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JAMA Intern Med. Author manuscript; available in PMC 2016 June 01.
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Published in final edited form as:

JAMA Intern Med. 2015 June ; 175(6): 968–969. doi:10.1001/jamainternmed.2015.0544.

Using Physical Activity to Gain the Most Public Health Bang for
the Buck
Todd M. Manini, PhD
Department of Aging and Geriatric Research, University of Florida, Gainesville

The overall health benefits of physical activity have been known for several decades. It is
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clear that consistent participation in physical activity leads to large physiologic adaptations
that are closely connected to improved cardiorespiratory, vascular, musculoskeletal, mental,
and metabolic health. These effects are pervasive across the lifespan. In fact, there is no
single medication treatment that can influence as many organ systems in a positive manner
as can physical activity. These findings have led several health organizations to publish
guidelines for the conduct of a recommended amount and intensity of physical activity (eg,
American Heart Association, The Obesity Society). These various recommendations
culminated in 2008 when the US Department of Health and Human Services published the
first Physical Activity Guidelines for Americans (http://www.health.gov/paguidelines/
guidelines/). The guidelines state that “…some physical activity is better than none, and
adults who participate in any amount of physical activity gain some health benefits”1(p7)
and that “For substantial health benefits, adults should do at least 150 minutes (2 hours and
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30 minutes) a week of moderate-intensity, or 75 minutes (1 hour and 15 minutes) a week of

vigorous-intensity aerobic physical activity….”1(p7) Adults should perform aerobic activity
in bouts of at least 10 minutes spread throughout the week. The recommendations state that
although there have been a few reports of heart complications due to very high levels of
activity, additional health benefits can be gained with higher doses of physical activity
beyond the recommended amount.

Although there is substantial evidence to support the recommendations that are extensively
outlined by the Physical Activity Guidelines Steering Committee, there was not a direct
comparison of the dose-response relationship between physical activity and health
outcomes. Arem and colleagues2 are among the first to provide such a direct comparison by
examining mortality outcomes over 14.2 years in a population-based sample of 661 137 men
and women. Questions about physical activity focused on those performed during leisure
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including walking, jogging or running, swimming, tennis or racquetball, bicycling, aerobics,

dance, and other strenuous activities. The questions were harmonized across the 6 large
cohorts by calculating metabolic equivalent hours per week: a convenient approach to
capture both the intensity and duration of activity. Consistent with the plethora of existing
evidence, the results clearly demonstrate that leisure time physical activity is associated with
reduced mortality risk with similar effects seen in cancer- and cardiovascular disease–related

Corresponding Author: Todd M. Manini, PhD, Department of Aging and Geriatric Research, University of Florida, 2004 Mowry
Rd, Gainesville, FL 32611 ([email protected]).
Conflict of Interest Disclosures: None reported.
 Manini Page 2

mortality. There is some important new knowledge. First, the mortality risk reduction tapers
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strikingly after reaching 3 times the minimum leisure time physical activity. Second,
individuals performing moderate-intensity activity at 2 times the minimum amount had the
same benefit as those performing 10 times the recommended level. Vigorous activity also
provided a benefit, but it was similar to activity done at a moderate intensity and the effect
of vigorous activity waned after achieving a 20% mortality rate reduction in individuals
meeting the minimum requirement. Lastly, individuals performing very high levels of
activity—more than 10 times the recommended minimum—did not have an elevated risk of
mortality. These findings varied little across different demographic and health-related
factors (ie, age, sex, race, obesity, smoking, and history of heart disease or cancer). The
results of the study are not applicable to the US population as a whole because the cohorts
were largely white (approximately 95%). The results are also not applicable to the many
other noted health benefits of physical activity, such as mental health, metabolic conditions,
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and maintaining an appropriate energy balance.

The findings of the present study2 generally support the 2008 Physical Activity Guidelines’
minimum requirement of moderate-intensity physical activity to reach reductions in
mortality. However, what is critical about this analysis is not the mortality reduction in
individuals who had met some level of the physical activity recommendation; rather, it is the
reference group. This group of 52 848 individuals, comprising only 8% of the total sample,
drove most of the associations, meaning that a lot of the mortality reductions were seen in
people only one step away from doing no leisure time physical activity. Compared with
more active groups, members of the reference group were more likely to be younger than 60
years, have a higher rate of smoking and obesity, and have less than a college education.
Practitioners have a unique opportunity to influence this reference group since they are the
most likely to receive benefit even with a small amount of physical activity. However,
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adherence to a specific level of physical activity is a complicated phenomenon that is

influenced by a variety of personal and social factors that partly consist of environmental
barriers and exercise self-efficacy.3,4 Essentially, the major barriers continue to be
motivation, time, access to facilities or equipment, energy, having a workout partner, and
exercise self-efficacy. Unfortunately, a practitioner is unable to remove all these barriers.
Despite the complexity associated with adherence to physical activity, evidence5 suggests
that physicians in particular can influence patient behavior through counseling. In addition,
almost 90% of primary care physicians believe they are competent to counsel their patients,
yet only approximately half of physicians felt they could motivate patients to change their
behavior.6 The fact that only approximately one-third of adults received counseling from a
physician or other health professional is disappointing, although this rate has improved by
40% from 2000 to 2010.7 A goal for Healthy People 2020 is to increase the rate of physician
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counseling or education related to physical activity. Physicians who seek out the segment of
the population that performs no leisure time physical activity could receive the most
payback in their patient’s health.

References
1. US Department of Health and Human Services. Physical Activity Guidelines for Americans.
Washington DC: US Dept of Health and Human Services; 2008.

JAMA Intern Med. Author manuscript; available in PMC 2016 June 01.
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2. Arem H, Moore SC, Patel A, et al. Leisure time physical activity and mortality: a detailed pooled
analysis of the dose-response relationship [published online April 6, 2015]. JAMA Intern Med.
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10.1001/jamainternmed.2015.0533
3. Jefferis BJ, Sartini C, Lee IM, et al. Adherence to physical activity guidelines in older adults, using
objectively measured physical activity in a population-based study. BMC Public Health. 2014;
14:382. [PubMed: 24745369]
4. Izquierdo-Porrera AM, Powell CC, Reiner J, Fontaine KR. Correlates of exercise adherence in an
African American church community. Cultur Divers Ethnic Minor Psychol. 2002; 8(4):389–394.
[PubMed: 12420701]
5. Grant RW, Schmittdiel JA, Neugebauer RS, Uratsu CS, Sternfeld B. Exercise as a vital sign: a
quasi-experimental analysis of a health system intervention to collect patient-reported exercise
levels. J Gen Intern Med. 2014; 29(2):341–348. [PubMed: 24309950]
6. Diehl K, Mayer M, Mayer F, et al. Physical activity counseling by primary care physicians:
attitudes, knowledge, implementation, and perceived success [published online April 17, 2014]. J
Phys Act Health.
7. Barnes PM, Schoenborn CA. Trends in adults receiving a recommendation for exercise or other
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physical activity from a physician or other health professional. NCHS Data Brief. Feb.2012 (86):1–
8. [PubMed: 22617014]
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JAMA Intern Med. Author manuscript; available in PMC 2016 June 01.