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HCO 320510

REVIEW

CURRENT
OPINION Health benefits of physical activity: a systematic
review of current systematic reviews
Darren E.R. Warburton and Shannon S.D. Bredin

Purpose of review
The health benefits of physical activity and exercise are clear; virtually everyone can benefit from becoming
more physically active. Most international guidelines recommend a goal of 150 min/week of moderate-to-
vigorous intensity physical activity. Many agencies have translated these recommendations to indicate that
this volume of activity is the minimum required for health benefits. However, recent evidence has challenged
this threshold-centered messaging as it may not be evidence-based and may create an unnecessary barrier to
those who might benefit greatly from simply becoming more active. This systematic review evaluates recent
systematic reviews that have examined the relationship between physical activity and health status.
Recent findings
Systematic reviews and/or meta-analyses (based largely on epidemiological studies consisting of large
cohorts) have demonstrated a dose–response relationship between physical activity and premature
mortality and the primary and secondary prevention of several chronic medical conditions. The
relationships between physical activity and health outcomes are generally curvilinear such that marked
health benefits are observed with relatively minor volumes of physical activity.
Summary
These findings challenge current threshold-based messaging related to physical activity and health. They
emphasize that clinically relevant health benefits can be accrued by simply becoming more physically active.
Video abstract
http://links.lww.com/HCO/A42.
Keywords
dose–response, health, knowledge translation, physical activity

INTRODUCTION risk reductions are observed when objective measures

&

There is overwhelming evidence supporting the
health benefits of physical activity, such that being
physically active is a common message within health
&
promotion settings [1 ,2]. Routine physical activity
participation has been associated with a marked
reduction in the risk for premature mortality and is
an established means of reducing the risks for more
than 25 chronic medical conditions [1 ,2]. Most
&
international physical activity guidelines recom-
mend meeting the goal of 150 min/week of moder-
ate-to-vigorous intensity physical activity (MVPA).
This messaging has also been incorporated within
guidelines for clinical populations (such as those
with diabetes) [3]. The available evidence indicates
a clear dose–response relationship between physical
activity and health with 20–30% risk reductions for
premature mortality and chronic disease often being
observed in those that meet or exceed current inter-
&
national recommendations [1 ,2,4,5]. Even greater
of health-related physical fitness are taken [1 ,2,6].
Collectively, this work reinforces the importance
of regular participation in physical activity and/or
exercise.
Considerable international messaging emanat-
ing from recent guideline work has stated (or
implied) that health benefits are only achieved
when a minimal level of physical activity is achieved
(i.e., 150 min/week of MVPA or 75 min/week of
vigorous intensity physical activity). This threshold
and expert opinion-based messaging is consistently
Physical Activity Promotion and Chronic Disease Prevention Unit, Uni-
versity of British Columbia, Vancouver, British Columbia, Canada
Correspondence to Darren E.R. Warburton, University of British Columbia,
2259 Lower Mall, Vancouver, BC V6T1Z4, Canada. Tel.: 604 822 4603;.
e-mail: darren.warburton@ubc.ca
Curr Opin Cardiol 2017, 32:000–000
DOI:10.1097/HCO.0000000000000437

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HCO 320510
Prevention
KEY POINTS
 There is irrefutable evidence that routine physical
activity reduces the risk for premature mortality and is
an effective primary and secondary preventive strategy
for at least 25 chronic medical conditions.
 Clinically relevant health benefits for a wide range of
medical conditions can be accrued at volumes of
physical activity that are well below current
international recommendations.
 Threshold-centered physical activity messaging that
implies (or states explicity) that health benefits can only
be accrued at a volume of physical activity consistent
with international messaging (e.g., 150 min/week of
MVPA) is not evidence based and may present a
significant barrier to those that serve to benefit greatly
from simply becoming more physically active.
 Clinicians should avoid threshold-based physical
activity messaging taking into account the unique
features of each client when creating evidence-based
and effective lifestyle recommendations.
 Effective lifestyle interventions should take an integrated
approach to health, promoting the importance of
engaging in healthy lifestyle behaviors (such reducing
sedentary time, increasing physical activity, healthy
nutrition, smoking cessation, stress management, and
alcohol moderation).
promoted in the face of current literature (and often
overlooked previous findings) that demonstrates
that a volume of physical activity of half (or even
less) of the 150 min/week recommendation can lead
& &&
to significant health benefits [1 ,2,7 ,8]. Various
experts have advised about the perils of promoting
threshold-centered messaging for eliciting effective
and sustainable health change at the individual and
&
population levels [1 ,2,9–11]. Moreover, a signifi-
cant error in knowledge translation may be intro-
duced when clear thresholds (such as the 150 min/
week of MVPA threshold) are provided, when the
evidence demonstrates a dose–response relation-
ship with no clear threshold for benefit. This
knowledge translation error is potentially further
compounded by the increasing volume of system-
atic reviews of the literature which reflect differing
interpretations of the literature; they may make it
difficult for clinicians to decide upon the optimal
evidence-based best practice.
Therefore, the primary purpose of this system-
atic review of systematic reviews is to evaluate crit-
ically the dose–response relationship between
physical activity and the risk for premature
mortality and chronic disease to determine whether
2 www.co-cardiology.com
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or not threshold-based messaging is valid and appro-
priate. We focus on recent systematic reviews and
meta-analyses of the literature to gain further clarity
on evidence-based best practice in the promotion of
physical activity for health benefits. We hypothes-
ized that a volume of physical activity far less than
currently recommended by many international
health and fitness agencies would be associated with
significant and clinically relevant health benefits
particularly in inactive individuals and those living
with chronic medical conditions. We also hypoth-
esized that this dose–response relationship would
extend to various chronic medical conditions and
premature mortality.
METHODS
Literature search
A rigorous, systematic, and evidence-based approach
was used to examine critically the current evidence
regarding the health benefits of physical activity.
We searched MEDLINE (OVID Interface), PubMed,
and EMBASE (OVID Interface) databases for the past
2 years (January 2015 to April 2017) to identify any
recent systematic reviews (and/or meta-analyses)
that evaluated the dose–response relationship
between physical activity and health indicators
(mortality and chronic disease). The medical sub-
ject headings were kept broad, and electronic search
strategies were created and carried out by research-
ers experienced with systematic reviews of the lit-
erature (D.E.R.W. and S.S.D.B.; see Table 1). Staff
and students working at the Systematic Reviews
Laboratory (University of British Columbia) pro-
vided further assistance with librarian oversight.
Systematic reviews/meta-analyses that examined
the relationship between at least three different levels
of physical activity (or exercise) and the key out-
comes of mortality or incidence of chronic disease
and/or disability were eligible for inclusion consist-
ent with our previous systematic reviews of the liter-
ature [4,12]. Any form of physical activity/exercise
assessment (e.g., self-report, pedometer, accelerom-
eter, maximal aerobic power (VO2max), indirect
oxygen consumption) was eligible for inclusion.
Only published, systematic reviews (or meta-
analyses) examining humans (across the lifespan)
were included. This review, included apparently
healthy (asymptomatic) adults and those with estab-
lished chronic medical conditions. When available,
reported data were used to generate a figure outlining
the dose–response relationship between physical
activity and various health outcomes.
Narrative reviews and commentaries were
excluded from the formal evaluation. Systematic
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Physical activity and health Warburton and Bredin

Table 1. Embase search (OVID, 16 April 2017)

Number Searches (14 April 2017) Results

1 Physical activity.mp. or exp exercise/or exp physical education/or exp physical activity/or exp 667 887
leisure/or physical performance
2 Physical inactivity/or inactivity/or physically inactive/or physical activities/or physically active/or 282 420
physical exercise/
3 Physical fitness.mp. or fitness/ 47 533
4 Aerobic power/or exp oxygen consumption/or aerobic fitness.mp. or aerobic capacity/or exp aerobic 664 237
exercise/or aerobic endurance/or exp physical endurance/or exertion
5 Musculoskeletal function/or exp muscle strength/or musculoskeletal fitness.mp. or muscular power/or 53 228
muscular endurance/
6 Sports.mp. or exp sport/ 177 005
7 Exp exercise therapy/or exercise medicine/or exp exercise tolerance/or exercise intolerance/ 82 100
8 Health behavior/or leisure time physical activity/or occupational physical activity/or total physical 1 286 240
activity/or household physical activity/or behavior.mp. (mp ¼ title, abstract, original title, name of
substance word, subject heading word, keyword heading word, protocol supplementary concept
word, rare disease supplementary concept word, unique identifier, synonyms)
9 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 2 370 265
10 Dose–response/or intensity/or volume/or exp energy expenditure/or exp oxygen consumption/or 784 668
METs/or metabolic equivalent/
11 9 and 10 432 825
12 Exp mortality/or mortality risk/or cardiovascular mortality/or cancer mortality/or exp mortality rate/or 2 796 590
mortality.mp. or exp premature mortality/or death/or fatal/or cardiovascular/or coronary/or
stroke/or ischemic/or ischemic/or cancer/or colon cancer/or diabetes/or heart disease/or
breast cancer/or colorectal cancer/or osteoporosis/
13 (All-cause mortality or chronic disease).mp. or exp chronic disease/or disability/or disability.mp. or 3 163 019
physical disability/or work disability/
14 12 or 13 2 100 690
15 11 and 14 61 065
16 Limit 15 to year ¼ 2015 – current 12 948
17 exp ‘systematic review’/or meta-analy.mp. 293 158
18 16 and 17 522

MET, metabolic equivalent.

reviews (or meta-analyses) that only examined the were removed from the search adhering to the
most active vs. least active populations (e.g., seden- guidelines established by the Preferred Reporting
tary/inactive vs. physically active) were excluded. Items for Systematic Reviews and Meta-Analyses
Group (see Fig. 1) [13].

Screening
Two reviewers independently screened titles
(D.E.R.W. and S.S.D.B.) and abstracts of citations
to identify potential articles for inclusion and
removal of duplicate citations. The reviewers were
not blinded to authors or journals. References of key
studies and reviews in the field were cross-refer-
enced. Full-text versions of articles appearing
relevant were obtained, and data were extracted
with a common template. Full consensus was
achieved. Reasons for exclusion of articles after
full-article screening were recorded. The citations
and related electronic versions of the article (where
available) were downloaded to an online research
management system (Endnote; Clarivate Analytics,
Philadelphia, PA). Internal and external duplicates
KEY FINDINGS
Systematic reviews and meta-analyses
Our systematic search retrieved 1493 articles,
including 199 duplicates leaving a total of 1294
articles for review (see Fig. 1). An additional 16
articles were found through the authors’ knowledge
and cross-referencing. The title and abstracts of the
1310 articles were scanned and a total of 232 full-
text articles were assessed for eligibility. We ident-
ified 16 recent systematic reviews and/or meta-
analyses examining the dose–response relationship
between physical activity and health outcomes
(Table 2). These studies involved millions of partici-
pants and diverse clinical outcomes (including

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HCO 320510
Prevention
FIGURE 1. Results of the systematic review of the literature.
cardiovascular disease, all-cause mortality, all-can-
cer mortality, type 2 diabetes, hypertension, breast
cancer, colon cancer, gestational diabetes, gallstone
disease, ischemic heart disease, ischemic stroke, and
self-reported health status). There was uniform
agreement with all studies demonstrating a dose–
response relationship between physical activity and
health outcomes (see Table 2). In the majority of the
systematic reviews, the relationship was nonlinear
with the greatest relative risk reductions occurring
when moving from no (or limited) activity to small
volumes of physical activity (Fig. 2). These analyses
were limited somewhat with the failure to look at
extremely small volumes of physical activity; how-
ever, these systematic reviews consistently demon-
strated that no minimal threshold existed for health
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benefits. That is, simply moving more led to signifi-
cant health benefits. This relationship was generally
observed in adults; however, one systematic review
also established this relationship in adolescents.
DISCUSSION
To our knowledge our article is the first systematic
review of systematic reviews examining the dose–
response relationship between physical activity
and health status. Our systematic review revealed
that there was overwhelming evidence (based on
millions of participants) that regular physical
activity is associated with a reduced risk for all-
cause mortality and several chronic medical con-
ditions (including cardiovascular disease, all-cause
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 Table 2. Findings from identified systematic reviews and/or meta-analyses
Meta-analysis
(dose–response
Assessment of meth- analyses, if avail-
Reference Included studies (a) Participants (group) Outcome variable (a) odological quality able) Key findings Comments
&&
Aune et al. [14 ] 81 (78 cohort studies Total PA n ¼ 104 908 Type 2 diabetes Yes Yes Comparing high vs. low PA groups Low intensity PA led to similar risk
and 3 RCT) (adults) reductions for type 2 diabetes
Leisure-time PA Total PA (18 276 incident Total PA: RR ¼ 0.65 (95% CI 0.59–0.71) The greatest relative risk reduction was
n ¼ 1 820 188 (adults) cases) seen at low PA levels (below
international PA recommendations)
Change in PA n ¼ 93 371 Leisure-time PA (151 677 Leisure time PA: RR ¼ 0.74 (95% CI 0.70–0.79)
(adults) incident cases)
Vigorous intensity PA Change in PA (2711 Vigorous intensity PA: RR ¼ 0.61 (95% CI 0.51–
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n ¼ 272 599 (adults) incident cases) 0.74)

Moderate intensity PA Vigorous PA (17 062 Moderate intensity PA: RR ¼ 0.68 (95% CI 0.52–
n ¼ 184 067 (adults) incident cases) 0.90)
Low intensity PA Moderate PA (14 790 Low intensity PA: RR ¼ 0.66 (95% CI 0.47–0.94)
n ¼ 107 269 (adults) incident cases)
Walking n ¼ 326 779 Low PA (3856 incident Walking: RR ¼ 0.85 (95% CI 0.79–0.91)
(adults) cases)
Resistance Exercise Walking (11 032 incident Leisure-time PA: dose–response
n ¼ 131 318 (adults) cases)
Occupational PA Resistance Exercise (5 769 RR ¼ 0.85 (95% CI 0.81–0.89)/20 MET-h/week
n ¼ 91 139 (adults) incident cases)
Cardiorespiratory fitness Occupational PA (9246 RR ¼ 0.75 (95% CI 0.67–0.85)/5 h/week
n ¼ 38 870 (adults) incident cases)
RR ¼ 0.87 (95% CI 0.79–0.95)/1000 kcal/week
increase in energy expenditure. The relationship
was relatively linear across kcal expenditures
HCO 320510

Change in PA
RR ¼ 0.91 (95% CI 0.46–1.83) in studies where

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participants reduced their level of physical activity
RR ¼ 0.64 (95% CI 0.54–0.76) in studies where
participants increased their PA from low-to-
moderate or high levels
RR ¼ 0.59 (95% CI 0.50–0.70) where participants
had a consistently moderate-to-high level of PA
Vigorous intensity PA (>6 METs): comparing high vs.
low PA groups
RR ¼ 0.61 (95% CI 0.51–0.74)
RR ¼ 0.54 (95% CI 0.47–0.62) when two study
outliers were excluded from analyses
Vigorous intensity PA (>6 METs): dose–response
RR ¼ 0.69 (95% CI 0.58–0.82)/5 h/week
Moderate intensity PA (3–6 METs): comparing high
vs. low PA groups
RR ¼ 0.68 (95% CI 0.52–0.90)
Low-intensity PA: comparing high vs. low PA groups
RR ¼ 0.66 (95% CI 0.47–0.94)
RR ¼ 0.71 (95% CI 0.52–0.97)/5 h/week of low-
intensity PA
Walking: comparing high vs. low PA groups
RR ¼ 0.85 (95% CI 0.79–0.91)
Walking: dose–response

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Physical activity and health Warburton and Bredin

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 6
Table 2 (Continued)
Meta-analysis
(dose–response
Assessment of meth- analyses, if avail-
Prevention

Reference Included studies (a) Participants (group) Outcome variable (a) odological quality able) Key findings Comments

RR ¼ 0.95 (95% CI 0.88–1.02)/10 MET-h/week of

walking
RR ¼ 0.92 (95% CI 0.85–0.99)/2 h/week
Reductions in risk were seen up to 10–15 MET-h/
week or up to 2–3 h/week of walking/week
Resistance exercise
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RR ¼ 0.72 (95% CI 0.57–0.91) for high vs. low

resistance exercise

www.co-cardiology.com
RR ¼ 0.70 (95% CI 0.58–0.84)/5 h/week
Occupational PA
RR ¼ 0.85 (95% CI 0.79–0.92) for high vs. low
occupational PA
Cardiorespiratory fitness
RR ¼ 0.45 (95% CI 0.29–0.70) high vs. low
cardiorespiratory fitness
RR ¼ 0.74 (95% CI 0.56–0.98)/20 ml/kg/min
Nonlinear relations were observed for leisure-time PA,
vigorous PA, walking, and resistance exercise with
steeper reductions in type 2 diabetes risk at low PA
levels vs. high activity levels
&&
Aune et al. [15 ] 25 (12 RCT and 11 Total PA before pregnancy Gestational diabetes Yes Yes (dose–response Inverse association between physical activity before The authors provided further details
HCO 320510

cohort studies) (n ¼ 4607 adults) analyses) pregnancy and in early pregnancy and the risk for regarding the effects of combined
gestational diabetes prepregnancy and early pregnancy
PA, walking, intensity of PA,
occupational PA and household PA,
and PA and abnormal glucose
tolerance
Total PA during pregnancy Total PA before pregnancy Total PA before pregnancy Higher leisure-time PA before and
(n ¼ 3996 adults) (293 incident cases) during pregnancy was associated
with a significant reduction in the risk
for gestational diabetes (22 and
20%, respectively)
Leisure-time PA before Total PA during pregnancy High vs. low total PA: RR ¼ 0.62 (95% CI 0.41– The greatest relative benefits were
pregnancy (n ¼ 32 592 (244 incident cases) 0.94) observed at lower levels of PA
adults)
Leisure-time PA during Leisure-time PA before Total PA during pregnancy
pregnancy (n ¼ 9804 pregnancy (2401
adults) incident cases)
Leisure-time PA during High vs. low total PA: RR ¼ 0.66 (95% CI 0.36–
pregnancy (900 1.21)
incident cases)
Leisure-time PA before pregnancy
High vs. low PA (before pregnancy): RR ¼ 0.78
(95% CI 0.61–1.00)
High vs. low PA (during pregnancy): RR ¼ 0.80
(95% CI 0.64–1.00)
A nonlinear dose–response analysis revealed a
12% reduction in the relative risk of gestational
diabetes for 30 MET-h/week of prepregnancy PA
compared to no activity
There was a 30 and 37% risk reduction in 7 h/week
of PA at prepregnancy and during pregnancy,
respectively, vs. no activity

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 Table 2 (Continued)
Reference
Ekelund et al. [16]
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&&
Granger et al. [17 ] 11 (9 cross-sectional
&&
Hupin et al. [18 ] 9
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Included studies (a) Participants (group) Outcome variable (a)
16 (cohort) n ¼ 1 005 791 (adults) All-cause mortality (84 609 Yes
n ¼ 110 330 (adolescents) Self-reported health status
and 2 cohort)
n ¼ 122 417 (older adults; All-cause mortality (18 122 No
73 745 women and
48 672 men)
Meta-analysis
(dose–response
Assessment of meth- analyses, if avail-
odological quality able) Key findings
Yes (dose–response The included studies were generally rated of high
incident cases) analyses) quality
There was a dose–response relationship between
sitting time and mortality, which was attenuated by
PA
High levels of moderate intensity PA (approximately
60–75 min/day) eliminated the increased risk of
death associated with high sitting time
Those in the quartile including the lowest sitting time
(<4 h/day) and highest level of PA (>35.5 MET-h/
week) had the lowest risk. There was a 59% risk
reduction in this group in comparison to the lowest
quartile of physical activity [<2.5 MET-h/week]
and sitting >8 h/day)
PA Quartiles
Lowest quartile ¼ 2.5 MET-h/week (approximately
5 min of moderate intensity PA/day)
Second PA quartile ¼ 16 MET-h/week
(approximately 25–35 min of moderate intensity
PA/day)
Third PA Quartile ¼ 30 MET-h/week (approximately
50–65 min of moderate intensity PA/day)
Fourth PA Quartile ¼ 355 MET-h/week (about 60–
75 min of moderate intensity PA/day)
Yes No There was some inconsistency in the literature.
However, the majority of the studies (nine out of
11) reported a significant positive relationship
between physical activity and self-reported health
status in adolescents
Two studies also provided evidence of dose–
response relationship between physical activity and
self-reported health
Yes (dose–response A clear dose–response relationship was observed
incident cases) analyses) between PA and mortality
Low-volume PA [(1–499 MET-min/week (15 min/
day)] ¼ 22% reduction
Medium volume PA (500–999 MET-min; roughly
equivalent to 150 min/week MVPA) ¼ 28% risk
reduction
Comments
Data from more than 1 million
participants were included
Study focused on sedentary behavior
(and the mediating effects of PA)
The secondary analyses revealed a
dose-dependent relationship between
PA and the risk for all-cause mortality
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There was no evidence for a threshold
of benefit with reductions in risk being
observed with lower levels of PA
The data was grouped in quartiles
such that it was not feasible to fully
appreciate the effects of levels of
activity above the inactive state and
below 16 MET-h/week
HCO 320510
A key purpose of the systematic review
was to determine whether or not the
WHOs’ recommendation for
adolescents’ daily levels of PA (i.e., 5
to 17-year olds should engage in at
least 60 min of moderate or vigorous
physical activity/day) were
appropriate
Improvements in self-reported health
were observed at levels below current
physical activity recommendations
The authors emphasized the perils of
threshold-based messaging for
inactive/sedentary adolescents who
may find the target discouraging
The authors highlighted the need for
more standardization in PA
measurement in adolescents
The greatest relative health benefits
were observed when moving from the
inactive state to a more active state
No evidence of a minimal threshold
for health benefits
The greatest relative benefits were
seen at the end of the first 15 min of
MVPA
Physical activity and health Warburton and Bredin
 8
Table 2 (Continued)
Meta-analysis
(dose–response
Assessment of meth- analyses, if avail-
Prevention

Reference Included studies (a) Participants (group) Outcome variable (a) odological quality able) Key findings Comments

&
Kyu et al. [19 ] 174 (35 breast
cancer, 19 colon
Higher volume PA (1000 MET-min) ¼ 35% risk Authors argued that 15 min/day could
reduction be a ‘reasonable target dose’ for
older adults. They further
recommended a goal of 15 min of
MVPA 5 days/week
Breast cancer (n ¼ 3 142 Breast cancer, colon Yes Yes (dose–response Examined the association between total PA The greatest relative benefits were
182) cancer, type 2 diabetes, analyses) standardized as a continuous scale (MET-min/ seen at the lower volumes of PA
CE: Swati; HCO/320510; Total nos of Pages: 16;

cancer, 55 ischemic heart disease, week) and five outcomes (breast cancer, colon
diabetes, 43 ischemic strokes cancer, diabetes, ischemic heart disease, and

www.co-cardiology.com
ischemic heart (incident cases were not ischemic stroke)
disease, and 26 reported)
ischemic stroke; all
cohort studies)
Colon cancer Higher volumes of total PA (from multiple domains There was an attenuation of the
(n ¼ 4 651 286) including leisure time, occupation, domestic and benefits at total PA levels higher than
transportation) were associated with reduced risks 3000–4000 MET-min/week
for breast cancer, colon cancer, type 2 diabetes,
heart disease, and ischemic stroke
Diabetes (n ¼ 2 106 240) 0 MET-min/week) was used as the reference No evidence for a minimal threshold
category for assessing the continuous dose– for health benefits
response associations
Ischemic heart disease The major relative gains were seen at the lower Authors concluded that total physical
(n ¼ 1 838 930) levels of PA, with minimal decrease in the risk at activity (not just leisure time) should
levels of total PA more than 3000–4000 MET-min/ be several times higher than
HCO 320510

week recommended levels for greater

reductions in the risk for the five
chronic medical conditions. This
recommendation focuses on the
optimal benefits associated with the
five conditions
Ischemic stroke
(n ¼ 1573231)
Li Y. et al. [20] 32 Cohort studies n.r. Cancer mortality (59 362 Yes Yes (dose–response The highest PA group had a 20% lower risk of Prediagnosis PA level was inversely
incident cases) analyses) cancer vs. the lowest PA group [RR ¼ 0.80 (95% associated with risk of cancer death
CI ¼ 0.76–0.85)]
The highest PA group had a 20% lower risk of The greatest relative benefits were
cancer vs. the lowest PA group [RR ¼ 0.80 (95% seen at the lower volumes of PA
CI ¼ 0.76–0.85)]
The risk for cancer-related mortality was 15% lower No evidence for a minimal threshold
for PA vs. non/occasional PA [RR ¼ 0.85 (95% CI for health benefits
0.82–0.88]
There was a nonlinear relationship between
prediagnosis PA level and cancer-related mortality
An increase of 10 MET-h/week of prediagnosis PA
was associated with a 7% lower risk of all cancer
mortality (RR ¼ 0.93, 95% CI 0.91–0.95)
Li T. et al. [21] 71 Cohort studies n ¼ 3 985 164 Cancer mortality (66 995 Yes Yes (dose–response The most active individuals had a reduced risk for The greatest relative benefits were
incident cases) analyses) cancer mortality in general population (HR ¼ 0.83 seen at the lower volumes of PA
(95% CI 0.79–0.87) and among cancer survivors
(HR ¼ 0.78 (95% CI 0.74–0.84)
Meeting international PA recommendations reduced No evidence for a minimal threshold
the risk for cancer mortality by 13–14% for health benefits
Cancer survivors that engage in 15 MET-h/week of Importance of PA participation after
PA had a 27% lower risk of cancer mortality cancer diagnosis is established
The protective effect of PA was greater in cancer
survivors that undertook PA postdiagnosis (15 MET-
h/week ¼ 35% risk reduction) vs. prediagnosis (15

Volume 32  Number 00  Month 2017

MET-h/week ¼ 21% risk reduction)

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 Table 2 (Continued)
Meta-analysis
(dose–response
Assessment of meth- analyses, if avail-
Reference Included studies (a) Participants (group) Outcome variable (a) odological quality able) Key findings Comments

There was a curvilinear relationship between PA

and cancer mortality. The HR for cancer mortality
were 0.88, 0.86, 0.86, 0.85 and 0.84 following
5, 10, 15, 20 and 25 MET-h/week of recreational
PA, respectively, in comparison to inactivity
There was a steep dose–response curve at PA
volumes below international PA recommendations
(approximately 7.5 MET-h/week in this review) with
an attenuation at higher volumes
CE: Swati; HCO/320510; Total nos of Pages: 16;

There was an approximate 2% reduction in cancer

mortality for every 1 MET-h/week increase below
international PA recommendations (i.e., <7.5 MET-
h/week) compared to a 1% reduction for every 10
MET-h/week over 7.5 MET-h/week.
Similar inverse relationships were observed in Asian
participants
Liu et al. [22] 22 n ¼ 330 222 Hypertension (67 698 Yes Yes (dose–response The studies included were generally of a high Study provided greater insight into the
incident cases) analyses) quality dose–response relationship at PA
volumes that were at or above the
150 min/week MVPA target. The
linear dose–response suggest benefits
at lower volumes
There was a dose–response relationship between Authors concluded health benefits of
leisure time PA and total PA and incident PA can be achieved even at relatively
hypertension low levels of PA (<150 min/week)
HCO 320510

The risk for hypertension was reduced by 6% with There was no evidence of a threshold
each 10 MET-h/week increment of leisure-time PA effect
20 MET-h/week of leisure-time PA ¼ 12% risk

0268-4705 Copyright ß 2017 Wolters Kluwer Health, Inc. All rights reserved.
reduction
60 MET-h/week of leisure-time PA ¼ 33% risk
reduction
The risk for hypertension was reduced by 7%/50
MET h/week increment in total PA
Neilson et al. [23] 58 Premenopausal 26 Cohort studies Breast cancer Yes Yes (dose–response For premenopausal breast cancer, there was a 20% Included studies that only examined
(n ¼ 1 334 557) (premenopauasal and analyses) risk reduction [RR ¼ 0.80 (95% CI 0.74–0.87)] in moderate-vigorous recreational PA
postmenopausasal) the highest vs. lowest categories of MVPA (metabolic equivalent 3.0)
recreational PA
43 Postmenopausal 41 Case–control studies Cohort studies (44 712 For postmenopausal breast cancer, there was a Dose–response curves were generally
(n ¼ 246 112) incident cancer cases) 21% risk reduction [RR ¼ 0.79 (95% CI 0.74– nonlinear with greatest benefits at
0.84)] in the highest vs. lowest categories of MVPA lower PA volumes
recreational PA
Case–control studies The inverse associations were weaker in the findings Difficult to fully discern the effects of
(67 768 incident cancer from postmenopausal cohort studies and studies small volumes of moderate-vigorous
cases) that controlled for nonrecreational PA PA
Nonlinear, inverse relationships were observed
between moderate-vigorous recreational PA volume
(MET-h/week) and pre and postmenopausal breast
cancer risk. There was attenuation in the slope of
the relationship at approximately 25 MET-h/week
In overweight/obese women, there was an inverse
association with postmenopausal breast cancer risk
(RR ¼ 0.88 [95% CI ¼ 0.82–0.95], but no
association with premenopausal breast cancer risk
(RR ¼ 0.99 [95% CI 0.98–1.00])

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Dose–response curves were generally nonlinear
Physical activity and health Warburton and Bredin

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 Table 2 (Continued)

10
Meta-analysis
(dose–response
Assessment of meth- analyses, if avail-
Reference Included studies (a) Participants (group) Outcome variable (a) odological quality able) Key findings Comments
Prevention

Pandey et al. [24] 12 Cohort studies n ¼ 370 460 Heart failure (20 203 Yes Yes Authors looked at the relationship between PA and There was an inverse relationship with
incident cases) heart failure risk in individuals engaging in PA no evidence of a threshold for benefit
levels at international recommendations (500 MET-
min/week) and two times (1000 MET-min/week)
and four times (2000 MET-min/week) the
recommended levels
There was an inverse relationship between PA and Focus of study was on PA volumes at
heart failure or above international
recommendations. Low-volume PA
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was grouped with inactive data

Compared to the lowest PA category, the highest PA

www.co-cardiology.com
group had a 30% lower risk. The moderate and
light PA groups had 22 and 15% lower risks of
heart failure, respectively, in comparison to the
lowest PA group
In the dose–response analysis, participants meeting
international recommendations (approximately 500
MET-min/week) had a 10% risk reduction
(HR ¼ 0.90; 95% CI 0.87–0.92) vs. the lowest
active group
Those engaging in twice and four times the
recommendation had a 19% risk reduction
(HR ¼ 0.81; 95% CI 0.77–0.86) and 35%
(HR ¼ 0.65; 95% CI 0.58–0.73) lower risk of risk
of heart failure, respectively
Pizot et al. [25] 38 n ¼ 4 124 275 women Breast cancer (116 304 No Yes (dose–response The highest level of PA was associated with a risk A dose–response relationship was
HCO 320510

incident cases) analyses) reduction of 12% for all breast cancer, 11% for observed
ERþ/PRþ breast cancer, and 20% for ER/PR
breast cancer
Risk reductions were not affected by the type of PA There was no evidence of a threshold
(occupational or nonoccupational), adiposity, and effect
menopausal status
Engaging in 150 min/week of MVPA reduces the
lifetime risk of breast cancer by 9%
The usage of hormone replacement therapy
removed the benefits seen with routine physically
activity
Shi et al. [26] 30 (Case control and n ¼ 2 242 789 adults Cancer (33 949 incident Yes Yes Revealed an inverse dose dependent association No evidence for a minimal threshold
cohort) cases) between household PA and cancer risk for health benefits
(dose–response Individuals with the highest household PA had a Clear dose–response relationship
analyses) 16% reduced total cancer risk compared to those between household PA and cancer
with the lowest household PA (RR ¼ 0.84, 95% risk
CI ¼ 0.76–0.93)
The relative cancer risk was 2% (RR ¼ 0.98, 95%
CI ¼ 0.97–1.00) for/additional 10 MET-h/week
and 1% (RR ¼ 0.99, 95% CI ¼ 0.98–0.99) for/1
h/week increase
The majority (70%) of the studies were considered to
be of a higher quality
Smith et al. [27] 28 n ¼ 1 261 991 Type 2 diabetes (84 134 No Yes (dose–response There was a curvilinear dose–response relationship No evidence for a minimal threshold
incident cases) analyses) between leisure time PA and incident type 2 for health benefits
diabetes
(cohort) 2.25 MET-h/week ¼ 7% risk reduction [RR ¼ 0.93 The greatest relative benefits were
(95% CI 0.92, 0.95)] observed at the lowest levels of
activity
4.5 MET-h/week ¼ 13% risk reduction [RR ¼ 0.87 Additional benefits are seen at
(95% CI 0.84, 0.90)] physical activity levels far greater
than current intentional
recommendations (i.e., > 150 min/

Volume 32  Number 00  Month 2017

week MVPA)

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 Table 2 (Continued)
Meta-analysis
(dose–response
Assessment of meth- analyses, if avail-
Reference Included studies (a) Participants (group) Outcome variable (a) odological quality able) Key findings Comments

10.0 MET-h/week ¼ 23% [RR ¼ 0.76 (95% CI 0.71,

0.81)]
11.25 MET-h/week ¼ 26% risk reduction [RR ¼ 0.74
(95% CI 0.69, 0.80)]
22.5 MET-h/week ¼ 36% risk reduction [RR ¼ 0.64
(95% CI 0.56, 0.73)]
30.0 MET-h/week ¼ 40% risk reduction [RR ¼ 0.60
(95% CI 0.51, 0.70)]
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60 MET-h/week ¼ 53% risk reduction [RR ¼ 0.47

(95% CI 0.34, 0.65)]
Wahid et al. [28] 36 (33 CVD; 3 type 2 n ¼ 3 439 874 CVD and type 2 diabetes Yes Yes (dose–response Used a single continuous PA metric adjusting for The authors focused on an increase of
diabetes) (179 393 incident analyses) body weight 11.25 MET-h/week (roughly
cases) equivalent to moving from inactive
behavior to achieving international
PA recommendations). However,
smaller doses were associated with
marked health benefits
CVD specific CVD specific (89 493 Included studies that had measures of at least 2 or 4 The greatest relative health gains were
(n ¼ 1 683 693) incident cases) domains of total PA observed with small amounts of PA (in
comparison to no activity).
Diabetes specific Diabetes specific (19 417 The studies included were considered to be There was no evidence of a minimal
(n ¼ 261 618) incident cases) generally of higher quality threshold for benefit
Moving from inactive to recommended PA levels
(i.e., 150 min/week MVPA) lowered the risk for
CVD mortality [23%; RR ¼ 0.77 (95% CI (0.71–
HCO 320510

0.84)], CVD incidence [17%; RR ¼ 0.83 (95% CI

(0.83 (0.77–0.89)], and Type 2 diabetes [26%;

0268-4705 Copyright ß 2017 Wolters Kluwer Health, Inc. All rights reserved.
RR ¼ 0.74 (95% CI (0.72–0.77)]
Dose–response relationships were nonlinear
The greatest relative risk reductions were projected
to occur with small changes in PA volume. The
authors projected that an additional 6 MET-h/week
was associated with a risk reduction of
approximately 4.3%/MET-h/week for CVD
mortality and 1.7% for CVD incidence, respectively
The relative risk reductions were only marginally
attenuated after controlling for body weight
Zhang et al. [29] 16 (11 cohort and 5 n ¼ approximately 260 000 Gallstone disease Yes Yes (dose–response Higher levels of PA were associated with a reduced There is a dose–response relationship
case control) (approximately 16 000 analyses) risk for gallstone disease in men and women between PA and gallstone disease
cases) (despite study heterogeneity)
The highest level of physical activity had a 15% There is no evidence of a minimal
reduced risk for gallstone disease in comparison to threshold for benefit
the lowest active group (men ¼ 24%;
women ¼ 13%)
There was a 13% risk reduction [RR ¼ 0.87 (95%
CI, 0.83–0.92)] for gallstone disease with every
20 MET-h/week of recreational PA
There was no evidence of a nonlinear relationship in
the two studies included in the dose–response
meta-analysis

Total physical activity ¼ sum of leisure-time, occupational, and transport activity.

www.co-cardiology.com
CI, confidence interval, CVD, cardiovascular disease; HR, hazard ratio; PA, physical activity; MET, metabolic equivalent; MVPA, moderate-to-vigorous intensity physical activity; n.r., data not reported; RCT, randomized
controlled trial; RR, relative risk.
Physical activity and health Warburton and Bredin

11

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CE: Swati; HCO/320510; Total nos of Pages: 16;
HCO 320510
Prevention
FIGURE 2. Relative risk for mortality and morbidity as a
function of estimated physical activity volume (MET-h/week).
Consistent with the methodology of Hupin and colleagues
[18 ] we related relative risks (or hazard ratios) as a
&&
function of reported median or mean physical activity levels
(in MET-hr/week). When systematic reviews provided
physical activity levels in ranges we estimated the midpoint
value by calculating the mean for the upper and lower
bound. For open-ended categories (such as often seen in the
highest and lowest categories) we assumed that the interval
length to be similar to the adjacent category. Data was
estimated using dose-response figures provided within the
meta-analyses for two studies [20,23]. MET, metabolic
equivalent.
mortality, all-cancer mortality, type 2 diabetes, hy-
pertension, breast cancer, colon cancer, gestational
diabetes, gallstone disease, ischemic heart disease,
and ischemic stroke). There is preliminary evidence
to demonstrate that physical activity is positively
associated (in a dose-dependent fashion) with self-
&&
perceived health in adolescents [14 ].
The vast majority of the studies revealed non-
linear relationships between physical activity and
health outcomes such that the greatest relative
benefits are seen at lower doses of physical activity
(i.e., when moving from an inactive state to a more
active state) often with an attenuation of benefit at
higher volumes of physical activity. There does not
appear to be a threshold for these benefits with risk
reductions often being observed at physical activity
volumes far below current international recommen-
dations for adults or older adults. This finding also
appears to extend to adolescents with marked
improvements in self-perceived health occurring
at levels below current recommendations for chil-
dren and youth (i.e., at least 60 min/day of MVPA).
Based on our current systematic review of the liter-
ature it is apparent that multiple dose–response
curves may exist and the optimal and minimal
dosages likely vary based on the primary outcome
&
measure [1 ]. This is consistent with the early pro-
jections of Gledhill and Jamnik [30]. Further
research is clearly warranted to look at the various
12 www.co-cardiology.com
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dose–response relationships according to chronic
medical condition.
The findings of our systematic review of current
systematic reviews compares well with previous
findings. For instance, in 2010, we created two
systematic reviews of the literature regarding the
health benefits of routine physical activity in adults
[4] and older adults [5]. In these articles, we dem-
onstrated that international physical activity
recommendations were associated with 20–30% risk
reductions for various chronic medical conditions
and premature mortality and significant improve-
ments in functional independence and cognitive
function in the elderly. These risk reductions are
consistent with the findings from our current study.
In 2010, we also stated that it remained to be deter-
mined what the optimal and minimal volume of
physical activity is required for health benefits. It is
clear that physical activity participation at levels
consistent with international recommendations
can lead to marked health benefits and a reduced
risk for premature mortality and at least 25 chronic
medical conditions [4,12]. However, there is mount-
ing evidence that this volume of activity is not the
minimal level required for health benefits and may
even be closer to the optimal level (depending upon
&
the medical outcome) [1 ]. This is supported by our
current systematic review of systematic reviews
wherein the greatest risk reductions were seen at
the lower volumes of physical activity with an
attenuation at higher physical activity volumes.
This is supported by compelling cohort trials
designed to look specifically at very low volumes
of physical activity that indicate that simply moving
from an inactive state to any level of physical
activity participation is associated with the greatest
&
relative risk reductions [1 ]. For example, Moore
et al. [31] recently reported that any volume of
physical activity (i.e., 0.1–3.74 metabolic equivalent
(MET-h/week) of leisure time MVPA, equivalent to
75 min/week of brisk walking) led to 1.8 year of life
gained with further benefits at higher levels of
physical activity [e.g., 4.5 year of life gained at
22.5 and above MET-h/week (or brisk walking for
&&
450þ min/week)]. Arem et al. [7 ] also recently
found that any level of physical activity participa-
tion (i.e., 0.1 to <7.5 MET-h/week) resulted in 20%
mortality risk reduction, whereas meeting current
recommendations had a mortality benefit of 31%
that was closer to the optimal risk reduction (39%)
seen at 3–5 times the international physical activity
recommendation.
Our current systematic review (including diverse
clinical outcomes) directly refutes threshold-
centered physical activity messaging that implies
(or explicitly states) that one must reach the
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HCO 320510
(a)
(b)
FIGURE 3. Theoretical dose–response relationship between
physical activity/fitness and health status. (a) In individuals
who are physically inactive/unfit, a small change in physical
activity/fitness will lead to a significant improvement in
health status including a reduction in the risk for chronic
disease and premature mortality. Dashed line represents the
potential attenuation in health status seen in highly
(extremely) trained endurance athletes. (b) If current
messaging regarding physical activity [i.e., individuals
should engage in at least 150 min of weekly moderate to
vigorous physical activity (MVPA) for health benefits] were
evidence-based the shape of the dose-response curve (blue
line) would show a clear threshold at 150 min of MVPA
wherein the benefits are accrued. Thus, the relationship
would be ‘‘L-’’ or ‘‘S-’’ shaped. However, the overwhelming
evidence indicates that this not the case. Modified from
Bredin et al. [32] with permission. MVPA, moderate-to-
vigorous intensity physical activity.
150 min/week MVPA threshold for health benefits.
Generally, the relationship is curvilinear with the
greatest relative risk reductions being observed
when moving from the inactive to a more active
state. Threshold-based messaging that states that
one ‘must’ reach a certain level of physical activity
for health benefits to be achieved implies that the
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Physical activity and health Warburton and Bredin
relationship would be ‘S’ or ‘L’ shaped (see Fig. 3).
Yet, as shown in our systematic review of systematic
reviews there is limited evidence to support a
threshold for health benefits at a physical activity
dose of 150 min/week MVPA. As such, based on the
available evidence it would appear that the greatest
relative risk reductions are seen when inactive per-
sons simply become more physically active/fit. As
such, threshold-based physical activity messaging
does not appear to be evidence-based (the central
requirement for adoption within clinical practice).
Thus, caution should be employed when recom-
mending a specific physical activity volume for
diverse populations in particular inactive individ-
uals and/or those living with chronic medical con-
ditions who would benefit greatly from becoming
more physically active.
It is important to highlight that physical activity
recommendations were designed to optimize health
benefits rather than provide targets for minimal
dosages for health benefits [33]. Moreover, physical
activity recommendations provide an objective
classification for determining the prevalence of
physical activity/inactivity in contemporary society
&
for surveillances purposes [1 ,34]. These are import-
ant goals. Based on our current systematic review
&&
and the findings of other recent research [7 ] it
would appear that current international physical
activity guidelines provide a dosage of physical
activity that is very close to the optimal level for
health benefits. However, as discussed above there
has been a consistent knowledge translation error
wherein the general public is often given threshold-
centered messaging that indicates that health
benefits can only be accrued by meeting these tar-
gets. Statements such as ‘you should aim for’ have
been replaced with declarations such as ‘you need to
do’, ‘you must,’ or ‘you must engage in at least’
despite irrefutable evidence that strongly supports
the importance of simply becoming more physically
&
active [1 ]. Various experts have acknowledged the
limitations associated with threshold-based messag-
&
ing [1 ,11]. In two recent commentaries, Hupin et al.
[35,36] highlighted the marked mortality benefits
with relatively small changes in physical activity
(i.e., the first 15 min of MVPA was associated with
the greatest mortality benefit) in older adults. They
further discussed the perils of the inappropriate
translation of evidence to the general public when
they stated ‘Inappropriate information may prevent
people from taking up physical activity or discour-
age them from progressing at their own speed. No
medical treatment can influence as many diseases in
a positive manner as physical activity, so obscuring
health messages about exercise could be deleteri-
ous.’’ We echoed this sentiment in our earlier
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HCO 320510
Prevention
systematic reviews [4,12] and more recent reviews
&
[1 ,34,37].
For many individuals reaching the goal of
150 min/week of MVPA may not be feasible [9,10]
and ‘off-putting’ creating an unobtainable target for
a significant proportion of society [11]. Knox et al.
[11] estimated that the 150 min/week MVPA
threshold would translate into an increase in
physical activity behavior of 100–400%. The
authors also highlighted how threshold-centered
messaging has been associated with lower percep-
tions of health for lower volumes of physical activity
despite the potential for clear health benefits. A key
concern regarding this knowledge translation error
is the fostering of an ‘all or none’ and/or ‘one size fits
all approach’ to physical activity promotion [34].
A clear discord in messaging related to physical
activity and sedentary behavior guidelines has
&
been acknowledged [1 ,34,37]. In many instances,
threshold-based messaging related to both seden-
tary and physical activity behaviors are provided.
However, this messaging is contradictory consider-
ing the growing body of evidence that demonstrates
that simply replacing sedentary behaviors with light
intensity (1.6–2.9 METs) activity/exercise (even as
&
little as 6 min/h) has health benefits [38 ]. Similar to
&&
Hupin et al. [18 ], Sparling et al. [39] recently high-
lighted how many older adults find it difficult to
meet MVPA targets. They argued that a more appro-
priate message is to ‘reduce sedentary time and
increase light activities.’ Despres [40] recently stated
‘. . .it is clear that we should emphasize over and over
the importance of avoiding prolonged periods with-
out any physical activity, even if the volume of
physical activity or exercise does not meet the guide-
&&
lines.’ Granger et al. [17 ] reiterated this belief when
they stated that ‘a policy change to encourage sed-
entary adolescents to engage even in low levels of
physical activity would be beneficial.’ Egan [41]
recently highlighted that for those groups with a
history of sedentary and inactive lifestyles [particu-
larly in at-risk groups (such as minorities, women,
those with lower socioeconomic status, and the
elderly)] health promotion initiatives designed to
increase low-intensity physical activity may be more
likely to be adopted and sustained than longer
duration MVPA. Moreover, Egan [41] argued that
it might be easier for inactive and sedentary persons
to transition from low-intensity physical activity to
MVPA than to move directly from an inactive and
sedentary state to MVPA. This sentiment has been
repeated by leading experts including those
involved in the creation of national and/or inter-
national physical activity guidelines. Simple mes-
saging, such as ‘move more, sit less!’ is likely more
appropriate and evidence based than threshold-
14 www.co-cardiology.com
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based guidelines for diverse clientele across the
lifespan.
Generic physical activity guidelines have also
been criticized on various other grounds including
the inability to address the key determinants of
changes in healthy lifestyle behaviors [42–44]. It
is clear that physical activity guidelines are poorly
understood and/or adopted by the general popu-
lation [9,45–47]. Guidelines are also infrequently
used in clinical practice [9,10] and even by key
health and fitness organizations with a clear invest-
ment in physical activity guidelines [47]. Research-
ers have argued that the poor uptake of physical
activity guidelines is the result of the focus on health
outcomes and dosages rather than the key determi-
nants of healthy lifestyle behaviors. There has been a
concerted effort to move away from focusing on the
health benefits of physical activity in knowledge
translation resources to describing methods to
promote physical activity/exercise enjoyment and
adherence. Segar et al. [43] recently stated ‘there is a
need to identify new messages that can make
physical activity more relevant and compelling to
patients and the general population.’ There is strong
evidence that affective judgment constructs (such as
affective attitude, enjoyment, intrinsic motivation)
are key predictors of physical activity behavior
[48–50]. In particular, exercise enjoyment is a key
predictor of behavioral change [43]. Recent research
has consistently demonstrated that the promotion
of the positive affective benefits of routine physical
activity (such as ‘feeling good’) have a greater poten-
tial for eliciting behavioral change than messages
related to health (such as ‘if you meet the 150 min/
week MVPA target your will have better health’).
Some have argued that current international
physical activity recommendations need to be
revised to focus on affective constructs. We also
recently argued that physical activity promotion
should not be done in isolation but rather as an
integrated approach to healthy lifestyle behaviors
&
[1 ]. Also, given the evidence relating optimism and
life enjoyment to reduced risks for premature
mortality [51] further recommendations should
highlight how routine physical activity participa-
tion can enhance overall optimism [52,53].
It is also important to highlight that very short
bouts (and low volumes) of walking, jogging, or
higher intensity exercise can lead to marked health
benefits in apparently healthy individuals and
persons living with chronic medical conditions
[54–58]. This has led many to question current
physical activity guidelines for the lack of inclusive-
ness of diverse physical activity/exercise approaches
[56] that may be more attractive for a significant
proportion of society.
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HCO 320510
LIMITATIONS
Any systematic review of the physical activity liter-
ature must acknowledge the intrinsic errors associ-
ated with self-reported physical activity behavior
[34]. The vast majority of the studies assessed
physical activity via self-report which can frequently
lead to an overestimation of actual physical activity
&
levels by 50% or more [1 ,59–61]. This will there-
fore, affect any interpretations of this evidence.
Scientists uniformly acknowledge the limitations
in self-reported physical activity, but this is seldom
translated to the general public further widening
the knowledge translation gap. Given the current
findings of this systematic review and the level of
anticipated physical activity overestimation it is
likely that the actual dosage of physical activity
required to see optimal health benefits is even lower
than projected. Future research should use objective
measures to examine the health benefits of physical
activity across the continuum from extremely low-
to-high physical activity volumes.
Our systematic review included various system-
atic reviews that often included the same evidence. As
such, certain trials (particularly with multiple health
outcomes) would have greater effect. Also, few stud-
ies were included from low-to-middle income
countries, which will affect the transferability of
these findings to these regions. Moreover, not all
potentially confounding variables were controlled
for in each study. These are common limitations of
systematic reviews of this nature; however, the evi-
dence is overwhelmingly strong relating the dose–
response relationship between physical activity and
health status.
CONCLUSION
Our systematic review of recent systematic reviews
revealed that there is dose–response relationship
between physical activity and health status. The
relationship is generally curvilinear with the great-
est relative health benefits occurring at relatively
low physical activity volumes. There is limited evi-
dence to support a threshold of benefit, which
directly contradicts threshold-centered physical
activity messaging. Based on the current evidence
it is important to highlight that health benefits can
be achieved at physical activity volumes that are half
(or less) of the current international recommen-
dations. Recent advancements in the field suggest
that knowledge translation resources and recom-
mendations should focus on the key determinants
of healthy lifestyle behaviors rather than simply
health outcomes. Promoting the enjoyment gained
and the need to address multiple lifestyle behaviors
is a good first step toward promoting healthy living.
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Physical activity and health Warburton and Bredin
Acknowledgements
We would like to thank Nana Wu and Ricky Yanfei and
other students and staff members at the Systematic
Reviews Laboratory (University of British Columbia)
for their assistance.
The authors were responsible for creating the systematic
reviews (and related papers) that informed the 2011
Canadian Physical Activity Guidelines.
Financial support and sponsorship
D.E.R.W. and S.S.D.B.’s laboratories are supported by
the Canadian Institutes of Health Research, the Michael
Smith Foundation for Health Research, the Canadian
Foundation of Innovation, the BC Knowledge Develop-
ment Fund, MITACs, the Public Health Agency of Can-
ada, the Natural Sciences and Engineering Research
Council of Canada, GE Healthcare, and the BC Ministry
of Health.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. Warburton DE, Bredin SS. Reflections on physical activity and health: what
& should we recommend? Can J Cardiol 2016; 32:495–504.
The narrative review outlines the controversies surrounding threshold-based
physical activity messaging related to health benefits.
2. Warburton DE, Bredin SS, Jamnik V, et al. Consensus on evidence-based
preparticipation screening and risk stratification. In: Annual review of ger-
ontology and geriatrics. New York City, NY: Springer Publishing Company;
2016. pp. 53–102.
3. Colberg SR, Sigal RJ, Yardley JE, et al. Physical activity/exercise and
diabetes: a position statement of the american diabetes association. Diabetes
Care 2016; 39:2065–2079.
4. Warburton DE, Charlesworth S, Ivey A, et al. A systematic review of the
evidence for Canada’s physical activity guidelines for adults. Int J Behav Nutr
Phys Act 2010; 7:39.
5. Paterson DH, Warburton DE. Physical activity and functional limitations in
older adults: a systematic review related to Canada’s physical activity guide-
lines. Int J Behav Nutr Phys Act 2010; 7:38.
6. Myers J, McAuley P, Lavie CJ, et al. Physical activity and cardiorespiratory
fitness as major markers of cardiovascular risk: their independent and inter-
woven importance to health status. Prog Cardiovasc Dis 2015; 57:306–314.
7. Arem H, Moore SC, Patel A, et al. Leisure time physical activity and mortality: a
&& detailed pooled analysis of the dose-response relationship. JAMA Intern Med
2015; 175:959–967.
The article demonstrates that marked health benefits can be accrued at relatively
small physical activity volumes. The greatest relative risk reductions were seen at
the lower end of the physical activity continuum. The authors also noted that
meeting current recommendations had a mortality benefit that was closer to the
optimal risk reduction.
8. Sattelmair J, Pertman J, Ding EL, et al. Dose response between physical
activity and risk of coronary heart disease: a meta-analysis. Circulation 2011;
124:789–795.
9. Bredin SS, Warburton DE. Physical activity line: effective knowledge transla-
tion of evidence-based best practice in the real-world setting. Can Fam
Physician 2013; 59:967–968.
10. Bredin SS, Gledhill N, Jamnik VK, Warburton DE. PAR-Qþ and ePARmed-
Xþ: new risk stratification and physical activity clearance strategy for physi-
cians and patients alike. Can Fam Physician 2013; 59:273–277.
11. Knox EC, Webb OJ, Esliger DW, et al. Using threshold messages to promote
physical activity: implications for public perceptions of health effects. Eur J
Public Health 2014; 24:195–199.
www.co-cardiology.com 15
CE: Swati; HCO/320510; Total nos of Pages: 16;
HCO 320510
Prevention
12. Warburton DE, Katzmarzyk PT, Rhodes RE, Shephard RJ. Evidence-informed
physical activity guidelines for Canadian adults. Appl Physiol Nutr Metab
2007; 32:S16–S68.
13. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic
reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;
6:e1000097.
14. Aune D, Norat T, Leitzmann M, et al. Physical activity and the risk of type 2
&& diabetes: a systematic review and dose-response meta-analysis. Eur J Epi-
demiol 2015; 30:529–542.
The systematic review of the literature revealed that the greatest relative risk
reduction was seen at low physical activity levels (below international recommen-
dations).
15. Aune D, Sen A, Henriksen T, et al. Physical activity and the risk of gestational
&& diabetes mellitus: a systematic review and dose-response meta-analysis of
epidemiological studies. Eur J Epidemiol 2016; 31:967–997.
The systmatic review of the literature reported that the greatest relative benefits for
the prevention of gestational diabetes were observed with lower levels of physical
activity.
16. Ekelund U, Steene-Johannessen J, Brown WJ, et al., Lancet Sedentary
Behaviour Working Group. Does physical activity attenuate, or even eliminate,
the detrimental association of sitting time with mortality? A harmonised meta-
analysis of data from more than 1 million men and women. Lancet 2016;
388:1302–1310.
17. Granger E, Di Nardo F, Harrison A, et al. A systematic review of the relation-
&& ship of physical activity and health status in adolescents. Eur J Public Health
2017.
These authors demonstrated that volumes of physical activity below current
international recommendations can lead to improved perceptions of health in
adolescents.
18. Hupin D, Roche F, Gremeaux V, et al. Even a low-dose of moderate-to-
&& vigorous physical activity reduces mortality by 22% in adults aged 60 years:
a systematic review and meta-analysis. Br J Sports Med 2015; 49:
1262–1267.
The systematic review revealed that there was a curvilinear relationship between
physical activity and mortality in older adults with the greatest relative health
benefits being observed a low volumes (dosages) of physical activity. The largest
benefits were seen at the end of the first 15 min of MVPA.
19. Kyu HH, Bachman VF, Alexander LT, et al. Physical activity and risk of breast
& cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke
events: systematic review and dose-response meta-analysis for the Global
Burden of Disease Study 2013. BMJ 2016; 354:i3857.
The systematic review revealed the importance of routine physical activity for the
reduction of the risk for multiple chronic medical conditions.
20. Li Y, Gu M, Jing F, et al. Association between physical activity and all cancer
mortality: dose-response meta-analysis of cohort studies. Int J Cancer 2016;
138:818–832.
21. Li T, Wei S, Shi Y, et al. The dose-response effect of physical activity on
cancer mortality: findings from 71 prospective cohort studies. Br J Sports
Med 2016; 50:339–345.
22. Liu X, Zhang D, Liu Y, et al. Dose-response association between physical
activity and incident hypertension: a systematic review and meta-analysis of
cohort studies. Hypertension 2017; 69:813–820.
23. Neilson HK, Farris MS, Stone CR, et al. Moderate-vigorous recreational
physical activity and breast cancer risk, stratified by menopause status: a
systematic review and meta-analysis. Menopause 2017; 24:322–344.
24. Pandey A, Garg S, Khunger M, et al. Dose-response relationship between
physical activity and risk of heart failure: a meta-analysis. Circulation 2015;
132:1786–1794.
25. Pizot C, Mullie P, Koechlin A, et al. Physical activity, hormone replacement
therapy and breast cancer risk: a meta-analysis of prospective studies. Eur J
Cancer 2016; 52:138–154.
26. Shi Y, Li T, Wang Y, et al. Household physical activity and cancer risk: a
systematic review and dose-response meta-analysis of epidemiological stu-
dies. Sci Rep 2015; 5:14901.
27. Smith AD, Crippa A, Woodcock J, Brage S. Physical activity and incident type
2 diabetes mellitus: a systematic review and dose-response meta-analysis of
prospective cohort studies. Diabetologia 2016; 59:2527–2545.
28. Wahid A, Manek N, Nichols M, et al. Quantifying the association between
physical activity and cardiovascular disease and diabetes: a systematic review
and meta-analysis. J Am Heart Assoc 2016; 5:.
29. Zhang YP, Zhao YL, Sun YL, et al. Physical activity and the risk of gallstone
disease: a systematic review and meta-analysis. J Clin Gastroenterol 2016.
30. Gledhill N, Jamnik V. Canadian physical activity, fitness and lifestyle approach,
3rd ed. Ottawa: Canadian Society for Exercise Physiology; 2003.
31. Moore SC, Patel AV, Matthews CE, et al. Leisure time physical activity of
moderate to vigorous intensity and mortality: a large pooled cohort analysis.
PLoS Med 2012; 9:e1001335.
32. Bredin SS, Jamnik V, Gledhill N, Warburton DE. Effective pre-participation
screening and risk stratification. In: Warburton DE, editor. Health-related
exercise prescription for the qualified exercise professional, Sixth ed.
Vancouver: Health & Fitness Society of BC; 2016. pp. 1–30.
33. Wasfy MM, Baggish AL. Exercise dose in clinical practice. Circulation 2016;
133:2297–2313.
16 www.co-cardiology.com
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
34. Warburton DER, Bredin SSD. Lost in translation: what does the physical
activity and health evidence actually tell us? In: Zibadi S, Watson RR, editors.
Lifestyle in heart health and disease. San Diego, CA: Elsevier; 2017.
35. Hupin D, Edouard P, Gremeaux V, et al. We need clear health messages
about exercise. BMJ 2016; 355:i6252.
36. Hupin D, Edouard P, Gremeaux V, et al. Re: Physical activity and risk of breast
cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke
events: systematic review and dose-response meta-analysis for the Global
Burden of Disease Study 2013. Fifty Shades of Physical Activity: Follow
WHO Recommendations! BMJ 2016.
37. Warburton DE, Taunton J, Bredin SS, Isserow S. The risk-benefit paradox of
exercise. BC Med Assoc J 2016; 58:210–218.
38. Dempsey PC, Sacre JW, Larsen RN, et al. Interrupting prolonged sitting with
& brief bouts of light walking or simple resistance activities reduces resting
blood pressure and plasma noradrenaline in type 2 diabetes. J Hypertens
2016; 34:2376–2382.
The study revealed that interrupting sedentary behaviour (prolonged sitting) with
brief bouts (low doses) of light aerobic or resistance exercise resulted in improved
blood pressure and catecholamine responses in type 2 diabetics.
39. Sparling PB, Howard BJ, Dunstan DW, Owen N. Recommendations for
physical activity in older adults. BMJ 2015; 350:h100.
40. Despres JP. Physical activity, sedentary behaviours, and cardiovascular
health: when will cardiorespiratory fitness become a vital sign? Can J Cardiol
2016; 32:505–513.
41. Egan BM. Physical activity and hypertension: knowing is not enough; we must
apply. willing is not enough; we must Do-von Goethe. Hypertension 2017;
69:404–406.
42. Fortier M, Guerin E, Segar ML. Words matter: reframing exercise is medicine
for the general population to optimize motivation and create sustainable
behaviour change. Appl Physiol Nutr Metab 2016; 41:1212–1215.
43. Segar ML, Guerin E, Phillips E, Fortier M. From a vital sign to vitality: selling
exercise so patients want to buy it. Curr Sports Med Rep 2016; 15:276–281.
44. Segar ML, Richardson CR. Prescribing pleasure and meaning: cultivating
walking motivation and maintenance. Am J Prev Med 2014; 47:838–841.
45. LeBlanc AG, Berry T, Deshpande S, et al. Knowledge and awareness of
Canadian physical activity and sedentary behaviour guidelines: a synthesis of
existing evidence. Appl Physiol Nutr Metab 2015; 40:716–724.
46. Dale LP, LeBlanc AG, Orr K, et al. Canadian physical activity guidelines
for adults: are Canadians aware? Appl Physiol Nutr Metab 2016; 41:
1008–1011.
47. Gainforth HL, Berry T, Faulkner G, et al. Evaluating the uptake of Canada’s
new physical activity and sedentary behavior guidelines on service organiza-
tions’ websites. Transl Behav Med 2013; 3:172–179.
48. Rhodes RE, Fiala B. Building motivation and sustainability into the prescription
and recommendations for physical activity and exercise therapy: the evidence.
Physiother Theory Pract 2009; 25:424–441.
49. Rhodes RE, Fiala B, Conner M. A review and meta-analysis of affective
judgments and physical activity in adult populations. Ann Behav Med
2009; 38:180–204.
50. Rhodes RE, Quinlan A. Predictors of physical activity change among adults
using observational designs. Sports Med 2015; 45:423–441.
51. Kim ES, Hagan KA, Grodstein F, et al. Optimism and cause-specific mortality:
a prospective cohort study. Am J Epidemiol 2017; 185:21–29.
52. Koo JE, Lee GU. An effect of physical activity-based recreation programs on
children’s optimism, humor styles, and school life adjustment. J Exerc Rehabil
2015; 11:169–174.
53. Pavey TG, Burton NW, Brown WJ. Prospective relationships between phy-
sical activity and optimism in young and mid-aged women. J Phys Act Health
2015; 12:915–923.
54. Lee IM, Rexrode KM, Cook NR, et al. Physical activity and coronary
heart disease in women: is ‘no pain, no gain’ passe? JAMA 2001; 285:
1447–1454.
55. Wisloff U, Nilsen TI, Droyvold WB, et al. A single weekly bout of exercise may
reduce cardiovascular mortality: how little pain for cardiac gain? ’The HUNT
study, Norway’. Eur J Cardiovasc Prev Rehabil 2006; 13:798–804.
56. Jung ME, Bourne JE, Little JP. Where does HIT fit? An examination of the
affective response to high-intensity intervals in comparison to continuous
moderate and continuous vigorous-intensity exercise in the exercise intensity-
affect continuum. PLoS One 2014; 9:e114541.
57. Safiyari-Hafizi H, Taunton J, Ignaszewski A, Warburton DE. The health benefits
of a 12-week home-based interval training cardiac rehabilitation program in
patients with heart failure. Can J Cardiol 2016; 32:561–567.
58. Foulds HJ, Bredin SS, Charlesworth SA, et al. Exercise volume and intensity: a
dose-response relationship with health benefits. Eur J Appl Physiol 2014;
114:1563–1571.
59. Tucker JM, Welk GJ, Beyler NK. Physical activity in U.S.: adults compliance
with the physical activity guidelines for Americans. Am J Prev Med 2011;
40:454–461.
60. Statistics Canada. Canadian health measures survey cycle 2. Ottawa: Sta-
tistics Canada; 2012; 2012-09-20.
61. Prince SA, Adamo KB, Hamel ME, et al. A comparison of direct versus self-
report measures for assessing physical activity in adults: a systematic review.
Int J Behav Nutr Phys Act 2008; 5:56.
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