





































Clinical Medicine Insights
Received 27 Mar 2021 | Revised 25 Apr 2021 | Accepted 28 May 2021 | Published Online 30 Jun 2021

DOI: https://doi.org/10.52845/CMI/2021-2-2-5 
CMI JOURNAL 2 (2), 124−143 (2021) ISSN (O) 2694-4626 

REVIEW ARTICLE

Exercise and Non-Communicable Diseases: Part II Cancer, Diabetes
Mellitus, Kidney Diseases, Alzheimer’s Disease, Arthritis

Shashi K. Agarwal, MD ∗
 

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

Abstract
Non-communicable diseases (NCDs) are the leading global cause of
death and disproportionately afflict those living in low-income and
lower-middle-income countries. Healthy lifestyle behaviors, includ-
ing eating a high-quality diet, non-smoking, engaging in moderate to
vigorous physical activity, and drinking alcohol in moderation, have
been associated with a lower risk of NCDs, a decline in worsening,
and a reduction in associated mortality. The first part of this two-
part series discussed exercise and its effects on cardiovascular and
respiratory diseases, obesity, depression, and liver ailments. This sec-
ond part discusses the deleterious effects of smoking on five non-
communicable diseases, viz., cancer, diabetes mellitus, chronic kidney
disease, Alzheimer’s disease, and arthritis. This manuscript highlights
the benefits of exercise, in reducing the incidence, progression, and
premature mortality of NCDs.
Keywords: exercise, non-communicable diseases, cancer, diabetes mel-
litus, chronic kidney disease, Alzheimer’s disease, arthritis

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

Exercise (or lack of it) is fast becoming
a major lifestyle factor in the prevention
and treatment of major non-communicable

diseases1. It is also used to treat back pain2
sports injuries3, osteoporosis4, inflammatory bowel
disease5, neurodegenerative diseases (such as
Parkinson’s disease)6, Huntington’s disease7, mul-

tiple sclerosis8, anxiety disorders9, and many other
ailments10−11. Exercise helps increase confidence,
improve socialization, brings happiness, and helps
improve sleep12,13. The overall quality of life is
also improved14. A recent US study suggested
that moderate to vigorous physical activity could
significantly reduce general premature mortality and
increase life expectancy15.

CMI JOURNAL 2 (2), 124−143 MEERP LTD 125

Open Access Journal

https://doi.org/10.52845/CMI/2021-2-3-11
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MEERP LTD
SHASHI K. AGARWAL, MD

The World Health Organization recommends that
adult men and women should accumulate at least
150 min of moderate-intensity physical exercise per
week, while young people aged 5–17 years should
accumulate at least 60 min of physical exercise of
moderate to vigorous intensity daily16.

2 DISCUSSION

Chronic NCDs are common conditions affecting
humans17. They are gradually replacing infectious
diseases as the leading health burden across the
world18. The Centers for Disease Control and Pre-
vention (CDC) of USA defines chronic diseases as
“conditions that last 1 year or more and require
ongoing medical attention or limit activities of daily
living or both”19. They estimate that six in ten adults
in the USA have a chronic disease, while four in
ten have two or more chronic diseases19. In a recent
study, Ng et al reported that most individuals develop
at least one chronic disease during their lifetime20.
Rosella et al found that in the Ontario population,
two-thirds of individuals had four or more chronic
conditions at the time of their death21. More and
more deaths globally, are now attributable to chronic
NCDs22. According to the World Health Organiza-
tion (WHO), chronic NCDs accounted for 71% of
the 57 million global deaths in 201623.
Chronic non-communicable diseases include car-
diovascular diseases (CVDs) (such as hyperten-
sion, coronary artery disease, stroke, and heart fail-
ure), cancer, chronic respiratory diseases (such as
chronic obstructive pulmonary disease, sleep apnea,
and asthma), diabetes mellitus, Alzheimer’s disease,
chronic kidney disease (CKD), arthritis, depression,
obesity, and liver diseases (such as nonalcoholic

Supplementary information The online version of 
this article (10.52845/CMI/2021-2-2-5) 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

and alcoholic hepatitis, viral hepatitis, cirrhosis of
liver)24. There is overwhelming evidence that exer-
cise also confers significant benefits in the preven-
tion and management of these diseases25,26. As dis-
cussed in part I of this two-part manuscript, it has sig-
nificant benefits for cardiovascular diseases, respira-
tory diseases, obesity, depression, and liver diseases.
This manuscript will discuss its benefits for cancer,
diabetes mellitus, kidney diseases, Alzheimer’s dis-
ease, and arthritis.
Cancer was diagnosed in 18 million individuals in
201827. Cancers of the lung (2.09 million cases),
breast (2.09million cases), and prostate (1.28million
cases) were themost common in this group27. Cancer
was responsible for 9.6 million deaths globally in
201828. Today, cancer-related mortality exceeds that
caused by communicable diseases such as human im-
munodeficiency virus/acquired immunodeficiency
syndrome, tuberculosis, and malaria, combined29.
Diabetes mellitus (DM) is also a common chronic
disease30. It is mainly categorized into 2 major sub-
types, type I DM (T1D) and type II DM (T2D)31.
T1D is an autoimmune disorder, with several ge-
netic, epigenetic, and environmental factors playing
a role in its genesis32. T2D is characterized by insulin
resistance and accounts for 90-95% of all diabetes
cases31. It often leads to the development of several
microvascular (retinopathy, nephropathy, and neu-
ropathy) andmacrovascular (coronary artery disease,
stroke, peripheral artery disease) complications33.
Deaths from DM continue to increase all over the
world34. CKD has an estimated prevalence of 10.6%-
13.4%35, and its prevalence is growing rapidly36.
CKD progresses to end-stage kidney disease requir-
ing a kidney transplant, and these numbers are also
on the increase37. It is estimated that the number of
people requiring renal replacement will double to 5.4
million by 203038. This population has a mortality
rate that is over 100-fold compared to that seen in the
normal population39. DM continues to be the leading
cause of CKD40. Dementia affects around 50 mil-
lion people worldwide and this number is projected
to increase to 152 million by 205041. Alzheimer’s
disease (AD) is the most common dementia and is
caused by amyloid-beta peptide accumulation in the
medial temporal lobe and neocortical structures42.
Treatment for AD is symptomatic as there is no

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mailto:usacardiologist@gmail.com


EXERCISE AND NON-COMMUNICABLE DISEASES: PART II CANCER, DIABETES MELLITUS, 
KIDNEY DISEASES, ALZHEIMER’S DISEASE, ARTHRITIS
cure available at this time43. Arthritis is of over 100
types, the most common being rheumatoid arthritis,
osteoarthritis, psoriatic arthritis, and inflammatory
arthritis44. Osteoarthritis (OA) is the most prevalent
chronic joint disease and is associated with cartilage
loss45,46. It usually affects the knees, although it
can affect any joint45,46. It is a major cause of dis-
ability in older adults47. Rheumatoid arthritis (RA)
is a chronic, systemic, immune-inflammatory dis-
ease, especially affecting the synovial joints resulting
in synovitis, joint erosion, and cartilage damage48.
Its etiology includes several genetic, environmental,
and endogenous factors49.
Lifestyle changes can beneficially modify chronic
NCDs50. The detrimental but modifiable lifestyle
factors include tobacco smoking, inadequate veg-
etable and fruit consumption, excessive alcohol con-
sumption, physical inactivity, and obesity51. Part
I reviewed the benefits of exercise for cardiovascular
diseases, respiratory diseases, obesity, depression,
and liver diseases. This manuscript will discuss its
benefits for cancer, diabetes mellitus, kidney dis-
eases, Alzheimer’s disease, and arthritis.

2.1 CANCER

In 1986, Winningham et al suggested that physical
activity may play a major role in oncology52. The
cancer modulating effect of exercise has been con-
firmed by several subsequent studies53−55. Behrens
and the group found that low physical activity ac-
counted for 6% of all cancers in Germany53. They re-
ported that physical inactivity resulted in an increase
in endometrial cancer by 15%, renal cancer by 17%,
liver cancer by 24%, and lung cancer by 19%53. Ac-
cording to Islami and the group, physical inactivity
accounted for 2.9% of all cancer cases in the US54.
They estimated that physical inactivity accounted
for 26.7% of uterine cancers, 16.3% of colorectal
cancers, and 3.9% of female breast cancers54. A re-
cent umbrella review, including 19 reviews, 26meta-
analyses, and 541 original studies, evaluating phys-
ical activity and cancer risk, concluded that regular
physical activity is beneficial in preventing 7 major
cancers (colon, breast, endometrium, lung, esoph-
agus, pancreas, and meningioma)55. The greatest
beneficial impact appears to be on breast and colon

cancer56. In a meta-analysis of 38 cohort studies in
2016 by Pizot et al, breast cancer risk was reduced by
12-21% in the most physically active women than in
those who were least physically active57. In another
more recent study, exercising 7 hours a week reduced
colon cancer risk by 40%58. Several studies have also
reported significant reductions in physical activity in
cancers of the stomach59, kidney60, bladder60, and
endometrium61. Minimal amounts of exercise may
have protective effects62, although there appears to
be a dose-dependent relationship63−65.
Following a cancer diagnosis, exercise is associ-
ated with better clinical outcomes66−69. Animal stud-
ies have demonstrated a decrease in cancer tumor
growth with exercise67. Exercise therapy before the
initiation of chemotherapy is associated with im-
provements in tolerance to cancer treatment68. Ben-
efits are also noted with exercise pre-surgery69. Pre-
treatment exercise results in mitigation of the sig-
nificant functional decline often noted in cancer
patients68,69.
Exercise during treatment also demonstrates clin-
ical benefits70−83. These patients notice an im-
proved tolerance to chemotherapy and surgery69.70.
Their hospital stay is decreased69. They have fewer
side effects and less fatigue71,72. Their aerobic en-
durance, strength, flexibility, and body composi-
tion improves73. They become more physically fit
and have increased energy levels and vitality74.
There is an improvement in sleep quality75 and a
reduction in depression76 and anxiety77, often ex-
perienced by these patients. Exercising cancer pa-
tients also improve their self-esteem71. Their QOL
improves78. Exercise helps decrease metastasis and
cancer recurrence79,80. Benefits of exercise have
also been seen in individuals after metastasis has
occurred81. Survival is increased82,83. Regular exer-
cise continues to be recommended by various world
health organizations for cancer patients84−88.
Physical activity induces several cancer-preventive
changes in the human body, including reducing adi-
pose tissue, improving insulin resistance, reducing
inflammation, enhancing immune function, modu-
lating sex hormones and growth factors, and en-
hancing resistance to oxidative stress and DNA
damage89. In patients with established malignant

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SHASHI K. AGARWAL, MD

tumors, physical activity/exercise paradigms regu-
late intra-tumoral vascular maturity and perfusion,
hypoxia, and metabolism and augment the antitumor
immune response90.
More than 40% of patients diagnosed with cancer
have comorbid NCDs, such as diabetes, obesity,
chronic obstructive pulmonary disease, and heart
failure91. Cancer itself may increase the risk of devel-
oping some of these diseases92,93. Breast cancer sur-
vivors experience an increased risk of cardiovascu-
lar disease92 and cardiovascular mortality93. Patients
with nonmetastatic breast cancer demonstrate a 23%
adjusted reduced risk of cardiovascular events, with
exercise94. Exercise benefits for cancer, therefore,
also extend to coexisting NCDs.

2.2 DIABETES MELLITUS

Several studies have stressed the value of regular
physical activity as part of lifestyle changes to help
prevent or delay type 2 diabetes95,96. Church et al
found that a weight loss of only 5%-7% achieved
with physical activity at least 150–175 min/week
and dietary energy restriction demonstrate reduc-
tions of 40%–70% in the risk of developing type 2
diabetes in people with impaired glucose tolerance97.
A systemic review of randomized controlled trials
found that lifestyle changes, including exercise, had
a preventive effect on the development of T2D in
people with impaired glucose tolerance. While the
control group had a diabetes incidence of 9.3% to
67.7%, in this study, the lifestyle intervention group
demonstrated a reduced incidence of 3% to 46%98.
A recent systematic review of 53 studies done by
Balk et al found that, compared with usual care, diet
and physical activity promotion programs improved
several cardiometabolic risk factors and reduced the
incidence of type 2 diabetes99.
Exercise, especially moderate to vigorous, confers
several benefits on patients with both type I and
type II diabetes100. Aerobic exercise in type I di-
abetes helps by decreasing insulin resistance and
improving lipid levels and endothelial function101.
In T2D, aerobic exercise reduces blood glucose,
A1C, triglycerides, blood pressure, and insulin
resistance102. Both T1D and T2D patients lose
weight and become more cardio-metabolically fit

with aerobic exercise. As a result, the cardiovas-
cular risk diminishes103−105. The latter is impor-
tant as diabetics have a higher risk of developing
CVDs106. CVDs are responsible for most deaths in
these patients107. Many diabetic patients are obese,
and exercise also helps them get more physically
fit and function better108. Resistance exercises are
also helpful in T2D109,110. These patients generate
more muscle mass, more bone mineral density, and
become stronger109. There is also improvement in
the cardiometabolic profile109. Resistance exercises
in T1D, if done before aerobic exercises, minimize
the risk of exercise-induced hypoglycemia110. Flex-
ibility and balance exercises help diabetics improve
their joint mobility, which often deteriorates with the
combination of hyperglycemia and aging111. Stretch-
ing exercises increase the range of motion of joints
and improve flexibility in these patients112. Diabetics
may have gait and balance problems, especially if
peripheral neuropathy is present113. Balance training
in these patients can therefore help reduce the risk of
falls114. Both Yoga and Tai Chi may help improve
glycemic control and many QOL parameters115,116.
Aerobic activity also helps reduce mortality in both
types I and type 2 diabetes117. Exercise stress testing
before starting an exercise program is recommended
for previously sedentary diabetics or those with car-
diovascular autonomic neuropathy118.

2.3 CHRONIC KIDNEY DISEASE

The role of sedentary behavior and exercise on
GFR and albuminuria, or both, has been extensively
studied119−123. Sedentary behavior increases the risk
of developing CKD, while physical exercise reduces
this risk124−126. In a prospective analysis of the Car-
diovascular Health Study, greater baseline physical
activity was associated with a lower risk of GFR
decline >3 mL/min/1.73 m2 per year over 7 years of
follow-up127. In the Second National Health and Nu-
tritional Examination Survey, highly active people,
when compared with inactive people, demonstrated
a reduced risk for developing kidney failure or dying
of CKD over a mean of 13 years128. A recent study
has also confirmed the preventive benefits of exer-
cise in CKD129 .

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Once CKD has developed, physical activity in the
affected individual slows down130. This deteriora-
tion in physical performance is evidenced by a de-
creased walking capacity, muscle strength, balance,
and fine motor skills131−134. With the initiation of
dialysis, physical functioning does not improve135
and continues to deteriorate136 usually becoming a
major disability137. The National Kidney Foundation
recommends that patients with CKD on dialysis be
“counseled and regularly encouraged by nephrology
and dialysis staff to increase their level of physical
activity”138. This is because several studies have
demonstrated that physical activity benefits patients
with CKD139. Exercise in these patients is associ-
ated with not only a slower decline in eGFR, but
often an improvement140,141. In a meta-analysis of 13
RCTs totaling 421 patients with CKD, Zhang et al
concluded that exercise therapy was associated with
a +2.6 mL/min increase in eGFR142. Greenwood
et al in a retrospective longitudinal cohort study
estimated that each extra hour of sedentary behavior
was associated with a worsening of kidney function,
while each extra hour of total physical activity was
associated with a better kidney function143. Exercise
training in dialysis patients prevents muscle atro-
phy and improves functional capacity and quality of
life144,145. Benefits of exercise have also been noted
in renal transplant patients146.
Besides the benefits for the kidneys, exercise in
CKD patients improves aerobic and functional
capacity147,148. It improves peak/maximum oxy-
gen consumption, strength, fine motor skills, and
balance149,150. There is a reduction in cardiovascular
outcomes151. Several benefits have also been noted
with exercise following renal transplantation152.
Overall, exercise in CKD patients imparts a bet-
ter prognosis, a better quality of life, and better
survival153−155. Exercise (aerobic, resistance, and
flexibility) has been recommended for CKD patients
by major kidney organizations156−158. Exercise is
usually feasible, and well-tolerated in CKD patients,
including those on dialysis and those following renal
transplantation159−161.
Physical activity may be associated with GFR and
albuminuria via mechanisms such as modulation
of inflammation, endothelial function, the renin-
angiotensin system, and renal sympathetic nerve

activity162−164. The beneficial change in GFR and
albuminuria may also be mediated by modifica-
tion of risk factors such as T2DM blood pressure,
adiposity, and dyslipidemia, by increased physical
activity165−168.

2.4 ALZHEIMER'S DISEASE

Exercise and brain health are intricately
associated169. Several cross-sectional, longitudinal
observational studies and narrative reviews have
discussed the benefits of exercise on cognitive
function170−172. Meta-analytic reviews have con-
cluded that older adults are protected against
cognitive decline if they engage in exercise173−175.
Northey and his group noted after analyzing 36
studies that physical exercise, in people over the
age of 50, improved cognitive function, irrespective
of their baseline cognitive status173. Falck et al
conducted a systematic review and meta-analysis
of 48 studies involving adults aged 60 or older
and noted that exercise was associated with an
improvement in cognitive function174. Chen et al
recently performed a meta-analysis of 33 RCT
studies and concluded that exercise interventions
improve executive function175. Executive functions
mainly originate in the prefrontal cortex and include
attentional control, working memory, inhibition, and
problem-solving. They are all important aspects of
cognition.
Hamer and Chida in a systematic review involving
163,000 non-psychotic participants found that the
risk of dementia and AD was lowered by 28% and
45% with physical activity176. Lautenschlager et al
found that in older adults with mild cognitive im-
pairment, 142minutes of extra exercise per week im-
proved cognition177. Twomore recent meta-analyses
have also confirmed the slowing effects of aerobic
exercise on cognitive decline, in patients with MCI
or even AD178,179. Zheng et al evaluated 11 studies
involving 1497 participants and found that in patients
with MCI, aerobic exercise improved global cogni-
tive ability and memory178. Panza and colleagues in
a meta-analysis of nineteen studies, which included
1,145 subjects, reported that exercise training may
delay the decline in cognitive function that occurs
in individuals who are at risk of or have devel-

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oped AD179. In patients with AD, exercise results in
an improvement in cognitive function180, decreased
neuropsychiatric symptoms, and a slower decline
in activities of daily living181. And, consequently,
reduced caregiver burden182. Patients with AD ex-
perience fewer side effects183 and better adherence
to medications184, with exercise.
The mechanisms behind the exercise-related
improvement in brain health have been well
studied185,186. Exercise preserves neurogenesis187,188
and helps beneficial neuroplasticity189. Exercise
also helps improve diabetes, hypertension, obesity,
stress, depression, and inflammation, which are also
risk factors for dementia190. In conclusion, physical
activity is inversely associated with the risk of
developing and the progression of dementia.

2.5 ARTHRITIS

The beneficial role of exercise in osteoarthritis is also
persuasive191−195. Improved pain and functional out-
comes after exercise therapy in OA are well demon-
strated by numerous meta-analytic studies191,192.
Goh et al showed that exercise not only significantly
reduced pain and improved function in patients with
OA, but improved performance and QOL in these
patients as compared with usual care at 8 weeks193.
Both traditional exercises such as aerobic, resistance,
and flexibility, and non-traditional exercises such
as Tai Chi, Yoga, and aquatics are effective in the
management of knee and hip osteoarthritis194. In
their systematic review of 44 clinical trials involv-
ing patients with knee osteoarthritis, there was an
improvement in physical function and the quality of
life, and these effects lasted up to six months after
cessation of land-based therapeutic exercises195. Se-
vere hip osteoarthritis is one of the main causes of
disabling pain, functional impairment, and reduced
quality of life in elderly patients196. In a review
of 10 RCTs, researchers concluded that land-based
therapeutic exercises can reduce pain and improve
physical function among people with symptomatic
hip OA197. Land- and aquatic-based physical activ-
ities help patients with both knee and hip OA to
reduce pain and increase mobility, muscle strength,
joint flexibility, and aerobic endurance198. Initially,
aquatic exercises may be deployed. The buoyancy

of the water decreases joint loading, which can help
decrease pain, and warm water may also have a
therapeutic effect199. Once patients become more
mobile, they can transition to land-based exercises.
Exercise should be the main intervention for OA
patients193,200. Weesandt and his group in a review
concluded that osteoarthritis can be successfully
managed and treated through exercise, with minimal
risk of negative consequences201.
Rheumatoid arthritis also responds well to physical
exercise202−208. These patients notice an improve-
ment in joint health and mobility. They increase their
aerobic work capacity and become more physically
active. They notice an improvement in endurance,
strength, and dynamic balance. Rheumatoid fatigue
and cachexia are reduced. There is also an improve-
ment in psychological well-being. Increased physical
activity and exercise also help reduce the impact of
systemic manifestations of RA209, such as increased
inflammation, disturbed vascular function, and in-
creased cardiovascular risk in these patients210−212.
Despite these benefits, RA patients have lower phys-
ical activity levels than healthy individuals213−215,
with 71 % of RA patients not participating in regular
physical activity216.
Exercise is relatively safe as compared with
pharmacological treatments in the management of
arthritis217. The American College of Rheumatol-
ogy/Arthritis Foundation guidelines for the manage-
ment of arthritis of the hip and knee emphasize the
importance of regularly performed physical exercise
as an important therapeutic intervention218.

3 CONCLUSION

Exercise plays a major preventive and therapeutic
role in most non-communicable diseases. It imparts
positive physical and psychological health outcomes.
It is safe and feasible for most NCD patients. It
can help maintain or increase physical independence
over time and decrease caregiver burden. Most pro-
fessional associations of NCDs emphasize the incor-
poration of exercise for the prevention and manage-
ment of these diseases.
Acknowledgment: None

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EXERCISE AND NON-COMMUNICABLE DISEASES: PART II CANCER, DIABETES MELLITUS, 
KIDNEY DISEASES, ALZHEIMER’S DISEASE, ARTHRITIS
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 II Cancer, Diabetes Mellitus, Kidney Dis-
eases, Alzheimer’s Disease, Arthritis. Clinical 
Medicine Insights. 2021;124−143. https://doi.or 
g /10.52845/CMI/2021-2-2-5

MEERP LTD CMI JOURNAL 2 (2), 124−143 (2021) 143


	Introduction
	Discussion
	CANCER
	DIABETES MELLITUS
	CHRONIC KIDNEY DISEASE
	ALZHEIMER'S DISEASE
	ARTHRITIS

	CONCLUSION



