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PHYSICAL ACTIVITY
A Guide For Health Practitioners

The benefits of physical activity
on our health and wellbeing
movement
for movement
Version 10 – November 2020

Preface
“If we could give every individual the right amount of nourishment
and exercise, not too little and not too much, we would
have found the safest way to health”
Hippocrates 460-377 BC
F
or the past six years, the physical activity educational programme Motivate2Move
has collaborated with the Movement for Movement undergraduate programme with
the common goal of training all student health professionals in the health and societal
benefits of physical activity and exercise.
The Motivate2Move team are again delighted to produce this 2020 edition of the student
guidebook for Movement for Movement. Updated extensively to include more medical
conditions, illustrative diagrams and practical advice, the guidebook has been described as
‘essential reading’ for all health care students.
As this guidebook has been developed throughout 2020, the world has been dealing with
the fallout from the Coronavirus infectious disease (COVID-19) pandemic that has affected
millions of people world-wide. COVID-19 has had far-reaching effects on our physical and
mental health, as well as devastating social and economic consequences. What has also
become clear, is that the most vulnerable in our society – older adults, the chronically ill
and the socially deprived - have suffered the most. Furthermore what has also been
highlighted is the importance of physical activity for both the prevention of chronic disease
linked with COVID-19 severity (i.e. obesity, diabetes) and the safeguarding of our mental
health and wellbeing.
In the light of this, Motivate2Move has produced a new section on the role of physical
activity and exercise in supporting the body’s immune system and how being more
physically active might potentially minimise the severity of symptoms of COVID-19 if
infected. With evidence now emerging that people have been less active during the
pandemic, educating health professional students about the benefits of physical
activity for health and wellbeing is more important than ever.
“Education is the most powerful weapon which

you can use to change the world”
Nelson Mandela
Motivate2Move would like to thank the the many people

and experts who have helped make this guidebook
and the British Association of Sport and Exercise
Medicine who funded the guidebook.
See Acknowledgements at the end of the guide.
We hope you enjoy reading this guidebook and

further advice and links can be found on the
Motivate2Move website
Dr Brian Johnson
November, 2020
PHYSICAL ACTIVITY: A GUIDE FOR HEALTH PRACTITIONERS (V10) 2 THE BENEFITS OF PHYSICAL ACTIVITY ON OUR HEALTH AND WELLBEING
CONTENTS
Introduction ...............................................................................................................................7
Chapter 1 Physical Activity, Exercise and Immune function........................................................8

• Background to exercise immunology.....................................................................................8
• Can exercise supress immune function?...............................................................................8
• Staying active during the Covid-19 pandemic ...................................................................9
• Practical considerations for lockdown and beyond .......................................................10
Chapter 2 Physical Activity Guidelines .................................................................................................11

• World Health Organisation – Global Action Plan on Physical Activity ...............11
• WHO guidelines on physical activity and sedentary behaviour ............................11
The 2019 UK Physical Activity Guidelines ......................................................................12
• Physical activity guidelines for Under-5s..............................................................................12
o Infants (less than 1 year)........................................................................................................12
o Toddlers (1-2 years) .................................................................................................................12
o Pre-schoolers (3-4 years).....................................................................................................12
• Children and young people (5-18 years of age) ................................................................13
• Adults (aged 19-65) ..........................................................................................................................13
• Older Adults (65+ years) ................................................................................................................14
• Physical activity during pregnancy and during postpartum .....................................14
• Physical activity for disabled adults ........................................................................................15
• Key principles of physical activity.............................................................................................15
o Physical activity for good health and wellbeing .....................................................15
o Some is good, more is better.............................................................................................15
o Muscle and bone strengthening and balance training activities. ..................16
o Wider benefits of being active..........................................................................................16
• Assessment of present levels of activity:..............................................................................16
• Take home messages: ....................................................................................................................17
• Glossary: ..................................................................................................................................................17
Chapter 3 Cancer .........................................................................................................................................18

• Physical activity and primary prevention .............................................................................18
• Physical activity pre-treatment ..................................................................................................18
• Physical activity during treatment............................................................................................18
• Physical activity after treatment................................................................................................18
• Physical activity and palliative care .........................................................................................18
• Physical activity and survival rates...........................................................................................18
• Safety considerations during and after treatment ..........................................................18
Chapter 4 Cardiovascular Health .......................................................................................................................19

• Ischaemic heart disease .................................................................................................................19
o Primary prevention ..................................................................................................................19
o Secondary prevention............................................................................................................19
• Erectile dysfunction ..........................................................................................................................19
• Heart failure. ..........................................................................................................................................20
• Atrial fibrillation ...................................................................................................................................20
• Obstructive sleep apnoea syndrome......................................................................................20
• Hypertension ........................................................................................................................................20
o Pharmacology v physical activity....................................................................................21
• Lipids ........................................................................................................................................................21
• Peripheral Arterial Disease............................................................................................................21
• Stroke. .......................................................................................................................................................22
o Primary prevention ..................................................................................................................22
o Secondary prevention............................................................................................................22
o Treatment ......................................................................................................................................22
Chapter 5 Chronic Kidney Disease (CKD) ...........................................................................................23

• Benefits of exercise in CKD ..........................................................................................................23
• Precautions ............................................................................................................................................23
• Recommendations. ...........................................................................................................................24
Continues on next page:
CONTENTS
Chapter 6 Mental Health.............................................................................................................................25

• Depression .............................................................................................................................................25
o Prevention of depression with physical activity ......................................................25
o Treatment of depression with physical activity .......................................................25
• Anxiety .....................................................................................................................................................25
• Post traumatic stress disorder ....................................................................................................25
• Schizophrenia .......................................................................................................................................26
• Sleep ..........................................................................................................................................................26
o Insomnia.........................................................................................................................................26
o Obstructive sleep disorder ..................................................................................................26
• Wellbeing and quality of life.........................................................................................................27
• Dementia.................................................................................................................................................28
o Prevention of dementia with physical activity..........................................................28
o Treatment of established dementia with physical activity ................................29
Chapter 7 Metabolic Health ......................................................................................................................30

• Metabolic Syndrome ........................................................................................................................30
• Non-Alcoholic Fatty Liver Disease (NAFLD)......................................................................30
o Benefits of regular physical activity and exercise for people with NAFLD ....30
o Physical activity and exercise for people with NAFLD........................................30
• Polycystic Ovary Syndrome (PCOS).......................................................................................30
o Benefits of regular physical activity and exercise for women with PCOS......30
o Precautions and contraindications .................................................................................31
• Pre-diabetes ..........................................................................................................................................31
o Benefits of regular physical activity and exercise for people with
pre-diabetes...........................................................................................................................................31
• Type 2 Diabetes...................................................................................................................................31
o Benefits of regular physical activity and exercise for people with
type 2 diabetes ..........................................................................................................................31
o Physical activity and exercise for people with type 2 diabetes ......................31
o Precautions and contraindications .................................................................................32
• Type 1 Diabetes ...................................................................................................................................32

o Introduction .................................................................................................................................32
o Current recommendations for physical activity and exercise .........................32
o Precautions and Contraindications ...............................................................................33
• General considerations for physical activity and exercise .........................................33
o Conclusion. ...................................................................................................................................34
Chapter 8 Musculoskeletal Health ..........................................................................................................35

• Fibromyalgia .........................................................................................................................................35
• Osteoarthritis ........................................................................................................................................35
• Osteoporosis.........................................................................................................................................35
o Prevention .....................................................................................................................................35
o Established disease .................................................................................................................35
• Rheumatoid Arthritis ........................................................................................................................36
o Special Considerations ..........................................................................................................36
• Prevention of falls and fracture ..................................................................................................37
Chapter 9 Obesity .........................................................................................................................................38

• Weight gain ...........................................................................................................................................38
• Physical activity alone or with diet ...........................................................................................38
• Physical activity and increased intensity ..............................................................................38
• Physical activity and prevention of weight gain. ..............................................................38
• Physical activity and weight maintenance ...........................................................................38
• Aerobic exercise or resistance training and weight loss ..............................................38
• The real health message of physical activity in obesity ...............................................38
CONTENTS
Chapter 10 Pregnancy and the postpartum period ...........................................................................40

• Key Benefits of Exercise During Pregnancy .......................................................................40
• Pre - Activity Evaluation .................................................................................................................40
• Risk Management...............................................................................................................................40
• Hyperthermia........................................................................................................................................40
• Modifications and Considerations ............................................................................................41
• When to stop exercising.................................................................................................................41
• ‘F.I.T.T.’ For Pregnancy .....................................................................................................................41
• Advice to a pregnant woman who is new to physical activity .................................41
• Advise to a woman who is already active ............................................................................42
• Three key safety messages...........................................................................................................42
• Physical activity after pregnancy ..............................................................................................42
o The benefits of physical activity after pregnancy..................................................42
o A staged approach to physical activity after pregnancy...................................42
o What about vigorous intensity activity?......................................................................42
Chapter 11 Respiratory Disease ................................................................................................................44

• Asthma ....................................................................................................................................................44
• Chronic Obstructive Pulmonary Disease (COPD) ...........................................................44
• Cystic Fibrosis ......................................................................................................................................45
Chapter 12 Perioperative Surgery ............................................................................................................46

• Conclusions ...........................................................................................................................................47
Chapter 13 Sedentary Behaviour ..............................................................................................................48

• Part 1: Sedentary Behaviour. ........................................................................................................48
o What can we do practically in the workplace and at home
to change this behaviour? ...................................................................................................48
o Summary .......................................................................................................................................48
o Useful resources for students ............................................................................................49
• Part 2: Sedentary Behaviour and Musculoskeletal Disorders ...................................50

o Introduction .................................................................................................................................50
o Back pain .......................................................................................................................................50
o Ankle ................................................................................................................................................51
o Knee .................................................................................................................................................51
o Shoulder. ........................................................................................................................................51
Chapter 14 Supporting people to change their health behaviour ...............................................52

• Enhancing Motivation to Change ..............................................................................................52
• Motivational Interviewing (MI) ....................................................................................................52
• Example MI Dialogue .......................................................................................................................53
• Increasing Capability to change ................................................................................................54
• Case study: Sarah...............................................................................................................................54
• Summary ...............................................................................................................................................55
CONTENTS
Chapter 15 Physical Activity and Starting to Get Active .................................................................56

• Chief medical officers’ (UK) Physical Activity Guidelines 2019 ...............................56
• Assessment of present levels of activity ...............................................................................56
• Four important aspects of exercise: ........................................................................................56
• Warm up and Cool down...............................................................................................................56
• Apply the FITT principle.................................................................................................................56
• Definitions of moderate and vigorous intensity................................................................57
• Monitoring ..............................................................................................................................................57
• How many steps is enough? ........................................................................................................57
• Getting Started....................................................................................................................................57
• Barriers, Motivation and Facilitators ........................................................................................58
• Brief Interventions..............................................................................................................................58
• The Referral Pathway .......................................................................................................................59
• Minimising risk of physical activity/exercise-related adverse events....................59
• Absolute Contraindications to Exercise ................................................................................59
• Disclaimer ...............................................................................................................................................60
Acknowledgements .............................................................................................................................61
References
• Chapter 1 Physical Activity, Exercise and Immune Function...............................................................62

• Chapter 2 Physical Activity Guidelines.............................................................................................................63
• Chapter 2 The 2019 UK Physical Activity Guidelines................................................................................63
• Chapter 3 Cancer..........................................................................................................................................................64
• Chapter 4 Cardiovascular Health .........................................................................................................................66
• Chapter 5 Chronic Kidney Disease (CKD).......................................................................................................68
• Chapter 6 Mental Health ...........................................................................................................................................70
• Chapter 7 Metabolic Health ....................................................................................................................................73
• Chapter 8 Musculoskeletal Health .......................................................................................................................77
• Chapter 9 Obesity ........................................................................................................................................................79
• Chapter 10 Physical Activity and Pregnancy ..................................................................................................80
• Chapter 11 Physical Activity and Respiratory Disease ..............................................................................80
• Chapter 12 Physical Activity and Perioperative Surgery..........................................................................81
• Chapter 13 Sedentary Behaviour...........................................................................................................................82
• Chapter 14 Supporting people to change their health behaviour ......................................................84
• Chapter 15 Physical Activity and Starting to Get Active ..........................................................................85
movement
for movement
Introduction
The purpose of this guidebook is to give students of all health care professions, the background information
to educate and motivate patients about the health benefits of physical activity.
Regular physical activity provides a range of physical and mental health benefits. These include reducing the
risk of disease, managing existing conditions, and developing and maintaining physical and mental function.1
More details on the conditions that benefit form physical activity follow in other parts of this resource.
It also contributes to a range of wider social benefits for individuals and communities, which include: improved
learning and attainment, managing stress and wellbeing, improved sleep, the development of social skills, and
better social interaction.1
Moderate or strong evidence for health benefit
Figure 1: Cumulative health benefits of physical activity across ages.2
Designed as brief information ‘bites’, the guide covers all aspects of physical activity and health from general
information to practical disease specific recommendations. It comprises four main sections:
• UK physical activity guidelines

• Health benefits - for 30 different medical conditions
• Behaviour change
• Starting to exercise
CHAPTER 1:
Physical Activity, Exercise and

Immune Function
This chapter has been developed by healthcare professionals and Over the longer-term, engaging regularly in physical activity is also
scientists, in response to the Coronavirus infectious disease-19 linked with a reduction in the number (≈ 40-50%) 11 and severity
(COVID-19) pandemic, and is written for healthcare professional of infectious episodes (e.g. common cold and flu) individuals
students to enhance their understanding of how physical activity/ experience throughout the year 11,12.
exercise can support immune function and potentially minimise Collectively, over time, exercise can induce an array of benefits
the severity of symptoms of COVID-19, if infected. to the immune system (Figure 1) that optimise health and reduce
the risk of infection and chronic disease.
Section 1: Background to exercise immunology
Researchers agree that regular bouts of moderate-to-vigorous Section 2: Can exercise suppress immune function?
intensity exercise (e.g. walking, running or cycling) can improve Despite agreement by researchers that regular moderate-to-
immune function and reduce systemic inflammation 1–3. vigorous intensity exercise can improve host immunity, it is a
The anti-inflammatory effects of exercise relate to changes in very contentious issue as to whether arduous exercise (see box
both body composition (i.e. lower central fat mass) and a steady 1 on next page) can actually increase the risk of infection 3. This
summation of changes to the immune system after each session of is of particular interest in the context of the current COVID-19
exercise 4. Increases in cardiac output, blood flow and the release pandemic (section 3).
of stress hormones (e.g. adrenaline) during exercise result in Traditionally, the J-shaped model of immunity has proposed that
immune cells with high functional capacity (i.e. neutrophils, natural regular moderate intensity exercise can lower the risk of upper
killer cells and cytotoxic T-cells – see glossary) being mobilised respiratory tract infections (≈ 60% of infections experienced),
into the bloodstream 5–7. These cells migrate from the circulation whereas a high volume of vigorous intensity exercise might
towards various tissues to survey the body for damage, infection increase this risk, relative to sedentary individuals 13. The evidence
and/or tumour cells 8. underpinning this model has been established from studies
Each session of exercise therefore primes the immune system reporting a higher incidence of self-reported infections after
to ‘patrol’ the body and do its job effectively. Furthermore, the competitive marathons 14 and heavy training periods in a variety of
release of cytokines from muscle (termed myokines) induce an competitive team sports 15–17. Since then, some data have indicated
anti-inflammatory environment after each individual exercise that aspects of immunity are impaired after single 18–21, consecutive
bout 4,9,10. These exercise-induced changes to the immune system 22–24
, and regular sessions (i.e. week/ months) 25–27 of arduous
are an important consideration for healthcare professionals. exercise (see box 1 on next page).
Figure 1:
Benefits of exercise on
Increased cardiac output, the immune system
blood flow and stress
hormones
Exercise-induced
mobilisation of
Improvements in Immune
immune cells Immune Function
Cell Mobilisation • ↑ innate & adaptive immunity
Numbers • ↑ response to viral & bacterial
in Blood infections
• ↑ surveillance of cancer cells
Migration
• ↑ antibody production
• ↑ response to vaccination
During After Exercise

Chronic Adaptation to Exercise
Exercise (≈3hrs)
Other physiological changes with Indirect benefits of exercise

acute exercise on immunity
• Negative energy balance • ↓ fat mass, thus ↓inflammation
• Vascular shear stress • ↑ immune cell recirculation
• Muscle-derived myokine release • ↑ anti-inflammatory blood profile
CHAPTER 1:

Immune Function
How much exercise is considered arduous for the Non-exercise factors that influence immunity (Box 2)
immune system? (Box 1)
1. Exposure to pathogen:
• A moderate amount of exercise is considered to be • Mass gatherings of people (touching eyes, nose or mouth)
approximately 150 minutes per week at a moderate- • Sharing drinks bottles and equipment or living/ training in
to-vigorous intensity (≈60-70% of maximal oxygen close proximity to others
consumption*), with individual sessions lasting less • Equipment/ clothes (not washing regularly and
than 1 hour. effectively)
• Hand hygiene (not washing hands)
• An arduous amount of exercise is considered a volume of
training far exceeding** the recommended 150 minutes 2. Psychological factors
per week for the general population, with individual • Lifestyle stress
sessions lasting over 2 hours at or above ≈60-70% of • Anxiety
maximal oxygen consumption. • Individual psychological traits, i.e. ability to regulate
mood and psychological strain during prolonged bouts
* the absolute intensity (i.e. workload) will be dependent of exercise.
on individual fitness levels
** studies reporting impaired immune function have 3. Lifestyle habits
involved both trained and untrained participants cycling • Quality of nutrition/ hydration
or running up to 540 minutes over 3 consecutive days • Quality of sleep
28–30
and up to 630 minutes over 7 consecutive days 31. • Recovery between training sessions
4. Environmental factors
From the studies conducted, exercise volume (intensity x • Air travel – exposure to hypoxia, radiation, pollution,
duration) of individual and consecutive sessions appears to be sleep disruption and dehydration
the key factor driving alterations in markers of immune function. • Extremes of temperature, humidity and altitude
It is believed that these alterations relate to the depletion of • Breathing cold, dry or polluted air
muscle glycogen and/ or depletion of energy reserves within • Allergies
immune cells, although these claims require further research to
be substantiated 3,32. The points of contention on this topic are
multiple, but primarily relate to disagreements over study design, Section 3: Staying active during the COVID-19 pandemic
validity of the biomarkers examined, appropriate diagnosis of Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
infection and the immunological techniques used 3. It is important is the strain of coronavirus known to cause COVID-19, an infection
to emphasise that the data indicating that high volumes of training of the lower respiratory tract that has caused widespread
can causatively supress immunity need to be considered in the infection, morbidity and mortality worldwide. The government
context of a range of other factors that can adversely affect lockdown on March 23rd 2020 resulted in a new way of life for
immunity (see box 2) 33. The body cannot distinguish between the British population. Isolation has confined individuals and
these different types of stress, and many of these variables families to their homes for prolonged periods, with restricted
intertwine with exercise volume when ‘suppressing’ measures of time outdoors. Emerging data from across the world are already
immunity (e.g. stress induces cortisol release, which can suppress indicating that lockdown resulted in reduced physical activity 35
immune function). It is clear that heavy sessions of exercise, and increased sedentary time 35,36. Even as lockdown restrictions
particularly if repeated over consecutive days, can dramatically ease, it is possible that these habits are maintained, which in
alter markers of immune function 18–27; however, the evidence does conjunction with the stress of the situation could be detrimental
not support a direct relationship between exercise load and an to immune function and the risk of further developing chronic
increased risk of infection. Indeed, a recent consensus statement health conditions 37. Further, the likelihood of subsequent waves of
from the International Olympic Committee suggests that elite infection may result in reinstatement of lockdown, so these forced
athletes who effectively manage their behavioural (i.e. minimise lifestyle and habit changes may be ongoing.
pathogen exposure) and lifestyle habits (i.e. stress, sleep and Given that we are still in the infancy of what could be long-term
nutrition) are not more likely to have a higher risk of infection, changes to our way of life, there is time to alter daily activity and
despite their very high training volumes 34. exercise habits to minimise the severity of symptoms of COVID-19,
if infected. There are no empirical data to indicate that being more
A key take home message for the general population is that there physically active or engaging in regular moderate-to-vigorous
is no evidence to indicate that engaging in vigorous intensity intensity exercise can directly reduce susceptibility to COVID-19
exercise within or even slightly over the recommended guidelines and/ or the severity of its symptoms.
of 150 minutes per week is detrimental to immune function. On the However, by building on the literature described in section 1, we
contrary, regular engagement in moderate to vigorous physical can intuitively suggest potential benefits of regular moderate-to-
activity and structured exercise is critical to stimulating the vigorous exercise that can enhance immune function and could
immune system to perform its job effectively. reduce the severity of COVID-19 symptoms and shorten recovery
times (see box 3 on next page).
CHAPTER 1:

Immune Function
Possible effects of physical activity and exercise on 1. For more vulnerable population groups (older individuals
immunity against SARS-CoV-2 (Box 3) and those shielding/ at a higher risk), home-based exercise is
recommended to minimise pathogen exposure risk. Adherence
1. Healthy weight loss: Obesity has been identified as a to government guidance on social distancing and personal
major risk factor for mortality associated with COVID-19 hygiene (hand washing and avoiding touching eyes, nose and
38,39
. This is, in part, due to a heightened inflammatory mouth) are critical to minimise virus exposure.
response from excess adipose tissue that can promote
vascular and thrombotic complications 39. Therefore, 2. Any increase in physical activity is of benefit. While 150 minutes
increased exercise/physical activity that results in a per week of moderate-to-vigorous intensity is a recommended
negative energy balance and subsequent weight loss target, regular bursts of exercise/activity for just a few minutes
(that is safe and gradual) may protect against the each day can benefit immune function and general health.
severity of COVID-19 symptoms. Some examples include: walking around the garden, jogging on
the spot, sit-to-stand exercises, or climbing the stairs in one’s
2. Stimulating immune cells to survey the body for house/apartment.
pathogens: Exercise mobilises immune cells with high
functional capacity (i.e. anti-viral) after each session. The 3. If one is using this time to strive for personal performance
cumulative effect of this process is known to protect the goals by programming a high volume of training, they should
body from common viruses that infect the respiratory pay special attention to their recovery time, nutrition, stress
tract, such as rhinovirus and influenza, and prevent levels and sleep quality. Previous evidence allows us with some
reactivation of latent viruses, such certainty to suggest that higher levels of aerobic fitness would
as Epstein-Barr (EBV) 40,41. likely reduce the severity of COVID-19 symptoms. However, it
is conceivable that large volumes or large increases in training
3. Contraction-induced release of immune-related load could depress immune function, particularly if the variables
proteins: Skeletal muscle releases signalling proteins outlined in Box 2 are not considered. It is a time to prioritise
(termed myokines) in response to exercise that reduce overall health and wellbeing, rather than performance.
inflammation (Interleukin (IL)-6) 4,9,10 and assist with
lymphocyte proliferation (IL-7) 42,43. In addition, it has Glossary
been suggested that muscle-derived release of IL-15
may assist with trafficking of anti-viral natural killer cells • Innate immunity: first line of defence against damage
towards vulnerable areas of the body that encounter and/or infection
pathogens 40, e.g. SARS-CoV-2 in the lungs.
• Adaptive immunity: a delayed and coordinated response that
4. Improved blood vessel & lymphatic system health: develops memory for a more enhanced response to infection
Improvements in vascular function are a well-established
adaptation to regular exercise training 44. Improvements • Neutrophils: most abundant innate immune cells in blood
in blood flow could assist with immune cell recirculation • Macrophages: innate immune cells residing within tissues of
between the blood, lymphatic system and peripheral the body
tissues in the event of infection. Furthermore, exercise
increases the flow of immune cells through the lymphatic • Natural Killer Cells: innate immune cells that kill viruses and
system (5-fold), with even mild activity stimulating cancerous cells
this movement 45,46. Thus, staying active is critical to
enhancing immunity, particularly in sedentary individuals. • T-cells: adaptive immune cells (lymphocytes) produced in the
thymus – kill viruses and cancerous cells
5. Improved response to vaccination: There is evidence
that regular exercise can enhance the antibody titre after • B-cells: adaptive immune cells (lymphocytes) produced in the
vaccination against influenza 47,48. Potentially, this may bone marrow – produce antibodies
enhance the response to a vaccination developed to
combat COVID-19. • Cytokines/ Interleukins: proteins that convey signals between
different immune cells
Section 4: Practical considerations for lockdown and beyond • Myokines: cytokines and other small proteins released from
Being more physically active and/or engaging in regular amounts skeletal muscle in response to contraction
of moderate-to-vigorous intensity exercise improves multiple
aspects of immune function, which lowers one’s risks for infection • Antibodies: proteins produced by B-cells in order to kill a
and chronic diseases. Some specific considerations about daily previously encountered infection (found in blood, saliva, tears
activity and exercise are highlighted below: and the mucosal surfaces of certain tissues, e.g. gut
and respiratory tract)
CHAPTER 2:
World Health Organisation (WHO) -

GLOBAL ACTION PLAN ON PHYSICAL ACTIVITY 2018-2030
Physical inactivity has been identified as a leading risk factor for global mortality and a contributor to
the global rise in overweight and obesity. Yet, much of the world is becoming less active. As countries
develop economically, levels of inactivity increase. In some countries, these levels can be as high as 70%,
due to changing transport patterns, increased use of technology, cultural values and urbanization.
Requests by countries to the WHO, for guidance and

a framework of effective and feasible policy actions
to increase physical activity at all levels, resulted in
The WHO Global Action Plan on Physical Activity
2018-2030 (GAPPA)1 (Fig 1).
The plan sets out four strategic objectives and policy

actions that are universally applicable to all countries
and address the multiple cultural, environmental and
individual determinants of inactivity:
1. Create Active Societies – 4 policy actions
2. Create Active Environments – 5 policy actions
3. Create Active People – 6 policy actions
4. Create Active Systems – 5 policy actions
The target of these is for countries to achieve a

15% relative reduction in the global prevalence
of physical inactivity in adults and adolescents
by 2030.
Fig 1 – The WHO Global Action Plan on Physical Activity 2018-30 1
WHO guidelines on physical activity and sedentary behaviour 2020
GAPPA also identified as a priority the updating of the WHO 2010 guidelines on physical activity in youths,
adults and older adults.
As a result, WHO has now developed guidelines for children and adolescents, adults, older adults and for
the first time make specific recommendations on physical activity in sub-populations such as pregnant
women and those living with chronic conditions or disability2. These guidelines will therefore replace the 2010
recommendations on physical activity for health. The separate WHO guidelines on physical activity, sedentary
behaviour and sleep for children under 5 years of age complement this update.
Many countries have developed their own guidelines, but the WHO guidelines present advice on these topics
if national guidance is not available, are available here.
For those people using this guidebook we present the 2019 UK Physical Activity Guidelines below.
CHAPTER 2:
The 2019 UK Physical Activity Guidelines
This summary of the new guidelines is drawn from the 2019 UK Infants (less than 1 year):
Chief Medical Officers physical activity guidelines documents.1 • Infants should be physically active several times every day, in
a variety of ways, including interactive floor-based activity
Physical activity guidelines for Under-5s e.g. crawling.
The evidence-base on physical activity in the Under-5s has
expanded substantially since the development of the previous • For infants not yet mobile, this includes at least 30 minutes of
set of guidelines2 There is now a large body of evidence that the tummy time spread throughout the day while awake (and other
amount of physical activity in the Under-5 period influences a wide movements such as reaching and grasping, pushing and pulling
range of both short-term and long-term health and developmental themselves independently, or rolling over); more is better.
outcomes.3,4 For example, low levels of physical activity have been
recognised as a contributor to increasing rates of child obesity NB: Tummy time may be unfamiliar to babies at first, but can
in this age group.5, 6 It has become very clear that higher levels be increased gradually, starting from a minute or two at a time as
of physical activity are better for health, and lower levels worse, the baby becomes used to it. Babies should not sleep on
and that there are benefits to increasing levels of physical activity their tummies
across the distribution of starting physical activity level.3, 4
Toddlers (1-2 years):
Despite concern over levels of physical activity in the Under-5s, in • Toddlers should spend at least 180 minutes (3 hours) per day in
both boys and girls, the average level of physical activity reaches a variety of physical activities at any intensity, including active
a lifetime peak around the age of school-entry (5 years old) and and outdoor play, spread throughout the day; more is better.
declines thereafter (17-19 years old). Maximising the higher levels of
physical activity in the early years should therefore help maintain Pre-schoolers (3-4 years):
higher levels later in childhood and adolescence.3,4,7,8 • Pre-schoolers should spend at least 180 minutes (3 hours) in a
variety of physical activities spread throughout the day, including
active and outdoor play. More is better; the 180 minutes should
include at least 60 minutes of moderate-vigorous intensity
physical activity (MVPA).
Physical activity, in the Under 5s should not be viewed in isolation,

but more as a continuum into older childhood and adolescence.
There is increasing evidence for the benefits of adequate physical
activity and sleep and the risks of some sedentary behaviour in
school-age children and adolescents.9-11
Levels of these behaviours in the pre-school period are closely

related to later levels in school-age children and sedentary
behaviour increases from the age of school entry which then
displaces physical activity and/or sleep.12-15
Download the Early Years CMO infographic here:
CHAPTER 2:
Children and young people (5-18 years of age): Adults (aged 19-65):
• Should engage in moderate-to-vigorous intensity physical • For good physical and mental health, adults should aim to be
activity for an average of 60 minutes per day across the week. physically active every day. Any activity is better than none, and
(This activity can include all forms of activity such as physical more is better still.
education, active travel, after-school activities, play and sports).
• Adults should do activities to develop or maintain strength in
• Should engage in a variety of types and intensities of physical the major muscle groups. These activities could include heavy
activity across the week to develop movement skills, muscular gardening, carrying heavy shopping, or resistance exercise.
fitness, and bone strength. Muscle strengthening activities should be done twice a week, but
any strengthening activity is better than none.
• Should aim to minimise the amount of time spent being
sedentary and when physically possible should break up long • Each week, adults should accumulate at least 150 minutes
periods of not moving with at least light physical activity (2 1/2 hours) of moderate intensity activity (such as brisk walking
or cycling); or 75 minutes of vigorous intensity activity (such
Download Children and young people infographic here: as running); or even shorter durations of very vigorous intensity
activity (such as sprinting or stair climbing); or a combination of
moderate, vigorous and very vigorous intensity activity.
• However, it is important to remember that any activity is better

than none, and more is better still.
• Adults should aim to minimise the amount of time spent being
sedentary, and when physically possible should break up long
periods of inactivity with at least light physical activity
Download Adult/Older adult PA Guideline infographic here:
CHAPTER 2:
Older Adults (65+ years)

• Older adults should participate in daily physical activity to gain
health benefits, including maintenance of good physical and
mental health, wellbeing, and social functioning. Some physical
activity is better than none, even light activity brings some
health benefits compared to being sedentary while more daily
physical activity provides greater health and social benefits.
• Older adults should maintain or improve their physical function

by undertaking activities aimed at improving or maintaining
muscle strength, balance and flexibility on at least 2 days a week.
These could be combined with sessions involving moderate
aerobic activity or could be additional sessions aimed at these
components of fitness.
• Each week older adults should aim to accumulate 150 minutes

(21/2 hours) of moderate intensity aerobic activity, building up
from current levels. Those who are already regularly active can
achieve these benefits through 75 minutes of vigorous intensity
activity, or a combination of moderate and vigorous activity, to
achieve greater benefits. Weight-bearing activities which create
an impact through the body help maintain bone health.
• Older adults should break up prolonged periods of sitting with

light activity when physically possible or at least with standing as
this has distinct health benefits for older people.
Physical activity during pregnancy and during postpartum

Pregnancy is considered a powerful motivator for behaviour
change and a favourable period to adopt a healthy lifestyle,
with the increased motivation to self-care coupled with frequent
access to maternity services. Physical activity can be safely Benefits of physical activity during pregnancy identified are:
recommended during and after pregnancy. UK Chief Medical • A reduction in hypertensive disorders
Officers recommend that pregnant woman aim for at least 150 • Improved cardiorespiratory fitness
minutes of moderate physical activity every week. • Lower gestational weight gain
• A reduction in risk of gestational diabetes
• Pregnant women who are already active should be encouraged
to maintain their physical activity levels. However, they may need See the specific Pregnancy section in this resource for further
to change the type of activity undertaken and adapt their activity information.
throughout their pregnancy, for example, replacing contact
sports with non-contact sport or an appropriate exercise class. Download the Physical activity for pregnant women
infographics here:
• Women who have been sedentary before pregnancy are
recommended to follow a gradual progression of exercise – The benefits of physical activity in the postpartum period
‘not active – start gradually’. (up to one year) include
• A reduction in depression
• Vigorous physical activity is not recommended for previous • Improved emotional wellbeing
inactive women. • Improved physical condition
• A reduction in postpartum weight
• Strengthening exercises twice a week are recommended. • A faster return to pre-pregnancy weight
• It is important to highlight to woman that ‘every activity counts’

and that they should always ‘listen to your body and adapt’ what
they do accordingly.
CHAPTER 2:
Physical activity for women

after childbirth (birth to 12 months)
Time for yourself - Helps to control weight Improves tummy
reduces worries and and return to pre- muscle tone and
depression pregnancy weight strength
Improves fitness Improves mood Improves sleep
Not active? Active before?

Start gradually Restart gradually
t
ou
Le
ab
isu
aim for
nd
at least
re
ta
150
Ou
minutes
of moderate intensity activity
every week
Build
Start back up
pelvic floor to muscle
exercises as strengthening
soon as you can activities twice
and continue daily
Home a week
It’s safe to be active. Depending on your You can be active

No evidence of harm delivery listen to
for post partum your body and
while
women start gently breastfeeding
UK Chief Medical Officers’ Physical Activity Guidelines, 2019
Physical activity can be safely be recommended to women benefits for disabled adults of engaging in physical activity were
after pregnancy and have no negative impact on breast comparable with those for the rest of the adult population.
feeding postpartum. It concluded that any myths about physical activity being
After the six to eight week postnatal check and depending on inherently harmful for disabled people should be dispelled.
how the woman feels, more intense activities can gradually
resume, i.e. building up intensity from moderate to vigorous Download the physical activity for disabled adults here:
over a period of at least 3 months.
Download the Physical activity for women after child birth Key principles of physical activity
infographic here:
Physical activity for good health and wellbeing
Regular physical activity provides a range of physical and
Physical activity for disabled adults mental health benefits. These include reducing the risk of
Disability refers to people who have long-term physical (e.g. disease, managing existing conditions, and developing and
spinal cord injury), sensory (e.g. visual impairment), cognitive (e.g. maintaining physical and mental function. More details on the
learning difficulties), and/or mental impairments (e.g. depression) conditions that benefit form physical activity follow in other
which in interaction with various barriers may hinder their full parts of these resources.
and effective participation in society on an equal basis with
others. Rather than focusing on just one impairment the UK CMO Some is good, more is better
guidelines considered a range of impairments. Our understanding of the relationship between physical activity
and health has grown. In general, the more time spent being
See United Nations Convention on the Rights of Persons physically active, the greater the health benefits. However, we
with Disabilities. now know that even relatively small increases in physical activity
can contribute to improved health and quality of life. The gains
UK CMO’s have reviewed the evidence base on physical activity are especially significant for those currently engaging in the
and the general benefits for disabled adults16. It found that with lowest levels of activity (fewer than 30 minutes per week), as
respect to safety, no evidence exists that suggests appropriate the improvement in health for each additional minute of physical
physical activity is a risk for disabled adults and that the health activity will be proportionately be greater (Fig 1 on next page).
CHAPTER 2:
As such, although we recommend that all individuals work towards

achieving these guidelines, they are not absolute thresholds and
we recognise the benefits that can be achieved at levels both
above and below the thresholds. The previous requirement for
a 10-minute bout of activity is no longer valid and is no longer
included. However, specific targets -such as aiming to do at least
10 minutes at a time -can be effective as a behavioural goal for
people starting from low levels of activity.17
AREA OF HIGHEST IMPACT
+
Health benefits
- 100 200 300 400 500 600

Sedentary
Weekly physical activity (min) xx
Figure 1: Dose-response curve of physical activity and benefits18
Muscle and bone strengthening and balance training activities

Muscle and bone strength play a critical role in ensuring good
muscular and skeletal health, and in maintaining physical function.
When undertaking muscle strengthening activities, it is important
to work all the major muscle groups. Bone strengthening involves Table 1: Types of activities that can help maintain or improve aerobic capacity,
moderate and high impact activities to stimulate bone growth strength, balance and bone health and contribute to meeting the physical activity
guidelines 20
and repair.
Strengthening activities are important throughout life for Wider benefits of being active
different reasons: to develop strength and build healthy bones Physical activity not only promotes good health and functioning
during childhood and young adulthood; to maintain strength and helps prevent and manage disease. It also contributes to a
in adulthood; and to delay the natural decline in muscle mass range of wider social benefits for individuals and communities.
and bone density which occurs from around 50 years of age,
maintaining function in later life. The relevance and importance of the wider benefits of physical
activity for individuals vary according to life stage and various
other factors but include: improved learning and attainment,
managing stress and improved wellbeing, improved sleep, the
development of social skills, and better social interaction.
In addition to the health benefits, increasing physical activity

across a population also has social, environmental and economic
benefits for communities and wider society.
Assessment of present levels of activity:

In most consultations with patients, opportunities arise where
the subject of physical activity may be used for prevention
or treatment of disease. Assessing a baseline of activity is
recommended to either raise the issue of physical activity,
measure progress or help shape any subsequent advice.
There are many assessment questionnaires available and
Figure 2: Physical activity for muscle and bone strength across the life course 19, 20 two most commonly used are:
Balance training involves a combination of movements that • The UK General Practice Physical Activity Questionnaire
challenge balance and reduce the likelihood of falling 21. (GPPAQ)22 can be used to categorize patients into
Different activities have differential effects on muscle recommended levels of activity.
and bone strength and balance.
Download the GPPAQ questionnaire and read codes here:
CHAPTER 2:
• ‘The Scot-PASQ’.23 A brief assessment using just three questions. Take home messages:
Used as a motivational screening tool to help raise the issue of • Physical activity is an important part of the lifestyle for any
physical activity and deliver advice patient because of the overwhelming evidence of the health
benefits at all ages.
o In the past week, on how many days have you been physically
active for a total of 30 minutes or more? • Being active every day provides a foundation for a healthier and
happier life.
o If four days or less, have you been physically active for at
least two and a half hours (150 minutes) over the course of • Even relatively small increases in physical activity can contribute
the past week? to improved health and quality of life.
o Are you interested in being more physically active? • Regular strength and balance activities are important throughout
life: being strong makes all movement easier and increases our
Read the brief guidance on how to use the Scot-PASQ tool by ability to perform normal daily tasks.
downloading it here:
• Any activity is better than none.
Read the full CMO report here:
Glossary Muscle Strength is the force or tension that a muscle or muscle

group can exert against a resistance in one maximal effort. In
Balance is the ability to maintain equilibrium while moving practical terms this is the ability to climb stairs, get out of a chair
or while stationary. Balance activities are those activities that or bath, the ability to walk to the shops and is essential as we
involve the maintenance of the body balance while stationary age to reduce the risk of falls.
or moving. They are an essential part of life as we get older to
prevent falls and particularly when going to the bathroom, bed Physical activity is defined as any bodily movement produced
or getting up from a chair. by skeletal muscles that results in energy expenditure. ...
Exercise is a subset of physical activity that is planned,
Bone health includes bone quality that refers to the capacity of structured, and repetitive and has as a final or an intermediate
bones to withstand a wide range of loading without breaking. objective the improvement or maintenance of physical fitness.
Bone health also includes bone mineral content, structure,
geometry and strength. Postpartum refers to a period of time after the end of
pregnancy. The postpartum period is commonly defined as
Flexibility is the range of motion available at a joint or group of up to six weeks following the end of pregnancy, with the late
joints. Essential for daily living in bending e.g. to put socks and postpartum period from six weeks up to one year after the end
shoes on or rotating to look behind you. of pregnancy. For the CMO guidelines postpartum includes up
to one year post delivery.
Metabolic Equivalent of Task (MET) is the objective measure of
the ratio of the rate at which a person expends energy, relative Sedentary behaviour. Inactive and sedentary behaviours are
to the mass of that person, while performing some specific those involving being in a sitting, reclining or lying posture
physical activity compared to the energy expended whilst during waking hours, undertaking little movement/activity
sedentary. and using little energy above what is used at rest. Common
sedentary behaviours include TV viewing, video game playing,
Moderate-to-vigorous physical activity (MVPA) are activities computer screen time, driving and reading.
that can be done at different intensities like cycling. They can
be differentiated by the ‘talk test’: being able to talk but not Vigorous physical activity (VPA) is an activity that requires
sing indicates moderate intensity activity, while having difficulty a large amount of effort and causes rapid breathing and
talking without pausing is a sign of vigorous activity substantial increase in heart rate.
CHAPTER 3:
Cancer
Although Cancer develops at a cellular level it is known to be Physical activity has been shown to improve quality of life during
influenced amongst others, by genetic, environmental and lifestyle the rehabilitation phase and should therefore be encouraged.13 - 17
factors via a number of interacting biological mechanisms.
Physical activity and palliative care: Despite a small evidence
Inactivity or largely sedentary behaviour is now widely base, intervention studies are promising and support the use of
recognised as a key component in the risk factors of physical activity in those in the advanced stages of cancer.18-21
several cancers. Benefits demonstrated include:
• Slowed decline in quality of life
There is clear data for the positive effects of physical activity • Preserved functional outcomes (e.g. walking ability,
both on the prevention of some cancers and on clinical muscular strength)
outcomes after diagnosis. • Less severe symptoms (dyspnoea, appetite loss)
Physical activity and primary prevention Physical activity and survival rates: An increasing number of
The leading authority on the links between physical activity as an studies have studied the relationship between physical activity
independent risk factor for the primary prevention of cancer is the and cancer survival. There have been reviews and studies across
World Research Fund’s Continuous Update Project.1 The evidence breast, colorectal, prostate, ovarian, lung and glioma brain cancer.
here is for physical activity as the only independent risk factor, 22-29
Although, this is still emerging evidence, these studies have
some cancers also have weight as a risk factor. shown an inverse relationship between physical activity and
mortality in people undertaking post diagnosis physical activity.
Strong convincing evidence Limited – no conclusion
Colon Bladder Rectal Risk reduction rates varies on these studies, from 15-67% for cancer
Strong probable evidence Kidney Skin specific mortality and 18 -67% for all-cause mortality.25 However,
the dose of physical activity to reduce cancer mortality varied
Breast (post-menopausal) Mouth/throat Stomach
between studies from 9 MET-hr (metabolic equivalent time) to 27
Breast (pre-menopausal) for vigorous exercise Ovary MET-hr, equivalent to approximately 180 to 500 minutes per week
Endometrial Pancreas respectfully, of moderate intensity physical activity. It is suggested
Limited - suggestive Prostrate that the association between physical activity and cancer-specific
mortality is not uniform and may vary according to the volume of
Liver Oesophagus Unlikely effect on risk
physical activity and between different cancer types.25
Lung Breast (pre-menopausal) None identified to date
NICE guidelines CG101 (2018)30 and CG81 (2017) 31 back up the
Physical activity pre-treatment: Pre-surgical exercise, through advice to those with early and advanced breast cancer, that
aerobic, resistance or pelvic floor training, may benefit cancer we should provide the information and access to an exercise
sufferers through effects on function and cardiovascular and programme to help with cancer related fatigue, lymphoedema
pulmonary fitness with emerging evidence of improvements and quality of life.
shown in:2- 5
• Rates of incontinence in prostate cancer Safety considerations during and after treatment 32
• Functional walking capacity
• Cardiorespiratory fitness
• Reduced hospital stays To avoid symptom exacerbation To prevent falls
Modify exercise Practice balance exercises
Physical activity during treatment: Although feeling unwell before Start moderately and progress slowly Practice strength exercises
or during treatment for cancer, physical activity helps maintain
During immunosuppression For people with lymphoedema
functional abilities and wellbeing and:6 - 9
• Significantly improves fitness and muscle strength Avoid high load/intensity Progress slowly
• Shows small improvements in anxiety levels and self esteem Monitor bloods for neutropenia Wear compression garments
• Shows evidence of an improvement of fatigue levels, greatest
in those with worst fatigue
• Increases lean muscle mass
Contraindications 33
• Improves arm function with no worsening of lymphoedema
In disease or treatment avoid activities that:
in breast cancer 10, 11 • Require high intensity in people with low Hb < 8.0g/dl
• Entail an increased risk for bacterial infection in people with
Physical activity after treatment: There is often a loss of physical a low wbc < 0.5 x 109/l
function as a result of their cancer treatments, but evidence
shows that physical activity after treatment can improve several
aspects: 6-9,12
• Increase in cardiovascular fitness and muscular strength
• Reduced fatigue, greatest in those with worse fatigue
• Improvements in quality of life, anxiety and depression
• Some reductions in body fat and increase in muscle mass
CHAPTER 4:
Cardiovascular Health
Ischaemic heart disease cardiac rehabilitation services for varied reasons.9 These should be
explored with the individual by primary and secondary care to see
Primary prevention: There is a clear inverse relationship between if any barriers to the individual can be overcome.
physical activity and cardiovascular disease (CVD) which is dose
responsive, with the largest benefits occurring when moving from NICE guideline CG172 on Myocardial infarction: cardiac
no activity to low levels of activity. Additional benefits do occur rehabilitation and prevention of cardiovascular disease10
with higher levels of activity.1 The reduction in cardiovascular recommend:
mortality is of the order of 20-35%, depending on the level of
physical fitness.2 • Offer cardiac rehabilitation programmes designed to motivate
people to attend and complete the programme. Explain the
Mechanisms which contribute to this effect from exercise benefits of attending
interventions are multiple: 3 - 4
• Direct cardiovascular effects on the heart • People should be advised to undertake regular physical activity
o Lower heart rate at rest and during exercise sufficient to increase exercise capacity
o Lower blood pressure at rest and during exercise
o Lower relative oxygen demand • They should be advised to be physically active for 20-30 min a
o Increased plasma volume day to the point of breathlessness
o Increased stroke volume
o Increased myocardial oxygen supply • People not achieving this should be advised to increase their
o Increased myocardial contraction electrical stability activity in a gradual step-by-step way, aiming to increase their
o Improved vascular endothelial function exercise capacity
o Decreased blood coagulability
o Increased coronary blood flow, coronary collateral vessels • They should start at a level that is comfortable, and increase the
and myocardial capillary density duration and intensity as they gain fitness
• Metabolic effects • The benefit of exercise may be enhanced by tailored advice from
o Increased high density lipids a suitable qualified professional
o Decreasing harmful low density cholesterol
o Improved insulin sensitivity
Contraindications to referral for exercise 11
• Unstable angina,
NICE guideline CG 1815 on Cardiovascular disease: risk assessment • Systolic blood pressure 180 and/or diastolic 100 mmHg,
and reduction, including lipid modification recommend: Lifestyle • BP drop > 20 mmHg demonstrated during ETT,
modifications for the primary and secondary prevention of CVD. • Resting tachycardia > 100 bpm,
• Advise people at high risk of or with CVD to do the • Uncontrolled atrial or ventricular arrythmias
following every week: • Unstable or acute heart failure
o At least 150 minutes of moderate intensity aerobic activity or
o 75 minutes of vigorous intensity aerobic activity or a mixture
of moderate and vigorous aerobic activity in line with national Erectile dysfunction
guidance for the general population Erectile dysfunction (ED) is the persistent inability to obtain or
o Advise people to do muscle-strengthening activities on 2 or maintain an erection satisfactory for sexual activity. Provided
more days a week that work all major muscle groups (legs, alternative hormonal, neurological and psychological causes are
hips, back, abdomen, chest, shoulders and arms) in line with excluded, then ED is thought to have a vasculogenic aetiology and
national guidance for the general population shares common risk factors with cardiovascular disease (CVD):
age, hypercholesterolaemia, hypertension, metabolic syndrome,
• Encourage people who are unable to perform moderate-intensity insulin resistance and diabetes, smoking, obesity, sedentary
physical activity because of comorbidity, medical conditions or behaviour and depression.1
personal circumstances to exercise at their maximum safe capacity
Many studies has established that ED is associated with
• Advice about physical activity should take into account the asymptomatic coronary artery disease (CAD) and that the ED
person’s needs, preferences and circumstances. Agree goals and precedes the CAD, stroke and peripheral arterial disease by a
provide the person with written information about the benefits of period of 2-5 years (average age 3 years). 2, 3 A meta-analysis also
activity and local opportunities to be active concluded that men with ED compared with subjects without have
a 44% higher risk for total cardiovascular events.2
Secondary prevention: in established heart disease, regular
adapted exercise is required to reduce mortality, and habitual This has important clinical implications for men presenting with
physical activity has been shown to reduce all-cause mortality ED. Careful history taking, including CVD symptoms, CVD risk
by 25-30%.6 The evidence of cardiac rehabilitation if it is used, is factors and presence of co-morbidities, is essential. Lifestyle
associated with a reduction in morbidity, cardiac mortality (26%), changes are then effective in improving sexual function in men;
hospital readmissions (18%) and improved health-related quality these include physical exercise, improved nutrition, reduced
of life.7, 8 The uptake of cardiac rehabilitation in England is 50%. alcohol intake, weight control and smoking cessation. 2, 3
This reflects that half of eligible people are still not taking up
CHAPTER 4:
Heart failure The European Heart Rhythm Association ( EHRA) and European
Trials support the evidence of the beneficial effect of physical Association of Cardiovascular Prevention and Rehabilitation
activity training in people with stable heart failure in NYHA class I, (EACPR), endorse the current evidence, which would suggest
II and III. 1-3 that moderate physical activity is associated with improved
cardiovascular health, decreased mortality and a decreased
Although there is no evidence of increased or decreased all-cause risk of AF.1
mortality in the short term (up to 12 months), the benefits of
exercise have been shown by meta-analysis to: 2,4,5 Obstructive sleep apnoea syndrome (OSAS)
• Physiologically increase VO2 max
• Functionally increase walking speed and tolerance
• Significantly reduce hospital admissi ons
• Improve quality of life.
In addition, there is an emerging trend towards reducing mortality

in trials longer than 1 year.2
NICE guideline CG 1086 on chronic heart failure recommend:
• Offer people with heart failure a personalised, exercise-based

cardiac rehabilitation programme, unless their condition is
unstable.
Contraindications
Heart failure which is acute, unstable 7 or severe NHHA class 1V1
Figure 1. Partial and complete airway obstruction resulting in hypopnea and apnea,
respectively. Reprinted from Hahn PY, Somers VK. Sleep apnea and hypertension.
In: Lip GYH, Hall JE, eds. Comprehensive Hypertension. St. Louis, Mo: Mosby;
2007:201–207. Copyright Elsevier 2007. Used with permission
Atrial fibrillation (AF)
OSAS is characterised by recurrent partial or complete collapse

of the upper airway during sleep. 1 It has been strongly associated
with hypertension, heart failure, myocardial infarction, stroke,
obesity and type 2 diabetes and up to a 5-fold higher incidence
of traffic and industrial accidents and all leading to a 50 % higher
mortality. 2-5
Atrial fibrillation (AF) is the most common cardiac arrhythmia, Repetitive bursts of sympathetic activity, surges of BP and
associated with significantly increased morbidity and mortality of oxidative stress, brought on by pain and episodic hypoxaemia
stroke, dementia, heart failure and myocardial infarction. 1 associated with increased levels of mediators of inflammation, are
thought to promote endothelial dysfunction and atherosclerosis.
Physical activity is known to lower cardiovascular morbidity 6
For these reasons, increased physical activity is recommended
and mortality and physical inactivity is a major risk factor of as part of the behaviour treatments for OSAS, that also include
cardiovascular disease.2 Habitual moderate physical activity avoiding alcohol, caffeine or other stimulants of wakefulness
may have several benefits that can reduce the incidence of AF: before sleep, discontinuation of sedating medications and obesity
lowering heart rate and blood pressure, improved glucose and control. 1 Continuous positive airway pressure remains the gold-
lipid control, weight loss, improved endothelial function, and lower standard therapy and reduces CV mortality and events. 7
systemic inflammation are just some of the benefits. 3 Conversely,
vigorous activity can cause acute catecholamine fluxes, autonomic There is strong evidence that habitual moderate-to-vigorous
tone changes, and atrial stretch, all which may contribute to an physical activity reduces the risk of excessive weight gain, an
increased AF risk. 1, 5 important risk factor for obstructive sleep apnoea, indicates that
physical activity could have a favourable impact on the incidence,
Whether physical activity increases or decreases the risk of AF has as well as the treatment of, obstructive sleep apnoea. 5
been unclear/controversial, with the reported relationship between
physical activity and AF varying between studies. 4 Hypertension
The evidence supports an inverse relationship between physical
A large meta-analysis of 22 studies (656,750 individuals) has activity and the incidence of hypertension, with inactive individuals
reported that moderate physical activity does protect against AF who are less active and fit having a 30-50% greater risk of
in both men and women. 6 However, vigorous exercise appears high blood pressure. 1,2 However, the optimum prescription for
to increase the risk of AF in men, but whilst remaining protective the prevention of hypertension remains elusive. 3 Apart from
against AF in women. prevention, it is also effective in treatment with clinically relevant
reductions in blood pressure.
CHAPTER 4:
• The acute effect of physical activity causes a decrease in blood In addition, a recent meta-analysis of randomised trials found, that
pressure lasting 4-10 hours, but may last up to 22 hours; thus, structured exercise achieved a modest but consistent reduction
daily activity may achieve clinically significant improvement 4 in high systolic blood pressure (>140/90) that was similar to those
seen with commonly used hypertensives. On average it was found
• For a long-term effect, regular maintenance physical that exercise reduced systolic blood pressure by a mean of 8.96
activity is required mmHg in hypertensive patients compared to matched controls. 13
(See Table 1)
• The effect seems to be greatest in those with
established hypertension Lipids
Isolated hypercholesterolaemia and mixed dyslipidaemia with high
• Review data support the observation that physical activity LDL cholesterol, high triglycerides and low HDL cholesterol are
training, with all forms of exercise, in hypertensive people can associated with an elevated risk of atherosclerosis.
show a reduction of 3-10 mmHg in systolic and 2-6 mmHg in
diastolic blood pressure respectively 5 Aerobic fitness training has been shown to be beneficial in
The BASES Expert Statement on Exercise
• The main recommendation is for aerobic fitness training but
reducing triglycerides 1,2 and elevating the protective HDL
cholesterol,3 with some effect in also lowering LDL cholesterol.1
Training for People with Intermittent
dynamic resistance and isometric resistance at moderate
intensity training is also beneficial 5,6 Best results are achieved with regular daily moderate intensity
Claudication due to Peripheral Arterial Disease aerobic exercise or vigorous exercise at slightly higher volumes of
• Reductions of this magnitude have important clinical implications the present UK guidelines, expending 1200-2000 kcal per week
o They are of a similar magnitude
Produced on to conventional
behalf of the medication
British Associationwhich of Sportequates to 360 minutes
and Exercise Sciencesmoderate
by Dr Garry activity
Tew,per week. This
o A 10mmHg reduction in systolic or 5mmHg in diastolic blood workload
Dr Amy Harwood, Prof Lee Ingle, Prof Ian Chetter andisProf
associated
Patrick with a 5-8% increase in HDL cholesterol
Doherty.
pressure would be associated with about a 40% lower risk of and a decrease in triglycerides of approximately 10%. 4 It should
stroke death and about 30% lower risk of death from IHD or
Introduction still supplement other interventions.
other vascular causesLower-limb
7
peripheral arterial disease is a type of cardiovascular distance at follow-up of 82 m (95% CI 72-92 m; follow-up ranging
o Even a 2mmHg reductiondiseasein insystolic
which theblood
bloodpressure is
vessels (arteries) Peripheral Arterial
that carry blood 6 weeks toDisease
2 years). The corresponding difference for maximum
associated with reductions of 10%
to the legs andare
and feet 7%hardened
in the risks of
and narrowed Peripheral
or blocked by arterial
walkingdisease (PAD)
distance was 120 maffects
(95% CIaround
51-190 m;13% of adults
10 trials, over
n=500).
the build-up
stroke and ishaemic heart disease of fatty plaques (called
respectively 7 atheroma). It affects50around Improvements
years old and is commonly of this magnitude
caused are by likely to help with independence.
atherosclerosis. Major
13% of adults over 50 years old, and major risk factors for its The same review also reported that there was moderate-quality1
risk factors include smoking, diabetes mellitus and dyslipidaemia.
development include smoking, diabetes mellitus and dyslipidaemia evidence for improvements in physical and mental aspects of
NICE guideline CG136 on 8
the clinical management of The
(Morley et al., 2018). The presence of peripheral arterial disease presence of PAD itself
quality of life, is also a
as assessed riskthe
using factor
SF-36 for cardiovascular
(Lane et al., 2017). A
primary hypertension in adults recommends
itself is also that
a risk factor for appropriate
other disease,
cardiovascular problems, such with meta-analysis
about 65% of ofdata
people with PAD
at 6 months also having
of follow-up showedclinically
the physical
guidance and written or audio-visual
as angina, heartmaterials to promote
attack and stroke. relevant cerebral
This is because the underlying or coronary
component summaryartery be 2 points(See
score todisease. 2
higherFigure 1)
in exercise
lifestyle changes are offered.
disease process, atherosclerosis, is a systemic
process, meaning that blood vessels elsewhere in the
body may also be affected.
Contraindications The most common symptom of peripheral arterial
Blood pressures of a systolicdisease>180 or diastolic
is intermittent >100 or
claudication higher
(IC), which is
should receive medication before
muscle pain orregular physical
discomfort activity
in the legs and/or9 buttocks
brought on by walking and relieved within minutes
on rest (see Figure 1). IC occurs due to an inability to
Pharmacology v physical sufficiently
activity increase blood flow (and oxygen delivery)
There is plenty of strong randomizedmetabolic
to match the demands
controlled trialofdata
the lower-limb
muscles during exercise and can cause marked
showing reductions in stroke risk in those taking antihypertensive
reductions in functional capacity and quality of life
medications.10 There is less evidence
(Morley et al., that
2018).they significantly
The walking distancereduce
or speed Figure1. 1.
Figure Intermittentclaudication
Intermittent claudication (IC)
(IC)due
duetotoperipheral
peripheral arterial disease.
arterial disease
the risk of all-cause mortality andsymptoms
at which myocardial occurinfarction, with the
depends on multiple Reproduced from Peripheral artery disease (Morley et al., 2018) with permission from BMJ Publishing Group Ltd.
factors Reproduced fromartery
Peripheral artery diseaseat(Morley et al., 2018)
Note: Iliac or femoral disease can cause symptoms multiple distal muscle sites.with permission
exception of thiazide diureticsincludingandtheangiotensin-converting
severity and site of the arterial enzyme
disease, from BMJ Publishing Group Ltd. https://doi.org/10.1136/bmj.j5842
inhibitors. 11 However, there walking pace, terrain,
is strong incline and
prospective footwear.
cohort evidence Note: Iliac or femoral artery disease can cause symptoms at multiple distal
that regular physical activity Treatments
can reduce for IC,
theaimed
risksat of
relieving symptoms and reducing muscle sites
all-cause versus control (95% CI 1-3; 5 trials, n=429). The corresponding
the risk of further12cardiovascular disease, include lifestyle changes difference for the mental component summary score was 4 points
mortality and cardiovascular mortality.
(e.g. stopping smoking, exercising more), vasoactive drugs (e.g. (95% CI 3-5; 4 trials, n=343). Again, such differences have the
naftidrofuryl oxalate) and revascularisation (i.e. angioplasty or potential to be clinically meaningful.
Intervention bypass surgery). In 2012, the United All-causeKingdom’s National Institute
mortality Cardio-vascular mortality Myocardial infarction
of Health and Care Excellence (NICE) published a clinical guideline Modes of exercise
ACE-I * 10%
on the management of peripheral arterial disease, which stated that 19% In most studies, exercise programmes NR have involved treadmill or
Thiazide a supervised exercise programme *9% NR
should be offered as a first-line track walking of sufficient intensity22% to bring on claudication pain.
therapy for IC (NICE, 2012). This statement provides an overview There is a strong evidence base for this type of training and clinical
β-blocker * 6% (NS) NR 8% (NS)
of the evidence on exercise training and recommendations for guidelines around the world cite it as the preferred modality
Ca2+ channel blockers people * -6% (NS)
delivering exercise programmes to this population. NR (e.g. NICE, 2012). Alternate exercise 29%modalities
(NS) have not been
Regular physical activity (self-reported) # 29% 30% extensively studied. However, a randomised NR trial of 104 participants
Evidence on exercise training provided evidence that both cycling and arm-cranking are viable
Regular physical activity Core(fitness
outcome tests) #
measures 41% 57% alternatives for improving walkingNR distances (Zwierska et al., 2005).
Walking ability and its impact on quality of life
NS: Not significant; NR: Not reported. *: Randomised control trials. #: Prospective are the most These modalities
cohort may be useful for patients who are unwilling or
studies
important outcome measures of intervention to clinicians and unable to walk because of the pain encountered. Resistance training
patients.
Table 1: Mortality and morbidity Measureswith
risk reductions of walking
long-termability include pain-freemedication
anti-hypertensive and maximum may have
and physical a complementary
activity 11 role (e.g. for improving muscular
walking distances (or times) obtained during standardised treadmill strength); however, it should not be used as a substitute for aerobic
testing, and the distance covered in the 6-minute corridor walk exercise because its impact on walking distances appears modest
PHYSICAL ACTIVITY: A GUIDEtest. FOR The ‘Gardner’
HEALTH treadmill test is(V10)
PRACTITIONERS commonly used, which 21 THE BENEFITS (e.g. OF
McDermott
PHYSICAL al., 2009). ON OUR HEALTH AND WELLBEING
et ACTIVITY
involves a constant speed of 3.2 km/h and an increase in gradient
of 2% every 2 minutes. Several generic and condition-specific Supervision
questionnaires have been used to assess quality of life, including the The systematic review of Gommans et al. (2014) reports the
CHAPTER 4:
The primary treatment option, before resorting to surgery is Treatment: there is a huge variation in the degree of disability after
exercise training as generally the disease responds poorly to a stroke. Once stabilised, an individualised aerobic fitness training
pharmacotherapy. 2 Meta-analysis reviews conclude there is high programme can increase the endurance for day to day activities,
quality evidence for supervised exercise programmes. These can mediated by improved mobility and balance and improves walking
enable walking an increased distance to the onset of pain by 89 function. 3, 6 This can improve self-confidence of people to take part
m and the maximum walking distance by 120 m. 3 Exercise should in physical activity themselves. 7 Similarly, muscle strengthening
continue lifelong, with an expected improvement in walking of the lower limbs has been shown to increase function thereby
distance and reduced pain. Additional benefits may include a improving quality of life. 4
higher quality of life and improved cardiovascular health. 4
NICE guideline CG 162 on stroke rehabilitation recommend: 8
Although Vasoactive drugs, such as Naftidrofuryl oxalate,
can improve walking distance,1 NICE only recommend it Strength training:
when a supervised exercise programme does fails to achieve • Consider strength training for people with muscle weakness
any satisfactory improvement AND the person declines no after stroke
surgical options.5
• Include progressive strength building through increasing
NICE guideline CG 147 on lower limb peripheral artery disease repetitions of body weight activities (for example, sit-to-stand
recommend: 5 repetitions), weights (for example, progressive resistance exercise),
• Offering a supervised exercise programme to all people with or resistance exercise on machines such as stationary cycles
intermittent claudication.
• Consider providing a supervised exercise programme Fitness training:
which involves: • Encourage people to participate in physical activity after stroke
o 2 hours of supervised exercise a week for a
three-month period • Cardiorespiratory and resistance training for people with stroke
o Encouraging people to exercise to the point of maximal pain should be started by a physiotherapist
• Offer all people with peripheral arterial disease, information, • Aim that the person continues the programme independently
advice, support and treatment regarding the secondary based on the physiotherapist’s instructions
prevention of cardiovascular disease in line with NICE guidance
• Physiotherapists should supply any necessary information about
interventions and adaptations so that where the person is using
Stroke an exercise provider, the provider can ensure their programme is
safe and tailored to their needs and goals
Primary prevention: the benefits of physical activity on the
prevention of stroke are well documented. 1-4 Risk factors for Walking therapies:
stroke include hypertension, type 2 diabetes and hyperlipidaemia • Offer walking training to people after stroke who are able to
all of which are beneficially affected by physical activity. It is not walk, with or without assistance, to help them build endurance
surprising then that there is a clear inverse relationship between and move more quickly
activity and risk of stroke. It is also clearly dose dependent and
depending on the amount of activity, the effect is a 20 - 35% • Consider treadmill training as one option of walking training for
lowering of risk. 1,3 people after stroke including those who require body support.
Secondary prevention: the adverse vascular disease profile of

many stroke sufferers remains after a first stroke and, physical
activity should continue to be encouraged. Meta-analysis has shown
exercise reduces mortality following a stroke and when compared
head to head exercise interventions have also been shown to be
more effective than anticoagulants and antiplatelet agents.5
“The reason I Exercise is for

the quality of life I enjoy”
Kenneth Cooper
CHAPTER 5:
Chronic Kidney Disease (CKD)
CKD - This term describes a group of progressive and irreversible Whilst studies are increasing, the evidence base in transplant
kidney disorders which are estimated to affect around 8% of the recipients remains small.
population in the UK. 1
Overall, both aerobic and resistance exercise are recommended
A progressive decline of renal function is associated with 2: due to their separate beneficial effects on cardiovascular health
• Increasing morbidity and mortality and skeletal muscle in these people, 23-26 who typically lead
• Muscle wasting and reduced physical function sedentary lifestyles27.
• Hypertension
• Anaemia The use of exercise in the treatment and rehabilitation of such
• Systemic inflammation people is relatively understudied, but there is now sufficient
• Metabolic co-morbidities, including type II diabetes and obesity evidence of the benefits for exercise to be mentioned in the
current NICE guidelines for the management of CKD:
A minority of people will eventually progress to end stage renal
failure (ESRF) requiring dialysis or transplantation, but by far the NICE guidelines CG182 28 on CKD in adults recommend:
most common cause of death is cardiovascular disease (CVD).2 • Encourage people with CKD to take exercise, achieve a healthy
weight and stop smoking. (2008)
People with CKD 3, 4 display poor physical fitness and reduced
exercise capacity, which is directly associated with all-cause The newly updated clinical practice guidelines29 from the UK Renal
mortality 5, 6. Physical activity levels vary amongst CKD Association for haemodialysis (2019) now recommend intradialytic
populations, with ~40% of non-ESRF individuals being physically exercise, i.e., exercising during haemodialysis treatment:
active, however levels decrease with disease progression and
are lowest amongst those receiving dialysis 7. However, higher • Intradialytic exercise should be available in all units, as a
levels of leisure time physical activity and walking are associated treatment for enhancing physical functioning, in patients without
with slower decline in kidney function, reduced risk of renal contraindication.
replacement therapy and mortality 8, 9.
• Intradialytic exercise may be considered as a method for
Benefits of exercise in CKD: enhancing quality of life.
Data coming from a number of systematic reviews and/or meta-
analyses10 - 15 and randomised controlled trials and experimental The American National Kidney Foundation guidelines include
studies16 - 24 into the effects of exercise across the spectrum of CKD a similar statement encouraging exercise, weight loss and
report the following benefits: smoking cessation in CKD; however, these current guidelines lack
specific advice for exercise and physical activity prescription.
• Significant positive effects on exercise capacity following all Greater information is provided in the 2012 American Kidney
types of exercise including, aerobic and resistance exercise Disease Improving Global Outcomes (KDIGO)30 guideline for
performed individually or in combination the management of blood pressure, who advocate performing
exercise “compatible with cardiovascular health and tolerance,
• Increased walking capacity aiming for at least 30 minutes 5 times per week”. Whilst current
clinical guidelines for exercise in the management of CKD people
• Significant positive effects of cardio-protective benefits and in the UK are lacking, more in-depth guidelines are included
reduction of cardiovascular risk factors including improved blood in the Swedish handbook ‘Physical activity in the Prevention
pressure control and reductions in arterial stiffness in non-ESRF and Treatment of Disease’ (FYSS in Swedish). 31 The UK Renal
CKD following aerobic exercise Association has commissioned the first UK exercise and lifestyle
guidelines for CKD (due in 2020).
• Reversal of CKD related muscle wasting with improvements in
muscle size and strength with progressive resistance exercise Precautions:
The usual absolute contraindications to exercise apply in CKD.
• Improved health related quality of life (e.g. depression, pain) See ‘Starting to exercise’.
following aerobic and resistance exercise performed individually
or in common The following can be considered CKD specific precautions and
contraindications 7, 11, 26, 32, 33:
• Reductions in systemic inflammation and circulating markers
of oxidative stress (malondialdehyde and 4-hydroxyalkenals) • With the high prevalence of CVD the people should have no
following aerobic exercise or stable angina, well controlled blood pressure and minimal
fluid retention.
• Improved allograft function (improved transplant function) in
people receiving a transplant • People with CKD are prone to fragility fractures and tendinoses
injuries with spontaneous tendon ruptures being reported in
The evidence base surrounding the benefits of exercise and CKD. Moreover, musculoskeletal and joint issues are likely to be a
physical activity in ESRF (in those requiring haemodialysis and common consequence of the initiation of exercise training due to
peritoneal dialysis therapy) is limited and many studies are at high the high prevalence of co-morbidities in most CKD sufferers.
risk of bias.23,24
CHAPTER 5:
Chronic Kidney Disease (CKD)
Therefore flexibility and stretching exercises along with a long People should be advised to incorporate increased physical
warm up and cool down period should be incorporated into a activity into their lifestyle wherever possible, gradually increasing
graded exposure to exercise. the intensity and duration. 35 To gain greater improvements in
aerobic capacity and muscle size and strength, people should
• People with polycystic disease kidneys and those with a kidney be encouraged to progress to moderate intensity, but the
transplant should avoid high impact exercises due to the risk of primary aim is to establish a sustained habit of regular physical
mechanical injury to their kidneys. activity. Incorporating forms of strength building exercises are
important for muscle function. Setting unrealistic targets is
• People with a fistula can exercise their fistula arm, but should not counterproductive as the person is unlikely to engage with a
apply weight to that area programme if they lack confidence and belief in their ability to
succeed, and failure is extremely demotivating. Therefore, to
effectively initiate and maintain exercise behaviour it is important
CKD specific contraindications
to work with the person and help them to:
1. Electrolyte abnormalities – especially hypo/hyperkalaemia
2. Recent ECG changes – especially symptomatic
tachyarrhythmias or brady-arrhythmias • understand the potential benefits of exercise in the context of
3. Excess inter-dialytic weight gain >4kg since last dialysis session their own health and lifestyle
4. Unstable dialysis treatment and titrating medication
5. Pulmonary congestions • assess and acknowledge perceived (e.g., time, motivation) and
objectives (e.g., co-morbidities) barriers to exercise
Recommendations: • identify attainable goals that are meaningful and appropriate to

Although it is important to recognise the precautions, it is the individual
equally important to bear in mind that in the absence of absolute
contraindications to exercise, sedentary behaviour probably • formulate a realistic plan of action and consider ways to manage
carries more health risks than performing regular physical activity potential barriers
at an appropriate moderate intensity.34
• monitor progress and recognise improvements
$
“When it comes to health and wellbeing,

regular exercise is about as close to a
magic potion as you can get”
Tich Nhat Hanh
CHAPTER 6:
Mental Health
Depression Advice on physical activity should be given in conjunction with

antidepressant medication and or psychotherapy treatments. 17
People with severe mental illness such as schizophrenia, depression
or bipolar disorder have poorer physical health and a shorter NICE guideline CG90 on Depression in adults: The treatment and
life expectancy of at least 10 years compared to the general management of depression in adults recommends 17
population. 1 The commonest physical illness being cardiovascular
disease and severe depression is associated with a 78% higher risk For people with persistent sub threshold depressive symptoms or
of developing cardiovascular disease and an 85% increased risk of mild to moderate depression, one choice is to offer referral for a
cardiovascular-related death.2 This excess cardiovascular mortality structured group physical activity programme which should:
in schizophrenia and bipolar disorder is attributed in part to the
increased modifiable coronary risk factors of: 1, 3 • Be delivered in groups with support from a competent practitioner
• unhealthy diets • Consist typically of three sessions per week of moderate duration
• obesity (45 minutes to 1 hour) over 10 to 14 weeks (average 12 weeks)
• smoking
• diabetes
• hypertension Anxiety
• hyperlipidaemia
Anxiety is a noticeable, psychophysiological emotional state,
In most of these conditions lifestyle factors of physical activity characterized by feelings of apprehension, fear or expectations
plays an important role. of fear, worry, nervousness and physical sensations arising from
activation of the autonomic nervous system.1 It demonstrates
Prevention of depression with physical activity: Studies examining itself in a number of forms such as phobias, panic disorders and
whether physical activity might be protective against the risk of generalized anxiety disorder. It also appears as a symptom in many
depression later in life have shown promising positive effects. 4 different physical and mental illnesses. The normal human emotion
Evidence appears effective from childhood (9-15yrs) and lasting becomes pathological when it results in marked changes in
up to twenty years later. 5 It has also suggested the majority of thoughts and actions, occurring in the absence of an eliciting event
this protective effect was at low levels of activity and observed and when the response is disproportionate and unmanageable. 2
regardless of intensity. A large meta-analysis of all existing data
(49 independent studies of over quarter of a million people) Many studies have evaluated the effect of physical activity on
comparing onset of depression in non-active vs. active individuals anxiety reduction looking at both single bouts of exercise (state
also found that 1 hour of exercise could prevent incident cases of anxiety: how anxious an individual feels at the moment) and as a
depression by up to 17%. 6 result of regular training (trait anxiety: how anxious an individual
feels most of the time). Studies indicate that an acute or single
Treatment of depression with physical activity: There is some bout of exercise can yield a small but significant reduction in state
good evidence that regular moderate intensity physical activity is anxiety. 3, 4
effective in the acute treatment of mild to moderate depression
and in reducing depression in adult non-clinical populations. 7-9 For individuals with chronic anxiety disorders, regular physical
activity has a significant effect on the reduction of trait anxiety
Studies suggest that activity may alleviate depressive symptoms symptoms.1 It is also important to note that reviews comparing the
in the general population and also that depressive symptoms may effect of exercise to other treatments, 5, 6 consistently reported
be a barrier to activity, i.e. the relationship is bidirectional. 10 As for that exercise interventions work as least as effectively as standard
the most effective form of activity, moderate intensity exercise care treatment for anxiety and sometimes better. 6
is effective but low intensity exercise appears to have no effect.11
Recent meta-analysis of the adult population, suggested that This has important clinical relevance with the wider benefits of
moderate intensity physical activity interventions, aerobic activity, exercise on wellbeing and cardiovascular health. These studies
and if supervised by exercise professionals, can have a greater reinforce exercise as an important treatment option in people with
effect on major depressive disorders. 12, 13 In children and young anxiety/stress disorders either in conjunction, or as part of non-
adults (up to age 20) scientific evidence has been conflicting pharmacological alternative treatments. 1
regarding the protective effects of physical activity on depression.
However, meta-analysis has suggested a small significant positive
effect for physical activity on depression. 14 Post-traumatic stress disorder (PTSD)
Physical activity matched to an individual’s preferred intensity Post-traumatic stress disorder (PTSD) is a significant and
has also been shown to improve mental health outcomes and recognised form of anxiety based mental disorder, that is also
exercise adherence rates. 15 When preferred intensity exercise was associated with high rates of obesity and cardiometabolic
combined with motivational support it improved the reduction of diseases, partly thought to be due to reduced physical activity
depressive symptoms, quality of life and exercise adherence rates.16 levels. 1 - 4
CHAPTER 6:
Mental Health
There are several reasons why PTSD may have an association with Most of these conditions are potentially open to modification by
reduced physical activity levels. Individuals with PTSD may limit physical activity.
their physical activity owing to a heightened concern for safety,
fear of bodily arousal symptoms, comorbid depression, substance A number of studies of people with schizophrenia have so far
use and insomnia. Reduced motivation, a lack of self-efficacy and shown a positive effect of physical activity on physical health,
social support will also contribute. 4,5 cardiometabolic factors, weight, quality of life, positive and
negative symptoms. 1,3,4 There is also some evidence that physical
To examine this association, physical activity levels trends, from activity can improve cognitive functioning among people with
20 years of data in the Nurse’s Health Study , were analysed. schizophrenia, particularly with increased exercise intervention. 4,5
Within this group, women who had suffered with a PTSD event, Increasing physical activity should therefore be advocated to all
were observed to have reduced physical activity levels following people with psychosis or schizophrenia. 6
the onset. 5 It was also noted that the more symptoms of PTSD
recorded, then the lower the level of subsequent physical activity. 5 NICE guideline CG 178 on Psychosis and Schizophrenia in adults:
treatment and management recommend: 7
• Before starting antipsychotic medication: an assessment of
nutritional status, diet and level of physical activity
• People with psychosis or schizophrenia, especially those taking
antipsychotics, should be offered a combined healthy eating and
physical activity programme by their mental healthcare provider
Sleep
Sleep is a reversible state of perpetual disengagement from

and unresponsiveness to the environment 1. It is an important
determinant of health and wellbeing across the lifespan 2 and an
essential biological function important for neural development,
learning, memory, emotional regulation, and cardiovascular and
metabolic health 3
Although research is very limited, the present evidence also Sleep consists of four formally recognised stages and has several
indicates that physical activity interventions are effective in features that comprise the totality of sleep. These stages and
reducing PTSD symptoms. 6, 7 However, at present, current features are used by everyone to recognise the quality and value
management of PTSD rarely incorporates physical activity as part of sleep 1, 4 (see table 1 on next page).
of its management.5
This has important clinical implications, the presence of PTSD Common sleep disorders include Insomnia and obstructive
symptoms should raise clinician concerns about the potential sleep apnoea
development of physical health problems and prompt close
attention to health behaviour. Physical activity can then be used as Insomnia
an adjunct, to normal accepted treatment as a means to improve Meta-analysis of sleep studies consistently show, small-to-
both the PTSD symptoms and the physical health of the individuals. moderate size benefits of both regular physical activity and acute
physical activity across multiple sleep outcomes; including total
sleep time, sleep efficiency, sleep onset latency, sleep quality and
Schizophrenia rapid eye movement sleep.5
Acute bouts of moderate to vigorous physical activity also
Poor physical health is often associated with severe mental illness reduce the time spent awake after falling asleep and shorten the
such as schizophrenia, depression and bipolar disorder. There time in stage 1 sleep.5 The relationship between physical activity
is a high risk of premature death and a shorter life expectancy and sleep appears consistent amongst the young, middle aged
of at least 10 years. 1 This excess cardiovascular mortality in men and older aged men and women.4
schizophrenia and bipolar disorder is attributed in part to the
increased modifiable coronary risk factors of: 1,2 Obstructive sleep apnoea
Moderate evidence exists associating physical activity with
• unhealthy diets significant improvements in apnoea hypopnoea index, reduced
• obesity daytime sleepiness and improved sleep efficiency of those with
• smoking obstructive sleep apnoea.4
• diabetes With its strong association with hypertension, heart failure,
• hypertension myocardial infarction, stroke, obesity and type 2 diabetes,
• hyperlipidaemia obstructive sleep apnoea is also dealt with in more detail in the
cardiovascular health section of this resource.
CHAPTER 6:
Mental Health
Sleep stages Sleep normally progresses through Wellbeing and quality of life
a series of four stages in repeated
cycles of about 90 minutes Many studies have shown improved wellbeing with physical
activity training. 1 Improved psychological wellbeing is also
Non-Rapid Eye Movement Stage N1 and N2, the two earliest the most common comment made on self-reported feedback
(NREM) - light sleep stages of sleep (except in infants), questionnaires. 1 Common wellbeing feelings, felt by people after
characterized by progressive physical activity are displayed in figure 1.
deepening sleep
Relaxed Satisfied Clear Minded
NREM slow wave sleep - Stage N3, deep sleep is characterised
deep sleep by slow brain activity and is associated Positive Calm Fitter
with memory consolidation. Maximal
in children and declines with age Worthwhile Alive Invigorated
Rapid Eye Movement Rapid Eye Movement sleep (REM) Good Healthy
sleep (REM) REM sleep is characterised by
episodes of rapid eye movement, Figure 1 - The Wellbeing feelings of Exercise
brain wave activation, lack of tone
in skeletal muscle and dreaming However, wellbeing concentrates largely on cognitive and
psychological feelings of our mental health and many studies on
Sleep outcomes and Definitions physical activity interventions, now research on the wider concept
behaviours of quality of life.
Sleep (onset) latency Length of time between going to Quality of life (QoL) “is a reflection of the way that individuals
bed and falling asleep perceive and react to their health status and to other, nonmedical
aspects of their lives”. 2 QoL is sometimes referred to as
Total sleep time (TST) Total time of actual sleep from the satisfaction with life. 3 QoL has a hierarchical structure with
sum of all stages domain-specific components under the umbrella of overall
QoL (Fig 2). One domain typically represents health related
Wake-time after Amount of time spent awake QoL (HRQoL) 4 this domain is often split further into further
sleep-onset (WASO) after sleep onset and before final sub-domains of physical health-related QoL and mental health-
awakening, usually in the morning related QoL. The other domain is non-health related QoL and not
discussed further in this resource.
Sleep efficiency The percentage of time of actual
sleep out of all the time sleeping The USA Physical activity guidelines examined the relationship
and trying to sleep between physical activity and QoL and concluded there was
strong evidence demonstrated for both adults and older adults
Table 1 – Components of sleep and Stages of sleep 4 that physical activity improves health-related quality of life when
compared with minimal or no-treatment controls. 5
This improved health-related quality of life from regular physical
activity can be expected to reduce health care costs from reduced
clinician appointments, medications and improved outcomes in
health. Even in the absence of disease, regular physical activity
should therefore be encouraged to all individuals to encourage
healthy ageing. 6
Figure 2- Hierarchical Structure of Quality of Life

Physical Health
Health-related QoL
Mental Health
Overall Quality of Life

(Life Satisfaction)
Financial
Non-Health-related QoL Relationships
Occupational
CHAPTER 6:
Mental Health
Dementia The 2017 Lancet Commission on Dementia prevention,

intervention and care35 suggests that “the potential mechanisms
Dementia is a term used to describe a group of symptoms for physical exercise to improve cognition or prevent dementia are
including memory loss, confusion, mood changes and difficulty indirect effects on other modifiable risk factors, such as obesity,
with day to day tasks. It encompasses several forms with insulin resistance, hypertension, hypercholesterolaemia and
Alzheimer’s disease being the commonest and vascular dementia general cardiovascular fitness, and via direct neurological effects
the second, followed by dementia with Lewy bodies. such as increased neurogenesis, cerebral blood flow and BDNF
concentrations.” 21-23
The risk of dementia rises with age, with 1 in 14 people over 65
affected. 1 Globally the World Health Organisation has estimated
there were 47 million people worldwide with dementia in 2015 and
this figure is predicted to rise to 131.5 million by 2050. 2
Given steady increases in life expectancy, dementia is now a huge

public health burden and there is therefore an urgent need to
identify modifiable risk factors that prevent or delay its onset. In
vascular dementia, the risk is thought to increase amongst those
with a family history, hypertension, high cholesterol, smoking and
diabetes, with all of these vascular factors being potentially open
to modification by physical activity.3 Across all forms of dementia,
it has been recently felt that 35% of dementia may be caused by
nine potentially modifiable risk factors, one of which being physical
inactivity (see diagram).4
Relative risk for Alzheimer’s disease 4

Physical Inactivity
Diabetes
Low educational attainment
Social isolation
Midlife hypertension
Midlife obesity
Smoking
Depression
Hearing loss
1.00 1.20 1.40 1.60 1.80 2.00
Prevention of dementia with physical activity: There are several

meta-analyses of observational studies suggesting evidence that
people who follow recommended levels of physical activity have a
reduction in risk of cognitive decline in the order of 18-30%.5-11
Higher levels of physical activity are thought to be associated

with better cognitive function and a 20% lower risk of cognitive
impairment in the highest quartile of activity. 11-14
Ideally, random controlled trials (RCT’s) would determine whether

implementing an increase in physical activity would lead to an
improvement in cognitive decline. A recent meta-analysis 15 of
RCT’s of exercise in over 50 year olds has shown physical activity
interventions improved cognitive function significantly, regardless
of cognitive status. Whilst another meta-analysis reported no
overall evidence that exercise improves cognition in healthy older
adults. 16 In addition, a recent long term study of 10,000 people
followed over 28 years, 17 coupled with other recent studies 16,
18-20
has challenged the previous thinking by finding no overall Figure 2- Risk factors for dementia (Lancet Commission)
protective effect of physical activity.
CHAPTER 6:
Mental Health
In conclusion, it is presently thought that physical activity is At present, the recommendation stands that the elderly with
beneficial for brain function and may delay a decline in cognitive dementia engage in physical activity for their cardiovascular
function. “In spite of this link there is not yet sufficient scientific and cerebrovascular health, for the reduction in the incidence of
evidence that physical activity can reduce the risk of brain disease diabetes and obesity and for protection against frailty.
that causes dementia (e.g. Alzheimer’s disease)”. 24
Exercise as a fall prevention measure amongst the healthy elderly
If, however, physical activity at recommended levels is combined is well established, but recent meta-analyses also suggest that
with a number of other interventions, then there is the potential physical activity has a positive effect on the prevention of falls in
to delay or prevent a third of dementia cases. The interventions those with cognitive impairment 31, 32 and Parkinson’s disease.32
include: the active treatment of hypertension in the middle aged
(45-65 years); increased childhood education; the maintenance of NICE guideline NG9733 on Dementia focuses the guidance
social engagement; a reduction in smoking and the management on managing the risk of falling for people with dementia (in
of hearing loss, depression, diabetes and obesity. (see figure 2) community and inpatient settings) by using NICE guidance on falls
in older people (see next chapter of this guidebook).
Treatment of established dementia with physical activity: When using this guidance:
The results from random controlled exercise interventions to
improve cognitive and functional outcomes for this population • Take account of the additional support people living with
are also mixed, but there is evidence that exercise has no adverse dementia may need to participate effectively
effects and can lead to: 25-30
• Enhanced mobility • Be aware that multiple factorial falls interventions may not be
• An improved ability to perform daily functional activities suitable for a person living with severe dementia
• A reduction of the burden on family members
• A possible improvement in some elements of cognitive functioning
“The sum of the whole is this: walk and be happy;

walk and be healthy. The best way to lengthen out
our days is to walk steadily and with a purpose”
Charles Dickens
CHAPTER 7:
Metabolic Health
Metabolic Syndrome However, a combination of the two has been seen to promote a
maximal benefit in people with obesity 3, 9, 10.
Metabolic syndrome is a cluster of factors including abdominal
obesity, insulin resistance, low HDL cholesterol levels, high plasma Physical activity and exercise recommendations for people
triglycerides and hypertension, which increase the risk of type with NAFLD
2 diabetes, cardiovascular disease, dementia and some forms Patients should aim to achieve at least 150 minutes each week of
of cancer. moderate exercise of ANY type and two strength training sessions
on non-consecutive days, for a minimum of 4 months to produce a
Regular physical activity has a beneficial effect on all these factors benefit in NAFLD, both with and without weight loss. Maintaining
and so may reduce the risk of these serious medical problems. a physical activity programme for 4 months is seen to significantly
improve metabolic parameters, more so than if exercise is halted
To prevent and treat, it is recommended to reduce sedentary time before the 4-month period 8.
and use moderate intensity exercise daily for a minimum of 30 but
preferably 60 minutes. 1
Polycystic Ovary Syndrome (PCOS)
Physical activity is proven to reduce the associated health
risks of metabolic syndrome even if individuals who exercise Polycystic ovary syndrome (PCOS) is a multifactorial condition
remain obese. 2, 3 This is a key point as both patients and health characterised by anovulation, hyperandrogenism and insulin
professionals are often over focused on weight and quickly resistance. Treatment thus needs to target both reproductive and
become demoralized if weight loss is not achieved. If physical metabolic outcomes.
activity is combined with sustained calorie restricted diet, then this
can support weight loss, nevertheless the primary objective is for Benefits of regular physical activity and exercise for women
physical activity to act on the pathophysiological factors leading with PCOS
to metabolic syndrome. Upon diagnosis, promotion of positive lifestyle behaviour patterns
is regarded as a first-line therapy. Regular physical activity
improves markers of cardiorespiratory fitness, body composition
Non-Alcoholic Fatty Liver Disease (NAFLD) and insulin resistance in people with PCOS 1. The benefits of
lifestyle intervention in those who are also overweight and obese is
Non-Alcoholic Fatty Liver Disease (NAFLD) is associated with often independent of significant weight loss 2.
an increased risk of insulin resistance, metabolic syndrome
and cardiovascular disease. The development of NAFLD and The effects of increased physical activity can be assessed in
progression to non-alcoholic steatohepatitis (NASH) is partly due relation to metabolic and cardiorespiratory function. Insulin
to a high level of sedentary behaviour 1. resistance, a hallmark of PCOS, is present in 60–80% and
increases to 95% in those who are obese 3-5. Insulin resistance
Benefits of regular physical activity and exercise for people is often independent of body weight, although is exacerbated
with NAFLD by the presence of concomitant obesity 6. Recent meta-analyses
There is a common consensus that an increase in physical activity conclude that vigorous physical activity can directly improve
of any type will improve outcomes in people with NAFLD. However, insulin resistance and cardiorespiratory fitness in women
exercise-based NAFLD studies are limited with small sample sizes with PCOS.
and large variations 2, 3. A recent analysis by the National Health and
Nutrition Examination Survey (NHANES) database concluded that The evidence for the beneficial impact of physical activity on
for every 10 minutes of physical activity, the overall mortality risk reproductive and cutaneous outcomes i.e. hirsutism, is more
was reduced by 7% in individuals with NAFLD 3, 4. limited. Nevertheless, increased physical activity is reported to
have a beneficial effect on reproductive hormones 7, ovulation 8
A meta-analysis of 20 randomised controlled trials, involving and menstrual regularity 9,10. Importantly, increased exercise and
more than 1000 individuals, showed that exercise alone can dietary modification have both been reported to improve free
promote beneficial effects in those with NAFLD, even in the androgen index (FAI) and hirsutism (measured via Ferriman-
absence of weight loss 5. Independent of dietary intervention, an Gallway score) 11. However, the data on any direct effects of
8-week web-based intervention reported no reduction in weight physical activity on hirsutism are limited, with studies to date
but significantly improved liver enzymes, including ALT and reporting either little to no effect 12,13 , or modest improvements
the surrogate fibrogenesis marker pro-collagen-3 (PRO-C3)6. only 14. It is known that insulin levels can modulate hirsutism
Secondary complications, including hepatic inflammation and in PCOS 15, therefore improvements in insulin resistance may
fibrosis, also showed marked improvements that were maintained ultimately yield benefit.
after exercise had been discontinued 2, 6.
Regular exercise alone may also improve mental health, physical,
The leading cause of death in people with NAFLD is associated general and social functioning by 10% 16.
with cardiometabolic function rather than liver related
complications 7. Marginal differences exist when comparing the
beneficial impact of aerobic and resistance exercise on liver
enzymes, metabolic parameters and hepatic steatosis 8.
CHAPTER 7:
Metabolic Health
Precautions Type 2 Diabetes

Excessive weight loss & weight regain: Individuals who initiate an
exercise programme may see a rapid and significant weight loss, Benefits of physical activity and exercise for people with
although this may not be sustained. Maintenance of weight loss is type 2 diabetes
challenging in the long-term. In patients with PCOS, weight gain Increasing physical activity and exercise is one of the three
exacerbates the risk of diabetes 17 in addition to clinical sequelae. cornerstones of type 2 diabetes treatment and should be
recommended alongside dietary alterations and the appropriate
medication 14. There are a variety of benefits of physical activity for
Pre-diabetes people with type 2 diabetes, including improved cardiovascular
fitness, improved function of blood vessels, lowered blood
Benefits of physical activity and exercise for people pressure, improved blood lipid profile and improved body
with pre-diabetes composition 15-19 However, the most important benefit of regular
Evidence from meta-analyses supports the view that regular physical activity / exercise for people with type 2 diabetes is
physical activity improves markers of cardiovascular and metabolic improved insulin sensitivity and glycaemic control 15-17, 20.
health in people with prediabetes 1 and also that there is a clear
dose-response relationship between levels of physical activity The benefits of exercise on blood sugar levels are largely explained
and future risk of type 2 diabetes 2. by changes in the exercising muscles and there are three distinct
effects of exercise:
Importantly, large diabetes prevention trials endorse physical
activity as part of a broader intensive lifestyle intervention, that 1. When muscles contract, they take up glucose from the
can directly prevent or delay the progression from prediabetes to blood to provide energy for the exercise. This happens
type 2 diabetes 3–9. In the largest trial, 6 the US Diabetes Prevention without the need for insulin, a hormone that in most other
Program, high risk individuals were divided into three groups: the circumstances, is needed for glucose uptake from the blood.
first was a placebo control, the second were assigned a lifestyle This effect wears off soon after stopping exercise, but the
intervention (including aerobic activity of at least 150min/week) skeletal muscle involved can remain more sensitive to insulin
and the third group were given metformin 850mg twice daily. for up to 48 hours post exercise.
(Figure 1)
2. In combination, the effects of insulin and physical
Lifestyle advice was nearly twice as effective in preventing exercise result in improved glycaemic control following
diabetes compared to metformin drug therapy in high risk carbohydrate containing meals and reduce the time spent
individuals (58% v 31% reductions in incidence) over 3 years in hypoglycaemia throughout the day when exercise is
of study performed 20.
3. If exercise is performed regularly, in addition to getting

Regular Physical Activity helps prevent diabetes the benefits if each single exercise session, skeletal muscle
(and whole body) adaptations, including alterations in
Placebo (n=1082)
Metformin (n=1073, p<0.001 vs Placebo)
body composition, can also contribute to better overall
40
Lifestyle (n=1079) p<0.001 vs Metformin, glycaemic control.
Cumulative incidence (%)
p<0.001 vs. Placebo

30
Physical activity and exercise recommendations for people
Risk reduction with pre-diabetes and type 2 diabetes
20 31% by metformin
58% by lifestyle Adults with pre-diabetes or type 2 diabetes should be encouraged
10 to engage in a combination of aerobic exercise, strength training
and should limit prolonged periods of inactivity 14, 21,22
0 2 3 4
0 1 For aerobic exercise, it is recommended that people with type 2
Years from randomization
diabetes accumulate at least 150 minutes of moderate intensity
The DPP Research Group, NEJM 346:393-403, 2002 activity each week 14, 21, 22. Increasing the intensity of aerobic
Figure 1 exercise, or performing high-intensity interval training (HIIT) -
that is short periods of vigorous aerobic exercise alternated with
Recent meta-analyses have documented a 30-40% relative periods of low intensity or resting recovery - can be recommended
risk reduction in the incidence of type 2 diabetes in the lifestyle for those willing and able to perform it and will accelerate
intervention group 10–12. Weight loss appears to be a key driver of improvements in cardiorespiratory fitness 14, 21.
risk reduction, with every 1 kg of body mass reduction associated
with a 16% relative risk reduction 13. The long term follow up studies For strength exercise, it is recognised that strength training also
show that lifestyle interventions delayed the onset of diabetes on improves glycaemic control 17, 23, 24 and there is some evidence from
average by two to four years rather than preventing it totally 8,9. randomised controlled trials that the greatest improvements in
glycaemic control are achieved when both aerobic and strength
exercise are performed regularly 25. The recommendation is
therefore to perform a minimum of 2 sessions on non-consecutive
days each week 14,21-22.
CHAPTER 7:
Metabolic Health
Sessions should target a range of muscle groups (8-10 different A reduction in basal and/or prandial insulin dose may be
exercises) and completion of 1-3 sets of 10-15 repetitions to near required around exercise to prevent (possible) hypoglycaemia
fatigue is appropriate 14,21-22. 14
. Irrespective, it is important to guide patients to recognise the
symptoms of hypoglycaemia and how to self-monitor.
The beneficial effects of each acute exercise session on glycaemic
control are short lived (24-48 hours) and thus frequency of NICE guidelines PH38 26 Type 2 diabetes - prevention in people
exercise is of key importance. Daily exercise is considered optimal at high risk recommend:
for maintaining good glycaemic control, but if this is not possible, • Give information about increasing physical activity and
then aiming for no more than two consecutive days without reducing the amount of time spent being sedentary
exercise is sufficient 14. • Consider referring those who want structured or supervised
exercise to an exercise referral scheme or supervised exercise
Prolonged periods of inactivity are known to be detrimental sessions, as part of an intensive lifestyle-change programme
to glycaemic control and metabolic health 14,21. In addition to • At least once a year, review the lifestyle changes made by
performing regular structured exercise, it is also recommended those at high risk
that people with prediabetes and type 2 diabetes decrease time • Raise awareness of importance of physical activity
spent in sedentary activities 14, 21,22. Any periods of prolonged sitting • Help individuals to find other ways to identify and overcome
(e.g. desk working) should be broken every 30 mins with short any barriers to physical activity
periods (3-5 mins) of light-moderate physical activity such as
walking or stretching 14, 21. Contraindications
• Uncontrolled blood glucose of >14 mmol or <6 mmol/l, which
should be corrected first 27
Adverse cardiovascular event: There is a small potential health risk • Vigorous exercise is contraindicated in those with
of physical activity (e.g. adverse cardiac events) for people with proliferative retinopathy 27
prediabetes or type 2 diabetes, but the risk is low and maintaining
an inactive/sedentary lifestyle is associated with greater risk over
the long term 14, 21.
Type 1 diabetes
For the vast majority of people with prediabetes or type 2
diabetes, who have no symptoms of underlying cardiovascular Introduction
disease or coronary ischemia, the risk of participating in low- Regular physical activity confers many health benefits in people
to moderate-intensity physical activity (i.e. not exceeding the with type 1 diabetes 1,2, with improvements noted in blood
demands of brisk walking) is low and medical clearance is not glucose, insulin sensitivity, lipid profiles, mental wellbeing, body
necessary 14, 21. composition and physical fitness 1,3,4. Accordingly, organisations
endorse exercise as a key component of the treatment plan of
For middle aged or older individuals with prediabetes or type 2 type 1 diabetes 5–8. However, many individuals with type 1 diabetes
diabetes, who wish to take part in more strenuous or prolonged struggle to achieve the recommended physical activity levels 4,
exercise (e.g. competitive racing, HIIT etc.), then assessment for with fears around hypoglycaemia and loss of glycaemic control
underlying conditions that may increase the risk of an adverse reported as major barriers to frequent exercise participation 9, 10 .
event is recommended 14, 21. This should include consideration of Educational support centred around nutritional and insulin therapy
signs and symptoms of myocardial ischemia, including chest-pain, strategies that seek to manage these concerns help foster safe
severe shortness of breath upon exertion and/or syncope, and a exercise performance and garner the physical and mental benefits
potential referral for a resting/ exercise ECG in any individual who of being regularly active 1.
is symptomatic 14, 21.
Current recommendations for physical activity and exercise
Foot care and exercise: Peripheral neuropathy is a feature of Adults with type 1 diabetes should be encouraged to engage in at
type 2 diabetes. People with severe peripheral neuropathy should least 150 minutes of moderate-to-vigorous intensity
thoroughly check their feet on a daily basis, especially (~40-59% VO2max) aerobic exercise (e.g. jogging, cycling, walking,
if they are planning to exercise, and appropriate footwear should swimming etc) per week 7, 11. Ideally, exercise should be spread
be worn 14, 21. Moderate intensity weight bearing activity can be over 3 days per week with activity breaks of no more than 2
participated in safely, provided there are no active ulcerations 14, 21. consecutive days. Shorter durations (minimum 75 minutes per
week) of vigorous-intensity exercise or interval training may
Interactions with medications: Hypoglycaemia rarely occurs be suitable for younger and/or more physically fit individuals.
with type 2 diabetes controlled with dietary adjustment or Additionally, muscle strengthening activities can be performed 2-3
with common diabetes medications, including metformin, times per week on non-consecutive days with additional flexibility
thiazolindinediones, glucagon-like peptides and SGLT inhibitors. sessions to support joint range of movement.
In general, the American Diabetes Association do not recommend
adjustment of the dose of medication when taking up exercise 14.
If treated with insulin alone, or in combination with medications
such as sulfonylureas, then hypoglycaemia may be more likely and
blood glucose should be monitored carefully 14.
CHAPTER 7:
Metabolic Health
Precautions • Recent hypoglycaemia: Exercise should be avoided if severe

Even those with diabetes-specific complications can derive hypoglycaemia (defined as a blood glucose value of <3.0
positive health outcomes from engaging in lower intensity mmol/l, and/or an event requiring external assistance) has
activities with minimal risk of adverse events 12. However, occurred within the preceding 24 hours, as this may impair
advice should be tailored on an individualised basis. The following glucose counter-regulation 14 and increase the risk
factors should be taken into consideration prior of another event 15, 16. Diligent glucose monitoring is necessary
to exercise prescription: to avoid hypoglycaemia in the lead up to planned exercise
sessions.
• Cardiovascular complications: If the patient has suffered
from cardiovascular complications including coronary
artery disease, hypertension, exertional angina, myocardial General considerations for increasing physical
infarction or stroke, it may be necessary to refer for a graded activity and exercise
exercise test to exclude underlying complications and reduce In order to minimise the risk of exercise-related dysglycaemia,
the risk of an adverse event 11. The emphasis should initially individuals with type 1 diabetes are encouraged to make
be placed on non-weight bearing aerobic activities (i.e. adjustments in insulin therapy dosing around a planned session
swimming, aqua-aerobics, cycling and seated exercises) at and/or increasing the amount of carbohydrates ingested before,
low to moderate intensities, preferably under supervision. during, and/or after exercise 5, 17-20.
High intensity exercises that cause sudden and substantial
elevations in heart rate or activities that involve the Valsalva • Safe blood glucose ranges
manoeuvre should be avoided. Blood glucose responses to exercise can be highly variable in
people with type 1 diabetes with factors such as the type and
• Nerve function: Where some degree of nerve damage is timing of exercise 21-23, the composition of the pre-exercise meal
suspected or known, non-weight bearing activities (i.e. 24
and the pre-exercise blood glucose value 25,26. Rapid declines
swimming, seated arm exercises etc) that reduce plantar in blood glucose may occur with exercise. Therefore, attention
pressure can be performed but load-bearing activities or should be paid to glycaemia in advance of starting exercise and
exercises that involve heavy pounding (i.e. jogging, running, appropriate dietary/therapy action should be taken to avoid
jumping) should be avoided. If the patient suffers from dysglycaemia during exercise. (See table 1).
peripheral neuropathy and/or foot ulcers/amputations,
proper foot care is essential. Feet should be examined Table 1: Suggested carbohydrate intake and precautionary
daily and appropriate treatment actioned to prevent actions based on blood glucose levels at the start of exercise
further complications.
Ingest 15-30 g fast acting carbohydrates
• Eyes: If the patient has mild to moderate retinopathy, all before aerobic exercise. Carbohydrate may
activities can be performed, but an annual eye examination <5.0 mmol/l not be necessary if the activity is brief (<30
should be carried out to monitor progression. If the patient minutes) or very intense (weight training,
has unstable proliferative retinopathy, vigorous intensity interval training).
weight bearing activities that involve jumping, jarring, breath
holding and head down actions should be avoided 5. Consume carbohydrates at the onset of
5.0-8.3 mmol/l exercise (~0.5-1.0 g/kg bm/hr) depending on
• Kidneys: Physical exercise can be performed regularly if the type, intensity, and duration of the activity.
the patient has microalbuminuria or nephropathy 13. If the
patient has advanced nephropathy or end-stage renal Initiate exercise and delay carbohydrate
disease, exercise should be progressive in both intensity and 8.4-13.9 mmol/l consumption until blood glucose levels drop
volume. Blood electrolytes should be monitored if activity is below 8.4 mmol/l.
performed during dialysis sessions.
Test ketones. Mild to moderate intensity
• Heat-related illness and dehydration: For patients who may 14.0-19.3 mmol/l exercise can be performed if ketone levels are
have impairments in temperature regulation (e.g. older adults, low (<0.6 mmol/l). However, avoid intense
those with poor glycaemic control and/or those with diabetic exercise until glucose is <14.0 mmol/l/.
neuropathy), exercising outdoors on very hot and/or humid
days should be avoided 7. Adequate hydration and electrolyte Test ketones. Mild to moderate intensity
drinks should be encouraged for appropriate exercise exercise can be performed if ketone levels
sessions. are low (<0.6 mmol/l). If ketones are negative
19.4 mmol/l (or trace), consider conservative insulin
• Elevated ketones: If the patient has unexplained correction (i.e. 50% correction) before
hyperglycaemia, check the ketones and exercise should only exercise depending on active insulin status.
go ahead if ketone values are low (<0.6 mmol/l). If blood Avoid intense exercise until glucose levels
ketones are elevated ( 1.5 mmol/l), exercise is contraindicated decrease considerably.
and individualised glucose management should be initiated 5.
Extract from Physical Activity/Exercise and Diabetes: A Position Statement of
the American Diabetes Association 7.
CHAPTER 7:
Metabolic Health
• Insulin therapy adjustments to manage blood glucose Manging hyperglycaemia: Very intense activities (sprinting,
Managing hypoglycaemia: In general, aerobic exercise lowers resistance exercise) may result in a small rise in blood glucose
blood glucose levels and hypoglycaemia is likely if the activity concentrations 32. For these activities, a reduction in bolus insulin
is performed in the postprandial phase with no adjustment to prior to exercise may not be needed 7, though careful glucose
pre-exercise bolus insulin dose 27. For mild to moderate intensity monitoring during exercise is still required. If exercise-induced
aerobic activities lasting 30-60 minutes when circulating insulin hyperglycaemia occurs, a small bolus insulin dose immediately after
concentrations are low (i.e. fasted or basal concentrations), exercise can help reduce blood glucose to euglycaemic levels 33.
consuming 10-15g of carbohydrates without a bolus insulin
dose reduction before exercise may be sufficient to avoid Alternatively, performing aerobic exercise after resistance/
hypoglycaemia 28. For both, multiple daily injections (MDI) and strengthening exercise may help lower glucose levels 34,35.
continuous subcutaneous insulin infusion (CSII) users, bolus A summary of the recommended bolus insulin dose alterations
insulin should be reduced by 25-50% for activities lasting 30-45 around exercise for people with type 1 diabetes can be found in
minutes, with larger dose reductions of 50-75% advised when Table 2.
exercise exceeds 45 minutes 5.
• Carbohydrate ingestion
Mixed activities (interval training and team/individual sports) Carbohydrate intake will vary depending on the exercise
typically result in more stable glucose levels than those characteristics (modality, timing, intensity) and on-board insulin
associated with aerobic exercise 22, 29. For these activities, the levels. Current recommendations suggest ingesting an upper
pre-exercise bolus insulin dose should be reduced by ~25% when limit of 0.5-1.0 g of carbohydrate per kg body mass per planned
exercise lasts for 30-45 minutes and by ~50% when exercise hour of exercise 5. Consuming a small carbohydrate-based snack
surpasses 45 minutes 5 . (0.4 grams of carbohydrates per kg body mass) before bed may
also help lower the risk of glycaemic declines after exercise 18,19,27.
For individuals on MDI, a 20% dose reduction in basal insulin
on the day of exercise may help avoid hypoglycaemia 19. For • Blood glucose monitoring
individuals on CSII a reduction 30 or suspension 31, in basal insulin Increased frequency of self-monitoring of blood glucose can
delivery 30-60 minutes before exercise can reduce the risk of lower the risk of hypoglycaemia 36. Use of continuous glucose
hypoglycaemia. monitoring devices provides another option to obtain glucose
readings through implantable interstitial glucose sensors 37, 38
Due to increases in tissue sensitivity to insulin, the risk of However, whilst these devices are convenient to monitor glucose
hypoglycaemia remains high for many hours after exercise. around exercise, they often fail to accurately report readings
Frequent blood glucose monitoring is key in detecting and when glucose is changing rapidly or when levels deviate from
preventing later onset hypoglycaemia. A low glycaemic index, the euglycaemic range 39. As such, caution should be taken
carbohydrate-rich meal alongside a 50% dose reduction in bolus when using them during exercise and clinical decision making
insulin can minimise glycaemic fluctuations as well as protect should always be based on blood glucose levels.
against post exercise and/or nocturnal hypoglycaemia 18, 27.
Conclusion
For CSII users, reducing basal insulin delivery rates for up to Regular physical activity and exercise is considered a cornerstone
12 hours post-exercise may be necessary to avoid later onset for the clinical management of type 1 diabetes. Each person’s
hypoglycaemia. response to exercise may be different, but prudent adjustments in
exogenous insulin dosing and carbohydrate intake around exercise
can help develop an individualised glucose management strategy
that assists them in achieving their exercising goals.
Table 2: Suggested initial pre-exercise meal bolus insulin dose reduction for activities started within 90 minutes of insulin administration
Exercise Intensity % VO2max Exercise duration

30 minutes 60 minutes
Mild aerobic 25% VO2max ~25% ~50%
Moderate aerobic ~50% VO2max ~50% ~75%
Heavy aerobic 70-75% VO2max ~75% NA
Intense aerobic/anaerobic >80% VO2max No reduction NA

necessary
Taken from Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association 7. NA,
not assessed as exercise intensity is too high to sustain for 60 minutes.
CHAPTER 8:
Musculoskeletal Health
Fibromyalgia Perhaps the greatest incentive for exercise in people with

osteoarthritis from 35 upwards with co-morbidities of
Fibromyalgia consists of a multi symptom syndrome characterised cardiovascular disease, diabetes, cancer and walking disability, is
by widespread diffuse treatment-resistant, non-inflammatory joint that they are at significantly enhanced risk of dying prematurely.17
and muscle pains of at least 3 months duration. 1 Two common It has been suggested even light exercise e.g.: moving around
symptoms are: reduced muscle strength and rapid fatigue with the house during commercial breaks for those people with OA
people typically being unfit.2, 3, 4 who watch many hours of TV, might mitigate the risk.18 Practical
recommendations have been made regarding specific exercise
Fibromyalgia is difficult to manage, but physical training combined prescription in terms of type, duration and delivery and can be
with cognitive behavioural therapy has been recognized as being discussed by the clinician or refer to a physiotherapist.10
the most promising treatment.5 Meta-analysis of random controlled
trials conclude that aerobic training has a beneficial effect on pain, NICE guideline CG 177 on Osteoarthritis and management in
fatigue, depressed mood and quality of life symptoms.6 Aerobic adults recommends:19
training is thought to have the main effect on physical fitness and
quality of life, whilst strength training having a greater effect on • Advise people with osteoarthritis to exercise as a core treatment
pain, tender points, depression and quality of life.7 irrespective of age, co morbidity, pain, severity or disability.
• Exercise should include local muscle strengthening and general

Osteoarthritis aerobic fitness
Contrary to common belief, there is no evidence that regular

physical activity promotes the development of osteoarthritis (OA), Osteoporosis
provided there is no associated major joint injury.8
Prevention: The peak bone mass is achieved by 20 – 30 years of
Major joint osteoarthritis is the commonest chronic disease in older age, so to achieve maximum bone mass during adolescence, a
people.9 The evidence that physical activity can be beneficial, is balanced diet and multi-activity physical education in schools with
best for OA of the knee, but studies on hip and hand point to the weight bearing exercise needs to be encouraged from early years
same conclusions 9, 10 and even from first walking.8 Once our peak bone mass is achieved,
a gradual bone loss commences and there is now increasing
Aerobic activity is thought to increase endorphin levels which evidence that physical activity can help prevent the bone loss
reduce the sensation of pain, whilst increased muscle strength and associated with ageing across the lifespan of individuals. 20-25
improved neuromuscular function improve the stability around a
joint. These factors, coupled with any associated weight control, Weight bearing exercise, especially resistance exercise, appears
will help reduce the load through the joint and hence exercise to have the greatest effect on bone mineral density.26 There is
programmes consisting of muscle strengthening, functional an inverse relationship of physical activity with the relative risk of
training and aerobic fitness have been shown to: 10, 11, 12 hip and vertebral fracture with risk reduction for hip fracture of
36 - 68% at the highest level of activity.8
• Reduce pain
• Improve function Warning: excessive physical activity can have an unintentional
• Improve overall wellbeing slightly in knee OA, but not in hip OA negative effect on bones in girls, who may develop exercise
dependent secondary amenorrhoea and then lose bone most
Exercise training also reduces pain and improves function commonly around a weight of 45kg.1
(strength, gait, balance) in the absence of weight loss. A key
message about exercise and weight loss is that it is better to talk Established disease: weight bearing exercise is still encouraged
about fat loss, as weight loss is often compromised by an increase to minimize further bone loss,25 but also to help prevent falls 27
in lean mass (i.e. muscle mass). For example, exercise might and subsequent fractures.28 Balance, strength and coordination
produce impressive improvements in body composition, e.g. a exercise combined with walking is complementary.1
2kg increase in lean mass and a 2.5kg decrease in fat mass, but an
unimpressive overall change in body weight, tending to discourage NICE clinical knowledge summary on Osteoporosis –
people who are primarily motivated by weight loss and not an prevention of fragility fractures28 recommend:
improvement in health.
• Advise the person to: Take regular exercise (tailored to the
There appears to be a dose-response relationship where strength individual) to improve muscle strength and reduce pain
and fitness improvements, lead to better gains.14, 15 Training is best and stiffness:
planned with small but steady increases in load on the joint and
with exercise; there is a greater reduction in pain Non Steroid • Encourage walking, especially outdoors, as this will increase
Anti-inflammatory Drug (NSAID) treatment occurring after 6-8 exposure to sunlight, increasing vitamin D production.
weeks of activity.14, 16 This gives a clear choice of activity over
NSAID medication for many people and a choice with relatively • Encourage strength training of different muscle groups (for
few side effects.16 example hip, wrist, and spine).
CHAPTER 8:
• A combination of exercise types, for example balance, flexibility, Historically, a major barrier to physical activity in RA was advice by
stretching, endurance and progressive strengthening exercises. clinicians to rest rather than exercise. However, a myriad of studies
support the incorporation of exercise training programs to help
Contraindications improve aerobic fitness, muscle strength and overall cardiovascular
Acute illness with pain and general deteriation health without aggravating disease activity or joint integrity6–8.
Avoid high impact activities or those with a high risk of falling29 Thus, RA patients should be encouraged to take part in regular
physical activity including aerobic training (to improve aerobic fitness
and reduce cardiovascular disease risk), resistance exercise (to
Rheumatoid Arthritis improve muscle strength) and flexibility (to improve range of motion).
Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory

musculoskeletal disease affecting ~0.9% of the UK population. It Special Considerations :
is characterised by pain, swelling and stiffness of the joints, and
if poorly managed, can lead to joint destruction and deformity. 1) Moderate-vigorous physical activity should be avoided during
Due to the debilitating nature of the condition (i.e. pain, fatigue acute flare-ups of RA disease activity. Instead, the person
and impaired mobility), up to 68% of those with RA are physically should lightly move joints through their full range of motion.
inactive which results in lower aerobic fitness and strength when
compared with the general population1,2. 2) Inform people that some discomfort 24–72 hours after training
(especially resistance training) is normal and is due to delayed
Decline in muscle mass due to inflammation (a condition termed onset muscle soreness. The person should be reassured that the
rheumatoid cachexia) further exacerbates strength loss and pain is not due to joint damage, and will gradually lessen as the
consequently lowers functional ability3. Importantly, RA sufferers weeks progress. It is worth noting that if people rate their pain
also have a 50% greater risk of cardiovascular disease when 2 hours after exercise higher than before exercise, the duration
compared with age- and sex-matched individuals from the and/or intensity of the subsequent session should be reduced.
general population, with cardiovascular disease being the leading
cause of mortality in this population4 . Indeed, physically inactive 3) It is important that resistance training exercises do not utilise
RA sufferers generally tend to have a worse cardiovascular risk excessive loads. People with painful shoulders should take care
profile (e.g. elevated systolic blood pressure and total cholesterol) in lifting weights above shoulder height and should gradually
when compared to those with RA who are physically active5. increase the load. Similarly, those with painful knees, ankles or
feet, should select a weight which is slightly lower than their
own bodyweight10.
4) Some people may present with swollen and tender joints in the
hands and wrist. It is advisable to use support bandages/braces.
If pain is severe, consider advising the person to perform
exercises utilising unaffected joints 10.
5) A person with damaged joints should avoid high-impact

activities such as running, unless they can tolerate this activity
and joints/muscles have adapted through a combination of
aerobic exercise and progressing resistance training. High-
impact activities can help to preserve bone mineral density,
reducing the risk of osteoporosis.
6) Exercises which improve functional ability (i.e. sit to stand, step-

ups, stair climbing and carrying) are highly recommended as
they better reflect activities of daily living11.
NICE guideline NG100 on Rheumatoid arthritis in adults:

management.12 People with RA should have access to specialist
physiotherapy, with periodic review to:
• Improve general fitness and encourage regular exercise
• Lean exercises for enhancing joint flexibility, muscle strength and

Table 1: Types of activities that can help maintain or improve aerobic capacity,
managing other functional impairments
strength, balance and bone health and contribute to meeting the physical
activity guidelines 9
CHAPTER 8:
Prevention of falls and fracture 1) Exercise programmes should aim to provide a high
challenge to balance
2) At least 3 hours of exercise should be undertaken each week
3) Ongoing participation is necessary or benefits will be lost
4) Fall prevention exercises should be targeted at the general

community as well as community-dwellers with an increased
risk of falls
5) Fall prevention exercises may be undertaken in a group or

home-based setting
6) Walking training may be included in addition to balance

training but high-risk individuals should not be prescribed brisk
Figure 2: Physical activity for muscle and bone strength across the life course 2,3 walking programmes
Older people, with or without co-morbidities, often experience 7) Strength training may be included in addition to balance training
diminishing muscle function and/or coexisting pain which limits
their daily activity and increase the risk of a fall and fracture. Yet 8) Exercise providers should make referrals for other risk factors
untargeted physical activity, such as walking and cycling, is not to be addressed
shown to have any effect on the risk of falls.1
9) Exercise as a single intervention may prevent falls in people with
However, the available evidence is that group and home based Parkinson’s disease or cognitive impairment. There is currently
programmes with muscle strengthening and balance reduce no evidence that exercise as a single intervention prevents falls
both the rate of falls and the risk of falling. 4,5 Different forms of in stroke survivors or people recently discharged from hospital.
exercise have different results. Exercise interventions of all types v Exercise should be delivered to those groups by providers with
controls reduce the rate of falls by 23%,6 whilst targeted exercise particular expertise.
programmes with multiple types of exercise (balance, functional
exercise plus resistance exercise) probably reduce falls by 34%.6
Tai Chi may also reduce the risk of falling by 19%6 and exercise NICE guideline CG161 on Falls in older people: assessing risk
interventions may reduce the risk of a falls related fracture.4,6 and prevention recommends:9
Although most evidence on fall prevention has been with cognitively • Multifactorial interventions with an exercise component are
healthy elderly people, recent evidence supports the evidence that recommended for older people in extended care settings who
physical activity also has a positive effect in the prevention of falls in are at risk of falling
the elderly with cognitive impairment and Parkinson’s disease 5,7
Strength and balance training may need to precede walking • A muscle-strengthening and balance programme should
exercise to make the physical activity possible. In older people two be offered
decades’ worth of strength and muscle mass loss can be regained
by just two months of strength training.8 • This should be individually prescribed and monitored by
an appropriately trained professional
The optimum characteristics of an exercise intervention for falls
prevention are as follows:5 • There is no evidence that brisk walking alone reduces the risk
of falling; however, there may be other health benefits of brisk
walking by older people#
“The only bad workout is the one

which didn’t work out”
Anonymous
CHAPTER 9:
Obesity
Overweight and obesity are defined as ‘abnormal or excessive There is little evidence that resistance training alone produces
fat accumulation that may impair health’.1 Using Body Mass Index any significant weight loss.11 However, resistance strength training
(weight (kg) / height2 (m)) (BMI) overweight is classified as a BMI has also been shown to maintain overall health, muscle strength
of 25-30 and obesity as >30. (preventing loss of skeletal muscle mass), preserve bone strength
14
and reduce mortality in men.9,15
Obesity is a major risk factor for many non-communicable
diseases (NCD) such as:1 The real health message of physical activity in obesity: It is very
important to stress that aerobic physical activity offers substantial
• Cardiovascular disease (mainly heart disease and stroke) health benefits even if weight loss is not achieved,10 as people
• Diabetes often have unrealistic weight loss expectations.16 However, weight
• Musculoskeletal disease (mainly osteoarthritis) loss is still recommended in obese people to reduce the risk of
• Some cancers (mainly colon and breast)2 non-communicable diseases and premature death.5, 6
Childhood obesity is associated with a higher chance of obesity, Many trials of exercise therapy have reported little or no weight
premature death 2 and disability in adulthood.1,2 However, in addition loss (<5kgs) but still have reported many health benefits
to future risks,3 childhood obesity is associated with considerable including:10
emotional and behavioural problems including in boys, conduct
problems, hyperactivity and inattention problems, peer relationship • Improved vascular endothelial function17
problems, prosocial behaviours and total social difficulties.4 • Lipoprotein particle size18
• Reduction in low density lipoprotein18
Mild weight loss in obesity, has been associated with • Reduction in triglycerides10
improvements in most cardiometabolic factors,5 whilst significant • Improved cardiovascular fitness19
weight loss (>5% of baseline weight) has been shown to be more • Lower diastolic blood pressure10
effective in reducing cardiac and diabetic risk factors, and even • Improved glucose control
death rates.6,7 • Quality of life20,21
Exercise may produce impressive improvements in body

Weight gain: An increase in weight is effected by the amount of composition, e.g. a 2kg increase in lean mass and 2.5kg decrease
energy expended verses the number of calories consumed. 8 If in fat mass but with an unimpressive change in total body weight
energy expended is low and dietary consumption excessive then which might discourage people who are often primarily motivated
weight gain will inevitably occur. by weight loss. This is the key concept to get across to overweight
people, that they can reduce their disease potential if they are
Physical activity alone or with diet: There is no strong evidence active, compared to an inactive individual of similar weight.
that physical activity of 150 minutes or less a week, on its own
achieves any significant weight loss.9,10 Without a dietary plan An example of this is a study of 58 sedentary and overweight men
involving calorific restriction individuals will experience weight loss who undertook a supervised aerobic exercise programme for 12
in a range of nil to no more than 2kg.10, 11 Exercise when combined weeks.22 The mean reduction in weight was 3.63kg. However, 26
with diet plans may result in a slight greater weight loss than diet of the 58 failed to achieve predicted weight loss and only had a
alone10 but the amounts are small and confirm that the majority of mean weight loss of 0.9kg. Other health parameters showed the
weight loss is to be gained from the calorific restriction.11 following significant outcomes:
Physical activity and increased intensity: Significant weight loss • Increased aerobic capacity (6-3 ml/kg/min, p<0.01)
can occur with aerobic exercise without calorific restriction, but it • Decreased systolic blood pressure (-6 mm Hg, p<0.05)
requires a high exercise volume of >225 minutes a week. For the • Decreased diastolic blood pressure (-3.9 mm Hg, p<0.01)
majority, these levels may not be practical or achievable.12 • Decreased waist circumference (-3.7 cm, p<0.01)
• Decreased resting pulse (-4.8 bpm, p<0.001)
Physical activity and prevention of weight gain: To prevent
the shift from normal weight to overweight and obesity, it is In addition, these individuals experienced an increase in positive
recommended that levels of 150-250 min/week of moderate to mood with acute exercise.
vigorous physical activity are required.12
Advice to obese individuals must be realistic as they are often
Physical activity and weight maintenance: After successful weight unfit and have coexisting co-morbidities present. You need to be
loss, physical activity levels of 200-300 min/week should be aware of the effort required to lose weight, what is a reasonable
maintained to avoid regaining weight.12 NICE guidelines suggest expectation of weight loss and of the stigma people feel being
even higher levels of 300-450 min/week.13 labelled overweight or obese.23
Aerobic exercise or resistance training and weight loss: Aerobic Small steps in gained activity through everyday changes should be
exercise is most beneficial by virtue of energy expenditure and encouraged and maintained even if more formal physical activity
health benefits of important risk factors.11 remains difficult. See Sedentary behaviour later in this booklet.
CHAPTER 9:
Obesity
Guidance on managing the overweight and obese has been • Encourage children to do at least 60 minutes of moderate or
summarized in NICE guidelines and the areas relative to physical greater intensity physical activity each day. Tips include:
activity are listed below.
• Can be split into several sessions
NICE clinical guideline CG 189 on managing overweight and
obesity in adults recommends: 13 • Awareness that children already obese may need to do
more than 60 min/day
• Encourage adults to increase their level of physical activity even
if they do not lose weight as a result, because of the other health • The activity can be in 1 session or several sessions
benefits it can bring (for example, reduced incidence of type 2 lasting 10 minutes or more
diabetes and cardiovascular disease).
• Encourage children to reduce inactive behaviours, such as
• Encourage adults to do at least 30 minutes of moderate or sitting and watching television or playing video games
greater intensity physical activity on 5 or more days a week. The
activity can be in 1 session or several lasting 10 minutes or more. • Give children the opportunity and support to do more
exercise in their daily lives
• Advise that to prevent obesity most people have to do 45-60
minutes/day of moderate-intensity exercise particularly if they do not • Give children the opportunity and support to do more
reduce their energy intake. Advise people who have been obese and regular, structured physical activity
lost weight that they may need to do 60-90 minutes/day of moderate-
intensity physical activity to avoid regaining weight once lost. • Make the choice of activity with the child, and ensure it
is appropriate to the child’s ability and confidence
• Encourage adults to build up to the recommended activity levels
for weight maintenance, using a managed approach with agreed
goals. Recommend types of physical activity, including: Summary
• No strong evidence that physical activity of 150 minutes a
• Activities that can be incorporated into everyday life, such as week, on its own achieves any significant weight loss
brisk walking, gardening or cycling • High levels of physical activity are required to lose weight
alone without dietary changes
• Supervised exercise programmes • 45-60 minutes/day of moderate-intensity physical activity are
required to prevent weight gain
• Other activities, such as swimming, aiming to walk a certain • 60-90 minutes/day of moderate-intensity physical activity are
number of steps each day, or stair climbing needed to avoid regaining weight once lost
• Weight loss with physical activity is best when combined with
• Take into account the person’s current physical fitness and ability dietary & behavioral interventions
for all activities. Encourage people to also reduce the amount
of time they spend inactive, such as watching television, using a Adults, who find it difficult to maintain their weight, should be
computer or playing video games. encouraged to:
• Reduce energy intake
• Minimise sedentary behavior
NICE clinical guideline CG 189 on managing overweight and
• Work on progressively increasing their physical activity,
obesity in children recommend: 13
initially up to and then past 30 minutes and up to 60 minutes
a day or more.
• Encourage children and young people to increase their level of • Aerobic physical activity offers substantial health benefits
physical activity, even if they do not lose weight because of the even if weight loss is not achieved
reduced risk of type 2 diabetes and cardiovascular disease.
“In every walk with nature one receives

more far more than he seeks”
John Muir
CHAPTER 10:
Pregnancy and the postpartum period
Pregnant women may be concerned that physical activity is not safe, Pre-Activity Evaluation
however, there is no evidence suggesting adverse maternal or infant
outcomes for healthy women resulting from moderate intensity Most pregnant women can safely partake in physical activity.
physical activity. Instead, pregnancy offers an ideal opportunity to There are very few absolute contraindications to moderate-
adopt a healthy lifestyle, with the increased motivation to self-care vigorous physical activity (MVPA) during pregnancy and these
coupled with frequent access to maternity services. are mostly related to the pregnancy itself e.g. intrauterine growth
restriction or presence of pre-eclampsia. However, there are a
Physical activity can be safely recommended during and after number of medical conditions where women need to be cautious
pregnancy. UK Chief Medical Officers recommend that pregnant and discussed with her obstetric healthcare professional8 (box 1).
woman aim for at least 150 minutes of moderate physical activity Here individualized exercise programmes may be needed.
every week and strength conditioning exercises twice a week. It is
important to highlight to woman that ‘every activity counts’ and
that they should always ‘listen to your body and adapt’ what they Box 1: Absolute Contraindications to Moderate-Vigorous
do accordingly. Physical Activity (MVPA) in Pregnancy8, however, activities of
daily living should still be continued.
• Severe respiratory diseases ( e.g. COPD, restrictive

lung disease and cystic fibrosis)
• Severe acquired or congenital heart disease with
exercise intolerance
• Uncontrolled or severe arrhythmia
• Placenta abruption
• Vasa previa
• Uncontrolled type 1 diabetes
• Intrauterine growth restriction (IUGR)
• Active preterm labour
• Severe pre-eclampsia
• Cervical insufficiency
Relative Contraindications to MVPA in Pregnancy8 that should

be discussed between the pregnant woman and her obstetric
healthcare professional
• Mild respiratory disorders
• Mild congenital or acquired heart disease
• Well controlled type 1 diabetes
• Mild pre-eclampsia
• Preterm premature rupture of membranes
• Placental previa after 28 weeks
• Untreated thyroid disease
• Symptomatic severe eating disorder
• Multiple nutrient deficiencies and/or chronic undernutrition
• Moderate-heavy smoking (>20 cigarettes per day) in the
presence of comorbidities
Risk Management
There are clear benefits for both mother and baby. Outside the conditions listed, there is no evidence that there is an
increased risk of complications for the mother or the baby if the
Key Benefits of Physical Activity During Pregnancy 1-5 woman is physically active during her pregnancy; however, there
are a few activities not recommended (box 2).2, 5
• Reduction in hypertensive disorders
• Improved cardiorespiratory fitness
• Lower gestational weight gain Hyperthermia
• Reduction in risk of developing gestational diabetes (>39.2°C): During the first trimester in particular, hyperthermia
can increase the risk of developmental problems (e.g. spina
Further low – moderate quality evidence exists for the woman bifida). There is no evidence that becoming slightly warm during
with reduced: 4-7 physical activity can cause this, however, the woman should be
• Pelvic and low back pain advised to not become uncomfortably hot. Keeping hydrated
• Pre-natal depression will help.2, 5
CHAPTER 10:
Box 2: Activities to avoid during pregnancy 2,5 ‘F.I.T.T.’ For Pregnancy
• Contact sports e.g. rugby, soccer, boxing, basketball and As with any physical activity advice, consider the woman’s activity
martial arts history and preferences. During the first trimester morning
• Sports where there is a risk of falling e.g. riding, skiing, sickness and fatigue may limit activity ability, but most women will
off road cycling, gymnastics and horse riding naturally reduce the intensity as it becomes more challenging.
• Scuba diving
• Sky diving FREQUENCY – most days of the week for aerobic work and twice
• Exercising at high altitude (>6000 feet) weekly women should perform 8 -12 repetitions of strengthening
• Exercising in hot temperatures (including ‘hot yoga’ activities of all major muscle groups.
or ‘hot Pilates’ )
INTENSITY – moderate; which is an activity that makes you to feel
After first trimester: warmer and breath faster but still be able to hold a conversation.
• Sports where there is a risk of being hit in the abdomen by Those women who are training more seriously may be used to
equipment e.g. tennis, squash monitoring their heart rate in which case they should be advised
• Avoid exercising lying flat on your back after 16/40 due to to work at 50% - 70% of their heart rate max. However, there is
venous compression and hypotension no indication for someone to start monitoring their heart rate just
because they are pregnant.
Modifications and Considerations: 2 TIME – aim to accumulate at least 150 minutes of moderate intensity
physical activity every week. Recent evidence has shown that there
Due to the production of relaxin, ligaments around the spine, hips is no minimum amount of physical activity required to achieve some
and pelvis will soften in preparation for delivery which may slightly health benefits, with some activity being better than none.
increase the risk of injury. Stability exercises (e.g. Pilates – as long
as it is modified for pregnancy by an experienced instructor) will TYPE – examples of activities and exercise that have been found
help to manage this. Also, this softening will effectively increase a to be safe and beneficial in pregnancy2:
woman’s flexibility so to protect their joints they should not stretch
beyond their normal range. • Walking
• Stationary cycling
Avoid exercising lying flat on back or standing still for long • Dancing
periods after 16/40 weeks due to venous compression and • Aerobic exercises (inform the instructor)
hypotension2. • Resistance exercises (e.g. Using weights, elastic bands)
• Stretching - Yoga / Pilates – beware not lying flat on the
The combination of increasing lumbar lordosis and weight puts back after 16/40
more strain on the joints, especially in the back and pelvis. In • Swimming / hydrotherapy water aerobics (water temp
addition, as the pregnancy progresses, stress incontinence will not >32deg)
become more likely (prevalence 32-64% 9). Stability and pelvic
floor exercises will help to protect against this; pelvic girdle pain
is not an inevitability during pregnancy (prevalence 50-70% 10), Advice to a pregnant woman who is new to physical activity:
but can be managed with prompt identification, assessment and
treatment by a physiotherapist 10, 11. As the woman progresses Women who have been sedentary are advised to start a gradual
through the second and third trimesters they should reduce the progression of physical activity – ‘not active – start gradually’
amount of any weights they are lifting. and build up to 30 minutes on most days at a moderate intensity.
Vigorous activity is not recommended for previous inactive
When to stop exercising:2 women. Strengthening exercises twice a week are
also recommended.
Advise to stop if there is:
Walking is a good way to start. Once they are used to doing some
• Vaginal bleeding walking on a regular basis they can add in other types of activity.
• Abdominal pain Women should also be advised to avoid prolonged periods of
• Regular painful contractions sitting and breaking up sedentary time with at least light physical
• Amniotic fluid leakage activity. It is also important to highlight that every activity counts
• Dyspnoea before exertion and women should ‘listen to their body and adapt’ what they
• Persistent excessive shortness of breath that does do accordingly.
not resolve with rest
• Dizziness
• Headache
• Chest pain
• Muscle weakness affecting balance
• Calf pain or swelling
CHAPTER 10:
Advise to a woman who is already active:

Physical activity for women
These women can be encouraged to continue what they are doing after childbirth (birth to 12 months)
and only adapt their activity, if it is not recommended (box 2) or
Time for yourself - Helps to control weight Improves tummy
becomes necessary later, as pregnancy progresses. reduces worries and and return to pre- muscle tone and
depression pregnancy weight strength
Improves fitness Improves mood Improves sleep
Three key safety messages:

Not active? Active before?
Start gradually Restart gradually
t
1. No evidence of harm
ou
Pregnant women may be concerned that physical activity is not
Le
ab
safe, however, there is no evidence suggesting adverse maternal
isu
aim for
nd
or infant outcomes for healthy women resulting from moderate at least
re
ta
150
intensity physical activity, indeed there are clear benefits.
Ou
2. Listen to your body and adapt
Some activities may feel different due to physiological changes
and may require adaptation as pregnancy progresses. A general minutes
rule is if it feels comfortable keep going, if it is uncomfortable of moderate intensity activity
stop and seek advice. every week
Build
3. Don’t bump the bump Start back up
pelvic floor to muscle
Certain activities may represent an increased risk of injury through exercises as strengthening
physical contact. Therefore, avoid contact sports and activities soon as you can activities twice
where there is a high risk of falls/trauma.

and continue daily
Home a week
It’s safe to be active. Depending on your You can be active

No evidence of harm delivery listen to
for post partum your body and
while
NICE guideline CG 62 on Antenatal care for uncomplicated women start gently breastfeeding
pregnancies recommend: 12
UK Chief Medical Officers’ Physical Activity Guidelines, 2019
Exercise in pregnancy
• Pregnant women should be informed that beginning or
continuing a moderate course of exercise during pregnancy is The benefits of physical activity after pregnancy
not associated with adverse outcomes. It helps recovery and improves physical and mental health.
Evidence is demonstrating that physical activity:14
• Pregnant women should be informed of the potential dangers of • Reduces depression
certain activities during pregnancy, for example, contact sports, • Improves emotional wellbeing
highimpact sports and vigorous racquet sports that may involve • Improved physical conditioning
the risk of abdominal trauma, falls or excessive joint stress, and • Reduces postpartum weight gain and a faster return
scuba diving, which may result in fetal birth defects and fetal to pre-pregnancy weight.
decompression disease.
The evidence is also strong for pelvic floor muscle training in
the treatment of urinary incontinence in the general postpartum
Physical activity after pregnancy population.15
The postpartum period is a time during which resumption of physical

activity levels can be challenging. Hormone levels remain high for A staged approach to physical activity after pregnancy 4,14
at least 4 to 6 weeks after delivery meaning ligaments will still be
relatively soft, potentially increasing the risk of injury. These effects 1. Physical activity can safely be recommended to women during and
will last longer if the woman is breast feeding. Coupled with recovery after pregnancy. Following a straightforward birth, a woman can
from the birth and fatigue from caring for a new born, regular training start gentle activities and exercises as soon as she feels up to it.
may be resumed gradually after pregnancy as soon as medically This could include walking, gentle stretches, pelvic floor exercises
safe, depending on mode of delivery and the presence or absence of and deep stomach exercises.
medical or surgical complications.2
2. After the 6-8 week postnatal check, advice should be tailored to
The Department of Health CMO commissioned Physical Activity and whether a woman was active before or during their pregnancy. If
Pregnancy Study Group, have made the following recommendations a woman was not active before, encourage her to start gradually.
and infographics. 1, 13 Vigorous activity is not recommended for previously inactive
women. Pelvic floor exercises should be discussed, actively
encouraged and should be continued daily.
CHAPTER 10:
3. If a woman was active before, encourage a gradual reintroduction If a woman experiences any of the signs and symptoms of pelvic floor
of physical activities. However, emphasise that they may need and/or abdominal wall dysfunction, more intense physical activity
to change or adapt the type of activity undertaken initially. For should not be resumed, and referral to a specialist pelvic health
example, returning to contact sports gradually and slowly building physiotherapist is required.19
up muscle tone and aerobic fitness. Pelvic floor exercises should be
discussed, encouraged and should be continued daily. • Urinary and/or faecal incontinence
• Urinary and/or faecal urgency that is difficult to defer
4. Women can also be reassured that moderate physical activity has • Heaviness/pressure/bulge/dragging in the pelvic area
no negative impact on breast feeding postpartum.13, 14 • Pain with intercourse
• Obstructive defecation
• Pendular abdomen, separated abdominal muscles and/or decreased
What about vigorous intensity activity? abdominal strength and function
• Profound physical and physiological changes accompany • Musculoskeletal lumbopelvic pain
pregnancy 16 and subsequently tissue healing following child birth
is understood to take 4-6 months17.For instance, running can cause
sudden rises in intra-abdominal pressures18 increasing the risk of Take home messages:
pelvic floor dysfunction, such as urinary incontinence, pelvic organ
prolapse, abdominal weaknesses and lumbopelvic pain. Guidelines Physical activity is an important part of any management for a woman
on returning to running safely postnatally, relate to all vigorous who is pregnant, leading to:
activity and recommend building up pelvic floor and abdominal • Reduction in hypertensive disorders
strength, alongside moderate intensity physical activities in the • Improved cardiorespiratory fitness
first three months.19 • Lower gestational weight gain
• Reduction in risk of developing gestational diabetes
• After having built up moderate intense physical activities over a • There is no evidence of harm when healthy pregnant or postnatal
minimum period of three months and in the absence of any signs women participate in moderate intensity physical activity
or symptoms pf pelvic floor or abdominal wall dysfunction, more • Keeping active in pregnancy could improve health outcomes for
intense activities, such as running , can gradually resume. both mother and baby
• Pregnancy offers an ideal opportunity to adopt a healthy lifestyle,
with the increased motivation to self-care coupled with frequent
access to maternity services
Consider: The importance of a healthy lifestyle should be reinforced

throughout pregnancy. This should be discussed in some detail at the
first booking appointment (typically with a midwife).
Infographic from Br J Sports Med, 51, 1516-1525.19 Used with permission
“Motivation is what gets you started.

Habit is what keeps you going”
Anonymous
CHAPTER 11:
Respiratory Disease
Asthma Chronic obstructive pulmonary disease (COPD)
Asthma is a common condition that affects people of all ages. Chronic obstructive pulmonary disease (COPD) results in
Respiratory symptoms, such as intermittent recurrent dyspnoea irreversible damage to lung tissue and long-term inflammation
and wheeze and variable expiratory airflow limitation are a of the airways, resulting in fixed airflow limitation. As COPD
result of increased airways hyper-responsiveness and progresses, symptoms such as breathlessness and muscle fatigue
airway inflammation. make exercise an unpleasant experience, which, together with a
sedentary lifestyle , leads to muscle deconditioning associated
Regular exercise is recommended as supplementary therapy with reduced physical activity. This subsequently contributes
to medication in people with stable asthma1. The key benefits to further decline in exercise capacity and perception of
of exercise training in people with asthma are improved cardio- breathlessness. Thus, people with COPD get trapped in a vicious
respiratory fitness and increased exercise capacity1-3. cycle of declining physical activity and increasing symptoms of
breathlessness during exercise 1.
In some individuals, regular exercise may also improve resting
lung function1, 3, asthma control and quality of life 1. While growing You feel
breathless
evidence suggests that obesity increases the risk of asthma4,5,
the benefits of weight loss for asthma control remain uncertain6.
Exercise is well tolerated by people with stable asthma2, 3.

Nonetheless, exercise can pose a particular problem in some Weak muscles use You become fearful
individuals, especially children, athletes and people with poorly more oxygen and of activity that makes
are less efficent you breathless
controlled asthma, as exercise is a common trigger of asthma
symptoms and bronchoconstriction. Symptoms and expiratory
airflow limitation typically worsen after exercise, which varies The vicious cycle
in severity and implications depending on the severity of the of inactivity
disease, and this may also contribute to lower participation in
physical activity7. Your muscles
You avoid those
activies which make
become weaker
you breathless
To prevent exercise-induced bronchoconstriction: 3, 8-11
• Prescribe pre-exercise medication (e.g. inhaled short-acting

ß2-agonist). Note: caution is recommended against over use of
You do less
inhaled ß2-agonists, as this can lead to tolerance and it has been
activity
shown there is a correlation with asthma mortality in people that
have been prescribed more than 12 short acting reliever inhalers
in the previous 12 months 12.
Pulmonary rehabilitation aims to break the vicious cycle of
• Advise individuals to complete a warm-up that includes inactivity by enabling people with COPD to become more
intermittent high-intensity exercise; active under supervision and ultimately, less afraid of exerting
themselves and getting out of breath.1,2. Pulmonary rehabilitation
• Encourage individuals to exercise in warm humid environments involves multidisciplinary programmes that are built around an
(e.g. swimming pools) or, when exercising in cold weather, to exercise training intervention, patient education and relaxation
cover their mouth with a scarf or use a face mask that warms and techniques. The potential benefits of exercise training alone in
humidifies the air; people with COPD include:3
• Improved health-related quality of life
• Advise individuals to limit exposure to environmental triggers • Increased psychological wellbeing
(e.g. air pollutants and allergens) when exercising. • Improved symptoms of breathlessness and limb discomfort
• Improved functional capacity
Contraindications • Increased participation in everyday activities
Unstable asthma or actively wheezing • Lower morbidity with fewer hospital admissions
• Reduced length of stay following acute exacerbations
Physical inactivity is associated with a higher risk of hospital

admissions and an increased risk of mortality in people with
COPD, and contributes to disease progression and poor
outcomes4. Thus, NICE recommendations state that people with
a Medical Research Council (MRC) dyspnoea grade of 3-5 who
are functionally limited by breathlessness should be referred for
outpatient pulmonary rehabilitation5.
CHAPTER 11:
Respiratory Disease
Further, the British Thoracic Society guidelines on pulmonary • Advise people of the benefits of pulmonary rehabilitation and the
rehabilitation include COPD sufferers with a MRC dyspnoea grade commitment needed to gain these.
of 2 who are functionally limited by breathlessness 6. However,
physical activity should be considered an integral part of the
Contraindications
clinical management of all people with COPD, irrespective of Pulmonary rehabilitation is not suitable for people who are
their MRC score. 1, 7. unable to walk, who have unstable angina or who have had a
recent myocardial infarction 5
Grade Degree of breathlessness related to activities
Cystic Fibrosis
1 Not troubled by breathlessness except on strenuous exercise
General
Exercise The progressive respiratory dysfunction associated with cystic
Advice fibrosis (CF) leads to fixed airways obstruction, abnormal
2 Short of breath when hurrying or walking up a slight hill
ventilatory responses and subsequent breathlessness during
Consider exercise, which limits exercise capacity and the ability to perform
3 Walks slower than contemporaries on level ground referral to
activities of daily living. Low levels of physical activity contribute to
Pulmonary
because of breathlessness, or has to stop for breath when Rehab disease progression in CF 1. Further, lower levels of aerobic fitness
walking at own pace are associated with a reduced life expectancy 2.
4 Stops for breath after walking about 100 metres or after a few
Exercise is an important adjunct to treatment for people with CF,
minutes on level ground
irrespective of age and disease severity 3. While evidence for the
5 Too breathless to leave the house, or breathless when dressing efficacy of exercise training in CF is relatively limited 4, regular
or undressing exercise and physical activity may provide a wide range
of benefits, including:
• Increased exercise capacity
NICE guidelines CG101 recommend:5 • Improved strength and endurance of the muscles
of ventilation
• Make pulmonary rehabilitation available to all appropriate • Reduced breathlessness
people with COPD, including people who have had a recent • Preserved pulmonary function
hospitalisation for an acute exacerbation; • Enhanced mucus clearance
• Offer pulmonary rehabilitation to all people who view NICE guidelines NG78 make the following recommendations 5:
themselves as functionally disabled by COPD • Advise people with CF and their family members or carers
(usually MRC grade 3 and above); (as appropriate) that regular exercise improves both lung
function and overall fitness;
• For pulmonary rehabilitation to be effective, and to improve • Offer people with CF an individualised exercise programme,
adherence, they should be held at times that suit people, in taking into account their capability and preferences;
buildings that are easy to get to and that have good access for • Regularly review exercise programmes to monitor the
people with disabilities; person’s progress and ensure that the programme continues
to be appropriate for their needs;
• Pulmonary rehabilitation programmes should include • Provide people with CF who are having inpatient care with:
multicomponent, multidisciplinary interventions that are tailored - an assessment of their exercise capacity;
to the individual person’s needs. The rehabilitation process should - the facilities and support to continue their exercise
incorporate a programme of physical training, disease education, programme (as appropriate), taking into account the
and nutritional, psychological and behavioural intervention; need to prevent cross-infection and local infection
control guidelines.
“Running is not just exercise;

it is a lifestyle”
John Bingham
CHAPTER 12:
Perioperative Surgery
The perioperative period includes the time before, during and that may predispose them to post-operative complications after
after surgery. The evidence for physical activity and health is well surgery, delayed discharge and surgical survival rates.2,3
established across many areas which may prevent or affect surgery:1
It has been shown that poor preoperative physical performance
• All-cause mortality – 30% risk reduction comparing most increases the risk of complications after major non cardiac surgery
active with least active 4,5
and prolongs recovery after abdominal surgery. 6 There is also
strong evidence that if cardiorespiratory fitness (CRF) is measured
• Risk reduction of hip fracture is up to 68% at the highest level preoperatively, it is predictive of complications in the postoperative
of activity period in several settings.7-13
• Lower risk of falls and fractures in elderly patients who regularly The assessment of CRF preoperatively has been shown to offer
participate in physical activity significant advantage when compared to age alone in predicting
mortality after major surgery.14 This same study also showed firstly:
• Colon cancer – 30% lower risk in those who are active CRF to be a significant independent predictor of length of stay
in hospital with patients older than 75 and secondly, a low CRF
• Breast cancer – 20% lower risk in those who are active associated with a median of 11 days longer in hospital and 2 days
longer in critical care.14
• Cardiovascular disease – 20-35% lower risk of cardiovascular
disease, coronary heart disease and stroke Another study of pre-operative fitness and outcomes after major
abdominal surgery also showed that physical fitness was an
With the physiological stress of any major operation, patients independent predictor of postoperative recovery in addition to
experience a drop in their functional status. In most cases, they will conventional predictors of age and co-morbidities.15 Prediction
recover back to baseline. (See figure 1) models for mortality, discharge destination and length of hospital
stay were once again all significantly improved by the physical
Surgery activity and fitness factors.
Activity
Status Patient
With the increasing evidence of the benefits of better preoperative
approaching
surgery… ry CRF, it follows that a reasonable intervention for improving surgical
ve
eco outcomes is to introduce exercise training preoperatively.
Independent R
ine (See figure 3)
out
R
Line of
dependency Surgery
Activity
Dependent Status tion
abili
Preh y
er
ov
Independent Rec
Figure 1:
ine
ut
Ro
Line of
Patients who experience complications tend to have a slower and dependency
possibly less complete recovery and some may fail to recover ry
cove
their preoperative status. In these cases, this may lead to a loss of Dependent
ated Re
plic
independence and a much reduced quality of life long term. Com
(See figure 2)
Figure 3:
Surgery
Activity Patients undertaking preoperative exercise may experience a
Status reduced risk of complications, a shorter stay in hospital and a more
er
y rapid recovery, through enhanced physical fitness. Importantly,
ov if complications occur, prehabilitated patients may still recover
Independent Rec
ine sufficiently to retain their independent functional status
ut
Ro
Line of
dependency In the area of cancer surgery, aerobic exercise programs
ry undertaken prior to surgery have mainly shown improved function
cove
Dependent
ated Re and physical capacity.16 However, patients often now require
plic
Com neo-adjuvant chemo and radiotherapy before major rectal cancer
surgery, which can reduce physical fitness, potentially increasing
Figure 2:
their complications. In a recent and important intervention study
it has been shown that structured exercise intervention post
However, there is emerging evidence that exercise perioperatively chemo and radiotherapy is both feasible and can restore fitness to
improves surgical outcomes and reduces in patient times in hospital. baseline levels again.17
Surgical patients increasingly have complex medical co-morbidities
CHAPTER 12:
Perioperative Surgery
This work correlates with the evidence presented in the cancer

section of this guidebook, where physical activity has been shown to
improve function before, during and after treatment for cancer. It has
also been shown to reduce mortality risk in breast and colon cancer.18
There are no specific NICE guidelines on surgery itself but

for vascular surgeons NICE guidelines CG14719 on lower limb Preparing for surgery
peripheral arterial disease recommend:
• Offering a supervised exercise programme to all patients with

Fitter
intermittent claudication.
Better
Sooner
• Consider providing a supervised exercise programme which
involves:
• 2 hours of supervised exercise a week for a three
month period
• Encouraging people to exercise to the point of
maximal pain
Key points
• Poor cardiorespiratory fitness (CRF) increases the risk of
complications of major surgery
• Conversely, improving CRF preoperatively has been
associated with reduced complications
• CRF assessment offers a better prognosis than age alone in
major surgery
• CRF is an independent predictor of mortality and length of
stay in hospital
Advice from the Royal College of Anaesthetists

Endorsed by
Conclusions
Surgeons, anaesthetists, nurses and those giving advice in primary
care should consider pre surgical exercise interventions as a useful
adjunct to therapy.
Use this preoperative risk education package to help understand

how to prepare your patients for surgery.
https://prepwell.co.uk/
To help introduce this to your patients, the Royal College of

Anaesthetists have developed a guide leaflet for patients on
preparing for and surgery called ‘Fitter Better Sooner’ 20 and the
patient information sheet can be Downloaded here .
“I have two doctors, my left leg and my right”

GM Trevelyn
CHAPTER 13:
Sedentary Behaviour
Figure 1: Risk of all-cause
Part 1: Sedentary Behaviour Daily Sitting Time mortality decreases
as one moves from red to green
Source: Adapted from data
In the 2019 UK Chief Medical Officers (CMO) guidelines on physical from Ekelund et al 2016 (19)
activity,1 adults are advised to aim to minimise the amount of time
spent being sedentary, and when physically possible should break
up long periods of inactivity with at least light physical activity.
What is the basis for this?

Adults and children increasingly spend time sitting: at a desk or
laptop, driving, watching TV or DVD’s, playing computer games
or social networking. Occupations have changed, from being
physical working to office working with ever increasing hours
working at a computer.
Evidence shows that prolonged sitting and a lack of whole-

body muscle movements are associated with obesity, metabolic
syndrome, type 2 diabetes, cardiovascular disease, cancer and
total mortality which are usually independent of daily moderate
to vigorous intensity physical activity (MVPA).2-9 In particular,
TV viewing time is implicated in obesity, with the concurrence of
snacking on sweet or fatty foods, low levels of physical activity
and inadequate sleep.10-12 It has also been observed that because
TV-viewing is usually after dinner - or with dinner in front of the TV,
this prolonged postprandial sitting may be particularly detrimental Moderate-to-Vigorous
Physical Activity
for glucose and lipid metabolism.13 Food advertising on TV is also
likely to affect eating behaviour.14
It has been thought that this sedentary time is likely to be in This study also found that, in comparison with other risk factors for
addition to the risks associated with insufficient MVPA. An health, the increased mortality risk (58%) in those who sit for more
Australian study estimated the extent to which TV viewing time than 8 hours/day and are also the least active, is similar to that of
reduced life expectancy. The research compared people who smoking20 and obesity.21
watched no TV with those who spend a lifetime average of 6 hrs
viewing a day and found the latter group were predicted to live 4.8 One would expect similar results when comparing physical
years less. The authors concluded that ‘TV viewing time may be activity and daily sitting times and TV-viewing times with all-cause
associated with a loss of life that is comparable to other major risk mortality. However, studies have suggested a greater effect of TV-
factors such as physical inactivity and obesity’.15 viewing on all-cause mortality,19, 22 and although high level activity
reduces considerably the risks associated from TV-viewing, it fails
With the strong evidence of the link between sedentary time to entirely remove this increased risk. 19
and poor cardiometabolic health, this may be a more important
indicator of poor health than MVPA levels.16 Thus it may be more What can we do practically in the workplace and at home to
effective in the prevention of type 2 diabetes to target reducing change this behaviour?
sedentary time rather than solely focusing on promoting MVPA. One simple way is to introduce the concept of NEAT (Non Exercise
Activity Thermogenesis), a term that refers to daily physical
Until recently, it has also been unclear whether sufficient levels activities that are not perceived as exercise or training.
of activity can modify by weakening or removing the damaging (see box 1 on next page). By promoting more standing, less sitting
effect of prolonged sitting as described above. 17, 18 A large meta- and more moving we now know that these activities, however
analysis of data from more than 1 million individuals,19 has explored small, are better than sitting; these small activities accumulate and
the associations of sedentary behaviour and physical activity with count towards our daily energy expenditure as well as reduce the
all-cause mortality. (see figure 1). Results suggest that across sitting sedentary risk factors.
time categories, all-cause mortality was considerably reduced with
higher levels of physical activity and eliminated in those who were Summary
the most active (60-75 min or more per day of moderate activity).19 As Health and Social Care Professionals, we may be able to do
little to alter the social changes that have occurred over the past
This level of activity is beyond the basic level of the Chief Medical few decades. However, by understanding the health problems
Officers (CMO) physical guidelines of 30 minutes a day (for which have developed from this, we can do more by advising and
five days a week) or 150 minutes a week of moderate intensity. guiding patients to think about their lifestyle and to address their
For these individuals, there were smaller increases in mortality health risks. Changing patterns of behaviour is not easy, but if small
risk associated with sitting time seen compared with the least changes are made and this is spread over large populations, then
active group (about 5 mins/day), even though the risks were not the effect will be significant. Increasing any physical activity is
completely eliminated.19 essential to mitigate the associated risks for inactivity.
CHAPTER 13:
Sedentary Behaviour
Useful resources for students:

Box 1: Examples of NEAT
• Promote and support standing meetings
The Chartered Society of Physiotherapists has postcards to buy
• Get up from the desk to walk across the office to speak
and a free pdf download for desk workers or even self use!
to a colleague rather than phone or email
http://www.csp.org.uk/publications/do-you-sit-desk-all-day
• Use a standing desk to work from
• Read your ipad/tablet whilst standing
• Walk and talk whilst speaking on the phone A fun 4-minute cartoon video on You Tube entitled – ‘Let’s Make
• Use manual buttons on televisions rather than a our Day Harder’ may help shift sedentary behaviour and be
remote if available motivational for some patients.
• Get up and move during commercial breaks on the TV
• Park the car on the far side of a car park
e.g. at the supermarket
• Using the stairs instead of the lift or escalator
“The best remedy for a short temper

is a long walk”
Jacqueline Schiff
CHAPTER 13:
Sedentary Behaviour
Part 2: Sedentary Behaviour and Musculoskeletal Disorders Back pain
Introduction Low back pain is one of the biggest causes of absence from the
Sedentary behaviour refers to any waking activity characterized by an workplace,7 accounts for a high demand on healthcare provision,
energy expenditure 1.5 metabolic equivalents and a sitting or reclining is multifactorial, and common aetiologies of which are; sedentary
posture. In general, this means that any time a person is sitting or lying behaviour, being overweight and obese, and harmful lifestyle
down, they are engaging in sedentary behaviour. Common sedentary choices e.g. smoking, poor diet, poor social interaction8.
behaviours include TV viewing, video game playing, computer screen Current thinking is moving away from rest and toward active
time, seated employment, driving and reading.1 recovery and rehabilitation alongside encouraging lifestyle
improvements. Physical inactivity is associated with in a clear
Lack of physical activity is a common factor in many dose-dependent manner9 with:
chronic conditions2 and inactivity has been directly linked to • narrower intervertebral discs
musculoskeletal changes.3 Physical inactivity is highlighted as a • higher fat content of lumbar muscle and fascial tissues
threat to musculoskeletal health across the lifespan.4 • high intensity low back pain and disability
Musculoskeletal disorders (MSDs) related to sedentary lifestyles A systemic review assessed how behavioural interventions
and minimal physical activity are: compare to no intervention and guideline-based active
• non-specific low back pain treatment 10 Interventions regarding behavioural approaches to
• sciatica/lumbar radicular pain help people better manage persistent low back were seen to
• osteoporosis yield good improvements in pain, disability and quality of life.
• osteoarthritis Another systemic review and meta-analysis11 of multidisciplinary
• neck pain with and without radiculopathy biopsychosocial rehabilitation (MBR) of patients with chronic low
• patellofemoral joint pain back pain consolidate this holistic approach finding MBR to be
• hip pain more effective than usual care (moderate quality evidence) and
physical treatments (low quality evidence) in decreasing pain and
It has been suggested that the mechanism through which the disability in people with chronic low back pain.
sedentary behaviour negatively affects joint health is largely
related to deconditioning.5 Further studies have shown the Lower back pain with lumbar radicular pain/sciatica is common7
greater risk of sarcopenia associated with longer sitting time.6 and through systematic review and meta-analysis, the risk of
The following section gives examples of the impact of sedentary occurrence has shown to be reduced with physical activity12
behaviour on some aspects of musculoskeletal health: increased with long smoking history, a high serum C-reactive
Deconditioning
Cardiopulmonary Muscular Bone and collagen Metabolic

Stroke volume Capillarization Bone density Insulin resistance
Heart rate Mitochondrial density + enzymes Tendon stiffness
Ventilatory efficiency Muscle mass
Motor unit recruitment
Slow to fast fiber type transition Blood pressue
Blood glucose
Blood lipids
Muscle fatigability
Muscle strength
Maximum cardiac output (Q) a-v 02
V02max Risk CVD

Exercise capacity Risk tendon injury Risk DMII
Key
= increase, = decrease, a-v 02 = mixed arterio-venous content difference, CVD = Cardiovascular disease, DMII = Diabetes Type II
Figure 2. The physiological consequences of deconditioning5.
CHAPTER 13:
Sedentary Behaviour
protein level,13 and being overweight and/or obese with a dose There is good evidence for the benefits of graded loading to
dependent relationship.14 Reviewing this alongside the Chief pathological tendons which can be applied to other tendinous
Medical Officers recommendation of 150 minutes per week of muscle attachment, such as patellar tendinopathy.22 Coupled with
moderate intensity exercise,15 sedentary lifestyle behaviour can this, obesity as a risk factor, has been identified for several types of
be suggested as a causative factor for non-specific low back pain. tendinopathy including: rotator cuff, elbow extensor compartment
A systematic review16 highlights the benefits of exercise therapy (tennis elbow), patellar, quadriceps, Achilles and the plantar fascia.23
for non-specific low back pain with regards to function and pain.
This highlights the need for patient specific exercise to encourage
participation and a move toward a more active lifestyle. Knee
Sedentary lifestyles play a part in the development of non-traumatic

NICE guidelines NG 59 17 on Low back pain and sciatica call for knee pain. A systematic review found some limited evidence for,
greater emphasis on exercise and psychological therapies: amongst other biomechanical factors: weight, BMI, and waist-to-hip
ratio.24 Treatment options highlighted have focussed on affecting
• Encourage patients to continue with normal activities these, with increasing strength, decreasing body weight and upper
leg flexibility identified as being most effective.
• Consider a group exercising programme as part of the
treatment regime Osteoarthritis of the knee is commonly seen in those entering the
later stages of life with a wide range of hypotheses on the causes
• Consider manual therapies (manipulations and soft tissue and effects of arthritis. NICE (2014) guidelines25 highlight exercise as
massage) but only as part of a treatment package including a core treatment to focus on local muscle strengthening and general
exercise, with or without psychological therapy aerobic fitness, although people with knee osteoarthritis tend to fall
short of physical activity guidelines and recommended daily steps.26
• Consider psychological therapies using a cognitive behavioural
approach but only as part of a treatment package including
exercise, with or without manual therapies Shoulder
In conclusion, sedentary lifestyles are a major factor in non- Musculoskeletal shoulder pathology includes: frozen shoulder,
specific low back pain and back pain with accompanying radicular rotator cuff pathology, and glenohumeral and acromioclavicular
pain and can be treated in many ways with exercise and a holistic joint osteoarthritis. Pain is frequently caused through falls and
multidisciplinary approach being particularly effective. degenerative changes in both the rotator cuff and glenohumeral
joint, particularly in elderly patients. Whereas exercise has been seen
Contraindications to be a highly effective treatment method for these conditions,27-29
Any suspected or known recent fracture, tumour or infection identification of factors associated with sedentary lifestyles have
of the back.18 been made in regards to increased risk of shoulder pathology.30
In a large cross-sectional study assessing associations of lifestyle

factors and metabolic factors with shoulder pain and rotator cuff
Ankle tendon pathology, associations of abdominal obesity and smoking
in male and females were clear. Thus, it could be concluded that
In relation to sedentary lifestyles, Achilles tendon pathology non-traumatic shoulder pain incidence is affected by sedentary
and pain is seen to be particularly susceptible to lower levels lifestyles and decreased physical inactivity and to affect this,
of physical activity19 and Achilles tendon pathology was more lifestyle changes regarding physical activity and combatting
common in patients with greater Body Mass Index (BMI).20 sedentary lifestyles would be of benefit.
Through retrospective analysis to elucidate the role of BMI in the
development and treatment of Achilles tendon pathology, a high
BMI was seen to play a role in the development of Achilles tendon Useful resources for students:
pathology, although, somewhat reassuringly, not affecting the
response to conservative treatment. The Chartered Society of Physiotherapists(CSP) has postcards to
buy and a free pdf download for desk workers or even self use!
It could be extrapolated that Achilles tendon pain could arise from http://www.csp.org.uk/publications/do-you-sit-desk-all-day
deconditioning associated with sedentary lifestyles and through
exercise, reconditioning of tissues along with the secondary The CSP also has a very useful website for conditions needing
effects of exercise such as decreased pain sensitivity21 could be an physiotherapy exercises for health professionals
effective management. https://www.csp.org.uk/conditions
CHAPTER 14:
Supporting people to change

their health behaviour
Drawing together all key theories of behaviour change, behavioural Moving from this direct style of consultation to a more guiding
scientists have identified three interacting elements that need style that encourages patient motivation has been shown to
to be present for people to change their health behaviours: increase the success of health promotion.
Motivation, Capability and Opportunity 1.
Motivational interviewing was originally developed in the field
• MOTIVATION – the desire to change of addiction counselling, but has also been used to promote
• CAPABILITY - the capacity to change (whether physically, behaviour change in a wide range of healthcare settings, such
mentally, socially, or otherwise) as smoking cessation, weight loss and promoting increased
• OPPORTUNITY – having a realistic opportunity for change physical activity.
There is increasing evidence of its effectiveness,2,3 with 80% of

CAPABILITY 72 studies finding that motivational interviewing outperformed
traditional advice-giving.4 It is associated with a more respectful
and less combative consultation – this feels professionally better
and is certainly more enjoyable for both doctors and their patients.
MOTIVATION BEHAVIOUR
Motivational Interviewing (MI) by Prof S Rollnick
OPPORTUNITY A consultation that leans on MI has one strong characteristic that

supersedes all else: instead of adopting an expert position and
using a directing style to persuade the patient why or how they
Much of the work we do with people in clinical settings targets might get more exercise, you adopt a guiding style. It is a more
motivation and capability and this chapter provides some collaborative process of helping the patients to say why and how
evidence-based advice for doing this; but it is important to they might get more exercise. You structure the consultation and
also recognise the influence that other factors can have on the provide information (with permission) but most of the time you are
likelihood that someone will change their behaviour. This may eliciting their own motivation to change. This is often expressed
be particularly important in understanding why our efforts to in the form of change talk.5 The more change talk you can elicit
help do not always work and why people appear motivated yet from the patient, the better the outcome is likely to be. There is
still do not change. For example, it has been established that it emerging evidence to support this focus on the language used
is more challenging for people living with social disadvantage to by the patient.6
change their health behaviours. This may be both as they focus
their resources (both physical and psychological) on other more One useful aid might be the recently developed framework for MI7
immediately pressing priorities, and as they have less social that describes four processes in a constructive conversation about
support for change if living in communities where those around behaviour change:
them also have poorer health behaviours. Our approach to
working with people to support the uptake of physical activity will • Engaging
be more effective if we can demonstrate empathy to the barriers • Focusing
to change, and take a person-centred approach to providing • Evoking
support and advice. • Planning
This Chapter provides insight to how we can support people They do not always emerge in a linear sequence, but the logic
to strengthen their motivation and capability to become more is this: step one is to engage with the patient and establish an
physically active. agreed focus for the conversation; then the central task is evoking
the patient’s own motivation to change, followed by planning if
the person is ready for this. These processes are highlighted in the
Enhancing Motivation to Change example below, alongside other key skills.
Health promotion forms part of many primary care consultations, While conducting a full motivational interview may require more
be it advice about exercise, weight loss, smoking or alcohol. These time than is available through standard consultations, adopting
consultations are often fraught with difficulty, as many patients are the guiding style even in brief interactions can have similar
resistant to being told what to do or ‘what is good for them’. beneficial results.
CHAPTER 14:

Example MI Dialogue. By Prof S Rollnick Pt: If I decide to do it and I haven’t yet. (Patient backs off)
This example is based on a fictitious consultation between a HCP: You don’t want to be pushed into this (HCP doesn’t try to
51 year old male and his healthcare professional (HCP). He is win the argument or be clever – just uses a listening statement)
overweight, with borderline raised BP, who gets short of breath
when walking secondary to his poor cardiovascular fitness and Pt: Exactly, but it might be worth thinking about. Thanks for not
sedentary job. He travels to work on the bus and works on the lecturing me HCP (laughs)
third floor of an office.
HCP: HCP summarises how patient feels and keeps the door open
HCP: OK, so that’s your tablets sorted out, and now I wanted to for another time.
ask you whether it’s ok with you to spend just a couple of minutes
talking about something completely different….. Would that be
OK? (Asking permission will help a lot) Six weeks later the patient returns for another check on his
borderline blood pressure.
Patient: Yeah OK, what’s that then?
HCP: Well thanks for coming back again. I saw you six weeks
HCP: It’s about physical activity. Would you mind if we chatted ago, didn’t I?
about that if I promise not to nag at you about it?
Pt: Yes, you asked me to come back to check the blood pressure.
Pt: Yeah OK, as long as you keep to that promise (laughs). (The
focus is clear. Engagement is not strong, yet.) HCP: (HCP checks BP) Well it’s still on the high side, so we could
now ask the question what will help you to get it down and
HCP: So rather than me talk about it, could you? Could you tell avoid this becoming a cause for concern in the future?
me how you feel about getting more exercise?
Pt: Well I know I don’t want any of those tablets for blood
Pt: Hate the thought to be honest with you. pressure if possible Doc.
HCP: You’re not persuaded about this one (That’s a reflective HCP: Sure, that’s fine for now. Can I raise the subject of exercise
listening statement, not a question) again, if I promise not to lecture you?
Pt: Well I do know that it would help my health (change talk), but Pt: You told me that last time, but fair game, you didn’t lecture
the effort is really too much. me, so yes fine (laughs)
HCP: You get quite a lot done each day, and adding exercise HCP: I promise again!
doesn’t seem like it could fit (another reflective listening statement)
Pt: I believe you again, but what now?
Pt: Yeah you guessed right, I don’t just sit around all day and the
thought of going to the gym just doesn’t fit for me. HCP: My question would be this: are there some simple small
steps you can take to introduce a little more exercise into
HCP: Going to the gym isn’t for you, you are busy enough and yet your daily life?
you know it would be good for your health to get more exercise,
have I got you? (A summary that also includes the change talk) Pt: I’m glad you are not on about the gym.
Pt: Yeah you’ve got me for sure. (Engagement is now much better, HCP: Sure, that’s too drastic for you (reflective listening)
as a result of listening and then summarising).
Pt: I don’t do drastic, my life’s busy enough.
HCP: Can I ask you how do you see the benefits of just a slow and
steady increase in exercise? (A question that allows the HCP to HCP: Small things might be possible (reflective listening again –
start evoking change talk) a guess about what might work)
Pt: Me? Well if it was slow, and I didn’t have to go crazy like at a Pt: Yes, maybe but I’m not sure what you mean by small things?
gym, it might help me (change talk).
HCP: Presents a range of options, not a single idea, with the aim
HCP: It would help you to feel healthier (a listening statement again, to of encouraging the patient to select thus: So that’s a number
reflect the change talk and it’s also a guess about why it might help) of possibilities. You will be the best judge of what might work
for you. (Reinforcing autonomy is a critical aspect of skilful
Pt: Sort of, but at least I could fit it in, and I might succeed, and I consulting about behaviour change).
could feel good about that. (More change talk)
Pt: Well of all those things you mention, there’s only two that
HCP: Because you don’t want to take on some big task like the make sense to me: walking up the stairs rather than the lift and
gym. What suits you more is something smaller to start with. getting off the bus 2 stops before work and walking the last part
(Reflecting again, trying to understand how he really feels) (patient emits change talk).
CHAPTER 14:

HCP: You can see a way of doing these simple things (the best partner) and emotional (e.g., encouragement) support from
response to change talk is a simple reflection). others for physical activity, whether from existing friends and
family or by forming new contacts with people attempting the
Pt: I guess I can, and if it works I might try walking that same same lifestyle changes, at the same time.
distance after work again (more change talk).
HCP: You want to experiment and see what works for you The following case study is an example of how motivational
(more reflection). interviewing and the inclusion of self-regulatory techniques
may help someone to initiate changes to become more
Pt: Yeah I am happy to try those two things (change talk). physically active:
HCP: (Summarises all the change talk that has emerged). So you
don’t want tablets, and you think you might be able to walk up Sarah
the stairs at work, and get off the bus two stops early, and walk In recent years, 50 year old Sarah has experienced more and
into work. more bouts of prolonged unhappiness. She has not been
diagnosed with clinical depression and her primary healthcare
Pt: Knowing me, I’ll give it a go. It might help me to feel better professional (HCP) has recommended she becomes physically
about myself (change talk). active. She has done little or no purposeful exercise since
her teenage years when she used to hate sport and physical
HCP: And would you mind coming to see me for a brief catch-up education at school, finding it threatening and embarrassing.
in six weeks? Sarah is on the borderline between overweight and obese with
a BMI of 29 and has been recently been diagnosed with mild
Pt: Sure......Etc etc hypertension. She has a family history of type 2 diabetes.
Sarah’s primary HCP knows that she doesn’t have time to

provide all the support that Sarah may need to take up physical
activity herself. However, she is aware that she can still play an
important role in helping Sarah to strengthen her motivation
to change and encourage her to seek help from other available
services. Adopting a guiding approach advocated through
motivational interviewing, Sarah’s primary HCP explores with
Sarah what she sees as the pros and cons of becoming more
active, what benefits she can identify for doing so, and what the
barriers for her may be.
During this discussion, Sarah shares her belief that being more
active could be important for her and might help her feel more
Watch this dialogue on You Tube describing the behavioural positive about herself and life in general, but that she has not
change dialogue tried to become more active previously as she is not confident
that she would be able to do enough to make a difference.
Sarah would value the benefits of being more active if it helped
Increasing Capability to change her to lose some weight and get her blood pressure down.
Sarah has friends who go to exercise classes, but feels she is
Changing behaviour can be thought of as having an initial not confident to join a group at the moment, but she would like
motivational phase in which people develop their own reasons to think she could join a group of women with similar kinds of
for and intention to change, and a subsequent volitional phase, in issues at some point.
which a person’s motivation is put into action. The motivational
phase can be very well supported by motivational interviewing, Sarah does not feel very sporty or athletic and finds it difficult
but other evidence-based behaviour change techniques, primarily to see ways in which she can be more active. Sarah’s primary
relating to self-regulation, are useful in providing to support HCP asks Sarah if she does much walking at the moment, and
the volitional phase of behaviour change. They help to support if increasing her walking could be a way to get more exercise
someone’s capability to take the first steps towards change, and to that Sarah feels is possible for her. Sarah appears surprised and
sustain these over time 8,9 encouraged that walking could be enough. Sarah also suggests
she is interested in going to the gym, but is not confident of
• Self-monitoring - knowing one’s starting point, and getting walking in for the first time. Having endorsed the importance
feedback on the outcome of attempts to change and progress of physical activity for health, and helped Sarah to identify
over time, some of other benefits that she may value, Sarah’s primary
• Goal setting – more specific goals (e.g., a time and place when HCP suggests that she may benefit from talking more about
one will exercise) and goals related to actions rather than the options with an exercise professional at the local exercise
outcomes (e.g., exercising twice a week rather than losing a referral service, and Sarah agrees to go along.
certain amount of weight) are shown to be more effective,
• Social support – having practical (e.g., having an exercise
CHAPTER 14:

Summary
Having met an exercise advisor at her local gym, the next
important task for Sarah is to set some short-term goals that NICE guidelines PH6 on behaviour change, recommend using
provide a sense of steady and meaningful improvement. To be techniques that create attitude and behaviour change within
effective short term goals have to have a flavour of where, when, health care interventions.11 Whilst no single method can be
and what. They need to be specific and agreed (following the universally applied, a combination of motivational interviewing and
SMART principle of being Specific, Measurable, Agreed, Realistic techniques to promote self-regulation and social support show
and Time phased). In addition, goals should be small enough good evidence of efficacy in research conducted in a range of
to be achievable but large enough to move a person towards settings and populations. 1,2
a perceptible change in their health or fitness. Goals that are
too demanding at this point may undermine confidence and
disappoint if they are not reached, and goals that are too small Consider:
may be discouraging as they provide little satisfaction or belief
that meaningful health or wellbeing benefits will be achieved. 1. Attending a course on behaviour change.
http://www.ucl.ac.uk/behaviour-change/training
The exercise advisor talks through the process of setting goals
with Sarah, taking into account her preferences and the barriers 2. Read more on this important topic.
she sees to being more active. Time is a barrier for Sarah as http://www.fyss.se/wp-content/uploads/2018/01/5.-
she is holding down a demanding full-time job and finding it Motivational-interviewing-about-physical.pdf
difficult to cope. Sarah suggests that her first goal could be to
walk part of the way to work, as it may not take much longer 3. Read NICE guidelines PH49
than waiting for and travelling by bus as she does now. She https://www.nice.org.uk/guidance/ph49/chapter/1-
commits to start by doing this on three mornings a week, and recommendations
to review this goal in a few weeks. The exercise advisor then and PH6
explains that we know that monitoring your own progress and https://www.nice.org.uk/guidance/ph6/chapter/Introduction
having some social support are important when changing
behaviour, and asks Sarah if there are ways in which she could 4. Read, listen and watch from a wide choice of resources on
incorporate these. Sarah immediately suggests that she will ask behaviour change
her son for his support, as she knows he enjoys physical activity http://www.ucl.ac.uk/behaviour-change/resources
and would no doubt be very encouraging. She knows he has an
app on his phone to count his own daily steps, so she will ask 5. The Royal College of Nursing has a useful set of pages on
him to install it on her phone too. supporting behaviour change
https://www.rcn.org.uk/clinical-topics/supporting-behaviour-
(Adapted from an original Case study10 ) change
“Remember any exercise is better

than no exercise”
Anonymous
CHAPTER 15:
Physical Activity and Starting to Get Active

For many people, the thought of starting to become physically Strengthening activities are important throughout life for different
active can be overwhelming. It is perceived as being difficult, reasons: to develop strength and build healthy bones during
painful, largely gym-based, with only demanding regimes childhood and young adulthood; to maintain strength in adulthood;
producing real benefits. and to delay the natural decline in muscle mass and bone density
which occurs from around 50 years of age, maintaining function in
These are misguided assumptions and advice should be more later life.
about incorporating physical activity into everyday life, with
available alternatives, to gym-based exercise. This section gives
brief guidance on the main principles of physical activity, how to
become more active and how to dispel these beliefs.
Chief medical officers’ (UK) Physical Activity Guidelines 2019
Our understanding of the relationship between physical activity

and health has grown. In general, the more time spent in being
physically active, the greater the health benefits. However, we now
know that even small increases in physical activity can contribute
to improved health and quality of life. As such, although we
recommend that all individuals work towards achieving these
guidelines (see chapter 2 in this guidebook), they are not absolute
thresholds and we recognise the benefits that can be achieved at Figure 1: Physical activity for muscle and bone strength across the life course 2, 3
levels both above and below the thresholds
Assessment of levels of activity: Muscle strength and endurance through balance training activities,
It is important to record the patient’s physical activity level to both are also essential to maintain mobility and prevention of falls,
establish a baseline for tracking progress and for understanding which increases in importance as we grow older. Flexibility is too
their existing risk. There are various tools for quantifying a patient’s often overlooked, but is also important as it reduces the possibility
level of physical activity, one of the simplest and most effective of injury, stiffness and an inability to perform simple tasks like
being the Scot-PASQ bending to tie shoe laces or hair washing.
• ‘The Scot-PASQ’. 1 A brief assessment using just 3 questions. There are some simple basic principles that can be used in
Used as a motivational screening tool to help raise the issue of ‘prescribing exercise’, which when grasped by patients, will
physical activity and deliver advice promote more enjoyment and increase motivation, helping them to
o In the past week, on how many days have you been get over some of their beliefs/fears of pain or difficulty.
physically active for a total of 30 minutes or more?
Warm up and Cool down
o If four days or less, have you been physically active for at It is desirable that individuals include a warm up and cool down as
least two and a half hours (150 minutes) over the course part of their activity. This may be the same activity performed at a
of the past week? lower intensity. For example, walking at a slow pace for your warm
up and cool down, with a moderate intensity walk for 30 minutes
o Are you interested in being more physically active? as the main activity.
Read the brief guidance on how to use the tool by Apply the FITT principle
downloading it here:
http://www.healthscotland.com/documents/6255.aspx • Frequency How many times a week for an activity?
Four important aspects of exercise: • Intensity How hard to exert?

• Cardiovascular fitness
• Muscle and bone strength • Time How long in minutes?
• Endurance
• Flexibility • Type Which type of activity agreed with the patient?
Many of the health benefits of physical activity come from The most important aspect to establish first is frequency, as
improved cardiovascular fitness using aerobic exercise. without a daily routine pattern it will not become a lifestyle change.
However, muscle, bone strength and resistance exercises are Motivation, or the desire to change, is what gets you started, but
often overlooked but play a critical role in ensuring we build our habit is what keeps you going.
strength for good muscular and skeletal health, and in maintaining
physical function. When undertaking muscle strengthening Those who have been inactive for a long time may need to start at
activities, it is important to work all the major muscle groups. a low Intensity. If walking, they will need to increase gradually over
Bone strengthening involves moderate and high impact activities time to a moderate intensity.
to stimulate bone growth and repair.
CHAPTER 15:
Moderate exercise when walking is when someone is breathing a How many steps is enough?
little faster and feeling a little warmer than normal but still able to Differing advice is often given over how many steps is good for
hold a conversation, taking a few extra breaths between sentences. our health, with 10,000 steps a day as the commonest quoted. 5-7
If they are gasping between words, then they are engaging in high Yet, adult physical activity guidelines advise at least 30 minutes
intensity activity. This is important to recognise in recommending of moderate intensity activity per day and this translates to only
activity. For example, walking up an incline may be mild to 3000 - 4000 steps, 8, 9
moderate exercise for a teenager, but would be vigorous exercise
to someone who is inactive, vulnerable or elderly. If walking, aim to To fit with public health guidelines these should be: 10, 11
increase the number of minutes of the walk first, before increasing
the intensity (by walking faster or uphill). • Of moderate intensity (i.e. over 100 steps/minute) 8
Time, or how long to exercise, should be established excluding any • Accumulated in at least 10 minute bouts
warm up or cool down. Guidelines previously advised that bouts
of physical activity of 10 min or more accumulated throughout the • Taken over and above some minimal level of physical
day are as effective as longer sessions. However, we now know activity (i.e., number of daily steps) below which individuals
that even smaller increases in physical activity can contribute may be classified as sedentary
to improved health and quality of life and people should be
encouraged to move more as often as they can. An accelerometer or pedometer will however, also register the
low intensity steps taken with everyday movements. These are
There are many activities available that can be started and it part of the daily step count but it is unlikely they will contribute
is important to find a Type of exercise that the individual finds as much to the overall health benefits. It is therefore suggested
enjoyable convenient, affordable and achievable. Walking, cycling that, total steps of less than 5000 steps/day, may reflect a level
and swimming are three of the commonest and available to of sedentary activity which is associated with a higher prevalence
virtually everyone, but there are many more. Dancing, yoga, Pilates of obesity. 10, 12 However, adding 3000-4000/day moderate
and Tai Chi are also very popular and all of these may help to intensity steps to this, then equates with a hierarchy level of
prevent falls and promote core strength. 7500-9999 steps/day (somewhat active) which may be more
useful for monitoring or motivation purposes.10
Definitions of moderate and vigorous intensity
Moderate intensity physical activity causes adults to feel warmer,
breathe harder and the heart beats faster with the example of
gh
brisk walking being the easiest to recognize.

Hi
re
itu
Physically
nd
Vigorous intensity physical activity causes adults to get warm Active

pe
Ex
Physically >7500 Meeting MVPA

quickly, breathe much harder, perspire and find it difficult to
ise
Active Lifestyle steps/day recommendations

rc
xe
maintain a conversation
E
ily
Da
Low Active 5000 - 7499 Not meeting MVPA

e
ag
er
Monitoring Lifestyle steps/day recommendations

Av
Physically
Some people find it helpful to monitor their progress and use this
w
Inactive
Lo
Sedentary <5000 Nonexercise physical activity deficiency;

to motivate themselves. Lack of movement;
Lifestyle steps/day Higher accumulated time in
sedentary behaviours
Ways of monitoring progress:
• Keep an exercise diary – cheap and easy to record your

Fig 2 Fig 2 Step - defined sedentary lifestyle index for adults:
progress, success, feelings and to identify barriers to exercise
MVPA, moderate – to - vigorous physical activity 11
• Pedometers – cheap and easy to use, but not always reliable 4 In summary, every step may be counted with even small
increases in physical activity contributing to improved health and
• Smart phones and ‘Fitbits’ – now commonly available and quality of life
with monitoring apps
Getting Started
• Accelerometers – more reliable and can be linked to a Increasing physical activity for many is difficult and
computer program for monitoring encouragement and ideas are needed to help integrate activity
into daily life.
• Walk4life – the walking web based site which is free to join; There are many ways of increasing activity and walking is one
it uses ordinance survey maps and routes and has a ‘track of the easiest ways. If 30 minutes all at once seems too much,
your progress’ page to monitor your own fitness then try short bouts in the day, such as 5-10 minutes and try to
build that up over time. We now know that even relatively small
increases in physical activity can contribute to improved health
and quality of life.
CHAPTER 15:
For example: • Swimming – traditional fun for the family and water aerobics
• Leave the car at home for short trips to shops or friends for some. Try to swim a little longer each time and try not to
take too many rests
• Walk to school with the children when you can
• Sport – There are a huge variety of local sports
• Park the car when used, at the far side of a car park opportunities available all of which can confer physical and
mental health benefits for people of all ages and abilities.
• If commuting, get off the train or bus one or two stops For information on local clubs and opportunities see
early to fit in a walk to work http://www.sports-clubs.net/
• Avoid lifts and escalators –use the stairs • Walking football is becoming popular, a new activity for
older people or those who cannot run any more
• Use a standing desk to work from
• Martial arts are popular and improve strength and flexibility
• Get up from a desk to walk across the office to speak to a as well as cardiac fitness
colleague rather than phone or email
• Yoga and Pilates – excellent activities for flexibility,
• Promote and support standing meetings (Standing burns 15 core strength and posture to relieve and prevent many
calories an hour compared to 5 an hour sitting) back problems.
• Have a walking meeting Remember every activity counts.
• Walk and talk whilst on the phone

Barriers, Motivation & Facilitators
• Meet friends for a walk
Studies have shown a range of contributing factors that influence
Around the house many jobs involve activity and can help get how and why people may or may not be physically active. It is
you going: important to understand those factors as there is no one size that
• Cleaning and polishing furniture, floors and windows fits all. Amongst those inhibitors and barriers most commonly
reported are:
• Vacuuming
• Personal issues including ill health, body image,
• Cutting the grass or the hedge embarrassment and lack of confidence
• Brushing the yard or raking up leaves • Structural issues including cost, organisation of local
services, transport and provision of childcare
• Washing and polishing the car by hand
• Environmental issues such as lighting, safety,
• DIY – carpentry, sanding, painting, building etc state of paths, cycleways etc
There are many other activities but most important is finding a • Social factors including family support and social
form of exercise that the individual finds enjoyable, social and interactions
achievable.
These factors will vary from individual to individual and the best
• Walking – walk with a friend or join a walking group. way to identify both specific issues and potential facilitators
http://www.walk4life.info has information on local walks and is through motivational interviewing, goal setting, progress
walking groups for many areas. There are also health walks, monitoring and planning for relapse.
which are short led walks in most local areas
• Cycling – many cycle paths have or are being developed Brief Interventions
across the UK and it is a fun activity for all the family.
http://www.sustrans.org.uk/ncn/map/national-cycle-network There is good evidence of the value and effectiveness of brief
interventions by health professionals in supporting a range of
• Cycle or walk around your local park – getting outside behaviour changes including improving physical activity levels.
and being in green space can help you feel better, there are (NICE, 2014) 13. Even a ‘very brief intervention’ (30 secs to 2
also lots of things to see as well, like wildlife, other people minutes) can prove beneficial if the patient is directed for further
and flowers advice or assistance, which might be anything from information
on local services and opportunities to formal referrals.
• Dance – increasingly popular, enjoyable and social for people
of all ages, genders and abilities
CHAPTER 15:
The Referral Pathway Promoting safe exercise for health
Finally, many health professionals are concerned about

Specialized physiotherapists, cardiac rehabilitation, encouraging physical activity believing that in so doing, they
pulmonary rehabilitation or SEM Consultants Small might harm their patient by worsening their symptoms or
High
numbers of condition. This is often coupled with the individual having
Risk
Patients the same self-belief barrier.
Patients Level 4 gym instructors
Whilst little in life is completely risk free, for most individuals,

Clinician with special interest or level 3 gym
there is good evidence-based guidance to show the health risks
instructor or physiotherapists
of inactivity and/or sedentary behaviour far outweigh the risks of
exercising. People without conditions or symptoms do not require
Local exercise referral schemes
medical clearance before engaging in a low to moderate intensity
Low Large exercise programme. However, people with chronic health
Risk Self-management of exercise with your local gym, numbers of
Patients
conditions or active, uncontrolled or unstable symptoms should
walks, cycle ways, swimming pools and dance etc Patients
consult their GP or healthcare professional prior to commencing
any increase in moderate or vigorous intensity exercise.
In Primary Care across the UK, there are almost 900,000 GP

Absolute Contraindications to referral for exercise 16
consultations daily. 14 The average patient visits their GP about 4
times per year. 15 During these visits there is ample opportunity • Unstable angina
for the GP, practice nurse and health care assistant to promote • Systolic blood pressure 180 and/or diastolic 100 mmHg
exercise as a beneficial lifestyle and as a form of treatment in • BP drop > 20 mmHg demonstrated during an Exercise
many diseases. In Secondary Care, there are many thousands of Tolerance Test
outpatients and inpatient consultations where exercise advice • Resting tachycardia > 100 bpm
should be incorporated into the treatment plan. • Uncontrolled atrial or ventricular arrythmias
• Unstable or acute heart failure
The majority of patients need encouragement towards being
more active through simple guiding techniques of Motivational
Interviewing and straight forward advice on promoting activity There are very few absolute contraindications to exercise and
or taking up exercise. Many patients do not want to go to a these are listed below. They were developed primarily for cardiac
gym, but prefer to participate in walking, cycling, swimming and rehabilitation exercise programmes and their pre-participation
dancing, the advice for which falls comfortably within the role health screening to judge whether their condition is sufficiently
of any health professional. stable to allow for an appropriate level of physical activity.16
As patients present with more complex problems, with one Apart from the absolute contraindications above, there are also
or more co-morbidities, doctors or nurses may prefer to refer a series of relative precautions or contraindications within certain
to Local Exercise Schemes or physiotherapists depending on medical conditions. These largely occur when a few conditions
the conditions and level of risk, for more detailed advice on become unstable and then exercise may become contraindicated
specific exercise plans. However, there is still plenty of simple for a period of time. Conditions which are well controlled will allow
encouragement regarding walking, gardening and housework, the vast majority to remain active.
which can be done in parallel, as any activity provides a valid
health benefit. Whilst pregnancy is a natural process, there are some
complications of pregnancy where women will be advised against
A small number of patients require rehabilitation through exercise and healthcare students should be aware of these.
specialised physiotherapists or high level 4 gym instructors, or In reality, it is nearly always safe to encourage and motivate people
through pulmonary or cardiac rehabilitation units. Assessments to increase their activity through a brief intervention. However,
of these patients may need to be made by Cardiac, Respiratory when referring to an exercise referral scheme, the health care
or, if available, Sport and Exercise Medicine (SEM) consultants. practitioner should ensure the person is stable with none of the
contraindications below.16
CHAPTER 15:
Cancer Contraindications 17 Pregnancy Absolute Contraindications to Moderate-Vigorous

In disease or treatment avoid activities that: Physical Activity (MVPA) in Pregnancy24 , however,
• Require high intensity in patients with low activities of daily living should be continued.
Hb < 8.0g/dl • Severe respiratory diseases ( e.g. COPD,
• Entail an increased risk for bacterial infection restrictive lung disease and cystic fibrosis)
in patients with a low wbc < 0.5 x 109/l • Severe acquired or congenital heart disease
• Involve contact sports if platelets < 50 x 105 with exercise intolerance
• Uncontrolled or severe arrhythmia
CKD Contraindications 18 • Placenta abruption
• Electrolyte abnormalities – especially hypo/ • Vasa previa
hyperkalaemia • Uncontrolled type 1 diabetes
• Recent ECG changes – especially • Intrauterine growth restriction (IUGR)
symptomatic tachyarrhythmias or • Active preterm labour
brady-arrhythmias • Severe pre-eclampsia
• Excess inter-dialytic weight gain >4kg • Cervical insufficiency
since last dialysis session
• Unstable dialysis treatment and Relative Contraindications to MVPA in
titrating medication Pregnancy24 that should be discussed between
• Pulmonary congestion the pregnant woman and her obstetric
• Peripheral oedema healthcare professional
• Mild respiratory disorders
Diabetes Contraindications 19, 20, 21 • Mild congenital or acquired heart disease
• Immediate pre-exercise blood glucose values • Well controlled type 1 diabetes
should be >5 mmol.l-1, but if >14 mmol.l-1, • Mild pre-eclampsia
and in the presence of raised blood ketones, • Preterm premature rupture of membranes
exercise should be delayed until values • Placental previa after 28 weeks
decline and ketones dissipate. • Untreated thyroid disease
• Acute ulceration in patients with diabetic • Symptomatic severe eating disorder
peripheral neuropathy • Multiple nutrient deficiencies and/or
• Vigorous exercise is contraindicated in those chronic undernutrition
with proliferative retinopathy • Moderate-heavy smoking (>20 cigarettes
• Any acute illness or infection in a diabetic. per day) in the presence of comorbidities
Osteoporosis Contraindications 22
• Avoid high impact activities or those with a Disclaimer
high risk of falling
Health professionals are not trained in giving exercise programmes
Asthma Contraindications 21 and this resource is not intended to encourage anyone to go
• Unstable asthma or actively wheezing. beyond their own experience. However, guiding someone to walk,
• In case of acute exacerbation or infection, a swim, cycle or dance is within everyone’s understanding.
break in exercise training is recommended
COPD Contraindications 23
• Pulmonary rehabilitation is not suitable for
people who are unable to walk, who have
unstable angina or who have had a recent
myocardial infarction.
“Take care of your body, it is the

only place you have to live in”
Jim Rohn
Acknowledgements
We are grateful to all of the people who have contributed to
this 2020 edition of this guidebook.
Dr Brian Johnson – Royal College of General Practitioners

Dr Alex Wadley – Birmingham University
Dr Sam Lucas – Birmingham University
Fiona Cunnah – Public Health Division of the Welsh Government
Prof Russ Jago - Bristol University
Dr Charlie Foster – Bristol University
Malcolm Ward – Public Health Wales
Mr Thomas Wilkinson – University of Leicester
Dr Simon Rosenbaum – University of New South Wales
Dr Brendon Stubbs – Kings College London
Dr Richard Bracken – Swansea University
Rachel Churm – Swansea University
Dr Olivia Mccarthy – Swansea University
Aled Rees – Cardiff University
Richard Metcalfe – Swansea University
Prof Stephen Bain – Swansea University
Mr Chris Tuckett - Chartered Society of Physiotherapists
Dr Pascale Kippelen – Brunel University
Mr Lee Romer - Brunel University
Dr Aamer Sandoo - Bangor University
Dr Eleanor Tillet – University College London Hospital
Dr Marlize DeVivo - Canterbury Christ Church University
Dr Hayley Mills – Canterbury Christ Church University
Prof Stephen Rollnick – Cardiff University
Fiona Gillson – Bath University
Anna Lowe – Chartered Society of Physiotherapists
Mr Simon Everitt - Chartered Society of Physiotherapists
Dr James Durrand – Royal College of Anaesthetics
Editorial team:
Mr Andrew Tullo, Elizabeth Johnson and Malcolm Ward.
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Scand J Med Sci Sports. 2015;25 Suppl 3:1-72
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2019-v1.6-FINAL-08Nov2018-wms.pdf 2. Pearse RM, Harrison DA, James P, et al. Identification and
characterisation of the high-risk surgical population in the
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Respiratory Society statement on physical activity in COPD.
Eur Respir J. 2014;44(6):1521-37. 3. Khuri SF, Henderson WG, DePalma RG, et al. Determinants of
long-term survival after major surgery and the adverse effect
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chronic obstructive pulmonary disease. Cochrane Database Sep;242(3):326-341
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PHYSICAL ACTIVITY

A Guide For Health Practitioners

Version 10 – November 2020

“Education is the most powerful weapon which

Motivate2Move would like to thank the the many people

We hope you enjoy reading this guidebook and

Chapter 1 Physical Activity, Exercise and Immune function........................................................8

Chapter 2 Physical Activity Guidelines .................................................................................................11

Chapter 3 Cancer .........................................................................................................................................18

Chapter 4 Cardiovascular Health .......................................................................................................................19

Chapter 5 Chronic Kidney Disease (CKD) ...........................................................................................23

Continues on next page:

Chapter 6 Mental Health.............................................................................................................................25

Chapter 7 Metabolic Health ......................................................................................................................30

• Type 1 Diabetes ...................................................................................................................................32

Chapter 8 Musculoskeletal Health ..........................................................................................................35

Chapter 9 Obesity .........................................................................................................................................38

Continues on next page:

Chapter 10 Pregnancy and the postpartum period ...........................................................................40

Chapter 11 Respiratory Disease ................................................................................................................44

Chapter 12 Perioperative Surgery ............................................................................................................46

Chapter 13 Sedentary Behaviour ..............................................................................................................48

• Part 2: Sedentary Behaviour and Musculoskeletal Disorders ...................................50

Chapter 14 Supporting people to change their health behaviour ...............................................52

Continues on next page:

Chapter 15 Physical Activity and Starting to Get Active .................................................................56

• Chapter 1 Physical Activity, Exercise and Immune Function...............................................................62

Moderate or strong evidence for health benefit

Figure 1: Cumulative health benefits of physical activity across ages.2

• UK physical activity guidelines

Physical Activity, Exercise and

During After Exercise

Other physiological changes with Indirect benefits of exercise

Physical Activity, Exercise and

Physical Activity, Exercise and

World Health Organisation (WHO) -

Requests by countries to the WHO, for guidance and

The plan sets out four strategic objectives and policy

1. Create Active Societies – 4 policy actions

2. Create Active Environments – 5 policy actions

3. Create Active People – 6 policy actions

4. Create Active Systems – 5 policy actions

The target of these is for countries to achieve a

Fig 1 – The WHO Global Action Plan on Physical Activity 2018-30 1

WHO guidelines on physical activity and sedentary behaviour 2020

The 2019 UK Physical Activity Guidelines

Physical activity, in the Under 5s should not be viewed in isolation,

Levels of these behaviours in the pre-school period are closely

Download the Early Years CMO infographic here:

The 2019 UK Physical Activity Guidelines

• However, it is important to remember that any activity is better

Download Adult/Older adult PA Guideline infographic here:

The 2019 UK Physical Activity Guidelines

Older Adults (65+ years)

• Older adults should maintain or improve their physical function

• Each week older adults should aim to accumulate 150 minutes

• Older adults should break up prolonged periods of sitting with

Physical activity during pregnancy and during postpartum