OPEN ACCESS J PREV MED HYG 2022; 63(SUPPL.

3): E150-E159

Review

Physical activity for health

KRISTJANA DHULI1,*, ZAKIRA NAUREEN2, MARIA CHIARA MEDORI1, FRANCESCO FIORETTI3, PAOLA CARUSO4,
MARCO ALFONSO PERRONE5, SAVINA NODARI3, PAOLO MANGANOTTI4, SUELA XHUFI6, MARSIDA BUSHATI6,
DHURATA BOZO6, STEPHEN THADDEUS CONNELLY7, KAREN L. HERBST8, MATTEO BERTELLI1,2,9
1
MAGI’S LAB, Rovereto (TN), Italy; 2 MAGI EUREGIO, Bolzano, Italy; 3 Department of Cardiology, University of Brescia
and ASST “Spedali Civili” Hospital, Brescia, Italy; 4 Clinical Unit of Neurology, Department of Medicine, Surgery and Health
Sciences, Cattinara University Hospital ASUGI, University of Trieste, Trieste, Italy; 5 Department of Cardiology and CardioLab,
University of Rome Tor Vergata, Rome, Italy; 6 University of Sports, Tirana (AL), Albania; 7 San Francisco Veterans Affairs Health
Care System, Department of Oral & Maxillofacial Surgery, University of California, San Francisco, CA, USA7; 8 Total Lipedema
Care, Beverly Hills California and Tucson Arizona, USA; 9 MAGISNAT, Peachtree Corners (GA), USA

Keywords

Physical activity • Med Diet • Health • Non-communicable diseases

Summary

Physical activity plays a substantial role in maintaining people’s associated with many health benefits and delayed mortality. How-
good health and mental wellbeing, but that is not all: not only it posi- ever, understanding the role of physical activity in modern society
tively affects the individuals’ mental and physical health, but a lack of and creating an awareness in the general population is one of the
physical exercise exerts a negative impact also on the overall econ- most important tasks of health and recreation promoters. Corre-
omy of a nation. In addition, physical inactivity not only increases spondingly, there is a dire need to enhance our knowledge, percep-
the risk of non-communicable diseases (NCD), but also contributes tion, and awareness of physical activity and its impacts on an individ-
significantly to the increased morbidity and mortality in patients suf- ual’s health, ultimately contributing to developing a healthy society.
fering from these diseases. On the contrary, physical activity reduces The current review will focus on the health benefits of the two most
the risk of NCDs – such as cardiovascular diseases, type 2 diabetes, widely studied modifiable lifestyle risk factors, physical activity and
and cancer – in a dose-dependent manner; regular exercise is also diet, focusing particularly on the Mediterranean diet.

Introduction had 19,464 participants who were followed up between

December 1999 and February 2016 [4]. The study re-
The conventional Mediterranean diet (Med Diet) – which ported that the synergistic effects of both PA and Med
includes olive oil, fresh vegetables, fruits, legumes, Diet reduced the hazard ratio (HR) and respective mor-
nuts, fish, and red wine, and is characterized by mini- tality. Furthermore, Med Diet alone lowers the mortali-
mal consumption of red/processed meats, fat-containing ty rate up to 95%, with multivariable adjusted HR 0.66.
dairy products, and sweets – was proven to have several This effect is further enhanced when combined with
health benefits for humans, including a marked reduc- high or moderate physical activity: in this case, the HR
tion in chronic diseases and improved health [1]. On the is reduced to 0.36 [2].
other hand, also physical activity (PA) has been proven The positive impact of PA on health has been known for
a booster of healthy life. Accordingly, the synergistic centuries. For instance, the ancient philosopher Plato em-
phasized the importance of PA by stating that “Lack of
effects of Med Diet and physical activity are apparent
activity destroys the good condition of every human be-
from several observational studies, as well as from per-
ing, while movement and methodical physical exercise
sonal experience of people belonging to different geo-
save it and preserve it”. In fact, this statement is as valid
graphic area. Both Med Diet and physical activity have today as it was in ancient times. The modern lifestyle not
been reported to improve longevity and quality of life. only has led to decreased PA in doing the normal day-
For instance, several studies showed that Med Diet has to-day chores, but also promoted human beings’ depen-
an inverse relationship with total mortality [1-3]. Also, dency on machines: for instance, people do not need to
there are strong inverse associations between the con- walk to work or school, they depend on vehicles instead.
sumption of foods following the principles of the Med This lifestyle has brought many comforts, of course, but
Diet and cardiovascular mortality [3]. Correspondingly, at the expense of people’s physical wellbeing: the re-
synergizing physical activity with Med Diet reduces the duced PA has raised great concerns about public health
risk for incidence and progression of cancer, mortality, and wellbeing. In fact, decreased PA, also coupled with
and CVD. A recent study, which hypothesized the com- diet regimes rich in fast and fried foods, has increased the
bined effect of Med Diet and physical activity on the obesity rates to alarming levels more or less worldwide [5,
reduction of total mortality, utilized data from the cohort 6]. In addition, this has resulted in an increased incidence
of Seguimiento Universidad de Navarra (SUN), which of non-communicable diseases such as diabetes, cancer,

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 PHYSICAL ACTIVITY FOR HEALTH

cardiovascular problems, inflammatory diseases, thus reduce the risk of mortality. Furthermore, vigorous or high
leading to increased morbidity and mortality [3-6]: lack intensity physical activity not only stimulates the body
of PA has become the fourth leading cause of mortality systems, but also exerts positive effects on overall health
[7]. Not only this is an alarming situation, but it also has condition. For instance, strong aerobic or endurance activ-
a huge socioeconomic impact on the healthcare system, ities (like swimming or fast running/walking 150 minutes
with nations spending millions of dollars as maintenance per week) not only reduce high blood pressure and type
cost of physically inactive citizens and in PA promotion 2 diabetes, but also improve the lipid profile and decrease
programs. Therefore, it is direly needed to make the pub- the risk of cardiovascular diseases (Tab. II) [17-19]. Ad-
lic realize the importance of physical activity, alone or in ditionally, weight endurance and weight-supporting ex-
combination with healthy dietary regimes like the Med ercises such as skipping, jumping, weight training, and
Diet, so that the full potential of both can be reaped for using playground equipment, lead to the development of
shaping a healthy and active lifestyle. a healthy bone mass, bone health, muscular power, and
musculoskeletal fitness [20].

Physical activity and health

Effects of physical activity
Physical activity can be defined as ‘any bodily movement on cardiovascular diseases
generated by skeletal muscles at the expense of energy
utilization’: lifting, working out, playing, travelling, walk- Physical activity does wonders on heart health and cir-
ing, cycling, dancing, gardening, housework are all ex- culation. This can be assessed by a simple fact: men are
amples of PA [7]. The compendium of PA is helpful in less prone to serious heart disease than women are, be-
estimating the metabolic intensity of activity, as compared cause generally they are more physically active. Phys-
to a resting stage, in terms of metabolic equivalent tasks ical activity, however, reduces 30-40% CVD risk in
(METs) [8]. METs are used to categorize activities, for women [17, 24, 29, 31]. Regular exercise will attenuate
example sedentary or inactive (such as watching televi- chronic heart diseases by improving the cardiovascular
sion, lying in supine position, desk work, light intensity or system (the heart contraction and relaxation is refined
effortless behaviour grocery shopping, slow walk), mod- with effective blood pumping and circulation) and by in-
erate intensity (such as slow cycling, lawn mowing), and creasing lung capacity to facilitate oxygen intake and to
energetic activity (such as fast cycling, jogging, running) improve dilation of blood vessels.
(Tab. I). Apart from PA levels, also the individual’s genet- Additionally, altering blood lipid profiles by increasing
ics influence PA results and the onset of several NCDs, ratio of protective high-density lipoprotein (HDL) to low
among which obesity and cardiovascular diseases [9-13]. density lipoprotein (LDL) and an enhanced usage of fat
Several studies have reported that physical inactivity leads as fuel. This leads to a reduction of heart disease and
to an enhanced risk of all-cause mortality, overall poor stroke risk factors, such as high blood pressure and ab-
health, and lower life expectancy, with high rates of mor- normal blood lipid profiles [32-34].
bidity and mortality in patients with underlying chronic
diseases such as hypertension, diabetes, CVD, chronic
obstructive pulmonary disease (COPD), especially when Effects of Physical activity on Type 2
the patient’s BMI is above 30, indicating obesity [14-16]. diabetes
These studies have also pointed out that a minimum in-
crease in physical activity, such as adding an hour of walk Type 2 diabetes is mostly seen in adults over 40 years,
weekly, could significantly improve the overall health and but also in children and young people having a seden-

Tab. I. Classification of physical activity levels in terms of METs and their corresponding risk of mortality in case of underlying chronic diseases.
Metabolic Risk of mortality in case of
Classification of
equivalents Examples of activity underlying chronic diseases and
activity
(METs) High Body mass Index (BMI) > 30*
Lying in supine position, meditating, desk work,
Sedentary or inactive
1.0-1.5 watching TV, listening to music without any High (risk rate: 2.0-2.5 on a 4 scale)
behaviour
physical activity
Slow walk, cooking, gardening, washing, arts
1.5-2.9 Light-intensity activity and crafts, playing an instrument, slow walking, High (risk rate: 2.0-2.5 on a 4 scale)
fishing, light yoga
Slow dancing, cycling at a speed of less than
Moderate-intensity Moderate (risk rate: 1.0-1.5 on a 4
3.0-5.9 10 mph, vigorous cleaning, mowing the lawn,
activity scale)
painting of walls, dancing, exercise class
Weightlifting, laborious jobs (such as carrying
Vigorous-intensity
>6 heavy loads or farming), fast dancing, cycling at Low (risk rate: < 1.0 on a 4 scale)
activity
more than 10 mph, running more than 4 mph
*Based on a study conducted by Myers et al., 2002 [14] and reviewed by Warbuton et al., 2006 [15].

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Tab. II. Effects of physical activity on cardiovascular conditions.

Exercise/
Conditions Subjects physical Results Reference
activity
Variables Higher fitness level and decreased
Cardiovascular (CV)
10,224 men 3,120 women acquired from CV and cancer mortality were [17]
diseases and Cancer
maxETT related to higher fitness levels
Variables Men with lower fitness levels had a
Cardiovascular
4,276 men acquired from higher risk rate (2.7) of dying from [18]
diseases
maxETT CV
Workout High fitness is linked to lower all-
Cardiovascular and
1,960 men using bycycle cause mortality [19]
all-cause mortality
ergometer and CV mortality
63% reduction in fatal CHD
Self-informed
observed because of moderate
Chronic heart physical activity
12,138 men (MRFIT trial) physical activity during leisure time [21]
disease during leisure
as compared to lower leisure time
time
PA
Burning more calories/week
Cardiovascular (CV) Calories burned
12,516 men resulted in reduced risk of CVD in [22]
diseases (kJ/week)
men
23% reduction CV and all-cause
> 4.5 METs
Cardiovascular (CV) mortality with moderately vigorous
10,269 men Regular [23]
diseases PA, as self-reported by Harvard
exercise
alumni
Inverse relationship between
Total PA
total PA and coronary events: the
Risk of coronary 72,488 women Nurses’ Health (walking,
higher the PA, the lower the risk of [24]
events Study vigorous
developing coronary events (even
exercise)
in women starting PA later in life)
Total calories Time spent on walking/week has
Coronary heart
39,372 women burnt by an inverse effect on the risk rate [25]
disease
walking of CHD
Net energy
Lower risk of hard CHD events
Coronary heart expenditure
9,758 men associated with high leisure time [26]
disease during leisure-
energy expenditure
time
Various
exercises such
Coronary heart as walking, Intense exercise, with a higher MET
44,452 men [27]
disease running, associated with reduced CHD risk
weight-
training, rowing
In CVD patients, death risk in
Variables subjects having exercise capacity <
Cardiovascular (CV)
6,213 men acquired from 5 METs was approximately double [14]
diseases
maxETT than those who could exercise > 8
METs
15,152 MI cases vs. 14,820 Self-reported Regular physical activity diminished
Myocardial infarction [28]
controls PA the risk of myocardial infarction
Fit men had a lower risk rate of all
All-cause premature Variables based cause and CVD death rate between
9,777 men [29]
death on maxETT follow up intervals than the unfit
men
Walking
Low fitness level associated with
Diabetes mellitus 2,478 men and women (18–30 duration on
high risk of developing DM, HTN, [30]
and hypertension yrs) treadmill during
and metabolic syndrome
ETT

tary lifestyle and obesity. Studies have shown that PA both men and women. High risk individuals with obesity
enhances blood glucose control and slows down the on- and inheritee or impaired glucose tolerance, can reduce
set of type 2-diabetes [35] in both men and women [36]. their risk of having type 2-diabetes risk by brisk exer-
Studies also show that, rather than sedentary activities, cises [37]. Physical activity reduces risk of diabetes by
physical activity reduces the risk of type 2-diabetes in long-term and short-term improvements in insulin action

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for better glucose control. In older men, exercise training The effect of physical activity on various cancers is men-
for two months shows significant improvement in insu- tioned below:
lin sensitivity and fasting glycaemia [37]. • Colon cancer: Individuals who exercise regularly
have a 40-50% lower risk of colon cancer than those
who do not [51];
Effects of physical activity on weight • Breast cancer: Women who are involved in vigorous
management and obesity physical activity can minimize up to 30-40% risk of
breast cancer in both premenopausal and postmeno-
Obesity has a strong correlation with physical inactivity. pausal active women [52, 53, 54]. Also, if women
It’s a common observation that people having sedentary increase physical activity after menopause, they are
lifestyle have a lower metabolic rate and tend to gain less prone to breast cancer [54, 55];
weight over time and become obese while those hav- • Bladder cancer: People who participated in recre-
ing regular exercise, walking or other forms of physi- ational activities had a 15% decreased risk of bladder
cal activity have a higher metabolic rate and are lean. cancer [56];
In addition, less physical activity means less energy ex- • Lung cancer: Physical activity can reduce the inci-
penditure, which results in weight gain over time and dence of lung cancer in both smokers and non-smok-
vice versa [38]. Obesity has turned into an epidemic ers, according to meta-analysis research [57, 58];
nowadays, with nearly half of the world population be- • Endometrial cancer: Obesity is the leading cause of
ing obese [39]. For instance, nearly three-fourths of the endometrial cancer, and it can be prevented with reg-
adult population in the USA are obese. Similar trends ular exercise. Endometrial cancer risk is reduced by
exist in other westernised countries and, according to 20% in highly active women [59];
the EU, countries estimate that in 2008 23% women • Uterine cancer: Uterine cancer risk was decreased
and 20% men are overweight or obese in the European in women who engaged in more physical activity.
countries [40]. In addition, a gradual increase in obesity There is a lower risk of uterine cancer in more active
has been observed also in children and adolescents in women [60];
Europe [41]. These increasing trends in obesity and be- • Oesophageal cancer: Increased physical exercise
ing overweight are largely dependent upon the physical lowers the risk of esophageal cancer by 21% [61];
inactivity as well as on dietary habits. Westernised food • Renal cell cancer: Renal cell cancer risk is reduced
regime, with fried and fat-rich food coupled with high by 12% in people who engage in vigorous physical
sugar and salt intakes, less vegetables and fruits more activity [62];
red meat are the contributory factors of high BMI in • Gastric cancer: Individuals who were the most phys-
half of the western population. Besides that, inadequate ically active had a 19% lower risk of stomach cancer
physical activity with more sedentary lifestyle is the ma- than those who were the least active [63].
jor cause for increased obesity and overweight in Eu-
rope. Physical activity coupled with proper food intake
has an inverse effect on weight gain and obesity. High Effects of Physical activity
physical activity leads to high energy expenditure and, on Musculoskeletal health
correspondingly reduction in stored fats (adiposity) and
lower BMI. In addition, this helps to lower diabetes and Regular exercise promotes bone density, healthy joints,
high blood pressure, and also improves lipid profile that strong muscles, tendons and ligaments, as well as op-
ultimately reduces the risk of developing NCDs [42-49]. timum growth and development. Additionally, it will
develop functional ability for elderly individuals to lift,
carry, climb stairs, etc. and lower the risk of osteoporo-
Effect of Physical activity on Cancer sis and hip fracture [44, 64]. Physical activity can have
beneficial effects on several musculoskeletal diseas-
Cancer has become a major concern because of the sed- es (Tab. III).
entary lifestyle of the European population. Cancer is a
leading cause of death in Europe, existing health-care
programs must be improved, and new initiatives must be Effects of Physical activity
developed to raise awareness of the role of PA in reduc- on Psychological health
ing cancer risk. Cancer is becoming the leading cause
of death in Europe. Physical activity plays a significant Everyone’s mental state can indeed be enhanced by
influence in cancer risk reduction [50]: physically active exercise, which can lessen the effects of depression
men have a 30-40% lower risk of colon cancer, where- by elevating mood and sensations, it [80, 81]. Addi-
as physically active women have a 20-30% lower risk tionally, it can improve awareness of stress and sleep
of breast cancer [50]. Physical activity lowers the risk efficiency. Physical activity helps young people’s cog-
of cancer through reducing long-term inflammation in nitive, learning, and judgmental abilities, and their ac-
the gut, which aids in the reduction of colon cancer, im- ademic performance [82]. It will strengthen older peo-
proves the immune system’s ability to fight cancer, and ples’ cognitive abilities, including short-term memory,
improves hormone balance [44]. planning, and decision-making [83]. Mental health can

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Tab. III. Effects of physical activity on musculoskeletal diseases.

Diseases Condition Symptoms Treatment References
Ailment that causes pain
throughout the body.
Broad, diffuse, non- Reduced muscle
Fibromyalgia inflammatory, treatment- strength, Aerobic training [65-67]
resistant joint and muscle rapid fatigue
aches, lasting at least three
months
Discomfort, stiffness,
A degenerative condition
sensitivity, loss of Physical exercises or aerobic
that progresses over time
Osteoarthritis flexibility bone spurs, a exercises training, Non-Steroidal [68-72]
and frequently causes
grating sensation, and Anti-inflammatory Drugs (NSAID)
severe discomfort
swelling
Fractures resulting from Weight bearing exercises,
A condition where the
fragility, loss of height, walking, sunlight exposure for
Osteoporosis quantity and thickness of [73-75]
gum recession, stooped vitamin D production, bone and
bone tissue declines
posture, lower back pain muscle strengthening exercises
A chronic disorder that
Morning stiffness, joint
affects the joints and
Rheumatoid Arthritis discomfort, tenderness, Regular low intensity exercise [71-74]
results in pain, swelling, and
and edema
stiffness

be enhanced by exercise, as reported by many studies: cal activity in the UK decreased by 20% between 1961
physical activity involves moving one’s body and us- and 2005. Eurobarometer surveys are used to monitor
ing their muscles, for example for walking, running, the levels of sports and physical activity. The survey
dancing, swimming, practicing yoga, or working in the reveals that in Europe the physical activity falls with
garden [84]. The length of exercise regimens appears age and men are more enthusiastic than women. Cor-
to mitigate the association between physical activity respondingly, well-educated individuals are more active
and psychological health, as lengthier programs regu- than less educated ones. The Northern part of Europe is
larly report. Mild to moderate mental health disorders, more active as compared to the Southern part, mostly en-
including depression and anxiety, may be effectively gaging in activities like cycling, dancing, and gardening
managed by engaging in physical activity. Increased (particularly interesting to nations like the Netherlands
aerobic exercise or strength training has been proven and the Nordic region), while walking is more preva-
to dramatically improve depressive symptoms, even lent in Southern and Eastern Europe. According to the
though people with depression often engage in less results of the overall survey, one in ten Europeans are
physical activity than those who do not suffer from it. unusually sedentary and unable to walk for 10 minutes
Moreover, regular exercise appears to have benefits each day [90].
comparable to those of meditation or relaxation for The WHO public health recommendations for physical
anxiety symptoms and panic disorder [85]. exercise are not being followed by about one third of Eu-
ropeans [87, 90]. A according to the “Health Behaviour
in School-aged Children” (HBSC) research, an average
Current physical activity levels of over 45% of girls and 2/3 of boys are unable to meet
the recommended 60 minutes per day of moderate ac-
Modern technologies are currently helping people in tivity, with girls being less physically active than boys,
doing less physical labour; for example, using a pri- according to reports (Tab. IV) [91]. Furthermore, accel-
vate vehicle lessens the need for physical activity-based erometers showed that 11-year-olds exercise more than
transportation, like walking or cycling. The introduction 15-year-olds.
of television, computers, and other electronic leisure
gradually made engaging in sedentary activities more
appealing than exercising, particularly for young people. Socioeconomic effects of
Accelerometers are the accepted methods of monitor- physical activity as opposed to
ing physical activity to evaluate people’s transportation, physical inactivity
household, and leisure activities. Low-income and mid-
dle-income countries are more active than high-income Brain development, emotional and social health, job per-
ones in terms of cycling and walking [86-88]. In the formance, and productivity are all enhanced by physical
future, low- and middle-income countries will reduce activity, resulting in the improvement of life skills like
their levels of physical activity because of technological grit, self-control, punctuality, emotional regulation, de-
changes [89]. cision-making, and goal-setting [94].
The method used to estimate an activity’s energy expen- Physical activity-related risks typically involve the
diture is called METs. According to MET hours, physi- musculoskeletal system, such as straining a mus-

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Tab. IV. Recommended PA for various age groups.

Age group Recommended PA Reference
Preschool children (3-5 years) Physical activity throughout the day [92]
Children and Adolescents (6-17 years) Daily 60 minutes or more PA [93]
Adults (18-64 years) 150 minutes moderate intensity PA weekly [93]
Older adults (65 years and more) At least 150 minutes of moderate-intensity aerobic PA weekly [93]
Adults with chronic disabilities 150 minutes of moderate intense aerobic activity in a week [92]
Pregnant and postpartum women 150 minutes of moderate intense aerobic activity (brisk walk) [92]

cle or twisting a joint. These issues are brought on Conclusion

by performing too many activities without adequate
warm-up or training. A person with heart disease runs It can be concluded that not only physical activity is ben-
a higher risk of having a heart attack if they partic- eficial for having a healthy life, but it is indeed essen-
ipate in vigorous activity without warming up first. tial to alleviate drastic consequences of various chronic
These hazards can be reduced simply by appropriately non-communicable diseases. Recommended level of
warming up before starting the more intensive exer- physical activity, coupled with a healthy diet such as
cises [95, 96]. To prepare the body for the increased Med Diet, can help to restore and maintain a healthy
demands on bones, muscles, the heart, and the lungs, body and, correspondingly, an ecstatic life.
muscle-strengthening exercises should be done grad-
ually over time [97].
Acknowledgements

Mediterranean diet and physical activity This research was funded by the Provincia Autono-
ma di Bolzano in the framework of LP 15/2020 (dgp
One of the most important factors that affect health 3174/2021).
globally is the lack of physical activity [97]: physical
inactivity is in fact a major risk factor for the develop- Conflicts of interest statement
ment of chronic diseases and early death, as demon-
strated by a wealth of research on the benefits of PA on Authors declare no conflict of interest.
health. The aging process will eventually be negatively
impacted if PA or exercise is replaced with inactivi-
ty or sedentary behaviour [98]. The two most widely Author's contributions
studied modifiable lifestyle risk factors, diet and PA,
increase the risk of developing lifestyle diseases like MB: study conception, editing and critical revision of
CVDs, obesity, type 2 diabetes, and several malignan- the manuscript; KD, ZN, MCM, FF, PC, MAP, SN,
cies, as well as their mortality and morbidity. In clinical PM, SX, MB, DB, STC, KLH: literature search, editing
practice, diet and PA are usually advised for promoting and critical revision of the manuscript. All authors have
general health, weight loss or maintenance, preventing read and approved the final manuscript.
chronic diseases, and improving quality of life [99],
being regarded as intricate variables that may interact
References
[100]. When compared to the MedDiet or PA alone,
there is already data to suggest that greater adherence [1] Hershey MS, Martínez-González MÁ, Álvarez-Álvarez I,
to both is linked to improved health biomarkers, a low- Martínez Hernández JA, Ruiz-Canela M. The Mediterranean
er risk of disease, and a lower mortality rate [100, 102]. diet and physical activity: better together than apart for the
prevention of premature mortality. Br J Nutr 2021;31:1-12.
If the person avoids smoking and alcohol abuse, the https://doi.org/10.1017/S0007114521002877
Med Diet may lower the risk of non-communicable ill- [2] Alvarez-Alvarez I, Zazpe I, Pérez de Rojas J, Bes-Rastrollo M,
nesses, improve health status, and lower total lifetime Ruiz-Canela M, Fernandez-Montero A, Hidalgo-Santamaría
healthcare expenses [103]. When combined with PA, M, Martínez-González MA. Mediterranean diet, physical
activity and their combined effect on all-cause mortality: The
these benefits may be even greater. This interaction of Seguimiento Universidad de Navarra (SUN) cohort. Prev Med
effects implies that lowering either element would also 2018;106:45-52. https://doi.org/10.1016/j.ypmed.2017.09.021
lower the likelihood that the other factor would result [3] Martínez-González MA. The SUN cohort study (Seguimiento
in a particular outcome. The presence of interaction University of Navarra). Public Health Nutr 2006;9(1A):127-31.
demonstrates that the effect of the two exposures is https://doi.org/10.1079/phn2005935.
different from the mere sum or multiplication of their [4] Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell
W, Ekelund U, Lancet Physical Activity Series Working
individual effects, depending on the nature of the link Group. Global physical activity levels: surveillance progress,
between exposures and the anticipated scale (additive pitfalls, and prospects. Lancet 2012;380:247-57. https://doi.
or multiplicative) for the interaction [104]. org/10.1016/S0140-6736(12)60646-1

E155
 K. DHULI ET AL.

[5] Kim BY, Choi DH, Jung CH, Kang SK, Mok JO, Kim CH. middle-aged Norwegian men. N Engl J Med 1993;328:533-7.
Obesity and Physical Activity. J Obes Metab Syndr 2017;26:15- https://doi.org/10.1056/NEJM199302253280803
22. https://doi.org/10.7570/jomes.2017.26.1.15 [20] Westcott WL. Resistance training is medicine: effects of
[6] Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk strength training on health. Curr Sports Med Rep 2012;11:209-
PT, Lancet Physical Activity Series Working Group. Effect 16. https://doi.org/10.1249/JSR.0b013e31825dabb8
of physical inactivity on major non-communicable diseases [21] Leon AS, Connett J, Jacobs DR Jr, Rauramaa R. Leisure-
worldwide: an analysis of burden of disease and life expectancy. time physical activity levels and risk of coronary heart
Lancet 2012;380:219-29. https://doi.org/10.1016/S0140- disease and death. The Multiple Risk Factor Intervention
6736(12)61031-9 Trial. JAMA 1987;258:2388-95. https://doi.org/10.1001/
[7] World Health Organization T. Global recommendations on jama.1987.03400170074026
physical activity for health. World Health Organization; [22] Sesso HD, Paffenbarger Jr RS, Lee IM. Physical activity and
2010. Available at: https://www.who.int/publications/i/ coronary heart disease in men: The Harvard Alumni Health
item/9789241599979. Accessed on: 01/07/2022. Study. Circulation 2000;102:975-80. https://doi.org/10.1161/01.
[8] Ainsworth BE, Haskell WL, Herrmann SD, Meckes N, cir.102.9.975
Bassett DR Jr, Tudor-Locke C, Greer JL, Vezina J, Whitt- [23] Paffenbarger Jr RS, Hyde RT, Wing AL, Lee IM, Jung DL,
Glover MC, Leon AS. 2011 Compendium of Physical Kampert JB. The association of changes in physical-activity
Activities: a second update of codes and MET values. Med level and other lifestyle characteristics with mortality among
Sci Sports Exerc 2011;43:1575-81. https://doi.org/10.1249/ men. N Engl J Med 1993;328:538-45. https://doi.org/10.1056/
MSS.0b013e31821ece12 NEJM199302253280804
[9] Naureen Z, Perrone M, Paolacci S, Maltese PE, Dhuli K, [24] Manson JE, Hu FB, Rich-Edwards JW, Colditz GA, Stampfer
Kurti D, Dautaj A, Miotto R, Casadei A, Fioretti B, Beccari MJ, Willett WC, Speizer FE, Hennekens CH. A prospective
T, Romeo F, Bertelli M. Genetic test for the personalization study of walking as compared with vigorous exercise in the
of sport training. Acta Biomed 2020;91:e2020012. https://doi. prevention of coronary heart disease in women. New England
org/10.23750/abm.v91i13-S.10593 N Engl J Med 1999;341:650-8. https://doi.org/10.1056/
[10] Vettori A, Paolacci S, Maltese PE, Herbst KL, Cestari M, NEJM199908263410904
Michelini S, Michelini S, Samaja M, Bertelli M. Genetic [25] Lee IM. No pain, no gain? Thoughts on the Caerphilly
Determinants of the Effects of Training on Muscle and Adipose study. Br J Sports Med 2004;38:4-5. https://doi.org/10.1136/
Tissue Homeostasis in Obesity Associated with Lymphedema. bjsm.2003.010264
Lymphat Res Biol 2021:19:322-33. https://doi.org/10.1089/
[26] Wagner A, Simon C, Evans A, Ferrières J, Montaye M,
lrb.2020.0057
Ducimetière P, Arveiler D. Physical activity and coronary event
[11] Persi A, Maltese PE, Bertelli M, Cecchin S, Ciaghi M, incidence in Northern Ireland and France: the Prospective
Guarnieri MC, Agnello L, Maggioni MA, Merati G, Veicsteinas Epidemiological Study of Myocardial Infarction (PRIME).
A. Polymorphisms of alpha-actinin-3 and ciliary neurotrophic Circulation 2002;105:2247-52. https://doi.org/10.1161/01.
factor in national-level Italian athletes. Panminerva Med cir.0000016345.58696.4f
2013;55:217-24.
[27] Tanasescu M, Leitzmann MF, Rimm EB, Willett WC, Stampfer
[12] Camilleri G, Kiani AK, Herbst KL, Kaftalli J, Bernini A, Dhuli MJ, Hu FB. Exercise type and intensity in relation to coronary
K, Manara E, Bonetti G, Stuppia L, Paolacci S, Dautaj A, Bertelli heart disease in men. JAMA 2002;288:1994-2000. https://doi.
M. Genetics of fat deposition. Eur Rev Med Pharmacol Sci org/10.1001/jama.288.16.1994
2021;25:14-22. https://doi.org/10.26355/eurrev_202112_27329 [28] Yusuf S, Hawken S, Ôunpuu S, Dans T, Avezum A, Lanas F,
[13] Dhuli K, Ceccarini MR, Precone V, Maltese PE, Bonetti G, McQueen M, Budaj A, Pais P, Varigos J, Lisheng L. Effect of
Paolacci S, Dautaj A, Guerri G, Marceddu G, Beccari T, potentially modifiable risk factors associated with myocardial
Michelini S, Bertelli M. Improvement of quality of life by intake infarction in 52 countries (the INTERHEART study): case-
of hydroxytyrosol in patients with lymphedema and association control study. Lancet 2004;364:937-52. https://doi.org/10.1016/
of lymphedema genes with obesity. Eur Rev Med Pharmacol Sci S0140-6736(04)17018-9
2021;25:33-42. https://doi.org/10.26355/eurrev_202112_27331 [29] Blair SN, Kohl HW 3rd, Barlow CE, Paffenbarger RS Jr,
[14] Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood Gibbons LW, Macera CA. Changes in physical fitness and all-
JE. Exercise capacity and mortality among men referred for cause mortality. A prospective study of healthy and unhealthy
exercise testing. N Engl J Med 2002;346:793-801. https://doi. men. JAMA 1995;273:1093-8. https://doi.org/10.1001/
org/10.1056/NEJMoa011858 jama.1995.03520380029031
[15] Warburton DE, Nicol CW, Bredin SS. Health benefits of [30] Carnethon MR, Gidding SS, Nehgme R, Sidney S, Jacobs Jr
physical activity: the evidence. CMAJ 2006;174:801-9. https:// DR, Liu K. Cardiorespiratory fitness in young adulthood and
doi.org/10.1503/cmaj.051351 the development of cardiovascular disease risk factors. JAMA
[16] Hakim AA, Curb JD, Petrovitch H, Rodriguez BL, Yano K, Ross 2003;290:3092-100. https://doi.org/10.1001/jama.290.23.3092
GW, White LR, Abbott RD. Effects of walking on coronary heart [31] Soares-Miranda L, Siscovick DS, Psaty BM, Longstreth WT Jr,
disease in elderly men: the Honolulu Heart Program. Circulation Mozaffarian D. Physical Activity and Risk of Coronary Heart
1999;100:9-13. https://doi.org/10.1161/01.CIR.100.1.9 Disease and Stroke in Older Adults: The Cardiovascular Health
[17] Blair SN, Kohl HW, Paffenbarger RS, Clark DG, Study. Circulation 2016;133:147-55. https://doi.org/10.1161/
Cooper KH, Gibbons LW. Physical fitness and all-cause CIRCULATIONAHA.115.018323
mortality: a prospective study of healthy men and women. [32] Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K,
JAMA 1989;262:2395-401. https://doi.org/10.1001/ Skidmore B, Stone JA, Thompson DR, Oldridge N. Exercise-
jama.1989.03430170057028 based rehabilitation for patients with coronary heart disease:
[18] Ekelund LG, Haskell WL, Johnson JL, Whaley FS, Criqui systematic review and meta-analysis of randomized controlled
MH, Sheps DS, Lipid Research Clinics Mortality Follow- trials. Am J Med 2004;116:682-92. https://doi.org/10.1016/j.
up Study. Physical fitness as a predictor of cardiovascular amjmed.2004.01.009
mortality in asymptomatic North American men. N [33] Cornelissen VA, Fagard RH. Effects of endurance training on
Engl J Med 1988;319:1379-84. https://doi.org/10.1056/ blood pressure, blood pressure-regulating mechanisms, and
NEJM198811243192104 cardiovascular risk factors. Hypertension 2005;46:667-75.
[19] Sandvik L, Erikssen J, Thaulow E, Erikssen G, Mundal R, Rodahl https://doi.org/10.1161/01.HYP.0000184225.05629.51
K. Physical fitness as a predictor of mortality among healthy, [34] Kodama S, Tanaka S, Saito K, Shu M, Sone Y, Onitake F, Suzuki

E156
 PHYSICAL ACTIVITY FOR HEALTH

E, Shimano H, Yamamoto S, Kondo K, Ohashi Y. Effect of aerobic [49] Folsom AR, Kushi LH, Hong CP. Physical activity and incident
exercise training on serum levels of high-density lipoprotein diabetes mellitus in postmenopausal women. American
cholesterol: a meta-analysis. Arch Intern Med 2007;167:999- Am J Public Health 2000;90:134. https://doi.org/10.2105/
1008. https://doi.org/10.1001/archinte.167.10.999 ajph.90.1.134
[35] Colberg SR, Sigal RJ, Fernhall B, Regensteiner JG, Blissmer BJ, [50] Lee IM. Physical activity and cancer prevention--data from
Rubin RR, Chasan-Taber L, Albright AL, Braun B. Exercise and epidemiologic studies. Med Sci Sports Exerc 2003;35:1823-7.
type 2 diabetes: the American College of Sports Medicine and the https://doi.org/10.1249/01.mss.0000093620.27893.23
American Diabetes Association: joint position statement. Diabetes [51] Liu L, Shi Y, Li T, Qin Q, Yin J, Pang S, Nie S, Wei S. Leisure
care 2010;33:e147-67. https://doi.org/10.2337/dc10-9990 time physical activity and cancer risk: evaluation of the WHO’s
[36] Gill JM, Cooper AR. Physical activity and prevention of type recommendation based on 126 high-quality epidemiological
2 diabetes mellitus. Sports Med 2008;38:807-24. https://doi. studies. Br J Sports Med 2016;50:372-8. https://doi.org/10.1136/
org/10.2165/00007256-200838100-00002 bjsports-2015-094728
[37] Ibañez J, Izquierdo M, ARGuelles I, Forga L, Larrión JL, García- [52] Pizot C, Boniol M, Mullie P, Koechlin A, Boniol M, Boyle P,
Unciti M, Idoate F, Gorostiaga EM. Twice-weekly progressive Autier P. Physical activity, hormone replacement therapy and
resistance training decreases abdominal fat and improves breast cancer risk: A meta-analysis of prospective studies.
insulin sensitivity in older men with type 2 diabetes. Diabetes Eur J Cancer 2016;52:138-54. https://doi.org/10.1016/j.
care 2005;28:662-7. https://doi.org/10.2337/diacare.28.3.662 ejca.2015.10.063
[38] Kim BY, Choi DH, Jung CH, Kang SK, Mok JO, Kim CH. [53] Hardefeldt PJ, Penninkilampi R, Edirimanne S, Eslick GD.
Obesity and physical activity. J Obes Metab Syndr 2017;26:15. Physical activity and weight loss reduce the risk of breast
https://doi.org/10.7570/jomes.2017.26.1.15 cancer: a meta-analysis of 139 prospective and retrospective
[39] Lavie CJ, Carbone S, Kachur S, O’keefe EL, Elagizi A. Effects studies. Clin Breast Cancer 2018;18:e601-12. https://doi.
of physical activity, exercise, and fitness on obesity-related org/10.1016/j.clbc.2017.10.010
morbidity and mortality. Curr Sports Med Rep 2019;18:292-8. [54] Eliassen AH, Hankinson SE, Rosner B, Holmes MD, Willett
https://doi.org/10.1249/JSR.0000000000000623 WC. Physical activity and risk of breast cancer among
[40] Finucane MM, Stevens GA, Cowan MJ, Danaei G, Lin JK, postmenopausal women. Arch Intern Med 2010;170:1758-64.
Paciorek CJ, Singh GM, Gutierrez HR, Lu Y, Bahalim AN, https://doi.org/10.1001/archinternmed.2010.363
Farzadfar F. National, regional, and global trends in body-mass [55] Fournier A, Dos Santos G, Guillas G, Bertsch J, Duclos
index since 1980: systematic analysis of health examination M, Boutron-Ruault MC, Clavel-Chapelon F, Mesrine S.
surveys and epidemiological studies with 960 country-years Recent recreational physical activity and breast cancer
and 1 million participants. Lancet 2011;377:557-67. https://doi. risk in postmenopausal women in the E3N cohort. Cancer
org/10.1016/S0140-6736(10)62037-5 Epidemiol Biomarkers Prev 2014;23:1893-902. https://doi.
[41] Janssen I, LeBlanc AG. Systematic review of the health org/10.1158/1055-9965.EPI-14-0150
benefits of physical activity and fitness in school-aged children [56] Keimling M, Behrens G, Schmid D, Jochem C, Leitzmann
and youth. Int J Behav Nutr Phys Act 2010;7:1-6. https://doi. MF. The association between physical activity and bladder
org/10.1186/1479-5868-7-40 cancer: systematic review and meta-analysis. Br J Cancer
[42] Gill DL, Hammond CC, Reifsteck EJ, Jehu CM, Williams RA, 2014;110:1862-70. https://doi.org/10.1038/bjc.2014.77
Adams MM, Lange EH, Becofsky K, Rodriguez E, Shang YT. [57] McTiernan AN, Friedenreich CM, Katzmarzyk PT, Powell
Physical activity and quality of life. J Prev Med Public Health KE, Macko R, Buchner D, Pescatello LS, Bloodgood B,
2013;46:S28. https://doi.org/10.3961/jpmph.2013.46.S.S28 Tennant B, Vaux-Bjerke A, George SM. Physical activity in
[43] Physical activity guidelines advisory committee. Physical cancer prevention and survival: a systematic review. Med
activity guidelines advisory committee report, 2008. Sci Sports Exerc 2019;51:1252. https://doi.org/10.1249/
Washington, DC: US Department of Health and Human Services MSS.0000000000001937
2008;24;2008:A1-H14. Available at https://health.gov/our- [58] Patel AV, Friedenreich CM, Moore SC, Hayes SC, Silver JK,
work/nutrition-physical-activity/physical-activity-guidelines/ Campbell KL, Winters-Stone K, Gerber LH, George SM, Fulton
previous-guidelines/2008-physical-activity-guidelines/ JE, Denlinger C. American College of Sports Medicine roundtable
advisory-report. Accessed on: 01/08/2022. report on physical activity, sedentary behavior, and cancer
[44] Warburton DE, Charlesworth S, Ivey A, Nettlefold L, Bredin prevention and control. Med Sci Sports Exerc 2019;51:2391.
SS. A systematic review of the evidence for Canada’s Physical https://doi.org/10.1249/MSS.0000000000002117
Activity Guidelines for Adults. Int J Behav Nutr Phys Act [59] Schmid D, Behrens G, Keimling M, Jochem C, Ricci C,
2010;7:1-220. https://doi.org/10.1186/1479-5868-7-39 Leitzmann M. A systematic review and meta-analysis of
[45] Cornelissen VA, Fagard RH. Effects of endurance training on physical activity and endometrial cancer risk. Eur J Epidemiol
blood pressure, blood pressure–regulating mechanisms, and 2015;30:397-412. https://doi.org/10.1007/s10654-015-0017-6
cardiovascular risk factors. Hypertension 2005;46:667-75. [60] Physical activity and cancer risk. https://www.cancer.net/
https://doi.org/10.1161/01.HYP.0000184225.05629.51 navigating-cancer-care/prevention-and-healthy-living/physical-
[46] Kodama S, Tanaka S, Saito K, Shu M, Sone Y, Onitake F, Suzuki activity-and-cancer-risk. Accessed 26 June, 2022.
E, Shimano H, Yamamoto S, Kondo K, Ohashi Y. Effect of aerobic [61] Behrens G, Jochem C, Keimling M, Ricci C, Schmid D,
exercise training on serum levels of high-density lipoprotein Leitzmann MF. The association between physical activity and
cholesterol: a meta-analysis. Arch Intern Med 2007;167:999- gastroesophageal cancer: systematic review and meta-analysis.
1008. https://doi.org/10.1001/archinte.167.10.999 Eur J Epidemiol 2014;29:151-70. https://doi.org/10.1007/
[47] Colberg SR, Sigal RJ, Fernhall B, Regensteiner JG, Blissmer BJ, s10654-014-9895-2
Rubin RR, Chasan-Taber L, Albright AL, Braun B. Exercise and [62] Behrens G, Leitzmann MF. The association between physical
type 2 diabetes: the American College of Sports Medicine and activity and renal cancer: systematic review and meta-analysis.
the American Diabetes Association: joint position statement. Br J Cancer 2013;108:798-811. https://doi.org/10.1038/
Diabetes care 2010;33:e147-67. https://doi.org/10.2337/dc10- bjc.2013.37
9990 [63] Psaltopoulou T, Ntanasis-Stathopoulos I, Tzanninis IG,
[48] Helmrich SP, Ragland DR, Leung RW, Paffenbarger Jr RS. Kantzanou M, Georgiadou D, Sergentanis TN. Physical activity
Physical activity and reduced occurrence of non-insulin- and gastric cancer risk: a systematic review and meta-analysis.
dependent diabetes mellitus. N Engl J Med 1991;325:147-52. Clin J Sport Med 2016;26:445-64. https://doi.org/10.1097/
https://doi.org/10.1056/NEJM199107183250302 JSM.0000000000000316

E157
 K. DHULI ET AL.

[64] Young J, Angevaren M, Rusted J, Tabet N. Aerobic exercise rheumatoid arthritis? Joint Bone Spine 2008;75:11-7. https://
to improve cognitive function in older people without known doi.org/10.1016/j.jbspin.2007.04.015
cognitive impairment. Cochrane Database Syst Rev 2015. [79] Rheumatoid arthritis in adults: management: NG100. London:
https://doi.org/10.1002/14651858.CD005381.pub4 National Institute for Health and Clinical Excellence 2018. https://
[65] Pedersen BK, Saltin B. Evidence for prescribing exercise as www.nice.org.uk/guidance/ng100. Accessed on: 04/07/2022
therapy in chronic disease. Scand J Med Sci Sports 2006;16:3- [80] World Health Organization (WHO). Global recommendations
63. https://doi.org/10.1111/j.1600-0838.2006.00520.x on physical activity for health. Geneva, Switzerland: WHO
[66] Bennett RM, Clark SR, Goldberg L, Nelson D, Bonafede - 2010. Available at https://www.who.int/publications/i/
RP, Porter J, Specht D. Aerobic fitness in patients with item/9789241599979. Accessed on: 26/06/2022.
fibrositis. A controlled study of respiratory gas exchange and [81] US Department of Health and Human Services. Physical
133xenon clearance from exercising muscle. Arthritis Rheum Activity Guidelines for Americans - 2008. Available at https://
1989;32:454-60. https://doi.org/10.1002/anr.1780320415 health.gov/our-work/nutrition-physical-activity/physical-
[67] Rossy LA, Buckelew SP, Dorr N, Hagglund KJ, Thayer activity-guidelines/previous-guidelines/2008-physical-activity-
JF, McIntosh MJ, Hewett JE, Johnson JC. A meta-analysis guidelines. Accessed on: 26/06/2022.
of fibromyalgia treatment interventions. Ann Behav Med [82] Janssen I, LeBlanc AG. Systematic review of the health
1999;21:180-91. https://doi.org/10.1007/BF02908299 benefits of physical activity and fitness in school-aged children
[68] Roos E. Osteoarthritis. In: Physical Activity in the Prevention and youth. Int J Behav Nutr Phys Act 2010;7:1-6. https://doi.
and Treatment of Disease. Professional associations for physical org/10.1186/1479-5868-7-40
activity (Sweden) 2010. Available at http://www.fyss.se/wp- [83] Swiss Federal Office of Sport and Federal Office of Public
content/uploads/2018/01/37.-Osteoarthritis.pdf. Accessed on: Health Health-Enhancing Physical Activity - Core document
04/07/2022. for Switzerland - 2013. Available at https://www.activevoice.eu/
[69] Bennell KL, Dobson F, Hinman RS. Exercise in osteoarthritis: pdfs/6.pdf. Accessed on: 26/06/2022.
moving from prescription to adherence.. Best Pract Res [84] Physical activity and mental health | Mental Health Foundation.
Clin Rheumatol 2014;28:93-117. https://doi.org/10.1016/j. Available at https://www.mentalhealth.org.uk/explore-mental-
berh.2014.01.009 health/a-z-topics/physical-activity-and-mental-health. Accessed
[70] Pendleton A, Arden N, Dougados M, Doherty M, Bannwarth on: 26/06/2022.
B, Bijlsma JWJ, Cluzeau F, Cooper C, Dieppe PA, Günther [85] Paluska SA, Schwenk TL. Physical activity and mental health.
KP, Hauselmann HJ. EULAR recommendations for the Sports Med 2000;29:167-80. https://doi.org/10.2165/00007256-
management of knee osteoarthritis: report of a task force of the 200029030-00003
Standing Committee for International Clinical Studies Including
Therapeutic Trials (ESCISIT). Ann Rheum Dis 2000;59:936- [86] Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell
44. https://doi.org/10.1136/ard.59.12.936 W, Ekelund U, Lancet Physical Activity Series Working
Group. Global physical activity levels: surveillance progress,
[71] Juhl C, Christensen R, Roos EM, Zhang W, Lund H. Impact pitfalls, and prospects. Lancet 2012;380:247-57. https://doi.
of exercise type and dose on pain and disability in knee org/10.1016/S0140-6736(12)60646-1
osteoarthritis: a systematic review and meta‐regression
analysis of randomized controlled trials. Arthritis Rheumatol [87] Designed to move, a physical activity action agenda. Available at
2014;66:622-36. https://doi.org/10.1002/art.38290 https://www.sportsthinktank.com/research,117856.html. Accessed
on: 01/12/2021
[72] Zhang W, Nuki G, Moskowitz RW, Abramson S, Altman RD,
Arden NK, Bierma-Zeinstra S, Brandt KD, Croft P, Doherty M, [88] European Commission Sport and Physical Activity, Special
Dougados M. OARSI recommendations for the management Eurobarometer 412 - 2014. Available at https://data.europa.
of hip and knee osteoarthritis: part III: Changes in evidence eu/data/datasets/s1116_80_2_412?locale=en. Accessed on:
following systematic cumulative update of research published 26/06/2022.
through January 2009. Osteoarthritis Cartilage 2010;18:476-99. [89] Ng SW, Popkin BM. Time use and physical activity: a shift
https://doi.org/10.1016/j.joca.2010.01.013 away from movement across the globe. Obes Rev 2012;13:659-
[73] Howe TE, Shea B, Dawson LJ, Downie F, Murray A. ross C, 80. https://doi.org/10.1111/j.1467-789X.2011.00982.x
Harbour rT, Caldwell LM, Creed G. Exercise for preventing [90] World Health Organization (WHO) Regional Office for Europe.
and treating osteoporosis in postmenopausal women. The challenge of obesity - quick statistics. Available at https://
Cochrane Database Syst Rev 2011;7:CD000333. https://doi. www.euro.who.int/__data/assets/pdf_file/0008/98243/E89858.
org/10.1002/14651858.CD000333.pub2 pdf. Accessed on: 01/12/2021.
[74] DE, Katzmarzyk PT, Rhodes RE, Shephard RJ. Evidence- [91] World Health Organization (WHO) Regional Office for Europe
informed physical activity guidelines for Canadian adults. (2012). Health Policy for Children and Adolescents No.6, Health
Can J Public Health 2007;32:S16-68. https://doi.org/10.1139/ behaviour in school-aged children, International report from the
H07-123 2009/2010 survey. Copenhagen, Denmark: WHO. Available at:
[75] Osteoporosis-prevention of fragility fractures: Clinical https://www.euro.who.int/__data/assets/pdf_file/0006/167424/
knowledge summaries. London: National Institute for Health E96444_part2_4.pdf. Accessed on: 01/07/2022.
and Care Excellence 2016. https://cks.nice.org.uk/osteoporosis- [92] Physical Activity for Different Groups. Available at: https://
prevention-of-fragility-fractures. Accessed on: 04/07/2022. www.cdc.gov/physicalactivity/basics/age-chart.html. Accessed
[76] Lemmey AB, Marcora SM, Chester K, Wilson S, Casanova F, on: 26/06/2022.
Maddison PJ. Effects of high‐intensity resistance training in [93] Physical Activity. Available at: https://www.euro.who.int/__
patients with rheumatoid arthritis: A randomized controlled data/assets/pdf_file/0005/288041/WHO-Fact-Sheet-PA-2015.
trial. Arthritis Rheum 2009;61:1726-34. https://doi.org/10.1002/ pdf. Accessed on: 26/06/2022
art.24891 [94] Bailey R, Hillman C, Arent S, Petitpas A. Physical activity: an
[77] Hurkmans E, van der Giesen FJ, Vlieland TP, Schoones J, Van underestimated investment in human capital? J Phys Act Health
den Ende EC. Dynamic exercise programs (aerobic capacity 2013;10:289-308. https://doi.org/10.1123/jpah.10.3.289
and/or muscle strength training) in patients with rheumatoid [95] EU Physical Activity Guidelines, recommended policy actions
arthritis. Cochrane Database Syst Rev 2009. https://doi. in support of health-enhancing physical activity. WHO.
org/10.1002/14651858.CD006853.pub2 Available at: https://ec.europa.eu/assets/eac/sport/library/
[78] Gaudin P, Leguen-Guegan S, Allenet B, Baillet A, Grange policy_documents/eu-physical-activity-guidelines-2008_
L, Juvin R. Is dynamic exercise beneficial in patients with en.pdf. Accessed on: 26/06/2022.

E158
 PHYSICAL ACTIVITY FOR HEALTH

[96] World Health Organization (WHO) Europe. Physical activity [101] Soltani S, Jayedi A, Shab-Bidar S, Becerra-Tomás N, Salas-
and health in Europe - Evidence for action. Copenhagen, Salvadó J. Adherence to the Mediterranean diet in relation to all-
Denmark: WHO. 2006. Available at: https://www.euro.who. cause mortality: a systematic review and dose-response meta-
int/__data/assets/pdf_file/0011/87545/E89490.pdf. Accessed analysis of prospective cohort studies. Adv Nutr 2019;10:1029-
on: 26/06/2022. 39. https://doi.org/10.1093/advances/nmz041
[97] Guthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends [102] Loprinzi PD, Smit E, Mahoney S. Physical activity and dietary
in insufficient physical activity from 2001 to 2016: a pooled behavior in US adults and their combined influence on health.
analysis of 358 population-based surveys with 1· 9 million Mayo Clin Proc 2014;1:190-8. https://doi.org/10.1016/j.
participants. Lancet Glob Health 2018;6:e1077-86. https://doi. mayocp.2013.09.018
org/10.1016/S2214-109X(18)30357-7 [103] Martinez-Lacoba R, Pardo-Garcia I, Amo-Saus E, Escribano-
[98] Harridge SD, Lazarus NR. Physical activity, aging, and Sotos F. Mediterranean diet and health outcomes: a systematic
physiological function. Physiology 2017;32:152-61. https://doi. meta-review. Eur J Public Health 2018;28:955-61. https://doi.
org/10.1152/physiol.00029.2016 org/10.1093/eurpub/cky113
[99] Meulenberg CJ. Health benefits induced by adherence to the [104] Rothman KJ, Greenland S, Walker AM. Concepts of interaction.
Mediterranean lifestyle components diet and physical activity. Am J Epidemiol 1980;112:467-70. https://doi.org/10.1093/
Ann Kin 2019;10:15-30. https://doi.org/10.35469/ak.2019.175 oxfordjournals.aje.a113015
[100] Ding EL, Hu FB. Commentary: Relative importance of diet vs
physical activity for health. Int J Epidemiol 2010;39:209-11.
https://doi.org/10.1093/ije/dyp348

Correspondence: Kristjana Dhuli, MAGI’S LAB, Rovereto (TN), 38068, Italy. E-mail: [email protected]

How to cite this article: Dhuli K, Naureen Z, Medori MC, Fioretti F, Caruso P, Perrone MA, Nodari S, Manganotti P, Xhufi S, Bushati
M, Bozo D, Connelly ST, Herbst KL, Bertelli M. Physical activity for health. J Prev Med Hyg 2022;63(suppl.3):E150-E159. https://doi.
org/10.15167/2421-4248/jpmh2022.63.2S3.2756

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