1. WHAT ARE THE HEALTH BENEFITS OF PHYSICAL ACTIVITY?
There is absolutely gold-standard evidence that physical activity can reduce morbidity and mortality due to multiple chronic conditions. The mountain of evidence can be gauged from the fact that there are 948 meta-analyses of 11,726 clinical trials, in addition to 1.4 million research papers, that leave no doubt about the unquestionable necessity of physical activity for good health. Drawing on the leading research, here we discuss the most popular and easier form of exercise, walking, to assemble the usable knowledge. For significant health benefits, World Health Organization (WHO) suggests, adults should do at least 150 to 300 minutes of moderate-intensity aerobic physical activity; or at least 75 to 150 minutes of vigorous intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity distributed throughout the week1. On an average, leisure-time regular physical activity should be within about 45 minutes a day.
Exercise can protect against metabolic syndrome2, hypertension3-5, cardiovascular disease6, type 2 diabetes7, depression5,8, dementia, Alzheimer's disease, cognitive decline9, migraine10, autoimmune diseases11,12, bone mass, mineral density and strength13-16, fall-prevention in elderly17, chronic low-back pain18, and at least 26 types of cancers19, among others. Exercise also lengthens telomeres20, reduces stress, and attenuates cellular aging21. It prevents frailty22 and age-related pathogenesis including macular degeneration23. In addition to protecting against non-communicable diseases, physical activity can help us fight communicable diseases, such as COVID-19, through enhanced immunity24-27. Higher, but not excessive, levels of physical activity increase the odds of healthy ageing by 39 percent28. Simple exercise such as walking also reduces postpartum depressive symptoms (PSD) in mothers29. Regular, moderate to vigorous physical activity also leads to reduced risk of community-acquired infectious diseases and infectious disease mortality. It enhances the first line of defence of the immune system, and interestingly, increases the potency of vaccination26. Physical activity for muscle-strengthening can reduce incidence of kidney cancer and total cancer mortality. In addition, a combination of muscle-strengthening and aerobic activities may provide a greater reduction in total cancer mortality30. Older adults, with a combination of resistance training with other forms of exercise, can get clinically meaningful benefits with lower doses than the WHO guidelines31.
Overall, physical activity contributes to healthy longevity, and promotes happiness, healthspan and well-being.
2. ARE PEOPLE REALLY PHYSICALLY ACTIVE?
Physical activity being so vital, the world must be craving to do that every day. Right? Well, not really. People have their own reasons for being lethargic. A study published in the Lancet Global Health on the worldwide trends in insufficient physical activity based on the pooled analysis of 358 surveys across 168 countries, among 1·9 million participants found the evidence otherwise. Global prevalence of insufficient physical activity was 27·5 percent32. This puts more than 1·4 billion adults at risk of developing or exacerbating diseases linked to inactivity33,34.
India has its own lazy-stars renowned for slothfulness. About 34 per cent of adult Indians are insufficiently active. Half of Indian children and adolescents do not meet the required levels of physical activity of 60 minutes per day35. This is giving rise to the occurrence of more than 3 disease conditions in the same person, often known as multimorbidity, in both rural and urban India36. The highest proportion of adults from northern India, i.e., 49.6%, have low levels of physical activity. On the other, the prevalence of metabolic risk factors including obesity, raised fasting blood glucose and raised blood pressure was highest in south India. The prevalence of raised blood pressure was high in north India almost similar in proportion to south India. More worrisome are the clustering of 3 or more risk factors (50.1%). Also, south India also has the highest cardiovascular diseases risk of 30% or more with existing CVD (18.1%)37.
The young people aged 10–24 years constitute 24 percent of the world's population, and more than 80 percent of them have insufficient physical activity38. Data from 298 school-based surveys from 146 countries, territories, and areas including 1·6 million students aged 11–17 years are instructive. Globally, 81·0 percent of students aged 11–17 years were insufficiently physically active39. Approximately 30% of people aged more than 60 years, experience a fall in a given year. Physical activity in such people can enhances resilience, robustness and fitness40.
3. WHAT IS THE COST OF PHYSICAL INACTIVITY?
This inaction costs hugely. Physical inactivity increases the risk of death from non-communicable diseases (NCDs). Only one previous global study has estimated the direct health-care costs resulting from physical inactivity using a disease prevalence-based approach. It reported an economic cost to society of INT$53·8 billion (2013 prices), of which 58% was paid by the public sector. Of this, 31·2 billion dollars is paid by the public sector, 12·9 billion dollars by the private sector, and 9·7 billion dollars by households. The physical inactivity related deaths contribute to 13·7 billion dollars in productivity losses. It is also responsible for 13·4 million disability-adjusted life-years worldwide41.
Now the first global study to provide estimates of the number of new cases and associated public health-care costs that would occur from 2020 to 2030 that could be prevented if levels of physical inactivity were reduced or eliminated has become available. It provides new population-attributable fractions for seven health outcomes and mental health conditions (coronary heart disease, stroke, type 2 diabetes, cancers [breast, colon, bladder, endometrial, gastric, oesophageal, and renal], depression, and dementia) with strong evidence for the association with physical inactivity. The results suggest that 499·2 million new cases of preventable major NCDs would occur globally by 2030 if the prevalence of physical inactivity does not change, with direct health-care costs of INT$520 billion. The global cost of inaction on physical inactivity would reach approximately $47·6 billion per year. Although 74% of new cases of NCDs would occur in low-income and middle-countries, high-income countries would bear a larger proportion (63%) of the economic costs. The cost of treatment and management of NCDs varied—although dementia accounted for only 3% of new preventable NCDs, the disease corresponded to 22% of all costs; type 2 diabetes accounted for 2% of new preventable cases but 9% of all costs; and cancers accounted for 1% of new preventable cases but 15% of all costs42.
Cardiovascular diseases, respiratory diseases, and diabetes kill more than 4 million Indians annually, and most of these deaths are premature, occurring among Indians aged 30–70 years43. Physical inactivity is the fourth leading cause of death worldwide44.
In terms of economic benefits, doing at least 150 min of moderate-intensity physical activity per week, as per lower limit of the range recommended by the 2020 WHO guidelines, would lead to an increase in global gross domestic product (GDP) of 0.15%-0.24% per year by 2050, worth up to US$314-446 billion per year and US$6.0-8.6 trillion cumulatively over the 30-year projection horizon (in 2019 prices)45. Increasing physical activity in the population would lead to reduction in working-age mortality and morbidity and an increase in productivity, particularly through lower presenteeism, leading to substantial economic gains for the global economy.
The time has come to move and keep moving every day. One of the easiest and most popular physical activity, recommended by the ancient India’s Sage-Scientist Acharya Sushruta, 5000 years ago in Ayurveda, is walking. Sage-Scientist Acharya Charaka says that physical activity is the best among all the factors that confer physical and mental resilience. Charaka and Sushruta prescribed exercise for health at least 1000 years before Hippocrates (460–370 B.C.) and Galen (129–210 A.D.). But, most of the European and American authors were too ignorant to recognize this truth. World's oldest definition and prescription of exercise as medicine is found in Caraka Samhita, that was redacted from the world's oldest record of medicine practice.
4. HOW MANY STEPS EVERY DAY ARE REQUIRED FOR GOOD HEALTH?
In this context, the number of steps taken per day is a simple measure of physical activity. Monitoring daily steps with the help of trackers and wearable mobile devices have become increasingly fashionable worldwide. We will, therefore, discuss about walking. Cycling, swimming, and many other forms require special arrangements. But walking can be performed in any place. Green spaces and safe urban forests are great environments to walk46. If you take a 50 min walk on a forest path and a 50 min walk along a busy road, both are not the same in terms of health outcome47. Green walking is very effective in reducing anxiety and increasing positive mood48. It is a mind-body green package for good health49. Our emphasis on walking is also driven by the fact that Global Burden of Disease Study50 treats physical activity as a single construct because evidence on health effects of individual components, beyond total volume and intensity of physical activity, is rare and only few population-level data are available to reliably estimate the exposure to various types of physical activity (eg, aerobic or muscle-strengthening exercise)51. This approach is consistent with WHO 2020 guidelines on physical activity that there is insufficient evidence supporting the varying health benefits of different types of activity1. Additionally, a 2019 meta-analysis52 suggests that total physical activity lowers the risk of all-cause mortality more than physical activity at light, moderate, or vigorous intensity. On top of that, the ability to walk is an important indicator of good health both according to modern scientific studies53, as well as Ayurveda.
We now turn our attention to evidence related to walking and steps per day.
First meta-analysis of randomized controlled trials has recently given multiple instances of physical activity in parks, forests and near water-bodies being beneficial to physical and mental health54. In fact, there is independent evidence that spending at least 120 minutes a week in nature is associated with good health and wellbeing55. Forest experience, green exercise, gardening, and nature viewing all have positive health impact56-59.
The question is, walking being the most convenient exercise for healthy persons, how many steps need to be taken per day? A commonly promoted goal is 10,000 steps per day, its origin is anecdotal. This number became popular from a marketing campaign in Japan. The WHO 2020 Physical Activity Guidelines specifically identified this gap in research on the dose–response connection between volume (steps per day) and intensity (steps per min) of physical activity and consequent health outcomes1,60,61. Uncertainty remains about the optimum step count per day for health promotion. Here, we provide new evidence that has become available through recent meta-analysis about various facets of walking for good health.
The most important guidance has now become available through four outstanding meta-analyses. First on relates to daily steps and all-cause mortality. It is based on a meta-analysis of 15 international cohorts with 47,471 adults. It suggests progressively decreasing risk of mortality among adults aged 60 years and older with increasing number of steps per day until 6,000–8,000 steps per day. For adults younger than 60 years, the step count is 8,000–10,000 steps per day62.
Second study found an answer to the associations of daily step counts with cancer and cardiovascular disease incidence and mortality as well as all-cause mortality. It also explored if the intensity of steps has additional benefits. This population-based prospective cohort study used the data for 78,500 individuals of average 61 years of age. This study found that more steps per day, up to about 10,000 steps, was associated with decline in mortality risks and decreased cancer and CVD incidence. These findings indicate that accumulating more steps per day, up to about 10 000, is useful to lower the risk of all-cause, cancer, and CVD mortality as well as incidence of cancer and CVD63. Higher step intensity or brisk walking may provide additional benefits, but it must not be taken to extreme. Faster a healthy person walks regularly, lower is the risk of stroke in future. With every 1 km/h increment in walking pace, the stroke risk gets decreased by 13%64.
Third study that included Seven prospective cohort studies with 175,370 person-years and 2310 cases of all-cause mortality found that even a modest increase in steps per day may be associated with a lower risk of death65.
Fourth study reports that the third quartile of the sample had a 40.36% lower risk of all-cause mortality and a 35.05% lower risk of cardiovascular event than the first quartile (all-cause mortality: Q1 = 4183 steps/day, Q3 = 8959 steps/day; cardiovascular event: Q1 = 3500 steps/day, Q3 = 9500 steps/day; respectively)66.
5. IF NOT OPTIMAL THEN WHAT?
What if you do not have time for taking 8,000 to 10,000 steps per day? Well, then main thing is exercise and it does not have to be 10,000 steps. If you are able to do 3 to 5 length-standardized vigorous physical activity bouts per day, lasting about 2 minutes each, it can bring about 40% reduction in all-cause and cancer mortality risk and about 50% reduction in CVD mortality risk67. Physical activity can prevent depression and provides mental health benefits, even at levels below the public health recommendations68. A meta-analysis of 15 prospective studies including more than 2 million person-years showed an inverse curvilinear association between physical activity and incident depression, with greater differences in risk at lower exposure levels. Adults meeting physical activity recommendations, equivalent to 2.5 hours per week of brisk walking, had lower risk of depression, compared with adults reporting no physical activity68. Brisk walking also improves several known risk factors for cardiovascular disease69. Another meta-analysis of total 52 studies pertaining to 131406 persons, likewise indicates that small amounts of vigorous physical activity can substantially lower the mortality risks70. Other recent meta-analysis has demonstrated that higher step count per day may be associated with lower all-cause mortality but this is not significantly different across small variations in number of steps71.
In brief, the evidence has strengthened the conclusions drawn in Ayurveda, 5,000 years ago72, including by Acharya Sushruta that moderate—but not excessive—walking enhances life-span, strength, intelligence, digestive power, and invigorates all our sense organs. Sushruta was a 600 B.C. physician who included exercise in his prescriptions to prevent and treat diseases73,74.
6. CAN PHYSICAL ACTIVITY WIPE OUT ALL SINS OF SEDEANTARY BEHAVIOUR?
Sedentary time is independently associated with deleterious health outcomes regardless of physical activity75. Higher sedentary time is associated with higher mortality in less active individuals. About 30-40 min of physical activity per day is required additionally to attenuate the association between sedentary time and risk of mortality76. So, do not keep sitting for a duration longer than 40 to 50 minutes. Interrupting prolonged sitting with short bouts of walking—but not merely standing—provides clinically meaningful improvements in metabolic health77. Take a break, walk a few brisk steps, stretch, do some deep-breathing, mindfully observe trees and green space from your window, and go back refreshed to work.
7. CONCLUDING REMARKS
We have not analysed about the running as physical activity here. Suffice it to say, however, that there is compelling evidence that running provides significant health benefits for the prevention of chronic diseases and premature mortality78. Running, regardless of its dose, is likely to lead to considerable improvements in health and longevity. And, any amount of running, even just once a week, is better than no running. But higher doses of running may not necessarily lead to greater benefits79. Yet, it is not the best exercise for everyone because various clinical conditions and old-age can impede its practice. Likewise, cycling is associated with numerous health benefits including lower incidence of cardiovascular diseases, all-cause mortality80,81, better bone health and fitness among others82.
Finally, please remember that with all the goodness of reasonable amount of physical activity, excessive exercise is a serious risk for health83. Both Ayurveda and modern science warn against excessive physical activity. Ayurveda notes numerous harmful effects of excessive physical activity (Ativyayama) including thirst, altered taste perception, nausea, vomiting, dizziness, exercise-related syncope, exertion, cough, shortness of breath, injury in the chest, excessive weight loss, bleeding disorders, cachexia, heat injury, fever, exertional shortness of breath in asthamatics84. Vyayama (exercise) is must for good health but must not be done beyond balardha (i.e., beyond half of your strength). Sweating, increased respiration, feeling lightness of body and tightness in cardiac region are signs of optimal physical activity. Extent of physical exercise is governed by individual’s capability. We should stop exercise before getting tired and should abstain from over exertion. Notwithstanding a cautionary note here, know that benefits of physical activity outweigh the risks. Move and keep moving. Stay healthy, stay happy.
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Reference
Deep Narayan Pandey
