The following are key points to remember from this health promotion series on promoting physical activity and exercise:

1. Physical activity is defined as bodily movement produced by skeletal muscle contraction that requires energy expenditure beyond basal levels. It includes normal daily activities such as housekeeping, yard work, occupational related, leisure related, and transportation (e.g., bike/walk to school/work). In contrast, exercise typically is differentiated from physical activity in that it is planned, repetitive, and structured with the objective of improving health and fitness.
2. Physical fitness is a state of good health and strength achieved through physical activity and exercise, and includes cardiorespiratory fitness as well as muscular strength and fitness. Physical inactivity and sedentary behavior are the opposite and affects about one in five adults, with an increase in developed countries, women, the elderly, and lower socioeconomic status. Nearly 60% of US adults do not achieve the recommended guidelines of 150 minutes of moderate-intensity physical activity or 75 minutes of vigorous physical activity. Although social, environmental, and psychological factors play a role in ‘the behavior of physical activity,’ other biological factors including genetic factors may determine activity and trainability.
3. Whether measured by time, type and frequency, or calories expended, large observational studies have consistently shown an inverse correlation of fitness, exercise, and total, work, and leisure time activity with coronary heart disease, cardiovascular risk factors, and total and cardiovascular mortality. The relative risk of physical inactivity is similar to that of traditional risk factors including hypertension, hypercholesterolemia, and smoking. Moderate physical activity negates the adverse effects of prolonged sitting with a 3-4 times lower risk of developing cardiovascular disease compared to those with sedentary behavior, with the benefit seen independent of age, gender, and ethnicities.
4. The anti-atherosclerotic benefits of exercise training include increase in insulin sensitivity and reduced blood glucose, lowering of systolic and diastolic blood pressure (both aerobic and resistance training), decrease in visceral adiposity, inflammatory markers and atherogenic cytokines, and triglycerides and low-density lipoprotein cholesterol, and increase in high-density lipoprotein cholesterol. Antithrombotic effects include increase in fibrinolysis, and decrease in platelet adhesion, fibrinogen, and blood viscosity. Antiarrhythmic activity includes increase in vagal tone and heart rate variability, and decrease in adrenergic activity. Hemodynamic benefits include lower blood pressure and heart rate at any work level, decrease in myocardial oxygen demand, improved resting coronary flow, increase in cultured circulating angiogenic cells and endothelial progenitor cells, and improved endothelial function.
5. In patients with coronary heart disease as documented by events or an abnormal stress electrocardiogram, there is an inverse correlation with peak exercise capacity and death. Each 1 metabolic equivalent increase in exercise capacity conferred a 12% improvement in survival.
6. The benefits of cardiac rehabilitation are well established and include reduction in CVD mortality, possibly total mortality, hospital costs, fatal myocardial infarction, improvement in heart failure symptoms and reduction in re-hospitalization, and improved psychological status. In peripheral arterial disease, rehabilitation improves walking distance, quality of life, and probably decreases mortality.
7. Key recommendations for integrating the assessment and promotion of physical activity into clinical practice: regular physical activity assessment with encouragement of 150 minutes/week with gradual increase in frequency or duration, but that even 60-100 minutes/week is helpful; use of wearable devices with tracking and goal setting; encourage resistance training with muscle strengthening and flexibility of muscle groups at least 2 times/week; and health providers should set by example with personal experiences.
8. While not totally clear, there are data accumulating that too much exercise may be harmful and the relationship between physical activity and health is U or J shaped, with higher mortality at higher doses of exercise. This appears to be true in healthy persons as well as survivors following a myocardial infarction. High doses of strenuous or vigorous exercise may attenuate the positive health benefits and may be associated with increased morbidity/mortality.

Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Lipid Metabolism, Nonstatins, Exercise, Hypertension, Smoking

Keywords: Adiposity, Arrhythmias, Cardiac, Atherosclerosis, Blood Pressure, Cardiac Rehabilitation, Cholesterol, Coronary Disease, Dyslipidemias, Electrocardiography, Exercise, Hemodynamics, Hypertension, Inflammation, Motor Activity, Muscle Strength, Peripheral Arterial Disease, Primary Prevention, Sedentary Behavior, Smoking, Thrombosis

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