The economic burden of physical inactivity in Canada. Prevention of type 2 diabetes Physical Activity and Risk for Cardiovascular Events in Diabetic Women Low Cardiorespiratory Fitness and Physical Inactivity as Predictors of Mortality in Men with Type 2 Diabetes The joint effects of physical activity and body mass index on coronary heart disease risk in women. Do sugar-sweetened beverages cause adverse health outcomes in children? A systematic review protocol Physical inactivity and short-term all-cause mortality in adults with chronic disease. Global, Regional, and National Burden of Cardiovascular Diseases for 10 Causes, 1990 to 2015 Association of Leisure-Time Physical Activity With Risk of 26 Types of Cancer in 1.44 Million Adults. World Salt Awareness Week. Combined effects of obesity and physical activity in predicting mortality among men. Copenhagen study of overweight patients with coronary artery disease undergoing low energy diet or interval training: the randomized CUT-IT trial protocol Relationship between low cardiorespiratory fitness and mortality in normal-weight, overweight, and obese men. The economic costs associated with physical inactivity and obesity in Canada: an update. A school-based intervention to reduce overweight and inactivity in children aged 6–12 years: study design of a randomized controlled trial An activity-based intervention for obese and physically inactive children organized in primary care: feasibility and impact on fitness and BMI Estimated Global, Regional, and National Disease Burdens Related to Sugar-Sweetened Beverage Consumption in 2010 Relationship of physical activity vs body mass index with type 2 diabetes in women. Effectiveness of parent‐centred interventions for the prevention and treatment of childhood overweight and obesity in community settings: a systematic review Influence of pre- and postdiagnosis physical activity on mortality in breast cancer survivors: the health, eating, activity, and lifestyle study. A cluster randomised school-based lifestyle intervention programme for the prevention of childhood obesity and related early cardiovascular disease (JuvenTUM 3) Long term health implications of fitness and physical activity patterns. Physical activity trajectories and mortality: population based cohort study
BACKGROUND About two-thirds of Canadians are physically inactive . As a risk factor for several chronic diseases , physical inactivity can potentially be a substantial public health burden . We estimated the direct health care costs attributable to  physical inactivity  in Canada , the number of lives lost prematurely each year that are attributable to a sedentary lifestyle and the effect that a reduction of 10 % in inactivity levels ( a Canadian objective for 2003 ) could have on reducing direct health care costs . METHODS We calculated summary relative risk ( RR ) estimates from prospect i ve longitudinal studies of the effects of physical inactivity on coronary artery disease , stroke , colon cancer , breast cancer , type 2 diabetes mellitus and osteoporosis . We then computed the population -attributable fraction ( PAF ) for each illness from the summary RR and the prevalence of physical inactivity ( i.e. , 62 % ) and applied the PAF to the total direct health care expenditures for 1999 and to the number of deaths in 1995 associated with each disease to determine the health care costs and lives lost prematurely that were directly attributable to physical inactivity . RESULTS About $ 2.1 billion , or 2.5 % of the total direct health care costs in Canada , were attributable to physical inactivity in 1999 . A sensitivity analysis ( simultaneously varying each of the health care costs and PAF by + /- 20 % ) indicated that the costs could be as low as $ 1.4 billion and as high as $ 3.1 billion . About 21,000 lives were lost prematurely in 1995 because of inactivity . A 10 % reduction in the prevalence of physical inactivity has the potential to reduce direct health care expenditures by $ 150 million a year . INTERPRETATION Physical inactivity represents an important public health burden in Canada . Even modest reductions in inactivity levels could result in substantial cost savings Almost three decades ago the Finnish led the way for prevention of coronary heart disease by successfully implementing the community based North Karelia project.1 With the recent publication of their r and omised controlled clinical trial of prevention of type 2 diabetes , Tuomilehto et al have now shown that effective lifestyle changes can prevent another major chronic disease of our time . 2 3 Type 2 diabetes has long been linked with behavioural and environmental factors such as overweight , physical inactivity , and dietary habits.4 The findings from the Finnish trial confirm this link . Major lifestyle changes result ing from industrialisation are contributing to a rapid rise in diabetes worldwide , but especially in industrialising countries . An estimated 135 million people worldwide had diagnosed diabetes in 1995 , and this number is expected to rise to at least 300 million by 2025.4 Between 1995 and 2025 the number of people with diabetes will increase by 42 % ( from 51 to 72 million ) in industrialised countries and by 170 % ( from 84 to 228 million ) in industrialising countries . Diabetes exerts a huge Cardiovascular disease is the leading cause of death in persons with diabetes mellitus . This disorder affects approximately 16 million Americans , at least 15 million of whom have type 2 diabetes mellitus ( 1 ) . Among diabetic persons , coronary heart disease causes more than 50 % of all deaths and stroke causes an additional 15 % ( 2 ) . Diabetic women are at particularly high risk for cardiovascular disease , and diabetes eliminates the usual female advantage for death from coronary disease . While an inverse association between increased physical activity and lower risk for cardiovascular disease is well established in the general population ( 3 ) , sparse data are available among diabetic persons ( 4 , 5 ) . Intervention studies have shown that exercise increases insulin sensitivity and glucose tolerance and induces favorable changes in blood lipid levels among persons with type 2 diabetes mellitus ( 6 ) . Exercise as an adjunct to diet regimens yields greater and more sustained weight loss in obese patients with type 2 diabetes mellitus ( 7 ) . Even moderately intense exercise , such as walking , improves insulin sensitivity and reduces body weight ( 8) . Because walking is safe and easy , it may provide a promising way to reduce risk for cardiovascular events among diabetic persons . In this study , we examined in detail the relationship between levels of physical activity  and incidence of coronary heart disease and stroke among women with type 2 diabetes mellitus in the Nurses ' Health Study . In particular , we evaluated  walking  ( the most common form of physical activity among diabetic persons ) in relation to cardiovascular events . Methods Study Sample The Nurses ' Health Study cohort was established in 1976 . The original cohort consisted of 121 700 female registered nurses who were 30 to 55 years of age and resided in 11 large U.S. states . The nurses completed a mailed question naire about their medical history and lifestyle , and follow-up question naires administered every 2 years up date information on potential risk factors and identify newly diagnosed cases of coronary heart disease and other illness . Our study includes 5125 women who , on any question naire from 1976 to 1992 , reported having physician-diagnosed diabetes mellitus and being 30 years of age or older at disease onset ( a working definition for type 2 diabetes mellitus ) . Women who reported a history of coronary heart disease ( including myocardial infa rct ion , angina , or coronary revascularization ) , stroke , or cancer on or before the 1980 question naire ( when physical activity was first assessed ) were excluded at baseline . The follow-up rate for nonfatal events was 97 % of the total potential person-years . Confirmation of Diabetes Mellitus A supplementary question naire regarding symptoms , diagnostic tests , and hypoglycemic  therapy was mailed to women who indicated on any biennial question naire that they had received a diagnosis of diabetes . A case of diabetes was considered confirmed if at least one of the following was reported on the supplementary question naire : 1 ) classic symptoms plus a fasting plasma glucose level of at least 140 mg/dL ( 7.8 mmol/L ) or a r and om plasma glucose level of at least 200 mg/dL [ 11.1 mmol/L ] , 2 ) at least two elevated plasma glucose concentrations on different occasions ( a fasting level 140 mg/dL [ 7.8 mmol/L ] or a r and om level 200 mg/dL [ 11.1 mmol/L ] , a concentration 200 mg/dL after 2 hours or more on oral glucose tolerance testing , or both ] in the absence of symptoms , or 3 ) treatment  with hypoglycemic medication ( insulin or an oral hypoglycemic agent ) . The validity of this question naire has been verified in a sub sample of the study cohort ( 9 ) . Of a r and om sample of 84 women classified by the question naire as having type 2 diabetes mellitus , 71 gave permission for their medical records to be review ed ; records were available for 62 of 71 . An endocrinologist blinded to the information on the supplementary question naires review ed the records according to National Diabetes Data Group ( NDDG ) criteria ( 10 ) . The diagnosis of type 2 diabetes mellitus was confirmed in 61 of 62 women ( 98 % ) ( 9 ) . A secondary set of analyses included only women with definite type 2 diabetes mellitus according to the NDDG criteria . We used the NDDG diagnostic criteria because the analytic cohort preceded the American Diabetes Association guideline , which was published in 1997 ( 11 ) . Assessment of Physical Activity Women were first asked about physical activity on the 1980 question naire . They were asked to report the average number of hours they had spent each week during the past year on such moderate and vigorous recreational activities as vigorous sports , jogging , brisk walking or striding , bicycling , heavy gardening , and heavy housework . On the 1982 question naire , women were asked a slightly different question : For how many hours per week , on average , do you engage in activity strenuous enough to build up a sweat ? In 1986 , 1988 , and 1992 , women were asked to report the average time spent per week on the following activities : walking , jogging , running , bicycling , lap swimming , playing tennis or squash , and participating in calisthenics . They were also asked to report the average number of flights of stairs that they climbed each week . Women also reported their usual walking pace : easy ( < 2 miles per hour [ mph ] ) , average ( 2 to 2.9 mph ) , brisk ( 3 to 3.9 mph ) , or very brisk ( 4 mph ) . Because fewer than 2 % of women reported a very brisk pace , we combined the brisk and very brisk categories in analyses of walking pace and diabetes risk . For 1980 , 1982 , 1986 , 1988 , and 1992 , we created a measure of average hours per week spent in moderate or vigorous recreational activities ( all activities described above except for hours spent walking at an easy or average pace ) . For 1986 , 1988 , and 1992 , using a list of physical activities ( 12 ) , we calculated a weekly metabolic equivalent of task ( MET ) score for total physical activities , vigorous activities ( requiring 6 MET/h ) , nonvigorous activities ( requiring<6 MET/h ) , and walking . The validity of the question naire in assessing physical activity has been described elsewhere ( 13 ) . Correlation between activities reported in four 1-week diaries and those reported on the question naire was 0.62 . Ascertainment of End Points The primary end points for this study were incident coronary heart disease ( defined as nonfatal myocardial infa rct ion or fatal coronary heart disease ) and stroke that occurred after the 1980 question naire was returned but before 1 June 1994 . We requested permission to review the medical records of women who reported having a nonfatal myocardial infa rct ion or stroke on a follow-up question naire . Study physicians with no knowledge of the women 's self-reported risk factors review ed the records . Nonfatal myocardial infa rct ion was confirmed if it met the criteria of the World Health Organization of symptoms and the patient 's records showed diagnostic electrocardiographic changes or elevated cardiac enzyme levels ( 14 ) . Infa rct ions that required hospital admission and were confirmed by interview or letter but for which no medical records were available were design ated as probable ( 19 % ) . We included all confirmed and probable cases in the analyses because the results were the same after probable cases were excluded . Stroke was confirmed by medical records according to the criteria of the National Survey of Stroke ( 15 ) , which define it as a constellation of neurologic deficits , sudden or rapid in onset , lasting at least 24 hours . Events were further subclassified as hemorrhagic stroke ( subarachnoid or intraparenchymal ) , ischemic stroke ( thrombotic or embolic ) , or stroke of unknown cause . Deaths were reported by next of kin and the U.S. Postal Service or were ascertained through the National Death Index . After combining all sources , we estimated that follow-up for deaths was more than 98 % complete ( 16 ) . Fatal coronary heart disease was defined as fatal myocardial infa rct ion if confirmed by hospital records or autopsy or if coronary heart disease was listed as the cause of death on the death certificate , was the underlying and most plausible cause , and was supported by evidence of previous coronary heart disease . The cause of death on the death certificate was never in itself considered to provide sufficient confirmation of death from coronary heart disease . We also included sudden death within 1 hour of onset of symptoms in women with no plausible cause other than coronary disease ( 8 % of fatal cases ) . Fatal strokes were coded by using the same criteria as nonfatal cases , but autopsy evidence as well as the death certificate listing was accepted . Statistical Analysis The study base was defined as the pool of person-time that gives rise to incident cases of cardiovascular disease among patients with both prevalent and incident diabetes . We conducted two sets of analyses , one using 1980 as the baseline to evaluate long-term overall effects of moderate or vigorous activities and the other using 1986 as the baseline to examine specific effects of regular walking .  Person-time for each participant was calculated from the date of return of the 1980 or 1986 question naires to the date of confirmed cardiovascular disease , death from any cause , or 1 June 1994 , whichever came first . In the first set of analyses , relative risks were computed as the incidence rate in a specific category of average hours spent on moderate or vigorous activities per week divided by the incidence rate in the lowest category , with adjustment for 5-year categories of age . Tests of linear trend across increasing categories of average hours spent on moderate or vigorous activities were conducted by treating the categories as a single continuous variable and assigning the median score for the category as its value . To best represent long-term levels of physical activity for individual women and to reduce measurement error , we created measures of the cumulative average of physical Exercise has become a st and ard therapy for patients with type 2 diabetes ( 1 ) . Regular exercise improves conventional clinical risk factors , cardiorespiratory fitness , and components of the insulin resistance syndrome ( 2 - 6 ) . However , it is unclear whether physical activity improves the prognosis of patients with diabetes . No data are available on the association of physical activity or cardiorespiratory fitness with mortality in patients with diabetes . The overall benefit of exercise for these patients is unclear , and some experts are concerned that macrovascular and microvascular complications may be worsened by an exercise program ( 1 , 7 ) . Some consider exercise only as a supplement to diet therapy ( 8) . Studies have shown repeatedly that low cardiorespiratory fitness and physical inactivity are directly associated with cardiovascular disease and all-cause mortality ( 9 - 14 ) , and our preliminary study with a small number of end points suggested that this association might persist across plasma glucose levels ( 15 ) . In the current study , we evaluated the prospect i ve association of cardiorespiratory fitness and physical inactivity with mortality in men who have type 2 diabetes . Methods The material presented in this report was derived from the Aerobics Center Longitudinal Study ( ACLS ) , a prospect i ve observational study of patients examined at The Cooper Clinic in Dallas , Texas . The study was review ed and approved annually by the institutional review board at The Cooper Institute . Additional details of study methods and study group characteristics of this cohort have been published elsewhere ( 12 , 13 ) . Patients Participants were men with type 2 diabetes who completed a baseline medical evaluation at The Cooper Clinic in Dallas , Texas , during 1970 to 1993 . These men came to The Cooper Clinic for a medical examination and health counseling . Many were sent by their employers for these services , some were referred by their personal physicians , and others were self-referred . More than 92 % of the patients are white , and most are employed in executive or professional occupations ; more than 75 % are college graduates . Study participants come from middle and upper socioeconomic strata , but they are similar to other well-characterized study group-based cohorts in terms of blood pressure , cholesterol level , body weight , and cardiorespiratory fitness ( 6 , 16 , 17 ) . We excluded men taking insulin and those with a history of cancer at baseline . Clinical Examination The baseline evaluation was performed after participants gave informed written consent for the baseline medical examination and registration in the follow-up study . Examinations followed an overnight fast of at least 12 hours and included personal and family health histories , a question naire on demographic characteristics and health habits , a physical examination , a maximal exercise test on a treadmill , anthropometry , electrocardiography , blood chemistry analyses , and blood pressure measurement . Technicians who followed a st and ard manual of operations administered all procedures . Question naire Patients completed an extensive self-report of personal and family medical diseases and conditions . Each clinic physician examines only four or five patients per day and thus has time for thorough additional probing of items on the self-reported question naire . This complete review of the patient 's medical history and the subsequent physical examination are strengths of the ACLS and provide a more thorough evaluation of baseline health status than is possible in many epidemiologic studies . The question naire also featured items on health habits , including current smoking status and smoking history and whether the participant was currently dieting to lose weight or following any other special dietary plan . Physical activity pattern was ascertained by self-report on the question naire . An extensive list of leisure-time physical activities was presented , and participants indicated activities in which they had participated in the 3 months before the examination . In later study years , they gave additional details on the number of times per week and the duration of exercise sessions . Laboratory Evaluations Cardiorespiratory fitness was assessed by using a maximal exercise test that followed a modified version of Balke and Ware 's protocol ( 18 ) . Briefly , the test began with the participant walking on a horizontal treadmill at 88 m/min . After the first minute , the elevation increased to 2 % , and it further increased 1 % each minute up to 25 minutes . For the few patients who were still able to continue , the elevation was held constant after 25 minutes and the speed increased to 5.4 m/min until the participant reached volitional fatigue . Exercise test performance with this protocol correlates highly with measured maximal oxygen uptake ( r=0.92 ) ( 19 ) . Serum sample s were analyzed by using automated techniques in a laboratory that participates in and meets the quality control st and ards of the Centers for Disease Control and Prevention Lipid St and ardization Program . Blood pressure was measured by auscultatory methods with a mercury sphygmomanometer according to American Heart Association guidelines ( 20 ) . The lowest of three blood pressure measurements at the clinic examination was recorded as the baseline blood pressure . Height and weight were measured by using a st and ard beam-balance scale and stadiometer , and body mass index was calculated . Type 2 Diabetes Diabetes was defined according to criteria of the American Diabetes Association : fasting plasma glucose level of 7.0 mmol/L or greater ( 126 mg/dL ) ( 21 ) . Three hundred seventy patients who did not meet this criterion but who gave a history of physician-diagnosed diabetes were considered to have diabetes . Patients were classified as having known diabetes or unknown diabetes according to their diabetes status before the baseline Cooper Clinic examination . Definition of Exposure Variables The principal exposure variables used in our analyses were  cardiorespiratory fitness and self-reported physical activity .  These exposures were determined at the baseline examination . Cardiorespiratory Fitness  We categorized  total time from the maximal exercise test into frequency distributions for specific age groups ( 30 to 39 , 40 to 49 , 50 to 59 , and 60 years ) . The least fit 20 % of the participants in each age group were classified as low fit , the next 40 % of the distribution as moderately fit , and the highest 40 % as high fit . We have used these cut-points to define fitness in previous studies ( 12 , 13 ) , and they are based on our entire cohort rather than on diabetic patients only . We selected these cut-points before undertaking the current analysis . Cardiorespiratory fitness is expressed as maximal metabolic units ( METs ) attained during the exercise test . The METs are calculated as the working metabolic rate divided by the resting metabolic rate , and 1 MET is equivalent to an oxygen uptake of 3.5 mL1 kg 1 . Physical Activity Patients who reported walking , jogging , or participating in aerobic exercise programs in the 3 months before the examination were classified as active , regardless of the frequency and duration of exercise . Otherwise , patients were classified as inactive . In our cohort , more than 76 % of men who reported being active at baseline still reported being active at the second visit after more than 1 year . In comparison , only 34 % of men who reported being inactive at baseline reported being active at the second examination ( P<0.001 ) . Self-reported physical activity status in our cohort is correlated with maximal exercise test performance ( 6 , 22 ) . Baseline or Parental Cardiovascular Disease We defined baseline cardiovascular disease as a personal history of heart attack , stroke , or a revascularization procedure ; an abnormal resting or exercise electrocardiogram ; or the highest heart rate during exercise testing that was less than 85 % of the age-predicted maximal heart rate ( [ 220 age in years ] 0.85 ) . Men who reported a history of cardiovascular disease in either parent were classified as having parental cardiovascular disease . Conventional Cardiovascular Disease Risk Factors We assigned men to risk strata for conventional cardiovascular disease risk factors on the basis of recent recommendations ( 23 ) . We defined high blood pressure as systolic blood pressure of 140 mm Hg or more , diastolic blood pressure of 90 mm Hg or more , or a history of physician-diagnosed hypertension . We classified participants with a total cholesterol level of 6.2 mmol/L ( 240 mg/dL ) or more as having high cholesterol , those with self-reported current smoking as current smokers , those with a self-reported parental history of myocardial infa rct ion or stroke as having a history of parental cardiovascular disease , those with a body mass index less than 25.0 kg/m2 as normal weight , and those with a body mass index of 25.0 kg/m2 or more as overweight . Statistical Analysis Our primary outcome measure was all-cause mortality . We used the National Death Index to identify  decedents in the ACLS . The National Death Index has been shown to be an effective , accurate means of ascertaining deaths in the general population , with a sensitivity of about 96 % and a specificity of 100 % ( 24 ) . We obtained official death certificates from states in which there were ACLS decedents , and we had the certificates coded by a nosologist according to the International Classification of Diseases , Ninth Revision . Only the underlying cause of death was used in analyses for this report . Data were analyzed by using the SAS statistical package ( SAS Institute , Inc. , Cary , North Carolina ) . The analyses assumed that physical activity and fitness were essentially unchanged during the study period . We used survival curves to estimate survival function against time and log [ log ( survival time ) ] to check the proportional hazards model assumption . Log [ log ( survival function ) ] estimates were approximately parallel across exposure BACKGROUND Physical activity and body mass index ( calculated as weight in kilograms divided by height in meters squared ) independently alter the risk of coronary heart disease ( CHD ) ; however , their combined effect on CHD is not established . Our objective was to study the combined association of physical activity and body mass index on CHD . METHODS Prospect i ve cohort study of 38,987 women free of cardiovascular disease , cancer , and diabetes at baseline in the Women 's Health Study , with 10.9 mean years of follow-up .  Weight , height , and recreational activities were reported on entry . Body mass index was categorized as normal weight ( < 25 ) , overweight ( 25 to < 30 ) , and obese ( > or = 30 ) . Active was defined as 1000 kilocalories or more expended on recreational activities weekly . Six joint body weight-physical activity categories were defined . The main outcome measure was the occurrence of incident CHD during follow-up , defined as a cardiovascular event including nonfatal myocardial infa rct ion , coronary artery bypass graft , percutaneous transluminal coronary angioplasty , or CHD death . RESULTS A total of 948 cases of incident CHD occurred during follow-up . Higher body mass index and physical inactivity were individual predictors of CHD . In joint analyses , compared with active normal-weight individuals , the multivariate-adjusted hazard ratios ( 95 % confidence intervals ) were 1.54 ( 1.14 - 2.08 ) for overweight-active ; 1.87 ( 1.29 - 2.71 ) for obese-active ; 1.08 ( 0.84 - 1.39 ) for normal weight-inactive ; 1.88 ( 1.46 - 2.42 ) for overweight-inactive ; and 2.53 ( 1.94 - 3.30 ) for obese-inactive . Increasing levels of walking also result ed in significant reductions in CHD risk for overweight and obese individuals . CONCLUSIONS The risk of CHD associated with elevated body mass index is considerably reduced by increased physical activity levels . However , the risk is not completely eliminated , reinforcing the importance of being lean and physically active Background Cardiovascular disease and type 2 diabetes are examples of chronic diseases that impose significant morbidity and mortality in the general population worldwide . Most chronic diseases are associated with underlying preventable risk factors , such as elevated blood pressure , high blood glucose or glucose intolerance , high lipid levels , physical inactivity , excessive sedentary behaviours , and overweight/obesity . The occurrence of intermediate outcomes during childhood increases the risk of disease in adulthood . Sugar-sweetened beverages are known to be significant sources of additional caloric intake , and given recent attention to their contribution in the development of chronic diseases , a systematic review is warranted . We will assess whether the consumption of sugar-sweetened beverages in children is associated with adverse health outcomes and what the potential moderating factors are . Methods / Design Of interest are studies addressing sugar-sweetened beverage consumption , taking a broad perspective . Both direct consumption studies as well as those evaluating interventions that influence consumption ( e.g. school policy , educational ) will be relevant . Non-specific or multi-faceted behavioural , educational , or policy interventions may also be included subject to the level of evidence that exists for the other interventions /exposures . Comparisons of interest and endpoints of interest are pre-specified . We will include r and omized controlled trials , controlled clinical trials , interrupted time series studies , controlled before-after studies , prospect i ve and retrospective comparative cohort studies , case – control studies , and nested case – control design s. The MEDLINE ® , Embase , The Cochrane Library , CINAHL , ERIC , and PsycINFO ® data bases and grey literature sources will be search ed . The processes for selecting studies , abstract ing data , and resolving conflicts are described . We will assess risk of bias using design -specific tools . To determine sets of confounding variables that should be adjusted for , we have developed causal directed acyclic graphs and will use those to inform our risk of bias assessment s. Meta- analysis will be conducted where appropriate ; parameters for exploring statistical heterogeneity and effect modifiers are pre-specified . The Grading of Recommendations Assessment , Development and Evaluation ( GRADE ) approach will be used to determine the quality of evidence for outcomes . Systematic review registration PROSPERO CRD42014009641 OBJECTIVE To ascertain the relationship of physical inactivity and short-term all-cause mortality in a prospect i ve cohort of r and omly selected managed care organization members aged 40 years and older who have multiple chronic diseases . METHODS Clinical data bases were used to identify all health plan members aged 40 years and older with 2 or more chronic health conditions ( hypertension , coronary heart disease , diabetes mellitus , or dyslipemia ) in 1994 . A r and om sample of 2336 members was surveyed by mail and telephone interview regarding their health-related behaviors .  Survey data were linked to mortality data from the 1995 to 1997 Minnesota Death Index . Cox proportional hazards regression was used to ascertain the association between physical inactivity and subsequent all-cause mortality , adjusting for potential confounders . RESULTS Members who reported less than 30 minutes a week of physical activity at baseline had a subsequent mortality risk ratio of 2.82 ( P<.001 ) vs those with 30 or more minutes of physical activity a week . Increased mortality risk persisted ( mortality risk ratio , 2.15 ; P<.001 ) after adjustments for age , sex , current smoking , functional impairment , and comorbidity score . CONCLUSIONS In adults with chronic diseases , the physically inactive had higher observed mortality within a 42-month period . If physical inactivity reflects an independent mortality risk , efforts to maintain physical activity in such patients may yield significant clinical benefits within a short period . By contrast , if inactivity is primarily a proxy for other factors that elevate mortality risks , a simple physician inquiry regarding inactivity may help to identify patients at risk of death Background The burden of cardiovascular diseases ( CVDs ) remains unclear in many regions of the world . Objectives The GBD ( Global Burden of Disease ) 2015 study integrated data on disease incidence , prevalence , and mortality to produce consistent , up-to- date estimates for cardiovascular burden . Methods CVD mortality was estimated from vital registration and verbal autopsy data . CVD prevalence was estimated using modeling software and data from health surveys , prospect i ve cohorts , health system administrative data , and registries . Years lived with disability ( YLD ) were estimated by multiplying prevalence by disability weights . Years of life lost ( YLL ) were estimated by multiplying age-specific CVD deaths by a reference life expectancy . A sociodemographic index ( SDI ) was created for each location based on income per capita , educational attainment , and fertility . Results In 2015 , there were an estimated 422.7 million cases of CVD ( 95 % uncertainty interval : 415.53 to 427.87 million cases ) and 17.92 million CVD deaths ( 95 % uncertainty interval : 17.59 to 18.28 million CVD deaths ) . Declines in the age-st and ardized CVD death rate occurred between 1990 and 2015 in all high-income and some middle-income countries . Ischemic heart disease was the leading cause of CVD health lost globally , as well as in each world region , followed by stroke . As SDI increased beyond 0.25 , the highest CVD mortality shifted from women to men . CVD mortality decreased sharply for both sexes in countries with an SDI > 0.75 . Conclusions CVDs remain a major cause of health loss for all regions of the world . Sociodemographic change over the past 25 years has been associated with dramatic declines in CVD in regions with very high SDI , but only a gradual decrease or no change in most regions . Future up date s of the GBD study can be used to guide policymakers who are focused on reducing the overall burden of noncommunicable disease and achieving specific global health targets for CVD IMPORTANCE Leisure-time physical activity has been associated with lower risk of heart-disease and all-cause mortality , but its association with risk of cancer is not well understood . OBJECTIVE To determine the association of leisure-time physical activity with incidence of common types of cancer and whether associations vary by body size and /or smoking . DESIGN , SETTING , AND PARTICIPANTS We pooled data from 12 prospect i ve US and European cohorts with self-reported physical activity ( baseline , 1987 - 2004 ) . We used multivariable Cox regression to estimate hazard ratios ( HRs ) and 95 % confidence intervals for associations of leisure-time physical activity with incidence of 26 types of cancer . Leisure-time physical activity  levels were modeled as cohort-specific percentiles on a continuous basis and cohort-specific results were synthesized by r and om-effects meta- analysis . Hazard ratios for high vs low levels of activity are based on a comparison of risk at the 90th vs 10th percentiles of activity . The data analysis was performed from January 1 , 2014 , to June 1 , 2015 . EXPOSURES Leisure-time physical activity of a moderate to vigorous intensity . MAIN OUTCOMES AND MEASURES Incident cancer during follow-up . RESULTS A total of 1.44 million participants ( median [ range ] age , 59 [ 19 - 98 ] years ; 57 % female ) and 186 932 cancers were included . High vs low levels of leisure-time physical activity were associated with lower risks of 13 cancers : esophageal adenocarcinoma ( HR , 0.58 ; 95 % CI , 0.37 - 0.89 ) , liver ( HR , 0.73 ; 95 % CI , 0.55 - 0.98 ) , lung ( HR , 0.74 ; 95 % CI , 0.71 - 0.77 ) , kidney ( HR , 0.77 ; 95 % CI , 0.70 - 0.85 ) , gastric cardia ( HR , 0.78 ; 95 % CI , 0.64 - 0.95 ) , endometrial ( HR , 0.79 ; 95 % CI , 0.68 - 0.92 ) , myeloid leukemia ( HR , 0.80 ; 95 % CI , 0.70 - 0.92 ) , myeloma ( HR , 0.83 ; 95 % CI , 0.72 - 0.95 ) , colon ( HR , 0.84 ; 95 % CI , 0.77 - 0.91 ) , head and neck ( HR , 0.85 ; 95 % CI , 0.78 - 0.93 ) , rectal ( HR , 0.87 ; 95 % CI , 0.80 - 0.95 ) , bladder ( HR , 0.87 ; 95 % CI , 0.82 - 0.92 ) , and breast ( HR , 0.90 ; 95 % CI , 0.87 - 0.93 ) . Body mass index adjustment modestly attenuated associations for several cancers , but 10 of 13 inverse associations remained statistically significant after this adjustment .  Leisure-time physical activity  was associated with higher risks of malignant melanoma ( HR , 1.27 ; 95 % CI , 1.16 - 1.40 ) and prostate cancer ( HR , 1.05 ; 95 % CI , 1.03 - 1.08 ) . Associations were generally similar between overweight/obese and normal-weight individuals . Smoking status modified the association for lung cancer but not other smoking-related cancers . CONCLUSIONS AND RELEVANCE Leisure-time physical activity was associated with lower risks of many cancer types . Health care professionals counseling inactive adults should emphasize that most of these associations were evident regardless of body size or smoking history , supporting broad generalizability of findings Cardiovascular disease ( CVD ) , including stroke , heart attack and heart failure , is the leading cause of death and disability worldwide . Raised blood pressure ( BP ) is a major cause of CVD , responsible for 62 % of stroke and 49 % of coronary heart disease cases . There is much evidence for a causal relationship between salt intake and BP . The current salt intake in many countries around the world is between 9 g ⁄d and 12 g ⁄d ( ie , 3.6–4.8 g of sodium ) . R and omized trials have demonstrated that a modest reduction in salt intake lowers BP in individuals with raised BP and also in those with ‘ ‘ normal ’ ’ BP . Furthermore , there is a dose-response relationship . Within the range of 12 g ⁄d to 3 g ⁄d , the lower the salt intake , the lower the BP . Because raised BP throughout its range is a major cause of CVD , salt reduction would reduce cardiovascular risk . It was estimated that a reduction of 6 g ⁄d in salt intake would reduce stroke by 24 % and coronary heart disease by 18 % . This would prevent approximately 35,000 stroke and coronary heart disease deaths a year in the United Kingdom and approximately 2.5 million deaths worldwide . Both prospect i ve studies and outcome trials have demonstrated that a lower salt intake is related to a reduced risk of CVD .  Salt reduction is one of the most cost-effective interventions to reduce CVD in both developed and developing countries . For example , the UK salt reduction campaign , which result ed in a fall in salt intake by approximately 10 % ( ie , from 9.5 g ⁄d in 2003 to 8.6 g ⁄d by May 2008 ) , cost just £ 15 million and led to approximately 6000 fewer CVD deaths per year , saving the UK economy approximately £ 1.5 billion per annum according to the recent report by the UK government ’s health advisory agency , the National Institute for Health and Clinical Excellence . In most developed countries , approximately 80 % of salt consumed is added to foods at the stage of manufacturing , and the consumers have no say over how much salt is added . Therefore , to achieve a reduction in population salt intake , it is imperative that the food industry make a gradual and sustained reduction in the amount of salt that is added to all foods . This approach has been successful in the United Kingdom and is now being exp and ed worldwide . World Salt Awareness Week was introduced by the salt reduction action group World Action on Salt and Health ( WASH ) in 2008 . The event serves as a platform for international experts in the fields of hypertension and nephrology to raise the profile of the importance of salt reduction to both the public and health professionals worldwide OBJECTIVE We evaluated the hypothesis that higher levels of total daily physical activity can eliminate the increased mortality rate associated with overweight and obesity . DESIGN Population -based prospect i ve cohort study . SETTING Central Sweden . SUBJECTS A total of 37,633 men at baseline 45 - 79 years of age and free of known cancer and cardiovascular disease and diabetes completed a  self-administered life-style question naire , which included questions on body-mass index ( BMI ) and physical activity . During 9.7 years of follow-up , we identified a total of 4086 deaths . MAIN OUTCOME MEASURES Mortality rate ratios ( RRs ) . RESULTS Compared to men who were lean ( BMI < 25 kg m(-2 ) ) and active ( top tertile of total physical activity level ) the multivariable adjusted RRs ( 95 % confidence interval ) of death from all causes were 1.44 ( 1.11 - 1.86 ) for obese ( BMI > or = 30 kg m(-2 ) ) and active men , 1.54 ( 1.34 - 1.77 ) for lean ( BMI < 25 kg m(-2 ) ) but inactive ( bottom tertile ) men , and 1.81 ( 1.48 - 2.23 ) for obese-inactive men . After excluding the first 3 years of follow-up , current and former smokers , those who had lost weight from age 20 years to age at baseline , and heavy manual workers , the adjusted RRs of death from all causes were 1.65 ( 1.20 - 2.27 ) for overweight-to-obese and active men , 2.15 ( 1.59 - 2.91 ) for lean-inactive men , and 2.04 ( 1.52 - 2.74 ) for overweight-to-obese and inactive men compared to lean-active men . CONCLUSIONS We conclude that both overweight and physical inactivity are important predictors of mortality . Our findings do not support the hypothesis that a higher level of physical activity compensates the excess mortality associated with overweight and obesity Background Coronary artery disease ( CAD ) is accountable for more than 7 million deaths each year according to the World Health Organization ( WHO ) . In a European population 80 % of patients diagnosed with CAD are overweight and 31 % are obese . Physical inactivity and overweight are major risk factors in CAD , thus central strategies in secondary prevention are increased physical activity and weight loss . Methods / Design In a r and omized controlled trial 70 participants with stable CAD , age 45–75 , body mass index 28–40 kg/m2 and no diabetes are r and omized ( 1:1 ) to 12 weeks of  intensive exercise or weight loss both succeeded by a 40-week follow-up . The exercise protocol consist of supervised aerobic interval training ( AIT ) at 85 - 90 % of VO2peak 3 times weekly for 12 weeks followed by supervised AIT twice weekly for 40 weeks . In the weight loss arm dieticians instruct the participants in a low energy diet ( 800–1000 kcal/day ) for 12 weeks , followed by 40 weeks of weight maintenance combined with supervised AIT twice weekly . The primary endpoint of the study is change in coronary flow reserve after the first 12 weeks ’ intervention . Secondary endpoints include cardiovascular , metabolic , inflammatory and anthropometric measures . Discussion The study will compare the short and long-term effects of a protocol consisting of AIT alone or a rapid weight loss followed by AIT . Additionally , it will provide new insight in mechanisms behind the benefits of exercise and weight loss . We wish to contribute to the creation of effective secondary prevention and sustainable rehabilitation strategies in the large population of overweight and obese patients diagnosed with CAD.Trial registration Clinical Trials.gov : CONTEXT Recent guidelines for treatment of overweight and obesity include recommendations for risk stratification by disease conditions and cardiovascular disease ( CVD ) risk factors , but the role of physical inactivity is not prominent in these recommendations . OBJECTIVE To quantify the influence of low cardiorespiratory fitness , an objective marker of physical inactivity , on CVD and all-cause mortality in normal-weight , overweight , and obese men and compare low fitness with other mortality predictors . DESIGN Prospect i ve observational data from the Aerobics Center Longitudinal Study . SETTING Preventive medicine clinic in Dallas , Tex . PARTICIPANTS A total of 25714 adult men ( average age , 43.8 years [ SD , 10.1 years ] ) who received a medical examination during 1970 to 1993 , with mortality follow-up to December 31 , 1994 . MAIN OUTCOME MEASURES Cardiovascular disease and all-cause mortality based on mortality predictors ( baseline CVD , type 2 diabetes mellitus , high serum cholesterol level , hypertension , current cigarette smoking , and low cardiorespiratory fitness ) stratified by body mass index . RESULTS During the study period , there were 1025 deaths ( 439 due to CVD ) during 258781 man-years of follow-up . Overweight and obese men with baseline CVD or CVD risk factors were at higher risk for all-cause and CVD mortality compared with normal-weight men without these predictors . Using normal-weight men without CVD as the referent , the strongest predictor of CVD death in obese men was baseline CVD ( age- and examination year-adjusted relative risk [ RR ] , 14.0 ; 95 % confidence interval [ CI ] , 9.4 - 20.8 ) ; RRs for obese men with diabetes mellitus , high cholesterol , hypertension , smoking , and low fitness were similar and ranged from 4.4 ( 95 % CI , 2.7 - 7.1 ) for smoking to 5.0 ( 95 % CI , 3.6 - 7.0 ) for low fitness . Relative risks for all-cause mortality in obese men ranged from 2.3 ( 95 % CI , 1.7 - 2.9 ) for men with hypertension to 4.7 ( 95 % CI , 3.6 - 6.1 ) for those with CVD at baseline . Relative risk for all-cause mortality in obese men with low fitness was 3.1 ( 95 % CI , 2.5 - 3.8 ) and in obese men with diabetes mellitus 3.1 ( 95 % CI , 2.3 - 4.2 ) and as slightly higher than the RRs for obese men who smoked or had high cholesterol levels . Low fitness was an independent predictor of mortality in all body mass index groups after adjustment for other mortality predictors . Approximately 50 % ( n = 1674 ) of obese men had low fitness , which led to a population -attributable risk of 39 % for CVD mortality and 44 % for all-cause mortality . Baseline CVD had population attributable risks of 51 % and 27 % for CVD and all-cause mortality , respectively . CONCLUSIONS In this analysis , low cardiorespiratory fitness was a strong and independent predictor of CVD and all-cause mortality and of comparable importance with that of diabetes mellitus and other CVD risk factors The purpose of this analytical review was to estimate the direct and indirect economic costs of  physical inactivity and obesity in Canada in 2001 . The relative risks of diseases associated with physical inactivity and obesity were determined from a meta- analysis of existing prospect i ve studies and applied to the health care costs of these diseases in Canada . Estimates were derived for both the direct health care expenditures and the indirect costs , which included the value of economic output lost because of illness , injury-related work disability , or premature death . The economic burden of physical inactivity was $ 5.3 billion ( $ 1.6 billion in direct costs and $ 3.7 billion in indirect costs ) while the cost associated with obesity was $ 4.3 billion ( $ 1.6 billion of direct costs and $ 2.7 billion of indirect costs ) . The total economic costs of physical inactivity and obesity represented 2.6 % and 2.2 % , respectively , of the total health care costs in Canada . The results underscore the importance of public health efforts aim ed at combating the current epidemics of physical inactivity and obesity in Canada Background Effective interventions to prevent overweight and obesity in children are urgently needed especially in inner-city neighbourhoods where prevalence of overweight and inactivity among primary school children is high . A school based intervention was developed aim ing at the reduction of overweight and inactivity in these children by addressing both behavioural and environmental determinants . Methods / design The main components of the intervention ( Lekker Fit ! ) are the re-establishment of a professional physical education teacher ; three ( instead of two ) PE classes per week ; additional sport and play activities outside school hours ; fitness testing ; classroom education on healthy nutrition , active living and healthy lifestyle choices ; and the involvement of parents . The effectiveness of the intervention is evaluated through a cluster r and omized controlled trial in 20 primary schools among grade s 3 through 8 ( 6–12 year olds ) . Primary outcome measures are BMI , waist circumference and fitness . Secondary outcome measures are assessed in a subgroup of grade 6–8 pupils ( 9–12 year olds ) through classroom question naires and constitute of nutrition and physical activity behaviours and behavioural determinants . Multilevel regression analyses are used to study differences in outcomes between children in the intervention schools and in  control schools , taking clustering of children within schools into account . Discussion Hypotheses are that the intervention results in a lower prevalence of children being overweight and an improved mean fitness score , in comparison with a control group where the intervention is not implemented . The results of our study will contribute to the discussion on the role of physical education and physical activity in the school curriculum . Trial registration [ IS RCT N84383524 Abstract Objective . To investigate the feasibility and impact on BMI and physical fitness of an intervention for obese and inactive children , based on physical activity and carried out in primary health care . Design . A prospect i ve , longitudinal one-year follow-up study . Setting . The community of Kristians and , Norway ( 80 000 inhabitants ) . Intervention . A 40-week structured intervention based on physical training with some lifestyle advice for the obese child and one parent . Subjects . A total of 62 physically inactive children aged 6–14 years with iso- BMI ≥ 30 kg/m2 . Main outcome measures . Body mass index ( BMI ) , maximum oxygen uptake , and physical fitness in tests of running , jumping , throwing , and climbing assessed at baseline and after six and 12 months as well as number of dropouts and predicting factors . Results . A total of 49 out of 62 children completed the first six months and 37 children completed 12 months . Dropout rate was higher when parents reported being physically inactive at baseline or avoided physical participation in the intervention . The children 's maximum oxygen uptake increased significantly after 12 months from 27.0 to 32.0 ml/kg/min ( means ) , as did physical fitness ( endurance , speed , agility , coordination , balance , strength ) and BMI was significantly reduced . Conclusion / implication s. This one-year activity-based intervention for obese and inactive children performed in primary health care succeeded by increasing cardiovascular capacity and physical fitness combined with reduced BMI in those who completed . Dropout was substantial and depended on the attendance and compliance with physical activity by the parents Background — Sugar-sweetened beverages ( SSBs ) are consumed globally and contribute to adiposity . However , the worldwide impact of SSBs on burdens of adiposity-related cardiovascular diseases ( CVDs ) , cancers , and diabetes mellitus has not been assessed by nation , age , and sex . Methods and Results — We modeled global , regional , and national burdens of disease associated with SSB consumption by age/sex in 2010 . Data on SSB consumption levels were pooled from national dietary surveys worldwide . The effects of SSB intake on body mass index and diabetes mellitus , and of elevated body mass index on CVD , diabetes mellitus , and cancers were derived from large prospect i ve cohort pooling studies . Disease-specific mortality/morbidity data were obtained from Global Burden of Diseases , Injuries , and Risk Factors 2010 Study . We computed cause-specific population -attributable fractions for SSB consumption , which were multiplied by cause-specific mortality/morbidity to compute estimates of SSB-attributable death/disability . Analyses were done by country/age/sex ; uncertainties of all input data were propagated into final estimates . Worldwide , the model estimated 184 000 ( 95 % uncertainty interval , 161 000–208 000 ) deaths/y attributable to SSB consumption : 133 000 ( 126 000–139 000 ) from diabetes mellitus , 45 000 ( 26 000–61 000 ) from CVD , and 6450 ( 4300–8600 ) from cancers . Five percent of  SSB-related deaths occurred in low-income , 70.9 % in middle-income , and 24.1 % in high-income countries . Proportional mortality attributable to SSBs ranged from < 1 % in Japanese > 65 years if age to 30 % in Mexicans < 45 years of age . Among the 20 most populous countries , Mexico had largest absolute ( 405 deaths/million adults ) and proportional ( 12.1 % ) deaths from SSBs . A total of 8.5 ( 2.8 , 19.2 ) million disability-adjusted life years were related to SSB intake ( 4.5 % of diabetes mellitus – related disability-adjusted life years ) . Conclusions — SSBs are a single , modifiable component of diet that can impact preventable death/disability in adults in high- , middle- , and low-income countries , indicating an urgent need for strong global prevention programs CONTEXT Physical inactivity and body mass index ( BMI ) are established independent risk factors in the development of type 2 diabetes ; however , their comparative importance and joint relationship with diabetes are unclear . OBJECTIVE To examine the relative contributions and joint association of physical activity and BMI with diabetes . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve cohort study of 37 878 women free of cardiovascular disease , cancer , and diabetes with 6.9 years of mean follow-up .  Weight , height , and recreational activities were reported at study entry . Normal weight was defined as a BMI of less than 25 ; overweight , 25 to less than 30 ; and obese , 30 or higher . Active was defined as expending more than 1000 kcal on recreational activities per week . MAIN OUTCOME MEASURE Incident type 2 diabetes , defined as a new self-reported diagnosis of diabetes . RESULTS During the follow-up , 1361 cases of incident diabetes occurred . Individually , BMI and physical activity were significant predictors of incident diabetes . Compared with normal-weight individuals , the multivariate-adjusted hazard ratio ( HR ) was 3.22 ( 95 % confidence interval [ CI ] , 2.69 - 3.87 ) for overweight individuals and 9.09 ( 95 % CI , 7.62 - 10.8 ) for obese individuals . For overall activity ( kilocalories expended per week ) , compared with the least active first quartile , the multivariate-adjusted HRs were 0.91 ( 95 % CI , 0.79 - 1.06 ) for the second quartile , 0.86 ( 95 % CI , 0.74 - 1.01 ) for the third , and 0.82 ( 95 % CI , 0.70 - 0.97 ) for the fourth ( P for trend = .01 ) . In the combined analyses , overweight and obese participants , whether active or inactive , had significantly elevated risks , compared with normal-weight active individuals . The multivariate-adjusted HRs were 1.15 ( 95 % CI , 0.83 - 1.59 ) for normal-weight inactive , 3.68 ( 95 % CI , 2.63 - 5.15 ) for overweight active , 4.16 ( 95 % CI , 3.05 - 5.66 ) for overweight inactive , 11.5 ( 95 % CI , 8.34 - 15.9 ) for obese active , and 11.8 ( 95 % CI , 8.75 - 16.0 ) for obese inactive participants . CONCLUSIONS Although BMI and physical inactivity are independent predictors of incident diabetes , the magnitude of the association with BMI was greater than with physical activity in combined analyses . These findings underscore the critical importance of adiposity as a determinant of diabetes Background Worldwide in 2000 , 10 % of children aged five to 17 years were reported as being overweight with an additional 2‐3 % being obese . Overweight and obesity in childhood can adversely impact on both physical and psychological health . The rise in the prevalence of childhood obesity is a complex issue but widely recognised contributors include increased energy intake , decreased levels of physical activity and greater time spent in sedentary pursuits . A large number of environmental and cultural factors have also been identified as contributing to the problem . Evidence to support an optimal approach to treating childhood obesity is limited with many studies showing only modest results at best in the long‐term . However , the importance of family‐based treatment that combines diet , physical activity and behavioral components has been acknowledged in a recent Cochrane Systematic Review . It has also been suggested that interventions offered in the community setting may help overcome barriers to participation , by making programs more accessible and allowing the targeting of specific sub‐groups of the population . Objectives The objective of this review was to identify the effectiveness of parent‐centred interventions implemented in the community setting in modifying eating and physical activity behaviors or weight‐related outcomes of children . Inclusion criteria Types of participants This review considered studies that included free‐living children of pre‐school , primary and secondary school age and /or their parents/guardians aged > 18 years . Types of intervention(s)/phenomena of interest Intervention programs were required to have a parental component , to target eating and /or exercise behaviors for the prevention or treatment of obesity , and child weight status reported . Types of studies All intervention studies were included in the review including : r and omized controlled trials ( RCTs ) ; non‐r and omized controlled trials , longitudinal studies , cohort ( both retrospective and prospect i ve ) , case control and time series studies which had been conducted in a community setting . Types of outcomes This review considered studies that included overweight/obesity related outcomes , eating behavior outcomes , physical activity behaviour outcomes , and sedentary behavior outcomes and constructs . Search strategy A literature search of community‐based parent‐centred intervention studies to promote nutrition and physical activity for the prevention and treatment and of childhood overweight and obesity was performed in eight electronic data bases dating from 1975 to April 2009 . Method ological quality Studies were critically appraised for method ological quality using st and ardized tools . Data collection Data was extracted by one review er using a st and ardized data extraction form developed by the research ers and checked for accuracy and consistency by a second review er . Data synthesis Data in relation to setting , methodology , intervention components and effect on weight , dietary intake and physical activity was extracted , and described in a narrative synthesis . Where possible a meta‐ analysis was undertaken . Results Of the home‐based interventions , five of nine studies reported statistically significant changes in anthropometric outcomes post intervention . Of the 10 studies in the before and after school care setting , seven reported a significant decrease in a weight‐related outcome post intervention , with only one reporting an increase . Conclusions Results from the review support the after‐school setting as the most promising for community intervention setting for targeting parents as agents of change within child obesity prevention and treatment programs . Implication s for practice At this stage , interventions to support parents should target the after‐school environment as opposed to being conducted in the home , summer camps , leisure centers or churches . Targeting a decrease in energy intake and sweetened beverages in parallel with increasing number of daily steps and decreasing screen time use . Implication s for research Future studies of high quality are needed across the full range of community setting s. Given that currently most of the higher quality RCTs and the studies showing positive impacts of weight change are in the after‐school setting , further studies in this area using similar method ologies to those already published will facilitate future meta‐analyses in this area PURPOSE To investigate the association between pre- and postdiagnosis physical activity ( as well as change in prediagnosis to postdiagnosis physical activity ) and mortality among women with breast cancer . PATIENTS AND METHODS This was a prospect i ve observational study of 933 women enrolled onto the Health , Eating , Activity , and Lifestyle Study who were diagnosed with local or regional breast cancer between 1995 and 1998 and observed until death or September 2004 , whichever came first . The primary outcomes measured were total deaths and breast cancer deaths . The primary exposures were  physical activity in the year before and 2 years after diagnosis and the pre- to postdiagnosis change in physical activity . RESULTS Compared with inactive women , the multivariable hazard ratios ( HRs ) for total deaths for women expending at least 9 metabolic equivalent hours per week ( approximately 2 to 3 h/wk of brisk walking ) were 0.69 ( 95 % CI , 0.45 to 1.06 ; P = .045 ) for those active in the year before diagnosis and 0.33 ( 95 % CI , 0.15 to 0.73 ; P = .046 ) for those active 2 years after diagnosis . Compared with women who were inactive both before and after diagnosis , women who increased physical activity  after diagnosis had a 45 % lower risk of death ( HR = 0.55 ; 95 % CI , 0.22 to 1.38 ) , and women who decreased physical activity  after diagnosis had a four-fold greater risk of death ( HR = 3.95 ; 95 % CI , 1.45 to 10.50 ) . CONCLUSION Moderate-intensity physical activity after a diagnosis of breast cancer may improve prognosis Background Childhood obesity is not only associated with adult obesity but also with increased risk of adult onset of type 2 diabetes and subsequent coronary heart disease . The potential effects of school-based health intervention programmes on cardiovascular risk and surrogate markers are unclear , as only few studies have attempted to investigate a complete risk profile including a detailed laboratory analysis or micro- and macrovascular function . In this study a comprehensive school-based r and omized intervention programme will be investigated in 10 - 14-year old children addressing the influence of lifestyle intervention on inactivity , cardiometabolic risk factors and early signs of vascular disease . Methods / Design 15 secondary schools in Southern Germany are r and omly assigned to intervention or control schools . Children in the fifth grade ( 10 - 11 years ) will be observed over four years . The study combines a school-based with a home-based approach , aim ing at children , teachers and parents . The main components are weekly lifestyle-lessons for children , taught by regular classroom teachers to increase physical activity in- and outside of school , to improve eating patterns at school and at home , to reduce media consumption and to amplify well-being . In 4 - 6 annual meetings , teachers receive information about health-related topics with worksheets for children and supporting equipment , accounting for school-specific needs and strategies . Parents ' trainings are provided on a regular basis . All examinations are performed at the beginning and at the end of every school year . Anthropometry includes measurements of BMI , waist and upper arm circumferences , skinfold thickness as well as peripheral blood pressure . Blood sampling includes lipid parameters , insulin , glucose , hsCRP , adiponectin , and IL-6 as well as testosteron and estrogen to determine maturation status . Vascular function is non-invasively assessed by measuring arterial stiffness in large arteries using a sphygmograph and by analysing arteriolar and venular diameters in the retinal microcirculation using a non-mydriatric vessel analyser . A question naire is filled out to determine daily physical activity , motivational factors , dietary habits , quality of life ( KINDL-R ) and socio-economic data . Physical fitness is assessed by a six-item test battery . Discussion Our study aims to provide a feasible long-term intervention strategy to re-establish childhood health and to prevent obesity-related cardiovascular dysfunction in children . Trial Registration Northern Irel and has the highest incidence of coronary heart disease ( CHD ) in the world . The physical fitness , activity patterns , health knowledge , attitudes , and dietary habits of a r and om , stratified sample of 3211 Northern Irish children , comprising 1540 boys and 1671 girls , age range 11 - 18 years were examined . At all ages boys were significantly more active than girls . The most important finding was an appreciable decline in physical activity levels after the age of 14 years reaching extremely low levels in older girls . While 75 % of exercise taken was not related to school , physical education classes constituted the only exercise taken by one third of pupils . Girls had healthier nutritional habits and were more inclined to employ weight control measures than boys . There was a preponderance of children with a higher body mass index indicating a tendency to obesity in the child population . Over 20 % of school leavers of both sexes regularly smoked cigarettes and 20 % regularly drank alcohol . The postulated relationship between childhood inactivity , adult sedentary lifestyle , and increased risk of CHD raises serious cause for concern regarding the future cardiovascular health of many children Abstract Objective To assess the prospect i ve associations of baseline and long term trajectories of physical activity on mortality from all causes , cardiovascular disease , and cancer . Design Population based cohort study . Setting Adults from the general population in the UK . Participants 14 599 men and women ( aged 40 to 79 ) from the European Prospect i ve Investigation into Cancer and Nutrition-Norfolk cohort , assessed at baseline ( 1993 to 1997 ) up to 2004 for lifestyle and other risk factors ; then followed to 2016 for mortality ( median of 12.5 years of follow-up , after the last exposure assessment ) . Main exposure  Physical activity energy expenditure ( PAEE ) derived from question naires , calibrated against combined movement and heart rate monitoring . Main outcome measures Mortality from all causes , cardiovascular disease , and cancer . Multivariable proportional hazards regression models were adjusted for age , sex , sociodemographics , and changes in medical history , overall diet quality , body mass index , blood pressure , triglycerides , and cholesterol levels . Results During 171 277 person years of follow-up , 3148 deaths occurred . Long term increases in PAEE were inversely associated with mortality , independent of baseline PAEE . For each 1 kJ/kg/day per year increase in PAEE ( equivalent to a trajectory of being inactive at baseline and gradually , over five years , meeting the World Health Organization minimum physical activity guidelines of 150 minutes/week of moderate-intensity physical activity ) , hazard ratios were : 0.76 ( 95 % confidence interval 0.71 to 0.82 ) for all cause mortality , 0.71 ( 0.62 to 0.82 ) for cardiovascular disease mortality , and 0.89 ( 0.79 to 0.99 ) for cancer mortality , adjusted for baseline PAEE , and established risk factors . Similar results were observed when analyses were stratified by medical history of cardiovascular disease and cancer . Joint analyses with baseline and trajectories of physical activity show that , compared with consistently inactive individuals , those with increasing physical activity trajectories over time experienced lower risks of mortality from all causes , with hazard ratios of 0.76 ( 0.65 to 0.88 ) , 0.62 ( 0.53 to 0.72 ) , and 0.58 ( 0.43 to 0.78 ) at low , medium , and high baseline physical activity , respectively . At the population level , meeting and maintaining at least the minimum physical activity recommendations would potentially prevent 46 % of deaths associated with physical inactivity . Conclusions Middle aged and older adults , including those with cardiovascular disease and cancer , can gain substantial longevity benefits by becoming more physically active , irrespective of past physical activity levels and established risk factors . Considerable population health impacts can be attained with consistent engagement in physical activity during mid to late life
There was some evidence that school-based physical activity interventions had a positive impact on four of the nine outcome measures .
Specifically positive effects were observed for duration of physical activity , television viewing , VO2 max , and blood cholesterol .
Generally , school-based interventions had little effect on physical activity rates , systolic and diastolic blood pressure , BMI , and pulse rate .
At a minimum , a combination of printed educational material s and changes to the school curriculum that promote physical activity result ed in positive effects .
Few changes in outcomes were observed in this up date with the exception of blood cholesterol and physical activity rates .
For example blood cholesterol was no longer positively impacted upon by school-based physical activity interventions .
The evidence suggests the ongoing implementation of school-based physical activity interventions at this time , given the positive effects on behavior and one physical health status measure .
BACKGROUND The World Health Organization ( WHO ) estimates that 1.9 million deaths worldwide are attributable to physical inactivity and at least 2.6 million deaths are a result of being overweight or obese .
In addition , WHO estimates that physical inactivity causes 10 % to 16 % of cases each of breast cancer , colon , and rectal cancers as well as type 2 diabetes , and 22 % of coronary heart disease and the burden of these and other chronic diseases has rapidly increased in recent decades .
OBJECTIVES The purpose of this systematic review was to summarize the evidence of the effectiveness of school-based interventions in promoting physical activity and fitness in children and adolescents .