Diet, Food & Fitness Vitamins and Minerals

Vitamin B1 (Thiamin)

by Health Jade Team on January 18, 2017

Vitamin B1

Vitamin B1 also known as thiamin or thiamine, is one of the water-soluble B vitamins. Vitamin B1 or thiamine is naturally present in some foods, added to some food products, and available as a dietary supplement. Vitamin B1 or thiamine plays a critical role in energy metabolism and, therefore, in the growth, development, and function of cells ¹. Foods rich in vitamin B1 or thiamine include whole grains, brown rice, lean pork, poultry, eggs, fish, soybean, nuts, dried beans, peas, and fortified or enriched grain products such as cereals, infant formulas, and bread ², ³, ⁴. Multivitamins will provide an additional 1.5 mg of thiamine on top of a diet rich in thiamine ⁵.

Ingested vitamin B1 or thiamine from food and dietary supplements is absorbed by the small intestine through active transport at nutritional doses and by passive diffusion at pharmacologic doses ⁶, ¹. Most dietary vitamin B1 or thiamine is in phosphorylated forms, and intestinal enzyme phosphatase hydrolyzes them to free thiamin before the vitamin is absorbed by the small intestine ¹. The remaining dietary vitamin B1 or thiamine is in free (absorbable) form ¹, ⁷. Thiamine, a water-soluble vitamin, cannot be stored in appreciable amounts ⁸. Humans store vitamin B1 or thiamine primarily in the liver, but in very small amounts (approximately 30 mg) ⁹. Vitamin B1 or thiamine has a short half‐life of 14 to 18 days and body stores are limited, so people require a continuous supply of thiamine from the diet ¹⁰, ⁶, ¹¹.

Vitamin B1 or thiamine is present in the body as free thiamine, as well as in several phosphorylated forms: thiamine monophosphate (TMP), thiamine diphosphate (TDP also known as thiamin pyrophosphate (TPP)), and thiamine triphosphate (TTP) ¹², ¹³, ¹⁴. About 80% of the approximately 25–30 mg of vitamin B1 or thiamine in the adult human body is in the form of thiamin pyrophosphate (TPP) also known as thiamin diphosphate (TDP), the main metabolically active form of vitamin B1 or thiamine. Bacteria in the large intestine also synthesize free thiamin and thiamin pyrophosphate (TPP), but their contribution, if any, to thiamin nutrition is currently unknown ¹⁵. Thiamin pyrophosphate (TPP) serves as an essential cofactor for five enzymes involved in glucose, amino acid (proteins), and fatty acids (lipids) metabolism (Figure 1) ¹⁶, ¹, ⁹.

Levels of vitamin B1 or thiamine in the blood are not reliable indicators of thiamin status. Thiamine status is often measured indirectly by assaying the activity of the transketolase enzyme, which depends on thiamin pyrophosphate (TPP), in red blood cell hemolysates in the presence and absence of added thiamin pyrophosphate (TPP) ⁹. The result, known as the “TPP effect,” reflects the extent of unsaturation of transketolase with TPP. The result is typically 0%–15% in healthy people, 15%–25% in those with marginal deficiency, and higher than 25% in people with thiamine deficiency. Another commonly used measure of vitamin B1 or thiamine status is urinary thiamine excretion, which provides data on dietary intakes but not tissue stores ¹⁷. For adults, excretion of less than 100 mcg/day vitamin B1 or thiamine in urine suggests insufficient thiamine intake, and less than 40 mcg/day indicates an extremely low intake ¹⁸.

Figure 1. Vitamin B1 (thiamine) function

Footnote: Major biochemical reactions requiring vitamin B1 or thiamine as a cofactor (a compound that is essential for the activity of an enzyme).

[Source ¹⁹ ]

What does vitamin B1 (Thiamine) do?

Vitamin B1 or thiamine helps turn the food you eat into the energy you need. Thiamine is important for the growth, development, and function of the cells in your body.

About 80% of the approximately 25–30 mg of vitamin B1 or thiamine in the adult human body is in the form of thiamin pyrophosphate (TPP) also known as thiamin diphosphate (TDP), the main metabolically active form of vitamin B1 or thiamine. The synthesis of thiamin pyrophosphate (TPP) from free thiamine requires magnesium, adenosine triphosphate (ATP), and the enzyme, thiamin pyrophosphokinase ¹⁹. In humans, thiamin pyrophosphate (TPP) serves as an essential cofactor for five enzymes involved in glucose, amino acid (proteins), and fatty acids (lipids) metabolism (Figure 1) ¹⁶, ¹, ⁹. Forms of thiamine are also needed for ribose synthesis and for α-oxidation of 3-methyl-branched fatty acids ¹⁹.

Pyruvate dehydrogenase, α-ketoglutarate dehydrogenase, 2-oxoadipate dehydrogenase, and branched-chain α-ketoacid dehydrogenase (BCKDH) each comprise a different enzyme complex found within cellular organelles called mitochondria ¹⁹. They catalyze the decarboxylation of pyruvate, α-ketoglutarate, 2-oxoadipate, and branched-chain amino acids (BCAAs) to form acetyl-coenzyme A (CoA), succinyl-CoA, glutaryl-CoA, and derivatives of branched-chain amino acid (BCAA), respectively (Figure 1). All products play critical roles in the production of energy from food through their connection to the citric acid (Krebs) cycle ²⁰. Branched-chain amino acid (BCAA), including leucine, isoleucine, and valine, are eventually degraded into acetyl-CoA and succinyl-CoA to fuel the citric acid cycle. The catabolism of the three branched-chain amino acids (BCAAs) also contributes to the production of cholesterol and donates nitrogen for the synthesis of the neurotransmitters, glutamate and g-aminobutyric acid (GABA) ²¹. In addition to the thiamin coenzyme (thiamin pyrophosphate), each dehydrogenase complex requires a niacin-containing coenzyme (NAD), a riboflavin-containing coenzyme (FAD), and lipoic acid.

Transketolase catalyzes critical reactions in another metabolic pathway occurring in the cytosol, known as the pentose phosphate pathway ¹⁹. One of the most important intermediates of this pathway is ribose-5-phosphate, a phosphorylated 5-carbon sugar required for the synthesis of the high-energy ribonucleotides, such as ATP and guanosine triphosphate (GTP). Nucleotides are the building blocks of nucleic acids, DNA, and RNA ¹⁹. The pentose phosphate pathway also supplies various anabolic pathways, including fatty acid synthesis, with the niacin-containing coenzyme NADPH ²², ²³. Because transketolase decreases early in thiamine deficiency and, unlike most thiamine-dependent enzymes, is present in red blood cells, measurement of its activity in red blood cells has been used to assess thiamine nutritional status ²⁰, ²⁴, ²⁵.

2-Hydroxyacyl-CoA lyase is a thiamin pyrophosphate-dependent enzyme in peroxisomes that catalyzes the catabolism of 3-methyl-branched fatty acids through the process of α-oxidation, the oxidative removal of a single carbon atom from fatty acids like phytanic acid ²⁶.

What are some effects of vitamin B1 on health?

Scientists are studying vitamin B1 or thiamine to better understand how it affects health. Here are some examples of what this research has shown.

Cataracts

A cross-sectional study of 2,900 Australian men and women, 49 years of age and older, found that those in the highest quintile of thiamin intake were 40% less likely to have nuclear cataracts than those in the lowest quintile ²⁷. In addition, a study in 408 US women found that higher dietary intakes of vitamin B1 or thiamine were inversely associated with five-year change in lens opacification ²⁸. However, these cross-sectional associations have yet to be elucidated by studies of causation.

Diabetes

People with diabetes have been reported to have low plasma concentrations and high renal clearance of thiamine, suggesting that individuals with type 1 or type 2 diabetes are at increased risk for thiamine deficiency ²⁹, ³⁰. Two thiamin transporters, thiamin transporter-1 (THTR-1) and thiamin transporter-2 (THTR-2), are involved in thiamine uptake by enterocytes in the small intestine and re-uptake in the proximal tubules of the kidneys. One study suggested that high blood sugar level (hyperglycemia) in patients with diabetes could affect thiamine re-uptake by decreasing the expression of thiamin transporters in the kidneys ³¹. Conversely, thiamine deficiency appears to impair the normal endocrine function of the pancreas and worsens hyperglycemia. Early studies showed that insulin synthesis and secretion were altered in the endocrine pancreatic cells of thiamine-deficient rats ³², ³³. In humans, thiamine deficiency caused by recessive mutations in the gene encoding thiamin transporter-1 (THTR-1) leads to diabetes mellitus in the thiamine-responsive megaloblastic anemia syndrome ¹⁹.

The proportion of people with type 1 or type 2 diabetes who have poor thiamine status based on erythrocyte transketolase activity ranges from 17% to 79% in studies conducted to date ³⁴. In a study of 76 consecutive patients with type 1 or type 2 diabetes, for example, 8% had mild thiamine deficiency and 32% had moderate thiamine deficiency based on assays of the transketolase enzyme ³⁵.

Some small studies have shown that oral high-dose thiamine supplementation with 150–300 mg/day vitamin B1 or thiamine can decrease glucose levels in patients with type 2 diabetes or impaired glucose tolerance ³⁶, ³⁷. Vitamin B1 or thiamine supplementation prevented any further increase in fasting glucose and insulin concentrations compared with placebo treatment but did not reduce the hyperglycemia ³⁷. One study suggested that vitamin B1 or thiamine supplementation might improve fasting glucose concentrations in in early stages of type 2 diabetes (i.e., pre-diabetes) ³⁶. However, the authors of these studies did not assess the potential clinical significance of these findings ¹⁷.

A few small randomized studies have assessed the effects of benfotiamine (man made thiamine) supplements on diabetic neuropathy. Three studies found that, compared to placebo, 120–900 mg/day benfotiamine with or without other B-vitamins decreased the severity of neuropathy symptoms and lowered urinary albumin excretion (a marker of early-stage diabetic nephropathy) ³⁸, ³⁹, ⁴⁰. However, another study found no effect of 900 mg/day benfotiamine on urinary excretion of albumin or kidney injury molecule-1, a marker of kidney injury ⁴¹.

Well-designed studies with larger sample sizes and longer durations are required to determine whether vitamin B1 or thiamine supplements can reduce glucose levels in patients with diabetes or decrease diabetic compications ¹⁷.

Heart failure

Severe thiamine deficiency (wet beriberi) can lead to impaired cardiac function and ultimately congestive heart failure ¹⁹. The rates of poor vitamin B1 or thiamine status in patients with congestive heart failure have ranged in studies from 21% to 98% ⁴. Explanations for this association include older age, comorbidities, insufficient dietary intake, treatment with diuretics, and frequent hospitalizations ⁴², ⁴³, ⁴⁴. Patients with congestive heart failure might also have altered thiamine metabolism, including reduced absorption of thiamine in the small intestine ⁴⁵. A 2015 meta-analysis of nine observational studies found a 2.5 times higher risk of thiamine deficiency in patients with heart failure compared to control subjects ⁴⁵. As in the general population, older patients with congestive heart failure were found to be at higher risk of thiamine deficiency than younger ones ⁴⁶.

The authors of one study reported that 33% of 100 patients with chronic heart failure had thiamine deficiency compared to 12% of 50 healthy volunteers ⁴³. Rates of thiamine deficiency were even higher when the investigators excluded those who used thiamine supplements. The different rates of thiamine deficiency in patients with heart failure in these and other studies are probably due to differences in nutrition status, comorbidities, medications and dietary supplements used, and techniques used to measure thiamine status ⁴².

An important measure of heart function in congestive heart failure is the left ventricular ejection fraction (LVEF), which can be assessed by echocardiogram. One study in 25 patients found that furosemide use at doses of 80 mg/day or greater was associated with a 98% prevalence of thiamine deficiency ⁴⁷. In a randomized, double-blind study of 30 patients with congestive heart failure, all of whom had been taking furosemide (80 mg/day) for at least three months, intravenous (IV) thiamine therapy (200 mg/day) for seven days resulted in an improved left ventricular ejection fraction (LVEF) compared to IV placebo ⁴⁸. When all 30 of the congestive heart failure patients in that study subsequently received six weeks of oral vitamin B1 or thiamine therapy (200 mg/day), the average left ventricular ejection fraction (LVEF) improved by 22%. This finding may be relevant because improvements in left ventricular ejection fraction (LVEF) have been associated with improved survival in congestive heart failure patients ⁴⁹. However, clinical trials of oral vitamin B1 or thiamine supplementation in heart failure patients have not found any benefit. In a randomized, double-blind, placebo-controlled trial in 52 patients with systolic heart failure, 300 mg/day of supplemental thiamin for one month did not improve LVEF compared to placebo ⁵⁰. A randomized, double-blind, placebo-controlled trial in 64 patients with heart failure reported that 200 mg/day or supplemental thiamin for six months did not improve LVEF ⁵¹.

The authors of a systematic literature review and meta-analysis found two randomized, double-blind, placebo-controlled trials of vitamin B1 or thiamine supplementation in people with heart failure that met their eligibility criteria ⁵². In these trials, vitamin B1 or thiamine supplements significantly improved net change in left ventricular ejection fraction (LVEF). However, the authors did not assess the clinical significance of this finding ¹⁷.

Although little evidence supports the routine use of supplemental vitamin B1 or thiamine in congestive heart failure patients and some authors suggest that it may be prudent to screen patients on long-term diuretic therapy for thiamine deficiency and treat accordingly ⁵³.

In summary, more research is needed to determine whether vitamin B1 or thiamine supplements might benefit people with heart failure, even if they have normal thiamine status.

Alzheimer’s disease

Some older adults are at increased risk for developing subclinical thiamine deficiency secondary to poor dietary intake, reduced gastrointestinal absorption, and multiple medical conditions ⁵⁴, ⁵⁵. Since thiamine deficiency can result in a form of dementia called Wernicke-Korsakoff syndrome, its relationship to Alzheimer’s disease and other forms of dementia have been investigated. Alzheimer’s disease is characterized by a decline in cognitive function in elderly people, accompanied by pathologic features that include beta-amyloid plaque deposition and neurofibrillary tangles formed by hyperphosphorylated Tau protein ⁵⁶.

Scientists are studying the possibility that thiamine deficiency could affect the dementia of Alzheimer’s disease. Whether thiamine supplements may help mental function in people with Alzheimer’s disease.

According to animal model studies, thiamine deficiency might play a role in the development of Alzheimer’s disease ⁵⁷. For example, thiamine deficiency produces oxidative stress in neurons, death of neurons, loss of memory, plaque formation, and changes in glucose metabolism—all markers of Alzheimer’s disease. Autopsy studies have shown that transketolase and other thiamine-dependent enzymes have decreased activity in the brains of people with Alzheimer’s disease ⁵⁸, ⁵⁹.

Few studies have assessed the prevalence of thiamine deficiency in people with Alzheimer’s disease. One of these studies found that 13% of 150 patients with cognitive impairment and acute-onset behavioral disturbances were considered thiamine deficient based on plasma levels ⁶⁰.

The authors of a 2001 Cochrane review assessed three double-blind, randomized trials (including two crossover trials) that compared the effects of 3 g/day oral thiamine to placebo on cognitive function in patients with Alzheimer’s type dementia ⁶¹. The three studies randomly assigned fewer than 20 patients each, and the two crossover studies did not include a washout period ⁶², ⁶³, ⁶⁴. The review authors stated that it was not possible to draw any conclusions from these three studies because they were small and the publications describing them did not provide enough detail to combine these data in a meta-analysis ⁶¹.

Larger, well-designed studies are needed to determine whether vitamin B1 or thiamine supplements are beneficial for Alzheimer’s disease.

Thiamine has not been shown to cause any harm.

Huntington’s disease

Huntington’s disease is an inherited neurodegenerative disorder characterized by selective degeneration of nerve cells known as striatal spiny neurons. Symptoms, such as movement disorders and impaired cognitive function, typically develop in the fourth decade of life and progressively deteriorate over time. A recent study found decreased levels of the thiamin transporter-2 (THTR-2) protein in the striatum and frontal cortex of patients with Huntington’s disease compared to age-and sex-matched healthy controls ⁶⁵. Compared to control subjects, this study also found lower concentrations of thiamin pyrophosphate (TPP) in the striatum and lower concentrations of thiamin monophosphate (TMP) in the cerebrospinal fluid of patients with Huntington’s disease ⁶⁵. Mutations in the SLC19A3 gene that encodes THTR-2 causes biotin-thiamin-responsive basal ganglia disease, which is treated with high-dose co-supplementation with biotin and thiamine for life. In a mouse model of Huntington’s disease, high-dose supplementation with both biotin and thiamine vitamins improved neuropathological and motor deficits but had no effect on lifespan ⁶⁵. A phase 2, open-label clinical trial evaluating the effect of combined thiamine-biotin supplementation, at moderate (600 mg/day of thiamine and 150 mg/day of biotin) and high (1,200 mg/day of thiamine and 300 mg/day of biotin) dosages, in Huntington’s disease is currently underway ⁶⁶.

Wernicke-Korsakoff syndrome

Wernicke-Korsakoff syndrome is caused by vitamin B1 or thiamine deficiency and is one of the most severe neuropsychiatric consequence of alcohol abuse primarily seen in alcoholics ⁶⁷. Wernicke-Korsakoff syndrome patients classically present with a clinical triad of altered mental status (i.e., confusion or dementia), nystagmus (or ophthalmoplegia), and ataxia ⁶⁸. However, less than a third of patients present with this complete triad ⁶⁹, ⁷⁰, ⁷¹.

The authors of a 2013 Cochrane review of thiamine to treat or prevent Wernicke-Korsakoff syndrome found only two studies that met their inclusion criteria, and one of these studies has not been published ⁶⁷. These randomized, double-blind, placebo-controlled trials compared 5 mg/day by mouth for 2 weeks or daily intramuscular doses of 5 to 200 mg/day thiamine over 2 consecutive days in a total of 177 people with a history of chronic alcohol use. The Cochrane review authors concluded that the evidence from randomized clinical trials is insufficient to guide health care providers in selecting the appropriate dose, frequency, duration, or route of thiamine supplementation to treat or prevent Wernicke-Korsakoff syndrome in patients with alcohol abuse ⁶⁷.

The authors of the European Federation of Neurological Societies guidelines for diagnosing, preventing, and treating Wernicke’s encephalopathy note that even high doses of oral vitamin B1 or thiamine supplements might not be effective in raising blood thiamin levels or curing Wernicke’s encephalopathy ⁷². They recommend 200 mg thiamine, preferably intravenously, three times daily (total of 600 mg/day) until the signs and symptoms stop, along with a balanced diet. In its guidelines for managing Wernicke’s encephalopathy in emergency departments, the Royal College of Physicians in London supports the administration of oral thiamin hydrochloride (100 mg three times a day) in patients with adequate dietary intakes of thiamin and no signs or symptoms of Wernicke’s encephalopathy ⁷³. However, the authors recommend parenteral thiamin supplementation for patients at high risk, such as those with ataxia, confusion, and a history of chronic alcohol misuse, because oral supplementation is unlikely to produce adequate blood levels.

Cancer

Thiamine deficiency and Wernicke-Korsakoff syndrome have been observed in some cancer patients with rapidly growing tumors ⁷⁴, ⁷⁵. Research in cell culture and animal models indicates that rapidly dividing cancer cells have a high requirement for thiamine ⁷⁶. All rapidly dividing cells require nucleic acids at an increased rate, and some cancer cells appear to rely heavily on the TPP-dependent enzyme, transketolase, to provide the ribose-5-phosphate necessary for nucleic acid synthesis. One study found that the levels of THTR-1, transketolase, and TPP mitochondrial transporters were increased in samples of human breast cancer tissue compared to normal tissue, suggesting an adaptation in thiamin homeostasis in support of cancer metabolism ⁷⁷. Other studies have found that the gene encoding THTR-2 is downregulated in certain cancers ⁷⁸. Moreover, use of the chemotherapeutic drug, 5-fluorouracil, inhibits phosphorylation of thiamin to thiamin pyrophosphate and may thus lead to thiamin deficiency ⁷⁹, ⁸⁰.

Vitamin B1 or thiamine supplementation in cancer patients is common to prevent thiamine deficiency, but Boros et al. ⁸¹ caution that too much thiamine may actually fuel the growth of some malignant tumors, suggesting that thiamin supplementation be reserved for those cancer patients who are actually deficient in thiamine. Presently, there is no evidence available from studies in humans to support or refute this theory. However, it would be prudent for individuals with cancer who are considering vitamin B1 or thiamine supplementation to discuss it with their clinician managing their cancer therapy. Intravenous, high-dose thiamine has been suggested as a treatment for cancer patients with confirmed Wernicke-Korsakoff syndrome ⁷⁵.

Sepsis

Sepsis is a life-threatening medical emergency caused by the body’s extreme response to an infection ⁸². Sepsis happens when an infection you already have triggers a chain reaction throughout your body. Infections that lead to sepsis most often start in the lung, urinary tract, skin, or gastrointestinal tract. Without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death ⁸². Because thiamine deficiency is common among septic patients ⁸³, several studies have investigated the treatment effect of intravenous thiamine – alone or in combination with other agents like vitamin C and hydrocortisone.

Observational studies examining the association of intravenous thiamine as a monotherapy have mainly looked at its association with lactic acidosis, which commonly occurs in both thiamine deficiency and sepsis, and with mortality. One retrospective study in 123 septic patients and 246 matched controls found that intravenous thiamin administration within 24 hours of hospital admission was linked to improvements in both lactate clearance and 28-day mortality ⁸⁴. In a small retrospective study of 53 alcohol-use disorder patients presenting with septic shock, lower mortality was observed in the 34 patients who received intravenous thiamin compared to the 19 patients who did not ⁸⁵.

A few randomized controlled trials have evaluated the effect of intravenous thiamine in the treatment of sepsis. A randomized, double-blind, placebo-controlled trial in 88 patients with sepsis and elevated blood concentrations of lactate reported that intravenous thiamine (200 mg twice daily for seven days or until discharge from the hospital) did not decrease lactate concentrations at 24 hours post initiation of treatment – the primary endpoint of the trial ⁸⁶. No differences between the treatment and placebo groups were found for the secondary endpoints, which included survival ⁸⁶. In a subsequent analysis of data from this trial, the septic patients that were given parenteral thiamin (n=31) had lower creatinine concentrations throughout the treatment and were less likely to need renal replacement therapy compared to placebo (n=39) ⁸⁷.

A 2020 meta-analysis of four studies – one observational and three randomized controlled trials – found no benefit of intravenous thiamine for improving lactate concentrations, length of hospital stay in intensive care, or overall survival ⁸⁸. Large-scale clinical trials are needed to determine whether parenteral administration of thiamin is beneficial in the treatment of sepsis. Administering thiamin in combination with vitamin C and corticosteroids may be more efficacious to treat sepsis ⁸⁹; some clinical trials of such treatments are currently underway ¹⁹.

Metabolic diseases

Vitamin B1 or thiamine supplementation is included in the clinical management of genetic diseases that affect the metabolism of carbohydrates and branched-chain amino acids (BCAAs).

Thiamin-responsive pyruvate dehydrogenase deficiency

Pyruvate dehydrogenase deficiency is characterized by the buildup of a chemical called lactic acid (lactic acidosis) in the body and a variety of neurological problems ⁹⁰. Signs and symptoms of pyruvate dehydrogenase deficiency usually first appear shortly after birth, and they can vary widely among affected individuals. The most common feature is a potentially life-threatening buildup of lactic acid (lactic acidosis), which can cause nausea, vomiting, severe breathing problems, and an abnormal heartbeat. People with pyruvate dehydrogenase deficiency usually have neurological problems as well. Most have delayed development of mental abilities and motor skills such as sitting and walking ⁹⁰. Other neurological problems can include intellectual disability, seizures, weak muscle tone (hypotonia), poor coordination, and difficulty walking ⁹⁰. Some affected individuals have abnormal brain structures, such as underdevelopment of the tissue connecting the left and right halves of the brain (corpus callosum), wasting away (atrophy) of the exterior part of the brain known as the cerebral cortex, or patches of damaged tissue (lesions) on some parts of the brain ⁹⁰. Because of the severe health effects, many individuals with pyruvate dehydrogenase deficiency do not survive past childhood, although some may live into adolescence or adulthood ⁹⁰.

The genes involved in pyruvate dehydrogenase deficiency each provide instructions for making a protein that is a component of a group of proteins called the pyruvate dehydrogenase complex. This complex plays an important role in the pathways that convert the energy from food into a form that cells can use. The pyruvate dehydrogenase complex converts a molecule called pyruvate, which is formed from the breakdown of carbohydrates, into another molecule called acetyl-CoA. This conversion is essential to begin the series of chemical reactions that produce energy for cells.

The pyruvate dehydrogenase complex is made up of multiple copies of several enzymes called E1, E2, and E3, each of which performs part of the chemical reaction that converts pyruvate to acetyl-CoA. In addition, other proteins included in the complex ensure its proper function. One of these proteins, E3 binding protein, attaches E3 to the complex and provides the correct structure for the complex to perform its function. Other associated proteins control the activity of the complex: pyruvate dehydrogenase phosphatase turns on (activates) the complex, while pyruvate dehydrogenase kinase turns off (inhibits) the complex.

The patients who respond to vitamin B1 or thiamine treatment (from a few mg/day to doses above 1,000 mg/day) exhibit pyruvate dehydrogenase complex (PDHC) deficiency due to the decreased affinity of pyruvate dehydrogenase complex (PDHC) deficiency for TPP ⁹¹, ⁹². Although vitamin B1 or thiamine supplementation can reduce lactate accumulation and improve the clinical features in thiamin-responsive patients, it does not constitute a cure ⁹³.

Maple syrup urine disease

Maple syrup urine disease is an inherited disorder in which the body is unable to process branched-chain amino acid (BCAA) properly ⁹⁴. Maple syrup urine disease gets its name from the distinctive sweet odor of affected infants’ urine. Alterations in the branched-chain amino acid (BCAA) catabolic pathway result in neurologic dysfunction caused by the accumulation of branched-chain amino acids (leucine, isoleucine, and valine) and their derivatives, branched-chain ketoacids (BCKA). Maple syrup urine disease is also characterized by poor feeding, vomiting, lack of energy (lethargy), abnormal movements, and delayed development. If untreated, maple syrup urine disease can lead to seizures, coma, and death ⁹⁴.

Maple syrup urine disease is often classified by its pattern of signs and symptoms. The most common and severe form of the disease is the classic type, which becomes apparent soon after birth. Variant forms of the disorder become apparent later in infancy or childhood and are typically milder, but they still lead to delayed development and other health problems if not treated.

Mutations in the BCKDHA, BCKDHB, and DBT genes can cause maple syrup urine disease ⁹⁴. The BCKDHA, BCKDHB, and DBT genes provide instructions for making proteins that work together as part of a complex. The protein complex is essential for breaking down the amino acids leucine, isoleucine, and valine, which are present in many kinds of food, particularly protein-rich foods such as milk, meat, and eggs.

Mutations in any of these three genes reduce or eliminate the function of the protein complex, preventing the normal breakdown of leucine, isoleucine, and valine. As a result, these amino acids and their byproducts build up in the body. Because high levels of these substances are toxic to the brain and other organs, their accumulation leads to the serious health problems associated with maple syrup urine disease.

Researchers are studying other genes related to the same protein complex that may also be associated with maple syrup urine disease.

The therapeutic approach includes a synthetic diet with reduced branched-chain amino acid (leucine, isoleucine, and valine) content, and thiamine (10-1,000 mg/day) is supplemented to patients with mutations in the E2 subunit of the BCKDH complex ⁹⁵. In thiamine-responsive individuals, the supplementation has been proven effective to correct the phenotype without recourse to the branched-chain amino acid (BCAA) restriction diet.

Thiamine-responsive megaloblastic anemia

Mutations in the SLC19A2 gene that encodes THTR-1 impairs intestinal thiamine uptake and causes thiamine deficiency, leading to thiamine-responsive megaloblastic anemia ⁹⁶. Thiamine-responsive megaloblastic anemia syndrome also called thiamin metabolism dysfunction syndrome-1, is characterized by megaloblastic anemia, diabetes mellitus, and deafness. A review of 30 cases reported additional neurologic, visual, and cardiac impairments ⁹⁷. High-dose oral supplementation with thiamine (up to 300 mg/day) helps to maintain health and correct hyperglycemia in prepubescent children. A recent study in 32 individuals with found no additional benefit of oral doses above 150 mg/day ⁹⁸. After puberty, a decline in pancreatic function results in the requirement of insulin together with thiamine to control the hyperglycemia. One study also reported that the treatment of a four-month-old girl with 100 mg/day of thiamin did not prevent hearing loss at 20 months of age ⁹⁹. Early diagnosis of the thiamine-responsive megaloblastic anemia syndrome and early treatment with thiamin is important for a better prognosis ⁹⁸.

Biotin-thiamin-responsive basal ganglia disease

Biotin-thiamin-responsive basal ganglia disease, also called biotin-responsive basal ganglia disease, thiamin transporter-2 deficiency, and thiamin metabolism dysfunction syndrome-2, is caused by an autosomal recessive mutation in the SLC19A3 gene that codes for THTR-2. The disease usually presents around 3 to 10 years of age ¹⁰⁰, but an early infantile form of the disease exists with onset as early as one month of age ¹⁰¹. Clinical features include subacute encephalopathy (confusion, drowsiness, altered level of consciousness), ataxia, and seizures.

A retrospective study of 18 affected individuals from the same family or the same tribe in Saudi Arabia showed that biotin monotherapy (5-10 mg/kg/day) efficiently abolished the clinical manifestations of the disease, although one-third of the patients suffered from recurrent acute crises ¹⁰². Often associated with poor outcomes, acute crises were not observed for a five-year follow-up period following thiamin supplementation (300-400 mg/day) – early diagnosis and immediate treatment with biotin and thiamin led to positive outcomes ¹⁰². Recent studies have found supplemental thiamin to be important in treating the condition. In an open-label study of 20 pediatric patients with the disease, supplemental thiamin alone was as effective as combined biotin-thiamin supplementation when given for 30 months ¹⁰³. Lifelong high-dose supplementation with a combination of biotin and thiamin is generally the treatment for biotin-thiamin-responsive basal ganglia disease ¹⁰⁰. Early diagnosis and treatment is important to ensure a better prognosis ¹⁰¹, ¹⁰⁴.

Other thiamine metabolism dysfunction syndromes

Supplemental thiamine has limited utility in treating other inborn errors of thiamin metabolism. Mutations in the SLC25A19 gene that codes for the mitochondrial TPP transporter can result in either thiamine metabolism dysfunction syndrome-3 (THMD3) or thiamine metabolism dysfunction syndrome-4 (THMD4). Of these rare syndromes, thiamine metabolism dysfunction syndrome-3 (THMD3), also called Amish-type microcephaly or Amish lethal microcephaly, has the more severe phenotype, resulting in a congenital microcephaly, elevated concentrations of α-ketoglutarate in urine, and usually death in infancy ¹⁰⁵. Thiamine metabolism dysfunction syndrome-4 (THMD4) is characterized by episodic encephalopathy and weakness, which often presents following a viral infection or febrile illness in childhood. Some patients affected with THMD4 may respond to high-dose thiamin supplementation ¹⁰⁶.

Mutations in the TPK1 gene result in thiamin pyrophosphokinase 1 deficiency and thiamine metabolism dysfunction syndrome-5 (THMD5), which usually manifests in early childhood. While the clinical presentation of THMD5 varies, affected individuals often experience episodic ataxia, dystonia, and lactic acidosis ¹⁰⁷. Only a few cases of thiamine metabolism dysfunction syndrome-5 (THMD5) have been reported to date; two of these patients experienced limited improvement of symptoms upon supplementation with thiamin, in conjunction with adherence to a high-fat diet ¹⁰⁸.

How much vitamin B1 do I need?

The amount of vitamin B1 or thiamine you need depends on your age and sex ¹⁰⁹. Average daily recommended amounts are listed in Table 1 below in milligrams (mg). The Recommended Dietary Allowance (RDA) is average daily level of intake sufficient to meet the nutrient requirements of nearly all (97%–98%) healthy individuals ¹¹⁰. Table 1 lists the current Recommended Dietary Allowance (RDA) for vitamin B1 or thiamine ¹¹⁰. For infants from birth to 12 months, the Food and Nutrition Board at the Institute of Medicine of the National Academies established an adequate intake (intake at this level is assumed to ensure nutritional adequacy; adequate intake is established when evidence is insufficient to develop an RDA). for vitamin B1 or thiamine that is equivalent to the mean intake of vitamin B1 or thiamine in healthy, breastfed infants ¹⁷.

Most people in the United States consume the recommended amounts of vitamin B1 or thiamine ¹⁷. An analysis of data from the 2003-2006 National Health and Nutrition Examination Survey showed that only 6% of the U.S. population has a usual intake below the estimated average requirement (average daily level of intake estimated to meet the requirements of 50% of healthy individuals. It is usually used to assess the adequacy of nutrient intakes in populations but not individuals) ³.

Among children and teens, the average daily vitamin B1 or thiamine intake from foods is 1.27 mg for ages 2–5 years, 1.54 mg for ages 6–11 years, and 1.68 mg for ages 12–19 years ¹¹¹. In adults aged 20 and older, the average daily vitamin B1 or thiamine intake from foods is 1.95 mg in men and 1.39 mg in women. The average daily vitamin B1 or thiamine intake from foods and supplements in children and teens is 1.51 mg for ages 2–5 years, 1.76 mg for ages 6–11 years, and 1.95 mg for ages 12–19 years. In adults aged 20 and older, the average daily vitamin B1 or thiamine intake from foods and supplements is 4.89 mg in men and 4.90 mg in women ¹⁷.

No current data on rates of thiamine deficiency in the U.S. population are available ¹⁷.

Most people in the United States get enough vitamin B1 or thiamine from the foods they eat. Thiamine deficiency is rare in this country. However, certain groups of people are more likely than others to have trouble getting enough vitamin B1 or thiamine:

People with alcohol dependence
Older individuals
People with HIV/AIDS
People with diabetes
People who have had weight loss surgery

Table 1. Recommended Dietary Allowances (RDAs) for vitamin B1 or thiamine

Life Stage	Recommended Amount
Birth to 6 months	0.2 mg
Infants 7–12 months	0.3 mg
Children 1–3 years	0.5 mg
Children 4–8 years	0.6 mg
Children 9–13 years	0.9 mg
Teen boys 14–18 years	1.2 mg
Teen girls 14–18 years	1.0 mg
Men	1.2 mg
Women	1.1 mg
Pregnant teens and women	1.4 mg
Breastfeeding teens and women	1.4 mg

[Source ¹⁰⁹ ]

What happens if I don’t get enough vitamin B1?

You can develop thiamine deficiency if you don’t get enough vitamin B1 or thiamine in the foods you eat or if your body eliminates too much or absorbs too little vitamin B1 or thiamine.

Thiamine deficiency can cause loss of weight and appetite, confusion, memory loss, muscle weakness, and heart problems. Severe thiamine deficiency leads to a disease called beriberi with the added symptoms of tingling and numbness in the feet and hands, loss of muscle, and poor reflexes. Beriberi is not common in the United States and other developed countries.

A more common example of thiamine deficiency in the United States is Wernicke-Korsakoff syndrome, which mostly affects people with alcoholism. It causes tingling and numbness in the hands and feet, severe memory loss, disorientation, and confusion.

VITAMIN B1 Thiamin rich foods

What foods provide vitamin B1?

Vitamin B1 or thiamine is found naturally in many foods and is added to some fortified foods. You can get recommended amounts of vitamin B1 or thiamine by eating a variety of foods, including the following ⁷:

Whole grains and fortified bread, cereal, pasta, and rice
Meat (especially pork) and fish
Legumes (such as black beans and soybeans), seeds, and nuts

Breads, cereals, and infant formulas in the United States and many other countries are fortified with thiamine ⁷. The most common sources of vitamin B1 or thiamine in the U.S. diet are cereals and bread ². Pork is another major source of the vitamin. Dairy products and most fruits contain little vitamin B1 or thiamine ⁹. About half of the vitamin B1 or thiamine in the U.S. diet comes from foods that naturally contain thiamin; the remainder comes from foods to which thiamine has been added ³.

The U.S. Department of Agriculture’s (USDA’s) FoodData Central website (https://fdc.nal.usda.gov) lists the nutrient content of many foods and provides a comprehensive list of foods containing vitamin B1 or thiamine arranged by nutrient content (https://ods.od.nih.gov/pubs/usdandb/Thiamin-Content.pdf) and by food name (https://ods.od.nih.gov/pubs/usdandb/Thiamin-Food.pdf).

Heating foods containing vitamin B1 or thiamine can reduce their thiamin content. For example, bread has 20%–30% less vitamin B1 or thiamine than its raw ingredients, and milk pasteurization reduces thiamin content (which is very small to begin with) in milk by up to 20% ⁹. Because vitamin B1 or thiamine dissolves in water, a significant amount of the vitamin is lost when cooking water is thrown out ⁹. Processing also alters vitamin B1 or thiamine levels in foods; for example, unless white rice is enriched with thiamin, it has one tenth the amount of thiamin in unenriched brown rice ¹¹².

Data on the bioavailability of vitamin B1 or thiamine from food are very limited ¹¹³. Some studies do show, however, that thiamin absorption increases when intakes are low ¹.

Several food sources of thiamine are listed in Table 2.

Table 2. Vitamin B1 (thiamine) food sources

Food	Milligrams (mg) per serving	*Percent Daily Value (DV)**
Breakfast cereals, fortified with 100% of the Daily Value (DV) for thiamine, 1 serving	1.2	100
Egg noodles, enriched, cooked, 1 cup	0.5	42
Pork chop, bone-in, broiled, 3 ounces	0.4	33
Trout, cooked, dry heat, 3 ounces	0.4	33
Black beans, boiled, ½ cup	0.4	33
English muffin, plain, enriched, 1 muffin	0.3	25
Mussels, blue, cooked, moist heat, 3 ounces	0.3	25
Tuna, Bluefin, cooked, dry heat, 3 ounces	0.2	17
Macaroni, whole wheat, cooked, 1 cup	0.2	17
Acorn squash, cubed, baked, ½ cup	0.2	17
Rice, brown, long grain, not enriched, cooked, ½ cup	0.2	17
Rice, white, long grain, enriched, cooked, ½ cup	0.1	8
Bread, whole wheat, 1 slice	0.1	8
Orange juice, prepared from concentrate, 1 cup	0.1	8
Sunflower seeds, toasted, 1 ounce	0.1	8
Beef steak, bottom round, trimmed of fat, braised, 3 ounces	0.1	8
Yogurt, plain, low fat, 1 cup	0.1	8
Oatmeal, regular and quick, unenriched, cooked with water, ½ cup	0.1	8
Corn, yellow, boiled, 1 medium ear	0.1	8
Milk, 2%, 1 cup	0.1	8
Barley, pearled, cooked, 1 cup	0.1	8
Cheddar cheese, 1½ ounces	0	0
Chicken, meat and skin, roasted, 3 ounces	0	0
Apple, sliced, 1 cup	0	0

Footnote: *DV = Daily Value. Daily Values were developed by the U.S. Food and Drug Administration (FDA) to help consumers compare the nutrient contents of products within the context of a total diet. The DV for thiamine is 1.5 mg for adults and children age 4 and older. Foods providing 20% or more of the Daily Value are considered to be high sources of a nutrient.

[Source ¹¹⁴ ]

Vitamin-B1-Rich-Foods

Vitamin B1 (Thiamine) Supplements

Vitamin B1 or thiamine is also available in many dietary supplements. Multivitamin or multimineral supplements with vitamin B1 or thiamine typically provide about 1.5 mg thiamine (100% of the Daily Value) and sometimes more ¹¹⁵. Supplements containing B-complex vitamins (including thiamin) or thiamine only are also available. The most commonly used forms of vitamin B1 or thiamine in supplements are thiamine mononitrate and thiamin hydrochloride, which are stable and water soluble ¹, ¹¹⁵.

Benfotiamine is a synthetic thiamine derivative that is used in some dietary supplements. Benfotiamine is not water soluble and is converted to thiamine in the body ¹¹⁶.

Thiamine (Vitamin B1) Deficiency

Thiamine deficiency, also called vitamin B1 deficiency, is a rare disorder that occurs if the recommended daily intake of vitamin B1 or thiamine is not maintained ¹¹⁷, ¹¹⁸. Populations and cultures that rely heavily upon rice based diets are at increased risk of thiamine deficiency ¹¹⁹. Thiamine deficiency may also occur due to impaired intestinal absorption or high excretion rates, such as in people with alcohol dependency, acquired immunodeficiency syndrome (AIDS), and malnutrition ¹²⁰, ¹²¹. Individuals with certain medical and non-medical conditions are more susceptible to vitamin B1 deficiency, e.g., alcohol dependency, older age, diabetes, post-weight loss surgery, cancers that have spread throughout the body, cancer chemotherapy with poor dietary intake, gastrointestinal disease, pregnancy with hyperemesis gravidarum (severe nausea and vomiting during pregnancy), lactation, fasting, starvation, use of unbalanced diets, malnourished patients with intestinal obstruction or malabsorption syndromes, hyperthyroidism (overactive thyroid), kidney failure on hemodialysis, and systemic infections ¹²², ¹²³, ¹¹⁹.

Thiamine is important for the growth, development, and function of the cells in your body. In the human body, thiamine or vitamin B1 exists mainly in the form of thiamin pyrophosphate (TPP). This is the main active form of thiamine and serves as a cofactor for many enzymes during the metabolism of glucose, branched-chain amino acids (protein), and fatty acids (lipids) (see Figure 1 above) ¹⁶. Thiamine or vitamin B1 deficiency can lead to severe (or even fatal) cardiovascular, muscular, gastrointestinal, and central and peripheral nervous systems complications, including heart failure, neuropathy leading to ataxia and paralysis, confusion, or delirium ¹²⁴, ²¹.

Thiamin deficiency causes degeneration of peripheral nerves, thalamus, mammillary bodies, and cerebellum. Cerebral blood flow is markedly reduced, and vascular resistance is increased.
The heart may become dilated; muscle fibers become swollen, fragmented, and vacuolized, with interstitial spaces dilated by fluid. Vasodilation occurs and can result in edema in the feet and legs. Arteriovenous shunting of blood increases. Eventually, high-output heart failure may occur.

Most people have no symptoms and signs of thiamine deficiency or vitamin B1 deficiency; therefore, it must be suspected in the appropriate clinical setting ¹²⁵. Thiamine deficiency or vitamin B1 deficiency early symptoms and signs are often nonspecific and vague, such as fatigue. However, early symptoms mainly arise from neurological, heart and gastrointestinal systems, where patients may experience weight loss, anorexia, confusion, short-term amnesia, malaise, muscle weakness, and heart symptoms due to heart failure ¹²⁶.

Generally, heart effects are referred to as “wet beriberi”, the peripheral neurological signs and symptoms are called “dry beriberi”, and delirium, mental confusion and abnormal eye movements (due to ophthalmoplegia, which is paralysis or weakness of the eye muscles), stance and gait ataxia are termed “cerebral beriberi” or Wernicke’s encephalopathy ¹²⁷, ²³, ¹⁹. “Gastrointestinal beriberi” is caused by lactic acidosis, a condition resulting from the accumulation of lactate and is often associated with nausea, vomiting, and severe abdominal pain ¹²⁸.

Beriberi is the classic diet related thiamine deficiency which can present as wet or dry types. “Wet beriberi” presents as a right sided high-output heart failure with signs of peripheral swelling (edema), an enlarged heart, warm extremities, rapid heart rate (tachycardia), and respiratory distress ¹²⁶. “Dry beriberi” is predominantly a neurological complication involving the peripheral nervous system and presents with painful peripheral neuropathy, malaise, muscle weakness, seizures, or brisk tendon reflexes ¹²³. Infants and children are susceptible to vitamin B1 deficiency too, presenting as infantile or childhood beriberi. Usually, infants present with swelling (edema), ill-looking appearance, pallor, anorexia, coffee ground vomiting, and diarrhea ¹²⁶. Neurological signs include a hoarse cry due to vocal cord paralysis, head lag, seizures, coma, and sudden infant death syndrome. “Juvenile beriberi” is uncommon and often misdiagnosed due to overlapping symptoms of meningitis ¹⁶.

If thiamine deficiency or vitamin B1 deficiency is prolonged or left untreated, an individual is at risk of advanced-stage symptoms due to irreversible neurological damage called Wernicke-Korsakoff syndrome ¹²⁹, ¹³⁰. Wernicke-Korsakoff syndrome is more common in the United States and 8 to 10 times more common among people with chronic alcohol consumption/misuse, severe gastrointestinal disorders, cancers, drug use, and AIDS ¹²⁶. Wernicke-Korsakoff syndrome presents in two phases. Wernicke’s encephalopathy occurs early and presents with polyneuropathy, ataxia, abnormal eye movements due to ophthalmoplegia (paralysis or weakness of the eye muscles), and gait abnormalities. Korsakoff’s syndrome also called Korsakoff psychosis, Korsakoff’s dementia, Korsakoff’s amnesia, or amnestic confabulatory syndrome, is a residual syndrome in patients who suffered from a Wernicke encephalopathy, but did not receive immediate and adequate treatment with thiamine or vitamin B1 replacement therapy ¹³⁰, ¹³¹, ¹³², ¹³³. The most conspicuous symptom of Korsakoff’s syndrome is global short-term amnesia, which can be very profound. In combination with other cognitive and behavioral deficits such as disorientation, confabulation, and hallucinations, which may have far-reaching effects on daily life ¹³⁴, ¹³⁵, ¹³⁶. Wernicke encephalopathy is acute and often reversible while Korsakoff syndrome is chronic and may be irreversible ¹³⁷. The most common cause of Korsakoff syndrome is chronic alcohol abuse ¹³⁸. Alcohol interferes with gastrointestinal tract absorption of thiamine as well as interfering with the liver’s ability to store thiamine. Additionally, accompanying malnutrition often compounds the effects of alcoholism leading to further thiamine deficiency. Other causes of Korsakoff syndrome include eating disorders, chronic vomiting (including hyperemesis gravidarum), psychiatric disorders, chemotherapy, and cancer ¹³⁹, ¹⁴⁰. As Korsakoff syndrome is advanced-stage symptoms of thiamine deficiency, parenteral thiamine treatment does not lead to recovery in about one-quarter of patients ¹³⁶.

To treat mild thiamine deficiency, the World Health Organization (WHO) recommends daily oral doses of 10 mg thiamine for a week, followed by 3–5 mg/daily for at least 6 weeks ¹⁴¹. For patients at risk of thiamine deficiency or with confirmed thiamine deficiency, parenteral (intravenously or intramuscularly) thiamine of 100 mg and 200 mg 3 times a day has been used, respectively, in clinical practice ⁷². The recommended treatment for severe thiamine deficiency consists of 25–30 mg intravenously in infants and 50–100 mg in adults, then 10 mg daily administered intramuscularly for approximately one week, followed by 3–5 mg/day oral thiamine for at least 6 weeks ¹⁷.

Thiamine (Vitamin B1) Deficiency causes

Thiamine deficiency or vitamin B1 deficiency may result from inadequate dietary thiamine intake, administration of total parenteral nutrition without adequate thiamine replacement, increased physiological requirements for thiamine, excessive loss of thiamine from the body, impaired intestinal absorption, small intestinal bacterial overgrowth (SIBO), consumption of anti-thiamine factors (ATF) in food, antacids, sulfites, or sodium bicarbonate food preservatives or a combination of these factors ¹⁴², ¹⁴³, ¹⁴⁴, ¹⁹.

The maximum body store of thiamine is 30 mg, which is rapidly depleted within 2 weeks of beginning a thiamine-deficient diet ⁸. Risk factors for decreased thiamine intake include protracted vomiting, weight loss surgery or gastrointestinal surgery, malnutrition, extreme nausea and vomiting during pregnancy (hyperemesis gravidarum), anorexia, and alcoholism ⁴².

Other conditions that may cause thiamine deficiency or vitamin B1 deficiency include:

HIV/AIDS
Cancers that have spread throughout the body
Extreme nausea and vomiting during pregnancy (hyperemesis gravidarum)
Heart failure (when treated with long-term diuretic therapy)
Long periods of intravenous (IV) nutrition without receiving thiamine supplements
Long-term dialysis
Taking high doses of diuretics (water pills)
Very high thyroid hormone levels (thyrotoxicosis)
Breastfed infants whose mother is lacking in thiamine
Infants fed unusual formulas that don’t have enough thiamine.

In rare cases, thiamine deficiency or vitamin B1 deficiency can be a genetic metabolic disease ¹⁴⁵, ¹⁴⁶. This condition is passed down through families. People with this condition lose the ability to absorb thiamine from foods. This can happen slowly over time. The symptoms occur when the person is an adult. However, this diagnosis is often missed. This is because health care providers may not consider thiamine deficiency in nonalcoholics ¹⁴⁶.

Inadequate dietary thiamine or vitamin B1 intake

Inadequate consumption of thiamine or vitamin B1 is the main cause of thiamine deficiency in developing countries ²⁰. Thiamine deficiency is common in low-income populations whose diets are high in carbohydrate and low in thiamine. Examples of foods that can lead to inadequate thiamine intake upon prolonged consumption include sago, cassava flour, unfortified white bread, or highly refined cereals such as polished white rice ⁸. The consumption of a diet composed mainly of refined carbohydrates or one that includes high alcohol intake also reduces body thiamine stores ⁸.

To attain maximal erythrocyte transketolase activity, at least 0.6 mg of thiamine per 1000 kcal of carbohydrate is required ⁸. Most humans will develop symptoms of thiamine deficiency when intake is below 0.2 mg of thiamine per 1000 kcal. Whole wheat flour contains 0.55 mg of thiamine per 100 g, brown rice 0.33 mg per 100 g, and highly milled white rice only 0.08 mg per 100 g ⁸. Adding baking powder (sodium bicarbonate) to wholemeal flour when baking bread reduces the thiamine content ⁸. Washing white rice in water prior to cooking reduces the thiamine content by half. Thiamine is heat labile, chlorine sensitive, and water soluble, so discarding the rice water after cooking or using chlorinated water for cooking or washing rice contributes to thiamine loss from the diet ¹⁴². Parboiling (partly cook food by boiling) of rice was originally developed in India but is not practiced in Southeast Asia or Japan, where milled white rice is preferred. Rice parboiling distributes the thiamine content from the bran and aluerone layer to the endosperm prior to milling. This is why beriberi is rare in India, where parboiled rice is the primary form of rice consumed ¹⁴².

After 1878, mechanical roller milling of wheat and polishing of rice became widespread ¹⁴⁷. Consumption of mass-produced, polished white rice as the staple diet in East Asian countries led to epidemics of thiamine deficiency (beriberi) in the 1800s and 1900s ¹⁴⁸, ¹⁴⁷. Polished rice and milled wheat were also popular because removal of the oil-rich bran layer from rice or the wheat bran from wheat grains prolonged storage times, minimized rancidity, and reduced the susceptibility to weevils. Mandatory fortification of wheat flour with the thiamine mononitrate vitamer was introduced in Australia in 1991. Since then, Wernicke-Korsakoff syndrome has become very uncommon in Australia. The thiamine mononitrate vitamer is used because it is non-hygroscopic and more stable than thiamine hydrochloride ¹⁴⁹. Mandatory fortification of bread with iodine and folate was commenced in Australia in 2009. Folate deficiency may indirectly contribute to thiamine deficiency, as folate is required for the regeneration of reduced nicotinamide adenine dinucleotide (NADH) by dihydrofolate reductase. NADH is necessary for the regeneration of TPP ¹⁵⁰. Vitamin C may protect against the development of symptoms of thiamine deficiency ¹⁴².

Breast-fed infants whose mothers are thiamine deficient are vulnerable to developing infantile beriberi. Alcoholism, which is associated with low intake of thiamine among other nutrients, is the primary cause of thiamine deficiency in industrialized countries. Some of the non-alcoholic conditions associated with Wernicke-Korsakoff syndrome include anorexia nervosa, bariatric surgery (weight-loss surgery), gastrointestinal malignancies, and malabsorption syndromes ¹⁵¹, ¹⁵², ¹⁵³, ¹⁵⁴. Obese individuals may also be at heightened risk of thiamine deficiency ¹⁵⁵, ¹⁵⁶. Moreover, cases of Wernicke’s encephalopathy have been linked with hyperemesis gravidarum (severe nausea and vomiting during pregnancy) ¹⁵⁷, ¹⁵⁸, and with parenteral nutrition lacking vitamin supplementation ¹⁵⁹, ¹⁶⁰.

Increased thiamine or vitamin B1 requirement

Conditions resulting in an increased requirement for thiamine or vitamin B1 include strenuous physical exertion, fever, severe infection or sepsis, hyperthyroidism, pregnancy, breast-feeding, adolescent growth, major surgery, refeeding syndrome, or rapid growth of cancers ⁶, ¹⁶¹, ¹⁶², ⁷⁴, ¹⁶³, ¹⁶⁴, ¹⁶⁵, ¹⁶⁶, ¹⁶⁷. Such conditions place individuals with marginal thiamine intake at risk for developing symptomatic thiamine deficiency.

Fever can critically increase the requirement for thiamine, as a rise in core body temperature of 1°C will increase the basal metabolic rate by 10% ¹⁶⁸. Consumption of a high-fat or a high-carbohydrate diet results in increased metabolic consumption of thiamine ¹⁵⁰. This is particularly relevant in individuals with preexisting thiamine deficiency, such as refugees, prisoners of war, persons with alcoholism, oncology patients, and postoperative bariatric surgery or gastrectomy patients. Administering oral, enteral, or parenteral nutrition to these patients without concomitant thiamine supplementation can result in fulminant beriberi or acute refeeding syndrome ¹⁴², ¹⁶⁹, ¹⁷⁰, ¹⁷¹, ¹⁷².

Malaria patients in Southeast Asia were found to be thiamine deficient more frequently than non-infected individuals ¹⁷³, ¹⁷⁴. Malarial infection leads to a large increase in the metabolic demand for glucose. Because thiamine is required for enzymes involved in glucose metabolism, the stresses induced by malarial infection could exacerbate thiamin deficiency in predisposed individuals. HIV-infected individuals, whether or not they had developed AIDS, were also found to be at increased risk for thiamine deficiency ¹⁷⁵. Furthermore, chronic alcohol abuse impairs intestinal absorption and utilization of thiamine ²³; therefore, alcoholics have increased requirements for thiamine or vitamin B1. Thiamine deficiency is also observed as a complication of the refeeding syndrome: the introduction of carbohydrates in severely starved individuals leads to an increased demand for thiamine in glycolysis and the citric acid cycle that precipitates thiamine deficiency ¹⁷⁶.

Anti-thiamin factors

The presence of anti-thiamin factors (ATF) in foods contributes to the risk of thiamin deficiency. Certain plants contain anti-thiamin factors (ATF), which react with thiamine to form an oxidized, inactive product. Consuming very large amounts of tea or coffee (including decaffeinated), as well as chewing tea leaves and betel nuts, might lower thiamin status due to the presence of anti-thiamin factors (ATF) ¹⁷⁷, ¹⁷⁸. Anti-thiamin factors (ATF) include mycotoxins (molds), thiaminases that break down thiamin in food, thiamine antagonists, and hemin ⁸. Individuals who habitually eat certain raw fresh-water fish, raw shellfish, or ferns are at higher risk of thiamine deficiency because these foods contain thiaminase that normally is inactivated by heat in cooking ²³, ²⁴, ¹⁷⁹, ¹⁸⁰, ¹⁸¹. In Nigeria, an acute, neurologic syndrome (seasonal ataxia) has been associated with thiamine deficiency precipitated by a thiaminase in African silkworms (Anaphe species), a traditional, high-protein food for some Nigerians ¹⁸².

Thiamine antagonists are found in tea and betel nuts (tannic acid), coffee (chlorogenic acid, caffeic acid), bracken fern (caffeic acid), and pigmented polyphenol-containing foods such as red cabbage, blueberries, red currants, and red beets ⁸. These cause oxidation of the thiazole ring of thiamine, forming nonabsorbable thiamine disulfide ¹⁴². For example, consumption of 1 g of dry tea leaves boiled in 100 mL of water for 5 minutes caused thiamine loss of 0.21 mg per hour ¹⁸³. Vitamin C and cysteine can protect thiamine from degradation caused by organic acids and polyphenols ¹⁸⁴. Outbreaks of beriberi in the wet season in some countries may be related to low availability of food, importation of poor-quality rice or milled white rice, seasonal variations in plant tannin levels, or the mycotoxin citreoviridin, produced by rice mold ¹⁸⁵, ¹⁶², ¹⁸⁶.

Food additives and thiamine

Thiamine is unstable under alkaline conditions produced by food additives such as preservatives and antacids (eg, sodium bicarbonate), which cause disruption of the thiamine methylene bridge ⁸. Sulfite-type food preservatives include sulfur dioxide, sodium sulfite, sodium and potassium bisulfite, and sodium and potassium metabisulfite ⁸. These are used extensively in the production and preservation of foods and beverages, including dried fruit, ready-to-eat salad vegetables, frozen fried potatoes, wine, beer, soft drinks, packaged fruit juices, shellfish, and pickled and pureed foods. Sulfites possess antioxidant and antimicrobial activities, which inhibit the enzymatic and nonenzymatic (browning) spoiling of food. This preserves the color, freshness, flavor, and crispness of food but substantially reduces the available thiamine. For example, respective thiamine loss from cabbage blanched with sulfite-treated water versus untreated water was 45% vs 15% ¹⁴². The use of sulfiting agents in foods recognized as important sources of thiamine is prohibited by the US Food and Drug Administration ¹⁸⁷, ¹⁸⁸, ¹⁸⁹, ¹⁹⁰.

Excessive loss of thiamine caused by thiamine-drug interactions

Excessive loss of thiamine may precipitate thiamine deficiency. Increased losses of ingested thiamine can be caused by drug-related polyuria or diarrhea, drug interactions, or chronic excessive alcohol consumption ⁸. Thiamine is a polar, water-soluble vitamin and is not protein bound, which allows it to be easily dialyzed or filtered in the glomerulus. Increased urine flow, loop diuretics, or dialysis can all cause thiamine deficiency. Thiamine deficiency is associated with drugs such as omeprazole, phenytoin, 5-fluorouracil, metformin, alcohol, antibiotics, furosemide, and thiazide diuretics ⁴². By increasing urinary flow, diuretics may prevent reabsorption of thiamine by the kidneys and increase its excretion in the urine ¹⁹¹, ¹⁹². The risk of thiamine deficiency is increased in diuretic-treated patients with marginal thiamine intake ¹⁹³ and in individuals receiving long-term, diuretic therapy ⁴⁷. Patients with congestive heart failure who receive chronic therapy with furosemide or thiazide diuretics can also develop thiamine deficiency. The prevalence of thiamine deficiency in this patient population varies from 21% to 98% ⁸. Supplementation with thiamine has been shown to improve left ventricular ejection fraction by 22%, New York Heart Association Functional Classification, and TPP effect (from 11.7% to 5.4%) in these patients ⁴⁸. Mechanisms for exacerbation of heart failure by diuretics include increased thiamine loss in urine, furosemide-related inhibition of cardiac myocyte thiamine uptake, furosemide-induced anorexia, furosemide inhibition of intestinal absorption or cellular uptake of thiamine, and hypomagnesemia ⁴². Unrecognized thiamine deficiency in heart failure patients treated with long-term diuretic therapy may result in Shoshin beriberi ¹⁹⁴.

Individuals with kidney failure requiring hemodialysis lose thiamine at an increased rate and are at risk for thiamine deficiency ¹⁹⁵. Alcoholics who maintain a high fluid intake and high urine flow rate may also experience increased loss of thiamine, exacerbating the effects of low thiamine intake ¹⁹⁶.

Omeprazole a proton pump inhibitor because of its azole analogue molecular structure may cause inactivation of pyruvate decarboxylase and human erythrocyte transketolase, resulting in antagonism of thiamine ¹⁹⁷. Omeprazole may inhibit gastric proton pumps by competing with thiamine for binding to hydrogen/potassium adenosine triphosphatase ¹⁴⁵, ¹⁹⁷. Proton pump inhibitor drugs or Roux-en-Y gastric bypass surgery may also worsen subclinical thiamine deficiency by promoting small intestinal bacterial overgrowth, which alters luminal thiamine levels ¹⁹⁸, ¹⁴⁴. Hypomagnesemia induced by proton pump inhibitors can contribute to functional thiamine deficiency, as magnesium is a required cofactor for the formation of TPP and acetyl coenzyme A ¹⁹⁸. 5-Fluorouracil decreases hepatic thiamine levels and thiamine-dependent transketolase activity. This is associated with an increase in the TPP effect in vitro and in whole blood ¹⁹⁹. 5-Fluorouracil is catabolized to fluoroacetate, which blocks the Krebs cycle and ATP production, leading to neurotoxicity, ammonia formation, and encephalopathy ²⁰⁰, ²⁰¹, ²⁰². Metformin, a substrate and inhibitor of the human thiamine transporter 2, reduces both intestinal absorption of thiamine and levels of thiamine in tissues and liver ²⁰³, ²⁰⁴, ²⁰⁵. Alcohol decreases carrier-mediated thiamine transport in the brush border and basolateral membrane of enterocytes in the jejunum (thiamine transporter 1) and potentially decreases thiamine production by intestinal flora in the lumen ²⁰⁶

Small intestinal bacterial overgrowth can be treated specifically with certain oral antibiotics such as rifaximin, neomycin, and metronidazole, which can improve postoperative thiamine deficiency in Roux-en-y gastric bypass patients ²⁰⁷, ¹⁴³, ¹⁴⁴. The use of broad-spectrum antibiotics (penicillins, cephalosporins, aminoglycosides, tetracyclines, fluoroquinolones, sulfonamides, trimethoprim), however, can potentially cause thiamine deficit in some patients by reducing counts of normal intestinal bacteria that produce thiamine (eg, Escherichia coli, bifidobacteria, Lactobacillus spp) and by promoting the growth of pathogenic flora such as Clostridium spp, which produce thiaminases ²⁰⁸, ⁴². Metronidazole, a thiazole, has been shown to be a substrate for thiaminase 1. Formation of thiamine antimetabolites from metronidazole, which can occur particularly with high cumulative doses or prolonged use of metronidazole, can inhibit thiamine pyrophosphokinase, leading to irreversible, painful, peripheral neuropathy ¹⁸⁴.

Table 3. Effects of drugs and antithiamine agents on thiamine

Drug family/antithiamine agent	Drug	Effect on thiamine
Alcohol	Ethanol	Decreased intestinal thiamine transport
Antibiotic	Metronidazole	Production of thiamine antimetabolites
Antibiotics	β-lactams, aminoglycosides, trimethoprim, quinolones	Decreased production of thiamine by intestinal microbiota
Chemotherapy	5-fluorouracil	Decreased production of hepatic thiamine, decreased TKT activity
Polyphenols (coffee, tea)	Caffeic acid, tannic acid	Oxidation of thiazole ring
Diuretics	Furosemide, thiazides	Increased renal excretion, decreased intestinal absorption
Flavonoids	Quercetin, rutin	Oxidation to thiamine disulfide
Food preservatives	Sulfites	Disruption of thiamine methylene bridge
Oral hypoglycemics (biguanide)	Metformin	THTR2 inhibitor, prevents active transport of thiamine
Proton pump inhibitors	Omeprazole	Inactivation of PDH, erythrocyte transketolase, and H/K ATPase

Abbreviations: H/K ATPase = hydrogen/potassium adenosine triphosphatase; PDH = pyruvate dehydrogenase; TKT = transketolase; THTR2 = thiamine transporter 2.

[Source ⁸ ]

Groups at risk of thiamine deficiency

The following groups are among those most likely to have inadequate thiamine status ¹⁷.

People with alcohol dependence

In highly industrialized countries, chronic alcohol use disorders appear to be the most common cause of thiamine deficiency ¹. Up to 80% of people with chronic alcoholism develop thiamine deficiency because ethanol reduces gastrointestinal absorption of thiamine, thiamine stores in the liver, and thiamine phosphorylation ⁹, ¹³². Also, people with alcoholism tend to have inadequate intakes of essential nutrients, including thiamine.

Older adults

Up to 20%–30% of older adults have laboratory indicators that suggest some degree of thiamine deficiency ⁷, ¹¹³. Possible reasons include low dietary intakes, a combination of chronic diseases, concomitant use of multiple medications, and low absorption of thiamin as a natural result of aging ²⁰⁹, ⁴⁶. Some small studies have found that the risk of deficiency is particularly high in elderly people who reside in an institution ⁵⁴, ⁶⁰.

People with HIV/AIDS

People with HIV infection have an increased risk of thiamin deficiency and its sequelae, including beriberi and Wernicke-Korsakoff syndrome ¹, ²¹⁰. Autopsies of 380 people with AIDS found that almost 10% had Wernicke’s encephalopathy ²¹¹, and some experts believe that thiamin deficiency is underdiagnosed in this population ²¹². The association between thiamin deficiency and HIV/AIDS is probably due to malnutrition as a result of the catabolic state associated with AIDS ¹⁷.

People with diabetes

Some small studies have found that thiamine levels in plasma are up to 76% lower in people with type 1 diabetes than in healthy volunteers and 50%–75% lower in people with type 2 diabetes ²¹³, ³⁰. Other studies have shown a higher risk of thiamine deficiency in people with type 1 and/or type 2 diabetes based on tests of erythrocyte transketolase activity ³⁵, ²¹⁴. These lower thiamine levels might be due to increases in clearance of thiamin by the kidneys. The relevance of these effects to clinical prognosis or outcomes is not known.

People who have undergone weight loss surgery

Weight loss surgery also called bariatric surgery for weight loss is associated with some risks, including severe thiamine deficiency due to malabsorption that can lead to beriberi or Wernicke’s encephalopathy ¹⁷. A 2008 literature review identified 84 cases of Wernicke’s encephalopathy after bariatric surgery (primarily gastric bypass surgery) between 1991 and 2008 ²¹⁵. About half of these patients experienced long-lasting neurologic impairments. Micronutrient supplements that include thiamine are almost always recommended for patients following weight loss surgery to avoid deficiencies ²¹⁶.

Thiamine deficiency prevention

Eating a proper diet that is rich in vitamins will prevent thiamine deficiency. Nursing mothers should make sure that their diet contains all vitamins. If your infant is not breastfed, make sure that the infant formula contains thiamine.

If you drink alcohol, try to cut down or quit. Also, take B vitamins to make sure your body is properly absorbing and storing thiamine.

Thiamine deficiency symptoms

Generally, heart effects of thiamine deficiency are referred to as “wet beriberi”, the peripheral neurological signs and symptoms of thiamine deficiency are called “dry beriberi”, and delirium, mental confusion and abnormal eye movements (due to ophthalmoplegia, which is paralysis or weakness of the eye muscles), stance and gait ataxia are termed “cerebral beriberi” or Wernicke’s encephalopathy ¹²⁷, ²³, ¹⁹. “Gastrointestinal beriberi” is caused by lactic acidosis, a condition resulting from the accumulation of lactate and is often associated with nausea, vomiting, and severe abdominal pain ¹²⁸.

Thiamine deficiency cardiovascular signs and symptoms are as follows:

Fast heart rate (tachycardia)
Chest pain
Wide pulse pressure
Heart failure (orthopnea with or without edema, warm skin due to vasodilation) ²¹⁷
Hypotension, shock

Thiamine deficiency gastroenterologic signs and symptoms are as follows:

Anorexia
Abdominal discomfort
Constipation
Difficulty swallowing (dysphagia) ²¹⁸

Thiamine deficiency neurologic signs and symptoms of thiamine deficiency are as follows ²¹⁹:

Poor memory, irritability, sleep disturbance
Wernicke encephalopathy and/or Korsakoff syndrome ²²⁰
Bilateral, symmetrical lower extremity paresthesias, burning pain
Muscle cramps
Decreased vibratory position sensation
Absent knee and ankle jerk
Muscle atrophy
Foot drop (late stage)
Abnormal eye movement (back and forth movements called nystagmus) – most common (early sign) ²²¹

Thiamine deficiency infantile beriberi signs and symptoms are as follows ²²²:

Congestive heart failure
Loss of voice (aphonia)
Absent deep tendon reflex.

A study by Mifsud et al ²²¹ described the characteristics of 56 cases of thiamine deficiency that were seen at a French tertiary hospital. A history of alcohol abuse was found in 45 patients (80%), and while neurologic symptoms were the basis for diagnosis in the majority of individuals, there were frequent instances of nonspecific and digestive symptoms. Moreover, the criteria for malnutrition were fulfilled in 34% of patients. Of the 54% of patients in whom brain magnetic resonance imaging (MRI) scans were performed, abnormal scans were found in 63% of cases ²²¹.

A study by Isenberg-Grzeda et al ²²³ indicated that thiamine deficiency may be a frequent occurrence among inpatients with cancer, even in those who are of normal weight or overweight, lack other vitamin deficiencies, and are receiving multivitamin supplements. The single-center study found thiamine deficiency in 55.3% of 217 patients, with risk factors for the deficiency including active cancer treatment and fluorouracil-based chemotherapy ²²³.

A literature review by Jain et al ⁴⁵ comparing the incidence of thiamine deficiency in patients with heart failure to that in controls reported an odds ratio of 2.53, with possible reasons for the deficiency in heart failure including diuretic use, dietary changes, and alterations in the absorption and metabolism of thiamine. The literature also indicated that thiamine supplementation may improve symptoms and ejection fraction in patients with heart failure ⁴⁵.

Beriberi signs and symptoms

Beriberi is a disease in which the body does not have enough thiamine or vitamin B1.

There are two major types of beriberi:

Wet beriberi: Thiamine deficiency with cardiovascular system involvement is termed wet beriberi. The chronic form of wet beriberi consists of 3 stages. In the first stage, peripheral vasodilation occurs, leading to a high cardiac output state. This leads to salt and water retention mediated through the renin-angiotensin-aldosterone system in the kidneys. As the vasodilation progresses, the kidneys detect a relative loss of volume and respond by conserving salt. With the salt retention, fluid is also absorbed into the circulatory system. The resulting fluid overload leads to edema of the dependent extremities.
Dry beriberi: Thiamine deficiency with nervous system involvement is termed dry beriberi. This presentation usually occurs when poor caloric intake and relative physical inactivity are present. The neurologic findings can be peripheral neuropathy characterized by symmetrical impairment of sensory, motor, and reflex functions of the extremities, especially in the distal lower limbs. Histologic analysis has shown that the lesions arise from a degeneration of the myelin in the muscular sheaths without inflammation ²²⁴.
Cerebral beriberi also known as Wernicke-Korsakoff syndrome that affects the nervous system ²²⁵.

Symptoms of “dry beriberi” include:

Difficulty walking
Loss of feeling (sensation) in hands and feet
Loss of muscle function or paralysis of the lower legs
Mental confusion
Pain
Speech difficulties
Strange eye movements (nystagmus)
Tingling
Vomiting

Symptoms of “wet beriberi” include:

Awakening at night short of breath
Increased heart rate
Shortness of breath with activity
Swelling of the lower legs

Wernicke-Korsakoff syndrome signs and symptoms

Wernicke encephalopathy and Korsakoff syndrome are often thought to be on a spectrum with one another as they are both due to thiamine or vitamin B1 deficiency. Wernicke’s encephalopathy causes brain damage in lower parts of the brain called the thalamus and hypothalamus ²²⁶. Korsakoff’s psychosis results from permanent damage to areas of the brain involved with memory ²²⁶. Therefore, clinicians should screen for them together. Wernicke encephalopathy classically presents with the triad of altered mental status, ophthalmoplegia, and ataxia. In reality, less than 20% of patients will present with all three of these findings ¹²⁹. Korsakoff syndrome or Korsakoff’s psychosis is a neuropsychiatric disorder associated with memory disturbances in which there are significant deficits in anterograde and retrograde memory. Immediate memory is maintained, but short-term memory is diminished with intact sensorium. The disorder is associated with patients fabricating stories in the setting of clear consciousness. Confabulations can be spontaneous or provoked with provoked confabulation commonly seen in chronic Korsakoff syndrome and spontaneous confabulation usually noted in the acute Wernicke’s encephalopathy ²²⁷, ²²⁸.

The following signs and symptoms should cause suspicion for Wernicke-Korsakoff syndrome ¹²⁹:

Altered mental status (up to 82% of patients) – amnesia, disorientation, confabulations
Oculomotor findings – most often horizontal nystagmus, retinal hemorrhage, ophthalmoplegia, cranial nerve IV palsy, conjugate gaze
Loss of muscular coordination (ataxia) – wide-based gait. Ataxia is likely to be a combination of polyneuropathy, cerebellar damage, and vestibular paresis. Vestibular dysfunction, usually without hearing loss, is universally impaired in the acute stages of Wernicke encephalopathy.

The cognitive impairments specific to Korsakoff syndrome vs. Wernicke encephalopathy include anterograde amnesia, profoundly limiting one’s learning capacity, retrograde amnesia, as well as executive deficits, resulting in decreased inhibition and difficulties with judgment, planning and problem-solving ²²⁹. Anterograde amnesia can result in the classic symptom of confabulations, replacing one’s gap in memory with untrue information ²³⁰.

Symptoms of Wernicke encephalopathy include:

Confusion and loss of mental activity that can progress to coma and death
Loss of muscle coordination (ataxia) that can cause leg tremor
Vision changes such as abnormal eye movements (back and forth movements called nystagmus), double vision, eyelid drooping
Alcohol withdrawal

Symptoms of Korsakoff syndrome include:

Inability to form new memories
Loss of memory, can be severe
Making up stories (confabulation)
Seeing or hearing things that are not really there (hallucinations)

Thiamine deficiency complications

Thiamine deficiency complications may include:

Coma
Congestive heart failure
Death
Psychosis

Thiamine deficiency diagnosis

A physical examination may show signs of congestive heart failure, including:

Difficulty breathing, with neck veins that stick out
Enlarged heart
Fluid in the lungs
Rapid heartbeat
Swelling in both lower legs

A person with late-stage beriberi may be confused or have memory loss and delusions. The person may be less able to sense vibrations. The person may appear poorly nourished.

A physical examination of the nervous and muscular system may show signs of damage to many nerve systems:

Changes in walking
Coordination problems
Abnormal eye movement
Drooping of the eyelids
Decreased or abnormal reflexes
Fast pulse (heart rate)
Low blood pressure
Low body temperature
Muscle weakness and atrophy (loss of tissue mass)
Problems with walk (gait) and coordination.

For practical reasons, replacing thiamine as an initial test may be most feasible ²³¹. If the patient responds to thiamine administration, it is safe to assume that a measure of thiamine deficiency was responsible for the signs and symptoms ²³¹. Thiamine is not toxic in high levels, which means that this route carries little risk. In addition, time is saved in treating the patient and money is saved in testing. However, although observation of a patient’s clinical response to thiamine administration remains the easiest, least expensive form of testing, clinicians usually miss the subclinical forms of thiamine deficiency ²³¹.

The diagnosis of Wernicke’s encephalopathy is a histopathological diagnosis, made after a postmortem examination of the brain ²³², ²³³, ²³⁴.

The Caine criteria have been described to have a sensitivity or 85% and specificity of 100% for Wernicke encephalopathy, in the alcoholic population ²³⁵, ¹²⁹. Because of the strong overlap, the Caine criteria can be used to help screen for Korsakoff syndrome as well.

Caine criteria for the diagnosis of Wernicke encephalopathy in chronic alcoholics ²³⁵. When 2 out of these 4 criteria apply, the clinical diagnosis of Wernicke encephalopathy is made ¹²⁹, ²³⁵:

Dietary deficiencies
- Undernutrition (body mass index <2 SD below normal)
- A history of grossly impaired dietary intake
- An abnormal thiamine status
Oculomotor abnormalities
- Ophthalmoplegia
- Nystagmus
- Gaze palsy
Cerebellar dysfunction
- Unsteadiness or ataxia
- Abnormalities of past pointing
- Dysdiadokokinesia
- Impaired heel-shin testing
Either an altered mental state OR mild memory impairment
- Altered mental status
  - Disorientation in two of three fields
  - Confused
  - An abnormal digit span
  - Comatose
- Mild memory impairment
  - Failure to remember two or more words in the four-item memory test
  - Impairment on more elaborate neuropsychological tests of memory function

The following tests are used to check a person’s nutrition level:

Serum albumin (relates to person’s general nutrition)
Transketolase activity in red blood cells (reduced in people with thiamine deficiency). The serum level of thiamin is not a reliable indicator of thiamin status. However, thiamin function can be measured by red blood cells transketolase activity (erythrocytes transketolase activity or ETKA). Red blood cells transketolase activity (EKTA) of 0 to 15% is considered adequate, 15 to 25% is considered a moderate risk, and 25% or higher is considered high risk for thiamin deficiency ²³⁶, ²³⁷.
Serum vitamin B1 or thiamine levels. Direct measurement of erythrocyte thiamin pyrophosphate (TPP) can be done using whole-blood testing and has more sensitivity, specificity, precision, and robustness ²³⁶. The concentration of TPP in the whole blood ranges from 70 to 180 nmol/L ¹²³.
Urine tests to see if thiamine is passing through the urine. Urinary thiamine excretion can be used to measure adequate dietary intake. However, it does not reflect the thiamine stores in the body. In adults, urinary thiamine excretion of <100 mcg/day suggests inadequate intake, and less than 40 mcg/day suggests thiamin deficiency ¹⁸.
Liver enzymes may be high in people with a history of long-term alcohol abuse.

A brain MRI may show changes in the tissue of the brain. But if Wernicke-Korsakoff syndrome is suspected, treatment should start immediately. Usually a brain MRI exam is not needed.

Thiamine deficiency treatment

In suspected cases of thiamine deficiency, prompt administration of parenteral (intravenously or intramuscularly) thiamine is indicated.

The preferred dose of thiamine treatment for Wernicke encephalopathy may be as high as 500 mg intravenous thiamine given three times daily for 3 to 5 days, followed by intravenous thiamine, 250 mg/day for 3 to 5 days or until the symptoms disappear, and then further treatment with oral thiamine, 100 mg/day ²³⁸, ²²⁵. The rationale for using three times daily dosing of intravenous thiamine in acute presentations is based on the short half-life of intravenous thiamine (96 minutes) and the slow, carrier mediated process of thiamine transport across the blood–brain barrier ⁸. A single intravenous dose of thiamine is less likely to achieve sufficient brain tissue levels, and the bioavailability of oral thiamine hydrochloride is only 3.7% to 5.3% ²³⁸.

All malnourished patient may need higher doses of thiamine ²²⁵. Thiamine is generally administered before or together with glucose solutions because the glucose oxidation can decrease thiamine levels thereby exacerbating the neurological symptoms of Wernicke encephalopathy ²²⁵. Patients with magnesium deficiency should also be treated as this can result in reduced recovery from Wernicke encephalopathy especially in patients with alcoholism ²³⁹, ²³⁰, ²⁴⁰. Following a review of 19 papers, it has been recommended not to delay in correcting hypoglycemia ²⁴¹. There are suggestions that prolonged and not acute replacement of glucose without thiamine supplementation increased the risk of Wernicke encephalopathy.

For Korsakoff syndrome high dose thiamine at 500 mg to 1500 mg, IV, three times daily for at least 3 days ¹²⁹. Electrolyte abnormalities should be corrected and fluids replaced. In particular, magnesium requires replacement, as thiamine-dependent enzymes cannot operate in a magnesium-deficient state. Many patients will present needing glucose replacement as well, and traditionally it was thought that replacing glucose before thiamine could exacerbate the patient’s symptoms ¹³⁸.

Thiamine, even at high concentrations, is not toxic in a person with normal kidney function ²⁴². No cases of thiamine toxicity have been reported from the use of thiamine at the dosages indicated, even in patients in critical condition ²⁴².

Once clinical symptoms improve, thiamine supplementation can switch to the oral route with a dose range of 50 to 100 mg per day ⁶. It is equally important in individuals with thiamine deficiency to require other nutrient supplementation such as magnesium, vitamin B2 (riboflavin), vitamin B3 (nicotinamide), vitamin B6 (pyridoxine), vitamin B12, vitamin C, potassium, and phosphate ¹⁷.

Support for cardiac function is necessary in cases of wet beriberi, because lack of cardiac support leads to low-output cardiac failure when the thiamine deficiency is corrected ²⁴².

Follow-up care until delivery of current pregnancy, intensive care for advanced cardiomyopathy, definitive care for hyperthyroidism, or further workup of intestinal derangement may be warranted in patients with thiamine deficiency ²⁴².

Blood tests may be repeated after the treatment is started. These tests will show how well you are responding to the medicine.

After the acute phase of vitamin and electrolyte replacement, there is mounting evidence that memory rehabilitation is beneficial in Korsakoff syndrome. Declarative memory (“knowing what”) seems to be most affected in Korsakoff syndrome, leading to many patients requiring lifelong care. Because procedural learning (“knowing how”) seems to remain somewhat maintained in Korsakoff syndrome, memory rehabilitation focussed in this area has shown promising outcomes. There has been some success in small Korsakoff syndrome patient populations in learning procedures and improving their autonomy ²²⁹.

Thiamine deficiency recovery time

Beriberi can be quickly fatal or can slowly rob an individual of almost all energy for even the simplest of daily activities. However, beriberi is one of the most easily treatable thiamine deficiency, with a remarkable recovery being possible even in severe cases ²⁴³. Therefore, the patient prognosis for beriberi is usually good, unless patients have established Korsakoff syndrome. While thiamine can induce partial improvement, the neuropsychological deficits persist in many cases. The confusional state usually improves when IV thiamine is administered but the learning and memory deficits only improve partially. A small number of patients fail to have any improvement and may develop Korsakoff psychosis or Korsakoff syndrome, which often requires institutionalization. Very few individuals recover at this point.

In cases of wet beriberi, clinical improvement can be observed within 12 hours of treatment, with normalization of heart function and size occurring in 1 or 2 days ²⁴³. The recovery is so dramatic that treatment with thiamine is a diagnostic test, which can be used in cases of acute heart failure and insidious peripheral neuropathy ²⁴³.

A retrospective study by Harel et al ²⁴⁴ indicated that thiamine deficiency in infancy can lead to long-term motor function problems. The study looked at children aged 5-6 years who, during the first 2 years of life, had been fed a faulty milk substitute that was deficient in thiamine, comparing them with age-matched controls. The Movement Assessment Battery for Children and the Zuk Assessment indicated that motor function difficulties existed in 56% and 59%, respectively, of the thiamine-deficient formula group, compared with 10% and 3%, respectively, of the control group. The results suggested that infantile thiamine deficiency affects gross and fine motor function, as well as balance skills ²⁴⁴.

Thiamine deficiency prognosis

Untreated, beriberi can be fatal. With treatment, symptoms usually improve quickly. Heart damage is usually reversible. A full recovery is expected in these cases. However, if acute heart failure has already occurred, the outlook is poor.

Nervous system damage is also reversible, if caught early. High suspicion for Wernicke’s encephalopathy is key to improving patient prognosis. Classically, the thinking was that once Korsakoff syndrome has set in, memory loss (amnesia) was generally irreversible, even with treatment ²⁴⁵, ²⁴⁶, ¹³⁸. Several case studies and eight double-blind trials have been published, where Korsakoff syndrome patients were treated with clonidine, fluvoxamine, reboxetine, or rivastigmine. Together, these studies did not produce any consistent evidence for the efficacy of any of these interventions ²⁴⁷. Therefore, until this date, no effective pharmacological treatment for Korsakoff syndrome is available ¹³⁰. More recent research has shown promise in memory rehabilitation including memory compensation techniques and error-less learning strategies ¹³⁰. If a person with Wernicke encephalopathy receives thiamine replacement, language problems, unusual eye movements, and walking difficulties may go away. However, Korsakoff syndrome or Korsakoff psychosis tends to develop as Wernicke symptoms go away.

Regarding neuroimaging, associations with cortical lesions have shown to correlate with a worse prognosis ¹²⁹.

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Onishi H, Ishida M, Uchida N, Shintani D, Nishikawa T, Hasegawa K, Fujiwara K, Akechi T. Subclinical thiamine deficiency identified by preoperative evaluation in an ovarian cancer patient: Diagnosis and the need for preoperative thiamine measurement. Palliat Support Care. 2019 Oct;17(5):609-610. doi: 10.1017/S1478951518000615[↩]
Oudman E, Wijnia JW, van Dam M, Biter LU, Postma A. Preventing Wernicke Encephalopathy After Bariatric Surgery. Obes Surg. 2018 Jul;28(7):2060-2068. doi: 10.1007/s11695-018-3262-4[↩]
Schabelman E, Kuo D. Glucose before thiamine for Wernicke encephalopathy: a literature review. J Emerg Med. 2012 Apr;42(4):488-94. doi: 10.1016/j.jemermed.2011.05.076[↩]
Beriberi (Thiamine Deficiency) Treatment & Management. https://emedicine.medscape.com/article/116930-treatment[↩][↩][↩][↩]
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Fujiwara E, Brand M, Borsutzky S, Steingass HP, Markowitsch HJ. Cognitive performance of detoxified alcoholic Korsakoff syndrome patients remains stable over two years. J Clin Exp Neuropsychol. 2008 Jul;30(5):576-87. doi: 10.1080/13803390701557271[↩]
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Benefits of exercise

Regular exercise strengthens and tones your brain just as it does your body. Research shows that sitting around too much increases your risk of chronic disease which may well lead to an early death. In fact people who exercise regularly live on average 7 years longer than those who are physically inactive. It also shows that as little as 15 minutes of physical activity a day can reduce your risk significantly and improve your quality of life.

Exercise can also help you maintain your weight loss. Studies show that people who lose weight and keep it off over the long term get regular physical activity.

Although the research isn’t fully conclusive, more studies are showing how essential exercise is for keeping your brain fit. And the best news? You can actually build a stronger brain through exercise.

These are just a few of the remarkable findings that might motivate you to either recommit to your fitness regimen or get started today. Staying active can help you:

Feel better. Walking and other moderate aerobic exercise has been shown to help stabilize your mood and help with depressive symptoms. Studies have also found that regular exercise helps people better control their stress and regulate their emotions.
Enhance learning. While scientists don’t fully understand how physical activity contributes to learning, they’re discovering that it works. In one study, when teachers added exercise routines to math lessons — called motor-enriched learning — math scores improved faster for the exercisers than for the kids who didn’t exercise during the lesson. Other studies have found that exercise helps improve reading comprehension, too.
Sharpen memory. Although brain size decreases as you age, research has shown that exercise can actually help reverse that — at any age. One study found that physical activity helped participants build measurable increases in the hippocampus, the part of the brain that enables you to create and store memories. Another study showed that people with better cardiovascular fitness as young adults had better memory, motor skills and executive function 25 years later as middle-aged adults.
Improve vision. When you exercise, you’re stimulating the neurons in the part of your brain that helps you sort out and understand what you’re seeing. Research has found evidence that your visual system becomes more sensitive during exercise and may actually enhance visual learning.
Keep and improve your strength so you can stay independent
Have more energy to do the things you want to do and reduce fatigue
Improve your balance and lower risk of falls and injuries from falls
Manage and prevent some diseases like arthritis, heart disease, stroke, type 2 diabetes, osteoporosis, and 8 types of cancer, including breast and colon cancer
Sleep better at home
Reduce levels of stress and anxiety
Reach or maintain a healthy weight and reduce risk of excessive weight gain
Control your blood pressure
Possibly improve or maintain some aspects of cognitive function, such as your ability to shift quickly between tasks or plan an activity and ignore irrelevant information
Perk up your mood and reduce feelings of depression

You don’t need to become a fitness fiend to reap benefits. In many studies, just walking briskly for 30 to 60 minutes, three to five times a week, contributed to measurable brain improvements.

Evidence does suggest that resistance training and aerobic exercise — walking, running, biking, swimming — may help your brain more than stretching exercises do. In one study, older adults with mild cognitive impairment who lifted weights two to three times a week improved muscle tone and cognitive function.

Your brain is amazing. Billions of nerve cells work together in harmony to coordinate every second of your life: your movements, behavior, thoughts, memories and emotions. So take your brain to the gym to maximize whole-body health.

4 Types of Exercise

Exercise and physical activity fall into four basic categories—endurance, strength, balance, and flexibility. Most people tend to focus on one activity or type of exercise and think they’re doing enough. Each type is different, though. Doing them all will give you more benefits. Mixing it up also helps to reduce boredom and cut your risk of injury.
Though we’ve described each type separately, some activities fit into more than one category. For example, many endurance activities also build strength. Strength exercises also help improve balance.

1) Endurance

Endurance, or aerobic, activities increase your breathing and heart rate. These activities help keep you healthy, improve your fitness, and help you do the tasks you need to do every day. Endurance exercises improve the health of your heart, lungs, and circulatory system. They also delay or prevent many diseases that are common in older adults such as diabetes, heart disease, and osteoporosis. Building your endurance makes it easier to carry out many of your everyday activities.

Brisk walking or jogging
Yard work (mowing, raking, digging)
Cycling
Dancing

2) Strength

Strength exercises make your muscles stronger. Even small increases in strength can make a big difference in your ability to stay independent and carry out everyday activities, such as climbing stairs and carrying groceries. These exercises also are called “strength training” or “resistance training.”

Lifting weights
Using a resistance band
Using your own body weight
Carry groceries in from the car
Pick up bags of mulch.

3) Balance

Balance exercises help prevent falls, a common problem in older adults. Many lower-body strength exercises also will improve your balance.

Standing on one foot
Heel-to-toe walk
Tai Chi

4) Flexibility

Flexibility exercises stretch your muscles and can help your body stay limber. Being flexible gives you more freedom of movement for other exercises as well as for your everyday activities.

Shoulder and upper arm stretch
Calf stretch
Yoga
Bend down to tie your shoes
Stretch to clean hard to reach areas of the house.

How Exercise Can Help You ?

Exercise and physical activity are good for just about everyone, including older adults. No matter your health and physical abilities, you can gain a lot by staying active. In fact, in most cases you have more to lose by not being active.
Here are just a few of the benefits. Exercise and physical activity:

Can help maintain and improve your physical strength and fitness.
Can help maintain and increases your flexibility
Gives you more energy
Helps control your weight
Helps build and maintain strong bones
Helps prevent or reduce the risk of major diseases, such as cardiovascular disease, diabetes mellitus, and certain types of cancer
Can help improve your ability to do the everyday things you want to do.
Can help improve your balance.
Can help manage and improve diseases like diabetes, heart disease, and osteoporosis.
Can help reduce feelings of depression and may improve mood and overall well-being. Relieves stress, improves sleep quality, and can help ease depression and anxiety
May improve your ability to shift quickly between tasks, plan an activity, and ignore irrelevant information.

The key word in all these benefits is YOU — how fit and active you are now and how much effort you put into being active. To gain the most benefits, enjoy all 4 types of exercise, stay safe while you exercise, and be sure to eat a healthy diet, too!

Exercise as Appetite Suppressant

Most weight loss occurs because of decreased caloric intake. However, evidence shows the only way to maintain weight loss is to be engaged in regular physical activity.

Another benefit of regular physical activity of any sort is that it temporarily curbs your appetite. Of course, many people joke that after a workout they feel extremely hungry and promptly indulge in a snack. But because exercise raises resting energy expenditure, people continue to burn calories at a relatively high rate. So a moderate snack after exercising does not erase the benefits of exercise in helping people control their weight.

Biologists now believe that most cells in your body are designed to fall apart after relatively short life spans. The net result is that you are actively destroying large parts of your body all the time. On purpose. To make room for new growth. For example, the muscle cells in your thigh are replaced every four months; you have armies of special cells whose job is to dissolve your bones so other cells can build them up again. The trick is to grow more than you throw out. This is where exercise comes in. It turns out that your muscles control the chemistry of growth throughout your body.

What are the Health Benefits of Regular Exercise

Most importantly, physical activity reduces risks of cardiovascular disease, cancer and diabetes beyond that produced by weight reduction alone. Regular physical activity helps maintain a healthy body. Exercise helps increase endurance, promotes good balance, and keeps you flexible — all of which help get you through the day at your best.

Is being sedentary linked to health risks ?

Yes. Sedentary behavior, such as prolonged periods of television viewing, sitting, and lying down, is a risk factor for developing chronic conditions, including cancer, cardiovascular disease, and type 2 diabetes, and for premature death ¹, ². In some studies, the association of sedentary behavior with these outcomes is independent of physical activity—that is, the increased risks of disease associated with being sedentary are not lessened by physical activity. However, in one large meta-analysis ³ an increase in cancer mortality was seen only in those sedentary people with the least physical activity.

Although exercise has long been associated with good health, it was only 20 years ago that lack of sufficient physical activity/exercise was considered a major risk factor of equal importance as high cholesterol, high blood pressure, and smoking ⁴.

Physical activity ⁵ helps to :

Maintain weight.
Reduce high blood pressure.
Reduce risk for type 2 diabetes, heart attack, stroke, and several forms of cancer.
Reduce arthritis pain and associated disability.
Reduce risk for osteoporosis and falls.
Reduce symptoms of depression and anxiety.

As the evidence base for the health benefits continued to expand, updated recommendations were issued by the American College of Sports Medicine and AHA in 2007 and the first ever federal guidelines on physical activity in 2008 ⁶, ⁷, ⁸.

Likewise, there are clear recommendations of the importance of exercise for secondary prevention of coronary and cardiovascular diseases ⁹. These reports document that sufficient amounts of physical activity or exercise are beneficial in the prevention and/or treatment of many chronic diseases. Despite the well accepted benefits, surveillance data from 2005 showed a majority of U.S. adults (53.3% of women and 50.3% of men) do not obtain sufficient physical activity for health-enhancement (defined as > 30 minutes at a moderate-intensity on most days of the week) ¹⁰.

Benefits of Regular Exercise

These studies ¹¹, ¹², ¹³, ¹⁴, ¹⁵, ¹⁶ revealed skeletal muscle as an endocrine organ releasing cytokines and other peptides. Since the initial reports ¹⁷, numerous research teams have demonstrated that physical exercise induces elevation of the plasma content of several cytokines, including tumor necrosis factor TNF-α, interleukins IL-1β, IL-6, IL-8, and IL-15, and leukemia inhibitory factor (LIF) ¹⁸. Indeed, in skeletal muscles, Interleukin 6 (IL-6) acts in autocrine or paracrine manner signaling through IL-6Ra receptors to increase glucose uptake and fat breakdown via phosphorylation of protein kinase B and AMP-activated protein kinase (AMPK), respectively, whereas acting in endocrine manner it provides energy supply via increase in glucose production in the liver and lipolysis (fat breakdown) in the adipose tissue ¹⁹. Interleukin 15 (IL-15) decreases lipid deposition in preadipocytes and the mass of white adipose tissue ²⁰. Leukemia inhibitory factor (LIF) induces cell proliferation, which is considered to be essential for proper muscle hypertrophy and regeneration ²¹. Considering this, the role of interleukins and other myokines in the beneficial action of exercise in the treatment of metabolic, cardiovascular, lung, and musculoskeletal disorders has been widely reviewed and discussed ²².

Regular exercise also increases the amount of energy you burn while you are exercising. But it also boosts your resting energy expenditure — the rate at which you burn calories when the workout is over and you are resting. Resting energy expenditure remains elevated as long as you exercise at least three days a week on a regular basis.

Because resting energy expenditure accounts for 60% to 75% of the calories you burn each day, any increase in resting energy expenditure is extremely important to your weight-loss effort. The kinds of vigorous activity that can stimulate your metabolism include walking briskly for two miles or riding a bike uphill. Even small, incremental amounts of energy expenditure, like standing up instead of sitting down, can add up.

Exercise and Calories Burned

Regular physical activity is important for good health and it’s especially important if you’re trying to lose weight or to maintain a healthy weight. The burning of calories through physical activity, combined with reducing the number of calories you eat, creates a “calorie deficit” that results in weight loss. There are numerous ways you can exercise every day. Help determine what exercise is right for you using the following information on calories burned by type of workout.

[Source ²³]

The following table shows calories used in common physical activities at both moderate and vigorous levels ⁵.

Calories Used per Hour in Common Physical Activities
Moderate Physical Activity	Approximate Calories/30 Minutes for a 154 lb Person¹	Approximate Calories/Hr for a 154 lb Person¹
Hiking	185	370
Light gardening/yard work	165	330
Dancing	165	330
Golf (walking and carrying clubs)	165	330
Bicycling (<10 mph)	145	290
Walking (3.5 mph)	140	280
Weight lifting (general light workout)	110	220
Stretching	90	180
Vigorous Physical Activity	Approximate Calories/30 Minutes for a 154 lb Person¹	Approximate Calories/Hr for a 154 lb Person¹
Running/jogging (5 mph)	295	590
Bicycling (>10 mph)	295	590
Swimming (slow freestyle laps)	255	510
Aerobics	240	480
Walking (4.5 mph)	230	460
Heavy yard work (chopping wood)	220	440
Weight lifting (vigorous effort)	220	440
Basketball (vigorous)	220	440
Calories burned per hour will be higher for persons who weigh more than 154 lbs (70 kg) and lower for persons who weigh less. [Source: Adapted from Dietary Guidelines for Americans 2005, page 16, Table 4 ²⁴]

Calories burned by doing dozens of activities listed by category

The table below lists the calories burned by doing dozens of activities listed by category (such as gym activities, training and sports activities, home repair etc.) for 30 minutes. Activities and exercises include walking (casual, race, and everything in between), swimming, jogging, yoga, and even watching TV and sleeping. In each category, activities are listed from least to most calories burned.

	Calories burned in 30-minute activities
Gym Activities	125-pound person	155-pound person	185-pound person
Weight Lifting: general	90	112	133
Aerobics: water	120	149	178
Stretching, Hatha Yoga	120	149	178
Calisthenics: moderate	135	167	200
Riders: general	150	186	222
Aerobics: low impact	165	205	244
Stair Step Machine: general	180	223	266
Teaching aerobics	180	223	266
Weight Lifting: vigorous	180	223	266
Aerobics, Step: low impact	210	260	311
Aerobics: high impact	210	260	311
Bicycling, Stationary: moderate	210	260	311
Rowing, Stationary: moderate	210	260	311
Calisthenics: vigorous	240	298	355
Circuit Training: general	240	298	355
Rowing, Stationary: vigorous	255	316	377
Elliptical Trainer: general	270	335	400
Ski Machine: general	285	353	422
Aerobics, Step: high impact	300	372	444
Bicycling, Stationary: vigorous	315	391	466

Training and Sport Activities
Billiards	75	93	111
Bowling	90	112	133
Dancing: slow, waltz, foxtrot	90	112	133
Frisbee	90	112	133
Volleyball: non-competitive, general play	90	112	133
Water Volleyball	90	112	133
Archery: non-hunting	105	130	155
Golf: using cart	105	130	155
Hang Gliding	105	130	155
Curling	120	149	178
Gymnastics: general	120	149	178
Horseback Riding: general	120	149	178
Tai Chi	120	149	178
Volleyball: competitive, gymnasium play	120	149	178
Walking: 3.5 mph (17 min/mi)	120	149	178
Badminton: general	135	167	200
Walking: 4 mph (15 min/mi)	135	167	200
Kayaking	150	186	222
Skateboarding	150	186	222
Snorkeling	150	186	222
Softball: general play	150	186	222
Walking: 4.5 mph (13 min/mi)	150	186	222
Whitewater: rafting, kayaking	150	186	222
Dancing: disco, ballroom, square	165	205	244
Golf: carrying clubs	165	205	244
Dancing: Fast, ballet, twist	180	223	266
Fencing	180	223	266
Hiking: cross-country	180	223	266
Skiing: downhill	180	223	266
Swimming: general	180	223	266
Walk/Jog: jog <10 min.	180	223	266
Water Skiing	180	223	266
Wrestling	180	223	266
Basketball: wheelchair	195	242	289
Race Walking	195	242	289
Ice Skating: general	210	260	311
Racquetball: casual, general	210	260	311
Rollerblade Skating	210	260	311
Scuba or skin diving	210	260	311
Sledding, luge, toboggan	210	260	311
Soccer: general	210	260	311
Tennis: general	210	260	311
Basketball: playing a game	240	298	355
Bicycling: 12-13.9 mph	240	298	355
Football: touch, flag, general	240	298	355
Hockey: field & ice	240	298	355
Rock Climbing: rappelling	240	298	355
Running: 5 mph (12 min/mile)	240	298	355
Running: pushing wheelchair, marathon wheeling	240	298	355
Skiing: cross-country	240	298	355
Snow Shoeing	240	298	355
Swimming: backstroke	240	298	355
Volleyball: beach	240	298	355
Bicycling: BMX or mountain	255	316	377
Boxing: sparring	270	335	400
Football: competitive	270	335	400
Orienteering	270	335	400
Running: 5.2 mph (11.5 min/mile)	270	335	400
Running: cross-country	270	335	400
Bicycling: 14-15.9 mph	300	372	444
Martial Arts: judo, karate, kickbox	300	372	444
Racquetball: competitive	300	372	444
Rope Jumping	300	372	444
Running: 6 mph (10 min/mile)	300	372	444
Swimming: breaststroke	300	372	444
Swimming: laps, vigorous	300	372	444
Swimming: treading, vigorous	300	372	444
Water Polo	300	372	444
Rock Climbing: ascending	330	409	488
Running: 6.7 mph (9 min/mile)	330	409	488
Swimming: butterfly	330	409	488
Swimming: crawl	330	409	488
Bicycling: 16-19 mph	360	446	533
Handball: general	360	446	533
Running: 7.5 mph (8 min/mile)	375	465	555
Running: 8.6 mph (7 min/mile)	435	539	644
Bicycling: > 20 mph	495	614	733
Running: 10 mph (6 min/mile)	495	614	733

Outdoor Activities
Planting seedlings, shrubs	120	149	178
Raking Lawn	120	149	178
Sacking grass or leaves	120	149	178
Gardening: general	135	167	200
Mowing Lawn: push, power	135	167	200
Operate Snow Blower: walking	135	167	200
Plant trees	135	167	200
Gardening: weeding	139	172	205
Carrying & stacking wood	150	186	222
Digging, spading dirt	150	186	222
Laying sod / crushed rock	150	186	222
Mowing Lawn: push, hand	165	205	244
Chopping & splitting wood	180	223	266
Shoveling Snow: by hand	180	223	266

Home & Daily Life Activities
Sleeping	19	23	28
Watching TV	23	28	33
Reading: sitting	34	42	50
Standing in line	38	47	56
Cooking	75	93	111
Child-care: bathing, feeding, etc.	105	130	155
Food Shopping: with cart	105	130	155
Moving: unpacking	105	130	155
Playing w/kids: moderate effort	120	149	178
Heavy Cleaning: wash car, windows	135	167	200
Child games: hop-scotch, jacks, etc.	150	186	222
Playing w/kids: vigorous effort	150	186	222
Moving: household furniture	180	223	266
Moving: carrying boxes	210	260	311

Home Repair
Auto Repair	90	112	133
Wiring and Plumbing	90	112	133
Carpentry: refinish furniture	135	167	200
Lay or remove carpet/tile	135	167	200
Paint, paper, remodel: inside	135	167	200
Cleaning rain gutters	150	186	222
Hanging storm windows	150	186	222
Paint house: outside	150	186	222
Carpentry: outside	180	223	266
Roofing	180	223	266

Occupational Activities
Computer Work	41	51	61
Light Office Work	45	56	67
Sitting in Meetings	49	60	72
Desk Work	53	65	78
Sitting in Class	53	65	78
Truck Driving: sitting	60	74	89
Bartending/Server	75	93	111
Heavy Equip. Operator	75	93	111
Police Officer	75	93	111
Theater Work	90	112	133
Welding	90	112	133
Carpentry Work	105	130	155
Coaching Sports	120	149	178
Masseur, standing	120	149	178
Construction, general	165	205	244
Coal Mining	180	223	266
Horse Grooming	180	223	266
Masonry	210	260	311
Forestry, general	240	298	355
Heavy Tools, not power	240	298	355
Steel Mill: general	240	298	355
Firefighting	360	446	533

[Source: Harvard University. Harvard Medical School ²⁵]

Exercise and Obesity

The importance of physical activity for weight loss assessed by body weight or BMI is controversial, but physical training leads to a reduction in fat mass and abdominal obesity, in addition to counteracting loss of muscle mass during dieting. Strong evidence exists that physical activity is important for preventing weight gain in general, as well as for maintaining body weight after weight loss.

Weight loss through physical training

A Cochrane Review from 2006 ²⁶ comprising 3476 overweight or obese individuals studied 41 randomized controlled trials and concluded that physical activity alone induced significant weight loss, while physical activity combined with a restricted diet and dietary counseling was more effective. High-intensity physical activity was more effective than moderate activity. The authors defined physical training as “any form of physical exercise that is repeated regularly for a certain period of time”. A prerequisite was that the physical training had to be quantifiable. The physical training intervention mainly consisted of walking, using an exercise bike, jogging, and weight training. In most of the studies, the intensity of the training was greater than 60% of the maximum oxygen uptake/heart rate. The participants exercised most frequently for 40–50 min per session, 3–5 times a week. All of the studies showed that physical exercise induced a slight reduction in body weight and BMI. The combination of exercise and diet resulted in an average greater weight loss and a greater decrease in BMI than diet alone. Without diet, high-intensity physical training (~60% of the maximum oxygen uptake/pulse) led to greater weight loss than low-intensity physical training.

The Cochrane Review showed that physical training for overweight and obese adults had positive effects on both body weight and risk factors for cardiovascular disease. Physical training combined with a restricted diet/dietary counseling reduces body weight slightly but significantly more than a restricted diet/dietary counseling only. Studies with physical training without dietary change showed that high-intensity physical training reduced body weight more than low-intensity physical training. These results are consistent with other meta-analyses ²⁷.

Maintaining body weight through physical exercise

A 2001 meta-analysis ²⁸ comprised six non-randomized studies containing information about the importance of physical activity for maintaining body weight after weight loss. The group of physically active subjects initially lost 21 kg, while the group of physically inactive subjects lost 22 kg. After 2.7 years, the weight loss in the physically active group was 15 and 7 kg for the physically inactive group.

A Danish follow-up study ²⁹ included 118 overweight post-menopausal women who had completed a randomized weight loss intervention in which they were allocated to 12 weeks of diet alone, diet plus physical training or to the control group. The 12 weeks of training had no long-term effect, but a significant effect on body weight and fat mass, if the women continued to exercise on their own.

Observational studies generally indicate that physical activity has a positive effect on maintenance of weight loss after a diet ³⁰. Individuals who increase their level of physical activity after a diet maintain their weight better in some studies ³¹, while other studies cannot demonstrate an effect from physical activity ³². Non-randomized weight loss studies with a prospective follow-up find that individuals with a high level of physical activity gain less weight than individuals who do not exercise ³³. One study found no such correlation ³⁴.

Studies in which participants were randomized to physical training or to a control group ³⁵ (n = 672) assessed the effect of physical activity on maintaining body weight. The patients who exercised had a weight gain of 4.8 kg, while the control group gained 6.0 kg. A number of studies ³⁶ assessed patients (n = 475) who were randomized to a weight reduction program with or without physical training. After 1–2 years, the exercise group had gained 4.8 kg on average, while the control group had gained 6.6 kg. Similar results were confirmed in a 1997 meta-analysis ³⁷, which showed that among 493 moderately overweight individuals, there was an average weight loss of 11 kg after 15 weeks of a restricted diet/counseling or restricted diet/counseling plus training. After 1 year, the restricted diet/counseling group had maintained a weight loss of 6.6 kg, while the restricted diet/dietary counseling plus exercise group had maintained its weight loss of 8.6 kg.

A literature review of 26 articles assessed the independent effects of normal weight vs obesity: fit vs unfit and physically active vs physically inactive. The risk of all-cause mortality and cardiovascular death was lower in individuals with high BMI who were physically fit compared to individuals with normal BMI and a lower level of physical fitness. The literature review, however, could not confirm results from other studies that showed that a high level of physical activity gave the same protection as being physically fit. Individuals with a high BMI and a high level of physical activity had a greater risk of developing type 2 diabetes and cardiovascular disease than those with a normal BMI and low level of physical activity.

There are many possible explanations as to why physical fitness and not a high level of physical activity protect against the serious health consequences of overweight and obesity. Information on physical activity in most studies is based on self-reported information, which is subject to considerable inaccuracy, while fitness is an objective measure. Another possible explanation is that primarily physical activity of high intensity leads to improved fitness and thereby protection against diseases associated with obesity ³⁸.

Obesity is often associated with hypertension, hypercholesterolemia, hypertriglyceridemia, and insulin resistance. The effect of physical training on these risk markers is described separately on pages 14, 16 and 26. Obesity is also frequently associated with erectile dysfunction, which physical training can contribute to prevent ³⁹.

How Much Activity Do People Need to Prevent Weight Gain?

Weight gain during adulthood can increase the risk of heart disease, diabetes, and other chronic conditions. Since it’s hard for people to lose weight and keep it off, it’s better to prevent weight gain in the first place. Encouragingly, there’s strong evidence that staying active can help people slow down or stave off “middle-age spread” ⁴⁰. The more active people are, the more likely they are to keep their weight steady ⁴¹; the more sedentary, the more likely they are to gain weight over time ⁴². But it’s still a matter of debate exactly how much activity people need to avoid gaining weight. The latest evidence suggests that the recommended two and a half hours a week may not be enough.

The Women’s Health Study, for example, followed 34,000 middle-age women for 13 years to see how much physical activity they needed to stay within 5 pounds of their weight at the start of the study. Researchers found that women in the normal weight range at the start needed the equivalent of an hour a day of moderate-to-vigorous physical activity to maintain a steady weight ⁴³.

Vigorous activities seem to be more effective for weight control than slow walking ⁴⁴, ⁴⁵. The Nurses’ Health Study II ⁴⁶, for example, followed more than 18,000 women for 16 years to study the relationship between changes in physical activity and weight. Although women gained, on average, about 20 pounds over the course of the study, those who increased their physical activity by 30 minutes per day gained less weight than women whose activity levels stayed steady. And the type of activity made a difference: Bicycling and brisk walking helped women avoid weight gain, but slow walking did not.

How Much Activity Do People Need to Lose Weight?

Exercise can help promote weight loss, but it seems to work best when combined with a lower calorie eating plan ⁴⁷. If people don’t curb their calories, however, they likely need to exercise for long periods of time-or at a high intensity-to lose weight ⁴⁸, ⁴⁹.

In one study ⁴⁸, for example, researchers randomly assigned 175 overweight, inactive adults to either a control group that did not receive any exercise instruction or to one of three exercise regimens-low intensity (equivalent to walking 12 miles/week), medium intensity (equivalent to jogging 12 miles/week), or high intensity (equivalent to jogging 20 miles per week). All study volunteers were asked to stick to their usual diets. After six months, those assigned to the high-intensity regimen lost abdominal fat, whereas those assigned to the low- and medium-intensity exercise regimens had no change in abdominal fat ⁴⁸.

More recently, researchers conducted a similar trial with 320 post-menopausal women ⁵⁰, randomly assigning them to either 45 minutes of moderate-to-vigorous aerobic activity, five days a week, or to a control group. Most of the women were overweight or obese at the start of the study. After one year, the exercisers had significant decreases in body weight, body fat, and abdominal fat, compared to the non-exercisers ⁵⁰.

The Bottom Line

For Weight Control, Aim for an Hour of Activity a Day

Being moderately active for at least 30 minutes a day on most days of the week can help lower the risk of chronic disease. But to stay at a healthy weight, or to lose weight, most people will need more physical activity-at least an hour a day-to counteract the effects of increasingly sedentary lifestyles, as well as the strong societal influences that encourage overeating.

Keep in mind that staying active is not purely an individual choice: The so-called “built environment”-buildings, neighborhoods, transportation systems, and other human-made elements of the landscape-influences how active people are ⁵¹. People are more prone to be active, for example, if they live near parks or playgrounds, in neighborhoods with sidewalks or bike paths, or close enough to work, school, or shopping to safely travel by bike or on foot. People are less likely to be active if they live in sprawling suburbs designed for driving or in neighborhoods without recreation opportunities.

Local and state governments wield several policy tools for shaping people’s physical surroundings, such as planning, zoning, and other regulations, as well as setting budget priorities for transportation and infrastructure. Strategies to create safe, active environments include curbing traffic to make walking and cycling safer, building schools and shops within walking distance of neighborhoods, and improving public transportation, to name a few. Such changes are essential to make physical activity an integral and natural part of people’s everyday lives-and ultimately, to turn around the obesity epidemic.

How much exercise do you need for general good health?

For general good health, the 2008 Physical Activity Guidelines for Americans ⁵² recommends that adults get a minimum of 2-1/2 hours per week of moderate-intensity aerobic activity. Yet many people may need more than 2-1/2 hours of moderate intensity activity a week to stay at a stable weight ⁵².

The Women’s Health Study ⁵³, for example, followed 34,000 middle-aged women for 13 years to see just how much physical activity they needed to stay within 5 pounds of their weight at the start of the study. Researchers found that women who were in the normal weight range at the start of the study needed the equivalent of an hour a day of physical activity to stay at a steady weight ⁵³.

If you are exercising mainly to lose weight, 60 minutes or so a day may be effective in conjunction with a healthy diet ⁵⁴.

If you currently don’t exercise and aren’t very active during the day, any increase in exercise or physical activity is good for you.

Aerobic physical activity—any activity that causes a noticeable increase in your heart rate—is especially beneficial for disease prevention.

Some studies show that walking briskly for even one to two hours a week (15 to 20 minutes a day) starts to decrease the chances of having a heart attack or stroke, developing diabetes, or dying prematurely.

You can combine moderate and vigorous exercise over the course of the week, and it’s fine to break up your activity into smaller bursts as long as you sustain the activity for at least 10 minutes.

Exercise Intensity

Moderate-intensity aerobic activity is any activity that causes a slight but noticeable increase in breathing and heart rate. One way to gauge moderate activity is with the “talk test”—exercising hard enough to break a sweat but not so hard you can’t comfortably carry on a conversation.

Vigorous-intensity aerobic activity causes more rapid breathing and a greater increase in heart rate, but you should still be able to carry on a conversation—with shorter sentences.

For moderate-intensity physical activity, your target heart rate should be between 64% and 76% of your maximum heart rate ⁵⁵, ⁵⁶. You can estimate your maximum heart rate based on your age. To estimate your maximum age-related heart rate, subtract your age from 220. For example, for a 50-year-old person, the estimated maximum age-related heart rate would be calculated as 220 – 50 years = 170 beats per minute (bpm). The 64% and 76% levels would be:

64% level: 170 x 0.64 = 109 bpm, and
76% level: 170 x 0.76 = 129 bpm

This shows that moderate-intensity physical activity for a 50-year-old person will require that the heart rate remains between 109 and 129 bpm during physical activity.

Most moderate activities can become vigorous if you increase your effort.

Examples of moderate intensity activities:

brisk walking
water aerobics
riding a bike
dancing
doubles tennis
pushing a lawn mower
hiking
rollerblading

For vigorous-intensity physical activity, your target heart rate should be between 77% and 93% of your maximum heart rate ⁵⁵, ⁵⁶. You can estimate your maximum heart rate based on your age. To estimate your maximum age-related heart rate, subtract your age from 220. For example, for a 35-year-old person, the estimated maximum age-related heart rate would be calculated as 220 – 35 years = 185 beats per minute (bpm). The 77% and 93% levels would be:

77% level: 185 x 0.77 = 142 bpm, and
93% level: 185 x 0.93 = 172 bpm

This shows that vigorous-intensity physical activity for a 35-year-old person will require that the heart rate remains between 142 and 172 bpm during physical activity.

In general, 75 minutes of vigorous intensity activity can give similar health benefits to 150 minutes of moderate intensity activity.

Examples of vigorous activities:

jogging or running
swimming fast
riding a bike fast or on hills
walking up the stairs
sports, like football, rugby, netball and hockey
skipping rope
aerobics
gymnastics
martial arts

Here is a summary of the 2008 Physical Activity Guidelines for Americans ⁵²

Children and adolescents should get at least 1 hour or more a day of physical activity in age-appropriate activities, spending most of that engaged in moderate- or vigorous–intensity aerobic activities. They should partake in vigorous-intensity aerobic activity on at least three days of the week, and include muscle-strengthening and bone strengthening activities on at least three days of the week.

Healthy adults should get a minimum of 2-1/2 hours per week of moderate-intensity aerobic activity, or a minimum of 1-1/4 hours per week of vigorous-intensity aerobic activity, or a combination of the two. That could mean a brisk walk for 30 minutes a day, five days a week; a high-intensity spinning class one day for 45 minutes, plus a half hour jog another day; or some other combination of moderate and vigorous activity. Doubling the amount of activity (5 hours moderate- or 2-1/2 hours vigorous-intensity aerobic activity) provides even more health benefits. Adults should also aim to do muscle-strengthening activities at least two days a week.

Healthy older Adults should follow the guidelines for healthy adults. Older adults who cannot meet the guidelines for healthy adults because of chronic conditions should be as physically active as their abilities and conditions allow. People who have chronic conditions such as arthritis and type 2 diabetes should talk to a healthcare provider about the amount and type of activity that is best. Physical activity can help people manage chronic conditions, as long as the activities that individuals choose match their fitness level and abilities. Even just an hour a week of activity has health benefits. Older adults who are at risk of falling should include activities that promote balance.

Strength training for all ages

Studies have shown strength training to increase lean body mass, decrease fat mass, and increase resting metabolic rate (a measurement of the amount of calories burned per day) in adults ⁵⁷. While strength training on its own typically does not lead to weight loss ⁵², its beneficial effects on body composition may make it easier to manage one’s weight and ultimately reduce the risk of disease, by slowing the gain of fat—especially abdominal fat ⁵⁸.

Muscle is metabolically active tissue; it utilizes calories to work, repair, and refuel itself. Fat, on the other hand, doesn’t use as much energy. We slowly lose muscle as part of the natural aging process, which means that the amount of calories we need each day starts to decrease, and it becomes easier to gain weight.
Strength training regularly helps preserve lean muscle tissue and can even rebuild some that has been lost already.
Weight training has also been shown to help fight osteoporosis. For example, a study in postmenopausal women examined whether regular strength training and high-impact aerobics sessions would help prevent osteoporosis. Researchers found that the women who participated in at least two sessions a week for three years were able to preserve bone mineral density at the spine and hip; over the same time period, a sedentary control group showed bone mineral density losses of 2 to 8 percent ⁵⁹.
In older populations, resistance training can help maintain the ability to perform functional tasks such as walking, rising from a chair, climbing stairs, and even carrying one’s own groceries. An emerging area of research suggests that muscular strength and fitness may also be important to reducing the risk of chronic disease and mortality, but more research is needed ⁶⁰, ⁶¹.
A systematic review of 8 studies ⁶² examining the effects of weight-bearing and resistance-based exercises on the bone mineral density in older men found resistance training to be an effective strategy for preventing osteoporosis in this population. Resistance training was found to have more positive effects on bone mineral density than walking, which has a lower impact ⁶².

The Physical Activity Guidelines for Americans recommends that muscle strengthening activities be done at least two days a week ⁵². Different types of strength training activities are best for different age groups.

When talking about the benefits of exercise, keeping the heart and blood vessels healthy usually gets most of the attention. For many individuals, though, stretching and strength training exercises may be just as important.
Strength training, also known as resistance training, weight training, or muscle-strengthening activity, is one of the most beneficial components of a fitness program.

Children and Adolescents: Choose unstructured activities rather than weight lifting exercises ⁵².

Examples:

Playing on playground equipment
Climbing trees
Playing tug-of-war

Active Adults: Weight training is a familiar example, but there are other options ⁵²:

Calisthenics that use body weight for resistance (such as push-ups, pull-ups, and sit-ups)
Carrying heavy loads
Heavy gardening (such as digging or hoeing)

Older Adults: The guidelines for older adults are similar to those for adults; older adults who have chronic conditions should consult with a health care provider to set their activity goals. Muscle strengthening activities in this age group include the following ⁵²:

Digging, lifting, and carrying as part of gardening
Carrying groceries
Some yoga and tai chi exercises
Strength exercises done as part of a rehab program or physical therapy

Flexibility training

Flexibility training or stretching exercise is another important part of overall fitness. It may help older adults preserve the range of motion they need to perform daily tasks and other physical activities ⁶³.

The American Heart Association ⁵⁷ recommends that healthy adults engage in flexibility training two to three days per week, stretching major muscle and tendon groups.
For older adults, the American Heart Association and American College of Sports Medicine recommend two days a week of flexibility training, in sessions at least 10 minutes long ⁶³. Older adults who are at risk of falling should also do exercises to improve their balance.

Exercise and Hyperlipidemia

Hyperlipidemia is a group of disorders of lipoprotein metabolism entailing elevated blood levels of certain forms of cholesterol and triglyceride. Primary hyperlipidemia caused by environmental and genetic factors are by far the most frequent, accounting for 98% of all cases. Isolated hypercholesterolemia and combined dyslipidemia are the most frequent types of dyslipidemia, and are due to excessive intake of fat in most people. These types of dyslipidemia entail an elevated risk of atherosclerosis. There is consensus that physical activity protects against the development of cardiovascular diseases ⁶⁴, ⁶⁵ and it has been suggested that one of many mechanisms could be a positive effect of exercise on the lipid profile of the blood ⁶⁶. Epidemiological studies indicate that physical activity prevents hyperlipidemia ⁶⁷.

Today, evidence shows that a large volume of physical training, independent of weight loss, has a beneficial effect on the lipid profile of the blood. A number of review articles summarize this knowledge ⁶⁸.

A 2007 meta-analysis studied the effect of training on high-density lipoprotein (HDL) cholesterol. The analysis included 25 randomized controlled trials. The training comprised walking, cycling or swimming ⁶⁹. Training had a significant but moderate effect on HDL cholesterol. The minimum amount of physical activity needed to cause an effect was 120 min of physical activity weekly or an energy expenditure equivalent to 3780 kJ. The duration of the physical activity was more important than its intensity. Each time the duration of the physical activity was increased by 10 min, the HDL cholesterol level increased on average by 1.4 mg/dL (0.036 mmol/L).

The average effect of physical activity on HDL is clinically relevant, albeit somewhat smaller than the effect achieved when using drugs that lower lipid levels ⁷⁰. It is estimated that each time HDL increases 0.025 mmol/L, the cardiovascular risk goes down by 2% for men and by at least 3% for women ⁷¹. Training induced a mean increase of 0.036 mmol/L in the level of HDL. For the subgroup of individuals with a BMI of less than 28 and a total cholesterol level over 5.7 mmol/L, it was found that exercise induced an increase of 0.054 mmol/L in the level of HDL ⁷². For the latter group, physical training was thus able to reduce the cardiovascular risk by about 4% for men and by 6% for women.

A review article from 2014 ⁶⁸ includes 13 published investigations and two review articles and conclude that both aerobic, resistance exercise and the combination of aerobic and resistance training have impact on cholesterol levels and blood lipids.

A randomized clinical controlled trial evaluated the effect of training volume and intensity in a study comprising 111 physically inactive overweight men with mild to moderate hyperlipidemia ⁷². The subjects were randomized to a control group or 8 months of high-volume/high-intensity physical training [32 km/week at 65–80% maximum oxygen uptake (VO2max)]; low volume/high intensity (19 km/week at 65–80% of VO2max) or low volume/low intensity (19 km/week at 40–55% of VO2max). This study distinguishes itself by evaluating an extensive lipid profile in which the size of the lipid–protein particles is also included. Subjects were asked to maintain their weight and individuals with excessive weight loss were excluded. Despite this, there was a small but significant amount of weight loss in the training groups. All of the training groups achieved a positive effect on their lipid profile compared to the control group, but there was no significant difference in the effect of training in the two groups with a low volume of exercise, although the high-intensity group achieved a greater improvement in fitness. There is a significantly better effect from a high volume of physical training on virtually all lipid parameters, although the two groups with high-intensity training achieved the same improvement in fitness level. There was no effect on the total cholesterol level. High-volume/high-intensity training reduced the level of low-density lipoprotein (LDL), intermediate-density lipoprotein (IDL), and small LDL particles and increased the size of the LDL particles and the level of HDL. All of the groups had a positive effect on the level of triglyceride, VLD triglyceride, and the size of VLDL. Thus, the volume of training had clear effects, but the intensity of the training had less impact.

A 2010 meta-analysis compared 13 randomized controlled trials that examined the effect of resistance training on parameters related to metabolic syndrome. Resistance training showed a significant effect on obesity, HbA1c, and systolic blood pressure, but no effect on total cholesterol, HDL cholesterol, or LDL cholesterol ⁷³.

A 2012 systematic review ⁷⁴ assessed the effect of supervised exercise interventions on lipid profiles and blood pressure control in patients with type 2 diabetes. Forty-two RCTs (2808 subjects) met inclusion criteria and were included in the meta-analysis. It was concluded that supervised exercise is effective in improving blood pressure control, lowering LDL-C, and elevating HDL-C levels in people with diabetes.

Exercise and Metabolic syndrome

Metabolic syndrome is also known as insulin resistance syndrome, as one of the traits of the disorder is reduced insulin activity. There are several definitions for metabolic syndrome but it encompasses abdominal obesity, insulin resistance, hypertension, and hyperlipidemia.

The International Diabetes Federation ⁷⁵ defines metabolic syndrome as follows:

Abdominal obesity, i.e., waist circumference ≥94 cm for men and ≥80 cm for women, plus at least two of the following four risk factors:

Plasma concentration of triglycerides	≥1.7 mmol/L
Plasma concentration of HDL cholesterol	<1.0 mmol/L for men and <1.2 mmol/L for women
Blood pressure	Systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥85 mmHg or receiving antihypersensitive therapy
Plasma concentration of glucose (fasting)	≥5.6 mmol/L or type 2 diabetes

Metabolic syndrome rarely occurs in people with normal weight but it can occur and there is a higher incidence among members of the Pakistani and Turkish ethnic minorities than members of the general population with the same BMI. Metabolic syndrome is a precursor of type 2 diabetes and large-scale epidemiological studies show that physical activity can prevent the onset of metabolic syndrome ⁷⁶.

Physical exercise and insulin resistance/prevention of type 2 diabetes

A 2008 Cochrane Review ⁷⁷ assessed the effect of a combination of diet and physical exercise as prophylaxis against type 2 diabetes. Physical exercise varied from a recommended increase in daily physical activity to supervised physical training of varying intensity and up to several times a week. Most programs included walking, running, or cycling at different intensities. The diets were low calorie with reduced fat and high fiber.

The participants in the analysis had a pathological glucose tolerance and/or metabolic syndrome. The analysis included eight trials with 2241 participants in one group, who were prescribed physical activity and placed on a diet as described above, and 2509 control persons. The studies ran over a period of 1 and 6 years. Exercise and diet significantly lowered the risk of type 2 diabetes. A significant impact on body weight, BMI, waist-to-hip ratio, and waist circumference was also identified, as was a moderate impact on blood lipids. The intervention had a marked effect on both systolic and diastolic blood pressure ⁷⁷.

The isolated effect of exercise alone as prevention against diabetes in patients with pathological glucose tolerance is sparsely documented but there is solid evidence pointing to the effect of combined physical exercise and diet. A Chinese study divided 577 people with pathological glucose tolerance into four groups: diet, exercise, diet + exercise and control, and monitored them over 6 years ⁷⁸. The risk of diabetes fell by 31% in the diet group, by 46% in the exercise group, and by 42% in the diet + exercise group.

In a Swedish study, 6956 men aged 48 were given a health check-up. Those with pathological glucose tolerance were divided into two groups: (a) exercise + diet (n = 288) and (b) no intervention (n = 135) ⁷⁹ and were monitored over 12 years. The mortality rate was the same in the intervention group as among the healthy control group (6.5% vs 6.2%) and lower than in the group with pathological glucose tolerance, which did not exercise (6.5% vs 14%). Thus, among all the participants with pathological glucose tolerance there was a predictive effect of intervention but not a predictive effect of BMI, blood pressure, smoking, cholesterol, or glucose level.

Two randomized controlled trials included people with pathological glucose tolerance and found that changes in lifestyle protected against development of type 2 diabetes. A Finnish study randomized 522 overweight middle-aged men and women with pathological glucose tolerance to physical exercise and diet or control ⁸⁰ and monitored them over 3.2 years. The lifestyle intervention consisted of individual counseling on reduction of calorie intake, reduction of fat intake, and an increase in fiber-rich foods and daily physical activity. The risk of type 2 diabetes fell by 58% in the intervention group. The greatest effect was recorded with the patients who underwent the most extensive lifestyle changes ⁸¹.

An American study randomized 3234 people with pathological glucose tolerance to either treatment with metformin or a lifestyle program involving moderate physical activity in the form of at least 150 min of brisk walking a week and a reduced-calorie diet or no intervention. The subjects were monitored over 2.8 years ⁸². The lifestyle intervention group had a 58% lower risk of contracting type 2 diabetes. Thus, the reduction matched the findings in the Finnish study ⁸⁰, while the metformin treatment only reduced the risk of diabetes by 31%. As can be seen, it is not formally possible to assess the isolated effect of exercise with respect to diet in three of the studies mentioned ⁸², but the intervention group experienced only a moderate weight loss.

In the Finnish study, weight loss after 2 years was 3.5 kg in the intervention group vs 0.8 kg in the control group ⁸⁰. The intervention group thus experienced a drop in BMI from around 31 to around 30 in the Finnish study ⁸⁰ and from 34 to 33 in the American study ⁸².

Physical exercise and abdominal obesity

Visceral fat constitutes an independent risk factor for developing heart disease. A cross-sectional study showed that overweight men with a high level of fitness have a significantly lower visceral fat than overweight men with a poor level of fitness ⁸³.

A group of young, healthy, normal weight men who normally walked 10 000 paces every day reduced their paces to 1500 per day over a period of 2 weeks. They experienced a significant rise in volume of visceral fat (7%) despite a total average weight loss of 1.2 kg ⁸⁴.

Irrespective of other fat deposits, abdominal obesity is a major risk factor for hyperlipidemia ⁸⁵, lower glucose tolerance ⁸⁶, insulin resistance ⁸⁷, systemic inflammation ⁸⁸, hypertension ⁸⁹, type 2 diabetes ⁹⁰, and all-cause mortality ⁹¹. There is a link between regular physical activity, with or without weight loss, and reduction in visceral fat volume ⁹².

Increasing physical activity to 60 min/day over 3 months has been found to reduce visceral fat volume by about 30%. It should be emphasized, however, that changes in visceral fat volume as a response to physical exercise vary considerably and that it is not possible to identify a clear correlation between amount of physical exercise and reduction in visceral fat.

In relation to reduction of visceral fat tissue deposits, however, no specific method exists (surgery, diet, physical activity, etc.) for achieving this. Intervention-induced reduction of visceral fat tissue deposits relates to reduction of the total volume of fat tissue and the initial ratio of volume of visceral fat tissue to volume of total fat, regardless of how the reduction in fat tissue is achieved.

Studies have shown that an increase in daily physical activity leads to a significant reduction in quantity of visceral fat and/or abdominal circumference, despite no or minimal alteration in total body weight. Thus, studies on people with type 2 diabetes show that 2–3 months of regular moderate-intensity aerobic training leads to a significant reduction in quantity of visceral fat. There is a corresponding finding for healthy, normal weight pre-menopausal women, healthy, middle-aged men and HIV-positive men with lipodystrophy.

Middle-aged, normal weight or overweight men, and overweight women can expect to see a reduction in visceral fat volume (−10 to −19%) after 3 months of regular physical activity. These results also apply to older, overweight individuals (60–80 years). As a result of exercise, either strength or stamina training for 80 min a week, test subjects did not accumulate visceral fat after dieting and losing weight, while the control group that did not exercise increased their volume of visceral fact by 38%.

Exercise and Type 2 diabetes

The positive gains from physical exercise for patients with type 2 diabetes are very well documented and there is an international consensus that physical exercise is one of the three cornerstones in the treatment of diabetes, along with diet and medication ⁹³.

Several reviews ⁹⁴ report that increased physical exercise produce a significant improvement in glucose control in people with type 2 diabetes, yielding an average improvement in hemoglobin A1c (HbA1c) of between −0.4% and −0.6%.

A 2006 Cochrane Review, which includes 14 randomized controlled trials with a total of 377 patients with type 2 diabetes, compares the independent effect of training with no training ⁹⁵. The training interventions were 8–10 months in length and consisted of progressive aerobic training, strength training or a combination of the two, with typically three training sessions per week. Compared to the control group, the training interventions showed a significant improvement in glycemic control in the form of a reduction in HbA1c (glycated hemoglobin) of 0.6%. By comparison, intensive glycemic control using metformin showed a reduction in HbAc1 of 0.6%, and a risk reduction of 32% for diabetes-related complications and of 42% for diabetes-related mortality ⁹⁶.

Despite the clear effect of exercise training on metabolic control, there was no significant effect on body weight. The reason for this is presumably that the exercise group reduced fat mass but increased muscle mass. One of the studies in the meta-analysis reported an increase in fat-free mass of 6.3 kg, measured by dual energy X-ray absorptiometry (DXA) scanning, and a reduction in visceral fat volume, measured in by magnetic resonance imaging (MRI) scanning, of −45.5 cm2. No adverse effects of physical exercise were reported.

Physical exercise significantly reduced insulin response as an expression of increased insulin sensitivity and triglyceride levels. This Cochrane Review found no significant difference with regard to quality of life, plasma cholesterol, or blood pressure ⁹⁵. The findings from the Cochrane Review ⁹⁵ agree with the conclusions from a 2001 meta-analysis, which also evaluated the impact of a minimum 8-week training program on glycemic control ⁹⁷. Training was found to have no effect on body weight ⁹⁷. There are several possible explanations for this: the training period was relatively short, the patients over-compensated for their loss of energy by eating more, or patients lost fat but their volume of fat-free mass increased. There is reason to assume that the final explanation is the most significant one. It is well-known that physically inactive people who start to exercise increase their fat-free mass ⁹⁸. Only one of the studies included in the meta-analysis assessed abdominal obesity using MRI scanning ⁹⁹. The aerobic training program (55 min three times a week over 10 weeks) resulted in a reduction of abdominal subcutaneous fat, measured using MRI scanning and visceral fat. The same study did not identify any effect from exercise on body weight.

A 2007 meta-analysis assessed the effect of self-management interventions with a view to increasing physical activity levels in patients with type 2 diabetes. The analysis involved 103 trials with 10 455 subjects. Self-management training was found to have a significant effect of 0.45% on HbA1c.

Interventions that included several different lifestyle recommendations such as diet and physical activity had less effect than interventions that included physical exercise only. Basic levels of HbA1c and BMI were not related to metabolic effect. The overall conclusion is that self-management interventions that include physical activity increase metabolic control ¹⁰⁰.

A 2009 systematic review included nine studies with 372 patients with type 2 diabetes. Progressive resistance training vs no training induced a statistically significant reduction in HbA1c of 0.3%. There was no difference between resistance training and aerobic training as far as the effect on changes in HbA1c was concerned. Progressive resistance training resulted in large improvements in strength compared to aerobic training or no training. No significant effect on body composition was found ¹⁰¹.

A meta-analysis from 2013 found that exercise lowers postprandial glucose but not fasting glucose in type 2 diabetes ¹⁰². A 2007 meta-analysis evaluated the effect of aerobic physical training for a minimum of 8 weeks on lipids and lipoproteins in patients with type 2 diabetes. The analysis included seven trials with 220 men and women, of which 112 were in a training group and 108 in a control group. A statistically significant reduction of approximately 5% in LDL cholesterol was found but there was no significant effect with regard to triglycerides, HDL cholesterol, or total cholesterol ¹⁰³.

A 2011 meta-analysis concluded that structured exercise training that consists of aerobic exercise, resistance training, or both combined is associated with HbA1c reduction in patients with type 2 diabetes. Structured exercise training of more than 150 min/week is associated with greater HbA1c declines than that of 150 min or less per week. Physical activity advice is associated with lower HbA1c, but only when combined with dietary advice ⁹⁴.

A systematic review and meta-analysis from 2014 compared resistance exercise and aerobic exercise and concluded that there was no evidence that resistance exercise differs from aerobic exercise in impact on glucose control, cardiovascular risk markers or safety. Using one or the other type of exercise for type 2 diabetes may be less important than doing some form of physical activity ¹⁰⁴.

Measures of fasting glucose and HbA1c do not accurately represent glycemic control because they do not reflect what occurs after meals and throughout the day in the free-living condition ¹⁰⁵. An accumulating body of evidence now suggests that postprandial glucose fluctuations are more tightly correlated with microvascular and macrovascular morbidities and cardiovascular mortality than HbA1c or fasting glucose, stagnant measure of glycemia. It is therefore important that unlike medications, which generally have a poor effect at improving postprandial glucose, exercise has been proven effective in reducing postprandial glycemic excursions in as little as a few days ¹⁰⁵.

Effect on fitness and muscle strength

Poor fitness is an independent prognostic marker for death in patients with type 2 diabetes ¹⁰⁶. A meta-analysis ¹⁰⁷ assesses the effect of a minimum of 8 weeks of physical training on maximum oxygen uptake (VO2max). The analysis involved 266 patients with type 2 diabetes. Average training quantity was 3.4 sessions/week, each lasting 49 min; intensity was 50–75% of maximum pulse; the length of the interventions was in average 20 weeks. Altogether, there was an 11.8% increase in VO2max in the training group vs a drop of 1% in the control group.

Older patients with type 2 diabetes (n = 31) were randomized to a 24-month resistance training program. Average increase in muscle strength was 31% in the exercise group, while no effect on muscle strength was identified in the control group ¹⁰⁸. Patients with type 2 diabetes can thus adapt to training with regard to both fitness and muscle strength.

There was a more striking impact on fitness when the physical exercise was supervised, was done in groups and took place over a long period. There was no correlation between level of fitness improvement and HbA1c, age, BMI, or sex ¹⁰⁹.

Effect on mortality

The Look AHEAD study included 16 centers in the United States, and randomly assigned 5145 overweight or obese patients with type 2 diabetes to participate in an intensive lifestyle intervention that promoted weight loss through decreased caloric intake and increased physical activity (intervention group) or to receive diabetes support and education (control group). The trial was stopped early on the basis of a futility analysis when the median follow-up was 9.6 years as the intervention did not reduce the rate of cardiovascular events in overweight or obese adults with type 2 diabetes. It is noteworthy that although weight loss was greater in the intervention group than in the control group, there was only an initial improvement in fitness and only when related to weight loss. The exercise training was not supervised and it appears that the intervention actually had very little effect on physical fitness ¹¹⁰.

Exercise and Type 1 diabetes

Type 1 diabetes is an autoimmune disease that occurs in children or adults. The disease is caused by the destruction of beta cells in the pancreas, which stops production of insulin. The etiology is still unknown, but environmental factors (e.g., viruses and chemicals), genetic disposition and autoimmune reactions all play a part.

Patients with type 1 diabetes have a high risk of developing cardiovascular disease ¹¹¹, and physical activity offers good prevention ¹¹². It is therefore important for patients with type 1 diabetes to be physically active on a regular basis. Insulin requirement decreases during physical activity, which is why patients must reduce their insulin dose if they plan to do physical training ¹¹³ and/or ingest carbohydrates in connection with training ¹¹⁴. Patients with type 1 diabetes thus need guidance on how to avoid hypoglycemia so that they, like others, can benefit from the positive effects of physical activity against other diseases.

A systematic review from 2014 analyzed physical activity interventions in children and young people with Type 1 diabetes mellitus. A total of 26 articles (10 randomized and 16 non-randomized studies), published in the period 1964–2012, were reviewed. Meta-analyses showed potential benefits of physical activity on HbA1c, BMI, triglycerides, and cholesterol ¹¹⁵.

There are relatively few studies that shed light on the specific impact of training in patients with type 1 diabetes, but in general little or no difference in glycemic control can be identified in patients with type 1 diabetes who are physically active compared to those who are inactive ¹¹⁶. Some studies find no improvement in HbA1c with physical training ¹¹⁷, whereas other find that the most physically active patients have the lowest HbA1c ¹¹⁸.

A large study included 4655 patients and found an inverse dose–response association was found between physical activity level and HbA1c ¹¹⁸. Another study showed that intense physical activity was associated with better metabolic control in patients with type 1 diabetes.

An observational, cross-sectional study included 130 adult patients with type 1 diabetes. The study found no differences in HbA1c levels in relation to time dedicated to moderate physical activities. However, patients who dedicated more than 150 min/week to intense physical activity had lower levels of HbA1c (HbA1c: 7.2 ± 1.0% vs 7.8 ± 1.1% vs 8.0 ± 1.0% in more than 149 min, between 0 and 149 min or 0 min of intense physical activity per week, respectively) ¹¹⁹.

On the other hand patients with type 1 diabetes – like non-diabetics – improve insulin sensitivity ¹²⁰, which is associated with a lower (ca. 5%) reduction in the exogenous insulin requirements ¹²¹. Endothelial dysfunction is a trait of some ¹²², though not all ¹²³, patients with type 1 diabetes, and the effect of physical training on this parameter is only sparsely illuminated. Endothelial function has been found to be both improved ¹²⁴ and unchanged ¹¹⁶ after physical training.

Physical training possibly has a positive impact on the lipid profile, also in patients with type 1 diabetes. Controlled studies show that training reduces the level of LDL cholesterol and triglycerides in the blood ¹²⁵ and increases the level of HDL cholesterol ¹²⁵ and HDL cholesterol/total cholesterol ratio ¹²⁰. The ratio, however, has not been thoroughly investigated and there might also be a difference between the sexes ¹²⁶. In uncontrolled or cross-sectional trials a link has been found between training and an increase in HDL2 cholesterol and a decrease in serum triglyceride and LDL cholesterol ¹²⁷.

A randomized controlled trial examined the effect of 30–60 min of running at a moderate intensity 3–5 times a week over 12–16 weeks. The study included young men with type 1 diabetes (n = 28 and the control group n = 28). Aerobic training increased fitness, exercise capacity, and improved lipid profile ¹²⁵. A controlled study showed that 4 months of aerobic training increased fitness by 27%, reduced insulin requirement ¹²⁸, and improved endothelial function ¹²⁹ in patients with type 1 diabetes.

Exercise and Hypertension

Hypertension is a significant risk factor for stroke, acute myocardial infarction, heart failure, and sudden death. The borderline between low and normal blood pressure is fuzzy, as the incidence of these cardiovascular diseases already rises from a relatively low blood pressure level. A meta-analysis involving 61 prospective studies (1 million people) showed a linear relationship between decrease in the risk of cardiovascular mortality and decrease in blood pressure to a systolic blood pressure of below 115 mmHg and a diastolic blood pressure of below 75 mmHg ¹³⁰. A decrease of 20 mmHg in systolic blood pressure or 10 mmHg in diastolic blood pressure halves the risk of cardiovascular mortality. Thus, for example, a person with systolic blood pressure of 120 mmHg has half the risk of cardiovascular mortality as a person with systolic blood pressure of 140 mmHg ¹³⁰. Hypertension is defined as systolic blood pressure >140 and diastolic blood pressure >90 mmHg. According to this definition, about 20% of the population have high blood pressure or require blood pressure-lowering medication ¹³¹. However, the borderlines between optimal and normal blood pressure and between mild, moderate, and severe hypertension are arbitrary ¹³¹. Large-scale epidemiological studies indicate that regular physical exercise and/or fitness prevents hypertension or lowers blood pressure ¹³².

Effect on resting blood pressure (normotensive and hypertensive)

Several meta-analyses have concluded that physical exercise has a positive effect on blood pressure in both normotensive and hypertensive cases ¹³³.

A meta-analysis included randomized controlled trials lasting ≥4 weeks investigating the effects of exercise on blood pressure in healthy adults (age ≥18 years) ¹³⁴.

The study included 93 trials, involving 105 endurance, 29 dynamic resistance, 14 combined, and 5 isometric resistance groups, totaling 5223 participants (3401 exercise and 1822 control). Systolic BP (SBP) was reduced after endurance (−3.5 mmHg), dynamic resistance (−1.8 mmHg), and isometric resistance (−10.9 mmHg) but not after combined training. Reductions in diastolic BP (DBP) were observed after endurance (−2.5 mmHg), dynamic resistance (−3.2 mmHg), isometric resistance (−6.2 mmHg), and combined (−2.2 mmHg) training. BP reductions after endurance training were greater in 26 study groups of hypertensive subjects (−8.3 mmHg) than in 50 groups of pre-hypertensive subjects (−2.1) and 29 groups of subjects with normal BP levels (−0.75). BP reductions after dynamic resistance training were largest for pre-hypertensive participants (−4.0 mmHg) compared with patients with hypertension or normal BP. It was concluded that endurance, dynamic resistance, and isometric resistance training lower SBP and DBP, whereas combined training lowers only DBP. Data from a small number of isometric resistance training studies suggest this form of training has the potential for the largest reductions in SBP.

A meta-analysis from 2010 focused specifically on the effect of isometric exercise, which has not traditionally been recommended as an alternative to dynamic exercise ¹³⁵. Five trials were identified including a total of 122 subjects. Isometric exercise for <1 h/week reduced systolic blood pressure by 10.4 mmHg and diastolic blood pressure by 6.7 mmHg. Also this study found that isometric exercise induces changes in blood pressure that are similar to that of endurance or dynamic resistance training and similar to those achieved with a single pharmacological agent. Interestingly, a smaller study suggested that even handgrip exercise had effect on blood pressure-lowering effects ¹³⁶.

Another meta-analysis from 2013 included aerobic exercise training studies among previously sedentary older adults ¹³⁷. Twenty-three studies, representing a total of 1226 older subjects, were included in the final analysis. Robust statistically significant effects were found when older exercisers were compared with the control group, representing a 3.9% reduction in SBP and a 4.5% reduction in DBP.

A meta-analysis was carried out in 2007 ¹³⁸ involving randomized controlled trials in which the training consisted of either endurance or resistance training. The meta-analysis was based on 72 trials and 105 study groups. Physical training was found to induce a significant reduction in resting blood pressure and systolic/diastolic blood pressure, measured during outpatient visits, of 3.0/2.4 mmHg and 3.3/3.5 mmHg, respectively. The reduction in blood pressure was more pronounced for the 30 hypersensitive trial groups, in which an effect of −6.9/−4.9 was achieved, while the normotensive group achieved an effect of −1.9/−1.6. Training had a positive effect on a number of clinical and paraclinical variables, namely systemic vascular resistance, plasma noradrenalin, plasma renin activity, body weight, abdominal girth, fat percentage, HOMA, and HDL cholesterol.

An expert panel of the American College of Sports Medicine (ACSM) ¹³⁹ extrapolated data from a total of 16 studies involving patients with hypertension (systolic blood pressure >140 mmHg; diastolic blood pressure >90 mmHg) and found the effect of physical training in people with hypertension to be a decrease in blood pressure of 7.4 mmHg (systolic) and 5.8 mmHg (diastolic). A general finding was that the blood pressure-lowering effect of physical training was most pronounced in the patients with the highest blood pressure.

A meta-analysis from 2011 identified studies that had examined the effect of strength training on blood pressure and other cardiovascular risk factors in adults ¹⁴⁰.

The study included 28 randomized, controlled trials, involving 33 study groups and 1012 participants. Overall, resistance training induced a significant blood pressure reduction in 28 normotensive or pre-hypertensive study groups [−3.9/−3.9 mmHg], whereas the reduction [−4.1/−1.5 mmHg] was not significant for the five hypertensive study groups. When study groups were divided according to the mode of training, isometric handgrip training in three groups resulted in a larger decrease in blood pressure [−13.5 /−6.1 mmHg] than dynamic resistance training in 30 groups [−2.8/−2.7 mmHg]. This meta-analysis supports the blood pressure-lowering potential of dynamic resistance training and point at an interesting effect of isometric handgrip training. The latter study adds to previous meta-analysis ¹⁴¹.

Blood pressure was measured daily (24 h) in 11 studies ¹³⁹ and showed the same effect from training as the studies mentioned above.

Acute effect of physical activity

Physical activity induced a decrease in blood pressure after it was carried out. This decrease in blood pressure typically lasted for 4–10 h, but was measured up to 22 h later. The average decrease was 15 mmHg and 4 mmHg for systolic and diastolic blood pressure, respectively¹³⁹. This means that people with hypertension can achieve normotensive values many hours of the day, which should be seen as having considerable clinical significance ¹³⁹.

Overall, it is well documented that training for hypersensitive people induces a clinically relevant lowering of blood pressure. Conventional treatment using blood pressure-lowering medication typically brings about a decrease in diastolic blood pressure of the same level ¹⁴², which in the long run lowers the risk of strokes by an estimated 30% and the risk of ischemic cardiac death by 30%. A meta-analysis involving one million people calculates that a reduction in systolic blood pressure of just 2 mmHg reduces stroke mortality by 10% and ischemic cardiac death mortality by 7% among middle-aged people ¹³⁰. These calculations coincide with findings from earlier analyses ¹⁴³.

Exercise and Stroke

Stroke (cerebrovascular accident, brain attack) is defined by WHO as a rapid onset disorder of brain function with symptoms lasting more than 24 h or leading to death, and where the probable cause is vascular. The reasons are infarction due to cardiac embolism, intracerebral hemorrhage, or subarachnoid hemorrhage after ruptured aneurysm. The average age is 75 years, but 20% of the patients are less than 65 years of age. Depending on localization of the brain damage, different parts of the brain functions are affected, but the majority of stroke patients have unilateral paresis of the upper and lower extremities, while about one-third also have aphasia. Moreover, most of the patients need hospitalization and will require rehabilitation ¹⁴⁴.

Most stroke patients are affected cognitively and emotionally after their attack. Approximately one-third of them experience post-stroke depression ¹⁴⁵. These effects coupled with low physical function make it difficult to comply with recommendations for physical activity. Patients with stroke generally have low levels of physical activity ¹⁴⁶.

Physical inactivity is a risk factor for atherosclerosis and hypertension, which explains why physical inactivity in epidemiological studies is a prognostic factor for apoplexy ¹⁴⁷. Stroke patients who have a relatively high level of physical activity have been found to have comparatively fewer severe stroke episodes and better recovery of function after 2 years ¹⁴⁸.

There is evidence that aerobic exercise in patients with stroke has a positive effect on walking speed and function. Furthermore, there is support for an effect on mortality.

A meta-analysis from 2014 included 38 randomized controlled trials. There was high evidence that in the subacute stage of stroke, specific walking training resulted in improved walking speed and distance compared with traditional walking training of the same intensity. In the chronic stage, walking training resulted in increased walking speed and walking distance compared with no/placebo treatment, and increased walking speed compared with overall physiotherapy. On average, 24 training sessions for 7 weeks were needed ¹⁴⁹.

A meta-analysis from 2013 of randomized trials included nine studies of treadmill training comprising 977 participants and found evidence that, for people with stroke who can walk, treadmill training without body weight support results in faster walking speed and greater distance than no intervention/non-walking intervention and the benefit is maintained beyond the training period ¹⁵⁰.

Another study from 2013 included meta-analyses of randomized controlled trials with mortality outcomes comparing the effectiveness of exercise and drug interventions with each other or with control (placebo or usual care). In total, they included 16 (four exercise and 12 drug) meta-analyses. Three trials concerned exercise interventions among patients with stroke (n = 227) compared with 10 trials of anticoagulants (n = 22 786), 14 of antiplatelets (n = 43 041), and three directly comparing anticoagulants with antiplatelets (n = 11 567). Physical activity interventions were more effective than drug treatment among patients with stroke ¹⁵¹.

As physical activity helps to prevent risk factors for stroke, i.e., hypertension, atherosclerosis, and type 2 diabetes, it is likely that physical training of stroke patients can prevent new episodes of stroke, but there is no evidence to support this.

A Cochrane Review from 2013 included 45 trials, involving 2188 participants, which comprised cardiorespiratory (22 trials, 995 participants), resistance (eight trials, 275 participants), and mixed training interventions (15 trials, 918 participants). It was concluded that there is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programs to improve the speed and tolerance of walking; improvement in balance may also occur. Presently, there is however insufficient evidence to support the use of resistance training ¹⁵².

However, individuals with hemiparesis are often older and have a low level of activity, and it must be assumed that this group can achieve the same advantages from strength training as individuals without neurological deficits. In other words, physically active people with hemiparesis will have lower mortality, more active years, reduced risk of metabolic syndrome, and increased bone density ¹⁵³.

Exercise and Coronary heart disease

The term coronary heart disease (CHD) refers to a pathophysiological condition where a decrease in blood flow to the heart muscle causes ischemia, i.e., reduces oxygen supply. The most common cause is atherosclerotic constriction in the coronary arteries, but myocardial ischemia can also occur in patients with heart valve disease, hypertrophic cardiomyopathy, severe hypertension and abnormal tendency toward coronary spasm. Level of physical activity and cardio-respiratory fitness correlate with cardiovascular endpoints in healthy people and in patients with CHD ¹⁰⁶.

There is solid evidence demonstrating the effect of physical training on patients with coronary heart disease. Physical training improves survival rates and is assumed to have a direct effect on the pathogenesis of the disease.

A Cochrane Review from 2011 aimed at determining the effectiveness of exercise-based cardiac rehabilitation (exercise training alone or in combination with psychosocial or educational interventions) on mortality, morbidity and health-related quality of life of patients with CHD ¹⁵⁴. The study included men and women of all ages who have had myocardial infarction (MI), coronary artery bypass graft (CABG), or percutaneous transluminal coronary angioplasty (PTCA), or who have angina pectoris or coronary artery disease defined by angiography. The Cochrane systematic review included 47 studies randomizing 10 794 patients to exercise-based cardiac rehabilitation or usual care. In medium to longer term (i.e., 12 or more months follow-up) exercise-based cardiac rehabilitation reduced overall and cardiovascular mortality [RR: 0.87 and 0.74 respectively], and hospital admissions [RR: 0.69] in the shorter term (<12 months follow-up). Cardiac rehabilitation did not reduce the risk of total MI, CABG, or PTCA. In 7of 10 trials reporting health-related quality of life using validated measures was there evidence of a significantly higher level of quality of life with exercise-based cardiac rehabilitation than usual care. Thus, it was concluded that exercise-based cardiac rehabilitation is effective in reducing total and cardiovascular mortality (in medium- to long-term studies) and hospital admissions (in short-term studies) but not total MI or revascularization (CABG or PTCA). The latter review is in agreement with previous meta-analyses ¹⁵⁵.

Physical training of patients with CHD was found to reduce total cholesterol and triglyceride levels and systolic blood pressure. Many of the subjects in the training groups had stopped smoking ¹⁵⁵.

Exercise and Heart failure

Heart failure is a condition where the heart is unable to pump sufficiently to maintain blood flow to meet the metabolic needs of the peripheral tissue ¹⁵⁶. Heart failure is a clinical syndrome with symptoms such as fluid retention, breathlessness, or excessive tiredness when resting or exercising, and with objective symptoms of reduced systolic function of the left ventricle at rest.

Asymptomatic left ventricular dysfunction is often the precursor of this syndrome. Symptoms vary from very light restriction of function to seriously disabling symptoms. Heart failure is often divided into left-sided (the most frequent and best researched type) and right-sided heart failure and into acute (pulmonary edema, cardiogenic shock) and chronic heart failure. Heart failure is often caused by ischemic disease, but can also be caused by, for example, hypertension or valvular heart disease ¹⁵⁶.

Maximum oxygen uptake (VO2max) is lower in patients with heart failure ¹⁵⁷. This is caused, among other things, by the reduced pumping function of the heart and by peripheral conditions in the muscles ¹⁵⁸. A common symptom with heart failure patients is muscle atrophy, tiredness, and reduced muscle strength ¹⁵⁹. Heart failure patients are characterized by defects in the renin–angiotensin system, increased levels of cytokines, also TNF, increased noradrenalin, and insulin resistance. These metabolic conditions can all be significant factors in the development of muscle atrophy with heart failure, although no direct link between VO2max and noradrenalin has been found. Thus, heart failure patients tend to have poor fitness, poor muscle strength and muscle atrophy. The characteristic symptom of tiredness is presumably related to diminishing physical ability. While there was a consensus in the 1970s that patients with all stages of heart failure should be advised to refrain from physical activity and be prescribed bed rest, the consensus now is the opposite ¹⁵⁷.

Exercise and Intermittent claudication

Arterial insufficiency in the lower limbs (lower limb ischemia, leg ischemia) is a chronic obstructive disease in the aorta below the outlet of the renal arteries, iliac artery and the arteries in the lower limbs probably caused by atherosclerosis. It is estimated that at least 4% of all people above the age of 65 have peripheral arteriosclerosis, which in 50% of cases causes intermittent pain (intermittent claudication). A minority of patients experience the progression of peripheral arteriosclerosis, which results in pain while at rest and ulcerations. Owing to the realization that medical treatment of the disease has limited efficacy, the international consensus today is that physical training is a key factor in the treatment of patients with intermittent claudication ¹⁶⁰. As the intermittent claudication becomes more severe, function level decreases and quality of life becomes affected. Increasing pain when walking and the consequent fear of moving gradually causes the patient to become static and socially isolated. In the long term, this leads to deterioration of fitness and the progression of arteriosclerosis, reduced muscle strength and muscle atrophy, trapping the patient in a vicious circle of poor fitness, pain, and social isolation. Physical activity can be used to interrupt this vicious circle and directly affect the pathogenesis of the disease by increasing fitness and muscle strength, changing pain thresholds and the perception of pain, allaying fear, and preventing disease progression.

There is solid evidence demonstrating the beneficial effect of physical training on patients with intermittent claudication. A Cochrane Reviews from 2014 ¹⁶¹ included 30 trials, involving a total of 1816 participants with stable leg pain. The follow-up period ranged from 2 weeks to 2 years. The types of exercise varied from strength training to polestriding and upper or lower limb exercises; generally supervised sessions were at least twice a week. Most trials used a treadmill walking test for one of the outcome measures. Twenty trials compared exercise with usual care or placebo, the remainder of the trials compared exercise to medication or pneumatic calf compression. Overall, when taking the first time point reported in each of the studies, exercise significantly improved maximal walking time when compared with usual care or placebo: mean difference (MD) 4.51 min with an overall improvement in walking ability of approximately 50% to 200%. Walking distances were also significantly improved: pain-free walking distance MD 82.29 meters and maximum walking distance MD 108.99 meters. Improvements were seen for up to 2 years. The effect of exercise, when compared with placebo or usual care, was inconclusive on mortality, amputation, and peak exercise calf blood flow due to limited data. At 3 months, physical function, vitality, and role physical were reported to be improved with exercise in two trials. At 6 months, five trials reported outcomes of a significantly improved physical summary score and mental summary score secondary to exercise. The authors concluded that exercise programs are of significant benefit compared with placebo or usual care in improving walking time and distance in people with leg pain from intermittent claudication who were considered to be fit for exercise intervention. This was obtained without any demonstrable effect on the patients’ ankle blood pressure measurements. The results were not conclusive for mortality and amputation.

In a controlled study, physical training was compared with percutaneous transluminal angioplasty (PTA) and the finding was that there was no significant difference after 6 months ¹⁶². A review article by Chong et al. ¹⁶³ assessed the results of physical training (9 studies, 294 patients) and PTA (12 studies, 2071 patients). The authors concluded that it was essentially impossible to compare the effect of two treatments in one non-controlled study design, but reported that the effect of PTA was minimally better than training, although PTA involved the risk of serious side effects.

A randomized study compared the effect of (a) physical exercise alone, (b) surgery, and (c) physical exercise + surgery. All groups achieved the same effect on walking distance, but there were side effects in 18% of the patients who underwent surgery ¹⁶⁴.

Another randomized study compared the effect of physical training and antithrombotic therapy ¹⁶⁵. A significantly larger improvement in walking distance was recorded for the group that exercised (86%) compared with the group that received medication (38%). A meta-analysis found that training programs were substantially cheaper and involved fewer risks than either surgery or PTA ¹⁶⁶. Furthermore, a meta-analysis has shown that quality of life increases with walking distance ¹⁶⁷.

A recent review analyzed the safety of supervised exercise training in patients with intermittent claudication ¹⁶⁸. There has been concern regarding the safety of performing supervised exercise training because intermittent claudication patients are at risk for cardiovascular events. The review selected 121 articles, of which 74 met the inclusion criteria. Studies represent 82 725 h of training in 2876 patients with intermittent claudication. Eight adverse events were reported, six of cardiac, and two of non-cardiac origin, resulting in an only all-cause complication rate of one event per 10 340 patient-hours.

Exercise and Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is characterized by an irreversible decrease in lung function. Advanced-stage COPD is a long and painful process of gradually increasing and ultimately disabling breathlessness as the main symptom. Today the international consensus is that rehabilitation programs are an important part of COPD treatment, which follows from the realization that drug therapy for COPD is inadequate.

A vicious cycle of deterioration in physical capacity, shortness of breath, anxiety, and social isolation develops. Rehabilitation can break this cycle by introducing physical training, psychological support and networking with other COPD patients ¹⁶⁹.

Reduction in muscle strength is a major cause of reduced exercise capacity and physical functional level ¹⁷⁰. A minor study showed that muscle mass in the quadriceps was approximately 15% less and muscle strength about 50% lower in elderly men with COPD than in healthy, physically inactive peers ¹⁷¹.

The positive impact of physical exercise for patients with COPD is well documented. A 2015 Cochrane Review/meta-analysis ¹⁷² added to previous meta-analyses. The 2015 update includes 65 RCTs involving 3822 participants. A total of 41 of the pulmonary rehabilitation programs were hospital based, 23 were community based and one study had both a hospital component and a community component. Most programs were of 12-week or 8-week duration with an overall range of 4–52 weeks. The authors found statistically significant improvement for all included outcomes. In four important domains of quality of life (Chronic Respiratory Questionnaire (CRQ) scores for dyspnea, fatigue, emotional function, and mastery), the effect was larger than the minimal clinically important difference of 0.5 units. Statistically significant improvements were noted in all domains of the St. George’s Respiratory Questionnaire, and improvement in total score was better than 4 units. Both functional exercise and maximal exercise showed statistically significant improvement. Researchers reported an increase in maximal exercise capacity [mean Wmax (W)] in participants allocated to pulmonary rehabilitation compared with usual care. In relation to functional exercise capacity, the 6-min walk distance mean treatment effect was greater than the threshold of clinical significance. The subgroup analysis, which compared hospital-based programs vs community-based programs, provided evidence of a significant difference in treatment effect between subgroups for all domains of the CRQ, with higher mean values, on average, in the hospital-based pulmonary rehabilitation group than in the community-based group. Subgroup analysis performed to look at the complexity of the pulmonary rehabilitation program provided no evidence of a significant difference in treatment effect between subgroups that received exercise only and those that received exercise combined with more complex interventions.

Studies show that rehabilitation programs lead to fewer hospitalizations and thus save resources ¹⁷³. Most studies use high-intensity walking exercise. One study compared the effect of walking or cycling at 80% of VO2max vs working out in the form of Callanetics exercises and found that high-intensity training increased fitness while the workout program increased arm muscle stamina. Both programs had a positive effect on the experience of dyspnea ¹⁷⁴. Oxygen treatment in conjunction with intensive training for patients with COPD increased training intensity and thus improved fitness in one study ¹⁷⁵, but not in another ¹⁷⁶. It is recommended that oxygenation therapy should be provided at the end of training if the patients are hypoxic or become desaturated during the training ¹⁷⁷. Training to music gave better results than without music, presumably because patients who run with music perceive the physical exertion to be less, even though they are doing the same amount of exercise. Specific training for inspiratory muscles increased the stamina of these muscles but did not give the patients a lower perception of dyspnea or improved fitness ¹⁷⁸. Thus, strong evidence exists that endurance training as part of pulmonary rehabilitation in patients with COPD improves exercise capacity and health-related quality of life. However, dyspnea limits the exercise intensity. Therefore, resistance training, which may cause less dyspnea, could be an alternative. Moreover, low muscle mass is associated with increased risk of mortality ¹⁷⁹.

A recent systematic review ¹⁸⁰ compared the effect of resistance and endurance training. The authors included eight randomized controlled trials (328 participants) and found that resistance training appeared to induce the same beneficial effects as endurance training. It was therefore recommended that resistance training should be considered according to patient preferences when designing a pulmonary rehabilitation program for patients with COPD. The same authors performed another systematic review ¹⁸¹ in which they assessed the efficiency of combining resistance training with endurance training compared with endurance training alone. For this analysis, they included 11 randomized controlled trials (331 participants) and 2 previous systematic reviews. They found equal improvements in quality of life, walking distance, and exercise capacity. However, they also found moderate evidence of a significant increase in leg muscle strength favoring a combination of resistance and endurance training and recommend that resistance training should be incorporated in rehabilitation of COPD together with endurance training.

Exercise and Bronchial asthma

Bronchial asthma (asthma) is a chronic inflammatory disorder characterized by episodic reversible impairment of pulmonary function and airway hyper-responsiveness to a variety of stimuli ¹⁸². Allergies are a major cause of asthma symptoms, especially in children, while many adults have asthma without an allergic component. Environmental factors, including tobacco smoke and air pollution, contribute to the development of asthma.

Physical exercise poses a particular problem for asthmatics as physical activity can provoke bronchoconstriction in most asthmatics ¹⁸³. Regular physical activity is important in the rehabilitation of patients with asthma ¹⁸⁴. Asthmatics need to be taught how to prevent exercise-induced symptoms in order to benefit, just like other people, from the positive effects of physical activity against other diseases. With children in particular, it is important that they are taught how physical activity can be adapted to asthma due to its importance for their motor and social development.

Exercise-induced asthma can be prevented by warming up thoroughly and by using a number of anti-asthma drugs, e.g., short- or long-acting beta-agonists, leukotriene antagonists, or chromones. Another way to help eliminate some exercise-induced symptoms is to adjust the prophylactic treatment so that the asthma and thus airway responsiveness are under control. Regular intake of anti-asthma medicine, especially inhaled steroids, is crucial to enabling physical training. Moreover, it is important to be aware of triggers such as airway infections or triggers in the surroundings where physical activity is carried out, e.g., pollen, mold fungus, cold, air pollution, and tobacco smoke. Some studies ¹⁸⁵, but not in others ¹⁸⁶, have found physical fitness to be poor in asthmatics. Irrespective of how physically fit the patient is, guidance and medicine are important to enabling all asthmatics the opportunity to be physically active without worrying about the symptoms.

A Cochrane Review from 2013 ¹⁸⁷ included randomized trials of people over 8 years of age with asthma who were randomized to undertake physical training or not. Physical training had to be undertaken for at least 20 min, two times a week, over a minimum period of 4 weeks. Twenty-one studies including 772 participants were included. Physical training was well tolerated with no adverse effects reported. None of the studies mentioned worsening of asthma symptoms following physical training. Physical training showed marked improvement in cardiopulmonary fitness as measured by an increase in maximum oxygen uptake; however, no statistically significant effects were observed for forced expiratory volume in 1 second, forced vital capacity, minute ventilation at maximal exercise, or peak expiratory flow rate. It was concluded that physical training showed a significant improvement in fitness, though no effects were observed in other measures of pulmonary function.

A Cochrane study concluded that swimming training is beneficial for children and adolescents with asthma ¹⁸⁸.

A non-controlled trial showed that it is possible for adult asthmatics to participate in high-intensity training ¹⁸⁹. The patients trained in an indoor swimming pool at 80–90% of maximum oxygen uptake (VO2max) for 45 min, initially once a week and then twice a week for 10 weeks. Physical fitness improved and there were fewer cases of exercise-induced asthma attacks, less anxiety in connection with physical exertion and less of a feeling of dyspnea. At the 3-year follow-up examination, 68% of the patients were still physically active and trained one to two times a week ¹⁸⁹. Physical training has a positive effect on the psycho-social morbidity and quality of life of asthma patients ¹⁹⁰.

Exercise and Cystic fibrosis

Cystic fibrosis is the most commonly occurring autosomal recessive, genetic, potentially life-threatening disease ¹⁹¹. Incidence among Caucasians is one in 2500. Cystic fibrosis is a system disease, but the predominant symptom is progressive obstructive pulmonary disease, which over time leads to respiratory failure and respiratory heart disease ¹⁹². Diminished pulmonary function restricts physical development, resulting in lower fitness and muscle function and the patients often develop osteoporosis and diabetes. Evidence exists that patients with cystic fibrosis have reduced physical fitness ¹⁹³ and exercise has been identified as an independent predictor of mortality and morbidity in cystic fibrosis patients ¹⁹⁴.

Moreover, exercise intolerance is associated with reduced pulmonary function as well as daily activity levels and infections. The goal of physical training for cystic fibrosis patients is to:

Mobilize the mucus in the lungs and to stimulate an increase in mucociliary transport
Achieve a satisfactory level of fitness and strength to be able to maintain a normal capacity for exercise
Maintain normal mobility, especially of the chest, to ensure that mucus clearance therapy is effective
Prevent osteoporosis and diseases related to physical inactivity
Increase self-confidence.

In theory, physical training may lower the risk for diabetes and infectious episodes.

In general, the evidence is poor for the effect of physical training in patients with cystic fibrosis, but it has been found that physical activity improves exercise capacity, slows the decline in lung function, and improves quality of life in patients with cystic fibrosis ¹⁹⁵.

In a Cochrane review from 2008 ¹⁹³, seven studies which included 231 participants met the inclusion criteria. The review provided some but limited evidence from both short- and long-term studies that aerobic or anaerobic physical training has a positive effect on primary outcomes (exercise capacity, strength, and lung function) but improvements are not consistent between studies.

A systematic 2010 meta-analysis assessed the effect of physical exercise on children with cystic fibrosis. The analysis covered only four randomized controlled trials ¹⁹⁶ and included 221 children with cystic fibrosis. The selected studies are strikingly heterogeneous concerning the severity of the cystic fibrosis, duration of the training intervention, and the mix of aerobic exercise and resistance training. All in all physical training was found to have a positive effect on lung function, muscle strength and fitness ¹⁹⁷.

Exercise and Depression

Depression is a common and important cause of morbidity and mortality worldwide. Depression is commonly treated with antidepressants and/or psychological therapy, but some people may prefer alternative approaches such as exercise.

A comprehensive study comprising 156 subjects over the age of 50 with severe depression randomized the patients to 4 months of aerobic exercise, 4 months of treatment with antidepressants (sertraline), and 4 months of treatment with both sertraline and physical training ¹⁹⁸. The exercise groups received supervised training of a relatively high intensity three times a week. Each session began with 10 min of warm-up, 30 min of cycling or jogging, and 5 min of cool down. Participants were assigned individual training ranges equivalent to 70% to 85% of heart rate reserve calculated from the maximum heart rate achieved during the treadmill test. The intensity was checked three times during each training session. The medical treatment had a quicker initial effect, but after 4 months, there was no difference between the three groups for symptoms of depression ¹⁹⁸. The patients were examined again after 10 months ¹⁹⁹. This check-up showed that there were significantly lower levels of depression symptoms and fewer incidences of relapse in the exercise groups. When all of the patients were analyzed together using multivariate analysis, there was a reduced risk of depression symptoms if the patients were physically active, regardless of group. This last fact does not exclude that the least depressed individuals had the strongest desire to exercise.

The 2013 Cochrane Review ²⁰⁰ concluded that the tendency was that more sessions have a larger effect on mood than a smaller number of sessions, and that resistance and mixed training were more effective than aerobic training. It appears, however, that it is not possible to determine the optimum type, frequency, and duration of exercise, whether it should be performed supervised or unsupervised, indoors or outdoors, or in a group or alone.

A meta-analysis from 2015 found some evidence that exercise may be effective in treating depression during pregnancy but the conclusion is based on only six low-moderate quality trials ²⁰¹. Another meta-analysis from 2014 found strong evidence for an effect of exercise on depression in patients with heart failure ²⁰².

Exercise and Anxiety

There is some, but limited knowledge about the effects of physical activity as a treatment for anxiety ²⁰³, ²⁰⁴. In several randomized controlled trials involving subjects with a normal or increased level of anxiety who do not meet the criteria for psychiatric diagnosis, it has been shown that physical activity can reduce symptoms of anxiety and tension. It is uncertain, however, whether it has a long-lasting effect ²⁰⁵.

Classical studies from the 1970s examine individuals who experienced anxiety attacks when they had to ride the bus. When the subjects got on the bus, they were gripped by anxiety, had a high pulse, were sweating, and felt they were unable to breathe. The patients were asked to run for the bus so they had a high pulse and were breathless when they got on it. Consequently, their physical symptoms were at their maximum level and did not worsen when they got on the bus. The patients attributed their high heart rate, tendency to perspire, and breathlessness to running for the bus and their fear declined ²⁰⁶.

A meta-analysis from 2010 comprising 40 studies concludes that physical training reduces symptoms of anxiety in people with chronic illnesses, including cardiovascular disease, fibromyalgia, multiple sclerosis, mental disorders, cancer, and chronic obstructive pulmonary disease ²⁰⁷.

Exercise and Stress

There is some, though modest evidence that physical training can have a positive effect on psychological stress symptoms. Physically fit individuals exhibit fewer pronounced signs of the physiological activation associated with psychosocial stress ²⁰⁸.

An American study ²⁰⁹ examines the relationship between level of physical fitness and mental well-being. The 5451 adult subjects (aged 20–88) in the study completed a treadmill test to determine their fitness level and filled out a questionnaire asking them to indicate their participation in leisure and sports activities over the preceding 3 months. The subjects’ mental well-being was evaluated based on questionnaires asking about the presence of symptoms of depression. The subjects were divided into three groups, depending on their level of fitness as measured by the treadmill test. The subjects were then divided into an additional four groups based on self-reported participation in regular exercise activities (inactive, insufficiently active, sufficiently active, and very active). The study showed the subjects who were more physically fit and more physically active experienced fewer symptoms of depression. Furthermore, an association was found between physical fitness and overall mental well-being.

One intervention study ²¹⁰ examines the effect of physical training on stress in adolescents (13- to 17-year olds). Sixty subjects were randomized into four groups. Over a period of 10 weeks, three of the groups completed training programs comprising, respectively, high-intensity aerobic exercise (70–75% of maximum pulse), moderately intense aerobic exercise (50–60% of maximum pulse), and stretching and flexibility training, while the last group did not exercise and thus served as the control group. Before and after the training program, the subjects completed questionnaires to determine self-reported stress levels (perceived stress scale), anxiety, and depression. They also did a step test to determine their level of fitness based on heart rate values. The group that did high-intensity cardio achieved a lower resting heart rate and improved diastolic blood pressure compared to the other groups. With regard to the self-reported stress level, the questionnaire results showed that the group that did high-intensity exercise had the greatest reduction in stress and anxiety symptoms. The findings from the study indicate that a relatively short period of training can have beneficial psychological effects in adolescents, including reducing stress if the exercise is of high intensity.

Another study showed, however, that moderately intense exercise can also reduce stress indicators ²¹¹. After 12 weeks of exercise, the subjects in the moderate-intensity exercise group [40–50% of maximum oxygen uptake (VO2max)] had a lower resting blood pressure and a lower blood pressure in response to a stress compared to the group that did high-intensity exercise (70–80% of VO2max).

The type of exercise also appears to determine whether it has a positive effect on stress ²¹². One study randomized healthy English police officers to either 10 weeks of aerobic training (n = 28) or 10 weeks of strength training (n = 24), while a group of 25 male police officers served as the control group. After the training period, the subjects in the aerobic exercise group had significantly less work-related stress than both the strength training and control group. There was, on the other hand, no difference in work-related stress between the strength training and control groups after the training period.

A systematic Review from 2014 ²¹³ suggests that qigong exercise immediately relieve anxiety among healthy adults, compared to lecture attendance and structured movements only.

In summary, there is thus some evidence to suggest that regular exercise and being physically fit can reduce stress levels. The degree of perceived stress is less apparent the higher one’s level of physical fitness is. There are divergent research findings in terms of whether to exercise at a high or moderate intensity to avoid stress, but aerobic exercise seems to have a better effect than strength training.

Exercise and Schizophrenia

Schizophrenia is the name for a group of mental disorders characterized by abnormal thoughts and emotions. Typical symptoms of schizophrenia are hallucinations, delusions, and thought disorder. Other symptoms include social withdrawal, lack of energy, impoverished language, lack of emotion and cognitive symptoms, such as problems with verbal learning, visual learning, social cognition, speed of information processing, and problems with forming and finding words. Life time risk is below 1% worldwide and schizophrenia affects 24 million people around the world ²¹⁴.

A meta-analysis from 2015 ²¹⁵ identified 20 eligible studies. Exercise interventions have no significant effect on body mass index (BMI), but can improve physical fitness and other cardiometabolic risk factors. Psychiatric symptoms were significantly reduced by interventions using around 90 min of moderate-to-vigorous exercise per week. This amount of exercise was also reported to improve functioning, co-morbid disorders, and cognition.

A systematic review from 2012 included 10 randomized controlled trials; six of these studies addressed the use of aerobic and strength exercises. In two of these studies, yoga techniques also were investigated. Four studies addressed the use of progressive muscle relaxation. There is evidence that aerobic and strength exercises and yoga reduce psychiatric symptoms, state anxiety, and psychological distress and improve health-related quality of life, that aerobic exercise improves short-term memory, that progressive muscle relaxation reduces state anxiety and psychological distress, and that physical training therapy in general offers added value in the multidisciplinary care of people with schizophrenia ²¹⁶. Routine physical activity/exercise appears to decrease the severity of negative symptoms ²¹⁷, reduce stress and anxiety ²¹⁸, improve concentration and attention ²¹⁹, and reduce depression severity ²²⁰ in schizophrenia.

Older studies indicate that physical activity reduces auditory hallucinations ²²¹. Other studies show that physically active patients experience auditory hallucinations as less distressing ²²².

People with schizophrenia are often overweight because their medication stimulates their appetite and at the same time increases social withdrawal and a physically inactive lifestyle. A healthy diet and physical activity are found to affect patients’ weight and simple health parameters such as triglycerides, total cholesterol, plasma insulin, and plasma glucose in the same way as they are said to affect the weight of people who do not suffer from mental illness ²²³.

People with schizophrenia often have accompanying symptoms, such as anxiety and stress, and physical activity can help alleviate these symptoms. In some cases, physical activity can provide an infrastructure and an environment that support social interactions and thus help the patients to establish networks, counteracting the tendency toward social withdrawal. Patients with schizophrenia are found to have a lower hippocampus volume compared to healthy people, a finding that may be significant for the pathogenesis of the chronic psychotic symptoms ²²⁴. A 2010 study shows that aerobic exercise over a 3-month period led to an increase in the size of the hippocampus and an improvement in the short-term memory of people with schizophrenia ²²⁵.

Exercise and Dementia

Despite the strong evidence that physical exercise may lower the risk of dementia, there are relatively few studies allowing to conclude on the effects of exercise in patients with a diagnosis of dementia. According to a Cochrane review 2013, there is promising evidence that exercise programs can have a significant impact in improving ability to perform activity of daily living (ADL) and possibly in improving cognition in people with dementia, although some caution is advised in interpreting these findings ²²⁶.

Sixteen trials with 937 participants met the inclusion criteria. The included trials were highly heterogeneous in terms of subtype and severity of participants’ dementia, and type, duration, and frequency of exercise. Only two trials included participants living at home. The meta-analysis suggested that exercise programs might have a significant impact on improving cognitive functioning and found a significant effect of exercise programs on the ability of people with dementia to perform ADLs. It was further found that the burden experienced by informal caregivers providing care in the home may be reduced when they supervise the participation of the family member with dementia in an exercise program.

One study ²²⁷ included 31 elderly subjects with dementia randomized to a training group or a control group. The training program comprised 15 weeks of 1 h of physical activity three times a week. After 15 weeks, the training group had improved their cognitive function, while the control group experienced a decline in cognitive function. The training group improved their gate function, but the opposite was true in the control group. Similar to the previous study, other studies find that simple interventions in the form of a few hours of physical activity per week have a positive effect on physical function in elderly people with dementia ²²⁸.

Most older persons with dementia living in nursing homes spend their days without engaging in much physical activity. A systematic review therefore looked at the influence that the environment has on their level of physical activity. Three hundred and twenty-six studies were selected as potentially relevant; of these, 24 met all the inclusion criteria. Positive results on the residents’ levels of physical activity were found for music, a homelike environment and functional modifications ²²⁹.

Studies have also been undertaken examining whether physical activity affects the cognitive function of elderly people without dementia. Lautenschlager et al. ²³⁰ included 170 elderly subjects who experienced subjective memory impairment without dementia. The participants were randomized to either a control group or a training group, which did a 24-week home-based program with 3 × 50 min workouts a week. The training had a significant, albeit modest, positive effect on the participant’s cognitive function. The effect was still present 1 year after cessation of exercise ²³⁰.

Baker et al. ²³¹ included 33 middle-aged and older people with mild cognitive impairment who were randomized to either a control group that did stretching and balance exercises or to a training group that did intensive aerobic training 45–60 min a day, 4 days a week for up to 6 months. There was a significant positive effect on the participants’ cognitive function measured with the help of a neurological test battery. The effect was twice as strong for women as for men ²³¹.

Erickson et al. ²³² included 120 elderly subjects who were randomized to either a control group that did stretching and muscle training or to a training group that walked three times a week for 40 min for a year at a brisk pace. The physical training had a significantly positive effect on the volume of the hippocampus and a non-significant effect on the participants’ spatial memory ²³².

Overall, there is some evidence that physical activity prevents dementia but only modest evidence for an effect of physical activity on cognitive function in people who have already developed dementia. Physical training has a positive effect on physical function, for example, the gait function of people with dementia.

Exercise and Parkinson’s disease

Parkinson’s disease is the second most common neurodegenerative disease after Alzheimer’s disease and affects approximately seven million people globally. Parkinson’s disease is more common in the elderly and prevalence rises from 1% in those over 60 years of age to 4% of the population over 80. The mean age of onset is around 60 years, although 5–10% of cases, classified as young onset, begin between the ages of 20 and 50 ²³³.

There is evidence pointing to the positive impact of physical training ²³⁴. A 2010 Cochrane Review ²³⁵ assessed the significance of treadmill training. The analysis included eight trials involving 203 participants. Treadmill training was found to increase walking speed, stride, and walking distance. The conclusions of the analysis echoed those of a systematic review from 2008 ²³⁶. These analyses add to a 2001 meta-analysis ²³⁷ involving a wide range of therapy, all-round physical training, sensory training, and mobility training. The duration of the physical exercise was 3–21 weeks with a total of 9–157.5 h of training. Overall, it was established that the training regime had a significant impact on walking speed.

A prospective crossover study investigated the effects of 4 weeks of treadmill training with partial body weight support and general physiotherapy (n = 10). The study found that the aerobic exercise, unlike the unspecific physiotherapy, improved the patients’ ability to manage their daily lives (ADL) and their muscle function ²³⁸. In a later study, patients were randomized for the same form of training or physiotherapy ²³⁹ (n = 24) and were monitored for 6 months. The training had a sustainable effect, especially on gait function.

In one study, 33 patients were randomized to walking training over 4 weeks or to conventional physiotherapy. The walking training had a positive effect on gait function ²⁴⁰. Randomizing for 10 weeks’ training with or without supervision by the physiotherapist showed that the supervised training had a greater effect than the training program carried out by the patients independently at home ²⁴¹.

Another study compared group boxing training to traditional group exercise on function and quality of life in persons with Parkinson’s disease. A convenience sample of adults with Parkinson’s disease (n = 31) were randomly assigned to boxing training or traditional exercise for 24–36 sessions, each lasting 90 min, over 12 weeks. Boxing training included: stretching, boxing (e.g., lateral foot work, punching bags), resistance exercises, and aerobic training. Traditional exercise included: stretching, resistance exercises, aerobic training, and balance activities. The traditional exercise group demonstrated greater gains in balance confidence than the boxing group. Only the boxing group demonstrated significant improvements in gait velocity and endurance over time. Both groups demonstrated significant improvements with the balance, mobility, and quality of life ²⁴².

A 16-month randomized controlled exercise intervention investigated three exercise approaches: flexibility/balance/function exercise (FBF), supervised aerobic exercise (AE), and home-based exercise (control). The participants were 121 individuals with early- or mid-stage Parkinson’s disease. The FBF program (individualized spinal and extremity flexibility exercises followed by group balance/functional training) was supervised by a physical therapist. The AE program (using a treadmill, bike, or elliptical trainer) was supervised by an exercise trainer. Supervision was provided 3 days/week for 4 months, and then monthly (16 months total). The control group participants exercised at home using the National Parkinson Foundation Fitness Counts program, with one supervised, clinic-based group session/month. Of the 121 participants, 86.8%, 82.6%, and 79.3% completed 4, 10, and 16 months, respectively, of the intervention. Findings demonstrated overall functional benefits at 4 months in the FBF group and improved walking economy (up to 16 months) in the AE group. Thus, both FBF and AE programs may be important for people with early- and mid-stage Parkinson’s disease ²⁴³.

The latter study showed that supervised training may have long-term effects in Parkinson’s disease. A pilot study explored the feasibility, acceptability, and preliminary evidence of the effectiveness of a virtual exercise coach to promote daily walking in community-dwelling persons with Parkinson’s disease. Twenty patients participated in this phase 1, single-group, non-randomized clinical trial. The subjects were instructed to interact with the virtual exercise coach for 5 min, wear a pedometer, and walk daily for 1 month. At the study completion, there was 100% retention rate. Interaction history revealed that the participants logged in for a mean (SD) of 25.4 days of the recommended 30 days. The mean adherence to daily walking was 85%. Both gait speed and the 6-min walk test significantly improved ²⁴⁴.

Exercise Guidelines for Adults With Parkinson’s Disease

People with Parkinson’s who exercise fare better over time than those who are not active.

Physical activity should be initiated early in the diagnosis and be a life-long commitment.
Engaging in aerobic activity, along with other activities for strength, flexibility and balance, improves Parkinson’s symptoms and sense of well-being.

Why Aerobic Activities ?

Aerobic activities make the body’s large muscles move in a rhythmic manner for a sustained period of time.
Aerobic activities improve physical fitness, including strength and endurance.
Aerobic activities have a positive effect on slowness and stiffness, as well as mood, and quality of life.
Examples: brisk walking, swimming, cycling, dancing, water aerobics, skating, hiking, treadmill or elliptical, Wii.

Why Flexibility Activities ?

Flexibility or stretching exercises improve mobility, increase range of motion, and reduce stiffness.
Improving range of motion affects posture and walking ability making everyday activities easier.
Examples: Tai Chi, stretching.

Why Strengthening Activities ?

Strengthening activities improve muscle strength, walking speed, posture and overall physical fitness.
Improving strength will help everyday activities, such as getting up from a chair, easier to manage.
Examples: yard work or gardening, weights/resistance (free weights, elastic bands, body weight)

Why Balance Activities ?

Balance activities improve posture and stability.
Better balance reduces the fear of falling and helps in performing daily tasks.
Examples: Yoga, hiking, Wii.

[Source: Canadian Society for Exercise Physiology. Canadian Physical Activity Guidelines for Physical Activity and Parkinson’s Disease ²⁴⁵]

Exercise and Multiple sclerosis

Multiple sclerosis is a chronic disease normally resulting in gradual, progressive disability. The number of people with multiple sclerosis is 2–2.5 million (approximately 30 per 100 000) globally, with rates varying widely in different regions. The disease occurs more often in women than in men and it usually develops between the ages of 20–40. It is characterized by recurring neurological deficits (attacks) in different parts of the nervous system caused by local demyelination processes (plaques). Over time, the symptoms spread to different parts of the body. Individual attacks can manifest themselves in highly different ways, but common symptoms are paresis, disturbed sensation, ataxia, loss of autonomic functions, weakness, and fatigue. The symptomatology of each patient is different, depending on the location of the plaques, which makes evidence-based studies difficult to carry out.

A systematic review from 2013 included 54 studies and found strong evidence that exercise performed two times/week at a moderate intensity increases aerobic capacity and muscular strength. The authors concluded that among those with mild to moderate disability from multiple sclerosis, there is sufficient evidence that exercise training is effective for improving both aerobic capacity and muscular strength and that exercise may improve mobility, fatigue, and health-related quality of life ²⁴⁶.

It has been suggested that physical exercise might have the potential to have an impact on multiple sclerosis pathology and thereby slow down the disease process in patients with multiple sclerosis. However, it was recently concluded that although some evidence supports the possibility of a disease-modifying potential of exercise (or physical activity) in MS patients, future studies using better methodologies are needed to confirm this ²⁴⁷.

A systematic review from 2012 evaluated the effect of resistance training ²⁴⁸. Sixteen studies were included. The authors found strong evidence regarding the beneficial effect of progressive resistance training on muscle strength. Regarding functional capacity, balance, and self-reported measures (fatigue, quality of life, and mood) evidence is less strong, but the tendency is overall positive. Indications of an effect on underlying mechanisms such as muscle morphological changes, neural adaptations and cytokines also exist, but the studies investigating these aspects are few and inconclusive ²⁴⁸. A 2009 meta-analysis ²⁴⁹, which includes 22 studies involving nearly 600 people with multiple sclerosis, assesses the effect of physical training on walking ability. The physical training involved physiotherapy both with and without equipment and different forms of physical training on land and in water. Walking ability was found to improvement by 19% and this increased to 32% if the training was supervised. The meta-analysis found that the physical training described above has an overall positive effect on patients’ quality of life ²⁵⁰.

A 2007 Cochrane Review evaluates the impact of multi-disciplinary interventions ²⁵¹. The main conclusion of the study, and that of a 2005 Cochrane Review, is that further research is needed on the effects of structured physical training for this patient group ²⁵².

A randomized controlled study assessed the effects of progressive strength training and identified a clear impact on strength and function after 12 weeks ²⁵³, as well as an improvement in depression score, fatigue symptoms, and quality of life ²⁵⁴.

The importance of aerobic exercise was assessed in a randomized controlled trial involving 54 patients with multiple sclerosis ²⁵⁵, which was randomized to a control group or training program consisting of 3 × 40 min of combined arm and leg bicycle ergometry over 15 weeks. The training group increased maximum oxygen uptake (VO2max), improved leg and arm muscle strength, improved bladder function, and showed fewer depression and fatigue symptoms. There was also an improvement in lipid profile.

Another randomized control trial ²⁵⁶ involving 18 patients with multiple sclerosis found that 6 months of physical training increased mobility but had only a moderate effect on walking ability. Two randomized controlled trials showed that it was possible to increase inspiratory and expiratory muscle strength and thus cough force after 3 months of training for the respiratory muscles ²⁵⁷.

A 2001 meta-analysis involving 23 studies shows that ergotherapy/physiotherapy increases muscle strength, mobility, and physical well-being, and improves the ability to carry out daily functions such as getting dressed and taking care of personal hygiene ²⁵⁸.

A meta-analysis from 2014 concludes that the available evidence indicates that exercise training can yield a small, yet statistically significant and reliable reduction in depressive symptoms for people with multiple sclerosis ²⁵⁹.

parkbenefits, adults aged 18-64 years with multiple sclerosis who have mild to moderate disability need at least:

30 minutes of moderate intensity aerobic activity, 2 times per week, AND
Strength training exercises for major muscle groups, 2 times per week.

Meeting these guidelines may also reduce fatigue, improve mobility and enhance elements of health-related quality of life.

[Source: Canadian Society for Exercise Physiology. Canadian Physical Activity Guidelines FOR ADULTS WITH MULTIPLE SCLEROSIS ²⁶⁰]

What is known about the relationship between exercise and cancer risk ?

Physical activity (exercise) is essential for people to maintain a balance between the number of calories consumed and the number of calories used. Consistently expending fewer calories than are consumed leads to obesity, which scientists have convincingly linked to increased risks of 13 different cancers ²⁶¹. Additionally, evidence indicates that physical activity may reduce the risks of several cancers through other mechanisms, independent of its effect on obesity.

There is substantial evidence that higher levels of physical activity are linked to lower risks of several cancers ²⁶².

Colon cancer: Colon cancer is one of the most extensively studied cancers in relation to physical activity ²⁶³. A 2009 meta-analysis of 52 epidemiologic studies that examined the association between physical activity and colon cancer risk found that the most physically active individuals had a 24% lower risk of colon cancer than those who were the least physically active ²⁶⁴. A pooled analysis of data on leisure-time physical activity (activities done at an individual’s discretion generally to improve or maintain fitness or health) from 12 prospective U.S. and European cohort studies reported a risk reduction of 16%, when comparing individuals who were most active to those where least active ²⁶⁵. Incidence of both distal colon and proximal colon cancers is lower in people who are more physically active than in those who are less physically active ²⁶⁶, ²⁶⁷. Physical activity is also associated with a decreased risk of colon adenomas (polyps), a type of colon polyp that may develop into colon cancer ²⁶⁸. However, it is less clear whether physical activity is associated with lower risks that polyps that have been removed will come back ²⁶⁹, ²⁷⁰, ²⁷¹.

Breast cancer: Many studies show that physically active women have a lower risk of breast cancer than inactive women; in a 2013 meta-analysis of 31 prospective studies, the average breast cancer risk reduction associated with physical activity was 12% (12). Physical activity has been associated with a reduced risk of breast cancer in both premenopausal and postmenopausal women; however, the evidence for an association is stronger for postmenopausal breast cancer ²⁷², ²⁷³, ²⁷⁴, ²⁷⁵. Women who increase their physical activity after menopause may also have a lower risk of breast cancer than women who do not ²⁷⁶, ²⁷⁵.

Endometrial cancer: Many studies have examined the relationship between physical activity and the risk of endometrial cancer (cancer of the lining of the uterus). In a meta-analysis of 33 studies, the average endometrial cancer risk reduction associated with high versus low physical activity was 20% ²⁷⁷. There is some evidence that the association between physical activity and endometrial cancer risk may reflect the effect of physical activity on obesity, a known risk factor for endometrial cancer ²⁷⁷, ²⁷⁸, ²⁷⁹.

For a number of other cancers, there is more limited evidence of a relationship with physical activity. In a study of over 1 million individuals, leisure-time physical activity was linked to reduced risks of esophageal adenocarcinoma, liver cancer, gastric cardia cancer (a type of stomach cancer), kidney cancer, myeloid leukemia, myeloma, and cancers of the head and neck, rectum, and bladder ²⁶⁵. These results are generally corroborated by large cohort studies ²⁸⁰ or meta-analyses ²⁸¹, ²⁸², ²⁸³.

How might physical activity be linked to reduced risks of cancer ?

Exercise has a number of biological effects on the body, some of which have been proposed to explain associations with specific cancers, including:

Lowering the levels of hormones, such as insulin and estrogen, and of certain growth factors that have been associated with cancer development and progression ²⁸⁴ [breast, colon]
Helping to prevent obesity and decreasing the harmful effects of obesity, particularly the development of insulin resistance (failure of the body’s cells to respond to insulin)
Reducing inflammation
Improving immune system function
Altering the metabolism of bile acids, resulting in decreased exposure of the gastrointestinal tract to these suspected carcinogens ²⁸⁵, ²⁸⁶ [colon]
Reducing the amount of time it takes for food to travel through the digestive system, which decreases gastrointestinal tract exposure to possible carcinogens [colon]

Is physical activity beneficial for cancer survivors ?

Research indicates that physical activity may have beneficial effects for several aspects of cancer survivorship–specifically, weight gain, quality of life, cancer recurrence or progression, and prognosis (likelihood of survival) ²⁸⁷, ²⁸⁸. Most of the evidence for the potential benefits of physical activity in cancer survivors comes from people diagnosed with breast, prostate, or colorectal cancer ¹.

Weight gain. Both reduced physical activity and the side effects of cancer treatment can contribute to weight gain after a cancer diagnosis. In a cohort study (a type of epidemiologic study), weight gain after breast cancer diagnosis was linked to worse survival ²⁸⁹. In a 2012 meta-analysis of randomized controlled clinical trials examining physical activity in cancer survivors, physical activity was found to reduce both body mass index and body weight ²⁹⁰.

Quality of life. A 2012 Cochrane Collaboration systematic review of controlled clinical trials of exercise interventions in cancer survivors indicated that physical activity may have beneficial effects on overall health-related quality of life and on specific quality-of-life issues, including body image/self-esteem, emotional well-being, sexuality, sleep disturbance, social functioning, anxiety, fatigue, and pain ²⁹¹. In a 2012 meta-analysis of randomized controlled trials examining physical activity in cancer survivors, physical activity was found to reduce fatigue and depression and to improve physical functioning, social functioning, and mental health ²⁹⁰.

Recurrence, progression, and survival. Being physically active after a cancer diagnosis is linked to better cancer-specific outcomes for several cancer types ²⁹².
Breast cancer: Consistent evidence from epidemiologic studies links physical activity after diagnosis with better breast cancer outcomes ²⁹³, ²⁹⁴. For example, a large cohort study found that women who exercised moderately (the equivalent of walking 3 to 5 hours per week at an average pace) after a breast cancer diagnosis had approximately 40% to 50% lower risks of breast cancer recurrence, death from breast cancer, and death from any cause compared with more sedentary women ²⁹⁵. The potential physical activity benefit with regard to death from breast cancer was most apparent in women with hormone receptor–positive tumors ²⁹⁵.Another prospective cohort study found that women who had breast cancer and who engaged in recreational physical activity roughly equivalent to walking at an average pace of 2 to 2.9 mph for 1 hour per week had a 35% to 49% lower risk of death from breast cancer compared with women who engaged in less physical activity ²⁹⁶.Colorectal cancer: Evidence from multiple epidemiologic studies suggests that physical activity after a colorectal cancer diagnosis is associated with reduced risks of dying from colorectal cancer ²⁹⁷. In a large prospective cohort of patients with colorectal cancer, those who engaged in leisure-time physical activity had a 31% lower risk of death than those who did not, independent of their leisure-time physical activity before diagnosis ²⁹⁸.Prostate cancer: Limited evidence from a few epidemiologic studies has suggested a possible link between physical activity and better outcomes among men diagnosed with prostate cancer. In one study, men with nonmetastatic prostate cancer who engaged in vigorous activity for at least 3 hours per week had a 61% lower risk of death from prostate cancer compared with men who engaged in vigorous activity for less than 1 hour per week ²⁹⁹. Another study of men with localized prostate cancer found that higher levels of physical activity were associated with reduced overall and prostate cancer–specific mortality ³⁰⁰.

Exercise and Polycystic ovarian syndrome

Polycystic ovary (PCO) is a term used when ovaries have numerous cysts, i.e., blisters, on their surface. PCO is diagnosed using ultrasound scanning. Most women are diagnosed with the condition in connection with examination for irregular menstruation or infertility ³⁰¹. PCO occurs in approximately 20% of all women of child-bearing age. Another term is polycystic ovary syndrome (PCOS), which occurs in 15% of women. The term PCOS indicates that women diagnosed with PCO can also have several other signs of hormone disorders.

PCOS is diagnosed in women who fulfill at least two of the following criteria: (a) PCO established after ultrasound scan; (b) irregular or no ovulation; and/or (c) increased body hair or increased levels of testosterone in the blood. Other causes of these symptoms must be ruled out, as several other hormone disorders can produce the same symptoms as PCOS. One of the most common symptoms of PCOS is an irregular menstrual cycle with long intervals between menstruation and no menstruation. This can be an indication of an ovulation disorder. Women with PCOS often tend to be overweight with an increased waist-to-hip ratio, and a large number of them are severely overweight. Many also have excess body hair, for example facial hair. Others have acne and a tendency to have thin hair or hair loss. Increased levels of testosterone are another frequent symptom.

The various symptoms in connection with PCOS manifest themselves very differently in each individual. Some women with PCOS have very light symptoms while others are more affected. PCOS can be present for a number of years without clinical symptoms before it becomes apparent, often in connection with an increase in weight and physical inactivity. The symptoms can also change over the years. Initial symptoms can already occur at the age of 14.

For many years, research on PCOS has focused on fertility and on investigating how women with PCOS can have a normal pregnancy. Families of women with PCOS, however, often have a high incidence of type 2 diabetes. Women with PCOS often have insulin resistance, higher cholesterol in the blood, abdominal obesity, and early signs of atherosclerosis. As the definition of PCOS has changed throughout the years, it is difficult to clearly and conclusively interpret earlier and present-day research in the field, but the evidence points to women with PCOS having a higher risk of developing clinical cardiovascular disease and type 2 diabetes. Of note, young women with PCOS engaged in physical activities less than controls. Also, women with PCOS were less likely to be aware of the positive effects of exercise on their health.

There is some evidence that physical exercise can have an impact. There is a 2011 systematic review that consists of eight manuscripts, five randomized controlled trials and three cohort studies. All studies involved moderate physical exercise (aerobic or strength training) over a period of 12–24 weeks. Training was found to have a positive effect on ovulation, insulin resistance, and weight loss. It was, however, not possible to identify a specific form of training program that produced the optimum effect ³⁰². This conclusion is supported by other systematic reviews ³⁰³. Training in connection with a hypocaloric diet leads to better body composition than diet alone ³⁰⁴ and exercise training enhances flow-mediated dilation, an adaptation associated with reduced cardiovascular disease risk. Of note, this effect occurred independent of changes in body composition ³⁰⁵.

Exercise while Pregnant and After having your Baby

It’s perfectly okay to to be physically active while you’re pregnant and after having your baby ³⁰⁶. The American College of Sports Medicine (ACSM) and American Congress of Obstetrics and Gynecology (ACOG) have similar guidelines that encourage pregnant women to engage in health-related physical activity during pregnancy ³⁰⁷.

Physical activity in pregnancy has minimal risks and has been shown to benefit most women, although some modification to exercise routines may be necessary because of normal anatomic and physiologic changes and fetal requirements. Women with uncomplicated pregnancies should be encouraged to engage in aerobic and strength-conditioning exercises before, during, and after pregnancy ³⁰⁷. Obstetrician–gynecologists and other obstetric care providers should carefully evaluate women with medical or obstetric complications before making recommendations on physical activity participation during pregnancy ³⁰⁷. Although frequently prescribed, bed rest is only rarely indicated and, in most cases, allowing ambulation should be considered. Regular physical activity during pregnancy improves or maintains physical fitness, helps with weight management, reduces the risk of gestational diabetes in obese women, and enhances psychologic well-being. An exercise program that leads to an eventual goal of moderate-intensity exercise for at least 20–30 minutes per day on most or all days of the week should be developed with the patient and adjusted as medically indicated ³⁰⁷.

Healthy women who already do vigorous-intensity aerobic activity, such as running, or large amounts of activity can continue doing so during and after their pregnancy provided they stay healthy and discuss with their health care provider how and when activity should be adjusted over time.

If you are a healthy pregnant or postpartum woman, physical activity is good for your overall health. For example, moderate-intensity physical activity, such as brisk walking, keeps your heart and lungs healthy during and after pregnancy. Physical activity also helps improve your mood throughout the postpartum period. After you have your baby, exercise helps maintain a healthy weight, and when combined with eating fewer calories helps with weight loss.

According to scientific evidence, the risks of moderate-intensity aerobic activity, such as brisk walking, are very low for healthy pregnant women. Physical activity does not increase your chances of low-birth weight, early delivery, or early pregnancy loss. It’s also not likely that the composition or amount of your breast milk or your baby’s growth will be affected by physical activity.

Unless you have a medical reason to avoid physical activity during or after your pregnancy, you can begin or continue moderate-intensity aerobic activity. If you begin physical activity during your pregnancy, start slowly and increase your amount gradually over time. While pregnant, you should avoid doing any activity that involves lying on your back or that puts you at risk of falling or abdominal injury, such as horseback riding, soccer, or basketball ³⁰⁶.

Is it safe to exercise during pregnancy ?

If you are healthy and your pregnancy is normal, it is safe to continue or start most types of exercise, but you may need to make a few changes. Physical activity does not increase your risk of miscarriage, low birth weight, or early delivery ³⁰⁸. However, it is important to discuss exercise with your obstetrician or other member of your health care team during your early prenatal visits. If your health care professional gives you the OK to exercise, you can decide together on an exercise routine that fits your needs and is safe during pregnancy.

Are there certain conditions that make exercise during pregnancy unsafe ?

Women with the following conditions or pregnancy complications should not exercise during pregnancy ³⁰⁸:

Certain types of heart and lung diseases
Cervical insufficiency (inability of the cervix to retain a pregnancy in the second trimester) or cerclage (a procedure in which the cervical opening is closed with stitches in order to prevent or delay preterm birth)
Being pregnant with twins or triplets (or more) with risk factors for preterm labor
Placenta previa (a condition in which the placenta lies very low in the uterus, so that the opening of the uterus is partially or completely covered) after 26 weeks of pregnancy.
Preterm (born before 37 completed weeks of pregnancy) labor or ruptured membranes (your water has broken) during this pregnancy
Preeclampsia or pregnancy-induced high blood pressure. Preeclampsia: A disorder that can occur during pregnancy or after childbirth in which there is high blood pressure and other signs of organ injury, such as an abnormal amount of protein in the urine, a low number of platelets, abnormal kidney or liver function, pain over the upper abdomen, fluid in the lungs, or a severe headache or changes in vision.
Severe anemia. Abnormally low levels of blood or red blood cells in the bloodstream. Most cases are caused by iron deficiency or lack of iron.

What are the benefits of exercise during pregnancy ?

Regular exercise during pregnancy benefits you and your baby in these key ways:

Reduces back pain
Eases constipation
May decrease your risk of gestational diabetes, preeclampsia, and cesarean delivery
Promotes healthy weight gain during pregnancy
Improves your overall general fitness and strengthens your heart and blood vessels
Helps you to lose the baby weight after your baby is born

How much exercise should you do during pregnancy ?

The Centers for Disease Control and Prevention recommend that pregnant women get at least 150 minutes of moderate-intensity aerobic activity every week. An aerobic activity is one in which you move large muscles of the body (like those in the legs and arms) in a rhythmic way. Moderate intensity means you are moving enough to raise your heart rate and start sweating. You still can talk normally, but you cannot sing.

Examples of moderate-intensity aerobic activity include brisk walking and general gardening (raking, weeding, or digging). You can divide the 150 minutes into 30-minute workouts on 5 days of the week or into smaller 10-minute workouts throughout each day.

If you are new to exercise, start out slowly and gradually increase your activity. Begin with as little as 5 minutes a day. Add 5 minutes each week until you can stay active for 30 minutes a day.

If you were very active before pregnancy, you can keep doing the same workouts with your health care professional’s approval. However, if you start to lose weight, you may need to increase the number of calories that you eat.

What changes occur in the body during pregnancy that can affect your exercise routine ?

Your body goes through many changes during pregnancy. It is important to choose exercises that take these changes into account:

Joints—The hormones made during pregnancy cause the ligaments that support your joints to become relaxed. This makes the joints more mobile and at risk of injury. Avoid jerky, bouncy, or high-impact motions that can increase your risk of being hurt.
Balance—During pregnancy, the extra weight in the front of your body shifts your center of gravity. This places stress on joints and muscles, especially those in your pelvis and low back. Because you are less stable and more likely to lose your balance, you are at greater risk of falling.
Breathing—When you exercise, oxygen and blood flow are directed to your muscles and away from other areas of your body. While you are pregnant, your need for oxygen increases. As your belly grows, you may become short of breath more easily because of increased pressure of the uterus on the diaphragm (a muscle that aids in breathing). These changes may affect your ability to do strenuous exercise, especially if you are overweight or obese.

What precautions should you take when exercising during pregnancy ?

There are a few precautions that pregnant women should keep in mind during exercise:

Drink plenty of water before, during, and after your workout. Signs of dehydration include dizziness, a racing or pounding heart, and urinating only small amounts or having urine that is dark yellow.
Wear a sports bra that gives lots of support to help protect your breasts. Later in pregnancy, a belly support belt may reduce discomfort while walking or running.
Avoid becoming overheated, especially in the first trimester. Drink plenty of water, wear loose-fitting clothing, and exercise in a temperature-controlled room. Do not exercise outside when it is very hot or humid.
Avoid standing still or lying flat on your back as much as possible. When you lie on your back, your uterus presses on a large vein that returns blood to the heart. Standing motionless can cause blood to pool in your legs and feet. Both of these positions can decrease the amount of blood returning to your heart and may cause your blood pressure to decrease for a short time.

What are some safe exercises you can do during pregnancy ?

Whether you are new to exercise or it already is part of your weekly routine, choose activities that experts agree are safest for pregnant women:

Walking—Brisk walking gives a total body workout and is easy on the joints and muscles.
Swimming and water workouts—Water workouts use many of the body’s muscles. The water supports your weight so you avoid injury and muscle strain. If you find brisk walking difficult because of low back pain, water exercise is a good way to stay active.
Stationary bicycling—Because your growing belly can affect your balance and make you more prone to falls, riding a standard bicycle during pregnancy can be risky. Cycling on a stationary bike is a better choice.
Modified yoga and modified Pilates—Yoga reduces stress, improves flexibility, and encourages stretching and focused breathing. There are even prenatal yoga and Pilates classes designed for pregnant women. These classes often teach modified poses that accommodate a pregnant woman’s shifting balance.
You also should avoid poses that require you to be still or lie on your back for long periods.

If you are an experienced runner, jogger, or racquet-sports player, you may be able to keep doing these activities during pregnancy. Discuss these activities with your health care professional.

What exercises you should avoid during pregnancy ?

While pregnant, avoid activities that put you at increased risk of injury, such as the following:

Contact sports and sports that put you at risk of getting hit in the abdomen, including ice hockey, boxing, soccer, and basketball
Skydiving
Activities that may result in a fall, such as downhill snow skiing, water skiing, surfing, off-road cycling, gymnastics, and horseback riding
“Hot yoga” or “hot Pilates,” which may cause you to become overheated
Scuba diving
Activities performed above 6,000 feet (if you do not already live at a high altitude)

What are warning signs that you should stop exercising ?

Stop exercising and call your obstetrician or other member of your health care team if you have any of these signs or symptoms:

Bleeding from the vagina
Feeling dizzy or faint
Shortness of breath before starting exercise
Chest pain
Headache
Muscle weakness
Calf pain or swelling
Regular, painful contractions of the uterus
Fluid leaking from the vagina

Why is it important to keep exercising after your baby is born ?

Exercising after your baby is born may help improve mood and decreases the risk of deep vein thrombosis, a condition that can occur more frequently in women in the weeks after childbirth. In addition to these health benefits, exercise after pregnancy can help you lose the extra pounds that you may have gained during pregnancy.

Exercise has the following benefits for postpartum women:

It helps strengthen and tone abdominal muscles.
It boosts energy.
It may be useful in preventing postpartum depression.
It promotes better sleep.
It relieves stress.

How much exercise you should do after you have a baby ?

After having a baby, it is recommended that you get at least 150 minutes of moderate-intensity aerobic activity every week.

What is aerobic activity ?

An aerobic activity is one in which you move large muscles of the body (like those in the legs and arms) in a rhythmic way.

What is moderate-intensity activity ?

Moderate intensity means you are moving enough to raise your heart rate and start sweating. You can still talk normally, but you cannot sing. Examples of moderate-intensity aerobic activities include brisk walking and riding a bike on a level surface. You can choose to divide the 150 minutes into 30-minute workouts on 5 days of the week or into smaller 10-minute sessions throughout each day. For example, you could go for three 10-minute walks each day.

What is vigorous-intensity activity ?

A vigorous-intensity activity is one in which it is hard to talk without pausing for breath. If you followed a vigorous-intensity exercise program before pregnancy, it may be possible to return to your regular workouts soon after the baby is born. Be sure to get your health care provider’s approval. Examples include running, jumping rope, and swimming laps.

What are muscle-strengthening workouts and how often should you do them ?

This type of exercise works the body’s major muscle groups, such as the legs, arms, and hips. Examples include yoga, Pilates, lifting weights, sit-ups, and push-ups. There also are special Kegel exercises that help tone the muscles of the pelvic floor. Muscle-strengthening activities should be done in addition to your aerobic activity on at least 2 days a week.

When can you start exercising after pregnancy ?

If you had a healthy pregnancy and a normal vaginal delivery, you should be able to start exercising again soon after the baby is born. Usually, it is safe to begin exercising a few days after giving birth—or as soon as you feel ready. If you had a cesarean delivery or other complications, ask your health care provider when it is safe to begin exercising again.

What are some guidelines you can follow when you begin exercising after pregnancy ?

Aim to stay active for 20–30 minutes a day. When you first start exercising after childbirth, try simple postpartum exercises that help strengthen major muscle groups, including abdominal and back muscles. Gradually add moderate-intensity exercise. Remember, even 10 minutes of exercise benefits your body. If you exercised vigorously before pregnancy or you are a competitive athlete, you can work up to vigorous-intensity activity. Stop exercising if you feel pain.

What are some ways to start exercising ?

When you are ready to start exercising, walking is a great way to get back in shape. Walking outside has an added bonus because you can push your baby in a stroller. There are special strollers made for this kind of activity, but using a regular stroller is fine. Another good way to get daily exercise is by joining an exercise class. Working out with a group and socializing with group members can help keep you motivated.

Where you can find out about exercise classes ?

Check with your local fitness clubs or community centers for classes that interest you, such as yoga, Pilates, spinning, and dance. Some gyms even offer special postpartum exercise classes and classes you can take with your baby. You also might consider working out with a personal trainer for the first few weeks.

What can you do if you want to exercise but don’t want to join a gym ?

If you do not want to join a gym but want the benefits of having someone to exercise with, ask a friend to be your workout buddy. If you want to exercise on your own, check out fitness DVDs and online exercise programs. Many are designed for women who have just had a baby. Some even show you how to involve your baby in the exercise routines.

How you can stay motivated once you start exercising ?

You may already have a great exercise tool in your pocket. Smart phone apps for exercise and fitness can help you stay motivated, keep track of your progress, and connect you with others with the same exercise goals. Many apps are free or cost very little.

How should you prepare for your workout ?

As you get ready for your workout, follow these steps:

Wear loose-fitting clothing that will help keep you cool.
If you are breastfeeding, feed your baby or express your milk before your workout to avoid any discomfort that may come from engorged breasts.
Wear a bra that fits well and gives plenty of support to protect your breasts.
Have a bottle of water handy and take several sips during your workout.

How you should warm up before your workout ?

Spend 10 minutes warming up to get your muscles ready for exercise. Try stretches for the lower back, pelvis, and thighs. Hold stretches for several seconds and return to the starting position. Walking in place also is a good way to warm up.

How you should cool down after your workout ?

End your workout with a 5-minute cool-down period that brings your heart rate back to normal. Walk slowly in place and stretch again to help avoid soreness.

Exercise for Older Adults and is Essential for Healthy Aging

Physical Activity is essential to healthy aging. As an older adult, regular physical activity is one of the most important things you can do for your health. It can prevent many of the health problems that seem to come with age. It also helps your muscles grow stronger so you can keep doing your day-to-day activities without becoming dependent on others ³⁰⁶.

Not doing any physical activity can be bad for you, no matter your age or health condition. Keep in mind, some physical activity is better than none at all. Your health benefits will also increase with the more physical activity that you do.

If you’re 65 years of age or older, are generally fit, and have no limiting health conditions you can follow the guidelines listed below ³⁰⁶. exercise and aging

Older adults need at least:

2 hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity (i.e., brisk walking) every week and weight training muscle-strengthening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms).

1 hour and 15 minutes (75 minutes) of vigorous-intensity aerobic activity (i.e., jogging or running) every week and weight training muscle-strengthening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms).

An equivalent mix of moderate- and vigorous-intensity aerobic activity and weight training muscle-strengthening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms).

For Even Greater Health Benefits

5 hours (300 minutes) each week of moderate-intensity aerobic activity and weight training muscle-strengthening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms).

2 hours and 30 minutes (150 minutes) each week of vigorous-intensity aerobic activity and weight training muscle-strengthening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms).

Muscle-strengthening activities

Besides aerobic activity, you need to do things to make your muscles stronger at least 2 days a week. These types of activities will help keep you from losing muscle as you get older.

To gain health benefits, muscle-strengthening activities need to be done to the point where it’s hard for you to do another repetition without help. A repetition is one complete movement of an activity, like lifting a weight or doing one sit-up. Try to do 8—12 repetitions per activity that count as 1 set. Try to do at least 1 set of muscle-strengthening activities, but to gain even more benefits, do 2 or 3 sets.

There are many ways you can strengthen your muscles, whether it’s at home or the gym. The activities you choose should work all the major muscle groups of your body (legs, hips, back, chest, abdomen, shoulders, and arms). You may want to try:

Lifting weights
Working with resistance bands
Doing exercises that use your body weight for resistance (push ups, sit ups)
Heavy gardening (digging, shoveling)
Yoga

What’s the Signal To Maintain Health and overcome Aging ?

The master signal for health, optimism, energy, effectiveness, and youth — is serious exercise, six days a week, until the day you die. Seventy percent of aging is in our own hands! You can overcome 70 percent of normal aging, until almost the end of life. You can be roughly the same woman or man you were at forty-five or fifty until you are eighty and beyond.

Exercising for 45-60 minutes a day for 6 days a week, sounds like it’s quite a lot, but it is actually a terrific deal because the body’s decay signals are running, nonstop, 24 / 7, and they are very effective. After age forty you lose up to 10 percent of your muscle mass a decade and the same is true for bone mass, as well as for coordination and balance. The amazing news is that we are able to reverse all that—over 70 percent of it anyway—by moving, doing physical exercise a measly forty-five to sixty minutes a day, six days a week.

Most Americans get less than 10 minutes of moderate exercise every day.

The nerve impulse to contract a muscle also sends a tiny signal to build it up, creating a moment-to-moment chemical balance between growth and decay within the muscle. Billions of signals racing around to every cell in the body, all day long. The system is amazingly subtle and complex; think for a second about the millions of mini-signals to the muscles every instant, just to enable us to stand upright. But curiously, the signals are pretty simple. It’s always one of two things: Grow or atrophy. Grow or decay. That’s the message to the cells all day
long, throughout our lives. So here’s the connection: When you exercise fairly hard, you stress your muscles, and you actually injure them slightly. When cells sense the damage from exercise, they automatically release chemicals to start the inflammation. The chemicals that
control inflammation are called cytokines; hundreds of them are at work in your body, regulating growth and decay down to the microscopic level.

Exercise for Children

Children and adolescents should do 60 minutes (1 hour) or more of physical activity each day ³⁰⁹.

Just make sure your child or adolescent is doing three types of physical activity:

Aerobic Activity

Aerobic activity should make up most of your child’s 60 or more minutes of physical activity each day. This can include either moderate-intensity aerobic activity, such as brisk walking, or vigorous-intensity activity, such as running. Be sure to include vigorous-intensity aerobic activity on at least 3 days per week.

Muscle Strengthening

Include muscle strengthening activities, such as gymnastics or push-ups, at least 3 days per week as part of your child’s 60 or more minutes.

Bone Strengthening

Include bone strengthening activities, such as jumping rope or running, at least 3 days per week as part of your child’s 60 or more minutes.

Some physical activity is better-suited for children than adolescents. For example, children do not usually need formal muscle-strengthening programs, such as lifting weights. Younger children usually strengthen their muscles when they do gymnastics, play on a jungle gym or climb trees. As children grow older and become adolescents, they may start structured weight programs. For example, they may do these types of programs along with their football or basketball team practice.

children and exercise

How much Exercise or Physical Activity do you need ?

When it comes to weight management, people vary greatly in how much physical activity they need. Here are some guidelines to follow:

To maintain your weight

Work your way up to 150 minutes of moderate-intensity aerobic activity, 75 minutes of vigorous-intensity aerobic activity, or an equivalent mix of the two each week. Strong scientific evidence shows that physical activity can help you maintain your weight over time. However, the exact amount of physical activity needed to do this is not clear since it varies greatly from person to person. It’s possible that you may need to do more than the equivalent of 150 minutes of moderate-intensity activity a week to maintain your weight.

To lose weight and keep it off

You will need a high amount of physical activity unless you also adjust your diet and reduce the amount of calories you’re eating and drinking. Getting to and staying at a healthy weight requires both regular physical activity and a healthy eating plan.

What do moderate and vigorous-intensity mean ?

To understand and measure the intensity (the level of effort required by a person to do an activity) of aerobic activity pay attention to how your physical activity affects your heart rate and breathing.

The talk test is a simple way to measure relative intensity. In general, if you’re doing moderate-intensity activity you can talk, but not sing, during the activity. If you’re doing vigorous-intensity activity, you will not be able to say more than a few words without pausing for a breath ³¹⁰.

Absolute Intensity

The amount of energy used by the body per minute of activity. The table below lists examples of activities classified as moderate-intensity or vigorous-intensity based upon the amount of energy used by the body while doing the activity ³¹⁰.

Moderate: While performing the physical activity, if your breathing and heart rate is noticeably faster but you can still carry on a conversation — it’s probably moderately intense. Examples include:
- Walking briskly (a 15-minute mile).
- Light yard work (raking/bagging leaves or using a lawn mower).
- Water aerobics
- Bicycling slower than 10 miles per hour (biking at a casual pace)
- Tennis (doubles)
- Ballroom dancing
- General gardening
- Light snow shoveling.
- Actively playing with children.
Vigorous: Your heart rate is increased substantially and you are breathing too hard and fast to have a conversation, it’s probably vigorously intense. Examples include:
- Jogging/running.
- Hiking uphill or with a heavy backpack
- Tennis (singles)
- Aerobic dancing
- Jumping rope
- Swimming laps.
- Rollerblading/inline skating at a brisk pace.
- Cross-country skiing.
- Most competitive sports (football, basketball, or soccer).
- Jumping rope.

Target Heart Rate and Estimated Maximum Heart Rate

One way of monitoring physical activity intensity is to determine whether a your pulse or heart rate is within the target zone during physical activity.

The basic way to calculate your maximum heart rate is to subtract your age from 220 ³¹¹. For example, if you’re 45 years old, subtract 45 from 220 to get a maximum heart rate of 175. This is the maximum number of times your heart should beat per minute during exercise.

Maximum Heart Rate = 220 – Age

For moderate-intensity physical activity, your target heart rate should be between 64% and 76% of your maximum heart rate ⁵⁵, ⁵⁶. This maximum rate is based on the person’s age. To estimate your maximum age-related heart rate, subtract your age from 220. For example, for a 50-year-old person, the estimated maximum age-related heart rate would be calculated as 220 – 50 years = 170 beats per minute (bpm). The 64% and 76% levels would be:

64% level: 170 x 0.64 = 109 bpm, and
76% level: 170 x 0.76 = 129 bpm

Thus, moderate-intensity physical activity for a 50-year-old person will require that the heart rate remains between 109 and 129 bpm during physical activity.

For vigorous-intensity physical activity, your target heart rate should be between 77% and 93% of your maximum heart rate ⁵⁵, ⁵⁶. You can estimate your maximum heart rate based on your age. To estimate your maximum age-related heart rate, subtract your age from 220. For example, for a 35-year-old person, the estimated maximum age-related heart rate would be calculated as 220 – 35 years = 185 beats per minute (bpm). The 77% and 93% levels would be:

77% level: 185 x 0.77 = 142 bpm, and
93% level: 185 x 0.93 = 172 bpm

This shows that vigorous-intensity physical activity for a 35-year-old person will require that the heart rate remains between 142 and 172 bpm during physical activity.

Taking Your Heart Rate

Generally, to determine whether you are exercising within the heart rate target zone, you must stop exercising briefly to take your pulse. You can take the pulse at the neck, the wrist, or the chest. We recommend the wrist. You can feel the radial pulse on the artery of the wrist in line with the thumb. Place the tips of the index and middle fingers over the artery and press lightly. Do not use the thumb. Take a full 60-second count of the heartbeats, or take for 30 seconds and multiply by 2. Start the count on a beat, which is counted as “zero.” If this number falls between 85 and 119 bpm in the case of the 50-year-old person, he or she is active within the target range for moderate-intensity activity.

Exercise improves general well-being.

People should engage in adequate levels of physical activity throughout their lives. The range of psychological and emotional benefits you get from exercise may be just as rich as what it can offer your physical body. At least 30 minutes of regular, moderate-intensity physical activity on most days reduces the risk of cardiovascular disease, type 2 diabetes, colon cancer and breast cancer. Muscle strengthening and balance training can reduce falls and improve mobility among older adults. Physical activity may be required for weight control.

Here are just some of the mental boosts you can benefit from when you incorporate regular physical activity into your healthy lifestyle.

You’ll be less stressed out. If you can’t eliminate stress from your life, you can at least learn to cope with it better. According to the American Psychological Association, exercise may have a positive impact on neurochemicals involved in stress responses by giving the body the chance to practice dealing with stress. When you have the cardiovascular system working with the nervous system and the muscular system and all sorts of other systems in the body, it naturally becomes more efficient when faced with stressful situations.

You may not suffer from as much anxiety or depression.

While there are varying levels of severity in anxiety and depression, anyone suffering from either condition shouldn’t discount the power of physical activity. When you exercise, your brain releases feel-good chemicals that may help combat negative thoughts, reduce chemicals in the immune systems that can worsen depression and create a calming effect by increasing your body temperature.

You’ll slow down the aging process of your brain and improve memory.

As we age, our cognitive abilities begin to deteriorate, but health and lifestyle factors can play an important role in how fast that happens. In one study, researchers assessed cognition, resting cerebral blood flow and cardiovascular fitness in a group of adults ages 57-75 before, in the middle of and after their 12-week aerobic workout regimen. They found that the exercises helped the participants’ improve their memory, brain health and physical fitness.

Your thinking and decision-making capabilities may improve.

Anyone who really wants to maximize their brainpower and increase productivity knows how important it is to avoid being sedentary. One study that monitored the activity of mice found that increased levels of cardiovascular exercise can produce more brain cells. Another study found that strenuous exercises leads to increased levels of proteins in the brain, called brain-derived neurotrophic factor (or BDNF). All of this is great news for those of us who want to keep our brains healthy and performing optimally.

You’ll get a boost in confidence.

Exercise may be hard for some people. It’s both physically uncomfortable to do and mentally uncomfortable to keep it up regularly when you really just don’t feel like doing it. But with a good, solid habit comes increased strength and goal achievements, which can have a great effect on your confidence levels. And that’s not even counting the added bonus of seeing and feeling the physical changes in your body.

You’ll be more present.

We already covered how regular exercise can help with anxiety, but it’s worth noting here at the end that it can pretty much help with clearing out all the crazy thoughts that are flying through your head. For many people, exercise has a meditative effect on them. It forces you to focus on the moment and what you’re doing—feeling your muscles work and your heart pump. And if you can get outside in a park or on a trail while doing it, that’s even better!

There’s a lot to be said about how our bodies were made to move, and it’s important to remember this as we’re all sitting at our office desks, driving in our cars, lounging on our couches and staring at our smartphones. One could argue that it really lays the foundation for how we live our lives.

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