





































Clinical Medicine Insights
Received 27 Mar 2021 | Revised 25 Apr 2021 | Accepted 20 May 2021 | Published Online 30 Jun 2021

DOI: https://doi.org/10.52845/CMI/2021-2-2-4
CMI JOURNAL 2 (2), 110−124  (2021) ISSN (O) 2694-4626

REVIEW ARTICLE

Exercise and Non-Communicable Diseases: Part I Cardiovascular Diseases,
Respiratory Diseases, Obesity, Depression, Liver Diseases

Shashi K. Agarwal, MD ∗
 

12227 US Highway 1, #309 North
Brunswick, NJ 08902,USA

Abstract
Physical activity has established itself as a major risk factor for many
chronic diseases. Individuals who lead a sedentary life have higher
morbidity and mortality. Exercise, a subcategory of physical activity,
is usually planned and structured involving large muscle groups. It is a
major recommendation from all professional health associations to pre-
vent and beneficially modulate the course of several chronic diseases.
There are also emotional benefits and exercising individuals experience
a better quality of life. This manuscript discusses the beneficial effects
of exercise on five major non-communicable diseases, namely cardio-
vascular diseases, respiratory diseases, obesity, depression, and liver
diseases.
Keywords: exercise, non-communicable diseases, cardiovascular dis-
eases, COPD, obesity, depression, liver diseases

Copyright : © 2021 The Authors. Published by Medical Editor and
Educational Research Publishers Ltd. This is an open access article
under the CC BY-NC-ND license
(https://creativecommons.org/licenses/by-nc-nd/4.0/).

1 INTRODUCTION

Physical activity (PA) is defined as any bod-
ily movement produced by the contraction of
skeletal muscles resulting in a substantial in-

crease in resting energy expenditure1. Exercise is de-
fined as ’any sport or activity that works large groups
of muscles, is continually maintained and performed
rhythmically2. Physical activity includes all move-
ment that increases energy use, whereas exercise is
planned, structured physical activity3. Exercises may
be aerobic or resistance, butmay also involve stretch-

ing, balance, and gait workouts and non-traditional
activities such as tai chi and yoga4−6. Activities
such as walking, cycling, jogging, and swimming are
primarily aerobic exercises. They increasemitochon-
drial density, insulin sensitivity, oxidative enzymes,
blood vessel compliance and reactivity, lung func-
tion, immune function, and cardiac output5. Resis-
tance exercises include workouts with free weights,
weight machines, bodyweight, or elastic resistance
bands6. They result in improvements inmuscle mass,
body composition, strength, physical function, bone
mineral density, insulin sensitivity, blood pressure,

CMI JOURNAL 2 (2), 110−124 MEERP LTD 110

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EXERCISE AND NON-COMMUNICABLE DISEASES: PART I CARDIOVASCULAR DISEASES, 
RESPIRATORY DISEASES, OBESITY, DEPRESSION, LIVER DISEASES
lipid profiles, and cardiovascular health7. Stretching
increases the range of motion around joints and en-
hances flexibility8. Balance training can reduce falls
risk by improving balance and gait9. Activities like
Tai Chi and Yoga combine flexibility, balance, and
resistance exercises10. Besides the physical benefits,
all exercises benefit mental and emotional health11.
The World Health Organization recommends that
adult men and women should accumulate at least
150 min of moderate-intensity physical exercise per
week and young people aged 5–17 years should
accumulate at least 60 min of physical exercise of
moderate to vigorous intensity daily12.
The benefits of exercise for common chronicmedical
conditions are discussed in this two-part manuscript.
Part I discusses the role of exercise in cardiovascular
diseases (CVD), chronic obstructive pulmonary dis-
ease (COPD), obesity, depression, and liver diseases.
Part II discusses its role in cancer, diabetes mellitus,
kidney diseases, Alzheimer’s disease, and arthritis.

2 DISCUSSION

The Centers for Disease Control and Prevention
(CDC) defines chronic diseases as “conditions that
last 1 year or more and require ongoing medical
attention or limit activities of daily living or both”13.
Chronic diseases are usually non-communicable dis-
eases (NCDs) and inflict a heavy global health
burden14. They include CVD (including hyperten-
sion, coronary artery disease, stroke, and heart fail-
ure), cancers, chronic respiratory diseases (chronic
obstructive pulmonary disease, sleep apnea, and
asthma), diabetes, Alzheimer’s disease, chronic kid-
ney disease, arthritis, depression, obesity, and liver
diseases (nonalcoholic and alcoholic hepatitis, vi-

Supplementary information The online version of 
this article (10.52845/CMI/2021-2-2-4) contains 
supplementary material, which is available to autho-
rized users.

Corresponding Author: Shashi K. Agarwal, MD 
Shashi K. Agarwal, MD 2227 US Highway 1, #309 
North Brunswick, NJ 08902,USA
Email: usacardiologist@gmail.com

ral hepatitis, cirrhosis of the liver)15. Cardiovascu-
lar diseases are the leading NCDs worldwide and
are the leading cause of loss of disability-adjusted
life years and deaths globally16. Chronic respiratory
diseases (such as asthma, chronic obstructive pul-
monary disease (COPD), and lung cancer) contribute
significantly to the rising burden of NCDs globally17.
Overweight/obesity is a pandemic – its worldwide
prevalence has doubled since 1980, and it is now
affecting nearly a third of the world’s population18.
Affected individuals face an increased risk of a mul-
titude of comorbidities, including cardiovascular dis-
ease, diabetes, and many cancers19. Depression is a
common disease and is on the increase20. Depression
cases worldwide registered an increase of 49.86% -
incident cases increased from 172 million in 1990
to 25,8 million in 201720. Depression affects both
mental and physical health and is often a potentially
lethal disease21. The burden of liver diseases, such as
nonalcoholic fatty liver disease (NAFLD), alcoholic
liver disease, and hepatocellular carcinoma, contin-
ues to rise worldwide22.
Several personal factors play an important role in
the genesis and progression of chronic NCDs – both
modifiable and non-modifiable23. Non-modifiable
risk factors include heredity, age, race, and gender24.
Lifestyle behaviors are modifiable risk factors
and include diet, obesity, smoking, and alcohol
consumption24. Another modifiable risk factor is
sedentary behavior and exercise24. The beneficial
effects of increased physical activity, including
structured activity such as exercise, on NCDs, are
enormous25,26. Its effect on cardiovascular diseases,
respiratory diseases, obesity, depression, and liver
diseases is discussed in this manuscript.

2.1 CARDIOVASCULAR DISEASES

A reduction in sedentary time and an increase in
exercise time beneficially modulate CVDs27−29. Ex-
ercise lowers CVD risk in a dose-dependent man-
ner; moderate physical activity is associated with a
26% reduction in CVD risk, whereas high-intensity
activities impart a 42% risk reduction30−32. Physical
activity and pro-active physical exercise can even
slow down or reverse CVD progression33−37. Reg-
ular PA also reduces the risk of CVD mortality, both

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SHASHI K. AGARWAL, MD

in healthy individuals38 and in cardiac patients39,40.
Moderate to high-intensity exercise has been shown
to increase life expectancy by 1.3 to 3.7 years and
active individuals remain free of CVD 1–3 years
longer than their sedentary peers41.
Aerobic exercise lowers blood pressure (BP) by 5-
7 mmHg42 while dynamic resistance training lowers
BP by 2–3 mmHg43 in adults with hypertension
(in both unmedicated and medicated patients). In-
terestingly, the magnitude of these BP reductions
rivals the magnitude of those obtained with first-
line antihypertensive medications44. Exercising as
little as one day per week is as effective as phar-
macotherapy for reducing all-cause mortality among
hypertensive patients45. In coronary artery disease
patients, exercise reduces angina, myocardial infarc-
tion, and sudden cardiac death46. Following a my-
ocardial infarction, exercise reduces re-infarction,
cardiac mortality, and all-cause mortality47. Physi-
cal inactivity48 and low levels of fitness49 are also
risk factors for stroke. Following a stroke, mod-
erate to high-intensity aerobic exercise (of 20–40
min and 3–5 days per week) helps improve phys-
ical fitness, maximal walking speed, and walking
endurance50. Exercise is preventive for heart fail-
ure (HF)51,52. Khan et al. demonstrated that men
in the top quartile of longterm fitness levels had a
53% lower risk of developing HF52. In those with
established heart failure53, exercise improves their
quality of life54, reduces hospitalizations55, and low-
ers mortality56. Physical activity has been noted to
reduce the risk of atrial fibrillation57. Several studies
have shown that exercise not only helps prevent
peripheral artery disease (PAD)58 but also helps im-
prove walking distance59 and the quality of life in
these patients60,61. Physical activity often reduces
the risk of erectile dysfunction (ED)62. It also helps
improve function in men with established ED63. Ex-
ercise also helps reduce several CVD risk factors,
such as smoking64, obesity65, diabetes mellitus66,
hyperlipidemia67, alcohol abuse68, chronic kidney
disease69, depression70, loneliness71, psychosomatic
stress71, sleep disturbances72, and illicit drug use73.
Many mechanisms play a role in the beneficial ef-
fects of exercise74. Regular exercise can help to
reduce weight, reduce blood pressure, and improve
lipid disorders, including raising HDL, decreasing

LDL, and lowering triglycerides75. It also decreases
insulin resistance, reduces blood coagulation and
systemic inflammation76. Vigorous physical activ-
ity reduces heart rate, increases myocardial oxygen
supply, improves myocardial contraction and stroke
volume, establishes electrical stability, and increases
physiological cardiac hypertrophy77−79.
However, older adults with chronic medical condi-
tions must be careful about exercising vigorously,
and stress testing may be required in people with
known CVD80. Further, in certain conditions, such
as decompensated congestive heart failure or se-
vere aortic stenosis, exercise may be restricted or
contraindicated81.

2.2 RESPIRATORY DISEASES

Exercise, both aerobic and resistance, decreases res-
piratory symptoms and leads to significant improve-
ments in functional capacity in patients with res-
piratory diseases82. The benefits of exercise train-
ing in patients with COPD have been documented
in several systematic review meta-analyses and
in two Cochrane reviews83,84. Exercise training is
an essential strategy in managing COPD, and re-
sults in an improvement in 6-minute walk test
(6MWT) distance84. Several studies using an in-
cremental cycle ergometer test to measure maxi-
mal exercise capacity also showed a significant im-
provement in those patients allocated to pulmonary
rehabilitation84. Besides a reduction in exercise-
induced hyperinflation, there is an increase in muscle
function, delaying the onset of peripheral muscle
fatigue and resulting in less dyspnea and an increase
in exercise tolerance84. People with COPD often
have comorbidities that markedly affect their func-
tional capacity85. These include chronic heart dis-
ease, metabolic syndrome, musculoskeletal or neu-
rological comorbidities, and many types of cancer86.
Many of these chronic co-morbidities also improve
with regular exercise in patients with respiratory
diseases87.
The role of exercise in the management of asthma
is not well listed in professional organization guide-
lines. Studies suggest that exercise improves asthma-
related symptoms and cardiopulmonary fitness88,89.

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Exercise training may lower the ventilatory require-
mentd of mild and moderate exercise thereby re-
ducing the likelihood of provoking exercise-induced
asthma90. In addition, a 12-week aerobic train-
ing program demonstrated reductions in bronchial
hyperresponsiveness and serum pro-inflammatory
cytokines91. There was a decrease in asthma exacer-
bations in adults with moderate to severe persistent
asthma91. The quality of life (QOL) also improved in
these patients91.
Exercise training has an established role in cystic
fibrosis (CF) management92. A Cochrane review
(total number of 15 studies with 487 participants)
examined the effects of exercise on CF93. Physical
exercise in these patients improves exercise capac-
ity, pulmonary function, and QOL93. There is an
increase in sputum clearance through a combination
of hyperventilation, mechanical vibration, coughing,
and changes in sputum rheology, thereby improv-
ing the much-needed bronchial hygiene in patients
with CF94. Patients with interstitial lung disease also
exhibit pulmonary benefits95−97. They experience
less breathlessness95. Their walking distance (dur-
ing the 6MWT) improves96. Similar benefits have
been documented by several other studies97. These
patients also report an improved QOL with exer-
cise rehabilitation and training97. In patients with
pulmonary arterial hypertension, exercise training
improves right ventricular function98. Benefits have
also been reported in patients with asbestosis and
pulmonary fibrosis99.

2.3 OBESITY

Sedentary behavior is also associated with
obesity100. Regular exercise help prevent obesity,
maintain weight or even lose weight101. A study
of >4500 adults from the U.S. National Health
and Nutrition Examination Survey showed that
greater (moderate to vigorous intensity) physical
activity was associated with a lower body mass
index or BMI102. There is a significant body of
evidence supporting the effect of physical activity
in both short-term and long-term weight loss in
adults103−105. Current recommendations from the
American College of Sports Medicine state that PA
between 150 and 250minutes per week helps prevent

weight gain, PA between 150 and 250 minutes per
week provides modest weight loss, while PA >250
minutes per week helps lose clinically significant
weight loss101. However, recent work by Flack
et al suggests that exercise closer to 300 minutes
per week is needed for weight loss as there is an
approximately 1000-kcal pe week compensatory
response that accompanies exercise106. Jakicic et al
reported that moderate to vigorous PA accumulated
in bouts that were >10 min in duration was effective
for weight loss at 18 months107. These bouts also
helped maintain >10% weight loss from 6 to 18
months. Bouts of exercise of <10 min in duration
were not effective. A study found that combining 5%
to 7% (intentional) weight loss with regular physical
activities, such as lifestyle activities or resistance
training, resulted in improved mobility and lower
extremity physical performance in overweight or
obese older adults108.
Resistance exercises are also effective, but data indi-
cates they produce only minimal reductions in body
weight. These exercises, however, help increase the
loss of fat mass and help increase fat-free mass. The
result is a reduction in the risk of several NCDs101.

2.4 DEPRESSION

Depressed people have lower levels of PA109 and
higher levels of sedentary behavior110. A recent
analysis of data from the Brazilian National Health
Survey, (59,399 individuals), found that a lack of PA
for leisure was associated with depression in young
males, middle aged, and older adults111. Several
other studies have confirmed the protective effects
of physical activity on depression112,113. Hamer et al
noted that risk reduction for depression was noted
at a minimal level of at least 20 min/week of any
physical activity, with a greater risk reduction with
activity at a higher volume and/or intensity114. In a
systematic narrative review of 30 prospective cohort
studies, Mammen and Faulkner reported that 25 of
the 30 studies found that PA resulted in reduced inci-
dent depression115. In a study of 49 studies (266,939
participants), Schuch and Stubbs found that PA low-
ered the risk of depression by between 17% to 41%,
across all ages and in all continents of the world116.

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Exercise has recently also shown promise as
an effective non-pharmaceutical treatment for
depression117−120. Exercise of lower duration or
lower intensity also imparts a reduction in depressive
symptoms118,119. A Cochrane Review and meta-
analysis of 35 randomized controlled trials (1356
individuals) found that exercise was moderately
effective at reducing depressive symptoms in
depressed adults117. Dunn et al. found that in patients
with mild to moderate severity of major depressive
disorder or MDD, a reduction in symptoms was
noted in 47% of patients with exercise (17.5
kcal/kg/week) for 12 weeks120 . In their study, they
found that rates of response and remission with ex-
ercise were comparable to the rates reported in trials
of cognitive-behavioral therapy and antidepressant
medication. Schuch et al in a meta-analysis of 25
studies (757 individuals randomized to exercise
and 730 to control conditions) found a significant
antidepressant effect with exercise121.
Patients with depression also have a higher risk
of type II diabetes122 and cardiovascular disease123
and exercise helps reduce the risk of both. Exercise
therapy also improves general physical health, body
image, patients coping strategies with stress, and the
quality of life in depressed individuals124. It also
helps them become more independent in activities of
daily living124.
Evidence suggests that both exercise and antidepres-
sant medication may alleviate depression through
several processes, such as increased expression of
neurotrophic factors125,126 and reduced systemic
inflammation127. These influence neuronal growth
and plasticity, leading to an increase in neurons,
synaptic connections between neurons, and cerebral
vasculature128−130. There is evidence that exercise
induces increases in hippocampal, prefrontal cortex,
and anterior cingulate cortex volume131.

2.5 LIVER DISEASES

Physical inactivity and its related reduced cardiores-
piratory fitness have been associated with increased
nonalcoholic steatohepatitis (NASH) severity132.
Among obese people, sedentary individuals have
an increased risk of having a fatty liver in com-
parison with weight-matched physically active

individuals133. These data provide support for the
hypothesis that increasing physical activity through
exercise, defined as a planned, structured, and
repetitive physical activity with a specific intensity,
frequency, and duration, has beneficial effects on
nonalcoholic fatty liver disease (NAFLD)134−136.
The American Gastroenterological Association, the
American Association for the Study of Liver Dis-
eases, and theAmericanCollege ofGastroenterology
all recommend physical exercise as a treatment for
NAFLD137. Whitsett et al. conducted a systematic
review of 18 studies and concluded that exercise
significantly reduced hepatic fat content138. Wong et
al demonstrated in a randomized trial of 145 NASH
patients, aerobic and resistance exercise along with
dietary restriction resulted in a 64% remission rate
compared to a 20% remission rate in the non-
intervention control group139. Several randomized
trials provide evidence that aerobic exercise and
resistance exercises are both effective in reducing
liver fat140,141. This occurs even if there is no loss in
body weight. Exercise in patients with NASH may
also reduce progression to hepatocellular cancer142.
Exercise has a direct effect on the liver. Aerobic
and resistance training improve insulin resistance,
liver fatty acid metabolism, and mitochondrial
function143. Exercise also affects inflammation144.
The result is a reduction in liver fat in these patients.
Hepatitis C (HCV) patients are at an increased risk of
CVD and have a lower QOL145. Studies have shown
that HCV patients have lower physical activity than
the general population146. Exercise in these patients
not only reduces the CVD risk but also improves
their QOL147. An improvement in the cognition
function of these patients with exercise has also been
noted148.
In cirrhotic patients, exercise can improve en-
durance and functional outcomes without any ad-
verse effects149. In this systematic narrative review,
moderate-intensity aerobic exercise or resistance
training, 4 days/week, 20 minutes, for at least 8
weeks, helps cirrhotic patients to improve their car-
diorespiratory system149.
Pretransplant exercise helps to improve the physical
and mental status of the patient while on the wait-
list. An exercise and nutritional program appear to
benefit their cardiopulmonary and musculoskeletal

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functions150. The patients notice an improved func-
tional status and a sense of well-being. Following
transplantation, exercise trainingwas associatedwith
a shorter length of hospital stay and a reduced 90-day
readmission rate151.

3 CONCLUSION

Physicians often overlook exercise as a prophylactic
measure or therapeutic modality for many common
diseases and ailments. The evidence for the preven-
tive and therapeutic effects of exercise on NCDs is
strong. Even small amounts of exercise help most
conditions, although the beneficial effect is greater
with moderate to vigorous exercise. Patients with
major risk factors for silent coronary artery disease,
such as diabetes, or those with pre-existing CVD,
should get a physician evaluation, with possibly a
stress test, before embarking on a vigorous exercise
program.
Acknowledgment: None
Funding: None
Conflict of interest: None
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How to cite this article: Agarwal S.K, MD, Exer-
cise and Non-Communicable Diseases: Part I 
Cardiovascular Diseases, Respiratory Dis-eases, 
Obesity, Depression, Liver Diseases. Clin-ical 
Medicine Insights. 2021; 110−124 . https://doi. 
org/10.52845/CMI/2021-2-2-4

MEERP LTD CMI JOURNAL 2 (2), 110−124 (2021) 124


	Introduction
	Discussion
	CARDIOVASCULAR DISEASES
	RESPIRATORY DISEASES
	OBESITY
	DEPRESSION
	LIVER DISEASES

	CONCLUSION



