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EXERCISE-THE KEY TO GOOD HEALTH

■Lifestyle diseases- causes of death■Why is Exercise beneficial ?■Why is sedentary behavior

harmful?■Need to understand what the

research is really saying

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Exercise is Medicine® created the Rx for Health series

■ https://www.exerciseismedicine.org/support_page.php/rx-for-health-series/

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Course plan- Day 1

■Predictors of Health■Active vs Sedentary■Overview of benefits

– Principles of Exercise– Components of exercise– Why not just any exercise can help

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Day 2- Health Benefits of Exercise■ Immediate effects■ Overall effects- (aging)■ Brain and nervous systems

– Stress management■ Cardio-respiratory systems■ Diabetes- metabolic syndrome■ Weight control■ Sleep

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Day 3

■ How to exercise safely?-When should you not exercise?

■ Factors for deciding “What type of exercise is best for you”?■ Benefits of different types of exercises■ Recommended amounts

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■Questions?■Brain Break

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Brain Break■ crossing the mid line and using your

brain

■ Dance– Both Arms up & down– Both arms side to side– 1 arm up& down, 1 arm side to

side

■ Fish and Snake – Both arms fish– Both arms snake– 1 arm- fish and 1 arm snake

■ Tap Your Head and Rub Your Tummy – Both arms tap head– Both arms rub tummy– Alternate arms

■ YMCA– Normal– backwards

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Humans are designed to move■Any movement is beneficial but it

is dose related–The more you move the more

benefits occur–You get benefits at any age–Movement Break

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Predictors of Health

■Genetics■Amount of excess Body fat

– Body composition not weight ■Diet■Exercise/ sedentary behavior■Stress Levels

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Exercise works best as preventative or conjunctive therapy

–Not cure■ Exercise can help slow cellular aging

–Helps preserve Telomeres– In one study-People who do vigorous exercise 5 days/

week had longer telomeres equal additional 9 years – Best results from cardiorespiratory exercise

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Benefits of exercise are separate from the risk of sedentary behavior

–Can be fit but sedentary–The more you sit the more exercise

you must do to compensate■ Get up frequently■ Use fitness monitors

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■ Attaining the health fitness standard requires only moderate physical activity

■ For high physical fitness, a high intensity exercise program is required

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Risk of Poor Health

Comparing sitting Time VS Physical Activity

What is Moderate and Vigorous Exercise?

■ Moderate ExerciseAble to sustain for a long time↑ heart rate and breathing rate but can singSome muscle fatigue

■ Vigorous Exercise– High Heart rate– Fast breathing so uncomfortable to say a long sentence or

sing– muscle fatigue– Can only do for shorter period of time

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Principles of Exercise■ Use it or lose it

– Can lose level of fitness in a few days of total rest– If you stop exercising, up to 50% of fitness improvements

are lost within 2 months■ Specificity- Specific Adaptation to Imposed Demands (SAID)

– Only the body systems used in exercise will improve■ Progressive Overload

– Only by working harder than normal will there be improvement

– Need to continue to increase work to improve

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Progressive Overload

■ FREQUENCY■ INTENSITY■ TIME■ PROGRESSION

■ Each component of Fitness is different

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Components of Exercise■ Cardio-respiratory Exercise-Measured –Volume of Oxygen used VO2

– Heart rate, breathing, perceived exertion

■Muscular Strength 1 rep max- amount of weight about to lift one time only

■Muscular Endurance time able work a muscle without fatigue

■ Flexibility Range of motion around a joint

■ Body composition– Ratio of fat to lean body mass, % fat

■ Balance ■ agility

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Exercise Recommendations■ All exercise recommendations are: Minimal levels

■ Need to do more than minimum to have good progression

– Designed to be appropriate of all age levels– Designed to be ultra safe

■ The Benefits are Dose-related– The greater the level of fitness > benefits– The greater the intensity> the benefits and rate of

progression

– https://www.acsm.org/acsm-positions-policy/physical-activity-guidelines-for-americans

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■ All should participate in moderate intensity aerobic PA for a minimum of 30 min on 5 days/week or vigorous intensity aerobic activity for a minimum of 20 min on 3 days/week

■ Combinations of moderate and vigorous intensity exercise can be performed to meet this recommendation.

■ Every adult should perform activities that maintain or increase muscular strength and endurance for a minimum of 2 days/week

ACSM, American College of Sports Medicine; AHA, American Heart Association

The ACSM-AHA Primary Physical Activity (PA) Recommendations for Healthy Adults aged 18-65

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Dose-response Relationship

■ More exercise has more benefits■ additional health benefits from

– 300 min/week of moderate intensity activity; – 150 min/week of vigorous intensity, aerobic

activity; or – an equivalent combination of moderate and

vigorous intensity, aerobic activity.

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■ 1,000 kcal/week- minimum– Sufficient to reduce disease risk– A great initial goal for some ■ especially. sedentary or unhealthy

– Enough to move from sedentary to low PA level

– Insufficient to maintain healthy body weight– Insufficient to experience full health benefits

Dose-Response Relationship

• Greater dose (~2,000 kcal/week) required to− maintain healthy body weight, − prevent weight gain, − provide additional health benefits, and − move a person from a sedentary to active PA level.

− Too much high intensity activity= > 5 structured hours/week can lead to negative health consequences or overuse injuries

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Sit Less

■ Non-exercise Activity Time- NEAT■ Frequent movement better than one long activity

time■ Try 2-3 minutes every 30 minutes■ Count steps per hour ( 250 steps/ hour)

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Why Need all of the Components of Fitness■ Specificity■ Different body parts use different energy systems■ Different energy systems use

– Carbohydrates- glucose– Fats– Or both– Protein is not a preferred fuel

■ Oxygen Debt

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Energy System of the Body

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Adenosine Triphosphate (ATP) ■ Immediate Energy is released through

hydrolysis of ATP. ■ Must be constantly replaced.■ anaerobic

■ ATP (ATPase) ADP + Pi + energy

Creatine Phosphate (CP)

■ Replenishes ATP■ Rapid system: one enzymatic step■ Anaerobic system■ A limited amount of ATP is produced

based on amount of CP

ADP + CP (creatine kinase) ATP + C

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Anaerobic Glycolysis ■ Can only use carbohydrates■ Carbohydrate (glycogen or glucose)

degrades to pyruvate – If O2 available - goes to Citrus Acid

Cycle (aerobic production of ATP )– Converts to lactate. (lactic Acid)

■ Series of enzymatically catalyzed steps■ Does not use oxygen■ Produces a net 2.5 ATP

Figure 5.5. A net yield of 32 ATPs from energy transfer during the complete oxidation of one glucose molecule in glycolysis, the citric acid cycle, and electronic transport. (From Katch VL, McArdle WD, Katch FI. Essentials of Exercise Physiology. 4th ed. Baltimore [MD]: Lippincott Williams & Wilkins; 2011. 790 p., with permission.)

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Aerobic Oxidation ■ Oxidative phosphorylation can use fat,

protein, and carbohydrate to produce ATP.■ Krebs cycle (citric acid cycle) and Oxygen

Transport System■ As duration and intensity of activity

increases, aerobic energy metabolism increases.■ 1 molecule of glucose = 32 ATP■ 1 molecule of fat = 130 ATP

CHO is preferred during high intensity exercise because its metabolism yields more energy per liter of O2 than fat metabolism.

kcal/l of O2

CHO (Carbs) 5.05 Fat 4.74

CHO can also produce energy without O2!!!

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Metabolic Efficiency

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Storage Efficiency

■ Fat is preferred during prolonged exercise because its metabolism provides more energy per unit mass than CHO metabolism.

kcal/g of fuelCHO (carbs) 4.10 Fat 9.45

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Days 2- Benefits of Exercise■ Immediate response/ benefits■ Overall benefits■ Brain and nervous systems

– Stress management– sleep

■ Cardio-respiratory systems■ Diabetes- metabolic syndrome■ Weight control

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Immediate response to exercise■ ↑ Heart Rate & Stroke Volume■ Vasodilation of arteries■ Dilation of Bronchioles■ ↑ ability for O2 to attach to red blood cell &

release CO2■ ↑ metabolism■ ↑ freedom of movement-joint, muscle

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Immediate response to exercise

■ ↑ mental alertness- Amygdala, Hypocampus■ ↑ focus■ ↑ reaction time■ ↑ serotonin and endorphins

– ↓ feelings of pain■ ↑ release of antioxidants

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Immediate Aftereffect of Exercise

■ ↓ stress response- cortisol, epinephrine■ ↑ Mood

– ↓ anxiety and depression■ ↓ blood pressure■ ↑ metabolism- depends on exercise■ Maintain > range of motion for hours

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Benefits of Regular Physical Activity and /or Exercise

■ Benefits accrue as soon as you start to exercise■ It is dose-related and type of

exercise related■ Excessive exercise and incorrect

exercise can be harmful

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Benefits- Reduces Morbidity & Mortality

■ Overall regular exercisers live longer■ Lose fewer telomeres

which slows aging■ It can reduce cellular age

as much as 7 years■ Includes maintenance of

number of brain cells

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Benefits- Reduces Morbidity & Mortality

■ Reduces deaths from all causes including cancers■ Shortens time of morbidity■ Reduces Falls and accidents of all causes■ Helps improve or maintenance of functionality

– Range of motion in joints– Strength and flexibility to continue to maintain

independence– Increase or maintain bone density

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Benefits- Stress Reduction

■ Reduces stress levels– Stress response designed for physical response– Serotonin– Meditative or concentrate on activity

■ Body learns to respond to stress at reduced level-resistance stage■ Helps change perceptions- self-confidence, self-

efficacy

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Benefits- Brain Functions

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• Maintains cognitive functioning- short and long term

• Veins remain straighter- better blood flow

• reduced risk of Alzheimer’s disease and other dementias

• Reduces feelings of anxiety and depression – healthy and clinical symptoms

Benefits- Brain Functions

■ Reduces risk of depression and as good a treatment as therapy- best as a supplement to treatment

■ Improves sense of well being including sense of control-reduces stress levels

■ Improve sleep and quality of sleep– Takes time to take effects– Helps reset circadian rhythms– Reduce stress– Reduce risk of sleep apnea due to obesity

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Benefits cardio-respiratory systems

■ ↑ ability to distribute and use Oxygen ■ ↑ ability of heart to pump more powerfully■ ↑ capillary density in muscles■ ↑ amount of work at same HR and VO2 level■ ↑ exercise threshold for lactate accumulation■ Reduce heart rate and BP at same work load■ ↑ exercise threshold for the onset of disease symptoms

such as angina, claudication, ischemic ST-segment suppression)

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Benefits cardio-respiratory systems

■ ↑ HDL and reduce LDL and triglycerides■ ↓ resting systolic/ diastolic■ ↓ blood platelet adhesiveness &

aggregation■ ↓ inflammation- nitric oxide

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Benefits- Diabetes, metabolic syndrome and Obesity

■ ↓ insulin needs and improve glucose tolerance

■ ↓ Insulin resistance

■ Fat metabolism is greater in fit individual– More mitochondria- citric acid cycle

■ Importance of fat location– Subcutaneous- under skin – Visceral- abdominal

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Benefits- Metabolic Health

■ Visceral fat is most metabolically active– Waist circumference-– Linked to high LDL, insulin

resistance, diabetes, cancers, gall bladder

– Responds well to increased exercise

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Disease risk based on Height, weight, and waist circumference■ The BMI is used to assess weight relative to height

and is calculated by dividing body weight in kilograms by height in meters squared (kg · m−2)

■ Disease Risk- BMI and Waist Calculatorhttps://www.webmd.com/diet/body-bmi-calculator

■ Does not account for muscle and body type but most often used

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Waist – narrowest between hip and ribs

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DAY 3

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Exercise-Related Cardiac Events in Adults

■ According to ACSM and CDC-■ Absolute risk of sudden cardiac death during vigorous intensity, physical

activity has been estimated at one per year for every 15,000–18,000 previously asymptomatic individuals.

■ Although these rates are low, more recent available research has confirmed the increased rate of sudden cardiac death and acute MI among adults performing vigorous intensity exercise when compared to their younger counterparts.

■ The physically active or fit adult has about 30%–40% lower risk of developing CVD compared to those who are inactive.

Fitness Website- EXRX

■https://exrx.net/■ Expert information■ Lists of exercises and programs for

– All types of exercise – Different goals

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Check with your Medical Professional before you begin a new exercise program or do high intensity activity■ Exercise can affect how you react to your

medications■ Especially Diabetic medication and diet regimens

and certain cardiac medications

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Why Do You Want to Exercise

■ Health– Mental– Physical

■ Weight Management■ Social ■ Fun

■ Competition■ Sports not the same

as an exercise program– Complement

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Exercise Notes

■ The best exercise is one you will actually do on a regular basis■ We actually build and repair our bodies on the rest

days. – Exercise tells our body to improve but we must

take time for repair■ Getting outside actually enhances the benefits of

exercise. ”Forest Bathing” “Light therapy “

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Workout- Begin with warm-up

■ Always warmup ■ 3-5 minutes■ Longer if have arthritis or injury■ Gradually increase intensity■ Move all muscle being used in

the activity■ Dynamic Stretching

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Why warm up

■ Gradually increases Heart Rate and vasodilation-– Needed if hypertensive or CHD

■ Increases body temperature and lubrication– Needed arthritis, bursitis, muscle and joint injury

or problems■ Improves performance

– Even reaction times

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How to Warm-up■ Any movement which involves the large muscles especially the

ones used for the activity■ Slow gentle movements which gradually increase in intensity■ NO fast starts or stops■ Tia Chi, yoga, Dynamic stretching■ https://www.teamusa.org/USA-

Triathlon/News/Blogs/Multisport-Lab/2019/May/13/For-Older-Athletes-Use-These-Gentle-Warm-up-Exercises

■ https://www.youtube.com/watch?v=uW3-Ue07H0M■ Dynamic stretching should not try to improve flexibility

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Cool Down

■ Always Cool Down■ Gradually return body to normal level■ Vasoconstriction- prevents blood pooling in feet

– Important for hypertension and CHD■ Blood continues to remove lactic acid from muscles■ Usually when you should do stretching to increase

flexibility

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Exercise Recommendations –Complete Exercise Program■ Cardio■ Strength■ Flexibility■ Agility■ Balance■ Burn calories-(fats)

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Exercise Recommendations-Any physical activity can help improve health

Recommendations

Health Benefits Improve Fitness Performance

Intensity Moderate65- 75% Max Heart Rate Can talk but not sing

Vigorous75 – 95% Max Heart RateUncomfortable to talk

Vigorous –maximal effortCan’t talk

Frequency 3 days/week 3 – 5 days/week 7 workouts /week

Time Minimum of 30 min/ day

30 – 60 min/ day +60 min/ day

Kcal 1,000 kcal/week =340 kcals/day

2,500 kcal/week =500 kcal/day

steps >8,000 steps/ day or equivalent

>12,000 steps/ day or equivalent 67

Changes in Exercise Recommendations

■ Multiple bouts of exercise better than one long– Best if at least 10 minutes or more– Two 15 minutes better than one 30 minute

■ Short bursts of Higher intensity programs produces greater fitness and weight loss than slow and low programs■ Don’t do static stretching before exercise■ Done correctly exercise is safe for almost everyone.

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What is High Intensity, HITT, or Tabata■ High Intensity or HITT=

– short burst of near maximal exercise (15 –60 sec)with short period of rest (15- 60 sec)

– If gradually work up to this= safe for all ages– NOT FOR EVERYONE- get MD okay– Most effective system to improve fitness and burn calories– Creates Oxygen debt– Only done once or twice/week ■ Other days moderate exercise/ sports

■ Tabata

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Oxygen Debt- why Important

■ Describes the difference between the required oxygen for meeting the energy demand of exercise and the actual oxygen consumption■ EPOC- Extra Post-exercise Oxygen Consumption

– # of kcal burned after exercise to repay the O2 debt – (higher % of fat)

– 1 liter of O2= 5 kcals

Extra calories from EPOC

■ EPOC burns about 6 to 15 % of the total calories burned, Andrew said. So if you burned 200 calories during your workout, EPOC burns an extra 12 to 30 calories ■ The amount of extra Kcal depends intensity and

length of exercise■ EPOC is repaid with slightly higher % of fat

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Exercise Compliance

■ Group exercise =– better exercise compliance– More social benefit– Need qualified instructor who give modifications

for exercises■ Make exercise an appointment■ Morning exercise> compliance but afternoon better

physiologically

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Example of Weekly Exercise Routine

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Cardio High Intensity

Rest/low intensity

moderate Intensity

High intensity intensity

Rest/low intensity

Moderate intensity

Moderate intensity

Strength Mild activity Total Body To fatigue rest Total Body

To fatigue rest Mildactivity

Mild activity

Flexibility 5- 10 minutes

5- 10 minutes

5- 10 minutes

5- 10 minutes

5- 10 minutes

5- 10 minutes

5- 10 minutes

AgilityCombine with other exercise

Combine with other exercise

Combine with other exercise

Combine with other exercise

Combine with other exercise

Combine with other exercise

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Cardio exercise

■ Fitness Level-– Max VO2 max Volume of O2 used/minute/kg■ Ml/kg/min

– METS= 3.5 ml/kg/min– Varies every day

■ METS on exercise equipment not accurate

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Cardio Intensity- How Measured

■ Max heart rate = 220-age

■ Problems– Medications– Measurement errors

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Intensity % of HRR % HR max

light 30-39 57-63

Moderate 40-59 64-76

Vigorous 60-89 77-95

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Using Resting HR & Heart Rate Reserve

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220- age = max heart rate (Max HR)Max HR- resting heart rate(RHR) = heart rate reserve (HRR)(HRR X training %) + RHR= training HR

220-70= 150 bpm HRmax RHR= 70 bpm150bpm- 70bpm= (80 bpm Heart Rate Reserve)

Moderate intensity-(80 X 40%) + 70 = 102 bpm(80 X 59%) + 70 = 117 bpm

Cardio Intensity- How Measured

■ Talk Test– Easily done during exercise– Very accurate assessment of actual VO2– Used with both healthy and individual with

cardiac and respiratory problems■ Rate of Perceived Exertion

– Accurate esp. when paired with talk test– Need some training

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Strength-■ Needed by everyone because

– increase # of myofibril- reduce sarcopenia– Improves posture & helps reduce falls

■ Women don’t get large muscles■ Need to work all major muscle groups

– Minimum 8- 10 exercises■ Intensity- need to lift to fatigue

– Lifting to failure- fit individuals only

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What Strength Exercises

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Strength-■ Repetitions- 8 +

– Higher reps- builds muscle as well as high weights

– Amount ■ Set-

– 1 set for beginner– 2-3 sets for most

■ 2 to 3 days/ week- not consecutive

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Type of Strength Training

■ Group exercise■ Water exercise■ Weight Training

– machines ; free weight; body weight■ Pilates■ Yoga

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Flexibility- Range of Motion

■ Do every Day - all major muscle groups – 8 – 10 different stretches– (5-10 minutes)

■ Intensity- Go to pull not pain – Stretch reflex

■ Reduces muscle pain■ Does not decrease risk of injury

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Types of Stretching

■ Dynamic- warm up –doesn’t increase flexibility■ Static- safest – go to pull and hold 15-60 sec

– Increases flexibility■ PNF- proprioceptive neuromuscular facilitation

– Stretch– Tense 10 sec– Increase stretch – Most gains in range of motion both short term and

long term

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DynamicStretches

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PNF Stretching

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Balance & Agility■ Getting out of a chair no hands

– Lowering to seat not flopping■ Getting off the floor■ Standing one leg

– Regular floor– Eyes closed– On toes – On unbalanced surface- teeter board, bosu, balance

pods

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Agility & Balance Drills For Seniors For Preventing Falls•Published on Feb 20, 2019

■ https://www.youtube.com/watch?v=rYs26HEawno

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Videos and articles■ How Exercise Rewires Your Brainhttps://www.youtube.com/watch?v=Aj_5SGdx7Xk

■ The brain-changing benefits of exercise | Wendy Suzuki

https://www.youtube.com/watch?v=BHY0FxzoKZE

■ Dr. Ingrid Brenner - The Stress-Busting Benefits of Physical Activity

https://www.youtube.com/watch?v=TlHsHwD9GOk

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■ ACSM Scientific Pronouncements: Physical Activity Guidelines for Americanshttps://www.acsm.org/acsm-positions-policy/physical-activity-guidelines-for-americansPhysical Activity: A Prescription for Healthhttps://www.exerciseismedicine.org/support_page.php/physical-activity-health-impact/

■ Mayo Clinic 7 reasons to try interval traininghttps://www.youtube.com/watch?v=rcN_VavTDOc

■ Research Update: Explore the Value of Exercise for Women’s Healthby Tori Lau, Bryanne Bellovary and Len Kravitz, PhD on Jun 14, 2018https://www.ideafit.com/fitness-library/explore-the-value-of-exercise-for-womenrsquos-health

■ Exercise is Medicine Fact Sheet-Rx for Health Serieshttps://www.exerciseismedicine.org/support_page.php/rx-for-health-series/

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Resources

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Joint associations of sitting time and moderate-to-vigorous physical activity with risk of all-cause mortality. From the 2018 Physical Activity Guidelines Advisory Committee Scientific Report (6), and based on data presented by Ekelund et al. (13). Medicine & Science in Sports & Exercise51(6):1227-1241, June 2019.

Sedentary Behavior and Health: Update from the 2018 Physical Activity Guidelines Advisory Committee

Acute Moderate-Intensity Exercise Induces Vasodilation Through an Increase in Nitric Oxide Bioavailiability in Humans: Chikara Goto, Kenji Nishioka, Takashi Umemura, Daisuke Jitsuiki, Akihiro Sakagutchi, Mitsutoshi Kawamura, Kazuaki Chayama, Masao Yoshizumi, Yukihito Higashi American Journal of Hypertension, Volume 20, Issue 8, August 2007, Pages 825–830, https://doi.org/10.1016/j.amjhyper.2007.02.014

Exercise, Telomeres, and Cancer: “The Exercise-Telomere Hypothesis”Nikitas N. Nomikos,1 Pantelis T. Nikolaidis,2 Caio V. Sousa,3 Apostolos E. Papalois,4 Thomas Rosemann,5 and Beat Knechtle5,6,* Published online 2018 Dec 18https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6305363/

Exercise, Telomeres, and Cancer: “The Exercise-Telomere Hypothesis”Nikitas N. Nomikos,1 Pantelis T. Nikolaidis,2 Caio V. Sousa,3 Apostolos E. Papalois,4Thomas Rosemann,5 and Beat Knechtle5,6,* Published online 2018 Dec 18. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6305363/

Association between Bout Duration of Physical Activity and Health-Systematic ReviewJAKICIC, JOHN M.1; KRAUS, WILLIAM E.2; POWELL, KENNETH E.3; CAMPBELL, WAYNE W.4; JANZ, KATHLEEN F.5; TROIANO, RICHARD P.6; SPROW, KYLE6; TORRES, ANDREA7; PIERCY, KATRINA L.8 FOR THE 2018 PHYSICAL ACTIVITY GUIDELINES ADVISORY COMMITTEE*Medicine & Science in Sports & Exercise: June 2019 - Volume 51 - Issue 6 - p 1213–1219

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Daily Step Counts for Measuring Physical Activity Exposure and Its Relation to HealthKRAUS, WILLIAM E.1; JANZ, KATHLEEN F.2; POWELL, KENNETH E.3; CAMPBELL, WAYNE W.4; JAKICIC, JOHN M.5; TROIANO, RICHARD P.6; SPROW, KYLE6; TORRES, ANDREA7; PIERCY, KATRINA L.8 FOR THE 2018 PHYSICAL ACTIVITY GUIDELINES ADVISORY COMMITTEE*. Medicine & Science in Sports & Exercise: June 2019 - Volume 51 - Issue 6 - p 1206–1212High-Intensity Interval Training for Cardiometabolic Disease Prevention.CAMPBELL, WAYNE W.1; KRAUS, WILLIAM E.2; POWELL, KENNETH E.3; HASKELL, WILLIAM L.4; JANZ, KATHLEEN F.5; JAKICIC, JOHN M.6; TROIANO, RICHARD P.7; SPROW, KYLE7; TORRES, ANDREA8; PIERCY, KATRINA L.9; BARTLETT, DAVID B.2 FOR THE 2018 PHYSICAL ACTIVITY GUIDELINES ADVISORY COMMITTEE* Medicine & Science in Sports & Exercise: June 2019 - Volume 51 - Issue 6 - p 1220–1226Sedentary Behavior and HealthKATZMARZYK, PETER T.1; POWELL, KENNETH E.2; JAKICIC, JOHN M.3; TROIANO, RICHARD P.4; PIERCY, KATRINA5; TENNANT, BETHANY6 FOR THE 2018 PHYSICAL ACTIVITY GUIDELINES ADVISORY COMMITTEE*; Medicine & Science in Sports & Exercise: June 2019 - Volume 51 -Issue 6 - p 1227–1241

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■ Physical activity for the prevention and treatment of major chronic disease: an overview of systematic reviews

David Nunan, Kamal R Mahtani, Nia Roberts & Carl Heneghan ; Systematic Reviewsvolume 2, Article number: 56 (201

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