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• Published: 16 November 2020

Exercise/physical activity and health outcomes: an overview of Cochrane systematic reviews

• Pawel Posadzki 1 , 2 ,
• Dawid Pieper   ORCID: orcid.org/0000-0002-0715-5182 3 ,
• Ram Bajpai 4 ,
• Hubert Makaruk 5 ,
• Nadja Könsgen 3 ,
• Annika Lena Neuhaus 3 &
• Monika Semwal 6  

BMC Public Health volume  20 , Article number:  1724 ( 2020 ) Cite this article

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Sedentary lifestyle is a major risk factor for noncommunicable diseases such as cardiovascular diseases, cancer and diabetes. It has been estimated that approximately 3.2 million deaths each year are attributable to insufficient levels of physical activity. We evaluated the available evidence from Cochrane systematic reviews (CSRs) on the effectiveness of exercise/physical activity for various health outcomes.

Overview and meta-analysis. The Cochrane Library was searched from 01.01.2000 to issue 1, 2019. No language restrictions were imposed. Only CSRs of randomised controlled trials (RCTs) were included. Both healthy individuals, those at risk of a disease, and medically compromised patients of any age and gender were eligible. We evaluated any type of exercise or physical activity interventions; against any types of controls; and measuring any type of health-related outcome measures. The AMSTAR-2 tool for assessing the methodological quality of the included studies was utilised.

Hundred and fifty CSRs met the inclusion criteria. There were 54 different conditions. Majority of CSRs were of high methodological quality. Hundred and thirty CSRs employed meta-analytic techniques and 20 did not. Limitations for studies were the most common reasons for downgrading the quality of the evidence. Based on 10 CSRs and 187 RCTs with 27,671 participants, there was a 13% reduction in mortality rates risk ratio (RR) 0.87 [95% confidence intervals (CI) 0.78 to 0.96]; I 2  = 26.6%, [prediction interval (PI) 0.70, 1.07], median effect size (MES) = 0.93 [interquartile range (IQR) 0.81, 1.00]. Data from 15 CSRs and 408 RCTs with 32,984 participants showed a small improvement in quality of life (QOL) standardised mean difference (SMD) 0.18 [95% CI 0.08, 0.28]; I 2  = 74.3%; PI -0.18, 0.53], MES = 0.20 [IQR 0.07, 0.39]. Subgroup analyses by the type of condition showed that the magnitude of effect size was the largest among patients with mental health conditions.

There is a plethora of CSRs evaluating the effectiveness of physical activity/exercise. The evidence suggests that physical activity/exercise reduces mortality rates and improves QOL with minimal or no safety concerns.

Trial registration

Registered in PROSPERO ( CRD42019120295 ) on 10th January 2019.

Peer Review reports

The World Health Organization (WHO) defines physical activity “as any bodily movement produced by skeletal muscles that requires energy expenditure” [ 1 ]. Therefore, physical activity is not only limited to sports but also includes walking, running, swimming, gymnastics, dance, ball games, and martial arts, for example. In the last years, several organizations have published or updated their guidelines on physical activity. For example, the Physical Activity Guidelines for Americans, 2nd edition, provides information and guidance on the types and amounts of physical activity that provide substantial health benefits [ 2 ]. The evidence about the health benefits of regular physical activity is well established and so are the risks of sedentary behaviour [ 2 ]. Exercise is dose dependent, meaning that people who achieve cumulative levels several times higher than the current recommended minimum level have a significant reduction in the risk of breast cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke events [ 3 ]. Benefits of physical activity have been reported for numerous outcomes such as mortality [ 4 , 5 ], cognitive and physical decline [ 5 , 6 , 7 ], glycaemic control [ 8 , 9 ], pain and disability [ 10 , 11 ], muscle and bone strength [ 12 ], depressive symptoms [ 13 ], and functional mobility and well-being [ 14 , 15 ]. Overall benefits of exercise apply to all bodily systems including immunological [ 16 ], musculoskeletal [ 17 ], respiratory [ 18 ], and hormonal [ 19 ]. Specifically for the cardiovascular system, exercise increases fatty acid oxidation, cardiac output, vascular smooth muscle relaxation, endothelial nitric oxide synthase expression and nitric oxide availability, improves plasma lipid profiles [ 15 ] while at the same time reducing resting heart rate and blood pressure, aortic valve calcification, and vascular resistance [ 20 ].

However, the degree of all the above-highlighted benefits vary considerably depending on individual fitness levels, types of populations, age groups and the intensity of different physical activities/exercises [ 21 ]. The majority of guidelines in different countries recommend a goal of 150 min/week of moderate-intensity aerobic physical activity (or equivalent of 75 min of vigorous-intensity) [ 22 ] with differences for cardiovascular disease [ 23 ] or obesity prevention [ 24 ] or age groups [ 25 ].

There is a plethora of systematic reviews published by the Cochrane Library critically evaluating the effectiveness of physical activity/exercise for various health outcomes. Cochrane systematic reviews (CSRs) are known to be a source of high-quality evidence. Thus, it is not only timely but relevant to evaluate the current knowledge, and determine the quality of the evidence-base, and the magnitude of the effect sizes given the negative lifestyle changes and rising physical inactivity-related burden of diseases. This overview will identify the breadth and scope to which CSRs have appraised the evidence for exercise on health outcomes; and this will help in directing future guidelines and identifying current gaps in the literature.

The objectives of this research were to a. answer the following research questions: in children, adolescents and adults (both healthy and medically compromised) what are the effects (and adverse effects) of exercise/physical activity in improving various health outcomes (e.g., pain, function, quality of life) reported in CSRs; b. estimate the magnitude of the effects by pooling the results quantitatively; c. evaluate the strength and quality of the existing evidence; and d. create recommendations for future researchers, patients, and clinicians.

Our overview was registered with PROSPERO (CRD42019120295) on 10th January 2019. The Cochrane Handbook for Systematic Reviews of interventions and Preferred Reporting Items for Overviews of Reviews were adhered to while writing and reporting this overview [ 26 , 27 ].

Search strategy and selection criteria

We followed the practical guidance for conducting overviews of reviews of health care interventions [ 28 ] and searched the Cochrane Database of Systematic Reviews (CDSR), 2019, Issue 1, on the Cochrane Library for relevant papers using the search strategy: (health) and (exercise or activity or physical). The decision to seek CSRs only was based on three main aspects. First, high quality (CSRs are considered to be the ‘gold methodological standard’) [ 29 , 30 , 31 ]. Second, data saturation (enough high-quality evidence to reach meaningful conclusions based on CSRs only). Third, including non-CSRs would have heavily increased the issue of overlapping reviews (also affecting data robustness and credibility of conclusions). One reviewer carried out the searches. The study screening and selection process were performed independently by two reviewers. We imported all identified references into reference manager software EndNote (X8). Any disagreements were resolved by discussion between the authors with third overview author acting as an arbiter, if necessary.

We included CSRs of randomised controlled trials (RCTs) involving both healthy individuals and medically compromised patients of any age and gender. Only CSRs assessing exercise or physical activity as a stand-alone intervention were included. This included interventions that could initially be taught by a professional or involve ongoing supervision (the WHO definition). Complex interventions e.g., assessing both exercise/physical activity and behavioural changes were excluded if the health effects of the interventions could not have been attributed to exercise distinctly.

Any types of controls were admissible. Reviews evaluating any type of health-related outcome measures were deemed eligible. However, we excluded protocols or/and CSRs that have been withdrawn from the Cochrane Library as well as reviews with no included studies.

Data analysis

Three authors (HM, ALN, NK) independently extracted relevant information from all the included studies using a custom-made data collection form. The methodological quality of SRs included was independently evaluated by same reviewers using the AMSTAR-2 tool [ 32 ]. Any disagreements on data extraction or CSR quality were resolved by discussion. The entire dataset was validated by three authors (PP, MS, DP) and any discrepant opinions were settled through discussions.

The results of CSRs are presented in a narrative fashion using descriptive tables. Where feasible, we presented outcome measures across CSRs. Data from the subset of homogeneous outcomes were pooled quantitatively using the approach previously described by Bellou et al. and Posadzki et al. [ 33 , 34 ]. For mortality and quality of life (QOL) outcomes, the number of participants and RCTs involved in the meta-analysis, summary effect sizes [with 95% confidence intervals (CI)] using random-effects model were calculated. For binary outcomes, we considered relative risks (RRs) as surrogate measures of the corresponding odds ratio (OR) or risk ratio/hazard ratio (HR). To stabilise the variance and normalise the distributions, we transformed RRs into their natural logarithms before pooling the data (a variation was allowed, however, it did not change interpretation of results) [ 35 ]. The standard error (SE) of the natural logarithm of RR was derived from the corresponding CIs, which was either provided in the study or calculated with standard formulas [ 36 ]. Binary outcomes reported as risk difference (RD) were also meta-analysed if two more estimates were available. For continuous outcomes, we only meta-analysed estimates that were available as standardised mean difference (SMD), and estimates reported with mean differences (MD) for QOL were presented separately in a supplementary Table  9 . To estimate the overall effect size, each study was weighted by the reciprocal of its variance. Random-effects meta-analysis, using DerSimonian and Laird method [ 37 ] was applied to individual CSR estimates to obtain a pooled summary estimate for RR or SMD. The 95% prediction interval (PI) was also calculated (where ≥3 studies were available), which further accounts for between-study heterogeneity and estimates the uncertainty around the effect that would be anticipated in a new study evaluating that same association. I -squared statistic was used to measure between study heterogeneity; and its various thresholds (small, substantial and considerable) were interpreted considering the size and direction of effects and the p -value from Cochran’s Q test ( p  < 0.1 considered as significance) [ 38 ]. Wherever possible, we calculated the median effect size (with interquartile range [IQR]) of each CSR to interpret the direction and magnitude of the effect size. Sub-group analyses are planned for type and intensity of the intervention; age group; gender; type and/or severity of the condition, risk of bias in RCTs, and the overall quality of the evidence (Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria). To assess overlap we calculated the corrected covered area (CCA) [ 39 ]. All statistical analyses were conducted on Stata statistical software version 15.2 (StataCorp LLC, College Station, Texas, USA).

The searches generated 280 potentially relevant CRSs. After removing of duplicates and screening, a total of 150 CSRs met our eligibility criteria [ 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 , 133 , 134 , 135 , 136 , 137 , 138 , 139 , 140 , 141 , 142 , 143 , 144 , 145 , 146 , 147 , 148 , 149 , 150 , 151 , 152 , 153 , 154 , 155 , 156 , 157 , 158 , 159 , 160 , 161 , 162 , 163 , 164 , 165 , 166 , 167 , 168 , 169 , 170 , 171 , 172 , 173 , 174 , 175 , 176 , 177 , 178 , 179 , 180 , 181 , 182 , 183 , 184 , 185 , 186 , 187 , 188 , 189 ] (Fig.  1 ). Reviews were published between September 2002 and December 2018. A total of 130 CSRs employed meta-analytic techniques and 20 did not. The total number of RCTs in the CSRs amounted to 2888; with 485,110 participants (mean = 3234, SD = 13,272). The age ranged from 3 to 87 and gender distribution was inestimable. The main characteristics of included reviews are summarised in supplementary Table  1 . Supplementary Table  2 summarises the effects of physical activity/exercise on health outcomes. Conclusions from CSRs are listed in supplementary Table  3 . Adverse effects are listed in supplementary Table  4 . Supplementary Table  5 presents summary of withdrawals/non-adherence. The methodological quality of CSRs is presented in supplementary Table  6 . Supplementary Table  7 summarises studies assessed at low risk of bias (by the authors of CSRs). GRADE-ings of the review’s main comparison are listed in supplementary Table  8 .

Study selection process

There were 54 separate populations/conditions, considerable range of interventions and comparators, co-interventions, and outcome measures. For detailed description of interventions, please refer to the supplementary tables . Most commonly measured outcomes were - function 112 (75%), QOL 83 (55%), AEs 70 (47%), pain 41 (27%), mortality 28 (19%), strength 30 (20%), costs 47 (31%), disability 14 (9%), and mental health in 35 (23%) CSRs.

There was a 13% reduction in mortality rates risk ratio (RR) 0.87 [95% CI 0.78 to 0.96]; I 2  = 26.6%, [PI 0.70, 1.07], median effect size (MES) = 0.93 [interquartile range (IQR) 0.81, 1.00]; 10 CSRs, 187 RCTs, 27,671 participants) following exercise when compared with various controls (Table 1 ). This reduction was smaller in ‘other groups’ of patients when compared to cardiovascular diseases (CVD) patients - RR 0.97 [95% CI 0.65, 1.45] versus 0.85 [0.76, 0.96] respectively. The effects of exercise were not intensity or frequency dependent. Sessions more than 3 times per week exerted a smaller reduction in mortality as compared with sessions of less than 3 times per week RR 0.87 [95% CI 0.78, 0.98] versus 0.63 [0.39, 1.00]. Subgroup analyses by risk of bias (ROB) in RCTs showed that RCTs at low ROB exerted smaller reductions in mortality when compared to RCTs at an unclear or high ROB, RR 0.90 [95% CI 0.78, 1.02] versus 0.72 [0.42, 1.22] versus 0.86 [0.69, 1.06] respectively. CSRs with moderate quality of evidence (GRADE), showed slightly smaller reductions in mortality when compared with CSRs that relied on very low to low quality evidence RR 0.88 [95% CI 0.79, 0.98] versus 0.70 [0.47, 1.04].

Exercise also showed an improvement in QOL, standardised mean difference (SMD) 0.18 [95% CI 0.08, 0.28]; I 2  = 74.3%; PI -0.18, 0.53], MES = 0.20 [IQR 0.07, 0.39]; 15 CSRs, 408 RCTs, 32,984 participants) when compared with various controls (Table 2 ). These improvements were greater observed for health related QOL when compared to overall QOL SMD 0.30 [95% CI 0.21, 0.39] vs 0.06 [− 0.08, 0.20] respectively. Again, the effects of exercise were duration and frequency dependent. For instance, sessions of more than 90 mins exerted a greater improvement in QOL as compared with sessions up to 90 min SMD 0.24 [95% CI 0.11, 0.37] versus 0.22 [− 0.30, 0.74]. Subgroup analyses by the type of condition showed that the magnitude of effect was the largest among patients with mental health conditions, followed by CVD and cancer. Physical activity exerted negative effects on QOL in patients with respiratory conditions (2 CSRs, 20 RCTs with 601 patients; SMD -0.97 [95% CI -1.43, 0.57]; I 2  = 87.8%; MES = -0.46 [IQR-0.97, 0.05]). Subgroup analyses by risk of bias (ROB) in RCTs showed that RCTs at low or unclear ROB exerted greater improvements in QOL when compared to RCTs at a high ROB SMD 0.21 [95% CI 0.10, 0.31] versus 0.17 [0.03, 0.31]. Analogically, CSRs with moderate to high quality of evidence showed slightly greater improvements in QOL when compared with CSRs that relied on very low to low quality evidence SMD 0.19 [95% CI 0.05, 0.33] versus 0.15 [− 0.02, 0.32]. Please also see supplementary Table  9 more studies reporting QOL outcomes as mean difference (not quantitatively synthesised herein).

Adverse events (AEs) were reported in 100 (66.6%) CSRs; and not reported in 50 (33.3%). The number of AEs ranged from 0 to 84 in the CSRs. The number was inestimable in 83 (55.3%) CSRs. Ten (6.6%) reported no occurrence of AEs. Mild AEs were reported in 28 (18.6%) CSRs, moderate in 9 (6%) and serious/severe in 20 (13.3%). There were 10 deaths and in majority of instances, the causality was not attributed to exercise. For this outcome, we were unable to pool the data as effect sizes were too heterogeneous (Table 3 ).

In 38 CSRs, the total number of trials reporting withdrawals/non-adherence was inestimable. There were different ways of reporting it such as adherence or attrition (high in 23.3% of CSRs) as well as various effect estimates including %, range, total numbers, MD, RD, RR, OR, mean and SD. The overall pooled estimates are reported in Table 3 .

Of all 16 domains of the AMSTAR-2 tool, 1876 (78.1%) scored ‘yes’, 76 (3.1%) ‘partial yes’; 375 (15.6%) ‘no’, and ‘not applicable’ in 25 (1%) CSRs. Ninety-six CSRs (64%) were scored as ‘no’ on reporting sources of funding for the studies followed by 88 (58.6%) failing to explain the selection of study designs for inclusion. One CSR (0.6%) each were judged as ‘no’ for reporting any potential sources of conflict of interest, including any funding for conducting the review as well for performing study selection in duplicate.

In 102 (68%) CSRs, there was predominantly a high risk of bias in RCTs. In 9 (6%) studies, this was reported as a range, e.g., low or unclear or low to high. Two CSRs used different terminology i.e., moderate methodological quality; and the risk of bias was inestimable in one CSR. Sixteen (10.6%) CSRs did not identify any studies (RCTs) at low risk of random sequence generation, 28 (18.6%) allocation concealment, 28 (18.6%) performance bias, 84 (54%) detection bias, 35 (23.3%) attrition bias, 18 (12%) reporting bias, and 29 (19.3%) other bias.

In 114 (76%) CSRs, limitation of studies was the main reason for downgrading the quality of the evidence followed by imprecision in 98 (65.3%) and inconsistency in 68 (45.3%). Publication bias was the least frequent reason for downgrading in 26 (17.3%) CSRs. Ninety-one (60.7%) CSRs reached equivocal conclusions, 49 (32.7%) reviews reached positive conclusions and 10 (6.7%) reached negative conclusions (as judged by the authors of CSRs).

In this systematic review of CSRs, we found a large body of evidence on the beneficial effects of physical activity/exercise on health outcomes in a wide range of heterogeneous populations. Our data shows a 13% reduction in mortality rates among 27,671 participants, and a small improvement in QOL and health-related QOL following various modes of physical activity/exercises. This means that both healthy individuals and medically compromised patients can significantly improve function, physical and mental health; or reduce pain and disability by exercising more [ 190 ]. In line with previous findings [ 191 , 192 , 193 , 194 ], where a dose-specific reduction in mortality has been found, our data shows a greater reduction in mortality in studies with longer follow-up (> 12 months) as compared to those with shorter follow-up (< 12 months). Interestingly, we found a consistent pattern in the findings, the higher the quality of evidence and the lower the risk of bias in primary studies, the smaller reductions in mortality. This pattern is observational in nature and cannot be over-generalised; however this might mean less certainty in the estimates measured. Furthermore, we found that the magnitude of the effect size was the largest among patients with mental health conditions. A possible mechanism of action may involve elevated levels of brain-derived neurotrophic factor or beta-endorphins [ 195 ].

We found the issue of poor reporting or underreporting of adherence/withdrawals in over a quarter of CSRs (25.3%). This is crucial both for improving the accuracy of the estimates at the RCT level as well as maintaining high levels of physical activity and associated health benefits at the population level.

Even the most promising interventions are not entirely risk-free; and some minor AEs such as post-exercise pain and soreness or discomfort related to physical activity/exercise have been reported. These were typically transient; resolved within a few days; and comparable between exercise and various control groups. However worryingly, the issue of poor reporting or underreporting of AEs has been observed in one third of the CSRs. Transparent reporting of AEs is crucial for identifying patients at risk and mitigating any potential negative or unintended consequences of the interventions.

High risk of bias of the RCTs evaluated was evident in more than two thirds of the CSRs. For example, more than half of reviews identified high risk of detection bias as a major source of bias suggesting that lack of blinding is still an issue in trials of behavioural interventions. Other shortcomings included insufficiently described randomisation and allocation concealment methods and often poor outcome reporting. This highlights the methodological challenges in RCTs of exercise and the need to counterbalance those with the underlying aim of strengthening internal and external validity of these trials.

Overall, high risk of bias in the primary trials was the main reason for downgrading the quality of the evidence using the GRADE criteria. Imprecision was frequently an issue, meaning the effective sample size was often small; studies were underpowered to detect the between-group differences. Pooling too heterogeneous results often resulted in inconsistent findings and inability to draw any meaningful conclusions. Indirectness and publication bias were lesser common reasons for downgrading. However, with regards to the latter, the generally accepted minimum number of 10 studies needed for quantitatively estimate the funnel plot asymmetry was not present in 69 (46%) CSRs.

Strengths of this research are the inclusion of large number of ‘gold standard’ systematic reviews, robust screening, data extractions and critical methodological appraisal. Nevertheless, some weaknesses need to be highlighted when interpreting findings of this overview. For instance, some of these CSRs analysed the same primary studies (RCTs) but, arrived at slightly different conclusions. Using, the Pieper et al. [ 39 ] formula, the amount of overlap ranged from 0.01% for AEs to 0.2% for adherence, which indicates slight overlap. All CSRs are vulnerable to publication bias [ 196 ] - hence the conclusions generated by them may be false-positive. Also, exercise was sometimes part of a complex intervention; and the effects of physical activity could not be distinguished from co-interventions. Often there were confounding effects of diet, educational, behavioural or lifestyle interventions; selection, and measurement bias were inevitably inherited in this overview too. Also, including CSRs only might lead to selection bias; and excluding reviews published before 2000 might limit the overall completeness and applicability of the evidence. A future update should consider these limitations, and in particular also including non-CSRs.

Conclusions

Trialists must improve the quality of primary studies. At the same time, strict compliance with the reporting standards should be enforced. Authors of CSRs should better explain eligibility criteria and report sources of funding for the primary studies. There are still insufficient physical activity trends worldwide amongst all age groups; and scalable interventions aimed at increasing physical activity levels should be prioritized [ 197 ]. Hence, policymakers and practitioners need to design and implement comprehensive and coordinated strategies aimed at targeting physical activity programs/interventions, health promotion and disease prevention campaigns at local, regional, national, and international levels [ 198 ].

Availability of data and materials

Data sharing is not applicable to this article as no raw data were analysed during the current study. All information in this article is based on published systematic reviews.

Abbreviations

Adverse events

Cardiovascular diseases

Cochrane Database of Systematic Reviews

Cochrane systematic reviews

Confidence interval

Grading of Recommendations Assessment, Development and Evaluation

Hazard ratio

Interquartile range

Mean difference

Prediction interval

Quality of life

Randomised controlled trials

Relative risk

Risk difference

Risk of bias

Standard error

Standardised mean difference

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PP wrote the protocol, ran the searches, validated, analysed and synthesised data, wrote and revised the drafts. HM, NK and ALN screened and extracted data. MS and DP validated and analysed the data. RB ran statistical analyses. All authors contributed to writing and reviewing the manuscript. PP is the guarantor. The authors read and approved the final manuscript.

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Additional file 1:.

Supplementary Table 1. Main characteristics of included Cochrane systematic reviews evaluating the effects of physical activity/exercise on health outcomes ( n  = 150). Supplementary Table 2. Additional information from Cochrane systematic reviews of the effects of physical activity/exercise on health outcomes ( n  = 150). Supplementary Table 3. Conclusions from Cochrane systematic reviews “quote”. Supplementary Table 4 . AEs reported in Cochrane systematic reviews. Supplementary Table 5. Summary of withdrawals/non-adherence. Supplementary Table 6. Methodological quality assessment of the included Cochrane reviews with AMSTAR-2. Supplementary Table 7. Number of studies assessed as low risk of bias per domain. Supplementary Table 8. GRADE for the review’s main comparison. Supplementary Table 9. Studies reporting quality of life outcomes as mean difference.

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Posadzki, P., Pieper, D., Bajpai, R. et al. Exercise/physical activity and health outcomes: an overview of Cochrane systematic reviews. BMC Public Health 20 , 1724 (2020). https://doi.org/10.1186/s12889-020-09855-3

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Article Contents

Cardiovascular and associated metabolic disease.

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Physical activity and health: current issues and research needs

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Adrianne E Hardman, Physical activity and health: current issues and research needs, International Journal of Epidemiology , Volume 30, Issue 5, October 2001, Pages 1193–1197, https://doi.org/10.1093/ije/30.5.1193

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A substantial body of evidence now demonstrates the burden of ill-health attributable to sedentary living. This is most compelling for coronary heart disease (CHD) and, combined with the high prevalence of inactivity, 1 provides the rationale for Professor Morris's claim that exercise is 'today's best buy in public health'. 2 Besides a reduced risk of CHD, evidence is secure for many other health gains from physical activity; these include a reduced risk of stroke, 3, 4 type II diabetes, 5, 6 colon cancer, 7, 8 and hip fracture. 9, 10 There is evidence enough to justify the further development of public health policies to promote physical activity. The difficulty is with the specifics of what to promote and prescribe.

This paper is concerned with future contributions by research to an evidence-based rationale for exercise recommendations—both to the public at large and to individuals. It is clear that physically active people have a lower disease risk than sedentary individuals but the components of activity which determine particular health gains are poorly understood. Thus the 'dose-response' relationships for physical activity are the subject of current research interest. Intuitively, these will not be the same for different health outcomes and this is one reason why further study of the associated mechanisms is important. Understanding the underlying mechanisms will clarify the relative importance of intensity, frequency, duration and mode of exercise for specified health gains. It will also help us to distinguish the effects of exercise per se from those of co-existing behaviours and to identify stages of life during which levels of particular types of activity are critical for given health outcomes. This paper presents a personal view of research needs.

How important is intensity?

The rate of energy expenditure (in oxygen uptake units) of common physical activities is expressed in METS. One MET is equivalent to the resting metabolic rate, assumed to be 3.5 ml oxygen per kg of body mass per minute.

Oxygen uptake reserve is obtained by subtracting one MET (3.5 ml . kg .–1 min –1 ) from the maximal oxygen uptake.

Its importance in the epidemiology of physical activity is evidenced by data from British civil servants. 12 Whereas only frequent vigorous exercise (defined as liable to entail peaks of energy expenditure of ≥7.5 kcal.min –1 [31.5 kJ.min –1 ]) was associated with protection against heart attack in men aged 45–54 at entry, there was a dose-response relationship for a lesser degree of such exercise (either <2 sessions per week or not so intense, e.g. 'fairly brisk' walking for >30 min. per day) among older men aged 55–64 at entry. Thus, for example, older men reporting moderately intense activity such as 'much stair climbing' (not judged sufficiently vigorous to be included in the 'vigorous aerobic' cluster of activities) showed a coronary rate which was significantly lower than that in less active men. Protection among younger men was limited to those reporting frequent vigorous aerobic exercise. This finding suggests that the key features of cardio-protective exercise include its intensity relative to individual capacity. V • O 2 max declines, on average, by about 10% per decade in middle-aged and older people, 13 so exercise of a given MET value represents a higher relative intensity for older people. Where the number of individuals surveyed permit, one approach 14 may be to express the MET value of the activity in relation to age-related average values for oxygen uptake reserve.

Frequency of exercise

Recent recommendations 15, 16 are for exercise on '… most, preferably all, days of the week', underlining the importance of frequent exercise. This notion reflects increasing recognition of the acute effects of exercise, i.e. altered physiological or metabolic responses lasting between several hours and a few days after a session of exercise. These include a decrease in blood pressure, 17 improved insulin sensitivity 18 and decreases in plasma triglycerides. 19 The time-courses over which they disappear are poorly understood, however. Some information is available, for example the attenuation of the postprandial rise in plasma triglycerides following a standard high-fat meal has been reported to disappear within 60 hours of an exercise session. 20 Improved insulin sensitivity may persist for a little longer. 21 More information is required, however, as the duration of these effects dictates the frequency with which exercise sessions must be taken if favourable postprandial responses are to be maintained. Similarly, the determinants of the magnitude of acute effects of exercise need to be elucidated. Theoretically, this may be enhanced by training 22 because training permits more frequent and longer exercise sessions to be accomplished without fatigue. To the author's knowledge, this proposition has seldom been tested. 23

Pattern of exercise

Epidemiological studies have found an inverse relationship between the total energy expended in leisure time physical activity and health outcomes. These include a lower risk of all-cause mortality, 24 cardiovascular morbidity and mortality, 24, 25 type II diabetes, 6 hypertension, 26 and site-specific cancers. 27, 28 Some activities contributing to high totals of energy expenditure seem likely to have been performed at least partly on an intermittent basis, for example walking, 29 climbing stairs, 25, 30 gardening, 29 and repair work. 24 Survey evidence therefore suggests that several short sessions of moderate physical activity during the day influence health outcomes in a positive manner, at least when they contribute to a high total energy expenditure.

Scientific evidence for the efficacy of this pattern of exercise as a means of eliciting chronic (training) effects is limited however, both in the number of randomly controlled trials (three to the author's knowledge) and scope (the only common outcome measure was fitness). 31 Evidence is limited to scientific studies with outcome measures primarily of fitness and/or fatness. Only one study reported the effect of exercise pattern on acute health-related responses. This found similar reductions in plasma triglycerides with three, 10-minute bouts of brisk walking at intervals during the day and one, 30-minute bout in sedentary people consuming normal meals. 32

Further research is clearly required before the principle of accumulating exercise in short bouts throughout the day can be endorsed with confidence.

Energy expenditure and energy turnover

The product of intensity, frequency and duration of exercise—sometimes described as the total 'volume' of exercise (a difficult term)—yields the total gross energy expenditure. Some evidence points to this as an important determinant of health gains. In addition to the surveys referred to above, this includes the finding from the US Runners' Health Study that running mileage was six times more important in predicting high density lipoprotein cholesterol concentration than running speed. 33 This was not the case for associations with blood pressure or waist circumference, however, where running speed was the more important determinant. 33 Total energy expenditure may also be the main determinant of some acute effects of exercise. Two examples are relevant. First, the increase in glucose disposal rate was similar following exercise at 50% or 75% V • O 2 max when the total energy expended was held constant. 34 Second, the attenuation of postprandial plasma triglycerides by prior exercise was strikingly similar following a long bout of low intensity exercise and a shorter bout of moderate exercise expending the same energy. 35 This topic, again under-researched, is related to that of the accumulation of exercise (referred to above) because that enshrines the notion that the total energy expenditure is all-important.

Of course, in free-living people, an increased level of physical activity is invariably associated with an increase in energy intake so that energy turnover is increased. Speculatively, a higher energy turnover may constitute a metabolically desirable state because of effects on the pathways concerned with the disposition, storage and degradation of muscle energy substrates. Evidence for the health gains from such a state include the finding that men who were classified as obese by body mass index (BMI) but who had a high level of physical fitness had lower cardiovascular and total mortality rates than lean men who were unfit. 36 Similarly, although both high BMI and a high energy intake were associated with increased risk of colon cancer among inactive people, this was not the case among physically active individuals. 8 This finding suggests that a high energy intake does not confer increased risk of this cancer in the presence of a high expenditure.

The suggestion that a high energy turnover is metabolically advantageous is not new. The term 'metabolic fitness' was introduced by Després and Lamarche, 37 on the basis of a series of studies showing that change to plasma lipoprotein lipids and body fatness were achieved through high-volume, low intensity training in the absence of increases in V • O 2 max. Efforts to test this hypothesis through comparing the effects of 'lifestyle' activity with those of traditional exercise programmes have recently been reported 38– 40 but information is needed for a variety of health outcomes in different populations.

Over the last decade, epidemiological data on physical activity (a behaviour) has been complemented by findings based on physical fitness (a set of attributes related to the ability to perform exercise). These studies show a dose-response relationship so that, although men in the highest fitness groups consistently show the lowest coronary attack and total mortality rates, moderate levels of fitness also confer a statistically significant and clinically important reduction in risk. 41, 42 Physical fitness, because it is probably a more objective measure than physical activity is an attractive outcome measure. Its use could be extended of course if it could be measured satisfactorily outside the laboratory. A low-cost, rapid, non-intimidating method for this would allow large surveys with the statistical power to detect, for example, effects in sub-groups and effects of specific activities. Walking tests such as the UKK Institute's 2 km protocol 43 are attractive for both practical and theoretical reasons. Performance on these tests measures not only functional capacity (V • O 2 max, the most frequently used laboratory measure), but also endurance. This is defined as the capability to sustain aerobic exercise using a high proportion of V • O 2 max. Endurance is more sensitive to changes in physical activity level than V • O 2 max and, because it derives largely from metabolic adaptations in muscle, may be a more important determinant of related health gains.

As mentioned, epidemiological studies show associations between fitness and a variety of health outcomes. The need to elucidate the relationships between the 'dose' and pattern of activity and the health outcome has been mentioned above. Fitness (particularly endurance) is labile and so rather easily changed through short-term interventions. It therefore offers a means of studying these dose-response relations indirectly (but inexpensively), serving a link between the behaviour and health outcomes.

Most epidemiological studies have classified physical activities according to estimated energy expenditure—either totals or threshold rates. Recommendations to the public (whether direct or via health professionals), however, need to promote activities rather than energy expenditures. Walking is an obvious example. It is popular, inexpensive and carries a low risk of injury. It is often the most commonly reported activity, particularly among women 44 and older men. 12 Some landmark studies, including those by Professor Morris's group, 12 have published separate analyses for walking. 25 In British civil servants brisk walking accounted for over half of the exercise which was protective against heart attack in 55–64-year-old men. 12 Protection from attack among fairly brisk walkers was not significantly affected by controlling for participation in sports and cycling or for a lot of other CHD predictive factors. In recent years more data has become available, however. In the US Nurses Health Study, for example, walking was inversely associated with coronary events; women in the highest quintile group for walking (≥3 h per week at a brisk pace) had a multivariate relative risk of 0.65 (95% CI : 0.47–0.91). 45 Similarly, healthy older men in the Honolulu Heart Study who walked >1.5 miles per day had half the coronary risk of those who walked <0.25 miles per day. 46 Walking has also been reported to be associated with a lower risk of type II diabetes 47 (independently of participation in vigorous activity).

These observations are consistent with reports that moderate levels of fitness, associated with a reduction in all-cause mortality, are attainable through brisk or fast walking. 48, 49 Bearing in mind that sedentary people seldom exert themselves at more than 30–35% of V • O 2 max, 50 such walking is sufficiently vigorous to improve fitness in a majority of people whose health is at risk because of their inactivity.

Walking is especially suitable for older people and the functional gains it elicits will likely improve quality of life. It is plainly acceptable for them, and carries a low risk of injury. In 13 weeks of training by walking, only one injury was sustained among 57 healthy men and women their 70s. 51 Among older people, regular walking has been associated with lower rates of hospitalization, 52 lower plasma triglycerides and higher bone mineral density. 53

Because it is accessible to all but the very frail, more information on the specific benefits from walking—according to pace and distance—is sorely needed.

Studies of the associations between physical activity habits and disease outcomes must be complemented by research into the underlying mechanisms. Not only does this increase confidence that such associations may be causal but it helps us to understand the relative importance of the different components of exercise as mediators of specified health gains. For cardiovascular disease much is known of the potential contribution from exercise-induced changes to blood lipids, with recent information about considerable effects on the dynamic postprandial phase. Other mechanisms must be involved, however, because patients with CHD get improved myocardial perfusion (and decreased risk of further episodes) without net regression. 54

Recent findings suggest effects on the acute phases of the disease. (This would be concordant with observations that only continuing, current exercise confers a lower risk; past exercise has no effect. 12, 55 ) These include improved flow-mediated dilatation. 56 There may be links here with lipoprotein metabolism because flow-mediated dilatation is impaired by high plasma triglycerides, in proportion to concentration. 57

Mechanisms need elucidating in other areas, for instance skeletal health. Is the lower risk of hip fracture among physically active older women due to a decreased risk of falling and/or to an effect on bone mineral density? Is physical activity level particularly important during the years when bone formation predominates? The relationship between physical activity and a reduced risk of colon cancer is among the most consistent finding in the epidemiological literature. Is the mechanism systemic (reduced growth-promoting milieu) or local (increased colonic peristalsis)? Women who regularly engage in exercise may have a lower risk of breast cancer. 58 Speculation on potential mechanisms has involved endocrine factors and/or improved weight maintenance. Depending on the answers to such questions, some forms and regimens of exercise may be more effective than others in the achievement of particular objectives.

Physical inactivity is a waste of human potential for health and well-being and its high prevalence is a cause for concern. Its potential contribution to positive health (not merely the absence of disease but associated with a capacity to enjoy life and to withstand challenges 16 ) is considerable. So much is known—yet we need to understand much more. The effective 'dose' of exercise needed to elicit effects likely to be of clinical importance must be defined and this information translated into practical advice readily understood by the population at risk. Ten years after Professor Morris's plea for 'physiology and epidemiology to get together', 12 the need for co-operative efforts from these disciplines is even more urgent.

'Thank you'

I thank Professor Morris for posing thought-provoking questions and for stimulating discussion of these. His contributions—to research, to the National Fitness Survey for England, and to the development of public health policies—are valued by so many. It continues to be an education and a privilege to work with him.

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Physical Activity Is Good for the Mind and the Body

Health and Well-Being Matter is the monthly blog of the Director of the Office of Disease Prevention and Health Promotion.

Everyone has their own way to “recharge” their sense of well-being — something that makes them feel good physically, emotionally, and spiritually even if they aren’t consciously aware of it. Personally, I know that few things can improve my day as quickly as a walk around the block or even just getting up from my desk and doing some push-ups. A hike through the woods is ideal when I can make it happen. But that’s me. It’s not simply that I enjoy these activities but also that they literally make me feel better and clear my mind.

Mental health and physical health are closely connected. No kidding — what’s good for the body is often good for the mind. Knowing what you can do physically that has this effect for you will change your day and your life.

Physical activity has many well-established mental health benefits. These are published in the Physical Activity Guidelines for Americans and include improved brain health and cognitive function (the ability to think, if you will), a reduced risk of anxiety and depression, and improved sleep and overall quality of life. Although not a cure-all, increasing physical activity directly contributes to improved mental health and better overall health and well-being.

Learning how to routinely manage stress and getting screened for depression are simply good prevention practices. Awareness is especially critical at this time of year when disruptions to healthy habits and choices can be more likely and more jarring. Shorter days and colder temperatures have a way of interrupting routines — as do the holidays, with both their joys and their stresses. When the plentiful sunshine and clear skies of temperate months give way to unpredictable weather, less daylight, and festive gatherings, it may happen unconsciously or seem natural to be distracted from being as physically active. However, that tendency is precisely why it’s so important that we are ever more mindful of our physical and emotional health — and how we can maintain both — during this time of year.

Roughly half of all people in the United States will be diagnosed with a mental health disorder at some point in their lifetime, with anxiety and anxiety disorders being the most common. Major depression, another of the most common mental health disorders, is also a leading cause of disability for middle-aged adults. Compounding all of this, mental health disorders like depression and anxiety can affect people’s ability to take part in health-promoting behaviors, including physical activity. In addition, physical health problems can contribute to mental health problems and make it harder for people to get treatment for mental health disorders.

The COVID-19 pandemic has brought the need to take care of our physical and emotional health to light even more so these past 2 years. Recently, the U.S. Surgeon General highlighted how the pandemic has exacerbated the mental health crisis in youth .

The good news is that even small amounts of physical activity can immediately reduce symptoms of anxiety in adults and older adults. Depression has also shown to be responsive to physical activity. Research suggests that increased physical activity, of any kind, can improve depression symptoms experienced by people across the lifespan. Engaging in regular physical activity has also been shown to reduce the risk of developing depression in children and adults.

Though the seasons and our life circumstances may change, our basic needs do not. Just as we shift from shorts to coats or fresh summer fruits and vegetables to heartier fall food choices, so too must we shift our seasonal approach to how we stay physically active. Some of that is simply adapting to conditions: bundling up for a walk, wearing the appropriate shoes, or playing in the snow with the kids instead of playing soccer in the grass.

Sometimes there’s a bit more creativity involved. Often this means finding ways to simplify activity or make it more accessible. For example, it may not be possible to get to the gym or even take a walk due to weather or any number of reasons. In those instances, other options include adding new types of movement — such as impromptu dance parties at home — or doing a few household chores (yes, it all counts as physical activity).

During the COVID-19 pandemic, I built a makeshift gym in my garage as an alternative to driving back and forth to the gym several miles from home. That has not only saved me time and money but also afforded me the opportunity to get 15 to 45 minutes of muscle-strengthening physical activity in at odd times of the day.

For more ideas on how to get active — on any day — or for help finding the motivation to get started, check out this Move Your Way® video .

The point to remember is that no matter the approach, the Physical Activity Guidelines recommend that adults get at least 150 minutes of moderate-intensity aerobic activity (anything that gets your heart beating faster) each week and at least 2 days per week of muscle-strengthening activity (anything that makes your muscles work harder than usual). Youth need 60 minutes or more of physical activity each day. Preschool-aged children ages 3 to 5 years need to be active throughout the day — with adult caregivers encouraging active play — to enhance growth and development. Striving toward these goals and then continuing to get physical activity, in some shape or form, contributes to better health outcomes both immediately and over the long term.

For youth, sports offer additional avenues to more physical activity and improved mental health. Youth who participate in sports may enjoy psychosocial health benefits beyond the benefits they gain from other forms of leisure-time physical activity. Psychological health benefits include higher levels of perceived competence, confidence, and self-esteem — not to mention the benefits of team building, leadership, and resilience, which are important skills to apply on the field and throughout life. Research has also shown that youth sports participants have a reduced risk of suicide and suicidal thoughts and tendencies. Additionally, team sports participation during adolescence may lead to better mental health outcomes in adulthood (e.g., less anxiety and depression) for people exposed to adverse childhood experiences. In addition to the physical and mental health benefits, sports can be just plain fun.

Physical activity’s implications for significant positive effects on mental health and social well-being are enormous, impacting every facet of life. In fact, because of this national imperative, the presidential executive order that re-established the President’s Council on Sports, Fitness & Nutrition explicitly seeks to “expand national awareness of the importance of mental health as it pertains to physical fitness and nutrition.” While physical activity is not a substitute for mental health treatment when needed and it’s not the answer to certain mental health challenges, it does play a significant role in our emotional and cognitive well-being.

No matter how we choose to be active during the holiday season — or any season — every effort to move counts toward achieving recommended physical activity goals and will have positive impacts on both the mind and the body. Along with preventing diabetes, high blood pressure, obesity, and the additional risks associated with these comorbidities, physical activity’s positive effect on mental health is yet another important reason to be active and Move Your Way .

As for me… I think it’s time for a walk. Happy and healthy holidays, everyone!

Yours in health, Paul

Paul Reed, MD Rear Admiral, U.S. Public Health Service Deputy Assistant Secretary for Health Director, Office of Disease Prevention and Health Promotion

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Articles on Physical health

Displaying all articles.

Healthy cities aren’t a question of boring or exciting buildings but about creating better public space

Haim Yacobi , UCL

Three ways to get your nature fix without a garden

Emma White , University of Surrey

Seven tips for a healthier relationship with your phone

Paul Levy , University of Brighton

Cost of living: why decreased access to swimming is harming children and young people

Karen Howells , Cardiff Metropolitan University

If you want to support the health and wellness of kids, stop focusing on their weight

Nichole Kelly , University of Oregon ; Elizabeth Budd , University of Oregon , and Nicole Giuliani , University of Oregon

Ramadan: four tips to help you eat right and stay healthy

Ayaz Safi , University of Westminster

Why words matter: The negative impacts of racial microaggressions on Indigenous and other racialized people

Iloradanon Efimoff , University of Manitoba

A year into the pandemic, COVID-19 exercise slump has hit women harder

Chloe Sher , University of Toronto and Caroline Fusco , University of Toronto

Five activities that can protect your mental and physical health as you age

Ziggi Ivan Santini , University of Southern Denmark ; Paul E. Jose , Te Herenga Waka — Victoria University of Wellington , and Vibeke Jenny Koushede , University of Copenhagen

How to maintain physical and mental health during coronavirus

Nita Bharti , Penn State

What are the effects of total isolation? An expert explains

Sarita Robinson , University of Central Lancashire

Is it good for you to be good?

Thomas Culham , Simon Fraser University

Four ways having a pet increases your lifespan

Janette Young , University of South Australia

A brief history (and a look into the future) of fitness technology

Brad Millington , University of Bath

How yoga makes us happy, according to science

Agnieszka Golec de Zavala , Goldsmiths, University of London and Dorottya Lantos , Goldsmiths, University of London

Physical inactivity is hurting the health of people in countries like Kenya. There’s a solution

Vincent O. Onywera , Kenyatta University

Physical health ignored in people with mental illness

Simon Rosenbaum , UNSW Sydney ; Katherine Samaras , UNSW Sydney , and Scott Teasdale , UNSW Sydney

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Senior Lecturer in Sport and Exercise Psychology, Cardiff Metropolitan University

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Benefits of Physical Activity

Obesity and Excess Weight Increase Risk of Severe Illness; Racial and Ethnic Disparities Persist

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Immediate Benefits

Weight management, reduce your health risk, strengthen your bones and muscles, improve your ability to do daily activities and prevent falls, increase your chances of living longer, manage chronic health conditions & disabilities.

Regular physical activity is one of the most important things you can do for your health. Being physically active can improve your brain health , help manage weight , reduce the risk of disease , strengthen bones and muscles , and improve your ability to do everyday activities .

Adults who sit less and do any amount of moderate-to-vigorous physical activity gain some health benefits. Only a few lifestyle choices have as large an impact on your health as physical activity.

Everyone can experience the health benefits of physical activity – age, abilities, ethnicity, shape, or size do not matter.

Some benefits of physical activity on brain health [PDF-14.4MB] happen right after a session of moderate-to-vigorous physical activity. Benefits include improved thinking or cognition for children 6 to 13 years of age and reduced short-term feelings of anxiety for adults. Regular physical activity can help keep your thinking, learning, and judgment skills sharp as you age. It can also reduce your risk of depression and anxiety and help you sleep better.

Both eating patterns and physical activity routines play a critical role in weight management. You gain weight when you consume more calories through eating and drinking than the amount of calories you burn , including those burned during physical activity.

To maintain your weight:  Work your way up to 150 minutes a week of moderate physical activity, which could include dancing or yard work. You could achieve the goal of 150 minutes a week with 30 minutes a day, 5 days a week.

People vary greatly in how much physical activity they need for weight management. You may need to be more active than others to reach or maintain a healthy weight.

To lose weight and keep it off: You will need a high amount of physical activity unless you also adjust your eating patterns and reduce the amount of calories you’re eating and drinking. Getting to and staying at a healthy weight requires both regular physical activity and healthy eating.

See more information about:

• Getting started with weight loss .
• Getting started with physical activity .
• Improving your eating patterns .

Learn more about the health benefits of physical activity  for children, adults, and adults age 65 and older.

See these tips  on getting started.

The good news [PDF-14.5MB]  is that  moderate physical activity , such as brisk walking, is generally  safe for most people .

Cardiovascular Disease

Heart disease and stroke are two leading causes of death in the United States. Getting at least 150 minutes a week of moderate physical activity can put you at a lower risk for these diseases. You can reduce your risk even further with more physical activity. Regular physical activity can also lower your blood pressure and improve your cholesterol levels.

Type 2 Diabetes and Metabolic Syndrome

Regular physical activity can reduce your risk of developing type 2 diabetes  and metabolic syndrome. Metabolic syndrome is some combination of too much fat around the waist, high blood pressure, low high-density lipoproteins (HDL) cholesterol, high triglycerides, or high blood sugar. People start to see benefits at levels from physical activity even without meeting the recommendations for 150 minutes a week of moderate physical activity. Additional amounts of physical activity seem to lower risk even more.

Infectious Diseases

Physical activity may help reduce the risk of serious outcomes from infectious diseases, including COVID-19, the flu, and pneumonia. For example:

• People who do little or no physical activity are more likely to get very sick from COVID-19 than those who are physically active. A CDC systematic review [PDF-931KB] found that physical activity is associated with a decrease in COVID-19 hospitalizations and deaths, while inactivity increases that risk.
• People who are more active may be less likely to die from flu or pneumonia. A CDC study found that adults who meet the aerobic and muscle-strengthening physical activity guidelines are about half as likely to die from flu and pneumonia as adults who meet neither guideline.

Some Cancers

Being physically active lowers your risk for developing several common cancers .  Adults who participate in greater amounts of physical activity have reduced risks of developing cancers of the:

• Colon (proximal and distal)
• Endometrium
• Esophagus (adenocarcinoma)
• Stomach (cardia and non-cardia adenocarcinoma)

If you are a cancer survivor, getting regular physical activity  not only helps give you a better quality of life, but also improves your physical fitness.

Learn more about Physical Activity and Cancer

As you age, it’s important to protect your bones, joints, and muscles – they support your body and help you move. Keeping bones, joints, and muscles healthy can help ensure that you’re able to do your daily activities and be physically active.

Muscle-strengthening activities like lifting weights can help you increase or maintain your muscle mass and strength. This is important for older adults who experience reduced muscle mass and muscle strength with aging. Slowly increasing the amount of weight and number of repetitions you do as part of muscle strengthening activities will give you even more benefits, no matter your age.

Everyday activities include climbing stairs, grocery shopping, or playing with your grandchildren. Being unable to do everyday activities is called a functional limitation. Physically active middle-aged or older adults have a lower risk of functional limitations than people who are inactive.

For older adults, doing a variety of physical activity improves physical function and decreases the risk of falls or injury from a fall . Include physical activities such as aerobic, muscle strengthening, and balance training. Multicomponent physical activity can be done at home or in a community setting as part of a structured program.

Hip fracture is a serious health condition that can result from a fall. Breaking a hip have life-changing negative effects, especially if you’re an older adult. Physically active people have a lower risk of hip fracture than inactive people.

See physical activity recommendations for different groups, including:

• Children age 3-5 .
• Children and adolescents age 6-17 .
• Adults age 18-64 .
• Adults 65 and older .
• Adults with chronic health conditions and disabilities .
• Healthy pregnant and postpartum women .

An estimated 110,000 deaths  per year could be prevented if US adults ages 40 and older increased their moderate-to-vigorous physical activity by a small amount. Even 10 minutes more a day would make a difference.

Taking more steps a day also helps lower the risk of premature death from all causes. For adults younger than 60, the risk of premature death leveled off at about 8,000 to 10,000 steps per day. For adults 60 and older, the risk of premature death leveled off at about 6,000 to 8,000 steps per day.

Regular physical activity can help people manage existing chronic conditions and disabilities. For example, regular physical activity can:

• Reduce pain and improve function, mood, and quality of life for adults with arthritis.
• Help control blood sugar levels and lower risk of heart disease and nerve damage for people with type 2 diabetes.
• Health Benefits Associated with Physical Activity for People with Chronic Conditions and Disabilities [PDF-14.4MB]
• Key Recommendations for Adults with Chronic Conditions and Disabilities [PDF-14.4MB]

Active People, Healthy Nation SM is a CDC initiative to help people be more physically active.

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Physical Activity

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Physical Fitness Linked to Better Mental Health in Young People

A new study bolsters existing research suggesting that exercise can protect against anxiety, depression and attention challenges.

By Matt Richtel

Physical fitness among children and adolescents may protect against developing depressive symptoms, anxiety and attention deficit hyperactivity disorder, according to a study published on Monday in JAMA Pediatrics.

The study also found that better performance in cardiovascular activities, strength and muscular endurance were each associated with greater protection against such mental health conditions. The researchers deemed this linkage “dose-dependent,” suggesting that a child or adolescent who is more fit may be accordingly less likely to experience the onset of a mental health disorder.

These findings come amid a surge of mental health diagnoses among children and adolescents, in the United States and abroad, that have prompted efforts to understand and curb the problem.

The new study, conducted by researchers in Taiwan, compared data from two large data sets: the Taiwan National Student Fitness Tests, which measures student fitness performance in schools, and the National Insurance Research Databases, which records medical claims, diagnoses prescriptions and other medical information. The researchers did not have access to the students’ names but were able to use the anonymized data to compare the students’ physical fitness and mental health results.

The risk of mental health disorder was weighted against three metrics for physical fitness: cardio fitness, as measured by a student’s time in an 800-meter run; muscle endurance, indicated by the number of situps performed; and muscle power, measured by the standing broad jump.

Improved performance in each activity was linked with a lower risk of mental health disorder. For instance, a 30-second decrease in 800-meter time was associated, in girls, with a lower risk of anxiety, depression and A.D.H.D. In boys, it was associated with lower anxiety and risk of the disorder.

An increase of five situps per minute was associated with lower anxiety and risk of the disorder in boys, and with decreased risk of depression and anxiety in girls.

“These findings suggest the potential of cardiorespiratory and muscular fitness as protective factors in mitigating the onset of mental health disorders among children and adolescents,” the researchers wrote in the journal article.

Physical and mental health were already assumed to be linked , they added, but previous research had relied largely on questionnaires and self-reports, whereas the new study drew from independent assessments and objective standards.

The Big Picture

The surgeon general, Dr. Vivek H. Murthy, has called mental health “the defining public health crisis of our time,” and he has made adolescent mental health central to his mission. In 2021 he issued a rare public advisory on the topic. Statistics at the time revealed alarming trends: From 2001 to 2019, the suicide rate for Americans ages 10 to 19 rose 40 percent, and emergency visits related to self-harm rose 88 percent.

Some policymakers and researchers have blamed the sharp increase on the heavy use of social media, but research has been limited and the findings sometimes contradictory. Other experts theorize that heavy screen use has affected adolescent mental health by displacing sleep, exercise and in-person activity, all of which are considered vital to healthy development. The new study appeared to support the link between physical fitness and mental health.

“The finding underscores the need for further research into targeted physical fitness programs,” its authors concluded. Such programs, they added, “hold significant potential as primary preventative interventions against mental disorders in children and adolescents.”

Matt Richtel is a health and science reporter for The Times, based in Boulder, Colo. More about Matt Richtel

Understanding A.D.H.D.

The challenges faced by those with attention deficit hyperactivity disorder can be daunting. but people who are diagnosed with it can still thrive..

Millions of children in the United States have received a diagnosis of A.D.H.D . Here is how their families can support them .

The condition is also being recognized more in adults . These are some of the behaviors  that might be associated with adult A.D.H.D.

Since a nationwide Adderall shortage started, some people with A.D.H.D. have said their medication no longer helps with their symptoms. But there could be other factors at play .

Everyone has bouts of distraction and forgetfulness. Here is when psychiatrists diagnose it as something clinical .

The disorder can put a strain on relationships. But there are ways to cope .

Though meditation can be beneficial to those with A.D.H.D., sitting still and focusing on breathing can be hard for them. These tips can help .

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Endurance exercise affects all tissues of the body, even those not normally associated with movement

NIH-funded project in rats also finds widespread differences between male and female organisms.

A large research project in young adult rats has found that that all bodily tissues tested respond to exercise training, amounting to over 35,000 biological molecules that respond and adapt to endurance exercise over time, including tissues from organs not usually associated with exercise. Researchers also found differences in responses between male and female rats that were more widespread than anticipated, highlighting the importance of including animals of both sexes in pre-clinical research. The effort, funded by the National Institutes of Health (NIH), used data from thousands of analyses of 19 tissue types and identified molecular changes in genes, proteins, and metabolites, which are substances essential to the metabolism of a particular organism or to a particular metabolic process. The findings are published in a group of papers in Nature.

While molecular changes were seen in all tissues, the way in which each tissue responded was unique. For example, effects on the functions of mitochondria, which are cellular hubs for energy production and metabolism, were observed across the body yet the specific changes observed differed depending on the tissue. For example, researchers found that mitochondria in the adrenal gland responded substantially to endurance training, including a change in regulation of nearly half the mitochondria-associated genes. This was surprising as adrenal glands had not been explored in detail for their role in exercise previously.

Additionally, differences were found in molecular responses to endurance exercise between young male and female rats in most tissues tested, including the brain, adrenal gland, lung, and fat tissue. Scientists uncovered striking differences in responses between the sexes in white fat tissue, findings that may play a role in researching how exercise interventions could be recommended for men or women experiencing conditions such as obesity. The differences between the exercise responses of the sexes in humans or animals have not been well characterized, and these findings emphasize the need for inclusion of both sexes in future exercise research to fully understand its role in health.

By tracking exercise’s impact on biological molecules in humans and rats, scientists are creating a map of molecular changes in the body following exercise. Studies in rats allow for a wider range of tissue types to be analyzed compared to human studies, and the resulting knowledge will allow a variety of hypotheses to be explored and guide the researchers in their analysis of the human data.

Researchers are currently conducting an exercise study in humans that will enhance our understand of why the body responds to exercise and how much the response varies for people of different ages, sexes, body compositions, and fitness levels. In the long-term, these insights could make it possible for clinicians to recommend specific, personalized exercise regimens to their patients to treat or prevent a variety of ailments and health conditions.

NIH’s Molecular Transducers of Physical Activity Consortium (MoTrPAC) , launched in 2016 to uncover how exercise improves and maintains our health at the molecular level, is funded by the  NIH Common Fund  and overseen in collaboration with the  National Institute on Aging  , the  National Institute of Arthritis and Musculoskeletal and Skin Diseases , and the  National Institute of Diabetes and Digestive and Kidney Diseases . For a list of current projects, visit https://commonfund.nih.gov/MolecularTransducers/fundedresearch . For more information on adult and pediatric clinical studies, visit clinicaltrials.gov  under NCT03960827 and NCT04151199 or visit the recruitment webpage to learn more about how you can participate.

The data produced through this research project is publicly available for further analysis and direct download to encourage more hypotheses from the biomedical community.

Concepcion Nierras, Ph.D., Office of the Director, Office of Strategic Coordination

MoTrPAC Study Group. 'Temporal dynamics of the multi-omic response to endurance exercise training' Nature 2024. DOI number: 10.1038/s41586-023-06877-w

About the NIH Common Fund : The NIH Common Fund encourages collaboration and supports a series of exceptionally high-impact, NIH-wide programs. Common Fund programs are managed by the Office of Strategic Coordination in the Division of Program Coordination, Planning, and Strategic Initiatives in the NIH Office of the Director in partnership with the NIH Institutes, Centers, and Offices. More information is available at the Common Fund website:  https://commonfund.nih.gov .

About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov .

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Physical Culture for Mental Health

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The recognition of psychiatric, psychological, and psychotherapeutic interventions in maintaining mental health is well-established. However, the significance of fostering, sustaining, and restoring mental well-being through physical culture is frequently overlooked. Physical culture encompasses various forms ...

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Stay active -- or get active -- to boost quality of life while aging, study suggests to middle-aged women

Data from more than 10,000 australian women showed a significant link between regular exercise during middle-age and physical health in later life, even when the exercise routine was not started until their mid-50s.

Consistent adherence to physical activity guidelines throughout middle-age is associated with a higher health-related quality of life in women, according to a new study publishing May 2 in the open-access journal PLOS Medicine by Binh Nguyen of University of Sydney, Australia, and colleagues.

The evidence for an association between physical activity and health-related quality of life has been based primarily on cross-sectional studies and short-term randomized controlled trials. Few longitudinal studies have measured physical activity at more than one time point and examined the long-term causal effects of exercise.

In the new study, researchers used data collected at three-year intervals beginning in 1996 from 11,336 participants in the Australian Longitudinal Study on Women's Health. Women were born in 1946 through 1951, making them 47 to 52 years old at the study outset. Participants were classified as either meeting WHO physical activity guidelines -- of 150 minutes of activity a week -- consistently throughout the fifteen-year exposure period, not initially meeting the guidelines but starting to meet them at age 55, 60 or 65, or never meeting the guidelines. Health-related quality of life was assessed using the physical health composite score (PCS) and mental health composite score (MCS) from the Short Form 36 Health Survey, which includes 36 questions about functional health and well-being.

On average, people who consistently met physical activity guidelines and those who first started to meet guidelines at age 55 had a three-point higher PCS (46.93 [95% CI 46.32 to 47.54] and 46.96 [95% CI 45.53 to 48.40], respectively), compared to those that did not meet physical activity guidelines (43.90 [95% CI 42.79 to 45.01]). The effect of physical activity on the PSC was significant even after controlling for socioeconomic factors and pre-existing health diagnoses. However, there was no significant association between physical activity and MCS.

"Combined with existing evidence, this study contributes to growing evidence of the benefits of maintaining or adopting an active lifestyle in mid-age," the authors say. "An important public health message is that being active for as many years as possible, even if women start to meet physical activity guidelines in their mid-50s, could have important health benefits in terms of physical health, especially in physical functioning."

The authors add, "Our study shows that it's important for women to be active throughout mid-age to gain the most benefits for physical health in later life. Ideally, women should increase their activity levels to meet the guidelines by age 55."

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• Binh Nguyen, Philip Clare, Gregore I. Mielke, Wendy J. Brown, Ding Ding. Physical activity across midlife and health-related quality of life in Australian women: A target trial emulation using a longitudinal cohort . PLOS Medicine , 2024; 21 (5): e1004384 DOI: 10.1371/journal.pmed.1004384

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Childhood sedentariness linked to premature heart damage: Light physical activity reverses risk, study shows

by University of Eastern Finland

An increase in sedentary time from childhood causes progressing heart enlargement, a new study shows. However, light physical activity could reduce the risk. The study was conducted in collaboration among the Universities of Bristol, Exeter and Eastern Finland, and the results were published in the European Journal of Preventive Cardiology .

Left ventricular hypetrophy refers to an excessive increase in heart mass and size. In adults, it is known to increase the risk for heart attacks, stroke, and premature death.

In the present study, 1,682 children drawn from the University of Bristol's Children of the 90s cohort were followed up from age 11 until 24 years. At baseline, they spent an average of six hours per day in sedentary activities, which increased to nine hours per day by young adulthood. This increase in sedentary time was associated with progressing heart enlargement, contributing 40% to the total increase in heart mass within a 7-year growth period from adolescence to young adulthood. Sedentariness increased heart mass regardless of obesity or elevated blood pressure status.

On the contrary, an average of three to four hours per day of light physical activity (LPA) throughout the follow-up reduced the increase in heart mass by 49%. Higher LPA was also associated with better cardiac function.

Participating in moderate-to-vigorous physical activity (MVPA) showed signs of slightly increasing the heart size, by 5%, which is largely physiologic.

Previous studies in the same population have linked excessive sedentariness to increased inflammation, high insulin, fat obesity, dyslipidemia, and arterial stiffness. LPA has emerged as an effective approach to diminishing the harmful effects of childhood sedentariness. However, no study in the world has previously examined whether long-term exposure to LPA from childhood holds the potential to reverse the increase in cardiac mass. This is because repeated echocardiography assessments of the heart in a large population of healthy youth are rare.

The current study is the largest and the longest follow-up accelerometer-measured movement behavior and repeated echocardiography study in the world. The participants wore accelerometer devices on their waists at ages 11, 15, and 24 years for 4–7 days and had echocardiography measurements of the heart structure and function at ages 17 and 24 years. Their fasting blood samples were also repeatedly measured for low-density lipoprotein cholesterol , high-density lipoprotein cholesterol, triglycerides, glucose, insulin, and high-sensitivity C-reactive protein.

Blood pressure, heart rate , smoking status, socio-economic status, family history of cardiovascular disease, as well as dual-energy X-ray absorptiometry-measured fat mass and lean mass were accounted for in the analyses.

"There is growing evidence that childhood sedentariness is a health threat that needs to be taken seriously. There must be a paradigm shift in how we view childhood sedentariness, as the mounting evidence is pointing at a ticking time bomb," says Andrew Agbaje, a physician and associate professor (docent) of clinical epidemiology and child health at the University of Eastern Finland.

"LPA is an effective antidote to sedentariness. It is easy to accumulate three to four hours of LPA daily. Examples of LPA are outdoor games, playing in the playground, walking a dog, running errands for parents, walking and biking to the shopping mall or to school, taking a stroll in the park, playing in the forest, gardening, casual basketball, soccer, floorball, golf, frisbee, etc. We can encourage children and adolescents to participate in LPA daily for better cardiovascular health," Agbaje says.

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Meditation: a simple, fast way to reduce stress.

Meditation can wipe away the day's stress, bringing with it inner peace. See how you can easily learn to practice meditation whenever you need it most.

If stress has you anxious, tense and worried, you might try meditation. Spending even a few minutes in meditation can help restore your calm and inner peace.

Anyone can practice meditation. It's simple and doesn't cost much. And you don't need any special equipment.

You can practice meditation wherever you are. You can meditate when you're out for a walk, riding the bus, waiting at the doctor's office or even in the middle of a business meeting.

Understanding meditation

Meditation has been around for thousands of years. Early meditation was meant to help deepen understanding of the sacred and mystical forces of life. These days, meditation is most often used to relax and lower stress.

Meditation is a type of mind-body complementary medicine. Meditation can help you relax deeply and calm your mind.

During meditation, you focus on one thing. You get rid of the stream of thoughts that may be crowding your mind and causing stress. This process can lead to better physical and emotional well-being.

Benefits of meditation

Meditation can give you a sense of calm, peace and balance that can benefit your emotional well-being and your overall health. You also can use it to relax and cope with stress by focusing on something that calms you. Meditation can help you learn to stay centered and keep inner peace.

These benefits don't end when your meditation session ends. Meditation can help take you more calmly through your day. And meditation may help you manage symptoms of some medical conditions.

Meditation and emotional and physical well-being

When you meditate, you may clear away the information overload that builds up every day and contributes to your stress.

The emotional and physical benefits of meditation can include:

• Giving you a new way to look at things that cause stress.
• Building skills to manage your stress.
• Making you more self-aware.
• Focusing on the present.
• Reducing negative feelings.
• Helping you be more creative.
• Helping you be more patient.
• Lowering resting heart rate.
• Lowering resting blood pressure.
• Helping you sleep better.

Meditation and illness

Meditation also might help if you have a medical condition. This is most often true if you have a condition that stress makes worse.

A lot of research shows that meditation is good for health. But some experts believe there's not enough research to prove that meditation helps.

With that in mind, some research suggests that meditation may help people manage symptoms of conditions such as:

• Chronic pain.
• Depression.
• Heart disease.
• High blood pressure.
• Irritable bowel syndrome.
• Sleep problems.
• Tension headaches.

Be sure to talk to your healthcare professional about the pros and cons of using meditation if you have any of these or other health conditions. Sometimes, meditation might worsen symptoms linked to some mental health conditions.

Meditation doesn't replace medical treatment. But it may help to add it to other treatments.

Types of meditation

Meditation is an umbrella term for the many ways to get to a relaxed state. There are many types of meditation and ways to relax that use parts of meditation. All share the same goal of gaining inner peace.

Ways to meditate can include:

Guided meditation. This is sometimes called guided imagery or visualization. With this method of meditation, you form mental images of places or things that help you relax.

You try to use as many senses as you can. These include things you can smell, see, hear and feel. You may be led through this process by a guide or teacher.

• Mantra meditation. In this type of meditation, you repeat a calming word, thought or phrase to keep out unwanted thoughts.

Mindfulness meditation. This type of meditation is based on being mindful. This means being more aware of the present.

In mindfulness meditation, you focus on one thing, such as the flow of your breath. You can notice your thoughts and feelings. But let them pass without judging them.

• Qigong. This practice most often combines meditation, relaxation, movement and breathing exercises to restore and maintain balance. Qigong (CHEE-gung) is part of Chinese medicine.
• Tai chi. This is a form of gentle Chinese martial arts training. In tai chi (TIE-CHEE), you do a series of postures or movements in a slow, graceful way. And you do deep breathing with the movements.
• Yoga. You do a series of postures with controlled breathing. This helps give you a more flexible body and a calm mind. To do the poses, you need to balance and focus. That helps you to focus less on your busy day and more on the moment.

Parts of meditation

Each type of meditation may include certain features to help you meditate. These may vary depending on whose guidance you follow or who's teaching a class. Some of the most common features in meditation include:

Focused attention. Focusing your attention is one of the most important elements of meditation.

Focusing your attention is what helps free your mind from the many things that cause stress and worry. You can focus your attention on things such as a certain object, an image, a mantra or even your breathing.

• Relaxed breathing. This technique involves deep, even-paced breathing using the muscle between your chest and your belly, called the diaphragm muscle, to expand your lungs. The purpose is to slow your breathing, take in more oxygen, and reduce the use of shoulder, neck and upper chest muscles while breathing so that you breathe better.

A quiet setting. If you're a beginner, meditation may be easier if you're in a quiet spot. Aim to have fewer things that can distract you, including no television, computers or cellphones.

As you get more skilled at meditation, you may be able to do it anywhere. This includes high-stress places, such as a traffic jam, a stressful work meeting or a long line at the grocery store. This is when you can get the most out of meditation.

• A comfortable position. You can practice meditation whether you're sitting, lying down, walking, or in other positions or activities. Just try to be comfortable so that you can get the most out of your meditation. Aim to keep good posture during meditation.
• Open attitude. Let thoughts pass through your mind without judging them.

Everyday ways to practice meditation

Don't let the thought of meditating the "right" way add to your stress. If you choose to, you can attend special meditation centers or group classes led by trained instructors. But you also can practice meditation easily on your own. There are apps to use too.

And you can make meditation as formal or informal as you like. Some people build meditation into their daily routine. For example, they may start and end each day with an hour of meditation. But all you really need is a few minutes a day for meditation.

Here are some ways you can practice meditation on your own, whenever you choose:

Breathe deeply. This is good for beginners because breathing is a natural function.

Focus all your attention on your breathing. Feel your breath and listen to it as you inhale and exhale through your nostrils. Breathe deeply and slowly. When your mind wanders, gently return your focus to your breathing.

Scan your body. When using this technique, focus attention on each part of your body. Become aware of how your body feels. That might be pain, tension, warmth or relaxation.

Mix body scanning with breathing exercises and think about breathing heat or relaxation into and out of the parts of your body.

• Repeat a mantra. You can create your own mantra. It can be religious or not. Examples of religious mantras include the Jesus Prayer in the Christian tradition, the holy name of God in Judaism, or the om mantra of Hinduism, Buddhism and other Eastern religions.

Walk and meditate. Meditating while walking is a good and healthy way to relax. You can use this technique anywhere you're walking, such as in a forest, on a city sidewalk or at the mall.

When you use this method, slow your walking pace so that you can focus on each movement of your legs or feet. Don't focus on where you're going. Focus on your legs and feet. Repeat action words in your mind such as "lifting," "moving" and "placing" as you lift each foot, move your leg forward and place your foot on the ground. Focus on the sights, sounds and smells around you.

Pray. Prayer is the best known and most widely used type of meditation. Spoken and written prayers are found in most faith traditions.

You can pray using your own words or read prayers written by others. Check the self-help section of your local bookstore for examples. Talk with your rabbi, priest, pastor or other spiritual leader about possible resources.

Read and reflect. Many people report that they benefit from reading poems or sacred texts and taking a few moments to think about their meaning.

You also can listen to sacred music, spoken words, or any music that relaxes or inspires you. You may want to write your thoughts in a journal or discuss them with a friend or spiritual leader.

• Focus your love and kindness. In this type of meditation, you think of others with feelings of love, compassion and kindness. This can help increase how connected you feel to others.

Building your meditation skills

Don't judge how you meditate. That can increase your stress. Meditation takes practice.

It's common for your mind to wander during meditation, no matter how long you've been practicing meditation. If you're meditating to calm your mind and your mind wanders, slowly return to what you're focusing on.

Try out ways to meditate to find out what types of meditation work best for you and what you enjoy doing. Adapt meditation to your needs as you go. Remember, there's no right way or wrong way to meditate. What matters is that meditation helps you reduce your stress and feel better overall.

Related information

• Relaxation techniques: Try these steps to lower stress - Related information Relaxation techniques: Try these steps to lower stress
• Stress relievers: Tips to tame stress - Related information Stress relievers: Tips to tame stress
• Video: Need to relax? Take a break for meditation - Related information Video: Need to relax? Take a break for meditation

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• Meditation: In depth. National Center for Complementary and Integrative Health. https://nccih.nih.gov/health/meditation/overview.htm. Accessed Dec. 23, 2021.
• Mindfulness meditation: A research-proven way to reduce stress. American Psychological Association. https://www.apa.org/topics/mindfulness/meditation. Accessed Dec. 23, 2021.
• AskMayoExpert. Meditation. Mayo Clinic. 2021.
• Papadakis MA, et al., eds. Meditation. In: Current Medical Diagnosis & Treatment 2022. 61st ed. McGraw Hill; 2022. https://accessmedicine.mhmedical.com. Accessed Dec. 23, 2021.
• Hilton L, et al. Mindfulness meditation for chronic pain: Systematic review and meta-analysis. Annals of Behavioral Medicine. 2017; doi:10.1007/s12160-016-9844-2.
• Seaward BL. Meditation. In: Essentials of Managing Stress. 5th ed. Jones & Bartlett Learning; 2021.
• Seaward BL. Managing Stress: Principles and Strategies for Health and Well-Being. 9th ed. Burlington, Mass.: Jones & Bartlett Learning; 2018.

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