225 Full

Review
Br J Sports Med: first published as 10.1136/bjsports-2022-106189 on 23 November 2022. Downloaded from http://bjsm.bmj.com/ on August 24, 2023 by guest. Protected by copyright.
Adherence to aerobic and muscle-strengthening
activities guidelines: a systematic review and meta-
analysis of 3.3 million participants across
32 countries
Antonio Garcia-Hermoso ‍ ‍,1 José Francisco López-Gil ‍ ‍,2
Robinson Ramírez-Vélez ‍ ‍,1,3 Alicia María Alonso-Martínez ‍ ‍,1,3
Mikel Izquierdo ‍ ‍,1,3 Yasmin Ezzatvar ‍ ‍4
► Additional supplemental ABSTRACT adults3 and 2008 in youth4 global physical activity
material is published online Objective To estimate the global prevalence of meeting guidelines for public health have included two or
only. To view, please visit the
journal online (http://d x.doi. the WHO guidelines for both aerobic and muscle- more days of muscle-strengthening activities (MSA)
org/1 0.1136/b jsports-2022- strengthening activities (MSA) in populations aged ≥5 (eg, weight/resistance training). Specifically, the
106189). years, and whenever possible to explore this prevalence 2020 WHO guidelines on physical activity call
1
according to sociodemographic and lifestyle factors. for children and adolescents to accumulate at least
Navarrabiomed, Hospital
Design A systematic review and meta-analysis. an average of 60 min of MVPA per day and also
Universitario de Navarra (HUN),
Public University of Navarra Data sources Five databases were systematically vigorous physical activities and MSA should each
(UPNA), IdiSNA, Pamplona, searched for studies published from inception to be incorporated at least 3 days per week.1 Among
Navarra, Spain
2
September 2022. adults and older adults, the recommendation
Health and Social Research Eligibility criteria for selecting studies Articles
Center, Universidad de Castilla- calls to accumulate an average weekly volume of
La Mancha, Cuenca, Spain with representative samples aged ≥5 years reporting the 150–300 min of moderate intensity or 75–150 min
3
CIBER of Frailty and Healthy prevalence of meeting both aerobic and MSA guidelines of vigorous intensity, or an equivalent combination
Aging (CIBERFES), Instituto de were included. of MVPA and 2 or more days a week of MSA at
Salud Carlos III, Madrid, Spain Results Twenty-one studies comprising 3 390 001
4
Department of Nursing,
moderate or greater intensity.1
individuals from 32 countries were included. Overall Considering the estimates for physical activity
Universitat de València,
Valencia, Spain adherence to the aerobic and MSA guidelines was levels in 122 countries from the WHO Global
17.12% (95% CI 15.42% to 18.88%) in adults ≥18 Health Observatory data repository,5 nearly one out
Correspondence to years (n=3 346 723). Among adolescents aged 12–17 of three adults (31.1%) do not meet public health
Antonio Garcia-Hermoso, years, adherence to both guidelines was 19.74% (95% guidelines for recommended levels of aerobic phys-
Navarrabiomed, Hospital CI 14.72% to 25.31%) (n=43 278). No studies reported
Universitario de Navarra (HUN), ical activity. A later study from 358 population-
data for children aged 5–11 years. Women, older age, based surveys across 168 countries with 1.9 million
Public University of Navarra
(UPNA), IdiSNA, Pamplona, low/medium education levels, underweight or obesity, adults confirmed these findings, showing a prev-
Navarra 31008, Spain; and poor and moderate self-rated health were associated
alence of insufficient aerobic physical activity of
a ntonio.garciah@u navarra.es with lower adherence to the physical activity guidelines
27.5%.6 Global prevalence of insufficient aerobic
(p<0.001) among adults, although the prevalence
Accepted 9 November 2022 physical activity among adolescents is even more
remained very low in all cases. Subgroup analyses were
Published Online First worrying, reaching prevalence rates of ~81%.5 7
23 November 2022 not conducted with children and adolescents due to a
However, MSA were overlooked in these studies in
lack of studies.
which those meeting only aerobic guidelines were
Conclusions Only one out of five adolescents and
considered as ‘physically active’. Of note, estimates
adults met the recommended combined aerobic and
Watch Video of physical activity prevalence based on aerobic
MSA guidelines. Large-scale public health interventions
bjsm.bmj.com promoting both types of exercise are needed to reduce physical activity guidelines are likely to underes-
the associated burden of non-communicable diseases. timate the true extent of physical inactivity at the
PROSPERO registration number CRD42022338422. population level. For example, based on data from
the National Health Interview Survey (NHIS) 1997–
2014,8 the prevalence of meeting aerobic guidelines
was 23.7%, whereas the prevalence of meeting both
INTRODUCTION aerobic and MSA guidelines was 15.9%. Similarly,
Increasing physical activity levels is a worldwide data from the Youth Risk Behavior Survey 2019 in
health priority.1 Indeed, the WHO recognises phys- US adolescents revealed differences between the
© Author(s) (or their prevalence of meeting aerobic (31% and 15.4%
employer(s)) 2023. No ical inactivity as a key risk factor in the prevention
commercial re-use. See rights and control of chronic diseases.1 Evidence-based in boys and girls, respectively) and both guidelines
and permissions. Published physical activity guidelines for health have been (23.1% and 10.2% in boys and girls, respectively).9
by BMJ. issued since 1995 by the US Centers for Disease The value of combining aerobic and MSA guide-
To cite: Garcia-Hermoso A, Control and Prevention and the American College lines is based on the epidemiological evidence
López-Gil JF, Ramírez-V
élez R, of Sports Medicine.2 Traditionally, these guidelines showing that each activity type has independent
et al. Br J Sports Med focused solely on moderate- to-
vigorous aerobic and cumulative health benefits among adults.10–12
2023;57:225–229. physical activity (MVPA); however, from 2007 in Moreover, meeting guidelines for both activities in
Garcia-Hermoso A, et al. Br J Sports Med 2023;57:225–229. doi:10.1136/bjsports-2022-106189 1 of 6

Review
comparison with meeting the guidelines for only one activity specifically designed for the present study: (1) study character-
was prospectively related to a lower risk of all-cause mortality in istics (ie, first author’s name, publication year, country, sample
adults.8 13 A recent meta-analysis examining the health outcomes size and population representativeness) and study design; (2)
of aerobic and MSA found a greater benefit for all-cause, cardio- participants’ information (eg, sex and age); (3) physical activity
vascular disease, and total cancer mortality when both guidelines assessment details (ie, self- reported, device- based measures,
were combined.10 definition) and (4) the proportion of participants meeting both
Despite being recommended globally, studies exploring the aerobic and MSA guidelines.
prevalence of both aerobic and MSA and its correlates among
general populations are limited compared with those reporting Study risk of bias assessment
the compliance with aerobic physical activities. Exploring phys- The risk of study bias assessment was evaluated using a specific
ical activity guidelines adherence across key sociodemographic/ tool for prevalence studies.16 The tool consists of 10 items that
lifestyle factors (eg, education, self-rated health, body mass address both the external and internal validity of prevalence
index) is essential to assist policy makers to implement non- studies. Each item can be classified as ‘yes (low risk)’ or ‘no (high
communicable diseases prevention strategies.14 Accordingly, the risk)’, which equals to 0 and 1 points, respectively. The overall
main aim of this study was to determine the global prevalence of risk of study bias is deemed to be at ‘low risk of bias’, ‘moderate
meeting both aerobic and MSA guidelines in the general popula- risk of bias’ or ‘high risk of bias’, if the points scored are 0–3,
tion. Whenever possible, we also explored prevalence according 4–6 or 7–9, respectively.
to sociodemographic and lifestyle-related correlates categories.
Effect measures
METHODS Prevalence estimations and its 95% CIs were calculated based on
We used the methods proposed in the Preferred Reporting the total number of people in the sample and the total number
Items for Systematic Reviews and Meta-
Analyses (PRISMA) of individuals who meet both aerobic and MSA guidelines in the
guidelines.15 sample.
Eligibility criteria Synthesis methods

To be eligible for inclusion in the present meta-analysis, studies We used Stata V.17.0 (StataCorp) and the metaprop proce-
had to meet the following criteria: (1) participants: individuals dure17 to pool data from multiple studies by applying a random-
aged ≥5 years; (2) outcome: adherence to both aerobic and effects model that displayed the results as forest plots using the
MSA guidelines assessed with questionnaires and/or device- DerSimonian and Laird method. The exact or Clopper-Pearson
based measures (ie, accelerometers, heart rate monitors) and method was used to establish 95% CIs for prevalence from the
(3) study design: cross- sectional, prospective and retrospec- selected individual studies18 and a Freeman-Tukey transforma-
tive cohort studies with representative samples. Studies were tion was used to normalise the results before calculating the
excluded if they reported duplicate data from the same source pooled prevalence.19 When a study includes data from several
and year and those that only included populations diagnosed year, a pooled prevalence of all years was calculated.
with chronic diseases (eg, cancer, arthritis). When two studies Metaprop tests for intragroup heterogeneity of pooled
included duplicate data from the same source and year, the study proportions were calculated using the I2 statistic and its p value.
with the larger sample size was selected. The Luis Furuya-Kanamori (LFK) index and the Doi plot were
used to assess potential small-study effects due to publication
Information sources bias. When the values of the LFK index were –1, between –1 and
Two authors (YE and AG-H) independently searched PubMed, –2, and >–2, were deemed to represent no, minor and major
Web of Science, SportDiscus, EMBASE and Scopus databases for asymmetry, respectively.20
studies listed from inception to September 2022. Searching was Whenever possible, subgroup analyses were conducted by age
restricted to articles in English and Spanish language in peer- group (adolescents, adults and older adults), sex, body weight
reviewed journals. A professional librarian was consulted to status (underweight, normal weight, overweight and obesity),
verify the quality of the search strategy. education level (low, medium and high), smoking status (former/
non-smoker and current smoker) and self- rated health status
Search strategy (poor, moderate and good/excellent).
The following string of terms was used: ‘aerobic exercise’ AND Finally, a sensitivity analysis was conducted to assess the
‘muscle-strengthening’ AND ‘representative’ AND ‘guidelines’. robustness of the summary estimates and to determine whether
Reference lists of eligible studies were manually examined for a particular study accounted for the inconsistency. To examine
further identification of relevant articles and included if appro- the effects of each result from each study on the overall preva-
priate. Any disagreement was resolved by consensus with a third lence, results were analysed with each study removed from the
author (JFL-G). Full search strategies for all databases are shown model once.
in online supplemental emethod 1.
RESULTS
Selection process Study selection
After removing duplicates and reviewing the title and abstract The electronic search strategy retrieved 3777 studies. After
of potential studies, two authors (YE and AG-H) systematically removing duplicates and screening titles, 67 studies were
assessed the full text of identified manuscripts for eligibility. assessed for eligibility based on full text. A total of 21 studies
were finally included in the present meta- analysis.8 9 21–39
Data collection process and data items The PRISMA flow diagram illustrating the number of studies
The following data were extracted from each study by two excluded at each stage of the systematic review and meta-
authors (YE and AG-H), using a Microsoft Excel spreadsheet analysis is shown in figure 1. A reference list of excluded
2 of 6 Garcia-Hermoso A, et al. Br J Sports Med 2023;57:225–229. doi:10.1136/bjsports-2022-106189

Review
%
Study Prevalence (95% CI) Weight Country n
Adolescents 12-17 years

CDC 2011 12.20 (11.57, 12.87) 2.01 USA 9701
Chen et al. 2021 19.20 (18.72, 19.69) 2.01 USA 25780
Duijvestijn et al. 2020 33.92 (31.35, 36.59) 1.95 The Netherlands 1250
Song et al. 2013 16.30 (15.42, 17.21) 2.00 USA 6547
Subtotal (I2 = 99.34%, p = 0.00) 19.74 (14.72, 25.31) 7.97
Adults ≥18 years old

Bennie and Wiesner 2022 21.61 (20.71, 22.53) 2.00 Norway 7845
Bennie and Wiesner 2022 9.10 (8.33, 9.93) 2.00 Lithuania 5011
Bennie and Wiesner 2022 11.40 (10.90, 11.92) 2.01 France 15107
Bennie and Wiesner 2022 30.60 (29.88, 31.33) 2.01 Austria 15519
Bennie and Wiesner 2022 11.51 (10.67, 12.40) 2.00 Estonia 5267
Bennie and Wiesner 2022 17.10 (16.58, 17.63) 2.01 United Kingdom 19810
Bennie and Wiesner 2022 24.20 (22.87, 25.57) 1.99 Luxembourg 3885
Bennie and Wiesner 2022 6.80 (6.20, 7.45) 2.00 Bulgaria 6221
Bennie and Wiesner 2022 23.51 (22.45, 24.60) 2.00 Slovenia 6015
Bennie and Wiesner 2022 13.89 (13.01, 14.82) 2.00 Hungary 5622
Bennie and Wiesner 2022 6.09 (5.39, 6.88) 1.99 Malta 3974
Bennie and Wiesner 2022 17.70 (16.98, 18.46) 2.01 Ireland 10246
Bennie and Wiesner 2022 8.30 (7.66, 8.99) 2.00 Czechia 6617
Bennie and Wiesner 2022 28.10 (27.53, 28.67) 2.01 Germany 24016
Bennie and Wiesner 2022 9.10 (8.69, 9.53) 2.01 Portugal 17769
Bennie and Wiesner 2022 11.10 (10.29, 11.97) 2.00 Slovakia 5350
Bennie and Wiesner 2022 9.10 (8.44, 9.80) 2.00 Latvia 6836
Bennie and Wiesner 2022 35.51 (34.30, 36.73) 2.00 Sweden 5982
Bennie and Wiesner 2022 5.60 (5.31, 5.90) 2.01 Poland 23281
Bennie and Wiesner 2022 9.80 (9.43, 10.18) 2.01 Italy 24493
Bennie and Wiesner 2022 30.80 (29.64, 31.98) 2.00 Finland 6000
Bennie and Wiesner 2022 30.70 (29.51, 31.91) 2.00 Denmark 5639
Bennie and Wiesner 2022 0.50 (0.40, 0.62) 2.01 Romania 16107
Bennie and Wiesner 2022 6.00 (5.35, 6.71) 2.00 Cyprus 4737
Bennie and Wiesner 2022 5.71 (5.11, 6.37) 2.00 Croatia 5256
Bennie and Wiesner 2022 7.50 (6.95, 8.10) 2.00 Greece 8103
Bennie and Wiesner 2022 11.50 (11.09, 11.93) 2.01 Spain 22321
Bennie and Wiesner 2022 53.39 (51.80, 54.98) 1.99 Iceland 3774
Bennie et al. 2016 15.00 (14.29, 15.75) 2.00 Australia 9284
Bennie et al. 2017 10.80 (10.56, 11.04) 2.01 Finland 64380
Bennie et al. 2020 A 20.20 (20.14, 20.26) 2.01 USA 1677108
Bennie et al. 2020 B 15.39 (14.67, 16.15) 2.00 South Korea 9120
Bennie et al. 2021 22.60 (22.08, 23.13) 2.01 Germany 24016
Churrilla et al. 2022 23.50 (23.35, 23.65) 2.01 USA 323435
Dankel et al. 2016 11.01 (10.14, 11.95) 2.00 USA 4587
de Cocker et al. 2020 25.70 (24.99, 26.43) 2.01 United Kingdom 14050
Dorner et al. 2021 23.80 (23.32, 24.29) 2.01 Austria 29531
Duijvestijn et al. 2020 43.55 (42.74, 44.36) 2.01 The Netherlands 14368
Lackinger and Dorner, 2015 39.40 (35.07, 43.90) 1.85 Austria 467
Lee et al. 2022 Cohort A 14.50 (14.25, 14.75) 2.01 South Korea 76395
Lee et al. 2022 Cohort B 12.68 (11.38, 14.10) 1.98 South Korea 2295
Sandercock et al. 2022 26.50 (26.34, 26.67) 2.01 United Kingdom 275182
Sung et al. 2022 14.50 (14.06, 14.96) 2.01 South Korea 23505
Wennman and Borodulin, 2020 34.21 (32.95, 35.49) 2.00 Finland 5335
WhitÞeld et al. 2019 24.30 (23.75, 24.86) 2.01 USA 23006
Zhao et al. 2020 15.90 (15.80, 16.00) 2.01 USA 479856
Subtotal (I2 = 99.92%, p = 0.00) 17.12 (15.42, 18.88) 92.03
Heterogeneity between groups: p = 0.345

Overall (I2 = 99.92%, p = 0.00); 17.32 (15.70, 19.01) 100.00
0 20 40 60
Figure 2 Forest plot of adherence to both aerobic and muscle-

strengthening activities guidelines in adolescents aged 12–17 years and
adults ≥18 years old.
Figure 1 PRISMA flow diagram. PRISMA, Preferred Reporting Items

for Systematic Reviews and Meta-Analyses. Risk of bias in studies
All studies were deemed to be at low risk of bias, presenting
scores ranging between 0 and 2 points. The main sources of bias
articles and reasons for exclusion based on the full text is were related to the reliability and validity of the study instrument
detailed in online supplemental emethod 2. that measured physical activity,22 24–26 28 30 34 37 39 or to response
rates lower than 75%.22 23 28 33 35 A summary of the risk of bias
scoring is shown in online supplemental eTable 2.
Study characteristics
The main characteristics of the included studies are described Results of individual studies and synthesis
in online supplemental eTable 1. Twenty-one studies fulfilled Figure 2 shows the overall adherence to both aerobic and MSA
eligibility criteria and were included in the systematic review, guidelines in adults. A total of 670 505 participants met both
including 3 390 001 participants (51.1% women). Age of the physical activity guidelines. The overall adherence to both phys-
participants ranged between 12 and 95 years, since no represen- ical activity guidelines in participants ≥18 years was 17.12%
tative studies reported data for children aged 5–11 years. (95% CI 15.42% to 18.88%, p<0.001, I2=99.92%) (n=3
Studies were conducted in Australia,21 Austria,30 32 Bulgaria,26 346 723) and 19.74% (95% CI 14.72% to 25.31%, p<0.001,
Croatia,26 Cyprus,26 Czechia,26 Denmark,26 Estonia,26 I2=99.34%) in individuals aged 12–17 years (n=43 278)
Finland,22 26 France,26 Germany,25 26 Greece,26 Hungary,26 (figure 2).
Iceland,26 Ireland,26 Italy,26 Latvia,26 Lithuania,26 Luxemburg,26 Subgroup analyses according to sex, age, body mass index,
Malta,26 The Netherlands,26 31 Norway,26 Poland,26 Portugal,26 education level, smoking status and self- rated health status
Romania,26 Slovakia,26 Slovenia,26 South Korea,24 33 36 Spain,26 among adults are shown in figure 3. Unfortunately, sociodemo-
Sweden,26 the UK26 and the USA.8 9 23 27 29 35 38 39 Sources of graphic and lifestyle factors among children and adolescents were
not explored due to insufficient information in this population.
information included the National Nutrition and Physical
Adherence to both physical activity guidelines was higher in men
Activity Survey,21 Regional Health and Well-being Study,22 US
(23.50%, 95% CI 20.46% to 26.67%, p<0.001, I2=99.91%)
Behavioural Risk Factor Surveillance System surveys,23 27 Korea
than in women (17.42%, 95% CI 14.73% to 20.30%, p<0.001,
National Health and Nutritional Examination Survey,24 36
I2=99.92%) (difference between groups p<0.001) (online
German Health Update Survey,25 European Health Interview supplemental eFigure 1). According to age group, adherence
Survey,26 National Youth Physical Activity and Nutrition Study,39 to physical activity guidelines was 21.21% (95% CI 17.45% to
Youth Risk Behaviour Survey,9 Health Survey for England 25.22%, p<0.001, I2=99.90%) and 13.63% (95% CI 8.18%
study,28 National Health and Nutrition Examination Survey,29 35 to 20.20%, p<0.001, I2=99.79%) in adults and older adults
Austrian Health Interview Surveys,30 32 Dutch Health Survey/ (difference between groups p=0.049), respectively (online
Lifestyle Monitor by Statistics Netherlands,31 National Health supplemental eFigure 2). Regarding weight status, adherence to
Insurance Service of South Korea,33 Active Lives Survey34 37 37 the physical activity guidelines was 12.62% (95% CI 9.92% to
and the NHIS.8 38 Aerobic and MSA were self-reported in most 15.60%, p<0.001, I2=82.72%), 19.87% (95% CI 17.93% to
studies, although one study29 directly measured aerobic physical 21.87%, p<0.001, I2=99.31%), 14.98% (95% CI 12.76% to
activity through accelerometers. 17.35%, p<0.001, I2=99.62%), and 9.77% (95% CI 7.98%

Review
P value* Participants Prevalence (95% CI) women, older age and individuals with low/medium education
Sex <0.001
23.50 (20.46 to 26.67)
levels, underweight or obesity, and poorer or moderate self-rated
Men 1 051 476
Women 1 148 869 17.42 (14.73 to 20.30) health showed lower adherence to the physical activity guide-
Age 0.049
Adolescents 12-17 years 43 278 19.74 (14.72 to 25.31) lines, although the prevalence remained very low in all cases.
Adults 18-64 years 514 958 21.21 (17.45 to 25.22)
13.63 (8.18 to 20.20)
Two studies that pooled adult aerobic physical activity levels
Older adults >64 years 106 619
BMI <0.001 from large population surveys found that the global prevalence
Underweight
was 69%5 and 73%.6 The physical activity prevalence estimates
11 284 12.62 (9.92 to 15.60)
Normalweight 337 186 19.87 (17.93 to 21.87)
Overweight 332 602 14.98 (12.76 to 17.35)
9.77 (7.98 to 11.71)
presented in the present study suggest that physical inactivity
Obesity 193 179
Education level <0.001 among global population is underestimated. Our findings indi-
Low 156 620 8.26 (4.63 to 12.80)
Medium 366 777 19.56 (14.23 to 25.50) cate that the prevalence of meeting both aerobic and MSA
High
0.136
318 155 26.50 (20.53 to 32.95)
guidelines is threefold lower. Lower prevalence of meeting
Smoking status
Former/non-smokers 486 209 17.23 (14.88 to 19.72) physical activity guidelines was found among adults from
Current smoker 126 864 14.30 (11.48 to 17.36)
Self-rated health <0.001 Southern and Central European countries (Romania, Poland,
Very good/good/excellent
Fair/moderate
34 340
94 185
20.56 (16.47 to 24.99)
8.16 (4.55 to 12.69)
Croatia, Cyprus and Malta) and the USA when compared with
Very poor/poor 246 973 5.06 (3.72 to 6.59) those from Northern European countries (Iceland, Sweden, The
Netherlands and Denmark). Within the context of the current
0 5 10 15 20 25 30 35
meta-analysis, we are unable to identify the key causes of the
Figure 3 Forest plot of adherence to aerobic and muscle- geographical differences; however, a possible explanation for
strengthening activities guidelines by age group, sex, body weight this might be the different instruments used to measure physical
status, education level, smoking status and self-rated health status. activity. Another possible explanation could be the adoption of
*Difference between groups. BMI, body mass index. different exercise promotion policies between countries. For
example, The Netherlands, one of the countries with higher
prevalence, adopted the physical activity guidelines in 2017,
to 11.71%, p<0.001, I2=99.16%) in participants with under- and aimed for 75% of the Dutch population to adhere to them.
weight, normal weight, overweight and obesity (difference The government launched several national policies or action
between groups p<0.001), respectively (online supplemental plans for the promotion of physical activity for health through
eFigure 3). In the case of education level, the adherence to the collaboration between central government, the sports sector,
both aerobic and MSA guidelines was 8.26% (95% CI 4.63% municipalities, businesses, care providers and civil society
to 12.80%, p<0.001, I2=99.85%), 19.56% (95% CI 14.23% organisations.40 In this country, Duijvestijn et al31 reported a
to 25.50%, p<0.001, I2=99.93%) and 26.50% (95% CI positive trend in adherence rates, with 39.9% adherence in
20.53% to 32.95%, p<0.001, I2=99.85%), in participants with 2001 to 46.0% in 2018. Furthermore, wealth inequalities across
low, medium and high education (difference between groups countries, which likely impact an individual’s access to fitness
p<0.001), respectively (online supplemental eFigure 4). In terms facilities or the availability of free time to engage in aerobic
of smoking status, adherence to the physical activity guidelines and MSA, could also explain some of these differences. In addi-
was similar in former/non-smokers (17.23%, 95% CI 14.88% to tion, environmental and security factors, such as safe access to
19.72%, p<0.001, I2=99.59%) and current smokers (14.30%, public transport, walkability (eg, access to parks, green space,
95% CI 11.48% to 17.36%, p<0.001, I2=98.98%) (differ- street connectivity), and engagement in active commuting (ie,
ence between groups p=0.136) (online supplemental eFigure walking, cycling and other physical modes of travel to work,
5). Finally, participants who self-reported very good/excellent/ school, parks, cafes, shops, a friend’s house or other destina-
good health presented higher adherence to the physical activity tions) could be other important aspects to consider.5 By contrast,
guidelines (20.56%, 95% CI 16.47% to 24.99%, p<0.001, among adolescents the results are strikingly similar to previous
I2=99.75%) than peers reporting fair/moderate (8.16%, 95% CI estimates from large sample sizes and aerobic guidelines.5 7 This
4.55% to 12.69%, p<0.001, I2=99.66%) and very poor/poor could be attributable to the greater number of days and time
(5.06%, 95% CI 3.72% to 6.59%, p<0.001, I2=94.25%) health needed to meet the aerobic guidelines compared with the MSA
(difference between groups p<0.001) (online supplemental guidelines (ie, daily vs at least 3 days per week). Representative
eFigure 6). studies in populations aged 5–11 years are necessary.
The LFK index for the Doi plots showed minor asymmetry The sociodemographic and lifestyle- related correlates of
in adults ≥18 years old (LFK=−1.20) (online supplemental adherence to aerobic and MSA guidelines observed here are
eFigure 7) and adolescents aged 12–17 years old (LFK=1.02) largely concordant with previous research using aerobic recom-
(online supplemental eFigure 8). mendations alone.5 6 Specifically, our data show that the popu-
Sensitivity analyses show that percentages remain similar lation subgroups at higher risk of not meeting the guidelines
even removing studies/countries with lower (17.71% 95% CI were women, older adults, individuals with low/medium educa-
16.11% to 19.37%, p<0.001, I2=99.91%)26 and higher phys- tion levels, those classified as underweight or obese, and those
ical activity guidelines adherence (16.46, 95% CI 14.81% to with poorer and moderate self-rated health. The lowest likeli-
18.19%, p<0.001, I2=99.92%)26 in adults. Among adolescents, hood of meeting the combined guidelines was identified among
range of prevalence was from 16.92% (95% CI 14.37% to those with poorer self-rated health, low education and in adults
19.62%, p<0.001)31 to 22.56% (95% CI 17.13% to 28.51%, with obesity, all of them directly related.41 Along this line, a
p<0.001).39 study by Bennie et al23 in ~1.7 million US adults found that
meeting both aerobic and MSA guidelines was associated with
DISCUSSION a lower prevalence of obesity, and associations were stronger
The key finding of the present meta-analysis is that only one for higher obesity classes. Similar differences in adherence to
out of five adolescents and adults meet guidelines for aerobic physical activity guidelines have been reported in other coun-
and MSA in large representative population samples from 32 tries, including Austria,30 Australia,21 Finland,22 Germany,25
countries. Regarding sociodemographic and lifestyle factors, The Netherlands31 and South Korea,33 36 indicating that these

Review
population subgroups should be the target for future large-scale shown in figure 2 compared with those reported by individual
aerobic and MSA interventions and health promotion strategies. studies.
Our study provides an accurate estimate of prevalence of
physical activity at the population level, which is an important
modifiable chronic disease risk factor.10 11 The importance of CONCLUSION
meeting both guidelines from a clinical perspective has previ- In large samples of individuals from 32 countries, only 19% of
ously been highlighted in some studies included in the present adolescents and 17% of adults met the guidelines for aerobic
meta-analysis. For example, adults engaging in aerobic and MSA and MSA. These low prevalence levels are concerning from a
at recommended levels showed important reductions in the public health perspective, and emphasise the need to provide
risk of all-cause and cause-specific mortality8 in addition to a large-scale physical activity interventions that must be supported
lower risk for multimorbidity (eg, cardiovascular risk and type by long-term political commitment and paired with coordinated
2 diabetes).24 29 30 and sustained dissemination and communication strategies across
The main strength of this study is the large representative sectors.43 Also, representative studies among children aged 5–11
sample sizes across 32 countries. Our study also has a number years are needed.
of limitations. The most important limitation is that the meta-
analysis included only a small number of worldwide regions, Correction notice This article has been corrected since it published Online First.
mainly countries from Europe. Second, only two countries The title and results section have been updated as well as figures 2 and 3.
represented the adolescent populations (The Netherlands and Contributors AG-H conceived the study, drafted the analysis plan and manuscript,
USA) and no studies analysed children aged 5–11 years old. and conducted statistical analyses; JFL-G reviewed the analysis plan and helped to
draft the manuscript; YE assisted with data cleaning and preparation and helped to
Third, the included studies evaluated aerobic and MSA guide- draft the manuscript; MI helped to draft the manuscript; RR-V and AMA-M helped
lines compliance using different self-reported questionnaires or to draft the manuscript and provided input on the analysis plan. All authors have
interview methods and used different instruments for measuring read and approved the final version of the manuscript, and agree with the order of
physical activity, which may have contributed to the heteroge- presentation of the authors.
neity in our findings. Actually, it has been shown that even in Funding The authors have not declared a specific grant for this research from any
the same study population, responses may vary depending on funding agency in the public, commercial or not-for-profit sectors.
the used survey and how a question is formulated,42 which could Disclaimer AG-H had full access to all the data in the study and takes
affect comparability between studies. Fourth, the prevalence of responsibility for the integrity of the data and the accuracy of the data analysis. Also,
physical activity was mostly determined by self-reported survey AG-H is the responsible for the data analysis.
data, which is subject to recall bias, desirability bias and respon- Competing interests YE is an associate editor of BJSM.
dent knowledge. Nonetheless, self- report assessments remain Patient consent for publication Not applicable.
the most common method used to assess physical activity in Provenance and peer review Not commissioned; externally peer reviewed.
large population samples. Fifth, the assessment of MSA did
Supplemental material This content has been supplied by the author(s). It
not include non-exercise activities (eg, carrying shopping bags, has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have
gardening and walking upstairs). Sixth, it could be that individ- been peer-reviewed. Any opinions or recommendations discussed are solely those
uals included MSA within overall training but, because these of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
activities consume a small percentage of the session, they do not responsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability
report it as MSA, partially explaining some differences across of the translations (including but not limited to local regulations, clinical guidelines,
studies. Finally, most studies reported weighted prevalence rates, terminology, drug names and drug dosages), and is not responsible for any error
which may explain the slightly different confidence intervals and/or omissions arising from translation and adaptation or otherwise.
ORCID iDs
Antonio Garcia-Hermoso http://orcid.org/0000-0002-1397-7182
What is already known José Francisco López-Gil http://orcid.org/0000-0002-7412-7624
Robinson Ramírez-Vélez http://orcid.org/0000-0003-3075-6960
⇒ Nearly one out of three adults and one out of five adolescents Alicia María Alonso-Martínez http://orcid.org/0000-0002-7204-696X
Mikel Izquierdo http://orcid.org/0000-0002-1506-4272
do not meet public health guidelines for recommended levels Yasmin Ezzatvar http://orcid.org/0000-0003-4998-4162
of aerobic physical activity.
⇒ Current physical activity guidelines recommend a
REFERENCES
combination of both aerobic and muscle-strengthening 1 Bull FC, Al-Ansari SS, Biddle S, et al. World Health organization 2020 guidelines on
activities, however, the adherence to these guidelines across physical activity and sedentary behaviour. Br J Sports Med 2020;54:1451–62.
countries remains unknown. 2 Pate RR, Pratt M, Blair SN, et al. Physical activity and public health. A recommendation
⇒ Estimates of physical activity prevalence based on aerobic from the centers for disease control and prevention and the American College of
sports medicine. JAMA 1995;273:402–7.
physical activity guidelines are likely to underestimate the 3 Haskell WL, Lee I-MIN, Pate RR, et al. Physical activity and public health. Med Sci
true extent of physical inactivity at the population level. Sports Exerc 2007;39:1423–34.
4 Services UD of H and H. 2008 physical activity guidelines for Americans. Washington,
DC: US Department, 2008.
5 Hallal PC, Andersen LB, Bull FC, et al. Global physical activity levels: surveillance
What are the new findings progress, pitfalls, and prospects. Lancet 2012;380:247–57.
6 Guthold R, Stevens GA, Riley LM, et al. Worldwide trends in insufficient physical
⇒ Only one out of five adolescents and adults meet activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with
1·9 million participants. Lancet Glob Health 2018;6:e1077–86.
international guidelines for combined aerobic and muscle-
7 Guthold R, Stevens GA, Riley LM, et al. Global trends in insufficient physical activity
strengthening activities. among adolescents: a pooled analysis of 298 population-based surveys with 1·6
⇒ Physical activity remains very low independent of sex, age, million participants. Lancet Child Adolesc Health 2020;4:23–35.
body mass index, education level, smoking status and self- 8 Zhao M, Veeranki SP, Magnussen CG, et al. Recommended physical activity and
rated health status. all cause and cause specific mortality in US adults: prospective cohort study. BMJ
2020;370:1–10.

Review
9 Chen TJ, Watson KB, Michael SL, et al. Sex-Stratified trends in meeting physical among 280,605 adults from 28 European countries. J Phys Act Health
activity guidelines, participating in sports, and attending physical education 2022;19:56–62.
among US adolescents, youth risk behavior survey 2009-2019. J Phys Act Health 27 Churilla JR, Johnson TM, Richardson MR. Mode of physical activity participation in US
2021;18:S102–13. adults: a regional perspective. South Med J 2022;115:118–24.
10 Momma H, Kawakami R, Honda T, et al. Muscle-strengthening activities are 28 De Cocker K, Teychenne M, White RL, et al. Adherence to aerobic and muscle-
associated with lower risk and mortality in major non-communicable diseases: strengthening exercise guidelines and associations with psychological distress: a
a systematic review and meta-analysis of cohort studies. Br J Sports Med cross-sectional study of 14,050 English adults. Prev Med 2020;139:106192.
2022;56:755–63. 29 Dankel SJ, Loenneke JP, Loprinzi PD. Combined associations of Muscle-Strengthening
11 Garber CE, Blissmer B, Deschenes MR, et al. Quantity and quality of exercise for activities and Accelerometer-Assessed physical activity on multimorbidity: findings
developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor from NHANES. Am J Health Promot 2017;31:274–7.
fitness in apparently healthy adults. Med Sci Sports Exerc 2011;43:1334–59. 30 Dorner TE, Lackinger C, Haider S, et al. Lifestyle parameters in patients with
12 Izquierdo M, Merchant RA, Morley JE, et al. International exercise recommendations diabetes mellitus and in the general adult Population-Trends over five years: results
in older adults (ICFSR): expert consensus guidelines. J Nutr Health Aging of the Austrian National health interview series. Int J Environ Res Public Health
2021;25:824–53. 2021;18:9910.
13 Stamatakis E, Lee I-M, Bennie J, et al. Does Strength-Promoting exercise confer 31 Duijvestijn M, van den Berg SW, Wendel-Vos GCW. Adhering to the 2017 Dutch
unique health benefits? A pooled analysis of data on 11 population cohorts physical activity guidelines: a trend over time 2001–2018. Int J Environ Res Public
with all-cause, cancer, and cardiovascular mortality endpoints. Am J Epidemiol Health 2020;17:681.
2018;187:1102–12. 32 Lackinger C, Dorner TE. Achievement of physical activity recommendation
14 Bauman AE, Reis RS, Sallis JF, et al. Correlates of physical activity: why are some and activity levels in students of human medicine compared with the general
people physically active and others not? The Lancet 2012;380:258–71. Austrian population aged between 20 and 29 years. Wien Med Wochenschr
15 Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated 2015;165:116–23.
guideline for reporting systematic reviews. BMJ 2021;372:n71.
33 Lee SW, Lee J, Moon SY, et al. Physical activity and the risk of SARS-CoV-2 infection,
16 Hoy D, Brooks P, Woolf A, et al. Assessing risk of bias in prevalence studies:
severe COVID-19 illness and COVID-19 related mortality in South Korea: a nationwide
modification of an existing tool and evidence of interrater agreement. J Clin Epidemiol
cohort study. Br J Sports Med 2022;56:901–12.
2012;65:934–9.
34 Sandercock GRH, Moran J, Cohen DD. Who is meeting the strengthening physical
17 Nyaga VN, Arbyn M, Aerts M. Metaprop: a Stata command to perform meta-analysis
activity guidelines by definition: a cross-sectional study of 253 423 English adults?
of binomial data. Arch Public Health 2014;72:1–10.
PLoS One 2022;17:e0267277–18.
18 Newcombe RG. Two-Sided confidence intervals for the single proportion: comparison
35 Song M, Carroll DD, Fulton JE. Meeting the 2008 physical activity guidelines for
of seven methods. Stat Med 1998;17:857–72.
Americans among U.S. youth. Am J Prev Med 2013;44:216–22.
19 Barendregt JJ, Doi SA, Lee YY, et al. Meta-Analysis of prevalence. J Epidemiol
36 Sung H, Kim G, Ma X, et al. Physical activity trends in Korean adults from Korea
Community Health 2013;67:974–8.
20 Furuya-Kanamori L, Barendregt JJ, Doi SAR. A new improved graphical and National health and nutritional examination survey from 2014 to 2019. Int J Environ
quantitative method for detecting bias in meta-analysis. Int J Evid Based Healthc Res Public Health 2022;19:5213.
2018;16:195–203. 37 Wennman H, Borodulin K. Associations between physical activity types and reaching
21 Bennie JA, Pedisic Z, van Uffelen JGZ, et al. The descriptive epidemiology of total the physical activity guidelines: the FinHealth 2017 study. Scand J Med Sci Sports
physical activity, muscle-strengthening exercises and sedentary behaviour among 2021;31:418–26.
Australian adults--results from the National Nutrition and Physical Activity Survey. 38 Whitfield GP, Carlson SA, Ussery EN, et al. Trends in meeting physical activity
BMC Public Health 2016;16:73. guidelines among urban and rural Dwelling adults — United States, 2008–2017.
22 Bennie JA, Pedisic Z, Suni JH, et al. Self-Reported health-enhancing physical activity MMWR Morb Mortal Wkly Rep 2019;68:513–8.
recommendation adherence among 64,380 Finnish adults. Scand J Med Sci Sports 39 Centers for Disease Control and Prevention (CDC). Physical activity levels of
2017;27:1842–53. high school students --- United States, 2010. MMWR Morb Mortal Wkly Rep
23 Bennie JA, De Cocker K, Pavey T, et al. Muscle strengthening, aerobic exercise, and 2011;60:773–7.
obesity: a pooled analysis of 1.7 million us adults. Obesity 2020;28:371–8. 40 World Health Organization. Netherlands physical activity Factsheet 2021, 2021.
24 Bennie JA, Ding D, Khan A, et al. Run, lift, or both? associations between concurrent Available: https://www.who.int/europe/publications/m/item/physical-activity-
aerobic-muscle strengthening exercise with adverse cardiometabolic biomarkers factsheet-netherlands-2021
among Korean adults. Eur J Prev Cardiol 2020;27:738–48. 41 Adler NE, Rehkopf DH. U.S. disparities in health: descriptions, causes, and
25 Bennie JA, De Cocker K, Tittlbach S. The epidemiology of muscle-strengthening and mechanisms. Annu Rev Public Health 2008;29:235–52.
aerobic physical activity guideline adherence among 24,016 German adults. Scand J 42 Brown WJ, Trost SG, Bauman A, et al. Test-Retest reliability of four physical activity
Med Sci Sports 2021;31:1096–104. measures used in population surveys. J Sci Med Sport 2004;7:205–15.
26 Bennie JA, Wiesner GH. Health-Enhancing physical activity in Europe-Combined 43 Ding D, Mutrie N, Bauman A, et al. Physical activity guidelines 2020: comprehensive
aerobic physical activity and Muscle-Strengthening exercise guideline adherence and inclusive recommendations to activate populations. Lancet 2020;396:1780–2.

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material placed on this supplemental material which has been supplied by the author(s) Br J Sports Med
Electronic supplementary material
Adherence to aerobic and muscle-strengthening activities guidelines: A systematic

review and meta-analysis of 3.3 million participants across 31 countries
Online supplemental emethod 1. Electronic search strategy.
Online supplemental emethod 2. Excluded studies and reasons for exclusion.
Online supplemental eTable 1. Results of the quality assessment checklist for

prevalence studies.
Online supplemental eFigure 1. Forest plot of adherence to aerobic and muscle-

strengthening activities guidelines by sex.

strengthening activities guidelines by age.

strengthening activities guidelines by weight status.

strengthening activities guidelines by education level.

strengthening activities guidelines by smoking status.

strengthening activities guidelines by self-rated health status.
Online supplemental eFigure 7. Doi plot for adults ≥ 18 years old.
Online supplemental eFigure 8. Doi plot for adolescents aged 12-17 years old.
Garcia-Hermoso A, et al. Br J Sports Med 2022;0:1–6. doi: 10.1136/bjsports-2022-106189

PubMed
#1 ((("aerobic"[All Fields] AND "aerobic"[All Fields]) OR OR "exercise"[MeSH

Terms] OR "exercise"[All Fields] AND ("exercise"[MeSH Terms] OR "exercise"[All
Fields] OR ("physical"[All Fields] AND "activity"[All Fields]) OR "physical
activity"[All Fields]) AND ("muscle-strengthening"[All Fields] AND ("activable"[All
Fields] OR "activate"[All Fields] OR "activated"[All Fields] OR "activates"[All Fields]
OR "activating"[All Fields] OR "activation"[All Fields] OR "activations"[All Fields]
OR "activator"[All Fields] OR "activator s"[All Fields] OR "activators"[All Fields] OR
"active"[All Fields] OR "actived"[All Fields] OR "actively"[All Fields] OR
"actives"[All Fields] OR "activities"[All Fields] OR "activity s"[All Fields] OR
"activitys"[All Fields] OR "motor activity"[MeSH Terms] OR ("motor"[All Fields]
AND "activity"[All Fields]) OR "motor activity"[All Fields] OR "activity"[All Fields]))
AND ("strengthen"[All Fields] OR "strengthened"[All Fields] OR "strengthening"[All
Fields] OR "strengthens"[All Fields])) OR ("muscle-strengthening"[All Fields] AND
("exercise"[MeSH Terms] OR "exercise"[All Fields] OR "exercises"[All Fields] OR
"exercise therapy"[MeSH Terms] OR ("exercise"[All Fields] AND "therapy"[All
Fields]) OR "exercise therapy"[All Fields] OR "exercise s"[All Fields] OR
"exercised"[All Fields] OR "exerciser"[All Fields] OR "exercisers"[All Fields] OR
"exercising"[All Fields])))
#2 ("adherance"[All Fields] OR "adhere"[All Fields] OR "adhered"[All Fields] OR

"adherence"[All Fields] OR "adherences"[All Fields] OR "adherent"[All Fields] OR
"adherents"[All Fields] OR "adherer"[All Fields] OR "adherers"[All Fields] OR
"adheres"[All Fields] OR "adhering"[All Fields]) AND ("guideline"[Publication Type]
OR "guidelines as topic"[MeSH Terms] OR "guidelines"[All Fields] OR
"recommendation as topic"[MeSH Terms] OR "recommendation"[All Fields])
#3 #1 AND #2
Web of Science
#1 TOPIC: ("aerobic physical activity" OR "exercise")
#2 TOPIC: ("muscle-strengthening" OR “strengthening” OR “strengthen” OR

“strengthened” OR “strengthens”)
#3 TOPIC: ("adherence" OR “adhering”)
#4 TOPIC: ("guideline" OR “guidelines” OR “recommendation”)
#5 #4 AND #3 AND #2 AND #1
SPORTDiscus

S1 (MH " aerobic physical activity") OR (MH "exercise")
S2 (MH " muscle-strengthening") OR ‘strengthening’ OR ‘strengthen’ OR

‘strengthened’ OR ‘strengthens’
S3 ((MH "adherence") OR ‘adhering’
S4 (MH "guideline") OR ‘guideline’ OR ‘recommendation’
S5 S4 AND S3
EMBASE
(('adherence'/exp OR adherence OR adhering:ti,ab,kw) AND 'physical activity':ti,ab,kw

OR exercise:ti,ab,kw) AND ('resistance training':ti,ab,kw OR 'strengthening
exercise':ti,ab,kw) AND (guideline:ti,ab,kw OR recommendation:ti,ab,kw OR
guidelines)
Scopus
( TITLE-ABS-KEY ( adherence OR adhering ) AND TITLE-ABS-KEY ( "aerobic

physical activity" OR exercise OR "physical activity" ) AND TITLE-ABS-KEY (
strength OR strengthening OR muscle-strengthening OR strengthen OR
strengthening ) AND TITLE-ABS-KEY ( guidelines OR guideline OR
recommendations ) )

Ahn, H., Choi, H. Y., & Ki, M. (2010). The association between levels of physical
activity and low handgrip strength: Korea National. People, 39(4), 412-23.
Reason for exclusion: Duplicated
Bennie, J. A., De Cocker, K., Teychenne, M. J., Brown, W. J., & Biddle, S. J. (2019).
The epidemiology of aerobic physical activity and muscle-strengthening activity
guideline adherence among 383,928 US adults. International Journal of Behavioral
Nutrition and Physical Activity, 16(1), 1-11.
Bennie, J. A., Teychenne, M. J., De Cocker, K., & Biddle, S. J. (2019). Associations
between aerobic and muscle-strengthening exercise with depressive symptom severity
among 17,839 US adults. Preventive medicine, 121, 121-127.
Bennie, J. A., De Cocker, K., Biddle, S. J., & Teychenne, M. J. (2020). Joint and dose‐
dependent associations between aerobic and muscle‐strengthening activity with
depression: A cross‐sectional study of 1.48 million adults between 2011 and 2017.
Depression and anxiety, 37(2), 166-178.
Bennie, J. A., De Cocker, K., & Duncan, M. J. (2021). Associations of muscle-

strengthening and aerobic exercise with self-reported components of sleep health among
a nationally representative sample of 47,564 US adults. Sleep Health, 7(2), 281-288.
Bennie, J. A., Ding, D., & De Cocker, K. Dose-dependent associations of joint aerobic
and muscle-strengthening exercise with obesity: A cross-sectional study of 280,605
adults. Journal of sport and health science, S2095-2546.
Blackwell, D. L., & Clarke, T. C. (2016). Occupational Differences Among Employed

Adults Who Met 2008 Federal Guidelines for Both Aerobic and Muscle-strengthening
Activities: United States, 2008-2014. National health statistics reports, (94), 1-12.
Blackwell, D. L., & Clarke, T. C. (2018). State variation in meeting the 2008 federal
guidelines for both aerobic and muscle-strengthening activities through leisure-time
physical activity among adults aged 18-64: United States, 2010-2015. National health
statistics reports, (112), 1-22.

Branscum, P., & Fairchild, G. (2019). Differences in determinants of aerobic and

muscle strengthening physical activity among college students: a reasoned action
approach. Journal of Sports Sciences, 37(1), 90-99.
Reason for exclusion: Non-representative sample
Buckner, S. L., Loenneke, J. P., & Loprinzi, P. D. (2017). Single and combined
associations of accelerometer‐assessed physical activity and muscle‐strengthening
activities on plasma homocysteine in a national sample. Clinical physiology and
functional imaging, 37(6), 669-674.
Carlson, S. A., Fulton, J. E., Schoenborn, C. A., & Loustalot, F. (2010). Trend and
prevalence estimates based on the 2008 Physical Activity Guidelines for Americans.
American journal of preventive medicine, 39(4), 305-313.
Centers for Disease Control and Prevention (CDC. (2013). Suicide among adults aged
35-64 years--United States, 1999-2010. MMWR. Morbidity and mortality weekly
report, 62(17), 321-325.
Harris, C. D., Watson, K. B., Carlson, S. A., Fulton, J. E., Dorn, J. M., & Elam-Evans,
L. (2013). Adult participation in aerobic and muscle-strengthening physical activities—
United States, 2011. Morbidity and Mortality Weekly Report, 62(17), 326-330.
Chen, S., Malete, L., & Ling, J. An examination of physical activity guidelines and
health-related quality of life among US older adults. Preventive medicine, 156, 106986.
Dankel, S. J., Loenneke, J. P., & Loprinzi, P. D. (2016). The individual, joint, and
additive interaction associations of aerobic-based physical activity and muscle
strengthening activities on metabolic syndrome. International journal of behavioral
medicine, 23(6), 707-713.
Desmond, R., Jackson, B. E., & Hunter, G. (2015). Utilization of 2013 BRFSS Physical
Activity Data for State Cancer Control Plan Objectives: Alabama Data. Southern
Medical Journal, 108(5), 290-297.

Du, Y., Liu, B., Sun, Y., Snetselaar, L. G., Wallace, R. B., & Bao, W. (2019). Trends in
adherence to the physical activity guidelines for Americans for aerobic activity and time
spent on sedentary behavior among US adults, 2007 to 2016. JAMA network open,
2(7), e197597.
Reason for exclusion: Study design
Lange, C., & Manz, K. (2017). Health-enhancing physical activity during leisure time
among adults in Germany. Journal of Health Monitoring, 2(2).
Grøntved, A., Pan, A., Mekary, R. A., Stampfer, M., Willett, W. C., Manson, J. E., &
Hu, F. B. (2014). Muscle-strengthening and conditioning activities and risk of type 2
diabetes: a prospective study in two cohorts of US women. PLoS medicine, 11(1),
e1001587.
Hyde, E. T., Whitfield, G. P., Omura, J. D., Fulton, J. E., & Carlson, S. A. (2021).
Trends in meeting the Physical Activity Guidelines: muscle-strengthening alone and
combined with aerobic activity, United States, 1998–2018. Journal of Physical Activity
and Health, 18(S1), S37-S44.
Hyde, E. T., Watson, K. B., Omura, J. D., Janz, K. F., Lee, S. M., Fulton, J. E., &
Carlson, S. A. (2021). Surveillance of Meeting the Youth Physical Activity Guideline:
Impact of Including Vigorous-Intensity and Bone-Strengthening Activities. Research
Quarterly for Exercise and Sport, 1-6.
Kim, J. (2017). Longitudinal trend of prevalence of meeting physical activity guidelines

among korean adults. Exercise Medicine, 1.
Lim, J., Park, S., & Kim, J. S. (2021). Joint association of aerobic physical activity and
muscle-strengthening activities with metabolic syndrome: the Korean National Health
and Nutrition Examination Survey 2014-2015. Epidemiology and health, 43, e2021096.
Mama, S. K., Bhuiyan, N., Foo, W., Segel, J. E., Bluethmann, S. M., Winkels, R. M., ...
& Schmitz, K. H. (2020). Rural-urban differences in meeting physical activity
recommendations and health status in cancer survivors in central Pennsylvania.
Supportive Care in Cancer, 28(10), 5013-5022.

Reason for exclusion: Clinical population
Mekary, R. A., Grøntved, A., Despres, J. P., De Moura, L. P., Asgarzadeh, M., Willett,
W. C., ... & Hu, F. B. (2015). Weight training, aerobic physical activities, and long‐term
waist circumference change in men. Obesity, 23(2), 461-467.
Merlo, C. L., Jones, S. E., Michael, S. L., Chen, T. J., Sliwa, S. A., Lee, S. H., ... &
Park, S. (2020). Dietary and Physical Activity Behaviors Among High School Students-
Youth Risk Behavior Survey, United States, 2019. MMWR supplements, 69(1), 64-76.
Mu, L., Cohen, A. J., & Mukamal, K. J. (2015). Prevalence and predictors of resistance
and aerobic exercise among hypertensive adults in the United States. Journal of human
hypertension, 29(6), 394-395.
Murphy, L. B., Hootman, J. M., Boring, M. A., Carlson, S. A., Qin, J., Barbour, K. E.,
... & Helmick, C. G. (2017). Leisure Time Physical Activity Among US Adults With
Arthritis, 2008− 2015. American Journal of Preventive Medicine, 53(3), 345-354.
Nie, J., Haberstroh, M., Acosta, T., Huang, W., Wang, Y., & Barengo, N. C. (2021).
Independent and joint associations between leisure time physical activity and strength
activities with mortality outcomes in older adults at least 65 years of age: a prospective
cohort study. The Journals of Gerontology: Series A, 76(12), 2122-2131.
Oftedal, S., Smith, J., Vandelanotte, C., Burton, N. W., & Duncan, M. J. (2019).
Resistance training in addition to aerobic activity is associated with lower likelihood of
depression and comorbid depression and anxiety symptoms: a cross sectional analysis
of Australian women. Preventive Medicine, 126, 105773.
Oftedal, S., Holliday, E. G., Reynolds, A. C., Bennie, J. A., Kline, C. E., & Duncan, M.
J. (2022). Prevalence, Trends, and Correlates of Joint Patterns of Aerobic and Muscle-
Strengthening Activity and Sleep Duration: A Pooled Analysis of 359,019 Adults in the
National Health Interview Survey 2004–2018. Journal of Physical Activity and Health,
19(4), 246-255.

Quinn, T. D., Wu, F., Mody, D., Bushover, B., Mendez, D. D., Schiff, M., & Fabio, A.
(2019). Associations Between Neighborhood Social Cohesion and Physical Activity in
the United States, National Health Interview Survey, 2017. Preventing Chronic Disease,
16, E163.
Schoenborn, C. A., & Stommel, M. (2011). Adherence to the 2008 adult physical
activity guidelines and mortality risk. American journal of preventive medicine, 40(5),
514-521.
Siahpush, M., Levan, T. D., Nguyen, M. N., Grimm, B. L., Ramos, A. K., Michaud, T.
L., & Johansson, P. L. (2019). The association of physical activity and mortality risk
reduction among smokers: Results from 1998–2009 national health Interview surveys–
national death index linkage. Journal of Physical Activity and Health, 16(10), 865-871.
Song, M., Nam, S., Buss, J., & Lee, S. J. (2020). Assessing the prevalence of meeting
physical activity recommendations among US healthcare workers: Data from the 2015
National Health Interview Survey. Archives of Environmental & Occupational Health,
75(7), 422-430.
Strain, T., Fitzsimons, C., Kelly, P., & Mutrie, N. (2016). The forgotten guidelines:
cross-sectional analysis of participation in muscle strengthening and balance & co-
ordination activities by adults and older adults in Scotland. BMC public health, 16(1),
1-12.
Sudeck, G., Geidl, W., Abu-Omar, K., Finger, J. D., Krauß, I., & Pfeifer, K. (2021). Do
adults with non-communicable diseases meet the German physical activity
recommendations?. German Journal of Exercise and Sport Research, 51(2), 183-193.
Sung, J. H., Son, S. R., Baek, S. H., & Kim, B. J. (2021). Association of occupation
with the daily physical activity and sedentary behaviour of middle-aged workers in
Korea: a cross-sectional study based on data from the Korea National Health and
Nutrition Examination Survey. BMJ open, 11(11), e055729.
Tarasenko, Y., Chen, C., & Schoenberg, N. (2017). Self‐reported physical activity
levels of older cancer survivors: Results from the 2014 National Health Interview
Survey. Journal of the American Geriatrics Society, 65(2), e39-e44.

Tarasenko, Y. N., Linder, D. F., & Miller, E. A. (2018). Muscle-strengthening and

aerobic activities and mortality among 3+ year cancer survivors in the US. Cancer
Causes & Control, 29(4), 475-484.
Tittlbach, S. A., Hoffmann, S. W., & Bennie, J. A. (2022). Association of meeting both
muscle strengthening and aerobic exercise guidelines with prevalent overweight and
obesity classes-results from a nationally representative sample of German adults.
European Journal of Sport Science, 22(3), 436-446.
Visaria, A., Nagaraj, B., Shah, M., Kethidi, N., Modak, A., Shahani, J., ... &
Raghuwanshi, M. (2022). Low Amount and Intensity of Leisure-time Physical Activity
in Asian Indian Adults. American Journal of Health Promotion, 36(3), 440-449.
Walker, T. J., Tullar, J. M., Diamond, P. M., Kohl, H. W., & Amick, B. C. (2017). The
relation of combined aerobic and muscle-strengthening physical activities with
presenteeism. Journal of Physical Activity and Health, 14(11), 893-898.
Watson, K. B., Whitfield, G., Chen, T. J., Hyde, E. T., & Omura, J. D. (2021). Trends in
Aerobic and Muscle-Strengthening Physical Activity by Race/Ethnicity Across Income
Levels Among US Adults, 1998–2018. Journal of Physical Activity and Health, 18(S1),
S45-S52.
Xin, F., Zhu, Z., Chen, S., Chen, H., Hu, X., Ma, X., ... & Tang, Y. (2022). Prevalence
and correlates of meeting the muscle-strengthening exercise recommendations among
Chinese children and adolescents: Results from 2019 Physical Activity and Fitness in
China—The Youth Study. Journal of Sport and Health Science, 11(3), 358-366.
Zhao, G., Li, C., Ford, E. S., Fulton, J. E., Carlson, S. A., Okoro, C. A., ... & Balluz, L.
S. (2014). Leisure-time aerobic physical activity, muscle-strengthening activity and
mortality risks among US adults: the NHANES linked mortality study. British journal
of sports medicine, 48(3), 244-249.

Online supplemental eTable 1. Characteristics of studies included in the meta-

analysis.
Physical activity
N (%
Author, Study Source of Study assessment and Overall
Country females)
year design information period physical active prevalence
/ Age
definition
Active Australia
Survey
National
9,284
Bennie et Nutrition and
Cross- 2011- (54.1) / ≥150 MVPA min
al. 2016 Australia Physical 15%
sectional 2012 18-85 per week and ≥2
[21] Activity Survey
years sessions per week
(NNPAS)
of strength or
toning activities
Self-reported
Finnish
recommendations:
≥150 moderate-
intensity min per
week or ≥75
vigorous-intensity
Bennie et Regional Health 69,032
Cross- 2013- min per week or
al. 2017 Finland and Well-being (52.0) / ≥ 10.8%
sectional 2014 an equivalent
[22] Study 18 years
combination of
both and reporting
MVPA on ≥3
days per week
and ≥2 times per
week of MSA
and/or balance
training
Behavioural Risk
Factor
Surveillance
System
Meeting both 150

min per week of
US Behavioral
moderate-
Risk Factor
Bennie et 1,677,108 intensity aerobic
Cross- Surveillance 2011-
al. 2020 A USA (51.6) / ≥ physical activity, 20.2%
sectional System 2017
[23] 18 years or 75 min per
(BRFSS)
week of vigorous-
surveys
intensity aerobic
physical activity,
or an equivalent
combination of
both and ≥ 2
sessions per week
of MSA

GPAQ
Korea National Meeting both
Bennie et Health and 9,120 MVPA ≥150
al. 2020 B South Cross- Nutritional 2014- (50.3) / minutes per week
15.4%
[24] Korea sectional Examination 2015 20-80 and muscle
Survey years strengthening
(KNHANES) exercise ≥2
sessions per week
Interview Survey
Physical Activity
Questionnaire
Bennie et 24,016 Meeting both

Cross- German Health
al. 2021 Germany 2014 (51.1) / ≥ MVPA ≥150 22.6%
sectional Update survey
[25] 18 years minutes per week
and muscle
strengthening
exercise ≥2
sessions per week
European
Health Interview
Survey – Physical
Activity
Questionnaire
European (EHIS-PAQ)
Bennie and 28 280,605
Cross- Health 2013-
Wiesner European (52.1) / ≥ 15.0%
sectional Interview 2014 Aerobic physical
2022 [26] countries 18 years
Survey activity ≥ 150
min/ per week
and muscle
strengthening
exercise ≥ 2
sessions per week
NYPANS
questions
Aerobic physical
activity and
National Youth muscle-
9,701
Physical strengthening
CDC 2011 Cross- (NR) /
USA Activity and 2010 activity 15.3%
[39] sectional 14–18
Nutrition Study participation in
years
(NYPANS) ≥60 minutes of
aerobic activity
per day, 7 days
per week and
MSA on ≥3 days
per week)
YRBS questions
86,869
Youth Risk Aerobic physical
Chen et al. Cross- 2011- (49.3) /
USA Behavior activity and 19.2%
2021 [9] sectional 2019 14-18
Survey (YRBS) muscle-
years
strengthening
activity

participation of ≥
60 min of aerobic
activity per day, 7
days per week
and MSA on ≥ 3
days per week
Behavioural Risk
Factor
Surveillance
US Behavioral System
Risk Factor
Churilla et 323,435
Cross- Surveillance Aerobic physical
al. 2022 USA 2019 (49.6) / ≥ 23.5%
sectional System activity ≥ 150 min
[27] 18 years
(BRFSS) per week and
surveys muscle
strengthening
exercise ≥ 2
sessions per week
Self-reported
questionnaire
≥ 150 min of
moderate activity
14,050 or 75 min of
de Cocker Health Survey
Cross- 2012- (56.0%) / vigorous activity
et al. 2020 UK for England 25.7%
sectional 2016 ≥ 16 per week or an
[28] (HSE) study
years equivalent
combination of
both; and
undertaking MSA
on at least two
days per week
Accelerometry
(ActiGraph 7164)
and questionnaire
National Health
Accelerometer-
Dankel et and Nutrition 4,587
Cross- 2003- determined
al. 2016 USA Examination (49.0) / ≥ 11.0%
sectional 2006 physical activity ≥
[29] Survey 20 years
150 min per week
(NHANES)
of MVPA and ≥ 8
days of MSA
within the past 30
days
European
Health Interview
Survey – Physical
Activity
31,232
Dorner et Austrian Health 2014 Questionnaire
Cross- (51.2%) /
al. 2021 Austria Interview and (EHIS-PAQ) 23.8%
sectional ≥ 15
[30] Surveys 2019
years
Aerobic physical
activity ≥ 150 min
per week and
muscle

strengthening
exercise ≥ 2
sessions per week
Short
Questionnaire to
Assess Health-
enhancing
physical activity
(SQUASH)
Adolescents:
Aerobic physical
activity and 33.9% (12-
muscle- 17 years
Dutch Health
226,083 strengthening old)
Duijvestijn Survey/Lifestyle
The Cross- (52.0%) / activity
et al. 2020 Monitor by 2018
Netherlands sectional ≥ 12 participation in ≥ 43.5%
[31] Statistics
years 60 min of aerobic (³18 years
Netherlands
activity per day, 7 old)
days per week
and MSA on ≥3
days per week
Adults: Aerobic
physical activity ≥
150 min per week
and muscle
strengthening
exercise ≥ 2
sessions per week
IPAQ
Aerobic physical
Lackinger 467
Austrian Health activity ≥ 150 min
and Cross- 2006- (46.7) /
Austria Interview per week and 39.4%
Dorner, sectional 2007 20-29
Survey muscle
2015 [32] years
strengthening
exercise ≥ 2
sessions per week
Self-reported
questionnaire
Cohort
≥ 150 min of
A: 76,395
moderate activity
(51.2) / ≥ Cohort A:
National Health or 75 min of
20 years 14.5%
Lee et al. South Cross- Insurance 2018- vigorous activity
2022 [33] Korea sectional Service of South 2019 per week or an
Cohort B: Cohort B:
Korea equivalent
2,295 12.7%
combination of
(53.5) / ≥
both; and
20 years
undertaking MSA
on at least two
days per week
Sandercock Active Lives
Cross- Active Lives 2015- 275,182
et al. 2022 UK dataset 26.5%
sectional Survey 2017 (48.9) /
[34]

18-95 150 min per week

years equivalent
moderate physical
activity including
two sessions of
strengthening
activities
Self-reported
questionnaire
National Health Aerobic physical

6547
and Nutrition activity and MSA
Song et al. Cross- 1999- (48.9) /
USA Examination participation in ≥ 16.3%
2013 [35] sectional 2006 12-17
Survey 60 min of aerobic
years
(NHANES) activity per day, 7
days per week
and MSA on ≥3
days per week
GPAQ
Korea National
Aerobic physical
Health and
23,505 activity ≥ 150 min
Sung et al. South Cross- Nutritional 2016-
(50.5) / ≥ per week and
2022 [36] Korea sectional Examination 2019 14.5%
20 years muscle
Survey
strengthening
(KNHANES)
exercise ≥ 2
sessions per week
FinHealth Health-
Enhancing
Physical Activity
Questionnaire
≥ 150 min of
Wennman moderate activity
5335
and Cross- FinHealth 2017 or 75 min of
Finland 2017 (56.0) / ≥ 34.2%
Borodulin, sectional Study vigorous activity
18 years
2020 [37] per week or an
equivalent
combination of
both; and
undertaking MSA
on at least two
days per week
Sample Adult
Core questions
150–300 min of
moderate-
Whitfield National Health 23,006
Cross- intensity, or 75–
et al. 2019 USA Interview 2017 (51.8) / ≥ 24.3%
sectional 150 min of
vigorous-intensity
aerobic physical
activity per week,
or an equivalent
combination of

moderate- and
vigorous-intensity
aerobic physical
activity and MSA
of at least
moderate
intensity that
involve all major
muscle groups on
≥ 2 days per week
Sample Adult
Core questions
≥ 150 min of
moderate activity
or 75 min of
National Health 479,856
Zhao et al. 1997- vigorous activity
USA Prospective Interview (48.2) / ≥ 15.9%
2020 [8] 2014 per week or an
Survey 18 years
equivalent
combination of
both; and
undertaking MSA
on at least two
days per week
Abbreviations: GPAQ, Global Physical Activity Questionnaire; IPAQ, international physical activity questionnaire;
MSA, Muscle-strengthening activities; MVPA, moderate-to-vigorous physical activity; NR, not reported.


prevalence studies.
Summary on the overall

Study 1 2 3 4 5 6 7 8 9 Total score
risk of study bias
Bennie et al. 2016 0 0 0 0 0 0 0 0 0 0 Low risk
Bennie et al. 2020 A 0 0 0 1 0 0 0 0 0 1 Low risk
Bennie et al. 2020 B 0 0 0 0 0 0 1 0 0 1 Low risk

Bennie & Wiesner
0 0 0 0 0 0 1 0 0 1 Low risk
2022
CDC 2011 0 0 0 0 0 0 1 0 0 1 Low risk
Chen et al. 2021 0 0 0 0 0 0 0 0 0 0 Low risk
Churilla et al. 2022 0 0 0 0 0 0 0 0 0 0 Low risk

De Cocker et al.
0 0 0 1 0 0 1 0 0 2 Low risk
2020
Dankel et al. 2016 0 0 0 0 0 0 0 0 0 0 Low risk
Dorner et al. 2021 0 0 0 0 0 0 1 0 0 1 Low risk

Duijvestijn et al.
0 0 0 0 0 0 0 0 0 0 Low risk
2020
Lackinger &
0 0 0 0 0 0 0 0 0 0 Low risk
Dorner, 2015
Lee et al. 2022 0 0 0 1 0 0 0 0 0 0 Low risk
Sandercock et al.
0 0 0 0 0 0 1 0 0 1 Low risk
2022
Song et al. 2013 0 0 0 1 0 0 0 0 0 1 Low risk
Sung et al. 2022 0 0 0 0 0 0 0 0 0 0 Low risk

Wennman &
0 0 0 0 0 0 1 0 0 1 Low risk
Borodulin, 2020
Whitfield et al. 2019 0 0 0 0 0 0 1 0 0 1 Low risk
Zhao et al. 2020 0 0 0 0 0 0 0 0 0 0 Low risk


%
Study 3UHYDOHQFH (95
(95% CI) Weight
0HQ
Bennie et al. 2016 16.91 (15.82, 18.06) 7.64
Bennie et al. 2017 9.60 (9.28, 9.93) 7.72
Bennie et al. 2021 24.70 (23.90, 25.52) 7.70
Bennie and Wiesner 2022 17.30 (17.09, 17.51) 7.73
CDC 2013 23.40 (23.28, 23.52) 7.73
Chen et al. 2021 23.10 (22.09, 24.15) 7.67
Duijvestijn et al. 2020 48.11 (46.99, 49.23) 7.68
Lee et al. 2022 19.31 (18.91, 19.71) 7.72
Sandercock et al. 2022 29.00 (28.76, 29.24) 7.73
Sung et al. 2022 19.84 (19.08, 20.62) 7.69
Wennman and Borodulin, 2020 34.00 (32.11, 35.94) 7.56
Whitfield et al. 2019 28.80 (27.97, 29.65) 7.70
Zhao et al. 2020 18.70 (18.54, 18.87) 7.73
Subtotal (I2 = 99.91%, p = 0.00) 23.50 (20.46, 26.67) 100.00
:RPHQ
Bennie et al. 2016 13.10 (12.20, 14.06) 7.65
Bennie et al. 2017 11.90 (11.56, 12.25) 7.72
Bennie et al. 2021 20.50 (19.82, 21.20) 7.70
CDC 2013 17.90 (17.79, 18.01) 7.73
Chen et al. 2021 10.20 (9.50, 10.95) 7.67
Lee et al. 2022 9.91 (9.62, 10.21) 7.72
Sandercock et al. 2022 24.00 (23.78, 24.22) 7.73
Sung et al. 2022 9.28 (8.79, 9.78) 7.70
Whitfield et al. 2019 20.10 (19.39, 20.83) 7.69
Zhao et al. 2020 13.33 (13.20, 13.46) 7.73
Subtotal (I2 = 99.92%, p = 0.00) 17.42 (14.73, 20.30) 100.00
0 20 40 60


%
(95% CI) Weight
$GXOWV\HDUV
Bennie et al. 2016 19.86 (18.69, 21.09) 7.69
Bennie et al. 2017 18.00 (17.54, 18.48) 7.74
Bennie et al. 2021 24.75 (23.88, 25.64) 7.73
Lackinger and Dorner, 2015 39.40 (35.07, 43.90) 7.24
Lee et al. 2022 18.70 (18.23, 19.18) 7.74
Sung et al. 2022 16.23 (15.65, 16.82) 7.74
Zhao et al. 2020 22.65 (22.46, 22.84) 7.75
Bennie et al. 2016 12.71 (11.58, 13.93) 7.67
Bennie et al. 2017 8.55 (8.20, 8.92) 7.74
Bennie et al. 2021 21.90 (21.06, 22.77) 7.72
Subtotal (I2 = 99.90%, p = 0.00) 21.21 (17.45, 25.22) 100.00
2OGHUDGXOWV!\HDUV
Bennie et al. 2016 6.18 (5.23, 7.29) 14.30
Bennie et al. 2017 4.80 (4.47, 5.15) 14.41
Bennie et al. 2021 20.20 (19.19, 21.25) 14.38
Sung et al. 2022 6.29 (5.58, 7.07) 14.36
Subtotal (I2 = 99.79%, p = 0.00) 13.63 (8.18, 20.20) 100.00
0 20 40 60


%
Study 3UHYDOHQFH (9
(955% CI) Weight
8QGHUZHLJKW
Bennie et al. 2016 8.26 (4.55, 14.55) 13.74
Bennie et al. 2021 18.60 (15.21, 22.55) 24.12
Sung et al. 2022 11.49 (9.55, 13.75) 28.47
Subtotal (I2 = 82.72%, p = 0.00) 12.62 (9.92, 15.60) 100.00
1RUPDOZHLJKW
Bennie et al. 2016 20.51 (19.04, 22.07) 18.47
Bennie et al. 2021 27.20 (26.37, 28.06) 20.06
Sung et al. 2022 15.08 (14.50, 15.67) 20.21
Zhao et al. 2020 18.80 (18.62, 18.97) 20.64
Subtotal (I2 = 99.31%, p = 0.00) 19.87 (17.93, 21.87) 100.00
2YHUZHLJKW
Bennie et al. 2016 15.80 (14.52, 17.18) 13.84
Bennie et al. 2017 9.00 (8.64, 9.37) 14.40
Bennie et al. 2021 21.90 (21.00, 22.83) 14.24
Lee et al. 2022 15.00 (14.53, 15.47) 14.39
Sung et al. 2022 14.56 (13.74, 15.41) 14.20
Zhao et al. 2020 16.58 (16.40, 16.76) 14.47
Subtotal (I2 = 99.62%, p = 0.00) 14.98 (12.76, 17.35) 100.00
2EHVLW\
Bennie et al. 2016 9.71 (8.55, 11.02) 13.88
Bennie et al. 2017 4.40 (4.04, 4.79) 14.61
Bennie et al. 2021 13.00 (11.97, 14.10) 14.26
Lee et al. 2022 12.48 (11.56, 13.46) 14.35
Sung et al. 2022 10.61 (9.08, 12.35) 13.38
Zhao et al. 2020 10.62 (10.45, 10.79) 14.78
Subtotal (I2 = 99.16%, p = 0.00) 9.77 (7.98, 11.71) 100.00
0 20 40


%
Study 3UHYDOHQFH (9
(955% CI) Weight
/RZ
Bennie et al. 2016 8.49 (7.48, 9.63) 16.55
Bennie et al. 2017 2.75 (2.48, 3.06) 16.70
Sung et al. 2022 5.88 (5.35, 6.45) 16.67
Zhao et al. 2020 5.54 (5.39, 5.70) 16.73
Subtotal (I2 = 99.85%, p = 0.00) 8.26 (4.63, 12.80) 100.00
0HGLXP
Bennie et al. 2016 15.39 (14.35, 16.50) 16.60
Bennie et al. 2017 10.95 (10.61, 11.30) 16.70
Sung et al. 2022 23.67 (22.73, 24.64) 16.65
Zhao et al. 2020 10.43 (10.27, 10.60) 16.71
Subtotal (I2 = 99.93%, p = 0.00) 19.56 (14.23, 25.50) 100.00
+LJK
Bennie et al. 2016 20.50 (18.93, 22.17) 16.52
Bennie et al. 2017 16.40 (15.87, 16.94) 16.71
Sung et al. 2022 25.25 (24.35, 26.16) 16.68
Zhao et al. 2020 22.31 (22.15, 22.47) 16.74
Subtotal (I2 = 99.85%, p = 0.00) 26.50 (20.53, 32.95) 100.00
0 20 40 60


Study 3UHYDOHQFH (9
(955% CI) Weight
&XUUHQWVPRNH
Bennie et al. 2016 10.08 (8.77, 11.57) 19.27
Bennie et al. 2021 18.40 (17.39, 19.46) 20.05
Lee et al. 2022 16.31 (15.70, 16.93) 20.30
Sung et al. 2022 15.44 (14.38, 16.57) 19.94
Zhao et al. 2020 11.79 (11.60, 11.99) 20.44
Subtotal (I2 = 98.98%, p = 0.00) 14.30 (11.48, 17.36) 100.00
)RUPHUQRQVPRNHUs
Bennie et al. 2016 16.20 (15.39, 17.04) 19.71
Bennie et al. 2021 23.90 (23.29, 24.52) 19.99
Lee et al. 2022 14.10 (13.83, 14.37) 20.13
Sung et al. 2022 15.54 (15.04, 16.06) 20.00
Zhao et al. 2020 17.03 (16.91, 17.15) 20.18
Subtotal (I2 = 99.59%, p = 0.00) 17.23 (14.88, 19.72) 100.00
0 20 40



(95% CI) Weight
9HU\SRRU3RRU
Bennie et al. 2016 5.24 (3.57, 7.62) 18.94
Bennie et al. 2017 4.01 (3.56, 4.51) 28.30
Bennie et al. 2021 8.68 (7.13, 10.51) 23.61
Subtotal (I2 = 94.25%, p = 0.00) 5.06 (3.72, 6.59) 100.00
)DLUPRGHUDWH
Bennie et al. 2016 5.42 (4.26, 6.87) 24.38
Bennie et al. 2017 4.20 (3.91, 4.51) 25.23
Bennie et al. 2021 16.10 (15.16, 17.09) 25.10
Subtotal (I2 = 99.66%, p = 0.00) 8.16 (4.55, 12.69) 100.00
9HU\JRRG*RRG([FHOHQW
Bennie et al. 2016 18.14 (17.29, 19.01) 24.84
Bennie et al. 2017 16.05 (15.69, 16.41) 25.06
Bennie et al. 2021 29.35 (28.66, 30.06) 24.99
Subtotal (I2 = 99.75%, p = 0.00) 20.56 (16.47, 24.99) 100.00
0 20 40 60

LFK index = -1.13 (minor asymmetry)
1
| Z-score |
4
0 .2 .4 .6
Prevalence (%)

LFK index = 2.15 (major asymmetry)
.5
| Z-score |
1.5
2.5
.15 .2 .25 .3 .35
Prevalence (%)



prevalence studies.







PubMed


#3 #1 AND #2
Web of Science

#5 #4 AND #3 AND #2 AND #1
SPORTDiscus


S5 S4 AND S3
EMBASE

guidelines)
Scopus

recommendations ) )





report, 62(17), 321-325.
medicine, 23(6), 707-713.

2(7), e197597.
e1001587.


19(4), 246-255.

16, E163.
514-521.
75(7), 422-430.
1-12.


Causes & Control, 29(4), 475-484.
S45-S52.


analysis.
Physical activity
N (%
Country females)
/ Age
definition
Active Australia
Survey
National
9,284
Cross- 2011- (54.1) / ≥150 MVPA min
(NNPAS)
of strength or
toning activities
Self-reported
Finnish
recommendations:
≥150 moderate-
intensity min per
week or ≥75
vigorous-intensity
[22] Study 18 years
combination of
both and reporting
MVPA on ≥3
days per week
and ≥2 times per
week of MSA
and/or balance
training
Behavioural Risk
Factor
Surveillance
System
Meeting both 150

min per week of
US Behavioral
moderate-
Risk Factor
(BRFSS)
week of vigorous-
surveys
intensity aerobic
physical activity,
or an equivalent
combination of
both and ≥ 2
sessions per week
of MSA

GPAQ
15.4%
sessions per week
Interview Survey
Physical Activity
Questionnaire

al. 2021 Germany 2014 (51.1) / ≥ MVPA ≥150 22.6%
and muscle
strengthening
exercise ≥2
sessions per week
European
Health Interview
Survey – Physical
Activity
Questionnaire
European (EHIS-PAQ)
Cross- Health 2013-
min/ per week
and muscle
strengthening
exercise ≥ 2
sessions per week
NYPANS
questions
Aerobic physical
activity and
9,701
years
aerobic activity
per day, 7 days
per week and
MSA on ≥3 days
per week)
YRBS questions
86,869
Chen et al. Cross- 2011- (49.3) /
2021 [9] sectional 2019 14-18
years
strengthening
activity

60 min of aerobic
activity per day, 7
days per week
and MSA on ≥ 3
days per week
Behavioural Risk
Factor
Surveillance
Risk Factor
Churilla et 323,435
al. 2022 USA 2019 (49.6) / ≥ 23.5%
[27] 18 years
surveys muscle
strengthening
exercise ≥ 2
sessions per week
Self-reported
questionnaire
≥ 150 min of
moderate activity
14,050 or 75 min of
[28] (HSE) study
years equivalent
combination of
both; and
undertaking MSA
on at least two
days per week
Accelerometry
(ActiGraph 7164)
and questionnaire
National Health
Accelerometer-
150 min per week
(NHANES)
of MVPA and ≥ 8
days of MSA
within the past 30
days
European
Health Interview
Survey – Physical
Activity
31,232
Cross- (51.2%) /
sectional ≥ 15
[30] Surveys 2019
years
Aerobic physical
per week and
muscle

strengthening
exercise ≥ 2
sessions per week
Short
Questionnaire to
Assess Health-
enhancing
physical activity
(SQUASH)
Adolescents:
Aerobic physical
muscle- 17 years
Dutch Health
[31] Statistics
years 60 min of aerobic (18 years
Netherlands
days per week
and MSA on ≥3
days per week
Adults: Aerobic
150 min per week
and muscle
strengthening
exercise ≥ 2
sessions per week
IPAQ
Aerobic physical
Lackinger 467
and Cross- 2006- (46.7) /
Survey muscle
2015 [32] years
strengthening
exercise ≥ 2
sessions per week
Self-reported
questionnaire
Cohort
≥ 150 min of
A: 76,395
moderate activity
(51.2) / ≥ Cohort A:
20 years 14.5%
Cohort B: Cohort B:
Korea equivalent
2,295 12.7%
combination of
(53.5) / ≥
both; and
20 years
undertaking MSA
on at least two
days per week
[34]


years equivalent
moderate physical
activity including
two sessions of
strengthening
activities
Self-reported
questionnaire

6547
Song et al. Cross- 1999- (48.9) /
2013 [35] sectional 2006 12-17
years
days per week
and MSA on ≥3
days per week
GPAQ
Korea National
Aerobic physical
Health and
20 years muscle
Survey
strengthening
(KNHANES)
exercise ≥ 2
sessions per week
FinHealth Health-
Enhancing
Physical Activity
Questionnaire
≥ 150 min of
5335
Finland 2017 (56.0) / ≥ 34.2%
18 years
equivalent
combination of
both; and
undertaking MSA
on at least two
days per week
Sample Adult
Core questions
150–300 min of
moderate-
vigorous-intensity
aerobic physical
activity per week,
or an equivalent
combination of

moderate- and
vigorous-intensity
aerobic physical
activity and MSA
of at least
moderate
intensity that
involve all major
muscle groups on
≥ 2 days per week
Sample Adult
Core questions
≥ 150 min of
moderate activity
or 75 min of
2020 [8] 2014 per week or an
Survey 18 years
equivalent
combination of
both; and
undertaking MSA
on at least two
days per week


prevalence studies.

risk of study bias

Bennie & Wiesner
0 0 0 0 0 0 1 0 0 1 Low risk
2022
CDC 2011 0 0 0 0 0 0 1 0 0 1 Low risk

De Cocker et al.
0 0 0 1 0 0 1 0 0 2 Low risk
2020

Duijvestijn et al.
0 0 0 0 0 0 0 0 0 0 Low risk
2020
Lackinger &
0 0 0 0 0 0 0 0 0 0 Low risk
Dorner, 2015
Lee et al. 2022 0 0 0 1 0 0 0 0 0 0 Low risk
Sandercock et al.
0 0 0 0 0 0 1 0 0 1 Low risk
2022

Wennman &
0 0 0 0 0 0 1 0 0 1 Low risk
Borodulin, 2020

















prevalence studies.







PubMed


#3 #1 AND #2
Web of Science

#5 #4 AND #3 AND #2 AND #1
SPORTDiscus


S5 S4 AND S3
EMBASE

guidelines)
Scopus

recommendations ) )





report, 62(17), 321-325.
medicine, 23(6), 707-713.

2(7), e197597.
e1001587.


19(4), 246-255.

16, E163.
514-521.
75(7), 422-430.
1-12.


Causes & Control, 29(4), 475-484.
S45-S52.


analysis.
Physical activity
N (%
Country females)
/ Age
definition
Active Australia
Survey
National
9,284
Cross- 2011- (54.1) / ≥150 MVPA min
(NNPAS)
of strength or
toning activities
Self-reported
Finnish
recommendations:
≥150 moderate-
intensity min per
week or ≥75
vigorous-intensity
[22] Study 18 years
combination of
both and reporting
MVPA on ≥3
days per week
and ≥2 times per
week of MSA
and/or balance
training
Behavioural Risk
Factor
Surveillance
System
Meeting both 150

min per week of
US Behavioral
moderate-
Risk Factor
(BRFSS)
week of vigorous-
surveys
intensity aerobic
physical activity,
or an equivalent
combination of
both and ≥ 2
sessions per week
of MSA

GPAQ
15.4%
sessions per week
Interview Survey
Physical Activity
Questionnaire

al. 2021 Germany 2014 (51.1) / ≥ MVPA ≥150 22.6%
and muscle
strengthening
exercise ≥2
sessions per week
European
Health Interview
Survey – Physical
Activity
Questionnaire
European (EHIS-PAQ)
Cross- Health 2013-
min/ per week
and muscle
strengthening
exercise ≥ 2
sessions per week
NYPANS
questions
Aerobic physical
activity and
9,701
years
aerobic activity
per day, 7 days
per week and
MSA on ≥3 days
per week)
YRBS questions
86,869
Chen et al. Cross- 2011- (49.3) /
2021 [9] sectional 2019 14-18
years
strengthening
activity

60 min of aerobic
activity per day, 7
days per week
and MSA on ≥ 3
days per week
Behavioural Risk
Factor
Surveillance
Risk Factor
Churilla et 323,435
al. 2022 USA 2019 (49.6) / ≥ 23.5%
[27] 18 years
surveys muscle
strengthening
exercise ≥ 2
sessions per week
Self-reported
questionnaire
≥ 150 min of
moderate activity
14,050 or 75 min of
[28] (HSE) study
years equivalent
combination of
both; and
undertaking MSA
on at least two
days per week
Accelerometry
(ActiGraph 7164)
and questionnaire
National Health
Accelerometer-
150 min per week
(NHANES)
of MVPA and ≥ 8
days of MSA
within the past 30
days
European
Health Interview
Survey – Physical
Activity
31,232
Cross- (51.2%) /
sectional ≥ 15
[30] Surveys 2019
years
Aerobic physical
per week and
muscle

strengthening
exercise ≥ 2
sessions per week
Short
Questionnaire to
Assess Health-
enhancing
physical activity
(SQUASH)
Adolescents:
Aerobic physical
muscle- 17 years
Dutch Health
[31] Statistics
years 60 min of aerobic (³18 years
Netherlands
days per week
and MSA on ≥3
days per week
Adults: Aerobic
150 min per week
and muscle
strengthening
exercise ≥ 2
sessions per week
IPAQ
Aerobic physical
Lackinger 467
and Cross- 2006- (46.7) /
Survey muscle
2015 [32] years
strengthening
exercise ≥ 2
sessions per week
Self-reported
questionnaire
Cohort
≥ 150 min of
A: 76,395
moderate activity
(51.2) / ≥ Cohort A:
20 years 14.5%
Cohort B: Cohort B:
Korea equivalent
2,295 12.7%
combination of
(53.5) / ≥
both; and
20 years
undertaking MSA
on at least two
days per week
[34]


years equivalent
moderate physical
activity including
two sessions of
strengthening
activities
Self-reported
questionnaire

6547
Song et al. Cross- 1999- (48.9) /
2013 [35] sectional 2006 12-17
years
days per week
and MSA on ≥3
days per week
GPAQ
Korea National
Aerobic physical
Health and
20 years muscle
Survey
strengthening
(KNHANES)
exercise ≥ 2
sessions per week
FinHealth Health-
Enhancing
Physical Activity
Questionnaire
≥ 150 min of
5335
Finland 2017 (56.0) / ≥ 34.2%
18 years
equivalent
combination of
both; and
undertaking MSA
on at least two
days per week
Sample Adult
Core questions
150–300 min of
moderate-
vigorous-intensity
aerobic physical
activity per week,
or an equivalent
combination of

moderate- and
vigorous-intensity
aerobic physical
activity and MSA
of at least
moderate
intensity that
involve all major
muscle groups on
≥ 2 days per week
Sample Adult
Core questions
≥ 150 min of
moderate activity
or 75 min of
2020 [8] 2014 per week or an
Survey 18 years
equivalent
combination of
both; and
undertaking MSA
on at least two
days per week


prevalence studies.

risk of study bias

Bennie & Wiesner
0 0 0 0 0 0 1 0 0 1 Low risk
2022
CDC 2011 0 0 0 0 0 0 1 0 0 1 Low risk

De Cocker et al.
0 0 0 1 0 0 1 0 0 2 Low risk
2020

Duijvestijn et al.
0 0 0 0 0 0 0 0 0 0 Low risk
2020
Lackinger &
0 0 0 0 0 0 0 0 0 0 Low risk
Dorner, 2015
Lee et al. 2022 0 0 0 1 0 0 0 0 0 0 Low risk
Sandercock et al.
0 0 0 0 0 0 1 0 0 1 Low risk
2022

Wennman &
0 0 0 0 0 0 1 0 0 1 Low risk
Borodulin, 2020


%
(95% CI) Weight
0HQ
Bennie et al. 2016 16.91 (15.82, 18.06) 7.64
Bennie et al. 2017 9.60 (9.28, 9.93) 7.72
Bennie et al. 2021 24.70 (23.90, 25.52) 7.70
CDC 2013 23.40 (23.28, 23.52) 7.73
Chen et al. 2021 23.10 (22.09, 24.15) 7.67
Lee et al. 2022 19.31 (18.91, 19.71) 7.72
Sandercock et al. 2022 29.00 (28.76, 29.24) 7.73
Sung et al. 2022 19.84 (19.08, 20.62) 7.69
Whitfield et al. 2019 28.80 (27.97, 29.65) 7.70
Zhao et al. 2020 18.70 (18.54, 18.87) 7.73
Subtotal (I2 = 99.91%, p = 0.00) 23.50 (20.46, 26.67) 100.00
:RPHQ
Bennie et al. 2016 13.10 (12.20, 14.06) 7.65
Bennie et al. 2017 11.90 (11.56, 12.25) 7.72
Bennie et al. 2021 20.50 (19.82, 21.20) 7.70
CDC 2013 17.90 (17.79, 18.01) 7.73
Chen et al. 2021 10.20 (9.50, 10.95) 7.67
Lee et al. 2022 9.91 (9.62, 10.21) 7.72
Sandercock et al. 2022 24.00 (23.78, 24.22) 7.73
Sung et al. 2022 9.28 (8.79, 9.78) 7.70
Whitfield et al. 2019 20.10 (19.39, 20.83) 7.69
Zhao et al. 2020 13.33 (13.20, 13.46) 7.73
Subtotal (I2 = 99.92%, p = 0.00) 17.42 (14.73, 20.30) 100.00
0 20 40 60


%
(95% CI) Weight
$GXOWV\HDUV
Bennie et al. 2016 19.86 (18.69, 21.09) 7.69
Bennie et al. 2017 18.00 (17.54, 18.48) 7.74
Bennie et al. 2021 24.75 (23.88, 25.64) 7.73
Lackinger and Dorner, 2015 39.40 (35.07, 43.90) 7.24
Lee et al. 2022 18.70 (18.23, 19.18) 7.74
Sung et al. 2022 16.23 (15.65, 16.82) 7.74
Zhao et al. 2020 22.65 (22.46, 22.84) 7.75
Bennie et al. 2016 12.71 (11.58, 13.93) 7.67
Bennie et al. 2017 8.55 (8.20, 8.92) 7.74
Bennie et al. 2021 21.90 (21.06, 22.77) 7.72
Subtotal (I2 = 99.90%, p = 0.00) 21.21 (17.45, 25.22) 100.00
2OGHUDGXOWV!\HDUV
Bennie et al. 2016 6.18 (5.23, 7.29) 14.30
Bennie et al. 2017 4.80 (4.47, 5.15) 14.41
Bennie et al. 2021 20.20 (19.19, 21.25) 14.38
Sung et al. 2022 6.29 (5.58, 7.07) 14.36
Subtotal (I2 = 99.79%, p = 0.00) 13.63 (8.18, 20.20) 100.00
0 20 40 60


%
Study 3UHYDOHQFH (9
(955% CI) Weight
8QGHUZHLJKW
Bennie et al. 2016 8.26 (4.55, 14.55) 13.74
Bennie et al. 2021 18.60 (15.21, 22.55) 24.12
Sung et al. 2022 11.49 (9.55, 13.75) 28.47
Subtotal (I2 = 82.72%, p = 0.00) 12.62 (9.92, 15.60) 100.00
1RUPDOZHLJKW
Bennie et al. 2016 20.51 (19.04, 22.07) 18.47
Bennie et al. 2021 27.20 (26.37, 28.06) 20.06
Sung et al. 2022 15.08 (14.50, 15.67) 20.21
Zhao et al. 2020 18.80 (18.62, 18.97) 20.64
Subtotal (I2 = 99.31%, p = 0.00) 19.87 (17.93, 21.87) 100.00
2YHUZHLJKW
Bennie et al. 2016 15.80 (14.52, 17.18) 13.84
Bennie et al. 2017 9.00 (8.64, 9.37) 14.40
Bennie et al. 2021 21.90 (21.00, 22.83) 14.24
Lee et al. 2022 15.00 (14.53, 15.47) 14.39
Sung et al. 2022 14.56 (13.74, 15.41) 14.20
Zhao et al. 2020 16.58 (16.40, 16.76) 14.47
Subtotal (I2 = 99.62%, p = 0.00) 14.98 (12.76, 17.35) 100.00
2EHVLW\
Bennie et al. 2016 9.71 (8.55, 11.02) 13.88
Bennie et al. 2017 4.40 (4.04, 4.79) 14.61
Bennie et al. 2021 13.00 (11.97, 14.10) 14.26
Lee et al. 2022 12.48 (11.56, 13.46) 14.35
Sung et al. 2022 10.61 (9.08, 12.35) 13.38
Zhao et al. 2020 10.62 (10.45, 10.79) 14.78
Subtotal (I2 = 99.16%, p = 0.00) 9.77 (7.98, 11.71) 100.00
0 20 40


%
Study 3UHYDOHQFH (9
(955% CI) Weight
/RZ
Bennie et al. 2016 8.49 (7.48, 9.63) 16.55
Bennie et al. 2017 2.75 (2.48, 3.06) 16.70
Sung et al. 2022 5.88 (5.35, 6.45) 16.67
Zhao et al. 2020 5.54 (5.39, 5.70) 16.73
Subtotal (I2 = 99.85%, p = 0.00) 8.26 (4.63, 12.80) 100.00
0HGLXP
Bennie et al. 2016 15.39 (14.35, 16.50) 16.60
Bennie et al. 2017 10.95 (10.61, 11.30) 16.70
Sung et al. 2022 23.67 (22.73, 24.64) 16.65
Zhao et al. 2020 10.43 (10.27, 10.60) 16.71
Subtotal (I2 = 99.93%, p = 0.00) 19.56 (14.23, 25.50) 100.00
+LJK
Bennie et al. 2016 20.50 (18.93, 22.17) 16.52
Bennie et al. 2017 16.40 (15.87, 16.94) 16.71
Sung et al. 2022 25.25 (24.35, 26.16) 16.68
Zhao et al. 2020 22.31 (22.15, 22.47) 16.74
Subtotal (I2 = 99.85%, p = 0.00) 26.50 (20.53, 32.95) 100.00
0 20 40 60


Study 3UHYDOHQFH (9
(955% CI) Weight
&XUUHQWVPRNH
Bennie et al. 2016 10.08 (8.77, 11.57) 19.27
Bennie et al. 2021 18.40 (17.39, 19.46) 20.05
Lee et al. 2022 16.31 (15.70, 16.93) 20.30
Sung et al. 2022 15.44 (14.38, 16.57) 19.94
Zhao et al. 2020 11.79 (11.60, 11.99) 20.44
Subtotal (I2 = 98.98%, p = 0.00) 14.30 (11.48, 17.36) 100.00
)RUPHUQRQVPRNHUs
Bennie et al. 2016 16.20 (15.39, 17.04) 19.71
Bennie et al. 2021 23.90 (23.29, 24.52) 19.99
Lee et al. 2022 14.10 (13.83, 14.37) 20.13
Sung et al. 2022 15.54 (15.04, 16.06) 20.00
Zhao et al. 2020 17.03 (16.91, 17.15) 20.18
Subtotal (I2 = 99.59%, p = 0.00) 17.23 (14.88, 19.72) 100.00
0 20 40



(95% CI) Weight
9HU\SRRU3RRU
Bennie et al. 2016 5.24 (3.57, 7.62) 18.94
Bennie et al. 2017 4.01 (3.56, 4.51) 28.30
Bennie et al. 2021 8.68 (7.13, 10.51) 23.61
Subtotal (I2 = 94.25%, p = 0.00) 5.06 (3.72, 6.59) 100.00
)DLUPRGHUDWH
Bennie et al. 2016 5.42 (4.26, 6.87) 24.38
Bennie et al. 2017 4.20 (3.91, 4.51) 25.23
Bennie et al. 2021 16.10 (15.16, 17.09) 25.10
Subtotal (I2 = 99.66%, p = 0.00) 8.16 (4.55, 12.69) 100.00
9HU\JRRG*RRG([FHOHQW
Bennie et al. 2016 18.14 (17.29, 19.01) 24.84
Bennie et al. 2017 16.05 (15.69, 16.41) 25.06
Bennie et al. 2021 29.35 (28.66, 30.06) 24.99
Subtotal (I2 = 99.75%, p = 0.00) 20.56 (16.47, 24.99) 100.00
0 20 40 60

LFK index = -1.13 (minor asymmetry)
1
| Z-score |
4
0 .2 .4 .6
Prevalence (%)

LFK index = 2.15 (major asymmetry)
.5
| Z-score |
1.5
2.5
.15 .2 .25 .3 .35
Prevalence (%)

225 Full

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

225 Full

Uploaded by

Copyright:

Available Formats

Review

Garcia-­Hermoso A, et al. Br J Sports Med 2023;57:225–229. doi:10.1136/bjsports-2022-106189 1 of 6

Eligibility criteria Synthesis methods

2 of 6 Garcia-­Hermoso A, et al. Br J Sports Med 2023;57:225–229. doi:10.1136/bjsports-2022-106189

Adolescents 12-17 years

Adults ≥18 years old

Heterogeneity between groups: p = 0.345

Figure 2 Forest plot of adherence to both aerobic and muscle-­

Figure 1 PRISMA flow diagram. PRISMA, Preferred Reporting Items

Garcia-­Hermoso A, et al. Br J Sports Med 2023;57:225–229. doi:10.1136/bjsports-2022-106189 3 of 6

4 of 6 Garcia-­Hermoso A, et al. Br J Sports Med 2023;57:225–229. doi:10.1136/bjsports-2022-106189

Garcia-­Hermoso A, et al. Br J Sports Med 2023;57:225–229. doi:10.1136/bjsports-2022-106189 5 of 6

6 of 6 Garcia-­Hermoso A, et al. Br J Sports Med 2023;57:225–229. doi:10.1136/bjsports-2022-106189

Electronic supplementary material

Adherence to aerobic and muscle-strengthening activities guidelines: A systematic

Online supplemental emethod 1. Electronic search strategy.

Online supplemental emethod 2. Excluded studies and reasons for exclusion.

Online supplemental eTable 1. Results of the quality assessment checklist for

Online supplemental eFigure 1. Forest plot of adherence to aerobic and muscle-

Online supplemental eFigure 2. Forest plot of adherence to aerobic and muscle-

Online supplemental eFigure 3. Forest plot of adherence to aerobic and muscle-

Online supplemental eFigure 4. Forest plot of adherence to aerobic and muscle-

Online supplemental eFigure 5. Forest plot of adherence to aerobic and muscle-

Online supplemental eFigure 6. Forest plot of adherence to aerobic and muscle-

Online supplemental eFigure 7. Doi plot for adults ≥ 18 years old.

Garcia-Hermoso A, et al. Br J Sports Med 2022;0:1–6. doi: 10.1136/bjsports-2022-106189

Online supplemental emethod 1. Electronic search strategy.

#1 ((("aerobic"[All Fields] AND "aerobic"[All Fields]) OR OR "exercise"[MeSH

#2 ("adherance"[All Fields] OR "adhere"[All Fields] OR "adhered"[All Fields] OR

#1 TOPIC: ("aerobic physical activity" OR "exercise")

#2 TOPIC: ("muscle-strengthening" OR “strengthening” OR “strengthen” OR

#3 TOPIC: ("adherence" OR “adhering”)

#4 TOPIC: ("guideline" OR “guidelines” OR “recommendation”)

#5 #4 AND #3 AND #2 AND #1

Garcia-Hermoso A, et al. Br J Sports Med 2022;0:1–6. doi: 10.1136/bjsports-2022-106189

S1 (MH " aerobic physical activity") OR (MH "exercise")

S2 (MH " muscle-strengthening") OR ‘strengthening’ OR ‘strengthen’ OR

S3 ((MH "adherence") OR ‘adhering’

S4 (MH "guideline") OR ‘guideline’ OR ‘recommendation’

(('adherence'/exp OR adherence OR adhering:ti,ab,kw) AND 'physical activity':ti,ab,kw

( TITLE-ABS-KEY ( adherence OR adhering ) AND TITLE-ABS-KEY ( "aerobic

Garcia-Hermoso A, et al. Br J Sports Med 2022;0:1–6. doi: 10.1136/bjsports-2022-106189

Online supplemental emethod 2. Excluded studies and reasons for exclusion.

Reason for exclusion: Duplicated

Reason for exclusion: Duplicated

Reason for exclusion: Duplicated

Reason for exclusion: Duplicated

Bennie, J. A., De Cocker, K., & Duncan, M. J. (2021). Associations of muscle-

Reason for exclusion: Duplicated

Reason for exclusion: Duplicated

Blackwell, D. L., & Clarke, T. C. (2016). Occupational Differences Among Employed

Reason for exclusion: Duplicated

Garcia-Hermoso A, et al. Br J Sports Med 2022;0:1–6. doi: 10.1136/bjsports-2022-106189

Reason for exclusion: Duplicated

Branscum, P., & Fairchild, G. (2019). Differences in determinants of aerobic and

Reason for exclusion: Non-representative sample

Reason for exclusion: Duplicated

Reason for exclusion: Duplicated

Reason for exclusion: Duplicated

Reason for exclusion: Duplicated

Reason for exclusion: Duplicated

Reason for exclusion: Duplicated

Garcia-Hermoso A, et al. Br J Sports Med 2022;0:1–6. doi: 10.1136/bjsports-2022-106189

Garcia-Hermoso A, et al. Br J Sports Med 2023;57:225–229. doi:10.1136/bjsports-2022-106189 1 of 6

2 of 6 Garcia-Hermoso A, et al. Br J Sports Med 2023;57:225–229. doi:10.1136/bjsports-2022-106189

Figure 2 Forest plot of adherence to both aerobic and muscle-

Garcia-Hermoso A, et al. Br J Sports Med 2023;57:225–229. doi:10.1136/bjsports-2022-106189 3 of 6

4 of 6 Garcia-Hermoso A, et al. Br J Sports Med 2023;57:225–229. doi:10.1136/bjsports-2022-106189

Garcia-Hermoso A, et al. Br J Sports Med 2023;57:225–229. doi:10.1136/bjsports-2022-106189 5 of 6

6 of 6 Garcia-Hermoso A, et al. Br J Sports Med 2023;57:225–229. doi:10.1136/bjsports-2022-106189