food & nutrition

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REVIEW ARTICLE
Physical activity: associations with health and summary of
guidelines
Katja Borodulin1,* and Sigmund Anderssen2
1
Age Institute, Helsinki, Finland; 2Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway

Popular scientific summary

• The understanding of how physical activity and sedentary behavior are associated with health out-
comes increases over time when more research on disease-specific outcomes, age groups, and special
population groups evolves. With new evidence, guidelines on physical activity and sedentary behav-
ior are updated. We present associations of physical activity and sedentary behavior with health-re-
lated outcomes, the updated guidelines by World Health Organization (WHO) and give references
to the country-specific guidelines in the Nordic and Baltic countries.

Abstract

The understanding of how physical activity and insufficient physical activity are associated with health out-
comes has increased considerably over the past decades. Along with physical activity, the evidence on the
associations between sedentary behavior and health has increased, which has resulted in the introduction
of recommendations of sedentary behavior. In this article, we 1) present terminology for physical activity
and sedentary behavior epidemiology, 2) show the relevant scientific evidence on associations of physical
­activity and sedentary behavior with selected health-related outcomes and 3) introduce the global guide-
lines for physical activity and sedentary behavior by the World Health Organization (WHO). Health-related
­outcomes include cardiovascular morbidity and mortality, total mortality, glucose regulation and type 2 dia-
betes, adiposity, overweight, obesity, cancer, musculoskeletal and bone health, brain health, and quality of
life. These health-related outcomes are reflected across age groups and some population groups, such as preg-
nant and postpartum women. Furthermore, we discuss physical activity levels across Nordic countries and
over time. For the Nordic Nutrition Recommendations, shared common physical activity guidelines were not
developed. Instead, each country has created their own guidelines that are being referenced in the article, along
with the global WHO guidelines.
Keywords: guidelines; health; physical activity; population; sedentary behavior

Received: 23 January 2023; Revised: 15 May 2023; Accepted: 16 May 2023; Published: 26 June 2023

T
he understanding of how physical activity and health. Literature search for this chapter relied on recent
insufficient physical activity are associated with systematic literature search processes that were carried
health outcomes has increased considerably over out by many national guideline development processes
the past decades. Epidemiologic research, clinical inter- and the WHO guideline development processes. The
ventions, and mechanistic studies have contributed to the most recent update on existing literature was updated
evidence that physical activity is essential to preventing in the WHO process, including literature published until
disease, improving health, and improving quality of life. September 2019. Thus, in this chapter we use the most
Physical activity can be done in different domains such as recent reviews, including umbrella reviews as well as some
during leisure time, education, occupation, and transpor- selected articles on each disease group.
tation. The reference list in this chapter includes several Healthy diet alone or sufficient physical activity alone
key references but does not intend to cover the entire body have a huge impact on our health and wellbeing. However,
of literature regarding the effects of physical activity on since there is a strong interaction between nutrition and

Food & Nutrition Research 2023. © 2023 Borodulin and Anderssen.This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (http:// 1
creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose,
even commercially, provided the original work is properly cited and states its license. Citation: Food & Nutrition Research 2023, 67: 9719 - http://dx.doi.org/10.29219/fnr.v67.9719
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Borodulin and Anderssen

physical activity they cannot be totally separated when Muscle-strengthening activity is exercise designed to
making recommendations for either one of them. For a increase skeletal muscle strength, power, endurance and
good public health impact, a combination of healthy diet mass. Examples include strength or resistance training.
and sufficient physical activity is needed. Occupation domain physical activity is undertaken
during work, which can be paid or voluntary working.
Glossary Physical activity is a comprehensive concept that encom-
Aerobic physical activity is activity that increases heart rate passes many terms related to movement of the body. It is
and breathing, involves large muscles in repetitive move- defined as any bodily movement achieved by contraction of
ments in a sustained period of time. Also known as endur- skeletal muscles that increases energy expenditure (EE)
ance training. Examples are walking, jogging, bicycling, above resting levels.
skiing and swimming. Physical fitness is a set of attributes related to the ability
Balance training improves an individual’s ability to sus- to perform physical activity and is something that people
tain postural balance and prevent falling in spite of pos- ‘have’ or ‘strive to achieve’. The term includes cardiorespira-
tural sway or stimuli from self-motion, the environment or tory fitness, strength, coordination, flexibility, etc.
other objects. Examples are static or dynamic exercises Physical inactivity is insufficient physical activity and is
that challenge body’s center of gravity, such as dance and defined as a failure to meet the current recommendations.
gymnastics. Sedentary behavior refers to any waking activity charac-
Bone-strengthening activity increases the strength of terized by an energy expenditure ≤ 1.5 metabolic equivalents
specific sites in bones that make up the skeletal system. and a sitting or reclining posture. In general, this means that
Movements that produce impact or tension force on the any time a person is sitting or lying down they are engaging
bones lead to bone growth and strength. Examples are hop- in sedentary behavior. Common sedentary behaviors include
ping, running, gymnastics, lifting weights, and racket games. TV viewing, video game playing, computer use (collectively
Domains of physical activity refer to context where activ- termed ‘screen time’), driving automobiles, and reading.
ity takes place, such as leisure-time, occupation, education, Transport domain physical activity is performed to get
household, or transportation. from one place to another in physically demanding modes,
Endurance training is repetitive, dynamic use of large such as walking, bicycling or wheeling. Term active trans-
muscles (e.g. swimming, walking, or bicycling). port is also used.
Exercise is any planned, structured, and repetitive bodily Vigorous intensity physical activity is activity requiring
movement carried out to improve or maintain one or more more than 6 METs.
components of physical fitness.
Household domain physical activity is performed in the Study designs and measurement challenges in
home including domestic tasks like cleaning, childcare, gar- physical activity
dening or snow shoveling. Health benefits of physical activity are broadly reported
Leisure-domain physical activity refers to activities like across different population groups and across different
sports participation, exercise conditioning or training, and health outcomes. Much of the existing evidence relies
recreational activities like walking, dancing and gardening. on observational studies, such as cohort studies that
Light intensity activity is defined as activity correspond- have followed participants over time after baseline mea-
ing to an energy expenditure between 1.5 and 3 metabolic surements or cross-sectional observations with physical
equivalent of tasks (MET) such as standing or walking activity and health indicator being measured at the same
slowly (<3.5 km/h). time. However, evidence is also available from randomized
Major muscle groups are legs, back, abdomen, shoulders clinical trials, where the causality from physical activity as
and arms. an exposure can be estimated with the outcome indicator
Metabolic equivalent of task is a unit used to estimate in a more controlled way than in observational studies.
energy expenditure (oxygen consumption) of physical Examples from observational studies include outcomes
activity. One MET equals energy expenditure at rest and such as cancer and cardiovascular diseases, and from clin-
corresponds to approximately 3.5 mL O2·kg-1·min-1. ical trials outcomes like gait speed, osteoarthritis, oste-
Moderate intensity physical activity is defined as activity oporosis and diabetes type 2. Measurement of physical
that requires three to six METs. activity has shown to be a challenge, as there is no gold
Multicomponent physical activity refers to activities that standard for self-reported methods. Laboratory measure-
combine elements of aerobic, strength, balance, agility or ments cannot be carried out for large samples, and move-
flexibility training. Multicomponent activity is targeted ment device-based methods have their own challenges (1).
to older adults to prevent falling and maintain mobility. However, movement devices, such as accelerometry have
Examples are stair climbing, weightlifting, gymnastics, and recently become more broadly used, also in large-scale
dancing. cohort studies.

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 Physical activity

The guidelines are largely based on the information with a lower mortality risk and that the risk gradually
gained from studies reporting self-reported physical activ- decreased until 7500 steps.
ity behavior, but device-based information adds to this Meeting the guidelines for both aerobic and muscle
body of evidence where appropriate. strengthening activities and meeting just muscle strength-
ening activities showed 29% and 20% lower all-cause
Morbidity and mortality from cardiovascular mortality risk, respectively when compared to those not
diseases and all-cause mortality meeting those guidelines (15).
Physical activity of any intensity is shown to associate Different domains of physical activity have also been
with all-cause and cardiovascular disease mortality in studied for health benefits. A review (16) of 11 prospective
numerous studies (2). It is estimated that physical inac- cohorts, albeit with large heterogeneity, concluded that
tivity may account for 9% of premature mortality (3). active commuters had 8% lower all-cause mortality risk in
Leisure-time physical activity may bring from 1.9 to 2.4 comparison to inactive persons. For occupational physi-
additional life-years in men and from 1.5 to 1.8 life-years cal activity, associations with cardiovascular or all-cause
in women when comparing groups of no leisure-time mortality have shown mixed findings and methodological
physical activity with low to high volume of leisure time shortcomings such as heterogeneity in the classification
physical activity (4). of occupational physical activity and residual confound-
Previous prospective studies, systematic reviews and ing from socioeconomic factors (17–19). A meta-analysis
18

meta-analyses have shown inverse associations of phys- suggested an 18% higher risk of all-cause mortality in
ical activity with all-cause mortality (5 –10) and with 6789
men with high occupational physical activity compared
cardiovascular disease incidence and mortality (3, 7, 8). to those with low occupational activity (17). Dalene et
A recent meta-analysis (6) in adults using a median fol- al (2021) suggested a positive dose-response relationship
low-up of 5.8 years showed a dose-response association between occupational physical activity and longevity in
between total accelerometer-based physical activity and men (18). Another meta-analysis (19) found occupational
all-cause mortality. The mortality risk, as compared to physical activity not to associate with overall cardiovascu-
the least active 1st quartile, was 46% lower in 2nd quartile, lar diseases, but to associate directly with a 15% increase
59% lower in 3rd quartile, and 66% Iower in 4th quartile. in ischemic heart disease mortality risk.
Similar inverse associations were found for light intensity Sedentary behavior is suggested to associate, inde-
physical activity and for moderate-to-vigorous intensity pendent of physical activity, with cardiovascular disease
physical activity. The greatest risk reductions for mor- incidence and mortality (20–22), as well as with all-cause
21

tality were seen at 375 min/d of light-intensity physical mortality (6, 7, 20, 21). Ekelund et al (6) suggest hazard
activity or 24 min/d of moderate-to-vigorous intensity. ratios of 1.28 in 2nd quartile, 1.71 in 3rd quartile, and 2.63
Another meta-analysis (8) concluded that reaching rec- in 4th quartile, as compared to the least sedentary quar-
ommended level of physical activity 750 MET/min week tile 1, in which the least sedentary people spent 7.5–9 h/
was associated with a 14% lower risk of all-cause mor- day (accelerometry-based). Some large cohort studies,
tality and a 27% lower risk of cardiovascular mortality, however, have also reported non-significant associations
when compared to those not reaching the recommended between sedentary behavior and cardiovascular disease
level of physical activity. (7, 11). Independent associations are reported between
Low intensities of physical activity are suggested to TV time and all-cause and cardiovascular mortality (21).
associate with cardiovascular disease and all-cause mor- However, studies have also pointed out that the detrimen-
tality (6), but there are also studies suggesting weak or tal effects of sedentary behavior can be attenuated or even
no association (7,11). It is likely that studies differ in prevented by physical activity (8,9, 23–25). Reaching the
24

their representativeness, age range, loss to and length of upper limit of physical activity recommendation can out-
follow-up, and placement and accuracy of devices that weigh the harms of sedentary behavior (23).
may all have a role in the inconsistent findings. A literature review that was carried out for the update
Daily steps are seen as an option for future recom- of the WHO 2020 guidelines came into the conclusion that
mendations as steps can be understood by lay people and current evidence does not allow quantifying the cut-off
are easily quantified using simple device. Daily steps are points for recommended time in sedentary behavior, nor is
reported to inversely associate with several health out- there enough evidence to make specific recommendations
comes (12). It is suggested that every 1000 increase in on the type or domain of sedentary behavior, or frequency
daily step count is associated with a 6-36% lower risk for or duration of bouts or breaks in sedentary behavior (20).
all-cause mortality and a 5%–21% lower risk for cardio-
vascular events (13). Furthermore, in a cohort of older Glucose regulation and type 2 diabetes
women (14), it was shown that compared to daily step The evidence from prospective cohort studies and from ran-
count of 2700, already 4400 daily steps were associated domized control trials show inverse associations between

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Borodulin and Anderssen

physical activity and type 2 diabetes or its pre-clinical con- Concerning sedentary behavior, the level of evidence
ditions, including elevated blood glucose levels (26). The on health outcomes is weaker than evidence found for
population attributable fraction from low physical activity physical activity. From existing systematic reviews and
is estimated to be 7% for type 2 diabetes (3). meta-analyses, low certainty evidence suggests that time
A recent systematic review summarized evidence on spent in sedentary activities may have a role in different
associations between accelerometry-based daily step measures of adiposity and weight status in school-aged
counts and dysglycemia from eight prospective studies children (9, 37) and in adults (20, 38, 39). There is limited
that had a follow-up time from 3 months to 5 years (13). evidence available on associations of different types of
Outcome on dysglycemia included elevated blood glucose sedentary behavior with adiposity (40).
levels and HbA1c, insulin resistance, 2-h glucose, insulin Replacing 30 min of daily sedentary time with light
sensitivity and incident dysglycemia or type 2 diabetes. intensity physical activity was found to be associated
Their findings suggest mixed results, where non-signifi- with reductions in waist circumference (28). In the same
cant or weak inverse associations were found. Two studies meta-analysis, replacing sedentary behavior with mod-
showed 2% and 13% lower diabetes and incident dysgly- erate-to-vigorous intensity physical activity showed even
cemia risk for each 1000-steps and 2000-steps increase, larger effect on reducing waist circumference and body
respectively. mass index.
Sedentary behavior may increase the risk of type 2
diabetes, independent of physical activity, as found in a Causal pathways concerning cardiovascular disease,
systematic review and a meta-analysis using 11 prospec- glucose regulation and adiposity
tive studies (21). A relative risk of 1.01 in total sitting Non-communicable diseases progress through life, and
time and 1.09 in TV viewing time were found for type 2 the biological mechanisms are complex. The causal
diabetes and a population attributable fraction of 29% pathways from physical activity or sedentary behavior
for TV viewing. Similar associations were observed from to cardiometabolic health outcomes share similarities
another systematic review that found 11% higher risk of for cardiovascular disease, type 2 diabetes, and obesity.
incident type 2 diabetes with higher level of sitting time Physical activity has favorable effects on cardiometabolic
(27). When reallocating 30 min of sedentary behavior in health, particularly by lowering the risk factor levels for
substitution analyses to light intensity activity, beneficial blood pressure, metabolic syndrome, type 2 diabetes,
associations were suggested for fasting insulin, and when and blood fatty acids and facilitates glucose homeosta-
reallocating to moderate to vigorous physical activity, sis (3, 41). Physical activity improves risk factor levels
even stronger associations were suggested to fasting glu- through a role in low grade inflammation. As impor-
cose and insulin (28). tantly, people with diagnosed cardiovascular diseases
can postpone the progression of the disease by engag-
Adiposity, overweight and obesity ing in physical activity (9). For sedentary behavior, the
Physical activity is associated with maintenance of causal pathway is suggested to be the opposite to physi-
healthy weight and attenuation of weight gain in adults cal activity. Sedentary behavior may increase all relevant
(29–31) and with reduction of excessive increase in body
30 metabolic risk factors for cardiovascular disease and sub-
weight and adiposity in children (9, 32, 33). Moderate- sequently lead to incident cardiovascular disease.
to-vigorous intensity physical activity has been shown to Potential mechanisms from the benefits of physical
associate with adult-age prevention of weight gain and activity on glucose regulation are well known (36). Being
the association may be even more pronounced when physically active increases body metabolism in multiple
exceeding 150 min/week of moderate-to-vigorous inten- ways and has direct effects on circulating glucose levels,
sity physical activity (34). Also, combining dietary restric- subsequently on insulin resistance, and energy consump-
tions and physical activity shows to be effective in weight tion. Physical activity may also prevent abdominal obesity
loss (35). and reduce subcutaneous fat, thus acting as a mediating
The evidence of the association between physical factor between obesity and glucose irregulation.
activity and adiposity is unsystematic and heterogenous, Physical activity is essentially part of energy consump-
despite the large amount of research on this topic (9). tion and directly affects whether body energy balance
Therefore, the strength of evidence in most recent reviews is negative or positive. The causal pathway from physi-
and guidelines has been stated as limited or not assign- cal activity or sedentary behavior is assumed to affect
able, where many research gaps are related to dose-re- through increased metabolism and increased energy
sponse-associations and specific types of physical activity uptake. Biological mechanism is complex, as physical
(9, 36). Furthermore, research gaps are recognized for activity may alter body composition such as muscle or fat
associations of physical activity or sedentary behavior mass, while body weight remains unchanged. It is likely
with sociodemographic variables and ethnicity (36). that physical activity brings health benefits regardless of

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 Physical activity

the adiposity level, which is often referred to the ‘fit but using many designs, such as randomized controlled trials,
fat’ theory (42, 43). Physical activity, sedentary behavior, cross-sectional, cohort and case-control studies, as well as
and adiposity jointly account for prevention of import- animal models. Furthermore, the benefits of exercise on
ant major diseases like cardiovascular disease and type 2 cancer treatment and on post-treatment wellbeing may
diabetes. act through improved physical fitness, maintained muscle
and bone mass and cardiac rehabilitation (46).
Cancer
A systematic review from 45 studies suggests a strong Musculo-skeletal and bone health
association between physical activity and bladder, breast, Physical activity and diet are the primary modifiable risk
colon, endometrial, esophageal adenocarcinoma, renal, factors associated with bone health (48, 49). Optimization
and gastric cancers (44). The relative risk reduction for of lifestyle factors, shown to influence 20%–40% of adult
these cancer types varied from 10%–20% between high- peak bone mass, is important to reduce osteoporosis later
est and lowest physical activity categories. Similar asso- in life. Physical activity, adequate intake of calcium and
ciations are reported by the WHO 2020 Guidelines vitamin D as well as stratification of fracture risk should
Development Group (9) and the 2018 Physical Activity be the main targets to prevent osteoporosis and fractures
Guidelines Advisory Committee (36), where it is stated (48). Reversible risk factors for falls include weak lower
that the evidence is insufficient concerning the associa- limb muscle strength, poor balance, and a poor level of
tions between physical activity and hematologic, head and overall physical fitness, all of which can be improved by
neck, ovary, pancreas, prostate, thyroid, rectal and brain regular physical activity (50). Muscle strength and muscle
cancer. Lung cancer is largely confounded by tobacco use. endurance diminish with increasing age and decreasing
Physical activity may also play a role in post-diagno- activity level, and physical activity can counteract and
sis survival rate (44, 45), as two systematic reviews found reverse this trend to a substantial degree.
moderate or limited associations between physical activity Physical activity contributes to increased bone density
and decreased all-cause and cancer-specific mortality in and can counteract osteoporosis, and physical activity
individuals with a diagnosis of breast, colorectal, or pros- immediately before and during puberty seems to yield
tate cancer, where relative risks varied from 40% to 50%. greater maximum bone density in adult life. In women
For sedentary behavior, moderate level evidence is both before and after menopause and in middle-aged and
reported for the associations between sedentary behavior older men, a beneficial effect on bone density has been
and incident endometrial, colon and lung cancer, while shown. The evidence is based on systematic reviews and
limited evidence was found on associations for cancer meta-analysis (51–54). However, there is a need to fur-
5253

mortality (39). ther explore possible gender differences with respect to

The required dose of physical activity needed for a the effect of exercise on bone health. To be beneficial for
lower risk of cancer varies between studies, although bone mass and structure, exercise should preferably be
some evidence on dose-response-type of associations has weight-bearing, and repeated weight-bearing and load-
been suggested (44). This has also been recognized for ing, such as walking and running, is more beneficial than
sedentary behavior (20). The type of physical activity or activities such as swimming and cycling. Even better for
sedentary behavior is still an area where more research bone health are activities with high impacts (e.g. tennis,
needs to be done to understand the associations between squash, and aerobics) or high-volume loading (weight
type of activity and cancer risk (20). The available evi- training). Information about the dose-response relation-
dence on cancers has been shown in adult populations, ship between physical activity and osteoporosis is not
but separate groups such as sex, ethnicity, and weight sta- conclusive enough and warrants future research. Possible
tus have been studied sparsely and have covered selected mechanisms of physical activity are beneficial influence
site-specific cancers. of the balance between osteocytes and osteoblasts, and
Causal pathways for associations between physical on hormones acting on the skeleton (for instance growth
activity, sedentary behavior and cancer prevention are hormone and IGF-1) (55).
largely suggested through metabolic processes. These Osteoarthritis is also a prevalent disease where physi-
processes are seen as mechanistic, hypothesized models, cal activity and healthy weight are significant for muscu-
as carcinogenesis is a long process and difficult to show loskeletal health. With increasing inactivity and obesity,
in typically used study designs in humans (46). It is sug- the prevalence of osteoarthritis has also increased signifi-
gested that pathways from physical activity to lower cantly, also in the middle-aged population. The Physical
cancer risk are related to sex hormones, metabolic hor- Activity Guidelines Advisory Committee (PAGAC) inves-
mones, inflammation and adiposity, immune function, tigated seven chronic conditions, among them osteoar-
oxidative stress, DNA repair, and xenobiotic enzyme thritis (36). Osteoarthritis affects a large portion of the
systems (46, 47). This evidence is gathered from studies general population (13.4% of the adult US population

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Borodulin and Anderssen

and 14% of the Norwegian population above 20 years of physical activity during the formative years strengthens
age) and is associated with high disability (56). There is the bones and connective tissues and yields greater max-
high quality evidence that physical activity and exercise imum bone density in adult life. Physical activity that
are effective for people with osteoarthritis (57). Physical provides high impact loading on bones is important for
activity and exercises that amount up to those consistent bone development, particularly during early puberty (2).
with 150 min/week of moderate-intensity have a substan- There is also evidence of an association between physi-
tial beneficial impact on health of individuals with osteo- cal activity and cardiovascular disease risk factors in
arthritis (57). children and adolescents (63). Furthermore, risk factors
We have high quality evidence that joint injury, obesity such as fatness, insulin glucose ratio, and lipids tend to
and muscle weakness are modifiable risk factors for osteo- cluster in children and adolescents with low cardiorespi-
arthritis. Early risk-based interventions are highlighted ratory fitness and low levels of physical activity (63, 64).
as significant for primary and secondary prevention of There is a growing body of evidence of a favorable asso-
osteoarthritis (58). ciation between physical activity and fundamental motor
skill development and academic performance in children
Brain health (65, 66). Furthermore, children and adolescents who are
There is evidence that regular physical activity reduces involved in physical activity seem to experience fewer
the risk of developing anxiety and depression (59). In a mental health problems (2). There is no indication that
meta-analysis including more than 250 000 individuals increased physical activity in school represents any risk of
around the world, it was shown that individuals with high impairing children’s cognitive skills as a result of less time
levels of physical activity had lower likelihood of develop- for theoretical school subjects (67).
ing depression compared to those with low levels of phys- For children of all ages, the associations between sed-
ical activity. This was true in youth, adults and the elderly, entary behavior and health outcomes are in line with the
and protective effects against depression were found information given in the earlier sections. Relevant issues
regardless of geographical region (60). However, there is in children are related to motor skill development, sleep,
not enough data to determine dose-response relationships academic achievements, and social interaction, for which
between physical activity and depression and anxiety. evidence suggests inverse associations against sedentary
There is also evidence that both acute and regular physical behavior (2, 33). Furthermore, unfavorable associations
activity can influence quality of life and sleep (36). There of sedentary behavior with well-being and quality of life
is evidence supporting the hypothesis that physical activ- are noted in school-aged children and adolescents (2).
ity can slow down the progression of Alzheimer’s disease Moreover, in this group, higher durations of screen time,
(61). Also, increased amount of physical activity is asso- television viewing and video game use may be associated
ciated with improvement of brain function and structure, with poorer mental health and pro-social behavior in chil-
and cognition. Evidence suggests that the greatest effect is dren and adolescents (2).
on executive function and memory. The positive effects of
physical activity herein seemed to be independent of the Older adults
type of activity. The mechanism is largely unknown; how- For older adults (referring to people aged 65 years and
ever, regular physical activity may have an impact on the above), all of the health outcomes from physical activity
creation of neurons and new blood vessels in the brain. and sedentary behavior apply as they are for any adults.
Moreover, physical activity may have a beneficial effect on Furthermore, association of physical activity or seden-
inflammatory markers (62). tary behavior with functional capacity and risk of falls
Further research is needed to study the volume and and fall-related outcomes are particularly relevant in the
mode of physical activity that is most beneficial to brain older population.
health (cognition, mental health and quality of life), Systematic reviews and a broad body of evidence show
and to explore the mechanisms through which physical that physical activity associates with and improves phys-
activity improves cognition. Further studies should also ical function (9,68–71). Aerobic, muscle-strengthening
6970

include sedentary behaviors as an exposure. and multicomponent physical activity programs show
the largest improvements in functional capacity (68).
Population group-specific conditions Furthermore, physical activity is suggested to associate
with better mobility, and a decline in physical activity
Children and adolescents to decrease life-space mobility and to increase a risk to
Regular physical activity is necessary for normal growth develop a walking difficulty (72). A large cohort of com-
and the development of cardiorespiratory endurance, munity-dwelling older people using accelerometry-based
muscle strength, flexibility, motor skills, cognitive func- physical activity and sedentary time suggested that higher
tion, academic outcomes and agility (2, 33). In addition, moderate-to-vigorous intensity physical activity was

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 Physical activity

associated with better hand grip strength, faster usual postpartum (86). Furthermore, postpartum pelvic floor
walking speed and faster timed chair stand speed (73). muscle training can reduce urinary incontinence (86).
No associations, independent of moderate-to-vigorous For sedentary behavior, the research covering preg-
intensity physical activity, were found between sedentary nancy and postpartum has been scarce. While sedentary
behavior and functioning (73). There is increasingly more behavior has been shown to associate with many adverse
evidence showing that people with physical impairments health outcomes in the adult population, this protective
and mobility decline benefit more from exercise training mechanism may also apply to pregnant and postpar-
than people with less functional impairments (70). tum women. The causal pathways from physical activity
Fall prevention is one of the relevant outcomes that or sedentary behavior to health outcomes are similar to
have recently evolved new evidence. It has been shown in those described earlier in this report.
randomized controlled trials that exercise reduces the rate
of falls by 23% (74). Balance and functional exercises, as The WHO recommendations on physical activity
compared to control, showed a 24% decrease in the rate and sedentary behavior
of falls in 39 studies and further a 42% reduction in rate The most recent guidelines for physical activity and
of falls if the weekly dose of training exceeded 3 h (74). sedentary behavior were launched by WHO (2, 33) as
given in detail in Tables 1 and 2 below. The guidelines
Pregnant and postpartum women were developed in accordance with the WHO Handbook
Aerobic and muscle strengthening physical activity is for guideline development. The guideline development
recommended for women with uncomplicated pregnan- group defined critical and relevant health outcomes,
cies before, during and after pregnancy, although some including both benefits and harms, and created PI/
modifications to exercise routines might be needed due ECO (Population, Intervention/Exposure, Comparison,
to normal anatomic and physiologic changes and fetal Outcome) questions that served the process for evi-
requirements (75). dence evaluation. Systematic reviews of evidence for
Physical activity brings benefits to pregnant and post- critical and important health outcomes were performed
partum women, where systematic evidence is shown in the by external reviewers and rated according to AMSTAR
prevention of gestational weight gain (76–78) and gesta- 77 2 (Assessment of Multiple Systematic Reviews) instru-
tional diabetes mellitus (78–80), also covering physical
79 ment. The evidence was rated from high to critically low,
activity before pregnancy and women with overweight stating the quality of available studies. Furthermore, the
and obesity. Weight gain is reported to be 1.14 kg lower body of evidence was synthesized using GRADE (The
among pregnant women when physically active are com- Grading of Recommendations Assessment, Development
pared to physically inactive, and the risk for gestational and Evaluation) method for each PI/ECO question. The
diabetes was 29% lower for the active women. The needed GRADE rating reflected the certainty of evidence, rang-
dose has varied across existing studies, but the recommen- ing from high to very low. After the process of evaluating
dation of 150 min/week of moderate intensity physical the available evidence, the guideline development group
activity has often been used. synthesized the body of evidence into recommendations,
Furthermore, it is shown that physical activity does separately for physical activity and sedentary behavior, as
not increase the likelihood for gestational hypertension well as for separate age and population groups. Each of
or preeclampsia (78, 79), does not increase the risk of the recommendation was graded strong, limited or not
adverse effects, such as those on fetal outcomes (77 –85) 7879 81828384 assignable (Tables 1 and 2). The guidelines underwent
or delivery complications, including pre-term birth and an international public consultation round before their
birthweight (82). There is some evidence suggesting that launch.
physical activity during pregnancy may be protective These public health guidelines are for all populations
against low birthweight, also in overweight and obese across the age groups, irrespective of gender, cultural
women or large-for-gestational-age babies (77). For men- background or socioeconomic status and are relevant for
tal health outcomes, it is demonstrated that physical activ- people of all abilities. Those with medical conditions and/
ity during pregnancy may be inversely associated with or disability and pregnant and postpartum women should
postpartum depression (85). try to meet these recommendations where possible and as
Pregnancy and childbirth bring challenges to the mus- able.
culoskeletal system, especially to the pelvic floor, lower It is emphasized that any physical activity is better than
back, pelvis and abdominal area. These challenges may none, for all populations groups. For those who are not
decrease women’s ability to participate in physical activ- currently meeting the recommendations, engaging in some
ity. Continent women who do pelvic floor muscle train- physical activity is already health-enhancing (Figure 1).
ing during pregnancy are 62% less likely to experience People should gradually increase the frequency, duration,
urinary incontinency in late pregnancy and 29% less in and intensity of physical activity. Furthermore, it is noted

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Borodulin and Anderssen

Table 1. World Health Organization guidelines on physical activity, sedentary behavior and sleep for children under 5 years of age (33)

Population group Physical activity guidelines Sedentary behavior guidelines Sleep

Children under • In a 24-h day; • In a 24-h day; • In a 24-h day;

5 years of age • Infants under 1 year should have • Infants under 1 year should not • Infants under 1 year should have
each day at least 30 min of physical be restrained for more than 1 14–17 h (0–3 months of age) or
activity; h at a time. Screen time is not 12–16 h (4–11 months of age) of good
• Children aged 1–2 years should do recommended; quality sleep, including naps;
at least 180 min of physical activity; • Children aged 1–2 years should not • Children aged 1–2 years should have
• Children aged 3–4 years should do be restrained for more than 1 hour 11–14 h of good quality sleep, including
at least 180 min of physical activity, at a time. For 1-year-old children, naps, with regular sleep and wake-up
of which at least 60 min moderate sedentary screen time is not rec- times;
to vigorous intensity physical activity. ommended. For those aged 2 years, • Children aged 3–4 years should have
sedentary screen time is limited to 10–13 h of good quality sleep, which
(strong recommendations, very low max 1 h daily, less is better; may include a nap, with regular sleep and
quality evidence)
• Children aged 3–4 years should not wake-up times.
be restrained for more than 1 h at a (strong recommendations, very low
time or sit for extended periods of quality evidence)
time. Sedentary screen time should
be no more than 1 h, less is better.
(strong recommendations, very low
quality evidence)
• Integrated recommendations:
• For the greatest health benefits, infants, and young children should meet all the recommendations for physical activity,
sedentary behavior and sleep in a 24-h period.
• Replacing restrained or sedentary screen time with more moderate- to vigorous- intensity physical activity, while preserving
sleep, can provide additional health benefits. (strong recommendation, very low quality evidence)

that pre-exercise medical clearance is generally unneces- perceived as a light intensity activity for a trained 30-year-
sary for individuals without contraindications prior to old but very hard for an untrained 30-year-old.
beginning light-intensity or moderate-intensity physical
activity. Adults with chronic conditions can consult a The WHO physical activity recommendation and
physical activity specialist or health care professional to energy requirement
receive guidance on types and amounts of physical activ- The recommendations do not differ largely from the old
ity based on their needs, abilities, functional limitations, concerning energy expenditure. The current WHO phys-
medications and overall treatment plans. ical activity recommendations no longer refer to daily
Children and adolescents are to be provided with safe physical activity level (PAL). However, to calculate PAL
and equitable opportunities and encouragement to partic- the MET-value of different activities should be multiplied
ipate in physical activity that is appropriate for their age by time spent in the specific activity and divided by 24. For
and ability, is enjoyable and offers variety. Older adults instance, an individual who sleeps 8 h (1 MET), engages
are guided to be as active as their functional ability allows 14 h in light intensity activity (2 METs), walks in mod-
and they should adjust the effort of activity relative to erate intensity for 2 h (5 METs) will have a PAL of 1.92.
their level of fitness.
Physical activity guidelines in the Nordic and Baltic
Regarding moderate and vigorous physical activity countries
Examples of energy requirements corresponding to In the Nordic and Baltic countries, there are no existing
3–6 METs (moderate intensity activity) and >6 METs common recommendations for physical activity. Instead,
(vigorous intensity activity) are given in Table 3. each country created their own national guidelines
Cardiorespiratory fitness, often expressed as maximal according to their own protocol. Here, in this section, we
oxygen uptake, decreases as people age. Hence, activity give a synopsis of the status of country-specific recom-
of a certain MET value requires a greater percentage of mendations. Table 4 lists the country-specific sources for
a person’s cardiorespiratory fitness as he or she ages (see information where the national guidelines can be found.
Table 3). Importantly, activity of a certain energy cost In general, most national recommendations are mir-
might be perceived quite differently even if they are of rored from the WHO recommendations, which, in turn,
the same age. For instance, jogging in 8 km/h might be are based on epidemiologic evidence on the associations

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 Physical activity

Table 2. World Health Organization 2020 guidelines for physical activity and sedentary behavior (WHO 2020)

Population group Physical activity guidelines Sedentary behavior guidelines

Children and adolescents • Should do at least an average of 60 min/day of moder- • Children and adolescents should
(aged 5–17 years), including ate-to-vigorous intensity, mostly aerobic, PA, across the week; limit the amount of time spent being
those living with disability • Vigorous-intensity aerobic activities, as well as those that sedentary, particularly the amount of
strengthen muscle and bone should be incorporated at least recreational screen time.
3 days a week. (strong recommendation, low certainty
(strong recommendation, moderate certainty evidence) evidence)
Adults (aged 18–64 years), • All adults should undertake regular physical activity; • Adults should limit the amount of
including those with chronic • Adults should do at least 150–300 min of moderate-intensity time spent being sedentary. Replacing
conditions and those living aerobic PA, or at least 75–150 of vigorous-intensity aerobic sedentary time with PA of any inten-
with disability PA, or an equivalent combination of moderate-intensity or sity (including light intensity) provides
vigorous-intensity activity throughout the week for substantial health benefits;
health benefits; • To help reduce the detrimental
• Adults should also do muscle-strengthening activities at mod- effects of high levels of SB on health,
erate or greater intensity that involve all major muscle groups adults should aim to do more than
on 2 or more days a week, as they provide additional health the recommended levels of MVPA.
benefits; (strong recommendation, moderate
(strong recommendation, moderate certainty evidence) certainty evidence)

• Adults may increase moderate-intensity aerobic PA to (For adults with chronic conditions
>300 min, or do >150 min of vigorous-intensity aerobic PA, or and those living with disability: strong
an equivalent combination of moderate-intensity and vigorous evidence, low certainty evidence)
intensity activity throughout the week for additional health
benefits (when not contraindicated for those with chronic
conditions).
(conditional recommendation, moderate certainty evidence)
Older adults (aged 65 years • PA recommendation as for adults; • SB as for adults.
and older), including those with • As part of their weekly physical activity, older adults should do
chronic conditions and those varied multicomponent PA that emphasizes functional balance
living with disability and strength training at moderate or greater intensity on 3
or more days a week, to enhance functional capacity and to
prevent falls. (strong recommendation, moderate certainty
evidence)
Pregnant and postpartum • Undertake regular PA throughout pregnancy and postpartum; • Pregnant and postpartum women
women (see note) • Do at least 150 min of moderate-intensity aerobic PA through- should limit the amount of time spent
out the week for substantial health benefits; being sedentary. Replacing sedentary
time with PA of any intensity
• incorporate a variety of aerobic and muscle-strengthening (including light intensity) provides
activities. Adding gentle stretching may also be beneficial. health benefits.
• in addition, women who, before pregnancy, habitually engaged (strong recommendation, low certainty
in vigorous-intensity aerobic activity or who were physically evidence)
active can continue these activities during pregnancy and the
postpartum period.
(strong recommendation, moderate certainty evidence)
PA = physical activity; SB = sedentary behavior. Additional safety considerations when engaging in PA for pregnant women are as follows: avoid PA during
excessive heat especially with high humidity, stay hydrated by drinking water before, during and after PA, avoid participating in activities which involve
physical contact, pose a high risk of falling or might limit oxygenation (such as activities at high altitude, when not normally living at altitude), avoid
activities in supine position after the first trimester of pregnancy; pregnant women considering athletic competition or exercising significantly above
the recommended guidelines should seek supervision from a specialist healthcare provider; pregnant women should be informed by their healthcare
provider of the danger signs to stop or limit PA and advised to consult a qualified healthcare providers if they occur. Return to PA gradually after delivery
and in consultation with a healthcare provider in the case of cesarean section.

between physical activity and health. Some recommenda- review process of scientific evidence. Some recommenda-
tions also state the frequency of activity and have slight tions rely on the existing evidence base and have replicated
differences in age group categories, but most refer to the WHO recommendations as they are. There are also
the duration, intensity or type of activity. Furthermore, some differences in the publishing organizations, where
some recommendations are created with the assistance of most recommendations are released by the Ministry of
a national scientific advisory group and have included a Health or subordinate agencies.

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Borodulin and Anderssen

How physically inactive are we? In pooled data analyses on self-reported physical
Surveillance of physical activity levels has progressed sub- activity – including data from 168 countries – global
stantially in the past decade including both standardized level of insufficiently active adults was estimated to be
self-report questionnaires and different device-based meth- 27.5% in the adult population (89). The analyses also
ods. The challenge, however, is that there is low agreement showed that the level of insufficient physical activity
between various instruments of self–reported physical between 2001 and 2016 was stable. However, when look-
activity and between subjective and objective assessment ing at high-income countries the number of insufficiently
of physical activity (88). The use of device-based methods active individuals has increased since 2001. The lowest
or wearable devices for population surveillance purpose level of physical inactivity was found in Finland (16.6%).
have some concerns due to several methodological chal- Also, data from Finland suggest that sedentary time has
lenges, such as interpretation of data from acceleration been stable in the period 2007 to 2014 in the adult pop-
into human behavior, location of devices, and inability to ulation (90).
measure separate components of activity recommenda- Gender difference in surveillance data often suggests that
tion, mainly muscle-strengthening or balance training (1). men are physically more active than women, while device-
based method reports higher levels for women (91). It may
also be that men engage in higher intensity activities while
women’s activity comprises more from moderate-to-low
intensity physical activity (22). For differences across age
groups, it is suggested that reaching the recommended lev-
els of physical activity is more likely among the younger
adults as compared to older adults (92).
Based on device measured physical activity harmonized
analyses of more than 47 000 children and youth around
Europe show the following: 29% of children and ado-
lescents were sufficiently physically active, however, with
substantial country differences in physical activity and
Fig. 1. Dose-response curve between physical activity and sedentary time (93). For instance, physical activity level
health benefits (World Health Organization; 2020. Licence: in the Nordic countries is higher compared to Southern
CC BY-NC-SA 3.0 IGO). European countries. Boys seem to be more active than

Table 3. Energy requirements for performing selected various activities in different age groups shown as METs and as percentages of cardiore-
spiratory fitness (≈ maximal oxygen uptake)

Activities Energy cost Energy requirements as percentages of cardiorespiratory fitness (≈ maximal oxygen uptake)
in METs and corresponding rating of perceived exertion (Borg scale, in bold)
according to age group in years.**

Young (20–39) Middle-aged Old (60–79) Very old (80+)

(40–59)

Watching TV/reading 1.3 10<10 13<10 15<10 18<10

Light household chores 2.5 20 <10
25 10–11 29 10–11
3510–11
Driving a car 1.5 12 <10
15 <10
18 <10
21<10
Moderate physical activity
Climbing stairs 5.5 4210–11 5512–13 6414–16 7715–17
Walking (4.8 km/h) 3.5 2710–11 3510–11 4110–11 4912–13
Walking (6.4 km/h) 5.0 3910–11 5012–13 5914–15 7014–16
Snow clearing (snow blower) 3.0 23 <10
30 10–11
35 10–11
4210–11
Snow clearing (manual) 6.0 4712–13
60 14–16
70 14–16
8415–17
Lawn mowing (manual) 4.5 3510–11
45 12–13
53 12–13
6314–16
Vigorous
Jogging 8.0 km/h 7.0 5512–13 8014–16 9317–19 >10020
** Activity of a certain energy cost might be perceived differently by people both as a function of age and of insufficient physical activity. Rating of per-
ceived exertion (Borg scale): Very light <10; Light 10–11; Somewhat hard 12–13; Hard 14–16; Very hard; 17–19; Very, very hard 20. Table copied from
NNR2012, page 204 (87).

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 Physical activity

Table 4. Current physical activity and sedentary behavior guidelines in the Nordic and Baltic countries

Denmark Reference or website

Children 0–5 years 0–1 years of age: Danish Health Authority (sst.dk)
1–4 years of age: Danish Health Authority (sst.dk)
Children 6–17 years (under 18) Fysisk-aktivitet-–-håndbog-om-forebyggelse-og-behandling.ashx (sst.dk) (page 17)
Adults 18 years and above Fysisk-aktivitet-–-håndbog-om-forebyggelse-og-behandling.ashx (sst.dk) (page 17)
SPECIFIC GUIDELINES
Older adults 65+ years Fysisk-aktivitet-–-håndbog-om-forebyggelse-og-behandling.ashx (sst.dk) (page 18)
Pregnant women Fysisk-aktivitet-–-håndbog-om-forebyggelse-og-behandling.ashx (sst.dk) (page 18)
Estonia
Children 0–5 years https://intra.tai.ee/images/prints/documents/149019033869_eesti%20toitumis-%20ja%20liikumissoovitused.pdf (page 45)
Children 6–17 years (under 18) https://intra.tai.ee/images/prints/documents/149019033869_eesti%20toitumis-%20ja%20liikumissoovitused.pdf (page 45)
Adults 18 years and above https://intra.tai.ee/images/prints/documents/149019033869_eesti%20toitumis-%20ja%20liikumissoovitused.pdf (page 45)
https://www.terviseinfo.ee/et/valdkonnad/liikumine/liikumispuramiid
Finland
Children 0–5 years http://urn.fi/URN:ISBN:978-952-263-413-9
Children 6–17 years (under 18) http://urn.fi/URN:ISBN:978-952-263-861-8
Adults 18 years and above https://ukkinstituutti.fi/en/products-services/physical-activity-recommendations/
SPECIFIC GUIDELINES
Older adults 65+ years https://ukkinstituutti.fi/en/products-services/physical-activity-recommendations/
Pregnant and postpartum https://ukkinstituutti.fi/en/products-services/physical-activity-recommendations/
women physical-activity-recommendation-during-pregnancy/

https://ukkinstituutti.fi/en/products-services/physical-activity-recommendations/
weekly-physical-activity-recommendation-after-delivery/
Disabled persons See children’s recommendations. Adults: https://ukkinstituutti.fi/en/products-services/physical-activity-recommendations/
weekly-physical-activity-recommendation-for-adults-with-functional-limitations/
Chronic disease conditions
Greenland
Children 0–5 years https://paarisa.gl/emner/det-gode-liv/fysisk-aktivitet/bevaegelse-for-de-mindste?sc_lang=da
Children 6–17 years (under 18) https://paarisa.gl/emner/det-gode-liv/fysisk-aktivitet?sc_lang=da
Adults 18 years and above https://paarisa.gl/emner/det-gode-liv/fysisk-aktivitet?sc_lang=da
SPECIFIC GUIDELINES
Older adults 65+ years https://paarisa.gl/emner/det-gode-liv/fysisk-aktivitet/bevaegelse-for-dig-der-er-over-65?sc_lang=da
Pregnant and postpartum women https://paarisa.gl/emner/det-gode-liv/fysisk-aktivitet/bevaegelse-for-dig-der-er-gravid?sc_lang=da
Iceland to be found at: https://island.is/hreyfing-radleggingar-landlaeknis
Children 0–5 years
Children 6–17 years (under 18)
Adults 18 years and above
SPECIFIC GUIDELINES
Older adults 65+ years
Pregnant and postpartum
women
Disabled persons
Chronic disease conditions
Latvia
Children 0–5 years https://www.spkc.gov.lv/lv/fiziskas-aktivitates
Children 6–17 years (under 18) https://www.spkc.gov.lv/lv/fiziskas-aktivitates
Adults 18 years and above https://www.spkc.gov.lv/lv/fiziskas-aktivitates
Lithuania
Children 0–5 years http://www.smlpc.lt/media/image/Naujienoms/2017%20metai/Lankstukai/Bendrasis_Fizinis_aktyvumas_reko.pdf
Children 6–17 years (under 18) http://www.smlpc.lt/media/image/Naujienoms/2017%20metai/Lankstukai/Bendrasis_Fizinis_aktyvumas_reko.pdf
Adults 18 years and above http://www.smlpc.lt/media/image/Naujienoms/2017%20metai/Lankstukai/Bendrasis_Fizinis_aktyvumas_reko.pdf

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Borodulin and Anderssen

Table 4. (Continued)

Denmark Reference or website

Norway
Children 0–5 years https://www.helsedirektoratet.no/faglige-rad/fysisk-aktivitet-i-forebygging-og-behandling/barn-og-unge
Children 6–17 years https://www.helsedirektoratet.no/faglige-rad/fysisk-aktivitet-i-forebygging-og-behandling/barn-og-unge
(under 18)
Adults 18–64 years https://www.helsedirektoratet.no/faglige-rad/fysisk-aktivitet-i-forebygging-og-behandling/voksne-og-eldre
SPECIFIC GUIDELINES
Older adults 65+ years https://www.helsedirektoratet.no/faglige-rad/fysisk-aktivitet-i-forebygging-og-behandling/voksne-og-eldre
Pregnant and postpartum https://www.helsedirektoratet.no/faglige-rad/fysisk-aktivitet-i-forebygging-og-behandling
women
Sweden
Children 0–5 years https://www.folkhalsomyndigheten.se/contentassets/106a679e1f6047eca88262bfdcbeb145/riktlinjer-fysisk-aktivitet-stil-
lasittande.pdf
Children 6–17 years https://www.folkhalsomyndigheten.se/contentassets/106a679e1f6047eca88262bfdcbeb145/riktlinjer-fysisk-aktivitet-stil-
(under 18) lasittande.pdf
Adults 18 years and above https://www.folkhalsomyndigheten.se/contentassets/106a679e1f6047eca88262bfdcbeb145/riktlinjer-fysisk-aktivitet-stil-
lasittande.pdf
SPECIFIC GUIDELINES
Older adults 65+ years https://www.folkhalsomyndigheten.se/contentassets/106a679e1f6047eca88262bfdcbeb145/riktlinjer-fysisk-aktivitet-stil-
lasittande.pdf
Pregnant and postpartum https://www.folkhalsomyndigheten.se/contentassets/106a679e1f6047eca88262bfdcbeb145/riktlinjer-fysisk-aktivitet-stil-
women lasittande.pdf
Each country has provided their own specific guidelines and no common guidelines exist. Some guidelines are a product of a scientific consultation
process including public hearing and some are produced with less scientific contribution. Some are released by an NGO. Icelandic recommendations
were not yet available at the time this article was published.

girls throughout childhood and adolescence. Estimates References

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meta-analysis. Nutrients 2018; 10: 698. doi: 10.3390/nu10060698 Director, Age Institute
81. Davenport MH, Kathol AJ, Mottola MF, Skow RJ, Meah VL, Jämsänkatu 2, 00520 Helsinki, Finland
Poitras VJ, et al. Prenatal exercise is not associated with fetal Email: Katja.Borodulin@ikainstituutti.fi

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