Res Exerc Epidemiol 2012; 14(1): 1-18.
c 2012 by the Japanese Association of Exercise Epidemiology
Copyright ○【Review Article】

Physical Activity, Exercise and Non-Communicable Diseases
Edward Archer 1), Steven N. Blair 1,2)
1）Departments of Exercise Science, Arnold School of Public Health, University of South Carolina
2）Epidemiology/Biostatistics, Arnold School of Public Health, University of South Carolina

ABSTRACT The modern environment has been explicitly engineered to reduce manual labor, increase physical
comfort and afford passive entertainment. As a result, physical inactivity and sedentary pastimes have become
ubiquitous features of the post-industrial world. Given the fact that human metabolic, cardiovascular andmusculoskeletal systems evolved in an environment in which survival necessitated extraordinary amounts ofphysical exertion, it is not surprising that physical inactivity has induced a host of morbidities. Epidemiologicalevidence has demonstrated that inactivity has significant risks and severe consequences for all individuals
independent of age, genetic endowment, personal history (e.g., past lifestyle), body composition and current
behavior (e.g., diet, alcohol consumption, smoking). Physical inactivity accelerates the aging process anddramatically increases the frequencies of non-communicable diseases (NCDs) such as cardiovascular disease(CVD), type-2 diabetes (T2D) and other pathologies (e.g., frailty, osteoporosis, sarcopenia, and obesity). The
relative risks of physical inactivity and mortality from NCDs begin in childhood and increase with advancing age.
Nevertheless, physical activity (PA) and exercise have been demonstrated to delay and/or prevent the onset of
NCDs and other pathologies associated with sedentary lifestyles and aging. This review surveys data fromobservational studies and randomized controled trials (RCTs) that support the premise PA and exercise are
essential elements in the maintenance of health as well as the prevention and treatment of age-related maladies
and NCDs.
Key words: epidemiology, health, sedentary, physical activity, chronic disease, exercise
The confluence of passive transportation, 9) spectatorbased entertainment,10) decrements in occupationalenergy expenditure,11) and household (i.e., domestic)
physical activity (PA)12-14) has engendered an increasein hypokinetically induced non-communicable chronic
diseases; NCDs (e.g., cardiovascular disease (CVD),
type-2 diabetes (T2D)) and mortality. 15-17) Given thefact that human physiology evolved within anenvironment that obligated remarkable amounts ofenergy expenditure via physical exertion,6,18) it is not
surprising that a lack of PA has induced a host of
morbidities and increased risk for mortality. 19-24)
Over the past five decades, a substantial accumulation of empirical evidence (both epidemiological andexperimental data) has established that well-known,
pervasive, and yet preventable behavioral risk factors
such as physical inactivity and unhealthy diets exact
an enormous toll25) as proximal elements in the causal

Environmental Changes, Epidemiology, and Noncommunicable Disease
Humans are extremely adept at altering theenvironments in which they live. 1,2) Over the past
century, the evolution of the physical, social, andcultural milieus has proceeded extremely rapidly2,3-7)
and humans are now immersed in a world explicitly
engineered to reduce physical labor, increase physical
comfort and afford passive entertainment. As a result,
physical inactivity and sedentary pastimes (e.g.,
web-surfing, TV viewing) have become ubiquitousfeatures of both developed and developing nations. 8)
Address for correspondence: Edward Archer; Departmentsof Exercise Science, Arnold School of Public Health,
University of South Carolina; 921 Assembly Street, Suite
212 Columbia, S.C. 29208, USA; archerec@email.sc.edu

1Res Exerc Epidemiol 2012; 14(1): 1-18.

pathway of NCDs.15,16,23,24,26-30) Fortunately, the lossof physiologic resources (e.g., strength, endurance)
and increments in metabolic impediments (e.g.,increased fat mass31-35) and insulin resistance28,36-45))
con- comitant with sedentary lifestyles and aging are
not inevitable.46-48) The evidence for the protective
effects of PA and the importance of exercise in
primary prevention as well as an empiricallysupported treatment of NCDs is extensive andincreasing.15,28,29,49-61) Accordingly, the World HealthOrganization,19,62) United Nations,63) American Heart
Association 51), American Cancer Society64), American
Diabetes Association and the European Association
for the Study of Diabetes65) have concluded that asedentary lifestyle is a major modifiable risk factor for
NCDs.
This review begins with a brief summary of theevolution of human physiology and the alterations of
the socio-cultural and physical environments that have
reduced the necessity of physical exertion andincreased the prevalence of sedentary lifestyles. We
then provide a survey of the evidence that humanphysiology requires a minimum amount of PA tomaintain health, and that the adoption of a physically
active lifestyle is now an essential component ofhealth and wellbeing.

resources over vast distances allowed early humans toeffectively utilize and eventually to dominate theirnatural environment. Over millions of years, theconfluence of socio-cultural evolution (i.e., thedevelopment of human society) and the progressionof human physiologic resources allowed humans tomeet the intense demands of their environment andbecome the preeminent species on Earth. 1)
Nevertheless, the socio-cultural evolution (i.e.,alterations of the social and natural environment) thatallowed modern humans to gain preeminence now
threatens human health and wellbeing. The modern
environment has evolved rapidly over the last century
and is now explicitly designed to reduce physicallabor, and for many people physical activity energy
expenditure (PAEE) is now well below that which isnecessary to maintain health. 69,70) As a result, modern
sedentary lifestyles have induced a host ofpathologies in the form of NCDs. The evidence thathumans suffer severe consequences from inactivity isextensive and increasing. 39,42,71-73)
While the medical community has only recently
begun to consider PA and exercise as modalities that
improve health, there is a vast evidence base thatsuggests that in the modern environment, PA andexercise not only improve health once it iscompromised, but are essential elements in its
maintenance.

The Environment and the Evolution of Human
Physiologic Resources

The evolution of the energy demands of survival.
Humans are social animals that have evolved
within the context of highly developed communal
structures, 74) and while a single human is remarkably
unprepared to survive in the wilds, a social milieu
obviates much of the physical burden and energy
demands of survival. Consequently, the evolution ofhuman socio-cultural evolution is inversely related to
PAEE 66,75) and the concomitant demands on thephysiologic resources so essential to health. Early
communal hierarchies allowed for the avoidance of
predators and the sharing of hunting and gathering offood. By 7000 BCE, the development of agriculture
facilitated the transition from foraging and persistence hunting (i.e., the “Neolithic revolution”) 76) to aless energetically costly way of life. 77) Attendant withthis transition was a dramatic reduction in the energy

Humans evolved in an environment in whichsurvival necessitated considerable amounts ofphysical exertion and energy expenditure. 66)
Extremes of temperature, altitude, terrain and otherenvironmental features regularly challenged thephysiology of early humans. 15) Consequently, humanmetabolic, cardiovascular and musculoskeletal systems (i.e., physiologic resources) evolved to meet thedemands of that milieu. It has been estimated that
hunter-gathers expended greater than 80 kj/kg/day(20 kcal/kg/day) in PA. 5,67) In light of this, it becomes
clear that it was not only an opposable thumb thatallowed early humans to gain ascendancy over otheranimals but the incomparable capacity to expend vast
amounts of energy in sustained PA. 18,68) The ability tostalk prey (i.e., persistence hunting) and gather

2

Res Exerc Epidemiol 2012; 14(1): 1-18.

costs of survival. 67) When humans toiled laboriously
to survive, they expended sufficient energy in PA totax physiologic resources and in doing so, forestall
many of the NCDs that now befall modern man. In
other words, the continuous and at times intense PA
from hunting, farming and other ‘occupational’
activities was more than adequate to support health,and most people succumbed to infectious rather thanchronic diseases. Nevertheless, as human societies
progressed from hunting and gathering to agrarian toindustrial and post-industrial (i.e., informational)
economies, the PAEE obligated by the environment
diminished significantly and reduced the demands onthe metabolic, cardiovascular and musculoskeletal
systems that are so vital to health.

person spends nearly 50% of their waking hours (andtherefore a large portion of their PAEE) at their job.
Any decrement in physical exertion and/or the timespent in occupational PA will have dramatic impacts
on health and obesity. It has been estimated that theworking population in the United States has experienced a decrease in occupational EE via reductions inboth the number of hours spent working13,100-102) aswell as the physical effort obligated by occupation. 11)
Over the past 50 years, the estimated decrement in
occupational EE via decreases in the physical effort
obligated by occupations in the United States isgreater than 420 kj/day (> 100 kcals/day).11) Thisdecrement in occupational EE approximates the‘energy gap’103) necessary for the increase in bodyweight and obesity experienced in the US over the
past 50 years.11)
In addition to decrements in transport and occupational EE, there have been substantial decreases
in PAEE in almost every other component of daily life.
For example, labor-saving devices have dramaticallychanged how housework is performed. 14,104) The
physical effort necessary in the performance ofdomestic activity and housework have been on the
decline since the middle of the 20th century and mostestimates suggest that women are performing 10-15
hrs less housework per week than in the
1960s.12-14,100,101,105) As the time spent doinghousework decreased, the amount of time in sedentary
behaviors (e.g., TV viewing and web surfing 13, 101, 106))
has increased dramatically. American adults now
spend over 16 hours per week watching television andadditional time in front of their computers. 13,100,101,
106,107)
The estimated change in energy expenditurefrom active housework (e.g., washing the dishes andsweeping the floor) to sedentary pastimes (e.g., using
a dishwasher while watching TV) is the equivalent of
more than 4,200 kj/week (> 1,000 kcals/week). The
decrement in PAEE from these findings suggests thatthe recent rise in bodyweight and obesity experienced
in the US is due to decreases in PA alone. Given thefact that PA is the major modifiable component of
total daily energy expenditure (TDEE), 108) the
substantial decrement in total PAEE from all activities(e.g., transport, occupational and housework) may be
so large that current levels of obesity would be

The modern environment.
Despite unconvincing claims that PA has notdeclined over the recent past, 78) modern sedentary
humans expend approximately 25-30% of the calories
that hunter-gatherer populations expended in PA (~20
kj/kg/day compared to > 80 kj/kg/day respectively).
5,67)This substantial reduction in PAEE is the result of
numerous anthropogenic changes in the physical,
social and cultural environments, 79-87) and is one ofthe primary drivers of the recent increase in
NCDs. 17,23,24,26,28,63,79-86)
Recent socio-cultural and environmental changes intransportation, occupation, domestic activity andentertainment have dramatically reduced PAEE. Overthe past five decades, there has been a remarkableworldwide increase in the use of passive transport(e.g., private vehicles) and a concomitant substantial
decline in active transport (e.g., walking, biking). 9,56,
87-95)The increased availability and use of laborsaving features in the urban environment (e.g.,
mass-transit, elevators, escalators and moving sidewalks) diminish PAEE as we move through modern
cities.87,89,92,96,97) For example, present-day Americans
take significantly fewer steps than individuals in
traditional agricultural lifestyles such as the Amish(i.e., < 10,000 steps/day vs. > 15,000 /steps/day).98,99)
Perhaps more importantly, there has been a substantial
decrease in occupational EE as mechanization and atransition from manufacturing to informational labor
have reduced the need for physical effort. The average3Res Exerc Epidemiol 2012; 14(1): 1-18.

considerably higher if energy intake (EI) levels had
increased. In agreement with other sources, 109-111)
these PA data suggest that EI has either diminished orremained static in some groups over the recent past.

reported PA. Since people tend to over-report their PA
levels, there is an attenuation of relationship between
PA and health.118) As such, we have been able toextend earlier work on PA and health outcomes by
objectively measuring cardiorespiratory fitness (CRF)
by a maximal exercise test, which is primarily
determined by a person’s PA during a few months
before the test.120) The ACLS has produced compelling evidence on the relationship between PA, CRF andhealth.23,55,117,119-125) In our first report on CRF andmortality, we followed over 13,000 healthy men andwomen for more than 8 years of follow-up (a total of110, 482 person-years of observation). The ageadjusted all-cause mortality rates for men increased
from a low of 18.6 per 10,000 person-years in the
most-fit quintile to 64.0 per 10,000 person-years in theleast-fit quintile. The corresponding values for women
were 8.5 per 10,000 person-years in the most fit to
39.5 per 10,000 person-years in the least fit. Thisstrong inverse trend remained after correcting for age,smoking, systolic blood pressure (SBP), cholesterollevels, family history of CVD and fasting serum
glucose levels. Higher levels of CRF delay all-cause
mortality through lower rates of NCDs (e.g., CVD andcancer). Our results clearly demonstrate that asedentary life style engenders a reduced CRF, whichleads to accelerated aging, and an increased risk for
NCDs and premature mortality. 28,55,117)

The Necessity of PA for HealthAncient wisdom.
The importance of PA for health has beenrecognized for millennia and the detrimental effects ofa sedentary lifestyle were observed well before the
21st century. As human societies evolved, theemergence of a leisure (i.e., sedentary) class supported
by slave and/or peasant economies gave rise to theearliest instances of sedentarism and hypokineticallyinduced NCDs. Sushruta, the famous Indian surgeon
from Kashi and father of Ayurvedic medicine (i.e.,knowledge of life), practiced around 600 BCE. 112,113)
His keen sense of observation led to the discovery that
his most inactive/sedentary clients suffered from anumber of classic hypokinetic diseases. 113,114) Sushruta
chronicled numerous NCDs such as madhumeha or“honey-like urine” (i.e., diabetes); vataraka (i.e.,
hypertension) and medoroga (i.e., obesity) in his
ancient text The Sushruta Samhita.112,115)
Modern evidence.
Since the 1950s, there has been a substantial
accumulation of epidemiological evidence on the
primacy of PA in the maintenance of health. Some of
the compelling modern evidence of the healthsustaining effects of PA is provided by two classic
studies: the College Alumni Study (CAS)116) and the
Aerobics Center Longitudinal Study (ACLS).117) The
CAS examined PA and all-cause mortality in over
36,500 men from their college entrance documents(1916-1950) and other public records. The work ofPaffenbarger and colleagues revealed an inverse doseresponse relationship between PA and all-cause
mortality. Greater levels of PA were associated with alower risk of death, and men expending > 8,400 kj per
week (2000 kcal/wk) in PA had a 27% lower risk ofmortality compared with men expending < 8,400 kj
per week (2000 kcal/wk).
While the CAS was a seminal and landmark study,
one of its greatest limitations was the use of self-

PA and mortality.
We recently examined the attributable fractions ofdeaths in the ACLS population. 24) Attributablefractions are based on the strength of a particular risk
factor with mortality and on the prevalence of the risk
factor in the population being examined. Figure 1
depicts the results of these analyses. The attributablefractions are the estimated number of deaths in the
population that are due to a specific risk factor. Eachrisk factor is adjusted for possible confounding factors,
including age, examination year, and each of the otherrisk factors in the figure. Low CRF is estimated tocause ~16% of deaths, which is far higher than any
other risk factor, with the possible exception of
hypertension in men, and is greater than the combined
deaths due to obesity, diabetes, and smoking in both
women and men.

4Res Exerc Epidemiol 2012; 14(1): 1-18.

18

attributed to five major risk factors (i.e., high bloodpressure, tobacco use, high blood glucose, physicalinactivity and overweight/obesity). 22) As global
patterns of PA and consumption changed, theincreasing prevalence of these well-known, pervasive
and yet preventable major risk factors has exacted anenormous toll25) as the proximal element in the causal
pathway of NCDs (e.g., CVD, T2D, stroke, cancer andchronic respiratory diseases).15,16,24,26,27) In concert
with the 2009 WHO report, the United Nations
General Assembly formally recognized that the spreadof NCDs represents a global crisis, and that men,
women, and children in all countries and in all income
groups are at risk.19,130)

Men

16

Women

14
12
10
8
6
4
2
0

Figure 1

Attributable fractions (%) for all-cause deathsin 40,842 (3,333 deaths) men and 12,943 (491 deaths)
women in the Aerobics Center Longitudinal Study. The

Direct costs.
The confluence of physical inactivity and the agingof the global population 131) has lead to a dramaticincrease in NCDs and their attendant costs. 21,26) The
increasing burden of NCDs represents a significant
threat to human, societal and economic development
throughout the world. NCDs are currently responsible
for over 65% of all deaths worldwide (i.e., > 36
million fatalities) and are projected to cause over 75%
of all deaths by 2030.22,132) In post-industrial nations,more than 85% of all deaths are due to NCDs. 21) It is
important to note that in the US ~20% of the
population smokes yet 40% are inactive. 21) Thissuggests increasing PA108) may be the most effective
solution to the global pandemics of obesity and NCDs.
The failure to reduce NCDs will result in heavy
losses in terms of both human life and economic
production.16,130,133) Two of the major risk factors,
obesity and physical inactivity have both direct andindirect effects on the mortality and morbidity
associated with NCDs via other risk factors (e.g., highblood pressure, high blood glucose). 15,26,120,122,133,134)
Globally, approximately 2.8 million adults die annually as a result of being overweight or obese, androughly 10% of all NCD mortality is due to insufficient PA.20,22,16,26) In the United States, obesityand physical inactivity account for nearly 20% of alldeaths (i.e., > 400,000 deaths annually),85) and a substantial portion of the burdens (i.e., disability andmortality) from certain cancers, diabetes and CVD are
directly attributable to inactivity-induced low levels of

attributable fractions are adjusted for age and each otheritem in the figure. *=cardiorespiratory fitness determinedby a maximal exercise test o a treadmill. (Reprinted bypermission of the Br J Sports Med)Over the past 50 years, the evidence base continues
to accrue via modern epidemiological studies, and it
demonstrates a strong, inverse dose-response relationship between PA and NCDs, especially CVD. The
health benefits of PA are irrefutable, 15,23,24,53,117,119,
120,122,126,127)and even small increments in PA via
reductions in sedentary behavior are beneficial, giventhat each is an independent risk factor for CVD. 128)
The maintenance of health, reduced mortality andimprovements in metabolic function, body composition, hemodynamics, musculoskeletal, and psychologic functioning are a few of the myriad benefits of
PA. Active individuals have lower rates of all-cause
mortality, CVD, high blood pressure, stroke, T2D,
metabolic syndrome, colon cancer, breast cancer,
depresssion, enhanced cognitive functioning, better
quality sleep and health-related quality of life
(QoL).129)
The Economic and Societal Costs of Inactivity
Risk factors for NCDs.
In 2009, the World Health Organization (WHO)reported on the leading global risk factors for
mortality.20) More than one third of all deaths were5Res Exerc Epidemiol 2012; 14(1): 1-18.

CRF and increased obesity.22,28,55,135) Additionally,
NCDs often result in slow painful deaths after
extended periods of disability. 20) As such, NCDs
diminish not only the quality and quantity of life, butalso deprive the local community of economic
production and independence.62,63)
As the prevalence of the major risk factors
increases, the costs of inaction will amplify and thefailure to reduce NCDs will result in heavy losses interms of both human life and economic production16,130,133) while threatening health systems andeconomic progress in both the developed anddeveloping world16). In addition to the human losses,
the economic costs associated with the lifestylerelated antecedents (i.e., major risk factors) of NCDs
are staggering. In the US, the cost of CVD & diabetes
alone account for $750 billion annually26) and areincreasing.22,136) In other countries the costs areequally burdensome: China $558 billion; India $237
Billion; and Britain $33 Billion. 17,26)

increased in parallel with the rise in childhood
sedentarism and hypokinetically-induced childhood
obesity. NAFLD is now one of the leading global
causes of chronic liver disease in children andadolescents. 85,171-174)
Premature aging.
In 2008, more than nine million of the deaths
attributed to NCDs occurred before the age of 60. 21,22)
These "premature" deaths are strong evidence of theacceleration of both aging and mortality frominactivity as well as other risk factors such as
smoking.21) In developing nations, the risk ofpremature death (< 60 yrs of age) from NCDs is 300%
greater than in post-industrial nations. 21)
In elderly populations, the major inactivityinduced NCDs are often comorbid with other pathologies associated with sedentary lifestyles (e.g.,
osteoporosis47,166,175-177), sarcopenia137,154), obesity
31,33,35,178)) as well as poor nutrition. 35,178,179) The
co-occurrence of these pathologies denotes a phenoltype of accelerated aging indicated by decrements inthe ability to perform activities of daily living (ADL)
and a reduced QoL. 138,139,176,180,181) These impairments
are engendered by alterations in energy metabolism(e.g., dysglycemia), 28,36-45) body composition (e.g.,loss of lean body mass,31,32,47,137,154,182-185) bone mass,
186,187)
and increments in fat mass 31-35)), musculoskeletal dysfunction (e.g., loss of muscle quality,
volume, force development), 137,154) decrements in
CRF188,189) and other indices of functional capacity. 164,189,190) The relationship between age, inactivityinduced decrements in physiologic resources andmorbidity are causal and not merely incidental. For
example, body composition explains > 80% of thevariation in energy metabolism (e.g., glucose disposal,
EI expenditure and storage). 191-193) Skeletal muscle
mass (SMM) is responsible for ~70-80% of insulinmediated glucose uptake 194) and post exercise, SMM
is responsible for dramatic increases in non-insulin
mediated glucose uptake (NIMGU). 28,46,195-205) Low
SMM from aging and inactivity is linked with insulin
resistance, 204,206-208) and frailty, 47,137,140,164,176,190,209)
while exercise training-induced increases in muscle
volume, quality and/or function improve insulin
sensitivity, sarcopenia and health. 38,53,205,210-215)

The Human Cost of Sedentary Lifestyles
Loss of Physiologic Resources.
It is well established that age and sedentary
lifestyles diminish the physiologic resources (e.g.,strength, CRF) necessary for humans to meet environmental demands (e.g., stair climbing, housework,
personal care) while decreasing QoL and increasing
morbidity and mortality. 26,137-139) Inactivity has
significant risks for all individuals independent of age,
genetic endowment, personal history (e.g., past
lifestyle), body composition and current behavior(e.g., diet, alcohol consumption and/or smoking).15,24,55,117,119,120,122,124) Sedentary lifestyles havesevere consequences for all individuals since therelative risks of physical inactivity and mortality from
NCDs begin in childhood and increase with advancing
age.39,79,140) A lifetime of physical inactivity attenuates
peak aerobic capacity, skeletal muscle strength andbone density,79) while predisposing individuals to ahost of morbidities in later life79,141-144) such as
T2D,28,45,145-150) osteoporosis151,152), sarcopenia,153-155)
CVD, 156-163) frailty,140,164) cancer,55,64,165-169) and fatty
liver disease. 171-174) Not surprisingly, the prevalenceof nonalcoholic fatty liver disease (NAFLD) has

6Res Exerc Epidemiol 2012; 14(1): 1-18.

hemoglobin (HbA1c) by 0.48% (95% CI -0.76 to-0.21; p = 0.0005), total fat mass by 2.33 kg (95% CI-4.71 to 0.04; p = 0.05) and SBP by 6.19 mmHg (95%
CI 1.00 to 11.38; p = 0.02). Thus, RT had both aclinically and statistically significant effect on multiple metabolic risk factors (e.g., obesity, HbA1c levels,and SBP)232)
A more recent review and meta-analysis of 47 RCTs
(duration > 12 weeks) examined a total of over 8,500
patients.233) Structured exercise training (e.g., aerobic
exercise, RT or both combined) was associated with adecline in HbA1c levels of -0.67% (95% CI, -0.84%
to -0.49%) compared with control participants. The
combination of both aerobic and RT was the mosteffective, resulting in HbA1c decrements of -0.51%(95% CI, -0.79% to -0.23%) when compared with
control participants.
These results clearly support exercise as an efficacious treatment of CVD and the reduction ofnumerous metabolic risk factors.

Exercise as Treatment for NCDs and other
Inactivity-induced Morbidities
The loss of physiologic resources and increments inmetabolic impediments (e.g., increased fat mass,insulin resistance) concomitant with sedentary lifestyles and aging are not inevitable. 46-48) Lifestylemodifications (e.g., increases in PA) have been
empirically examined for over 30 years, 216-220) andhave been demonstrated to improve the metabolic risk
factors (e.g., inflammation, insulin resistance) for anumber of NCDs: Hypertension, T2D, cancer and
CVD.15,57,120,221) A considerable accumulation of datafrom randomized trials suggest that exercise interventions (EXs) may prove both efficacious and costeffective in the prevention as well as treatment of
numerous NCDs. 17,28,53,57,218,222-228) EXs enhancephysiologic resources (e.g., strength, CRF), ameliorate or even reverse the underlying pathologies that
inhibit the ability to meet environmental demands(e.g., stair climbing) and halt progression along thecontinuum from inactivity to disability and death.

Summary
Rapid and dramatic alterations of the natural andsocio-cultural environments over the past century
have PAEE below that which is necessary for healthand wellbeing69,70) and as a consequence, increased
the prevalence of NCDs. Over the past 50 years, a
substantial accumulation of epidemiological and experimental evidence has established a causal relationship between NCDs and preventable behavioral risk
factors such as sedentary lifestyles and unhealthy
diets.15,16,24,26,27) As such, physical inactivity leading to
low levels of fitness is a leading cause of morbidity
and mortality in the world. 16,17,26,63,130) Nevertheless,there exists a lack of appreciation of the necessity of
PA and exercise in the maintenance of health as well
as a lack of implementation of PA interventions in the
primary prevention and treatment of NCDs.

CVD.
In 2011, a Cochrane systematic review allowed ananalysis of 47 studies which included 10,794 CVD
patients randomized to either exercise-based cardiac
rehabilitation or usual care. 229) With 12 months ormore of follow-up, exercise-based cardiac rehabilitation reduced all-cause and CVD mortality signifycantly: RR 0.87 (95% CI 0.7 to 0.99) and 0.74 (95%
CI 0.63 to 0.87), respectively. In 70% of these studies,
there was evidence of a significantly higher selfreported QoL with the exercise treatment compared tousual care. Given these and other results, theprescription of PA and exercise is now an essential,
but all too often underutilized component of thetreatment of CVD.15,230)
Metabolic disorders: diabetes, dysglycemia andinsulin resistance.
A meta-analysis in 2006231) demonstrated thatexercise significantly improves glycemic control andreduces visceral adipose tissue and plasma triglycerides. In 2010, a meta-analysis of 13 RCTs showedthat resistance training (RT) reduced glycosylated

It is our hope that the vast accumulation of evidence
on the relationship between the health-sustaining
benefits of PA and exercise is recognized andappreciated so that future generations do not suffer theconsequences of inactive lifestyles.

7

Res Exerc Epidemiol 2012; 14(1): 1-18.

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