Lesson 3: Exercise Guidelines and Health Benefits

Table of Contents

Introduction

In lessons 1 and 2 I discussed the physiology of exercise and the body’s adaptations to exercise training. These adaptations mainly occur within the nervous, musculoskeletal, cardiovascular, and other energy utilization systems. In addition to the performance benefits from these physiologic changes, there are many health benefits that accrue as well. I will discuss these health benefits and the recommended amounts of activity to obtain them in this lesson.

2018 Physical Activity Guidelines for Americans (PAGA)

The Physical Activity Guidelines for Americans (“PAGA”) was first published in 2008; a 2nd edition, applicable to ages ≥3 years, was published in 2018. These were put together by a panel of experts and issued by the US Department of Health and Human Services. Click here for an overview of this process and the guidelines themselves. These guidelines complement the Dietary Guidelines for Americans (discussed extensively in the nutrition and weight management course on this site).

Recommended physical activity levels

I have reproduced the key recommendations of these guidelines in the note below.

Note: The 2018 Physical Activity Guidelines for Americans recommends:

  • age 3-5 years: should be physically active throughout the day to enhance growth & development
  • age 6-17 years: should perform 60 minutes or more of moderate-to-vigorous physical activity (“MVPA”) daily
    • most of this should be aerobic activity
    • they should perform vigorous-intensity physical activity (“VPA”) at least 3 days a week
    • they should include both muscle-strengthening and bone-strengthening physical activity at least 3 days a week
  • adults: should aim for 150-300 minutes of moderate-intensity physical activity (“MPA”) or 75-150 minutes of VPA spread throughout the week
    • moving more & sitting less throughout the day is beneficial if VPA is <30-40 minutes daily and MPA is <60-75 minutes daily
    • they should include muscle-strengthening activity of moderate or greater intensity involving all major muscle groups at least 2 days weekly
    • if chronic conditions or disabilities are present then adults should consult their healthcare provider and perform as much activity to try to meet the guidelines as their limitations allow
  • older adults: should follow the guidelines for adults
    • they should also perform multi-component physical activity that includes balance training as well as aerobic & muscle-strengthening activities
    • if there are chronic health conditions older adults should understand how this influences their ability to perform exercise
    • if there are limitations such that older adults cannot meet the guidelines they should perform as much weekly MPA as possible
  • pregnancy & postpartum: should perform at least 150 minutes of MPA weekly, preferably spread throughout the week
    • for individuals who normally perform VPA they can continue VPA
    • they should consult with their healthcare provider about how anything should be changed
    • they should avoid exercises that involve lying on their back after the 1st trimester of pregnancy as this can restrict blood flow to the uterus & fetus
    • additionally, they should also avoid contact/collision sports & activities with a high risk of falling or abdominal trauma such as soccer/basketball/horseback riding/downhill skiing

Muscle-strengthening activity is any activity against increased resistance (ie, lifting weights, push-ups, carrying something heavy, etc).

Bone-strengthening activity is any weight-bearing activity that involves impacts of some type, such as running, jumping jacks, and lifting weights.

The guidelines state that generally healthy individuals can begin to gradually increase physical activity without first consulting their healthcare provider. However, if physical symptoms develop or if individuals plan to start VPA then consulting one’s healthcare provider is more advisable. Additionally, to help minimize health risks it is important to start with a small amount of activity. One should gradually increase the duration and frequency of sessions prior to increasing the intensity.

Of note, one big change from this version of the guideline compared to the prior one is the duration of activity needed to count towards the weekly total. In the 2008 version there was a minimum requirement of 10 minutes duration of MVPA to count. In this new guideline, any duration counts (even 1 minute).

Tip: The fact that even 1 minute of activity counts can be very helpful for a lot of people. You can simply incorporate sporadic “exercise snacks” throughout the day and this will assist in overall health.(Islam, 2022) This may apply to resistance training as well.(Fyfe, 2021) There is not much research on this yet, and there is a concern that if people try to incorporate exercise snacks they may predominantly perform light physical activity (defined below), but theoretically this should be better than sedentary activity and if done purposefully  you can certainly perform brief bouts of exercise in the moderate-to-vigorous intensity range (also defined below).(Sanders, 2021)

Definitions of physical activity intensity

These guidelines are fairly straightforward; however, it is important to understand what qualifies as MVPA to be able to meet them. The guidelines provide definitions as indicated in the note below.

Note: According to the 2018 PAGA, the various activity levels are defined as follows:

  • Inactive: people who perform no MVPA
  • Insufficiently active: people who perform some MVPA but less than what is recommended in the guidelines
  • Active: people with activity levels falling within the recommendations of the guidelines
  • Highly active: people with activity levels beyond those recommended in the guidelines

People of any activity level will generally experience health benefits from increasing activity. However, the lower your activity at baseline the greater the benefits will be for any given increase.

The guidelines note that decreasing sedentary behavior in inactive individuals has several health benefits. These include decreasing the risk of all-cause mortality (“ACM”), cardiovascular disease (“CVD”), type 2 diabetes mellitus (“T2DM”) incidence, and cancer development/progression.

To define MVPA, they use metabolic equivalents of task (“METs”).

  • MET: the ratio of the rate of energy expended during an activity to the rate of energy expended at rest
    • If you normally burns 10 calories while at rest in 10 minutes, and while doing a specific activity for 10 minutes you burn 25 calories, that activity will have a MET value of 25/10 = 2.5.
  • Sedentary behavior: waking activity at ≤ 1.5 METs while sitting, reclining, or lying
  • Light physical activity (LPA): non-sedentary waking activity that is <3.0 METs
  • MPA:
    • absolute measurement: activity generating >3.0 but <6.0 METs
    • relative measurement: activity considered to be 5-6/10 on a rating of perceived exertion (RPE) scale, in general you can talk but not sing
  • VPA:
    • absolute measurement: activity generating >6.0 METs
    • relative measurement: activity considered to be 7-8/10 RPE, in general you cannot say more than a few words without becoming short of breath

The importance of the relative measurements should not be overlooked. For individuals with significant health conditions or who are elderly it may not be possible to reach the absolute MET levels needed for VPA, but since the relative measurements also count these can be used instead.

If interested:

Of note, for each 1 MET increase in exercise capacity, up to 10 METs, the overall risk of mortality decreases 15%.(Franklin, 2022b) Other data indicates an increase in exercise capacity by >2.0 METs, even in decently fit individuals, will also significantly decrease the risk of mortality, while decreases in exercise capacity >2.0 METs from any starting fitness level associates with a significantly increased risk of mortality.(Kokkinos, 2023)

Now I’ll work through an example to tie all of this together.

Example: Let’s check some of these numbers and see how we can make them fit the guideline.

The guidelines state adults should perform 150-300 minutes of MPA or 75-150 minutes of VPA each week. They also suggest to spread this out throughout the week. Thus, you can perform 30 minutes of MPA Monday – Friday, 25 minutes of VPA on three separate days, or some other combination. This will meet the minimum requirements; any additional physical activity you do in your leisure time adds to this.

As MPA is at least 3.0 METs and VPA is at least 6.0 METs, then technically ~1 minute of VPA can count for ~2 minutes of MPA. At a minimum of 6.0 METs for VPA, this comes to at least 75 * 6.0 = 450 MET-minutes per week. Moreover, at the upper limit of the guideline this equals 900 MET-minutes/week or 15 MET-hours/week.

Looking at the above link for adults we find that:

  • running at a 15 minute mile pace (4.0 miles per hour) equals ~6 METs
  • running at a 10 minute mile pace (6.0 miles per hour) equals ~10 METs
  • cleaning the home with moderate effort equals 3-4 METs
  • resistance training equals 3-5 METs
  • mowing the lawn without a power mower equals 5-6 METs
  • raking leaves equals ~4 METs
  • walking at a slow pace equals 2-3 METs
  • walking briskly equals 3-4 METs or even greater if walking >4.0 miles per hour

Keeping the math simple, running a 6.0 mile per hour pace (~10 METs) for 60 minutes equals 600 MET-minutes. Thus, a 1 hour run at a 10-minute mile pace meets the weekly guidelines for MET-minutes of MVPA. To meet the time goal of 75 minutes of VPA this would equal 750 MET-minutes in one session. However, the guidelines do suggest spreading physical activity out to ≥3 days weekly. Therefore, running a 10-minute mile pace for 25 minutes (2.5 miles total) 3 days weekly meets this guideline. Additionally, since running involves significant ground impact this counts for bone-strengthening activity. However, you will need to perform additional muscle-strengthening activity.

If 25 minutes of running 3 days a week does not seem realistic, you can break this up further since the guidelines suggest no minimum needed duration of activity to yield health benefits. Thus, you can run 13 minutes 6 days a week at a 10-minute mile pace (13*6 = 78, which is >75). Running 7 minutes twice a day for 6 days a week is also adequate (12*7 = 84, which is >75). However, practically speaking most people will find it more convenient to perform one 13 minute session than two 7 minute sessions.

If you aim for 30 minutes of VPA daily to help offset the negative effects of an otherwise completely sedentary lifestyle (as indicated in the guideline box above), then you need 180 MET-minutes per day (30 minutes * 6.0 METs = 180 MET-minutes). Therefore, running at a 10 minute mile pace requires 18 minutes of running daily to meet this goal., though based on the time recommendation you would still need to run 30 minutes.

Lastly, as indicated in the note above, some people will need to rely on relative measurements to assess whether physical activity is MPA or VPA. In this situation simply use the RPE metrics stated above to determine if your physical activity is MPA or VPA and just consider the total time you spend doing this rather than considering MET-minutes.

Tip: There is a clear contradiction in the prior example; when you perform physical activity that is >6.0 METs you can meet the MET-minute goal without meeting the time requirement goal. Unfortunately, it’s not completely clear in the guideline if meeting the total time targets are necessary if you have already met the MET-minute targets. However, most sources reference the time targets rather than the MET-minutes targets regarding the recommendations. Additionally, as discussed below, more activity generally leads to better health outcomes. Thus, I advise you to meet the listed time targets even if you surpass the MET-minute targets.

Health benefits when following the guidelines

Within the 2018 PAGA many health benefits of exercise are discussed. Some of these include:

  • Children:
    • lower risk of depression
    • improved bone health, weight status, cardiorespiratory fitness, muscular fitness, cardiometabolic health, cognition
  • Adults and older adults:
    • lower risk of ACM, CVD, hypertension, T2DM, abnormal blood lipids, several cancers, dementia, anxiety, depression, risk of falls & fall-related injuries
    • improved cognition, quality of life, sleep, bone health, physical function
    • can aid weight loss & help prevent weight regain
  • Pregnant women:
    • decreased risk of excessive weight gain, gestational diabetes, postpartum depression
    • may help decrease the risk of complications such as preeclampsia and the risk of needing a c-section

2020 World Health Organization guidelines on physical activity and sedentary behavior

More recently the World Health Organization (“WHO”) came out with updated guidelines as well.(Bull, 2020) These include:

  • a 2019 guideline discussing, physical activity, sedentary behavior, and sleep under age 5 years that can be found here
  • a 2020 update for their general guideline on physical activity and sedentary behavior for ages ≥5 years that can be found here

The latter is largely based on the PAGA above; they additionally updated several of the systematic reviews (“SR”) that were used to derive the PAGA with literature searches near the end of 2019 and included a few topics that were not covered in the PAGA. An easy to read concise list compiling both of these guidelines can be found here. Given similarity to the 2018 PAGA above, I will simply highlight the differences for ages ≥5 years in the note below. For the guidelines <5 years old please click on the prior linked compilation.

Note: The 2020 WHO guidelines on physical activity and sedentary behavior are largely in line with the 2018 PAGA. Differences include:

  • these guidelines are for age ≥5 years, they have a separate guideline for age 1-4 years (see the link provided above)
  • children and adolescents: they highlight that MVPA should average at least 60 minutes daily while the PAGA states they should get at least 60 minutes every single day
    • Of note, this may seem like a subtle distinction but practically it may be much more feasible to engage in a large amount of activity on say 4 days a week as opposed to engaging in 1 hour of activity 7 days a week; it would be much easier for some people to meet guidelines of a daily average as opposed to a daily minimum. Only one study (to my knowledge) has evaluated the health metrics of children comparing those averaging 60 minutes daily versus those performing at least 60 minutes daily of MVPA, finding no meaningfully significant differences between them.(White, 2022)
  • adults and older adults: they recommend aiming for the same exercise ranges as the PAGA but they emphasize greater health benefits are seen when going beyond this
  • additionally for older adults: similar to the PAGA they recommend including multi-component physical activity that incorporates balance & strength training but specify this should be at least 3 days weekly
  • for all ages and conditions: they emphasize health benefits from converting sedentary time to physical activity of any intensity

The 2020 WHO guidelines also state health benefits from meeting the guidelines; much of this is consistent with the benefits seen in the 2018 PAGA. They do list additional benefits of exercise for people with cancer, hypertension, T2DM, HIV, multiple sclerosis, spinal cord injury, impaired cognitive function, and disabilities as a whole. Most of these benefits align with those listed above.

If curious, a recent analysis found that <20% of people worldwide adhere to these guidelines.(Garcia-Hermoso, 2023)

Tip: The above guidelines are good minimum targets but increased health benefits are seen at progressively higher levels of exercise.(Blond, 2018; Franklin, 2020) In fact, higher levels of physical activity have recently been associated with higher levels of lean body mass (generally health-promoting) across the entire lifespan.(Westerterp, 2021) For insufficiently-active individuals, working towards meeting the guidelines is an excellent lifestyle change to work towards better health. However, if your goal is to optimize your overall health then consider gradual increases beyond the guidelines above, with one recent analysis finding going up to 150-300 minutes/week of VPA, 300-600 minutes/week of MPA, or an equivalent combination of both, yielding maximal benefits for protection against mortality.(Lee, 2022)

A great way to start working on becoming more physically active is to simply walk more. Below is a YouTube video I created discussing some of the data on this, but the highlights are that you should:

  • Aim to walk 7,000-8,000 steps daily, with diminishing returns beyond this point.
  • Aiming to walk 3 miles per hour, which for most adults will be ~100 steps per minute, will help ensure your walking is moderate-intensity physical activity.
  • Some step counters can be off by 20-30%, so consider manually tracking for a few minutes with different activities to determine how inaccurate your step counter is and then adjust your daily step goal as indicated.

I am keeping the more pertinent references in the reference list below.

Note: You do not need to meet the minimum threshold to obtain health benefits. A 2023 SR/MA including 196 articles found that even meeting half the minimum threshold of the guidelines compared to no activity will decrease the risk of ACM by 23%, total CVD by 19%, and total cancer by 10%.(Garcia, 2023)

2021 physical activity guidelines for obesity in adults

The European Association for the Study of Obesity (EASO) Physical Activity Working Group exercise guidance for the management of obesity in adults was published in April, 2021, with more information found here.

The recommendations are fairly broad but specific insights that are not mentioned in the above guidelines include:

  • they recommend 150-200 minutes of moderate-intensity aerobic exercise weekly for weight loss
  • they recommend 200-300 minutes of moderate-intensity aerobic exercise weekly for weight maintenance after weight loss
  • aerobic training will preferentially aid visceral and intra-hepatic fat loss as well as blood pressure
  • any exercise type will aid insulin sensitivity, cardiorespiratory fitness, and quality of life
  • resistance training is preferred for muscular fitness and preservation of lean body mass during weight loss
  • exercise will not have a substantial impact on energy intake but may increase fasting hunger while also improving the strength of satiety

Note: A case can actually be made that the health benefits from improved fitness in people with obesity are superior to the benefits from the typical amounts of weight loss that people experience when attempting to lose weight.(Gaesser, 2021) It has also been shown that exercise can provide health benefits in people with obesity even when there is no weight loss.(Pojednic, 2022) This does not mean that people with obesity should only focus on improving fitness in lieu of weight loss, but anyone who is struggling to lose weight can focus on improving cardiorespiratory fitness to still improve their overall health significantly.

Other health benefits of exercise indicated by the literature

The PAGA and WHO guidelines were published in 2018 and 2020 with most of the included research being published by late 2019. While much of the included research is relatively recent, the summary statements in the guidelines are fairly general. Therefore, I will discuss more specific benefits here.

Literature in youth populations: Physical activity in youth under age 6 is beneficial for body composition, bone health, and possibly cognition, while the same benefits as well as other improvements in cardiovascular risk factors are seen from ages 6-17.(Pate, 2019) Physical activity interventions also aid a variety of mental health outcomes (ie, self-esteem, body image, depression) though simply participating in studies may mediate some of the benefits.(Gow, 2020; King, 2020) Additionally, resistance exercise in youth is associated with improved metabolic function; it is not clear if this is due to changes in body composition or if there are benefits independent of changes in body composition.(Bea, 2017)

Moreover, muscular fitness itself in childhood and adolescence is associated with future improvements in waist circumference, triglycerides, bone mineral density, insulin resistance, and cardiovascular/cardiometabolic risk, though more studies that adjust for baseline values and body size are needed.(García-Hermoso, 2019; Rodrigues de Lima, 2020; Fraser, 2021) Importantly, positive changes in overall fitness are associated beneficially with changes in anthropometric measurements, cholesterol metrics, and overall cardiometabolic risk.(García-Hermoso, 2020; Santaliestra-Pasías, 2021; Sehn, 2021) Vigorous physical activity may have more overall benefits than moderate physical activity for anthropometric measurements and cardiorespiratory fitness, but significant and meaningful results can be obtained with both.(Gralla, 2016)

In children with obesity concurrent aerobic plus resistance exercise compared to aerobic exercise alone yields beneficial changes in body weight, body fat, lean body mass, LDL cholesterol (the “bad” cholesterol), and adiponectin (a hormone that promotes positive health effects).(García-Hermoso, 2018) In sedentary adolescents with obesity exercise interventions lead to significant improvements in BMI, various lipid parameters, insulin resistance, and cardiorespiratory fitness.(Li, 2021) In fact, children with a variety of different medical conditions can engage in physical activity productively and with a beneficial impact on their clinical condition(s).(Kapsal, 2019; West, 2019; Alvarez-Pitti, 2020) Lastly, resistance training in youth, even prior to puberty, can lead to skeletal muscle hypertrophy, increased strength, several other musculoskeletal benefits, and is safe.(Legerlotz, 2016; Peitz, 2018; Chaabene, 2020; Stricker, 2020; Faigenbaum, 2021) I will discuss exercise in youth populations further in Lesson 15.

Literature in elderly populations: Improvements in skeletal muscle hypertrophy with resistance training are possible into the eighth and possibly even into the ninth decades of life, so there really isn’t an age that is “too late” to start training to see benefits.(Straight, 2020) In fact, a recent analysis of many different types of exercise interventions in elderly populations found resistance training to be more beneficial than any other type.(Di Lorito, 2021) When specifically looking at perimenopausal and older women beneficial results are also seen with resistance training.(Ransdell, 2021)

Additionally, endurance and resistance training yield benefits for several body systems that help attenuate many of the effects of aging.(Winett, 2019; Valenzuela, 2020) Importantly, increased physical activity in general yields several additional benefits in the elderly. These include helping to prevent falls and associated injuries as well as helping to preserve physical function.(Dipietro, 2019) Both aerobic and resistance training seem to have positive effects on cognitive function and possibly slow cognitive decline in elderly populations, at least in those with more mild cognitive impairment as opposed to severe.(Liu-Ambrose, 2018) I will discuss exercise in elderly populations further in Lesson 15.

Literature in pregnant populations: During pregnancy, and after delivery when breastfeeding, there are additional considerations regarding the safety, risks, and benefits of performing exercise. It is always best to check with your own healthcare provider regarding this topic, but recently a general overview with many considerations was published for those who would like further reading.(Meah, 2020) Additionally, there is a growing body of evidence (albeit with a significant portion of the research done in rodents) indicating that paternal and maternal exercise prior to conception, exercise during pregnancy, and exercising while breastfeeding may all impart significant health benefits to one’s children.(Beleza, 2021) Exercise specifically during pregnancy helps to decrease the risk of various pregnancy & delivery complications.(Chen, 2021; Ferrari, 2021) I will discuss exercise in pregnancy further in Lesson 15.

Literature on the health impacts of sedentary behavior: Sedentary behavior is associated with several negative short- and long-term health outcomes(Saunders, 2020; Dunstan, 2021; Silveira, 2022; Wu, 2022) A 2021 SR/MA indicates that sitting for 2 hours, even with scattered short breaks, may be the break point at which decreases in vascular function are observed.(Taylor, 2022) Increasing overall activity levels can help counteract these negative effects.(Ekelund, 2019) However, it is unclear if simply incorporating more breaks in sedentary behavior is beneficial(Stamatakis, 2018), though a more recent SR and general review does indicate benefit(Loh, 2020; Bell, 2022), and in particular aerobic-type breaks show benefit for counteracting the increase in blood pressure that can occur with prolonged sedentary activity.(Paterson, 2021) Regarding timing, physical activity after eating seems more beneficial for bringing down postprandial glucose levels than physical activity prior to eating.(Engeroff, 2023) Additionally, individuals who are less fit likely benefit more readily from increased breaks in sedentary behavior.(Benatti, 2015) Light physical activity (ie, walking, simple activities of daily living) leads to mild benefits(Chastin, 2019); more vigorous physical activity such as running even just once weekly may provide additional benefit.(Pedisic, 2020)

However, when comparing LPA to MVPA for an equal activity amount of 150 MET-minutes there may be more similar protection against cardiovascular mortality.(Qiu, 2021) LPA may have several other beneficial roles regarding weight loss and weight loss maintenance as well.(Bourdier, 2022) MVPA likely has additional health benefits relative to LPA but engaging in LPA seems much better than being sedentary.

Literature on the benefits of aerobic and resistance exercise: Aerobic and resistance training, even without significant weight loss, help decrease unhealthy body fat stores such as visceral adiposity(Kim, 2017; Wewege, 2021; Recchia, 2023) and myosteatosis (fatty tissue within muscle).(Ramírez-Vélez, 2021) Exercise of all types can have significant health benefits in a variety of ways for people with obesity, even without weight loss.(Battista 2021; van Baak, 2021; Verboven, 2021) This extends to individuals with heart failure, where in most cases both resistance and aerobic training can be performed productively without a significant risk of adverse events.(Fisher, 2021)

Additionally, aerobic exercise can help prevent weight gain in adults, particularly at >150 minutes of weekly MVPA.(Jakicic, 2019) More intense aerobic training can help increase cardiorespiratory fitness, which is associated with several significant health benefits and decreased risk of mortality.(Han, 2022; Laukkanen, 2022) Regular aerobic exercise not only provides several cardiovascular benefits but can also reverse some of the pathology seen in diseased and aged hearts as well as reduce liver fat.(Moreira, 2020; Sabag, 2021; Sanchis-Gomar, 2021) Aerobic exercise may also shift more fibers to type I physiology, and a higher proportion of type I fibers has been correlated with decreased rates of obesity (of note, this is correlational data, it’s unclear if training for this purpose will specifically be beneficial to treat obesity).(Damer, 2022)

Resistance training alone aids cardiovascular risk markers, yielding benefits for cardiorespiratory fitness, blood pressure, fasting glucose, insulin resistance, cholesterol & triglycerides (moreso in individuals who are older and with greater health risks), and flow-mediated dilatation (a marker of endothelial function that indicates risk of future cardiovascular events).(Ashton, 2020; Abrahin, 2021; Silva, 2021) This is likely at least in part due to the release of several exerkines (small compounds released from various bodily tissues during exercise) that can have many health implications.(Chow, 2022; Zunner, 2022) Furthermore, resistance training improves bone mineral density and connective tissue health, as well as body composition across the life-span.(Maestroni, 2020; Lopez, 2022)

Resistance training decreases the risk of ACM, CVD, cancer, and T2DM, with maximal benefits potentially seen at ~60 minutes weekly (and with possible increased risks beyond 130-140 minutes weekly, though more research is needed to ensure this negative association is not due to reverse causality, associated drug use, a lack of aerobic exercise, or otherwise spurious(Boyle, 2023; Burtscher, 2023)); benefits are increased further when also performing aerobic training.(El-Kotob, 2020; Momma, 2022; Rosa, 2022; Shailendra, 2022) The benefits of resistance training for mortality seem synergistic with the benefits of aerobic training; the best results are obtained by performing both modalities.(Gorzelitz, 2022)

Resistance training for muscle strengthening on its own seems to help prevent many chronic diseases; however, when combined with aerobic training this seems to have a larger impact on cardiometabolic biomarkers and mental health than either modality in isolation.(Bennie, 2020) Both resistance and endurance training yield several mental health benefits (including regarding depression, anxiety, mood, stress, and cognition).(Kramer, 2020)

Potential health concerns of excessive exercise

Here I will briefly discuss what the literature suggests regarding safety of exercising well above the recommendations in the guidelines. This will only impact a small percentage of people.

Increasing activity levels to 6-7 times higher than the guidelines is still associated with benefits without obvious harms.(Blond, 2018) Elite athletes have health benefits throughout their lifespan; there may be confounding regarding lifestyle choices but this implies very high levels of activity for many years does not induce harm.(Runacres, 2021) While large cohort studies have at times shown that the highest levels of physical activity associate with worsening mortality relative to more moderate physical activity, it appears this may be secondary to measurement error and reverse causation bias.(Lee, 2021) A 2021 review article composed by several experts in their respective fields found few concerns of ultraendurance running; concerns included increased risks of atrial fibrillation and other heart problems in susceptible individuals (see more below) as well as stress fractures, while other potential concerns such as long term kidney damage are more speculative in nature.(Scheer, 2021)

Considering specifically the impact of high activity levels on cardiac adaptations, there seem to be several changes that occur, some potentially harmful, as shown in the following figure.(Mannakkara, 2023)

Reproduced from: Nilanka N Mannakkara, Gherardo Finocchiaro. Exercise and the Heart: Benefits, Risks and Adverse Effects of Exercise Training. Rev. Cardiovasc. Med. 2023, 24(3), 94. doi:10.31083/j.rcm2403094

These cardiac adaptations have been discussed at length in several recent pieces of literature.(Franklin, 2020; Mehta, 2020; O’Keefe, 2020; Parry-Williams, 2020; Stöhr, 2021; Franklin, 2022a; De Bosscher, 2023) Collectively, they suggest there are some changes in myocardial fibrosis, coronary artery calcification, and coronary atherosclerosis, but there is no evidence to suggest these changes directly lead to worse outcomes. There may be an increase in risk of right ventricular dysfunction and there does seem to be an increased risk of atrial fibrillation. Importantly, none of these authors, nor a recent statement by the American Heart Association(Franklin, 2020), advocate limiting limiting activity levels due to these concerns.

Thus, for healthy individuals who enjoy engaging in physical activity levels well beyond the recommended guidelines, I do not see any reason to reduce activity levels as a prophylactic step to prevent heart disease or mortality. For individuals with baseline cardiac disease or specific genetic conditions who wish to engage in physical activity well beyond the guidelines there are additional considerations(Franklin, 2020); consider discussing this with your healthcare provider or cardiologist if this applies to you.

Use caution with certain health conditions and undesirable symptoms

While exercise is safe when done correctly, it is important to take some precautions to help ensure safety. The guidelines above suggest there is no need to consult a healthcare provider if you are in good health prior to starting to exercise; however, for individuals with medical conditions there can be additional considerations(Hansen, 2018) and it is likely a good idea to check with your healthcare provider prior to working towards more vigorous activity. This is particularly true if you have any cardiovascular health conditions (ie, heart disease, uncontrolled hypertension, angina, peripheral artery disease, etc), diabetes mellitus, cirrhosis, or other conditions that can affect your heart, lung, or nerve supply throughout your body.

When people do have heart complications with new onset activity these typically occur when vigorous activity is performed without gradually acclimating to it (ie, when shoveling snow after being inactive for awhile).(Franklin, 2020; Franklin, 2022b) The risk is still small overall but it is imperative to slowly progress with exercise intensity to help minimize the risk of heart problems, injuries, and other health issues.

If at any point in time you start to develop chest pain, feel your heart beat in an unusual way, or believe you are unusually fatigued relative to the amount of exercise you are performing, you should stop exercising and discuss with your healthcare provider. It is possible any perception of abnormal fatigue is simply due to deconditioning (ie, being out of shape), but better safe than sorry.

Lastly, similar to how some individuals can take healthy eating “too far” and develop concerns with disordered eating or even eating disorders, the same can happen with exercise.(Marques, 2019; Trott, 2020) While exercise can effectively aid mental health in a variety of ways as indicated above, some people do develop body dysmorphia, exercise addiction, or other mental health issues related to increased activity. If at any point you feel this may be occurring with yourself I recommend stopping physical activity and consulting a mental health professional to determine how best to proceed.

Conclusion

There are official exercise guidelines for people of all ages to follow, and there is considerable evidence that following these guidelines leads to many health benefits. These benefits include, but are not limited to, positive changes in body composition, blood lipids, blood pressure, blood glucose metrics, blood flow throughout the body, cognition, mental health, overall fitness, pregnancy outcomes, cardiovascular disease incidence, and all-cause mortality. Even better outcomes are obtained by going beyond these guidelines. Caution should be taken to slowly increase activity levels to minimize the risk of injury or harm. Overall, regarding health outcomes, the substantial benefits far outweigh the risks when appropriate exercise strategies are utilized.

With the background obtained in the first three lessons providing a rationale regarding how the body performs movement and how exercise can benefit us, in the next lesson I will build on this by discussing terminology and concepts specific to resistance training.

Click here to proceed to Lesson 4

References

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