EXERCISE

AS DEFENSIVE
NUTRITIONAL
PARADIGM
COURSE NAME: NUTRITION ACROSS LIFE SPAN
SEMESTER III

Submitted to: Submitted by:

Ms. Tasneem Ravat Ms. Reema Kinjalkar (07)
Class: MSc II FPP (2019- 2020)
 INDEX
SR.NO TOPICS REMARKS
1. Exercise, movement and health:
definitions
2. Types of exercise
3. Importance of exercise
4. Dosage of exercise
5. Green exercise
6. Benefits of exercise
7. Role of exercise in prevention of diseases
8. Importance of nutrition in exercise
9. References
 EXERCISE AS DEFENSIVE NUTRITIONAL PARADIGM
 EXERCISE, MOVEMENT AND HEALTH: DEFINITIONS (1,2)
Health promotion is the science and art of helping people change their lifestyle to move towards a state of
optimal health. The World Health Organization defines health as ‘Physical, mental, and social well-being,
not merely the absence of disease and infirmity’. Physical fitness is defined as the physiologic state of well-
being that allows one to meet the demands of daily living (health-related physical fitness) or that provides
the basis for sport performance (performance-related physical fitness), or both. Although we are aware that
there is a clear difference between the terms physical activity (‘any bodily movement’) and exercise (‘a
subset of physical activity that is characterized by a planned and purposeful training’),.There is
consensus that regular physical activity (PA) can improve physical fitness (PF) and health and assist in the
prevention of disease .Several studies have shown that physically active adults are healthier and have a
higher PF than inactive adults throughout different nations and populations groups. Physical activity is
therefore promoted as part of a healthy lifestyle

 TYPES OF EXERCISE (3,4)

Exercise and physical activity fall into four basic categories—
endurance, strength, balance, and flexibility. Most people have a habit of to focus on one activity or type of
exercise and think they're doing enough for their health. Each type of exercise is different, however, doing
them all will give you extra benefits. Mixing it up also helps to reduce boredom and stop the possibility of
injury.
 Endurance
Endurance, or aerobic, activities increase your breathing and heart rate. They keep your heart, lungs, and
circulatory system healthy and improve your overall fitness. Building your endurance makes it easier to
carry out many of your everyday activities. Walking or jogging, mowing, raking, digging and Dancing are
kinds of this type.
 Strength
Strength exercises make your muscles stronger. Even small increases in strength can make a big difference
in your ability. We can find this type of exercise in Lifting weights, using a resistance band with your own
body weight.
 Balance
Balance exercises help prevent falls, a public problem in older adults. Many lower-body strength exercises
also will improve your balance. This type can be noticeable in Standing on one foot, Heel-to-toe walk and
Tai Chi.

 Flexibility
Flexibility exercises stretch your muscles and can help your body stay limber. Being flexible gives you more
freedom of movement for other exercises as well as for your everyday activities. Some examples for that in
Shoulder and upper arm stretch, Calf stretch and Yoga
Depending on the overall effect on the human body Physical exercises can be generally
grouped into two types:
 Aerobic exercise is any physical activity that uses large muscle groups and causes the body to use
more oxygen than it would while resting. The goal of aerobic exercise is to increase cardiovascular
endurance. Examples of aerobic exercise include cycling, swimming, brisk walking, skipping rope,
rowing, hiking, playing tennis, continuous training, and long slow distance training.
 Anaerobic exercise, which includes strength and resistance training, can firm, strengthen, and tone
muscles, as well as improve bone strength, balance, and coordination. Examples of strength moves
are push-ups, lunges, and bicep curls using dumbbells. Anaerobic exercise also includes weight
training, functional training, eccentric training, Interval training, sprinting, and high-intensity interval
training increase short-term muscle strength.
 According to the intensities of the exercise it can also divided to three categories, heart Rate is
typically used as a measure of exercise intensity. Heart rate can be an indicator of the challenge
to the cardiovascular system that the exercise represents
 Light exercise: Does not induce sweating unless it's a hot, humid day. There is no obvious change in
breathing patterns, sleeping, writing, desk work, typing, very slow walking, are examples for the first
category.
 Moderate exercise: It should raise your heart rate, make you breathe faster and make you feel warm
enough to start to sweat after performing the activity for about 10 minutes. Breathing becomes
deeper and more frequent. You can carry on a conversation but not sing, bicycling, very light effort,
calisthenics, home exercise, light or moderate effort are examples for the second one.
 Vigorous exercise: will make you breathe hard, increase your heart rate significantly and make you
hot enough to sweat profusely after 3-5 minutes. Breathing is deep and rapid. You can only talk in
short phrases, the examples for this type include running, jogging, jogging in place, calisthenics (e.g.
pushups, sit-ups, pull ups, jumping jacks), heavy vigorous effort, rope jumping.

 IMPORTANCE OF EXERCISE (3)

Each one of us has a physical body made of muscles, blood, bones and various other living tissue. When any
of these are injured or not working properly then we get ill. Nobody likes to be ill. So, it is important that we
keep our body healthy and fit. Exercising the body is one way of keeping it healthy. If we do not exercise
then our muscles become weaker and we are less able to do things properly. Also, the bones can become
weaker and thus break easily. It is performed for various reasons, including increasing growth and
development, preventing aging, strengthening muscles and the cardiovascular system, honing athletic skills,
weight loss or maintenance, and merely enjoyment. Frequent and regular physical exercise boosts the
immune system and helps prevent "diseases of affluence" such as cardiovascular, type 2 diabetes, and
obesity. It may also help prevent stress and depression, increase quality of sleep and act as a non-
pharmaceutical sleep aid to treat diseases such as insomnia, help promote or maintain positive self-esteem,
improve mental health, maintain steady digestion and treat constipation and gas, regulate fertility health, and
augment an individual's sex appeal or body image, which has been found to be linked with higher levels of
self-esteem. Childhood obesity is a growing global concern, and physical exercise may help decrease some
of the effects of childhood and adult obesity. Some care providers call exercise the "miracle" or "wonder"
drug—alluding to the wide variety of benefits that it can provide for many individuals.
In the United Kingdom two to four hours of light activity are recommended during working hours. This
includes walking and standing. In the United States, the CDC/ACSM consensus statement and the Surgeon
General's report states that every adult should participate in moderate exercise, such as walking, swimming,
and household tasks, for a minimum of 30 minutes daily.

 THE DOSAGE OF EXERCISE (1)

There is a continuous debate on how much, what type, how often, what intensity and how lengthy physical
activity should be. This is important for issuing public health recommendations. Summarizing available
information across studies is difficult because investigators have measured exercise intensity in different
ways and classified physical activity according to different dose schemes that are often difficult to compare.
Over the years, various expert groups, based on the best evidence available, have postulated different
physical activity recommendations and guidelines (see Table 1).
Intensity levels of physical activity can be expressed relative to oxygen consumption (VO2) or to heart rate.
Moderate-intensity activities are those in which heart rate and breathing are raised; but, still, it is possible to
speak comfortably. This occurs around 4–6 METs and brisk walking at 3.0 mph (80.4 m·min-1) is one such
activity. Vigorous-intensity activities are that in which heart rate is higher, breathing is heavier and
conversation is harder (about 6–8 METs), for instance jogging. It has been shown that exercising at even
50% of the recommended levels (72 min of moderate exercise a week) appears sufficient to provide some
improvement in fitness. However, at this low exercise dosage, cardiovascular risk factors (blood pressure,
lipid profile and weight) do not improve. In fact, for many individuals, up to 60 min of daily physical
activity are more appropriate if weight control is the primary goal. Thus, dose response relations between
physical activity and different health outcomes are different. The evaluation of the minimum amount of
physical activity (lower dose) necessary to achieve its beneficial effects has been the object of intense
research. Wen et al. (2011) have recently found that 15 min a day or 90 min a week of moderate-intensity
exercise is of benefit in terms of life expectancy, even for subjects with cardiovascular risks

 GREEN EXERCISE (7)

Green exercise is physical exercise engage in natural environment . Physical exercise is widely known to
supply physical and psychological health benefits. The research about the specific benefits of green exercise
is growing. A recent systematic review summarizes a wide range of health and well-being outcomes, such as
higher positive and lower negative emotions, after exercising in a natural rather than a more synthetic
environment (e.g. non-green outdoor built environments and indoor environments). Physiological outcomes,
such as healthy levels of blood pressure and cortisol, are less supportive of consistent positive evidence.
There is also some support, but again not very strong, for greater attention and concentration after practicing
in a natural environment. Another review summarized how the great outdoors can promote physical activity
and health in the general population,exploring the impact of green exercise on psychological and
physiological health markers, and also the mechanisms by which green exercise has an impact on health.
Outdoor natural environments, beyond the benefits of simple exposure, may facilitate adherence to physical
activity, through lower levels of perceived effort, stress and mental fatigue, leading to improved mood (e.g.
reducing tension, anger and depression), self-esteem and perceived health state. Green exercise also
promotes physiological functioning, including health markers, such as heart rate, blood pressure and
autonomic control, and endocrine markers, such as noradrenaline, adrenaline and cortisol. Moreover, green
exercise can facilitate adherence to physical activity through promoting attention to an external pleasant and
green environment, which consequently distracts from and reduces awareness of physiological sensations
and negative emotions, thus minimizing the perception of effort. Positive outcomes of green exercise for
individuals’ mental health improvements are observed even for short periods of practice.These effects on
self-esteem and mood are independent of location, duration, intensity, gender, age, and health status.

 BENEFITS OF EXERCISE (3)

Regular exercise makes the heart stronger and the lungs fitter, enabling the cardiovascular system to deliver
more oxygen to the body with every heartbeat and the pulmonary system to increase the maximum amount
of oxygen that the lungs can take in. Exercise lowers blood pressure, slightly decreases the levels of total
and low-density lipoprotein (LDL) cholesterol (the bad cholesterol), and increases the level of high-density
lipoprotein (HDL) cholesterol (the good cholesterol). These helpful effects decrease the risk of heart attack,
stroke, and coronary artery disease. In addition, colon cancer and some forms of diabetes are less likely to
occur in people who exercise regularly. Exercise makes muscles stronger, allowing people to do tasks that
they otherwise might not be able to do or to do them more easily. Every physical task requires muscle
strength and some degree of range of motion in joints. Regular exercise can improve both of these qualities.
Exercise stretches muscles and joints, which in turn can increase flexibility and help prevent injuries.
Exercise may also improve balance by increasing strength of the tissues around joints and throughout the
body, thus helping to prevent falls. Weight-bearing exercise, such as brisk walking and weight training,
strengthens bones and helps prevent osteoporosis. Other health benefits include the following:

1. Reduce stress and anxiety

Stress relief is one of the most common mental benefits of exercise. Regular Exercise can help to manage
physical and mental stress. Exercise also increases concentrations of norepinephrine, a chemical that can
moderate the brain’s response to stress. Being active greatly causes a reduction in tress levels. Aerobic and
anaerobic physical training helpful for overall health. Study suggests that 30 Minutes Exercise for 5 or more
days in a week, it helps in lowering the desperation and mental stress. On the other hand, Physical activity
makes you more tired so you’re more ready to sleep. Good quality sleep helps improve overall wellness and
can reduce stress. Regarding anxiety, the warm and chemicals that are released during and after any physical
exercise can help people with anxiety disorders calm down. Jumping on the track or treadmill for some
moderate-to-high intensity aerobic exercise can reduce anxiety sensitivity.

2. Boost happy chemicals

Exercise releases endorphins, which create feelings of happiness and euphoria. Studies have shown that
exercise can even improve symptoms among the clinically depressed. For this reason, doctors recommend
that people suffering from depression or anxiety. In some cases, exercise can be just as effective as
antidepressant pills in treating depression. Higher energy levels resulting from exercise help a person in
remaining fresh and happy. Following a suitable exercise program can add some fun and brightness to the
day. Working out for just 30 minutes a few times a week can instantly boost overall mood.

3. Improve Self-Confidence and Self-Image

Physical fitness can boost self-esteem and improve positive self-image. Regardless of weight, size, gender,
or age, exercise can quickly elevate a person's perception of his or her attractiveness, that is, self-worth. It
has been proved that in less time of aerobic exercise and resistance training method definitely will help to
improve self-image. One of the latest researches was in consistency with most of the previous studies which
found significant relationship between physical activity and self-esteem by using different study designs and
self-esteem scales. This finding can be considered to recommend increased physical activity participation
for college student who face self-esteem problems. Even if you will take your workout outside and start
Exercising in the great outdoors can also increase self-esteem even more.

4. Increase brainpower
Various studies on mice and men have shown that cardiovascular exercise can create new brain cells (aka
neurogenesis) and improve overall brain performance. Studies suggest that a vigorous workout increases
levels of a brain-derived protein (known as BDNF) in the body, believed to help with decision making,
higher thinking, and learning.

5. Sharpen memory
Regular physical activity increases memory and ability to learn new things. Getting sweaty increases
production of cells in hippocampus responsible for memory and learning. For this reason, research has
linked children’s brain development with level of physical fitness, but exercise-based brainpower isn’t just
for kids, regular exercise can boost memory among adults, too. A study showed that running sprints
improved vocabulary retention among healthy adults.

6. Improves muscles and bones strength

Exercise involves a series of sustained muscle contractions, of either long or short duration, depending on
the nature of the physical activity. Muscle-strengthening activities can help you increase or maintain your
muscle mass and strength. Strong muscles and ligaments reduce your risk of joint and lower back pain by
keeping joints in proper alignment. Additionally, with exercise improvements to the circulatory and
respiratory systems can facilitate better delivery of oxygen and glucose to the muscle. Research shows that
doing aerobics bone strengthening physical activity of at least a moderately-intense level can slow the loss
of bone density that comes with age, along with that hip fracture is a serious health condition that can have
life-changing negative effects, especially if you're an older adult. But research shows that people who do
120 to 300 minutes of at least moderate-intensity aerobic activity each week have a lower risk of hip
fracture.
7. Reduce the Risk of Heart Diseases
The heart is a muscle and needs exercise to stay in shape. When it's exercised, the heart can pump more
blood through the body and continue working at optimal efficiency with little strain. This will likely help it
to stay healthy longer. Regular exercise also helps to keep arteries and other blood vessels flexible, ensuring
good blood flow and normal blood pressure. Daily exercise helps in strengthening of heart muscles. It helps
maintain desired cholesterol levels. Daily physical activity reduces one’s chances of stroke and the risk of
heart disease. According to the American Heart Association (AHA), exercising 30 minutes a day, five days a
week will improve your heart health and help reduce your risk of heart disease. You can even break it up
into quick and manageable 10minute sessions, three times a day.

8. Preventing Obesity
Obesity and overweight are associated with increased risk for hypertension, osteoarthritis, abnormal
cholesterol and triglyceride levels, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, sleep
apnea, respiratory problems and some cancers. Obesity is a significant health problem all over the world for
all ages. Genetics can play a role in the possibility that a person will become obese, the condition occurs
when the number of calories consumed exceeds the amount of calories expended over a long period of time.
The more you exercise, the easier it is to keep your weight under control. Excess calories are stored as fat in
the body, and with long-term caloric excess, an individual eventually becomes obese. Exercise can help
prevent excess weight gain or help maintain weight loss. When you engage in physical activity, you burn
calories. The more intense the activity, the more calories you burn. Regular exercise (and proper nutrition)
can help reduce body fat. Weight loss will achieve most effectively when we follow a cardiovascular
exercise of moderate intensity activity accumulated over 5-7 days per week. Eating a healthy diet are ways
in which to combat obesity.

9. Exercise and Diabetes

Diabetes and exercise go hand in hand, at least when it comes to managing your diabetes. Exercise can help
you improve your blood sugar control, boost your overall fitness, and reduce your risk of heart disease and
stroke. But diabetes and exercise pose unique challenges, too. To exercise safely, it's crucial to track your
blood sugar before, during and after physical activity. You'll learn how your body responds to exercise,
which can help you prevent potentially dangerous blood sugar fluctuations. The affect physical activity has
on your blood glucose will vary depending on how long you are active and many other factors. Physical
activity can lower your blood glucose up to 24 hours or more after your work out by making your body
more sensitive to insulin.

10. Exercise and Cancer

Exercise is one of the most important actions you can take to help guard against many types of cancer. Up
to one-third of cancer-related deaths are due to obesity and a sedentary lifestyle, including two of the most
common cancers in the United States, breast and colon cancer. Many people exercise to prevent heart
disease, but exercise can also play a key role in preventing and reducing the danger of many cancers. It is
estimated that 30 to 60 minutes of moderate to vigorous physical activity per day is needed to protect against
colon cancer, endometrial cancer and lung cancer. Most studies suggest that 30 to 60 minutes per day of
moderate- to high-intensity physical activity is associated with a reduction in breast cancer risk also, there is
one recent study suggested that regular vigorous activity could slow the progression of prostate cancer in
men age 65 or older.

 EXERCISE AS DEFENSIVE AGENT AGAINST NON-COMMUNICABLE DISEASES

 Benefits of Regular Exercise on Cardiovascular Risk Factors (5)

 Increase in exercise tolerance
 Reduction in body weight
 Reduction in blood pressure
 Reduction in bad (LDL and total) cholesterol
 Increase in good (HDL) cholesterol
 Increase in insulin sensitivity

There are a number of physiological benefits of exercise; examples are improvements in muscular function
and strength and improvement in the body’s ability to take in and use oxygen (maximal oxygen
consumption or aerobic capacity). As one’s ability to transport and use oxygen improves, regular daily
activities can be performed with less fatigue. This is particularly important for patients with cardiovascular
disease, whose exercise capacity is typically lower than that of healthy individuals. There is also evidence
that exercise training improves the capacity of the blood vessels to dilate in response to exercise or
hormones, consistent with better vascular wall function and an improved ability to provide oxygen to the
muscles during exercise. Studies measuring muscular strength and flexibility before and after exercise
programs suggest that there are improvements in bone health and ability to perform daily activities, as well
as a lower likelihood of developing back pain and of disability, particularly in older age groups.

Patients with newly diagnosed heart disease who participate in an exercise program report an earlier return
to work and improvements in other measures of quality of life, such as more self-confidence, lower stress,
and less anxiety. Importantly, by combining controlled studies, researchers have found that for heart attack
patients who participated in a formal exercise program, the death rate is reduced by 20% to 25%. This is
strong evidence in support of physical activity for patients with heart disease. Although the benefits of
exercise are unquestionable, it should be noted that exercise programs alone for patients with heart disease
have not convincingly shown improvement in the heart’s pumping ability or the diameter of the coronary
vessels that supply oxygen to the heart muscle.

Primary prevention (6)

Since the seminal work of Morris and colleagues in the1950s and the early work of Paffenbarger and
colleagues in the 1970s, there have been numerous long-term prospective follow-up studies (mainly
involving men but more recently women also) that have assessed the relative risk of death from any cause
and from specific diseases (e.g., cardiovascular disease) associated with physical inactivity. Both men and
women who reported increased levels of physical activity and fitness were found to have reductions in
relative risk (by about 20%–35%) of death.

For example, in a study involving healthy middle-aged men and women followed up for 8 years, the lowest
quintiles of physical fitness, as measured on an exercise treadmill, were associated with an increased risk of
death from any cause compared with the top quintile for fitness (relative risk among men 3.4, 95%
confidence interval [CI] 2.0 to 5.8, and among women 4.7, 95% CI 2.2 to 9.8). Recent investigations have
revealed even greater reductions in the risk of death from any cause and from cardiovascular disease. For
instance, being fit or active was associated with a greater than 50% reduction in risk. Furthermore, an
increase in energy expenditure from physical activity of 1000 kcal (4200 kJ) per week or an increase in
physical fitness of 1 MET (metabolic equivalent) was associated with a mortality benefit of about 20%.
Physically inactive middle-aged women (engaging in less than 1 hour of exercise per week) experienced a
52% increase in all-cause mortality, a doubling of cardiovascular related mortality and a 29% increase in
cancer-related mortality compared with physically active women. These relative risks are similar to those for
hypertension, hypercholesterolemia and obesity, and they approach those associated with moderate cigarette
smoking. Moreover, it appears that people who are fit yet have other risk factors for cardiovascular disease.

May be at lower risk of premature death than people who are sedentary with no risk factors for
cardiovascular disease. An increase in physical fitness will reduce the risk of premature death, and a
decrease in physical fitness will increase the risk. The effect appears to be graded, such that even Small
improvements in physical fitness are associated with a significant reduction in risk. In one study,
participants with the highest levels of physical fitness at baseline and who maintained or improved their
physical fitness over a prolonged period had the lowest risk of premature death. Modest enhancements in
physical fitness in previously sedentary people have been associated with large improvements in health
status. For instance, in another study, people who went from unfit to fit over a 5-year period had a reduction
of 44% in the relative risk of death compared with people who remained unfit.

A recent systematic review of the literature regarding primary prevention in women revealed that there was
a graded inverse relation between physical activity and the risk of cardiovascular- related death, with the
most active women having a relative risk of 0.67 (95% CI 0.52 to 0.85) compared with the least active
group. These protective effects were seen with as little as 1 hour of walking per week.
In summary, observational studies provide compelling evidence that regular physical activity and a high
fitness level are associated with a reduced risk of premature death from any cause and from cardiovascular
disease in particular among asymptomatic men and women. Furthermore, a dose response relation appears
to exist, such that people who have the highest levels of physical activity and fitness are at lowest risk of
premature death
Secondary prevention of cardiovascular disease (6)
The benefits of physical activity and fitness extend to patients with established cardiovascular disease. This
is important because, for a long time, rest and physical inactivity had been recommended for patients with
heart disease. Unlike studies of primary prevention, many studies of secondary prevention are RCTs.
Several systematic reviews have clearly shown the importance of engaging in regular exercise to attenuate
or reverse the disease process in patients with cardiovascular disease. For instance, a systematic review and
meta-analysis of clinical trials revealed that, compared with usual care, cardiac rehabilitation significantly
reduced the incidence of premature death from any cause and from cardiovascular disease in particular. An
energy expenditure of about 1600 kcal (6720 kJ) per week has been found to be effective in halting the
progression of coronary artery disease, and an energy expenditure of about 2200 kcal (9240 kJ) per week
has been shown to be associated with plaque reduction in patients with heart disease. Low-intensity exercise
training (e.g., exercise at less than 45% of maximum aerobic power) has also been associated with an
improvement in health status among patients with cardiovascular disease. However, the minimum training
intensity recommended for patients with heart disease is generally 45% of heart rate reserve.
In summary, regular physical activity is clearly effective in the secondary prevention of cardiovascular
disease and is effective in attenuating the risk of premature death among men and women.

 Diabetes mellitus

Aerobic Exercise Benefits (8)

Aerobic training increases mitochondrial density, insulin sensitivity, oxidative enzymes, compliance
and reactivity of blood vessels, lung function, immune function, and cardiac output. Moderate to high
volumes of aerobic activity are associated with substantially lower cardiovascular and overall mortality risks
in both type 1 and type 2 diabetes. In type 1 diabetes, aerobic training increases cardiorespiratory fitness,
decreases insulin resistance, and improves lipid levels and endothelial function. In individuals with type
2 diabetes, regular training reduces A1C, triglycerides, blood pressure, and insulin resistance. Alternatively,
high-intensity interval training (HIIT) promotes rapid enhancement of skeletal muscle oxidative
capacity, insulin sensitivity, and glycemic control in adults with type 2 diabetes and can be performed
without deterioration in glycemic control in type 1 diabetes.

Resistance Exercise Benefits (8)

Diabetes is an independent risk factor for low muscular strength and accelerated decline in muscle strength
and functional status. The health benefits of resistance training for all adults include improvements in
muscle mass, body composition, strength, physical function, mental health, bone mineral density, insulin
sensitivity, blood pressure, lipid profiles, and cardiovascular health. The effect of resistance exercise on
glycemic control in type 1 diabetes is unclear. However, resistance exercise can assist in minimizing risk
of exercise-induced hypoglycemia in type 1 diabetes. When resistance and aerobic exercise are
undertaken in one exercise session, performing resistance exercise first results in less hypoglycemia than
when aerobic exercise is performed first. Resistance training benefits for individuals with type 2 diabetes
include improvements in glycemic control, insulin resistance, fat mass, blood pressure, strength, and
lean body mass.

Benefits of Other Types of Physical Activity (8)

Flexibility and balance exercises are likely important for older adults with diabetes. Limited joint mobility is
frequently present, resulting in part from the formation of advanced glycation end products, which
accumulate during normal aging and are accelerated by hyperglycemia. Stretching increases range of
motion around joints and flexibility but does not affect glycemic control. Balance training can reduce
falls risk by improving balance and gait, even when peripheral neuropathy is present. Group exercise
interventions (resistance and balance training, tai chi classes) may reduce falls by 28%−29%. The benefits of
alternative training like yoga and tai chi are less established, although yoga may promote improvement in
glycemic control, lipid levels, and body composition in adults with type 2 diabetes. Tai chi training may
improve glycemic control, balance, neuropathic symptoms, and some dimensions of quality of life in
adults with diabetes and neuropathy, although high-quality studies on this training are lacking.

Insulin Action and Physical Activity (8)

Insulin action in muscle and liver can be modified by acute bouts of exercise and by regular physical
activity. Acutely, aerobic exercise increases muscle glucose uptake up to fivefold through insulin-
independent mechanisms. After exercise, glucose uptake remains elevated by insulin-independent (∼2 h)
and insulin-dependent (up to 48 h) mechanisms if exercise is prolonged, which is linked with muscle
glycogen repletion. Improvements in insulin action may last for 24 h following shorter duration activities
(∼20 min) if the intensity is elevated to near-maximal effort intermittently. Even low-intensity aerobic
exercise lasting ≥60 min enhances insulin action in obese, insulin-resistant adults for at least 24 h. If
enhanced insulin action is a primary goal, then daily moderate- or high-intensity exercise is likely optimal.
Regular training increases muscle capillary density, oxidative capacity, lipid metabolism, and insulin
signaling proteins, which are all reversible with detraining. Both aerobic and resistance training promote
adaptations in skeletal muscle, adipose tissue, and liver associated with enhanced insulin action, even
without weight loss. Regular aerobic training increases muscle insulin sensitivity in individuals with
prediabetes and type 2 diabetes in proportion to exercise volume. Even low-volume training (expending just
400 kcal/week) improves insulin action in previously sedentary adults. Those with higher baseline insulin
resistance have the largest improvements, and a dose response is observed up to about 2,500 kcal/week.
Resistance training enhances insulin action similarly, as do HIIT and other modes. Combining endurance
exercise with resistance exercise may provide greater improvements, and HIIT may be superior to
continuous aerobic training in adults with diabetes

Primary prevention (6)

Both aerobic and resistance types of exercise have been shown to be associated with a decreased risk of type
2 diabetes. In a large prospective study, each increase of 500 kcal (2100 kJ) in energy expenditure per week
was associated with a decreased incidence of type 2 diabetes of 6% (relative risk 0.94, 95% CI –0.90 to
0.98)). This benefit was particularly evident among people at high risk of diabetes (i.e., those with a high
body mass index), a finding that has been supported by several other investigators. For instance, among 271
male physicians, those who reported weekly physical activity sufficient to cause a sweat had a reduced
incidence of type 2 diabetes. Moderately intense levels of physical activity (5.5 METs for at least 40 minutes
per week) and of cardiovascular fitness (> 31 mL oxygen per kilogram per minute) have also been shown to
be protective against the development of type 2 diabetes in middle-aged men, with an even greater effect
among those at high risk of diabetes. Several investigators have reported a reduced incidence of type 2
diabetes among high-risk people (e.g., those who are overweight) after lifestyle interventions. A review
of RCTs on the topic concluded that modest weight loss through diet and exercise reduced the incidence of
the disease among high-risk people by about 40%–60% over 3–4 years. In one of the RCTs,53 a lifestyle
intervention that included moderate physical activity for at least 150 minutes per week was found to be more
effective than metformin alone in reducing the incidence of diabetes. It showed that only 7 people would
need to be “treated” with the lifestyle intervention to prevent a single case of diabetes over a 3- year period,
compared with 14 people given metformin.
In summary, increasing research supports the importance of regular physical activity for the primary
prevention of type 2 diabetes. Further research is warranted to uncover the ideal methods (e.g., resistance v.
aerobic training) and intensity levels of exercise

Secondary prevention (6)

Exercise interventions are also effective in the management of diabetes. One prospective cohort study
showed that walking at least 2 hours per week was associated with a reduction in the incidence of
premature death of 39%–54% from any cause and of 34%–53% from cardiovascular disease among
patients with diabetes. Moreover, walking that led to moderate increases in heart and breathing rates was
associated with significant reductions in all-cause mortality (hazard rate ratio 0.57, 95% CI 0.41 to 0.80) and
cardiovascular-related mortality (hazard rate ratio 0.69, 95% CI 0.43 to 1.09). In another cohort study,
physically inactive men with established type 2 diabetes had a 1.7-fold increased risk of premature death
compared with physically active men with type 2 diabetes. This difference has also been observed among
people with metabolic syndrome. Several clinical trials have been conducted on the topic. Both aerobic and
resistance training have been shown to be of benefit for the control of diabetes; however, resistance training
may have greater benefits for glycemic control than aerobic training may have. A meta-analysis of 14
controlled trials (11 randomized) revealed that exercise interventions resulted in a small but clinically
and statistically significant reduction in glycosylated hemoglobin (0.66%) compared with no exercise
intervention; in most of the trials, participants in both the exercise and control groups were treated
concurrently with oral hypoglycemic agents. This level of change is similar to that observed in studies
comparing intensive glucose-lowering therapy with conventional treatments, a change that is known to be
associated with a 42% reduction in diabetes-related mortality.
In summary, exercise interventions for patients with diabetes are beneficial in improving glucose
homeostasis. Prospective studies with adequate follow-up show a strong association between exercise and
reduced rates of death from any cause and from diabetes in particular. Future research will need to
concentrate on examining the effects of dose (intensity and frequency of exercise).

 Cancer
How might physical activity be linked to reduced risks of cancer? (9)
Exercise has a number of biological effects on the body, some of which have been proposed to explain
associations with specific cancers, including:

 Lowering the levels of hormones, such as insulin and estrogen, and of certain growth factors that have
been associated with cancer development and progression [breast, colon]
 Helping to prevent obesity and decreasing the harmful effects of obesity, particularly the development
of insulin resistance (failure of the body's cells to respond to insulin)
 Reducing inflammation
 Improving immune system function
 Altering the metabolism of bile acids, resulting in decreased exposure of the gastrointestinal tract to
these suspected carcinogens [colon]
 Reducing the amount of time, it takes for food to travel through the digestive system, which decreases
gastrointestinal tract exposure to possible carcinogens [colon]

Primary prevention (6)

Several seminal reviews have been published regarding the relation between cancer and routine physical. Of
the available literature (including over 100 epidemiologic studies), it appears that routine physical activity,
whether as part of a job or as a leisure activity, is associated with reductions in the incidence of specific
cancers, in particular colon and breast cancer. A systematic review of epidemiologic studies revealed that
moderate physical activity (> 4.5 METs [equivalent to mowing the lawn]) was associated with a greater
protective effect than activities of less intensity. Physically active men and women exhibited a 30%–40%
reduction in the relative risk of colon cancer, and physically active women a 20%–30% reduction in the
relative risk of breast cancer compared with their inactive counterparts. In summary, there is compelling
evidence that routine physical activity is associated with reductions in the incidence of specific cancers, in
particular breast and colon cancer.

Secondary prevention (6)

There is a paucity of information regarding the effectiveness of physical activity in preventing death from
cancer or from any cause in patients with cancer. An early (5.5-year) follow-up study involving women with
breast cancer revealed little association between total recreational physical activity and the risk of death
from breast cancer; however, the study had some important limitations. Two recent follow-up studies
involving cancer patients (breast and colon cancer) revealed that increased self-reported physical activity
was associated with a decreased recurrence of cancer and risk of death from cancer. One investigation
revealed a reduction of 26%–40% in the relative risk of cancer-related death and recurrence of breast cancer
among the most active women compared with the least active. Other studies have shown similar
associations. There are ongoing efforts to try to understand the mechanism of this survival effect, including
the effects of exercise on the effectiveness of chemotherapy. Regular physical activity has also been shown
to be associated with an improvement in overall quality of life and health status of patients with cancer.
In summary, regular physical activity appears to confer a health benefit to patients with established cancer.
However, further research is warranted to examine its role in the secondary prevention of cancer. In
particular, large RCTs evaluating the effectiveness of an exercise intervention are required to fully elucidate
the importance of regular physical activity for the health status of patients with cancer.

 Osteoporosis
Primary prevention (6)
Weight-bearing exercise, especially resistance exercise, appears to have the greatest effects on bone
mineral density. In one review, several cross-sectional reports revealed that people who did resistance
training had increased bone mineral density compared with those who did not do such training. Furthermore,
athletes who engaged in high-impact sports tended to have increased bone mineral density compared with
athletes who engaged in low-impact sports.
Numerous longitudinal studies have examined the effects of exercise training on bone health in children,
adolescents, and young, middle-aged and older adults. Although the numbers of studies and total
participants examined are relatively small compared with those in the cardiovascular literature, there is
compelling evidence that routine physical activity, especially weight-bearing and impact exercise,
prevents bone loss associated with aging. In a meta-analysis of RCTs, exercise training programs were
found to prevent or reverse almost 1% of bone loss per year in the lumbar spine and femoral neck in both
pre- and postmenopausal women. Exercise training appears to significantly reduce the risk and number
of falls. The risk and incidence of fractures is also reduced among active people. Among 3262 healthy men
(mean age 44 years) followed for 21 years, intense physical activity at baseline was associated with a
reduced incidence of hip fracture (hazard ratio 0.38, 95% CI 0.16 to 0.91). This observation supports
findings from an earlier investigation in which fracture rates were lower among people who performed more
weight-bearing activities than among sedentary people. In summary, routine physical activity appears to be
important in preventing loss of bone mineral density and osteoporosis, particularly in postmenopausal
women. The benefits clearly outweigh the potential risks, particularly in older people.

Secondary prevention (6)

Preliminary evidence from an RCT indicates that exercise training is effective in improving bone density in
older women (75–85 years of age) with low bone mineral density. In this 6-month RCT, women were
randomly assigned to participate in resistance training (n = 32), agility training (n = 34) or stretching (sham
exercise, n = 32). Agility training resulted in a significant increase in cortical bone density by 0.5%
(standard error of the mean [SEM] 0.2%) at the tibia shaft, and resistance training resulted in a significant
increase in cortical bone density by 1.4% (SEM 0.6%) at the radial shaft; the stretching group experienced
losses in cortical bone density. Furthermore, a study involving early postmenopausal osteopenic women
revealed that a 2-year intensive training program was effective in attenuating the rate of bone loss.
In summary, preliminary evidence indicates that regular physical activity is an effective secondary
preventive strategy for the maintenance of bone health and the fight against osteoporosis.

 INTRODUCTION TO THE IMPORTANCE AND INFLUENCE OF NUTRITION ON

EXERCISE (10, 11)
General nutritional needs for physical activity
Good nutrition assists in the ability to train intensely, as well as in muscle recovery and metabolic
adaptations to endurance exercise. Adequate energy should derive from a wide variety of available foods
that provide carbohydrates, proteins, fat and micronutrients.

In most instances, a well-balanced diet should be sufficient in energy in order to maintain the energy balance
in individuals with increased energy requirements because of physical activity. However, it might be
challenging to meet the energy needs of athletes with a high body weight and height, i.e. larger athletes and
athletes who partake in high-volume intense training. A negative energy balance is common in endurance
athletes, such as runners, cyclists, swimmers and triathletes, as well as in sports in which dietary restriction
is part of the strategy to modify body composition and size, such as gymnastics, skating, dancing, wrestling
and boxing. These athletes sometimes attempt to lose weight too quickly and in mismanaged ways.
Historically, female athletes are more prone to eating disorders, which lead to a disturbed energy balance. A
negative energy balance in female athletes can lead to the development of the female athlete triad, which
includes disturbed eating patterns, menstrual disorders and low bone mineral density. It is possible for a
female athlete to become energy deficient without having a clinically diagnosed eating disorder. Apart from
this, high intensity training can decrease appetite and change hunger patterns. Some athletes may be
uncomfortable eating meals before exercise because of gastrointestinal discomfort. Travel and training also
influence food availability and safety, and careful planning around travel schedules is of vital importance.
Insufficient energy intake can result in weight loss, especially of muscle mass; injury, illness, increased
prevalence of overtraining syndrome and ultimately decreased exercise performance. To overcome this,
athletes should focus on maintaining an energy balance to suit their energy expenditure and have 4-6 meals
per day, including nutrient dense food. The use of low-risk supplements, such as liquid meal replacements
and multivitamin and mineral preparations, can also be considered.

The ACSM recommends that “athletes need to consume adequate energy during periods of high intensity
and/or long duration training to maintain body weight and health and to maximise training effects”.The
ACSM recommends that energy requirements are calculated using either the dietary reference intakes
(DRIs) or prediction equations, such as the Cunningham or Harris-Benedict equations, where the basal or
resting metabolic rate is calculated using a physical activity factor (1.8-2.3) depending on the type, duration
and intensity of exercise. Energy expenditure can also be calculated by means of metabolic equivalents.5
The ISSN recommends that energy requirements are calculated according to level of physical activity and
body weight, as summarized in below

 Fat requirements
The fat requirements of athletes are similar, and are slightly higher than those in non-athletes. It is
important to consume adequate amounts of fat to ensure optimal health, maintenance of energy balance,
optimal intake of essential fatty acids and fat-soluble vitamins, as well as to replenish intramuscular
triacylglycerol stores. The amount of required fat depends largely on the training status and goals of the
athletes. The ACSM recommends that daily fat intake for athletes should be 20-35% of total energy intake
and that fat intake should not decrease below 20% of total energy intake, as the intake of fat is important
for the ingestion of fat-soluble vitamins and essential fatty acids. High-fat diets for athletes are not
recommended.
The ISSN suggests a moderate fat intake of 30% of total energy for athletes. This can increase to 50%
of total energy for high-volume training, i.e. elite competitor training of 40 hours/week (like the Ironman).
In order to reduce body fat or lose body weight, a fat intake of 0.5-1.0 g/kg BW/day is suggested.
Optimization of the type of dietary fatty acids is important. The focus should be on increasing dietary
sources of unsaturated or essential fatty acids.
The IOC recommends following a diet that does not contain less than 15-20% fat of total energy. It is
suggested that athletes should be cautious of high-fat diets (> 30% of total energy intake). The
recommendation from the ACSM regarding fat intake should suffice for any athlete. A high-fat intake can
be at the expense of carbohydrate intake and may have negative effects on training and racing performance.
 Carbohydrates requirements
  Protein
While protein consumption prior to and during endurance and resistance exercise has been shown to
enhance rates of muscle protein synthesis (MPS), a recent review found protein ingestion alongside
carbohydrate during exercise does not improve time–trial performance when compared with the ingestion of
adequate amounts of carbohydrate alone.

 Fluid and electrolytes

The purpose of fluid consumption during exercise is primarily to maintain hydration and
thermoregulation, thereby benefiting performance. Evidence is emerging on increased risk of oxidative
stress with dehydration. Fluid consumption prior to exercise is recommended to ensure that the athlete is
well-hydrated prior to commencing exercise. In addition, carefully planned hyper hydration (fluid
overloading) prior to an event may reset fluid balance and increase fluid retention, and consequently
improve heat tolerance. However, fluid overloading may increase the risk of hyponatremia and impact
negatively on performance due to feelings of fullness and the need to urinate.

Hydration requirements are closely linked to sweat loss, which is highly variable (0.5–2.0 L/hour) and
dependent on type and duration of exercise, ambient temperature, and athletes’ individual characteristics.
Sodium losses linked to high temperature can be substantial, and in events of long duration or in hot
temperatures, sodium must be replaced along with fluid to reduce risk of hyponatremia.
It has long been suggested that fluid losses greater than 2% of BM can impair performance, but there is
controversy over the recommendation that athletes maintain BM by fluid ingestion throughout an event.
Well-trained athletes who “drink to thirst” have been found to lose as much as 3.1% of BM with no
impairment of performance in ultra-endurance events. Ambient temperature is important, and a review
illustrated that exercise performance was preserved if loss was restricted to 1.8% and 3.2% of BM in hot and
temperate conditions, respectively.
Table :American College of Sports Medicine guidelines on fluid and electrolyte replacement for
physical activity
Fluid and electrolyte recommendations for physical activity
Before Pre-hydration should be initiated several hours before exercise to ensure fluid absorption
exercise and normal urine output. Beverages and sodium-containing and salted snacks can increase
the sensation of thirst and retain fluids.

During Fluid programmes should be customised for each individual, based on body weight
exercise measurements before and after exercise. Athletes should aim to prevent > 2% body weight
loss during exercise. Fluids should contain carbohydrates and electrolytes to maintain fluid
balance and exercise performance
After exercise Normal meals and beverages will induce euhydration. If more rapid recovery is required,
1.5 l of fluid per kg body weight loss during exercise should be ingested. Beverages and
snacks should contain sodium to help with rapid recovery, stimulation of thirst and fluid
retention
 Dietary supplementation: nitrates, beta-alanine, and vitamin D
Vitamins and minerals are essential nutrients in terms of providing a health benefit, although the ergogenic
effect of most micronutrients is still unclear and warrants further research. According to the ISSN, specific
vitamins may exhibit some health benefit, e.g. vitamin E, niacin, folic acid and vitamin C. However, few
have been reported to provide direct ergogenic properties. Some vitamins may assist physically active
individuals to endure heavy training and exercise, thereby improving exercise performance. In particular,
vitamins C and E may decrease oxidative damage caused by vigorous training schedules and may also help
to support a healthy immune system. Minerals are essential nutrients too, and are important for most bodily
functions. Some studies have shown mineral deficiencies in athletes. These can impact negatively on sports
performance. The health and ergogenic value of some minerals has been studied. These include calcium,
which reduces the risk of developing premature osteoporosis, and maintains body composition; iron,
particularly in the case of athletes who are prone to iron deficiency; sodium phosphate, which increases
maximal oxygen uptake, anaerobic threshold and endurance capacity; sodium chloride, to maintain fluid and
electrolyte balance; and zinc, which decreases exercise-induced changes in immune functioning. However,
there is little evidence to link improved sporting performance to boron, chromium, magnesium or vanadium.

Performance supplements shown to enhance performance include caffeine, beetroot juice, beta-alanine
(BA), creatine, and bicarbonate. Comprehensive reviews on other supplements including caffeine, creatine,
and bicarbonate can be found elsewhere. In recent years, research has focused on the role of nitrate, BA, and
vitamin D and performance. Nitrate is most commonly provided as sodium nitrate or beetroot juice. Dietary
nitrates are reduced (in mouth and stomach) to nitrites, and then to nitric oxide. During exercise, nitric
oxide potentially influences skeletal muscle function through regulation of blood flow and glucose
homeostasis, as well as mitochondrial respiration. During endurance exercise, nitrate supplementation
has been shown to increase exercise efficiency (4%–5% reduction in VO2 at a steady state; 0.9%
improvement in time trials), reduce fatigue, and attenuate oxidative stress. Similarly, a 4.2%
improvement in performance was shown in a test designed to simulate a football game.

BA is a precursor of carnosine, which is thought to have a number of performance-enhancing functions

including the reduction of acidosis, regulation of calcium, and antioxidant properties. Supplementation with
BA has been shown to augment intracellular carnosine concentration. A systematic review concluded that
BA may increase power output and working capacity and decrease feelings of fatigue, but that there are
still questions about safety. The authors suggest caution in the use of BA as an ergogenic aid.
 Vitamin D is essential for the maintenance of bone health and control of calcium homeostasis, but is
also important for muscle strength, regulation of the immune system, and cardiovascular health. Thus,
inadequate vitamin D status has potential implications for the overall health of athletes and performance. A
recent review found that the vitamin D status of most athletes reflects that of the population in their locality,
with lower levels in winter, and athletes who train predominantly indoors are at greater risk of deficiency.
There are no dietary vitamin D recommendations for athletes; however, for muscle function, bone health,
and avoidance of respiratory infections, current evidence supports maintenance of serum 25-hydroxyvitamin
D (circulating form) concentrations of 80–100 nmol/L.

 Sports food and supplement requirements

The ACSM has concluded that “athletes should be counselled regarding the appropriate use of ergogenic
aids. Such products should only be used after careful evaluation for safety, efficacy, potency, and legality”.
The ISSN 2010 review notes that while some supplements might have a beneficial effect on athletic
performance, no amount of supplementation will compensate for inadequate dietary intake.

According to this consensus document, supplements are categorized in the following manner according to
safety and efficacy:
 Apparently effective and generally safe: These supplements include weight-gain powders, creatine,
protein, EAAs, lowcalorie foods, ephedra (a banned substance), caffeine, water and carbohydrate-
electrolyte solutions, sodium phosphate and bicarbonate and beta-alanine.

 Supplements that are possibly effective: These include β-hydroxy-β-methyl butyrate in untrained
subjects, branched chain amino acids (BCAA), calcium, conjugated linoleic acid (CLA) and green
tea extract.

 Supplements whose effectiveness is too early to tell: The list extends to α-ketoglutarate, α-
ketoisocaprate, ecdysterones, growth hormone-releasing peptides and secretogues, ornithineα-
ketoglutarate, zinc-magnesium aspartate, chitosan, phosphatidl choline, betaine, Coleus Forskoli,
dehydroepiandrosterone (DHEA), psychotropic nutrients or herbs and medium-chain triglycerides.

 Supplements which are apparently not effective or are dangerous to use: Examples of such
supplements are glutamine, smilax, isoflavones, sulphopolysaccharides, boron, chromium, CLA,
gamma oryzanol, prohormones, tribulus terrestris, vanadium, calcium pyruvate, chitosan, L-
carnitine, phosphates, herbal diuretics, ribose and inosine.

According to the IOC, the following supplements increase exercise performance. This is strongly supported
by evidence:
 Alkalinizing agents (sodium bicarbonate and sodium citrate) increase anaerobic exercise
performance.
 L-arginine boosts aerobic endurance. (There is little, but convincing evidence in this regard).
 Beta-alanine enhances anaerobic and aerobic exercise performance.
 Caffeine improves endurance and reaction time.
 Creatine increases performance in strength and power events
 Nitrate advances aerobic endurance exercise.
 Carbohydrates, proteins, water, electrolytes and amino acids have ergogenic properties.

The IOC strongly discourages the indiscriminate use of supplements, supplementation when nutritional
needs can be met via dietary intake, the use of supplements that pose a risk of a positive doping outcome and
supplement use by young athletes (< 18 years). The IOC cautions against the widespread use of
supplements, especially in terms of acute or long-term effects on health, positive doping outcomes and
possible detrimental effects on exercise performance. Current regulations that govern supplement use are
more liberal compared to those by the pharmaceutical market. Often, supplements either contain little or no
active ingredient or too much of certain toxic nutrients. They may also contain harmful impurities, such as
lead, broken glass and animal faeces because of poor manufacturing practices. The majority of products on
the market fail to reach expected standards. Other involved risks include inaccurate labelling, failure to
declare the ingredients on the label and cross-contamination of supplements.

Supplements and sports food are used extensively by athletes at various levels, as well as by non-athletes.
Although the use of some supplements may have added benefits in terms of improving body composition,
sports performance and overall health, the risk to benefit ratio needs to be carefully considered before
embarking on the widespread use of supplements. Dietary supplements are poorly regulated in South Africa
and other countries. Although the manufacturers of these products are not allowed to state that a supplement
can prevent or treat any illness or disease without sufficient scientific evidence, monitoring is not thorough.
Regulation of supplements is also further complicated by the widespread sale thereof on the Internet. This
promotes the use of supplements from unidentified sources.

The product safety and purity, claimed benefits and safety of the supplement for short- and long-term, needs
to be considered carefully before it is taken. Poor quality control of supplements on sale in pharmacies and
supermarkets can also potentially increase the likelihood of athletes obtaining negative results in doping
tests. Poor hygiene and lack of good manufacturing practices can result in supplements containing impurities
such as lead, broken glass and animal faeces, which carries obvious health risks for athletes and other users.
Direct or deliberate, and indirect contamination of dietary supplements with undeclared and unlabelled
anabolic steroids also places supplement users in a difficult position. Some supplements may not contain the
exact amount of ingredients that are listed on the label as a marketing tool. Athletes may be unaware of the
potential negative effects of using these supplements. Currently, the World Anti-Doping Agency (WADA)
does not distinguish between deliberate cheating and inadvertent doping, and the responsibility and future
athletic career of the individual rests solely with the athlete.

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