｢健康づくりのための運動基準 2006 英訳｣

Exercise and Physical Activity Reference for Health Promotion 2006
(EPAR2006):
Physical Activity, Exercise, and Physical Fitness

OutlinePrepared in August, 2006
By the Office for Lifestyle-Related Diseases Control,
General Affairs Division, Health Service Bureau,
Ministry of Health, Labour and Welfare of Japan

Translated in April, 2007
by Dr. Izumi Tabata,
Director of Health Promotion and Exercise Program
National Institute of Health and Nutrition, Japan

This English report was prepared under the Health and Labour Sciences Research Grants ofDr. Izumi Tabata for the research on exercise and physical activity guidelines, awarded from
the Ministry of Health, Labour and Welfare, Japan.

Executive summary

We reviewed the recommended exercise allowances for health promotion (1989) and set
reference values for physical activity, exercise, and physical fitness for Japanese aged 2069 years. Specifically, for individuals who intend to promote health mainly throughphysical activity, a daily walk of 8,000 to 10,000 steps is set as the target. For those who
rely on exercise for health promotion, the target was set at 35 min of jogging or playing
tennis or one hour of brisk walking every week.

1.

This report, which concerns the quantity of physical activity and exercise for healthpromotion, specifically for preventing lifestyle-related diseases, is promulgated by
the “Preparation Committee for the Recommended Exercise Allowance and Exercise
Guidelines” that was established on August 8, 2005. The basis for the report was the“Recommended Exercise Allowances for Health Promotion” compiled in 1989,
utilizing the latest scientific findings.

2.

The content of this report differs markedly from the Recommended Exercise
Allowances for Health Promotion established in 1989, with the emphasis placed on
the prevention of lifestyle-related diseases. Some of the outstanding features in thereport are: (1) both domestic and overseas publications were thoroughly examined(systematic review) and the references for the quantity of physical activity, exercise
and physical fitness (maximal oxygen uptake) are indicated; and (2) the relationshipbetween the prevention of lifestyle-related diseases and physical fitness (including
muscle strength) was also evaluated.

3.

Reference values for the quantity of physical activity and exercise for healthpromotion

EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)

i

(1)

Quantity of physical activity: 23 METs·hour/week(Equivalent of an activity lasting aproximatley 60 min per day at an
intensity of 3 METs. If the activity is composed mainly of walking, thequantity is equivalent to 8,000 to 10,000 steps per day)(2)

Quantity of exercise: 4 METs·hour/week(e.g., 60 min of fast walking or 35 min of jogging or playing tennis)

4.

Reference values for the maximal oxygen uptake for health promotion by gender andage (mL·kg-1·min-1)

Gender/Age
Males
Females

20-29 years
40
33

30-39 years
38
32

40-49 years
37
31

50-59 years
34
29

60-69 years
33
28

5. This report incorporates the latest scientific findings concerning the relationshipbetween health and physical activity, exercise and physical fitness. To amass new
findings that may emerge later, including findings on questions that have not been
elucidated, it is necessary to continue studies, acquire new scientific findings andperiodically update this report.

EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)ii

Exercise and Physical Activity Reference for Health Promotion 2006
(EPAR2006)⎯Physical Activity, Exercise, and Physical Fitness⎯
A Report

Preparation Committee for the Recommended Exercise Allowances and Exercise Guidelines

2006

1. Introduction
As an all-out approach to formulate a national policy for health promotion, the First
National Program for Health Promotion was issued in 1978, followed by the Second one in
1988. In 2000, the “National Health Promotion in the 21st century (Health Japan 21)” wasestablished. As a legislative support for health promotion and disease prevention in citizens,with special reference to “Health Japan 21,” the Health Promotion Law was formulated in
2002 and various programs for health promotion have been well on its way since then.
In view of the global trends for health promotion, “Health Japan 21” purports toachieve objectives such as extending one’s healthy life expectancy: specifically, topics wereselected that relate to improving one’s lifestyle affecting the development and progression oflifestyle-related diseases (e.g., cancer, cardiovascular diseases, stroke and diabetes). Target
values were set for 70 specific indicators in 9 areas; “Nutrition and diet,” “Physical activity
and exercise,” “Rest and the promotion of mental health,” “Tobacco,” “Alcohol,” “Dental
health,” “Diabetes,” “Cardiovascular diseases” and “Cancer.” Currently, efforts are being
made to promote health in these areas.
As the starting point in promoting health through physical activity and exercise, thecommittee, based on scientific findings, established the “Recommended Exercise Allowancesfor Health Promotion” in 1989 to set the target quantity of exercise considered necessary tomaintain one’s health. To create a happy, active and healthy life, in 1993, the “Exercise
Guidelines for Health Promotion” was established. This was followed in 1997 by a reportfrom the “Study Committee on Physical Activity for Health throughout One’s Life.”
Recently, however, with rapid aging of the population, the major health problems
have changed: the morbidity rates of lifestyle-related diseases (e.g., cancer, ischemic heartdisease, cerebrovascular diseases and diabetes) increased. Among the causes of death, about
60% was attributed to lifestyle-related diseases (cancer 30.5%, ischemic heart diseases 15.7%,

EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)2cerebrovascular diseases 13.0%, diabetes 1.3% and hypertensive diseases 0.6%). In fiscal
year 2003, the medical cost for these diseases amounted to 10.2 trillion (2.8 trillion for eachof hypertensive diseases and cancers; 2.0 for cerebrovascular diseases; 1.9 for diabetes
including its complications; and 800 billion for ischemic heart diseases). Within theframework of health insurance, the total amount accounts for about 30% of the national
medical expenditures, indicating the increased burden of health insurance among the nations.
As these diseases increase in severity, the burden on national nursing care insurance will also
increase.
Consequently, in May 2004, the “Health Frontier Strategic Plan” was formulated at a
meeting by the Secretary General and the Chairman of the Policy Research Council fromeach of the Ruling Parties. In response to this development, the Government adopted thefollowing as central policies to extend one’s healthy life expectancy by about 2 years: 1)“plan to assure health during the productive years,” 2) “urgent anti-cancer policy for women,”3) “a 10-year strategy for nursing care and disease prevention,” and 4) “promotion ofscientific technology to extend healthy life expectancy.” Starting in 2005, active programs arebeing and will be developed over the succeeding 10 years.

2. Background
The “Recommended Exercise Allowances for Health Promotion (1989)” wasformulated mainly to prevent coronary artery diseases. Having passed more than 15 years
since the establishment of this standard, the nation’s morbidity pattern changed, where
lifestyle-related diseases - such as diabetes, hypertension and hyperlipidemia - come to theforefront. Furthermore, the disease concept and diagnostic standard for “metabolic
syndrome,” the basis for the aforementioned conditions, were explicated at the related 8
academic societies in April 2005.(1)EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)

3

Metabolic syndrome is a pathophysiologic condition manifested by elevated fastingblood glucose, blood fat disorders and elevated blood pressure, all of which share a common
etiology: a visceral-type obesity. If one has these disease conditions concurrently, the risk fordeveloping ischemic heart diseases and cerebrovascular disorders increases; therefore thebasic rationale concerning this metabolic syndrome is that such a risk may be reduced whenthe visceral fat is minimized.
By promoting the policies to control lifestyle-related diseases, incorporating theconcept of metabolic syndrome, in particular by encouraging people to engage in physicalactivity and exercise and improving the understanding on the importance of “prevention”
among the population and also the personnel concerned with public health, it is believed thatthe current policies may be effectively carried out.
According to the “National Health and Nutrition Survey in Japan, 2004,” theproportion of those who were regularly exercising was 30.9% for men and 25.8% for women
after the establishment of the Recommended Exercise Allowances for Health Promotion in
1989. In spite of the efforts represented by “Health Japan 21,” these percentages failed toincrease, showing that two-thirds of the population did not have the habit of exercising
regularly.
While the general public is becoming increasingly more aware of the policies
concerning lifestyle-related diseases, the Community Health Promotion and Nutrition Sectionof the Health Sciences Council formulated “The Promotion of Future Policies concerning
Lifestyle-Related Diseases (an interim report). Thus, following the slogan of “Firstly,
physical activity and exercise. Secondly, diet and complete smoking cessation. Lastly,
medication”, further emphasis was placed on policies for physical activities and exercise.
Under this circumstance, it was decided to draw up the “Recommended Exercise
Allowance for Health Promotion (1989)” to show the references for physical activity,

EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)

4exercise and physical fitness. These references, based on the latest scientific findings, were
designed to maintain and promote the health of people and prevent lifestyle-related diseases
through improving their habits on physical activity and exercise.

3. Basic concepts
Health promotion and control of lifestyle-related diseases
With a rapid aging of the population over the last few decades, the country’s healthproblems have changed drastically: the morbidity rates of lifestyle-diseases, such as cancer,
ischemic heart diseases, cerebrovascular diseases and diabetes have increased. Likewise,
lifestyle-related diseases also accounts for about 60% of the causes of death. Besides, whenthese diseases become more severe, many patients require nursing care.
Association

betweenpreventionoflifestyle-relateddiseasesandphysical

activity/exercise has been explored in both domestic and foreign studies. It is therefore
expected that promotion of people’s physical activity and exercise would have a notably
positive effect on the prevention of lifestyle-related diseases.
The present “Exercise and Physical Activity Reference for Health Promotion 2006
(EPAR2006)”, therefore, aims to prevent lifestyle-related diseases for health promotion of the
population.

Association between the prevention of lifestyle-related diseases and physical activity, exercise
and physical fitness
Scientific studies on physical activity, exercise, lifestyle-related diseases, and total
mortality have rapidly advanced during the last quarter of a century: the preventive effects ofphysical activity and exercise, not only on coronary artery diseases but also on lifestylerelated diseases, such as diabetes, have been scientifically proven. A considerable amount of

EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)5evidence on prevention of lifestyle-related diseases through physical activity and exercise has
been amassed, in particular, since the previous Recommended Exercise Allowances (1989).
For the current EPAR2006, therefore, it was decided to employ a systematic review based on
the accumulated scientific evidence and to indicate the quantity of physical activity andexercise that is necessary to prevent lifestyle-related diseases.
In general, the level of physical fitness is higher in a person who is physically
active.(2-4) However, there is a lower limit in the exercise intensity to enhance physicalfitness,(5) and the correlation between the physical activity that is quantified by the totalenergy expenditure (kcal/day) and physical fitness is not necessarily evident.(6) Especially, alarge quantity of physical activity with low intensity is not always associated with highphysical fitness.(7)There is also significant genetic influence on physical fitness.(8) According to the recent
studies conducted in the West, not only the quantity of physical activity but also physicalfitness act as independent factors to predict the development of a lifestyle-related disease.(9)Therefore in the EPAR2006, a reference for physical fitness was independently defined, in
addition to those for physical activity and exercise.

Standardization of Terminology
Definitions of the terminology related to physical activity and exercise described inthis report are given in the section of reference materials.

4. Physical activity and exercise for health promotion
A systematic review of the domestic and foreign literature was conducted on therelationship between physical activity/exercise and lifestyle-related diseases to define theEPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)

6reference that is given below. In this instance, separate references were selected for physicalactivity and exercise, both intensities being over 3 metabolic equivalents (METs).
Since there was no evidence to require the classification by gender or age for the
subject aged under 69 years, the references for physical activity and exercise(METs·hour/week) were set regardless of the gender or age.

Quantity of physical activity
For physical activity, the reference was set as 23 METs·hour/week.
The results from the systematic review indicated that the lower threshold of physicalactivity that is effective for preventing lifestyle-related diseases is distributed between 19 and26 METs·hour/week. The necessary time to attain the same quantity of physical activity falls
between 54 and 74 min per day, with intensity of 3 METs (walking at normal pace). However,
it is not easy for the general people to determine the time for physical activity at an intensityof 3 METs; nor is it possible to fully recognize the range of 20 min. Thus, a single value - themean of the values extracted from the systematic review - was used as a reference forphysical activity.
People are expected to exceed this reference, depending on one’s current level ofphysical activity. By which, it is expected that the risk of developing lifestyle-related diseases
will be reduced.
Physical activity with intensity of 3 METs or higher include exercise as well as
walking (e. g., shopping, commuting), cleaning floors, gardening, carrying materials andplaying with children. The reference of 23 METs·hour/week ( ≒ 3.3 METs·hour/day),therefore, corresponds to undertaking these activities with intensity ≥ 3 METs for about 60
minutes per day. Most of these activities with intensity ≥ 3 METs would, even not always,
involve walking. If one’s daily activity is composed mainly of walking, it is equivalent toEPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)

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walking for about 60 min per day (about 6,000 steps, if 1,000 steps per 10 min). In daily
activities, one takes 2,000 to 4,000 steps with low intensity unconsciously, (10) hence,
approximately 8,000 to 10,000 steps in total per day. By which, the energy expenditure can be
about 1,450kcal and 1,700kcal per week for a person with 60kg and 70 kg respectively.

Quantity of exercise
The reference and its range for exercise were set as 4 METs·hour/week and2~10 METs·hour/week, respectively.
These are based on the systematic review where the exercise quantity distributed
between 2 and 10 METs·hour/week and the mean value was 4 METs·hour/week. Dependingon the current exercise level, a person should set his/her target above the reference value or its
range. For example, a person who has no habit of exercise should set the goal at 2
METs·hour/week; one whose habitual exercise quantity is below the reference value should
target the reference; and for a person whose exercise quantity exceeds the reference should
aim at 10 METs·hour/week. It is expected that, consequently, the risk for developing lifestylerelated diseases will be reduced
Specific examples of exercises with intensity of 3 METs and more include brisk
walking, physical exercises (with active movements), jogging, running, swimming and ballgames. For example, brisk walking (90~100m/min) has intensity of 4 METs·hour/week.
Therefore, 4 METs·hour/week corresponds to brisk walking for 60 min per week. Similarly, it
corresponds to jogging or playing tennis with intensity of 7 METs for about 35 min per week.
By these exercises, the energy expenditure can be about 250kcal and 300kcal per week for a
person with 60kg and 70 kg respectively.

5. Physical fitness for health promotion

EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)

8Based on the systematic review of domestic and foreign articles on the association
between physical fitness and lifestyle-related diseases, the reference value for physical fitness
was defined using maximal oxygen uptake, an index for endurance fitness. As for muscle
strength, the evidence for setting the reference value was less, thus it was described
qualitatively.

Maximal oxygen uptake
The references for maximal oxygen uptake and its range were defined by gender andage group (see Table 1), based on the systematic review of the domestic and foreign articles
on the association between maximal oxygen uptake and lifestyle-related diseases. The
systematic review provided us with the lowest values (of the maximal oxygen uptake) thatshow the significant difference in the risk of developing lifestyle-related diseases. The
reference value for maximal oxygen uptake to prevent lifestyle-related diseases should be
defined by gender and age group, for which the mean values were calculated in each category.

Table 1. Reference values for the maximal oxygen uptake for health promotion by gender and age(mL·kg-1·min-1)
Gender/Age
20-29 years
30-39 years
40-49 years
50-59 years
60-69 years
Males
40
38
37
34
33
Females
33
32
31
29
28

In addition to the reference values, the current study exhibits the range for the
maximal oxygen uptake for health promotion. These figures show the range of lowest valuesof the maximal oxygen uptake for which at least one study revealed, during the systematic
review, the preventive effect of the maximal oxygen uptake on lifestyle-related diseases.
Therefore, if one’s maximal oxygen uptake is below this range, s/he should first make efforts
to reach to the lower values of the range. If one’s maximal oxygen uptake is below thereference, s/he should target this reference value. And, even though one’s maximal oxygen

EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)

9

uptake is higher than the reference or the upper values of the range shown in Table 2, s/heshould ensure that lifestyle-related diseases are effectively prevented by improving his/her
physical fitness.

Table 2. Range of maximal oxygen uptake that is effective for health promotion (mL·kg-1·min-1)
Gender/Age
20-29 years
30-39 years
40-49 years
50-59 years
60-69 years
Males
23-47
31-45
30-45
26-45
25-41
Females
27-38
27-36
26-33
26-32
26-30

Muscle strength
Regarding the association between muscle strength and reductions in total mortality
risk, several studies indicated that muscle strength is inversely associates with total mortality
risk among men, whereas in most of these studies, no association was detected among women.
On the other hand, when the analyses were not performed by gender, all these studies showedthat muscle strength was inversely associated with the total mortality risk.
There are various methods to measure muscle strength. Regardless of the method
adopted, the total mortality is significantly lower in those who have muscle strength
exceeding the mean value of the study group. Maintaining a certain level of muscle strengthis important also to prevent osteoporosis and fractures.
Muscle strength and muscle volume decrease with age. Reductions in the total
mortality or the risk of fractures due to osteoporosis have been observed in those who havemuscle strength exceeding the mean values in each group. Therefore, maintaining muscle
strength over the current mean values of each age group can be suggested as a reference forthe present Japanese.

Other parameters for physical fitness
It has been known that the risk for fractures due to osteoporosis is lower in those whohave good balance and nimbleness. However, no study has yet examined the association
EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)

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between balance/nimbleness and reductions in mortality or prevention of lifestyle-relateddiseases. Therefore, we did not define quantitative reference for these parameters.

6. Notes for applying these references
Sufficient care must be taken because excessive or inappropriate exercise may haveadverse effects on one’s health. If a person with a certain illness plans to start exercise, s/heshould follow the guidance of a physician.

7. Future objectives and directions
The impacts of physical activity and exercise practiced following the EPAR2006
should be evaluated after a certain period. In addition, the references should be periodicallyrevised, considering the above results as well as the findings of new studies.
Based on the current study, the followings are considered necessary as future research:● Accumulation of scientific evidence on physical activity, exercise and physicalfitness (including muscle strength and muscle volume) of Japanese, as well as on
their association with prevention of lifestyle-related diseases.
● Standardization of methods to assess physical activity● Evaluation of physical activity, exercise and physical fitness according to genderand age group (from childhood to elderly), as well as to the type of life-relateddiseases● Evaluation of specific indices for muscle strength and muscle volume● Evaluation of the upper limit of physical activity and exercise for health promotion● Determination of the effect of moderating medical expenses by pursuing thereference quantity of physical activity and exercise

EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)

11

[Reference Materials]

Standardization of terminology and its explanation (definition of the terms)

1) Exercise and Physical Activity for Health Promotion 2006 (physical activity,
exercise, and physical fitness)
The “recommended allowances” in the previously issued “recommended exercise
allowance for health promotion (1989)” was applied in the same way as that in“Recommended Dietary Allowance for Japanese, 4th Revision in 1989”. The concept of“recommended dietary allowances” was that “The recommended intake values of energy andeach nutrient per day for people to achieve healthy growth, to maintain and promote health aswell as to prevent diseases”. Likewise, the “recommended exercise allowances” means therecommended quantity of exercise for maintaining health.”
In practice, a medial regression line was drawn for maximal oxygen uptake, which
was indirectly estimated by extrapolating a linear relationship with heart rate, and each risk
factor for lifestyle-related diseases (then called adult diseases); in particular the risk factors
for coronary arteriosclerosis (expressed by systolic and diastolic blood pressures, totalcholesterol and HDL cholesterol levels and percentage of body fat). Next, maximal oxygen
uptake, at which none of the aforementioned risk factors showed abnormal values, wasderived from the intersections with abnormal values of the above-mentioned risk factors forcoronary arteriosclerosis, according to gender and age group. Finally, the quantity of exercise
to maintain this maximal oxygen uptake (time per week, when exercise is performed withintensity of 50% of the maximal oxygen uptake) was calculated, which was set as therecommended quantity of exercise.

EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)

12Since the concept of dietary reference intakes was recently adopted, the expression of therecommended dietary allowance (RDA) was replaced by the Dietary Reference Intakes(DRIs). Consequently, in order to ensure consistency of the terminology, it was decided not to
use the term of “recommended exercise allowance”, and instead “reference” is used in thepresent reference.

Method to determine the reference value
Quantity of physical activity and exercise
Epidemiological studies on the association between physical activity, exercise andlifestyle-related diseases cover a wide range of issues, including all types of physical activity
in one’s daily life and exercise mainly by sport activities. These studies showed that moderatelevel of physical activity, not necessarily called exercise, has a preventive effect on lifestylerelated diseases. Considering that in modern society, many have difficulty in exercising
regularly, a number of studies focused not only on exercises but also on physical activity of atleast an intermediate level after the CDC/ACSM report was published in 1995.11) Yet, manyof the articles extracted by our systematic review include epidemiological findings on
exercise as well. This study therefore sets references of both physical activity and exercise forhealth promotion.
The border values of physical activity and exercise of the group who showedsignificantly lower risk for developing lifestyle-related diseases (compared to the group withthe lowest level of physical activity and exercise) or the ones of the group who showedsignificantly higher risk (compared to the group with the highest level of physical activity andexercise) were calculated using the data obtained by the systematic review. If the figure isderived from a single study, the decision of its application is easy. However, in reality, anumber of research results have been presented by the efforts of many researchers, and theEPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)

13

reported values tend to vary widely. It is likely that this variability was due to the researchmethods employed (e.g., numbers of groups, survey methods and subjects of the studies).
Nevertheless, careful examination of these articles failed to show any systematic cause of thisvariability. When the data were examined by gender and age group, no logical basis wasfound for classifying subjects by these variables. Thus, the means of these values werecomputed and a single value for quantity of physical activity and exercise (METs·hour/week)
was used as the reference regardless of gender or age.

Maximal oxygen uptake
The maximal oxygen uptake was also taken up in the Recommended Exercise
Allowance for Health Promotion in 1989, and has been explored as a risk factor for
developing lifestyle-related diseases independent of the quantity of physical activity andexercise in many recent studies. The border values of the maximal oxygen uptake of thegroup who showed significantly lower risk of developing lifestyle-related diseases (comparedto the group whose maximal oxygen uptake is lowest) or the ones of the group who showedsignificantly higher risk (compared to the group whose maximal oxygen uptake is highest)
were obtained. It is appropriate to set the reference value for the maximal oxygen uptake toprevent lifestyle-related diseases between the minimum and maximum border values
according to gender and age group; so a mean value was calculated and used as the reference.

Concept of the reference value
As stated earlier, these values for physical activity/exercise and the maximal oxygen
uptake were the minimum ones with which the group showed significantly lower morbidity
for each lifestyle-related disease, compared to the group whose physical activity, exercise andphysical fitness are at the lowest within the cohort. Therefore in a simple sense, these are theEPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)

14

minimum values at which the effect of preventing lifestyle-related diseases is expected fromphysical activity, exercise and physical fitness. However, lifestyle-related diseases areassociated not only with physical activity, exercise and physical fitness, but also with diet andother lifestyle habits. Therefore even if one meets the reference values of physical activity,
exercise and physical fitness, s/he is not necessarily protected from lifestyle-related diseases.
Thus, it is not appropriate to use the phrase of the “minimum values of physical activity,
exercise and physical fitness that will protect one from developing lifestyle-related diseases”.
According to The Dietary Reference Intake for Japanese (2005), a tentative dietary
goal (DG) for the proportion of energy from fat is set as “20-30%” for prevention of lifestylerelated diseases. The present references for physical activity, exercise, and physical fitness
also have similar concept to DG, though our references are not “goal” in a strict sense. In
order to coordinate with the discipline of nutrition, the use of “goal” was avoided and instead,“reference” was used.

Validity of reference values in view of the current quantity of physical activity andexercise
Quantity of physical activity
The reference for the quantity of physical activity is 8,000 to 10,000 when converted
to the number of steps. This is more than the current average number of steps among Japanese,
according to the results of the National Health and Nutrition Survey in Japan in 2004 (7,532
and 6,446 steps for men and women, respectively). The reference corresponds to the target of“Health Japan 21” (over 9,200 and 8,300 steps for men and women, respectively) and isconsidered to be an appropriate target.

Quantity of exercise

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The reference, 4 METs·hour/week corresponds to brisk walking for 60 min/week (30min, twice), which is also the category of “regular exerciser” in the National Health andNutrition Survey (30 min or more per time, twice or more per week, continued for at least oneyear). The proportions of “regular exerciser” are 30.9% of men and 25.8% of women,
indicating that two-thirds of the population do not meet the reference values. This value is theminimum at which the effect of preventing lifestyle-related diseases is evident, which is also
the target at which the majority of the population should aim.

Maximal oxygen uptake
The reference for the maximal oxygen uptake was found to be slightly lower than themean value of Japanese. This reference therefore can be regarded both practical andappropriate for those people whose physical fitness level is low, having high risk fordeveloping lifestyle-related diseases.
As described above, the references adopted for the present revision are designed forthe overall purpose of preventing lifestyle-related diseases. They are considered suitable forthose people who are not exerting themselves enough in physical activity and not exercisingadequately. At a low level of physical fitness, they should recognize the importance ofphysical endeavors in preventing these lifestyle-related diseases. Needless to add, thosepeople who exceed the reference values for physical activity, exercise and physical fitness
should target the upper values of the range shown in Table 2.

2) Physical activity
Physical activity is defined as any bodily movement produced by skeletal muscles
results in energy expenditure above resting energy expenditure. The physical activity can bedivided into two; one is nonexercise physical activity (e.g. daily work, housework,

EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)

16commuting to office/school) and the other is exercise that is practiced intentionally for
maintaining and improving one’s physical fitness. Here, the present reference counts only
physical activities with intensity of 3 METs or more (see the figure below).

Fig 1: Physical activity and exercise
Physical activity

brisk walking, jogging,
tennis, swimming…

Moderate or high-intensity
nonexercise activity

walking, cleaning floors, gardening, carwashing, walking up and down stairs,
playing with children…

Low-intensity
Exercise(3METs or more)
Moderate orModerate or highintensity exercise

Nonexercise activity

high-intensity

Exercisestretching…

standing, cooking, doing laundry,
playing piano…

Low-intensity

Low-intensity nonexercise
activity

3) Exercise
Exercise is defined as a kind of physical activity that is planned, structured, repetitive,and designed to improve or maintain one or more components of physical fitness (including
both sports performance-related fitness and health-related fitness). For the current reference,
exercises with intensity of 3 METs or more, such as brisk walking, jogging, running,bicycling, swimming, tennis, badminton and soccer are concerned, and the activities withlower intensity (such as stretching) are excluded.

4) Physical fitness

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17

There have been various definitions of physical fitness, which encompass a wide
range of components. In the present reference, physical fitness is defined as a composite ofmultifaceted elements (latent potentials) related to the capacity to perform physical activity,
or in a narrow sense, as the status that can be comprehended objectively and quantitatively. It
is composed of the followings: 1) endurance, 2) muscle strength, 3) balance, 4) flexibility and5) others.

5) Maximal oxygen uptake (Vo2max)
Maximal oxygen uptake is defined as the maximum amount of oxygen taken in perunit time (l/min or ml/kg/min). The amount of oxygen uptake during exercise reflects theamount of energy produced in the active muscles. The higher its maximum value, the greater
the capacity to produce energy, indicating an ability to engage in exercise with greater
intensity for a longer duration. In other words, the maximal oxygen uptake is an index forevaluating one’s endurance.
The maximal oxygen uptake is measured by physical activity in which a large muscle
group is used. This is often measured by walking or running on a treadmill or by using abicycle ergometer. The amount of oxygen uptake at the increment of exercise intensity ismeasured by the analyzing expired gas. With the increase in exercise intensity, oxygen uptake
linearly increases and its highest amount is called “maximal oxygen uptake”. In this process,it is important to confirm the point where oxygen intake starts leveling-off. This is clearly
different from the definition of the peak oxygen uptake measured by the protocol of a gradedexercise load 12) Yet, this peak oxygen intake may often be used as a substitute for the
maximal oxygen uptake. In general, the maximal oxygen uptake while running is 5 to 10%
higher than the one measured by a bicycle ergometer.13) In the current systematic review,
about 70% of the data on maximal oxygen uptake were derived from the studies by treadmill,

EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)

18while the remainder used a bicycle ergometer. Therefore, the current reference reflects theresults of running exercise, and thus care should be taken when we estimate the outcomes of
exercise using a bicycle ergometer.
Measurement of the maximal oxygen uptake requires not only expensive equipments,
such as the one for exercise loading apparatus , the expired gas analyzer and anelectrocardiogram recording device. In addition, a number of skilled personnel are required.
Therefore, several simple methods to estimate the maximal oxygen uptake have beendeveloped (e.g. the one that does not impose the maximum effort on the subject, the one
without using the gas analyzer). Since their adequacy and reproducibility have been
confirmed, they are utilized in many studies.

6) Muscle strength
The value for muscle strength varies widely, depending on the method adopted or thesite where the measurement is made. Commonly used methods for evaluating muscle strength
include: 1) Maximum isometric muscle strength that is measured when the muscle length
remains unchanged [maximum voluntary contraction: MVC (kg weight)] and 2) isotonic
maximum muscular strength that is measured when the muscle length is shortened with
applying the constant tension to the muscle [1 RM(repletion max)(kg weight)]. By using
these methods, muscle strength in the articular movement of the extremities and truncal
region can be determined.
To determine the isometric maximum muscle strength of handgrip exercise, grip
strength (kg weight) has been used because of its safety and simplicity. As the references, thenationwide data are compiled according to gender and age, based on the results of a sports
test (test for physical fitness) conducted by the Ministry of Education, Culture, Sports,

EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)

19

Science and Technology and other related studies. These data are used as an index for muscle
strength in, not only domestic but also international, epidemiological studies.

7) MET
MET (metabolic equivalent) is an index for physical activity intensity, calculated asenergy expenditure (oxygen untake, mL/kg/min) during specific physical activity andexercise divided by sitting/resting energy expenditure (equivalent to 3.5 mL/kg/min inoxygen uptake) .

8) METs·hour
METs·hour is defined as METs multiplied by hours spent in physical activity andexercise. If the oxygen consumption of 1.0 liter is converted into the energy expenditure of
5.0 kcal, 1.0 MET·hour corresponds to 74 and 63 kcal with a body weight of 70 and 60 kg,
respectively. For a standard body composition, 1.0 MET·hour can be the energy expenditurealmost equal to body weight. In this way, METs·hour is frequently used to quantify physicalactivity. The energy expenditure for 2, 4, 10 and 23 METs·hour used for the current
references, is shown in the Table below. It should be noted that these values are total energy
expenditure for physical activity or exercise, and they do not represent the excess energy
consumption over that when the subject is at rest.
METs·hour and corresponding kcal
METs·hour
2
4
10
23

With body weight of 60 kg (kcal)
130
250
630
1450

With body weight of 70 kg (kcal)
150
200
740
1690

The following computation was made with a metabolism at rest set at 3.5 mL/kg/min
and 5.0 kcal per L of oxygen uptake:
Example: energy expenditure for a person weighing 60 kg with 4 METs·hour:

EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)20

= (3.5 ml/kg/min x 60 kg/1000) x 5.0 kcal/L x (4 x 60 min)≒ 250 kcal
To simplify, energy expenditure (kcal) may be calculated from METs·hour, using
METs and body weight (kg) as follows:
1.05 x METs·hour x body weight (kg)
MET values for major activities are shown below.

EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)

21Nonexercise physical activity of 3 METs or more (included in the computation of the reference for thequantity of physical activity)(The time equivalent of 23 MET·hours is expressed per day, not per week)
METs

Examples of activity

3.0

Walking (level, 67m/min.), walking with small child(ren), walking the dog,
shopping
Fishing (from boat, sitting (2.5) to fishing in stream (6.0))
House cleaning, putting away household items, carpentry, packing, etc.
Playing guitar, rock and roll band (standing)Loading/unloading a car
Walking down the stairs
Child care, standing
Carpet sweeping, sweeping floors
Walking (level, 80m/min., moderate pace) commuting
Mopping, vacuuming, packing/unpacking boxes, carrying light load
Electrical work and plumbing
Scrubbing floor on hands and knees, scrubbing bathroom/bathtab
Walking for exercise (level, 94 m/min.)Walking at a brisk pace (level, 95-100 m/min.)Bicycling：< 16 km/h, leisure, to work or for pleasure
Walk/run - playing with child(ren)or animals, moderate
Raking roof with snow rake
Playing drums
Pushing a wheelchair
Playing with a child (walk or run, at a moderate intensity)
Planting seedlings/shrubs, weeding, cultivating garden
Farming: feeding cattle/horses
Walk/run – playing with child(ren) or animals, vigorously
Walking at a very brisk pace (on level ground, very brisk pace = 107m/min.)
Mowing lawn, walk, power mower
Moving furniture, household items, carrying boxes
Shoveling snow by hand
Carrying heavy loads
Farming: forking straw bales, cleaning corral or barn, poultry, vigorously
Climbing the stairs
Carrying load upstairs

3.0
3.0
3.0
3.0
3.0
3.0
3.3
3.3
3.5
3.5
3.8
3.8
4.0
4.0
4.0
4.0
4.0
4.0
4.0
4.5
4.5
5.0
5.0
5.5
6.0
6.0
8.0
8.0
8.0
9.0

EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)

Time (min/day)corresponding to
23 MET·hours

66
66
66
66
66
66
66
60
60
56
56
52
52
49
49
49
49
49
49
49
44
44
39
39
36
33
33
25
25
25
22

22

Exercise of 3 METs or more (included in the computation of the reference for the quantity of exercise)
METs

Examples of activity

Time (min/day)corresponding to
4 METs·hour

3.0
3.0
3.0
3.0
3.0
3.5
3.5
3.8
4.0
4.0
4.0
4.0
4.0
4.5
4.8
5.0
5.0
5.0
5.5
6.0
6.0
6.0
6.0
6.0
6.5
7.0
7.0
7.0
7.0
7.0
7.0
7.5
8.0
8.0
8.0
10.0
10.0
10.0
10.0
11.0
11.0
15.0

Bicycling using a stationary ergometer: 50 watts, very light effort
Weight lifting, light or moderate effort
Bowling
Playing frisbee
Volleyball
Calisthenics, home exercise, light or moderate effort
Playing golf, using power cart
Walking for exercise (level, 94 m/min.)Walking at a brisk pace (level, 95-100 m/min.)water exercises or water calisthenics
table tennis, ping-pong
Tai chiwater aerobics, water calisthenics
badmintonballet or modern dance, twist, jazz or tap dancing
softball or baseballchildren’s games (hopscotch, dodge ball, playground apparatus, marbles etc.)
Walking (level, very brisk pace, 107 m/min.)Bicycling using a stationary ergometer: 100 watts, light effort
Weight lifting (power lifting or body building), vigorous effort
slimnastics, jazzercise
Jog/walk combination (jogging component of less than 10 min)basketball
Swimming, leisurely
Aerobics
Jogging
Skating
SoccerTennisSwimming, backstroke
Skating, skiing
Mountain climbing with 1-2 kg load
Cycling (approx. 20 km/h), leisure, moderate effort
Running: 134 m/min.
Swimming, slow crawl (approx. 45 m/min.), moderate or light effort
Running: 161 m/min.
judo, jujitsu, karate, kick boxing and tae-kwan-do
rugby
Swimming, breaststroke
Swimming, butterfly
Swimming, fast crawl (approx 70 m/min.), vigorous effort
Running, stairs, up

80
80
80
80
80
69
69
63
60
60
60
60
60
53
50
48
48
48
44
40
40
40
40
40
37
34
34
34
34
34
34
32
30
30
30
24
24
24
24
22
22
16

EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)

23

Reference: Activities of less than 3 METs (excluded in the calculation of the reference for the quantity ofphysical activity and exercise)
METs
Examples of activity
1.0
1.2
1.3
1.5
1.5
1.5
1.8
2.0
2.0
2.0
2.0
2.0
2.0
2.0
2.0
2.3
2.3
2.3
2.5
2.5
2.5
2.5
2.5
2.5
2.5
2.5
2.5
2.5
2.5
2.5
2.8

Sitting quietly (or lying down), watching television or listening to music; reclining; riding in acarStanding quietly
Sitting - reading book or newspaper
Sitting - talking or talking on the phone, reading, eating, driving a car, light desk work, knitting,
doing a manual craft and typing (in a sitting position)
Taking care of a pet (in a sitting position, light intensity)
Bathing (sitting)Standing – talking or talking on the phone, reading and doing a manual craft
Cooking or food preparing - standing or sitting
Implied standing - laundry, fold or hang cloths, put clothes in washer or dryer, packing
Playing guitar, classical or folk (sitting)
Dressing, undressing
Talking and eating or eating only (standing)Grooming (washing, shaving, brushing teeth, washing hands, putting on make-up)
Showering, toweling off (standing)
Walking slowly (level, outdoors or indoors, less than 54 m/min.)Wash dishes (standing), ironing,
Implied walking - putting away clothes, gathering cloths to pack, putting away laundry
Standing - casino gambling, duplicating machineStanding - light work (bartening, store clerk, duplicating etc.)
Stretching* and hatha yoga*
Light cleaning (dusting, straightening up, changing linen and carrying out trash)
Serving food, setting table, cooking or food preparation, and putting away (walking), etc.
Watering plants
Sitting - playing with child(ren) or animals
Child care (sitting/kneeling)
Playing piano or organ
Farming, driving harvester, cutting hay, irrigation work
Playing catch (football or baseball)*Operating a motor scooter or motorcycle
Pushing or pulling stroller with child or walking with children
Walking (level, slow pace, 54 m/min.)Standing - playing with child(ren), playing with animals＊

Indicates exercise: the others are classified as physical activities.

(Ainsworth BE, Haskell WL, Whitt MC, et al. Compendium of physical activities: an update of activity codes and MET
intensities. Med Sci Sports Exerc, 2000; 32 (Suppl): S498-S516.)

Note 1: When there are multiple values for a single activity, the one that is considered to appear more frequently
is listed (c.f., taking the value for leisure activity over that for competitive sport).
Note 2: Each value represents that while engaged in activity, not while resting.

EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)

248) The target values of “Healthy Japan 21” in comparison with provisionally selectedmost recent value

The target values of “Healthy Japan 21” in comparison with provisionally selected most recent actual value.

TargetBaseline value for setting the reference

Goal

Provisionallyselected
mostrecent actual value

2.1 Increasing the number of

ADULT(20 years or older)Male51.8%1)
Female 53.1%1)

63%or more
63% or more

54.2%2)*
55.5%2)*9,200 steps or
more
8,300 steps ormore
39 % or more
35% or more

7,532 steps4)“people who intentionallyand actively participate inphysical
activities
tomaintain and promote theirhealth in their daily life”
2.2 Increasing the number ofsteps walked in daily lifeMale

8,202 steps3)

Female 7,282 steps3)

2.3 Increasing the number ofindividuals who do regularphysical exercise

2.4 Increasing the number of
elderly who take a positive
attitudetowardgoing
outside2.5 Increasing the percentage ofthe elderly who join certain
local community activity
programs
2.6 Increasing the number ofsteps walked in daily life

Male
Female28.6%3)
24.6%3)

Elderly
Male (60-yr or older) 59.8%5)
Female (60-yr or older) 59.0%5)
All (60-yr or older)
46.3%5)
Male (60-yr or older)48.3%6)
Female (60-yr or older)39.7%6)

70% or more
70% or more
56% or more
58% or more
50% or more

6,446 steps4)
30.9%4)
25.8%4)
51.8%2)*
51.4%2)*
38.7%2)*
66.0%2)*
61.0%2)*

Male (70-yr or older) 5,436 steps3) 6,700 steps or

5,386 steps 4)

Female (70-yr or older) 4,604 steps3) 5,900 steps or

3,917 steps 4)

more
more

1) Health and Welfare Statistics, 1996
2) National Health and Nutrition Survey in Japan, 2003
3) National Nutrition Survey in Japan, 1997
4) National Health and Nutrition Survey in Japan, 2004
5) Awareness Survey on Daily Living of the Elderly, 1999
6) Awareness Survey on Participation of the Elderly in Community Activities 1998
Notes:
Data for the “provisionally selected most recent actual value” are the ones as of March 8, 2006.
* The survey for the baseline data and the one for the latest data are different.

9) Systematic review(1) Purpose

EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)25

A systematic review was conducted to set the reference quantity of physical activity
and exercise for health promotion: the target populations are healthy individuals, as well as
those who were found to have minor abnormalities (such as an elevated blood pressure and anelevated fasting blood glucose) at a health examination and told to improve their lifestyle.
(2) Method for search
A literature search was conducted on observational studies on the effects of physicalactivity, exercise and physical fitness (major components of reference quantity of physicalactivity and exercise for health promotion) on the development of lifestyle-related diseases.
c Databases: PubMed and Japana Centra Rebuo Medicinad Published date: Before April 11, 2005
e Search format: In PubMed, the following was used;(“physical activity” OR exercise OR “physical training” OR fitness) AND (eachdisease entity) AND (follow* OR observation* OR prospective OR longitudinal OR
retrospective)
f Search limited to: human studies
g Publication category: original articles
h Age: from school age (6 years and older) to the elderlyi Target lifestyle-related diseases:
obesity, hypertension, hyperlipemia, diabetes, cerebrovascular disorders, death due tocirculatory diseases, osteoporosis, ADL and total mortality(3) Inclusion criteria
Among the articles that were retrieved through the search, those that met thefollowing criteria were selected to obtain the necessary quantitative information;c Studies in which individuals who, as a rule, were free of severe illnesses (healthypeople or those having minor symptoms but capable of doing exercise) were observed

EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)

26

for a long term (over 2 years) and their mortality or incidences of disease wereanalyzed according to physical activity, exercise, and physical fitness.
d Studies clearly indicating information on quantity of physical activity and exercisethat were evaluated by quantitative methods (type, intensity, duration: min/week or
min/day, frequency: times/week). If the information on “frequency” is not available,
the data may be calculated using the data of “type, intensity and min/week.”
e Studies clearly indicating information on physical fitness that was determined byquantitative methods.
f Studies in which quantity of physical activity and exercise and physical fitness are
divided into groups and the cut-off lines are set logically.
g Studies in which the effects of physical activity and exercise are individually
analyzed [the effect of other factors (sex, age, smoking, metabolic risk factors, etc.)
are statistically adjusted].
h The number of subjects is determined by the method of analysis or the accuracy ofmeasurement.
(4) Results
The search formula given above retrieved 8,134 articles. Following the primary
screening by examining their titles and abstracts, the number decreased to 794. The full textof each article was obtained for a thorough examination. Finally, the number of the articles
that satisfied the inclusion criteria given in the above was 84.

EPAR2006 (Tabata I. National Institute of Health and Nutrition, Japan)

27

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Lynch J, Helmrich SP, Lakka TA, et al. Moderately intense physical activities andhigh levels of cardiorespiratory fitness reduce the risk of non-insulin-dependent
diabetes mellitus in middle-aged men. Arch Intern Med 1996;156:1307-14.

15.

Lee CD, Jackson AS, Blair SN. US weight guidelines: is it also important to consider
cardiorespiratory fitness? Int J Obes Relat Metab Disord 1998;22 Suppl 2:S2-7.

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Lee CD, Blair SN, Jackson AS. Cardiorespiratory fitness, body composition, and allcause and cardiovascular disease mortality in men. Am J Clin Nutr 1999;69:373-80.

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Wei M, Gibbons LW, Mitchell TL, Kampert JB, Lee CD, Blair SN. The association
between cardiorespiratory fitness and impaired fasting glucose and type 2 diabetes
mellitus in men. Ann Intern Med 1999;130:89-96.

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Sawada S, Muto K. Prospective study on the relationship between physical fitness andall-cause mortality in Japanese men. Nippon Koshu Eisei Zasshi (Jpn J Public Health)
1999;46:113-21. (in Japanese)

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Lakka TA, Laukkanen JA, Rauramaa R, et al. Cardiorespiratory fitness and theprogression of carotid atherosclerosis in middle-aged men. Ann Intern Med
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Laukkanen JA, Lakka TA, Rauramaa R, et al. Cardiovascular fitness as a predictor ofmortality in men. Arch Intern Med 2001;161:825-31.

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Farrell SW, Braun L, Barlow CE, Cheng YJ, Blair SN. The relation of body massindex, cardiorespiratory fitness, and all-cause mortality in women. Obes Res
2002;10:417-23.

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Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE. Exercise capacityand mortality among men referred for exercise testing. N Engl J Med 2002;346:793801.

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Carnethon MR, Gidding SS, Nehgme R, Sidney S, Jacobs DR, Jr., Liu K.
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24.

Evenson KR, Stevens J, Cai J, Thomas R, Thomas O. The effect of cardiorespiratory
fitness and obesity on cancer mortality in women and men. Med Sci Sports Exerc
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Gulati M, Pandey DK, Arnsdorf MF, et al. Exercise capacity and the risk of death inwomen: the St James Women Take Heart Project. Circulation 2003;108:1554-9.

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Kurl S, Laukkanen JA, Rauramaa R, Lakka TA, Sivenius J, Salonen JT.
Cardiorespiratory fitness and the risk for stroke in men. Arch Intern Med
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Mora S, Redberg RF, Cui Y, et al. Ability of exercise testing to predict cardiovascularand all-cause death in asymptomatic women: a 20-year follow-up of the lipid researchclinics prevalence study. JAMA 2003;290:1600-7.

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Sawada SS, Lee IM, Muto T, Matuszaki K, Blair SN. Cardiorespiratory fitness andthe incidence of type 2 diabetes: prospective study of Japanese men. Diabetes Care
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3) Literature referred to in determining physical fitness (muscular strength and others)
required in maintaining and promoting health.
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Fujita Y, Nakamura Y, Hiraoka J, et al. Physical-strength tests and mortality among
visitors to health-promotion centers in Japan. J Clin Epidemiol 1995;48:1349-59.

2.

Nguyen TV, Eisman JA, Kelly PJ, Sambrook PN. Risk factors for osteoporotic fracturesin elderly men. Am J Epidemiol 1996;144:255-63.

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Seeley DG, Kelsey J, Jergas M, Nevitt MC. Predictors of ankle and foot fractures inolder women. The Study of Osteoporotic Fractures Research Group. J Bone Miner
Res 1996;11:1347-55.

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4.

Schroll M, Avlund K, Davidsen M. Predictors of five-year functional ability in alongitudinal survey of men and women aged 75 to 80. The 1914-population in Glostrup,
Denmark. Aging (Milano) 1997;9:143-52.

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Rantanen T, Masaki K, Foley D, Izmirlian G, White L, Guralnik JM. Grip strengthchanges over 27 yr in Japanese-American men. J Appl Physiol 1998;85:2047-53.

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Anstey KJ, Luszcz MA, Giles LC, Andrews GR. Demographic, health, cognitive, andsensory variables as predictors of mortality in very old adults. Psychol Aging
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Al Snih S, Markides KS, Ray L, Ostir GV, Goodwin JS. Handgrip strength andmortality in older Mexican Americans. J Am Geriatr Soc 2002;50:1250-6.

8.

Katzmarzyk PT, Craig CL. Musculoskeletal fitness and risk of mortality. Med Sci
Sports Exerc 2002;34:740-4.

9.

Lee SH, Dargent-Molina P, Breart G. Risk factors for fractures of the proximal
humerus: results from the EPIDOS prospective study. J Bone Miner Res 2002;17:81725.

10.

Metter EJ, Talbot LA, Schrager M, Conwit R. Skeletal muscle strength as a predictor of
all-cause mortality in healthy men. J Gerontol A Biol Sci Med Sci 2002;57:B359-65.

11.

Albrand G, Munoz F, Sornay-Rendu E, DuBoeuf F, Delmas PD. Independent predictorsof all osteoporosis-related fractures in healthy postmenopausal women: the OFELY
study. Bone 2003;32:78-85.

12.

Rantanen T, Volpato S, Ferrucci L, Heikkinen E, Fried LP, Guralnik JM. Handgrip
strength and cause-specific and total mortality in older disabled women: exploring themechanism. J Am Geriatr Soc 2003;51:636-41.

13.

Stel VS, Smit JH, Pluijm SM, Lips P. Balance and mobility performance as treatablerisk factors for recurrent falling in older persons. J Clin Epidemiol 2003;56:659-68.

14.

Metter EJ, Talbot LA, Schrager M, Conwit RA. Arm-cranking muscle power and arm
isometric muscle strength are independent predictors of all-cause mortality in men. J
Appl Physiol 2004;96:814-21.

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