Dietary control and increased physical activity (PA) are recommended for patients with metabolic (dysfunction-) associated fatty liver disease (MAFLD). However, not all patients can sustain both exercise and a healthy diet. This study explored the interaction between dietary quality, PA levels, and mortality in MAFLD patients.
Methods
The Third National Health and Nutrition Examination Survey and linked mortality data were used in this study. Diet quality was assessed with the Healthy Eating Index (HEI). PA level was calculated by multiply self-reported exercise frequency and its Metabolic Equivalent A high-quality diet was associated. A Cox proportional hazard model was used to explore risk factors for mortality in MAFLD patients.
Results
In total, 3709 participants with MAFLD were included in the final analysis. The median follow-up time was 26.2 (interquartile range 19.3–28.1) years and 1549 (41.8%) deaths were recorded over follow-up. Cox multivariate regression was used to adjust for potential confounders of mortality. The results showed both HEI score and PA level were inversely correlated with all-cause mortality (P < 0.05). In the subgroup analysis stratified by PA level, higher diet quality decreased all-cause mortality, cardiovascular-related mortality and cancer-related mortality in PA inactive of MAFLD patients (P < 0.05), but these correlations were not present in active PA groups.
Conclusion
Healthy diet and physical activity may have different impact as lifestyle interventions for MAFLD. A high-quality diet is associated less mortality in inactive individuals with MAFLD but not in those with active PA levels. Sedentary individuals require healthier diet.
Introduction
Metabolic (dysfunction-) associated fatty liver disease (MAFLD), previously called non-alcoholic fatty liver disease (NAFLD), is characterized by the presence of metabolic dysfunction and excessive accumulation of triglycerides in the liver [1]. MAFLD has been associated with an increased risk of mortality [2,3,4].
Currently, there are no approved pharmacological treatments for MAFLD. Lifestyle modification, including dietary control and increased physical activity (PA), remains the first-line intervention [1, 5]. Combined diet and exercise strategies have been more effective in reducing lipid accumulation and improving histology [1].
However, it is difficult for many people to sustain exercise routines. There are many barriers to exercise in patients with fatty liver disease, including physiologic, psychological, and socio-environmental factors [6, 7]. A recent study revealed lower compliance with the Physical Activity Guidelines for Americans in individuals with fatty liver disease than in those without [8].
Low dietary quality is another independent risk factor of NAFLD-related liver mortality [9]. Diet quality can be evaluated using the Healthy Eating Index (HEI), a quantitative score developed by the United States Department of Agriculture to measure the overall quality of people’s diets [10]. It remains unclear how the interaction between diet quality and PA levels might influence the MAFLD outcomes. In this study, we used publicly accessed longitudinal data to explore the association between diet quality, PA levels, and mortality in MAFLD patients, particularly in physically inactive individuals.
Discussion
Lifestyle modification, including dietary management and increased physical activity, are currently effective interventions for MAFLD. In this cohort study, we found that a healthy diet improved the survival of MAFLD individuals with low PA levels. However, dietary quality did not add additional benefit regarding long-term survival to those with active PA levels. This result indicates that healthy diet and physical activity may have various impact as lifestyle interventions for MAFLD. The importance of a high-quality diet should be emphasized, especially for individuals with MAFLD and sedentary lifestyles, regarding long-term prognosis.
We found that in patients with moderate or active PA levels, lower dietary quality did not significantly affect mortality. This finding has been supported by previous studies, in which researchers found that exercise can mitigate the harmful effects of poor-quality food consumption. Aerobic exercise training has been reported to prevent endothelial dysfunction in healthy young men consuming sugar-sweetened beverages [19]. Similarly, high-intensity exercise has been shown to offset the deleterious effects of 14 days of fast-food meals [20], excess energy intake [21], or a high-fructose diet [22]. The harm of low diet quality may be offset by higher exercise levels; therefore, for individuals who have already been physically active, diet quality seems to be less essential.
However, in physically inactive individuals, diet is a major determinant of long-term outcomes. It is noteworthy that at baseline, patients with higher HEI scores were older and had more metabolic dysfunction, which were all unfavorable factors for survival. Interestingly, however, they also had a lower mortality rate than those with lower dietary quality. It has been reported that a low-quality diet is associated with oxidative stress and high levels of pro-inflammatory biomarkers [23]. The dietary quality score is inversely associated with the risk of frailty and mortality in adults [24]. A meta-analysis of 12 cohort studies and one cross-sectional study showed that strict adherence to a high-quality diet reduced the risks of all-cause and cause-specific mortality [25]. Therefore, individualized dietary management is important for patients with MAFLD.
A meta-analysis of 20 randomized control trials and 1073 patients with NAFLD showed that exercise alone or combined with dietary intervention improved serum levels of liver enzymes and liver fat or histology [26]. According to the results of this study, active exercise is important for individuals with MAFLD, but for those who cannot maintain a physical exercise routine, a high-quality diet is strongly recommended to reduce the future mortality risk. Therefore, adherence to at least one approach, being active or having a good quality diet, may offer the benefits of lifestyle modifications.
We found that high dietary quality may reduce the risk of mortality in patients with MAFLD. However, Yoo et al. failed to find an association between dietary quality and lower mortality risk in NAFLD [27]. This discrepancy may be due to the different definitions of fatty liver disease between the studies (MAFLD vs. NAFLD) and the adjustments for PA levels in the present study. As mentioned above, exercise may supersede the deleterious mortality effects of low-quality diets.
In this study, although all participants were diagnosed with MAFLD, some had active exercise levels and high-quality diets, which was counterintuitive at first glance. It should be noted that PA and diet information were obtained at the time of the survey, and those patients may have already been diagnosed with fatty liver disease or other metabolic syndromes and thus, had increased awareness of lifestyle modifications. We only analyzed exercise and dietary habits at the beginning of follow-up. Lifestyle patterns could have changed over time. A well-designed longitudinal cohort study is needed to verify our findings.
The strengths of this study are the nationally representative cohort and follow-up duration of >25 years to assess mortality in a large number of individuals. Thus, our findings can be generalized. However, our study had several limitations. First, diet and PA were self-reported, which can mean reporting and recall biases. Second, the HEI score was calculated using the 24-hour dietary recall. The limitations of this method for measuring dietary quality are well recognized. However, it is adequate for grouping participants into various levels of diet quality. Third, the American College of Sports Medicine recommends moderate- and vigorous-intensity exercise to achieve a total energy expenditure of ≥500-1000 MET·min·wk [11]. In this study, we were not able to calculate the exact energy expenditure of each participant as the time duration of each exercise session was not precisely defined in the original database. To solve this problem, we simply divided study population into two group according to the median calculated-PA scores. This might inevitably lead to missed classification of some patients. Finally, the assessments of PA and diet information rely solely on self-administered questionnaires, which could easily result in recall bias. More objective evaluation methods, such as detailed food diaries and wearable activity trackers, are required in future study.
In conclusion, a high-quality diet may improve the survival rate of patients with low PA levels. The quality of diet assessed by the HEI score did not significantly influence the mortality of MAFLD patients with moderate to active PA levels. The importance of a high-quality diet should be emphasized, especially for individuals with MAFLD and sedentary lifestyles.
Several misconceptions surround the relationship between physical activity and prostate cancer, leading to confusion and misinformation. One common misconception is that engaging in intense physical activity increases the risk of developing prostate cancer. In reality, several studies suggest that regular, moderate exercise may have a protective effect against prostate cancer. Sedentary lifestyles, on the other hand, have been associated with a higher risk.
Another misconception is the belief that only vigorous exercise provides benefits. While vigorous activities can be beneficial, even light to moderate physical activity, such as brisk walking, gardening, or cycling, has been linked to a reduced risk of prostate cancer. It’s important for individuals to understand that incorporating any form of regular physical activity into their routine can contribute to overall health and potentially lower the risk of prostate cancer.
Some may also believe that age is a barrier to the positive effects of physical activity on prostate health. However, research suggests that older men who engage in regular exercise still experience health benefits, including a potential reduction in the risk of developing prostate cancer. Exercise can also play a crucial role in improving the quality of life for prostate cancer survivors, helping manage treatment side effects and promoting overall well-being.
Lastly, there is a misconception that physical activity is only relevant after a prostate cancer diagnosis. While exercise is beneficial during and after treatment, maintaining an active lifestyle before diagnosis may contribute to a lower risk of developing prostate cancer in the first place. It’s crucial to dispel the notion that the benefits of physical activity are limited to specific stages of life or health conditions.
In summary, regular physical activity, even at moderate intensity, is associated with a lower risk of prostate cancer. Dispelling misconceptions and promoting awareness of the positive impact of exercise on prostate health can contribute to better-informed lifestyle choices and ultimately help reduce the incidence of this common cancer.
The frequent lack of appropriate statistical evidence regarding physical activity benefits in patients with cancer has meant that either epidemiologic or retrospective observational studies have provided the basis for our knowledge. The level of evidence for results has been weak and the basis of a controversial and not well-established issue. Scientific and clinical evidence is much more limited for less frequent and low survival cancers such as pancreatic cancer. Conducting randomized controlled trials on physical activity implementation in individuals with cancer is challenging due to the low observed adherence to trial recommendations and completion of quality-of-life questionnaires; the interference of environmental, social, and structural barriers; comorbidities as well as symptoms derived from cancer and its treatment; and the high number of patients needed, which is difficult to achieve in uncommon and deadly cancers. In the article by Neuzillet et al1 elsewhere in this issue, we can learn from a well-designed randomized trial on the positive effects of increasing physical activity in quality-of-life parameters for patients with advanced pancreatic cancer who are receiving treatment.
We have known that healthy habits contribute to a healthier life. Patients with heart disease, type 2 diabetes, hypertension, and cancer, which are quite frequent and major causes of morbidity and mortality in our Western world, do benefit from a systematic increase in physical activity. Patients desire to be more active and would like help and guidance from their doctor. The American Cancer Society recommends that individuals maintain healthy behaviors regarding diet and physical activity in order to reduce cancer risk.2 Indeed, in a recent analysis, the combination of risk factors (excess body weight, physical inactivity, poor diet, and alcohol consumption) accounted for at least 18.2% of cancer cases and 15.8% of cancer deaths in the United States.3 Feeling fit could help patients physically and psychologically cope with the development of cancer, as well as with the therapeutic strategies needed to cure or control this disease. The beneficial effect of physical activity implementation in cancer prevention and during cancer treatment has been demonstrated.4 This finding is potentially the result of a dose–response association5 and independent of critical confounders such as smoking or increased body mass index.6 Even individuals who were sedentary throughout most of their adult life (age 19–60 years) but routinely increased physical activity in their 50s or 60s showed a lower risk for all-cause mortality (hazard ratio [HR], 0.65; 95% CI, 0.62–0.68), cardiovascular disease–related mortality (HR, 0.57; 95% CI, 0.53–0.61), and cancer-related mortality (HR, 0.84; 95% CI, 0.77–0.92).7
A systematic review and meta-analysis of hundreds of epidemiologic studies with several million participants showed that there was a 10% to 20% reduction in bladder, breast, endometrial, renal, colon, and gastroesophageal cancers in people with a dynamic lifestyle. A 40% to 50% reduction in mortality was also seen in people with prostate, breast, and colorectal cancer who were physically active.8
On the other side, cancer treatments damage patient’s tissues and can contribute to accelerated biological aging. Psychological stress from cancer and its treatments favors prolonged toxicities, impairs essential repair mechanisms, and promotes a lack of will to do what has been recommended. Therapeutic objectives are to control disease growth and dissemination, reduce stress, improve sleep, increase physical activity according to patient’s performance status, improve self-esteem, preserve mental well-being, sustain a healthy diet, and maintain a healthy body weight.
Benefits of regular physical activity include stress reduction, sleep quality improvement, mood enhancement, muscle strength and tone enhancement, and cardiovascular and lung fitness augmentation for improving quality of life and aging outcomes. This is especially relevant for patients with sedentary lifestyles. More recently, the use of smart devices has increased adherence to physical exercise programs.
At the molecular level, the enhancement of immune function is a strong candidate to explain these effects, at least partly. Evidence has shown a stimulating effect of vigorous physical activity on immune effectors, mainly natural killer (NK) cells and CD8+ T cells, against tumors, as well as a decrease in inflammatory markers such as prostaglandin E2 and an increase in gut microbiota diversity, while also potentially reducing the levels of tumor-promoting bacteria.9
During physical exercise, skeletal muscle secretes myokines into the bloodstream, such as IL-6, IL-7, and IL-15, that can circulate free or are packaged into exosomes. IL-6 causes an anti-inflammatory effect by inducing the release of IL-1 receptor antagonist (IL-1RA), and it can also bind to NK cells to accelerate their mobilization into the bloodstream. IL-7 helps to preserve thymic mass and enhances the output of naive T cells. IL-7, together with IL-15, plays a relevant role in T-cell survival and CD8+ T-cell homoeostasis. As recently reported in pancreatic cancer,9,10 regular physical activity may act on inflammation and immunity through IL-15–mediated activation of CD8+ T cells, decreasing tumor growth and enhancing sensitivity to chemotherapy and anti–PD-1 antibodies. These molecular findings underline the potential benefit of constant physical exercise and point to IL-15 as a useful resource for pancreatic cancer treatment.9 The diminution in myokine secretion owing to the aging-related decline in skeletal muscle mass is a fact that triggers immune senescence, a condition linked to cancer immune evasion.11
The cognitive benefits of systematic physical activity are tied to an increased plasticity and reduced inflammation within the hippocampus, and to a decelerated neurodegeneration. One of the underlying mechanisms is an increase in clusterin, a complement cascade inhibitor, that reduces neuroinflammatory gene expression.12
A highly disease-specific microbiota-based classification model confined to pancreatic cancer–enriched species has been identified and could be useful as a control group for future randomized trials and for the early detection of pancreatic cancer.13 In contrast to dysbiosis, changes toward increased microbial abundance, diversity, and composition observed with physical activity training significantly change the function of the gut microbiota in favor of the patient, including improvements in immune function and inflammatory profiles.14 Many other physical activity mechanisms of action remain to be discovered.
Physical activity programs must be properly tailored to a patient’s characteristics by an expert team. In this way, a positive impact can be made on the health status of patients with cancer, even those with advanced-stage cancer, as well as persons living beyond cancer. All should have a lifestyle as active as possible to avoid complications that could occur when physical activity is not adequately prescribed and closely followed. In clinical practice, rehabilitation professionals must ask patients about their daily or weekly physical activity, and must record the information. Patients should then be given a written prescription specifying the type of exercise, frequency, and duration appropriate for them. Patients can start small and low, and increase duration and frequency over time. It is crucial for patients to measure the physical activity performed. Health monitoring wearables are helpful and support adherence to the recommendations. Clinicians should follow up on their patients’ physical activity program, asking about it at every contact. Reinforcement of this advice is relevant, and pointing out that physical activity can help preserve functional independence can be particularly motivating for patients. If rehabilitative services are not available, patients should be referred to another institution that provides them.
And last but not least, there is room for improvement, given that exercise is the most cost-effective medical intervention for patients with cancer. No financial toxicity is associated with it. Our health teams will not be properly organized until physical exercise and the professionals involved in it are part of the pancreatic cancer treatment circuit within the multidisciplinary team.
Increased sedentary time as a child through adolescence is directly linked to childhood obesity, but new research has found light physical activity may completely reverse the adverse process.
The study – conducted in collaboration with between University of Exeter, University of Eastern Finland, University of Bristol, and University of Colorado and published in Nature Communications – is the largest and longest follow-up to objectively measure physical activity and fat mass, using the University of Bristol’s Children of the 90s data (also known as the Avon Longitudinal Study of Parents and Children). The study included 6,059 children (53 percent female) aged 11 years who were followed up until the age of 24.
Recent reports concluded that more than 80 percent of adolescents across the globe do not meet the World Health Organization’s (WHO) recommended average of 60 minutes a day of moderate-to-vigorous physical activity. It is estimated that physical inactivity will have caused 500 million new cases of heart disease, obesity, diabetes, or other noncommunicable diseases by 2030, costing £21-million annually. This alarming forecast regarding the morbid danger of physical inactivity necessitates urgent research on the most effective preventive approach.
Yet results from this new study shows that moderate-to-vigorous physical activity is up to ten times less effective than light physical activity in decreasing overall gain in fat mass.
Dr Andrew Agbaje of the University of Exeter led the study and said: “These new findings strongly emphasise that light physical activity may be an unsung hero in preventing fat mass obesity from early life. It is about time the world replaced the mantra of ‘an average of 60 minutes a day of moderate-to-vigorous physical activity’ with ‘at least 3 hours a day of light physical activity’. Light physical activity appears to be the antidote to the catastrophic effect of sedentary time in the young population.”
During the study, a waist-worn accelerometer measured sedentary time, light physical activity, and moderate-to-vigorous physical activity among participants at ages 11, 15, and 24 years. Dual-energy X-ray absorptiometry-measured fat mass and skeletal muscle mass were also collected at the same ages and fasting blood samples were repeatedly measured for glucose, insulin, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglyceride, and high-sensitivity C-reactive protein. In addition, blood pressure, heart rate, smoking status, socio-economic status, and family history of cardiovascular disease were measured and controlled for in the analyses.
During the 13-year follow-up, sedentary time increased from approximately six hours a day in childhood to nine hours a day in young adulthood. Light physical activity decreased from six hours a day to three hours a day, while moderate-to-vigorous physical activity was relatively stable at around 50 minutes a day from childhood through young adulthood.
It was observed that each minute spent sedentary was associated with a 1.3-gram increase in total body fat mass. Both male and female children gained an average of 10kg of fat mass during growth from childhood until young adulthood. However, sedentary time potentially contributed 700 grams to 1kg of fat mass (approximately seven to ten percent) of the total fat mass gained during growth from childhood until young adulthood. A 1kg increase in fat has been linked to a 60-percent higher risk of premature death in a person’s early 50s.
Each minute spent in light physical activity during growth from childhood through young adulthood was associated with a 3.6-gram reduction in total body fat mass. This implies that cumulative light physical activity decreased total body fat mass by 950 grams to 1.5kg during growth from childhood to young adulthood, (approximately 9.5 to 15 percent decrease in overall gain in fat mass during the 13-year observation period). Examples of light physical activity are long walks, house chores, slow dancing, slow swimming, and slow bicycling.
In contrast, time spent in moderate-to-vigorous physical activity – including meeting the 60 minutes a day recommended by the WHO – during growth from childhood through young adulthood was associated with 70 to 170 grams (approximately 0.7 to 1.7 percent) reduction in total body fat mass. Prior to this study, it has not been possible to quantify the long-term contribution of sedentary time to fat mass obesity and the magnitude by which physical activity may reduce it. But this study confirmed the report from a recent meta-analysis of 140 school-based randomised controlled trials across the globe that engaging in moderate-to-vigorous physical activity had minimal or no effect in reducing childhood BMI-obesity.
Dr Andrew Agbaje of the University of Exeter said: “Our study provides novel information that would be useful in updating future health guidelines and policy statements. Public health experts, health policymakers, health journalists and bloggers, paediatricians, and parents should encourage continued and sustained participation in light physical activity to prevent childhood obesity.”
Dr Andrew Agbaje’s research group (urFIT-child) is supported by research grants from Jenny and Antti Wihuri Foundation, the Finnish Cultural Foundation Central Fund, the Finnish Cultural Foundation North Savo Regional Fund, the Orion Research Foundation, the Aarne Koskelo Foundation, the Antti and Tyyne Soininen Foundation, the Paulo Foundation, the Yrjö Jahnsson Foundation, the Paavo Nurmi Foundation, the Finnish Foundation for Cardiovascular Research, Ida Montin Foundation, Eino Räsänen Fund, Matti and Vappu Maukonen Fund, and the Foundation for Pediatric Research.
Wouldn’t it be nice, with the wisdom of hindsight, to draw on some of the lifestyle experiences of our past to enable a healthier and more productive future for all young people? Rather than engineering (consciously or unconsciously) physical activity out of the lifestyle of youngsters and perpetuating an inactive phenotype and its attendant health consequences, we should assert the benefits of nutrition and physical activity for the growing child more aggressively. Imagining a simpler lifestyle may well be one of the key platforms to underpin a healthier future. Profound improvements in the status quo could be realised by greater investment in the health and wellbeing of young children and maximising the plasticity of the developing brain to foster human capital. Many historical examples underscore the power of early and concerted investment in young people, including the Heckman curve developed by Nobel laureate economist, James J. Heckman. Heckman postulates a significant return on investment can be realised for society by supporting early childhood learning (https://heckmanequation.org/).
Throughout my adult life I’ve been fascinated by the potential social and economic advantages of investing in human capital through the health and education of our young, and my inspiration to provide all children with quality early life experiences has stemmed from many sources. Imagine what the world would look like if the growth and development of all children, irrespective of background, was optimised through quality nutrition and physical activity across the formative years?
My crystal ball posits that we have much to learn from the past, including the notion that we would benefit from a return to the simpler aspects of life, things experienced in less technologically ‘advanced’ times in our history. How might we draw on earlier wisdom to help solve the multitude of humankind’s current health dilemmas, including obesity in childhood? This includes the suggestion that a better understanding of the processes of growth and maturation would greatly assist in managing obesity in the early years. [1]
I’ve been working in the obesity field for so long I may legitimately refer to my career as an abject failure. In essence, I commenced working in obesity prevention and management long before it was ‘fashionable’ only to find that decades later, the global prevalence of paediatric overweight and obesity continues to rise. Interesting parallels may be drawn between the scale of the obesity pandemic, declining global levels of physical activity, and corresponding increases in sedentary behaviours. We urgently need to harness our collective wisdom for greater impact, including through more progressive collaborative initiatives such as the Healthy Living for Pandemic Event Protection (HL – PIVOT) Network facilitated by close colleague, Ross Arena (https://ahs.uic.edu/physical-therapy/healthspan/hl-pivot-healthy-living-for-pandemic-event-protection/).
Early life, education and the Pacific North-West
My passion for optimising the physical growth and development of children stems from my own early experiences. An enthusiastic athlete but average high-school scholar, I was constantly drawn to sport with my number one love being Australian Rules football. As a young person and school Prefect, I had no idea what area of study I should pursue, so in my final year of high-school, I decided to ‘try out’ for a place in a new 4-year concurrent Bachelor of Education degree being offered at the University of Tasmania. As a competent athlete with no family role model in education but strong support from loving parents, I was one of only 20 recipients of a prestigious scholarship to university and kickstart a career as a Health and Physical Education teacher. First in family to attend university, I relished the opportunity to combine my love of sport and physical activity with a burgeoning interest for working with others. Early in my undergraduate program, I knew I was destined to further my studies and leave the island, often referred to as ‘the edge of the world’, and pursue another goal, overseas travel.
My early career was dotted with great opportunities, and I vividly recall peers intimating that I must have been born with the proverbial ‘spoon in my mouth’. The truth is that I never shied away from hard work and despite my less than stellar academic credentials, was dogged in my determination to do my family proud. I attended a wonderful state (public) school on the Derwent River south of Hobart, Taroona High, completed a teaching practicum there and was subsequently rewarded with my first teaching appointment at the same school. However, my sojourn as a high-school teacher was short-lived and within a few years I commenced my long academic career at the entry level of Senior Tutor.
In 1980, I was awarded a Rotary Foundation Graduate Fellowship to undertake a Master of Science at the University of Oregon (UO) in Eugene (like Claude Bouchard and many other luminaries). In fact, a raft of prominent Australian academics completed higher degree research at the UO in the 1970s and 80s. This group is sometimes affectionately referred to as the Oregon ‘mafia’ and includes John Bloomfield, the first full professor of Human Movement Science at an Australian university, and Tony Parker, the prime mover in the progression of Exercise and Sport Science in the country. The original home of Nike and the famous Athletics West running club, Eugene was frequented by many top athletes of the day, including now infamous distance runners, Alberto Salazar and Mary Decker. Hayward Field at the UO is also the traditional home of the US Olympic Track and Field trials and was the site of the 2022 World Athletic Championships. During my time at Oregon, I had the luxury of training twice daily – when I could still run!
My primary interest in auxology (the science of physical growth and development), was the launching pad to my career focus on physical activity and health and honed my passion for obesity research. I was inspired by a host of influential scholars and some of their books on physical growth and related fields were prized possessions in my personal library. These included Growth at Adolescence (JM Tanner, 1962); [2] Growth and Development of Children (GH Lowrey, 1978); [3] Physical Activity: Human Growth and Development (GL Rarick 1973) [4] and later, Growth, Maturation and Physical Activity (Robert M Malina & Claude Bouchard, 1991) [5] and the Second Edition with Oded Bar-Or (2004). [6]
At the UO, one of the doyens of physical growth and development, Jan Broekhoff had a significant influence, not least of which because of his role in early longitudinal growth studies, including the Medford Boy’s Growth Study developed by H. Harrison Clarke. Broekhoff hailed from The Netherlands along with those involved in the Amsterdam Longitudinal Study, including Willem van Mechelen. The power of capturing multiple snapshots of individuals across the growing years underscored the early significance of such foundational pieces of work and was particularly illuminating, along with the fine characters responsible. These included Albrecht Claessens and the late Gaston Beunen, both involved in the Leuven Growth Study.
I returned to Australia in 1982 but soon after, left my home state again to commence a PhD in Anatomical Sciences at the University of Queensland (UQ) in Brisbane.
The Brisbane years
My postgraduate journey was long and arduous as I completed my PhD (1990) part-time while I worked as a lecturer. Supervised by mentor Tony Parker, my PhD thesis focused on the Locomotor Characteristics of Pre-pubertal Children with Obesity and helped to frame my career-long interest in life course aspects of cardiometabolic and musculoskeletal health.
The 1980s in Australia saw the beginning of the demise of school Health and Physical Education and removal from its rightful place as a centrepiece of the curriculum. Of note, this coincided with the development of the new Human Movement Studies discipline. In many universities, departments morphed over time into what is now more commonly referred to as Exercise and Sport Science. During this period, the Australian Association for Exercise and Sport Science (AAESS) was formed and later, having splintered from Sports Medicine Australia (SMA), Exercise and Sport Science Australia (ESSA) became the premier professional body.
Sadly, the changing face of the profession resulted in some collateral damage, including the unintentional impact on physical activity and nutrition for health and wellbeing. Who would have predicted that in 2022, thousands of Exercise Scientists and Clinical Exercise Physiologists would be accredited in Australia? Similarly, who could have foreseen the dramatic reductions in quality school Health and Physical Education offerings? How did we allow a ‘best bet’ or non-negotiable aspect of schooling to be so seriously downgraded? More importantly, how can we learn from these mistakes? One could contend that we have ‘thrown the baby out with the bathwater’ and are now training a new profession to manage many of the ills of society, including those stemming from low levels of physical activity during the growing years. Much more needs to be done to educate the population regarding the profession. Any straw poll of community members would indicate that most have no idea of the scope of practice, role, and distinctive contribution of those involved in Exercise and Sport Science. Unfortunately, the same may be true regarding public knowledge and understanding of many health professions. Great opportunities may be realised if we offered high-quality Health and Physical Education programs across the school years and employed an inter- and multidisciplinary mindset to our work. [7]
My professional career has included strong involvement with a range of organisations, including the International Council of Sport Science and Physical Education (ICSSPE), the International Federation of Sports Medicine (FIMS), and Sports Medicine Australia (SMA). I also had a longstanding commitment to the once prominent but now discontinued, International Council for Physical Activity and Fitness Research (ICPAFR). Significant scientific contributions and friendships stemmed from scientific meetings of ICPAFR, including with Franco Viviani, Albrecht Claessens, Oded Bar-Or, Toivo Jürimäe, Willem van Mechelen, Neil Armstrong and many others. Important contributions were also made to the International Conference on Diet and Activity Methods (ICDAM), previously the International Conference on Dietary Assessment Methods. This included the brokering of a new focus on both diet and physical activity methodology commenced at ICDAM6 (Copenhagen, 2006) (Berit Heitmann, Lauren Lissner, and Anna Winkvist), a fine example of interdisciplinary success subsequently reflected in ICDAM7 (Washington DC, 2009) (Amy Subar), ICDAM8 (Rome, 2012) chaired by Barbara Burlingame at FAO, and ICDAM9 (Brisbane, 2015) chaired by me. However, the predominant focus of my work has been with the obesity fraternity, nationally and internationally.
Over the years, I served in a range of executive roles before being elected as the first non-medical President of the Australasian Society for the Study of Obesity (ASSO), the forerunner of the Australian and New Zealand Obesity Society (ANZOS). In this capacity, I was heavily involved in preparations for the 10th International Congress on Obesity (ICO Sydney, 2006) and the preceding Satellite Conference on Physical Activity and Obesity (Brisbane, 2006), along with close collaborator and life partner, Nuala Byrne. Together, we have explored numerous research questions, most related to nutritional physiology and adaptation to weight loss in people with obesity. A primary goal during this work has been to remember the sage advice of Marcel Proust, that “the real voyage of discovery consists not in seeking new landscapes but in having new eyes”. Nuala’s passion for advancing knowledge in the field by questioning traditional maxims is exemplary, and from numerous examples, includes exploration of the shortcomings of the metabolic equivalent (MET) and acknowledgement that one size does not fit all. [8]
Over many years, books and book chapters dominated my scholarly outputs, a reflection of my somewhat non-traditional career. I wrote relatively few papers until my mid-30s with academic life focused on teaching and service. Early books included the first edited text on Exercise and Obesity (Smith-Gordon, first published in 1994) [9] with Mark Wahlqvist and contributions from leading international scientists. I am also particularly proud of other early work with Czech colleague, Jana Pařízková, including two editions of the comprehensive Childhood Obesity: Prevention and Treatment (CRC Press, 2001; 2005). [10, 11] Later, with Nuala and Neil King, we edited Physical Activity and Obesity (Smith-Gordon, 2006) [12] in conjunction with the ICO2006 Satellite Conference, and the following year with ICSSPE, Children, Obesity and Exercise (Routledge, 2007). [13]
If I was to shortlist the European cities with the greatest impact across my career, the standouts would surely be Prague and Vienna. I’ve been fortunate to spend significant blocks of time in both places, writing tracts of the Childhood Obesity books in Prague, and working with colleagues in the Nutrition and Health-Related Environmental Studies Section at the International Atomic Energy Agency (IAEA). Opportunities to serve the international community through research projects and Expert Missions related to obesity, body composition and energy expenditure assessment, particularly on behalf of the IAEA, can be traced to an invitation to present at the WHO Expert Meeting on Childhood Obesity (Kobe, Japan, 2005) and subsequent collaboration with Najat Mokhtar, now Deputy Director General and Head, Department of Nuclear Sciences and Applications, IAEA. The same meeting forged other important research collaborations, including with Anoop Misra and colleagues (then All India Institute of Medical Sciences [AIIMS] and now, Fortis Centre for Diabetes, Obesity and Cholesterol [C-DOC]), and a long history of work in South Asia. I have thoroughly enjoyed and much appreciated being ‘accepted’ by other esteemed colleagues in the region including Jeya Henry, Mario Soares, the late Prakash Shetty, Anura Kurpad, Ismail Noor and PhD scholars and Postdoctoral Fellows who have achieved great success in their own careers, including Ranil Jayawardena, Chathuranga Ranasinghe, and Masaharu Kagawa. [14]
My collaboration with Jana Pařízková has been particularly impactful, including recognition of her body of work, encompassing two editions of Nutrition, Physical Activity and Health in Early Life (CRC Press, 2010; 2017). [15, 16] Weaving threads from the past and acknowledging the contributions of others remains a poignant theme, highlighted again for me recently in reading the powerful accounts in The Golden Maze: A Biography of Prague (2020) [17] by Richard Fidler. To move forward, we need to move full circle to replicate important features of earlier generations. Too many early contributions in the growth and development, nutrition and physical activity fields have been forgotten, sometimes because of not being as readily accessible in today’s digital world. Acknowledging maxims from the past was also a focus of one of our earlier papers. [18]
In 2001, I joined Jan Borms and Marcel Hebbelinck (Free University of Brussels) and later, Tim Noakes (University of Cape Town), as a Series Editor of the prestigious Medicine and Sport Science Series (S. Karger AG, Basel). Since then, we have co-edited a long list of volumes after personally completing two earlier prominent titles with Jana Pařízková (Vol. 43, Physical Fitness and Nutrition During Growth, 1998) [19] and Toivo Jürimäe (Vol. 44, Body Composition Assessment in Children and Adolescents, 2001). [20] In 2006–2007, I had the pleasure of joining an international team of experts who delivered the IAEA Nobel Peace Prize Fund Nutrition Schools in Kampala, Uganda and Dhaka, Bangladesh on the double burden of malnutrition. I’ve also had the good fortune of serving on many other IAEA-funded regional projects and trained numerous Research Fellows from developing countries on the use of stable isotopes in nutrition with the support of the IAEA and the Australian Nuclear Science and Technology Organisation (ANSTO). These included a six-nation Regional Technical Cooperation project on Childhood Obesity Prevention in Asia and a twelve-nation Collaborative Research Project on Body Fat and Metabolic Risk in Pre-adolescents and Adolescents. More recently, I have been a Principal Investigator and Australian site lead on the large international Multi-Centre Infant Body Composition Reference Study (MIBCRS) to develop global references for infant body composition to sit alongside the WHO Child Growth Standards.
Reflections of the way life used to be!
Imagine for a moment if our respective communities aspired to be the healthiest in our country and by doing this, created a positive legacy for subsequent generations. Why wait for the problem of obesity to worsen? In the words of David Rothkopf, “sometimes a problem reaches a point of acuity where there are just two choices left: bold action or permanent crisis”. There is no better time than the present to sow the seeds to realise this goal by working more closely with young people to improve their health and wellbeing. Here, the words of the former President of the United States of America, Theodore Roosevelt resonate, “what we do for ourselves dies with us. What we do for our communities lives long after we are gone”.
This reminds me of the relevance of the words, ‘reflections of … the way life used to be!’ from the classic hit song Reflections by the Supremes (1966). Our focus must be to build on existing capacity of our communities and in so doing, provide the foundation for the next generation to flourish and be healthier than their parents and grandparents. This aspiration is essential if we are serious about challenging ballooning childhood obesity statistics and the dire forecast by Olshansky et al. [21] Without “effective population-level interventions to reduce obesity … the youth of today may, on average, live less healthy and possibly even shorter lives than their parents”. Is this how we want to be remembered for the way we nurtured, (or not), our greatest assets, the next generation? In the words of Nelson Mandela, “there can be no keener revelation of a society’s soul than the way in which it treats its children”.
Young children are the key to the future with nutrition and physical activity being so critical that we must do everything possible not to restrict their movement. Health and education are central to the future of our children but sadly, too many are robbed of their developmental potential. Physical activity can be described as an underestimated investment in human capital with numerous developmental markers linked to appropriate levels of activity. [22] Physical literacy, the repertoire of movement skills necessary for an individual’s meaningful engagement in physical activity, and consistent with the establishment of fundamental movement (or motor) skills (FMS), is one of the most important life skills. However, as too many young children have a poor start to life characterised by unhealthy activity and eating behaviours, novel approaches are urgently needed to establish optimal conditions for the development and progression of FMS, and sound nutritional practices.
Imagine tackling the problem head-on globally within early education and care settings using a targeted and multi-pronged approach including collaboration between educators, teachers, families, and children. The realisation of baseline FMS would be a major step towards all children flourishing and reaching their physical health and education potential. Even better if across the school years, foundational FMS was capped with a high-quality Health and Physical Education curriculum, as referenced earlier.
Many parents happily accept the premise that children would benefit from a greater proportion of the school curriculum being devoted to academic pursuits (commonly at the expense of Health and Physical Education and the arts). Much less attention has been paid to the demise of physical activity across the curriculum and the resultant impact on health and wellbeing. Trudeau and Shephard [23] concluded that with competent delivery, physical activity can be added to the school curriculum by taking time from other subjects without compromising academic achievement. Adding time to ‘academic’ subjects by taking time from physical education does not guarantee an increase in grades—however the reverse is true, it is very likely to be detrimental to a young person’s health and wellbeing.
A focus on prevention is essential along with translation of current evidence or ‘best bets’ into practice; ideally utilising multi-level, whole-of-government, and multi-sectoral approaches. Sustainable changes are needed across all sectors including education, health, and transport, along with rigorous program evaluation. Everyone has a role to play, it is everyone’s responsibility.
The first 1000 days from conception to 2 years of age, or even better, the first 2000 days to 5 years of age, hold the key to the prevention of unhealthy weight gain. Indeed, I contend that infancy and the early childhood years constitute a critical and under-utilised life stage for obesity prevention. For maximum impact during these years of growth and development, physical activity and nutrition must return to being a higher priority along with physical environments conducive to active play. [24]
The minimum investment should see consistent education and support of parents and teachers, and the propagation of community nutrition and activity opportunities, including walking to and from school. When I was at primary school, albeit it many moons ago, everyone walked or cycled to and from school, and often back and forth from home for lunch. Why can’t the same be true today, at least for a significant proportion of young children? Concerns regarding safety from increased vehicular traffic and ‘stranger danger’ are the most common excuses used to limit engagement in such an important physical activity opportunity. The flipside is that if everyone walked or cycled to and from school, safety in numbers would be assured, particularly if oversight was provided by rostered adults, including parents and/or grandparents.
In the 1990s, we were lauded as progressive and innovative for the design, promotion, and delivery of Walk to School programs in Queensland primary schools, a simple and daily form of physical activity I took for granted during my formative years. A sad indictment of present-day society is that we needed a sophisticated training program for walking leaders and comprehensive insurance coverage for the Walk to School program to operate!
One of the best international active transport initiatives I have experienced is the Swiss walking school Pedibus (https://pedibus.ch/fr/) seen firsthand on regular sojourns to the Institute of Physiology, University of Lausanne to work with Yves Schutz and Dominique Durrer (see Fig. 1). In many parts of Switzerland, it is commonplace for approximately 75% of children from 4 years of age to walk to school ‘on’ the Pedibus supervised by parents and/or senior volunteers. What a wonderful intergenerational example of physical activity. There is absolutely no reason such an approach could not be replicated in many places across the globe.
Fig. 1
In my opinion, one of the more counterproductive features of obesity research has been a preoccupation by some to determine whether nutrition or physical activity is the major driver of the obesity pandemic. As physical activity and eating behaviours ‘cluster’, we should address both together in obesity prevention efforts. Parents, siblings, and the family environment, along with early childhood education and care settings and schools, are all critically important. A new baseline may include encouragement and support of ‘small changes’ in diet and/or physical activity as modest changes are more likely to be tolerated by the greater proportion of individuals. [25]
Other ‘best bets’ for obesity prevention should encompass greater opportunities for young mothers and families to gain the knowledge and skills necessary to maximise health and wellbeing. Such knowledge and understanding would help adults and caregivers be better placed to support the healthy growth and development of their offspring. Consistent with increasing evidence of the importance of preconception health to improved outcomes for the next generation, strategies to optimise the health and wellbeing of adolescents would be a great investment in the future. [26, 27] I am particularly honoured to be a Chief Investigator on the Centre for Research Excellence Health in Preconception and Pregnancy (CRE-HiPP) working with Helen Skouteris and colleagues (https://hipp.org.au/). Other initiatives I am passionate about in the space include the wonderful work undertaken by colleagues as part of the B4 Early Years Coalition (https://b4.education.tas.gov.au/). Given the very strong evidence that quality early health and education has such an integral bearing on long-term outcomes, imagine if the first 2000 days of life was everyone’s responsibility!
To move forward with impact and make a dent in the number of children living with obesity globally, we would be wise to acknowledge some of our earlier failings. This might include reconceptualising our intervention approaches, recognising the collective assets of our communities, and systematically focusing on the co-creation of shared value. Such approaches have been variously described, including as asset-based community development (ABCD) and more recently, collective impact, where a strengths (as opposed to deficit-based) approach, is employed. A strengths-based approach encompasses the co-design or co-creation of workable, relevant, place-based initiatives with increased likelihood of sustainability, particularly in more resource-poor settings.
In North-West (NW) Tasmania, we have been working to improve the health and wellbeing of residents in three sentinel site communities using such a capacity building approach. The region has often been described as one of the most picturesque and visually appealing locations in the state, and one of the primary food bowls. Rich and productive volcanic soils guarantee fine vegetables and fruit and support high-quality dairy herds and Wagyu beef cattle. Sadly, people in this region are often maligned for their poor health outcomes and low educational attainment, a situation diametrically opposed to the idyllic physical environment.
Interestingly, the NW Coast also has a rich and proud history of sport and engagement in habitual physical activity, but the health profile of the present-day population is characterised by high levels of overweight and obesity at all ages. How is it that such dichotomies exist? How could we have got things so wrong, and more importantly, how could we possibly make a difference now? The overarching goal of our project, CAPITOL (Critical Age Periods Impacting the Trajectory of Obesogenic Lifestyles) (https://www.utas.edu.au/health/community-programs/capitol), is to work with community to co-design place-based approaches to intervention. Such an undertaking is uncommon compared to the mainstream practice of introducing favoured or road-tested interventions parachuted into communities to ‘solve’ challenges. In our experience, there is often a lack of appropriate co-designed, collaborative, and community-led relevant information. Priority initiatives include approaches to supporting parents and educators across the first 1000 days, including nutrition and activity, and school gardens and nutrition embedded in the curriculum being the norm rather than exception.
The notion of ‘free range’ children resonates with me as this was certainly the nature of the childhood I experienced, replete with opportunities to be physically active. We have transitioned from this to a generation of ‘backseat’ kids, commonly transported everywhere, including to and from school. Many parents are not happy unless they can drop their child as close to the front door of the school as possible. It appears that the preference for some would be to drive into the school grounds, up the front steps, to drop their child off at the classroom door! It should be little surprise that the greatest daily accident risk for children coincides with school drop-off and pick-up times.
Michael Young, the influential social innovator, who developed a multitude of social enterprises, including the Open University, had some poignant advice regarding schools and schooling. Young described traditional education, including higher education, as a ‘diet thought up by educators about what they (children) should have.’ According to Young, being ready to learn was a much more important factor than assuming all children would learn in the same way and on the same timetable. This thinking also reminds me of the Finnish education system and is exemplified in the writing of Pasi Sahlberg. Along with Michael Doyle, Sahlberg wrote the informative book, Let the Children Play: How more Play will Save our Schools and help Children Thrive, [28] and illustrates how we have lost sight of what is important for many children. My strong suggestion is that active play should be featured in the school curriculum, even better if positive play experiences co-existed with opportunities for children to grow, harvest, and cook with bounty nurtured in school and community gardens.
People with hypertrophic cardiomyopathy (HCM), whether or not they are competitive athletes, needn’t be routinely advised against vigorous exercise or upping the intensity of their daily activity, suggests a prospective study of patients with clinically evident or a genetic predisposition to HCM.
Patients with HCM have traditionally been advised against activities that require intense exercise, including recreational or competitive sports, so as not to worsen their already elevated risk of ventricular arrhythmias or sudden death.
But such cautions, applied to everyone with HCM, are probably unfounded and may unnecessarily deprive such patients of the health benefits of exercise and its other rewards, say researchers reporting results from the LIVE-HCM study.
Risk for the study’s clinical primary endpoint over 3 years was similar for those of the 1660 patients who self-reported engaging in vigorous exercise, as defined on a questionnaire, and those who exercised “non-vigorously,” that is, at low to moderate levels. It was also similar for those in the vigorous-exercise group who engaged or did not engage in high-intensity competitive sports.
The composite endpoint, which consisted of death, cardiac arrest, syncope considered likely to be arrhythmic, or appropriate implantable-defibrillator shocks, occurred in fewer than 5% of study patients overall, reported Rachel Lampert, MD, on March 6 at the American College of Cardiology (ACC) Scientific Session/World Congress of Cardiology (WCC) 2023, held live and virtually from New Orleans, Louisiana.
The findings “do not support universal restriction of vigorous exercise in patients with hypertrophic cardiomyopathy.” Rather, they should inform discussion between patients and their physicians regarding safe levels of exercise “in the context of expert assessment and management of HCM using an individualized shared decision-making framework,” said Lampert, director of sports cardiology at Yale School of Medicine, New Haven, Connecticut.
Among the caveats about the trial, she said, were that the patients weren’t a randomly selected sample and received care at experienced HCM centers.
Lampert told theheart.org | Medscape Cardiology that participants were asked at the outset what their physicians had recommended to them about exercise.
About 75% of the patients with overt, clinical HCM, she said, and even a third of the phenotype-negative, genotype-positive participants had been advised not to exercise.
But given these results, “We’re now able now to say to HCM patients — after they have been appropriately evaluated by and talked with HCM experts, so that we know they’ve been assessed and treated appropriately — that you can join that soccer league, you can get all the enjoyment and physical benefits of exercise, because it’s not going to put you at higher risk than you already are.”
Exercise restriction can be an enormous burden for patients with HCM, she added. “We know that restriction from exercise worsens your quality of life. And so, I think that this,” the study’s findings, “will be liberating for that group.”
That vigorous exercise did not appear to raise the patients’ risk for major cardiac events was “really encouraging,” agreed sports cardiologist Eugene H. Chung, MD, MPH, University of Michigan Health, Ann Arbor, who isn’t associated with LIVE-HCM.
For such patients and for any level of exercise, “it’s not as high-risk as we used to think. Therefore, the message is that we should be less restrictive than we have been,” he told theheart.org | Medscape Cardiology.
In the previously published RESET-HCM trial, he noted, HCM patients who engaged in a 4-month moderately intensive exercise training program showed improved cardiovascular fitness with no increase in arrhythmic risk.
“There were essentially no real events over the follow-up period, a moderate level of activity seemed reasonable,” Chung said. Now, LIVE-HCM seems to say that “higher-intensity levels are very reasonable too.”
LIVE-HCM enrolled 1660 patients aged 8 to 60 years who had clinical HCM or a genetic predisposition but not the disease at 42 centers in North America, the United Kingdom, Australia, and New Zealand; 42% were female. Any with exercise-restricting clinical disease, such as advanced heart failure, were excluded.
Participants self-reported their level of regular exercise as vigorous (at least one activity of >6 METS for more than 60 h/y) or moderate (activities between 4 and 6 METS for more than 60 h/y) or low (not meeting criteria for vigorous or moderate exercise), per definitions in the Minnesota Leisure Time Activity Questionnaire.
About 42% and 43% of participants reported vigorous or moderate exercise, respectively; the remainder reported low exercise levels. The primary analysis compared the vigorous-exercise group to those reporting non-vigorous exercise, that is, the moderate- and low-level exercise groups combined. All events were blindly adjudicated.
The primary endpoint rate was 15.3 per 1000 person-years for the 961 patients reporting non-vigorous exercise and 15.9 per 1000 person-years for those reporting vigorous exercise. Their rates for components of the primary endpoint were also similar. Of note, about equal proportions of patients had implantable defibrillators, and all endpoint events occurred in those with clinical HCM.
Of the 699 patients reporting vigorous exercise, 259 said it was in the context of competitive sports: 440 reported vigorous noncompetitive exercise. Their primary endpoint rates per 1000 person-years were similar at 13.1 and 17.6, respectively.
The appropriate doctor-patient discussion regarding HCM and exercise may be evolving to become less about avoiding higher-intensity activity and more about the benefits of exercise, Chung observed. The message, he said, “will be that everyone needs to exercise, and that at whatever level you want to do it, it’s relatively low risk. I think we’re heading in that direction.”
Fewer than 20% of adults and adolescents around the world meet WHO’s physical activity guidelines, according to researchers.
The guidelines from 2020 recommend that children and adolescents complete 60 minutes of moderate-to-vigorous aerobic physical activity every day, and muscle-strengthening activities (MSA) 3 days per week. For adults and older adults, the guidelines call for 150 to 300 minutes of moderate physical activity or 75 to 150 minutes of vigorous intensity per week and MSA 2 days per week.
Globally, only one in five adults meet physical activity guidelines, according to researchers. Source: Adobe Stock
In a systematic review and meta-analysis, Antonio Garcia-Hermoso, PhD, head of the children and youth physical activity unit at Navarrabiomed, which is affiliated with the Public University of Navarra, and colleagues sought to estimate the proportion of the global population that was meeting WHO’s recommendations.
“Our study provides an accurate estimate of the prevalence of physical activity at the population level, which is an important modifiable chronic disease risk factor,” Garcia-Hermoso and colleagues wrote in the British Journal of Sports Medicine. “Adults engaging in aerobic and MSA at recommended levels showed important reductions in the risk of all-cause and cause-specific mortality in addition to a lower risk for multimorbidity (eg, cardiovascular risk and type 2 diabetes).”
The researchers searched five databases and identified 21 studies that included approximately 3.4 million people from 31 countries.
Overall, they found that the prevalence of adherence to the guidelines was 17.15% (95%, CI 15.44%-18.94%) among adults. The prevalence of adherence was slightly higher among teens, at 19.45% (95% CI, 16.34%-22.75%)
They additionally noted that adherence was lower among adults with low or medium education levels, those who were older, women, people who had underweight or obesity and those who self-rated their health as poor or moderate (P < 0.001), “although the prevalence remained very low in all cases.”
The researchers also analyzed prevalence by geographic location. Compared with those from Northern European countries like Iceland, Sweden, Denmark and the Netherlands, the United States and Southern and Central European countries like Malta, Cyprus, Croatia, Romania and Poland had lower prevalence of meeting guidelines.
Garcia-Hermoso and colleagues wrote that they were “unable to identify the key causes of the geographical differences” but offered a few possible explanations, like the different tools used to measure physical activity or “adoption of different exercise promotion policies between countries.”
“The Netherlands, one of the countries with higher prevalence, adopted the physical activity guidelines in 2017, and aimed for 75% of the Dutch population to adhere to them,” the researchers wrote. “The government launched several national policies or action plans for the promotion of physical activity for health through the collaboration between central government, the sports sector, municipalities, businesses, care providers and civil society organizations.”
Additionally, “wealth inequalities across countries, which likely impact an individual’s access to fitness facilities or the availability of free time to engage in aerobic and MSA, could also explain some of these differences.”
Garcia-Hermoso and colleagues concluded that “only one out of five adolescents and adults met the recommended combined aerobic and MSA guidelines,” and “large-scale public health interventions promoting both types of exercise are needed to reduce the associated burden of noncommunicable diseases.”
“These low prevalence levels are concerning from a public health perspective and emphasize the need to provide large-scale physical activity interventions that must be supported by long-term political commitment and paired with coordinated and sustained dissemination and communication strategies across sectors,” they wrote.
Your body was designed to move—a lot. When our ancestors began transitioning from a more sedentary existence toward a hunter-gatherer lifestyle, the increase in aerobic activity may very well have contributed to the evolution of greater longevity. As hominids appeared, we came down from the trees onto the savanna and began traveling long distances in our search for food and running to chase our prey. Our longevity increased in direct proportion to our activity level. The same strategy that enabled our ApoE4 predecessors to thrive provides important clues for optimizing our lives today. Evolution suggests that we were born to run. In fact, of all of the strategies we recommend, none has more scientific evidence than exercise. Being active is the single most important strategy you can employ to prevent and remediate cognitive decline. But it alone is rarely sufficient—it exerts its best effects when used in concert with the other features of the protocol, like fasting and diet.
Exercise protects us at a cellular level.
It upregulates Nrf2, which protects our cells by conferring epigenetic protection for greater resilience to environmental stressors and by increasing the cells’ capacity to prevent and resist disease. Exercise is also an important strategy to heal the damaged mitochondria that accompany insulin resistance.
Exercise is beneficial in many other ways.
It can help you maintain a healthy BMI and reduce insulin resistance, blood pressure, and the risk for heart disease and stroke. It also reduces stress and anxiety while improving mood and sleep. The great news is that any form of exercise helps by increasing brain volume—everything from walking to gardening to dancing. When starting any exercise program, be sure to check with your physician to make sure that you’re healthy enough to engage in your preferred activity. It’s always tempting to overdo, but you ultimately hurt yourself if you sustain an injury and have to refrain from exercise while you heal.
Everyone wants to know the best form of exercise for brain health.
Aerobic exercise has been studied in greater depth than strength training and might take a slight lead, but both have been found to be vitally important as we age. The term aerobic exercise is used for any sustained physical activity—examples are walking, jogging, cycling, or rowing—that improves the efficiency of the body’s cardiovascular system.
Aerobic exercise is thought to be helpful in several ways. Most important, it provides a more constant and sustained level of cerebral blood flow. Increasing blood flow to the brain is vitally important, as a deficit in this is one of the first measurable manifestations of the Alzheimer’s disease process.
Strength training as it relates to cognitive health hasn’t been as well studied, but being strong is an important part of general health. Strength training prevents sarcopenia, the natural loss of lean muscle mass that occurs with aging. Sarcopenia is correlated with cognitive decline. Strength training also prevents the loss of bone, which reduces the risk of cognitive decline, slows aging, and prevents brain atrophy.
Rethink exercise.
Rather than viewing your workout as an obligation, make it the highlight of your day. Whether it’s a long meditative hike in nature or a social group bike ride, schedule everything else around this sacred time. This is your dedicated time to move your strong body. If you keep the experience joyful and fun, it will soon become a self-perpetuating habit. Intellectually understanding that exercise is a powerful neuroprotective strategy is important, but translating that knowledge into daily practice is what matters.
One of the simplest forms of aerobic exercise, which incorporates strength training because it’s naturally weight bearing, is walking. Try to incorporate a daily walk into your routine. Walk with purpose, as if you were late for an appointment. Depending on your current fitness level, you may need to start slowly. That’s okay. Just try to increase the length of your walk by a few minutes per day until you reach thirty minutes or more.
Below are strategies for getting the most out of your walk.
Walk with a friend. Connecting with others is vital for brain health. Socialize as you exercise.
Play with speed. As you feel stronger on your daily walk, consider increasing your speed and even adding periods of running or sprinting.
Add music. When you are walking alone, listen to your favorite music and even sing along. You could also listen to meditative music to unwind as you walk.
Train your brain. Incorporate cognitive training into your daily walk. While walking, practice saying the alphabet backward. Try to count backward from one hundred by sixes, sevens, eights, and nines.
Learn while you “burn.” Use exercise as a time to learn while you’re burning your own body fat, harnessing the power of the mind/body connection.
Use a weighted vest. This is especially helpful for those working to increase bone density. Research has shown that this is a safe and effective way of increasing the demand on your body and improving bone density. Start with a low weight and slowly move up.
Add walking lunges. Incorporating a few sets of walking lunges adds variety to your walk, while increasing your leg strength.
Make nature your gym. Look for opportunities to add other calisthenics on your walk. When you pass a bench or a log, for instance, stop for a set of triceps dips or push-ups.
Consider getting a dog. There are many healthful aspects to pet ownership, but the responsibility of having to walk a dog several times throughout the day may provide the motivation you need for a number of daily walks.
Track your progress. Use a pedometer to monitor your motion.
Remember, there are no FDA-approved medications (nor any in the pipeline) that come close to demonstrating the improvements seen with daily exercise. None. Exercise is free and accessible to everyone. Baby steps turn into exhilarating hikes through nature. The more active you become, the better you’ll feel and the more you’ll want to exercise.
Summary: Higher rates of light physical activity and moderate-to-vigorous exercise were associated with a lower risk of death. Sedentary lifestyles were associated with a higher risk of death. The findings were consistent among women with different levels of genetic predispositions to longevity.
Source: UCSD
Previous research has shown that low physical activity and greater time spent sitting are associated with a higher risk of death. Does risk change if a person is genetically predisposed to live a long life?
That is the question researchers at the Herbert Wertheim School of Public Health and Human Longevity Science at University of California San Diego set out to answer in a study published in the August 24, 2022 online edition of the Journal of Aging and Physical Activity.
“The goal of this research was to understand whether associations between physical activity and sedentary time with death varied based on different levels of genetic predisposition for longevity,” said lead author Alexander Posis, M.P.H., a fourth-year doctoral student in the San Diego State University/UC San Diego Joint Doctoral Program in Public Health.
In 2012, as part of the Women’s Health Initiative Objective Physical Activity and Cardiovascular Health study (OPACH), researchers began measuring the physical activity of 5,446 women in the United States who were 63 and older, following them through 2020 to determine mortality. Participants wore a research-grade accelerometer for up to seven days to measure how much time they spent moving, the intensity of physical activity, and sedentary time.
Participants wore a research-grade accelerometer for up to seven days to measure how much time they spent moving, the intensity of physical activity, and sedentary time.
The prospective study found that higher levels of light physical activity and moderate-to-vigorous physical activity were associated with lower risk of death. Higher sedentary time was associated with higher risk of mortality. These associations were consistent among women who had different levels of genetic predisposition for longevity.
“Our study showed that, even if you aren’t likely to live long based on your genes, you can still extend your lifespan by engaging in positive lifestyle behaviors such as regular exercise and sitting less,” said senior author Aladdin H. Shadyab, Ph.D., assistant professor at the Herbert Wertheim School of Public Health and Human Longevity Science at UC San Diego. “Conversely, even if your genes predispose you to a long life, remaining physically active is still important to achieve longevity.”
Given the aging adult population in the United States, and longer time spent engaging in lower intensity activities, the study findings support recommendations that older women should participate in physical activity of any intensity to reduce the risk of disease and premature death, wrote the authors.
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