The primary purpose of this narrative review was to evaluate the current literature and to provide further insight into the role physical inactivity plays in the development of chronic disease and premature death. We confirm that there is irrefutable evidence of the effectiveness of regular physical activity in the primary and secondary prevention of several chronic diseases (e.g., cardiovascular disease, diabetes, cancer, hypertension, obesity, depression and osteoporosis) and premature death. We also reveal that the current Health Canada physical activity guidelines are sufficient to elicit health benefits, especially in previously sedentary people. There appears to be a linear relation between physical activity and health status, such that a further increase in physical activity and fitness will lead to additional improvements in health status. Read more about exipure healthy benefits.

Physical inactivity is a modifiable risk factor for cardiovascular disease and a widening variety of other chronic diseases, including diabetes mellitus, cancer (colon and breast), obesity, hypertension, bone and joint diseases (osteoporosis and osteoarthritis), and depression.1–14 The prevalence of physical inactivity (among 51% of adult Canadians) is higher than that of all other modifiable risk factors.15 In this article we review the current evidence relating to physical activity in the primary and secondary prevention of premature death from any cause, cardiovascular disease, diabetes, some cancers and osteoporosis. We also discuss the evidence relating to physical fitness and musculoskeletal fitness and briefly describe the independent effects of frequency and intensity of physical activity. (A glossary of terms related to the topic appears in Appendix 1). In a companion paper, to be published in the Mar. 28 issue, we will review how to evaluate the health-related physical fitness and activity levels of patients and will provide exercise recommendations for health. Check out the latest Java burn reviews.

Several authors have attempted to summarize the evidence in systematic reviews and meta-analyses. These evaluations are often overlapping (reviewing the same evidence). Some of the most commonly cited cohorts have been described in different studies over time as more data accumulate (see Appendix 2, available online at In this review, we searched the literature using the key words “physical activity,” “health,” “health status,” “fitness,” “exercise,” “chronic disease,” “mortality” and disease-specific terms (e.g., “cardiovascular disease,” “cancer,” “diabetes” and “osteoporosis”). Using our best judgment, we selected individual studies that were frequently included in systematic reviews, consensus statements and meta-analyses and considered them as examples of the best evidence available. We also have included important new findings regarding the relation between physical activity and fitness and all-cause and cardiovascular-related mortality.

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All-cause and cardiovascular-related death

Primary prevention

Since the seminal work of Morris and colleagues in the 1950s16,17 and the early work of Paffenbarger and colleagues in the 1970s,18,19 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., carciovascular disease) associated with physical inactivity.6,20–26

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%27,28) of death (see Appendix 2, available at 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).7

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.29 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.30 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 (see Fig. 1) may be at lower risk of premature death than people who are sedentary with no risk factors for cardiovascular disease.3133

Fig. 1: Relative risks of death from any cause among participants with various risk factors (e.g., history of hypertension, chronic obstructive pulmonary disease [COPD], diabetes, smoking, elevated body mass index [BMI ≥ 30] and high total cholesterol level [TC ≥ 5.70 mmol/L) who achieved an exercise capacity of less than 5 METs (metabolic equivalents) or 5–8 METs, as compared with participants whose exercise capacity was more than 8 METs. Error bars represent 95% confidence intervals. Adapted, with permission, from Myers et al38 (N Engl J Med 2002;346:793-801). Copyright © 2002 Massachusetts Medical Society. All rights reserved.

An increase in physical fitness will reduce the risk of premature death, and a decrease in physical fitness will increase the risk.34–37 The effect appears to be graded,34,35 such that even small improvements in physical fitness are associated with a significant reduction in risk (Fig. 2). In one study,35 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 (Fig. 2). Modest enhancements in physical fitness in previously sedentary people have been associated with large improvements in health status.38 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.36

Fig. 2: Relation between changes in physical fitness and changes in mortality over time. Participants were evaluated at baseline (PF1) and again 13 years later (PF2). The ratio of PF2/PF1 × 100 was calculated to evaluate changes in physical fitness over the study period compared with fitness level at baseline. For this figure, participants were grouped according to fitness quartiles (Q1 = least fit, Q4 = most fit) for the baseline evaluation and to quartiles for change in fitness from baseline to 13-year follow-up (Q1 PF2/PF1 = least change, Q4 PF2/PF1 = most change). Adapted, with permission, from Erikssen et al35 (Lancet 1998;352:759-62).

A recent systematic review of the literature regarding primary prevention in women39 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 (as discussed later).

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