Skip to main content

Main menu

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums

User menu

  • My alerts

Search

  • Advanced search
The College of Family Physicians of Canada
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums
  • My alerts
The College of Family Physicians of Canada

Advanced Search

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • RSS feeds
  • Follow cfp Template on Twitter
Article CommentaryCommentary

Impediments to clinical application of exercise interventions in the treatment of cardiometabolic disease

N. John Bosomworth
Canadian Family Physician March 2019, 65 (3) 164-170;
N. John Bosomworth
Honorary Lecturer in the Department of Family Practice at the University of British Columbia in Vancouver.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: jbosomworth@gmail.com
  • Article
  • Figures & Data
  • eLetters
  • Info & Metrics
  • PDF
Loading

Before enlightenment, chop wood, carry water. After enlightenment, chop wood, carry water.

Zen proverb

Statins have become a pharmacologic cornerstone for the prevention and treatment of cardiovascular disease (CVD). However, it is clear from the large statin trials that maximal lowering of low-density lipoprotein cholesterol (LDL-C) levels still allows 2 out of 3 cardiovascular events to occur.1 These events represent the so-called residual risk that remains after optimized statin therapy. Attempts to further lower LDL-C levels in patients with established CVD using high-dose statins,2 adding ezetimibe,3 or adding proprotein convertase subtilisin-kexin type 9 inhibitors4,5 have each resulted in a further modest absolute event reduction of 1% to 2% over 2 to 6 years. None of these augmentation trials has shown a reduction in all-cause mortality.

The prevalence of obesity has continued to increase in Canada6 and the United States.7 There is concern that since 1990 the mortality benefits from control of smoking, hypertension, and lipid levels have been offset by the harmful cardiometabolic effects of obesity.7 These effects are associated with hyperinsulinemia, diabetes, and metabolic syndrome. Many people with obesity exhibit the profile of “atherogenic dyslipidemia,” which is characterized by high triglyceride levels, low or dysfunctional high-density lipoprotein (HDL) levels, and a predominance of small dense LDL particles.8 The serum can contain large quantities of intensely atherogenic particles such as very low density lipoprotein, intermediate-density lipoprotein, chylomicron remnants, and remnant lipoproteins.9 Attempts to reduce cardiovascular events by lowering triglyceride levels and raising HDL levels using niacin10 or fenofibrate11 in addition to statins have been ineffective in large randomized trials. Similarly, the addition of cholesterol ester transfer protein inhibitors to statins in high-risk patients has statistically significantly raised HDL levels, but has not resulted in event reduction.12,13

As we seem to have reached maximum therapeutic potential in terms of statin use, and as add-on drug therapy currently affords only modest additional benefit, it seems prudent to refocus our emphasis on lifestyle options that can provide event reduction in conjunction with statin therapy. There has been great success with smoking cessation.14 Dietary and physical activity (PA) interventions can be similarly effective (physical activity is defined in Box 115,16). Suboptimal implementation of effective PA interventions might reflect poor physician uptake as much as patient nonadherence, and the reasons for this will be explored further in this article.

Box 1.

Glossary of terms

  • Cardiovascular fitness: Attributes that enhance ability to perform PA. Measured by maximal oxygen uptake. Might be partially genetic in origin, but can be trainable with exercise15

  • Exercise: A subset of PA that has a conditioning or maintenance objective, and that is planned, structured, and repetitive16

  • MET: 1 MET is defined as 1 kcal/kg per hour and is roughly the energy equivalent expended by an individual at rest

  • PA: Body movement produced by skeletal muscle requiring energy expenditure. Might include occupational, recreational, and conditioning activities, as well as activities of daily living

METs—metabolic equivalents, PA—physical activity.

Evidence for statins and PA

While statin benefits are well established, it might be less appreciated that PA is equally effective in preventing CVD mortality in secondary prevention17 and could actually be superior in CVD and all-cause mortality reduction in primary prevention (Table 1)3,17–57; however, the level of evidence for PA interventions is less robust. Table 13,17–57 summarizes meta-analyses and salient randomized controlled trials (RCTs) evaluating benefits of statins and PA. There is, for example, good evidence that diabetes is increased in statin users,32,33 while PA is a very effective preventive measure.34,35 Similarly, obesity is higher in statin users,36 while PA is an aid in prevention of weight gain.37 Lower incidence of all cancers except melanoma is directly associated with PA,44,45 as is a reduction in falls,48,49 while statins have no such effect.47 Quality of life, a key objective of health interventions, is uniformly improved with PA.55–57 This outcome exists independent of sex and many chronic disease states, including cancer.58 No useful data are available for the influence of statins on quality of life.

View this table:
  • View inline
  • View popup
Table 1.

Meta-analyses and RCTs evaluating effects of statins and PA on health outcomes

Suboptimal implementation

There are several possible reasons for suboptimal implementation of exercise interventions.

Reliance on inappropriate surrogate markers of success

Lipoprotein changes: Triglyceride levels fall reliably with exercise and levels are reduced for up to 15 days following a period of activity.35 High-density lipoprotein cholesterol level is increased, but this occurs primarily in those who exercise the most.59 Total cholesterol and LDL-C levels are generally unchanged with PA in available meta-analyses of RCTs.60–63 Included trials tend to have a duration of 1 to 6 months on average. It has been shown that short-term variability in cholesterol levels might vary by about −0.80 mmol/L to 0.80 mmol/L, and that it might take up to 4 years for long-term variation to exceed short-term variability.64 True benefits of PA are therefore unlikely to be reflected in the standard lipid profile over the short term. Benefits might instead be mediated by a reduction in LDL particle number as reflected by apolipoprotein B values65 or by direct measurement,66 making diffusion of atherogenic particles across the vascular endothelium less likely. Reliance on changes in LDL-C and total cholesterol levels will not reinforce the use of PA as a beneficial intervention.

Weight change: While the recommendation of engaging in moderate exercise for 30 minutes for 5 days a week plus 2 days of resistance training is effective in preserving cardiometabolic health,67 it is insufficient to prevent ongoing weight gain over time. Prevention of transition to overweight or obese status in our current food environment requires exercising for 45 to 60 minutes a day,68 and weight loss would require even more time if exercise alone were the intervention. Improved cardiometabolic health through exercise can be achieved without weight loss.69,70 It seems more reasonable to regularly monitor any changes in activity behaviour patterns as a measure of PA adherence, rather than to have a weight-loss expectation.

Reliance on short-term RCTs for information on long-term outcomes

There are no long-term RCTs that establish the causal effect of PA on CVD incidence.60 Ethical and feasibility issues make group assignment and adherence impossible to initiate and maintain. In fact, different studies are necessary to differentiate the efficacy and effectiveness of an intervention.71 Randomized controlled trials address efficacy and establish what we might expect. Effectiveness under real-world conditions requires an observational study, preferably a pragmatic controlled trial, with follow-up of study cohorts over time.72 It is difficult to enforce randomization in a preference-dominated world for sufficiently long periods of time.71 The most informative PA studies are prospective cohorts that are followed long enough to detect potential adverse effects and that stratify participants to be compared according to baseline risk, controlling as best as possible for confounding. Strength of association is also enhanced if a number of the Bradford Hill criteria73,74 for establishment of causality are met (Table 2).15,19,23,31,73–79 Randomized controlled trials cannot properly evaluate benefits and adverse effects over time while addressing patient preference and ensuring adherence under real-world conditions.

View this table:
  • View inline
  • View popup
Table 2.

Bradford Hill criteria for assessing the causal nature of an observed association

Concern over nonadherence

No studies were found on documenting adherence to an exercise prescription over time. A 2-year prospective study found that 18% to 24% of adults maintained recommended PA levels over the entire period.80 These subjects were self-motivated and received no prescription. On the other hand, 2-year adherence to statin medication was 40% following acute coronary syndrome, but only 25% for primary prevention.81 It seems likely that if activity interventions were reinforced as often and as enthusiastically as drug interventions, uptake and adherence might be similar to statin therapy. Small changes in activity produce large gains. Going from a sedentary state to a low level of any activity is associated with the highest incremental cardiometabolic benefit.82 Interventions far short of current recommendations can still have a considerable effect on cardiovascular outcomes.83

Failure to address diet

Excessive caloric and simple carbohydrate intake will completely overwhelm the weight-moderating effects of PA.84 Physical activity can aid weight control, and beneficial cardiometabolic effects will occur without weight loss, but there must be control of excess caloric and simple carbohydrate intake in our obesogenic environment if the usual default weight gain is to be avoided over time.85,86 The Mediterranean eating pattern is the best alternative for avoidance of weight gain,87 with no weight increase shown over 5 years despite unrestricted caloric intake in a large RCT.88

Insufficient knowledge to provide an appropriate prescription

Physicians’ lack of knowledge or confidence in generating an exercise prescription (Box 2) is a reflection of the fact that our teaching lacks the conviction that PA can be an effective health intervention. We therefore rely upon drugs, which are inferior to PA in many ways, including in mortality reduction and improvement in quality of life. The exercise prescription should be tailored for the individual patient considering baseline status, available time, and desired outcome. Brief interventions regularly reinforced have been shown by some to be effective.89,90 A sample prescription form can be found at www.exerciseismedicine.org/canada/assets/page_documents/EIMC_Pad_ENnewlogo_v3.0_1_copy.pdf. Table 356,67,68,83,89,91–100 presents illustrative exercise intervention scenarios for different patient needs.

Box 2.

Strategies that might help reinforce an increase in PA

When trying to increase a patient’s PA levels ...

  • Be an enthusiastic and committed prescriber with confidence in the evidence

  • Pay attention to objective measures of behaviour change rather than to unhelpful surrogates as measures of success

  • Consider suggesting dietary modification and simple carbohydrate reduction to avoid hyperinsulinemia and avoid default weight gain

  • Have confidence in generating an appropriate exercise prescription for every sedentary patient

  • Be willing to reinforce an exercise prescription with a program referral or a brief intervention at every visit

  • Recognize that we must not rely only upon pharmacotherapy to improve QOL and longevity

PA—physical activity, QOL—quality of life.

View this table:
  • View inline
  • View popup
Table 3.

Illustrative exercise interventions for varying patient needs

Cardiorespiratory fitness, a measurable outcome of increased PA, is one of the strongest prognostic indicators for long-term survival, surpassed only by patient age.75 The combination of increased fitness and statin therapy is additive when examined in long-term retrospective75 and prospective23 cohorts. Most older adults can achieve an exercise capacity of 5 to 7 metabolic equivalents (METs), which confers the same protection as a statin given to unfit subjects with an exercise capacity of less than 5 METs (Box 1)15,16; however, adding a statin at this level of fitness produces a further 35% relative risk reduction.23 Generally, an improvement in exercise capacity of 1 MET confers a mortality risk reduction of 12% to 15% according to meta-analysis.101

Statins added to PA might expose the patient to increased myopathy risk, especially at the extremes of drug and activity dosing, and in the elderly.102 The exercise prescription should precede the statin prescription, and an optimized PA program should be in place before adding drug therapy.103,104

Conclusion

Atherosclerosis is a lifestyle problem and deserves a lifestyle solution, especially in primary prevention.105 Strategies outlined in Box 2 might help reinforce an increase in PA.

Footnotes

  • Competing interests

    None declared

  • The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.

  • This article has been peer reviewed.

  • La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de mars 2019 à la page e79.

  • Copyright© the College of Family Physicians of Canada

References

  1. 1.↵
    1. Libby P
    . The forgotten majority: unfinished business in cardiovascular risk reduction. J Am Coll Cardiol 2005;46(7):1225-8.
    OpenUrlFREE Full Text
  2. 2.↵
    1. LaRosa JC,
    2. Grundy SM,
    3. Waters DD,
    4. Shear C,
    5. Barter P,
    6. Fruchart JC,
    7. et al
    . Intensive lipid lowering with atorvastatin in patients with stable coronary disease. N Engl J Med 2005;352(14):1425-35. Epub 2005 Mar 8.
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Cannon CP,
    2. Blazing MA,
    3. Giugliano RP,
    4. McCagg A,
    5. White JA,
    6. Theroux P,
    7. et al
    . Ezetimibe added to statin therapy after acute coronary syndromes. N Engl J Med 2015;372(25):2387-97. Epub 2015 Jun 3.
    OpenUrlCrossRefPubMed
  4. 4.↵
    1. Sabatine MS,
    2. Giugliano RP,
    3. Keech AC,
    4. Honarpour N,
    5. Wiviott SD,
    6. Murphy SA,
    7. et al
    . Evolocumab and clinical outcomes in patients with cardiovascular disease. N Engl J Med 2017;376(18):1713-22. Epub 2017 Mar 17.
    OpenUrlCrossRefPubMed
  5. 5.↵
    1. Robinson JG,
    2. Farnier M,
    3. Krempf M,
    4. Bergeron J,
    5. Luc G,
    6. Averna M,
    7. et al
    . Efficacy and safety of alirocumab in reducing lipids and cardiovascular events. N Engl J Med 2015;372(16):1489-99. Epub 2015 Mar 15.
    OpenUrlCrossRefPubMed
  6. 6.↵
    1. Statistics Canada [website]
    . Overweight and obese adults (self-reported), 2014. Ottawa, ON: Government of Canada; 2015. Available from: www150.statcan.gc.ca/n1/pub/82-625-x/2015001/article/14185-eng.htm. Accessed 2019 Jan 30.
  7. 7.↵
    1. Smith CY,
    2. Bailey KR,
    3. Emerson JA,
    4. Nemetz PN,
    5. Roger VL,
    6. Palumbo PJ,
    7. et al
    . Contributions of increasing obesity and diabetes to slowing decline in subclinical coronary artery disease. J Am Heart Assoc 2015;4(4):e001524. pii:.
    OpenUrlAbstract/FREE Full Text
  8. 8.↵
    1. Athyros VG,
    2. Tziomalos K,
    3. Karagiannis A,
    4. Mikahilidis P
    . Dyslipidaemia of obesity, metabolic syndrome and type 2 diabetes mellitus: the case for residual risk reduction after statin treatment. Open Cardiovasc Med J 2011;5:24-34. Epub 2011 Feb 24.
    OpenUrlCrossRefPubMed
  9. 9.↵
    1. Kones R
    . Primary prevention of coronary heart disease: integration of new data, evolving views, revised goals, and role of rosuvastatin in management. A comprehensive survey. Drug Des Devel Ther 2011;5:325-80. Epub 2011 Jun 13.
    OpenUrlPubMed
  10. 10.↵
    1. The AIM-HIGH Investigators,
    2. Boden WE,
    3. Probstfield JL,
    4. Anderson T,
    5. Chaitman BR,
    6. Desvignes-Nickens P,
    7. et al
    . Niacin in patients with low HDL cholesterol levels receiving intensive statin therapy. N Engl J Med 2011;365(24):2255-67. Epub 2011 Nov 15.
    OpenUrlCrossRefPubMed
  11. 11.↵
    1. ACCORD Study Group,
    2. Ginsberg HN,
    3. Elam MB,
    4. Lovato LC,
    5. Crouse JR 3rd,
    6. Leiter LA,
    7. et al
    . Effects of combination lipid therapy in type 2 diabetes mellitus. N Engl J Med 2010;362(17):1563-74. Epub 2010 Mar 14. Erratum in: N Engl J Med 2010;362(18):1748.
    OpenUrlCrossRefPubMed
  12. 12.↵
    1. Schwartz GG,
    2. Olsson AG,
    3. Abt M,
    4. Ballantyne CM,
    5. Barter PJ,
    6. Brumm J,
    7. et al
    . Effects of dalcetrapib in patients with a recent acute coronary syndrome. N Engl J Med 2012;367(22):2089-99. Epub 2012 Nov 5.
    OpenUrlCrossRefPubMed
  13. 13.↵
    1. Lincoff AM,
    2. Nicholls SJ,
    3. Reismeyer JS,
    4. Barter PJ,
    5. Brewer HB,
    6. Fox KA,
    7. et al
    . Evacetrapib and cardiovascular outcomes in high-risk vascular disease. N Engl J Med 2017;376(20):1933-42.
    OpenUrlCrossRefPubMed
  14. 14.↵
    1. Corsi DJ,
    2. Boyle MH,
    3. Lear SA,
    4. Chow CK,
    5. Teo KK,
    6. Subramanian SV
    . Trends in smoking in Canada from 1950 to 2011: progression of the tobacco epidemic according to socioeconomic status and geography. Cancer Causes Control 2014;25(1):45-57. Epub 2013 Oct 25.
    OpenUrlCrossRefPubMed
  15. 15.↵
    1. Earnest CP,
    2. Artero EG,
    3. Sui X,
    4. Lee DC,
    5. Church TS,
    6. Blair SN
    . Maximal estimated cardiorespiratory fitness, cardiometabolic risk factors and metabolic syndrome in the Aerobics Center Longitudinal Study. Mayo Clin Proc 2013;88(3):259-70.
    OpenUrlCrossRefPubMed
  16. 16.↵
    1. Caspersen CJ,
    2. Powell KE,
    3. Christensen GM
    . Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep 1985;100(2):126-31.
    OpenUrlPubMed
  17. 17.↵
    1. Naci H,
    2. Ioannidis JP
    . Comparative effectiveness of exercise and drug interventions on mortality outcomes: a metaepidemiological study. BMJ 2013;347:f5577.
    OpenUrlAbstract/FREE Full Text
  18. 18.
    1. Brugts JJ,
    2. Yetgin T,
    3. Hoeks SE,
    4. Gotto AM,
    5. Shepherd J,
    6. Westendorp RG,
    7. et al
    . The benefits of statins in people without established cardiovascular disease but with cardiovascular risk factors: meta-analysis of randomized controlled trials. BMJ 2009;338:b2376.
    OpenUrlAbstract/FREE Full Text
  19. 19.↵
    1. Hamer M,
    2. Chida Y
    . Walking and primary prevention: a meta-analysis of prospective cohort studies. Br J Sports Med 2008;42(4):238-43. Epub 2007 Nov 29.
    OpenUrlAbstract/FREE Full Text
  20. 20.
    1. Sofi F,
    2. Capalbo A,
    3. Cesari F,
    4. Abbate R,
    5. Gensini GF
    . Physical activity during leisure time and primary prevention of coronary heart disease: an updated meta-analysis of cohort studies. Eur J Cardiovasc Prev Rehabil 2008;15(3):247-57.
    OpenUrlCrossRefPubMed
  21. 21.
    1. Li TY,
    2. Rana JS,
    3. Manson JE,
    4. Willett WC,
    5. Stampfer MJ,
    6. Colditz GA,
    7. et al
    . Obesity as compared with physical activity in predicting risk of coronary heart disease in women. Circulation 2006;113(4):499-506.
    OpenUrlAbstract/FREE Full Text
  22. 22.
    1. Myers J,
    2. Kokkinos P,
    3. Soares de Araújo CG
    . Coronary artery disease prevention: should exercise, statins, or both be prescribed. Rev DERC 2014;20(4):102-5.
    OpenUrl
  23. 23.↵
    1. Kokkinos PF,
    2. Faselis C,
    3. Myers J,
    4. Panagiotakos D,
    5. Doumas M
    . Interactive effects of fitness and statin treatment on mortality risk in veterans with dyslipidaemia: a cohort study. Lancet 2013;381(9864):394-9. Epub 2012 Nov 28.
    OpenUrlCrossRefPubMed
  24. 24.
    1. Taylor F,
    2. Huffman MD,
    3. Macedo AF,
    4. Moore TH,
    5. Burke M,
    6. Davey SG,
    7. et al
    . Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev 2013;(1):CD004816.
  25. 25.
    1. Ray KK,
    2. Seshasai SR,
    3. Erqou S,
    4. Sever P,
    5. Jukema JW,
    6. Ford I,
    7. et al
    . Statins and all-cause mortality in high-risk primary prevention: a meta-analysis of 11 randomized controlled trials involving 65,229 participants. Arch Intern Med 2010;170(12):1024-31.
    OpenUrlCrossRefPubMed
  26. 26.
    1. Thavendiranathan P,
    2. Bagai A,
    3. Brookhard MA,
    4. Choudhry NK
    . Primary prevention of cardiovascular diseases with statin therapy: a meta-analysis of randomized controlled trials. Arch Intern Med 2006;166(21):2307-13.
    OpenUrlCrossRefPubMed
  27. 27.
    1. Bukkapatnam RN,
    2. Gabler NB,
    3. Lewis WR
    . Statins for primary prevention of cardiovascular mortality in women: a systematic review and meta-analysis. Prev Cardiol 2010;13(2):84-90.
    OpenUrlCrossRefPubMed
  28. 28.
    1. Kostis WJ,
    2. Cheng JQ,
    3. Dobrzynski JM,
    4. Cabera J,
    5. Kostis JB
    . Meta-analysis of statin effects in women versus men. J Am Coll Cardiol 2012;59(6):572-82. Erratum in: J Am Coll Cardiol 2012;59(16)1491.
    OpenUrlFREE Full Text
  29. 29.
    1. Cholesterol Treatment Trialists’ Collaborators,
    2. Mihaylova B,
    3. Emberson J,
    4. Blackwell L,
    5. Keech A,
    6. Simes J,
    7. et al
    . The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet 2012;380(9841):581-90. Epub 2012 May 17.
    OpenUrlCrossRefPubMed
  30. 30.
    1. Nocon M,
    2. Hiemann T,
    3. Müller-Riemenschneider F,
    4. Thalau F,
    5. Roll S,
    6. Willich S
    . Association of physical activity with all-cause and cardiovascular mortality: a systematic review and meta-analysis. Eur J Cardiovasc Prev Rehabil 2008;15(3):239-46.
    OpenUrlCrossRefPubMed
  31. 31.↵
    1. Evenson KR,
    2. Wen F,
    3. Herring AH
    . Association of accelerometry-assessed and self-reported physical activity and sedentary behaviour with all-cause and cardiovascular mortality among US adults. Am J Epidemiol 2016;184(9):621-32. Epub 2016 Oct 19.
    OpenUrlCrossRefPubMed
  32. 32.↵
    1. Sattar N,
    2. Preiss D,
    3. Murray HM,
    4. Welsh P,
    5. Buckley BM,
    6. de Craen AJ,
    7. et al
    . Statins and the risk of incident diabetes: a collaborative meta-analysis of randomised statin trials. Lancet 2010;375(9716):735-42. Epub 2010 Feb 16.
    OpenUrlCrossRefPubMed
  33. 33.↵
    1. Preiss D,
    2. Seshasai SR,
    3. Welsh P,
    4. Murphy SA,
    5. Ho JE,
    6. Waters DD,
    7. et al
    . Risk of incident diabetes with intensive-dose compared with moderate-dose statin therapy: a meta-analysis. JAMA 2011;305(24):2556-64.
    OpenUrlCrossRefPubMed
  34. 34.↵
    1. Smith AD,
    2. Crippa A,
    3. Woodcock J,
    4. Brage S
    . Physical activity and incident type 2 diabetes mellitus: a systematic review and dose-response meta-analysis of prospective cohort studies. Diabetologia 2016;59(12):2527-45. Epub 2016 Oct 17.
    OpenUrlCrossRefPubMed
  35. 35.↵
    1. Slentz CA,
    2. Houmard JA,
    3. Johnson JL,
    4. Bateman LA,
    5. Tanner CJ,
    6. McCartney JS,
    7. et al
    . Inactivity, exercise training and detraining, and plasma lipoproteins. STRRIDE: a randomized controlled study of exercise intensity and amount. J Appl Physiol (1985) 2007;103(2):432-42. Epub 2007 Mar 29.
    OpenUrlCrossRefPubMed
  36. 36.↵
    1. Sugiyama T,
    2. Tsugawa Y,
    3. Tseng CH,
    4. Kobayashi Y,
    5. Shapiro MF
    . Is there gluttony in the time of statins? Different time trends of caloric fat intake between statin users and non-users among US adults. JAMA Intern Med 2014;174(7):1038-45.
    OpenUrl
  37. 37.↵
    1. Chin SH,
    2. Kahathudhua CN,
    3. Brinks M
    . Physical activity and obesity: what we know and what we need to know. Obes Rev 2016;17(12):1226-44. Epub 2016 Oct 14.
    OpenUrlPubMed
  38. 38.
    1. McGuinness B,
    2. Craig D,
    3. Bullock R,
    4. Malouf R,
    5. Passmore P
    . Statins for the treatment of dementia. Cochrane Database Syst Rev 2014;(7):CD007514.
  39. 39.
    1. McGuinness B,
    2. Craig D,
    3. Bullock R,
    4. Passmore P
    . Statins for the prevention of dementia. Cochrane Database Syst Rev 2016;(1):CD003160.
  40. 40.
    1. Blondell SJ,
    2. Hammersley-Mather R,
    3. Veerman JL
    . Does physical activity prevent cognitive decline and dementia? A systematic review and meta-analysis of longitudinal studies. BMC Public Health 2014;14:510.
    OpenUrlCrossRefPubMed
  41. 41.
    1. Young J,
    2. Angevaren M,
    3. Rusted J,
    4. Tabet N
    . Aerobic exercise to improve cognitive function in older people without known cognitive impairment. Cochrane Database Syst Rev 2015;(4):CD005381.
  42. 42.
    1. Collins R,
    2. Reith C,
    3. Emberson J,
    4. Armitage J,
    5. Baigent C,
    6. Blackwell L,
    7. et al
    . Interpretation of the evidence for the efficacy and safety of statin therapy. Lancet 2016;388(10059):2532-61. Epub 2016 Sep 8.
    OpenUrlCrossRef
  43. 43.
    1. Lv HL,
    2. Jin DM,
    3. Liu M,
    4. Liu YM,
    5. Wang JF,
    6. Geng DF
    . Long-term efficacy and safety of statin treatment beyond six years: a meta-analysis of randomized controlled trials with extended follow-up. Pharmacol Res 2014;81:64-73. Epub 2014 Mar 3.
    OpenUrlCrossRefPubMed
  44. 44.↵
    1. Moore SC,
    2. Lee IM,
    3. Weiderpass E,
    4. Campbell PT,
    5. Sampson JN,
    6. Kitahara CM,
    7. et al
    . Association of leisure-time physical activity with risk of 26 types of cancer in 1.44 million adults. JAMA Intern Med 2016;176(6):816-25.
    OpenUrl
  45. 45.↵
    1. Li T,
    2. Wei S,
    3. Shi Y,
    4. Pang S,
    5. Qin Q,
    6. Yin J,
    7. et al
    . The dose-response effect of physical activity on cancer mortality: findings from 71 prospective cohort studies. Br J Sports Med 2016;50(6):339-45. Epub 2015 Sep 18.
    OpenUrlAbstract/FREE Full Text
  46. 46.
    1. Haerer W,
    2. Delbaere K,
    3. Bartlett H,
    4. Lord SR,
    5. Rowland J
    . Relationships between HMG-CoA reductase inhibitors (statin) use and strength, balance and falls in older people. Intern Med J 2012;42(12):1329-34.
    OpenUrlCrossRefPubMed
  47. 47.↵
    1. Scott D,
    2. Blizzard L,
    3. Fell J,
    4. Jones G
    . Statin therapy, muscle function and falls risk in community-dwelling older adults. QJM 2009;102(9):625-33. Epub 2009 Jul 24.
    OpenUrlCrossRefPubMed
  48. 48.↵
    1. Gillespie LD,
    2. Robertson MC,
    3. Gillespie WJ,
    4. Sherrington C,
    5. Gates S,
    6. Clemson LM,
    7. et al
    . Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012;(9):CD007146.
  49. 49.↵
    1. El-Khoury F,
    2. Cassou B,
    3. Charles MA,
    4. Dargent-Molina P
    . The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials. BMJ 2013;347:f6234.
    OpenUrlAbstract/FREE Full Text
  50. 50.
    1. Jin S,
    2. Jiang J,
    3. Bai P,
    4. Zhang M,
    5. Tong X,
    6. Wang H,
    7. et al
    . Statin use and risk of fracture: a meta-analysis. Int J Clin Exp Med 2015;8(5):8269-75.
    OpenUrl
  51. 51.
    1. Qu X,
    2. Zhang X,
    3. Zhai Z,
    4. Li H,
    5. Lui X,
    6. Li H,
    7. et al
    . Association between physical activity and risk of fracture. J Bone Miner Res 2014;29(1):202-11.
    OpenUrlCrossRefPubMed
  52. 52.
    1. Savarese G,
    2. Gotto AM Jr,
    3. Paolillo S,
    4. D’Amore C,
    5. Losco T,
    6. Musella F,
    7. et al
    . Benefits of statins in elderly subjects without established cardiovascular disease. J Am Coll Cardiol 2013;62(22):2090-9. Erratum in: J Am Coll Cardiol 2014;63(11):1122.
    OpenUrlFREE Full Text
  53. 53.
    1. Afilalo J,
    2. Duque G,
    3. Steele R,
    4. Jukema JW,
    5. Craen AJ,
    6. Eisenberg MJ
    . Statins for secondary prevention in elderly patients: a hierarchical Bayesian meta-analysis. J Am Coll Cardiol 2008;51(1):37-45.
    OpenUrlFREE Full Text
  54. 54.
    1. Hupin D,
    2. Roche F,
    3. Gremeaux V,
    4. Chatard JC,
    5. Oriol M,
    6. Gaspoz JM,
    7. et al
    . Even a low-dose of moderate-to-vigorous physical activity reduces mortality by 22% in adults aged ≥ 60 years: a systematic review and meta-analysis. Br J Sports Med 2015;49(19):1262-7. Epub 2015 Aug 3.
    OpenUrlAbstract/FREE Full Text
  55. 55.↵
    1. Anderson L,
    2. Thompson DR,
    3. Oldridge N,
    4. Zwisler AD,
    5. Rees K,
    6. Martin N,
    7. et al
    . Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2016;(1):CD001800.
  56. 56.↵
    1. Martin CK,
    2. Church TS,
    3. Thompson AM,
    4. Earnest CP,
    5. Blair SN
    . Exercise dose and quality of life: results of a randomized controlled trial. Arch Intern Med 2009;169(3):269-78.
    OpenUrlCrossRefPubMed
  57. 57.↵
    1. Myers VH,
    2. McVay MA,
    3. Brashear MM,
    4. Johannsen MN,
    5. Swift DL,
    6. Kramer K,
    7. et al
    . Exercise training and quality of life in individuals with type 2 diabetes. A randomized controlled trial. Diabetes Care 2013;36(7):1884-90. Epub 2013 Feb 12.
    OpenUrlAbstract/FREE Full Text
  58. 58.↵
    1. Buffart LM,
    2. Kalter J,
    3. Sweegers MG,
    4. Courneya KS,
    5. Newton RU,
    6. Aronson NK,
    7. et al
    . Effects and moderators of exercise on quality of life and physical function in patients with cancer: an individual patient data meta-analysis of 34 RCTs. Cancer Treat Rev 2017;52:91-104. Epub 2016 Dec 5.
    OpenUrlPubMed
  59. 59.↵
    1. Thompson PD,
    2. Rader DJ
    . Does exercise increase HDL cholesterol in those who need it the most? Arterioscler Thromb Vasc Biol 2001;21(7):1097-8.
    OpenUrlFREE Full Text
  60. 60.↵
    1. Lin X,
    2. Zhang X,
    3. Guo JJ,
    4. Roberts CK,
    5. McKenzie S,
    6. Wu WC,
    7. et al
    . Effects of exercise training on cardiorespiratory fitness and biomarkers of cardiometabolic health: a systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc 2015;4(7):e002014. pii:.
    OpenUrlAbstract/FREE Full Text
  61. 61.
    1. Hespanhol Junior LC,
    2. Pillay JD,
    3. van Mechelen W,
    4. Verhagen E
    . Meta-analyses of the effects of habitual running on indices of health in physically inactive adults. Sports Med 2015;45(10):1455-68.
    OpenUrlCrossRefPubMed
  62. 62.
    1. Sarzynski MA,
    2. Burton J,
    3. Rankinen T,
    4. Blair SN,
    5. Church TS,
    6. Després JP,
    7. et al
    . The effects of exercise on the lipoprotein subclass profile: a meta-analysis of 10 interventions. Atherosclerosis 2015;243(2):364-72. Epub 2015 Oct 17.
    OpenUrl
  63. 63.↵
    1. Murtagh EM,
    2. Nichols L,
    3. Mohammed MA,
    4. Holder R,
    5. Nevill AM,
    6. Murphy MH
    . The effect of walking on risk factors for cardiovascular disease: an updated systematic review and meta-analysis of randomized controlled trials. Prev Med 2015;72:34-43. Epub 2015 Jan 8.
    OpenUrlCrossRefPubMed
  64. 64.↵
    1. Glasziou PP,
    2. Irwig L,
    3. Heritier S,
    4. Simes RJ,
    5. Tonkin A,
    6. LIPID Study Investigators
    . Monitoring cholesterol levels: measurement error or true change? Ann Intern Med 2008;148(9):656-61.
    OpenUrlCrossRefPubMed
  65. 65.↵
    1. Holme I,
    2. Høstmark AT,
    3. Anderssen SA
    . ApoB but not LDL-cholesterol is reduced by exercise training in overweight healthy men. Results from the 1-year randomized Oslo diet and exercise study. J Intern Med 2007;262(2):235-43.
    OpenUrlCrossRefPubMed
  66. 66.↵
    1. Huffman KM,
    2. Hawk VH,
    3. Henes ST,
    4. Ocampo CI,
    5. Orenduff MC,
    6. Slentz CA,
    7. et al
    . Exercise effects on lipids in persons with varying dietary patterns – does it matter if they exercise? Responses in STRRIDE I. Am Heart J 2012;164(1):117-24.
    OpenUrlCrossRefPubMed
  67. 67.↵
    1. Garber CE,
    2. Blissmer B,
    3. Deschenes MR,
    4. Franklin BA,
    5. Lamonte MJ,
    6. Lee IM,
    7. et al
    . American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc 2011;43(7):1334-59.
    OpenUrlCrossRefPubMed
  68. 68.↵
    1. Saris WH,
    2. Blair SN,
    3. van Baak MA,
    4. Eaton SB,
    5. Davies PS,
    6. Di Pietro L,
    7. et al
    . How much physical activity is enough to prevent unhealthy weight gain? Outcome of the IASO 1st Stock Conference and consensus statement. Obes Rev 2003;4(2):101-14.
    OpenUrlCrossRefPubMed
  69. 69.↵
    1. Hainer V,
    2. Toplak H,
    3. Stich V
    . Fat or fit? What is more important? Diabetes Care 2009;32(Suppl 2):S392-7.
    OpenUrlFREE Full Text
  70. 70.↵
    1. He XZ,
    2. Baker DW
    . Body mass index, physical activity, and risk of decline in overall health and physical functioning in late middle age. Am J Public Health 2004;94(9):1567-73.
    OpenUrlCrossRefPubMed
  71. 71.↵
    1. Porzsolt F,
    2. Rocha NG,
    3. Toledo-Arruda AC,
    4. Thomaz TG,
    5. Moraes C,
    6. Bessa-Guerra TR,
    7. et al
    . Efficacy and effectiveness trials have different goals, use different tools, and generate different messages. Pragmat Obs Res 2015;6:47-54.
    OpenUrl
  72. 72.↵
    1. Guyton JR,
    2. Bays HE,
    3. Grundy SM,
    4. Jacobson TA,
    5. The National Lipid Association Statin Intolerance Panel
    . An assessment by the statin intolerance panel: 2014 update. J Clin Lipidol 2014;8(Suppl 3):S72-81.
    OpenUrlCrossRefPubMed
  73. 73.↵
    1. Lucas RM,
    2. McMichael AJ
    . Association or causation: evaluating links between “environment and disease”. Bull World Health Organ 2005;83(10):792-5. Epub 2005 Nov 10.
    OpenUrlPubMed
  74. 74.↵
    1. Hill AB
    . The environment and disease: association or causation? J R Soc Med 2015;108(1):32-7.
    OpenUrlCrossRefPubMed
  75. 75.↵
    1. Hung RK,
    2. Al-Mallah MH,
    3. Qadi MA,
    4. Shaya GE,
    5. Blumenthal RS,
    6. Nasir K,
    7. et al
    . Cardiorespiratory fitness attenuates risk for major adverse cardiac events in hyperlipidemic men and women independent of statin therapy: The Henry Ford Exercise Testing Project. Am Heart J 2015;170(2):390-9. Epub 2015 May 2.
    OpenUrl
  76. 76.
    1. Church TS,
    2. Thomas DM,
    3. Tudor-Locke C,
    4. Katzmarzyk PT,
    5. Earnest CP,
    6. Rodarte RQ,
    7. et al
    . Trends over 5 decades in U.S. occupation-related physical activity and their associations with obesity. PLoS One 2011;6(5):e19657. Epub 2011 May 25.
    OpenUrlCrossRefPubMed
  77. 77.
    1. Szostak J,
    2. Laurant P
    . The forgotten face of regular physical exercise: a “natural” anti-atherogenic activity. Clin Sci (Lond) 2011;121(3):91-106.
    OpenUrlPubMed
  78. 78.
    1. Hambrecht R,
    2. Walther C,
    3. Möbius-Winkler S,
    4. Gielen S,
    5. Linke A,
    6. Conradi K,
    7. et al
    . Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial. Circulation 2004;109(11):1371-8. Epub 2004 Mar 8.
    OpenUrlAbstract/FREE Full Text
  79. 79.↵
    1. Sigal RJ,
    2. Kenny GP,
    3. Boulé NG,
    4. Wells GA,
    5. Prud’homme D,
    6. Fortier M,
    7. et al
    . Effects of aerobic training, resistance training, or both on glycemic control in type 2 diabetes: a randomized trial. Ann Intern Med 2007;147(6):357-69.
    OpenUrlCrossRefPubMed
  80. 80.↵
    1. Dishman RK,
    2. Rooks CR,
    3. Thom NJ,
    4. Motl RW,
    5. Nigg CR
    . Meeting U.S. healthy people 2010 levels of physical activity: agreement of 2 measures across 2 years. Ann Epidemiol 2010;20(7):511-23.
    OpenUrlCrossRefPubMed
  81. 81.↵
    1. Jackevicius CA,
    2. Mamandi M,
    3. Tu JV
    . Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA 2002;288(4):462-7.
    OpenUrlCrossRefPubMed
  82. 82.↵
    1. Lee PH
    . Examining non-linear associations between accelerometer-measured physical activity, sedentary behaviour, and all-cause mortality using segmented Cox regression. Front Physiol 2016;7:272.
    OpenUrl
  83. 83.↵
    1. Wen CP,
    2. Wai JP,
    3. Tsai MK
    . Minimal amount of exercise to prolong life. To walk, to run, or just mix it up? J Am Coll Cardiol 2014;64(5):482-4.
    OpenUrlFREE Full Text
  84. 84.↵
    1. Malhotra A,
    2. Noakes T,
    3. Phinney S
    . It is time to bust the myth of physical inactivity and obesity: you cannot outrun a bad diet. Br J Sports Med 2015;49(15):967-8. Epub 2015 Apr 22.
    OpenUrlFREE Full Text
  85. 85.↵
    1. Kirk SF,
    2. Penney TL,
    3. Freedhoff Y
    . Running away with the facts on food and fatness. Public Health Nutr 2010;13(1):147-8.
    OpenUrlCrossRefPubMed
  86. 86.↵
    1. Luke A,
    2. Cooper RS
    . Physical activity does not influence obesity risk: time to clarify the public health message. Int J Epidemiol 2013;42(6):1831-6.
    OpenUrlCrossRefPubMed
  87. 87.↵
    1. Esposito K,
    2. Kastorini CM,
    3. Panagiotakos DB,
    4. Giugliano D
    . Mediterranean diet and weight loss: a meta-analysis of randomized controlled trials. Metab Syndr Relat Disord 2011;9(1):1-12. Epub 2010 Oct 25.
    OpenUrlCrossRefPubMed
  88. 88.↵
    1. Estruch R,
    2. Ros E,
    3. Salas-Salvadó J,
    4. Covas MI,
    5. Corella D,
    6. Arós F,
    7. et al
    . Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013;368(14):1279-90. Epub 2013 Feb 25.
    OpenUrlCrossRefPubMed
  89. 89.↵
    1. Foster C,
    2. Hillsdon M,
    3. Thorogood M,
    4. Kaur A,
    5. Wedatilake T
    . Interventions for promoting physical activity. Cochrane Database Syst Rev 2005;(1):CD003180.
  90. 90.↵
    1. Elley CR,
    2. Kerse N,
    3. Arroll B,
    4. Robinson E
    . Effectiveness of counselling patients on physical activity in general practice: cluster randomized trial. BMJ 2003;326(7393):793.
    OpenUrlAbstract/FREE Full Text
  91. 91.↵
    1. Stead LF,
    2. Buitrago D,
    3. Preciado N,
    4. Sanchez G,
    5. Hartmann-Boyce J,
    6. Lancaster T
    . Physician advice for smoking cessation. Cochrane Database Syst Rev 2013;(5):CD000165.
  92. 92.
    1. Vallis M,
    2. Piccinini-Vallis H,
    3. Sharma AM,
    4. Freedhoff Y
    . Modified 5 As. Minimal intervention for obesity counseling in primary care. Can Fam Physician 2013;59:27-31. (Eng), e1–5 (Fr).
    OpenUrlAbstract/FREE Full Text
  93. 93.
    1. Tudor-Locke C,
    2. Craig CL,
    3. Brown WJ,
    4. Clemes SA,
    5. De Cocker K,
    6. Giles-Corti B,
    7. et al
    . How many steps/day are enough? For adults. Int J Behav Nutr Phys Act 2011;8:79.
    OpenUrlCrossRefPubMed
  94. 94.
    1. Lee DC,
    2. Pate RR,
    3. Lavie CJ,
    4. Sui X,
    5. Church TS,
    6. Blair SN
    . Leisure-time running reduces all-cause and cardiovascular mortality risk. J Am Coll Cardiol 2014;64(5):472-81. Erratum in: J Am Coll Cardiol 2014;64(14):1537.
    OpenUrlFREE Full Text
  95. 95.
    1. Kyu HH,
    2. Bachman VF,
    3. Alexander LT,
    4. Mumford JE,
    5. Afshin A,
    6. Estep K,
    7. et al
    . Physical activity and risk of breast cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke events: systematic review and dose-response meta-analysis for the Global Burden of Disease Study 2013. BMJ 2016;354:i3857.
    OpenUrlAbstract/FREE Full Text
  96. 96.
    1. Arem H,
    2. Moore SC,
    3. Patel A,
    4. Hartge P,
    5. Berrington de Gonzales AB,
    6. Visvanathan K,
    7. et al
    . Leisure time physical activity and mortality: a detailed pooled analysis of the dose-response relationship. JAMA Intern Med 2015;175(6):959-67.
    OpenUrl
  97. 97.
    1. Shook RP,
    2. Hand GA,
    3. Drenowatz C,
    4. Hebert JR,
    5. Paluch AE,
    6. Blundel JE,
    7. et al
    . Low levels of physical activity are associated with dysregulation of energy intake and fat mass gain over 1 year. Am J Clin Nutr 2015;102(6):1332-8. Epub 2015 Nov 11.
    OpenUrlAbstract/FREE Full Text
  98. 98.
    1. Estruch R,
    2. Martinez-González MA,
    3. Corella D,
    4. Salas-Salvadó J,
    5. Fitó M,
    6. Chiva-Blanch G,
    7. et al
    . Effect of a high-fat Mediterranean diet on bodyweight and waist circumference: a prespecified secondary outcomes analysis of the PREDIMED randomised controlled trial. Lancet Diabetes Endocrinol 2016;4(8):666-76. Epub 2016 Jun 6.
    OpenUrl
  99. 99.
    1. Donnelly JE,
    2. Blair SN,
    3. Jakicic JM,
    4. Manore MM,
    5. Rankin JW,
    6. Smith BK,
    7. American College of Sports Medicine Position Stand
    . Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc 2009;41(2):459-71. Erratum in: Med Sci Sports Exerc 2009;41(7):1532.
    OpenUrlCrossRefPubMed
  100. 100.↵
    1. O’Keefe JH,
    2. Franklin B,
    3. Lavie CJ
    . Exercising for health and longevity vs peak performance: different regimens for different goals. Mayo Clin Proc 2014;89(9):1171-5. Epub 2014 Aug 12.
    OpenUrlCrossRefPubMed
  101. 101.↵
    1. Kodama S,
    2. Saito K,
    3. Tanaka S,
    4. Maki M,
    5. Yachi Y,
    6. Asumi M,
    7. et al
    . Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: a meta-analysis. JAMA 2009;301(19):2024-35.
    OpenUrlCrossRefPubMed
  102. 102.↵
    1. Bosomworth NJ
    . Statin therapy as primary prevention in exercising adults: best evidence for avoiding myalgia. J Am Board Fam Med 2016;29(6):727-40.
    OpenUrlAbstract/FREE Full Text
  103. 103.↵
    1. Bonfim MR,
    2. Oliveira AS,
    3. do Amaral SL,
    4. Monteiro L
    . Treatment of dyslipidemia with statins and physical exercises: recent findings of skeletal muscle responses. Arq Bras Cardiol 2015;104(4):324-32. Epub 2015 Feb 13.
    OpenUrl
  104. 104.↵
    1. Gui YJ,
    2. Liao CX,
    3. Liu Q,
    4. Guo Y,
    5. Yang T,
    6. Chen JY,
    7. et al
    . Efficacy and safety of statins and exercise combination therapy compared to statin monotherapy in patients with dyslipidaemia: a systematic review and meta-analysis. Eur J Prev Cardiol 2017;24(9):907-16. Epub 2017 Feb 13.
    OpenUrl
  105. 105.↵
    1. Expert Dyslipidemia Panel of the International Atherosclerosis Society
    . An International Atherosclerosis Society position paper: global recommendations for the management of dyslipidemia – full report. J Clin Lipidol 2014;8(1):29-60. Epub 2013 Dec 17.
    OpenUrlCrossRefPubMed
PreviousNext
Back to top

In this issue

Canadian Family Physician: 65 (3)
Canadian Family Physician
Vol. 65, Issue 3
1 Mar 2019
  • Table of Contents
  • About the Cover
  • Index by author
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on The College of Family Physicians of Canada.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Impediments to clinical application of exercise interventions in the treatment of cardiometabolic disease
(Your Name) has sent you a message from The College of Family Physicians of Canada
(Your Name) thought you would like to see the The College of Family Physicians of Canada web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Impediments to clinical application of exercise interventions in the treatment of cardiometabolic disease
N. John Bosomworth
Canadian Family Physician Mar 2019, 65 (3) 164-170;

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Respond to this article
Share
Impediments to clinical application of exercise interventions in the treatment of cardiometabolic disease
N. John Bosomworth
Canadian Family Physician Mar 2019, 65 (3) 164-170;
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Evidence for statins and PA
    • Suboptimal implementation
    • Conclusion
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • eLetters
  • PDF

Related Articles

  • Obstacles aux interventions cliniques liées à l’activité physique dans le traitement des maladies cardiométaboliques
  • PubMed
  • Google Scholar

Cited By...

  • Decrease in energy expenditure in transportation
  • Google Scholar

More in this TOC Section

  • Systemic racism and health disparities
  • Making social determinants of health screening truly universal means including adolescents
  • Challenges in the virtual assessment of COVID-19 infections in the community
Show more Commentary

Similar Articles

Navigate

  • Home
  • Current Issue
  • Archive
  • Collections - English
  • Collections - Française

For Authors

  • Authors and Reviewers
  • Submit a Manuscript
  • Permissions
  • Terms of Use

General Information

  • About CFP
  • About the CFPC
  • Advertisers
  • Careers & Locums
  • Editorial Advisory Board
  • Subscribers

Journal Services

  • Email Alerts
  • Twitter
  • RSS Feeds

Copyright © 2021 by The College of Family Physicians of Canada

Powered by HighWire