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Research Quarterly for Exercise and Sport

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Physical Activity and Health: Atherosclerotic,

Metabolic, and Hypertensive Diseases
a b
Claude Bouchard PhD & Jean-Pierre Després
a
Physical Activity Sciences Laboratory , Laval University in Sainte-Foy , Québec , Canada
b
Lipid Research Center , Laval University Medical Center , USA
Published online: 22 Feb 2013.

To cite this article: Claude Bouchard PhD & Jean-Pierre Després (1995) Physical Activity and Health: Atherosclerotic,
Metabolic, and Hypertensive Diseases, Research Quarterly for Exercise and Sport, 66:4, 268-275, DOI:
10.1080/02701367.1995.10607911

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 Research Quarterly for Exercise and Sport
© 1995 bytheAmerican Alliance for Health.
Physical Education. Recreation and Dance
Vol. 66. No.4.pp.268-275

Physical Activity and Health: Atherosclerotic, Metabolic, and

Hypertensive Diseases
Claude Bouchard andJean-Pierre Despres

Key words: abdominal obesity, lipoproteins, diabetes, in- value. In addition, energy intake and energy expendi-
sulin resistance ture fluctuate naturally from day to day. For instance,
the standard deviation of energy intake assessed over a
s~dentary lifestyle is a risk factor for a number of
A large number of days for a given person reaches about
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diseases that become more prevalent with age in 1,000 kJ per day. Because physical activity accounts, on
both'genders, In contrast, regular physical activity per- average, for only about 20% of the daily energy ex-
formed in a variety of circumstances is proving to be a pended in sedentary individuals, a slight increase in ha-
health-related behavior with favorable consequences on bitual physical activity is unlikely to have a substantial
commonly recognized health outcomes. This paper impact on total daily energy expenditure and thus on
presents an overview of the evidence for the negative ef- energy balance. Moreover, the increase in level of activ-
fects of sedentarism and the positive influences of a ity may be accompanied by a corresponding decrease in
physically active lifestyle on atherosclerotic, metabolic, spontaneous activity or by an increase in energy intake.
and hypertensive diseases. Both factors are likely to obscure the effects of a slight
As the body of data on this topic has grown consid-
increase in regular physical activity on energy balance
erably over the last decade, it will not be possible to re- and body energy content. Little attention has been
view all aspects of the relationships between physical ac- given to these two compensatory phenomena, which
tivity or inactivity and the relevant health outcomes. should receive more attention. Indeed, the minimal ex-
Only the main dimensions of the problems will be em- ercise prescription that would increase daily energy ex-
phasized in this short document. These topics were re- penditure and generate a sufficient negative energy
viewed in considerably more detail in the proceedings of deficit in both men and women remains to be deter-
the 1992 Toronto International Consensus Symposium mined. The spontaneous adjustment of energy intake
on Physical Activity, Fitness, and Health (Bouchard, to increases in energy expenditure produced by in-
Shephard, & Stephens, 1994) to which the interested creased physical activity clearly warrants further study.
reader is referred for a more comprehensive expose. With a more substantial energy expenditure result-
ing from a higher level of habitual physical activity,
greater influences are likely to be seen on energy bal-
Overweight and Obesity ance and body energy content (Bouchard, Despres, &
Tremblay, 1993; Thompson, Jarvie, Lahey, & Cureton,
Variations in body energy content over time can 1982; Tremblay, Despres, & Bouchard, 1985). From a
provide indication about whether a person has been or practical point of view, daily physical activity leading to
is currently in positive or negative energy balance. The an extra energy expenditure of approximately 800 to
determinants of energy balance can be grouped into 1,000 kJ or about 5.5 to 7.0 MJ per week should be suffi-
three categories: energy intake, energy expenditure, cient to generate a significant energy deficit. There is
and biological factors modulating nutrient partitioning. clear experimental evidence that a negative energy bal-
All three classes of affectors are very difficult to mea- ance of that magnitude sustained for several months
sure with precision in ~ree-living individuals. Typically, causes a substantial loss of body energy content
the standard deviation of repeated measurements of (Bouchard, Tremblay, et al., 1990, 1994). Interestingly,
these determinants reaches about 10% of the mean when such a substantial negative energy balance is gen-
erated by regular physical activity instead of by reduced
caloric intake, the weight loss is mostly accounted for by
Claude Bouchard andJean-Pierre Despres are with the Physical a loss of body fat (Bouchard, Tremblay, et al., 1990,
ActivitySciences Laboratory at Laval University in Sainte-Fay, 1994). In contrast, when the negative energy balance is
Quebec, Canada. Jean-Pierre Despres is alsowith theLipid caused by lowering energy intake, one loses a significant
Research Center at Laval University MedicalCenter. amount of lean tissues, which may attain under some

268 ROES: December 1995

 Bouchard and Despres

circumstances as much as 50% of the total weight loss larly in android obesity, are important risk factors for
(Tremblay et al., 1985). hypertension. High alcohol and salt intake may cause
It seems that a sustained negative energy balance hypertension in a large segment of the population. Los-
state as a result of a higher level of habitual physical activ- ing weight and reducing alcohol and salt intake may re-
ity is more easily achieved in men than in women duce elevated blood pressure in many cases. Essential
(Despres et al., 1984; Krotkiewski, 1983, 1985; Tremblay, hypertension is a result of functional disturbances in
Despres, Leblanc, & Bouchard, 1984). The most impor- blood volume, cardiac output, total peripheral resis-
tant reason for such a gender difference appears to be tance, and regulation of kidney functions. Some of
the acute increase in energy intake in response to exer- these alterations are highly prevalent among sedentary
cise in women, a phenomenon which has not been and overweight individuals. Any perturbation in the
noted in men (Tremblay, Despres, & Bouchard, 1988). regulatory mechanisms of these functions and systems
Another potential gender difference in response to may chronically elevate blood pressure.
regular physical activity associated with a sustained Many epidemiological studies have reported an in-
negative energy balance state concerns the site of fat verse relationship between level of habitual physical ac-
mobilization. Thus, lipid stores from upper body and tivity and resting blood pressure (Hagberg, 1989, 1990;
abdominal adipose depots are apparently mobilized to Paffenbarger, Jung, Leung, & Hyde, 1991). Interven-
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a greater extent in men than in women (Despres, tion studies have shown that regular physical activity in
Tremblay, & Bouchard, 1989). This is not a trivial issue essential hypertensives can reduce systolic and diastolic
given the metabolic impact of abdominal and upper blood pressures by approximately 10 mmHg (Hagberg,
body fat (Bouchard, Bray, & Hubbard, 1990; Despres et 1990), a reduction which is, in several instances, of clini-
aI., 1990) and the fact that the loss of abdominal and cal significance. This favorable effect has not been
upper body fat is well correlated with the improvement noted in all cases, and increased physical activity alone
in glucose and lipid metabolism observed with regular may not always be sufficient to normalize blood pres-
aerobic exercise (Despres et al., 1988, 1991). sure. The current available data suggest that regular en-
A common finding of the studies designed to inves- durance exercise at an intensity of 40 to 60% of maxi-
tigate the role of regular physical activity in the treat- mal oxygen uptake (V0 2max) is sufficient to induce
ment of obesity is that it is likely to produce better re- these effects (Hagberg, 1990).
sults in overweight or moderately obese cases (Hill, The same beneficial influences of regular physical
Drougas, & Peters, 1994) than in severely obese patients activity on blood pressure are also observed in older
(Atkinson & Walberg-Rankin, 1994). Moreover, regular people (Hagberg, 1989). On the other hand, regular
physical activity is becoming one of the most useful be- physical activity is not likely to have a major impact on
haviors to emphasize in the maintenance of a reduced the blood pressure of normotensive individuals (Fagard
body weight as suggested by several recent intervention & Tipton, 1994). However, as suggested by prospective
studies (Hill et al., 1994). studies, a reasonable level of habitual physical activity or
fitness may be protective against the increase in blood
pressure commonly seen with age in Western societies
(Blair, Goodyear, Gibbons, & Cooper, 1984; Paffenbarger,
Hypertension Wing, Hyde, &Jung, 1983).

Hypertension is a major public health problem. El-

evated diastolic or systolic blood pressure is associated
with a greater risk of developing congestive heart fail- Blood Lipids, Lipoproteins, and
ure, coronary heart disease, stroke, kidney failure, and Dyslipoproteinemias
intermittent peripheral claudication in men and
women. There is a onefold increase in the risk of devel- The influences of regular physical activity or a sed-
oping these diseases when blood pressure is greater entary lifestyle on blood lipids and lipoproteins have
than 140/90 mmHg. Furthermore, the risk increases by been the object of several investigations over the last
at least threefold when blood pressure values of 160/95 decade. The surge in scientific and clinical research was
mmHg and higher are reached, The prevalence of hy- motivated by the observation that some plasma lipids
pertension is higher in men prior to age 65, but is and lipoproteins are strong predictors of coronary
greater in women 65 years and older (National Heart, heart disease and other atherosclerotic diseases. It is
Lung, and Blood Institute Report, 1991). now generally recognized that regular physical activity
Hypertension is a heterogeneous condition, and in- has favorable effects on several aspects of lipid
dividuals with high blood pressure also show highly vari- metabolism (Despres& Lamarche, 1994;Wood &Stefanick,
able responses to preventive and therapeutic measures. 1990) and may also be helpful in the nonpharmacological
Obesity, and its related hyperinsulinemic state, particu- treatment of some dyslipoproteinemias (Hanefeld, 1991).

ROES: December 1995 269

 Bouchard and Despres

Cross-sectional comparisons of athletes or very active protein levels and metabolism occur with regular physi-
individuals with age- and gender-matched sedentary cal activity are only partially understood (Stefanick &
persons have consistently found substantial differences Wood, 1994). Three key enzymes of lipoprotein me-
in plasma lipids and lipoprotein profiles favoring the tabolism appear to be favorably influenced by regular
active people. Although exercise intervention studies physical activity: Lipoprotein lipase activity is increased,
have been supportive of these findings, the magnitude hepatic lipase activity is decreased, and cholesteryl-ester
of the changes in blood and lipoproteins with regular transfer protein activity is reduced (Despres et al., 1991;
physical activity is generally smaller than suggested by Haskell, 1986; Seip et al., 1993; Wood & Stefanick,
cross-sectional comparisons. 1990). The increase in lipoprotein lipase activity, the
Briefly, regular physical activity lowers plasma key enzyme in the conversion of very low-density lipo-
triglycerides in individuals with initially high levels but protein to HDL, associated with regular exercise may
has little impact on those with normal concentrations. contribute to the augmentation ofthe HDL-C level, par-
On the average, regular physical activity increases high- ticularly the HD~ subfraction. On the other hand, he-
density lipoprotein cholesterol (HDL-C), particularly patic lipase is thought to impact on many aspects of li-
the cholesterol content of the HDL 2 subfraction, and poprotein metabolism, one of which is involved either
may also increase apolipoprotein A-I, the main in the hepatic degradation of HDL 2 or in the conver-
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apolipoprotein of HDL. Occasionally, especially among sion of HDL 2 to HDL g. The reduction in hepatic lipase
individuals with elevated cholesterol levels, regular activity observed with regular exercise may be one of
physical activity is associated with decreases in total cho- the mechanisms favoring the high levels of HD~-C ob-
lesterol and low-density lipoprotein cholesterol(LDL-C). served in active individuals. Another mechanism that
However, regular physical activity may also reduce the should be considered is the role of regular physical ac-
LDL particle number without a concomitant decrease tivity on in vivo insulin action, as activity intends to in-
in LDL-C levels. This notion has important implications crease insulin sensitivity and reduce plasma insulin lev-
as elevated cholesterol and LDL-C levels are not the els, a phenomenon that may also favorably alter plasma
most prevalent dyslipidemias in coronary heart disease lipoprotein-lipid levels.
patients. Indeed, hypertriglyceridemia, elevated apoli- The above summary undoubtedly presents an opti-
poprotein B concentrations, and low HDL-C levels are mistic picture of the net effects of regular physical activ-
quite common in coronary heart disease patients, and ity on blood lipids and lipoproteins. Several confound-
these variables have been shown to be favorably modi- ers must be considered before the specific influences of
fied when the exercise prescription was adequate regular physical activity can be fully appreciated. For in-
(Despres & Lamarche, 1994; Wood & Stefanick, 1990). stance, some of the changes observed in lipoprotein
Several ratios of plasma lipids and lipoproteins are com- metabolism in exercise intervention studies may be
monly used to assess the overall risk of coronary heart largely mediated by changes in body mass and body
disease, and they are also generally influenced favorably composition (Wood & Stefanick, 1990). Cross-sectional
by regular physical activity. Thus, the ratio of total cho- comparisons of active versus inactive individuals may
lesterol to HDL-C, the ratio of HDL 2-C to HDLg-C, and likewise be affected by group differences in body com-
the ratio of apolipoprotein A-I to apolipoprotein Bare position. Other confounding factors that may contrib-
higher in highly active individuals as compared to sed- ute in cross-sectional or longitudinal study designs in-
entary individuals and are often increased by regular clude the amount of upper body fat, the amount of ab-
exercise interventions (Despres & Lamarche, 1994). dominal visceral adipose tissue, smoking, dietary cho-
In other words, low plasma triglyceride, total cho- lesterol, dietary fat, and alcohol consumption. Finally,
lesterol, and LDL-C levels, as well as elevated HDL-C lev- as we have shown that some genotypes are more suscep-
els, are generally recognized as being associated with a tible to dyslipoproteinemia in the presence of excess
low coronary heart disease risk. Regular physical activity abdominal fat (Despres et al., 1990), it is likely that some
is thought to alter lipid transport in the direction of this individuals are genetically more susceptible or resistant
favorable profile (Haskell, 1986; Wood & Stefanick, to improvements of the lipoprotein profile in response to
1990). Moreover, the lipid profile may be favorablyal- increased physical activity (Despres et al., 1988).
tered with exercise at a lower intensity than has gener-
ally been thought to be required (Hardman, Hudson,
Jones, & Norgan, 1989; Leon, Conrad, Hunninghake, &
Serfass, 1979; Sopko et al., 1983; Tucker & Friedman, Glucose Intolerance. Insulin Resistance. and
1990) as long as the increase in energy expenditure Diabetes Mellitus
generated by exercise is sufficient to induce a substan-
tial negative energy balance (Despres & Lamarche, The impairment of the in vivo glucose disposal rate
1994). in the presence of insulin is the consequence of an insu-
The mechanisms by which changes in plasma lipo- lin-resistant state in peripheral tissues, particularly the

270 ROES: December 1995

 Bouchard andDespres

skeletal muscle. A diminished insulin-mediated inhibi- removal of insulin, or a combination of these mecha-
tion of hepatic glucose output also occurs when the nisms. It is also difficult to dissociate these factors, as a
liver becomes resistant to the action of insulin. Both diminished insulin secretion following training will, per
phenomena are associated with various degrees to the se, be associated with a greater proportion of insulin
development of an abnormal glucose intolerance and extracted by the liver (Bjorntorp, 1981).
to hyperinsulinemia resulting from insulin resistance. The specific contribution of increased physical ac-
These are some of the characteristic features involved tivity versus concomitant dietary changes and the
in the etiology of non-insulin-dependent diabetes melli- weight loss often noted when individuals exercise regu-
tus, which develops primarily in adult men and women larly have not been clearly delineated (Exercise and
who are overweight (about 85% of non-insulin-depen- Noninsulin Dependent Diabetes Mellitus, 1990). An
dent diabetes mellitus cases) and who have excess ab- important issue is whether the improvements generally
dominal fat accumulation. The vascular complications seen in glucose and insulin metabolism are lasting ef-
of diabetes are numerous and include not only coro- fects of the previous exercise episode or result from
nary heart disease, which is the most frequent cause of long-term adaptations and fitness increments. Despite
death in diabetic patients, but also peripheral vascular these limitations in current knowledge, it is well recog-
disease, nephropathy, retinopathy, and other condi- nized that regular physical activity is beneficial to non-
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tions. insulin-dependent diabetes mellitus patients who are

It is thought that regular physical activity has ben- prone to atherosclerotic diseases (Exercise and
eficial effects on plasma glucose and insulin homeosta- Noninsulin Dependent Diabetes Mellitus, 1990; Vranic
sis in nondiabetic and non-insulin-dependent diabetes & Wasserman, 1990) by normalizing triglyceride and li-
mellitus individuals. One apparent consequence of poprotein levels (Gudat, Berger, & Lefebvre, 1994;
regular exercise is an improvement in the sensitivity of Lampman & Schteingart, 1991).
liver, skeletal muscle, and adipose tissues to insulin ac- However, the most compelling evidence for a useful
tion (Rodnick, Haskell, Swislocki, Foley, & Reaven, role of regular physical activity has to do with the preven-
1987). Among the manifestations of the phenomenon, tion of non-insulin-dependent diabetes mellitus. Three
there is a decrease in the basal level of plasma glucose in large prospective studies have recently been reported
hyperglycemic individuals, a decrease in fasting insulin concerning the relations between regular physical activ-
levels, a reduction in the insulin response to a glucose ity and the incidence of non-insulin-dependent diabetes
load, and an increase in the glucose disposal rate as- mellitus in adult men or women (Helmrich, Ragland,
sessed under various conditions during euglycemic- Leung, & Paffenbarger, 1991; Manson et al., 1992;
hyperinsulinemic clamp procedures (Exercise and Manson et al., 1991). These three studies unanimously
Noninsulin Dependent Diabetes Mellitus, 1990; Vranic concluded that active people were less likely to become
& Wasserman, 1990). Regular physical activity may also diabetics with age, with the reduction in risk reaching
playa significant role in maintaining normoglycemia about 20% and, at times, even more. The protective ef-
and insulin sensitivity in nondiabetic people as sug- fects of regular exercise were strongest in the obese in-
gested by several epidemiological studies. dividuals and in other individuals who were at greater
Glycemic control is improved by regular physical risk for the development of non-insulin-dependent dia-
activity, with the response to training generally being betes mellitus. It is therefore believed that regular
better in those with an initially impaired glucose toler- physical activity may playa greater role in the preven-
ance (Exercise and Noninsulin Dependent Diabetes tion rather than in the treatment of non-insulin-depen-
Mellitus, 1990). Plasma insulin levels decrease with dent diabetes mellitus (Gudatetal., 1994). Mechanisms
regular exercise (Leon et al., 1979; Tremblay et al., involved for this protective effect have been examined
1990), with hyperinsulinemic patients showing the larg- but will require further study.
est reduction in insulin levels in response to training
(Exercise and Noninsulin Dependent Diabetes Melli-
tus, 1990). Such changes are observed with programs of
walking (Leon et al., 1979) and low-intensity.Iong-dura- Vascular Diseases
tion exercise sessions that do not necessarily cause an
increase in maximal oxygen intake (Oshida, There is some .evidence indicating that regular
Yamanouchi, Hazamizu, & Sato, 1989; Tremblay et aI., physical activity may be beneficial in the prevention and
1990). It is not fully established whether the insulin-low- treatment of three main types of vascular diseases,
ering effect of regular physical activity and the apparent namely peripheral vascular disease, coronary heart dis-
improvement of an insulin-resistant state result from an ease, and stroke. Progressive atherogenic obstruction of
acute or a persistent increase in the insulin sensitivity of peripheral blood vessels is not a rare phenomenon, as
skeletal muscle and other peripheral tissues, a reduc- about 10% of the adult population suffers from periph-
tion in insulin secretion, an increased rate of hepatic eral claudication. Regular physical activity may indeed

ROES: December 1995 271

 Bouchard and Despres

be a method of choice in the prevention of the clinical effects on mortality are significant and graded even af-
symptoms associated with claudication and also in the ter adjustment for a variety of common risk factors,
treatment of the early stages of the diseases (Ernst, such as body mass index, blood pressure, smoking,
1987). The mechanisms by which these benefits are blood cholesterol, parental history, and other risk fac-
brought about with regular physical activity are still a tors (Blair, 1994; Blair et aI., 1989; Lakka et aI., 1994).
matter of debate (Barnard, 1994). An extensive review of 43 studies that provided suf-
In the case of stroke, the evidence is somewhat ficient data to calculate a relative risk for the occur-
tenuous (Kohl & McKenzie, 1994), but it is growing rence of coronary heart disease at different levels of
(Shinton & Sagar, 1993). There is some epidemiologi- physical activity was published by Powell, Thompson,
cal evidence suggesting that the risk of cerebrovascular Caspersen, and Kendrick (1987). They concluded that
accidents is reduced in active individuals (Kohl & an inverse association between physical activity and inci-
McKenzie, 1994). It is not clear, however, if the dimin- dence of coronary heart disease was consistently ob-
ished risk can be accounted for by conventional risk fac- served, particularly in the better designed studies. They
tors, such as high blood pressure or obesity. One cannot also reported that the association was appropriately se-
rule out the possibility that regular exercise may have a quenced, biologically graded, and coherent with exist-
favorable influence on cerebral blood vessels and blood ing knowledge. Since then several other investigators
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flow; thrombotic factors and fibrinolytic activity (Bourey have confirmed this inverse relationship in various
& Santoro, 1988), and other important aspects of the populations. A recent meta-analysis of studies dealing
brain's circulation. It has been suggested that vigorous with physical activity in the prevention of coronary
physical activity during early adulthood may confer heart disease concluded that the overall relative risk was
some protection from stroke in later life (Shinton & increased by about 90% in sedentary people compared
Sagar, 1993). Interestingly, physical activity may reduce to active people (Berlin & Colditz, 1990). There is also
the risk of thromboembolic stroke only in nonsmokers suggestive evidence to the effect that regular physical
(Abbott, Rodriguez, Burchfeil, & Curb, 1994). activity may be helpful in preventing new infarctions in
Several epidemiological studies, dating back to the postmyocardial patients (O'Connor et al., 1989; Oldridge,
study by Morris, Heady, Raffle, Roberts, and Parks Guyatt, Fischer, & Rimm, 1988).
(1953), have shown that high levels of energy expendi- Some of the mechanisms that may account for the
ture at work were related to a lower rate of coronary potential influences of regular physical activity on the
episodes and to less severe and less often fatal heart at- proneness to ischemic heart disease have been reviewed
tacks (Paffenbarger, Hyde, & Wing, 1990). Similar by Leon (1991) and by Morris and Froelicher (1991).
trends have been reported for leisure-time physical ac- These mechanisms include attenuation of other risk
tivity. Those active in sports or other physical activities factors, antithrombotic effects, increased myocardial
during their leisure time have a lower rate of ischemic vascularity and function, and better cardiac electrical
heart disease and fatal heart attacks. The effect appears stability. One important issue is the intensity and vol-
to be graded as the risk decreases progressively with the ume of physical activity that is needed to bring about
increase in the level of habitual physical activity. The these beneficial effects. Many have reported that a mod-
volume of activity necessary to induce some of these ap- erate volume of physical activity was sufficient to gener-
parent benefits is not overwhelmingly high. However, ate most of the benefits (Blair et aI., 1989; Leon, 1991;
the risk diminishes almost linearly with weekly energy Shaper & Wannamethee, 1991), whereas others found
expenditure due to physical activity, ranging from that the effect was graded from low-to-high volumes of
about 500 to 3,000 kcal (Paffenbarger et al., 1990). In activity or energy expenditure (Paffenbarger et al.,
other words, a low level of habitual physical activity will 1990). This is an area deserving of further research be-
have only a small effect, but higher levels will further cause of its potentially enormous impact on the health
reduce the risk. If 2,000 kcal per week is taken as the of the citizenry, as coronary heart disease is still the
threshold between low and high levels of activity, the number one cause of mortality in North America. Fi-
more active participants of the 16,936 members of the nally, as it is quite difficult and costly to measure a com-
Harvard Alumni Study had a 28% lower risk of death prehensive set of metabolic variables in large cohorts
from any cause during a 16-year follow-up period used in epidemiological studies, we do not know
(Paffenbarger et al., 1990). whether there would be a significan t relation of physical
There is also some evidence that the level of car- activity to the incidence of ischemic heart disease after
diopulmonary fitness, as assessed variously from cycle adjustment for metabolic variables, such as plasma lipo-
ergometer or treadmill tests, is also negatively related proteins, glucose tolerance, and plasma insulin, as well
with all-eause mortality rate and death rate from coro- as for thrombotic factors. It is therefore relevant to con-
nary heart disease. These relationships have been ob- sider entering the area of metabolic epidemiology in
served in men and women (Blair et aI., 1989). For both order to address this issue.
level of habitual physical activity and level of fitness, the If physical inactivity is an important risk factor for

272 ROES: December 1995

 Bouchard and Despres

ischemic heart disease, it is interesting then to compare (1994). Physical activity in older middle aged men and
it to other known risk factors in terms of relative and reduced risk of stroke: The Honolulu Heart Program.
population attributable risk. In a major United States AmericanjournalofEpidemiology, 139,881-893.
study, it has been estimated that the association between Atkinson, R. L., & Walberg-Rankin,J. (1994). Physical activity,
fitness, and severe obesity. In C. Bouchard, RJ. Shephard,
physical inactivity and coronary heart disease was simi-
& T. Stephens (Eds.), Physical activity,fitness, and heaUh (pp.
lar to that for hypercholesterolemia, hypertension, and
696-711). Champaign, IL: Human Kinetics.
cigarette smoking (The Pooling Project Research Barnard, R J. (1994). Physical activity, fitness, and claudica-
Group, 1978). Hypertension and high cholesterol levels tion. In C. Bouchard, R J. Shephard, & T. Stephens
were seen in about 10% of the United States adult (Eds.), Physical activity, fitness, and health (pp. 622-632).
population. Twenty percent of these adults were smok- Champaign, IL: Human Kinetics.
ers, but almost 60% were classified as physically inactive. Berlin, J. A., & Colditz, G. A. (1990). A meta-analysis of physi-
Hence the population-based attributable risk analysis cal activity in the prevention of coronary heart disease.
would indicate that because physical inactivity is so AmericanjournalofEpidemiology, 132,612-628.
prevalent, it constitutes a more important risk factor Bijnen, F. C. H., Caspersen, C. J., & Mosterd, W. L. (1994).
than the other three combined (U.S. Department of Physical inactivity as a risk factor for coronary heart dis-
ease: A WHO and International Society and Federation
Health and Human Services, 1987).
Downloaded by [Temple University Libraries] at 02:41 06 January 2015

of Cardiology position statement. Bulletin of the World

Health Organization, 72, 1-4.
Bjorntorp, P. (1981). Effects of exercise on plasma insulin. In-
ternationaljournal ofSports Medicine, 2, 125-129.
Conclusions Blair, S. N. (1994). Physical activity, fitness, and coronary
heart disease. In C. Bouchard, R J. Shephard, & T.
Regular physical activity has much to offer from a Stephens (Eds.), Physical activity, fitness, and health (pp.
population point of view in terms of risk reduction for 579-590). Champaign, IL: Human Kinetics.
overweight and obesity (particularly abdominal obe- Blair, S. N., Goodyear, N. N., Gibbons, L. W., & Cooper, K. N.
sity), glucose intolerance and non-insulin-dependent (1984). Physical fitness and incidence of hypertension in
diabetes mellitus, blood lipid and lipoprotein abnor- healthy normotensive men and women. journal of the
American Medical Association, 252, 487-490.
malities, hypertension, peripheral vascular disease,
Blair, S. N., Kohl, H. W., Paffenbarger, R. S.,Jr., Clark, D. G.,
cerebrovascular accidents, and coronary heart disease.
Cooper, K. H., & Gibbons, L. W. (1989). Physical fitness
Not everyone who is physically active on a regular basis and all-cause mortality: A prospective study of healthy
will remain free from these vascular and metabolic dis- men and women. journal of the American Medical Associa-
eases, but the protective effects and the reduction in tion, 262(Suppl. 17), 2395-2401.
risk levels are substantial enough to justify the promo- Bouchard, C., Bray, G. A., & Hubbard, V. S. (1990). Basic and
tion of a physically active lifestyle in all segments of the clinical aspects of regional fat distribution. Americanjour-
population. nal of Clinical Nutrition, 52,946-950.
The recognition by major health agencies (e.g., the Bouchard, C., Despres.]. -P., & Tremblay, A. (1993). Exercise
World Health Organization, International Society and and obesity. ObesityResearch, 1, 40-54.
Federation of Cardiology Federation Internationale de Bouchard, C., Shephard, RJ., & Stephens, T. (Eds.). (1994).
Physical activity, fitness, and health. Champaign, IL: Human
Medecine du Sport, Centers for Disease Control,
Kinetics.
American College of Sports Medicine, American Diabe-
Bouchard, C., Tremblay, A., Despres, J. -P., Theriault, G.,
tes Association, and American Heart Association) that a Nadeau, A., Lupien, P.J., Moorjani, S., Prud'homme, D.,
sustained sedentary inactive lifestyle is a risk factor for & Fournier, G. (1994). The response to exercise with con-
several health outcomes has considerable public health stant energy intake in identical twins. Obesity Research, 2,
implications (Bijnen, Caspersen, & Mosterd, 1994; 400-410.
Fletcher et aI., 1992; Pate et al., 1995; WHO/FIMS Com- Bouchard, C., Tremblay, A., Nadeau, A., Dussault.]., Despres,
mittee on Physical Activity for Health, 1995). Regular J. -P., Theriault, G., Lupien, P.J., Serresse, 0., Boulay, M.
physical activity may well represent the most cost-effec- R, & Fournier, G. (1990). Long-term exercise training
tive and important preventive medicine measure that with constant energy intake. 1: Effect on body composi-
could be promoted by developed and developing coun- tion and selected metabolic variables. International jour-
nalofObesity, 14,57-73.
tries, particularly in light of the escalating health care
Bourey, R E., & Santoro, S. A. (1988). Interactions of exercise,
budgets around the world.
coagulation, platelets, and fibrinolysis: A brief review.
Medicine and Sciencein Sports and Exercise, 20, 439-446.
Despres, J. -P., Bouchard, C., 'Savard, R., Tremblay, A.,
Marcotte, M., & Theriault, G. (1984). The effect of a 20-
References week endurance training program on adipose tissue mor-
phology and lipolysis in men and women. Metabolism, 33,
Abbott, R D., Rodriguez, B. L., Burchfeil, C. M., & Curb,J. D. 235-239.

ROES: December 1995 273

 Bouchard andDespres

Despres, j. -P., & Lamarche, B. (1994). Low-intensity endur- Helmrich, S. P., Ragland, D. R, Leung, R W., & Paffenbarger,
ance training, plasma lipoproteins, and the risk of coro- R S.,jr. (1991). Physical activity and reduced occurrence
nary heart disease. Journal ojInternal Medicine, 236, 7-22. on non-insulin-dependent diabetes mellitus. New England
Despres, ]. -P., Moorjani, S., Lupien, P. I.. Tremblay, A., Journal ojMedicine, 335, 147-152.
Nadeau, A., & Bouchard, C. (1990). Regional distribu- Hill,]. 0., Drougas, H.]., & Peters,]. C. (1994). Physical activ-
tion of body fat, plasma lipoproteins, and cardiovascular ity, fitness, and moderate obesity. In C. Bouchard, R j.
disease. Arteriosclerosis, 10, 497-511. Shephard, & T. Stephens (Eds.), Physical activity, fitness,
Despres, j. ·P., Moorjani, S., Tremblay, A., Poehlman, E. T., and health (pp. 684-695). Champaign, IL: Human Kinet-
Lupien, P.]., Nadeau, A., & Bouchard, C. (1988). Hered- ics.
ity and changes in plasma lipids and lipoproteins after Kohl, H. w., & McKenzie,]. D. (1994). Physical activity, fitness,
short-term exercise training in men. Arteriosclerosis, 8, and stroke. In C. Bouchard, R ]. Shephard, & T.
402-409. Stephens (Eds.), Physical activity, fitness, and health (pp.
Despres, ]. -P., Pouliot, M. C., Moorjani, S., Nadeau, A., 609-621). Champaign, IL: Human Kinetics.
Tremblay, A., Lupien, P.]., Theriault, G., & Bouchard, C. Krotkiewski, M. (1983). Physical training in the prophylaxis
(1991). Loss of abdominal fat and metabolic response to and treatment of obesity, hypertension, and diabetes.
exercise training in obese women. American Journal oj Scandinavian Journal ojRehabilitation Medicine, (Supp!. 9),
Physiology, 261, EI59-EI67. 55-70.
Downloaded by [Temple University Libraries] at 02:41 06 January 2015

Despres,]. -P., Tremblay, A., & Bouchard, C. (1989). Sex dif- Krotkiewski, M. (1985). Physical training in obesity with vary-
fererlces in the regulation of body fat mass with exercise ing degrees of glucose intolerance. Journal oj Obesity and
training. In P. Bjorntorp & S. Rossner (Eds.), Obesity in Weight Regulation, 4, 179-209.
Europe I (pp. 297-304). London: Libbey. Lakka, T. A., Venalainen, j. M., Rauramaa, R, Salonen, R,
Ernst, E. (1987). Physical exercise for peripheral vascular dis- Tuomilehtu. j., & Salonen,]. T. (1994). Relation of lei-
ease: A review. Vasa, 16,227-231. sure-time physical activity and cardiorespiratory fitness to
Exercise and noninsulin dependent diabetes mellitus. (1990). the risk of acute myocardial infarction in men. New En-
Diabetes Care, 13, 785-789. glandJournal ojMedicine, 330, 1549-1554.
Fagard, R H., & Tipton, C. M. (1994). Physical activity, fitness, Lampman, R M., & Schteingart, D. E. (1991). Effects of exer-
and hypertension. In C. Bouchard, R]. Shephard, and T. cise training on glucose control, lipid metabolism, and
Stephens (Eds.), Physical activity, fitness, and health (pp. insulin sensitivity in hypertriglyceridemia and non-insu-
633-655). Champaign, IL: Human Kinetics. lin-dependent diabetes mellitus. Medicine and Science in
Fletcher, G. F., Blair, S. N., Blumenthal, J. Caspersen, C., Sports and Exercise, 23, 703-712.
Chaitman, B., Epstein, S., Falls, H., Froelicher, E. S. S., Leon, A. S. (1991). Physical activity and risk of ischemic heart
Froelicher, V. F., & Pina, I. L. (1992). Statement on exer- disease: An update 1990. In P. Oja & R Telama (Eds.),
cise-benefits and recommendations for physical activity Sport Jor all (pp. 251-264). Amsterdam: Elsevier.
programs for all Americans: A statement for health pro- Leon, A. S., Conrad,]., Hunninghake, D. B., & Serfass, R
fessionals by the Committee on Exercise and Cardiac Re- (1979). Effects of a vigorous walking program on body
habilitation of the Council on Clinical Cardiology, composition and carbohydrate and lipid metabolism of
American Heart Association. Circulation, 86, 340-344. obese young men. American Journal oj Clinical Nutrition,
Gudat, U., Berger, M., & Lefebvre, P.]. (1994). Physical activ- 32, 1776-1787.
ity, fitness, and non-insulin-dependent (Type II) diabetes Manson.]. E., Nathan, D. M., Krolewski, A. S., Stampfer, M.].,
mellitus. In C. Bouchard, R]. Shephard, & T. Stephens Willett, W. C., & Hennekens, C. H. (1992). A prospective
(Eds.), Physical activity, fitness, and health (pp, 669-683). study of exercise and incidence of diabetes among US
Champaign, IL: Human Kinetics. male physicians. Journal ojthe American Medical Association,
Hagberg,]. M. (1989). Effect of exercise and training on 268,63-67.
older men and women with essential hypertension. In W. Manson, ]. E., Rimm, E. B., Stampfer, M. J. Rosner, B.,
W. Spirduso & H. M. Eckert (Eds.), Physical activity and Hennekens, C. H., Speizer, F. E., Colditz, G. A., Willett,
aging (pp. 186-193). Champaign, IL: Human Kinetics. W. C., & Krolewski, A. S. (1991). Physical activity and inci-
Hagberg.]. M. (1990). Exercise, fitness, and hypertension. In dence of non-insulin-dependent diabetes mellitus in
C. Bouchard, R]. Shephard, T. Stephens.], R Sutton, & women. Lancet, 338, 774-778.
B. D. McPherson (Eds.), Exercise, fitness, and health: A con- Morris, C. K., & Froelicher, V. F. (1991). Cardiovascular ben-
sensus oj current knowledge (pp. 455-466). Champaign, IL: efits of physical activity. Hen, 16,222-236.
Human Kinetics. Morris,]. N., Heady,]. A., Raffle, P. A. B., Roberts, C. G., &
Hanefeld, M. (1991). Exercise for patients with hyperlipo- Parks,]. W. (1953). Coronary heart disease and physical
proteinemia. In P. Oja & R Telama (Eds.), Sport Jor all activity of work. Lancet, ii, 1053-1057, 1111-1120.
(pp, 271-279). Amsterdam: Elsevier. National Heart, Lung, and Blood Institute Report of the Task
Hardman, A. E., Hudson, A., jones, P. R M., & Norgan, N. G. Force on Research in Hypertension. (1991, September).
(1989). Brisk walking and plasma high density lipopro- Bethesda, MD: National Institutes of Health.
tein cholesterol concentration in previously sedentary O'Connor, G., Buring.j., Yusuf, S., Goldhaber, S., Olmstead,
women. British MedicalJournal, 299, 1204-1205. E., Paffenbarger, R, & Hennekens, C. (1989). An over-
Haskell, W. L. (1986). The influence of exercise training on view of randomized trials of rehabilitation with exercise
plasma lipids and lipoproteins in health and disease. Acta after myocardial infarction. Circulation, 80, 234-244.
Medica Scandinavica, (Supp!. 711), 25-37. Oldridge, N., Guyatt, G., Fischer, M., & Rimm, A. (1988). Car-

274 ROES: December 1995

 Bouchard andDespres

diac rehabilitation after myocardial infarction. Journal of activity, fitness, and health (pp. 417-431). Champaign, IL:
the American Medical Association, 260, 945-950. Human Kinetics.
Oshida, Y, Yamanouchi, K., Hazamizu, S., & Sato, Y (1989). Thompson,]. K., Jarvie, G.]., Lahey, B. B., & Cureton, K.].
Long-term mild jogging increases insulin action despite (1982). Exercise and obesity: Etiology, physiology, and in-
no influence on body mass index or V0 2 max. Journal of tervention. PsychologicalBulletin, 91,55-79.
Applied Physiology, 66,2206-2210. Tremblay, A., Despres,]. -P., & Bouchard, C. (1985). The ef-
Paffenbarger, R S., Jr., Hyde, R T., & Wing, A. L. (1990). fects of exercise training on energy balance and adipose
Physical activity and physical fitness as determinants of tissue morphology and metabolism. Sports Medicine, 2,
health and longevity. In C. Bouchard, R J. Shephard, T. 223-233.
Stephens,]. R Sutton, & B. D. McPherson (Eds.), Exercise, Tremblay, A., Despres, J. -P., & Bouchard, C. (1988). Alter-
fitness, and health: A consensus of current knowledge (pp. 33- ation in body fat and fat distribution with exercise. In C.
48). Champaign, IL: Human Kinetics. Bouchard & F. E. Johnston (Eds.), Fat distribution during
Paffenbarger, R S.,Jr.,Jung, D. L., Leung, R W., & Hyde, R T. growth and later health outcomes (pp. 297-312). New York:
(1991). Physical activity and hypertension: An epidemio- Alan R. Liss.
logical view. Annals ofMedicine, 23, 319-327. Tremblay, A., Despres, ]. -P., Leblanc, C., & Bouchard, C.
Paffenbarger, R. S.,Jr., Wing, A. L., Hyde, R T., &Jung, D. L. (1984). Sex dimorphism in fat loss in response to exer-
(1983). Physical activity and incidence of hypertension in cise training. Journal of Obesity and Weight Regulation, 3,
Downloaded by [Temple University Libraries] at 02:41 06 January 2015

collfge alumni. AmericanJournal ofEpidemiology, 117, 245- 193-203.

257. Tremblay, A., Nadeau, A., Despres,]. -P., St:Jean, L., Theriault,
Pate, R R, Pratt, M., Blair, S. N., Haskell, W. L., Macera, C. A., G., & Bouchard, C. (1990). Long-term exercise training
Bouchard, C., Buchner, D., Caspersen, C.]., Ettinger, w., with constant energy intake. 2: Effect on glucose metabo-
Heath, G. W., King, A. C., Kriska, A., Leon, A. S., Marcus, lism and resting energy expenditure. InternationalJournal
B. H., Morrisj., Paffenbarger, R S., Jr., Patrick, K., Pol- of Obesity, 14, 75-84.
lock, M. L., Rippe,]. M., Sallis, J., & Wilmore, ]. H. Tucker, L. A., & Friedman, G. M. (1990). Walking and serum
(1995). Physical activity and public health: A recommen- cholesterol in adults. AmericanJournal ofPublic Health, 80,
dation from the Centers for Disease Control and Preven- 1111-1113.
tion and the American College of Sports Medicine. U.S. Department of Health and Human Services. (1987). Pro-
Journal of the American Medical Association, 273, 402-407. tective effects of physical activity on coronary heart dis-
The Pooling Project Research Group. (1978). Relationship of ease. Morbidity and Mortality Weekly Report, 36, 426-430.
blood pressure, serum cholesterol, smoking habit, rela- Vranic, M., & Wasserman, D. (1990). Exercise, fitness, and dia-
tive weight, and ECG abnormalities to incidence of major betes. In C. Bouchard, R]. Shephard, T. Stephens,]. R
coronary events: Final report of the Pooling Project. Jour- Sutton, & B. D. McPherson (Eds.), Exercise, fitness, and
nal of Chronic Disease, 31, 202-306. health: A consensus of current knowledge (pp. 467-490).
Powell, K. E., Thompson, P. D., Caspersen, C.]., & Kendrick.], Champaign, IL: Human Kinetics.
S. (1987). Physical activity and the incidence of coronary Wood, P. D., & Stefanick, M. L. (1990). Exercise, fitness, and
heart disease. Annual Review ofPublic Health, 8, 253-287. atherosclerosis. In C. Bouchard, R ]. Shephard, T.
Rodnick, K.J., Haskell, W. L., Swislocki, A. L. M., Foley,]. E., & Stephens,]. R Sutton, & B. D. McPherson (Eds.), Exercise,
Reaven, G. M. (1987). Improved insulin action in muscle, fitness, and health: A consensus ofcurrent knowledge (pp. 409-
liver, and adipose tissue in physically trained human indi- 423). Champaign, IL: Human Kinetics.
viduals. AmericanJournal ofPhysiology, 253, E489-E495. WHO/FIMS Committee on Physical Activity for Health.
Seip, R L., Moulin, P., Cocke, T., Tall, A., Kohrt, W. M., (1995). Exercise for health. Bulletin ofthe World Health Or-
Mankowitz, K., Semenkovich, C. F., Ostlund, R, & ganization, 73, 135-136.
Schonfeld, G. (1993). Exercise training decreases plasma
cholesteryl ester transfer protein. Arteriosclerosis and
Thrombosis, 13, 1359-1367.
Shaper, A. G., & Wan namethee, G. (1991). Physical activity
and ischaemic heart disease in middle-age British men.
British HeartJournal, 66,384-394.
Shinton, R, & Sagar, G. (1993). Lifelong exercise and stroke.
British Medical journal; 307, 231-234.
Authors' Note
Sopko, G., Jacobs, D. R,Jeffery, R, Mittelmark, M., Lenz, K.,
Hedding, E., Lipcjik, R, & Gerber, W. (1983). Effects on Correspondence concerning this article should be ad-
blood lipids and body weight in high risk men of a practi- dressed to Claude Bouchard, PhD, Physical Activity Sci-
cal exercise program. Atherosclerosis, 49,219-229. ences Laboratory, PEPS, Laval University, Sainte-Fey,
Stefanick, M. L., & Wood, P. D. (1994). Physical activity, lipid Quebec, Canada GIK 7P4.
and lipoprotein metabolism, and lipid transport. In C.
Bouchard, R]. Shephard, & T. Stephens (Eds.), Physical E-mail: [email protected]

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