Updating the evidence that physical activity is good

for health: an epidemiological review 2 0 0 0 - 2 0 0 3

AE Bauman
NSW Centre for Physical Activity and Health and School of Public Health, The University of Sydney, Australia

Bauman, AE. Updating the evidence that physical activity is good for health - an epidemiological
review 2000-2003. Journal of Science and Medicine in Sport 7 {1)."Supplement: 6-19.
Developing policy and strategic initiatives to increase population levels of physical
activity (PA) requires constant referral to the epidemiological evidence base. This paper
updates the evidence that PA confers a positive benefit on health, using research
studies in the peer-reviewed scientific literature published between 2000-2003. Areas
covered include updates in all-cause mortality and in cardiovascular disease prevention,
diabetes, stroke, mental health, falls and injuries, and in obesity prevention. Recent
evidence on PA and all-cause mortality replicates previous findings, and is consistent
with current Australian moderate PA recommendations. Recent papers have reinforced
our understanding of the cardiovascular protective effects of moderate PA, with new
evidence that walking reduces the risk of CVD and, in two studies, at least as much
as vigorous activity. The evidence base for protective effects of activity for women, older
adults and for special populations has strengthened. Cancer prevention studies have
proliferated during this period but the best evidence remains for colon cancer, with better
evidence accumulating for breast cancer prevention, and uncertain or mixed evidence
for the primary prevention of other cancers. Important new controlled-trial evidence has
accumulated in the area of type 2 diabetes: moderate PA combined with weight loss,
and a balanced diet can confer a 50-60% reduction in risk of developing diabetes among
those already at high risk. Limited new evidence has accumulated for the role of PA in
promoting mental health and preventing falls.

Introduction
P h y s i c a l a c t i v i t y (PA) is r e c o g n i s e d a s b e i n g i m p o r t a n t for r e d u c i n g t h e o v e r a l l
b u r d e n of d i s e a s e (1,2). B a s e d o n s o u n d e p i d e m i o l o g i c a l e v i d e n c e , A u s t r a l i a n
P h y s i c a l A c t i v i t y g u i d e l i n e s w e r e p u b l i s h e d in 1999, w h i c h r e c o m m e n d e d
t h a t e v e r y a d u l t s h o u l d a c c u m u l a t e m o d e r a t e i n t e n s i t y a c t i v i t y for h a l f a n
h o u r o n m o s t d a y s of t h e w e e k {3). A d d i t i o n a l h e a l t h b e n e f i t s w o u l d a c c r u e for
t h o s e u n d e r t a k i n g s o m e a d d i t i o n a l v i g o r o u s a c t i v i t i e s , a n d for t h o s e i n c l u d i n g
m o r e o p p o r t u n i t i e s to b e p h y s i c a l l y a c t i v e i n t o all a s p e c t s o f e v e r y d a y life.
It is i m p o r t a n t c o n t i n u a l l y to u p d a t e t h e evidence on w h i c h t h e s e r e c o m m e n d a t i o n s
a r e b a s e d . This review f o c u s e s on a d u l t s , a n d u p d a t e s t h e evidence o n t h e
r e l a t i o n s h i p b e t w e e n PA a n d a l l - c a u s e mortality, c a r d i o v a s c u l a r d i s e a s e , d i a b e t e s ,
obesity, cancer, mel~tal a n d m u s c u l o s k e l e t a l health. This d o c u m e n t u p d a t e s t h e
evidence s i n c e t h e p u b l i c a t i o n of G e t t i n g A u s t r a l i a Active (4).

Methods
T h i s r e v i e w u s e d m u l t i p l e e l e c t r o n i c d a t a b a s e s , i n c l u d i n g NIH P u b M e d ,
Medline, Current Contents, Cinhal, Psychlit, Embase and the evidence-
b a s e d d i r e c t o r i e s ( C o c h r a n e , DARE). S t u d i e s p u b l i s h e d b e t w e e n 2 0 0 0 - 2 0 0 3
w e r e s o u g h t u s i n g p r e v i o u s l y d e f i n e d s e a r c h a p p r o a c h e s (4). P o p u l a t i o n - b a s e d
 Updating the evidence...

studies, r a t h e r t h a n evidence from clinical or small scale trials, are the

p r i m a r y focus for this review. I n s t e a d of providing a detailed description of
the more t h a n 200 studies t h a t have been p u b l i s h e d in this period, this review
focuses on those studies t h a t provide new perspectives on the evidence.
Epidemiological developments in the conceptualisation of physical activity
measures
There are challenges in the epidemiological m e a s u r e m e n t of exposure (PA
a n d fitness a n d related attributes) in relation to health outcomes. Measures
have r a n g e d from self-report surveys a n d interviews to objective m e a s u r e s
of cardiorespiratory fitness (CRF). There are still debates a b o u t the relative
benefits of PA and cardiorespiratory fitness in t e r m s of which confers health
benefits 15J, a n d the differences are of policy relevance. Both a p p e a r to have
health benefits b u t the health o u t c o m e s and biological m e c h a n i s m s m a y be
different.
Furthermore, the current national PA recommendations are based on
epidemiological studies of leisure time physical activity (LTPA), but this represents
only a small fraction of total daily energy expenditure (EE). In recent years, a
broader conceptualisation of EE is now thought relevant to health outcomes and
obesity prevention. This includes the accumulation of PA through 'activities of
daily living', active transport, and in occupational and domestic settings. Some
studies have focused on sedentary time, sitting time or measures of 'inactivity' as
being of interest in relation to health outcomes. New technologies for assessing
step counts and all movement (pedometers and accelerometers) may be used for
more accurate exposure measurements in population studies.
Physical activity and All Cause Mortality (ACM)
Recent s t u d i e s reaffirm the dose r e s p o n s e relationship between PA a n d all-
c a u s e mortality (ACM). There is typically a risk reduction of a r o u n d 30% for
those achieving the r e c o m m e n d e d levels of at least moderate intensity PA on
m o s t days of the week, c o m p a r e d with t h o s e who are inactive 16). F u r t h e r m o r e ,
the m a x i m u m benefits on ACM a p p e a r to be in moving people from the
m o s t s e d e n t a r y group to the middle of the PA or cardio-respiratory fitness
distribution curve [at least 'moderately active']. Other p a p e r s illustrate some
n e w elements of this association.
Andersen (7) described data from a Danish cohort, showing that moderate levels
of LTPA conferred a 35% risk reduction compared with the sedentary. This study
also showed a benefit of regular 'active commuting', with those who cycled to work
for 3 h o u r s per week having a 30% lower ACM risk.
Data from Puerto Rico show a dose response reduction in ACM risk vcith
increasing PA levels; those in the middle of the distribution of PA in the population
had a 32-37% reduction in risk ts). Compared with the most sedentary quartile, the
next most active quartile of the population had an accumulated survival that was
around three years longer.
Gregg(9) examined changes in PA and its impact on ACM amongst a cohort of
7500 older women in the USA who were followed for six years. Those who became
active or maintained activity levels, had around 60% the risk of ACM compared
with those who stayed sedentary.
Wannamethee ~1°) reported data from a cohort of older British males, followed
for 12-14 years. There was a dose response reduction in ACM risk across PA
categories, observed for all ages, among those with cardiac symptoms. The
relationships were similar for all-cause mortality and for cardiovascular deaths.
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Updating the evidence...

Walking was protective ff more t h a n 40 minutes a day (relative risk (RR) for ACM
=0.48). Moderate or heavy gardening was also protective, reducing ACM by 41%,
b u t with no significant impact for light gardening. Those who were inactive and
became moderately active had a 42% risk reduction of all-cause mortality (RR
0.58, 95% CI 0.33 to 1.03, p=0.06).
Lee (hI reported on further data from the Harvard Alumni male cohort. Light PA
showed a non significant relationship with ACM, while vigorous PA was clearly
protective. With respect to walking, only those achieving > 20 kflometres a week
of walking showed a decrease in risk, and only those climbing >20 flights of stairs
per week showed a reduced risk of ACM.
Physical Activity and Cardiovascular Disease Prevention
The relationship b e t w e e n PA a n d incident a n d fatal c a r d i o v a s c u l a r disease
(CVD) h a s b e e n recognised since the s y s t e m a t i c review of Powell tl~) a n d the
m e t a - a n a l y s i s by Berlin (13). An interesting policy challenge h a s b e e n the
slow u p t a k e of this evidence b y clinicians a n d health d e c i s i o n - m a k e r s . The
p o p u l a t i o n risk r e d u c t i o n c o n s i s t e n t l y a p p e a r s g r e a t e s t for i n c r e a s i n g PA or
fitness a m o n g those who are s e d e n t a r y [or unfit] a n d moving t h e m to the
r e c o m m e n d e d PA levels (L3).
Recent reviews support previous Australian and US recommendations (~4'15).The
relationships appears to be valid for m e n and women in middle ages and a m o n g
older adults. For tertiary prevention, which is rehabilitation or post heart attack,
PA m a y be effective, b u t there are too few exercise-only studies to m a k e definitive
statements here. Dissenting reviews have been published by Williams, who h a s
suggested that the cardiovascular benefits for fitness are clearly greater t h a n
for self-reported PA(5). A further s t u d y h a s challenged the relationship between
changes in fitness and s u b s e q u e n t CVD (16)by suggesting that m e a s u r e m e n t error
could account for the observed cardioprotective associations. The consistency
of epidemiological research across populations and the diversity of m e a s u r e s
of self-report and objective PA a n d fitness m a k e it unlikely t h a t the consistent
cardioprotective relationships are spurious, as Williams contends (16).
The methods used in this CVD review are descriptive. A s u m m a r y of the
evidence relating PA or fitness to cardiovascular disease or coronary heart disease
risk, from studies published in 2000-2003, is shown in Figure 1. Data are
described compared with the least active or least fit segment of the population,
which is assigned a relative risk of 1.0. The next increments, by Fifths or quarters
of PA in the population, are c o m p a r e d to the most inactive. Where estimates are
not given in the papers, linear interpolation is used to estimate intermediate risks.
All studies had at least three actual data points to contribute to the figure.
The data show the generally consistent pattern of reduction in risk, maximal
by about the midpoint of the distribution [median reduction of 31% in the middle
distribution of PA for CVD risk across studies shown in the figure]. This level
of activity approximates to the recommendations of half a n hour, of moderate
intensity activity on m o s t days. There is further risk reduction for those expending
greater a m o u n t s of energy [levels 4 a n d 5 in the figure]. New studies have explored
the dose-response relationship for at least moderate intensity walking (3.5-4 k m
per hour). For example, Manson ~7) observed a dose response relationship for
walking quintiles and CVD outcomes (RRs 1.0, .91, .82, .75, .68), and similar
findings were reported across walking quartiles by LeetIS),(RRs 1.0, .86, .49, .48).
These data support the notion of health benefits for regular walking.
 Updating the evidence..,

Lee2001 --I--Crespo 2002 ,~---Wagner 2002 ~Wannemethee 200(

--~--Manson2002 ~Davey2OO0 ~ Yu2003 --0-- Hu2001
- -,O- - Tanasescu 2003 -- - Cheung2003 - -C- - Baby2002

90 ¸

60- ~~=
50-

40- =--'~ --N

30 - =...~

20- • , r i

1 lowest 2 3 4 5 highest
Level of physical activity / fitness
Figure 1: Risk reducti•n estimates •f the re•ati•nship between physica• acuvity and cardi•vascu•ar disease•
from epidemiologicalstudies published 2000-2003.

Similar relationships were shown for general population samples and a m o n g

those with diabetes (shown as dotted lines in the figure) a9-22). The first two of these
studies also showed significantly lower CHD rates a m o n g those who were in the
highest quintiles of walking hours per week.
The Whitehall British civil servants study showed no protective association with
moderate activity (23), b u t this study did show more significant relationships across
tertiles of PA for all-cause mortality (RRs across tei~Jles 1.0, .92, .66), and for the
relationship between walking pace and CHD (RRs 1.0, .76, .69). Data from the
Caerphilly s t u d y in W a l e s (241 observed a cardioprotective relationship across total
PA levels (as shown in the figure), b u t observed a n independent relationship only
for vigorous activity, not for combined light and moderate activity alone.
There have been a few studies furthering the evidence that PA improves other
cardiovascular risk factors. Systematic reviews of the relationships between PA
and hypertension have suggested a reduction of around 3 m m Hg for systolic BP,
and 2 m m Hg for diastolic BP (2a 271. These reductions were particularly evident for
moderate levels of PA, including walking. Favourable effects on other risk factors,
including regular walking influencing lipid levels, have also been reported (2s).
There is evidence that even short.bouts of PA, s u c h as stair climbing, m a y impact
on cardiovascular risk factors in a favourable m a n n e r (291. Biological m e c h a n i s m s
are being explored, with effects of exercise a p p a r e n t on cardiac endothelial
function(30.31).
There is little new evidence concerning PA and the risk of stroke. There is
a n ongoing suggestion that PA m a y protect against ischaemic stroke, b u t this
evidence h a s been mostly a m o n g males. Hu (a2) reported data from a cohort of
72,488 n u r s e s and identified a dose response reduction in stroke risk for all PA

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Updating the evidence...

(quintiles RR: 1, .98, .82, .74, .66) and for brisk walking (RR 1,.76,.78,.70,.66).
Lee and Blair (a3) reported data from the Dallas cohort of middle-aged males.
The results showed t h a t the middle and u p p e r third of cardiorespiratory fitness
demonstrated a two-thirds reduction in the risk of stroke death, compared with
the least fit third of the population, b u t the study was limited b y small n u m b e r s
of stroke outcomes. A study by Ivey(34) demonstrated that a single exercise session
could increase levels of tissue Plasminogen Activator (tPA) and reduce risks of
blood clotting, which is a possible biologic m e c h a n i s m for reducing atherosclerosis
risk, and preventing ischaemic stroke.
Physical activity and obesity prevention
I n c r e a s i n g t r e n d s in obesity h a v e o c c u r r e d globally over the p a s t two decades,
especially in developed c o u n t r i e s (aS,36). These i n c r e a s e s are poorly u n d e r s t o o d ,
b u t pose challenges to p o p u l a t i o n health. Recently, efforts h a v e b e e n m a d e
to quantify the role of PA in the genesis of the obesity epidemic 137). Several
a u t h o r s h a v e s u g g e s t e d t h a t t h e r e have b e e n only small i n c r e a s e s in energy
intake d u r i n g the last two d e c a d e s (3s,39). Although no d a t a h a v e m o n i t o r e d
energy e x p e n d i t u r e (EE) in a c o m p r e h e n s i v e fashion, it is s u g g e s t e d t h a t EE
h a s declined. Although the leisure time PA c o m p o n e n t h a s r e m a i n e d m o s t l y
u n c h a n g e d or only declined slightly, other m o d e s of EE are t h o u g h t to h a v e
declined markedly. The r e a s o n s for this include technological a d v a n c e s
which require less EE in the d o m e s t i c a n d o c c u p a t i o n a l settings, a n d g r e a t e r
u s e of m o t o r i s e d (and therefore sedentary) m o d e s of t r a n s p o r t (ag). Even small
c o n s i s t e n t declines in EE, a v e r a g e d over a year, could r e s u l t in p o p u l a t i o n
weight gain. This s u g g e s t s t h a t i n c r e a s i n g total inactivity h a s b e e n a n
i m p o r t a n t c o n t r i b u t o r to the obesity epidemic.
Current debates rage around the a m o u n t of PA which might be required to
[i] prevent weight gain in populations, and [ill induce and maintain weight loss
in populations already obese or overweight (1~). There are no clear answers to
these questions, so the results of consensus discussions are presented. The
International Association for the Study of Obesity (IASO) c o n s e n s u s group
reported on the deliberations of a meeting held in 2002 (4°/. This review concluded
that there were m a n y health benefits to be gained from the current 30 minutes
moderate-intensity PA recommendations in preventing hypertension, diabetes
and heart disease. However, "for the prevention of weight regain in formerly obese
individuals, at least 60-90 m i n u t e s o f moderate intensity PA or lesser a m o u n t s o f
vigorous PA are required". This is slightly more t h a n the a m o u n t r e c o m m e n d e d to
prevent the transition to overweight or obesity in the general population [weight
maintenance], where "moderate intensity activity o f at least 45-60 m i n u t e s p e r
day, or i. 7 PAL is required '(4°). The latter measure, PAL, is a n estimate of total
daily average PA level, where a PAL of 1.0 is basal resting metabolic rate. This
a m o u n t of activity is around twice the current recommendations for CVD and
diabetes prevention.
The new concept tfere is energy balance, and the total a m o u n t of PA expended
across the whole day is what a p p e a r s necessary for population level obesity
prevention. The only strategies likely to succeed in increasing population levels
of total EE are related to policy, regulatory mad environmental changes to re-
engineer PA into everyday life(15).
Physical activity and diabetes prevention,
Epidemiological r e s e a r c h in the 1980s a n d 1990s explored the r e l a t i o n s h i p

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 Updating the evidence...

between PA a n d diabetes. Initial s t u d i e s were cross sectional or c o h o r t

studies, showing high rates of diabetes in s e d e n t a r y populations, suggesting
t h a t d e c r e a s e d PA was as i m p o r t a n t a risk factor for developing diabetes as
was i n c r e a s e d body m a s s index t41,42).
Other observational studies have provided new ideas about PA and diabetes.
Hu (4a described a cohort of male health professionals, and showed an increased
risk of diabetes among those who watched >40 hours per week of television, which
was independent of the protective benefits of PA participation. Fulton-Kehoe t44)
carried out a case-control study among Hispanics in Colorado, and showed a
40% decrease in the odds ratio of being diabetic in the most active third of the
population, whether leisure time or occupational PA was measured. A study of
middle-aged Finnish adults showed that at least moderate intensity occupational
activity, active commuting or LTPA were each associated with reduced diabetes
incidence t45). Finally, early evidence is appearing that suggests that contributors
to the Metabolic Syndrome might be reduced substantially in those exposed to
prolonged vigorous exercise programs (46).
In the last few years, even stronger evidence has become available from
randomised controlled trials (RCTs), which have explored the concept of diabetes
prevention in high risk populations. This review summarises three trials and their
impact on diabetes prevention.
The Da Qing study t47)was an RCT of 577 people with impaired glucose tolerance
in China. Randomisation was by outpatient clinics, and patients were allocated
to four intervention groups: [i] control, [ii] diet, [iii] an exercise group, [iv] exercise
and diet groups. The behavioural outcomes showed increases in exercise in
groups [iii] and [iv], but no differences in weight were noted for groups [i], [ill and
[iii]. Diabetes incidence showed a graded reduction across groups i-iv, with rates
of 15.7, 10, 8.3 and 9.6 per 100 person years. A greater risk reduction effect
seemed to be attributable to exercise t h a n to diet, although both were significantly
different from the control group.
The Finnish Diabetes Prevention Study (48) was an RCT of 522 people with
impaired glucose tolerance (IGT). The intervention included intensive nutritional
counselling and some endurance exercise advice. The aims were to reduce weight
by about 5% (achieved by 43% intervention, 13% controls), to reduce total fat
intake to a r o u n d 30% or less (47% intervention, 26% controls), and to achieve
the moderate PA recommendations of 30 minutes per day (increased PA 36%
intervention, 16% controls). Intervention subjects lost around 4.2 kg (compared
with 0.8kg in controls) at 12 months, and also showed greater reductions in
waist circumference and in blood pressure t h a n controls. Diabetes incidence
was reduced by 58% more among the intervention group than controls, and
was related to the a m o u n t of lifestyle change. It was concluded that for every 22
people with IGT who received the intervention, one more case of diabetes might
be prevented.
The Diabetes Prevention Project (49) (DPP group, 2002) was a multi-centre RCT
in the USA with 3234 adults with IGT. There were three trial arms: an intensive
16-session lifestyle intervention, a usual care arm, and a pharmacological arm
(Mefformin). The behavioural outcomes showed that 74% achieved their PA
goal at one year, and also achieved their weight loss goal of around 7% (weight
loss of about 7 kg). There was a 58% reduction in the incidence of diabetes in
the intensive lifestyle intervention group and a 31% reduction in the Metformin
group, compared with controls. Given the strength of the evidence, the study was
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Updating the evidence...

stopped early, with the behavioural intervention significantly more effective in

preventing diabetes t h a n Mefformin.
These three trials provide evidence that diabetes can be prevented in those at
high risk. One caveat is the expense of these intensive interventions, with the DPP
behavioral intervention trial costing around $3,000 per participant tS°) (DPP 2003).
There is a n urgent need now to translate this evidence into more cost-effective
population-level interventions.
Physical activity and mental health
There are few new studies in the a r e a of PA a n d m e n t a l health, b u t m u c h
r e m a i n s to be clarified with r e s p e c t to evidence of PA a n d diverse m e n t a l
health outcomes. For example, clinical studies h a v e explored PA a n d anxiety
or d e p r e s s i o n in small s a m p l e s (al,a2), b u t few h a v e u s e d r e p r e s e n t a t i v e or large
p o p u l a t i o n samples. F u r t h e r m o r e , even less w o r k h a s b e e n carried out to
explore the r e l a t i o n s h i p b e t w e e n PA and p s y c h o s o c i a l wellbeing or positive
m e n t a l health, other t h a n positive a s s o c i a t i o n s in c r o s s - s e c t i o n a l analytic
surveys t53~. R e s e a r c h evidence on psychosocial wellbeing is least clear,
p r o b a b l y reflecting its c o n c e p t u a l i s a t i o n variously as 'self esteem', cognitive
function, sleep quality a n d m o r e generalised m e n t a l h e a l t h states.
D u n n (54/has documented the need for further clarification and for standardised
m e a s u r e s of mental health outcomes. Although reviews of earlier studies have
shown cross sectional associations between PA and exercise a n d s y m p t o m s of
depression, cohort studies have shown mixed relationships, with some studies
showing a decreased risk of depression in those who are physically active
and other studies showing no clear associations. T h u s the evidence is mixed,
especially a m o n g the better-designed longitudinal research studies.
Lawlor (Saconducted a systematic review of 14 small clinical trials, which explored
exercise as therapy for the m a n a g e m e n t of depression. Exercise, compared with
no intervention, seemed to have a significant effect across these studies, b u t again
there were substantial methodological concerns. For example, the dose or type
of PA required was not stated, few trials used 'intention to treat' m e t h o d s (which
should be standard practice in controlled trial research) and m o s t were unblinded
trials, suggesting the possibility of social desirability bias. Some excellent trials
are in progress (DOSE study (55)) b u t Final results have not been reported.
In spite of all this research the evidence b a s e is still relatively m o d e s t .....
',especially for whole populations "(al,52). The widely held attributed mental health
benefits of being active cannot be substantiated at this stage. The research to date
is suggestive, b u t definitive policy decisions and investments in this a r e a require
a m u c h stronger evidence base. The research needs include better prospective
observational studies to examine the dose response relationship, and larger RCTs
to identify the dose and type of activity required. There is also a need to explore
the biological m e c h a n i s m s for observed mental health benefits.
Physical activity and ,cancer prevention
PA a n d c a n c e r is a relatively n e w a r e a of epidemiological r e s e a r c h , with
i n c r e a s i n g evidence of PA c o n t r i b u t i n g to r e d u c i n g the r i s k of a l l - c a u s e
c a n c e r s (56,57). A review b y T h u n e (58~ n o t e d t h a t t h e r e w a s a n overall r i s k
r e d u c t i o n r e l a t i o n s h i p b e t w e e n activity a n d all c a n c e r d e a t h s , with a dose-
r e s p o n s e relationship, b u t t h a t this w a s s t r o n g e s t for colon c a n c e r a n d
b r e a s t cancer, which are i m p o r t a n t c o n t r i b u t o r s to all c a n c e r d e a t h s .
Recent consensus statements b y the International Agency for R e s e a r c h into
Cancer (IARC)(591have concluded t h a t "there was sufficient evidence for the role of
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 Updating the evidence...

PA in preventing colon and breast cancers ... Some of these effects appeared to be
independent of weight (control) .... the working group considered t h a t excess body
weight and physical inactivity account for approximately a quarter to one third of
cancers of the colon and breast .... T h u s adiposity a n d inactivity a p p e a r to be the
m o s t important avoidable causes of these cancers..."te°). Similar statements were
m a d e a b o u t the American Cancer Society report by Willetttel): "that, after avoiding
tobacco, staying lean and active provides the greatest potential for minimizing
cancer risks". The most recent epidemiological review (77) concluded "there was a
30-40% risk reduction for colon cancer, and the evidence for breast cancer was
also moderately strong....but the evidence, for other cancers (prostate, endometrial
, ovarian, lung or, renal cancer) was weaker or inconsistent".
Specific details of the relationship between PA and breast cancer remain
unclear. The target groups at risk and types of PA required are not yet defined,
and recent studies have generally added to the confusion. Some studies have
reported protective associations with b r e a s t cancer and some have notl6a); while
some have reported 'risk reduction', these were not statistically significant (6a).
Other studies have shown a protective relationship, b u t only for more vigorous
activity or only a m o n g post-menopausal w o m e n (64,65~.
Implications of these conclusions are t h a t PA h a s a defined role in the primary
prevention of colon and probably breast cancers. Considerations of the population
health b u r d e n of these two cancers should consider physical inactivity as an
independent risk factor. Finally, evidence around tertiary prevention studies
is now growing, with exercise programs demonstrating quality of life and
psychosocial benefits for those with established cancer (66). This is extending the
range of cancer-related PA research and evidence generation.
Physical activity and musculoskeletal health
PA is t h o u g h t to h a v e benefits for m u s c u l o s k e l e t a l health, t h r o u g h the
p r e v e n t i o n of o s t e o p o r o s i s a n d in r e d u c i n g r i s k s or c o n s e q u e n c e s of arthritis.
No m a j o r or n e w b r e a k t h r o u g h p a p e r s or reviews have b e e n p u b l i s h e d since
the p r e v i o u s review (4).
It is recognised that bone mineralisation p e a k s by the end of the second decade
and that gradual bone loss thereafter contributes to osteoporosis and the risk
of falls and fractures (67). Therefore, one prevention focus should be to encourage
vigorous weight-bearing PA a m o n g children a n d adolescents, during which period
bone deposition occurs (67). In middle-aged and older people, resistance training
and balance activities are encouraged to help maintain strength and balance and
prevent falls and fractures (67).
The evidence on PA and arthritis h a s not progressed in the period reviev~ed.
There is some support for possible benefits of moderate intensity PA, and it
is unlikely to do harm; on the other hand, vigorous or prolonged activity m a y
exacerbate or worsen the severity of knee a n d other large joint osteoarthritis and
m a y be associated with higher injury rates. Increasing evidence suggests that
older patients who have osteoarthritis m a y benefit from PA and exercise programs
in t e r m s of improved functional status a n d independent living (68-7I).
A few epidemiological studies have examined aspects of musculoskeletal health
and all c a u s e mortality or other outcomes. Katzmarzyk and Craig (72}examined the
Canadian Fitness Survey cohort (n=8116, followed since 1981), and showed that
aspects of musculoskeletal fitness (sit ups, grip strength) were associated with
all-cause mortality. Lowered grip strength was also associated with functional
limitations a m o n g older adults (7a.
13
Updating the evidence...

Finally, the net s u m of evidence on falls prevention remains promising,

although the relative contributions of different types of activity (including strength
training, balance and gait training) remain uncertain. Review papers have shown
inactivity to be a consistent risk factor for hip fractures (74). Another systematic
review h a s shown that moving from being sedentary to at least moderately active
can reduce the risk of hip fractures b y 20-40% (75). These reviews support public
health recommendations regarding PA and falls prevention.

Conclusions
This u p d a t e of the epidemiological evidence r e a f f i r m s the evidence
u n d e r p i n n i n g the National Physical Activity Guidelines for Australia(a):
m o d e r a t e i n t e n s i t y PA, on m o s t d a y s of the week, for a b o u t half a n hour,
provides the m a x i m a l p o p u l a t i o n h e a l t h benefit. Recent s t u d i e s r e p o r t e d h e r e
h a v e s u g g e s t e d t h a t walking, especially b r i s k walking (at l e a s t 3.2-4.8 k m
per hour), itself confers a benefit which is i n d e p e n d e n t of o t h e r m o d e s of PA.
Active c o m m u t i n g is s u p p o r t e d b y a few studies (7), b u t evidence in this a r e a
r e m a i n s s p a r s e . The benefits of b e i n g active a c c r u e to different p o p u l a t i o n
s u b - g r o u p s ; evidence is n o w clear for w o m e n as well as men, a n d for people
with diabetes or those who are overweight. T h u s , it is a n i m p o r t a n t public
health s t r a t e g y to e n c o u r a g e activity a m o n g the overweight a n d t h o s e with
diabetes, irrespective of the p o t e n t i a l for PA to i m p a c t directly on weight
loss.
One confusing area remains in the q u a n t u m of activity for weight loss and
weight maintenance. Each of these areas have different c o n s e n s u s statements,
b u t both recommend more t h a n the 30 minutes per day; at least 45-60 minutes
of additional activity per day a p p e a r s to be a m i n i m u m for obesity prevention.
The m o s t exciting new information h a s been in the area of diabetes prevention.
Several controlled trials have demonstrated that lifestyle change can reduce
the incidence of diabetes in at-risk populations. The challenge here will be
translational research, which can be developed and disseminated in whole
populations and population groups at risk of developing diabetes.
The evidence for mental health and for musculoskeletal health h a s not changed
m u c h in the period u n d e r review. Further research in both of these health
outcome areas is required to clarify the existence and magnitude of PA-related
health benefits. For cancer prevention, evidence is strong for colon cancer,
moderate for breast cancer prevention and uncertain for other cancers. Current
work around tertiary prevention will be a strong focus in the coming decade.
Finally, a review of the population b u r d e n of disease attributable to inactivity is
in progress, and will redefine the global b u r d e n of illness and disease attributable
to physical inactivity. A global strategy for diet and PA is being prepared by the
World Health Organisation, and will be submitted to the World Health Assembly
in May 2004 (76). This will allow for policy development, using the existing
epidemiological data," to develop global and national approaches to tacking the
problem of physical inactivity.

14
 Updating the evidence.,.

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