JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 72, NO.

14, 2018

ª 2018 PUBLISHED BY ELSEVIER ON BEHALF OF THE

AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

JACC FOCUS SEMINAR: CV HEALTH PROMOTION

JACC FOCUS SEMINAR

Promoting Physical Activity and Exercise

JACC Health Promotion Series

Gerald F. Fletcher, MD,a Carolyn Landolfo, MD,a Josef Niebauer, MD, PHD, MBA,b Cemal Ozemek, PHD,c
Ross Arena, PHD, PT,c Carl J. Lavie, MDd

ABSTRACT

Physical inactivity is one of the leading modifiable risk factors for global mortality, with an estimated 20% to 30%
increased risk of death compared with those who are physically active. The “behavior” of physical activity (PA) is
multifactorial, including social, environmental, psychological, and genetic factors. Abundant scientific evidence has
demonstrated that physically active people of all age groups and ethnicities have higher levels of cardiorespiratory
fitness, health, and wellness, and a lower risk for developing several chronic medical illnesses, including cardiovascular
disease, compared with those who are physically inactive. Although more intense and longer durations of PA correlate
directly with improved outcomes, even small amounts of PA provide protective health benefits. In this state-of-the-art
review, the authors focus on “healthy PA” with the emphasis on the pathophysiological effects of physical inactivity and
PA on the cardiovascular system, mechanistic/triggering factors, the role of preventive actions through personal,
education/environment, and societal/authoritative factors, as well as factors to provide guidance for caregivers of health
promotion regarding PA. Sustainable and comprehensive programs to increase PA among all individuals need to
be developed and implemented at local, regional, national, and international levels to effect positive changes
and improve global health, especially the reduction of cardiovascular disease. (J Am Coll Cardiol 2018;72:1622–39)
© 2018 Published by Elsevier on behalf of the American College of Cardiology Foundation.

C ardiovascular (CV) disease (CVD) remains

the leading cause of death in the United
States and across most of the Westernized
World. Even though the American Heart Association
(AHA) and the American College of Sports Medicine,
among other leading organizations, have emphasized
sedentary behavior (SB) and physical inactivity (PI) as
major modifiable risk factors, a substantial percent-
age of the United States and world’s population
have low or very low levels of physical activity (PA)
(1–3). Certainly, increasing levels of PA and aerobic
exercise to increase levels of cardiorespiratory fitness
(CRF) are needed in the United States and worldwide
to reduce chronic diseases, especially CVD (4–7).
As recently reviewed in the Journal (8), a major
emphasis is making “Health Promotion a Priority”
with an 8-part seminar series on the behavioral fac-
tors that impact CV health, including the importance
of SB/PI and increasing levels of PA/exercise. In this
state-of-the-art review, we focus on PA/exercise and
CRF, with the emphasis on the pathophysiological
effects of SB/PI on the CV system and the benefits of
PA/exercise, mechanistic/triggering factors for PI, the
role of preventative actions to improve PA/exercise/
CRF, as well as factors to promote guidance to care-
givers of health promotion to promote and increase
PA and reduce SB/PI in efforts to reduce chronic dis-
eases, especially CVD (Central Illustration) (9).

Listen to this manuscript’s

audio summary by
JACC Editor-in-Chief
Dr. Valentin Fuster.
From the aDepartment of Cardiovascular Diseases, Mayo Clinic Florida, Jacksonville, Florida; bUniversitätsinstitut für Präventive
und Rehabilitative Sportmedizin, Institut für Sportmedizin des Landes Salzburg, Sportmedizin des Olympiazentrums Salzburg-
Rif, Salzburg, Austria; cDepartment of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago,
Chicago, Illinois; and the dDepartment of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute Ochsner Clinical
School–The University of Queensland School of Medicine, New Orleans, Louisiana. The authors have reported that they have no
relationships relevant to the contents of this paper to disclose.

Manuscript received August 17, 2018; accepted August 21, 2018.

ISSN 0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2018.08.2141

JACC VOL. 72, NO. 14, 2018
OCTOBER 2, 2018:1622–39
DEFINING PI AND PA
Typically, PA is defined as bodily movement pro-
duced by skeletal muscle contraction that requires
energy expenditure above basal levels. It includes
activities related to activities of daily life, such as
housekeeping, yardwork, occupational-related, lei-
sure-related, and transportation (e.g., walking/biking
to and from work/school). Exercise typically is
differentiated from PA in that it is typically planned,
repetitive, and structured with the main objective of
improving health and fitness. Physical fitness is a
state of good health and strength achieved through
PA and exercise, and includes both CRF, which is
generally emphasized, as well as muscular strength
and muscular fitness. Presently, PI defines at least 1
of every 5 adults worldwide (10) with an increased
prevalence in more developed countries, among
women, the elderly, and those with lower socioeco-
nomic status. Furthermore, time spent in SB (e.g.,
sitting in front of a computer, viewing television,
and so on) occupies approximately 54.9% of time
(7.7 h/day) (11,12). Clearly, PI is extremely prevalent
in the United States, where the percentage of SB has
increased from 55% (2003 to 2004) to 58% (2005 to
2006) in recent years (13). On the basis of the 2008
Physical Activity Guidelines for Americans, which
advocate for 150 min of moderate-intensity PA or
75 min of vigorous PA weekly, 56.5% of respondents
to the National Health Survey in 2008 did not meet
these criteria (14).
ADVERSE HEALTH EFFECTS
ASSOCIATED WITH PI
Several large studies have demonstrated adverse
health effects, including increased mortality, associ-
ated with PI/SB/prolonged sitting. A study published
in the Lancet in 2012 found that world-wide, PI
accounted for 9% (range 5.1% to 12.5%) of premature
mortality worldwide and that elimination of PI could
increase the life expectancy of the world population
by 0.68 (range 0.41 to 0.95) years (15). In addition to
mortality, PI was found to be independently respon-
sible for several chronic diseases, including 6% (range
3.2% to 8%) of coronary heart disease (CHD), 7%
(range 3.9% to 9.6%) of type II diabetes mellitus
(T2DM), 10% (range 5.6% to 14.1%) of breast cancer
and considerable risk (range 5.7% to 13.8%) of colon
cancer, respectively. Similarly, a large meta-analysis
demonstrated significant hazard ratio associations
between self-reported SB with all-cause mortality
(hazard ratio [HR]: 1.240, 95% confidence interval:
Fletcher et al. 1623
Promoting Physical Activity and Exercise
[CI]: 1.090 to 1.410), CVD mortality (HR: 1.179, ABBREVIATIONS
95% CI: 1.106 to 1.257), CVD incidence AND ACRONYMS
(HR: 1.143, 95% CI: 1.002 to 1.729), cancer
AHA = American Heart
mortality (HR: 1.173, 95% CI: 1.108 to 1.242), Association
cancer incidence (HR: 1.130, 95% CI: 1.053 to
BP = blood pressure
1.213), and T2DM incidence (HR: 1.910,
CHD = coronary heart disease
95% CI: 1.642 to 2.222) (16). In a large
CI = confidence interval
meta-analysis reviewing 13 studies
CR = cardiac rehabilitation
(including 1,005,791 subjects) with respect
CRF = cardiorespiratory fitness
to sitting time and all-cause mortality,
the investigators found that compared with CV = cardiovascular
the referent most active group (i.e., CVD = cardiovascular disease
sitting <4 h/day and performing >35.5 meta- DAF = definitely associated
factor
bolic equivalent [MET]-h/week), mortality
rates were highest in those with the least PA HF = heart failure
(<2.5 MET-h/week and sitting >8 h/day; HR: HR = hazard ratio
1.27, 95% CI: 1.22 to 1.31) (17). Interestingly, HTN = hypertension
daily sitting time was not associated with MET = metabolic equivalent
increased all-cause mortality in those in the MI = myocardial infarction
most active quartile of PA (HR: 1.04, 95% CI: PA = physical activity
0.99 to 1.10), suggesting that moderate- PI = physical inactivity
intensity PA may negate the adverse effects
RR = relative risk
associated with prolonged sitting time. For
SB = sedentary behavior
less active adults, replacing 1 h/day of sitting
T2DM = type 2 diabetes
with an equal amount of PA was associated mellitus
with lower all-cause mortality for both exer-
cise (HR: 0.58 [95% CI: 0.54 to 0.63]) and non-
exercise PA (HR: 0.70 [95% CI: 0.66 to 0.74]),
including household chores, lawn and garden work,
and daily walking (18), emphasizing the fact that even
lower volumes (i.e., less time at lower intensities) of
PA have positive CV benefits.
From a CVD standpoint specifically, the adverse
relationship between PI and the incidence of CVD has
been well-established (19). In a comprehensive re-
view of 47 studies evaluating this association, the
relative risk (RR) of CVD related to PI was 1.9 overall,
with higher RRs (up to 2.4) reported in selected series.
In addition, the RR of PI proved to be similar in
magnitude to the adverse risks posed by traditional
CVD risk factors, such as hypertension (HTN), hy-
percholesterolemia, and smoking. Numerous studies
have been published demonstrating the inverse
relationship between PA, CRF level, and regular ex-
ercise, with the risk of CVD, myocardial infarction
(MI), and CVD mortality. The benefits of being phys-
ically active, physically fit, and engaging in regular
exercise exist regardless of sex, ethnicity, or age.
Overall, the most active individuals have an approx-
imate 30% to 40% lower risk of developing CVD
compared with those who do not exercise. In a case
control study evaluating multiple CVD risk factors for
acute MI across 52 countries, habitual physical
1624 Fletcher et al. JACC VOL. 72, NO. 14, 2018

Promoting Physical Activity and Exercise OCTOBER 2, 2018:1622–39

C E NT R AL IL L U STR AT IO N PA/PI and CVD Prevention

Fletcher, G.F. et al. J Am Coll Cardiol. 2018;72(14):1622–39.

Physical inactivity (PI) is associated with systemic pathophysiology that contributes to the development of metabolic and cardiovascular disorders, osteoporosis, and
certain cancers. Initiation of a physically active lifestyle dramatically reduces one’s risk for developing these disorders as well as mortality. Facilitating the adoption of
a physically active lifestyle can be accomplished through a multidisciplinary team approach that fosters behavior change through regular interactions and individu-
alization of preventive actions. CDE ¼ certified diabetes educator; CEP ¼ clinical exercise physiologist; CVD ¼ cardiovascular disease; HF ¼ heart failure;
HTN ¼ hypertension; OT ¼ occupational therapist; PA ¼ physical activity; PI ¼ physical inactivity; PT ¼ physical therapist; RD ¼ registered dietitian; RN ¼ registered
nurse; SM ¼ skeletal muscle; T2DM ¼ type 2 diabetes mellitus.

exercise appeared protective (odds ratio: 0.86 for first
MI) among men and women of all age groups and
ethnicities. Conversely, lack of PA accounted for 12%
of the population-attributable risk of MI (20).
BENEFICIAL HEALTH EFFECTS ASSOCIATED
WITH PA: FROM PHYSIOLOGY TO
CLINICAL PRESENTATION
The benefits of exercise have been proven at both
biological and disease-specific levels (21,22). At the
cellular level, aerobic forms of exercise have been
shown to have several beneficial antiatherogenic ef-
fects, including a decrease in serum triglycerides, an
increase in high-density lipoprotein, and a decrease
in low-density lipoprotein (23–25).
inflammation decrease with regular PA and exercise.
In one study evaluating the effects of a regular exer-
cise regimen in patients at risk for CVD, mononuclear
cell production of atherogenic cytokines fell by
58.3%, and the production of atheroprotective cyto-
kines increased by 35.9% (26).
Hemostatic factors associated with thrombosis
have also been shown to improve with exercise
(27,28). Specifically, platelet aggregation and adhe-
siveness have been shown to decrease with exercise
training; however, in the setting of deconditioning,
these positive effects revert to pre-training levels
(27). Concentrations of plasminogen activator inhibi-
tor 1 and tissue plasminogen activator antigen are
lower in physically active women compared with
non-obese sedentary control subjects, although levels
of fibrinogen are similar (28). In one observational
study, blood viscosity was shown to decrease relative
Markers of to an increase in leisure-time PA (29); however, this
beneficial effect could not be reproduced following a
formal exercise regimen in patients with known CVD
(30). Exercise also has been shown to improve
JACC VOL. 72, NO. 14, 2018 Fletcher et al. 1625
OCTOBER 2, 2018:1622–39 Promoting Physical Activity and Exercise

F I G U R E 1 Benefits of PA/Exercise

Cardioprotective Mechanisms of Physical Activity

Anti-
Psychologic Anti-Arrhythmic Anti-Thrombotic Hemodynamics
atherosclerotic

↑ Social ↑ Heart Rate ↑ Fibrinolysis ↑ Insulin Cardiac

Interactions Variability Sensitivity Remodeling
↓ Platelet
↓ Psychosocial ↓ Adrenergic Adhesion ↑ HDL / ↓ LDL ↑ Coronary Flow
Stress Activity
↓ Fibrinogen ↓ Triglycerides ↑ EPCs and CACs
↓ Depression ↑ Vagal Tone
↓ Blood Viscosity ↓ Blood Pressure ↓ Myocardial O2
Demand
↓ Adiposity
↓ Endothelial
↓ Inflammation Dysfunction

↑ Nitric Oxide

Mechanisms by which moderate-to-vigorous exercise training may reduce the risk for nonfatal and fatal cardiovascular events. *Nitric oxide
also has antithrombotic effects. [ ¼ increased; Y ¼ decreased. BP ¼ blood pressure; CAC ¼ cultured/circulating angiogenic cell;
EPC ¼ endothelial progenitor cell. Reproduced with permission from Kachur et al. (35).

endothelial function and autonomic function, and dementia, and reduction in anxiety and depression
have both anti-ischemic and antiarrhythmic effects (42–47).
(31–34). Thus, there are multiple positive biological
ROLE OF PA FOR THE
effects that clearly have a beneficial effect (Figure 1)
PRIMARY PREVENTION OF CVD
(21,22,35).
Regarding the benefits of exercise at a disease-
Regarding primary prevention of CVD, the protective
specific level, systemic blood pressure (BP) improves
effects of physical fitness, PA, and energy expendi-
with both habitual aerobic exercise and with resis-
ture have been demonstrated in numerous studies.
tance training. Systolic and diastolic BP decrease as
The study populations and results of a select number
much as 15 and 9 mm Hg, respectively, among patients
of these studies are summarized in Table 1 (20,48–70).
with mild essential HTN (36). Exercise also reduces the
The findings of these studies support that all forms of
risk of ischemic stroke (37,38), improves glycemic
PA, regardless of age, sex, or ethnicity, have a bene-
control in patients with T2DM, and may help to pre-
ficial effect in CVD prevention. In most studies, both
vent the development of metabolic syndrome and/or
intensity and duration of exercise or PA also have
T2DM (34,35). Exercise also has been shown to afford
been shown to be directly related to improved out-
modest protection from a spectrum of cancers,
comes and mortality. Compared with no regular ex-
including breast, gastrointestinal, prostate, endome-
ercise, however, any type of PA provides a protective
trial, and pancreatic carcinomas (39–41). Regular ex-
effect against the risk of CVD (71).
ercise has been shown to be protective against both
proximal and distal colon cancers, with a significant ROLE OF PA FOR THE
risk reduction of 27% for active individuals (42). In SECONDARY PREVENTION OF CVD
terms of other health benefits, exercise has beneficial
effects related to osteoporosis and hip-fracture pre- For secondary prevention among patients with CVD,
vention (specifically, weight-bearing exercise), smok- numerous studies, many summarized in Table 2
ing cessation, improved cognition, prevention of (67,72–75), have shown the protective effects of PA,
1626 Fletcher et al. JACC VOL. 72, NO. 14, 2018

Promoting Physical Activity and Exercise OCTOBER 2, 2018:1622–39

T A B L E 1 Relationship Between PA, Exercise, and Fitness with Primary Prevention of CHD, CVD Risk Factors, and Mortality

Physical Activity/
First Author (Ref. #) Subjects Exercise Variables Measured Results

Blair et al. (48) 10,224 men Variables obtained from maxETT Lower CV and cancer mortality were related to higher fitness levels
3,120 women Age-adjusted all-cause mortality:
Men—least fit: 64/10,000 person-yrs
Men—most fit: 18.6/10,000 person-yrs
Women—least fit: 39.5/10,000 person-yrs
Women—most fit: 8.5/10,000 person-yrs
Blair et al. (49) 5,341 men Variables obtained from maxETT Moderate fitness was protective against other CV risk factors
7,080 women Adjusted all-cause mortality:
Men—low fitness: (RR: 1.52, 95% CI: 1.28–1.82)
Women—low fitness: (RR: 2.10, 95% CI: 1.39–1.97)
Sandvik et al. (50) 1,960 men Total work by bicycle ergometer Higher levels of fitness were associated with lower mortality
All-cause mortality: (RR: 0.54, 95% CI: 0.32–0.89)
CV mortality: (RR: 0.41, 95% CI: 0.20–0.94)
Leon et al. (51) 12,138 men (MRFIT trial) Self-reported leisure time PA Moderate levels of leisure time physical activity were associated with 63%
fewer fatal CHD events and sudden cardiac death compared with lower
levels of leisure time PA.
Paffenbarger et al. (52) 10,269 men Habitual exercise, >4.5 METs Moderately vigorous exercise was associated with a 23% reduction in all-
Harvard alumni cause and CV mortality (95% CI: 4–42%).
Sesso et al. (53) 12,516 men Calories burned (kJ/week) RR for CV events (CHD, Ml, PCI, CABG, death) was reduced in men who
burned more calories per week.
Compared with men expending <2100 kJ/week, RR ranged from 0.90 to
0.81 for those expending >2,100–12,600 kJ/week.
Lee et al. (54) 7,307 men Self-reported PA After controlling for confounding variables, total energy expenditure during
Harvard alumni physical exercise was more important than duration.
Lee et al. (55) 7,337 men Self-reported perceived level of Inverse relationship demonstrated between an individual’s perceived level
Harvard alumni exertion using Borg scale of exertion and risk of CHD: 0.86 (95% CI: 0.66–1.13) for “moderate” vs.
0.72 (95% CI: 0.52–1.00) for “intense.”
Ekelund et al. (56) 4,276 men Variables obtained from maxETT Men with poor fitness had a higher risk of death
RR of death from CV causes was 2.7 (95% CI: 1.4–5.1) for increment in HR
>35 beats/min during stage 2 and 3.0 (95% CI: 1.5–5.0) for those with a
decrement of 4.4 min in exercise time.
Kujala et al. (57) 7,295 men Self-reported PA Odds ratio of death in “conditioning exercisers” was 0.57 (95% CI: 0.45–
7,977 women 0.74) for all subjects and 0.44 (95% CI: 0.23–0.83) among the twin
Finnish Twin Cohort pairs discordant for death compared with sedentary subjects.
Manson et al. (58) 72,488 women Total PA, walking, vigorous Strong inverse relationship demonstrated between total PA, amount of
Nurses’ Health exercise walking, and vigorous activity with the risk for coronary events.
Study Vigorous exercise resulted in 30%–40% reduction of coronary events.
Women who became active later in life also showed a beneficial effect.
Manson et al. (59) 73,743 women Quintiles of METS derived from Women with higher levels of energy expenditure had fewer CHD events.
Women’s Health Initiative activity questionnaires Age-adjusted RR of coronary events with increasing quintiles of energy
expenditure: 1.00, 0.73, 0.69, 0.68, and 0.47.
Walking and vigorous exercise were similar with respect to risk reduction.
Results did not vary according to race, age, or BMI.
Lee et al. (60) 39,372 women Kcal/week burned, time spent The RR of CHD was inversely related to the number of kcal burned per week,
walking, walking pace the duration of walking and the pace of walking, although the time
spent walking had greater impact than pace.
Mora et al. (61) 2,994 women Variables obtained from maxETT Low exercise capacity, low HR recovery, and failure to achieve target HR,
but not ST-segment depression, were independently associated with all-
cause and CV mortality.
Gulati et al. (62) 5,721 women Variables obtained from maxETT A nomogram to predicted exercise capacity (predicted MET ¼ 14.7  (0.13 
age) was used predict death. Subjects unable to achieve
85% of predicted MET value had twice the risk of death.
Wagner et al. (63) 9,758 men Leisure-time net energy Leisure time PA energy expenditure was associated with a lower risk of hard
expenditure CHD events; by contrast, walking or cycling to work did not correlate
with hard events.
Tanasescu et al. (64) 44,452 men Total physical activity, rowing, Several forms of exercise were associated with reduced CHD risk.
running, weight- training, More intense exercise (MET level) and faster walking pace were associated
walking with further reduced CHD risk reduction:
Running for> 1 h/week—42% (RR: 0.58; 95% CI: 0.44–0.77)
Weight training >30 min/week—23% (RR: 0.77; 95% CI: 0.61–0.98)
Rowing >1 h/week—18% (RR: 0.82; 05% CI: 0.68–0.99)
Walking briskly >0.5 h/day–18%/RR: 0.82; 05% CI: 0.68–0.99)
LaMonte et al. (65) 3,232 men Variables obtained from maxETT Favorable inverse associations between fitness and most CHD risk factors
1,128 women were demonstrated among men and women. Higher fitness significantly
reduced the odds of clinically relevant risk factor values among men and
women without CHD.
Continued on the next page
JACC VOL. 72, NO. 14, 2018
OCTOBER 2, 2018:1622–39
T A B L E 1 Continued
First Author (Ref. #) Subjects
Laukkanen et al. (66) 1,294 men
Myers et al. (67) 62,13 men
Yusuf et al. (20) 15,152 MI cases vs.
14,820 controls
Blair et al. (68) 9,777 men
Carnethon et al. (69) 2,478 men and women
(18–30 yrs)
Soares-Miranda 4,207 men and women
et al. (70)
BMI ¼ body mass index; BP ¼ blood pressure; CABG ¼ coronary artery bypass grafting; CHD ¼ coronary heart disease; CI ¼ confidence interval; CV ¼ cardiovascular; DM ¼ diabetes mellitus; ETT ¼ exercise
treadmill test; HR ¼ heart rate; HTN ¼ hypertension; MET ¼ metabolic equivalent; MI ¼ myocardial infarction; OR ¼ odds ratio; PA ¼ physical activity; PAR ¼ population attributable risks; PCI ¼ percutaneous
coronary intervention; RR ¼ relative risk.
exercise, and CRF in terms of reduction of recurrent
CVD events. Among patients with documented or
presumed CVD based on the presence of a positive
stress test, peak exercise capacity or CRF was
the strongest predictor of survival (72). In a large
meta-analysis evaluating the benefits of cardiac
prevention programs in patients with CVD, exercise
programs were associated with a RR of 0.72 (95% CI:
0.54 to 0.95) for mortality (73). Cardiac rehabilitation
(CR) for patients with CVD probably reduces all-
cause and certainly CVD mortality, with additional
beneficial effects on lipids, BP, smoking, inflamma-
tion, and especially on psychological risk factors,
such as depression, anxiety, hostility, and total
levels of psychological stress. The benefits of CR,
particularly in CHD, are well known, although these
benefits have now been extended to heart failure
(HF) and peripheral arterial disease, and are sum-
marized in Table 3 (35,47,76–78).
In general, PA, including light and moderate
habitual exercise, and moderate recreational PA, re-
duces mortality among men with CVD. In a study
population of 772 men with established CVD from the
United Kingdom, the lowest risks for all-cause and
CVD mortality were seen in light and moderate PA
Fletcher et al. 1627
Promoting Physical Activity and Exercise
Physical Activity/
Exercise Variables Measured Results
Max oxygen uptake by RR of death was significantly lower for fit men compared with unfit men. RR
cardiopulmonary stress testing of overall and CV mortality was 2.76 (95% CI: 1.43–5.33) and 3.09
(95% CI: l.10–9.56), respectively, for unfit men (maximal oxygen
uptake <27.6 ml/kg/min) compared with fit men (maximal oxygen
uptake >37.1 ml/kg/min). Exercise duration also had a strong inverse
relationship to overall and CV-related mortality. RR of CV-related death
was 3.44 (95% CI: l.09–10.80) for men in the highest quartile compared
with those in the lowest.
Variables obtained from maxETT Peak exercise capacity measured in METs was the strongest predictor of the
risk of death among both normal subjects and those with CVD. In all
subgroups, risk of death from any cause in subjects whose exercise
capacity was <5 METs was approximately double that of subjects who
achieved >8 METs.
Self-reported PA In addition to several other variables studied, regular PA was protective
against the risk of myocardial infarction (OR: 0.86, PAR: 12.2%).
Variables obtained from maxETT Highest and lowest age-adjusted death rates were observed in men unfit
from 2 studies approximately 5 (122.0/10,000 man-yrs) and fit (39.6/10,000 man-yrs), respectively,
yrs apart on both examinations. Those improving from unfit to fit between tests
had a 44% (95% CI: 25%–59%) reduction in mortality.
Duration on treadmill during ETT Subjects with low fitness (<20th percentile) were 3- to 6-fold more likely to
develop DM, HTN, and metabolic syndrome compared with those with
high fitness $60th percentile) after 15 yrs.
Self-reported regular PA and Greater PA was inversely associated with CHD, stroke, and total CV disease,
leisure time activity even in subjects >75 yrs. Walking pace and exercise intensity were
associated with lower risk. Subjects who habitually walked at a pace >3
miles/h had a lower risk of CHD (RR: 0.50, 95% CI: 0.38–0.67), stroke
(RR: 0.47, 95% CI: 0.33–0.66, and overall CVD/RR 0.50; 95% CI: 0.40–
0.62).
groups. Recreational PA of $4 h per weekend, mod-
erate or heavy gardening, and regular walking (>40
min/day) were all associated with a significant
reduction in mortality. Men who were initially
sedentary but began at least light PA showed lower
mortality rates on follow-up than those who
remained sedentary (RR: 0.58, 95% CI: 0.33 to 1.03;
p ¼ 0.06) (74). In patients with CHD, recent studies
indicate that PA is more important than weight (79),
and changes in PA are considerably more important
than long-term changes in body mass index regarding
long-term prognosis (80).
According to current guidelines, “30 to 60 minutes
of moderate-intensity aerobic PA, such as brisk
walking, at least 5 days and preferably 7 days per
week, supplemented by an increase in daily lifestyle
PA (e.g., walking breaks at work, gardening, house-
hold work) to improve CRF” is recommended for pa-
tients with stable CVD (81).
MECHANISTIC/TRIGGERING FACTORS FOR
BEING PHYSICALLY ACTIVE
Understanding the multiple factors that influence
participation in PA and regular exercise is important
1628 Fletcher et al.
Promoting Physical Activity and Exercise
T A B L E 2 PA and Secondary Prevention
First Author (Ref. #) Subjects Results
Myers et al. (67) 6,213 men (3,679 Peak exercise capacity in METs was the strongest
with abnormal predictor of death both in normal subjects and
stress or those with CVD. Each 1-MET increase in
documented CHD) exercise capacity conferred a 12%
improvement in survival.
Clark et al. (72) 21,295 pts with CHD Comparison of the effects of cardiac prevention
(from 63 programs with or without exercise. Overall,
randomized trials) the summary risk ratio was 0.85 (95% Cl: 0.77
to 0.94) for all-cause mortality and 0.83
(95% Cl: 0.74 to 0.94) for recurrent Ml at
12 months.
Risk factor education þ exercise program: 0.88
(95% Cl: 0.74 to 1.04) for mortality and 0.62
(95% Cl: 0.44 to 0.87) for myocardial
infarction.
Risk factor education alone: 0.87 (95% Cl: 0.76
to 0.99) for mortality and 0.86 (95% Cl: 0.72
to 1.03) for myocardial infarction.
Exercise program alone 0.72 (95% Cl: 0.54 to
0.95) for mortality and 0.76 (95% Cl: 0.57 to
1.01) for myocardial infarction.
Taylor et al. (73) 8,940 pts with CHD Cardiac rehabilitation was associated with
from 48 trials reduced all-cause mortality (OR: 0.80; 95%
CI: 0.68 to 0.93) and cardiac mortality (OR:
0.74; 95% CI: 0.61 to 0.96). There were
greater reductions in total cholesterol,
triglyceride levels, systolic blood pressure,
and lower rates of self-reported smoking.
There were no significant differences in the
rates of nonfatal myocardial infarction and
revascularization, and no changes in high- and
low-density lipoprotein cholesterol levels and
diastolic pressure.
Wannamethee 5,934 men The lowest risks for all-cause and cardiovascular
et al. (74) with CHD mortality were seen in light and moderate
activity groups (adjusted relative risk
compared with inactive/occasionally active:
light 0.42 (0.25 to 0.71); moderate 0.47 (0.24
to 0.92); and moderately vigorous/vigorous
0.63 (0.39 to 1.03). Recreational activity
of $4 h/weekend, moderate or heavy
gardening, and regular walking (>40 min/
day) were all associated with a significant
reduction in all-cause mortality.
Steffen-Batey 406 Mexican Over a 7-yr period, the relative risk (95% Cl)
et al. (75) American and of death compared with the sedentary, no
non-Hispanic change group was as follows: 0.21 (0.10 to
white women and 0.44) for the active, no change group; 0.11
men Ml survivors (0.03 to 0.46) for the increased activity
group; and 0.49 (0.26 to 0.90) for the
decreased activity group. The relative risk of
reinfarction was as follows: 0.40 (0.24 to
0.66) for the active, no change group; 0.22
(0.09 to 0.50) for the increased activity
group; and 0.93 (0.59 to 1.42) for the
decreased activity group.
Abbreviations as in Table 1.
in improving the well-being of the general public.
The behavior of PA is affected by factors operating
at multiple levels, including personal (such as bio-
logical and psychological attributes), social (family,
affiliation group, and work factors), and environ-
mental (habitat for different forms of PA, availability
of facilities) (82), as well as probably genetic
influences.
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ROLE OF GENETICS IN PA/PI
Although social, environmental, and psychological
variables clearly play a role in “the behavior of PA,”
other biological factors, including genetic factors, may
determine whether one is physically active or inac-
tive. Several areas of interest relate to the genetics of
CRF and adaptation to exercise. What is the genetic
contribution to human variation in the sedentary and
active states? Is there a genetic basis for differences in
the individual response to habitual exercise? Does
variability in genes and alleles contribute to individ-
ual variability in trainability during PA? (2).
Due to the size of the human genome, researchers
have attempted to identify certain genomic regions
associated with PA. Researchers analyzing data from
genome-wide association studies, from which it is
possible to assay hundreds of thousands in a single
reaction, have demonstrated genetic associations for
participating in regular exercise. The genome-wide
association studies strategy has the advantage of
covering the entire genome with enough sensitivity
to detect smaller gene effects of relatively common
sequence variants in the setting of a large sample
size (83).
Additional evidence suggests that being physically
active or inactive may be related to 2 distinct phe-
notypes, each with a distinct physiological mecha-
nism that results in distinct behaviors. Heritability is
defined as the influence of genetic factors on the
variance of any phenotype between individuals and is
expressed as a value from 0 to 100% with zero
meaning that there is no heritable influence on the
phenotype and 100% meaning that the phenotype
arose exclusively from genetic factors. Several
studies have evaluated the impact of heritability on
PA, and most studies have shown an active herita-
bility estimate of approximately 25% (2,84). One of
the earlier studies, the Quebec Family Study, used a
3-day activity survey in 300 families, reporting that
genetic factors accounted for 20% to 29% of the
hereditability of PA (85). The hereditability of PA in a
subsequent phase of the study was lower at 16% to
25%, with findings explained by a combination of
environmental and genetic factors. The PI phenotype
had a slightly higher level of hereditability (86).
Several monozygous twin studies have also been
performed to assess the genetic contribution to PA
based on the assumption that, because the in-
dividuals are genetically identical, any phenotypic
differences must be related to environmental factors.
One large twin study (13,676 monozygous pairs
and 23,375 dizygous pairs) with subjects from 7
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T A B L E 3 Benefits of CR Programs
I. Coronary heart disease
A. Improvement in fitness
B. Improvement in psychological risk factors and QoL
C. Reductions in metabolic syndrome
D. Reduction in inflammation
E. Reduction in obesity indices
F. Improvement in blood rheology
G. Major morbidity and mortality
a) Reduction in CVD mortality
b) Possible reductions in total mortality
c) Reduction in hospital costs
d) Reduction in fatal MI
II. Systolic heart failure
A. Improvement in fitness
B. Reduction in hospitalizations
C. Possible reduction in mortality
D. Improvements in depression and QoL
III. Peripheral arterial disease
A. Improvements in walking distance
B. Probable mortality reductions
C. Improvements in QoL
CR ¼ cardiac rehabilitation; QoL ¼ quality of life; other abbreviations as in Table 1.
different countries evaluated the heritability of
leisure-time PA. These investigators found that the
heritability for exercise activity of at least 60 min/week
ranged from 27% (men in Norway) to 71% (women
in the United Kingdom), with a median heritability
of 62% for all countries (86). Clearly, PA levels had
higher correlation in monozygotic compared with
dizygotic pairs. The Vietnam Era Twin Registry
investigators concluded that there was indeed a
genetic contribution to PA (87). Another twin study
comparing the duration of exercise (150 min/week
vs. 60 min/week) suggested that, although both
genetic and unique environmental
contribute significantly to participation
common environmental factors
stronger influence on duration
Regarding differential heritability of PA in males
versus females, there is currently no consensus,
given conflicting results in several large studies.
ROLE OF NONGENETIC FACTORS
In a systematic review compiling the results of 25
published reviews that addressed the potential vari-
ables related to participation in PA (88), multiple
personal and environmental factors were identified.
Personal variables evaluated included demographics,
biological characteristics, behavioral factors, social
and cultural factors, and psychological, cognitive,
and emotional factors. Environmental
included availability of facilities,
Fletcher et al. 1629
Promoting Physical Activity and Exercise
neighborhood, safety, home environment, location of
region, and climate. In this study, factors with a true
correlation were deemed a “definitely associated
factor” (DAF). Multiple personal factors, including
age, health and/or fitness status, intention to exer-
cise, outcome expectations, perceived behavioral
control, self-efficacy, and perceived fitness were
assessed as DAFs in at least 3 of the 25 studies
reviewed. Environmental factors considered as DAFs
included accessibility to fitness centers, presence of
sidewalks, and aesthetics. These specific associations
that may influence participation in PA could provide
directions for health care and aid community and
governmental leaders to better design programs and
facilities that may help to improve participation in PA
and ultimately improve the health and wellness of
our society (discussed in the following text).
THE ROLE OF CR IN PROMOTING PA IN
SECONDARY PREVENTION
In the United States, Europe, and much of the world,
CR is a Class I, Level of Evidence: A indication for the
treatment of CVD and has thus received the highest
classification possible from major professional soci-
eties (35,89,90). Indeed, there is reduced morbidity
and mortality, especially CVD mortality, in patients
who receive outpatient CR as opposed to those who
do not (77,91,92). For inpatient CR, there is a paucity
of such data. Nevertheless, most candidates for CR
following major CHD events do not participate in
formal CR and exercise training programs, and now,
in the United States, the recommendation for formal
CR has been extended to chronic, stable HF with a
reduced ejection fraction as well as to patients with
peripheral arterial disease (35). The barriers to
factors
attending and completing CR programs have been
in PA,
well described (35,77), including low referrals, inad-
likely have a
equate “vigorous” referral, distance from the CR
of PA (87).
center, transportation issues, employment, costs
(including lack of insurance coverage and high
copays), and women and elderly are less likely to be
referred and attend CR programs (35,77,93–95).
Clearly, great efforts are needed to make these CR
programs more available and affordable, not to
mention “cost-effective” (78).
For many CR candidates, automatic referral has
become increasingly adopted. However, without
strong endorsement of CR participation by the health
care providers, patients are much less likely to attend
CR (35,77,95,96). Strong multifaceted endorsement of
CR from health care providers, including nurses, ex-
variables ercise specialists, physical therapists, social workers,
type of and others, as well as from the physicians, is an
1630 Fletcher et al.
Promoting Physical Activity and Exercise
T A B L E 4 Key Recommendations for Integrating the Assessment
and Promotion of PA into Clinical Practice
PA assessment is a priority during all patient visits—particularly those
at high risk for or diagnosed with 1 or more chronic diseases. The 2
central questions include:
“On average, how many days per week do you engage in moderate or
greater intensity PA (like a brisk walk)?”
“On average, how many minutes do you engage in this PA on those
days?”
If the product of the responses to the questions above indicate the
individual is below the recommended U.S. PA guideline
recommendation of 150 min/week, individuals should be advised
of the health benefits of regular PA and encouraged to gradually
increase either their frequency or duration of activity
Consumer-oriented wearable devices or smartphones can objectively
assess PA levels. Self-tracking is helpful to some individuals to
increase their PA levels in the short term. A more structured
promotion/referral/behavior change plan is needed for the
maintenance of effects.
The recommended U.S. PA guidelines may be perceived by some
individuals as unattainable. Health professionals should stress that
accumulating at least 60 to 100 min/week of PA also has
significant health benefits.
As recommended by the U.S. guidelines for Americans, a
comprehensive assessment of PA should include engaging in
muscle-strengthening, resistance, and flexibility exercises for
major muscle groups at least twice a week. The following question
can be used:
“How many days a week do you perform muscle-strengthening
exercises such as body weight exercises or resistance training?”
Behavior change is a dynamic phenomenon; attempting to change
unhealthy behaviors often entails a series of stages. Identifying
behavioral readiness with the transtheoretical model of behavior
change can help tailor the PA counseling.
In addition to behavioral readiness, assessment of physical readiness
for exercise constitutes an important step for PA promotion. The
deleterious health effects of inactivity far outweigh the risks of
adverse events triggered by exercise. Following a pre-exercise
screening protocol can reduce these risks and build trust between
the provider and the patient.
To make PA promotion efforts more credible and motivating, health
professionals should ensure that they lead a physically active
lifestyle themselves. Personal experience influences a health care
professional’s view and approach to PA promotion.
Adapted from Lobelo et al. (123).
Abbreviations as in Table 1.
important catalyst for CR participation that is often
lacking (96). The recently emphasized that the “one
size fits all” CR model has substantial limitations and
will be even less effective in the future (35,77,78).
Given the current interests in technology, the po-
tential exists to greatly enhance the current outreach
of CR, regardless of the practice setting, including the
location (e.g., United States, rural or city, Europe,
Canada, Asia, and so on) and infrastructure (35,77,95–
97). The use of web-based and various mobile appli-
cations, telephonic coaching, the internet, hand-held
computer technologies, and various wearable
PA-tracking devices, provide potential applications to
more regularly engage CR candidates into these effec-
tive interventions. More comprehensive CR models,
including home-, internet-, and community-based
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programs, are needed to provide alternatives to
conventional, medically supervised, facility-based
CR exercise interventions (35,77,95–97).
Clearly, improvements in CRF explain most of the
benefits of CR programs on subsequent prognosis
(98,99). Recently, remote CR has been shown in a
randomized trial, not only to provide similar im-
provements in CRF compared with conventional,
facility-based programs, but also to improve quality
of life and most risk factors to a similar degree
(78,100). Certainly, as has recently been emphasized
in the Journal, it is clearly time to “rebrand and
reinvigorate” CR in the United States and worldwide
(35,77,97).
PREVENTIVE ACTIONS TO REDUCE PI
AND INCREASE PA
Decades of scientific evidence have unequivocally
demonstrated the protective effects of PA from CVD
across sex and ethnicity. Despite expansive under-
standing and appreciation for the multisystemic
benefits of PA, PI remains a cornerstone issue
throughout developed societies. By leveraging our
understanding of the characteristics contributing to
PI, as well as evidence-based interventions to pro-
mote PA, practitioners will be able to identify effec-
tive clinical pathways that facilitate the societal
adoption of a physically active lifestyle. An in-depth
understanding of how personal, educational/com-
munity, and societal actions can be implemented is
necessary to prevent SB and increase PA to mitigate
the risk of developing CVD (Central Illustration).
PERSONAL ACTION. The relation between PA and
CVD risk follows a curvilinear trend, with the highest
risk of CVD attributed to PI and the lowest risk to
those with high aerobic exercise volumes. Several
studies have shown that even a small amount of PA
confers beneficial effects, as discussed above
(101,102), especially relatively small amounts of
running (103). Additionally, the CVD risk–lowering
benefits of PA are not exclusive to certain modalities
of movement, but can also be acquired through short
durations of several different types of exercise
(running, rowing, brisk walking, lifting weights) (64).
Although one can accumulate benefits by performing
“low dose” PA, several studies have demonstrated a
larger reduction in CVD events and CVD risk factors
for more vigorous as compared with moderate-
intensity exercise (104). However, it is clear and
well accepted that when performed regularly, any
and all movement imparts positive health benefits
compared with SB (105). Yet, regular participation in
PA has historically remained low, with only 50% of
JACC VOL. 72, NO. 14, 2018
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adults meeting the aerobic component of the guide-
lines, and only 20% meeting both aerobic and muscle-
strengthening guidelines (106).
To begin to rationalize the discouragingly low PA
levels and be able to reverse behavior, one must un-
derstand personal barriers to PA across populations.
Frequently cited personal barriers to becoming
physically active include, but are not limited to, lack
of time, lack of enjoyment, reduced self-efficacy, low
social support, companionship, safety, and/or a
misconception of the type, intensity, duration, and
frequency of PA necessary to lower risk of CVD
(107,108). Experiencing 1 or more of these barriers
makes adopting a physically active lifestyle a formi-
dable challenge for a large portion of the population.
Additionally, 1-dimensional, one size fits all
messaging strategies (i.e., “walk briskly for 150 min
per week”) by health professionals, may contribute to
fortifying misconceptions of the volume and type of
PA necessary to acquire health benefits. However,
participation in “nontraditional” forms of PA, such as
dance (109), ball games (109,110), and nonautomotive
means of commuting to work (111,112), instill im-
provements in highly prognostic measures of future
morbidity and mortality. A greater emphasis should
therefore be placed on promoting all forms of PA and
identifying health practitioners that can guide
behavior change interventions, while considering the
individual’s personal barriers to becoming physically
active.
Developing sustained PA behaviors are highly
dependent on an individual’s self-regulatory skills,
which encompass: 1) an awareness of the goal an in-
dividual is trying to accomplish; 2) the ability to self-
monitor behavior and establish a link to their goals;
3) acquisition of feedback and information about their
progress toward each goal; 4) self-evaluation of
progress; and 5) ability to correct behavior that leads
to progress toward their goal (113). The advent of
consumer-wearable PA monitors was presented as
ideal self-regulatory tools. In recent years, there has
been exponential growth in the adoption of wearable
consumer PA monitors to track and promote personal
PA. Each generation of commercially competitive
models have increased their ability to accurately
quantify PA (i.e., step counts) and are quickly
approaching the accuracy of research-grade models
(114). Naturally, investigators have capitalized on the
population’s embrace of wearable PA monitors by
working to identify effective interventions to modify
PA behavior (115). A recent meta-analysis revealed
that self-monitoring PA through popular technologies
contributed to a 2,500 daily step increase from base-
line and approached recommended daily step counts
Fletcher et al. 1631
Promoting Physical Activity and Exercise
(7,000 steps) for overall health (116). Efforts have also
been made to merge the self-monitoring capabilities
of these devices with mobile applications that incor-
porate evidence-based behavior modification the-
ories and have been efficacious in meaningfully
improving PA (117). The favorable outcomes reported
in these studies may certainly imply that mobile
health and personal PA trackers are the solution to PI.
However, it is important to keep in mind that many of
these studies were conducted over a relatively short
period of time (i.e., 6 months) and are not reflective of
long-term PA adoption. Findings from a large-scale,
24-month-long trial by Jakicic et al. (118) demon-
strated lower weight loss (difference of 2.4 kg) in
participants that followed an evidence-based pro-
gram in combination with a wearable PA device
compared with participants following the weight loss
program alone. Although there may have been many
contributing factors to this observation, one limita-
tion may have been related to the ability of older-
generation PA monitors to accurately quantify PA,
leading participants to potentially believe that they
were more active than they actually were. Accord-
ingly, more recent iterations of consumer PA moni-
tors seek to mitigate this limitation by making heart
rate monitoring readily available and incorporating
algorithms to quantify the time spent in moderate
and vigorous heart rate ranges (119). However, future
studies with these devices are needed to establish
their efficacy.
ACTION TAKEN THROUGH EDUCATION AND THE
COMMUNITY. The seminal works of Drs. Morris and
Paffenbarger ignited a field of inquiry that aims to
identify sobering consequences associated with SB
and highlight the dose response relation between PA
and health outcomes, with the aim of optimizing
community health through movement. A culmination
of subsequent findings from landmark observational
and intervention studies helped formulate PA guide-
lines for reducing the risk of developing non-
communicable diseases (120). Despite scientific,
national, and global institutions spearheading
educational campaigns to bring awareness to the PA
recommendations, an initial analysis demonstrated
that only 36% of U.S. adults had seen, read, or heard
of the governmental PA guidelines, with just 1%
aware that the recommended volume of exercise for
substantial health benefits was 150 min of moderate
intensity PA per week (121). It became quickly evident
that more direct methods were necessary to effec-
tively increase awareness and education regarding
the PA guidelines (122). Although many approaches
exist to enable the dissemination of health
education, strong physician endorsement of PA
1632 Fletcher et al.
Promoting Physical Activity and Exercise
during outpatient visits is one way in which in-
dividuals at risk for developing CVD can be reached.
Recent observations within a large health care system
adopting the concept of treating PA as a vital sign had
80% to 96% of physicians addressing and promoting
PA during outpatient visits (123,124), contributing to
modest improvements in well-established risk factors
for CVD (125). Yet, this initiative is only an initial step
toward widespread community adoption of healthy
lifestyle practices, particularly when considering that
many intervention trials that utilize standard of care
(i.e., providing education on the PA guidelines) as the
control group, do not show clinically meaningful
changes in prognostic health markers. Additionally,
physicians are often inundated with clinical re-
sponsibilities and are left little time to effectively
discuss strategies to become physically active,
let alone conduct routine assessments of patient PA
status. Thus, implementing multidisciplinary ap-
proaches across health care professionals is a more
attractive approach to healthy lifestyle behavior
change (126,127).
Although PA intervention trials have clearly
established the efficacy of improving CVD risk factors,
the highly controlled nature of these investigations
may become unrealistic for many exercise-naive in-
dividuals to maintain and/or perform as a result of
limited access to resources (i.e., exercise facilities/
equipment, individualized attention from exercise
professionals). Community-based PA interventions
on the other hand generally require fewer resources
to identify impactful PA options for participants. The
successful implementation of community-level PA
interventions has been largely predicated upon
providing a comprehensive intervention that assists
participants to successfully move through the stages
of behavior change (i.e., pre-contemplation,
contemplation, preparation, action, and mainte-
nance). Partnerships among clinicians, healthy life-
style practitioners, and community health centers
serve as the ideal framework to deliver such pro-
grams. Gong et al. (128) provided compelling out-
comes in a group of hypertensive adults enrolled in
an 8-session (6 main sessions with 2 “booster” ses-
sions), group-based PA intervention. The aim of the
intervention was to utilize educational, individual,
and small group sessions to progress participants
through the different stages of behavior change (129).
Group-based lectures occurred during the first 2 ses-
sions (pre-contemplation and contemplation phases),
followed by 2 personal PA counseling sessions
(preparation phase), and then concluding with 2 small
meetings to discuss overcoming new obstacles and
promoting social support (action phase). One session
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took place every week, whereas the booster sessions
that reviewed the action phase occurred on the 14th
and 15th weeks of the intervention. After completion
of the intervention, participants were followed for
30 months to track maintenance of regular PA (at least
30 min/day for at least 3 to 5 times per week) and new
cases of stroke and MI were monitored through
medical records. A greater proportion (65%) of par-
ticipants in the intervention group were shown to
maintain regular PA compared with the education-
only control group (40%). The intervention was
found to be particularly successful in reducing the
incidence rate of stroke in the intervention group
(11.81%, 95% CI: 5.90% to 17.72%) compared with the
control group (19.78%, 95% CI: 14.07% to 25.50%;
p ¼ 0.03), however, no effect on incidence rate of MI
(3.34%, 95% CI: 1.19% to 8.58%, and 6.68%, 95% CI:
1.64% to 11.73%, respectively) was observed. These
favorable outcomes provide initial evidence sup-
porting a group-based method of promoting and
sustaining long-term PA adherence. Practitioners in
clinical settings should be aware of similar programs
available to the surrounding community or pursue
establishing group-based programs in collaboration
with key stakeholders in health and PA promotion for
future patient referral.
CONSIDERATIONS OF SOCIETAL FACTORS TO
INCREASE PA. The “Westernization” of societies is
often considered to be synonymous with progress
and modernization of industries and technology that
increase efficiency in the labor, transportation, and
food production sectors. Consequently, societies that
take steps toward Westernization have experienced
sobering increases in the prevalence of metabolic
disorders and CVD (130). Although many factors in-
fluence these trends, reductions in PA and increases
in SB are major contributors (131). In the United
States, there has been a 32% reduction in reported PA
since 1965 (from 235 MET-h/week to 160 MET-h/week),
and it is forecasted that PA levels will be
142 MET-h/week in 2020 due to reductions in occu-
pational, domestic, and travel PA, with sedentary time
increasing to 40 h/week (131).
Characteristics of the built environment can influ-
ence PA behavior and the health profile of community
members (132). Neighborhoods with greater
perceived walkability, active transport infrastructure,
and access to parks and playgrounds are often asso-
ciated with more active residents (133). Recent out-
comes reported from the Multi-Ethnic Study of
Atherosclerosis demonstrate the changes in built
environment are associated with increases in re-
ported PA (134) as well as reductions in body mass
index (135). Furthermore, individuals that report
JACC VOL. 72, NO. 14, 2018
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regularly (3 times per week) bike commuting to work
are associated with 20% lower cardiometabolic risk
factors compared with those that drive (111). Yet,
regularly biking for individuals who are overweight,
older, and/or inactive may initially be perceived as a
daunting task. For this reason, electronically assisted
bicycles have become more popular in recent years. A
short, 4-week intervention comparing the effects of
regular electronically assisted bike commuting to
conventional bike commuting in untrained over-
weight adults lead to similar increases in CRF (136).
This form of transportation and activity may be un-
realistic for a large portion of the population, and
therefore, parks and those parks that incorporate
outdoor fitness equipment may serve as an alternate,
cost-effective strategy to increase moderate-intensity
PA (137,138). Installation of these outdoor gyms have
shown to significantly increase moderate- to
vigorous-intensity PA performed by park users from
6% to 40% over a 12-month period, as well as signif-
icantly reducing the number of individuals who walk
past an outdoor gym from 46% to 16%, indicating
increased use over a 1-year period (139). However,
there is less evidence quantifying the number of new
park goers because of building outdoor gyms and the
extent to which outdoor exercise spaces confer sig-
nificant changes in PA behavior across populations,
particularly untrained individuals. Accordingly,
Arena et al. (137) have proposed to capitalize on the
use of public parks to implement healthy lifestyle
interventions by utilizing healthy lifestyle practi-
tioners to facilitate the effective and broad use of
outdoor gyms through a “HealthPark” model.
It is also essential to consider that the aforemen-
tioned features are more commonly available in
communities of economically advantaged in-
dividuals/families. Underserved communities, pre-
dominately composed of individuals with a lower
socioeconomic status, face a paucity of sidewalks,
active transportation options, and reduced percep-
tions of safety from crime, which are associated with
low walking time and high vehicle time (140).
Therefore, clinicians and other health practitioners
providing PA counseling should be mindful of the
individual’s socioeconomic background, built envi-
ronment, and perceptions of neighborhood safety to
adjust PA recommendations accordingly. There will
also have to be future investigative efforts to identify
best practice strategies to incorporate PA in-
terventions in these communities. Collectively, there
are numerous factors that influence an individual’s
and community’s ability to take on an active lifestyle
and maintain long-term compliance. The successful
clinical application of PA interventions will depend
Fletcher et al. 1633
Promoting Physical Activity and Exercise
upon practitioners’ considerations for personal, edu-
cation, community, and societal actions and consid-
erations to best direct individuals to resources that
can provide individualized PA guidance.
TYPE, DURATION, AND INTENSITY OF PA:
WHAT IS THE CORRECT PRESCRIPTION?
The exact formula (i.e., frequency, type, intensity,
and duration) of exercise that provides the beneficial
effects on primary and secondary prevention of CVD
morbidity and mortality remains indeterminate. The
relationship between PA and CVD risk has typically
been described as curvilinear, with the highest risk
attributed to those physically inactive and the lowest
risk to those with the highest aerobic exercise vol-
umes. Although the 2008 Physical Activity Guidelines
Advisory Committee Report has recommended 150
min/week of moderate or 75 min/week of vigorous
aerobic PA in conjunction with muscle-strengthening
activities for most adults in this country (120,141), a
small percentage of Americans comply with these
guidelines. Despite the failure of most to fulfill these
guidelines, several studies have shown that even a
small amount of PA has a beneficial effect. At the
lower end of the PA spectrum, those who engage in as
little as 75 min of exercise 1 to 2 times per week, the
so-called weekend warriors, have decreased all-cause
and CVD mortality compared with sedentary in-
dividuals (1,142), supporting the notion that even
small amounts of PA provide positive CV benefits.
In terms of the type of exercise performed, one
large cohort of 44,452 men demonstrated the benefit
of short durations of several types of exercise in
reducing CVD risk. Running for 1 h or more per week,
rowing for 1 h or more per week, brisk walking for
30 min or more per day, or lifting weights for as little
as 30 min per week had a significant positive effect in
reducing the risk of CVD and mortality (2,64,103,143).
Another large study (55,137 adults) evaluating the
associations of running with all-cause and CVD mor-
tality risks found that, at 15 years, runners had 30%
and 45% lower adjusted risks of all-cause and CVD
mortality, respectively, compared with nonrunners,
conferring a 3-year life expectancy benefit. Interest-
ingly, the mortality benefits in runners were similar
across quintiles of running time, distance, frequency,
amount, and speed. Persistent runners had the most
significant benefits. Even those subjects running only
5 to 10 min daily and at slow speeds had marked
reduction in risk of death from all causes and CVD
(103). These data showing the benefits of even low
levels of PA should encourage health care providers
to discuss these findings with their patients with the
1634 Fletcher et al.
Promoting Physical Activity and Exercise
potential to motivate sedentary individuals to begin
and continue exercise to obtain significant mortality
benefits.
Although “low-dose” PA confers positive benefits,
several studies have demonstrated a larger reduction
in CVD events and risk factors for more vigorous as
compared to moderate-intensity exercise (104). An
increase in PA from the minimum effective duration
of moderate PA (15 min a day) (144) or vigorous PA
intensity (8 min a day) (9,103) to the national PA
guidelines of 30 min a day of moderate-intensity ex-
ercise or 75 min a week of vigorous-intensity exercise
significantly improves health outcomes (120). In one
study, every additional 15 min of moderate-intensity
PA translated into a 4% further reduction of all-
cause mortality over 13 years. The greatest benefit
was obtained by the most active individuals (63 to
88 min a day), with higher mortality reductions for
vigorous-intensity versus moderate-intensity exer-
cise (144). Although the upper limit for moderate-
intensity PA in healthy individuals has not been
defined, exercise of more than 100 min a day does not
appear to be associated with additional reductions in
mortality rates. For vigorous PA, low doses confer
large benefits, whereas doses up to 10 times the rec-
ommended PA levels do not further reduce mortality
(9,103,144).
IS TOO MUCH EXERCISE HARMFUL
TO THE CV SYSTEM?
Controversy exists regarding the potential for harm-
ful doses of PA. Although it generally has been
accepted that the relationship between PA and health
is curvilinear, more recent studies have suggested
that a U- or J-shaped curve better defines this asso-
ciation with higher mortality rates at high doses of
exercise (145–151). In a large study evaluating the PA
of 49,113 women over a 9-year period, women
reporting moderate PA, as expected, had significantly
lower risk of a first CVD or venous thromboembolic
event compared with inactive women (152). However,
women reporting strenuous daily PA had higher risks
of CVD, cerebrovascular disease, and venous throm-
boembolism compared with those performing stren-
uous PA limited to only 2 or 3 times a week. In a study
evaluating graded exercise among survivors of a MI,
running or walking was associated with decreased
CVD mortality risk in a progressive fashion at most
levels of exercise; however, the benefit was attenu-
ated at the highest levels of exercise. Patients
exceeding these PA limits had a mortality risk at 10.4
years that was similar to that of inactive survivors of a
MI (146). Similar findings indicating a reverse
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OCTOBER 2, 2018:1622–39
J-shaped association of PA with CVD mortality was
reported from a prospective cohort of 1,038 subjects
with stable CVD. Both inactive and daily active pa-
tients had increased hazards of mortality compared
with the reference group of patients whose activity
was limited to 2 to 4 times per week (147). Although PI
is associated with the highest mortality among all
populations, high doses of strenuous or vigorous PA,
especially among patients with CVD, may attenuate
the positive health benefits and may be associated
with increased morbidity/mortality.
CAREGIVERS OF HEALTH PROMOTION
The health care sector and, on a broader scale, soci-
eties across the globe recognize the magnitude of the
current and projected chronic disease burden we face.
Poor lifestyle habits are at the center of this crisis;
poor CRF and PI are core components of the un-
healthy lifestyle phenotype that portend a signifi-
cantly higher risk for chronic disease (153,154). As
elucidated in other sections of this review, high CRF
and PA portend enormous health benefits. The evi-
dence is so overwhelming that there is now recogni-
tion that “exercise is medicine” (2,155). In fact, the
case can be made that, more broadly, movement is
medicine (i.e., sitting as little as possible, taking as
many steps as you can every day, and participating in
a regular exercise program) is an even more appro-
priate and impactful premise (156). Clearly, PA pat-
terns as well as CRF should also be considered vital
signs (153,155). With broad and growing agreement
that exercise and movement in general are medicine,
and both PA status and CRF are vital signs, there is a
need for health care professionals to integrate these
concepts into their delivery of care. To achieve this
goal, the way we train health care professionals and
what is expected of them once they begin practicing
must evolve.
The AHA addressed the topic of lifestyle coun-
seling during medical school training in a recent sci-
entific statement, citing there is currently a low
percentage of physicians who discuss lifestyle issues
with patients, including PA (157). In a recent survey of
physicians before receiving lifestyle training, exercise
prescriptions were provided in <10% of office visits
(158). The frequency of PA counseling is also low in
those individuals who are in particularly urgent need
of moving more. For example, a cohort of obese pa-
tients reported their primary care providers coun-
seled them on exercise and PA during z20% of office
visits (159). In truth, there is currently a low preva-
lence of training on the importance of regular exer-
cise, moving more throughout the day, and CRF in
JACC VOL. 72, NO. 14, 2018
OCTOBER 2, 2018:1622–39
medical schools (157,160). The lack of training in this
area translates into a perceived lack of importance on
the topic, which in turn leads to a failure to integrate
PA, exercise, and CRF assessments and interventions
into clinical practice. Conversely, medical training
that includes lifestyle counseling into the curriculum
in a meaningful way leads to students recognizing the
importance of a healthy lifestyle into their clinical
practice (161). Numerous leading
including the AHA, American College of Cardiology
Foundation, American College of Physicians and the
Institute of Medicine endorse meaningful integration
of how to assess PA patterns and effectively counsel
those patients who have excess SB or have subopti-
mal PA patterns into medical school curricula
(157,162,163). For those physicians who are currently
practicing, research demonstrates that additional
training on the importance of PA and exercise can
significantly improve the integration of these impor-
tant principles into their patient examinations and
care plans (158,164,165).
Clearly, PA, exercise, and CRF assessments and
interventions should be integrated into the practice
of all health professionals. As examples, nurses,
pharmacists, dentists, physical and occupational
therapists, clinical exercise physiologists, and regis-
tered dieticians all have an important role to play.
Granted, the amount of time spent assessing PA, ex-
ercise habits, and CRF will vary greatly across prac-
titioners. At a minimum, however, all health care
professionals should ask simple questions related to
how much the patients they care for exercise, and
stress the importance of being more physically active
if the patient reports leading a less than ideally active
or completely sedentary lifestyle. Health care pro-
fessionals without a primary focus on exercise as
medicine should also be cognizant of when to refer
patients to other members of the multidisciplinary
team (i.e., clinical exercise physiologists) when there
is a need of intensive lifestyle interventions (e.g.,
patient diagnosed with CVD and eligible for CR).
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Similar to medical school, with the exception of
clinical exercise physiologists, the curricula of other
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CONCLUSIONS
The data and discussion herein provide a convincing
perspective that exercise and a physically active
lifestyle are of vast importance world-wide to prevent
and control the increasing problem of CVD and
stroke, as well as a myriad of other chronic debili-
tating conditions. To ensure that this lifestyle change
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KEY WORDS cardiac rehabilitation,
exercise, genetics, physical activity