Physical exercise and risk of arterial hypertension and diabetes mellitus. Let’s move, it is never too late

Despite the recent decline in mortality from cardiovascular diseases, their burden in contemporary populations remains elevated.1 Arterial hypertension (AH) and diabetes mellitus are major cardiovascular risk factors and share an elevate prevalence and incidence, which continue to accelerate with global ageing and lifestyle changes, requiring preventive actions at a population level.2 Epidemiological studies demonstrated that low physical activity levels (occupational or leisure-time) are a risk factor for AH and diabetes mellitus.3 Vice versa, regular physical activity may reduce the risk of developing both diseases.4,5 Recent meta-analysis showed that adherence to guidelines recommended minimum physical activity level reduced incidence of both AH (relative risk (RR) 0.94; 95% confidence interval (CI) 0.92–0.97)6 and diabetes mellitus (RR 0.74, 95% CI 0.72–0.77).7 Regarding physical activity intensity, the body of literature supports a dose–response relationship.6 Real life implementation studies, performed in different settings and populations, proved that physical activity focused lifestyle interventions can be effective in prevention of AH and diabetes mellitus. Physical activity may exert preventive actions against the development of AH and diabetes mellitus through different mechanisms. Both a reduction in sympathetic activity and an improvement in endothelial function have been proposed as regards decreased AH incidence. Insulin resistance, besides, is one common feature of both prediabetes and prehypertension and an antecedent of progression to two respective disease states. Regular physical activity reduces insulin resistance, improving insulin sensitivity, and is associated with increases in glucose uptake from circulating blood, reduction in intramuscular saturated fatty acids, increased muscle glycogen utilization, enhanced B cell activity, more favourable profile of inflammatory markers and positive effects on many other risk factors, including high-density lipoprotein cholesterol and body weight.8,9 Finally, it is noticeable that exercise counteracts the statin-induced adverse effects on skeletal muscles and incidence of diabetes mellitus.10 The paper by Lee et al.,11 published in this issue of the European Journal of Preventive Cardiology, confirms the existing literature on the multiple health benefits of physical activity. It utilizes data from the Kangbuk Samsung Health Study, a very large cohort study of relatively healthy South Koreans over 18 years old, undergoing comprehensive periodic health screenings. According to their baseline physical activity levels, assessed using a self-reported questionnaire, the 174,314 subjects were classified into different categories. After a multivariate adjustment, sufficient baseline physical activity was associated with significantly lower risk for incident AH, and showed a lower trend in diabetes mellitus incidence. Also, the paper tackles a thorny issue: even in a relatively short time, increasing physical activity is associated with a lower AH and diabetes mellitus risk. According to temporal changes in physical activity level between baseline and consecutive follow-up, subjects with physical activity increase showed significantly decreased AH and diabetes mellitus risk. Thus, it is never too late to improve one’s physical activity. Also, in a Danish cohort, late-in-life initiation of cycling lowered diabetes mellitus risk.5 Other points in the article by Lee et al. merit attention. Follow-up information was obtained from a National Population Registry, confirming the utility of employing big data in medical research. Finally, surprisingly, a higher proportion of obese individuals was detected in the group of baseline sufficient physical activity. The point that despite this unfavourable risk profile the incidence of AH and diabetes mellitus was lower further strengthens the importance of physical activity for everyone across all body mass index strata. Although contrasting data exist,12 this finding suggests that the beneficial impact of physical activity might outweigh the negative impact of overweight and obesity, highlighting the risk associated with inactivity even among normal weight people.13,14 Notwithstanding these evidences, real world data are worrying. According to the Italian Health Examination Survey,15 in the years 2008–2012, 32.3% of men and 41.6% of women were physically inactive during leisure time, that is, they did less than the 150 minutes per week of moderate intensity physical activity, as recommended by the 2016 European Guidelines on Cardiovascular Disease Prevention,2 which also emphasized lifestyle advice as a first population approach. In an era of limited resources, any simple, widely applicable, low-cost strategy in health promotion and primordial prevention such as physical activity is, of course, highly desirable. We have to ask ourselves again: are we aggressive enough in striving for an effective modification of sedentary lifestyles?16 This applies at the level of both individual (patients bear the ultimate responsibility for the success or failure of lifestyle change, but healthcare professionals, undoubtedly, have a key role in helping individuals to change their wrong attitudes) and the healthcare system as a whole, which can play an influential role through both a continuous education campaign at the population level and policy-relevant environmental measures (such as walkability, air pollution, public green: health-orientated urban planning).16 According to the German author Johann Wolfgang von Goethe (1749–1832), ‘Knowing is not enough; we must apply. Willing is not enough; we must do’.4 The author(s) declares no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The author(s) received no financial support for the research, authorship, and/or publication of this article.