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• W4244920996 abstract "Physical inactivity increases the risk of many chronic disorders. Numerous studies have convincingly demonstrated that undertaking and maintaining moderate levels of physical activity (eg, brisk walking 3 hours a week) greatly reduces the incidence of developing many chronic health conditions, most notably type 2 diabetes mellitus, obesity, cardiovascular disease, and many types of cancers. However, the underlying mechanistic details of how physical activity confers such protective effects are not well understood and consequently constitute an active area of research. Although changing an individual's ingrained behavior is commonly perceived to be difficult, encouraging evidence suggests that intensive and repeated counseling by health care professionals can cause patients to become more physically active. Therefore, counseling patients to undertake physical activity to prevent chronic health conditions becomes a primary prevention modality. This article summarizes the vast epidemiologic and biochemical evidence supporting the many beneficial health implications of undertaking moderate physical activity and provides a rationale for incorporating physical activity counseling as part of routine practice in the primary care setting. Physical inactivity increases the risk of many chronic disorders. Numerous studies have convincingly demonstrated that undertaking and maintaining moderate levels of physical activity (eg, brisk walking 3 hours a week) greatly reduces the incidence of developing many chronic health conditions, most notably type 2 diabetes mellitus, obesity, cardiovascular disease, and many types of cancers. However, the underlying mechanistic details of how physical activity confers such protective effects are not well understood and consequently constitute an active area of research. Although changing an individual's ingrained behavior is commonly perceived to be difficult, encouraging evidence suggests that intensive and repeated counseling by health care professionals can cause patients to become more physically active. Therefore, counseling patients to undertake physical activity to prevent chronic health conditions becomes a primary prevention modality. This article summarizes the vast epidemiologic and biochemical evidence supporting the many beneficial health implications of undertaking moderate physical activity and provides a rationale for incorporating physical activity counseling as part of routine practice in the primary care setting. One in 10 Americans now die prematurely of disorders with origins related to physical inactivity.1Hahn RA Teutsch SM Rothenberg RB Marks JS Excess deaths from nine chronic diseases in the United States, 1986.JAMA. 1990; 264: 2654-2659Crossref PubMed Scopus (165) Google Scholar, 2Booth FW Gordon SE Carlson CJ Hamilton MT Waging war on modern chronic diseases: primary prevention through exercise biology.J Appl Physiol. 2000; 88: 774-787PubMed Google Scholar In 1986, annual deaths in the United States from colon cancer, coronary heart disease, and stroke numbered 256,686 in persons aged 18 to 65 years who reported being sedentary or irregularly physically active.1Hahn RA Teutsch SM Rothenberg RB Marks JS Excess deaths from nine chronic diseases in the United States, 1986.JAMA. 1990; 264: 2654-2659Crossref PubMed Scopus (165) Google Scholar Moderate physical activity may annually eliminate 250,000 premature deaths from coronary heart disease, colon cancer, and type 2 diabetes mellitus.2Booth FW Gordon SE Carlson CJ Hamilton MT Waging war on modern chronic diseases: primary prevention through exercise biology.J Appl Physiol. 2000; 88: 774-787PubMed Google Scholar Physical activity is a first-line therapy and protects against many chronic health conditions by improving glucose uptake and insulin sensitivity, improving blood lipid profiles, lowering blood pressure, improving the health of blood vessels, and protecting against obesity.3Pate RR Pratt M Blair SN et al.Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine.JAMA. 1995; 273: 402-407Crossref PubMed Scopus (5920) Google Scholar In other words, physical activity could be viewed as primary therapy to prevent other more costly therapies. Emerging evidence suggests that intensive and sustained counseling by health care professionals is effective in increasing the level of physical activity in previ-ously sedentary individuals.4Writing Group for the Activity Counseling Trial Research Group Effects of physical activity counseling in primary care: the Activity Counseling Trial: a randomized controlled trial.JAMA. 2001; 286: 677-687Crossref PubMed Scopus (315) Google Scholar Therefore, a major aim of this article is to urge the medical community to aggressively counsel sedentary patients to incorporate physical activity as a part of daily life. Increased physical activity may be a clinically effective and economically intelligent means of preventing the burgeoning rise of many chronic health conditions. Chronic health conditions (CHCs) are the most common types of conditions seen in the primary care setting. Their natural history is generally indolent (for example, diabetes mellitus, coronary heart disease, obesity, hypertension, colon cancer), spans many decades, and is usually marked with transient periods of acute exacerbation or alleviation. Unless screened, the affected patient is generally unaware of the problem until end-organ damage occurs. Thus, the person afflicted with a CHC generally lives with the disorder throughout life. Chronic health conditions have been a leading public health concern since the 1920s.5Hoffman C Rice D Sung HY Persons with chronic conditions: their prevalence and costs.JAMA. 1996; 276: 1473-1479Crossref PubMed Google Scholar These conditions now affect more than 100 million individuals in the United States and account for 76% of all direct medical costs,5Hoffman C Rice D Sung HY Persons with chronic conditions: their prevalence and costs.JAMA. 1996; 276: 1473-1479Crossref PubMed Google Scholar and the incidence of CHCs continues to increase. Obesity and type 2 diabetes mellitus are now considered epidemics by the Centers for Disease Control and Prevention.6Mokdad AH Serdula MK Dietz WH Bowman BA Marks JS Koplan JP The continuing epidemic of obesity in the United States.JAMA. 2000; 284: 1650-1651Crossref PubMed Scopus (310) Google Scholar, 7Pinhas-Hamiel O Zeitler P “Who is the wise man?—the one who foresees consequences”: childhood obesity, new associated comorbidity and prevention.Prev Med. 2000; 31: 702-705Crossref PubMed Scopus (43) Google Scholar Obesity increased 57% in US adults from 1991 to 1999.8Koplan JP Dietz WH Caloric imbalance and public health policy.JAMA. 1999; 282: 1579-1581Crossref PubMed Scopus (210) Google Scholar More than 50% of American adults and nearly 25% of American youth are overweight or obese.8Koplan JP Dietz WH Caloric imbalance and public health policy.JAMA. 1999; 282: 1579-1581Crossref PubMed Scopus (210) Google Scholar, 9Sokol RJ The chronic disease of childhood obesity: the sleeping giant has awakened [editorial].J Pediatr. 2000; 136: 711-713Abstract Full Text PDF Scopus (81) Google Scholar Prevalence of type 2 diabetes mellitus in the United States has increased 5-fold since 1958.10Harris MI Eastman RC Early detection of undiagnosed diabetes mellitus: a US perspective.Diabetes Metab Res Rev. 2000; 16: 230-236Crossref PubMed Scopus (218) Google Scholar It was once referred to as adult-onset diabetes but is now frequently diagnosed in adolescents. Additionally, many CHCs do not begin during early adulthood or in middle age. Sixty percent of overweight 5- to 10-year-old children already have 1 biochemical or clinical cardiovascular risk factor (such as hyperlipidemia), elevated blood pressure, or increased insulin levels, and 25% have 2 or more risk factors.8Koplan JP Dietz WH Caloric imbalance and public health policy.JAMA. 1999; 282: 1579-1581Crossref PubMed Scopus (210) Google Scholar These risk factors observed in children mean that CHCs may become clinically overt earlier in adulthood.9Sokol RJ The chronic disease of childhood obesity: the sleeping giant has awakened [editorial].J Pediatr. 2000; 136: 711-713Abstract Full Text PDF Scopus (81) Google Scholar Thus, effective primary prevention strategies in all age groups would greatly diminish the overall morbidity and mortality associated with CHCs. Approximately 70% of US adults either do not undertake physical activity or are underactive, and nearly half of America's youth (aged 12-21 years) are not vigorously active on a regular basis.11Centers for Disease Control and Prevention Physical Activity and Health: A Report of the Surgeon General. US Dept of Health and Human Services, Atlanta, Ga1996Available at: www.cdc.gov/nccdphp/sgr/sgr.htmGoogle Scholar If physical activity is such a potent primary preventive medicine, why is it not more popular? One possibility is that the word “exercise” elicits a negative response in many people. Exercise may suggest intense activity that is associated with pain, specialized equipment, or membership in a health club. Also, some individuals may have negative feelings about exercise due to experiences as children and teenagers if their lack of athletic abilities evoked ridicule from peers. However, undertaking even moderate physical activity (ie, activity performed at 3-6 times the basal metabolic rate, which is the equivalent of brisk walking at 3-4 mph for 30 minutes each day in most healthy adults3Pate RR Pratt M Blair SN et al.Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine.JAMA. 1995; 273: 402-407Crossref PubMed Scopus (5920) Google Scholar) is protective against many CHCs. While health clubs and personal trainers serve a purpose for some individuals, completely sedentary individuals will benefit from increasing physical activity within the structure of their own daily living. Such a concept is termed functional physical activity and could contribute to personal health, as well as the overall health of the nation. Therefore, we suggest that instead of approaching exercise as a time-consuming ordeal, physicians should explain to their sedentary patients that physical activities such as walking or bicycling 10 to 15 minutes twice a day instead of driving a short distance, parking on the far side of the mall parking lot instead of driving around for the closest space, climbing stairs, and doing yard work will all be beneficial. Likewise, playing with children or grandchildren and restricting time watching television are other ways to increase physical activity in those 70% of Americans who perform less than the 30 minutes a day of moderate activities as recommended by the US surgeon general.11Centers for Disease Control and Prevention Physical Activity and Health: A Report of the Surgeon General. US Dept of Health and Human Services, Atlanta, Ga1996Available at: www.cdc.gov/nccdphp/sgr/sgr.htmGoogle Scholar Three weeks of continuous bed rest by healthy volunteers was associated with muscle wasting, bone loss, insulin resistance, 30% reductions in maximal cardiac output and stroke volume, orthostatic intolerance, decreased immune function, and decreased physical capacity.12Saltin B Blomqvist G Mitchell JH Johnson Jr, RL Wildenthal K Chapman CB Response to exercise after bed rest and after training: a longitudinal study of adaptive changes in oxygen transport and body composition.Circulation. 1968; 38: 1-78Google Scholar These are changes that also occur with aging, and physical inactivity directly contributes to them. In this context, progressive regimens of resistance exercise training improve muscle strength and size in frail elderly (90-year-old) people.13Fiatarone MA Marks EC Ryan ND Meredith CN Lipsitz LA Evans WJ High-intensity strength training in nonagenarians: effects on skeletal muscle.JAMA. 1990; 263: 3029-3034Crossref PubMed Scopus (1791) Google Scholar These changes are accompanied by improvement in mobility, an increased level of spontaneous physical activity, ability to carry out activities of daily living, and dynamic balance, which in turn reduces falls.14Fiatarone MA O'Neill EF Ryan ND et al.Exercise training and nutritional supplementation for physical frailty in very elderly people.N Engl J Med. 1994; 330: 1769-1775Crossref PubMed Scopus (2282) Google Scholar Many of these beneficial effects of exercise are appreciated only if regular physical activity is maintained. However, from clinical experience, it is well known that implementation of programs to consistently maintain increased physical activity in the elderly population is challenging. Using physical activity promotion programs such as the Community Health Activities Model Program for Seniors (CHAMPS II),15Stewart AL Verboncoeur CJ McLellan BY et al.Physical activity outcomes of CHAMPS II: a physical activity promotion program for older adults.J Gerontol A Biol Sci Med Sci. 2001; 56: M465-M470Crossref PubMed Scopus (216) Google Scholar 95% of those aged 65 to 90 years randomly assigned to the intervention group completed the 1-year program during which they increased both moderate-intensity energy expenditure by 46% or 487 kcal/wk (equivalent to adding a 20-minute-mile brisk walk 5 times a week) as well as light- and moderate-intensity physical activity by 36% or 687 kcal/wk (equivalent to the brisk walking plus lighter activities). Thus, physical activity programs can be effectively promoted in older people and serve as a key strategy to limit the impact of aging on our society. Only a small percentage of all diseases are produced by a single gene defect.16Beaudet AL Scriver CR Sly WS Valle D Genetics, biochemistry, and molecular basis of variant human phenotypes.in: Scriver CR Beaudet AL Sly WS Valle D 7th ed. The Metabolic and Molecular Bases of Inherited Disease. Vol 1. McGraw-Hill, New York, NY1995: 79Google Scholar Most diseases, and in particular chronic diseases, are determined by the dynamic interaction of multiple genes with the environment. This poorly understood interaction determines whether a specific threshold of biological importance is crossed and overt clinical symptoms associated with a particular disease occur.16Beaudet AL Scriver CR Sly WS Valle D Genetics, biochemistry, and molecular basis of variant human phenotypes.in: Scriver CR Beaudet AL Sly WS Valle D 7th ed. The Metabolic and Molecular Bases of Inherited Disease. Vol 1. McGraw-Hill, New York, NY1995: 79Google Scholar Additionally, on a population basis, genes change slowly and the environment can change rapidly. As noted by the recent CDC report,6Mokdad AH Serdula MK Dietz WH Bowman BA Marks JS Koplan JP The continuing epidemic of obesity in the United States.JAMA. 2000; 284: 1650-1651Crossref PubMed Scopus (310) Google Scholar the “genes related to obesity are not responsible for the epidemic of obesity because the US gene pool did not change significantly between 1991 and 1999.” The much-publicized search for genes causing obesity and diabetes can only broadly determine genes responding to changes in the environment, eg, lifestyle,16Beaudet AL Scriver CR Sly WS Valle D Genetics, biochemistry, and molecular basis of variant human phenotypes.in: Scriver CR Beaudet AL Sly WS Valle D 7th ed. The Metabolic and Molecular Bases of Inherited Disease. Vol 1. McGraw-Hill, New York, NY1995: 79Google Scholar, 17Campbell L Rossner S Management of obesity in patients with type 2 diabetes.Diabet Med. 2001; 18: 345-354Crossref PubMed Scopus (28) Google Scholar which in turn is a key initiating factor. Taken together, the concept is that the environment we live in and our lifestyles affect our cellular environment, and our genes respond to these subcellular changes by a pathologic over- or underexpression of various gene products and consequent clinical manifestations of disease. It is logical then to presume that primary preventive medicine would reverse the changes in the cellular environment and thus diminish or even eliminate the occurrence of CHCs such as obesity and diabetes mellitus. With this general idea as a background, then from a practical point of view, physicians can counsel changes in lifestyle more easily and effectively than they can treat inherent gene sequences in a living human being. This measure alone would produce an immediate positive impact for the more than 100 million Americans afflicted with a variety of chronic conditions.5Hoffman C Rice D Sung HY Persons with chronic conditions: their prevalence and costs.JAMA. 1996; 276: 1473-1479Crossref PubMed Google Scholar Our general position is supported by anthropological evidence. Cultures that depended on physical activity (eg, hunter-gatherers) for their daily survival expended more energy per unit of body weight,18Diamond JM Human evolution: diabetes running wild.Nature. 1992; 357: 362-363Crossref PubMed Scopus (54) Google Scholar suggesting that genes may have evolved to support higher rates of metabolism than are present in today's sedentary society. When food is plentiful, it would be beneficial for humans to gain weight as a buffer against future famine. When humans became modernized, energy intake and, particularly, energy output (physical work) decreased compared with hunter-gatherer societies.18Diamond JM Human evolution: diabetes running wild.Nature. 1992; 357: 362-363Crossref PubMed Scopus (54) Google Scholar, 19Neel JV Weder AB Julius S Type II diabetes, essential hypertension, and obesity as “syndromes of impaired genetic homeostasis”: the “thrifty genotype” hypothesis enters the 21st century.Perspect Biol Med. 1998; 42: 44-74Crossref PubMed Scopus (210) Google Scholar Affluent humans also consume a greater percentage of dietary fat, gain weight, and develop chronic diseases such as diabetes mellitus and hypertension.18Diamond JM Human evolution: diabetes running wild.Nature. 1992; 357: 362-363Crossref PubMed Scopus (54) Google Scholar, 20Zimmet P Globalization, coca-colonization and the chronic disease epidemic: can the Doomsday scenario be averted?.J Intern Med. 2000; 247: 301-310Crossref PubMed Scopus (271) Google Scholar Therefore, it appears that the genes that evolved in generations that had physically active lifestyles and less certain food supplies maladapt to sedentary affluent living.21Cockram CS The epidemiology of diabetes mellitus in the Asia-Pacific region.Hong Kong Med J. 2000; 6: 43-52PubMed Google Scholar, 22Neel JV Diabetes mellitus: a “thifty” genotype rendered detrimental by “progress”?.Am J Hum Genet. 1962; 14: 353-362PubMed Google Scholar Sedentary individuals do not oxidize enough food to keep their genes expressing enough of the proteins (ie, glucose transporters, beneficial lipoproteins, and vasodilating substances) to prevent the modern-day metabolic and circulatory dysfunctions. Physical activity improves the expression of genes contributing to health in 3 possible ways. (1) Exercise training has been shown to improve endothelium-dependent vasodilation in both coronary arteries and resistance vessels, thus protecting against heart disease and hypertension. This protection is mediated via an increase in nitric oxide synthase activity and protein level in the vessels, which produces vasodilation, increases structural diameter of blood vessels, and is antiatherogenic.23Hambrecht R Wolf A Gielen S et al.Effect of exercise on coronary endothelial function in patients with coronary artery disease.N Engl J Med. 2000; 342: 454-460Crossref PubMed Scopus (1074) Google Scholar (2) Complete bed rest for 3 days produces glucose intolerance, mimicking type 2 diabetes. Contraction of limb muscles reverses insulin resistance by stimulating the translocation of the glucose transporter GLUT4 to the sarcolemma of the myofiber and also by inducing the production of more GLUT4 protein. Exercise signals these effects independent of the insulin-signaling pathway allowing those with diabetes to lower blood glucose levels.24Goodyear LJ Kahn BB Exercise, glucose transport, and insulin sensitivity.Annu Rev Med. 1998; 49: 235-261Crossref PubMed Scopus (800) Google Scholar Such effects explain the long-standing observation that insulin dosage must be decreased when diabetic patients exercise. (3) Blood triglyceride levels increase less after a meal if an exercise bout was undertaken approximately 18 hours earlier, probably because of the increase in lipoprotein lipase activity and protein production.25Herd SL Kiens B Boobis LH Hardman AE Moderate exercise, postprandial lipemia, and skeletal muscle lipoprotein lipase activity.Metabolism. 2001; 50: 756-762Abstract Full Text PDF PubMed Scopus (126) Google Scholar The proteins responsible for the adaptations listed above emphasize the predominant role that physical inactivity has in altering the cellular environment to permit a threshold of biological importance to be passed such that an individual is affected with overt clinical disease. Finally, the recent sequencing of the human genome may eventually lead to individualized genetic medicine and new drugs and gene therapies to prevent or treat chronic diseases. However, these new treatments are likely to be expensive. How will the 44 million Americans without health insurance26Davis K Universal coverage in the United States: lessons from experience of the 20th century.J Urban Health. 2001; 78: 46-58Crossref PubMed Scopus (16) Google Scholar afford these expensive diagnostic tests and pharmaceuticals for easily preventable diseases? In addition, costs for private insurance and taxes for governmental health programs will exponentially rise to pay for expensive gene-based medications to replace the prescription of safe, scientifically proven primary prevention modalities such as habitual physical activity and/or dietary modifications to combat CHCs. Such increases in health care costs will only add to the complex and vicious cycle in our health care system, which in our opinion will make delivery of basic clinical care more inaccessible for even more of our population. Epidemiologic and interventional data now indicate unequivocally that individuals who perform even minimal physical activity have important reductions in chronic disease. In the Harvard nurses’ studies,27Manson JE Hu FB Rich-Edwards JW et al.A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women.N Engl J Med. 1999; 341: 650-658Crossref PubMed Scopus (780) Google Scholar, 28Hu FB Sigal RJ Rich-Edwards JW et al.Walking compared with vigorous physical activity and risk of type 2 diabetes in women: a prospective study.JAMA. 1999; 282: 1433-1439Crossref PubMed Scopus (687) Google Scholar, 29Hu FB Stampfer MJ Colditz GA et al.Physical activity and risk of stroke in women.JAMA. 2000; 283: 2961-2967Crossref PubMed Scopus (374) Google Scholar a prospective study of 72,000 women aged 45 to 65 years demonstrated a dramatic 30% reduction in the incidences of coronary heart disease, stroke, and type 2 diabetes simply by brisk walking (<3 mph) for at least 3 hours a week, compared with those in the study who did less than 3 hours of brisk walking each week. A threshold of 3 mph was found to be necessary to decrease the risk of coronary heart disease in this study, whereas the speed of walking per se is unim portant in the prevention of gains in body fat. A lack of physical activity is the risk factor most consistently shown to be associated with an increased risk of colon cancer.30Tomeo CA Colditz GA Willett WC et al.Harvard Report on Cancer Prevention: volume 3: prevention of colon cancer in the United States.Cancer Causes Control. 1999; 10: 167-180Crossref PubMed Scopus (100) Google Scholar Accumulating epidemiologic evidence also indicates that obese individuals who are physically active have a lower incidence of developing many chronic diseases, compared with their unfit obese counterparts. As illustrated by the Physicians’ Health Study31Manson JE Nathan DM Krolewski AS Stampfer MJ Willett WC Hennekens CH A prospective study of exercise and incidence of diabetes among US male physicians.JAMA. 1992; 268: 63-67Crossref PubMed Scopus (618) Google Scholar (n=21,271), when obese individuals become physically active, the risk of CHCs begins to return to that of the unfit normal-weight individual. When compared with physicians with a BMI less than 23 kg/m2, physicians with a BMI higher than 26.4 kg/m2 had a 7-fold increased risk of developing type 2 diabetes if they exercised vigorously (defined as any activity that resulted in working up a sweat) less than once per week.31Manson JE Nathan DM Krolewski AS Stampfer MJ Willett WC Hennekens CH A prospective study of exercise and incidence of diabetes among US male physicians.JAMA. 1992; 268: 63-67Crossref PubMed Scopus (618) Google Scholar This increased risk was reduced to 4-fold in physicians of equal BMI (<26.4 kg/m2) who exercised vigorously more than once per week. Thus, these findings suggest that physical activity independent of obesity lowers the risk of type 2 diabetes. Similarly, in the Harvard study of 72,000 nurses,27Manson JE Hu FB Rich-Edwards JW et al.A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women.N Engl J Med. 1999; 341: 650-658Crossref PubMed Scopus (780) Google Scholar the relative risk of having acute coronary events was demonstrated to be 85% higher in those with a BMI higher than 29 kg/m2 and having the lowest total physical activity, compared with the most active nurses with a BMI lower than 29 kg/m2. However, physically active nurses with a BMI higher than 29 kg/m2 had only a 28% higher risk of developing acute coronary events when compared with the most active nurses with a BMI lower than 29 kg/m2, whereas the group with a BMI lower than 29 kg/m2 and the lowest total physical activity had a 46% higher risk.27Manson JE Hu FB Rich-Edwards JW et al.A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women.N Engl J Med. 1999; 341: 650-658Crossref PubMed Scopus (780) Google Scholar Taken together, such epidemiologic data provide a rational basis to suggest that physical inactivity is an important independent risk factor for the development of morbid CHCs. They also suggest a negative synergy between inactivity and other risk factors. Furthermore, physical inactivity in patients with multiple chronic conditions has been reported to be associated with twice the rate of subsequent mortality over a short (42- month) follow-up period than that of more active people.32Martinson BC O'Connor PJ Pronk NP Physical inactivity and short-term all-cause mortality in adults with chronic disease.Arch Intern Med. 2001; 161: 1173-1180Crossref PubMed Scopus (56) Google Scholar The authors of this study suggested that clinical and population-based interventions to increase physical activity in such patients might have the potential to decrease mortality and costs of care. Importantly, timing of when to undertake physical activity is not age dependent. Individuals who become active in later life by way of a moderate-intensity walking program and who make only modest gains in fitness nevertheless reduce their chronic disease risk.33Dunn AL Marcus BH Kampert JB Garcia ME Kohl III, HW Blair SN Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness: a randomized trial.JAMA. 1999; 281: 327-334Crossref PubMed Scopus (903) Google Scholar, 34Tuomilehto J Lindstrom J Eriksson JG Finnish Diabetes Prevention Study Group et al.Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance.N Engl J Med. 2001; 344: 1343-1350Crossref PubMed Scopus (8348) Google Scholar High-intensity physical activity is not needed to lower the risk of CHCs. For example, moderate exercise (about 2½/2 hours of walking each week) and a low-fat diet produced a 58% reduction in the development of type 2 diabetes (a 71% reduction occurred for those ≥60 years old).35National Institute of Diabetes and Digestive and Kidney Diseases Diet and exercise dramatically delay type 2 diabetes: diabetes medication metformin also effective.Available at: www.niddk.nih.gov/welcome/releases/8_8_01.htmGoogle Scholar Indeed, the Diabetes Prevention Program clinical trial35National Institute of Diabetes and Digestive and Kidney Diseases Diet and exercise dramatically delay type 2 diabetes: diabetes medication metformin also effective.Available at: www.niddk.nih.gov/welcome/releases/8_8_01.htmGoogle Scholar ended a year early because of the dramatic health benefits accrued over its 3-year course. The subjects started the trial with impaired glucose tolerance (a condition that often precedes overt diabetes) and BMIs of 34 kg/m2 but ended with a 5% to 7% sustained loss in body weight. Other participants randomized to a different treatment group receiving only metformin reduced the incidence of type 2 diabetes by 31%, indicating that lifestyle measures and exercise were twice as good as this drug. Additionally, randomized controlled studies by Ross et al36Ross R Dagnone D Jones PJ et al.Reduction in obesity and related comorbid conditions after diet-induced weight loss or exercise-induced weight loss in men: a randomized, controlled trial.Ann Intern Med. 2000; 133: 92-103Crossref PubMed Scopus (1079) Google Scholar elegantly demonstrated that weight loss that was induced by daily physical activity without energy restriction was more effective than diet-induced weight loss in markedly reducing truncal obesity and insulin resistance in men. Of greater concern is also the com" @default.
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• W4244920996 title "An Obligation for Primary Care Physicians to Prescribe Physical Activity to Sedentary Patients to Reduce the Risk of Chronic Health Conditions" @default.
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