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BACKGROUND About two-thirds of Canadians are physically inactive . As a risk factor for several chronic diseases , physical inactivity can potentially be a substantial public health burden . We estimated the direct health care costs attributable to  physical inactivity  in Canada , the number of lives lost prematurely each year that are attributable to a sedentary lifestyle and the effect that a reduction of 10 % in inactivity levels ( a Canadian objective for 2003 ) could have on reducing direct health care costs . METHODS We calculated summary relative risk ( RR ) estimates from prospect i ve longitudinal studies of the effects of physical inactivity on coronary artery disease , stroke , colon cancer , breast cancer , type 2 diabetes mellitus and osteoporosis . We then computed the population -attributable fraction ( PAF ) for each illness from the summary RR and the prevalence of physical inactivity ( i.e. , 62 % ) and applied the PAF to the total direct health care expenditures for 1999 and to the number of deaths in 1995 associated with each disease to determine the health care costs and lives lost prematurely that were directly attributable to physical inactivity . RESULTS About $ 2.1 billion , or 2.5 % of the total direct health care costs in Canada , were attributable to physical inactivity in 1999 . A sensitivity analysis ( simultaneously varying each of the health care costs and PAF by + /- 20 % ) indicated that the costs could be as low as $ 1.4 billion and as high as $ 3.1 billion . About 21,000 lives were lost prematurely in 1995 because of inactivity . A 10 % reduction in the prevalence of physical inactivity has the potential to reduce direct health care expenditures by $ 150 million a year . INTERPRETATION Physical inactivity represents an important public health burden in Canada . Even modest reductions in inactivity levels could result in substantial cost savings BACKGROUND Physical activity and dietary behavior changes are important to both the primary prevention and secondary management of the majority of our most prevalent chronic conditions ( i.e. , cardiovascular disease , hypertension , type 2 diabetes , breast and colon cancer ) . With over 85 % of Australian adults visiting a general practitioner each year , the general practice setting has enormous potential to facilitate wide scale delivery of health behaviour interventions . However , there are also many barriers to delivery in such setting s , including lack of time , training , re sources and remuneration . Thus there is an important need to evaluate other feasible and effective means of delivering evidence -based physical activity and dietary behaviour programs to patients in primary care , including telephone counseling interventions . METHODS Using a cluster r and omized design with practice as the unit of r and omization , this study evaluated a telephone-delivered intervention for physical activity and dietary change targeting patients with chronic conditions ( type 2 diabetes or hypertension ) recruited from primary care practice s in a socially disadvantaged community in Queensl and , Australia . Ten practice s were r and omly assigned to the telephone intervention or to  usual care  , and 434 patients were recruited . Patients in intervention practice s received a workbook and 18 calls over 12 months . Assessment at baseline , 4- , 12- and 18-months allows for assessment of initial change and maintenance of primary outcomes ( physical activity and dietary behavior change ) and secondary outcomes ( quality of life , cost-effectiveness , support for health behavior change ) . CONCLUSIONS This effectiveness trial adds to the currently limited number of telephone-delivered intervention studies targeting both physical activity and dietary change . It also addresses some of the shortcomings of previous trials by targeting patients from a disadvantaged community , and by including detailed reporting on participant representativeness , intervention implementation and cost-effectiveness , as well as an evaluation of maintenance of health behavior change Cardiovascular disease is the leading cause of death in persons with diabetes mellitus . This disorder affects approximately 16 million Americans , at least 15 million of whom have type 2 diabetes mellitus ( 1 ) . Among diabetic persons , coronary heart disease causes more than 50 % of all deaths and stroke causes an additional 15 % ( 2 ) . Diabetic women are at particularly high risk for cardiovascular disease , and diabetes eliminates the usual female advantage for death from coronary disease . While an inverse association between increased physical activity and lower risk for cardiovascular disease is well established in the general population ( 3 ) , sparse data are available among diabetic persons ( 4 , 5 ) . Intervention studies have shown that exercise increases insulin sensitivity and glucose tolerance and induces favorable changes in blood lipid levels among persons with type 2 diabetes mellitus ( 6 ) . Exercise as an adjunct to diet regimens yields greater and more sustained weight loss in obese patients with type 2 diabetes mellitus ( 7 ) . Even moderately intense exercise , such as walking , improves insulin sensitivity and reduces body weight ( 8) . Because walking is safe and easy , it may provide a promising way to reduce risk for cardiovascular events among diabetic persons . In this study , we examined in detail the relationship between levels of physical activity  and incidence of coronary heart disease and stroke among women with type 2 diabetes mellitus in the Nurses ' Health Study . In particular , we evaluated  walking  ( the most common form of physical activity among diabetic persons ) in relation to cardiovascular events . Methods Study Sample The Nurses ' Health Study cohort was established in 1976 . The original cohort consisted of 121 700 female registered nurses who were 30 to 55 years of age and resided in 11 large U.S. states . The nurses completed a mailed question naire about their medical history and lifestyle , and follow-up question naires administered every 2 years up date information on potential risk factors and identify newly diagnosed cases of coronary heart disease and other illness . Our study includes 5125 women who , on any question naire from 1976 to 1992 , reported having physician-diagnosed diabetes mellitus and being 30 years of age or older at disease onset ( a working definition for type 2 diabetes mellitus ) . Women who reported a history of coronary heart disease ( including myocardial infa rct ion , angina , or coronary revascularization ) , stroke , or cancer on or before the 1980 question naire ( when physical activity was first assessed ) were excluded at baseline . The follow-up rate for nonfatal events was 97 % of the total potential person-years . Confirmation of Diabetes Mellitus A supplementary question naire regarding symptoms , diagnostic tests , and hypoglycemic  therapy was mailed to women who indicated on any biennial question naire that they had received a diagnosis of diabetes . A case of diabetes was considered confirmed if at least one of the following was reported on the supplementary question naire : 1 ) classic symptoms plus a fasting plasma glucose level of at least 140 mg/dL ( 7.8 mmol/L ) or a r and om plasma glucose level of at least 200 mg/dL [ 11.1 mmol/L ] , 2 ) at least two elevated plasma glucose concentrations on different occasions ( a fasting level 140 mg/dL [ 7.8 mmol/L ] or a r and om level 200 mg/dL [ 11.1 mmol/L ] , a concentration 200 mg/dL after 2 hours or more on oral glucose tolerance testing , or both ] in the absence of symptoms , or 3 ) treatment  with hypoglycemic medication ( insulin or an oral hypoglycemic agent ) . The validity of this question naire has been verified in a sub sample of the study cohort ( 9 ) . Of a r and om sample of 84 women classified by the question naire as having type 2 diabetes mellitus , 71 gave permission for their medical records to be review ed ; records were available for 62 of 71 . An endocrinologist blinded to the information on the supplementary question naires review ed the records according to National Diabetes Data Group ( NDDG ) criteria ( 10 ) . The diagnosis of type 2 diabetes mellitus was confirmed in 61 of 62 women ( 98 % ) ( 9 ) . A secondary set of analyses included only women with definite type 2 diabetes mellitus according to the NDDG criteria . We used the NDDG diagnostic criteria because the analytic cohort preceded the American Diabetes Association guideline , which was published in 1997 ( 11 ) . Assessment of Physical Activity Women were first asked about physical activity on the 1980 question naire . They were asked to report the average number of hours they had spent each week during the past year on such moderate and vigorous recreational activities as vigorous sports , jogging , brisk walking or striding , bicycling , heavy gardening , and heavy housework . On the 1982 question naire , women were asked a slightly different question : For how many hours per week , on average , do you engage in activity strenuous enough to build up a sweat ? In 1986 , 1988 , and 1992 , women were asked to report the average time spent per week on the following activities : walking , jogging , running , bicycling , lap swimming , playing tennis or squash , and participating in calisthenics . They were also asked to report the average number of flights of stairs that they climbed each week . Women also reported their usual walking pace : easy ( < 2 miles per hour [ mph ] ) , average ( 2 to 2.9 mph ) , brisk ( 3 to 3.9 mph ) , or very brisk ( 4 mph ) . Because fewer than 2 % of women reported a very brisk pace , we combined the brisk and very brisk categories in analyses of walking pace and diabetes risk . For 1980 , 1982 , 1986 , 1988 , and 1992 , we created a measure of average hours per week spent in moderate or vigorous recreational activities ( all activities described above except for hours spent walking at an easy or average pace ) . For 1986 , 1988 , and 1992 , using a list of physical activities ( 12 ) , we calculated a weekly metabolic equivalent of task ( MET ) score for total physical activities , vigorous activities ( requiring 6 MET/h ) , nonvigorous activities ( requiring<6 MET/h ) , and walking . The validity of the question naire in assessing physical activity has been described elsewhere ( 13 ) . Correlation between activities reported in four 1-week diaries and those reported on the question naire was 0.62 . Ascertainment of End Points The primary end points for this study were incident coronary heart disease ( defined as nonfatal myocardial infa rct ion or fatal coronary heart disease ) and stroke that occurred after the 1980 question naire was returned but before 1 June 1994 . We requested permission to review the medical records of women who reported having a nonfatal myocardial infa rct ion or stroke on a follow-up question naire . Study physicians with no knowledge of the women 's self-reported risk factors review ed the records . Nonfatal myocardial infa rct ion was confirmed if it met the criteria of the World Health Organization of symptoms and the patient 's records showed diagnostic electrocardiographic changes or elevated cardiac enzyme levels ( 14 ) . Infa rct ions that required hospital admission and were confirmed by interview or letter but for which no medical records were available were design ated as probable ( 19 % ) . We included all confirmed and probable cases in the analyses because the results were the same after probable cases were excluded . Stroke was confirmed by medical records according to the criteria of the National Survey of Stroke ( 15 ) , which define it as a constellation of neurologic deficits , sudden or rapid in onset , lasting at least 24 hours . Events were further subclassified as hemorrhagic stroke ( subarachnoid or intraparenchymal ) , ischemic stroke ( thrombotic or embolic ) , or stroke of unknown cause . Deaths were reported by next of kin and the U.S. Postal Service or were ascertained through the National Death Index . After combining all sources , we estimated that follow-up for deaths was more than 98 % complete ( 16 ) . Fatal coronary heart disease was defined as fatal myocardial infa rct ion if confirmed by hospital records or autopsy or if coronary heart disease was listed as the cause of death on the death certificate , was the underlying and most plausible cause , and was supported by evidence of previous coronary heart disease . The cause of death on the death certificate was never in itself considered to provide sufficient confirmation of death from coronary heart disease . We also included sudden death within 1 hour of onset of symptoms in women with no plausible cause other than coronary disease ( 8 % of fatal cases ) . Fatal strokes were coded by using the same criteria as nonfatal cases , but autopsy evidence as well as the death certificate listing was accepted . Statistical Analysis The study base was defined as the pool of person-time that gives rise to incident cases of cardiovascular disease among patients with both prevalent and incident diabetes . We conducted two sets of analyses , one using 1980 as the baseline to evaluate long-term overall effects of moderate or vigorous activities and the other using 1986 as the baseline to examine specific effects of regular walking .  Person-time for each participant was calculated from the date of return of the 1980 or 1986 question naires to the date of confirmed cardiovascular disease , death from any cause , or 1 June 1994 , whichever came first . In the first set of analyses , relative risks were computed as the incidence rate in a specific category of average hours spent on moderate or vigorous activities per week divided by the incidence rate in the lowest category , with adjustment for 5-year categories of age . Tests of linear trend across increasing categories of average hours spent on moderate or vigorous activities were conducted by treating the categories as a single continuous variable and assigning the median score for the category as its value . To best represent long-term levels of physical activity for individual women and to reduce measurement error , we created measures of the cumulative average of physical Background Limited research has examined the association between physical activity , health-related fitness , and disease outcomes in breast cancer survivors . Here , we present the rationale and design of the Alberta Moving Beyond Breast Cancer ( AMBER ) Study , a prospect i ve cohort study design ed specifically to examine the role of physical activity and health-related fitness in breast cancer survivorship from the time of diagnosis and for the balance of life . The AMBER Study will examine the role of physical activity and health-related fitness in facilitating treatment completion , alleviating treatment side effects , hastening recovery after treatments , improving long term quality of life , and reducing the risks of disease recurrence , other chronic diseases , and premature death . Methods / Design The AMBER Study will enroll 1500 newly diagnosed , incident , stage I-IIIc breast cancer survivors in Alberta , Canada over a 5 year period . Assessment s will be made at baseline ( within 90 days of surgery ) , 1 year , and 3 years consisting of objective and self-reported measurements of physical activity , health-related fitness , blood collection , lymphedema , patient-reported outcomes , and determinants of physical activity . A final assessment at 5 years will measure patient-reported data only . The cohort members will be followed for an additional 5 years for disease outcomes . Discussion The AMBER cohort will answer key questions related to physical activity and health-related fitness in breast cancer survivors including : ( 1 ) the independent and interactive associations of physical activity and health-related fitness with disease outcomes ( e.g. , recurrence , breast cancer-specific mortality , overall survival ) , treatment completion rates , symptoms and side effects ( e.g. , pain , lymphedema , fatigue , neuropathy ) , quality of life , and psychosocial functioning ( e.g. , anxiety , depression , self-esteem , happiness ) , ( 2 ) the determinants of physical activity and health-related fitness including demographic , medical , social cognitive , and environmental variables , ( 3 ) the mediators of any observed associations between physical activity , health-related fitness , and health outcomes including biological , functional , and psychosocial , and ( 4 ) the moderators of any observed associations including demographic , medical , and biological/disease factors . Taken together , these data will provide a comprehensive inquiry into the outcomes , determinants , mechanisms , and moderators of physical activity and health-related fitness in breast cancer survivors Abstract The study aim ed to investigate whether meeting leisure time physical activity recommendations was associated with reduced incident and fatal cancer or cardiovascular disease ( CVD )  in a community-based cohort of middle- to late-aged adults with long-term follow-up . At baseline , 2,320 individuals were assessed on a large number of lifestyle and clinical parameters including their level of physical activity  per week , other risk factors ( e.g. smoking and alcohol use ) various anthropometric measures , blood tests and medical history . Individuals were linked to hospital and mortality registry data to identify future cancer and cardiovascular events ( fatal and non-fatal ) out to 15 years of follow-up . Cox regression analyses adjusted for relevant confounders identified a priori were used to estimate risk for all-cause , cancer-specific and CVD-specific mortality . In the full cohort an estimated 21 % decreased risk for all-cause mortality ( HR 0.79 ; 95 % CI 0.66–0.96 ) and 22 % decreased risk for fatal/non-fatal CVD events ( HR 0.78 ; 95 % CI 0.66–0.92 ) was associated with baseline self-reported physical activity levels of 150 min or more . After exclusion of those with chronic co-morbidities ( CVD , cancer , diabetes , chronic obstructive pulmonary disease , hypertension treatment ) at baseline , lower risk for fatal/non-fatal CVD events remained significantly associated with 150 min or more of physical activity ( HR 0.77 ; 95 % CI 0.62–0.96 ) . Results from this well established prospect i ve community-based cohort study support the role of leisure time physical activity in reducing all-cause mortality and CVD events ( fatal/nonfatal ) in the broader population studied . The data also suggest that physical activity associated reductions in risk for CVD events ( fatal/nonfatal ) were not overly impacted by prevalent key non-communicable diseases OBJECTIVE To ascertain the relationship of physical inactivity and short-term all-cause mortality in a prospect i ve cohort of r and omly selected managed care organization members aged 40 years and older who have multiple chronic diseases . METHODS Clinical data bases were used to identify all health plan members aged 40 years and older with 2 or more chronic health conditions ( hypertension , coronary heart disease , diabetes mellitus , or dyslipemia ) in 1994 . A r and om sample of 2336 members was surveyed by mail and telephone interview regarding their health-related behaviors .  Survey data were linked to mortality data from the 1995 to 1997 Minnesota Death Index . Cox proportional hazards regression was used to ascertain the association between physical inactivity and subsequent all-cause mortality , adjusting for potential confounders . RESULTS Members who reported less than 30 minutes a week of physical activity at baseline had a subsequent mortality risk ratio of 2.82 ( P<.001 ) vs those with 30 or more minutes of physical activity a week . Increased mortality risk persisted ( mortality risk ratio , 2.15 ; P<.001 ) after adjustments for age , sex , current smoking , functional impairment , and comorbidity score . CONCLUSIONS In adults with chronic diseases , the physically inactive had higher observed mortality within a 42-month period . If physical inactivity reflects an independent mortality risk , efforts to maintain physical activity in such patients may yield significant clinical benefits within a short period . By contrast , if inactivity is primarily a proxy for other factors that elevate mortality risks , a simple physician inquiry regarding inactivity may help to identify patients at risk of death Background / Aims : Although the effect of exercise on health is well established , nephrologists seldom consider physical activity in the treatment of chronic kidney disease ( CKD ) or CKD in the presence of diabetes mellitus ( DM/CKD ) . The aim of the present study was to analyze the benefits of leisure-time physical activity ( LTPA ) in DM/CKD . Methods : A total of 445,075 adult participants who underwent a medical screening program between 1996 and 2008 were prospect ively recruited . Of these , 7,863 DM/CKD subjects were identified . Each participant was categorized according to  LTPA level ( a product of duration and intensity ) as inactive , low-active or fully active .  Hazard ratios ( HRs ) for mortality risk were calculated . Results : Fully active LTPA was associated with lower odds of DM/CKD development and lower risk of mortality among patients with DM/CKD in a dose-response relationship . The fully active and low-active DM/CKD groups had a 26 % ( HR 0.74 , 95 % CI 0.66 - 0.85 ) and 13 % ( HR 0.87 , 95 % CI 0.75 - 1.01 ) lower risk of all-cause mortality , respectively , in comparison to the inactive group . The association of exercise with mortality rate reduction was more pronounced among DM/CKD subjects ( mortality rate reduction of 446.5 per 100,000 person-years ) than among subjects with diabetes alone or CKD alone . Conclusion : Exercise , at the recommended level or more , is associated not only with lower odds of DM/CKD but also with a 26 % lower mortality risk among DM/CKD patients . Nephrologists should encourage all DM/CKD subjects to be physically active Exercise has become a st and ard therapy for patients with type 2 diabetes ( 1 ) . Regular exercise improves conventional clinical risk factors , cardiorespiratory fitness , and components of the insulin resistance syndrome ( 2 - 6 ) . However , it is unclear whether physical activity improves the prognosis of patients with diabetes . No data are available on the association of physical activity or cardiorespiratory fitness with mortality in patients with diabetes . The overall benefit of exercise for these patients is unclear , and some experts are concerned that macrovascular and microvascular complications may be worsened by an exercise program ( 1 , 7 ) . Some consider exercise only as a supplement to diet therapy ( 8) . Studies have shown repeatedly that low cardiorespiratory fitness and physical inactivity are directly associated with cardiovascular disease and all-cause mortality ( 9 - 14 ) , and our preliminary study with a small number of end points suggested that this association might persist across plasma glucose levels ( 15 ) . In the current study , we evaluated the prospect i ve association of cardiorespiratory fitness and physical inactivity with mortality in men who have type 2 diabetes . Methods The material presented in this report was derived from the Aerobics Center Longitudinal Study ( ACLS ) , a prospect i ve observational study of patients examined at The Cooper Clinic in Dallas , Texas . The study was review ed and approved annually by the institutional review board at The Cooper Institute . Additional details of study methods and study group characteristics of this cohort have been published elsewhere ( 12 , 13 ) . Patients Participants were men with type 2 diabetes who completed a baseline medical evaluation at The Cooper Clinic in Dallas , Texas , during 1970 to 1993 . These men came to The Cooper Clinic for a medical examination and health counseling . Many were sent by their employers for these services , some were referred by their personal physicians , and others were self-referred . More than 92 % of the patients are white , and most are employed in executive or professional occupations ; more than 75 % are college graduates . Study participants come from middle and upper socioeconomic strata , but they are similar to other well-characterized study group-based cohorts in terms of blood pressure , cholesterol level , body weight , and cardiorespiratory fitness ( 6 , 16 , 17 ) . We excluded men taking insulin and those with a history of cancer at baseline . Clinical Examination The baseline evaluation was performed after participants gave informed written consent for the baseline medical examination and registration in the follow-up study . Examinations followed an overnight fast of at least 12 hours and included personal and family health histories , a question naire on demographic characteristics and health habits , a physical examination , a maximal exercise test on a treadmill , anthropometry , electrocardiography , blood chemistry analyses , and blood pressure measurement . Technicians who followed a st and ard manual of operations administered all procedures . Question naire Patients completed an extensive self-report of personal and family medical diseases and conditions . Each clinic physician examines only four or five patients per day and thus has time for thorough additional probing of items on the self-reported question naire . This complete review of the patient 's medical history and the subsequent physical examination are strengths of the ACLS and provide a more thorough evaluation of baseline health status than is possible in many epidemiologic studies . The question naire also featured items on health habits , including current smoking status and smoking history and whether the participant was currently dieting to lose weight or following any other special dietary plan . Physical activity pattern was ascertained by self-report on the question naire . An extensive list of leisure-time physical activities was presented , and participants indicated activities in which they had participated in the 3 months before the examination . In later study years , they gave additional details on the number of times per week and the duration of exercise sessions . Laboratory Evaluations Cardiorespiratory fitness was assessed by using a maximal exercise test that followed a modified version of Balke and Ware 's protocol ( 18 ) . Briefly , the test began with the participant walking on a horizontal treadmill at 88 m/min . After the first minute , the elevation increased to 2 % , and it further increased 1 % each minute up to 25 minutes . For the few patients who were still able to continue , the elevation was held constant after 25 minutes and the speed increased to 5.4 m/min until the participant reached volitional fatigue . Exercise test performance with this protocol correlates highly with measured maximal oxygen uptake ( r=0.92 ) ( 19 ) . Serum sample s were analyzed by using automated techniques in a laboratory that participates in and meets the quality control st and ards of the Centers for Disease Control and Prevention Lipid St and ardization Program . Blood pressure was measured by auscultatory methods with a mercury sphygmomanometer according to American Heart Association guidelines ( 20 ) . The lowest of three blood pressure measurements at the clinic examination was recorded as the baseline blood pressure . Height and weight were measured by using a st and ard beam-balance scale and stadiometer , and body mass index was calculated . Type 2 Diabetes Diabetes was defined according to criteria of the American Diabetes Association : fasting plasma glucose level of 7.0 mmol/L or greater ( 126 mg/dL ) ( 21 ) . Three hundred seventy patients who did not meet this criterion but who gave a history of physician-diagnosed diabetes were considered to have diabetes . Patients were classified as having known diabetes or unknown diabetes according to their diabetes status before the baseline Cooper Clinic examination . Definition of Exposure Variables The principal exposure variables used in our analyses were  cardiorespiratory fitness and self-reported physical activity .  These exposures were determined at the baseline examination . Cardiorespiratory Fitness  We categorized  total time from the maximal exercise test into frequency distributions for specific age groups ( 30 to 39 , 40 to 49 , 50 to 59 , and 60 years ) . The least fit 20 % of the participants in each age group were classified as low fit , the next 40 % of the distribution as moderately fit , and the highest 40 % as high fit . We have used these cut-points to define fitness in previous studies ( 12 , 13 ) , and they are based on our entire cohort rather than on diabetic patients only . We selected these cut-points before undertaking the current analysis . Cardiorespiratory fitness is expressed as maximal metabolic units ( METs ) attained during the exercise test . The METs are calculated as the working metabolic rate divided by the resting metabolic rate , and 1 MET is equivalent to an oxygen uptake of 3.5 mL1 kg 1 . Physical Activity Patients who reported walking , jogging , or participating in aerobic exercise programs in the 3 months before the examination were classified as active , regardless of the frequency and duration of exercise . Otherwise , patients were classified as inactive . In our cohort , more than 76 % of men who reported being active at baseline still reported being active at the second visit after more than 1 year . In comparison , only 34 % of men who reported being inactive at baseline reported being active at the second examination ( P<0.001 ) . Self-reported physical activity status in our cohort is correlated with maximal exercise test performance ( 6 , 22 ) . Baseline or Parental Cardiovascular Disease We defined baseline cardiovascular disease as a personal history of heart attack , stroke , or a revascularization procedure ; an abnormal resting or exercise electrocardiogram ; or the highest heart rate during exercise testing that was less than 85 % of the age-predicted maximal heart rate ( [ 220 age in years ] 0.85 ) . Men who reported a history of cardiovascular disease in either parent were classified as having parental cardiovascular disease . Conventional Cardiovascular Disease Risk Factors We assigned men to risk strata for conventional cardiovascular disease risk factors on the basis of recent recommendations ( 23 ) . We defined high blood pressure as systolic blood pressure of 140 mm Hg or more , diastolic blood pressure of 90 mm Hg or more , or a history of physician-diagnosed hypertension . We classified participants with a total cholesterol level of 6.2 mmol/L ( 240 mg/dL ) or more as having high cholesterol , those with self-reported current smoking as current smokers , those with a self-reported parental history of myocardial infa rct ion or stroke as having a history of parental cardiovascular disease , those with a body mass index less than 25.0 kg/m2 as normal weight , and those with a body mass index of 25.0 kg/m2 or more as overweight . Statistical Analysis Our primary outcome measure was all-cause mortality . We used the National Death Index to identify  decedents in the ACLS . The National Death Index has been shown to be an effective , accurate means of ascertaining deaths in the general population , with a sensitivity of about 96 % and a specificity of 100 % ( 24 ) . We obtained official death certificates from states in which there were ACLS decedents , and we had the certificates coded by a nosologist according to the International Classification of Diseases , Ninth Revision . Only the underlying cause of death was used in analyses for this report . Data were analyzed by using the SAS statistical package ( SAS Institute , Inc. , Cary , North Carolina ) . The analyses assumed that physical activity and fitness were essentially unchanged during the study period . We used survival curves to estimate survival function against time and log [ log ( survival time ) ] to check the proportional hazards model assumption . Log [ log ( survival function ) ] estimates were approximately parallel across exposure Background  Physical activity levels among breast cancer survivors are typically low , and knowledge of the correlates of increased physical activity among cancer survivors is limited . The purpose of this study was to examine factors that are associated with physical activity or inactivity among breast cancer survivors . Methods Data from 3088 women participating in the Women ’s Healthy Eating and Living ( WHEL ) Study , collected prior to r and omization , were the focus of the current analyses . Self-reports of physical activity levels , quality of life , depression , and dietary intakes  were collected . Pearson correlation analyses were employed to examine the associations among these variables , and multiple regression analyses were performed to examine the relationship between selected health behaviors and physical activity levels , after controlling for demographic , breast cancer-related , and psychosocial variables . Results Demographic and psychosocial variables were related to physical activity levels ( P < 0.001 for all ) . Cancer treatment type and cancer stage were correlated with survivors ’ physical activity levels ( P < 0.01 ) , but the associations were no longer significant after controlling for demographic variables . Physical activity levels were strongly associated with other health behaviors , especially dietary intakes ( P < 0.001 ) , even after controlling for demographic , cancer-related , and psychosocial factors . Conclusion Low physical activity  levels in breast cancer survivors are associated with specific behavioral and other factors , which can be considered as indicators of women at higher risk . Findings of significant differences in  physical activity levels based on demographic characteristics suggest the importance of promoting physical activity particularly among breast cancer survivors of ethnic minority or lower education levels BACKGROUND Prolonged sitting is considered detrimental to health , but evidence regarding the independent relationship of total sitting time with all-cause mortality is limited . This study aim ed to determine the independent relationship of sitting time with all-cause mortality . METHODS We linked prospect i ve question naire data from 222 497 individuals 45 years or older from the 45 and Up Study to mortality data from the New South Wales Registry of Births , Deaths , and Marriages ( Australia ) from February 1 , 2006 , through December 31 , 2010 . Cox proportional hazards models examined all-cause mortality in relation to sitting time , adjusting for potential confounders that included sex , age , education , urban/rural residence , physical activity , body mass index , smoking status , self-rated health , and disability . RESULTS During 621 695 person-years of follow-up ( mean follow-up , 2.8 years ) , 5405 deaths were registered . All-cause mortality hazard ratios were 1.02 ( 95 % CI , 0.95 - 1.09 ) , 1.15 ( 1.06 - 1.25 ) , and 1.40 ( 1.27 - 1.55 ) for 4 to less than 8 , 8 to less than 11 , and 11 or more h/d of sitting , respectively , compared with less than 4 h/d , adjusting for physical activity and other confounders . The population -attributable fraction for sitting was 6.9 % . The association between sitting and all-cause mortality appeared consistent across the sexes , age groups , body mass index categories , and physical activity levels and across healthy participants compared with participants with preexisting cardiovascular disease or diabetes mellitus . CONCLUSIONS Prolonged sitting is a risk factor for all-cause mortality , independent of physical activity . Public health programs should focus on reducing sitting time in addition to increasing physical activity levels PURPOSE Although moderate-to-vigorous physical activity is related to premature mortality , the relationship between sedentary behaviors and mortality has not been fully explored and may represent a different paradigm than that associated with lack of exercise . We prospect ively examined  sitting time  and mortality in a representative sample of 17,013 Canadians 18 - 90 yr of age . METHODS Evaluation of  daily sitting time  ( almost none of the time , one fourth of the time , half of the time , three fourths of the time , almost all of the time ) ,  leisure time physical activity , smoking status , and alcohol consumption  was conducted at baseline . Participants were followed prospect ively for an average of 12.0 yr for the ascertainment of mortality status . RESULTS There were 1832 deaths  ( 759 of cardiovascular disease ( CVD ) and 547 of cancer ) during 204,732 person-yr of follow-up . After adjustment for potential confounders , there was a progressively higher risk of mortality across higher levels of sitting time from all causes ( hazard ratios ( HR ) : 1.00 , 1.00 , 1.11 , 1.36 , 1.54 ; P for trend < 0.0001 ) and CVD ( HR:1.00 , 1.01 , 1.22 , 1.47 , 1.54 ; P for trend < 0.0001 ) but not cancer . Similar results were obtained when stratified by sex , age , smoking status , and body mass index . Age-adjusted all-cause mortality rates per 10,000 person-yr of follow-up were 87 , 86 , 105 , 130 , and 161 ( P for trend < 0.0001 ) in physically inactive participants and 75 , 69 , 76 , 98 , 105 ( P for trend = 0.008 ) in active participants across sitting time categories . CONCLUSIONS These data demonstrate a dose-response association between  sitting time  and mortality from all causes and CVD , independent of leisure time physical activity . In addition to the promotion of moderate-to-vigorous physical activity and a healthy weight , physicians should discourage sitting for extended periods Background The purpose of this study was to describe the associations between different levels of long-term physical activity in leisure time and subsequent causes of deaths . Design The Copenhagen City Heart Study is a prospect i ve cardiovascular population study of 19 329 men and women aged 20–93 in 1976 .  Physical activity in leisure time was estimated at the examinations in 1976–78 and 1981–83 . This analysis consists of 2136 healthy men and 2758 women aged 20–79 years , with unchanged physical activity at the two examinations , and with all covariates included in the multivariate analyses : smoking , total-cholesterol , high-density lipoprotein-cholesterol , systolic blood pressure , diabetes mellitus , alcohol consumption , body mass index , education , income , and forced expiratory volume in 10.78 ( % predicted ) . Results Adjusted relative risks ( 95 % confidence interval ) for coronary heart disease were , for moderate physical activity 0.71 ( 0.51 , 0.99 ) and for high 0.56 ( 0.38 , 0.82 ) . For cancer , moderate activity 0.77 ( 0.61 , 0.97 ) and high activity 0.73 ( 0.56 , 0.95 ) and for all-cause mortality , moderate 0.78 ( 0.68 , 0.89 ) and high 0.75 ( 0.64 , 0.87 ) for both sexes combined . Using Kaplan — Meier plots we calculated gained years of expected lifetime from age 50 . Men with high physical activity  survived 6.8 years longer , and men with moderate physical activity 4.9 years longer than sedentary men . For women the figures were 6.4 and 5.5 years , respectively . Conclusion Long-term  moderate or high physical activity  was in both sexes associated with significantly lower mortality from coronary heart disease , cancer and all-causes . The same tendency was found for stroke and respiratory diseases , but the associations did not reach statistical significance . Eur J Cardiovasc Prev Rehabil 13:173–179 © 2006 The European Society of BACKGROUND AND OBJECTIVE Physical inactivity and an unhealthy diet have been implicated as risk factors for several chronic diseases that are known to be associated with periodontitis , such as cardiovascular diseases , obesity and diabetes . Studies investigating the relationship between periodontitis and physical activity and diet are limited . Therefore , this study was conducted to determine the relationship between physical activity , healthy eating habits and periodontal health status . MATERIAL AND METHODS A systematic r and om sample of 340 persons , 18 - 70 years of age , was selected from persons accompanying their relative patients who attended the outpatient clinics in the medical center of Jordan University of Science and Technology in north of Jordan . Data collected included socio-demographic and clinical characteristics , anthropometric measurements , physical activity level and dietary assessment . RESULTS Individuals who were highly physically active had a significantly lower average plaque index , average gingival index , average clinical attachment loss ( CAL ) and percentage of sites with CAL ≥ 3 mm compared to individuals with a low level of physical activity and individuals with a moderate level of physical activity . Those who had a poor diet had a significantly higher average number of missing teeth and an average CAL compared with those who had a good diet . In the multivariate analysis , a low level of physical activity and a poor diet ( diets with a healthy eating index score of < 50 points ) were significantly associated with increased odds of periodontitis . CONCLUSIONS A low physical activity level and a poor diet were significantly associated with increased odds of periodontal disease . Further studies are needed to underst and this relationship in greater detail Context Previous studies have examined the association between coffee consumption and a variety of specific diseases , such as type 2 diabetes , different types of cancer , and cardiovascular disease . However , the relationship between coffee consumption and all-cause mortality remains unclear . Contribution This study followed 2 large cohorts of men and women who provided data on coffee consumption , other behaviors , and health outcomes every 2 to 4 years over 2 decades . High coffee consumption was not related to increased mortality and may even be associated with lower total and cardiovascular mortality . Caution Misclassification of coffee consumption or confounding by other behavioral factors may account for these observations . The Editors Several epidemiologic studies have examined coffee consumption and risk for coronary heart disease and other chronic diseases , but data on coffee consumption in relation to all-cause and disease-specific mortality are sparse . Some studies found that those who drank coffee were the healthiest cohort members ( 15 ) , an inverse association that has been attributed to a possible confounding effect by morbidity . However , it has recently been suggested that the inverse association between coffee and all-cause mortality is attributable to the beneficial effect of coffee consumption on inflammation ( 6 ) . The Appendix Table lists the previous studies that have examined coffee consumption and the risk for mortality by different causes . Appendix Table . Cohort Studies Addressing the Association between  Coffee Consumption and All-Cause and Disease-Specific Mortality  In support of this hypothesis , we found in a previous study an inverse association between  coffee consumption and several markers of inflammation and endothelial dysfunction ( 7 ) . In addition , in the NHS ( Nurses ' Health Study ) and HPFS ( Health Professionals Follow-up Study ) , consumption of 6 or more cups of coffee per day was associated with a slightly lower risk for fatal coronary heart disease versus nonconsumers in both men and women ( 8) . Moreover , epidemiologic studies have consistently found an association between higher coffee consumption and lower risk for type 2 diabetes ( 9 ) . Finally , several studies have suggested that coffee might decrease the risk for some types of cancer , such as liver , colon , oral , pharyngeal , and esophageal ( 1012 ) . The objective of this study was to assess the association of  coffee consumption with all-cause , cardiovascular disease ( CVD ) , and cancer mortality . The long follow-up and the use of repeated dietary measurements allowed us to assess long-term coffee consumption . In addition , information about incident diseases during the follow-up and up date d measurements of main risk factors for CVD and cancer allowed us to control for potential confounders in detail . Methods Study Population The HPFS was established in 1986 and the NHS in 1976 . Information ( excluding diet ) on the cohort members has been up date d every 2 years . Further details have been published elsewhere ( 13 ) . We used 1980 as baseline for the NHS because this was the first year in which dietary information was collected in this cohort . After excluding participants with CVD or cancer at baseline or those with no information about coffee consumption at baseline ( 1183 persons in the HPFS and 879 in the NHS ) , we included 41736 men and 86214 women who were followed until 2004 . The Harvard School of Public Health and Brigham and Women 's Hospital Human Subjects Committee Review Board approved the study protocol . Assessment of  Coffee Consumption  Dietary question naires were sent to the HPFS participants in 1986 , 1990 , 1994 , and 1998 and to the NHS participants in 1980 , 1984 , 1986 , 1990 , 1994 , and 1998 . In each question naire , participants were asked how often on average during the previous year they had consumed coffee and tea . The participants could choose from 9 responses .  Decaffeinated coffee and different types of caffeinated soft drinks  were first assessed in 1986 in the HPFS and in 1984 in the NHS . We also inquired at baseline about whether the participant 's consumption for each beverage had greatly increased or decreased during the preceding 10 years . Using the U.S. Department of Agriculture food composition sources supplemented with other sources , we estimated that the caffeine content was 137 mg per cup of coffee , 47 mg per cup of tea , 46 mg per can or 12-ounce bottle of a soft drink , and 7 mg per 1-ounce serving of chocolate c and y. We assessed the total intake of caffeine by summing the caffeine content for a unit of each food during the previous year multiplied by a weight proportional to the frequency of its consumption . In our validation study , we obtained high correlations between consumption of coffee and other caffeinated beverages estimated from the food frequency question naire and consumption estimated from repeated 1-week diet records ( coffee , r= 0.78 ; tea , r= 0.93 ; and caffeinated soft drinks , r= 0.85 ) ( 14 ) . Ascertainment of Mortality Deaths were reported by the next of kin or the postal authorities or were ascertained through the National Death Index . We estimated that follow-up for deaths was more than 98 % complete ( 15 ) . For all deaths , we sought death certificates and , when appropriate , requested permission from the next of kin to review medical records . The underlying cause of death was assigned according to the International Classification of Diseases , Eighth Revision ( ICD-8 ) . The primary end point in this analysis was death from any cause . We also conducted analyses according to the main causes of deaths in the cohorts , which were CVD ( ICD-8 codes 390.0 through 458.9 and 795.0 to 795.9 ) and cancer ( ICD-8 codes 140.0 through 207.9 ) , and according to secondary causes of death , such as chronic liver disease and cirrhosis ( ICD-8 code 571.0 ) , chronic obstructive pulmonary disease ( ICD-8 codes 492.0 , 496.0 , and 519.0 ) , diabetes ( ICD-8 codes 250.0 , 250.1 , and 250.9 ) , neurodegenerative diseases ( ICD-8 codes 331.0 and 332.0 ) , and sudden death ( ICD-8 code 798.0 ) . Assessment of Medical History , Anthropometric Data , and Lifestyle Factors In the baseline question naires , we requested information about age ; weight and height ; smoking status ; parental history with respect to myocardial infa rct ion ; menopausal status and use of hormone therapy in women ; and history of hypertension , hypercholesterolemia , and type 2 diabetes mellitus . We up date d this information , with the exception of height and parental history , in the biennial follow-up question naires . We assessed perceived health in 2000 by asking the participants to describe their health as excellent , very good , good , fair , or poor . We calculated body mass index , and we also assessed physical activity biennially . In the HPFS , participants were queried about the average time spent per week during the preceding year in specific activities ( for example , walking outdoors , jogging , and bicycling ) ( 16 ) . The time spent in each activity in hours per week was multiplied by its typical energy expenditure , expressed in metabolic equivalent tasks and then summed over all activities to yield a metabolic equivalent task or hour score . In the NHS , physical activity was reported in hours per week of moderate ( for example , brisk walking ) and vigorous exercise ( for example , strenuous sports and jogging ) ( 17 ) . St and ard portion sizes for alcoholic drinks were specified as a can , bottle , or glass for beer ; 4-oz glass for wine ; and 1 drink or shot for liquor . Detailed information on the validity and reproducibility of the information from the question naires about self-reported weight , physical activity , and alcohol consumption has been reported elsewhere ( 1820 ) . Statistical Analysis We classified participants according to levels of coffee consumption . We calculated person-years of exposure from the date of return of the baseline question naire to the date of death or 1 June 2004 , whichever came first . To reduce within-participant variation and best represent long-term diet , we used the cumulative average of coffee consumption from all available dietary question naires up to the start of each 2-year follow-up interval ( 21 ) ; for example , in the HPFS , the average of the 1986 and 1990 intake was used for the follow-up between 1990 and 1994 ; and the average of the 1986 , 1990 , and 1994 intake was used for the follow-up between 1994 and 1998 . When a food frequency question naire had a missing value for coffee , we used the value from the previous question naire . We used sex-specific Cox proportional hazard models to investigate the association between coffee consumption and incidence of all-cause and disease-specific mortality . To control as finely as possible for confounding by age and calendar time , we stratified the analysis jointly by age in months at start of follow-up and calendar year of the current question naire cycle . We used hazard ratios to estimate relative risks in each category in comparison with participants in the lower category of coffee consumption . We adjusted multivariable models for smoking status , body mass index , physical activity , alcohol intake , use of hormone therapy for women , parental history of myocardial infa rct ion , and dietary factors ( total energy intake ; use of multivitamin and vitamin E supplements ; polyunsaturated , saturated , n-3 , and trans fat intake ; glycemic load ; and folic acid intake ) by using categorical variables . To test for linear trends across categories , we modeled coffee consumption as a continuous variable by using the median value of each level of coffee consumption . In addition , we calculated pooled relative risks for all-cause mortality in men and women combined across categories of coffee consumption by using a r and om-effects method . We also examined a possible nonlinear relation between coffee consumption and total and cardiovascular mortality nonparametrically with restricted cubic splines ( 22 ) . We conducted stratified analyses according to smoking status , alcohol Background / objectives Walking pace is associated with risk of premature mortality . However , whether this relationship is independent of total volume of physical activity and highest physical activity intensity remains unclear . We examined the associations between  walking pace  and cause-specific mortality , investigating the potential modifying effect of factors such as total physical activity volume , highest physical activity intensity , age , sex and body mass index ( BMI ) . Methods Prospect i ve pooled analysis of 11 population -based baseline surveys in Engl and and Scotl and between 1994 and 2008 that were linked with mortality records . Multivariate-adjusted Cox proportional hazards models examined associations between  walking pace  ( slow , average , brisk/fast ) and all-cause , cancer and cardiovascular disease ( CVD ) mortality . Results 50 225 walkers were entered in the core analyses . Among participants who did not experience an event in the first 2 years of follow-up ( n=49 731 ) , walking at an average or brisk/fast pace was associated with a reduced risk of all-cause ( 20 % ( 95 % CI 12 % to 28 % ) and 24 % ( 95 % CI 13 % to 33 % ) , respectively ) and CVD mortality ( 24 % ( 95 % CI 9 % to 36 % ) and 21 % ( 95 % CI 1 % to 38 % ) , respectively ) , compared with reporting walking at a slow pace . In stratified analyses , such associations were evident among those over 50 years , those not meeting the physical activity recommendations and those who did not undertake vigorous-intensity activity . There were no interactions by sex or BMI . No associations were seen between pace and cancer mortality . Conclusion Walking benefits health . Assuming causality , these analyses suggest that increasing walking pace could reduce risk for all-cause and CVD mortality .  Walking pace could be emphasised in public health messages , especially in situations when increase in walking volume or frequency is less feasible BACKGROUND Prospect i ve studies suggested that substituting whole-grain products for refined-grain products lowers the risks of type 2 diabetes and cardiovascular disease ( CVD ) in women . Although breakfast cereals are a major source of whole and refined grains , little is known about their direct association with the risk of premature mortality . OBJECTIVE We prospect ively evaluated the association between whole- and refined-grain breakfast cereal intakes and total and CVD-specific mortality in a cohort of US men . DESIGN We examined 86,190 US male physicians aged 40 - 84 y in 1982 who were free of known CVD and cancer at baseline . RESULTS During 5.5 y , we documented 3114 deaths from all causes , including 1381 due to  CVD  ( 488 myocardial infa rct ions and 146 strokes ) . Whole-grain breakfast cereal intake was inversely associated with total and CVD-specific mortality , independent of age ; body mass index ; smoking ; alcohol intake ; physical activity ; history of diabetes , hypertension , or high cholesterol ; and use of multivitamins . Compared with men who rarely or never consumed whole-grain cereal , men in the highest category of whole-grain cereal intake ( > or = 1 serving/d ) had multivariate-estimated relative risks of total and CVD-specific mortality of 0.83 ( 95 % CI : 0.73 , 0.94 ; P for trend < 0.001 ) and 0.80 ( 0.66 , 0.97 ; P for trend < 0.001 ) , respectively . In contrast , total and refined-grain breakfast cereal intakes were not significantly associated with total and CVD-specific mortality . These findings persisted in analyses stratified by history of type 2 diabetes , hypertension , and high cholesterol . CONCLUSIONS Both total mortality and CVD-specific mortality were inversely associated with whole-grain but not refined-grain breakfast cereal intake . These prospect i ve data highlight the importance of distinguishing whole-grain from refined-grain cereals in the prevention of chronic diseases BACKGROUND AND PURPOSE Physical activity reduces the risk of premature death and cardiovascular disease , but the relationship to stroke is less well studied . The objective of this study was to investigate the association between leisure-time physical activity and  ischemic stroke in an urban , elderly , multiethnic population . METHODS The Northern Manhattan Stroke Study is a population -based incidence and case-control study . Case subjects had first ischemic stroke , and control subjects were derived through r and om-digit dialing with 1:2 matching for age , sex , and race/ethnicity .  Physical activity  was recorded through a st and ardized in-person interview regarding the frequency and duration of 14 activities over the 2 prior weeks . Conditional logistic regression was used to calculate odds ratios ( OR ) and 95 % confidence intervals after adjustment for medical and socioeconomic confounders . RESULTS Over 30 months , 369 case subjects and 678 control subjects were enrolled . Mean age was 69.9 + /- 12 years ; 57 % were women , 18 % whites , 30 % blacks , and 52 % Hispanics .  Leisure-time physical activity  was significantly protective for stroke after adjustment for cardiac disease , peripheral vascular disease , hypertension , diabetes , smoking , alcohol use , obesity , medical reasons for limited activity , education , and season of enrollment ( OR = 0.37 ; 95 % confidence interval=0.25 to 0.55 ) . The protective effect of  physical activity  was detected in both younger and older groups , in men and women , and in whites , blacks , and Hispanics . A dose-response relationship was shown for both intensity ( light-moderate activity OR = 0.39 ; heavy OR = 0.23 ) and duration ( < 2 h/wk OR = 0.42 ; 2 to < 5 h/wk OR = 0.35 ; > or = 5 h/wk OR = 0.31 ) of physical activity . CONCLUSIONS Leisure-time physical activity was related to a decreased occurrence of ischemic stroke in our elderly , multiethnic , urban subjects . More emphasis on physical activity in stroke prevention campaigns is needed among the elderly IMPORTANCE Few studies have examined how different proportions of moderate and vigorous physical activity affect health outcomes . OBJECTIVE To examine whether the proportion of total moderate to vigorous activity ( MVPA ) that is achieved through vigorous activity is associated with all-cause mortality independently of the total amount of MVPA . DESIGN , SETTING , AND PARTICIPANTS We performed a prospect i ve cohort study with activity data linked to all-cause mortality data from February 1 , 2006 , through June 15 , 2014 , in 204,542 adults aged 45 through 75 years from the 45 and Up population -based cohort study from New South Wales , Australia ( mean [ SD ] follow-up , 6.52 [ 1.23 ] years ) . Associations between different contributions of vigorous activity to total MVPA and mortality were examined using Cox proportional hazards models , adjusted for total MVPA and sociodemographic and health covariates . EXPOSURES Different proportions of total MVPA as vigorous activity . Physical activity was measured with the Active Australia Survey . MAIN OUTCOMES AND MEASURES All-cause mortality during the follow-up period . RESULTS During 1,444,927 person-years of follow-up , 7435 deaths were registered . Compared with those who reported no MVPA ( crude death rate , 8.34 % ) , the adjusted hazard ratios for all-cause mortality were 0.66 ( 95 % CI , 0.61 - 0.71 ; crude death rate , 4.81 % ) , 0.53 ( 95 % CI , 0.48 - 0.57 ; crude death rate , 3.17 % ) , and 0.46 ( 95 % CI , 0.43 - 0.49 ; crude death rate , 2.64 % ) for reporting 10 through 149 , 150 through 299 , and 300 min/wk or more of activity , respectively . Among those who reported any MVPA , the proportion of vigorous activity revealed an inverse dose-response relationship with all-cause mortality : compared with those reporting no vigorous activity ( crude death rate , 3.84 % ) the fully adjusted hazard ratio was 0.91 ( 95 % CI , 0.84 - 0.98 ; crude death rate , 2.35 % ) in those who reported some vigorous activity ( but < 30 % of total activity ) and 0.87 ( 95 % CI , 0.81 - 0.93 ; crude death rate , 2.08 % ) among those who reported 30 % or more of activity as vigorous . These associations were consistent in men and women , across categories of body mass index and volume of MVPA , and in those with and without existing cardiovascular disease or diabetes mellitus . CONCLUSIONS AND RELEVANCE Among people reporting any activity , there was an inverse dose-response relationship between proportion of vigorous activity and mortality . Our findings suggest that vigorous activities should be endorsed in clinical and public health activity guidelines to maximize the population benefits of physical activity Background Given high rates of obesity , hypertension , and diabetes mellitus , black persons are at risk to develop heart failure . The association of moderate to vigorous physical activity ( MVPA ) and heart failure  in black adults is under research ed . The purpose of this study was to explore whether greater MVPA was associated with lower risk of heart failure hospitalizations ( HFHs ) among black adults with normal ejection fractions . Methods and Results We performed a prospect i ve analysis of 4066 black adults who participated in the Jackson Heart Study and who had physical activity measured , had normal ejection fraction on 2‐dimensional echocardiograms , and were followed for 7 years for incident HFH . We used Cox proportional regression analyses adjusted for age , sex , body mass index , smoking status , hypertension , diabetes mellitus , chronic obstructive pulmonary disease , coronary heart disease , atrial fibrillation , and chronic kidney disease and examined effect modification by sex and body mass index . Of the eligible population , 1925 participants , according to the duration of MVPA , had poor health ( 0 minutes/week ) , 1332 had intermediate health ( 1–149 minutes/week ) , and 809 had ideal health ( ≥150 minutes/week ) . There were 168 incident HFHs .  MVPA for intermediate and ideal health was associated with decreasing risk of incident HFH ( hazard ratio : 0.70 [ 95 % confidence interval , 49–1.00 ] and 0.35 [ 95 % confidence interval , 0.19–0.64 ] , respectively ; P trend=0.003 ) . The full model revealed hazard ratios of 0.74 [ 95 % confidence interval , 0.52–1.07 ] and 0.41 [ 95 % confidence interval , 0.22–0.74 ] , respectively . There was no effect modification  between MVPA and body mass index or sex on incident HFH . Conclusions A dose‐response relationship between increasing levels of MVPA and protection from incident HFH was found in black men and women with normal ejection fractions Purpose of review This review highlights recent work evaluating the relationship between exercise , physical activity and physical and mental health . Both cross-sectional and longitudinal studies , as well as r and omized clinical trials , are included . Special attention is given to physical conditions , including obesity , cancer , cardiovascular disease and sexual dysfunction . Furthermore , studies relating physical activity to depression and other mood states are review ed . The studies include diverse ethnic population s , including men and women , as well as several age groups ( e.g. adolescents , middle-aged and older adults ) . Recent findings Results of the studies continue to support a growing literature suggesting that exercise , physical activity and physical-activity interventions have beneficial effects across several physical and mental-health outcomes . Generally , participants engaging in regular physical activity display more desirable health outcomes across a variety of physical conditions . Similarly , participants in r and omized clinical trials of physical-activity interventions show better health outcomes , including better general and health-related quality of life , better functional capacity and better mood states . Summary The studies have several implication s for clinical practice and research . Most work suggests that exercise and physical activity are associated with better quality of life and health outcomes . Therefore , assessment and promotion of exercise and physical activity may be beneficial in achieving desired benefits across several population s. Several limitations were noted , particularly in research involving r and omized clinical trials . These trials tend to involve limited sample sizes with short follow-up periods , thus limiting the clinical implication s of the benefits associated with physical activity . Abbreviations CAD : coronary artery disease ; COPD : chronic obstructive pulmonary disease ; CRP : cardiac rehabilitation program ; CVD : cardiovascular disease ; GMCB : group-mediated cognitive – behavioural ; HRQOL : health-related quality of life OBJECTIVE The aims of the study were to assess how baseline  leisure-time physical activity ( LTPA )  and its exercise components intensity , duration , and frequency are associated with all-cause and cardiovascular mortality in patients with type 1 diabetes 1 ) overall , 2 ) stratified by presence or absence of chronic kidney disease ( CKD ) , and 3 ) stratified by sex . RESEARCH DESIGN AND METHODS The study design was prospect i ve and observational and included 2,639 patients with type 1 diabetes from the ongoing nationwide multicenter Finnish Diabetic Nephropathy ( FinnDiane ) Study . Mean follow-up time was 11.4 ± 3.5 years . LTPA was assessed by using a vali date d self-report question naire .  Three hundred ten patients ( 11.7 % ) had CKD defined as an estimated glomerular filtration rate of ≤60 mL/min/1.73 m2 . RESULTS During follow-up , 270 deaths occurred . LTPA and all its components were associated with all-cause mortality , even after adjustment for the potential confounders sex , diabetic nephropathy , duration of diabetes , age at onset of diabetes , systolic blood pressure , triglycerides , BMI , and HbA1c . Only exercise intensity was associated with cardiovascular mortality after adjustment for the confounders . Of the patients with CKD , 127 died during follow-up . The total amount of LTPA and exercise frequency were independently associated with lower risk of all-cause mortality when adjusted for covariates . CONCLUSIONS Exercise is associated with a lower risk of premature all-cause and cardiovascular mortality in patients with type 1 diabetes . This study also demonstrates that physical activity is associated with a lower risk of mortality in patients with type 1 diabetes and CKD OBJECTIVES Physical activity ( PA ) is a preventive strategy for cardiovascular disease and for managing cardiovascular risk factors . There is little information on the effectiveness of PA for the prevention of cardiovascular outcomes once cardiovascular disease is present . Thus , we studied the relationship between PA at baseline and cardiovascular events in a high-risk population . DESIGN A prespecified analyses of observational data in a prospect i ve , r and omized hypertension study . SETTING Losartan Intervention For Endpoint reduction in hypertension ( LIFE ) study . SUBJECTS Hypertension and left ventricular hypertrophy ( LVH ) ( n = 9,193 ) . INTERVENTIONS Losartan versus atenolol . MAIN OUTCOME MEASURES Reported level of PA : never exercise , exercise < or=30 min twice per week , or exercise > 30 min twice per week at baseline and after a mean of 4.8 years of treatment with losartan- versus atenolol-based therapy . Risk reductions were calculated by level of PA for the primary composite end-point and its components cardiovascular death , stroke and myocardial infa rct ion , and also all-cause mortality and new-onset diabetes . RESULTS A modest level of PA ( > 30 min twice per week ) was associated with significant reductions in risk for the primary composite end-point [ adjusted hazard ratio ( aHR ) 0.70 , P < 0.001 ) and its components , all-cause mortality ( aHR 0.65 , P < 0.001 ) , and new-onset diabetes ( aHR 0.66 , P < 0.001 ) . CONCLUSION A modest level of self-reported PA ( > 30 min twice per week ) in patients with hypertension and LVH in the LIFE study was associated with significant reductions in risk for the primary composite end-point and its components of cardiovascular death , stroke , and myocardial infa rct ion , all-cause mortality , and new-onset diabetes BACKGROUND The remarkable similarity of lifestyle and environmental risk factors for type 2 ( non-insulin-dependent ) diabetes mellitus and colon cancer has led to the hypothesis that diabetes may increase the risk of this cancer . We prospect ively examined the relationship between diabetes and risk of colorectal cancer in a cohort of 118403 women aged 30 through 55 years who were without previously diagnosed cancer at baseline in 1976 . METHODS The women , who were enrolled in the Nurses ' Health Study , were assessed for history of diabetes at baseline and during follow-up by use of biennial question naires . Self-reported diabetes was vali date d by information obtained from a supplemental question naire on symptoms and treatment and was confirmed by medical record review in a sample of the participants . Incident cases of colorectal cancer were ascertained through medical record review . All reported P values are two-sided . RESULTS During 18 years of follow-up ( 201061 person-years ) , we documented 892 new cases of colorectal cancer . After adjustment for age , body mass index ( weight in kg/height in m2 ) , physical activity , and other covariates , relative risks ( RRs ) were 1.43 ( 95 % confidence interval [ CI ] = 1.10 - 1.87 ; P = .009 ) for colorectal cancer , 1.49 ( 95 % CI = 1.09 - 2.06 ; P = .01 ) for colon cancer , 1.11 ( 95 % CI = 0.56 - 2.21 ; P = .76 ) for rectal cancer , 1.56 ( 95 % CI = 1.07 - 2.28 ; P = .02 ) for advanced colorectal cancer , and 2.39 ( 95 % CI = 1.46 - 3.92 ; P = .0005 ) for fatal colorectal cancer . CONCLUSION Our data provide support for the hypothesis that diabetes is associated with an increased risk of colorectal cancer in women AIMS Given that studies of individuals with Type 2 diabetes or impaired glucose tolerance indicate that physical activity has a normalizing effect on several indices of coronary heart disease ( CHD ) risk-including body weight , blood pressure , blood lipids , and cardiorespiratory fitness-it is plausible that activity may reduce CHD incidence in this group in the long term . The aim of the present analysis was to explore this hypothesis using data from a prospect i ve observational study . METHODS We examined the relation of two indices of physical activity-walking pace and leisure activity-to total mortality , CHD , and other cardiovascular diseases in a 25-year follow-up of 6408 male British Civil Servants who underwent an oral glucose tolerance test at study entry . RESULTS In 352 men who were identified as having Type 2 diabetes or impaired glucose tolerance ( diabetes/IGT ) at baseline , 215 had died at follow-up and , in 6056 normoglycaemics , 2550 deaths had occurred . The two indices of physical activity were inversely related to all-cause , CHD , and other cardiovascular disease mortality in both normoglycaemics and in men with diabetes/IGT . Although these associations were attenuated somewhat after statistical adjustment for a range of covariates , the majority held , suggesting an independent effect for physical activity . The gradient of the activity-mortality association was steeper in individuals with diabetes/IGT in comparison with the normoglycaemics , with the linear trend across activity levels for CHD risk differing markedly in the analyses of both walking pace ( P-value for interaction test = 0.05 ) and leisure activity ( P-value = 0.02 ) . CONCLUSIONS The findings of the present analysis of men with Type 2 diabetes/IGT provide support for those from a small number of other studies of persons with Type 2 diabetes suggesting that this group may benefit from physical activity in terms of CHD risk reduction BACKGROUND Our objective was to describe the reduction in relative risk of developing major chronic diseases such as cardiovascular disease , diabetes , and cancer associated with 4 healthy lifestyle factors among German adults . METHODS We used data from 23,153 German participants aged 35 to 65 years from the European Prospect i ve Investigation Into Cancer and Nutrition-Potsdam study . End points included confirmed incident type 2 diabetes mellitus , myocardial infa rct ion , stroke , and cancer . The 4 factors were never smoking , having a body mass index lower than 30 ( calculated as weight in kilograms divided by height in meters squared ) , performing 3.5 h/wk or more of physical activity , and adhering to healthy dietary principles ( high intake of fruits , vegetables , and whole-grain bread and low meat consumption ) . The 4 factors ( healthy , 1 point ; unhealthy , 0 points ) were summed to form an index that ranged from 0 to 4 . RESULTS During a mean follow-up of 7.8 years , 2006 participants developed new-onset diabetes ( 3.7 % ) , myocardial infa rct ion ( 0.9 % ) , stroke ( 0.8 % ) , or cancer ( 3.8 % ) . Fewer than 4 % of participants had zero healthy factors , most had 1 to 3 healthy factors , and approximately 9 % had 4 factors . After adjusting for age , sex , educational status , and occupational status , the hazard ratio for developing a chronic disease decreased progressively as the number of healthy factors increased . Participants with all 4 factors at baseline had a 78 % ( 95 % confidence interval [ CI ] , 72 % to 83 % ) lower risk of developing a chronic disease ( diabetes , 93 % [ 95 % CI , 88 % to 95 % ] ; myocardial infa rct ion , 81 % [ 95 % CI , 47 % to 93 % ] ; stroke , 50 % [ 95 % CI , -18 % to 79 % ] ; and cancer , 36 % [ 95 % CI , 5 % to 57 % ] ) than participants without a healthy factor . CONCLUSION Adhering to 4 simple healthy lifestyle factors can have a strong impact on the prevention of chronic diseases CONTEXT Physical inactivity and body mass index ( BMI ) are established independent risk factors in the development of type 2 diabetes ; however , their comparative importance and joint relationship with diabetes are unclear . OBJECTIVE To examine the relative contributions and joint association of physical activity and BMI with diabetes . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve cohort study of 37 878 women free of cardiovascular disease , cancer , and diabetes with 6.9 years of mean follow-up .  Weight , height , and recreational activities were reported at study entry . Normal weight was defined as a BMI of less than 25 ; overweight , 25 to less than 30 ; and obese , 30 or higher . Active was defined as expending more than 1000 kcal on recreational activities per week . MAIN OUTCOME MEASURE Incident type 2 diabetes , defined as a new self-reported diagnosis of diabetes . RESULTS During the follow-up , 1361 cases of incident diabetes occurred . Individually , BMI and physical activity were significant predictors of incident diabetes . Compared with normal-weight individuals , the multivariate-adjusted hazard ratio ( HR ) was 3.22 ( 95 % confidence interval [ CI ] , 2.69 - 3.87 ) for overweight individuals and 9.09 ( 95 % CI , 7.62 - 10.8 ) for obese individuals . For overall activity ( kilocalories expended per week ) , compared with the least active first quartile , the multivariate-adjusted HRs were 0.91 ( 95 % CI , 0.79 - 1.06 ) for the second quartile , 0.86 ( 95 % CI , 0.74 - 1.01 ) for the third , and 0.82 ( 95 % CI , 0.70 - 0.97 ) for the fourth ( P for trend = .01 ) . In the combined analyses , overweight and obese participants , whether active or inactive , had significantly elevated risks , compared with normal-weight active individuals . The multivariate-adjusted HRs were 1.15 ( 95 % CI , 0.83 - 1.59 ) for normal-weight inactive , 3.68 ( 95 % CI , 2.63 - 5.15 ) for overweight active , 4.16 ( 95 % CI , 3.05 - 5.66 ) for overweight inactive , 11.5 ( 95 % CI , 8.34 - 15.9 ) for obese active , and 11.8 ( 95 % CI , 8.75 - 16.0 ) for obese inactive participants . CONCLUSIONS Although BMI and physical inactivity are independent predictors of incident diabetes , the magnitude of the association with BMI was greater than with physical activity in combined analyses . These findings underscore the critical importance of adiposity as a determinant of diabetes BACKGROUND Healthy lifestyle behaviors are among the cornerstones of diabetes self-management , but the extent to which healthy lifestyle factors could potentially prevent premature mortality among people with diabetes remains unknown . The aim of the present study was to estimate the reduction in mortality that could be achieved if people with diabetes did not smoke , had a body mass index < 30 kg/m(2 ) , performed physical activity for ≥3.5 h/week , reported better dietary habits , and consumed alcohol moderately . METHODS A prospect i ve cohort study of 1263 German men and women with diabetes aged 35 - 65 years who were followed for an average of 7.8 years was used and multivariate Cox regression models for all-cause and cause-specific mortality were calculated . RESULTS Approximately 7 % of study participants had no favorable factors , 24 % had one , 35 % had two , and 34 % had three or more . Compared with participants who had no favorable factors , the reduction in risk was 34 % [ 95 % confidence interval ( CI ) 19 % , 63 % ] for those with one favorable factor , 49 % ( 95 % CI 9 % , 71 % ) for those with two , and 63 % ( 95 % CI 31 % , 80 % ) for those with three or more . Furthermore , a competing risk analysis did not show any difference in the inverse associations with mortality due to cardiovascular disease , cancer , or other causes . CONCLUSIONS Favorable lifestyle factors can potentially achieve substantial reductions in premature mortality among people with diabetes . Our results emphasize the importance of helping people with diabetes optimize their lifestyle behaviors Loneliness is a prevalent and global problem for adult population s and has been linked to multiple chronic conditions in quantitative studies . This paper presents a systematic review of quantitative studies that examined the links between  loneliness  and common chronic conditions including : heart disease , hypertension , stroke , lung disease , and metabolic disorders . A comprehensive literature search process guided by the PRISMA statement led to the inclusion of 33 articles that measure loneliness in chronic illness population s.  Loneliness is a significant biopsychosocial stressor that is prevalent in adults with heart disease , hypertension , stroke , and lung disease . The relationships among loneliness , obesity , and metabolic disorders are understudied but current research indicates that loneliness is associated with obesity and with psychological stress in obese persons . Limited interventions have demonstrated long-term effectiveness for reducing loneliness in adults with these same chronic conditions . Future longitudinal r and omized trials that enhance knowledge of how diminishing loneliness can lead to improved health outcomes in persons with common chronic conditions would continue to build evidence to support the translation of findings to recommendations for clinical care There is limited evidence demonstrating the benefits of physical activity with regard to mortality risk or the harms associated with sedentary behavior in black adults , so we examined the relationships between these health behaviors and cause-specific mortality in a prospect i ve study that had a large proportion of black adults . Participants ( 40 - 79 years of age ) enrolled in the Southern Community Cohort Study between 2002 and 2009 ( n = 63,308 ) were prospect ively followed over 6.4 years , and 3,613 and 1,394 deaths occurred in blacks and whites , respectively . Black adults who reported the highest overall physical activity level ( ≥32.3 metabolic equivalent-hours/day vs. < 9.7 metabolic equivalent-hours/day ) had lower risks of death from all causes ( hazard ratio ( HR ) = 0.76 . 95 % confidence interval ( CI ) : 0.69 , 0.85 ) , cardiovascular disease ( HR = 0.81 , 95 % CI : 0.67 , 0.98 ) , and cancer ( HR = 0.76 , 95 % CI : 0.62 , 0.94 ) . In whites , a higher physical activity level was associated with a lower risk of death from all causes ( HR = 0.76 , 95 % CI : 0.64 , 0.90 ) and cardiovascular disease ( HR = 0.69 , 95 % CI : 0.49 , 0.99 ) but not cancer ( HR = 0.95 , 95 % CI : 0.67 , 1.34 ) . Spending more time being sedentary ( > 12 hours/day vs. < 5.76 hours/day ) was associated with a 20%-25 % increased risk of all-cause mortality in blacks and whites . Blacks who reported the most time spent being sedentary ( ≥10.5 hours/day ) and lowest level of physical activity ( < 12.6 metabolic equivalent-hours/day ) had a greater risk of death ( HR = 1.47 , 95 % CI : 1.25 , 1.71 ) . Our study provides evidence that suggests that health promotion efforts to increase physical activity level and decrease  sedentary time could help reduce mortality risk in black adults OBJECTIVES To evaluate the effect on overall and cardiovascular mortality of diet and physical activity amongst diabetic persons . DESIGN Population -based prospect i ve investigation , from 1993 to mid-2004 , in the Greek arm of the European Prospect i ve Investigation into Cancer and Nutrition . SETTING Volunteers from the general adult Greek population . SUBJECTS From an original sample of 28 572 volunteers , 1013 were taking at enrolment drugs for diabetes mellitus , had no missing information on the study variables and no comorbidity .  Diet was assessed at baseline through a vali date d question naire . Proportional hazards regression was used to assess the relation of dietary factors and physical activity with mortality . INTERVENTIONS None . MAIN OUTCOME MEASURES Mortality ratios overall and from cardiovascular causes . RESULTS During 4579 person-years , 80 deaths have occurred , 46 of which from cardiovascular causes . Physical activity was strongly inversely associated with mortality . Two nutritional variables were significantly associated with diabetic mortality , with hazard ratios for increases of daily intake by one st and ard deviation being 1.31 for eggs [ 95 % confidence interval ( 95 % CI ) 1.07 to 1.60 ] and 1.82 for saturated lipids ( 95 % CI , 1.14 to 2.90 ) . These two associations were considerably stronger for cardiovascular mortality . Waist-to-height ratio was positively , whereas hip circumference inversely associated with mortality . No significant interactions with gender for any of the study variables were evident . DISCUSSION Amongst confirmed diabetic persons , increased physical activity is associated with significant reduction of mortality , whereas increased consumption of eggs and saturated fats is associated with significant increase of mortality . Monounsaturated lipids are preferable for diabetic persons Purpose . Determine the proportion of adults aware of Canada 's Physical Activity Guide to Healthy Active Living ( Guide ) and its specific recommendations ( objective 1 ) ; whether key demographic factors ( objective 2a ) and physical activity behavior ( objective 2b ) are associated with awareness and specific familiarity with the Guide ; and if changes in awareness and specific recommendations with the Guide occurred over a 1-year period ( objective 3a and 3b ) . Design . R and om selection with computer-assisted telephone interviewing . Setting . Edmonton , Alberta , Canada . Subjects . A total of 2803 adults 18 years or older completed interviews from 4831 telephone contacts ( response rate , 58.0 % ) , and after 1 year , 1423 individuals ( 55 % ) completed interviews . Measures . Demographic , physical activity , Guide awareness . Analysis . Chi-square , analysis of variance . Results . At baseline , 27.3 % were aware of the Guide , and 15.6 % were familiar with the Guide 's specific recommendations . Younger individuals ( p = .01 ) , women ( p < .001 ) , and those with a higher education ( p < .001 ) were more likely to be generally aware of the Guide , and women were also more specifically aware ( p = .01 ) . Physical activity levels were positively associated with the general ( p < .001 ) and specific ( p < .001 ) awareness of the Guide . Changes in general familiarity and specific recommendations over 1 year were observed . Conclusions . The majority of those surveyed were not familiar with the Guide . Men , individuals with a lower education , and older individuals may need to be specifically targeted . ( Am J Health Promot 2011;25[5]:294 - 297 . Rationale : The evidence regarding the potential health benefits of nut consumption among individuals with type 2 diabetes mellitus is limited . Objective : To examine intake of total and specific types of nuts , including tree nuts and peanuts , in relation to subsequent risk of cardiovascular disease ( CVD ) , including coronary heart disease and stroke , and all-cause and cause-specific mortality among individuals with diabetes mellitus . Methods and Results : This prospect i ve analysis included 16 217 men and women with diabetes mellitus at baseline or diagnosed during follow-up ( Nurses ’ Health Study : 1980–2014 , Health Professionals Follow-Up Study : 1986–2014 ) .  Nut consumption was assessed using a vali date d food frequency question naire and up date d every 2 to 4 years . During 223 682 and 254 923 person-years of follow-up , there were 3336 incident CVD cases and 5682 deaths , respectively . Higher total nut consumption was associated with a lower risk of CVD incidence and mortality . The multivariate-adjusted hazard ratios ( 95 % CIs ) for participants who consumed 5 or more servings of total nuts per week ( 1 serving=28 g ) , compared with those who consumed < 1 serving per month , were 0.83 ( 0.71–0.98 ; P trend=0.01 ) for total CVD incidence , 0.80 ( 0.67–0.96 ; P trend=0.005 ) for coronary heart disease incidence , 0.66 ( 0.52–0.84 ; P trend < 0.001 ) for CVD mortality , and 0.69 ( 0.61–0.77 ; P trend < 0.001 ) for all-cause mortality .  Total nut consumption was not significantly associated with risk of stroke incidence or cancer mortality . For specific types of nuts , higher tree nut consumption was associated with lower risk of total CVD , coronary heart disease incidence , and mortality because of CVD , cancer , and all causes , whereas peanut consumption was associated with lower all-cause mortality only ( all P trend < 0.001 ) . In addition , compared with participants who did not change the consumption of total nuts from pre- to post-diabetes mellitus diagnosis , participants who increased consumption of total nuts after diabetes mellitus diagnosis had an 11 % lower risk of CVD , a 15 % lower coronary heart disease risk , a 25 % lower CVD mortality , and a 27 % lower all-cause mortality . The associations persisted in subgroup analyses stratified by sex/cohort , body mass index at diabetes mellitus diagnosis , smoking status , diabetes mellitus duration , nut consumption before diabetes mellitus diagnosis , or diet quality . Conclusions : Higher consumption of nuts , especially tree nuts , is associated with lower CVD incidence and mortality among participants with diabetes mellitus . These data provide novel evidence that supports the recommendation of incorporating nuts into healthy dietary patterns for the prevention of CVD complications and premature deaths among individuals with diabetes mellitus Background The evidence that higher levels of physical activity and /or lower levels of physical inactivity are associated with beneficial health-related outcomes stems mainly from observational studies . Findings from these studies often differ from r and omised controlled trials and systematic review s currently demonstrate mixed results , due partly to heterogeneity in physical activity interventions , method ologies used and population s studied . As a result , translation into clinical practice has been difficult . It is therefore essential that an overview is carried out to compare and contrast systematic review s , and to identify those physical activity interventions that are the most effective in preventing and /or treating major chronic disease . This protocol has been registered on PROSPERO 2013 : CRD42013003523 . Methods We will carry out an overview of Cochrane systematic review s. We will search the Cochrane Data base of Systematic Review s for systematic review s of r and omised controlled trials that have a primary focus on disease-related outcomes . We will restrict review s to those in selected major chronic diseases . Two authors will independently screen search outputs , select studies , extract data and assess the quality of included review s using the assessment of multiple systematic review s tool ; all discrepancies will be resolved by discussing and reaching a consensus , or by arbitration with a third author . The data extraction form will summarise key information from each review , including details of the population ( s ) ( for example , disease condition ) , the context ( for example , prevention , treatment or management ) , the participants , the intervention(s ) , the comparison(s ) and the outcomes . The primary outcomes of interest are the prevention of chronic disease and /or improved outcomes , in the treatment or management of chronic disease . These outcomes will be summarised and presented for individual chronic diseases ( for example , any change in blood pressure in hypertension or glucose control in diabetes ) . Secondary outcomes of interest are to describe the structure and delivery of physical activity interventions  across chronic disease conditions and adverse events associated with physical activity . Discussion We anticipate that our results could inform research ers , guideline groups and policymakers of the most efficacious physical activity interventions in preventing and /or managing major chronic disease Introduction Type 2 diabetes ( T2D ) is a major health concern among population s of South Asian ethnicity . Although dietary and physical activity interventions may reduce the risk of T2D , the effectiveness has been moderate among South Asians . This might ( in part ) be because this subgroup follows strategies that were originally developed for interventions among other population s. Therefore , this review aims to assess the evidence for the current dietary and physical activity strategies recommended in T2D prevention intervention studies and guidelines for South Asians . Methods and analysis Included will be all studies and guidelines on dietary and /or physical activity strategies to prevent T2D in adult South Asians . Two review ers will search online data bases from their start until the present date for published and unpublished experimental/quasiexperimental studies , with at least an abstract in English . References of identified articles and key review s will be screened for additional studies . Guidelines will be identified by search es in online data bases and websites of public organisations . Finally , expert consultations will be held to supplement any missing information . Trial quality will be assessed with the Quality Assessment Tool for Quantitative Studies Data , and guidelines with the Appraisal of Guidelines for Research & Evaluation II . Data on the strategies recommended , targeting and evidence on effectiveness will be extracted by two review ers and presented in tabular and narrative forms . Recommendations will be compared with the National Institute for Health and Care Excellence guidelines [ PH35 ] . Overall findings on  dietary and physical activity recommendations , as well as findings for specific subgroups ( eg , by sex ) , will be discussed . Ethics and dissemination Ethics assessment is not required . Start date : 1 January 2016 , finishing and reporting date 31 July 2016 . Results will be published in a peer- review ed scientific journal , the project report of EuroDHYAN ( www.eurodhyan.eu ) and in a PhD dissertation . Trial registration number The protocol is registered with the International Prospect i ve Register of Systematic Review s ( PROSPERO ) registration number CRD42015027067 Background Modifiable behavioural risk factors — including exercise , obesity and smoking — have been causally associated with  colorectal cancer mortality . However , results have been inconsistent and undiagnosed cancers may affect baseline risk factors , distorting the temporal relationship that is observed between them . Objective To determine whether risk factors for colorectal cancers available in the Whitehall I study were predictive of colonic or rectal cancer mortality . Methods Prospect i ve cohort study over 40 years on Whitehall I men aged 40–69 on entry between 1967 and 1970 . Associations between baseline risk factors and cause-specific mortality were tested with Cox proportional hazards models . Events within the first 10 years of follow-up were excluded to minimise ‘ reverse causality . ’ Results 329 colon and 121 rectal cancer deaths occurred among 17 949 men followed up for a total of 472 523 person-years . Age and smoking were associated with increased mortality from colorectal cancers . Compared with never-smokers , current smoking was associated with age-adjusted HRs for colon and rectal cancers of 1.45 ( 95 % CI 1.03 to 2.03 ) and 1.97 ( 95 % CI 1.02 to 3.80 ) , respectively . A significant effect of current smoking on rectal cancer mortality was only apparent after events in the first 10 years of follow-up were excluded . No convincing evidence was found that body mass index , diabetes mellitus , blood pressure or physical activity were associated with colorectal cancer mortality . Conclusion Smoking significantly increases mortality from colorectal cancer  and its decreasing prevalence in the UK may partly explain falling mortality from the disease . Changes in health behaviours in response to early cancer symptoms may result in differential misclassification or ‘ reverse causality ’ unless early events are excluded . Although many individual cohort studies have not shown significant relationships between behavioural risk factors and colorectal cancer mortality , their contribution to meta-analyses remains important CONTEXT Depression and diabetes mellitus have been associated with an increased risk of all-cause and cardiovascular disease ( CVD ) mortality . However , data evaluating the joint effects of these 2 conditions on mortality are sparse . OBJECTIVES To evaluate the individual and joint effects of depression and diabetes on all-cause and CVD mortality rate . DESIGN Prospect i ve cohort study . SETTING The 11 states of the Nurses ' Health Study . PARTICIPANTS A total of 78 282 women who participated in the Nurses ' Health Study aged 54 to 79 years at baseline in 2000 were followed up until 2006 . Depression was defined as having self-reported diagnosed depression , treatment with antidepressant medications , or a score indicating severe depressive symptoms ( ie , a 5-item Mental Health Index score ≤52 ) . Self-reported type 2 diabetes was confirmed using a supplementary question naire . MAIN OUTCOME MEASURES All-cause and CVD-specific mortality rate . RESULTS During 6 years of follow-up ( 433 066 person-years ) , 4654 deaths were documented , including 979 deaths from CVD . Compared with participants without either condition , the age-adjusted relative risks ( RRs ) ( 95 % confidence interval ) for all-cause mortality were 1.76 ( 1.64 - 1.89 ) for women with depression only , 1.71 ( 1.54 - 1.89 ) for individuals with diabetes only , and 3.11 ( 2.70 - 3.58 ) for women with both conditions . The corresponding age-adjusted RRs of CVD mortality were 1.81 ( 1.54 - 2.13 ) , 2.67 ( 2.20 - 3.23 ) , and 5.38 ( 4.19 - 6.91 ) , respectively . These associations were attenuated after multivariate adjustment for other demographic variables , body mass index , smoking status , alcohol intake , physical activity , and major comorbidities ( including hypertension , hypercholesterolemia , heart diseases , stroke , and cancer ) but remained significant , with the highest RRs for all-cause and CVD mortality found in those with both conditions ( 2.07 [ 1.79 - 2.40 ] and 2.72 [ 2.09 - 3.54 ] , respectively ) . Furthermore , the combination of depression with a long duration of diabetes mellitus ( ie , > 10 years ) or insulin therapy was associated with a particularly higher risk of CVD mortality after multivariate adjustment ( RRs , 3.22 and 4.90 , respectively ) . CONCLUSIONS Depression and diabetes are associated with a significantly increased risk of all-cause and CVD mortality rate . The coexistence of these conditions identifies women at particularly high risk OBJECTIVE To evaluate the relationship between changes in physical fitness and  risk of mortality in men . DESIGN Prospect i ve study , with two clinical examinations ( mean interval between examinations , 4.9 years ) to assess change or lack of change in physical fitness as associated with risk of mortality during follow-up after the subsequent examination ( mean follow-up from subsequent examination , 5.1 years ) . SETTING Preventive medicine clinic . STUDY PARTICIPANTS Participants were 9777 men given two preventive medical examinations  , each of which included assessment of physical fitness by maximal exercise tests and evaluation of health status . MAIN OUTCOME MEASURES All cause ( n = 223 ) and cardiovascular disease ( n = 87 ) mortality . RESULTS The highest age-adjusted all-cause death rate was observed in men who were unfit at both examinations ( 122.0/10,000 man-years ) ; the lowest death rate was in men who were physically fit at both examinations ( 39.6/10,000 man-years ) . Men who improved from unfit to fit between the first and subsequent examinations had an age-adjusted death rate of 67.7/10,000 man-years . This is a reduction in mortality risk of 44 % ( 95 % confidence interval , 25 % to 59 % ) relative to men who remained unfit at both examinations . Improvement in fitness was associated with lower death rates after adjusting for age , health status , and other risk factors of premature mortality . For each minute increase in maximal treadmill time between examinations , there was a corresponding 7.9 % ( P = .001 ) decrease in risk of mortality . Similar results were seen when the group was stratified by health status , and for cardiovascular disease mortality . CONCLUSIONS Men who maintained or improved adequate physical fitness were less likely to die from all causes and from cardiovascular disease during follow-up than persistently unfit men . Physicians should encourage unfit men to improve their fitness by starting a physical activity program CONTEXT Physical activity has been related to reduced mortality , but it is not clear whether changes in physical activity affect mortality among older women . OBJECTIVE To examine the relationship of changes in physical activity and mortality  among older women . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve cohort study conducted at 4 US research centers ( Baltimore , Md ; Portl and , Ore ; Minneapolis , Minn ; and Monongahela Valley , Pa ) among 9518 community-dwelling white women aged 65 years or older who were assessed at baseline ( 1986 - 1988 ) , 7553 of whom were reassessed at a follow-up visit ( 1992 - 1994 ; median , 5.7 years later ) . MAIN OUTCOME MEASURES  Walking and other physical activities at baseline and follow-up ; vital status , with cause of death confirmed by death certificates/discharge summaries , tracked for up to 12.5 years after baseline ( up to 6.7 years after the follow-up visit ) . RESULTS Compared with continually sedentary women , those who increased physical activity levels between baseline and follow-up had lower mortality from all causes ( hazard rate ratio [ HRR ] , 0.52 ; 95 % confidence interval [ CI ] , 0.40 - 0.69 ) , cardiovascular disease ( HRR , 0.64 ; 95 % CI , 0.42 - 0.97 ) , and cancer ( HRR , 0.49 ; 95 % CI , 0.29 - 0.84 ) , independent of age , smoking , body mass index , comorbid conditions , and baseline physical activity level . Associations between changes in physical activity and reduced mortality were similar in women with and without chronic diseases but tended to be weaker among women aged at least 75 years and among those with poor health status . Women who were physically active at both visits also had lower all-cause mortality ( HRR , 0.68 ; 95 % CI , 0.56 - 0.82 ) and cardiovascular mortality ( HRR , 0.62 ; 95 % CI , 0.44 - 0.88 ) than sedentary women . CONCLUSION Increasing and maintaining physical activity levels could lengthen life for older women but appears to provide less benefit for women aged at least 75 years and those with poor health status Purpose . To examine the relationship between vigorous physical activity and  dementia risk . Design . Prospect i ve study design utilizing physical activity data from the Health and Retirement Study and cognitive outcome data from the Aging , Demographics , and Memory Study . Setting . Community-based . Subjects . Adults age 71 and over ( N = 808 ) with 3 to 7 years of physical activity information prior to dementia/no dementia diagnosis . Measures .  Physical activity  was measured by  participation in vigorous activities such as aerobics , sports , running , bicycling , and heavy housework three or more times per week  ( yes/no ) . Dementia diagnosis was based on an expert panel ( e.g. , neuropsychologists , neurologists , geropsychiatrists ) who performed and review ed a battery of neuropsychological tests . Analysis . Binary logistic regression models were used to account for demographic characteristics , genetic risk factors ( one or two apolipoprotein E ε4 alleles ) , health behaviors ( e.g. , smoking , drinking alcohol ) , health indicators ( body mass index ) , and health conditions ( e.g. , diabetes , heart disease ) in a sequential model-building process . Results . The relationship between vigorous physical activity and dementia risk remained robust across models . In the final model , older adults who were physically active were 21 % ( p ≤ .05 ) less likely than their counterparts to be diagnosed with dementia . Conclusion . Vigorous physical activity may reduce the risk for dementia independently of the factors examined here . This study 's findings are important given that few preventative strategies for dementia have been explored beyond hormonal therapy and anti-inflammatory drugs Background — The relation between endogenous testosterone concentrations and health in men is controversial . Methods and Results — We examined the prospect i ve relationship between endogenous testosterone concentrations and mortality due to all causes , cardiovascular disease , and cancer in a nested case-control study based on 11 606 men aged 40 to 79 years surveyed in 1993 to 1997 and followed up to 2003 . Among those without prevalent cancer or cardiovascular disease , 825 men who subsequently died were compared with a control group of 1489 men still alive , matched for age and date of baseline visit .  Endogenous testosterone concentrations at baseline were inversely related to mortality due to all causes ( 825 deaths ) , cardiovascular disease ( 369 deaths ) , and cancer ( 304 deaths ) . Odds ratios ( 95 % confidence intervals ) for mortality for increasing quartiles of endogenous testosterone compared with the lowest quartile were 0.75 ( 0.55 to 1.00 ) , 0.62 ( 0.45 to 0.84 ) , and 0.59 ( 0.42 to 0.85 ) , respectively ( P<0.001 for trend after adjustment for age , date of visit , body mass index , systolic blood pressure , blood cholesterol , cigarette smoking , diabetes mellitus , alcohol intake , physical activity , social class , education , dehydroepi and rosterone sulfate , and rostanediol glucuronide , and sex hormone binding globulin ) . An increase of 6 nmol/L serum testosterone ( ≈1 SD ) was associated with a 0.81 ( 95 % confidence interval 0.71 to 0.92 , P<0.01 ) multivariable-adjusted odds ratio for mortality . Inverse relationships were also observed for deaths due to cardiovascular causes and cancer and after the exclusion of deaths that occurred in the first 2 years . Conclusions — In men  , endogenous testosterone concentrations are inversely related to mortality due to cardiovascular disease and all causes . Low testosterone may be a predictive marker for those at high risk of cardiovascular disease CONTEXT Although many studies suggest that physical activity may reduce risk of type 2 diabetes , the role of moderate-intensity activity such as walking is not well understood . OBJECTIVES To examine the relationship of total physical activity and incidence of type 2 diabetes in women and to compare the benefits of walking vs vigorous activity as predictors of subsequent risk of type 2 diabetes . DESIGN AND SETTING The Nurses ' Health Study , a prospect i ve cohort study that included detailed data for physical activity from women surveyed in 11 US states in 1986 , with up date s in 1988 and 1992 . PARTICIPANTS A total of 70,102 female nurses aged 40 to 65 years who did not have diabetes , cardiovascular disease , or cancer at baseline ( 1986 ) . MAIN OUTCOME MEASURE Risk of type 2 diabetes by quintile of metabolic equivalent task ( MET ) score , based on time spent per week on each of 8 common physical activities , including  walking .  RESULTS During 8 years of follow-up ( 534 , 928 person-years ) , we documented 1419 incident cases of type 2 diabetes . After adjusting for age , smoking , alcohol use , history of hypertension , history of high cholesterol level , and other covariates , the relative risks ( RRs ) of developing type 2 diabetes across quintiles of physical activity ( least to most ) were 1.0 , 0.77 , 0.75 , 0.62 , and 0.54 ( P for trend < .001 ) ; after adjusting for body mass index ( BMI ) , RRs were 1.0 , 0.84 , 0.87 , 0.77 , and 0.74 ( P for trend = .002 ) . Among women who did not perform vigorous activity , multivariate RRs of type 2 diabetes across quintiles of MET score for walking were 1.0 , 0.91,0.73 , 0.69 , and 0.58 ( P for trend < .001 ) . After adjusting for BMI , the trend remained statistically significant ( RRs were 1.0 , 0.95 , 0.80 , 0.81 , 0.74 ; P for trend = .01 ) . Faster usual walking pace was independently associated with decreased risk . Equivalent energy expenditures from walking and vigorous activity result ed in comparable magnitudes of risk reduction . CONCLUSIONS Our data suggest that greater physical activity level is associated with substantial reduction in risk of type 2 diabetes , including physical activity of moderate intensity and duration OBJECTIVE To examine the association between low to moderate alcohol consumption and the incidence of type 2 diabetes mellitus ( DM ) in men . DESIGN Prospect i ve cohort study . SUBJECTS AND METHODS Over an average period of 12.1 years , we evaluated 20 951 participants in the Physicians ' Health Study between ages 40 and 84 years who were free of cardiovascular disease , cancer , and diabetes and provided data on alcohol consumption at baseline . MAIN OUTCOME MEASURE Type 2 DM diagnosed after r and omization . RESULTS Among 20 951 physicians , 766 cases of incident DM were reported over an average follow-up period of 12.1 years . After adjustment for age , r and omized treatment assignment , smoking , physical activity , and body mass index , the relative risk estimates and 95 % confidence intervals for those reporting alcohol use of rarely/ never , 1 to 3 drinks per month , 1 drink per week , 2 to 4 drinks per week , 5 to 6 drinks per week , and 1 or more drinks per day were 1.00 ( referent ) , 1.03 ( 0.80 - 1.33 ) , 0.89 ( 0.70 - 1.14 ) , 0.74 ( 0.59 - 0.93 ) , 0.67 ( 0.51 - 0.89 ) , and 0.57 ( 0.45 - 0.73 ) , respectively ( linear trend , P<.001 ) . Additional adjustment for baseline history of hypertension , high cholesterol level , or parental history of myocardial infa rct ion or family history of diabetes ( data collected at 9 years ) did not material ly alter the results . These associations persisted in analyses stratified by age , smoking status , body mass index , physical activity , and family history of DM . CONCLUSION These data indicate that apparently healthy men who self-select for light to moderate alcohol consumption have a decreased subsequent risk of type 2 DM BACKGROUND It has been suggested that the inverse association between alcohol and type 2 diabetes could be explained by moderate drinkers ' healthier lifestyles . OBJECTIVE We studied whether moderate alcohol consumption is associated with a lower risk of type 2 diabetes in adults with combined low-risk lifestyle behaviors . DESIGN We prospect ively examined 35,625 adults of the Dutch European Prospect i ve Investigation into Cancer and Nutrition ( EPIC-NL ) cohort aged 20 - 70 y , who were free of diabetes , cardiovascular disease , and cancer at baseline ( 1993 - 1997 ) . In addition to moderate alcohol consumption ( women : 5.0 - 14.9 g/d ; men : 5.0 - 29.9 g/d ) , we defined low-risk categories of 4 lifestyle behaviors : optimal weight [ body mass index ( in kg/m(2 ) ) < 25 ] , physically active ( > or = 30 min of physical activity/d ) , current nonsmoker , and a healthy diet [ upper 2 quintiles of the Dietary Approaches to Stop Hypertension ( DASH ) diet ] . RESULTS During a median of 10.3 y , we identified 796 incident cases of type 2 diabetes . Compared with teetotalers , hazard ratios of moderate alcohol consumers for risk of type 2 diabetes in low-risk lifestyle strata after multivariable adjustments were 0.35 ( 95 % CI : 0.17 , 0.72 ) when of a normal weight , 0.65 ( 95 % CI : 0.46 , 0.91 ) when physically active , 0.54 ( 95 % CI : 0.41 , 0.71 ) when nonsmoking , and 0.57 ( 95 % CI : 0.39 , 0.84 ) when consuming a healthy diet . When > or =3 low-risk lifestyle behaviors were combined , the hazard ratio for incidence of type 2 diabetes in moderate alcohol consumers after multivariable adjustments was 0.56 ( 95 % CI : 0.32 , 1.00 ) . CONCLUSION In subjects already at lower risk of type 2 diabetes on the basis of multiple low-risk lifestyle behaviors , moderate alcohol consumption was associated with an approximately 40 % lower risk compared with abstention There is growing evidence that yoga may offer a safe and cost-effective intervention for Type 2 Diabetes mellitus ( DM 2 ) . However , systematic review s are lacking . This article critically review s the published literature regarding the effects of yoga-based programs on physiologic and anthropometric risk profiles and related clinical outcomes in adults with DM 2 . We performed a comprehensive literature search using four computerized English and Indian scientific data bases . The search was restricted to original studies ( 1970–2006 ) that evaluated the metabolic and clinical effects of  yoga in adults with DM 2 . Studies targeting clinical population s with cardiovascular disorders that included adults with comorbid DM were also evaluated . Data were extracted regarding study design , setting , target population , intervention , comparison group or condition , outcome assessment , data analysis and presentation , follow-up , and key results , and the quality of each study was evaluated according to specific predetermined criteria . We identified 25 eligible studies , including 15 uncontrolled trials , 6 non-r and omized controlled trials and 4 r and omized controlled trials ( RCTs ) . Overall , these studies suggest beneficial changes in several risk indices , including glucose tolerance and insulin sensitivity , lipid profiles , anthropometric characteristics , blood pressure , oxidative stress , coagulation profiles , sympathetic activation and pulmonary function , as well as improvement in specific clinical outcomes .  Yoga may improve risk profiles in adults with DM 2 , and may have promise for the prevention and management of cardiovascular complications in this population . However , the limitations characterizing most studies preclude drawing firm conclusions . Additional high- quality RCTs are needed to confirm and further eluci date the effects of st and ardized yoga programs in population s with DM 2 OBJECTIVE Physical fitness is inversely related to mortality in the general population and in subjects with type 2 diabetes . Here , we present data concerning the relationship between changes in physical fitness and modifiable cardiovascular risk factors in subjects with type 2 diabetes from the Italian Diabetes and Exercise Study . RESEARCH DESIGN AND METHODS Sedentary patients with type 2 diabetes ( n = 606 ) were enrolled in 22 outpatient diabetes clinics and r and omized to twice-a-week supervised aerobic and resistance training plus exercise counseling versus counseling alone for 12 months . Baseline to end-of- study changes in cardiorespiratory fitness , strength , and flexibility , as assessed by Vo2max estimation , a 5–8 maximal repetition test , and a hip/trunk flexibility test , respectively , were calculated in the whole cohort , and multiple regression analyses were applied to assess the relationship with cardiovascular risk factors . RESULTS Changes in Vo2max , upper and lower body strength , and flexibility were significantly associated with the variation in the volume of physical activity , HbA1c , BMI , waist circumference , high-sensitivity C-reactive protein ( hs-CRP ) , coronary heart disease ( CHD ) risk score , and inversely , HDL cholesterol . Changes in fitness predicted improvements in HbA1c , waist circumference , HDL cholesterol , hs-CRP , and CHD risk score , independent of study arm , BMI , and in case of strength , also waist circumference . CONCLUSIONS Physical activity/exercise-induced increases in fitness , particularly muscular , predict improvements in cardiovascular risk factors in subjects with type 2 diabetes independently of weight loss , thus indicating the need for targeting fitness in these individuals , particularly in subjects who struggle to lose weight OBJECTIVE To examine the independent associations of vigorous ( > or = 6 resting metabolic rate [ MET ] score ) and nonvigorous ( < 6 MET score ) physical activity with longevity . DESIGN Prospect i ve cohort study , following up men from 1962 or 1966 through 1988 . SETTING / PARTICIPANTS Subjects were Harvard University alumni , without self-reported , physician-diagnosed cardiovascular disease , cancer , or chronic obstructive pulmonary disease ( n = 17,321 ) . Men with a mean age of 46 years reported their physical activities on question naires at baseline . MAIN OUTCOME MEASURE  All-cause mortality  ( 3728 deaths ) . RESULTS Total energy expenditure and energy expenditure from vigorous activities , but not energy expenditure from nonvigorous activities , related inversely to mortality . After adjustment for potential confounders , the relative risks of dying associated with increasing quintiles of total energy expenditure were 1.00 ( referent ) , 0.94 , 0.95 , 0.91 and 0.91 , respectively ( P [ trend ] < .05 ) . The relative risks of dying associated with less than 630 , 630 to less than 1680 , 1680 to less than 3150 , 3150 to less than 6300 , and 6300 or more kJ/wk expended on vigorous activities were 1.00 ( referent ) , 0.88 , 0.92 , 0.87 , and 0.87 , respectively ( P [ trend ] = .007 ) . Corresponding relative risks for energy expended on nonvigorous activities were 1.00 ( referent ) , 0.89 , 1.00 , 0.98 , and 0.92 , respectively ( P [ trend ] = .36 ) . Analyses of vigorous and nonvigorous activities were mutually adjusted . Among men who reported only vigorous activities ( 259 deaths ) , we observed decreasing age-st and ardized mortality rates with increasing activity ( P = .05 ) ; among men who reported only nonvigorous activities ( 380 deaths ) , no trend was apparent ( P = .99 ) . CONCLUSIONS These data demonstrate a grade d inverse relationship between total physical activity and mortality . Furthermore , vigorous activities but not nonvigorous activities were associated with longevity . These findings pertain only to all-cause mortality ;  nonvigorous exercise has been shown to benefit other aspects of health Puerto Ricans living in the United States mainl and present multiple disparities in prevalence of chronic diseases , relative to other racial and ethnic groups . Allostatic load ( AL ) , or the cumulative wear and tear of physiological responses to stressors such as major life events , social and environmental burden , has been proposed as a possible mechanism for the inequalities observed in minority groups , but has not been studied in Puerto Ricans . The aim of this study was to determine the association of AL to six chronic diseases ( abdominal obesity , hypertension , diabetes , and self-reported cardiovascular disease ( CVD ) , arthritis and cancer ) in Puerto Ricans , and to contrast AL to metabolic syndrome ( MetS ) . Participants of the Boston Puerto Rican Health Study ( n=1116 , ages 45 - 75 years ) underwent a  home-based interview  , where question naires were completed and biological sample s collected . A summary definition of AL was constructed using clinical ly-defined cutoffs and medication use for 10 physiological parameters in different body systems . Logistic regression models were run to determine associations between AL score and disease status , controlling for age , sex , smoking , alcohol use , physical activity , total fat intake and energy intake . Parallel models were also run with MetS score replacing AL . We found that increasing categories of AL score were significantly associated with abdominal obesity , hypertension , diabetes and self-reported cardiovascular disease ( CVD ) and arthritis , but not with self-reported cancer . The strength of associations of AL with all conditions , except diabetes and cancer , was similar to or larger than those of MetS score . In conclusion , Puerto Rican older adults experienced physiological dysregulation that was associated with increased odds of chronic conditions . AL was more strongly associated with most conditions , compared to MetS , suggesting that this cumulative measure may be a better predictor of disease . These results have prospect i ve research implication s for Puerto Ricans and other ethnic groups Few studies have investigated the independent effects of domain-specific physical activity on mortality . We sought to investigate the association of physical activity performed in different domains of daily living on all-cause , cardiovascular ( CVD ) and cancer mortality .  Using a prospect i ve cohort design , 4,672 men and women , aged 25–74 years , who participated in the baseline examination of the MONICA/KORA Augsburg Survey 1989/1990 were classified according to their activity level ( no , light , moderate , vigorous ) . Domains of self-reported physical activity ( work , transportation , household , leisure time ) and total activity were assessed by the vali date d MOSPA ( MONICA Optional Study on Physical Activity ) question naire . After a median follow-up of 17.8 years , a total of 995 deaths occurred , with 452 from CVD and 326 from cancer . For all-cause mortality , hazard ratios and 95 % confidence interval ( HR , 95 % CI ) of the highly active versus the inactive reference group were 0.69 ( 0.48–1.00 ) for work , 0.48 ( 0.36–0.65 ) for leisure time , and 0.73 ( 0.59–0.90 ) for total activity after multivariable adjustments . Reduced risks of CVD mortality were observed for high levels of work ( 0.54 , 0.31–0.93 ) , household ( 0.80 , 0.54–1.19 ) , leisure time ( 0.50 , 0.31–0.79 ) and total activity ( 0.75 , 0.55–1.03 ) . Leisure time ( 0.36 , 0.23–0.59 ) and total activity ( 0.62 , 0.43–0.88 ) were associated with reduced risks of cancer mortality . Light household activity was related to lower all-cause ( 0.82 , 0.71–0.95 ) and CVD ( 0.72 , 0.58–0.89 ) mortality . No clear effects were found for transportation activities . Our findings suggest that work , household , leisure time and total physical activity  , but not transportation activity , may protect from premature mortality Physical activity has been shown to reduce colorectal cancer risk . However , the association of physical activity levels separately with colon and rectum cancer mortality is less clear . We included 226 089 Korean in a large prospect i ve cohort study . We assessed the associations of  physical activity levels ( length , frequency , and intensity ) with colon and rectum cancer mortality using Cox proportional hazards model . Men , but not women , who had regular physical activity showed a lower risk of death from colon cancer . The association for high intensity of physical activity  was borderline significant in men ( hazard ratio 0.67 ; 95 % CI = 0.45 - 1.00 for > 17.5 MET-hour/week ) . The associations were largely consistent among those aged < 55 years , body mass index < 25 kg/m2 , low high-density lipoprotein cholesterol , current smoker , and without hypertension or history of cardiovascular disease . In conclusion , higher length or intensity of physical activity  decreased colon , but not rectum cancer mortality in men .  Regular physical activity may have beneficial effects on colon cancer survival The mechanisms that underlie successful initiation and adherence to physical activity regimens are not well understood . Few theoretical models have used consistent explanatory variables that are theory-driven and many findings that use extant models are equivocal . Social Cognitive Theory ( SCT ) as presented by B and ura ( 1986 , 1997 ) appears to have strong promise as a guide to underst and ing physical activity behaviors and developing clinical ly relevant interventions to promote the initiation and maintenance of physical activity . This critical systematic review of research using SCT was completed to determine the predictive ability of model constructs in explaining physical activity behavior and in identifying key intervention components found to enhance physical activity initiation and maintenance . Following review for quality and adequacy , published research during the years 1990 - 1998 contained 27 studies that examined the relationship between the construct of SCT , self-efficacy  , and physical activity .  All of the descriptive studies found a statistically significant relationship between self-efficacy and exercise behavior . Intervention studies demonstrated that participation in an exercise program promoted self-efficacy , and that programs design ed to increase outcome expectations and self-efficacy significantly increased exercise behavior . Due to the central ity of self-efficacy in many of the social psychological theories that help explain the attitude-intention-behavior triad , a strong need remains to design interventions to maximize its usefulness . Clear , generalizable , systematic and theoretically comprehensive , r and omized , controlled studies are needed to underst and the usefulness of the construct Background The purpose was to conduct systematic review s of the relationship between physical activity of healthy community-dwelling older ( > 65 years ) adults and outcomes of  functional limitations , disability , or loss of independence .  Methods Prospect i ve cohort studies with an outcome related to functional independence or to cognitive function  were search ed , as well as exercise training interventions that reported a functional outcome . Electronic data base search strategies were used to identify citations which were screened ( title and abstract ) for inclusion . Included articles were review ed to complete st and ardized data extraction tables , and assess study quality . An established system of assessing the level and grade of evidence for recommendations was employed . Results Sixty-six studies met inclusion criteria for the relationship between physical activity and functional independence , and 34 were included with a cognitive function outcome . Greater physical activity of an aerobic nature ( categorized by a variety of methods ) was associated with higher functional status ( expressed by a host of outcome measures ) in older age . For functional independence , moderate ( and high ) levels of physical activity appeared effective in conferring a reduced risk ( odds ratio ~0.5 ) of functional limitations or disability . Limitation in higher level performance outcomes was reduced ( odds ratio ~0.5 ) with vigorous ( or high ) activity with an apparent dose-response of moderate through to high activity . Exercise training interventions ( including aerobic and resistance ) of older adults showed improvement in physiological and functional measures , and suggestion of longer-term reduction in incidence of mobility disability . A relatively high level of physical activity was related to better cognitive function and reduced risk of developing dementia ; however , there were mixed results of the effects of exercise interventions on cognitive function indices . Conclusions There is a consistency of findings across studies and a range of outcome measures related to functional independence ; regular aerobic activity and short-term exercise programmes confer a reduced risk of functional limitations and disability in older age . Although a precise characterization of a minimal or effective physical activity dose to maintain functional independence is difficult , it appears moderate to higher levels of activity are effective and there may be a threshold of at least moderate activity for significant outcomes Reports of studies relating physical activity to stroke and cancer sub-types indicate inconsistent findings . Some are hampered by low statistical power , owing to a low number of events , and a failure to adjust for potential confounding variables . The purpose of this study was to relate physical activity to 12 mortality endpoints in a prospect i ve cohort study of 11,663 men aged 40–64 years who responded to an enquiry about travel activity during a baseline medical examination conducted between 1967 and 1969 . During 25 years of follow-up there were 4672  deaths .  Travel activity  was inversely related to mortality attributable to all-causes , coronary heart disease , respiratory disease and lung cancer , whereas the association with stroke was positive . There was evidence for attenuation of some of these associations on adjustment for potentially confounding variables . Our simplistic measure of physical activity may , in part , explain the weak associations seen A prospect i ve cohort study of London civil servants was used to examine the relation of physical activity to various causes of death .  6,702 men aged 40 - 64 y who participated in a baseline examination between 1969 and 1970 were followed up for 25 y during which time there were 2859 deaths . The association of two measures of physical activity ( leisure time activity and usual walking pace ) with cause-specific mortality was examined . Walking pace demonstrated inverse relations with mortality from all-causes , coronary heart disease ( CHD ) , other cardiovascular disease ( CVD ) , all cancers , respiratory disease , colorectal cancer and haematopoietic cancer following adjustment for risk factors which included age , employment grade , smoking , body mass index , and forced expiratory volume ( P [trend]<0.05 for all ) . In analyses restricted to men without disease at entry , walking pace retained inverse associations with all-cause , CHD , other cardiovascular disease , and haematopoietic cancer mortality ( P [trend]<0.05 for all ) .  Leisure time activity  was also inversely associated with mortality from all-causes , CHD , other CVD , and all-cancers following adjustment for risk factors ( P [trend]<0.05 for all ) . Eliminating deaths in the first 5 and 10 y of follow-up did not greatly alter these associations . It is concluded that physical activity may confer protection against death due to some cancers , in addition to reducing cardiovascular disease risk Objectives To investigate associations between modest levels of total and domain-specific ( commuting , other utility , recreational ) cycling and  mortality from all causes , cardiovascular disease and cancer . Design Population -based cohort study ( European Prospect i ve Investigation into Cancer and Nutrition study -Norfolk ) . Setting Participants were recruited from general practice s in the east of Engl and and attended health examinations between 1993 and 1997 and again between 1998 and 2000 . At the first health assessment , participants reported their average weekly duration of cycling for all purpose s using a simple measure of physical activity . At the second health assessment , participants reported a more detailed breakdown of their weekly cycling behaviour using the EPAQ2 physical activity question naire . Participants Adults aged 40–79 years at the first health assessment . Primary outcome measure All participants were followed for mortality ( all-cause , cardiovascular and cancer ) until March 2011 . Results There were 22 450 participants with complete data at the first health assessment , of whom 4398 died during follow-up ; and 13 346 participants with complete data at the second health assessment , of whom 1670 died during follow-up . Preliminary analyses using exposure data from the first health assessment showed that cycling for at least 60 min/week in total was associated with a 9 % reduced risk of all-cause mortality ( adjusted HR 0.91 , 95 % CI 0.84 to 0.99 ) . Using the more precise measures of cycling available from the second health assessment , all types of cycling were associated with greater total moderate-to-vigorous physical activity ; however , there was little evidence of an association between overall or domain-specific cycling and mortality . Conclusions Cycling , in particular for utility purpose s , was associated with greater moderate-to-vigorous and total physical activity . While this study provides tentative evidence that modest levels of cycling may reduce the risk of mortality , further research is required to confirm how much cycling is sufficient to induce health benefits INTRODUCTION Many breast cancer survivors experience problems with  cognitive functioning  that can persist years after treatment . Increasing physical activity has been shown to improve cognitive functioning in healthy and cognitively impaired adults , but has not yet been tested in cancer survivors . The primary aim of this r and omized controlled trial is to examine the effects of a 3-month physical activity intervention compared to a waitlist Control arm on neuropsychological outcomes and subjective cognitive concerns in breast cancer survivors . METHODS Eighty sedentary breast cancer survivors , self-reporting difficulties with cognition , will be r and omized into an Exercise arm or Control arm . The Exercise arm includes an activity tracker ( i.e. , a Fitbit ) , phone calls , plus tailored and non-tailored email content . The Control arm will receive emails on women 's health topics on the same schedule as the Exercise arm . Assessment s conducted at baseline and 3 months include : neuropsychological testing , cognitive concerns and other aspects of quality of life , and 7 days of a hip-worn accelerometer . Participants will also provide fasting blood draws to assess brain-derived neurotropic factor , Insulin-like growth factor 1 , insulin resistance , and C-reactive protein . Primary and secondary outcomes are changes in neuropsychological testing and cognitive concerns . Biomarkers will be examined to further underst and the underlying relationship between physical activity and cognition . CONCLUSION The Memory & Motion study is design ed to test whether increasing physical activity can improve cognitive functioning in breast cancer survivors . Results from this study could be used to guide development of interventions to improve cognitive functioning in breast cancer survivors BACKGROUND Patients with type 1 diabetes mellitus ( T1DM ) may experience poor muscle health as a result of chronic hyperglycemia . Despite this , muscle function in children with T1DM with good or poor glycemic control has yet to be examined in detail . OBJECTIVE To assess differences in muscle-related fitness variables in children with T1DM with good glycemic control ( T1DM-G ) , as well as those with poor glycemic control ( T1DM-P ) , and non-diabetic , healthy controls . SUBJECTS Eight children with T1DM-G [ glycosylated hemoglobin ( HbA1c ) ≤ 7.5 % for 9 months ] , eight children with T1DM-P ( HbA1c ≥ 9.0 % for 9 months ) , and eight healthy controls completed one exercise session .  METHODS Anaerobic and aerobic muscle functions were assessed with a maximal isometric grip strength test , a Wingate test , and an incremental continuous cycling test until exhaustion . Blood sample s were collected at rest to determine HbA1c at the time of testing . Physical activity  was monitored over 7 d using accelerometry . RESULTS Children with T1DM-P displayed lower peak oxygen consumption ( VO2peak ) values ( mL/kg/min ) compared to healthy controls ( T1DM-P : 33.2 ± 5.6 , controls : 43.5 ± 6.3 , p < 0.01 ) , while T1DM-G ( 43.5 ± 6.3 ) had values similar to controls and T1DM-P. There was a negative relationship between VO2peak and HbA1c% ( r = -0.54 , p < 0.01 ) . All groups were similar in all other fitness variables . There were no group differences in physical activity variables . CONCLUSION Children with T1DM-G did not display signs of impaired muscle function , while children with T1DM-P have signs of altered aerobic muscle capacity OBJECTIVE To examine whether improvements in health behaviors are associated with reduced risk of cardiovascular disease ( CVD ) in individuals with newly diagnosed type 2 diabetes . RESEARCH DESIGN AND METHODS Population -based prospect i ve cohort study of 867 newly diagnosed diabetic patients aged between 40 and 69 years from the treatment phase of the ADDITION-Cambridge study . Because the results for all analyses were similar by trial arm , data were pooled , and results were presented for the whole cohort . Participants were identified via  population -based stepwise screening between 2002 and 2006 , and underwent assessment of physical activity  ( European Prospect i ve Investigation into Cancer-Norfolk Physical Activity Question naire ) , diet ( plasma vitamin C and self-report ) , and alcohol consumption ( self-report ) at baseline and 1 year . A composite primary CVD outcome was examined , comprised of cardiovascular mortality , nonfatal myocardial infa rct ion , nonfatal stroke , and revascularization . RESULTS After a median ( interquartile range ) follow-up period of 5.0 years ( 1.3 years ) , 6 % of the cohort experienced a CVD event ( 12.2 per 1,000 person-years ; 95 % CI 9.3–15.9 ) . CVD risk was inversely related to the number of positive health behaviors changed in the year after diabetes diagnosis . The relative risk for primary CVD event in individuals who did not change any health behavior compared with those who adopted three/four healthy behaviors was 4.17 ( 95 % CI 1.02–17.09 ) , adjusting for age , sex , study group , social class , occupation , and prescription of cardioprotective medication ( P for trend = 0.005 ) . CONCLUSIONS CVD risk was inversely associated with the number of healthy behavior changes adopted in the year after the diagnosis of diabetes . Interventions that promote early achievement of these goals in patients with newly diagnosed diabetes could help reduce the burden of diabetes-related morbidity and mortality OBJECTIVES To describe the prevalence of self reported sleep disturbances in older men and women and to describe their relationships with health status and cardiovascular disease ( CVD ) . DESIGN Cross-sectional study of sleep disturbance , CVD , general health , psychosocial factors , physical function , and use of psychotropic medications . SETTING Participants of the Cardiovascular Health Study , 5201 adults aged 65 and older recruited from a r and om sample of noninstitutionalized Medicare enrollees in four US communities . MEASURES  Self-reported sleep disturbances and st and ardized question naires for cardiopulmonary symptoms and diseases , depression , social support , activities of daily living , physical activity , cognitive function , and current medications , spirometry , ECG , echocardiography , and carotid ultrasound . RESULTS Women were twice as likely as men to report difficulty falling asleep ( 30 % vs 14 % ) . Daytime sleepiness , difficulty falling asleep , and frequent awakenings increased in prevalence with age . All symptoms were related strongly to depression . Symptoms of daytime sleepiness were also related strongly to poor health and limitations in activities of daily living in men and women . In multivariate analysis , men taking benzodiazepines were likely to report difficulty falling asleep and daytime sleepiness , whereas women taking benzodiazepines reported difficulty falling asleep and waking up too early . After accounting for these factors , the only cardiovascular disease independently associated with sleep disturbances was angina . Men and women with confirmed angina were 1.6 times more likely to report trouble falling asleep . Independent relationships between sleep disturbances and cardiovascular risk factors such as obesity , hypertension , smoking , and diabetes were relatively weak and inconsistent , though smokers were less likely to report frequent awakenings . CONCLUSIONS Sleep disturbances are relatively common in older men and women and are associated with poor health , depression , angina , limitations in activities of daily living , and the use of benzodiazepines BACKGROUND Health behaviors of adults living with cardiovascular disease ( CVD ) risk factors affect additional risk , where lifestyle behavioral choices become even more important in controlling disease and preventing additional negative health outcomes . In addition , both lifestyle behaviors and CVD risk factor prevalence can vary by ethnicity . OBJECTIVE We compared multiple health behaviors of adults with diabetes , hypertension , high cholesterol , and obesity to the behaviors of adults without those conditions in a diverse ethnic sample to determine if significant differences existed between groups . METHODS Data were obtained from  30-minute r and om-digit-dial telephone surveys in 2007 ( n = 3607 ) . All data were self-reports . Healthy behaviors  included meeting recommendations for intake of fruits and vegetables ; consuming low or very low amounts of dietary fat ; eating breakfast six or seven days per week ; having a healthy diet ; and meeting recommendations for walking , moderate , and vigorous physical activity . Unhealthy behaviors included  frequent consumption of soda and fast food , smoking , binge drinking ,  and high stress .  RESULTS More than 6 % of respondents had diabetes , 15.9 % had hypertension , 16.4 % had high cholesterol , and 18.5 % were obese . Significantly fewer healthy and more unhealthy behaviors were reported for those who had CVD risk factors than were reported by those who did not have such conditions . Ethnic differences in CVD risk factor prevalence and health behaviors existed as well ( p < 0.001 ) . Logistic regression models indicated that not eating a healthy diet ( odds ratio [ OR ] = 1.82 ) was a significant predictor for diabetes ; not eating a healthy diet ( OR = 1.52 ) and not doing vigorous physical activity ( OR = 1.79 ) were significant predictors for hypertension ; consumption of high amounts of dietary fat ( OR = 1.70 ) and of fast food ( OR = 1.51 ) were significant predictors for high cholesterol levels ; and not eating a healthy diet ( OR = 1.52 ) , high consumption of dietary fat ( OR = 2.20 ) , not eating breakfast ( OR = 1.33 ) and not performing vigorous physical activity ( OR = 1.63 ) , but less consumption of fast food ( OR = 0.64 ) were significant predictors for obesity . CONCLUSIONS Specifically tailored and culturally sensitive interventions that address multiple health behaviors may be necessary for these high-risk population Objective : To examine the optimal intensity of leisure time physical activity ( LTPA ) to decrease the risk of all cause , cardiovascular disease ( CVD ) , and coronary heart disease ( CHD ) mortality in a population sample of middle aged British men . Design : Prospect i ve study of middle aged men with an 11 year follow up . Setting : A whole population sample of men from Caerphilly , South Wales , UK . Subjects : 1975 men aged 49–64 years without historical or clinical evidence of CHD at baseline examination . Main outcome measures : All cause , CVD , and CHD mortality . Results : Total ( cumulative ) LTPA had a grade d , significant relation with all cause , CVD , and CHD mortality but no trend with cancer deaths . When different intensities of activity were considered , light and moderate intensity LTPA had inconsistent and non-significant relations with all cause , CVD , or CHD mortality whether adjusted only for age or for other cardiovascular risk factors . In contrast a significant dose – response relation was found for heavy intensity LTPA for all cause , CVD , and CHD mortality fully adjusted for other risk factors . Conclusions : These data suggest that , in a population of men without evidence of CHD at baseline , only leisure exercise classified as heavy or vigorous was independently associated with reduced risk of premature death from CVD BACKGROUND An inverse association between moderate alcohol consumption and  coronary heart disease ( CHD ) has been observed in several epidemiological studies . To assess whether a similar association exists among diabetics , we examined the relation between light to moderate alcohol consumption and CHD in men with and without diabetes mellitus in a prospect i ve cohort study . METHODS AND RESULTS A total of 87 938 US physicians ( 2790 with diagnosed diabetes mellitus ) who were invited to participate in the Physicians ' Health Study and were free of myocardial infa rct ion , stroke , cancer , or liver disease at baseline were followed for an average of 5.5 years for death with CHD as the underlying cause . During 480 876 person-years of follow-up , 850 deaths caused by CHD were documented : 717 deaths among nondiabetic men and 133 deaths among diabetic men . Among men without diabetes at baseline , the relative risk estimates for those reporting rarely/never , monthly , weekly , and daily alcohol consumption were 1.00 ( referent ) , 1.02 , 0 . 82 , and 0.61 ( 95 % CI 0.49 to 0.78 ; P for trend < 0.0001 ) after adjustment for age , aspirin use , smoking , physical activity , body mass index , and history of angina , hypertension , and high cholesterol . Among men with diabetes at baseline , the relative risk estimates were 1.00 ( referent ) , 1.11 , 0.67 , and 0.42 ( 95 % CI 0.23 to 0.77 ; P for trend=0.0019 ) . CONCLUSIONS These results suggest that light to moderate alcohol consumption is associated with similar risk reductions in CHD among diabetic and nondiabetic men At the end of a long week in the office , you sink back into your chair , reflecting on some of the more memorable patients you cared for and counseled . Through gentle history taking , you discovered that urinary incontinence is the underlying cause of an elderly patient 's increasing social isolation . During a careful physical examination , you detected bruising on the torso of a woman with chronic headaches and began to explore the longst and ing abusive relationship between the woman and her alcoholic partner . You discontinued procainamide therapy in a 72-year-old man who had asymptomatic premature ventricular contractions after myocardial infa rct ion . To prevent bleeding from esophageal varices , you started -blocker therapy in a woman with long-st and ing cryptogenic cirrhosis and portal hypertension . In couples ' therapy , discussing the future quality of life of a middle-aged gay man with human immunodeficiency virus infection , you journeyed through emotionally intense dialogue about advance directives . You presented the risk factors for major and minor bleeding to a 39-year-old woman who was considering warfarin therapy because of recently diagnosed atrial fibrillation and valvular heart disease . You listened to , made diagnoses for , treated , advised , and comforted many patients . Yet there were some hiccoughs in your practice along the way . You stumbled while debating the pros and cons of breast cancer screening with a healthy 48-year-old woman who has been staying current with information on the Internet . You question ed the merits of a personalized walking program suggested to you by a motivated 66-year-old man with severe claudication . Explaining that you wanted to review the best current evidence on these issues , you resolved to address your uncertainties before these patients made their next office visits , in a week 's time . Sighing deeply , you acknowledge that you have little time to read . You subscribe to three journals , which you browse months after they arrive-either when your journal stack becomes precariously high or when your guilt is sufficiently motivational . You sometimes find the conclusions of individual articles conflicting or confusing . You know that some of the decisions and suggestions you made this week , specifically your decisions about stopping procainamide therapy and starting -blocker therapy and your advice about bleeding risks from anticoagulant therapy , were based on the best current research evidence [ 1 - 3 ] . On the other h and , your patients ' inquiries about breast cancer screening and exercise treatment for claudication highlight your need for a concise , current , rigorous synthesis of the best available evidence on each of these topics : in brief , a systematic review [ 4 , 5 ] . Incorporating Research Evidence into Clinical Decision Making The foregoing scenario is familiar to practitioners . In a typical week , we encounter patients with diverse problems ; exercise numerous clinical , interpersonal , and technical skills ; and make many decisions . The factors that affect these decisions and their outcomes are complex . For instance , each patient has unique sociodemographic characteristics , cultural circumstances , and personal preferences . Each physician has unique knowledge , experiences , and values . Moreover , practitioners and their patients make decisions within the context of a rapidly changing health care system that influences the availability , accessibility , and cost of diagnostic tests and therapies [ 6 ] . Timely , useful evidence from the biomedical literature should be an integral component of clinical decision making . If one treatment has been shown to be better than another , we need to know , so that we can recommend the treatment to the appropriate patients . The worldwide effort to develop new tests and treatments , and to determine their usefulness , has never been stronger , and our patients and their families expect us to be fonts of the knowledge that results from this effort [ 7 ] . Unfortunately , it is easy for current best research evidence to pass us by [ 8 ] . We may lack the time , motivation , and basic skills needed to find , critically appraise , and synthesize information , all of which we must do if we are to integrate the results of original studies into our practice . Fortunately , several potent methods are emerging that can greatly enhance our ability to interpret and apply research evidence ; foremost among them is the systematic review . This article begins a series in Annals that will examine systematic review s in detail and explore their many applications . Systematic review s represent the best chance that most practitioners will have to underst and and accurately apply the key signals arising from the robust and increasingly productive search for solutions to medical problems . A properly conducted systematic review faithfully summarizes the evidence from all relevant studies on the topic of interest , and it does so concisely and transparently . What Is a Systematic Review ? Systematic review s are scientific investigations in themselves , with pre-planned methods and an assembly of original studies as their subjects . They synthesize the results of multiple primary investigations by using strategies that limit bias and r and om error [ 9 , 10 ] . These strategies include a comprehensive search of all potentially relevant articles and the use of explicit , reproducible criteria in the selection of articles for review . Primary research design s and study characteristics are appraised , data are synthesized , and results are interpreted . When the results of primary studies are summarized but not statistically combined , the review may be called a qualitative systematic review . A quantitative systematic review , or meta- analysis , is a systematic review that uses statistical methods to combine the results of two or more studies . The term overview is sometimes used to denote a systematic review , whether quantitative or qualitative . Summaries of research that lack explicit descriptions of systematic methods are often called narrative review s. Review articles are one type of integrative publication ; practice guidelines , economic evaluations , and clinical decision analyses are others . These other types of integrative articles often incorporate the results of systematic review s. For example , practice guidelines are systematic ally developed statements intended to assist practitioners and patients with decisions about appropriate health care for specific clinical circumstances [ 11 ] . Evidence -based practice guidelines are based on systematic review s of the literature , appropriately adapted to local circumstances and values . Economic evaluations compare both the costs and the consequences of different courses of action ; the knowledge of consequences that are considered in these evaluations is often generated by systematic review s of primary studies . Decision analyses quantify both the likelihood and the valuation of the expected outcomes associated with competing alternatives . Differences between Systematic and Narrative Review s All review s , narrative and systematic alike , are retrospective , observational research studies and are therefore subject to systematic and r and om error . Accordingly , the quality of a review - and thus its worth-depends on the extent to which scientific review methods have been used to minimize error and bias . This is the key feature that distinguishes traditional narrative review s from systematic review s ( Table 1 ) . If a review is prepared according to the steps outlined in the right column of Table 1 , it is more likely to be systematic and to provide unbiased conclusions . If review methods approximate those found in the middle column of Table 1 , the article is more likely to be a narrative review , and the conclusions are less likely to be based on an unbiased summary of all relevant evidence . Table 1 . Differences between Narrative Review s and Systematic Review s Systematic review s are generated to answer specific , often narrow , clinical questions in depth . These questions can be formulated explicitly according to four variables : a specific population and setting ( such as elderly out patients ) , the condition of interest ( for example , hypertension ) , an exposure to a test or treatment ( such as pharmacologic management ) , and one or more specific outcomes ( such as cardiovascular and cerebrovascular events and mortality ) [ 12 ] . Thus , an example of a well-formulated , clinical ly relevant question is , Does pharmacologic treatment of hypertension in the elderly prevent strokes and myocardial infa rct ions or delay death ? If the question that is driving the review is not clear from the title , abstract , or introduction , or if no methods section is included , the paper is more likely to be a narrative review than a systematic review [ 13 ] . Most narrative review articles deal with a broad range of issues related to a given topic rather than addressing a particular issue in depth [ 9 ] . For example , a narrative review on diabetes ( such as that which might be found in a textbook chapter ) might include sections on the physiology and pathophysiology of carbohydrate , lipid , and protein metabolism ; the epidemiology of and prognosis associated with diabetes ; diagnostic and screening approaches ; and preventive , therapeutic , rehabilitative , and palliative interventions . Thus , narrative review s may be most useful for obtaining a broad perspective on a topic ; they are less often useful in furnishing quantitative answers to specific clinical questions . Narrative review s are appropriate for describing the history or development of a problem and its management . Narrative review s may better describe cutting-edge developments if research is scant or preliminary or if studies are very limited by flawed design or execution [ 13 ] . They may be particularly useful for discussing data in light of underlying theory and context . Narrative review s can draw analogies and can conceptually integrate two independent fields of research , such as Introduction Challenges exist in identifying , recruiting and motivating sedentary patients with cancer to initiate physical activity towards recommended levels . We hypothesise that the onset period of adjuvant chemotherapy can be ‘ the open window of opportunity ’ to identify and motivate sedentary patients with breast and colon cancers , at risk for developing coronary heart disease , to initiate and sustain lifestyle changes . Aims To investigate the feasibility of oncologists/nurses screening for physical inactivity , in order to identify and recruit an at-risk population of sedentary patients with breast or colon cancer at the onset of adjuvant chemotherapy . Furthermore , the study will examine the adherence to one of two multimodal exercise interventions lasting 12 weeks ; ( 1 ) hospital-based , high intensity , group exercise intervention ( 2 ) home-based , low intensity , individual , pedometer intervention . Both arms will be compared with a control group . Methods and analyses All newly referred patients will be screened for sedentary behaviour , using national recommendations . Testing at baseline , 6 , 12 and 39 weeks will include ; ( 1 ) physiological testing ( VO2-peak , one repetition maximum muscle strength and lung function ( 2 ) fasting full body dual-energy X-ray absorptiometry scan ( 3 ) fasting blood glucose , insulin , lipids and cholesterols , ( 4 ) psychometric question naires ( general well-being , quality of life , anxiety and depression , motivational readiness ) . The r and omised controlled trial feasibility design is selected in order to examine barriers for recruitment , programme adherence , safety aspects and potential efficacy to the interventions during adjuvant chemotherapy . Ethics and dissemination The Scientific Committee of the Capital Region ( case No. H-1 - 2011 - 131 ) and the Danish Data Protection Agency ( j. No. 2011 - 41 - 6349 ) approved the study . Data will be entered and locked into a data base hosted by the Copenhagen Trial Unit , Rigshosptialet . Data will be available for analyses to project members and the trial statistician after the 45 included patients have completed the 12-week test . Results will be published in peer- review ed scientific journals . Trial registration Current Controlled Trials IS RCT N24901641 Atherosclerotic cardiovascular disease ( ASCVD ) is the leading cause of death , decreased quality of life , and medical costs in the United States . Nearly 1 in 3 Americans die of heart disease and stroke ( 1 ) . Most ASCVD is preventable through a healthy lifestyle and effective treatment of cholesterol and blood pressure . The 2013 Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults from the American College of Cardiology and American Heart Association ( ACC/AHA ) provides an evidence -based approach to reducing ASCVD risk ( 2 ) . Guideline Development Process In 2008 , the National Heart , Lung , and Blood Institute ( NHLBI ) convened the Adult Treatment Panel ( ATP ) IV to up date the 2001 ATP-III cholesterol guidelines using a rigorous systematic process to identify and review r and omized , controlled trials ( RCTs ) with cardiovascular outcomes and meta-analyses of these RCTs . The panel comprised experts and clinicians from the fields of cardiology , epidemiology , primary care , and endocrinology ( 2 ) and received support from the Lifestyle Management and Risk Assessment Work Groups ( 3 , 4 ) . Systematic evidence review s conducted according to principles recommended by the Institute of Medicine ( 5 ) were performed to answer 3 questions relevant to clinical care . Two questions focused on the evidence supporting low-density lipoprotein cholesterol ( LDL-C ) and nonhigh-density lipoprotein cholesterol ( HDL-C ) levels as targets of treatment . One question examined the reduction in ASCVD events and adverse effects for each cholesterol-lowering drug class . The panel synthesized the evidence from these 3 review s as well as from Lifestyle Management and Risk Assessment Work Groups review s ( 3 , 4 ) that addressed 5 additional critical questions . Systematic electronic search es of relevant data bases of the peer- review ed English- language literature published from 1 January 1995 through 1 December 2009 for each critical question were conducted by an NHLBI-selected independent contractor and focused on RCTs and systematic review s and meta-analyses of RCTs assessed as fair to good quality . In addition , RCTs with ASCVD outcomes that included coronary heart disease , stroke , and cardiovascular deaths published after that date were eligible for consideration through July 2013 . Evidence tables were constructed , and the strength of evidence was rated according to the NHLBI ( Table 1 of the Supplement ) . Recommendations were grade d according to criteria from the NHLBI ( Table 2 of the Supplement ) and ACC/AHA ( Table 3 of the Supplement ) . Because of the inherent differences in grading systems and the clinical questions driving the recommendations , alignment between the NHLBI and ACC/AHA formats was imperfect . A complete description of the methods used and results of the evidence review are provided in the guideline ( 2 ) and the NHLBI evidence report ( www.nhlbi.nih.gov/ guidelines /cholesterol/ser/index.htm ) . Supplement . NHLBI and ACC/AHA Criteria for Rating Strength of Evidence To help clinicians estimate ASCVD risk , the risk assessment working group developed the Pooled Cohort Equations using data from 5 NHLBI-sponsored longitudinal , population -based cohorts of African American and non-Hispanic white men and women to estimate risk for a first myocardial infa rct ion , coronary heart disease death , or fatal or nonfatal stroke on the basis of age , sex , race , smoking status , total cholesterol level , HDL-C level , systolic blood pressure , antihypertensive therapy , and diabetes ( 4 , 6 ) . These equations significantly advance ASCVD risk estimation by providing sex- and race-specific estimates and including stroke as an outcome . The earlier Framingham equations calculated only coronary heart disease risk for non-Hispanic whites . The draft recommendations were review ed by 23 experts and representatives of federal agencies identified by the NHLBI . In September 2013 , the recommendations developed by the panel were transitioned to the ACC/AHA and had additional review by 4 experts nominated by the ACC Foundation and the AHA . The governing bodies of the ACC and AHA approved the guideline , which also received endorsement from the American Association of Cardiovascular and Pulmonary Rehabilitation , American Pharmacists Association , American Society for Preventive Cardiology , Association of Black Cardiologists , Preventive Cardiovascular Nurses Association , and WomenHeart : The National Coalition for Women with Heart Disease . Recommendations The guideline focuses on treatment of blood cholesterol to reduce ASCVD risk in adults . Major recommendations are summarized here and in Table 1 . The guideline report provides a complete listing of recommendations and supporting evidence behind each recommendation ( 2 ) . Table 1 . Major Recommendations for the Treatment of Blood Cholesterol to Reduce ASCVD Risk in Adults * 1 . Encourage Adherence to a Healthy Lifestyle A healthy lifestyle is the foundation for cardiovascular health . The panel endorsed the 2013 ACC/AHA Lifestyle Management Guideline ( 3 ) for a diet that is low in saturated fat , trans fat , and sodium ; emphasizes vegetables , fruits , whole grains , low-fat dairy products , poultry , fish , legumes , nontropical vegetable oils , and nuts ; and limits sweets , sugar-sweetened beverages , and red meats and engage in regular aerobic physical activity . Adults also should maintain a healthy body weight , avoid smoking , and control hypertension and diabetes when present . 2 . Statin Therapy Is Recommended for Adults in Groups Demonstrated to Benefit Strong RCT evidence shows that reduction in ASCVD events from statin therapy exceeds adverse events for 4 patient groups : those with clinical ASCVD ( acute coronary syndromes , myocardial infa rct ion , stable angina , coronary or other arterial revascularization , stroke , transient ischemic attack , or peripheral arterial disease of atherosclerotic origin ) when  statins are used for secondary prevention , and those with LDL-C levels 190 mg/dL ; those aged 40 to 75 years with diabetes and LDL-C levels 70 to 189 mg/dL ; and those aged 40 to 75 years without diabetes and with a 10-year ASCVD risk 7.5 % when statins are used for primary prevention . Moderate evidence supports consideration of statin therapy for primary prevention in individuals with a 10-year ASCVD risk of 5 % to < 7.5 % . Routine initiation of statin therapy is not recommended in adults with New York Heart Association heart failure class II to IV or those receiving maintenance hemodialysis . R and omized , controlled trials in these groups showed no reduction in ASCVD . 3 . Statins have an Acceptable Margin of Safety When Used in Properly Selected Individuals and Appropriately Monitored Strong RCT evidence supports safety of statins when they are used as directed in conjunction with regular follow-up assessment s in properly selected patients . Adjustment of statin intensity is recommended in individuals older than 75 years with a history of statin intolerance or other characteristics ( 2 ) or those receiving drug therapy that may increase statin adverse events . Routine monitoring of hepatic aminotransferase level or creatine kinase level is not recommended unless clinical ly indicated by symptoms suggesting hepatotoxicity or myopathy . Given the potential for decreasing ASCVD events and death , the relationship of muscle and other symptoms to statin treatment must be confirmed . Therefore , eliciting a history of muscle symptoms before statin initiation and carefully monitoring symptoms during statin discontinuation and rechallenge is recommended . Severe myopathy , rhabdomyolysis , and possibly hemorrhagic stroke are rare complications of statin therapy . Although statin therapy modestly increases the risk for type 2 diabetes , ASCVD risk reduction outweighs the excess risk for diabetes for high-intensity statins in secondary prevention or for 10-year ASCVD risk 7.5 % . Similarly , ASCVD risk reduction outweighs the excess risk for diabetes for moderate-intensity statin therapy in adults with a 10-year ASCVD risk 5 % . 4 . Engage in a ClinicianPatient Discussion Before Initiating Statin Therapy , Especially for Primary Prevention in Patients With Lower ASCVD Risk Decisions to initiate statin therapy in primary prevention should be based on clinical judgment and preferences of informed patients . In adults without clinical ASCVD or diabetes whose LDL-C level is < 190 mg/dL , calculating the estimated 10-year ASCVD risk should be the start of the clinicianpatient discussion and should not automatically lead to statin initiation . As the absolute risk for ASCVD events decreases , so does the net benefit of the intervention . Therefore , discussion of the potential for ASCVD event reduction , adverse effects , drugdrug interactions , and patient preferences is especially important for lower-risk primary prevention . The discussion provides the opportunity to encourage healthy lifestyle habits and control other risk factors . Additional factors may be considered when a risk-based decision is uncertain , including LDL-C levels 160 mg/dL , family history of premature ASCVD , elevated  lifetime ASCVD risk  , high-sensitivity C-reactive protein level 2.0 mg/L ,  coronary artery calcification score  > 300 Agatston units , and anklebrachial index < 0.9 . After age 75 years , comorbid conditions , anticipated longevity , safety considerations , and patient preferences should play a large role in decision making . 5 . Use the Newly Developed Pooled Cohort Equations for Estimating 10-Year ASCVD Risk The Pooled Cohort Equations are currently the best available method for estimating 10-year ASCVD risk to guide statin initiation ( 4 , 6 ) . Application of the inclusion and exclusion criteria from RCTs is cumbersome and results in underidentifying high-risk and overidentifying low-risk individuals for statin treatment . The Pooled Cohort Equations were developed using recent data from 5 NHLBI-sponsored , longitudinal , population -based cohorts of African American and white men and women ( ARIC [ PURPOSE The objective is to examine the association between  physical activity level ( PAL )  and incident type 2 diabetes among middle-age and older Chinese men and women in urban China . METHODS This prospect i ve study included 6348 participants ( age 35 to 74 yr ) who were free of diabetes and cardiovascular disease at baseline .  PAL was estimated on the basis of self-reported overall physical activity on a typical day . According to PAL , participants were classified into four groups : sedentary ( PAL , 1.00 - 1.39 ) , low active ( PAL , 1.40 - 1.59 ) , active ( PAL , 1.60 - 1.89 ) , and very active ( PAL , > 1.89 ) . The association of PAL with incident diabetes was examined by Cox proportional hazards model . RESULTS During 7.9 yr of follow-up ( 50,293 person-years ) , 478 incident cases of type 2 diabetes were identified . After adjustment for age , sex , geographic region , educational level , smoking , alcohol use , and family history of diabetes , the HR ( 95 % CI ) values for type 2 diabetes across increasing categories of PAL were 1.00 ( reference ) , 0.82 ( 0.62 - 1.09 ) , 0.63 ( 0.47 - 0.83 ) , and 0.47 ( 0.36 - 0.61 ) , respectively ( P for trend < 0.0001 ) . Additional adjustment for baseline body mass index or waist circumference attenuated the magnitude of risk reduction , but it remained significant . The inverse association between PAL and risk of incident diabetes was persistent in subgroup analyses according to age , sex , hypertension , smoking , body mass index , waist circumference , and fasting plasma glucose level . CONCLUSIONS Higher PAL is associated with substantial reduction in risk of type 2 diabetes . Our findings suggest the importance of a physically active lifestyle in the prevention of diabetes PURPOSE Physical activity ( PA ) has been suggested to help increase the survival of individuals with cancer . The objective of this review was to systematic ally evaluate and summarize the available evidence investigating the effect of PA on the survival of individuals with cancer . METHODS Electronic data bases ( CINAHL , EMBASE , and MEDLINE ) were systematic ally search ed for r and omized controlled trials and cohort studies . Selected studies were assessed by two independent investigators for method ological quality , using the PEDro scale . RESULTS Ten prospect i ve cohort studies met the inclusion criteria . Quality - assessment scores averaged 5/10 on the PEDro scale , with two articles obtaining a score of 6/10 . The majority of studies found that individuals participating in higher levels of physical activity had a reduced risk of cancer-related mortality . This trend was observed specifically for breast , colon , and colorectal cancers . On average , it appears that engaging in higher levels of metabolic equivalent hours per week may help to improve survival rates among individuals diagnosed with cancer . CONCLUSION Patients diagnosed with cancer demonstrated a trend toward increased survival with greater levels of PA . However , because only prospect i ve cohort studies were included in the study , the conclusions drawn should be regarded with caution OBJECTIVE The aim of this study was to examine both single and joint associations of physical activity and conventional cardiovascular risk factors with total and cardiovascular mortality among patients with diabetes . RESEARCH DESIGN AND METHODS We prospect ively followed 3,708 Finnish patients with type 2 diabetes aged 25 - 74 years .  Physical activity , smoking status , blood pressure , height , weight , and serum cholesterol level were determined at baseline . Cox proportional hazard models were used to estimate single and joint effects of physical activity and other cardiovascular risk factors on the risk of mortality . RESULTS During a mean follow-up of 18.7 years , 1,423 deaths were recorded , 906 of which were due to cardiovascular disease . Moderate or high levels of physical activity were associated with decreased total and cardiovascular mortality , whereas higher levels of BMI and blood pressure and current smoking were associated with increased total and cardiovascular mortality . High serum cholesterol levels also increased cardiovascular mortality . The protective effect of physical activity was consistent in diabetic patients with any levels of BMI , blood pressure , total cholesterol , and smoking . CONCLUSIONS A moderate or high level of physical activity was associated with a reduced risk of total and cardiovascular mortality among patients with type 2 diabetes . The favorable association of physical activity with longevity was observed regardless of the levels of BMI , blood pressure , total cholesterol , and smoking INTRODUCTION Engaging in > 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity physical activity weekly is recommended for optimal health . The relationship between walking , the most common activity especially for older adults , and total mortality is not well documented . METHODS Data from a large U.S. prospect i ve cohort study including 62,178 men ( mean age 70.7 years ) and 77,077 women ( mean age 68.9 years ) , among whom 24,688 men and 18,933 women died during 13 years of follow-up ( 1999 - 2012 ) , were used to compute multivariable-adjusted hazard rate ratios and 95 % CIs for walking as the sole form of activity or adjusted for other moderate- or vigorous-intensity physical activity in relation to total and cause-specific mortality ( data analysis 2015 - 2016 ) . RESULTS Inactivity compared with walking only at less than recommended levels was associated with higher all-cause mortality ( hazard rate ratio=1.26 , 95 % CI=1.21 , 1.31 ) . Meeting one to two times the recommendations through walking only was associated with lower all-cause mortality ( hazard rate ratio=0.80 , 95 % CI=0.78 , 0.83 ) . Associations with walking adjusted for other moderate- or vigorous-intensity physical activity were similar to walking only . Walking was most strongly associated with respiratory disease mortality followed by cardiovascular disease mortality and then cancer mortality . CONCLUSIONS In older adults , walking below minimum recommended levels is associated with lower all-cause mortality compared with inactivity . Walking at or above physical activity recommendations is associated with even greater decreased risk . Walking is simple , free , and does not require any training , and thus is an ideal activity for most Americans , especially as they age CONTEXT Declines in physical performance are associated with aging and chronic health conditions . Appropriate physical activity interventions can reverse functional limitations and help maintain independent living . Tai chi is a popular form of exercise in China among older adults . OBJECTIVE To determine whether tai chi improves balance , muscular strength and endurance , and flexibility over time . DESIGN Repeated measures intervention ; data collected at baseline , 6 weeks , and 12 weeks . SETTING Community center in the San Francisco Bay Area . PARTICIPANTS Thirty-nine Chinese adults with at least 1 cardiovascular disease ( CVD ) risk factor . INTERVENTIONS A 60-minute tai chi exercise class 3 times per week for 12 weeks . MAIN OUTCOME MEASURES A battery of physical fitness measures specifically developed for older adults assessed balance , muscular strength and endurance , and flexibility . RESULTS Subjects were 65.7 ( + /- 8.3 ) years old , Cantonese-speaking ( 97 % ) immigrants , with 12 years or less of formal education ( 87 % ) and very low income ( 67 % ) . Reported CVD risk factors were hypertension ( 92 % ) , hypercholesteremia ( 49 % ) , diabetes ( 21 % ) , and 1 current smoker . Subjects were below the 50th percentile of fitness at baseline compared to age- and gender-specific normative US data . Statistically significant improvements were observed in all balance , muscular strength and endurance , and flexibility measures after 6 weeks , and they increased further after 12 weeks . CONCLUSIONS Tai chi is a potent intervention that improved balance , upper- and lower-body muscular strength and endurance , and upper- and lower-body flexibility in these older Chinese adults . These findings provide important information for future community-based tai chi exercise programs and support current public health initiatives to reduce disability from chronic health conditions and enhance physical function in older adults BACKGROUND Evidence is limited regarding the impact of healthy lifestyle practice s on the risk of subsequent cardiovascular events among patients with diabetes . OBJECTIVES The purpose of this study was to examine the associations of an overall healthy lifestyle , defined by eating a high- quality diet ( top two-fifths of Alternative Healthy Eating Index ) , nonsmoking , engaging in moderate- to vigorous-intensity physical activity ( ≥150 min/week ) , and drinking alcohol in moderation ( 5 to 15 g/day for women and 5 to 30 g/day for men ) , with the risk of developing cardiovascular disease ( CVD ) and CVD mortality among adults with type 2 diabetes ( T2D ) . METHODS This prospect i ve analysis included 11,527 participants with T2D diagnosed during follow-up ( 8,970 women from the Nurses ' Health Study and 2,557 men from the Health Professionals Follow-Up Study ) , who were free of CVD and cancer at the time of diabetes diagnosis .  Diet and lifestyle factors before and after T2D diagnosis were repeatedly assessed every 2 to 4 years . RESULTS There were 2,311 incident CVD cases and 858 CVD deaths during an average of 13.3 years of follow-up . After multivariate adjustment of covariates , the low-risk lifestyle factors after diabetes diagnosis were each associated with a lower risk of CVD incidence and CVD mortality . The multivariate-adjusted hazard ratios for participants with 3 or more low-risk lifestyle factors compared with 0 were 0.48 ( 95 % confidence interval [ CI ] : 0.40 to 0.59 ) for total CVD incidence , 0.53 ( 95 % CI : 0.42 to 0.66 ) for incidence of coronary heart disease , 0.33 ( 95 % CI : 0.21 to 0.51 ) for stroke incidence , and 0.32 ( 95 % CI : 0.22 to 0.47 ) for CVD mortality ( all p trend < 0.001 ) . The population -attributable risk for poor adherence to the overall healthy lifestyle ( <3 low-risk factors ) was 40.9 % ( 95 % CI : 28.5 % to 52.0 % ) for CVD mortality . In addition , greater improvements in healthy lifestyle factors from pre-diabetes to post-diabetes diagnosis were also significantly associated with a lower risk of CVD incidence and CVD mortality . For each number increment in low-risk lifestyle factors there was a 14 % lower risk of incident total CVD , a 12 % lower risk of coronary heart disease , a 21 % lower risk of stroke , and a 27 % lower risk of CVD mortality ( all p < 0.001 ) . Similar results were observed when analyses were stratified by diabetes duration , sex/cohort , body mass index at diabetes diagnosis , smoking status , and lifestyle factors before diabetes diagnosis . CONCLUSIONS Greater adherence to an overall healthy lifestyle is associated with a substantially lower risk of CVD incidence and CVD mortality  among adults with T2D . These findings further support the tremendous benefits of adopting a healthy lifestyle in reducing the subsequent burden of cardiovascular complications in patients with T2D Evidence is emerging that physical activity ( PA ) may improve overall survival after breast cancer diagnosis . However , the effect of PA on breast cancer recurrence and on cause-specific mortality is less investigated . We assessed the association of pre-diagnosis PA with recurrence , overall and cause-specific survival in a prospect i ve cohort study in Germany including 3,393 non-metastatic breast cancer patients aged 50 - 74 years .  Cox proportional hazards models were calculated adjusted for relevant prognostic factors . During a median follow-up of 5.6 years , 367 patients deceased .  Overall mortality was significantly inversely associated with pre-diagnosis recreational PA . However , this effect was mainly attributed to deaths due to causes other than breast cancer . Multiple fractional polynomial analyses yielded a nonlinear association with markedly increased non-breast cancer mortality for women who did not engage in any sports or cycling in the years before the breast cancer diagnosis with a hazard ratio ( HR , none vs. any ) of 1.71 , 95 % confidence interval ( 1.16 , 2.52 ) . There were no further risk reductions with increasing activity levels . The association with breast cancer-specific mortality showed a similar dose-response but was far less pronounced with HR ( none vs. any ) = 1.22 ( 0.91 , 1.64 ) . In contrast , regarding cancer recurrence the dose-response was linear . However , this association was restricted to estrogen/progesterone receptor-negative ( ER-/PR- ) cases ( p interaction = 0.033 ) with HR ( highest vs. no recreational PA ) = 0.53 ( 0.24 , 1.16 ) , p trend = 0.0045 . Thus , breast cancer patients with a physically inactive lifestyle pre-diagnosis may decease prematurely irrespective of their cancer prognosis . Higher levels of exercise may reduce the risk of recurrence of ER-/PR- breast tumors OBJECTIVE A 2-year follow-up study of a cohort of 200 historically disadvantaged older South Africans was conducted to : ( i ) characterise current levels of habitual physical activity ; ( ii ) relate physical activity to current risk factors for chronic disease ; and ( iii ) identify risk factors associated with 2-year mortality . The baseline sample , drawn in 1993 , was found to have a high prevalence of hypertension ( 71.7 % ) . RESEARCH DESIGN Retrospective cohort study . METHODS A baseline sample of 200 persons aged > or = 65 years , resident in the Cape Peninsula , was r and omly drawn by means of a two-stage cluster design . Baseline measurements included : anthropometry , waist/hip ratio , systolic and diastolic blood pressure , body mass index ( BMI ) , serum albumin , serum ferritin , haemoglobin and fasting plasma glucose levels , plasma lipid profiles , oral glucose tolerance test and self-reported health status . Subjects were revisited after 2 years , at which time an adapted version of the Yale Physical Activity Survey was administered and measurements of blood pressure and anthropometry were repeated . STATISTICAL ANALYSES Spearman 's rank-order correlations were used to describe relationships between various current risk factors and physical activity . Logistic regression was used to determine predictors of 2-year mortality from baseline data . RESULTS At follow-up , 142 of the subjects ( 66 men , 76 women ) were traced and measurements collected . Thirty-two subjects were reported to have died by relatives living in the same household ( 22 men , 10 women ) . Levels of reported physical activity  in the survivors were two-thirds lower than those reported in a sample of North Americans of similar age . There was an inverse association between age and physical activity ( r = -0.31 ; P < 0.0005 ) and a positive association between BMI and physical activity ( r = 0.29 ; P < 0.005 ) . There was , however , no association between physical activity and systolic or diastolic blood pressure . In men , BMI in the lower tertile ( P = 0.07 ) and serum ferritin levels were positively associated with increased mortality . Serum albumin levels were protective over the 2-year follow-up period ( OR = 0.85 ; P < 0.05 ) . In women , being diabetic ( OR = 4.88 ; P = 0.06 ) and having a waist/hip ratio in the upper tertile ( OR = 3.26 ; P = 0.06 ) were associated with mortality . CONCLUSIONS Physical activity levels in this sample of older historically disadvantaged South Africans were habitually low . Simple anthropometric assessment s incorporating weight and waist/hip ratio , together with serum albumin measurements , may be useful to screen general health risk for older adults at primary care level and provide indications for social or medical intervention . Further , strategies for earlier detection and effective management of diabetes , particularly in older women , may reduce premature mortality in this population CONTEXT Recent guidelines for treatment of overweight and obesity include recommendations for risk stratification by disease conditions and cardiovascular disease ( CVD ) risk factors , but the role of physical inactivity is not prominent in these recommendations . OBJECTIVE To quantify the influence of low cardiorespiratory fitness , an objective marker of physical inactivity , on CVD and all-cause mortality in normal-weight , overweight , and obese men and compare low fitness with other mortality predictors . DESIGN Prospect i ve observational data from the Aerobics Center Longitudinal Study . SETTING Preventive medicine clinic in Dallas , Tex . PARTICIPANTS A total of 25714 adult men ( average age , 43.8 years [ SD , 10.1 years ] ) who received a medical examination during 1970 to 1993 , with mortality follow-up to December 31 , 1994 . MAIN OUTCOME MEASURES Cardiovascular disease and all-cause mortality based on mortality predictors ( baseline CVD , type 2 diabetes mellitus , high serum cholesterol level , hypertension , current cigarette smoking , and low cardiorespiratory fitness ) stratified by body mass index . RESULTS During the study period , there were 1025 deaths ( 439 due to CVD ) during 258781 man-years of follow-up . Overweight and obese men with baseline CVD or CVD risk factors were at higher risk for all-cause and CVD mortality compared with normal-weight men without these predictors . Using normal-weight men without CVD as the referent , the strongest predictor of CVD death in obese men was baseline CVD ( age- and examination year-adjusted relative risk [ RR ] , 14.0 ; 95 % confidence interval [ CI ] , 9.4 - 20.8 ) ; RRs for obese men with diabetes mellitus , high cholesterol , hypertension , smoking , and low fitness were similar and ranged from 4.4 ( 95 % CI , 2.7 - 7.1 ) for smoking to 5.0 ( 95 % CI , 3.6 - 7.0 ) for low fitness . Relative risks for all-cause mortality in obese men ranged from 2.3 ( 95 % CI , 1.7 - 2.9 ) for men with hypertension to 4.7 ( 95 % CI , 3.6 - 6.1 ) for those with CVD at baseline . Relative risk for all-cause mortality in obese men with low fitness was 3.1 ( 95 % CI , 2.5 - 3.8 ) and in obese men with diabetes mellitus 3.1 ( 95 % CI , 2.3 - 4.2 ) and as slightly higher than the RRs for obese men who smoked or had high cholesterol levels . Low fitness was an independent predictor of mortality in all body mass index groups after adjustment for other mortality predictors . Approximately 50 % ( n = 1674 ) of obese men had low fitness , which led to a population -attributable risk of 39 % for CVD mortality and 44 % for all-cause mortality . Baseline CVD had population attributable risks of 51 % and 27 % for CVD and all-cause mortality , respectively . CONCLUSIONS In this analysis , low cardiorespiratory fitness was a strong and independent predictor of CVD and all-cause mortality and of comparable importance with that of diabetes mellitus and other CVD risk factors Abstract Objective To assess the prospect i ve associations of baseline and long term trajectories of physical activity on mortality from all causes , cardiovascular disease , and cancer . Design Population based cohort study . Setting Adults from the general population in the UK . Participants 14 599 men and women ( aged 40 to 79 ) from the European Prospect i ve Investigation into Cancer and Nutrition-Norfolk cohort , assessed at baseline ( 1993 to 1997 ) up to 2004 for lifestyle and other risk factors ; then followed to 2016 for mortality ( median of 12.5 years of follow-up , after the last exposure assessment ) . Main exposure  Physical activity energy expenditure ( PAEE ) derived from question naires , calibrated against combined movement and heart rate monitoring . Main outcome measures Mortality from all causes , cardiovascular disease , and cancer . Multivariable proportional hazards regression models were adjusted for age , sex , sociodemographics , and changes in medical history , overall diet quality , body mass index , blood pressure , triglycerides , and cholesterol levels . Results During 171 277 person years of follow-up , 3148 deaths occurred . Long term increases in PAEE were inversely associated with mortality , independent of baseline PAEE . For each 1 kJ/kg/day per year increase in PAEE ( equivalent to a trajectory of being inactive at baseline and gradually , over five years , meeting the World Health Organization minimum physical activity guidelines of 150 minutes/week of moderate-intensity physical activity ) , hazard ratios were : 0.76 ( 95 % confidence interval 0.71 to 0.82 ) for all cause mortality , 0.71 ( 0.62 to 0.82 ) for cardiovascular disease mortality , and 0.89 ( 0.79 to 0.99 ) for cancer mortality , adjusted for baseline PAEE , and established risk factors . Similar results were observed when analyses were stratified by medical history of cardiovascular disease and cancer . Joint analyses with baseline and trajectories of physical activity show that , compared with consistently inactive individuals , those with increasing physical activity trajectories over time experienced lower risks of mortality from all causes , with hazard ratios of 0.76 ( 0.65 to 0.88 ) , 0.62 ( 0.53 to 0.72 ) , and 0.58 ( 0.43 to 0.78 ) at low , medium , and high baseline physical activity , respectively . At the population level , meeting and maintaining at least the minimum physical activity recommendations would potentially prevent 46 % of deaths associated with physical inactivity . Conclusions Middle aged and older adults , including those with cardiovascular disease and cancer , can gain substantial longevity benefits by becoming more physically active , irrespective of past physical activity levels and established risk factors . Considerable population health impacts can be attained with consistent engagement in physical activity during mid to late life Objective A history of diabetes has been fairly consistently related to a reduced prostate cancer risk , but previous investigations have not always addressed whether the relation with diabetes varies by prostate cancer aggressiveness or the association between diabetes and prostate cancer is modified by physical activity level and body mass , variables closely related to glucose metabolism . Methods We prospect ively examined the diabetes – prostate cancer risk relationship among 33,088 men in the screening arm of the Prostate , Lung , Colorectal and Ovarian ( PLCO ) Cancer Screening Trial . Results During 8.9 years follow-up , we ascertained 2,058 incident prostate cancer cases . Diabetes history was related to decreased risk of total prostate cancer ( RR = 0.80 , 95 % CI = 0.68–0.95 ) . The apparent protection afforded by diabetes was primarily due to the inverse relation with non-aggressive disease ( i.e. , the combination of low grade ( Gleason sum < 8) and low stage ( clinical stages I or II ) ; RR = 0.75 ; 95 % CI = 0.62–0.91 ) . In contrast , no association was noted between diabetes and aggressive disease ( i.e. , high grade or high stage ( Gleason sum ≥8 or clinical stages III or IV ) ; RR = 1.04 , 95 % CI = 0.74–1.45 ) . In further analyses , the association between diabetes and aggressive prostate cancer was suggestively positive for men who were lean ( RR = 1.64 , 95 % CI = 0.87–3.07 ; BMI < 25 kg/m2 ) and it was positive for men who were the most physically active ( RR = 1.63 ; 95 % CI = 1.07–2.62 ; 3 + hours vigorous activity/week ) . By comparison , no relations of diabetes to aggressive prostate cancer were noted for their heavier or physically less active counterparts ( p-value for tests of interaction = 0.10 and 0.03 BMI and physical activity , respectively ) . Conclusion In this study , diabetes showed divergent relations with prostate cancer by tumor aggressiveness . Specifically , diabetes was inversely associated with early stage prostate cancer but it showed no relation with aggressive prostate cancer . Exploratory analyses suggested a positive association  between diabetes and aggressive prostate cancer in the subgroup of men with a low BMI The aim of this study is to review recent data on dietary fiber ( DF ) and the glycemic index ( GI ) , with special focus on studies from the Nordic countries regarding cardiometabolic risk factors , type 2 diabetes , cardiovascular disease , cancer , and total mortality . In this study , recent guidelines and scientific background papers or up date s on older reports on DF and GI published between 2000 and 2011 from the US , EU , WHO , and the World Cancer Research Fund were review ed , as well as prospect i ve cohort and intervention studies carried out in the Nordic countries . All of the reports support the role for fiber-rich foods and DF as an important part of a healthy diet . All of the five identified Nordic papers found protective associations between high intake of DF and health outcomes ; lower risk of cardiovascular disease , type 2 diabetes , colorectal and breast cancer . None of the reports and few of the Nordic papers found clear evidence for the GI in prevention of risk factors or diseases in healthy population s , although association was found in sub-groups , e.g. overweight and obese individuals and suggestive for prevention of type 2 diabetes . It was concluded that DF is associated with decreased risk of different chronic diseases and metabolic conditions . There is not enough evidence that choosing foods with low GI will decrease the risk of chronic diseases in the population overall . However , there is suggestive evidence that ranking food based on their GI might be of use for overweight and obese individuals . Issues regarding methodology , validity and practicality of the GI remain to be clarified Background Grade d health benefits of physical activity have been demonstrated for the reduction of coronary heart disease , some cancers , and type-2 diabetes , and for injury reduction and improvements in mental health .  Older adults are particularly at risk of physical inactivity , and would greatly benefit from successful targeted physical activity interventions . Methods / Design The Healthy Steps study is a 12-month r and omized controlled trial comparing the efficacy of a pedometer-based Green Prescription with the conventional time-based Green Prescription in increasing and maintaining physical activity levels in low-active adults over 65 years of age . The Green Prescription interventions involve a primary care physical activity prescription with 3 follow-up telephone counselling sessions delivered by trained physical activity counsellors over 3 months . Those in the pedometer group received a pedometer and counselling based around increasing steps that can be monitored on the pedometer , while those in the st and ard Green Prescription group received counselling using time-based goals . Baseline , 3 month ( end of intervention ) , and 12 month measures were assessed in face-to-face home visits with outcomes measures being physical activity ( Auckl and Heart Study Physical Activity Question naire ) , quality of life ( SF-36 and EQ-5D ) , depressive symptoms ( Geriatric Depression Scale ) , blood pressure , weight status , functional status ( gait speed , chair st and s , and t and em balance test ) and falls and adverse events ( self-report ) . Utilisation of health services was assessed for the economic evaluation carried out alongside this trial . As well , a process evaluation of the interventions and an examination of barriers and motives for physical activity in the sample were conducted . The perceptions of primary care physicians in relation to delivering physical activity counselling were also assessed . Discussion The findings from the Healthy Steps trial are due in late 2009 . If successful in improving physical activity in older adults , the pedometer-based Green Prescription could assist in reducing utilisation of health services and improve cardiovascular health and reduction of risk for a range of non-communicable lifestyles diseases . Trial registration Australian and New Zeal and Clinical Trials Registry It is the responsibility of the scientist to balance passion with dispassion . John C. Polanyi The Responsibility of the Scientist Department of Physiology Lecture Series : Frontiers in Physiology and Pharmacology , University of Toronto , 22 M Because no previous study evaluating the benefit of screening for breast cancer had specifically addressed efficacy in women aged 40 to 49 years , the results of the Canadian National Breast Screening Study ( NBSS ) were impatiently awaited . When they were finally published in November 1992 [ 1 , 2 ] , the results showed no reduction in breast cancer mortality after 7 years in screened women aged 40 to 49 years . Further , mammography did not achieve an incremental mortality benefit over and above clinical examination in women 50 to 59 years old , although it did achieve higher rates of cancer detection . What one wants to believe is easy to believe . Results from the NBSS , however , were difficult for many to believe . Given the passionately held belief that early detection of breast cancer achieved by mammography screening benefits women aged 40 to 49 years , it was not surprising that the NBSS became the focus of much attention . Some of the criticisms that have been generated are addressed in this article in the hope that a better underst and ing of the issues involved will be reached . Methods Planned in the late 1970s , the NBSS began screening women in January 1980 . Its design [ 3 ] addressed the unanswered questions prevailing at the time . The New York Health Insurance Plan breast screening trial had shown that combined annual screening with mammography and physical examination reduced breast cancer mortality in women 50 years of age and over when compared with no screening [ 4 ] . Although the separate contributions of mammography and physical examination of the breasts to mortality reduction were not known , it was believed that clinical examination of the breasts made a major contribution . Also not known in 1980 was whether combined annual screening  reduced breast cancer mortality in women aged 40 to 49 years when compared with no screening intervention . To determine the benefit of combined screening in women aged 40 to 49 years , the NBSS recruited 50 430 women individually r and omly assigned so that 25 214 received annual mammography and physical examination and 25 216 received a single physical examination  , thereafter returning to usual community care with annual follow-up by mailed question naire . To determine the separate contribution of mammography to breast cancer mortality reduction , 39 405 women ages 50 to 59 years were recruited , of whom 19 711 were r and omly assigned to receive annual mammography and physical examination of the breasts and 19 694 to receive an  annual physical examination alone . Entry criteria included meeting the age criteria , not being pregnant , not having been diagnosed with breast cancer , not having had a mammogram in the 12 months before entry , and signing informed consent forms . Women were instructed in breast self-examination at entry and those eligible for re-screening received repeated instruction and evaluation . All su bmi tted annual question naires that tracked breast procedures generated outside the NBSS . Screening Sites Each of the 15 centers across Canada had an adequate population base from which to draw participants and had recognized expertise in breast cancer . Six centers were in provincial cancer institutions ( all in the forefront of cancer research and treatment ) and eight in university teaching hospitals . Recruitment extended over 6 years , from 1980 to 1985 . R and omization Women who met the entry criteria and completed two question naires ( yielding identifying and demographic data including risk factors for breast cancer ) then signed informed consent forms in the examining room . The screen-examiner asked if the participant had breast symptoms ( lump , pain , discharge ) and recorded the responses . A physical examination of the breasts and instruction in breast self-examination followed , after which the examiner decided if the clinical findings required the participant 's referral to the NBSS surgical review clinic ( usually held within 1 week ) . This decision was documented on the examiner 's form , and the woman was informed . The examiner then left the participant and approached the center coordinator or her deputy , who carried out the r and omization procedure . R and omization lists , contained in four separate books that each included one quinquennium ( 40 to 44 years , 45 to 49 years , and so on ) , were provided to all centers . On learning the participant 's age , the coordinator chose the appropriate book and entered the date and name on the first available line , thus assigning to the participant her identification number and allocation . The coordinator entered the number and allocation on all chart forms , and the examiner told the participant if she was to have mammography . From the examiner 's perspective , it was not important to obtain a mammography allocation if a breast lump had been found because the participant would already be referred for surgical review . From the coordinator 's perspective , skipping a line to achieve a desired allocation was not feasible because she could not predict when the next appropriately aged woman would arrive to fill the skipped slot . The coordinators were well educated , well trained , and responsible , and recognized the importance of the r and omization procedure . At each month 's end , the original r and omization sheets were su bmi tted to the central coordinating office where each sheet was examined for suspicious entries , inappropriate date s , and lack of congruence with participant records . Mammography Mammography was done on site and interpreted by study radiologists . Details of the equipment used , the audit procedures , and sensitivity and specificity estimates have been previously published [ 5 - 7 ] . Clinical Examination of the Breasts Breast examination and breast self-examination instruction and evaluation were done by locally trained nurse-examiners in all centers outside the province of Quebec and by physicians in Quebec . The duration of the clinical examination ranged from 5 to 15 minutes , depending on the size of the breasts and on the amount of verbal interaction required . Descriptions of the role of the nurse-examiner , sensitivity and specificity estimates for breast examination , and breast self-examination behavior have all been previously published [ 8 - 10 ] . Surgical Review Study surgeons appointed at each center to examine women with abnormalities detected by either or both screening  interventions  decided if diagnostic follow-up was required . If so , they forwarded their recommendations to the woman 's physician , who then determined if and where the procedure would be done . Most recommended procedures were done [ 1 , 2 ] . In women aged 40 to 49 years , diagnostic mammography was done as a consequence of the screening examination in 0.8 % and 1.5 % of the mammography and comparison groups , respectively . Pathology Review Reference pathologists appointed for each center review ed slides from all surgical procedures done on participants from their center , whether or not the procedure result ed from NBSS recommendations . Follow-up Procedures During the 3 or 4 years each participant was in the study ( participants entering in 1984 and 1985 were eligible for only a 3-year and four-screen schedule ) , the centers ' routine follow-up procedures ensured high compliance with screening , and question naire information was obtained for most of the noncompliant participants [ 1 , 2 ] . These procedures also achieved almost complete ascertainment of cases of breast cancer and deaths , shown by subsequent record linkage . After participants ' screening schedules ended , active follow-up continued only for participants with known breast cancer . All such patients have always been and continue to be followed annually through contact with their physicians , whether their breast cancers were detected as a result of screening , during the screening schedule but not as a result of screening , or through record linkage during or after screening . Thus , the vital status of all women identified as having breast cancer is ascertained within , at most , 1 year of death . Passive follow-up to identify new cases of breast cancer through linkage with cancer registries across Canada ascertained breast cancer diagnoses occurring after completion of screening schedules and in the very small proportion of women ( 1 % of women from 40 to 49 years ) who dropped out of the study before completing their schedule . In a few cases , breast cancer was first identified through the National Mortality Data base as a cause of , or contributing to , death . In such cases , surgical , pathology , and other clinical records were review ed retrospectively . Figure 1 shows the follow-up procedures . Figure 1 . Flow chart of follow-up procedures . Results Seven years after entry , breast screening had no effect on breast cancer deaths when women aged 40 to 49 years receiving annual screening with mammography and physical examination  ( 38 deaths ) were compared with women receiving only a single physical examination of the breasts at entry into the  study followed by usual community care ( 28 deaths ) . The numeric difference is not statistically significant . Further , no effect on breast cancer mortality was observed in women aged 50 to 59 years at entry who received annual mammography and physical examination of the breasts ( 38 deaths ) compared with women who received only annual physical examination of the breasts ( 39 deaths ) . In both age groups , mammography was associated with higher cancer detection rates [ 1 , 2 ] . Controversy When the results were published , controversy arose [ 11 - 13 ] , some of which was defused at a recent International Workshop on Breast Cancer Screening where it was observed that NBSS results were consistent with findings from other screening studies [ 14 ] . Nevertheless , NBSS results were unwelcome in a milieu The prevalence of type 2 diabetes mellitus is rapidly increasing in the United States ( 1 , 2 ) and worldwide ( 3 ) . Ecologic studies ( 4 ) , migration studies ( 4 , 5 ) , and analyses of secular trends ( 4 , 6 ) suggest that adoption of a western diet may be associated with increased incidence of type 2 diabetes . However , these studies could not separate the effects of diet from those of other risk factors , such as obesity and physical activity . Studies of the relation between diet and incidence of type 2 diabetes on an individual level have predominantly focused on intake of macronutrients and fiber ( 7 ) . However , these dietary factors alone probably explain only part of the effect of diet on glucose metabolism . Other nutrients , additives , contaminants , and unknown compounds and the physical properties of foods and interactions between nutrients ( for example , with respect to bioavailability ) may play a role in the deterioration of glucose metabolism . Hence , the examination of effects of food consumption may be an important complementary approach . Recently , the analysis of patterns of food consumption by using factor analysis has emerged as a useful tool for elucidating relationships between diet and health ( 8 - 11 ) . The overall dietary pattern may affect health more than individual foods and nutrients do . Furthermore , dietary patterns reflect the way foods are consumed in reality , which may provide insight into possibilities for dietary changes and may facilitate the translation of findings to public health recommendations . Recent dietary intervention studies have indicated that interventions focused on dietary patterns can decrease blood pressure ( 12 ) and reduce cardiovascular complications ( 13 ) . Data on dietary patterns and risk for type 2 diabetes are sparse . Although two cross-sectional studies of dietary patterns and diabetes have been conducted ( 11 , 14 ) , these studies incompletely controlled for confounding by other lifestyle factors . Therefore , we prospect ively examined the association between major dietary patterns and risk for type 2 diabetes in a large prospect i ve study of U.S. professional men with extensive , repeatedly obtained information on diet and other lifestyle factors . Methods Participants The Health Professionals Follow-up Study started in 1986 , when 51 529 male health professionals ( dentists , veterinarians , pharmacists , optometrists , osteopathic physicians , and podiatrists ) completed a detailed mailed question naire on medical history , diet , and other potential risk factors for major diseases .  The participants lived in all 50 U.S. states , were predominantly white , and were 40 to 75 years of age in 1986 . We excluded from the current analysis 1595 men who did not satisfy the a priori criteria of reporting daily energy intake of 3.3 to 17.6 MJ ( 800 to 4200 kcal/24 h ) and leaving fewer than 70 responses blank of the 131 food items on the diet question naire ( < 5 % had > 11 blanks ) . We also excluded men who reported having diabetes , cardiovascular disease ( myocardial infa rct ion , angina pectoris , coronary artery surgery , or stroke ) , or cancer ( except nonmelanoma skin cancer ) at baseline because having these diagnoses may affect diet or reporting of diet . After exclusions , the study sample comprised 42 504 men , who were followed for incidence of type 2 diabetes and other diseases for 12 years ( 1986 to 1998 ) . Every 2 years , the participants received question naires by mail that asked for up date d information on exposures and newly diagnosed diseases . The follow-up rate for potential person-years was about 97 % for nonfatal events . We identified deaths by reports from family members , coworkers , or postal authorities or through systematic search es of the National Death Index . Assessment of Dietary Patterns To assess dietary intake , we used a 131-item semiquantitative food-frequency question naire in 1986 , 1990 , and 1994 . The question naire specified for each food a commonly used unit or portion size , and the participants were asked to indicate how often , on average , they had consumed a given amount of the specified food during the past year . Each such item provided nine possible responses , ranging from never or less than once a month to 6 or more times per day . To reduce within-respondent variation and to best represent long-term dietary habits , we averaged the dietary intakes from all available dietary question naires up to the start of each follow-up interval ( the average of the 1986 and 1990 dietary intakes was related to incidence of type 2 diabetes between 1990 and 1994 ) ( 15 ) . To identify dietary patterns , we applied factor analysis to data from the food-frequency question naire . First , we grouped the food items on the question naire into 37 predefined food groups . We combined food items that were similar in nutrient profile and culinary use ( for example , spinach , iceberg or head lettuce , and romaine or leaf lettuce were combined into green leafy vegetables ) . We classified a food item individually if its composition differed substantially from that of other foods ( for example , eggs or pizza ) or if we suspected that it represents a particular dietary habit ( for example , wine or French fries ) . Second , we applied the principal components program for factor analysis of SAS software ( 16 ) with varimax rotation to the 37 food groups . Factor analysis aggregates correlated variables . The obtained factors are linear combinations of the included variables , explaining as much of the variation in the original variables as possible . Our analysis retained two factors based on the eigenvalue of the factors , the Scree test , and the interpretability of the derived factors , and we labeled these diets as the prudent pattern and the western pattern ( 9 ) . Third , for each participant , we calculated a  prudent pattern score and a  western pattern score  by summing the st and ardized intake of foods , weighted by the factor loadings of the foods ( 17 ) . We used these scores to rank participants according to the degree to which they conformed to each dietary pattern . We divided dietary pattern scores into quintiles ; thus , on this basis of his scores , each participant was grouped in a prudent-pattern quintile and a western-pattern quintile . To test the validity and reproducibility of the assessment of the dietary pattern scores by the food-frequency question naire , we examined a subgroup of 127 participants ( 9 ) . The Pearson correlation coefficient ( corrected for week-to-week variation in the diet records ) for a comparison between the responses to the food-frequency question naire and the diet records was 0.52 for the prudent dietary pattern and 0.74 for the western dietary pattern . Assessment of Nondietary Exposures The 1986 question naire and each biennial follow-up question naire assessed weight , smoking status , and physical activity .  Participants provided information on age , diagnosis of hypertension and hypercholesterolemia , and height in 1986 and on family history of diabetes in 1987 . The criterion for family history of type 2 diabetes was having at least one first-degree relative with a diagnosis of diabetes after 30 years of age . For each participant , we determined a physical activity level , measured in weekly metabolic equivalent hours , on the basis of reported time spent on various activities , which we weighted according to intensity level ( 18 ) . The validity of self-reported weight ( 19 ) and physical activity ( 18 ) in this cohort has been reported previously . Ascertainment of Type 2 Diabetes Mellitus We mailed a supplementary question naire on symptoms , diagnostic tests , and medication use to participants who indicated on any biennial follow-up question naire that he had received a diagnosis of diabetes mellitus . Confirmation of diabetes required at least one of the following : 1 ) an elevated plasma glucose level ( fasting plasma glucose level 7.8 mmol/L [ 140 mg/dL ] ; r and om plasma glucose level 11.1 mmol/L [ 200 mg/dL ] ; or  plasma glucose level after 2 hours or more during an oral glucose tolerance test 11.1 mmol/L [ 200 mg/dL ] ) plus at least one classic symptom [ excessive thirst , polyuria , weight loss , or hunger ] ; 2 ) at least two elevated plasma glucose levels measured on different occasions ; or 3 ) treatment with insulin or oral hypoglycemic medication . We excluded men who reported having type 1 diabetes on the supplementary question naire . These criteria for diabetes are consistent with those from the World Health Organization in 1985 ( 20 ) . We did not use the current diabetes classification of the American Diabetes Association ( 21 ) because among the men in our study , most cases of diabetes were diagnosed before these criteria were published . The validity of our assessment of type 2 diabetes was verified with medical records in a sub sample of 71 participants . A physician blinded to the information on the supplementary question naire review ed the records according to the diagnostic criteria . Of the 71 participants classified as having type 2 diabetes , 12 had incomplete medical recordsfor example , absent laboratory data ( n = 2 ) or only one set of laboratory data ( n = 9 ) . We confirmed the classification of type 2 diabetes in 57 ( 97 % ) of the other 59 other men in the sub sample . One participant denied having diabetes , and another participant lacked evidence of diabetes in his su bmi tted records . Statistical Analysis We used pooled logistic regression analyses with 2-year intervals to estimate the adjusted relative risk for each quintile compared with the lowest quintile of intake . With short time intervals and low rates of events , this approach gives results very similar to those of Cox proportional-hazards analyses ( 22 ) . Participants who died or received a diagnosis of diabetes during a 2-year cycle were censored at the end of that 2-year period and were not entered in any subsequent 2-year cycle . We used the cumulative average of available dietary assessment s up to the start of each 2-year follow-up interval ( 15 ) . We stopped updating a participant 's dietary Background / Objectives : Vitamin D deficiency is associated with cardiovascular disease , osteoporosis , poor muscle strength , falls , fractures and mortality . Although older adults are at a higher risk of vitamin D deficiency , the relationship of serum 25-hydroxyvitamin D ( 25(OH)D ) with all-cause and cardiovascular disease mortality has not been well characterized in the elderly . We hypothesized that low serum 25(OH)D levels predicted mortality in older adults . Subjects/ Methods : Serum 25(OH)D  as well as all-cause and cardiovascular disease mortality were examined in 1006 adults , aged ⩾65 years , who participated in the InCHIANTI ( Invecchiare in Chianti , Aging in the Chianti Area ) study , a population -based , prospect i ve cohort study of aging in Tuscany , Italy . Serum 25(OH)D levels were measured at the time of enrollment in 1998–1999 , and participants were followed up for mortality . Results : During 6.5 years of follow-up , 228 ( 22.7 % ) participants died , of whom 107 died due to cardiovascular diseases . Compared with participants in the highest quartile of serum 25(OH)D ( > 26.5 ng/ml ) ( to convert to nmol/l , multiply by 2.496 ) , those in the lowest quartile ( < 10.5 ng/ml ) had increased risk of all-cause mortality ( Hazard Ratio ( H.R. ) 2.11 , 95 % Confidence Interval ( 95 % C.I. ) : 1.22–3.64 , P=0.007 ) and cardiovascular disease mortality ( H.R. 2.64 , 95 % C.I. : 1.14–4.79 , P=0.02 ) , in multivariate Cox proportional hazards models that adjusted for age , sex , education , season , physical activity and other potential confounders . Conclusions : Older community-dwelling adults with low serum 25(OH)D levels are at higher risk of all-cause and cardiovascular disease mortality UNLABELLED In June 2008 , the Medical Advisory Secretariat began work on the Diabetes Strategy Evidence Project , an evidence -based review of the literature surrounding strategies for successful management and treatment of diabetes . This project came about when the Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the Ministry 's newly released Diabetes Strategy .After an initial review of the strategy and consultation with experts , the secretariat identified five key areas in which evidence was needed . Evidence -based analyses have been prepared for each of these five areas : insulin pumps , behavioural interventions , bariatric surgery , home telemonitoring , and community based care . For each area , an economic analysis was completed where appropriate and is described in a separate report . To review these titles within the Diabetes Strategy Evidence series , please visit the Medical Advisory Secretariat Web site , http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html,DIABETES STRATEGY EVIDENCE PLATFORM : Summary of Evidence -Based AnalysesContinuous Subcutaneous Insulin Infusion Pumps for Type 1 and Type 2 Adult Diabetics : An Evidence -Based Analysis Behavioural Interventions for Type 2 Diabetes : An Evidence -Based Analysis  BARIATRIC SURGERY FOR PEOPLE WITH DIABETES AND MORBID OBESITY : An Evidence -Based Summary Community-Based Care for the Management of Type 2 Diabetes : An Evidence -Based Analysis Home Telemonitoring for Type 2 Diabetes : An Evidence -Based Analysis Application of the Ontario Diabetes Economic Model ( ODEM ) to Determine the Cost-effectiveness and Budget Impact of Selected Type 2 Diabetes Interventions in Ontario OBJECTIVE The objective of this report is to determine whether behavioural interventions are effective in improving glycemic control in adults with type 2 diabetes . BACKGROUND Diabetes is a serious chronic condition affecting millions of people worldwide and is the sixth leading cause of death in Canada . In 2005 , an estimated 8.8 % of Ontario 's population had diabetes , representing more than 816,000 Ontarians . The direct health care cost of diabetes was $ 1.76 billion in the year 2000 and is projected to rise to a total cost of $ 3.14 billion by 2016 . Much of this cost arises from the serious long-term complications associated with the disease including : coronary heart disease , stroke , adult blindness , limb amputations and kidney disease . Type 2 diabetes accounts for 90 - 95 % of diabetes and while type 2 diabetes is more prevalent in people aged 40 years and older , prevalence in younger population s is increasing due to a rise in obesity and physical inactivity in children . Data from the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) has shown that tight glycemic control can significantly reduce the risk of developing serious complications in type 2 diabetics . Despite physicians ' and patients ' knowledge of the importance of glycemic control , Canadian data has shown that only 38 % of patients with diabetes have HbA1C levels in the optimal range of 7 % or less . This statistic highlights the complexities involved in the management of diabetes , which is characterized by extensive patient involvement in addition to the support provided by physicians . An enormous dem and is , therefore , placed on patients to self-manage the physical , emotional and psychological aspects of living with a chronic illness . Despite differences in individual needs to cope with diabetes , there is general agreement for the necessity of supportive programs for patient self-management . While traditional programs were didactic models with the goal of improving patients ' knowledge of their disease , current models focus on behavioural approaches aim ed at providing patients with the skills and strategies required to promote and change their behaviour . Several meta-analyses and systematic review s have demonstrated improved health outcomes with  self-management support programs in type 2 diabetics . They have all , however , either looked at a specific component of self-management support programs ( i.e. self-management education ) or have been conducted in specific population s. Most review s are also qualitative and do not clearly define the interventions of interest , making findings difficult to interpret . Moreover , heterogeneity in the interventions has led to conflicting evidence on the components of effective programs . There is thus much uncertainty regarding the optimal design and delivery of these programs by policymakers . EVIDENCE -BASED ANALYSIS OF EFFECTIVENESS : RESEARCH QUESTIONS Are behavioural interventions  effective in improving glycemic control in adults with type 2 diabetes?Is the effectiveness of the intervention impacted by intervention characteristics ( e.g. delivery of intervention , length of intervention , mode of instruction , interventionist etc . ) ? INCLUSION CRITERIA English Language Published between January 1996 to August 2008 Type 2 diabetic adult population ( > 18 years)R and omized controlled trials ( RCTs ) Systematic review s , or meta-analyses Describing a multi-faceted self-management support intervention as defined by the 2007 Self-Management Mapping Guide (1)Reporting outcomes of glycemic control ( HbA1c ) with extractable data Studies with a minimum of 6-month follow up EXCLUSION CRITERIA Studies with a control group other than usual care Studies with a sample size < 30 Studies without a clearly defined intervention OUTCOMES OF INTEREST PRIMARY OUTCOME glycemic control ( HbA1c ) SECONDARY OUTCOMES systolic blood pressure ( SBP ) control , lipid control , change in smoking status , weight change , quality of life , knowledge , self-efficacy , managing psychosocial aspects of diabetes , assessing dissatisfaction and readiness to change , and setting and achieving diabetes goals . SEARCH STRATEGY A search was performed in OVID MEDLINE , MEDLINE In-Process and Other Non-Indexed Citations , EMBASE , the Cumulative Index to Nursing & Allied Health Literature ( CINAHL ) , The Cochrane Library , and the International Agency for Health Technology Assessment ( INAHTA ) for studies published between January 1996 and August 2008 . Abstract s were review ed by a single author and studies meeting the inclusion criteria outlined above were obtained . Data on population characteristics , glycemic control outcomes , and study design were extracted . Reference lists were also checked for relevant studies . The quality of the evidence was assessed as being either high , moderate , low , or very low according to the GRADE methodology . SUMMARY OF FINDINGS The search identified 638 citations published between 1996 and August 2008 , of which 12 met the inclusion criteria and one was a meta- analysis ( Gary et al. 2003 ) . The remaining 11 studies were RCTs ( 9 were used in the meta- analysis ) and only one was defined as small ( total sample size N=47 ) . SUMMARY OF PARTICIPANT DEMOGRAPHICS ACROSS STUDIES : A total of 2,549 participants were included in the 11 identified studies . The mean age of participants reported was approximately 58 years and the mean duration of diabetes was approximately 6 years . Most studies reported gender with a mean percentage of females of approximately 67 % . Of the eleven studies , two focused only on women and four included only Hispanic individuals . All studies evaluated type 2 diabetes patients exclusively . STUDY CHARACTERISTICS : The studies were conducted between 2002 and 2008 . Approximately six of 11 studies were carried out within the USA , with the remaining studies conducted in the UK , Sweden , and Israel ( sample size ranged from 47 to 824 participants ) . The quality of the studies ranged from moderate to low with four of the studies being of moderate quality and the remaining seven of low quality ( based on the Consort Checklist ) . Differences in quality were mainly due to method ological issues such as inadequate description of r and omization , sample size calculation allocation concealment , blinding and uncertainty of the use of intention-to-treat ( ITT ) analysis . Patients were recruited from several setting s : six studies from primary or general medical practice s , three studies from the community ( e.g. via advertisements ) , and two from outpatient diabetes clinics . A usual care control group was reported in nine of 11 of the studies and two studies reported some type of minimal diabetes care in addition to usual care for the control group . INTERVENTION CHARACTERISTICS : All of the interventions examined in the studies were mapped to the 2007 Self-management Mapping Guide . The interventions most often focused on problem solving , goal setting and encouraging participants to engage in activities that protect and promote health ( e.g. modifying behaviour , change in diet , and increase physical activity ) . All of the studies examined comprehensive interventions targeted at least two self-care topics ( e.g. diet , physical activity , blood glucose monitoring , foot care , etc . ) . Despite the homogeneity in the aims of the interventions , there was substantial clinical heterogeneity in other intervention characteristics such as duration , intensity , setting , mode of delivery ( group vs. individual ) , interventionist , and outcomes of interest ( discussed below ) . DURATION , INTENSITY AND MODE OF DELIVERY : Intervention duration s ranged from 2 days to 1 year , with many falling into the range of 6 to 10 weeks . The rest of the interventions fell into categories of ≤ 2 weeks ( 2 studies ) , 6 months ( 2 studies ) , or 1 year ( 3 studies ) . Intensity of the interventions varied widely from 6 hours over 2 days , to 52 hours over 1 year ; however , the majority consisted of interventions of 6 to 15 hours . Both individual and group sessions were used to deliver interventions . Group counselling was used in five studies as a mode of instruction , three studies used both individual and group sessions , and one study used individual sessions as its sole mode of instruction . ( ABSTRACT OBJECTIVE : To examine the association of physical activity and body mass index ( BMI ) , and their combined effect , with the risk of total , cardiovascular disease ( CVD ) and cancer mortality .  DESIGN : Prospect i ve follow-up study .SUBJECTS : In all , 22 528 men and 24 684 women aged 25–64 y at baseline having 7394 deaths during a mean follow-up of 17.7 y . MEASUREMENT : A self-administered question naire data on smoking , socioeconomic factors , physical activity and medical history , together with measured height , weight , blood pressure and serum cholesterol using st and ardized protocol . RESULT : Physically active subjects had significantly lower age-adjusted mortality from cardiovascular , cancer and all causes compared with sedentary ones . Further adjustment for smoking , systolic blood pressure , cholesterol , BMI , diabetes and education affected the results only slightly . Obese subjects ( BMI ≥30 kg/m2 ) had significantly higher cardiovascular and total mortality than the normal weight ( 18.5≤ BMI < 25 kg/m2 ) subjects . Part of increased mortality among obese subjects was mediated through obesity-related cardiovascular risk factors . BMI had an inverse association with cancer mortality among men and almost significant direct association among women . Total mortality was also increased among the lean ( BMI < 18.5 kg/m2 ) subjects . However , less than 0.3 % of deaths were attributed to low body weight , whereas in men 5.5 % and in women 17.7 % of deaths were attributed to obesity . CONCLUSION : Regular physical activity and normal weight are both important indicators for a decreased risk of mortality from all causes , CVD and cancer . Physical activity had a strong independent effect on mortality , whereas the effect of BMI was partly mediated through other obesity-related risk factors IMPORTANCE The 2008 Physical Activity Guidelines for Americans recommended a minimum of 75 vigorous-intensity or 150 moderate-intensity minutes per week ( 7.5 metabolic-equivalent hours per week ) of aerobic activity for substantial health benefit and suggested additional benefits by doing more than double this amount . However , the upper limit of longevity benefit or possible harm with more physical activity is unclear . OBJECTIVE To quantify the dose-response association between leisure time physical activity and mortality and define the upper limit of benefit or harm associated with increased levels of physical activity . DESIGN , SETTING , AND PARTICIPANTS We pooled data from 6 studies in the National Cancer Institute Cohort Consortium ( baseline 1992 - 2003 ) . Population -based prospect i ve cohorts in the United States and Europe with self-reported physical activity were analyzed in 2014 . A total of 661,137 men and women ( median age , 62 years ; range , 21 - 98 years ) and 116,686 deaths were included . We used Cox proportional hazards regression with cohort stratification to generate multivariable-adjusted hazard ratios ( HRs ) and 95 % CIs . Median follow-up time was 14.2 years . EXPOSURES Leisure time moderate- to vigorous-intensity physical activity . MAIN OUTCOMES AND MEASURES The upper limit of mortality benefit from high levels of leisure time physical activity . RESULTS Compared with individuals reporting no leisure time physical activity , we observed a 20 % lower mortality risk among those performing less than the recommended minimum of 7.5 metabolic-equivalent hours per week ( HR , 0.80 [ 95 % CI , 0.78 - 0.82 ] ) , a 31 % lower risk at 1 to 2 times the recommended minimum ( HR , 0.69 [ 95 % CI , 0.67 - 0.70 ] ) , and a 37 % lower risk at 2 to 3 times the minimum ( HR , 0.63 [ 95 % CI , 0.62 - 0.65 ] ) . An upper threshold for mortality benefit occurred at 3 to 5 times the physical activity recommendation ( HR , 0.61 [ 95 % CI , 0.59 - 0.62 ] ) ; however , compared with the recommended minimum , the additional benefit was modest ( 31 % vs 39 % ) . There was no evidence of harm at 10 or more times the recommended minimum ( HR , 0.69 [ 95 % CI , 0.59 - 0.78 ] ) . A similar dose-response relationship was observed for mortality due to cardiovascular disease and to cancer . CONCLUSIONS AND RELEVANCE Meeting the 2008 Physical Activity Guidelines for Americans minimum by either moderate- or vigorous-intensity activities was associated with nearly the maximum longevity benefit . We observed a benefit threshold at approximately 3 to 5 times the recommended leisure time physical activity minimum and no excess risk at 10 or more times the minimum . In regard to mortality , health care professionals should encourage inactive adults to perform leisure time physical activity and do not need to discourage adults who already participate in high-activity levels BACKGROUND Despite the numerous studies on the relation of albuminuria with increased risk of all-cause mortality in type 2 diabetes mellitus , it remains uncertain whether microalbuminuria and /or gross proteinuria are independent risk factors for cardiovascular mortality . Moreover , the association of albuminuria with cardiovascular mortality in people with type 2 diabetes mellitus has not been well described in US population s. OBJECTIVE To estimate the relative risks ( RRs ) for the associations of microalbuminuria and gross proteinuria with cardiovascular disease mortality among persons with older-onset diabetes mellitus . METHODS We conducted a prospect i ve cohort study of 840 people with older-onset diabetes mellitus who provided urine sample s in the 1984 - 1986 examination of a population -based study of diabetic persons . The presence of microalbuminuria was determined by an agglutination inhibition assay and gross proteinuria by a reagent strip . The main outcome was time to mortality from cardiovascular disease , as determined from death certificates . RESULTS Of the 840 older-onset diabetic persons , 54.8 % had normoalbuminuria , while 24.8 % had microalbuminuria and 20.5 % had gross proteinuria . During the 12-year follow-up ( 6127 person-years ) , we identified 364 deaths from cardiovascular disease . Compared with persons with normoalbuminuria , those with microalbuminuria and gross proteinuria had significantly higher risks of cardiovascular mortality . The RR as controlled for age , sex , glycemic control , insulin use , alcohol intake , physical activity , cardiovascular disease history , antihypertensive use , and retinopathy severity , was 1.84 ( 95 % confidence interval [ CI ] , 1.42 - 2.40 ) for those with microalbuminuria and 2.61 ( 95 % CI , 1.99 - 3.43 ) for those with gross proteinuria . Further adjustment for other factors did not change the relations we found . When the end point used was mortality from coronary heart disease , stroke , or all causes , the increased risks were significant for both microalbuminuria ( adjusted RRs [ 95 % CIs ] , 1.96 [ 1.42 - 2.72 ] , 2.20 [ 1.29 - 3.75 ] , and 1.68 [ 1.35 - 2.09 ] , respectively ) and gross proteinuria ( adjusted RRs [ 95 % CIs ] , 2.73 [ 1.95 - 3.81 ] , 2.33 [ 1.28 - 4.24 ] , and 2.47 [ 1.97 - 3.10 ] , respectively ) . CONCLUSIONS Results from our population -based study strongly suggest that both microalbuminuria and gross proteinuria were significantly associated with subsequent mortality from all causes and from cardiovascular , cerebrovascular , and coronary heart diseases . These associations were independent of known cardiovascular risk factors and diabetes-related variables OBJECTIVE While low physical activity and high body mass index ( BMI ) have been associated with higher endometrial cancer incidence , no previous studies have evaluated the association between physical activity and survival after endometrial cancer diagnosis , and studies on BMI and survival have not been performed in a prospect i ve cohort . METHODS We examined pre-diagnosis BMI and moderate- to vigorous-intensity physical activity in relation to overall and disease-specific survival among 983 postmenopausal women who were diagnosed with endometrial cancer in the Women 's Health Initiative Observational Study and Clinical Trials . RESULTS Over a median 5.2 ( max 14.1 ) years from diagnosis to death or end of follow-up , 163 total deaths were observed , 66 of which were due to endometrial cancer . We observed a higher all-cause mortality hazard ratio ( HR ) = 1.85 ( 95 % CI 1.19 - 2.88 ) comparing women with a BMI ≥ 35 kg/m(2 ) to women with BMI < 25 kg/m(2 ) . For endometrial cancer-specific mortality the HR = 2.23 ( 95 % CI 1.09 - 4.54 ) comparing extreme BMI categories . To examine histologic subtypes we analyzed type I endometrial tumors separately and found an HR = 1.20 ( 95 % CI 1.07 - 1.35 ) associated with all-cause mortality for each 5-unit change in BMI . Moderate- to vigorous-intensity physical activity was not associated with all-cause or endometrial cancer-specific mortality . CONCLUSIONS Pre-diagnosis BMI , but not physical activity , was associated with survival among women with endometrial cancer . Future studies should investigate mechanisms and timing of BMI onset to better underst and the burden of disease attributable to BMI IMPORTANCE Leisure-time physical activity has been associated with lower risk of heart-disease and all-cause mortality , but its association with risk of cancer is not well understood . OBJECTIVE To determine the association of leisure-time physical activity with incidence of common types of cancer and whether associations vary by body size and /or smoking . DESIGN , SETTING , AND PARTICIPANTS We pooled data from 12 prospect i ve US and European cohorts with self-reported physical activity ( baseline , 1987 - 2004 ) . We used multivariable Cox regression to estimate hazard ratios ( HRs ) and 95 % confidence intervals for associations of leisure-time physical activity with incidence of 26 types of cancer . Leisure-time physical activity  levels were modeled as cohort-specific percentiles on a continuous basis and cohort-specific results were synthesized by r and om-effects meta- analysis . Hazard ratios for high vs low levels of activity are based on a comparison of risk at the 90th vs 10th percentiles of activity . The data analysis was performed from January 1 , 2014 , to June 1 , 2015 . EXPOSURES Leisure-time physical activity of a moderate to vigorous intensity . MAIN OUTCOMES AND MEASURES Incident cancer during follow-up . RESULTS A total of 1.44 million participants ( median [ range ] age , 59 [ 19 - 98 ] years ; 57 % female ) and 186 932 cancers were included . High vs low levels of leisure-time physical activity were associated with lower risks of 13 cancers : esophageal adenocarcinoma ( HR , 0.58 ; 95 % CI , 0.37 - 0.89 ) , liver ( HR , 0.73 ; 95 % CI , 0.55 - 0.98 ) , lung ( HR , 0.74 ; 95 % CI , 0.71 - 0.77 ) , kidney ( HR , 0.77 ; 95 % CI , 0.70 - 0.85 ) , gastric cardia ( HR , 0.78 ; 95 % CI , 0.64 - 0.95 ) , endometrial ( HR , 0.79 ; 95 % CI , 0.68 - 0.92 ) , myeloid leukemia ( HR , 0.80 ; 95 % CI , 0.70 - 0.92 ) , myeloma ( HR , 0.83 ; 95 % CI , 0.72 - 0.95 ) , colon ( HR , 0.84 ; 95 % CI , 0.77 - 0.91 ) , head and neck ( HR , 0.85 ; 95 % CI , 0.78 - 0.93 ) , rectal ( HR , 0.87 ; 95 % CI , 0.80 - 0.95 ) , bladder ( HR , 0.87 ; 95 % CI , 0.82 - 0.92 ) , and breast ( HR , 0.90 ; 95 % CI , 0.87 - 0.93 ) . Body mass index adjustment modestly attenuated associations for several cancers , but 10 of 13 inverse associations remained statistically significant after this adjustment .  Leisure-time physical activity  was associated with higher risks of malignant melanoma ( HR , 1.27 ; 95 % CI , 1.16 - 1.40 ) and prostate cancer ( HR , 1.05 ; 95 % CI , 1.03 - 1.08 ) . Associations were generally similar between overweight/obese and normal-weight individuals . Smoking status modified the association for lung cancer but not other smoking-related cancers . CONCLUSIONS AND RELEVANCE Leisure-time physical activity was associated with lower risks of many cancer types . Health care professionals counseling inactive adults should emphasize that most of these associations were evident regardless of body size or smoking history , supporting broad generalizability of findings OBJECTIVE Hypoglycemia is associated with serious health outcomes for patients treated for diabetes . However , the outcome of out patients with type 2 diabetes who have experienced hypoglycemia episodes is largely unknown . RESEARCH DESIGN AND METHODS The study population , derived from the National Health Insurance Research Data base released by the Taiwan National Health Research Institutes during 1998–2009 , comprised 77,611 patients with newly diagnosed type 2 diabetes . We design ed a prospect i ve study consisting of r and omly selected hypoglycemic type 2 diabetic patients and matched type 2 diabetic patients without hypoglycemia .  We investigated the relationships of hypoglycemia with total mortality and cardiovascular events , including stroke , coronary heart disease , cardiovascular diseases , and all-cause hospitalization . RESULTS There were 1,844 hypoglycemic events ( 500 in patients and 1,344 out patients ) among the 77,611 patients . Both mild ( outpatient ) and severe ( inpatient ) hypoglycemia cases had a higher percentage of comorbidities , including hypertension , renal diseases , cancer , stroke , and heart disease . In multivariate Cox regression models , including diabetes treatment adjustment , diabetic patients with hypoglycemia had a significantly higher risk of cardiovascular events during clinical treatment periods . After constructing a model adjusted with propensity scores , mild and severe hypoglycemia still demonstrated higher hazard ratios ( HRs ) for cardiovascular diseases ( HR 2.09 [ 95 % CI 1.63–2.67 ] ) , all-cause hospitalization ( 2.51 [ 2.00–3.16 ] ) , and total mortality ( 2.48 [ 1.41–4.38 ] ) . CONCLUSIONS Symptomatic hypoglycemia , whether clinical ly mild or severe , is associated with an increased risk of cardiovascular events , all-cause hospitalization , and all-cause mortality . More attention may be needed for diabetic patients with hypoglycemic episodes OBJECTIVE Assess the pattern of relationships between personal- background characteristics and dimensions of quality of life ( QOL ) in diabetic patients . DESIGN Cross-sectional descriptive study . SAMPLE 117 adults with type 2 diabetes ( 100 female , 17 male ) r and omly selected from out patients referred to Sina hospital ( Tabriz , Iran ) . METHODS Participants answered a three-part question naire including ( 1 ) sociodemographic and medical ( diabetes-related ) personal- background characteristics ; ( 2 ) general health-related QOL instrument based on Swedish Health-Related QOL ; ( 3 ) disease-specific instrument for diabetic patients . Nine QOL dimensions were covered : physical function , pain , daily activities , feelings , sleep , relationships with relatives , overall health , problems with diabetes , satisfaction with diabetes treatment methods . Data were analyzed with inferential statistics , correlation , and multi-stage stepwise regression . RESULTS Personal background characteristics ( age , presence of medically educated people in family , whether patient was family breadwinner , unemployment , complications of diabetes ) accounted for 27 % of variance in the physical function dimension of QOL dimension . Other QOL dimensions ( daily activities , overall health , sleep , satisfaction with diabetes treatment . ) were also related to personal background characteristics . CONCLUSIONS Diabetic patients face great challenges in many dimensions of QOL . Nursing instructors and nursing educators in educational centers for diabetics can use the findings of this research to assess their patients more effectively Objective To examine prospect ively the association between muscular strength and mortality from all causes , cardiovascular disease , and cancer in men . Design Prospect i ve cohort study . Setting Aerobics centre longitudinal study . Participants 8762 men aged 20 - 80 . Main outcome measures All cause mortality up to 31 December 2003 ; muscular strength , quantified by combining one repetition maximal measures for leg and bench presses and further categorised as age specific thirds of the combined strength variable ; and cardiorespiratory fitness assessed by a maximal exercise test on a treadmill . Results During an average follow-up of 18.9 years , 503 deaths occurred ( 145 cardiovascular disease , 199 cancer ) . Age adjusted death rates per 10 000 person years across incremental thirds of muscular strength were 38.9 , 25.9 , and 26.6 for all causes ; 12.1 , 7.6 , and 6.6 for cardiovascular disease ; and 6.1 , 4.9 , and 4.2 for cancer ( all P<0.01 for linear trend ) . After adjusting for age , physical activity , smoking , alcohol intake , body mass index , baseline medical conditions , and family history of cardiovascular disease , hazard ratios across incremental thirds of muscular strength for all cause mortality were 1.0 ( referent ) , 0.72 ( 95 % confidence interval 0.58 to 0.90 ) , and 0.77 ( 0.62 to 0.96 ) ; for death from cardiovascular disease were 1.0 ( referent ) , 0.74 ( 0.50 to 1.10 ) , and 0.71 ( 0.47 to 1.07 ) ; and for death from cancer were 1.0 ( referent ) , 0.72 ( 0.51 to 1.00 ) , and 0.68 ( 0.48 to 0.97 ) . The pattern of the association between muscular strength and death from all causes and cancer persisted after further adjustment for cardiorespiratory fitness ; however , the association between muscular strength and death from cardiovascular disease was attenuated after further adjustment for cardiorespiratory fitness . Conclusion Muscular strength is inversely and independently associated with death from all causes and cancer in men , even after adjusting for cardiorespiratory fitness and other potential confounders AIMS Individuals with Type 2 diabetes are at high risk for coronary heart disease , and may benefit from aggressive lifestyle modification . We evaluated the prevalence of Type 2 diabetes , in a Greek adult population , in relation to physical activity and dietary habits . METHODS From May 2001 to December 2002 , we r and omly enrolled 1514 men and 1528 women , with no evidence of cardiovascular or any other chronic disease . The sampling was stratified by the age and gender distribution of the general population in the greater area of Athens ( census 2001 ) . Diabetes was defined according to the established American Diabetes Association criteria .  Dietary habits  were assessed through a vali date d food frequency question naire and a diet score  was developed , in which higher values suggest greater adherence to the Mediterranean diet . Weekly energy expenditure  was assessed by considering frequency , duration and intensity of sports-related physical activity during a usual week . RESULTS After age adjustment for the Greek adult population ( 2001 census ) , the projected prevalence of Type 2 diabetes was 7.6 % in men and 5.9 % in women . A significant proportion of diabetic subjects ( 24 % of men and 30 % of women ) were unaware of their condition . Moreover , a 10-unit increase in the diet score was associated with 21 % lower odds of diabetes ( P < 0.05 ) , while individuals taking light physical activity were at 35 % lower odds ratio of diabetes compared with sedentary individuals ( P < 0.05 ) . CONCLUSIONS Diabetes mellitus is common in our population , with approximately 1 in 5 individuals with Type 2 diabetes being unaware of their condition . The lifestyle approach described here may contribute significantly to the reduction in the prevalence of diabetes , at a population level Introduction Chronic diseases such as cancer , cardiovascular disease , stroke , and diabetes are responsible for most deaths in the United States . Lifestyle factors — poor nutrition , sedentary living , and tobacco use — appear to play a prominent role in the development of many chronic diseases . This study determined the behavioral and clinical impact of a therapeutic lifestyle-modification intervention on a group of community volunteers . Methods Participants included 348 volunteers aged 24 to 81 years from the Rockford , Ill , metropolitan area who participated in a r and omized clinical trial . The intervention group attended a 40-hour educational course delivered as lectures during a 4-week period . Participants learned the importance of making better lifestyle choices and how to make improvements in nutrition and physical activity . Changes in nutrition , physical activity behavior , and several chronic disease risk factors were assessed at baseline and 6 months . Results Intervention participants showed significant 6-month improvement in all nutrition and physical activity measures except calories from protein and whole-grain servings and all clinical measures except blood glucose , total cholesterol , triglycerides , and high-sensitivity C-reactive protein . Total cholesterol and low-density lipoprotein cholesterol were worse after 6 months in both groups but only significantly worse in the control group . The control group experienced small but significant improvements in systolic and diastolic blood pressure and high-density lipoproteins . Change-score comparisons between the intervention and control groups were significant for all nutrition and physical activity variables except total steps per week and daily sodium intake and were also significant for the clinical measures of weight , body fat , and body mass index . Conclusion This therapeutic lifestyle-modification program can significantly improve nutrition and physical activity behavior and can reduce many of the risk factors associated with common chronic diseases Background and Purpose — The role of physical activity , especially that of occupational and commuting physical activity , in the prediction of stroke risk is not properly established . We assessed the relationship of different types of physical activity with total and type-specific stroke risk . Methods — We prospect ively followed 47 721 Finnish subjects 25 to 64 years of age without a history of coronary heart disease , stroke , or cancer at baseline .  Hazard ratios ( HRs ) for incident stroke were estimated for different levels of leisure time , occupational , and commuting physical activity . Results — During a mean follow-up of 19.0 years , 2863 incident stroke events were ascertained . The multivariate-adjusted ( age , sex , area , study year , body mass index , systolic blood pressure , cholesterol , education , smoking , alcohol consumption , diabetes , and other 2 types of physical activity ) HRs associated with low , moderate , and high leisure time physical activity were 1.00 , 0.86 , and 0.74 ( Ptrend<0.001 ) for total stroke , 1.00 , 0.87 , and 0.46 ( Ptrend=0.011 ) for subarachnoid hemorrhage , 1.00 , 0.77 , and 0.63 ( Ptrend=0.024 ) for intracerebral hemorrhage , and 1.00 , 0.87 , and 0.80 ( Ptrend=0.001 ) for ischemic stroke , respectively . The multivariate-adjusted HRs associated with none , 1 to 29 , and ≥30 minutes of active commuting were 1.00 , 0.92 , and 0.89 ( Ptrend=0.043 ) for total stroke , and 1.00 , 0.93 , and 0.86 ( Ptrend=0.028 ) for ischemic stroke , respectively . Occupational activity had a modest association with ischemic stroke in the multivariate analysis ( Ptrend=0.046 ) . Conclusion — A high level of leisure time physical activity  reduces the risk of all subtypes of stroke . Daily active commuting also reduces the risk of ischemic stroke The potential role of physical activity in the primary prevention of  non-insulin-dependent diabetes mellitus ( NIDDM ) is largely unknown . We examined the association between regular vigorous exercise and the subsequent incidence of NIDDM in a prospect i ve cohort of 87,253 US women aged 34 - 59 years and free of diagnosed diabetes , cardiovascular disease , and cancer in 1980 . During 8 years of follow-up , we confirmed 1303 cases of NIDDM . Women who engaged in vigorous exercise at least once per week had an age-adjusted relative risk ( RR ) of NIDDM of 0.67 ( p less than 0.0001 ) compared with women who did not exercise weekly . After adjustment for body-mass index , the reduction in risk was attenuated but remained statistically significant ( RR = 0.84 , p = 0.005 ) . When analysis was restricted to the first 2 years after ascertainment of physical activity level and to symptomatic NIDDM as the outcome , age-adjusted RR of those who exercised was 0.5 , and age and body-mass index adjusted RR was 0.69 . Among women who exercised at least once per week , there was no clear dose-response gradient according to frequency of exercise . Family history of diabetes did not modify the effect of exercise , and risk reduction with exercise  was evident among both obese and nonobese women . Multivariate adjustments for age , body-mass index , family history of diabetes , and other variables did not alter the reduced risk found with exercise . Our results indicate that physical activity may be a promising approach to the primary prevention of NIDDM PURPOSE Patients with chronic heart failure ( CHF ) report difficulty performing activities of daily living . To our knowledge , however , no study has directly measured performance in activities of daily living in these patients to systematic ally assess their level of physical disability . Moreover , the contribution of skeletal muscle weakness to physical disability in CHF remains unclear . Thus , we measured performance in activities of daily living in CHF patients and controls , its relationship to aerobic capacity and muscle strength , and the effect of resistance exercise training to improve muscle strength and physical disability . METHODS Patients and controls were assessed for performance in activities of daily living , self-reported physical function , peak aerobic capacity , body composition , and muscle strength before and after an 18-wk resistance training program . To remove the confounding effects of several disease-related factors ( muscle disuse , hospitalization , acute illness ) , we recruited controls with similar activity levels as CHF patients and tested patients > 6 months after any disease exacerbation/hospitalization . RESULTS Performance in activities of daily living was 30 % lower ( P < 0.05 ) in CHF patients versus controls and was related to both reduced aerobic capacity ( P < 0.001 ) and muscle strength ( P < 0.01 ) . Moreover , resistance training improved ( P < 0.05 to P < 0.001 ) physical function and muscle strength in patients and controls similarly , without altering aerobic capacity . CONCLUSIONS CHF patients are characterized by marked physical disability compared with age- and physical activity-matched controls , which is related to reduced aerobic capacity and muscle strength . CHF patients respond to resistance training with normal strength/functional adaptations . Our results support muscle weakness as a determinant of physical disability in CHF and show that interventions that increase muscle strength  ( resistance training ) reduce physical disability Physical activity has frequently been reported to decrease the risk of colon cancer in men , but data on the relation of physical activity to  colon cancer risk in women have generally been less consistent . To further investigate the relationship of physical activity with  colon cancer risk in women , we studied a cohort of 31,783 US women participating in the Breast Cancer Detection Demonstration Project Follow-up Study . Information on daily physical activity over the past year was ascertained using a self-administered question naire at study baseline . The Cox proportional hazards model was used to estimate relative risks ( RRs ) relating physical activity to the risk of incident colon cancer . During 270,325 person-years of follow-up , 243 colon cancer cases were identified . No association was observed between  physical activity  and the subsequent risk of colon cancer . The multivariable RRs of colon cancer across increasing quintiles of total physical activity were 1.0 , 1.45 , 1.16 , 1.27 and 1.15 ( 95 % CI : 0.76 , 1.75 ; p(trend ) = 0.77 ) . The multivariable RRs comparing women at the extremes of moderate and vigorous physical activity , respectively , were 1.07 ( 95 % CI : 0.70 , 1.62 ) and 1.10 ( 95 % CI : 0.78 , 1.55 ) . The relationship between  physical activity and colon cancer risk did not vary by anatomic subsite or across subgroups defined by age , body mass , dietary fiber intake , menopausal status , menopausal hormone use or aspirin use . The results of this large prospect i ve cohort study among women do not support the hypothesis that physical activity is related to a lower incidence of colon cancer BACKGROUND Although epidemiologic studies have shown associations between sedentary behavior and mortality , few have focused on older women with adequate minority representation and few have controlled for both physical activity and functional status . PURPOSE The objective of this study was to determine the relationship between sedentary time and total ; cardiovascular disease ( CVD ) ; coronary heart disease ( CHD ) ; and cancer mortality in a prospect i ve , multiethnic cohort of postmenopausal women . METHODS The study population included 92,234 women aged 50 - 79 years at baseline ( 1993 - 1998 ) who participated in the Women 's Health Initiative Observational Study through September 2010 .  Self-reported sedentary time  was assessed by question naire and examined in 4 categories ( ≤4 , > 4 - 8 , ≥8 - 11 , > 11 hours ) . Mortality risks were examined using Cox proportional hazard models adjusting for confounders . Models were also stratified by age , race/ethnicity , body mass index , physical activity , physical function , and chronic disease to examine possible effect modification . Analyses were conducted in 2012 - 2013 . RESULTS The mean follow-up period was 12 years . Compared with women who reported the least sedentary time , women reporting the highest sedentary time had increased risk of all-cause mortality in the multivariate model ( HR=1.12 , 95 % CI=1.05 , 1.21 ) . Results comparing the highest versus lowest categories for CVD , CHD , and cancer mortality were as follows : HR=1.13 , 95 % CI=0.99 , 1.29 ; HR=1.27 , 95 % CI=1.04 , 1.55 ; and HR=1.21 , 95 % CI=1.07 , 1.37 , respectively . For all mortality outcomes , there were significant linear tests for trend . CONCLUSIONS There was a linear relationship between greater amounts  of sedentary time and mortality risk after controlling for multiple potential confounders Background Colorectal cancer ( CRC ) is the third most commonly diagnosed cancer and the second highest cause of cancer death in the UK . Most cases occur in people over 50 years and CRC often co-exists with other lifestyle related disorders including obesity , type 2 diabetes mellitus ( T2DM ) and cardiovascular disease ( CVD ) . These diseases share risk factors related to the metabolic syndrome including large body size , abnormal lipids and markers of insulin resistance indicating common aetiological pathways . Methods / Design This 3 year study will be a two-arm , multicentre , r and omised controlled trial comparing the BeWEL lifestyle ( diet , physical activity and behaviour change ) programme against usual care . The pre-trial development will take 6 months and participants will be recruited over a 12 month period and undertake the intervention and follow up for 12 months ( total 24 months recruitment and intervention implementation ) with a further 6 months for data collection , analysis and interpretation . Four hundred and fifty two participants who have had a colorectal adenoma detected and removed ( through the national colorectal screening programme ) will provide 80 % power to detect a weight loss of 7 % over 12 months . Primary outcomes are changes in body weight and waist circumference . Secondary outcomes will include cardiovascular risk factors , psycho-social measures and intervention costs . Discussion The results from this study will enhance the evidence base for lifestyle change in patients at higher risk of chronic disease including obesity related cancers . International St and ard R and omised Controlled Trials No : IS RCT CONTEXT Current public health campaigns to reduce obesity and type 2 diabetes have largely focused on increasing exercise , but have paid little attention to the reduction of sedentary behaviors . OBJECTIVE To examine the relationship between various sedentary behaviors , especially prolonged television ( TV ) watching , and risk of obesity and type 2 diabetes in women . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve cohort study conducted from 1992 to 1998 among women from 11 states in the Nurses ' Health Study . The obesity analysis included 50 277 women who had a body mass index ( BMI ) of less than 30 and were free from diagnosed cardiovascular disease , diabetes , or cancer and completed questions on physical activity and sedentary behaviors at baseline . The diabetes analysis included 68 497 women who at baseline were free from diagnosed diabetes mellitus , cardiovascular disease , or cancer . MAIN OUTCOME MEASURES Onset of obesity and type 2 diabetes mellitus . RESULTS During 6 years of follow-up , 3757 ( 7.5 % ) of 50 277 women who had a BMI of less than 30 in 1992 became obese ( BMI > or = 30 ) . Overall , we documented 1515 new cases of type 2 diabetes .  Time spent watching TV was positively associated with risk of obesity and type 2 diabetes . In the multivariate analyses adjusting for age , smoking , exercise levels , dietary factors , and other covariates , each 2-h/d increment in TV watching was associated with a 23 % ( 95 % confidence interval [ CI ] , 17%-30 % ) increase in obesity and a 14 % ( 95 % CI , 5%-23 % ) increase in risk of diabetes ; each 2-h/d increment in sitting at work was associated with a 5 % ( 95 % CI , 0%-10 % ) increase in obesity and a 7 % ( 95 % CI , 0%-16 % ) increase in diabetes . In contrast , st and ing or walking around at home ( 2 h/d ) was associated with a 9 % ( 95 % CI , 6%-12 % ) reduction in obesity and a 12 % ( 95 % CI , 7%-16 % ) reduction in diabetes . Each 1 hour per day of brisk walking was associated with a 24 % ( 95 % CI , 19%-29 % ) reduction in obesity and a 34 % ( 95 % CI , 27%-41 % ) reduction in diabetes . We estimated that in our cohort , 30 % ( 95 % CI , 24%-36 % ) of new cases of obesity and 43 % ( 95 % CI , 32%-52 % ) of new cases of diabetes could be prevented by adopting a relatively active lifestyle ( < 10 h/wk of TV watching and > or = 30 min/d of brisk walking ) . CONCLUSIONS Independent of exercise levels , sedentary behaviors , especially TV watching , were associated with significantly elevated risk of obesity and type 2 diabetes , whereas even light to moderate activity was associated with substantially lower risk . This study emphasizes the importance of reducing prolonged TV watching and other sedentary behaviors for preventing obesity and diabetes We set out to examine the long-term effect of work-related and leisure time physical activity on risk of death from  coronary heart disease ( CHD ) and other causes . Data were obtained from a large prospect i ve population study of 7142 participant men aged 47 to 55 years at baseline in 1970 - 1973 and without symptomatic CHD . Data on physical activity at work and at leisure were assessed by way of a question naire . After 20 years follow-up men with physically dem and ing work had a slightly higher mortality from all causes , but not from CHD . The association with all-cause mortality disappeared after controlling for smoking , occupational class , and alcohol abuse . Men who were physically active during leisure time had a lower risk of death from CHD , cancer , and all causes . After controlling for smoking , diastolic blood pressure , serum cholesterol , body mass index , diabetes alcohol abuse , and low occupational class , the most active men had a relative risk ( RR ) of dying from CHD of 0.72 ( 0.56 - 0.92 95 % CI ) and of all causes of 0.70 ( 0.61 - 0.80 95 % CI ) . The adjusted relative risk for cancer death was of borderline significance . Noncardiovascular deaths other than cancer showed a strong relationship with low physical activity in the present study that remained after controlling for smoking , alcohol abuse , and other factors ( adjusted RR 0.55 ( 0.42 - 0.73 95 % CI ) ) . The protective effect of CHD and on mortality was present after excluding the first 8 years of follow-up , and at all levels of other risk factors , such as smoking , diastolic blood pressure , serum cholesterol , and body mass index . In conclusion , this long-term study demonstrates the protective effect of  leisure time physical activity on CHD death , cancer death , and on death from all causes . The effect on coronary death and on death from all causes was independent of other risk factors OBJECTIVE Physical activity is integral to the management of type 2 diabetes . Unfortunately , the majority of adults with type 2 diabetes do not regularly engage in physical activity . The purpose of this study was to assess  physical activity behavior  and its correlates ( i.e. , physical activity knowledge , barriers , and performance and outcome expectations ) in older adults with type 2 diabetes . RESEARCH DESIGN AND METHODS A subgroup of 260 adults with type 2 diabetes was identified from a larger stratified r and om sample of adults aged > or = 55 years . Participants completed an interviewer-administered survey design ed from focus group findings and social learning theory . RESULTS The majority of the respondents ( 54.6 % ) reported 0 min of weekly physical activity . This was especially true of older female respondents . Performance expectation scores were lower among respondents who were in the oldest age-group , namely , white women . Physical activity knowledge varied by age-group , and barriers to physical activity were prevalent in all groups . The following are significant correlates of reported weekly physical activity : younger age , more education , fewer motivational barriers , and greater perceived health and performance expectations . CONCLUSIONS Given the importance of physical activity to diabetes management , the low prevalence of physical activity found in this and other studies should raise concerns among clinicians . Future research to identify predictors of physical activity is needed to guide clinicians in the promotion of physical activity OBJECTIVES To compare the prevalence and correlates of meeting current recommendations for physical activity  in older adults with and without diabetes mellitus ( DM ) in the United States . DESIGN A cross-sectional , population -based sample . SETTING The 2007 Behavioral Risk Factor Surveillance Survey , which employs r and om-digit dialing to interview noninstitutionalized U.S. adults . PARTICIPANTS Ninety-nine thous and one hundred seventy-two adults ( 18,370 with DM ) aged 65 and older . MEASUREMENTS The age-adjusted prevalence and the odds ratios for physical activity patterns ( defined on the basis of the physical activity guidelines from the American Diabetes Association ( ADA 2007 ) and the Department of Health and Human Services ( DHHS 2008 ) ) were obtained using multiple logistic regression analyses . The correlates of meeting physical activity recommendations were assessed using log-binomial regression analyses . RESULTS Overall , 25 % and 42 % of older adults with diabetes mellitus met recommendations for total physical activity based on the ADA 2007 and the DHHS 2008 guidelines , respectively . Adults with DM were 31 % to 34 % ( P < .001 ) less likely to engage in physical activity at recommended levels and 13 % to 19 % ( P < .001 ) less likely to be physically active at insufficient levels than those without DM . Analyses limited to participants who reported no disability yielded similar results . In adults with DM , older age ( ≥ 75 ) ; being female ; being non-Hispanic black ; and having obesity , coronary heart disease , and disability were associated with less likelihood , whereas advanced educational status was associated with greater likelihood of meeting physical activity recommendations . CONCLUSION In the United States , efforts to boost physical activity participation in older adults with DM are needed Introduction Optimal vitamin D status promotes skeletal health and is recommended with specific treatment in individuals at high risk for fragility fractures . A growing body of literature has provided indirect and some direct evidence for possible extraskeletal vitamin D-related effects . Purpose and Methods Members of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis have review ed the main evidence for possible proven benefits of vitamin D supplementation in adults at risk of or with overt chronic extra-skeletal diseases , providing recommendations and guidelines for future studies in this field . Results and conclusions Robust mechanistic evidence is available from in vitro studies and in vivo animal studies , usually employing cholecalciferol , calcidiol or calcitriol in pharmacologic rather than physiologic doses . Although many cross-sectional and prospect i ve association studies in humans have shown that low 25-hydroxyvitamin D levels ( i.e. , < 50 nmol/L ) are consistently associated with chronic diseases , further strengthened by a dose-response relationship , several meta-analyses of clinical trials have shown contradictory results . Overall , large r and omized controlled trials with sufficient doses of vitamin D are missing , and available small to moderate-size trials often included people with baseline levels of serum 25-hydroxyvitamin D levels  > 50 nmol/L , did not simultaneously assess multiple outcomes , and did not report overall safety ( e.g. , falls ) . Thus , no recommendations can be made to date for the use of vitamin D supplementation in general , parental compounds , or non-hypercalcemic vitamin D analogs in the prevention and treatment of extra-skeletal chronic diseases . Moreover , attainment of serum 25-hydroxyvitamin D levels well above the threshold desired for bone health can not be recommended based on current evidence , since safety has yet to be confirmed . Finally , the promising findings from mechanistic studies , large cohort studies , and small clinical trials obtained for autoimmune diseases ( including type 1 diabetes , multiple sclerosis , and systemic lupus erythematosus ) , cardiovascular disorders , and overall reduction in mortality require further confirmation BACKGROUND Regular physical activity can help to prevent cardiovascular disease in women . Underst and ing midlife women 's exercise goals could offer insight into their motivational facilitators and barriers , and assist in the development of better primary prevention strategies for this population . OBJECTIVES We sought to investigate the relationship between midlife women 's  physical activity goals and their physical activity participation over time . METHODS A r and om sample of healthy , midlife women ( 40 - 60 years of age ) was selected to participate in a longitudinal study ( n = 156 ) . This study fit a linear mixed model to the data to investigate the fixed effects of physical activity goals on physical activity participation , controlling for Body Mass Index ( BMI ) and Social Support . Mediational analyses were conducted to investigate whether commitment and planning mediated these results . RESULTS There were significant differences between participants with distinct types of goals on physical activity participation over time ( i.e. , baseline , 1 month , and 1 year postbaseline ) , controlling for the effects of BMI and Social Support . Participants with Weight Loss and Health Benefits goals participated in significantly less physical activity than those with Sense of Well-being and Stress Reduction goals . Commitment and Planning each mediated the relationship between participant goals and their physical activity participation . CONCLUSIONS These data suggest having physical activity goals that aim to decrease weight or benefit health may not bode well for healthy midlife women who desire to sustain physically active lives . Instead , health care providers and health promotion specialists might better facilitate long-term participation among healthy women if they emphasize physical activity as a means to enhance their quality of life Context Several studies suggest that blood glucose levels are associated with cardiovascular disease , even at blood glucose values that do not meet diagnostic criteria for diabetes . Contribution Among adult residents of Norfolk , United Kingdom , there was a continuous relationship between hemoglobin A1c levels and cardiovascular disease and total mortality . This relationship was apparent even among persons without diabetes . Implication s These observations justify the need for studies that address whether improvements in glycemic control might improve health outcomes in persons who do not have diabetes . The Editors Diabetes mellitus is of major and increasing global public health importance ( 1 ) . Persons with diabetes are at increased risk for premature disability and death associated with vascular , renal , retinal , and neuropathic complications . Raised fasting and postchallenge blood glucose levels in an oral glucose tolerance test are used to diagnose diabetes . The diagnostic threshold is based on the shape of the risk curve between glucose levels and specific microvascular complications of diabetes ( 2 - 6 ) . Diabetes also increases the risk for macrovascular diseases , such as coronary heart disease and stroke ( 7 ) . In contrast to microvascular disease , increasing evidence suggests that the relationship between blood glucose level and macrovascular disease is continuous and does not have an obvious threshold ( 2 , 8 , 9 ) . Hemoglobin A1c concentration is an indicator of average blood glucose concentrations over the preceding 3 months ; it is useful for characterizing dysglycemia in population studies because it is simpler to perform than the oral glucose tolerance test ( 10 ) . In a 3-year follow-up of men in a prospect i ve study , we previously reported that hemoglobin A1c concentrations were related to cardiovascular disease and all-cause mortality ( 11 ) . However , we had insufficient power to examine risk relationships at concentrations close to the diagnostic threshold of 7 % or to examine the relationship in women . We report the relation between hemoglobin A1c concentrations and fatal and nonfatal coronary heart disease , cardiovascular disease events , and all-cause mortality in men and women after an average of 6 years of follow-up . Methods The European Prospect i ve Investigation into Cancer in Norfolk ( EPICNorfolk ) is a prospect i ve population study of 25 623 men and women who were between 40 and 79 years of age and who resided in Norfolk , United Kingdom . Participants were recruited from general practice registers . Information on the recruitment process is available elsewhere ( 12 ) . Between 1993 and 1997 , participants completed a health and lifestyle question naire . Participants were asked whether a doctor had ever told them that they have any of the conditions contained in a list that included diabetes , heart attack , and stroke . People with known diabetes were defined as those who responded yes to the diabetes option of this question . Smoking history was derived from responses ( yes or no ) to the questions : Have you ever smoked as much as 1 cigarette a day for as long as a year ? and Do you smoke cigarettes now ? At a clinic , trained nurses performed a health examination for each participant . Body mass index was estimated as weight (kg)/height ( m2 ) , and waist-to-hip ratio was determined by measurements of the circumference of the waist and hips . Blood pressure was measured by using an Accutorr ( Data scope , Mahwah , New Jersey ) noninvasive  blood pressure  monitor after the participant had been seated for 5 minutes . The mean of 2 readings was used for analysis . Nonfasting blood sample s were taken ; sample s for assay were stored in a refrigerator at 4 C until transport within 1 week of sampling to the Department of Clinical Biochemistry , University of Cambridge . Starting in 1995 , hemoglobin A1c was measured on fresh EDTA blood sample s by using high-performance liquid chromatography ( BioRad Diamat Automated Glycosylated Haemoglobin Analyser , Hemel Hempstead , United Kingdom ) . We report results for follow-up to January 2003 , an average of about 6 years . All participants were flagged for death certification at the Office of National Statistics ; vital status was obtained for the entire cohort . Trained nosologists coded death certificates according to the International Classification of Diseases , Ninth or Tenth Revisions ( ICD-9 or ICD-10 ) . Cardiovascular death ( stroke , coronary heart disease , and other vascular causes ) was defined as those whose underlying cause of death was coded as ICD-9 400448 or ICD-10 I10I79 . Death from coronary heart disease was defined as those whose cause of death was coded as ICD-9 410414 or ICD-10 I22I25 . Participants admitted to a hospital were identified by their National Health Service number . Hospitals were linked to the East Norfolk Health Authority data base , which identifies all hospital contacts throughout Engl and and Wales for Norfolk residents . We used the same ICD diagnostic codes described in the preceding paragraphs to ascertain hospital episodes of cardiovascular disease and coronary heart disease in our cohort . Participants were identified as having a coronary heart disease event during follow-up if they had a hospital admission or died with coronary heart disease as the cause of death . Of the coronary heart disease events identified , 21 % ( 112 of 529 ) were fatal ; of the cardiovascular disease events , 23 % ( 197 of 806 ) were fatal . In men , 24 % ( 76 of 321 ) of deaths were attributed to heart disease and 29 % ( 117 of 321 ) were attributed to cardiovascular disease . In women , 18 % ( 36 of 200 ) of deaths were attributed to heart disease and 35 % ( 70 of 200 ) were attributed to cardiovascular causes . The Norwich Ethics Committee approved the study , and participants gave signed informed consent . Statistical Analysis These analyses , undertaken by using SPSS software , version 10.0 ( SPSS , Inc. , Chicago , Illinois ) , included 10 232 men and women age 45 to 79 years who completed the health and lifestyle question naire and had available hemoglobin A1c measurements . We divided the cohort into 7 categories on the basis of baseline data : known diabetes , high likelihood of previously undiagnosed diabetes ( no personal history of diabetes but a hemoglobin A1c concentration 7 % ) , and hemoglobin A1c concentrations in 0.5percentage point intervals ( < 5 % , 5 % to 5.4 % , 5.5 % to 5.9 % , 6.0 % to 6.4 % , and 6.5 % to 6.9 % ) . We examined risk factor distributions and then coronary heart disease , cardiovascular disease , and all-cause mortality rates by hemoglobin A1c and diabetes category . Age-adjusted odds ratios were calculated by using logistic regression models . We used a Cox proportional hazards model to determine the independent contribution of hemoglobin A1c to total mortality and cardiovascular and coronary heart disease after adjustment for age , body mass index , waist-to-hip ratio , systolic blood pressure , blood cholesterol concentrations , cigarette smoking , and history of heart attack or stroke . Participants with missing baseline data for 1 or more risk factors ( 130 men and 186 women ) were excluded from the multivariate analyses . Role of the Funding Sources The funding sources had no role in the design , conduct , and reporting of the study or in the decision to su bmi t the manuscript for publication . Results Table 1 presents characteristics of the participants according to hemoglobin A1c concentration and self-reported diabetes . Those with known diabetes had higher mean ( SD ) hemoglobin A1c concentrations ( 8.0 % 1.9 % ) than the rest of the study sample ( 5.3 % 0.7 % ) . They were older and had a higher body mass index , waist-to-hip ratio , and systolic blood pressure ; they were also more likely to report having had a previous heart attack or stroke . Participants with probable but previously undiagnosed diabetes ( hemoglobin A1c 7 % ) shared these characteristics . Mean risk factor levels rose with increasing concentration of hemoglobin A1c less than 7 % . Table 1 . Distribution of Variables by  Hemoglobin A1c Concentration and Known Diabetes in 4662 Men and 5570 Women Age 45 to 79 Years ( European Prospect i ve Investigation into Cancer in Norfolk , 1995 to 1997 ) Table 2 shows adjusted odds ratios for hemoglobin A1c concentrations , diabetes status , and outcomes .  Persons with known or undiagnosed diabetes had a greater risk for all-cause mortality and cardiovascular or coronary heart disease than those without diabetes . Risk for coronary heart or cardiovascular disease and total mortality increased throughout the whole range of hemoglobin A1c concentrations ; those with hemoglobin A1c concentrations less than 5 % had the lowest rates . For men , a gradient of increasing rates through the distribution was apparent for all end points . For women , odds ratios for cardiovascular or coronary heart disease did not increase significantly until the hemoglobin A1c concentration reached 6 % ; odds ratios were very high in women with concentrations greater than 7 % . Table 2 . Rates and Age-Adjusted Relative Risks for Total Coronary Heart Disease Events , Cardiovascular Disease Events , and All-cause Mortality by Category of Hemoglobin A1c Concentration and Known Diabetes in 4462 Men and 5570 Women Age 45 to 79 Years ( European Prospect i ve Investigation into Cancer in Norfolk , 1995 to 2003 ) Table 3 shows outcomes after adjustment for age alone and then after adjustment for age and other risk factors . In men , known diabetes predicted coronary heart and cardiovascular disease events and total mortality with approximate 2-fold relative risks . These relative risks were only slightly attenuated after adjustment for known risk factors . In women , known diabetes status predicted an approximate 5-fold increase in risk for coronary heart and 3-fold increase in risk for cardiovascular disease events ; these increases were attenuated after adjustment for known risk factors to 3-fold and 2-fold risk , respectively . In men and women , hemoglobin A1c concentrations predicted an increased risk for Context Guidelines disagree about who should receive screening for diabetes . Screening all adults would be expensive and lead to many false-positive results . Contribution The authors created a tool that allows people to estimate their own diabetes risk with questions they can easily answer ( age , sex , family history of diabetes , personal history of high blood pressure , obesity , and physical activity ) . This tool performs better than other available methods . Implication People can use this tool to help decide whether their risk for diabetes is high enough to warrant seeing a doctor to have blood glucose measured . The Editors Diabetes and its complications are major causes of morbidity and mortality worldwide . More than 60 million U.S. adults are estimated to have diagnosed diabetes , undiagnosed diabetes , or prediabetes , and approximately 30 % of diabetes cases are estimated to be undiagnosed . With the steadily increasing prevalence of diabetes , prevention of diabetes has become a major health priority ( 15 ) . Recent clinical trials demonstrate that lifestyle ( 68 ) and pharmaceutical ( 6 , 9 , 10 ) interventions in persons with impaired glucose tolerance can prevent or delay diabetes , providing a rationale for the identification of high-risk persons who may benefit from early lifestyle interventions . National guidelines for diabetes screening are available to help detect undiagnosed disease , and various risk assessment tools for prevalent or incident diabetes have been developed to identify persons most in need of screening . Yet , many of these risk assessment tools were developed from specific cohorts , which often have restricted age ranges or racial or ethnic groups , limiting generalizability to the entire population . In the United States , 3 national guidelines for diabetes screening are those of the Centers for Disease Control and Prevention ( 11 ) , the American Diabetes Association ( ADA ) ( 12 ) , and the U.S. Preventive Services Task Force ( 13 ) . In addition , 2 risk-scoring algorithms for undiagnosed diabetes have been derived from nationally representative sample s : Herman and colleagues ' ( 14 ) model from the NHANES ( National Health and Nutrition Examination Survey ) II ( conducted from 1976 to 1980 ) and Heikes and colleagues ' ( 4 ) model from the NHANES III ( conducted from 1988 to 1994 ) . These 2 algorithms are also known as the ADA diabetes question naires . We developed a new screening score for undiagnosed diabetes in multiethnic U.S. adults by using readily available health information . Our aim was to improve existing algorithms for diabetes-risk scoring by using a more contemporary NHANES ( 1999 to 2006 ) and formulating an easy scoring system that enables laypersons to assess their own risk for undiagnosed diabetes . Methods Study Design and Participants The NHANES is a cross-sectional study conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention . To represent the U.S. population , NHANES used complex , multistage probability sampling of the civilian , noninstitutionalized population . To produce reliable statistics , NHANES over sample d elderly persons and some racial and ethnic minorities . We used deidentified data from multiple years of NHANES ( 1999 to 2006 ) that are publicly available . We included participants aged 20 years or older who had fasting plasma glucose ( FPG ) results . We excluded pregnant women . We used NHANES 1999 to 2004 for prediction modeling and screening score development and NHANES 2005 to 2006 for validation . We conducted further validation by combining the baseline data from 2 biracial cohort studies : the ARIC ( Atherosclerosis Risk in Communities ) Study ( 15 ) and the CHS ( Cardiovascular Health Study ) ( 16 ) . Detailed descriptions of these studies are published elsewhere ( 15 , 16 ) . In brief , ARIC enrolled 15732 participants aged 45 to 64 years between 1987 and 1989 from 4 communities , and CHS recruited 5201 participants aged 65 years or older between 1989 and 1990 from 4 communities . Between 1992 and 1993 , CHS enrolled an additional 687 black persons to increase minority participation . Participant Data For each participant , we retrieved data that were collected through interviews , physical examinations , and laboratory tests . Specifically , we used data on participants ' demographic and socioeconomic characteristics , health care use , personal and family medical histories , health habits , physical examinations ( including anthropometric findings ) , and laboratory test results . For the obesity measure , we combined body mass index and waist circumference . For variable categorization , we used conventional cutoffs or well-accepted clinical guidelines when available . If information was missing or unknown in categorical variables , we defined the condition as absent , a convention commonly adopted in the risk- question naire setting . In our question naire , we instructed users , Enter your score ( but if you do n't know the answer , enter 0 ) . We stratified the participants into 4 groups by diabetes status : known diabetes , normal glucose metabolism ( FPG level < 5.5 mmol/L [ < 100 mg/dL ] ) , impaired fasting glucose or prediabetes ( FPG level of 5.6 to 6.9 mmol/L [ 100 to 125 mg/dL ] ) , and undiagnosed diabetes ( FPG level 7.0 mmol/L [ 126 mg/dL ] ) ( 4 , 17 , 18 ) . Specifically , we classified participants as having known diabetes if they answered yes to the question , Other than during pregnancy , have you ever been told by a doctor or health professional that you have diabetes or sugar diabetes ? or reported use of insulin or other diabetes medications . For medical history variables , we considered data from multiple sources . For example , we classified participants as having hypertension if they reported a history of hypertension , reported using prescribed medication for hypertension , had a systolic blood pressure of 140 mm Hg or higher , or had a diastolic blood pressure of 90 mm Hg or higher . We defined hyperlipidemia as a total cholesterol level of 5.17 mmol/L ( 200 mg/dL ) or greater or a triglyceride level of 1.69 mmol/L ( 150 mg/dL ) or greater ( 19 ) , and high cholesterol level as history of high cholesterol , use of cholesterol-lowering medication , or a fasting low-density lipoprotein cholesterol level of 2.59 mmol/L ( 100 mg/dL ) or greater with a history of cardiovascular disease ( 20 ) . We defined cardiovascular disease as myocardial infa rct ion or stroke . When definitions of variables were not identical across the different studies ( for example , physical activity ) , we tried to use the best available variables to achieve reasonable consistency across data bases . For example , in NHANES , we classified participants as physically active if they answered more active to the question , Compare your activity with others of the same age . Otherwise , we classified participants as not physically active . In ARIC , physical activity was assessed in a question with a response of yes or no , whereas in CHS , we dichotomized the physical activity question into no or low versus moderate or high . None of the data bases we used collected data during pregnancy . Finally , some ARIC participants ( n= 521 ) did not fast . For these persons , we used a r and om blood glucose level of 11.1 mmol/L ( 200 mg/dL ) as the cut-point to define diabetes ( 12 , 18 , 21 ) . We did not include nonfasting participants in the model development ( using NHANES ) but did include them in the external validation to reflect a realistic scenario . Statistical Analysis We used descriptive statistics to characterize the 4 groups according to diabetes status : we used means ( SEs ) for continuous variables and percentages for categorical variables . For model fitting , we used multiple logistic regression with cases of undiagnosed diabetes as the end point , excluding cases of diagnosed diabetes . Because of small proportions of missing data , we used all nonmissing observations available in the relevant analyses . The only exception is that we imputed family history of diabetes by using a statistical technique ( missing data imputation procedure , Proc MI , in SAS , SAS Institute , Cary , North Carolina ) to h and le missing data in CHS because this information was not collected in CHS ( 22 , 23 ) . Development of a New Screening Score Using the development data set ( NHANES 1999 to 2004 ) , we included a comprehensive list of predictors known to be potentially associated with undiagnosed diabetes in an initial model . Specifically , we included the main effects of all variables listed in Appendix Table 1 and their interaction effects with age . Because the number of covariates was large , we started with continuous variables and later categorized them in the final model . We used backward elimination ( deleting the covariate with the largest P value , 1 at a time ) from the initial model until we reached a final model with statistically significant covariates . We were guided by statistical significance for the model building but also used scientific and qualitative judgments as well . For example , although income and health insurance status were statistically significant , we did not keep these variables in the final model because we deemed them less appropriate or less user-friendly in risk assessment question naires . Physical activity showed borderline significance ( P= 0.064 ) in the development data set but was kept because this is an underlying protective factor that often does not reach statistical significance for various reasons ( for example , difficult to quantify , misclassification , or insufficient statistical power ) . Moreover , physical activity is highly modifiable compared with demographic and health history variables ( 24 ) . Appendix Table 1 . Characteristics of Participants in NHANES 1999 to 2004 , by Diabetes Status In the final model , we double-checked that any important covariates were not erroneously omitted in this sequential process . We intentionally used only categorized variables that captured easy but relevant and vali date d health information in the prediction model , to develop a user-friendly and BACKGROUND AND PURPOSE From a physiological perspective , physical activity might be expected to decrease the risk of developing stroke . However , epidemiological studies of physical activity and stroke risk have yielded divergent findings . We therefore sought to examine the association between exercise and stroke risk . METHODS This was a prospect i ve cohort study of 21 823 men , followed up for an average of 11.1 years . Participants were from the Physicians ' Health Study , a r and omized trial of low-dose aspirin and beta carotene . Men , aged 40 to 84 years at baseline , were free of self-reported myocardial infa rct ion , stroke , transient ischemic attack , and cancer . At baseline , they reported on the frequency of exercise vigorous enough to work up a sweat . Stroke occurrence was reported by participants and confirmed after medical record review ( n=533 ) . We used Cox proportional hazards regression to analyze the data . RESULTS With adjustment for age , treatment assignment , smoking , alcohol intake , history of angina , and parental history of myocardial infa rct ion , the relative risks of total stroke associated with vigorous exercise < 1 time , 1 time , 2 to 4 times , and > /=5 times per week at baseline were 1.00 ( referent ) , 0.79 ( 95 % confidence interval [ CI ] , 0.61 to 1 . 03 ) , 0.80 ( 95 % CI , 0.65 to 0.99 ) , and 0.79 ( 95 % CI , 0.61 to 1.03 ) , respectively ; P for trend=0.04 . In subgroup analyses , the inverse association appeared stronger with hemorrhagic than ischemic stroke . When we additionally adjusted for body mass index , history of hypertension , high cholesterol , and diabetes mellitus , corresponding relative risks for total stroke were 1.00 ( referent ) , 0.81 ( 95 % CI , 0.61 to 1.07 ) , 0.88 ( 95 % CI , 0.70 to 1.10 ) , and 0.86 ( 95 % CI , 0.65 to 1.13 ) , respectively ; P for trend=0.25 . CONCLUSIONS Exercise vigorous enough to work up a sweat is associated with decreased  stroke risk in men . In the present study , the inverse association with physical activity appeared to be mediated through beneficial effects on body weight , blood pressure , serum cholesterol , and glucose tolerance . Apart from its favorable influences on these variables , physical activity had no significant residual association with stroke incidence Background This study aim ed to estimate the cost-effectiveness of a universal strategy to promote physical activity in primary care . Methods Data were analysed for a cohort of participants from the general practice research data base . Empirical estimates informed a Markov model that included five long-term conditions ( diabetes , coronary heart disease , stroke , colorectal cancer and depression ) . Simulations compared an intervention promoting physical activity in healthy adults with st and ard care . The intervention effect on physical activity was from a meta- analysis of r and omised trials . The annual cost of intervention , in the base case , was one family practice consultation per participant year . The primary outcome was net health benefit in quality adjusted life years ( QALYs ) . Results A cohort of 262,704 healthy participants entered the model . Intervention was associated with an increase in life years lived free from physical disease . With 5 years intervention the increase was 52 ( 95 % interval −11 to 115 ) per 1,000 participants entering the model ( probability increased 91.9 % ) ; with 10 years intervention the increase was 102 ( 42–164 ) per 1,000 ( probability 99.7 % ) . Net health benefits at a threshold of £ 30,000 per QALY were 3.2 ( −11.1 to 16.9 ) QALYs per 1,000 participants with 5 years intervention ( probability cost-effective 64.7 % ) and 5.0 ( −9.5 to 19.3 ) with 10 years intervention ( probability cost-effective 72.4 % ) . Conclusions A universal strategy to promote physical activity in primary care has the potential to increase life years lived free from physical disease . There is only weak evidence that a universal intervention strategy might prove cost-effective Numerous studies have examined the relationship between physical activity and cognitive function , demonstrating that greater physical activity is associated with lower incidence of cognitive impairment in later life . Due to an increasingly large number of older adults at risk for cognitive impairment , the relationship between physical activity and cognition has garnered increasing public health relevance and multiple r and omized trials have demonstrated that exercise interventions among sedentary adults improve cognitive performance in multiple domains of function . This article will examine the relationship between physical activity and cognitive function by review ing several different areas of literature , including the prevalence of cognitive impairment , assessment methods , observational studies examining physical activity and cognition , and intervention studies . The present review is intended to provide a historical tutorial of existing literature linking  physical activity , exercise , and cognitive function among both healthy and clinical population
Overall , the current literature supports clearly the dose-response relationship between physical activity and the seven chronic conditions identified .
Moreover , higher levels of physical activity reduce the risk for premature all-cause mortality .
The current Canadian guidelines appear to be appropriate to reduce the risk for the seven chronic conditions identified above and all-cause mortality
This systematic review examines critically the scientific basis for Canada 's Physical Activity Guide for Healthy Active Living for adults .
Particular reference is given to the dose-response relationship between physical activity and premature all-cause mortality and seven chronic diseases ( cardiovascular disease , stroke , hypertension , colon cancer , breast cancer , type 2 diabetes ( diabetes mellitus ) and osteoporosis ) .
The strength of the relationship between physical activity and specific health outcomes is evaluated critically .