Consensus Physical Activity Guidelines for Asian Indians

Abstract

India is currently undergoing rapid economic, demographic, and lifestyle transformations. A key feature of the latter transformation has been inappropriate and inadequate diets and decreases in physical activity. Data from various parts of India have shown a steady increase in the prevalence of lifestyle-related diseases such as type 2 diabetes mellitus (T2DM), the metabolic syndrome, hypertension, coronary heart disease (CHD), etc., frequently in association with overweight or obesity. Comparative data show that Asian Indians are more sedentary than white Caucasians. In this review, the Consensus Group considered the available physical activity guidelines from international and Indian studies and formulated India-specific guidelines. A total of 60 min of physical activity is recommended every day for healthy Asian Indians in view of the high predisposition to develop T2DM and CHD. This should include at least 30 min of moderate-intensity aerobic activity, 15 min of work-related activity, and 15 min of muscle-strengthening exercises. For children, moderate-intensity physical activity for 60 min daily should be in the form of sport and physical activity. This consensus statement also includes physical activity guidelines for pregnant women, the elderly, and those suffering from obesity, T2DM, CHD, etc. Proper application of guidelines is likely to have a significant impact on the prevalence and management of obesity, the metabolic syndrome, T2DM, and CHD in Asian Indians.

Background

A ccording to current World Health Organization estimates, non-communicable diseases represent 43% of disease burden globally. This figure is projected to rise to 60% of the disease burden and 73% of all deaths by 2020. In 1990, nearly 40% of deaths were attributable to non-communicable diseases, and it has been projected that this will increase to 66% in 2020.¹ India is currently undergoing rapid economic, demographic, and lifestyle transitions. A key feature of these transitions has been inappropriate and inadequate diets and increases in physical inactivity. Data from various parts of India have shown the rising prevalence of lifestyle-related diseases such as type 2 diabetes mellitus (T2DM), the metabolic syndrome, hypertension, coronary heart disease (CHD), etc., frequently in association with overweight or obesity.^2,3

Several studies have shown that Asian Indians are more sedentary than white Caucasians.⁴ For example, findings from the Newcastle Heart Project (comprising South Asians [n=105] and Europeans [n=416]) showed that South Asians are less physically active than Europeans.⁴ Similarly, another U.K. study showed that lower physical activity in Asian Indians, Pakistanis, or Bangladeshis than in Europeans was inversely correlated with body mass index, waist circumference, systolic blood pressure, and plasma glucose and insulin levels.⁵ The prevalence of T2DM and impaired glucose tolerance has been shown to be significantly lower in higher quartiles of physical activity (i.e., 16.8%, 13.2%, and 11% for sedentary, moderately heavy, and heavy workers in South India, respectively).⁶ It is believed that a sedentary lifestyle is an important factor contributing to the development of T2DM and CHD in Asian Indians.^7,8

The health benefits of physical activity are well established.⁹ Positive outcomes of moderate-intensity physical activity include an increase in high-density lipoprotein cholesterol levels, reduction of blood pressure, long-term maintenance of weight loss, and decreased risk of death from lifestyle-related diseases.⁹ These benefits are most noticeable in sedentary individuals who introduce regular physical activity into their lifestyle. Lifestyle intervention studies with appropriate physical activity and diet have demonstrated that T2DM and CHD can be prevented. For example, in the Diabetes Prevention Program Outcomes Study, an extension of the Diabetes Prevention Program, the incidence of diabetes was compared in individuals with prediabetes among three therapy groups—lifestyle (n=910), metformin (n=924), and placebo (n=932)—after 10 years of intervention; results showed that with modest weight loss, prevention or delay in the development of diabetes was significantly associated with intensive lifestyle modification.^7,8

International physical activity guidelines have commonly been derived from studies on white Caucasians.¹⁰ The most well-known evidence-based physical activity recommendations for public health were first issued by the American Heart Association, the American College of Sports Medicine,^11,12 and the U.S. Department of Health and Human Services.¹⁰ For healthy adults, 150 min/week of moderate-intensity, 75 min/week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic physical activity is recommended by the U.S. Department of Health and Human Services.¹⁰ Although the U.S. guidelines include a toolkit for “building awareness and participation” in communities, they do not explicitly cover “putting the guidelines into practice.”

There is a paucity of studies regarding physical activity in Asian Indians. Nevertheless, physicians, nutritionists, and exercise therapists need to have physical activity guidelines not only for healthy adults but also for children, pregnant women, and those suffering from T2DM and CHD, etc., within a local sociocultural framework and based on current trends in diets and physical activity. Although we have recently published a consensus statement on diets for the prevention of obesity and T2DM in Asian Indians,¹³ there was a need to develop physical activity guidelines for Asian Indians, an ethnic group predisposed to develop insulin resistance, T2DM, and CHD.

Objectives and Process of Consensus Development

This consensus statement was prepared by renowned experts from India (n=102) and also includes input from Asian Indian experts from the United States, the United Kingdom, and Australia (n=27), having expertise in diabetes, exercise physiology, nutrition, internal medicine, metabolic diseases, endocrinology, cardiology, and sports medicine.

In this consensus statement, we have derived data from studies on physical activity globally and those undertaken on Asian Indians residing in India and elsewhere. Selected steering committee experts summarized relevant data from the national and international scientific literature in a National Workshop, the proceedings of which were used as the framework for the current document. For purpose of this review, the literature search was undertaken using the key words “Physical activity and Asian Indians,” “Physical activity recommendations for Asian Indians,” or “Physical activity in” “healthy individuals,” “pregnancy and lactation,” “obesity,” “children,” “elderly,” “diabetes,” or “CHD” from the medical search engine PubMed (National Library of Medicine, Bethesda, MD) from 1966 to October 2010 and also from the Google Scholar search engine. Manual searches for other important references and physical activity guidelines in other ethnic groups were also completed. When no data were available for Asian Indians, available international guidelines were adapted with the Indian perspective in mind.

Steering committee experts (see Appendix 2) prepared the first draft of consensus statements for each topic area. Draft guidelines for each topic were circulated to all selected experts for feedback and comment before the meeting. The final draft was modified, subsequently circulated again to all experts for comments, and then finalized for publication.

Definitions of Physical Activity Intensity Levels

1. Low-intensity physical activity elicits a slight increase in breathing rate and is relative to a given individual (e.g., strolling <3 km/h on level firm ground, tidying the house, leisurely stationary cycling <50 W or <16 km/h, and cooking).

2. Moderate-intensity physical activity elicits a moderate, noticeable increase in depth and rate of breathing while still allowing comfortable talking and is relative to a given individual (e.g., purposeful walking 3–6 km/h on level firm ground, water aerobics, cycling outdoors for pleasure at 19–23 km/h, cleaning the house, hiking, gardening, etc.).

3. Vigorous-intensity physical activity elicits a noticeable increase in depth and rate of breathing and will not allow an individual to speak more than a few words without pausing for a breath (e.g., walking 1 km in less than 10 min, jogging, cycling outdoors at 23–26 km/h, aerobic dancing, and jumping rope).

Safety Concerns of Exercise

Any person starting an exercise regimen should observe the following:

1. Appropriate type of physical activity according to fitness level and individualized health goals.

2. Gradual increase in physical activity over time to meet guidelines or health goals.

3. Protection must be ensured by using appropriate clothing and sports equipment, exercising in safe environments, and making sensible choices about when, where, and how to be active.

4. Supervision of a healthcare provider is suggested if an individual has severe chronic conditions or symptoms.

5. Adequate hydration should be ensured prior to physical activity (e.g., 500 mL of fluid consumed 2 h before physical activity). During physical activity, fluid should be taken early and frequently in an amount sufficient to compensate for losses in sweat reflected in body weight loss, or hydration with maximal amount of fluid comfortably tolerated without causing any gastrointestinal discomfort.

Physical Activity Guidelines for Healthy Adults

These guidelines are adapted and modified from a previously published consensus statement:¹⁴

1. Physical inactivity should be avoided as far as possible.

2. Inactive people should start slow and gradually increase physical activity.

3. Preparticipation medical consultation is recommended for those with chronic diseases, particularly cardiovascular disease (CVD), those who are symptomatic, and those who are sedentary.

4. In general, a total of 60 min of physical activity is recommended every day, which includes aerobic activity, work-related activity, and muscle-strengthening activity.

a. This should include at least 30 min of moderate-intensity aerobic activity (e.g., brisk walking, jogging, hiking, gardening, bicycling, etc.), 15 min of work-related activity (e.g., climbing stairs, walking during breaks, etc.), and 15 min of muscle-strengthening exercises. The latter should be done using light weights. (See Appendix 3.)

b. Aerobic activity should be performed in bouts of at least 10 min in duration. The total duration of physical activity could also be accumulated in small 10–15 min periods of physical activity two or three times a day.

5. Brisk walking (walking at an intensity wherein an individual finds speaking difficult but not impossible) is the preferred initial mode of exercise as this does not require any special training or equipment.

6. For additional health benefits, adults should increase their moderate-intensity aerobic physical activity to 300 min or more per week or engage in vigorous-intensity aerobic physical activity 150 min or more per week or an equivalent combination of moderate- and vigorous-intensity activity.

7. Physically intensive yoga exercises should be encouraged, but more research is required in this area.

Summary recommendations for healthy adults

Recommended physical activity for adults is 60 min every day, which should include at least 30 min of moderate-intensity aerobic activity, 15 min of work-related activity, and 15 min of muscle strengthening exercises.

Physical Activity Guidelines for Children and Adolescents

Background and evidence

Regular physical activity during childhood and adolescence is widely acknowledged as essential for healthy growth and development.^15,16 Despite assessment difficulties, evidence suggests that many children and adolescents are less active than is recommended. The evidence suggests that obese youngsters are less physically active than those with a healthy body composition^17,18 and spend more time in sedentary activities, such as watching television and using other electronic media.^18
–20 Potential outcomes of reduced activity levels are suboptimal development of motor skills and a lack of motivation to participate wholeheartedly in physical activity.²¹ There is also some evidence that physical activity levels decline from childhood through the adolescent years.²²

Most studies to date have related to aerobic physical activity, whereas resistance training is traditionally considered to be unsafe and potentially injurious to the growth and development of children and adolescents.²³ However, evidence related to the safety and efficacy of resistance exercise for this subgroup has increased over recent years.²³ Risk of injury in relation to resistance training is largely associated with inadequate professional supervision encompassing poor exercise prescription rather than the activity per se.

Available guidelines and principles¹⁰

1. Children and youth 5–17 years old should accumulate at least 60 min of moderate- to vigorous-intensity physical activity daily. Preferably these activities should be aerobic, in the form of games and sports.¹⁰

2. Children who are currently sedentary should start with moderate-intensity physical activity for 30 min/day.¹⁰

3. Skeletal health is improved by modest volumes of resistance training and other weight-bearing activities (e.g., jumping) performed 2–3 days/week. Vigorous weight-bearing physical activity should be incorporated when possible, including activities that strengthen muscle and bone.²⁴

4. Most health outcomes—in particular, obesity and related measures of cardiometabolic health—respond to aerobic physical activity with greatest benefits commonly achieved at the higher end of the physical activity spectrum.²⁵

5. Participation in regular physical exercise results in better cognitive development²⁶ and improved cardiovascular fitness,²⁷ which also results in effective autonomic control.^28,29

6. Screen time for leisure-time television/computer viewing should be less than 2 h/day.¹⁴

School-based approach

Schools represent a key opportunity for physical activity given the significant amount of time children spend in this setting. A school-based multicomponent model of health education including physical activity not only improved knowledge, attitudes, and practice, but also improved anthropometric and metabolic variables of Asian Indian schoolchildren in North India.^30,31

Schools can facilitate a combination of strategies and approaches to help children be more active, including:

1. Creating infrastructure (e.g., playgrounds) and policies (mandatory exercise periods) to encourage physical activity for all students.

2. More emphasis on exercise/physical activity-related activities in the overall assessment of students.

3. Maintaining quality physical activity programs that engage students in moderate- to vigorous-intensity physical activity for at least 50% of physical activity class time and perhaps consider intramural sports teams beginning at the middle school level (5^th or 6^th standard).

4. Providing a variety of activities and specific skills so that students can be physically active not just during class, but throughout the day and across the school year.

5. Providing qualified professionals who are trained in teaching methods to engage students in physical education, including for students who face greater barriers to activity.

6. Collecting valid and reliable data and using analytical tools and systems to understand a student's physical activity needs and fitness levels and promoting approaches that are effective in changing physical activity behaviors and, ultimately, health outcomes.

Summary recommendation for Asian Indian children

General physical activity guidelines for children and adolescents should include the accumulation of a minimum of 1 h and up to several hours of at least moderate-intensity aerobic physical activity daily (Table 1). Activity may mostly comprise sports activities and active transport and be over and above habitual physical activity. Sedentary behavior, including television viewing and working on computers, should be restricted to less than 2 h/day during leisure time.

Table 1.

Exercise Prescription for Children and Adolescents

Type of exercise	Frequency	Duration
Moderate- or vigorous-intensity aerobic physical activity (such as running, hopping, skipping, jumping rope, swimming, dancing, and bicycling)	Preferably daily¹⁴	60+ min/day
Muscle-strengthening physical activity (such as playing on playground equipment, climbing trees, playing tug-of-war, lifting weights, or working with resistance bands)	At least 3 days/week	20–30 min^*
Bone-strengthening physical activity (such as running, jumping rope, basketball, tennis, and hopscotch)	At least 3 days/week	20–30 min^*

This prescription is based on Warburton et al.⁹ and www.health.gov/paguidelines/ ¹⁰

After comfortable completion of 10–15 repetitions of an exercise, the resistance can be increased by 10%.

Physical Activity Guidelines for Pregnant and Lactating Women

Background and evidence

Exercise is an important component of a healthy lifestyle during pregnancy. Despite a comprehensive understanding of the physiologic and musculoskeletal changes during pregnancy, the responses of the pregnant woman and fetus to exercise have not been well investigated.³² In particular, very little information exists regarding exercise tolerance and adaptations to resistance training during pregnancy. Response to exercise largely depends on the health and fitness of the woman pre- and during pregnancy. Specifically, in India, a long-standing traditional mindset is that pregnant women should not exercise.

A lower incidence of obesity and diabetes in both mother and child is seen in the most active category of women.^33,34 A high level of fitness prepregnancy and regular physical activity during pregnancy can prevent excessive weight gain during this period.³⁵ Regular physical activity in women is associated with reduced risk of gestational diabetes and pre-eclampsia.^34,36 The protective effect of physical activity can be explained by an enhanced placental growth and vascularity,³⁷ by decreased oxidative stress,³⁸ and reduced inflammation.³⁹

Available guidelines and principles

1. All decisions regarding exercise in pregnant women should be taken in consultation with the treating obstetrician.

2. Exercise selection should be based on the health status of the pregnant woman and exercise goals and should be individualized. It is important to note that some women may not be able to exercise during the third trimester of pregnancy or may only be able to manage mild exercise.⁴⁰

3. Traditional exercise recommendations for pregnant women have been consistent with public health guidelines for adults: moderate-intensity exercise for at least 30 min on most, if not all, days of the week (∼150 min/week) in the absence of any contraindications.⁴⁰ A range of aerobic exercise modalities, including walking, cycling, and swimming, is recommended.⁴¹

4. Healthy pregnant women who engaged in vigorous-intensity aerobic activity before pregnancy are encouraged to continue physical activity, but there is no basis for recommending vigorous aerobic exercise for inactive women.⁴²

5. Additionally, resistance training using light weights and moderate-to-high repetitions (one to two sets of 12–15 repetitions) is recommended to maintain flexibility and muscle tone and prevent lower back pain.⁴³ Resistance training on machines is recommended; however, free weights, elastic bands, and calisthenics may be substituted if exercise machines become too difficult to use because of increased size and balance problems. Women should be encouraged to practice controlled breathing while lifting and not hold their breath. Pregnant women should avoid exercising in the supine position after ∼16 weeks of gestation.⁴²

6. Exercises that cause pain, discomfort, or any obstetric-related symptoms should be discontinued.

7. Because of a weakening of the pelvic floor muscles during pregnancy and potential damage during birth, it is important to begin conditioning the pelvic floor muscles from the start of pregnancy and to continue throughout.

8. Exercises should be recommenced as soon as practicable following the birth of the baby.

Summary recommendations for pregnant women

Healthy women who have uncomplicated pregnancies can maintain their previous exercise program following consultation with their doctor. There is now general consensus that it is safe to commence an exercise program during pregnancy. Moderate-intensity exercise for at least 30 min on most, if not all, days of the week (∼150 min/week) in the absence of any contraindications is considered safe throughout pregnancy; however, there is a lack of evidence regarding a safe upper limit of exercise as pregnancy progresses. Exercises should be recommenced as soon as practicable following the birth of the baby.

Physical Activity Guidelines for the Elderly

Background and evidence

In India, the elderly are defined as those who have attained the age of 60 years and above.⁴⁴ Declines in muscular strength and endurance occur as a function of biological aging and reductions in physical activity.⁴⁵ Low levels of muscular strength, particularly in the muscles of the lower back and lower limb, can compromise mobility and increase the risk of falls in older adults.^45,46 Aging leads to a decline in muscle mass, increase in body fat (“sarcopenic obesity”), and redistribution of body fat, thereby increasing truncal, including abdominal, fat. These body composition changes may be more marked in Asian Indians, who have a high amount of truncal adiposity and low muscle mass.² All these body composition changes lead to increased tendency for T2DM and atherogenic dyslipidemia.⁴⁷

There is strong evidence of the benefits of aerobic physical activity for older adults.¹² Regular aerobic physical activity has an inverse dose–response relationship with major chronic diseases (CHD, T2DM, depression, some cancers, dementia, disability, and loss of function).⁴⁸ The recommended dose of aerobic physical activity reduces the risk of these conditions and functional limitations by 30–50%, and higher doses of physical activity provide further benefits.¹²

Available guidelines and principles

1. Recommended doses of aerobic activity and muscle-strengthening activity for men and women over 65 years of age (and those 50–64 years old with clinically significant chronic conditions and/or functional limitations) are similar to those for all healthy adults.¹²

2. Resistance training may be particularly beneficial in older adults because of the potential to reduce the age-related sarcopenia and risk of falls.¹² Older adults should also engage in resistance exercises on 2 days/week that should involve the major muscle groups (using small weights).

3. Daily activities that involve lifting, carrying, and pushing tasks should be maintained because they can also benefit muscle and bone health.

4. Greater strength and muscle power assist in the maintenance of function and prevention of disability, including a reduced risk of falling. Balance training, along with activities to strengthen the muscles of the legs, is the best strategy to reduce falls and complications from falls.

5. All decisions regarding the initiation of exercise programs for the elderly should be taken in consultation with a physician. In sedentary individuals, gradual escalation of physical activity is recommended after pre-activity medical evaluation, especially in those with chronic diseases, particularly CHD. Periodic medical evaluation is also warranted in individuals who exercise regularly.

6. Sudden initiation or accelerations in physical activity or any high-intensity exercises should be avoided.

Summary recommendations for the elderly

All decisions regarding the initiation of exercise programs for the elderly should be taken in consultation with a physician. Recommended doses of aerobic and muscle-strengthening activity for men and women over 65 years of age (and those 50–64 years old with clinically significant chronic conditions and/or functional limitations) are similar to those for all healthy adults. Resistance training is acknowledged as an effective intervention for improving strength and physical functioning in older adults.

Physical Activity Guidelines for Non-Communicable Diseases

CVDs and hypertension

Background and evidence

CVD is the leading cause of death in India, and its contribution to mortality is rising; deaths due to CVD are expected to double from 1985 to 2015.⁴⁹ Regular physical activity reduces the risk of obesity, blood lipid abnormalities, hypertension, and T2DM and has been shown to reduce the risk of CHD.^50

–53 Despite this, more than half of the Indian population, including those with CVD, are physically inactive.⁵⁴ The benefits of cardiac rehabilitation have been established beyond doubt; however, such rehabilitation is underutilized. Only some 25–30% of men and 11–20% of women eligible for cardiac rehabilitation participate in such programs.⁵²

Design and administration of the exercise training program: program structure

Cardiac rehabilitation programs are generally recommended for patients with established CHD and heart failure.⁵¹ Physician endorsement of cardiac rehabilitation is one of the most important predictors of participation. One of the most effective ways to combat the lack of referral is to include cardiac rehabilitation in standardized order sets for appropriate cardiac patients. The program is divided into three or four phases on the basis of the patient's clinical status (Table 2). Patients with hypertension or other modifiable CHD risk factors can start unsupervised physical activity after a pre-activity evaluation.

Table 2.

Phases of Cardiac Rehabilitation by Physical Activity

Phase	Description
Phase 1	Inpatient rehabilitation directed by physical therapy departments or a dedicated cardiac rehabilitation staff that emphasizes a gradual, progressive approach to exercise and an education program that helps the patient understand the disease process.
Phase 2	Physician-supervised outpatient programs. Emphasizes safe physical activity to improve conditioning with continued behavior modification aimed at smoking cessation, weight loss, healthy eating, and other factors to reduce disease risk. This multifaceted outpatient rehabilitation should last 2–3 months.
Phase 3	Supervised rehabilitation, lasting 6–12 months, establishes a prescription for safe exercise that can be performed at home and continues to emphasize risk factor reduction.
Phase 4	Programs that do not usually provide medical supervision and are usually provided by health clubs and fitness facilities. It is a maintenance program and needs to be carried on for an indefinite period.

Supervised versus unsupervised physical activity.

1. Patients who have advanced CHD and those who lack confidence will benefit most from up to 12 weeks of supervised exercise rehabilitation that incorporates endurance and resistance activity.⁵⁵ Supervision may be beneficial to reduce anxiety, monitor symptoms and arrhythmias, and establish appropriate physical activity intensity after an acute cardiovascular event or vessel revascularization.

2. Patients in unsupervised programs should generally be encouraged to exercise to the onset of mild dyspnea for the reasons mentioned previously.⁵³ Patients exercising on their own can also be encouraged to judge their exercise intensity using the “talk test” (i.e., exercising at the fastest walking rate that still permits comfortable conversation).

3. High-intensity exercise, a sudden start to exercise, and exercise in extreme weather conditions, should be avoided.

Pre-activity evaluation

1. All decisions regarding the initiation of exercise programs in the elderly should be taken in consultation with a physician/cardiologist. All patients with CHD must undergo a pre-activity evaluation.

2. Those with established CHD should undergo a symptom-limited exercise test before commencing a training program. The exercise test is required to exclude important symptoms, ischemia, or arrhythmias that might require other interventions before exercise training. The exercise test also serves to establish baseline exercise capacity and optimal maximum volume of O₂ and to determine maximum heart rate for use in prescribing exercise. These tests are usually done with the patient on his or her usual medications to mimic the heart rate response likely to occur during exercise training.⁵⁶

Physical activity session: guidelines and principles

1. Most patients with hypertension and other modifiable risk factors for atherosclerosis should aim to commence with 35–40 min of moderate-intensity activity on most, preferably all, days of the week.⁴⁹

2. Those enrolled in a cardiac rehabilitation program should begin with a 5-min general warm-up followed by at least 20 min of aerobic exercise training and 5–15 min of cool-down.⁵⁷

3. The aerobic exercise training component is generally performed at 60–70% of maximum volume of O₂, which corresponds to approximately 70–80% of maximum heart rate (Table 3).⁵³

4. Patients who did not undergo exercise testing before the program can exercise at a heart rate 20 beats higher than their normal resting value.⁵⁸

5. Some patients, especially those with left ventricular dysfunction, require lower training intensities. Such patients can exercise to the point of mild dyspnea and maintain that level during the training session. Although 20 min of exercise training is standard, shorter periods of exercise training are beneficial, and longer sessions almost certainly provide additional benefit.⁵⁹

Table 3.

Exercise Prescription for Patients with Coronary Artery Disease

Patients	Intensity	Frequency	Duration
Aerobic exercise
General CAD	70–85% peak HR	≥3 times weekly	≥20 min per session
With asymptomatic ischemia	70–85% ischemic HR	≥3 times weekly	≥20 min per session
With angina	70–85% ischemic HR or angina onset	≥3 times weekly	≥20 min per session
With claudication	Walking to pain tolerance	≥3 times weekly	≥30 min per session
With New York Heart Association Class I-III heart failure	Walking until onset of dyspnea	≥3 times weekly	As per effort tolerance
Hypertension	Moderate-intensity	≥3 times weekly	≥30 min per session
Resistance exercise
For most patients with cardiovascular disease	30–50% of the 1-RM or one-repetition maximum^a	2–3 times weekly	1 set of exercise consisting of 12–15 repetitions per each muscle group^b

1-RM or one-repetition maximum, maximal weight the individual can lift for one exercise (see Thompson⁵³).

Muscle group exercises: chest press, shoulder press, triceps extension, biceps curl, pull-down (upper back), lower-back extension, abdominal crunch/curl-up, quadriceps extension or leg press, leg curls (hamstrings), calf raise.

CAD, coronary artery disease; HR, heart rate.

Summary recommendations for patients with CHD and hypertension

The exercise sessions should be individualized according to cardiac and physical status of patient. Usually, 210 min/week of moderate-intensity physical activity should be achieved. Depending on the clinical condition, a low-intensity, individualized, supervised exercise program could also be devised (Table 3).

Prediabetes and diabetes

Background and evidence

The prevalence of diabetes in Indians between 20 and 79 years of age was projected to be 7.1% in 2010 (giving a total population with diabetes of 50.7 million) and estimated to rise to 8.6% by 2030 (87.0 million).⁶⁰ The increasing trend of diabetes in Asian Indians living in India is more apparent in urban populations (exponential trend R ²=0.744) than rural populations (R ²=0.289).⁶¹

Evidence from the Diabetes Prevention Program Outcomes Study and other prevention trials conducted in patients with prediabetes shows that appropriate lifestyle modification, including physical activity, could lead to risk reduction in incidence of T2DM by almost 58%.⁷ Studies have shown that resistance and aerobic exercise is effective in improving the metabolic profile of adults with T2DM.⁶² Improved insulin sensitivity/resistance and reductions in hyperglycemia-related medications has been reported as a result of exercise training.^63,64 In particular, supervised resistance training (10 repetitions for >3 days/week) has been shown to lead to significant improvement in insulin sensitivity and values of glycosylated hemoglobin and lipid profile and decrease in truncal and peripheral subcutaneous adipose tissue in Asian Indians with T2DM.⁶²

It has been reported that children and adolescents with type 1 diabetes should complete a minimum of 30–60 min of moderate-intensity physical activity daily.⁶⁵ Additional physical activity beyond 60 min/day would be helpful in maintaining glycemic profile for T2DM patients.⁶²

Cautions

1. All decisions regarding the initiation of exercise programs for patients with diabetes should be taken in consultation with a physician/diabetologist.

2. Ideally, all patients should undergo a pre-activity evaluation.

3. Sudden commencement or acceleration in physical activity dose or any high-intensity exercises should be avoided.

4. It is best to avoid exercise if:

a. Blood glucose level is >300 mg/dL.

b. Low blood glucose level (hypoglycemia) is <70 mg/dL.

c. In type 1 diabetes, fasting glucose level is >250 mg/dL and/or ketosis is present.

d. In the presence of proliferative or severe non-proliferative diabetic retinopathy, vigorous aerobic or resistance exercise may be contraindicated because of the potential risk of triggering vitreous hemorrhage or retinal detachment.

e. In the presence of severe peripheral neuropathy, it may be best to encourage non–weight-bearing activities such as swimming, bicycling, or arm exercises.

Summary recommendations for patients with diabetes

Daily physical activity of 60 min in duration including 10–15 min of resistance exercise and work-related activity is recommended.

Obesity

Background and evidence

Many urban and semi-urban Asian Indians are becoming increasingly sedentary because of mechanization and increasing use of televisions and computers.² Environmental factors such as psychological and social behavior and lack of facilities such as gyms and playgrounds, plus safety issues, are also contributing to physical inactivity in urban areas. Obesity is increasingly seen in adults² and children.^66,67 Mostly, Asian Indians have abdominal obesity,⁶⁸ which dysregulates glucose insulin metabolism and predisposes to the metabolic syndrome and dysglycemia.⁶⁸

Prevention of obesity can potentially have a major impact in reducing morbidity and mortality that result from the chronic effects of excess adiposity.² Commonly available guidelines support physical activity and behavior therapy in weight management. Public health policies and regulations are required to create environments to help achieve and sustain healthful lifestyle behaviors.^2,69

Guidelines and principles

1. Gradual initiation and increase in duration of physical activity among sedentary individuals is recommended.

2. Some observational data indicate that individuals performing at least 45–60 min of activity on most days gain less weight than less active men.⁷⁰

3. At least the equivalent of 150 min/week of moderate-intensity aerobic physical activity for substantial health benefits and 300 min/week of moderate-intensity physical activity for more and sustained weight loss.¹⁰

4. To prevent weight regain after weight loss, 60–90 min of daily moderate-intensity physical activity is recommended.⁷¹

Summary recommendations for individuals with obesity

Obese persons, after starting aerobic activity at a low intensity and for a short duration, should escalate slowly to achieve 60 min of continuous moderate-intensity aerobic exercise seven times per week (Table 4). Once an individual loses weight, a maintenance phase with a similar or greater duration, intensity, and frequency of exercise should be maintained for an indefinite period (Table 5).²⁵

Table 4.

Guidelines for Physical Activity for Overweight and Obesity

Intensity	Duration	Frequency
Moderate-intensity aerobic exercise	60 min	Daily
Vigorous-intensity exercise	60 min	3 or more days/week

See Faigenbaum et al.²⁴

Table 5.

Phases of Weight Management

Phase	Description
Phase 1	Screening for metabolic, cardiovascular, and respiratory adequacy. Any clinically and biochemically significant abnormalities require full evaluation by appropriate specialist physicians, and only after these issues are adequately managed and stabilized should an active exercise program be initiated.
Phase 2	Behavioral change treatment would be required with a trained professional having an in-depth discussion with the patient regarding the changes required. The main strategies used in behavioral therapy for weight control are self-monitoring, stimulus control, problem solving, contingency management, cognitive restructuring, and social support.
Phase 3	Phase 3 refers to a physician-supervised reasonable goal for weight loss. Weight loss goals for each patient must be individualized and cannot be unilaterally based on standard weight-for-height norms.
Phase 4	Maintenance phase should be continued for an indefinite period.

Physical Activity Action Plan for the General Population

1. Mass awareness programs regarding health benefits of physical activity are most important and should be directed mostly towards people with inadequate levels of knowledge and understanding, awareness, and health education.

2. Community fitness programs such as health walks should be encouraged.

3. Periodic monitoring of nutritional and obesity status of children and adults should be undertaken by a National Monitoring Team.

4. Fitness rooms, gyms, playgrounds, and walking and bicycling tracks, accessible to people from all socioeconomic status levels, should be established.

5. Physical activity in the workplace should be encouraged. (See Appendix 4.)

6. Safe neighborhoods that encourage physical activity (e.g., include sidewalks, bike lanes, adequate lighting, multi-use trails, walkways, and parks) should be designed.

7. In addition, opportunities should be provided for all socioeconomic status groups to participate in physical activity (e.g., low-cost fitness classes at community centers) to promote functional health.

8. Safe, accessible, and affordable places for physical activity (e.g., parks, playgrounds, community centers, schools, fitness centers, trails, and gardens) can increase activity levels.

9. Girls and women should be particularly targeted for awareness and intervention.

10. School-based programs should be based on the importance of a healthy lifestyle and increased physical activity. It should be mandatory for each school to employ qualified professionals who are trained in teaching methods to engage students in physical education, including students who face greater barriers to activity. In India, we have initiated a comprehensive program aimed at childhood obesity, “MARG” (Hindi for “The Path”).³¹ Children are given nutritional and physical activity education through lectures and leaflets and with the help of debates, skits, and drama related to health topics. Parents and children also take part in making healthy recipes. These comprehensive programs initiated on a large scale for the first time in South Asia aim to cover nearly 5,000,000 children in 15 cities of North India. Furthermore, we aim to impart education regarding diet and physical activity, not only to children, but also to teachers and parents. The MARG program is the first large-scale community intervention project in South Asia that focuses 100% on primary prevention of not only diabetes, but non-communicable diseases in general.

Further Research on Asian Indians

1. Epidemiological studies on the level of physical activity and various non-communicable diseases are required.

2. More research is needed to determine the optimal dose of aerobic and muscle-strengthening exercise for the prevention of obesity and diabetes and other non-communicable diseases.

3. Intervention studies with different types and duration of physical activity and its effect on cardiovascular risk factors are needed.

4. The effect of duration and intensity of physical activity such as classical dancing, playing cricket, etc., on physical fitness should be determined.

5. Studies on the effect of yoga on metabolism and cardiovascular risk factors and controlled interventions with yogic exercises should be done.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Appendix 1

Anoop Misra, M.D., Fortis-CDOC Center of Excellence for Diabetes, Metabolic Diseases and Endocrinology, Fortis Flt. Lt. Rajan Dhall Hospital, New Delhi; Diabetes Foundation, New Delhi; National Foundation for Diabetes, Obesity and Cholesterol, New Delhi; Priyanka Nigam, Ph.D., Diabetes Foundation, New Delhi; National Foundation for Diabetes, Obesity and Cholesterol, New Delhi; Andrew P. Hills, Ph.D., Mater Mother's Hospital, Mater Medical Research Institute, South Brisbane; Australia; Griffith Health Institute, Griffith University, Parklands, Australia; Davinder S. Chadha, M.D., D.M., Command Hospital (Air Force), Bangalore, India; Vineeta Sharma, Ph.D., Science for Equity, Empowerment and Development Division, Department of Science and Technology, Ministry of Science and Technology, Government of India, New Delhi; K.K. Deepak, M.D., Ph.D., All India Institute of Medical Sciences, New Delhi; Naval K. Vikram, M.D., All India Institute of Medical Sciences, New Delhi; Shashank Joshi, M.D., D.M., Lilavati & Bhatia Hospital, Mumbai, India; Ashish Chauhan, M.D., Air Force Central Medical Establishment, New Delhi; Kumud Khanna, Ph.D., Department of Nutrition, Institute of Home Economics, New Delhi; Rekha Sharma, M.Sc., Diabetes Foundation, New Delhi; Kanchan Mittal, M.P.T., All India Institute of Medical Sciences, New Delhi; Santosh Jain Passi, Ph.D., Department of Nutrition, Institute of Home Economics, New Delhi; Veenu Seth, Ph.D., Lady Irwin College, New Delhi; Seema Puri, Ph.D., Department of Nutrition, Institute of Home Economics, New Delhi; Ratna Devi, MBBS, Chronic Care Foundation, New Delhi; A.P. Dubey, M.D., Sir Gangaram Hospital, New Delhi; Sunita Gupta, M.D., Fortis Hospital, New Delhi.

Appendix 2: Physical Activity Consensus Group

Appendix 3

Appendix 4

Table A1.

Calorie Expenditure of Various Types of Physical Activities

	Males		Females
Activity	Average MET	MET range	Average MET	MET range
General personal activities
Sleeping	1.0		1.0
Lying	1.2		1.2
Sitting quietly	1.2		1.2
Standing	1.4		1.5
Dressing	2.4	1.6–3.3	3.3
Washing hands/face and hair	2.3
Plaiting hair			1.8
Eating and drinking	1.4		1.6
Means of transport
Walking around/strolling	2.1	2.0–2.2	2.5	2.1–2.9
Walking slowly	2.8	2.6–3.0	3.0
Walking quickly	3.8
Walking uphill	7.1	5.5–8.6	5.4	4.8–6.1
Walking downhill	3.5	3.1–4.0	3.2
Climbing stairs	5.0
Sitting on a bus/train	1.2
Cycling	5.6	3.8–8.6	3.6
Cycling on a dirt road	7.0	5.0–9.0
Driving a motorcycle	2.7	2.4–3.0
Driving a car/truck	2.0
Paddling a canoe	3.0
Pulling a rickshaw (one person/no load)	5.3	4.0–6.6
Pulling a rickshaw (two people)	7.2	6.7–7.8
Horseback riding (slow)	3.6
Horseback riding (trotting)	5.2	4.8–5.5
Activities involving weight-bearing
Walking with 15–20 kg load			3.5	3.4–3.5
Walking with 25–30 kg load			3.9	3.8–4.1
Carrying 20–30 kg load on head	3.5	2.4–4.2
Carrying 35–60 kg load on head	5.8	5.0–7.0
Carrying 27 kg load with shoulder straps, varying gradients	5.0	2.3–7.7
Carrying 27 kg load with forehead strap, varying gradients	5.32	2.4–8.0
Loading 9 kg sack on to a truck	5.78
Loading 16 kg sack on to a truck	9.65
Pulling hand cart, unloaded	4.82
Pulling hand cart with 185–370 kg load	8.3	7.0–9.6
Domestic chores
Cooking/preparing food
Collecting wood (for fuel)	3.3
Collecting water (from well)			4.5
Chopping wood (for fuel)	4.2	2.3–6.5
Kneading dough			3.4
Making tortillas			2.4
Peeling vegetables	1.9	1.3–2.4	1.5
Pounding grain			5.6	5.0–6.3
Shopping			4.6
Squeezing coconut			2.4
Washing dishes			1.7	1.6–1.9
Child care
Child care (unspecified)			2.5
Bathing child (standing)			3.5
Carrying child			1.9
House cleaning
Housework (unspecified)			2.8	2.5–3.0
Beating mats/carpets			6.2	5.1–7.4
Bed making (tropical climate)			3.4
Bed making (cold climate)			4.9	4.6–5.1
Mopping/washing floor			4.4	3.4–6.5
Polishing floor			4.4
Sweeping			2.3	2.0–2.5
Vacuuming			3.9
Window cleaning	3.0	2.8–3.3
Laundry
Washing clothes (sitting/squatting)			2.8	2.6–3.0
Hanging washing out to dry			4.4	4.3–4.6
Ironing clothes	3.5		1.7
Sewing/knitting	1.6		1.5	1.3–1.8
Care of the yard/garden
Cleaning/sweeping yard	3.7	2.9–4.5	3.6
Weeding garden	3.3	2.4–5.1	2.9	2.7–3.6
Shoveling snow from driveway	7.9
Agricultural activities
General activities
Digging	5.6		5.7
Driving a tractor	2.1	1.9–2.3
Fertilizing (spreading manure)	5.2	4.9–5.4
Gleaning			4.5
Grinding grain using a mill stone			4.6
Hoeing	4.2	3.6–4.6	5.3	4.7–6.5
Loading sacks on to a truck	6.6
Plowing with
Horse	4.8
Tractor	3.4
Buffalo			3.6
Spraying crops	4.3
Weeding	4.0	2.6–4.7	3.7	3.7–3.8
Cocoa crop
Collecting cocoa			2.9
Pruning	2.4
Splitting cocoa			2.0
Activities for coconut crop
Collecting (climbing trees)	4.2
Husking	5.6
Bagging and splitting	3.9
Fruit crops (apple, orange)
Picking (with pole)			3.8
Picking by hand	3.4
Pruning trees	3.6
Groundnut crop
Harvesting	4.7
Planting	3.1
Shelling	1.6
Sorting	1.9
Weeding	3.2
Maize crop
Harvesting	5.1
Planting	4.1
Rice crop
Bundling rice	3.7		3.0
Fertilizing	3.1
Harvesting	3.5	2.4–4.2	3.8	3.5–4.4
Planting	3.7	3.5–4.0	3.6	2.6–4.7
Spraying	5.2
Threshing	5.4	4.6–5.0	5.1	4.8–5.4
Transplanting seedlings	3.3	3.1–3.4	3.7	3.5–4.0
Winnowing	2.9	2.3–3.6	2.7	2.5–2.9
Sugar cane crop
Cutting	7.0	6.6–7.9
Loading on to wagon	5.6
Tying cane	3.0
Tuber crops
Harvesting	4.4	3.5–5.7	3.0	2.8–3.4
Planting	5.0		3.9	3.6–5.0
Sorting (kneeling)	2.2	1.6–2.7
Animal husbandry
Carrying straw	3.1
Cleaning equipment	4.0
Cutting straw	5.0
Feeding animals	3.6
Grooming horses	5.5	3.8–7.1
Milking by hand	3.6	3.1–4.1
Milking by machine	3.2
Tending animals (feeding, watering, cleaning stable)	4.6
Hunting/fishing
Crabbing			4.51
Fishing with a line	1.9
Fishing with a spear	2.3
Fishing with hands			3.94
Hunting (bats, birds, pigs)	3.2
Occupational categories
Bakery work			2.5
Brewery work			2.9
Brickmaker
Earth cutting	5.6	5.5–5.7
Making mud bricks (squatting)	3.0
Builder
Carrying wood	6.6
Cement mixing with shovel	5.3
Chipping cement walls	3.3
Chiseling	5.0
Nailing	3.0
Planing softwood	5.7	4.4–7.1
Planing hardwood	8.0
Roofing	2.9
Sandpapering	2.9
Sawing softwood	5.3	5.0–5.6
Sawing hardwood	6.6
Painting	3.6
Firefighter
Dragging fire hose	9.8
Climbing steps with full gear	12.2
Flight attendant (serving food and beverages and galley work)	3.0		3.1
Forester
Tree cutting	6.9	5.4–8.0
Sawing	5.7
Planting trees	4.1
Nursery work	3.6
Military training
Digging trenches	6.4	4.6–7.9
Drill	4.5	4.1–4.8
March (slow)	3.18
March 2–4 m/h (3.2–6.4 km/h) with 279 kg load	4.9
Obstacle course	5.7	5.0–6.3
Miner
Drilling with jackhammer	3.9
Loading operations	3.2
Shoveling	4.6
Office worker
Filing	1.3		1.5
Reading	1.3		1.5
Sitting at desk	1.3
Standing/moving around	1.6
Typing	1.8		1.8
Writing	1.4		1.4
Postal worker
Climbing stairs	8.9	7.7–10.7
Sorting parcels (habitual)	5.4
Shoemaker	2.6		2.2
Tailor	2.5
Textile factory worker (average of spinning, weaving, dyeing)	3.1		2.2
Sports activities
Aerobic dancing
Low-intensity	3.51		4.24
High-intensity	7.93		8.31
Basketball	6.95		7.74
Batting	4.85
Bowling	4.21
Calisthenics	5.44
Circuit training	6.96		6.29
Football	8.0	7.5–8.5
Golf	4.38
Rowing	6.7		5.34
Running
Long distance	6.34		6.55
Sprinting	8.21		8.28
Sailing	1.42		1.54
Swimming	9	8.5–9.4
Tennis	5.8		5.92
Volleyball	6.06		6.06
Miscellaneous recreational activities
Dancing	5.0		5.09
Listening to radio/music	1.57	1.45–1.9	1.43
Painting	1.25		1.27
Playing cards/board games	1.5	1.4–1.8	1.75
Playing the drums	3.71
Playing the piano	2.25
Playing the trumpet	1.77
Reading	1.22		1.25
Watching TV	1.64		1.72

From Ainsworth et al.⁷²

MET metabolic equivalent of task; the ratio of the work metabolic rate to the resting metabolic rate. One MET is defined as 1 kcal/kg/h and is roughly equivalent to the energy cost of sitting quietly.

References

International Diabetes Federation. Diabetes Facts. www.idf.org. 2010 November 10.

Misra

, Khurana

. Obesity and the metabolic syndrome in developing countries. J Clin Endocrinol Metab, 2008; 93,11 Suppl 1:S9–S30.

Misra

, Singhal

, Khurana

. Obesity, the metabolic syndrome, and type 2 diabetes in developing countries: role of dietary fats and oils. J Am Coll Nutr, 2010; 29,3 Suppl:289S–301S.

Kamath

, Hussain

, Amin

, Mortillaro

, West

, Peterson

, Aryee

, Murillo

, Alekel

. Cardiovascular disease risk factors in 2 distinct ethnic groups: Indian and Pakistani compared with American premenopausal women. Am J Clin Nutr, 1999; 69:621–631.

Hayes

, White

, Unwin

, Bhopal

, Fischbacher

, Harland

, Alberti

. Patterns of physical activity and relationship with risk markers for cardiovascular disease and diabetes in Indian, Pakistani, Bangladeshi and European adults in a UK population. J Public Health Med, 2002; 24:170–178.

Viswanathan

, McCarthy

, Snehalatha

, Hitman

, Ramachandran

. Familial aggregation of type 2 (non-insulin-dependent) diabetes mellitus in south India; absence of excess maternal transmission. Diabet Med, 1996; 13:232–237.

Knowler

, Fowler

, Hamman

, Christophi

, Hoffman

, Brenneman

, Brown-Friday

, Goldberg

, Venditti

, Nathan

. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet, 2009; 374:1677–1686.

Misra

. Prevention of type 2 diabetes: the long and winding road. Lancet, 2009; 374:1655–1656.

Warburton

, Nicol

, Bredin

. Health benefits of physical activity: the evidence. CMAJ, 2006; 174:801–809.

10.

Physical Activity Guidelines Advisory Committee Report. www.health.gov/paguidelines. 2010 November 10.

11.

Haskell

, Lee

, Pate

, Powell

, Blair

, Franklin

, Macera

, Heath

, Thompson

, Bauman

. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation, 2007; 116:1081–1093.

12.

Nelson

, Rejeski

, Blair

, Duncan

, Judge

, King

, Macera

, Castaneda-Sceppa

. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Circulation, 2007; 116:1094–1105.

13.

Misra

, Sharma

, Gulati

, Joshi

, Sharma

, Ghafoorunissa , Ibrahim

, Joshi

, Laxmaiah

, Kurpad

, Raj

, Mohan

, Chandalia

, Krishnaswamy

, Boindala

, Gopalan

, Bhattiprolu

, Modi

, Vikram

, Makkar

, Mathur

, Dey

, Vasudevan

, Gupta

, Puri

, Joshi

, Khanna

, Mathur

, Krishnaswamy

, Madan

, Karmarkar

, Seth

, Passi

, Chadha

, Bhardwaj

. National Dietary Guidelines Consensus Group. Consensus dietary guidelines for healthy living and prevention of obesity, the metabolic syndrome, diabetes, and related disorders in Asian Indians. Diabetes Technol Ther, 2011; 13:683–694.

14.

Misra

, Chowbey

, Makkar

, Vikram

, Wasir

, Chadha

, Joshi

, Sadikot

, Gupta

, Gulati

, Munjal

. Consensus Group. Consensus statement for diagnosis of obesity, abdominal obesity and the metabolic syndrome for Asian Indians and recommendations for physical activity, medical and surgical management. J Assoc Physicians India, 2009; 57:163–170.

15.

Cooper

, Cawley

, Bhalla

, Egger

, Ring

, Morton

, Barker

. Childhood growth, physical activity, and peak bone mass in women. J Bone Miner Res, 1995; 10:940–947.

16.

Hills

, King

, Armstrong

. The contribution of physical activity and sedentary behaviours to the growth and development of children and adolescents: implications for overweight and obesity. Sports Med, 2007; 37:533–545.

17.

Janssen

, Katzmarzyk

, Boyce

, King

, Pickett

. Overweight and obesity in Canadian adolescents and their associations with dietary habits and physical activity patterns. J Adolesc Health, 2004; 35:360–367.

18.

Vandewater

, Shim

, Caplovitz

. Linking obesity and activity level with children's television and video game use. J Adolesc, 2004; 27:71–85.

19.

Caroli

, Argentieri

, Cardone

, Masi

. Role of television in childhood obesity prevention. Int J Obes Relat Metab Disord, 2004; 28,Suppl 3:S104–S108.

20.

Hesketh

, Wake

, Graham

, Waters

. Stability of television viewing and electronic game/computer use in a prospective cohort study of Australian children: relationship with body mass index. Int J Behav Nutr Phys Act, 2007; 4:60.

21.

Wrotniak

, Epstein

, Dorn

, Jones

, Kondilis

. The relationship between motor proficiency and physical activity in children. Pediatrics, 2006; 118:e1758–e1765.

22.

Stephens

, Jacobs

Jr , White

. A descriptive epidemiology of leisure-time physical activity. Public Health Rep, 1985; 100:147–158.

23.

Faigenbaum

, Myer

. Pediatric resistance training: benefits, concerns, and program design considerations. Curr Sports Med Rep, 2010; 9:161–168.

24.

Faigenbaum

, Westcott

, Loud

, Long

. The effects of different resistance training protocols on muscular strength and endurance development in children. Pediatrics, 1999; 104:e5.

25.

U.S. Department of Health and Human Services. 2008. Physical Activity Guidelines for Americans. Washington, DC: U.S. Department of Health and Human Services, 2008.

26.

Davis

, Tomporowski

, Boyle

, Waller

, Miller

, Naglieri

, Gregoski

. Effects of aerobic exercise on overweight children's cognitive functioning: a randomized controlled trial. Res Q Exerc Sport, 2007; 78:510–519.

27.

Sibley

, Etnier

. The relationship between physical activity and cognition in children: a meta-analysis. Pediatr Exerc Sci, 2003; 15:243–256.

28.

Davy

, DeSouza

, Jones

, Seals

. Elevated heart rate variability in physically active young and older adult women. Clin Sci (Lond), 1998; 94:579–584.

29.

Amano

, Kanda

, Ue

, Moritani

. Exercise training and autonomic nervous system activity in obese individuals. Med Sci Sports Exerc, 2001; 33:1287–1291.

30.

Singhal

, Misra

, Shah

, Gulati

. Effects of controlled school-based multi-component model of nutrition and lifestyle interventions on behavior modification, anthropometry and metabolic risk profile of urban Asian Indian adolescents in North India. Eur J Clin Nutr, 2010; 64:364–373.

31.

Shah

, Misra

, Gupta

, Hazra

, Gupta

, Seth

, Agarwal

, Gupta

, Jain

, Kulshreshta

, Hazra

, Khanna

, Gangwar

, Bansal

, Tallikoti

, Mohan

, Bhargava

, Sharma

, Gulati

, Bharadwaj

, Pandey

, Goel

. Improvement in nutrition-related knowledge and behaviour of urban Asian Indian school children: findings from the ‘Medical education for children/Adolescents for Realistic prevention of obesity and diabetes and for healthy aGeing’ (MARG) intervention study. Br J Nutr, 2010; 104:427–436.

32.

DeMaio

, Magann

. Exercise and pregnancy. J Am Acad Orthop Surg, 2009; 17:504–514.

33.

Melzer

, Schutz

, Boulvain

, Kayser

. Physical activity and pregnancy: cardiovascular adaptations, recommendations and pregnancy outcomes. Sports Med, 2010; 40:493–507.

34.

Tobias

, Zhang

, van Dam

, Bowers

, Hu

. Physical activity before and during pregnancy and risk of gestational diabetes mellitus: a meta-analysis. Diabetes Care, 2011; 34:223–229.

35.

Polley

, Wing

, Sims

. Randomized controlled trial to prevent excessive weight gain in pregnant women. Int J Obes Relat Metab Disord, 2002; 26:1494–1502.

36.

Sorensen

, Williams

, Lee

, Dashow

, Thompson

, Luthy

. Recreational physical activity during pregnancy and risk of preeclampsia. Hypertension, 2003; 41:1273–1280.

37.

Clapp JF 3^rd:. The effects of maternal exercise on fetal oxygenation and feto-placental growth. Eur J Obstet Gynecol Reprod Biol, 2003; 110,Suppl 1:S80–S85.

38.

Kobe

, Nakai

, Koshino

, Araki

. Effect of regular maternal exercise on lipid peroxidation levels and antioxidant enzymatic activities before and after delivery. J Nippon Med Sch, 2002; 69:542–548.

39.

Kasapis

, Thompson

. The effects of physical activity on serum C-reactive protein and inflammatory markers: a systematic review. J Am Coll Cardiol, 2005; 45:1563–1569.

40.

ACOG Committee opinion. Number 267, January 2002: exercise during pregnancy and the postpartum period. Obstet Gynecol, 2002; 99:171–173.

41.

Artal

, O'Toole

. Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy, the postpartum period. Br J Sports Med, 2003; 37:6–12discussion 12.

42.

Davies

, Wolfe

, Mottola

, MacKinnon

. Joint SOGC/CSEP clinical practice guideline: exercise in pregnancy and the postpartum period. Can J Appl Physiol, 2003; 28:330–341.

43.

Hall

, Kaufmann

. Effects of aerobic and strength conditioning on pregnancy outcomes. Am J Obstet Gynecol, 1987; 157:1199–1203.

44.

Government of India, Central Statistical Organisation. Elderly in India: Profile, Programmes. New Delhi: Ministry of Statistics and Programme Implementation, 2000.

45.

Liu

, Latham

. Progressive resistance strength training for improving physical function in older adults. Cochrane Database Syst Rev, 2009; 3:CD002759.

46.

Paterson

, Warburton

. Physical activity and functional limitations in older adults: a systematic review related to Canada's Physical Activity Guidelines. Int J Behav Nutr Phys Act, 2010; 7:38.

47.

Baan

, Stolk

, Grobbee

, Witteman

, Feskens

. Physical activity in elderly subjects with impaired glucose tolerance and newly diagnosed diabetes mellitus. Am J Epidemiol, 1999; 149:219–227.

48.

Kesaniemi

, Riddoch

, Reeder

, Blair

, Sorensen

. Advancing the future of physical activity guidelines in Canada: an independent expert panel interpretation of the evidence. Int J Behav Nutr Phys Act, 2010; 7:41.

49.

Rastogi

, Vaz

, Spiegelman

, Reddy

, Bharathi

, Stampfer

, Willett

, Ascherio

. Physical activity and risk of coronary heart disease in India. Int J Epidemiol, 2004; 33:759–767.

50.

Jolly

, Taylor

, Lip

, Stevens

. Home-based cardiac rehabilitation compared with centre-based rehabilitation and usual care: a systematic review and meta-analysis. Int J Cardiol, 2006; 111:343–351.

51.

Leon

, Franklin

, Costa

, Balady

, Berra

, Stewart

, Thompson

, Williams

, Lauer

. Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American association of Cardiovascular and Pulmonary Rehabilitation. Circulation, 2005; 111:369–376.

52.

Taylor

, Brown

, Ebrahim

, Jolliffe

, Noorani

, Rees

, Skidmore

, Stone

, Thompson

, Oldridge

. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med, 2004; 116:682–692.

53.

Thompson

. Exercise prescription and proscription for patients with coronary artery disease. Circulation, 2005; 112:2354–2363.

54.

Vaz

, Bharathi

. Practices and perceptions of physical activity in urban, employed, middle-class Indians. Indian Heart J, 2000; 52:301–306.

55.

Briffa

, Maiorana

, Sheerin

, Stubbs

, Oldenburg

, Sammel

, Allan

. Physical activity for people with cardiovascular disease: recommendations of the National Heart Foundation of Australia. Med J Aust, 2006; 184:71–75.

56.

Specchia

, De Servi

, Scire

, Assandri

, Berzuini

, Angoli

, La Rovere

, Cobelli

. Interaction between exercise training and ejection fraction in predicting prognosis after a first myocardial infarction. Circulation, 1996; 94:978–982.

57.

American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Cardiac Rehabilitation Programs, 2nd. Champaign, IL: Human Kinetics Books, 1995; 14.

58.

Simms

, Myers

, Adams

, Hartman

, Lindsey

, Doler

, Suhr

. Exercise tolerance testing in a cardiac rehabilitation setting: an exploratory study of its safety and practicality for exercise prescription and outcome data collection. Proc Baylor Univ Med Center, 2007; 20:344–347.

59.

Giannuzzi

, Temporelli

, Corra

, Gattone

, Giordano

, Tavazzi

. Attenuation of unfavorable remodeling by exercise training in postinfarction patients with left ventricular dysfunction: results of the Exercise in Left Ventricular Dysfunction (ELVD) trial. Circulation, 1997; 96:1790–1797.

60.

Shaw

, Sicree

, Zimmet

. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract, 2010; 87:4–14.

61.

Gupta

, Misra

. Type 2 diabetes in India: regional disparities. Br J Diabetes Vasc Dis, 2007; 7:12–16.

62.

Misra

, Alappan

, Vikram

, Goel

, Gupta

, Mittal

, Bhatt

, Luthra

. Effect of supervised progressive resistance-exercise training protocol on insulin sensitivity, glycemia, lipids, and body composition in Asian Indians with type 2 diabetes. Diabetes Care, 2008; 31:1282–1287.

63.

Cuff

, Meneilly

, Martin

, Ignaszewski

, Tildesley

, Frohlich

. Effective exercise modality to reduce insulin resistance in women with type 2 diabetes. Diabetes Care, 2003; 26:2977–2982.

64.

Ishii

, Yamakita

, Sato

, Tanaka

, Fujii

. Resistance training improves insulin sensitivity in NIDDM subjects without altering maximal oxygen uptake. Diabetes Care, 1998; 21:1353–1355.

65.

Silverstein

, Klingensmith

, Copeland

, Plotnick

, Kaufman

, Laffel

, Deeb

, Grey

, Anderson

, Holzmeister

, Clark

. Care of children and adolescents with type 1 diabetes: a statement of the American Diabetes Association. Diabetes Care, 2005; 28:186–212.

66.

Bhardwaj

, Misra

, Khurana

, Gulati

, Shah

, Vikram

. Childhood obesity in Asian Indians: a burgeoning cause of insulin resistance, diabetes and sub-clinical inflammation. Asia Pac J Clin Nutr, 2008; 17,Suppl 1:172–175.

67.

Gupta

, Shah

, Misra

, Bharadwaj

, Gulati

, Gupta

, Sharma

, Pandey

, Goel

. Secular trends in prevalence of overweight and obesity from 2006 to 2009 in urban Asian Indian adolescents aged 14–17 years. PLoS One, 2011; 6:e17221.

68.

Misra

, Vikram

. Clinical and pathophysiological consequences of abdominal adiposity and abdominal adipose tissue depots. Nutrition, 2003; 19:457–466.

69.

Misra

, Singhal

, Khurana

. Obesity, the metabolic syndrome, and type 2 diabetes in developing countries: role of dietary fats and oils. J Am Coll Nutr, 2010; 29,3 Suppl:289S–301S.

70.

Haskell

, Lee

, Pate

, Powell

, Blair

, Franklin

, Macera

, Heath

, Thompson

, Bauman

. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc, 2007; 39:1423–1434.

71.

Saris

, Blair

, van Baak

, Eaton

, Davies

, Di Pietro

, Fogelholm

, Rissanen

, Schoeller

, Swinburn

, Tremblay

, Westerterp

, Wyatt

. How much physical activity is enough to prevent unhealthy weight gain? Outcome of the IASO 1st Stock Conference and consensus statement. Obes Rev, 2003; 4:101–114.

72.

Ainsworth

, Haskell

, Whitt

, Irwin

, Swartz

, Strath

, O'Brien

, Bassett

Jr , Schmitz

, Emplaincourt

, Jacobs

Jr , Leon

. Compendium of physical activities: an update of activity codes and MET intensities. Med Sci Sports Exerc, 2000; 32,9 Suppl:S498–S504.

Consensus Physical Activity Guidelines for Asian Indians

Abstract

Background

Objectives and Process of Consensus Development

Definitions of Physical Activity Intensity Levels

Safety Concerns of Exercise

Physical Activity Guidelines for Healthy Adults

Summary recommendations for healthy adults

Physical Activity Guidelines for Children and Adolescents

Background and evidence

Available guidelines and principles 10

School-based approach

Summary recommendation for Asian Indian children

Physical Activity Guidelines for Pregnant and Lactating Women

Background and evidence

Available guidelines and principles

Summary recommendations for pregnant women

Physical Activity Guidelines for the Elderly

Background and evidence

Available guidelines and principles

Summary recommendations for the elderly

Physical Activity Guidelines for Non-Communicable Diseases

CVDs and hypertension

Background and evidence

Design and administration of the exercise training program: program structure

Supervised versus unsupervised physical activity.

Pre-activity evaluation

Physical activity session: guidelines and principles

Summary recommendations for patients with CHD and hypertension

Prediabetes and diabetes

Background and evidence

Cautions

Summary recommendations for patients with diabetes

Obesity

Background and evidence

Guidelines and principles

Summary recommendations for individuals with obesity

Physical Activity Action Plan for the General Population

Further Research on Asian Indians

Footnotes

Author Disclosure Statement

Appendix 1

Appendix 2: Physical Activity Consensus Group

Appendix 3

Appendix 4

References

Available guidelines and principles¹⁰