Physical Activity and the Risk

of Disease

Hardman AE, Stensel DJ. Physical Activity and Health: Routledge, 2009.
 Cardiovascular disease

• CVDs are a major cause of mortality and morbidity in developed countries and
their prevalence is increasing in developing countries.

• Coronary heart disease (CHD) (the cardiovascular disease (CVD) with the highest
prevalence) is largely due to environmental influences.

• Genetic predisposition also plays a role.

• Atherosclerosis is the major cause of CVD. It has a long clinical history and may be
well progressed before symptoms occur.
 CATEGORIES OF CVD
• Hypertension (high blood pressure).

• CHD : this category includes angina and myocardial infarction (heart attack).

• Cerebrovascular disease (stroke): this can be due to the formation of a thrombus (blood clot), that is,
a thromboembolytic or ischemic stroke, or to a bleed into the brain, that is, a haemorrhagic stroke.

• Peripheral vascular disease: this is a narrowing of peripheral arteries which compromises blood flow.
This most often affects the femoral artery, causing pain on walking.

• Heart failure: the heart is unable to pump blood forward at a rate sufficient to meet the metabolic
demands of the body, usually because of impaired left ventricular function.

• Rheumatic heart disease: the valves of the heart are damaged, impairing its capability to control the
direction of blood flow.

• Cardiomyopathies: disorders that occur due to major structural abnormalities of the myocardium.
• Evidence that inactivity and low fitness are strong risk factors for CHD is
compelling. Both confer an increase in risk similar to that associated with
smoking, hypertension and high blood cholesterol.

• There are many mechanisms by which physical activity may modify CVD risk,
including beneficial effects on lipoprotein metabolism, blood pressure and
endothelial function.
Age-adjusted relative
risk of CHD in US
men enrolled in the
Health Professionals
Follow-up Study
Major risk factors for cardiovascular disease
 High-density lipoprotein (HDL) cholesterol concentrations
(mmol per l) in seven groups of individuals characterized by
widely different habitual physical activity levels.
The percentage narrowing (reduction in cross-sectional area) in
the coronary arteries of sedentary and physically
active monkeys consuming an atherogenic diet.
Blood pressure classification for adults aged 18
and older
New Guidelines

https://www.health.harvard.edu/heart-health/reading-the-new-blood-pressure-guidelines
Choosing

• Select a monitor that goes around your upper arm. Wrist and finger
monitors are not as precise.
• Select an automated monitor, which has a cuff that inflates itself.
• Look for a digital readout that is large and bright enough to see
clearly.
• Consider a monitor that also plugs into your smartphone to transfer
the readings to an app, which then creates a graph of your progress.
Some devices can send readings wirelessly to your phone.

https://www.health.harvard.edu/heart-health/reading-the-new-blood-pressure-guidelines
Using

• Avoid caffeinated or alcoholic beverages 30 minutes beforehand.

• Sit quietly for five minutes with your back supported and your legs
uncrossed.
• Support your arm so your elbow is at or near heart level.
• Wrap the cuff over bare skin.
• Don't talk during the measurement.
• Leave the deflated cuff in place, wait a minute, then take a second reading.
If the readings are close, average them. If not, repeat again and average the
three readings.
• Keep a record of your blood pressure readings, including the time of day.

https://www.health.harvard.edu/heart-health/reading-the-new-blood-pressure-guidelines
Resting arterial blood pressure values in untreated patients with
hypertension. All subjects completed
three, four week trials in a random order
• There is strong evidence supporting the effectiveness of physical activity as a
central component of cardiac rehabilitation programs. Exercise training may be
particularly effective in this regard because it enhances myocardial perfusion and
hence oxygen delivery to the heart.

• Exercise is beneficial for reducing the symptoms of claudication and heart failure
and may help to lower blood pressure in hypertensive individuals.
 Diabetes
• Chronic Illness
• Among top 10 causes of death

• Type 2 diabetes increases the risk of CVD, which is a major cause of

premature mortality in those afflicted with type 2 diabetes.

• The prevalence of type 2 diabetes is increasing in many countries and

this appears to be linked to increases in the prevalence of obesity – a
major risk factor for type 2 diabetes.
Diabetes Types 1 and 2 Compared
Percentage of cases
Age of Onset
Body cells
Insulin shots required
Natural insulin secretion
Pancreatic function
Severity of symptoms
Insulin-dependent diabetes
Type 1 Diabetes
5-10%
Childhood or mid-life, <30yrs
Responsive to insulin action
Always
Pancreas makes too little or none
Insulin-producing cells impaired
or nonfunctional: destruction of
pancreatic beta cells
Relatively severe, many are
apparent on diagnosis:
autoimmune disease, viral
infections
Juvenile-onset diabetes
mellitus (IDDM)
Type 2 Diabetes
90-95%
Adulthood, >45yrs
Resistant to insulin action
Sometimes
Varies: normal, increased or
decreased
Insulin producing cells normal
Relatively mild; few or one may be
present on diagnosis:
overweight/obesity, heart
disease, hypertension,
hyperlipidemia
Insulin resistance
Adult-onset diabetes
Non-insulin-dependent
diabetes mellitus (IDDM)
Prediabetes
• Fasting Blood Glucose FBG slightly higher than
normal

• FBG test: measure BG after 8h fasting

• HbA1C test: non fasting, measure % glycated
hemoglobin, reflects blood glucose control for
past few month
• For type 2 DB
Prediabetes Diabetes
Fasting plasma glucose 100-125 mg/dl ≥126 mg/dl
HbA1C 5.7-6.4% ≥6.5%
 Prevention
 Healthy body weight
 Nutritious eating pattern
 Regular physical activity
Managing Diabetes: MNT
• Controlling CHO
• quantities and timing
• Adequate in Fiber
• Low in added sugars and alcohol
• Low in saturated fat
• Adequate but not too high proteins
• Regular physical activity
Multivariate relative risk of developing type 2 diabetes
according to physical activity levels in women with and
without a parental history of diabetes.
T2D and PA
• Lifestyle intervention programs are effective in preventing type 2 diabetes

• Exercise promotes a variety of metabolic responses and adaptations which

collectively improve glucose tolerance and insulin sensitivity.

• Among individuals with type 2 diabetes, high levels of physical activity and
physical fitness are associated with a reduced risk of CVD and all-cause mortality.

• Exercise training reduces HbA1c concentrations in people with type 2 diabetes,

indicating improved glycaemic control and confirming the importance of exercise
as a therapy for type 2 diabetes.
Physical Activity & Diabetes II
Improves glucose
tolerance

Improves insulin
action
In persons with
Exercise training
diabetes type 2: Improves
cardiovascular
fitness

Improves blood
lipid profiles
 Obesity
Classification of overweight and obesity by BMI, waist circumference, and associated
disease risk (i.e. type 2 diabetes, hypertension and cardiovascular disease)
• Obesity is defined as an excess of body fat to the point that health is
endangered.

• Obesity is most commonly determined using the body mass index,

with a value of 30 kg m2 or more representing obesity. Elevated waist
circumference is another useful marker for obesity.

• Obesity develops due to an imbalance between energy intake and

energy expenditure. Genes appear to play a major role in determining
an individual’s susceptibility to obesity
Prevalence of obesity (BMI >30 kg m2) among adults (aged 16–
64 years) in England between 1986/7 and 2004.
Association between time spent walking or cycling to work and the risk of
obesity (BMI >30 kg m2) in Finnish men and women
Time allocation for different postures for ten obese and ten lean
sedentary subjects.
Temporal trends in diet (left) and activity (right) in relation to
obesity in Britain.
Relationship between weekly exercise duration and weight loss in 148
overweight and obese women participating in an 18-month weight-
control program
 Influence of prior exercise on postprandial responses of plasma
triglycerides (top panel) and insulin (bottom panel) in lean men (left
panel) and centrally obese men (right panel)
• Obesity, particularly severe obesity, increases the risk of premature
mortality, type 2 diabetes, CVD, some forms of cancer and
osteoarthritis. The extent to which overweight increases the risk of
these outcomes is less certain.
• Exercise can be effective in the management of obesity, particularly for those
with mild obesity. Exercise is most effective when combined with diet. Weight
regain is common among those who have lost weight through diet and exercise,
but long-term maintenance of weight loss is possible in highly motivated
individuals who maintain healthy dietary and exercise habits.

• Recommendations suggest that 45–60 minutes of exercise per day is required to

prevent obesity and 60–90 minutes of exercise per day is required to prevent
weight regain in formerly obese individuals, but there will be individual variation
in the response to these doses of exercise.
 The metabolic syndrome
• The metabolic syndrome is the name given to a cluster of risk factors for
CVD. Physical inactivity, obesity and genetic make-up probably interact
with dietary factors to explain its high prevalence.

• Its importance is that it helps to identify individuals who are at high risk
of type 2 diabetes and CVD.
Criteria definitions of Metabolic Syndrome
According to ATP-III
if > 3 of these criteria:
- abdominal obesity if waistline
man > 102 cm
Woman > 88 cm
•Blood pressure > 130 / > 85 mmHg
• Fasting blood glucose > 6.1 mmol / l
• triglycerides > 1.7 mmol / l

• HDL-chol
man <1.04 mmol / l
woman <1.3 mmol / l

JAMA 2001; 285: 2486-9

Rdar / Oct04
Incidence of metabolic syndrome according to category of
cardiorespiratory fitness in men and women
PA and MS
• Physical inactivity, low fitness and sedentary behaviors are associated
with increased prevalence of the metabolic syndrome in cross-
sectional and prospective studies.

• Lipid and non-lipid disturbances during the postprandial period are

important abnormalities that are attenuated by physical activity.

• Prevention
Cancer
• Cancer is a major cause of morbidity and mortality. Over half of
cancer deaths are accounted for by cancers of the lung, breast, large
bowel and prostate. Risk factors vary by tumor site.

• Carcinogenesis involves disruption of the orderly fashion in which

normal body cells grow, divide and die.
Relative risk of colon cancer according to level of leisure-time
physical activity in the US Nurses’ Health Study
MET-h week–1
• Question – the median value for nurses in the top quintile for walking
was 20 MET-h week–1 (Manson et al. 1999). For how many hours did
they walk?

• Answer – walking at a ‘normal’ speed of 4.8 km h–1 demands 3.5

METs. So, walking for one hour at this speed gives 3.5 MET-h and 20
MET-h week–1 means walking for 5.7 hours during a week, covering
27.4 km (17 miles).
• Increasing levels of physical activity are associated with reductions in
the risk of several site-specific cancers.

• At least 30–60 minutes per day of moderate to vigorous activity may

be needed for optimal reduction in risk of cancers of the colon and
breast.
 Skeletal Health
• Bone is a dynamic tissue that responds to changes
in the internal or external environment. Functional
loading is the most important influence on bone
remodeling.

• Strain rate and an unusual strain distribution are

important determinants of the site-specific
osteogenic effects of mechanical loading.
• The potential of exercise to augment bone mineral in the mature
skeleton is clear but small. In premenopausal women its effect is
mainly conservation of bone, although specific bone-loading exercise
can lead to modest bone accrual. In older women its effect is to reduce
the rate of bone loss.

• Women with a physically active lifestyle, including walking for exercise,

have a lower risk of osteoporotic fracture of the hip and maybe of the
spine.
• Many fractures are caused by falls. Exercise can decrease the risk of
falls through improving balance, strength and maybe neuromuscular
coordination.

• Participation in sports involving high-intensity impacts or torsional

types of stress increases the risk for osteoarthritis. On the other hand,
moderate amounts and intensities of exercise have a favorable effect
on pain and function in patients with osteoarthritis of the knee.
Schematic representation of changes in BMD over the life-span
RISK FACTORS FOR PRIMARY OSTEOPOROSIS
Side-to-side differences of bone variables at the humeral shaft of female
tennis and squash players, according to
age of starting training, and age-matched controls
 Recommendations
Recommended level of physical activity:
For adults: at least 150 minutes (2 ½
hours) per week of moderate-intensity
activity (in bouts of 10 minutes or more).
E.g: 30 minutes on at least 5 days a week.

For Children and young people: at least 60

mins of moderate- to vigorous-intensity
physical activity every day.
 Mifflin equation: (REE calculation)
• Males: REE = 10 x weight (kg) +6.25 x height (cm) – 5 x age (y) + 5

• Females: REE = 10 x weight (kg) + 6.25 x height (cm) – 5 x age (y) –

161

Mifflin, M. D., S. T. St Jeor, et al. (1990). "A new predictive equation for resting energy expenditure
in healthy individuals." Am J Clin Nutr 51(2): 24 1-247
 TDEE calculation

• TEE = REE x AF (study or population-specific activity factor)

Black, A. E., W. A. Coward, et al. (1996). "Human energy expenditure in affluent societies: an analysis
of 574 doubly-labelled water measurements."Eur J Clin Nutr 50:72-92
 Recommendations
• A PAL of ~1.75 (~60-90min per day of PA) is recommended to prevent
age-related weight gain
• PAL = Total Energy Expenditure (TEE)/ Basal Metabolic Rate (BMR)
 Recommendations
• Treatment of Obesity
• Early studies  PA alone without caloric restrictions was not a useful
strategy for weight loss (obesity treatment)
• Later studies  Weight loss is positively related to the volume of PA
performed
•  Recommendation: 200-300 min PA/week or 50 min/day to lose
0.5kg per week for overweight & obese people