 45-64 65+ Age (year) Territorial Conference of Ministers Responsible for Sport 2003. which calls for a 20% increase in the proportion of Canadians who are at least moderately active for at least 30 min/d (Health Canada 2005). Health Canada 2005). RPE.S24 Appl. Adapted from Warburton et al. The target of increasing physical activity levels is echoed in the Pan-Canadian Healthy Living Strategy. Fig. 2007 Table 3. diabetes was evaluated by self-report. percentage of heart rate reserve.5 kcalÁkg–1Ád–1. Metab. 3. 32(Suppl. High cholesterol was defined as a plasma cholesterol level above 5. diagnosed diabetes. inactivity was defined as a usual daily leisure-time energy expenditure of <1. 2006b using information provided by the Handbook for Canada’s physical activity guide to healthy active living (Health Canada and the Canadian Society for Exercise Physiology 1998b) and Howley (2001). The federal. 2004 Physical Activity Monitor (Canadian Fitness and Lifestyle Research Institute 2004). Physiol. smoking was defined as daily tobacco smoking. 2007 / Can.2 mmolÁL–1 (>200 mgÁdL–1). { Category–ratio RPE scale (0–10). rating of perceived exertion. Nutr. alcohol was defined as alcohol use in excess of 9 and 14 drinks/week for women and men. There are some encouraging indicators of success in promoting physical activity within Canada. Intensity Very light effort Light effort Moderate effort Vigorous/hard effort Very hard effort Maximal effort %HRR <20 20–39 40–59 60–84 >84 100 %HRmax <50 50–63 64–76 77–93 >93 100 RPE* <10 10–11 12–13 14–16 17–19 20 RPE{ <2 2–3 4–6 7–8 9 10 Breathing rate Normal Slight increase Greater increase More out of breath Greater increase Completely out of breath Body temperature Normal Start to feel warm Warmer Quite warm Hot Very hot/perspiring heavily Example activity Dusting Light gardening Brisk walking Jogging Running fast Sprinting all-out Note: The intensity required for health ranges from light to vigorous/hard effort. and the The Changing Face of Heart Disease and Stroke in Canada (Heart and Stroke Foundation of Canada 2000). %HRmax. J. percentage of heart rate maximum. Source: National Population Health Survey 1996–1997 (Statistics Canada 1996). a policy also urged by the Canadian Medical Association (2004). Table 4. Inactivity was defined as a usual daily leisure-time energy expenditure of <1. Percent of population Rank 1 2 3 4 5 Activity Walking Gardening. yard work Home exercise Swimming Bicycling Total 69 48 29 24 24 Women 75 45 31 24 19 Men 64 51 26 24 28 Note: National Population Health Survey. 2). 2E). 1998/99 (Statistics Canada 2001). respectively. provincial. Source: 2004 Physical Activity Monitor (Canadian Fitness and Lifestyle Research Institute 2004). %HRR. hypertension was defined as a blood pressure of ‡140/ 90 mmHg. Top five physical recreation activities of Canadian adults (age 20+ years).

Regular physical activity is effective in the primary and secondary prevention of CVD. Our article is thus restricted to information on the prevention of CVD (including CHD and stroke).31 1. as well as between premature disease-specific and all-cause mortality (Blair and Brodney 1999. Colditz (1999). CVD. osteoporosis. Currently.0 14.’’ Although these reports are encouraging. hypertension.Warburton et al. . In view of their high prevalence and the substantial medical costs associated with CVD and obesity. and T2DM. McGinnis and Foege 1993. quality-adjusted life expectancy. Morris et al. colon cancer. including 10%–16% of cases of breast cancer.8 18. Warburton et al. stroke.0 NA 1. 1994. chronic disease.2 1. 2004. health status. An Australian report (Stephenson et al. effectiveness. arthritis. rectal cancer. Mokdad et al. both are related to health status in a dosedependent manner (Warburton et al. obesity. cancer.5 2. The World Health Organization (2002) estimated that globally. Canada Disease CHD Stroke Hypertension Colon cancer Breast cancer Type 2 diabetes Osteoporosis RR 1.1 1. US Department of Health and Human Services 1996). hypertension. Our literature search used the terms physical activity. they require confirmation because of several limitations to current physical activity monitoring systems (Katzmarzyk and Tremblay 2007). Katzmarzyk and Janssen 2004. Although physical activity is a behaviour and physical fitness is an attained state. and 22% of cases of CHD (World Health Organization 2002).4 24. 1978). and Health was created to address this concern (World Health Organization 2004). some forms of cancer (particularly of the colon and breast). and osteoporosis). we have addressed each condition individually in the context of the Canadian physical activity guidelines.41 1. Older adults are also less likely to meet current recommendations. the dosage required (minimal versus optimal). Consideration was given to efficacy (does physical activity lead to a specific health benefit). obesity. and mortality. T2DM. Studies of both physical activity and physical fitness thus informed this report. 2000. Australia.2 21. considerable epidemiological research has documented the health benefits of regular physical activity (Bouchard et al.50 1. 2). osteoporosis. 2000.0 Australia RR 1. breast cancer. and the USA. *Evaluated the incidence of falls/fractures. men tend to be more active than women (Fig. health. and consensus statements. The Global Strategy on Diet. US data. Physical inactivity imposes an enormous burden on Canadian society through related health care costs and human suffering (Katzmarzyk et al. Australian data. 2004). 2000) suggested that Canada was ‘‘the best case scenario for feasible population change.5 2. hypertension. Numerous reports document associations between physical inactivity or fitness and chronic disease. Survey (Canadian Fitness and Lifestyle Research Institute 2004).60 1.45 1. the secondary treatment of these conditions is also evaluated briefly. 2006a). colon cancer. T2DM. and mechanisms of action. At all ages. physical inactivity causes 2 million premature deaths each year. and health-care costs).30 1.3 13. Oguma et al. Eight chronic conditions were identified as having the strongest supporting literature (and probably the greatest importance from the viewpoints of premature mortality.0 NA 1. 2006a).1 24. 2002. We reviewed the literature following a similar strategy to that adopted by the ‘‘Adequacy of Evidence for Physical Activity Guidelines Development: Workshop Summary’’ (West Suitor and Kraak 2007). Stephenson et al. obesity.5 2. The preferred types of activity vary with sex (Table 4) and age (Canadian Fitness and Lifestyle Research Institute 2004). Warburton et al. fitness. and several psychologi© NRC Canada 2007 / © Canadian Public Health Association 2007 Methods Our research team adopted several tactics to evaluate levels of evidence on physical activity and health. Physical Activity. diabetes. Relative risks and population-attributable risks (PAR%) for physical inactivity in Canada. Paffenbarger et al. and 24% as active (Canadian Fitness and Lifestyle Research Institute 2004). A low socioeconomic status and (or) less education are correlates of physical inactivity.59 PAR% 19. In Australia and the US. (2000).5 1. meta-analyses. exercise. 1953) and Paffenbarger (Paffenbarger and Hale 1975. Katzmarzyk et al. As there appear to be multiple dose–response curves for various endpoints (see Gledhill and Jamnik’s work in the Canadian physical activity and lifestyle approach (Canadian Society for Exercise Physiology 2003)). We relied heavily on major systematic reviews. 49% of adult Canadians are classed as at least moderately active. Table 5. physical inactivity (and diet) are second only to tobacco control as potential mechanisms for preventing chronic disease (Australian Institute of Health and Welfare 2006.0 PAR% 22 NA 12 22 5 12 18* S25 Note: Canadian data are from Katzmarzyk and Janssen (2004). as well as the promotion of psychological well-being. together with disease-specific terms (for example. Canadian population-attributable risk data are comparable with figures from other developed countries (Table 5).0 1. Physical inactivity and chronic disease Since the landmark work of Morris (Morris and Heady 1953.3 1.4* PAR% 18 16 NA 19 9 13 18* USA RR 2. 2006a).

2001a. in Canada. High cholesterol was considered as ‡240 mgÁdL–1 (‡6. Trolle-Lagerros et al. 2007 / Can. 1996).5 0. obesity. The risk of all-cause mortality has been consistently lower in habitually active individuals. 2006b). leading Powell and colleagues (1987) to assert that .49%) (Statistics Canada 2004). 1986a. 2007. and smoking cessation. 1989.0 0. Nevertheless. if these inferences are correct. Data adapted from Blair et al. J. 1989).0 <500 500-900 1000-1499 1500-1999 2000-2499 2500-2999 3000-3499 >3500 0. 2006a). or cigarette smoking (Fig. 5. 2004. Paffenbarger et al. 2006a. with sub-analyses revealing similar reductions in the risk for all-cause mortality between sexes (Andersen et al.5 0. Recent studies (Andersen et al. 3. Macera and Powell 2001. 2001b).0 0. Early investigations examining the relative risks of all-cause mortality as a function of physical activity or fitness level. 2003. 2). High systolic blood pressure (BP) was considered as ‡140 mmHg. Elevated body mass index (BMI) was ‡27.2 (A) Relative Risk for All-cause Mortality Men Women 2. Katzmarzyk and Craig 2006. Warburton et al. 2007 Fig. Warburton et al. . Katzmarzyk and Craig 2006.8 2. 1 0 Q1 Q2 Q3 Q4 Q5 Physical Fitness Quintile An epidemiological study of 25 341 men and 7080 women demonstrated that low physical fitness was a more important risk factor for all-cause mortality than hypertension. Top panel shows physical activity levels (kcal/week) in the Harvard Alumni Study (Paffenbarger et al. 4) (Blair et al. cancers (29. 4. 1996. 2003) found an inverse © NRC Canada 2007 / © Canadian Public Health Association 2007 . Public Health 98(Suppl. and T2DM (3. Bouchard and Shephard 1994. Myers et al. 1989). Individuals in the higher fitness categories also had the lowest mortality rates from CVD and cancer (Blair et al.0 Low Fitness Smoking Systolic BP Cholestrol BMI 5 (B) Physical Activity Levels (kcal/week) Relative Risk of All-Cause Mortality Risk Factor cal disorders (American College of Sports Medicine 1998a.3%). physical inactivity is a major cause of mortality from diseases of the circulatory system (33. Nutr.0 was considered a normal risk. 1986b. 1. homicide.2 0. McAuley 1994. Blair et al.4 (men) and 4. 2003.1%). . high cholesterol.2 mmolÁL–1). Lee and Paffenbarger 2000. Taylor et al.0 Fig. Lee et al. 2000.6 1.S26 Appl. 2001. 4 MEN WOMEN 3 2 Physical inactivity and all-cause mortality Assessments of all-cause mortality are complicated by the inclusion of deaths from suicides.4 1. 1986b). 2005) have also revealed large reductions in the risk for all-cause mortality.5 Relative Risk of All-Cause Mortality 1. US Department of Health and Human Services 1991. dietary modification to lower serum cholesterol. 32(Suppl.0 0. Warburton et al. In 1989. Blair and Brodney 1999.regular physical activity should be promoted as vigorously as blood pressure control. Paffenbarger et al. Many of these studies have included women. Physiol. Slentz et al. 5) suggest that the greatest differences in risk occur between the lowest and the nextlowest fitness category. and accidents (Katzmarzyk 2005). 2004. an 8-year follow-up of healthy middle-aged men (n = 10 224) and women (n = 3120) revealed a progressively lower all-cause mortality rate across physical fitness quintiles. Relative risk was corrected for age and examination year. with individuals in the lowest quintile showing a risk of 3. Trolle-Lagerros et al. A meta-analysis (Katzmarzyk et al. 2005). then sedentary individuals could substantially improve their health status with only a minor increment in habitual physical activity (Erikssen 2001. 2000.7 (women) relative to the top quintile. Bottom panel shows quintiles of cardiorespiratory fitness in the Aerobics Center Longitudinal Study (Blair et al. A relative risk of 1. Numerous reviews (including several systematic and (or) meta-analytic reviews) have highlighted the relationship between physical inactivity or fitness and premature all-cause mortality (Appendix Table A1). Metab. This study and others (Fig. Long-term prospective studies have consistently shown that physically active men and women have a 20%–35% lower all-cause and cardiovascular-related mortality than their sedentary peers (Macera et al. Puett and Griffin 1994. 2E). The importance of low physical fitness for the risk for allcause mortality in comparison with other known risk factors.

Myers et al. 2004). respectively).9-1.0) S27 Fig.55–0.5-3.5) 2.6) 1. 6). The ‘‘fit’’ classification was based on a Duke Activity Status Index score of ‡25 mLÁkg–1Ámin–1 (‡7 METs).91) and sports participation (RR 0. Four categories of leisure activity were established.6-2. chronic obstructive pulmonary disease (COPD). and 0.0) 2.2-1. 95% confidence interval (CI) = 0. (1. Major adverse events were defined as death. and a high serum cholesterol (Fig. Data adapted from Myers et al. smoking. unstable angina.0 (1.5 10 0.2-2. T2DM. 3.87 in men) were also associated with a lower mortality. non-fatal myocardial infarction.5 years.6-2.3) (1.69.0-2. 95% CI = 0.1-1.68. Andersen and co-workers (2000) examined the relationship between all-cause mortality and physical activity during work. or non-fatal stroke. (2004) noted that cardiovascular fitness attenuated the risk of all-cause and CVD mortality in men with the metabolic syndrome (Fig.42–0.8) (1. and high cholesterol (TC ‡ 220 mgÁdL–1).0 Hypertension COPD Diabetes Smoking BMI TC 0 Not Obese Obese Not Obese Obese Risk Factors >8 MET (n = 2743) 5-8 MET (n = 1885) <5 MET (n 1585) Major Adverse Events All Adverse Events Fig.0 20 0. Mortality rates in groups 2. stroke. while cycling to work.000 Man-years 60 Unfit Fit 50 the sedentary group (RR = 0. Katzmarzyk et al. Wessel et al. Note: All-cause and cardiovascular disease rates were adjusted for age and year of examination (n = 19 223 men aged 20–83 years).9) (1.6) 30 1.2 MJ/week (1000 kcal/week) increase in physical activity.53. Fig. Data adapted from Katmarzyk et al.7-2.3) (1. 2004.8-3. congestive heart failure. A sample of 13 375 women and 17 265 men aged 20–93 years was followed for 14.7) Unfit Fit 40 (1. during leisure time.1) (0. Physical inactivity and co-morbidities Physical activity or enhanced aerobic fitness appears to reduce the risk of premature mortality even in the presence of other chronic disease risk factors (Figs. 2004. (2002) observed a markedly lower risk of death from any cause among fit participants.75 in women. ‡30). and 4 were significantly lower than those in .57–0. 95% CI = 0.5 (0. was associated with a mortality benefit of around 20%. despite the presence of other cardiovascular risk factors (Katzmarzyk et al. an elevated body mass index (BMI. bicycling to work (3 h/week) (RR = 0. Myers et al. despite having such risk factors as hypertension. (2004) reported that being fit or physically active was associated with a more than 50% lower mortality risk in men.56. The importance of physical fitness for all-cause mortality risk in patients with other known risk factors and the relative risk for death of any cause among participants with various risk factors including a history of hypertension. Two other investigations confirmed a better health status in physically active individuals.Warburton et al. elevated body mass index (BMI ‡ 30 kg/m2). or other vascular occurrences.61. 2002). After multivariate adjustment. 7. 8. 6–8).72. a 4.3) Population with Adverse Event (%) Relative Risk of Death (1. 0. their data showed a significant dose–response relationship. All-cause and cardiovascular disease mortality rates by cardiorespiratory fitness levels in healthy men and men with the metabolic syndrome. All-cause and cardiovascular mortality are consistently © NRC Canada 2007 / © Canadian Public Health Association 2007 40 30 20 10 0 Healthy Metabolic Healthy Metabolic All Cause Cardiovascular Disease dose–response relationship between physical activity and allcause mortality across all age groups and in both sexes. chronic obstructive pulmonary disease. Obesity was classified as a body mass index (BMI) ‡ 30. diabetes. The effects of physical fitness and obesity on the incidence of adverse cardiovascular events. Data adapted from Wessel et al. 70 Death Rate per 10. All adverse events included all-cause death or hospitalization for nonfatal myocardial infarction. The all-cause mortality was some two times greater in individuals with a peak exercise capacity of less than 5 METs than in individuals with a capacity of greater than 8 METs. smoking. 0. 6.2-1. 2002.8-2.5 (1. 50 (1. irrespective of other risk factors (Myers et al. 7). and during sports participation. or a 1 MET higher physical fitness level. 2004.

but instead we can. Wannamethee et al. 2000. A systematic review (Blair et al. irrespective of BMI or cigarette smoking.6 0.0 Relative Risk of Mortality 1. Paffenbarger et al. The relative risk of mortality as a function of changes in physical activity or fitness. Nevertheless. Katzmarzyk et al. Top panel includes studies that used the ‘‘Active/Fit to Active/Fit’’ group as the referent.8 0. whereas decreases in activity or fitness are linked to a greater risk (Bijnen et al. although the independent contribution of adiposity was difficult to assess because of the large number of covariates used in most analyses. We think it is likely that if sedentary persons do the latter. The literature clearly supports the value of physical activity in the prevention of CVD and CHD (Appendix Table A1). Fig. Haapanen-Niemi et al. Blair et al. 2003. physically active women had lower mortality rates at all levels of waist circumference. Blair et al. 1995 1. Public Health 98(Suppl.0–1. Kujala et al.4. 95% CI = 1. Erikssen 2001. there was an 8% lower mortality risk for every 1 min increase in maximal treadmill time. Johansson and Sundquist (1999) reported that physical activity was associated with significantly lower mortality. A growing body of evidence supports this view (Fig.3– 1. Wannamethee et al. 2E). Changes in physical activity Longitudinal studies have demonstrated that improvements in either physical activity or fitness are associated with lower mortality. Metab. Katzmarzyk and Craig (2006) found that physical activity remained an independent predictor of 12-year mortality in Canadian women aged 20–69 years. Risk reductions of greater than 50% are not uncommon in physically fit individuals (Myers et al.33) was seen in individuals who were fit at baseline and maintained or improved their fitness over the 5-year period. Nutr. From the public health perspective. Wannamethee and Shaper (2001) noted that several large prospective investigations showed an independent association between regular physical activity and a 40%–50% © NRC Canada 2007 / © Canadian Public Health Association 2007 . Warburton et al. 95% CI = 1. 2003 Wannamethee et al. Nevertheless. Blair et al. 2004. 1993 Blair et al. Both physical inactivity and adiposity were important determinants of mortality. Shephard 2003).4 0. and should. 2003a.8). (1995) found a 44% lower 5-year mortality among individuals who improved from the unfit to the fit category. This is not surprising.0 Active/Fit to Active/Fit Inactive/Unfit to Active/Fit Active/Fit to Inactive/Unfit Inactive/Unfit to Inactive/Unfit Change in Physical Activity/Fitness 1. 1998.8) and in sedentary versus physically active occupations (RR = 1. Williams 2001). 1999.5 Johansson and Sundquist 1999 Bijnen et al. 32(Suppl. 1999. Kujala et al.0 0. Erikssen et al. 1998). Gregg et al. 2001): It would not make sense to encourage individuals to ‘become fit’. Since then.0 Active/Fit to Active/Fit Inactive/Unfit to Active/Fit Active/Fit to Inactive/Unfit Inactive/Unfit to Inactive/Unfit Change in Physical Activity/Fitness Cardiovascular disease prevention Systematic reviews and meta-analyses have examined the relationship between physical inactivity and development of CVD (Bauman 2004. Katzmarzyk and Craig 2006). recommend that individuals ‘increase activity’. as the associations were not corrected for attenuation by measurement error. Johansson and Sundquist 1999. 2. Williams 2001). 1998. (2003) revealed that physically active individuals had a lower risk of premature mortality irrespective of adiposity. J. the relationship between physical activity and health status is incontrovertible. 2001.2 Gregg et al.S28 Appl.5 1. 2004. 2).6.5 0. A review by Kohl (2001) suggested that CHD incidence and mortality bore inverse dose-dependent relationships to physical activity. Kohl 2001. Most reviews have dealt with CVDs as a whole and (or) CHD. even when waist circumference was included in the prediction model. 9. Williams 2001). Lee and Paffenbarger 2000). (2000) found that leisure-time physical activity was associated with a lower mortality risk in both obese and non-obese men and women. we should target increasing physical activity (Blair et al. Morris and colleagues were the first to demonstrate that men in physically demanding occupations (bus conductors and postmen) had a significantly lower risk of CHD than individuals who selected less-demanding jobs (bus drivers and office workers) (Morris et al. Gregg et al. Johansson and Sundquist 1999. 1995. 1995. Physiol.0 0. 2007 / Can. 2006a). most recent studies suggest that physical inactivity and obesity are independent predictors of mortality (Hu et al. Physical fitness appears to be a better predictor of cardiovascular and all-cause mortality than physical activity (Blair et al. The lowest risk (RR = 0. 2002. Stroke has also gained increasing attention recently. Bottom panel includes investigations that used the ‘‘Inactive/Unfit to Inactive/ Unfit’’ group as the referent (Bijnen et al. 1998 Paffenbarger et al. Berlin and Colditz 1990. Johansson and Sundquist 1999. they will achieve the former. 2002 2. 2002. A metaanalysis by Berlin and Colditz (1990) found a greater risk of CHD both in individuals with low rather than high nonoccupational physical activity (RR = 1. 2007 Relative Risk of Mortality lower in fit individuals across the spectrum of adiposity (Haapanen-Niemi et al. 2004. A systematic review by Katzmarzyk et al. physical fitness is usually determined objectively. 1993. 1999 Kujala et al. 2001) revealed that health was more strongly related to physical fitness than to physical activity. 2003a. and in fit and unfit participants. 9). several influential reports have asserted the role of physical activity in the prevention of CHD and CVD-related mortality. Myers et al. 1953).2 0. whereas most assessments of physical activity are based on self-reports of limited accuracy (Katzmarzyk 2005.

In a study of 72 488 women aged 40–65 years.0 0 25 50 75 100 Percentile cal activity carried an RR of 1. 10). These associations were similar in non-obese and obese groups. the risk of dying was 66% lower in moderately active than in inactive men (versus 46% in uncorrected data). in men and women of all ages. similar to or higher than that for CHD (1. Lee et al. In the Harvard Alumni study of 11 130 men.80) for stroke. and the relationship seems to extend to non-white populations (Manson et al.45). 8). or who enhance their status. (2005) explored the effects of withinperson variation on relationships between physical activity and CVD. and a lower risk of cardiovascular events (Fig. Lee et al.59). respectively) than the least fit men (estimated peak METs 8. there is growing evidence supporting the preventive value of physical activity (Hu et al. Wannamethee © NRC Canada 2007 / © Canadian Public Health Association 2007 . Williams (2001) noted that both physical activity and physical fitness showed an inverse dose-dependent relationship to the risk of CVD and (or) CHD.8 0. The difference of CHD risk is similar for men and women. 1999). those with higher scores on the self-reported Duke Physical Activity Status Index had fewer CAD risk factors.4 0. 2000).5) had significantly lower risks of stroke mortality (68% and 63%. (1999) found an inverse relationship between physical activity and total stroke incidence. the risk of stroke was lower at a weekly energy expenditure of 4. Wessel et al. hypertension (1. Their conclusion is consistent with another report that made repeated measurements of physical activity. The highest physical activity quintile was associated with a 48% lower risk of ischemic stroke. However. breast cancer (1. Comparison of risk reductions for cardiovascular disease associated with physical activity and physical fitness.76) (Lee and Paffenbarger 1998).54 (0.31). Wisloff et al.60 (95% CI = 1.6 MJ/week (2000– 2999 kcal/week) the RR dropped to 0.50). colon cancer (1. As with the all-cause mortality data. Lee and Paffenbarger 1998). CVD-related mortality is lower in those taking relatively small amounts of physical activity (Oguma and Shinoda-Tagawa 2004. Lee and Blair 2002.4 MJ (1000–1999 kcal/week) (RR = 0. Men and women who maintain adequate physical activity or fitness. and osteoporosis (1. 2001). However.41).Warburton et al. with greater gradients observed in trials using objective measures of physical fitness (Williams 2001).38 to 0. 0.1) and the moderate fitness group (estimated peak METs 10.2 Fitness Level Physical Activity Level 1.98). T2DM (1. They argued that risk associations derived from baseline measurements did not identify the ‘‘true’’ relationship because of within-person variation. After correction for within-person variation (taking into account information provided across follow-up assessments). (2004) observed that among women undergoing evaluation for suspected myocardial ischemia.4–12. However. 2006). there was no significant association between physical activity and subarachnoid haemorrhage or intracerebral haemorrhage (Hu et al. 2004). Emberson et al. the risk of CHD seems to bear a graded inverse relationship to physical activity. It is also unclear whether physical activity is associated with protection against both ischemic and haemorrhagic stroke (Katzmarzyk 2005).2– 8.30). this data showed that women who walked at least 2 h/week experienced a 67% lower risk of CHD than their inactive peers (Lee et al. Lee and Blair (2002) noted an inverse relationship between cardiorespiratory fitness and stroke mortality in 16 878 men from the Aerobics Center Longitudinal Study. It remains unclear whether there is a dose–response relationship between physical activity and the risk of stroke (Kohl 2001). In contrast.6 0. Physical inactivity and stroke Stroke affects a significant proportion of Canadians (some 50 000 new cases each year) (Heart and Stroke Foundation of Canada 2007).2 0. the risk advantage was twice as large for physical fitness as for increases in leisure time physical activity (Fig. A review by Katzmarzyk and Janssen (2004) reported that lack of physi- Relative Risk 0. 2000. whether with or without established CVD (Wannamethee and Shaper 2001). Hu and co-workers (2000) found that physical activity bore an inverse dose-dependent relationship to the risk of both total stroke and ischemic stroke. 2002). The relationship between habitual physical activity and the risk of stroke has had less extensive examination than CHD (Katzmarzyk 2005.59 to 0. have a lower risk of CHD than individuals who remain unfit.0 lower risk of CVD. Each 1 MET increase in the Duke Activity Status Index was associated with 8% fewer major cardiovascular events during a 4-year followup. physical activity confers health benefits independently of other known risk factors (Lee et al. failure to consider this factor led to a substantial underestimation of the importance of physical activity to cardiovascular risk (Emberson et al. 1. 2001. The high-fitness group (estimated peak METs = 13. Secondary prevention of cardiovascular disease There is mounting evidence that routine physical activity yields marked improvements in the health status of patients with established CVD (Appendix Table A1). Wessel et al. Kohl 2001). less angiographic CHD. 2005). 1999. With expenditures of 8. As with all-cause mortality. Data adapted from Williams 2001. 10. S29 Fig. Some evidence suggests that in both men and women.42–1. Brisk walking was also associated with a lower risk of both total and ischemic stroke. with a stronger relationship for haemorrhagic than for ischemic stroke (Lee et al.76 (95% CI.5). The difference in CVD-related mortality approximates 20%–50%.

there was a gradient of all-cause mortality with levels of physical activity (Fig. Weekly volumes of even less than 4. Dose–response considerations for all-cause mortality and for cardiovascular-related morbidity and mortality There is compelling evidence that 30 min of moderateintensity (~40%–59% of heart rate reserve) exercise on most days of the week (equivalent to 4. at least a 20% lower risk is seen if individuals meet current guidelines (approximately 4. The authors concluded that this evidence challenges current recommendations that require at least 1000 kcal/week of caloric expenditure to achieve exercise-induced protection against premature cardiovascular death.86.2 MJ/week or 1000 kcal/week) reaches a threshold associated with significant reductions in all-cause and cardiovascular-related mortality (Myers et al. and blood pressure).2 MJ/week (‡1000 kcal/week) is linked to a lower incidence of CVD and (or) premature mortality (Lee and Skerrett 2001. Moreover. but diminishing returns at the upper end of the physical activity and fitness distributions (Blair et al. 2005). The form of the curvilinear dose–response relationship seems such as to predict a steep decline in risk with relatively low levels of physical activity and (or) fitness.3 per 1 000 000 patient–hours of supervised exercise training (Pavy et al. and >6.27–0. Jolliffe et al. 2007 / Can. these were more strongly associated with walking intensity than with duration. Lee et al. Taylor et al. In summary. 95% CI = 0.4. Paffenbarger et al.28–0. Paffenbarger et al. The RR of CVD in the highest MET quintile was 0.2 MJ/ week. 2006). Moreover. A systematic review of the effects of lifestyle and dietary modification in patients with CHD indicated a 24% reduction in all-cause mortality (Iestra et al. aged 20–93. intensity (low. Wisloff et al. and 0. The risks of cardiac rehabilitation in established CVD are quite low. concluding that brisk walking was preferable to a slower pace (Schnohr et al. 2000b). Sesso et al. and 1 per 8484 exercise stress tests.76.49–0. 2000.4 MJ/week (>2000 kcal/week) was associated with a 1–2-year increase in the life expectancy of middle-aged men. (1986b) established that physical activity of >8. They found similar differences in risk with an increase in MET score. 95% CI = 0. no additional benefit was seen with higher durations or frequency of exercise sessions. Taken as a whole. 95% CI = 0. Paffenbarger et al. 1986b). 2004. 2000). (2004) conducted a systematic review and meta-analysis of 48 randomized controlled trials.25–0. have recognized there is some potential health benefit from low volumes of physical activity. cholesterol.2–4. (2000) noted that total cardiac mortality was reduced by 31% in ‘‘exercise-only’’ and by 26% in ‘‘comprehensive’’ cardiac rehabilitation programmes. all-cause mortality not uncommonly being 20%–30% less with this level of physical activity (Lee and Skerrett 2001. 1000 kcal/week). Nutr. They noted a graded inverse relationship between walking intensity and the risk of death. 1993). 2007 et al.48 (95% CI = 0. there is compelling evidence that habitual physical activity is an effective form of secondary prevention in CVD.49. and socio-economic status. 0. Metab.65) in white women.(no sweating) or high-intensity (sweating and exhausted)). 2005. 11). 2006). Paffenbarger et al. with a cardiac arrest rate of 1. although further health benefits are observed with higher volumes and (or) intensities of physical activity (Lee and Skerrett 2001. Leon et al.8–6. 1987. respectively). as reflected by such statements as ‘‘Every little bit counts. sex. (2006) examined the association between the amount and intensity of exercise and CVD-related mortality in 27 143 men and 28 929 women over a 16-year period. An even smaller volume of exercise may be cardio-protective (Wisloff et al.S30 Appl. Another systematic review by Karmisholt and Gotzsche (2005) reported a 27% reduction in all-cause and CHD mortality in response to increased physical activity.5 h/week had a 30% lower risk of CVD. there were 1391 deaths. 1986b. many current guidelines.75) and women (RR = 0. including Canada’s physical activity guidelines. 2E).47–0. (2007) examined the effects of intensity versus duration of walking in 7308 initially healthy women and men.4 km/h. Warburton et al.49. Lee and Skerrett 2001.61. Jolliffe et al. J. One recent investigation cited event rates of 1 per 49 565 patient–hours of exercise training. 2006a). Over a 12-year follow-up. This is supported by several systematic reviews and meta-analyses (Iestra et al. (2000b) reported that men with established CHD who commenced at least light physical activity had a significantly lower all-cause mortality risk than those who remained sedentary. (2002) reported that women who walked or exercised vigorously for at least 2. Public Health 98(Suppl. Further research is needed to examine effects of age. and duration of physical activity (less than or greater than 30 min/d). Habitual walking and (or) moderate or heavy gardening seemed sufficient to lead to health benefits (Wannamethee et al.58 for walking speeds of 3. but more is even better – everyone can do it!’’ Lee and Skerrett (2001) recently postulated that a half of the currently recommended volume of © NRC Canada 2007 / © Canadian Public Health Association 2007 . 4. A single weekly bout of self-reported high intensity exercise was associated with a lower risk of cardiovascular death relative to those reporting no activity in both men (RR = 0. Manson et al. Individuals were classified into categories based on the frequency. 2006a).55 (95% CI = 0. 2004. especially for the extremely deconditioned and the frail elderly (Warburton et al.8.2 MJ (1000 kcal) may have some cardio-protective effect (Kushi et al. 1997. (2001) found that as little as 1 h/week of walking was associated with a 50% lower CVD mortality in one sample of women (RR = 0. 2006a). 2001). Lee et al. reducing all-cause mortality by 25%–30%. 2006). Approximately half of this benefit was due to reductions in modifiable risk factors (such as smoking habits. ethnicity. 2). Subsequent work has demonstrated that an energy expenditure of ‡4. 2006). A review of 19 ‘‘exercise-only’’ cardiac rehabilitation trials revealed an average 28% reduction in cardiac mortality (Taylor et al.86).89) (Fig. Physiol. Warburton et al.93) for black women and 0. 1993. However. Schnohr et al. 32(Suppl. Karmisholt and Gotzsche 2005. there was a significant gradient with increasing habitual speeds of walking (risks relative to inactive women of 0. 5). finding significantly lower cardiac (20%) and allcause (26%) mortality when cardiac rehabilitation was compared with usual care. 2001. 2007). Taylor et al. Further.

the loss is proportional to what might be expected from the amount of physical activity undertaken (Ross and Janssen 2001). In most short-term trials.0 <30min Low <30min High >29min Low >29min High S31 from CVD (Blumenthal et al. Saris et al. Obesity is one of a myriad of adverse health consequences of our current sedentary lifestyle (Avenell et al. 11. Any discussion of physical activity guidelines must be made within the context of this reality. with 2% underweight. 2005). Although Canada’s physical activity guide to healthy active living lists maintenance of body mass as one of the health benefits associated with physical activity. Kay and Fiatarone Singh 2006. it is more ‘‘normal’’ to be overweight or obese than to have a healthy weight. The 2005 Canadian Community Health Survey found that 51% of adults were physically inactive (defined as a gross energy expenditure on active leisure pursuits of less than 6. 2003. Current recommendations are 45– 60 min/d of physical activity to prevent weight gain.6 0. 1993). 2004. 2001.0 <30min Low <30min High >29min Low >29min High 0. United States Department of Health and Human Services 1996). and 39% having a weight in the desired range (Statistics Canada 2006). The total required volume of physical activity depends on the desired weight loss. in contemporary Canadian society. and 60–90 min/d to sustain long-term weight loss (Jakicic et al. Hambrecht et al. 2003. the search for a minimum dose should not undermine the fact that progressive increments in health status are associated with larger doses of physical activity. no specific recommendations are made for either the prevention of weight gain or the treatment of obesity. 2006). Warburton et al. Fig.2 0. 1988). Further. Saris et al. and an expenditure of approximately 9. duration. Specific physical activity recommendations for ‘‘weight loss’’ are rare. a weekly energy expenditure of approximately 6.3 kJÁkg–1Ád–1 (Statistics Canada 2006). and have not been integrated with other public health recommendations. Shaw et al. informed largely by the experience of weight loss and obesity trials that focused on changes in body mass without regard for other health outcomes.8 0.4 0. 0. The Institute of Medicine (IOM) of the US National Academies of Science has based population physical activity recommendations on a Dietary Reference Intake approach. Thus. 1997. Men Relative Risk of Cardiovascular-related Death 1. training at >45% of heart rate reserve is generally recommended for patients with heart disease. Kay and Fiatarone Singh 2006. 2004. Specific recommendations for the prevention of weight gain or the maintenance of weight loss have appeared in the US (Jakicic et al.2 0. Recommendations for the maintenance of body mass have not been widely disseminated. drawing upon cross-sectional doubly labelled water determi© NRC Canada 2007 / © Canadian Public Health Association 2007 0. Relative risk of cardiovascular disease-related death among Norwegian men and women (grouped into categories of frequency. Obesity prevention and treatment Most existing physical activity guidelines were conceived to maintain or promote good health. In the secondary prevention of CVD. 2006).8 0. This is important to ascertain because recommending an even lower volume of physical activity for health surely will be more palatable to the many sedentary individuals in the world. 2001. As Lee and Skerrett (2001) stated. Shaw et al.4 Obesity and dose–response considerations Routine physical activity plays an important role in body mass management (Avenell et al. and additional health benefits are likely at higher exercise intensities (Meyer et al. and intensity of physical activity) (Wisloff et al. with recommendations based on epidemiological studies of the relationship between physical activity or fitness and chronic disease or mortality outcomes (Health Canada and the Canadian Society for Exercise Physiology 1998a.2 MJ (2200 kcal) reduces the size of atherosclerotic plaques (Franklin et al. US Department of Health and Human Services and US Department of Agriculture 2005). However.Warburton et al.7 MJ (1600 kcal) seems effective in halting disease progression. 2003. approximately 59% of Canadian adults were overweight or obese.0 No Activity 1d/wk 2-3d/wk >3d/wk Physical Activity Level (d/wk) Women Relative Risk of Cardiovascular-related Death 1. 1995. Pate et al.6 0. Even modest levels of exercise such as training at less than 45% of maximal aerobic power carry significant health benefits for individuals who are already suffering . 2006).0 No Activity 1d/wk 2-3d/wk >3d/wk Physical Activity Level (d/wk) physical activity might yield important health benefits. US Department of Health and Human Services and US Department of Agriculture 2005). Nevertheless.

as the mean PAL values were quite similar for normal weight and overweight/obese individuals (Blair et al. equivalent to mowing the lawn) had greater protective effects than lighter-intensity activities. . 2007. . Public Health 98(Suppl. there was only a weak association between breast cancer risk and physical activity in pre-menopausal women. levels of physical activity that would result in weight loss of overweight or obese individuals are not provided. it may be also have value against other forms of cancer. 1998. Rockhill et al. 2004). current public health recommendations targeted at the sedentary population and that call for a minimal amount of physical activity may be a prescription for obesity. (2007) found a 6% lower risk of breast cancer for each additional hour of physical activity per week. 2007 / Can. However. overweight. Lee (2003) reported that physically active men and women had a 30%–40% lower risk of colon cancer. Another systematic review provided strong evidence for a 20%–80% lower risk of breast cancer in active postmenopausal women (Monninkhof et al. Nutr. and physically active women had a 20%–30% lower risk of Diabetes prevention Several observational studies show that regular physical activity is associated with a lower risk of developing T2DM (Folsom et al. The most recent iteration of Dietary guidelines for Americans (US Department of Health and Human Services and US Department of Agriculture 2005) includes physical activity recommendations for both the maintenance of general health and the management of body mass. Sesso et al.2 MJ (‡1000 kcal). 1991. it was not clear whether the relationship was linear. Thune and Furberg 2001). nevertheless. In summary. breast cancer compared with their inactive counterparts. Current evidence suggests that energy expenditures for the prevention of weight gain and the maintenance of weight loss must be larger than for the prevention of chronic disease. there is clear evidence that habitual physical activity is associated with lower risks of colon cancer (approximately 30%) and breast cancer (approximately 20%). Cust et al.2 MJ (500–999 kcal). Wannamethee et al. Hsia et al. The International Agency for Research on Cancer (2002)) recommended 45–60 min/d of moderate-to-vigorous exercise to reduce the risk of colorectal cancer (International Agency for Research on Cancer 2002). Other researchers have shown a linear relationship between physical activity and breast cancer. Thus. Helmrich et al. 2007). but higher levels of physical activity are recommended for the prevention of weight gain and maintenance of weight loss. A growing body of evidence supports the protective effects of habitual physical activity against other forms of cancer. Cancer and dose–response considerations Lee (2003) concluded that there is likely a dose–response relationship for cancers of the colon and breast. Physiol. Based on this information. this corresponds to a physical activity level (PAL. representing an attempt to address the issue of obesity within broader public health recommendations.6. Further. Similarly. although further research is required to determine if light-intensity exercise also protects against cancer. 1992. 1991. 2000a). many studies exhibited a dose–response relationship. and vigorous activity might all be linked to a lower risk (Cust et al. Given that the majority of the Canadian adult population is currently overweight or obese. total daily energy expenditure / basal energy expenditure) of >1. finding a 30% lower RR for active individuals. Shephard and Futcher 1997. 2). 2005. 2E). this amount of activity is recommended for normal weight adults. J. the IOM has recommended 60 min/d of physical activity. Monninkhof et al. Hu et al.and post-menopausal samples. 2006). Their review of the literature suggested that moderate physical activity (>4. (1999) reported significantly lower risks (12% or more) of breast cancer in women who accumulated at least 1 h of moderate or vigorous physical activity each week. 2003a.and leisure-related physical activity showed an inverse graded dose–response relationship to the risk of colon and breast cancer. Although the two sets of messages are not fully integrated. Rockhill et al. 2007). Because an average of 60 min/d of moderateintensity physical activity provides a PAL associated with a normal BMI range. Habitual physical activity is inversely related to the development of colon and breast cancer (see Appendix Table A2). 2007 nations of energy expenditure in a large sample of normal weight. In a systematic review. Further. in comparison. The report states explicitly that because the Dietary Reference Intakes are provided for the apparently healthy population . and yet lower risk (51% reduction) at expenditures ‡4. The logic behind the IOM recommendations has been questioned. Manson et al. given that two thirds of the US (and Canadian) population is currently overweight or obese (Ogden et al. 1999.S32 Appl. 30–60 min/d of moderate-to-vigorous physical activity was associated with a lower risk of both colon and breast cancer. recommendations targeted at people of ‘‘healthy’’ weight are applicable to only one third of the population.1–4. Lynch et al. physically active individuals had a 15%–20% lower risk of breast cancer. 2000. 1994. 1996. obesity probably results from the accumulation of small errors in energy balance. it seems appropriate to consider integrating information on the maintenance of a healthy body mass into physical activity recommendations for general health. Thune and Furberg (2001) reported that both occupation. there was evidence that light. Combining pre. Metab. Sesso et al. (2007) reviewed epidemiological reports for endometrial cancer. and obese adults (Institute of Medicine of the National Academies of Science 2002). Monninkhof et al. 32(Suppl. they appear together in the document. It is difficult to envision contemporary guidelines that do not target overweight and obese populations. The primary prevention of cancer Considerable research has linked physical inactivity to site-specific cancers (Lee 2003. Cardiorespiratory © NRC Canada 2007 / © Canadian Public Health Association 2007 . The general recommendations for physical activity thus seem appropriate to prevent colon and breast cancer.5 METs. The basic message here is 30 min/d of moderateintensity physical activity. These effects did not appear to be confounded by inter-individual differences in BMI. moderate. (1998) observed an 8% lower risk with a weekly energy expenditure of 2.

1998. 2005). A meta-analysis of 44 randomized interventions (68 groups) revealed that exercise led to net reductions of both systolic (–3. Fagard and Cornelissen 2007. S33 fitness is also inversely associated with the risk of T2DM (Lynch et al. McAlister et al. nificantly greater with sedentary behaviour (TV watching) (Hu et al. graded.4 mmHg. Pereira et al. S. 95% CI = –4. 2004). 95% CI = –3.4 MJ/week (2000 kcal/week) had a 30% greater risk of developing hypertension over a 6–10year period. and the impact of socio-economic status on the observed relationships. moderate occupational. In the US Diabetes Prevention Program. 1999). To prevent a single case of diabetes over a 3-year period. Several reviews (Appendix Table A4) have evaluated the relationship between physical activity and blood pressure (Cornelissen and Fagard 2005a. Fagard 1999. (ii) metformin drug therapy (850 mg twice daily). Kelley 1999. 2002). with available evidence supporting an inverse relationship between physical activity or fitness and the incidence of hypertension (Fagard 1999). 1997. Small changes in activity levels can yield a significant reduction in the risk of T2DM (particularly in high-risk individuals). 2003a). 1996). the risks of obesity and T2DM were sig- . Further research is needed to uncover the ideal modalities (e. Paffenbarger et al. versus prescription of metformin for 14 persons (Knowler et al. approximately 7 persons would need to participate in the lifestyle intervention. et al. Whelton. Haapanen et al. and leisure-time physical activities all have a significant inverse relationship with risk in middle-aged men and women (Hu et al. 2004). The authors found that lifestyle changes reduced the risk of T2DM by approximately 54% in women and 63% in men (Tuomilehto et al. 1992).46) for hypertension. 1999). et al.5 to –2. In summary. Several randomized controlled trials show that habitual physical activity can lead to clinically relevant reductions in resting blood pressure.4 mmHg.P. 1990. 2006.g. Hispanic or Asian) women. resistance versus aerobic exercise). and (iii) a lifestyle intervention.g. Katzmarzyk and Janssen (2004) calculated that physically inactive individuals had an RR of 1. finding a strong. Paffenbarger and associates (1983) found that individuals expending less than 8. Tuomilehto et al. Each participant received detailed advice about moderate-intensity physical activity (30 min/d) and detailed dietary control. Similarly. Katzmarzyk et al. 2004). Whelton. Gregg et al. McGavock et al. possible effects of race and ethnicity. 2005). (2005) conducted a prospective 5-year study of 87 907 post-menopausal women. Hu and co-workers (2003a) recently reported on a 6-year follow up of 68 497 nurses. Prevention and treatment of hypertension In Canada. Also. (2001) conducted a randomized controlled trial with middleaged. S. Similarly. (1990) concluded that women with low physical activity levels were 43% more likely to develop hypertension over a 2year period than women with high activity levels. Honkola et al. A 55year-old normotensive Canadian also has a greater than 90% chance of developing hypertension before reaching the age of 80 years (McAlister et al. Wei et al. 2005b. Manson and co-workers (1992) noted that physical activity sufficient to cause a sweat was associated (in graded fashion) with a lower incidence of T2DM. 2003b). Prospective trials have evaluated the relationship between physical activity and hypertension (Folsom et al. Dickinson et al. Hamer et al.5 METs for at least 40 min/week) and (or) cardiovascular fitness >31 mLÁkg–1Ámin–1 have also been associated with a lower risk of T2DM in middle-aged men (Lynch et al. 1998. Benefit is also seen in © NRC Canada 2007 / © Canadian Public Health Association 2007 Diabetes and dose–response considerations Several investigators have shown a dose-dependent relationship between T2DM and levels of physical activity or fitness. the population-attributable risk being 13.and resistance-type activities appear to reduce the risk for T2DM (Eriksson et al. the effect being greatest in high-risk individuals. 2001. Hsia et al. Whelton. 2002).P. 2006.. Ishii et al. 1996. 3234 highrisk participants were randomly assigned to one of three groups: (i) a placebo control..Warburton et al. 2007). 1997. The relationship was stronger in ‘‘Caucasian’’ than in minority (African-American.16–1. modest weight loss via diet and physical activity reduced the incidence of T2DM in high-risk individuals by 40%–60% (Williamson et al. Fagard and Cornelissen 2007.2 to –1. The lifestyle intervention (which included physical activity for at least 150 min/week) was more effective than metformin alone (respective reductions in incidence: 58% and 31%). 2001). S. those who engaged in 1 h/d of brisk walking had 24% less obesity and 34% less T2DM. inverse relationship between physical activity and T2DM. 1983. In contrast. 1997. 1997. Exercise training is also an effective strategy for secondary prevention (Eriksson et al. 2002). and risks are much lower in those engaging in moderate-intensity exercise. A review by Williamson and co-workers (2004) concluded that over a 3–4-year period. one fifth of adults report a diagnosis of hypertension (Joffres et al.30 (95% CI = 1. 2003b. male physicians who exercised vigorously at least once weekly had a 29% lower incidence of T2DM than individuals who did not exercise on a weekly basis (Manson et al. 2006.8%. This relationship seems relatively linear across the physical activity and fitness spectrum. overweight subjects with impaired glucose tolerance (172 males and 350 females).6) blood pressure (Fagard 2001). Folsom et al. 2005. Investigators have shown a reduced incidence of T2DM in high-risk (e.3) and diastolic (–2. Several reviews of this topic have been completed (Appendix Table A3). Both aerobic. commuting. but also extends to the prevention and treatment of hypertension in the overweight and obese (Fagard 1999. there is compelling evidence that habitual physical activity is effective in preventing T2DM. the authors postulated this finding might reflect less precise risk assessments in minority women (Hsia et al. 2005). overweight) individuals after lifestyle interventions (Williamson et al. Available evidence supports the notion that physical activity is effective in the primary and secondary treatment of hypertension in both normotensive and hypertensive individuals. Moderately intense physical activity (‡5. This assessment has been supported by more recent meta-analyses (Fagard and Cornelissen 2007. The effect appears to be greatest in those with hypertension. et al.P. 2002). over a 5-year period.

Individually tailored programs (involving resistance. (2002) undertook a meta-analysis of 18 randomized controlled trials on post-menopausal women from the Cochrane database and found that aerobic. Kelley 1998a. 2E). Physiol. 2006a). Nutr. A recent position stand (Pescatello et al. 2004. Several cross-sectional investigations have reported that resistance-trained individuals have greater bone mineral density than their non-trained counterparts (Warburton et al. days of the week at a moderate intensity. They also recommended supplementing endurance-type activities with resistance exercise. 2001a. Thompson et al. Gregg et al.16–0. Joakimsen et al. Similar results were found in pre-menopausal women (Wallace and Cumming 2000). and preferably all. 1996).38. and weight-bearing exercise were all effective in increasing bone mineral density in the spine. 2001b. However. 2004) asserted that habitual activity (primarily aerobic) is integral to the prevention of hypertension and the lowering of blood pressure in both normotensive and hypertensive individuals. Another metaanalysis (Wallace and Cumming 2000) revealed that impact exercise improved bone mineral density in the lumbar spine and the femoral neck (preventing respective bone losses of 1. athletes that participate in high-impact sports have a greater bone mineral den- .59 (95% CI = 1. J. weight lifting) also resulted in improvements in the lumbar spine (1. Wolff et al. 2001a).S34 Appl. (1999) estimated that exercise interventions prevented or reversed 1% of bone loss per year in the lumbar spine and the femoral neck of pre. 2002. 2001a). Kelley and Kelley 2004. Stevens et al. the fracture risk and (or) incidence is lower in active individuals (Carter et al. 1994. There is compelling evidence that weight-bearing and impact exercise benefits bone health across the lifespan (Warburton et al. 2004. Kujala et al. 2004). Dose–response issues for the prevention and treatment of hypertension Physical activity is effective in both primary and secondary treatment of hypertension. and that walking benefited bone mineral density in the hip.0% in post-menopausal women).6% and 1. Weightbearing exercise (especially resistance exercise) appears to have positive effects on bone mineral density (Warburton et al. and highlight the importance of physical activity for © NRC Canada 2007 / © Canadian Public Health Association 2007 Primary prevention of osteoporosis Relationships between bone mineral density or bone mineral content and physical activity have been evaluated extensively (Appendix Table A5). This is supported by research indicating that moderate-intensity resistance training can reduce blood pressure (Cornelissen and Fagard 2005a). Analyzing observational trials. with the greatest effect in hypertensive individuals (Fagard 2001. Katzmarzyk and Janssen (2004) estimated the RR of inactivity was 1. Shaw and Snow 1998. resistance. The American College of Sports Medicine (Pescatello et al. Bonaiuti et al. 1999) and consensus statements (Brown and Josse 2002) have dealt predominantly with bone health in pre. Bonaiuti et al. 2001a. 1998b. In a 21-year cohort study. 32(Suppl. 2007 / Can. These acute changes highlight the ability of a single exercise session to affect blood pressure positively. Liu-Ambrose et al. Case-control studies of older persons who suffered a hip fracture revealed that these individuals undertook significantly less physical activity throughout adulthood (Boyce and Vessey 1988. 2). Systematic and (or) meta-analytic reviews (Berard et al. 2002. In a meta-analysis of 10 randomized aerobic exercise trials (in 732 adult women). blood pressure reductions of 5–7 mmHg have important clinical implications. Intervention trials have evaluated the effects of both aerobic and resistance training on bone mineral density across the lifespan (from children to the elderly).g.and post-menopausal women. This supports earlier reports of lower fracture rates in individuals who perform more weight-bearing activities (Joakimsen et al. for 30 min/d or more (continuous or accumulated). Kelley (1999) found decreases in systolic and diastolic blood pressure of approximately 2% and 1%. individuals should exercise on most. Metab.40–1. 95% CI = 0.80). Furthermore. It is not uncommon to see a reduction in pressures for 12–22 h after a single exercise session (with the largest decrements in individuals with hypertension) (Pescatello et al. Wolff et al.. 2000. the optimal dose remains unclear. 2004). Prospective studies have also shown an inverse relationship between the incidence of fractures and physical activity (Feskanich et al. Furthermore. Moderate-intensity resistance training can also reduce resting blood pressure (Cornelissen and Fagard 2005a. 2001b). and various ethnic groups (Pescatello et al. respectively. Prevention of falls and fractures Several studies have shown that exercise reduces the risk and (or) the number of falls in comparison with inactive controls (Carter et al.’’ These benefits clearly outweigh potential risks. 2004) recently advocated that to prevent hypertension. 2000). Further research is needed to refine these guidelines for women. Feskanich et al. the recommendation of daily exercise for the control or prevention of hypertension is likely warranted. Public Health 98(Suppl. Wolf et al. Tinetti et al. (2000) demonstrated that intense physical activity (at baseline) was associated with a lower incidence of hip fracture (hazard ratio = 0. 2001). 1998. 2006). When considering these benefits. (2002) noted a linear association between moderate physical activity and a lower risk of hip fracture in postmenopausal women who were not receiving hormone replacement therapy. Fagard and Cornelissen 2007). aerobic and balance training) are thought to be effective in reducing falls and injuries (Brown and Josse 2002). 2007 women. older adults.0%). 1997). Haennel and Lemire 2002). The Canadian Medical Association (Brown and Josse 2002) reached a consensus that a ‘‘higher level of activity throughout middle life is associated with a reduced risk of hip fracture in old age. Moderate-intensity aerobic exercise seems sufficient to lower blood pressure. 1997. Exercise also induces beneficial acute changes in blood pressure (Hamer et al. In the latter. sity than athletes from low-impact sports (Warburton et al. a 2 mmHg reduction in SBP is associated with respective reductions of 14% and 9% in the risks of stroke and CHD (Pescatello et al. 1998). Non-impact exercise (e.91). and that the population-attributable risk in Canada was 24%.and post-menopausal women. Kujala et al. Brown and Josse 2002).

Katzmarzyk et al. and pulmonary disorders. fitness and lifestyle approach (Canadian Society for Exercise Physiology 2003). Warburton et al. and overall quality of life. stroke. habitual physical activity appears to be important in the attenuation and (or) reversal of bone mineral density losses and the overall prevention of osteoporosis (particularly in post-menopausal women). Those in the lowest third of the grip strength distribution had an 8-fold higher risk of disability. Bone mineral density was sometimes lower in those running longer distances (Brown and Josse 2002). Katzmarzyk and Craig (2002) found a significantly greater risk of premature mortality in those with the lowest quartile of sit-up scores in both men (RR = 2. 2000). (2002) found that the risk of hip fracture was 6% lower for each 3 METÁh higher activity per week or 1 h/week of walking at an average pace. (2007)) Two systematic reviews (Warburton et al. These studies provide empirical support for the inclusion of resistance and flexibility training in general physical activity © NRC Canada 2007 / © Canadian Public Health Association 2007 . 2001a. 2001b. Thus. bone health. This observation has led to a greater focus on the health benefits of musculoskeletal fitness (Payne et al. 2001b. 1996. 2006a). morbidity. had 78% greater odds of significant weight gain (‡10 kg) compared with those with high musculoskeletal fitness. Katzmarzyk and Craig 2002. In summary. particularly in individuals with a low musculoskeletal reserve. CHD. psychological well-being. Metter et al. However. and premature mortality. S35 Fig. (1998) noted that individuals with the lowest grip strength had an earlier mortality over a 27-year follow-up. Rantanen et al. further research is required. especially as one ages (see Paterson et al.56 and 0. those with a faster rate of decline in muscular strength (>1. Data adapted from Brill et al. preliminary evidence suggests that current physical activity guidelines may be sufficient to maintain and (or) improve bone health. Individuals with a high muscular strength also developed fewer functional limitations over a 5-year period (Fig. Importance of muscular strength in reducing the incidence of functional limitations in men and women (age = 30–82 years) over a 5-year period. arthritis. 2002). mobility. respectively. 2001b). 2000b. particularly in older individuals and (or) those who are extremely deconditioned (Warburton et al. 2001a. Three recent Canadian epidemiological investigations (Katzmarzyk and Craig 2002. 2000. 2006a).26). In this investigation. but not in women. Warburton et al. Current evidence indicates that adaptations are load dependent and site specific (Kerr et al. regular physical activity can reduce the prevalence of risk factors for chronic disease and disability (American College of Sports Medicine 1998a. 2006a). 2007). 2006a). 2001a. 1995. muscular strength. Men Women Musculoskeletal fitness and health Significant enhancements in health status can occur with increased physical activity in the absence of marked changes in aerobic fitness (Warburton et al. 16 14 Functional Limitations (%) bone health. Physical activities that involve significant loading or impact are thus advocated for the prevention of osteoporosis.Warburton et al. 2001a. Grip strength also predicted mortality in men (RR = 1. Mason et al. The risk of hip fracture also showed an inverse linear gradient with higher levels of physical activity. Warburton et al. there were also negative associations with fall risk. 12 10 8 6 4 2 0 High Strength Low Strength Osteoporosis and dose–response considerations There is limited information on minimal and optimal doses of physical activity for the prevention of osteoporosis. Mason et al.49). Feskanich et al. and flexibility also likely contribute to the reduced risk associated with routine physical activity (Warburton et al.5%/year) or a very low grip strength (<210 N) had a greater incidence of chronic diseases such as diabetes. 12. as indicated by the CSEP’s Canadian physical activity. The lower risk of falling and (or) fractures in physically active individuals is not solely the result of changes in bone mineral density. 2002. A literature review showed that running 22–30 km/week was associated with bone mineral accrual or maintenance. Furthermore. Grip strength is inversely related to premature mortality and (or) morbidity (Fujita et al. Individuals with low musculoskeletal fitness. Rantanen et al. 2001a. Changes in balance control. Interventions that increased musculoskeletal fitness had a significant positive effect on health status. mobility. 2007) have related musculoskeletal fitness to health status. 12) (Brill et al. In summary.72) and women (RR = 2. 2000a. particularly to examine the relationships between physical activity and bone health in groups from different ethnic and (or) racial backgrounds. Walking for at least 4 h/week was associated with a 41% lower risk of hip fracture compared to individuals exercising less than 1 h/week (Feskanich et al. 2001b) reported that positive associations between musculoskeletal fitness and glucose homeostasis. Warburton et al. 2001b) without necessarily changing traditional determinants of cardiovascular fitness such as maximal cardiac output and oxidative potential. Some evidence suggests that current physical activity guidelines may be sufficient to maintain and (or) improve bone health. 1998). (2007) reported that musculoskeletal fitness was a significant predictor of weight gain over a 20-year period. 2007. functional independence. the odds ratios of reporting functional limitations at follow-up in men and women (with high levels of strength) were 0. especially for older individuals (Warburton et al.54.

.g. meeting at least moderate-intensity physical activity guidelines may be associated with most health-related quality of life domains (e. and global self-esteem. 2E). we discuss and overview the evidence for the effect of physical activity on central mental health outcomes that have received research attention: depressive symptoms. social.. the study showed that depressive symptoms were lower with standard moderate physical activity guidelines (64 kJÁkg–1Áweek–1. Laforge et al. 15. the results suggested that physical activity at all intensities. the focus has been on basic associations with physical activity and not on dose–response or meeting specific guideline recommendations. 1991). A meta-analysis of 14 randomized controlled trials with participants reporting clinical depression (Lawlor and Hopker 2001) paralleled these results (effect size (ES) d = –1. arguably the central and fundamental construct of overall well-being (Blacklock et al. Dunn et al. 2000). duration. Nonetheless. 1998). The impact of adequate physical activity on clinical depression seems as great as pharmacological treatment (Blumenthal et al.0 kcalÁkg–1Áweek–1) could not be distinguished from controls. most studies relating health-related quality of life and well-being to physical activity have focused on clinical populations. with current evidence mixed as to what intensity. Blair et al. Firm conclusions cannot be drawn about the effectiveness of regular physical activity in alleviating depressive symptoms among non-clinical populations owing to a lack of methodological rigour. Like depressive symptoms. Wendel-Vos et al. 1996).S36 Appl. 2007 / Can. was related to lower scores for depressive symptoms.24 to d = –0. 7. the magnitude of effect being comparable with other anxiety-reduction methods such as relaxation (O’Connor et al. perceived health status) and generalized well-being (e.5 kcalÁkg–1Áweek–1). regular moderate physical activity appears an effective intervention to alleviate depressive symptoms for those with clinical depression. Petruzzello et al. across different time periods.56. 2005. and physical). Assessment of a dose–response relationship for the anxiolytic effect has proven difficult. 32(Suppl. mental. Health-related quality of life and generalized well-being Perceived health-related quality of life (i. found trivial effects in all domains but social functioning (Wendel-Vos et al. well-being. Physical activity and mental health Maintenance of positive mental health and the prevention of mental disorders through regular physical activity has been a focus of considerable research. 2007 guidelines (American College of Sports Medicine 1998a. 1990). Smale and Dupuis 1993. and 19 quasiexperimental studies. 2004). In the general adult population. However. (2001) reviewed studies featuring participants who had been diagnosed with Diagnostic and statistical manual of mental disorders IV (DSM-IV) depressive and anxiety disorders: 9 cross-sectional epidemiological studies.1 (Cohen 1992)). Public Health 98(Suppl. 2005). Gauvin 1989. 1999. Furthermore. no marked dose-related differences were seen (Brown et al. In the single study to evaluate effects of frequency and duration. but that individuals engaging in a lower dose (29kJÁkg–1Áweek–1. Anxiety Over 100 studies and several reviews (Appendix Table A6) have evaluated the effect of physical activity on anxiety (state and trait). 2007). or populations with chronic illness. All are correlational surveys using self-reports of physical activity and various measures for quality of life/well-being (covaried for sociodemographic factors). 2000. 2007. a longitudinal study using change in physical activity to predict quality of life/well-being. physical activity consistently reduces anxiety symptoms among asymptomatic adults. Most importantly. the effect size ranging from small to borderlinemedium. social functioning. 2004. 2007.g. anxiety. perceived general happiness.. Physiol. Dose–response relationships have not been established. Below. Since © NRC Canada 2007 / © Canadian Public Health Association 2007 . mild-intensity activity does not appear to be associated with quality of life or well-being outcomes (Blacklock et al. Thus. but no definitive conclusions could be drawn in terms of dose owing to a lack of controlled studies (Dunn et al. The effect size has ranged from d = –0. The most rigorous work on depressive symptoms and physical activity has focused on clinical depression. 2004). Vuillemin et al. and the most rigorously controlled study to date found similar effects (Dunn et al. and with all modalities. The majority are large-scale epidemiological surveys suggesting that lower scores for depressive symptoms are associated with higher levels of physical activity (medium effect size). but warrant sustained research. older adults. Metab. prospective correlational evidence is supportive of a preventive relationship (North et al. 2001). but the effect is small and it may not generalize to overall life satisfaction. perceived health-related quality of life. 1991). Overall. 2005). Overall. In conclusion. depending on the anxiety measures used and the initial levels of participant anxiety (O’Connor et al. 2004). Depressive symptoms Over 100 original studies and 10 meta-analyses or narrative reviews report on the association between depressive symptoms and physical activity (Appendix Table A6). 2000) and pharmacological treatments (Brooks et al. eight quality of life or well-being studies have focused on a relationship with physical activity (Blacklock et al. and frequency provide the best anxiolytic response. the majority using undergraduate convenience samples. but Health Canada’s mild activity guidelines may not be sufficient for this purpose. Almost all of these studies have been conducted with nonclinical populations. In general. 2000. 2). 2004). nevertheless. Petruzzello et al. 20 min post-exercise moderate aerobic exercise seems superior to high-intensity resistance training (O’Connor et al. most studies link physical activity to lower anxiety. Still. McTeer and Curtis 1990. which afflicts approximately 5% of the Canadian population (Patten et al. J. Brown et al. psychological function) are difficult to disentangle in existing research because of mixed and unstandardized methods of measurement (Rejeski et al. Almost all studies show small but positive relationships between quality of life and physical activity (construed as meeting moderate or vigorous guidelines). 1999) and may even have better sustainability (Babyak et al. 9 prospective epidemiological studies. Nutr.e. 1990). Correlational studies with modest sample sizes also failed to show associations with life satisfaction. Gauvin 1989). one of the most comprehensive meta-analyses has provided evidence that non-clinical and clinical populations may reap rather similar benefits (North et al.

Paffenbarger et al. although it has recently been suggested that physical inactivity may have a negative impact on life expectancy (Katzmarzyk and Craig 2006). the risk of CVD was associated with the number of hours spent sitting each day. Regular physical activity not only prolongs one’s life expectancy (Lee et al. sex. this is probably due to the myriad factors that can affect these global executive perceptions.01–1. obesity. The healthy lifespan approach The average life expectancy continues to increase in Canada (Statistics Canada 2007). brisk walking was associated with a significantly lower risk of both obesity and T2DM. For example. Hu et al. 1999. 2003a. Kelley and Goodpaster 1999. S37 research to date is limited to correlational designs. 2005). and 1. Thus. Kobayashi et al. but the evidence to date is only correlational. 2004a. Accordingly. 1998. 2000a. (2003a) noted that the time spent watching TV was also directly related to the risk of obesity and T2DM. osteoporosis. it also delays the onset of chronic disease and (or) disability. reduced abdominal obesity and improved weight control). but also have significant implications for the prevention and (or) treatment of various other chronic diseases including T2DM. 2001b). the greater the change in fitness. frequency. Indirect adaptations include improvements in body composition (e. a series of adaptations have particular benefit for the prevention and (or) treatment of T2DM. Brenes et al. 2002. 1983). no definitive conclusions are yet possible. The overall effect size was small (d = +0. duration. Manson et al. enhanced lipid lipoprotein profiles (Berg et al. Tell and Vellar 1988. improved autonomic tone (Adamopoulos et al. Global self-esteem The self is probably one of the most-studied psychological constructs and its relationship to mental health is wellestablished (Keyes and Waterman 2003). 1986). Hambrecht et al. Collectively. these adaptations are of particular importance for diseases of the cardiovascular system. improved coronary blood flow (Hambrecht et al. of incident obesity and T2DM could be prevented by adopting an active lifestyle (including less than 10 h/week of TV watching and 30 min/d or more of brisk walking). and psychological wellbeing. specifically. 1996. 1991. These results suggest that physical activity may have a small overall effect on global self-esteem.. 1997). 1986. Further. Several reviews have been focused on physical activity and global self-esteem (Appendix Table A6). Global self-esteem sits at the top of the hierarchy in multi-faceted self-esteem models (Shavelson et al. but dose-related differences are negligible. respectively.. it is generally only briefly. The RR was 1. Therefore. although dose– response issues still need experimental research with a prevention-based focus. life expectancy in itself does not take into account the years a person may live in a dependent or diseased state. 2001a. Manson et al. (2002) reported that in 73 743 women aged 50–79 years. at the end of life (Powell and Blair 1994). when promoting the health benefits of physical activity it is important to acknowledge its capacity to improve quality of life across the lifespan.64) in those who sat at least 16 h/d in comparison with those who spent less than 4 h/d lying down or sleeping. McGavock et al. In contrast. each 2 h/d increase in sitting at work was associated with a 5% higher risk of obesity and a 7% higher risk of T2DM. Spence et al. type of participants. Taimela et al. enhanced cardiac function (Warburton et al. In summary. A growing body of research has evaluated the impact of the time spent in sedentary behaviour (e. 2003. and improved endothelial function (Gokce et al. reduced resting blood pressure (American College of Sports Medicine 1993. This is covered in greater detail in the companion article by Paterson and colleagues (2007).87) in women that sat for 12–15 h/d. but change in fitness moderated this relationship. 2006a.68 (95% CI = 1. 2001b. cancer.07–2. (2005) conducted a meta-analysis of 113 experimental studies on the effect of physical activity on global self-esteem among adults. Nevertheless. 1976).38 (95% CI = 1. 1992. Halle et al. and age did not influence the effect (Spence et al. Warburton et al. improved glucose homeostasis and insulin sensitivity (American College of Sports Medicine 1998a. . Wallberg-Henriksson et al. Tiukinhoy et al. hypertension. Mechanisms of action Several biological mechanisms may explain directly or indirectly the vast capacity of physical activity to affect multiple disease states. Direct adaptations include reduced systemic inflammation (Nicklas et al. decreased blood coagulation (Rauramaa et al. 2006b). Mode of activity. 1997. 2003). 1993. The authors concluded that 30% and 43%. 2002). Young 1995). 2005). If disability does develop in an active person. length of programme. watching television) upon the risk of chronic disease (Hu et al. 2000b). the greater the increase in self-esteem. 1994.g. O’Connor et al. For each 2 h/d decrease in TV watching there was a 23% lower risk of obesity and a 14% lower risk of T2DM. The WHO has recently introduced the health-adjusted life expectancy (HALE) scale that takes into account anticipated years of ill-health to provide an estimate of years of healthy living. 1995. DuRant et al.Warburton et al. 2004b). The overall quality of life is of utmost importance (especially as one ages). 2001a. There is a small positive relationship between general physical activity meeting moderate activity guidelines and measures of mental health-related quality of life and well-being. including increased GLUT-4 protein and mRNA ex© NRC Canada 2007 / © Canadian Public Health Association 2007 Physical inactivity and sedentary behaviour Many agencies are now recognizing the need to address the issue of sedentary behaviour as well as physical activity. Generalized indicators of well-being and self-esteem may have a very small relationship with physical activity in asymptomatic adults regardless of dose.23). and thus is the most applicable to overall mental health. Warburton et al. health agencies are now adopting new criteria reflecting the number of years a person might live in a healthy state. intensity. the effect of physical activity on depressive symptoms and anxiety is well-established. physical activity is an effective means of increasing the number of years that a person lives in a healthy state. Physical activity may also result in adaptations that are of particular benefit for individual disease states (Warburton et al. sitting.g. 2004).

The leadership and administrative assistance was provided by the Canadian Society for Exercise Physiology. and flexibility in healthy adults. Lea & Febiger. 1991. Med. lationship is linear.. Lea & Febiger. Am.1097/00005768-199806000-00032. 6th ed. All-cause mortality associated with physical activity during leisure time.. Cardiol. Med. 2000. Further investigation of responses is also warranted in specific sub-populations such as recent immigrants and those of low socio-economic status. and literature supporting marked reductions in the risk for varied chronic conditions and premature mortality. the dose–response re- .1016/0002-9149(92)90460-G. Australian Government. depression. Nutr. Pa. The minimal amount of physical activity currently advocated may be a prescription for obesity. Metab.160. Dr. sports. various racial and ethnic groups. PMID:8231750. M. 2nd ed. Philadelphia. Guidelines for graded exercise testing and prescription. 30: 975–991. doi:10. 70: 1576–1582. If the entire Canadian population (Katzmarzyk et al. McCance. up to 20% of deaths related to hypertension could be prevented. and increased glycogen synthase (Christ-Roberts et al. and hypertension. H. Rhodes were supported by a Canadian Institutes of Health Research (CIHR) New Investigator award and a Michael Smith Foundation for Health Research Scholar award. American College of Sports Medicine. Physical activity may also have a small overall effect on global self-esteem. approximately 20% of deaths related to colon cancer and T2DM could be prevented.S38 Appl. Position stand: the recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness. Andersen. hypertension. 1994). Med.1097/00005768-199806000-00033. colon cancer.. Position stand: physical activity. American College of Sports Medicine. Acknowledgements This project was supported by the Public Health Agency of Canada. 3rd ed.1621. We are indebted to the work conducted by Lindsay Nettlefold in the review of the literature and the development of tables for this manuscript. J. Philadelphia. Philadelphia. Pa. 1984). Lea & Febiger. and cycling to work. Med. Dela et al. stroke. 160: 1621–1628. J.. changes in fat stores (Shephard and Futcher 1997). Pa. 1980. Piepoli. 1984). Position stand: exercise and physical activity for older adults. 1st ed.. References Adamopoulos. 30: 992–1008. expert opinion. and those of low socio-economic status). Further examination of the minimal and optimal level of physical activity needed to address the current epidemic of obesity is warranted. and approximately one quarter of deaths related to osteoporosis could be prevented. PMID:9624662. Sports Exerc. PMID:1466326. ACSM’s guidelines for exercise testing and prescription. Bernardi. Katzmarzyk and Janssen 2004) followed the current physical activity guidelines. Guidelines for graded exercise testing and prescription. Philadelphia. Intern. Philadelphia. American College of Sports Medicine. obesity. O. The current Canadian physical activity guidelines for adults seem sufficient to reduce the risk of many chronic diseases simultaneously.. Arch. 1993. further refinement is likely required to tackle the current epidemic of obesity. 1975. approximately one third of deaths related to CHD could be prevented. Pa. American College of Sports Medicine. The current Canadian physical activity guidelines for adults are consistent with international guidelines. and osteoporosis. et al. Lippincott Williams & Wilkins. 2004. Physiol. National physical activity guidelines © NRC Canada 2007 / © Canadian Public Health Association 2007 Areas requiring further investigation Further investigation is required to establish clearly whether a volume of exercise lower than that currently recommended by most health and fitness agencies is associated with a lower risk for varied chronic conditions. Schroll. 2007 / Can. American College of Sports Medicine. 1992. Sports Exerc. reduced free-radical generation (Westerlind 2003). 4th ed. 1986. PMID:10847255.B..11. Public Health 98(Suppl. Comparison of different methods for assessing sympathovagal balance in chronic congestive heart failure secondary to coronary artery disease. with further health benefits accruing from increasing levels of activity. activity-related alterations in sex hormones. 2000. Sports Exerc. 1998a.O. improved muscle capillary density (resulting in improved glucose delivery to the muscle) (Mandroukas et al. Habitual activity may affect cancer rates via an increased energy expenditure that offsets a high-fat diet (Shephard and Futcher 1997). American College of Sports Medicine. Evidence-informed recommendations for physical activity in adult Canadians Most international physical activity guidelines support the incorporation of moderate-intensity physical activity on most (preferably all) days of the week. P. physical fitness. approximately one quarter of deaths related to stroke could be prevented. 2007 pression (Christ-Roberts et al. and Hein.. M. Summary There is overwhelming evidence that regular physical activity is an effective strategy for preventing premature mortality. T2DM. The prevention of weight gain and the maintenance of weight loss require greater physical activity levels than the general physical activity recommendations. breast cancer. doi:10. Sci. American College of Sports Medicine. or whether such a level helps in initiating a more active lifestyle. Pa. doi:10. CHD. 1998b. American College of Sports Medicine. Warburton and Dr. Guidelines for graded exercise testing and prescription. However. Rocadaelli. and additional research is required to examine the relationships between physical activity and certain specific sub-populations (including females. PMID:9624661. 2000. and direct effects on the tumour (Westerlind 2003)..1001/archinte. A. L. 32(Suppl. A. In many instances. 1999. enhanced immune function. Ormerod. Guidelines for graded exercise testing and prescription. Lea & Febiger. 25: i–x. 2004) and hexokinase activity (Mandroukas et al. insulin and insulin-like growth factors. work. 2E). 2). doi:10. S. L. up to 14% of deaths related to breast cancer could be prevented. Sci. Schnohr. Sci.

Med.J. 1990.A. Doraiswamy.. PMID:9182653. Med. J.. Y. Jr. N. Baseline and previous physical activity in relation to mortality in elderly men: the Zutphen Elderly Study. Australian Capital Territory. 1988. A prospective study of healthy men and women. S.17. and Smith. G.1001/jama. pp.. Paffenbarger. Int. S. Canberra. Emery. Kohl. Berard. L. J. et al. Brill. High density lipoprotein cholesterol concentrations in physically active and sedentary spinal cord injured patients... Progress in prevention bulletin 31. R. S. H.K. C. Khatri. Robinson.. S. 1997. Activ. 9–76. 132: 612–628. C. T.G. Babyak.00530. 150: 1289–1296.1365-277X. Med. Canadian Fitness and Lifestyle Research Institute.. Department of Health and Aged Care.. Physical activity and lipoprotein metabolism: epidemiological evidence and clinical trials. 31(Suppl.A. Bonaiuti.. Boyce. Effects of exercise training on older patients with major depression.. P.F.A. Exercise treatment for major depression: maintenance of therapeutic benefit at 10 months. Med.W.. Nagelkerke.. and Brown. S.1016/0002-9149(88) 91298-2..A. Associations between physical activity dose and health related quality of life.1097/00005768-200002000-00023.. Cat. Blumenthal. Physical activity fitness and health: the model and key concepts. Jung. E. Sports Exerc. and Gauthier.. 77–88. Brown. Ottawa.H.2395.x. 2002. et al..1249/01.A. 1994.. Bouchard. S.J. Med. and Macera. A.. J. I. R. Edited by C. R. Bouchard. R. Comparison of aerobic exercise. Rehabil. M.5.. 36: 890–896. 2004 physical activity monitor. H. 61: 26–30.1093. Brooks. Med.. C. Brown. 67: 445–450. 2000. 2001. Clark.. Human Kinetics. Phys. C. Sports Exerc. W. R..E... C. Dearwater. PMID:11020092. Shephard.. 7: 331–337. 62: 633–638. C. M. W.. Broom. PMID:3729689. doi:10...A. Kohl. K. Nutr. Grant. Sci. PMID:15126726. Meeting guidelines.E.. Sport. and Keul. Macera. V. 32: 412–416.E. 1996. J. 1986. D. S. Bauman. M. National Heart Foundation of Australia physical activity policy: a position paper prepared by the National Physical Activity Program Committee. 2004. W... Giles. W. Canadian Fitness and Lifestyle Research Institute.. C.. Brown. H.159. PMID:7707596.M. L. PMID: 10604771.MSS.N. Clin.. 2004.1097/00005768199911001-00002. Moore.0000126778.E. Australian Institute of Health and Welfare. Wright. Relationship between regular walking. 14. Champaign.] doi:10. D. M.W. Blair.C. Gibbons. R. Blumenthal.. Blair. Ottawa. and Kromhout. Nutr. Barlow. C.A. PMID:3337013. Bandelow. The evolution of physical activity recommendations: how much is enough? Am. J.W.G.C. Khatri. Sci. PMID:17570884.. AUS73. doi:10. Miller. PMID:15250841. J.. Feskens. Assoc. Bartmann. A. doi:10.. 79: 913S–920S. Champaign. Canadian Fitness and Lifestyle Research Institute. J. Pekrun. Brown... doi:10. R. Ont. Paffenbarger. J. Brenes. K. and Gordon. Kampert. 10): S1–S34. 1997. doi:10. Roark.76.J.319.273. Hum.S. L. Sci. J. A. Australian Government. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. Am. exercise. Stephens.. and Gibbons. 1988. Bauman. Cardiol.1001/archinte. PMID:10547175. for adults. 155: 603–609. 1998. Sci. T.N.T. D. N. 17: 319–327.S.. S. A prospective study of healthy and unhealthy men..276. (3): CD000333. doi:10. A... and Shephard...H. 262: 2395–2401. 17: 293–316. 3rd. C. doi:10. PMID:10593518.J.J... Arch.. J. 6): S379–S399.A. S. J.S. 11): S646–S662. Berlin. Negrini. Psychosom.E. PMID:10694125. U.. and Stephens. Canberra... J. Blair. In Physical activity fitness and health: International proceedings and consensus statement.L. 2000.. P.. A... J. 31(Suppl. and Collins.Z. E. 159: 2349–2356. Davis. Shea.S. R.W.. Balluz. PMID:10593541. E. Sports Exerc.3. 276: 205–210. Med. Meyer. and Holder. and Josse. 2004.N.E.and lowintensity exercise training early after acute myocardial infarction. Blumenthal. R.1111/j.. PMID:2144946. 273: 1093–1098. and Vessey.N. LaMonte. Bravo... Walsh-Riddle.N. PMID:2795824. Sci.. and Brown. doi:10. Berg. 1007/BF01623773. Med. Ill. Jr.. R. Physical fitness and all-cause mortality. 2006.1001/jama. Age Ageing. Changes in physical fitness and all-cause mortality.J... 77049. P. Ford. doi:10. D. Sports Exerc. J. C. Campbell. C. Avenell. [discussion S419–S420. Health. M. Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women.N. Cheng. Meta-analysis of the effectiveness of physical activity for the prevention of bone loss in postmenopausal women. Updating the evidence that physical activity is good for health: an epidemiological review 2000–2003.A.W. Hillmer-Vogel...G.. A. Babyak. PMID:15214597. et al. Blacklock.A. G.J. and Brodney. J. Australia’s health: the 10th biennial health report of the Australian Institute of Health and Welfare.. Am. Mosterd. J. and placebo in the treatment of panic disorder. Craighead. Herman. Australia. Halle. Macera.J.262. J.W.C.1016/S1440-2440(04) 80273-1.. Am. Bouchard.1001/jama.. No. 1995. S. E.. 4: 138–152. doi:10. Comparison of high. R. Kemper. A meta-analysis of physical activity in the prevention of coronary heart disease.. McGee.N. doi:10.1097/00005768-200105001-01549. Sports Exerc.H. What interventions should we add to weight reducing diets in adults with obesity? A systematic review of randomized controlled trials of adding drug therapy. S. clomipramine.. F. B.. G. W. L. 1999. Epidemiol.2004.. Med.Warburton et al... Bouchard. and T.. Shapera. S. 1999. Bijnen. Muscular strength and physical function. and Gibbons. Habitual physical inertia and other factors in relation to risk of fracture of the proximal femur. 7(1 Suppl): 6–19. Sci. R. Blair. JAMA. The consensus statement. Psychiatry. W. behaviour therapy or combinations of these interventions. and Mokdad. Iovine. Caspersen. JAMA. JAMA.. PMID:9373566. 2004. and Ruther. Ont. © NRC Canada 2007 / © Canadian Public Health Association 2007 . Intern. Blair. Edited by C.205.A.E.W. Eur. J.B. Am. and Blair. G. M. Cooper.. Can.P. Paffenbarger. 11): S498–S501.N. M.. Osteoporos. National Heart Foundation of Australia. G. 2004. R. Ill. S.. In Physical activity fitness and health: International proceedings and consensus statement. Arch. M. R. Moore. S.. 1994. doi:10. doi:10.. J.. P. Jr. 1999.. B.19. LaPorte. 2002. Rev. H. Shephard. Diet. pp.R. Cochrane Database Syst. Franz. Bouchard.P. Blair. Stephens.2349. Introductory comments for the consensus on physical activity and obesity. Kohl. D. Med. and T. PMID:3232586. Shephard. Rejeski... PMID:15113739.. M... PMID:8667564. A. 1998. Effects of physical inactivity and obesity on morbidity and mortality: current evidence and research issues. Res. A.S. M. 1999. A. U. and Nichaman.. D.. 2: 259–264. 3rd. et al.J.. Phys. Is physical activity S39 or physical fitness more important in defining health benefits? Med. 33(Suppl. Blair. George. Australian Capital Territory.. W. 2007. 2001.J. PMID:12137611. Human Kinetics. Exercise for preventing and treating osteoporosis in postmenopausal women. Canadian Fitness and Lifestyle Research Institute. T. Barlow.R. Herman.1097/00005768-199911001-00025. K.A. Epidemiol. Australian Institute of Health & Welfare. Rhodes. Heath. PMID: 11427763. and Colditz. 1989. S. 167(Suppl.. H.1093/ageing/17. physical activity and health-related quality of life.

J. R.S40 Appl. Sovijarvi. Cornelissen. 14: 12–17. 1994..5. J. J. S. Peltonen. Berria.1111/j... PMID:15334390. Baranowski.2004. Physical fitness and changes in mortality: the survival of the fittest. Physical training increases muscle GLUT4 protein and mRNA in patients with NIDDM. W. J.03. Physiol. 2005b.L. Physical activity and endometrial cancer risk: a review of the current evidence. J. H. Waterman.. Pharmacol. Ont.J.. et al. R. 352: 759–762.289. 18: 242–246. C. Colditz. J. PMID:12748199. 2007 / Can. S. F.1038/sj. Can. PMID:9503037. Pratipanawatr. Canadian Hypertension Society. Exp. J. Bjornholt. Sports Med. 1993.D. A. and Shaper.H.. Williams. Exercise training increases glycogen synthase activity and GLUT4 expression but not insulin signaling in overweight nondiabetic and type 2 diabetic subjects.. 123: 185–192.V. G. 23: 251–259. 33(Suppl. and Petrella. Exercise is good for your blood pressure: effects of endurance training and resistance training. M. 0b013e3280128bbb.J. PMID:8345412. Khan.7.H. Rhodes. Foster.. Laboratory Centre for Disease Control at Health Canada.J. T. Diabetes. J. J. 2001a.C. doi:10. 2001b.04453. Feldman. C. Nutr. B... Lindholm. N. 31(Suppl. Effect of exercise on blood pressure control in hypertensive patients. Jr. [discussion 609–610. Fagard. Ploug. N. J.. and cardiovascular risk factors. J. 2006. Ottawa. 4. 2). A.. Valle.. J. Association among serum lipid and lipoprotein concentrations and physical activity.. Slimani. doi:10. Br. B. and Greaves. [discussion S493–484. Oja. and Khan. 46: 667–675. G.0000184225. Pratipanawatr. Exercise characteristics and the blood pressure response to dynamic physical training. P. R.A. 19(Suppl. Med. Prev. Hypertens.A. Physical activity in the prevention and treatment of hypertension in the obese. 31: 571–576.1007/s10552-006-0094-7. PMID:17206535. PMID:11579072. 1998.2560. Cushman. Canadian Fitness and Lifestyle Research Institute. A. R. and Fagard. 31: 427–438. PMID:16508562. Eur. Black. doi:10. 160(Suppl.E. Sports Med.. Cardiovasc. Assoc. Izzo. J. R.. Resistance training in the treatment of non-insulindependent diabetes mellitus. Eriksson. 2007...19.. 2003.O.] doi:10. London. PMID: 16157788. Ont. 3): S20–S24. Thompson. PMID:10593542. L. Larsen.D. Med. Donaldson.. R. Dunn. T. Effects of endurance training on blood pressure. doi:10. JAMA. Psychological Bulletin. 1992. L.022. Heart and Stroke Foundation of Canada... doi:10. A.R..1016/S01406736(98)02268-5. J.. Lifestyle interventions to reduce raised blood pressure: a systematic review of randomized controlled trials. 1999. Med. Armstrong. J.A. PMID:15821008. R. A.. 1999. and O’Neal. 24: 215–233. C.. Evaluation. Green.J. J.2337/diabetes. PMID:11427774. 2003. PMID:16922820. Sports Exerc. doi:10. Rehabil. Med.. Sandvik. L. Sports Med.. Cameron. PMID:9737279.2165/ 00007256-200131080-00001. Kannus. Med.. Eur. Ottawa. At least five a week: evidence on the impact of physical activity and its relationship to health. Kampert..A. U.M.. Department of Health Physical Activity Health Improvement and Prevention. Effect of resistance training on resting blood pressure: a meta-analysis of randomized controlled trials. Pediatr.862. E. 53: 1233–1242. PMID:10593538. Metabolism. Hypertension. Cohen. An evidence-based approach to physical activity promotion and policy development in Europe: contrasting case studies. Liestol. 31(Suppl. Heart J... 30: 37–41. and Mandarino. V. and Ford. 1999. Campbell. R.L. Lifestyle modifications to prevent and control hypertension. 33: 853–856..V. Erikssen.. doi:10.Y. blood pressure-regulating mechanisms.W. Dela.R.. L.jhh. 2005a. Canadian Coalition for High Blood Pressure Prevention and Control. J.A. Int. 2005. Cleroux.1097/HJR. Canadian physical activity. V. Dickinson. Tuominen. J. R. B.G... Physical activity dose–response effects on outcomes of depression and anxiety. Department of Health. K. G.A. and body composition in young children. Lancet. and Chambliss. Cornelissen. Thaulow.H.K. Dunn. biologic mechanisms and the quality of physical activity assessment methods.1440-1681. Emberson. Gutin.. S. Sports Exerc.43.M. V. Exercise treatment for depression: efficacy and dose response.M. 1999. G. Parviainen.B. Petit. H. Clark.. and Beaulieu. Canadian Society for Exercise Physiology.348.. and Martin.. and Fagard. Changes in physical fitness and changes in mortality. Russell.. C. 26: 1774–1782..2165/00007256-200131060-00003. Taimela..H.05629.O. 289: 2560–2572. Effects of exercise. V. Eriksson. Sports Med. 2006. 2004. R. doi:10.J. Craig. J. 10% increase in physical activity by 2010. A power primer. Morris. N. Puhl.R. PMID:9231838.51. N. Whincup.. J. Physiol.1055/s-2007-972627. Recommendations on physical exercise training.. 2007 Canadian Medical Association. K. Canadian Society for Exercise Physiology..1001956. 2007. Lifestyle and cardiovascular disease in middle-aged British men: the effect of adjusting for withinperson variation.. Mason. Trivedi. PMID:16302006. Friedenreich.O. 2E). M. 9): S21–S28. 2001. Res. Ont. PMID:11475318. Hypertens. Nicolson.1161/01. 32(Suppl. 1997. Sci. R. Fagard.G.H. W. and Erikssen. PMID:17017287.L. C. doi:10. R. Sci. R... et al. Prev. doi:10. F.1093/ eurheartj/ehi224.H. 13: 104–111. H. 2001. K..G. diet and their combination on blood pressure. K. 35: 348–351. Belfort. H.. A. Sci. T.. Beyer. PMID: 8013748.. H.H. DuRant. Foundation for joint action: reducing physical inactivity.. Exercise in the prevention of falls in older people: a systematic literature review examining the rationale and the evidence. Metab. J.. doi:10.1097/ 00004872-200502000-00003. Christ-Roberts. Hum. and Koivisto. Tuomilehto. Heinonen..H. 11): S624–S630.x.1016/S0022-3476(05) 81687-7. doi:10.. D. Educ.1097/00005768-19991100100022. S. C.1001/jama. and Cornelissen. Fagard.. W. Federal–Provincial–Territorial Conference of Ministers Responsible © NRC Canada 2007 / © Canadian Public Health Association 2007 . 2006. J.. 6): S484–S492.] doi:10.35.. 6): S587–S597. Economic costs of obesity and inactivity.. R.M. Fagard.metabol.. 1016/j... 11): S663–S667. doi:10.H. Canadian Medical Association. doi:10.G. Cavill. Handberg.1097/00005768-200106001-00027. T.A. UK. Cust. Clin..1136/bjsm. A. 1998. J. PMID:11394562..L. 2006. 2004.. Carroll. Metab. A.H. physical fitness. 1: 281–288. Sports Exerc... Aerobic endurance exercise or circuit-type resistance training for individuals with impaired glucose tolerance? Horm. doi:10.A. Am. Chobanian.. K. Ottawa. 2001. 2004. Kashyap. S. Bakris.. Cook. Sundberg. H.1097/ 00005768-199911001-00026. The seventh report of the Joint National Committee on Prevention. P. 33(Suppl. 3rd ed. and Kujala.1097/ 00005768-200106001-00018. B. M.W. Carter. PMID:15662209. Promot. J. J. Wannamethee. fitness and lifestyle approach. 2005.A. C. Sci. Erikssen.. and Treatment of High Blood Pressure: the JNC 7 report. and Bauman. Results of a 10 week community based strength and balance training programme to reduce fall risk factors: a randomised controlled trial in 65–75-year-old women with osteoporosis.HYP. 18: 243–258.. F. S. 112:155–159.. Trivedi. K. Petersen.. A.L.J.N.H. Detection. PMID:11427783. doi:10.. Eriksson.. A. doi:10. J. Sports Exerc. Public Health 98(Suppl. doi:10. Carter. Cancer Causes Control.. Hypertens. P. M. T. 43: 862–865. Mikines. Fagard. Med. G...D. PMID:17301622.. 2005. and Galbo.

Hambrecht. R. R. Blumenthal.. H39-429/1998-2E. Obes.. M. 2002. L.. J.. Holbrook. S.. PMID:12824093. and Yanagawa. M. JAMA. J.. Hunter.. No. J. Health Canada. Pasanen. Physical activity.. Konig. The relationship between regular physical activity and subjective well-being. E. J..com. doi:10. Gledhill. P. How much is enough? Can. T. Statement on exercise: benefits and recommendations for physical activity programs for all Americans. 1093/ije/26. C.W. 48: 1349–1359. Cummings.paguide.A.R.J. Am. 288: 2300–2306. JAMA. D... Hamer. Caspersen.. Metab. Vuori. Physical activity and incident diabetes mellitus in postmenopausal women.. I. Relationship of changes in physical activity and mortality among older women. M.A. the Council on Cardiovascular Nursing. Subcommittee on Exercise. PMID:9236457. Y.. Ottawa. B. 1998a. Nagai.1016/j. 2002. Med. doi:10. Recreation and Fitness target increase in physical activity. Coll. PMID: 8335816. Int. Circulation. 26: 739–747.J. S. 2000b. 18: 116–123. 163: 1440–1447.. Health Canada and the Canadian Society for Exercise Physiology. C.G. 96: 355–357. Physical-strength tests and mortality among visitors to health. and Colditz. Fletcher. PMID: 12746361. N.. Walking and leisure-time activity and risk of hip fracture in postmenopausal women. and Caspersen. Canada’s physical activity guide to healthy active living for older adults [online]. Cardiac Rehabilitation. D.. Available from www.A4. H39-611/2002-2E. 2006. 109: 2031–2041. power athletes. American Heart Association. Prineas. N. Canada’s physical activity guide for children. Ont. Y. H39-611/2002-1E. R.. 94: 857–862. B.1440. and Prevention. 2003... Handbook for Canada’s physical activity guide to healthy active living [online]. Public Health. G. 28: 962–966. Fletcher. von Stein.. doi:10. 1990.. 90: 134–138. A. B. Chaitman. 2003. J. Fujita. S. Engl. Fam. 2300. Kobayashi. Ont. Available from www. PMID:10675425. Hiraoka. N.A. Haapanen. Cardiovasc. No. Health Canada. 1997. and Malmberg. Erbs.. falls. 2002. PMID:10630154. Gulanick. A.18.04. Folsom. Relat. Cat. PMID:10968291. Swain. Health Canada. M. Balady. K. D. K. E. No..paguide. Circulation. Soc. PMID:12106840. A. Epidemiol. 48: 65–71. © NRC Canada 2007 / © Canadian Public Health Association 2007 . P. 2004. Ont.S.M. Ottawa..1038/sj.. Int. Wolf. Sci...com. PMID:11852614. Nurs. Ont.J. F. G.2005.65777. Chair summary and comments..F. S. J. doi:10. 21: 701–706. Health Canada.M. doi:10. K. Linke. Oja. 1989.23. Marburger.1161/01.W. Cat.R. M..004. 2000. Canada’s physical activity guide for youth.. Haapanen-Niemi. M. Health Canada and the Canadian Society for Exercise Physiology. Kaye. Hambrecht.P.. Hambrecht. E. J. Cardiol.A.. Physician. Hofer. Federal and Provincial/Territorial Ministers Responsible for Sport. Thompson. 2005. M.. G. Friedenreich. hypertension and diabetes in middleaged men and women. J. 283: 3095–3101. Health Canada and the Canadian Society for Exercise Physiology. Incidence of hypertension and stroke in relation to body fat distribution and other risk factors in older women.CIR. K. Vita.. Walther. J. 2000a. H39-429/1998-1E. Caspersen. H.12. Ont. Niebauer. physical inactivity and low level of physical fitness as determinants of all-cause and cardiovascular disease mortality–16 y follow-up of middle-aged and elderly men and women.. PMID:8871904. Body mass index. Folsom. The effect of acute aerobic exercise on stress related blood pressure responses: a systematic review and meta-analysis.3095.N. A. R. PMID:12425707. Effect of exercise on coronary endothelial function in patients with coronary artery disease. Cat.18. Fiehn. Miilunpalo. C. 2000.. Cardiol. S. and Schuler.J. A. Health Canada and the Canadian Society for Exercise Physiology. 48: 883–893. Ministry of Health. E. PMID:10865304. and Shephard.L. Cauley. et al. N. C.. No.W. Franklin. 2003b. Med. J. 2002b. 2000. 1997.. S41 Gregg. 2002a.739. Effects of exercise training on left ventricular function and peripheral resistance in patients with chronic heart failure: a randomized trial. and Shephard. Bader. PMID:15117863. 2000. 342: 454–460. How to implement physical activity in primary and secondary prevention.. J. Canada’s physical activity guide to healthy active living [online]. N.1056/ NEJM200002173420702. A. Gerzoff. Ottawa. Cat.1001/jama. Oja.. 2003a. 1995. Cat. Berg. Sport Behav. Available from www. Sports Exerc. Stroke. 1996. Ottawa. Geriatr. Sakata. G. Williamson. American Heart Association. JAMA. PMID:15979232.1097/00005768-200106001-00014. Health Canada.A. Sherman. PMID:2339449. 11: 107–114. D. and Steptoe.. Gregg. I. Baumstark. 22: 468–477. Kalberer.. L. Sports Exerc. Association of leisure time physical activity with the risk of coronary heart disease.4. M.. Arch. and Schuler. Toronto. J. 1996. Med. 24: 1465–1474.. Schoene. D. D.. PMID:8772712. Various intensities of leisure time physical activity in patients with coronary artery disease: effects on cardiorespiratory fitness and progression of coronary atherosclerotic lesions... Vuori. 71: 183–190. Ont.promotion centers in Japan..A.. Ont. doi:10. Am. Effect of exercise on upper and lower extremity endothelial function in patients with coronary artery disease. Gielen. Taylor.P. for Sport. 0000126280.M. Psychol.. Willett.ijo. S.. Circulation. Gregg. doi:10. N.E. Feskanich. and Lemire. Ottawa. B. PMID:9279605. and Ensrud. J.paguide.. Physical activity and exercise recommendations for stroke survivors: an American Heart Association scientific statement from the Council on Clinical Cardiology. J.. T. Bathurst. doi:10... Clin. C.paguide. and Pasanen. doi:10.G. Linke. and Hong..W. et al. 1993.288. J. K. A statement for health professionals by the Committee on Exercise and Cardiac Rehabilitation of the Council on Clinical Cardiology.289. G.. J. Kushi.. 90: 124–127... Relationship of walking to mortality among US adults with diabetes. J. Pereira.0801426. J. Roth... W. and Munger. Available from www. et al. Intern.. Gauvin. Physical activity to prevent cardiovascular disease..paguide. C. H39-429/1999-1E.com.163. Gokce. T. Hauer. 289: 2379–2386. The integrated pan-Canadian healthy living strategy. Epidemiol. PMID:7490598. Schoene. Physical Activity. doi:10. Halle. Miilunpalo.B.B. S. 2001. Costa. Health Canada.283. 33: s452–s453. Biol. Am. Blair. and Keul.F.F.J. Yu. New insights in the prescription of exercise for coronary patients. Nakamura. N.. G.. N. M. 1998b. E.C.1016/S00029149(02)02433-5.. Physical activity and cancer: review of the evidence for a preventive role.biopsycho. G. L.1001/jama..J. PMID:11126344.. Fletcher. K. Report prepared for the Physical Activity and Cancer Prevention Workshop. Health Canada and the Canadian Society for Exercise Physiology.. Available from www.com. Med. F. Sci.H. and Narayan. No. and fractures among older adults: a review of the epidemiologic evidence. A.. J. Lipoproteina in endurance athletes. PMID:12680570.. and the Stroke Council.R. Bauer. S. Ottawa. M. the Council on Nutrition. R. Stone.F. and sedentary controls. doi:10. Franklin. R. Haennel.. and Metabolism. Cancer Care Ontario.. 1999. C. A. N.1016/0895-4356(95) 00533-1.1001/jama.. A statement for healthcareprofessionals from the Task Force on Risk-reduction... D. Disord. Gordon.com.2379. doi:10.. R.1001/archinte. Am. Grunze... Gielen.Warburton et al. R..

J. Eriksson.1007/s00125006-0554-3.. fat. G. Philadelphia.I.C. PMID:9702447. and Craig. Med. 2007. 1994. 2007. Ishii. A.. PMID:17221212. Available from http://www. Li. 6. doi:10. J. S..T.] Helmrich. Colditz.2003.1467-789X. 26: 824–830. Q. Jr. Med. Appl. M. 1149. J. van der Schouw. New Zealand. S. 31: 271–276. D. Katzmarzyk. W. Melanson.W. Appl. Fodor. 2007. Musculoskeletal fitness and risk of mortality.E. C. Katzmarzyk.1056/NEJMoa042135.A. N. HEPA. 10: 1097–1102. Lindstrom.00120.1998.. 50: 538–544. PMID:10865274. [discussion S419–420. 4. Coleman. M. Med. [Accessed 21 May 2007.. K. D. Rees. PMID:15626551. P.T. 6): S364–S369. Available from http://ww2. A. I. PMID:12687329. J. F... Torrens. Petrasovits. Gledhill.. Sport & Recreation New Zealand.7.. Ont. P. A..E. cholesterol. PMID:9661079.J. A. Qiao. 2004. Willett. Silventoinen. and Craig.13.I. V. Physiol. Washington. Dan... doi:10.. 33: 2145–2156. J.22. and leisure-time physical activity in relation to risk for type 2 diabetes in middle-aged Finnish men and women. Arch. J. T.. L.. Katzmarzyk. Health-enhancing physical activity: recommendations of the Swiss Federal Office for Sports. Hu. Stampfer. P. doi:10. Ragland. Tollan. D. Sci. Metab.S. Diabetologia. M. PMID:16087812. Lippincott.2961. S. R.H. Hypertens. 2001.. Intern. Edited by H. Physiol. Med. P. W. 2001.T. Oldridge. Med.B. M. H. Assoc. and Eriksson. R. Hsia. Stormer.T. Sports Exerc. Can. 28: 1073–1080. PMID: 7934754.1161/CIRCULATIONAHA.A..A. and Tremblay.heartandstroke.. 2005.. Leung. C. 2007 / Can. Allen.. 1997. Prev.. protein. Am. 2003b. The Tromso Study: physical activity and the incidence of fractures in a middle-aged population. Weight control and physical activity. N. Institute of Medicine of the National Academies of Science.M. Willett. Karmisholt. and control of hypertension in Canada. Diabetes Care.. Katzmarzyk..M.. amepre. Willett. P. and Janssen.A. doi:10. P.6. Physical activity and reduced occurrence of non-insulin-dependent diabetes mellitus.J. The economic costs associated with physical inactivity and obesity in Canada: an update.. Church. Med. J. PMID:2052059.E.J. and Sogaard. Metab.L.L.Janssen. Public Health 98(Suppl. National Academy Press.E. Ottawa. asp?PageID=33&ArticleID=5596&Src=news&From=SubCate gory.1092.. Adiposity.A. Tanaka. P. Cardiorespiratory fitness attenuates the effects of the metabolic syndrome on all-cause and cardiovascular disease mortality in men..Physicalinactivity.. D.S. Awareness. 351: 2694–2703.B.. Med. Bone Miner.. Chockalingam.A. 2002. doi:10. doi:10. Sports Exerc. 2004. 2005.. 2005..T. Type of activity: resistance. Systematic reviews of randomised clinical trials.S. 2007 Heart and Stroke Foundation of Canada. J.Y..C. N.R. 4: 257–290. 2E): this issue. P.andArdern. Int. PMID:9370379. Rev. P.. 2001.. Foreyt. 2000. 2006. J. 46: 322–329. and Ebrahim. Katzmarzyk. 5th ed. 2000..E. International Agency for Research on Cancer. Exercise-based rehabilitation for coronary heart disease..N.. Physical activity status and chronic diseases. Nutr. Oberman. 2006. Li.012... Ascherio.. Limitations of Canada’s physical activity data: implications for monitoring trends. D. J. P.P. Appl. 325: 147–152. Physiol. PMID:16009053. Resistance training improves insulin sensitivity in NIDDM subjects without altering maximal oxygen uptake. Am. P... F.. S. doi:10. 13: 1149–1157.T. J.R. K. Engl. J.1359/jbmr. Sci. G.1073. Y. G. R. Bull. The influence of physi© NRC Canada 2007 / © Canadian Public Health Association 2007 . PMID:16770355. Wellington. 1998. Magnus... Ragland. and Gauvin. Kay. Heart and Stroke Foundation of Canada.283. doi:10. S. R. the Swiss Federal Office of Public Health and the Swiss Health and Physical Activity Network.. Rexrode. and Paffenbarger..8.. J. Boshuizen. Donnelly. Nutr. 503995. J. S. R. doi:10.T.P. Hu.. 1997.. 2005. S. Johansson.. Adiposity as compared with physical activity in predicting mortality among women. PMID:15616204. J. J. G.. T. and Manson.A. J. 34: 245–248.C. Med. Honkola. and Sundquist.1097/ 00005768-200105001-01720. Helmrich. and Hamet. K.. Hu. 2002.1016/S0895-7061(97)00224-0. 28: 19–25. Metab. Occupational.G. 112: 924–934. Jr.T. JAMA.L.1093/ije/28. M.ca/Page.09. aerobic and leisure versus occupational physical activity.. PMID:11427761. T. R. Dietary reference intakes for energy. Forsen.1097/ 00005768-200106001-00005.2004. 33(Suppl.T. E. J. Colditz. E. PMID:9451466. 289: 1785–1791. 122–135. Appropriate intervention strategies for weight loss and prevention of weight regain for adults.1016/j. J. Physical activity for secondary prevention of disease. PMID:11740312. J. J. PMID:14649376. N.R. American College of Sports Medicine position stand. Sports Exerc. Acta Diabetol. Yamakita. Sci.x.... and Fujii.E...G. L.1001/jama.. and amino acids (macronutrients).B.. S. 1998. Independent effects of waist circumference and physical activity on all-cause mortality in Canadian women. J. and Shephard.2337/diacare. 2003a. et al.. In ACSM’s resource manual for guidelines for exercise testing and prescription. treatment. Sato. K. et al.T. Diabetologia. Physiol... National Physical Activity Guidelines.. C. Katzmarzyk. doi:10. PMID:15159266. Williams and Wilkins.P.1139/H05-038. Effect size estimates of lifestyle and dietary changes on all-cause mortality in coronary artery disease patients: a systematic review. Jolliffe.289. J.. Katzmarzyk. Rev. J. 1999. Can. and Paffenbarger. Taylor. PMID: 10661650.10. 163: 1435–1440. and Blair.14. and van Staveren.. T. Howley.104..S42 Appl. 32(Suppl. Kohl. P. Lawson. Ghadirian. Hillary Commission. D. — Canadian leads effort to raise awareness of stroke as a global health epidemic [online]. PMID:11984288.L. commuting. E. 1001/jama. The changing face of heart disease and stroke in Canada 2000. Nutr. Grobbee.E. fiber. Thompson. A. 1991. 32(Suppl..] doi:10. Engl. 164: 1092–1097. Katzmarzyk. T. Vol. Colditz. Change in lifestyle factors and their influence on health status and all-cause mortality. excess adiposity and premature mortality. 2000.hepa. 52: 90–94. Physical activity and diabetes risk in postmenopausal women.. doi:10.C. F. Circulation. Sci. Volek. S. 2002. J. T. J. Resistance training improves the metabolic profile in individuals with type 2 diabetes. and Manson. physical fitness and incident diabetes: the physical activity longitudinal study. 2000. Hu. Heart and Stroke Foundation of Canada. 2004.1097/00005768-200205001-01269. The economic burden of physical inactivity in Canada. and Fiatarone Singh. doi:10. A. and Manson. Res. Jousilahti. doi:10. fatty acids. Fonnebo.. IARC.. Epidemiol. PMID: 12684356. 34: 740–744.21..164.. Joffres. 2000.W. Wu. Movement = Health. Katzmarzyk.. and Volpe. Kromhout. Sports Exerc. Penn.2003.1785.J. Med. 2).C. pp. Stampfer. J..C. Physical activity and risk of stroke in women. A.S. doi:10.ca.1001/archinte. Clark. Med. carbohydrate.. Iestra. Obes. 2E).1007/s005920050082. W.. Craig... Jakicic. Prevention of non-insulin-dependent diabetes mellitus with physical activity.. Joakimsen.1046/j. 21: 1353–1355. W. Television watching and other sedentary behaviors in relation to risk of obesity and type 2 diabetes mellitus in women. K. doi:10. C. JAMA. 29: 90–115. W.1353. PMID:15001807. T. and Gotzsche. Heart and Stroke Foundation of Canada. doi:10.C. 283: 2961–2967.J. Cochrane Database Syst.M.

H. PMID:9109466. Rehabil.. Barrett-Connor. Davidson. doi:10. Lewanczuk.. Hootman.. Macera.A.. S. 1999. Physical activity and cancer prevention–data from epidemiologic studies. 477–497. R. 28: 264–275. S. J. I. Sports Exerc. J.1249/01. Folsom. Med. 1999.. 2003.Z. Moderately intense physical activities and high levels of cardiorespiratory fitness reduce the risk of non-insulin-dependent diabetes mellitus in middleaged men. PMID:12579603.O. doi:10. and K. Cook. The Multiple Risk Factor Intervention Trial. Lynch..1532-5415.. Lee. Lawrence Erlbaum Associates Publishers.x. Sports Exerc. J. Mahwah. T.. S. 2001. Cardiorespiratory fitness and stroke mortality in men. T. R.. 1999. doi:10. and Koskenvuo.M. S43 Lawlor. BMJ. J. Sarna.M.E.. N. Lee. J. PMID:16003449. In Well-being: positive development across the life course. and Paffenbarger. 00250. G. JAMA. Aerobic exercise and resting blood pressure among women: a meta-analysis. K. S. doi:10. Lord. Med. Lee. Phys. PMID:8651839.. 1999.M... R. Obes. and Kelley.S. 28: 349–360. L. Jr. Anderson. PMID:9922061.M.. Efficacy of resistance exercise on lumbar spine and femoral neck bone mineral density in premenopausal women: a meta-analysis of individual patient data. 2005.1006/pmed. Arthritis Rheum. Buring. and Goodpaster... Prev. J. 6): S635–S639. Physical activity and coronary heart disease in wo´ ? JAMA. Kerr. Sports Exerc. cal activity on abdominal fat: a systematic review of the literature.. and Sellers. Keyes. P.M.1111/j.therapy. Epidemiol.J. 67: 505–510. Med.L. The 2005 Canadian hypertension education program recommendations for the management of hypertension: part II . J. Med. W. Laforge. J. Kujala. Physiol. 2001. Sci. PMID:15086643. K. N. Sports Exerc..M. J.1307.. Dick.. doi:10.160. Physical activity and all-cause mortality: what is the dose–response relation? Med. Kelley.L.. Dimensions of wellbeing and mental health in adulthood. Lee. R. Womens Health.A. 277.P. J.STR. and Paffenbarger. Lachin. Lee. Kelley.T.. 156: 1307–1314. M.E.1253/circj. and Waterman. T..2006. Macera.N.. Yasu. Sports Exerc.. I. Sci. Salonen. S. 3rd. Eng. Knowler.. PMID:3669210.. 2000. Intern. Jr. PMID:9880379. doi:10.F. Med. Wroblewski. J. P. Morton.S. 27: 798–807.1006/pmed. Med. 156: 985–993. C. Med.5. D.. Effects of muscle morphology. doi:10.S.156.9D. Stroke. Liu-Ambrose. Physical activity and its relation to cancer risk: a prospective study of college alumni.1002/art.0429. Leisure-time physical activity levels and risk of coronary heart disease and death. and function. 34: 592–595. doi:10. Stroke.H.S. Velicer. JAMA.. P. Appl. Ikeda. F. [discussion 640–631. doi:10.] doi:10. and Koskenvuo.. G. [discussion S493–474. 32: 21–28. Prev. M.. Sci. Physical activity and osteoporotic hip fracture risk in men.1097/00005768-20010600100016.N. 2000.1998. PMID:11427773. Sci. and Buring. J. Folsom.1998.B. Exercise and risk of stroke in male physicians. Prochaska. 258: 2388–2395.H. Rev. PMID:11932565.. Prev.D. Berger.0000091843. 35: 1823–1827. 2003.. M. Sci.12. and vigorous intensity physical activity with longevity.1007/ BF00943363. Rexrode. Kannus. K..2004. doi:10. N. J. R. Kelley. Helmrich.. C.x.A. PMID:12808267. PMID:7934755. Cardiol.. Med. C. Kaplan. Am.J. Stage of regular exercise and health-related quality of life. C. Walker. 1997. 52: 657–665. Bornstein. Geriatr..Warburton et al. I.M. Aerobic exercise and bone density at the hip in postmenopausal women: a meta-analysis..R.H.. I..E. G.1097/00005768199911001-00021. A. I. R. Physical activity and cardiovascular disease: evidence for a dose response.A.A.1447.1001/jama..A. G.M. 2004. U. doi:10. R. Iwasawa. 6): S459–S471. 33(Suppl. J. 49: 122–128. Can. Lee. Rossi. R.A.. Kaprio.J. and Grimby. K. Arch. G. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. Jacobs. Sci. 1998. Hashimoto.. Lee. PMID:11427772. S. R. 505. Edited by M.0360. PMID:10670554.. Manson. Kelley. E. J. Janssen.D.A. Major public health benefits of physical activity. doi:10. R.1097/00005768-200205001-01747. I.1467-789X. C. et al.A.M. Circ.. and Manson. Sci.. 11: 218–225.. PMID:10593537.. 2001. J.. and Rauramaa.11. J.A.. 2002.A. J. and Prince.. K. D. 6): S472–S483. N. Aging (Milano). J. Physical activity and mortality in postmenopausal women. 29: 2049–2054. Touyz.. A. doi:10.1097/ 00005768-200106001-00032. biochemistry. and Hennekens. McAlister. 34: 2475–2481.A.M.R. 52: 355–361. Y.A.E.D. Physical training in obese women. Am. 13: 293–300. doi:10.. Associations of light.R. 31(Suppl. 1997.A. A...R. Intern. Jr. S. physical fitness and longevity. 2002. C. Effects of physical activity on insulin action and glucose tolerance in obesity. Physical activity. 2001. and Blair. 77: 76–87. 33(Suppl. 285: 1447–1454. and Sniezek. 2002. Cohen. Kobayashi.M. P. PMID:14500932. Krotkiewski. 705. Exercise effects on bone mass in postmenopausal women are site-specific and loaddependent. M.. Physical activity and stroke incidence: the Harvard Alumni Health Study. T. Keyes.S.258. 1987. Tsuruya. K. Med. H.M.1097/ 00002060-199801000-00018.. E. PMID:11255420. J.0417. and Skerrett. T. Hedberg. doi:10.52200.17.. 346: 393–403. Modifiable risk factors as predictors of all-cause mortality: the roles of genetics and childhood environment.M.C. U. S.M. PMID:12446254. W. and Salonen. moderate. J. D.1097/ 00005768-200105001-01015. 2004.1001/jama..2388. D. C.. J. PMID:10072745. Exercise and regional bone mineral density in postmenopausal women: a meta-analytic review of randomized trials. 160: 705–708. Sports Exerc. Med. 151: 293–299. doi:10. Bjorntorp. and Blair. D. Am. controlled trial. R. R.67.0000093620. 2003. 1996.S. 1996.1056/ NEJMoa012512.. Leon. doi:10.M.27893. C. 21: 657–672. 277: 1287–1292. et al.. Eur. PMID:11427788. N. PMID:15130258.S.E..1001/ archinte.H... B. and McHorney. I.M. Padwal. Paffenbarger..A. and Hopker. Khan.. Kushi. PMID:9756580.285..A. no gain’’ passe doi:10. J. Epidemiol. Exercise training in patients with chronic heart failure improves endothelial function predominantly in the trained extremities. 1984.J.02517. PMID:9482383. K. Soc.G. Am. 7: 183–200.. Jr. J. Lee.W. L. Hamman. Arch.H. and McKay. PMID:16629874. Kohl. and Paffenbarger. 2001.M. PMID:14600545. PMID:9177581. 1994.W. 33(Suppl. Rabkin.R. Moore.1001/archinte. Mandroukas. 1998a. 2003. The Harvard Alumni Health Study.. Mink..1093/aje/kwf151. Med. men: is ‘‘no pain. Lee. doi:10.1111/j. Physical activity and stroke risk: a meta-analysis. PMID:10724057.23.. PMID:8822346. Engl.MSS.E. PMID:10090864.M. 1998b. Res. Fowler. M. Kujala. Sports Exerc.. S.1006/pmed.M.10907.. and Nathan. Hennekens. Bone Miner. doi:10. Jr. Connett. A. The effectiveness of exercise as an intervention in the management of depression: Systematic review and meta-regression analysis of randomized controlled trials. Population attributable risk: implications of physical activity dose. Kelley. 11): S619–S623. G. I.] doi:10.1287. R. J. Stroke. 30: 1–6.. Med. Fee. © NRC Canada 2007 / © Canadian Public Health Association 2007 . 2003. N.16. pp. R.. Z. Resistance and agility training reduce fall risk in women aged 75 to 85 with low bone mass: a 6-month randomized. doi:10. P. Kaprio. and Powell... Lee. C..1001/jama. 1161/01.1998.F. Lakka. Levesque. I.A.. PMID:11832527.E. Khan. 26: 831–837. 9: 2–11....E....E. Med. D.

PMID:8411605.241.E. J. 3: 3. Jung. W. Koller. Med. A. doi:10. doi:10.. PMID:17130685.10. 2005. 1991. 1990. J. M. M. PMID:8426621.. L... S.. S. 1996. C. A prospective study of exercise and incidence of diabetes among US male physicians.L. McAlister. Human Kinetics. Metter.. PMID:11893790. S..75581. Hyde. Quinney. Sci. F. Ann. A.E. Wing. Manson. Actual causes of death in the United States..T. Stephens. Physical activity and incidence of non-insulin-dependent diabetes mellitus in women.M.N. C.C. and Kampert.. J.. E.. R. PMID: 1128551. The association of changes in physical-activity level and other lifestyle characteristics with mortality among men. J. 142: 1147–1156. Colditz. doi:10.E. J. Epidemiol. anxiety and anxiety disorders. N.M. O’Connor. and Flegal. doi:10. R. Haskell. A. Engl. N. 1056/NEJM199302253280804. Ogden. Rimm.E.S. 7: 329–346. Int.. Wooltorton. PMID:15165657. Craig. Diabetol. Med. R.. 2004.. Sesso.. 1995. Bouchard. Physical activity and public health. C. Jr. Gerontol. 347: 716–725. 2007. and Wing. et al. R..Z. M. Paffenbarger.W. Pate. N. Med. 36: 162–172. Fitness versus physical activity patterns in predicting mortality in men. National Institute of Health. Energy expenditure. Metab..W. R. A.C. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. W.. Stroup.13. G. Lancet. S.S. Hajric. 173: 508–509. PMID:12242311. R. all-cause mortality. B. Mouton. Shephard. 31: 136–155. Myers.. 23: 319–327.1001/jama. Suppl. and longevity of college alumni.. J.273. doi:10.. M. Myers. Am. 273: 402–407. D...L. Public Health 98(Suppl.291. © NRC Canada 2007 / © Canadian Public Health Association 2007 .L. doi:10.S. and van Leeuwen.. C. Physical activity and breast cancer: a systematic review. Behavioural treatments for chronic systemic inflammation: effects of dietary weight loss and exercise training..E. fitness and health: the consensus knowledge.. and Martinsen. I. Physical activity and cardiovascular health.1549.R. Jr. R.. JAMA. 1953. and Campbell. North.98. Paffenbarger.L. and Hsieh.. L. and VuTran. McCullagh.A.W. J. F. C.1016/S0140-6736(53) 91495-0. PMID:3945246. et al. PMID: 15023235. E.02. Hyde. Physical activity. V. I. C. Pratt. Br. McTeer. J. Breslow. Sports Exerc. Am.. Assoc. J. Skeletal muscle strength as a predictor of all-cause mortality in healthy men. Muhll. JAMA. Paffenbarger. J...1238. J.1016/j. Engl.T. J.. N. K. Jr. Vlems. R. J. Jung. Hsieh. Med... Physical activity and incidence of hypertension in college alumni.. 1975. R. 1999–2004.. JAMA.1.W. 1993. and Hennekens. Interval training in patients with severe chronic heart failure: analysis and recommendations for exercise procedures. 314: 605–613.J.L. Mason.1016/0140-6736(91)90664-B. Jr.R. PMID:1681160. Willett. Engl. Cardiovasc. Meyer.402.... P. Med. J. A Biol.. PMID:1608115. 270. In Physical activity.C. 2004.. 1986b. Lehmann. D.E. You. T... 1249/00003677-199001000-00016. J. and Roskamm.. 39: 38–43. and Shinoda-Tagawa. Blair... Sociol. 1978. A. 108: 12–18.1056/NEJMoa011858. Musculoskeletal fitness and weight gain in Canada.S. PMID:6829553. 270: 2207–2212...1056/ NEJMoa021067. Lee. Sport Sci.. Physical activity and all cause mortality in women: a review of the evidence.J. et al. PMID:685971. Y. M. Epidemiol.F.L. W. Med..M. Voskuil. 2002. J. D. Scand. Hyde. Y.G.. K.1186/1475-2840-3-3. 2002.. and Katzmarzyk. S. doi:10. and Buring.268. 268: 63–67.. Med. E. Brand. pp.S. 57: B359–B365. Samek. 2002. 1983. PMID:13106231. Sci..1001/jama. Monninkhof. Wing. Morris. and Lee. Wing. H... 117: 912–918. George. Lancet.N.J. J. Med.H..A. PMID:15010446.A. W.amjmed. Bouchard. J.2004. Schuit. JAMA. PMID:16595758. J. 32(Suppl. Champaign. 295: 1549–1555. PMID:9139168.. Sci.. PMID:7485061. JAMA.T. PMID:1930924.3. 551–568.. Can.H. Ind. S.J.. Rev. and T. PMID:2141567. doi:10. C. PMID:12213942. PMID:8667571. Jr.T. doi:10. Engl..L. 346: 793–801. Paffenbarger. 1992.. Stampfer. Med. and Gerberding. JAMA. Sports Med. Oguma.A.2207.S44 Appl. J.18. van der Tweel. Curtin. 2E). and Conwit. Assoc. Physical activity. M.276. 29: 306–312. Abella... N. Hennekens. 26: 407–418. W. A. I. C. Do.. R. Mandic. Heady.. S.amepre. 2007 / Can. and Hale. J. Physical activity decreases cardiovascular disease risk in women: review and metaanalysis.1001/jama.L. cardiovascular disease and longevity. 1953..L.R. R.E.B. R. and Jung. NIH Consensus Development Panel on Physical Activity and Cardiovascular Health. Zaheer.. Sports Exerc.H. 276: 241–246. Am. McGavock. Physiol. Physical exercise and reduced risk of nonfatal myocardial infarction. H. 1993.H.1503/cmaj. Beneke.D. The Canadian Hypertension Education Program (CHEP) recommendations: launching a new series..E.. Mortality in relation to the physical activity of work: a preliminary note on experience in middle age. L. Work activity and coronary heart mortality... D. Med.. T. M. PMID:12055109.S.ede. 2007. Leung. A..S. Med. Paffenbarger. 1994.. and Curtis. 2000.162. 71: 185–191.S.. Jr. Prevalence of overweight and obesity in the United States. C. J.1001/jama. 2). et al.. Greenland..36..J. Med.M. Sci. doi:10. A. V.. Roberts. Brien.. 1990.. Paffenbarger.V.. Morris. Stampfer. and Heady.M.C.. R. and Pahor. Cardiovascular adaptations to exercise training in postmenopausal women with type 2 diabetes mellitus.. J.S.. Krolewski. W.. 1991. and blood pressure level as related to death from specific diseases. Ill. Macera. C. P. 291: 1238–1245... doi:10. M. 2006. D.L. Schrager. doi:10. Partington. Lee. 2000.S. Sholtz. Can. and Parks. J. A.. Talbot.1016/j. cigarette smoking. Exerc. PMID:13110075. Sport J. PMID: 15629729. Tabak.. E.. F.P..C.. L.L. Am. and Froelicher. Med.1503/cmaj.. R. R. Epidemiology. J..N.D. and Atwood. and Jung. doi:10. Physical activity and psychosocial outcomes.. Jr. R. 292: 545–550.1001/jama. 10: 245–254. R.. P..1097/01. 2007 Manson. 2004. O’Connor. PMID:17218882. R. Marks. 117: 245–257. McGinnis. doi:10. Willett.. M.06... and Hyde.G.T.E. J. Am. Exercise capacity and mortality among men referred for exercise testing.. other life-style patterns... Yamazaki. Paffenbarger. I. P.A. Physical activity. R. Manson.J. Raffle. I. Goldhaber. E. P.. McAuley. Paffenbarger..J.. and Foege. Physical activity and psychological well-being: testing alternative sociological interpretations. Walking compared with vigorous exercise for the prevention of cardiovascular events in women. J. Actual causes of death in the United States. doi:10.295. Willett. Coronary heart-disease and physical activity of work. J. S. J. Nutr.J. M.T. J.Z.007. doi:10...3. Acta Med. 18: 379–415. Westbrook. Prakash.050737. doi:10.1040769. A. A.5. Carroll. J.. Stefanick. A. Engl. 2005.M. Sport Psychol.1001/jama.L. J. S.. Effect of exercise on depression. Elias. D. Med. W. 328: 538–545. Raglin. R.. 172: 1199–1209. Froelicher. N. Gauvin.. J. 1986a. Edited by C. T.A. 2004. M. 265: 1111–1120. J.S. Kaykha.J. N.. E. D. Nicklas. Z. Physical activity and hypertension: an epidemiological view.. Epidemiol. Schwaibold. Lear.A.S. doi:10. Oberman. McDowell. 2004. Krolewski. Prev. R.. Mokdad. PMID:7823386.C.I.S.. C.047. Br.A. Oguma.0000251167.L.B.T. Jr. J. G. Lewanczuk. J. Nathan.. doi:10. M. 18: 137–157.L. D.M.. Paffenbarger. 1136/bjsm. T.A. J. 338: 774–778. C. Hyde..63. 1995. 2002. R. 1997. R.. J.. LaCroix.

Ihanainen. Rauramaa. Prev. N. 25: 236–249. D.J. Metab.5f. and Rissanen. A Biol. Shavelson. 1976. doi:10. M. Circulation. Chronic Dis. K. Appl. Med.. 2004. 74: 939–944. Folsom. 2E): this issue.1097/01.79536.x. Iliou. PMID:3555525. Promoting heart health–a European consensus.T.H. L. C. J.J. Statistics Canada. J. C. Prev.. Patten. White. Physiol. V. and Maxwell. Med. Statistics Canada. Pereira.A.. Paterson. Measurement issues related to the evaluation and monitoring of major depression prevalence in Canada. H.. V.G. and Hutchinson.. Exercise and hypertension. J. 1991. Manson. Sports Exerc.H. W. PMID:9570295. doi:10. 2001. 2004. Safety of exercise training for cardiac patients: results of the French registry of complications during cardiac rehabilitation.2003.1998. Physical activity and health-related quality of life. 32(Suppl. Eur.. 2007.2290. G.050187. R. Brawley. R. Jones. Med.. D. T.1001/archinte. Prev. S. doi:10. S. Rockhill. PMID: 9843525. Sports Exerc. Educ. Whistler 2001: a Health Canada/CDC conference on ‘‘Communicating physical activity and health messages: science into practice’’. The effect of exercise on global self-esteem: A quantitative review. PMID:16390627. 1998. 2005. PMID:12782543. Appl..1249/01.1097/01. and Snow. C. Hubner. Nutr. J. Limits to the measurement of habitual physical activity by questionnaires. Sci.. [discussion 206.A. Arnett. Sci. and Kendrick.... R. et al. © NRC Canada 2007 / © Canadian Public Health Association 2007 . Jr. Can.adults.3A. Grip strength changes over 27 yr in Japanese-American men. S. S.L. I.M. O’Rourke. PMID:10815849.. Rehabil.0000115224. Davies. Foley.A. J. Farquhar.K. 11: 85–86. B.S. Arch. K. PMID:12350456. PMID: 10072750. PMID:7934758. Venalainen. Eur.C. Puett.R.1249/00003677-199600240-00005. doi:10. and Kraus. R. 11: 143–182. Saris..01.A. R. J. Sci. Res.Y. P. Physiol.. Szklo. 1996.L. Selfconcept: Validation of construct interpretations..C. Sport Sci. D. PMID:11427779.. Rejeski. J.B. J. P. 11: 87–100. 46: 407–441.S.1136/bjsm.J.1046/j.1097/00005768-20010500100824. E.166. 14: 72–78. 85: 2047–2053.. W. Fagard.. Thompson.N. S. B. M..M. Obes. 24: 71–108. 37: 197–206. B. K. and Jensen.0b013e3280144470.. Tabet. 2000b.M. PMID:9794176. K. Can. Rev. Sports Med. and history of back pain... Di Pietro. and Rice. PMID:10961960. Inhibition of platelet aggregability by moderate-intensity physical exercise: a randomized clinical trial in overweight men. Prev.. Katzmarzyk. 1997.19.J. Sports Exerc. G.. Beck. 1994. Arch.S. Salonen. doi:10. 88514. Shephard. PMID:17130385.D. 9: 433–439..J. Payne. Masaki. R. R.. 1999. S. Meurin. Physical activity. Rev. doi:10. PMID:17054187. Powell.37. A. The public health burdens of sedentary living habits: theoretical but realistic estimates. The Filipino pyramid activity guide . Weighted vest exercise improves indices of fall risk in older women...M. 1016/S0749-3797(02)00501-9.] doi:10. Cardiovasc. 6): S400–S418. Gerontol.1001/archinte. 18: 281–300. C. Shaw.Warburton et al.. 166: 2329–2334. Can. doi:10. and Salazar. Pavy.J. 0000240019. and Lee. Intensity versus duration of walking.A. Franklin..R. W. Br. Recrea. 36: 533–553. Cardiovasc..R.0000125758. Sports Med. Rantanen. 33(Suppl. K. 159: 2290–2296. Paffenbarger.E... Shelley. and Griffin. H. Exerc. Hatfield. 33(Suppl. R. P. Sci. Med. doi:10. Ottawa.D. B. and Jamnik. Gledhill. Payne. Rev.A. A meta-analysis on the anxiety-reducing effects of acute and chronic exercise. and Dupuis. J. doi:10... W. PMID:17211189.. N. 25: 114–126. Sport Exercise Psychol. Rehabil. PMID:15187812. doi:10. doi:10.M. McGannon. 1986. Schnohr. Caspersen. J.A. M. Physiol. Seppanen.S. doi:10. 2003. Oncog. Ageing and physical activity: evidence to develop exercise recommendations for older adults. Modest exercise prevents the progressive disease associated with physical inactivity..33795. February 2004. P.hjr.. Appl. [discussion S419–420. Prev. Appl. Health implications of musculoskeletal fitness. Hunter.1146/annurev. van Baak. K.] doi:10.D.J. H. 26: 851–856.S. PMID:15187811. Exerc.. L. Salonen.S. L.J.A. S.. N.MSS.pu. R..R. S... and Poon. 2006. R. Hankinson. The relationship between leisure activity participation and psychological well-being across the lifespan. J. W.L.2307/1170010.07502.T. J. PMID:12760445. 1999..E. G. Cancer Causes Control. and Lee..G.M.0431... 4: 101–114. Kelley.. 28: 304–312.. D. 1998. McGovern. P.. M. Philippine Association for the Study of Overweight and Obesity.A. Gledhill. Sci. H.. I. Spence. (4): CD003817. 2007. 2007. Blair. Promoting heart health–a European consensus. Wang. J. total and regional obesity: dose–response considerations.. Houmard. Smale. Sesso. 53: M53–M58. doi:10.N. M. and Janssen. M. 1996. 2000. 121: 133–140. Eur. Slentz. and Shumaker. Katzmarzyk. Rehabil. Med.J.. American College of Sports Medicine position stand. 1994. Ireland. J.B. J.. Absolute versus relative intensity of physical activity in a dose–response context. and Guralnik. Sport Sci. B.2329. and Ryden. and Ferguson. I. Physical activity and breast cancer risk in the College Alumni Health Study (United States). Ont. G. PMID:1828608. Jr. Exercise for overweight or obesity. C. PMID:15076798. J. Gennat.c2. Rev. C. 2003. Physical activity and cancer: how may protection be maximized? Crit. 8: 219–272. PMID:10547168... D. Physical activity and the incidence of coronary heart disease. Health-related fitness. Shephard. Rev. Intern. Shaw.D. Physical activity and incident hypertension in black and white adults: the Atherosclerosis Risk in Communities Study.00101. 6): S521–S527. J. J. P.. Scharling.jes. D. J.. Willett. PMID:3533315. P. M. Carpenter. 26: 100–107.. P. Shephard. Liao. impact on mortality: the Copenhagen City Heart Study.W. 1998. Intern. R. 27: 311–334. Paffenbarger. and Futcher. Am. PMID:9467434.J. 2001. PMID:17301630.. 102: 975–980. Published trials of nonmedicinal and noninvasive therapies for hip and knee osteoarthritis. N. 1993. R.. PMID:8017727. 8: 253–287.J. Powell. Eaton. S45 Ross. and Del Mar. doi:10. PMID: 8744247.A.1023/A:1008827903302. and Colditz.1467-789X.C. PMID:10953062.. physical activity. Appl. and Blair. Kubitz..T.197. J. Med.. Cochrane Database Syst.1097/HJR.0000125756.E. doi:10. P. C. L. J.. C. Sci. Background paper prepared by the Irish Presidency for a meeting in Cork. 2000a. Med. 23: 221–225. 2002. Physiol.1249/01. 2006. S.. 21.08. How much physical activity is enough to prevent unhealthy weight gain? Outcome of the IASO 1st Stock Conference and consensus statement. W... Med. National Population Health Survey. Jamnik.. 1987. PMID:11427764. K.C.B. V. and Stanton.. A prospective study of recreational physical activity and breast cancer risk.E.J. Landers.A. L. J. 2000.hjr.... G..3. Med. and Corone. Izmirlian. Rev.. R. E. Intern. and Ray.. 2004.. Petruzzello..A. J..1006/pmed. Ann. Med.M.159. Shelley. S. Annu Rev Public Health.1097/ 00005768-200106001-00008. 2005. Res.001345. D. 35: 18–23. Shephard. Circulation.. Sesso. Cardiovasc.R. Physical activity and coronary heart disease in men: The Harvard Alumni Health Study. Sports Exerc.E.. Pescatello.. Philippine Association for the Study of Overweight and Obesity.

. 23: 84–87.01. McGavock. R. Cardiovasc. Blood volume expansion and cardiorespiratory function: © NRC Canada 2007 / © Canadian Public Health Association 2007 . J. Thune.. doi:10.1097/00005768-199906000-00007.. Ottawa.I.. Powell.160. D. D... S. and Zierath. J.006. J.2005.A. Smith. Viikari. B. Med. VO2 max and performance of elite cyclists. Physical activity and health: a report of the Surgeon General.] Stephenson.ede. 102: 1358–1363. A. 2000. Tissue Int.B.. Commonwealth Department of Health and Aged Care and the Australian Sports Commission... 2000a. Kelley.22.K. Executive summary..M. J. B. N.. Vol. A. B. 2005. R. Stevens. physical activity. Department of Health and Human Services. PMID:10908406. and Dahlen. 13: 369–374.. J. J. 2nd ed. 1016/j. Lancet. PMID:11333990. Rees. 1097/01. A. US Department of Health and Human Services. Smith.. cardiac function. Stone. Deaths. and Walker. N. 25: 25–35. Med. 2004a. all sites and site-specific. [Accessed 27 September 2004.A. and cardiovascular disease risk factors in adolescents: the Oslo Youth Study. Am.1056/ NEJM199409293311301. J.01. 2001a.. US Department of Health and Human Services and US Department of Agriculture. Warburton. 2004... Med. J. K.M. 33(Suppl. 116: 682–692. US Department of Health and Human Services. Statistics Canada. 2000b. D. 26: 161–216.E. Available from http://www. 7: 54–61. Changes in physical activity.B. 82-221-XIE. J. S. 1998. Tell. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance.E. G.. Sci. Statistics Canada. and Quinney.. 2005.. doi:10. Washington. mortality. Engl.D.G.S. Sports Exerc. US Department of Health and Human Services. S. Crouse. Tessier. N. Statistics Canada.S46 Appl. Physical activity as a determinant of mortality in women. K. Atlanta. 1999. R. 2000. PMID:11427781. Bertrais. C. Calcif. Gouvernement du Que ´ bec. S. Gledhill. Deaths. and a little more for health Que ´ du´ bec.htm. Teo. J. Wallberg-Henriksson. Taylor. et al. Lipoprotein (a) levels in children and young adults: the influence of physical activity. Public Health 98(Suppl. A.. Circulation. 1994. Wannamethee. H. J. D. 2001b. N.T. Appl. G. Physiol. K. 31: 800–808. 2). Washington.. M. Gottschalk. 17: 12–24. doi:10. Gledhill. 31: 101–114. Physical fitness. Ebrahim. D): 3D–19D. Sports Exerc. Ont. S. Statistics Canada. Catalogue No. 2007 Statistics Canada. doi:10... doi:10.. Mucci.C. Boini. T.H. Haykowsky. Physical activity and mortality in older men with diagnosed coronary heart disease. Rehabil.. J.1016/j. Wallace. .statcan. Ont. doi:10. Can. PMID:10904453. Ministe ` re de l’E practitioners... 2006. S. doi:10.. Armstrong.. Warburton. Epidemiology. B.E. L.pdf. PMID:11312417..G. Trolle-Lagerros.. Sports Med. M.1016/ S0140-6736(97)12355-8. and Sattin. A. Ont. Brown.1056/NEJM200105033441801.1016/S1047-2797(96)00110-X.A. Oppert. Critchley. 2005. Sci.E. Guillemin. O.2165/00007256-19982501000003. Can. 344: 1343–1350. 1998. PMID:10993852.. (PHS)91–50212.E. 1998/ 99. and Alberti. Taylor. P. Nutr. DHHS Publication No. 41: 562–569. National Center for Chronic Disease Prevention and Health Promotion. Ann..S.14. 1994. doi:10. Gledhill. PMID:15121495. Warburton. J. Systematic review of randomized trials of the effect of exercise on bone mass in preand postmenopausal women. S. DC. and Walker. and Card.G. Braaten.. and Furberg.] Statistics Canada. Appl. M. Physical activity in the prevention of cardiovascular disease: an epidemiological perspective. E.1001/archinte.. and the risk of fall-related fractures in community-dwelling elderly. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. 2006. Physical activity. A. Hamalainen. E. Ga. Krip. 1988. 2001. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. J..W. H. H.S.ypmed. Washington. doi:10. 1999. PMID:16926666.ca/english/ freepub/84F0211XIE/84F0211XIE2004000.. Acta Paediatr.D. J. 6): S438–S445.0000181312. D. Prev. F.. Taylor.A.Q. doi:10. et al.V. M.2165/00007256200131020-00003. [Accessed 18 February 2007. doi:10. Engl. S.C. Beohar. T. K. Epidemiol. 2001. Cardiopulm.. doi:10. Goodpaster. J. 6): S530–S550. I. doi:10. 2001. Ilanne-Parikka.. Healthy People 2010: Understanding and Improving Health. doi:10.C.. Taimela. Unal. H. S. Y. Hereberg. 33(Suppl. 83: 1258–1263. Prev. and Capewell. and Shaper. PMID:7734865. Wannamethee. doi:10. Leisure-time physical activity and health-related quality of life. and Briancon. Tiukinhoy. Valle. 1991. N. 2004. PMID:9620713. PMID:11427768. Jolliffe. A.. 2004 [online].. Garrett.. J. J..R. Porkka.R. Eriksson.. metabolic factors. S.. Baker. and Arthur. 16: 780–785. 160: 2108–2116.G.G.. Quinney. Wingo. P. Centers for Disease Control and Prevention. Ont.. P.G. 351: 1603–1608. Rehabil. Ottawa. PMID:15917053. PMID:11312416.1097/00005768-200106001-00012. PMID:8078528.A. B. H. 1997.1016/00917435(88)90068-0.. The acute versus the chronic response to exercise. Cardiol. The effects of changes in musculoskeletal fitness on health. PMID:12668927. Physical activity and cancer risk: dose–response and cancer. McAvay. M.A.. V. Musculoskeletal fitness and health. US Government Printing Office. Wannamethee. cation. 26: 217–237.. Lindstrom.G. and Hsie. S.009.S. Blackmore. Shaper. and Bellew. Physiol. Warburton.2108. et al. and Vellar. K. J. L. D. Med. 2001. T. PMID:10378906. D.... D. Statistics Canada. PMID:11227978... doi:10. Physical activity. Tinetti.S. N. The Cardiovascular Risk in Young Finns Study. 2001. and Cumming. Med.J. Arch. Statistics Canada. 2007 / Can. Canberra. The costs of illness attributable to physical inactivity in Australia: a preliminary study. and incidence of coronary heart disease in older men.. J.G. Prev. Australian Captial Territory.A. Vuillemin. Med. S. P. 32(Suppl. et al.. National Population Health Survey. Claus. 2005.P. .G.. Canadian guidelines for cardiac rehabilitation and cardiovascular disease prevention. M.. Moyna. Metab. 2E). Hsieh.A. Intern.. R. Tuomilehto. Kumle. Health Indicators. Sci. Available from http://www.G.35964.1007/s00223001089.. A. 67: 10–18. N. Improvement in heart rate recovery after cardiac rehabilitation. 2007.2004.F. Que Thompson. Shaper. M. functional limitations. 2000.. How much physical activity is needed to improve health: highlights of a position statement of the Kino´ bec scientific committee. US Department of Health and Human Services.. Physiol. Noorani. doi:10. Dietary Guidelines for Americans 2005. Med. 21(Suppl. P.. Exercise in the management of non-insulin-dependent diabetes mellitus.1097/00149831-200606000-00012. Med. 331: 821–827. S. PMID:9458525..statcan.. Ottawa. A. J. Shaper. J.amjmed. Thibaut. A. D. Med. D. Induced hypervolemia... and Humen. Rincon. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials..ca/Daily/ English/040927/d040927a. Sports Med. S. and Pescatello.. 1. US Department of Health and Human Services. 2003. PMID:3362798. Jamnik.. Can. Wannamethee.. Weiderpass. 1996.1097/ 00005768-200106001-00025. N. Ottawa. G. PMID:16222168.1097/00008483-200303000-00002. PMID:9034407.G. S. and the incidence of coronary heart disease and type 2 diabetes.. G. Sports Exerc.E.. and Quinney.. 2002 [online]. D.. Mortality reductions in patients receiving exercise-based cardiac rehabilitation: how much can be attributed to cardiovascular risk factor improvements? Eur. B.

G.. 0000021313. 2006b. Cardiol. S. R. T.D.. Warburton. Whitney Nicol. Med.2004.X. S. S.. Slordahl. Sports Exerc. Williams.B. Geneva.. D. Primary prevention of type 2 diabetes mellitus by lifestyle intervention: implications for health policy.. S.C..R. Gibbons. JAMA. Sports Exerc.. and Blair. 292: 1179–1187. 93: 939–943. Atlanta FICSIT Group.0000216548. 13: 667–677. P. Available from http://www. Whelton. 2007. T.. S. Med. A.. J. 2001. S. PMID:15179169..84560. S47 C. D. 2006a. and Kraak. P. Effectiveness of high-intensity interval training for the rehabilitation of patients with coronary artery disease.. Droyvold. J.D. Am. Wessel. 2004b.51397. Washington. Warburton..C. 1995.K. D.J... van Croonenborg..88298.P. J. Eur. X. Vinicor. Xin. Cutler. and Bredin.. Williamson. Kampert. Global strategy on diet.12. 140: 951–957.N. Johnson. PMID:14600547. A. T. Arant. doi:10. 174: 961–974. Med.C. PMID:11926784.B7. © NRC Canada 2007 / © Canadian Public Health Association 2007 . J.. Kostense.J. Coogler. Lee. Stewart.. Gatto.. 33: 754–761. 2003.A.B. Sharaf.N. Am. D.S. Kemper.. 1999..E. Sci.A. Wei.. H.. PMID:12377087. physical activity and health.1503/cmaj. 1996.R. PMID:15130029.ac. The effect of exercise training programs on bone mass: a meta-analysis of published controlled trials in preand postmenopausal women. and He. C. B. McNeely.E. K.. Primary prevention of hypertension: clinical and public health advisory from The National High Blood Pressure Education Program. 13: 798–804. S.N. promoting healthy life.1249/01.T. doi:10. L.D.. The World Health Report: reducing risks. Rehabil. Intern.C. et al. PMID:15050506. Appel.. Wolff.... 2007. 2002. 2005.. Mitchell.1016/j.1097/01. C. 2004. 136: 493–503.Y. 1007/s001980050109. doi:10. P..33. National Academy of Sciences. Soc. He.. Risk Management. 36: 991–1000.C. Olson. Hodges.G. Med. 35: 1834–1840. 2004. Med. Sports Med. Adequacy of evidence for physical activity guidelines development: workshop summary.CB. who.. World Health Organization.J. Intern.C. 3:1–17. World Health Organization..288. Ann.051351..292. 174: 801–809.E.. 2004. and Kromhout.0000093619. Wendel-Vos.M. J.B. doi:10.D. Intern. Sports Exerc. World Health Organization. Sci.. E. Levy. Prescribing exercise as preventive therapy. doi:10. J. I. C.12. M. 2006.S.MSS.. doi:10. T. Morkved. S. World Health Organization. Appendix A Appendix A appears on the following pages.. Warburton. 2004. Taylor. doi:10.B. body mass index with coronary artery disease and cardiovascular events in women.. 130: 89–96.W. N. S. Havas... S.A. D. Prev. B. Can.. D. A. Assoc. PMID:11323544. Ann. PMID:15172920. Sci. Geriatr. J. and Bredin. Int. Reducing frailty and falls in older persons: an investigation of Tai Chi and computerized balance training.I. D.J. C. and McKenzie. Warburton.2003. doi:10.37805. Health.1001/ jama. J.. The association between cardiorespiratory fitness and impaired fasting glucose and type 2 diabetes mellitus in men.P. 19: 43–54. Switzerland. T.A. Warburton. Med. 2002.. Yoshida. 95: 1080–1084.. J.hjr. M. West Suitor. Cardiol. S. Westerlind. C. Norway. Wisloff. J. J. Can. Haykowsky. A. PMID:7740246.R.. Physical activity and cancer prevention– mechanisms.1016/j. et al.15. and Twisk. A.J. P. L. PMID:15842976.10. Switzerland. 1249/01. 288: 1882–1888. U. A. Leisure time physical activity and health-related quality of life: cross-sectional and longitudinal associations.A. PMID:17001221.L.amjcard. PMID:15353530. Reis. Whelton. Young. PMID:10367023.W.063..E.S. doi:10.E.J. effects of training modality. S. Cardiovascular disease and osteoporosis: balancing risk management. Health benefits of physical activity: the evidence.I. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized.L.. Physical fitness and activity as separate heart disease risk factors: a meta-analysis. Shoemaker. Relationship of physical fitness vs. Med.int/PressRoom/pressnotes/20061117_1. 9: 1–12.F.E. M.. C. Vasc. Kotchen. Schuit. V.. Geneva. Assoc. I... L. Osteoporos. doi:10.1040750.. Ann. World Health Organization. controlled trials. Barnhart.B.. Tijhuis. PMID:8617895. and Bowman. 2006. H.L. W. practical considerations. and Xu. Kutner. 44: 489–497. doi:10. J.. Nicol. 2002. Nilsen. 1999.W. M..1001/ jama. Sheel. Physical activity: a basic requirement for health [online]. Qual. D.Warburton et al..C. J. Cardiovasc.1179. and Bredin.W. D.euro. Am.1503/cmaj.0000128163. PMID:10068380. and Vatten. Frailty and injuries: cooperative studies of intervention techniques.030. Ignaszewski. Nicol. and Chan. Med. B.1023/B:QURE. A single weekly bout of exercise may reduce cardiovascular mortality: how little pain for cardiac gain? The HUNT study. F.amjcard. E.. Chin. Effects of upper extremity exercise training on peak aerobic and anaerobic fitness in patients after transplantation. Wolf. Life Res.1882. D. Exercise prescription for individuals with metabolic disorders. McKenzie.MSS. JAMA.

RR = 1.2). Studies were separated into work-related activity and leisure-time related activity (studies that used both were grouped with the leisure-time studies) Eaton 1992 To examine the relationship between PA and physical fitness with CHD Pooled RR (95% CI) for CHD death. Purpose of review To examine (via metaanalytic procedures) the relationship between PA and CHD All-cause mortality results Cardiovascular mortality/morbidity results Main findings/conclusions Convincing evidence that PA is protective against CHD. High vs. 2). High vs. moderate PA in studies that reported moderate and sedentary comparison groups (1 study)). Occupational activity. Eight additional articles published since the study of Powell et al.2–2. High vs.3 (1. RR = 1. Representative reviews of the literature examining the dose–response relationship between physical activity and risk for all-cause mortality and cardiovascular-related morbidity and (or) mortality. Metab.1–2. 7 articles examined the relationship between physical fitness and CHD Not described . Public Health 98(Suppl.4). High PA vs.6–2.6 (1.0). cancer and allcause mortality Thompson 1994 A search of MEDLINE was supplemented by a manual search of the literature. 32(Suppl.0–1. RR = 1. 2E).5 (1. RR = 1.7).4). most fit ranged from 1. low PA in studies that did not separate moderate and sedentary comparison groups (6 studies). RR = 1. Physiol. moderate PA in studies that reported moderate and sedentary comparison groups (5 studies).9 (1. RR = 1.2).1–2. RR = 1. High vs. sedentary in studies that reported moderate and sedentary comparison groups (4 studies). RR = 1.6 (1.3) All 7 studies demonstrated a reduction in CHD with increased physical fitness.0–3. High vs. further research is needed to discover clinical and public health implications Strong evidence for a reduction in all-cause mortality with exercise Strong evidence for a reduction in risk of CVD with exercise Literature suggests that exercise is effective in reducing the risk for CVD and all-cause mortality. 2007 © NRC Canada 2007 / © Canadian Public Health Association 2007 To describe the physiological aspects of exercise and its effect on risk for CVD. 2007 / Can. RR for least vs. J.4 (1. High PA vs.2–2. pattern of association noted in this study is supportive of a dose–response relationship Author Design Berlin and Colditz 1990 Performed a meta-analysis on data extracted in a previous review (Powell 1987). moderate PA in studies that reported moderate and sedentary comparison groups (3 studies).S48 Table A1. Nutr. High PA vs.9 (1.7 (1. were identified by a MEDLINE search and by checking reference lists.8 Evidence supports a causal relationship between physical fitness and CHD. sedentary from studies that reported both moderate and sedentary comparison groups (1 study). Non-occupational activity. low PA in studies that did not separate moderate and sedentary comparison groups (2 studies.8).2 to 4. with some disagreement Appl.2–1. sedentary from studies that reported both moderate and sedentary comparison groups (5 studies). Non-occupational activity (including the studies that were not included in Powell’s article).

0. Most studies showed at least a 50% lower mortality rate in the highest fitness group compared to the lowest fitness group Pooled effects estimate. morbidity and health-related quality of life. N = 8440 CHD patients Most studies show an inverse graded response between activity levels and reduced risk of CHD. relationship is commonly curvilinear with a steeper response in the lower fitness groups and a more shallow response (i. 1999). EMBASE and the Cochrane Library (Issue 3.57 – 0.. not just CVD) and assessment of PA (49 studies).71 – 1.96) = comprehensive program © NRC Canada 2007 / © Canadian Public Health Association 2007 To examine the effectiveness of exercise only or exercise as part of a comprehensive cardiac rehabilitation program on mortality. odds ratio (95% CI). 2000 To examine the effectiveness of different lifestyle interventions in the primary and secondary prevention of CVD in adults 1 study revealed a positive effect on total mortality A search of MEDLINE (1966-December 1998). 0. Pate 1995 Not described Blair and Connelly 1996 Reviewed selected recent representative studies supplemented by classical studies in the area Strong and consistent evidence for a reduction in risk Evidence shows an inverse relationship between the risk of disease and levels of PA or fitness Bauman and Owen 1999 Not described To review and summarize the evidence regarding the type and amount of exercise necessary for health and function To review the recent epidemiological evidence for the association between PA and health Ketola et al.74 (0.e. 2001 PubMed search from 1990 to August 25.05) = comprehensive program Research since 1995 (following the US Surgeon General’s report) has similar results to the US Surgeon General’s report: individuals in the low fitness group are at twice the risk of cardiovascular events or mortality than those in higher fitness groups. increases in PA or fitness were associated with lower mortality risks than staying at the same level of PA All-cause mortality results Cardiovascular mortality/morbidity results Main findings/conclusions Graded response between most health parameters and PA levels Author Design Warburton et al. and stroke. 0. Included articles that had 3 or more categories of activity or fitness and a health outcome. CVD Mortality. However.87 (0. In studies examining the change in PA.Table A1 (continued).e. Purpose of review To examine the literature concerning the dose–response relationship between PA and health PA or fitness is inversely related to all cause mortality. there is evidence for a dose–response relationship More research should be performed examining the use of exercise as primary prevention. 57 articles met the inclusion criteria To assess whether there is a dose–response relationship between PA and (or) physical fitness and health Across fitness groups (9 studies).54 – 0.. 2000. 2001 Maximum benefit seen when moving from sedentary or low fitness group to moderate fitness group.69 (0. Jolliffe et al. future studies should adhere to a standard of outcome measurement to facilitate evaluations of effectiveness Blair et al. an asymptote) in the higher fitness groups Exercise rehabilitation is effective in reducing cardiac-related and allcause mortality in men and women with CHD S49 .94) = exercise only. odds ratio (95% CI). 2 of these showed an effect of exercise It was not possible to quantify a dose–response relationship because of a wide range of health outcomes (i. DARE.51 – 0. all studies included showed a reduction in mortality with increasing fitness.98) = exercise only. The outcome measures were varied between studies and could not be combined.73 (0. 0. A total of 67 articles were included (All Evidence Category C) Cochrane database systematic review to December 1998. The RR between the most and least active groups suggests that those individuals in the least active group have about double the risk as those in the most active group 10/16 studies that included changes in exercise had positive outcomes. most studies show an inverse graded response for health outcomes across PA categories Pooled effects estimate. 8/ 16 studies used CVD mortality as an endpoint. CVD.

S50 Table A1 (continued). non-randomized. Findings were supplemented by consensus reports and other published literature Lee and Skerrett 2001 Review of papers published between 1966 and July 2000. Ebsco. Physiol. Public Health 98(Suppl. Sport. Findings were supplemented by previous review articles and previously collected published literature One study suggested an energy expenditure of 8. 2E). in a dose– response manner. 44 papers identified with >2 levels of PA To examine the dose–response relationship between PA and all-cause mortality Oja 2001 To examine the characteristics of the dose–response relationship between volume of PA and fitness and health outcomes Cross-sectional and follow-up observational studies suggest a graded positive dose response between total volume of PA and all-cause mortality A search of MEDLINE.4MJ/week was needed to reduce the size of atherosclerotic lesions Observational studies (category C evidence) demonstrate an inverse dose–response relationship between volume of PA and all-cause mortality rates in men and women. 32(Suppl. 2007 / Can. absolute intensity of PA in health outcomes The literature included for analysis in this review suggests an absolute intensity of about 6 METs was required for reductions in all-cause mortality. Purpose of review To summarize the existing literature regarding the dose–response relationship between PA and CVD endpoints Major observational studies indicate a dose–response relationship between PA and CVD incidence/ mortality. with the risk of CVD. Academic Search Elite. Nutr. unknown how this relates to relative intensities or to the volume of activity . several studies have suggested that benefits may occur with energy expenditure below this level Observational studies demonstrate a dose–response relationship between the volume of PA and health measures. Metab. uncontrolled randomized and RCTs did not show a dose–response relationship between PA volume and health and fitness A number of reports suggest that the threshold for all-cause or CVD benefit is an absolute intensity of about 6 METs. evidence for a dose–response relationship between PA and stroke is equivocal Author Design Kohl 2001 MEDLINE search of the literature up to August 2000. There is disagreement in the literature concerning the effect of PA on the risk for stroke with some studies showing a dose–response relationship. Cochrane Systematic Reviews and Dare databases yielded 19 observational and 15 RCT To examine relative vs. others showing no relationship and still others showing ‘‘U’’ shaped relationships Clear evidence of an inverse linear dose–response relationship All-cause mortality results Cardiovascular mortality/morbidity results Main findings/conclusions PA is inversely associated. 2). Some studies have shown health benefits to occur at light and moderate intensities as well Appl. 2007 © NRC Canada 2007 / © Canadian Public Health Association 2007 Shephard 2001 MEDLINE search from 1991 – December 1999. J. evidence suggests that the relationship is linear rather than L-shaped or with a threshold and that PA eliciting an energy expenditure of ~1000 kcal/week reduces all-cause mortality ~20%–30%.

Table A1 (continued). 0. 0. increasing either fitness or LTPA was associated with a reduction in risk. brisk walking) on most days of the week An active lifestyle decreases mortality and can reduce risk factors for CVD © NRC Canada 2007 / © Canadian Public Health Association 2007 To examine the association of PA or fitness with all-cause mortality in women Oguma et al. although the minimal effective dose remains unknown. the literature suggests a linear dose–response relationship between PA and CVD at least up until certain amount of PA Comparison demonstrates that LTPA and fitness have significantly different relationships to CVD/CHD risk. women only Median RR (CI not reported) = 0. significant reductions in the incidence and mortality of CVD are noted with 30–60 min moderate activity (i.. energy expenditures of ~4200 kJÁweek–1 are associated with substantial health benefits. 0.e.75 = total PA.54 = OPA. 2002 MEDLINE and CINAHL search from 1990 to August 2000. Purpose of review To examine the epidemiological evidence for a relationship between PA and CVD Not discussed The literature generally supports the theory that there is an association between the amount of PA and reductions in CVD mortality in both men and women All-cause mortality results Cardiovascular mortality/morbidity results Main findings/conclusions Author Design Warburton et al. stroke and CVD. with or without pre-existing CVD.66. but the reductions in RR with increasing fitness are almost twice as large as the reductions in RR with increasing LTPA Clear evidence of an inverse linear relationship between the amount of PA and all-cause and CVD-related mortality. This was supplemented by consensus documents and by checking the reference lists The literature suggests an inverse relationship between the weekly amount of PA and the incidence of CVD-related mortality Houde and Melillo 2002 To evaluate the current status of the literature concerning PA and CVD risk factors in older adults Study outcomes overwhelmingly support the contention that the risk of mortality is reduced in more active individuals Large prospective studies have shown that PA is independently associated with a 40%–50% reduction in the risk of stroke and CHD in men and women. Wannamethee and Shaper 2001 Review of epidemiological studies regarding PA and CVD Williams 2001 Meta-analysis of 16 cohorts (1 012 809 person–years) included in the Surgeon General’s Report To compare the dose–response relationships between CVD endpoints and LTPA/fitness Each percentile of PA‡25th percentile has significantly lower risk of CHD or CVD in comparison to the referent (least active) group Haennel and Lemire 2002 To examine the role of PA in the prevention of CVD-related mortality with an emphasis on the intensity and amount of PA needed for health benefits Moderate levels of PA are associated with lower mortality rates in older and younger men and women. A total of 44 articles were reviewed that examined PA and cardiovascular health in older adults Review of papers published between January 1966 – December 2000.66 = LTPA. The literature supports an inverse linear relationship between all-cause mortality and the amount of PA A MEDLINE search from Jan 1991 – Dec 2000 yielded 39 articles. Types of PA RR (CI’s not reported). regular PA at a moderate intensity appears to be sufficient to obtain significant benefits for CHD. 0.55 = physical fitness Adherence to current PA guidelines (4200 kJ of energy expenditure per week) can postpone mortality in women S51 . whether young or old.

80 (0.80 – 0. Without adiposity as covariate: 0. evidence comes from limited RCT and nonrandomized studies) and it is very likely that the results can be generalized to women There is a graded reduction in the risk for CVD in women with increasing levels of PA.74 – 1. evidence supporting this recommendation is considered class I (i.02) CVD Mortality: RR (95%CI)) Exercise cardiac rehabilitation: 0. This was performed to update the evidence found in the 1998 Cochrane systematic review All cause mortality: RR (95%CI).57–0.94) = second least active. as little as 1 h/week of walking is associated with a reduced risk for CVD Appl. Comprehensive cardiac rehabilitation: 0. Exercise cardiac rehabilitation: 0. useful and effective). Nutr.. days of the week.52–0.61 – 0.59 – 0. 2984 patients) or comprehensive cardiac rehabilitation (27 studies. odds ratio (95% CI) = 0. referent.77 (0. 0. Metab. 2E). comprehensive cardiac rehabilitation programs may have a somewhat greater effect than exercise only programs on risk factors Author Design Brown 2003 Katzmarzyk et al.80(0. 2004 Systematic review & metaanalysis of RCTs.S52 Table A1 (continued). if not all.82 (0. 2004 MEDLINE (1966-July 3.84 (0.74 (0. This was performed to update the evidence found in the 1998 Cochrane systematic review. 2007 © NRC Canada 2007 / © Canadian Public Health Association 2007 To compare cardiac rehabilitation vs. Studies were categorized as exercise cardiac rehabilitation (19 studies.96) Exercise-based cardiac rehabilitation is of benefit for reducing cardiac and all-cause mortality in patients with CHD . J.76 (0. 0. 0. 2003). Purpose of review To review cardiac rehabilitation programs with exercise components for secondary prevention of CVD in terms of clinical and cost effectiveness..96). women only Women should be encouraged to accumulate at least 30 min of moderate intensity PA on most. 48 trials.98).99) All-cause mortality results Cardiovascular mortality/morbidity results Main findings/conclusions Cardiac rehabilitation programs including exercise appear to be beneficial in the reduction of cardiac and total mortality.93) CVD-related morbidity and (or) mortality RR (95% CI). Public Health 98(Suppl.69–0.87 (0. The search yielded 10 new trials that have been published since the Cochrane review. 1. 5693 patients) A variance-based method of meta analysis was used to summarize 55 analyses (31 studies) for physical inactivity Physical activity and mortality are inversely related independent of adiposity Mosca et al.75–0.65 – 0. usual care Taylor et al. up to March 2003.87) = third most active.82).83) = second most active.80 (0. 8940 patients with CHD Reduced all-cause mortality.e. 2007 / Can. category B (i.84) To develop a set of evidence-based guidelines for the prevention of CVD in adult women A systematic review and meta analysis of the literature using the same methods as the Cochrane systematic review wherever possible. Physiol.78 – 0.68 – 0. Comprehensive cardiac rehabilitation: 0.00 = least active level. 2). 0. CINAHL (1982 – 3 July 2003) and PsycInfo (1872 – 3 July 2003) searches identified 399 articles Oguma and ShinodaTagawa 2004 To examine the dose–response relationship between PA and CVDrelated morbidity and (or) mortality in women Systematic review and meta-analysis of 30 papers published between January 1966 – March 2003. odds ratio (95% CI) = 0.56 – 0.73 (0. With adiposity as covariate: 0. This brought the total number of articles to 46.69 (0. 32(Suppl. 2003 To identify the independent effects of physical inactivity and excess adiposity on premature mortality All cause mortality (summary relative risk (95% CI)).67 (0.85) = most active Reduced cardiac mortality.e.

confidence interval. occupational physical activity. type 2 diabetes mellitus. 2005 Warburton et al. This comprised 21 295 patients with coronary disease. control (Risk ratio (95% CI)) 0. randomized control trials. exercise only Narrative review of the literature To examine the evidence for PA in the primary and secondary prevention of varied chronic conditions Regular PA is an effective primary and secondary preventive strategy for CVD (and multiple other chronic conditions) There is irrefutable evidence of the effectiveness of regular PA in the primary and secondary prevention of several chronic diseases (e.g.76 – 0. CI.54 – 0.83 (0. there is a dose–response relationship between PA and health status © NRC Canada 2007 / © Canadian Public Health Association 2007 Note: PA. CHD. All Cause Mortality: Program with exercise or exercise only vs.0. HRR. hypertension. EMBASE (1980– 2004). RR. kilojoules/week. 63 unique randomized clinical trials met all of the inclusion criteria. LTPA. cardiovascular disease. physical activity. 2006 There is compelling evidence that moderate PA levels are associated with risk reductions of at least 20%–35% for premature mortality A search of MEDLINE (1966–2004). S53 . This was supplemented by manual searches of reference lists and references provided by the Centers for Medicare & Medicaid Services. Clark et al.Table A1 (concluded). Cochrane Central Register of Controlled Trials (Issue 4. CINAHL (1982– 2004). control (Risk ratio (95% CI)) .72 (0.95).99) All-cause mortality results Cardiovascular mortality/morbidity results Main findings/conclusions Secondary prevention programs with and without exercise are effective in improving health in patients with CHD Author Design Warburton et al. kJ/week. Purpose of review To evaluate (via metaanalytic procedures) secondary prevention programs for cardiovascular disease both with and without exercise components All Cause Mortality: Exercise only vs. hazard rate ratio. relative risk ratio. CVD.72 – 0. current Canadian PA guidelines are sufficient to elicit health benefits.96). Three categories of interventions were described: Program without exercise.. All Cause Mortality: Program with no exercise (Risk ratio (95% CI)) . leisure-time physical activity.87 (0. SIGLE (1980– 2004) and PubMed (Jan 2004 – Dec 2004) for RCTs. RCT. program with exercise. OPA. especially in previously sedentary people. 2004). obesity. T2DM. depression and osteoporosis) and premature death. CVD. T2DM. coronary heart disease.0. cancer.

* In general. Embase and the Cochrane Library database up to January 2002. PA and rectal cancer in either men (1.78 (0.29) or women (1. 2005 19 cohort studies and 28 case-control studies met the inclusion criteria for the review To review the evidence regarding an association between PA and large bowel cancer A search of Medline. 2 appeared to show a dose–response relationship but presented no P values for trend and 1 reported a significant test for trend however the graph did not appear to show a dose–response effect. Occupational PA: 0. Case-control (LTPA.87). 4/6 studies showed a reduction in risk. PA elicits a reduction in risk of 15%–20%. Developed a quality assessment tool and split the studies about the median score into lower and higher quality groups. Public Health 98(Suppl. Cohort Studies: Physically active men RR (95% CI). Cohort studies (LTPA. Recreational PA: 0. 14/28 showed a reduction in risk ranging from 23%–65%.61 (0.51–1.49 (0. Nutr. Case-Control Studies: Physically active men RR (95% CI). Physically active women RR (95% CI). Recreational PA: 0. Of these.79 (0. 95% CI = 0.88) No association between.47) © NRC Canada 2007 / © Canadian Public Health Association 2007 .70 (0. 2007 To examine the epidemiologic evidence for an association between PA and risk of breast cancer. 2007 Samad et al.91).46).11 (0. No association between PA and rectal cancer in either men (0. one no association.58 (0. n = 6).53–1. Metab. 0.00. 40 studies showed a reduction in risk in men. Of these. A dose–response relationship was observed in half of the high quality studies that showed a reduction in risk with PA. To evaluate whether PA is more or less effective in reducing risk at different points in life (for example pre and post-menopause).88). Men and women experience similar reductions in risk except for cohort studies of occupational PA Author Objective Monninkhof et al.8<RR<1.94.83). 95% CI = 0.87. * 6/7 studies reporting>2 levels of PA showed an inverse dose–response relationship. To examine how study quality affects the outcome Appl.57–0. 9 appeared to show a dose–response relationship Colon and colorectal cancer.07) or women (0. Case-control (total activity.45–0. Recreational PA: 0. J. 2007 / Can. Occupational PA: 0.77). The authors suggest that the evidence for a relationship between PA and pre-menopausal breast cancer is weak and indecisive.64–0. n = 17). 2).83–1.8 as reduced risk. n = 28). one increased risk. 9/17 showed no association. n = 3). Physically active women RR (95% CI). Occupational PA: 0. Physiol. 2E).71 (0.72–0.47–0. Overall.25 as no association and RR>1. This was supplemented by a manual search of reference lists Cohort studies (total activity. 95% CI = 0. Inconsistent results: one decreased risk. 8/17 studies showed a reduction in risk.78–1.65).68–0. 32(Suppl. The risk reduction was *6% with each additional hour of PA/ week. lower quality studies showed greater reductions in risk. 18 studies showed a reduction in risk in women.25 as increased risk 19 cohort studies and 29 case-control studies met the inclusion criteria for the review Participants Primary results Main findings/conclusion The studies reviewed show strong evidence of an inverse relationship between PA and post-menopausal breast cancer (20%– 80% risk reduction). ‘‘Being physically active as an adult appears to reduce breast cancer risk irrespective of the amounts of activity before age 20’’ PA appears to be protective against colon cancer but not against rectal cancer. Used RR<0. Method Systematic search of PubMed up to February 2006. Occupational PA: not significant: 1.37–0.84–1. 95% CI = 0. This was supplemented by a manual search of reference lists. Selected systematic reviews or meta-analyses examining the relationship between physical activity and the risk of breast or colon cancer.72).00. Recreational PA: 0.S54 Table A2.

LTPA. Non-worker: 0. crude dose–response relationship between LTPA and colon cancer. OPA or total PA. peri. This was supplemented by a manual search of reference lists 48 studies involving colorectal. the combined evidence confirms that PA is protective in a dose– response manner against breast and colon cancer. Sedentary: 1. Light: 0.98). and alterations in free radical damage Research generally supports the hypothesis that increased levels of PA are associated with reduced risks for colon cancer.39–0.Table A2 (concluded). Sedentary: 1. Method A systematic search of Medline and PubMed until August 2000. Potential biological mechanisms include alterations in hormones levels.34–1. OPA.00 (referent) Active: 0. occupational physical activity.78). 16/28 studies showed a dose–response relationship between PA and risk for breast cancer Occupational PA and colon cancer multivariate adjusted RR (95% CI).00 (referent). However. 26/41 studies showed an association with PA and a lower risk (*30%) of breast cancer in pre-. Moderate/heavy: 0.and post-menopausal women.59–1. improved body composition. S55 . colon and rectal cancer were identified (23 cohort studies. physical activity. 12 original research articles were identified (6 prospective cohort. There was no relationship between PA and rectal cancer in 80% of 24 studies. and the potential mechanisms of cancer prevention Recent evidence supports the fact that 30–60 min of daily moderate-to-vigorous physical activity is required to protect against breast and colon cancer. inverse. metaanalyses and articles published in the area The number of studies evaluated was not provided To examine the relationship between physical activity and cancer risk. 21/33 studies showed a significant. Thune and Furberg 2001 To examine the evidence for a dose–response relationship between the volume of PA and cancer risk Quadrilatero and Hoffman-Goetz 2003 To review the proposed mechanisms linking physical activity and colorectal cancer A 3-stage systematic search of Medline from 1970 to 2002 23 review articles were identified to generate hypotheses.04). Additional research is required to understand the biological mechanisms responsible and the specific exercise prescription for various cancer sites © NRC Canada 2007 / © Canadian Public Health Association 2007 Note: PA. leisure time physical activity. research systematically examining the mechanisms for the relationship between PA and colon cancer is limited. 6 case-control) 35/48 studies observed 10%–70% reductions in colon/colorectal cancer risk with LTPA.60 (0. but not against rectal cancer Participants Primary results Main findings/conclusion Author Objective Warburton et al. At the moment the indirect evidence most strongly supports a link between PA and insulin-like growth factors Regular PA is associated with reduced risks for colon and breast cancer.45 (0.61 (0.82 (0. LTPA and colon cancer RR (95%CI). enhanced immune function.26–0.13) Kruk and Aboul-Enein 2006 A narrative review of recent systematic reviews. 25 case-control studies) The authors state that despite methodological limitations.

2E). reduced visceral adipose tissue and increased insulin sensitivity in people with type 2 diabetes. 58% relative reduction in incidence of diabetes with lifestyle intervention (weight reduction. Physiol.168 participants) met the inclusion criteria. Insulin sensitivity increased (1 study): 131 AUC (20 to 242) Regular PA (cycling or walking) reduced HbAc1. Issue 2). However.71 (95% CI –1. control group Exercise vs. Methods A systematic search of MEDLINE.0001. EMBASE and manual searches of bibliographies up to March 3. and consultation with experts in obesity research. EMBASE.8 to –27. Issue 2) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2004. physical activity. there were 7 trials (266 patients) examining physical fitness in type 2 diabetics Glucose homeostasis can be enhanced through both aerobic and resistance exercise. J. and behavioral weight loss/weight control interventions for adults with prediabetes 9 studies (5. ERIC.32) Appl. Follow up ranged from 1–10 y (mean 3. The authors note that the exercise trials were generally of low quality and the results need to be confirmed in higher quality trials. physical activity) vs.2 years) 5/9 studies reported incidence of diabetes as an outcome. Karmisholt and Gotzsche 2005 To conduct a meta-analysis of systematic reviews of PA for secondary prevention of disease A search of MEDLINE and The Cochrane Database of Systematic Reviews from 1998– 2004 17 systematic reviews met the inclusion criteria. 2006 14 RCTs (377 participants) comparing exercise against no exercise in type 2 diabetes met the inclusion criteria To assess the effects of exercise in T2DM Search of Cochrane Central Register of Controlled Trials (CENTRAL). this was supplemented by manual searches of bibliographies Criteria for inclusion of studies was not discussed Participants Primary Results Main Findings/Conclusion Lifestyle modifications including exercise (30 min or more. 2005 To conduct a systematic review and meta-analysis to assess dietary. 2005 Exercise significantly improved glycemic control. 2007 / Can. Nutr. Web of Science. CINAHL.3). Systematic reviews and meta-analyses evaluating the relationship between physical activity and type 2 diabetes.6% HbA1c (– 0.S56 Table A3. the exercise intervention was only one component of a comprehensive program and there were too few studies to determine whether the exercise increased the effectiveness of dietary interventions. 2005 To assess different strategies in the prevention of type 2 diabetes Thomas et al.3). and Nutrition Abstracts and Review.5 cm2 (–63.9 to –0. control (95% CI). 31% reduction with metformin. Public Health 98(Suppl. food intake. HbA1c reduced (13 studies): –0. standardized mean difference –0. The Cochrane Library (2004. P<0. 32(Suppl. PsychINFO. Biosis. 3/5 observed a reduction in the intervention group vs. this was supplemented by hand searches of selected journals. Of these. most or preferably all days of the week). 58% relative reduction in progression of diabetes with lifestyle intervention (nutrition and exercise) vs. EMBASE and the Cochrane Library from January 1990 to December 2004. The 3 studies that observed a reduction in the incidence of diabetes were large and appropriately powered to detect effects. MEDLINE. the last search was conducted May 2004 Norris et al.10 to –0. Metab. 2). 2007 © NRC Canada 2007 / © Canadian Public Health Association 2007 A search of MEDLINE. control The effect of exercise is comparable to metformin and appears to be independent of changes in body mass. healthy diet and weight loss are effective in the prevention of type 2 diabetes Author Objective Abuissa et al. despite no change in body mass. Visceral adipose tissue reduced (2 studies): – 45. .

and the Cochrane Controlled Trials Register up to Dec 2000.32.Table A3 (continued).0004) Post-intervention standardized mean difference for VO2max was significantly associated with the weighted mean difference for HbA1c (r = –0. 2003 7 RCTs met the inclusion criteria (266 patients) The objective was to compare the effect of structured aerobic exercise with no exercise on the cardiorespiratory fitness of adults with type 2 diabetes HbA1c was reduced post-intervention in the exercise groups.66%. p < 0. Lung. this was supplemented by hand searches of selected journals. 2004 To assess dietary. Issue 2) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2004. there was considerable heterogeneity among studies Future research should examine optimal strategies for implementing dietary. p = 0. and behavioral weight loss/ weight control interventions for adults with type 2 diabetes Boule et al. Health Star. Web of Science. major textbooks. no studies that included drug cointerventions HbA1c lower in exercise vs. Biosis. ERIC. this was supplemented by hand searches of reference lists.04). suggesting greater glycaemic control with increasing VO2 max © NRC Canada 2007 / © Canadian Public Health Association 2007 Boule et al. control group. The Cochrane Library (2004. studies published in any language were eligible. HealthSTAR. Follow up ranged from 1–5 y 3 studies incorporating diet and physical activity observed reductions in HbA1c in the intervention vs. physical activity. PsychINFO. Methods 22 studies (4. control groups (0. the National Heart. most between group changes in this outcome variable were related to changes in weight and were not significant.001) Exercise training reduces HbA1c to an extent that is of clinical benefit to persons with type 2 diabetes S57 . weighted mean difference = 0. EMBASE. Searched MEDLINE.71 (95% CI: –1. National Health Centre for Reviews and Dissemination review (1997). reviews and consultation with experts in the area. CINAHL. Sport Discuss. 2001 To conduct a systematic review and quantification of the effect of exercise on HbA1c and body mass in patients with type 2 diabetes A search of MEDLINE. EMBASE.72. the last search was conducted in May 2004 A search of MEDLINE. Norris et al. Dissertation Abstracts.10 to –0. this was supplemented by searching reference lists from textbooks and identified articles Meta-analysis of 14 controlled clinical trials in type 2 dibetics & glycemic control. SPORTDiscus. and Nutrition Abstracts and Review. and Blood Institute 1998 Review and the University of York. Dissertation Abstracts and the Cochrane Controlled Trials Register was performed up to March 2002. Issue 2). physical activity and behavioural interventions in individuals with type 2 diabetes Participants Primary Results Main Findings/Conclusion Author Objective Warburton et al. experts in obesity research were also contacted for additional citations.659 participants) met the inclusion criteria. p = 0. EMBASE.

© NRC Canada 2007 / © Canadian Public Health Association 2007 . Fit men with a BMI of ‡27. high fitness = 3. 32(Suppl. RCT. M.Low fitness vs. 2007 Note: F. female. Nutr. male. length of followup.0 had a slightly lower incidence of type 2 diabetes than unfit men in the BMI<27. CI. ‘‘Physical Activity and Health: A Report of the Surgeon General’’ in combination with searches of databases. 2007 / Can. high density lipoprotein cholesterol. personal files and reference lists in identified published articles. BMI. confidence interval. cigarette smoking status. 2E). total cholesterol. glycosylated hemoglobin. alcohol intake. Methods Searched for papers identified in the 1996 publication. Adjusted odds ratio for the development of type 2 diabetes in men .S58 Table A3 (concluded). Public Health 98(Suppl. and change in fitness PA and fitness appear to confer some protection against the development of type 2 diabetes Participants Primary Results Main Findings/Conclusion Author Objective Blair and Brodney 1999 The review addressed 3 questions: Do higher levels of physical activity attenuate the increased health risk normally observed in overweight or obese individuals? Do obese but active individuals actually have a lower morbidity and mortality risk than normal weight persons who are sedentary? Which is a more important predictor of mortality. history of parental diabetes. Physiol.2. Adjusted for age. J. randomized controlled trial. triglycerides. Metab. more than 700 potentially relevant articles were identified with 24 meeting all inclusion criteria 24 articles met the inclusion criteria Active individuals (both M and F) had a lower incidence of type 2 diabetes than sedentary participants. HbA1c. overweight or inactivity? Appl. high blood pressure.0 group. 2).

4 (95% CI. –2. Fagard 1999 To examine the role of physical activity in the prevention and treatment of hypertension with particular attention to interactions with body mass Kelley 1999 732 adult women To examine the effects of aerobic exercise training on resting blood pressure in women Epidemiological findings: There is an inverse relationship between physical activity or fitness and the incidence of hypertension. appears to be effective for blood pressure reduction © NRC Canada 2007 / © Canadian Public Health Association 2007 A systematic review and metaanalysis of articles retrieved through a search of MEDLINE and SPORTdiscus up to September 2001 complemented with hand searches of reference lists Whelton. and Current Contents (articles published between January 1966 and January 1998) complemented with hand searches of reference lists 44 RCTs published prior to August 1998 Overall: systolic –3. –8. Selected reviews evaluating the relationship between physical activity and blood pressure. regardless of weight loss during the trial.7 to –1. 2002 To examine the effects of various characteristics of the exercise training program (in particular exercise intensity) on blood pressure in normotensive and hypertensive individuals. –10. Diastolic –1 (95% CI. To evaluate the effect of aerobic exercise on blood pressure 54 trials (34 reports including 2419 participants) met the inclusion criteria Systolic . diastolic – 1.6 (95% CI.Table A4. exercise appears to be more effective in persons of African and Asian descent S59 .8 (95% CI. 30–60 min/ d.4 (95% CI.8 (95% CI.3 mmHg).5 to –2. S. 2674 participants (65% were men) A meta-analysis of 10 RCTs retrieved through a search of MEDLINE.6 mmHg). –3.6 to –1.0 to –3. SPORTdiscus. normotensive.P.5 mmHg).6 mmHg) Training 3–5 d/week.4 (95% CI. Methods An analysis of epidemiological studies and 44 RCTs (68 study groups).3 mmHg).97 mmHg). diastolic –5. diastolic – 2.2 to –1. –2 to –1 mmHg) Aerobic exercise training results in small reductions in resting blood pressure in women. Participants Primary results Main findings/conclusion Author Objective Warburton et al.5 mmHg) Systolic –2 (95% CI. 68 study groups (52 with normotensive and 16 with hypertensive individuals). at moderate to vigorous intensity.84 (95% CI. et al. –1.1 mmHg). diastolic –2. systolic –7.72 to – 4. –3.5 to –4.Randomized Controlled Trials Overall: systolic –3.58 (95% CI.81 to –3. hypertensive. –4. Physical activity contributes to blood pressure control in overweight and lean individuals. 2674 participants (65% were men).5 to –2. systolic –2. this effect was either independent of body mass or more pronounced in the overweight. –3 to –1) mmHg.4 (95% CI.2 to –1. diastolic –2.3 mmHg). –2. –4. –3.35 mmHg) Aerobic exercise lowers blood pressure in hypertensive and normotensive participants. Fagard 2001 68 study groups.3.4 (95% CI.

4 (95% CI. EMBASE and CENTRAL (1998 to May 2003) and from previous guidelines and reviews (published prior to 1998) Hypertensive individuals should regulate their diet and participate in aerobic exercise. Appl.2 to –4.1 to –0. this was supplemented by a MEDLINE search up to December 2003 and a search of reference lists from published articles and review articles A systematic review and metaanalysis of articles retrieved through a search of MEDLINE. –0. 95% CI. 2E). –2. respectively Resting blood pressure was significantly reduced: Systolic: 3. 95% CI –1. 0.8. when weighted by the reciprocal of the variance of the blood pressure change.1 to +0. –6.0 to 4. more studies are needed to confirm the benefit. –2.0.7 to 3.0/2. magnesium or potassium supplements. –3. the change for systolic blood pressure was not significant.5 mmHg on average.7 mmHg) and –3. calcium. diastolic: 3. Nutr. 1. fish oil supplements (–2.9 mmHg). 2). 1.3 (95% CI. alcohol restriction (–3.2 mmHg but was not significant. 2. 2007 © NRC Canada 2007 / © Canadian Public Health Association 2007 Not described Fagard 2006 To describe the results of previous meta-analyses examining the effect of aerobic and resistance training on resting and ambulatory blood pressure Aerobic exercise: 72 trials (3936 participants. no significant effect on night time blood pressure. resistance training: systolic blood pressure was reduced 3. –7. 2007 / Can.0 to –7.0 mmHg).3.9 to 5. 2006 105 trials (6805 participants) met the inclusion criteria To evaluate the effectiveness of lifestyle interventions in the hypertensive population Studies were identified through a database of RCTs examining the effect of exercise on blood pressure.S60 Table A4 (continued). this appears to occur through a reduction in vascular resistance and favourably affects cardiovascular risk factors Dickinson et al. 95% CI.4 to –6.5 to –4. average age 20– 72 years) met the inclusion criteria Moderate-intensity resistance training is not contraindicated.1 mmHg). 95% CI. J. aerobic exercise (–4. however. 95% CI.1 to –1.3/3.9 to 5.4 mmHg on average. Methods A systematic review and metaanalysis of articles (up to December 2003) retrieved through a MEDLINE search complemented with hand searches of reference lists Nine RCTs (341 participants. 32(Suppl.8 mmHg). diastolic blood pressure was reduced 3. average age 21–83 years).3 mmHg) Aerobic exercise: resting blood pressure was reduced 3.6 mmHg). Metab. –8.1 mmHg).6. Resistance exercise: 9 trials (341 participants.4 mmHg). sodium restriction (–3.0 (95% CI. Public Health 98(Suppl.2 mmHg) There is a positive effect of exercise on blood pressure.5 (95% CI. particularly in the hypertensive population Participants Primary results Main findings/conclusion Author Objective Cornelissen and Fagard 2005a To review the literature for the effect of resistance training on resting blood pressure in sedentary adults Cornelissen and Fagard 2005b 72 trials (3936 participants.5 (95% CI.1 to –7.1 mmHg).4 to –1.5 mmHg The evidence suggests that aerobic endurance exercise reduces blood pressure.0 (95% CI. diet (–5. Physiol. average age 20– 72 years) Statistically significant reductions in systolic blood pressure were observed for interventions targeting. –10. ambulatory blood pressure was reduced 3. The evidence does not suggest a therapeutic effect of relaxation therapies.0 mmHg). respectively. both systolic and diastolic blood pressure were significantly reduced by –6. ambulatory blood pressure was significantly reduced: systolic: 3. average age 21– 83 years) met the inclusion criteria To review the effect of aerobic endurance exercise on resting and ambulatory blood pressure The weighted (by number of participants) changes for systolic and diastolic blood pressure were –3. diastolic: 2.2 (95% CI.6.7 (95% CI. there is fewer data available for resistance training but it also suggests a reduction in blood pressure with exercise .6 mmHg) and –4.

confidence interval. 17– 60 years) 10/15 studies demonstrated significant reductions in post-exercise stress-related BP responses in comparison with control. average reduction in post-exercise stress-related diastolic blood pressure of 3. complemented with hand searches of reference lists A total of 15 studies met the inclusion criteria (496 participants. absolute reduction in post-exercise stress-related systolic blood pressure of 3. Hamer 2006 To review the literature for the effect of acute aerobic exercise on stress-related blood pressure Note: RCT. CI. greater effects were observed with increasing does of exercise.7 mmHg. a significant effect was shown at a minimum dosage of 30 min at 50% VO2 max Most evidence suggests that there is a significant effect of an acute bout of aerobic exercise on stress-related blood pressure Participants Primary results Main findings/conclusion Author Objective Warburton et al.Table A4 (concluded). © NRC Canada 2007 / © Canadian Public Health Association 2007 S61 . randomized controlled trial.0±2.7±3. Methods A systematic review and metaanalysis of articles retrieved through a MEDLINE search.9 mmHg.

35%) difference in lumbar spine BMD between groups. Public Health 98(Suppl.5% (95% CI = 0. Selected reviews evaluating bone mineral density or bone mineral content and physical activity.96).and post-menopausal women Appl. Post-menopausal: endurance = 0. strength only = 0.6%).83±0.60 to–0.33 – 4.36 – 1.46% (95% CI. non-exercise = –2. non-exercise group. respectively.37)(p<0. combined exercise = 0. In the lumbar spine.29 – 1. respectively.49)(p<0.44 – 1. 2007 / Can.44 (95% CI –0.and post-menopausal women. impact exercise prevented bone loss at the femoral neck in post-menopausal women (1. January 1975 – December 1995 Meta-analysis of 10 prospective investigations.2% (95% CI = 0. running.and postmenopausal women.90 (95% CI 0.12–2. January 1975 – December 1994 Aerobic activity vs.48 – 0. Physiol.4%– 1. 719 post-menopausal women (370 exercise.65% (95% CI. Post-menopausal: endurance = 0.6%–2.50) (p<0.05).69% (95% CI –4. Nutr. 2007 © NRC Canada 2007 / © Canadian Public Health Association 2007 Wallace and Cumming 2000 Meta-analysis of 35 RCTs of impact (aerobic) and non-impact (resistance) training on lumbar spine and femoral neck in pre. impact exercise also appears to have a positive effect at the femoral neck . exercise = +0. aerobic and (or) strength training Vertebral column (L2–4) BMD = large ES (0. strength only = 0. similar findings in the lumbar spine in pre-menopausal women. Metab. –0. 1997 Meta-analysis of 18 prospective intervention trials evaluating healthy post-menopausal women between 1966 – 1996 Kelley 1998a Exercise programs in post-menopausal women (>50 year) are effective for preventing BMD loss of the vertebral column Exercise may slow the rate of bone loss in post-menopausal women Kelley 1998b Meta-analysis of 11 RCTs. impact and non-impact exercise prevented bone loss of 1.0%– 2.51) (p<0.0% (95% CI = 0. non-exercise group.89 (95% CI 0.91 (95% CI 0. Overall treatment effect (inverse variance weighting) at lumbar spine for RCTs: Pre-menopausal:endurance + strength training = 0. pre. and possibly in pre-menopausal women Both impact and non-impact exercise appear to have a positive effect on bone health at the lumbar spine in pre.05). 32(Suppl.4%) and 1.18 – 1.86 (95% CI –0.96 (95% CI 0.6 (95% CI = 1.05).7%).and postmenopausal women Aerobic and strength training effects on bone mineral density Aerobic training = +1.91).43 – 1. change in lumbar spine BMD Exercise helps maintain lumbar BMD in post-menopausal women Wolff et al.90 (95% CI 0.05).42) (p<0.05). 2 or more interventions compared with each other.58).12) regional BMD.7%–1. 1. 0. combined exercise = 0. 1. no effect seen on forearm and femoral bone mass Results Main findings/conclusion Author Participants Berard et al.6%).21). 1966 – December 1996 Endurance and (or) strength training.94 to – 1. Activity Moderate intensity programs of primarily walking. 138 non-exercise). physical conditioning and aerobics Exercise vs. change in BMD or BMC of lumbar spine & femoral neck RCTs reveal consistently that exercise training prevents or reverses the approximate 1% bone loss per year in both the lumbar spine and femoral neck for both pre. 349 non-exercise).8745. strength training = +0. in post-menopausal women. overall treatment effect (inverse variance weighting) at femoral neck RCTs: Pre-menopausal: endurance = 0.83) regional BMD 2.79 (95% CI 0. 330 post-menopausal women (192 exercise. 2).29 – 1.5±2. impact and nonimpact exercise programs prevented bone loss of 1. J.77% (95% CI.2%) and 1. 1999 Meta-analyses of 25 RCTs and controlled trials.35 – 1.05).05).62% (95% CI. p<0.32±2.22)(p<0.32 to 1.S62 Table A5. 2E).4%– 1.0% (95% CI = 0.

control group WMD: combined aerobic & weight bearing = +1.31±2.21 – 1.22% (95% CI.10% & control = 0.05). Bonaiuti et al. © NRC Canada 2007 / © Canadian Public Health Association 2007 S63 .74±7. –0. weighted mean difference. RCT. walking effective on BMD of spine = +1.97%. no statistically significant difference in either BMD found within or between groups (p>0.92% (95% CI. L. 0. walking is also of benefit for BMD in the hip Results Main findings/conclusion Author Participants Warburton et al. 3 walking studies. 9 aerobic studies. BMD.31% (95%CI.71 – 1. 69 control) Results do not support the effectiveness of resistance training for increasing or maintaining lumbar spine and femoral neck BMD in pre-menopausal women Note: BMC.79% (95% CI. Lumbar spine BMD: exercise = 0. lumbar.74).58 – 3. 0.Table A5 (concluded). WMD. and weightbearing exercise are all effective for increasing BMD in the spine of post-menopausal women.99% & control = 0. 143 pre-menopausal women (74 exercise. usual activity or placebo with or without drug consumption.64). effect size. randomized controlled trial. 0. & 1 weighted leg flexion study Resistance exercise on lumbar spine and femoral neck BMD vs.64±2. Activity Aerobic. 2002 Cochrane database of systematic reviews of 18 RCTs. only aerobic exercise increased BMD of wrist = 1. weight bearing. Aerobic.46±3. 4 resistance studies. 289 healthy post-menopausal women Kelley and Kelley 2004 Meta-analyses of individual patient data. bone mineral content. 1 repetitive back extension study.01).58%. bone mineral density. ES.65) & hip = +0. resistance. and resistance exercise efficacy on BMD of the spine (13 studies) or hip (8 studies) vs. femoral neck BMD: exercise = 0.03 – 2.

S64 Table A6.17 (Depressed).83 (Normals) & d = –1. aerobic exercise was more effective in those subjects who were clinically depressed Investigations are supportive of anti-depressant effects of exercise programs. more randomized controlled trials needed to demonstrate efficacy in clinical populations d = –1. most notable affects on clinical populations d = –0. Asymptomatic & symptomatic Asymptomatic Asymptomatic & symptomatic Asymptomatic Asymptomatic & symptomatic Asymptomatic & symptomatic Asymptomatic & symptomatic Meta-analysis Meta-analysis Narrative review Narrative review Narrative review Narrative review Narrative review Narrative review Meta-analysis Petruzzello et al. Population Symptomatic Asymptomatic & symptomatic Asymptomatic & symptomatic Meta-analysis Meta-analysis Narrative review Review method Conclusions Author Depression Martinsen 1990 North et al. Nutr. 2007 / Can. little evidence exists for PA dose response effects on depressive symptoms due to lack of studies Exercise reduces depression in both asymptomatic and symptomatic populations PA improves depressive symptoms. J. consistent PA may prevent onset of depression Anxiety Gleser and Mendelberg 1990 McDonald and Hodgdon 1991 Asymptomatic & symptomatic N. most + affects are among those who adhere to exercise regimes over several months Exercise has a moderate reducing effect on anxiety Acute & chronic exercise decrease anxiety in normal & clinical populations Exercise associated with increased SE.36 contrast group. sig.45 within group & d = 0. acute & chronic exercise effectively reduce clinical depression.25.72 Sufficient evidence exists for the effectiveness of exercise in the treatment of clinical depression PA associated with a decreased risk of developing clinical depression. d = –0. decrease in depression with aerobic exercise. short bursts of PA are efficient. aerobic & resistance exercise are effective in treating depression Studies suggest PA is –associated with depression.C. 1998 Craft and Landers 1998 Fox 1999 Mutrie 2000 O’Neal et al. Non-aerobic & aerobic exercise equally effective d = –0. mechanisms are not known PA has steadily been found to increase SE in diverse populations Appl. particularly in high-stress individuals PA + affects anxiety. PA – associated with clinical depression. aerobic & non-aerobic exercise are both effective d = –1.59. 2). 2007 © NRC Canada 2007 / © Canadian Public Health Association 2007 Global Self-Esteem (GSE) Sonstroem 1984 Gleser and Mendelberg 1990 . Physiol. Public Health 98(Suppl. 32(Suppl. exercise effective in reducing anxiety.25.1 when exercise compared with no treatment. 2001 Asymptomatic & symptomatic Asymptomatic & symptomatic Systematic review Narrative review Asymptomatic & symptomatic Systematic review Callaghan 2004 Penedo and Dahn 2005 Exercise association with anti-depressive effects in clinical patients. short term exercise is – associated with depressive symptoms. Selected reviews examining the relationship between physical activity and psychological well-being. high intensity aerobic exercise more than 20 min duration associated with reductions in anxiety d = 0. anxiety reducing effects only apparent for young/middle-aged male participants performing various types of exercise d = –0. 2000 Moderate to vigorous exercise is successful in reducing state anxiety d = –0. 1991 Long and Stavel 1995 Scully et al. effectiveness of exercise on clinical populations unknown due to poor quality research PA – associated with depressive symptoms. many methodological problems need to be addressed Evidence is + for relations between PA & depression. 2E).22. Metab. 1990 McDonald and Hodgdon 1991 Byrne and Byrne 1993 Asymptomatic & symptomatic Asymptomatic & symptomatic Symptomatic Asymptomatic & symptomatic Symptomatic Asymptomatic & symptomatic Asymptomatic & symptomatic Systematic review Narrative review Narrative review Narrative review Meta-analysis Narrative review Narrative review Asymptomatic & symptomatic Narrative review Weyerer and Kupfer 1994 Scully et al. 1998 Fox 1999 O’Connor et al. more specific research is necessary PA – associated with depression. 2000 Lawlor and Hopker 2001 Dunn et al.

2007 PA is associated with improvements with various aspects of HRQoL. 2003 Macera et al. general health perceptions & vitality Moderate association between PA & subjective well-being Individuals attaining recommended PA guidelines had higher overall HRQOL Review of studies supports the association between PA and health in diseased populations Cross-sectional association between moderate PA and general health perceptions. description of participant characteristics is not clear.C. 2005 Blacklock et al. 1999 Biddle 2000 Brown et al. variables most strongly associated were physical functioning.Warburton et al.C. exercise leads to small.C. 2004 Asymptomatic Asymptomatic Asymptomatic Correlational survey Narrative review Correlational survey Asymptomatic Correlational survey Penedo and Dahn 2005 Vuillemin et al.C. or health of the participants Research provides support for a + relationship between exercise & subjective wellbeing Exercise stage is associated with self-perceived quality of life. 2004 Lustyk et al. inconsistent & weak relationship between PA & SE Exercise can increase GSE particularly with initial low GSE individuals Weak relationship between PA & SE Inconsistent & weak relationship between PA & GSE d = 0.C. S65 . 2004 Brown et al.23. 1996 Asymptomatic & symptomatic Asymptomatic Asymptomatic & symptomatic Correlational survey Narrative review Narrative review Fox 1999 Laforge et al. Table A6 (concluded). Asymptomatic Symptomatic Narrative review Correlational survey Narrative review Wendel-Vos et al. activity status. N. Cross-sectional associations were found for physical components of QoL Moderate or vigorous PA is independently associated with higher levels of HRQoL. regardless of age. 2003 Asymptomatic Asymptomatic & symptomatic Correlational survey Correlational survey N. Population N. Asymptomatic & symptomatic Asymptomatic & symptomatic N. change in fitness necessary for increase in GSE to occur Author McDonald and Hodgdon 1991 Spence and Poon 1997 Fox 1999 Fox 2000a Fox 2000b Spence et al. participation in daily moderate or vigorous PA for very short or extended periods of time is associated with poorer HRQoL High frequency PA of mild intensity performed to improve health & fitness has the strongest influence on QoL Exercise & PA associated with better HRQOL. 2005 Generalized well-being Rejeski et al..22. but significant increases in GSE. weak relations between PA and overall happiness © NRC Canada 2007 / © Canadian Public Health Association 2007 Note: N. Asymptomatic & symptomatic Review method Meta-analysis Meta-analysis Narrative review Narrative review Narrative review Meta-analysis Conclusions Aerobic exercise leads to moderate changes in GSE d = 0. further research is needed Higher leisure time PA and meeting public health guidelines for PA was associated with higher HRQoL HRQoL is related to walking interventions and annual income.

N. 2004.W.J. 2001. Cornelissen. PMID: 10593541. and Brodney. Ment. Kenny. Sports Exerc.. PMID:10593538. Sports Exerc. Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials. 2006.J. [discussion S493–484. 1992. Exp. 31(Suppl. 11): S624–S630. S. Callaghan. PMID:10610081. Fagard. Pharmacol. Ann.M. Meta-analysis of the effectiveness of physical activity for the prevention of bone loss in postmenopausal women...R. and Sigal. V. Isr. Routledge. K. D. PMID:9373566.A.R. PMID:2144946. Fox. Rev. V. J. P.C. A. Hartling.04453. PMID:8410742. Brown. 33(Suppl. E. 5: 31–42.. J. doi:10. Hypertens. PMID:11559268. Kenny. S. K. Edited by S. Int.H. K. 2003. 2007 / Can. Boule. Exercise characteristics and the blood pressure response to dynamic physical training. anxiety and other mood states: a review. 46: 1071–1081. Hamer.. Routledge. Ford. F. K. P.1218. Exercise and sport in mental health: a review of the literature.. 1999..1097/00005768-200105001-01549. and McAlister. Clark.1097/00005768-199911001-00025. Metab. Opin. Hypertension. and Ford.. Sci. PMID: 14572437. G.G.. O’Keefe. R. Med.. Byrne. Biddle.1016/S0091-7435(03)00179-8. PMID:17570884.B. D. Wells. Dunn..00751. Med. Physical activity of adult Australians: epidemiological evidence and potential strategies for health gain. Meta-analysis: secondary prevention programs for patients with coronary artery disease. Pract. 1996. R. Med. Heath. Sports Exerc. J. doi:10. S. D. Cornelissen. G.S. How much physical activity should we do? The case for moderate amounts and intensities of physical activity. Med. 32(Suppl. PMID:11427783. 1990. PMID:11852614. Q. Boule. blood pressure-regulating mechanisms. F. PMID: 16157788. 2005a. 2). Iovine. Boutcher.H.. Res. Self-esteem. Associations between physical activity dose and health related quality of life. H. Sci. Haddad.H. Sports Exerc. 2000a.P. Med. A meta-analysis of physical activity in the prevention of coronary heart disease. Moriarty.H. Bravo.1440-1681. G. PMID:15662209. J. mood and physical activity. Relation of physical activity and cardiovascular fitness to coronary heart disease. Physical activity to prevent cardiovascular disease. Fox.P. and Mokdad.. A. 2000b.] doi:10. doi:10. PMID:2211073. Vandermeer. Associations between recommended levels of physical activity and health-related quality of life.R. Fox and S. The effects of exercise on self-preceptions and self-esteem. J. A.C. 2005.G. Effects of physical inactivity and obesity on morbidity and mortality: current evidence and research issues. L.1097/00005768-200106001-00027. 31: 411–418. Fox.. Lifestyle interventions to reduce raised blood pressure: a systematic review of randomized controlled trials. J. and Mendelberg. 2000b. 2000. and Connelly. and Jr. Fagard. G. and Gauthier.M.A. D. Med. Craft.R.2004. J.MSS. Robinson. 37: 565–574.W. 33(Suppl. Osteoporos. Sport. Blacklock. Exercise for preventing and treating osteoporosis in postmenopausal women. 2: 30–41.. Mason. Strategies to prevent type 2 diabetes. Exercise is good for your blood pressure: effects of endurance training and resistance training. M. et al. J.] doi:10.. Med. Med. PMID:11427774.. PMID: 12856082. R. D. Biddle... S. Sci. Sci. Dickinson.H. Res. Fam. D. 2001. V.A. doi:10. F. 286: 1218–1227. B. Exerc.. doi:10... PMID:16922820. Heath. J. Physical activity dose–response effects on outcomes of depression and anxiety.G. R. Negrini. Bel. Physician.S. G. L. and cardiovascular risk factors. Blair. Ottawa.0000184225. S. 2001. The anti-hypertensive effects of exercise: inte© NRC Canada 2007 / © Canadian Public Health Association 2007 .] doi:10. 1007/BF01623773. 2006.. Diabetologia. and Mokdad.. J. Exercise: a neglected intervention in mental health care? J. J. Am.. UK.1097/ 00005768-200106001-00018. 6): S587–S597.. Health. Int. Campbell. 2006. Giles. R. In press.. 1993. 2003. and Brown. Findings from the 2001 Behavioral Risk Factor Surveillance System (BRFSS) survey.H. and Fagard.G. A. [discussion 609–610.H.H. 11): S646– S662.x. Psychiatry Relat. S.. 2003.A. The influence of physical activity on mental wellbeing. 7: 331–337. (3): CD000333. Sci. E. doi:10. 2007 References Abuissa. A. H. 31(Suppl..1365-2850..1016/S14402440(99)80182-0.W. Physiol.. B. Phys.. K. 2E). Y. Board Fam. PMID:15255923. J. 2002. Berlin.. 48: 65–71. 77049.. Wells.O. C. Relationship between regular walking. Gleser. Balluz. 6): S484–S492..1001/jama. 36: 890–896. Nutr. PMID:10331474.H.. PMID:12137611.N. 24: 215– 233. and Owen. D. 6): S379–S399. J. 33: 853–856. G. Rhodes. doi:10.A.. and Fagard.1185/030079905X50606.H.1161/01. Bonaiuti. S. Boutcher. Psychosom. doi:10. 1998... Effect of resistance training on resting blood pressure: a meta-analysis of randomized controlled trials.x.M. G.H. A. R.R. 132: 612–628. In Physical activity and psychological well-being. Curr. [discussion S419–S320. A. Cook. Cochrane Database Syst.V. E.S. Intern. Physiol. Hypertens. D. J. 33(Suppl. N.1111/j. R. Psychiatr. Effects of endurance training on blood pressure. Williams. 2006. Haennel.. 2001. Sci. 1990. Sport.1007/s00125-003-1160-2. London. Is physical activity or physical fitness more important in defining health benefits? Med.10. L. W. PMID:1532879.A. Blair.J. 1997. J. Ford.. doi:10. PMID:16508562.A. Sport Psychol. doi:10. 67: 193–205. 2005. Haddad.E. R.76.1016/0022-3999(93)90050-P.0000126778. and Sigal. PMID:8835998.05629. and Landers.H. doi:10. Shea. Bauman.J. Brown. doi:10. G. J.J.H. doi:10.L. Blair. In Physical activity and psychological well-being.. Res. N..G. H. Public Health 98(Suppl.E.. R.. The effect of exercise on depression. J.. Beyer. physical activity and health-related quality of life. Med. 2002. and Colditz..1249/01.1097/ 00004872-200502000-00003. Edited by S. Activ. Physical activity in the prevention and treatment of hypertension in the obese. J. 2007.R. 2005b. UK. A. Kemper. Berard. JAMA.S66 Appl.N. 2004. doi:10... Sci.. 23: 251–259. Epidemiol. W. 20: 339–357.1111/j. and Holder. Exercise-based cardiac rehabilitation programs for coronary artery disease: a systematic clinical & economic review.H. B. Fagard. The effect of exercise on clinical depression and depression resulting from mental illness: a meta-analysis. N. R. 21: 1107–1114. 2(3a): 411–418. PMID:15126726.HYP. Health Nurs.A.51. D. 11: 476–483. Prev. 37: 520–528. Sports Exerc. F.L.J.. Public Health Nutr. PMID:16263889. Fox. G. self-perceptions and exercise.. H. 143: 659–672.. 1999. and S.. M.. Part I: a meta-analysis of the independent relation of physical activity and coronary heart disease. Eaton. Am.A. Emotion. E. 27: 99–112. Trivedi.286. Nicolson. PMID:16004680. 1999. L. Biddle. Giles. PMID:11427763.R. Cheng. H. and Lemire. Sport Exercise Psychol. Brown. Meta-analysis of the effect of structured exercise training on cardiorespiratory fitness in Type 2 diabetes mellitus. H.H. Sci. London. Clin.. Brown. How much is enough? Can.S. Sports Exerc.1097/00005768-19991100100022.S..G. 1999. R. and Byrne. and O’Neal. Balluz. 46: 667– 675.

H. 2001. Exercise-based rehabilitation for coronary heart disease. Phys. PMID:9475440.1046/j. O’Connor. N. J. PMID:15130258. 117: 762–774. The relationship betweeen physical activity and clinically defined depression. J.L.. S. Kelley. 2004. Effects of exercise training on anxiety: a meta-analysis. C. London. Obes. grating acute and chronic mechanisms.. excess adiposity and premature mortality. Taylor. F. 006. D. Soc. and motives. and Shinoda-Tagawa. S. Benefits of exercise for the treatment of depression.E. J. R. 26: 407–418. J. Thromb. Kubitz.. Appl.C. 2000. T. A. PMID:11427772. 2001.. B. Kohl. Monninkhof. PMID:14649376. J. 49: 122– 128. 7: 11–21.81. UK. N.pu. PMID:8775587. Physical activity in the prevention of cancer. G. Sports Exerc. [discussion S493–474.A. Ketola. Physical activity. Houde. B.C. 11: 143–182..D. Am.A.E.x.M. 46: 143–152.x. Long. Physical activity decreases cardiovascular disease risk in women: review and metaanalysis. and Aboul-Enein. PMID:16464120. T. Effect of exercise on depression. Vlems. Benjamin. Z. PMID:11427773. X. L. PMID:1828608.. Am. Efficacy of resistance exercise on lumbar spine and femoral neck bone mineral density in premenopausal women: a meta-analysis of individual patient data.] doi:10.A.. G. PMID:3555525.. PMID:9482383.V.2165/00007256-200636020-00002. Schmid.W.D.Warburton et al.36. doi:10. E. 1998a.. 28: 349–360. Opin. G.Y. and van Leeuwen. Y.A. The effectiveness of exercise as an intervention in the management of depression: Systematic review and meta-regression analysis of randomized controlled trials.. intensity. doi:10. 1990. 7: 167–189. 28: 264–275.M. Bowman.Janssen. PMID:16629509. 43: 121–138.A. D. 28: 126–139.C.1365-2648. 2004.. A systematic review of potential mechanisms. PMID:12853893. doi:10.Y. R. Behav. Sport Psychol. Sports Exerc. Dan..ATV. Sport Psychol.001345. 36: 162–172. North. © NRC Canada 2007 / © Canadian Public Health Association 2007 . PMID:10090864.. K. and VuTran.050187.1016/j. Katzmarzyk.H.M. Epidemiology. 2001. J. Dose response between total volume of physical activity and health and fitness. Bowman. Med... and Hopker.M. 2000. Exerc.1097/01. doi:10. Kelley. Rossi.C. Am.08.O... Med. Ann. doi:10. PMID:11427767. Kelley. doi:10.3. Gregg. H.] doi:10.0417. Thompson.R. Womens Health.. D. Physical activity and colon cancer. J. Oja. Sports Exerc. J.. McCullagh. Rev. Am. L. Schuit. J. Sports Med.1097/ 00002060-199801000-00018.1097/00005768200106001-00011. Gregg. Kelley. Norris. P. J. Cancer Prev. 2005.amepre. Prev.2002. Rev. Med. M.M. J. 1995. 38: 219–234. P. Long-term effectiveness of weight-loss interventions in adults with pre-diabetes A review. Physical activity and health: dose–response issues. Oguma. Levesque.. 36: 109– 116. PMID:17130685. K.J. 9: 380–389. K.G. Mutrie.3200/BMED.T. E..S. Med.I.P. 6): S459–S471. Paffenbarger.02. D. Med.amjmed. Sesso..1046/j. Major public health benefits of physical activity.1016/j. Physical activity and cardiovascular disease: evidence for a dose response. (1): CD001800.. Berra..J. 32: 239–251. 18: 379–415. 1249/00003677-199001000-00016. Psychiatry. Rev.E.J.. A. I.. 6): S472–S483.. Raglin.. PMID:16639173. Geriatr. A. Sport. PMID:15541326. Evidence-based guidelines for cardiovascular disease prevention in women. and Lau.1146/annurev. Sci. Biol. K. PMID:15816315. 2005. Fox and S. Prev.I. Elias. and Ebrahim. P.. and Gotzsche. pp. J. Petruzzello. American Heart Association scientific statement. Prochaska. Stage of regular exercise and health-related quality of life. Rehabil. doi:10. Springer.L..10907. D. S. L. 1990. J. 66: 313–317.30. Effectiveness of individual lifestyle interventions in reducing cardiovascular disease and risk factors.. PMID:12055109.. Arthritis Rheum. 3rd. H. W. and Lee. Bull. S. Fabunmi.. I. 24: e29–e50. R. I. Landers.andArdern.1998. Sci..A. Lustyk. Routledge. 2004. 1136/bjsm.P.1016/ j.. 2006. Rees. and Melillo..024. J. doi:10. Quadrilatero. Sipila.2004. Physical activity and the incidence of coronary heart disease. 4: 257–290. Exerc.. J. Phys. 6): S428–S437. Mosca.1097/ 00005768-200105001-01015.] doi:10. K. M. Velicer. Med. Kruk.. 1995. and Salazar. Hatfield. 2002. W. J. F. 2004. Sports Med. doi:10.08. J. K. doi:10. and McHorney. [discussion S493–454. PMID:2141567. J.3. Zhang.C.2003. 46–62. volume. Physical activity for secondary prevention of disease. M.. Sport Sci. van der Tweel. C. Hootman.C. A. Karmisholt. doi:10. J. S. 2003. Chandra-Strobos.L.0000114834.. Am.. R. 33(Suppl.1006/pmed. Aerobic exercise and resting blood pressure among women: a meta-analysis. Caspersen.. Voskuil. Appel. 2005. J.. 2000. Edited by S. PMID:11279730. K. Pate... Exercise and regional bone mineral density in postmenopausal women: a meta-analytic review of randomized trials. Curr.. Prev. Penedo. and Martinsen. and Hoffman-Goetz. 77: 76–87. J.2003.. C..1161/01. Lawlor... 2004. Oldridge. E. Norris. Sports Med. J. 33(Suppl. 2003. 8: 253–287. 1991.amepre.Physicalinactivity. doi:10. B.W.S. Serdula. P. 1999. [discussion S452–423. doi:10.2004. and Martinsen. Cochrane Database Syst. and Hodgdon. 2007. D. Macera. Q. 31: 136–155. Sport Psychol. Lee. Physical activity and breast cancer: a systematic review.J.R. Dunn. and Kelley.. F.. PMID:16009053. J. PMID:2192427. Martinsen. E. 1097/00005768-200106001-00016. doi:10. and Kendrick. Exercise and well-being: a review of mental and physical health benefits associated with physical activity. Physical activity and quality of life: assessing the influence of activity frequency. Med. Arterioscler.A..R. Widman. Med. Nurs. Boutcher. and Dahn. et al. Vasc.. Biddle. J. A meta-analysis on the anxiety-reducing effects of acute and chronic exercise. X.J. and Makela..D. 18: 137–157. 1987. 2000.05. et al.1097/ 00001504-200503000-00013.A. Psychological effects of S67 aerobic fitness training: research and theory. Adv. Annu Rev Public Health.1467-789X. 2001. Med.W..1006/pmed... Sports Med. Aerobic exercise and lumbar spine bone mineral density in postmenopausal women: a meta-analysis. Int.02172. P. Thompson.K. Paschane.F. Avenell.. PMID:11972658.W. New York.124-132. Y. H.162. 33(Suppl. E..1998.S. Systematic reviews of randomised clinical trials.G. Avenell.G. doi:10. E. Int.007. McDonald. Powell.J. Res. N. 18: 189–193.. Physical activity and all-cause mortality: what is the dose–response relation? Med.. doi:10.ede.75581. and Olson.S. 1991. PMID:15626569. 1999... R.A. 30: 124–131. J.0000251167.H. P.A. 32: 21–28. anxiety and anxiety disorders.W... O’Neal. N.J. 2002. H.D.85476. and Stavel. E. S. L.. K. Depression and exercise.A. B. Br. Med. PMID:10852140. Cardiovascular health and physical activity in older adults: an integrative review of research methodology and results. 2004. Laforge.A. PMID:12579603. A. R.. Physical activity and all cause mortality in women: a review of the evidence.. 1998b. Prev. Sports Med. doi:10.. Med. In Physical activity and psychological well-being..S. C. Zhang.J. 52: 90–94. and Skerrett. R. 2001.98. PMID:15003974. Fitness.. E. G. 31: 110–135. Long-term effectiveness of lifestyle and behavioral weight loss interventions in adults with type 2 diabetes: a meta-analysis. Oguma.J. Sci.0429. PMID:15165657. S. Jolliffe. Asian Pac.00120. K. and Sniezek. PMID:10072745. 13: 293–300.S. Jr. BMJ.1002/art.

2005.. K. PMID:11427764. R. F. Sport Sci. J. Graham. The effect of physical activity on self-concept: a meta-analysis. G.G. 3CD002968. S. K. Colorectal Dis. and Poon...33.0000021313. J. A. 13: 667–677. 2). van Croonenborg.C.S. Shephard. © NRC Canada 2007 / © Canadian Public Health Association 2007 .1097/ 00005768-200106001-00008. Calcif. J.S. A..J. J. J. 7: 204–213. P. Systematic review of randomized trials of the effect of exercise on bone mass in preand postmenopausal women. 51397. [discussion S419–420.. Med. 17: 108–116. 24: 71–108.. Wallace. Sci. Brawley.. Wendel-Vos. Cochrane Database Syst. and Kromhout. 6): S400–S418.. C. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized.R.amjmed.1249/00003677-198401000-00007. Wannamethee. Brown. Guillemin. Med. Physical exercise and psychological well being: a critical review. H. W. Sport Sci.01. Rees. Schuit.M.J.. 136: 493–503. Tijhuis.01.051351. doi:10. doi:10. A meta-analysis of the association of physical activity with reduced risk of colorectal cancer.G. PMID: 8744247. 6): S530–S550.00747.] doi:10. Med. 32(Suppl.. PMID:10367023. Rev. 1994. J. Exerc. 2004.G. Physical activity in the prevention of cardiovascular disease: an epidemiological perspective. doi:10. Leisure-time physical activity and health-related quality of life. 1999. Williams. I.J. PMID:15859955. Ann.. J..1503/cmaj. Meade. PMID:8171221. Physiol. Qual. Sports Med.J. 33(Suppl.K. doi:10. Exercise and self-esteem. M. J.1016/j. Oppert..W..R. and Chapman.G. R. R. 27: 311–334. Noorani.1007/s00223001089. Sports Med. Spence. Kemper. Whelton.2005. A.1016/j. PMID:8178213. and Twisk.009. Sports Exerc. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. R. A. Taylor. D.x.S.A.. doi:10... J. Absolute versus relative intensity of physical activity in a dose–response context.R. doi:10. 2001. PMID:11227978.. PMID: 15917053. all sites and site-specific. Marshall.] doi:10. T. Int. E.2004... doi:10. Physical activity and health-related quality of life.1249/00003677-199600240-00005. PMID: 11427781. 2001.A. and Dudgeon. and Bredin. Warburton. D. 9: 1–12. Exerc. K. 67: 10–18. W.. P. Med. PMID:11926784. and Poon.. Intern.. Bertrais. PMID:10908406. [discussion S609– 510. Sports Med. 33: 754–761. J. 2006. J. S. 31: 101–114. PMID:9631216.C. S. 2007 Rejeski. Nicol. PMID:11323544.. and Furberg.T. 2001. Med. doi:10. 87: 567–574.. Sci. McGannon. Sonstroem.ypmed. M. Hereberg. Vuillemin. Exercise for type 2 diabetes mellitus.1111/j. D.. and He. S. Br. Taylor. 32: 111–120..E. Weyerer. Med. 1994. Nutr. Spence. S. 12: 123–155.J. doi:10. 2004.. Am.. 2005. PMID:6376132. J. 1984. Update..A. Thomas. A. Alberta Centre Well-Being Res. Public Health 98(Suppl. 2005. Kremer.. S.. and Kupfer. 33(Suppl. Med. Rev.J.. 2006. and Cumming. Chin. et al. controlled trials.. Life Res.. Sport Exercise Psychol. The effect of exercise on global self-esteem: A quantitative review. Leisure time physical activity and health-related quality of life: cross-sectional and longitudinal associations.. Med. S. Osteoporos. 1007/s001980050109. Samad. R. Health benefits of physical activity: the evidence. Sci. X. J. A.. Sports Exerc. 1996. Thompson. 174: 801–809. Metab. Rev. Physical fitness and activity as separate heart disease risk factors: a meta-analysis. D.C. A. 2007 / Can. S. 2000. and Briancon. PMID:15130029. Sports Exerc. The effect of exercise training programs on bone mass: a meta-analysis of published controlled trials in preand postmenopausal women. 2E).. Physical activity and cancer risk: dose–response and cancer.006. I. S. Assoc. Ebrahim.1463-1318..A. Tissue Int.J. and Shumaker. P.. Prev.. B. Elliott. L. Wolff. 1997. H. S. Xin. P.1097/00005768-200106001-00025. and Shaper. Boini. B..2165/00007256200131020-00003. 41: 562–569. and Naughton.S68 Appl. J. 2002.P.1023/B:QURE. Jolliffe. Scully.. PMID:15121495. 116: 682–692.A.. Thune. 2001. 1998. Can. G. S.W.S. Physical exercise and psychological health. Exercise and health: fact or hype? South. Kostense.E.C. M. R. doi:10. 2005. Tessier. 4: 4.