WHO guidelines on physical activity and sedentary behaviour

WHO GUIDELINES ON PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOUR

WHO GUIDELINES ON PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOUR WHO guidelines on physical activity and sedentary behaviour ISBN 978-92-4-001512-8 (electronic version) ISBN 978-92-4-001513-5 (print edition) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Design: Eddy Hill Design Printed in Switzerland ii iii W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CONTENTS Acknowledgements iv Abbreviations and acronyms v Glossary of terms vi Executive summary 1 Background 15 Methods 18 Recommendations 24 Children and adolescents (aged 5–17 years) 25 Physical activity recommendation 25 Sedentary behaviour recommendation 29 Adults (aged 18–64 years) 32 Physical activity recommendation 32 Sedentary behaviour recommendation 38 Older adults (aged 65 years and older) 43 Physical activity recommendation 43 Sedentary behaviour recommendation 46 Pregnant and postpartum women 47 Physical activity recommendation 47 Sedentary behaviour recommendation 51 Adults and older adults with chronic  conditions (aged 18 years and older) 52 Physical activity recommendation 52 Sedentary behaviour recommendation 58 Children and adolescents (aged 5–17 years) and adults (aged 18 years and over) living with disability 60 Physical activity recommendation 60 Sedentary behaviour recommendation 64 Evidence to recommendations 66 Assessment of the certainty of evidence 66 Benefits and harms 67 Values and preferences 67 Resource implications 67 Equity, acceptability and feasibility 68 Research needs 69 Adoption, dissemination, implementation and evaluation 70 Adoption 70 Dissemination 71 Communication campaigns 71 Implementation of policy and programmes 72 Surveillance and evaluation 73 Updating 73 References 75 Annex 1: Management of guideline development process 85 Annex 2: Guideline development group, external peer reviewers, and who staff involved in the development of these guidelines 88 Annex 3: Summary of declaration of interest and how these were managed 92 Web Annex: Evidence profiles https://apps.who.int/iris/bitstream/handle/ 10665/336657/9789240015111-eng.pdf ii iiiContents ACKNOWLEDGEMENTS The World Health Organization (WHO) gratefully acknowledges the contribution to and support of the following individuals and organizations in the development of these guidelines: Fiona Bull and Juana Willumsen led the process of developing these guidelines. Valentina Baltag, Maurice Bucagu, Alex Butchart, Neerja Chowdhary, Regina Guthold, Riitta-Maija Hämäläinen, Andre Ilbawi, Wasiq Khan, Lindsay Lee, Alana Officer, Leanne Riley and Gojka Roglic were members of the WHO Steering Group that managed the guideline development process. The members of the Guideline Development Group (GDG) included Salih Saad Al-Ansari, Stuart Biddle, Katja Borodulin, Matthew Buman, Greet Cardon (co-chair), Catherine Carty, Jean-Philippe Chaput, Sebastien Chastin, Paddy Dempsey, Loretta DiPietro, Ulf Ekelund, Joseph Firth, Christine Friedenreich, Leandro Garcia, Muthoni Gichu, Russ Jago, Peter Katzmarzyk, Estelle V. Lambert, Michael Leitzmann, Karen Milton, Francisco B. Ortega, Chathuranga Ranasinghe, Emmanuel Stamatakis (co-chair), Anne Tiedemann, Richard Troiano, Hidde van der Ploeg, Vicky Wari. Roger Chou served as GRADE methodologist. The external review group included Kingsley Akinroye, Huda Alsiyabi, Alberto Flórez-Pregonero, Shigeru Inoue, Agus Mahendra, Deborah Salvo and Jasper Schipperijn. Systematic reviews of evidence prepared for 2018 US Physical Activity Guidelines Advisory Committee Scientific Report to the Secretary of Health and Human Services were updated thanks to additional literature searches conducted by Kyle Sprow (National Cancer Institutes, National Institutes of Health, Maryland, USA). Additional support to review papers identified was provided by Elif Eroglu (University of Sydney), Andrea Hillreiner (University of Regensburg), Bo-Huei Huang (University of Sydney), Carmen Jochem (University of Regensburg), Jairo H. Migueles (University of Granada), Chelsea Stone (University of Calgary) and Léonie Uijtdewilligen (Amsterdam UMC). Summaries of evidence and GRADE tables were prepared by Carrie Patnode and Michelle Henninger (The Kaiser Foundation Hospitals, Center for Health Research, Portland, Oregon, USA). Additional reviews of evidence were conducted by N Fairhall, J Oliveira, M Pinheiro, and C Sherrington (Institute for Musculoskeletal Health, School of Public Health, The University of Sydney, Sydney, Australia) and A Bauman (Prevention Research Collaboration, School of Public Health, The University of Sydney, Sydney, Australia; and WHO Collaborating Centre for Physical Activity, Nutrition and Obesity); S Mabweazara, M-J Laguette, K Larmuth, F Odunitan-Wayas (Research Centre for Health through Physical Activity, Lifestyle and Sports Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa), L Leach, S Onagbiye (Department of Sport, Recreation and Exercise Science, Faculty of Health Sciences, University of the Western Cape, Cape Town, South Africa), M Mthethwa (Chronic Disease Initiative for Africa, University of Cape Town, Cape Town, South Africa), P Smith (The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa) and F Mashili (Department of Physiology, Muhimbili University of Allied Sciences, Dar Es Salaam, United Republic of Tanzania); B Cillekens, M Lang, W van Mechelen, E Verhagen, M Huysmans, A van der Beek, P Coenen (Department of Public and Occupational Health at Amsterdam University Medical Centre, Amsterdam, Netherlands). The Public Health Agency of Canada and the Government of Norway provided financial support, without which this work could not have been completed. iv v W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ADHD attention deficit hyperactive disorder AOR adjusted odds ratio BMI body mass index CI confidence interval CVD cardiovascular disease DBP diastolic blood pressure EtD Evidence to Decisions GDG Group Development Group GRADE Grading of Recommendations Assessment, Development and Evaluation HR hazards ratio MET Metabolic Equivalent of Task MD mean difference MICT moderate intensity continuous training NCD noncommunicable disease OR odds ratio PA physical activity PAGAC United States Physical Activity Guidelines Advisory Committee PI/ECO Population, Intervention/Exposure, Comparison, Outcome RaR Relative attributable risk RCT randomized control trial RR relative risk SBP systolic blood pressure SMD standardized mean difference SPPB short physical performance battery TV television WHA World Health Assembly WHO World Health Organization ABBREVIATIONS AND ACRONYMS iv vAbbreviations and acronyms Term Definition Aerobic physical activity Activity in which the body’s large muscles move in a rhythmic manner for a sustained period of time. Aerobic activity – also called endurance activity – improves cardiorespiratory fitness. Examples include walking, running, swimming, and bicycling. Anaerobic physical activity Anaerobic physical activity consists of brief intense bursts of exercise, such as weightlifting and sprints, where oxygen demand surpasses oxygen supply. Balance training Static and dynamic exercises that are designed to improve an individual’s ability to withstand challenges from postural sway or destabilizing stimuli caused by self-motion, the environment, or other objects. Body mass index (BMI) Weight (kg) / height (m)2 BMI-for-age or BMI z-score BMI adjusted for age, standardized for children. BMI standard deviation scores are measures of relative weight adjusted for child age and sex. Given a child’s age, sex, BMI, and an appropriate reference standard, a BMI z-score (or its equivalent BMI-for-age percentile) can be determined. Bone-strengthening activity Physical activity primarily designed to increase the strength of specific sites in bones that make up the skeletal system. Bone-strengthening activities produce an impact or tension force on the bones that promotes bone growth and strength. Running, jumping rope, and lifting weights are examples of bone-strengthening activities. Cardiometabolic health The interplay of blood pressure, blood lipids, blood glucose and insulin on health. Cardiorespiratory fitness (endurance) A health-related component of physical fitness. The ability of the circulatory and respiratory systems to supply oxygen during sustained physical activity. Usually expressed as measured or estimated maximal oxygen uptake (VO2 max). Cognitive function Cerebral activities, i.e. reasoning, memory, attention, and language that lead to the attainment of information and knowledge. This can also include learning. Disability From the International Classification of Functioning, Disability and Health, an umbrella term for impairments, activity limitations, and participation restrictions, denoting the negative aspects of the interaction between an individual (with a health condition) and that individual’s contextual factors (environmental and personal factors). Domains of physical activity Physical activity levels can be assessed in various domains, including one of more of the following: leisure-time, occupation, education, household and/or transportation. Exercise A subcategory of physical activity that is planned, structured, repetitive, and purposeful in the sense that the improvement or maintenance of one or more components of physical fitness is the objective. “Exercise” and “exercise training” frequently are used interchangeably and generally refer to physical activity performed during leisure time with the primary purpose of improving or maintaining physical fitness, physical performance, or health. Executive function Includes constructs such as: working memory, cognitive flexibility (also called flexible thinking) and inhibitory control (which includes self-control). Fitness A measure of the body's ability to function efficiently and effectively in work and leisure activities, and includes, for example, physical fitness and cardiorespiratory fitness. Flexibility A health- and performance-related component of physical fitness that is the range of motion possible at a joint. Flexibility is specific to each joint and depends on a number of specific variables including, but not limited to, the tightness of specific ligaments and tendons. Flexibility exercises enhance the ability of a joint to move through its full range of motion. Functional exercises Exercises that can be embedded into everyday tasks to improve lower-body strength, balance, and motor performance. Examples include tandem and one-leg stands, squatting, chair stands, toe raises, and stepping over obstacles. Household domain physical activity Physical activity undertaken in the home for domestic duties (such as cleaning, caring for children, gardening etc.). Leisure-domain physical activity Physical activity performed by an individual that is not required as an essential activity of daily living and is performed at the discretion of the individual. Such activities include sports participation, exercise conditioning or training, and recreational activities such as going for a walk, dancing, and gardening. GLOSSARY OF TERMS vi vii W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Term Definition Light-intensity physical activity Light-intensity physical activity is between 1.5 and 3 METs, i.e. activities with energy cost less than 3 times the energy expenditure at rest for that person. This can include slow walking, bathing, or other incidental activities that do not result in a substantial increase in heart rate or breathing rate. Major muscle groups Major muscle groups include the legs, back, abdomen, chest, shoulders and arms. Metabolic equivalent of task (MET) The metabolic equivalent of task, or simply metabolic equivalent, is a physiological measure expressing the intensity of physical activities. One MET is the energy equivalent expended by an individual while seated at rest. Moderate-intensity physical activity On an absolute scale, moderate-intensity refers to the physical activity that is performed between 3 and less than 6 times the intensity of rest. On a scale relative to an individual’s personal capacity, moderate-intensity physical activity is usually a 5 or 6 on a scale of 0–10. Muscle-strengthening activity Physical activity and exercise that increase skeletal muscle strength, power, endurance, and mass (e.g. strength training, resistance training, or muscular strength and endurance exercises). Multicomponent physical activity For older adults, multicomponent physical activity is important to improve physical function and decrease the risk of falls or injury from a fall. These activities can be done at home or in a structured group setting. Many studied interventions combine all types of exercise (aerobic, muscle strengthening, and balance training) into a session, and this has been shown to be effective. An example of a multicomponent physical activity programme could include walking (aerobic activity), lifting weights (muscle strengthening), and incorporates balance training. Examples of balance training can include walking backwards or sideways or standing on one foot while doing an upper body muscle-strengthening activity, such as bicep curls. Dancing also combines aerobic and balance components. Occupation domain physical activity See work domain physical activity. Physical activity Any bodily movement produced by skeletal muscles that requires energy expenditure. Physical inactivity An insufficient physical activity level to meet present physical activity recommendations. Psychosocial health Include mental, emotional and social dimensions of health. Recreational screen time Time spent watching screens (television (TV), computer, mobile devices) for purposes other than those related to education/study or work. Sedentary screen time Time spent watching screen-based entertainment (TV, computer, mobile devices). Does not include active screen-based games where physical activity or movement is required. Sedentary behaviour Any waking behaviour characterized by an energy expenditure of 1.5 METS or lower while sitting, reclining, or lying. Most desk-based office work, driving a car, and watching television are examples of sedentary behaviours; these can also apply to those unable to stand, such as wheelchair users. The guidelines operationalize the definition of sedentary behaviour to include self-reported low movement sitting (leisure time, occupational, and total), television (TV viewing or screen time, and low levels of movement measured by devices that assess movement or posture). Sport Sport covers a range of activities performed within a set of rules and undertaken as part of leisure or competition. Sporting activities involve physical activity carried out by teams or individuals and may be supported by an institutional framework, such as a sporting agency. Transport domain physical activity Physical activity performed for the purpose of getting to and from places, and refers to walking, cycling and wheeling (the use of non-motorized means of locomotion with wheels, such as scooters, rollerblades, manual wheelchair etc.). Vigorous-intensity physical activity On an absolute scale, vigorous-intensity refers to physical activity that is performed at 6.0 or more METS. On a scale relative to an individual’s personal capacity, vigorous-intensity physical activity is usually a 7 or 8 on a scale of 0–10. Work domain physical activity Physical activity undertaken during paid or voluntary work. vi viiGlossary of terms The WHO Guidelines on physical activity and sedentary behaviour provide evidence-based public health recommendations for children, adolescents, adults and older adults on the amount of physical activity (frequency, intensity and duration) required to offer significant health benefits and mitigate health risks. For the first time, recommendations are provided on the associations between sedentary behaviour and health outcomes, as well as for subpopulations, such as pregnant and postpartum women, and people living with chronic conditions or disability. The guidelines are intended for policy-makers in high-, middle-, and low-income countries in ministries of health, education, youth, sport and/or social or family welfare; government officials responsible for developing national, sub regional or municipal plans to increase physical activity and reduce sedentary behaviour in population groups through guidance documents; people working in nongovernmental organizations, the education sector, private sector, research; and health- care providers. The guidelines were prepared in accordance with the WHO handbook for guideline development. Systematic reviews of evidence were conducted for the critical and important outcomes, and recommendations were developed after consideration of the benefits and harms, values, preferences, feasibility and acceptability, and the implications for equity and resources. The final public health recommendations presented are for all populations and age groups ranging from 5 years to 65 years and older, irrespective of gender, cultural background or socioeconomic status, and are relevant for people of all abilities. Those with chronic medical conditions and/or disability and pregnant and postpartum women should try to meet the recommendations where possible and as able. The development of these guidelines provide a set of evidence-based recommendations that governments can adopt as part of their national policy frameworks to support comprehensive approaches to increasing population levels of physical activity. Within the adoption process, consideration should be given to the need to contextualize the guidelines. Practical tools to support adoption, dissemination, communication campaigns and implementation of the guidelines will support governments and stakeholders work together to increase physical activity and reduce sedentary behaviours across the life course. These supporting resources will be available through the WHO website following publication of the guidelines Despite the large quantity of supporting data relating physical activity and, increasingly, sedentary behaviours to health outcomes across the life-span, important evidence gaps remain. In particular, there is less evidence from low- and middle-income countries and economically disadvantaged or underserved communities, and a dearth of evidence from subpopulations including people living with disabilities. Investment in more research is needed to build evidence particularly in these areas. In addition, the changes introduced to these recommendations will have some implications for surveillance systems and assessment instruments currently used to monitor national levels of physical activity. Existing global and national instruments should be reviewed, and reporting protocols updated, to inform future reporting against the new guidelines. The Global action plan on physical activity 2018–2030 set a target to reduce physical inactivity by 15% by 2030, and outlined 20 recommended policy actions and interventions. These guidelines support all countries to implement the GAPPA recommendations and “ACTIVE”, the technical package of toolkits that provides guidance on how to promote physical activity across the life course and through multiple settings. EXECUTIVE SUMMARY viii 1 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CHILDREN AND ADOLESCENTS (aged 5–17 years) It is recommended that: Children and adolescents should do at least an average of 60 minutes per day of moderate- to vigorous-intensity, mostly aerobic, physical activity, across the week. Strong recommendation, moderate certainty evidence Vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone, should be incorporated at least 3 days a week. Strong recommendation, moderate certainty evidence • Doing some physical activity is better than doing none. • If children and adolescents are not meeting the recommendations, doing some physical activity will benefit their health. • Children and adolescents should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • It is important to provide all children and adolescents with safe and equitable opportunities, and encouragement, to participate in physical activities that are enjoyable, offer variety, and are appropriate for their age and ability. G O O D P R A C TI C E ST A TE M EN TS In children and adolescents, physical activity confers benefits for the following health outcomes: improved physical fitness (cardiorespiratory and muscular fitness), cardiometabolic health (blood pressure, dyslipidaemia, glucose, and insulin resistance), bone health, cognitive outcomes (academic performance, executive function), mental health (reduced symptoms of depression); and reduced adiposity. In children and adolescents, higher amounts of sedentary behaviour are associated with the following poor health outcomes: increased adiposity; poorer cardiometabolic health, fitness, behavioural conduct/pro-social behaviour; and reduced sleep duration. It is recommended that: Children and adolescents should limit the amount of time spent being sedentary, particularly the amount of recreational screen time. Strong recommendation, low certainty evidence 1 GRADE: Grading of Recommendations Assessment Development and Evaluation Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf INTRODUCTION Regular physical activity is a key protective factor for the prevention and management of noncommunicable diseases (NCDs) such as cardiovascular disease, type-2 diabetes, and a number of cancers. Physical activity also benefits mental health, including prevention of cognitive decline and symptoms of depression and anxiety; and can contribute to the maintenance of healthy weight and general well-being. Global estimates indicate that 27.5% of adults (1) and 81% of adolescents (2) do not meet the 2010 WHO recommendations for physical activity (3) with almost no improvements seen during the past decade. There are also notable inequalities: data show that in most countries girls and women are less active than boys and men, and that there are significant differences in levels of physical activity between higher and lower economic groups, and between countries and regions. SCOPE The WHO Guidelines on physical activity and sedentary behaviour provide evidence-based public health recommendations for children, adolescents, adults and older adults on the amount of physical activity (frequency, intensity and duration) required to offer significant health benefits and mitigate health risks. For the first time, recommendations are provided on the associations between sedentary behaviour and health outcomes, as well as for subpopulations, such as pregnant and postpartum women, and people living with chronic conditions or disability. TARGET AUDIENCE The guidelines are intended for policy-makers in high-, middle-, and low-income countries in ministries of health, education, youth, sport and/or social or family welfare; government officials responsible for developing national, sub regional or municipal plans to increase physical activity and reduce sedentary behaviour in population groups through guidance documents; people working in nongovernmental organizations, the education sector, private sector, research; and health-care providers. DEVELOPMENT PROCESS The guidelines were prepared in accordance with the WHO handbook for guideline development (4). In 2019 a Guideline Development Group (GDG) was formed comprising technical experts and relevant stakeholders from all six WHO regions. The group met in July 2019 to formulate the key questions, review the evidence-bases, and agree the methods for updates of literature, and, where needed, for additional new reviews. In February 2020, the GDG met again to review the evidence for the critical and important outcomes, consider the benefits and harms, values, preferences, feasibility and acceptability, and the implications for equity and resources. The recommendations were developed through consensus and posted online for public consultation. The final updated recommendations are summarized below. The GRADE 1 tables and evidence profiles are available as a Web annex . Practical tools to support adoption, dissemination, communication campaigns and implementation of the guidelines will support governments and stakeholders work together to increase physical activity and reduce sedentary behaviours across the life course. RECOMMENDATIONS The public health recommendations presented in the WHO Guidelines on physical activity and sedentary behaviour are for all populations and age groups ranging from 5 years to 65 years and older, irrespective of gender, cultural background or socioeconomic status, and are relevant for people of all abilities. Those with chronic medical conditions and/or disability and pregnant and postpartum women should try to meet the recommendations where possible and as able. LIMIT the amount of time spent being sedentary, particularly recreational screen time. 3 vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated. On at least days a week 60 moderate- to vigorous-intensity physical activity across the week; most of this physical activity should be aerobic. minutes a day At least 2 3 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendationsviii 1Executive summary It is recommended that: Adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, moderate certainty evidence It is recommended that: All adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults should do at least 150– 300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence ADULTS (aged 18–64 years) ADULTS (aged 18–64 years) 2 Site-specific cancers of: bladder, breast, colon, endometrial, oesophageal adenocarcinoma, gastric, and renal. • Doing some physical activity is better than doing none. • If adults are not meeting these recommendations, doing some physical activity will benefit their health. • Adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. G O O D P R A C TI C E ST A TE M EN TS In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and type-2 diabetes. In adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site-specific cancers, 2 incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression); cognitive health, and sleep; measures of adiposity may also improve. Adults may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence Adults should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 4 5 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations 1 1 2 3 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r It is recommended that: Adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, moderate certainty evidence It is recommended that: All adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults should do at least 150– 300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence ADULTS (aged 18–64 years) ADULTS (aged 18–64 years) 2 Site-specific cancers of: bladder, breast, colon, endometrial, oesophageal adenocarcinoma, gastric, and renal. • Doing some physical activity is better than doing none. • If adults are not meeting these recommendations, doing some physical activity will benefit their health. • Adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. G O O D P R A C TI C E ST A TE M EN TS In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and type-2 diabetes. In adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site-specific cancers, 2 incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression); cognitive health, and sleep; measures of adiposity may also improve. Adults may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence Adults should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 4 5 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations2 3Executive summary It is recommended that: All older adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Older adults should do at least 150– 300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence OLDER ADULTS (aged 65 years and older) OLDER ADULTS (aged 65 years and older) • Doing some physical activity is better than doing none. • If older adults are not meeting the recommendations, doing some physical activity will bring benefits to health. • Older adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • Older adults should be as physically active as their functional ability allows, and adjust their level of effort for physical activity relative to their level of fitness. G O O D P R A C TI C E ST A TE M EN TS In older adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Older adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, older adults should aim to do more than the recommended levels of moderate- to vigorous- intensity physical activity. Strong recommendation, moderate certainty evidence In older adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site-specific cancers, incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression), cognitive health, and sleep; measures of adiposity may also improve. In older adults, physical activity helps prevent falls and falls-related injuries and declines in bone health and functional ability. Older adults may increase moderate- intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week, for additional health benefits. Conditional recommendation, moderate certainty evidence Older adults should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence As part of their weekly physical activity, older adults should do varied multicomponent physical activity that emphasizes functional balance 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 LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 6 7 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations4 5 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r It is recommended that: All older adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Older adults should do at least 150– 300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence OLDER ADULTS (aged 65 years and older) OLDER ADULTS (aged 65 years and older) • Doing some physical activity is better than doing none. • If older adults are not meeting the recommendations, doing some physical activity will bring benefits to health. • Older adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • Older adults should be as physically active as their functional ability allows, and adjust their level of effort for physical activity relative to their level of fitness. G O O D P R A C TI C E ST A TE M EN TS In older adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Older adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, older adults should aim to do more than the recommended levels of moderate- to vigorous- intensity physical activity. Strong recommendation, moderate certainty evidence In older adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site-specific cancers, incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression), cognitive health, and sleep; measures of adiposity may also improve. In older adults, physical activity helps prevent falls and falls-related injuries and declines in bone health and functional ability. Older adults may increase moderate- intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week, for additional health benefits. Conditional recommendation, moderate certainty evidence Older adults should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence As part of their weekly physical activity, older adults should do varied multicomponent physical activity that emphasizes functional balance 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 LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 6 7 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations4 5Executive summary In pregnant and postpartum women, physical activity during pregnancy and postpartum confers benefits on the following maternal and fetal health benefits: decreased risk of pre-eclampsia, gestational hypertension, gestational diabetes, excessive gestational weight gain, delivery complications and postpartum depression, and fewer newborn complications, no adverse effects on birthweight; and no increase in risk of stillbirth. It is recommended that all pregnant and postpartum women without contraindication should: Undertake regular physical activity throughout pregnancy and postpartum. Strong recommendation, moderate certainty evidence In addition: Women who, before pregnancy, habitually engaged in vigorous- intensity aerobic activity, or who were physically active, can continue these activities during pregnancy and the postpartum period. Strong recommendation, moderate certainty evidence Do at least 150 minutes of moderate- intensity aerobic physical activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence Incorporate a variety of aerobic and muscle- strengthening activities. Adding gentle stretching may also be beneficial. Strong recommendation, moderate certainty evidence PREGNANT AND POSTPARTUM WOMEN PREGNANT AND POSTPARTUM WOMEN G O O D P R A C TI C E ST A TE M EN TS • Doing some physical activity is better than doing none. • If pregnant and postpartum women are not meeting the recommendations, doing some physical activity will benefit their health. • Pregnant and postpartum women should start by doing small amounts of physical activity, and gradually increase frequency, intensity and duration over time. • Pelvic floor muscle training may be performed on a daily basis to reduce the risk of urinary incontinence. • Avoid physical activity during excessive heat, especially with high humidity. • Stay hydrated by drinking water before, during, and after physical activity. • 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 high altitude). • Avoid activities in supine position after the first trimester of pregnancy. • When considering athletic competition, or exercising significantly above the recommended guidelines pregnant women should seek supervision from a specialist health-care provider. • Pregnant women should be informed by their health-care provider of the danger signs alerting them as to when to stop; or to limit physical activity and consult a qualified health-care provider immediately should they occur. • Return to physical activity gradually after delivery, and in consultation with a health-care provider, in the case of delivery by Caesarean section. Additional safety considerations for pregnant women when undertaking physical activity are: In pregnant and postpartum women, as in all adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Pregnant and postpartum women should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence Doing some physical activity is better than doing none. LIMIT REPLACE the amount of time spent being sedentary with physical activity of any intensity (including light intensity). 150 moderate-intensity aerobic physical activity At least minutes a week 8 9 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations6 7 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r In pregnant and postpartum women, physical activity during pregnancy and postpartum confers benefits on the following maternal and fetal health benefits: decreased risk of pre-eclampsia, gestational hypertension, gestational diabetes, excessive gestational weight gain, delivery complications and postpartum depression, and fewer newborn complications, no adverse effects on birthweight; and no increase in risk of stillbirth. It is recommended that all pregnant and postpartum women without contraindication should: Undertake regular physical activity throughout pregnancy and postpartum. Strong recommendation, moderate certainty evidence In addition: Women who, before pregnancy, habitually engaged in vigorous- intensity aerobic activity, or who were physically active, can continue these activities during pregnancy and the postpartum period. Strong recommendation, moderate certainty evidence Do at least 150 minutes of moderate- intensity aerobic physical activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence Incorporate a variety of aerobic and muscle- strengthening activities. Adding gentle stretching may also be beneficial. Strong recommendation, moderate certainty evidence PREGNANT AND POSTPARTUM WOMEN PREGNANT AND POSTPARTUM WOMEN G O O D P R A C TI C E ST A TE M EN TS • Doing some physical activity is better than doing none. • If pregnant and postpartum women are not meeting the recommendations, doing some physical activity will benefit their health. • Pregnant and postpartum women should start by doing small amounts of physical activity, and gradually increase frequency, intensity and duration over time. • Pelvic floor muscle training may be performed on a daily basis to reduce the risk of urinary incontinence. • Avoid physical activity during excessive heat, especially with high humidity. • Stay hydrated by drinking water before, during, and after physical activity. • 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 high altitude). • Avoid activities in supine position after the first trimester of pregnancy. • When considering athletic competition, or exercising significantly above the recommended guidelines pregnant women should seek supervision from a specialist health-care provider. • Pregnant women should be informed by their health-care provider of the danger signs alerting them as to when to stop; or to limit physical activity and consult a qualified health-care provider immediately should they occur. • Return to physical activity gradually after delivery, and in consultation with a health-care provider, in the case of delivery by Caesarean section. Additional safety considerations for pregnant women when undertaking physical activity are: In pregnant and postpartum women, as in all adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Pregnant and postpartum women should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence Doing some physical activity is better than doing none. LIMIT REPLACE the amount of time spent being sedentary with physical activity of any intensity (including light intensity). 150 moderate-intensity aerobic physical activity At least minutes a week 8 9 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations6 7Executive summary Adults and older adults with chronic conditions should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults and older adults with chronic conditions should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence For cancer survivors, and adults living with hypertension, type-2 diabetes and HIV, it is recommended that: It is recommended that: All adults and older adults with the above chronic conditions should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults and older adults with these chronic conditions should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence When not contraindicated, adults and older adults with these chronic conditions may increase moderate- intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence As part of their weekly physical activity, older adults with these chronic conditions should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence Adults and older adults with these chronic conditions should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional benefits. Strong recommendation, moderate certainty evidence ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) Physical activity can confer health benefits for adults and older adults living with the following chronic conditions: for cancer survivors – physical activity improves all-cause mortality, cancer-specific mortality, and risk of cancer recurrence or second primary cancer; for people living with hypertension – physical activity improves cardiovascular disease mortality, disease progression, physical function, health-related quality of life; for people living with type-2 diabetes – physical activity reduces rates of mortality from cardiovascular disease and indicators disease progression; and for people living with HIV – physical activity can improve physical fitness and mental health (reduced symptoms of anxiety and depression), and does not adversely affect disease progression (CD4 count and viral load) or body composition. G O O D P R A C TI C E ST A TE M EN TS • When not able to meet the above recommendations, adults with these chronic conditions should aim to engage in physical activity according to their abilities. • Adults with these chronic conditions should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • Adults with these chronic conditions may wish to consult with a physical activity specialist or health-care professional for advice on the types and amounts of activity appropriate for their individual needs, abilities, functional limitations/complications, medications, and overall treatment plan. • Pre-exercise medical clearance is generally unnecessary for individuals without contraindications prior to beginning light- or moderate-intensity physical activity not exceeding the demands of brisk walking or everyday living. In adults, including cancer survivors and people living with hypertension, type-2 diabetes and HIV, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 150 300 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 150 10 11 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations8 9 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Adults and older adults with chronic conditions should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults and older adults with chronic conditions should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence For cancer survivors, and adults living with hypertension, type-2 diabetes and HIV, it is recommended that: It is recommended that: All adults and older adults with the above chronic conditions should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults and older adults with these chronic conditions should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence When not contraindicated, adults and older adults with these chronic conditions may increase moderate- intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence As part of their weekly physical activity, older adults with these chronic conditions should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence Adults and older adults with these chronic conditions should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional benefits. Strong recommendation, moderate certainty evidence ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) Physical activity can confer health benefits for adults and older adults living with the following chronic conditions: for cancer survivors – physical activity improves all-cause mortality, cancer-specific mortality, and risk of cancer recurrence or second primary cancer; for people living with hypertension – physical activity improves cardiovascular disease mortality, disease progression, physical function, health-related quality of life; for people living with type-2 diabetes – physical activity reduces rates of mortality from cardiovascular disease and indicators disease progression; and for people living with HIV – physical activity can improve physical fitness and mental health (reduced symptoms of anxiety and depression), and does not adversely affect disease progression (CD4 count and viral load) or body composition. G O O D P R A C TI C E ST A TE M EN TS • When not able to meet the above recommendations, adults with these chronic conditions should aim to engage in physical activity according to their abilities. • Adults with these chronic conditions should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • Adults with these chronic conditions may wish to consult with a physical activity specialist or health-care professional for advice on the types and amounts of activity appropriate for their individual needs, abilities, functional limitations/complications, medications, and overall treatment plan. • Pre-exercise medical clearance is generally unnecessary for individuals without contraindications prior to beginning light- or moderate-intensity physical activity not exceeding the demands of brisk walking or everyday living. In adults, including cancer survivors and people living with hypertension, type-2 diabetes and HIV, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 150 300 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 150 10 11 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations8 9Executive summary CHILDREN AND ADOLESCENTS (aged 5–17 years) LIVING WITH DISABILITY CHILDREN AND ADOLESCENTS (aged 5–17 years) LIVING WITH DISABILITY Many of the health benefits of physical activity for children and adolescents, as set out in the section above, also relate to those children and adolescents living with disability. Additional benefits of physical activity to health outcomes for those living with disability include: improved cognition in individuals with diseases or disorders that impair cognitive function, including attention-deficit/ hyperactivity disorder (ADHD); improvements in physical function may occur in children with intellectual disability. • Doing some physical activity is better than doing none. • If children and adolescents living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Children and adolescents living with disability should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • There are no major risks for children and adolescents living with disability engaging in physical activity when it is appropriate to an individual’s current activity level, health status and physical function; and the health benefits accrued outweigh the risks. • Children and adolescents living with disability may need to consult a health-care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. G O O D P R A C TI C E ST A TE M EN TS In children and adolescents, higher amounts of sedentary behaviour are associated with the following poor health outcomes: increased adiposity; poorer cardiometabolic health, fitness, and behavioural conduct/pro-social behaviour; and reduced sleep duration. It is recommended that: Children and adolescents living with disability should limit the amount of time spent being sedentary, particularly the amount of recreational screen time. Strong recommendation, low certainty evidence It is recommended that: Children and adolescents living with disability should do at least an average of 60 minutes per day of moderate-to-vigorous intensity, mostly aerobic, physical activity, across the week. Strong recommendation, moderate certainty evidence Vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated at least 3 days a week. Strong recommendation, moderate certainty evidence Doing some physical activity is better than doing none. Start by doing small amounts of physical activity. 60 moderate-to-vigorous intensity, mostly physical activity, across the week; most of this physical activity should be aerobic. At least minutes a day 3 vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated. On at least days a week LIMIT the amount of time spent being sedentary, particularly recreational screen time. 12 13 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations0 1 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CHILDREN AND ADOLESCENTS (aged 5–17 years) LIVING WITH DISABILITY CHILDREN AND ADOLESCENTS (aged 5–17 years) LIVING WITH DISABILITY Many of the health benefits of physical activity for children and adolescents, as set out in the section above, also relate to those children and adolescents living with disability. Additional benefits of physical activity to health outcomes for those living with disability include: improved cognition in individuals with diseases or disorders that impair cognitive function, including attention-deficit/ hyperactivity disorder (ADHD); improvements in physical function may occur in children with intellectual disability. • Doing some physical activity is better than doing none. • If children and adolescents living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Children and adolescents living with disability should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • There are no major risks for children and adolescents living with disability engaging in physical activity when it is appropriate to an individual’s current activity level, health status and physical function; and the health benefits accrued outweigh the risks. • Children and adolescents living with disability may need to consult a health-care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. G O O D P R A C TI C E ST A TE M EN TS In children and adolescents, higher amounts of sedentary behaviour are associated with the following poor health outcomes: increased adiposity; poorer cardiometabolic health, fitness, and behavioural conduct/pro-social behaviour; and reduced sleep duration. It is recommended that: Children and adolescents living with disability should limit the amount of time spent being sedentary, particularly the amount of recreational screen time. Strong recommendation, low certainty evidence It is recommended that: Children and adolescents living with disability should do at least an average of 60 minutes per day of moderate-to-vigorous intensity, mostly aerobic, physical activity, across the week. Strong recommendation, moderate certainty evidence Vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated at least 3 days a week. Strong recommendation, moderate certainty evidence Doing some physical activity is better than doing none. Start by doing small amounts of physical activity. 60 moderate-to-vigorous intensity, mostly physical activity, across the week; most of this physical activity should be aerobic. At least minutes a day 3 vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated. On at least days a week LIMIT the amount of time spent being sedentary, particularly recreational screen time. 12 13 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations0 1Executive summary It is recommended that: Adults living with disability should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults living with disability should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence It is recommended that: All adults living with disability should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults living with disability should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence Adults living with disability should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence ADULTS (aged 18 years and older) LIVING WITH DISABILITY ADULTS (aged 18 years and older) LIVING WITH DISABILITY Many of the health benefits of physical activity for adults, as set out in the section above, also relate to adults living with disability. Additional benefits of physical activity to health outcomes for those living with disability include the following: for adults with multiple sclerosis – improved physical function, and physical, mental, and social domains of health-related quality of life; for individuals with spinal cord injury – improved walking function, muscular strength, and upper extremity function; and enhanced health-related quality of life; for individuals with diseases or disorders that impair cognitive function – improved physical function and cognition (in individuals with Parkinson’s disease and those with a history of stroke); beneficial effects on cognition; and may improve quality of life (in adults with schizophrenia); and may improve physical function (in adults with intellectual disability); and improves quality of life (in adults with major clinical depression). In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and type-2 diabetes. Adults living with disability may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence As part of their weekly physical activity, older adults living with disability should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence G O O D P R A C TI C E ST A TE M EN TS • Doing some physical activity is better than doing none. • If adults living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Adults living with disability should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • There are no major risks to adults living with disability engaging in physical activity when it is appropriate to the individual’s current activity level, health status and physical function; and when the health benefits accrued outweigh the risks. • Adults living with disability may need to consult a health- care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 300 150 minutes moderate-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: vigorous- intensity aerobic physical activity For additional health benefits: 2 days a week On at least muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups. 14 15 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations2 3 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r It is recommended that: Adults living with disability should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults living with disability should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence It is recommended that: All adults living with disability should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults living with disability should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence Adults living with disability should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence ADULTS (aged 18 years and older) LIVING WITH DISABILITY ADULTS (aged 18 years and older) LIVING WITH DISABILITY Many of the health benefits of physical activity for adults, as set out in the section above, also relate to adults living with disability. Additional benefits of physical activity to health outcomes for those living with disability include the following: for adults with multiple sclerosis – improved physical function, and physical, mental, and social domains of health-related quality of life; for individuals with spinal cord injury – improved walking function, muscular strength, and upper extremity function; and enhanced health-related quality of life; for individuals with diseases or disorders that impair cognitive function – improved physical function and cognition (in individuals with Parkinson’s disease and those with a history of stroke); beneficial effects on cognition; and may improve quality of life (in adults with schizophrenia); and may improve physical function (in adults with intellectual disability); and improves quality of life (in adults with major clinical depression). In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and type-2 diabetes. Adults living with disability may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence As part of their weekly physical activity, older adults living with disability should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence G O O D P R A C TI C E ST A TE M EN TS • Doing some physical activity is better than doing none. • If adults living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Adults living with disability should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • There are no major risks to adults living with disability engaging in physical activity when it is appropriate to the individual’s current activity level, health status and physical function; and when the health benefits accrued outweigh the risks. • Adults living with disability may need to consult a health- care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 300 150 minutes moderate-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: vigorous- intensity aerobic physical activity For additional health benefits: 2 days a week On at least muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups. 14 15 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations2 3Executive summary 14 15 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Regular physical activity is a known protective factor for the prevention and management of noncommunicable diseases such as cardiovascular disease, type-2 diabetes, breast and colon cancer (1–3). Physical activity also has benefits for mental health (4), delays the onset of dementia (5), and can contribute to the maintenance of healthy weight (1) and general well-being (6). Physical activity is defined as any bodily movement produced by skeletal muscles that requires energy expenditure (1) and can be performed at a variety of intensities, as part of work, domestic chores, transportation or during leisure time, or when participating in exercise or sports activities. At the low end of the intensity range, sedentary behaviour is defined as any waking behaviour while in a sitting, reclining or lying posture with low energy expenditure (7). Emerging new evidence indicates that high levels of sedentary behaviour are associated with cardiovascular disease and type-2 diabetes as well as cardiovascular, cancer and all-cause mortality (8–10). Physical inactivity is defined as not meeting the 2010 Global recommendations on physical activity for health (1) and is a leading contributor to global mortality. It is estimated that between four and five million deaths per year could be averted if the global population was more active (2, 11). Global estimates of physical inactivity indicate that in 2016, 27.5% of adults (12) and 81% of adolescents (13) did not meet the 2010 WHO recommendations (1), and trend data show limited global improvement during the past decade. The data also highlight that women are less active than men in most countries and that there are significant differences in levels of physical activity within and between countries and regions. These differences can be explained by inequities in access to opportunities to be physically active, further amplifying inequalities in health. Currently, there are no global estimates of sedentary behaviour, but technological innovation and the transition towards more sedentary occupations and recreation, and the increasing use of personal motorized transportation are contributing to changing patterns of physical activity and increased sedentary behaviour across the world. The Global action plan on physical activity 2018–2030 (14) sets out 4 strategic objectives and 20 policy actions to achieve a 15% relative reduction in the global prevalence of physical inactivity in adults and adolescents by 2030. In 2010, WHO published the Global recommendations on physical activity for health (1), the first population-based public health guidelines for children and adolescents, adults and older adults. In 2018, the World Health Assembly, in resolution WHA71.6, 1 called for WHO to update the 2010 recommendations. In 2019, WHO published Guidelines on physical activity, sedentary behaviour and sleep for children under 5 years of age (15). The guidelines were called for by the Commission on Ending Childhood Obesity (recommendation 4.12) (16), and address the omission of this younger age group in the 2010 Global recommendations on physical activity for health (1). The 2020 WHO Guidelines on physical activity and sedentary behaviour, replace the 2010 guidelines and are based on the most recent advances in the evidence for the selected behaviours and associated health consequences. They will form part of the overall set of global recommendations on physical activity and sedentary behaviour. BACKGROUND 1 WHA71.6 WHO Global Action Plan on Physical Activity 2018–2030. 14 15Background OTHER KEY WHO GUIDELINES The importance of physical activity for health is recognized in other WHO guidelines. The WHO Package of essential noncommunicable disease interventions for primary health care in low-resource settings (17) provides a protocol for the clinical management of hypertension, type-2 diabetes, raised cardiovascular risk, asthma, and chronic obstructive pulmonary disease, and includes counselling to progressively increase physical activity to moderate levels (such as brisk walking) and at least 150 minutes per week, in line with the 2010 global recommendations. Recent WHO guidance in Risk reduction of cognitive decline and dementia (18) states that physical activity should be recommended to adults with normal cognition (strong recommendation) and those with mild cognitive impairment (conditional recommendation) to reduce the risk of cognitive decline. WHO Integrated care for older people: guidelines on community-level interventions to manage declines in intrinsic capacity (19) recommend multimodal exercises to prevent falls, and exercises for older adults with declining mobility. WHO recommendations on antenatal care for a positive pregnancy experience (20) recommend counselling on healthy eating and being physically active during pregnancy to stay healthy and to prevent excessive weight gain, but do not address the wider health benefits of physical activity during pregnancy and the postpartum period. The existing WHO guidelines, combined with these updated guidelines, provide an increasingly comprehensive set of global guidance on the contribution of physical activity and sedentary behaviours to the prevention and management of key diseases and to the promotion of health and well-being across the life course. RATIONALE AND PURPOSE The past 10 years has seen a significant increase in the body of evidence on the health impact of different types, amounts and durations of physical activity, as well as on the impact of sedentary behaviours and its interrelationship with levels of physical activity and health. In addition, the evidence base for physical activity in subpopulations, such as pregnant women and those living with chronic conditions and/or disability now permits the examination of the relationship between physical activity and health outcomes in these groups. In the Global action plan on physical activity 2018–2030 (14), action 4.1 calls for WHO to develop and disseminate global recommendations for physical activity and sedentary behaviours in children under 5 years of age, young people, adults, older adults and specific subpopulations, such as pregnant women, people living with chronic conditions and disability. Updating and broadening the scope of the guidelines, as requested by the World Health Assembly, ensures that population groups not included in the 2010 recommendations are provided with specific recommendations for physical activity. This aligns with the key principles and goals of the global action plan on physical activity, namely to reduce inequalities and to support all people to be more physically active every day. The overarching purpose of these guidelines is to provide evidence-based public health recommendations on how much and what type of physical activity children and adolescents, adults, older adults and subpopulations such as pregnant women and those living with chronic conditions or disability, should do for significant health benefits and mitigation of health risks. The guidelines also provide evidence- based recommendations on the associations between sedentary behaviour and health outcomes. 16 17 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r The guidelines have been developed for children and adolescents (aged 5–17 years), adults (aged 18–64 years), older adults (aged 65 years and above), and include for the first time specific recommendations on physical activity for subpopulations such as pregnant women and those living with chronic conditions or disability. Recommendations are made for each specific age group and subpopulation, to provide those working with particular communities easy access to the relevant information. Providing separate recommendations for subpopulations, especially people living with chronic conditions or with disability, highlights the importance of including these subpopulations in policy and planning of physical activity and sedentary behaviour interventions. These guidelines do not address sleep as a behaviour. Sleep is an important health-related issue and an emerging topic within population health science. However, it was deemed beyond the scope of the mandate to include sleep in the updated recommendations. Nonetheless, the importance of sleep is recognized and was included as an important health outcome when considering the impact of physical activity and sedentary behaviour. TARGET AUDIENCE This document reports the process and summarizes the evidence-base reviewed to develop the recommendations. The primary audiences are: 1. Policy-makers in ministries of health, education, youth, sport and/or social or family welfare, working in high as well as low- and middle-income countries, who formulate country-specific guidelines, and who plan health, education, workplace, residential or community-based intervention programmes across the life course. 2. Government officials who develop national, subregional or municipal plans to increase physical activity and reduce sedentary behaviours in population groups through guidance documents. 3. Persons working in nongovernmental organizations, education and workplace organizations or research. 4. Persons working in health services and those providing advice and guidance, such as community, family, primary or tertiary nurses or doctors, or allied health and exercise professionals working beyond the health sector. These guidelines can inform the content of their advice on these topics, if national guidance is not available. The recommendations on physical activity and sedentary behaviour contained within the guidelines should be used to inform pre-service training and professional development courses for health-care workers, physical activity specialists and education professionals. Derivative products are needed that convey these guidelines to specific end-users, stakeholders in sectors outside of health, and the wider community, that use tailored communications to meet the specific needs of each audience. 16 17Background These guidelines were developed in accordance with the WHO Handbook for guideline development (2nd edition) (21). A WHO Steering Group, led by the Department of Health Promotion, was established, with representation from WHO regional offices and relevant WHO departments. A Guideline Development Group (GDG) was formed, consisting of 27 experts and stakeholders, taking into account gender balance and geographical diversity. The draft guidelines were externally reviewed by seven independent reviewers, who provided feedback on the scientific evidence, its interpretation and content. In addition, an online public consultation was conducted on the draft guidelines, and feedback was received from over 400 contributors. These inputs from scientists, practitioners and the general public were collated and used by the GDG to finalize the guidelines. Full details of the management of the guideline development process are available in Annex 1. SCOPE OF GUIDELINES AND QUESTIONS OF INTEREST The GDG reviewed the scope of the guidelines and, at their first meeting, agreed on the most relevant PI/ ECO (Population, Intervention/Exposure, Comparison, Outcome) questions. The key questions addressed for each subpopulation are summarized as follows: For physical activity: a. What is the association between physical activity and health-related outcomes? b. Is there a dose-response association (volume, duration, frequency, intensity)? c. Does the association vary by type or domain of physical activity? For sedentary behaviour: a. What is the association between sedentary behaviour and health-related outcomes? b. Is there a dose-response association (total volume, frequency, duration and intensity of interruption)? c. Does the association vary by type and domain of sedentary behaviour? d. In adults only: Does physical activity modify the effect of sedentary behaviour on mortality? For each population (P), the exposure (E) was greater volume, duration, frequency or intensity of physical activity; for, as comparison (C) no physical activity or lesser volume, frequency, intensity or duration of physical activity. The critical and important outcomes for each population are summarized in Table 1 and the details of each PI/ECO question in the relevant section of the Web Annex: Evidence profiles . METHODS Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 18 19 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Table 1: Summary of critical and important* health outcomes addressed by population groups Outcomes (in alphabetical order) Children and adolescents aged 5–17 years: PA and sedentary Adults aged 18–64 years: PA Adults aged over 18 years: sedentary Adults aged over 65 years: PA a Pregnancy and postpartum Chronic conditions b Children and adults with disability c Adiposity (weight gain, weight change, weight control, weight stability, weight status and weight maintenance) Critical Critical Critical Critical a Critical Critical – HIV – Adverse events Critical Critical – Critical a Critical (fetal outcomes) – – All-cause and cause-specific mortality – Critical (cancer and CVD specific) Critical Critical a – Critical – Bone health Critical – Important – – – – Cardiometabolic health Critical – – – – – – Cognitive outcomes Critical Critical Important Critical a – – Critical – MS, PD, Stk, Sch, ADHD Delivery complications – – – – Important – – Disease progression – – – – – Critical – HT, T2D, HIV, Critical – cancer recurrence – Falls and fall-related injuries – – – Critical – – – Fetal outcomes (birthweight, preterm birth) – – – – Critical – – Functional ability – – – Critical – – – Gestational diabetes mellitus – – – – Critical – – Gestational hypertension/ preeclampsia – – – – Critical – – Health-related quality of life – Important Important Important a – Critical – HT, T2D, HIV Critical – MS, SCI, ID, MCD, Sch Incidence of cancer – Critical Critical Critical a – – – Incidence of CVD – Critical Critical Critical a – – – Incidence of hypertension – Important Important a – – – Incidence of type-2 diabetes – Critical Critical Critical a – – – Mental health (symptoms of anxiety and depression) Critical Critical Important Critical a Critical – – Osteoporosis – – – Critical – – – Physical fitness Critical – Important – – – – Physical function – – Important – – Critical – HT, T2D, HIV Critical – MS, SCI, ID, PD, Stk Pro-social behaviour Important – – – – – – Psychosocial outcomes – – – Important – – – Risk of co-morbid conditions – – – – – Critical – HT, T2D, HIV Critical – MS, SCI, ID Sleep Important Important Important Important a – – – * Critical outcome: an outcome that is critical to decision-making; Important outcome: an outcome that is important, but not critical to decision-making. a The critical and important outcomes considered for the adult population, including older adults. b Outcomes are for subpopulation condition as listed: Cancer – cancer survivors; HT – hypertension; T2D – type-2 diabetes; HIV. c Outcomes are for subpopulation condition as listed: MS – muscular sclerosis; SCI – spinal cord injury; ID – intellectual disability; PD – Parkinson’s disease; Stk – in stroke survivors; Sch – schizophrenia; ADHD – attention deficit/hyperactivity disorder. Critical and important outcomes for the age-specific population were considered and extrapolated. 18 19Methods THE EVIDENCE The revision of the 2010 WHO recommendations on physical activity was conducted by identifying, and then updating, the most recent, relevant umbrella reviews related to the scope of these guidelines. This approach was adopted due to an extensive body of recent systematic reviews which were conducted to inform the development of several national physical activity guidelines. The additional updating was undertaken to ensure the new WHO guidelines reflect the most recent available data in a rapidly developing field of public health. Umbrella reviews were selected if they met the following three criteria: i) the evidence reviews had been conducted according to standard systematic processes that were well documented; ii) the assessment of the certainty of the evidence used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method or an equivalent methodology that was clearly described and documented; and iii) the evidence reviews addressed the populations of interest with no restrictions to country or country income level. The PI/ECO questions and the critical and important health outcomes were mapped against existing evidence reviews and, where needed, additional new reviews were commissioned to address gaps. The GDG requested that the evidence reviews be updated, using the same search terms, search languages, and databases as the original reviews. The following evidence reviews were identified as meeting the above three criteria and were chosen for recency and comprehensiveness: • A systematic review of the literature conducted by Poitras et al. (2016) on the association between physical activity and health indicators in school-aged children and youth (22) as part of the process for developing the Canadian 24-hour movement guidelines for children and youth (23). This review focused solely on studies that used objective measurements of physical activity. A total of 162 studies were included, representing 204 171 participants from 31 countries. • A systematic review of the literature of the association between sedentary behaviour and health indicators in school-aged children conducted by Carson et al. (2016) (24), as part of the process for developing the Canadian 24-hour movement guidelines for children and youth (23). A total of 235 studies (194 unique samples) were included representing 1 657 064 unique participants from 71 countries. • A systematic review conducted by Okely et al. (2019) (25) undertaken to update Poitras et al. (2016) (22) and Carson et al. (2018) (24) as part of the development of the 2019 Australian 24-hour movement guidelines for children and young people (aged 5–17 years) (26). This report identified an additional 42 studies on physical activity, and 32 on sedentary behaviour, published through to July 2918 (25). The GRADE tables developed by Okely et al. were used as the basis for the commissioned update conducted for WHO. The GRADE tables along with the evidence profiles are presented in the Web Annex: Evidence profiles . • The 12 systematic reviews conducted and synthesized as part of the development of the 2019 Canadian guideline for physical activity throughout pregnancy (27). These 12 reviews assessed over 25 000 related studies in English, Spanish and French language on maternal physical activity during pregnancy that reported on maternal, fetal, or neonatal morbidity, or fetal mortality outcomes. Seven of these systematic reviews addressed outcomes deemed critical and important by the GDG (28–34) The GRADE tables from these evidence reviews were used as the basis for the literature search conducted to update and inform the development of WHO recommendations. The updated evidence profiles are presented in the Web Annex: Evidence profiles . • The scientific report of the Physical Activity Guidelines Advisory Group (PAGAC) (35) which provides a systematic update of evidence on physical activity and sedentary behaviours and health outcomes published 2008–2016 as part of the development of the 2018 Physical activity guidelines for Americans, 2nd Edition (36). The evidence summarized addressed a total of 38 main research questions and 104 subquestions selected for their public health relevance. The evidence comprised results from systematic reviews which consisted of a total of 1130 articles, each abstracted to answer the 38 research questions (35). The protocols used a modified version of “A Measurement Tool to Assess Systematic Reviews” (AMSTARExBP) to assess the methodological quality of systematic reviews and meta-analyses. Risk of bias, or internal validity, was assessed for each original study using an adapted version of the USDA NEL Bias Assessment Tool (BAT) (37). The new evidence identified in the updated searches conducted for these WHO guidelines is presented in the evidence profiles in the Web Annex: Evidence profiles ; links are provided to the report and supplementary materials of PAGAC (35). Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 20 21 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Methods for updating the evidence and data extraction A search for systematic reviews and pooled analyses of cohort studies was conducted for studies published from the date of the last searches carried out for each of the included reviews (listed above) to September 2019; standardized data extraction protocols were developed and employed. To update the searches conducted by Poitras et al. (2016) (22), Carson et al. (2016) (24), and Okely et al. (2019) (25), the databases MEDLINE, EMBASE, PsycINFO, and SportDiscus were searched to identify reviews that were peer-reviewed, written in English or French. To update the searches conducted by PAGAC (35), PubMed, CINAHL and Cochrane databases were searched to identify reviews that were peer-reviewed, written in English. A de novo search for important outcomes, where these were not included by PAGAC (35), was not conducted due to resource constraints. Searches were performed with no restriction by country or country income status, and inclusive of reviews addressing any subjectively or objectively measured physical activity or sedentary behaviour. It was decided not to conduct searches in languages other than those of the original searches, due to resource constraints and previous experience in the field indicating that such searches yielded very few, if any, additional reviews. Reviews were considered that examined an association between physical activity or sedentary behaviour and health-related outcomes (based on levels above or below a threshold of physical activity or sedentary behaviour), and that explored the dose-response relationship between these and health-related outcomes. An external team of reviewers used the AMSTAR 2 (Assessment of Multiple Systematic Reviews) instrument to rate the credibility of the systematic reviews under consideration for inclusion (38). The AMSTAR 2 tool contains 16 items that relate to the planning and conduct of the review. The overall confidence in the results of each review was rated according to published guidance: a rating of “high” reflects that the review had zero or one noncritical weakness; “moderate” indicates the review was judged to have more than one noncritical weakness; “low” means the review was judged to have one critical flaw with or without noncritical weaknesses, or multiple noncritical weaknesses; and “critically low” signifies that more than one critical flaw was present. One reviewer completed the AMSTAR 2 tool for all provisionally included reviews. Reviews that were rated critically low by one reviewer were reviewed by a second reviewer using the same tool. Reviews ultimately rated as critically low were excluded because they were judged to be too unreliable to provide an accurate and comprehensive summary of the available evidence, unless it was the only review available for a particular outcome. This body of evidence also included pooled cohort studies. An external team of reviewers used the Newcastle- Ottawa Scale to assess the quality of the studies (39). Each study was given a quality rating of “good”, “fair”, or “poor”. In general, a good-quality study met all criteria on the Newcastle-Ottawa scale. A fair-quality study did not meet, or it was unclear whether it met, at least one criterion, but also had no known important limitations that could invalidate its results. A poor-quality study had a single fatal flaw, or multiple important limitations. Poor-quality studies were excluded. There was an assessment for overlap, recognizing potential for duplication of studies in multiple reviews. Reviews containing redundant bodies of evidence, overviews of reviews, and some pooled cohort studies were excluded, where other more comprehensive and/or recent reviews were identified. Methods for new reviews Where gaps in existing evidence were identified, new umbrella reviews were commissioned to examine: 1. the relationship between occupational (i.e. work- related) physical activity and health-related outcomes (40); and 2. the association between leisure-domain physical activity and adverse health outcomes (41). (For numbers 1 and 2 above, searches were undertaken using PubMed, SportDiscus and EMBASE for reviews published from 2009 to December 2019.) 3. the association between physical activity and falls prevention; the 2019 Cochrane Collaboration Systematic Review by Sherrington et al. (42) was used, and updated with evidence published from the end search date of their original review, through to November 2019. 4. the association between physical activity and osteoporosis and sarcopenia. The search for existing systematic reviews on osteoporosis and sarcopenia, conducted in PubMed for reviews published from 2008 up to November 2019, identified no new reviews and eight new primary studies. 5. the evidence on associations between physical activity and health outcomes in people living with HIV. A scoping review ascertained the availability of 20 21Methods evidence on physical activity and health-related outcomes among people living with HIV to support conducting an umbrella review which was conducted for evidence published up to October 2019 with no start date limitation using PubMed, CINAHL and Web of Science. Summary of characteristics of the evidence and assessment methods of physical activity and sedentary behaviour Until recently, the primary methods for measuring physical activity and sedentary behaviours in adults has been by self-report (i.e. survey) and, for children, either self-report or parental recall. Although these methods have well-established strengths, limitations include being prone to reporting bias and measurement error (43). In recent years, with digital technology rapidly growing in this area, there has been an increase in the use of device-based measures for assessing physical activity and sedentary time and their associations with health outcomes. However, challenges remain in comparing results between studies due to differences between the technical features and placement of different devices (accelerometers), and differences in the analyses and reporting of the data. For example, when measuring sedentary time with device-based measures, miscalculation may occur as many of the devices do not currently distinguish between positions (e.g. lying, sitting and standing still). Difficulties also exist when comparing findings from studies using device- based measures with those reporting results from self-report measures. Self-report instruments vary in content, in the examples of physical activity, response options and domains covered. Until recently, studies focused primarily on assessing either total physical activity, or physical activity in the leisure/recreation domain only, but now increasingly include other domains such as physical activity for transport (e.g. walking and cycling), at work, and in the household. The majority of evidence reports on associations between aerobic physical activity and health outcomes, however studies are now assessing the benefits of muscle- strengthening exercise, as well as combinations of different types of activity and other domains. Results on the association between physical activity levels and health outcomes are reported and compared in different ways. Many studies report comparisons between quartiles or quintiles of physical activity, other studies compare those “meeting” versus “not meeting” national guidelines. Calculation of total physical activity, when reported, is usually estimated in MET-hours per week and some studies compare “highest” versus “lowest”, although categories also vary across studies. The literature frequently reports results from analyses that apply data cut points based on an existing guideline, or the current WHO Global recommendation, or metrics from previous research (for example the cut points of 60 minutes per day in research on youth populations, or the frequency of 2–3 times per week for strength training intervention). When such cut points become commonplace the building of evidence on the associations of higher or lower levels of physical activity exposure on health outcomes can be limited. Most of the evidence assessing the associations between sedentary behaviours and health outcomes for children and adolescents is cross-sectional in nature, and a majority of studies rely on self- or parent-reported measures of sedentary time that are subject to measurement errors and recall biases. Evidence from longitudinal observational studies and intervention trials was prioritized, and reviews that solely or primarily synthesized cross-sectional evidence were not considered. Greater emphasis was given to evidence provided by reviews graded moderate certainty and above, and to those providing evidence from studies using device-based measures of exposure. Grading the body of evidence The Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was used to rate the certainty of the evidence for each PI/ECO (44), based on the underlying evidence in the reviews. When available, the GRADE “Evidence Profiles” or “Summary of Findings” tables from each review, were used as a starting point. If no table was available within the existing systematic reviews, “Evidence Profile” tables for each population and outcome of interest were constructed. The GRADE method was used to rate the certainty of the evidence for each PI/ECO (44) with the following criteria considered: study design; risk of bias; consistency of effect; indirectness; precision of effect; and other limitations, including publication bias and factors for upgrading observational evidence (magnitude of effect, dose-response, and effects of confounders). Observational evidence from well- conducted longitudinal studies was also upgraded to reflect more appropriately the increased certainty in findings regarding associations between physical 22 23 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r activity or sedentary behaviour and outcomes from such studies. Studies that evaluated intermediate/ indirect outcomes were not necessarily downgraded, as the outcomes (including intermediate outcomes) were prioritized by the GDG; the GRADE rating reflects the certainty in effects on those outcomes. In some cases, the GRADE ratings from existing reviews were modified to ensure consistency in application of GRADE methods. The certainty in the body of evidence for each outcome was assigned based on the following guidance (45): High Very confident that the true effect lies close to that of the estimate of the effect. Moderate Moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low Confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect. Very low Very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of  effect. Going from evidence to recommendations The GDG employed the GRADE Evidence to Decisions (EtD) framework for generating question-specific recommendations. The EtD framework is a systematic, structured and transparent approach to decision- making. The framework uses explicit criteria for generating guideline recommendations considering research evidence, certainty of evidence and, where required, expert opinion and topical knowledge from the perspective of the target audience. The criteria elicit judgments about the balance between the observed evidence of desirable and undesirable outcomes, overall certainty of evidence, relative values of patients for desirable and undesirable outcomes, resource use (cost considerations) where applicable, potential impact on inequities in health, acceptability and feasibility of recommendations. The GDG considered the body of evidence in totality for each recommendation for all critical outcomes, and all available important outcomes. For a particular exposure/intervention and outcome link, studies differed widely in the specific exposure/intervention assessed, outcomes assessed, study design, and analytic methods, resulting in heterogeneity in the available evidence. Therefore, it was not possible to apply the classic GRADE approach to each specific exposure/intervention and outcome link; rather, GRADE was applied for the overall body of evidence addressing each exposure/intervention and outcome link, across study design types and variations in exposure/intervention measurements and analyses. When these factors resulted in concerns regarding the coherence of the evidence (i.e. that the evidence for a particular exposure/intervention and outcome link did not correspond when looked at in different ways), the panel downgraded the certainty of evidence (21). The GDG prioritized the following health outcomes to consider the effects of physical activity and sedentary behaviour: reduced all-cause and cause- specific mortality (cardiovascular disease and cancer); reduced incidence of cardiovascular disease; cancer (site-specific); type-2 diabetes; improved physical fitness (e.g. cardiorespiratory, motor development, muscular fitness); improved cardiometabolic health (e.g. blood pressure, dyslipidaemia, glucose, insulin resistance); bone health; mental health (e.g. reduction in depressive symptoms, self-esteem, anxiety symptoms, ADHD); and improved cognitive outcomes (e.g. academic performance, executive function); and reduced adiposity. Adverse effects (e.g. injuries and harms) were also considered. Additional considerations For each population and all PI/ECO questions, the GDG also considered values and preferences of those affected by the guidelines; the resource implications of the recommendations; the impact on health equity; and the acceptability and feasibility of the recommendations. As there was considerable duplication in these considerations, and in the GDG’s assessment, for each population group, a summary of the discussions regarding assessments for these elements are described in the “Evidence to recommendations” section. 22 23Methods The public health recommendations presented in the WHO Guidelines on physical activity and sedentary behaviour are for all populations and age groups ranging from 5 years to 65 years and older, irrespective of gender, cultural background or socioeconomic status, and are relevant for people of all abilities. The new guidelines are presented by age group and behaviour (physical activity and sedentary). For each set of recommendations, an introductory statement summarizes the health outcomes associated with physical activity and sedentary behaviour respectively; the recommendations then follow. A set of good practice statements is provided to further clarify how the recommendation can be met safely by the target population. These good practice statements are not “graded recommendations” per se, but are derived from scientific evidence and from practical considerations reviewed and recommended by the GDG. For each set of recommendations, a summary of the supporting scientific evidence is provided, structured by the three PI/ECO questions; presenting first the evidence on the associations with the critical health outcomes, followed by a summary of evidence on dose response. Finally, a summary of evidence on the relationships between different types or domains of exposure and health outcomes is presented, where this exists. RECOMMENDATIONS G O O D P R A C TI C E ST A TE M EN TS 24 25 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Supporting evidence and rationale For these guidelines for children and adolescents, systematic reviews (22, 25, 35) were used and updated with 16 new reviews identified that met inclusion criteria. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . • Doing some physical activity is better than doing none. • If children and adolescents are not meeting the recommendations, doing some physical activity will benefit their health. • Children and adolescents should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • It is important to provide all children and adolescents with safe and equitable opportunities, and encouragement, to participate in physical activities that are enjoyable, offer variety, and are appropriate for their age and ability. G O O D P R A C TI C E ST A TE M EN TS In children and adolescents, physical activity confers benefits for the following health outcomes: improved physical fitness (cardiorespiratory and muscular fitness), cardiometabolic health (blood pressure, dyslipidaemia, glucose, and insulin resistance), bone health, cognitive outcomes (academic performance, executive function), mental health (reduced symptoms of depression); and reduced adiposity. It is recommended that: Children and adolescents should do at least an average of 60 minutes per day of moderate- to vigorous-intensity, mostly aerobic, physical activity, across the week. Strong recommendation, moderate certainty evidence Vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone, should be incorporated at least 3 days a week. Strong recommendation, moderate certainty evidence CHILDREN AND ADOLESCENTS (aged 5–17 years) Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf For children and adolescents, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), physical education, transportation (wheeling, walking and cycling) or household chores, in the context of educational, home, and community settings. PHYSICAL ACTIVITY RECOMMENDATION 24 25Recommendations In children and adolescents (aged 5–17 years), what is the association between physical activity and health-related outcomes? A large body of evidence previously established that greater amounts and higher intensities of physical activity in children and adolescents are associated with multiple beneficial health outcomes (1). Recent evidence reaffirms that increased physical activity improves cardiorespiratory fitness and musculoskeletal fitness in children and adolescents (22, 35). For example, positive impacts are obtained when participating in moderate- to vigorous-intensity physical activity for 3 or more days per week, for 30 to 60 minutes (22, 35). Regular physical activity, largely aerobic, in children and adolescents is positively associated with beneficial cardiometabolic health outcomes, including improved blood pressure, lipid profile, glucose control and insulin resistance (35). Recent reviews examined the effectiveness of school-based physical activity programmes (46), high-intensity interval training (47) and resistance training (48), versus no intervention on measures of cardiometabolic health. Within all 3 reviews, there was consistent evidence that interventions were associated with better cardiometabolic outcome measures, although there was varied precision in effect sizes and few individual trials found statistically significant benefits of physical activity across all cardiometabolic outcomes. One review of 19 RCTs (n= 11 988) (46) reported that school-based physical activity programmes were associated with statistically significant improvements in diastolic blood pressure (ES= 0.21 [95% CI: 0.42 to 0.01]; p= 0.04) and fasting insulin (ES= 0.12 [95% CI: 0.42 to 0.04]; p= 0.03) compared with no physical activity interventions. Physical activity has been reported to be favourably associated with adiposity, and higher levels of activity may be associated with healthy weight status in children and adolescents (22, 35). The results are generally strongest in cross-sectional studies, while the results are more mixed from prospective observational studies, which limits understanding of the directionality of the reported associations. More recent reviews of physical activity interventions trials (laboratory-based high- intensity interval training [HIIT], classroom-based active learning, resistance training) reported inconsistent results with the majority of the studies included in the reviews not reporting an effect (47, 49, 50). However, a review of longitudinal and cross-sectional studies reported a negative relationship between pedometer- measured physical activity and measures of adiposity, BMI or waist circumference (51). Overall there is low certainty evidence that physical activity is associated with the management of a healthy weight status and more research is needed to determine directionality and strength of association. There is less evidence examining the association between physical activity and motor skill development in children and adolescents, with current reviews demonstrating null findings (22). More research is needed with motor development as an outcome to inform future guidelines. For children and adolescents, bone-loading activities can be performed as part of playing games, running, turning, or jumping. Physical activity is positively associated with bone mass accrual and/or bone structure, and recent evidence supports that children and adolescents who are more physically active than their peers have greater bone mass, higher bone mineral content or density, and greater bone strength (35). Maximizing bone health in childhood and adolescence can help protect from osteoporosis and related fractures later in life. Developing and maintaining cognitive function is essential across the entire lifespan. In children and adolescents, physical activity has positive effects on cognitive function and academic outcomes (e.g. school performance, memory and executive function) (22, 35). One recent review (19 RCTs; n= 5038) demonstrated that exercise interventions with multiple sessions per week, for 6 weeks or longer, were associated with greater change in measures of cognitive function such as inhibitory control (SMD 0.26 [95% CI: 0.08 to 0.45], p= < 0.01); working memory (SMD 0.10 [95% CI: -0.05 to 0.25], p= < 0.02), and cognitive flexibility (SMD 0.14 [95% CI: -0.03 to 0.31], p= < 0.04) compared with no exercise interventions (52). Physical activity also reduces the risk of experiencing depression and depressive symptoms in children and adolescents with and without major depression (35), and may be comparable to psychological and pharmaceutical therapies in reducing symptoms. Although all physical activity comes with some risk of adverse event (53) there is limited evidence reporting harms associated with physical activity levels recommended for health benefit (35). Based on available evidence and expert opinion, the potential risks associated with the amounts and types of physical activity recommended for children and adolescents CHILDREN AND ADOLESCENTS (AGED 5–17 YEARS) 26 27 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r were considered to be low (35) and can be reduced by a progressive increase in the activity level and intensity, especially in children and adolescents who are inactive. It is known that participation in some sports increases the risk of injury, as does increasing exercise intensity (53). More research is needed to strengthen the knowledge base in this area. The GDG concluded that: • There is moderate certainty evidence that greater amounts of moderate- and vigorous-intensity physical activity are associated with improved cardiorespiratory fitness and muscular fitness, cardiometabolic health and bone health in children and adolescents. • There is moderate certainty evidence that both short- and long-term moderate- to vigorous-intensity physical activity have positive effects on cognitive function, academic outcomes and mental health. • There is low certainty evidence that physical activity is favourably associated with the management of healthy weight status in children and adolescents. • There is low-certainty evidence that the risks for the amounts and types of physical activity recommended for children and adolescents are low and are outweighed by the benefits. Is there a dose-response association (volume, duration, frequency, intensity)? Although there is a substantial body of evidence demonstrating a positive association between physical activity and health outcomes in children and adolescents, very few studies have addressed the issue of dose-response. Therefore, the exact shape of the dose-response curve and/or the presence of threshold values (that differentiate lower versus higher risk) for physical activity and specific health outcomes is less well understood in children and adolescents compared with adult populations. Nonetheless, a substantial body of evidence shows that many of the health benefits occur with 60 minutes of physical activity daily (22, 35), and given no contradictory evidence, it was concluded that the updated evidence reaffirms the current WHO recommendation for 60 minutes of moderate- to vigorous-intensity physical activity per day (1). However, the review of all evidence, including recent results from studies using device-based measures of physical activity, did not support retaining the specification of a “minimum” daily threshold of 60 minutes of moderate- to vigorous-intensity physical activity for health benefits, given that studies broadly used “an average” threshold of 60 minutes per day, not a minimum daily threshold of 60 minutes, to assess the benefits of physical activity on health outcomes. The review concluded that the new guideline should be amended to more closely reflect this evidence. The benefits of regular vigorous-intensity activity on cardiometabolic health outcomes has been previously established (1) and recent reviews provided further supporting evidence (35). For example, a recent review (54) showed that high-intensity interval training, compared with moderate-intensity continuous training, had a moderate beneficial effect on cardiorespiratory fitness (SMD= 0.51 [95% CI: 0.33 to 0.69], p= < 0.01; I 2= 0%). There was no evidence that intervention duration, exercise modality, exercise and rest ratio, and total bouts modified the effect on cardiorespiratory fitness. These results were consistent overall with other recent reviews (22, 35, 47) and provide support to retaining the recommendation that youth and adolescents should do regular vigorous-intensity activity to improve cardiorespiratory fitness. The GDG concluded that: • Evidence affirms the previous WHO recommendation for 60 minutes of moderate- to vigorous-intensity physical activity per day. • Evidence supports amending the previous specification of a minimum daily threshold of 60 minutes of physical activity to an average of 60 minutes per day per week, which more closely reflects the evidence. • There is moderate certainty evidence that greater amounts of vigorous-intensity physical activity are associated with improved cardiorespiratory fitness. Does the association vary by type or domain of physical activity? For children and adolescents, physical activity includes play, games, sports, transportation, recreation, physical education or planned exercise, in the context of family, school, and community activities. However, few studies have directly compared different types or domains of physical activity in children and adolescents and thus there is insufficient evidence to determine if the association between physical activity and health outcomes varies by type of activity (e.g. aerobic versus muscle-strengthening exercise) or domain of physical activity (e.g. active transport (walking and cycling) versus physical education, versus sports/recreation). CHILDREN AND ADOLESCENTS (AGED 5–17 YEARS) 26 27Recommendations There is evidence showing that both increased levels of aerobic moderate- to vigorous-intensity physical activity are associated with increased cardiorespiratory fitness, and that increased muscle-strengthening activity increases muscular fitness in children and adolescents. This evidence informed the 2010 WHO Global recommendations on physical activity for health (1) which recommended incorporating activities that strengthen muscles and bones at least 3 days per week. Updated evidence reaffirmed that regular muscle- strengthening activity 3 times per week was effective for improving indicators of muscular fitness; however, there is insufficient evidence to state specific details of session duration and intensity, largely due to the heterogeneity of exposures assessed in the literature (22, 35). There is less evidence for a protective effect of resistance training on cardiometabolic health. Given the absence of new evidence on characteristics other than the frequency of muscle strengthening activities for children and adolescents, such as duration, it was not possible to specify any further details. Future research should address the health benefits of specific types and domains of physical activity in order to provide more specificity to this component of the guidelines. The GDG concluded that: • There is moderate certainty evidence that muscle- strengthening activities should be incorporated at least 3 days a week. CHILDREN AND ADOLESCENTS (AGED 5–17 YEARS) 28 29 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Supporting evidence and rationale Sedentary behaviour was not included in the WHO 2010 recommendations, yet during the past decade, there has been a growing body of research examining the health outcomes associated with different measures and types of sedentary behaviours. Technology and digital communications have influenced how people work, study, travel and spend leisure-time. In most countries, children and adolescents are spending greater time engaged in sedentary behaviours, particularly for recreation, such as screen-based entertainment (television and computers) and digital communications, such as mobile phones. For these guidelines for children and adolescents, systematic reviews (24, 25) were used and updated with seven new reviews identified that met inclusion criteria. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . In children and adolescents, higher amounts of sedentary behaviour are associated with the following poor health outcomes: increased adiposity; poorer cardiometabolic health, fitness, behavioural conduct/pro-social behaviour; and reduced sleep duration. It is recommended that: Children and adolescents should limit the amount of time spent being sedentary, particularly the amount of recreational screen time. Strong recommendation, low certainty evidence Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Sedentary behaviour is defined as time spent sitting or lying with low energy expenditure, while awake, in the context of educational, home, and community settings and transportation. CHILDREN AND ADOLESCENTS (aged 5–17 years) SEDENTARY BEHAVIOUR RECOMMENDATION 28 29Recommendations In children and adolescents (aged 5–17 years), what is the association between sedentary behaviour and health-related outcomes? Evidence indicates that greater time spent in sedentary behaviour, especially recreational screen time, is related to poorer health outcomes (24, 35). For example, higher duration of screen time (including television viewing) is associated with poorer fitness and cardiometabolic health (24, 25) in children and adolescents. Evidence from device-based assessment of association with sedentary behaviour and interventions studies showed modest effects, although stronger effects for those already living with obesity (55). There is limited evidence suggesting that sedentary behaviour is not related to bone health in children and adolescents. Despite more mixed results, evidence also suggests that sedentary behaviour may be associated with unfavourable measures of adiposity (24, 25). One review of largely cross-sectional studies, reported that sedentary behaviour (measured as total screen time) of more than 2 hours per day was positively associated with childhood overweight/obesity compared with lower levels (< 2 hours/day) (56). However, another review of 20 cross-sectional studies (57) found no statistically significant association between sedentary video gaming and body mass index among children or adolescents. A large review of 29 systematic reviews concluded that many studies report unfavourable associations between sedentary behaviour and markers of adiposity in young people when the behaviour is self-reported as some form of screen time (55). However, the review noted that the magnitude of such associations was small and, for studies using device-based assessment of sedentary time, largely zero (55). Intervention studies showed modest effects, although stronger effects for those already living with obesity (55). Further research is needed to inform the association between sedentary behaviours and measures of adiposity. Although still an emerging area of research, some evidence shows that there may be a negative association between sedentary behaviour and well-being and quality of life, as well as an unfavourable relationship between depression and leisure screen time in children and adolescents (58, 59). For example, higher durations of sedentary behaviour, assessed as screen time, and some aspects of computer use, can be associated with poorer mental health (24). In another recent review, an association between sedentary behaviour and anxiety symptoms was found in 5 of 8 studies, although results were inconsistent across different measures of sedentary behaviour within studies (60). Other evidence demonstrates that higher durations of television viewing and video game use were significantly associated with unfavourable measures of behavioural conduct/pro-social behaviour (24); and more screen time and television viewing is associated with shorter sleep duration, although there was no association between computer use/gaming and sleep duration (61). Investigations into the relationship between sedentary behaviours and mental health is a rapidly developing field with many unknowns, and reverse causality is likely to be in evidence. Further research is needed to inform on the direction and strength of this association. The GDG concluded that: • There is low certainty evidence that higher duration of sedentary behaviour (screen time) is significantly associated with lower physical fitness and cardiometabolic health in children and adolescents. • There is very low to moderate certainty evidence that higher durations of sedentary behaviour (screen time, television viewing and video game use) are significantly associated with unfavourable measures of mental health and behavioural conduct/pro-social behaviour in children and adolescents. • There is low certainty evidence that greater time spent in sedentary behaviour (screen time and television viewing) is associated with detrimental effects on sleep duration in children and adolescents. • The benefits of limiting the amount of sedentary behaviour for children and adolescents outweigh the harms. Is there a dose-response association (total volume, duration, frequency, intensity of interruption)? There is insufficient evidence available to determine whether a dose-response relationship exists between sedentary time (including recreational screen time) and health outcomes in children and adolescents. Most of the evidence assessing the associations between sedentary behaviours and health outcomes in children and adolescents is cross-sectional in nature, with low certainty evidence according to GRADE, and a majority of studies relied on self- or parent-reported measures of sedentary time that are subject to measurement errors and recall biases. There is, however, evidence that less time spent in sedentary behaviours appears to be CHILDREN AND ADOLESCENTS (AGED 5–17 YEARS) 30 31 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r better for health outcomes, and the association between sedentary behaviour and adverse health outcomes is generally stronger for sedentary behaviour when assessed as television viewing or recreational screen time as the exposure variable, than for total sedentary time. However, overall the evidence was considered insufficient to support specifying time limits. Evidence that sedentary behaviours are linked to adverse health outcomes could be the result of either direct effects of the sedentary behaviours, displacement of time spent in more physically active behaviours, or both. Although there are studies that have reported associations between screen time and adverse health outcomes in children and adolescents, total sedentary time (as assessed in studies using device-based measurements of sedentary behaviour) has consistently not been associated with health outcomes when time in moderate- to vigorous-intensity physical activity is taken into account (62). Conversely, the evidence linking moderate- to vigorous-intensity physical activity to positive health outcomes is strong and well documented across diverse settings; replacing some sedentary behaviour with physical activity (especially moderate- to vigorous-intensity physical activity) may improve health outcomes. Research investigating the associations and interplay between sedentary behaviour, physical activity and health outcomes is rapidly growing, and evidence from device-based measures of sedentary behaviour and cardiometabolic health show the association is attenuated when moderate- to vigorous-intensity physical activity is taken into account (i.e. statistically adjusted for) (62–64). There is therefore a need for further prospective studies using device-based measures of exposure, to advance knowledge of these associations and inform future recommendations. The GDG concluded that: • There is low certainty evidence that greater time spent in sedentary behaviour is related to poorer health outcomes. • There is insufficient evidence to specify time limits on sedentary behaviour. • Replacing sedentary time with moderate- to vigorous- intensity physical activity may provide health benefits. Does the association vary by type or domain of sedentary behaviour? The study of health effects of sedentary behaviour is a relatively new field of research. As such the findings are from studies using different instruments and measures of exposure. Exposure assessed as “total time spent doing sedentary behaviours” is frequently used, as is sedentary time spent using “screens” or “television viewing”. Available evidence suggests that the association between sedentary behaviour and adverse health outcomes is generally stronger for television viewing or recreational screen time than for total sedentary time (24, 35). The increased use of device-based assessment of sedentary behaviour in the more recent research is advancing knowledge, and when combined with standardized reporting will help inform future guidelines. It is acknowledged that not all sedentary behaviour is harmful. Evidence suggests certain types of sedentary behaviour, such as reading and doing homework outside of school, are associated with higher academic achievement, indicating that there are differences in outcome depending on the activity (24, 25). Sedentary behaviour may include time spent engaged in educational pursuits/study or quiet play, or social interaction without electronic media. These pursuits (e.g. reading, doing puzzles, drawing, crafting, singing, music) are important for child development and have cognitive as well as other benefits. The GDG acknowledged that: • Some sedentary activities confer benefits for cognitive function and social interaction in children and adolescents. • Evidence on the adverse health effects of sedentary behaviour is generally stronger for television viewing or recreational screen time than for total sedentary time. CHILDREN AND ADOLESCENTS (AGED 5–17 YEARS) 30 31Recommendations ADULTS (aged 18–64 years) In adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site- specific cancers, 1 incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression); cognitive health, and sleep; measures of adiposity may also improve. It is recommended that: All adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence Adults should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence Adults may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence For adults, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), transportation (wheeling, walking and cycling), work or household chores, in the context of daily occupational, educational, home and community settings. PHYSICAL ACTIVITY RECOMMENDATION • Doing some physical activity is better than doing none. • If adults are not meeting these recommendations, doing some physical activity will benefit their health. • Adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. G O O D P R A C TI C E ST A TE M EN TS 1 Site-specific cancers of: bladder, breast, colon, endometrial, oesophageal adenocarcinoma, gastric, and renal. 32 33 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ADULTS (aged 18–64 years) Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Supporting evidence and rationale For these guidelines, the synthesis of evidence undertaken by the United States Physical Activity Guidelines Advisory Committee (PAGAC) (35) was used and updated. The GDG considered the entire body of evidence, including both the findings reported by PAGAC and the 28 reviews and 3 pooled cohort studies, published from 2017 through to November 2019, that met inclusion criteria, and contributed evidence on the association between physical activity and health-related outcomes in adults. In addition, two umbrella reviews were commissioned to address evidence gaps and examine i) the relationship between occupational (i.e. work-related) physical activity and health-related outcomes (40); and ii) the association between leisure-domain physical activity and adverse health outcomes (41). The umbrella reviews identified 36 and 15 systematic reviews respectively. Evidence from longitudinal observational studies and intervention trials was prioritized, and reviews that solely, or primarily, synthesized cross-sectional evidence were not considered. Greater emphasis was given to evidence provided by reviews graded moderate certainty and above, and to those providing evidence from studies using device-based measures of exposure. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . In adults (aged 18–64 years), what is the association between physical activity and health-related outcomes? The association between physical activity and all-cause mortality and cardiovascular disease mortality in adults is already well-established (1). Findings from recent reviews reaffirmed that compared with the lowest levels of physical activity, higher levels of physical activity were associated with a lower risk of mortality. New evidence from studies using device-based measures of physical activity reaffirmed and extended the evidence showing that compared with the lowest levels of physical activity, any level and all intensities (including light intensity) of physical activity, were associated with a lower risk of mortality (65). For example, compared with the least active (referent, 1.00), adjusted HR for quartiles of total physical activity improved across quartiles of physical activity: 2nd quartile (0.48 [95% CI: 0.43 to 0.54]); 3rd quartile (0.34 [95% CI: 0.26 to 0.45]); and 4th quartile (0.27 [95% CI: 0.23 to 0.32]) (65). New evidence also reaffirmed the well-established (1) inverse relationship between physical activity and cardiovascular disease mortality (66). The benefits of physical activity for reducing cardiovascular disease and hypertension incidence is well-documented (1). Physical activity promotes many physiological responses that cause beneficial short- and long-term autonomic and haemodynamic adaptations, resulting in lowered risk of hypertension, which is a key risk factor for cardiovascular disease. Evidence reaffirmed an inverse relationship between physical activity and incident hypertension among adults with normal blood pressure, and that physical activity reduces blood pressure among adults with prehypertension and normal blood pressure (35). The inverse association between physical activity and developing type-2 diabetes in adults is well-established (1). Recent evidence reaffirmed an inverse curvilinear relationship between higher volumes of physical activity and incidence of type-2 diabetes (35), with a decreasing slope at higher levels of physical activity. A new review found that this effect is consistent across individuals of different backgrounds with a reduced risk of developing type-2 diabetes in “highest” versus “lowest” levels of physical activity among non-Hispanic whites (RR= 0.71 [95% CI: 0.60 to 0.85]); Asians (RR= 0.76 [95% CI: 0.67 to 0.85]); Hispanics (RR = 0.74 [95% CI 0.64 to 0.84]); and American Indians (RR = 0.73 [95% CI: 0.60 to 0.88]), although the effect among non-Hispanic blacks was not significant (RR = 0.91 [95% CI: 0.76 to 1.08]) (67). Evidence suggests there is no effect modification by weight status and that the inverse relationship between a higher volume of physical activity and lower incidence of type- 2 diabetes exists for people who have normal weight, overweight or obesity (35). The associations between higher levels of physical activity and reduced risks of colon cancer and breast cancer have been well-established (1). In previous reviews of the evidence, higher levels of physical activity have been found to be associated with a reduced risk of 32 33Recommendations developing breast cancer and colon cancer (1). Following an extensive increase in physical activity and cancer research, there is new evidence demonstrating higher levels of physical activity are also associated with reduced risk of developing bladder, endometrial, oesophageal adenocarcinoma, gastric and renal cancers, as well as reaffirming that physical activity is protective for breast cancer and colon cancer (35). Higher levels of physical activity are associated with risk reductions ranging from approximately 10–20% (35). For example, one review reported an inverse association with liver cancer risk when comparing high levels of physical activity to low levels of physical activity (HR= 0.75 [95% CI: 0.63 to 0.89]) (68). There is insufficient evidence on the association between increased physical activity and decreased risks of hematologic, head and neck, ovary, pancreas, prostate, thyroid, rectal and brain cancer (35). While evidence suggests a reduction in risk of lung cancer between the highest versus lowest levels of physical activity, these findings may be confounded by tobacco use and it was determined that overall there is insufficient evidence to establish an association. The association between physical activity and adiposity in adult populations is less well established despite a large, but heterogenous, body of evidence assessing this relationship across various outcome measures (weight gain, weight change, weight control, weight stability, weight status and weight maintenance) (35, 69, 70). Overall the evidence shows that higher levels of physical activity may be associated with more favourable measures of adiposity and attenuation of weight gain in adults (35). Further research is needed to establish consistent results and strength of associations. Research on physical activity and mental health, cognition and sleep has increased substantially since the development of the 2010 Global recommendations on physical activity for health (1). At that time, there was sufficient evidence to conclude only that physical activity may reduce the risk of depression and cognitive decline in adults. New evidence reviewed for these guidelines showed that adults engaging in higher versus lower physical activity are at reduced risk of developing anxiety and depression. For example, adults with high, versus low, levels of physical activity were at reduced odds of developing anxiety (AOR= 0.81 [95% CI: 0.69 to 0.95]) (71) or depression (AOR= 0.78 [95% CI: 0.70 to 0.87) (72). Greater amounts of moderate- to vigorous-intensity physical activity are associated with improvements in cognition (e.g. processing speed, memory, and executive function) (35), brain function and structure, and a reduced ADULTS (aged 18–64 years) risk of developing cognitive impairment, including Alzheimer’s disease (73–76). The evidence included several adult populations representing a gradient of normal to impaired cognitive health status and the beneficial effects of physical activity were reported across a variety of types, including aerobic activity, walking, muscle-strengthening activity, and yoga (74). There is evidence that both acute bouts and regular physical activity improve sleep and health-related quality of life outcomes in adults (35). Evidence examining physical activity and symptoms of depression, symptoms of anxiety, and the development of anxiety and depression indicated that physical activity was associated with reduced symptoms of anxiety (77, 78) and reduced symptoms of depression (77, 79). All physical activity comes with some risk. Evidence from a commissioned review on the adverse effects, injuries and harms associated with leisure physical activity in adults (41) suggests an unfavourable association between levels of leisure-time physical activity and musculoskeletal injuries, and a favourable relationship between leisure- time physical activity and risk of fracture and onset of knee or hip osteoarthritis. Additional existing evidence (35) indicates sudden cardiac adverse events are rare and associated with acute sessions of relatively vigorous- intensity physical activity. Generally, the risks of adverse events are very low with moderate-intensity physical activity and when increases in physical activity frequency, intensity and duration are gradual (35). The GDG concluded that: • There is high certainty evidence that any level and any intensity of physical activity is associated with lower risk of all-cause mortality and cardiovascular disease mortality, incidence of hypertension, cardiovascular disease and type-2 diabetes. • There is moderate to high certainty evidence on the associations between higher levels of physical activity and lower risk of incidence of site-specific cancers. • There is moderate certainty evidence supporting an association between physical activity and improvements in mental health, cognitive health and sleep outcomes. • There is evidence of an association between higher levels of physical activity and more favourable measures of adiposity and attenuation of weight gain in adults. • There is low certainty evidence that physical activity recommended for adults will not be harmful and that the health benefits from such activity outweigh the risks. 34 35 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Is there a dose-response association (volume, duration, frequency, intensity)? Overall the evidence across cardiovascular and metabolic health outcomes shows a consistent curvilinear inverse dose-response relationship between physical activity and major outcomes such as all-cause mortality, cardiovascular disease mortality, incident type-2 diabetes (67), and incident site-specific cancers in adults. As described in Figure 1, the shape of the dose-response curve indicates that there is no lower threshold for benefit, and the greatest benefits are seen at the lower end of the dose-response curve (65). The curvilinear inverse association is consistently reported and across studies using different measures of physical activity. Important new evidence was provided in a meta- analysis of eight prospective cohort studies, with mean follow-up of 5.8 years (range 3–14.5 years) (65) that reported the adjusted HR for quartiles of total physical activity using device-based measures of exposure and all-cause mortality. The results showed a dose- response with increasing volume of physical activity and benefits of higher levels of any intensity of physical activity compared with the least active (referent, 1.00): 2nd quartile (adjusted HR= 0.48 [95% CI: 0.43 to 0.54]); 3rd quartile (adjusted HR= 0.34 [95% CI: 0.26 to 0.45]); and 4th quartile (adjusted HR= 0.27 [95% CI: 0.23 to 0.32]). Maximal risk reductions for moderate- to vigorous- intensity physical activity were observed at 24 minutes per day (equivalent to 168 minutes per week), which ADULTS (aged 18–64 years) closely reflects the recommendation of 150 minutes per week, and provides new device-based evidence reinforcing the existing global guidance to adults of 150–300 minutes of physical activity per week (65). These findings are consistent with the evidence from existing reviews (35) and the other new identified reviews (66). At the upper end, higher levels of physical activity continue to provide benefits in terms of reduced risk of mortality with no increased risk of harms. For example, evidence from a new review with findings from a meta- analysis of individual data from device-based measures of exposure (65), indicates that although reduced risk of mortality is observed up to 750 minutes of moderate- to vigorous-intensity physical activity per week, the relative risk of mortality levels off beyond 300 minutes per week. These results accord with previous evidence which consistently showed that more physical activity is associated with further health benefits, although the relative benefits are reduced at higher levels of physical activity (35, 80, 81). There is, however, insufficient evidence to identify the exact physical activity level where diminished returns of health benefits begin for adults. Evidence also reaffirmed the well-established inverse relationship between physical activity and cardiovascular disease mortality, providing additional evidence of a dose-response relationship well beyond current recommended volumes of physical activity. Figure 1: Dose response curve Weekly physical activity (minutes) RIS KS AN D HA RM SBE NE FI TS H ea lt h a n d  fi tn es s b en efi ts Sedentary Recommended range 150 300 34 35Recommendations A meta-analysis of 48 prospective studies assessing physical activity (total, leisure, and occupational) provided additional evidence of a dose-response relationship (66) well beyond current recommended volumes of physical activity. Compared with the recommended level of 750 MET minutes per week, participation in 5000 MET minutes per week (1000 minutes of moderate-intensity activity) resulted in a significantly lower risk for cardiovascular disease mortality (HR= 0.73 [95% CI: 0.56 to 0.95]) (66).Previous WHO recommendations (1) concluded that aerobic activity should be performed in bouts of at least 10 minutes duration. However, new evidence, using device-based assessments, demonstrates that physical activity of any duration, without a minimum threshold, is associated with improved health outcomes, including all-cause mortality (65, 82). For example, new evidence from reviews of studies assessing physical activity by accelerometry reaffirms similar associations between all indices of physical activity and all-cause mortality, with hazard ratios of 0.27 for total physical activity, 0.28 for 5-minute bouts, and 0.35 for 10-minute bouts, comparing the highest versus lowest quartiles (83). These results, reaffirmed by findings in the new review by Ekelund et al. 2019 (65), provide evidence that physical activity of any bout duration is associated with improved health outcomes, including all-cause mortality (82). Based on new evidence, the recommendation for bouts of least 10 minutes duration has been removed. Although evidence showing the associations between higher levels of physical activity and lower risk of incidence of site-specific cancers was deemed to be consistent overall, there is insufficient evidence to determine the specific levels of physical activity that correspond to the reported risk reduction due to the large heterogeneity in the assessment and classification of exposure across studies. There is however, no evidence to suggest that there is a lower threshold below which no beneficial effect of physical activity is evident, thus suggesting that any level of physical activity can confer benefit on reducing the risk of site-specific cancers. Future research assessing the nature of the dose- response and using more consistent measures and reporting is needed to inform future guidelines. Although there is a large body of evidence on the associations between physical activity and various measures of adiposity, weight gain and the management of a healthy weight status (35), currently there is insufficient evidence to describe more specifically ADULTS (aged 18–64 years) the dose-response relationship or identify a threshold of effect. Further research is needed to inform future guidelines. Greater amounts of moderate- to vigorous-intensity physical activity are associated with improvements in cognition (e.g. processing speed, memory, and executive function) (35), brain function and structure, and a reduced risk of developing cognitive impairment, including Alzheimer’s disease (73–76). There is evidence that both acute bouts and regular physical activity improve sleep and health-related quality of life outcomes in adults (35). There is however insufficient evidence to describe more specifically the dose-response relationship between physical activity and individual mental and cognitive health outcomes. Similarly, more evidence is needed to further describe the dose-response relationship between volume and/or intensity of aerobic physical activity and muscle-strength training and specific health outcomes. Such information is key to establishing minimal effective doses and maximum safety thresholds of physical activity for different population subgroups. The GDG concluded that: • There is evidence that more physical activity is associated with larger effects on health outcomes, although the relative benefits level off at higher levels of physical activity. There was insufficient evidence to identify the exact level where diminished returns start to occur. • There is high certainty evidence that higher levels of physical activity are associated with lower risk of all- cause mortality, cardiovascular disease mortality, cancer mortality, cardiovascular disease incidence, and incidence of hypertension and type-2 diabetes, with no increased risk of harms. • There is moderate certainty evidence that physical activity of any duration is associated with improved health outcomes, and prior specification that aerobic activity should be performed in bouts of at least 10 minutes duration should be removed. • There is evidence that higher amounts of physical activity may be associated with more favourable measures of adiposity and attenuation of weight gain in adults and there is a low risk that physical activity will be harmful for the management of healthy weight status in adults. • There is moderate certainty evidence that 150–300 minutes of moderate intensity aerobic physical activity or equivalent, per week, reduces risk for multiple health outcomes, and risk reduction continues, but starts to plateau, beyond 300 minutes per week. 36 37 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Does the association vary by type or domain of physical activity? Evidence shows that different types of physical activity and physical activity undertaken in different domains (i.e. occupation, transport, or leisure) can provide favourable health outcomes. For all-cause and cardiovascular disease mortality, undertaking aerobic physical activity alone, or combining with strength-promoting exercise shows beneficial associations, although performing recommended levels of both types is optimal (84). More recent moderate certainty evidence indicates that muscle-strengthening physical activity, independent of aerobic physical activity, is also associated with lower risk of all-cause mortality. Results reported by Stamatakis et al. (2018), from a pooled analysis of 11 cohorts examining the 2 days per week muscle-strengthening exercise recommendation against all-cause mortality, showed that undertaking both aerobic and muscle-strengthening physical activity at recommended levels (1) versus not meeting either recommendation (adjusted HR= 0.71 [95% CI: 0.57 to 0.87]) as well as adherence to just the strength exercise recommendation versus not adhering (HR= 0.80 [95% CI: 0.70 to 0.91]) was associated with significantly lower risk of all-cause mortality (84). These data affirm that health benefits associated with muscle-strengthening exercise were independent of aerobic physical activity and also provide evidence to support recommending a frequency of 2 days per week of muscle-strengthening exercise. Other findings reported by Dinu et al. (2019) provided supporting evidence reaffirming that physical activity undertaken in domains other than leisure (or recreation) can be beneficial and specifically showed that active commuting (i.e. walking and cycling for transport) can significantly lower risk of all-cause mortality (RR= 0.92 [95% CI: 0.85–0.98]) (85). Recent research provides evidence demonstrating that for those who participate in active commuting (i.e. walking or cycling for transport), there is reduced risk of cardiovascular disease (coronary heart disease, stroke and heart failure) compared with those participating in no active commuting (RR= 0.91 [95% CI 0.83 to 0.99]) (85); and that there is sufficient evidence from these health outcomes to conclude that activity in different domains can be beneficial. However, there is insufficient evidence to differentiate the effect of different domains of physical activity on every health outcome. For example, there is insufficient evidence to determine if the association between physical activity and cancer risk or type-2 diabetes incidence varies by type or domain of physical activity. ADULTS (aged 18–64 years) For mental health outcomes, evidence (35) shows that a variety of types of physical activity, including aerobic activity, walking, muscle-strengthening activity, and yoga can provide beneficial effects for reducing symptoms of depression and development of anxiety (74, 79, 86). For example recent evidence for the beneficial effects of resistance exercise interventions and mental health was provided by two reviews reporting moderately large reductions in symptoms of depression (77) and small reductions in symptoms of anxiety (78) compared with control conditions. Evidence from a new review affirmed that high levels of occupational physical activity is associated with reduced risk of many cancers, coronary heart disease, and type- 2 diabetes (40). However, higher levels of occupational physical activity may also be associated with an increased risk of osteoarthritis, poor sleep quality, and all-cause mortality among males (but not among females). There is insufficient evidence to determine the relationship between occupational physical activity and adiposity, prevention of body weight gain, mental health, and health-related quality of life (40). There is also insufficient evidence to determine if the association between physical activity and cancer risk varies by type or domain of physical activity. There is less evidence on associations by different domains of physical activity, and therefore it was difficult to differentiate the effect of different domains of physical activity on various health outcomes. The GDG concluded that: • There is moderate certainty evidence that muscle- strengthening activities undertaken on 2 or more days a week, provide additional health benefits, but there is insufficient evidence to specify a specific duration for optimal health benefits. • There is moderate certainty evidence that physical activity undertaken in different domains (e.g. leisure, transport, occupational) can provide health benefits, although currently it is not possible to differentiate the effect of different domains of physical activity on various health outcomes. • Although higher levels of occupational physical activity may be associated with an increased risk of osteoarthritis, poor sleep quality, and all-cause mortality among males (but not among females), overall there is moderate certainty evidence that occupational physical activity can provide health benefits. 36 37Recommendations Supporting evidence and rationale For these guidelines, the synthesis of evidence undertaken by PAGAC (35) was used and updated. The GDG considered the entire body of evidence, including both the findings reported by PAGAC and the 13 new reviews that met inclusion criteria, to contribute evidence on the association between sedentary behaviour and health- related outcomes in adults. Investigating the association between sedentary behaviour and health outcomes is a relatively new field of public health compared with that of physical inactivity, yet it has developed rapidly in the past decade. Studies have typically measured sedentary behaviour using either i) self-report questionnaires which ask about “total time” spent in sedentary behaviours, or time spent in specific behaviours, such as television viewing, computer/screen use, and sitting; or ii) device-based assessments. There are no standardized measures or analytical protocols for sedentary behaviour and thus the reporting of results is heterogeneous. Recent methodological developments include the use of device-based assessment of time spent sedentary which can reduce measurement error and other biases inherent in self-reported recall. In considering the total body of evidence, the GDG gave greater emphasis to evidence provided by reviews graded moderate and above, taken from reviews providing evidence from studies using measures of total sedentary or sitting time, or device-based measures of sedentary behaviour where available. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . Research on the potential adverse health effects associated with sedentary behaviour has rapidly accumulated during the past decade. In more recent studies, notable developments include an increase in evidence reporting on dose-response relationships between sedentary behaviour and multiple health outcomes, and on the interplay between sedentary behaviour and physical activity. In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and type-2 diabetes. It is recommended that: Adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults should aim to do more than the recommended levels of moderate- to vigorous- intensity physical activity. Strong recommendation, moderate certainty evidence Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf For adults, sedentary behaviour is defined as time spent sitting or lying with low energy expenditure, while awake, in the context of occupational, educational, home and community settings, and transportation. SEDENTARY BEHAVIOUR RECOMMENDATION ADULTS (aged 18–64 years) 38 39 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ADULTS (aged 18–64 years) In adults (aged over 18 years), what is the association between sedentary behaviour and health-related outcomes? Overall, there is evidence of an association between greater time spent in sedentary behaviour (examined mostly via self-reporting or device-based assessments of sitting or television viewing time) and higher all-cause mortality, cardiovascular mortality, cardiovascular disease incidence and type-2 diabetes incidence (8, 35, 65, 87). For example, supporting evidence includes results from a recent large meta-analysis (n= 36 383; mean age 62.6 years; 72.8% women) of accelerometer assessed total sedentary time and all-cause mortality (65) and showed that increasing time spent in sedentary behaviour was significantly associated with all-cause mortality. Similar findings from a meta-analysis comprising more than 1 million participants (87) showed associations for total sedentary behaviour with all-cause mortality, and cardiovascular disease mortality, after adjustment for physical activity (87), although in this study the associations with cancer mortality were not statistically significant after adjustment for physical activity (87). Another recent meta-analysis (8) reported significant associations between sedentary behaviour (assessed as sitting) and cardiovascular disease and cancer mortality, with results indicating a 9–32% (p for trend < 0.001) higher risk of cardiovascular disease mortality with higher levels of sedentary behaviour when measured as sitting time in the “inactive”, lowest quartile of physical activity (~ 5 min/day). The study reported that adults who were sedentary (sitting) for more than 8 hours per day had a higher risk of cardiovascular disease mortality, except for those who were “most active” (i.e. > 35.5 MET-hours/week, or ~ 60–75 mins/ day), where the association was mitigated. Results on the associations between sedentary behaviours and cancer mortality were generally weaker, although a 6–21% higher dose-related risk was observed with longer sitting time (particularly > 8 hours/day), but only among those in the lowest quartile of physical activity (< 2.5 MET-hours/week) (8). Evidence supports an association between sedentary behaviour (measured as total sitting time) and increased incident cardiovascular disease (HR= 1.29 [95% CI: 1.27 to 1.30]) which was attenuated following adjustment for potential covariates, including level of physical activity (HR= 1.14 [95% CI: 1.04 to 1.23]) (88). A review of studies in south-east Asian populations provided evidence of low certainly that greater sedentary time was associated with an increased likelihood of unfavourable cardiometabolic indicators (including type-2 diabetes, higher BMI, higher blood pressure) (89). Two recent reviews report on the association of total daily sitting time (88) and total sedentary behaviour and television viewing (87) with type-2 diabetes incidence. Both studies found a higher level of sedentary behaviour was associated with increased risk of type-2 diabetes incidence. For example, a linear association with type-2 diabetes was observed for total sedentary behaviour (RR= 1.01 [95% CI: 1.00 to 1.01] p= < 0.001) and television viewing (RR= 1.09 [95% CI: 1.07 to 1.12] p= < 0.001), when adjusted for physical activity (87). There is also supporting evidence for a significant association between sedentary behaviour (when measured as time spent viewing television) and cancer mortality (35, 87). Several more recent reviews, of low and very low certainty, provide supporting evidence for an association between sedentary behaviours and colorectal cancer (90), but no associations with incident prostate, breast or rectal cancer (90–93). Additional evidence (35) reported significant associations between greater time spent in sedentary behaviour and higher risk of developing endometrial, colon and lung cancers (35). There is low certainty evidence of an unfavourable relationship between time spent in sedentary behaviour and adiposity and other indicators of weight status, and whether the relationship between sedentary behaviour and weight status varies by amount of moderate- to vigorous-intensity physical activity. Overall, it was concluded that there was insufficient evidence to inform these recommendations/guidelines and that further research is needed. There is limited evidence assessing adverse effects of reducing sedentary time. Expert opinion informed the conclusion that recommending the reduction in sedentary time would be unlikely to increase risk of injury, especially if replaced with light-intensity physical activity. 38 39Recommendations The GDG concluded that: • Overall there is sufficient evidence to support the development of a new WHO recommendation to limit sedentary behaviour to reduce health risks. • There is moderate certainty evidence of an association between greater time spent in sedentary behaviour and higher all-cause mortality, cardiovascular disease mortality, cancer mortality and incidence of cardiovascular disease and type-2 diabetes. • There is low to moderate certainty evidence of an association between greater time spent in sedentary behaviour and higher risk of incident endometrial, colon, and lung cancers. • There is insufficient evidence on the association between sedentary behaviour and measures of adiposity and further research is needed. • The benefits of limiting sedentary behaviour outweigh any potential risks. Is there a dose-response association (total volume, frequency, duration, intensity of interruption)? Overall, moderate certainty evidence indicates a non- linear dose-response relationship between sedentary time (sitting or television viewing time assessed by self-reporting, or by device-based assessments) and all- cause mortality, cardiovascular disease mortality, cancer mortality, and incident cardiovascular disease (8, 35, 87). A recent meta-analysis provided high certainty evidence on the dose-response relationship between accelerometer assessed total sedentary time and all-cause mortality (65) reporting that increasing time spent in sedentary behaviour was significantly associated with all-cause mortality. The hazard ratios for increasing quartiles of sedentary time were 1.00 (referent; least sedentary); 1.28 (1.09– 1.51); 1.71 (1.36–2.15); and 2.63 (1.94–3.56), after adjustment for potential confounders including time spent in moderate- to vigorous-intensity physical activity (65). This analysis of dose-response relations between sedentary time and mortality showed risk increased gradually from about 7.5–9 hours and was more pronounced at greater than 9.5 hours. Sedentary behaviour of 10 hours and 12 hours each day were associated with 1.48 (1.22–1.79) and 2.92 (2.24–3.83) higher risk of death, respectively (65). Another recent meta-analysis assessed dose-response and reported non-linear associations for total sedentary time and all-cause mortality (RR per 1 hour/day = 1.01 (1.00–1.01) for ≤ 8 hours/day; and 1.04 (1.03–1.05) for > 8 hours/day of exposure); and cardiovascular disease mortality (RR= 1.01 (0.99–1.02) for ≤ 6 hours/day; and RR= 1.04 (1.03–1.04) for > 6 hours/day) after adjustment for physical activity (87). In this same study, a small linear dose-response association between type-2 diabetes was observed for total sedentary behaviour (1.01 (1.00– 1.01)) when adjusted for physical activity and television viewing (1.09 (1.07–1.12)) (87). Overall, evidence supports that higher amounts of sedentary behaviour are associated with less favourable health outcomes and it was concluded that there is sufficient evidence to support minimizing sedentary time to reduce health risks. However, given the considerable variations in how sedentary behaviour was assessed across reviews (via self-reported sitting time, television viewing time, or device-based (accelerometer) assessments) and the probability that thresholds for sedentary time might vary across health outcomes, by levels of moderate- to vigorous-intensity physical activity, and among population subgroups, there is insufficient evidence to set a time-based (quantified) recommendation. In addition to overall volume of sedentary behaviour, evidence on the patterns by which sedentary behaviour is accrued was reviewed. However, there was limited evidence to make recommendations on the frequency and/or duration of breaks in sedentary behaviour. The GDG concluded that: • There is insufficient evidence to set quantified (time- based) recommendations on sedentary behaviours. • There is insufficient evidence to make recommendations on the frequency and/or duration of breaks in sedentary behaviour. ADULTS (aged 18–64 years) 40 41 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Does the association vary by type and domain of sedentary behaviour? Some domains or different types of sedentary behaviour may be more detrimental than others, both in terms of their direct associations and in their potential to displace time spent in more healthful physical activity. Although there has been a rapid growth in research on sedentary behaviour, there is limited evidence available directly comparing the association between different types of sedentary behaviour and different health outcomes. For example, some studies report stronger results with sedentary behaviour measured as television viewing compared with total sitting time (87). This may be due to the differential measurement error or residual confounding associated with self-report measures and instruments. Currently, there is insufficient evidence to determine the different associations with different health outcomes and how these may vary by subpopulation. A growing number of studies are using device- based measures of physical activity and sedentary time in relation to health outcomes. However, some misclassification may occur from device-based measures of sedentary time as many of these device placements (e.g. wrist, waist) do not currently distinguish between positions (e.g. lying, sitting and standing still). Future research using harmonized reporting, and methods that distinguish between positions, will help to strengthen the knowledge on the patterns of sedentary behaviour. The GDG concluded that: • There is insufficient evidence to make recommendations on different types or domains of sedentary behaviour. ADULTS (aged 18–64 years) Does level of physical activity modify the effect of sedentary behaviour on mortality? The increased interest in the impact of sedentary behaviour on health outcomes has stimulated investigation into the potential interplay between different levels of physical activity and levels of sedentary behaviour. Based on available research, there is moderate certainty evidence that the relationship between sedentary behaviour and all-cause mortality, cardiovascular disease mortality and cancer mortality varies by amount of moderate- to vigorous-intensity physical activity (8, 9, 35). Overall findings show that the effect of sedentary behaviour is stronger in those who do low amounts of moderate- to vigorous-intensity physical activity or, phrased conversely, that higher amounts of moderate- to vigorous-intensity physical activity can mitigate the unfavourable health outcomes associated with higher levels of sedentary behaviours. The risk associated with sedentary time and all-cause mortality has been shown to be more pronounced at lower levels of physical activity than at higher levels (35). In a harmonized meta-analysis, Ekelund et al. investigated the joint and stratified effects of sedentary behaviour and physical activity with all-cause mortality in more than 1 million men and women, and showed that the associations differed depending on the level of physical activity (9). The analyses used quartiles of sedentary behaviour (sitting) and quartiles of moderate- to vigorous-intensity physical activity, and found that compared with the referent (< 4 hours of sitting per day and highest quartile of moderate- to vigorous-intensity physical activity [> 35.5 MET-hours/ week]), there was no increased risk of dying during follow-up in those who sat for more than 8 hours per day but who also reported more than 35.5 MET- hours per week of activity (HR= 1.04 [95% CI: 0.99 to 1.10]). In contrast, those who sat the least (< 4 hours/ day) and were in the lowest (< 2.5 MET-hours/week) physical activity quartile had a significantly increased risk of dying during follow-up (HR= 1.27 [95% CI: 1.22 to 1.31]). The study concluded that levels of moderate- to vigorous-intensity physical activity of about 60–75 minutes per day (the highest quartile) can attenuate, and even eliminate, the detrimental association between sedentary behaviour and health outcomes (9). 40 41Recommendations ADULTS (aged 18–64 years) G O O D P R A C TI C E ST A TE M EN TS This relationship between levels of sedentary behaviour and moderate- to vigorous-intensity physical activity was summarized in the systematic review by PAGAC (35) as shown in Figure 2. Another recent study provided new evidence investigating the same associations with cause-specific mortality and showed similar findings (8). In a large harmonized meta-analysis (9 studies, n= 850 000, CVD mortality; 8 studies, n= 777 000, cancer mortality), results showed that higher levels of moderate- to vigorous- intensity physical activity mitigated the increased risk of cardiovascular disease mortality with high levels of sedentary behaviour, whether measured as time spent sitting or time spent viewing television (8). The study showed that in individuals who were sitting for more than 8 hours per day, there was an association with higher risk of death, except in the most active quartile, where the association was mitigated. More specifically, the hazard of cardiovascular disease mortality was 32% higher in those who sat for more than 8 hours per day compared with the reference group (< 4 hours/day) (p for trend < 0.001). The results were less pronounced but remained significant compared with the reference group for the other quartiles of physical activity (2nd quartile, HR= 1.11 [95% CI: 1.03 to 1.20]; 3rd quartile, HR= 1.14 [95% CI: 1.03 to 1.26]). Similar associations were observed for television time and cardiovascular disease mortality across strata of moderate- to vigorous- intensity physical activity (8). The associations for cancer mortality were more mixed, although generally showed that higher levels of physical activity attenuated the detrimental effects of sedentary behaviour when assessed as total sitting time. Based on this evidence, it was agreed that higher levels of moderate- to vigorous-intensity physical activity should be recommended for those individuals who undertake high levels of sedentary behaviour and that the benefits would outweigh the risks. The GDG concluded that: • There is moderate certainty evidence that the relationship between sedentary behaviour and all-cause mortality, cardiovascular disease and cancer mortality varies by amount of moderate- to vigorous-intensity physical activity. • Higher amounts of moderate- to vigorous-intensity physical activity can attenuate the detrimental association between sedentary behaviour and health outcomes. Figure 2: The relationship between levels of sedentary behaviour and physical activity Adapted from PAGAC More physical activity M or e se d en ta ry t im e HIGH RISK LOW RISK Less sedentary tim e & m ore physical activity Increase physical activityRed u ce sedentary time 42 43 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r OLDER ADULTS (aged 65 years and older) In older adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site-specific cancers, incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression), cognitive health, and sleep; measures of adiposity may also improve. In older adults, physical activity helps prevent falls and falls-related injuries and declines in bone health and functional ability. It is recommended that: All older adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Older adults should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence Older adults should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence As part of their weekly physical activity, older adults should do varied multicomponent physical activity that emphasizes functional balance 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 Older adults may increase moderate- intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week, for additional health benefits. Conditional recommendation, moderate certainty evidence For older adults, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), transportation (wheeling, walking and cycling), work, or household chores, in the context of daily occupational, educational, home or community settings. PHYSICAL ACTIVITY RECOMMENDATION • Doing some physical activity is better than doing none. • If older adults are not meeting the recommendations, doing some physical activity will bring benefits to health. • Older adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • Older adults should be as physically active as their functional ability allows, and adjust their level of effort for physical activity relative to their level of fitness. G O O D P R A C TI C E ST A TE M EN TS 42 43Recommendations Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Supporting evidence and rationale For these guidelines, for older adults, the comprehensive synthesis of evidence undertaken by PAGAC (35) was used and updated. Fifteen reviews met the inclusion criteria and informed the examination of the association between physical activity and health-related outcomes specific to older adults (falls prevention, fall-related injuries, physical function, frailty, and osteoporosis). The evidence for falls prevention used and updated the 2019 Cochrane Collaboration Systematic Review by Sherrington et al. (42), with evidence published from the end search date of their original review, to November 2019 (9 new studies). A search for existing systematic reviews on osteoporosis and sarcopenia was conducted in PubMed for reviews published from 2008 through to November 2019 and identified no new reviews and 8 new studies. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . In older adults (aged 65 years and over), what is the association between physical activity and health-related outcomes? The primary evidence base for assessing the associations between physical activity and health outcomes, such as all-cause and cause-specific mortality, cardiovascular disease, type-2 diabetes, cancer incidence, adiposity, mental health, and cognitive outcomes in older adult populations was the same scientific literature collated and reviewed for adult populations. This same body of evidence was accepted and extrapolated to older adults because the majority of studies stated no upper age limit criterion and therefore included adults over the age of 65 years. A further review of evidence was conducted to examine and inform on the association between physical activity and health-related outcomes specific to older adults, including falls prevention, fall-related injuries, physical function, frailty and osteoporosis. Declining physical capacity in older people often manifests in falls and fall-related injuries that can have serious consequences. Accidental falls are due to a combination of extrinsic (environmental) and intrinsic (e.g. musculoskeletal or nervous system abnormalities affecting postural control) factors. Evidence demonstrates that physical activity – in particular multicomponent physical activity programmes that include combinations of balance, strength, endurance, gait, and physical function training – is associated with a reduced rate of falls and risk of injury from falls in older adults. Recent evidence demonstrates that exercise may reduce the rate of falls by as much as 23% (pooled rate ratio (RaR) 0.77 [95% CI: 0.71 to 0.83]) in older adults, which can significantly reduce the risk of injury from falls, including severe falls that result in bone fracture, head trauma, open wound, soft tissue injury, or any other injury requiring medical care or admission to hospital (42). This evidence was consistent with, and reaffirmed findings in, other reviews (35). After reaching a peak in early adulthood, muscle and bone mass tends to decline with increasing age (i.e. sarcopaenia and osteopaenia/osteoporosis), and this can be associated with declining strength and physical function. Evidence demonstrates that regular physical activity improves physical function and reduces the risk of age-related loss of physical function in older adults. Findings show beneficial effects on dynamic balance (SMD= 1.10 [95% CI: 0.29 to 1.90]); muscle strength (SMD= 1.13 [95% CI: 0.30 to 1.96]); flexibility (SMD= 1.22 [95% CI: 0.39 to 2.04]); and cardiorespiratory fitness (SMD= 1.48 [95% CI: 0.42 to 2.54]) (94). Evidence also shows that higher levels of physical activity may improve bone health and thus prevent osteoporosis in older adults (pooled standardized effect size 0.21 [95% CI: 0.06 to 0.36]) (95). Physical activity interventions may improve lumbar spine and femoral neck (hip) bone mineral density. The GDG concluded that: • There is moderate certainty evidence that physical activity improves physical function and reduces risk of age-related loss of physical function in the general ageing population. • There is low-certainty evidence that the risks for the amounts and types of physical activity recommended for older adults are low and are outweighed by the benefits. OLDER ADULTS (aged 65 years and over) 44 45 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Is there a dose-response association (volume, duration, frequency, intensity)? Evidence shows an inverse relationship between the amount of physical activity performed by older adults and the risk of physical function limitations. In general, more physical activity (frequency, duration and/or volume) is associated with greater benefits (35). Evidence suggests that fast-intended velocity resistance training may be superior to moderate-velocity resistance training for improvements in general functional capacity (SMD= 0.41 [95% CI: 0.18 to 0.65]; and SPPB (SMD= 0.52 [95% CI: 0.10 to 0.94])) (96). There is limited evidence examining the dose-response relationship between physical activity and prevention of falls; however the majority of studies providing supportive evidence show testing a programme consistent with 3 days per week. The GDG concluded that: • There is high certainty evidence of an inverse dose- response relationship between volume of aerobic physical activity and risk of physical functional limitations in the general older adult population. Does the association vary by type or domain of physical activity? Physical activity programmes that include combinations of balance, strength, endurance, gait, and physical function training are associated with a reduced rate of falls and risk of injury from falls in older adults. Evidence from a review of 11 RCT showed that by engaging in a variety of different physical activity interventions (commonly balance and functional exercises plus resistance exercises), older adults can reduce rate of falls by up to 28% (RaR= 0.72 [95% CI: 0.56 to 0.93]) (42). The effect of resistance exercises was uncertain and based on limited data (RR= 0.97 [95% CI: 0.14 to 6.49]; 1 trial; n= 73) (42). Evidence also suggests that programmes which include multiple exercise types have greater positive effects on bone health (standardized effect size 0.45 [95% CI: 0.20 to 0.71]; p= 0.001), compared with those which do not (95). The GDG concluded that: • There is high certainty evidence that higher levels of physical activity that combines balance, strength, gait, and functional training (e.g. multicomponent physical activity) are associated with a reduced rate of falls and risk of injury from falls in older adults. • There is moderate certainty evidence that programmes involving multiple exercise types may have significant effects on bone health and osteoporosis prevention. OLDER ADULTS (aged 65 years and over) 44 45Recommendations OLDER ADULTS (aged 65 years and older) Supporting evidence and rationale Sedentary behaviour was not included in the 2010 Global recommendations on physical activity for health (1). Due to a lack of population-specific evidence, the primary evidence base for assessing the associations between sedentary behaviour and health outcomes in older adult populations was the same scientific literature collated and reviewed for adult populations because the majority of studies stated no upper age limit criterion and therefore included adults over the age of 65 years. The findings from evidence on sedentary behaviours in the general adult population were reviewed, including assessing if there was evidence that the outcomes would be any different, or would not apply to, or would be contraindicated, for older adults. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . In older adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Older adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, older adults should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, moderate certainty evidence For older adults, sedentary behaviour is defined as time spent sitting or lying with low energy expenditure, while awake, in the context of occupational, educational, home and community settings and transportation. SEDENTARY BEHAVIOUR RECOMMENDATION Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 46 47 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r PREGNANT AND POSTPARTUM WOMEN PREGNANT AND POSTPARTUM WOMEN PHYSICAL ACTIVITY RECOMMENDATION For pregnant and postpartum women, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), transportation (wheeling, walking and cycling), work, household chores, in the context of daily occupational, educational, home and community settings. These guidelines address physical activity and maternal and fetal health outcomes during pregnancy and the postpartum period. They are for all pregnant and postpartum women, irrespective of age, cultural background, or socioeconomic status. Pregnancy and the period after delivery are stages in a woman’s life, and the benefits of being physically active throughout adulthood are detailed in the recommendations provided for adults. Pregnant and postpartum women should be under the care of a health-care provider for antenatal and postnatal care who can advise on special considerations given their medical history and any contraindications to participating in physical activity during pregnancy or in the postpartum period. These guidelines are public health and population- based. Clinical guidance should be sought for women with complications associated with pregnancy or delivery. Pregnant and postpartum women should try to meet these recommendations where possible, as able, and without contraindication. In pregnant and postpartum women, physical activity during pregnancy and postpartum confers benefits on the following maternal and fetal health benefits: decreased risk of pre-eclampsia, gestational hypertension, gestational diabetes, excessive gestational weight gain, delivery complications and postpartum depression, and fewer newborn complications, no adverse effects on birthweight; and no increase in risk of stillbirth. It is recommended that all pregnant and postpartum women without contraindication should: undertake regular physical activity throughout pregnancy and postpartum; Strong recommendation, moderate certainty evidence do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week for substantial health benefits; and Strong recommendation, moderate certainty evidence incorporate a variety of aerobic and muscle-strengthening activities. Adding gentle stretching may also be beneficial. Strong recommendation, moderate certainty evidence In addition: Women who, before pregnancy, habitually engaged in vigorous-intensity aerobic activity, or who were physically active, can continue these activities during pregnancy and the postpartum period. Strong recommendation, moderate certainty evidence 46 47Recommendations G O O D P R A C TI C E ST A TE M EN TS • Doing some physical activity is better than doing none. • If pregnant and postpartum women are not meeting the recommendations, doing some physical activity will benefit their health. • Pregnant and postpartum women should start by doing small amounts of physical activity, and gradually increase frequency, intensity and duration over time. • Pelvic floor muscle training may be performed on a daily basis to reduce the risk of urinary incontinence. Additional safety considerations for pregnant women when undertaking physical activity are: • Avoid physical activity during excessive heat, especially with high humidity; • Stay hydrated by drinking water before, during, and after physical activity; • 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 high altitude); • Avoid activities in supine position after the first trimester of pregnancy; • When considering athletic competition, or exercising significantly above the recommended guidelines pregnant women should seek supervision from a specialist health-care provider; • Pregnant women should be informed by their health-care provider of the danger signs alerting them as to when to stop; or to limit physical activity and consult a qualified health-care provider immediately should they occur; • Return to physical activity gradually after delivery, and in consultation with a health-care provider, in the case of delivery by Caesarean section. PREGNANT AND POSTPARTUM WOMEN Supporting evidence and rationale For these Guidelines on physical activity and sedentary behaviour (2020) for pregnant and postpartum women, the evidence syntheses from 7 systematic reviews addressing the critical and important outcomes (28–34) were used and updated. Four of the 7 reviews met inclusion criteria. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf In pregnant and postpartum women, what is the association between physical activity and health-related outcomes? Physical activity before and during pregnancy can help reduce the risk of common complications of pregnancy. Engaging in physical activity during pregnancy is significantly associated with reduced gestational weight gain (MD= 1.14 kg [95% CI: 1.67 to 0.62]) (97), and a reduced risk of gestational diabetes (RR= 0.71 [95% CI: 0.57 to 0.89]) (97), as is being physically active before pregnancy (OR= 0.70 [95% CI: 0.57 to 0.85]) (31, 34, 97), including in women with overweight or obesity (97). Physical activity during pregnancy does not appear to increase the incidence of gestational hypertension or preeclampsia (31). Evidence suggests that among pregnant women with overweight or obesity, there is no significant difference in the incidence of gestational hypertension (RR= 0.63 [95% CI: 0.38 to 1.05]) or in preeclampsia (RR= 1.39 [95% CI: 0.66 to 2.93]) between physical activity intervention groups versus standard antenatal care (97). There have been long-standing concerns about potential adverse effects of maternal physical activity on the developing fetus and delivery. However, recent evidence demonstrates that physical activity is not associated with increased risk of the incidence of miscarriage, stillbirth or delivery complications (32). Evidence suggests no difference in the incidence of Caesarean delivery among pregnant women with overweight or obesity between physical activity intervention groups versus standard antenatal care (97). Physical activity during pregnancy is not associated with increased risk of adverse effects on birthweight (98) or preterm birth (32), and may even be protective, reducing the overall risk (98), even among pregnant women with overweight or obesity (RR= 1.02 [95% CI: 0.54 to 1.92]) or 48 49 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r PREGNANT AND POSTPARTUM WOMEN large-for-gestational-age babies (RR= 0.90 [95% CI: 0.65 to 1.25]) between physical activity intervention groups versus standard antenatal care) (97). In the postpartum period, mothers can experience many physical and emotional changes. Evidence demonstrates that physical activity during pregnancy may be inversely associated with postpartum depression (29). Evidence from a meta-analysis of 6 trials and 11 observational studies of physical activity during pregnancy (99) showed a significant inverse relationship between physical activity during pregnancy and postpartum depression (SMD= 0.58 [95% CI: 1.09 to 0.08]). The effect was stronger when limited to 5 studies with at least moderate-intensity interventions (SMD= 0.70 [95% CI: 1.19 to 0.22]) (99). The GDG concluded that: • There is high certainty evidence that physical activity during pregnancy may reduce gestational weight gain and risk of gestational diabetes mellitus. • There is moderate to high certainty evidence that physical activity does not increase the incidence of gestational hypertension. • There is moderate certainty evidence that physical activity does not increase the incidence of miscarriage, stillbirth or delivery complications; and moderate certainty evidence of a reduced risk of preterm birth for mothers engaged in vigorous-intensity physical activity. • There is low to moderate certainty evidence that physical activity does not increase the risk of low birth weight, or small-for-gestational-age, or large-for- gestational-age babies. • There is low certainty evidence that physical activity during pregnancy is associated with lower levels of postpartum depression. • The risks for the amounts and types of physical activity recommended for pregnant and postpartum women are low and are outweighed by the benefits. Is there a dose-response association (volume, duration, frequency, intensity)? Across the evidence on physical activity during pregnancy and the postpartum period, the interventions varied in the amount (i.e. dose) of physical activity, both in duration in minutes and frequency per week. In general, the evidence available reflected a frequency of aerobic physical activity of at least 3 times per week, typically for between 30 and 60 minutes. This evidence is taken from studies assessing the health impact of a dose broadly consistent with the amount of activity recommended for the general adult population – namely 150 minutes of moderate-intensity physical activity per week. While more physical activity (frequency, duration and/or volume) is generally found to be associated with greater benefits, further research is needed to understand in more detail the dose-response relationship. Participating in higher versus lower amounts of leisure time physical activity pre-pregnancy is associated with a significantly lower risk of gestational diabetes (OR= 0.54 [95% CI: 0.34 to 0.87]) (100). There is also evidence of a small, but significant, reduced risk of preterm birth in babies of mothers who engaged in vigorous-intensity physical activity (RR= 0.20 [95% CI: 0.36 to 0.03]) (98). No evidence was identified regarding the safety or additional benefit of exercising at levels significantly above the recommendations. The GDG concluded that: • There is insufficient evidence to determine a dose- response association between physical activity and specific critical health outcomes during pregnancy and the postpartum period. • The overall evidence shows benefits to critical health outcomes and is based on interventions that are broadly consistent with the amount of physical activity recommended for the general adult population, namely 150 minutes of moderate-intensity physical activity per week. • There was no reason to alter the amount or frequency of recommended moderate-intensity physical activity for pregnant and postpartum women compared with the general adult population. • There is moderate certainty evidence of a reduced risk of preterm birth for mothers engaged in vigorous- intensity physical activity. 48 49Recommendations Does the association vary by type or domain or timing (pre-pregnancy, antenatal or postnatal) of physical activity? Evidence is available from studies that mostly assessed leisure domain physical activity; the type of activity was mostly aerobic (such as walking or swimming), although there is some evidence from studies assessing interventions that also included strength training (e.g. circuit training), or combinations of aerobic and muscle-strengthening exercise. However, overall there is insufficient evidence to determine if the associations between physical activity and health outcomes vary by type or domain or timing (pre-pregnancy, antenatal or postnatal) of physical activity. The GDG concluded that: • There is moderate certainty evidence that pregnant and postpartum women should incorporate a variety of aerobic and muscle-strengthening activities. Gentle stretching may also be beneficial. PREGNANT AND POSTPARTUM WOMEN 50 51 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Supporting evidence and rationale Sedentary behaviour was not included in the 2020 Global recommendations on physical activity for health (1). Due to a lack of population-specific evidence, the primary evidence base for assessing the associations between sedentary behaviour and health outcomes in pregnant and postpartum women was the scientific literature collated and reviewed for adult populations. The findings from evidence on sedentary behaviours in the general adult population were reviewed, including assessing whether the outcomes would be any different, or would not apply to, or would be contraindicated, for pregnant and postpartum women. In pregnant and postpartum women, as in all adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Pregnant and postpartum women should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence For pregnant and postpartum women, sedentary behaviour is defined as time spent sitting or lying with low energy expenditure while awake, in the context of occupational, educational, home and community settings and transportation. SEDENTARY BEHAVIOUR RECOMMENDATION PREGNANT AND POSTPARTUM WOMEN Based on available evidence and expert opinion, the evidence was extrapolated to inform the new WHO recommendations on sedentary behaviour for pregnant and postpartum women for the common set of critical health outcomes. Due to indirectness of the evidence, the level of certainty was downgraded. Given the lack of evidence specific to this population, and that pregnant women were excluded from studies, the recommendation to increase levels of physical activity beyond recommended levels to counter the detrimental effect of high sedentary behaviour was not extrapolated for women during pregnancy and the postpartum period. The GDG concluded that: • The evidence on sedentary behaviours in the general adult population could be extrapolated to inform recommendations for pregnant and postpartum women for the common set of critical health outcomes. • The benefits of minimizing sedentary behaviour outweigh the risks for pregnant and postpartum women. • The certainty of the evidence should be downgraded due to indirectness. 50 51Recommendations ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) To date, most physical activity guidelines for people with chronic conditions have been limited to clinical or therapeutic guidance. For example, there are clinical practice recommendations and resources developed by the professional medical associations for oncology (101), type-2 diabetes (102), hypertension (103), and other chronic diseases (104). WHO also has clinical practice guidance which includes recommending physical activity to patients with chronic disease (17). These guidelines are the first WHO population-based guidelines on physical activity for people living with chronic conditions, specifically those living with cancer (from here on referred to as “cancer survivors”), hypertension, type-2 diabetes, and HIV. Given the advances of effective and widely available antiretroviral treatment for HIV, this condition is now also considered a chronic condition. For patients undergoing acute treatment (e.g. chemotherapy), or not yet stabilized on their chronic medication, health-care providers should also refer to clinical practice guidelines relevant to each chronic condition. PHYSICAL ACTIVITY RECOMMENDATION For adults living with chronic conditions, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), transportation (wheeling, walking and cycling), work or household chores, in the context of daily occupational, educational, home or community settings. All adult cancer survivors and those living with hypertension, type-2 diabetes and HIV, should try to meet these recommendations where possible, as able and without contraindication. Physical activity can confer health benefits for adults and older adults living with the following chronic conditions: for cancer survivors – physical activity improves all-cause mortality, cancer-specific mortality, and risk of cancer recurrence or second primary cancer; for people living with hypertension – physical activity improves cardiovascular disease mortality, disease progression, physical function, health-related quality of life; for people living with type-2 diabetes – physical activity reduces rates of mortality from cardiovascular disease and indicators disease progression; and for people living with HIV – physical activity can improve physical fitness and mental health (reduced symptoms of anxiety and depression), and does not adversely affect disease progression (CD4 count and viral load) or body composition. It is recommended that: All adults and older adults with these chronic conditions should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults and older adults with these chronic conditions should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence G O O D P R A C TI C E ST A TE M EN TS 52 53 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) Adults and older adults with these chronic conditions should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional benefits. Strong recommendation, moderate certainty evidence As part of their weekly physical activity, older adults with these chronic conditions should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence When not contraindicated, adults and older adults with these chronic conditions may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence • When not able to meet the above recommendations, adults with these chronic conditions should aim to engage in physical activity according to their abilities. • Adults with these chronic conditions should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • Adults with these chronic conditions may wish to consult with a physical activity specialist or health-care professional for advice on the types and amounts of activity appropriate for their individual needs, abilities, functional limitations/ complications, medications, and overall treatment plan. • Pre-exercise medical clearance is generally unnecessary for individuals without contraindications prior to beginning light- or moderate-intensity physical activity not exceeding the demands of brisk walking or everyday living. G O O D P R A C TI C E ST A TE M EN TS Supporting evidence and rationale The scope of these guidelines assessed the associations between physical activity and the following health outcomes: for cancer survivors – all-cause mortality, cancer-specific mortality, and risk of cancer recurrence or second primary cancer; for people living with hypertension – cardiovascular disease mortality, risk of co-morbid conditions, physical function, health-related quality of life, and disease progression (here defined as the blood pressure response to physical activity); for people living with type-2 diabetes – cardiovascular disease mortality, risk of co-morbid conditions, physical function, health-related quality of life, and disease progression; and for people living with HIV – physical function (physical fitness, exercise tolerance and strength), health-related quality of life, mental health (symptoms of anxiety and depression), cardiometabolic disease risk indicators (blood lipids, blood glucose and body composition) and adverse effects on disease progression (namely CD4 count and viral load). The evidence informing these guidelines was the report of PAGAC (35) which was updated with 16 new reviews identified from 2017 to 2019 for cancer (n= 1), hypertension (n= 2) and type-2 diabetes (n= 13). In addition, a commissioned umbrella review on physical activity and health-related outcomes among people living with HIV provided evidence from 19 eligible reviews published 2002–2018. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 52 53Recommendations In adults and older adults (aged 18 years and over) living with cancer (cancer survivors), hypertension, type-2 diabetes, or HIV, what is the association between physical activity and health-related outcomes? Physical activity promotes beneficial short- and long- term changes in metabolic, hormonal, and inflammatory pathways, which are thought to be protective for cancer incidence and survival (35). Evidence shows that higher levels of physical activity after cancer diagnosis were found to be protective for all-cause mortality following breast cancer (HR= 0.58 [95% CI: 0.52 to 0.65], 17 studies); colorectal cancer (HR= 0.63 [95% CI: 0.50 to 0.78], 10 studies), female reproductive cancer (HR= 0.66 [95% CI: 0.49 to 0.88], 4 studies); glioma (HR= 0.64 [95% CI: 0.46 to 0.91], 1 study); hematologic cancer (HR= 0.60 [95% CI: 0.51 to 0.69], 2 studies); kidney cancer (HR= 0.60 [95% CI: 0.38 to 0.95], 1 study); lung cancer (HR= 0.76 [95% CI: 0.60 to 0.97], 2 studies); prostate cancer (HR= 0.60 [95% CI: 0.46 to 0.79], 5 studies); and stomach cancer (HR= 0.75 [95% CI: 0.61 to 0.93], 1 study) (105). Greater amounts of physical activity after cancer diagnosis are also associated with lower risks of cause-specific mortality in breast cancer, colorectal cancer, and prostate cancer survivors. The meta-analysis found reduced hazards of mortality for those in the highest versus the lowest levels of postdiagnosis total physical activity for all cancers combined (HR= 0.63 [95% CI: 0.53 to 0.75], 4 studies); breast cancer (HR= 0.63 [95% CI: 0.50 to 0.78], 13 studies); colorectal cancer (HR= 0.62 [95% CI: 0.44 to 0.86], 6 studies); and prostate cancer (HR= 0.70 [95% CI: 0.55 to 0.90], 4 studies) (105). There was, however, insufficient evidence to determine if physical activity is associated with cancer recurrence or second primary cancer. Physical activity is important for both the primary prevention and management of hypertension, with evidence showing that physical activity improves physical function, cardiovascular disease progression (i.e. blood pressure response to physical activity), and cardiovascular disease mortality in people living with hypertension (35). For example, compared with no exercise control groups, people with hypertension who are physically active can reduce systolic blood pressure by approximately 12mm Hg and diastolic blood pressure by approximately 6mm Hg (SBP MD= 12.26 mm Hg [95% CI: 15.17 to 9.34], p= < 0.05; DBP MD= 6.12 mm Hg [95% CI: 7.76 to 4.48], p= < 0.05) (106). Emerging evidence demonstrates that people with ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) hypertension who are physically active can significantly improve their health-related quality of life compared with those with hypertension who are inactive (54). Physical activity, including aerobic activity, muscle- strengthening activity, and aerobic plus muscle- strengthening activity, is associated with improved secondary indicators of risk of progression (HbA1c, blood pressure, BMI, and lipids) in adults with type-2 diabetes (35). For example, recent research found that resistance training was associated with greater reduction in HbA1c versus control groups, and that high-intensity resistance training has significant positive effects on fasting insulin (107). There is insufficient evidence to assess the effects of physical activity on health-related quality of life and physical function in adults with type-2 diabetes. Physical activity in people living with HIV improves cardiorespiratory fitness. The interventions studied involved either aerobic exercise, or exercise combined with progressive muscle-strengthening exercise, for at least 30 minutes, 3 times per week (108, 109). There is also evidence that physical activity interventions can improve markers of cardiometabolic risk (e.g. lipids) although results are mixed; no effects were established on insulin concentration, although glucose was lowered after aerobic training (110). Physical activity, whether aerobic, or combined with muscle-strengthening exercise, in people living with HIV is positively associated with health-related quality of life (111) and a reduction in symptoms of depression and anxiety (112). The meta- analysis for depression (9 studies) showed an SMD of 0.84 (95% CI: 1.57 to 0.11) favouring the intervention groups (p= 0.02). The SMD for reduction in anxiety (5 studies) was also statistically significant, favouring the intervention ( 1.23 [95% CI: 2.42 to 0.04], p= 0.04) (112). Physical activity is also associated with significant standardized mean increases in lean body mass of 1.75 kg and a significant decrease in percent body fat of 1.12% for participants in the exercising control groups, as well as an increase in peripheral leg and arm muscle area, compared with participants in the non-exercising control groups (111), but is not associated with changes in BMI or waist circumference in people living with HIV (111). Physical activity does not adversely influence markers of HIV disease progression, such as CD4 count (cells/mm3) or viral load (111). Importantly, this evidence suggests that HIV as a chronic disease will not be adversely affected by physical activity. 54 55 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r The GDG concluded that: • There is moderate certainty evidence that greater amounts of physical activity after cancer diagnosis are associated with lower risks of all-cause, cause-specific, and cancer-specific mortality in cancer survivors. • There is high certainty evidence that physical activity reduces the risk of cardiovascular disease progression in adults with hypertension. • There is moderate certainty evidence that physical activity improves physical function and health-related quality of life outcomes in adults with hypertension. • There is high certainty evidence that physical activity improves markers of disease progression (HbA1c, blood pressure, BMI, and lipids) in adults with type-2 diabetes. • There is moderate certainty evidence of an association between physical activity and improvements in fitness (maximal oxygen consumption, exercise tolerance) and muscular strength for people living with HIV, and favourable associations between physical activity and body composition, health-related quality of life, reduced symptoms of depression and anxiety, and no change in viral load or CD4 count in people living with HIV. • The benefits associated with engaging in regular physical activity in cancer survivors and people living with hypertension, type-2 diabetes, and HIV in relation to specific health outcomes, outweigh the risks. Is there a dose-response association (volume, duration, frequency, intensity)? Greater amounts of physical activity after cancer diagnosis have been linked with lower risks of all-cause, and cancer- specific mortality. Evidence demonstrates a non-linear relationship between increasing levels of post-diagnosis physical activity and breast cancer-specific and all-cause mortality up to 10–15 MET-hours per week (consistent with 150 mins/week of moderate- to vigorous-intensity physical activity) with no evidence for harms at higher levels (105). There is a suggestion of similar dose-response association for other cancer sites however there were too few studies to permit a formal meta-analysis. Further research is needed to determine strength of association. There is a clear dose-response relationship between physical activity and cardiovascular disease mortality for people living with hypertension (35). Findings show that as systolic blood pressure increases within hypertensive ranges, the risk of cardiovascular disease mortality increases, but this increased risk is attenuated with higher levels of physical activity (35). Similar to recommendations for the general population, most of the traditional interventions are based around 30–60 minutes of moderate-intensity aerobic activity, 3 days per week, and/or 2–3 sessions of resistance training per week. There is substantial evidence of an inverse curvilinear association between volume of physical activity and risk of cardiovascular mortality in adults with type-2 diabetes (113–115). Higher amounts of physical activity (from both below and at, or above the recommended levels of 150 mins/week of moderate-intensity activity) progressively reduce risk. For example, compared with doing no activity, engaging in some activity was associated with a 32% reduction in risk of cardiovascular disease mortality (adjusted HR= 0.68 [95% CI: 0.51 to 0.92]), while engaging in amounts of activity meeting physical activity guidelines or above was associated with a larger 40% reduction in risk of cardiovascular disease mortality (adjusted HR= 0.60 [95% CI: 0.44 to 0.82]) (115). Most interventions are based around 150–300 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity activity, and/ or 2–3 sessions of resistance training per week. For some outcomes (e.g. HBA1c and blood pressure) in adults with type-2 diabetes, there is evidence for a stronger effect with more aerobic activity (i.e. greater than 150 mins/week versus less than 150 mins/week), but limited evidence for intensity (35). In people living with HIV, there is insufficient evidence to establish a dose-response relationship between physical activity and body composition, or for intermediate markers of cardiometabolic diseases (such as blood lipid profiles, insulin resistance, fasting glucose concentrations or blood pressure). The majority of studies providing evidence involved physical activity interventions conducted at least 3 times a week for 12–48 weeks, and involved at least 30 minutes of moderate- to vigorous-intensity aerobic exercise alone or in combination with progressive resistance training. There is also insufficient evidence to establish more precisely the dose-response relationship for mental health and health-related quality of life outcomes. The available evidence is from studies typically assessing physical activity interventions of 3 or more times weekly. Overall there was evidence ranging from moderate to high certainty to support a physical activity recommendation of 150–300 minutes of moderate-intensity physical activity (or equivalent) for the specified populations of people living with chronic disease and the specific set of health outcomes. There was clearer evidence of higher levels of activity being associated with greater benefits in the evidence addressing people living with hypertension, ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) 54 55Recommendations type-2 diabetes and cancer survivors. The variations in the certainty and directness of the evidence according to the specific chronic condition and specific outcomes examined was acknowledged. Where evidence showed positive outcomes from strength training exercise, the frequency of activity was 2 or 3 sessions of resistance training per week. The GDG concluded that: • There is moderate certainty evidence of a dose-response relationship between physical activity and decreased all- cause mortality and cancer-specific mortality in cancer survivors. • There is high certainty evidence of a dose- response relationship between physical activity and cardiovascular disease mortality for adults with hypertension. • There is evidence of an inverse, curvilinear dose- response relationship between activity volume and risk of cardiovascular mortality among adults with type-2 diabetes. • There is insufficient evidence for a dose-response relationship between physical activity and intermediate markers of cardiometabolic diseases, body composition, and health-related quality of life symptoms of anxiety and depression in people living with HIV. • Interventions in the range of 150–300 minutes of moderate-intensity aerobic activity (or equivalent) provided favourable health outcomes, and positive outcomes from strength training exercise, where noted, with 2 or 3 sessions of resistance training per week. Does the association vary by type or domain of physical activity? There is evidence that different types and domains of physical activity provide favourable health outcomes. Cancer survivors who are meeting recommended levels of aerobic and muscle-strengthening physical activity, versus not meeting either recommendation, have significantly lower risk of cancer mortality (adjusted HR= 0.70 [95% CI: 0.50 to 0.98]) (84). Evidence demonstrates that adhering solely to muscle- strengthening physical activity recommendations versus not adhering is also beneficial in improving cancer mortality outcomes (HR= 0.66 [95% CI: 0.48 to 0.92]) (84). A meta-analysis also reported these associations by physical activity domain and found the most consistent reductions in mortality for all cancers, breast cancer, and colorectal cancer-specific mortality for recreational physical activity (105). For adults living with hypertension, evidence supports aerobic activity, muscle-strengthening activity, and combinations of the two for improving cardiovascular disease progression. The blood pressure lowering effects between traditional modes of physical activity (i.e. aerobic and resistance activity) do not appear to vary significantly among people with hypertension (35); however, this evidence is not based on direct comparisons between activity types. There is also emerging evidence to support beneficial effects of other forms of exercises in people living with hypertension (e.g. Tai Chi, yoga, Qigong), however further research is needed to explore these specific types of activity to determine strength of association. Aerobic activity, muscle-strengthening activity, or a combination of both, is associated with improved secondary indicators of risk of progression (HbA1c, blood pressure, BMI, and lipids) among adults with type-2 diabetes (35, 107). One review of 24 RCTs (n= 962) reported that resistance training was associated with greater reduction in HbA1c versus control groups (MD= 0.45 [95% CI: 0.65 to 0.25], 20 trials; n= 824). Statistically significant effects were found for high- intensity resistance training versus control groups on fasting insulin (MD= 4.60 [95% CI: 7.53 to 1.67], 5 trials; n= 174) (107). Another review of 7 RCTs (n= 189) reported that interval training (2–5 times/week; intervals 1–4 mins duration; total session lengths 20–60 mins) was associated with statistically significantly decreased HbA1c by 0.26% (95% CI: 0.46 to 0.07%, 5 RCTs) compared with MICT, and by 0.83% (95% CI: 1.39% to 0.27%, 4 RCTs) compared with no-exercise control groups (116). As with recommendations for the general population, most of these interventions are based around aerobic activity consistent with the recommendation of 150–300 minutes of moderate-intensity aerobic activity (or 75 minutes of vigorous-intensity activity) and muscle-strengthening activity conducted 2–3 sessions per week. For some outcomes (e.g. HBA1c and blood pressure), there is evidence for a stronger effect with more aerobic activity (i.e. greater than 150 mins/week versus less than 150 mins/ week), but limited evidence for intensity. More recent studies provide evidence that traditional Chinese exercise, such as Tai Chi may have glycaemic benefits, but these were of moderate and variable certainty (i.e. risk of bias or inconsistency). Further research is needed to determine these associations. ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) 56 57 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Multiple types of physical activity, including aerobic and resistance-training, have been shown to have positive effects on health-related quality of life in people living with HIV (111). Recent research examining changes in health-related quality of life in response to aerobic, progressive resistance exercise, or a combination of both, demonstrates significant improvements in general health, and mental health. There is also evidence that both aerobic and multicomponent activity is related to a reduction in symptoms of depression and anxiety in people living with HIV (112). Evidence for the effects of physical activity on mental health symptoms has involved aerobic or aerobic combined with progressive muscle-strengthening activity, or yoga. Evidence also demonstrates that aerobic exercise alone, or when combined with resistance exercise, does not result in any significant change in viral load or CD4 count in people living with HIV (111). Direct evidence, from both the existing and updated literature, supports the inclusion of the recommendations for people living with type-2 diabetes and hypertension to undertake aerobic and muscle-strengthening physical activity. Although there is a lack of published evidence, there is biological plausibility for the benefits of aerobic and muscle-strengthening physical activity for adults living with HIV and cancer survivors. Furthermore, as noted by the GDG, established international clinical practice guidelines recommend aerobic and muscle- strengthening physical activity for these populations (for example ACSM “Moving Through Cancer” guidelines (101) based on a systematic review of evidence (3)). Recognizing this evidence base is still emerging, the level of certainty was downgraded. The GDG concluded that: • There is moderate certainty evidence for combined or additive effects of aerobic or muscle-strengthening activity for reduced cancer mortality, improvements in blood pressure among those with hypertension. • There is high certainty evidence that aerobic activity, muscle-strengthening activity, and aerobic plus muscle- strengthening activity improve markers of disease progression (HbA1C, blood pressure, BMI, and lipids) in adults with type-2 diabetes. • There is moderate certainty evidence that regular aerobic exercise alone, or combined with resistance exercise, does not result in any significant change in viral load or CD4 count in people living with HIV. • There is insufficient evidence for an effect of strength training alone on health-related quality of life in people living with HIV. ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) 56 57Recommendations ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) Supporting evidence and rationale Due to a lack of population-specific evidence, the primary evidence base for assessing the associations between sedentary behaviour and health outcomes in adults and older adult cancer survivors and those adults and older adults living with hypertension, type-2 diabetes, and HIV, was the scientific literature collated and reviewed for adult populations. The findings from evidence on sedentary behaviours in the general adult population were reviewed, including assessing if there was evidence that the outcomes would be any different, or would not apply to, or would be contraindicated, for adults and older adults living with chronic conditions. In adults, including cancer survivors and people living with hypertension, type-2 diabetes and HIV, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality; cardiovascular disease mortality; cancer mortality; incidence of cardiovascular disease; cancer; and type-2 diabetes. For cancer survivors, and adults living with hypertension, type-2 diabetes and HIV, it is recommended that: Adults and older adults with chronic conditions should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults and older adults with chronic conditions should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence Sedentary behaviour was not included in the 2010 Global recommendations on physical activity for health (1). The scope of this new recommendation on sedentary behaviours in cancer survivors and those people living with hypertension, type-2 diabetes and HIV. Sedentary behaviour is defined as time spent sitting or lying with low energy expenditure, while awake, in the context of occupational, educational, home and community settings, and transportation. SEDENTARY BEHAVIOUR RECOMMENDATION 58 59 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) Based on available evidence and expert opinion, the evidence was extrapolated to inform the new WHO recommendations on sedentary behaviour for adults living with chronic conditions for the common set of critical health outcomes. The extrapolation of evidence is supported largely by the assessment that the majority of studies imposed no upper age limit criterion, included adults over the age of 65 years and may have included adults with chronic conditions, such as cancer survivors, those living with hypertension or type-2 diabetes. For people living with HIV, no reasons were identified as to why the evidence on the health impacts of sedentary behaviours would not apply. Due to indirectness of the evidence to develop these recommendations, the level of certainty was downgraded. The applicability of evidence on the benefit of undertaking more moderate- and vigorous-intensity physical activity to help counteract the potential risks of high levels of sedentary behaviour was also considered and was also extrapolated to inform recommendations for adults with chronic conditions for the common set of critical health outcomes. Given the indirectness, the certainty of the evidence was downgraded. The GDG concluded that: • The evidence on sedentary behaviours in the general adult population could be extrapolated to inform recommendations for adult and older adult cancer survivors and those adults and older adults living with hypertension, type-2 diabetes, and HIV for the common set of critical outcomes, with the level of certainty of the evidence downgraded due to indirectness. • The evidence on the benefits of undertaking more moderate- and vigorous-intensity physical activity to help counteract the potential risks of high levels of sedentary behaviour in the general adult population could be extrapolated to inform recommendations for adult and older adult cancer survivors and those adults and older adults living with hypertension, type-2 diabetes, and HIV for the common set of critical outcomes, with the level of certainty of the evidence downgraded due to indirectness. • The benefits for minimizing sedentary behaviours outweigh the harms for cancer survivors and those people living with hypertension, type-2 diabetes, and HIV. 58 59Recommendations CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and older) LIVING WITH DISABILITY Many of the health benefits of physical activity for children and adolescents, as set out in the section above, also relate to those children and adolescents living with disability. Additional benefits of physical activity to health outcomes for those living with disability include: improved cognition in individuals with diseases or disorders that impair cognitive function, including attention-deficit/hyperactivity disorder (ADHD); improvements in physical function may occur in children with intellectual disability. It is recommended that: Children and adolescents living with disability should do at least an average of 60 minutes per day of moderate- to vigorous-intensity, mostly aerobic, physical activity, across the week. Strong recommendation, moderate certainty evidence Vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated at least 3 days a week. Strong recommendation, moderate certainty evidence Children, adolescents and adults living with disability can achieve important health benefits from physical activity. Children, adolescents and adults with disability should try to meet these recommendations where possible and as able. For children, adolescents and adults living with disability, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), physical education, transportation (wheeling, walking and cycling) or household chores, in the context of home, educational, occupational and community settings. It is important to provide all children, adolescents and adults living with disability with opportunities and encouragement to participate in physical activities appropriate for their age and ability, that are enjoyable, and that offer variety. PHYSICAL ACTIVITY RECOMMENDATION • Doing some physical activity is better than doing none. • If children and adolescents living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Children and adolescents living with disability should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • There are no major risks for children and adolescents living with disability engaging in physical activity when it is appropriate to an individual’s current activity level, health status and physical function; and the health benefits accrued outweigh the risks. • Children and adolescents living with disability may need to consult a health-care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. G O O D P R A C TI C E ST A TE M EN TS G O O D P R A C TI C E ST A TE M EN TS 60 61 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and over) LIVING WITH DISABILITY Many of the health benefits of physical activity for adults, as set out in the section above, also relate to adults living with disability. Additional benefits of physical activity to health outcomes for those living with disability include the following: for adults with multiple sclerosis – improved physical function, and physical, mental, and social domains of health- related quality of life; for individuals with spinal cord injury – improved walking function, muscular strength, and upper extremity function; and enhanced health-related quality of life; for individuals with diseases or disorders that impair cognitive function – improved physical function and cognition (in individuals with Parkinson’s disease and those with a history of stroke); beneficial effects on cognition; and may improve quality of life (in adults with schizophrenia); and may improve physical function (in adults with intellectual disability); and improves quality of life (in adults with major clinical depression). It is recommended that: All adults living with disability should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults living with disability should do at least 150–300 minutes of moderate- intensity aerobic physical activity; or at least 75–150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence Adults living with disability should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence As part of their weekly physical activity, older adults living with disability should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence Adults living with disability may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence • Doing some physical activity is better than doing none. • If adults living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Adults living with disability should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • There are no major risks to adults living with disability engaging in physical activity when it is appropriate to the individual’s current activity level, health status and physical function; and when the health benefits accrued outweigh the risks. • Adults living with disability may need to consult a health-care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. G O O D P R A C TI C E ST A TE M EN TS 60 61Recommendations CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and over) LIVING WITH DISABILITY Supporting evidence and rationale For these guidelines for children, adolescents and adults living with disability, the comprehensive evidence synthesis undertaken by PAGAC (35) was used and updated. Full details of the methods, data extraction and summary evidence tables of this existing evidence on physical activity and health outcomes is available (35) and was reviewed by the GDG in addition to the findings of the updated search. The update conducted for these guidelines identified 39 reviews published from 2017 to 2019. Of these, 27 met the inclusion criteria and informed the examination of the association between physical activity and health-related outcomes among children, adolescents and adults living with disability. Full details of the methods, data extraction and summary evidence portfolios can be found in the Web Annex: Evidence profiles . Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf The evidence reviewed considered the association between physical activity and health-related outcomes in children, adolescents and adults living with disability resulting from the following health conditions: multiple sclerosis, spinal cord injury, intellectual disability, Parkinson’s disease, stroke, major clinical depression, schizophrenia, and attention-deficit/hyperactivity disorder (ADHD). The four health-related outcomes examined included risk of co-morbid conditions, physical function, cognitive function and health-related quality of life, although not all outcomes were explored for each condition. The impact of environmental factors on disability in the context of physical activity was beyond the scope of these guidelines and was not analysed. In children and adolescents (aged 5–17 years) and adults (aged over 18 years) living with disability, what is the association between physical activity and health-related outcomes? For people living with multiple sclerosis, physical activity improves physical function, functional mobility, walking speed and endurance, and cardiorespiratory fitness, strength and balance. For example, high-intensity interval training over 3–12 weeks demonstrated improvements in cardiorespiratory fitness or muscle strength (117) and lower limb strength training found strength increased by 23.1% (95% CI: 11.8 to 34.4) over an average training period of 13.2 weeks (118) over an average of 13 weeks resulted in increases in strength, and dance interventions studies reported improvements in functional mobility and balance (119). As well as physical health benefits, existing evidence demonstrates that physical activity can benefit cognition in people living with multiple sclerosis (35). Newer research reveals that aerobic exercise has a small yet significant effect on physical, mental and social domains of health-related quality of life (including symptoms of fatigue and depressive symptoms) (35, 120). For people living with spinal cord injury, physical activity can improve walking function, muscular strength and upper extremity function (35). Physical activity may also reduce shoulder pain, improve vascular function and enhance health-related quality of life (35). For people living with Parkinson’s disease, physical activity can improve motor symptoms, functional mobility and performance, endurance, freezing of gait and velocity of forward and backward movement (35, 121, 122). New evidence suggests that exercise can also help global cognitive function in individuals with Parkinson’s disease (123). For people with a history of stroke, physical activity can improve physical function, notably upper limb function, sensory motor function of the lower limb, balance, walking speed, distance, ability and endurance, cardiorespiratory fitness, mobility and activities of daily living. Existing evidence suggests that physical activity may also have beneficial effects on cognition (35). For people with major clinical depression, new reviews (124, 125) supported existing evidence (35) that physical activity can improve health-related quality of life (35, 124, 125). For individuals with diseases or disorders that impair cognitive function, including schizophrenia –physical activity can have beneficial effects on cognition, working memory, social cognition and attention/vigilance (35, 126). One review found that moderate- to vigorous-intensity physical activity delivered significant improvements in health-related quality of life and disability (35, 124). 62 63 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and over) LIVING WITH DISABILITY For people living with intellectual disability, physical activity has been shown to improve physical function. The interventions reviewed largely focused on balance and strength activities over 6–24 weeks and reported significant improvement in static balance, dynamic balance and static-dynamic balance compared with controls (35, 127, 128). For children with attention-deficit/hyperactivity disorder, evidence, including one review of 5 RCTs involving ADHD (129), demonstrates a positive association between exercise and attention, executive function and social disorders (35, 129). The GDG considered the evidence from the general population of children, adolescents and adults and concluded that as there is no reason to believe that there would be an effect modification due to impairment and that the same health physiological benefits will be conferred by being physically active. The GDG acknowledged that few studies include people living with disability, and that effect modification is seldom tested. This evidence in the area disability, combined with the broader evidence for the general population, supported the general population recommendation being inclusive of people with disability, noting reference to “all adults”, “all older adults” and “people of all abilities”. The GDG concluded that: In individuals with spinal cord injury, there is: • low certainty evidence that physical activity reduces shoulder pain and improves vascular function in paralysed limbs and enhances health-related quality of life; and • moderate certainty evidence that physical activity improves walking function, muscular strength, and upper extremity function. In individuals with diseases or disorders that impair cognitive function, including Parkinson’s disease, there is: • high certainty evidence that physical activity improves a number of functional outcomes including walking, balance, strength, and disease specific motor scores; and • moderate certainty evidence that moderate- to vigorous-intensity physical activity can have beneficial effects on cognition. In individuals with a history of stroke, there is: • moderate certainty evidence that mobility-oriented physical activity can have beneficial effects on physical function and cognition. In individuals with diseases or disorders that impair cognitive function, including schizophrenia, there is: • moderate certainty evidence that physical activity improves quality of life; and • high certainty evidence that moderate- to vigorous- intensity physical activity can have beneficial effects on cognition, working memory, social cognition and attention. In adults with major clinical depression there is: • moderate certainty evidence that physical activity improves quality of life. In adults with multiple sclerosis, there is: • high certainty evidence that physical activity, particularly aerobic and muscle-strengthening activities, improves physical function, functional mobility, walking speed and endurance, and cardiorespiratory fitness, strength and balance; • moderate certainty evidence that physical activity can have a beneficial effect on cognition; and • low certainty evidence that physical activity improves quality of life including symptoms of fatigue and depressive symptoms. In children and adults with intellectual disability, there is: • low certainty evidence that physical activity improves physical function. In children and adolescents with ADHD, there is: • moderate certainty evidence that moderate- to vigorous-intensity physical activity can have beneficial effects on cognition, including attention, executive function, and social disorders. The GDG further concluded that there is sufficient scientific evidence on the positive impact of physical activity on a variety of health outcomes across a broad range of impairment areas, and that the benefits of physical activity for people living with disability outweigh the potential harms. Due to indirectness of the evidence to develop these recommendations, the level of certainty was downgraded. 62 63Recommendations CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and older) LIVING WITH DISABILITY Supporting evidence and rationale Sedentary behaviour was not included in The Global recommendations on physical activity for health (2010). Due to a lack of population-specific evidence, the primary evidence base for assessing the associations between sedentary behaviour and health outcomes in children, adolescents and adults living disability was the scientific literature collated and reviewed for populations without disability. The findings from evidence on sedentary behaviours in the general population were reviewed including assessing if there was evidence that the outcomes would be any different, or would not apply to, or would be contraindicated for children, adolescents and adults living with disability. In children and adolescents, higher amounts of sedentary behaviour are associated with the following poor health outcomes: increased adiposity; poorer cardiometabolic health, fitness, and behavioural conduct/pro-social behaviour; and reduced sleep duration. It is recommended that: Children and adolescents living with disability should limit the amount of time spent being sedentary, particularly the amount of recreational screen time. Strong recommendation, low certainty evidence In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and type-2 diabetes. It is recommended that: Adults living with disability should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light- intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults living with disability should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence For children, adolescents and adults living with disability, sedentary behaviour is defined as time spent sitting or lying with low energy expenditure, while awake, in the context of educational, home and community settings, and transportation. It is possible to avoid sedentary behaviour and be physically active while sitting or lying, through, for example, upper body led activities, inclusive and/or wheelchair-specific sport and activities. SEDENTARY BEHAVIOUR RECOMMENDATION 64 65 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and over) LIVING WITH DISABILITY Based on available evidence and expert opinion, the evidence was extrapolated to inform new WHO recommendations on sedentary behaviour for individuals living with disability for the common set of critical health outcomes, recognizing that certain population groups, such as wheelchair users, unavoidably sit for long periods of time and sitting may therefore be the norm. For these groups, sedentary behaviour should be defined as time spent with low energy expenditure, e.g. moving in a power chair or being pushed while sitting in a manual wheelchair. There is a lack of research on the association between sedentary behaviour and health outcomes in individuals living with disability. However, based on expert opinion, there are no reasons to believe that there would be an effect modification due to impairment, and therefore the same physiological health benefits will be conferred by limiting sedentary behaviour in individuals living with disability. Due to indirectness of the evidence to develop these recommendations, the level of certainty was downgraded. The applicability of evidence on the benefit of adults undertaking more moderate- and vigorous-intensity physical activity to help counteract the potential risks of high levels of sedentary behaviour was also considered and was also extrapolated to inform recommendations for adults living with disability for the common set of critical health outcomes. Given the indirectness, the certainty of the evidence was downgraded. The GDG concluded that: • The evidence on sedentary behaviours in child and adolescent populations could generally be extrapolated to children and adolescents living with disability, according to their specific ability. • The evidence on sedentary behaviours in the general adult population, including the benefit for adults of undertaking more moderate- to vigorous- intensity physical activity to help counteract the potential risks of high levels of sedentary behaviour, could generally be extrapolated to adults and older adults living with disability, according to their specific ability. However, the certainty of the evidence was downgraded due to indirectness. • The benefits of minimizing sedentary behaviour in children, adolescents, adults and older adults living with disability outweigh the harms. 64 65Recommendations In accordance with the GRADE process, the proposed wording of the updated recommendations, and the rating of their strength (“strong” or “conditional”), were based on consideration of the balance of benefits to harms; the certainty of evidence; sensitivity to the values and preferences of those affected by the guidelines; the potential impact on gender, social and health equity; and acceptability, feasibility and resource implications. These were considered for each population group, but given the similarity of issues and considerations discussed, are consolidated and presented here. The strength of the recommendation was primarily based on the assessed balance of benefits to harms. Recommendations were graded “strong” if the balance of benefits to harms was assessed as substantial for the target population for the recommendation, and “conditional” if the balance of benefits to harms was small or there was important likely variability in benefits in the target population. The evidence on harms was specifically sought through the commissioning of a new systematic review. However, this was limited, as most evidence focuses on injuries and harms to elite and competitive athletes, rather than the general population. Overall, despite the limited evidence, and informed by expert opinion, it was concluded that the risk was no greater than small. The evidence generally indicated that the benefits of physical activity far outweighed the harms, and that physical activity can be an important intervention to support closing an existing health gap, particularly for disadvantaged populations. Issues of health equity, feasibility and acceptability were also considered by the GDG and formed part of the online public consultation on the draft recommendations held between 31 March 2020 and 17 April 2020. The survey for the public consultation asked specific questions on the balance between the costs to individuals and governments of implementing the recommendations, and the potential health benefits, and whether the guidelines would improve health equity. In addition, the draft recommendations and the feedback form were sent to countries that had recently expressed an interest in developing, or had initiated the process of drafting, national guidelines on physical activity. Feedback was received from more than 420 submissions to the online consultation, and additional collation of feedback from the WHO European Regional Office, incorporating comments from WHO Collaborating Centres and Member States. The feedback from this consultation was collated, reviewed by the GDG, and used to further inform the consideration on feasibility, resource implications, and health equity through consultation with the Steering Group and the GDG. Decisions were reached by consensus through discussion. The GDG came to consensus on each recommendation and on the strength of the recommendation; ratings and voting were not required. ASSESSMENT OF THE CERTAINTY OF EVIDENCE The GRADE framework was used by the GDG to examine the certainty of primary research contributing to each outcome identified in the PI/ECOs, and assessed the overall certainty of evidence taking into consideration the risk of bias, inconsistency, imprecision, indirectness of the evidence and publication bias across each outcome. GRADE tables detailing this information for each PI/ECO are available in the Web Annex: Evidence profiles . The assessment of the certainty of the evidence was based on an overall assessment across all evaluated outcomes and prioritized all-cause mortality and cardiovascular mortality as the most critical outcomes, followed by other clinical outcomes (falls, depression, cognition, health-related quality of life, etc), then intermediate outcomes (e.g. cardiometabolic markers, other metabolic markers), as well as harms. Where the evidence had not been specifically reviewed, such as for sedentary behaviour in subpopulations primarily due to a lack of evidence for these groups, the evidence for the general population was extrapolated and downgraded where this was deemed appropriate, due to indirectness. EVIDENCE TO RECOMMENDATIONS Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 66 67 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r BENEFITS AND HARMS The development of the recommendations included an assessment of adverse impacts or risks. Where there was limited evidence, decisions were based on the expertise of the GDG. Overall, for all populations it was concluded that the benefits of physical activity and limiting sedentary behaviour outweighed the potential harms. These guidelines are for the general population and do not address the benefits and harms experienced by athletes undertaking the types and amounts of activity necessary to improve performance-related fitness for participation in competition. Doing some physical activity is better than doing none. If individuals are not currently meeting these recommendations, doing some physical activity will bring benefits to their health. They should start by doing small amounts of physical activity, gradually increasing frequency, intensity and duration over time. Pre-exercise medical clearance is generally unnecessary. Inactive individuals who gradually progress to undertaking moderate-intensity activity have no known risk of sudden cardiac events and very low risk of bone, muscle, or joint injuries. An individual who is habitually engaging in moderate-intensity activity can gradually increase to vigorous-intensity without needing to consult a health- care provider. Those who develop new symptoms when increasing their levels of activity should consult a health- care provider. The choice of appropriate types and amounts of physical activity can be affected by pregnancy, chronic conditions, and disability, and should be undertaken as able and without contraindication. These individuals may wish to consult with a physical activity specialist or health-care professional for advice on the types and amounts of activity appropriate for their individual needs, abilities, functional limitations/complications, medications, and overall treatment plan. Light- and moderate-intensity physical activity are generally low risk and are recommended for all. VALUES AND PREFERENCES The values and preferences of those affected by the guidelines (in this case parents and caregivers, children and adolescents, adults, older adults, pregnant and postpartum women, people living with chronic conditions and/or disability) were considered. Overall it was concluded that there was little or no uncertainty about preferences regarding the main outcomes, including mortality and cardiovascular mortality. The estimated potential benefits greatly outweighed any potential harms, and as such, the GDG considered the recommendations to be not preference-sensitive. RESOURCE IMPLICATIONS The expert opinion of the GDG, and a small body of evidence reporting on economic analyses of interventions and savings to the health-care systems from increasing levels of physical activity, informed discussion on the resource implications of the recommendations in different settings. In addition, results from the online public consultation showed that over 75% of respondents agreed, or strongly agreed, that the benefits of implementing the guidelines would outweigh the cost to the individual, and 81% agreed, or strongly agreed, that the benefits of implementing the guidelines would outweigh the cost to government. Available evidence and expert opinion recognize that substantial health benefits can be achieved at low risk through activities such as walking, that require no specific equipment or cost to the individual. Further, it was acknowledged that other forms of physical activities, for example structured sports, cycling and exercise classes, may incur costs, which can be a barrier for some individuals, particularly those with lower incomes. Government implementation of policy and programmes to promote and enable physical activity also requires investments in areas such as human resources, policy development, provision of facilities and services and potentially, equipment, some of which is incurred by ministries of health, but also in sectors outside of health, such as sport, education, transport and urban planning. The resources required may be at more than one level of government (national, subnational and local levels) to ensure all communities have equal access to physical activity opportunities. These investments may involve new resources, but also can be addressed by reallocation of existing budgets to reflect the prioritization of facilities and programmes towards increasing population levels of physical activity. Examples of budget reallocation include towards infrastructure for walking and cycling from the existing transport budget, and towards “sports for all” from the sports budgets. In key settings, such as schools and workplaces, low-cost interventions, combined with changes to the physical environment, can support participation in physical activity and would also contribute to reducing inequities in opportunities to be active, 66 67Evidence to recommendations experienced by some subpopulation groups. Overall, it was assessed that while there are resource implications to achieve these draft recommendations, implementation of actions is possible within current governance structures. Further, evidence supports that substantial health savings are possible for the health-care system resulting from increasing levels of physical activity. In 2013 the global annual cost of physical inactivity was estimated at INT$ 54 billion due to direct health costs alone (130); and at a national level, inactivity is estimated to cost between 1–3 % of health-care budgets (131). Within the wider context of noncommunicable disease (NCD) prevention, additional costs to government and nongovernmental organizations of guideline implementation may be minimized if recommended physical activity can be relatively easily incorporated by individuals into their lives; likewise if existing resources in primary and secondary care, schools, workplaces or transportation can be shifted, resulting in increased physical activity. Analysis of the cost and benefits of physical activity promotion indicate positive returns on investment over 15 years, in terms of NCD prevention, in many countries where the investment cases have been conducted (132). Interventions such as public education and awareness campaigns and physical activity counselling and referral are a “best buy” and a “good buy” respectively, of recommended interventions to address NCDs based on an update of Appendix 3 of the Global action plan for the prevention and control of NCDs 2013–2020 (133). Overall, the GDG concluded that the benefits of implementing the recommendations outweigh the costs. Delivering on physical activity guidelines for people with disability may require investment, such as the training of activity specialists, adapted equipment where needed, and facilities that need to be made accessible. These investments can facilitate the needs of a wide range of population groups. Evidence demonstrates a significant participation gradient between people with and without disability in relation to physical activity, due to multiple barriers regarding access, choice of activities offered, and the attitudes of others. Universal design principles should be applied to ensure full and effective participation by people living with disability. With innovation, it is possible to address many of these resource implications. Adopting universal design approaches would mitigate against these costs in the future. EQUITY, ACCEPTABILITY AND FEASIBILITY In updating the 2010 recommendations the decision was taken to explicitly include consideration of vulnerable populations, such as those living with chronic conditions and/or disability. The GDG and Steering Group included members representing such groups. The GDG discussed each recommendation at length, considering whether implementing the recommendations would decrease health equity, and the issues related to implementation, to ensure that the recommendations did not worsen equity issues (for example, ensuring that there are safe facilities and opportunities accessible for all, including people living with disability, and socioeconomically and other disadvantaged people, to engage in physical activity; addressing gender and other cultural biases that could restrict access and opportunity to participate in physical activity, etc.). Of respondents to the online public consultation, 76% agreed, or strongly agreed, that implementing the guidelines can achieve a reduction in health inequity by increasing opportunities for all to be active and improve health outcomes. It was noted that supporting environments are key to enabling participation in physical activity. A comprehensive approach to the design and implementation of policies across a number of sectors will be required to address barriers to physical activity for vulnerable groups, such as socioeconomically disadvantaged women and girls, and people with disability. People with disability experience worse health outcomes than people without disability, yet the benefits of physical activity far outweigh the harms and can be an important intervention to close this health gap. Evidence demonstrates a significant participation gradient between people with and without disability in relation to physical activity, due to multiple barriers regarding access, choice of activities offered, and the attitudes of others. For many people with disability, it should be possible to engage in various forms of physical activity without the need for adapted equipment or facilities. However, in order for people with disability to engage in physical activity on an equal basis with others, adapted equipment may need to be obtained, facilities may need to be made accessible, and activity specialists may need to be trained. 68 69 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Despite the large quantity of data relating physical activity and, increasingly, sedentary behaviours to health outcomes across the life span, the GDG discussions revealed important evidence gaps, which should be prioritized to inform future guidelines. Evidence gaps across population subgroups included a lack of information on: 1) the more precise details on the dose-response relationship between physical activity and/or sedentary behaviour and several of the health outcomes studied; 2) the health benefits of light-intensity physical activity and of breaking up sedentary time with light- intensity activity; 3) differences in the health effects of different types and domains of physical activity (leisure time; occupational; transportation; household; education) and of sedentary behaviour (occupational; screen time; television viewing); and 4) the joint association between physical activity and sedentary time with health outcomes across the life course. It was also noted that there remains limited evidence from low- and middle-income countries, economically disadvantaged or underserved communities, and in people living with disability and/or chronic disease. Many studies are not designed or powered to test for effect modification by various sociodemographic factors (age, sex, race/ethnicity, socioeconomic status) that may modify the health effects of physical activity. Such information is important for making more specific public health recommendations and for reducing health disparities in more vulnerable sectors of the population. Further details on the research gaps arising from these new guidelines can also be found in published literature (134). RESEARCH NEEDS 68 69Research needs The goal of these guidelines is to provide policy- makers, and those who develop health-care, education, workplace and community intervention programmes, with recommendations on how much time children, adolescents, adults and older adults should spend each day being physically active, and recommendations on limiting time spent being sedentary. However, developing global guidelines is not an end in itself: without dissemination and implementation, changes in physical activity levels will not be achieved. ADOPTION WHO undertakes a rigorous and extensive process to develop globally relevant guidelines (21) for use by all countries. These Guidelines on physical activity and sedentary behaviour provide evidence-based recommendations on the health impacts of physical activity and sedentary behaviour that national governments can adopt and use as part of their national policy frameworks. The development of global guidelines, with extensive consultation, should largely remove the need for individual countries to use resources to undertake the lengthy scientific process. Reviewing and adopting these global physical activity and sedentary behaviour guidelines provides a rapid and cost-effective method to develop guidelines tailored to local context. Adopting the WHO guidelines at regional or national level will ensure countries provide consistent recommendations on physical activity and sedentary behaviour, which are informed by the latest and best available scientific evidence. In addition, consistency of the recommendations across countries will facilitate national surveillance, global estimates of physical activity and sedentary behaviour, and cross- country comparisons. Throughout the adoption process, consideration should be given to the need to contextualize and tailor the guidelines. Translation into the local language is one element of adoption and contextualization. Examples of physical activities may need to be changed to be locally relevant and the use of images tailored to reflect local cultures, norms and values. A step-by-step framework to support country adoption of the Global guidelines is under development, following a series of regional workshops with relevant stakeholders. This framework can be populated with relevant national data (for example physical activity prevalence estimates), and will provide a fast-track approach to the development of a national guidelines document. These supporting resources will be available in 2021 through the WHO website. When considering adopting the guidelines it is recommended that the following ten-step process is applied: 1. Advocate for a review of current national guidelines on physical activity and the adoption of the WHO guidelines to secure government authorization. 2. Engage key stakeholders both within the health sector and other relevant sectors, such as sport, education, transport; engage relevant professional associations and scientists, with topic expertise. 3. Assess the applicability, acceptability and feasibility of the recommendations. 4. Adapt guidelines to the local context, including language, examples, and other cultural considerations. 5. Conduct an external review with target users, including policy-makers, practitioners, and the general public. 6. Establish a budget and clear plan for dissemination and communication. 7. Publish and promote the national guidelines, ideally alongside a launch event to generate publicity and interest. 8. Engage relevant professional bodies or organizations and support policy alignment and/or endorsement. 9. Implement national policies and practices to support implementation of national guidelines and behaviour change. 10. Agree a timeline for evaluation, review, and update of the guidelines. ADOPTION, DISSEMINATION, IMPLEMENTATION AND EVALUATION 70 71 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r DISSEMINATION National physical activity guidelines are a core component of the governance structures for a comprehensive approach to increasing population levels of physical activity. National guidelines inform the development and priorities of national and subnational strategy planning and require dissemination of the correct information, to the relevant groups of people, in an appropriate way. Unfortunately, too often, national guidelines are not disseminated, and so awareness of recommendations among both professional audiences and the wider community can remain very low. Securing dedicated resources to support wide-scale dissemination is an important first step to changing awareness and knowledge about the importance of increasing physical activity and reducing sedentary behaviours. Key audiences for dissemination of national guidelines on physical activity and sedentary behaviour include: • Policy-makers within and outside the health sector (including transport, planning, education, workplaces, sport, parks and recreation), to increase: a. knowledge of the contribution that increasing physical activity and reducing sedentary behaviour can have in improving not only health, but also a range of diverse yet related agendas, including gender equity, human rights obligations, and sustainable development; b. integration of policy and programmes on physical activity and sedentary behaviour into all relevant policies; and c. investment in scaled-up and coordinated national and local actions. • Non-state actors (including nongovernmental organizations, academic and research organizations, the private sector as well as the media and research funding agencies), to: a. raise awareness of the importance of increasing physical activity and reducing sedentary behaviours across all ages; b. encourage and ensure policy alignment; and c. increase collaboration and investment in policy implementation and local action. • Practitioners in health and non-health sectors (including sport, education, transport, and planning) to increase: a. awareness and knowledge of national guidelines on physical activity and sedentary behaviours; b. knowledge, skills and confidence in promoting increased physical activity and reduction in sedentary behaviours; and c. integration of physical activity promotion into routine practice where applicable. • The general public and specific population subgroups, to increase: a. awareness and knowledge of the guidelines on physical activity and sedentary behaviour; b. knowledge of how to achieve the physical activity and sedentary behaviour guidelines; and c. intentions and motivation to be more physically active and to reduce sedentary behaviour. COMMUNICATION CAMPAIGNS Different stakeholders will benefit from different materials; therefore to communicate guidelines to multiple audiences effectively, consideration must be given to the content, format, and delivery channels for guideline communication. When developing a guideline communication strategy, formative research can help determine the key audiences and understand the values, needs and preferences that influence levels of physical activity and sedentary behaviour. This should include exploration of the barriers to physical activity or to the integration of physical activity into policy and practice, as well as testing of draft messages and materials with different groups. This will help inform the key messages that are used, as well as the appropriate format(s) and channel(s) for communication. A comprehensive communication strategy will include a range of communications aimed at different audiences. Countries may need to prioritize specific groups depending on available resources (human and financial). Communication campaigns on physical activity targeting the general public or specific subpopulations are a cost- effective intervention (133) and recommended in the WHO Global action plan on physical activity 2018–2030 (14). National and subnational campaigns on physical activity typically establish an overarching campaign slogan (for example “Be Active” or “Move More”), and develop design elements or characters, which may include tailored messages for different audiences 70 71Adoption, dissemination, implementation and evaluation (such as for young children, adolescents, adults or older adults, the less active, people living with disability or chronic conditions). Campaign messages and resources that are tailored to specific population groups are likely to be more effective than generic materials. Communication campaigns should consider the reach and effectiveness of both traditional media channels (such as television, radio, billboards, printed resources) as well as digital media channels (websites, mobile phones, Apps). Providing information on the national guidelines in a variety of formats is also useful. For example, a relatively new but increasingly common approach to communicating physical activity guidelines is through the use of infographics or short animated videos. WHO has supporting materials for developing and implementing such communication campaigns (135). The academic and research community are likely to be interested in the scientific report which details the epidemiological evidence on which the guidelines are based. However the specific details of the underlying research is unlikely to be of interest to other more general audiences. Policy-makers may prefer a summary of the science, or even a short briefing document. Other audiences, such as health and non-health professionals, are more likely to favour different types of resources, for example a brochure or factsheet about the guidelines, or about how to integrate physical activity promotion into routine practice (for example in patient consultations in a health-care setting, or when developing building or transport plans for urban environments). Different professionals will require resources that are tailored to their role. Health professions, in particular, may benefit from a suite of resources to reflect the diverse population groups that they work with. IMPLEMENTATION OF POLICY AND PROGRAMMES National guidelines on physical activity and sedentary behaviour, in isolation, are unlikely to lead to increases in population levels of physical activity and should therefore be seen as one element of a policy and planning framework. It is critical that national guidelines are disseminated to key audiences and supported by a sustained national communication strategy that will lead to increased awareness and knowledge about the multiple benefits of regular physical activity and reducing sedentary behaviours. However, in order to achieve sustained behaviour change, these actions must be supported by policies that create supportive environments that enable and encourage people to be active, along with increased local, appropriate opportunities for people to participate in physical activity. Policies and programmes must consider and be adapted to the local context, in terms of both the health system and the complex multisector institutions that have an interest in, or opportunity to support, physical activity promotion. Action should be taken using a “whole of government” approach and consider the “system” of policies and multiple actions that can, through engagement of a wide range of stakeholders, support more people to be physical active across multiple sectors and settings. Using a “systems” approach that is aligned with a sustained communication strategy ensures that increased demand for physical activity, generated through effective communication, is matched by the provision of environments and opportunities for people to be physically active. 72 73 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r The WHO Global action plan on physical activity 2018–2030 set a target to reduce physical inactivity by 15% by 2030, and outlined 20 recommended policy actions and interventions (14). These included recommending that all countries implement sustained national public education and awareness campaigns and the integration of physical activity counselling programmes into primary and secondary health care. Other recommendations included the creation of appropriate environments for physical activity, including walking, cycling and wheeling, for all population groups and the provision of more opportunities and programmes for physical activity in schools, workplaces and sports clubs and venues. Implementation across all 20 recommendations may not be feasible in the short term in all countries, but should be viewed as a long-term goal. To identify an appropriate and feasible set of immediate actions, WHO Member States should conduct a situational analysis of current policy and practice. This will enable multisector collaboration and help identify areas of strength as well as gaps and opportunities, and can be used as the basis for developing or updating national and subnational plans. These new WHO guidelines support expanding the scope of actions to include additional groups, such as people living with disability or chronic conditions, and women who are pregnant or postpartum. Policy will need to support appropriate programme delivery and practice that recognizes community needs and the diversity of groups and contexts. A number of sector-specific toolkits are under development to support implementation of the ACTIVE technical package (135); these will provide each sector with guidance on how to promote physical activity, for example through schools, through primary health care, or by improving provision for walking and cycling. The ACTIVE toolkit, as well as other WHO regional and national resources will support implementation of these physical activity and sedentary behaviour guidelines. SURVEILLANCE AND EVALUATION The WHO Global recommendations for physical activity for health have been used as benchmarks for population health monitoring and surveillance since 2010. The changes introduced to the recommendations in these updated guidelines will have some implications for surveillance systems and assessment instruments currently used to monitor national levels of physical activity. The publication of these new guidelines will call for a review of current instruments and reporting protocols to inform any adjustments and recommendations on future reporting against the new guidelines. Instruments, such as the Global Physical Activity Questionnaire and Global Student Health Survey, will be reviewed and protocols updated to align with these new guidelines; supporting guidance to all countries will be provided in 2021. The WHO NCD Country Capacity Survey (CCS) is the main instrument used to monitor global progress on NCD policy implementation, and is conducted every two years. The CCS includes specific questions on population surveillance systems on physical activity for each age group covered by these WHO guidelines on physical activity and sedentary behaviour, and since 2019, on the existence of national physical activity guidelines. WHO Member States are requested to upload documentation to support their response. In 2019, of the 194 WHO Member States, 78 (40%) reported having physical activity guidelines (136). A detailed document analysis of responses to the CCS in 2019 was carried out, and identified that only two thirds of the 78 Member States (52/78) with national guidelines include statements on how much physical activity their populations should do; and of these, only 42 countries aligned fully with the 2010 WHO Global recommendations on physical activity for health (1). Data from the 2021 and subsequent surveys will provide information on uptake of these updated guidelines. UPDATING These guidelines will be updated after ten years, unless advances in the science of how physical activity is assessed using device-based measurement, and the rapidly evolving science on sedentary behaviour, prompt an earlier update. 72 73Adoption, dissemination, implementation and evaluation 74 75 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 1. World Health Organization. Global recommendations on physical activity for health. 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DiPietro L, Al-Ansari S, Biddle S, Borodulin K, Bull F, Buman M, et al. Advancing the global physical activity agenda: recommendations for future research by the 2020 WHO Physical Activity and Sedentary Behavior Guidelines Development Group. Int J Behav Nutr Phys Act. 2020;In press. 135. World Health Organization. ACTIVE: a technical package for increasing physical activity. Geneva: World Health Organization; 2018. 136. World Health Organization. Assessing national capacity for the prevention and control of noncommunicable diseases: report of the 2019 global survey. Geneva: World Health Organization; 2020. 82 83 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r G lo be b as ed o n io at /S hu tt er st oc k, s ilh ou et te s ha pe s or ig in al ly b as ed o n Sh ut te rs to ck s ou rc es 82 83References 84 85 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r WHO Steering Group The Steering Group included experts in the areas of physical activity, adolescent health, ageing disability, mental health, injury prevention, cancer, pregnancy and surveillance from both headquarters and regional offices. Valentina Baltag Department of Maternal, Newborn, Child and Adolescent Health and Ageing – adolescent health Maurice Bucagu Department of Maternal, Newborn, Child and Adolescent Health and Ageing – pregnancy Fiona Bull Chairperson Department for Health Promotion – physical activity Alex Butchart Department of Social Determinants of Health – injury prevention Neerja Chowdhary Department of Noncommunicable Diseases – mental  health/dementia Regina Guthold Department of Maternal, Newborn, Child and Adolescent Health and Ageing – adolescent surveillance Riitta-Maija Hämäläinen Western Pacific Regional Office Andre Ilbawi Department of Noncommunicable Diseases – cancer Wasiq Khan Eastern Mediterranean Regional Office Lindsay Lee Department of Noncommunicable Diseases – disability Alana Officer Ageing Leanne Riley Department for Noncommunicable Diseases – surveillance Gojka Roglic Department for Noncommunicable Diseases – diabetes Juana Willumsen Department for Health Promotion – physical activity The Steering Group drafted the scope of the guidelines, and the PI/ECOs. They reviewed the declaration of interests; and drafted, reviewed and finalized the guidelines. Contributors to guideline development ANNEX 1: MANAGEMENT OF GUIDELINE DEVELOPMENT PROCESS 84 85Annex 1 Guideline Development Group (GDG) The Guideline Development Group consisted of a broad group of relevant experts in the field and end users of, and persons affected by, the recommendations. The members of the Guideline Development Group included: Dr Salih Saad Al-Ansari (advocate in health promotion and education to combat NCDs through physical activity and walking); Dr Stuart Biddle (physical activity and sedentary behaviour, and behaviour change); Dr Katja Borodulin (physical activity in pregnancy and older adults); Dr Matthew Buman (sleep, sedentary behaviour, and physical activity in people living with chronic conditions); Dr Greet Cardon (physical activity in children and adolescents); Ms Catherine Carty (physical activity in people living with disability); Dr Jean-Philippe  Chaput (sleep, sedentary behaviour and physical activity in children and adolescents); Dr Sebastien Chastin (physical activity, sedentary behaviour and health, objective measurement of physical activity and sedentary behaviour); Dr Paddy Dempsey (physical activity and sedentary behaviour in adults and people living with chronic conditions); Dr Loretta DiPietro (physical activity in pregnancy and older adults); Dr Ulf Ekelund (sedentary behaviour and physical activity, physical activity in children and adolescents); Dr Joseph Firth (physical activity and mental health); Dr Christine Friedenreich (physical activity in people living with chronic conditions, physical activity and cancer risk); Dr Leandro Garcia (physical activity and health in adults); Dr Muthoni Gichu (policy implementation, national government); Dr Russ Jago (physical activity in children and adolescents); Dr Peter Katzmarzyk (physical activity and sedentary behaviour); Dr Estelle V. Lambert (physical activity and obesity); Dr Michael Leitzmann (sedentary behaviour and physical activity in people living with chronic conditions); Dr Karen Milton (translating recommendations into practice); Dr Francisco B. Ortega (physical activity in children and adolescents, mental health and objective measurement); Dr Chathuranga Ranasinghe (promotion of physical activity and health in the community, workplace and school settings); Dr Emmanuel Stamatakis (physical activity and sedentary behaviour and multiple health outcomes in adults); Dr Anne Tiedemann (physical activity in older adults); Dr Richard Troiano (policy development); Dr Hidde van der Ploeg (physical activity and sedentary behaviour in adults); Ms Vicky Wari (policy implementation – national government); Dr Roger Chou (Pacific Northwest Evidence- based Practice Center and Professor of Medicine, Departments of Medicine, Medical Informatics and Clinical Epidemiology of the Oregon Health and Science University) served as GRADE methodologist. Further details of the GDG are available in Annex 2. A first GDG meeting was held 2–4 July 2019, at which the GDG decided on the PI/ECO questions, reviewed the existing systematic reviews, and identified updates required. The Group agreed on the process for decision-making on recommendations and the strength of the evidence to be applied at the second GDG meeting. The second meeting was held 11–14 February 2020; updated evidence was reviewed and final recommendations agreed upon by consensus. 86 87 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r External Review Group (ERG) Seven peer reviewers were drawn from a list of individuals suggested by the GDG and Steering Group. They provided relevant expertise, including programme implementation and represented all six WHO regions. The ERG reviewed the draft guidelines and provided feedback to the Steering Group on issues of clarity and implementation, which was incorporated, as appropriate. External peer reviewers did not make changes to the recommendations. External peer reviewers are listed in Annex 2. Declarations of Interest All GDG members and external peer reviewers completed and submitted a WHO Declaration of Interests form and signed confidentiality undertakings prior to attending any GDG meetings. The Steering Group reviewed and assessed the submitted curriculum vitae and declarations of interest and performed an internet and publications search to identify any obvious public controversies or interests that may lead to compromising situations. The names and brief biographies of all proposed GDG members were published on the WHO Physical Activity webpage for public consultation for a period of 14 days. No comments were received. If additional guidance on management of any declaration or conflicts of interest had been required, the Steering Group would have consulted with colleagues in Office of Compliance, Risk Management and Ethics. If deemed necessary, individuals found to have conflicts of interest, financial or non-financial, would have been excluded from participation on any topics where interests were conflicting. The management of conflicts of interest was reviewed throughout the process. GDG members were required to update their Declaration of Interest, if necessary, before each meeting and a verbal declaration of interest was solicited at the beginning of each GDG meeting. Declared interests of the GDG and of the external peer reviewers are summarized in Annex 3. No conflict of interest was identified. Peer review The draft guidelines were reviewed by seven external peer reviewers identified by the GDG and Steering Group. External peer reviewers were requested to provide comments on issues of clarity, presentation of the evidence, and implementation; comments were incorporated as appropriate. External peer reviewers could not change the recommendations decided upon by the GDG. External peer reviewers are listed in Annex 2; a summary of declarations of interest are provided in Annex 3. In addition, inputs were actively sought from WHO regional offices. 86 87Annex 1 Guideline Development Group Dr Salih Al-Ansari Assistant Professor Family & Community Medicine Founder and CEO Health Promotion Center Riyadh SAUDI ARABIA Dr Stuart Biddle Professor of Physical Activity & Health Physically Active Lifestyles Research Group Centre for Health Research Institute for Resilient Regions University of Southern Queensland Springfield Central AUSTRALIA Dr Katja Borodulin The Age Institute Helsinki FINLAND Dr Matthew Buman College of Health Solutions Arizona State University Phoenix USA Dr Greet Cardon Department of Movement and Sports Sciences Faculty of Medicine and Health Sciences Ghent University Gent BELGIUM Ms Catherine Carty UNESCO Chair Project Manager Institute of Technology Tralee Co Kerry IRELAND Dr Jean-Philippe Chaput Senior Scientist, Healthy Active Living and Obesity (HALO) Research Group Children’s Hospital of Eastern Ontario (CHEO) Research Institute Department of Pediatrics University of Ottawa Ottawa, Ontario CANADA Dr Sebastien Chastin Professor of Health Behaviour Dynamics School of Health and Life Sciences Department of Psychology, Social Work and Allied Health Sciences Glasgow Caledonian University Glasgow UNITED KINGDOM Dr Roger Chou (GRADE Methodologist) Departments of Medicine, and Medical Informatics & Clinical Epidemiology Oregon Health & Science University Portland, Oregon USA Dr Paddy Dempsey MRC Epidemiology Unit University of Cambridge School of Clinical Medicine Institute of Metabolic Science Cambridge UNITED KINGDOM ANNEX 2: GUIDELINE DEVELOPMENT GROUP, EXTERNAL PEER REVIEWERS, AND WHO STAFF INVOLVED IN THE DEVELOPMENT OF THESE GUIDELINES 88 89 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Dr Loretta DiPietro Department of Exercise and Nutrition Sciences Milken Institute School of Public Health The George Washington University Washington, DC USA Dr Ulf Ekelund Department of Sport Medicine Norwegian School of Sport Science Oslo NORWAY Dr Joseph Firth Presidential Fellow School of Health Sciences University of Manchester Manchester UNITED KINGDOM Dr Christine Friedenreich Scientific Director Department of Cancer Epidemiology and Prevention Research Cancer Control Alberta Alberta Health Services Calgary CANADA Dr Leandro Garcia Research Associate Centre for Public Health Queen’s University Belfast Belfast UNITED KINGDOM Dr Muthoni Gichu Head Division of Geriatric Medicine Department of Non-Communicable Diseases Ministry of Health Nairobi KENYA Dr Russell Jago Professor of Paediatric Physical Activity & Public Health Centre for Exercise, Nutrition & Health Sciences School for Policy Studies University of Bristol Bristol UNITED KINGDOM Dr Peter T. Katzmarzyk Associate Executive Director for Population and Public Health  Sciences Professor and Marie Edana Corcoran Endowed Chair in Pediatric Obesity and Diabetes Pennington Biomedical Research Center Baton Rouge USA Dr Estelle V. Lambert Director Research Centre for Health Through Physical Activity, Lifestyle  and Sport University of Cape Town Cape Town SOUTH AFRICA Dr Michael Leitzmann Professor of Epidemiology Department of Epidemiology and Preventive Medicine University of Regensburg Regensburg GERMANY Dr Karen Milton Associate Professor in Public Health Norwich Medical School University of East Anglia Norwich UNITED KINGDOM Dr Francisco B. Ortega Head Unit of Physical Activity and Health Promotion Research Institute of Sport and Health (iMUDS) Department of Physical Education and Sports University of Granada Granada SPAIN 88 89Annex 2 Dr Chathuranga Ranasinghe Chairperson NIROGI Lanka project Sri Lanka Medical Association Senior lecturer Sports and Exercise Medicine Unit Faculty of Medicine University of Colombo C Colombo SRI LANKA Dr Emmanuel Stamatakis Charles Perkins Centre Faculty of Medicine and Health School of Public Health University of Sydney Sydney AUSTRALIA Dr Anne Tiedemann Associate Professor Institute for Musculoskeletal Health School of Public Health Faculty of Medicine and Health University of Sydney Sydney AUSTRALIA Dr Richard Troiano Epidemiology and Genomics Research Program National Cancer Institute National Institutes of Health Rockville USA Dr Hidde van der Ploeg Associate Professor Department of Public and Occupational Health Amsterdam Public Health Research Institute Amsterdam University Medical Centres Amsterdam NETHERLANDS Ms Vicky Wari* Programme Manager, NCD National Department of Health Port Moresby PAPUA NEW GUINEA External review group Dr Kingsley Akinroye NCD Alliance Nigeria NIGERIA Dr Huda Alsiyabi Director Department of Community Based Initiatives Ministry of Health OMAN Dr Alberto Flórez-Pregonero Pontificia Universidad Javeriana COLOMBIA Dr Shigeru Inoue Department of Preventive Medicine and Public Health Tokyo Medical University JAPAN Dr Agus Mahendra Department of Physical education Universitas Pendidikan INDONESIA Dr Deborah Salvo Prevention Research Center in St. Louis Brown School Washington University USA Dr Jasper Schipperijn President-Elect 2020–2022 International Society of Physical Activity and Health Department of Sports Science and Clinical Biomechanics University of Southern Denmark DENMARK * unable to attend90 91 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r * unable to attend WHO Steering Group Dr Valentina Baltag Head Adolescent and Young Adult Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND Dr Maurice Bucagu Medical Officer Maternal Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND Dr Alexander Buchart Head Violence Prevention Social Determinants of Health Department WHO Headquarters Geneva SWITZERLAND Dr Fiona Bull Head Physical Activity Department of Health Promotion WHO Headquarters Geneva SWITZERLAND Dr Regina Guthold Scientist Adolescent and Young Adult Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND Dr Riitta-Maija Hämäläinen Technical Officer Noncommunicable Diseases and Health Promotion WHO Regional Office for the Western Pacific Manila PHILIPPINES Dr Andre Ilbawi Technical Officer Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Dr Wasiq Khan* Regional Adviser Health Education and Promotion WHO Regional Office for the Eastern Mediterranean Cairo EGYPT Ms Lindsay Lee Technical Officer Sensory Functions, Disability and Rehabilitation Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Ms Alana Officer Senior Health Adviser Healthy Ageing Office of the Director-General WHO Headquarters Geneva SWITZERLAND Ms Leanne Riley Head Surveillance Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Dr Gojka Roglic Medical Officer Noncommunicable Diseases Management Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Dr Juana Willumsen Technical Officer Physical Activity Department of Health Promotion WHO Headquarters Geneva SWITZERLAND 90 91Annex 2 ANNEX 3: SUMMARY OF DECLARATION OF INTEREST AND HOW THESE WERE MANAGED Guideline Development Group members Name Gender Expertise Disclosure of interest Conflict of interest and management Dr Salih Saad Al-Ansari Male Advocate in health promotion and education to combat NCDs through physical activity and walking Owner and Chief Executive Officer of the Health Promotion Center No conflict of interest identified Dr Stuart Biddle Male Physical activity in youth Research funds and paid consultancy No conflict of interest identified Dr Katja Borodulin Female Physical activity in pregnancy Employment at National Institute for Health and Welfare and Age Institute; research funds No conflict of interest identified Dr Matthew Buman Male Sleep and physical activity in people living with chronic conditions None declared No conflict of interest identified Dr Greet Cardon Female Physical activity in youth None declared No conflict of interest identified Ms Catherine Carty Female Physical activity in people living with disability Research funds No conflict of interest identified Dr Jean-Philippe Chaput Male Sleep None declared No conflict of interest identified Dr Sebastien Chastin Male Physical activity and health, objective measurement of physical activity Research funds No conflict of interest identified Dr Paddy Dempsey Male Physical activity and sedentary behaviour in adults and people living with chronic conditions Employment and research funds No conflict of interest identified Dr Loretta DiPietro Female Physical activity in older adults None declared No conflict of interest identified Dr Ulf Ekelund Male Sedentary behaviour and physical activity in youth None declared No conflict of interest identified Dr Joseph Firth Male Physical activity and mental health None declared No conflict of interest identified Dr Christine Friedenreich Female Physical activity in people living with chronic conditions, physical activity and cancer risk None declared No conflict of interest identified Dr Leandro Garcia Male Physical activity and mental health Employment and paid consultancy No conflict of interest identified Dr Muthoni Gichu Female Policy implementation (national government) None declared No conflict of interest identified Dr Russ Jago Male Physical activity in youth None declared No conflict of interest identified 92 93 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Name Gender Expertise Disclosure of interest Conflict of interest and management Dr Peter Katzmarzyk Male Physical activity and sedentary behaviour in youth Travel support to assist guideline committees No conflict of interest identified Dr Estelle V. Lambert Female Physical activity and obesity None declared No conflict of interest identified Dr Michael Leitzmann Male Sedentary behaviour and chronic conditions None declared No conflict of interest identified Dr Karen Milton Female Translating recommendations into practice Travel support to assist guideline committee No conflict of interest identified Dr Francisco Ortega Male Physical activity in youth, mental health and objective measurement None declared No conflict of interest identified Dr Chathuranga Ranasinghe Male Promotion of physical activity and health in the community, workplace and school settings Research funds No conflict of interest identified Dr Emmanuel Stamatakis Male Physical activity and multiple health outcomes in adults Grant for technology company for objective measurement of physical activity No conflict of interest identified Dr Anne Tiedemann Female Physical activity and health outcomes in older adults None declared No conflict of interest identified Dr Richard Troiano Male Policy development None declared No conflict of interest identified Dr Hidde van der Ploeg Male Physical activity, sedentary behaviour and health outcomes in adults Travel support to assist 2017 Dutch Physical Activity Guidelines committee and research funds No conflict of interest identified Ms Vicky Wari Female Policy implementation (national government) Shares (not relevant to guideline) No conflict of interest identified External peer reviewers Name Gender Expertise Disclosure of interest Conflict of interest and management Kingsley Akinroye Male Advocacy, noncommunicable diseases None declared No conflict of interest identified Dr Huda Alsiyabi Female Policy and programme implementation None declared No conflict of interest identified Dr Alberto Flórez- Pregonero Male Physical activity and sedentary behaviour measurement and surveillance None declared No conflict of interest identified Dr Shigeru Inoue Male Epidemiology and physical activity promotion None declared No conflict of interest identified Dr Agus Mahendra Male Physical activity and movement skills in children None declared No conflict of interest identified Dr Deborah Salvo Female Health and social disparities, with a particular emphasis on chronic disease prevention None declared No conflict of interest identified Dr Jasper Schipperijn Male Physical activity and the built environment President-Elect of the International Society for Physical Activity and Health (ISPAH) No conflict of interest identified 92 93Annex 3 ISBN 978-92-4-001513-52 8

WHO GUIDELINES ON PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOUR

WHO GUIDELINES ON PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOUR WHO guidelines on physical activity and sedentary behaviour ISBN 978-92-4-001512-8 (electronic version) ISBN 978-92-4-001513-5 (print edition) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Design: Eddy Hill Design Printed in Switzerland ii iii W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CONTENTS Acknowledgements iv Abbreviations and acronyms v Glossary of terms vi Executive summary 1 Background 15 Methods 18 Recommendations 24 Children and adolescents (aged 5–17 years) 25 Physical activity recommendation 25 Sedentary behaviour recommendation 29 Adults (aged 18–64 years) 32 Physical activity recommendation 32 Sedentary behaviour recommendation 38 Older adults (aged 65 years and older) 43 Physical activity recommendation 43 Sedentary behaviour recommendation 46 Pregnant and postpartum women 47 Physical activity recommendation 47 Sedentary behaviour recommendation 51 Adults and older adults with chronic  conditions (aged 18 years and older) 52 Physical activity recommendation 52 Sedentary behaviour recommendation 58 Children and adolescents (aged 5–17 years) and adults (aged 18 years and over) living with disability 60 Physical activity recommendation 60 Sedentary behaviour recommendation 64 Evidence to recommendations 66 Assessment of the certainty of evidence 66 Benefits and harms 67 Values and preferences 67 Resource implications 67 Equity, acceptability and feasibility 68 Research needs 69 Adoption, dissemination, implementation and evaluation 70 Adoption 70 Dissemination 71 Communication campaigns 71 Implementation of policy and programmes 72 Surveillance and evaluation 73 Updating 73 References 75 Annex 1: Management of guideline development process 85 Annex 2: Guideline development group, external peer reviewers, and who staff involved in the development of these guidelines 88 Annex 3: Summary of declaration of interest and how these were managed 92 Web Annex: Evidence profiles https://apps.who.int/iris/bitstream/handle/ 10665/336657/9789240015111-eng.pdf ii iiiContents ACKNOWLEDGEMENTS The World Health Organization (WHO) gratefully acknowledges the contribution to and support of the following individuals and organizations in the development of these guidelines: Fiona Bull and Juana Willumsen led the process of developing these guidelines. Valentina Baltag, Maurice Bucagu, Alex Butchart, Neerja Chowdhary, Regina Guthold, Riitta-Maija Hämäläinen, Andre Ilbawi, Wasiq Khan, Lindsay Lee, Alana Officer, Leanne Riley and Gojka Roglic were members of the WHO Steering Group that managed the guideline development process. The members of the Guideline Development Group (GDG) included Salih Saad Al-Ansari, Stuart Biddle, Katja Borodulin, Matthew Buman, Greet Cardon (co-chair), Catherine Carty, Jean-Philippe Chaput, Sebastien Chastin, Paddy Dempsey, Loretta DiPietro, Ulf Ekelund, Joseph Firth, Christine Friedenreich, Leandro Garcia, Muthoni Gichu, Russ Jago, Peter Katzmarzyk, Estelle V. Lambert, Michael Leitzmann, Karen Milton, Francisco B. Ortega, Chathuranga Ranasinghe, Emmanuel Stamatakis (co-chair), Anne Tiedemann, Richard Troiano, Hidde van der Ploeg, Vicky Wari. Roger Chou served as GRADE methodologist. The external review group included Kingsley Akinroye, Huda Alsiyabi, Alberto Flórez-Pregonero, Shigeru Inoue, Agus Mahendra, Deborah Salvo and Jasper Schipperijn. Systematic reviews of evidence prepared for 2018 US Physical Activity Guidelines Advisory Committee Scientific Report to the Secretary of Health and Human Services were updated thanks to additional literature searches conducted by Kyle Sprow (National Cancer Institutes, National Institutes of Health, Maryland, USA). Additional support to review papers identified was provided by Elif Eroglu (University of Sydney), Andrea Hillreiner (University of Regensburg), Bo-Huei Huang (University of Sydney), Carmen Jochem (University of Regensburg), Jairo H. Migueles (University of Granada), Chelsea Stone (University of Calgary) and Léonie Uijtdewilligen (Amsterdam UMC). Summaries of evidence and GRADE tables were prepared by Carrie Patnode and Michelle Henninger (The Kaiser Foundation Hospitals, Center for Health Research, Portland, Oregon, USA). Additional reviews of evidence were conducted by N Fairhall, J Oliveira, M Pinheiro, and C Sherrington (Institute for Musculoskeletal Health, School of Public Health, The University of Sydney, Sydney, Australia) and A Bauman (Prevention Research Collaboration, School of Public Health, The University of Sydney, Sydney, Australia; and WHO Collaborating Centre for Physical Activity, Nutrition and Obesity); S Mabweazara, M-J Laguette, K Larmuth, F Odunitan-Wayas (Research Centre for Health through Physical Activity, Lifestyle and Sports Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa), L Leach, S Onagbiye (Department of Sport, Recreation and Exercise Science, Faculty of Health Sciences, University of the Western Cape, Cape Town, South Africa), M Mthethwa (Chronic Disease Initiative for Africa, University of Cape Town, Cape Town, South Africa), P Smith (The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa) and F Mashili (Department of Physiology, Muhimbili University of Allied Sciences, Dar Es Salaam, United Republic of Tanzania); B Cillekens, M Lang, W van Mechelen, E Verhagen, M Huysmans, A van der Beek, P Coenen (Department of Public and Occupational Health at Amsterdam University Medical Centre, Amsterdam, Netherlands). The Public Health Agency of Canada and the Government of Norway provided financial support, without which this work could not have been completed. iv v W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ADHD attention deficit hyperactive disorder AOR adjusted odds ratio BMI body mass index CI confidence interval CVD cardiovascular disease DBP diastolic blood pressure EtD Evidence to Decisions GDG Guideline Development Group GRADE Grading of Recommendations Assessment, Development and Evaluation HR hazards ratio MET Metabolic Equivalent of Task MD mean difference MICT moderate intensity continuous training NCD noncommunicable disease OR odds ratio PA physical activity PAGAC United States Physical Activity Guidelines Advisory Committee PI/ECO Population, Intervention/Exposure, Comparison, Outcome RaR Relative attributable risk RCT randomized control trial RR relative risk SBP systolic blood pressure SMD standardized mean difference SPPB short physical performance battery TV television WHA World Health Assembly WHO World Health Organization ABBREVIATIONS AND ACRONYMS iv vAbbreviations and acronyms Term Definition Aerobic physical activity Activity in which the body’s large muscles move in a rhythmic manner for a sustained period of time. Aerobic activity – also called endurance activity – improves cardiorespiratory fitness. Examples include walking, running, swimming, and bicycling. Anaerobic physical activity Anaerobic physical activity consists of brief intense bursts of exercise, such as weightlifting and sprints, where oxygen demand surpasses oxygen supply. Balance training Static and dynamic exercises that are designed to improve an individual’s ability to withstand challenges from postural sway or destabilizing stimuli caused by self-motion, the environment, or other objects. Body mass index (BMI) Weight (kg) / height (m)2 BMI-for-age or BMI z-score BMI adjusted for age, standardized for children. BMI standard deviation scores are measures of relative weight adjusted for child age and sex. Given a child’s age, sex, BMI, and an appropriate reference standard, a BMI z-score (or its equivalent BMI-for-age percentile) can be determined. Bone-strengthening activity Physical activity primarily designed to increase the strength of specific sites in bones that make up the skeletal system. Bone-strengthening activities produce an impact or tension force on the bones that promotes bone growth and strength. Running, jumping rope, and lifting weights are examples of bone-strengthening activities. Cardiometabolic health The interplay of blood pressure, blood lipids, blood glucose and insulin on health. Cardiorespiratory fitness (endurance) A health-related component of physical fitness. The ability of the circulatory and respiratory systems to supply oxygen during sustained physical activity. Usually expressed as measured or estimated maximal oxygen uptake (VO2 max). Cognitive function Cerebral activities, i.e. reasoning, memory, attention, and language that lead to the attainment of information and knowledge. This can also include learning. Disability From the International Classification of Functioning, Disability and Health, an umbrella term for impairments, activity limitations, and participation restrictions, denoting the negative aspects of the interaction between an individual (with a health condition) and that individual’s contextual factors (environmental and personal factors). Domains of physical activity Physical activity levels can be assessed in various domains, including one of more of the following: leisure-time, occupation, education, household and/or transportation. Exercise A subcategory of physical activity that is planned, structured, repetitive, and purposeful in the sense that the improvement or maintenance of one or more components of physical fitness is the objective. “Exercise” and “exercise training” frequently are used interchangeably and generally refer to physical activity performed during leisure time with the primary purpose of improving or maintaining physical fitness, physical performance, or health. Executive function Includes constructs such as: working memory, cognitive flexibility (also called flexible thinking) and inhibitory control (which includes self-control). Fitness A measure of the body's ability to function efficiently and effectively in work and leisure activities, and includes, for example, physical fitness and cardiorespiratory fitness. Flexibility A health- and performance-related component of physical fitness that is the range of motion possible at a joint. Flexibility is specific to each joint and depends on a number of specific variables including, but not limited to, the tightness of specific ligaments and tendons. Flexibility exercises enhance the ability of a joint to move through its full range of motion. Functional exercises Exercises that can be embedded into everyday tasks to improve lower-body strength, balance, and motor performance. Examples include tandem and one-leg stands, squatting, chair stands, toe raises, and stepping over obstacles. Household domain physical activity Physical activity undertaken in the home for domestic duties (such as cleaning, caring for children, gardening etc.). Leisure-domain physical activity Physical activity performed by an individual that is not required as an essential activity of daily living and is performed at the discretion of the individual. Such activities include sports participation, exercise conditioning or training, and recreational activities such as going for a walk, dancing, and gardening. GLOSSARY OF TERMS vi vii W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Term Definition Light-intensity physical activity Light-intensity physical activity is between 1.5 and 3 METs, i.e. activities with energy cost less than 3 times the energy expenditure at rest for that person. This can include slow walking, bathing, or other incidental activities that do not result in a substantial increase in heart rate or breathing rate. Major muscle groups Major muscle groups include the legs, back, abdomen, chest, shoulders and arms. Metabolic equivalent of task (MET) The metabolic equivalent of task, or simply metabolic equivalent, is a physiological measure expressing the intensity of physical activities. One MET is the energy equivalent expended by an individual while seated at rest. Moderate-intensity physical activity On an absolute scale, moderate-intensity refers to the physical activity that is performed between 3 and less than 6 times the intensity of rest. On a scale relative to an individual’s personal capacity, moderate-intensity physical activity is usually a 5 or 6 on a scale of 0–10. Muscle-strengthening activity Physical activity and exercise that increase skeletal muscle strength, power, endurance, and mass (e.g. strength training, resistance training, or muscular strength and endurance exercises). Multicomponent physical activity For older adults, multicomponent physical activity is important to improve physical function and decrease the risk of falls or injury from a fall. These activities can be done at home or in a structured group setting. Many studied interventions combine all types of exercise (aerobic, muscle strengthening, and balance training) into a session, and this has been shown to be effective. An example of a multicomponent physical activity programme could include walking (aerobic activity), lifting weights (muscle strengthening), and incorporates balance training. Examples of balance training can include walking backwards or sideways or standing on one foot while doing an upper body muscle-strengthening activity, such as bicep curls. Dancing also combines aerobic and balance components. Occupation domain physical activity See work domain physical activity. Physical activity Any bodily movement produced by skeletal muscles that requires energy expenditure. Physical inactivity An insufficient physical activity level to meet present physical activity recommendations. Psychosocial health Include mental, emotional and social dimensions of health. Recreational screen time Time spent watching screens (television (TV), computer, mobile devices) for purposes other than those related to education/study or work. Sedentary screen time Time spent watching screen-based entertainment (TV, computer, mobile devices). Does not include active screen-based games where physical activity or movement is required. Sedentary behaviour Any waking behaviour characterized by an energy expenditure of 1.5 METS or lower while sitting, reclining, or lying. Most desk-based office work, driving a car, and watching television are examples of sedentary behaviours; these can also apply to those unable to stand, such as wheelchair users. The guidelines operationalize the definition of sedentary behaviour to include self-reported low movement sitting (leisure time, occupational, and total), television (TV viewing or screen time, and low levels of movement measured by devices that assess movement or posture). Sport Sport covers a range of activities performed within a set of rules and undertaken as part of leisure or competition. Sporting activities involve physical activity carried out by teams or individuals and may be supported by an institutional framework, such as a sporting agency. Transport domain physical activity Physical activity performed for the purpose of getting to and from places, and refers to walking, cycling and wheeling (the use of non-motorized means of locomotion with wheels, such as scooters, rollerblades, manual wheelchair etc.). Vigorous-intensity physical activity On an absolute scale, vigorous-intensity refers to physical activity that is performed at 6.0 or more METS. On a scale relative to an individual’s personal capacity, vigorous-intensity physical activity is usually a 7 or 8 on a scale of 0–10. Work domain physical activity Physical activity undertaken during paid or voluntary work. vi viiGlossary of terms The WHO Guidelines on physical activity and sedentary behaviour provide evidence-based public health recommendations for children, adolescents, adults and older adults on the amount of physical activity (frequency, intensity and duration) required to offer significant health benefits and mitigate health risks. For the first time, recommendations are provided on the associations between sedentary behaviour and health outcomes, as well as for subpopulations, such as pregnant and postpartum women, and people living with chronic conditions or disability. The guidelines are intended for policy-makers in high-, middle-, and low-income countries in ministries of health, education, youth, sport and/or social or family welfare; government officials responsible for developing national, sub regional or municipal plans to increase physical activity and reduce sedentary behaviour in population groups through guidance documents; people working in nongovernmental organizations, the education sector, private sector, research; and health- care providers. The guidelines were prepared in accordance with the WHO handbook for guideline development. Systematic reviews of evidence were conducted for the critical and important outcomes, and recommendations were developed after consideration of the benefits and harms, values, preferences, feasibility and acceptability, and the implications for equity and resources. The final public health recommendations presented are for all populations and age groups ranging from 5 years to 65 years and older, irrespective of gender, cultural background or socioeconomic status, and are relevant for people of all abilities. Those with chronic medical conditions and/or disability and pregnant and postpartum women should try to meet the recommendations where possible and as able. The development of these guidelines provide a set of evidence-based recommendations that governments can adopt as part of their national policy frameworks to support comprehensive approaches to increasing population levels of physical activity. Within the adoption process, consideration should be given to the need to contextualize the guidelines. Practical tools to support adoption, dissemination, communication campaigns and implementation of the guidelines will support governments and stakeholders work together to increase physical activity and reduce sedentary behaviours across the life course. These supporting resources will be available through the WHO website following publication of the guidelines Despite the large quantity of supporting data relating physical activity and, increasingly, sedentary behaviours to health outcomes across the life-span, important evidence gaps remain. In particular, there is less evidence from low- and middle-income countries and economically disadvantaged or underserved communities, and a dearth of evidence from subpopulations including people living with disabilities. Investment in more research is needed to build evidence particularly in these areas. In addition, the changes introduced to these recommendations will have some implications for surveillance systems and assessment instruments currently used to monitor national levels of physical activity. Existing global and national instruments should be reviewed, and reporting protocols updated, to inform future reporting against the new guidelines. The Global action plan on physical activity 2018–2030 set a target to reduce physical inactivity by 15% by 2030, and outlined 20 recommended policy actions and interventions. These guidelines support all countries to implement the GAPPA recommendations and “ACTIVE”, the technical package of toolkits that provides guidance on how to promote physical activity across the life course and through multiple settings. EXECUTIVE SUMMARY viii 1 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CHILDREN AND ADOLESCENTS (aged 5–17 years) It is recommended that: Children and adolescents should do at least an average of 60 minutes per day of moderate- to vigorous-intensity, mostly aerobic, physical activity, across the week. Strong recommendation, moderate certainty evidence Vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone, should be incorporated at least 3 days a week. Strong recommendation, moderate certainty evidence • Doing some physical activity is better than doing none. • If children and adolescents are not meeting the recommendations, doing some physical activity will benefit their health. • Children and adolescents should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • It is important to provide all children and adolescents with safe and equitable opportunities, and encouragement, to participate in physical activities that are enjoyable, offer variety, and are appropriate for their age and ability. G O O D P R A C TI C E ST A TE M EN TS In children and adolescents, physical activity confers benefits for the following health outcomes: improved physical fitness (cardiorespiratory and muscular fitness), cardiometabolic health (blood pressure, dyslipidaemia, glucose, and insulin resistance), bone health, cognitive outcomes (academic performance, executive function), mental health (reduced symptoms of depression); and reduced adiposity. In children and adolescents, higher amounts of sedentary behaviour are associated with the following poor health outcomes: increased adiposity; poorer cardiometabolic health, fitness, behavioural conduct/pro-social behaviour; and reduced sleep duration. It is recommended that: Children and adolescents should limit the amount of time spent being sedentary, particularly the amount of recreational screen time. Strong recommendation, low certainty evidence 1 GRADE: Grading of Recommendations Assessment Development and Evaluation Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf INTRODUCTION Regular physical activity is a key protective factor for the prevention and management of noncommunicable diseases (NCDs) such as cardiovascular disease, type-2 diabetes, and a number of cancers. Physical activity also benefits mental health, including prevention of cognitive decline and symptoms of depression and anxiety; and can contribute to the maintenance of healthy weight and general well-being. Global estimates indicate that 27.5% of adults (1) and 81% of adolescents (2) do not meet the 2010 WHO recommendations for physical activity (3) with almost no improvements seen during the past decade. There are also notable inequalities: data show that in most countries girls and women are less active than boys and men, and that there are significant differences in levels of physical activity between higher and lower economic groups, and between countries and regions. SCOPE The WHO Guidelines on physical activity and sedentary behaviour provide evidence-based public health recommendations for children, adolescents, adults and older adults on the amount of physical activity (frequency, intensity and duration) required to offer significant health benefits and mitigate health risks. For the first time, recommendations are provided on the associations between sedentary behaviour and health outcomes, as well as for subpopulations, such as pregnant and postpartum women, and people living with chronic conditions or disability. TARGET AUDIENCE The guidelines are intended for policy-makers in high-, middle-, and low-income countries in ministries of health, education, youth, sport and/or social or family welfare; government officials responsible for developing national, sub regional or municipal plans to increase physical activity and reduce sedentary behaviour in population groups through guidance documents; people working in nongovernmental organizations, the education sector, private sector, research; and health-care providers. DEVELOPMENT PROCESS The guidelines were prepared in accordance with the WHO handbook for guideline development (4). In 2019 a Guideline Development Group (GDG) was formed comprising technical experts and relevant stakeholders from all six WHO regions. The group met in July 2019 to formulate the key questions, review the evidence-bases, and agree the methods for updates of literature, and, where needed, for additional new reviews. In February 2020, the GDG met again to review the evidence for the critical and important outcomes, consider the benefits and harms, values, preferences, feasibility and acceptability, and the implications for equity and resources. The recommendations were developed through consensus and posted online for public consultation. The final updated recommendations are summarized below. The GRADE 1 tables and evidence profiles are available as a Web annex . Practical tools to support adoption, dissemination, communication campaigns and implementation of the guidelines will support governments and stakeholders work together to increase physical activity and reduce sedentary behaviours across the life course. RECOMMENDATIONS The public health recommendations presented in the WHO Guidelines on physical activity and sedentary behaviour are for all populations and age groups ranging from 5 years to 65 years and older, irrespective of gender, cultural background or socioeconomic status, and are relevant for people of all abilities. Those with chronic medical conditions and/or disability and pregnant and postpartum women should try to meet the recommendations where possible and as able. LIMIT the amount of time spent being sedentary, particularly recreational screen time. 3 vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated. On at least days a week 60 moderate- to vigorous-intensity physical activity across the week; most of this physical activity should be aerobic. minutes a day At least 2 3 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendationsviii 1Executive summary It is recommended that: Adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, moderate certainty evidence It is recommended that: All adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults should do at least 150– 300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence ADULTS (aged 18–64 years) ADULTS (aged 18–64 years) 2 Site-specific cancers of: bladder, breast, colon, endometrial, oesophageal adenocarcinoma, gastric, and renal. • Doing some physical activity is better than doing none. • If adults are not meeting these recommendations, doing some physical activity will benefit their health. • Adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. G O O D P R A C TI C E ST A TE M EN TS In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and type-2 diabetes. In adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site-specific cancers, 2 incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression); cognitive health, and sleep; measures of adiposity may also improve. Adults may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence Adults should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 4 5 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations 1 1 2 3 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r It is recommended that: Adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, moderate certainty evidence It is recommended that: All adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults should do at least 150– 300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence ADULTS (aged 18–64 years) ADULTS (aged 18–64 years) 2 Site-specific cancers of: bladder, breast, colon, endometrial, oesophageal adenocarcinoma, gastric, and renal. • Doing some physical activity is better than doing none. • If adults are not meeting these recommendations, doing some physical activity will benefit their health. • Adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. G O O D P R A C TI C E ST A TE M EN TS In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and type-2 diabetes. In adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site-specific cancers, 2 incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression); cognitive health, and sleep; measures of adiposity may also improve. Adults may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence Adults should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 4 5 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations2 3Executive summary It is recommended that: All older adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Older adults should do at least 150– 300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence OLDER ADULTS (aged 65 years and older) OLDER ADULTS (aged 65 years and older) • Doing some physical activity is better than doing none. • If older adults are not meeting the recommendations, doing some physical activity will bring benefits to health. • Older adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • Older adults should be as physically active as their functional ability allows, and adjust their level of effort for physical activity relative to their level of fitness. G O O D P R A C TI C E ST A TE M EN TS In older adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Older adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, older adults should aim to do more than the recommended levels of moderate- to vigorous- intensity physical activity. Strong recommendation, moderate certainty evidence In older adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site-specific cancers, incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression), cognitive health, and sleep; measures of adiposity may also improve. In older adults, physical activity helps prevent falls and falls-related injuries and declines in bone health and functional ability. Older adults may increase moderate- intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week, for additional health benefits. Conditional recommendation, moderate certainty evidence Older adults should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence As part of their weekly physical activity, older adults should do varied multicomponent physical activity that emphasizes functional balance 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 LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 6 7 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations4 5 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r It is recommended that: All older adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Older adults should do at least 150– 300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence OLDER ADULTS (aged 65 years and older) OLDER ADULTS (aged 65 years and older) • Doing some physical activity is better than doing none. • If older adults are not meeting the recommendations, doing some physical activity will bring benefits to health. • Older adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • Older adults should be as physically active as their functional ability allows, and adjust their level of effort for physical activity relative to their level of fitness. G O O D P R A C TI C E ST A TE M EN TS In older adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Older adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, older adults should aim to do more than the recommended levels of moderate- to vigorous- intensity physical activity. Strong recommendation, moderate certainty evidence In older adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site-specific cancers, incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression), cognitive health, and sleep; measures of adiposity may also improve. In older adults, physical activity helps prevent falls and falls-related injuries and declines in bone health and functional ability. Older adults may increase moderate- intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week, for additional health benefits. Conditional recommendation, moderate certainty evidence Older adults should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence As part of their weekly physical activity, older adults should do varied multicomponent physical activity that emphasizes functional balance 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 LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 6 7 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations4 5Executive summary In pregnant and postpartum women, physical activity during pregnancy and postpartum confers benefits on the following maternal and fetal health benefits: decreased risk of pre-eclampsia, gestational hypertension, gestational diabetes, excessive gestational weight gain, delivery complications and postpartum depression, and fewer newborn complications, no adverse effects on birthweight; and no increase in risk of stillbirth. It is recommended that all pregnant and postpartum women without contraindication should: Undertake regular physical activity throughout pregnancy and postpartum. Strong recommendation, moderate certainty evidence In addition: Women who, before pregnancy, habitually engaged in vigorous- intensity aerobic activity, or who were physically active, can continue these activities during pregnancy and the postpartum period. Strong recommendation, moderate certainty evidence Do at least 150 minutes of moderate- intensity aerobic physical activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence Incorporate a variety of aerobic and muscle- strengthening activities. Adding gentle stretching may also be beneficial. Strong recommendation, moderate certainty evidence PREGNANT AND POSTPARTUM WOMEN PREGNANT AND POSTPARTUM WOMEN G O O D P R A C TI C E ST A TE M EN TS • Doing some physical activity is better than doing none. • If pregnant and postpartum women are not meeting the recommendations, doing some physical activity will benefit their health. • Pregnant and postpartum women should start by doing small amounts of physical activity, and gradually increase frequency, intensity and duration over time. • Pelvic floor muscle training may be performed on a daily basis to reduce the risk of urinary incontinence. • Avoid physical activity during excessive heat, especially with high humidity. • Stay hydrated by drinking water before, during, and after physical activity. • 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 high altitude). • Avoid activities in supine position after the first trimester of pregnancy. • When considering athletic competition, or exercising significantly above the recommended guidelines pregnant women should seek supervision from a specialist health-care provider. • Pregnant women should be informed by their health-care provider of the danger signs alerting them as to when to stop; or to limit physical activity and consult a qualified health-care provider immediately should they occur. • Return to physical activity gradually after delivery, and in consultation with a health-care provider, in the case of delivery by Caesarean section. Additional safety considerations for pregnant women when undertaking physical activity are: In pregnant and postpartum women, as in all adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Pregnant and postpartum women should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence Doing some physical activity is better than doing none. LIMIT REPLACE the amount of time spent being sedentary with physical activity of any intensity (including light intensity). 150 moderate-intensity aerobic physical activity At least minutes a week 8 9 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations6 7 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r In pregnant and postpartum women, physical activity during pregnancy and postpartum confers benefits on the following maternal and fetal health benefits: decreased risk of pre-eclampsia, gestational hypertension, gestational diabetes, excessive gestational weight gain, delivery complications and postpartum depression, and fewer newborn complications, no adverse effects on birthweight; and no increase in risk of stillbirth. It is recommended that all pregnant and postpartum women without contraindication should: Undertake regular physical activity throughout pregnancy and postpartum. Strong recommendation, moderate certainty evidence In addition: Women who, before pregnancy, habitually engaged in vigorous- intensity aerobic activity, or who were physically active, can continue these activities during pregnancy and the postpartum period. Strong recommendation, moderate certainty evidence Do at least 150 minutes of moderate- intensity aerobic physical activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence Incorporate a variety of aerobic and muscle- strengthening activities. Adding gentle stretching may also be beneficial. Strong recommendation, moderate certainty evidence PREGNANT AND POSTPARTUM WOMEN PREGNANT AND POSTPARTUM WOMEN G O O D P R A C TI C E ST A TE M EN TS • Doing some physical activity is better than doing none. • If pregnant and postpartum women are not meeting the recommendations, doing some physical activity will benefit their health. • Pregnant and postpartum women should start by doing small amounts of physical activity, and gradually increase frequency, intensity and duration over time. • Pelvic floor muscle training may be performed on a daily basis to reduce the risk of urinary incontinence. • Avoid physical activity during excessive heat, especially with high humidity. • Stay hydrated by drinking water before, during, and after physical activity. • 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 high altitude). • Avoid activities in supine position after the first trimester of pregnancy. • When considering athletic competition, or exercising significantly above the recommended guidelines pregnant women should seek supervision from a specialist health-care provider. • Pregnant women should be informed by their health-care provider of the danger signs alerting them as to when to stop; or to limit physical activity and consult a qualified health-care provider immediately should they occur. • Return to physical activity gradually after delivery, and in consultation with a health-care provider, in the case of delivery by Caesarean section. Additional safety considerations for pregnant women when undertaking physical activity are: In pregnant and postpartum women, as in all adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Pregnant and postpartum women should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence Doing some physical activity is better than doing none. LIMIT REPLACE the amount of time spent being sedentary with physical activity of any intensity (including light intensity). 150 moderate-intensity aerobic physical activity At least minutes a week 8 9 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations6 7Executive summary Adults and older adults with chronic conditions should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults and older adults with chronic conditions should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence For cancer survivors, and adults living with hypertension, type-2 diabetes and HIV, it is recommended that: It is recommended that: All adults and older adults with the above chronic conditions should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults and older adults with these chronic conditions should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence When not contraindicated, adults and older adults with these chronic conditions may increase moderate- intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence As part of their weekly physical activity, older adults with these chronic conditions should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence Adults and older adults with these chronic conditions should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional benefits. Strong recommendation, moderate certainty evidence ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) Physical activity can confer health benefits for adults and older adults living with the following chronic conditions: for cancer survivors – physical activity improves all-cause mortality, cancer-specific mortality, and risk of cancer recurrence or second primary cancer; for people living with hypertension – physical activity improves cardiovascular disease mortality, disease progression, physical function, health-related quality of life; for people living with type-2 diabetes – physical activity reduces rates of mortality from cardiovascular disease and indicators disease progression; and for people living with HIV – physical activity can improve physical fitness and mental health (reduced symptoms of anxiety and depression), and does not adversely affect disease progression (CD4 count and viral load) or body composition. G O O D P R A C TI C E ST A TE M EN TS • When not able to meet the above recommendations, adults with these chronic conditions should aim to engage in physical activity according to their abilities. • Adults with these chronic conditions should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • Adults with these chronic conditions may wish to consult with a physical activity specialist or health-care professional for advice on the types and amounts of activity appropriate for their individual needs, abilities, functional limitations/complications, medications, and overall treatment plan. • Pre-exercise medical clearance is generally unnecessary for individuals without contraindications prior to beginning light- or moderate-intensity physical activity not exceeding the demands of brisk walking or everyday living. In adults, including cancer survivors and people living with hypertension, type-2 diabetes and HIV, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 150 300 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 150 10 11 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations8 9 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Adults and older adults with chronic conditions should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults and older adults with chronic conditions should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence For cancer survivors, and adults living with hypertension, type-2 diabetes and HIV, it is recommended that: It is recommended that: All adults and older adults with the above chronic conditions should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults and older adults with these chronic conditions should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence When not contraindicated, adults and older adults with these chronic conditions may increase moderate- intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence As part of their weekly physical activity, older adults with these chronic conditions should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence Adults and older adults with these chronic conditions should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional benefits. Strong recommendation, moderate certainty evidence ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) Physical activity can confer health benefits for adults and older adults living with the following chronic conditions: for cancer survivors – physical activity improves all-cause mortality, cancer-specific mortality, and risk of cancer recurrence or second primary cancer; for people living with hypertension – physical activity improves cardiovascular disease mortality, disease progression, physical function, health-related quality of life; for people living with type-2 diabetes – physical activity reduces rates of mortality from cardiovascular disease and indicators disease progression; and for people living with HIV – physical activity can improve physical fitness and mental health (reduced symptoms of anxiety and depression), and does not adversely affect disease progression (CD4 count and viral load) or body composition. G O O D P R A C TI C E ST A TE M EN TS • When not able to meet the above recommendations, adults with these chronic conditions should aim to engage in physical activity according to their abilities. • Adults with these chronic conditions should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • Adults with these chronic conditions may wish to consult with a physical activity specialist or health-care professional for advice on the types and amounts of activity appropriate for their individual needs, abilities, functional limitations/complications, medications, and overall treatment plan. • Pre-exercise medical clearance is generally unnecessary for individuals without contraindications prior to beginning light- or moderate-intensity physical activity not exceeding the demands of brisk walking or everyday living. In adults, including cancer survivors and people living with hypertension, type-2 diabetes and HIV, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 150 300 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 150 10 11 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations8 9Executive summary CHILDREN AND ADOLESCENTS (aged 5–17 years) LIVING WITH DISABILITY CHILDREN AND ADOLESCENTS (aged 5–17 years) LIVING WITH DISABILITY Many of the health benefits of physical activity for children and adolescents, as set out in the section above, also relate to those children and adolescents living with disability. Additional benefits of physical activity to health outcomes for those living with disability include: improved cognition in individuals with diseases or disorders that impair cognitive function, including attention-deficit/ hyperactivity disorder (ADHD); improvements in physical function may occur in children with intellectual disability. • Doing some physical activity is better than doing none. • If children and adolescents living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Children and adolescents living with disability should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • There are no major risks for children and adolescents living with disability engaging in physical activity when it is appropriate to an individual’s current activity level, health status and physical function; and the health benefits accrued outweigh the risks. • Children and adolescents living with disability may need to consult a health-care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. G O O D P R A C TI C E ST A TE M EN TS In children and adolescents, higher amounts of sedentary behaviour are associated with the following poor health outcomes: increased adiposity; poorer cardiometabolic health, fitness, and behavioural conduct/pro-social behaviour; and reduced sleep duration. It is recommended that: Children and adolescents living with disability should limit the amount of time spent being sedentary, particularly the amount of recreational screen time. Strong recommendation, low certainty evidence It is recommended that: Children and adolescents living with disability should do at least an average of 60 minutes per day of moderate- to vigorous- intensity, mostly aerobic, physical activity, across the week. Strong recommendation, moderate certainty evidence Vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated at least 3 days a week. Strong recommendation, moderate certainty evidence Doing some physical activity is better than doing none. Start by doing small amounts of physical activity. 60 moderate- to vigorous-intensity physical activity across the week; most of this physical activity should be aerobic. At least minutes a day 3 vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated. On at least days a week LIMIT the amount of time spent being sedentary, particularly recreational screen time. 12 13 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations0 1 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CHILDREN AND ADOLESCENTS (aged 5–17 years) LIVING WITH DISABILITY CHILDREN AND ADOLESCENTS (aged 5–17 years) LIVING WITH DISABILITY Many of the health benefits of physical activity for children and adolescents, as set out in the section above, also relate to those children and adolescents living with disability. Additional benefits of physical activity to health outcomes for those living with disability include: improved cognition in individuals with diseases or disorders that impair cognitive function, including attention-deficit/ hyperactivity disorder (ADHD); improvements in physical function may occur in children with intellectual disability. • Doing some physical activity is better than doing none. • If children and adolescents living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Children and adolescents living with disability should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • There are no major risks for children and adolescents living with disability engaging in physical activity when it is appropriate to an individual’s current activity level, health status and physical function; and the health benefits accrued outweigh the risks. • Children and adolescents living with disability may need to consult a health-care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. G O O D P R A C TI C E ST A TE M EN TS In children and adolescents, higher amounts of sedentary behaviour are associated with the following poor health outcomes: increased adiposity; poorer cardiometabolic health, fitness, and behavioural conduct/pro-social behaviour; and reduced sleep duration. It is recommended that: Children and adolescents living with disability should limit the amount of time spent being sedentary, particularly the amount of recreational screen time. Strong recommendation, low certainty evidence It is recommended that: Children and adolescents living with disability should do at least an average of 60 minutes per day of moderate- to vigorous- intensity, mostly aerobic, physical activity, across the week. Strong recommendation, moderate certainty evidence Vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated at least 3 days a week. Strong recommendation, moderate certainty evidence Doing some physical activity is better than doing none. Start by doing small amounts of physical activity. 60 moderate- to vigorous-intensity physical activity across the week; most of this physical activity should be aerobic. At least minutes a day 3 vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated. On at least days a week LIMIT the amount of time spent being sedentary, particularly recreational screen time. 12 13 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations0 1Executive summary It is recommended that: Adults living with disability should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults living with disability should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence It is recommended that: All adults living with disability should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults living with disability should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence Adults living with disability should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence ADULTS (aged 18 years and older) LIVING WITH DISABILITY ADULTS (aged 18 years and older) LIVING WITH DISABILITY Many of the health benefits of physical activity for adults, as set out in the section above, also relate to adults living with disability. Additional benefits of physical activity to health outcomes for those living with disability include the following: for adults with multiple sclerosis – improved physical function, and physical, mental, and social domains of health-related quality of life; for individuals with spinal cord injury – improved walking function, muscular strength, and upper extremity function; and enhanced health-related quality of life; for individuals with diseases or disorders that impair cognitive function – improved physical function and cognition (in individuals with Parkinson’s disease and those with a history of stroke); beneficial effects on cognition; and may improve quality of life (in adults with schizophrenia); and may improve physical function (in adults with intellectual disability); and improves quality of life (in adults with major clinical depression). In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and type-2 diabetes. Adults living with disability may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence As part of their weekly physical activity, older adults living with disability should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence G O O D P R A C TI C E ST A TE M EN TS • Doing some physical activity is better than doing none. • If adults living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Adults living with disability should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • There are no major risks to adults living with disability engaging in physical activity when it is appropriate to the individual’s current activity level, health status and physical function; and when the health benefits accrued outweigh the risks. • Adults living with disability may need to consult a health- care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 300 150 minutes moderate-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: vigorous- intensity aerobic physical activity For additional health benefits: 2 days a week On at least muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups. 14 15 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations2 3 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r It is recommended that: Adults living with disability should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults living with disability should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence It is recommended that: All adults living with disability should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults living with disability should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence Adults living with disability should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence ADULTS (aged 18 years and older) LIVING WITH DISABILITY ADULTS (aged 18 years and older) LIVING WITH DISABILITY Many of the health benefits of physical activity for adults, as set out in the section above, also relate to adults living with disability. Additional benefits of physical activity to health outcomes for those living with disability include the following: for adults with multiple sclerosis – improved physical function, and physical, mental, and social domains of health-related quality of life; for individuals with spinal cord injury – improved walking function, muscular strength, and upper extremity function; and enhanced health-related quality of life; for individuals with diseases or disorders that impair cognitive function – improved physical function and cognition (in individuals with Parkinson’s disease and those with a history of stroke); beneficial effects on cognition; and may improve quality of life (in adults with schizophrenia); and may improve physical function (in adults with intellectual disability); and improves quality of life (in adults with major clinical depression). In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and type-2 diabetes. Adults living with disability may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence As part of their weekly physical activity, older adults living with disability should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence G O O D P R A C TI C E ST A TE M EN TS • Doing some physical activity is better than doing none. • If adults living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Adults living with disability should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • There are no major risks to adults living with disability engaging in physical activity when it is appropriate to the individual’s current activity level, health status and physical function; and when the health benefits accrued outweigh the risks. • Adults living with disability may need to consult a health- care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 300 150 minutes moderate-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: vigorous- intensity aerobic physical activity For additional health benefits: 2 days a week On at least muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups. 14 15 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations2 3Executive summary 14 15 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Regular physical activity is a known protective factor for the prevention and management of noncommunicable diseases such as cardiovascular disease, type-2 diabetes, breast and colon cancer (1–3). Physical activity also has benefits for mental health (4), delays the onset of dementia (5), and can contribute to the maintenance of healthy weight (1) and general well-being (6). Physical activity is defined as any bodily movement produced by skeletal muscles that requires energy expenditure (1) and can be performed at a variety of intensities, as part of work, domestic chores, transportation or during leisure time, or when participating in exercise or sports activities. At the low end of the intensity range, sedentary behaviour is defined as any waking behaviour while in a sitting, reclining or lying posture with low energy expenditure (7). Emerging new evidence indicates that high levels of sedentary behaviour are associated with cardiovascular disease and type-2 diabetes as well as cardiovascular, cancer and all-cause mortality (8–10). Physical inactivity is defined as not meeting the 2010 Global recommendations on physical activity for health (1) and is a leading contributor to global mortality. It is estimated that between four and five million deaths per year could be averted if the global population was more active (2, 11). Global estimates of physical inactivity indicate that in 2016, 27.5% of adults (12) and 81% of adolescents (13) did not meet the 2010 WHO recommendations (1), and trend data show limited global improvement during the past decade. The data also highlight that women are less active than men in most countries and that there are significant differences in levels of physical activity within and between countries and regions. These differences can be explained by inequities in access to opportunities to be physically active, further amplifying inequalities in health. Currently, there are no global estimates of sedentary behaviour, but technological innovation and the transition towards more sedentary occupations and recreation, and the increasing use of personal motorized transportation are contributing to changing patterns of physical activity and increased sedentary behaviour across the world. The Global action plan on physical activity 2018–2030 (14) sets out 4 strategic objectives and 20 policy actions to achieve a 15% relative reduction in the global prevalence of physical inactivity in adults and adolescents by 2030. In 2010, WHO published the Global recommendations on physical activity for health (1), the first population-based public health guidelines for children and adolescents, adults and older adults. In 2018, the World Health Assembly, in resolution WHA71.6, 1 called for WHO to update the 2010 recommendations. In 2019, WHO published Guidelines on physical activity, sedentary behaviour and sleep for children under 5 years of age (15). The guidelines were called for by the Commission on Ending Childhood Obesity (recommendation 4.12) (16), and address the omission of this younger age group in the 2010 Global recommendations on physical activity for health (1). The 2020 WHO Guidelines on physical activity and sedentary behaviour, replace the 2010 guidelines and are based on the most recent advances in the evidence for the selected behaviours and associated health consequences. They will form part of the overall set of global recommendations on physical activity and sedentary behaviour. BACKGROUND 1 WHA71.6 WHO Global Action Plan on Physical Activity 2018–2030. 14 15Background OTHER KEY WHO GUIDELINES The importance of physical activity for health is recognized in other WHO guidelines. The WHO Package of essential noncommunicable disease interventions for primary health care in low-resource settings (17) provides a protocol for the clinical management of hypertension, type-2 diabetes, raised cardiovascular risk, asthma, and chronic obstructive pulmonary disease, and includes counselling to progressively increase physical activity to moderate levels (such as brisk walking) and at least 150 minutes per week, in line with the 2010 global recommendations. Recent WHO guidance in Risk reduction of cognitive decline and dementia (18) states that physical activity should be recommended to adults with normal cognition (strong recommendation) and those with mild cognitive impairment (conditional recommendation) to reduce the risk of cognitive decline. WHO Integrated care for older people: guidelines on community-level interventions to manage declines in intrinsic capacity (19) recommend multimodal exercises to prevent falls, and exercises for older adults with declining mobility. WHO recommendations on antenatal care for a positive pregnancy experience (20) recommend counselling on healthy eating and being physically active during pregnancy to stay healthy and to prevent excessive weight gain, but do not address the wider health benefits of physical activity during pregnancy and the postpartum period. The existing WHO guidelines, combined with these updated guidelines, provide an increasingly comprehensive set of global guidance on the contribution of physical activity and sedentary behaviours to the prevention and management of key diseases and to the promotion of health and well-being across the life course. RATIONALE AND PURPOSE The past 10 years has seen a significant increase in the body of evidence on the health impact of different types, amounts and durations of physical activity, as well as on the impact of sedentary behaviours and its interrelationship with levels of physical activity and health. In addition, the evidence base for physical activity in subpopulations, such as pregnant women and those living with chronic conditions and/or disability now permits the examination of the relationship between physical activity and health outcomes in these groups. In the Global action plan on physical activity 2018–2030 (14), action 4.1 calls for WHO to develop and disseminate global recommendations for physical activity and sedentary behaviours in children under 5 years of age, young people, adults, older adults and specific subpopulations, such as pregnant women, people living with chronic conditions and disability. Updating and broadening the scope of the guidelines, as requested by the World Health Assembly, ensures that population groups not included in the 2010 recommendations are provided with specific recommendations for physical activity. This aligns with the key principles and goals of the global action plan on physical activity, namely to reduce inequalities and to support all people to be more physically active every day. The overarching purpose of these guidelines is to provide evidence-based public health recommendations on how much and what type of physical activity children and adolescents, adults, older adults and subpopulations such as pregnant women and those living with chronic conditions or disability, should do for significant health benefits and mitigation of health risks. The guidelines also provide evidence- based recommendations on the associations between sedentary behaviour and health outcomes. 16 17 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r The guidelines have been developed for children and adolescents (aged 5–17 years), adults (aged 18–64 years), older adults (aged 65 years and above), and include for the first time specific recommendations on physical activity for subpopulations such as pregnant women and those living with chronic conditions or disability. Recommendations are made for each specific age group and subpopulation, to provide those working with particular communities easy access to the relevant information. Providing separate recommendations for subpopulations, especially people living with chronic conditions or with disability, highlights the importance of including these subpopulations in policy and planning of physical activity and sedentary behaviour interventions. These guidelines do not address sleep as a behaviour. Sleep is an important health-related issue and an emerging topic within population health science. However, it was deemed beyond the scope of the mandate to include sleep in the updated recommendations. Nonetheless, the importance of sleep is recognized and was included as an important health outcome when considering the impact of physical activity and sedentary behaviour. TARGET AUDIENCE This document reports the process and summarizes the evidence-base reviewed to develop the recommendations. The primary audiences are: 1. Policy-makers in ministries of health, education, youth, sport and/or social or family welfare, working in high as well as low- and middle-income countries, who formulate country-specific guidelines, and who plan health, education, workplace, residential or community-based intervention programmes across the life course. 2. Government officials who develop national, subregional or municipal plans to increase physical activity and reduce sedentary behaviours in population groups through guidance documents. 3. Persons working in nongovernmental organizations, education and workplace organizations or research. 4. Persons working in health services and those providing advice and guidance, such as community, family, primary or tertiary nurses or doctors, or allied health and exercise professionals working beyond the health sector. These guidelines can inform the content of their advice on these topics, if national guidance is not available. The recommendations on physical activity and sedentary behaviour contained within the guidelines should be used to inform pre-service training and professional development courses for health-care workers, physical activity specialists and education professionals. Derivative products are needed that convey these guidelines to specific end-users, stakeholders in sectors outside of health, and the wider community, that use tailored communications to meet the specific needs of each audience. 16 17Background These guidelines were developed in accordance with the WHO Handbook for guideline development (2nd edition) (21). A WHO Steering Group, led by the Department of Health Promotion, was established, with representation from WHO regional offices and relevant WHO departments. A Guideline Development Group (GDG) was formed, consisting of 27 experts and stakeholders, taking into account gender balance and geographical diversity. The draft guidelines were externally reviewed by seven independent reviewers, who provided feedback on the scientific evidence, its interpretation and content. In addition, an online public consultation was conducted on the draft guidelines, and feedback was received from over 400 contributors. These inputs from scientists, practitioners and the general public were collated and used by the GDG to finalize the guidelines. Full details of the management of the guideline development process are available in Annex 1. SCOPE OF GUIDELINES AND QUESTIONS OF INTEREST The GDG reviewed the scope of the guidelines and, at their first meeting, agreed on the most relevant PI/ ECO (Population, Intervention/Exposure, Comparison, Outcome) questions. The key questions addressed for each subpopulation are summarized as follows: For physical activity: a. What is the association between physical activity and health-related outcomes? b. Is there a dose-response association (volume, duration, frequency, intensity)? c. Does the association vary by type or domain of physical activity? For sedentary behaviour: a. What is the association between sedentary behaviour and health-related outcomes? b. Is there a dose-response association (total volume, frequency, duration and intensity of interruption)? c. Does the association vary by type and domain of sedentary behaviour? d. In adults only: Does physical activity modify the effect of sedentary behaviour on mortality? For each population (P), the exposure (E) was greater volume, duration, frequency or intensity of physical activity; for, as comparison (C) no physical activity or lesser volume, frequency, intensity or duration of physical activity. The critical and important outcomes for each population are summarized in Table 1 and the details of each PI/ECO question in the relevant section of the Web Annex: Evidence profiles . METHODS Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 18 19 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Table 1: Summary of critical and important* health outcomes addressed by population groups Outcomes (in alphabetical order) Children and adolescents aged 5–17 years: PA and sedentary Adults aged 18–64 years: PA Adults aged over 18 years: sedentary Adults aged over 65 years: PA a Pregnancy and postpartum Chronic conditions b Children and adults with disability c Adiposity (weight gain, weight change, weight control, weight stability, weight status and weight maintenance) Critical Critical Critical Critical a Critical Critical – HIV – Adverse events Critical Critical – Critical a Critical (fetal outcomes) – – All-cause and cause-specific mortality – Critical (cancer and CVD specific) Critical Critical a – Critical – Bone health Critical – Important – – – – Cardiometabolic health Critical – – – – – – Cognitive outcomes Critical Critical Important Critical a – – Critical – MS, PD, Stk, Sch, ADHD Delivery complications – – – – Important – – Disease progression – – – – – Critical – HT, T2D, HIV, Critical – cancer recurrence – Falls and fall-related injuries – – – Critical – – – Fetal outcomes (birthweight, preterm birth) – – – – Critical – – Functional ability – – – Critical – – – Gestational diabetes mellitus – – – – Critical – – Gestational hypertension/ preeclampsia – – – – Critical – – Health-related quality of life – Important Important Important a – Critical – HT, T2D, HIV Critical – MS, SCI, ID, MCD, Sch Incidence of cancer – Critical Critical Critical a – – – Incidence of CVD – Critical Critical Critical a – – – Incidence of hypertension – Important Important a – – – Incidence of type-2 diabetes – Critical Critical Critical a – – – Mental health (symptoms of anxiety and depression) Critical Critical Important Critical a Critical – – Osteoporosis – – – Critical – – – Physical fitness Critical – Important – – – – Physical function – – Important – – Critical – HT, T2D, HIV Critical – MS, SCI, ID, PD, Stk Pro-social behaviour Important – – – – – – Psychosocial outcomes – – – Important – – – Risk of co-morbid conditions – – – – – Critical – HT, T2D, HIV Critical – MS, SCI, ID Sleep Important Important Important Important a – – – * Critical outcome: an outcome that is critical to decision-making; Important outcome: an outcome that is important, but not critical to decision-making. a The critical and important outcomes considered for the adult population, including older adults. b Outcomes are for subpopulation condition as listed: Cancer – cancer survivors; HT – hypertension; T2D – type-2 diabetes; HIV. c Outcomes are for subpopulation condition as listed: MS – muscular sclerosis; SCI – spinal cord injury; ID – intellectual disability; PD – Parkinson’s disease; Stk – in stroke survivors; Sch – schizophrenia; ADHD – attention deficit/hyperactivity disorder. Critical and important outcomes for the age-specific population were considered and extrapolated. 18 19Methods THE EVIDENCE The revision of the 2010 WHO recommendations on physical activity was conducted by identifying, and then updating, the most recent, relevant umbrella reviews related to the scope of these guidelines. This approach was adopted due to an extensive body of recent systematic reviews which were conducted to inform the development of several national physical activity guidelines. The additional updating was undertaken to ensure the new WHO guidelines reflect the most recent available data in a rapidly developing field of public health. Umbrella reviews were selected if they met the following three criteria: i) the evidence reviews had been conducted according to standard systematic processes that were well documented; ii) the assessment of the certainty of the evidence used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method or an equivalent methodology that was clearly described and documented; and iii) the evidence reviews addressed the populations of interest with no restrictions to country or country income level. The PI/ECO questions and the critical and important health outcomes were mapped against existing evidence reviews and, where needed, additional new reviews were commissioned to address gaps. The GDG requested that the evidence reviews be updated, using the same search terms, search languages, and databases as the original reviews. The following evidence reviews were identified as meeting the above three criteria and were chosen for recency and comprehensiveness: • A systematic review of the literature conducted by Poitras et al. (2016) on the association between physical activity and health indicators in school-aged children and youth (22) as part of the process for developing the Canadian 24-hour movement guidelines for children and youth (23). This review focused solely on studies that used objective measurements of physical activity. A total of 162 studies were included, representing 204 171 participants from 31 countries. • A systematic review of the literature of the association between sedentary behaviour and health indicators in school-aged children conducted by Carson et al. (2016) (24), as part of the process for developing the Canadian 24-hour movement guidelines for children and youth (23). A total of 235 studies (194 unique samples) were included representing 1 657 064 unique participants from 71 countries. • A systematic review conducted by Okely et al. (2019) (25) undertaken to update Poitras et al. (2016) (22) and Carson et al. (2018) (24) as part of the development of the 2019 Australian 24-hour movement guidelines for children and young people (aged 5–17 years) (26). This report identified an additional 42 studies on physical activity, and 32 on sedentary behaviour, published through to July 2918 (25). The GRADE tables developed by Okely et al. were used as the basis for the commissioned update conducted for WHO. The GRADE tables along with the evidence profiles are presented in the Web Annex: Evidence profiles . • The 12 systematic reviews conducted and synthesized as part of the development of the 2019 Canadian guideline for physical activity throughout pregnancy (27). These 12 reviews assessed over 25 000 related studies in English, Spanish and French language on maternal physical activity during pregnancy that reported on maternal, fetal, or neonatal morbidity, or fetal mortality outcomes. Seven of these systematic reviews addressed outcomes deemed critical and important by the GDG (28–34) The GRADE tables from these evidence reviews were used as the basis for the literature search conducted to update and inform the development of WHO recommendations. The updated evidence profiles are presented in the Web Annex: Evidence profiles . • The scientific report of the Physical Activity Guidelines Advisory Group (PAGAC) (35) which provides a systematic update of evidence on physical activity and sedentary behaviours and health outcomes published 2008–2016 as part of the development of the 2018 Physical activity guidelines for Americans, 2nd Edition (36). The evidence summarized addressed a total of 38 main research questions and 104 subquestions selected for their public health relevance. The evidence comprised results from systematic reviews which consisted of a total of 1130 articles, each abstracted to answer the 38 research questions (35). The protocols used a modified version of “A Measurement Tool to Assess Systematic Reviews” (AMSTARExBP) to assess the methodological quality of systematic reviews and meta-analyses. Risk of bias, or internal validity, was assessed for each original study using an adapted version of the USDA NEL Bias Assessment Tool (BAT) (37). The new evidence identified in the updated searches conducted for these WHO guidelines is presented in the evidence profiles in the Web Annex: Evidence profiles ; links are provided to the report and supplementary materials of PAGAC (35). Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 20 21 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Methods for updating the evidence and data extraction A search for systematic reviews and pooled analyses of cohort studies was conducted for studies published from the date of the last searches carried out for each of the included reviews (listed above) to September 2019; standardized data extraction protocols were developed and employed. To update the searches conducted by Poitras et al. (2016) (22), Carson et al. (2016) (24), and Okely et al. (2019) (25), the databases MEDLINE, EMBASE, PsycINFO, and SportDiscus were searched to identify reviews that were peer-reviewed, written in English or French. To update the searches conducted by PAGAC (35), PubMed, CINAHL and Cochrane databases were searched to identify reviews that were peer-reviewed, written in English. A de novo search for important outcomes, where these were not included by PAGAC (35), was not conducted due to resource constraints. Searches were performed with no restriction by country or country income status, and inclusive of reviews addressing any subjectively or objectively measured physical activity or sedentary behaviour. It was decided not to conduct searches in languages other than those of the original searches, due to resource constraints and previous experience in the field indicating that such searches yielded very few, if any, additional reviews. Reviews were considered that examined an association between physical activity or sedentary behaviour and health-related outcomes (based on levels above or below a threshold of physical activity or sedentary behaviour), and that explored the dose-response relationship between these and health-related outcomes. An external team of reviewers used the AMSTAR 2 (Assessment of Multiple Systematic Reviews) instrument to rate the credibility of the systematic reviews under consideration for inclusion (38). The AMSTAR 2 tool contains 16 items that relate to the planning and conduct of the review. The overall confidence in the results of each review was rated according to published guidance: a rating of “high” reflects that the review had zero or one noncritical weakness; “moderate” indicates the review was judged to have more than one noncritical weakness; “low” means the review was judged to have one critical flaw with or without noncritical weaknesses, or multiple noncritical weaknesses; and “critically low” signifies that more than one critical flaw was present. One reviewer completed the AMSTAR 2 tool for all provisionally included reviews. Reviews that were rated critically low by one reviewer were reviewed by a second reviewer using the same tool. Reviews ultimately rated as critically low were excluded because they were judged to be too unreliable to provide an accurate and comprehensive summary of the available evidence, unless it was the only review available for a particular outcome. This body of evidence also included pooled cohort studies. An external team of reviewers used the Newcastle- Ottawa Scale to assess the quality of the studies (39). Each study was given a quality rating of “good”, “fair”, or “poor”. In general, a good-quality study met all criteria on the Newcastle-Ottawa scale. A fair-quality study did not meet, or it was unclear whether it met, at least one criterion, but also had no known important limitations that could invalidate its results. A poor-quality study had a single fatal flaw, or multiple important limitations. Poor-quality studies were excluded. There was an assessment for overlap, recognizing potential for duplication of studies in multiple reviews. Reviews containing redundant bodies of evidence, overviews of reviews, and some pooled cohort studies were excluded, where other more comprehensive and/or recent reviews were identified. Methods for new reviews Where gaps in existing evidence were identified, new umbrella reviews were commissioned to examine: 1. the relationship between occupational (i.e. work- related) physical activity and health-related outcomes (40); and 2. the association between leisure-domain physical activity and adverse health outcomes (41). (For numbers 1 and 2 above, searches were undertaken using PubMed, SportDiscus and EMBASE for reviews published from 2009 to December 2019.) 3. the association between physical activity and falls prevention; the 2019 Cochrane Collaboration Systematic Review by Sherrington et al. (42) was used, and updated with evidence published from the end search date of their original review, through to November 2019. 4. the association between physical activity and osteoporosis and sarcopenia. The search for existing systematic reviews on osteoporosis and sarcopenia, conducted in PubMed for reviews published from 2008 up to November 2019, identified no new reviews and eight new primary studies. 5. the evidence on associations between physical activity and health outcomes in people living with HIV. A scoping review ascertained the availability of 20 21Methods evidence on physical activity and health-related outcomes among people living with HIV to support conducting an umbrella review which was conducted for evidence published up to October 2019 with no start date limitation using PubMed, CINAHL and Web of Science. Summary of characteristics of the evidence and assessment methods of physical activity and sedentary behaviour Until recently, the primary methods for measuring physical activity and sedentary behaviours in adults has been by self-report (i.e. survey) and, for children, either self-report or parental recall. Although these methods have well-established strengths, limitations include being prone to reporting bias and measurement error (43). In recent years, with digital technology rapidly growing in this area, there has been an increase in the use of device-based measures for assessing physical activity and sedentary time and their associations with health outcomes. However, challenges remain in comparing results between studies due to differences between the technical features and placement of different devices (accelerometers), and differences in the analyses and reporting of the data. For example, when measuring sedentary time with device-based measures, miscalculation may occur as many of the devices do not currently distinguish between positions (e.g. lying, sitting and standing still). Difficulties also exist when comparing findings from studies using device- based measures with those reporting results from self-report measures. Self-report instruments vary in content, in the examples of physical activity, response options and domains covered. Until recently, studies focused primarily on assessing either total physical activity, or physical activity in the leisure/recreation domain only, but now increasingly include other domains such as physical activity for transport (e.g. walking and cycling), at work, and in the household. The majority of evidence reports on associations between aerobic physical activity and health outcomes, however studies are now assessing the benefits of muscle- strengthening exercise, as well as combinations of different types of activity and other domains. Results on the association between physical activity levels and health outcomes are reported and compared in different ways. Many studies report comparisons between quartiles or quintiles of physical activity, other studies compare those “meeting” versus “not meeting” national guidelines. Calculation of total physical activity, when reported, is usually estimated in MET-hours per week and some studies compare “highest” versus “lowest”, although categories also vary across studies. The literature frequently reports results from analyses that apply data cut points based on an existing guideline, or the current WHO Global recommendation, or metrics from previous research (for example the cut points of 60 minutes per day in research on youth populations, or the frequency of 2–3 times per week for strength training intervention). When such cut points become commonplace the building of evidence on the associations of higher or lower levels of physical activity exposure on health outcomes can be limited. Most of the evidence assessing the associations between sedentary behaviours and health outcomes for children and adolescents is cross-sectional in nature, and a majority of studies rely on self- or parent-reported measures of sedentary time that are subject to measurement errors and recall biases. Evidence from longitudinal observational studies and intervention trials was prioritized, and reviews that solely or primarily synthesized cross-sectional evidence were not considered. Greater emphasis was given to evidence provided by reviews graded moderate certainty and above, and to those providing evidence from studies using device-based measures of exposure. Grading the body of evidence The Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was used to rate the certainty of the evidence for each PI/ECO (44), based on the underlying evidence in the reviews. When available, the GRADE “Evidence Profiles” or “Summary of Findings” tables from each review, were used as a starting point. If no table was available within the existing systematic reviews, “Evidence Profile” tables for each population and outcome of interest were constructed. The GRADE method was used to rate the certainty of the evidence for each PI/ECO (44) with the following criteria considered: study design; risk of bias; consistency of effect; indirectness; precision of effect; and other limitations, including publication bias and factors for upgrading observational evidence (magnitude of effect, dose-response, and effects of confounders). Observational evidence from well- conducted longitudinal studies was also upgraded to reflect more appropriately the increased certainty in findings regarding associations between physical 22 23 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r activity or sedentary behaviour and outcomes from such studies. Studies that evaluated intermediate/ indirect outcomes were not necessarily downgraded, as the outcomes (including intermediate outcomes) were prioritized by the GDG; the GRADE rating reflects the certainty in effects on those outcomes. In some cases, the GRADE ratings from existing reviews were modified to ensure consistency in application of GRADE methods. The certainty in the body of evidence for each outcome was assigned based on the following guidance (45): High Very confident that the true effect lies close to that of the estimate of the effect. Moderate Moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low Confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect. Very low Very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of  effect. Going from evidence to recommendations The GDG employed the GRADE Evidence to Decisions (EtD) framework for generating question-specific recommendations. The EtD framework is a systematic, structured and transparent approach to decision- making. The framework uses explicit criteria for generating guideline recommendations considering research evidence, certainty of evidence and, where required, expert opinion and topical knowledge from the perspective of the target audience. The criteria elicit judgments about the balance between the observed evidence of desirable and undesirable outcomes, overall certainty of evidence, relative values of patients for desirable and undesirable outcomes, resource use (cost considerations) where applicable, potential impact on inequities in health, acceptability and feasibility of recommendations. The GDG considered the body of evidence in totality for each recommendation for all critical outcomes, and all available important outcomes. For a particular exposure/intervention and outcome link, studies differed widely in the specific exposure/intervention assessed, outcomes assessed, study design, and analytic methods, resulting in heterogeneity in the available evidence. Therefore, it was not possible to apply the classic GRADE approach to each specific exposure/intervention and outcome link; rather, GRADE was applied for the overall body of evidence addressing each exposure/intervention and outcome link, across study design types and variations in exposure/intervention measurements and analyses. When these factors resulted in concerns regarding the coherence of the evidence (i.e. that the evidence for a particular exposure/intervention and outcome link did not correspond when looked at in different ways), the panel downgraded the certainty of evidence (21). The GDG prioritized the following health outcomes to consider the effects of physical activity and sedentary behaviour: reduced all-cause and cause- specific mortality (cardiovascular disease and cancer); reduced incidence of cardiovascular disease; cancer (site-specific); type-2 diabetes; improved physical fitness (e.g. cardiorespiratory, motor development, muscular fitness); improved cardiometabolic health (e.g. blood pressure, dyslipidaemia, glucose, insulin resistance); bone health; mental health (e.g. reduction in depressive symptoms, self-esteem, anxiety symptoms, ADHD); and improved cognitive outcomes (e.g. academic performance, executive function); and reduced adiposity. Adverse effects (e.g. injuries and harms) were also considered. Additional considerations For each population and all PI/ECO questions, the GDG also considered values and preferences of those affected by the guidelines; the resource implications of the recommendations; the impact on health equity; and the acceptability and feasibility of the recommendations. As there was considerable duplication in these considerations, and in the GDG’s assessment, for each population group, a summary of the discussions regarding assessments for these elements are described in the “Evidence to recommendations” section. 22 23Methods The public health recommendations presented in the WHO Guidelines on physical activity and sedentary behaviour are for all populations and age groups ranging from 5 years to 65 years and older, irrespective of gender, cultural background or socioeconomic status, and are relevant for people of all abilities. The new guidelines are presented by age group and behaviour (physical activity and sedentary). For each set of recommendations, an introductory statement summarizes the health outcomes associated with physical activity and sedentary behaviour respectively; the recommendations then follow. A set of good practice statements is provided to further clarify how the recommendation can be met safely by the target population. These good practice statements are not “graded recommendations” per se, but are derived from scientific evidence and from practical considerations reviewed and recommended by the GDG. For each set of recommendations, a summary of the supporting scientific evidence is provided, structured by the three PI/ECO questions; presenting first the evidence on the associations with the critical health outcomes, followed by a summary of evidence on dose response. Finally, a summary of evidence on the relationships between different types or domains of exposure and health outcomes is presented, where this exists. RECOMMENDATIONS G O O D P R A C TI C E ST A TE M EN TS 24 25 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Supporting evidence and rationale For these guidelines for children and adolescents, systematic reviews (22, 25, 35) were used and updated with 16 new reviews identified that met inclusion criteria. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . • Doing some physical activity is better than doing none. • If children and adolescents are not meeting the recommendations, doing some physical activity will benefit their health. • Children and adolescents should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • It is important to provide all children and adolescents with safe and equitable opportunities, and encouragement, to participate in physical activities that are enjoyable, offer variety, and are appropriate for their age and ability. G O O D P R A C TI C E ST A TE M EN TS In children and adolescents, physical activity confers benefits for the following health outcomes: improved physical fitness (cardiorespiratory and muscular fitness), cardiometabolic health (blood pressure, dyslipidaemia, glucose, and insulin resistance), bone health, cognitive outcomes (academic performance, executive function), mental health (reduced symptoms of depression); and reduced adiposity. It is recommended that: Children and adolescents should do at least an average of 60 minutes per day of moderate- to vigorous-intensity, mostly aerobic, physical activity, across the week. Strong recommendation, moderate certainty evidence Vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone, should be incorporated at least 3 days a week. Strong recommendation, moderate certainty evidence CHILDREN AND ADOLESCENTS (aged 5–17 years) Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf For children and adolescents, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), physical education, transportation (wheeling, walking and cycling) or household chores, in the context of educational, home, and community settings. PHYSICAL ACTIVITY RECOMMENDATION 24 25Recommendations In children and adolescents (aged 5–17 years), what is the association between physical activity and health-related outcomes? A large body of evidence previously established that greater amounts and higher intensities of physical activity in children and adolescents are associated with multiple beneficial health outcomes (1). Recent evidence reaffirms that increased physical activity improves cardiorespiratory fitness and musculoskeletal fitness in children and adolescents (22, 35). For example, positive impacts are obtained when participating in moderate- to vigorous-intensity physical activity for 3 or more days per week, for 30 to 60 minutes (22, 35). Regular physical activity, largely aerobic, in children and adolescents is positively associated with beneficial cardiometabolic health outcomes, including improved blood pressure, lipid profile, glucose control and insulin resistance (35). Recent reviews examined the effectiveness of school-based physical activity programmes (46), high-intensity interval training (47) and resistance training (48), versus no intervention on measures of cardiometabolic health. Within all 3 reviews, there was consistent evidence that interventions were associated with better cardiometabolic outcome measures, although there was varied precision in effect sizes and few individual trials found statistically significant benefits of physical activity across all cardiometabolic outcomes. One review of 19 RCTs (n= 11 988) (46) reported that school-based physical activity programmes were associated with statistically significant improvements in diastolic blood pressure (ES= 0.21 [95% CI: 0.42 to 0.01]; p= 0.04) and fasting insulin (ES= 0.12 [95% CI: 0.42 to 0.04]; p= 0.03) compared with no physical activity interventions. Physical activity has been reported to be favourably associated with adiposity, and higher levels of activity may be associated with healthy weight status in children and adolescents (22, 35). The results are generally strongest in cross-sectional studies, while the results are more mixed from prospective observational studies, which limits understanding of the directionality of the reported associations. More recent reviews of physical activity interventions trials (laboratory-based high- intensity interval training [HIIT], classroom-based active learning, resistance training) reported inconsistent results with the majority of the studies included in the reviews not reporting an effect (47, 49, 50). However, a review of longitudinal and cross-sectional studies reported a negative relationship between pedometer- measured physical activity and measures of adiposity, BMI or waist circumference (51). Overall there is low certainty evidence that physical activity is associated with the management of a healthy weight status and more research is needed to determine directionality and strength of association. There is less evidence examining the association between physical activity and motor skill development in children and adolescents, with current reviews demonstrating null findings (22). More research is needed with motor development as an outcome to inform future guidelines. For children and adolescents, bone-loading activities can be performed as part of playing games, running, turning, or jumping. Physical activity is positively associated with bone mass accrual and/or bone structure, and recent evidence supports that children and adolescents who are more physically active than their peers have greater bone mass, higher bone mineral content or density, and greater bone strength (35). Maximizing bone health in childhood and adolescence can help protect from osteoporosis and related fractures later in life. Developing and maintaining cognitive function is essential across the entire lifespan. In children and adolescents, physical activity has positive effects on cognitive function and academic outcomes (e.g. school performance, memory and executive function) (22, 35). One recent review (19 RCTs; n= 5038) demonstrated that exercise interventions with multiple sessions per week, for 6 weeks or longer, were associated with greater change in measures of cognitive function such as inhibitory control (SMD 0.26 [95% CI: 0.08 to 0.45], p= < 0.01); working memory (SMD 0.10 [95% CI: -0.05 to 0.25], p= < 0.02), and cognitive flexibility (SMD 0.14 [95% CI: -0.03 to 0.31], p= < 0.04) compared with no exercise interventions (52). Physical activity also reduces the risk of experiencing depression and depressive symptoms in children and adolescents with and without major depression (35), and may be comparable to psychological and pharmaceutical therapies in reducing symptoms. Although all physical activity comes with some risk of adverse event (53) there is limited evidence reporting harms associated with physical activity levels recommended for health benefit (35). Based on available evidence and expert opinion, the potential risks associated with the amounts and types of physical activity recommended for children and adolescents CHILDREN AND ADOLESCENTS (AGED 5–17 YEARS) 26 27 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r were considered to be low (35) and can be reduced by a progressive increase in the activity level and intensity, especially in children and adolescents who are inactive. It is known that participation in some sports increases the risk of injury, as does increasing exercise intensity (53). More research is needed to strengthen the knowledge base in this area. The GDG concluded that: • There is moderate certainty evidence that greater amounts of moderate- and vigorous-intensity physical activity are associated with improved cardiorespiratory fitness and muscular fitness, cardiometabolic health and bone health in children and adolescents. • There is moderate certainty evidence that both short- and long-term moderate- to vigorous-intensity physical activity have positive effects on cognitive function, academic outcomes and mental health. • There is low certainty evidence that physical activity is favourably associated with the management of healthy weight status in children and adolescents. • There is low-certainty evidence that the risks for the amounts and types of physical activity recommended for children and adolescents are low and are outweighed by the benefits. Is there a dose-response association (volume, duration, frequency, intensity)? Although there is a substantial body of evidence demonstrating a positive association between physical activity and health outcomes in children and adolescents, very few studies have addressed the issue of dose-response. Therefore, the exact shape of the dose-response curve and/or the presence of threshold values (that differentiate lower versus higher risk) for physical activity and specific health outcomes is less well understood in children and adolescents compared with adult populations. Nonetheless, a substantial body of evidence shows that many of the health benefits occur with 60 minutes of physical activity daily (22, 35), and given no contradictory evidence, it was concluded that the updated evidence reaffirms the current WHO recommendation for 60 minutes of moderate- to vigorous-intensity physical activity per day (1). However, the review of all evidence, including recent results from studies using device-based measures of physical activity, did not support retaining the specification of a “minimum” daily threshold of 60 minutes of moderate- to vigorous-intensity physical activity for health benefits, given that studies broadly used “an average” threshold of 60 minutes per day, not a minimum daily threshold of 60 minutes, to assess the benefits of physical activity on health outcomes. The review concluded that the new guideline should be amended to more closely reflect this evidence. The benefits of regular vigorous-intensity activity on cardiometabolic health outcomes has been previously established (1) and recent reviews provided further supporting evidence (35). For example, a recent review (54) showed that high-intensity interval training, compared with moderate-intensity continuous training, had a moderate beneficial effect on cardiorespiratory fitness (SMD= 0.51 [95% CI: 0.33 to 0.69], p= < 0.01; I 2= 0%). There was no evidence that intervention duration, exercise modality, exercise and rest ratio, and total bouts modified the effect on cardiorespiratory fitness. These results were consistent overall with other recent reviews (22, 35, 47) and provide support to retaining the recommendation that youth and adolescents should do regular vigorous-intensity activity to improve cardiorespiratory fitness. The GDG concluded that: • Evidence affirms the previous WHO recommendation for 60 minutes of moderate- to vigorous-intensity physical activity per day. • Evidence supports amending the previous specification of a minimum daily threshold of 60 minutes of physical activity to an average of 60 minutes per day per week, which more closely reflects the evidence. • There is moderate certainty evidence that greater amounts of vigorous-intensity physical activity are associated with improved cardiorespiratory fitness. Does the association vary by type or domain of physical activity? For children and adolescents, physical activity includes play, games, sports, transportation, recreation, physical education or planned exercise, in the context of family, school, and community activities. However, few studies have directly compared different types or domains of physical activity in children and adolescents and thus there is insufficient evidence to determine if the association between physical activity and health outcomes varies by type of activity (e.g. aerobic versus muscle-strengthening exercise) or domain of physical activity (e.g. active transport (walking and cycling) versus physical education, versus sports/recreation). CHILDREN AND ADOLESCENTS (AGED 5–17 YEARS) 26 27Recommendations There is evidence showing that both increased levels of aerobic moderate- to vigorous-intensity physical activity are associated with increased cardiorespiratory fitness, and that increased muscle-strengthening activity increases muscular fitness in children and adolescents. This evidence informed the 2010 WHO Global recommendations on physical activity for health (1) which recommended incorporating activities that strengthen muscles and bones at least 3 days per week. Updated evidence reaffirmed that regular muscle- strengthening activity 3 times per week was effective for improving indicators of muscular fitness; however, there is insufficient evidence to state specific details of session duration and intensity, largely due to the heterogeneity of exposures assessed in the literature (22, 35). There is less evidence for a protective effect of resistance training on cardiometabolic health. Given the absence of new evidence on characteristics other than the frequency of muscle strengthening activities for children and adolescents, such as duration, it was not possible to specify any further details. Future research should address the health benefits of specific types and domains of physical activity in order to provide more specificity to this component of the guidelines. The GDG concluded that: • There is moderate certainty evidence that muscle- strengthening activities should be incorporated at least 3 days a week. CHILDREN AND ADOLESCENTS (AGED 5–17 YEARS) 28 29 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Supporting evidence and rationale Sedentary behaviour was not included in the WHO 2010 recommendations, yet during the past decade, there has been a growing body of research examining the health outcomes associated with different measures and types of sedentary behaviours. Technology and digital communications have influenced how people work, study, travel and spend leisure-time. In most countries, children and adolescents are spending greater time engaged in sedentary behaviours, particularly for recreation, such as screen-based entertainment (television and computers) and digital communications, such as mobile phones. For these guidelines for children and adolescents, systematic reviews (24, 25) were used and updated with seven new reviews identified that met inclusion criteria. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . In children and adolescents, higher amounts of sedentary behaviour are associated with the following poor health outcomes: increased adiposity; poorer cardiometabolic health, fitness, behavioural conduct/pro-social behaviour; and reduced sleep duration. It is recommended that: Children and adolescents should limit the amount of time spent being sedentary, particularly the amount of recreational screen time. Strong recommendation, low certainty evidence Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Sedentary behaviour is defined as time spent sitting or lying with low energy expenditure, while awake, in the context of educational, home, and community settings and transportation. CHILDREN AND ADOLESCENTS (aged 5–17 years) SEDENTARY BEHAVIOUR RECOMMENDATION 28 29Recommendations In children and adolescents (aged 5–17 years), what is the association between sedentary behaviour and health-related outcomes? Evidence indicates that greater time spent in sedentary behaviour, especially recreational screen time, is related to poorer health outcomes (24, 35). For example, higher duration of screen time (including television viewing) is associated with poorer fitness and cardiometabolic health (24, 25) in children and adolescents. Evidence from device-based assessment of association with sedentary behaviour and interventions studies showed modest effects, although stronger effects for those already living with obesity (55). There is limited evidence suggesting that sedentary behaviour is not related to bone health in children and adolescents. Despite more mixed results, evidence also suggests that sedentary behaviour may be associated with unfavourable measures of adiposity (24, 25). One review of largely cross-sectional studies, reported that sedentary behaviour (measured as total screen time) of more than 2 hours per day was positively associated with childhood overweight/obesity compared with lower levels (< 2 hours/day) (56). However, another review of 20 cross-sectional studies (57) found no statistically significant association between sedentary video gaming and body mass index among children or adolescents. A large review of 29 systematic reviews concluded that many studies report unfavourable associations between sedentary behaviour and markers of adiposity in young people when the behaviour is self-reported as some form of screen time (55). However, the review noted that the magnitude of such associations was small and, for studies using device-based assessment of sedentary time, largely zero (55). Intervention studies showed modest effects, although stronger effects for those already living with obesity (55). Further research is needed to inform the association between sedentary behaviours and measures of adiposity. Although still an emerging area of research, some evidence shows that there may be a negative association between sedentary behaviour and well-being and quality of life, as well as an unfavourable relationship between depression and leisure screen time in children and adolescents (58, 59). For example, higher durations of sedentary behaviour, assessed as screen time, and some aspects of computer use, can be associated with poorer mental health (24). In another recent review, an association between sedentary behaviour and anxiety symptoms was found in 5 of 8 studies, although results were inconsistent across different measures of sedentary behaviour within studies (60). Other evidence demonstrates that higher durations of television viewing and video game use were significantly associated with unfavourable measures of behavioural conduct/pro-social behaviour (24); and more screen time and television viewing is associated with shorter sleep duration, although there was no association between computer use/gaming and sleep duration (61). Investigations into the relationship between sedentary behaviours and mental health is a rapidly developing field with many unknowns, and reverse causality is likely to be in evidence. Further research is needed to inform on the direction and strength of this association. The GDG concluded that: • There is low certainty evidence that higher duration of sedentary behaviour (screen time) is significantly associated with lower physical fitness and cardiometabolic health in children and adolescents. • There is very low to moderate certainty evidence that higher durations of sedentary behaviour (screen time, television viewing and video game use) are significantly associated with unfavourable measures of mental health and behavioural conduct/pro-social behaviour in children and adolescents. • There is low certainty evidence that greater time spent in sedentary behaviour (screen time and television viewing) is associated with detrimental effects on sleep duration in children and adolescents. • The benefits of limiting the amount of sedentary behaviour for children and adolescents outweigh the harms. Is there a dose-response association (total volume, duration, frequency, intensity of interruption)? There is insufficient evidence available to determine whether a dose-response relationship exists between sedentary time (including recreational screen time) and health outcomes in children and adolescents. Most of the evidence assessing the associations between sedentary behaviours and health outcomes in children and adolescents is cross-sectional in nature, with low certainty evidence according to GRADE, and a majority of studies relied on self- or parent-reported measures of sedentary time that are subject to measurement errors and recall biases. There is, however, evidence that less time spent in sedentary behaviours appears to be CHILDREN AND ADOLESCENTS (AGED 5–17 YEARS) 30 31 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r better for health outcomes, and the association between sedentary behaviour and adverse health outcomes is generally stronger for sedentary behaviour when assessed as television viewing or recreational screen time as the exposure variable, than for total sedentary time. However, overall the evidence was considered insufficient to support specifying time limits. Evidence that sedentary behaviours are linked to adverse health outcomes could be the result of either direct effects of the sedentary behaviours, displacement of time spent in more physically active behaviours, or both. Although there are studies that have reported associations between screen time and adverse health outcomes in children and adolescents, total sedentary time (as assessed in studies using device-based measurements of sedentary behaviour) has consistently not been associated with health outcomes when time in moderate- to vigorous-intensity physical activity is taken into account (62). Conversely, the evidence linking moderate- to vigorous-intensity physical activity to positive health outcomes is strong and well documented across diverse settings; replacing some sedentary behaviour with physical activity (especially moderate- to vigorous-intensity physical activity) may improve health outcomes. Research investigating the associations and interplay between sedentary behaviour, physical activity and health outcomes is rapidly growing, and evidence from device-based measures of sedentary behaviour and cardiometabolic health show the association is attenuated when moderate- to vigorous-intensity physical activity is taken into account (i.e. statistically adjusted for) (62–64). There is therefore a need for further prospective studies using device-based measures of exposure, to advance knowledge of these associations and inform future recommendations. The GDG concluded that: • There is low certainty evidence that greater time spent in sedentary behaviour is related to poorer health outcomes. • There is insufficient evidence to specify time limits on sedentary behaviour. • Replacing sedentary time with moderate- to vigorous- intensity physical activity may provide health benefits. Does the association vary by type or domain of sedentary behaviour? The study of health effects of sedentary behaviour is a relatively new field of research. As such the findings are from studies using different instruments and measures of exposure. Exposure assessed as “total time spent doing sedentary behaviours” is frequently used, as is sedentary time spent using “screens” or “television viewing”. Available evidence suggests that the association between sedentary behaviour and adverse health outcomes is generally stronger for television viewing or recreational screen time than for total sedentary time (24, 35). The increased use of device-based assessment of sedentary behaviour in the more recent research is advancing knowledge, and when combined with standardized reporting will help inform future guidelines. It is acknowledged that not all sedentary behaviour is harmful. Evidence suggests certain types of sedentary behaviour, such as reading and doing homework outside of school, are associated with higher academic achievement, indicating that there are differences in outcome depending on the activity (24, 25). Sedentary behaviour may include time spent engaged in educational pursuits/study or quiet play, or social interaction without electronic media. These pursuits (e.g. reading, doing puzzles, drawing, crafting, singing, music) are important for child development and have cognitive as well as other benefits. The GDG acknowledged that: • Some sedentary activities confer benefits for cognitive function and social interaction in children and adolescents. • Evidence on the adverse health effects of sedentary behaviour is generally stronger for television viewing or recreational screen time than for total sedentary time. CHILDREN AND ADOLESCENTS (AGED 5–17 YEARS) 30 31Recommendations ADULTS (aged 18–64 years) In adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site- specific cancers, 1 incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression); cognitive health, and sleep; measures of adiposity may also improve. It is recommended that: All adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence Adults should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence Adults may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence For adults, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), transportation (wheeling, walking and cycling), work or household chores, in the context of daily occupational, educational, home and community settings. PHYSICAL ACTIVITY RECOMMENDATION • Doing some physical activity is better than doing none. • If adults are not meeting these recommendations, doing some physical activity will benefit their health. • Adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. G O O D P R A C TI C E ST A TE M EN TS 1 Site-specific cancers of: bladder, breast, colon, endometrial, oesophageal adenocarcinoma, gastric, and renal. 32 33 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ADULTS (aged 18–64 years) Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Supporting evidence and rationale For these guidelines, the synthesis of evidence undertaken by the United States Physical Activity Guidelines Advisory Committee (PAGAC) (35) was used and updated. The GDG considered the entire body of evidence, including both the findings reported by PAGAC and the 28 reviews and 3 pooled cohort studies, published from 2017 through to November 2019, that met inclusion criteria, and contributed evidence on the association between physical activity and health-related outcomes in adults. In addition, two umbrella reviews were commissioned to address evidence gaps and examine i) the relationship between occupational (i.e. work-related) physical activity and health-related outcomes (40); and ii) the association between leisure-domain physical activity and adverse health outcomes (41). The umbrella reviews identified 36 and 15 systematic reviews respectively. Evidence from longitudinal observational studies and intervention trials was prioritized, and reviews that solely, or primarily, synthesized cross-sectional evidence were not considered. Greater emphasis was given to evidence provided by reviews graded moderate certainty and above, and to those providing evidence from studies using device-based measures of exposure. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . In adults (aged 18–64 years), what is the association between physical activity and health-related outcomes? The association between physical activity and all-cause mortality and cardiovascular disease mortality in adults is already well-established (1). Findings from recent reviews reaffirmed that compared with the lowest levels of physical activity, higher levels of physical activity were associated with a lower risk of mortality. New evidence from studies using device-based measures of physical activity reaffirmed and extended the evidence showing that compared with the lowest levels of physical activity, any level and all intensities (including light intensity) of physical activity, were associated with a lower risk of mortality (65). For example, compared with the least active (referent, 1.00), adjusted HR for quartiles of total physical activity improved across quartiles of physical activity: 2nd quartile (0.48 [95% CI: 0.43 to 0.54]); 3rd quartile (0.34 [95% CI: 0.26 to 0.45]); and 4th quartile (0.27 [95% CI: 0.23 to 0.32]) (65). New evidence also reaffirmed the well-established (1) inverse relationship between physical activity and cardiovascular disease mortality (66). The benefits of physical activity for reducing cardiovascular disease and hypertension incidence is well-documented (1). Physical activity promotes many physiological responses that cause beneficial short- and long-term autonomic and haemodynamic adaptations, resulting in lowered risk of hypertension, which is a key risk factor for cardiovascular disease. Evidence reaffirmed an inverse relationship between physical activity and incident hypertension among adults with normal blood pressure, and that physical activity reduces blood pressure among adults with prehypertension and normal blood pressure (35). The inverse association between physical activity and developing type-2 diabetes in adults is well-established (1). Recent evidence reaffirmed an inverse curvilinear relationship between higher volumes of physical activity and incidence of type-2 diabetes (35), with a decreasing slope at higher levels of physical activity. A new review found that this effect is consistent across individuals of different backgrounds with a reduced risk of developing type-2 diabetes in “highest” versus “lowest” levels of physical activity among non-Hispanic whites (RR= 0.71 [95% CI: 0.60 to 0.85]); Asians (RR= 0.76 [95% CI: 0.67 to 0.85]); Hispanics (RR = 0.74 [95% CI 0.64 to 0.84]); and American Indians (RR = 0.73 [95% CI: 0.60 to 0.88]), although the effect among non-Hispanic blacks was not significant (RR = 0.91 [95% CI: 0.76 to 1.08]) (67). Evidence suggests there is no effect modification by weight status and that the inverse relationship between a higher volume of physical activity and lower incidence of type- 2 diabetes exists for people who have normal weight, overweight or obesity (35). The associations between higher levels of physical activity and reduced risks of colon cancer and breast cancer have been well-established (1). In previous reviews of the evidence, higher levels of physical activity have been found to be associated with a reduced risk of 32 33Recommendations developing breast cancer and colon cancer (1). Following an extensive increase in physical activity and cancer research, there is new evidence demonstrating higher levels of physical activity are also associated with reduced risk of developing bladder, endometrial, oesophageal adenocarcinoma, gastric and renal cancers, as well as reaffirming that physical activity is protective for breast cancer and colon cancer (35). Higher levels of physical activity are associated with risk reductions ranging from approximately 10–20% (35). For example, one review reported an inverse association with liver cancer risk when comparing high levels of physical activity to low levels of physical activity (HR= 0.75 [95% CI: 0.63 to 0.89]) (68). There is insufficient evidence on the association between increased physical activity and decreased risks of hematologic, head and neck, ovary, pancreas, prostate, thyroid, rectal and brain cancer (35). While evidence suggests a reduction in risk of lung cancer between the highest versus lowest levels of physical activity, these findings may be confounded by tobacco use and it was determined that overall there is insufficient evidence to establish an association. The association between physical activity and adiposity in adult populations is less well established despite a large, but heterogenous, body of evidence assessing this relationship across various outcome measures (weight gain, weight change, weight control, weight stability, weight status and weight maintenance) (35, 69, 70). Overall the evidence shows that higher levels of physical activity may be associated with more favourable measures of adiposity and attenuation of weight gain in adults (35). Further research is needed to establish consistent results and strength of associations. Research on physical activity and mental health, cognition and sleep has increased substantially since the development of the 2010 Global recommendations on physical activity for health (1). At that time, there was sufficient evidence to conclude only that physical activity may reduce the risk of depression and cognitive decline in adults. New evidence reviewed for these guidelines showed that adults engaging in higher versus lower physical activity are at reduced risk of developing anxiety and depression. For example, adults with high, versus low, levels of physical activity were at reduced odds of developing anxiety (AOR= 0.81 [95% CI: 0.69 to 0.95]) (71) or depression (AOR= 0.78 [95% CI: 0.70 to 0.87) (72). Greater amounts of moderate- to vigorous-intensity physical activity are associated with improvements in cognition (e.g. processing speed, memory, and executive function) (35), brain function and structure, and a reduced ADULTS (aged 18–64 years) risk of developing cognitive impairment, including Alzheimer’s disease (73–76). The evidence included several adult populations representing a gradient of normal to impaired cognitive health status and the beneficial effects of physical activity were reported across a variety of types, including aerobic activity, walking, muscle-strengthening activity, and yoga (74). There is evidence that both acute bouts and regular physical activity improve sleep and health-related quality of life outcomes in adults (35). Evidence examining physical activity and symptoms of depression, symptoms of anxiety, and the development of anxiety and depression indicated that physical activity was associated with reduced symptoms of anxiety (77, 78) and reduced symptoms of depression (77, 79). All physical activity comes with some risk. Evidence from a commissioned review on the adverse effects, injuries and harms associated with leisure physical activity in adults (41) suggests an unfavourable association between levels of leisure-time physical activity and musculoskeletal injuries, and a favourable relationship between leisure- time physical activity and risk of fracture and onset of knee or hip osteoarthritis. Additional existing evidence (35) indicates sudden cardiac adverse events are rare and associated with acute sessions of relatively vigorous- intensity physical activity. Generally, the risks of adverse events are very low with moderate-intensity physical activity and when increases in physical activity frequency, intensity and duration are gradual (35). The GDG concluded that: • There is high certainty evidence that any level and any intensity of physical activity is associated with lower risk of all-cause mortality and cardiovascular disease mortality, incidence of hypertension, cardiovascular disease and type-2 diabetes. • There is moderate to high certainty evidence on the associations between higher levels of physical activity and lower risk of incidence of site-specific cancers. • There is moderate certainty evidence supporting an association between physical activity and improvements in mental health, cognitive health and sleep outcomes. • There is evidence of an association between higher levels of physical activity and more favourable measures of adiposity and attenuation of weight gain in adults. • There is low certainty evidence that physical activity recommended for adults will not be harmful and that the health benefits from such activity outweigh the risks. 34 35 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Is there a dose-response association (volume, duration, frequency, intensity)? Overall the evidence across cardiovascular and metabolic health outcomes shows a consistent curvilinear inverse dose-response relationship between physical activity and major outcomes such as all-cause mortality, cardiovascular disease mortality, incident type-2 diabetes (67), and incident site-specific cancers in adults. As described in Figure 1, the shape of the dose-response curve indicates that there is no lower threshold for benefit, and the greatest benefits are seen at the lower end of the dose-response curve (65). The curvilinear inverse association is consistently reported and across studies using different measures of physical activity. Important new evidence was provided in a meta- analysis of eight prospective cohort studies, with mean follow-up of 5.8 years (range 3–14.5 years) (65) that reported the adjusted HR for quartiles of total physical activity using device-based measures of exposure and all-cause mortality. The results showed a dose- response with increasing volume of physical activity and benefits of higher levels of any intensity of physical activity compared with the least active (referent, 1.00): 2nd quartile (adjusted HR= 0.48 [95% CI: 0.43 to 0.54]); 3rd quartile (adjusted HR= 0.34 [95% CI: 0.26 to 0.45]); and 4th quartile (adjusted HR= 0.27 [95% CI: 0.23 to 0.32]). Maximal risk reductions for moderate- to vigorous- intensity physical activity were observed at 24 minutes per day (equivalent to 168 minutes per week), which ADULTS (aged 18–64 years) closely reflects the recommendation of 150 minutes per week, and provides new device-based evidence reinforcing the existing global guidance to adults of 150–300 minutes of physical activity per week (65). These findings are consistent with the evidence from existing reviews (35) and the other new identified reviews (66). At the upper end, higher levels of physical activity continue to provide benefits in terms of reduced risk of mortality with no increased risk of harms. For example, evidence from a new review with findings from a meta- analysis of individual data from device-based measures of exposure (65), indicates that although reduced risk of mortality is observed up to 750 minutes of moderate- to vigorous-intensity physical activity per week, the relative risk of mortality levels off beyond 300 minutes per week. These results accord with previous evidence which consistently showed that more physical activity is associated with further health benefits, although the relative benefits are reduced at higher levels of physical activity (35, 80, 81). There is, however, insufficient evidence to identify the exact physical activity level where diminished returns of health benefits begin for adults. Evidence also reaffirmed the well-established inverse relationship between physical activity and cardiovascular disease mortality, providing additional evidence of a dose-response relationship well beyond current recommended volumes of physical activity. Figure 1: Dose response curve Weekly physical activity (minutes) RIS KS AN D HA RM SBE NE FI TS H ea lt h a n d  fi tn es s b en efi ts Sedentary Recommended range 150 300 34 35Recommendations A meta-analysis of 48 prospective studies assessing physical activity (total, leisure, and occupational) provided additional evidence of a dose-response relationship (66) well beyond current recommended volumes of physical activity. Compared with the recommended level of 750 MET minutes per week, participation in 5000 MET minutes per week (1000 minutes of moderate-intensity activity) resulted in a significantly lower risk for cardiovascular disease mortality (HR= 0.73 [95% CI: 0.56 to 0.95]) (66).Previous WHO recommendations (1) concluded that aerobic activity should be performed in bouts of at least 10 minutes duration. However, new evidence, using device-based assessments, demonstrates that physical activity of any duration, without a minimum threshold, is associated with improved health outcomes, including all-cause mortality (65, 82). For example, new evidence from reviews of studies assessing physical activity by accelerometry reaffirms similar associations between all indices of physical activity and all-cause mortality, with hazard ratios of 0.27 for total physical activity, 0.28 for 5-minute bouts, and 0.35 for 10-minute bouts, comparing the highest versus lowest quartiles (83). These results, reaffirmed by findings in the new review by Ekelund et al. 2019 (65), provide evidence that physical activity of any bout duration is associated with improved health outcomes, including all-cause mortality (82). Based on new evidence, the recommendation for bouts of least 10 minutes duration has been removed. Although evidence showing the associations between higher levels of physical activity and lower risk of incidence of site-specific cancers was deemed to be consistent overall, there is insufficient evidence to determine the specific levels of physical activity that correspond to the reported risk reduction due to the large heterogeneity in the assessment and classification of exposure across studies. There is however, no evidence to suggest that there is a lower threshold below which no beneficial effect of physical activity is evident, thus suggesting that any level of physical activity can confer benefit on reducing the risk of site-specific cancers. Future research assessing the nature of the dose- response and using more consistent measures and reporting is needed to inform future guidelines. Although there is a large body of evidence on the associations between physical activity and various measures of adiposity, weight gain and the management of a healthy weight status (35), currently there is insufficient evidence to describe more specifically ADULTS (aged 18–64 years) the dose-response relationship or identify a threshold of effect. Further research is needed to inform future guidelines. Greater amounts of moderate- to vigorous-intensity physical activity are associated with improvements in cognition (e.g. processing speed, memory, and executive function) (35), brain function and structure, and a reduced risk of developing cognitive impairment, including Alzheimer’s disease (73–76). There is evidence that both acute bouts and regular physical activity improve sleep and health-related quality of life outcomes in adults (35). There is however insufficient evidence to describe more specifically the dose-response relationship between physical activity and individual mental and cognitive health outcomes. Similarly, more evidence is needed to further describe the dose-response relationship between volume and/or intensity of aerobic physical activity and muscle-strength training and specific health outcomes. Such information is key to establishing minimal effective doses and maximum safety thresholds of physical activity for different population subgroups. The GDG concluded that: • There is evidence that more physical activity is associated with larger effects on health outcomes, although the relative benefits level off at higher levels of physical activity. There was insufficient evidence to identify the exact level where diminished returns start to occur. • There is high certainty evidence that higher levels of physical activity are associated with lower risk of all- cause mortality, cardiovascular disease mortality, cancer mortality, cardiovascular disease incidence, and incidence of hypertension and type-2 diabetes, with no increased risk of harms. • There is moderate certainty evidence that physical activity of any duration is associated with improved health outcomes, and prior specification that aerobic activity should be performed in bouts of at least 10 minutes duration should be removed. • There is evidence that higher amounts of physical activity may be associated with more favourable measures of adiposity and attenuation of weight gain in adults and there is a low risk that physical activity will be harmful for the management of healthy weight status in adults. • There is moderate certainty evidence that 150–300 minutes of moderate intensity aerobic physical activity or equivalent, per week, reduces risk for multiple health outcomes, and risk reduction continues, but starts to plateau, beyond 300 minutes per week. 36 37 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Does the association vary by type or domain of physical activity? Evidence shows that different types of physical activity and physical activity undertaken in different domains (i.e. occupation, transport, or leisure) can provide favourable health outcomes. For all-cause and cardiovascular disease mortality, undertaking aerobic physical activity alone, or combining with strength-promoting exercise shows beneficial associations, although performing recommended levels of both types is optimal (84). More recent moderate certainty evidence indicates that muscle-strengthening physical activity, independent of aerobic physical activity, is also associated with lower risk of all-cause mortality. Results reported by Stamatakis et al. (2018), from a pooled analysis of 11 cohorts examining the 2 days per week muscle-strengthening exercise recommendation against all-cause mortality, showed that undertaking both aerobic and muscle-strengthening physical activity at recommended levels (1) versus not meeting either recommendation (adjusted HR= 0.71 [95% CI: 0.57 to 0.87]) as well as adherence to just the strength exercise recommendation versus not adhering (HR= 0.80 [95% CI: 0.70 to 0.91]) was associated with significantly lower risk of all-cause mortality (84). These data affirm that health benefits associated with muscle-strengthening exercise were independent of aerobic physical activity and also provide evidence to support recommending a frequency of 2 days per week of muscle-strengthening exercise. Other findings reported by Dinu et al. (2019) provided supporting evidence reaffirming that physical activity undertaken in domains other than leisure (or recreation) can be beneficial and specifically showed that active commuting (i.e. walking and cycling for transport) can significantly lower risk of all-cause mortality (RR= 0.92 [95% CI: 0.85–0.98]) (85). Recent research provides evidence demonstrating that for those who participate in active commuting (i.e. walking or cycling for transport), there is reduced risk of cardiovascular disease (coronary heart disease, stroke and heart failure) compared with those participating in no active commuting (RR= 0.91 [95% CI 0.83 to 0.99]) (85); and that there is sufficient evidence from these health outcomes to conclude that activity in different domains can be beneficial. However, there is insufficient evidence to differentiate the effect of different domains of physical activity on every health outcome. For example, there is insufficient evidence to determine if the association between physical activity and cancer risk or type-2 diabetes incidence varies by type or domain of physical activity. ADULTS (aged 18–64 years) For mental health outcomes, evidence (35) shows that a variety of types of physical activity, including aerobic activity, walking, muscle-strengthening activity, and yoga can provide beneficial effects for reducing symptoms of depression and development of anxiety (74, 79, 86). For example recent evidence for the beneficial effects of resistance exercise interventions and mental health was provided by two reviews reporting moderately large reductions in symptoms of depression (77) and small reductions in symptoms of anxiety (78) compared with control conditions. Evidence from a new review affirmed that high levels of occupational physical activity is associated with reduced risk of many cancers, coronary heart disease, and type- 2 diabetes (40). However, higher levels of occupational physical activity may also be associated with an increased risk of osteoarthritis, poor sleep quality, and all-cause mortality among males (but not among females). There is insufficient evidence to determine the relationship between occupational physical activity and adiposity, prevention of body weight gain, mental health, and health-related quality of life (40). There is also insufficient evidence to determine if the association between physical activity and cancer risk varies by type or domain of physical activity. There is less evidence on associations by different domains of physical activity, and therefore it was difficult to differentiate the effect of different domains of physical activity on various health outcomes. The GDG concluded that: • There is moderate certainty evidence that muscle- strengthening activities undertaken on 2 or more days a week, provide additional health benefits, but there is insufficient evidence to specify a specific duration for optimal health benefits. • There is moderate certainty evidence that physical activity undertaken in different domains (e.g. leisure, transport, occupational) can provide health benefits, although currently it is not possible to differentiate the effect of different domains of physical activity on various health outcomes. • Although higher levels of occupational physical activity may be associated with an increased risk of osteoarthritis, poor sleep quality, and all-cause mortality among males (but not among females), overall there is moderate certainty evidence that occupational physical activity can provide health benefits. 36 37Recommendations Supporting evidence and rationale For these guidelines, the synthesis of evidence undertaken by PAGAC (35) was used and updated. The GDG considered the entire body of evidence, including both the findings reported by PAGAC and the 13 new reviews that met inclusion criteria, to contribute evidence on the association between sedentary behaviour and health- related outcomes in adults. Investigating the association between sedentary behaviour and health outcomes is a relatively new field of public health compared with that of physical inactivity, yet it has developed rapidly in the past decade. Studies have typically measured sedentary behaviour using either i) self-report questionnaires which ask about “total time” spent in sedentary behaviours, or time spent in specific behaviours, such as television viewing, computer/screen use, and sitting; or ii) device-based assessments. There are no standardized measures or analytical protocols for sedentary behaviour and thus the reporting of results is heterogeneous. Recent methodological developments include the use of device-based assessment of time spent sedentary which can reduce measurement error and other biases inherent in self-reported recall. In considering the total body of evidence, the GDG gave greater emphasis to evidence provided by reviews graded moderate and above, taken from reviews providing evidence from studies using measures of total sedentary or sitting time, or device-based measures of sedentary behaviour where available. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . Research on the potential adverse health effects associated with sedentary behaviour has rapidly accumulated during the past decade. In more recent studies, notable developments include an increase in evidence reporting on dose-response relationships between sedentary behaviour and multiple health outcomes, and on the interplay between sedentary behaviour and physical activity. In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and type-2 diabetes. It is recommended that: Adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults should aim to do more than the recommended levels of moderate- to vigorous- intensity physical activity. Strong recommendation, moderate certainty evidence Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf For adults, sedentary behaviour is defined as time spent sitting or lying with low energy expenditure, while awake, in the context of occupational, educational, home and community settings, and transportation. SEDENTARY BEHAVIOUR RECOMMENDATION ADULTS (aged 18–64 years) 38 39 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ADULTS (aged 18–64 years) In adults (aged over 18 years), what is the association between sedentary behaviour and health-related outcomes? Overall, there is evidence of an association between greater time spent in sedentary behaviour (examined mostly via self-reporting or device-based assessments of sitting or television viewing time) and higher all-cause mortality, cardiovascular mortality, cardiovascular disease incidence and type-2 diabetes incidence (8, 35, 65, 87). For example, supporting evidence includes results from a recent large meta-analysis (n= 36 383; mean age 62.6 years; 72.8% women) of accelerometer assessed total sedentary time and all-cause mortality (65) and showed that increasing time spent in sedentary behaviour was significantly associated with all-cause mortality. Similar findings from a meta-analysis comprising more than 1 million participants (87) showed associations for total sedentary behaviour with all-cause mortality, and cardiovascular disease mortality, after adjustment for physical activity (87), although in this study the associations with cancer mortality were not statistically significant after adjustment for physical activity (87). Another recent meta-analysis (8) reported significant associations between sedentary behaviour (assessed as sitting) and cardiovascular disease and cancer mortality, with results indicating a 9–32% (p for trend < 0.001) higher risk of cardiovascular disease mortality with higher levels of sedentary behaviour when measured as sitting time in the “inactive”, lowest quartile of physical activity (~ 5 min/day). The study reported that adults who were sedentary (sitting) for more than 8 hours per day had a higher risk of cardiovascular disease mortality, except for those who were “most active” (i.e. > 35.5 MET-hours/week, or ~ 60–75 mins/ day), where the association was mitigated. Results on the associations between sedentary behaviours and cancer mortality were generally weaker, although a 6–21% higher dose-related risk was observed with longer sitting time (particularly > 8 hours/day), but only among those in the lowest quartile of physical activity (< 2.5 MET-hours/week) (8). Evidence supports an association between sedentary behaviour (measured as total sitting time) and increased incident cardiovascular disease (HR= 1.29 [95% CI: 1.27 to 1.30]) which was attenuated following adjustment for potential covariates, including level of physical activity (HR= 1.14 [95% CI: 1.04 to 1.23]) (88). A review of studies in south-east Asian populations provided evidence of low certainly that greater sedentary time was associated with an increased likelihood of unfavourable cardiometabolic indicators (including type-2 diabetes, higher BMI, higher blood pressure) (89). Two recent reviews report on the association of total daily sitting time (88) and total sedentary behaviour and television viewing (87) with type-2 diabetes incidence. Both studies found a higher level of sedentary behaviour was associated with increased risk of type-2 diabetes incidence. For example, a linear association with type-2 diabetes was observed for total sedentary behaviour (RR= 1.01 [95% CI: 1.00 to 1.01] p= < 0.001) and television viewing (RR= 1.09 [95% CI: 1.07 to 1.12] p= < 0.001), when adjusted for physical activity (87). There is also supporting evidence for a significant association between sedentary behaviour (when measured as time spent viewing television) and cancer mortality (35, 87). Several more recent reviews, of low and very low certainty, provide supporting evidence for an association between sedentary behaviours and colorectal cancer (90), but no associations with incident prostate, breast or rectal cancer (90–93). Additional evidence (35) reported significant associations between greater time spent in sedentary behaviour and higher risk of developing endometrial, colon and lung cancers (35). There is low certainty evidence of an unfavourable relationship between time spent in sedentary behaviour and adiposity and other indicators of weight status, and whether the relationship between sedentary behaviour and weight status varies by amount of moderate- to vigorous-intensity physical activity. Overall, it was concluded that there was insufficient evidence to inform these recommendations/guidelines and that further research is needed. There is limited evidence assessing adverse effects of reducing sedentary time. Expert opinion informed the conclusion that recommending the reduction in sedentary time would be unlikely to increase risk of injury, especially if replaced with light-intensity physical activity. 38 39Recommendations The GDG concluded that: • Overall there is sufficient evidence to support the development of a new WHO recommendation to limit sedentary behaviour to reduce health risks. • There is moderate certainty evidence of an association between greater time spent in sedentary behaviour and higher all-cause mortality, cardiovascular disease mortality, cancer mortality and incidence of cardiovascular disease and type-2 diabetes. • There is low to moderate certainty evidence of an association between greater time spent in sedentary behaviour and higher risk of incident endometrial, colon, and lung cancers. • There is insufficient evidence on the association between sedentary behaviour and measures of adiposity and further research is needed. • The benefits of limiting sedentary behaviour outweigh any potential risks. Is there a dose-response association (total volume, frequency, duration, intensity of interruption)? Overall, moderate certainty evidence indicates a non- linear dose-response relationship between sedentary time (sitting or television viewing time assessed by self-reporting, or by device-based assessments) and all- cause mortality, cardiovascular disease mortality, cancer mortality, and incident cardiovascular disease (8, 35, 87). A recent meta-analysis provided high certainty evidence on the dose-response relationship between accelerometer assessed total sedentary time and all-cause mortality (65) reporting that increasing time spent in sedentary behaviour was significantly associated with all-cause mortality. The hazard ratios for increasing quartiles of sedentary time were 1.00 (referent; least sedentary); 1.28 (1.09– 1.51); 1.71 (1.36–2.15); and 2.63 (1.94–3.56), after adjustment for potential confounders including time spent in moderate- to vigorous-intensity physical activity (65). This analysis of dose-response relations between sedentary time and mortality showed risk increased gradually from about 7.5–9 hours and was more pronounced at greater than 9.5 hours. Sedentary behaviour of 10 hours and 12 hours each day were associated with 1.48 (1.22–1.79) and 2.92 (2.24–3.83) higher risk of death, respectively (65). Another recent meta-analysis assessed dose-response and reported non-linear associations for total sedentary time and all-cause mortality (RR per 1 hour/day = 1.01 (1.00–1.01) for ≤ 8 hours/day; and 1.04 (1.03–1.05) for > 8 hours/day of exposure); and cardiovascular disease mortality (RR= 1.01 (0.99–1.02) for ≤ 6 hours/day; and RR= 1.04 (1.03–1.04) for > 6 hours/day) after adjustment for physical activity (87). In this same study, a small linear dose-response association between type-2 diabetes was observed for total sedentary behaviour (1.01 (1.00– 1.01)) when adjusted for physical activity and television viewing (1.09 (1.07–1.12)) (87). Overall, evidence supports that higher amounts of sedentary behaviour are associated with less favourable health outcomes and it was concluded that there is sufficient evidence to support minimizing sedentary time to reduce health risks. However, given the considerable variations in how sedentary behaviour was assessed across reviews (via self-reported sitting time, television viewing time, or device-based (accelerometer) assessments) and the probability that thresholds for sedentary time might vary across health outcomes, by levels of moderate- to vigorous-intensity physical activity, and among population subgroups, there is insufficient evidence to set a time-based (quantified) recommendation. In addition to overall volume of sedentary behaviour, evidence on the patterns by which sedentary behaviour is accrued was reviewed. However, there was limited evidence to make recommendations on the frequency and/or duration of breaks in sedentary behaviour. The GDG concluded that: • There is insufficient evidence to set quantified (time- based) recommendations on sedentary behaviours. • There is insufficient evidence to make recommendations on the frequency and/or duration of breaks in sedentary behaviour. ADULTS (aged 18–64 years) 40 41 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Does the association vary by type and domain of sedentary behaviour? Some domains or different types of sedentary behaviour may be more detrimental than others, both in terms of their direct associations and in their potential to displace time spent in more healthful physical activity. Although there has been a rapid growth in research on sedentary behaviour, there is limited evidence available directly comparing the association between different types of sedentary behaviour and different health outcomes. For example, some studies report stronger results with sedentary behaviour measured as television viewing compared with total sitting time (87). This may be due to the differential measurement error or residual confounding associated with self-report measures and instruments. Currently, there is insufficient evidence to determine the different associations with different health outcomes and how these may vary by subpopulation. A growing number of studies are using device- based measures of physical activity and sedentary time in relation to health outcomes. However, some misclassification may occur from device-based measures of sedentary time as many of these device placements (e.g. wrist, waist) do not currently distinguish between positions (e.g. lying, sitting and standing still). Future research using harmonized reporting, and methods that distinguish between positions, will help to strengthen the knowledge on the patterns of sedentary behaviour. The GDG concluded that: • There is insufficient evidence to make recommendations on different types or domains of sedentary behaviour. ADULTS (aged 18–64 years) Does level of physical activity modify the effect of sedentary behaviour on mortality? The increased interest in the impact of sedentary behaviour on health outcomes has stimulated investigation into the potential interplay between different levels of physical activity and levels of sedentary behaviour. Based on available research, there is moderate certainty evidence that the relationship between sedentary behaviour and all-cause mortality, cardiovascular disease mortality and cancer mortality varies by amount of moderate- to vigorous-intensity physical activity (8, 9, 35). Overall findings show that the effect of sedentary behaviour is stronger in those who do low amounts of moderate- to vigorous-intensity physical activity or, phrased conversely, that higher amounts of moderate- to vigorous-intensity physical activity can mitigate the unfavourable health outcomes associated with higher levels of sedentary behaviours. The risk associated with sedentary time and all-cause mortality has been shown to be more pronounced at lower levels of physical activity than at higher levels (35). In a harmonized meta-analysis, Ekelund et al. investigated the joint and stratified effects of sedentary behaviour and physical activity with all-cause mortality in more than 1 million men and women, and showed that the associations differed depending on the level of physical activity (9). The analyses used quartiles of sedentary behaviour (sitting) and quartiles of moderate- to vigorous-intensity physical activity, and found that compared with the referent (< 4 hours of sitting per day and highest quartile of moderate- to vigorous-intensity physical activity [> 35.5 MET-hours/ week]), there was no increased risk of dying during follow-up in those who sat for more than 8 hours per day but who also reported more than 35.5 MET- hours per week of activity (HR= 1.04 [95% CI: 0.99 to 1.10]). In contrast, those who sat the least (< 4 hours/ day) and were in the lowest (< 2.5 MET-hours/week) physical activity quartile had a significantly increased risk of dying during follow-up (HR= 1.27 [95% CI: 1.22 to 1.31]). The study concluded that levels of moderate- to vigorous-intensity physical activity of about 60–75 minutes per day (the highest quartile) can attenuate, and even eliminate, the detrimental association between sedentary behaviour and health outcomes (9). 40 41Recommendations ADULTS (aged 18–64 years) G O O D P R A C TI C E ST A TE M EN TS This relationship between levels of sedentary behaviour and moderate- to vigorous-intensity physical activity was summarized in the systematic review by PAGAC (35) as shown in Figure 2. Another recent study provided new evidence investigating the same associations with cause-specific mortality and showed similar findings (8). In a large harmonized meta-analysis (9 studies, n= 850 000, CVD mortality; 8 studies, n= 777 000, cancer mortality), results showed that higher levels of moderate- to vigorous- intensity physical activity mitigated the increased risk of cardiovascular disease mortality with high levels of sedentary behaviour, whether measured as time spent sitting or time spent viewing television (8). The study showed that in individuals who were sitting for more than 8 hours per day, there was an association with higher risk of death, except in the most active quartile, where the association was mitigated. More specifically, the hazard of cardiovascular disease mortality was 32% higher in those who sat for more than 8 hours per day compared with the reference group (< 4 hours/day) (p for trend < 0.001). The results were less pronounced but remained significant compared with the reference group for the other quartiles of physical activity (2nd quartile, HR= 1.11 [95% CI: 1.03 to 1.20]; 3rd quartile, HR= 1.14 [95% CI: 1.03 to 1.26]). Similar associations were observed for television time and cardiovascular disease mortality across strata of moderate- to vigorous- intensity physical activity (8). The associations for cancer mortality were more mixed, although generally showed that higher levels of physical activity attenuated the detrimental effects of sedentary behaviour when assessed as total sitting time. Based on this evidence, it was agreed that higher levels of moderate- to vigorous-intensity physical activity should be recommended for those individuals who undertake high levels of sedentary behaviour and that the benefits would outweigh the risks. The GDG concluded that: • There is moderate certainty evidence that the relationship between sedentary behaviour and all-cause mortality, cardiovascular disease and cancer mortality varies by amount of moderate- to vigorous-intensity physical activity. • Higher amounts of moderate- to vigorous-intensity physical activity can attenuate the detrimental association between sedentary behaviour and health outcomes. Figure 2: The relationship between levels of sedentary behaviour and physical activity Adapted from PAGAC More physical activity M or e se d en ta ry t im e HIGH RISK LOW RISK Less sedentary tim e & m ore physical activity Increase physical activityRed u ce sedentary time 42 43 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r OLDER ADULTS (aged 65 years and older) In older adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site-specific cancers, incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression), cognitive health, and sleep; measures of adiposity may also improve. In older adults, physical activity helps prevent falls and falls-related injuries and declines in bone health and functional ability. It is recommended that: All older adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Older adults should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence Older adults should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence As part of their weekly physical activity, older adults should do varied multicomponent physical activity that emphasizes functional balance 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 Older adults may increase moderate- intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week, for additional health benefits. Conditional recommendation, moderate certainty evidence For older adults, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), transportation (wheeling, walking and cycling), work, or household chores, in the context of daily occupational, educational, home or community settings. PHYSICAL ACTIVITY RECOMMENDATION • Doing some physical activity is better than doing none. • If older adults are not meeting the recommendations, doing some physical activity will bring benefits to health. • Older adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • Older adults should be as physically active as their functional ability allows, and adjust their level of effort for physical activity relative to their level of fitness. G O O D P R A C TI C E ST A TE M EN TS 42 43Recommendations Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Supporting evidence and rationale For these guidelines, for older adults, the comprehensive synthesis of evidence undertaken by PAGAC (35) was used and updated. Fifteen reviews met the inclusion criteria and informed the examination of the association between physical activity and health-related outcomes specific to older adults (falls prevention, fall-related injuries, physical function, frailty, and osteoporosis). The evidence for falls prevention used and updated the 2019 Cochrane Collaboration Systematic Review by Sherrington et al. (42), with evidence published from the end search date of their original review, to November 2019 (9 new studies). A search for existing systematic reviews on osteoporosis and sarcopenia was conducted in PubMed for reviews published from 2008 through to November 2019 and identified no new reviews and 8 new studies. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . In older adults (aged 65 years and over), what is the association between physical activity and health-related outcomes? The primary evidence base for assessing the associations between physical activity and health outcomes, such as all-cause and cause-specific mortality, cardiovascular disease, type-2 diabetes, cancer incidence, adiposity, mental health, and cognitive outcomes in older adult populations was the same scientific literature collated and reviewed for adult populations. This same body of evidence was accepted and extrapolated to older adults because the majority of studies stated no upper age limit criterion and therefore included adults over the age of 65 years. A further review of evidence was conducted to examine and inform on the association between physical activity and health-related outcomes specific to older adults, including falls prevention, fall-related injuries, physical function, frailty and osteoporosis. Declining physical capacity in older people often manifests in falls and fall-related injuries that can have serious consequences. Accidental falls are due to a combination of extrinsic (environmental) and intrinsic (e.g. musculoskeletal or nervous system abnormalities affecting postural control) factors. Evidence demonstrates that physical activity – in particular multicomponent physical activity programmes that include combinations of balance, strength, endurance, gait, and physical function training – is associated with a reduced rate of falls and risk of injury from falls in older adults. Recent evidence demonstrates that exercise may reduce the rate of falls by as much as 23% (pooled rate ratio (RaR) 0.77 [95% CI: 0.71 to 0.83]) in older adults, which can significantly reduce the risk of injury from falls, including severe falls that result in bone fracture, head trauma, open wound, soft tissue injury, or any other injury requiring medical care or admission to hospital (42). This evidence was consistent with, and reaffirmed findings in, other reviews (35). After reaching a peak in early adulthood, muscle and bone mass tends to decline with increasing age (i.e. sarcopaenia and osteopaenia/osteoporosis), and this can be associated with declining strength and physical function. Evidence demonstrates that regular physical activity improves physical function and reduces the risk of age-related loss of physical function in older adults. Findings show beneficial effects on dynamic balance (SMD= 1.10 [95% CI: 0.29 to 1.90]); muscle strength (SMD= 1.13 [95% CI: 0.30 to 1.96]); flexibility (SMD= 1.22 [95% CI: 0.39 to 2.04]); and cardiorespiratory fitness (SMD= 1.48 [95% CI: 0.42 to 2.54]) (94). Evidence also shows that higher levels of physical activity may improve bone health and thus prevent osteoporosis in older adults (pooled standardized effect size 0.21 [95% CI: 0.06 to 0.36]) (95). Physical activity interventions may improve lumbar spine and femoral neck (hip) bone mineral density. The GDG concluded that: • There is moderate certainty evidence that physical activity improves physical function and reduces risk of age-related loss of physical function in the general ageing population. • There is low-certainty evidence that the risks for the amounts and types of physical activity recommended for older adults are low and are outweighed by the benefits. OLDER ADULTS (aged 65 years and over) 44 45 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Is there a dose-response association (volume, duration, frequency, intensity)? Evidence shows an inverse relationship between the amount of physical activity performed by older adults and the risk of physical function limitations. In general, more physical activity (frequency, duration and/or volume) is associated with greater benefits (35). Evidence suggests that fast-intended velocity resistance training may be superior to moderate-velocity resistance training for improvements in general functional capacity (SMD= 0.41 [95% CI: 0.18 to 0.65]; and SPPB (SMD= 0.52 [95% CI: 0.10 to 0.94])) (96). There is limited evidence examining the dose-response relationship between physical activity and prevention of falls; however the majority of studies providing supportive evidence show testing a programme consistent with 3 days per week. The GDG concluded that: • There is high certainty evidence of an inverse dose- response relationship between volume of aerobic physical activity and risk of physical functional limitations in the general older adult population. Does the association vary by type or domain of physical activity? Physical activity programmes that include combinations of balance, strength, endurance, gait, and physical function training are associated with a reduced rate of falls and risk of injury from falls in older adults. Evidence from a review of 11 RCT showed that by engaging in a variety of different physical activity interventions (commonly balance and functional exercises plus resistance exercises), older adults can reduce rate of falls by up to 28% (RaR= 0.72 [95% CI: 0.56 to 0.93]) (42). The effect of resistance exercises was uncertain and based on limited data (RR= 0.97 [95% CI: 0.14 to 6.49]; 1 trial; n= 73) (42). Evidence also suggests that programmes which include multiple exercise types have greater positive effects on bone health (standardized effect size 0.45 [95% CI: 0.20 to 0.71]; p= 0.001), compared with those which do not (95). The GDG concluded that: • There is high certainty evidence that higher levels of physical activity that combines balance, strength, gait, and functional training (e.g. multicomponent physical activity) are associated with a reduced rate of falls and risk of injury from falls in older adults. • There is moderate certainty evidence that programmes involving multiple exercise types may have significant effects on bone health and osteoporosis prevention. OLDER ADULTS (aged 65 years and over) 44 45Recommendations OLDER ADULTS (aged 65 years and older) Supporting evidence and rationale Sedentary behaviour was not included in the 2010 Global recommendations on physical activity for health (1). Due to a lack of population-specific evidence, the primary evidence base for assessing the associations between sedentary behaviour and health outcomes in older adult populations was the same scientific literature collated and reviewed for adult populations because the majority of studies stated no upper age limit criterion and therefore included adults over the age of 65 years. The findings from evidence on sedentary behaviours in the general adult population were reviewed, including assessing if there was evidence that the outcomes would be any different, or would not apply to, or would be contraindicated, for older adults. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . In older adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Older adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, older adults should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, moderate certainty evidence For older adults, sedentary behaviour is defined as time spent sitting or lying with low energy expenditure, while awake, in the context of occupational, educational, home and community settings and transportation. SEDENTARY BEHAVIOUR RECOMMENDATION Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 46 47 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r PREGNANT AND POSTPARTUM WOMEN PREGNANT AND POSTPARTUM WOMEN PHYSICAL ACTIVITY RECOMMENDATION For pregnant and postpartum women, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), transportation (wheeling, walking and cycling), work, household chores, in the context of daily occupational, educational, home and community settings. These guidelines address physical activity and maternal and fetal health outcomes during pregnancy and the postpartum period. They are for all pregnant and postpartum women, irrespective of age, cultural background, or socioeconomic status. Pregnancy and the period after delivery are stages in a woman’s life, and the benefits of being physically active throughout adulthood are detailed in the recommendations provided for adults. Pregnant and postpartum women should be under the care of a health-care provider for antenatal and postnatal care who can advise on special considerations given their medical history and any contraindications to participating in physical activity during pregnancy or in the postpartum period. These guidelines are public health and population- based. Clinical guidance should be sought for women with complications associated with pregnancy or delivery. Pregnant and postpartum women should try to meet these recommendations where possible, as able, and without contraindication. In pregnant and postpartum women, physical activity during pregnancy and postpartum confers benefits on the following maternal and fetal health benefits: decreased risk of pre-eclampsia, gestational hypertension, gestational diabetes, excessive gestational weight gain, delivery complications and postpartum depression, and fewer newborn complications, no adverse effects on birthweight; and no increase in risk of stillbirth. It is recommended that all pregnant and postpartum women without contraindication should: undertake regular physical activity throughout pregnancy and postpartum; Strong recommendation, moderate certainty evidence do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week for substantial health benefits; and Strong recommendation, moderate certainty evidence incorporate a variety of aerobic and muscle-strengthening activities. Adding gentle stretching may also be beneficial. Strong recommendation, moderate certainty evidence In addition: Women who, before pregnancy, habitually engaged in vigorous-intensity aerobic activity, or who were physically active, can continue these activities during pregnancy and the postpartum period. Strong recommendation, moderate certainty evidence 46 47Recommendations G O O D P R A C TI C E ST A TE M EN TS • Doing some physical activity is better than doing none. • If pregnant and postpartum women are not meeting the recommendations, doing some physical activity will benefit their health. • Pregnant and postpartum women should start by doing small amounts of physical activity, and gradually increase frequency, intensity and duration over time. • Pelvic floor muscle training may be performed on a daily basis to reduce the risk of urinary incontinence. Additional safety considerations for pregnant women when undertaking physical activity are: • Avoid physical activity during excessive heat, especially with high humidity; • Stay hydrated by drinking water before, during, and after physical activity; • 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 high altitude); • Avoid activities in supine position after the first trimester of pregnancy; • When considering athletic competition, or exercising significantly above the recommended guidelines pregnant women should seek supervision from a specialist health-care provider; • Pregnant women should be informed by their health-care provider of the danger signs alerting them as to when to stop; or to limit physical activity and consult a qualified health-care provider immediately should they occur; • Return to physical activity gradually after delivery, and in consultation with a health-care provider, in the case of delivery by Caesarean section. PREGNANT AND POSTPARTUM WOMEN Supporting evidence and rationale For these Guidelines on physical activity and sedentary behaviour (2020) for pregnant and postpartum women, the evidence syntheses from 7 systematic reviews addressing the critical and important outcomes (28–34) were used and updated. Four of the 7 reviews met inclusion criteria. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf In pregnant and postpartum women, what is the association between physical activity and health-related outcomes? Physical activity before and during pregnancy can help reduce the risk of common complications of pregnancy. Engaging in physical activity during pregnancy is significantly associated with reduced gestational weight gain (MD= 1.14 kg [95% CI: 1.67 to 0.62]) (97), and a reduced risk of gestational diabetes (RR= 0.71 [95% CI: 0.57 to 0.89]) (97), as is being physically active before pregnancy (OR= 0.70 [95% CI: 0.57 to 0.85]) (31, 34, 97), including in women with overweight or obesity (97). Physical activity during pregnancy does not appear to increase the incidence of gestational hypertension or preeclampsia (31). Evidence suggests that among pregnant women with overweight or obesity, there is no significant difference in the incidence of gestational hypertension (RR= 0.63 [95% CI: 0.38 to 1.05]) or in preeclampsia (RR= 1.39 [95% CI: 0.66 to 2.93]) between physical activity intervention groups versus standard antenatal care (97). There have been long-standing concerns about potential adverse effects of maternal physical activity on the developing fetus and delivery. However, recent evidence demonstrates that physical activity is not associated with increased risk of the incidence of miscarriage, stillbirth or delivery complications (32). Evidence suggests no difference in the incidence of Caesarean delivery among pregnant women with overweight or obesity between physical activity intervention groups versus standard antenatal care (97). Physical activity during pregnancy is not associated with increased risk of adverse effects on birthweight (98) or preterm birth (32), and may even be protective, reducing the overall risk (98), even among pregnant women with overweight or obesity (RR= 1.02 [95% CI: 0.54 to 1.92]) or 48 49 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r PREGNANT AND POSTPARTUM WOMEN large-for-gestational-age babies (RR= 0.90 [95% CI: 0.65 to 1.25]) between physical activity intervention groups versus standard antenatal care) (97). In the postpartum period, mothers can experience many physical and emotional changes. Evidence demonstrates that physical activity during pregnancy may be inversely associated with postpartum depression (29). Evidence from a meta-analysis of 6 trials and 11 observational studies of physical activity during pregnancy (99) showed a significant inverse relationship between physical activity during pregnancy and postpartum depression (SMD= 0.58 [95% CI: 1.09 to 0.08]). The effect was stronger when limited to 5 studies with at least moderate-intensity interventions (SMD= 0.70 [95% CI: 1.19 to 0.22]) (99). The GDG concluded that: • There is high certainty evidence that physical activity during pregnancy may reduce gestational weight gain and risk of gestational diabetes mellitus. • There is moderate to high certainty evidence that physical activity does not increase the incidence of gestational hypertension. • There is moderate certainty evidence that physical activity does not increase the incidence of miscarriage, stillbirth or delivery complications; and moderate certainty evidence of a reduced risk of preterm birth for mothers engaged in vigorous-intensity physical activity. • There is low to moderate certainty evidence that physical activity does not increase the risk of low birth weight, or small-for-gestational-age, or large-for- gestational-age babies. • There is low certainty evidence that physical activity during pregnancy is associated with lower levels of postpartum depression. • The risks for the amounts and types of physical activity recommended for pregnant and postpartum women are low and are outweighed by the benefits. Is there a dose-response association (volume, duration, frequency, intensity)? Across the evidence on physical activity during pregnancy and the postpartum period, the interventions varied in the amount (i.e. dose) of physical activity, both in duration in minutes and frequency per week. In general, the evidence available reflected a frequency of aerobic physical activity of at least 3 times per week, typically for between 30 and 60 minutes. This evidence is taken from studies assessing the health impact of a dose broadly consistent with the amount of activity recommended for the general adult population – namely 150 minutes of moderate-intensity physical activity per week. While more physical activity (frequency, duration and/or volume) is generally found to be associated with greater benefits, further research is needed to understand in more detail the dose-response relationship. Participating in higher versus lower amounts of leisure time physical activity pre-pregnancy is associated with a significantly lower risk of gestational diabetes (OR= 0.54 [95% CI: 0.34 to 0.87]) (100). There is also evidence of a small, but significant, reduced risk of preterm birth in babies of mothers who engaged in vigorous-intensity physical activity (RR= 0.20 [95% CI: 0.36 to 0.03]) (98). No evidence was identified regarding the safety or additional benefit of exercising at levels significantly above the recommendations. The GDG concluded that: • There is insufficient evidence to determine a dose- response association between physical activity and specific critical health outcomes during pregnancy and the postpartum period. • The overall evidence shows benefits to critical health outcomes and is based on interventions that are broadly consistent with the amount of physical activity recommended for the general adult population, namely 150 minutes of moderate-intensity physical activity per week. • There was no reason to alter the amount or frequency of recommended moderate-intensity physical activity for pregnant and postpartum women compared with the general adult population. • There is moderate certainty evidence of a reduced risk of preterm birth for mothers engaged in vigorous- intensity physical activity. 48 49Recommendations Does the association vary by type or domain or timing (pre-pregnancy, antenatal or postnatal) of physical activity? Evidence is available from studies that mostly assessed leisure domain physical activity; the type of activity was mostly aerobic (such as walking or swimming), although there is some evidence from studies assessing interventions that also included strength training (e.g. circuit training), or combinations of aerobic and muscle-strengthening exercise. However, overall there is insufficient evidence to determine if the associations between physical activity and health outcomes vary by type or domain or timing (pre-pregnancy, antenatal or postnatal) of physical activity. The GDG concluded that: • There is moderate certainty evidence that pregnant and postpartum women should incorporate a variety of aerobic and muscle-strengthening activities. Gentle stretching may also be beneficial. PREGNANT AND POSTPARTUM WOMEN 50 51 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Supporting evidence and rationale Sedentary behaviour was not included in the 2020 Global recommendations on physical activity for health (1). Due to a lack of population-specific evidence, the primary evidence base for assessing the associations between sedentary behaviour and health outcomes in pregnant and postpartum women was the scientific literature collated and reviewed for adult populations. The findings from evidence on sedentary behaviours in the general adult population were reviewed, including assessing whether the outcomes would be any different, or would not apply to, or would be contraindicated, for pregnant and postpartum women. In pregnant and postpartum women, as in all adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Pregnant and postpartum women should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence For pregnant and postpartum women, sedentary behaviour is defined as time spent sitting or lying with low energy expenditure while awake, in the context of occupational, educational, home and community settings and transportation. SEDENTARY BEHAVIOUR RECOMMENDATION PREGNANT AND POSTPARTUM WOMEN Based on available evidence and expert opinion, the evidence was extrapolated to inform the new WHO recommendations on sedentary behaviour for pregnant and postpartum women for the common set of critical health outcomes. Due to indirectness of the evidence, the level of certainty was downgraded. Given the lack of evidence specific to this population, and that pregnant women were excluded from studies, the recommendation to increase levels of physical activity beyond recommended levels to counter the detrimental effect of high sedentary behaviour was not extrapolated for women during pregnancy and the postpartum period. The GDG concluded that: • The evidence on sedentary behaviours in the general adult population could be extrapolated to inform recommendations for pregnant and postpartum women for the common set of critical health outcomes. • The benefits of minimizing sedentary behaviour outweigh the risks for pregnant and postpartum women. • The certainty of the evidence should be downgraded due to indirectness. 50 51Recommendations ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) To date, most physical activity guidelines for people with chronic conditions have been limited to clinical or therapeutic guidance. For example, there are clinical practice recommendations and resources developed by the professional medical associations for oncology (101), type-2 diabetes (102), hypertension (103), and other chronic diseases (104). WHO also has clinical practice guidance which includes recommending physical activity to patients with chronic disease (17). These guidelines are the first WHO population-based guidelines on physical activity for people living with chronic conditions, specifically those living with cancer (from here on referred to as “cancer survivors”), hypertension, type-2 diabetes, and HIV. Given the advances of effective and widely available antiretroviral treatment for HIV, this condition is now also considered a chronic condition. For patients undergoing acute treatment (e.g. chemotherapy), or not yet stabilized on their chronic medication, health-care providers should also refer to clinical practice guidelines relevant to each chronic condition. PHYSICAL ACTIVITY RECOMMENDATION For adults living with chronic conditions, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), transportation (wheeling, walking and cycling), work or household chores, in the context of daily occupational, educational, home or community settings. All adult cancer survivors and those living with hypertension, type-2 diabetes and HIV, should try to meet these recommendations where possible, as able and without contraindication. Physical activity can confer health benefits for adults and older adults living with the following chronic conditions: for cancer survivors – physical activity improves all-cause mortality, cancer-specific mortality, and risk of cancer recurrence or second primary cancer; for people living with hypertension – physical activity improves cardiovascular disease mortality, disease progression, physical function, health-related quality of life; for people living with type-2 diabetes – physical activity reduces rates of mortality from cardiovascular disease and indicators disease progression; and for people living with HIV – physical activity can improve physical fitness and mental health (reduced symptoms of anxiety and depression), and does not adversely affect disease progression (CD4 count and viral load) or body composition. It is recommended that: All adults and older adults with these chronic conditions should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults and older adults with these chronic conditions should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence G O O D P R A C TI C E ST A TE M EN TS 52 53 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) Adults and older adults with these chronic conditions should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional benefits. Strong recommendation, moderate certainty evidence As part of their weekly physical activity, older adults with these chronic conditions should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence When not contraindicated, adults and older adults with these chronic conditions may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence • When not able to meet the above recommendations, adults with these chronic conditions should aim to engage in physical activity according to their abilities. • Adults with these chronic conditions should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • Adults with these chronic conditions may wish to consult with a physical activity specialist or health-care professional for advice on the types and amounts of activity appropriate for their individual needs, abilities, functional limitations/ complications, medications, and overall treatment plan. • Pre-exercise medical clearance is generally unnecessary for individuals without contraindications prior to beginning light- or moderate-intensity physical activity not exceeding the demands of brisk walking or everyday living. G O O D P R A C TI C E ST A TE M EN TS Supporting evidence and rationale The scope of these guidelines assessed the associations between physical activity and the following health outcomes: for cancer survivors – all-cause mortality, cancer-specific mortality, and risk of cancer recurrence or second primary cancer; for people living with hypertension – cardiovascular disease mortality, risk of co-morbid conditions, physical function, health-related quality of life, and disease progression (here defined as the blood pressure response to physical activity); for people living with type-2 diabetes – cardiovascular disease mortality, risk of co-morbid conditions, physical function, health-related quality of life, and disease progression; and for people living with HIV – physical function (physical fitness, exercise tolerance and strength), health-related quality of life, mental health (symptoms of anxiety and depression), cardiometabolic disease risk indicators (blood lipids, blood glucose and body composition) and adverse effects on disease progression (namely CD4 count and viral load). The evidence informing these guidelines was the report of PAGAC (35) which was updated with 16 new reviews identified from 2017 to 2019 for cancer (n= 1), hypertension (n= 2) and type-2 diabetes (n= 13). In addition, a commissioned umbrella review on physical activity and health-related outcomes among people living with HIV provided evidence from 19 eligible reviews published 2002–2018. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 52 53Recommendations In adults and older adults (aged 18 years and over) living with cancer (cancer survivors), hypertension, type-2 diabetes, or HIV, what is the association between physical activity and health-related outcomes? Physical activity promotes beneficial short- and long- term changes in metabolic, hormonal, and inflammatory pathways, which are thought to be protective for cancer incidence and survival (35). Evidence shows that higher levels of physical activity after cancer diagnosis were found to be protective for all-cause mortality following breast cancer (HR= 0.58 [95% CI: 0.52 to 0.65], 17 studies); colorectal cancer (HR= 0.63 [95% CI: 0.50 to 0.78], 10 studies), female reproductive cancer (HR= 0.66 [95% CI: 0.49 to 0.88], 4 studies); glioma (HR= 0.64 [95% CI: 0.46 to 0.91], 1 study); hematologic cancer (HR= 0.60 [95% CI: 0.51 to 0.69], 2 studies); kidney cancer (HR= 0.60 [95% CI: 0.38 to 0.95], 1 study); lung cancer (HR= 0.76 [95% CI: 0.60 to 0.97], 2 studies); prostate cancer (HR= 0.60 [95% CI: 0.46 to 0.79], 5 studies); and stomach cancer (HR= 0.75 [95% CI: 0.61 to 0.93], 1 study) (105). Greater amounts of physical activity after cancer diagnosis are also associated with lower risks of cause-specific mortality in breast cancer, colorectal cancer, and prostate cancer survivors. The meta-analysis found reduced hazards of mortality for those in the highest versus the lowest levels of postdiagnosis total physical activity for all cancers combined (HR= 0.63 [95% CI: 0.53 to 0.75], 4 studies); breast cancer (HR= 0.63 [95% CI: 0.50 to 0.78], 13 studies); colorectal cancer (HR= 0.62 [95% CI: 0.44 to 0.86], 6 studies); and prostate cancer (HR= 0.70 [95% CI: 0.55 to 0.90], 4 studies) (105). There was, however, insufficient evidence to determine if physical activity is associated with cancer recurrence or second primary cancer. Physical activity is important for both the primary prevention and management of hypertension, with evidence showing that physical activity improves physical function, cardiovascular disease progression (i.e. blood pressure response to physical activity), and cardiovascular disease mortality in people living with hypertension (35). For example, compared with no exercise control groups, people with hypertension who are physically active can reduce systolic blood pressure by approximately 12mm Hg and diastolic blood pressure by approximately 6mm Hg (SBP MD= 12.26 mm Hg [95% CI: 15.17 to 9.34], p= < 0.05; DBP MD= 6.12 mm Hg [95% CI: 7.76 to 4.48], p= < 0.05) (106). Emerging evidence demonstrates that people with ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) hypertension who are physically active can significantly improve their health-related quality of life compared with those with hypertension who are inactive (54). Physical activity, including aerobic activity, muscle- strengthening activity, and aerobic plus muscle- strengthening activity, is associated with improved secondary indicators of risk of progression (HbA1c, blood pressure, BMI, and lipids) in adults with type-2 diabetes (35). For example, recent research found that resistance training was associated with greater reduction in HbA1c versus control groups, and that high-intensity resistance training has significant positive effects on fasting insulin (107). There is insufficient evidence to assess the effects of physical activity on health-related quality of life and physical function in adults with type-2 diabetes. Physical activity in people living with HIV improves cardiorespiratory fitness. The interventions studied involved either aerobic exercise, or exercise combined with progressive muscle-strengthening exercise, for at least 30 minutes, 3 times per week (108, 109). There is also evidence that physical activity interventions can improve markers of cardiometabolic risk (e.g. lipids) although results are mixed; no effects were established on insulin concentration, although glucose was lowered after aerobic training (110). Physical activity, whether aerobic, or combined with muscle-strengthening exercise, in people living with HIV is positively associated with health-related quality of life (111) and a reduction in symptoms of depression and anxiety (112). The meta- analysis for depression (9 studies) showed an SMD of 0.84 (95% CI: 1.57 to 0.11) favouring the intervention groups (p= 0.02). The SMD for reduction in anxiety (5 studies) was also statistically significant, favouring the intervention ( 1.23 [95% CI: 2.42 to 0.04], p= 0.04) (112). Physical activity is also associated with significant standardized mean increases in lean body mass of 1.75 kg and a significant decrease in percent body fat of 1.12% for participants in the exercising control groups, as well as an increase in peripheral leg and arm muscle area, compared with participants in the non-exercising control groups (111), but is not associated with changes in BMI or waist circumference in people living with HIV (111). Physical activity does not adversely influence markers of HIV disease progression, such as CD4 count (cells/mm3) or viral load (111). Importantly, this evidence suggests that HIV as a chronic disease will not be adversely affected by physical activity. 54 55 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r The GDG concluded that: • There is moderate certainty evidence that greater amounts of physical activity after cancer diagnosis are associated with lower risks of all-cause, cause-specific, and cancer-specific mortality in cancer survivors. • There is high certainty evidence that physical activity reduces the risk of cardiovascular disease progression in adults with hypertension. • There is moderate certainty evidence that physical activity improves physical function and health-related quality of life outcomes in adults with hypertension. • There is high certainty evidence that physical activity improves markers of disease progression (HbA1c, blood pressure, BMI, and lipids) in adults with type-2 diabetes. • There is moderate certainty evidence of an association between physical activity and improvements in fitness (maximal oxygen consumption, exercise tolerance) and muscular strength for people living with HIV, and favourable associations between physical activity and body composition, health-related quality of life, reduced symptoms of depression and anxiety, and no change in viral load or CD4 count in people living with HIV. • The benefits associated with engaging in regular physical activity in cancer survivors and people living with hypertension, type-2 diabetes, and HIV in relation to specific health outcomes, outweigh the risks. Is there a dose-response association (volume, duration, frequency, intensity)? Greater amounts of physical activity after cancer diagnosis have been linked with lower risks of all-cause, and cancer- specific mortality. Evidence demonstrates a non-linear relationship between increasing levels of post-diagnosis physical activity and breast cancer-specific and all-cause mortality up to 10–15 MET-hours per week (consistent with 150 mins/week of moderate- to vigorous-intensity physical activity) with no evidence for harms at higher levels (105). There is a suggestion of similar dose-response association for other cancer sites however there were too few studies to permit a formal meta-analysis. Further research is needed to determine strength of association. There is a clear dose-response relationship between physical activity and cardiovascular disease mortality for people living with hypertension (35). Findings show that as systolic blood pressure increases within hypertensive ranges, the risk of cardiovascular disease mortality increases, but this increased risk is attenuated with higher levels of physical activity (35). Similar to recommendations for the general population, most of the traditional interventions are based around 30–60 minutes of moderate-intensity aerobic activity, 3 days per week, and/or 2–3 sessions of resistance training per week. There is substantial evidence of an inverse curvilinear association between volume of physical activity and risk of cardiovascular mortality in adults with type-2 diabetes (113–115). Higher amounts of physical activity (from both below and at, or above the recommended levels of 150 mins/week of moderate-intensity activity) progressively reduce risk. For example, compared with doing no activity, engaging in some activity was associated with a 32% reduction in risk of cardiovascular disease mortality (adjusted HR= 0.68 [95% CI: 0.51 to 0.92]), while engaging in amounts of activity meeting physical activity guidelines or above was associated with a larger 40% reduction in risk of cardiovascular disease mortality (adjusted HR= 0.60 [95% CI: 0.44 to 0.82]) (115). Most interventions are based around 150–300 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity activity, and/ or 2–3 sessions of resistance training per week. For some outcomes (e.g. HBA1c and blood pressure) in adults with type-2 diabetes, there is evidence for a stronger effect with more aerobic activity (i.e. greater than 150 mins/week versus less than 150 mins/week), but limited evidence for intensity (35). In people living with HIV, there is insufficient evidence to establish a dose-response relationship between physical activity and body composition, or for intermediate markers of cardiometabolic diseases (such as blood lipid profiles, insulin resistance, fasting glucose concentrations or blood pressure). The majority of studies providing evidence involved physical activity interventions conducted at least 3 times a week for 12–48 weeks, and involved at least 30 minutes of moderate- to vigorous-intensity aerobic exercise alone or in combination with progressive resistance training. There is also insufficient evidence to establish more precisely the dose-response relationship for mental health and health-related quality of life outcomes. The available evidence is from studies typically assessing physical activity interventions of 3 or more times weekly. Overall there was evidence ranging from moderate to high certainty to support a physical activity recommendation of 150–300 minutes of moderate-intensity physical activity (or equivalent) for the specified populations of people living with chronic disease and the specific set of health outcomes. There was clearer evidence of higher levels of activity being associated with greater benefits in the evidence addressing people living with hypertension, ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) 54 55Recommendations type-2 diabetes and cancer survivors. The variations in the certainty and directness of the evidence according to the specific chronic condition and specific outcomes examined was acknowledged. Where evidence showed positive outcomes from strength training exercise, the frequency of activity was 2 or 3 sessions of resistance training per week. The GDG concluded that: • There is moderate certainty evidence of a dose-response relationship between physical activity and decreased all- cause mortality and cancer-specific mortality in cancer survivors. • There is high certainty evidence of a dose- response relationship between physical activity and cardiovascular disease mortality for adults with hypertension. • There is evidence of an inverse, curvilinear dose- response relationship between activity volume and risk of cardiovascular mortality among adults with type-2 diabetes. • There is insufficient evidence for a dose-response relationship between physical activity and intermediate markers of cardiometabolic diseases, body composition, and health-related quality of life symptoms of anxiety and depression in people living with HIV. • Interventions in the range of 150–300 minutes of moderate-intensity aerobic activity (or equivalent) provided favourable health outcomes, and positive outcomes from strength training exercise, where noted, with 2 or 3 sessions of resistance training per week. Does the association vary by type or domain of physical activity? There is evidence that different types and domains of physical activity provide favourable health outcomes. Cancer survivors who are meeting recommended levels of aerobic and muscle-strengthening physical activity, versus not meeting either recommendation, have significantly lower risk of cancer mortality (adjusted HR= 0.70 [95% CI: 0.50 to 0.98]) (84). Evidence demonstrates that adhering solely to muscle- strengthening physical activity recommendations versus not adhering is also beneficial in improving cancer mortality outcomes (HR= 0.66 [95% CI: 0.48 to 0.92]) (84). A meta-analysis also reported these associations by physical activity domain and found the most consistent reductions in mortality for all cancers, breast cancer, and colorectal cancer-specific mortality for recreational physical activity (105). For adults living with hypertension, evidence supports aerobic activity, muscle-strengthening activity, and combinations of the two for improving cardiovascular disease progression. The blood pressure lowering effects between traditional modes of physical activity (i.e. aerobic and resistance activity) do not appear to vary significantly among people with hypertension (35); however, this evidence is not based on direct comparisons between activity types. There is also emerging evidence to support beneficial effects of other forms of exercises in people living with hypertension (e.g. Tai Chi, yoga, Qigong), however further research is needed to explore these specific types of activity to determine strength of association. Aerobic activity, muscle-strengthening activity, or a combination of both, is associated with improved secondary indicators of risk of progression (HbA1c, blood pressure, BMI, and lipids) among adults with type-2 diabetes (35, 107). One review of 24 RCTs (n= 962) reported that resistance training was associated with greater reduction in HbA1c versus control groups (MD= 0.45 [95% CI: 0.65 to 0.25], 20 trials; n= 824). Statistically significant effects were found for high- intensity resistance training versus control groups on fasting insulin (MD= 4.60 [95% CI: 7.53 to 1.67], 5 trials; n= 174) (107). Another review of 7 RCTs (n= 189) reported that interval training (2–5 times/week; intervals 1–4 mins duration; total session lengths 20–60 mins) was associated with statistically significantly decreased HbA1c by 0.26% (95% CI: 0.46 to 0.07%, 5 RCTs) compared with MICT, and by 0.83% (95% CI: 1.39% to 0.27%, 4 RCTs) compared with no-exercise control groups (116). As with recommendations for the general population, most of these interventions are based around aerobic activity consistent with the recommendation of 150–300 minutes of moderate-intensity aerobic activity (or 75 minutes of vigorous-intensity activity) and muscle-strengthening activity conducted 2–3 sessions per week. For some outcomes (e.g. HBA1c and blood pressure), there is evidence for a stronger effect with more aerobic activity (i.e. greater than 150 mins/week versus less than 150 mins/ week), but limited evidence for intensity. More recent studies provide evidence that traditional Chinese exercise, such as Tai Chi may have glycaemic benefits, but these were of moderate and variable certainty (i.e. risk of bias or inconsistency). Further research is needed to determine these associations. ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) 56 57 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Multiple types of physical activity, including aerobic and resistance-training, have been shown to have positive effects on health-related quality of life in people living with HIV (111). Recent research examining changes in health-related quality of life in response to aerobic, progressive resistance exercise, or a combination of both, demonstrates significant improvements in general health, and mental health. There is also evidence that both aerobic and multicomponent activity is related to a reduction in symptoms of depression and anxiety in people living with HIV (112). Evidence for the effects of physical activity on mental health symptoms has involved aerobic or aerobic combined with progressive muscle-strengthening activity, or yoga. Evidence also demonstrates that aerobic exercise alone, or when combined with resistance exercise, does not result in any significant change in viral load or CD4 count in people living with HIV (111). Direct evidence, from both the existing and updated literature, supports the inclusion of the recommendations for people living with type-2 diabetes and hypertension to undertake aerobic and muscle-strengthening physical activity. Although there is a lack of published evidence, there is biological plausibility for the benefits of aerobic and muscle-strengthening physical activity for adults living with HIV and cancer survivors. Furthermore, as noted by the GDG, established international clinical practice guidelines recommend aerobic and muscle- strengthening physical activity for these populations (for example ACSM “Moving Through Cancer” guidelines (101) based on a systematic review of evidence (3)). Recognizing this evidence base is still emerging, the level of certainty was downgraded. The GDG concluded that: • There is moderate certainty evidence for combined or additive effects of aerobic or muscle-strengthening activity for reduced cancer mortality, improvements in blood pressure among those with hypertension. • There is high certainty evidence that aerobic activity, muscle-strengthening activity, and aerobic plus muscle- strengthening activity improve markers of disease progression (HbA1C, blood pressure, BMI, and lipids) in adults with type-2 diabetes. • There is moderate certainty evidence that regular aerobic exercise alone, or combined with resistance exercise, does not result in any significant change in viral load or CD4 count in people living with HIV. • There is insufficient evidence for an effect of strength training alone on health-related quality of life in people living with HIV. ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) 56 57Recommendations ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) Supporting evidence and rationale Due to a lack of population-specific evidence, the primary evidence base for assessing the associations between sedentary behaviour and health outcomes in adults and older adult cancer survivors and those adults and older adults living with hypertension, type-2 diabetes, and HIV, was the scientific literature collated and reviewed for adult populations. The findings from evidence on sedentary behaviours in the general adult population were reviewed, including assessing if there was evidence that the outcomes would be any different, or would not apply to, or would be contraindicated, for adults and older adults living with chronic conditions. In adults, including cancer survivors and people living with hypertension, type-2 diabetes and HIV, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality; cardiovascular disease mortality; cancer mortality; incidence of cardiovascular disease; cancer; and type-2 diabetes. For cancer survivors, and adults living with hypertension, type-2 diabetes and HIV, it is recommended that: Adults and older adults with chronic conditions should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults and older adults with chronic conditions should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence Sedentary behaviour was not included in the 2010 Global recommendations on physical activity for health (1). The scope of this new recommendation on sedentary behaviours in cancer survivors and those people living with hypertension, type-2 diabetes and HIV. Sedentary behaviour is defined as time spent sitting or lying with low energy expenditure, while awake, in the context of occupational, educational, home and community settings, and transportation. SEDENTARY BEHAVIOUR RECOMMENDATION 58 59 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) Based on available evidence and expert opinion, the evidence was extrapolated to inform the new WHO recommendations on sedentary behaviour for adults living with chronic conditions for the common set of critical health outcomes. The extrapolation of evidence is supported largely by the assessment that the majority of studies imposed no upper age limit criterion, included adults over the age of 65 years and may have included adults with chronic conditions, such as cancer survivors, those living with hypertension or type-2 diabetes. For people living with HIV, no reasons were identified as to why the evidence on the health impacts of sedentary behaviours would not apply. Due to indirectness of the evidence to develop these recommendations, the level of certainty was downgraded. The applicability of evidence on the benefit of undertaking more moderate- and vigorous-intensity physical activity to help counteract the potential risks of high levels of sedentary behaviour was also considered and was also extrapolated to inform recommendations for adults with chronic conditions for the common set of critical health outcomes. Given the indirectness, the certainty of the evidence was downgraded. The GDG concluded that: • The evidence on sedentary behaviours in the general adult population could be extrapolated to inform recommendations for adult and older adult cancer survivors and those adults and older adults living with hypertension, type-2 diabetes, and HIV for the common set of critical outcomes, with the level of certainty of the evidence downgraded due to indirectness. • The evidence on the benefits of undertaking more moderate- and vigorous-intensity physical activity to help counteract the potential risks of high levels of sedentary behaviour in the general adult population could be extrapolated to inform recommendations for adult and older adult cancer survivors and those adults and older adults living with hypertension, type-2 diabetes, and HIV for the common set of critical outcomes, with the level of certainty of the evidence downgraded due to indirectness. • The benefits for minimizing sedentary behaviours outweigh the harms for cancer survivors and those people living with hypertension, type-2 diabetes, and HIV. 58 59Recommendations CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and older) LIVING WITH DISABILITY Many of the health benefits of physical activity for children and adolescents, as set out in the section above, also relate to those children and adolescents living with disability. Additional benefits of physical activity to health outcomes for those living with disability include: improved cognition in individuals with diseases or disorders that impair cognitive function, including attention-deficit/hyperactivity disorder (ADHD); improvements in physical function may occur in children with intellectual disability. It is recommended that: Children and adolescents living with disability should do at least an average of 60 minutes per day of moderate- to vigorous-intensity, mostly aerobic, physical activity, across the week. Strong recommendation, moderate certainty evidence Vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated at least 3 days a week. Strong recommendation, moderate certainty evidence Children, adolescents and adults living with disability can achieve important health benefits from physical activity. Children, adolescents and adults with disability should try to meet these recommendations where possible and as able. For children, adolescents and adults living with disability, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), physical education, transportation (wheeling, walking and cycling) or household chores, in the context of home, educational, occupational and community settings. It is important to provide all children, adolescents and adults living with disability with opportunities and encouragement to participate in physical activities appropriate for their age and ability, that are enjoyable, and that offer variety. PHYSICAL ACTIVITY RECOMMENDATION • Doing some physical activity is better than doing none. • If children and adolescents living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Children and adolescents living with disability should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • There are no major risks for children and adolescents living with disability engaging in physical activity when it is appropriate to an individual’s current activity level, health status and physical function; and the health benefits accrued outweigh the risks. • Children and adolescents living with disability may need to consult a health-care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. G O O D P R A C TI C E ST A TE M EN TS G O O D P R A C TI C E ST A TE M EN TS 60 61 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and over) LIVING WITH DISABILITY Many of the health benefits of physical activity for adults, as set out in the section above, also relate to adults living with disability. Additional benefits of physical activity to health outcomes for those living with disability include the following: for adults with multiple sclerosis – improved physical function, and physical, mental, and social domains of health- related quality of life; for individuals with spinal cord injury – improved walking function, muscular strength, and upper extremity function; and enhanced health-related quality of life; for individuals with diseases or disorders that impair cognitive function – improved physical function and cognition (in individuals with Parkinson’s disease and those with a history of stroke); beneficial effects on cognition; and may improve quality of life (in adults with schizophrenia); and may improve physical function (in adults with intellectual disability); and improves quality of life (in adults with major clinical depression). It is recommended that: All adults living with disability should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults living with disability should do at least 150–300 minutes of moderate- intensity aerobic physical activity; or at least 75–150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence Adults living with disability should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence As part of their weekly physical activity, older adults living with disability should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence Adults living with disability may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence • Doing some physical activity is better than doing none. • If adults living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Adults living with disability should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • There are no major risks to adults living with disability engaging in physical activity when it is appropriate to the individual’s current activity level, health status and physical function; and when the health benefits accrued outweigh the risks. • Adults living with disability may need to consult a health-care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. G O O D P R A C TI C E ST A TE M EN TS 60 61Recommendations CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and over) LIVING WITH DISABILITY Supporting evidence and rationale For these guidelines for children, adolescents and adults living with disability, the comprehensive evidence synthesis undertaken by PAGAC (35) was used and updated. Full details of the methods, data extraction and summary evidence tables of this existing evidence on physical activity and health outcomes is available (35) and was reviewed by the GDG in addition to the findings of the updated search. The update conducted for these guidelines identified 39 reviews published from 2017 to 2019. Of these, 27 met the inclusion criteria and informed the examination of the association between physical activity and health-related outcomes among children, adolescents and adults living with disability. Full details of the methods, data extraction and summary evidence portfolios can be found in the Web Annex: Evidence profiles . Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf The evidence reviewed considered the association between physical activity and health-related outcomes in children, adolescents and adults living with disability resulting from the following health conditions: multiple sclerosis, spinal cord injury, intellectual disability, Parkinson’s disease, stroke, major clinical depression, schizophrenia, and attention-deficit/hyperactivity disorder (ADHD). The four health-related outcomes examined included risk of co-morbid conditions, physical function, cognitive function and health-related quality of life, although not all outcomes were explored for each condition. The impact of environmental factors on disability in the context of physical activity was beyond the scope of these guidelines and was not analysed. In children and adolescents (aged 5–17 years) and adults (aged over 18 years) living with disability, what is the association between physical activity and health-related outcomes? For people living with multiple sclerosis, physical activity improves physical function, functional mobility, walking speed and endurance, and cardiorespiratory fitness, strength and balance. For example, high-intensity interval training over 3–12 weeks demonstrated improvements in cardiorespiratory fitness or muscle strength (117) and lower limb strength training found strength increased by 23.1% (95% CI: 11.8 to 34.4) over an average training period of 13.2 weeks (118) over an average of 13 weeks resulted in increases in strength, and dance interventions studies reported improvements in functional mobility and balance (119). As well as physical health benefits, existing evidence demonstrates that physical activity can benefit cognition in people living with multiple sclerosis (35). Newer research reveals that aerobic exercise has a small yet significant effect on physical, mental and social domains of health-related quality of life (including symptoms of fatigue and depressive symptoms) (35, 120). For people living with spinal cord injury, physical activity can improve walking function, muscular strength and upper extremity function (35). Physical activity may also reduce shoulder pain, improve vascular function and enhance health-related quality of life (35). For people living with Parkinson’s disease, physical activity can improve motor symptoms, functional mobility and performance, endurance, freezing of gait and velocity of forward and backward movement (35, 121, 122). New evidence suggests that exercise can also help global cognitive function in individuals with Parkinson’s disease (123). For people with a history of stroke, physical activity can improve physical function, notably upper limb function, sensory motor function of the lower limb, balance, walking speed, distance, ability and endurance, cardiorespiratory fitness, mobility and activities of daily living. Existing evidence suggests that physical activity may also have beneficial effects on cognition (35). For people with major clinical depression, new reviews (124, 125) supported existing evidence (35) that physical activity can improve health-related quality of life (35, 124, 125). For individuals with diseases or disorders that impair cognitive function, including schizophrenia –physical activity can have beneficial effects on cognition, working memory, social cognition and attention/vigilance (35, 126). One review found that moderate- to vigorous-intensity physical activity delivered significant improvements in health-related quality of life and disability (35, 124). 62 63 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and over) LIVING WITH DISABILITY For people living with intellectual disability, physical activity has been shown to improve physical function. The interventions reviewed largely focused on balance and strength activities over 6–24 weeks and reported significant improvement in static balance, dynamic balance and static-dynamic balance compared with controls (35, 127, 128). For children with attention-deficit/hyperactivity disorder, evidence, including one review of 5 RCTs involving ADHD (129), demonstrates a positive association between exercise and attention, executive function and social disorders (35, 129). The GDG considered the evidence from the general population of children, adolescents and adults and concluded that as there is no reason to believe that there would be an effect modification due to impairment and that the same health physiological benefits will be conferred by being physically active. The GDG acknowledged that few studies include people living with disability, and that effect modification is seldom tested. This evidence in the area disability, combined with the broader evidence for the general population, supported the general population recommendation being inclusive of people with disability, noting reference to “all adults”, “all older adults” and “people of all abilities”. The GDG concluded that: In individuals with spinal cord injury, there is: • low certainty evidence that physical activity reduces shoulder pain and improves vascular function in paralysed limbs and enhances health-related quality of life; and • moderate certainty evidence that physical activity improves walking function, muscular strength, and upper extremity function. In individuals with diseases or disorders that impair cognitive function, including Parkinson’s disease, there is: • high certainty evidence that physical activity improves a number of functional outcomes including walking, balance, strength, and disease specific motor scores; and • moderate certainty evidence that moderate- to vigorous-intensity physical activity can have beneficial effects on cognition. In individuals with a history of stroke, there is: • moderate certainty evidence that mobility-oriented physical activity can have beneficial effects on physical function and cognition. In individuals with diseases or disorders that impair cognitive function, including schizophrenia, there is: • moderate certainty evidence that physical activity improves quality of life; and • high certainty evidence that moderate- to vigorous- intensity physical activity can have beneficial effects on cognition, working memory, social cognition and attention. In adults with major clinical depression there is: • moderate certainty evidence that physical activity improves quality of life. In adults with multiple sclerosis, there is: • high certainty evidence that physical activity, particularly aerobic and muscle-strengthening activities, improves physical function, functional mobility, walking speed and endurance, and cardiorespiratory fitness, strength and balance; • moderate certainty evidence that physical activity can have a beneficial effect on cognition; and • low certainty evidence that physical activity improves quality of life including symptoms of fatigue and depressive symptoms. In children and adults with intellectual disability, there is: • low certainty evidence that physical activity improves physical function. In children and adolescents with ADHD, there is: • moderate certainty evidence that moderate- to vigorous-intensity physical activity can have beneficial effects on cognition, including attention, executive function, and social disorders. The GDG further concluded that there is sufficient scientific evidence on the positive impact of physical activity on a variety of health outcomes across a broad range of impairment areas, and that the benefits of physical activity for people living with disability outweigh the potential harms. Due to indirectness of the evidence to develop these recommendations, the level of certainty was downgraded. 62 63Recommendations CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and older) LIVING WITH DISABILITY Supporting evidence and rationale Sedentary behaviour was not included in The Global recommendations on physical activity for health (2010). Due to a lack of population-specific evidence, the primary evidence base for assessing the associations between sedentary behaviour and health outcomes in children, adolescents and adults living disability was the scientific literature collated and reviewed for populations without disability. The findings from evidence on sedentary behaviours in the general population were reviewed including assessing if there was evidence that the outcomes would be any different, or would not apply to, or would be contraindicated for children, adolescents and adults living with disability. In children and adolescents, higher amounts of sedentary behaviour are associated with the following poor health outcomes: increased adiposity; poorer cardiometabolic health, fitness, and behavioural conduct/pro-social behaviour; and reduced sleep duration. It is recommended that: Children and adolescents living with disability should limit the amount of time spent being sedentary, particularly the amount of recreational screen time. Strong recommendation, low certainty evidence In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and type-2 diabetes. It is recommended that: Adults living with disability should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light- intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults living with disability should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence For children, adolescents and adults living with disability, sedentary behaviour is defined as time spent sitting or lying with low energy expenditure, while awake, in the context of educational, home and community settings, and transportation. It is possible to avoid sedentary behaviour and be physically active while sitting or lying, through, for example, upper body led activities, inclusive and/or wheelchair-specific sport and activities. SEDENTARY BEHAVIOUR RECOMMENDATION 64 65 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and over) LIVING WITH DISABILITY Based on available evidence and expert opinion, the evidence was extrapolated to inform new WHO recommendations on sedentary behaviour for individuals living with disability for the common set of critical health outcomes, recognizing that certain population groups, such as wheelchair users, unavoidably sit for long periods of time and sitting may therefore be the norm. For these groups, sedentary behaviour should be defined as time spent with low energy expenditure, e.g. moving in a power chair or being pushed while sitting in a manual wheelchair. There is a lack of research on the association between sedentary behaviour and health outcomes in individuals living with disability. However, based on expert opinion, there are no reasons to believe that there would be an effect modification due to impairment, and therefore the same physiological health benefits will be conferred by limiting sedentary behaviour in individuals living with disability. Due to indirectness of the evidence to develop these recommendations, the level of certainty was downgraded. The applicability of evidence on the benefit of adults undertaking more moderate- and vigorous-intensity physical activity to help counteract the potential risks of high levels of sedentary behaviour was also considered and was also extrapolated to inform recommendations for adults living with disability for the common set of critical health outcomes. Given the indirectness, the certainty of the evidence was downgraded. The GDG concluded that: • The evidence on sedentary behaviours in child and adolescent populations could generally be extrapolated to children and adolescents living with disability, according to their specific ability. • The evidence on sedentary behaviours in the general adult population, including the benefit for adults of undertaking more moderate- to vigorous- intensity physical activity to help counteract the potential risks of high levels of sedentary behaviour, could generally be extrapolated to adults and older adults living with disability, according to their specific ability. However, the certainty of the evidence was downgraded due to indirectness. • The benefits of minimizing sedentary behaviour in children, adolescents, adults and older adults living with disability outweigh the harms. 64 65Recommendations In accordance with the GRADE process, the proposed wording of the updated recommendations, and the rating of their strength (“strong” or “conditional”), were based on consideration of the balance of benefits to harms; the certainty of evidence; sensitivity to the values and preferences of those affected by the guidelines; the potential impact on gender, social and health equity; and acceptability, feasibility and resource implications. These were considered for each population group, but given the similarity of issues and considerations discussed, are consolidated and presented here. The strength of the recommendation was primarily based on the assessed balance of benefits to harms. Recommendations were graded “strong” if the balance of benefits to harms was assessed as substantial for the target population for the recommendation, and “conditional” if the balance of benefits to harms was small or there was important likely variability in benefits in the target population. The evidence on harms was specifically sought through the commissioning of a new systematic review. However, this was limited, as most evidence focuses on injuries and harms to elite and competitive athletes, rather than the general population. Overall, despite the limited evidence, and informed by expert opinion, it was concluded that the risk was no greater than small. The evidence generally indicated that the benefits of physical activity far outweighed the harms, and that physical activity can be an important intervention to support closing an existing health gap, particularly for disadvantaged populations. Issues of health equity, feasibility and acceptability were also considered by the GDG and formed part of the online public consultation on the draft recommendations held between 31 March 2020 and 17 April 2020. The survey for the public consultation asked specific questions on the balance between the costs to individuals and governments of implementing the recommendations, and the potential health benefits, and whether the guidelines would improve health equity. In addition, the draft recommendations and the feedback form were sent to countries that had recently expressed an interest in developing, or had initiated the process of drafting, national guidelines on physical activity. Feedback was received from more than 420 submissions to the online consultation, and additional collation of feedback from the WHO European Regional Office, incorporating comments from WHO Collaborating Centres and Member States. The feedback from this consultation was collated, reviewed by the GDG, and used to further inform the consideration on feasibility, resource implications, and health equity through consultation with the Steering Group and the GDG. Decisions were reached by consensus through discussion. The GDG came to consensus on each recommendation and on the strength of the recommendation; ratings and voting were not required. ASSESSMENT OF THE CERTAINTY OF EVIDENCE The GRADE framework was used by the GDG to examine the certainty of primary research contributing to each outcome identified in the PI/ECOs, and assessed the overall certainty of evidence taking into consideration the risk of bias, inconsistency, imprecision, indirectness of the evidence and publication bias across each outcome. GRADE tables detailing this information for each PI/ECO are available in the Web Annex: Evidence profiles . The assessment of the certainty of the evidence was based on an overall assessment across all evaluated outcomes and prioritized all-cause mortality and cardiovascular mortality as the most critical outcomes, followed by other clinical outcomes (falls, depression, cognition, health-related quality of life, etc), then intermediate outcomes (e.g. cardiometabolic markers, other metabolic markers), as well as harms. Where the evidence had not been specifically reviewed, such as for sedentary behaviour in subpopulations primarily due to a lack of evidence for these groups, the evidence for the general population was extrapolated and downgraded where this was deemed appropriate, due to indirectness. EVIDENCE TO RECOMMENDATIONS Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 66 67 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r BENEFITS AND HARMS The development of the recommendations included an assessment of adverse impacts or risks. Where there was limited evidence, decisions were based on the expertise of the GDG. Overall, for all populations it was concluded that the benefits of physical activity and limiting sedentary behaviour outweighed the potential harms. These guidelines are for the general population and do not address the benefits and harms experienced by athletes undertaking the types and amounts of activity necessary to improve performance-related fitness for participation in competition. Doing some physical activity is better than doing none. If individuals are not currently meeting these recommendations, doing some physical activity will bring benefits to their health. They should start by doing small amounts of physical activity, gradually increasing frequency, intensity and duration over time. Pre-exercise medical clearance is generally unnecessary. Inactive individuals who gradually progress to undertaking moderate-intensity activity have no known risk of sudden cardiac events and very low risk of bone, muscle, or joint injuries. An individual who is habitually engaging in moderate-intensity activity can gradually increase to vigorous-intensity without needing to consult a health- care provider. Those who develop new symptoms when increasing their levels of activity should consult a health- care provider. The choice of appropriate types and amounts of physical activity can be affected by pregnancy, chronic conditions, and disability, and should be undertaken as able and without contraindication. These individuals may wish to consult with a physical activity specialist or health-care professional for advice on the types and amounts of activity appropriate for their individual needs, abilities, functional limitations/complications, medications, and overall treatment plan. Light- and moderate-intensity physical activity are generally low risk and are recommended for all. VALUES AND PREFERENCES The values and preferences of those affected by the guidelines (in this case parents and caregivers, children and adolescents, adults, older adults, pregnant and postpartum women, people living with chronic conditions and/or disability) were considered. Overall it was concluded that there was little or no uncertainty about preferences regarding the main outcomes, including mortality and cardiovascular mortality. The estimated potential benefits greatly outweighed any potential harms, and as such, the GDG considered the recommendations to be not preference-sensitive. RESOURCE IMPLICATIONS The expert opinion of the GDG, and a small body of evidence reporting on economic analyses of interventions and savings to the health-care systems from increasing levels of physical activity, informed discussion on the resource implications of the recommendations in different settings. In addition, results from the online public consultation showed that over 75% of respondents agreed, or strongly agreed, that the benefits of implementing the guidelines would outweigh the cost to the individual, and 81% agreed, or strongly agreed, that the benefits of implementing the guidelines would outweigh the cost to government. Available evidence and expert opinion recognize that substantial health benefits can be achieved at low risk through activities such as walking, that require no specific equipment or cost to the individual. Further, it was acknowledged that other forms of physical activities, for example structured sports, cycling and exercise classes, may incur costs, which can be a barrier for some individuals, particularly those with lower incomes. Government implementation of policy and programmes to promote and enable physical activity also requires investments in areas such as human resources, policy development, provision of facilities and services and potentially, equipment, some of which is incurred by ministries of health, but also in sectors outside of health, such as sport, education, transport and urban planning. The resources required may be at more than one level of government (national, subnational and local levels) to ensure all communities have equal access to physical activity opportunities. These investments may involve new resources, but also can be addressed by reallocation of existing budgets to reflect the prioritization of facilities and programmes towards increasing population levels of physical activity. Examples of budget reallocation include towards infrastructure for walking and cycling from the existing transport budget, and towards “sports for all” from the sports budgets. In key settings, such as schools and workplaces, low-cost interventions, combined with changes to the physical environment, can support participation in physical activity and would also contribute to reducing inequities in opportunities to be active, 66 67Evidence to recommendations experienced by some subpopulation groups. Overall, it was assessed that while there are resource implications to achieve these draft recommendations, implementation of actions is possible within current governance structures. Further, evidence supports that substantial health savings are possible for the health-care system resulting from increasing levels of physical activity. In 2013 the global annual cost of physical inactivity was estimated at INT$ 54 billion due to direct health costs alone (130); and at a national level, inactivity is estimated to cost between 1–3 % of health-care budgets (131). Within the wider context of noncommunicable disease (NCD) prevention, additional costs to government and nongovernmental organizations of guideline implementation may be minimized if recommended physical activity can be relatively easily incorporated by individuals into their lives; likewise if existing resources in primary and secondary care, schools, workplaces or transportation can be shifted, resulting in increased physical activity. Analysis of the cost and benefits of physical activity promotion indicate positive returns on investment over 15 years, in terms of NCD prevention, in many countries where the investment cases have been conducted (132). Interventions such as public education and awareness campaigns and physical activity counselling and referral are a “best buy” and a “good buy” respectively, of recommended interventions to address NCDs based on an update of Appendix 3 of the Global action plan for the prevention and control of NCDs 2013–2020 (133). Overall, the GDG concluded that the benefits of implementing the recommendations outweigh the costs. Delivering on physical activity guidelines for people with disability may require investment, such as the training of activity specialists, adapted equipment where needed, and facilities that need to be made accessible. These investments can facilitate the needs of a wide range of population groups. Evidence demonstrates a significant participation gradient between people with and without disability in relation to physical activity, due to multiple barriers regarding access, choice of activities offered, and the attitudes of others. Universal design principles should be applied to ensure full and effective participation by people living with disability. With innovation, it is possible to address many of these resource implications. Adopting universal design approaches would mitigate against these costs in the future. EQUITY, ACCEPTABILITY AND FEASIBILITY In updating the 2010 recommendations the decision was taken to explicitly include consideration of vulnerable populations, such as those living with chronic conditions and/or disability. The GDG and Steering Group included members representing such groups. The GDG discussed each recommendation at length, considering whether implementing the recommendations would decrease health equity, and the issues related to implementation, to ensure that the recommendations did not worsen equity issues (for example, ensuring that there are safe facilities and opportunities accessible for all, including people living with disability, and socioeconomically and other disadvantaged people, to engage in physical activity; addressing gender and other cultural biases that could restrict access and opportunity to participate in physical activity, etc.). Of respondents to the online public consultation, 76% agreed, or strongly agreed, that implementing the guidelines can achieve a reduction in health inequity by increasing opportunities for all to be active and improve health outcomes. It was noted that supporting environments are key to enabling participation in physical activity. A comprehensive approach to the design and implementation of policies across a number of sectors will be required to address barriers to physical activity for vulnerable groups, such as socioeconomically disadvantaged women and girls, and people with disability. People with disability experience worse health outcomes than people without disability, yet the benefits of physical activity far outweigh the harms and can be an important intervention to close this health gap. Evidence demonstrates a significant participation gradient between people with and without disability in relation to physical activity, due to multiple barriers regarding access, choice of activities offered, and the attitudes of others. For many people with disability, it should be possible to engage in various forms of physical activity without the need for adapted equipment or facilities. However, in order for people with disability to engage in physical activity on an equal basis with others, adapted equipment may need to be obtained, facilities may need to be made accessible, and activity specialists may need to be trained. 68 69 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Despite the large quantity of data relating physical activity and, increasingly, sedentary behaviours to health outcomes across the life span, the GDG discussions revealed important evidence gaps, which should be prioritized to inform future guidelines. Evidence gaps across population subgroups included a lack of information on: 1) the more precise details on the dose-response relationship between physical activity and/or sedentary behaviour and several of the health outcomes studied; 2) the health benefits of light-intensity physical activity and of breaking up sedentary time with light- intensity activity; 3) differences in the health effects of different types and domains of physical activity (leisure time; occupational; transportation; household; education) and of sedentary behaviour (occupational; screen time; television viewing); and 4) the joint association between physical activity and sedentary time with health outcomes across the life course. It was also noted that there remains limited evidence from low- and middle-income countries, economically disadvantaged or underserved communities, and in people living with disability and/or chronic disease. Many studies are not designed or powered to test for effect modification by various sociodemographic factors (age, sex, race/ethnicity, socioeconomic status) that may modify the health effects of physical activity. Such information is important for making more specific public health recommendations and for reducing health disparities in more vulnerable sectors of the population. Further details on the research gaps arising from these new guidelines can also be found in published literature (134). RESEARCH NEEDS 68 69Research needs The goal of these guidelines is to provide policy- makers, and those who develop health-care, education, workplace and community intervention programmes, with recommendations on how much time children, adolescents, adults and older adults should spend each day being physically active, and recommendations on limiting time spent being sedentary. However, developing global guidelines is not an end in itself: without dissemination and implementation, changes in physical activity levels will not be achieved. ADOPTION WHO undertakes a rigorous and extensive process to develop globally relevant guidelines (21) for use by all countries. These Guidelines on physical activity and sedentary behaviour provide evidence-based recommendations on the health impacts of physical activity and sedentary behaviour that national governments can adopt and use as part of their national policy frameworks. The development of global guidelines, with extensive consultation, should largely remove the need for individual countries to use resources to undertake the lengthy scientific process. Reviewing and adopting these global physical activity and sedentary behaviour guidelines provides a rapid and cost-effective method to develop guidelines tailored to local context. Adopting the WHO guidelines at regional or national level will ensure countries provide consistent recommendations on physical activity and sedentary behaviour, which are informed by the latest and best available scientific evidence. In addition, consistency of the recommendations across countries will facilitate national surveillance, global estimates of physical activity and sedentary behaviour, and cross- country comparisons. Throughout the adoption process, consideration should be given to the need to contextualize and tailor the guidelines. Translation into the local language is one element of adoption and contextualization. Examples of physical activities may need to be changed to be locally relevant and the use of images tailored to reflect local cultures, norms and values. A step-by-step framework to support country adoption of the Global guidelines is under development, following a series of regional workshops with relevant stakeholders. This framework can be populated with relevant national data (for example physical activity prevalence estimates), and will provide a fast-track approach to the development of a national guidelines document. These supporting resources will be available in 2021 through the WHO website. When considering adopting the guidelines it is recommended that the following ten-step process is applied: 1. Advocate for a review of current national guidelines on physical activity and the adoption of the WHO guidelines to secure government authorization. 2. Engage key stakeholders both within the health sector and other relevant sectors, such as sport, education, transport; engage relevant professional associations and scientists, with topic expertise. 3. Assess the applicability, acceptability and feasibility of the recommendations. 4. Adapt guidelines to the local context, including language, examples, and other cultural considerations. 5. Conduct an external review with target users, including policy-makers, practitioners, and the general public. 6. Establish a budget and clear plan for dissemination and communication. 7. Publish and promote the national guidelines, ideally alongside a launch event to generate publicity and interest. 8. Engage relevant professional bodies or organizations and support policy alignment and/or endorsement. 9. Implement national policies and practices to support implementation of national guidelines and behaviour change. 10. Agree a timeline for evaluation, review, and update of the guidelines. ADOPTION, DISSEMINATION, IMPLEMENTATION AND EVALUATION 70 71 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r DISSEMINATION National physical activity guidelines are a core component of the governance structures for a comprehensive approach to increasing population levels of physical activity. National guidelines inform the development and priorities of national and subnational strategy planning and require dissemination of the correct information, to the relevant groups of people, in an appropriate way. Unfortunately, too often, national guidelines are not disseminated, and so awareness of recommendations among both professional audiences and the wider community can remain very low. Securing dedicated resources to support wide-scale dissemination is an important first step to changing awareness and knowledge about the importance of increasing physical activity and reducing sedentary behaviours. Key audiences for dissemination of national guidelines on physical activity and sedentary behaviour include: • Policy-makers within and outside the health sector (including transport, planning, education, workplaces, sport, parks and recreation), to increase: a. knowledge of the contribution that increasing physical activity and reducing sedentary behaviour can have in improving not only health, but also a range of diverse yet related agendas, including gender equity, human rights obligations, and sustainable development; b. integration of policy and programmes on physical activity and sedentary behaviour into all relevant policies; and c. investment in scaled-up and coordinated national and local actions. • Non-state actors (including nongovernmental organizations, academic and research organizations, the private sector as well as the media and research funding agencies), to: a. raise awareness of the importance of increasing physical activity and reducing sedentary behaviours across all ages; b. encourage and ensure policy alignment; and c. increase collaboration and investment in policy implementation and local action. • Practitioners in health and non-health sectors (including sport, education, transport, and planning) to increase: a. awareness and knowledge of national guidelines on physical activity and sedentary behaviours; b. knowledge, skills and confidence in promoting increased physical activity and reduction in sedentary behaviours; and c. integration of physical activity promotion into routine practice where applicable. • The general public and specific population subgroups, to increase: a. awareness and knowledge of the guidelines on physical activity and sedentary behaviour; b. knowledge of how to achieve the physical activity and sedentary behaviour guidelines; and c. intentions and motivation to be more physically active and to reduce sedentary behaviour. COMMUNICATION CAMPAIGNS Different stakeholders will benefit from different materials; therefore to communicate guidelines to multiple audiences effectively, consideration must be given to the content, format, and delivery channels for guideline communication. When developing a guideline communication strategy, formative research can help determine the key audiences and understand the values, needs and preferences that influence levels of physical activity and sedentary behaviour. This should include exploration of the barriers to physical activity or to the integration of physical activity into policy and practice, as well as testing of draft messages and materials with different groups. This will help inform the key messages that are used, as well as the appropriate format(s) and channel(s) for communication. A comprehensive communication strategy will include a range of communications aimed at different audiences. Countries may need to prioritize specific groups depending on available resources (human and financial). Communication campaigns on physical activity targeting the general public or specific subpopulations are a cost- effective intervention (133) and recommended in the WHO Global action plan on physical activity 2018–2030 (14). National and subnational campaigns on physical activity typically establish an overarching campaign slogan (for example “Be Active” or “Move More”), and develop design elements or characters, which may include tailored messages for different audiences 70 71Adoption, dissemination, implementation and evaluation (such as for young children, adolescents, adults or older adults, the less active, people living with disability or chronic conditions). Campaign messages and resources that are tailored to specific population groups are likely to be more effective than generic materials. Communication campaigns should consider the reach and effectiveness of both traditional media channels (such as television, radio, billboards, printed resources) as well as digital media channels (websites, mobile phones, Apps). Providing information on the national guidelines in a variety of formats is also useful. For example, a relatively new but increasingly common approach to communicating physical activity guidelines is through the use of infographics or short animated videos. WHO has supporting materials for developing and implementing such communication campaigns (135). The academic and research community are likely to be interested in the scientific report which details the epidemiological evidence on which the guidelines are based. However the specific details of the underlying research is unlikely to be of interest to other more general audiences. Policy-makers may prefer a summary of the science, or even a short briefing document. Other audiences, such as health and non-health professionals, are more likely to favour different types of resources, for example a brochure or factsheet about the guidelines, or about how to integrate physical activity promotion into routine practice (for example in patient consultations in a health-care setting, or when developing building or transport plans for urban environments). Different professionals will require resources that are tailored to their role. Health professions, in particular, may benefit from a suite of resources to reflect the diverse population groups that they work with. IMPLEMENTATION OF POLICY AND PROGRAMMES National guidelines on physical activity and sedentary behaviour, in isolation, are unlikely to lead to increases in population levels of physical activity and should therefore be seen as one element of a policy and planning framework. It is critical that national guidelines are disseminated to key audiences and supported by a sustained national communication strategy that will lead to increased awareness and knowledge about the multiple benefits of regular physical activity and reducing sedentary behaviours. However, in order to achieve sustained behaviour change, these actions must be supported by policies that create supportive environments that enable and encourage people to be active, along with increased local, appropriate opportunities for people to participate in physical activity. Policies and programmes must consider and be adapted to the local context, in terms of both the health system and the complex multisector institutions that have an interest in, or opportunity to support, physical activity promotion. Action should be taken using a “whole of government” approach and consider the “system” of policies and multiple actions that can, through engagement of a wide range of stakeholders, support more people to be physical active across multiple sectors and settings. Using a “systems” approach that is aligned with a sustained communication strategy ensures that increased demand for physical activity, generated through effective communication, is matched by the provision of environments and opportunities for people to be physically active. 72 73 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r The WHO Global action plan on physical activity 2018–2030 set a target to reduce physical inactivity by 15% by 2030, and outlined 20 recommended policy actions and interventions (14). These included recommending that all countries implement sustained national public education and awareness campaigns and the integration of physical activity counselling programmes into primary and secondary health care. Other recommendations included the creation of appropriate environments for physical activity, including walking, cycling and wheeling, for all population groups and the provision of more opportunities and programmes for physical activity in schools, workplaces and sports clubs and venues. Implementation across all 20 recommendations may not be feasible in the short term in all countries, but should be viewed as a long-term goal. To identify an appropriate and feasible set of immediate actions, WHO Member States should conduct a situational analysis of current policy and practice. This will enable multisector collaboration and help identify areas of strength as well as gaps and opportunities, and can be used as the basis for developing or updating national and subnational plans. These new WHO guidelines support expanding the scope of actions to include additional groups, such as people living with disability or chronic conditions, and women who are pregnant or postpartum. Policy will need to support appropriate programme delivery and practice that recognizes community needs and the diversity of groups and contexts. A number of sector-specific toolkits are under development to support implementation of the ACTIVE technical package (135); these will provide each sector with guidance on how to promote physical activity, for example through schools, through primary health care, or by improving provision for walking and cycling. The ACTIVE toolkit, as well as other WHO regional and national resources will support implementation of these physical activity and sedentary behaviour guidelines. SURVEILLANCE AND EVALUATION The WHO Global recommendations for physical activity for health have been used as benchmarks for population health monitoring and surveillance since 2010. The changes introduced to the recommendations in these updated guidelines will have some implications for surveillance systems and assessment instruments currently used to monitor national levels of physical activity. The publication of these new guidelines will call for a review of current instruments and reporting protocols to inform any adjustments and recommendations on future reporting against the new guidelines. Instruments, such as the Global Physical Activity Questionnaire and Global Student Health Survey, will be reviewed and protocols updated to align with these new guidelines; supporting guidance to all countries will be provided in 2021. The WHO NCD Country Capacity Survey (CCS) is the main instrument used to monitor global progress on NCD policy implementation, and is conducted every two years. The CCS includes specific questions on population surveillance systems on physical activity for each age group covered by these WHO guidelines on physical activity and sedentary behaviour, and since 2019, on the existence of national physical activity guidelines. WHO Member States are requested to upload documentation to support their response. In 2019, of the 194 WHO Member States, 78 (40%) reported having physical activity guidelines (136). A detailed document analysis of responses to the CCS in 2019 was carried out, and identified that only two thirds of the 78 Member States (52/78) with national guidelines include statements on how much physical activity their populations should do; and of these, only 42 countries aligned fully with the 2010 WHO Global recommendations on physical activity for health (1). Data from the 2021 and subsequent surveys will provide information on uptake of these updated guidelines. UPDATING These guidelines will be updated after ten years, unless advances in the science of how physical activity is assessed using device-based measurement, and the rapidly evolving science on sedentary behaviour, prompt an earlier update. 72 73Adoption, dissemination, implementation and evaluation 74 75 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 1. World Health Organization. Global recommendations on physical activity for health. 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DiPietro L, Al-Ansari S, Biddle S, Borodulin K, Bull F, Buman M, et al. Advancing the global physical activity agenda: recommendations for future research by the 2020 WHO Physical Activity and Sedentary Behavior Guidelines Development Group. Int J Behav Nutr Phys Act. 2020;In press. 135. World Health Organization. ACTIVE: a technical package for increasing physical activity. Geneva: World Health Organization; 2018. 136. World Health Organization. Assessing national capacity for the prevention and control of noncommunicable diseases: report of the 2019 global survey. Geneva: World Health Organization; 2020. 82 83 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r G lo be b as ed o n io at /S hu tt er st oc k, s ilh ou et te s ha pe s or ig in al ly b as ed o n Sh ut te rs to ck s ou rc es 82 83References 84 85 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r WHO Steering Group The Steering Group included experts in the areas of physical activity, adolescent health, ageing disability, mental health, injury prevention, cancer, pregnancy and surveillance from both headquarters and regional offices. Valentina Baltag Department of Maternal, Newborn, Child and Adolescent Health and Ageing – adolescent health Maurice Bucagu Department of Maternal, Newborn, Child and Adolescent Health and Ageing – pregnancy Fiona Bull Chairperson Department for Health Promotion – physical activity Alex Butchart Department of Social Determinants of Health – injury prevention Neerja Chowdhary Department of Noncommunicable Diseases – mental  health/dementia Regina Guthold Department of Maternal, Newborn, Child and Adolescent Health and Ageing – adolescent surveillance Riitta-Maija Hämäläinen Western Pacific Regional Office Andre Ilbawi Department of Noncommunicable Diseases – cancer Wasiq Khan Eastern Mediterranean Regional Office Lindsay Lee Department of Noncommunicable Diseases – disability Alana Officer Ageing Leanne Riley Department for Noncommunicable Diseases – surveillance Gojka Roglic Department for Noncommunicable Diseases – diabetes Juana Willumsen Department for Health Promotion – physical activity The Steering Group drafted the scope of the guidelines, and the PI/ECOs. They reviewed the declaration of interests; and drafted, reviewed and finalized the guidelines. Contributors to guideline development ANNEX 1: MANAGEMENT OF GUIDELINE DEVELOPMENT PROCESS 84 85Annex 1 Guideline Development Group (GDG) The Guideline Development Group consisted of a broad group of relevant experts in the field and end users of, and persons affected by, the recommendations. The members of the Guideline Development Group included: Dr Salih Saad Al-Ansari (advocate in health promotion and education to combat NCDs through physical activity and walking); Dr Stuart Biddle (physical activity and sedentary behaviour, and behaviour change); Dr Katja Borodulin (physical activity in pregnancy and older adults); Dr Matthew Buman (sleep, sedentary behaviour, and physical activity in people living with chronic conditions); Dr Greet Cardon (physical activity in children and adolescents); Ms Catherine Carty (physical activity in people living with disability); Dr Jean-Philippe  Chaput (sleep, sedentary behaviour and physical activity in children and adolescents); Dr Sebastien Chastin (physical activity, sedentary behaviour and health, objective measurement of physical activity and sedentary behaviour); Dr Paddy Dempsey (physical activity and sedentary behaviour in adults and people living with chronic conditions); Dr Loretta DiPietro (physical activity in pregnancy and older adults); Dr Ulf Ekelund (sedentary behaviour and physical activity, physical activity in children and adolescents); Dr Joseph Firth (physical activity and mental health); Dr Christine Friedenreich (physical activity in people living with chronic conditions, physical activity and cancer risk); Dr Leandro Garcia (physical activity and health in adults); Dr Muthoni Gichu (policy implementation, national government); Dr Russ Jago (physical activity in children and adolescents); Dr Peter Katzmarzyk (physical activity and sedentary behaviour); Dr Estelle V. Lambert (physical activity and obesity); Dr Michael Leitzmann (sedentary behaviour and physical activity in people living with chronic conditions); Dr Karen Milton (translating recommendations into practice); Dr Francisco B. Ortega (physical activity in children and adolescents, mental health and objective measurement); Dr Chathuranga Ranasinghe (promotion of physical activity and health in the community, workplace and school settings); Dr Emmanuel Stamatakis (physical activity and sedentary behaviour and multiple health outcomes in adults); Dr Anne Tiedemann (physical activity in older adults); Dr Richard Troiano (policy development); Dr Hidde van der Ploeg (physical activity and sedentary behaviour in adults); Ms Vicky Wari (policy implementation – national government); Dr Roger Chou (Pacific Northwest Evidence- based Practice Center and Professor of Medicine, Departments of Medicine, Medical Informatics and Clinical Epidemiology of the Oregon Health and Science University) served as GRADE methodologist. Further details of the GDG are available in Annex 2. A first GDG meeting was held 2–4 July 2019, at which the GDG decided on the PI/ECO questions, reviewed the existing systematic reviews, and identified updates required. The Group agreed on the process for decision-making on recommendations and the strength of the evidence to be applied at the second GDG meeting. The second meeting was held 11–14 February 2020; updated evidence was reviewed and final recommendations agreed upon by consensus. 86 87 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r External Review Group (ERG) Seven peer reviewers were drawn from a list of individuals suggested by the GDG and Steering Group. They provided relevant expertise, including programme implementation and represented all six WHO regions. The ERG reviewed the draft guidelines and provided feedback to the Steering Group on issues of clarity and implementation, which was incorporated, as appropriate. External peer reviewers did not make changes to the recommendations. External peer reviewers are listed in Annex 2. Declarations of Interest All GDG members and external peer reviewers completed and submitted a WHO Declaration of Interests form and signed confidentiality undertakings prior to attending any GDG meetings. The Steering Group reviewed and assessed the submitted curriculum vitae and declarations of interest and performed an internet and publications search to identify any obvious public controversies or interests that may lead to compromising situations. The names and brief biographies of all proposed GDG members were published on the WHO Physical Activity webpage for public consultation for a period of 14 days. No comments were received. If additional guidance on management of any declaration or conflicts of interest had been required, the Steering Group would have consulted with colleagues in Office of Compliance, Risk Management and Ethics. If deemed necessary, individuals found to have conflicts of interest, financial or non-financial, would have been excluded from participation on any topics where interests were conflicting. The management of conflicts of interest was reviewed throughout the process. GDG members were required to update their Declaration of Interest, if necessary, before each meeting and a verbal declaration of interest was solicited at the beginning of each GDG meeting. Declared interests of the GDG and of the external peer reviewers are summarized in Annex 3. No conflict of interest was identified. Peer review The draft guidelines were reviewed by seven external peer reviewers identified by the GDG and Steering Group. External peer reviewers were requested to provide comments on issues of clarity, presentation of the evidence, and implementation; comments were incorporated as appropriate. External peer reviewers could not change the recommendations decided upon by the GDG. External peer reviewers are listed in Annex 2; a summary of declarations of interest are provided in Annex 3. In addition, inputs were actively sought from WHO regional offices. 86 87Annex 1 Guideline Development Group Dr Salih Al-Ansari Assistant Professor Family & Community Medicine Founder and CEO Health Promotion Center Riyadh SAUDI ARABIA Dr Stuart Biddle Professor of Physical Activity & Health Physically Active Lifestyles Research Group Centre for Health Research Institute for Resilient Regions University of Southern Queensland Springfield Central AUSTRALIA Dr Katja Borodulin The Age Institute Helsinki FINLAND Dr Matthew Buman College of Health Solutions Arizona State University Phoenix USA Dr Greet Cardon Department of Movement and Sports Sciences Faculty of Medicine and Health Sciences Ghent University Gent BELGIUM Ms Catherine Carty UNESCO Chair Project Manager Institute of Technology Tralee Co Kerry IRELAND Dr Jean-Philippe Chaput Senior Scientist, Healthy Active Living and Obesity (HALO) Research Group Children’s Hospital of Eastern Ontario (CHEO) Research Institute Department of Pediatrics University of Ottawa Ottawa, Ontario CANADA Dr Sebastien Chastin Professor of Health Behaviour Dynamics School of Health and Life Sciences Department of Psychology, Social Work and Allied Health Sciences Glasgow Caledonian University Glasgow UNITED KINGDOM Dr Roger Chou (GRADE Methodologist) Departments of Medicine, and Medical Informatics & Clinical Epidemiology Oregon Health & Science University Portland, Oregon USA Dr Paddy Dempsey MRC Epidemiology Unit University of Cambridge School of Clinical Medicine Institute of Metabolic Science Cambridge UNITED KINGDOM ANNEX 2: GUIDELINE DEVELOPMENT GROUP, EXTERNAL PEER REVIEWERS, AND WHO STAFF INVOLVED IN THE DEVELOPMENT OF THESE GUIDELINES 88 89 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Dr Loretta DiPietro Department of Exercise and Nutrition Sciences Milken Institute School of Public Health The George Washington University Washington, DC USA Dr Ulf Ekelund Department of Sport Medicine Norwegian School of Sport Science Oslo NORWAY Dr Joseph Firth Presidential Fellow School of Health Sciences University of Manchester Manchester UNITED KINGDOM Dr Christine Friedenreich Scientific Director Department of Cancer Epidemiology and Prevention Research Cancer Control Alberta Alberta Health Services Calgary CANADA Dr Leandro Garcia Research Associate Centre for Public Health Queen’s University Belfast Belfast UNITED KINGDOM Dr Muthoni Gichu Head Division of Geriatric Medicine Department of Non-Communicable Diseases Ministry of Health Nairobi KENYA Dr Russell Jago Professor of Paediatric Physical Activity & Public Health Centre for Exercise, Nutrition & Health Sciences School for Policy Studies University of Bristol Bristol UNITED KINGDOM Dr Peter T. Katzmarzyk Associate Executive Director for Population and Public Health  Sciences Professor and Marie Edana Corcoran Endowed Chair in Pediatric Obesity and Diabetes Pennington Biomedical Research Center Baton Rouge USA Dr Estelle V. Lambert Director Research Centre for Health Through Physical Activity, Lifestyle  and Sport University of Cape Town Cape Town SOUTH AFRICA Dr Michael Leitzmann Professor of Epidemiology Department of Epidemiology and Preventive Medicine University of Regensburg Regensburg GERMANY Dr Karen Milton Associate Professor in Public Health Norwich Medical School University of East Anglia Norwich UNITED KINGDOM Dr Francisco B. Ortega Head Unit of Physical Activity and Health Promotion Research Institute of Sport and Health (iMUDS) Department of Physical Education and Sports University of Granada Granada SPAIN 88 89Annex 2 Dr Chathuranga Ranasinghe Chairperson NIROGI Lanka project Sri Lanka Medical Association Senior lecturer Sports and Exercise Medicine Unit Faculty of Medicine University of Colombo C Colombo SRI LANKA Dr Emmanuel Stamatakis Charles Perkins Centre Faculty of Medicine and Health School of Public Health University of Sydney Sydney AUSTRALIA Dr Anne Tiedemann Associate Professor Institute for Musculoskeletal Health School of Public Health Faculty of Medicine and Health University of Sydney Sydney AUSTRALIA Dr Richard Troiano Epidemiology and Genomics Research Program National Cancer Institute National Institutes of Health Rockville USA Dr Hidde van der Ploeg Associate Professor Department of Public and Occupational Health Amsterdam Public Health Research Institute Amsterdam University Medical Centres Amsterdam NETHERLANDS Ms Vicky Wari* Programme Manager, NCD National Department of Health Port Moresby PAPUA NEW GUINEA External review group Dr Kingsley Akinroye NCD Alliance Nigeria NIGERIA Dr Huda Alsiyabi Director Department of Community Based Initiatives Ministry of Health OMAN Dr Alberto Flórez-Pregonero Pontificia Universidad Javeriana COLOMBIA Dr Shigeru Inoue Department of Preventive Medicine and Public Health Tokyo Medical University JAPAN Dr Agus Mahendra Department of Physical education Universitas Pendidikan INDONESIA Dr Deborah Salvo Prevention Research Center in St. Louis Brown School Washington University USA Dr Jasper Schipperijn President-Elect 2020–2022 International Society of Physical Activity and Health Department of Sports Science and Clinical Biomechanics University of Southern Denmark DENMARK * unable to attend90 91 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r * unable to attend WHO Steering Group Dr Valentina Baltag Head Adolescent and Young Adult Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND Dr Maurice Bucagu Medical Officer Maternal Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND Dr Alexander Buchart Head Violence Prevention Social Determinants of Health Department WHO Headquarters Geneva SWITZERLAND Dr Fiona Bull Head Physical Activity Department of Health Promotion WHO Headquarters Geneva SWITZERLAND Dr Regina Guthold Scientist Adolescent and Young Adult Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND Dr Riitta-Maija Hämäläinen Technical Officer Noncommunicable Diseases and Health Promotion WHO Regional Office for the Western Pacific Manila PHILIPPINES Dr Andre Ilbawi Technical Officer Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Dr Wasiq Khan* Regional Adviser Health Education and Promotion WHO Regional Office for the Eastern Mediterranean Cairo EGYPT Ms Lindsay Lee Technical Officer Sensory Functions, Disability and Rehabilitation Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Ms Alana Officer Senior Health Adviser Healthy Ageing Office of the Director-General WHO Headquarters Geneva SWITZERLAND Ms Leanne Riley Head Surveillance Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Dr Gojka Roglic Medical Officer Noncommunicable Diseases Management Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Dr Juana Willumsen Technical Officer Physical Activity Department of Health Promotion WHO Headquarters Geneva SWITZERLAND 90 91Annex 2 ANNEX 3: SUMMARY OF DECLARATION OF INTEREST AND HOW THESE WERE MANAGED Guideline Development Group members Name Gender Expertise Disclosure of interest Conflict of interest and management Dr Salih Saad Al-Ansari Male Advocate in health promotion and education to combat NCDs through physical activity and walking Owner and Chief Executive Officer of the Health Promotion Center No conflict of interest identified Dr Stuart Biddle Male Physical activity in youth Research funds and paid consultancy No conflict of interest identified Dr Katja Borodulin Female Physical activity in pregnancy Employment at National Institute for Health and Welfare and Age Institute; research funds No conflict of interest identified Dr Matthew Buman Male Sleep and physical activity in people living with chronic conditions None declared No conflict of interest identified Dr Greet Cardon Female Physical activity in youth None declared No conflict of interest identified Ms Catherine Carty Female Physical activity in people living with disability Research funds No conflict of interest identified Dr Jean-Philippe Chaput Male Sleep None declared No conflict of interest identified Dr Sebastien Chastin Male Physical activity and health, objective measurement of physical activity Research funds No conflict of interest identified Dr Paddy Dempsey Male Physical activity and sedentary behaviour in adults and people living with chronic conditions Employment and research funds No conflict of interest identified Dr Loretta DiPietro Female Physical activity in older adults None declared No conflict of interest identified Dr Ulf Ekelund Male Sedentary behaviour and physical activity in youth None declared No conflict of interest identified Dr Joseph Firth Male Physical activity and mental health None declared No conflict of interest identified Dr Christine Friedenreich Female Physical activity in people living with chronic conditions, physical activity and cancer risk None declared No conflict of interest identified Dr Leandro Garcia Male Physical activity and mental health Employment and paid consultancy No conflict of interest identified Dr Muthoni Gichu Female Policy implementation (national government) None declared No conflict of interest identified Dr Russ Jago Male Physical activity in youth None declared No conflict of interest identified 92 93 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Name Gender Expertise Disclosure of interest Conflict of interest and management Dr Peter Katzmarzyk Male Physical activity and sedentary behaviour in youth Travel support to assist guideline committees No conflict of interest identified Dr Estelle V. Lambert Female Physical activity and obesity None declared No conflict of interest identified Dr Michael Leitzmann Male Sedentary behaviour and chronic conditions None declared No conflict of interest identified Dr Karen Milton Female Translating recommendations into practice Travel support to assist guideline committee No conflict of interest identified Dr Francisco Ortega Male Physical activity in youth, mental health and objective measurement None declared No conflict of interest identified Dr Chathuranga Ranasinghe Male Promotion of physical activity and health in the community, workplace and school settings Research funds No conflict of interest identified Dr Emmanuel Stamatakis Male Physical activity and multiple health outcomes in adults Grant for technology company for objective measurement of physical activity No conflict of interest identified Dr Anne Tiedemann Female Physical activity and health outcomes in older adults None declared No conflict of interest identified Dr Richard Troiano Male Policy development None declared No conflict of interest identified Dr Hidde van der Ploeg Male Physical activity, sedentary behaviour and health outcomes in adults Travel support to assist 2017 Dutch Physical Activity Guidelines committee and research funds No conflict of interest identified Ms Vicky Wari Female Policy implementation (national government) Shares (not relevant to guideline) No conflict of interest identified External peer reviewers Name Gender Expertise Disclosure of interest Conflict of interest and management Kingsley Akinroye Male Advocacy, noncommunicable diseases None declared No conflict of interest identified Dr Huda Alsiyabi Female Policy and programme implementation None declared No conflict of interest identified Dr Alberto Flórez- Pregonero Male Physical activity and sedentary behaviour measurement and surveillance None declared No conflict of interest identified Dr Shigeru Inoue Male Epidemiology and physical activity promotion None declared No conflict of interest identified Dr Agus Mahendra Male Physical activity and movement skills in children None declared No conflict of interest identified Dr Deborah Salvo Female Health and social disparities, with a particular emphasis on chronic disease prevention None declared No conflict of interest identified Dr Jasper Schipperijn Male Physical activity and the built environment President-Elect of the International Society for Physical Activity and Health (ISPAH) No conflict of interest identified 92 93Annex 3 ISBN 978-92-4-001513-52 8

WHO GUIDELINES ON PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOUR

WHO GUIDELINES ON PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOUR WHO guidelines on physical activity and sedentary behaviour ISBN 978-92-4-001512-8 (electronic version) ISBN 978-92-4-001513-5 (print edition) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Design: Eddy Hill Design Printed in Switzerland ii iii W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CONTENTS Acknowledgements iv Abbreviations and acronyms v Glossary of terms vi Executive summary 1 Background 15 Methods 18 Recommendations 24 Children and adolescents (aged 5–17 years) 25 Physical activity recommendation 25 Sedentary behaviour recommendation 29 Adults (aged 18–64 years) 32 Physical activity recommendation 32 Sedentary behaviour recommendation 38 Older adults (aged 65 years and older) 43 Physical activity recommendation 43 Sedentary behaviour recommendation 46 Pregnant and postpartum women 47 Physical activity recommendation 47 Sedentary behaviour recommendation 51 Adults and older adults with chronic  conditions (aged 18 years and older) 52 Physical activity recommendation 52 Sedentary behaviour recommendation 58 Children and adolescents (aged 5–17 years) and adults (aged 18 years and over) living with disability 60 Physical activity recommendation 60 Sedentary behaviour recommendation 64 Evidence to recommendations 66 Assessment of the certainty of evidence 66 Benefits and harms 67 Values and preferences 67 Resource implications 67 Equity, acceptability and feasibility 68 Research needs 69 Adoption, dissemination, implementation and evaluation 70 Adoption 70 Dissemination 71 Communication campaigns 71 Implementation of policy and programmes 72 Surveillance and evaluation 73 Updating 73 References 75 Annex 1: Management of guideline development process 85 Annex 2: Guideline development group, external peer reviewers, and who staff involved in the development of these guidelines 88 Annex 3: Summary of declaration of interest and how these were managed 92 Web Annex: Evidence profiles https://apps.who.int/iris/bitstream/handle/ 10665/336657/9789240015111-eng.pdf ii iiiContents ACKNOWLEDGEMENTS The World Health Organization (WHO) gratefully acknowledges the contribution to and support of the following individuals and organizations in the development of these guidelines: Fiona Bull and Juana Willumsen led the process of developing these guidelines. Valentina Baltag, Maurice Bucagu, Alex Butchart, Neerja Chowdhary, Regina Guthold, Riitta-Maija Hämäläinen, Andre Ilbawi, Wasiq Khan, Lindsay Lee, Alana Officer, Leanne Riley and Gojka Roglic were members of the WHO Steering Group that managed the guideline development process. The members of the Guideline Development Group (GDG) included Salih Saad Al-Ansari, Stuart Biddle, Katja Borodulin, Matthew Buman, Greet Cardon (co-chair), Catherine Carty, Jean-Philippe Chaput, Sebastien Chastin, Paddy Dempsey, Loretta DiPietro, Ulf Ekelund, Joseph Firth, Christine Friedenreich, Leandro Garcia, Muthoni Gichu, Russ Jago, Peter Katzmarzyk, Estelle V. Lambert, Michael Leitzmann, Karen Milton, Francisco B. Ortega, Chathuranga Ranasinghe, Emmanuel Stamatakis (co-chair), Anne Tiedemann, Richard Troiano, Hidde van der Ploeg, Vicky Wari. Roger Chou served as GRADE methodologist. The external review group included Kingsley Akinroye, Huda Alsiyabi, Alberto Flórez-Pregonero, Shigeru Inoue, Agus Mahendra, Deborah Salvo and Jasper Schipperijn. Systematic reviews of evidence prepared for 2018 US Physical Activity Guidelines Advisory Committee Scientific Report to the Secretary of Health and Human Services were updated thanks to additional literature searches conducted by Kyle Sprow (National Cancer Institutes, National Institutes of Health, Maryland, USA). Additional support to review papers identified was provided by Elif Eroglu (University of Sydney), Andrea Hillreiner (University of Regensburg), Bo-Huei Huang (University of Sydney), Carmen Jochem (University of Regensburg), Jairo H. Migueles (University of Granada), Chelsea Stone (University of Calgary) and Léonie Uijtdewilligen (Amsterdam UMC). Summaries of evidence and GRADE tables were prepared by Carrie Patnode and Michelle Henninger (The Kaiser Foundation Hospitals, Center for Health Research, Portland, Oregon, USA). Additional reviews of evidence were conducted by N Fairhall, J Oliveira, M Pinheiro, and C Sherrington (Institute for Musculoskeletal Health, School of Public Health, The University of Sydney, Sydney, Australia) and A Bauman (Prevention Research Collaboration, School of Public Health, The University of Sydney, Sydney, Australia; and WHO Collaborating Centre for Physical Activity, Nutrition and Obesity); S Mabweazara, M-J Laguette, K Larmuth, F Odunitan-Wayas (Research Centre for Health through Physical Activity, Lifestyle and Sports Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa), L Leach, S Onagbiye (Department of Sport, Recreation and Exercise Science, Faculty of Health Sciences, University of the Western Cape, Cape Town, South Africa), M Mthethwa (Chronic Disease Initiative for Africa, University of Cape Town, Cape Town, South Africa), P Smith (The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa) and F Mashili (Department of Physiology, Muhimbili University of Allied Sciences, Dar Es Salaam, United Republic of Tanzania); B Cillekens, M Lang, W van Mechelen, E Verhagen, M Huysmans, A van der Beek, P Coenen (Department of Public and Occupational Health at Amsterdam University Medical Centre, Amsterdam, Netherlands). The Public Health Agency of Canada and the Government of Norway provided financial support, without which this work could not have been completed. iv v W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ADHD attention deficit hyperactive disorder AOR adjusted odds ratio BMI body mass index CI confidence interval CVD cardiovascular disease DBP diastolic blood pressure EtD Evidence to Decisions GDG Guideline Development Group GRADE Grading of Recommendations Assessment, Development and Evaluation HR hazards ratio MET Metabolic Equivalent of Task MD mean difference MICT moderate intensity continuous training NCD noncommunicable disease OR odds ratio PA physical activity PAGAC United States Physical Activity Guidelines Advisory Committee PI/ECO Population, Intervention/Exposure, Comparison, Outcome RaR Relative attributable risk RCT randomized control trial RR relative risk SBP systolic blood pressure SMD standardized mean difference SPPB short physical performance battery TV television WHA World Health Assembly WHO World Health Organization ABBREVIATIONS AND ACRONYMS iv vAbbreviations and acronyms Term Definition Aerobic physical activity Activity in which the body’s large muscles move in a rhythmic manner for a sustained period of time. Aerobic activity – also called endurance activity – improves cardiorespiratory fitness. Examples include walking, running, swimming, and bicycling. Anaerobic physical activity Anaerobic physical activity consists of brief intense bursts of exercise, such as weightlifting and sprints, where oxygen demand surpasses oxygen supply. Balance training Static and dynamic exercises that are designed to improve an individual’s ability to withstand challenges from postural sway or destabilizing stimuli caused by self-motion, the environment, or other objects. Body mass index (BMI) Weight (kg) / height (m)2 BMI-for-age or BMI z-score BMI adjusted for age, standardized for children. BMI standard deviation scores are measures of relative weight adjusted for child age and sex. Given a child’s age, sex, BMI, and an appropriate reference standard, a BMI z-score (or its equivalent BMI-for-age percentile) can be determined. Bone-strengthening activity Physical activity primarily designed to increase the strength of specific sites in bones that make up the skeletal system. Bone-strengthening activities produce an impact or tension force on the bones that promotes bone growth and strength. Running, jumping rope, and lifting weights are examples of bone-strengthening activities. Cardiometabolic health The interplay of blood pressure, blood lipids, blood glucose and insulin on health. Cardiorespiratory fitness (endurance) A health-related component of physical fitness. The ability of the circulatory and respiratory systems to supply oxygen during sustained physical activity. Usually expressed as measured or estimated maximal oxygen uptake (VO2 max). Cognitive function Cerebral activities, i.e. reasoning, memory, attention, and language that lead to the attainment of information and knowledge. This can also include learning. Disability From the International Classification of Functioning, Disability and Health, an umbrella term for impairments, activity limitations, and participation restrictions, denoting the negative aspects of the interaction between an individual (with a health condition) and that individual’s contextual factors (environmental and personal factors). Domains of physical activity Physical activity levels can be assessed in various domains, including one of more of the following: leisure-time, occupation, education, household and/or transportation. Exercise A subcategory of physical activity that is planned, structured, repetitive, and purposeful in the sense that the improvement or maintenance of one or more components of physical fitness is the objective. “Exercise” and “exercise training” frequently are used interchangeably and generally refer to physical activity performed during leisure time with the primary purpose of improving or maintaining physical fitness, physical performance, or health. Executive function Includes constructs such as: working memory, cognitive flexibility (also called flexible thinking) and inhibitory control (which includes self-control). Fitness A measure of the body's ability to function efficiently and effectively in work and leisure activities, and includes, for example, physical fitness and cardiorespiratory fitness. Flexibility A health- and performance-related component of physical fitness that is the range of motion possible at a joint. Flexibility is specific to each joint and depends on a number of specific variables including, but not limited to, the tightness of specific ligaments and tendons. Flexibility exercises enhance the ability of a joint to move through its full range of motion. Functional exercises Exercises that can be embedded into everyday tasks to improve lower-body strength, balance, and motor performance. Examples include tandem and one-leg stands, squatting, chair stands, toe raises, and stepping over obstacles. Household domain physical activity Physical activity undertaken in the home for domestic duties (such as cleaning, caring for children, gardening etc.). Leisure-domain physical activity Physical activity performed by an individual that is not required as an essential activity of daily living and is performed at the discretion of the individual. Such activities include sports participation, exercise conditioning or training, and recreational activities such as going for a walk, dancing, and gardening. GLOSSARY OF TERMS vi vii W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Term Definition Light-intensity physical activity Light-intensity physical activity is between 1.5 and 3 METs, i.e. activities with energy cost less than 3 times the energy expenditure at rest for that person. This can include slow walking, bathing, or other incidental activities that do not result in a substantial increase in heart rate or breathing rate. Major muscle groups Major muscle groups include the legs, back, abdomen, chest, shoulders and arms. Metabolic equivalent of task (MET) The metabolic equivalent of task, or simply metabolic equivalent, is a physiological measure expressing the intensity of physical activities. One MET is the energy equivalent expended by an individual while seated at rest. Moderate-intensity physical activity On an absolute scale, moderate-intensity refers to the physical activity that is performed between 3 and less than 6 times the intensity of rest. On a scale relative to an individual’s personal capacity, moderate-intensity physical activity is usually a 5 or 6 on a scale of 0–10. Muscle-strengthening activity Physical activity and exercise that increase skeletal muscle strength, power, endurance, and mass (e.g. strength training, resistance training, or muscular strength and endurance exercises). Multicomponent physical activity For older adults, multicomponent physical activity is important to improve physical function and decrease the risk of falls or injury from a fall. These activities can be done at home or in a structured group setting. Many studied interventions combine all types of exercise (aerobic, muscle strengthening, and balance training) into a session, and this has been shown to be effective. An example of a multicomponent physical activity programme could include walking (aerobic activity), lifting weights (muscle strengthening), and incorporates balance training. Examples of balance training can include walking backwards or sideways or standing on one foot while doing an upper body muscle-strengthening activity, such as bicep curls. Dancing also combines aerobic and balance components. Occupation domain physical activity See work domain physical activity. Physical activity Any bodily movement produced by skeletal muscles that requires energy expenditure. Physical inactivity An insufficient physical activity level to meet present physical activity recommendations. Psychosocial health Include mental, emotional and social dimensions of health. Recreational screen time Time spent watching screens (television (TV), computer, mobile devices) for purposes other than those related to education/study or work. Sedentary screen time Time spent watching screen-based entertainment (TV, computer, mobile devices). Does not include active screen-based games where physical activity or movement is required. Sedentary behaviour Any waking behaviour characterized by an energy expenditure of 1.5 METS or lower while sitting, reclining, or lying. Most desk-based office work, driving a car, and watching television are examples of sedentary behaviours; these can also apply to those unable to stand, such as wheelchair users. The guidelines operationalize the definition of sedentary behaviour to include self-reported low movement sitting (leisure time, occupational, and total), television (TV viewing or screen time, and low levels of movement measured by devices that assess movement or posture). Sport Sport covers a range of activities performed within a set of rules and undertaken as part of leisure or competition. Sporting activities involve physical activity carried out by teams or individuals and may be supported by an institutional framework, such as a sporting agency. Transport domain physical activity Physical activity performed for the purpose of getting to and from places, and refers to walking, cycling and wheeling (the use of non-motorized means of locomotion with wheels, such as scooters, rollerblades, manual wheelchair etc.). Vigorous-intensity physical activity On an absolute scale, vigorous-intensity refers to physical activity that is performed at 6.0 or more METS. On a scale relative to an individual’s personal capacity, vigorous-intensity physical activity is usually a 7 or 8 on a scale of 0–10. Work domain physical activity Physical activity undertaken during paid or voluntary work. vi viiGlossary of terms The WHO Guidelines on physical activity and sedentary behaviour provide evidence-based public health recommendations for children, adolescents, adults and older adults on the amount of physical activity (frequency, intensity and duration) required to offer significant health benefits and mitigate health risks. For the first time, recommendations are provided on the associations between sedentary behaviour and health outcomes, as well as for subpopulations, such as pregnant and postpartum women, and people living with chronic conditions or disability. The guidelines are intended for policy-makers in high-, middle-, and low-income countries in ministries of health, education, youth, sport and/or social or family welfare; government officials responsible for developing national, sub regional or municipal plans to increase physical activity and reduce sedentary behaviour in population groups through guidance documents; people working in nongovernmental organizations, the education sector, private sector, research; and health- care providers. The guidelines were prepared in accordance with the WHO handbook for guideline development. Systematic reviews of evidence were conducted for the critical and important outcomes, and recommendations were developed after consideration of the benefits and harms, values, preferences, feasibility and acceptability, and the implications for equity and resources. The final public health recommendations presented are for all populations and age groups ranging from 5 years to 65 years and older, irrespective of gender, cultural background or socioeconomic status, and are relevant for people of all abilities. Those with chronic medical conditions and/or disability and pregnant and postpartum women should try to meet the recommendations where possible and as able. The development of these guidelines provide a set of evidence-based recommendations that governments can adopt as part of their national policy frameworks to support comprehensive approaches to increasing population levels of physical activity. Within the adoption process, consideration should be given to the need to contextualize the guidelines. Practical tools to support adoption, dissemination, communication campaigns and implementation of the guidelines will support governments and stakeholders work together to increase physical activity and reduce sedentary behaviours across the life course. These supporting resources will be available through the WHO website following publication of the guidelines Despite the large quantity of supporting data relating physical activity and, increasingly, sedentary behaviours to health outcomes across the life-span, important evidence gaps remain. In particular, there is less evidence from low- and middle-income countries and economically disadvantaged or underserved communities, and a dearth of evidence from subpopulations including people living with disabilities. Investment in more research is needed to build evidence particularly in these areas. In addition, the changes introduced to these recommendations will have some implications for surveillance systems and assessment instruments currently used to monitor national levels of physical activity. Existing global and national instruments should be reviewed, and reporting protocols updated, to inform future reporting against the new guidelines. The Global action plan on physical activity 2018–2030 set a target to reduce physical inactivity by 15% by 2030, and outlined 20 recommended policy actions and interventions. These guidelines support all countries to implement the GAPPA recommendations and “ACTIVE”, the technical package of toolkits that provides guidance on how to promote physical activity across the life course and through multiple settings. EXECUTIVE SUMMARY viii 1 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CHILDREN AND ADOLESCENTS (aged 5–17 years) It is recommended that: Children and adolescents should do at least an average of 60 minutes per day of moderate- to vigorous-intensity, mostly aerobic, physical activity, across the week. Strong recommendation, moderate certainty evidence Vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone, should be incorporated at least 3 days a week. Strong recommendation, moderate certainty evidence • Doing some physical activity is better than doing none. • If children and adolescents are not meeting the recommendations, doing some physical activity will benefit their health. • Children and adolescents should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • It is important to provide all children and adolescents with safe and equitable opportunities, and encouragement, to participate in physical activities that are enjoyable, offer variety, and are appropriate for their age and ability. G O O D P R A C TI C E ST A TE M EN TS In children and adolescents, physical activity confers benefits for the following health outcomes: improved physical fitness (cardiorespiratory and muscular fitness), cardiometabolic health (blood pressure, dyslipidaemia, glucose, and insulin resistance), bone health, cognitive outcomes (academic performance, executive function), mental health (reduced symptoms of depression); and reduced adiposity. In children and adolescents, higher amounts of sedentary behaviour are associated with the following poor health outcomes: increased adiposity; poorer cardiometabolic health, fitness, behavioural conduct/pro-social behaviour; and reduced sleep duration. It is recommended that: Children and adolescents should limit the amount of time spent being sedentary, particularly the amount of recreational screen time. Strong recommendation, low certainty evidence 1 GRADE: Grading of Recommendations Assessment Development and Evaluation Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf INTRODUCTION Regular physical activity is a key protective factor for the prevention and management of noncommunicable diseases (NCDs) such as cardiovascular disease, type-2 diabetes, and a number of cancers. Physical activity also benefits mental health, including prevention of cognitive decline and symptoms of depression and anxiety; and can contribute to the maintenance of healthy weight and general well-being. Global estimates indicate that 27.5% of adults (1) and 81% of adolescents (2) do not meet the 2010 WHO recommendations for physical activity (3) with almost no improvements seen during the past decade. There are also notable inequalities: data show that in most countries girls and women are less active than boys and men, and that there are significant differences in levels of physical activity between higher and lower economic groups, and between countries and regions. SCOPE The WHO Guidelines on physical activity and sedentary behaviour provide evidence-based public health recommendations for children, adolescents, adults and older adults on the amount of physical activity (frequency, intensity and duration) required to offer significant health benefits and mitigate health risks. For the first time, recommendations are provided on the associations between sedentary behaviour and health outcomes, as well as for subpopulations, such as pregnant and postpartum women, and people living with chronic conditions or disability. TARGET AUDIENCE The guidelines are intended for policy-makers in high-, middle-, and low-income countries in ministries of health, education, youth, sport and/or social or family welfare; government officials responsible for developing national, sub regional or municipal plans to increase physical activity and reduce sedentary behaviour in population groups through guidance documents; people working in nongovernmental organizations, the education sector, private sector, research; and health-care providers. DEVELOPMENT PROCESS The guidelines were prepared in accordance with the WHO handbook for guideline development (4). In 2019 a Guideline Development Group (GDG) was formed comprising technical experts and relevant stakeholders from all six WHO regions. The group met in July 2019 to formulate the key questions, review the evidence-bases, and agree the methods for updates of literature, and, where needed, for additional new reviews. In February 2020, the GDG met again to review the evidence for the critical and important outcomes, consider the benefits and harms, values, preferences, feasibility and acceptability, and the implications for equity and resources. The recommendations were developed through consensus and posted online for public consultation. The final updated recommendations are summarized below. The GRADE 1 tables and evidence profiles are available as a Web annex . Practical tools to support adoption, dissemination, communication campaigns and implementation of the guidelines will support governments and stakeholders work together to increase physical activity and reduce sedentary behaviours across the life course. RECOMMENDATIONS The public health recommendations presented in the WHO Guidelines on physical activity and sedentary behaviour are for all populations and age groups ranging from 5 years to 65 years and older, irrespective of gender, cultural background or socioeconomic status, and are relevant for people of all abilities. Those with chronic medical conditions and/or disability and pregnant and postpartum women should try to meet the recommendations where possible and as able. LIMIT the amount of time spent being sedentary, particularly recreational screen time. 3 vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated. On at least days a week 60 moderate- to vigorous-intensity physical activity across the week; most of this physical activity should be aerobic. minutes a day At least 2 3 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendationsviii 1Executive summary It is recommended that: Adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, moderate certainty evidence It is recommended that: All adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults should do at least 150– 300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence ADULTS (aged 18–64 years) ADULTS (aged 18–64 years) 2 Site-specific cancers of: bladder, breast, colon, endometrial, oesophageal adenocarcinoma, gastric, and renal. • Doing some physical activity is better than doing none. • If adults are not meeting these recommendations, doing some physical activity will benefit their health. • Adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. G O O D P R A C TI C E ST A TE M EN TS In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and type-2 diabetes. In adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site-specific cancers, 2 incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression); cognitive health, and sleep; measures of adiposity may also improve. Adults may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence Adults should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 4 5 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations 1 1 2 3 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r It is recommended that: Adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, moderate certainty evidence It is recommended that: All adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults should do at least 150– 300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence ADULTS (aged 18–64 years) ADULTS (aged 18–64 years) 2 Site-specific cancers of: bladder, breast, colon, endometrial, oesophageal adenocarcinoma, gastric, and renal. • Doing some physical activity is better than doing none. • If adults are not meeting these recommendations, doing some physical activity will benefit their health. • Adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. G O O D P R A C TI C E ST A TE M EN TS In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and type-2 diabetes. In adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site-specific cancers, 2 incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression); cognitive health, and sleep; measures of adiposity may also improve. Adults may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence Adults should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 4 5 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations2 3Executive summary It is recommended that: All older adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Older adults should do at least 150– 300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence OLDER ADULTS (aged 65 years and older) OLDER ADULTS (aged 65 years and older) • Doing some physical activity is better than doing none. • If older adults are not meeting the recommendations, doing some physical activity will bring benefits to health. • Older adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • Older adults should be as physically active as their functional ability allows, and adjust their level of effort for physical activity relative to their level of fitness. G O O D P R A C TI C E ST A TE M EN TS In older adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Older adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, older adults should aim to do more than the recommended levels of moderate- to vigorous- intensity physical activity. Strong recommendation, moderate certainty evidence In older adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site-specific cancers, incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression), cognitive health, and sleep; measures of adiposity may also improve. In older adults, physical activity helps prevent falls and falls-related injuries and declines in bone health and functional ability. Older adults may increase moderate- intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week, for additional health benefits. Conditional recommendation, moderate certainty evidence Older adults should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence As part of their weekly physical activity, older adults should do varied multicomponent physical activity that emphasizes functional balance 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 LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 6 7 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations4 5 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r It is recommended that: All older adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Older adults should do at least 150– 300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence OLDER ADULTS (aged 65 years and older) OLDER ADULTS (aged 65 years and older) • Doing some physical activity is better than doing none. • If older adults are not meeting the recommendations, doing some physical activity will bring benefits to health. • Older adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • Older adults should be as physically active as their functional ability allows, and adjust their level of effort for physical activity relative to their level of fitness. G O O D P R A C TI C E ST A TE M EN TS In older adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Older adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, older adults should aim to do more than the recommended levels of moderate- to vigorous- intensity physical activity. Strong recommendation, moderate certainty evidence In older adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site-specific cancers, incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression), cognitive health, and sleep; measures of adiposity may also improve. In older adults, physical activity helps prevent falls and falls-related injuries and declines in bone health and functional ability. Older adults may increase moderate- intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week, for additional health benefits. Conditional recommendation, moderate certainty evidence Older adults should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence As part of their weekly physical activity, older adults should do varied multicomponent physical activity that emphasizes functional balance 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 LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 6 7 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations4 5Executive summary In pregnant and postpartum women, physical activity during pregnancy and postpartum confers benefits on the following maternal and fetal health benefits: decreased risk of pre-eclampsia, gestational hypertension, gestational diabetes, excessive gestational weight gain, delivery complications and postpartum depression, and fewer newborn complications, no adverse effects on birthweight; and no increase in risk of stillbirth. It is recommended that all pregnant and postpartum women without contraindication should: Undertake regular physical activity throughout pregnancy and postpartum. Strong recommendation, moderate certainty evidence In addition: Women who, before pregnancy, habitually engaged in vigorous- intensity aerobic activity, or who were physically active, can continue these activities during pregnancy and the postpartum period. Strong recommendation, moderate certainty evidence Do at least 150 minutes of moderate- intensity aerobic physical activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence Incorporate a variety of aerobic and muscle- strengthening activities. Adding gentle stretching may also be beneficial. Strong recommendation, moderate certainty evidence PREGNANT AND POSTPARTUM WOMEN PREGNANT AND POSTPARTUM WOMEN G O O D P R A C TI C E ST A TE M EN TS • Doing some physical activity is better than doing none. • If pregnant and postpartum women are not meeting the recommendations, doing some physical activity will benefit their health. • Pregnant and postpartum women should start by doing small amounts of physical activity, and gradually increase frequency, intensity and duration over time. • Pelvic floor muscle training may be performed on a daily basis to reduce the risk of urinary incontinence. • Avoid physical activity during excessive heat, especially with high humidity. • Stay hydrated by drinking water before, during, and after physical activity. • 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 high altitude). • Avoid activities in supine position after the first trimester of pregnancy. • When considering athletic competition, or exercising significantly above the recommended guidelines pregnant women should seek supervision from a specialist health-care provider. • Pregnant women should be informed by their health-care provider of the danger signs alerting them as to when to stop; or to limit physical activity and consult a qualified health-care provider immediately should they occur. • Return to physical activity gradually after delivery, and in consultation with a health-care provider, in the case of delivery by Caesarean section. Additional safety considerations for pregnant women when undertaking physical activity are: In pregnant and postpartum women, as in all adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Pregnant and postpartum women should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence Doing some physical activity is better than doing none. LIMIT REPLACE the amount of time spent being sedentary with physical activity of any intensity (including light intensity). 150 moderate-intensity aerobic physical activity At least minutes a week 8 9 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations6 7 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r In pregnant and postpartum women, physical activity during pregnancy and postpartum confers benefits on the following maternal and fetal health benefits: decreased risk of pre-eclampsia, gestational hypertension, gestational diabetes, excessive gestational weight gain, delivery complications and postpartum depression, and fewer newborn complications, no adverse effects on birthweight; and no increase in risk of stillbirth. It is recommended that all pregnant and postpartum women without contraindication should: Undertake regular physical activity throughout pregnancy and postpartum. Strong recommendation, moderate certainty evidence In addition: Women who, before pregnancy, habitually engaged in vigorous- intensity aerobic activity, or who were physically active, can continue these activities during pregnancy and the postpartum period. Strong recommendation, moderate certainty evidence Do at least 150 minutes of moderate- intensity aerobic physical activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence Incorporate a variety of aerobic and muscle- strengthening activities. Adding gentle stretching may also be beneficial. Strong recommendation, moderate certainty evidence PREGNANT AND POSTPARTUM WOMEN PREGNANT AND POSTPARTUM WOMEN G O O D P R A C TI C E ST A TE M EN TS • Doing some physical activity is better than doing none. • If pregnant and postpartum women are not meeting the recommendations, doing some physical activity will benefit their health. • Pregnant and postpartum women should start by doing small amounts of physical activity, and gradually increase frequency, intensity and duration over time. • Pelvic floor muscle training may be performed on a daily basis to reduce the risk of urinary incontinence. • Avoid physical activity during excessive heat, especially with high humidity. • Stay hydrated by drinking water before, during, and after physical activity. • 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 high altitude). • Avoid activities in supine position after the first trimester of pregnancy. • When considering athletic competition, or exercising significantly above the recommended guidelines pregnant women should seek supervision from a specialist health-care provider. • Pregnant women should be informed by their health-care provider of the danger signs alerting them as to when to stop; or to limit physical activity and consult a qualified health-care provider immediately should they occur. • Return to physical activity gradually after delivery, and in consultation with a health-care provider, in the case of delivery by Caesarean section. Additional safety considerations for pregnant women when undertaking physical activity are: In pregnant and postpartum women, as in all adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Pregnant and postpartum women should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence Doing some physical activity is better than doing none. LIMIT REPLACE the amount of time spent being sedentary with physical activity of any intensity (including light intensity). 150 moderate-intensity aerobic physical activity At least minutes a week 8 9 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations6 7Executive summary Adults and older adults with chronic conditions should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults and older adults with chronic conditions should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence For cancer survivors, and adults living with hypertension, type-2 diabetes and HIV, it is recommended that: It is recommended that: All adults and older adults with the above chronic conditions should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults and older adults with these chronic conditions should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence When not contraindicated, adults and older adults with these chronic conditions may increase moderate- intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence As part of their weekly physical activity, older adults with these chronic conditions should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence Adults and older adults with these chronic conditions should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional benefits. Strong recommendation, moderate certainty evidence ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) Physical activity can confer health benefits for adults and older adults living with the following chronic conditions: for cancer survivors – physical activity improves all-cause mortality, cancer-specific mortality, and risk of cancer recurrence or second primary cancer; for people living with hypertension – physical activity improves cardiovascular disease mortality, disease progression, physical function, health-related quality of life; for people living with type-2 diabetes – physical activity reduces rates of mortality from cardiovascular disease and indicators disease progression; and for people living with HIV – physical activity can improve physical fitness and mental health (reduced symptoms of anxiety and depression), and does not adversely affect disease progression (CD4 count and viral load) or body composition. G O O D P R A C TI C E ST A TE M EN TS • When not able to meet the above recommendations, adults with these chronic conditions should aim to engage in physical activity according to their abilities. • Adults with these chronic conditions should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • Adults with these chronic conditions may wish to consult with a physical activity specialist or health-care professional for advice on the types and amounts of activity appropriate for their individual needs, abilities, functional limitations/complications, medications, and overall treatment plan. • Pre-exercise medical clearance is generally unnecessary for individuals without contraindications prior to beginning light- or moderate-intensity physical activity not exceeding the demands of brisk walking or everyday living. In adults, including cancer survivors and people living with hypertension, type-2 diabetes and HIV, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 150 300 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 150 10 11 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations8 9 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Adults and older adults with chronic conditions should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults and older adults with chronic conditions should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence For cancer survivors, and adults living with hypertension, type-2 diabetes and HIV, it is recommended that: It is recommended that: All adults and older adults with the above chronic conditions should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults and older adults with these chronic conditions should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence When not contraindicated, adults and older adults with these chronic conditions may increase moderate- intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence As part of their weekly physical activity, older adults with these chronic conditions should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence Adults and older adults with these chronic conditions should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional benefits. Strong recommendation, moderate certainty evidence ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) Physical activity can confer health benefits for adults and older adults living with the following chronic conditions: for cancer survivors – physical activity improves all-cause mortality, cancer-specific mortality, and risk of cancer recurrence or second primary cancer; for people living with hypertension – physical activity improves cardiovascular disease mortality, disease progression, physical function, health-related quality of life; for people living with type-2 diabetes – physical activity reduces rates of mortality from cardiovascular disease and indicators disease progression; and for people living with HIV – physical activity can improve physical fitness and mental health (reduced symptoms of anxiety and depression), and does not adversely affect disease progression (CD4 count and viral load) or body composition. G O O D P R A C TI C E ST A TE M EN TS • When not able to meet the above recommendations, adults with these chronic conditions should aim to engage in physical activity according to their abilities. • Adults with these chronic conditions should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • Adults with these chronic conditions may wish to consult with a physical activity specialist or health-care professional for advice on the types and amounts of activity appropriate for their individual needs, abilities, functional limitations/complications, medications, and overall treatment plan. • Pre-exercise medical clearance is generally unnecessary for individuals without contraindications prior to beginning light- or moderate-intensity physical activity not exceeding the demands of brisk walking or everyday living. In adults, including cancer survivors and people living with hypertension, type-2 diabetes and HIV, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 150 300 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 150 10 11 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations8 9Executive summary CHILDREN AND ADOLESCENTS (aged 5–17 years) LIVING WITH DISABILITY CHILDREN AND ADOLESCENTS (aged 5–17 years) LIVING WITH DISABILITY Many of the health benefits of physical activity for children and adolescents, as set out in the section above, also relate to those children and adolescents living with disability. Additional benefits of physical activity to health outcomes for those living with disability include: improved cognition in individuals with diseases or disorders that impair cognitive function, including attention-deficit/ hyperactivity disorder (ADHD); improvements in physical function may occur in children with intellectual disability. • Doing some physical activity is better than doing none. • If children and adolescents living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Children and adolescents living with disability should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • There are no major risks for children and adolescents living with disability engaging in physical activity when it is appropriate to an individual’s current activity level, health status and physical function; and the health benefits accrued outweigh the risks. • Children and adolescents living with disability may need to consult a health-care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. G O O D P R A C TI C E ST A TE M EN TS In children and adolescents, higher amounts of sedentary behaviour are associated with the following poor health outcomes: increased adiposity; poorer cardiometabolic health, fitness, and behavioural conduct/pro-social behaviour; and reduced sleep duration. It is recommended that: Children and adolescents living with disability should limit the amount of time spent being sedentary, particularly the amount of recreational screen time. Strong recommendation, low certainty evidence It is recommended that: Children and adolescents living with disability should do at least an average of 60 minutes per day of moderate- to vigorous- intensity, mostly aerobic, physical activity, across the week. Strong recommendation, moderate certainty evidence Vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated at least 3 days a week. Strong recommendation, moderate certainty evidence Doing some physical activity is better than doing none. Start by doing small amounts of physical activity. 60 moderate- to vigorous-intensity physical activity across the week; most of this physical activity should be aerobic. At least minutes a day 3 vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated. On at least days a week LIMIT the amount of time spent being sedentary, particularly recreational screen time. 12 13 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations0 1 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CHILDREN AND ADOLESCENTS (aged 5–17 years) LIVING WITH DISABILITY CHILDREN AND ADOLESCENTS (aged 5–17 years) LIVING WITH DISABILITY Many of the health benefits of physical activity for children and adolescents, as set out in the section above, also relate to those children and adolescents living with disability. Additional benefits of physical activity to health outcomes for those living with disability include: improved cognition in individuals with diseases or disorders that impair cognitive function, including attention-deficit/ hyperactivity disorder (ADHD); improvements in physical function may occur in children with intellectual disability. • Doing some physical activity is better than doing none. • If children and adolescents living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Children and adolescents living with disability should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • There are no major risks for children and adolescents living with disability engaging in physical activity when it is appropriate to an individual’s current activity level, health status and physical function; and the health benefits accrued outweigh the risks. • Children and adolescents living with disability may need to consult a health-care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. G O O D P R A C TI C E ST A TE M EN TS In children and adolescents, higher amounts of sedentary behaviour are associated with the following poor health outcomes: increased adiposity; poorer cardiometabolic health, fitness, and behavioural conduct/pro-social behaviour; and reduced sleep duration. It is recommended that: Children and adolescents living with disability should limit the amount of time spent being sedentary, particularly the amount of recreational screen time. Strong recommendation, low certainty evidence It is recommended that: Children and adolescents living with disability should do at least an average of 60 minutes per day of moderate- to vigorous- intensity, mostly aerobic, physical activity, across the week. Strong recommendation, moderate certainty evidence Vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated at least 3 days a week. Strong recommendation, moderate certainty evidence Doing some physical activity is better than doing none. Start by doing small amounts of physical activity. 60 moderate- to vigorous-intensity physical activity across the week; most of this physical activity should be aerobic. At least minutes a day 3 vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated. On at least days a week LIMIT the amount of time spent being sedentary, particularly recreational screen time. 12 13 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations0 1Executive summary It is recommended that: Adults living with disability should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults living with disability should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence It is recommended that: All adults living with disability should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults living with disability should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence Adults living with disability should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence ADULTS (aged 18 years and older) LIVING WITH DISABILITY ADULTS (aged 18 years and older) LIVING WITH DISABILITY Many of the health benefits of physical activity for adults, as set out in the section above, also relate to adults living with disability. Additional benefits of physical activity to health outcomes for those living with disability include the following: for adults with multiple sclerosis – improved physical function, and physical, mental, and social domains of health-related quality of life; for individuals with spinal cord injury – improved walking function, muscular strength, and upper extremity function; and enhanced health-related quality of life; for individuals with diseases or disorders that impair cognitive function – improved physical function and cognition (in individuals with Parkinson’s disease and those with a history of stroke); beneficial effects on cognition; and may improve quality of life (in adults with schizophrenia); and may improve physical function (in adults with intellectual disability); and improves quality of life (in adults with major clinical depression). In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and type-2 diabetes. Adults living with disability may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence As part of their weekly physical activity, older adults living with disability should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence G O O D P R A C TI C E ST A TE M EN TS • Doing some physical activity is better than doing none. • If adults living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Adults living with disability should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • There are no major risks to adults living with disability engaging in physical activity when it is appropriate to the individual’s current activity level, health status and physical function; and when the health benefits accrued outweigh the risks. • Adults living with disability may need to consult a health- care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 300 150 minutes moderate-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: vigorous- intensity aerobic physical activity For additional health benefits: 2 days a week On at least muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups. 14 15 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations2 3 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r It is recommended that: Adults living with disability should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults living with disability should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence It is recommended that: All adults living with disability should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults living with disability should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence Adults living with disability should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence ADULTS (aged 18 years and older) LIVING WITH DISABILITY ADULTS (aged 18 years and older) LIVING WITH DISABILITY Many of the health benefits of physical activity for adults, as set out in the section above, also relate to adults living with disability. Additional benefits of physical activity to health outcomes for those living with disability include the following: for adults with multiple sclerosis – improved physical function, and physical, mental, and social domains of health-related quality of life; for individuals with spinal cord injury – improved walking function, muscular strength, and upper extremity function; and enhanced health-related quality of life; for individuals with diseases or disorders that impair cognitive function – improved physical function and cognition (in individuals with Parkinson’s disease and those with a history of stroke); beneficial effects on cognition; and may improve quality of life (in adults with schizophrenia); and may improve physical function (in adults with intellectual disability); and improves quality of life (in adults with major clinical depression). In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and type-2 diabetes. Adults living with disability may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence As part of their weekly physical activity, older adults living with disability should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence G O O D P R A C TI C E ST A TE M EN TS • Doing some physical activity is better than doing none. • If adults living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Adults living with disability should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • There are no major risks to adults living with disability engaging in physical activity when it is appropriate to the individual’s current activity level, health status and physical function; and when the health benefits accrued outweigh the risks. • Adults living with disability may need to consult a health- care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 300 150 minutes moderate-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: vigorous- intensity aerobic physical activity For additional health benefits: 2 days a week On at least muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups. 14 15 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations2 3Executive summary 14 15 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Regular physical activity is a known protective factor for the prevention and management of noncommunicable diseases such as cardiovascular disease, type-2 diabetes, breast and colon cancer (1–3). Physical activity also has benefits for mental health (4), delays the onset of dementia (5), and can contribute to the maintenance of healthy weight (1) and general well-being (6). Physical activity is defined as any bodily movement produced by skeletal muscles that requires energy expenditure (1) and can be performed at a variety of intensities, as part of work, domestic chores, transportation or during leisure time, or when participating in exercise or sports activities. At the low end of the intensity range, sedentary behaviour is defined as any waking behaviour while in a sitting, reclining or lying posture with low energy expenditure (7). Emerging new evidence indicates that high levels of sedentary behaviour are associated with cardiovascular disease and type-2 diabetes as well as cardiovascular, cancer and all-cause mortality (8–10). Physical inactivity is defined as not meeting the 2010 Global recommendations on physical activity for health (1) and is a leading contributor to global mortality. It is estimated that between four and five million deaths per year could be averted if the global population was more active (2, 11). Global estimates of physical inactivity indicate that in 2016, 27.5% of adults (12) and 81% of adolescents (13) did not meet the 2010 WHO recommendations (1), and trend data show limited global improvement during the past decade. The data also highlight that women are less active than men in most countries and that there are significant differences in levels of physical activity within and between countries and regions. These differences can be explained by inequities in access to opportunities to be physically active, further amplifying inequalities in health. Currently, there are no global estimates of sedentary behaviour, but technological innovation and the transition towards more sedentary occupations and recreation, and the increasing use of personal motorized transportation are contributing to changing patterns of physical activity and increased sedentary behaviour across the world. The Global action plan on physical activity 2018–2030 (14) sets out 4 strategic objectives and 20 policy actions to achieve a 15% relative reduction in the global prevalence of physical inactivity in adults and adolescents by 2030. In 2010, WHO published the Global recommendations on physical activity for health (1), the first population-based public health guidelines for children and adolescents, adults and older adults. In 2018, the World Health Assembly, in resolution WHA71.6, 1 called for WHO to update the 2010 recommendations. In 2019, WHO published Guidelines on physical activity, sedentary behaviour and sleep for children under 5 years of age (15). The guidelines were called for by the Commission on Ending Childhood Obesity (recommendation 4.12) (16), and address the omission of this younger age group in the 2010 Global recommendations on physical activity for health (1). The 2020 WHO Guidelines on physical activity and sedentary behaviour, replace the 2010 guidelines and are based on the most recent advances in the evidence for the selected behaviours and associated health consequences. They will form part of the overall set of global recommendations on physical activity and sedentary behaviour. BACKGROUND 1 WHA71.6 WHO Global Action Plan on Physical Activity 2018–2030. 14 15Background OTHER KEY WHO GUIDELINES The importance of physical activity for health is recognized in other WHO guidelines. The WHO Package of essential noncommunicable disease interventions for primary health care in low-resource settings (17) provides a protocol for the clinical management of hypertension, type-2 diabetes, raised cardiovascular risk, asthma, and chronic obstructive pulmonary disease, and includes counselling to progressively increase physical activity to moderate levels (such as brisk walking) and at least 150 minutes per week, in line with the 2010 global recommendations. Recent WHO guidance in Risk reduction of cognitive decline and dementia (18) states that physical activity should be recommended to adults with normal cognition (strong recommendation) and those with mild cognitive impairment (conditional recommendation) to reduce the risk of cognitive decline. WHO Integrated care for older people: guidelines on community-level interventions to manage declines in intrinsic capacity (19) recommend multimodal exercises to prevent falls, and exercises for older adults with declining mobility. WHO recommendations on antenatal care for a positive pregnancy experience (20) recommend counselling on healthy eating and being physically active during pregnancy to stay healthy and to prevent excessive weight gain, but do not address the wider health benefits of physical activity during pregnancy and the postpartum period. The existing WHO guidelines, combined with these updated guidelines, provide an increasingly comprehensive set of global guidance on the contribution of physical activity and sedentary behaviours to the prevention and management of key diseases and to the promotion of health and well-being across the life course. RATIONALE AND PURPOSE The past 10 years has seen a significant increase in the body of evidence on the health impact of different types, amounts and durations of physical activity, as well as on the impact of sedentary behaviours and its interrelationship with levels of physical activity and health. In addition, the evidence base for physical activity in subpopulations, such as pregnant women and those living with chronic conditions and/or disability now permits the examination of the relationship between physical activity and health outcomes in these groups. In the Global action plan on physical activity 2018–2030 (14), action 4.1 calls for WHO to develop and disseminate global recommendations for physical activity and sedentary behaviours in children under 5 years of age, young people, adults, older adults and specific subpopulations, such as pregnant women, people living with chronic conditions and disability. Updating and broadening the scope of the guidelines, as requested by the World Health Assembly, ensures that population groups not included in the 2010 recommendations are provided with specific recommendations for physical activity. This aligns with the key principles and goals of the global action plan on physical activity, namely to reduce inequalities and to support all people to be more physically active every day. The overarching purpose of these guidelines is to provide evidence-based public health recommendations on how much and what type of physical activity children and adolescents, adults, older adults and subpopulations such as pregnant women and those living with chronic conditions or disability, should do for significant health benefits and mitigation of health risks. The guidelines also provide evidence- based recommendations on the associations between sedentary behaviour and health outcomes. 16 17 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r The guidelines have been developed for children and adolescents (aged 5–17 years), adults (aged 18–64 years), older adults (aged 65 years and above), and include for the first time specific recommendations on physical activity for subpopulations such as pregnant women and those living with chronic conditions or disability. Recommendations are made for each specific age group and subpopulation, to provide those working with particular communities easy access to the relevant information. Providing separate recommendations for subpopulations, especially people living with chronic conditions or with disability, highlights the importance of including these subpopulations in policy and planning of physical activity and sedentary behaviour interventions. These guidelines do not address sleep as a behaviour. Sleep is an important health-related issue and an emerging topic within population health science. However, it was deemed beyond the scope of the mandate to include sleep in the updated recommendations. Nonetheless, the importance of sleep is recognized and was included as an important health outcome when considering the impact of physical activity and sedentary behaviour. TARGET AUDIENCE This document reports the process and summarizes the evidence-base reviewed to develop the recommendations. The primary audiences are: 1. Policy-makers in ministries of health, education, youth, sport and/or social or family welfare, working in high as well as low- and middle-income countries, who formulate country-specific guidelines, and who plan health, education, workplace, residential or community-based intervention programmes across the life course. 2. Government officials who develop national, subregional or municipal plans to increase physical activity and reduce sedentary behaviours in population groups through guidance documents. 3. Persons working in nongovernmental organizations, education and workplace organizations or research. 4. Persons working in health services and those providing advice and guidance, such as community, family, primary or tertiary nurses or doctors, or allied health and exercise professionals working beyond the health sector. These guidelines can inform the content of their advice on these topics, if national guidance is not available. The recommendations on physical activity and sedentary behaviour contained within the guidelines should be used to inform pre-service training and professional development courses for health-care workers, physical activity specialists and education professionals. Derivative products are needed that convey these guidelines to specific end-users, stakeholders in sectors outside of health, and the wider community, that use tailored communications to meet the specific needs of each audience. 16 17Background These guidelines were developed in accordance with the WHO Handbook for guideline development (2nd edition) (21). A WHO Steering Group, led by the Department of Health Promotion, was established, with representation from WHO regional offices and relevant WHO departments. A Guideline Development Group (GDG) was formed, consisting of 27 experts and stakeholders, taking into account gender balance and geographical diversity. The draft guidelines were externally reviewed by seven independent reviewers, who provided feedback on the scientific evidence, its interpretation and content. In addition, an online public consultation was conducted on the draft guidelines, and feedback was received from over 400 contributors. These inputs from scientists, practitioners and the general public were collated and used by the GDG to finalize the guidelines. Full details of the management of the guideline development process are available in Annex 1. SCOPE OF GUIDELINES AND QUESTIONS OF INTEREST The GDG reviewed the scope of the guidelines and, at their first meeting, agreed on the most relevant PI/ ECO (Population, Intervention/Exposure, Comparison, Outcome) questions. The key questions addressed for each subpopulation are summarized as follows: For physical activity: a. What is the association between physical activity and health-related outcomes? b. Is there a dose-response association (volume, duration, frequency, intensity)? c. Does the association vary by type or domain of physical activity? For sedentary behaviour: a. What is the association between sedentary behaviour and health-related outcomes? b. Is there a dose-response association (total volume, frequency, duration and intensity of interruption)? c. Does the association vary by type and domain of sedentary behaviour? d. In adults only: Does physical activity modify the effect of sedentary behaviour on mortality? For each population (P), the exposure (E) was greater volume, duration, frequency or intensity of physical activity; for, as comparison (C) no physical activity or lesser volume, frequency, intensity or duration of physical activity. The critical and important outcomes for each population are summarized in Table 1 and the details of each PI/ECO question in the relevant section of the Web Annex: Evidence profiles . METHODS Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 18 19 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Table 1: Summary of critical and important* health outcomes addressed by population groups Outcomes (in alphabetical order) Children and adolescents aged 5–17 years: PA and sedentary Adults aged 18–64 years: PA Adults aged over 18 years: sedentary Adults aged over 65 years: PA a Pregnancy and postpartum Chronic conditions b Children and adults with disability c Adiposity (weight gain, weight change, weight control, weight stability, weight status and weight maintenance) Critical Critical Critical Critical a Critical Critical – HIV – Adverse events Critical Critical – Critical a Critical (fetal outcomes) – – All-cause and cause-specific mortality – Critical (cancer and CVD specific) Critical Critical a – Critical – Bone health Critical – Important – – – – Cardiometabolic health Critical – – – – – – Cognitive outcomes Critical Critical Important Critical a – – Critical – MS, PD, Stk, Sch, ADHD Delivery complications – – – – Important – – Disease progression – – – – – Critical – HT, T2D, HIV, Critical – cancer recurrence – Falls and fall-related injuries – – – Critical – – – Fetal outcomes (birthweight, preterm birth) – – – – Critical – – Functional ability – – – Critical – – – Gestational diabetes mellitus – – – – Critical – – Gestational hypertension/ preeclampsia – – – – Critical – – Health-related quality of life – Important Important Important a – Critical – HT, T2D, HIV Critical – MS, SCI, ID, MCD, Sch Incidence of cancer – Critical Critical Critical a – – – Incidence of CVD – Critical Critical Critical a – – – Incidence of hypertension – Important Important a – – – Incidence of type-2 diabetes – Critical Critical Critical a – – – Mental health (symptoms of anxiety and depression) Critical Critical Important Critical a Critical – – Osteoporosis – – – Critical – – – Physical fitness Critical – Important – – – – Physical function – – Important – – Critical – HT, T2D, HIV Critical – MS, SCI, ID, PD, Stk Pro-social behaviour Important – – – – – – Psychosocial outcomes – – – Important – – – Risk of co-morbid conditions – – – – – Critical – HT, T2D, HIV Critical – MS, SCI, ID Sleep Important Important Important Important a – – – * Critical outcome: an outcome that is critical to decision-making; Important outcome: an outcome that is important, but not critical to decision-making. a The critical and important outcomes considered for the adult population, including older adults. b Outcomes are for subpopulation condition as listed: Cancer – cancer survivors; HT – hypertension; T2D – type-2 diabetes; HIV. c Outcomes are for subpopulation condition as listed: MS – muscular sclerosis; SCI – spinal cord injury; ID – intellectual disability; PD – Parkinson’s disease; Stk – in stroke survivors; Sch – schizophrenia; ADHD – attention deficit/hyperactivity disorder. Critical and important outcomes for the age-specific population were considered and extrapolated. 18 19Methods THE EVIDENCE The revision of the 2010 WHO recommendations on physical activity was conducted by identifying, and then updating, the most recent, relevant umbrella reviews related to the scope of these guidelines. This approach was adopted due to an extensive body of recent systematic reviews which were conducted to inform the development of several national physical activity guidelines. The additional updating was undertaken to ensure the new WHO guidelines reflect the most recent available data in a rapidly developing field of public health. Umbrella reviews were selected if they met the following three criteria: i) the evidence reviews had been conducted according to standard systematic processes that were well documented; ii) the assessment of the certainty of the evidence used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method or an equivalent methodology that was clearly described and documented; and iii) the evidence reviews addressed the populations of interest with no restrictions to country or country income level. The PI/ECO questions and the critical and important health outcomes were mapped against existing evidence reviews and, where needed, additional new reviews were commissioned to address gaps. The GDG requested that the evidence reviews be updated, using the same search terms, search languages, and databases as the original reviews. The following evidence reviews were identified as meeting the above three criteria and were chosen for recency and comprehensiveness: • A systematic review of the literature conducted by Poitras et al. (2016) on the association between physical activity and health indicators in school-aged children and youth (22) as part of the process for developing the Canadian 24-hour movement guidelines for children and youth (23). This review focused solely on studies that used objective measurements of physical activity. A total of 162 studies were included, representing 204 171 participants from 31 countries. • A systematic review of the literature of the association between sedentary behaviour and health indicators in school-aged children conducted by Carson et al. (2016) (24), as part of the process for developing the Canadian 24-hour movement guidelines for children and youth (23). A total of 235 studies (194 unique samples) were included representing 1 657 064 unique participants from 71 countries. • A systematic review conducted by Okely et al. (2019) (25) undertaken to update Poitras et al. (2016) (22) and Carson et al. (2018) (24) as part of the development of the 2019 Australian 24-hour movement guidelines for children and young people (aged 5–17 years) (26). This report identified an additional 42 studies on physical activity, and 32 on sedentary behaviour, published through to July 2918 (25). The GRADE tables developed by Okely et al. were used as the basis for the commissioned update conducted for WHO. The GRADE tables along with the evidence profiles are presented in the Web Annex: Evidence profiles . • The 12 systematic reviews conducted and synthesized as part of the development of the 2019 Canadian guideline for physical activity throughout pregnancy (27). These 12 reviews assessed over 25 000 related studies in English, Spanish and French language on maternal physical activity during pregnancy that reported on maternal, fetal, or neonatal morbidity, or fetal mortality outcomes. Seven of these systematic reviews addressed outcomes deemed critical and important by the GDG (28–34) The GRADE tables from these evidence reviews were used as the basis for the literature search conducted to update and inform the development of WHO recommendations. The updated evidence profiles are presented in the Web Annex: Evidence profiles . • The scientific report of the Physical Activity Guidelines Advisory Group (PAGAC) (35) which provides a systematic update of evidence on physical activity and sedentary behaviours and health outcomes published 2008–2016 as part of the development of the 2018 Physical activity guidelines for Americans, 2nd Edition (36). The evidence summarized addressed a total of 38 main research questions and 104 subquestions selected for their public health relevance. The evidence comprised results from systematic reviews which consisted of a total of 1130 articles, each abstracted to answer the 38 research questions (35). The protocols used a modified version of “A Measurement Tool to Assess Systematic Reviews” (AMSTARExBP) to assess the methodological quality of systematic reviews and meta-analyses. Risk of bias, or internal validity, was assessed for each original study using an adapted version of the USDA NEL Bias Assessment Tool (BAT) (37). The new evidence identified in the updated searches conducted for these WHO guidelines is presented in the evidence profiles in the Web Annex: Evidence profiles ; links are provided to the report and supplementary materials of PAGAC (35). Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 20 21 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Methods for updating the evidence and data extraction A search for systematic reviews and pooled analyses of cohort studies was conducted for studies published from the date of the last searches carried out for each of the included reviews (listed above) to September 2019; standardized data extraction protocols were developed and employed. To update the searches conducted by Poitras et al. (2016) (22), Carson et al. (2016) (24), and Okely et al. (2019) (25), the databases MEDLINE, EMBASE, PsycINFO, and SportDiscus were searched to identify reviews that were peer-reviewed, written in English or French. To update the searches conducted by PAGAC (35), PubMed, CINAHL and Cochrane databases were searched to identify reviews that were peer-reviewed, written in English. A de novo search for important outcomes, where these were not included by PAGAC (35), was not conducted due to resource constraints. Searches were performed with no restriction by country or country income status, and inclusive of reviews addressing any subjectively or objectively measured physical activity or sedentary behaviour. It was decided not to conduct searches in languages other than those of the original searches, due to resource constraints and previous experience in the field indicating that such searches yielded very few, if any, additional reviews. Reviews were considered that examined an association between physical activity or sedentary behaviour and health-related outcomes (based on levels above or below a threshold of physical activity or sedentary behaviour), and that explored the dose-response relationship between these and health-related outcomes. An external team of reviewers used the AMSTAR 2 (Assessment of Multiple Systematic Reviews) instrument to rate the credibility of the systematic reviews under consideration for inclusion (38). The AMSTAR 2 tool contains 16 items that relate to the planning and conduct of the review. The overall confidence in the results of each review was rated according to published guidance: a rating of “high” reflects that the review had zero or one noncritical weakness; “moderate” indicates the review was judged to have more than one noncritical weakness; “low” means the review was judged to have one critical flaw with or without noncritical weaknesses, or multiple noncritical weaknesses; and “critically low” signifies that more than one critical flaw was present. One reviewer completed the AMSTAR 2 tool for all provisionally included reviews. Reviews that were rated critically low by one reviewer were reviewed by a second reviewer using the same tool. Reviews ultimately rated as critically low were excluded because they were judged to be too unreliable to provide an accurate and comprehensive summary of the available evidence, unless it was the only review available for a particular outcome. This body of evidence also included pooled cohort studies. An external team of reviewers used the Newcastle- Ottawa Scale to assess the quality of the studies (39). Each study was given a quality rating of “good”, “fair”, or “poor”. In general, a good-quality study met all criteria on the Newcastle-Ottawa scale. A fair-quality study did not meet, or it was unclear whether it met, at least one criterion, but also had no known important limitations that could invalidate its results. A poor-quality study had a single fatal flaw, or multiple important limitations. Poor-quality studies were excluded. There was an assessment for overlap, recognizing potential for duplication of studies in multiple reviews. Reviews containing redundant bodies of evidence, overviews of reviews, and some pooled cohort studies were excluded, where other more comprehensive and/or recent reviews were identified. Methods for new reviews Where gaps in existing evidence were identified, new umbrella reviews were commissioned to examine: 1. the relationship between occupational (i.e. work- related) physical activity and health-related outcomes (40); and 2. the association between leisure-domain physical activity and adverse health outcomes (41). (For numbers 1 and 2 above, searches were undertaken using PubMed, SportDiscus and EMBASE for reviews published from 2009 to December 2019.) 3. the association between physical activity and falls prevention; the 2019 Cochrane Collaboration Systematic Review by Sherrington et al. (42) was used, and updated with evidence published from the end search date of their original review, through to November 2019. 4. the association between physical activity and osteoporosis and sarcopenia. The search for existing systematic reviews on osteoporosis and sarcopenia, conducted in PubMed for reviews published from 2008 up to November 2019, identified no new reviews and eight new primary studies. 5. the evidence on associations between physical activity and health outcomes in people living with HIV. A scoping review ascertained the availability of 20 21Methods evidence on physical activity and health-related outcomes among people living with HIV to support conducting an umbrella review which was conducted for evidence published up to October 2019 with no start date limitation using PubMed, CINAHL and Web of Science. Summary of characteristics of the evidence and assessment methods of physical activity and sedentary behaviour Until recently, the primary methods for measuring physical activity and sedentary behaviours in adults has been by self-report (i.e. survey) and, for children, either self-report or parental recall. Although these methods have well-established strengths, limitations include being prone to reporting bias and measurement error (43). In recent years, with digital technology rapidly growing in this area, there has been an increase in the use of device-based measures for assessing physical activity and sedentary time and their associations with health outcomes. However, challenges remain in comparing results between studies due to differences between the technical features and placement of different devices (accelerometers), and differences in the analyses and reporting of the data. For example, when measuring sedentary time with device-based measures, miscalculation may occur as many of the devices do not currently distinguish between positions (e.g. lying, sitting and standing still). Difficulties also exist when comparing findings from studies using device- based measures with those reporting results from self-report measures. Self-report instruments vary in content, in the examples of physical activity, response options and domains covered. Until recently, studies focused primarily on assessing either total physical activity, or physical activity in the leisure/recreation domain only, but now increasingly include other domains such as physical activity for transport (e.g. walking and cycling), at work, and in the household. The majority of evidence reports on associations between aerobic physical activity and health outcomes, however studies are now assessing the benefits of muscle- strengthening exercise, as well as combinations of different types of activity and other domains. Results on the association between physical activity levels and health outcomes are reported and compared in different ways. Many studies report comparisons between quartiles or quintiles of physical activity, other studies compare those “meeting” versus “not meeting” national guidelines. Calculation of total physical activity, when reported, is usually estimated in MET-hours per week and some studies compare “highest” versus “lowest”, although categories also vary across studies. The literature frequently reports results from analyses that apply data cut points based on an existing guideline, or the current WHO Global recommendation, or metrics from previous research (for example the cut points of 60 minutes per day in research on youth populations, or the frequency of 2–3 times per week for strength training intervention). When such cut points become commonplace the building of evidence on the associations of higher or lower levels of physical activity exposure on health outcomes can be limited. Most of the evidence assessing the associations between sedentary behaviours and health outcomes for children and adolescents is cross-sectional in nature, and a majority of studies rely on self- or parent-reported measures of sedentary time that are subject to measurement errors and recall biases. Evidence from longitudinal observational studies and intervention trials was prioritized, and reviews that solely or primarily synthesized cross-sectional evidence were not considered. Greater emphasis was given to evidence provided by reviews graded moderate certainty and above, and to those providing evidence from studies using device-based measures of exposure. Grading the body of evidence The Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was used to rate the certainty of the evidence for each PI/ECO (44), based on the underlying evidence in the reviews. When available, the GRADE “Evidence Profiles” or “Summary of Findings” tables from each review, were used as a starting point. If no table was available within the existing systematic reviews, “Evidence Profile” tables for each population and outcome of interest were constructed. The GRADE method was used to rate the certainty of the evidence for each PI/ECO (44) with the following criteria considered: study design; risk of bias; consistency of effect; indirectness; precision of effect; and other limitations, including publication bias and factors for upgrading observational evidence (magnitude of effect, dose-response, and effects of confounders). Observational evidence from well- conducted longitudinal studies was also upgraded to reflect more appropriately the increased certainty in findings regarding associations between physical 22 23 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r activity or sedentary behaviour and outcomes from such studies. Studies that evaluated intermediate/ indirect outcomes were not necessarily downgraded, as the outcomes (including intermediate outcomes) were prioritized by the GDG; the GRADE rating reflects the certainty in effects on those outcomes. In some cases, the GRADE ratings from existing reviews were modified to ensure consistency in application of GRADE methods. The certainty in the body of evidence for each outcome was assigned based on the following guidance (45): High Very confident that the true effect lies close to that of the estimate of the effect. Moderate Moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low Confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect. Very low Very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of  effect. Going from evidence to recommendations The GDG employed the GRADE Evidence to Decisions (EtD) framework for generating question-specific recommendations. The EtD framework is a systematic, structured and transparent approach to decision- making. The framework uses explicit criteria for generating guideline recommendations considering research evidence, certainty of evidence and, where required, expert opinion and topical knowledge from the perspective of the target audience. The criteria elicit judgments about the balance between the observed evidence of desirable and undesirable outcomes, overall certainty of evidence, relative values of patients for desirable and undesirable outcomes, resource use (cost considerations) where applicable, potential impact on inequities in health, acceptability and feasibility of recommendations. The GDG considered the body of evidence in totality for each recommendation for all critical outcomes, and all available important outcomes. For a particular exposure/intervention and outcome link, studies differed widely in the specific exposure/intervention assessed, outcomes assessed, study design, and analytic methods, resulting in heterogeneity in the available evidence. Therefore, it was not possible to apply the classic GRADE approach to each specific exposure/intervention and outcome link; rather, GRADE was applied for the overall body of evidence addressing each exposure/intervention and outcome link, across study design types and variations in exposure/intervention measurements and analyses. When these factors resulted in concerns regarding the coherence of the evidence (i.e. that the evidence for a particular exposure/intervention and outcome link did not correspond when looked at in different ways), the panel downgraded the certainty of evidence (21). The GDG prioritized the following health outcomes to consider the effects of physical activity and sedentary behaviour: reduced all-cause and cause- specific mortality (cardiovascular disease and cancer); reduced incidence of cardiovascular disease; cancer (site-specific); type-2 diabetes; improved physical fitness (e.g. cardiorespiratory, motor development, muscular fitness); improved cardiometabolic health (e.g. blood pressure, dyslipidaemia, glucose, insulin resistance); bone health; mental health (e.g. reduction in depressive symptoms, self-esteem, anxiety symptoms, ADHD); and improved cognitive outcomes (e.g. academic performance, executive function); and reduced adiposity. Adverse effects (e.g. injuries and harms) were also considered. Additional considerations For each population and all PI/ECO questions, the GDG also considered values and preferences of those affected by the guidelines; the resource implications of the recommendations; the impact on health equity; and the acceptability and feasibility of the recommendations. As there was considerable duplication in these considerations, and in the GDG’s assessment, for each population group, a summary of the discussions regarding assessments for these elements are described in the “Evidence to recommendations” section. 22 23Methods The public health recommendations presented in the WHO Guidelines on physical activity and sedentary behaviour are for all populations and age groups ranging from 5 years to 65 years and older, irrespective of gender, cultural background or socioeconomic status, and are relevant for people of all abilities. The new guidelines are presented by age group and behaviour (physical activity and sedentary). For each set of recommendations, an introductory statement summarizes the health outcomes associated with physical activity and sedentary behaviour respectively; the recommendations then follow. A set of good practice statements is provided to further clarify how the recommendation can be met safely by the target population. These good practice statements are not “graded recommendations” per se, but are derived from scientific evidence and from practical considerations reviewed and recommended by the GDG. For each set of recommendations, a summary of the supporting scientific evidence is provided, structured by the three PI/ECO questions; presenting first the evidence on the associations with the critical health outcomes, followed by a summary of evidence on dose response. Finally, a summary of evidence on the relationships between different types or domains of exposure and health outcomes is presented, where this exists. RECOMMENDATIONS G O O D P R A C TI C E ST A TE M EN TS 24 25 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Supporting evidence and rationale For these guidelines for children and adolescents, systematic reviews (22, 25, 35) were used and updated with 16 new reviews identified that met inclusion criteria. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . • Doing some physical activity is better than doing none. • If children and adolescents are not meeting the recommendations, doing some physical activity will benefit their health. • Children and adolescents should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • It is important to provide all children and adolescents with safe and equitable opportunities, and encouragement, to participate in physical activities that are enjoyable, offer variety, and are appropriate for their age and ability. G O O D P R A C TI C E ST A TE M EN TS In children and adolescents, physical activity confers benefits for the following health outcomes: improved physical fitness (cardiorespiratory and muscular fitness), cardiometabolic health (blood pressure, dyslipidaemia, glucose, and insulin resistance), bone health, cognitive outcomes (academic performance, executive function), mental health (reduced symptoms of depression); and reduced adiposity. It is recommended that: Children and adolescents should do at least an average of 60 minutes per day of moderate- to vigorous-intensity, mostly aerobic, physical activity, across the week. Strong recommendation, moderate certainty evidence Vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone, should be incorporated at least 3 days a week. Strong recommendation, moderate certainty evidence CHILDREN AND ADOLESCENTS (aged 5–17 years) Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf For children and adolescents, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), physical education, transportation (wheeling, walking and cycling) or household chores, in the context of educational, home, and community settings. PHYSICAL ACTIVITY RECOMMENDATION 24 25Recommendations In children and adolescents (aged 5–17 years), what is the association between physical activity and health-related outcomes? A large body of evidence previously established that greater amounts and higher intensities of physical activity in children and adolescents are associated with multiple beneficial health outcomes (1). Recent evidence reaffirms that increased physical activity improves cardiorespiratory fitness and musculoskeletal fitness in children and adolescents (22, 35). For example, positive impacts are obtained when participating in moderate- to vigorous-intensity physical activity for 3 or more days per week, for 30 to 60 minutes (22, 35). Regular physical activity, largely aerobic, in children and adolescents is positively associated with beneficial cardiometabolic health outcomes, including improved blood pressure, lipid profile, glucose control and insulin resistance (35). Recent reviews examined the effectiveness of school-based physical activity programmes (46), high-intensity interval training (47) and resistance training (48), versus no intervention on measures of cardiometabolic health. Within all 3 reviews, there was consistent evidence that interventions were associated with better cardiometabolic outcome measures, although there was varied precision in effect sizes and few individual trials found statistically significant benefits of physical activity across all cardiometabolic outcomes. One review of 19 RCTs (n= 11 988) (46) reported that school-based physical activity programmes were associated with statistically significant improvements in diastolic blood pressure (ES= 0.21 [95% CI: 0.42 to 0.01]; p= 0.04) and fasting insulin (ES= 0.12 [95% CI: 0.42 to 0.04]; p= 0.03) compared with no physical activity interventions. Physical activity has been reported to be favourably associated with adiposity, and higher levels of activity may be associated with healthy weight status in children and adolescents (22, 35). The results are generally strongest in cross-sectional studies, while the results are more mixed from prospective observational studies, which limits understanding of the directionality of the reported associations. More recent reviews of physical activity interventions trials (laboratory-based high- intensity interval training [HIIT], classroom-based active learning, resistance training) reported inconsistent results with the majority of the studies included in the reviews not reporting an effect (47, 49, 50). However, a review of longitudinal and cross-sectional studies reported a negative relationship between pedometer- measured physical activity and measures of adiposity, BMI or waist circumference (51). Overall there is low certainty evidence that physical activity is associated with the management of a healthy weight status and more research is needed to determine directionality and strength of association. There is less evidence examining the association between physical activity and motor skill development in children and adolescents, with current reviews demonstrating null findings (22). More research is needed with motor development as an outcome to inform future guidelines. For children and adolescents, bone-loading activities can be performed as part of playing games, running, turning, or jumping. Physical activity is positively associated with bone mass accrual and/or bone structure, and recent evidence supports that children and adolescents who are more physically active than their peers have greater bone mass, higher bone mineral content or density, and greater bone strength (35). Maximizing bone health in childhood and adolescence can help protect from osteoporosis and related fractures later in life. Developing and maintaining cognitive function is essential across the entire lifespan. In children and adolescents, physical activity has positive effects on cognitive function and academic outcomes (e.g. school performance, memory and executive function) (22, 35). One recent review (19 RCTs; n= 5038) demonstrated that exercise interventions with multiple sessions per week, for 6 weeks or longer, were associated with greater change in measures of cognitive function such as inhibitory control (SMD 0.26 [95% CI: 0.08 to 0.45], p= < 0.01); working memory (SMD 0.10 [95% CI: -0.05 to 0.25], p= < 0.02), and cognitive flexibility (SMD 0.14 [95% CI: -0.03 to 0.31], p= < 0.04) compared with no exercise interventions (52). Physical activity also reduces the risk of experiencing depression and depressive symptoms in children and adolescents with and without major depression (35), and may be comparable to psychological and pharmaceutical therapies in reducing symptoms. Although all physical activity comes with some risk of adverse event (53) there is limited evidence reporting harms associated with physical activity levels recommended for health benefit (35). Based on available evidence and expert opinion, the potential risks associated with the amounts and types of physical activity recommended for children and adolescents CHILDREN AND ADOLESCENTS (AGED 5–17 YEARS) 26 27 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r were considered to be low (35) and can be reduced by a progressive increase in the activity level and intensity, especially in children and adolescents who are inactive. It is known that participation in some sports increases the risk of injury, as does increasing exercise intensity (53). More research is needed to strengthen the knowledge base in this area. The GDG concluded that: • There is moderate certainty evidence that greater amounts of moderate- and vigorous-intensity physical activity are associated with improved cardiorespiratory fitness and muscular fitness, cardiometabolic health and bone health in children and adolescents. • There is moderate certainty evidence that both short- and long-term moderate- to vigorous-intensity physical activity have positive effects on cognitive function, academic outcomes and mental health. • There is low certainty evidence that physical activity is favourably associated with the management of healthy weight status in children and adolescents. • There is low-certainty evidence that the risks for the amounts and types of physical activity recommended for children and adolescents are low and are outweighed by the benefits. Is there a dose-response association (volume, duration, frequency, intensity)? Although there is a substantial body of evidence demonstrating a positive association between physical activity and health outcomes in children and adolescents, very few studies have addressed the issue of dose-response. Therefore, the exact shape of the dose-response curve and/or the presence of threshold values (that differentiate lower versus higher risk) for physical activity and specific health outcomes is less well understood in children and adolescents compared with adult populations. Nonetheless, a substantial body of evidence shows that many of the health benefits occur with 60 minutes of physical activity daily (22, 35), and given no contradictory evidence, it was concluded that the updated evidence reaffirms the current WHO recommendation for 60 minutes of moderate- to vigorous-intensity physical activity per day (1). However, the review of all evidence, including recent results from studies using device-based measures of physical activity, did not support retaining the specification of a “minimum” daily threshold of 60 minutes of moderate- to vigorous-intensity physical activity for health benefits, given that studies broadly used “an average” threshold of 60 minutes per day, not a minimum daily threshold of 60 minutes, to assess the benefits of physical activity on health outcomes. The review concluded that the new guideline should be amended to more closely reflect this evidence. The benefits of regular vigorous-intensity activity on cardiometabolic health outcomes has been previously established (1) and recent reviews provided further supporting evidence (35). For example, a recent review (54) showed that high-intensity interval training, compared with moderate-intensity continuous training, had a moderate beneficial effect on cardiorespiratory fitness (SMD= 0.51 [95% CI: 0.33 to 0.69], p= < 0.01; I 2= 0%). There was no evidence that intervention duration, exercise modality, exercise and rest ratio, and total bouts modified the effect on cardiorespiratory fitness. These results were consistent overall with other recent reviews (22, 35, 47) and provide support to retaining the recommendation that youth and adolescents should do regular vigorous-intensity activity to improve cardiorespiratory fitness. The GDG concluded that: • Evidence affirms the previous WHO recommendation for 60 minutes of moderate- to vigorous-intensity physical activity per day. • Evidence supports amending the previous specification of a minimum daily threshold of 60 minutes of physical activity to an average of 60 minutes per day per week, which more closely reflects the evidence. • There is moderate certainty evidence that greater amounts of vigorous-intensity physical activity are associated with improved cardiorespiratory fitness. Does the association vary by type or domain of physical activity? For children and adolescents, physical activity includes play, games, sports, transportation, recreation, physical education or planned exercise, in the context of family, school, and community activities. However, few studies have directly compared different types or domains of physical activity in children and adolescents and thus there is insufficient evidence to determine if the association between physical activity and health outcomes varies by type of activity (e.g. aerobic versus muscle-strengthening exercise) or domain of physical activity (e.g. active transport (walking and cycling) versus physical education, versus sports/recreation). CHILDREN AND ADOLESCENTS (AGED 5–17 YEARS) 26 27Recommendations There is evidence showing that both increased levels of aerobic moderate- to vigorous-intensity physical activity are associated with increased cardiorespiratory fitness, and that increased muscle-strengthening activity increases muscular fitness in children and adolescents. This evidence informed the 2010 WHO Global recommendations on physical activity for health (1) which recommended incorporating activities that strengthen muscles and bones at least 3 days per week. Updated evidence reaffirmed that regular muscle- strengthening activity 3 times per week was effective for improving indicators of muscular fitness; however, there is insufficient evidence to state specific details of session duration and intensity, largely due to the heterogeneity of exposures assessed in the literature (22, 35). There is less evidence for a protective effect of resistance training on cardiometabolic health. Given the absence of new evidence on characteristics other than the frequency of muscle strengthening activities for children and adolescents, such as duration, it was not possible to specify any further details. Future research should address the health benefits of specific types and domains of physical activity in order to provide more specificity to this component of the guidelines. The GDG concluded that: • There is moderate certainty evidence that muscle- strengthening activities should be incorporated at least 3 days a week. CHILDREN AND ADOLESCENTS (AGED 5–17 YEARS) 28 29 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Supporting evidence and rationale Sedentary behaviour was not included in the WHO 2010 recommendations, yet during the past decade, there has been a growing body of research examining the health outcomes associated with different measures and types of sedentary behaviours. Technology and digital communications have influenced how people work, study, travel and spend leisure-time. In most countries, children and adolescents are spending greater time engaged in sedentary behaviours, particularly for recreation, such as screen-based entertainment (television and computers) and digital communications, such as mobile phones. For these guidelines for children and adolescents, systematic reviews (24, 25) were used and updated with seven new reviews identified that met inclusion criteria. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . In children and adolescents, higher amounts of sedentary behaviour are associated with the following poor health outcomes: increased adiposity; poorer cardiometabolic health, fitness, behavioural conduct/pro-social behaviour; and reduced sleep duration. It is recommended that: Children and adolescents should limit the amount of time spent being sedentary, particularly the amount of recreational screen time. Strong recommendation, low certainty evidence Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Sedentary behaviour is defined as time spent sitting or lying with low energy expenditure, while awake, in the context of educational, home, and community settings and transportation. CHILDREN AND ADOLESCENTS (aged 5–17 years) SEDENTARY BEHAVIOUR RECOMMENDATION 28 29Recommendations In children and adolescents (aged 5–17 years), what is the association between sedentary behaviour and health-related outcomes? Evidence indicates that greater time spent in sedentary behaviour, especially recreational screen time, is related to poorer health outcomes (24, 35). For example, higher duration of screen time (including television viewing) is associated with poorer fitness and cardiometabolic health (24, 25) in children and adolescents. Evidence from device-based assessment of association with sedentary behaviour and interventions studies showed modest effects, although stronger effects for those already living with obesity (55). There is limited evidence suggesting that sedentary behaviour is not related to bone health in children and adolescents. Despite more mixed results, evidence also suggests that sedentary behaviour may be associated with unfavourable measures of adiposity (24, 25). One review of largely cross-sectional studies, reported that sedentary behaviour (measured as total screen time) of more than 2 hours per day was positively associated with childhood overweight/obesity compared with lower levels (< 2 hours/day) (56). However, another review of 20 cross-sectional studies (57) found no statistically significant association between sedentary video gaming and body mass index among children or adolescents. A large review of 29 systematic reviews concluded that many studies report unfavourable associations between sedentary behaviour and markers of adiposity in young people when the behaviour is self-reported as some form of screen time (55). However, the review noted that the magnitude of such associations was small and, for studies using device-based assessment of sedentary time, largely zero (55). Intervention studies showed modest effects, although stronger effects for those already living with obesity (55). Further research is needed to inform the association between sedentary behaviours and measures of adiposity. Although still an emerging area of research, some evidence shows that there may be a negative association between sedentary behaviour and well-being and quality of life, as well as an unfavourable relationship between depression and leisure screen time in children and adolescents (58, 59). For example, higher durations of sedentary behaviour, assessed as screen time, and some aspects of computer use, can be associated with poorer mental health (24). In another recent review, an association between sedentary behaviour and anxiety symptoms was found in 5 of 8 studies, although results were inconsistent across different measures of sedentary behaviour within studies (60). Other evidence demonstrates that higher durations of television viewing and video game use were significantly associated with unfavourable measures of behavioural conduct/pro-social behaviour (24); and more screen time and television viewing is associated with shorter sleep duration, although there was no association between computer use/gaming and sleep duration (61). Investigations into the relationship between sedentary behaviours and mental health is a rapidly developing field with many unknowns, and reverse causality is likely to be in evidence. Further research is needed to inform on the direction and strength of this association. The GDG concluded that: • There is low certainty evidence that higher duration of sedentary behaviour (screen time) is significantly associated with lower physical fitness and cardiometabolic health in children and adolescents. • There is very low to moderate certainty evidence that higher durations of sedentary behaviour (screen time, television viewing and video game use) are significantly associated with unfavourable measures of mental health and behavioural conduct/pro-social behaviour in children and adolescents. • There is low certainty evidence that greater time spent in sedentary behaviour (screen time and television viewing) is associated with detrimental effects on sleep duration in children and adolescents. • The benefits of limiting the amount of sedentary behaviour for children and adolescents outweigh the harms. Is there a dose-response association (total volume, duration, frequency, intensity of interruption)? There is insufficient evidence available to determine whether a dose-response relationship exists between sedentary time (including recreational screen time) and health outcomes in children and adolescents. Most of the evidence assessing the associations between sedentary behaviours and health outcomes in children and adolescents is cross-sectional in nature, with low certainty evidence according to GRADE, and a majority of studies relied on self- or parent-reported measures of sedentary time that are subject to measurement errors and recall biases. There is, however, evidence that less time spent in sedentary behaviours appears to be CHILDREN AND ADOLESCENTS (AGED 5–17 YEARS) 30 31 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r better for health outcomes, and the association between sedentary behaviour and adverse health outcomes is generally stronger for sedentary behaviour when assessed as television viewing or recreational screen time as the exposure variable, than for total sedentary time. However, overall the evidence was considered insufficient to support specifying time limits. Evidence that sedentary behaviours are linked to adverse health outcomes could be the result of either direct effects of the sedentary behaviours, displacement of time spent in more physically active behaviours, or both. Although there are studies that have reported associations between screen time and adverse health outcomes in children and adolescents, total sedentary time (as assessed in studies using device-based measurements of sedentary behaviour) has consistently not been associated with health outcomes when time in moderate- to vigorous-intensity physical activity is taken into account (62). Conversely, the evidence linking moderate- to vigorous-intensity physical activity to positive health outcomes is strong and well documented across diverse settings; replacing some sedentary behaviour with physical activity (especially moderate- to vigorous-intensity physical activity) may improve health outcomes. Research investigating the associations and interplay between sedentary behaviour, physical activity and health outcomes is rapidly growing, and evidence from device-based measures of sedentary behaviour and cardiometabolic health show the association is attenuated when moderate- to vigorous-intensity physical activity is taken into account (i.e. statistically adjusted for) (62–64). There is therefore a need for further prospective studies using device-based measures of exposure, to advance knowledge of these associations and inform future recommendations. The GDG concluded that: • There is low certainty evidence that greater time spent in sedentary behaviour is related to poorer health outcomes. • There is insufficient evidence to specify time limits on sedentary behaviour. • Replacing sedentary time with moderate- to vigorous- intensity physical activity may provide health benefits. Does the association vary by type or domain of sedentary behaviour? The study of health effects of sedentary behaviour is a relatively new field of research. As such the findings are from studies using different instruments and measures of exposure. Exposure assessed as “total time spent doing sedentary behaviours” is frequently used, as is sedentary time spent using “screens” or “television viewing”. Available evidence suggests that the association between sedentary behaviour and adverse health outcomes is generally stronger for television viewing or recreational screen time than for total sedentary time (24, 35). The increased use of device-based assessment of sedentary behaviour in the more recent research is advancing knowledge, and when combined with standardized reporting will help inform future guidelines. It is acknowledged that not all sedentary behaviour is harmful. Evidence suggests certain types of sedentary behaviour, such as reading and doing homework outside of school, are associated with higher academic achievement, indicating that there are differences in outcome depending on the activity (24, 25). Sedentary behaviour may include time spent engaged in educational pursuits/study or quiet play, or social interaction without electronic media. These pursuits (e.g. reading, doing puzzles, drawing, crafting, singing, music) are important for child development and have cognitive as well as other benefits. The GDG acknowledged that: • Some sedentary activities confer benefits for cognitive function and social interaction in children and adolescents. • Evidence on the adverse health effects of sedentary behaviour is generally stronger for television viewing or recreational screen time than for total sedentary time. CHILDREN AND ADOLESCENTS (AGED 5–17 YEARS) 30 31Recommendations ADULTS (aged 18–64 years) In adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site- specific cancers, 1 incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression); cognitive health, and sleep; measures of adiposity may also improve. It is recommended that: All adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence Adults should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence Adults may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence For adults, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), transportation (wheeling, walking and cycling), work or household chores, in the context of daily occupational, educational, home and community settings. PHYSICAL ACTIVITY RECOMMENDATION • Doing some physical activity is better than doing none. • If adults are not meeting these recommendations, doing some physical activity will benefit their health. • Adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. G O O D P R A C TI C E ST A TE M EN TS 1 Site-specific cancers of: bladder, breast, colon, endometrial, oesophageal adenocarcinoma, gastric, and renal. 32 33 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ADULTS (aged 18–64 years) Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Supporting evidence and rationale For these guidelines, the synthesis of evidence undertaken by the United States Physical Activity Guidelines Advisory Committee (PAGAC) (35) was used and updated. The GDG considered the entire body of evidence, including both the findings reported by PAGAC and the 28 reviews and 3 pooled cohort studies, published from 2017 through to November 2019, that met inclusion criteria, and contributed evidence on the association between physical activity and health-related outcomes in adults. In addition, two umbrella reviews were commissioned to address evidence gaps and examine i) the relationship between occupational (i.e. work-related) physical activity and health-related outcomes (40); and ii) the association between leisure-domain physical activity and adverse health outcomes (41). The umbrella reviews identified 36 and 15 systematic reviews respectively. Evidence from longitudinal observational studies and intervention trials was prioritized, and reviews that solely, or primarily, synthesized cross-sectional evidence were not considered. Greater emphasis was given to evidence provided by reviews graded moderate certainty and above, and to those providing evidence from studies using device-based measures of exposure. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . In adults (aged 18–64 years), what is the association between physical activity and health-related outcomes? The association between physical activity and all-cause mortality and cardiovascular disease mortality in adults is already well-established (1). Findings from recent reviews reaffirmed that compared with the lowest levels of physical activity, higher levels of physical activity were associated with a lower risk of mortality. New evidence from studies using device-based measures of physical activity reaffirmed and extended the evidence showing that compared with the lowest levels of physical activity, any level and all intensities (including light intensity) of physical activity, were associated with a lower risk of mortality (65). For example, compared with the least active (referent, 1.00), adjusted HR for quartiles of total physical activity improved across quartiles of physical activity: 2nd quartile (0.48 [95% CI: 0.43 to 0.54]); 3rd quartile (0.34 [95% CI: 0.26 to 0.45]); and 4th quartile (0.27 [95% CI: 0.23 to 0.32]) (65). New evidence also reaffirmed the well-established (1) inverse relationship between physical activity and cardiovascular disease mortality (66). The benefits of physical activity for reducing cardiovascular disease and hypertension incidence is well-documented (1). Physical activity promotes many physiological responses that cause beneficial short- and long-term autonomic and haemodynamic adaptations, resulting in lowered risk of hypertension, which is a key risk factor for cardiovascular disease. Evidence reaffirmed an inverse relationship between physical activity and incident hypertension among adults with normal blood pressure, and that physical activity reduces blood pressure among adults with prehypertension and normal blood pressure (35). The inverse association between physical activity and developing type-2 diabetes in adults is well-established (1). Recent evidence reaffirmed an inverse curvilinear relationship between higher volumes of physical activity and incidence of type-2 diabetes (35), with a decreasing slope at higher levels of physical activity. A new review found that this effect is consistent across individuals of different backgrounds with a reduced risk of developing type-2 diabetes in “highest” versus “lowest” levels of physical activity among non-Hispanic whites (RR= 0.71 [95% CI: 0.60 to 0.85]); Asians (RR= 0.76 [95% CI: 0.67 to 0.85]); Hispanics (RR = 0.74 [95% CI 0.64 to 0.84]); and American Indians (RR = 0.73 [95% CI: 0.60 to 0.88]), although the effect among non-Hispanic blacks was not significant (RR = 0.91 [95% CI: 0.76 to 1.08]) (67). Evidence suggests there is no effect modification by weight status and that the inverse relationship between a higher volume of physical activity and lower incidence of type- 2 diabetes exists for people who have normal weight, overweight or obesity (35). The associations between higher levels of physical activity and reduced risks of colon cancer and breast cancer have been well-established (1). In previous reviews of the evidence, higher levels of physical activity have been found to be associated with a reduced risk of 32 33Recommendations developing breast cancer and colon cancer (1). Following an extensive increase in physical activity and cancer research, there is new evidence demonstrating higher levels of physical activity are also associated with reduced risk of developing bladder, endometrial, oesophageal adenocarcinoma, gastric and renal cancers, as well as reaffirming that physical activity is protective for breast cancer and colon cancer (35). Higher levels of physical activity are associated with risk reductions ranging from approximately 10–20% (35). For example, one review reported an inverse association with liver cancer risk when comparing high levels of physical activity to low levels of physical activity (HR= 0.75 [95% CI: 0.63 to 0.89]) (68). There is insufficient evidence on the association between increased physical activity and decreased risks of hematologic, head and neck, ovary, pancreas, prostate, thyroid, rectal and brain cancer (35). While evidence suggests a reduction in risk of lung cancer between the highest versus lowest levels of physical activity, these findings may be confounded by tobacco use and it was determined that overall there is insufficient evidence to establish an association. The association between physical activity and adiposity in adult populations is less well established despite a large, but heterogenous, body of evidence assessing this relationship across various outcome measures (weight gain, weight change, weight control, weight stability, weight status and weight maintenance) (35, 69, 70). Overall the evidence shows that higher levels of physical activity may be associated with more favourable measures of adiposity and attenuation of weight gain in adults (35). Further research is needed to establish consistent results and strength of associations. Research on physical activity and mental health, cognition and sleep has increased substantially since the development of the 2010 Global recommendations on physical activity for health (1). At that time, there was sufficient evidence to conclude only that physical activity may reduce the risk of depression and cognitive decline in adults. New evidence reviewed for these guidelines showed that adults engaging in higher versus lower physical activity are at reduced risk of developing anxiety and depression. For example, adults with high, versus low, levels of physical activity were at reduced odds of developing anxiety (AOR= 0.81 [95% CI: 0.69 to 0.95]) (71) or depression (AOR= 0.78 [95% CI: 0.70 to 0.87) (72). Greater amounts of moderate- to vigorous-intensity physical activity are associated with improvements in cognition (e.g. processing speed, memory, and executive function) (35), brain function and structure, and a reduced ADULTS (aged 18–64 years) risk of developing cognitive impairment, including Alzheimer’s disease (73–76). The evidence included several adult populations representing a gradient of normal to impaired cognitive health status and the beneficial effects of physical activity were reported across a variety of types, including aerobic activity, walking, muscle-strengthening activity, and yoga (74). There is evidence that both acute bouts and regular physical activity improve sleep and health-related quality of life outcomes in adults (35). Evidence examining physical activity and symptoms of depression, symptoms of anxiety, and the development of anxiety and depression indicated that physical activity was associated with reduced symptoms of anxiety (77, 78) and reduced symptoms of depression (77, 79). All physical activity comes with some risk. Evidence from a commissioned review on the adverse effects, injuries and harms associated with leisure physical activity in adults (41) suggests an unfavourable association between levels of leisure-time physical activity and musculoskeletal injuries, and a favourable relationship between leisure- time physical activity and risk of fracture and onset of knee or hip osteoarthritis. Additional existing evidence (35) indicates sudden cardiac adverse events are rare and associated with acute sessions of relatively vigorous- intensity physical activity. Generally, the risks of adverse events are very low with moderate-intensity physical activity and when increases in physical activity frequency, intensity and duration are gradual (35). The GDG concluded that: • There is high certainty evidence that any level and any intensity of physical activity is associated with lower risk of all-cause mortality and cardiovascular disease mortality, incidence of hypertension, cardiovascular disease and type-2 diabetes. • There is moderate to high certainty evidence on the associations between higher levels of physical activity and lower risk of incidence of site-specific cancers. • There is moderate certainty evidence supporting an association between physical activity and improvements in mental health, cognitive health and sleep outcomes. • There is evidence of an association between higher levels of physical activity and more favourable measures of adiposity and attenuation of weight gain in adults. • There is low certainty evidence that physical activity recommended for adults will not be harmful and that the health benefits from such activity outweigh the risks. 34 35 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Is there a dose-response association (volume, duration, frequency, intensity)? Overall the evidence across cardiovascular and metabolic health outcomes shows a consistent curvilinear inverse dose-response relationship between physical activity and major outcomes such as all-cause mortality, cardiovascular disease mortality, incident type-2 diabetes (67), and incident site-specific cancers in adults. As described in Figure 1, the shape of the dose-response curve indicates that there is no lower threshold for benefit, and the greatest benefits are seen at the lower end of the dose-response curve (65). The curvilinear inverse association is consistently reported and across studies using different measures of physical activity. Important new evidence was provided in a meta- analysis of eight prospective cohort studies, with mean follow-up of 5.8 years (range 3–14.5 years) (65) that reported the adjusted HR for quartiles of total physical activity using device-based measures of exposure and all-cause mortality. The results showed a dose- response with increasing volume of physical activity and benefits of higher levels of any intensity of physical activity compared with the least active (referent, 1.00): 2nd quartile (adjusted HR= 0.48 [95% CI: 0.43 to 0.54]); 3rd quartile (adjusted HR= 0.34 [95% CI: 0.26 to 0.45]); and 4th quartile (adjusted HR= 0.27 [95% CI: 0.23 to 0.32]). Maximal risk reductions for moderate- to vigorous- intensity physical activity were observed at 24 minutes per day (equivalent to 168 minutes per week), which ADULTS (aged 18–64 years) closely reflects the recommendation of 150 minutes per week, and provides new device-based evidence reinforcing the existing global guidance to adults of 150–300 minutes of physical activity per week (65). These findings are consistent with the evidence from existing reviews (35) and the other new identified reviews (66). At the upper end, higher levels of physical activity continue to provide benefits in terms of reduced risk of mortality with no increased risk of harms. For example, evidence from a new review with findings from a meta- analysis of individual data from device-based measures of exposure (65), indicates that although reduced risk of mortality is observed up to 750 minutes of moderate- to vigorous-intensity physical activity per week, the relative risk of mortality levels off beyond 300 minutes per week. These results accord with previous evidence which consistently showed that more physical activity is associated with further health benefits, although the relative benefits are reduced at higher levels of physical activity (35, 80, 81). There is, however, insufficient evidence to identify the exact physical activity level where diminished returns of health benefits begin for adults. Evidence also reaffirmed the well-established inverse relationship between physical activity and cardiovascular disease mortality, providing additional evidence of a dose-response relationship well beyond current recommended volumes of physical activity. Figure 1: Dose response curve Weekly physical activity (minutes) RIS KS AN D HA RM SBE NE FI TS H ea lt h a n d  fi tn es s b en efi ts Sedentary Recommended range 150 300 34 35Recommendations A meta-analysis of 48 prospective studies assessing physical activity (total, leisure, and occupational) provided additional evidence of a dose-response relationship (66) well beyond current recommended volumes of physical activity. Compared with the recommended level of 750 MET minutes per week, participation in 5000 MET minutes per week (1000 minutes of moderate-intensity activity) resulted in a significantly lower risk for cardiovascular disease mortality (HR= 0.73 [95% CI: 0.56 to 0.95]) (66).Previous WHO recommendations (1) concluded that aerobic activity should be performed in bouts of at least 10 minutes duration. However, new evidence, using device-based assessments, demonstrates that physical activity of any duration, without a minimum threshold, is associated with improved health outcomes, including all-cause mortality (65, 82). For example, new evidence from reviews of studies assessing physical activity by accelerometry reaffirms similar associations between all indices of physical activity and all-cause mortality, with hazard ratios of 0.27 for total physical activity, 0.28 for 5-minute bouts, and 0.35 for 10-minute bouts, comparing the highest versus lowest quartiles (83). These results, reaffirmed by findings in the new review by Ekelund et al. 2019 (65), provide evidence that physical activity of any bout duration is associated with improved health outcomes, including all-cause mortality (82). Based on new evidence, the recommendation for bouts of least 10 minutes duration has been removed. Although evidence showing the associations between higher levels of physical activity and lower risk of incidence of site-specific cancers was deemed to be consistent overall, there is insufficient evidence to determine the specific levels of physical activity that correspond to the reported risk reduction due to the large heterogeneity in the assessment and classification of exposure across studies. There is however, no evidence to suggest that there is a lower threshold below which no beneficial effect of physical activity is evident, thus suggesting that any level of physical activity can confer benefit on reducing the risk of site-specific cancers. Future research assessing the nature of the dose- response and using more consistent measures and reporting is needed to inform future guidelines. Although there is a large body of evidence on the associations between physical activity and various measures of adiposity, weight gain and the management of a healthy weight status (35), currently there is insufficient evidence to describe more specifically ADULTS (aged 18–64 years) the dose-response relationship or identify a threshold of effect. Further research is needed to inform future guidelines. Greater amounts of moderate- to vigorous-intensity physical activity are associated with improvements in cognition (e.g. processing speed, memory, and executive function) (35), brain function and structure, and a reduced risk of developing cognitive impairment, including Alzheimer’s disease (73–76). There is evidence that both acute bouts and regular physical activity improve sleep and health-related quality of life outcomes in adults (35). There is however insufficient evidence to describe more specifically the dose-response relationship between physical activity and individual mental and cognitive health outcomes. Similarly, more evidence is needed to further describe the dose-response relationship between volume and/or intensity of aerobic physical activity and muscle-strength training and specific health outcomes. Such information is key to establishing minimal effective doses and maximum safety thresholds of physical activity for different population subgroups. The GDG concluded that: • There is evidence that more physical activity is associated with larger effects on health outcomes, although the relative benefits level off at higher levels of physical activity. There was insufficient evidence to identify the exact level where diminished returns start to occur. • There is high certainty evidence that higher levels of physical activity are associated with lower risk of all- cause mortality, cardiovascular disease mortality, cancer mortality, cardiovascular disease incidence, and incidence of hypertension and type-2 diabetes, with no increased risk of harms. • There is moderate certainty evidence that physical activity of any duration is associated with improved health outcomes, and prior specification that aerobic activity should be performed in bouts of at least 10 minutes duration should be removed. • There is evidence that higher amounts of physical activity may be associated with more favourable measures of adiposity and attenuation of weight gain in adults and there is a low risk that physical activity will be harmful for the management of healthy weight status in adults. • There is moderate certainty evidence that 150–300 minutes of moderate intensity aerobic physical activity or equivalent, per week, reduces risk for multiple health outcomes, and risk reduction continues, but starts to plateau, beyond 300 minutes per week. 36 37 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Does the association vary by type or domain of physical activity? Evidence shows that different types of physical activity and physical activity undertaken in different domains (i.e. occupation, transport, or leisure) can provide favourable health outcomes. For all-cause and cardiovascular disease mortality, undertaking aerobic physical activity alone, or combining with strength-promoting exercise shows beneficial associations, although performing recommended levels of both types is optimal (84). More recent moderate certainty evidence indicates that muscle-strengthening physical activity, independent of aerobic physical activity, is also associated with lower risk of all-cause mortality. Results reported by Stamatakis et al. (2018), from a pooled analysis of 11 cohorts examining the 2 days per week muscle-strengthening exercise recommendation against all-cause mortality, showed that undertaking both aerobic and muscle-strengthening physical activity at recommended levels (1) versus not meeting either recommendation (adjusted HR= 0.71 [95% CI: 0.57 to 0.87]) as well as adherence to just the strength exercise recommendation versus not adhering (HR= 0.80 [95% CI: 0.70 to 0.91]) was associated with significantly lower risk of all-cause mortality (84). These data affirm that health benefits associated with muscle-strengthening exercise were independent of aerobic physical activity and also provide evidence to support recommending a frequency of 2 days per week of muscle-strengthening exercise. Other findings reported by Dinu et al. (2019) provided supporting evidence reaffirming that physical activity undertaken in domains other than leisure (or recreation) can be beneficial and specifically showed that active commuting (i.e. walking and cycling for transport) can significantly lower risk of all-cause mortality (RR= 0.92 [95% CI: 0.85–0.98]) (85). Recent research provides evidence demonstrating that for those who participate in active commuting (i.e. walking or cycling for transport), there is reduced risk of cardiovascular disease (coronary heart disease, stroke and heart failure) compared with those participating in no active commuting (RR= 0.91 [95% CI 0.83 to 0.99]) (85); and that there is sufficient evidence from these health outcomes to conclude that activity in different domains can be beneficial. However, there is insufficient evidence to differentiate the effect of different domains of physical activity on every health outcome. For example, there is insufficient evidence to determine if the association between physical activity and cancer risk or type-2 diabetes incidence varies by type or domain of physical activity. ADULTS (aged 18–64 years) For mental health outcomes, evidence (35) shows that a variety of types of physical activity, including aerobic activity, walking, muscle-strengthening activity, and yoga can provide beneficial effects for reducing symptoms of depression and development of anxiety (74, 79, 86). For example recent evidence for the beneficial effects of resistance exercise interventions and mental health was provided by two reviews reporting moderately large reductions in symptoms of depression (77) and small reductions in symptoms of anxiety (78) compared with control conditions. Evidence from a new review affirmed that high levels of occupational physical activity is associated with reduced risk of many cancers, coronary heart disease, and type- 2 diabetes (40). However, higher levels of occupational physical activity may also be associated with an increased risk of osteoarthritis, poor sleep quality, and all-cause mortality among males (but not among females). There is insufficient evidence to determine the relationship between occupational physical activity and adiposity, prevention of body weight gain, mental health, and health-related quality of life (40). There is also insufficient evidence to determine if the association between physical activity and cancer risk varies by type or domain of physical activity. There is less evidence on associations by different domains of physical activity, and therefore it was difficult to differentiate the effect of different domains of physical activity on various health outcomes. The GDG concluded that: • There is moderate certainty evidence that muscle- strengthening activities undertaken on 2 or more days a week, provide additional health benefits, but there is insufficient evidence to specify a specific duration for optimal health benefits. • There is moderate certainty evidence that physical activity undertaken in different domains (e.g. leisure, transport, occupational) can provide health benefits, although currently it is not possible to differentiate the effect of different domains of physical activity on various health outcomes. • Although higher levels of occupational physical activity may be associated with an increased risk of osteoarthritis, poor sleep quality, and all-cause mortality among males (but not among females), overall there is moderate certainty evidence that occupational physical activity can provide health benefits. 36 37Recommendations Supporting evidence and rationale For these guidelines, the synthesis of evidence undertaken by PAGAC (35) was used and updated. The GDG considered the entire body of evidence, including both the findings reported by PAGAC and the 13 new reviews that met inclusion criteria, to contribute evidence on the association between sedentary behaviour and health- related outcomes in adults. Investigating the association between sedentary behaviour and health outcomes is a relatively new field of public health compared with that of physical inactivity, yet it has developed rapidly in the past decade. Studies have typically measured sedentary behaviour using either i) self-report questionnaires which ask about “total time” spent in sedentary behaviours, or time spent in specific behaviours, such as television viewing, computer/screen use, and sitting; or ii) device-based assessments. There are no standardized measures or analytical protocols for sedentary behaviour and thus the reporting of results is heterogeneous. Recent methodological developments include the use of device-based assessment of time spent sedentary which can reduce measurement error and other biases inherent in self-reported recall. In considering the total body of evidence, the GDG gave greater emphasis to evidence provided by reviews graded moderate and above, taken from reviews providing evidence from studies using measures of total sedentary or sitting time, or device-based measures of sedentary behaviour where available. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . Research on the potential adverse health effects associated with sedentary behaviour has rapidly accumulated during the past decade. In more recent studies, notable developments include an increase in evidence reporting on dose-response relationships between sedentary behaviour and multiple health outcomes, and on the interplay between sedentary behaviour and physical activity. In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and type-2 diabetes. It is recommended that: Adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults should aim to do more than the recommended levels of moderate- to vigorous- intensity physical activity. Strong recommendation, moderate certainty evidence Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf For adults, sedentary behaviour is defined as time spent sitting or lying with low energy expenditure, while awake, in the context of occupational, educational, home and community settings, and transportation. SEDENTARY BEHAVIOUR RECOMMENDATION ADULTS (aged 18–64 years) 38 39 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ADULTS (aged 18–64 years) In adults (aged over 18 years), what is the association between sedentary behaviour and health-related outcomes? Overall, there is evidence of an association between greater time spent in sedentary behaviour (examined mostly via self-reporting or device-based assessments of sitting or television viewing time) and higher all-cause mortality, cardiovascular mortality, cardiovascular disease incidence and type-2 diabetes incidence (8, 35, 65, 87). For example, supporting evidence includes results from a recent large meta-analysis (n= 36 383; mean age 62.6 years; 72.8% women) of accelerometer assessed total sedentary time and all-cause mortality (65) and showed that increasing time spent in sedentary behaviour was significantly associated with all-cause mortality. Similar findings from a meta-analysis comprising more than 1 million participants (87) showed associations for total sedentary behaviour with all-cause mortality, and cardiovascular disease mortality, after adjustment for physical activity (87), although in this study the associations with cancer mortality were not statistically significant after adjustment for physical activity (87). Another recent meta-analysis (8) reported significant associations between sedentary behaviour (assessed as sitting) and cardiovascular disease and cancer mortality, with results indicating a 9–32% (p for trend < 0.001) higher risk of cardiovascular disease mortality with higher levels of sedentary behaviour when measured as sitting time in the “inactive”, lowest quartile of physical activity (~ 5 min/day). The study reported that adults who were sedentary (sitting) for more than 8 hours per day had a higher risk of cardiovascular disease mortality, except for those who were “most active” (i.e. > 35.5 MET-hours/week, or ~ 60–75 mins/ day), where the association was mitigated. Results on the associations between sedentary behaviours and cancer mortality were generally weaker, although a 6–21% higher dose-related risk was observed with longer sitting time (particularly > 8 hours/day), but only among those in the lowest quartile of physical activity (< 2.5 MET-hours/week) (8). Evidence supports an association between sedentary behaviour (measured as total sitting time) and increased incident cardiovascular disease (HR= 1.29 [95% CI: 1.27 to 1.30]) which was attenuated following adjustment for potential covariates, including level of physical activity (HR= 1.14 [95% CI: 1.04 to 1.23]) (88). A review of studies in south-east Asian populations provided evidence of low certainly that greater sedentary time was associated with an increased likelihood of unfavourable cardiometabolic indicators (including type-2 diabetes, higher BMI, higher blood pressure) (89). Two recent reviews report on the association of total daily sitting time (88) and total sedentary behaviour and television viewing (87) with type-2 diabetes incidence. Both studies found a higher level of sedentary behaviour was associated with increased risk of type-2 diabetes incidence. For example, a linear association with type-2 diabetes was observed for total sedentary behaviour (RR= 1.01 [95% CI: 1.00 to 1.01] p= < 0.001) and television viewing (RR= 1.09 [95% CI: 1.07 to 1.12] p= < 0.001), when adjusted for physical activity (87). There is also supporting evidence for a significant association between sedentary behaviour (when measured as time spent viewing television) and cancer mortality (35, 87). Several more recent reviews, of low and very low certainty, provide supporting evidence for an association between sedentary behaviours and colorectal cancer (90), but no associations with incident prostate, breast or rectal cancer (90–93). Additional evidence (35) reported significant associations between greater time spent in sedentary behaviour and higher risk of developing endometrial, colon and lung cancers (35). There is low certainty evidence of an unfavourable relationship between time spent in sedentary behaviour and adiposity and other indicators of weight status, and whether the relationship between sedentary behaviour and weight status varies by amount of moderate- to vigorous-intensity physical activity. Overall, it was concluded that there was insufficient evidence to inform these recommendations/guidelines and that further research is needed. There is limited evidence assessing adverse effects of reducing sedentary time. Expert opinion informed the conclusion that recommending the reduction in sedentary time would be unlikely to increase risk of injury, especially if replaced with light-intensity physical activity. 38 39Recommendations The GDG concluded that: • Overall there is sufficient evidence to support the development of a new WHO recommendation to limit sedentary behaviour to reduce health risks. • There is moderate certainty evidence of an association between greater time spent in sedentary behaviour and higher all-cause mortality, cardiovascular disease mortality, cancer mortality and incidence of cardiovascular disease and type-2 diabetes. • There is low to moderate certainty evidence of an association between greater time spent in sedentary behaviour and higher risk of incident endometrial, colon, and lung cancers. • There is insufficient evidence on the association between sedentary behaviour and measures of adiposity and further research is needed. • The benefits of limiting sedentary behaviour outweigh any potential risks. Is there a dose-response association (total volume, frequency, duration, intensity of interruption)? Overall, moderate certainty evidence indicates a non- linear dose-response relationship between sedentary time (sitting or television viewing time assessed by self-reporting, or by device-based assessments) and all- cause mortality, cardiovascular disease mortality, cancer mortality, and incident cardiovascular disease (8, 35, 87). A recent meta-analysis provided high certainty evidence on the dose-response relationship between accelerometer assessed total sedentary time and all-cause mortality (65) reporting that increasing time spent in sedentary behaviour was significantly associated with all-cause mortality. The hazard ratios for increasing quartiles of sedentary time were 1.00 (referent; least sedentary); 1.28 (1.09– 1.51); 1.71 (1.36–2.15); and 2.63 (1.94–3.56), after adjustment for potential confounders including time spent in moderate- to vigorous-intensity physical activity (65). This analysis of dose-response relations between sedentary time and mortality showed risk increased gradually from about 7.5–9 hours and was more pronounced at greater than 9.5 hours. Sedentary behaviour of 10 hours and 12 hours each day were associated with 1.48 (1.22–1.79) and 2.92 (2.24–3.83) higher risk of death, respectively (65). Another recent meta-analysis assessed dose-response and reported non-linear associations for total sedentary time and all-cause mortality (RR per 1 hour/day = 1.01 (1.00–1.01) for ≤ 8 hours/day; and 1.04 (1.03–1.05) for > 8 hours/day of exposure); and cardiovascular disease mortality (RR= 1.01 (0.99–1.02) for ≤ 6 hours/day; and RR= 1.04 (1.03–1.04) for > 6 hours/day) after adjustment for physical activity (87). In this same study, a small linear dose-response association between type-2 diabetes was observed for total sedentary behaviour (1.01 (1.00– 1.01)) when adjusted for physical activity and television viewing (1.09 (1.07–1.12)) (87). Overall, evidence supports that higher amounts of sedentary behaviour are associated with less favourable health outcomes and it was concluded that there is sufficient evidence to support minimizing sedentary time to reduce health risks. However, given the considerable variations in how sedentary behaviour was assessed across reviews (via self-reported sitting time, television viewing time, or device-based (accelerometer) assessments) and the probability that thresholds for sedentary time might vary across health outcomes, by levels of moderate- to vigorous-intensity physical activity, and among population subgroups, there is insufficient evidence to set a time-based (quantified) recommendation. In addition to overall volume of sedentary behaviour, evidence on the patterns by which sedentary behaviour is accrued was reviewed. However, there was limited evidence to make recommendations on the frequency and/or duration of breaks in sedentary behaviour. The GDG concluded that: • There is insufficient evidence to set quantified (time- based) recommendations on sedentary behaviours. • There is insufficient evidence to make recommendations on the frequency and/or duration of breaks in sedentary behaviour. ADULTS (aged 18–64 years) 40 41 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Does the association vary by type and domain of sedentary behaviour? Some domains or different types of sedentary behaviour may be more detrimental than others, both in terms of their direct associations and in their potential to displace time spent in more healthful physical activity. Although there has been a rapid growth in research on sedentary behaviour, there is limited evidence available directly comparing the association between different types of sedentary behaviour and different health outcomes. For example, some studies report stronger results with sedentary behaviour measured as television viewing compared with total sitting time (87). This may be due to the differential measurement error or residual confounding associated with self-report measures and instruments. Currently, there is insufficient evidence to determine the different associations with different health outcomes and how these may vary by subpopulation. A growing number of studies are using device- based measures of physical activity and sedentary time in relation to health outcomes. However, some misclassification may occur from device-based measures of sedentary time as many of these device placements (e.g. wrist, waist) do not currently distinguish between positions (e.g. lying, sitting and standing still). Future research using harmonized reporting, and methods that distinguish between positions, will help to strengthen the knowledge on the patterns of sedentary behaviour. The GDG concluded that: • There is insufficient evidence to make recommendations on different types or domains of sedentary behaviour. ADULTS (aged 18–64 years) Does level of physical activity modify the effect of sedentary behaviour on mortality? The increased interest in the impact of sedentary behaviour on health outcomes has stimulated investigation into the potential interplay between different levels of physical activity and levels of sedentary behaviour. Based on available research, there is moderate certainty evidence that the relationship between sedentary behaviour and all-cause mortality, cardiovascular disease mortality and cancer mortality varies by amount of moderate- to vigorous-intensity physical activity (8, 9, 35). Overall findings show that the effect of sedentary behaviour is stronger in those who do low amounts of moderate- to vigorous-intensity physical activity or, phrased conversely, that higher amounts of moderate- to vigorous-intensity physical activity can mitigate the unfavourable health outcomes associated with higher levels of sedentary behaviours. The risk associated with sedentary time and all-cause mortality has been shown to be more pronounced at lower levels of physical activity than at higher levels (35). In a harmonized meta-analysis, Ekelund et al. investigated the joint and stratified effects of sedentary behaviour and physical activity with all-cause mortality in more than 1 million men and women, and showed that the associations differed depending on the level of physical activity (9). The analyses used quartiles of sedentary behaviour (sitting) and quartiles of moderate- to vigorous-intensity physical activity, and found that compared with the referent (< 4 hours of sitting per day and highest quartile of moderate- to vigorous-intensity physical activity [> 35.5 MET-hours/ week]), there was no increased risk of dying during follow-up in those who sat for more than 8 hours per day but who also reported more than 35.5 MET- hours per week of activity (HR= 1.04 [95% CI: 0.99 to 1.10]). In contrast, those who sat the least (< 4 hours/ day) and were in the lowest (< 2.5 MET-hours/week) physical activity quartile had a significantly increased risk of dying during follow-up (HR= 1.27 [95% CI: 1.22 to 1.31]). The study concluded that levels of moderate- to vigorous-intensity physical activity of about 60–75 minutes per day (the highest quartile) can attenuate, and even eliminate, the detrimental association between sedentary behaviour and health outcomes (9). 40 41Recommendations ADULTS (aged 18–64 years) G O O D P R A C TI C E ST A TE M EN TS This relationship between levels of sedentary behaviour and moderate- to vigorous-intensity physical activity was summarized in the systematic review by PAGAC (35) as shown in Figure 2. Another recent study provided new evidence investigating the same associations with cause-specific mortality and showed similar findings (8). In a large harmonized meta-analysis (9 studies, n= 850 000, CVD mortality; 8 studies, n= 777 000, cancer mortality), results showed that higher levels of moderate- to vigorous- intensity physical activity mitigated the increased risk of cardiovascular disease mortality with high levels of sedentary behaviour, whether measured as time spent sitting or time spent viewing television (8). The study showed that in individuals who were sitting for more than 8 hours per day, there was an association with higher risk of death, except in the most active quartile, where the association was mitigated. More specifically, the hazard of cardiovascular disease mortality was 32% higher in those who sat for more than 8 hours per day compared with the reference group (< 4 hours/day) (p for trend < 0.001). The results were less pronounced but remained significant compared with the reference group for the other quartiles of physical activity (2nd quartile, HR= 1.11 [95% CI: 1.03 to 1.20]; 3rd quartile, HR= 1.14 [95% CI: 1.03 to 1.26]). Similar associations were observed for television time and cardiovascular disease mortality across strata of moderate- to vigorous- intensity physical activity (8). The associations for cancer mortality were more mixed, although generally showed that higher levels of physical activity attenuated the detrimental effects of sedentary behaviour when assessed as total sitting time. Based on this evidence, it was agreed that higher levels of moderate- to vigorous-intensity physical activity should be recommended for those individuals who undertake high levels of sedentary behaviour and that the benefits would outweigh the risks. The GDG concluded that: • There is moderate certainty evidence that the relationship between sedentary behaviour and all-cause mortality, cardiovascular disease and cancer mortality varies by amount of moderate- to vigorous-intensity physical activity. • Higher amounts of moderate- to vigorous-intensity physical activity can attenuate the detrimental association between sedentary behaviour and health outcomes. Figure 2: The relationship between levels of sedentary behaviour and physical activity Adapted from PAGAC More physical activity M or e se d en ta ry t im e HIGH RISK LOW RISK Less sedentary tim e & m ore physical activity Increase physical activityRed u ce sedentary time 42 43 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r OLDER ADULTS (aged 65 years and older) In older adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site-specific cancers, incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression), cognitive health, and sleep; measures of adiposity may also improve. In older adults, physical activity helps prevent falls and falls-related injuries and declines in bone health and functional ability. It is recommended that: All older adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Older adults should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence Older adults should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence As part of their weekly physical activity, older adults should do varied multicomponent physical activity that emphasizes functional balance 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 Older adults may increase moderate- intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week, for additional health benefits. Conditional recommendation, moderate certainty evidence For older adults, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), transportation (wheeling, walking and cycling), work, or household chores, in the context of daily occupational, educational, home or community settings. PHYSICAL ACTIVITY RECOMMENDATION • Doing some physical activity is better than doing none. • If older adults are not meeting the recommendations, doing some physical activity will bring benefits to health. • Older adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • Older adults should be as physically active as their functional ability allows, and adjust their level of effort for physical activity relative to their level of fitness. G O O D P R A C TI C E ST A TE M EN TS 42 43Recommendations Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Supporting evidence and rationale For these guidelines, for older adults, the comprehensive synthesis of evidence undertaken by PAGAC (35) was used and updated. Fifteen reviews met the inclusion criteria and informed the examination of the association between physical activity and health-related outcomes specific to older adults (falls prevention, fall-related injuries, physical function, frailty, and osteoporosis). The evidence for falls prevention used and updated the 2019 Cochrane Collaboration Systematic Review by Sherrington et al. (42), with evidence published from the end search date of their original review, to November 2019 (9 new studies). A search for existing systematic reviews on osteoporosis and sarcopenia was conducted in PubMed for reviews published from 2008 through to November 2019 and identified no new reviews and 8 new studies. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . In older adults (aged 65 years and over), what is the association between physical activity and health-related outcomes? The primary evidence base for assessing the associations between physical activity and health outcomes, such as all-cause and cause-specific mortality, cardiovascular disease, type-2 diabetes, cancer incidence, adiposity, mental health, and cognitive outcomes in older adult populations was the same scientific literature collated and reviewed for adult populations. This same body of evidence was accepted and extrapolated to older adults because the majority of studies stated no upper age limit criterion and therefore included adults over the age of 65 years. A further review of evidence was conducted to examine and inform on the association between physical activity and health-related outcomes specific to older adults, including falls prevention, fall-related injuries, physical function, frailty and osteoporosis. Declining physical capacity in older people often manifests in falls and fall-related injuries that can have serious consequences. Accidental falls are due to a combination of extrinsic (environmental) and intrinsic (e.g. musculoskeletal or nervous system abnormalities affecting postural control) factors. Evidence demonstrates that physical activity – in particular multicomponent physical activity programmes that include combinations of balance, strength, endurance, gait, and physical function training – is associated with a reduced rate of falls and risk of injury from falls in older adults. Recent evidence demonstrates that exercise may reduce the rate of falls by as much as 23% (pooled rate ratio (RaR) 0.77 [95% CI: 0.71 to 0.83]) in older adults, which can significantly reduce the risk of injury from falls, including severe falls that result in bone fracture, head trauma, open wound, soft tissue injury, or any other injury requiring medical care or admission to hospital (42). This evidence was consistent with, and reaffirmed findings in, other reviews (35). After reaching a peak in early adulthood, muscle and bone mass tends to decline with increasing age (i.e. sarcopaenia and osteopaenia/osteoporosis), and this can be associated with declining strength and physical function. Evidence demonstrates that regular physical activity improves physical function and reduces the risk of age-related loss of physical function in older adults. Findings show beneficial effects on dynamic balance (SMD= 1.10 [95% CI: 0.29 to 1.90]); muscle strength (SMD= 1.13 [95% CI: 0.30 to 1.96]); flexibility (SMD= 1.22 [95% CI: 0.39 to 2.04]); and cardiorespiratory fitness (SMD= 1.48 [95% CI: 0.42 to 2.54]) (94). Evidence also shows that higher levels of physical activity may improve bone health and thus prevent osteoporosis in older adults (pooled standardized effect size 0.21 [95% CI: 0.06 to 0.36]) (95). Physical activity interventions may improve lumbar spine and femoral neck (hip) bone mineral density. The GDG concluded that: • There is moderate certainty evidence that physical activity improves physical function and reduces risk of age-related loss of physical function in the general ageing population. • There is low-certainty evidence that the risks for the amounts and types of physical activity recommended for older adults are low and are outweighed by the benefits. OLDER ADULTS (aged 65 years and over) 44 45 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Is there a dose-response association (volume, duration, frequency, intensity)? Evidence shows an inverse relationship between the amount of physical activity performed by older adults and the risk of physical function limitations. In general, more physical activity (frequency, duration and/or volume) is associated with greater benefits (35). Evidence suggests that fast-intended velocity resistance training may be superior to moderate-velocity resistance training for improvements in general functional capacity (SMD= 0.41 [95% CI: 0.18 to 0.65]; and SPPB (SMD= 0.52 [95% CI: 0.10 to 0.94])) (96). There is limited evidence examining the dose-response relationship between physical activity and prevention of falls; however the majority of studies providing supportive evidence show testing a programme consistent with 3 days per week. The GDG concluded that: • There is high certainty evidence of an inverse dose- response relationship between volume of aerobic physical activity and risk of physical functional limitations in the general older adult population. Does the association vary by type or domain of physical activity? Physical activity programmes that include combinations of balance, strength, endurance, gait, and physical function training are associated with a reduced rate of falls and risk of injury from falls in older adults. Evidence from a review of 11 RCT showed that by engaging in a variety of different physical activity interventions (commonly balance and functional exercises plus resistance exercises), older adults can reduce rate of falls by up to 28% (RaR= 0.72 [95% CI: 0.56 to 0.93]) (42). The effect of resistance exercises was uncertain and based on limited data (RR= 0.97 [95% CI: 0.14 to 6.49]; 1 trial; n= 73) (42). Evidence also suggests that programmes which include multiple exercise types have greater positive effects on bone health (standardized effect size 0.45 [95% CI: 0.20 to 0.71]; p= 0.001), compared with those which do not (95). The GDG concluded that: • There is high certainty evidence that higher levels of physical activity that combines balance, strength, gait, and functional training (e.g. multicomponent physical activity) are associated with a reduced rate of falls and risk of injury from falls in older adults. • There is moderate certainty evidence that programmes involving multiple exercise types may have significant effects on bone health and osteoporosis prevention. OLDER ADULTS (aged 65 years and over) 44 45Recommendations OLDER ADULTS (aged 65 years and older) Supporting evidence and rationale Sedentary behaviour was not included in the 2010 Global recommendations on physical activity for health (1). Due to a lack of population-specific evidence, the primary evidence base for assessing the associations between sedentary behaviour and health outcomes in older adult populations was the same scientific literature collated and reviewed for adult populations because the majority of studies stated no upper age limit criterion and therefore included adults over the age of 65 years. The findings from evidence on sedentary behaviours in the general adult population were reviewed, including assessing if there was evidence that the outcomes would be any different, or would not apply to, or would be contraindicated, for older adults. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . In older adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Older adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, older adults should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, moderate certainty evidence For older adults, sedentary behaviour is defined as time spent sitting or lying with low energy expenditure, while awake, in the context of occupational, educational, home and community settings and transportation. SEDENTARY BEHAVIOUR RECOMMENDATION Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 46 47 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r PREGNANT AND POSTPARTUM WOMEN PREGNANT AND POSTPARTUM WOMEN PHYSICAL ACTIVITY RECOMMENDATION For pregnant and postpartum women, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), transportation (wheeling, walking and cycling), work, household chores, in the context of daily occupational, educational, home and community settings. These guidelines address physical activity and maternal and fetal health outcomes during pregnancy and the postpartum period. They are for all pregnant and postpartum women, irrespective of age, cultural background, or socioeconomic status. Pregnancy and the period after delivery are stages in a woman’s life, and the benefits of being physically active throughout adulthood are detailed in the recommendations provided for adults. Pregnant and postpartum women should be under the care of a health-care provider for antenatal and postnatal care who can advise on special considerations given their medical history and any contraindications to participating in physical activity during pregnancy or in the postpartum period. These guidelines are public health and population- based. Clinical guidance should be sought for women with complications associated with pregnancy or delivery. Pregnant and postpartum women should try to meet these recommendations where possible, as able, and without contraindication. In pregnant and postpartum women, physical activity during pregnancy and postpartum confers benefits on the following maternal and fetal health benefits: decreased risk of pre-eclampsia, gestational hypertension, gestational diabetes, excessive gestational weight gain, delivery complications and postpartum depression, and fewer newborn complications, no adverse effects on birthweight; and no increase in risk of stillbirth. It is recommended that all pregnant and postpartum women without contraindication should: undertake regular physical activity throughout pregnancy and postpartum; Strong recommendation, moderate certainty evidence do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week for substantial health benefits; and Strong recommendation, moderate certainty evidence incorporate a variety of aerobic and muscle-strengthening activities. Adding gentle stretching may also be beneficial. Strong recommendation, moderate certainty evidence In addition: Women who, before pregnancy, habitually engaged in vigorous-intensity aerobic activity, or who were physically active, can continue these activities during pregnancy and the postpartum period. Strong recommendation, moderate certainty evidence 46 47Recommendations G O O D P R A C TI C E ST A TE M EN TS • Doing some physical activity is better than doing none. • If pregnant and postpartum women are not meeting the recommendations, doing some physical activity will benefit their health. • Pregnant and postpartum women should start by doing small amounts of physical activity, and gradually increase frequency, intensity and duration over time. • Pelvic floor muscle training may be performed on a daily basis to reduce the risk of urinary incontinence. Additional safety considerations for pregnant women when undertaking physical activity are: • Avoid physical activity during excessive heat, especially with high humidity; • Stay hydrated by drinking water before, during, and after physical activity; • 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 high altitude); • Avoid activities in supine position after the first trimester of pregnancy; • When considering athletic competition, or exercising significantly above the recommended guidelines pregnant women should seek supervision from a specialist health-care provider; • Pregnant women should be informed by their health-care provider of the danger signs alerting them as to when to stop; or to limit physical activity and consult a qualified health-care provider immediately should they occur; • Return to physical activity gradually after delivery, and in consultation with a health-care provider, in the case of delivery by Caesarean section. PREGNANT AND POSTPARTUM WOMEN Supporting evidence and rationale For these Guidelines on physical activity and sedentary behaviour (2020) for pregnant and postpartum women, the evidence syntheses from 7 systematic reviews addressing the critical and important outcomes (28–34) were used and updated. Four of the 7 reviews met inclusion criteria. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf In pregnant and postpartum women, what is the association between physical activity and health-related outcomes? Physical activity before and during pregnancy can help reduce the risk of common complications of pregnancy. Engaging in physical activity during pregnancy is significantly associated with reduced gestational weight gain (MD= 1.14 kg [95% CI: 1.67 to 0.62]) (97), and a reduced risk of gestational diabetes (RR= 0.71 [95% CI: 0.57 to 0.89]) (97), as is being physically active before pregnancy (OR= 0.70 [95% CI: 0.57 to 0.85]) (31, 34, 97), including in women with overweight or obesity (97). Physical activity during pregnancy does not appear to increase the incidence of gestational hypertension or preeclampsia (31). Evidence suggests that among pregnant women with overweight or obesity, there is no significant difference in the incidence of gestational hypertension (RR= 0.63 [95% CI: 0.38 to 1.05]) or in preeclampsia (RR= 1.39 [95% CI: 0.66 to 2.93]) between physical activity intervention groups versus standard antenatal care (97). There have been long-standing concerns about potential adverse effects of maternal physical activity on the developing fetus and delivery. However, recent evidence demonstrates that physical activity is not associated with increased risk of the incidence of miscarriage, stillbirth or delivery complications (32). Evidence suggests no difference in the incidence of Caesarean delivery among pregnant women with overweight or obesity between physical activity intervention groups versus standard antenatal care (97). Physical activity during pregnancy is not associated with increased risk of adverse effects on birthweight (98) or preterm birth (32), and may even be protective, reducing the overall risk (98), even among pregnant women with overweight or obesity (RR= 1.02 [95% CI: 0.54 to 1.92]) or 48 49 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r PREGNANT AND POSTPARTUM WOMEN large-for-gestational-age babies (RR= 0.90 [95% CI: 0.65 to 1.25]) between physical activity intervention groups versus standard antenatal care) (97). In the postpartum period, mothers can experience many physical and emotional changes. Evidence demonstrates that physical activity during pregnancy may be inversely associated with postpartum depression (29). Evidence from a meta-analysis of 6 trials and 11 observational studies of physical activity during pregnancy (99) showed a significant inverse relationship between physical activity during pregnancy and postpartum depression (SMD= 0.58 [95% CI: 1.09 to 0.08]). The effect was stronger when limited to 5 studies with at least moderate-intensity interventions (SMD= 0.70 [95% CI: 1.19 to 0.22]) (99). The GDG concluded that: • There is high certainty evidence that physical activity during pregnancy may reduce gestational weight gain and risk of gestational diabetes mellitus. • There is moderate to high certainty evidence that physical activity does not increase the incidence of gestational hypertension. • There is moderate certainty evidence that physical activity does not increase the incidence of miscarriage, stillbirth or delivery complications; and moderate certainty evidence of a reduced risk of preterm birth for mothers engaged in vigorous-intensity physical activity. • There is low to moderate certainty evidence that physical activity does not increase the risk of low birth weight, or small-for-gestational-age, or large-for- gestational-age babies. • There is low certainty evidence that physical activity during pregnancy is associated with lower levels of postpartum depression. • The risks for the amounts and types of physical activity recommended for pregnant and postpartum women are low and are outweighed by the benefits. Is there a dose-response association (volume, duration, frequency, intensity)? Across the evidence on physical activity during pregnancy and the postpartum period, the interventions varied in the amount (i.e. dose) of physical activity, both in duration in minutes and frequency per week. In general, the evidence available reflected a frequency of aerobic physical activity of at least 3 times per week, typically for between 30 and 60 minutes. This evidence is taken from studies assessing the health impact of a dose broadly consistent with the amount of activity recommended for the general adult population – namely 150 minutes of moderate-intensity physical activity per week. While more physical activity (frequency, duration and/or volume) is generally found to be associated with greater benefits, further research is needed to understand in more detail the dose-response relationship. Participating in higher versus lower amounts of leisure time physical activity pre-pregnancy is associated with a significantly lower risk of gestational diabetes (OR= 0.54 [95% CI: 0.34 to 0.87]) (100). There is also evidence of a small, but significant, reduced risk of preterm birth in babies of mothers who engaged in vigorous-intensity physical activity (RR= 0.20 [95% CI: 0.36 to 0.03]) (98). No evidence was identified regarding the safety or additional benefit of exercising at levels significantly above the recommendations. The GDG concluded that: • There is insufficient evidence to determine a dose- response association between physical activity and specific critical health outcomes during pregnancy and the postpartum period. • The overall evidence shows benefits to critical health outcomes and is based on interventions that are broadly consistent with the amount of physical activity recommended for the general adult population, namely 150 minutes of moderate-intensity physical activity per week. • There was no reason to alter the amount or frequency of recommended moderate-intensity physical activity for pregnant and postpartum women compared with the general adult population. • There is moderate certainty evidence of a reduced risk of preterm birth for mothers engaged in vigorous- intensity physical activity. 48 49Recommendations Does the association vary by type or domain or timing (pre-pregnancy, antenatal or postnatal) of physical activity? Evidence is available from studies that mostly assessed leisure domain physical activity; the type of activity was mostly aerobic (such as walking or swimming), although there is some evidence from studies assessing interventions that also included strength training (e.g. circuit training), or combinations of aerobic and muscle-strengthening exercise. However, overall there is insufficient evidence to determine if the associations between physical activity and health outcomes vary by type or domain or timing (pre-pregnancy, antenatal or postnatal) of physical activity. The GDG concluded that: • There is moderate certainty evidence that pregnant and postpartum women should incorporate a variety of aerobic and muscle-strengthening activities. Gentle stretching may also be beneficial. PREGNANT AND POSTPARTUM WOMEN 50 51 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Supporting evidence and rationale Sedentary behaviour was not included in the 2020 Global recommendations on physical activity for health (1). Due to a lack of population-specific evidence, the primary evidence base for assessing the associations between sedentary behaviour and health outcomes in pregnant and postpartum women was the scientific literature collated and reviewed for adult populations. The findings from evidence on sedentary behaviours in the general adult population were reviewed, including assessing whether the outcomes would be any different, or would not apply to, or would be contraindicated, for pregnant and postpartum women. In pregnant and postpartum women, as in all adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Pregnant and postpartum women should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence For pregnant and postpartum women, sedentary behaviour is defined as time spent sitting or lying with low energy expenditure while awake, in the context of occupational, educational, home and community settings and transportation. SEDENTARY BEHAVIOUR RECOMMENDATION PREGNANT AND POSTPARTUM WOMEN Based on available evidence and expert opinion, the evidence was extrapolated to inform the new WHO recommendations on sedentary behaviour for pregnant and postpartum women for the common set of critical health outcomes. Due to indirectness of the evidence, the level of certainty was downgraded. Given the lack of evidence specific to this population, and that pregnant women were excluded from studies, the recommendation to increase levels of physical activity beyond recommended levels to counter the detrimental effect of high sedentary behaviour was not extrapolated for women during pregnancy and the postpartum period. The GDG concluded that: • The evidence on sedentary behaviours in the general adult population could be extrapolated to inform recommendations for pregnant and postpartum women for the common set of critical health outcomes. • The benefits of minimizing sedentary behaviour outweigh the risks for pregnant and postpartum women. • The certainty of the evidence should be downgraded due to indirectness. 50 51Recommendations ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) To date, most physical activity guidelines for people with chronic conditions have been limited to clinical or therapeutic guidance. For example, there are clinical practice recommendations and resources developed by the professional medical associations for oncology (101), type-2 diabetes (102), hypertension (103), and other chronic diseases (104). WHO also has clinical practice guidance which includes recommending physical activity to patients with chronic disease (17). These guidelines are the first WHO population-based guidelines on physical activity for people living with chronic conditions, specifically those living with cancer (from here on referred to as “cancer survivors”), hypertension, type-2 diabetes, and HIV. Given the advances of effective and widely available antiretroviral treatment for HIV, this condition is now also considered a chronic condition. For patients undergoing acute treatment (e.g. chemotherapy), or not yet stabilized on their chronic medication, health-care providers should also refer to clinical practice guidelines relevant to each chronic condition. PHYSICAL ACTIVITY RECOMMENDATION For adults living with chronic conditions, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), transportation (wheeling, walking and cycling), work or household chores, in the context of daily occupational, educational, home or community settings. All adult cancer survivors and those living with hypertension, type-2 diabetes and HIV, should try to meet these recommendations where possible, as able and without contraindication. Physical activity can confer health benefits for adults and older adults living with the following chronic conditions: for cancer survivors – physical activity improves all-cause mortality, cancer-specific mortality, and risk of cancer recurrence or second primary cancer; for people living with hypertension – physical activity improves cardiovascular disease mortality, disease progression, physical function, health-related quality of life; for people living with type-2 diabetes – physical activity reduces rates of mortality from cardiovascular disease and indicators disease progression; and for people living with HIV – physical activity can improve physical fitness and mental health (reduced symptoms of anxiety and depression), and does not adversely affect disease progression (CD4 count and viral load) or body composition. It is recommended that: All adults and older adults with these chronic conditions should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults and older adults with these chronic conditions should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence G O O D P R A C TI C E ST A TE M EN TS 52 53 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) Adults and older adults with these chronic conditions should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional benefits. Strong recommendation, moderate certainty evidence As part of their weekly physical activity, older adults with these chronic conditions should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence When not contraindicated, adults and older adults with these chronic conditions may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence • When not able to meet the above recommendations, adults with these chronic conditions should aim to engage in physical activity according to their abilities. • Adults with these chronic conditions should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • Adults with these chronic conditions may wish to consult with a physical activity specialist or health-care professional for advice on the types and amounts of activity appropriate for their individual needs, abilities, functional limitations/ complications, medications, and overall treatment plan. • Pre-exercise medical clearance is generally unnecessary for individuals without contraindications prior to beginning light- or moderate-intensity physical activity not exceeding the demands of brisk walking or everyday living. G O O D P R A C TI C E ST A TE M EN TS Supporting evidence and rationale The scope of these guidelines assessed the associations between physical activity and the following health outcomes: for cancer survivors – all-cause mortality, cancer-specific mortality, and risk of cancer recurrence or second primary cancer; for people living with hypertension – cardiovascular disease mortality, risk of co-morbid conditions, physical function, health-related quality of life, and disease progression (here defined as the blood pressure response to physical activity); for people living with type-2 diabetes – cardiovascular disease mortality, risk of co-morbid conditions, physical function, health-related quality of life, and disease progression; and for people living with HIV – physical function (physical fitness, exercise tolerance and strength), health-related quality of life, mental health (symptoms of anxiety and depression), cardiometabolic disease risk indicators (blood lipids, blood glucose and body composition) and adverse effects on disease progression (namely CD4 count and viral load). The evidence informing these guidelines was the report of PAGAC (35) which was updated with 16 new reviews identified from 2017 to 2019 for cancer (n= 1), hypertension (n= 2) and type-2 diabetes (n= 13). In addition, a commissioned umbrella review on physical activity and health-related outcomes among people living with HIV provided evidence from 19 eligible reviews published 2002–2018. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 52 53Recommendations In adults and older adults (aged 18 years and over) living with cancer (cancer survivors), hypertension, type-2 diabetes, or HIV, what is the association between physical activity and health-related outcomes? Physical activity promotes beneficial short- and long- term changes in metabolic, hormonal, and inflammatory pathways, which are thought to be protective for cancer incidence and survival (35). Evidence shows that higher levels of physical activity after cancer diagnosis were found to be protective for all-cause mortality following breast cancer (HR= 0.58 [95% CI: 0.52 to 0.65], 17 studies); colorectal cancer (HR= 0.63 [95% CI: 0.50 to 0.78], 10 studies), female reproductive cancer (HR= 0.66 [95% CI: 0.49 to 0.88], 4 studies); glioma (HR= 0.64 [95% CI: 0.46 to 0.91], 1 study); hematologic cancer (HR= 0.60 [95% CI: 0.51 to 0.69], 2 studies); kidney cancer (HR= 0.60 [95% CI: 0.38 to 0.95], 1 study); lung cancer (HR= 0.76 [95% CI: 0.60 to 0.97], 2 studies); prostate cancer (HR= 0.60 [95% CI: 0.46 to 0.79], 5 studies); and stomach cancer (HR= 0.75 [95% CI: 0.61 to 0.93], 1 study) (105). Greater amounts of physical activity after cancer diagnosis are also associated with lower risks of cause-specific mortality in breast cancer, colorectal cancer, and prostate cancer survivors. The meta-analysis found reduced hazards of mortality for those in the highest versus the lowest levels of postdiagnosis total physical activity for all cancers combined (HR= 0.63 [95% CI: 0.53 to 0.75], 4 studies); breast cancer (HR= 0.63 [95% CI: 0.50 to 0.78], 13 studies); colorectal cancer (HR= 0.62 [95% CI: 0.44 to 0.86], 6 studies); and prostate cancer (HR= 0.70 [95% CI: 0.55 to 0.90], 4 studies) (105). There was, however, insufficient evidence to determine if physical activity is associated with cancer recurrence or second primary cancer. Physical activity is important for both the primary prevention and management of hypertension, with evidence showing that physical activity improves physical function, cardiovascular disease progression (i.e. blood pressure response to physical activity), and cardiovascular disease mortality in people living with hypertension (35). For example, compared with no exercise control groups, people with hypertension who are physically active can reduce systolic blood pressure by approximately 12mm Hg and diastolic blood pressure by approximately 6mm Hg (SBP MD= 12.26 mm Hg [95% CI: 15.17 to 9.34], p= < 0.05; DBP MD= 6.12 mm Hg [95% CI: 7.76 to 4.48], p= < 0.05) (106). Emerging evidence demonstrates that people with ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) hypertension who are physically active can significantly improve their health-related quality of life compared with those with hypertension who are inactive (54). Physical activity, including aerobic activity, muscle- strengthening activity, and aerobic plus muscle- strengthening activity, is associated with improved secondary indicators of risk of progression (HbA1c, blood pressure, BMI, and lipids) in adults with type-2 diabetes (35). For example, recent research found that resistance training was associated with greater reduction in HbA1c versus control groups, and that high-intensity resistance training has significant positive effects on fasting insulin (107). There is insufficient evidence to assess the effects of physical activity on health-related quality of life and physical function in adults with type-2 diabetes. Physical activity in people living with HIV improves cardiorespiratory fitness. The interventions studied involved either aerobic exercise, or exercise combined with progressive muscle-strengthening exercise, for at least 30 minutes, 3 times per week (108, 109). There is also evidence that physical activity interventions can improve markers of cardiometabolic risk (e.g. lipids) although results are mixed; no effects were established on insulin concentration, although glucose was lowered after aerobic training (110). Physical activity, whether aerobic, or combined with muscle-strengthening exercise, in people living with HIV is positively associated with health-related quality of life (111) and a reduction in symptoms of depression and anxiety (112). The meta- analysis for depression (9 studies) showed an SMD of 0.84 (95% CI: 1.57 to 0.11) favouring the intervention groups (p= 0.02). The SMD for reduction in anxiety (5 studies) was also statistically significant, favouring the intervention ( 1.23 [95% CI: 2.42 to 0.04], p= 0.04) (112). Physical activity is also associated with significant standardized mean increases in lean body mass of 1.75 kg and a significant decrease in percent body fat of 1.12% for participants in the exercising control groups, as well as an increase in peripheral leg and arm muscle area, compared with participants in the non-exercising control groups (111), but is not associated with changes in BMI or waist circumference in people living with HIV (111). Physical activity does not adversely influence markers of HIV disease progression, such as CD4 count (cells/mm3) or viral load (111). Importantly, this evidence suggests that HIV as a chronic disease will not be adversely affected by physical activity. 54 55 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r The GDG concluded that: • There is moderate certainty evidence that greater amounts of physical activity after cancer diagnosis are associated with lower risks of all-cause, cause-specific, and cancer-specific mortality in cancer survivors. • There is high certainty evidence that physical activity reduces the risk of cardiovascular disease progression in adults with hypertension. • There is moderate certainty evidence that physical activity improves physical function and health-related quality of life outcomes in adults with hypertension. • There is high certainty evidence that physical activity improves markers of disease progression (HbA1c, blood pressure, BMI, and lipids) in adults with type-2 diabetes. • There is moderate certainty evidence of an association between physical activity and improvements in fitness (maximal oxygen consumption, exercise tolerance) and muscular strength for people living with HIV, and favourable associations between physical activity and body composition, health-related quality of life, reduced symptoms of depression and anxiety, and no change in viral load or CD4 count in people living with HIV. • The benefits associated with engaging in regular physical activity in cancer survivors and people living with hypertension, type-2 diabetes, and HIV in relation to specific health outcomes, outweigh the risks. Is there a dose-response association (volume, duration, frequency, intensity)? Greater amounts of physical activity after cancer diagnosis have been linked with lower risks of all-cause, and cancer- specific mortality. Evidence demonstrates a non-linear relationship between increasing levels of post-diagnosis physical activity and breast cancer-specific and all-cause mortality up to 10–15 MET-hours per week (consistent with 150 mins/week of moderate- to vigorous-intensity physical activity) with no evidence for harms at higher levels (105). There is a suggestion of similar dose-response association for other cancer sites however there were too few studies to permit a formal meta-analysis. Further research is needed to determine strength of association. There is a clear dose-response relationship between physical activity and cardiovascular disease mortality for people living with hypertension (35). Findings show that as systolic blood pressure increases within hypertensive ranges, the risk of cardiovascular disease mortality increases, but this increased risk is attenuated with higher levels of physical activity (35). Similar to recommendations for the general population, most of the traditional interventions are based around 30–60 minutes of moderate-intensity aerobic activity, 3 days per week, and/or 2–3 sessions of resistance training per week. There is substantial evidence of an inverse curvilinear association between volume of physical activity and risk of cardiovascular mortality in adults with type-2 diabetes (113–115). Higher amounts of physical activity (from both below and at, or above the recommended levels of 150 mins/week of moderate-intensity activity) progressively reduce risk. For example, compared with doing no activity, engaging in some activity was associated with a 32% reduction in risk of cardiovascular disease mortality (adjusted HR= 0.68 [95% CI: 0.51 to 0.92]), while engaging in amounts of activity meeting physical activity guidelines or above was associated with a larger 40% reduction in risk of cardiovascular disease mortality (adjusted HR= 0.60 [95% CI: 0.44 to 0.82]) (115). Most interventions are based around 150–300 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity activity, and/ or 2–3 sessions of resistance training per week. For some outcomes (e.g. HBA1c and blood pressure) in adults with type-2 diabetes, there is evidence for a stronger effect with more aerobic activity (i.e. greater than 150 mins/week versus less than 150 mins/week), but limited evidence for intensity (35). In people living with HIV, there is insufficient evidence to establish a dose-response relationship between physical activity and body composition, or for intermediate markers of cardiometabolic diseases (such as blood lipid profiles, insulin resistance, fasting glucose concentrations or blood pressure). The majority of studies providing evidence involved physical activity interventions conducted at least 3 times a week for 12–48 weeks, and involved at least 30 minutes of moderate- to vigorous-intensity aerobic exercise alone or in combination with progressive resistance training. There is also insufficient evidence to establish more precisely the dose-response relationship for mental health and health-related quality of life outcomes. The available evidence is from studies typically assessing physical activity interventions of 3 or more times weekly. Overall there was evidence ranging from moderate to high certainty to support a physical activity recommendation of 150–300 minutes of moderate-intensity physical activity (or equivalent) for the specified populations of people living with chronic disease and the specific set of health outcomes. There was clearer evidence of higher levels of activity being associated with greater benefits in the evidence addressing people living with hypertension, ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) 54 55Recommendations type-2 diabetes and cancer survivors. The variations in the certainty and directness of the evidence according to the specific chronic condition and specific outcomes examined was acknowledged. Where evidence showed positive outcomes from strength training exercise, the frequency of activity was 2 or 3 sessions of resistance training per week. The GDG concluded that: • There is moderate certainty evidence of a dose-response relationship between physical activity and decreased all- cause mortality and cancer-specific mortality in cancer survivors. • There is high certainty evidence of a dose- response relationship between physical activity and cardiovascular disease mortality for adults with hypertension. • There is evidence of an inverse, curvilinear dose- response relationship between activity volume and risk of cardiovascular mortality among adults with type-2 diabetes. • There is insufficient evidence for a dose-response relationship between physical activity and intermediate markers of cardiometabolic diseases, body composition, and health-related quality of life symptoms of anxiety and depression in people living with HIV. • Interventions in the range of 150–300 minutes of moderate-intensity aerobic activity (or equivalent) provided favourable health outcomes, and positive outcomes from strength training exercise, where noted, with 2 or 3 sessions of resistance training per week. Does the association vary by type or domain of physical activity? There is evidence that different types and domains of physical activity provide favourable health outcomes. Cancer survivors who are meeting recommended levels of aerobic and muscle-strengthening physical activity, versus not meeting either recommendation, have significantly lower risk of cancer mortality (adjusted HR= 0.70 [95% CI: 0.50 to 0.98]) (84). Evidence demonstrates that adhering solely to muscle- strengthening physical activity recommendations versus not adhering is also beneficial in improving cancer mortality outcomes (HR= 0.66 [95% CI: 0.48 to 0.92]) (84). A meta-analysis also reported these associations by physical activity domain and found the most consistent reductions in mortality for all cancers, breast cancer, and colorectal cancer-specific mortality for recreational physical activity (105). For adults living with hypertension, evidence supports aerobic activity, muscle-strengthening activity, and combinations of the two for improving cardiovascular disease progression. The blood pressure lowering effects between traditional modes of physical activity (i.e. aerobic and resistance activity) do not appear to vary significantly among people with hypertension (35); however, this evidence is not based on direct comparisons between activity types. There is also emerging evidence to support beneficial effects of other forms of exercises in people living with hypertension (e.g. Tai Chi, yoga, Qigong), however further research is needed to explore these specific types of activity to determine strength of association. Aerobic activity, muscle-strengthening activity, or a combination of both, is associated with improved secondary indicators of risk of progression (HbA1c, blood pressure, BMI, and lipids) among adults with type-2 diabetes (35, 107). One review of 24 RCTs (n= 962) reported that resistance training was associated with greater reduction in HbA1c versus control groups (MD= 0.45 [95% CI: 0.65 to 0.25], 20 trials; n= 824). Statistically significant effects were found for high- intensity resistance training versus control groups on fasting insulin (MD= 4.60 [95% CI: 7.53 to 1.67], 5 trials; n= 174) (107). Another review of 7 RCTs (n= 189) reported that interval training (2–5 times/week; intervals 1–4 mins duration; total session lengths 20–60 mins) was associated with statistically significantly decreased HbA1c by 0.26% (95% CI: 0.46 to 0.07%, 5 RCTs) compared with MICT, and by 0.83% (95% CI: 1.39% to 0.27%, 4 RCTs) compared with no-exercise control groups (116). As with recommendations for the general population, most of these interventions are based around aerobic activity consistent with the recommendation of 150–300 minutes of moderate-intensity aerobic activity (or 75 minutes of vigorous-intensity activity) and muscle-strengthening activity conducted 2–3 sessions per week. For some outcomes (e.g. HBA1c and blood pressure), there is evidence for a stronger effect with more aerobic activity (i.e. greater than 150 mins/week versus less than 150 mins/ week), but limited evidence for intensity. More recent studies provide evidence that traditional Chinese exercise, such as Tai Chi may have glycaemic benefits, but these were of moderate and variable certainty (i.e. risk of bias or inconsistency). Further research is needed to determine these associations. ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) 56 57 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Multiple types of physical activity, including aerobic and resistance-training, have been shown to have positive effects on health-related quality of life in people living with HIV (111). Recent research examining changes in health-related quality of life in response to aerobic, progressive resistance exercise, or a combination of both, demonstrates significant improvements in general health, and mental health. There is also evidence that both aerobic and multicomponent activity is related to a reduction in symptoms of depression and anxiety in people living with HIV (112). Evidence for the effects of physical activity on mental health symptoms has involved aerobic or aerobic combined with progressive muscle-strengthening activity, or yoga. Evidence also demonstrates that aerobic exercise alone, or when combined with resistance exercise, does not result in any significant change in viral load or CD4 count in people living with HIV (111). Direct evidence, from both the existing and updated literature, supports the inclusion of the recommendations for people living with type-2 diabetes and hypertension to undertake aerobic and muscle-strengthening physical activity. Although there is a lack of published evidence, there is biological plausibility for the benefits of aerobic and muscle-strengthening physical activity for adults living with HIV and cancer survivors. Furthermore, as noted by the GDG, established international clinical practice guidelines recommend aerobic and muscle- strengthening physical activity for these populations (for example ACSM “Moving Through Cancer” guidelines (101) based on a systematic review of evidence (3)). Recognizing this evidence base is still emerging, the level of certainty was downgraded. The GDG concluded that: • There is moderate certainty evidence for combined or additive effects of aerobic or muscle-strengthening activity for reduced cancer mortality, improvements in blood pressure among those with hypertension. • There is high certainty evidence that aerobic activity, muscle-strengthening activity, and aerobic plus muscle- strengthening activity improve markers of disease progression (HbA1C, blood pressure, BMI, and lipids) in adults with type-2 diabetes. • There is moderate certainty evidence that regular aerobic exercise alone, or combined with resistance exercise, does not result in any significant change in viral load or CD4 count in people living with HIV. • There is insufficient evidence for an effect of strength training alone on health-related quality of life in people living with HIV. ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) 56 57Recommendations ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) Supporting evidence and rationale Due to a lack of population-specific evidence, the primary evidence base for assessing the associations between sedentary behaviour and health outcomes in adults and older adult cancer survivors and those adults and older adults living with hypertension, type-2 diabetes, and HIV, was the scientific literature collated and reviewed for adult populations. The findings from evidence on sedentary behaviours in the general adult population were reviewed, including assessing if there was evidence that the outcomes would be any different, or would not apply to, or would be contraindicated, for adults and older adults living with chronic conditions. In adults, including cancer survivors and people living with hypertension, type-2 diabetes and HIV, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality; cardiovascular disease mortality; cancer mortality; incidence of cardiovascular disease; cancer; and type-2 diabetes. For cancer survivors, and adults living with hypertension, type-2 diabetes and HIV, it is recommended that: Adults and older adults with chronic conditions should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults and older adults with chronic conditions should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence Sedentary behaviour was not included in the 2010 Global recommendations on physical activity for health (1). The scope of this new recommendation on sedentary behaviours in cancer survivors and those people living with hypertension, type-2 diabetes and HIV. Sedentary behaviour is defined as time spent sitting or lying with low energy expenditure, while awake, in the context of occupational, educational, home and community settings, and transportation. SEDENTARY BEHAVIOUR RECOMMENDATION 58 59 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) Based on available evidence and expert opinion, the evidence was extrapolated to inform the new WHO recommendations on sedentary behaviour for adults living with chronic conditions for the common set of critical health outcomes. The extrapolation of evidence is supported largely by the assessment that the majority of studies imposed no upper age limit criterion, included adults over the age of 65 years and may have included adults with chronic conditions, such as cancer survivors, those living with hypertension or type-2 diabetes. For people living with HIV, no reasons were identified as to why the evidence on the health impacts of sedentary behaviours would not apply. Due to indirectness of the evidence to develop these recommendations, the level of certainty was downgraded. The applicability of evidence on the benefit of undertaking more moderate- and vigorous-intensity physical activity to help counteract the potential risks of high levels of sedentary behaviour was also considered and was also extrapolated to inform recommendations for adults with chronic conditions for the common set of critical health outcomes. Given the indirectness, the certainty of the evidence was downgraded. The GDG concluded that: • The evidence on sedentary behaviours in the general adult population could be extrapolated to inform recommendations for adult and older adult cancer survivors and those adults and older adults living with hypertension, type-2 diabetes, and HIV for the common set of critical outcomes, with the level of certainty of the evidence downgraded due to indirectness. • The evidence on the benefits of undertaking more moderate- and vigorous-intensity physical activity to help counteract the potential risks of high levels of sedentary behaviour in the general adult population could be extrapolated to inform recommendations for adult and older adult cancer survivors and those adults and older adults living with hypertension, type-2 diabetes, and HIV for the common set of critical outcomes, with the level of certainty of the evidence downgraded due to indirectness. • The benefits for minimizing sedentary behaviours outweigh the harms for cancer survivors and those people living with hypertension, type-2 diabetes, and HIV. 58 59Recommendations CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and older) LIVING WITH DISABILITY Many of the health benefits of physical activity for children and adolescents, as set out in the section above, also relate to those children and adolescents living with disability. Additional benefits of physical activity to health outcomes for those living with disability include: improved cognition in individuals with diseases or disorders that impair cognitive function, including attention-deficit/hyperactivity disorder (ADHD); improvements in physical function may occur in children with intellectual disability. It is recommended that: Children and adolescents living with disability should do at least an average of 60 minutes per day of moderate- to vigorous-intensity, mostly aerobic, physical activity, across the week. Strong recommendation, moderate certainty evidence Vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated at least 3 days a week. Strong recommendation, moderate certainty evidence Children, adolescents and adults living with disability can achieve important health benefits from physical activity. Children, adolescents and adults with disability should try to meet these recommendations where possible and as able. For children, adolescents and adults living with disability, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), physical education, transportation (wheeling, walking and cycling) or household chores, in the context of home, educational, occupational and community settings. It is important to provide all children, adolescents and adults living with disability with opportunities and encouragement to participate in physical activities appropriate for their age and ability, that are enjoyable, and that offer variety. PHYSICAL ACTIVITY RECOMMENDATION • Doing some physical activity is better than doing none. • If children and adolescents living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Children and adolescents living with disability should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • There are no major risks for children and adolescents living with disability engaging in physical activity when it is appropriate to an individual’s current activity level, health status and physical function; and the health benefits accrued outweigh the risks. • Children and adolescents living with disability may need to consult a health-care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. G O O D P R A C TI C E ST A TE M EN TS G O O D P R A C TI C E ST A TE M EN TS 60 61 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and over) LIVING WITH DISABILITY Many of the health benefits of physical activity for adults, as set out in the section above, also relate to adults living with disability. Additional benefits of physical activity to health outcomes for those living with disability include the following: for adults with multiple sclerosis – improved physical function, and physical, mental, and social domains of health- related quality of life; for individuals with spinal cord injury – improved walking function, muscular strength, and upper extremity function; and enhanced health-related quality of life; for individuals with diseases or disorders that impair cognitive function – improved physical function and cognition (in individuals with Parkinson’s disease and those with a history of stroke); beneficial effects on cognition; and may improve quality of life (in adults with schizophrenia); and may improve physical function (in adults with intellectual disability); and improves quality of life (in adults with major clinical depression). It is recommended that: All adults living with disability should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults living with disability should do at least 150–300 minutes of moderate- intensity aerobic physical activity; or at least 75–150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence Adults living with disability should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence As part of their weekly physical activity, older adults living with disability should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence Adults living with disability may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence • Doing some physical activity is better than doing none. • If adults living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Adults living with disability should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • There are no major risks to adults living with disability engaging in physical activity when it is appropriate to the individual’s current activity level, health status and physical function; and when the health benefits accrued outweigh the risks. • Adults living with disability may need to consult a health-care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. G O O D P R A C TI C E ST A TE M EN TS 60 61Recommendations CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and over) LIVING WITH DISABILITY Supporting evidence and rationale For these guidelines for children, adolescents and adults living with disability, the comprehensive evidence synthesis undertaken by PAGAC (35) was used and updated. Full details of the methods, data extraction and summary evidence tables of this existing evidence on physical activity and health outcomes is available (35) and was reviewed by the GDG in addition to the findings of the updated search. The update conducted for these guidelines identified 39 reviews published from 2017 to 2019. Of these, 27 met the inclusion criteria and informed the examination of the association between physical activity and health-related outcomes among children, adolescents and adults living with disability. Full details of the methods, data extraction and summary evidence portfolios can be found in the Web Annex: Evidence profiles . Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf The evidence reviewed considered the association between physical activity and health-related outcomes in children, adolescents and adults living with disability resulting from the following health conditions: multiple sclerosis, spinal cord injury, intellectual disability, Parkinson’s disease, stroke, major clinical depression, schizophrenia, and attention-deficit/hyperactivity disorder (ADHD). The four health-related outcomes examined included risk of co-morbid conditions, physical function, cognitive function and health-related quality of life, although not all outcomes were explored for each condition. The impact of environmental factors on disability in the context of physical activity was beyond the scope of these guidelines and was not analysed. In children and adolescents (aged 5–17 years) and adults (aged over 18 years) living with disability, what is the association between physical activity and health-related outcomes? For people living with multiple sclerosis, physical activity improves physical function, functional mobility, walking speed and endurance, and cardiorespiratory fitness, strength and balance. For example, high-intensity interval training over 3–12 weeks demonstrated improvements in cardiorespiratory fitness or muscle strength (117) and lower limb strength training found strength increased by 23.1% (95% CI: 11.8 to 34.4) over an average training period of 13.2 weeks (118) over an average of 13 weeks resulted in increases in strength, and dance interventions studies reported improvements in functional mobility and balance (119). As well as physical health benefits, existing evidence demonstrates that physical activity can benefit cognition in people living with multiple sclerosis (35). Newer research reveals that aerobic exercise has a small yet significant effect on physical, mental and social domains of health-related quality of life (including symptoms of fatigue and depressive symptoms) (35, 120). For people living with spinal cord injury, physical activity can improve walking function, muscular strength and upper extremity function (35). Physical activity may also reduce shoulder pain, improve vascular function and enhance health-related quality of life (35). For people living with Parkinson’s disease, physical activity can improve motor symptoms, functional mobility and performance, endurance, freezing of gait and velocity of forward and backward movement (35, 121, 122). New evidence suggests that exercise can also help global cognitive function in individuals with Parkinson’s disease (123). For people with a history of stroke, physical activity can improve physical function, notably upper limb function, sensory motor function of the lower limb, balance, walking speed, distance, ability and endurance, cardiorespiratory fitness, mobility and activities of daily living. Existing evidence suggests that physical activity may also have beneficial effects on cognition (35). For people with major clinical depression, new reviews (124, 125) supported existing evidence (35) that physical activity can improve health-related quality of life (35, 124, 125). For individuals with diseases or disorders that impair cognitive function, including schizophrenia –physical activity can have beneficial effects on cognition, working memory, social cognition and attention/vigilance (35, 126). One review found that moderate- to vigorous-intensity physical activity delivered significant improvements in health-related quality of life and disability (35, 124). 62 63 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and over) LIVING WITH DISABILITY For people living with intellectual disability, physical activity has been shown to improve physical function. The interventions reviewed largely focused on balance and strength activities over 6–24 weeks and reported significant improvement in static balance, dynamic balance and static-dynamic balance compared with controls (35, 127, 128). For children with attention-deficit/hyperactivity disorder, evidence, including one review of 5 RCTs involving ADHD (129), demonstrates a positive association between exercise and attention, executive function and social disorders (35, 129). The GDG considered the evidence from the general population of children, adolescents and adults and concluded that as there is no reason to believe that there would be an effect modification due to impairment and that the same health physiological benefits will be conferred by being physically active. The GDG acknowledged that few studies include people living with disability, and that effect modification is seldom tested. This evidence in the area disability, combined with the broader evidence for the general population, supported the general population recommendation being inclusive of people with disability, noting reference to “all adults”, “all older adults” and “people of all abilities”. The GDG concluded that: In individuals with spinal cord injury, there is: • low certainty evidence that physical activity reduces shoulder pain and improves vascular function in paralysed limbs and enhances health-related quality of life; and • moderate certainty evidence that physical activity improves walking function, muscular strength, and upper extremity function. In individuals with diseases or disorders that impair cognitive function, including Parkinson’s disease, there is: • high certainty evidence that physical activity improves a number of functional outcomes including walking, balance, strength, and disease specific motor scores; and • moderate certainty evidence that moderate- to vigorous-intensity physical activity can have beneficial effects on cognition. In individuals with a history of stroke, there is: • moderate certainty evidence that mobility-oriented physical activity can have beneficial effects on physical function and cognition. In individuals with diseases or disorders that impair cognitive function, including schizophrenia, there is: • moderate certainty evidence that physical activity improves quality of life; and • high certainty evidence that moderate- to vigorous- intensity physical activity can have beneficial effects on cognition, working memory, social cognition and attention. In adults with major clinical depression there is: • moderate certainty evidence that physical activity improves quality of life. In adults with multiple sclerosis, there is: • high certainty evidence that physical activity, particularly aerobic and muscle-strengthening activities, improves physical function, functional mobility, walking speed and endurance, and cardiorespiratory fitness, strength and balance; • moderate certainty evidence that physical activity can have a beneficial effect on cognition; and • low certainty evidence that physical activity improves quality of life including symptoms of fatigue and depressive symptoms. In children and adults with intellectual disability, there is: • low certainty evidence that physical activity improves physical function. In children and adolescents with ADHD, there is: • moderate certainty evidence that moderate- to vigorous-intensity physical activity can have beneficial effects on cognition, including attention, executive function, and social disorders. The GDG further concluded that there is sufficient scientific evidence on the positive impact of physical activity on a variety of health outcomes across a broad range of impairment areas, and that the benefits of physical activity for people living with disability outweigh the potential harms. Due to indirectness of the evidence to develop these recommendations, the level of certainty was downgraded. 62 63Recommendations CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and older) LIVING WITH DISABILITY Supporting evidence and rationale Sedentary behaviour was not included in The Global recommendations on physical activity for health (2010). Due to a lack of population-specific evidence, the primary evidence base for assessing the associations between sedentary behaviour and health outcomes in children, adolescents and adults living disability was the scientific literature collated and reviewed for populations without disability. The findings from evidence on sedentary behaviours in the general population were reviewed including assessing if there was evidence that the outcomes would be any different, or would not apply to, or would be contraindicated for children, adolescents and adults living with disability. In children and adolescents, higher amounts of sedentary behaviour are associated with the following poor health outcomes: increased adiposity; poorer cardiometabolic health, fitness, and behavioural conduct/pro-social behaviour; and reduced sleep duration. It is recommended that: Children and adolescents living with disability should limit the amount of time spent being sedentary, particularly the amount of recreational screen time. Strong recommendation, low certainty evidence In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and type-2 diabetes. It is recommended that: Adults living with disability should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light- intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults living with disability should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence For children, adolescents and adults living with disability, sedentary behaviour is defined as time spent sitting or lying with low energy expenditure, while awake, in the context of educational, home and community settings, and transportation. It is possible to avoid sedentary behaviour and be physically active while sitting or lying, through, for example, upper body led activities, inclusive and/or wheelchair-specific sport and activities. SEDENTARY BEHAVIOUR RECOMMENDATION 64 65 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and over) LIVING WITH DISABILITY Based on available evidence and expert opinion, the evidence was extrapolated to inform new WHO recommendations on sedentary behaviour for individuals living with disability for the common set of critical health outcomes, recognizing that certain population groups, such as wheelchair users, unavoidably sit for long periods of time and sitting may therefore be the norm. For these groups, sedentary behaviour should be defined as time spent with low energy expenditure, e.g. moving in a power chair or being pushed while sitting in a manual wheelchair. There is a lack of research on the association between sedentary behaviour and health outcomes in individuals living with disability. However, based on expert opinion, there are no reasons to believe that there would be an effect modification due to impairment, and therefore the same physiological health benefits will be conferred by limiting sedentary behaviour in individuals living with disability. Due to indirectness of the evidence to develop these recommendations, the level of certainty was downgraded. The applicability of evidence on the benefit of adults undertaking more moderate- and vigorous-intensity physical activity to help counteract the potential risks of high levels of sedentary behaviour was also considered and was also extrapolated to inform recommendations for adults living with disability for the common set of critical health outcomes. Given the indirectness, the certainty of the evidence was downgraded. The GDG concluded that: • The evidence on sedentary behaviours in child and adolescent populations could generally be extrapolated to children and adolescents living with disability, according to their specific ability. • The evidence on sedentary behaviours in the general adult population, including the benefit for adults of undertaking more moderate- to vigorous- intensity physical activity to help counteract the potential risks of high levels of sedentary behaviour, could generally be extrapolated to adults and older adults living with disability, according to their specific ability. However, the certainty of the evidence was downgraded due to indirectness. • The benefits of minimizing sedentary behaviour in children, adolescents, adults and older adults living with disability outweigh the harms. 64 65Recommendations In accordance with the GRADE process, the proposed wording of the updated recommendations, and the rating of their strength (“strong” or “conditional”), were based on consideration of the balance of benefits to harms; the certainty of evidence; sensitivity to the values and preferences of those affected by the guidelines; the potential impact on gender, social and health equity; and acceptability, feasibility and resource implications. These were considered for each population group, but given the similarity of issues and considerations discussed, are consolidated and presented here. The strength of the recommendation was primarily based on the assessed balance of benefits to harms. Recommendations were graded “strong” if the balance of benefits to harms was assessed as substantial for the target population for the recommendation, and “conditional” if the balance of benefits to harms was small or there was important likely variability in benefits in the target population. The evidence on harms was specifically sought through the commissioning of a new systematic review. However, this was limited, as most evidence focuses on injuries and harms to elite and competitive athletes, rather than the general population. Overall, despite the limited evidence, and informed by expert opinion, it was concluded that the risk was no greater than small. The evidence generally indicated that the benefits of physical activity far outweighed the harms, and that physical activity can be an important intervention to support closing an existing health gap, particularly for disadvantaged populations. Issues of health equity, feasibility and acceptability were also considered by the GDG and formed part of the online public consultation on the draft recommendations held between 31 March 2020 and 17 April 2020. The survey for the public consultation asked specific questions on the balance between the costs to individuals and governments of implementing the recommendations, and the potential health benefits, and whether the guidelines would improve health equity. In addition, the draft recommendations and the feedback form were sent to countries that had recently expressed an interest in developing, or had initiated the process of drafting, national guidelines on physical activity. Feedback was received from more than 420 submissions to the online consultation, and additional collation of feedback from the WHO European Regional Office, incorporating comments from WHO Collaborating Centres and Member States. The feedback from this consultation was collated, reviewed by the GDG, and used to further inform the consideration on feasibility, resource implications, and health equity through consultation with the Steering Group and the GDG. Decisions were reached by consensus through discussion. The GDG came to consensus on each recommendation and on the strength of the recommendation; ratings and voting were not required. ASSESSMENT OF THE CERTAINTY OF EVIDENCE The GRADE framework was used by the GDG to examine the certainty of primary research contributing to each outcome identified in the PI/ECOs, and assessed the overall certainty of evidence taking into consideration the risk of bias, inconsistency, imprecision, indirectness of the evidence and publication bias across each outcome. GRADE tables detailing this information for each PI/ECO are available in the Web Annex: Evidence profiles . The assessment of the certainty of the evidence was based on an overall assessment across all evaluated outcomes and prioritized all-cause mortality and cardiovascular mortality as the most critical outcomes, followed by other clinical outcomes (falls, depression, cognition, health-related quality of life, etc), then intermediate outcomes (e.g. cardiometabolic markers, other metabolic markers), as well as harms. Where the evidence had not been specifically reviewed, such as for sedentary behaviour in subpopulations primarily due to a lack of evidence for these groups, the evidence for the general population was extrapolated and downgraded where this was deemed appropriate, due to indirectness. EVIDENCE TO RECOMMENDATIONS Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 66 67 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r BENEFITS AND HARMS The development of the recommendations included an assessment of adverse impacts or risks. Where there was limited evidence, decisions were based on the expertise of the GDG. Overall, for all populations it was concluded that the benefits of physical activity and limiting sedentary behaviour outweighed the potential harms. These guidelines are for the general population and do not address the benefits and harms experienced by athletes undertaking the types and amounts of activity necessary to improve performance-related fitness for participation in competition. Doing some physical activity is better than doing none. If individuals are not currently meeting these recommendations, doing some physical activity will bring benefits to their health. They should start by doing small amounts of physical activity, gradually increasing frequency, intensity and duration over time. Pre-exercise medical clearance is generally unnecessary. Inactive individuals who gradually progress to undertaking moderate-intensity activity have no known risk of sudden cardiac events and very low risk of bone, muscle, or joint injuries. An individual who is habitually engaging in moderate-intensity activity can gradually increase to vigorous-intensity without needing to consult a health- care provider. Those who develop new symptoms when increasing their levels of activity should consult a health- care provider. The choice of appropriate types and amounts of physical activity can be affected by pregnancy, chronic conditions, and disability, and should be undertaken as able and without contraindication. These individuals may wish to consult with a physical activity specialist or health-care professional for advice on the types and amounts of activity appropriate for their individual needs, abilities, functional limitations/complications, medications, and overall treatment plan. Light- and moderate-intensity physical activity are generally low risk and are recommended for all. VALUES AND PREFERENCES The values and preferences of those affected by the guidelines (in this case parents and caregivers, children and adolescents, adults, older adults, pregnant and postpartum women, people living with chronic conditions and/or disability) were considered. Overall it was concluded that there was little or no uncertainty about preferences regarding the main outcomes, including mortality and cardiovascular mortality. The estimated potential benefits greatly outweighed any potential harms, and as such, the GDG considered the recommendations to be not preference-sensitive. RESOURCE IMPLICATIONS The expert opinion of the GDG, and a small body of evidence reporting on economic analyses of interventions and savings to the health-care systems from increasing levels of physical activity, informed discussion on the resource implications of the recommendations in different settings. In addition, results from the online public consultation showed that over 75% of respondents agreed, or strongly agreed, that the benefits of implementing the guidelines would outweigh the cost to the individual, and 81% agreed, or strongly agreed, that the benefits of implementing the guidelines would outweigh the cost to government. Available evidence and expert opinion recognize that substantial health benefits can be achieved at low risk through activities such as walking, that require no specific equipment or cost to the individual. Further, it was acknowledged that other forms of physical activities, for example structured sports, cycling and exercise classes, may incur costs, which can be a barrier for some individuals, particularly those with lower incomes. Government implementation of policy and programmes to promote and enable physical activity also requires investments in areas such as human resources, policy development, provision of facilities and services and potentially, equipment, some of which is incurred by ministries of health, but also in sectors outside of health, such as sport, education, transport and urban planning. The resources required may be at more than one level of government (national, subnational and local levels) to ensure all communities have equal access to physical activity opportunities. These investments may involve new resources, but also can be addressed by reallocation of existing budgets to reflect the prioritization of facilities and programmes towards increasing population levels of physical activity. Examples of budget reallocation include towards infrastructure for walking and cycling from the existing transport budget, and towards “sports for all” from the sports budgets. In key settings, such as schools and workplaces, low-cost interventions, combined with changes to the physical environment, can support participation in physical activity and would also contribute to reducing inequities in opportunities to be active, 66 67Evidence to recommendations experienced by some subpopulation groups. Overall, it was assessed that while there are resource implications to achieve these draft recommendations, implementation of actions is possible within current governance structures. Further, evidence supports that substantial health savings are possible for the health-care system resulting from increasing levels of physical activity. In 2013 the global annual cost of physical inactivity was estimated at INT$ 54 billion due to direct health costs alone (130); and at a national level, inactivity is estimated to cost between 1–3 % of health-care budgets (131). Within the wider context of noncommunicable disease (NCD) prevention, additional costs to government and nongovernmental organizations of guideline implementation may be minimized if recommended physical activity can be relatively easily incorporated by individuals into their lives; likewise if existing resources in primary and secondary care, schools, workplaces or transportation can be shifted, resulting in increased physical activity. Analysis of the cost and benefits of physical activity promotion indicate positive returns on investment over 15 years, in terms of NCD prevention, in many countries where the investment cases have been conducted (132). Interventions such as public education and awareness campaigns and physical activity counselling and referral are a “best buy” and a “good buy” respectively, of recommended interventions to address NCDs based on an update of Appendix 3 of the Global action plan for the prevention and control of NCDs 2013–2020 (133). Overall, the GDG concluded that the benefits of implementing the recommendations outweigh the costs. Delivering on physical activity guidelines for people with disability may require investment, such as the training of activity specialists, adapted equipment where needed, and facilities that need to be made accessible. These investments can facilitate the needs of a wide range of population groups. Evidence demonstrates a significant participation gradient between people with and without disability in relation to physical activity, due to multiple barriers regarding access, choice of activities offered, and the attitudes of others. Universal design principles should be applied to ensure full and effective participation by people living with disability. With innovation, it is possible to address many of these resource implications. Adopting universal design approaches would mitigate against these costs in the future. EQUITY, ACCEPTABILITY AND FEASIBILITY In updating the 2010 recommendations the decision was taken to explicitly include consideration of vulnerable populations, such as those living with chronic conditions and/or disability. The GDG and Steering Group included members representing such groups. The GDG discussed each recommendation at length, considering whether implementing the recommendations would decrease health equity, and the issues related to implementation, to ensure that the recommendations did not worsen equity issues (for example, ensuring that there are safe facilities and opportunities accessible for all, including people living with disability, and socioeconomically and other disadvantaged people, to engage in physical activity; addressing gender and other cultural biases that could restrict access and opportunity to participate in physical activity, etc.). Of respondents to the online public consultation, 76% agreed, or strongly agreed, that implementing the guidelines can achieve a reduction in health inequity by increasing opportunities for all to be active and improve health outcomes. It was noted that supporting environments are key to enabling participation in physical activity. A comprehensive approach to the design and implementation of policies across a number of sectors will be required to address barriers to physical activity for vulnerable groups, such as socioeconomically disadvantaged women and girls, and people with disability. People with disability experience worse health outcomes than people without disability, yet the benefits of physical activity far outweigh the harms and can be an important intervention to close this health gap. Evidence demonstrates a significant participation gradient between people with and without disability in relation to physical activity, due to multiple barriers regarding access, choice of activities offered, and the attitudes of others. For many people with disability, it should be possible to engage in various forms of physical activity without the need for adapted equipment or facilities. However, in order for people with disability to engage in physical activity on an equal basis with others, adapted equipment may need to be obtained, facilities may need to be made accessible, and activity specialists may need to be trained. 68 69 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Despite the large quantity of data relating physical activity and, increasingly, sedentary behaviours to health outcomes across the life span, the GDG discussions revealed important evidence gaps, which should be prioritized to inform future guidelines. Evidence gaps across population subgroups included a lack of information on: 1) the more precise details on the dose-response relationship between physical activity and/or sedentary behaviour and several of the health outcomes studied; 2) the health benefits of light-intensity physical activity and of breaking up sedentary time with light- intensity activity; 3) differences in the health effects of different types and domains of physical activity (leisure time; occupational; transportation; household; education) and of sedentary behaviour (occupational; screen time; television viewing); and 4) the joint association between physical activity and sedentary time with health outcomes across the life course. It was also noted that there remains limited evidence from low- and middle-income countries, economically disadvantaged or underserved communities, and in people living with disability and/or chronic disease. Many studies are not designed or powered to test for effect modification by various sociodemographic factors (age, sex, race/ethnicity, socioeconomic status) that may modify the health effects of physical activity. Such information is important for making more specific public health recommendations and for reducing health disparities in more vulnerable sectors of the population. Further details on the research gaps arising from these new guidelines can also be found in published literature (134). RESEARCH NEEDS 68 69Research needs The goal of these guidelines is to provide policy- makers, and those who develop health-care, education, workplace and community intervention programmes, with recommendations on how much time children, adolescents, adults and older adults should spend each day being physically active, and recommendations on limiting time spent being sedentary. However, developing global guidelines is not an end in itself: without dissemination and implementation, changes in physical activity levels will not be achieved. ADOPTION WHO undertakes a rigorous and extensive process to develop globally relevant guidelines (21) for use by all countries. These Guidelines on physical activity and sedentary behaviour provide evidence-based recommendations on the health impacts of physical activity and sedentary behaviour that national governments can adopt and use as part of their national policy frameworks. The development of global guidelines, with extensive consultation, should largely remove the need for individual countries to use resources to undertake the lengthy scientific process. Reviewing and adopting these global physical activity and sedentary behaviour guidelines provides a rapid and cost-effective method to develop guidelines tailored to local context. Adopting the WHO guidelines at regional or national level will ensure countries provide consistent recommendations on physical activity and sedentary behaviour, which are informed by the latest and best available scientific evidence. In addition, consistency of the recommendations across countries will facilitate national surveillance, global estimates of physical activity and sedentary behaviour, and cross- country comparisons. Throughout the adoption process, consideration should be given to the need to contextualize and tailor the guidelines. Translation into the local language is one element of adoption and contextualization. Examples of physical activities may need to be changed to be locally relevant and the use of images tailored to reflect local cultures, norms and values. A step-by-step framework to support country adoption of the Global guidelines is under development, following a series of regional workshops with relevant stakeholders. This framework can be populated with relevant national data (for example physical activity prevalence estimates), and will provide a fast-track approach to the development of a national guidelines document. These supporting resources will be available in 2021 through the WHO website. When considering adopting the guidelines it is recommended that the following ten-step process is applied: 1. Advocate for a review of current national guidelines on physical activity and the adoption of the WHO guidelines to secure government authorization. 2. Engage key stakeholders both within the health sector and other relevant sectors, such as sport, education, transport; engage relevant professional associations and scientists, with topic expertise. 3. Assess the applicability, acceptability and feasibility of the recommendations. 4. Adapt guidelines to the local context, including language, examples, and other cultural considerations. 5. Conduct an external review with target users, including policy-makers, practitioners, and the general public. 6. Establish a budget and clear plan for dissemination and communication. 7. Publish and promote the national guidelines, ideally alongside a launch event to generate publicity and interest. 8. Engage relevant professional bodies or organizations and support policy alignment and/or endorsement. 9. Implement national policies and practices to support implementation of national guidelines and behaviour change. 10. Agree a timeline for evaluation, review, and update of the guidelines. ADOPTION, DISSEMINATION, IMPLEMENTATION AND EVALUATION 70 71 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r DISSEMINATION National physical activity guidelines are a core component of the governance structures for a comprehensive approach to increasing population levels of physical activity. National guidelines inform the development and priorities of national and subnational strategy planning and require dissemination of the correct information, to the relevant groups of people, in an appropriate way. Unfortunately, too often, national guidelines are not disseminated, and so awareness of recommendations among both professional audiences and the wider community can remain very low. Securing dedicated resources to support wide-scale dissemination is an important first step to changing awareness and knowledge about the importance of increasing physical activity and reducing sedentary behaviours. Key audiences for dissemination of national guidelines on physical activity and sedentary behaviour include: • Policy-makers within and outside the health sector (including transport, planning, education, workplaces, sport, parks and recreation), to increase: a. knowledge of the contribution that increasing physical activity and reducing sedentary behaviour can have in improving not only health, but also a range of diverse yet related agendas, including gender equity, human rights obligations, and sustainable development; b. integration of policy and programmes on physical activity and sedentary behaviour into all relevant policies; and c. investment in scaled-up and coordinated national and local actions. • Non-state actors (including nongovernmental organizations, academic and research organizations, the private sector as well as the media and research funding agencies), to: a. raise awareness of the importance of increasing physical activity and reducing sedentary behaviours across all ages; b. encourage and ensure policy alignment; and c. increase collaboration and investment in policy implementation and local action. • Practitioners in health and non-health sectors (including sport, education, transport, and planning) to increase: a. awareness and knowledge of national guidelines on physical activity and sedentary behaviours; b. knowledge, skills and confidence in promoting increased physical activity and reduction in sedentary behaviours; and c. integration of physical activity promotion into routine practice where applicable. • The general public and specific population subgroups, to increase: a. awareness and knowledge of the guidelines on physical activity and sedentary behaviour; b. knowledge of how to achieve the physical activity and sedentary behaviour guidelines; and c. intentions and motivation to be more physically active and to reduce sedentary behaviour. COMMUNICATION CAMPAIGNS Different stakeholders will benefit from different materials; therefore to communicate guidelines to multiple audiences effectively, consideration must be given to the content, format, and delivery channels for guideline communication. When developing a guideline communication strategy, formative research can help determine the key audiences and understand the values, needs and preferences that influence levels of physical activity and sedentary behaviour. This should include exploration of the barriers to physical activity or to the integration of physical activity into policy and practice, as well as testing of draft messages and materials with different groups. This will help inform the key messages that are used, as well as the appropriate format(s) and channel(s) for communication. A comprehensive communication strategy will include a range of communications aimed at different audiences. Countries may need to prioritize specific groups depending on available resources (human and financial). Communication campaigns on physical activity targeting the general public or specific subpopulations are a cost- effective intervention (133) and recommended in the WHO Global action plan on physical activity 2018–2030 (14). National and subnational campaigns on physical activity typically establish an overarching campaign slogan (for example “Be Active” or “Move More”), and develop design elements or characters, which may include tailored messages for different audiences 70 71Adoption, dissemination, implementation and evaluation (such as for young children, adolescents, adults or older adults, the less active, people living with disability or chronic conditions). Campaign messages and resources that are tailored to specific population groups are likely to be more effective than generic materials. Communication campaigns should consider the reach and effectiveness of both traditional media channels (such as television, radio, billboards, printed resources) as well as digital media channels (websites, mobile phones, Apps). Providing information on the national guidelines in a variety of formats is also useful. For example, a relatively new but increasingly common approach to communicating physical activity guidelines is through the use of infographics or short animated videos. WHO has supporting materials for developing and implementing such communication campaigns (135). The academic and research community are likely to be interested in the scientific report which details the epidemiological evidence on which the guidelines are based. However the specific details of the underlying research is unlikely to be of interest to other more general audiences. Policy-makers may prefer a summary of the science, or even a short briefing document. Other audiences, such as health and non-health professionals, are more likely to favour different types of resources, for example a brochure or factsheet about the guidelines, or about how to integrate physical activity promotion into routine practice (for example in patient consultations in a health-care setting, or when developing building or transport plans for urban environments). Different professionals will require resources that are tailored to their role. Health professions, in particular, may benefit from a suite of resources to reflect the diverse population groups that they work with. IMPLEMENTATION OF POLICY AND PROGRAMMES National guidelines on physical activity and sedentary behaviour, in isolation, are unlikely to lead to increases in population levels of physical activity and should therefore be seen as one element of a policy and planning framework. It is critical that national guidelines are disseminated to key audiences and supported by a sustained national communication strategy that will lead to increased awareness and knowledge about the multiple benefits of regular physical activity and reducing sedentary behaviours. However, in order to achieve sustained behaviour change, these actions must be supported by policies that create supportive environments that enable and encourage people to be active, along with increased local, appropriate opportunities for people to participate in physical activity. Policies and programmes must consider and be adapted to the local context, in terms of both the health system and the complex multisector institutions that have an interest in, or opportunity to support, physical activity promotion. Action should be taken using a “whole of government” approach and consider the “system” of policies and multiple actions that can, through engagement of a wide range of stakeholders, support more people to be physical active across multiple sectors and settings. Using a “systems” approach that is aligned with a sustained communication strategy ensures that increased demand for physical activity, generated through effective communication, is matched by the provision of environments and opportunities for people to be physically active. 72 73 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r The WHO Global action plan on physical activity 2018–2030 set a target to reduce physical inactivity by 15% by 2030, and outlined 20 recommended policy actions and interventions (14). These included recommending that all countries implement sustained national public education and awareness campaigns and the integration of physical activity counselling programmes into primary and secondary health care. Other recommendations included the creation of appropriate environments for physical activity, including walking, cycling and wheeling, for all population groups and the provision of more opportunities and programmes for physical activity in schools, workplaces and sports clubs and venues. Implementation across all 20 recommendations may not be feasible in the short term in all countries, but should be viewed as a long-term goal. To identify an appropriate and feasible set of immediate actions, WHO Member States should conduct a situational analysis of current policy and practice. This will enable multisector collaboration and help identify areas of strength as well as gaps and opportunities, and can be used as the basis for developing or updating national and subnational plans. These new WHO guidelines support expanding the scope of actions to include additional groups, such as people living with disability or chronic conditions, and women who are pregnant or postpartum. Policy will need to support appropriate programme delivery and practice that recognizes community needs and the diversity of groups and contexts. A number of sector-specific toolkits are under development to support implementation of the ACTIVE technical package (135); these will provide each sector with guidance on how to promote physical activity, for example through schools, through primary health care, or by improving provision for walking and cycling. The ACTIVE toolkit, as well as other WHO regional and national resources will support implementation of these physical activity and sedentary behaviour guidelines. SURVEILLANCE AND EVALUATION The WHO Global recommendations for physical activity for health have been used as benchmarks for population health monitoring and surveillance since 2010. The changes introduced to the recommendations in these updated guidelines will have some implications for surveillance systems and assessment instruments currently used to monitor national levels of physical activity. The publication of these new guidelines will call for a review of current instruments and reporting protocols to inform any adjustments and recommendations on future reporting against the new guidelines. Instruments, such as the Global Physical Activity Questionnaire and Global Student Health Survey, will be reviewed and protocols updated to align with these new guidelines; supporting guidance to all countries will be provided in 2021. The WHO NCD Country Capacity Survey (CCS) is the main instrument used to monitor global progress on NCD policy implementation, and is conducted every two years. The CCS includes specific questions on population surveillance systems on physical activity for each age group covered by these WHO guidelines on physical activity and sedentary behaviour, and since 2019, on the existence of national physical activity guidelines. WHO Member States are requested to upload documentation to support their response. In 2019, of the 194 WHO Member States, 78 (40%) reported having physical activity guidelines (136). A detailed document analysis of responses to the CCS in 2019 was carried out, and identified that only two thirds of the 78 Member States (52/78) with national guidelines include statements on how much physical activity their populations should do; and of these, only 42 countries aligned fully with the 2010 WHO Global recommendations on physical activity for health (1). Data from the 2021 and subsequent surveys will provide information on uptake of these updated guidelines. UPDATING These guidelines will be updated after ten years, unless advances in the science of how physical activity is assessed using device-based measurement, and the rapidly evolving science on sedentary behaviour, prompt an earlier update. 72 73Adoption, dissemination, implementation and evaluation 74 75 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 1. World Health Organization. Global recommendations on physical activity for health. 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DiPietro L, Al-Ansari S, Biddle S, Borodulin K, Bull F, Buman M, et al. Advancing the global physical activity agenda: recommendations for future research by the 2020 WHO Physical Activity and Sedentary Behavior Guidelines Development Group. Int J Behav Nutr Phys Act. 2020;In press. 135. World Health Organization. ACTIVE: a technical package for increasing physical activity. Geneva: World Health Organization; 2018. 136. World Health Organization. Assessing national capacity for the prevention and control of noncommunicable diseases: report of the 2019 global survey. Geneva: World Health Organization; 2020. 82 83 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r G lo be b as ed o n io at /S hu tt er st oc k, s ilh ou et te s ha pe s or ig in al ly b as ed o n Sh ut te rs to ck s ou rc es 82 83References 84 85 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r WHO Steering Group The Steering Group included experts in the areas of physical activity, adolescent health, ageing disability, mental health, injury prevention, cancer, pregnancy and surveillance from both headquarters and regional offices. Valentina Baltag Department of Maternal, Newborn, Child and Adolescent Health and Ageing – adolescent health Maurice Bucagu Department of Maternal, Newborn, Child and Adolescent Health and Ageing – pregnancy Fiona Bull Chairperson Department for Health Promotion – physical activity Alex Butchart Department of Social Determinants of Health – injury prevention Neerja Chowdhary Department of Noncommunicable Diseases – mental  health/dementia Regina Guthold Department of Maternal, Newborn, Child and Adolescent Health and Ageing – adolescent surveillance Riitta-Maija Hämäläinen Western Pacific Regional Office Andre Ilbawi Department of Noncommunicable Diseases – cancer Wasiq Khan Eastern Mediterranean Regional Office Lindsay Lee Department of Noncommunicable Diseases – disability Alana Officer Ageing Leanne Riley Department for Noncommunicable Diseases – surveillance Gojka Roglic Department for Noncommunicable Diseases – diabetes Juana Willumsen Department for Health Promotion – physical activity The Steering Group drafted the scope of the guidelines, and the PI/ECOs. They reviewed the declaration of interests; and drafted, reviewed and finalized the guidelines. Contributors to guideline development ANNEX 1: MANAGEMENT OF GUIDELINE DEVELOPMENT PROCESS 84 85Annex 1 Guideline Development Group (GDG) The Guideline Development Group consisted of a broad group of relevant experts in the field and end users of, and persons affected by, the recommendations. The members of the Guideline Development Group included: Dr Salih Saad Al-Ansari (advocate in health promotion and education to combat NCDs through physical activity and walking); Dr Stuart Biddle (physical activity and sedentary behaviour, and behaviour change); Dr Katja Borodulin (physical activity in pregnancy and older adults); Dr Matthew Buman (sleep, sedentary behaviour, and physical activity in people living with chronic conditions); Dr Greet Cardon (physical activity in children and adolescents); Ms Catherine Carty (physical activity in people living with disability); Dr Jean-Philippe  Chaput (sleep, sedentary behaviour and physical activity in children and adolescents); Dr Sebastien Chastin (physical activity, sedentary behaviour and health, objective measurement of physical activity and sedentary behaviour); Dr Paddy Dempsey (physical activity and sedentary behaviour in adults and people living with chronic conditions); Dr Loretta DiPietro (physical activity in pregnancy and older adults); Dr Ulf Ekelund (sedentary behaviour and physical activity, physical activity in children and adolescents); Dr Joseph Firth (physical activity and mental health); Dr Christine Friedenreich (physical activity in people living with chronic conditions, physical activity and cancer risk); Dr Leandro Garcia (physical activity and health in adults); Dr Muthoni Gichu (policy implementation, national government); Dr Russ Jago (physical activity in children and adolescents); Dr Peter Katzmarzyk (physical activity and sedentary behaviour); Dr Estelle V. Lambert (physical activity and obesity); Dr Michael Leitzmann (sedentary behaviour and physical activity in people living with chronic conditions); Dr Karen Milton (translating recommendations into practice); Dr Francisco B. Ortega (physical activity in children and adolescents, mental health and objective measurement); Dr Chathuranga Ranasinghe (promotion of physical activity and health in the community, workplace and school settings); Dr Emmanuel Stamatakis (physical activity and sedentary behaviour and multiple health outcomes in adults); Dr Anne Tiedemann (physical activity in older adults); Dr Richard Troiano (policy development); Dr Hidde van der Ploeg (physical activity and sedentary behaviour in adults); Ms Vicky Wari (policy implementation – national government); Dr Roger Chou (Pacific Northwest Evidence- based Practice Center and Professor of Medicine, Departments of Medicine, Medical Informatics and Clinical Epidemiology of the Oregon Health and Science University) served as GRADE methodologist. Further details of the GDG are available in Annex 2. A first GDG meeting was held 2–4 July 2019, at which the GDG decided on the PI/ECO questions, reviewed the existing systematic reviews, and identified updates required. The Group agreed on the process for decision-making on recommendations and the strength of the evidence to be applied at the second GDG meeting. The second meeting was held 11–14 February 2020; updated evidence was reviewed and final recommendations agreed upon by consensus. 86 87 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r External Review Group (ERG) Seven peer reviewers were drawn from a list of individuals suggested by the GDG and Steering Group. They provided relevant expertise, including programme implementation and represented all six WHO regions. The ERG reviewed the draft guidelines and provided feedback to the Steering Group on issues of clarity and implementation, which was incorporated, as appropriate. External peer reviewers did not make changes to the recommendations. External peer reviewers are listed in Annex 2. Declarations of Interest All GDG members and external peer reviewers completed and submitted a WHO Declaration of Interests form and signed confidentiality undertakings prior to attending any GDG meetings. The Steering Group reviewed and assessed the submitted curriculum vitae and declarations of interest and performed an internet and publications search to identify any obvious public controversies or interests that may lead to compromising situations. The names and brief biographies of all proposed GDG members were published on the WHO Physical Activity webpage for public consultation for a period of 14 days. No comments were received. If additional guidance on management of any declaration or conflicts of interest had been required, the Steering Group would have consulted with colleagues in Office of Compliance, Risk Management and Ethics. If deemed necessary, individuals found to have conflicts of interest, financial or non-financial, would have been excluded from participation on any topics where interests were conflicting. The management of conflicts of interest was reviewed throughout the process. GDG members were required to update their Declaration of Interest, if necessary, before each meeting and a verbal declaration of interest was solicited at the beginning of each GDG meeting. Declared interests of the GDG and of the external peer reviewers are summarized in Annex 3. No conflict of interest was identified. Peer review The draft guidelines were reviewed by seven external peer reviewers identified by the GDG and Steering Group. External peer reviewers were requested to provide comments on issues of clarity, presentation of the evidence, and implementation; comments were incorporated as appropriate. External peer reviewers could not change the recommendations decided upon by the GDG. External peer reviewers are listed in Annex 2; a summary of declarations of interest are provided in Annex 3. In addition, inputs were actively sought from WHO regional offices. 86 87Annex 1 Guideline Development Group Dr Salih Al-Ansari Assistant Professor Family & Community Medicine Founder and CEO Health Promotion Center Riyadh SAUDI ARABIA Dr Stuart Biddle Professor of Physical Activity & Health Physically Active Lifestyles Research Group Centre for Health Research Institute for Resilient Regions University of Southern Queensland Springfield Central AUSTRALIA Dr Katja Borodulin The Age Institute Helsinki FINLAND Dr Matthew Buman College of Health Solutions Arizona State University Phoenix USA Dr Greet Cardon Department of Movement and Sports Sciences Faculty of Medicine and Health Sciences Ghent University Gent BELGIUM Ms Catherine Carty UNESCO Chair Project Manager Institute of Technology Tralee Co Kerry IRELAND Dr Jean-Philippe Chaput Senior Scientist, Healthy Active Living and Obesity (HALO) Research Group Children’s Hospital of Eastern Ontario (CHEO) Research Institute Department of Pediatrics University of Ottawa Ottawa, Ontario CANADA Dr Sebastien Chastin Professor of Health Behaviour Dynamics School of Health and Life Sciences Department of Psychology, Social Work and Allied Health Sciences Glasgow Caledonian University Glasgow UNITED KINGDOM Dr Roger Chou (GRADE Methodologist) Departments of Medicine, and Medical Informatics & Clinical Epidemiology Oregon Health & Science University Portland, Oregon USA Dr Paddy Dempsey MRC Epidemiology Unit University of Cambridge School of Clinical Medicine Institute of Metabolic Science Cambridge UNITED KINGDOM ANNEX 2: GUIDELINE DEVELOPMENT GROUP, EXTERNAL PEER REVIEWERS, AND WHO STAFF INVOLVED IN THE DEVELOPMENT OF THESE GUIDELINES 88 89 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Dr Loretta DiPietro Department of Exercise and Nutrition Sciences Milken Institute School of Public Health The George Washington University Washington, DC USA Dr Ulf Ekelund Department of Sport Medicine Norwegian School of Sport Science Oslo NORWAY Dr Joseph Firth Presidential Fellow School of Health Sciences University of Manchester Manchester UNITED KINGDOM Dr Christine Friedenreich Scientific Director Department of Cancer Epidemiology and Prevention Research Cancer Control Alberta Alberta Health Services Calgary CANADA Dr Leandro Garcia Research Associate Centre for Public Health Queen’s University Belfast Belfast UNITED KINGDOM Dr Muthoni Gichu Head Division of Geriatric Medicine Department of Non-Communicable Diseases Ministry of Health Nairobi KENYA Dr Russell Jago Professor of Paediatric Physical Activity & Public Health Centre for Exercise, Nutrition & Health Sciences School for Policy Studies University of Bristol Bristol UNITED KINGDOM Dr Peter T. Katzmarzyk Associate Executive Director for Population and Public Health  Sciences Professor and Marie Edana Corcoran Endowed Chair in Pediatric Obesity and Diabetes Pennington Biomedical Research Center Baton Rouge USA Dr Estelle V. Lambert Director Research Centre for Health Through Physical Activity, Lifestyle  and Sport University of Cape Town Cape Town SOUTH AFRICA Dr Michael Leitzmann Professor of Epidemiology Department of Epidemiology and Preventive Medicine University of Regensburg Regensburg GERMANY Dr Karen Milton Associate Professor in Public Health Norwich Medical School University of East Anglia Norwich UNITED KINGDOM Dr Francisco B. Ortega Head Unit of Physical Activity and Health Promotion Research Institute of Sport and Health (iMUDS) Department of Physical Education and Sports University of Granada Granada SPAIN 88 89Annex 2 Dr Chathuranga Ranasinghe Chairperson NIROGI Lanka project Sri Lanka Medical Association Senior lecturer Sports and Exercise Medicine Unit Faculty of Medicine University of Colombo C Colombo SRI LANKA Dr Emmanuel Stamatakis Charles Perkins Centre Faculty of Medicine and Health School of Public Health University of Sydney Sydney AUSTRALIA Dr Anne Tiedemann Associate Professor Institute for Musculoskeletal Health School of Public Health Faculty of Medicine and Health University of Sydney Sydney AUSTRALIA Dr Richard Troiano Epidemiology and Genomics Research Program National Cancer Institute National Institutes of Health Rockville USA Dr Hidde van der Ploeg Associate Professor Department of Public and Occupational Health Amsterdam Public Health Research Institute Amsterdam University Medical Centres Amsterdam NETHERLANDS Ms Vicky Wari* Programme Manager, NCD National Department of Health Port Moresby PAPUA NEW GUINEA External review group Dr Kingsley Akinroye NCD Alliance Nigeria NIGERIA Dr Huda Alsiyabi Director Department of Community Based Initiatives Ministry of Health OMAN Dr Alberto Flórez-Pregonero Pontificia Universidad Javeriana COLOMBIA Dr Shigeru Inoue Department of Preventive Medicine and Public Health Tokyo Medical University JAPAN Dr Agus Mahendra Department of Physical education Universitas Pendidikan INDONESIA Dr Deborah Salvo Prevention Research Center in St. Louis Brown School Washington University USA Dr Jasper Schipperijn President-Elect 2020–2022 International Society of Physical Activity and Health Department of Sports Science and Clinical Biomechanics University of Southern Denmark DENMARK * unable to attend90 91 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r * unable to attend WHO Steering Group Dr Valentina Baltag Head Adolescent and Young Adult Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND Dr Maurice Bucagu Medical Officer Maternal Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND Dr Alexander Buchart Head Violence Prevention Social Determinants of Health Department WHO Headquarters Geneva SWITZERLAND Dr Fiona Bull Head Physical Activity Department of Health Promotion WHO Headquarters Geneva SWITZERLAND Dr Regina Guthold Scientist Adolescent and Young Adult Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND Dr Riitta-Maija Hämäläinen Technical Officer Noncommunicable Diseases and Health Promotion WHO Regional Office for the Western Pacific Manila PHILIPPINES Dr Andre Ilbawi Technical Officer Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Dr Wasiq Khan* Regional Adviser Health Education and Promotion WHO Regional Office for the Eastern Mediterranean Cairo EGYPT Ms Lindsay Lee Technical Officer Sensory Functions, Disability and Rehabilitation Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Ms Alana Officer Senior Health Adviser Healthy Ageing Office of the Director-General WHO Headquarters Geneva SWITZERLAND Ms Leanne Riley Head Surveillance Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Dr Gojka Roglic Medical Officer Noncommunicable Diseases Management Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Dr Juana Willumsen Technical Officer Physical Activity Department of Health Promotion WHO Headquarters Geneva SWITZERLAND 90 91Annex 2 ANNEX 3: SUMMARY OF DECLARATION OF INTEREST AND HOW THESE WERE MANAGED Guideline Development Group members Name Gender Expertise Disclosure of interest Conflict of interest and management Dr Salih Saad Al-Ansari Male Advocate in health promotion and education to combat NCDs through physical activity and walking Owner and Chief Executive Officer of the Health Promotion Center No conflict of interest identified Dr Stuart Biddle Male Physical activity in youth Research funds and paid consultancy No conflict of interest identified Dr Katja Borodulin Female Physical activity in pregnancy Employment at National Institute for Health and Welfare and Age Institute; research funds No conflict of interest identified Dr Matthew Buman Male Sleep and physical activity in people living with chronic conditions None declared No conflict of interest identified Dr Greet Cardon Female Physical activity in youth None declared No conflict of interest identified Ms Catherine Carty Female Physical activity in people living with disability Research funds No conflict of interest identified Dr Jean-Philippe Chaput Male Sleep None declared No conflict of interest identified Dr Sebastien Chastin Male Physical activity and health, objective measurement of physical activity Research funds No conflict of interest identified Dr Paddy Dempsey Male Physical activity and sedentary behaviour in adults and people living with chronic conditions Employment and research funds No conflict of interest identified Dr Loretta DiPietro Female Physical activity in older adults None declared No conflict of interest identified Dr Ulf Ekelund Male Sedentary behaviour and physical activity in youth None declared No conflict of interest identified Dr Joseph Firth Male Physical activity and mental health None declared No conflict of interest identified Dr Christine Friedenreich Female Physical activity in people living with chronic conditions, physical activity and cancer risk None declared No conflict of interest identified Dr Leandro Garcia Male Physical activity and mental health Employment and paid consultancy No conflict of interest identified Dr Muthoni Gichu Female Policy implementation (national government) None declared No conflict of interest identified Dr Russ Jago Male Physical activity in youth None declared No conflict of interest identified 92 93 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Name Gender Expertise Disclosure of interest Conflict of interest and management Dr Peter Katzmarzyk Male Physical activity and sedentary behaviour in youth Travel support to assist guideline committees No conflict of interest identified Dr Estelle V. Lambert Female Physical activity and obesity None declared No conflict of interest identified Dr Michael Leitzmann Male Sedentary behaviour and chronic conditions None declared No conflict of interest identified Dr Karen Milton Female Translating recommendations into practice Travel support to assist guideline committee No conflict of interest identified Dr Francisco Ortega Male Physical activity in youth, mental health and objective measurement None declared No conflict of interest identified Dr Chathuranga Ranasinghe Male Promotion of physical activity and health in the community, workplace and school settings Research funds No conflict of interest identified Dr Emmanuel Stamatakis Male Physical activity and multiple health outcomes in adults Grant for technology company for objective measurement of physical activity No conflict of interest identified Dr Anne Tiedemann Female Physical activity and health outcomes in older adults None declared No conflict of interest identified Dr Richard Troiano Male Policy development None declared No conflict of interest identified Dr Hidde van der Ploeg Male Physical activity, sedentary behaviour and health outcomes in adults Travel support to assist 2017 Dutch Physical Activity Guidelines committee and research funds No conflict of interest identified Ms Vicky Wari Female Policy implementation (national government) Shares (not relevant to guideline) No conflict of interest identified External peer reviewers Name Gender Expertise Disclosure of interest Conflict of interest and management Kingsley Akinroye Male Advocacy, noncommunicable diseases None declared No conflict of interest identified Dr Huda Alsiyabi Female Policy and programme implementation None declared No conflict of interest identified Dr Alberto Flórez- Pregonero Male Physical activity and sedentary behaviour measurement and surveillance None declared No conflict of interest identified Dr Shigeru Inoue Male Epidemiology and physical activity promotion None declared No conflict of interest identified Dr Agus Mahendra Male Physical activity and movement skills in children None declared No conflict of interest identified Dr Deborah Salvo Female Health and social disparities, with a particular emphasis on chronic disease prevention None declared No conflict of interest identified Dr Jasper Schipperijn Male Physical activity and the built environment President-Elect of the International Society for Physical Activity and Health (ISPAH) No conflict of interest identified 92 93Annex 3 ISBN 978-92-4-001513-52 8

WHO GUIDELINES ON PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOUR

WHO GUIDELINES ON PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOUR WHO guidelines on physical activity and sedentary behaviour ISBN 978-92-4-001512-8 (electronic version) ISBN 978-92-4-001513-5 (print edition) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Design: Eddy Hill Design Printed in Switzerland ii iii W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CONTENTS Acknowledgements iv Abbreviations and acronyms v Glossary of terms vi Executive summary 1 Background 15 Methods 18 Recommendations 24 Children and adolescents (aged 5–17 years) 25 Physical activity recommendation 25 Sedentary behaviour recommendation 29 Adults (aged 18–64 years) 32 Physical activity recommendation 32 Sedentary behaviour recommendation 38 Older adults (aged 65 years and older) 43 Physical activity recommendation 43 Sedentary behaviour recommendation 46 Pregnant and postpartum women 47 Physical activity recommendation 47 Sedentary behaviour recommendation 51 Adults and older adults with chronic  conditions (aged 18 years and older) 52 Physical activity recommendation 52 Sedentary behaviour recommendation 58 Children and adolescents (aged 5–17 years) and adults (aged 18 years and over) living with disability 60 Physical activity recommendation 60 Sedentary behaviour recommendation 64 Evidence to recommendations 66 Assessment of the certainty of evidence 66 Benefits and harms 67 Values and preferences 67 Resource implications 67 Equity, acceptability and feasibility 68 Research needs 69 Adoption, dissemination, implementation and evaluation 70 Adoption 70 Dissemination 71 Communication campaigns 71 Implementation of policy and programmes 72 Surveillance and evaluation 73 Updating 73 References 75 Annex 1: Management of guideline development process 85 Annex 2: Guideline development group, external peer reviewers, and who staff involved in the development of these guidelines 88 Annex 3: Summary of declaration of interest and how these were managed 92 Web Annex: Evidence profiles https://apps.who.int/iris/bitstream/handle/ 10665/336657/9789240015111-eng.pdf ii iiiContents ACKNOWLEDGEMENTS The World Health Organization (WHO) gratefully acknowledges the contribution to and support of the following individuals and organizations in the development of these guidelines: Fiona Bull and Juana Willumsen led the process of developing these guidelines. Valentina Baltag, Maurice Bucagu, Alex Butchart, Neerja Chowdhary, Regina Guthold, Riitta-Maija Hämäläinen, Andre Ilbawi, Wasiq Khan, Lindsay Lee, Alana Officer, Leanne Riley and Gojka Roglic were members of the WHO Steering Group that managed the guideline development process. The members of the Guideline Development Group (GDG) included Salih Saad Al-Ansari, Stuart Biddle, Katja Borodulin, Matthew Buman, Greet Cardon (co-chair), Catherine Carty, Jean-Philippe Chaput, Sebastien Chastin, Paddy Dempsey, Loretta DiPietro, Ulf Ekelund, Joseph Firth, Christine Friedenreich, Leandro Garcia, Muthoni Gichu, Russ Jago, Peter Katzmarzyk, Estelle V. Lambert, Michael Leitzmann, Karen Milton, Francisco B. Ortega, Chathuranga Ranasinghe, Emmanuel Stamatakis (co-chair), Anne Tiedemann, Richard Troiano, Hidde van der Ploeg, Vicky Wari. Roger Chou served as GRADE methodologist. The external review group included Kingsley Akinroye, Huda Alsiyabi, Alberto Flórez-Pregonero, Shigeru Inoue, Agus Mahendra, Deborah Salvo and Jasper Schipperijn. Systematic reviews of evidence prepared for 2018 US Physical Activity Guidelines Advisory Committee Scientific Report to the Secretary of Health and Human Services were updated thanks to additional literature searches conducted by Kyle Sprow (National Cancer Institutes, National Institutes of Health, Maryland, USA). Additional support to review papers identified was provided by Elif Eroglu (University of Sydney), Andrea Hillreiner (University of Regensburg), Bo-Huei Huang (University of Sydney), Carmen Jochem (University of Regensburg), Jairo H. Migueles (University of Granada), Chelsea Stone (University of Calgary) and Léonie Uijtdewilligen (Amsterdam UMC). Summaries of evidence and GRADE tables were prepared by Carrie Patnode and Michelle Henninger (The Kaiser Foundation Hospitals, Center for Health Research, Portland, Oregon, USA). Additional reviews of evidence were conducted by N Fairhall, J Oliveira, M Pinheiro, and C Sherrington (Institute for Musculoskeletal Health, School of Public Health, The University of Sydney, Sydney, Australia) and A Bauman (Prevention Research Collaboration, School of Public Health, The University of Sydney, Sydney, Australia; and WHO Collaborating Centre for Physical Activity, Nutrition and Obesity); S Mabweazara, M-J Laguette, K Larmuth, F Odunitan-Wayas (Research Centre for Health through Physical Activity, Lifestyle and Sports Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa), L Leach, S Onagbiye (Department of Sport, Recreation and Exercise Science, Faculty of Health Sciences, University of the Western Cape, Cape Town, South Africa), M Mthethwa (Chronic Disease Initiative for Africa, University of Cape Town, Cape Town, South Africa), P Smith (The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa) and F Mashili (Department of Physiology, Muhimbili University of Allied Sciences, Dar Es Salaam, United Republic of Tanzania); B Cillekens, M Lang, W van Mechelen, E Verhagen, M Huysmans, A van der Beek, P Coenen (Department of Public and Occupational Health at Amsterdam University Medical Centre, Amsterdam, Netherlands). The Public Health Agency of Canada and the Government of Norway provided financial support, without which this work could not have been completed. iv v W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ADHD attention deficit hyperactive disorder AOR adjusted odds ratio BMI body mass index CI confidence interval CVD cardiovascular disease DBP diastolic blood pressure EtD Evidence to Decisions GDG Guideline Development Group GRADE Grading of Recommendations Assessment, Development and Evaluation HR hazards ratio MET Metabolic Equivalent of Task MD mean difference MICT moderate intensity continuous training NCD noncommunicable disease OR odds ratio PA physical activity PAGAC United States Physical Activity Guidelines Advisory Committee PI/ECO Population, Intervention/Exposure, Comparison, Outcome RaR Relative attributable risk RCT randomized control trial RR relative risk SBP systolic blood pressure SMD standardized mean difference SPPB short physical performance battery TV television WHA World Health Assembly WHO World Health Organization ABBREVIATIONS AND ACRONYMS iv vAbbreviations and acronyms Term Definition Aerobic physical activity Activity in which the body’s large muscles move in a rhythmic manner for a sustained period of time. Aerobic activity – also called endurance activity – improves cardiorespiratory fitness. Examples include walking, running, swimming, and bicycling. Anaerobic physical activity Anaerobic physical activity consists of brief intense bursts of exercise, such as weightlifting and sprints, where oxygen demand surpasses oxygen supply. Balance training Static and dynamic exercises that are designed to improve an individual’s ability to withstand challenges from postural sway or destabilizing stimuli caused by self-motion, the environment, or other objects. Body mass index (BMI) Weight (kg) / height (m)2 BMI-for-age or BMI z-score BMI adjusted for age, standardized for children. BMI standard deviation scores are measures of relative weight adjusted for child age and sex. Given a child’s age, sex, BMI, and an appropriate reference standard, a BMI z-score (or its equivalent BMI-for-age percentile) can be determined. Bone-strengthening activity Physical activity primarily designed to increase the strength of specific sites in bones that make up the skeletal system. Bone-strengthening activities produce an impact or tension force on the bones that promotes bone growth and strength. Running, jumping rope, and lifting weights are examples of bone-strengthening activities. Cardiometabolic health The interplay of blood pressure, blood lipids, blood glucose and insulin on health. Cardiorespiratory fitness (endurance) A health-related component of physical fitness. The ability of the circulatory and respiratory systems to supply oxygen during sustained physical activity. Usually expressed as measured or estimated maximal oxygen uptake (VO2 max). Cognitive function Cerebral activities, i.e. reasoning, memory, attention, and language that lead to the attainment of information and knowledge. This can also include learning. Disability From the International Classification of Functioning, Disability and Health, an umbrella term for impairments, activity limitations, and participation restrictions, denoting the negative aspects of the interaction between an individual (with a health condition) and that individual’s contextual factors (environmental and personal factors). Domains of physical activity Physical activity levels can be assessed in various domains, including one of more of the following: leisure-time, occupation, education, household and/or transportation. Exercise A subcategory of physical activity that is planned, structured, repetitive, and purposeful in the sense that the improvement or maintenance of one or more components of physical fitness is the objective. “Exercise” and “exercise training” frequently are used interchangeably and generally refer to physical activity performed during leisure time with the primary purpose of improving or maintaining physical fitness, physical performance, or health. Executive function Includes constructs such as: working memory, cognitive flexibility (also called flexible thinking) and inhibitory control (which includes self-control). Fitness A measure of the body's ability to function efficiently and effectively in work and leisure activities, and includes, for example, physical fitness and cardiorespiratory fitness. Flexibility A health- and performance-related component of physical fitness that is the range of motion possible at a joint. Flexibility is specific to each joint and depends on a number of specific variables including, but not limited to, the tightness of specific ligaments and tendons. Flexibility exercises enhance the ability of a joint to move through its full range of motion. Functional exercises Exercises that can be embedded into everyday tasks to improve lower-body strength, balance, and motor performance. Examples include tandem and one-leg stands, squatting, chair stands, toe raises, and stepping over obstacles. Household domain physical activity Physical activity undertaken in the home for domestic duties (such as cleaning, caring for children, gardening etc.). Leisure-domain physical activity Physical activity performed by an individual that is not required as an essential activity of daily living and is performed at the discretion of the individual. Such activities include sports participation, exercise conditioning or training, and recreational activities such as going for a walk, dancing, and gardening. GLOSSARY OF TERMS vi vii W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Term Definition Light-intensity physical activity Light-intensity physical activity is between 1.5 and 3 METs, i.e. activities with energy cost less than 3 times the energy expenditure at rest for that person. This can include slow walking, bathing, or other incidental activities that do not result in a substantial increase in heart rate or breathing rate. Major muscle groups Major muscle groups include the legs, back, abdomen, chest, shoulders and arms. Metabolic equivalent of task (MET) The metabolic equivalent of task, or simply metabolic equivalent, is a physiological measure expressing the intensity of physical activities. One MET is the energy equivalent expended by an individual while seated at rest. Moderate-intensity physical activity On an absolute scale, moderate-intensity refers to the physical activity that is performed between 3 and less than 6 times the intensity of rest. On a scale relative to an individual’s personal capacity, moderate-intensity physical activity is usually a 5 or 6 on a scale of 0–10. Muscle-strengthening activity Physical activity and exercise that increase skeletal muscle strength, power, endurance, and mass (e.g. strength training, resistance training, or muscular strength and endurance exercises). Multicomponent physical activity For older adults, multicomponent physical activity is important to improve physical function and decrease the risk of falls or injury from a fall. These activities can be done at home or in a structured group setting. Many studied interventions combine all types of exercise (aerobic, muscle strengthening, and balance training) into a session, and this has been shown to be effective. An example of a multicomponent physical activity programme could include walking (aerobic activity), lifting weights (muscle strengthening), and incorporates balance training. Examples of balance training can include walking backwards or sideways or standing on one foot while doing an upper body muscle-strengthening activity, such as bicep curls. Dancing also combines aerobic and balance components. Occupation domain physical activity See work domain physical activity. Physical activity Any bodily movement produced by skeletal muscles that requires energy expenditure. Physical inactivity An insufficient physical activity level to meet present physical activity recommendations. Psychosocial health Include mental, emotional and social dimensions of health. Recreational screen time Time spent watching screens (television (TV), computer, mobile devices) for purposes other than those related to education/study or work. Sedentary screen time Time spent watching screen-based entertainment (TV, computer, mobile devices). Does not include active screen-based games where physical activity or movement is required. Sedentary behaviour Any waking behaviour characterized by an energy expenditure of 1.5 METS or lower while sitting, reclining, or lying. Most desk-based office work, driving a car, and watching television are examples of sedentary behaviours; these can also apply to those unable to stand, such as wheelchair users. The guidelines operationalize the definition of sedentary behaviour to include self-reported low movement sitting (leisure time, occupational, and total), television (TV viewing or screen time, and low levels of movement measured by devices that assess movement or posture). Sport Sport covers a range of activities performed within a set of rules and undertaken as part of leisure or competition. Sporting activities involve physical activity carried out by teams or individuals and may be supported by an institutional framework, such as a sporting agency. Transport domain physical activity Physical activity performed for the purpose of getting to and from places, and refers to walking, cycling and wheeling (the use of non-motorized means of locomotion with wheels, such as scooters, rollerblades, manual wheelchair etc.). Vigorous-intensity physical activity On an absolute scale, vigorous-intensity refers to physical activity that is performed at 6.0 or more METS. On a scale relative to an individual’s personal capacity, vigorous-intensity physical activity is usually a 7 or 8 on a scale of 0–10. Work domain physical activity Physical activity undertaken during paid or voluntary work. vi viiGlossary of terms The WHO Guidelines on physical activity and sedentary behaviour provide evidence-based public health recommendations for children, adolescents, adults and older adults on the amount of physical activity (frequency, intensity and duration) required to offer significant health benefits and mitigate health risks. For the first time, recommendations are provided on the associations between sedentary behaviour and health outcomes, as well as for subpopulations, such as pregnant and postpartum women, and people living with chronic conditions or disability. The guidelines are intended for policy-makers in high-, middle-, and low-income countries in ministries of health, education, youth, sport and/or social or family welfare; government officials responsible for developing national, sub regional or municipal plans to increase physical activity and reduce sedentary behaviour in population groups through guidance documents; people working in nongovernmental organizations, the education sector, private sector, research; and health- care providers. The guidelines were prepared in accordance with the WHO handbook for guideline development. Systematic reviews of evidence were conducted for the critical and important outcomes, and recommendations were developed after consideration of the benefits and harms, values, preferences, feasibility and acceptability, and the implications for equity and resources. The final public health recommendations presented are for all populations and age groups ranging from 5 years to 65 years and older, irrespective of gender, cultural background or socioeconomic status, and are relevant for people of all abilities. Those with chronic medical conditions and/or disability and pregnant and postpartum women should try to meet the recommendations where possible and as able. The development of these guidelines provide a set of evidence-based recommendations that governments can adopt as part of their national policy frameworks to support comprehensive approaches to increasing population levels of physical activity. Within the adoption process, consideration should be given to the need to contextualize the guidelines. Practical tools to support adoption, dissemination, communication campaigns and implementation of the guidelines will support governments and stakeholders work together to increase physical activity and reduce sedentary behaviours across the life course. These supporting resources will be available through the WHO website following publication of the guidelines Despite the large quantity of supporting data relating physical activity and, increasingly, sedentary behaviours to health outcomes across the life-span, important evidence gaps remain. In particular, there is less evidence from low- and middle-income countries and economically disadvantaged or underserved communities, and a dearth of evidence from subpopulations including people living with disabilities. Investment in more research is needed to build evidence particularly in these areas. In addition, the changes introduced to these recommendations will have some implications for surveillance systems and assessment instruments currently used to monitor national levels of physical activity. Existing global and national instruments should be reviewed, and reporting protocols updated, to inform future reporting against the new guidelines. The Global action plan on physical activity 2018–2030 set a target to reduce physical inactivity by 15% by 2030, and outlined 20 recommended policy actions and interventions. These guidelines support all countries to implement the GAPPA recommendations and “ACTIVE”, the technical package of toolkits that provides guidance on how to promote physical activity across the life course and through multiple settings. EXECUTIVE SUMMARY viii 1 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CHILDREN AND ADOLESCENTS (aged 5–17 years) It is recommended that: Children and adolescents should do at least an average of 60 minutes per day of moderate- to vigorous-intensity, mostly aerobic, physical activity, across the week. Strong recommendation, moderate certainty evidence Vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone, should be incorporated at least 3 days a week. Strong recommendation, moderate certainty evidence • Doing some physical activity is better than doing none. • If children and adolescents are not meeting the recommendations, doing some physical activity will benefit their health. • Children and adolescents should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • It is important to provide all children and adolescents with safe and equitable opportunities, and encouragement, to participate in physical activities that are enjoyable, offer variety, and are appropriate for their age and ability. G O O D P R A C TI C E ST A TE M EN TS In children and adolescents, physical activity confers benefits for the following health outcomes: improved physical fitness (cardiorespiratory and muscular fitness), cardiometabolic health (blood pressure, dyslipidaemia, glucose, and insulin resistance), bone health, cognitive outcomes (academic performance, executive function), mental health (reduced symptoms of depression); and reduced adiposity. In children and adolescents, higher amounts of sedentary behaviour are associated with the following poor health outcomes: increased adiposity; poorer cardiometabolic health, fitness, behavioural conduct/pro-social behaviour; and reduced sleep duration. It is recommended that: Children and adolescents should limit the amount of time spent being sedentary, particularly the amount of recreational screen time. Strong recommendation, low certainty evidence 1 GRADE: Grading of Recommendations Assessment Development and Evaluation Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf INTRODUCTION Regular physical activity is a key protective factor for the prevention and management of noncommunicable diseases (NCDs) such as cardiovascular disease, type-2 diabetes, and a number of cancers. Physical activity also benefits mental health, including prevention of cognitive decline and symptoms of depression and anxiety; and can contribute to the maintenance of healthy weight and general well-being. Global estimates indicate that 27.5% of adults (1) and 81% of adolescents (2) do not meet the 2010 WHO recommendations for physical activity (3) with almost no improvements seen during the past decade. There are also notable inequalities: data show that in most countries girls and women are less active than boys and men, and that there are significant differences in levels of physical activity between higher and lower economic groups, and between countries and regions. SCOPE The WHO Guidelines on physical activity and sedentary behaviour provide evidence-based public health recommendations for children, adolescents, adults and older adults on the amount of physical activity (frequency, intensity and duration) required to offer significant health benefits and mitigate health risks. For the first time, recommendations are provided on the associations between sedentary behaviour and health outcomes, as well as for subpopulations, such as pregnant and postpartum women, and people living with chronic conditions or disability. TARGET AUDIENCE The guidelines are intended for policy-makers in high-, middle-, and low-income countries in ministries of health, education, youth, sport and/or social or family welfare; government officials responsible for developing national, sub regional or municipal plans to increase physical activity and reduce sedentary behaviour in population groups through guidance documents; people working in nongovernmental organizations, the education sector, private sector, research; and health-care providers. DEVELOPMENT PROCESS The guidelines were prepared in accordance with the WHO handbook for guideline development (4). In 2019 a Guideline Development Group (GDG) was formed comprising technical experts and relevant stakeholders from all six WHO regions. The group met in July 2019 to formulate the key questions, review the evidence-bases, and agree the methods for updates of literature, and, where needed, for additional new reviews. In February 2020, the GDG met again to review the evidence for the critical and important outcomes, consider the benefits and harms, values, preferences, feasibility and acceptability, and the implications for equity and resources. The recommendations were developed through consensus and posted online for public consultation. The final updated recommendations are summarized below. The GRADE 1 tables and evidence profiles are available as a Web annex . Practical tools to support adoption, dissemination, communication campaigns and implementation of the guidelines will support governments and stakeholders work together to increase physical activity and reduce sedentary behaviours across the life course. RECOMMENDATIONS The public health recommendations presented in the WHO Guidelines on physical activity and sedentary behaviour are for all populations and age groups ranging from 5 years to 65 years and older, irrespective of gender, cultural background or socioeconomic status, and are relevant for people of all abilities. Those with chronic medical conditions and/or disability and pregnant and postpartum women should try to meet the recommendations where possible and as able. LIMIT the amount of time spent being sedentary, particularly recreational screen time. 3 vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated. On at least days a week 60 moderate- to vigorous-intensity physical activity across the week; most of this physical activity should be aerobic. minutes a day At least 2 3 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendationsviii 1Executive summary It is recommended that: Adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, moderate certainty evidence It is recommended that: All adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults should do at least 150– 300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence ADULTS (aged 18–64 years) ADULTS (aged 18–64 years) 2 Site-specific cancers of: bladder, breast, colon, endometrial, oesophageal adenocarcinoma, gastric, and renal. • Doing some physical activity is better than doing none. • If adults are not meeting these recommendations, doing some physical activity will benefit their health. • Adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. G O O D P R A C TI C E ST A TE M EN TS In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and type-2 diabetes. In adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site-specific cancers, 2 incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression); cognitive health, and sleep; measures of adiposity may also improve. Adults may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence Adults should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 4 5 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations 1 1 2 3 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r It is recommended that: Adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, moderate certainty evidence It is recommended that: All adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults should do at least 150– 300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence ADULTS (aged 18–64 years) ADULTS (aged 18–64 years) 2 Site-specific cancers of: bladder, breast, colon, endometrial, oesophageal adenocarcinoma, gastric, and renal. • Doing some physical activity is better than doing none. • If adults are not meeting these recommendations, doing some physical activity will benefit their health. • Adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. G O O D P R A C TI C E ST A TE M EN TS In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and type-2 diabetes. In adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site-specific cancers, 2 incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression); cognitive health, and sleep; measures of adiposity may also improve. Adults may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence Adults should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 4 5 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations2 3Executive summary It is recommended that: All older adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Older adults should do at least 150– 300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence OLDER ADULTS (aged 65 years and older) OLDER ADULTS (aged 65 years and older) • Doing some physical activity is better than doing none. • If older adults are not meeting the recommendations, doing some physical activity will bring benefits to health. • Older adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • Older adults should be as physically active as their functional ability allows, and adjust their level of effort for physical activity relative to their level of fitness. G O O D P R A C TI C E ST A TE M EN TS In older adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Older adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, older adults should aim to do more than the recommended levels of moderate- to vigorous- intensity physical activity. Strong recommendation, moderate certainty evidence In older adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site-specific cancers, incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression), cognitive health, and sleep; measures of adiposity may also improve. In older adults, physical activity helps prevent falls and falls-related injuries and declines in bone health and functional ability. Older adults may increase moderate- intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week, for additional health benefits. Conditional recommendation, moderate certainty evidence Older adults should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence As part of their weekly physical activity, older adults should do varied multicomponent physical activity that emphasizes functional balance 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 LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 6 7 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations4 5 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r It is recommended that: All older adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Older adults should do at least 150– 300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence OLDER ADULTS (aged 65 years and older) OLDER ADULTS (aged 65 years and older) • Doing some physical activity is better than doing none. • If older adults are not meeting the recommendations, doing some physical activity will bring benefits to health. • Older adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • Older adults should be as physically active as their functional ability allows, and adjust their level of effort for physical activity relative to their level of fitness. G O O D P R A C TI C E ST A TE M EN TS In older adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Older adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, older adults should aim to do more than the recommended levels of moderate- to vigorous- intensity physical activity. Strong recommendation, moderate certainty evidence In older adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site-specific cancers, incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression), cognitive health, and sleep; measures of adiposity may also improve. In older adults, physical activity helps prevent falls and falls-related injuries and declines in bone health and functional ability. Older adults may increase moderate- intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week, for additional health benefits. Conditional recommendation, moderate certainty evidence Older adults should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence As part of their weekly physical activity, older adults should do varied multicomponent physical activity that emphasizes functional balance 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 LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 6 7 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations4 5Executive summary In pregnant and postpartum women, physical activity during pregnancy and postpartum confers benefits on the following maternal and fetal health benefits: decreased risk of pre-eclampsia, gestational hypertension, gestational diabetes, excessive gestational weight gain, delivery complications and postpartum depression, and fewer newborn complications, no adverse effects on birthweight; and no increase in risk of stillbirth. It is recommended that all pregnant and postpartum women without contraindication should: Undertake regular physical activity throughout pregnancy and postpartum. Strong recommendation, moderate certainty evidence In addition: Women who, before pregnancy, habitually engaged in vigorous- intensity aerobic activity, or who were physically active, can continue these activities during pregnancy and the postpartum period. Strong recommendation, moderate certainty evidence Do at least 150 minutes of moderate- intensity aerobic physical activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence Incorporate a variety of aerobic and muscle- strengthening activities. Adding gentle stretching may also be beneficial. Strong recommendation, moderate certainty evidence PREGNANT AND POSTPARTUM WOMEN PREGNANT AND POSTPARTUM WOMEN G O O D P R A C TI C E ST A TE M EN TS • Doing some physical activity is better than doing none. • If pregnant and postpartum women are not meeting the recommendations, doing some physical activity will benefit their health. • Pregnant and postpartum women should start by doing small amounts of physical activity, and gradually increase frequency, intensity and duration over time. • Pelvic floor muscle training may be performed on a daily basis to reduce the risk of urinary incontinence. • Avoid physical activity during excessive heat, especially with high humidity. • Stay hydrated by drinking water before, during, and after physical activity. • 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 high altitude). • Avoid activities in supine position after the first trimester of pregnancy. • When considering athletic competition, or exercising significantly above the recommended guidelines pregnant women should seek supervision from a specialist health-care provider. • Pregnant women should be informed by their health-care provider of the danger signs alerting them as to when to stop; or to limit physical activity and consult a qualified health-care provider immediately should they occur. • Return to physical activity gradually after delivery, and in consultation with a health-care provider, in the case of delivery by Caesarean section. Additional safety considerations for pregnant women when undertaking physical activity are: In pregnant and postpartum women, as in all adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Pregnant and postpartum women should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence Doing some physical activity is better than doing none. LIMIT REPLACE the amount of time spent being sedentary with physical activity of any intensity (including light intensity). 150 moderate-intensity aerobic physical activity At least minutes a week 8 9 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations6 7 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r In pregnant and postpartum women, physical activity during pregnancy and postpartum confers benefits on the following maternal and fetal health benefits: decreased risk of pre-eclampsia, gestational hypertension, gestational diabetes, excessive gestational weight gain, delivery complications and postpartum depression, and fewer newborn complications, no adverse effects on birthweight; and no increase in risk of stillbirth. It is recommended that all pregnant and postpartum women without contraindication should: Undertake regular physical activity throughout pregnancy and postpartum. Strong recommendation, moderate certainty evidence In addition: Women who, before pregnancy, habitually engaged in vigorous- intensity aerobic activity, or who were physically active, can continue these activities during pregnancy and the postpartum period. Strong recommendation, moderate certainty evidence Do at least 150 minutes of moderate- intensity aerobic physical activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence Incorporate a variety of aerobic and muscle- strengthening activities. Adding gentle stretching may also be beneficial. Strong recommendation, moderate certainty evidence PREGNANT AND POSTPARTUM WOMEN PREGNANT AND POSTPARTUM WOMEN G O O D P R A C TI C E ST A TE M EN TS • Doing some physical activity is better than doing none. • If pregnant and postpartum women are not meeting the recommendations, doing some physical activity will benefit their health. • Pregnant and postpartum women should start by doing small amounts of physical activity, and gradually increase frequency, intensity and duration over time. • Pelvic floor muscle training may be performed on a daily basis to reduce the risk of urinary incontinence. • Avoid physical activity during excessive heat, especially with high humidity. • Stay hydrated by drinking water before, during, and after physical activity. • 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 high altitude). • Avoid activities in supine position after the first trimester of pregnancy. • When considering athletic competition, or exercising significantly above the recommended guidelines pregnant women should seek supervision from a specialist health-care provider. • Pregnant women should be informed by their health-care provider of the danger signs alerting them as to when to stop; or to limit physical activity and consult a qualified health-care provider immediately should they occur. • Return to physical activity gradually after delivery, and in consultation with a health-care provider, in the case of delivery by Caesarean section. Additional safety considerations for pregnant women when undertaking physical activity are: In pregnant and postpartum women, as in all adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Pregnant and postpartum women should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence Doing some physical activity is better than doing none. LIMIT REPLACE the amount of time spent being sedentary with physical activity of any intensity (including light intensity). 150 moderate-intensity aerobic physical activity At least minutes a week 8 9 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations6 7Executive summary Adults and older adults with chronic conditions should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults and older adults with chronic conditions should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence For cancer survivors, and adults living with hypertension, type-2 diabetes and HIV, it is recommended that: It is recommended that: All adults and older adults with the above chronic conditions should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults and older adults with these chronic conditions should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence When not contraindicated, adults and older adults with these chronic conditions may increase moderate- intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence As part of their weekly physical activity, older adults with these chronic conditions should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence Adults and older adults with these chronic conditions should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional benefits. Strong recommendation, moderate certainty evidence ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) Physical activity can confer health benefits for adults and older adults living with the following chronic conditions: for cancer survivors – physical activity improves all-cause mortality, cancer-specific mortality, and risk of cancer recurrence or second primary cancer; for people living with hypertension – physical activity improves cardiovascular disease mortality, disease progression, physical function, health-related quality of life; for people living with type-2 diabetes – physical activity reduces rates of mortality from cardiovascular disease and indicators disease progression; and for people living with HIV – physical activity can improve physical fitness and mental health (reduced symptoms of anxiety and depression), and does not adversely affect disease progression (CD4 count and viral load) or body composition. G O O D P R A C TI C E ST A TE M EN TS • When not able to meet the above recommendations, adults with these chronic conditions should aim to engage in physical activity according to their abilities. • Adults with these chronic conditions should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • Adults with these chronic conditions may wish to consult with a physical activity specialist or health-care professional for advice on the types and amounts of activity appropriate for their individual needs, abilities, functional limitations/complications, medications, and overall treatment plan. • Pre-exercise medical clearance is generally unnecessary for individuals without contraindications prior to beginning light- or moderate-intensity physical activity not exceeding the demands of brisk walking or everyday living. In adults, including cancer survivors and people living with hypertension, type-2 diabetes and HIV, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 150 300 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 150 10 11 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations8 9 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Adults and older adults with chronic conditions should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults and older adults with chronic conditions should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence For cancer survivors, and adults living with hypertension, type-2 diabetes and HIV, it is recommended that: It is recommended that: All adults and older adults with the above chronic conditions should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults and older adults with these chronic conditions should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence When not contraindicated, adults and older adults with these chronic conditions may increase moderate- intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence As part of their weekly physical activity, older adults with these chronic conditions should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence Adults and older adults with these chronic conditions should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional benefits. Strong recommendation, moderate certainty evidence ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) Physical activity can confer health benefits for adults and older adults living with the following chronic conditions: for cancer survivors – physical activity improves all-cause mortality, cancer-specific mortality, and risk of cancer recurrence or second primary cancer; for people living with hypertension – physical activity improves cardiovascular disease mortality, disease progression, physical function, health-related quality of life; for people living with type-2 diabetes – physical activity reduces rates of mortality from cardiovascular disease and indicators disease progression; and for people living with HIV – physical activity can improve physical fitness and mental health (reduced symptoms of anxiety and depression), and does not adversely affect disease progression (CD4 count and viral load) or body composition. G O O D P R A C TI C E ST A TE M EN TS • When not able to meet the above recommendations, adults with these chronic conditions should aim to engage in physical activity according to their abilities. • Adults with these chronic conditions should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • Adults with these chronic conditions may wish to consult with a physical activity specialist or health-care professional for advice on the types and amounts of activity appropriate for their individual needs, abilities, functional limitations/complications, medications, and overall treatment plan. • Pre-exercise medical clearance is generally unnecessary for individuals without contraindications prior to beginning light- or moderate-intensity physical activity not exceeding the demands of brisk walking or everyday living. In adults, including cancer survivors and people living with hypertension, type-2 diabetes and HIV, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups. For additional health benefits: 2 days a week On at least varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 300 150 minutes moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: 150 300 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 150 10 11 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations8 9Executive summary CHILDREN AND ADOLESCENTS (aged 5–17 years) LIVING WITH DISABILITY CHILDREN AND ADOLESCENTS (aged 5–17 years) LIVING WITH DISABILITY Many of the health benefits of physical activity for children and adolescents, as set out in the section above, also relate to those children and adolescents living with disability. Additional benefits of physical activity to health outcomes for those living with disability include: improved cognition in individuals with diseases or disorders that impair cognitive function, including attention-deficit/ hyperactivity disorder (ADHD); improvements in physical function may occur in children with intellectual disability. • Doing some physical activity is better than doing none. • If children and adolescents living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Children and adolescents living with disability should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • There are no major risks for children and adolescents living with disability engaging in physical activity when it is appropriate to an individual’s current activity level, health status and physical function; and the health benefits accrued outweigh the risks. • Children and adolescents living with disability may need to consult a health-care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. G O O D P R A C TI C E ST A TE M EN TS In children and adolescents, higher amounts of sedentary behaviour are associated with the following poor health outcomes: increased adiposity; poorer cardiometabolic health, fitness, and behavioural conduct/pro-social behaviour; and reduced sleep duration. It is recommended that: Children and adolescents living with disability should limit the amount of time spent being sedentary, particularly the amount of recreational screen time. Strong recommendation, low certainty evidence It is recommended that: Children and adolescents living with disability should do at least an average of 60 minutes per day of moderate- to vigorous- intensity, mostly aerobic, physical activity, across the week. Strong recommendation, moderate certainty evidence Vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated at least 3 days a week. Strong recommendation, moderate certainty evidence Doing some physical activity is better than doing none. Start by doing small amounts of physical activity. 60 moderate- to vigorous-intensity physical activity across the week; most of this physical activity should be aerobic. At least minutes a day 3 vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated. On at least days a week LIMIT the amount of time spent being sedentary, particularly recreational screen time. 12 13 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations0 1 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CHILDREN AND ADOLESCENTS (aged 5–17 years) LIVING WITH DISABILITY CHILDREN AND ADOLESCENTS (aged 5–17 years) LIVING WITH DISABILITY Many of the health benefits of physical activity for children and adolescents, as set out in the section above, also relate to those children and adolescents living with disability. Additional benefits of physical activity to health outcomes for those living with disability include: improved cognition in individuals with diseases or disorders that impair cognitive function, including attention-deficit/ hyperactivity disorder (ADHD); improvements in physical function may occur in children with intellectual disability. • Doing some physical activity is better than doing none. • If children and adolescents living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Children and adolescents living with disability should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • There are no major risks for children and adolescents living with disability engaging in physical activity when it is appropriate to an individual’s current activity level, health status and physical function; and the health benefits accrued outweigh the risks. • Children and adolescents living with disability may need to consult a health-care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. G O O D P R A C TI C E ST A TE M EN TS In children and adolescents, higher amounts of sedentary behaviour are associated with the following poor health outcomes: increased adiposity; poorer cardiometabolic health, fitness, and behavioural conduct/pro-social behaviour; and reduced sleep duration. It is recommended that: Children and adolescents living with disability should limit the amount of time spent being sedentary, particularly the amount of recreational screen time. Strong recommendation, low certainty evidence It is recommended that: Children and adolescents living with disability should do at least an average of 60 minutes per day of moderate- to vigorous- intensity, mostly aerobic, physical activity, across the week. Strong recommendation, moderate certainty evidence Vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated at least 3 days a week. Strong recommendation, moderate certainty evidence Doing some physical activity is better than doing none. Start by doing small amounts of physical activity. 60 moderate- to vigorous-intensity physical activity across the week; most of this physical activity should be aerobic. At least minutes a day 3 vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated. On at least days a week LIMIT the amount of time spent being sedentary, particularly recreational screen time. 12 13 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations0 1Executive summary It is recommended that: Adults living with disability should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults living with disability should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence It is recommended that: All adults living with disability should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults living with disability should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence Adults living with disability should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence ADULTS (aged 18 years and older) LIVING WITH DISABILITY ADULTS (aged 18 years and older) LIVING WITH DISABILITY Many of the health benefits of physical activity for adults, as set out in the section above, also relate to adults living with disability. Additional benefits of physical activity to health outcomes for those living with disability include the following: for adults with multiple sclerosis – improved physical function, and physical, mental, and social domains of health-related quality of life; for individuals with spinal cord injury – improved walking function, muscular strength, and upper extremity function; and enhanced health-related quality of life; for individuals with diseases or disorders that impair cognitive function – improved physical function and cognition (in individuals with Parkinson’s disease and those with a history of stroke); beneficial effects on cognition; and may improve quality of life (in adults with schizophrenia); and may improve physical function (in adults with intellectual disability); and improves quality of life (in adults with major clinical depression). In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and type-2 diabetes. Adults living with disability may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence As part of their weekly physical activity, older adults living with disability should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence G O O D P R A C TI C E ST A TE M EN TS • Doing some physical activity is better than doing none. • If adults living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Adults living with disability should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • There are no major risks to adults living with disability engaging in physical activity when it is appropriate to the individual’s current activity level, health status and physical function; and when the health benefits accrued outweigh the risks. • Adults living with disability may need to consult a health- care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 300 150 minutes moderate-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: vigorous- intensity aerobic physical activity For additional health benefits: 2 days a week On at least muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups. 14 15 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations2 3 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r It is recommended that: Adults living with disability should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults living with disability should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence It is recommended that: All adults living with disability should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults living with disability should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence Adults living with disability should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence ADULTS (aged 18 years and older) LIVING WITH DISABILITY ADULTS (aged 18 years and older) LIVING WITH DISABILITY Many of the health benefits of physical activity for adults, as set out in the section above, also relate to adults living with disability. Additional benefits of physical activity to health outcomes for those living with disability include the following: for adults with multiple sclerosis – improved physical function, and physical, mental, and social domains of health-related quality of life; for individuals with spinal cord injury – improved walking function, muscular strength, and upper extremity function; and enhanced health-related quality of life; for individuals with diseases or disorders that impair cognitive function – improved physical function and cognition (in individuals with Parkinson’s disease and those with a history of stroke); beneficial effects on cognition; and may improve quality of life (in adults with schizophrenia); and may improve physical function (in adults with intellectual disability); and improves quality of life (in adults with major clinical depression). In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and type-2 diabetes. Adults living with disability may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence As part of their weekly physical activity, older adults living with disability should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence G O O D P R A C TI C E ST A TE M EN TS • Doing some physical activity is better than doing none. • If adults living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Adults living with disability should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • There are no major risks to adults living with disability engaging in physical activity when it is appropriate to the individual’s current activity level, health status and physical function; and when the health benefits accrued outweigh the risks. • Adults living with disability may need to consult a health- care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. LIMIT REPLACE the amount of time spent being sedentary with more physical activity of any intensity (including light intensity). 150 300 150 minutes to to moderate-intensity aerobic physical activity vigorous-intensity aerobic physical activity or an equivalent combination throughout the week minutes or at leastAt least 75 varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity. 3 days a week On at least 300 150 minutes moderate-intensity aerobic physical activity or an equivalent combination throughout the week minutes or more thanmore than For additional health benefits: vigorous- intensity aerobic physical activity For additional health benefits: 2 days a week On at least muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups. 14 15 G u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r: at a g la n ce Recommendations2 3Executive summary 14 15 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Regular physical activity is a known protective factor for the prevention and management of noncommunicable diseases such as cardiovascular disease, type-2 diabetes, breast and colon cancer (1–3). Physical activity also has benefits for mental health (4), delays the onset of dementia (5), and can contribute to the maintenance of healthy weight (1) and general well-being (6). Physical activity is defined as any bodily movement produced by skeletal muscles that requires energy expenditure (1) and can be performed at a variety of intensities, as part of work, domestic chores, transportation or during leisure time, or when participating in exercise or sports activities. At the low end of the intensity range, sedentary behaviour is defined as any waking behaviour while in a sitting, reclining or lying posture with low energy expenditure (7). Emerging new evidence indicates that high levels of sedentary behaviour are associated with cardiovascular disease and type-2 diabetes as well as cardiovascular, cancer and all-cause mortality (8–10). Physical inactivity is defined as not meeting the 2010 Global recommendations on physical activity for health (1) and is a leading contributor to global mortality. It is estimated that between four and five million deaths per year could be averted if the global population was more active (2, 11). Global estimates of physical inactivity indicate that in 2016, 27.5% of adults (12) and 81% of adolescents (13) did not meet the 2010 WHO recommendations (1), and trend data show limited global improvement during the past decade. The data also highlight that women are less active than men in most countries and that there are significant differences in levels of physical activity within and between countries and regions. These differences can be explained by inequities in access to opportunities to be physically active, further amplifying inequalities in health. Currently, there are no global estimates of sedentary behaviour, but technological innovation and the transition towards more sedentary occupations and recreation, and the increasing use of personal motorized transportation are contributing to changing patterns of physical activity and increased sedentary behaviour across the world. The Global action plan on physical activity 2018–2030 (14) sets out 4 strategic objectives and 20 policy actions to achieve a 15% relative reduction in the global prevalence of physical inactivity in adults and adolescents by 2030. In 2010, WHO published the Global recommendations on physical activity for health (1), the first population-based public health guidelines for children and adolescents, adults and older adults. In 2018, the World Health Assembly, in resolution WHA71.6, 1 called for WHO to update the 2010 recommendations. In 2019, WHO published Guidelines on physical activity, sedentary behaviour and sleep for children under 5 years of age (15). The guidelines were called for by the Commission on Ending Childhood Obesity (recommendation 4.12) (16), and address the omission of this younger age group in the 2010 Global recommendations on physical activity for health (1). The 2020 WHO Guidelines on physical activity and sedentary behaviour, replace the 2010 guidelines and are based on the most recent advances in the evidence for the selected behaviours and associated health consequences. They will form part of the overall set of global recommendations on physical activity and sedentary behaviour. BACKGROUND 1 WHA71.6 WHO Global Action Plan on Physical Activity 2018–2030. 14 15Background OTHER KEY WHO GUIDELINES The importance of physical activity for health is recognized in other WHO guidelines. The WHO Package of essential noncommunicable disease interventions for primary health care in low-resource settings (17) provides a protocol for the clinical management of hypertension, type-2 diabetes, raised cardiovascular risk, asthma, and chronic obstructive pulmonary disease, and includes counselling to progressively increase physical activity to moderate levels (such as brisk walking) and at least 150 minutes per week, in line with the 2010 global recommendations. Recent WHO guidance in Risk reduction of cognitive decline and dementia (18) states that physical activity should be recommended to adults with normal cognition (strong recommendation) and those with mild cognitive impairment (conditional recommendation) to reduce the risk of cognitive decline. WHO Integrated care for older people: guidelines on community-level interventions to manage declines in intrinsic capacity (19) recommend multimodal exercises to prevent falls, and exercises for older adults with declining mobility. WHO recommendations on antenatal care for a positive pregnancy experience (20) recommend counselling on healthy eating and being physically active during pregnancy to stay healthy and to prevent excessive weight gain, but do not address the wider health benefits of physical activity during pregnancy and the postpartum period. The existing WHO guidelines, combined with these updated guidelines, provide an increasingly comprehensive set of global guidance on the contribution of physical activity and sedentary behaviours to the prevention and management of key diseases and to the promotion of health and well-being across the life course. RATIONALE AND PURPOSE The past 10 years has seen a significant increase in the body of evidence on the health impact of different types, amounts and durations of physical activity, as well as on the impact of sedentary behaviours and its interrelationship with levels of physical activity and health. In addition, the evidence base for physical activity in subpopulations, such as pregnant women and those living with chronic conditions and/or disability now permits the examination of the relationship between physical activity and health outcomes in these groups. In the Global action plan on physical activity 2018–2030 (14), action 4.1 calls for WHO to develop and disseminate global recommendations for physical activity and sedentary behaviours in children under 5 years of age, young people, adults, older adults and specific subpopulations, such as pregnant women, people living with chronic conditions and disability. Updating and broadening the scope of the guidelines, as requested by the World Health Assembly, ensures that population groups not included in the 2010 recommendations are provided with specific recommendations for physical activity. This aligns with the key principles and goals of the global action plan on physical activity, namely to reduce inequalities and to support all people to be more physically active every day. The overarching purpose of these guidelines is to provide evidence-based public health recommendations on how much and what type of physical activity children and adolescents, adults, older adults and subpopulations such as pregnant women and those living with chronic conditions or disability, should do for significant health benefits and mitigation of health risks. The guidelines also provide evidence- based recommendations on the associations between sedentary behaviour and health outcomes. 16 17 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r The guidelines have been developed for children and adolescents (aged 5–17 years), adults (aged 18–64 years), older adults (aged 65 years and above), and include for the first time specific recommendations on physical activity for subpopulations such as pregnant women and those living with chronic conditions or disability. Recommendations are made for each specific age group and subpopulation, to provide those working with particular communities easy access to the relevant information. Providing separate recommendations for subpopulations, especially people living with chronic conditions or with disability, highlights the importance of including these subpopulations in policy and planning of physical activity and sedentary behaviour interventions. These guidelines do not address sleep as a behaviour. Sleep is an important health-related issue and an emerging topic within population health science. However, it was deemed beyond the scope of the mandate to include sleep in the updated recommendations. Nonetheless, the importance of sleep is recognized and was included as an important health outcome when considering the impact of physical activity and sedentary behaviour. TARGET AUDIENCE This document reports the process and summarizes the evidence-base reviewed to develop the recommendations. The primary audiences are: 1. Policy-makers in ministries of health, education, youth, sport and/or social or family welfare, working in high as well as low- and middle-income countries, who formulate country-specific guidelines, and who plan health, education, workplace, residential or community-based intervention programmes across the life course. 2. Government officials who develop national, subregional or municipal plans to increase physical activity and reduce sedentary behaviours in population groups through guidance documents. 3. Persons working in nongovernmental organizations, education and workplace organizations or research. 4. Persons working in health services and those providing advice and guidance, such as community, family, primary or tertiary nurses or doctors, or allied health and exercise professionals working beyond the health sector. These guidelines can inform the content of their advice on these topics, if national guidance is not available. The recommendations on physical activity and sedentary behaviour contained within the guidelines should be used to inform pre-service training and professional development courses for health-care workers, physical activity specialists and education professionals. Derivative products are needed that convey these guidelines to specific end-users, stakeholders in sectors outside of health, and the wider community, that use tailored communications to meet the specific needs of each audience. 16 17Background These guidelines were developed in accordance with the WHO Handbook for guideline development (2nd edition) (21). A WHO Steering Group, led by the Department of Health Promotion, was established, with representation from WHO regional offices and relevant WHO departments. A Guideline Development Group (GDG) was formed, consisting of 27 experts and stakeholders, taking into account gender balance and geographical diversity. The draft guidelines were externally reviewed by seven independent reviewers, who provided feedback on the scientific evidence, its interpretation and content. In addition, an online public consultation was conducted on the draft guidelines, and feedback was received from over 400 contributors. These inputs from scientists, practitioners and the general public were collated and used by the GDG to finalize the guidelines. Full details of the management of the guideline development process are available in Annex 1. SCOPE OF GUIDELINES AND QUESTIONS OF INTEREST The GDG reviewed the scope of the guidelines and, at their first meeting, agreed on the most relevant PI/ ECO (Population, Intervention/Exposure, Comparison, Outcome) questions. The key questions addressed for each subpopulation are summarized as follows: For physical activity: a. What is the association between physical activity and health-related outcomes? b. Is there a dose-response association (volume, duration, frequency, intensity)? c. Does the association vary by type or domain of physical activity? For sedentary behaviour: a. What is the association between sedentary behaviour and health-related outcomes? b. Is there a dose-response association (total volume, frequency, duration and intensity of interruption)? c. Does the association vary by type and domain of sedentary behaviour? d. In adults only: Does physical activity modify the effect of sedentary behaviour on mortality? For each population (P), the exposure (E) was greater volume, duration, frequency or intensity of physical activity; for, as comparison (C) no physical activity or lesser volume, frequency, intensity or duration of physical activity. The critical and important outcomes for each population are summarized in Table 1 and the details of each PI/ECO question in the relevant section of the Web Annex: Evidence profiles . METHODS Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 18 19 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Table 1: Summary of critical and important* health outcomes addressed by population groups Outcomes (in alphabetical order) Children and adolescents aged 5–17 years: PA and sedentary Adults aged 18–64 years: PA Adults aged over 18 years: sedentary Adults aged over 65 years: PA a Pregnancy and postpartum Chronic conditions b Children and adults with disability c Adiposity (weight gain, weight change, weight control, weight stability, weight status and weight maintenance) Critical Critical Critical Critical a Critical Critical – HIV – Adverse events Critical Critical – Critical a Critical (fetal outcomes) – – All-cause and cause-specific mortality – Critical (cancer and CVD specific) Critical Critical a – Critical – Bone health Critical – Important – – – – Cardiometabolic health Critical – – – – – – Cognitive outcomes Critical Critical Important Critical a – – Critical – MS, PD, Stk, Sch, ADHD Delivery complications – – – – Important – – Disease progression – – – – – Critical – HT, T2D, HIV, Critical – cancer recurrence – Falls and fall-related injuries – – – Critical – – – Fetal outcomes (birthweight, preterm birth) – – – – Critical – – Functional ability – – – Critical – – – Gestational diabetes mellitus – – – – Critical – – Gestational hypertension/ preeclampsia – – – – Critical – – Health-related quality of life – Important Important Important a – Critical – HT, T2D, HIV Critical – MS, SCI, ID, MCD, Sch Incidence of cancer – Critical Critical Critical a – – – Incidence of CVD – Critical Critical Critical a – – – Incidence of hypertension – Important Important a – – – Incidence of type-2 diabetes – Critical Critical Critical a – – – Mental health (symptoms of anxiety and depression) Critical Critical Important Critical a Critical – – Osteoporosis – – – Critical – – – Physical fitness Critical – Important – – – – Physical function – – Important – – Critical – HT, T2D, HIV Critical – MS, SCI, ID, PD, Stk Pro-social behaviour Important – – – – – – Psychosocial outcomes – – – Important – – – Risk of co-morbid conditions – – – – – Critical – HT, T2D, HIV Critical – MS, SCI, ID Sleep Important Important Important Important a – – – * Critical outcome: an outcome that is critical to decision-making; Important outcome: an outcome that is important, but not critical to decision-making. a The critical and important outcomes considered for the adult population, including older adults. b Outcomes are for subpopulation condition as listed: Cancer – cancer survivors; HT – hypertension; T2D – type-2 diabetes; HIV. c Outcomes are for subpopulation condition as listed: MS – muscular sclerosis; SCI – spinal cord injury; ID – intellectual disability; PD – Parkinson’s disease; Stk – in stroke survivors; Sch – schizophrenia; ADHD – attention deficit/hyperactivity disorder. Critical and important outcomes for the age-specific population were considered and extrapolated. 18 19Methods THE EVIDENCE The revision of the 2010 WHO recommendations on physical activity was conducted by identifying, and then updating, the most recent, relevant umbrella reviews related to the scope of these guidelines. This approach was adopted due to an extensive body of recent systematic reviews which were conducted to inform the development of several national physical activity guidelines. The additional updating was undertaken to ensure the new WHO guidelines reflect the most recent available data in a rapidly developing field of public health. Umbrella reviews were selected if they met the following three criteria: i) the evidence reviews had been conducted according to standard systematic processes that were well documented; ii) the assessment of the certainty of the evidence used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method or an equivalent methodology that was clearly described and documented; and iii) the evidence reviews addressed the populations of interest with no restrictions to country or country income level. The PI/ECO questions and the critical and important health outcomes were mapped against existing evidence reviews and, where needed, additional new reviews were commissioned to address gaps. The GDG requested that the evidence reviews be updated, using the same search terms, search languages, and databases as the original reviews. The following evidence reviews were identified as meeting the above three criteria and were chosen for recency and comprehensiveness: • A systematic review of the literature conducted by Poitras et al. (2016) on the association between physical activity and health indicators in school-aged children and youth (22) as part of the process for developing the Canadian 24-hour movement guidelines for children and youth (23). This review focused solely on studies that used objective measurements of physical activity. A total of 162 studies were included, representing 204 171 participants from 31 countries. • A systematic review of the literature of the association between sedentary behaviour and health indicators in school-aged children conducted by Carson et al. (2016) (24), as part of the process for developing the Canadian 24-hour movement guidelines for children and youth (23). A total of 235 studies (194 unique samples) were included representing 1 657 064 unique participants from 71 countries. • A systematic review conducted by Okely et al. (2019) (25) undertaken to update Poitras et al. (2016) (22) and Carson et al. (2018) (24) as part of the development of the 2019 Australian 24-hour movement guidelines for children and young people (aged 5–17 years) (26). This report identified an additional 42 studies on physical activity, and 32 on sedentary behaviour, published through to July 2918 (25). The GRADE tables developed by Okely et al. were used as the basis for the commissioned update conducted for WHO. The GRADE tables along with the evidence profiles are presented in the Web Annex: Evidence profiles . • The 12 systematic reviews conducted and synthesized as part of the development of the 2019 Canadian guideline for physical activity throughout pregnancy (27). These 12 reviews assessed over 25 000 related studies in English, Spanish and French language on maternal physical activity during pregnancy that reported on maternal, fetal, or neonatal morbidity, or fetal mortality outcomes. Seven of these systematic reviews addressed outcomes deemed critical and important by the GDG (28–34) The GRADE tables from these evidence reviews were used as the basis for the literature search conducted to update and inform the development of WHO recommendations. The updated evidence profiles are presented in the Web Annex: Evidence profiles . • The scientific report of the Physical Activity Guidelines Advisory Group (PAGAC) (35) which provides a systematic update of evidence on physical activity and sedentary behaviours and health outcomes published 2008–2016 as part of the development of the 2018 Physical activity guidelines for Americans, 2nd Edition (36). The evidence summarized addressed a total of 38 main research questions and 104 subquestions selected for their public health relevance. The evidence comprised results from systematic reviews which consisted of a total of 1130 articles, each abstracted to answer the 38 research questions (35). The protocols used a modified version of “A Measurement Tool to Assess Systematic Reviews” (AMSTARExBP) to assess the methodological quality of systematic reviews and meta-analyses. Risk of bias, or internal validity, was assessed for each original study using an adapted version of the USDA NEL Bias Assessment Tool (BAT) (37). The new evidence identified in the updated searches conducted for these WHO guidelines is presented in the evidence profiles in the Web Annex: Evidence profiles ; links are provided to the report and supplementary materials of PAGAC (35). Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 20 21 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Methods for updating the evidence and data extraction A search for systematic reviews and pooled analyses of cohort studies was conducted for studies published from the date of the last searches carried out for each of the included reviews (listed above) to September 2019; standardized data extraction protocols were developed and employed. To update the searches conducted by Poitras et al. (2016) (22), Carson et al. (2016) (24), and Okely et al. (2019) (25), the databases MEDLINE, EMBASE, PsycINFO, and SportDiscus were searched to identify reviews that were peer-reviewed, written in English or French. To update the searches conducted by PAGAC (35), PubMed, CINAHL and Cochrane databases were searched to identify reviews that were peer-reviewed, written in English. A de novo search for important outcomes, where these were not included by PAGAC (35), was not conducted due to resource constraints. Searches were performed with no restriction by country or country income status, and inclusive of reviews addressing any subjectively or objectively measured physical activity or sedentary behaviour. It was decided not to conduct searches in languages other than those of the original searches, due to resource constraints and previous experience in the field indicating that such searches yielded very few, if any, additional reviews. Reviews were considered that examined an association between physical activity or sedentary behaviour and health-related outcomes (based on levels above or below a threshold of physical activity or sedentary behaviour), and that explored the dose-response relationship between these and health-related outcomes. An external team of reviewers used the AMSTAR 2 (Assessment of Multiple Systematic Reviews) instrument to rate the credibility of the systematic reviews under consideration for inclusion (38). The AMSTAR 2 tool contains 16 items that relate to the planning and conduct of the review. The overall confidence in the results of each review was rated according to published guidance: a rating of “high” reflects that the review had zero or one noncritical weakness; “moderate” indicates the review was judged to have more than one noncritical weakness; “low” means the review was judged to have one critical flaw with or without noncritical weaknesses, or multiple noncritical weaknesses; and “critically low” signifies that more than one critical flaw was present. One reviewer completed the AMSTAR 2 tool for all provisionally included reviews. Reviews that were rated critically low by one reviewer were reviewed by a second reviewer using the same tool. Reviews ultimately rated as critically low were excluded because they were judged to be too unreliable to provide an accurate and comprehensive summary of the available evidence, unless it was the only review available for a particular outcome. This body of evidence also included pooled cohort studies. An external team of reviewers used the Newcastle- Ottawa Scale to assess the quality of the studies (39). Each study was given a quality rating of “good”, “fair”, or “poor”. In general, a good-quality study met all criteria on the Newcastle-Ottawa scale. A fair-quality study did not meet, or it was unclear whether it met, at least one criterion, but also had no known important limitations that could invalidate its results. A poor-quality study had a single fatal flaw, or multiple important limitations. Poor-quality studies were excluded. There was an assessment for overlap, recognizing potential for duplication of studies in multiple reviews. Reviews containing redundant bodies of evidence, overviews of reviews, and some pooled cohort studies were excluded, where other more comprehensive and/or recent reviews were identified. Methods for new reviews Where gaps in existing evidence were identified, new umbrella reviews were commissioned to examine: 1. the relationship between occupational (i.e. work- related) physical activity and health-related outcomes (40); and 2. the association between leisure-domain physical activity and adverse health outcomes (41). (For numbers 1 and 2 above, searches were undertaken using PubMed, SportDiscus and EMBASE for reviews published from 2009 to December 2019.) 3. the association between physical activity and falls prevention; the 2019 Cochrane Collaboration Systematic Review by Sherrington et al. (42) was used, and updated with evidence published from the end search date of their original review, through to November 2019. 4. the association between physical activity and osteoporosis and sarcopenia. The search for existing systematic reviews on osteoporosis and sarcopenia, conducted in PubMed for reviews published from 2008 up to November 2019, identified no new reviews and eight new primary studies. 5. the evidence on associations between physical activity and health outcomes in people living with HIV. A scoping review ascertained the availability of 20 21Methods evidence on physical activity and health-related outcomes among people living with HIV to support conducting an umbrella review which was conducted for evidence published up to October 2019 with no start date limitation using PubMed, CINAHL and Web of Science. Summary of characteristics of the evidence and assessment methods of physical activity and sedentary behaviour Until recently, the primary methods for measuring physical activity and sedentary behaviours in adults has been by self-report (i.e. survey) and, for children, either self-report or parental recall. Although these methods have well-established strengths, limitations include being prone to reporting bias and measurement error (43). In recent years, with digital technology rapidly growing in this area, there has been an increase in the use of device-based measures for assessing physical activity and sedentary time and their associations with health outcomes. However, challenges remain in comparing results between studies due to differences between the technical features and placement of different devices (accelerometers), and differences in the analyses and reporting of the data. For example, when measuring sedentary time with device-based measures, miscalculation may occur as many of the devices do not currently distinguish between positions (e.g. lying, sitting and standing still). Difficulties also exist when comparing findings from studies using device- based measures with those reporting results from self-report measures. Self-report instruments vary in content, in the examples of physical activity, response options and domains covered. Until recently, studies focused primarily on assessing either total physical activity, or physical activity in the leisure/recreation domain only, but now increasingly include other domains such as physical activity for transport (e.g. walking and cycling), at work, and in the household. The majority of evidence reports on associations between aerobic physical activity and health outcomes, however studies are now assessing the benefits of muscle- strengthening exercise, as well as combinations of different types of activity and other domains. Results on the association between physical activity levels and health outcomes are reported and compared in different ways. Many studies report comparisons between quartiles or quintiles of physical activity, other studies compare those “meeting” versus “not meeting” national guidelines. Calculation of total physical activity, when reported, is usually estimated in MET-hours per week and some studies compare “highest” versus “lowest”, although categories also vary across studies. The literature frequently reports results from analyses that apply data cut points based on an existing guideline, or the current WHO Global recommendation, or metrics from previous research (for example the cut points of 60 minutes per day in research on youth populations, or the frequency of 2–3 times per week for strength training intervention). When such cut points become commonplace the building of evidence on the associations of higher or lower levels of physical activity exposure on health outcomes can be limited. Most of the evidence assessing the associations between sedentary behaviours and health outcomes for children and adolescents is cross-sectional in nature, and a majority of studies rely on self- or parent-reported measures of sedentary time that are subject to measurement errors and recall biases. Evidence from longitudinal observational studies and intervention trials was prioritized, and reviews that solely or primarily synthesized cross-sectional evidence were not considered. Greater emphasis was given to evidence provided by reviews graded moderate certainty and above, and to those providing evidence from studies using device-based measures of exposure. Grading the body of evidence The Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was used to rate the certainty of the evidence for each PI/ECO (44), based on the underlying evidence in the reviews. When available, the GRADE “Evidence Profiles” or “Summary of Findings” tables from each review, were used as a starting point. If no table was available within the existing systematic reviews, “Evidence Profile” tables for each population and outcome of interest were constructed. The GRADE method was used to rate the certainty of the evidence for each PI/ECO (44) with the following criteria considered: study design; risk of bias; consistency of effect; indirectness; precision of effect; and other limitations, including publication bias and factors for upgrading observational evidence (magnitude of effect, dose-response, and effects of confounders). Observational evidence from well- conducted longitudinal studies was also upgraded to reflect more appropriately the increased certainty in findings regarding associations between physical 22 23 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r activity or sedentary behaviour and outcomes from such studies. Studies that evaluated intermediate/ indirect outcomes were not necessarily downgraded, as the outcomes (including intermediate outcomes) were prioritized by the GDG; the GRADE rating reflects the certainty in effects on those outcomes. In some cases, the GRADE ratings from existing reviews were modified to ensure consistency in application of GRADE methods. The certainty in the body of evidence for each outcome was assigned based on the following guidance (45): High Very confident that the true effect lies close to that of the estimate of the effect. Moderate Moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low Confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect. Very low Very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of  effect. Going from evidence to recommendations The GDG employed the GRADE Evidence to Decisions (EtD) framework for generating question-specific recommendations. The EtD framework is a systematic, structured and transparent approach to decision- making. The framework uses explicit criteria for generating guideline recommendations considering research evidence, certainty of evidence and, where required, expert opinion and topical knowledge from the perspective of the target audience. The criteria elicit judgments about the balance between the observed evidence of desirable and undesirable outcomes, overall certainty of evidence, relative values of patients for desirable and undesirable outcomes, resource use (cost considerations) where applicable, potential impact on inequities in health, acceptability and feasibility of recommendations. The GDG considered the body of evidence in totality for each recommendation for all critical outcomes, and all available important outcomes. For a particular exposure/intervention and outcome link, studies differed widely in the specific exposure/intervention assessed, outcomes assessed, study design, and analytic methods, resulting in heterogeneity in the available evidence. Therefore, it was not possible to apply the classic GRADE approach to each specific exposure/intervention and outcome link; rather, GRADE was applied for the overall body of evidence addressing each exposure/intervention and outcome link, across study design types and variations in exposure/intervention measurements and analyses. When these factors resulted in concerns regarding the coherence of the evidence (i.e. that the evidence for a particular exposure/intervention and outcome link did not correspond when looked at in different ways), the panel downgraded the certainty of evidence (21). The GDG prioritized the following health outcomes to consider the effects of physical activity and sedentary behaviour: reduced all-cause and cause- specific mortality (cardiovascular disease and cancer); reduced incidence of cardiovascular disease; cancer (site-specific); type-2 diabetes; improved physical fitness (e.g. cardiorespiratory, motor development, muscular fitness); improved cardiometabolic health (e.g. blood pressure, dyslipidaemia, glucose, insulin resistance); bone health; mental health (e.g. reduction in depressive symptoms, self-esteem, anxiety symptoms, ADHD); and improved cognitive outcomes (e.g. academic performance, executive function); and reduced adiposity. Adverse effects (e.g. injuries and harms) were also considered. Additional considerations For each population and all PI/ECO questions, the GDG also considered values and preferences of those affected by the guidelines; the resource implications of the recommendations; the impact on health equity; and the acceptability and feasibility of the recommendations. As there was considerable duplication in these considerations, and in the GDG’s assessment, for each population group, a summary of the discussions regarding assessments for these elements are described in the “Evidence to recommendations” section. 22 23Methods The public health recommendations presented in the WHO Guidelines on physical activity and sedentary behaviour are for all populations and age groups ranging from 5 years to 65 years and older, irrespective of gender, cultural background or socioeconomic status, and are relevant for people of all abilities. The new guidelines are presented by age group and behaviour (physical activity and sedentary). For each set of recommendations, an introductory statement summarizes the health outcomes associated with physical activity and sedentary behaviour respectively; the recommendations then follow. A set of good practice statements is provided to further clarify how the recommendation can be met safely by the target population. These good practice statements are not “graded recommendations” per se, but are derived from scientific evidence and from practical considerations reviewed and recommended by the GDG. For each set of recommendations, a summary of the supporting scientific evidence is provided, structured by the three PI/ECO questions; presenting first the evidence on the associations with the critical health outcomes, followed by a summary of evidence on dose response. Finally, a summary of evidence on the relationships between different types or domains of exposure and health outcomes is presented, where this exists. RECOMMENDATIONS G O O D P R A C TI C E ST A TE M EN TS 24 25 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Supporting evidence and rationale For these guidelines for children and adolescents, systematic reviews (22, 25, 35) were used and updated with 16 new reviews identified that met inclusion criteria. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . • Doing some physical activity is better than doing none. • If children and adolescents are not meeting the recommendations, doing some physical activity will benefit their health. • Children and adolescents should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • It is important to provide all children and adolescents with safe and equitable opportunities, and encouragement, to participate in physical activities that are enjoyable, offer variety, and are appropriate for their age and ability. G O O D P R A C TI C E ST A TE M EN TS In children and adolescents, physical activity confers benefits for the following health outcomes: improved physical fitness (cardiorespiratory and muscular fitness), cardiometabolic health (blood pressure, dyslipidaemia, glucose, and insulin resistance), bone health, cognitive outcomes (academic performance, executive function), mental health (reduced symptoms of depression); and reduced adiposity. It is recommended that: Children and adolescents should do at least an average of 60 minutes per day of moderate- to vigorous-intensity, mostly aerobic, physical activity, across the week. Strong recommendation, moderate certainty evidence Vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone, should be incorporated at least 3 days a week. Strong recommendation, moderate certainty evidence CHILDREN AND ADOLESCENTS (aged 5–17 years) Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf For children and adolescents, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), physical education, transportation (wheeling, walking and cycling) or household chores, in the context of educational, home, and community settings. PHYSICAL ACTIVITY RECOMMENDATION 24 25Recommendations In children and adolescents (aged 5–17 years), what is the association between physical activity and health-related outcomes? A large body of evidence previously established that greater amounts and higher intensities of physical activity in children and adolescents are associated with multiple beneficial health outcomes (1). Recent evidence reaffirms that increased physical activity improves cardiorespiratory fitness and musculoskeletal fitness in children and adolescents (22, 35). For example, positive impacts are obtained when participating in moderate- to vigorous-intensity physical activity for 3 or more days per week, for 30 to 60 minutes (22, 35). Regular physical activity, largely aerobic, in children and adolescents is positively associated with beneficial cardiometabolic health outcomes, including improved blood pressure, lipid profile, glucose control and insulin resistance (35). Recent reviews examined the effectiveness of school-based physical activity programmes (46), high-intensity interval training (47) and resistance training (48), versus no intervention on measures of cardiometabolic health. Within all 3 reviews, there was consistent evidence that interventions were associated with better cardiometabolic outcome measures, although there was varied precision in effect sizes and few individual trials found statistically significant benefits of physical activity across all cardiometabolic outcomes. One review of 19 RCTs (n= 11 988) (46) reported that school-based physical activity programmes were associated with statistically significant improvements in diastolic blood pressure (ES= 0.21 [95% CI: 0.42 to 0.01]; p= 0.04) and fasting insulin (ES= 0.12 [95% CI: 0.42 to 0.04]; p= 0.03) compared with no physical activity interventions. Physical activity has been reported to be favourably associated with adiposity, and higher levels of activity may be associated with healthy weight status in children and adolescents (22, 35). The results are generally strongest in cross-sectional studies, while the results are more mixed from prospective observational studies, which limits understanding of the directionality of the reported associations. More recent reviews of physical activity interventions trials (laboratory-based high- intensity interval training [HIIT], classroom-based active learning, resistance training) reported inconsistent results with the majority of the studies included in the reviews not reporting an effect (47, 49, 50). However, a review of longitudinal and cross-sectional studies reported a negative relationship between pedometer- measured physical activity and measures of adiposity, BMI or waist circumference (51). Overall there is low certainty evidence that physical activity is associated with the management of a healthy weight status and more research is needed to determine directionality and strength of association. There is less evidence examining the association between physical activity and motor skill development in children and adolescents, with current reviews demonstrating null findings (22). More research is needed with motor development as an outcome to inform future guidelines. For children and adolescents, bone-loading activities can be performed as part of playing games, running, turning, or jumping. Physical activity is positively associated with bone mass accrual and/or bone structure, and recent evidence supports that children and adolescents who are more physically active than their peers have greater bone mass, higher bone mineral content or density, and greater bone strength (35). Maximizing bone health in childhood and adolescence can help protect from osteoporosis and related fractures later in life. Developing and maintaining cognitive function is essential across the entire lifespan. In children and adolescents, physical activity has positive effects on cognitive function and academic outcomes (e.g. school performance, memory and executive function) (22, 35). One recent review (19 RCTs; n= 5038) demonstrated that exercise interventions with multiple sessions per week, for 6 weeks or longer, were associated with greater change in measures of cognitive function such as inhibitory control (SMD 0.26 [95% CI: 0.08 to 0.45], p= < 0.01); working memory (SMD 0.10 [95% CI: -0.05 to 0.25], p= < 0.02), and cognitive flexibility (SMD 0.14 [95% CI: -0.03 to 0.31], p= < 0.04) compared with no exercise interventions (52). Physical activity also reduces the risk of experiencing depression and depressive symptoms in children and adolescents with and without major depression (35), and may be comparable to psychological and pharmaceutical therapies in reducing symptoms. Although all physical activity comes with some risk of adverse event (53) there is limited evidence reporting harms associated with physical activity levels recommended for health benefit (35). Based on available evidence and expert opinion, the potential risks associated with the amounts and types of physical activity recommended for children and adolescents CHILDREN AND ADOLESCENTS (AGED 5–17 YEARS) 26 27 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r were considered to be low (35) and can be reduced by a progressive increase in the activity level and intensity, especially in children and adolescents who are inactive. It is known that participation in some sports increases the risk of injury, as does increasing exercise intensity (53). More research is needed to strengthen the knowledge base in this area. The GDG concluded that: • There is moderate certainty evidence that greater amounts of moderate- and vigorous-intensity physical activity are associated with improved cardiorespiratory fitness and muscular fitness, cardiometabolic health and bone health in children and adolescents. • There is moderate certainty evidence that both short- and long-term moderate- to vigorous-intensity physical activity have positive effects on cognitive function, academic outcomes and mental health. • There is low certainty evidence that physical activity is favourably associated with the management of healthy weight status in children and adolescents. • There is low-certainty evidence that the risks for the amounts and types of physical activity recommended for children and adolescents are low and are outweighed by the benefits. Is there a dose-response association (volume, duration, frequency, intensity)? Although there is a substantial body of evidence demonstrating a positive association between physical activity and health outcomes in children and adolescents, very few studies have addressed the issue of dose-response. Therefore, the exact shape of the dose-response curve and/or the presence of threshold values (that differentiate lower versus higher risk) for physical activity and specific health outcomes is less well understood in children and adolescents compared with adult populations. Nonetheless, a substantial body of evidence shows that many of the health benefits occur with 60 minutes of physical activity daily (22, 35), and given no contradictory evidence, it was concluded that the updated evidence reaffirms the current WHO recommendation for 60 minutes of moderate- to vigorous-intensity physical activity per day (1). However, the review of all evidence, including recent results from studies using device-based measures of physical activity, did not support retaining the specification of a “minimum” daily threshold of 60 minutes of moderate- to vigorous-intensity physical activity for health benefits, given that studies broadly used “an average” threshold of 60 minutes per day, not a minimum daily threshold of 60 minutes, to assess the benefits of physical activity on health outcomes. The review concluded that the new guideline should be amended to more closely reflect this evidence. The benefits of regular vigorous-intensity activity on cardiometabolic health outcomes has been previously established (1) and recent reviews provided further supporting evidence (35). For example, a recent review (54) showed that high-intensity interval training, compared with moderate-intensity continuous training, had a moderate beneficial effect on cardiorespiratory fitness (SMD= 0.51 [95% CI: 0.33 to 0.69], p= < 0.01; I 2= 0%). There was no evidence that intervention duration, exercise modality, exercise and rest ratio, and total bouts modified the effect on cardiorespiratory fitness. These results were consistent overall with other recent reviews (22, 35, 47) and provide support to retaining the recommendation that youth and adolescents should do regular vigorous-intensity activity to improve cardiorespiratory fitness. The GDG concluded that: • Evidence affirms the previous WHO recommendation for 60 minutes of moderate- to vigorous-intensity physical activity per day. • Evidence supports amending the previous specification of a minimum daily threshold of 60 minutes of physical activity to an average of 60 minutes per day per week, which more closely reflects the evidence. • There is moderate certainty evidence that greater amounts of vigorous-intensity physical activity are associated with improved cardiorespiratory fitness. Does the association vary by type or domain of physical activity? For children and adolescents, physical activity includes play, games, sports, transportation, recreation, physical education or planned exercise, in the context of family, school, and community activities. However, few studies have directly compared different types or domains of physical activity in children and adolescents and thus there is insufficient evidence to determine if the association between physical activity and health outcomes varies by type of activity (e.g. aerobic versus muscle-strengthening exercise) or domain of physical activity (e.g. active transport (walking and cycling) versus physical education, versus sports/recreation). CHILDREN AND ADOLESCENTS (AGED 5–17 YEARS) 26 27Recommendations There is evidence showing that both increased levels of aerobic moderate- to vigorous-intensity physical activity are associated with increased cardiorespiratory fitness, and that increased muscle-strengthening activity increases muscular fitness in children and adolescents. This evidence informed the 2010 WHO Global recommendations on physical activity for health (1) which recommended incorporating activities that strengthen muscles and bones at least 3 days per week. Updated evidence reaffirmed that regular muscle- strengthening activity 3 times per week was effective for improving indicators of muscular fitness; however, there is insufficient evidence to state specific details of session duration and intensity, largely due to the heterogeneity of exposures assessed in the literature (22, 35). There is less evidence for a protective effect of resistance training on cardiometabolic health. Given the absence of new evidence on characteristics other than the frequency of muscle strengthening activities for children and adolescents, such as duration, it was not possible to specify any further details. Future research should address the health benefits of specific types and domains of physical activity in order to provide more specificity to this component of the guidelines. The GDG concluded that: • There is moderate certainty evidence that muscle- strengthening activities should be incorporated at least 3 days a week. CHILDREN AND ADOLESCENTS (AGED 5–17 YEARS) 28 29 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Supporting evidence and rationale Sedentary behaviour was not included in the WHO 2010 recommendations, yet during the past decade, there has been a growing body of research examining the health outcomes associated with different measures and types of sedentary behaviours. Technology and digital communications have influenced how people work, study, travel and spend leisure-time. In most countries, children and adolescents are spending greater time engaged in sedentary behaviours, particularly for recreation, such as screen-based entertainment (television and computers) and digital communications, such as mobile phones. For these guidelines for children and adolescents, systematic reviews (24, 25) were used and updated with seven new reviews identified that met inclusion criteria. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . In children and adolescents, higher amounts of sedentary behaviour are associated with the following poor health outcomes: increased adiposity; poorer cardiometabolic health, fitness, behavioural conduct/pro-social behaviour; and reduced sleep duration. It is recommended that: Children and adolescents should limit the amount of time spent being sedentary, particularly the amount of recreational screen time. Strong recommendation, low certainty evidence Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Sedentary behaviour is defined as time spent sitting or lying with low energy expenditure, while awake, in the context of educational, home, and community settings and transportation. CHILDREN AND ADOLESCENTS (aged 5–17 years) SEDENTARY BEHAVIOUR RECOMMENDATION 28 29Recommendations In children and adolescents (aged 5–17 years), what is the association between sedentary behaviour and health-related outcomes? Evidence indicates that greater time spent in sedentary behaviour, especially recreational screen time, is related to poorer health outcomes (24, 35). For example, higher duration of screen time (including television viewing) is associated with poorer fitness and cardiometabolic health (24, 25) in children and adolescents. Evidence from device-based assessment of association with sedentary behaviour and interventions studies showed modest effects, although stronger effects for those already living with obesity (55). There is limited evidence suggesting that sedentary behaviour is not related to bone health in children and adolescents. Despite more mixed results, evidence also suggests that sedentary behaviour may be associated with unfavourable measures of adiposity (24, 25). One review of largely cross-sectional studies, reported that sedentary behaviour (measured as total screen time) of more than 2 hours per day was positively associated with childhood overweight/obesity compared with lower levels (< 2 hours/day) (56). However, another review of 20 cross-sectional studies (57) found no statistically significant association between sedentary video gaming and body mass index among children or adolescents. A large review of 29 systematic reviews concluded that many studies report unfavourable associations between sedentary behaviour and markers of adiposity in young people when the behaviour is self-reported as some form of screen time (55). However, the review noted that the magnitude of such associations was small and, for studies using device-based assessment of sedentary time, largely zero (55). Intervention studies showed modest effects, although stronger effects for those already living with obesity (55). Further research is needed to inform the association between sedentary behaviours and measures of adiposity. Although still an emerging area of research, some evidence shows that there may be a negative association between sedentary behaviour and well-being and quality of life, as well as an unfavourable relationship between depression and leisure screen time in children and adolescents (58, 59). For example, higher durations of sedentary behaviour, assessed as screen time, and some aspects of computer use, can be associated with poorer mental health (24). In another recent review, an association between sedentary behaviour and anxiety symptoms was found in 5 of 8 studies, although results were inconsistent across different measures of sedentary behaviour within studies (60). Other evidence demonstrates that higher durations of television viewing and video game use were significantly associated with unfavourable measures of behavioural conduct/pro-social behaviour (24); and more screen time and television viewing is associated with shorter sleep duration, although there was no association between computer use/gaming and sleep duration (61). Investigations into the relationship between sedentary behaviours and mental health is a rapidly developing field with many unknowns, and reverse causality is likely to be in evidence. Further research is needed to inform on the direction and strength of this association. The GDG concluded that: • There is low certainty evidence that higher duration of sedentary behaviour (screen time) is significantly associated with lower physical fitness and cardiometabolic health in children and adolescents. • There is very low to moderate certainty evidence that higher durations of sedentary behaviour (screen time, television viewing and video game use) are significantly associated with unfavourable measures of mental health and behavioural conduct/pro-social behaviour in children and adolescents. • There is low certainty evidence that greater time spent in sedentary behaviour (screen time and television viewing) is associated with detrimental effects on sleep duration in children and adolescents. • The benefits of limiting the amount of sedentary behaviour for children and adolescents outweigh the harms. Is there a dose-response association (total volume, duration, frequency, intensity of interruption)? There is insufficient evidence available to determine whether a dose-response relationship exists between sedentary time (including recreational screen time) and health outcomes in children and adolescents. Most of the evidence assessing the associations between sedentary behaviours and health outcomes in children and adolescents is cross-sectional in nature, with low certainty evidence according to GRADE, and a majority of studies relied on self- or parent-reported measures of sedentary time that are subject to measurement errors and recall biases. There is, however, evidence that less time spent in sedentary behaviours appears to be CHILDREN AND ADOLESCENTS (AGED 5–17 YEARS) 30 31 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r better for health outcomes, and the association between sedentary behaviour and adverse health outcomes is generally stronger for sedentary behaviour when assessed as television viewing or recreational screen time as the exposure variable, than for total sedentary time. However, overall the evidence was considered insufficient to support specifying time limits. Evidence that sedentary behaviours are linked to adverse health outcomes could be the result of either direct effects of the sedentary behaviours, displacement of time spent in more physically active behaviours, or both. Although there are studies that have reported associations between screen time and adverse health outcomes in children and adolescents, total sedentary time (as assessed in studies using device-based measurements of sedentary behaviour) has consistently not been associated with health outcomes when time in moderate- to vigorous-intensity physical activity is taken into account (62). Conversely, the evidence linking moderate- to vigorous-intensity physical activity to positive health outcomes is strong and well documented across diverse settings; replacing some sedentary behaviour with physical activity (especially moderate- to vigorous-intensity physical activity) may improve health outcomes. Research investigating the associations and interplay between sedentary behaviour, physical activity and health outcomes is rapidly growing, and evidence from device-based measures of sedentary behaviour and cardiometabolic health show the association is attenuated when moderate- to vigorous-intensity physical activity is taken into account (i.e. statistically adjusted for) (62–64). There is therefore a need for further prospective studies using device-based measures of exposure, to advance knowledge of these associations and inform future recommendations. The GDG concluded that: • There is low certainty evidence that greater time spent in sedentary behaviour is related to poorer health outcomes. • There is insufficient evidence to specify time limits on sedentary behaviour. • Replacing sedentary time with moderate- to vigorous- intensity physical activity may provide health benefits. Does the association vary by type or domain of sedentary behaviour? The study of health effects of sedentary behaviour is a relatively new field of research. As such the findings are from studies using different instruments and measures of exposure. Exposure assessed as “total time spent doing sedentary behaviours” is frequently used, as is sedentary time spent using “screens” or “television viewing”. Available evidence suggests that the association between sedentary behaviour and adverse health outcomes is generally stronger for television viewing or recreational screen time than for total sedentary time (24, 35). The increased use of device-based assessment of sedentary behaviour in the more recent research is advancing knowledge, and when combined with standardized reporting will help inform future guidelines. It is acknowledged that not all sedentary behaviour is harmful. Evidence suggests certain types of sedentary behaviour, such as reading and doing homework outside of school, are associated with higher academic achievement, indicating that there are differences in outcome depending on the activity (24, 25). Sedentary behaviour may include time spent engaged in educational pursuits/study or quiet play, or social interaction without electronic media. These pursuits (e.g. reading, doing puzzles, drawing, crafting, singing, music) are important for child development and have cognitive as well as other benefits. The GDG acknowledged that: • Some sedentary activities confer benefits for cognitive function and social interaction in children and adolescents. • Evidence on the adverse health effects of sedentary behaviour is generally stronger for television viewing or recreational screen time than for total sedentary time. CHILDREN AND ADOLESCENTS (AGED 5–17 YEARS) 30 31Recommendations ADULTS (aged 18–64 years) In adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site- specific cancers, 1 incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression); cognitive health, and sleep; measures of adiposity may also improve. It is recommended that: All adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence Adults should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence Adults may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence For adults, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), transportation (wheeling, walking and cycling), work or household chores, in the context of daily occupational, educational, home and community settings. PHYSICAL ACTIVITY RECOMMENDATION • Doing some physical activity is better than doing none. • If adults are not meeting these recommendations, doing some physical activity will benefit their health. • Adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. G O O D P R A C TI C E ST A TE M EN TS 1 Site-specific cancers of: bladder, breast, colon, endometrial, oesophageal adenocarcinoma, gastric, and renal. 32 33 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ADULTS (aged 18–64 years) Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Supporting evidence and rationale For these guidelines, the synthesis of evidence undertaken by the United States Physical Activity Guidelines Advisory Committee (PAGAC) (35) was used and updated. The GDG considered the entire body of evidence, including both the findings reported by PAGAC and the 28 reviews and 3 pooled cohort studies, published from 2017 through to November 2019, that met inclusion criteria, and contributed evidence on the association between physical activity and health-related outcomes in adults. In addition, two umbrella reviews were commissioned to address evidence gaps and examine i) the relationship between occupational (i.e. work-related) physical activity and health-related outcomes (40); and ii) the association between leisure-domain physical activity and adverse health outcomes (41). The umbrella reviews identified 36 and 15 systematic reviews respectively. Evidence from longitudinal observational studies and intervention trials was prioritized, and reviews that solely, or primarily, synthesized cross-sectional evidence were not considered. Greater emphasis was given to evidence provided by reviews graded moderate certainty and above, and to those providing evidence from studies using device-based measures of exposure. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . In adults (aged 18–64 years), what is the association between physical activity and health-related outcomes? The association between physical activity and all-cause mortality and cardiovascular disease mortality in adults is already well-established (1). Findings from recent reviews reaffirmed that compared with the lowest levels of physical activity, higher levels of physical activity were associated with a lower risk of mortality. New evidence from studies using device-based measures of physical activity reaffirmed and extended the evidence showing that compared with the lowest levels of physical activity, any level and all intensities (including light intensity) of physical activity, were associated with a lower risk of mortality (65). For example, compared with the least active (referent, 1.00), adjusted HR for quartiles of total physical activity improved across quartiles of physical activity: 2nd quartile (0.48 [95% CI: 0.43 to 0.54]); 3rd quartile (0.34 [95% CI: 0.26 to 0.45]); and 4th quartile (0.27 [95% CI: 0.23 to 0.32]) (65). New evidence also reaffirmed the well-established (1) inverse relationship between physical activity and cardiovascular disease mortality (66). The benefits of physical activity for reducing cardiovascular disease and hypertension incidence is well-documented (1). Physical activity promotes many physiological responses that cause beneficial short- and long-term autonomic and haemodynamic adaptations, resulting in lowered risk of hypertension, which is a key risk factor for cardiovascular disease. Evidence reaffirmed an inverse relationship between physical activity and incident hypertension among adults with normal blood pressure, and that physical activity reduces blood pressure among adults with prehypertension and normal blood pressure (35). The inverse association between physical activity and developing type-2 diabetes in adults is well-established (1). Recent evidence reaffirmed an inverse curvilinear relationship between higher volumes of physical activity and incidence of type-2 diabetes (35), with a decreasing slope at higher levels of physical activity. A new review found that this effect is consistent across individuals of different backgrounds with a reduced risk of developing type-2 diabetes in “highest” versus “lowest” levels of physical activity among non-Hispanic whites (RR= 0.71 [95% CI: 0.60 to 0.85]); Asians (RR= 0.76 [95% CI: 0.67 to 0.85]); Hispanics (RR = 0.74 [95% CI 0.64 to 0.84]); and American Indians (RR = 0.73 [95% CI: 0.60 to 0.88]), although the effect among non-Hispanic blacks was not significant (RR = 0.91 [95% CI: 0.76 to 1.08]) (67). Evidence suggests there is no effect modification by weight status and that the inverse relationship between a higher volume of physical activity and lower incidence of type- 2 diabetes exists for people who have normal weight, overweight or obesity (35). The associations between higher levels of physical activity and reduced risks of colon cancer and breast cancer have been well-established (1). In previous reviews of the evidence, higher levels of physical activity have been found to be associated with a reduced risk of 32 33Recommendations developing breast cancer and colon cancer (1). Following an extensive increase in physical activity and cancer research, there is new evidence demonstrating higher levels of physical activity are also associated with reduced risk of developing bladder, endometrial, oesophageal adenocarcinoma, gastric and renal cancers, as well as reaffirming that physical activity is protective for breast cancer and colon cancer (35). Higher levels of physical activity are associated with risk reductions ranging from approximately 10–20% (35). For example, one review reported an inverse association with liver cancer risk when comparing high levels of physical activity to low levels of physical activity (HR= 0.75 [95% CI: 0.63 to 0.89]) (68). There is insufficient evidence on the association between increased physical activity and decreased risks of hematologic, head and neck, ovary, pancreas, prostate, thyroid, rectal and brain cancer (35). While evidence suggests a reduction in risk of lung cancer between the highest versus lowest levels of physical activity, these findings may be confounded by tobacco use and it was determined that overall there is insufficient evidence to establish an association. The association between physical activity and adiposity in adult populations is less well established despite a large, but heterogenous, body of evidence assessing this relationship across various outcome measures (weight gain, weight change, weight control, weight stability, weight status and weight maintenance) (35, 69, 70). Overall the evidence shows that higher levels of physical activity may be associated with more favourable measures of adiposity and attenuation of weight gain in adults (35). Further research is needed to establish consistent results and strength of associations. Research on physical activity and mental health, cognition and sleep has increased substantially since the development of the 2010 Global recommendations on physical activity for health (1). At that time, there was sufficient evidence to conclude only that physical activity may reduce the risk of depression and cognitive decline in adults. New evidence reviewed for these guidelines showed that adults engaging in higher versus lower physical activity are at reduced risk of developing anxiety and depression. For example, adults with high, versus low, levels of physical activity were at reduced odds of developing anxiety (AOR= 0.81 [95% CI: 0.69 to 0.95]) (71) or depression (AOR= 0.78 [95% CI: 0.70 to 0.87) (72). Greater amounts of moderate- to vigorous-intensity physical activity are associated with improvements in cognition (e.g. processing speed, memory, and executive function) (35), brain function and structure, and a reduced ADULTS (aged 18–64 years) risk of developing cognitive impairment, including Alzheimer’s disease (73–76). The evidence included several adult populations representing a gradient of normal to impaired cognitive health status and the beneficial effects of physical activity were reported across a variety of types, including aerobic activity, walking, muscle-strengthening activity, and yoga (74). There is evidence that both acute bouts and regular physical activity improve sleep and health-related quality of life outcomes in adults (35). Evidence examining physical activity and symptoms of depression, symptoms of anxiety, and the development of anxiety and depression indicated that physical activity was associated with reduced symptoms of anxiety (77, 78) and reduced symptoms of depression (77, 79). All physical activity comes with some risk. Evidence from a commissioned review on the adverse effects, injuries and harms associated with leisure physical activity in adults (41) suggests an unfavourable association between levels of leisure-time physical activity and musculoskeletal injuries, and a favourable relationship between leisure- time physical activity and risk of fracture and onset of knee or hip osteoarthritis. Additional existing evidence (35) indicates sudden cardiac adverse events are rare and associated with acute sessions of relatively vigorous- intensity physical activity. Generally, the risks of adverse events are very low with moderate-intensity physical activity and when increases in physical activity frequency, intensity and duration are gradual (35). The GDG concluded that: • There is high certainty evidence that any level and any intensity of physical activity is associated with lower risk of all-cause mortality and cardiovascular disease mortality, incidence of hypertension, cardiovascular disease and type-2 diabetes. • There is moderate to high certainty evidence on the associations between higher levels of physical activity and lower risk of incidence of site-specific cancers. • There is moderate certainty evidence supporting an association between physical activity and improvements in mental health, cognitive health and sleep outcomes. • There is evidence of an association between higher levels of physical activity and more favourable measures of adiposity and attenuation of weight gain in adults. • There is low certainty evidence that physical activity recommended for adults will not be harmful and that the health benefits from such activity outweigh the risks. 34 35 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Is there a dose-response association (volume, duration, frequency, intensity)? Overall the evidence across cardiovascular and metabolic health outcomes shows a consistent curvilinear inverse dose-response relationship between physical activity and major outcomes such as all-cause mortality, cardiovascular disease mortality, incident type-2 diabetes (67), and incident site-specific cancers in adults. As described in Figure 1, the shape of the dose-response curve indicates that there is no lower threshold for benefit, and the greatest benefits are seen at the lower end of the dose-response curve (65). The curvilinear inverse association is consistently reported and across studies using different measures of physical activity. Important new evidence was provided in a meta- analysis of eight prospective cohort studies, with mean follow-up of 5.8 years (range 3–14.5 years) (65) that reported the adjusted HR for quartiles of total physical activity using device-based measures of exposure and all-cause mortality. The results showed a dose- response with increasing volume of physical activity and benefits of higher levels of any intensity of physical activity compared with the least active (referent, 1.00): 2nd quartile (adjusted HR= 0.48 [95% CI: 0.43 to 0.54]); 3rd quartile (adjusted HR= 0.34 [95% CI: 0.26 to 0.45]); and 4th quartile (adjusted HR= 0.27 [95% CI: 0.23 to 0.32]). Maximal risk reductions for moderate- to vigorous- intensity physical activity were observed at 24 minutes per day (equivalent to 168 minutes per week), which ADULTS (aged 18–64 years) closely reflects the recommendation of 150 minutes per week, and provides new device-based evidence reinforcing the existing global guidance to adults of 150–300 minutes of physical activity per week (65). These findings are consistent with the evidence from existing reviews (35) and the other new identified reviews (66). At the upper end, higher levels of physical activity continue to provide benefits in terms of reduced risk of mortality with no increased risk of harms. For example, evidence from a new review with findings from a meta- analysis of individual data from device-based measures of exposure (65), indicates that although reduced risk of mortality is observed up to 750 minutes of moderate- to vigorous-intensity physical activity per week, the relative risk of mortality levels off beyond 300 minutes per week. These results accord with previous evidence which consistently showed that more physical activity is associated with further health benefits, although the relative benefits are reduced at higher levels of physical activity (35, 80, 81). There is, however, insufficient evidence to identify the exact physical activity level where diminished returns of health benefits begin for adults. Evidence also reaffirmed the well-established inverse relationship between physical activity and cardiovascular disease mortality, providing additional evidence of a dose-response relationship well beyond current recommended volumes of physical activity. Figure 1: Dose response curve Weekly physical activity (minutes) RIS KS AN D HA RM SBE NE FI TS H ea lt h a n d  fi tn es s b en efi ts Sedentary Recommended range 150 300 34 35Recommendations A meta-analysis of 48 prospective studies assessing physical activity (total, leisure, and occupational) provided additional evidence of a dose-response relationship (66) well beyond current recommended volumes of physical activity. Compared with the recommended level of 750 MET minutes per week, participation in 5000 MET minutes per week (1000 minutes of moderate-intensity activity) resulted in a significantly lower risk for cardiovascular disease mortality (HR= 0.73 [95% CI: 0.56 to 0.95]) (66).Previous WHO recommendations (1) concluded that aerobic activity should be performed in bouts of at least 10 minutes duration. However, new evidence, using device-based assessments, demonstrates that physical activity of any duration, without a minimum threshold, is associated with improved health outcomes, including all-cause mortality (65, 82). For example, new evidence from reviews of studies assessing physical activity by accelerometry reaffirms similar associations between all indices of physical activity and all-cause mortality, with hazard ratios of 0.27 for total physical activity, 0.28 for 5-minute bouts, and 0.35 for 10-minute bouts, comparing the highest versus lowest quartiles (83). These results, reaffirmed by findings in the new review by Ekelund et al. 2019 (65), provide evidence that physical activity of any bout duration is associated with improved health outcomes, including all-cause mortality (82). Based on new evidence, the recommendation for bouts of least 10 minutes duration has been removed. Although evidence showing the associations between higher levels of physical activity and lower risk of incidence of site-specific cancers was deemed to be consistent overall, there is insufficient evidence to determine the specific levels of physical activity that correspond to the reported risk reduction due to the large heterogeneity in the assessment and classification of exposure across studies. There is however, no evidence to suggest that there is a lower threshold below which no beneficial effect of physical activity is evident, thus suggesting that any level of physical activity can confer benefit on reducing the risk of site-specific cancers. Future research assessing the nature of the dose- response and using more consistent measures and reporting is needed to inform future guidelines. Although there is a large body of evidence on the associations between physical activity and various measures of adiposity, weight gain and the management of a healthy weight status (35), currently there is insufficient evidence to describe more specifically ADULTS (aged 18–64 years) the dose-response relationship or identify a threshold of effect. Further research is needed to inform future guidelines. Greater amounts of moderate- to vigorous-intensity physical activity are associated with improvements in cognition (e.g. processing speed, memory, and executive function) (35), brain function and structure, and a reduced risk of developing cognitive impairment, including Alzheimer’s disease (73–76). There is evidence that both acute bouts and regular physical activity improve sleep and health-related quality of life outcomes in adults (35). There is however insufficient evidence to describe more specifically the dose-response relationship between physical activity and individual mental and cognitive health outcomes. Similarly, more evidence is needed to further describe the dose-response relationship between volume and/or intensity of aerobic physical activity and muscle-strength training and specific health outcomes. Such information is key to establishing minimal effective doses and maximum safety thresholds of physical activity for different population subgroups. The GDG concluded that: • There is evidence that more physical activity is associated with larger effects on health outcomes, although the relative benefits level off at higher levels of physical activity. There was insufficient evidence to identify the exact level where diminished returns start to occur. • There is high certainty evidence that higher levels of physical activity are associated with lower risk of all- cause mortality, cardiovascular disease mortality, cancer mortality, cardiovascular disease incidence, and incidence of hypertension and type-2 diabetes, with no increased risk of harms. • There is moderate certainty evidence that physical activity of any duration is associated with improved health outcomes, and prior specification that aerobic activity should be performed in bouts of at least 10 minutes duration should be removed. • There is evidence that higher amounts of physical activity may be associated with more favourable measures of adiposity and attenuation of weight gain in adults and there is a low risk that physical activity will be harmful for the management of healthy weight status in adults. • There is moderate certainty evidence that 150–300 minutes of moderate intensity aerobic physical activity or equivalent, per week, reduces risk for multiple health outcomes, and risk reduction continues, but starts to plateau, beyond 300 minutes per week. 36 37 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Does the association vary by type or domain of physical activity? Evidence shows that different types of physical activity and physical activity undertaken in different domains (i.e. occupation, transport, or leisure) can provide favourable health outcomes. For all-cause and cardiovascular disease mortality, undertaking aerobic physical activity alone, or combining with strength-promoting exercise shows beneficial associations, although performing recommended levels of both types is optimal (84). More recent moderate certainty evidence indicates that muscle-strengthening physical activity, independent of aerobic physical activity, is also associated with lower risk of all-cause mortality. Results reported by Stamatakis et al. (2018), from a pooled analysis of 11 cohorts examining the 2 days per week muscle-strengthening exercise recommendation against all-cause mortality, showed that undertaking both aerobic and muscle-strengthening physical activity at recommended levels (1) versus not meeting either recommendation (adjusted HR= 0.71 [95% CI: 0.57 to 0.87]) as well as adherence to just the strength exercise recommendation versus not adhering (HR= 0.80 [95% CI: 0.70 to 0.91]) was associated with significantly lower risk of all-cause mortality (84). These data affirm that health benefits associated with muscle-strengthening exercise were independent of aerobic physical activity and also provide evidence to support recommending a frequency of 2 days per week of muscle-strengthening exercise. Other findings reported by Dinu et al. (2019) provided supporting evidence reaffirming that physical activity undertaken in domains other than leisure (or recreation) can be beneficial and specifically showed that active commuting (i.e. walking and cycling for transport) can significantly lower risk of all-cause mortality (RR= 0.92 [95% CI: 0.85–0.98]) (85). Recent research provides evidence demonstrating that for those who participate in active commuting (i.e. walking or cycling for transport), there is reduced risk of cardiovascular disease (coronary heart disease, stroke and heart failure) compared with those participating in no active commuting (RR= 0.91 [95% CI 0.83 to 0.99]) (85); and that there is sufficient evidence from these health outcomes to conclude that activity in different domains can be beneficial. However, there is insufficient evidence to differentiate the effect of different domains of physical activity on every health outcome. For example, there is insufficient evidence to determine if the association between physical activity and cancer risk or type-2 diabetes incidence varies by type or domain of physical activity. ADULTS (aged 18–64 years) For mental health outcomes, evidence (35) shows that a variety of types of physical activity, including aerobic activity, walking, muscle-strengthening activity, and yoga can provide beneficial effects for reducing symptoms of depression and development of anxiety (74, 79, 86). For example recent evidence for the beneficial effects of resistance exercise interventions and mental health was provided by two reviews reporting moderately large reductions in symptoms of depression (77) and small reductions in symptoms of anxiety (78) compared with control conditions. Evidence from a new review affirmed that high levels of occupational physical activity is associated with reduced risk of many cancers, coronary heart disease, and type- 2 diabetes (40). However, higher levels of occupational physical activity may also be associated with an increased risk of osteoarthritis, poor sleep quality, and all-cause mortality among males (but not among females). There is insufficient evidence to determine the relationship between occupational physical activity and adiposity, prevention of body weight gain, mental health, and health-related quality of life (40). There is also insufficient evidence to determine if the association between physical activity and cancer risk varies by type or domain of physical activity. There is less evidence on associations by different domains of physical activity, and therefore it was difficult to differentiate the effect of different domains of physical activity on various health outcomes. The GDG concluded that: • There is moderate certainty evidence that muscle- strengthening activities undertaken on 2 or more days a week, provide additional health benefits, but there is insufficient evidence to specify a specific duration for optimal health benefits. • There is moderate certainty evidence that physical activity undertaken in different domains (e.g. leisure, transport, occupational) can provide health benefits, although currently it is not possible to differentiate the effect of different domains of physical activity on various health outcomes. • Although higher levels of occupational physical activity may be associated with an increased risk of osteoarthritis, poor sleep quality, and all-cause mortality among males (but not among females), overall there is moderate certainty evidence that occupational physical activity can provide health benefits. 36 37Recommendations Supporting evidence and rationale For these guidelines, the synthesis of evidence undertaken by PAGAC (35) was used and updated. The GDG considered the entire body of evidence, including both the findings reported by PAGAC and the 13 new reviews that met inclusion criteria, to contribute evidence on the association between sedentary behaviour and health- related outcomes in adults. Investigating the association between sedentary behaviour and health outcomes is a relatively new field of public health compared with that of physical inactivity, yet it has developed rapidly in the past decade. Studies have typically measured sedentary behaviour using either i) self-report questionnaires which ask about “total time” spent in sedentary behaviours, or time spent in specific behaviours, such as television viewing, computer/screen use, and sitting; or ii) device-based assessments. There are no standardized measures or analytical protocols for sedentary behaviour and thus the reporting of results is heterogeneous. Recent methodological developments include the use of device-based assessment of time spent sedentary which can reduce measurement error and other biases inherent in self-reported recall. In considering the total body of evidence, the GDG gave greater emphasis to evidence provided by reviews graded moderate and above, taken from reviews providing evidence from studies using measures of total sedentary or sitting time, or device-based measures of sedentary behaviour where available. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . Research on the potential adverse health effects associated with sedentary behaviour has rapidly accumulated during the past decade. In more recent studies, notable developments include an increase in evidence reporting on dose-response relationships between sedentary behaviour and multiple health outcomes, and on the interplay between sedentary behaviour and physical activity. In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and type-2 diabetes. It is recommended that: Adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults should aim to do more than the recommended levels of moderate- to vigorous- intensity physical activity. Strong recommendation, moderate certainty evidence Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf For adults, sedentary behaviour is defined as time spent sitting or lying with low energy expenditure, while awake, in the context of occupational, educational, home and community settings, and transportation. SEDENTARY BEHAVIOUR RECOMMENDATION ADULTS (aged 18–64 years) 38 39 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ADULTS (aged 18–64 years) In adults (aged over 18 years), what is the association between sedentary behaviour and health-related outcomes? Overall, there is evidence of an association between greater time spent in sedentary behaviour (examined mostly via self-reporting or device-based assessments of sitting or television viewing time) and higher all-cause mortality, cardiovascular mortality, cardiovascular disease incidence and type-2 diabetes incidence (8, 35, 65, 87). For example, supporting evidence includes results from a recent large meta-analysis (n= 36 383; mean age 62.6 years; 72.8% women) of accelerometer assessed total sedentary time and all-cause mortality (65) and showed that increasing time spent in sedentary behaviour was significantly associated with all-cause mortality. Similar findings from a meta-analysis comprising more than 1 million participants (87) showed associations for total sedentary behaviour with all-cause mortality, and cardiovascular disease mortality, after adjustment for physical activity (87), although in this study the associations with cancer mortality were not statistically significant after adjustment for physical activity (87). Another recent meta-analysis (8) reported significant associations between sedentary behaviour (assessed as sitting) and cardiovascular disease and cancer mortality, with results indicating a 9–32% (p for trend < 0.001) higher risk of cardiovascular disease mortality with higher levels of sedentary behaviour when measured as sitting time in the “inactive”, lowest quartile of physical activity (~ 5 min/day). The study reported that adults who were sedentary (sitting) for more than 8 hours per day had a higher risk of cardiovascular disease mortality, except for those who were “most active” (i.e. > 35.5 MET-hours/week, or ~ 60–75 mins/ day), where the association was mitigated. Results on the associations between sedentary behaviours and cancer mortality were generally weaker, although a 6–21% higher dose-related risk was observed with longer sitting time (particularly > 8 hours/day), but only among those in the lowest quartile of physical activity (< 2.5 MET-hours/week) (8). Evidence supports an association between sedentary behaviour (measured as total sitting time) and increased incident cardiovascular disease (HR= 1.29 [95% CI: 1.27 to 1.30]) which was attenuated following adjustment for potential covariates, including level of physical activity (HR= 1.14 [95% CI: 1.04 to 1.23]) (88). A review of studies in south-east Asian populations provided evidence of low certainly that greater sedentary time was associated with an increased likelihood of unfavourable cardiometabolic indicators (including type-2 diabetes, higher BMI, higher blood pressure) (89). Two recent reviews report on the association of total daily sitting time (88) and total sedentary behaviour and television viewing (87) with type-2 diabetes incidence. Both studies found a higher level of sedentary behaviour was associated with increased risk of type-2 diabetes incidence. For example, a linear association with type-2 diabetes was observed for total sedentary behaviour (RR= 1.01 [95% CI: 1.00 to 1.01] p= < 0.001) and television viewing (RR= 1.09 [95% CI: 1.07 to 1.12] p= < 0.001), when adjusted for physical activity (87). There is also supporting evidence for a significant association between sedentary behaviour (when measured as time spent viewing television) and cancer mortality (35, 87). Several more recent reviews, of low and very low certainty, provide supporting evidence for an association between sedentary behaviours and colorectal cancer (90), but no associations with incident prostate, breast or rectal cancer (90–93). Additional evidence (35) reported significant associations between greater time spent in sedentary behaviour and higher risk of developing endometrial, colon and lung cancers (35). There is low certainty evidence of an unfavourable relationship between time spent in sedentary behaviour and adiposity and other indicators of weight status, and whether the relationship between sedentary behaviour and weight status varies by amount of moderate- to vigorous-intensity physical activity. Overall, it was concluded that there was insufficient evidence to inform these recommendations/guidelines and that further research is needed. There is limited evidence assessing adverse effects of reducing sedentary time. Expert opinion informed the conclusion that recommending the reduction in sedentary time would be unlikely to increase risk of injury, especially if replaced with light-intensity physical activity. 38 39Recommendations The GDG concluded that: • Overall there is sufficient evidence to support the development of a new WHO recommendation to limit sedentary behaviour to reduce health risks. • There is moderate certainty evidence of an association between greater time spent in sedentary behaviour and higher all-cause mortality, cardiovascular disease mortality, cancer mortality and incidence of cardiovascular disease and type-2 diabetes. • There is low to moderate certainty evidence of an association between greater time spent in sedentary behaviour and higher risk of incident endometrial, colon, and lung cancers. • There is insufficient evidence on the association between sedentary behaviour and measures of adiposity and further research is needed. • The benefits of limiting sedentary behaviour outweigh any potential risks. Is there a dose-response association (total volume, frequency, duration, intensity of interruption)? Overall, moderate certainty evidence indicates a non- linear dose-response relationship between sedentary time (sitting or television viewing time assessed by self-reporting, or by device-based assessments) and all- cause mortality, cardiovascular disease mortality, cancer mortality, and incident cardiovascular disease (8, 35, 87). A recent meta-analysis provided high certainty evidence on the dose-response relationship between accelerometer assessed total sedentary time and all-cause mortality (65) reporting that increasing time spent in sedentary behaviour was significantly associated with all-cause mortality. The hazard ratios for increasing quartiles of sedentary time were 1.00 (referent; least sedentary); 1.28 (1.09– 1.51); 1.71 (1.36–2.15); and 2.63 (1.94–3.56), after adjustment for potential confounders including time spent in moderate- to vigorous-intensity physical activity (65). This analysis of dose-response relations between sedentary time and mortality showed risk increased gradually from about 7.5–9 hours and was more pronounced at greater than 9.5 hours. Sedentary behaviour of 10 hours and 12 hours each day were associated with 1.48 (1.22–1.79) and 2.92 (2.24–3.83) higher risk of death, respectively (65). Another recent meta-analysis assessed dose-response and reported non-linear associations for total sedentary time and all-cause mortality (RR per 1 hour/day = 1.01 (1.00–1.01) for ≤ 8 hours/day; and 1.04 (1.03–1.05) for > 8 hours/day of exposure); and cardiovascular disease mortality (RR= 1.01 (0.99–1.02) for ≤ 6 hours/day; and RR= 1.04 (1.03–1.04) for > 6 hours/day) after adjustment for physical activity (87). In this same study, a small linear dose-response association between type-2 diabetes was observed for total sedentary behaviour (1.01 (1.00– 1.01)) when adjusted for physical activity and television viewing (1.09 (1.07–1.12)) (87). Overall, evidence supports that higher amounts of sedentary behaviour are associated with less favourable health outcomes and it was concluded that there is sufficient evidence to support minimizing sedentary time to reduce health risks. However, given the considerable variations in how sedentary behaviour was assessed across reviews (via self-reported sitting time, television viewing time, or device-based (accelerometer) assessments) and the probability that thresholds for sedentary time might vary across health outcomes, by levels of moderate- to vigorous-intensity physical activity, and among population subgroups, there is insufficient evidence to set a time-based (quantified) recommendation. In addition to overall volume of sedentary behaviour, evidence on the patterns by which sedentary behaviour is accrued was reviewed. However, there was limited evidence to make recommendations on the frequency and/or duration of breaks in sedentary behaviour. The GDG concluded that: • There is insufficient evidence to set quantified (time- based) recommendations on sedentary behaviours. • There is insufficient evidence to make recommendations on the frequency and/or duration of breaks in sedentary behaviour. ADULTS (aged 18–64 years) 40 41 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Does the association vary by type and domain of sedentary behaviour? Some domains or different types of sedentary behaviour may be more detrimental than others, both in terms of their direct associations and in their potential to displace time spent in more healthful physical activity. Although there has been a rapid growth in research on sedentary behaviour, there is limited evidence available directly comparing the association between different types of sedentary behaviour and different health outcomes. For example, some studies report stronger results with sedentary behaviour measured as television viewing compared with total sitting time (87). This may be due to the differential measurement error or residual confounding associated with self-report measures and instruments. Currently, there is insufficient evidence to determine the different associations with different health outcomes and how these may vary by subpopulation. A growing number of studies are using device- based measures of physical activity and sedentary time in relation to health outcomes. However, some misclassification may occur from device-based measures of sedentary time as many of these device placements (e.g. wrist, waist) do not currently distinguish between positions (e.g. lying, sitting and standing still). Future research using harmonized reporting, and methods that distinguish between positions, will help to strengthen the knowledge on the patterns of sedentary behaviour. The GDG concluded that: • There is insufficient evidence to make recommendations on different types or domains of sedentary behaviour. ADULTS (aged 18–64 years) Does level of physical activity modify the effect of sedentary behaviour on mortality? The increased interest in the impact of sedentary behaviour on health outcomes has stimulated investigation into the potential interplay between different levels of physical activity and levels of sedentary behaviour. Based on available research, there is moderate certainty evidence that the relationship between sedentary behaviour and all-cause mortality, cardiovascular disease mortality and cancer mortality varies by amount of moderate- to vigorous-intensity physical activity (8, 9, 35). Overall findings show that the effect of sedentary behaviour is stronger in those who do low amounts of moderate- to vigorous-intensity physical activity or, phrased conversely, that higher amounts of moderate- to vigorous-intensity physical activity can mitigate the unfavourable health outcomes associated with higher levels of sedentary behaviours. The risk associated with sedentary time and all-cause mortality has been shown to be more pronounced at lower levels of physical activity than at higher levels (35). In a harmonized meta-analysis, Ekelund et al. investigated the joint and stratified effects of sedentary behaviour and physical activity with all-cause mortality in more than 1 million men and women, and showed that the associations differed depending on the level of physical activity (9). The analyses used quartiles of sedentary behaviour (sitting) and quartiles of moderate- to vigorous-intensity physical activity, and found that compared with the referent (< 4 hours of sitting per day and highest quartile of moderate- to vigorous-intensity physical activity [> 35.5 MET-hours/ week]), there was no increased risk of dying during follow-up in those who sat for more than 8 hours per day but who also reported more than 35.5 MET- hours per week of activity (HR= 1.04 [95% CI: 0.99 to 1.10]). In contrast, those who sat the least (< 4 hours/ day) and were in the lowest (< 2.5 MET-hours/week) physical activity quartile had a significantly increased risk of dying during follow-up (HR= 1.27 [95% CI: 1.22 to 1.31]). The study concluded that levels of moderate- to vigorous-intensity physical activity of about 60–75 minutes per day (the highest quartile) can attenuate, and even eliminate, the detrimental association between sedentary behaviour and health outcomes (9). 40 41Recommendations ADULTS (aged 18–64 years) G O O D P R A C TI C E ST A TE M EN TS This relationship between levels of sedentary behaviour and moderate- to vigorous-intensity physical activity was summarized in the systematic review by PAGAC (35) as shown in Figure 2. Another recent study provided new evidence investigating the same associations with cause-specific mortality and showed similar findings (8). In a large harmonized meta-analysis (9 studies, n= 850 000, CVD mortality; 8 studies, n= 777 000, cancer mortality), results showed that higher levels of moderate- to vigorous- intensity physical activity mitigated the increased risk of cardiovascular disease mortality with high levels of sedentary behaviour, whether measured as time spent sitting or time spent viewing television (8). The study showed that in individuals who were sitting for more than 8 hours per day, there was an association with higher risk of death, except in the most active quartile, where the association was mitigated. More specifically, the hazard of cardiovascular disease mortality was 32% higher in those who sat for more than 8 hours per day compared with the reference group (< 4 hours/day) (p for trend < 0.001). The results were less pronounced but remained significant compared with the reference group for the other quartiles of physical activity (2nd quartile, HR= 1.11 [95% CI: 1.03 to 1.20]; 3rd quartile, HR= 1.14 [95% CI: 1.03 to 1.26]). Similar associations were observed for television time and cardiovascular disease mortality across strata of moderate- to vigorous- intensity physical activity (8). The associations for cancer mortality were more mixed, although generally showed that higher levels of physical activity attenuated the detrimental effects of sedentary behaviour when assessed as total sitting time. Based on this evidence, it was agreed that higher levels of moderate- to vigorous-intensity physical activity should be recommended for those individuals who undertake high levels of sedentary behaviour and that the benefits would outweigh the risks. The GDG concluded that: • There is moderate certainty evidence that the relationship between sedentary behaviour and all-cause mortality, cardiovascular disease and cancer mortality varies by amount of moderate- to vigorous-intensity physical activity. • Higher amounts of moderate- to vigorous-intensity physical activity can attenuate the detrimental association between sedentary behaviour and health outcomes. Figure 2: The relationship between levels of sedentary behaviour and physical activity Adapted from PAGAC More physical activity M or e se d en ta ry t im e HIGH RISK LOW RISK Less sedentary tim e & m ore physical activity Increase physical activityRed u ce sedentary time 42 43 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r OLDER ADULTS (aged 65 years and older) In older adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascular disease mortality, incident hypertension, incident site-specific cancers, incident type-2 diabetes, mental health (reduced symptoms of anxiety and depression), cognitive health, and sleep; measures of adiposity may also improve. In older adults, physical activity helps prevent falls and falls-related injuries and declines in bone health and functional ability. It is recommended that: All older adults should undertake regular physical activity. Strong recommendation, moderate certainty evidence Older adults should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week, for substantial health benefits. Strong recommendation, moderate certainty evidence Older adults should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence As part of their weekly physical activity, older adults should do varied multicomponent physical activity that emphasizes functional balance 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 Older adults may increase moderate- intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous- intensity activity throughout the week, for additional health benefits. Conditional recommendation, moderate certainty evidence For older adults, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), transportation (wheeling, walking and cycling), work, or household chores, in the context of daily occupational, educational, home or community settings. PHYSICAL ACTIVITY RECOMMENDATION • Doing some physical activity is better than doing none. • If older adults are not meeting the recommendations, doing some physical activity will bring benefits to health. • Older adults should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • Older adults should be as physically active as their functional ability allows, and adjust their level of effort for physical activity relative to their level of fitness. G O O D P R A C TI C E ST A TE M EN TS 42 43Recommendations Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Supporting evidence and rationale For these guidelines, for older adults, the comprehensive synthesis of evidence undertaken by PAGAC (35) was used and updated. Fifteen reviews met the inclusion criteria and informed the examination of the association between physical activity and health-related outcomes specific to older adults (falls prevention, fall-related injuries, physical function, frailty, and osteoporosis). The evidence for falls prevention used and updated the 2019 Cochrane Collaboration Systematic Review by Sherrington et al. (42), with evidence published from the end search date of their original review, to November 2019 (9 new studies). A search for existing systematic reviews on osteoporosis and sarcopenia was conducted in PubMed for reviews published from 2008 through to November 2019 and identified no new reviews and 8 new studies. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . In older adults (aged 65 years and over), what is the association between physical activity and health-related outcomes? The primary evidence base for assessing the associations between physical activity and health outcomes, such as all-cause and cause-specific mortality, cardiovascular disease, type-2 diabetes, cancer incidence, adiposity, mental health, and cognitive outcomes in older adult populations was the same scientific literature collated and reviewed for adult populations. This same body of evidence was accepted and extrapolated to older adults because the majority of studies stated no upper age limit criterion and therefore included adults over the age of 65 years. A further review of evidence was conducted to examine and inform on the association between physical activity and health-related outcomes specific to older adults, including falls prevention, fall-related injuries, physical function, frailty and osteoporosis. Declining physical capacity in older people often manifests in falls and fall-related injuries that can have serious consequences. Accidental falls are due to a combination of extrinsic (environmental) and intrinsic (e.g. musculoskeletal or nervous system abnormalities affecting postural control) factors. Evidence demonstrates that physical activity – in particular multicomponent physical activity programmes that include combinations of balance, strength, endurance, gait, and physical function training – is associated with a reduced rate of falls and risk of injury from falls in older adults. Recent evidence demonstrates that exercise may reduce the rate of falls by as much as 23% (pooled rate ratio (RaR) 0.77 [95% CI: 0.71 to 0.83]) in older adults, which can significantly reduce the risk of injury from falls, including severe falls that result in bone fracture, head trauma, open wound, soft tissue injury, or any other injury requiring medical care or admission to hospital (42). This evidence was consistent with, and reaffirmed findings in, other reviews (35). After reaching a peak in early adulthood, muscle and bone mass tends to decline with increasing age (i.e. sarcopaenia and osteopaenia/osteoporosis), and this can be associated with declining strength and physical function. Evidence demonstrates that regular physical activity improves physical function and reduces the risk of age-related loss of physical function in older adults. Findings show beneficial effects on dynamic balance (SMD= 1.10 [95% CI: 0.29 to 1.90]); muscle strength (SMD= 1.13 [95% CI: 0.30 to 1.96]); flexibility (SMD= 1.22 [95% CI: 0.39 to 2.04]); and cardiorespiratory fitness (SMD= 1.48 [95% CI: 0.42 to 2.54]) (94). Evidence also shows that higher levels of physical activity may improve bone health and thus prevent osteoporosis in older adults (pooled standardized effect size 0.21 [95% CI: 0.06 to 0.36]) (95). Physical activity interventions may improve lumbar spine and femoral neck (hip) bone mineral density. The GDG concluded that: • There is moderate certainty evidence that physical activity improves physical function and reduces risk of age-related loss of physical function in the general ageing population. • There is low-certainty evidence that the risks for the amounts and types of physical activity recommended for older adults are low and are outweighed by the benefits. OLDER ADULTS (aged 65 years and over) 44 45 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Is there a dose-response association (volume, duration, frequency, intensity)? Evidence shows an inverse relationship between the amount of physical activity performed by older adults and the risk of physical function limitations. In general, more physical activity (frequency, duration and/or volume) is associated with greater benefits (35). Evidence suggests that fast-intended velocity resistance training may be superior to moderate-velocity resistance training for improvements in general functional capacity (SMD= 0.41 [95% CI: 0.18 to 0.65]; and SPPB (SMD= 0.52 [95% CI: 0.10 to 0.94])) (96). There is limited evidence examining the dose-response relationship between physical activity and prevention of falls; however the majority of studies providing supportive evidence show testing a programme consistent with 3 days per week. The GDG concluded that: • There is high certainty evidence of an inverse dose- response relationship between volume of aerobic physical activity and risk of physical functional limitations in the general older adult population. Does the association vary by type or domain of physical activity? Physical activity programmes that include combinations of balance, strength, endurance, gait, and physical function training are associated with a reduced rate of falls and risk of injury from falls in older adults. Evidence from a review of 11 RCT showed that by engaging in a variety of different physical activity interventions (commonly balance and functional exercises plus resistance exercises), older adults can reduce rate of falls by up to 28% (RaR= 0.72 [95% CI: 0.56 to 0.93]) (42). The effect of resistance exercises was uncertain and based on limited data (RR= 0.97 [95% CI: 0.14 to 6.49]; 1 trial; n= 73) (42). Evidence also suggests that programmes which include multiple exercise types have greater positive effects on bone health (standardized effect size 0.45 [95% CI: 0.20 to 0.71]; p= 0.001), compared with those which do not (95). The GDG concluded that: • There is high certainty evidence that higher levels of physical activity that combines balance, strength, gait, and functional training (e.g. multicomponent physical activity) are associated with a reduced rate of falls and risk of injury from falls in older adults. • There is moderate certainty evidence that programmes involving multiple exercise types may have significant effects on bone health and osteoporosis prevention. OLDER ADULTS (aged 65 years and over) 44 45Recommendations OLDER ADULTS (aged 65 years and older) Supporting evidence and rationale Sedentary behaviour was not included in the 2010 Global recommendations on physical activity for health (1). Due to a lack of population-specific evidence, the primary evidence base for assessing the associations between sedentary behaviour and health outcomes in older adult populations was the same scientific literature collated and reviewed for adult populations because the majority of studies stated no upper age limit criterion and therefore included adults over the age of 65 years. The findings from evidence on sedentary behaviours in the general adult population were reviewed, including assessing if there was evidence that the outcomes would be any different, or would not apply to, or would be contraindicated, for older adults. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . In older adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Older adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, moderate certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, older adults should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, moderate certainty evidence For older adults, sedentary behaviour is defined as time spent sitting or lying with low energy expenditure, while awake, in the context of occupational, educational, home and community settings and transportation. SEDENTARY BEHAVIOUR RECOMMENDATION Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 46 47 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r PREGNANT AND POSTPARTUM WOMEN PREGNANT AND POSTPARTUM WOMEN PHYSICAL ACTIVITY RECOMMENDATION For pregnant and postpartum women, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), transportation (wheeling, walking and cycling), work, household chores, in the context of daily occupational, educational, home and community settings. These guidelines address physical activity and maternal and fetal health outcomes during pregnancy and the postpartum period. They are for all pregnant and postpartum women, irrespective of age, cultural background, or socioeconomic status. Pregnancy and the period after delivery are stages in a woman’s life, and the benefits of being physically active throughout adulthood are detailed in the recommendations provided for adults. Pregnant and postpartum women should be under the care of a health-care provider for antenatal and postnatal care who can advise on special considerations given their medical history and any contraindications to participating in physical activity during pregnancy or in the postpartum period. These guidelines are public health and population- based. Clinical guidance should be sought for women with complications associated with pregnancy or delivery. Pregnant and postpartum women should try to meet these recommendations where possible, as able, and without contraindication. In pregnant and postpartum women, physical activity during pregnancy and postpartum confers benefits on the following maternal and fetal health benefits: decreased risk of pre-eclampsia, gestational hypertension, gestational diabetes, excessive gestational weight gain, delivery complications and postpartum depression, and fewer newborn complications, no adverse effects on birthweight; and no increase in risk of stillbirth. It is recommended that all pregnant and postpartum women without contraindication should: undertake regular physical activity throughout pregnancy and postpartum; Strong recommendation, moderate certainty evidence do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week for substantial health benefits; and Strong recommendation, moderate certainty evidence incorporate a variety of aerobic and muscle-strengthening activities. Adding gentle stretching may also be beneficial. Strong recommendation, moderate certainty evidence In addition: Women who, before pregnancy, habitually engaged in vigorous-intensity aerobic activity, or who were physically active, can continue these activities during pregnancy and the postpartum period. Strong recommendation, moderate certainty evidence 46 47Recommendations G O O D P R A C TI C E ST A TE M EN TS • Doing some physical activity is better than doing none. • If pregnant and postpartum women are not meeting the recommendations, doing some physical activity will benefit their health. • Pregnant and postpartum women should start by doing small amounts of physical activity, and gradually increase frequency, intensity and duration over time. • Pelvic floor muscle training may be performed on a daily basis to reduce the risk of urinary incontinence. Additional safety considerations for pregnant women when undertaking physical activity are: • Avoid physical activity during excessive heat, especially with high humidity; • Stay hydrated by drinking water before, during, and after physical activity; • 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 high altitude); • Avoid activities in supine position after the first trimester of pregnancy; • When considering athletic competition, or exercising significantly above the recommended guidelines pregnant women should seek supervision from a specialist health-care provider; • Pregnant women should be informed by their health-care provider of the danger signs alerting them as to when to stop; or to limit physical activity and consult a qualified health-care provider immediately should they occur; • Return to physical activity gradually after delivery, and in consultation with a health-care provider, in the case of delivery by Caesarean section. PREGNANT AND POSTPARTUM WOMEN Supporting evidence and rationale For these Guidelines on physical activity and sedentary behaviour (2020) for pregnant and postpartum women, the evidence syntheses from 7 systematic reviews addressing the critical and important outcomes (28–34) were used and updated. Four of the 7 reviews met inclusion criteria. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf In pregnant and postpartum women, what is the association between physical activity and health-related outcomes? Physical activity before and during pregnancy can help reduce the risk of common complications of pregnancy. Engaging in physical activity during pregnancy is significantly associated with reduced gestational weight gain (MD= 1.14 kg [95% CI: 1.67 to 0.62]) (97), and a reduced risk of gestational diabetes (RR= 0.71 [95% CI: 0.57 to 0.89]) (97), as is being physically active before pregnancy (OR= 0.70 [95% CI: 0.57 to 0.85]) (31, 34, 97), including in women with overweight or obesity (97). Physical activity during pregnancy does not appear to increase the incidence of gestational hypertension or preeclampsia (31). Evidence suggests that among pregnant women with overweight or obesity, there is no significant difference in the incidence of gestational hypertension (RR= 0.63 [95% CI: 0.38 to 1.05]) or in preeclampsia (RR= 1.39 [95% CI: 0.66 to 2.93]) between physical activity intervention groups versus standard antenatal care (97). There have been long-standing concerns about potential adverse effects of maternal physical activity on the developing fetus and delivery. However, recent evidence demonstrates that physical activity is not associated with increased risk of the incidence of miscarriage, stillbirth or delivery complications (32). Evidence suggests no difference in the incidence of Caesarean delivery among pregnant women with overweight or obesity between physical activity intervention groups versus standard antenatal care (97). Physical activity during pregnancy is not associated with increased risk of adverse effects on birthweight (98) or preterm birth (32), and may even be protective, reducing the overall risk (98), even among pregnant women with overweight or obesity (RR= 1.02 [95% CI: 0.54 to 1.92]) or 48 49 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r PREGNANT AND POSTPARTUM WOMEN large-for-gestational-age babies (RR= 0.90 [95% CI: 0.65 to 1.25]) between physical activity intervention groups versus standard antenatal care) (97). In the postpartum period, mothers can experience many physical and emotional changes. Evidence demonstrates that physical activity during pregnancy may be inversely associated with postpartum depression (29). Evidence from a meta-analysis of 6 trials and 11 observational studies of physical activity during pregnancy (99) showed a significant inverse relationship between physical activity during pregnancy and postpartum depression (SMD= 0.58 [95% CI: 1.09 to 0.08]). The effect was stronger when limited to 5 studies with at least moderate-intensity interventions (SMD= 0.70 [95% CI: 1.19 to 0.22]) (99). The GDG concluded that: • There is high certainty evidence that physical activity during pregnancy may reduce gestational weight gain and risk of gestational diabetes mellitus. • There is moderate to high certainty evidence that physical activity does not increase the incidence of gestational hypertension. • There is moderate certainty evidence that physical activity does not increase the incidence of miscarriage, stillbirth or delivery complications; and moderate certainty evidence of a reduced risk of preterm birth for mothers engaged in vigorous-intensity physical activity. • There is low to moderate certainty evidence that physical activity does not increase the risk of low birth weight, or small-for-gestational-age, or large-for- gestational-age babies. • There is low certainty evidence that physical activity during pregnancy is associated with lower levels of postpartum depression. • The risks for the amounts and types of physical activity recommended for pregnant and postpartum women are low and are outweighed by the benefits. Is there a dose-response association (volume, duration, frequency, intensity)? Across the evidence on physical activity during pregnancy and the postpartum period, the interventions varied in the amount (i.e. dose) of physical activity, both in duration in minutes and frequency per week. In general, the evidence available reflected a frequency of aerobic physical activity of at least 3 times per week, typically for between 30 and 60 minutes. This evidence is taken from studies assessing the health impact of a dose broadly consistent with the amount of activity recommended for the general adult population – namely 150 minutes of moderate-intensity physical activity per week. While more physical activity (frequency, duration and/or volume) is generally found to be associated with greater benefits, further research is needed to understand in more detail the dose-response relationship. Participating in higher versus lower amounts of leisure time physical activity pre-pregnancy is associated with a significantly lower risk of gestational diabetes (OR= 0.54 [95% CI: 0.34 to 0.87]) (100). There is also evidence of a small, but significant, reduced risk of preterm birth in babies of mothers who engaged in vigorous-intensity physical activity (RR= 0.20 [95% CI: 0.36 to 0.03]) (98). No evidence was identified regarding the safety or additional benefit of exercising at levels significantly above the recommendations. The GDG concluded that: • There is insufficient evidence to determine a dose- response association between physical activity and specific critical health outcomes during pregnancy and the postpartum period. • The overall evidence shows benefits to critical health outcomes and is based on interventions that are broadly consistent with the amount of physical activity recommended for the general adult population, namely 150 minutes of moderate-intensity physical activity per week. • There was no reason to alter the amount or frequency of recommended moderate-intensity physical activity for pregnant and postpartum women compared with the general adult population. • There is moderate certainty evidence of a reduced risk of preterm birth for mothers engaged in vigorous- intensity physical activity. 48 49Recommendations Does the association vary by type or domain or timing (pre-pregnancy, antenatal or postnatal) of physical activity? Evidence is available from studies that mostly assessed leisure domain physical activity; the type of activity was mostly aerobic (such as walking or swimming), although there is some evidence from studies assessing interventions that also included strength training (e.g. circuit training), or combinations of aerobic and muscle-strengthening exercise. However, overall there is insufficient evidence to determine if the associations between physical activity and health outcomes vary by type or domain or timing (pre-pregnancy, antenatal or postnatal) of physical activity. The GDG concluded that: • There is moderate certainty evidence that pregnant and postpartum women should incorporate a variety of aerobic and muscle-strengthening activities. Gentle stretching may also be beneficial. PREGNANT AND POSTPARTUM WOMEN 50 51 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Supporting evidence and rationale Sedentary behaviour was not included in the 2020 Global recommendations on physical activity for health (1). Due to a lack of population-specific evidence, the primary evidence base for assessing the associations between sedentary behaviour and health outcomes in pregnant and postpartum women was the scientific literature collated and reviewed for adult populations. The findings from evidence on sedentary behaviours in the general adult population were reviewed, including assessing whether the outcomes would be any different, or would not apply to, or would be contraindicated, for pregnant and postpartum women. In pregnant and postpartum women, as in all adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and incidence of type-2 diabetes. It is recommended that: Pregnant and postpartum women should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence For pregnant and postpartum women, sedentary behaviour is defined as time spent sitting or lying with low energy expenditure while awake, in the context of occupational, educational, home and community settings and transportation. SEDENTARY BEHAVIOUR RECOMMENDATION PREGNANT AND POSTPARTUM WOMEN Based on available evidence and expert opinion, the evidence was extrapolated to inform the new WHO recommendations on sedentary behaviour for pregnant and postpartum women for the common set of critical health outcomes. Due to indirectness of the evidence, the level of certainty was downgraded. Given the lack of evidence specific to this population, and that pregnant women were excluded from studies, the recommendation to increase levels of physical activity beyond recommended levels to counter the detrimental effect of high sedentary behaviour was not extrapolated for women during pregnancy and the postpartum period. The GDG concluded that: • The evidence on sedentary behaviours in the general adult population could be extrapolated to inform recommendations for pregnant and postpartum women for the common set of critical health outcomes. • The benefits of minimizing sedentary behaviour outweigh the risks for pregnant and postpartum women. • The certainty of the evidence should be downgraded due to indirectness. 50 51Recommendations ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) To date, most physical activity guidelines for people with chronic conditions have been limited to clinical or therapeutic guidance. For example, there are clinical practice recommendations and resources developed by the professional medical associations for oncology (101), type-2 diabetes (102), hypertension (103), and other chronic diseases (104). WHO also has clinical practice guidance which includes recommending physical activity to patients with chronic disease (17). These guidelines are the first WHO population-based guidelines on physical activity for people living with chronic conditions, specifically those living with cancer (from here on referred to as “cancer survivors”), hypertension, type-2 diabetes, and HIV. Given the advances of effective and widely available antiretroviral treatment for HIV, this condition is now also considered a chronic condition. For patients undergoing acute treatment (e.g. chemotherapy), or not yet stabilized on their chronic medication, health-care providers should also refer to clinical practice guidelines relevant to each chronic condition. PHYSICAL ACTIVITY RECOMMENDATION For adults living with chronic conditions, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), transportation (wheeling, walking and cycling), work or household chores, in the context of daily occupational, educational, home or community settings. All adult cancer survivors and those living with hypertension, type-2 diabetes and HIV, should try to meet these recommendations where possible, as able and without contraindication. Physical activity can confer health benefits for adults and older adults living with the following chronic conditions: for cancer survivors – physical activity improves all-cause mortality, cancer-specific mortality, and risk of cancer recurrence or second primary cancer; for people living with hypertension – physical activity improves cardiovascular disease mortality, disease progression, physical function, health-related quality of life; for people living with type-2 diabetes – physical activity reduces rates of mortality from cardiovascular disease and indicators disease progression; and for people living with HIV – physical activity can improve physical fitness and mental health (reduced symptoms of anxiety and depression), and does not adversely affect disease progression (CD4 count and viral load) or body composition. It is recommended that: All adults and older adults with these chronic conditions should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults and older adults with these chronic conditions should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence G O O D P R A C TI C E ST A TE M EN TS 52 53 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) Adults and older adults with these chronic conditions should also do muscle- strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional benefits. Strong recommendation, moderate certainty evidence As part of their weekly physical activity, older adults with these chronic conditions should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence When not contraindicated, adults and older adults with these chronic conditions may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence • When not able to meet the above recommendations, adults with these chronic conditions should aim to engage in physical activity according to their abilities. • Adults with these chronic conditions should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • Adults with these chronic conditions may wish to consult with a physical activity specialist or health-care professional for advice on the types and amounts of activity appropriate for their individual needs, abilities, functional limitations/ complications, medications, and overall treatment plan. • Pre-exercise medical clearance is generally unnecessary for individuals without contraindications prior to beginning light- or moderate-intensity physical activity not exceeding the demands of brisk walking or everyday living. G O O D P R A C TI C E ST A TE M EN TS Supporting evidence and rationale The scope of these guidelines assessed the associations between physical activity and the following health outcomes: for cancer survivors – all-cause mortality, cancer-specific mortality, and risk of cancer recurrence or second primary cancer; for people living with hypertension – cardiovascular disease mortality, risk of co-morbid conditions, physical function, health-related quality of life, and disease progression (here defined as the blood pressure response to physical activity); for people living with type-2 diabetes – cardiovascular disease mortality, risk of co-morbid conditions, physical function, health-related quality of life, and disease progression; and for people living with HIV – physical function (physical fitness, exercise tolerance and strength), health-related quality of life, mental health (symptoms of anxiety and depression), cardiometabolic disease risk indicators (blood lipids, blood glucose and body composition) and adverse effects on disease progression (namely CD4 count and viral load). The evidence informing these guidelines was the report of PAGAC (35) which was updated with 16 new reviews identified from 2017 to 2019 for cancer (n= 1), hypertension (n= 2) and type-2 diabetes (n= 13). In addition, a commissioned umbrella review on physical activity and health-related outcomes among people living with HIV provided evidence from 19 eligible reviews published 2002–2018. Full details of the methods, data extraction and evidence profiles can be found in the Web Annex: Evidence profiles . Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 52 53Recommendations In adults and older adults (aged 18 years and over) living with cancer (cancer survivors), hypertension, type-2 diabetes, or HIV, what is the association between physical activity and health-related outcomes? Physical activity promotes beneficial short- and long- term changes in metabolic, hormonal, and inflammatory pathways, which are thought to be protective for cancer incidence and survival (35). Evidence shows that higher levels of physical activity after cancer diagnosis were found to be protective for all-cause mortality following breast cancer (HR= 0.58 [95% CI: 0.52 to 0.65], 17 studies); colorectal cancer (HR= 0.63 [95% CI: 0.50 to 0.78], 10 studies), female reproductive cancer (HR= 0.66 [95% CI: 0.49 to 0.88], 4 studies); glioma (HR= 0.64 [95% CI: 0.46 to 0.91], 1 study); hematologic cancer (HR= 0.60 [95% CI: 0.51 to 0.69], 2 studies); kidney cancer (HR= 0.60 [95% CI: 0.38 to 0.95], 1 study); lung cancer (HR= 0.76 [95% CI: 0.60 to 0.97], 2 studies); prostate cancer (HR= 0.60 [95% CI: 0.46 to 0.79], 5 studies); and stomach cancer (HR= 0.75 [95% CI: 0.61 to 0.93], 1 study) (105). Greater amounts of physical activity after cancer diagnosis are also associated with lower risks of cause-specific mortality in breast cancer, colorectal cancer, and prostate cancer survivors. The meta-analysis found reduced hazards of mortality for those in the highest versus the lowest levels of postdiagnosis total physical activity for all cancers combined (HR= 0.63 [95% CI: 0.53 to 0.75], 4 studies); breast cancer (HR= 0.63 [95% CI: 0.50 to 0.78], 13 studies); colorectal cancer (HR= 0.62 [95% CI: 0.44 to 0.86], 6 studies); and prostate cancer (HR= 0.70 [95% CI: 0.55 to 0.90], 4 studies) (105). There was, however, insufficient evidence to determine if physical activity is associated with cancer recurrence or second primary cancer. Physical activity is important for both the primary prevention and management of hypertension, with evidence showing that physical activity improves physical function, cardiovascular disease progression (i.e. blood pressure response to physical activity), and cardiovascular disease mortality in people living with hypertension (35). For example, compared with no exercise control groups, people with hypertension who are physically active can reduce systolic blood pressure by approximately 12mm Hg and diastolic blood pressure by approximately 6mm Hg (SBP MD= 12.26 mm Hg [95% CI: 15.17 to 9.34], p= < 0.05; DBP MD= 6.12 mm Hg [95% CI: 7.76 to 4.48], p= < 0.05) (106). Emerging evidence demonstrates that people with ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) hypertension who are physically active can significantly improve their health-related quality of life compared with those with hypertension who are inactive (54). Physical activity, including aerobic activity, muscle- strengthening activity, and aerobic plus muscle- strengthening activity, is associated with improved secondary indicators of risk of progression (HbA1c, blood pressure, BMI, and lipids) in adults with type-2 diabetes (35). For example, recent research found that resistance training was associated with greater reduction in HbA1c versus control groups, and that high-intensity resistance training has significant positive effects on fasting insulin (107). There is insufficient evidence to assess the effects of physical activity on health-related quality of life and physical function in adults with type-2 diabetes. Physical activity in people living with HIV improves cardiorespiratory fitness. The interventions studied involved either aerobic exercise, or exercise combined with progressive muscle-strengthening exercise, for at least 30 minutes, 3 times per week (108, 109). There is also evidence that physical activity interventions can improve markers of cardiometabolic risk (e.g. lipids) although results are mixed; no effects were established on insulin concentration, although glucose was lowered after aerobic training (110). Physical activity, whether aerobic, or combined with muscle-strengthening exercise, in people living with HIV is positively associated with health-related quality of life (111) and a reduction in symptoms of depression and anxiety (112). The meta- analysis for depression (9 studies) showed an SMD of 0.84 (95% CI: 1.57 to 0.11) favouring the intervention groups (p= 0.02). The SMD for reduction in anxiety (5 studies) was also statistically significant, favouring the intervention ( 1.23 [95% CI: 2.42 to 0.04], p= 0.04) (112). Physical activity is also associated with significant standardized mean increases in lean body mass of 1.75 kg and a significant decrease in percent body fat of 1.12% for participants in the exercising control groups, as well as an increase in peripheral leg and arm muscle area, compared with participants in the non-exercising control groups (111), but is not associated with changes in BMI or waist circumference in people living with HIV (111). Physical activity does not adversely influence markers of HIV disease progression, such as CD4 count (cells/mm3) or viral load (111). Importantly, this evidence suggests that HIV as a chronic disease will not be adversely affected by physical activity. 54 55 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r The GDG concluded that: • There is moderate certainty evidence that greater amounts of physical activity after cancer diagnosis are associated with lower risks of all-cause, cause-specific, and cancer-specific mortality in cancer survivors. • There is high certainty evidence that physical activity reduces the risk of cardiovascular disease progression in adults with hypertension. • There is moderate certainty evidence that physical activity improves physical function and health-related quality of life outcomes in adults with hypertension. • There is high certainty evidence that physical activity improves markers of disease progression (HbA1c, blood pressure, BMI, and lipids) in adults with type-2 diabetes. • There is moderate certainty evidence of an association between physical activity and improvements in fitness (maximal oxygen consumption, exercise tolerance) and muscular strength for people living with HIV, and favourable associations between physical activity and body composition, health-related quality of life, reduced symptoms of depression and anxiety, and no change in viral load or CD4 count in people living with HIV. • The benefits associated with engaging in regular physical activity in cancer survivors and people living with hypertension, type-2 diabetes, and HIV in relation to specific health outcomes, outweigh the risks. Is there a dose-response association (volume, duration, frequency, intensity)? Greater amounts of physical activity after cancer diagnosis have been linked with lower risks of all-cause, and cancer- specific mortality. Evidence demonstrates a non-linear relationship between increasing levels of post-diagnosis physical activity and breast cancer-specific and all-cause mortality up to 10–15 MET-hours per week (consistent with 150 mins/week of moderate- to vigorous-intensity physical activity) with no evidence for harms at higher levels (105). There is a suggestion of similar dose-response association for other cancer sites however there were too few studies to permit a formal meta-analysis. Further research is needed to determine strength of association. There is a clear dose-response relationship between physical activity and cardiovascular disease mortality for people living with hypertension (35). Findings show that as systolic blood pressure increases within hypertensive ranges, the risk of cardiovascular disease mortality increases, but this increased risk is attenuated with higher levels of physical activity (35). Similar to recommendations for the general population, most of the traditional interventions are based around 30–60 minutes of moderate-intensity aerobic activity, 3 days per week, and/or 2–3 sessions of resistance training per week. There is substantial evidence of an inverse curvilinear association between volume of physical activity and risk of cardiovascular mortality in adults with type-2 diabetes (113–115). Higher amounts of physical activity (from both below and at, or above the recommended levels of 150 mins/week of moderate-intensity activity) progressively reduce risk. For example, compared with doing no activity, engaging in some activity was associated with a 32% reduction in risk of cardiovascular disease mortality (adjusted HR= 0.68 [95% CI: 0.51 to 0.92]), while engaging in amounts of activity meeting physical activity guidelines or above was associated with a larger 40% reduction in risk of cardiovascular disease mortality (adjusted HR= 0.60 [95% CI: 0.44 to 0.82]) (115). Most interventions are based around 150–300 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity activity, and/ or 2–3 sessions of resistance training per week. For some outcomes (e.g. HBA1c and blood pressure) in adults with type-2 diabetes, there is evidence for a stronger effect with more aerobic activity (i.e. greater than 150 mins/week versus less than 150 mins/week), but limited evidence for intensity (35). In people living with HIV, there is insufficient evidence to establish a dose-response relationship between physical activity and body composition, or for intermediate markers of cardiometabolic diseases (such as blood lipid profiles, insulin resistance, fasting glucose concentrations or blood pressure). The majority of studies providing evidence involved physical activity interventions conducted at least 3 times a week for 12–48 weeks, and involved at least 30 minutes of moderate- to vigorous-intensity aerobic exercise alone or in combination with progressive resistance training. There is also insufficient evidence to establish more precisely the dose-response relationship for mental health and health-related quality of life outcomes. The available evidence is from studies typically assessing physical activity interventions of 3 or more times weekly. Overall there was evidence ranging from moderate to high certainty to support a physical activity recommendation of 150–300 minutes of moderate-intensity physical activity (or equivalent) for the specified populations of people living with chronic disease and the specific set of health outcomes. There was clearer evidence of higher levels of activity being associated with greater benefits in the evidence addressing people living with hypertension, ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) 54 55Recommendations type-2 diabetes and cancer survivors. The variations in the certainty and directness of the evidence according to the specific chronic condition and specific outcomes examined was acknowledged. Where evidence showed positive outcomes from strength training exercise, the frequency of activity was 2 or 3 sessions of resistance training per week. The GDG concluded that: • There is moderate certainty evidence of a dose-response relationship between physical activity and decreased all- cause mortality and cancer-specific mortality in cancer survivors. • There is high certainty evidence of a dose- response relationship between physical activity and cardiovascular disease mortality for adults with hypertension. • There is evidence of an inverse, curvilinear dose- response relationship between activity volume and risk of cardiovascular mortality among adults with type-2 diabetes. • There is insufficient evidence for a dose-response relationship between physical activity and intermediate markers of cardiometabolic diseases, body composition, and health-related quality of life symptoms of anxiety and depression in people living with HIV. • Interventions in the range of 150–300 minutes of moderate-intensity aerobic activity (or equivalent) provided favourable health outcomes, and positive outcomes from strength training exercise, where noted, with 2 or 3 sessions of resistance training per week. Does the association vary by type or domain of physical activity? There is evidence that different types and domains of physical activity provide favourable health outcomes. Cancer survivors who are meeting recommended levels of aerobic and muscle-strengthening physical activity, versus not meeting either recommendation, have significantly lower risk of cancer mortality (adjusted HR= 0.70 [95% CI: 0.50 to 0.98]) (84). Evidence demonstrates that adhering solely to muscle- strengthening physical activity recommendations versus not adhering is also beneficial in improving cancer mortality outcomes (HR= 0.66 [95% CI: 0.48 to 0.92]) (84). A meta-analysis also reported these associations by physical activity domain and found the most consistent reductions in mortality for all cancers, breast cancer, and colorectal cancer-specific mortality for recreational physical activity (105). For adults living with hypertension, evidence supports aerobic activity, muscle-strengthening activity, and combinations of the two for improving cardiovascular disease progression. The blood pressure lowering effects between traditional modes of physical activity (i.e. aerobic and resistance activity) do not appear to vary significantly among people with hypertension (35); however, this evidence is not based on direct comparisons between activity types. There is also emerging evidence to support beneficial effects of other forms of exercises in people living with hypertension (e.g. Tai Chi, yoga, Qigong), however further research is needed to explore these specific types of activity to determine strength of association. Aerobic activity, muscle-strengthening activity, or a combination of both, is associated with improved secondary indicators of risk of progression (HbA1c, blood pressure, BMI, and lipids) among adults with type-2 diabetes (35, 107). One review of 24 RCTs (n= 962) reported that resistance training was associated with greater reduction in HbA1c versus control groups (MD= 0.45 [95% CI: 0.65 to 0.25], 20 trials; n= 824). Statistically significant effects were found for high- intensity resistance training versus control groups on fasting insulin (MD= 4.60 [95% CI: 7.53 to 1.67], 5 trials; n= 174) (107). Another review of 7 RCTs (n= 189) reported that interval training (2–5 times/week; intervals 1–4 mins duration; total session lengths 20–60 mins) was associated with statistically significantly decreased HbA1c by 0.26% (95% CI: 0.46 to 0.07%, 5 RCTs) compared with MICT, and by 0.83% (95% CI: 1.39% to 0.27%, 4 RCTs) compared with no-exercise control groups (116). As with recommendations for the general population, most of these interventions are based around aerobic activity consistent with the recommendation of 150–300 minutes of moderate-intensity aerobic activity (or 75 minutes of vigorous-intensity activity) and muscle-strengthening activity conducted 2–3 sessions per week. For some outcomes (e.g. HBA1c and blood pressure), there is evidence for a stronger effect with more aerobic activity (i.e. greater than 150 mins/week versus less than 150 mins/ week), but limited evidence for intensity. More recent studies provide evidence that traditional Chinese exercise, such as Tai Chi may have glycaemic benefits, but these were of moderate and variable certainty (i.e. risk of bias or inconsistency). Further research is needed to determine these associations. ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) 56 57 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Multiple types of physical activity, including aerobic and resistance-training, have been shown to have positive effects on health-related quality of life in people living with HIV (111). Recent research examining changes in health-related quality of life in response to aerobic, progressive resistance exercise, or a combination of both, demonstrates significant improvements in general health, and mental health. There is also evidence that both aerobic and multicomponent activity is related to a reduction in symptoms of depression and anxiety in people living with HIV (112). Evidence for the effects of physical activity on mental health symptoms has involved aerobic or aerobic combined with progressive muscle-strengthening activity, or yoga. Evidence also demonstrates that aerobic exercise alone, or when combined with resistance exercise, does not result in any significant change in viral load or CD4 count in people living with HIV (111). Direct evidence, from both the existing and updated literature, supports the inclusion of the recommendations for people living with type-2 diabetes and hypertension to undertake aerobic and muscle-strengthening physical activity. Although there is a lack of published evidence, there is biological plausibility for the benefits of aerobic and muscle-strengthening physical activity for adults living with HIV and cancer survivors. Furthermore, as noted by the GDG, established international clinical practice guidelines recommend aerobic and muscle- strengthening physical activity for these populations (for example ACSM “Moving Through Cancer” guidelines (101) based on a systematic review of evidence (3)). Recognizing this evidence base is still emerging, the level of certainty was downgraded. The GDG concluded that: • There is moderate certainty evidence for combined or additive effects of aerobic or muscle-strengthening activity for reduced cancer mortality, improvements in blood pressure among those with hypertension. • There is high certainty evidence that aerobic activity, muscle-strengthening activity, and aerobic plus muscle- strengthening activity improve markers of disease progression (HbA1C, blood pressure, BMI, and lipids) in adults with type-2 diabetes. • There is moderate certainty evidence that regular aerobic exercise alone, or combined with resistance exercise, does not result in any significant change in viral load or CD4 count in people living with HIV. • There is insufficient evidence for an effect of strength training alone on health-related quality of life in people living with HIV. ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) 56 57Recommendations ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) Supporting evidence and rationale Due to a lack of population-specific evidence, the primary evidence base for assessing the associations between sedentary behaviour and health outcomes in adults and older adult cancer survivors and those adults and older adults living with hypertension, type-2 diabetes, and HIV, was the scientific literature collated and reviewed for adult populations. The findings from evidence on sedentary behaviours in the general adult population were reviewed, including assessing if there was evidence that the outcomes would be any different, or would not apply to, or would be contraindicated, for adults and older adults living with chronic conditions. In adults, including cancer survivors and people living with hypertension, type-2 diabetes and HIV, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality; cardiovascular disease mortality; cancer mortality; incidence of cardiovascular disease; cancer; and type-2 diabetes. For cancer survivors, and adults living with hypertension, type-2 diabetes and HIV, it is recommended that: Adults and older adults with chronic conditions should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults and older adults with chronic conditions should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence Sedentary behaviour was not included in the 2010 Global recommendations on physical activity for health (1). The scope of this new recommendation on sedentary behaviours in cancer survivors and those people living with hypertension, type-2 diabetes and HIV. Sedentary behaviour is defined as time spent sitting or lying with low energy expenditure, while awake, in the context of occupational, educational, home and community settings, and transportation. SEDENTARY BEHAVIOUR RECOMMENDATION 58 59 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ADULTS AND OLDER ADULTS WITH CHRONIC CONDITIONS (aged 18 years and older) Based on available evidence and expert opinion, the evidence was extrapolated to inform the new WHO recommendations on sedentary behaviour for adults living with chronic conditions for the common set of critical health outcomes. The extrapolation of evidence is supported largely by the assessment that the majority of studies imposed no upper age limit criterion, included adults over the age of 65 years and may have included adults with chronic conditions, such as cancer survivors, those living with hypertension or type-2 diabetes. For people living with HIV, no reasons were identified as to why the evidence on the health impacts of sedentary behaviours would not apply. Due to indirectness of the evidence to develop these recommendations, the level of certainty was downgraded. The applicability of evidence on the benefit of undertaking more moderate- and vigorous-intensity physical activity to help counteract the potential risks of high levels of sedentary behaviour was also considered and was also extrapolated to inform recommendations for adults with chronic conditions for the common set of critical health outcomes. Given the indirectness, the certainty of the evidence was downgraded. The GDG concluded that: • The evidence on sedentary behaviours in the general adult population could be extrapolated to inform recommendations for adult and older adult cancer survivors and those adults and older adults living with hypertension, type-2 diabetes, and HIV for the common set of critical outcomes, with the level of certainty of the evidence downgraded due to indirectness. • The evidence on the benefits of undertaking more moderate- and vigorous-intensity physical activity to help counteract the potential risks of high levels of sedentary behaviour in the general adult population could be extrapolated to inform recommendations for adult and older adult cancer survivors and those adults and older adults living with hypertension, type-2 diabetes, and HIV for the common set of critical outcomes, with the level of certainty of the evidence downgraded due to indirectness. • The benefits for minimizing sedentary behaviours outweigh the harms for cancer survivors and those people living with hypertension, type-2 diabetes, and HIV. 58 59Recommendations CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and older) LIVING WITH DISABILITY Many of the health benefits of physical activity for children and adolescents, as set out in the section above, also relate to those children and adolescents living with disability. Additional benefits of physical activity to health outcomes for those living with disability include: improved cognition in individuals with diseases or disorders that impair cognitive function, including attention-deficit/hyperactivity disorder (ADHD); improvements in physical function may occur in children with intellectual disability. It is recommended that: Children and adolescents living with disability should do at least an average of 60 minutes per day of moderate- to vigorous-intensity, mostly aerobic, physical activity, across the week. Strong recommendation, moderate certainty evidence Vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone should be incorporated at least 3 days a week. Strong recommendation, moderate certainty evidence Children, adolescents and adults living with disability can achieve important health benefits from physical activity. Children, adolescents and adults with disability should try to meet these recommendations where possible and as able. For children, adolescents and adults living with disability, physical activity can be undertaken as part of recreation and leisure (play, games, sports or planned exercise), physical education, transportation (wheeling, walking and cycling) or household chores, in the context of home, educational, occupational and community settings. It is important to provide all children, adolescents and adults living with disability with opportunities and encouragement to participate in physical activities appropriate for their age and ability, that are enjoyable, and that offer variety. PHYSICAL ACTIVITY RECOMMENDATION • Doing some physical activity is better than doing none. • If children and adolescents living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Children and adolescents living with disability should start by doing small amounts of physical activity and gradually increase the frequency, intensity and duration over time. • There are no major risks for children and adolescents living with disability engaging in physical activity when it is appropriate to an individual’s current activity level, health status and physical function; and the health benefits accrued outweigh the risks. • Children and adolescents living with disability may need to consult a health-care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. G O O D P R A C TI C E ST A TE M EN TS G O O D P R A C TI C E ST A TE M EN TS 60 61 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and over) LIVING WITH DISABILITY Many of the health benefits of physical activity for adults, as set out in the section above, also relate to adults living with disability. Additional benefits of physical activity to health outcomes for those living with disability include the following: for adults with multiple sclerosis – improved physical function, and physical, mental, and social domains of health- related quality of life; for individuals with spinal cord injury – improved walking function, muscular strength, and upper extremity function; and enhanced health-related quality of life; for individuals with diseases or disorders that impair cognitive function – improved physical function and cognition (in individuals with Parkinson’s disease and those with a history of stroke); beneficial effects on cognition; and may improve quality of life (in adults with schizophrenia); and may improve physical function (in adults with intellectual disability); and improves quality of life (in adults with major clinical depression). It is recommended that: All adults living with disability should undertake regular physical activity. Strong recommendation, moderate certainty evidence Adults living with disability should do at least 150–300 minutes of moderate- intensity aerobic physical activity; or at least 75–150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for substantial health benefits. Strong recommendation, moderate certainty evidence Adults living with disability should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits. Strong recommendation, moderate certainty evidence As part of their weekly physical activity, older adults living with disability should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and prevent falls. Strong recommendation, moderate certainty evidence Adults living with disability may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous- intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits. Conditional recommendation, moderate certainty evidence • Doing some physical activity is better than doing none. • If adults living with disability are not meeting these recommendations, doing some physical activity will bring benefits to health. • Adults living with disability should start by doing small amounts of physical activity, and gradually increase the frequency, intensity and duration over time. • There are no major risks to adults living with disability engaging in physical activity when it is appropriate to the individual’s current activity level, health status and physical function; and when the health benefits accrued outweigh the risks. • Adults living with disability may need to consult a health-care professional or other physical activity and disability specialist to help determine the type and amount of activity appropriate for them. G O O D P R A C TI C E ST A TE M EN TS 60 61Recommendations CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and over) LIVING WITH DISABILITY Supporting evidence and rationale For these guidelines for children, adolescents and adults living with disability, the comprehensive evidence synthesis undertaken by PAGAC (35) was used and updated. Full details of the methods, data extraction and summary evidence tables of this existing evidence on physical activity and health outcomes is available (35) and was reviewed by the GDG in addition to the findings of the updated search. The update conducted for these guidelines identified 39 reviews published from 2017 to 2019. Of these, 27 met the inclusion criteria and informed the examination of the association between physical activity and health-related outcomes among children, adolescents and adults living with disability. Full details of the methods, data extraction and summary evidence portfolios can be found in the Web Annex: Evidence profiles . Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf The evidence reviewed considered the association between physical activity and health-related outcomes in children, adolescents and adults living with disability resulting from the following health conditions: multiple sclerosis, spinal cord injury, intellectual disability, Parkinson’s disease, stroke, major clinical depression, schizophrenia, and attention-deficit/hyperactivity disorder (ADHD). The four health-related outcomes examined included risk of co-morbid conditions, physical function, cognitive function and health-related quality of life, although not all outcomes were explored for each condition. The impact of environmental factors on disability in the context of physical activity was beyond the scope of these guidelines and was not analysed. In children and adolescents (aged 5–17 years) and adults (aged over 18 years) living with disability, what is the association between physical activity and health-related outcomes? For people living with multiple sclerosis, physical activity improves physical function, functional mobility, walking speed and endurance, and cardiorespiratory fitness, strength and balance. For example, high-intensity interval training over 3–12 weeks demonstrated improvements in cardiorespiratory fitness or muscle strength (117) and lower limb strength training found strength increased by 23.1% (95% CI: 11.8 to 34.4) over an average training period of 13.2 weeks (118) over an average of 13 weeks resulted in increases in strength, and dance interventions studies reported improvements in functional mobility and balance (119). As well as physical health benefits, existing evidence demonstrates that physical activity can benefit cognition in people living with multiple sclerosis (35). Newer research reveals that aerobic exercise has a small yet significant effect on physical, mental and social domains of health-related quality of life (including symptoms of fatigue and depressive symptoms) (35, 120). For people living with spinal cord injury, physical activity can improve walking function, muscular strength and upper extremity function (35). Physical activity may also reduce shoulder pain, improve vascular function and enhance health-related quality of life (35). For people living with Parkinson’s disease, physical activity can improve motor symptoms, functional mobility and performance, endurance, freezing of gait and velocity of forward and backward movement (35, 121, 122). New evidence suggests that exercise can also help global cognitive function in individuals with Parkinson’s disease (123). For people with a history of stroke, physical activity can improve physical function, notably upper limb function, sensory motor function of the lower limb, balance, walking speed, distance, ability and endurance, cardiorespiratory fitness, mobility and activities of daily living. Existing evidence suggests that physical activity may also have beneficial effects on cognition (35). For people with major clinical depression, new reviews (124, 125) supported existing evidence (35) that physical activity can improve health-related quality of life (35, 124, 125). For individuals with diseases or disorders that impair cognitive function, including schizophrenia –physical activity can have beneficial effects on cognition, working memory, social cognition and attention/vigilance (35, 126). One review found that moderate- to vigorous-intensity physical activity delivered significant improvements in health-related quality of life and disability (35, 124). 62 63 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and over) LIVING WITH DISABILITY For people living with intellectual disability, physical activity has been shown to improve physical function. The interventions reviewed largely focused on balance and strength activities over 6–24 weeks and reported significant improvement in static balance, dynamic balance and static-dynamic balance compared with controls (35, 127, 128). For children with attention-deficit/hyperactivity disorder, evidence, including one review of 5 RCTs involving ADHD (129), demonstrates a positive association between exercise and attention, executive function and social disorders (35, 129). The GDG considered the evidence from the general population of children, adolescents and adults and concluded that as there is no reason to believe that there would be an effect modification due to impairment and that the same health physiological benefits will be conferred by being physically active. The GDG acknowledged that few studies include people living with disability, and that effect modification is seldom tested. This evidence in the area disability, combined with the broader evidence for the general population, supported the general population recommendation being inclusive of people with disability, noting reference to “all adults”, “all older adults” and “people of all abilities”. The GDG concluded that: In individuals with spinal cord injury, there is: • low certainty evidence that physical activity reduces shoulder pain and improves vascular function in paralysed limbs and enhances health-related quality of life; and • moderate certainty evidence that physical activity improves walking function, muscular strength, and upper extremity function. In individuals with diseases or disorders that impair cognitive function, including Parkinson’s disease, there is: • high certainty evidence that physical activity improves a number of functional outcomes including walking, balance, strength, and disease specific motor scores; and • moderate certainty evidence that moderate- to vigorous-intensity physical activity can have beneficial effects on cognition. In individuals with a history of stroke, there is: • moderate certainty evidence that mobility-oriented physical activity can have beneficial effects on physical function and cognition. In individuals with diseases or disorders that impair cognitive function, including schizophrenia, there is: • moderate certainty evidence that physical activity improves quality of life; and • high certainty evidence that moderate- to vigorous- intensity physical activity can have beneficial effects on cognition, working memory, social cognition and attention. In adults with major clinical depression there is: • moderate certainty evidence that physical activity improves quality of life. In adults with multiple sclerosis, there is: • high certainty evidence that physical activity, particularly aerobic and muscle-strengthening activities, improves physical function, functional mobility, walking speed and endurance, and cardiorespiratory fitness, strength and balance; • moderate certainty evidence that physical activity can have a beneficial effect on cognition; and • low certainty evidence that physical activity improves quality of life including symptoms of fatigue and depressive symptoms. In children and adults with intellectual disability, there is: • low certainty evidence that physical activity improves physical function. In children and adolescents with ADHD, there is: • moderate certainty evidence that moderate- to vigorous-intensity physical activity can have beneficial effects on cognition, including attention, executive function, and social disorders. The GDG further concluded that there is sufficient scientific evidence on the positive impact of physical activity on a variety of health outcomes across a broad range of impairment areas, and that the benefits of physical activity for people living with disability outweigh the potential harms. Due to indirectness of the evidence to develop these recommendations, the level of certainty was downgraded. 62 63Recommendations CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and older) LIVING WITH DISABILITY Supporting evidence and rationale Sedentary behaviour was not included in The Global recommendations on physical activity for health (2010). Due to a lack of population-specific evidence, the primary evidence base for assessing the associations between sedentary behaviour and health outcomes in children, adolescents and adults living disability was the scientific literature collated and reviewed for populations without disability. The findings from evidence on sedentary behaviours in the general population were reviewed including assessing if there was evidence that the outcomes would be any different, or would not apply to, or would be contraindicated for children, adolescents and adults living with disability. In children and adolescents, higher amounts of sedentary behaviour are associated with the following poor health outcomes: increased adiposity; poorer cardiometabolic health, fitness, and behavioural conduct/pro-social behaviour; and reduced sleep duration. It is recommended that: Children and adolescents living with disability should limit the amount of time spent being sedentary, particularly the amount of recreational screen time. Strong recommendation, low certainty evidence In adults, higher amounts of sedentary behaviour are associated with the following poor health outcomes: all-cause mortality, cardiovascular disease mortality and cancer mortality, and incidence of cardiovascular disease, cancer and type-2 diabetes. It is recommended that: Adults living with disability should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light- intensity) provides health benefits. Strong recommendation, low certainty evidence To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults living with disability should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. Strong recommendation, low certainty evidence For children, adolescents and adults living with disability, sedentary behaviour is defined as time spent sitting or lying with low energy expenditure, while awake, in the context of educational, home and community settings, and transportation. It is possible to avoid sedentary behaviour and be physically active while sitting or lying, through, for example, upper body led activities, inclusive and/or wheelchair-specific sport and activities. SEDENTARY BEHAVIOUR RECOMMENDATION 64 65 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and over) LIVING WITH DISABILITY Based on available evidence and expert opinion, the evidence was extrapolated to inform new WHO recommendations on sedentary behaviour for individuals living with disability for the common set of critical health outcomes, recognizing that certain population groups, such as wheelchair users, unavoidably sit for long periods of time and sitting may therefore be the norm. For these groups, sedentary behaviour should be defined as time spent with low energy expenditure, e.g. moving in a power chair or being pushed while sitting in a manual wheelchair. There is a lack of research on the association between sedentary behaviour and health outcomes in individuals living with disability. However, based on expert opinion, there are no reasons to believe that there would be an effect modification due to impairment, and therefore the same physiological health benefits will be conferred by limiting sedentary behaviour in individuals living with disability. Due to indirectness of the evidence to develop these recommendations, the level of certainty was downgraded. The applicability of evidence on the benefit of adults undertaking more moderate- and vigorous-intensity physical activity to help counteract the potential risks of high levels of sedentary behaviour was also considered and was also extrapolated to inform recommendations for adults living with disability for the common set of critical health outcomes. Given the indirectness, the certainty of the evidence was downgraded. The GDG concluded that: • The evidence on sedentary behaviours in child and adolescent populations could generally be extrapolated to children and adolescents living with disability, according to their specific ability. • The evidence on sedentary behaviours in the general adult population, including the benefit for adults of undertaking more moderate- to vigorous- intensity physical activity to help counteract the potential risks of high levels of sedentary behaviour, could generally be extrapolated to adults and older adults living with disability, according to their specific ability. However, the certainty of the evidence was downgraded due to indirectness. • The benefits of minimizing sedentary behaviour in children, adolescents, adults and older adults living with disability outweigh the harms. 64 65Recommendations In accordance with the GRADE process, the proposed wording of the updated recommendations, and the rating of their strength (“strong” or “conditional”), were based on consideration of the balance of benefits to harms; the certainty of evidence; sensitivity to the values and preferences of those affected by the guidelines; the potential impact on gender, social and health equity; and acceptability, feasibility and resource implications. These were considered for each population group, but given the similarity of issues and considerations discussed, are consolidated and presented here. The strength of the recommendation was primarily based on the assessed balance of benefits to harms. Recommendations were graded “strong” if the balance of benefits to harms was assessed as substantial for the target population for the recommendation, and “conditional” if the balance of benefits to harms was small or there was important likely variability in benefits in the target population. The evidence on harms was specifically sought through the commissioning of a new systematic review. However, this was limited, as most evidence focuses on injuries and harms to elite and competitive athletes, rather than the general population. Overall, despite the limited evidence, and informed by expert opinion, it was concluded that the risk was no greater than small. The evidence generally indicated that the benefits of physical activity far outweighed the harms, and that physical activity can be an important intervention to support closing an existing health gap, particularly for disadvantaged populations. Issues of health equity, feasibility and acceptability were also considered by the GDG and formed part of the online public consultation on the draft recommendations held between 31 March 2020 and 17 April 2020. The survey for the public consultation asked specific questions on the balance between the costs to individuals and governments of implementing the recommendations, and the potential health benefits, and whether the guidelines would improve health equity. In addition, the draft recommendations and the feedback form were sent to countries that had recently expressed an interest in developing, or had initiated the process of drafting, national guidelines on physical activity. Feedback was received from more than 420 submissions to the online consultation, and additional collation of feedback from the WHO European Regional Office, incorporating comments from WHO Collaborating Centres and Member States. The feedback from this consultation was collated, reviewed by the GDG, and used to further inform the consideration on feasibility, resource implications, and health equity through consultation with the Steering Group and the GDG. Decisions were reached by consensus through discussion. The GDG came to consensus on each recommendation and on the strength of the recommendation; ratings and voting were not required. ASSESSMENT OF THE CERTAINTY OF EVIDENCE The GRADE framework was used by the GDG to examine the certainty of primary research contributing to each outcome identified in the PI/ECOs, and assessed the overall certainty of evidence taking into consideration the risk of bias, inconsistency, imprecision, indirectness of the evidence and publication bias across each outcome. GRADE tables detailing this information for each PI/ECO are available in the Web Annex: Evidence profiles . The assessment of the certainty of the evidence was based on an overall assessment across all evaluated outcomes and prioritized all-cause mortality and cardiovascular mortality as the most critical outcomes, followed by other clinical outcomes (falls, depression, cognition, health-related quality of life, etc), then intermediate outcomes (e.g. cardiometabolic markers, other metabolic markers), as well as harms. Where the evidence had not been specifically reviewed, such as for sedentary behaviour in subpopulations primarily due to a lack of evidence for these groups, the evidence for the general population was extrapolated and downgraded where this was deemed appropriate, due to indirectness. EVIDENCE TO RECOMMENDATIONS Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 66 67 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r BENEFITS AND HARMS The development of the recommendations included an assessment of adverse impacts or risks. Where there was limited evidence, decisions were based on the expertise of the GDG. Overall, for all populations it was concluded that the benefits of physical activity and limiting sedentary behaviour outweighed the potential harms. These guidelines are for the general population and do not address the benefits and harms experienced by athletes undertaking the types and amounts of activity necessary to improve performance-related fitness for participation in competition. Doing some physical activity is better than doing none. If individuals are not currently meeting these recommendations, doing some physical activity will bring benefits to their health. They should start by doing small amounts of physical activity, gradually increasing frequency, intensity and duration over time. Pre-exercise medical clearance is generally unnecessary. Inactive individuals who gradually progress to undertaking moderate-intensity activity have no known risk of sudden cardiac events and very low risk of bone, muscle, or joint injuries. An individual who is habitually engaging in moderate-intensity activity can gradually increase to vigorous-intensity without needing to consult a health- care provider. Those who develop new symptoms when increasing their levels of activity should consult a health- care provider. The choice of appropriate types and amounts of physical activity can be affected by pregnancy, chronic conditions, and disability, and should be undertaken as able and without contraindication. These individuals may wish to consult with a physical activity specialist or health-care professional for advice on the types and amounts of activity appropriate for their individual needs, abilities, functional limitations/complications, medications, and overall treatment plan. Light- and moderate-intensity physical activity are generally low risk and are recommended for all. VALUES AND PREFERENCES The values and preferences of those affected by the guidelines (in this case parents and caregivers, children and adolescents, adults, older adults, pregnant and postpartum women, people living with chronic conditions and/or disability) were considered. Overall it was concluded that there was little or no uncertainty about preferences regarding the main outcomes, including mortality and cardiovascular mortality. The estimated potential benefits greatly outweighed any potential harms, and as such, the GDG considered the recommendations to be not preference-sensitive. RESOURCE IMPLICATIONS The expert opinion of the GDG, and a small body of evidence reporting on economic analyses of interventions and savings to the health-care systems from increasing levels of physical activity, informed discussion on the resource implications of the recommendations in different settings. In addition, results from the online public consultation showed that over 75% of respondents agreed, or strongly agreed, that the benefits of implementing the guidelines would outweigh the cost to the individual, and 81% agreed, or strongly agreed, that the benefits of implementing the guidelines would outweigh the cost to government. Available evidence and expert opinion recognize that substantial health benefits can be achieved at low risk through activities such as walking, that require no specific equipment or cost to the individual. Further, it was acknowledged that other forms of physical activities, for example structured sports, cycling and exercise classes, may incur costs, which can be a barrier for some individuals, particularly those with lower incomes. Government implementation of policy and programmes to promote and enable physical activity also requires investments in areas such as human resources, policy development, provision of facilities and services and potentially, equipment, some of which is incurred by ministries of health, but also in sectors outside of health, such as sport, education, transport and urban planning. The resources required may be at more than one level of government (national, subnational and local levels) to ensure all communities have equal access to physical activity opportunities. These investments may involve new resources, but also can be addressed by reallocation of existing budgets to reflect the prioritization of facilities and programmes towards increasing population levels of physical activity. Examples of budget reallocation include towards infrastructure for walking and cycling from the existing transport budget, and towards “sports for all” from the sports budgets. In key settings, such as schools and workplaces, low-cost interventions, combined with changes to the physical environment, can support participation in physical activity and would also contribute to reducing inequities in opportunities to be active, 66 67Evidence to recommendations experienced by some subpopulation groups. Overall, it was assessed that while there are resource implications to achieve these draft recommendations, implementation of actions is possible within current governance structures. Further, evidence supports that substantial health savings are possible for the health-care system resulting from increasing levels of physical activity. In 2013 the global annual cost of physical inactivity was estimated at INT$ 54 billion due to direct health costs alone (130); and at a national level, inactivity is estimated to cost between 1–3 % of health-care budgets (131). Within the wider context of noncommunicable disease (NCD) prevention, additional costs to government and nongovernmental organizations of guideline implementation may be minimized if recommended physical activity can be relatively easily incorporated by individuals into their lives; likewise if existing resources in primary and secondary care, schools, workplaces or transportation can be shifted, resulting in increased physical activity. Analysis of the cost and benefits of physical activity promotion indicate positive returns on investment over 15 years, in terms of NCD prevention, in many countries where the investment cases have been conducted (132). Interventions such as public education and awareness campaigns and physical activity counselling and referral are a “best buy” and a “good buy” respectively, of recommended interventions to address NCDs based on an update of Appendix 3 of the Global action plan for the prevention and control of NCDs 2013–2020 (133). Overall, the GDG concluded that the benefits of implementing the recommendations outweigh the costs. Delivering on physical activity guidelines for people with disability may require investment, such as the training of activity specialists, adapted equipment where needed, and facilities that need to be made accessible. These investments can facilitate the needs of a wide range of population groups. Evidence demonstrates a significant participation gradient between people with and without disability in relation to physical activity, due to multiple barriers regarding access, choice of activities offered, and the attitudes of others. Universal design principles should be applied to ensure full and effective participation by people living with disability. With innovation, it is possible to address many of these resource implications. Adopting universal design approaches would mitigate against these costs in the future. EQUITY, ACCEPTABILITY AND FEASIBILITY In updating the 2010 recommendations the decision was taken to explicitly include consideration of vulnerable populations, such as those living with chronic conditions and/or disability. The GDG and Steering Group included members representing such groups. The GDG discussed each recommendation at length, considering whether implementing the recommendations would decrease health equity, and the issues related to implementation, to ensure that the recommendations did not worsen equity issues (for example, ensuring that there are safe facilities and opportunities accessible for all, including people living with disability, and socioeconomically and other disadvantaged people, to engage in physical activity; addressing gender and other cultural biases that could restrict access and opportunity to participate in physical activity, etc.). Of respondents to the online public consultation, 76% agreed, or strongly agreed, that implementing the guidelines can achieve a reduction in health inequity by increasing opportunities for all to be active and improve health outcomes. It was noted that supporting environments are key to enabling participation in physical activity. A comprehensive approach to the design and implementation of policies across a number of sectors will be required to address barriers to physical activity for vulnerable groups, such as socioeconomically disadvantaged women and girls, and people with disability. People with disability experience worse health outcomes than people without disability, yet the benefits of physical activity far outweigh the harms and can be an important intervention to close this health gap. Evidence demonstrates a significant participation gradient between people with and without disability in relation to physical activity, due to multiple barriers regarding access, choice of activities offered, and the attitudes of others. For many people with disability, it should be possible to engage in various forms of physical activity without the need for adapted equipment or facilities. However, in order for people with disability to engage in physical activity on an equal basis with others, adapted equipment may need to be obtained, facilities may need to be made accessible, and activity specialists may need to be trained. 68 69 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Despite the large quantity of data relating physical activity and, increasingly, sedentary behaviours to health outcomes across the life span, the GDG discussions revealed important evidence gaps, which should be prioritized to inform future guidelines. Evidence gaps across population subgroups included a lack of information on: 1) the more precise details on the dose-response relationship between physical activity and/or sedentary behaviour and several of the health outcomes studied; 2) the health benefits of light-intensity physical activity and of breaking up sedentary time with light- intensity activity; 3) differences in the health effects of different types and domains of physical activity (leisure time; occupational; transportation; household; education) and of sedentary behaviour (occupational; screen time; television viewing); and 4) the joint association between physical activity and sedentary time with health outcomes across the life course. It was also noted that there remains limited evidence from low- and middle-income countries, economically disadvantaged or underserved communities, and in people living with disability and/or chronic disease. Many studies are not designed or powered to test for effect modification by various sociodemographic factors (age, sex, race/ethnicity, socioeconomic status) that may modify the health effects of physical activity. Such information is important for making more specific public health recommendations and for reducing health disparities in more vulnerable sectors of the population. Further details on the research gaps arising from these new guidelines can also be found in published literature (134). RESEARCH NEEDS 68 69Research needs The goal of these guidelines is to provide policy- makers, and those who develop health-care, education, workplace and community intervention programmes, with recommendations on how much time children, adolescents, adults and older adults should spend each day being physically active, and recommendations on limiting time spent being sedentary. However, developing global guidelines is not an end in itself: without dissemination and implementation, changes in physical activity levels will not be achieved. ADOPTION WHO undertakes a rigorous and extensive process to develop globally relevant guidelines (21) for use by all countries. These Guidelines on physical activity and sedentary behaviour provide evidence-based recommendations on the health impacts of physical activity and sedentary behaviour that national governments can adopt and use as part of their national policy frameworks. The development of global guidelines, with extensive consultation, should largely remove the need for individual countries to use resources to undertake the lengthy scientific process. Reviewing and adopting these global physical activity and sedentary behaviour guidelines provides a rapid and cost-effective method to develop guidelines tailored to local context. Adopting the WHO guidelines at regional or national level will ensure countries provide consistent recommendations on physical activity and sedentary behaviour, which are informed by the latest and best available scientific evidence. In addition, consistency of the recommendations across countries will facilitate national surveillance, global estimates of physical activity and sedentary behaviour, and cross- country comparisons. Throughout the adoption process, consideration should be given to the need to contextualize and tailor the guidelines. Translation into the local language is one element of adoption and contextualization. Examples of physical activities may need to be changed to be locally relevant and the use of images tailored to reflect local cultures, norms and values. A step-by-step framework to support country adoption of the Global guidelines is under development, following a series of regional workshops with relevant stakeholders. This framework can be populated with relevant national data (for example physical activity prevalence estimates), and will provide a fast-track approach to the development of a national guidelines document. These supporting resources will be available in 2021 through the WHO website. When considering adopting the guidelines it is recommended that the following ten-step process is applied: 1. Advocate for a review of current national guidelines on physical activity and the adoption of the WHO guidelines to secure government authorization. 2. Engage key stakeholders both within the health sector and other relevant sectors, such as sport, education, transport; engage relevant professional associations and scientists, with topic expertise. 3. Assess the applicability, acceptability and feasibility of the recommendations. 4. Adapt guidelines to the local context, including language, examples, and other cultural considerations. 5. Conduct an external review with target users, including policy-makers, practitioners, and the general public. 6. Establish a budget and clear plan for dissemination and communication. 7. Publish and promote the national guidelines, ideally alongside a launch event to generate publicity and interest. 8. Engage relevant professional bodies or organizations and support policy alignment and/or endorsement. 9. Implement national policies and practices to support implementation of national guidelines and behaviour change. 10. Agree a timeline for evaluation, review, and update of the guidelines. ADOPTION, DISSEMINATION, IMPLEMENTATION AND EVALUATION 70 71 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r DISSEMINATION National physical activity guidelines are a core component of the governance structures for a comprehensive approach to increasing population levels of physical activity. National guidelines inform the development and priorities of national and subnational strategy planning and require dissemination of the correct information, to the relevant groups of people, in an appropriate way. Unfortunately, too often, national guidelines are not disseminated, and so awareness of recommendations among both professional audiences and the wider community can remain very low. Securing dedicated resources to support wide-scale dissemination is an important first step to changing awareness and knowledge about the importance of increasing physical activity and reducing sedentary behaviours. Key audiences for dissemination of national guidelines on physical activity and sedentary behaviour include: • Policy-makers within and outside the health sector (including transport, planning, education, workplaces, sport, parks and recreation), to increase: a. knowledge of the contribution that increasing physical activity and reducing sedentary behaviour can have in improving not only health, but also a range of diverse yet related agendas, including gender equity, human rights obligations, and sustainable development; b. integration of policy and programmes on physical activity and sedentary behaviour into all relevant policies; and c. investment in scaled-up and coordinated national and local actions. • Non-state actors (including nongovernmental organizations, academic and research organizations, the private sector as well as the media and research funding agencies), to: a. raise awareness of the importance of increasing physical activity and reducing sedentary behaviours across all ages; b. encourage and ensure policy alignment; and c. increase collaboration and investment in policy implementation and local action. • Practitioners in health and non-health sectors (including sport, education, transport, and planning) to increase: a. awareness and knowledge of national guidelines on physical activity and sedentary behaviours; b. knowledge, skills and confidence in promoting increased physical activity and reduction in sedentary behaviours; and c. integration of physical activity promotion into routine practice where applicable. • The general public and specific population subgroups, to increase: a. awareness and knowledge of the guidelines on physical activity and sedentary behaviour; b. knowledge of how to achieve the physical activity and sedentary behaviour guidelines; and c. intentions and motivation to be more physically active and to reduce sedentary behaviour. COMMUNICATION CAMPAIGNS Different stakeholders will benefit from different materials; therefore to communicate guidelines to multiple audiences effectively, consideration must be given to the content, format, and delivery channels for guideline communication. When developing a guideline communication strategy, formative research can help determine the key audiences and understand the values, needs and preferences that influence levels of physical activity and sedentary behaviour. This should include exploration of the barriers to physical activity or to the integration of physical activity into policy and practice, as well as testing of draft messages and materials with different groups. This will help inform the key messages that are used, as well as the appropriate format(s) and channel(s) for communication. A comprehensive communication strategy will include a range of communications aimed at different audiences. Countries may need to prioritize specific groups depending on available resources (human and financial). Communication campaigns on physical activity targeting the general public or specific subpopulations are a cost- effective intervention (133) and recommended in the WHO Global action plan on physical activity 2018–2030 (14). National and subnational campaigns on physical activity typically establish an overarching campaign slogan (for example “Be Active” or “Move More”), and develop design elements or characters, which may include tailored messages for different audiences 70 71Adoption, dissemination, implementation and evaluation (such as for young children, adolescents, adults or older adults, the less active, people living with disability or chronic conditions). Campaign messages and resources that are tailored to specific population groups are likely to be more effective than generic materials. Communication campaigns should consider the reach and effectiveness of both traditional media channels (such as television, radio, billboards, printed resources) as well as digital media channels (websites, mobile phones, Apps). Providing information on the national guidelines in a variety of formats is also useful. For example, a relatively new but increasingly common approach to communicating physical activity guidelines is through the use of infographics or short animated videos. WHO has supporting materials for developing and implementing such communication campaigns (135). The academic and research community are likely to be interested in the scientific report which details the epidemiological evidence on which the guidelines are based. However the specific details of the underlying research is unlikely to be of interest to other more general audiences. Policy-makers may prefer a summary of the science, or even a short briefing document. Other audiences, such as health and non-health professionals, are more likely to favour different types of resources, for example a brochure or factsheet about the guidelines, or about how to integrate physical activity promotion into routine practice (for example in patient consultations in a health-care setting, or when developing building or transport plans for urban environments). Different professionals will require resources that are tailored to their role. Health professions, in particular, may benefit from a suite of resources to reflect the diverse population groups that they work with. IMPLEMENTATION OF POLICY AND PROGRAMMES National guidelines on physical activity and sedentary behaviour, in isolation, are unlikely to lead to increases in population levels of physical activity and should therefore be seen as one element of a policy and planning framework. It is critical that national guidelines are disseminated to key audiences and supported by a sustained national communication strategy that will lead to increased awareness and knowledge about the multiple benefits of regular physical activity and reducing sedentary behaviours. However, in order to achieve sustained behaviour change, these actions must be supported by policies that create supportive environments that enable and encourage people to be active, along with increased local, appropriate opportunities for people to participate in physical activity. Policies and programmes must consider and be adapted to the local context, in terms of both the health system and the complex multisector institutions that have an interest in, or opportunity to support, physical activity promotion. Action should be taken using a “whole of government” approach and consider the “system” of policies and multiple actions that can, through engagement of a wide range of stakeholders, support more people to be physical active across multiple sectors and settings. Using a “systems” approach that is aligned with a sustained communication strategy ensures that increased demand for physical activity, generated through effective communication, is matched by the provision of environments and opportunities for people to be physically active. 72 73 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r The WHO Global action plan on physical activity 2018–2030 set a target to reduce physical inactivity by 15% by 2030, and outlined 20 recommended policy actions and interventions (14). These included recommending that all countries implement sustained national public education and awareness campaigns and the integration of physical activity counselling programmes into primary and secondary health care. Other recommendations included the creation of appropriate environments for physical activity, including walking, cycling and wheeling, for all population groups and the provision of more opportunities and programmes for physical activity in schools, workplaces and sports clubs and venues. Implementation across all 20 recommendations may not be feasible in the short term in all countries, but should be viewed as a long-term goal. To identify an appropriate and feasible set of immediate actions, WHO Member States should conduct a situational analysis of current policy and practice. This will enable multisector collaboration and help identify areas of strength as well as gaps and opportunities, and can be used as the basis for developing or updating national and subnational plans. These new WHO guidelines support expanding the scope of actions to include additional groups, such as people living with disability or chronic conditions, and women who are pregnant or postpartum. Policy will need to support appropriate programme delivery and practice that recognizes community needs and the diversity of groups and contexts. A number of sector-specific toolkits are under development to support implementation of the ACTIVE technical package (135); these will provide each sector with guidance on how to promote physical activity, for example through schools, through primary health care, or by improving provision for walking and cycling. The ACTIVE toolkit, as well as other WHO regional and national resources will support implementation of these physical activity and sedentary behaviour guidelines. SURVEILLANCE AND EVALUATION The WHO Global recommendations for physical activity for health have been used as benchmarks for population health monitoring and surveillance since 2010. The changes introduced to the recommendations in these updated guidelines will have some implications for surveillance systems and assessment instruments currently used to monitor national levels of physical activity. The publication of these new guidelines will call for a review of current instruments and reporting protocols to inform any adjustments and recommendations on future reporting against the new guidelines. Instruments, such as the Global Physical Activity Questionnaire and Global Student Health Survey, will be reviewed and protocols updated to align with these new guidelines; supporting guidance to all countries will be provided in 2021. The WHO NCD Country Capacity Survey (CCS) is the main instrument used to monitor global progress on NCD policy implementation, and is conducted every two years. The CCS includes specific questions on population surveillance systems on physical activity for each age group covered by these WHO guidelines on physical activity and sedentary behaviour, and since 2019, on the existence of national physical activity guidelines. WHO Member States are requested to upload documentation to support their response. In 2019, of the 194 WHO Member States, 78 (40%) reported having physical activity guidelines (136). A detailed document analysis of responses to the CCS in 2019 was carried out, and identified that only two thirds of the 78 Member States (52/78) with national guidelines include statements on how much physical activity their populations should do; and of these, only 42 countries aligned fully with the 2010 WHO Global recommendations on physical activity for health (1). Data from the 2021 and subsequent surveys will provide information on uptake of these updated guidelines. UPDATING These guidelines will be updated after ten years, unless advances in the science of how physical activity is assessed using device-based measurement, and the rapidly evolving science on sedentary behaviour, prompt an earlier update. 72 73Adoption, dissemination, implementation and evaluation 74 75 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 1. World Health Organization. Global recommendations on physical activity for health. 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Geneva: World Health Organization; 2020. 82 83 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r G lo be b as ed o n io at /S hu tt er st oc k, s ilh ou et te s ha pe s or ig in al ly b as ed o n Sh ut te rs to ck s ou rc es 82 83References 84 85 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r WHO Steering Group The Steering Group included experts in the areas of physical activity, adolescent health, ageing disability, mental health, injury prevention, cancer, pregnancy and surveillance from both headquarters and regional offices. Valentina Baltag Department of Maternal, Newborn, Child and Adolescent Health and Ageing – adolescent health Maurice Bucagu Department of Maternal, Newborn, Child and Adolescent Health and Ageing – pregnancy Fiona Bull Chairperson Department for Health Promotion – physical activity Alex Butchart Department of Social Determinants of Health – injury prevention Neerja Chowdhary Department of Noncommunicable Diseases – mental  health/dementia Regina Guthold Department of Maternal, Newborn, Child and Adolescent Health and Ageing – adolescent surveillance Riitta-Maija Hämäläinen Western Pacific Regional Office Andre Ilbawi Department of Noncommunicable Diseases – cancer Wasiq Khan Eastern Mediterranean Regional Office Lindsay Lee Department of Noncommunicable Diseases – disability Alana Officer Ageing Leanne Riley Department for Noncommunicable Diseases – surveillance Gojka Roglic Department for Noncommunicable Diseases – diabetes Juana Willumsen Department for Health Promotion – physical activity The Steering Group drafted the scope of the guidelines, and the PI/ECOs. They reviewed the declaration of interests; and drafted, reviewed and finalized the guidelines. Contributors to guideline development ANNEX 1: MANAGEMENT OF GUIDELINE DEVELOPMENT PROCESS 84 85Annex 1 Guideline Development Group (GDG) The Guideline Development Group consisted of a broad group of relevant experts in the field and end users of, and persons affected by, the recommendations. The members of the Guideline Development Group included: Dr Salih Saad Al-Ansari (advocate in health promotion and education to combat NCDs through physical activity and walking); Dr Stuart Biddle (physical activity and sedentary behaviour, and behaviour change); Dr Katja Borodulin (physical activity in pregnancy and older adults); Dr Matthew Buman (sleep, sedentary behaviour, and physical activity in people living with chronic conditions); Dr Greet Cardon (physical activity in children and adolescents); Ms Catherine Carty (physical activity in people living with disability); Dr Jean-Philippe  Chaput (sleep, sedentary behaviour and physical activity in children and adolescents); Dr Sebastien Chastin (physical activity, sedentary behaviour and health, objective measurement of physical activity and sedentary behaviour); Dr Paddy Dempsey (physical activity and sedentary behaviour in adults and people living with chronic conditions); Dr Loretta DiPietro (physical activity in pregnancy and older adults); Dr Ulf Ekelund (sedentary behaviour and physical activity, physical activity in children and adolescents); Dr Joseph Firth (physical activity and mental health); Dr Christine Friedenreich (physical activity in people living with chronic conditions, physical activity and cancer risk); Dr Leandro Garcia (physical activity and health in adults); Dr Muthoni Gichu (policy implementation, national government); Dr Russ Jago (physical activity in children and adolescents); Dr Peter Katzmarzyk (physical activity and sedentary behaviour); Dr Estelle V. Lambert (physical activity and obesity); Dr Michael Leitzmann (sedentary behaviour and physical activity in people living with chronic conditions); Dr Karen Milton (translating recommendations into practice); Dr Francisco B. Ortega (physical activity in children and adolescents, mental health and objective measurement); Dr Chathuranga Ranasinghe (promotion of physical activity and health in the community, workplace and school settings); Dr Emmanuel Stamatakis (physical activity and sedentary behaviour and multiple health outcomes in adults); Dr Anne Tiedemann (physical activity in older adults); Dr Richard Troiano (policy development); Dr Hidde van der Ploeg (physical activity and sedentary behaviour in adults); Ms Vicky Wari (policy implementation – national government); Dr Roger Chou (Pacific Northwest Evidence- based Practice Center and Professor of Medicine, Departments of Medicine, Medical Informatics and Clinical Epidemiology of the Oregon Health and Science University) served as GRADE methodologist. Further details of the GDG are available in Annex 2. A first GDG meeting was held 2–4 July 2019, at which the GDG decided on the PI/ECO questions, reviewed the existing systematic reviews, and identified updates required. The Group agreed on the process for decision-making on recommendations and the strength of the evidence to be applied at the second GDG meeting. The second meeting was held 11–14 February 2020; updated evidence was reviewed and final recommendations agreed upon by consensus. 86 87 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r External Review Group (ERG) Seven peer reviewers were drawn from a list of individuals suggested by the GDG and Steering Group. They provided relevant expertise, including programme implementation and represented all six WHO regions. The ERG reviewed the draft guidelines and provided feedback to the Steering Group on issues of clarity and implementation, which was incorporated, as appropriate. External peer reviewers did not make changes to the recommendations. External peer reviewers are listed in Annex 2. Declarations of Interest All GDG members and external peer reviewers completed and submitted a WHO Declaration of Interests form and signed confidentiality undertakings prior to attending any GDG meetings. The Steering Group reviewed and assessed the submitted curriculum vitae and declarations of interest and performed an internet and publications search to identify any obvious public controversies or interests that may lead to compromising situations. The names and brief biographies of all proposed GDG members were published on the WHO Physical Activity webpage for public consultation for a period of 14 days. No comments were received. If additional guidance on management of any declaration or conflicts of interest had been required, the Steering Group would have consulted with colleagues in Office of Compliance, Risk Management and Ethics. If deemed necessary, individuals found to have conflicts of interest, financial or non-financial, would have been excluded from participation on any topics where interests were conflicting. The management of conflicts of interest was reviewed throughout the process. GDG members were required to update their Declaration of Interest, if necessary, before each meeting and a verbal declaration of interest was solicited at the beginning of each GDG meeting. Declared interests of the GDG and of the external peer reviewers are summarized in Annex 3. No conflict of interest was identified. Peer review The draft guidelines were reviewed by seven external peer reviewers identified by the GDG and Steering Group. External peer reviewers were requested to provide comments on issues of clarity, presentation of the evidence, and implementation; comments were incorporated as appropriate. External peer reviewers could not change the recommendations decided upon by the GDG. External peer reviewers are listed in Annex 2; a summary of declarations of interest are provided in Annex 3. In addition, inputs were actively sought from WHO regional offices. 86 87Annex 1 Guideline Development Group Dr Salih Al-Ansari Assistant Professor Family & Community Medicine Founder and CEO Health Promotion Center Riyadh SAUDI ARABIA Dr Stuart Biddle Professor of Physical Activity & Health Physically Active Lifestyles Research Group Centre for Health Research Institute for Resilient Regions University of Southern Queensland Springfield Central AUSTRALIA Dr Katja Borodulin The Age Institute Helsinki FINLAND Dr Matthew Buman College of Health Solutions Arizona State University Phoenix USA Dr Greet Cardon Department of Movement and Sports Sciences Faculty of Medicine and Health Sciences Ghent University Gent BELGIUM Ms Catherine Carty UNESCO Chair Project Manager Institute of Technology Tralee Co Kerry IRELAND Dr Jean-Philippe Chaput Senior Scientist, Healthy Active Living and Obesity (HALO) Research Group Children’s Hospital of Eastern Ontario (CHEO) Research Institute Department of Pediatrics University of Ottawa Ottawa, Ontario CANADA Dr Sebastien Chastin Professor of Health Behaviour Dynamics School of Health and Life Sciences Department of Psychology, Social Work and Allied Health Sciences Glasgow Caledonian University Glasgow UNITED KINGDOM Dr Roger Chou (GRADE Methodologist) Departments of Medicine, and Medical Informatics & Clinical Epidemiology Oregon Health & Science University Portland, Oregon USA Dr Paddy Dempsey MRC Epidemiology Unit University of Cambridge School of Clinical Medicine Institute of Metabolic Science Cambridge UNITED KINGDOM ANNEX 2: GUIDELINE DEVELOPMENT GROUP, EXTERNAL PEER REVIEWERS, AND WHO STAFF INVOLVED IN THE DEVELOPMENT OF THESE GUIDELINES 88 89 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Dr Loretta DiPietro Department of Exercise and Nutrition Sciences Milken Institute School of Public Health The George Washington University Washington, DC USA Dr Ulf Ekelund Department of Sport Medicine Norwegian School of Sport Science Oslo NORWAY Dr Joseph Firth Presidential Fellow School of Health Sciences University of Manchester Manchester UNITED KINGDOM Dr Christine Friedenreich Scientific Director Department of Cancer Epidemiology and Prevention Research Cancer Control Alberta Alberta Health Services Calgary CANADA Dr Leandro Garcia Research Associate Centre for Public Health Queen’s University Belfast Belfast UNITED KINGDOM Dr Muthoni Gichu Head Division of Geriatric Medicine Department of Non-Communicable Diseases Ministry of Health Nairobi KENYA Dr Russell Jago Professor of Paediatric Physical Activity & Public Health Centre for Exercise, Nutrition & Health Sciences School for Policy Studies University of Bristol Bristol UNITED KINGDOM Dr Peter T. Katzmarzyk Associate Executive Director for Population and Public Health  Sciences Professor and Marie Edana Corcoran Endowed Chair in Pediatric Obesity and Diabetes Pennington Biomedical Research Center Baton Rouge USA Dr Estelle V. Lambert Director Research Centre for Health Through Physical Activity, Lifestyle  and Sport University of Cape Town Cape Town SOUTH AFRICA Dr Michael Leitzmann Professor of Epidemiology Department of Epidemiology and Preventive Medicine University of Regensburg Regensburg GERMANY Dr Karen Milton Associate Professor in Public Health Norwich Medical School University of East Anglia Norwich UNITED KINGDOM Dr Francisco B. Ortega Head Unit of Physical Activity and Health Promotion Research Institute of Sport and Health (iMUDS) Department of Physical Education and Sports University of Granada Granada SPAIN 88 89Annex 2 Dr Chathuranga Ranasinghe Chairperson NIROGI Lanka project Sri Lanka Medical Association Senior lecturer Sports and Exercise Medicine Unit Faculty of Medicine University of Colombo C Colombo SRI LANKA Dr Emmanuel Stamatakis Charles Perkins Centre Faculty of Medicine and Health School of Public Health University of Sydney Sydney AUSTRALIA Dr Anne Tiedemann Associate Professor Institute for Musculoskeletal Health School of Public Health Faculty of Medicine and Health University of Sydney Sydney AUSTRALIA Dr Richard Troiano Epidemiology and Genomics Research Program National Cancer Institute National Institutes of Health Rockville USA Dr Hidde van der Ploeg Associate Professor Department of Public and Occupational Health Amsterdam Public Health Research Institute Amsterdam University Medical Centres Amsterdam NETHERLANDS Ms Vicky Wari* Programme Manager, NCD National Department of Health Port Moresby PAPUA NEW GUINEA External review group Dr Kingsley Akinroye NCD Alliance Nigeria NIGERIA Dr Huda Alsiyabi Director Department of Community Based Initiatives Ministry of Health OMAN Dr Alberto Flórez-Pregonero Pontificia Universidad Javeriana COLOMBIA Dr Shigeru Inoue Department of Preventive Medicine and Public Health Tokyo Medical University JAPAN Dr Agus Mahendra Department of Physical education Universitas Pendidikan INDONESIA Dr Deborah Salvo Prevention Research Center in St. Louis Brown School Washington University USA Dr Jasper Schipperijn President-Elect 2020–2022 International Society of Physical Activity and Health Department of Sports Science and Clinical Biomechanics University of Southern Denmark DENMARK * unable to attend90 91 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r * unable to attend WHO Steering Group Dr Valentina Baltag Head Adolescent and Young Adult Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND Dr Maurice Bucagu Medical Officer Maternal Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND Dr Alexander Buchart Head Violence Prevention Social Determinants of Health Department WHO Headquarters Geneva SWITZERLAND Dr Fiona Bull Head Physical Activity Department of Health Promotion WHO Headquarters Geneva SWITZERLAND Dr Regina Guthold Scientist Adolescent and Young Adult Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND Dr Riitta-Maija Hämäläinen Technical Officer Noncommunicable Diseases and Health Promotion WHO Regional Office for the Western Pacific Manila PHILIPPINES Dr Andre Ilbawi Technical Officer Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Dr Wasiq Khan* Regional Adviser Health Education and Promotion WHO Regional Office for the Eastern Mediterranean Cairo EGYPT Ms Lindsay Lee Technical Officer Sensory Functions, Disability and Rehabilitation Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Ms Alana Officer Senior Health Adviser Healthy Ageing Office of the Director-General WHO Headquarters Geneva SWITZERLAND Ms Leanne Riley Head Surveillance Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Dr Gojka Roglic Medical Officer Noncommunicable Diseases Management Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Dr Juana Willumsen Technical Officer Physical Activity Department of Health Promotion WHO Headquarters Geneva SWITZERLAND 90 91Annex 2 ANNEX 3: SUMMARY OF DECLARATION OF INTEREST AND HOW THESE WERE MANAGED Guideline Development Group members Name Gender Expertise Disclosure of interest Conflict of interest and management Dr Salih Saad Al-Ansari Male Advocate in health promotion and education to combat NCDs through physical activity and walking Owner and Chief Executive Officer of the Health Promotion Center No conflict of interest identified Dr Stuart Biddle Male Physical activity in youth Research funds and paid consultancy No conflict of interest identified Dr Katja Borodulin Female Physical activity in pregnancy Employment at National Institute for Health and Welfare and Age Institute; research funds No conflict of interest identified Dr Matthew Buman Male Sleep and physical activity in people living with chronic conditions None declared No conflict of interest identified Dr Greet Cardon Female Physical activity in youth None declared No conflict of interest identified Ms Catherine Carty Female Physical activity in people living with disability Research funds No conflict of interest identified Dr Jean-Philippe Chaput Male Sleep None declared No conflict of interest identified Dr Sebastien Chastin Male Physical activity and health, objective measurement of physical activity Research funds No conflict of interest identified Dr Paddy Dempsey Male Physical activity and sedentary behaviour in adults and people living with chronic conditions Employment and research funds No conflict of interest identified Dr Loretta DiPietro Female Physical activity in older adults None declared No conflict of interest identified Dr Ulf Ekelund Male Sedentary behaviour and physical activity in youth None declared No conflict of interest identified Dr Joseph Firth Male Physical activity and mental health None declared No conflict of interest identified Dr Christine Friedenreich Female Physical activity in people living with chronic conditions, physical activity and cancer risk None declared No conflict of interest identified Dr Leandro Garcia Male Physical activity and mental health Employment and paid consultancy No conflict of interest identified Dr Muthoni Gichu Female Policy implementation (national government) None declared No conflict of interest identified Dr Russ Jago Male Physical activity in youth None declared No conflict of interest identified 92 93 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r Name Gender Expertise Disclosure of interest Conflict of interest and management Dr Peter Katzmarzyk Male Physical activity and sedentary behaviour in youth Travel support to assist guideline committees No conflict of interest identified Dr Estelle V. Lambert Female Physical activity and obesity None declared No conflict of interest identified Dr Michael Leitzmann Male Sedentary behaviour and chronic conditions None declared No conflict of interest identified Dr Karen Milton Female Translating recommendations into practice Travel support to assist guideline committee No conflict of interest identified Dr Francisco Ortega Male Physical activity in youth, mental health and objective measurement None declared No conflict of interest identified Dr Chathuranga Ranasinghe Male Promotion of physical activity and health in the community, workplace and school settings Research funds No conflict of interest identified Dr Emmanuel Stamatakis Male Physical activity and multiple health outcomes in adults Grant for technology company for objective measurement of physical activity No conflict of interest identified Dr Anne Tiedemann Female Physical activity and health outcomes in older adults None declared No conflict of interest identified Dr Richard Troiano Male Policy development None declared No conflict of interest identified Dr Hidde van der Ploeg Male Physical activity, sedentary behaviour and health outcomes in adults Travel support to assist 2017 Dutch Physical Activity Guidelines committee and research funds No conflict of interest identified Ms Vicky Wari Female Policy implementation (national government) Shares (not relevant to guideline) No conflict of interest identified External peer reviewers Name Gender Expertise Disclosure of interest Conflict of interest and management Kingsley Akinroye Male Advocacy, noncommunicable diseases None declared No conflict of interest identified Dr Huda Alsiyabi Female Policy and programme implementation None declared No conflict of interest identified Dr Alberto Flórez- Pregonero Male Physical activity and sedentary behaviour measurement and surveillance None declared No conflict of interest identified Dr Shigeru Inoue Male Epidemiology and physical activity promotion None declared No conflict of interest identified Dr Agus Mahendra Male Physical activity and movement skills in children None declared No conflict of interest identified Dr Deborah Salvo Female Health and social disparities, with a particular emphasis on chronic disease prevention None declared No conflict of interest identified Dr Jasper Schipperijn Male Physical activity and the built environment President-Elect of the International Society for Physical Activity and Health (ISPAH) No conflict of interest identified 92 93Annex 3 ISBN 978-92-4-001513-52 8

OME-REN GIDALERROAK JARDUERA FISIKOARI ETA SEDENTARISMOARI BURUZ OME-REN GIDALERROAK JARDUERA FISIKOARI ETA SEDENTARISMOARI BURUZ ii OME-ren gidalerroak jarduera fisikoari eta sedentarismoari buruz. Vitoria-Gasteiz: Eusko Jaurlaritza, 2021. Zenbait eskubide erreserbatuta. Lan hau Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International lizentziapean dago eskuragarri (CC BY-NC-SA 4.0; https://creativecommons.org/licenses/by-nc-sa/4.0/) © Eusko Jaurlaritza. 2021 Osasunaren Mundu Erakundeak (OME) ez du itzulpen hau burutu. OMEk ez du inolako erantzukizunik izango itzulpen honen eduki edo zehaztasunari dagokienez. Ingelesezko jatorrizko testua (WHO guidelines on physical activity and sedentary behaviour) da benetako bertsio loteslea. Jatorrizkoaren lizentzia: CC BY-NC-SA 3.0 IGO. Iradokitzen den aipamena: OME-ren gidalerroak jarduera fisikoari eta sedentarismoari buruz. Vitoria-Gasteiz: Eusko Jaurlaritza, 2021. Lizentzia: CC BY-NC-SA 4.0 IGO. Itzulpena: BITEZ, S.L. Itzulpenaren zuzenketa: Mugiment idazkaritza teknikoa eta Eusko Jaurlaritzaren Jarduera Fisikoaren eta Kirolaren Zuzendaritza. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z iii Edukiak EDUKIAK Eskertza iv Laburdurak eta akronimoak v Terminoen glosarioa vi Laburpena 1 Testuingurua 15 Metodoak 18 Gomendioak 24 Haurrak eta nerabeak (5–17 urte) 25 Jarduera fisikorako gomendioa 25 Portaera sedentariorako gomendioa 29 Helduak (adina 18–64 urte) 32 Jarduera fisikorako gomendioa 32 Portaera sedentariorako gomendioa 38 Adinekoak (adina 65 urte eta gehiago) 43 Jarduera fisikorako gomendioa 43 Portaera sedentariorako gomendioa 46 Emakumeak haurdunaldian eta erditu ondoren 47 Jarduera fisikorako gomendioa 47 Portaera sedentariorako gomendioa 51 Helduak eta adinekoak gaixotasun kronikoekin (adina 18 urte eta gehiago) 52 Jarduera fisikorako gomendioa 52 Portaera sedentariorako gomendioa 58 Haurrak eta nerabeak (adina 5–17 urte) eta helduak (adina 18 urte eta gehiago) desgaitasunarekin 60 Jarduera fisikorako gomendioa 60 Portaera sedentariorako gomendioa 64 Ebidentziatik gomendioetara 66 Ebidentziaren ziurtasunaren ebaluazioa 66 Onurak eta kalteak 67 Balioak eta lehentasunak 67 Baliabideen inplikazioak 67 Ekitatea, onargarritasuna eta bideragarritasuna 68 Ikerketa-premiak 69 Gomendioak hartzea, hedatzea, ezartzea eta ebaluatzea 70 Gomendioak hartzea 70 Hedatzea 71 Komunikazio-kanpainak 71 Politikak eta programak ezartzea 72 Gomendioak zaintzea eta ebaluatzea 73 Eguneratzea 73 Erreferentziak 75 1. eranskina: Gidalerroen garapen-prozesuaren kudeaketa 85 2. eranskina: Gidalerroak garatzeko taldea, kidekoen kanpoko berrikusleak, eta gidalerro hauen garapenean parte hartu duten OMEko kideak 88 3. eranskina: Interes-adierazpenen laburpena eta kudeatzeko modua 92 Web-eranskina: Ebidentzia-profilak https://apps.who.int/iris/bitstream/handle/ 10665/336657/9789240015111-eng.pdf O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z ESKERTZA Osasunaren Mundu Erakundeak (OME) eskerrak eman nahi dizkie honako pertsona eta erakunde hauei dokumentu hau lantzen laguntzeagatik eta berengandik jasotako babesagatik: Fiona Bull eta Juana Willumsen izan ziren gidalerro hauek lantzeko prozesuaren zuzendari, eta OMEko Zuzendaritza Taldeko kide hauek kudeatu zuten prozesua: Valentina Baltag,Maurice Bucagu, Alex Butchart, Neerja Chowdhary, Regina Guthold, Riitta-Maija Hämäläinen, Andre Ilbawi, Wasiq Khan, Lindsay Lee, Alana Officer, Leanne Riley eta Gojka Roglic. Gidalerroak Lantzeko Taldea (GLT) osatu zuten kideak hauek izan ziren: Salih Saad Al-Ansari, Stuart Biddle, Katja Borodulin, Matthew Buman, Greet Cardon (zuzendarikidea), Catherine Carty, Jean-Philippe Chaput, Sebastien Chastin, Paddy Dempsey, Loretta DiPietro, Ulf Ekelund, Joseph Firth, Christine Friedenreich, Leandro Garcia, Muthoni Gichu, Russ Jago, Peter Katzmarzyk, Estelle V. Lambert, Michael Leitzmann, Karen Milton, Francisco B. Ortega, Chathuranga Ranasinghe, Emmanuel Stamatakis (zuzendarikidea), Anne Tiedemann, Richard Troiano, Hidde van der Ploeg, Vicky Wari. Roger Chou izan zen GRADE metodologiaren arduraduna. Kanpoko berrikuspen-taldea hauek osatu zuten: Kingsley Akinroye, Huda Alsiyabi, Alberto Flórez-Pregonero, Shigeru Inoue, Agus Mahendra, Deborah Salvo eta Jasper Schipperijn. 2018ko AEBetako Jarduera Fisikorako Gidalerroen Aholkularitza BatzordearenTxosten Zientifikoa Osasun eta Giza Zerbitzuetako Idazkaritzari txostenerako prestatu zen ebidentziaren berrikuspen sistematikoak eguneratu egin ziren Kyle Sprowek (Minbiziaren Institutu Nazionalak, Osasunaren Institutu Nazionalak, Maryland, AEB) egindako bilaketa bibliografiko gehigarriei esker. Identifikatutako artikuluen berrikuspen- lanean honako hauek ere lagundu zuten: Elif Eroglu (Sydneyko Unibertsitatea), Andrea Hillreiner (Regensburgeko Unibertsitatea), Bo-Huei Huang (Sydneyko Unibertsitatea), Carmen Jochem (Regensburgeko Unibertsitatea), Jairo H. Migueles (Granadako Unibertsitatea), Chelsea Stone (Calgaryko Unibertsitatea) eta Léonie Uijtdewilligen (Amsterdam UMC). Ebidentziaren laburbilketak eta GRADE taulak Carrie Patnodek eta Michelle Henningerrek prestatu zituzten (Kaiser Fundazioaren Ospitaleak, Osasun Ikerketarako Zentroa, Portland, Oregon, AEB). Bestalde, ondokoek gidatu zituzten ebidentziaren berrikuspen gehigarriak: N Fairhall, J Oliveira, M Pinheiro, eta C Sherrington (Osasun Muskulueskeletikoko Institutua, Osasun Publikoko Eskola, Sydneyko Unibertsitatea, Sydney, Australia) eta A Bauman (Prebentzioaren Ikerketarako Kolaborazioa, Osasun Publikoko Eskola, Sydneyko Unibertsitatea, Sydney, Australia; eta OMEren Zentro Kolaboratzailea Jarduera Fisikoaren, Nutrizioren eta Obesitatearen arloetan); S Mabweazara, M-J Laguette, K Larmuth, F Odunitan- Wayas (Osasunari buruzko Ikerketa Zentroa, Jarduera Fisikoaren, Bizi-estiloaren eta Kirol Medikuntzaren bidez, Osasun Zientzietako Fakultatea, Cape Town-eko Unibertsitatea, Cape Town, Hego Afrika), L Leach, S Onagbiye (Kiroleko, Aisialdiko eta Ariketa Zientziako Saila, Osasun Zientzietako Fakultatea, Western Cape-ko Unibertsitatea, Cape Town, Hego Africa), M Mthethwa (Gaixotasun Kronikoetarako Ekimena Afrikan, Cape Town-eko Unibertsitatea, Cape Town, Hego Africa), P Smith (Desmond Tutu GIB Zentroa, Gaixotasun Infekziosoetako eta Medikuntza Molekularreko Institutua, Osasun Zientzietako Fakultatea, Cape Town-eko Unibertsitatea, Cape Town, Hego Africa) eta F Mashili (Fisiologiako Saila, Muhimbili-ko Osasuneko eta Loturiko Zientzietako Unibertsitatea, Dar Es Salaam, Tanzaniako Errepublika BAtua); B Cillekens, M Lang, W van Mechelen, E Verhagen, M Huysmans, A van der Beek, P Coenen (Osasun Publiko eta Laneko Osasuneko Saila, Amsterdameko Unibertsitatearen Medikuntza Zentroa, Amsterdam, Herbehereak). Kanadako Osasun Publikoko Erakundeak eta Norvegiako Gobernuak emandako babes finantzarioari esker gauzatu ahal izan da lan hau. iv Laburdurak eta akronimoak v LABURDURAK ETA AKRONIMOAK ADHN arreta-defizitaren eta hiperaktibitatearen nahasmendua AOR momio-ratio egokitua BMI gorputz-masaren indizea CI konfiantza-tartea CVD gaixotasun kardiobaskularrak DBP tentsio arterial diastolikoa EtD Ebidentziatik Erabakietara GDG Gidalerroak Garatzeko Taldea GRADE Gomendioak Baliozkotzeko, Garatzeko eta Ebaluatzeko Kalifikazioa HR arrisku-zatidura MET Jardueraren Baliokide Metabolikoa MD batez besteko diferentzia MICT intentsitate ertaineko entrenamendu jarraitua NCD gaixotasun ez kutsakorra OR momio-ratioa PA jarduera fisikoa PAGAC Estatu Batuetako Jarduera Fisikorako Gidalerroen Aholkularitza Batzordea PI/ECO Populazioa, Interbentzioa/Esposioa, Konparazioa, Emaitza RaR arrisku erlatibo egozgarria RCT proba kontrolatu aleatorizatua RR arrisku erlatiboa SBP presio arterial sistolikoa SMD batez besteko diferentzia estandarizatua SPPB errendimendu fisikoaren bateria laburra TB telebista WHA Osasunaren Mundu Batzarra WHO Osasunaren Mundu Erakundea vi TERMINOEN GLOSARIOA Terminoa Definizioa Jarduera fisiko aerobikoa Gorputzaren muskulu handiak erritmikoki mugitzen diren jarduera denbora-tarte iraunkor batean. Jarduera aerobikoak –erresistentzia-jarduera ere deitua– hobetu egiten du bihotzaren eta arnas sistemaren gaitasuna. Adibideak: ibiltzea, korrika egitea, igeri egitea, bizikletan ibiltzea. Jarduera fisiko anaerobikoa Jarduera fisiko anaerobikoa, oldarrez eta denbora-tarte laburretan egiten den ariketa da, besteak beste, pisu- jasotzea eta esprintak, non oxigeno-eskariak gainditu egiten duen oxigeno-hornidura. Oreka-entrenamendua Ariketa estatikoak eta dinamikoak, norberak estimulu ez-egonkorrek eragindako erronkei aurre egiteko duen gaitasuna hobetzeko diseinatuak, norbere mugimenduaren, ingurunearen, edo hainbat objekturen ondorioz. Gorputz-masaren indizea (GMI) Pisua (kg) / garaiera (m)2 GMI/adina edo GMI z- balioa GMI adinera egokitua, haurrentzat estandarizatua. GMI desbideratze-aldagai aldakorrak haurren adin eta sexuaren arabera egokitutako pisu erlatiboen neurriak dira. Haur baten adina, sexua, GMI, eta erreferentzia-estandar egoki bat kontuan hartuta, GMI z-balioa (edo bere baliokide GMI/adina pertzentila) zehaz daiteke. Hezurrak indartzeko jarduera Jarduera fisikoa, batez ere eskeleto-sistema osatzen duten hezur-gune espezifikoen indarra areagotzeko diseinatua. Hezurrak indartzeko jarduerek inpaktua edo indar-tentsioa sortzen dute hezurretan, hezurrak garatzeko eta indartzeko onuragarriak. Korrika egitea, soka-saltoa, eta pisu-jasotzea dira hezurrak indartzeko jardueren adibide batzuk. Gaitasun kardiometabolikoa Presio arterialaren, odoleko lipidoen, odoleko gluklosaren eta intsulinaren interakzioa osasunean. Bihotz eta arnas sistemaren gaitasuna (erresistentzia) Osasunarekin lotutako egoera fisikoaren osagai bat. Zirkulazio- eta arnas sistemek jarduera fisiko iraunkorrean oxigenoa emateko duten gaitasuna. Oro har, neurtu edo kalkulatutako oxigeno-kontsumo maximo gisa adierazten da (VO2 max.). Funtzio kognitiboa Garuneko jarduerak, hau da, informazioa eta ezagutza lortzera daramaten arrazoiketa, oroimena, arreta eta hizkuntza. Horrek ikaskuntza ere barne har dezake. Desgaitasuna Termino orokorra, Funtzionamenduaren, Desgaitasunaren eta Osasunaren Nazioarteko Sailkapenetik, urritasunetarako, jarduera-mugetarako eta parte hartzeko murrizketetarako, gizabanako baten (gaixotasun batekin) eta haren testuinguruko faktoreen (inguruneko faktoreak eta faktore pertsonalak) arteko elkarreraginaren alderdi negatiboak adierazten dituena. Jarduera fisikoaren eremuak Jarduera fisikoaren mailak hainbat eremutan ebalua daitezke, hauetako batean edo gehiagotan: aisialdia, lanbidea, hezkuntza, etxea eta/edo garraioa. Ariketa Jarduera fisikoaren azpikategoria planifikatua, egituratua, errepikakorra, eta irmoa, helburua denean gaitasun fisikoaren osagai bat edo gehiago hobetzea edo mantentzea. “Ariketa” eta “entrenamendua ariketekin” maiz erabiltzen dira txandakatzeko moduan, eta batez ere gaitasun fisikoa, errendimendu fisikoa edo osasuna hobetzeko edo mantentzeko asmoz aisialdian egiten den jarduera fisikoa esan nahi du oro har . Exekuzio-funtzioa Besteak beste: oroimen funtzionala, malgutasun kognitiboa (pentsamendu malgua ere esaten zaio) eta kontrol inhibitorioa (autokontrola barne). Egoera fisiko ona Gorputzak lanean eta aisialdiko jardueretan modu egoki eta eraginkor batean funtzionatzeko duen gaitasuna; gaitasun fisikoa eta bihotz eta arnas sistemarena barne hartzen ditu, besteren artean. Malgutasuna Osasunarekin eta errendimenduarekin lotutako egoera fisikoaren osagai bat, artikulazio batean izan daitekeen mugimendu-tartea. Malgutasuna espezifikoa da artikulazio bakoitzean, eta zenbait aldagai espezifikoren mende dago, besteak beste, lotailuen eta tendoi espezifikoen tentsioa. Malgutasun-ariketek hobetu egiten dute artikulazio batek bere mugimen-maila osoan mugitzeko duen gaitasuna. Ariketa funtzionalak Gorputzaren beheko aldearen indarra, oreka eta errendimendu motorra hobetzeko eguneroko zereginetan sar daitezkeen ariketak. Adibideak: tandem-jarrera, bi edo hanka baten gainean zutik, kukubilko-jarrera, aulki-ariketak, behatzak altxatzea eta oztopoen gainetik ibiltzea. Jarduera fisikoa etxe- eremuan Etxeko zereginetan egiten den jarduera fisikoa (garbiketa, ume-zaintza, lorezaintza…). Jarduera fisikoa aisia- eremuan Norberak egiten duen jarduera fisikoa, eguneroko bizitzan ezinbestekotzat jo gabe, bakoitzaren nahierara egina (kiroletan parte hartzea, sasoian egoteko ariketa edo entrenamenduak, eta ibiltzea, dantza egitea, loretzaintza…). O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z vii Terminoen glosarioa Terminoa Definizioa Intentsitate baxuko jarduera fisikoa Intentsitate baxuko jarduera fisikoa 1,5 eta 3 MET artekoa da, hau da, pertsonak pausagunean egiten duen energia-gastua halako 3 baino kostu energetiko txikiagoa duten jarduerak. Horren barruan sar daitezke poliki ibiltzea, bainatzea edo bihotz-maiztasuna edo arnas maiztasuna nabarmen handitzea eragiten ez duten beste jarduera batzuk. Muskulu-talde nagusiak Muskulu-talde nagusiak hankak, bizkarra, sabelaldea, bularra, sorbaldak eta besoak dira. Zereginaren baliokide metabolikoa (MET) Zereginaren baliokide metabolikoa, edo, besterik gabe, baliokide metabolikoa, jarduera fisikoen intentsitatea adierazten duen neurri fisiologiko bat da. MET bat pertsona batek eserita edo atseden hartzen dagoen bitartean gastatzen duen energia baliokidea da. Intentsitate ertaineko jarduera fisikoa Eskala absolutu batean, intentsitate ertainak esan nahi du jarduera fisikoa egitean 3 aldiz eta 6 alditik behera dela atsedenaren intentsitatea. Norbanako baten gaitasunari buruzko eskala batean, intentsitate ertaineko jarduera fisikoa 5 edo 6koa izaten da 0 eta 10 bitarteko eskala batean. Muskuluak indartzeko jarduera Muskulu eskeletikoaren indarra, potentzia, erresistentzia eta masa areagotzen duten jarduera fisikoa eta ariketa (adibidez, indar-entrenamendua, erresistentzia-entrenamendua edo muskuluen indar- eta erresistentzia-ariketak). Osagai anitzeko jarduera fisikoa Adinekoentzat, osagai anitzeko jarduera fisikoa garrantzitsua da funtzio fisikoa hobetzeko eta erorikoen ondorioz lesioak izateko arriskua murrizteko. Jarduera horiek etxean edo talde egituratu batean egin daitezke. Aztertutako interbentzio askok ariketa-mota guztiak konbinatzen dituzte saio batean (aerobikoa, muskuluen indartzea eta orekaren entrenamendua), eta hori eraginkorra dela frogatu da. Osagai anitzeko jarduera fisikoko programa baten adibide bat oinez ibiltzea (jarduera aerobikoa), pisuak altxatzea (muskuluak indartzea) eta oreka entrenatzea izan daitezke. Oreka entrenatzeko adibideetan sar daiteke atzeraka edo alboz ibiltzea edo oin baten gainean gelditzea gorputzaren goiko aldeko muskuluak indartzeko jarduera egiten den bitartean, hala nola bizeps-flexioak. Dantzak osagai aerobikoak eta orekazkoak ere lantzen ditu. Jarduera fisikoa lanbide-eremuan Ikus jarduera fisikoa lan-eremuan. Jarduera fisikoa Muskulu eskeletikoek eragindako edozein gorputz-mugimendu, energia-gastua eskatzen duena. Jarduera fisikoaren eza Jarduera fisikoaren egungo gomendioak betetzeko nahikoa ez den jarduera fisikoa. Gaitasun psikosoziala Osasunaren dimentsio mentala, emozionala eta soziala barne hartzen ditu. Pantaila aurreko aisialdiko denbora Pantailak (telebista, ordenagailua, gailu mugikorrak) begiratzen emandako denbora, hezkuntza/ikasketekin edo lanarekin zerikusia ez duten helburuekin. Pantailako denbora sedentarioa Pantailan entretenimendua ikusten emandako denbora (telebista, ordenagailua, gailu mugikorrak). Ez dira sartzen pantailan oinarritutako joko aktiboak, jarduera fisikoa edo mugimendua eskatzen dutenak. Sedentarismoa Eserita, erdi etzanda edo etzanda egon bitartean 1,5 METeko edo gutxiagoko energia-gastua duen edozein portaera esna gaudenean. Bulegoko zeregin gehienak, autoa gidatzea eta telebista ikustea, sedentarismoaren adibideak dira; zutik egon ezin duten pertsonak ere hartzen dira barnean, gurpil-aulkien erabiltzaileak, esaterako. Gidalerroek, sedentarismoaren definizioan, autoinformatutako mugimendu-maila baxua sartzen dute, eserita (aisialdian, lanean eta guztira), telebista ikusten (denbora TB edo pantaila aurrean) eta mugimendua edo jarrera ebaluatzen duten gailuen bidez neurtutako maila baxuak ere. Kirola Kirolak arau zehatzei jarraituta eta aisialdiaren edo lehiaketaren parte gisa egindako jarduera-sorta bat hartzen du barnean. Kirol-jardueretan sartzen da taldeek edo norbanakoek egindako jarduera fisikoa, eta esparru instituzional baten babesa izan dezakete, kirol-elkarte batena, adibidez. Jarduera fisikoa garraio-eremuan Lekualdatzeko egiten den jarduera fisikoa, oinez, bizikletan edo gurpiletan (motordunak ez diren ibilgailuak gurpilekin, besteak beste, patineteak, patinak, eskuzko gurpil-aulkiak). Intentsitate biziko jarduera fisikoa Eskala absolutu batean, intentsitate bizia 6.0 MET edo gehiagotan egindako jarduera fisikoa da. Norbanakoaren gaitasunari buruzko eskala batean, intentsitate biziko jarduera fisikoa 7 edo 8 izan ohi da 0–10 eskalan. Jarduera fisikoa lan- eremuan Ordaindutako edo borondatezko lanean egindako jarduera fisikoa. viii LABURPENA OMEren Jarduera fisikoari eta sedentarismoari buruzko gidalerroek osasun publikoko gomendioak ematen dituzte, haur, nerabe, heldu eta adinekoentzako ebidentzietan oinarrituta, osasunerako onura garrantzitsuak eskaintzeko eta osasunerako arriskuak arintzeko behar den jarduera fisikoaren kopuruari buruz (maiztasuna, intentsitatea eta iraupena). Lehen aldiz, gomendioak ematen dira jokabide sedentarioaren eta osasun-emaitzen arteko loturei buruz, bai eta azpipopulazioentzat ere, hala nola emakume haurdunak eta erditze ondokoak, eta gaixotasun kronikoekin edo desgaitasunarekin bizi diren pertsonak. Osasun, hezkuntza, gazteria, kirol eta/edo gizarte- edo familia-ongizateko ministerioetan diru-sarrera altuak, ertainak eta baxuak dituzten herrialdeetan politikak diseinatzearen arduradunei zuzenduta daude gidalerroak; orientazio-dokumentuen bidez, jarduera fisikoa areagotzeko eta populazio- taldeetan sedentarismoa murrizteko plan nazionalak, azpieskualdekoak edo udaletakoak garatzeaz arduratzen diren gobernu-funtzionarioei; gobernuz kanpoko erakundeei, hezkuntza- sektoreari, sektore pribatuari, Ikertzaileei eta osasun-arretako profesionalei. Gidalerroak garatzeko OMEren gidaliburuaren arabera prestatu ziren gidalerroak. Emaitza kritiko eta garrantzitsuetarako ebidentzia-berrikuspen sistematikoak egin ziren, eta onurak eta kalteak, balioak, lehentasunak, bideragarritasuna eta onargarritasuna eta ekitaterako eta baliabideetarako inplikazioak kontuan hartu ondoren garatu ziren. Aurkeztutako osasun publikoko azken gomendioak 5 urtetik 65 urte edo gehiago dituzten populazio eta adin-talde guztientzat dira, sexua, kultura- aurrekariak edo maila sozioekonomikoa edozein izanik ere, eta garrantzitsuak dira gaitasun guztietako pertsonentzat. Baldintza mediko kronikoak eta/edo desgaituak dituztenek eta haurdun dauden eta erditu ondoren dauden emakumeek gomendioak betetzen saiatu behar dute, ahal den guztietan. Gidalerro hauek garatzeak hainbat gomendio ematen ditu, gobernuek beren politika nazionalen esparruetan har ditzaketen ebidentzietan oinarrituta, jarduera fisikoaren populazio-mailak handitzeko ikuspegi integralak bultzatzeko. Adopzio-prozesuaren barruan, kontuan hartu behar da gidalerroak testuinguruan kokatzeko beharra. Adopzioa, zabalkundea, komunikazio- kanpainak eta gidalerroen ezarpena bultzatzeko tresna praktikoek lagunduko diete gobernuei eta interesa duten alderdiei elkarrekin lan egiten, jarduera fisikoa areagotzeko eta jokabide sedentarioak murrizteko bizialdian zehar. Laguntza-baliabide horiek OMEren webgunean egongo dira eskuragarri, gidalerroak argitaratu ondoren. Jarduera fisikoa eta jokabide sedentarioak bizitza osoko osasun-emaitzekin lotzen dituzten laguntza- datu asko egon arren, ebidentzian hutsune handiak daude oraindik. Bereziki, diru-sarrera txikiko eta ertaineko herrialdeen eta ekonomikoki ahulak diren edo arretarik ez duten komunitateen ebidentzia txikiagoa dago, eta azpipopulazioen proba gutxi daude, desgaitasunak dituzten pertsonak barne. Ikerketa gehiagotan inbertitu behar da ebidentzia sortzeko, bereziki arlo horietan. Gainera, gomendio horietan egindako aldaketek zenbait ondorio izango dituzte gaur egun jarduera fisikoaren maila nazionalak monitorizatzeko erabiltzen diren zaintza- sistemetan eta ebaluazio-tresnetan. Dauden tresna nazionalak eta mundukoak berrikusi behar dira, eta txostenak aurkezteko protokoloak eguneratu, etorkizuneko txostenen aurkezpena gidalerro berrien arabera oinarritzeko. 2018-2030 aldirako jarduera fisikoari buruzko munduko ekintza-planak jarduera fisikorik eza % 15 murrizteko helburua ezarri zuen 2030erako, eta gomendatutako politikako 20 ekintza eta esku- hartze deskribatu zituen. Gidalerro horiek herrialde guztiei laguntzen diete GAPPAren gomendioak inplementatzen eta “ACTIVE” tresna-sorta teknikoa ezartzen, bizialdian zehar eta hainbat ingurunetan jarduera fisikoa sustatzeko orientazioa ematen duena. O M E re n gi da le rr oa k ja rd ue ra fi si ko ar i e ta s ed en ta ris m oa ri bu ru z HAURRAK ETA NERABEAK (adina 5–17 urte) Haur eta nerabeetan, jarduera fisikoak onurak dakartza osasun-emaitza hauetarako: hobekuntza osasun fisikoan (bihotz eta arnas sistemaren eta muskuluen gaitasuna), osasun kardiometabolikoan (presio arteriala, dislipidemia, glukosa eta intsulinarekiko erresistentzia), hezurren osasunean, emaitza kongitiboetan (errendimendu akademikoa, exekuzio-funtzioa), osasun mentalean (depresio-sintoma murriztuak); eta adipositate murriztua. Hau gomendatzen da: Haur eta nerabeek, batez beste astean 60 minutu gutxienez egin behar dute jarduera fisikoa ‒ intentsitate ertainetik bizira‒, aerobikoa batez ere. Gomendio sendoa, ziurtasun ertaineko ebidentzia Intentsitate biziko jarduera aerobikoak, baita muskuluak eta hezurrak indartzekoak ere, astean gutxienez 3 egunetan egin behar dira. Gomendio sendoa, ziurtasun ertaineko ebidentzia Haurren eta nerabeen sedentarismo maila altuak harremana du osasun ondorio hauekin: adipositate handiagoa; osasun kardiometaboliko, gaitasun fisiko, portaera/jokabide prosozial urriagoak; eta loaldia murriztea. Hau gomendatzen da: Haurrek eta nerabeek mugatu egin behar dute sedentario izaten emandako denbora, batez ere pantaila aurreko aisialdiarekin. Gomendio sendoa, ziurtasun baxuko ebidentzia Gutxienez 60 minutu egunean J A R D U N B ID E E G O K IA K S T A T E M E N T S Gutxienez 3 egun astean 2 e c glan a at : vi ou r beha y sedentar d an y tiv it c a sical y p h o n es G ui de lin 2 Site-specific cancers of: bladder, breast, colon, endometrial, oesophageal adenocarcinoma, gastric, and renal. In adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascula disease mortality, incident hypertension, incident site-specifi cancers,2 incident type-2 diabetes, mental health (reduced sy of anxiety and depression); cognitive health, and sleep; meas of adiposity may also improve. Hel etan, jarduer fisikoak onu ak dakartza osasun-emaitza hauetarako: gutxitu egiten ditu kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eragindakoa, hipertentsioaren, minbizi espezifikoen , II motako diabetesaren intzidentzia; eta hobetu egiten ditu osasun mentala (antsietate- eta depresio- sintoma gutxiago), osasun kognitiboa eta loa; adipositate-mailak ere hobe ditzake. Hau gomendatzen da: Heldu guztiek erregulartasunez egin behar dute jarduera fisikoa. Gomendio sendoa, ziurtasun ertaineko ebidentzia Helduek intentsitate ertaineko jarduera fisiko aerobikoa egin behar dute, gutxienez 150-300 minutu; edo intentsitate biziko jarduera fisiko aerobikoa, gutxienez 75-150 minutu; edo astean zehar intentsitate ertain eta biziko jardueren konbinazio baliokide bat, osasunerako onura handiak lortzeko. Gomendio sendoa,ziurtasun ertaineko ebidentzia Helduek muskuluak indartzeko jarduerak egin behar dituzte ‒ intentsitate ertaina edo handiagoa‒ astean 2 egunetan edo gehiagotan, muskulu-talde nagusi guztiak landu eta osasun-onura gehigarriak ematen baitituzte. Gomendio sendoa, ziurtasun ertaineko ebidentzia 1 Minbizi espezifiko hauek: maskurikoa, bularr koa, kol nekoa, endometrioko , hestegorrikoa, gastrikoa eta giltzurrunekoa. Gutxienez Gutxienez O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Recommendations 5 Helduek intentsitate ertaineko jarduera fisiko aerobikoa 300 minututik gora egin dezakete; eta intentsitate biziko jarduera fisiko aerobikoa 150 minututik gora; edo astean zehar intentsitate ertain eta biziko jardueren konbinazio baliokide bat egin dezakete osasunerako onura gehigarriak lortzeko. Baldintzapeko gomendioa, ziurtasun ertaineko ebidentzia Helduetan, zenbat eta handiagoa sedentarismoa, orduan eta emaitza okerragoak osasunarentzat: handitu egiten da kausa guztiengatiko hilkortasuna, eta gaixotasun kardiobaskularrek eta minbiziak eragindakoa, baita gaixotasun kardiobaskularren, minbiziaren eta II motako diabetesaren intzidentzia ere. Hau gomendatzen da: Helduek mugatu egin behar dute sedentario izaten emandako denbora. Denbora sedentarioa edozein intentsitateko jarduera fisikoarekin ordezteak (intentsitatea baxua izanda ere) osasunerako onurak dakartza. Gomendio sendoa, ziurtasun ertaineko ebidentzia Helduek, sedentarismoaren maila handiek osasunean dituzten ondorio kaltegarriak murrizten laguntzeko, saiatu egin behar dute igotzen jarduera fisikorako gomendatzen diren mailak, intentsitate ertainekoak eta intentsitate bizikoak. Gomendio sendoa, ziurtasun ertaineko ebidentzia Laburpena J A R D U N B ID E E G O K IA K edo 150 minutu baino gehiago 6 4 ADINEKOAK (adina 65 urte eta gehiago) Adinekoetan, jarduera fisikoak onurak dakartza osasun-emaitza hauetarako: gutxitu egiten ditu kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eragindakoa, hipertentsioaren, minbizi espezifikoen, II motako diabetesaren intzidentzia; eta hobetu egiten ditu osasun mentala (antsietate-eta depresio-sintoma gutxiago), osasun kognitiboa eta loa; adipositate-mailak ere hobe ditzake. Adinekoetan, jarduera fisikoak lagundu egiten du prebenitzen erorikoak eta hezurren osasunaren eta gaitasun funtzionalaren narriadurari eta erorikoei lotutako lesioak. Hau gomendatzen da: Adineko guztiek erregulartasunez egin behar dute jarduera fisikoa. Gomendio sendoa, ziurtasun ertaineko ebidentzia Adinekoek intentsitate ertaineko 150-300 minutuko jarduera fisiko aerobikoa egin behar dute gutxienez; edo intentsitate biziko 75-150 minutuko jarduera fisiko aerobikoa; edo astean zehar intentsitate ertain eta biziko jardueren konbinazio baliokide bat, osasunerako onura esanguratsuak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Adinekoek muskuluak indartzeko jarduerak egin behar dituzte ‒ intentsitate ertaina edo handiagoa‒ astean 2 egunetan edo gehiagotan, muskulu-talde nagusi guztiak landu eta osasun-onura gehigarriak ematen baitituzte. Gomendio sendoa, ziurtasun ertaineko ebidentzia Adinekoek astero egindako jarduera fisikoak askotarikoa izan behar du, oreka funtzionala eta indar- entrenamendua batez ere, intentsitate ertain edo handiagokoa, astean 3 egun edo gehiagotan, gaitasun funtzionala hobetzeko eta erorikoak prebenitzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Gutxienez 150- 300 minutu Gutxienez 75- 300 minutu edo Adinekoek 300 minututik gora egin dezakete intentsitate ertaineko jarduera fisiko aerobikoa; edo 150 minututik gora intentsitate biziko jarduera fisiko aerobikoa; edo astean zehar intentsitate ertain eta biziko jardueren konbinazio baliokide bat egin dezakete, osasunerako onura gehigarriak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Adinekoetan, zenbat eta handiagoa sedentarismoa, orduan eta osasun-emaitza okerragoak: handitu egiten da kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eta minbiziak eragindakoa, baita gaixotasun kardiobaskularren, minbiziaren eta II motako diabetesaren intzidentzia ere. Hau gomendatzen da: Adinekoek mugatu egin behar dute sedentario izaten emandako denbora. Denbora sedentarioa edozein intentsitateko jarduera fisikoarekin ordezkatzeak (intentsitatea txikia izanda ere) osasunerako onurak dakartza. Gomendio sendoa, ziurtasun ertaineko ebidentzia Adinekoek, sedentarismoaren maila handiek osasunean dituzten ondorio kaltegarriak murrizten laguntzeko, saiatu egin behar dute igotzen jarduera fisikorako gomendatzen diren mailak, intentsitate ertain eta bizikoak. Gomendio sendoa, ziurtasun ertaineko ebidentzia J A R D U N B ID E E G O K IA K 300 minutu baino gehiago 150 minutu baino gehiago edo Laburpena 8 6 e c glan a at : vi ou r beha y sedentar d an y tiv it c a sical y p h o n es G ui de lin Emakumeek, haurdunaldian eta erditu ondoren, jarduera fisikoa egiteak onura hauek dakartza amaren eta fetuaren osasunerako: arriskua gutxitzen du aurre-eklanpsia, haurdunaldiko hipertentsioa, haurdunaldiko diabetesa, haurdunaldiko gainpisua izateko, konplikazioak erditzean, depresioa erditu ondoren, konplikazioak jaioberriarengan, eta eragin kaltegarriak jaiotza- pisuan; eta ez du fetu hila erditzeko arriskua handitzen. Emakume ororentzat, haurdunaldian eta erditu ondoren, kontraindikaziorik ezean, gomendatzen da: Jarduera fisikoa erregulartasunez egitea haurdunaldian eta erditu ondoren. Gomendio sendoa, ziurtasun ertaineko ebidentzia Astean zehar intentsitate ertaineko 150 minutuko jarduera fisiko aerobikoa egin, osasunerako funtsezko onurak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Askotariko jarduera aerobikoak eta muskuluak indartzekoak sartu. Luzaketa leunak gehitzea ere onuragarria izan daiteke. Gomendio sendoa, ziurtasun ertaineko ebidentzia Horrez gain: Haurdunaldiaren aurretik intentsitate biziko jarduera aerobikoak egiten zituzten edo fisikoki aktiboak ziren emakumeek jarduera horiekin jarrai dezakete haurdunaldian eta erditu ondorengo aldian. Gomendio sendoa, ziurtasun ertaineko ebidentzia O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z EMAKUMEAK HAURDUNALDIAN ETA ERDITU ONDOREN Gutxienez 150 minutu Recommendations 9 • Jarduera fisiko pixka bat egitea ezer ez egitea baino hobe da. Jarduera fisikoa egitean haurdun dauden emakumeentzako segurtasun-ohar gehigarriak: • Haurdun dauden eta erditu ondoren dauden emakumeek gomendioak betetzen ez badituzte, jarduera fisikoren bat egitea onuragarria izango da haien osasunerako. • Emakumeek, haurdunaldian eta erditu ondoren, gutxika hasi behar dute jarduera fisikoa egiten, eta denborarekin maiztasuna, intentsitatea eta iraupena pixkanaka handitu. • Zoru pelbikoko muskuluen entrenamendua egunero egin daiteke, inkontinentzia- arriskua murrizteko. • Saihestu jarduera fisikoa gehiegizko beroan, batez ere hezetasun handiarekin. • Hidratatuta eduki ura edaten jarduera fisikoaren aurretik, bitartean eta ondoren. • Saihestu kontaktu fisikoa dakarten jardueretan parte hartzea; erortzeko arrisku handia dakarte, edo oxigenazioa murriztu dezakete (altitude handiko jarduerak, normalean altitude handian bizi ez direnean). • Saihestu ahoz gorako jarduerak haurdunaldiaren lehen hiruhilekoaren ondoren. • Emakume haurdunek, atletismoko leihaketetan parte hartzeko edo gidalerro gomendatuen gainetik ariketa esanguratsua egiteko asmoa badute, osasun-arloko profesional batengana jo behar dute azter ditzan. • Haurdun dauden emakumeei osasun- arretako profesionalak jarduera eteteko edo mugatzeko ohartarazten dien arrisku-seinaleen berri eman behar die; arrisku-seinale horiek izanez gero, berehala kontsultatu behar die osasun-arretako profesional bati. • Erditu ondoren pixkanaka jarduera fisikora itzultzea, eta osasun-arloko profesional batekin kontsultatuta, zesarea bidez erdituz gero. Emakumeetan, haurdunaldian eta erditu ondoren, heldu guztietan bezala, jokabide sedentario handiagoa osasun txarreko emaitza hauekin lotzen da: kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eta minbiziak eragindakoa eta gaixotasun kardiobaskularren, minbiziaren eta II motako diabetesaren intzidentzia. MUGATU sedentario izaten emandako denbora ORDEZTU edozein intentsitateko jarduera fisikoarekin (intentsitate baxua barne). Hau gomendatzen da: Emakumeek, haurdunaldian eta erditu ondoren, mugatu egin behar dute sedentario izaten emandako denbora. Denbora sedentarioa edozein intentsitateko jarduera fisikoarekin ordezteak (intentsitate baxua barne) osasunerako onurak dakartza. Gomendio sendoa, ziurtasun baxuko ebidentzia Jarduera fisiko pixka bat egitea ezer ez egitea baino hobe da. J A R D U N B ID E E G O K IA K 8 e c glan a at : vi ou r beha y sedentar d an y tiv it c a sical y p h o n es G ui de lin 10 HELDUAK ETA ADINEKOAK GAIXOTASUN KRONIKOEKIN (adina 18 urte eta gehiago) Jarduera fisikoak gaixotasun kroniko hauek dituzten heldu eta adinekoen osasunerako onurak ekar ditzake: minbizitik bizirik irtendakoentzat – jarduera fisikoak hobetu egiten ditu kausa guztiengatiko hilkortasuna, minbizi espezifikoek eragindakoa eta minbizia errepikatzeko edo bigarren minbizi primarioa izateko arriskua; hipertentsioa dutenentzat – jarduera fisikoak hobetu egiten ditu gaixotasun kardiobaskularrengatiko hilkortasuna, gaixotasunen progresioa, funtzio fisikoa, osasunarekin lotutako bizi-kalitatea; II motako diabetesa dutenentzat – jarduera fisikoak murriztu egiten ditu gaixotasun kardiobaskularrengatiko hilkortasun-tasak, eta gaixotasun-progresioaren adierazleak; eta GIBa dutenentzat – jarduera fisikoak egoera fisikoa eta osasun mentala hobe ditzake (antsietate- eta depresio-sintomak murriztea), eta ez du eragin negatiborik gaixotasunaren progresioan (CD4 zenbaketa eta karga birala) edo gorputz-osaeran. Hau gomendatzen da: Aipatutako gaixotasun kronikoak dituzten heldu guztiek erregulartasunez egin behar dute jarduera fisikoa. Gomendio sendoa, ziurtasun ertaineko ebidentzia Gaixotasun kroniko horiek dituzten helduek intentsitate ertaineko jarduera fisiko aerobikoa egin behar dute gutxienez 150 -300 minutu; edo intentsitate biziko jarduera fisiko aerobikoa gutxienez 75-150 minutu; edo astean zehar intentsitate ertain eta biziko jardueren konbinazio baliokide bat, osasunerako onura nabarmenak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Gaixotasun kroniko horiek dituzten helduek eta adinekoek muskuluak indartzeko jarduerak egin behar dituzte ‒intentsitate ertaina edo handiagoa‒ astean 2 egun edo gehiagotan, muskulu-talde nagusi guztiak landu eta osasun-onura gehigarriak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Gaixotasun kroniko horiek dituzten adinekoek askotariko jarduera fisikoa egin behar dute, osagai anitzekoa, astean 3 egun edo gehiagotan, intentsitate ertain edo handiagoan, nagusiki oreka funtzionala eta indar- entrenamendua, gaitasun funtzionala indartzeko eta erorikoak prebenitzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Gutxienez 150- 300 minutu Gutxienez 75- 150 minutu edo 8 Recommendations 11 Kontraindikaziorik ezean, gaixotasun kroniko horiek dituzten helduek eta adinekoek intentsitate ertaineko jarduera fisiko aerobikoa 300 minututik gora egin dezakete; edo intentsitate biziko jarduera fisiko aerobikoa 150 minututik gora; edo astean zehar intentsitate ertain eta biziko jardueren konbinazio baliokide bat egin dezakete, osasunerako onura gehigarriak lortzeko. Baldintzapeko gomendioa, ziurtasun ertaineko ebidentzia • Aurreko gomendioak bete ezin dituztenean, gaixotasun kroniko horiek dituzten helduek beren gaitasunen arabera saiatu behar dute jarduera fisikoa egiten. • Gaixotasun kroniko horiek dituzten helduek jarduera fisikoa gutxika egiten hasi behar dute, eta denborarekin maiztasuna, intentsitatea eta iraupena pixkanaka handitu. • Gaixotasun kroniko horiek dituzten helduentzat komeni da jarduera fisikoko espezialista bati edo osasun-arloko profesional bati kontsultatzea, norbere premia indibidualak, trebetasunak, muga/konplikazio funtzionalak, hartzen dituzten medikamentuak eta tratamenduak kontuan hartuta, jarduera-mota eta -kantitate egokiei buruzko aholkularitza jasotzeko. • Ariketa egin aurreko baimen medikoa ez da beharrezkoa izaten kontraindikaziorik ez duten pertsonentzat, intentsitate arineko edo ertaineko jarduera fisiko bat hasi aurretik, ibilaldi azkar baten edo eguneroko bizitzaren eskakizunak gainditzen ez baditu. Helduetan, minbizitik irtendakoak eta hipertentsioa, II motako diabetesa eta GIBa duten pertsonak barne, sedentarismo handiagoa osasun-emaitza txar hauekin lotzen da: kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eta minbiziak eragindakoa, eta gaixotasun kardiobaskularren, minbiziaren eta II motako diabetesaren intzidentzia. Helduetan, minbizitik bizirik irtendakoei eta hipertentsioa, II motako diabetesa eta GIBa dutenei gomendatzen zaie: Gaixotasun kronikoak dituzten helduek eta adinekoek mugatu egin behar dute sedentario izaten emandako denbora. Denbora sedentarioa edozein intentsitateko jarduera fisikoarekin ordezteak (intentsitate baxua barne) osasunerako onurak dakartza. Gomendio sendoa, ziurtasun baxuko ebidentzia Sedentarismoaren maila handiek osasunean dituzten ondorio kaltegarriak murrizten laguntzeko, gaixotasun kronikoak dituzten heldu eta adinekoek saiatu egin behar dute maila gomendatuak gainditzen intentsitate ertainetik bizirako jarduera fisikoa egitean. Gomendio sendoa, ziurtasun baxuko ebidentzia J A R D U N B ID E E G O K IA K 300 minutu baino gehiago 150 minutu baino gehiago 12 0 e c glan a at : vi o ur beha y sedentar d an y tiv it c a sical y p h o n es g ui d eli n HO W HAURRAK ETA NERABEAK (adina 5–17 urte) DESGAITASUNAREKIN Jarduera fisikoak haurren eta nerabeen osasunerako dituen onura ugari, aurreko atalean adierazi bezala, desgaitasunen bat duten haur eta nerabeekin ere daude lotuta. Jarduera fisikoak desgaitasuna duten pertsonen osasun-emaitzetarako dituen onura gehigarriak honako hauek dira: hobetu egiten du kognizioa, funtzio kognitiboa narriatzen duten gaixotasunak edo nahasmenduak dituzten pertsonetan, arreta- defizitaren/hiperaktibitatearen nahasmendua (ADHN) barne; funtzio fisikoan hobekuntzak ekar ditzake desgaitasun intelektuala duten haurretan. Hau gomendatzen da: Desgaitasuna duten haur eta nerabeek egunero batez beste 60 minutu egin behar dute jarduera fisikoa astean zehar, intentsitate ertain eta handiagokoa, eta batez ere aerobikoa. Gomendio sendoa, ziurtasun ertaineko ebidentzia Intentsitate handiko jarduera aerobikoak, baita muskuluak eta hezurrak indartzen dituztenak ere, gutxienez astean 3 egunetan egin behar dira. Gomendio sendoa, ziurtasun ertaineko ebidentzia O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z 5 10 Recommendations 13 Haurren eta nerabeen sedentarismoa zenbat eta handiagoa, orduan eta txarragoak haien osasun-emaitzak: areagotu egiten da adipositatea; urritu egiten da bihotz eta arnas sistemaren gaitasuna, gaitasun fisikoa, portaera/jokabide prosoziala; eta murriztu egiten da loa. Hau gomendatzen da: Desgaitasuna duten haur eta nerabeek mugatu egin behar dute sedentario izaten emandako denbora, batez ere pantaila aurreko aisialdiko denbora. Gomendio sendoa, ziurtasun baxuko ebidentzia 1 J A R D U N B ID E E G O K IA K Has zaitez gutxika jarduera fisikoa egiten. 14 2 e c glan a at : vi ou r beha y sedentar d an y tiv it c a sical y p h o n es G ui de lin HELDUAK (adina 18 urte eta gehiago) DESGAITASUNAREKIN Aurreko atalean adierazi bezala, jarduera fisikoak helduen osasunean dituen onuretako asko desgaitasuna duten helduei dagozkie. Desgaitasuna duten pertsonen osasun-emaitzetarako jarduera fisikoak dituen onura gehigarriak honako hauek dira: esklerosi anizkoitza duten helduentzat – funtzio fisikoa hobetzea, baita osasunarekin lotutako bizi-kalitaterako gaitasun fisikoa, mentala eta soziala ere; bizkarrezur-muineko lesioa dutenentzat – hobetu egiten ditu ibiltzeko funtzioa, muskuluen indarra eta goiko gorputz-adarraren funtzioa; eta osasunarekin lotutako bizi-kalitatea; funtzio kognitiboa narriatzen duten gaixotasunak edo nahasmenduak dituztenentzat – funtzio fisiko eta kognizio hobea (Parkinsonen gaixotasuna duten eta istripu zerebrobaskularren aurrekariak dituzten pertsonetan); kognizioaren gaineko ondorio onuragarriak; eta bizi-kalitatea hobe dezake (eskizofrenia duten helduak); baita funtzio fisikoa (desgaitasun intelektuala duten helduetan) eta bizi-kalitatea ere (depresio klinikoa duten helduetan). Hau gomendatzen da: Desgaitasuna duten heldu guztiek erregulartasunez egin behar dute jarduera fisikoa. Gomendio sendoa, ziurtasun ertaineko ebidentzia Desgaitasuna duten helduek gutxienez intentsitate ertaineko 150-300 minutuko jarduera fisiko aerobikoa egin behar dute; edo intentsitate biziko jarduera fisiko aerobikoa, gutxienez 75-150 minutukoa; edo astean zehar intentsitate ertaineko eta biziko jardueren konbinazio baliokide bat, osasunerako onura nabarmenak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Desgaitasuna duten helduek ere muskuluak indartzeko jarduerak egin behar dituzte ‒intentsitate ertaina edo handiagoa‒ astean 2 egun edo gehiagotan, muskulu- talde nagusi guztiak landu eta osasun-onura gehigarriak ematen baitituzte. Gomendio sendoa, ziurtasun ertaineko ebidentzia edo konbinazio baliokide bat astean zehar O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Gutxienez 150- 300 minutu intentsitate ertaineko jarduera fisikoaerobikoa intentsitate biziko jarduera fisiko aerobikoa Gutxienez 75- 150 minutu edo 3 Gutxienez osagai anitzeko askotariko jarduera fisikoa, oreka funtzionala eta indar- entrenamendua nagusiki, intentsitate ertain edo handiagoan Astean egiten duten jarduera fisikoaren barruan, desgaitasuna duten adinekoek askotariko jarduera fisikoa egin behar dute, oreka funtzionala eta indar-entrenamendua batez ere, intentsitate ertain edo handiagoan, astean 3 egunetan edo gehiagotan, gaitasun funtzionala hobetzeko eta erorikoak prebenitzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Osasun-onura gehigarrietarako: Desgaitasuna duten helduek intentsitate ertaineko jarduera fisiko aerobikoa 300 minututik gora igo dezakete; eta intentsitate biziko jarduera fisiko aerobikoa 150 minututik gora; edo astean zehar intentsitate ertain eta biziko jardueraren konbinazio baliokide bat egin dezakete, osasun-onura gehigarriak lortzeko. intentsitate ertaineko jarduera fisiko aerobikoa intentsitate biziko jarduera fisiko aerobikoa Baldintzapeko gomendioa, ziurtasun ertaineko ebidentzia edo konbinazio bakoikide bat astean zehar • Jarduera fisiko pixka bat egitea ezer ez egitea baino hobe da. • Desgaitasuna duten helduek ez badituzte gomendio hauek betetzen, jarduera fisikoren bat egitea onuragarria izango da beren osasunarentzat. • Desgaitasun bat duten helduek gutxika hasi behar dute jarduera fisikoa egiten, eta denborarekin maiztasuna, intentsitatea eta iraupena pixkanaka handitu. • Ez dago arrisku esanguratsurik desgaitasuna duten helduek jarduera fisikoa egiten dutenean, baldin eta egokia bada norberaren unean-uneko jarduera-mailarako, osasun- egoerarako eta funtzio fisikorako; eta osasun-onurek arriskuak gainditzen dituzte. • Baliteke desgaitasuna duten helduek osasun-arloko profesional bati edo jarduera fisikoko eta desgaitasuneko espezialista bati kontsultatu behar izatea, haientzat egokia den jarduera-mota eta -maila zehazten laguntzeko. Helduetan, zenbat eta handiagoa sedentarismoa, orduan eta osasun-emaitza txarragoak, ondokoei lotuta: kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eta minbiziak eragindakoa; eta gaixotasun kardiobaskularren, minbiziaren eta II motako diabetesaren intzidentzia. Hau gomendatzen da: Desgaitasuna duten helduek mugatu egin behar dute sedentario izaten emandako denbora. Denbora sedentarioa edozein intentsitateko jarduera fisikoarekin ordezteak (intentsitate baxua barne) onurak dakartza osasunarentzat. Gomendio sendoa, ziurtasun baxuko ebidentzia Sedentarismoaren maila handiek osasunean dituzten ondorio kaltegarriak murrizten laguntzeko, desgaitasuna duten helduek saiatu egin behar dute intentsitate ertainetik bizirako jarduera fisikoaren maila gomendatuak igotzen. Gomendio sendoa, ziurtasun baxuko ebidentzia 13 J A R D U N B ID E E G O K IA K egun astean 300 minutu baino gehiago 150 minutu baino gehiago edo 14 O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z TESTUINGURUA Jakina da jarduera fisikoa erregulartasunez egiteak lagundu egiten duela gaixotasun ez- transmitigarriak prebenitzen eta tratatzen, besteak beste, gaixotasun kardiobaskularrak, II motako diabetesa, bularreko eta koloneko minbizia (1-3). Jarduera fisikoak osasun mentalerako ere baditu onurak (4), dementziaren agerpena atzeratzen du (5) eta lagungarria izan daiteke pisu osasungarriari eusteko (1) eta ongizate orokorrerako (6). Jarduera fisikoa honela definitzen da: muskulu eskeletikoek eragindako gorputz-mugimendu oro, energia-gastua eskatzen duena (1) eta hainbat intentsitatetan egin daitekeena, lan-jardunean, etxeko lanetan, garraiatzean edo aisialdian, edo ariketan edo kiroletan parte hartzean. Intentsitate- tartearen beheko muturrean, sedentarismoa honela definitzen da: esna gauden bitartean, eserita, erdi etzanda edo etzanda, energia-gastu gutxi eskatzen duen portaera oro (7). Agertzen ari den ebidentzia berriak adierazten du sedentarismoaren maila altuak gaixotasun kardiobaskularrekin eta II motako diabetesarekin lotuta daudela, baita hilkortasun kardiobaskularrarekin eta minbiziak eta kausa guztiek eragindakoarekin ere (8-10). Jarduera fisikoaren eza honela definitzen da: 2010eko Osasunerako jarduera fisikoari buruzko gomendio globalak (1) ez betetzea, eta munduko hilkortasunaren eragile nagusietako bat da. Kalkuluen arabera, urtean lau miliotik bostera arteko heriotza saihes daitezke munduko populazio aktiboagoa balitz (2, 11). Jarduera fisikorik ezaren inguruko kalkulu globalek adierazten dutenez, 2016an, helduen % 27,5ek (12) eta nerabeen % 81ek (13) ez zituzten bete OMEren 2010eko gomendioak (1), eta joeren datuek erakusten dute hobekuntza orokorra mugatua izan dela azken hamarkadan. Datuek nabarmentzen dute, halaber, emakumeak ez direla gizonak bezain aktiboak herrialde gehienetan, eta alde nabarmenak daudela jarduera fisikoaren mailetan herrialdeen eta eskualdeen artean. Desberdintasun horiek jarduera fisikoa egiteko aukeretan dauden desberdintasunen ondorioz azal daitezke, eta horrek are gehiago handitzen ditu osasun-arloko desberdintasunak. Gaur egun ez dago sedentarismoaren kalkulu globalik, baina, besteren artean, berrikuntza teknologikoa, trantsizio sedentarioagoa lanean eta aisialdian, eta motordun garraio pertsonalaren erabilera gero eta handiagoa mundu osoan ari dira jarduera fisikoaren ereduak aldatzen eta sedentarismoa areagotzen. Jarduera fisikoari buruzko ekintza-plan globalak 2018-2030 (14) 4 helburu estrategiko eta 20 politika-ekintza ezartzen ditu, 2030erako helduen eta nerabeen jarduera fisikorik ezaren prebalentzi globalean % 15eko murrizketa erlatiboa lortzeko. 2010ean OMEk Osasunerako jarduera fisikoari buruzko gomendio globalak (1) argitaratu zituen; populazion oinarritutako osasun publikoko lehen gidalerroak haurrentzat eta nerabeentzat, eta helduentzat eta adinekoentzat. 2018an, Osasunaren Mundu Batzarrak, WHA71.61 ebazpenean, 2010eko gomendioak eguneratzeko eskatu zion OMEri. 2019an OMEk 5 urtetik beherako haurrentzako jarduera fisikoari, sedentarismoari eta loari buruzko gidalerroak (15) argitaratu zituen. Haurren obesitateari azkena emateko (4.12 gomendioa) Batzordeak eskatu zituen (16) gidalerroak, eta 2010eko Osasunerako jarduera fisikoari buruzko gomendio globaletan (1) adin-talde gazteago horren omisioari heltzen diote. 2020ko OMEren Jarduera fisikoari eta sedentarismoari buruzko gidalerroek 2010ekoak ordezten dituzte, eta hautatutako portaeren ebidentzian eta osasunari lotutako ondorioetan izandako azkenaldiko aurrerapenetan oinarritzen dira. Jarduera fisikoari eta sedentarismoari buruzko gomendio globalen multzo orokorraren parte izango dira. 1 WHA71.6 OME Jarduera fisikoari buruzko ekintza-plan globala 2018–2030. Testuingurua 15 16 OME-REN FUNTSEZKO BESTE GIDALERRO BATZUK Jarduera fisikoak osasunerako duen garrantzia OMEren beste gidalerro batzuetan aitortzen da. OMEren Baliabide urriko inguruneetako lehen mailako osasun-arretarako gaixotasun ez kutsakorren funtsezko intebentzio-paketeak (17) protokolo bat ematen du hipertentsioaren, II motako diabetesaren, arrisku kardiobaskular handiaren, asmaren eta biriketako gaixotasun buxatzaile kronikoaren tratamendu klinikorako, eta gomendatu egiten du jarduera fisikoa pixkanaka maila ertainera (adibidez, bizkor ibiltzea) eta astean gutxienez 150 minutura handitzea. Narriadura kognitiboaren eta dementziaren arriskua murriztea (18) OMEren gida berriak ezartzen duenez, narriadura kognitiboaren arriskua murrizteko jarduera fisikoa gomendatu behar da hauentzat: kognizio normala duten helduak (gomendio sendoa) eta narriadura kognitibo arina dutenak (baldintzapeko gomendioa). OMEren Arreta integratua adinekoentzat: funtsezko gaitasun-murrizketak zuzentzeko komunitate-mailako interbentzioei buruzko gidalerroek (19) erorikoak prebenitzeko mota anitzeko ariketak gomendatzen dituzte mugikortasuna urritzen ari zaien adinekoentzat. OMEren Haurdunaldiaren esperientzia positiboa izateko jaiotza aurreko arretari buruz gomendioek (20) aholkularitza gomendatzen dute elikadura osasungarriari eta haurdunaldiko jarduera fisikoari buruz, osasuntsu mantentzeko eta pisua gehiegi ez handitzeko, baina ez diete heltzen haurdunaldian eta erditu ondoren jarduera fisikoak osasunerako dituen onura gehigarriei. OMEren gidalerroek, eguneratutako gidalerro hauekin batera, aholku osatuagoak ematen dituzte jarduera fisikoari eta sedentarismoari buruz, funtsezko gaixotasunak prebenitzen eta tratatzen, eta bizitzan zehar osasuna eta ongizatea sustatzen laguntzeko. OINARRIA ETA HELBURUA Azken 10 urteetan, jarduera fisikoaren mota, kantitate eta iraupen desberdinek osasunean duten eraginari buruzko ebidentzia-multzoak nabarmen gora egin duela ikusi da, baita sedentarismoaren eraginari eta jarduera fisikoaren eta osasunaren mailekin duen erlazioari buruz ere. Gainera, jarduera fisikorako ebidentzia-oinarriak azpipopulazioetan, hala nola haurdun dauden emakumeetan eta gaixotasun kronikoak eta/edo desgaitasuna dutenetan, orain aukera ematen du jarduera fisikoaren eta talde horietako osasun-emaitzen arteko lotura aztertzeko. Jarduera fisikoari buruzko ekintza-plan globalean 2018- 2030 (14), 4.1 ekintzak OMEri eskatzen dio egin eta zabal ditzala jarduera fisikoari eta sedentarismoari buruzko gomendio globalak 5 urtetik beherako haurrentzat, gazteentzat, helduentzat, adinekoentzat eta azpipopulazio espezifikoentzat (besteak beste, emakume haurdunak, gaixotasun kronikoak eta desgaitasuna duten pertsonak). Osasunaren Mundu Batzarrak eskatu bezala, gidalerroen irismena eguneratu eta zabaltzeak bermatu egiten du 2010eko gomendioetan sartzen ez diren populazio- taldeek jarduera fisikorako gomendio espezifikoak jasoko dituztela. Hori bat dator jarduera fisikoari buruzko ekintza-plan globalaren funtsezko printzipio eta helburuekin, hau da: desberdintasunak murriztea eta pertsona guztiei fisikoki aktiboagoak izaten laguntzea egunetik egunera. Gidalerro hauen helburu orokorra da osasun publikoko gomendioak ematea, jarduera fisikoaren neurriari eta motari buruzko ebidentzian oinarrituta. Haur eta nerabeei, helduei, adinekoei eta Azpipopulazioei (besteak beste, emakume haurdunak eta gaixotasun kronikoak edo desgaitasuna duten pertsonak) zuzendutako gomendioak dira, osasun-onura nabarmenak lortzeko eta osasun-arriskuak arintzeko bete beharrekoak. Gidalerroetan sedentarismoaren eta osasun-emaitzen arteko loturei buruzko ebidentzian oinarritutako gomendioak ere ematen dira. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Gidalerroak haur eta nerabeentzat (5-17 urte), helduentzat (18-64 urte) eta adinekoentzat (65 urtetik aurrera) garatu dira, eta lehen aldiz jarduera fisikoari buruzko gomendio espezifikoak jasotzen dituzte azpipopulazioentzat, besteak beste, haurdun dauden emakumeentzat eta gaixotasun kronikoak edo desgaitasuna duten pertsonentzat. Adin-talde eta azpipopulazio espezifiko bakoitzerako egiten dira gomendioak, komunitate bereziekin lan egiten dutenei informazio garrantzitsua erraz eskuratzeko aukera emateko. Azpipopulazioentzat gomendio espezifikoak emateak, batez ere gaixotasun kronikoak edo desgaitasuna dutenentzat, nabarmendu egiten du azpipopulazio horiek jarduera fisikoko eta sedentarismoko interbentzio-politiketan eta plangintzan sartzearen garrantzia. Gidalerro hauek ez du loa portaeratzat hartzen. Loa osasunarekin lotutako alderdi garrantzitsua da, populazioaren osasun-zientzien barruan jorratzen ari den gaia, baina aginteen irismenetik kanpo geratu zen gomendioak eguneratzean. Hala ere, aitortu egiten da loaren garrantzia, eta garrantzizko osasun- emaitza gisa barne hartu zen jarduera fisikoaren eta sedentarismoaren eragina kontuan hartzean. NORI ZUZENDUAK Dokumentu honek prozesuaren berri ematen du eta gomendioak garatzeko berrikusitako ebidentzia-oinarria laburbiltzen du. Hauei dago nagusiki zuzendua: 1. Politiken diseinuaren arduradunak osasun, hezkuntza, gazteria, kirol eta/edo gizarte- edo familia-ongizateko ministerioetan, diru-sarrera altu, baxu eta ertaineko herrialdeetan lan egiten dutenak herrialde bakoitzerako gidalerro espezifikoak emateko, eta bizitza osoan zehar interbentzio-programak planifikatzen dituztenak eremu hauetan: osasuna, hezkuntza, lana, familia edo komunitatea. 2. Gobernu-funtzionarioak, populazio-taldeetan jarduera fisikoa areagotzeko eta sedentarismoa murrizteko plan nazionalak, eskualde azpikoak edo udalekoak garatzen dituztenak orientazio- agirien bidez. 3. Gobernuz kanpoko erakundeetan, hezkuntza- eta lan-erakundeetan edo ikerketa-erakundeetan lan egiten duten pertsonak. 4. Osasun-zerbitzuetan lan egiten duten pertsonak eta aholkularitza eta orientazioa ematen dutenak, besteak beste, erizain edo mediku komunitarioak, familiakoak, lehen arretakoak edo espezializatuak, edo osasunari eta ariketari lotutako bestelako profesionalak, osasun-sektoretik harago lan egiten dutenak. Gidalerro hauek gai horiei buruzko aholkuen edukiaren berri eman dezakete, gidalerro nazionalik ez badago. Gidalerroetan jarduera fisikoari eta sedentarismoari buruz jasotako gomendioak zerbitzua eman aurreko prestakuntzarako eta lanbide-garapenerako ikastaroetan informazioa emateko erabili behar dira osasun-arloko langileentzat, jarduera fisikoko espezialistentzat eta hezkuntzako profesionalentzat. Produktu eratorriak behar dira gidalerro hauek azken erabiltzaile espezifikoei, osasunetik kanpoko sektoreetan interesa duten aldeei eta, oro har, komunitateari transmititzeko, komunikazio pertsonalizatuak erabiltzen dituztenei hartzaile bakoitzaren behar espezifikoei erantzuteko. Testuingurua 17 18 METODOAK Gidalerro hauek OMEren Gidalerroak garatzeko eskuliburuaren (bigarren edizioa) (21) arabera garatu ziren. OMEren zuzendaritza-talde bat ezarri zen, Osasuna Sustatzeko Sailak zuzendua, OMEren eskualde- bulegoen eta dagokien OMEren sailen ordezkaritzarekin. Gidalerroak Garatzeko Taldea (GDG) eratu zen, 27 adituk eta alderdi interesatuk osatua, genero-oreka eta geografia-aniztasuna kontuan hartuta. Gidalerroen zirriborroa kanpotik berrikusi zuten zazpi ikuskatzaile independentek, eta ebidentzia zientifikoari, haren interpretazioari eta edukiari buruzko iruzkinak egin zituzten. Gainera, gidalerroen zirriborroari buruzko online kontsulta publiko bat egin zen, eta 400 kolaboratzailek baino gehiagok egindako iruzkinak jaso ziren. Zientzialari, mediku eta publiko orokorraren ekarpen horiek GDGk bildu eta erabili zituen gidalerroak amaitzeko. Gidalerroak garatzeko prozesuaren kudeaketari buruzko xehetasun guztiak 1. eranskinean daude eskuragarri. GIDALERROEN IRISMENA ETA INTERESEKO GALDERAK GDGk gidalerroen irismena berrikusi zuen eta, lehen bileran, PI/ECO (Populazioa, Interbentzioa/Esposizioa, Konparazioa, Emaitza) galdera garrantzitsuenak adostu zituen. Azpipopulazio bakoitzerako landutako funtsezko galderak jarraian laburbiltzen dira: Jarduera fisikorako: a. Zein da jarduera fisikoaren eta osasun- emaitzen arteko lotura? b. Badago dosi-erantzun loturarik (guztizko kantitatea, iraupena, maiztasuna, etenaldiaren intentsitatea)? c. Lotura aldatzen da jarduera fisikoaren motaren edo eremuaren arabera? Sedentarismorako: a. Zein da sedentarismoaren eta osasun- emaitzen arteko lotura? b. Badago dosi-erantzun loturarik (guztizko kantitatea, maiztasuna, iraupena eta intentsitatea)? c. Lotura aldatzen da sedentarismoaren motaren eta eremuaren arabera? d. Helduetan soilik: Jarduera fisikoak aldatzen du sedentarismoak hilkortasunean duen eragina? Populazio (P) bakoitzarentzat, esposizioa (E) hau izan zen: jarduera fisikoaren kantitate, iraupen, maiztasun edo intentsitate handiagoa; konparazioa (K) hau izan zen: jarduera fisikorik eza edo jarduera fisikoaren kantitate, maiztasun, intentsitate edo iraupen gutxiago. Populazio bakoitzaren emaitza kritiko eta garrantzitsuak 1. taulan laburbiltzen dira, eta PI/ECO galdera bakoitzaren xehetasunak web-eranskinean, dagokion atalean: ebidentzia-profilak .. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Metodoak 19 1. taula: Osasun-emaitza kritiko eta garrantzitsuen laburpena* populazio-taldeen araberagroups Emaitzak (ordena alfabetikoan) Haur eta nerabeak adina 5–17 urte: PA eta sedentarioa Helduak adina 18– 64 urte: PA Helduak 18 urte eta gehiago sedentarioa Gaixotasun kronikoakb Haurrak eta helduak desgaitasunarekinc Adipositatea (pisu gehitzea, pisu aldatzea, pisu kontrola, pisu egonkortasuna, pisu egoera eta pisu mantentzea) Kritikoa Kritikoa Kritikoa Kritikoaa Kritikoa Kritikoa – GIB – Gertakari kaltegarriak Kritikoa Kritikoa – Kritikoaa Kritikoa (emaitzak fetuan) – – Hilkortasuna kausa guztiengatik eta kausa espezifikoengatik – Kritikoa (minbizi eta CVD espezifikoa) Kritikoa Kritikoaa – Kritikoa – Hezurren osasuna Kritikoa – Garrantzitsua – – – – Osasun kardiometabolikoa Kritikoa – – – – – – Emaitza kognitiboak Kritikoa Kritikoa Garrantzitsua Kritikoaa – – Kritikoa – MS, PD, Stk, Sch, ADHD Konplikazioak erditzean – – – – Garrantzits ua – – Gaixotasunaren progresioa – – – – – Kritikoa – HT, T2D, HIV, Kritikoa – minbizi errekurrentzia – Erorikoak eta haiei lotutako lesioak – – – Kritikoa – – – Fetuen emaitzak (jaiotza-pisua, jaiotza goiztiarra) – – – – Kritikoa – – Gaitasun funtzionala – – – Kritikoa – – – Diabetes mellitus gestazionala – – – – Kritikoa – – Haurdunaldiko hipertentsioa/ aurre- eklanpsia – – – – Kritikoa – – Osasunarekin lotutako bizi- kalitatea – Garrantzitsua Garrantzitsua Garrantzitsuaa – Kritikoa – HT, T2D, HIV Kritikoa – MS, SCI, ID, MCD, Sch Minbizi-intzidentzia – Kritikoa Kritikoa Kritikoaa – – – CVD intzidentzia – Kritikoa Kritikoa Kritikoaa – – – Hipertentsio-intzidentzia – Garrantzitsua Garrantzitsuaa – – – II motako diabetes-intzidentzia – Kritikoa Kritikoa Kritikoaa – – – Osasun mentala (antsietate- eta depresio-sintomak) Kritikoa Kritikoa Garrantzitsua Kritikoaa Kritikoa – – Osteoporosia – – – Kritikoa – – – Gaitasun fisikoa Kritikoa – Garrantzitsua – – – – Funtzio fisikoa – – Garrantzitsua – – Kritikoa – HT, T2D, HIV Kritikoa – MS, SCI, ID, PD, Stk Jokabide prosoziala Garrantzitsua – – – – – – Emaitza psikosozialak – – – Garrantzitsua – – – Gaixotasun komorbidoen arriskua – – – – – Kritikoa – HT, T2D, HIV Kritikoa – MS, SCI, ID Loa Garrantzitsua Garrantzitsua Garrantzitsua Garrantzitsuaa – – – * Emaitza kritikoa: erabakiak hartzeko funtsezkoa den emaitza; Emaitza garrantzitsua: emaitza garrantzitsua da, baina ez da kritikoa erabakiak hartzeko a Helduentzat, adinekoak barne, kontuan hartutako emaitza kritiko eta garrantzitsuak. b Emaitzak azpipopulazioaren gaixotasunei dagozkie, zerrendaren arabera: minbizia – minbizitik bizirik irtendakoak; HT – hipertentsioa; T2D – II motako diabetesa; GIB c Emaitzak azpipopulazioaren gaixotasunei dagozkie, zerrendaren arabera: ME – esklerosi muskularra; SCI – bizkarrezur-muineko lesioa; ID – desgaitasun intelektuala; PD – Parkinsonen gaixotasuna; Stk – istripu zerebrobaskularretatik bizirik irtendakoak; Sch – eskizofrenia; ADHN –arreta-defizit/hiperaktibitate nahasmendua. Helduak 65 urte eta gehiago: PA* Haurdunaldia eta erditu ondoren 20 Online eskuragarri, hemen: https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf EBIDENTZIA Jarduera fisikoari buruzko OMEren 2010eko gomendioen berrikuspena egiteko, gidalerro hauen irismenarekin lotutako berrikuspen orokor esanguratsuenak eta berrienak identifikatu eta eguneratu ziren. Jarduera fisikoari buruzko zenbait gidalerro nazionalen garapenaz informatzeko aurrera eramandako berrikuspen sistematiko berrien ugaritasunagatik egin zen hurbilketa hori. Eta eguneratze gehigarriari ekin zitzaion, bermatzeko OMEren gidalerro berriek jaso egiten dituztela bizkor garatzen ari den osasun publikoaren eremu zehatz honetan eskuragarri dauden datu berrienak. Berrikuspen orokorrak hautatu ziren, baldin eta honako hiru irizpide hauek betetzen bazituzten: i) ebidentziaren berrikuspenak ondo dokumentatutako prozesu sistematiko estandarren arabera egin ziren; ii) ebidentziaren ziurtasuna ebaluatzeko Gomendioak Baliozkotzeko, Garatzeko eta Ebaluatzeko Kalifikazioa (GRADE) metodoa edo argi deskribatu eta dokumentatutako metodologia baliokide bat erabili zen; eta iii) ebidentziaren berrikuspenak intereseko populazioei zuzendu zitzaizkien, herrialdeari edo herrialdeko diru-sarreren mailari mugarik ezarri gabe. PI/ECOren galderak eta osasun-emaitza kritiko eta garrantzitsuak alderatu ziren dauden ebidentzia- berrikuspenekin, eta, beharrezkoa izan zenean, beste berrikuspen batzuk eskatu ziren arrakalei heltzeko. GDGk ebidentzia-berrikuspenak eguneratzeko eskatu zuen, jatorrizko berrikuspenen ikerketa-termino berak, hizkuntza- termino berak eta datu-base berak erabilita. Ondoko ebidentzia-berrikuspenek aurreko hiru irizpideak betetzen zituztela identifikatu zen, eta haien gaurkotasun eta zabaltasunaren arabera hautatu ziren: • Literaturaren berrikuspen sistematikoa jarduera fisikoaren eta eskola-adineko haur eta gazteen osasun- adierazleen arteko loturari buruz (22), Poitras et al.-ek (2016) egina, Kanadako haur eta gazteentzako 24 orduko mugimendu-gidalerroak (23) garatzeko prozesuaren barruan. Berrikuspen hori jarduera fisikoaren neurketa objektiboak erabili zituzten azterlanetan soilik oinarritu zen. Guztira 162 azterlan bildu ziren, 31 herrialdetako 204.171 parte-hartzaile ordezkatzen zituztenak. • Literaturaren berrikuspen sistematikoa, eskola-adineko haurren sedentarismoaren eta osasun-adierazleen arteko loturari buruz, Carson et al.-ek (2016) (24) egina, Kanadako haur eta gazteentzako 24 orduko mugimendu- gidalerroak (23) garatzeko prozesuaren barruan. Guztira 235 azterlan sartu ziren (194 lagin bakar), 71 herrialdetako 1.657.064 parte-hartzaile ordezkatzen zituztenak. • Berrikuspen sistematikoa, Okely et al.-ek (2019) (25) egina, Poitras et al. (2016) (22) eta Carson et al. (2018) (24) eguneratzeko, 2019ko Australiako haur eta gazteentzako 24 orduko mugimendu-gidalerroen (adina 5-17 urte) (26) garapenaren barruan. Txosten horrek jarduera fisikoari buruzko 42 azterlan eta sedentarismoari buruzko 32 azterlan identifikatu zituen, 2018ko uztailaren 29ra arte argitaratuak (25). Okely et al.-ek garatutako GRADE taulak OMErentzat egindako eguneratzearen oinarri gisa erabili ziren. GRADE taulak eta ebidentzia-profilak web- eranskinean daude: Ebidentzia-profilak. • 12 berrikuspen sistematikoak, 2019ko Haurdunaldiko jarduera fisikorako Kanadako gidalerroen (27) garapenaren barruan eginak eta laburbilduak. 12 berrikuspen horiek haurdunaldiko jarduera fisikoari buruzko 25.000 azterlan (ingelesez, gaztelaniaz eta frantsesez) baino gehiago ebaluatu zituzten amaren, fetuaren edo jaioberriaren morbilitateari edo fetuaren heriotza-tasari buruz informatzeko. Berrikuspen sistematiko horietatik zazpik GDGk kritikotzat eta garrantzitsutzat jotako emaitzak jorratu zituzten (28- 34). Ebidentzia-berrikuspen horien GRADE taulak OMEren gomendioen garapena eguneratzeko eta informatzeko egindako bilaketa bibliografikorako oinarri gisa erabili ziren. Ebidentzia-profil eguneratuak web-eranskinean aurkezten dira: Ebidentzia-profilak. • Jarduera Fisikorako Gidalerroen Aholkularitza Batzordearen (PAGAC) (35) txosten zientifikoa, 2018ko Estatubatuarren jarduera fisikorako gidalerroen ( 2. edizioa) (36) garapenaren barruan 2008-2016 artean argitaratutako jarduera fisikoari eta sedentarismoari buruzko ebidentziaren eta osasun- emaitzen eguneratze sistematikoa ematen duena. Ebidentzia-sintesiak ikerketako 38 galdera nagusi eta 104 azpigaldera jorratu zituen, osasun publikoan duten garrantziagatik hautatuak. Ebidentziak emaitzak jaso zituen berrikuspen sistematikoetatik: 1.130 artikulu guztira, bakoitza ikerketako 38 galderei erantzuteko laburtua (35). Protokoloek "Berrikuspen Sistematikoak Ebaluatzeko Neurketa Tresna"-ren (AMSTARExBP) bertsio aldatua erabili zuten berrikuspen sistematikoen eta metanalisien kalitate metodologikoa ebaluatzeko. Alborapen-arriskua, edo barne-baliozkotasuna, jatorrizko azterlan bakoitzean ebaluatu zen, USDAren NEL Alborapena Ebaluatzeko Tresnaren (BAT) (37) bertsio egokitua erabilita. OMEren gidalerro hauetarako egindako bilaketa eguneratuetan identifikatutako ebidentzia berria ebidentzia-profiletan aurkezten da web-eranskinean: Ebidentzia- profilak; txostenerako estekak eta PAGACen material osagarriak ematen dira (35). O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Metodoak 21 Ebidentzia eguneratzeko eta datuak erauzteko metodoak Berrikuspen sistematikoen bilaketa egin zen, baita kohorte- azterlanen analisi konbinatuak ere, barne hartutako berrikuspen bakoitzari dagozkion azken bilaketen datatik (goian adieraziak) 2019ko irailera arte argitaratutako azterlanetarako; datuak ateratzeko protokolo estandarizatuak garatu eta erabili ziren. Poitras et al-ek (2016) (22), Carson et al.-ek (2016) (24) eta Okely et al.-ek (2019) (25) egindako bilaketak eguneratzeko, bilaketak egin ziren MEDLINE, EMBASE, PsycINFO eta SportDiscus datu-baseetan, kidekoek egindako berrikuspenak, ingelesez edo frantsesez idatziak, identifikatzeko. PAGACek (35) egindako bilaketak eguneratzeko, PubMed, CINAHL eta Cochrane datu- baseetan egin ziren bilaketak, kidekoen berrikuspenak, ingelesez idatziak, identifikatzeko. Ez zen emaitza garrantzitsuen bilaketa berririk egin, PAGACek (35) barne hartu ez zituen horienak baliabideetan mugak ezarri zirelako. Bilaketak egitean ez zen mugarik ezarri herrialdeei edo haien diru-sarreren mailari dagokienez, eta subjektiboki edo objektiboki neurtutako edozein jarduera fisiko edo portaera sedentario jorratzen duten berrikuspenak barnean hartuta. Bilaketak jatorrizko hizkuntzetan bakarrik egitea erabaki zen, baliabideak mugatuta zeudelako eta, aurrez izandako esperientziak kontuan hartuta, bilaketa horiek oso berrikuspen gehigarri gutxi (edo batere ez) izan zutelako. Jarduera fisikoaren edo sedentarismoaren eta osasun- emaitzen arteko lotura aztertu zuten berrikuspenak hartu ziren kontuan (jarduera fisikoaren edo sedentarismoaren atalase batetik gorako edo beherako mailetan oinarrituta), eta horien eta osasun-emaitzen arteko dosi-erantzun erlazioa aztertu ziren. Kanpoko ikuskatzaile-talde batek AMSTAR 2 (Berrikuspen Sistematiko Anizkoitzen Ebaluazioa) tresna erabili zuen barnean hartzeko xedez kontuan hartu ziren berrikuspen sistematikoen sinesgarritasuna kalifikatzeko (38). AMSTAR 2 tresnak 16 elementu biltzen ditu, berrikuspena planifikatzearekin eta egitearekin lotuak. Berrikuspen bakoitzaren emaitzekiko konfiantza orokorra argitaratutako gidaren arabera kalifikatu zen: "altua", berrikuspenaren ahultasun ez kritikoa zero edo bat denean; "ertaina", berrikuspenaren ahultasun ez kritikoa bat baino gehiago dela uste denean; "baxua", berrikuspenaren akats kritikoa bat dela uste denean, ahultasun ez kritikoekin edo gabe, edo ahultasun ez kritiko anitzekin; eta "kritikoki baxua" akats kritiko bat baino gehiago ageri denean. Berrikusle batek AMSTAR 2 tresna osatu zuen behin-behinean barne hartutako berrikuspen guztietarako. Ikuskatzaile batek kritikoki baxutzat jo zituen berrikuspenak tresna bera erabilita berrikusi zituen bigarren ikuskatzaile batek. Azkenean baztertu egin ziren kritikoki baxutzat jotako berrikuspenak, uste zelako ez zirela fidagarriegiak eskura zegoen ebidentziaren laburpen zehatza eta osoa emateko, emaitza jakin baterako eskuragarri zegoen berrikuspen bakarra izan ezean. Ebidentzia-multzo horretan kohorte-azterlan partekatuak ere sartu ziren. Kanpoko ikuskatzaile talde batek Newcastle-Ottawa eskala erabili zuen azterlanen kalitatea ebaluatzeko (39). Azterlan bakoitzak "altua", "ertaina" edo "baxua" kalifikazioa jaso zuen. Oro har, kalitate oneko azterlan batek Newcastle-Ottawa eskalako irizpide guztiak betetzen zituen. Kalitate ertaineko azterlan batek ez zuen betetzen, edo ez zegoen argi irizpide bat gutxienez betetzen zuenik, baina ez zuen bere emaitzak baliogabetzeko muga garrantzitsu jakinik ere. Kalitate txarreko azterlan batek akats nabarmen bakar bat zuen, edo muga garrantzitsu ugari. Baztertu egin ziren kalitate txarreko azterlanak. Gainjartzeak ebaluatu ziren, berrikuspen anitzetan azterlanen bikoizketa-potentziala aintzat hartuta. Baztertu egin ziren ebidentzia-multzo erredundanteak zituzten berrikuspenak, berrikuspenen laburpenak eta kohorte-azterlanen analisi konbinatu batzuk, non beste berrikuspen osatuagoak eta/edo berriagoak identifikatu baitziren. Berrikuspen berrietarako metodoak Ebidentzian hutsuneak identifikatu zirenean, berrikuspen orokor berriak egiteko eskatu zen, honako hauek aztertzeko: 1. lan-eremuko jarduera fisikoaren (hau da, lanarekin lotua) eta osasun-emaitzen arteko lotura (40); eta 2. aisia-eremuko jarduera fisikoaren eta osasun- emaitza kaltegarrien arteko lotura (41). (Aurreko 1. eta 2. zenbakietarako, PubMed, SportDiscus eta EMBASE erabilita egin ziren bilaketak, 2009tik 2019ko abendura arte argitaratutako berrikuspenetarako) 3. jarduera fisikoaren eta erorikoen prebentzioaren arteko lotura; Sherrington et al.-en (42) 2019ko Cochrane Collaboration Systematic Review berrikuspena erabili zen, eta haien jatorrizko berrikuspenaren azken bilaketaren datatik 2019ko azarora arte argitaratutako ebidentziarekin eguneratu zen. 4. jarduera fisikoaren eta osteoporosiaren eta sarkopeniaren arteko lotura. Osteoporosiari eta sarkopeniari buruzko berrikuspen sistematikoen bilaketak, PubMed-en egina 2008tik 2019ko azarora arte argitaratutako berrikuspenetarako, ez zuen identifikatu berrikuspen berririk bai, ordea, lehen mailako zortzi azterlan berri. 5. jarduera fisikoaren eta osasun-emaitzen arteko loturei buruzko ebidentzia GIBa duten pertsonetan. GIBa duten pertsonen artean, jarduera fisikoari eta osasun-emaitzei buruzko 22 ebidentziaren eskuragarritasuna aurretiko berrikuspen batek zehaztu zuen, berrikuspen orokor bat egiten laguntzeko, hasiera-datan mugarik ezarri gabe 2019ko urrira arte argitaratutako ebidentziarako, PubMed, CINAHL eta Web of Science erabilita. Ebidentziaren ezaugarrien laburpena eta jarduera fisikoa eta sedentarismoa ebaluatzeko metodoak Duela gutxi arte, helduen kasuan, jarduera fisikoa eta sedentarismoa neurtzeko metodo nagusiak autoinformea (hau da, inkesta) izan da, eta, haurren kasuan, autoinformea edo gurasoen oroimena. Metodo horiek ondo ezarritako indarguneak dituzten arren, mugek oroimen- alborapenak eta neurketa-akatsak jakinarazteko joera hartzen dute barne (43). Azken urteotan, arlo horretan teknologia digitala azkar hazi denez, handitu egin da jarduera fisikoa eta denbora sedentarioa ebaluatzeko gailuetan oinarritutako neurrien erabilera, bai eta osasun- emaitzekin dituen loturak ere. Hala ere, oraindik ere badaude erronkak azterlanen arteko emaitzak alderatzeko, ezaugarri teknikoen eta gailuen kokapenaren (azelerometroak) eta datuen analisien eta txostenen arteko aldeak direla eta. Adibidez, denbora sedentarioa gailuetan oinarritutako neurriekin neurtzean, kalkulu-akatsak gerta daitezke, gaur egun gailu askok ez baitituzte jarrerak bereizten (adibidez, etzanda, eserita eta geldirik). Zailtasunak daude, halaber, gailuetan oinarritutako neurriak erabiltzen dituzten azterlanen emaitzak autoinforme- neurrien emaitzak informatzen dituztenekin alderatzean. Autoinforme-tresnak edukiz aldatzen dira, jarduera fisikoaren adibideetan, erantzun-aukeretan eta barne hartutako arloetan. Duela gutxi arte, azterlanek guztizko jarduera fisikoa edo jarduera fisikoa aisia/jolas eremuan soilik ebaluatzen zuten nagusiki, baina orain gero eta eremu gehiago sartzen dituzte, hala nola garraiatzeko jarduera fisikoa (adibidez, oinez eta bizikletaz ibiltzea), lanean eta etxean. Ebidentzia gehienek jarduera fisiko aerobikoaren eta osasun-emaitzen arteko loturei buruzko informazioa ematen dute; hala ere, orain, muskuluak indartzearen onurak ebaluatzen ari dira, baita jarduera- mota desberdinen eta beste eremu batzuen konbinazioak ere. Jarduera fisikoaren mailen eta osasun-emaitzen arteko loturari buruzko emaitzak hainbat modutara informatzen eta alderatzen dira. Ikerketa askok jarduera fisikoaren kuartilen edo kintilen arteko alderaketak egiten dituzte, eta beste ikerketa batzuek gidalerro nazionalak "betetzen ez" dituztenak alderatzen dituzte. Jarduera fisikoaren mailen eta osasun-emaitzen arteko loturari buruzko emaitzak hainbat modutara informatzen eta alderatzen dira. Ikerketa askok jarduera fisikoaren kuartilen edo kintilen arteko alderaketak egiten dituzte, eta beste ikerketa batzuek gidalerro nazionalak "betetzen ez" dituztenak alderatzen dituzte. Informatzen denean, guztizko jarduera fisikoaren kalkulua asteko MET orduetan kalkulatzen da oro har, eta zenbait azterlanek "altuena" eta "baxuena" alderatzen dituzte, nahiz eta kategoriak ere aldatu egiten diren azterlanen artean. Literaturak sarritan ematen ditu datuen ebaki-puntuak aplikatzen dituzten analisien emaitzen berri, dagoen gida batean oinarrituta, edo OMEren gaur egungo gomendio globalean, edo aurreko ikerketen metriketan (adibidez, eguneko 60 minutuko ebaki-puntuak populazio gazteei buruzko ikerketan, edo astean 2-3 aldiko maiztasuna indar-entrenamenduaren interbentzioan). Ebaki-puntu horiek ohikoak bilakatzen direnean, mugatu egin daiteke jarduera fisikoaren esposizio-maila altuenak edo baxuenak osasun-emaitzekin lotzen dituzten ebidentzien metaketa. Haur eta nerabeen sedentarismoaren eta osasun- emaitzen arteko loturak ebaluatzen dituen ebidentzia gehiena zeharkakoa da, eta azterlan gehienak gurasoek jakinarazitako denbora sedentarioaren neurrietan oinarritzen dira, neurketa-akatsak eta oroimen- alborapenak dituztela kontuan hartuta. Luzetarako behaketa-azterlanen eta interbentzio- proben ebidentzia lehenetsi zen, eta ez ziren kontuan hartu zeharkako ebidentzia bakarrik edo nagusiki laburbiltzen zuten berrikuspenak. Garrantzi handiagoa eman zitzaion ziurtasun ertaineko edo altuagoko berrikuspenek emandako ebidentziari, baita gailuetan oinarritutako esposizio-neurriak erabiltzen dituzten azterlanen ebidentzia eman zutenei ere. Ebidentzia-multzoaren kalifikazioa Gomendioak Baliozkotzeko, Garatzeko eta Ebaluatzeko Kalifikazioa (GRADE) metodoa erabili zen ebidentziaren ziurtasuna kalifikatzeko IP/ECO (44) bakoitzerako, berrikuspenen azpiko ebidentzian oinarrituta. Eskuragarri egon zirenean, berrikuspen bakoitzeko "Ebidentzia-profilak" edo "Aurkikuntzen laburpena" GRADE taulak erabili ziren abiapuntu gisa. Dauden berrikuspen sistematikoen barruan taula eskuragarririk ez bazegoen, "Ebidentzia-profila" taulak egin ziren populazio eta emaitza interesgarri bakoitzerako. GRADE metodoa erabili zen IP/ECO (44) bakoitzerako ebidentziaren ziurtasuna kalifikatzeko, irizpide hauek kontuan hartuta: azterlanaren diseinua; alborapen- arriskua; eraginaren sendotasuna; zeharkakotasuna; eraginaren zehaztasuna; eta beste muga batzuk, joeren eta faktoreen argitalpena barne, behaketa-ebidentzia eguneratzeko (eraginaren magnitudea, dosi-erantzuna eta nahaste-faktoreen eraginak) barne. Ondo burututako luzetarako azterlanen behaketa-ebidentzia ere eguneratu zen, egokiago islatzeko aurkikuntzetan ziurtasuna altuagoa dela jarduera fisikoaren edo sedentarismoaren eta azterlan horien emaitzen arteko loturei dagokienez. Tarteko/zeharkako emaitzak ebaluatu zituzten azterlanak ez ziren baztertu, GDGk O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Metodoak 23 emaitzak lehenetsi baitzituen (tarteko emaitzak barne); GRADE kalifikazioak emaitza horien gaineko eraginen ziurtasuna islatzen du. Kasu batzuetan, berrikuspenen GRADE kalifikazioak aldatu egin ziren GRADE metodoen aplikazioan koherentzia bermatzeko. Emaitza bakoitzerako ebidentzia-multzoaren ziurtasuna gida honetan oinarrituta eman zen (45): Altua Ziurtasun handia eragin erreala hurbildu egiten dela eraginaren kalkulura. Ertaina Ziurtasun ertaina eraginaren kalkuluan: litekeena da eragin erreala eraginaren kalkulura hurbiltzea, baina gerta daiteke ere desberdintasuna nabarmena izatea. Baxua Ziurtasun mugatua eraginaren kalkuluan: desberdintasuna nabarmena izan daiteke eragin errealaren eta eraginaren kalkuluaren artean. Oso baxua Ziurtasun oso urria eraginaren kalkuluan: litekeena da eragin errealaren eta eraginaren kakuluaren arteko desberdintasuna nabarmena izatea. Ebidentziatik gomendioetara GRADE Ebidentziatik Erabakira (EtD) esparrua erabili zuen GDGk, galdera espezifikoetarako gomendioak sortzeko. EtD esparrua erabakiak hartzeko ikuspegi sistematikoa, egituratua eta gardena da. Esparruak irizpide esplizituak erabiltzen ditu gidalerroen gomendioak sortzeko, kontuan hartuta ikerketaren ebidentzia, ebidentziaren ziurtasuna eta, beharrezkoa denean, adituen iritzia eta gaiari buruzko ezagutza xede-publikoaren ikuspegitik. Irizpideek honako hauen arteko orekari buruzko iritziak sortzen dituzte: behatutako emaitza desiragarri eta ez desiragarrien ebidentzia, ebidentziaren ziurtasun orokorra, pazienteen balio erlatiboak emaitza desiragarri eta ez desiragarrietarako, baliabideen erabilera (kostuei buruzko kontsiderazioak) hala dagokionean, inpaktu potentziala osasun-arloko ekitaterik ezean, gomendioen onargarritasuna eta bideragarritasuna. GDGk gomendio bakoitzerako ebidentzia-multzoa bere osotasunean aztertu zuen emaitza kritiko guztietarako eta eskura zeuden emaitza garrantzitsu guztietarako. Esposizio/interbentzioaren eta emaitzaren arteko lotura jakin baterako, azterlanek alde handiak izan zituzten ebaluatutako esposizio/interbentzio espezifikoan, ebaluatutako emaitzetan, azterlan eta metodo analitikoen diseinuan, eta horrek heterogeneotasuna ematen dio eskura dagoen ebidentziari. Beraz, ezin izan zen ohiko GRADE hurbilketa aplikatu esposizio/interbentzio espezifiko eta emaitza arteko lotura bakoitzean; aitzitik, esposizio/interbentzio eta emaitza arteko lotura espezifikoari heltzen dioten ebidentzia-multzo orokorrerako GRADE aplikatu zen, azterlanen diseinu- motetan eta esposizio/interbentzioaren neurketen eta analisien aldagaietan. Faktore horiek ebidentziaren koherentziari buruzko kezkak sortu zituztenean (hau da, esposizio/interbentzio jakin baten eta emaitzaren arteko loturaren ebidentzia ez zetorrenean bat modu desberdinetan behatuta), panelak ebidentziaren ziurtasuna murriztu zuen (21). GDGk, jarduera fisikoaren eta sedentarismoaren eraginak jorratzeko, osasun-emaitza hauek lehenetsi zituen: hilkortasuna txikiagoa kausa guztiek eta espezifikoek (gaixotasun kardiobaskularrak eta minbizia) eraginda; intzidentzia gutxiago gaixotasun kardiobaskularretan; minbizi espezifikoetan; II motako diabetesean; hobekuntza gaitasun fisikoan (adibidez, bihotz eta arnas sistema, garapen motorra, muskuluen gaitasuna); hobekuntza osasun kardiometabolikoan (adibidez, presio arteriala, dislipidemia, glukosa, erresistentzia insulinarekiko); hezurren osasunean; osasun mentalean (adibidez, depresio-eta antsietate- sintoma, autoestimu-arazo, ADHN murriztuak); eta emaitza kognitibo hobeak (adibidez, errendimendu akademikoa, funtzio exekutiboa); eta adipositate murriztua. Ondorio kaltegarriak ere kontuan hartu ziren (adibidez, lesioak eta minak). Ohar gehigarriak Populazio bakoitzerako eta PI/ECOren galdera guztietarako, GDGk ondokoak kontuan hartu zituen: gidalerroak zuzentzen zaizkien pertsonen balioak eta lehentasunak; gomendioen inplikazioak baliabideetan; eragina osasun-arloko ekitatean; eta gomendioen onargarritasuna eta bideragarritasuna. Populazio-talde bakoitzerako nabarmena izan zenez bikoizketa kontsiderazio horietan, eta GDGren ebaluazioan, elementu horien ebaluazioari buruzko eztabaiden laburpen bat azaltzen da "Ebidentziatik gomendioetara" atalean. 24 GOMENDIOAK OMEren Jarduera fisikoari eta sedentarismoari buruzko gidalerroetan aurkeztutako osasun publikoko gomendioak populazio guztientzat dira, eta adin- taldeak 5 urtetik hasi eta 65 urte edo gehiagora, generoa, jatorri kulturala edo egoera sozioekonomikoa edozein dela ere, eta garrantzitsuak dira gaitasun oro dituzten pertsonentzat. Gidalerro berriak adin-taldearen eta portaeraren (jarduera fisikoa eta sedentarismoa) arabera aurkezten dira. Gomendio-multzo bakoitzerako, sarrerako adierazpen batek jarduera fisikoarekin eta sedentarismoarekin lotutako osasun-emaitzak laburbiltzen ditu, hurrenez hurren; ondoren, gomendioak agertzen dira. Jardunbide egokien adierazpen-multzo bat ematen da, xede-populazioak gomendioa modu seguru batean nola bete dezakeen argitzeko. Jardunbide egokien adierazpen horiek ez dira, berez, "gomendio sailkatuak", baizik eta ebidentzia zientifikotik eta GDGk berrikusi eta gomendatutako kontsiderazio praktikoetatik eratorriak. Gomendio multzo bakoitzerako, ebidentzia zientifikoen laburpen bat ematen da, PI/ECO hiru galderen bidez egituratua; lehenik eta behin, osasun-emaitza kritikoekin lotutako ebidentzia aurkezten da eta, ondoren, dosi- erantzunari buruzko ebidentziaren laburpen bat. Azkenik, esposizio-mota edo -eremu desberdinen eta osasun- emaitzen arteko loturari buruzko ebidentziaren laburpena aurkezten da, halakorik dagoenean. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Gomendioak 25 Haur eta nerabeentzat, jarduera fisikoa ondokoetan sar daiteke: aisialdian (jolasa, jokoak, kirolak edo ariketa planifikatua), gorputz-heziketan, garraiatzean (gurpiletan, oinez eta bizikletan ibiltzea) edo etxeko zereginetan, eta hezkuntzako, familiako eta komunitateko inguruneetan. Aldeko ebidentzia eta oinarria Haur eta nerabeentzako gidalerro hauetarako berrikuspen sistematikoak erabili ziren (22, 25, 35), eta 16 berrikuspen identifikaturekin eguneratu ziren, inklusio-irizpideak betez. Metodoen, datu-erauzketaren eta ebidentzia-profilen xehetasun guztiak web-eranskinean aurki daitezke: ebidentzia-profilak . Online eskuragarri, hemen: https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf J A R D U IN B ID E E G O K IA K Haur eta nerabeetan, jarduera fisikoak onurak dakartza osasun-emaitza hauetarako: hobetu egiten ditu gaitasun fisikoa (bihotz eta arnas sistemaren gaitasuna eta muskuluena), osasun kardiometabolikoa (presio arteriala, dislipidemia, glukosa eta intsulinarekiko erresistentzia), hezurren osasuna, emaitza kognitiboak (errendimendu akademikoa, funtzio exekutiboa), osasun mentala (depresio-sintoma gutxiago); eta murriztu egiten du adipositatea. Hau gomendatzen da:  Haur eta nerabeek eguneko batez beste 60 minutu egin behar dute jarduera fisikoa intentsitate ertaina eta bizia batez ere aerobikoa, astean zehar. Gomendio sendoa, ziurtasun ertaineko ebidentzia  Intentsitate biziko jarduera aerobikoak, baita muskuluak eta hezurrak indartzekoak ere, gutxienez astean 3 egunetan egin behar dira. Gomendio sendoa, ziurtasun ertaineko ebidentzia 26 Haur eta nerabeetan (5-17 urte) zein da jarduera fisikoaren eta osasun-emaitzen arteko lotura? Ebidentzia askok aldez aurretik ezarri zuten, haur eta nerabeetan, jarduera fisikoaren kantitate eta intentsitate handiagoak osasunerako emaitza onuragarri ugarirekin lotzen direla (1). Oraintsuko ebidentziak berresten du jarduera fisikoa areagotzeak hobetu egiten dituela bihotz eta arnas sistemaren gaitasuna eta gaitasun muskulueskeletikoa haur eta nerabeetan (22, 35). Adibidez, eragin positiboak lortzen dira intentsitate ertain eta biziko jarduera fisiko batean parte hartzean astean 3 egunetan edo gehiagotan, 30-60 minutuz (22, 35). Jarduera fisiko erregularra, batez ere aerobikoa, positiboki lotzen da haur eta nerabeen osasun kardiometabolikorako onuragarriak diren emaitzekin, presio arteriala, lipidoen profila, glukosaren kontrola eta intsulinarekiko erresistentzia hobetzea barne (35). Berriki egindako azterlanek eskolako jarduera fisikoko programen (46), intentsitate biziko entrenamendua pausaldiekin (47) eta erresistentzia-entrenamenduaren (48) eraginkortasuna aztertu zuten, inolako interbentziorekin alderatuta bihotz eta arnas sistemaren osasunaren neurrietan. Hiru berrikuspenetan, argi geratu zen interbentzioak emaitza kardiometabolikoko neurri hobeekin lotu zirela, baina askotariko zehaztasunak egon ziren eraginaren tamainan, eta proba indibidual gutxik aurkitu zituzten jarduera fisikoaren onurak, estatistikoki esanguratsuak, emaitza kardiometaboliko guztietan. 19 RCTtako (n = 11988) (46) berrikuspen batek jakinarazi zuen jarduera fisikoko eskola-programak estatistikoki esanguratsuak diren hobekuntzekin lotu zirela presio arterial diastolikoan (ES= 0.21 [% 95eko CI: 0.42tik 0.01era]; p= 0.04) eta intsulina-baraualdian(es = 0,12 [ % 95eko CI: 0,42tik 0,04ra]; p = 0,03), jarduera fisikoko inolako interbentziorekin alderatuta. Jakinarazi da jarduera fisikoa onuragarria dela adipositaterako, eta jarduera-maila handiagoak haurren eta nerabeen pisu osasungarriarekin lotuta egon daitezke (22, 35). Emaitzak, oro har, sendoagoak dira zeharkako azterlanetan; emaitzak, berriz, nahasiagoak dira behaketa-azterlan prospektiboekin, eta horrek mugatu egiten du informatutako loturen norabidea ulertzea. Jarduera fisikoko interbentzioen proben berrikuspen berriagoek (intentsitate biziko tartekako entrenamendua [HIIT] laborategian oinarritua, ikasketa aktiboa ikasgelan oinarritua, erresistentzia- entrenamendua) sendotasunik gabeko emaitzen berri eman zuten, eta berrikuspenetan sartutako azterlan gehienek ez zuten eraginik jakinarazi (47, 49, 50). Hala ere, luzetarako eta zeharkako azterlanen berrikuspen batek jakinarazi zuen lotura negatiboa dagoela podometroak neurtutako jarduera fisikoaren eta adipositate, BMI edo gerriaren zirkunferentziaren neurrien artean (51). Oro har, ziurtasun baxuko ebidentzia dago jarduera fisikoa pisu osasungarri bati eustearekin lotuta dagoela eta ikerketa gehiago behar da lotura horren norabidea eta indarra zehazteko. Ebidentzia gutxiagok aztertzen du haur eta nerabeen jarduera fisikoaren eta haien trebetasun motorren garapenaren arteko lotura, eta egungo berrikuspenek emaitza nuluak erakusten dituzte (22). Ikerketa gehiago egin behar da garapen motorraren inguruan, etorkizuneko gidalerroen berri emateko. Haur eta nerabeetan, hezur-kargako jarduerak sar daitezke jolasetan, korrika egitean, biraketetan edo salto egitean. Jarduera fisikoa positiboki lotzen da hezur- masaren metaketarekin eta/edo hezur-egiturarekin, eta oraintsuko ebidentziaren arabera, fisikoki beren parekoak baino aktiboagoak diren haur eta nerabeek hezur-masa sendoagoa, hezur-eduki edo -dentsitate altuagoa eta hezur-erresistentzia handiagoa dute (35). Haurtzaroan eta nerabezaroan hezurren osasuna maximizatuz gero, osteoporosiaren eta gerora bizitzan izandako hausturen aurka babesten lagun dezake. Funtzio kognitiboa garatzea eta mantentzea funtsezkoa da bizitza osoan zehar. Haur eta nerabeetan, jarduera fisikoak ondorio positiboak ditu funtzio kognitiboan eta emaitza akademikoetan (adibidez, eskola- errendimendua, oroimena eta funtzioa) (22, 35). Berriki egindako berrikuspen batek (19 RCT; n = 5038) frogatu zuen ariketa-interbentzioak, asteko saio ugarirekin, 6 aste edo gehiagotan, aldaketa handiagoarekin lotu zirela funtzio kognitiboaren neurrietan, hala nola: kontrol inhibitorioa (SMD 0,26 [% 95eko IC: 0,08tik 0,45era], p = < 0,01); oroimen funtzionala (SMD 0,10 [% 95eko IC: 0,5), p= < 0.02), eta malgutasun kognitiboa (SMD 0.14 [95% CI: -0.03 to 0.31], p= < 0.04), inolako ariketa- interbetziorekin alderatuta (52). Jarduera fisikoak depresioa eta sintoma depresiboak izateko arriskua murrizten du depresio larria duten eta ez duten haur eta nerabeetan (35), eta terapia psikologiko eta farmazeutikoekin aldera daiteke sintomak murrizteko. Jarduera fisiko oro gertakari kaltegarrien arriskuren batekin badator ere (53), mugatua da ebidentzia, kalteen berri ematen duena osasunaren onurarako gomendatutako jarduera fisikoaren mailekin lotua (35). Eskura dagoen ebidentziaren eta adituen iritziaren arabera, haur eta nerabeentzat gomendatutako jarduera fisikoaren kantitate eta motei lotutako arrisku O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z 27 Gomendioak potentzialak baxutzat jo ziren (35), eta murriztu egin daitezke jarduera-maila eta intentsitatea pixkanaka handituz, batez ere haur eta nerabe ez aktiboetan. Jakina da kirol batzuetan parte hartzeak lesioak izateko arriskua areagotzen duela, baita ariketaren intentsitatea handitzeak ere (53). Ikerketa gehiago behar da arlo honetako ezagutzen oinarria sendotzeko. OMEk honako hau ondorioztatu zuen: • Ziurtasun ertaineko ebidentzia dago haur eta nerabeetan intentsitate ertain eta biziko jarduera fisiko gehiago onura hauekin lotzen dela: hobetu egiten da bihotz eta asnas sistemaren gaitasuna, muskuluen gaitasuna, bihotz eta arnas sistemaren osasuna eta hezurren osasuna. • Ziurtasun ertaineko ebidentzia dago intentsitate ertaineko jarduera fisikoak, epe laburrera zein luzera, ondorio positiboak dituela funtzio kognitiboan, emaitza akademikoetan eta osasun mentalean. • Ziurtasuna baxua da jarduera fisikoa haur eta nerabeentzat onuragarria dela pisu osasungarriari eusteko. • Ziurtasun baxuko ebidentzia dago haur eta nerabeentzat gomendatutako jarduera fisikoaren kantitate eta motetarako arriskuak urriak direla eta onurek konpentsatzen dituztela. Badago dosi-erantzun loturarik (kantitatea, iraupena, maiztasuna, intentsitatea)? Jarduera fisikoaren eta haur eta nerabeen osasun- emaitzen arteko lotura positiboa erakusten duen funtsezko ebidentzia-multzo bat dagoen arren, oso azterlan gutxik jorratu dute dosi-erantzunaren gaia. Beraz, jarduera fisikorako eta osasun-emaitza espezifikoetarako dosi-erantzun kurbaren eta/edo atalase-balioen (arrisku baxuagoa eta altuagoa bereizten dutenak) presentziaren forma zehatza ez da hain ondo ulertzen haur eta nerabeetan, populazio helduekin alderatuta. Hala ere, funtsezko ebidentzia-multzo batek erakusten du osasunerako onura ugari egunean 60 minutuko jarduera fisikoa eginez lortzen dela (22, 35), eta ebidentzia kontraesankorrik gabe, ondorioztatu zen ebidentzia eguneratuak berretsi egiten duela OMEren gaur egungo gomendioa: eguneko 60 minutuko jarduera fisikoa egitea, intentsitate ertainetik bizira (1). Hala ere, ebidentzia guztiaren berrikuspena, gailuetan onarritutako jarduera fisikoaren neurriak erabiltzen dituzten azterlanen azken emaitzak barne, ez zen eguneroko atalase "minimo" baten zehaztapena mantentzearen alde agertu, osasun-onurak lortzeko 60 minutuko jarduera fisikoa, intentsitate ertain eta bizikoa, egiteari dagokiona. Izan ere, azterlanek nabarmen erabili zuten eguneko 60 minutuko "batez besteko" atalasea, eta ez eguneko 60 minutuko gutxieneko atalasea, jarduera fisikoak osasun-emaitzetan dituen onurak ebaluatzeko. Berrikuspenak ondorioztatu zuen gidalerro berria aldatu egin beharko litzatekeela ebidentzia hori hurbilagotik islatzeko. Osasun kardiometabolikoaren emaitzen gaineko intentsitate biziko jarduera erregularraren onurak aldez aurretik ezarri ziren (1), eta berriki egindako berrikuspenek aldeko ebidentzia gehigarria eman zuten (35). Adibidez, duela gutxiko berrikuspen batek (54) frogatu zuen intentsitate biziko aldizkako entrenamenduak, intentsitate ertaineko etengabeko entrenamenduarekin alderatuta, eragin onuragarri ertaina izan zuela bihotz eta asnas sistemaren osasunean (SMD = 0,51 [ % 95eko CI: 0,33tik 0,69ra], p = < 0,01; I2 = % 0). Ez zen ebidentziarik egon bihotz eta arnas sistemaren osasunaren gaineko eragina aldatu zutenik interbentzioaren iraupenak, ariketa-motak, ariketa- eta atseden-ratioak, eta guztizko saioek. Emaitza horiek, oro har, duela gutxiko beste berrikuspen batzuekin bat etorri ziren (22, 35, 47), eta lagundu egiten dute gomendio hau mantentzen: gazteek eta nerabeek intentsitate biziko jarduera erregularrak egin behar dituzte bihotz eta arnas sistemaren gaitasuna hobetzeko. GDGk honako hau ondorioztatu zuen: • Ebidentziak OMEren aurreko gomendioa berresten du: eguneko 60 minutuko jarduera fisikoa egitea, intentsitate ertain eta bizikoa. • Ebidentziak aurreko zehaztapenaren aldaketa babesten du, hau da, jarduera fisikoaren 60 minutuko eguneko gutxieneko atalasearen ordez jarduera fisikoaren 60 minutuko eguneko/asteko batez bestekoa erabiltzea, eta horrek ebidentzia zehatzagoa islatzen du. • Ziurtasun ertaineko ebidentzia dago intentsitate biziko jarduera fisiko gehiagok lotura duela bihotz eta asnas sistemaren gaitasun hobearekin. Lotura aldatzen da jarduera fisikoaren motaren edo eremuaren arabera? Haur eta nerabeetan, jarduera fisikoak barne hartzen ditu jolasa, jokoak, kirolak, garraiatzea, aisialdia, gorputz- heziketa edo ariketa planifikatua, familiako, eskolako eta komunitateko eremuen testuinguruan. Hala ere, azterlan gutxik alderatu dituzte zuzenean haur eta nerabeen jarduera fisikoaren mota edo eremu desberdinak, eta, beraz, ez dago ebidentzia nahikorik erabakitzeko jarduera fisikoaren eta osasun-emaitzen arteko lotura aldatzen den jarduera-motaren arabera (adib., ariketa aerobikoa versus muskuluak indartzeko ariketa) edo jarduera fisikoaren 28 eremuaren arabera (adib., garraiatzea (oinez eta bizikletan ibiltzea) versus gorputz-heziketa, versus kirola/jolasa). Ebidentzia batek erakusten du intentsitate ertaineko eta biziko jarduera fisiko aerobikoaren maila handiagoak bihotz eta arnas sistemaren gaitasun handiagoarekin lotzen direla, eta muskuluak indartzeko jarduera-maila handiagoak muskuluen gaitasun handiagoarekin lotzen direla haur eta nerabeetan. OMEren 2010eko Osasunerako jarduera fisikoari buruzko gomendio globalen (1) berri eman zuen ebidentzia horrek. Gomendio horien arabera, muskuluak eta hezurrak indartzeko jarduerak egitea gomendatzen zen, gutxienez astean 3 egunetan. Eguneratutako ebidentziak berretsi zuen muskuluak astean 3 aldiz indartzeko jarduera erregularra eraginkorra dela muskulu-gaitasunaren adierazleak hobetzeko; hala ere, ez dago ebidentzia nahikorik saioaren iraupenari eta intentsitateari buruzko xehetasun espezifikoak ezartzeko, neurri handi batean literaturan ebaluatutako esposizioen heterogeneotasuna dela eta (22, 35). Ebidentzia gutxiago dago osasun kardiometabolikoaren gaineko erresistentzia-entrenamenduaren babes-efektuaren inguruan. Haur eta nerabeetan, muskuluak indartzeko jardueren maiztasunaz bestelako ezaugarriei buruzko ebidentzia berririk ez zegoenez (iraupena, adibidez), ezin izan zen xehetasun gehiago zehaztu. Etorkizuneko ikerketek jarduera fisikoaren mota eta eremu espezifikoek osasunerako dituzten onurei heldu behar diete, gidalerroen osagai honi espezifikotasun handiagoa emateko. GDGk honako hau ondorioztatu zuen: • Ziurtasun ertaineko ebidentzia dago muskuluak indartzeko jarduerak gutxienez astean 3 egunetan sartu behar direla. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Haur eta nerabeetan, sedentarismo handiagoa osasun-emaitza txar hauekin lotzen da: adipositate handiagoa; osasun kardiometaboliko, gaitasun fisiko, portaera/jokabide prosozial urriagoa; eta loa murriztea. Hau gomendatzen da: 29 Gomendioak Sedentarismoa honela definitzen da: esna gauden bitartean, eserita edo etzanda igarotzen dugun denbora, energia-gastu gutxirekin, hezkuntza-ingurunearen, etxearen, komunitatearen eta garraioaren testuinguruan. Aldeko ebidentzia eta oinarria Sedentarismoa ez zen sartu OMEren 2010eko gomendioetan; hala ere, azken hamarkadan, gero eta gehiago dira ikerketak sedentarismoaren maila eta mota desberdinei lotutako osasun-emaitzak aztertzen dituztenak. Teknologiak eta komunikazio digitalek eragina izan dute pertsonek lan egiteko, ikasteko, bidaiatzeko eta aisialdia igarotzeko moduan. Herrialde gehienetan, haurrek eta nerabeek denbora gehiago ematen dute portaera sedentarioetan, bereziki aisialdian: pantailako entretenimendua (telebista eta ordenagailuak) eta komunikazio digitalekoa (telefono mugikorretan). Haur eta nerabeentzako gidalerro hauetarako, berrikuspen sistematikoak erabili ziren (24, 25), eta zazpi berrikuspen identifikaturekin eguneratu ziren, inklusio-irizpideak betez. Metodoen, datu-erauzketaren eta ebidentzia-profilen xehetasun guztiak web-eranskinean aurki daitezke: ebidentzia-profilak . Online eskuragarri, hemen: https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 30 HAURRAK ETA NERABEAK (ADINA 5–17 URTE) Haur eta nerabeetan (5-17 urte) zein da sedentarismoaren eta osasun-emaitzen arteko lotura? Ebidentziak adierazten duenez, zenbat eta denbora gehiago eman portaera sedentarioetan (batez ere pantailako jolas-denbora) orduan eta txarragoak dira osasun-emaitzak (24, 35). Adibidez, zenbat eta denbora gehiago pantailarekin (telebista barne) orduan eta okerragoa haur eta nerabeen egoera fisikoa eta osasun kardiometabolikoa (24, 25). Sedentarismoaren eta interbentzio-azterlanen loturari buruzko ebaluazioaren (gailuetan oinarritua) ebidentziak eragin urriak erakutsi zituen, baina eragin sendoagoak jada obesitatea dutenentzat (55). Ebidentzia mugatua da iradokitzen duena sedentarismoak ez duela loturarik haurren eta nerabeen hezur-osasunarekin. Emaitzak mistoagoak izan arren, ebidentziak iradokitzen du sedentarismoa adipositate-neurri kaltegarriekin lotuta egon daitekeela (24, 25). Zeharkako azterlanen berrikuspen batek, jakinarazi zuen egunean 2 ordutik gorako sedentarismo-maila (pantailako guztizko denbora gisa neurtua) haurren gehiegizko pisuarekin/obesitatearekin lotzen zela, maila txikiagoekin alderatuta (< 2 ordu/egun) (56). Hala ere, zeharkako 20 azterlanen beste berrikuspen batek (57) ez zuen estatistikoki esanguratsua den loturarik aurkitu bideo-joko sedentarioen eta haurren edo nerabeen gorputz-masaren indizearen artean. Berrikuspen zabal batek, 29 berrikuspen sistematikok osatuak, ondorioztatu zuen azterlan askok gazteen sedentarismoaren eta adipositate-adierazleen arteko lotura negatiboak adierazten dituztela, sedentarismoa autoinformatzen denean pantailako denborarekin lotuta (55). Hala ere, berrikuspenak adierazi zuen lotura horien garrantzia txikia zela eta, gailuetan oinarritutako denbora sedentarioaren ebaluazioa erabiltzen duten azterlanetan, neurri handi batean, garrantzirik gabea (55). Interbentzio- azterlanek eragin urria erakutsi zuten, baina ondorio nabarmenagoak lehendik obesitatea zutenentzat (55). Ikerketa gehiago behar dira sedentarismoaren eta adipositate-neurrien arteko loturaren berri emateko. Agertu berri den ikerketa-arloa bada ere, ebidentziaren batek erakusten du lotura negatiboa egon daitekeela sedentarismoaren eta ongizatearen eta bizi-kalitatearen artean, baita erlazio kaltegarria ere depresioaren eta pantaila aurreko aisialdiko denboraren artean, haur eta nerabeetan (58, 59). Adibidez, portaera sedentarioaren iraunaldi luzeagoak, pantailako denbora gisa ebaluatuak, eta ordenagailuaren erabileraren zenbait alderdi, lotuta (24). egon daitezke osasun mental urriagoarekin Duela gutxi egindako beste berrikuspen batean, 8 azterlanetik 5etan sedentarismoaren eta antsietate-sintomen arteko lotura bat aurkitu zen, baina azterlanetan emaitzak ez zetozen bat sedentarismoaren neurrietan (60). Beste ebidentzia batek erakusten du telebista ikusten eta bideo-jokoetan denbora gehiago ematea lotura nabarmena izan zuela portaera/jokabide prosozialaren neurri negatiboekin (24); eta pantailaren eta telebistaren aurrean denbora gehiago ematea lotuta dago loaren iraupen urriagoarekin, nahiz eta ez zen loturarik egon ordenagailuaren/jokoen erabileraren eta loaren iraupenaren artean (61). Sedentarismoaren eta osasun mentalaren arteko loturari buruzko ikerketak oso azkar garatzen ari dira, eta litekeena da ebidentzian alderantzizko kausalitatea egotea. Ikerketa gehiago behar da lotura horren norabidearen eta indarraren berri emateko. GDGk honako hau ondorioztatu zuen: • Ziurtasuna baxuko ebidentzia dago portaera sedentarioaren iraupen handiagoa (pantailako denbora) nabarmen lotzen dela haurren eta nerabeen egoera fisiko eta osasun kardiometaboliko okerragoarekin. • Ziurtasun oso baxutik ertainera bitarteko ebidentzia dago portaera sedentarioaren iraupen handiagoa (pantailako denbora, telebista ikusten eta bideo- jokoetan) nabarmen lotzen dela osasun mentalaren eta portaera/jokabide prosozialaren neurri negatiboekin, haur eta nerabeetan. • Ziurtasun baxuko ebidentzia dago portaera sedentarioaren iraupen handiagoa (pantailako denbora eta telebista ikusten) lotuta dagoela haur eta nerabeen loaren iraupenaren gaineko eragin kaltegarriekin. • Haurren eta nerabeen sedentarismoa zenbat eta mugatuagoa, orduan eta urriagoak kalteak. Badago dosi-erantzun loturarik (guztizko kantitatea, iraupena, maiztasuna, etenaldiaren intentsitatea)? Ez dago ebidentzia nahikorik zehazteko dosi-erantzun erlaziorik dagoen haur eta nerabeen denbora sedentarioaren (pantailako jolas-denbora barne) eta haien osasun-emaitzen artean. Haurren eta nerabeen sedentarismoaren eta osasun-emaitzen arteko loturak ebaluatzen dituen ebidentzia gehiena, berez, zeharkakoa da, eta ziurtasun baxuko ebidentzia erakusten du GRADEren arabera, eta azterlan gehienak autoinformatutako edo gurasoek O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z 31 Gomendioak jakinarazitako denbora sedentarioaren neurrietan oinarritu ziren, kontuan hartuta neurketa-akatsak eta oroimen-alborapenak izan ditzaketela. Hala ere, ebidentzia dago zenbat eta denbora gutxiago eman sedentario izaten, orduan eta hobeak direla osasun- emaitzak eta, oro har, sedentarismoaren eta osasun- emaitza txarren arteko lotura sendoagoa da telebistako eta pantaila aurreko aisialdiko denbora ebaluatzen denean esposizio-aldagaitzat, guztizko denbora sedentariorako baino. Hala ere, oro har, ebidentzia ez zen nahikotzat jo denbora-mugen zehaztapena babesteko. Sedentarismoa osasun-emaitza txarrekin lotuta dagoelako ebidentzia izan daiteke portaera sedentarioen eragin zuzenen emaitza, portaera fisiko aktiboagoetan emandako denboraren desplazamenduarena, edo biena. Zenbait azterlanek pantailako denboraren eta haur eta nerabeen osasun- emaitza txarren arteko lotura adierazi duten arren, guztizko denbora sedentarioa (gailuetan oinarritutako sedentarismoaren neurketak erabiltzen dituzten azterlanetan ebaluatutakoaren arabera) ez da sendotasunez lotu osasun-emaitzekin jarduera fisikoa intentsitate ertainetik bizira egiten emandako denbora kontuan hartzen denean (62). Aitzitik, jarduera fisikoa ‒ intentsitate ertainetik bizira‒ osasun-emaitza positiboekin lotzen duen ebidentzia sendoa da eta ondo dokumentatuta dago hainbat ingurunetan; portaera sedentario batzuk jarduera fisikoarekin (bereziki intentsitate ertainetik bizira) ordezkatzeak osasun-emaitza hobeak ekar ditzake. Sedentarismoaren, jarduera fisikoaren eta osasun- emaitzen arteko loturak eta elkarrekintza aztertzen dituen ikerlana bizkor ari dira hazten, eta sedentarismoaren eta osasun kardiometabolikoaren neurrien (gailuetan oinarrituta) ebidentziak erakusten du lotura arindu egiten dela jarduera fisikoa ‒ intentsitate ertainetik bizira‒ kontuan hartzen denean (hau da, estatistikoki doituta) (62 – 64). Beraz, gailuetan oinarritutako esposizio-neurriak erabiltzen dituzten azterlan prospektibo gehiago behar dira lotura horien ezagutzan aurrera egiteko eta etorkizuneko gomendioen berri emateko. GDGk honako hau ondorioztatu zuen: • Ziurtasun baxuko ebidentzia dago sedentario izaten denbora gehiago ematea osasun-emaitza okerragoekin lotuta dagoela. • Ez dago ebidentzia nahikorik sedentarismoan denbora-mugak zehazteko. • Denbora sedentarioa jarduera fisikoarekin ‒ intentsitate ertainetik bizira‒ ordezkatzeak osasun- onurak ekar ditzake. Lotura aldatzen da sedentarismoaren motaren edo eremuaren arabera? Sedentarismoak osasunean dituen ondorioen azterketa nahiko ikerketa-eremu berria da. Hala, aurkikuntzak esposizio-tresna eta -neurri desberdinak erabiltzen dituzten azterlanetatik datoz. "Sedentario izaten emandako guztizko denbora" gisa ebaluatutako esposizioa maiz erabiltzen da, baina baita "pantailak" erabiltzen edo "telebista ikusten" emandako denbora sedentario gisa ere. Eskuragarri dagoen ebidentziak iradokitzen du sedentarismoaren eta osasun-emaitza kaltegarrien arteko lotura, oro har, sendoagoa dela telebista ikusten edo pantaila aurreko aisialdian emandako denborarako, guztizko denbora sedentariorako baino (24, 35). Ikerketa berrienetan sedentarismoa gailuetan oinarrituta ebaluatzeak areagotu egin du ezagutza, eta, txosten estandarizatuekin konbinatzen bada, etorkizuneko gidalerroen berri ematen lagunduko du horrek. Onartzen da portaera sedentario oro ez dela kaltegarria. Ebidentziak iradokitzen du portaera sedentario mota batzuk, hala nola irakurtzea eta atazak eskolatik kanpo egitea, errendimendu akademiko handiagoarekin lotzen direla, eta horrek adierazten du emaitzak desberdinak direla jardueraren arabera (24, 25). Portaera sedentarioak hauek barne har ditzake: hezkuntza- jardueretan/ikasketetan edo jolas lasaian emandako denbora, edo interakzio soziala baliabide elektronikorik gabe. Jarduera horiek (adibidez, irakurtzea, buruhausgarriak egitea, marraztea, eskulanak egitea, abestea, musika entzutea) garrantzitsuak dira haurraren garapenerako, eta onura kognitiboak eta bestelakoak ekartzen dituzte. GDGk honako hau onartu zuen: • Jarduera sedentario batzuek onurak dakartzate haur eta nerabeen funtzio kognitiborako eta interakzio sozialerako. • Sedentarismoak osasunean dituen eragin kaltegarriei buruzko ebidentzia, oro har, sendoagoa da telebista ikusten edo pantaila aurreko aisialdian emandako denborarako, guztizko denbora sedentariorako baino. 32 Helduentzat, jarduera fisikoa ondokoetan sar daiteke: aisialdian (jolasa, jokoak, kirolak edo ariketa planifikatua), garraiatzean (gurpiletan, oinez eta bizikletan ibiltzea), laneko eta etxeko zereginetan, lanbideko, hezkuntzako, familiako eta komunitateko eguneroko jardueren testuinguruan. Helduetan, jarduera fisikoak onurak dakartza osasun-emaitza hauetarako: kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eragindakoa, hipertentsioa, minbizi espezifikoak1, II motako diabetesa, osasun mentala (antsietate eta depresioaren sintomak gutxitzen ditu); osasun kognitiboa eta loa, eta adipositate-neurriak ere hobe ditzake. Hau gomendatzen da: Heldu guztiek erregulartasunez egin behar dute jarduera fisikoa. Gomendio sendoa, ziurtasun ertaineko ebidentzia Helduek intentsitate ertaineko jarduera fisiko aerobikoa egin behar dute, gutxienez 150-300 minutukoa; edo intentsitate biziko jarduera fisiko aerobikoa, gutxienez 75-150 minutukoa; edo astean zehar intentsitate ertain eta biziko jardueraren konbinazio baliokide bat, osasun-onura esanguratsuak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Helduek, astean 2 egunetan edo gehiagotan, muskuluak indartzeko jarduerak ere egin behar dituzte, intentsitate ertain edo handiagokoak, muskulu-talde nagusi guztiak landu eta osasunerako onura gehigarriak ematen baitituzte. Gomendio sendoa, ziurtasun ertaineko ebidentzia Helduek intentsitate ertaineko jarduera fisiko aerobikoa 300 minutu baino gehiagora igo dezakete; edo intentsitate biziko 150 minutu baino gehiagoko ariketa fisiko aerobikoa egin dezakete; edo intentsitate ertain eta biziko jardueren konbinazio baliokide bat astean zehar, osasun-onura gehigarriak lortzeko. Baldintzapeko gomendioa, ziurtasun ertaineko ebidentzia 1 Minbizi espezifikoak: maskurikoa, bularrekoa, kolonekoa, endometriaal, esofago-adenokartzinoma, gastrikoa, eta giltzurrunekoa. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z J A R D U N B ID E E G O K IA K     33 33 Gomendioak Aldeko ebidentzia eta oinarria Gidalerro hauetarako, Estatu Batuetako Jarduera Fisikorako Gidalerroen Aholku Batzordeak (PAGAC) egindako ebidentzia-sintesia erabili eta eguneratu zen (35). GDGk ebidentzia-multzo osoa kontuan hartu zuen, PAGACek jakinarazitako aurkikuntzak eta 2017tik 2019ko azarora arte argitaratutako 28 berrikuspenak eta 3 kohorte-analisi konbinatuak barne. Horiek guztiek inklusio-irizpideak bete zituzten eta helduen jarduera fisikoaren eta osasun-emaitzen arteko loturari buruzko ebidentzia eman zuten. Gainera, bi berrikuspen orokor egin ziren, ebidentzia-hutsuneei heltzeko eta i) lan-eremuko jarduera fisikoa (hau da, lanarekin lotua) eta osasun-emaitzen arteko lotura aztertzeko (40); eta ii) aisialdiko jarduera fisikoaren eta osasun-emaitza kaltegarrien arteko lotura aztertzeko (41). Berrikuspen orokorrek 36 eta 15 berrikuspen sistematiko identifikatu zituzten, hurrenez hurren. Luzetarako behaketa-azterketen eta interbentzio-proben ebidentzia lehenetsi zen, eta ez ziren kontuan hartu zeharkako ebidentzia bakarrik edo nagusiki laburbildu zuten berrikuspenak. Garrantzi handiagoa eman zitzaion ziurtasun ertaineko edo handiagoko berrikuspenek emandako ebidentziari, baita gailuetan oinarritutako esposizio-neurriak erabiltzen dituzten azterlanen ebidentzia eman zutenei ere. Metodoen, datu-erauzketaren eta ebidentzia-profilen xehetasun guztiak web-eranskinean aurki daitezke: ebidentzia-profilak . Helduetan (18-64 urte), zein da jarduera fisikoaren eta osasun-emaitzen arteko lotura? Helduetan, jarduera fisikoaren eta kausa guztiengatiko hilkortasunaren eta gaixotasun kardiobaskularrek eragindakoen arteko lotura ondo ezarrita dago (1). Azkenaldiko berrikuspenen emaitzek berretsi zuten jarduera fisikoaren mailarik baxuenekin alderatuta, jarduera fisikoaren mailarik altuenak hilkortasun-arrisku gutxiagorekin lotuta zeudela. Jarduera fisikoaren neurriak gailuetan oinarrituta erabiltzen dituzten azterlanen ebidentzia berriak berretsi eta zabaldu egin zuen ebidentzia, erakutsiz jarduera fisikoaren mailarik baxuenekin alderatuta, jarduera fisikoaren edozein maila eta intentsitate guztiak (intentsitate arina barne) hilkortasun-arrisku gutxiagorekin lotuta zeudela (65). Adibidez, gutxien aktibo dagoenarekin alderatuta (erreferentea, 1,00), guztizko jarduera fisikoaren kuartiletarako doitutako HRa hobetu egin zen jarduera fisikoaren kuartiletan: 2. kuartila (0,48 [ % 95eko CI: 0,43tik 0,54ra]); 3. kuartila (0,34 [ % 95eko CI: 0,26tik 0,45era]); eta 4. kuartila ( % 0,27 [ % 95eko CI: Ebidentzia berriak ondo ezarritako alderantzizko erlazioa berretsi zuen (1) jarduera fisikoaren eta gaixotasun kardiobaskularrengatiko hilkortasunaren artean (66). Ondo dokumentatuta daude jarduera fisikoak gaixotasun kardiobaskularrak eta hipertentsioaren intzidentzia murrizteko dituen onurak (1). Jarduera fisikoak erantzun fisiologiko ugari sustatzen ditu, eta horiek egokitzapen onuragarriak eragiten dituzte epe labur eta luzera; horren ondorioz, hipertentsioa izateko arriskua urriagoa da, kontuan hartuta funtsezko arrisku-faktorea dela gaixotasun kardiobaskularretarako. Ebidentziak berretsi zuen alderantzizko erlazioa zegoela jarduera fisikoaren eta hipertentsioaren intzidentziaren artean presio arterial normala duten helduen artean, eta jarduera fisikoak presio arteriala murrizten duela prehipertentsio eta presio arterial normala duten helduen artean (35). Jarduera fisikoaren eta helduen II motako diabetesaren garapenaren arteko alderantzizko lotura ondo ezarrita dago (1). Oraintsuko ebidentziak alderantzizko erlazio lerromakurra berretsi zuen jarduera fisikoaren kantitate handiagoen eta II motako diabetesaren intzidentziaren artean (35), eta beheranzko maldarekin jarduera fisikoaren maila altuagoetan. Beste berrikuspen batek ikusi zuen eragin hori bat datorrela jatorri desberdinetako gizabanakoen artean, II motako diabetesa garatzeko arrisku urriarekin, jarduera fisikoaren maila “altuenetan” versus “baxuenetan”, hauengan: zuri ez hispanoak (RR = 0,71 [ % 95eko CI: 0,60tik 0,85era]); Asiakoak (RR = 0,76 [ % 95eko CI: 0,67tik 0,85era]); Hispanoak (RR = 0.74 [% 95eko CI: 0.64tik 0.84ra]); eta AEBetako Indiarrak (RR = 0.73 [95% CI: 0.60tik 0.88ra]), nahiz eta beltz ez hispanoen artean eragina ez zen esanguratsua izan (RR = 0.91 [95% CI: 0.76 to 1.08]) (67). Ebidentziak iradokitzen du ez dagoela eragin-aldaketarik pisu-egoeragatik, eta alderantzizko erlazioa dagoela jarduera fisikoaren kantitate handiagoaren eta II motako diabetesaren intzidentzia txikiagoaren artean, pisu normala, gainpisua edo obesitatea duten pertsonentzat (35). Ondo ezarrita daude jarduera fisikoaren maila altuenen eta koloneko minbiziaren eta bularreko minbiziaren arrisku txikiagoen arteko loturak (1). Ebidentziaren aurreko berrikuspenetan ikusi da Online eskuragarri, hemen:https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 34 jarduera fisikoaren maila altuenak bularreko minbizia eta koloneko minbizia garatzeko arrisku txikiarekin lotzen direla (1) Gero eta gehiago dira jarduera fisikoari eta minbiziari buruzko ikerketak, eta ebidentzia berri batek erakusten du jarduera fisikoaren maila altuagoak maskuriko adenokartzinoma, endometrioa, esofagoa, urdaileko minbizia eta giltzurrunekoa garatzeko arriskuak murriztearekin lotzen direla, eta berretsi egiten du jarduera fisikoa faktore babeslea dela bularreko eta koloneko minbizietarako (35). Jarduera fisikoaren mailarik altuenak % 10 eta % 20 bitarteko arrisku- murrizketekin lotzen dira (35). Adibidez, berrikuspen batek alderantzizko lotura bat jakinarazi zuen gibeleko minbiziaren arriskuarekin, jarduera fisikoaren maila altuak eta baxuak alderatu zirenean (HR = 0,75 [ % 95eko CI: 0,63tik 0,89ra]) (68). Ez dago ebidentzia nahikorik jarduera fisikoa handitzearen eta minbizi hematologikoaren, buruko eta lepoko minbiziaren, obario, pankrea, prostata, tiroide, ondeste eta garuneko minbiziaren arriskuak murriztearen arteko loturari buruz (35). Ebidentziak iradokitzen du biriketako minbiziaren arriskua murriztu egiten dela jarduera fisikoaren maila altuenen eta baxuenen artean, baina aurkikuntza horiek tabakoaren kontsumoarekin nahas daitezke, eta, oro har, lotura bat ezartzeko froga nahikorik ez dagoela erabaki zen. Populazio helduetan jarduera fisikoaren eta adipositatearen arteko lotura ez dago hain ondo ezarrita ebidentzia-multzoa handia izan arren; heterogeneoa da eta erlazio hori hainbat emaitza-neurritan ebaluatzen du (pisua handitzea, pisua aldatzea, pisua kontrolatzea, pisu- egonkortasuna, pisu-egoera eta pisuari eustea) (35, 69, 70). Oro har, ebidentziak erakusten du jarduera fisikoaren maila altuagoak lotuta egon daitezkeela helduen adipositate-neurri hobeekin eta gainpisua arintzearekin (35). Ikerketa gehiago behar da emaitza sendoak eta loturen indarra ezartzeko. Jarduera fisikoari eta osasun mentalari, kognizioari eta loari buruzko ikerketak nabarmen egin du gora osasunerako jarduera fisikoari buruzko 2010eko Gomendio globalak garatu zirenetik (1). Une horretan, nahikoa froga egon zen ondorioztatzeko jarduera fisikoak helduen depresioa eta narriadura kognitiboa izateko arriskua murriz dezakeela. Gidalerro hauetarako berrikusitako ebidentzia berriak erakutsi zuen adingabeko batekin alderatuta jarduera fisiko handiagoa egiten duten helduek antsietatea eta depresioa garatzeko arrisku txikia dutela. Adibidez, helduek, maila altuko versus baxuko jarduera fisikoa eginda, joera gutxiago zuten antsietatea (AOR = 0,81 [ % 95eko CI: 0,69tik 0,95era]) (71) edo depresioa (AOR = 0,78 [ % 95eko CI: 0,70etik 0,87ra) (72) garatzeko. Intentsitate ertain eta biziko jarduera fisiko gehiago kognizioaren hobekuntzarekin lotzen da (adibidez, prozesamendu-abiadura, oroimena eta funtzio exekutiboa) (35), garunaren funtzioa eta egitura, eta narriadura kognitiboa garatzeko arrisku txikia, Alzheimerren gaixotasuna barne (73 – 76). Ebidentziaren arabera, populazio heldu batzuek osasun-egoera kognitiboaren gradiente normala eta narriatua adierazten dute, eta jarduera fisikoaren ondorio onuragarriak hainbat motatakoak izan ziren, jarduera aerobikoa, ibilaldiak, muskuluak indartzeko jarduera eta yoga barne (74). Frogatuta dago bai gertakari akutuek bai jarduera fisiko erregularrak loaren emaitzak eta eta osasunarekin lotutako bizi-kalitatea hobetzen dituztela helduetan (35). Depresio-sintomak, antsietate-sintomak eta antsietatearen eta depresioaren garapena aztertu zituen ebidentzia batek adierazi zuen jarduera fisikoa antsietate-sintomak murriztearekin (77, 78) eta depresio- sintomak murriztearekin (77, 79) lotu zela. Jarduera fisiko orok dakar arriskuren bat. Helduen aisialdiko jarduera fisikoarekin lotutako ondorio kaltegarriei, lesioei eta kalteei buruzko azterketa baten ebidentziak (41) iradokitzen du lotura negatiboa dagoela aisialdiko jarduera fisikoaren mailaren eta lesio muskulueskeletikoen artean, eta lotura positiboa aisialdiko jarduera fisikoaren eta haustura-arriskuaren eta belauneko edo aldakako artrosiaren agerpenaren artean. Dagoen ebidentzia gehigarriak (35) adierazten du bat-bateko bihotzeko gertakari kaltegarriak gutxitan izaten direla eta nahiko intentsitate biziko jarduera fisikoko saio gogorrekin lotuta daudela. Oro har, gertakari kaltegarrien arriskuak oso txikiak dira jarduera fisikoa intentsitate ertainekoa denean eta jarduera fisikoaren maiztasun, intentsitate eta iraupenaren igoerak mailakatuak direnean (35) GDGk honako hau ondorioztatu zuen: • Ziurtasun handiko ebidentzia dago jarduera fisikoaren edozein maila eta intentsitate lotuta dagoela ondokoen arrisku gutxiagorekin: kausa guztiengatiko hilkoltasuna eta gaixotasun kardiobaskularrek eragindakoa, eta hipertentsioaren, gaixotasun kardiobaskularren eta II motako diabetesaren intzidentzia. • Ziurtasun ertain eta altuko ebidentzia dago jarduera fisikoaren maila altuagoen eta minbizi espezifikoen intzidentzia-arrisku txikiagoaren arteko loturei dagokienez. • Ziurtasun ertaineko ebidentzia dago babesten duena lotura dagoela jarduera fisikoaren eta osasun mentala, osasun kognitiboa eta loa hobetzearen artean. • Ebidentzia dago lotura dagoela jarduera fisikoaren maila altuagoen eta helduen adipositate-neurri hobeen eta pisua gutxiago gehitzearen artean. • Ziurtasun baxuko ebidentzia dago helduentzat gomendatutako jarduera fisikoa ez dela kaltegarria izango eta jarduera horren ondoriozko osasun- onurak arriskuak baino handiagoak direla. 35 Gomendioak 1. irudia: Dosi erantzun kurba Badago dosi-erantzun loturarik (kantitatea, iraupena, maiztasuna, intentsitatea)? Oro har, osasun kardiobaskularraren eta metabolikoaren emaitzen ebidentziak alderantzizko dosi-erantzun lotura lerromakur nabarmen bat erakusten du jarduera fisikoaren eta emaitza nagusien artean (kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eragindakoa, II motako diabetesaren intzidentzia (67) eta minbizi espezifikoena). 1. irudian adierazi bezala, dosi-erantzun kurbaren formak adierazten du ez dagoela onurarako atalase baxuagorik, eta onura handienak dosi-erantzun kurbaren beheko muturrean ikusten dira (65). Alderantzizko lotura lerrokamurra modu sendo batean agertzen da, eta jarduera fisikoaren neurri desberdinak erabiltzen dituzten azterlanetan. Beste ebidentzia garrantzitsu bat eman zen prospekzio-kohorteen zortzi azterlanen metanalisi batean, 5,8 urteko batez besteko jarraipenarekin (3 eta 14,5 urte arteko tartea) (65). Horiek jarduera fisiko osoaren kuartiletarako doitutako HRren berri eman zuten, esposizioaren eta kausa guztiengatiko hilkortasunaren neurriak erabiliz, gailuetan oinarrituta. Emaitzek dosi-erantzun bat erakutsi zuten, jarduera fisikoaren gero eta kantitate handiagoarekin eta jarduera fisikoren edozein intentsitateren maila altuagoen onurekin, gutxien aktibo direnekin alderatuta (erreferentea, 1,00): 2. kuartila (HR doitua =0,48 [ % 95eko CI: 0,43tik 0,54ra]); 3. kuartila (HR doitua = 0,34 [ % 95eko CI: 0,26tik 0,45era]); eta 4. kuartila(HR doitua= 0.27 [% 95eko CI: 0.23tik 0.32ra]). Intentsitate ertain eta biziko jarduera fisikorako arrisku murrizketa maximoak ikusi ziren eguneko 24 minututan (asteko 168 minuturen baliokidea), eta horrek oso gertutik islatzen du asteko 150 minutuko gomendioa, eta gailuetan oinarritutako ebidentzia berri bat ematen du, orain helduei zuzendutako gomendio globala sendotzen duena: jarduera fisikoa egitea 150-300 minutu asteko (65). Aurkikuntza horiek bat datoz dauden berrikuspenen ebidentziarekin (35) eta identifikatutako beste berrikuspen berriekin (66). Goiko muturrean, jarduera fisikoaren mailarik altuenek onurak ematen jarraitzen dute hilkortasun-arriskua murrizteari dagokionez, kalte-arrisku handiagorik gabe. Adibidez, gailuetan oinarritutako esposizio-neurriei buruzko datu indibidualen metanalisitik aurkikuntzak lortu zituen berrikuspen bateko (65) ebidentziak adierazten duenez, hilkortasun-arrisku baxua ikusten den arren asteko 750 minutura arteko jarduera fisikoan ‒intentsitate ertainetik bizira‒, hilkortasun-arrisku erlatiboa egonkortu egiten da asteko 300 minututatik gora. Emaitza horiek bat datoz jarduera fisiko handiagoa osasun-onura gehiagorekin lotzen dela erakutsi zuen aurretiazko ebidentziarekin, nahiz eta onura erlatiboak murriztu egiten diren jarduera fisikoaren maila altuagoetan (35, 80, 81). Hala ere, ez dago ebidentzia nahikorik jarduera fisikoaren maila zehatza identifikatzeko helduentzako osasun-onurak murrizten hasten direnean. Ebidentziak, halaber, jarduera fisikoaren eta gaixotasun kardiobaskularrengatiko hilkortasunaren artean ondo ezarritako alderantzizko erlazioa berretsi zuen, eta horrek dosi-erantzun erlazio baten ebidentzia gehigarria ematen du, gaur egun gomendatzen diren jarduera fisikoaren kantitateetatik askoz harago. O n u ra k o s a s u n e ta g a it a s u n f is ik o ra k o Maila gomendatuak Asteroko jarduera fisikoa (minutu) Sedentario 36 Jarduera fisikoa (guztizkoa, aisialdikoa eta lan- eremukoa) ebaluatzen duten 48 azterlan prospektiboren metaanalisiak dosi-erantzun erlazio baten ebidentzia gehigarria eman zuen (66), gaur egun gomendatzen diren jarduera fisikoaren kantitateetatik askoz harago. Gomendatutako asteko 750 MET minutuko mailarekin alderatuta, asteko 5.000 MET minututan parte hartzeak (1.000 minutuko intentsitate ertaineko jarduera) gaixotasun kardiobaskularraren ondoriozko hilkortasun-arrisku nabarmen txikiagoa eragin zuen (HR = 0,73 [ % 95eko CI: 0,56tik 0,95era]) (66). OMEren aurreko gomendioek (1) ondorioztatu zuten jarduera aerobikoa gutxienez 10 minutuko serieetan egin behar dela. Hala ere, gailuetan oinarritutako ebaluazioak erabiltzen dituzten proba berriek erakusten dute edozein iraupeneko jarduera fisikoa, gutxieneko atalaserik gabe, osasun-emaitza hobeekin lotzen dela, kausa guztiengatiko hilkortasuna barne (65, 82). Adibidez, jarduera fisikoa azelerometriaren bidez ebaluatzen duten azterlanen berrikuspenen ebidentzia berriak berretsi egiten du antzeko loturak daudela jarduera fisikoaren indize guztien eta kausa guztiengatiko hilkortasunaren artean, 0,27ko arrisku-zatidurarekin guztizko jarduera fisikorako, 0,28koa 5 minutuko tarteetarako eta 0,35ekoa 10 minutuko tarteetarako, kuartilik altuenak baxuenekin alderatuta (83). Emaitza horiek Ekelund et al.-k 2019 (65) egindako berrikuspen berrian jasotako aurkikuntzek berretsi ditu, zeinak ebidentzia ematen duen edozein iraupeneko jarduera fisikoa osasun- emaitza hobeekin lotzen dela, kausa guztiengatiko hilkortasuna barne (82). Ebidentzia berrian oinarrituta, berriz, gutxienez 10 minutu irauten duten tarteen gomendioa baztertu da. Jarduera fisikoaren maila altuagoen eta mibizi espezifikoen intzidentzia-arrisku baxuagoaren arteko loturak erakusten dituen ebidentzia oro har sendotzat jo izan arren, ez dago nahikoa ebidentzia zehazteko jarduera fisikoaren maila espezifikoak, informatutako arriskuaren murrizketari dagozkionak, azterlanen arteko esposizioaren ebaluazioan eta sailkapenean heterogeneotasun handia dagoelako. Hala ere, ez dago ebidentziarik iradokitzen duenik atalase baxuago bat dagoela, eta horren azpitik ez dagoela jarduera fisikoaren eragin onuragarri nabarmenik; horrek iradokitzen du edozein jarduera fisikok onurak ekar ditzakeela minbizi espezifikoen arriskua murrizteko. Etorkizuneko ikerketak behar dira, dosi-erantzunaren izaera ebaluatzeko eta neurri eta txosten sendoagoak erabiltzeko, etorkizuneko gidalerroen berri emateko. Nahiz eta ebidentzia-multzo zabal bat dagoen jarduera fisikoaren eta hainbat adipositate-neurriren, pisua gehitzearen eta pisu-egoera osasungarria eustearen (35) arteko loturei buruz, gaur egun ez dago ebidentzia nahikorik dosi-erantzun erlazioa zehatzago adierazteko edo eragin-atalasea identifikatzeko. Ikerketa gehiago behar da etorkizuneko gidalerroen berri emateko. Ikerketa gehiago behar da etorkizuneko gidalerroen berri emateko. Jarduera fisiko gehiago ‒intentsitate ertainetik bizira‒ osasun- onura hauekin lotzen da: kognizioaren (adibidez, prozesamendu-abiadura, oroimena eta funtzio exekutiboa) (35) eta garunaren funtzio eta egituraren hobekuntza, eta narriadura kognitiboa garatzeko arrisku gutxiago, Alzheimerren gaixotasuna barne (73 – 76). Ebidentzia dago, helduetan, loaren eta osasunarekin lotutako bizi- kalitatearen emaitzak hobetzen dituztela bai jarduera fisikoa erregularrak, bai tarte bizkorretan egiten denak (35). Hala ere, ez dago ebidentzia nahikorik jarduera fisikoaren eta osasun mentalaren eta kognitiboaren banakako emaitzen arteko dosi- erantzun erlazioa zehatzago deskribatzeko. Era berean, proba gehiago behar dira jarduera fisiko aerobikoaren kantitatearen eta/edo intentsitatearen eta muskuluak indartzeko entrenamenduaren eta osasun-emaitza espezifikoen arteko dosi-erantzun erlazioa zehatzago deskribatzeko. Informazio hori funtsezkoa da gutxieneko dosia eta jarduera fisikoaren gehieneko segurtasun-atalaseak ezartzeko azpipopulazio desberdinentzat. GDGk honako hau ondorioztatu zuen: • Ebidentzia dago jarduera fisiko handiagoa osasun-emaitzetan eragin handiagoarekin lotzen dela, nahiz eta onura erlatiboak jarduera fisikoaren maila altuagoetan egonkortzen diren. Ez zen ebidentzia nahikorik egon errendimendu murriztuak gertatzen hasten diren maila zehatza identifikatzeko. • Ziurtasun handiko ebidentzia dago jarduera fisikoaren maila altuagoak ondokoen arrisku txikiagoarekin lotuta daudela: kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eta minbiziak eragindakoa, gaixotasun kardiobaskularren intzidentzia eta II motako hipertentsio eta diabetesaren intzidentzia, kalteen arrisku handiagorik gabe. • Ziurtasun ertaineko ebidentzia dago edozein iraupeneko jarduera fisikoa osasun-emaitza hobeekin lotzen dela, eta baztertu egin behar da jarduera aerobikoa gutxienez 10 minutuko tarteetan egin behar dela dioen aldez aurreko zehaztapena. • Ebidentzia dago jarduera fisikoaren kantitate handiagoak lotuta egon daitezkeela helduen adipositate-neurri hobeekin eta gainpisua arintzearekin, eta arrisku baxua dagoela helduetan jarduera fisikoa kaltegarria izateko pisu osasungarriari eusteko. • Ziurtasun ertaineko ebidentzia dago intentsitate ertaineko jarduera fisiko aerobikoak, 150-300 minutu astean, edo baliokideak, murriztu egiten duela osasun-emaitza negatibo ugari izateko arriskua, eta arriskuak murrizten jarraitzen duela, baina egonkortzen hasten dela, astean 300 minututik gora. Gomendioak 37 Lotura aldatzen da jarduera fisikoaren motaren edo eremuaren arabera? Ebidentziak erakusten duenez, jarduera fisiko mota desberdinek eta hainbat eremutan (hau da, lanean, garraiatzean edo aisialdian) egiten den jarduera fisikoak osasun-emaitza onak ekar ditzakete. Kausa guztiengatiko eta gaixotasun kardiobaskularrengatiko hilkortasunerako, jarduera fisiko aerobikoa bakarrik egiteak, edo indar- ariketarekin konbinatzeak, lotura onuragarriak erakusten ditu, eta hobetu egiten dira emaitzak bi motetako maila gomendatuak egiten direnean (84). Ziurtasun ertaineko ebidentzia berrienak adierazten du muskuluak indartzeko jarduera fisikoa, jarduera fisiko aerobikoaz aparte, kausa guztiengatiko hilkortasun- arrisku txikiagoarekin lotzen dela. Stamatakis et al.-ek (2018) aurkeztutako emaitzek, kausa guztiengatiko hilkortasunaren aurrean astean 2 egunez muskuluak indartzeko gomendioa aztertzen zuten 11 kohorteen analisi konbinatu batekoek, erakutsi zuten jarduera fisiko aerobikoa eta maila gomendatuetan muskuluak indartzeko jarduera fisikoa egitea (1) versus gomendio bat ere ez betetzea (HR doitua = 0,71 [ % 95eko CI: 0,57tik 0,87ra], baita indar-ariketaren gomendioa bakarrik betetzea versus ez betetzea ere (HR = 0,80 [ % 95eko CI: 0,70etik 0,91ra]) kausa guztiengatiko hilkortasun- arriskuaren murrizketa nabarmenarekin lotuta zeudela (84). Datu horiek baieztatzen dute muskuluak indartzearekin lotutako osasun-onurak jarduera fisiko aerobikotik independenteak zirela, eta ebidentzia ematen dute, halaber, muskuluen indartze-ariketaren astean 2 eguneko maiztasunaren gomendioa babesteko. Dinu et al.-ek (2019) aurkeztutako beste aurkikuntza batzuk babes-ebidentzia eman zuen, aisialdiaz (edo jolasaz) bestelako eremuetan egindako jarduera fisikoa onuragarria izan daitekeela berresten duena, eta berariaz erakutsi zuen garraiatze aktiboak (hau da, bizikletaz eta oinez lekualdatzea) nabarmen murriztu dezaketela kausa guztiengatiko hilkortasun-arriskua (RR = 0,92). [ % 95eko CI: 0,85-0,98]) (85). Oraintsuko ikerketek ebidentzia ematen dute frogatzeko garraiatze aktiboan (hau da, oinez edo bizikletaz lekualdatzea) parte hartzen dutenek gaixotasun kardiobaskularrak (gutxiegitasun koronarioa, istripu zerebrobaskularra eta bihotz-hutsegitea) izateko arrisku txikiagoa dutela garraiatze ez aktiboetan parte hartzen dutenekin alderatuta (RR = 0,91 [IC % 95: 0,83-0,99]) (85); eta osasun-emaitza horien ebidentzia nahikoa dagoela ondorioztatzeko eremu derberdinetan aktibo izatea onuragarria izan daitekeela. Hala ere, ez dago ebidentzia nahikorik bereizteko jarduera fisikoaren eremu desberdinek osasun-emaitza bakoitzean duten eragina. Adibidez, ez dago ebidentzia nahikorik jarduera fisikoaren eta minbizi-arriskuaren arteko lotura edo II motako diabetesaren intzidentzia jarduera fisikoaren motaren edo eremuaren arabera aldatzen den zehazteko. Osasun mentalaren emaitzetarako, ebidentziak (35) erakusten du jarduera fisiko mota askok, jarduera aerobikoak, ibiltzeak, muskuluak indartzeko jarduerak eta yogak barne, ondorio onuragarriak izan ditzaketela depresio-sintomak eta antsietatearen garapena murrizteko (74, 79, 86). Adibidez, erresistentzia-ariketek osasun mentalean eragin onuragarria dutela babesten duen ebidentzia berria bi berrikuspenek eman zuten. Berrikuspen horiek depresio-sintomen murrizketa nahiko handiak (77) eta antsietate-sintomen murrizketa txikiak (78) aurkeztu zituzten kontrol-egoerekin alderatuta. Berrikuspen berri baten ebidentziak baieztatu zuen lan- eremuko jarduera fisikoaren maila altuak lotuta daudela minbizi askoren, gaixotasun koronarioaren eta II motako diabetesaren arrisku murriztuarekin (40). Hala ere, lan- eremuko jarduera fisikoaren mailarik altuenak lotuta egon daitezke osteoartritisaren arrisku handiagoarekin, loaren kalitate txarrarekin eta kausa guztiengatiko hilkortasunarekin gizonen artean (baina ez emakumeen artean). Ez dago ebidentzia nahikorik zehazteko zer lotura dagoen lan-eremuko jarduera fisikoaren eta adipositatearen, gorputzaren pisua handitzearen prebentzioaren, osasun mentalaren eta osasunarekin lotutako bizi-kalitatearen artean (40). Era berean, ez dago ebidentzia nahikorik jarduera fisikoaren eta minbizi- arriskuaren arteko lotura jarduera fisikoaren motaren edo eremuaren arabera aldatzen den zehazteko. Ebidentzia gutxiago dago jarduera fisikoaren loturei buruz eremu desberdinetan eta, beraz, zaila izan zen bereiztea jarduera fisikoaren eremu desberdinek osasun-emaitza desberdinetan duten eragina. GDGk honako hau ondorioztatu zuen: • Ziurtasun ertaineko ebidentzia dago muskuluak indartzeko astean 2 egunetan edo gehiagotan egindako jarduerek osasun-onura gehigarriak ematen dituztela, baina ez dago ebidentzia nahikorik iraupen espezifiko bat zehazteko osasun-onura optimoak lortzeko. • Ziurtasun ertaineko ebidentzia dago hainbat eremutan egindako jarduera fisikoak (adibidez, aisialdian, garraiatzean, lanean) osasun-onurak ekar ditzakeela, nahiz eta gaur egun ezin den bereizi jarduera fisikoaren eremu desberdinen eragina zenbait osasun-emaitzatan. • Nahiz eta lan-eremuko jarduera fisikoaren mailarik altuenak lotuta egon daitezkeen osteoartritis-arrisku handiagoarekin, loaren kalitate txarrarekin eta kausa guztiengatiko hilkortasunarekin gizonen artean (baina ez emakumeen artean), oro har, ziurtasun ertaineko ebidentzia dago lan-eremuko jarduera fisikoak osasun- onurak ekar ditzakeela. 38 Helduentzat, sedentarismoa honela definitzen da: esna egon bitartean, eserita edo etzanda emandako denbora, energia-gastu gutxirekin, lanbideko, hezkuntzako, familiako eta komunitateko inguruneetan eta garraioaren testuinguruan. Aldeko ebidentzia eta oinarria Gidalerro hauetarako, PAGACek egindako ebidentzia-sintesia erabili eta eguneratu zen (35). GDGk ebidentzia-multzo osoa hartu zuen kontuan, PAGACek jakinarazitako aurkikuntzak eta inklusio-irizpideak bete zituzten 13 berrikuspen berriak barne, sedentarismoaren eta helduen osasun-emaitzen arteko loturari buruzko ebidentzia emateko. Sedentarismoaren eta osasun-emaitzen arteko loturaren ikerketa nahiko eremu berria da osasun publikoan, jarduera fisikorik ezarekin alderatuta egindakoaren aldean, baina azkar garatu da azken hamarkadan. Ikerketek sedentarismoa honela neurtu dute: i) autoinforme-galdetegiak erabilita portaera sedentarioetan emandako "guztizko denborari" edo portaera espezifikoetan (telebista ikustea, ordenagailua/pantaila erabiltzea eta eserita egotea) emandako denborari buruz; edo ii) gailuetan oinarritutako ebaluazioak erabilita. Ez dago neurri estandarizaturik edo protokolo analitikorik sedentarismorako eta, beraz, emaitzen txostena heterogeneoa da. Oraintsuko garapen metodologikoen barruan sartzen da sedentario izaten emandako denbora gailuetan oinarrituta ebaluatzea, neurketa-akatsak eta oroimen- alborapenak murritz ditzakeelako autoinformeetan. Ebidentzia-multzo osoa aztertzean, GDGk garrantzi handiagoa eman zion ertainetik gorako berrikuspenek emandako ebidentziari. Berrikuspen horiek guztizko denbora sedentarioaren edo eserita emandakoaren neurriak erabiltzen dituzten azterlanen ebidentzia ematen dute, edo gailuetan oinarritutako sedentarismoaren neurriak, eskuragarri daudenean. Metodoen, datu-erauzketaren eta ebidentzia-profilen xehetasun guztiak web-eranskinean aurki daitezke: ebidentzia- profilak . Sedentarismoarekin lotutako osasun-emaitza kaltegarriei buruzko ikerketa azkar ugaritu da azken hamarkadan. Ikerketa berriagoetan, garapen nabarmenen artean, areagotu egin da sedentarismoaren eta osasun-emaitza ugarien arteko dosi-erantzun erlazioei buruzko ebidentzia eta sedentarismoaren eta jarduera fisikoaren arteko interakzioaren berri ematen duena. Online eskuragarri, hemen: https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Helduetan, sedentarismo handiagoa osasun-emaitza txar hauekin lotzen da: kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eta minbiziak eragindakoa, eta gaixotasun kardiobaskularren, minbiziaren eta II motako diabetesaren intzidentzia. Hau gomendatzen da:  Helduek mugatu egin behar dute sedentario izaten ematen duten denbora. Denbora sedentarioa edozein intentsitateko jarduera fisikoarekin ordezkatzeak (intentsitatea baxua barne) osasun-onurak dakartza. Gomendio sendoa, ziurtasun ertaineko ebidentzia  Sedentarismo maila handiek osasunean dituzten eragin kaltegarriak murrizten laguntzeko, gomendatutako jarduera fisikoko mailak ‒intentsitate ertainetik bizira) baino gehiago egiten saiatu behar dute helduek. Gomendio sendoa, ziurtasun ertaineko ebidentzia ADULTS (aged 18–64 years) 39 Gomendioak Helduetan (adina 18 urtetik gora), zein da sedentarismoaren eta osasun-emaitzen artean dagoen lotura? Oro har, ebidentzia dago lotura bat dagoela sedentario izaten emandako denbora gehiagoren (batez ere, autoinformeen bidez edo gailuetan oinarritutako ebaluazioen bidez aztertu da eserita edo telebista ikusten emandako denbora) eta kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eragindakoa, eta gaixotasun kardiobaskularren eta II motako diabetesaren intzidentzia handitzearen artean (8, 35, 65, 87). Adibidez, aldeko ebidentziak berriki egindako metanalisi handi baten emaitzak biltzen ditu (n = 36 383; batez besteko adina: 62,6 urte; % 72,8 emakumeak); azelerometro batek ebaluatutako guztizko denbora sedentarioa eta kausa guztiengatiko hilkortasuna jasotzen ditu (65), eta sedentario izaten emandako denboraren igoera kausa guztiengatiko hilkortasunarekin nabarmen lotu zela erakutsi zuen. Milioi bat parte- hartzaile baino gehiago sartu zituen metanalisi baten antzeko emaitzek (87) erakutsi zuten lotura zegoela guztizko sedentarismoaren eta kausa guztiengatiko hilkortasunaren eta gaixotasun kardiobaskularrek eragindakoaren artean, jarduera fisikorako doikuntzak egin ondoren (87), nahiz eta azterlan honetan minbiziagatiko hilkortasunarekin lotutako asoziazioak ez ziren estatistikoki esanguratsuak izan jarduera fisikoa egokitu ondoren (87). Oraintsuko beste metanalisi batek (8) sedentarismoaren (eserita gisa ebaluatua) eta gaixotasun kardiobaskularrengatiko eta minbiziagatiko hilkortasunaren arteko lotura esanguratsuei buruzko informazioa eman zuen. Emaitza horien arabera, gaixotasun kardiobaskularren ondoriozko heriotza- arriskua handiagoa da (p < 0,001 joerarako) sedentarismoaren mailak altuak direnean, jarduera fisikoko kuartil baxuenean eserita emandako denbora honela neurtzen denean: "inaktiboa" (~ 5 min/egun). Azterlanaren arabera, heldu sedentarioek (egunean 8 ordu baino gehiago eserita) gaixotasun kardiobaskularren ondoriozko heriotza-arrisku handiagoa zuten; "aktiboagoak" zirenetan, berriz, (hau da, > 35,5 MET-ordu astean edo ~ 60-75 minutu egunean) arindu egin zen lotura. Sedentarismoaren eta minbiziagatiko hilkortasunaren arteko loturei buruzko emaitzak, oro har, ahulagoak izan ziren; behatutakoaren arabera, ordea, dosiari lotutako arriskua % 6-% 21 handitzen zen eserita denbora gehiago emanda (bereziki > 8 ordu egunean), baina soilik jarduera fisikoaren kuartilik baxuenean (< 2.5 MET-ordu astean) (8). Ebidentziak sedentarismoaren (eserita emandako guztizko denbora gisa neurtua) eta gaixotasun kardiobaskularren intzidentziaren (HR = 1,29 [ % 95eko CI: 1,27tik 1,30era]) arteko lotura bat bermatzen du, koaldagai potentzialetarako doikuntzaren ondoren arindu zena, jarduera fisikoaren maila barne (HR = 1,14 [ % 95eko CI: 1,04tik 1,23ra]) (88). Asiako hego-ekialdeko populazioetan egindako azterlanen berrikuspen batek ziurtasun baxuko ebidentzia eman zuen denbora sedentario handiagoa adierazle kardiometaboliko kaltegarrien probabilitate handiagoarekin lotzen dela (II motako diabetesa, BMI handiagoa, presio arterial handiagoa barne) (89). Oraintsuko bi azterlanek lotura baten berri ematen dute eguneko guztizko denbora eserita (88) eta guztizko denbora sedentarioa telebista ikusten (87) eta II motako diabetesaren intzidentziaren artean. Bi azterlanek aurkitu zuten sedentarismo handiagoa II motako diabetesaren intzidentzia-arrisku handiagoarekin lotzen zela. Adibidez, II motako diabetesarekin lotura lineal bat ikusi zen jarduera fisikorako doitzean (87) guztizko denbora sedentarioa (RR = 1,01 [ % 95eko CI: 1,00etatik 1,01era] p = < 0,001) eta telebista ikusten (RR = 1,09 [ % 95eko CI: 1,07tik 1,12ra] p = < 0,001). Gainera, lotura esanguratsu baten aldeko ebidentzia dago sedentarismoaren (telebista ikusten emandako denbora gisa neurtua) eta minbiziagatiko hilkortasunaren (35, 87) artean. Berrikuspen berriago batzuek, ziurtasun baxu eta oso baxukoek, sedentarismoaren eta kolon eta ondesteko minbiziaren (90) arteko lotura babesten duen ebidentzia ematen dute, baina ez prostatako, bularreko edo ondesteko minbiziaren intzidentziarenik (90-93). Ebidentzia gehigarriak (35) lotura esanguratsuen berri eman zuen, sedentario izaten emandako denboraren eta endometrioko, koloneko eta biriketako minbiziak garatzeko arrisku handiagoaren artean (35). Ziurtasun baxuko ebidentzia dago denbora sedentarioaren eta adipositatearen eta pisu-egoeraren beste adierazle batzuen arteko erlazio kaltegarriaren ziurtasunari dagokionez, eta sedentarismoaren eta pisu-egoeraren arteko erlazioa jarduera fisikoaren ‒intentsitate ertainetik bizira‒ kantitatearen arabera aldatzen den ala ez. Oro har, gomendio/gidalerro hauen berri emateko ebidentzia nahikorik ez zegoela eta ikerketa gehiago behar zela ondorioztatu zen. Ebidentzia mugatua dago denbora sedentarioaren murrizketaren eragin kaltegarriak ebaluatzen dituena. Adituen arabera, denbora sedentarioaren murrizketa gomendatzeak ez luke lesio-arriskurik handituko, batez ere intentsitate baxuko jarduera fisikoarekin ordezkatuz gero. ADULTS (aged 18–64 years) 40 GDGk honako hau ondorioztatu zuen: • Oro har, nahikoa ebidentzia dago OMEren gomendio berri bat garatzen laguntzeko, sedentarismoa mugatzeko eta osasunerako arriskuak murrizteko. • Ziurtasun ertaineko ebidentzia dago lotura bat dagoela denbora sedentario handiagoaren eta kausa guztiengatiko hilkortasuna eta gaixotasun kardiobaskularrek eta minbiziak eragindakoa, eta gaixotasun kardiobaskularren eta II motako diabetesaren intzidentzia handitzearen artean. • Ziurtasun baxutik ertainera arteko ebidentzia dago denbora sedentario handiagoaren eta endometrioko, koloneko eta biriketako minbizia izateko arriskua handitzearen artean. • Ez dago ebidentzia nahikorik sedentarismoaren eta adipositate-neurrien arteko loturari buruz, eta ikerketa gehiago behar da. • Sedentarismoa mugatzearen onurek edozein arrisku potentzial gainditzen dute. Badago dosi-erantzun loturarik (guztizko kantitatea, maiztasuna, iraupena, etenaldien intentsitatea)? Oro har, ziurtasun ertaineko ebidentziak dosi-erantzun erlazio ez lineala adierazten du denbora sedentarioaren (eserita edo telebista ikusten, autoinforme bidez edo gailuetan oinarrituta ebaluatua) eta kausa guztiengatiko hilkortasunaren eta gaixotasun kardiobaskularrek eta minbiziak eragindakoaren, eta gaixotasun kardiobaskularren indizearen artean (8, 35, 87). Oraintsuko metanalisi batek ziurtasun handiko ebidentzia eman zuen, azelerometroak ebaluatutako guztizko denbora sedentarioaren eta kausa kausa guztiengatiko hilkortasunaren arteko dosi-erantzun erlazioari buruz (65). Horrek adierazten du denbora sedentarioaren igoera nabarmen lotu zela kausa guztiengatiko hilkortasunarekin. Denbora sedentario gero eta handiagoetarako arrisku- zatidurak hauek izan ziren: 1,00 (erreferentea; ez hain sedentarioa); 1,28 (1,09-1,51); 1,71 (1,36-2,15); and 2.63 (1.94–3.56), balizko nahasmendu-faktoreen ondoriozko doikuntzaren ondoren, intentsitate ertainetik bizira bitarteko jarduera fisikoan emandako denbora barne (65). Sedentarismoaren eta hilkortasunaren arteko dosi-erantzun erlazioen azterketa horrek erakutsi zuen arriskua pixkanaka handitzen ari zela 7,5 ordutik 9 ordura, eta nabarmenagoa zela 9,5 ordutik gora. Egunean 10 ordu eta 12 orduko sedentarismoa 1,48 (1,22-1,79) eta 2,92 (2,24-3,83) hiltzeko arriskuarekin lotu zen, hurrenez hurren (65). Oraintsuko beste metanalisi batek dosi-erantzuna ebaluatu zuen eta lotura ez linealen berri eman zuen guztizko denbora sedentariorako eta kausa guztiengatiko hilkortasunerako (RR = 1 ordu/egun = 1,01 (1,00-1,01) ≤ 8 ordu/eguneko; eta 1,04 (1,03 – 1.05) > 8 ordu/esposizio-eguneko; eta gaixotasun kardiobaskularrengatiko hilkortasunerako (RR= 1.01 (0.99–1.02) ≤ 6 ordu/eguneko; eta RR= 1.04 (1.03–1.04) > 6 ordu/eguneko) jarduera fisikorako doikuntza egin ondoren (87). Azterlan berean, ikusi zen dosi-erantzun lotura lineal txiki bat zegoela II motako diabetesaren eta guztizko denbora sedentarioaren (1.01 (1.00 – 1.01)) artean, jarduera fisikorako eta telebista ikusteko denborarako doitu zenean (1.09 (1.07 – 1.12)) (87). Oro har, ebidentziaren arabera, sedentarismo handiagoa osasun-emaitza txarrarekin lotzen da, eta ondorioztatu zen ebidentzia nahikoa dagoela denbora sedentarioa minimizatzeko, osasunerako arriskuak murrizte aldera. Hala ere, kontuan hartuta berrikuspenetan sedentarismoa ebaluatzeko moduan aldaketa nabarmenak izan zirela (eseritako denbora, telebista ikusteko denbora autoinformatua edo gailuetan oinarrituta (azelerometroa) ebaluatua), eta denbora sedentariorako atalaseak desberdinak izan daitezkeela osasun-emaitzetan, jarduera fisikoaren mailen arabera ‒intentsitate ertainetik bizira‒ eta populazio-azpitaldeen artean, ez dago nahikoa ebidentzia denboran oinarritutako gomendio bat finkatzeko. Sedentarismoaren kantitate orokorraz gain, sedentarismoa metatzen duten patroiei buruzko ebidentzia berrikusi zen. Hala ere, ebidentzia mugatua egon zen sedentarismoan etenaldien maiztasunari eta/edo iraupenari buruzko gomendioak egiteko. GDGko honako hau ondorioztatu zuen: • Ez dago ebidentzia nahikorik sedentarismoari buruzko gomendio kuantifikatuak (denboran oinarrituak) finkatzeko. • Ez dago ebidentzia nahikorik sedentarismoan etenaldien maiztasunari eta/edo iraupenari buruzko gomendioak egiteko. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z ADULTS (aged 18–64 years) Lotura aldatzen da sedentarismoaren motaren eta eremuaren arabera? Sedentarismoaren eremu edo mota batzuk beste batzuk baino kaltegarriagoak izan daitezke, bai beren lotura zuzenei dagokienez, bai jarduera fisiko osasungarriago batean emandako denbora ordezteko potentzialari dagokionez. Sedentarismoari buruzko ikerketan hazkunde azkarra egon den arren, ebidentzia mugatuak daude, sedentarismoaren mota desberdinen eta osasun-emaitza desberdinen arteko lotura zuzenean alderatzen dutenak. Adibidez, ikerketa batzuek emaitza sendoagoak ematen dituzte sedentarismoa neurtzen denean telebista ikustearekin eta eserita emandako guztizko denborarekin alderatuta (87). Hori neurketa-akats diferentzialaren edo autoinformeko neurri eta tresnekin lotutako hondar- nahastearen ondorio izan liteke. Gaur egun, ez dago ebidentzia nahikorik osasun-emaitza desberdinekiko lotura desberdinak eta azpipopulazioaren arabera aldatzen diren modua zehazteko. Gero eta azterlan gehiagok gailuetan oinarrituta neurtzen dituzte jarduera fisikoa eta denbora sedentarioa osasun-emaitzekin lotzeko. Hala ere, gailuetan oinarritutako denbora sedentarioaren neurketatik abiatuta, sailkapen okerra gerta daiteke; izan ere, gailuen kokapen askok (adibidez, eskumuturra, gerria) ez dituzte jarrerak bereizten (adibidez, etzanda, eserita eta geldirik). Etorkizuneko ikerketek, txosten konbinatuak eta jarrerak bereizten dituzten metodoak erabilita, sedentarismorako patroiei buruzko ezagutza indartzen lagunduko dute. GDGk honako hau ondorioztatu zuen: • Ez dago ebidentzia nahikorik sedentarismoaren mota edo eremu desberdinei buruzko gomendioak egiteko. Jarduera fisikoaren mailak aldatzen du sedentarismoak hilkortasunean duen eragina? Sedentarismoak osasun-emaitzetan duen eraginean gero eta interes handiagoa dagoenez, jarduera fisikoaren mailen eta sedentarismoaren mailen arteko elkarreragin potentzialari buruzko ikerketa bultzatu da. Eskuragarri dagoen ikerketaren arabera, ziurtasun ertaineko ebidentzia dago sedentarismoaren eta kausa guztiengatiko hilkortasunaren, gaixotasun kardiobaskularrek eta minbiziak eragindakoaren arteko erlazioa aldatu egiten dela intentsitate ertaineko jarduera fisikoaren kantitatearen eta intentsitate bizikoaren artean (8, 9, 35). Aurkikuntza orokorrek erakusten dute sedentarismoaren eragina sendoagoa dela intentsitate ertainetik bizira bitarteko jarduera fisikoa kantitate baxuak egiten dituztenetan, edo, alderantziz, intentsitate ertainetik bizira bitarteko jarduera fisikoaren kantitate altuagoek arindu ditzaketela sedentarismoaren maila handiagoekin lotutako osasun- emaitza kaltegarriak. Frogatu da denbora sedentarioarekin eta kausa guztiengatiko hilkortasunarekin lotutako arriskua nabarmenagoa dela jarduera fisikoaren maila baxuagoetan maila altuagoetan baino (35). Metanalisi konbinatu batean, Ekelund et al.-ek sedentarismoaren eta jarduera fisikoaren eragin konbinatuak eta estratifikatuak ikertu zituzten kausa guztiengatiko hilkortasunean, milioi bat gizon eta emakume baino gehiagorengan, eta loturak jarduera fisikoaren mailaren arabera desberdinak zirela erakutsi zuten (9). Analisiek sedentarismoaren ‒eserita‒ eta jarduera fisikoaren ‒intentsitate ertainetik bizira‒ kuartilak erabili zituzten, eta ikusi zuten erreferentearekin alderatuta (< 4 ordu eserita eguneko eta jarduera fisikoaren ‒intentsitate ertainik bizira‒ kuartil altuena [> 35,5 MET-ordu astean]) alderatuta, ez zegoela heriotza-arrisku handiagorik 8 ordu baino gehiago eserita egoten zirenen jarraipenean, haien jarduera fisikoa 35,5 MET-ordu asteko (HR = 1,04 [ % 95eko CI: 0,99tik 1,10era]) baino gehiago izanik. Aldiz, gutxiago esertzen ziren (< 4 ordu/egun) haien jarraipenean, jarduera fisikoaren kuartilik baxuenean egonda (< 2,5 MET-ordu/aste) askoz ere heriotza-arrisku handiagoa ikusten zen (HR = 1,27 [ % 95 ik: 1,22tik 1,31ra]). Azterlanak ondorioztatu zuen, eguneko 60-75 minutu inguruko (kuartilik altuena) jarduera fisikoaren mailek ‒intentsitate ertainetik bizira‒ arindu egin dezaketela sedentarismoaren eta osasun-emaitzen arteko lotura kaltegarria, baita ezabatu ere. (9). Gomendioak 41 ADULTS (aged 18–64 years) 42 ARRISKU ALTUA 2. irudia: Sedentarismoaren eta jarduera fisikoaren arteko erlazioa PAGACetik egokitua ARRISKU BAXUA Jarduera fisiko gehiago Sedentarismoaren mailen eta jarduera fisikoaren ‒ intentsitate ertainetik bizira‒ arteko erlazio hori PAGACen berrikuspen sistematikoan laburbildu zen (35), 2. irudian erakusten den bezala. Azterlan berri batek beste ebidentzia bat eman zuen, kausa espezifikoengatiko hilkortasunarekin lotutako lotura berak aztertzean, eta antzeko aurkikuntzak erakutsi ziren (8). Metanalisi konbinatu handi batean (9 azterlan, n = 850.000, CVD hilkortasuna; 8 azterlan, n = 777.000, minbiziagatiko hilkortasuna), emaitzek erakutsi zuten, intentsitate ertainetik bizira, jarduera fisikoaren mailarik altuenek arindu egin zutela gaixotasun kardiobaskularrengatiko hilkortasun-arrisku handiagoa sedentarismoaren maila handiekin, bai eserita emandako denbora gisa neurtuta, bai telebista ikusten emandako denbora gisa neurtuta (8). Ikerketaren arabera, egunean 8 ordu baino gehiagoz eserita zeuden pertsonen artean, lotura bat zegoen heriotza-arrisku handiagoarekin, kuartil aktiboenean izan ezik, non lotura arindu egin zen. Zehatzago esanda, gaixotasun kardiobaskularrengatiko hilkortasun-arriskua % 32 handiagoa zen egunean 8 ordu baino gehiagoz eserita zeudenen artean,erreferentziazko taldearekin alderatuta (< 4 ordu/egun)(p < 0,001eko joerarako). Emaitzak ez ziren hain nabarmenak izan, baina adierazgarriak izaten jarraitu zuten, jarduera fisikoaren ziren telebista-denborarako eta gaixotasun kardiobaskularrengatiko hilkortasunerako, intentsitate ertainetik bizira bitarteko jarduera fisikoko estratuetan (8). Minbiziagatiko hilkortasunerako loturak mistoagoak izan ziren, nahiz eta, oro har, frogatu zuten jarduera fisikoaren maila altuagoek arindu egin zituztela sedentarismoaren eragin kaltegarriak, eserita emandako guztizko denbora gisa ebaluatu zirenean. Ebidentzia hori oinarri hartuta, erabaki zen jarduera fisikoaren maila altuagoak gomendatu beharko liratekeela, intentsitate ertainetik bizira, sedentarismo handia duten eta onurek arriskuak gaindituko lituzketen pertsonentzat. GDGk honako hau ondorioztatu zuen: • Ziurtasun ertaineko ebidentzia dago sedentarismoaren eta kausa guztiengatiko hilkortasunaren, eta gaixotasun kardiobaskularrek eta minbiziak eragindakoaren arteko erlazioa aldatu egiten dela jarduera fisikoaren ‒intentsitate ertainetik bizira‒ kantitatearen arabera. • Jarduera fisiko gehiago ‒intentsitate ertainetik bizira‒ egiteak arindu egin dezake sedentarismoaren eta osasun-emaitzen arteko lotura kaltegarria. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z M o re s e d e n ta ry t im e D e n b o ra s e n d e n ta ri o g e h ia g o Adinekoentzat, jarduera fisikoa ondokoetan sar daiteke: aisialdian (jolasa, jolasak, kirolak edo ariketa planifikatua), garraioatzean (bizikletan ibiltzea, oinez ibiltzea eta bizikletan ibiltzea), lanaren edo etxeko lanen zati gisa egin daiteke, eguneroko zereginei, hezkuntzari, etxeko edo komunitateko inguruneei dagokienez. Adinekoetan, jarduera fisikoak onurak dakartza osasun-emaitza hauetarako: hobetu egiten du kausa guztiengatiko hilkortasuna eta gaixotasun kardiobaskularrek eragindakoa, hipertentsioren, minbizi espezifikoen eta II motako diabetesaren intzidentzia, osasun mentala (antsietate eta depresioaren sintoma txikiak), osasun kognitiboa eta loa; adipositate-neurriak ere hobetu ditzakete. Adinekoetan, jarduera fisikoak erorikoak prebenitzen laguntzen du, eta hezur-osasunaren eta gaitasun funtzionalaren narriaduraren ondoriozko erorikoekin lotutako lesioak. Hau gomendatzen da:  Adineko guztiek erregulartasunez egin behar dute jarduera fisikoa. Gomendio sendoa, ziurtasun ertaineko ebidentzia  Adinekoek gutxienez 150-300 minutuko intentsitate ertaineko jarduera fisiko aerobikoa egin behar dute; edo intentsitate biziko jarduera fisiko aerobikoa, gutxienez 75-150 minutukoa; edo astean zehar intentsitate ertainetik bizirako jardueraren konbinazio baliokide bat, osasun-onura esanguratsuak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia  Adinekoek gutxienez 150-300 minutuko intentsitate ertaineko jarduera fisiko aerobikoa egin behar dute; edo intentsitate biziko jarduera fisiko aerobikoa, gutxienez 75-150 minutukoa; edo astean zehar intentsitate ertainetik bizirako jardueraren konbinazio baliokide bat, osasun-onura esanguratsuak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia  Asteko jarduera fisikoaren barruan, adinekoek, astean 3 egunetan edo gehiagotan, oreka funtzionala eta indar-entrenamendua nabarmentzen dituen osagai anitzeko jarduera fisikoa ‒intentsitate ertaina edo handiagoa‒ egin behar dute gaitasun funtzionala hobetzeko eta erorikoak prebenitzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia  Adinekoek 300 minutu baino gehiagora igo dezakete intentsitate ertaineko jarduera fisiko aerobikoa; edo 150 minututik gora egin intentsitate biziko jarduera fisiko aerobikoa; edo astean zehar intentsitate ertain eta biziko jardueraren konbinazio baliokide bat egin dezakete, osasunerako onura gehigarriak lortzeko. Baldintzapeko gomendioa, ziurtasun ertaineko ebidentzia Gomendioak 43 J A R D U N B ID E E G O K IA K OLDER ADULTS (aged 65 years and over) 44 Online eskuragarri, hemen: https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Aldeko ebidentzia eta oinarria Gidalerro hauetarako, adinekoentzat, PAGACek egindako ebidentziaren sintesi osoa erabili eta eguneratu zen (35). Hamabost berrikuspenek inklusio-irizpideak bete zituzten, eta loturaren berri eman zuten jarduera fisikoaren eta adinekoen osasun-emaitza espezifikoen artean (erorikoen prebentzioa eta erorikoekin, funtzio fisikoarekin, hauskortasunarekin eta osteoporosiarekin lotutako lesioak). Erorikoak prebenitzeko ebidentziak Sherrington et al-en 2019ko Cochrane Collaboration Systematic Review (42) berrikuspena erabili eta eguneratu zuen, bere jatorrizko berrikuspenaren azken bilaketa-datatik 2019ko azarora arte (bederatzi azterlan berri) argitaratutako ebidentziarekin. PubMed-en egin ziren osteoporosiari eta sarkopeniari buruz dauden berrikuspen sistematikoen bilaketak (2008tik 2019ko azarora arte argitaratuak) eta berrikuspen berririk ez eta 8 azterlan berri identifikatu ziren. Metodoen, datu-erauzketaren eta ebidentzia-profilen xehetasun guztiak web-eranskinean aurki daitezke: ebidentzia- profilak . Adinekoetan (adina 65 urte eta gehiago), zein da jarduera fisikoaren eta osasun-emaitzen arteko lotura? Ebidentzia primarioaren oinarria adinekoen populazioetan osasun-emaitzek (besteak beste, kausa guztiengatiko eta kausa espezifikoengatiko hilkortasuna, gaixotasun kardiobaskularren, II motako diabetesaren eta minbiziaren intzidentzia, adipositatea, osasun mentala eta emaitza kognitiboak) eta jarduera fisikoak dituzten loturak ebaluatzeko, helduen populazioetan bildu eta berrikusi zen literatura zientifiko bera izan zen. Ebidentzia-multzo hori bera onartu eta estrapolatu zen adinekoentzat, azterlan gehienek ez zutelako ezarri goragoko adin-mugaren irizpiderik, eta, beraz, 65 urtetik gorako helduak barne hartu zituzten. Ebidentziaren berrikuspen gehigarri bat egin zen, loturak aztertzeko eta jakinarazteko jarduera fisikoaren eta adinekoen osasun-emaitza espezifikoen artean, erorikoen prebentzioa, eta erorikoekin, funtzio fisikoarekin, hauskortasunarekin eta osteoporosiarekin lotutako lesioak barne. Adinekoen gaitasun fisikoaren murrizketaren eraginez, askotan, erorikoak eta erorikoekin lotutako lesioak gertatu ohi dira, eta ondorio larriak izan ditzakete. Istripuzko erorikoak kanpo-faktoreen (ingurunekoak) eta barne-faktoreen (adibidez, kontrol posturalean eragina duten anomalia muskuloeskeletikoak edo nerbio-sistemakoak) konbinazioaren ondorio dira. Ebidentziak erakusten duenez, jarduera fisikoa, bereziki osagai anitzeko jarduera fisikoko programak, orekaren, indarraren, erresistentziaren, ibilketaren eta funtzio fisikoaren entrenamenduaren konbinazioak barne hartzen dituztenak, erorikoen tasa murriztuarekin eta erorikoengatiko lesio-arrisku gutxiagorekin lotzen da. Oraintsuko ebidentziak erakusten du, adinekoetan, ariketa fisikoak erorikoen tasa % 23raino murriz dezakeela (tasa-arrazoi konbinatua (RaR) 0,77 [ % 95eko CI: 0,71tik 0,83ra]); horrek nabarmen murriz dezake erorikoen ondoriozko lesio-arriskua, hauek barne: hezur-hausturak, traumatismo kraneoentzefalikoa, zauri irekia, ehun bigunetako lesioa eragiten duten eroriko larriak, edo arreta medikoa edo ospitalizazioa eskatzen duen beste edozein lesio. Ebidentzia hau sendoa izan zen eta beste berrikuspen batzuen aurkikuntzak berretsi zituen (35). Helduaro goiztiarrean goren maila batera iritsi ondoren, muskulu- eta hezur-masa murriztu egiten da adinean aurrera egin ahala (hau da, sarkopenia eta osteopenia/osteoporosia) eta hori indar eta funtzio fisikoaren murrizketarekin lotuta egon daiteke. Ebidentziak erakusten du jarduera fisiko erregularrak funtzio fisikoa hobetzen duela eta adinarekin lotutako funtzio fisikoa galtzeko arriskua murrizten duela adinekoen artean. Emaitzek ondorio onuragarriak erakusten dituzte oreka dinamikoan (SMD = 1,10 [ % 95eko CI: 0,29tik 1,90era]); muskulu-indarrean (SMD = 1,13 [ % 95eko CI: 0,30etik 1,96ra]); malgutasunean (SMD = 1,22 [ % 95eko CI: 0,39tik 2,04ra]); eta bihotz eta arnas sistemen gaitasunean (SMD = 1,48 [IC del 95%: 0,42 a 2,54]) (94). Ebidentziak erakusten du, halaber, jarduera fisikoaren maila altuagoek hezurren osasuna hobetu dezaketela, eta, beraz, adinekoen osteoporosia prebenitu (eraginaren tamaina estandarizatu konbinatua 0,21 [ % 95eko CI: 0,06tik 0,36ra]) (95). Jarduera fisikoko interbentzioek bizkarrezurraren eta lepo femoralaren (aldaka) hezur-dentsitate minerala hobetu dezakete. GDGk honako hau ondorioztatu zuen: • Ziurtasun ertaineko ebidentzia dago jarduera fisikoak funtzio fisikoa hobetzen duela eta adinarekin lotutako funtzio fisikoa galtzeko arriskua murrizten duela oro har zahartzen ari den populazioan. • Ziurtasun baxuko ebidentzia dago adinekoentzat gomendatutako jarduera fisikoaren kantitateetarako eta motetarako arriskuak baxuak direla eta onurek gainditzen dituztela. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Badago dosi-erantzun loturarik (kantitatea, iraupena, maiztasuna, intentsitatea)? Ebidentziak alderantzizko erlazioa erakusten du adinekoek egindako jarduera fisikoaren kantitatearen eta funtzio fisikoa murrizteko arriskuaren artean. Oro har, jarduera fisiko handiagoa (maiztasuna, iraupena eta/edo kantitatea) onura handiagoekin lotzen da (35). Ebidentziaren arabera, nahita egindako abiadura azkarreko erresistentzia-entrenamendua gaitasun funtzional orokorra hobetzeko abiadura ertaineko erresistentzia-entrenamendua baino handiagoa izan daiteke (SMD= 0.41 [% 95 CI: 0.18 - 0.65]; eta SPPB (SMD= 0.52 [% 95 CI: 0.10 - 0.94])) (96). Jarduera fisikoaren eta erorikoen prebentzioaren arteko dosi-erantzun erlazioa aztertzen duen ebidentzia mugatua dago; hala ere, babes-ebidentzia ematen duten azterlan gehienek aurkezten dute astean 3 egunekin bat datorren programa bat. GDGk honako hau ondorioztatu zuen: • Ziurtasun altuko ebidentzia dago dosi-erantzun erlazioa alderantzizkoa dela jarduera fisiko aerobikoaren kantitatearen eta funtzio fisikoa murrizteko arriskuaren artean, adinekoen populazio orokorrean. Lotura aldatzen da jarduera fisikoaren motaren edo eremuaren arabera? Oreka, indarra, erresistentzia, ibilketa eta funtzio fisikoaren entrenamendua konbinatzen dituzten jarduera fisikoko programak lotuta daude adinekoen erorikoen tasa baxuarekin eta erorikoen ondoriozko lesioen arriskuarekin. 11 ECAren berrikuspen baten ebidentziak erakutsi zuen jarduera fisikoko hainbat interbentziotan parte hartzean (oro har, oreka- eta funtzio-ariketak gehi erresistentzia- ariketak), adinekoetan % 28ra murriz daitekeela eroriko- tasa (RaR= 0.72 [% 95 CI: 0.56 - 0.93]) (42). Erresistentzia- ariketen eragina zalantzazkoa izan zen eta datu mugatuetan oinarritu zen (RR= 0.97 [% 95 CI: 0.14 - 6.49]; proba 1; n= 73) (42). Ebidentziak iradokitzen du, halaber, askotariko ariketa- programek eragin positibo handiagoak dituztela hezurren osasunean (eraginaren tamaina estandarizatua: 0,45 [% 95 CI: 0,20 - 0,71]; p = 0,001), ariketarik egiten ez dutenekin alderatuta (95). GDGk honako hau ondorioztatu zuen: • Ziurtasun handiko ebidentzia dago oreka, indarra, martxa eta entrenamendu funtzionala (adibidez, osagai anitzeko jarduera fisikoa) konbinatzen dituzten jarduera fisikoaren mailarik altuenak adinekoen eroriko-tasa baxuarekin eta erorikoen ondoriozko lesio-arrisku gutxiagorekin lotzen direla. • Ziurtasun ertaineko ebidentzia dago askotariko ariketak sartzen dituzten programek ondorio esanguratsuak izan ditzaketela hezurren osasunean eta osteoporosiaren prebentzioan. 45 46 Online eskuragarri, hemen: https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Adinekoentzat, honela definitzen da sedentarismoa: esna egon bitartean, eserita edo etzanda emandako denbora, energia-gastu gutxirekin, lanbideko, hezkuntzako, familiako eta komunitateko inguruneetan eta garraioaren testuinguruan. Aldeko ebidentzia eta oinarria Sedentarismoa ez zen sartu 2010eko osasunerako jarduera fisikoari buruzko gomendio orokorretan (1). Populazioaren ebidentzia espezifikorik eza dela eta, adinekoen populazioen sedentarismoaren eta osasun- emaitzen arteko loturak ebaluatzeko ebidentzia-oinarri nagusia helduen populazioentzat bildutako eta berraztertutako literatura zientifiko bera izan zen, azterlan gehienek ez baitzuten adin-muga handiagoko irizpiderik ezarri, eta, beraz, 65 urtetik gorako helduak sartu ziren. Sedentarismoari buruzko ebidentziaren aurkikuntzak berrikusi ziren helduen populazio orokorrean, eta ebaluatu egin zen ebidentziarik ote zegoen emaitzak desberdinak izango liratekeela, edo ez liratekeela aplikatzekoak edo kontraindikatuta egongo liratekeela adinekoentzat. Metodoen, datu-erauzketaren eta ebidentzia-profilen xehetasun guztiak web-eranskinean aurki daitezke: ebidentzia-profilak . O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Adinekoetan, sedentarismoaren kantitate handiagoa osasun-emaitza txar hauekin lotzen da: kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eta minbiziak eragindakoa, eta gaixotasun kardiobaskularren, minbiziaren eta II motako diabetesaren intzidentzia. Hau gomendatzen da:  Adinekoek mugatu egin behar dute sedentario izaten igarotzen duten denbora. Denbora sedentarioa edozein intentsitateko jarduera fisikoarekin ordezkatzeak (intentsitate baxua barne) osasun-onurak dakartza. Gomendio sendoa, ziurtasun ertaineko ebidentzia  Sedentarismo maila handiek osasunean dituzten ondorio kaltegarriak murrizten laguntzeko, adinekoek saiatu egin behar dute jarduera fisikorako gomendatutako mailak ‒intentsitate ertainetik bizira‒ gainditzen. Gomendio sendoa, ziurtasun ertaineko ebidentzia 47 Gomendioak EMAKUMEAK HAURDUNALDIAN ETA ERDITU ONDOREN Gidalerro hauek jarduera fisikoari eta amaren eta fetuaren osasun-emaitzei heltzen diete haurdunaldian eta erditze ondoko aldian. Emakume haurdun eta erditu ondorengo guztientzat dira, haien adina, testinguru kulturala edo maila sozioekonomikoa edozein izanda ere. Haurdunaldia eta erditu ondorengo aldia emakumearen bizitzako etapak dira, eta helduaroan fisikoki aktiboak izatearen onurak helduei zuzendutako gomendioetan zehazten dira. Emakumeek, haurdunaldian eta erditu ondoren, jaio aurreko eta erditu osteko arreta medikoko espezialista baten zaintzapean egon behar dute. Espezialistak aholkuak eman ahal izango ditu haurdunaldian edo erditu ondoren emakumeek jarduera fisikoan parte hartzeko kontuan hartu beharreko alderdi bereziei buruz, haien historia medikoa eta edozein kontraindikazio kontuan hartuta. Jarraibide horiek osasun publikoan eta populazioan oinarritzen dira. Haurdunaldiarekin edo erditzearekin lotutako konplikazioak dituzten emakumeentzako orientazio klinikoa bilatu behar da. Emakumeek, haurdunaldian eta erditu ondoren, gomendio hauek betetzen saiatu behar dute ahal duten neurrian eta kontraindikaziorik ezean. JARDUERA FISIKORAKO GOMENDIOA Emakumeentzat, haurdunaldian eta erditu ondoren, jarduera fisikoa ondokoetan sar daiteke: aisialdian (jokoa, jolasak, kirolak edo ariketa planifikatua), garraiatzean (gurpiletan, oinez eta bizikletan ibiltzea), laneko eta etxeko zereginetan, eta lanbideko, hezkuntzako, familiako eta komunitateko eguneroko inguruneetan. Emakume haurdunetan eta erditu ondorengoetan, jarduera fisikoak amaren eta fetuaren osasun-onura hauek dakartza: murriztu egiten ditu aurre-eklanpsia izateko arriskua, haurdunaldiko hipertentsioa, diabetesa, gainpisua, erditzearen konplikazioak eta erditu ondorengo depresioa, baita konplikazioak ere jaioberriarengan, jaiotza-pisuan eragin kaltegarririk ekarri gabe; eta ez du handitzen fetu hilaren jaiotza-arriskua. Emakume guztientzat, haurdunaldian eta erditu ondoren, kontraindikaziorik ezean, gomendatzen da:  haurdunaldian eta erditu ondoren jarduera fisikoa erregulartasunez egitea; Gomendio sendoa, ziurtasun ertaineko ebidentzia  astean zehar intentsitate ertaineko 150 minutuko jarduera fisiko aerobikoa egitea, osasun-onura esanguratsuak lortzeko; eta Gomendio sendoa, ziurtasun ertaineko ebidentzia  jarduera aerobiko eta muskuluak indartzeko jarduera askotarikoak txertatzea. Halaber, onuragarria izan daiteke luzaketa-ariketa leunak gehitzea. Gomendio sendoa, ziurtasun ertaineko ebidentzia Horrez gain:  Haurdunaldiaren aurretik intentsitate biziko jarduera aerobikoa egin ohi zuten emakumeek, edo fisikoki aktiboak zirenek, jarduera horiek egiten jarrai dezakete haurdunaldian eta erditu ondoren. Gomendio sendoa, ziurtasun ertaineko ebidentzia PREGNANT AND POSTPARTUM WOMEN 48 Online eskuragarri, hemen: https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf • Jarduera fisiko pixka bat egitea ezer ez egitea baino hobe da. • Emakumeek, haurdunaldian eta erditu ondoren, ez badituzte gomendio hauek betetzen, jarduera fisikoren bat egitea onuragarria izango da beren osasunarentzat. • Emakumeek, haurdunaldian eta erditu ondoren, pixkanaka hasi behar dute jarduera fisikoa egiten, eta maiztasuna, intentsitatea eta iraupena gutxika handitu. • Zoru pelbikoko muskuluen entrenamendua egunero egin daiteke gernu-inkontinentzia arriskua murrizteko. Jarduera fisikoa egitean haurdun dauden emakumeentzako segurtasun-ohar gehigarriak: • Saihestu jarduera fisikoa gehiegizko beroan, batez ere hezetasuna handia denean; • Hidratatuta egon ura edanda jarduera fisikoa egin aurretik, bitartean eta ondoren; • Saihestu kontaktu fisikoa dakarten jardueretan parte hartzea; erorikoen arrisku handia dakarte, edo oxigenazioa murriz dezakete (jarduerak altitude handian, normalean altitude handian bizi ez direnean); • Saihestu, haurdunaldiaren lehen hiruhilekoaren ondoren, ahoz gorako jarreran egiten diren jarduerak; • Emakume haurdunek, kirol leihaketetan parte hartzeko edo gidalerro gomendatuen gainetik ariketa esanguratsua egiteko asmoa badute, osasun- arloko profesional batengana jo behar dute azter ditzan; • Haurdun dauden emakumeei osasun-arretako profesionalak jarduera eteteko edo mugatzeko ohartarazten dien arrisku-seinaleen berri eman behar die; arrisku-seinale horiek izanez gero, berehala kontsultatu behar die osasun-arretako hornitzaile bati • Erditu ondoren pixkanaka jarduera fisikora itzultzea, eta osasun-arloko profesional batekin kontsultatuta, zesarea bidez erdituz gero. Aldeko ebidentzia eta oinarria Emakumeentzat, haurdunaldian eta erditu ondoren, Jarduera fisikoari eta sedentarismoari buruzko gidalerro hauetarako (2020), emaitza kritiko eta garrantzitsuei heltzen dieten 7 berrikuspen sistematikoren ebidentzia- laburpenak erabili eta eguneratu ziren (28-34). 7 berrikuspenetatik lauk inklusio-irizpideak bete zituzten. Metodoen, datu-erauzketaren eta ebidentzia-profilen xehetasun guztiak web-eranskinean aurki daitezke: ebidentzia-profilak . Emakumeetan, haurdunaldian eta erditu ondoren, zein da jarduera fisikoaren eta osasun-emaitzen arteko lotura? Haurdun egon aurretik eta haurdunaldian, jarduera fisikoa egiteak haurdunaldiko konplikazio arruntak izateko arriskua murrizten lagun dezake. Haurdunaldian jarduera fisikoa egitea nabarmen lotzen da haurdunaldiko pisu gehitzea murriztearekin (MD= 1.14 kg [% 95eko CI: 1.67tik 0.62ra]) (97), eta haurdunaldiko diabetesaren arrisku baxuarekin (RR= 0.71 [% 95eko CI: 0.57tik 0.89ra]) (97), haurdunaldiaren aurretik fisikoki aktibo egotean bezala (OR= 0.70 [% 95eko CI: 0.57tik 0.85era]) (31, 34, 97), gainpisua edo obesitatea duten emakumeetan ere (97). Haurdunaldiko jarduera fisikoak ez dirudi areagotu egiten duenik haurdunaldiko hipertentsioaren edo aurre-eklanpsiaren intzidentzia (31). Ebidentziaren arabera, gainpisua edo obesitatea duten emakume haurdunen artean ez dago alde esanguratsurik haurdunaldiko hipertentsioaren intzidentzian (RR = 0,63 [ % 95eko CI: 0,38tik 1,05era]) edo aurre-eklanpsian (RR = 1,39 [ % 95eko CI: 0,66tik 2.93ra]) jarduera fisikoko interbentzio-taldeak versus jaio aurreko arreta estandarra artean (97). Aspaldi batez egon dira kezkak amaren jarduera fisikoak fetuaren garapenean eta erditzean izan ditzakeen ondorio kaltegarriei buruz. Hala ere, oraintsuko ebidentziak erakusten du jarduera fisikoa ez dagoela lotuta ondoko arrisku-intzidentziak areagotzearekin: abortua, hildako fetua erditzea edo konplikazioak erditzean (32). Ebidentziak iradokitzen du ez dagoela alderik zesarea bidezko erditzearen intzidentzian gainpisua edo obesitatea duten emakume haurdunetan jarduera fisikoko interbentzio-taldeen versus jaio aurreko arreta estandarraren artean (97). Haurdunaldiko jarduera fisikoa ez da lotzen jaiotza- pisuan (98) edo jaiotza goiztiarrean (32) eragin kaltegarriak izateko arrisku handiagoarekin, eta are O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z J A R D U N B ID E E G O K IA K 49 Gomendioak gehiago, arrisku orokorra murriz daiteke (98), baita gainpisua edo obesitatea duten emakume haurdunetan ere (RR = 1,02 [% 95eko IC: 0,54tik 1,92ra]) edo haurdunaldian pisua altua duten haurretan (RR= 0.90 [% 95eko CI: 0.65etik 1.25era]) jarduera fisikoko interbentzio-taldeen versus jaio aurreko arreta estandarraren artean (97) Erditze ondoko aldian, amek aldaketa fisiko eta emozional asko izan ditzakete. Ebidentziak erakusten du haurdunaldiko jarduera fisikoa alderantziz lotuta egon daitekeela erditze ondoko depresioarekin (29). Haurdunaldiko jarduera fisikoari buruzko 6 probako eta 11 behaketa-azterketako metanalisiaren ebidentziak (99) alderantzizko erlazio esanguratsua erakutsi zuen haurdunaldiko jarduera fisikoaren eta erditze osteko depresioaren artean (SMD = 0,58 [ % 95eko CI: 1,09tik 0,08ra]). Eragina handiagoa izan zen bost azterlanetara mugatu zenean gutxienez intentsitate ertaineko interbentzioekin (SMD = 0,70 [ % 95eko CI: 1,19tik 0,22ra]) (99). GDGk honako hau ondorioztatu zuen: • Ziurtasun altuko ebidentzia dago haurdunaldiko jarduera fisikoak haurdunaldian pisua gehitzeko eta diabetes mellitusa izateko arriskua murriz dezakeela. • Ziurtasun ertain eta altuko ebidentzia dago jarduera fisikoak ez duela handitzen haurdunaldiko hipertentsioaren intzidentzia. • Ziurtasun ertaineko ebidentzia dago, jarduera fisikoak abortuaren, hildako fetuaren jaiotzaren edo erditzearen konplikazioen intzidentzia handitzen ez duelako; eta ziurtasun ertaineko ebidentzia, intentsitate handiko jarduera fisikoa egiten duten ametan erditze goiztiarra izateko arriskua baxua dela. • Ziurtasun baxu/ertaineko ebidentzia dago jarduera fisikoak ez duela handitzen jaiotza- pisua baxua izateko arriskua, edo haurdunaldian haurraren pisua baxua izateko arriskua, edo haurdunaldian haurraren pisua altua izateko arriskua. • Ziurtasun baxuko ebidentzia dago haurdunaldiko jarduera fisikoa erditze ondoko depresio-maila baxuagoekin lotuta dagoelako. • Arriskuak baxuak dira haurdunaldian eta erditu ondoren emakumeentzat gomendatzen diren jarduera fisikoaren kantitateei eta motei dagokienez, eta onurek konpentsatzen dituzte. Badago dosi-erantzun loturarik (kantitatea, iraupena, maiztasuna, intentsitatea)? Haurdunaldiko eta erditu ondorengo aldiko jarduera fisikoari buruzko ebidentzian zehar, interbentzioak desberdinak ziren jarduera fisikoaren kopuruan (hau da, dosia), bai minutuen araberako iraupenean, bai asteko maiztasunean. Oro har, eskuragarri zegoen ebidentziak astean gutxienez 3 aldiz adierazten zuen jarduera fisiko aerobikoaren maiztasuna, normalean 30- 60 minutukoa. Ebidentzia hori helduentzat oro har gomendatzen den jarduera-kantitatearekin (hau da, astean 150 minutu intentsitate ertainean) bat datorren dosi batek osasunean duen eragina ebaluatzen duten azterlanetatik hartu da. Oro har, jarduera fisiko gehiago (maiztasuna, iraupena eta/edo kantitatea) onura handiagoekin lotzen bada ere, ikerketa gehiago behar da dosi-erantzun erlazioa zehatzago ulertzeko. Haurdunaldiaren aurretik aisialdian jarduera fisikoaren kantitate handiagoa versus txikiagoa egitea lotuta dago haurdunaldiko diabetesaren arriskua nabarmen jaistearekin (OR = 0,54 [ % 95eko CI: 0,34tik 0,87ra]) (100). Era berean, intentsitate biziko jarduera fisikoa egin zuten ametan erditze goiztiarra izateko arriskuaren murrizketa baxua baina esanguratsua dagoela erakusten duen ebidentzia dago (RR = 0,20 [ % 95eko CI: 0,36tik 0,03ra]) (98). Ez zen ebidentziarik identifikatu gomendioen gainetik dauden mailetan ariketa egitearen segurtasunari edo onura gehigarriari buruz. GDGk honako hau ondorioztatu zuen: • Ez dago ebidentzia nahikorik jarduera fisikoaren eta haurdunaldiko eta erditu ondoko osasun-emaitza kritiko espezifikoen arteko dosi-erantzun lotura zehazteko. • Ebidentzia orokorrak onurak erakusten ditu osasun- emaitza kritikoetarako, eta helduentzat oro har gomendatzen den jarduera fisikoaren kantitateekin oso koherenteak diren interbentzioetan oinarritzen da, hau da, astean 150 minutuko jarduera fisikoa, intentsitate ertainekoa. • Ez zegoen inolako oinarririk emakumeentzat, haurdunaldian eta erditu ondoren, gomendatutako intentsitate ertaineko jarduera fisikoaren kantitatea edo maiztasuna aldatzeko, populazio heldu orokorrarekin alderatuta. • Ziurtasun ertaineko ebidentzia dago arriskua baxua dela intentsitate biziko jarduera fisikoa egiten duten ametan erditze goiztiarra izateko. PREGNANT AND POSTPARTUM WOMEN 50 Lotura aldatzen al da jarduera fisikoaren motaren, domeinuaren edo unearen arabera (haurdunaldiaren, jaio aurrekoaren edo jaio ostekoaren aurretik)? Jarduera fisikoa aisialdian batez ere ebaluatu zuten azterlanen ebidentzia dago; jarduera mota aerobikoa zen nagusiki (oinez ibiltzea edo igeri egitea, adibidez), baina bada ebindentzia indar- entrenamendua (adibidez, zirkuituko entrenamendua) edo ariketa aerobikoen eta muskuluak indartzeko ariketen konbinazioak barne hartzen zituzten interbentzioak ebaluatzen dituzten azterlanena. Hala ere, oro har, ez dago ebidentzia nahikorik jarduera fisikoaren eta osasun-emaitzen arteko loturak jarduera fisikoaren motaren, eremuaren edo unearen arabera (haurdunaldiaren aurretik, jaiotza aurretik edo jaiotza ondoren) aldatzen diren zehazteko. GDGk honako hau ondorioztatu zuen: • Ziurtasun ertaineko ebidentzia dago emakumeek, haurdunaldian eta erditu ondoren, askotariko jarduera fisikoak sartu behar dituztela (aerobikoa eta muskuluak indartzekoa). Luzaketa-ariketa leunak ere onuragarriak izan daitezke. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z SEDENTARISMORAKO GOMENDIOA 51 Gomendioak Emakumeentzat, haurdunaldian eta erditu ondoren, honela definitzen da sedentarismoa: esna egon bitartean, eserita edo etzanda emandako denbora, energia-gastu gutxirekin, lanbideko, hezkuntzako, familiako, komunitateko inguruneetan eta garraioaren testuinguruan. Aldeko ebidentzia eta oinarria Sedentarismoa ez zen sartu 2020ko Osasunerako jarduera fisikoari buruzko gomendio globaletan (1). Populazio espezifikoen ebidentziarik ez zegoenez, haurdunaldian eta erditu ondoren emakumeen sedentarismoaren eta osasun-emaitzen arteko loturak ebaluatzeko ebidentzia-oinarri nagusia populazio helduentzat bildutako eta berraztertutako literatura zientifikoa izan zen. Populazio helduaren sedentarismoari buruzko ebidentziaren aurkikuntzak berrikusi ziren, eta ebaluazio bat ere egin zen ikusteko emaitzak desberdinak izango ote ziren, edo esanguratsuak izango ez ote ziren, edo kontraindikatuta egongo ote ziren emakumeentzat, haurdunaldian eta erditu ondoren. Eskura dagoen ebidentzia eta adituen iritzia oinarri hartuta, ebidentzia estrapolatu egin zen, haurdunaldian eta erditu ondoren emakumeentzako osasun-emaitza kritiko arruntetarako sedentarismoari buruz OMEk emandako gomendio berriak informatzeko. Ebidentziaren zeharkakotasuna zela eta, murriztu egin zen ziurtasun-maila. Populazio horrentzako ebidentzia espezifikorik ez zegoenez, eta emakume haurdunak azterlanetatik baztertu zirenez, jarduera fisikoaren mailak igotzeko gomendioa (sedentarismo handiaren eragin kaltegarriari aurre egiteko gomendatutako mailetatik harago) ez zen estrapolatu emakumeentzat haurdunaldian eta erditu ondoren. GDGk honako hau ondorioztatu zuen: • Populazio heldu orokorraren sedentarismoari buruzko ebidentzia estrapolatu egin daiteke gomendioak informatzeko emakumeentzat haurdunaldian eta erditu ondoren, osasun- emaitza kritiko arruntetarako. • Emakumeetan, haurdunaldian eta erditu ondoren, sedentarismoa minimizatzearen onurek gainditu egiten dituzte arriskuak. • Ebidentziaren ziurtasuna murriztu behar da, zeharkakoa delako. EMAKUMEAK HAURDUNALDIAN ETA ERDITU ONDOREN Emakumeetan, haurdunaldian eta erditu ondoren, heldu guztietan bezala, sedentarismo handiagoa honako osasun-emaitza txarrekin lotzen da: kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eta minbiziak eragindakoa, eta gaixotasun kardiobaskularren, minbiziaren eta II motako diabetesaren intzidentzia. Hau gomendatzen da: Emakumeek, haurdunaldian eta erditu ondoren, mugatu egin behar dute sedentario izaten ematen duten denbora. Denbora sedentarioa edozein intentsitateko jarduera fisikoarekin ordezkatzeak ( intentsitate baxua barne) osasunerako onurak dakartza. Gomendio sendoa, ziurtasun baxuko ebidentzia 52 HELDUAK ETA ADINEKOAK GAIXOTASUN KRONIKOEKIN (adina 18 urte eta gehiago) Orain arte, gaixotasun kronikoak dituzten pertsonentzako jarduera fisikoko gidalerro gehienak orientazio kliniko edo terapeutikora mugatu dira. Adibidez, praktika klinikoko gomendioak eta elkarte mediko profesionalek garatutako baliabideak daude onkologiarako (101), II motako diabeteserako (102), hipertentsiorako (103) eta beste gaixotasun kroniko batzuetarako (104).OMEk praktika klinikoko gida bat ere badu, gaixotasun kronikoak dituzten pazienteei jarduera fisikoa gomendatzeko (17). Gidalerro hauek dira OMEk jarduera fisikoari buruz ematen dituen lehenak gaixotasun kronikoak dituzten pertsonen populazioarentzat, bereziki minbizia (aurrerantzean, "minbizitik bizirik irtendakoak"), hipertentsioa, II motako diabetesa eta GIBa dutenentzat. GIBaren tratamendu antirretrobiral eraginkor eta oso erabilgarriaren aurrerapenak direla eta, gaixotasun hori ere kronikotzat jotzen da orain. Tratamendu akutua (kimioterapia, adibidez) jasotzen duten pazienteentzat, edo oraindik medikazioarekin egonkortu ez direnentzat, arreta medikoko profesionalek gaixotasun kroniko bakoitzerako garrantzitsuak diren praktika klinikoko gidak ere kontsultatu behar dituzte. JARDUERA FISIKORAKO GOMENDIOA Gaixotasun kronikoak dituzten helduentzat, ondokoetan sar dezakete jarduera fisikoa: aisialdian (jolasa, jokoak, kirolak edo ariketa planifikatua), garraiatzean (gurpiletan, oinez eta bizikletan ibiltzea), eta laneko edo etxeko zereginetan, lanbideko, hezkuntzako, familiako eta komunitateko eguneroko inguruneetan. Minbizitik bizirik irtendako heldu guztiek, eta hipertentsioa, II motako diabetesa eta GIBa dutenek gomendio hauek betetzen saiatu behar dute, ahal den neurrian eta kontraindikaziorik ezean. Jarduera fisikoak onurak ekar ditzake gaixotasun kroniko hauek dituzten helduen eta adinekoen osasunerako: minbizitik irtendakoentzat, jarduera fisikoak hobetu egiten ditu kausa guztiengatiko hilkortasuna, minbizi espezifikoek eragindakoa, eta minbizia berriro izateko edo bigarren minbizi primarioa izateko arriskua; hipertentsioa dutenentzat, jarduera fisikoak hobetu egiten du gaixotasun kardiobaskularrengatiko hilkortasuna, gaixotasunaren progresioa, funtzio fisikoa eta osasunarekin lotutako bizi- kalitatea; II motako diabetesa dutenentzat, jarduera fisikoak murriztu egiten ditu gaixotasun kardiobaskularrengatiko hilkortasuna eta gaixotasunaren progresio- adierazleak; eta GIBa dutenentzat, jarduera fisikoak hobetu egin ditzake egoera fisikoa eta osasun mentala (antsietate- eta depresio-sintomak murriztea) eta ez du eragin negatiborik gaixotasunaren progresioan (hau da CD4 zenbaketa eta karga birala) edo gorputz-osaeran. Hau gomendatzen da: Gaixotasun kroniko horiek dituzten heldu guztiek erregulartasunez egin behar dute jarduera fisikoa. Gomendio sendoa, ziurtasun ertaineko ebidentzia Gaixotasun kroniko horiek dituzten helduek intentsitate ertaineko jarduera fisiko aerobikoa egin behar dute gutxienez 150-300 minutu; edo intentsitate biziko jarduera fisiko aerobikoa gutxienez 75-150 minutu; edo intentsitate ertain eta biziko jardueren konbinazio baliokide bat astean zehar, osasunerako onura nabarmenak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z HELDUAK ETA ADINEKOAK GAIXOTASUN KRONIKOEKIN (adina 18 urte eta gehiago) Gomendioak 53 Aldeko ebidentzia eta oinarria Gidalerro hauen irismenak jarduera fisikoaren eta osasun-emaitza hauen arteko loturak ebaluatu zituen: minbizitik bizirik irtendakoentzat, kausa guztiengatiko hilkortasuna, minbizi espezifikoek eragindakoa, eta minbizia errepikatzeko edo bigarren minbizi primario bat izateko arriskua; hipertentsioa dutenentzat, gaixotasun kardiobaskularrengatiko hilkortasuna, gaixotasun komorbidoen arriskua, funtzio fisikoa, osasunarekin lotutako bizi- kalitatea eta gaixotasunaren progresioa; II motako diabetesa dutenentzat, gaixotasun kardiobaskularrengatiko hilkortasuna, gaixotasun komorbidoen arriskua, funtzio fisikoa, osasunarekin lotutako bizi-kalitatea eta gaixotasunaren progresioa; eta GIBa dutenentzat, funtzio fisikoa (gaitasun fisikoa, ariketarekiko tolerantzia eta indarra) , osasunarekin lotutako bizi-kalitatea, osasun mentala (antsietate- eta depresio-sintomak) gaixotasun kardiometabolikoaren arrisku- adierazleak (odol-lipidoak, glukoas odolean eta gorputz-konposizioa) eta eragin negatiboak gaixotasunaren progresioan (hau da CD4 zenbaketa eta eta karga birala). Gidalerro hauek azaltzen dituen ebidentzia PAGACen txostena izan zen (35), eta 2017tik 2019ra arte identifikatutako 16 berrikuspen berrirekin eguneratu zen, minbiziari (n = 1), hipertentsioari (n = 2) eta II motako diabetesari (n = 13) dagokienez. Horrez gain, GIBa duten pertsonen jarduera fisikoari eta osasun-emaitzei buruzko berrikuspen orokor batek 2002tik 2018ra argitaratutako 19 berrikuspen hautagarriren ebidentzia eman zuen. Metodoen, datu-erauzketaren eta ebidentzia-profilen xehetasun guztiak web-eranskinean aurki daitezke: ebidentzia-profilak . Online eskuragarri, hemen: https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf J A R D U N B ID E E G O K IA K • Aurreko gomendioak bete ezin dituztenean, gaixutasun kroniko horiek dituzten helduek beren gaitasunen arabera saiatu behar dute jarduera fisikoa egiten. • Gaixotasun kroniko horiek dituzten helduek gutxika egiten hasi behar dute jarduera fisikoa, eta denborarekin maiztasuna, intentsitatea eta iraupena pixkanaka handitu. • Gaixotasun kroniko horiek dituzten helduentzat komeni da jarduera fisikoko espezialista bati edo osasun-arloko profesional bati kontsultatzea, jarduera-motei eta -kantitateei buruzko aholkularitza egokia lortzeko, ondokoei lotuta: beren beharrizan indibidualak, gaitasunak, muga funtzionalak/konplikazioak, medikamentuak eta tratamendu-plan orokorra. • Ariketa egin aurreko baimen medikoa ez da beharrezkoa izaten kontraindikaziorik ez duten pertsonentzat, intentsitate baxu edo ertaineko jarduera fisiko bat hasi aurretik, betiere azkar ibiltzeko edo eguneroko bizitzako zereginak betetzeko eskakizunetara mugatzen denean. Gaixotasun kronikoak dituzten helduek eta adinekoek muskuluak indartzeko jarduerak ere egin behar dituzte ‒intentsitate ertaina edo handiagoa‒ muskulu- talde nagusi guztiak lantzeko, astean 2 alditan edo gehiagotan, osasun-onura gehigarriak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Astean egiten duten jarduera fisikoaren barruan, gaixotasun kronikoak dituzten adinekoek osagai anitzeko askotariko jarduera fisikoa egin behar dute, batez ere oreka funtzionala eta indar-entrenamendua ‒intentsitate ertaina edo handiagoa‒ astean 3 egun edo gehiagotan, gaitasun funtzionala areagotzeko eta erorikoak prebenitzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia  Kontraindikaziorik ezean, gaixotasun kroniko horiek dituzten helduek eta adinekoek 300 minutu baino gehiago egin dezakete intentsitate ertaineko jarduera fisiko aerobikoa; edo 150 minutu baino gehiago intentsitate biziko jarduera fisiko aerobikoa; edo intentsitate ertaineko eta biziko jardueraren konbinazio baliokide bat astean zehar, osasun-onura gehigarriak lortzeko. Baldintzapeko gomendioa, ziurtasun ertaineko ebidentzia 54 HELDUAK ETA ADINEKOAK GAIXOTASUN KRONIKOEKIN (adina 18 urte eta gehiago) Minbizia (minbizitik bizirik irtendakoak), hipertentsioa, II motako diabetesa edo GIBa duten 18 urtetik gorako helduetan, zein da jarduera fisikoaren eta osasun-emaitzen arteko lotura? Jarduera fisikoak aldaketa onuragarriak sustatzen ditu epe laburrera eta luzera bide metaboliko, hormonal eta inflamatorioetan, eta uste da aldaketa horiek minbiziaren intzidentzian eta minbizitik bizirik irteten laguntzen dutela (35). Ebidentziak erakusten duenez, aurkitu zen fisikoaren maila altuagoek, minbiziaren diagnostikoen ondoren, babestu egiten zutela kausa guztiengatiko hilkortasuna eta jarraian bularreko minbizia (HR = 0,58 [ % 95eko CI: 0,52tik 0,65era], 17 azterlan); kolon eta ondesteko minbizia (HR = 0,63 [ % 95eko CI: 0,50etik 0,78ra], 10 azterlan), emakumeen ugalketa-sistemako minbizia (HR= 0.66 [95% CI: 0.49tik 0.88ra]), 4 azterlan); glioma (HR= 0.64 [% 95 CI: 0.46tik 0.91ra], azterlan 1); minbizi hematologikoa (HR = 0,60 [IC % 95: 0,51tik 0,69ra], 2 azterlan ); giltzurruneko minbizia (HR = 0,60 [IC % 95ekoa: 0,38tik 0,95era], azterlan 1); birikako minbizia (HR = 0,76 [IC % 95ekoa: 0,60tik 0,97ra], 2 azterlan); prostatako minbizia (HR = 0,60 [IC del 95%: 0,46 a 0,79], 5 azterlan); eta urdaileko minbizia (HR = 0,75 [CI 95%: 0,61 a 0,93], azterlan 1) (105). Minbiziaren diagnostikoaren ondorengo jarduera fisiko handiagoa lotuta dago gainera kausa espezifikoek eragindako hilkortasunaren arrisku baxuagoarekin, bularreko minbizitik, kolon eta ondestekotik, eta prostatakotik bizirik irtendakoetan. Metanalisiak hilkortasun-arriskuen murrizketa aurkitu zuen diagnostikoaren ondorengo guztizko jarduera fisikoaren mailarik altuenetan versus baxuenean, ondokoetan: minbizi konbinatu guztiak (HR = 0,63 [ % 95eko CI: 0,53tik 0,75era], 4 azterlan); bularreko minbizia (HR = 0,63 [ % 95eko CI: 0,50etik 0,78ra], 13 azterlan); kolon eta ondesteko minbizia (HR= 0.62 [% 95eko CI: 0.44tik 0.86ra], 6 azterlan) eta postatako minbizia (HR= 0.70 [% 95eko CI: 0.55etik 0.90era], 4 azterlan) (105). Hala ere, ez zen ebidentzia nahikorik egon jarduera fisikoa minbiziaren errepikapenarekin edo bigarren minbizi primarioarekin lotuta dagoen zehazteko. Jarduera fisikoa garrantzitsua da hipertentsioaren lehen mailako prebentziorako eta berau maneiatzeko, eta argi dago jarduera fisikoak hobetu egiten dituela funtzio fisikoa, gaixotasun kardiobaskularren progresioa (hau da, presio arterialaren erantzuna jarduera fisikoari) eta hipertentsioa duten pertsonen gaixotasun kardiobaskularrengatiko hilkortasuna (35). Adibidez, ariketa gabeko kontrol-taldeekin alderatuta, fisikoki aktiboak diren pertsona hipertentsoek presio arterial sistolikoa gutxi gorabehera 12 mm Hg murriz dezakete, eta presio arterial diastolikoa 6 mm Hg gutxi gorabehera (SBP MD = 12,26 mm Hg [ % 95eko CI: 15,17tik 9,34ra], p = < 0,05; DBP MD = 6,12 mm Hg [% 95eko CI: 7.76 to 4.48], p= < 0.05) (106). Agertutako ebidentziak erakusten du fisikoki aktiboak diren pertsona hipertentsoek nabarmen hobe dezaketela osasunarekin lotutako bizi-kalitatea, inaktibo dauden pertsona hipertentsoekin alderatuta (54). Jarduera fisikoa, jarduera aerobikoa, muskuluak indartzeko jarduera eta jarduera aerobikoa gehi muskuluak indartzeko jarduera barne, lotuta dago progresio-arriskuaren adierazle sekundario hobeekin (HbA1c, presio arteriala, BMI eta lipidoak) II motako diabetesa duten helduetan (35). Adibidez, berriki egindako ikerketa baten arabera, erresistentzia-entrenamendua lotuta zegoen HbA1c-ren murrizketa handiagoarekin versus kontrol-taldeak, eta intentsitate handiko erresistentzia-entrenamenduak eragin positibo esanguratsuak ditu baraualdiko intsulinan (107). Ez dago ebidentzia nahikorik jarduera fisikoak dituen eraginak ebaluatzeko osasunarekin lotutako bizi-kalitatean eta funtzio fisikoan II motako diabetesa duten helduetan. GIBa duten pertsonetan jarduera fisikoak bihotz eta arnas sistemako gaitasuna hobetzen du. Aztertutako interbentzioek barnean hartu zituzten bai ariketa aerobikoa, bai ariketa muskuluak indartzeko ariketa progresiboarekin konbinatuta, gutxienez 30 minutuz, astean 3 aldiz (108, 109). Era berean, argi dago jarduera fisikoko interbentzioek arrisku kardiometabolikoaren adierazleak hobe ditzaketela (adib., lipidoak), nahiz eta emaitzak mistoak izan; ez zen eraginik ezarri intsulinaren kontzentrazioan, nahiz eta glukosa murriztu egin zen entrenamendu aerobikoaren ondoren (110). Jarduera fisikoa, bai aerobikoa, bai muskuluak indartzeko ariketarekin konbinatua, GIBa duten pertsonetan, osasunarekin lotutako bizi-kalitatearekin (111) eta depresio- eta antsietate-sintomak murriztearekin (112) positiboki lotzen da. Depresiorako metanalisiak (9 azterlan) 0,84ko SMD bat (% 95eko CI: 1,57tik 0,11ra) erakutsi zuen interbentzio-taldeen alde (p = 0,02). Antsietatea murrizteko SMD (5 azterlan) ere estatistikoki esanguratsua izan zen, interbentzioaren alde (1,23 [CI % 95: 2,42tik 0,04ra], p = 0,04) (112). Jarduera fisikoa lotzen da, halaber, batez besteko gehikuntza estandarizatu esanguratsuekin 1,75 kg-ko gorputz-masa baxuetan, eta ariketa egiten duten kontrol-taldeetako parte-hartzaileen gorputz-gantzaren % 1,12ko murrizketa nabarmenarekin, bai eta hanketako eta besoetako muskulu periferikoen eremua handitzearekin ere, ariketa egiten ez duten kontrol-taldeetako kideekin alderatuta (111), baina ez da lotzen GIBa duten pertsonen BMI edo gerriaren zirkunferentziaren aldaketekin (111). Jarduera fisikoak ez du eragin negatiborik GIBaren progresio-adierazleetan, besteak beste, CD4 zenbaketa (zelulak/mm3) edo karga birala (111). Nabarmentzekoa da ebidentzia horrek iradokitzen duena, hau da, jarduera fisikoak ez duela eragin negatiborik izango GIBan, gaixotasun kroniko bat denez gero. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z HELDUAK ETA ADINEKOAK GAIXOTASUN KRONIKOEKIN (adina 18 urte eta gehiago) Gomendioak 55 GDGk honako hau ondorioztatu zuen: • Ziurtasun ertaineko ebidentzia dago minbizia diagnostikatu ondoren jarduera fisiko handiagoa lotu egiten dela hilkortasun-arrisku batxuagoarekin, kausa guztiek, kausa espezifikoek eta minbizi espezifikoek eragindakoa denean, minbizitik bizirik irtendakoetan. • Ziurtasun altuko ebidentzia dago jarduera fisikoak gaixotasun kardiobaskularren progresio-arriskua murrizten duela hipertentsioa duten helduetan. • Ziurtasun ertaineko ebidentzia dago jarduera fisikoak hipertentsioa duten helduen funtzio fisikoa eta osasunarekin lotutako bizi-kalitatearen emaitzak hobetzen dituela. • Ziurtasun altuko ebidentzia dago jarduera fisikoak gaixotasunaren progresio-adierazleak hobetzen dituela (HbA1c, presio arteriala, BMI eta lipidoak) II motako diabetesa duten helduetan. • Ziurtasun ertaineko ebidentzia dago lotura bat dagoela jarduera fisikoaren eta gaitasun fisikoaren (oxigeno-kontsumo maximoa, ariketarekiko tolerantzia) eta muskuluen indarraren hobekuntzaren artean GIBa duten pertsonetan, eta lotura onuragarriak jarduera fisikoaren eta gorputz- osaeraren, osasunarekin lotutako bizi-kalitatearen, depresio- eta antsietate-sintomak murriztearen artean, eta dagoela aldaketarik birus-kargan edo CD4 zenbaketan GIBa duten pertsonetan. • Osasun-emaitza espezifikoei dagokienez, minbizitik bizirik irtendakoek, hipertentsioa, II motako diabetesa eta GIBa dutenek jarduera fisikoa erregulartasunez egitean arriskuak gainditzen dituzte onurek Badago dosi-erantzun loturarik (kantitatea, iraupena, maiztasuna, intentsitatea)? Minbiziaren diagnostikoaren ondoren, jarduera fisiko gehiago egitea lotu egin da kausa guztiengatiko eta minbizi espezifikoek eragindkao hilkortasun-arrisku baxuagoarekin. Ebidentziak erakusten du erlazio ez lineala dagoela diagnostikoaren ondorengo jarduera fisikoaren goranzko mailen eta bularreko minbizi espezifikoagatiko eta kausa guztiengatiko hilkortasunaren artean, astean 10-15 MET-ordu arte egiten denean (jarduera fisikoaren intentsitate ertainetik bizirako 150 minutu/aste), maila altuagoetan izandako kalteen ebidentziarik gabe (105). Beste minbizi espezifiko batzuetarako antzeko dosi-erantzun lotura bat adierazten da, baina oso azterlan gutxi egin ziren metanalisi formala ahalbidetzeko. Ikerketa gehiago behar dira loturaren indarra zehazteko. Dosi-erantzun lotura argia dago jarduera fisikoaren eta gaixotasun kardiobaskularrengatiko hilkortasunaren artean hipertentsioa duten pertsonetan (35). Emaitzek erakusten dutenez, hipertentsio-mailen barruan presio arterial sistolikoak gora egin ahala, gaixotasun kardiobaskularrengatiko hilkortasun-arriskuak gora egiten du, baina arriskuaren igoera hori jarduera fisikoaren maila altuagoekin arintzen da (35). Populazio orokorrarentzako gomendioen antzera, ohiko interbentzio gehienak intentsitate ertaineko jarduera aerobikoan oinarritzen da: 30-60 minutu, astean 3 egunetan, eta/edo 2-3 erresistentzia-entrenamendu saio astean. II motako diabetesa duten helduetan, jarduera fisikoaren kantitatearen eta gaixotasun kardiobaskularrengatiko hilkortasun-arriskuaren arteko alderantzizko lotura baten funtsezko ebidentzia dago (113-115). Jarduera fisikoaren kantitate handiagoek (intentsitate ertaineko jarduera fisikoaren 150 minutu/aste gomendatutako mailetan, azpitik nahiz gainetik) pixkanaka murrizten dute arriskua. Adibidez, jarduerarik ez egitearekin alderatuta, jardueraren bat egitea gaixotasun kardiobaskularrengatiko hilkortasun-arriskua % 32 murriztearekin lotu zen (HR doitua = 0,68 [ % 95eko CI: 0,51tik 0,92ra]); aldiz, jarduera fisikorako gidalerroak edo maila horietatik gora betetzea gaixotasun kardiobaskularrengatiko hilkortasun-arriskua % 40 murriztearekin lotu zen (HR doitua= 0.60 [% 95 CI: 0.44 to 0.82]) (115). Interbentzio gehienak hauetan oinarritzen dira: intentsitate ertaineko 150-300 minutuko jarduera fisiko aerobikoa edo intentsitate biziko 75 minutukoa, edo/eta erresistentzia-entrenamenduko 2 edo 3 saio astean. Emaitza batzuetarako (adibidez, HBA1c eta presio arteriala), II motako diabetesa duten helduetan, jarduera aerobiko handiagoaren eragin sendoago baten ebidentzia dago (hau da, astean 150 minutu baino gehiago versus astean 150 minutu baino gutxiago), baina intentsitaterako ebidentzia mugatua da (35). GIBa duten pertsonetan, ez dago ebidentzia nahikorik jarduera fisikoaren eta gorputz-osaeraren arteko dosi- erantzun erlazioa ezartzeko, edo gaixotasun kardiometabolikoen erdi mailako adierazleetarako (odoleko lipidoen profilak, intsulinarekiko erresistentzia, baraualdiko glukosa-kontzentrazioak edo presio arteriala). Ebidentzia eman zuten azterlan gehienek 12 eta 48 aste bitartean astean gutxienez 3 aldiz egindako jarduera fisikoko interbentzioak barne hartu zituzten, barne hartzen zituztenak gutxienez 30 minutuko ariketa aerobikoa, intentsitate ertainetik bizira, bakarrik edo erresistentzia-entrenamendu progresiboarekin batera. Era berean, ez dago ebidentzia nahikorik osasun mentalaren eta osasunarekin lotutako bizi-kalitatearen emaitzetarako dosi-erantzun erlazioa zehaztasun 56 HELDUAK ETA ADINEKOAK GAIXOTASUN KRONIKOEKIN (adina 18 urte eta gehiago) handiagoz ezartzeko. Eskura dagoen ebidentzia astean 3 aldiz edo gehiagotan jarduera fisikoko interbentzioak ebaluatzen dituzten azterlanetatik dator. Oro har, ziurtasun ertainetik alturako ebidentzia zegoen intentsitate ertaineko (edo baliokidea) 150-300 minutuko jarduera fisikoaren gomendio bat babesteko, gaixotasun kronikoak dituzten pertsonen populazio espezifikoentzat eta osasun-emaitzen multzo espezifikoarentzat. Ebidentzia argiagoa zegoen jardueraren maila altuagoak lotuta zeudela hipertentsioa eta II motako diabetesa dutenen eta minbizitik bizirik irtenden osasun-onura handiagoekin. Ebidentziaren ziurtasunean eta zehaztasunean izandako aldaketak aitortu ziren, gaixotasun kroniko espezifikoaren eta aztertutako emaitza espezifikoen arabera. Ebidentziak indar-entrenamenduaren emaitza positiboak erakutsi zituen, jardueraren maiztasuna erresistentzia-entrenamenduko 2 edo 3 saiokoa izan zenean astean. GDGk honako hau ondorioztatu zuen: • Ziurtasun ertaineko ebidentzia dago dosi-erantzun erlazioa dagoela jarduera fisikoaren eta kausa guztiengatiko hilkortasunaren eta minbizi espezifikoengatiko hilkortasunaren murrizketaren artean minbizitik bizirik irtendakoetan. • Ziurtasun altuko ebidentzia dago dosi-erantzun erlazioa dagoela jarduera fisikoaren eta gaixotasun kardiobaskularrengatiko hilkortasunaren artean hipertentsioa duten helduetan. • Ebidentzia dago dosi-erantzun erlazio alderantzizkoa dagoela jardueraren kantitatearen eta gaixotasun kardiobaskularrengatiko hilkortasun-arriskuaren artean II motako diabetesa duten helduetan. • Ez dago ebidentzia nahikorik dosi-erantzun erlazioa dagoela jarduera fisikoaren eta gaixotasun kardiometabolikoen erdi mailako adierazleen, gorputz- osaeraren, osasunarekin lotutako bizi-kalitatearen eta antsietate- eta depresio-sintomen artean, GIBa duten pertsonetan. • Intentsitate ertaineko 150-300 minutuko jarduera aerobikoko (edo baliokideko) interbentzioek osasun- emaitza onak eta indar-entrenamenduaren emaitza positiboak eman zituzten, ikusi zenean, erresistentzia- entrenamenduko 2 edo 3 saio astean egiten zirenean. Lotura aldatzen da jarduera fisikoaren motaren edo eremuaren arabera? Ebidentzia argia dago jarduera fisikoaren mota eta eremu desberdinek osasun-emaitza onak ematen dituztela. Minbizitik bizirik irtendakoek, jarduera fisiko aerobikoaren eta muskuluak indartzeko ariketen maila gomendatuak betetzen dituztenek, gomendio horiek betetzen ez dituztenen aldean, minbiziagatiko hilkortasun- arrisku baxuagoa dute (HR doitua = 0,70 [% 95eko CI: 0,50etik 0,98ra]) (84). Ebidentziak erakusten du muskuluak indartzeko jarduera fisikorako gomendioa bakarrik betetzea ere, ez betetzearekin alderatuta, onuragarria dela minbiziagatiko hilkortasun-emaitzak hobetzeko (HR = 0,66 [ % 95eko CI: 0,48tik 0,92ra]) (84). Metanalisi batek jarduera fisikoaren eremuaren araberako lotura horien berri eman zuen, eta murrizketa esanguratsuenak minbizi guztiengatiko hilkortasunean, eta bularreko minbiziak, eta kolon eta ondesteko minbiziak eragindakoan aurkitu zituen, aisialdiko jarduera fisikorako (105). Hipertentsioa duten helduetan, ebidentziak babestu egiten ditu jarduera aerobikoa, muskuluak indartzeko jarduera eta bien konbinazioa gaixotasun kardiobaskularren progresioa murrizteko. Hipertentsioa duten pertsonetan ez dirudi nabarmen aldatzen direnik presio arteriala murrizteko dituzten eraginak jarduera fisikoa egiteko ohiko moduek (hau da, jarduera aerobikoa eta erresistentziakoa) (35); hala ere, ebidentzia hori ez da jarduera moten arteko konparazio zuzenetan oinarritzen. Hipertentsioa duten pertsonetan, beste ariketa-mota batzuen (adibidez, Tai Chi, yoga, Qigong) eragin onuragarriak babesteko ere ebidentzia dago; hala ere, ikerketa gehiago behar dira jarduera-mota espezifiko horiek aztertzeko, loturaren indarra zehazteko. Jarduera aerobikoa, muskuluak indartzeko jarduera edo bien arteko konbinazioa, lotuta progresio-arriskuaren (HbA1c, presio arteriala, BMI eta lipidoak) bigarren mailako adierazle hobetuekin II motako diabetesa duten helduetan (35, 107). 24 IKE RCTren (n = 962) berrikuspen batek jakinarazi zuen erresistentzia- entrenamendua HbA1c-ren murrizketa handiagoarekin lotuta zegola, kontrol-taldeekin alderatuta (MD = 0,45 [% 95eko CI: 0,65etik 0,25era], 20 proba; n = 824). Eragin estatistikoki esanguratsuak aurkitu ziren intentsitate biziko erresistentzia entrenatzeko versus kontrol-taldeak intsulinarekin baraualdian (MD = 4,60 [ % 95eko CI: 7,53tik 1,67ra], 5 proba; n = 174) (107). 7 RCTren (n = 189) beste berrikuspen batek jakinarazi zuen entrenamendua pausaldiekin (astean 2-5 aldiz; 1-4 minutuko pausaldiak; saioaren guztizko iraupena 20-60 minutu) lotuta zegoela HbA1c-ren % 0,26ko ( % 95eko CI: % 0,46tik % 0,07ra, 5 RCT) murrizketa estatistiko esanguratsuarekin, MICTekin alderatuta, eta % 0,83ko (95% CI: 1.39% to 0.27%, 4 RCT) murrizketarekin ariketarik egin gabeko kontrol-taldeekin alderatuta (116). Populazio orokorrarentzako gomendioetan bezala, interbentzio gehienak jarduera aerobikoan oinarritzen dira, 150-300 minutuko intentsitate ertaineko jarduera aerobikoaren (edo 75 minutuko intentsitate biziko jardueraren) eta muskuluak indartzeko astean 2-3 saioko jardueraren gomendioaren O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z HELDUAK ETA ADINEKOAK GAIXOTASUN KRONIKOEKIN (adina 18 urte eta gehiago) 57 arabera. Emaitza batzuetarako (adib.: HBA1c eta presio arteriala), eragin sendoagoaren ebidentziak daude jarduera aerobiko gehiago eginda (hau da, astean 150 minutu baino gehiago versus astean 150 minutu baino gutxiago), baina ebidentzia mugatua da intentsitaterako. Ikerketa berriagoek Ariketa txinatar tradizionalek, Tai Chi kasu, onura gluzemikoak izan ditzaketela erakusten dute, baina ziurtasun ertain eta aldakorreko ebidentziak izan ziren (hau da, alborapen-arriskua edo bat ez etortzea). Ikerketa gehiago behar da lotura horiek zehazteko. Ebidentzia dago askotariko jarduera fisikoak, entrenamendu aerobikoak eta erresistentziakoak barne, eragin positiboak dituztela GIBa (111) duten pertsonen osasunarekin lotutako bizi-kalitatean. Ariketa aerobikoari, erresistentzia progresiboari edo bien konbinazioari erantzunez, osasunarekin lotutako bizi-kalitatearen aldaketak aztertzen dituzten ikerketa berriek osasun orokorrean eta osasun mentalean hobekuntza nabarmenak daudela erakusten dute. Era berean, agerikoa da jarduera aerobikoa eta osagai anitzekoa lotuta dagoela GIBa duten pertsonen depresio- eta antsietate-sintomak murriztearekin (112). Jarduera fisikoak osasun mentalaren sintometan dituen eraginen ebidentziak hartu hartu ditu barnean: jarduera aerobikoa, edo aerobikoa eta muskuluak indartzeko jarduera progresiboa konbinatuta, edo yoga. Ebidentziak erakusten du ariketa aerobikoak bakarrik edo erresistentzia- ariketarekin konbinatuta ez duela aldaketa esanguratsurik eragiten GIBa duten pertsonen birus- kargan edo CD4 zenbaketan (111). Literatura eguneratuaren ebidentzia zuzenak II motako diabetesa eta hipertentsioa duten pertsonek jarduera fisiko aerobikoa eta muskuluak indartzekoa egiteko gomendioak sartzea laguntzen du. Ebidentziarik argitaratu ez bada ere, ikuspegi biologikotik onartua dago jarduera fisiko aerobikoak eta muskuluak indartzekoak GIBa duten helduei eta minbizitik bizirik irtendakoei onurak dakarzkiela. Gainera, GDGk adierazi zuenez, ezarritako nazioarteko praktika klinikoko gidalerroek gomendatu egiten dute jarduera fisiko aerobikoa eta muskuluak indartzekoa populazio horietarako (adibidez, ACSM "Moving Through Cancer" gidalerroak (101) ebidentziaren berrikuspen sistematikoan oinarrituta (3). Ebidentzia-oinarri hori oraindik azaleratzen ari dela onartuta, ziurtasun-maila murriztu egin zen. GDGk honako hau ondorioztatu zuen: • Ziurtasun ertaineko ebidentzia dago jarduera aerobikoaren edo muskuluak indartzekoaren eragin konbinatu edo gehigarrietarako, minbiziagatiko hilkortasuna murrizteko eta hipertentsioa duten pertsonen presio arteriala hobetzeko. • Ziurtasun altuko ebidentzia dago jarduera aerobikoak, muskuluak indartzeko jarduerak, eta aerobikoak gehi muskuluak indartzekoak, gaixotasunaren progresio- adierazleak (HbA1C, presio arteriala, BMI eta lipidoak) hobetzen dituztela II motako diabetesa duten helduetan. • Ziurtasun ertaineko ebidentzia dago ariketa aerobiko erregularrak, bakarrik edo erresistentzia-ariketarekin konbinatuta, ez duela aldaketa esanguratsurik eragiten GIBa duten pertsonen birus-kargan edo CD4 zenbaketan. • Ez dago ebidentzia nahikorik indar-entrenamenduak soilik bizi-kalitatean eragina duela GIBa duten pertsonetan. 58 Sedentarismoa ez zen sartu 2010eko Osasunerako jarduera fisikoari buruzko gomendio globaletan (1). Minbizitik irtendakoen eta hipertentsioa, II motako diabetesa eta GIBa dutenen sedentarismoari buruzko gomendio berri honen irismena. Sedentarismoa honela definitzen da: esna egon bitartean, eserita edo etzanda emandako denbora, energia- gastu gutxirekin, lanbideko, hezkuntzako, familiako eta komunitateko inguruneen eta garraioaren testuinguruan. Aldeko ebidentzia eta oinarria Ebidentziarik ez dagoenez populazioaren espezifikoentzat, minbizitik bizirik irtendako heldu eta adinekoetan eta hipertentsioa, II motako diabetesa eta GIBa duten heldu eta adinekoetan, sedentarismoaren eta osasun-emaitzen arteko loturak ebaluatzeko ebidentzia-oinarri nagusia populazio helduentzat bildu eta berrikusitako literatura zientifikoa izan zen. Helduen populazio orokorraren sedentarismoaren inguruko aurkikuntzak berrikusi ziren, eta ebaluatu ere egin zen ebidentziarik egongo ote zen emaitzak desberdinak izango liratekeela edo ez liratekeela aplikatzekoak edo kontraindikatuta egongo liratekeela gaixotasun kronikoak dituzten heldu eta adinekoetan. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Helduetan, minbizitik bizirik irtendakoak eta hipertentsioa, II motako diabetesa eta GIBa dutenak barne, sedentarismo handiagoa osasun-emaitza txar hauekin lotzen da: kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eta minbiziak eragindakoa; eta gaixotasun kardiobaskularren, minbiziaren eta II motako diabetesaren intzidentzia. Minbizitik irtendako helduentzat, eta hipertentsioa, II motako diabetesa eta GIBa duten helduentzat, honako hau gomendatzen da: Gaixotasun kronikoak dituzten heldu eta adinekoek mugatu egin behar dute sedentario izaten igarotzen duten denbora. Denbora sedentarioa edozein intentsitateko jarduera fisikoarekin ordezkatzeak (intentsitate baxua barne) osasunerako onurak dakartza. Gomendio sendoa, ziurtasun baxuko ebidentzia Sedentarismo maila handiek osasunean dituzten eragin kaltegarriak murrizten laguntzeko, gaixotasun kronikoak dituzten helduek eta adinekoek saiatu egin behar dute jarduera fisikorako ‒intentsitate ertainetik bizira‒ gomendatzen diren mailak gainditzen. Gomendio sendoa, ziurtasun baxuko ebidentzia HELDUAK ETA ADINEKOAK GAIXOTASUN KRONIKOEKIN (adina 18 urte eta gehiago) Eskura dagoen ebidentzia eta adituen iritzia oinarri hartuta, ebidentzia estrapolatu egin zen gaixotasun kronikoak dituzten helduentzako sedentarismoari buruz OMEk emandako gomendio berriei buruz informatzeko, osasun-emaitza kritikoen multzo konbinaturako. Ebidentziaren estrapolazioa, neurri handi batean, honako ebaluazio honek babesten du: azterlan gehienek ez zuten goi-mailako adin- mugaren irizpiderik ezarri, 65 urtetik gorako helduak barne hartu zituzten eta gaixotasun kronikoak dituzten helduak sar zitzaketen, hala nola minbizitik bizirik irtendakoak, eta hipertentsioa edo II motako diabetesa dutenak. GIBa duten pertsonentzat, ez zen identifikatu arrazoirik jakiteko zergatik sedentarismoak osasunean duen eraginari buruzko ebidentzia ez litzatekeen aplikatzekoa. Gomendio horiek garatzeko ebidentzia zeharkakoa zenez, ziurtasun-maila murriztu egin zen. Era berean, intentsitate ertain eta biziko jarduera fisiko gehiago egitearen onurari buruzko ebidentziaren aplikagarritasuna ere kontuan hartu zen, sedentarismo handiaren arrisku potentzialei aurre egiten laguntzeko, eta estrapolatu ere egin zen, gaixotasun kronikoak dituzten helduentzako gomendioen berri emateko, osasun-emaitza kritikoen multzorako. Zeharkakoa zenez, ebidentziaren ziurtasuna murriztu egin zen. GDGk honako hau ondorioztatu zuen: • Populazio heldu orokorraren sedentarismoari buruzko ebidentzia estrapolatu egin daiteke, minbizitik bizirik irtendako heldu eta adinekoentzako eta hipertentsioa, II motako diabetesa eta GIBa duten heldu eta adinekoentzako gomendioak informatzeko, emaitza kritikoen multzo konbinaturako. Ebidentziaren ziurtasun-maila murriztu egin zen zeharkakoa zelako. • Populazio heldu orokorrean, sedentarismo handiaren arrisku potentzialei aurre egiten laguntzeko intentsitate ertain eta biziko jarduera fisiko gehiago egiteak dituen onurei buruzko ebidentzia estrapolatu egin liteke, minbizitik bizirik irtendako heldu eta adinekoentzat eta hipertentsioa, II motako diabetesa eta GIBa duten heldu eta adinekoentzako gomendioak informatzeko, emaitza kritikoen multzo konbinaturako. Ebidentziaren ziurtasun-maila murriztu egin zen zeharkakoa zelako. • Sedentarismoa minimizatzearen onurek gainditu egiten dituzte kalteak minbizitik bizirik irtendakoentzat eta hipertentsioa, II motako diabetesa eta GIBa duten pertsonentzat.. 59 60 Desgaitasuna duten haur, nerabe eta helduek osasun-onura handiak lor ditzakete jarduera fisikoa egiten badute. Desgaitasun bat duten haur, nerabe eta helduek gomendio hauek betetzen saiatu behar dute, ahal duten neurrian. Desgaitasuna duten haur, nerabe eta helduentzat, jarduera fisikoa ondokoetan sar daiteke: aisialdian (jolasa, jokoak, kirolak edo ariketa planifikatua), gorputz-heziketan, garraiatzean (gurpiletan, oinez eta bizikletan ibiltzea) edo etxeko zereginetan, familiako, hezkuntzako, lanbideko eta komunitateko inguruneetan. Garrantzitsua da desgaitasuna duten haur, nerabe eta heldu guztiei beren adinerako eta gaitasunerako egokiak, atseginak eta askotarikoak diren jarduera fisikoetan parte hartzeko aukerak eta pizgarriak ematea. Jarduera fisikoak haur eta nerabeentzat dituen onuretako asko, aurreko atalean adierazi bezala, desgaitasuna duten haur eta nerabeekin ere lotzen dira. Jarduera fisikoak desgaitasun bat duten pertsonen osasun-emaitzei dakarzkien onura gehigarriak honako hauek dira: kognizioa hobetzea funtzio kognitiboa narriatzen duten gaixotasunak edo nahasmenduak dituzten pertsonetan, arreta-defizitaren/hiperaktibitatearen nahasmendua (ADHN) barne; funtzio fisikoan hobekuntzak ekar ditzake desgaitasun intelektuala duten haurretan. Hau gomendatzen da:  Desgaitasuna duten haur eta nerabeek, astean zehar, batez beste eguneko 60 minutu egin behar dute jarduera fisikoa ‒ intentsitate ertainetik bizira ‒ eta batez ere aerobikoa. Gomendio sendoa, ziurtasun ertaineko ebidentzia  Intentsitate biziko jarduera aerobikoak, bai eta muskuluak eta hezurrak indartzen dituztenak ere, gutxienez astean 3 egunetan sartu behar dira. Gomendio sendoa, ziurtasun ertaineko ebidentzia Jarduera fisiko pixka bat egitea ezer ez egitea baino hobe da. Desgaitasuna duten haurrek eta nerabeek ez badituzte gomendio hauek betetzen, jarduera fisikoren bat egitea onuragarria izango da beren osasunarentzat. Desgaitasuna duten haurrek eta nerabeek gutxika hasi behar dute jarduera fisikoa egiten, eta maiztasuna, intentsitatea eta iraupena pixkanaka handitu. Ez dago arrisku esanguratsurik desgaitasuna duten haur eta nerabeentzat jarduera fisikoa egitean, baldin eta egokia bada pertsonaren unean-uneko jarduera-mailarako, osasun-egoerarako eta funtzio fisikorako; eta osasun-onurak gehituta, gutxitu egiten dira arriskuak. Baliteke desgaitasuna duten haurrek eta nerabeek osasun-arloko profesional bati edo jarduera fisikoko eta desgaitasuneko espezialista bati kontsultatu behar izatea, haientzat egokia den jarduera-mota eta -maila zehazten laguntzeko. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z J A R D U N B ID E E G O K IA K HAURRA ETA NERABEAK (adina 5–17 urte) ETA HELDUAK (adina 18 eta gehiago) DESGAITASUNAREKIN Aurreko atalean adierazi bezala, jarduera fisikoak helduentzat dituen osasun-onuretako asko desgaitasuna duten helduekin ere erlazionatzen dira. Desgaitasuna duten pertsonen osasun- emaitzetarako jarduera fisikoak dituen onura gehigarriak honako hauek dira: esklerosi anizkoitza duten helduentzat, hobekuntza funtzio fisikoan, eta gaitasun fisiko, mental eta sozialean, osasunarekin lotutako bizi-kalitateari dagokionez; bizkarrezur-muineko lesioa dutenentzat, hobekuntza ibiltzeko funtzioan, baita muskuluen indarrean eta goiko gorputz- adarren funtzioan ere, eta osasunarekin lotutako bizi-kalitate hobea; funtzio kognitiboa narriatzen duten nahasmenduak dituztenentzat, hobekuntza funtzio fisikoan eta kognitiboan (Parkinsonen gaixotasuna dutenetan eta istripu zerebrobaskularren aurrekariak dituztenetan), kognizioaren gaineko eragin onuragarriak, eta hobetu egin ditzake bizi-kalitatea (eskizofrenia duten helduetan), eta funtzio fisikoa (desgaitasun intelektuala duten helduetan), baita bizi-kalitatea ere (depresio klinikoa duten helduetan). Hau gomendatzen da: Desgaitasuna duten heldu guztiek erregulartasunez egin behar dute jarduera fisikoa. Gomendio sendoa, ziurtasun ertaineko ebidentzia Desgaitasuna duten helduek intentsitate ertaineko 150-300 minutuko jarduera fisiko aerobikoa egin behar dute; edo intentsitate biziko jarduera fisiko aerobikoa 75- 150 minutu gutxienez; edo astean zehar intentsitate ertain eta biziko jardueraren konbinazio baliokide bat, osasun-onura esanguratsuak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Desgaitasuna duten helduek muskuluak indartzeko jarduerak ere egin behar dituzte, intentsitate ertain edo handiagokoak, astean 2 egunetan edo gehigotan, muskulu- talde nagusi guztiak lantzeko, osasun-onura gehigarriak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Asteko jarduera fisikoaren barruan, desgaitasuna duten adinekoek askotariko jarduera fisikoa egin behar dute, osagai anitzekoa, oreka funtzionala eta indar-entrenamendua nabarmenduz, intentsitate ertain edo handiagoan, astean 3 egunetan edo gehiagotan, gaitasun funtzionala hobetzeko eta erorikoak prebenitzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Desgaitasuna duten helduek intentsitate ertaineko jarduera fisiko aerobikoa 300 minututik gora igo dezakete; eta intentsitate biziko jarduera fisiko aerobikoa 150 minututik gora; edo astean zehar intentsitate ertain eta biziko jardueraren konbinazio baliokide bat, osasun-onura gehigarriak lortzeko. Baldintzapeko gomendioa, ziurtasun ertaineko ebidentzia Jarduera fisiko pixka bat egitea ezer ez egitea baino hobe da. Desgaitasuna duten helduek ez badituzte gomendio hauek betetzen, jarduera fisikoren bat egitea onuragarria izango da beren osasunarentzat. Desgaitasuna duten helduek gutxika hasi behar dute jarduera fisikoa egiten, eta maiztasuna, intentsitatea eta iraupena pixkanaka handitu. Ez dago arrisku esanguratsurik desgaitasuna duten helduentzat jarduera fisikoa egitean, baldin eta egokia bada pertsonaren unean-uneko jarduera-mailarako, osasun-egoerarako eta funtzio fisikorako; eta osasun-onurak gehituta, gutxitu egiten dira arriskuak. Baliteke desgaitasuna duten helduek osasun-arloko profesional bati edo jarduera fisikoko eta desgaitasuneko espezialista bati kontsultatu behar izatea, haientzat egokia den jarduera-mota eta -maila zehazten laguntzeko. J A R D U N B ID E E G O K IA K > > > > > Gomendioak 61 62 Aldeko ebidentzia eta oinarria Desgaitasuna duten haur, nerabe eta helduentzako gidalerro hauetarako, PAGACek egindako ebidentzia integralaren sintesia erabili eta eguneratu zen (35). Jarduera fisikoari eta osasun-emaitzei buruz dagoen ebidentzia honen taula laburtuak eta metodoen eta datu-erauzketaren xehetasun guztiak eskuragarri daude (35), eta GDGk berrikusi zituen, bilaketa eguneratuaren aurkikuntzez gain. Gidalerro hauetarako egindako eguneratzeak 39 berrikuspen identifikatu zituen, 2017tik 2019ra bitartean argitaratutakoak. Horietatik 27k inklusio-irizpideak bete zituzten, eta jarduera fisikoaren eta desgaitasuna duten haur, nerabe eta helduen osasunarekin lotutako emaitzen arteko loturaren azterketaren berri eman zuten. Metodoen, datu-erauzketaren eta ebidentziaren lan-sorta laburtuak web-eranskinean aurki daitezke: ebidentzia- profilak . Berrikusitako ebidentziak jarduera fisikoaren eta desgaitasuna duten haur, nerabe eta helduen osasun- emaitzen arteko lotura kontuan hartu zuen, honako osasun-egoera hauetatik ondorioztatuta: esklerosi anizkoitza, bizkarrezur-muineko lesioa, desgaitasun intelektuala, Parkinsonen gaixotasuna, istripu zerebrobaskularra, depresio kliniko larria, eskizofrenia eta arreta-defizitaren/hiperaktibitatearen nahasmendua (ADHN). Osasunarekin lotuta azertutako lau emaitzetan, gaixotasun komorbidoak izateko arriskua, funtzio fisikoa, funtzio kognitiboa eta osasunarekin lotutako bizi-kalitatea sartu ziren, baina ez ziren gaixotasun bakoitzerako emaitza guztiak aztertu. Jarduera fisikoaren testuinguruan ingurumen- faktoreek desgaitasunean duten eragina gidalerro hauen irismenetik haratago zegoen eta ez zen aztertu. Desgaitasuna duten haur eta nerabeetan (5- 17 urte) eta helduetan (18 urtetik gorakoak), zein lotura dago jarduera fisikoaren eta osasun-emaitzen artean? Esklerosi anizkoitza duten pertsonentzat, jarduera fisikoak hobetu egiten ditu funtzio fisikoa, mugikortasun funtzionala, abiadura eta ibiltzeko erresistentzia, eta bihotz eta arnas sistemaren gaitasuna, indarra eta oreka. Adibidez, intentsitate handiko entrenamenduak pausaldiekin, 3-12 astez eginda, erakutsi zuen hobekuntzak zekartzala bihotz eta arnas sistemaren gaitasunean edo muskuluen indarrean (117), eta beheko gorputz-adarretako indar- entrenamendua eginda ikusi zen indarra % 23,1 handitu zela ( % 95eko CI: 11,8tik 34,4ra) 13,2 asteko batez besteko entrenamendu-aldian (118), 13 asteko batez besteko entrenamendu aldiaren emaitzaz handitu egiten zen indarra, eta dantza- interbentzioetako azterlanek hobekuntzen berri eman zuten mugikortasun funtzionalean eta orekan. Osasun fisikorako onurez gain, ebidentziak erakusten du jarduera fisikoa mesedegarria izan daitekeela esklerosi anizkoitza duten pertsonen kognizioan (35). Ikerketa berriagoek erakusten dutenez, ariketa aerobikoak eragin txikia baina esangurtsua du osasunarekin lotutako bizi-kalitatearen arlo fisiko, mental eta sozialetan (neke- sintomak eta sintoma depresiboak barne) (35, 120). Bizkarrezur-muineko lesioa duten pertsonentzat, jarduera fisikoak ibiltzearen funtzioa, indar muskularra eta goiko gorputz-adarren funtzioa hobetu ditzake (35). Jarduera fisikoak sorbaldako mina ere murriz dezake, eta funtzio baskularra eta osasunarekin lotutako bizi-kalitatea hobetu (35). Parkinsonen gaixotasuna duten pertsonentzat, jarduera fisikoak hobetu egin ditzake sintoma motorrak, mugikortasun funtzionala eta errendimendua, erresistentzia, ibilera bizkorra mantentzea eta aurrerako eta atzerako mugimenduaren abiadura (35, 121, 122). Ebidentzia berriak iradokitzen du ariketak Parkinsonen gaixotasuna duten pertsonen funtzio kognitibo globalari ere lagun diezaiokeela (123). Istripu zerebrobaskularren aurrekariak dituzten pertsonentzat, jarduera fisikoak funtzio fisikoa hobetu dezake, bereziki goiko gorputz-adarren funtzioa, beheko gorputz-adarraren funtzio sentsorial motorra, oreka, ibileraren abiadura, distantzia, gaitasuna eta erresistentzia, bihotz eta arnas sistemaren gaitasuna, mugikortasuna eta eguneroko bizitzako jarduerak egitekoa. Dagoen ebidentziak iradokitzen du jarduera fisikoak ere eragin onuragarriak izan ditzakeela kognizioan (35). Depresio kliniko larria duten pertsonentzat, berrikuspen berriek (124, 125) babestu egin zuten jarduera fisikoak osasunarekin lotutako bizi-kalitatea hobetu dezakeela erakusten duen ebidentzia (35, 124, 125). Funtzio kognitiboa narriatzen duten gaixotasunak edo nahasmenduak, eskizofrenia barne, dituzten pertsonentzat, jarduera fisikoak eragin onuragarriak izan ditzake kognizioan, oroimen funtzionalean, kognizio sozialean eta arretan/zaintzan (35, 126). Berrikuspen baten arabera, intentsitate ertainetik bizira bitarteko jarduera fisikoak hobekuntza nabarmenak eragin zituen osasunarekin eta desgaitasunarekin lotutako bizi-kalitatean (35, 124). Online eskuragarri, hemen: https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Desgaitasun intelektuala duten pertsonetan, jarduera fisikoak funtzio fisikoa hobetzen duela frogatu da. Berrikusitako interbentzioek jarduera hauetan oinarritu ziren batez ere: oreka- eta indar-jarduerak, 6- 24 astez. Hala, oreka estatikoa, oreka dinamikoa eta oreka estatiko/dinamikoa nabarmen hobetu zirela adierazi zuten, kontrol-taldeekin alderatuta (35, 127, 128). Arreta-defizit eta hiperaktibitatearen nahasmendua duten haurretan, ebidentziak, ADHN barne hartzen duten 5 IKEren RTCren berrikuspena biltzen duenak (129), lotura positiboa erakusten du ariketaren eta ondokoekin lotutako nahasmenduen artean: arreta, funtzio exekutiboa eta kognizio soziala (35, 129). GDGk haurren, nerabeen eta helduen populazio orokorraren ebidentzia hartu zuen kontuan, eta ondorioztatu zuen ez dagoela arrazoirik uste izateko desgaitasunaren eragina aldatuko litzatekeela eta osasun-onura fisiologiko berberak ekarriko lituzkeela fisikoki aktiboa izanda. GDGk aitortu zuen azterlan gutxik jasotzen dituztela desgaitasuna duten pertsonak, eta eraginaren aldaketa gutxitan frogatzen dela. Desgaitasunaren arloko ebidentzia horrek, populazio orokorrarentzako ebidentzia zabalagoarekin batera, babestu egin zuen populazio orokorrean desgaitasuna duten pertsonak barne hartzeko egindako gomendioa, "heldu guztiak", "adineko guztiak" eta "gaitasun guztietako pertsonak" aipatuz. GDGk honako hau ondorioztatu zuen: Bizkarrezur-muineko lesioa duten pertsonetan, ebidentzia hau dago: • ziurtasun baxuko ebidentzia, jarduera fisikoak sorbaldako mina murrizten duela, gorputz-adar geldietako funtzio baskularra hobetzen duela, baita osasunarekin lotutako bizi-kalitatea ere; eta • ziurtasun ertaineko ebidentzia, jarduera fisikoak ibiltzearen funtzioa, indar muskularra eta goiko gorputz-adarren funtzioa hobetzen dituela. Funtzio kognitiboa, Parkinsonen gaixotasuna barne, narriatzen duten gaixotasunak edo nahasmenduak dituzten pertsonetan, ebidentzia hau dago: • ziurtasun altuko ebidentzia, jarduera fisikoak zenbait emaitza funtzional hobetzen dituela, hala nola ibiltzea, orekaren, indarraren eta gaixotasunaren berariazko emaitza motorrak; eta • ziurtasun ertaineko ebidentzia, jarduera fisikoak ‒intentsitate ertainetik bizira‒ kognizioan eragin onuragarriak izan ditzakeela. Istripu zerebrobaskularraren aurrekariak dituzten pertsonetan, ebidentzia hau dago: • ziurtasun ertaineko ebidentzia, mugikortasunera bideratutako jarduera fisikoak funtzio fisikoan eta kognizioan eragin onuragarriak izan ditzakeela. Funtzio kognitiboa, eskizofrenia barne, narriatzen duten gaixotasunak edo nahasmenduak dituzten pertsonetan, ebidentzia hau dago: • ziurtasun ertaineko ebidentzia, jarduera fisikoak bizi- kalitatea hobetzen duela; eta • ziurtasun altuko ebidentzia, jarduera fisikoak ‒intentsitate ertainetik bizira‒ kognizioan, oroimen funtzionalean, kognizio sozialean eta arretan ondorio onuragarriak izan ditzakeela. Depresio kliniko larria duten helduetan, ebidentzia hau dago: • ziurtasun ertaineko ebidentzia, jarduera fisikoak bizi- kalitatea hobetzen duela. Esklerosi anizkoitza duten helduetan, ebidentzia hau dago: • ziurtasun altuko ebidentzia, jarduera fisikoak, bereziki jarduera aerobikoak eta muskuluak indartzekoak, hobetu egiten dituela funtzio fisikoa, mugikortasun funtzionala, abiadura eta ibiltzeko erresistentzia, eta bihotz eta arnas sistemaren gaitasuna, indarra eta oreka; • ziurtasun ertaineko ebidentzia, jarduera fisikoak kognizioan eragin onuragarria izan dezakeela; eta • ziurtasun baxuko ebidentzia, jarduera fisikoak bizi-kalitatea hobetzen duela, nekearen sintomak eta depresio-sintomak barne. Desgaitasun intelektuala duten haur eta helduetan, ebidentzia hau dago: • ziurtasun gutxiko ebidentzia, jarduera fisikoak funtzio fisikoa hobetzen duela. ADHN duten haur eta nerabeetan, ebidentzia hau dago: • ziurtasun ertaineko ebidentzia, jarduera fisikoak ‒ intentsitate ertainetik bizira‒ kognizioan eragin onuragarriak izan ditzakeela, arreta, funtzio exekutiboa eta kognizio soziala barne. GDGk ondorioztatu zuen, gainera, nahikoa ebidentzia zientifiko dagoela jarduera fisikoak desgaitasun-eremu askotan osasun-emaitza anitzetan duen eragin positiboari buruz, eta jarduera fisikoak desgaitasuna duten pertsonentzat dituen onurek kalte potentzialak gainditzen dituztela. Gomendio horiek garatzeko ebidentzia zeharkakoa zenez, ziurtasun-maila murriztu egin zen. Gomendioak 63 64 Desgaitasuna duten haur, nerabe eta helduentzat, honela definitzen da sedentarismoa: esna dauden bitartean, eserita edo etzanda igarotzen duten denbora, energia-gastu gutxirekin, hezkuntzako, familiako eta komunitateko inguruneetan, eta garraiatzean. Posible da sedentarismoa saihestea eta fisikoki aktiboa izatea eserita, erdi etzanda edo etzanda egon bitartean, adibidez, goiko gorputz-adarra lantzeko jarduerak, eta gurpil-aulkientzako jarduera espezifikoak eta kirol inklusiboak eginda. Aldeko ebidentzia eta oinarria Sedentarismoa ez zen sartu Osasunerako jarduera fisikoari buruzko gomendio globaletan (2010). Populazio espezifikoen ebidentziarik ez dagoenez, desgaitasuna duten haur, nerabe eta helduen sedentarismoaren eta osasun-emaitzen arteko loturak ebaluatzeko ebidentzia-oinarri nagusia desgaitasunik gabeko populazioentzat bildutako eta berrikusitako literatura zientifikoa izan zen. Populazio orokorraren sedentarismoari buruzko ebidentziaren aurkikuntzak berrikusi ziren, baita ebaluatu ere ebidentziarik ote zegoen emaitzak desberdinak izango liratekeela, edo ez liratekeela aplikatzekoak izango edo kontraindikatuta egongo liratekeela desgaitasuna duten haur, nerabe eta helduetan. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Helduetan, sedentarismo handiagoa osasun-emaitza txar hauekin lotzen da: kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskulek eta minbiziak eragindakoa, eta gaixotasun kardiobaskularren, minbiziaren eta II motako diabetesaren intzidentzia. Hau gomendatzen da:  Desgaitasuna duten helduek mugatu egin behar dute sedentario izaten igarotzen duten denbora. Denbora sedentarioa edozein intentsitateko jarduera fisikoarekin ordezkatzeak (intentsitate baxua barne) osasun-onurak dakartza. Gomendio sendoa, ziurtasun baxuko ebidentzia  Sedentarismo maila handiek osasunean dituzten eragin kaltegarriak murrizten laguntzeko, desgaitasuna duten helduek jarduera fisikoa egin behar dute intentsitate ertainetik bizira eta gomendatutako mailak gainditzen saiatu. Gomendio sendoa, ziurtasun baxuko ebidentzia Haur eta nerabeetan, sedentarismo handiagoa osasun-emaitza txar hauekin lotzen da: adipositatea handitzen da; bihotz eta arnas sistemaren gaitasuna urritzen da, baita gaitasun fisikoa eta portaera/jokabide prosoziala ere; eta loaren iraupena murrizten da. Hau gomendatzen da:  Desgaitasuna duten haur eta nerabeek mugatu egin behar dute sedentario izaten igarotzen duten denbora, batez ere pantaila aurreko aisialdiko denbora. Gomendio sendoa, ziurtasun baxuko ebidentzia CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and over) LIVING WITH DISABILITY Eskura dagoen ebidentzia eta adituen iritzia oinarri hartuta, ebidentzia estrapolatu egin zen desgaitasuna duten helduentzako sedentarismoari buruz OMEk emandako gomendio berriak informatzeko, osasun-emaitza kritikoen multzo konbinaturako, eta aitortu zen populazio-talde jakin batzuk, gurpil-aulkien erabiltzaileak kasu, ezinbestean esertzen direla denbora-tarte luzeetan, eta, beraz, esertzea litzatekeela araua. Talde horietan, sedentarismoa honela definitu behar da: energia-gastu baxuko denbora, adibidez, aulki elektriko batean mugitzea edo eskuzko gurpil-aulki batean eserita egonda bultzatua izatea. Ez dago ikerketarik sedentarismoaren eta osasun-emaitzen arteko loturari buruz desgaitasuna duten pertsonetan. Hala ere, adituen iritziaren arabera, ez dago arrazoirik uste izateko desgaitasunaren eragina aldatuko litzatekeenik, eta, beraz, osasun-onura fisiologiko berberak lortuko lirateke, desgaitasuna duten pertsonen sedentarismoa mugatuta. Gomendio horiek garatzeko ebidentzia zeharkakoa zenez, ziurtasuna murriztu egin zen. Kontuan hartu zen, halaber, helduek jarduera fisiko gehiago ‒intentsitate ertainetik bizira‒ egitearen onurari buruzko ebidentziaren aplikagarritasuna, sedentarismo handiaren arrisku potentzialei aurre egiten laguntzeko, eta estrapolatu ere egin zen, desgaitasuna duten helduentzako gomendioak informatzeko, osasun-emaitza kritikoen multzo konbinaturako. Zeharkakoa zenez, ebidentziaren ziurtasuna murriztu egin zen. GDGk honako hau ondorioztatu zuen: • Haur eta nerabeen populazioen sedentarismoari buruzko ebidentzia, oro har, desgaitasuna duten haur eta nerabeetara estrapolatu daiteke, haien gaitasun espezifikoaren arabera. • Helduen populazio orokorraren sedentarismoari buruzko ebidentzia, helduentzat jarduera fisikoa ‒ intentsitate ertainetik bizira‒ gehiago egiteak dakartzan onurak barne, sedentarismo handiaren arrisku potentzialak murrizten laguntzeko, oro har estrapolatu egin daiteke desgaitasuna duten heldu eta adinekoetara, beren gaitasun espezifikoaren arabera. Hala ere, ebidentziaren ziurtasuna murriztu egin zen zeharkakoa zelako. • Desgaitasuna duten haur, nerabe, heldu eta adinekoen sedentarismoa minimizatzearen onurek kalteak gainditzen dituzte. 65 HAUR AK ETA NERABEAK (adina 5–17 urte) ETA HELDUAK (adina 18 urte eta gehiago) DESGAITASUNAREKIN 66 EBIDENTZIATIK GOMENDIOETARA GRADE prozesuaren arabera, gomendio eguneratuen idazketa eta haren sendotasunaren kalifikazioa ("sendoa" edo "baldintzapekoa") honako hauetan oinarritu ziren: onuren eta kalteen balantzea; ebidentziaren ziurtasuna; gidalerroen eraginpean daudenen balioekiko eta lehentasunekiko sentikortasuna; generoaren, gizartearen eta osasunaren ekitatean izan dezaketen eragina; eta onargarritasuna, bideragarritasuna eta baliabideen inplikazioak. Hauek populazio talde bakoitzarentzat kontuan hartu ziren, baina eztabaidatutako gaien eta kontsiderazioen antzekotasuna dela eta, hemen finkatu eta aurkezten dira. Gomendioaren sendotasuna onuren eta kalteen balantze ebaluatuan oinarritu zen batez ere. Gomendioak "sendoak" izan ziren onuren eta kalteen arteko oreka funtsezkotzat jo bazen gomendioaren xede-populazioarentzat, eta "baldintzapekotzat" onuren eta kalteen arteko oreka baxua bazen edo xede-populazioan onuretan aldakortasun handia egon bazen. Kalteei buruzko ebidentzia beste berrikuspen sistematiko bat enkargatuz bilatu zen espezifikoki. Hala ere, mugatua izan zen; izan ere, ebidentzia gehienak eliteko atletei eta lehiaketetan parte hartzen dutenei eragindako lesioak eta kalteak dira, populazio orokorrari egindakoak baino gehiago. Oro har, ebidentzia mugatua izanda, eta adituen iritziaren arabera informatua, ondorioztatu zen arriskua ez zela baxuagoa edo altuagoa. Oro har, ebidentziak adierazten du jarduera fisikoaren onurek nabarmen gainditzen dituztela kalteak, eta jarduera fisikoa interbentzio garrantzitsua izan daitekeela dagoen osasun-arrakala bat ixten laguntzeko, batez ere desabantailan dauden populazioentzat. GDGk osasunaren zuzentasunari, bideragarritasunari eta onargarritasunari buruzko gaiak ere hartu zituen kontuan, eta 2020ko martxoaren 31tik 2020ko apirilaren 17ra bitartean egindako gomendioen proiektuari buruzko online kontsulta publikoan parte hartu zuen. Kontsulta publikorako inkestak galdera espezifikoak planteatzen zituen gomendioak ezartzeak norbanakoei eta gobernuei eragiten dizkien kostuen eta osasunerako izan ditzakeen onuren arteko orekari buruz, bai eta gidalerroek osasuneko ekitatea hobetuko ote luketen ere. Gainera, gomendioen proiektua eta iruzkinen formularioa jarduera fisikoari buruzko gidalerro nazionalak idazteko prozesua hasi berri zuten herrialdeei bidali zitzaizkien. Online kontsultaren 420 aurkezpen baino gehiagoren iruzkinak jaso ziren, baita OMEren Europako Eskualde Bulegoaren iruzkinen bilduma gehigarri bat ere,OMEren eta estatu kideen zentro laguntzaileen iruzkinak erantsita. Kontsulta horretako iruzkinak bildu, GDGk berrikusi eta bideragarritasunari, baliabideen inplikazioei eta osasun-ekitateari buruzko iritzia emateko erabili ziren, Zuzendaritza Taldearekin eta GDGrekin egindako kontsulten bidez. Erabakiak adostasunez hartu ziren, eztabaida bidez. GDGk gomendio bakoitzari eta gomendioaren indarrari buruzko adostasuna lortu zuen; ez zen kalifikaziorik edo bozketarik behar izan. EBIDENTZIAREN ZIURTASUNAREN EBALUAZIOA GRADE markoa GDGk erabili zuen IP/ECOetan identifikatutako emaitza bakoitzari laguntzen dion lehen mailako ikerketaren ziurtasuna aztertzeko, eta ebidentziaren ziurtasun orokorra ebaluatu zuen, hauek kontuan hartuta: ebidentziaren alborapen, sendotasun falta, zehaztugabetasun eta zeharkakotasun arriskua eta argitalpenen joera emaitza bakoitzean. Informazio hori IP/ECO bakoitzerako zehazten duten taula grafikoak web-eranskinean daude eskuragarri ebidentzia-profilak . Ebidentziaren ziurtasunaren ebaluazioa ebaluatutako emaitza guztien ebaluazio orokorrean oinarritu zen, eta kausa guztiengatiko hilkortasuna eta hilkortasun kardiobaskularra lehenetsi zituen emaitzarik kritikoenetan, ondoren beste emaitza kliniko batzuk (erorikoak, depresioa, kognizioa, osasunarekin lotutako bizi-kalitatea, etab.), eta gero tarteko emaitzak (adibidez, adierazle kardiometabolikoak, beste adierazle metaboliko batzuk), baita kalteak ere. Ebidentzia espezifikoki berrikusi ez zenean, besteak beste azpipopulazioen sedentarismorako, batez ere talde horien ebidentzia faltagatik, populazio orokorrarentzat ebidentzia estrapolatu eta murriztu egin zen egokitzat jo zenean, zeharkakoa izateagatik. Online eskuragarri, hemen: https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z ONURAK ETA KALTEAK Gomendioak garatzean, inpaktu edo arrisku kaltegarrien ebaluazioa egin zen. Ebidentzia mugatua zenean, erabakiak GDGren esperientzian oinarritu ziren. Oro har, populazio guztientzat ondorioztatu zen jarduera fisikoaren onurak eta sedentarismoa mugatzeak kalte potentzialak gainditzen zituztela. Gidalerro hauek herritar guztientzat dira, eta ez diete heltzen atletek izandako onurei eta kalteei beharrezko jarduera-motak eta kantitatea egiten dutenean lehiaketetarako errendimendu hobea lortzeko. Jarduera fisiko pixka bat egitea ezer ez egitea baino hobe da. Gaur egun pertsonek ez badituzte gomendio hauek betetzen, jarduera fisikoren bat egiteak osasun-onurak ekarriko dizkie. Hasteko, jarduera fisikoa gutxika egiten hasi behar dute, eta denborarekin maiztasuna, intentsitatea eta iraupena pixkanaka handitu. Ariketa egin aurreko baimen medikoa normalean ez da beharrezkoa. Pertsona inaktiboek, intentsitate ertaineko jarduera bati ekiteko pixkanaka hasten direnek, ez dute bat-bateko bihotz-gertakarien arrisku ezagunik, eta arrisku oso baxua dute hezur, muskulu edo artikulazioetako lesioak izateko. Intentsitate ertaineko jarduera egin ohi duen pertsona intentsitate bizira igaro daiteke pixkanaka, osasun-arloko profesional bati kontsultatu beharrik izan gabe. Beren jarduera-maila handitzean sintoma berriak garatzen dituztenek galdetu egin behar diote osasun-arretako profesional bati. Jarduera fisiko mota eta kantitate egokia aukeratzeak eragina izan dezake haurdunaldian, gaixotasun kronikoetan eta desgaitasunetan, eta ahal den neurrian eta kontraindikaziorik ezean egin behar da. Baliteke pertsona horiek jarduera fisikoko espezialista bati edo osasun-arloko profesional bati kontsultatu nahi izatea, aholkularitza jasotzeko ondokoei buruz: haien premia indibidualetarako egokiak diren jarduera-mota eta -kantitatea, haien trebetasunak, muga funtzionalak/konplikazioak, medikamentuak eta tratamendu-plan orokorra. Jarduera fisikoak, intentsitate baxu eta ertainekoak, oro har, ez dakar arrisku handirik, eta denentzat gomendatzen da. BALIOAK ETA LEHENTASUNAK Gidalerroen eraginpean daudenen balioak eta lehentasunak hartu ziren kontuan (kasu honetan, gurasoak eta zaintzaileak, haurrak eta nerabeak, helduak, adinekoak, emakume haurdunak eta erditze ondokoak, gaixotasun kronikoak eta/edo desgaitasunak dituzten pertsonak). Oro har, lehentasunei buruz ziurgabetasun gutxi edo batere ez zegoela ondorioztatu zen, emaitza nagusiei dagokienez, hilkortasuna eta hilkortasun kardiobaskularra barne. Kalkulatutako onura potentzialek kalte potentzial oro gainditu zuten neurri handi batean; beraz, GDGk ikusi zuen gomendioetan ez zutela eraginik lehentasunek. BALIABIDEEN INPLIKAZIOA GDGren iritzi adituak eta ebidentzia-multzo txiki batek, jarduera fisikoaren mailak handitzearen ondoriozko osasun-arretako sistemetarako interbentzioen eta aurrezpenen analisi ekonomikoak informatzen dituenak, gomendioek ingurune desberdinetako baliabideetan zituzten inplikazioei buruzko eztabaidaren berri eman zuten. Gainera, online kontsulta publikoaren emaitzek erakutsi zutenez, inkestatuen % 75 baino gehiago ados edo oso ados zeuden gidalerroak ezartzearen onurek norbanakoarentzat kostua gaindituko zutela, eta % 81 ados edo oso ados zeuden gidalerroak ezartzearen onurek gobernuarentzat kostua konpentsatuko zutela. Eskura dagoen ebidentziak eta adituen iritziak onartzen dute osasun-onura esanguratsuak lor daitezkeela oinez ibiltzearen moduko jarduerak eginda, gizabanakoarentzat ekipamendurik edo kostu espezifikorik behar ez dutenak. Gainera, onartu egin zen beste jarduera fisiko mota batzuek, hala nola kirol egituratuek, bizikletan ibiltzeak eta ariketa-klaseek, kostuak eragin ditzaketela, eta hori oztopo bat izan daiteke pertsona batzuentzat, bereziki diru-sarrera txikienak dituztenentzat. Jarduera fisikoa sustatzeko eta ahalbidetzeko politikak eta programak gobernuak ezartzeko, inbertsioak egin behar dira hainbat arlotan, hala nola giza baliabideetan, politiken garapenean, instalazioen eta zerbitzuen horniduran eta, potentzialki, ekipoetan; horietako batzuk osasun-ministerioek kontratatzen dituzte, baina baita osasunarekin zerikusirik ez duten sektoreetan ere, hala nola kirolean, hezkuntzan, garraioan eta hiri- plangintzan. Beharrezkoak diren baliabideak gobernu- maila batean baino gehiagotan egon daitezke (maila nazionala, azpinazionala eta tokikoa), komunitate guztiek jarduera fisikorako aukera berdinak dituztela bermatzeko. Inbertsio horiek baliabide berriak barne har ditzakete, baina, era berean, lehendik dauden aurrekontuak birbanatu daitezke, populazioaren jarduera fisikoaren mailak handitzeko instalazioen eta programen lehentasuna jasotzeko. Aurrekontuak birbanatzearen adibideetan honako hauetara bideratuak barne har daitezke: batetik, oinez eta bizikletan ibiltzeko azpiegiturak dagoen garraio- aurrekontutik, eta bestetik, "guztiontzako kirolak" dagoen kirol-aurrekontutik. Funtsezko inguruneetan, hala nola eskoletan eta lantokietan, kostu txikiko interbentzioak, ingurune fisikoan izandako aldaketekin batera, baliagarriak izan daitezke jarduera fisikoan parte hartzeko, eta gainera lagungarriak izan daitezke aktibo izateko azpipopulazio- talde batzuen aukera-desberdintasunak murrizteko. Oro Ebidentziatik gomendioetara 67 68 har, ebaluatutakoaren arabera, gomendioen zirriborro hori lortzeko baliabideak behar badira ere, posible da gaur egungo gobernantza-egituren barruan ekintzak ezartzea. Gainera, ebidentziaren arabera, osasun-sistemak aurrezpen nabarmenak lor ditzake, jarduera fisikoaren mailak goratzearen ondorioz. 2013an, jarduera fisikorik ezaren urteko kostua 54.000 milioi dolar INT$ izan zela kalkulatu zen, osasun-kostu zuzenengatik soilik (130); eta maila nazionalean, jarduerarik ezak osasun- arretarako aurrekontuen % 1 - % 3ko kostua duela kalkulatzen da (131). Gaixotasun ez kutsakorren prebentzioaren testuinguru zabalagoaren barruan, gobernuak eta gobernuz kanpoko erakundeek gidalerroak ezartzeko dituzten kostu gehigarriak minimora murriz daitezke, baldin eta gomendatutako jarduera fisikoa beren bizitzan eragozpen handirik gabe ekin ahal badiote pertsonek; eta baldin eta lehen eta bigarren mailako arretan dauden baliabideak, eskolak, lantokiak edo garraioa alda badaitezke jarduera fisiko gehiagoren alde. Jarduera fisikoa sustatzearen kostuen eta onuren analisiek 15 urteko inbertsioaren etekin positiboak adierazten dituzte, NCDen (Gaixotasun Ez Kutsakorrak) prebentzioari dagokionez, inbertsioak egin dituzten herrialde askotan (132). Hainbat interbentzio, besteak beste, kontzientziazio eta hezkuntza publikoko kanpainak, eta jarduera fisikoari buruzko aholkularitza eta erreferentziak, gomendatutako interbentzioen "erosketa onena" eta "erosketa ona" dira, hurrenez hurren, NCDei ekiteko 2013–2020 aldirako NCDak prebenitu eta kontrolatzeko ekintza-plan globaleko (133) 3. eranskinaren eguneraketan oinarrituta. Oro har, GDGk ondorioztatu zuen gomendioak ezartzearen onurek kostuak gainditzen dituztela. Desgaitasuna dutenei zuzendutako jarduera fisikorako gidalerroak betetzeko inbertsioa egin behar izango da, hala nola jardueretako espezialistak gaitzea, ekipamendu egokituak, beharrezkoa denean, eta instalazio irisgarriak. Inbertsio horiek populazio-talde askoren premiak bete ditzakete. Ebidentziak erakusten duenez, jarduera fisikoari dagokionez, parte-hartze malda esanguratsu bat dago desgaitasuna duten eta ez duten pertsonen artean, hainbat oztoporen ondorioz (besteak beste, irisgarritasuna, eskainitako jardueren aukerak eta gainerakoen jarrerak). Diseinu unibertsalaren printzipioak aplikatu behar dira, desgaitasuna duten pertsonek parte-hartze osoa eta eraginkorra izango dutela bermatzeko. Berrikuntzarekin, posible da baliabideen inplikazio horietako askori heltzea. Diseinu unibertsaleko ikuspegiak hartzeak kostu horiek arinduko lituzke etorkizunean. EKITATEA, ONARGARRITASUNA ETA BIDERAGARRITASUNA 2010eko gomendioak eguneratzean, erabaki zen esplizituki sartzea populazio kalteberen kontsiderazioa, hala nola gaixotasun kronikoak eta/edo desgaitasuna duten pertsonena. GDGk eta Zuzendaritza Taldeak talde horiek ordezkatzen zituzten kideak zituzten. GDGk gomendio bakoitza sakon eztabaidatu zuen, eta hausnartu zuen gomendioak ezartzeak murriztuko ote zituen osasun-arloko ekitatea eta ezarpenarekin lotutako arazoak, gomendioek ekitate-arazoak handitzen ez dituztela bermatzeko (adibidez, jarduera fisikoa egiteko instalazio seguruak eta aukera irisgarriak bermatzea guztientzat, desgaitasuna dutenentzat, maila sozioekonomikoan kalteberak direnentzat eta beste desabantaila batzuk dituztenentzat barne; jarduera fisikorako sarbidea eta horietan parte hartzeko aukera murriz ditzaketen genero-aurreiritziei eta beste kultura-aurreiritzi batzuei heltzea eta abar). Online kontsulta publikoari erantzun ziotenen artean, % 76 ados edo oso ados zeuden gidalerroak ezartzeak osasun-arloko ekitate eza murriztea lor dezakeela, guztiak aktibo izateko eta osasun-emaitzak hobetzeko aukerak areagotzean. Adierazi zen laguntza-inguruneak funtsezkoak direla jarduera fisikoan parte hartzeko. Ikuspegi integral bat beharko da hainbat sektoretan politikak diseinatzeko eta ezartzeko, talde kalteberentzat jarduera fisikorako oztopoei heltzeko, hala nola desabantaila sozioekonomikoa duten emakume eta neskentzat eta desgaitasuna duten pertsonentzat. Desgaitasuna duten pertsonek desgaitasunik gabeko pertsonek baino osasun-emaitza txarragoak izaten dituzte; hala ere, jarduera fisikoaren onurek nabarmen gainditzen dituzte kalteak, eta interbentzio garrantzitsua izan daiteke osasun-arrakala hori ixteko. Ebidentziak erakusten duenez, jarduera fisikoari dagokionez, parte-hartze malda esanguratsua dago desgaitasuna duten eta ez duten pertsonen artean, oztopo ugari baitaude, besteak beste, irisgarritasuna, eskainitako jardueren aukerak eta gainerakoen jarrerak. Desgaitasuna duten pertsona askok aukera izan beharko lukete jarduera fisiko mota desberdinak egiteko, egokitutako ekipamendu edo instalaziorik behar izan gabe. Hala ere, desgaitasuna duten pertsonek gainerakoen baldintza beretan jarduera fisikoetan parte hartu ahal izateko, premia hauei erantzun behar izango zaie: ekipamendu egokituak lortzea, instalazioak irisgarri egitea, eta jardueretako espezialistak gaitzea. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z IKERKETA-PREMIAK Jarduera fisikoa eta sedentarismoa bizitza osoko osasun-emaitzekin lotzen dituzten datu asko egon arren, GDGren eztabaidek ebidentzia-hutsune handiak erakutsi zituzten, eta horiek lehenetsi beharko lirateke etorkizuneko gidalerroen berri emateko. Populazio-azpitaldeetako ebidentzia- arrakalek honako hauei buruzko informaziorik eza barne hartu zuten: 1) jarduera fisikoaren eta/edo sedentarismoaren eta aztertutako osasun-emaitza batzuen arteko dosi-erantzun erlazioari buruzko xehetasunik zehatzenak; 2) intentsitate baxuko jarduera fisikoaren osasun- onurak eta denbora sedentarioa intentsitate baxuko jarduerarekin ordezkatzearenak; 3) osasunean mota eta eremu ezberdinek duten eragin ezberdina, jarduera fisikoarenak (aisialdia, lana, joan-etorriak, etxeko-lanak, ikasketak) eta sedentarismoarenak (lana, pantaila aurreko denbora, telebista ikusten); eta 4) jarduera fisikoaren eta denbora sedentarioaren arteko lotura osasun- emaitzekin bizitzan zehar. Halaber, adierazi zenez, ebidentzia mugatua dago diru-sarrera baxu eta ertaineko herrialdeetarako, egoera ekonomiko ahulean dauden edo arreta urria jasotzen duten komunitateetarako, eta desgaitasuna eta/edo gaixotasun kronikoak dituztenentzako. Azterlan asko ez daude diseinatuta edo sustatuta hainbat faktore soziodemografikoren (adina, sexua, arraza/etnia, maila sozioekonomikoa) ondoriozko eragin-aldaketa frogatzeko, jarduera fisikoak osasunean dituen eraginak alda ditzaketen faktoreak izanik. Informazio hori garrantzitsua da osasun publikoko gomendio espezifikoagoak lantzeko eta populazioaren sektore ahulenetan osasun- desberdintasunak murrizteko. Argitaratutako literaturan gidalerro berri hautetatik sortzen diren ikerketa-arrakalei buruzko xehetasun gehiago ere aurki daitezke (134). Ikerketa-premiak 69 70 GIDALERROAK HARTZEA, HEDATZEA, EZARTZEA ETA EBALUATZEA Gidalerro hauen helburua da politikak diseinatzearen arduradunei eta interbentzio-programak garatzen dituztenei (osasun-, hezkuntza-, lan- eta komunitate- eremuetan) gomendioak ematea, jakin dezaten haurrek, nerabeek, helduek eta adinekoek jarduera fisikoa egiten zenbat denbora eman behar duten egunean, baita denbora sedentarioa mugatzeko gomendioak ematea ere. Hala ere, gidalerro globalak garatzea ez da berez helburu bat: hedapenik eta ezarpenik gabe, ez da aldaketarik lortuko jarduera fisikoaren mailetan. GIDALERROAK HARTZEA OMEk prozesu zorrotza eta zabala egiten du gidalerro global (21) garrantzitsuak garatzeko, herrialde guztiek erabil ditzaten. Jarduera fisikoari eta sedentarismoari buruzko gidalerro hauek ebidentzietan oinarritutako gomendioak ematen dituzte jarduera fisikoak eta sedentarismoak osasunean dituzten eraginei buruz, gobernuek euren esparru politiko nazionalaren barruan hartu eta erabil ditzaten. Gidalerro globalen garapenak, kontsulta zabal bat eginda, ezabatu egin beharko luke herrialdeetako bakoitzak baliabideetara jotzeko duen premia prozesu zientifiko luze honi ekiteko. Hala, jarduera fisikoari eta sedentarismoari buruzko gidalerro global hauek berrikusi eta hartuz gero, metodo azkar eta errentagarri bat lortzen da tokiko testuingurura egokitutako gidalerroak garatzeko. OMEren gidalerroak eskualde- edo nazio-mailan hartzeak bermatu egingo du herrialdeek gomendio koherenteak ematea jarduera fisikoari eta sedentarismoari buruz, eskuragarri dauden azken ebidentzia zientifiko sendoenetan oinarrituta. Gainera, herrialdeen artean, gomendioen koherentziak erraztu egingo ditu berrikuspen-lana, jarduera fisikoaren eta sedentarismoaren kalkulu globalak eta herrialdeen arteko konparazioak. Gidalerroak hartzeko prozesuan, kontuan hartu behar da testuinguruan kokatu eta hartara egokitu egin behar direla. Tokiko hizkuntzara itzultzea neurrietako bat da gidalerroak hartu eta testuinguruan kokatzeko. Baliteke jarduera fisikoen adibideak aldatu behar izatea dagokion tokirako esanguratsuak izan daitezen, baita irudien erabilera ere, tokiko kulturak, arauak eta balioak isla ditzaten. Prestaketa-prozesuan da herrialdeei gidalerro Globalak hartzen laguntzeko urratsez urratseko esparru bat, interesdunekin eskualde-mailako tailerrak egin ondoren. Esparru hori garrantzizko datu nazionalekin osa daiteke (adibidez, jarduera fisikoaren prebalentziaren kalkuluak) eta horrek hurbilketa azkar bat emango du gidalerro nazionalen dokumentu bat garatzeko. Laguntza-baliabide horiek eskuragarri egongo dira 2021ean, OMEren webgunean. Gidalerroak hartzea kontuan hartzean, hamar urratseko prozesu hau aplikatzea gomendatzen da: 1. Jarduera fisikoari buruzko egungo gidalerro nazionalak berrikusi daitezen eta OMEren gidalerroak har daitezen defendatzea, gobernuaren baimena bermatzeko. 2. Alderdi interesdun nagusiak inplikatzea, bai osasunaren sektorean, bai beste sektore garrantzitsu batzuetan, hala nola kirolean, hezkuntzan eta garraioan; gaian esperientzia duten elkarte profesional eta zientifiko gailenak inplikatzea. 3. Gomendioen aplikagarritasuna, onargarritasuna eta bideragarritasuna ebaluatzea. 4. Ikustea gidalerroak egokitzen diren tokiko testuingurura, hizkuntza, adibideak eta beste kontsiderazio kultural batzuk barne. 5. Kanpoko berrikuspen bat egitea xede-erabiltzaileekin, politikak diseinatzearen arduradunak, profesionalak eta publiko orokorra barne. 6. Hedapenerako eta komunikaziorako aurrekontu eta plan argi bat ezartzea. 7. Gidalerro nazionalak argitaratzea eta sustatzea, merkaturatzeko ekitaldi batekin batera, publizitatea eta interesa sortzeko. 8. Erakunde profesional garrantzitsuak inplikatzea eta politikak lerrokatzen eta/edo babesten laguntzea. 9. Politika eta praktika nazionalak ezartzea, gidalerro nazionalen ezarpena eta portaera-aldaketa bultzatzeko. 10. Gidalerroak ebaluatzeko, berrikusteko eta eguneratzeko kronograma bat adostea. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z 71 Gidalerroak hartzea, hedatzea, ezartzea eta ebaluatzea HEDAPENA Jarduera fisikorako gidalerro nazionalak gobernantza- egituren funtsezko osagaia dira, populazioaren jarduera fisikoaren mailak handitzeko ikuspegi integral baterako. Gidalerro nazionalek plan estrategiko nazionalaren eta azpinazionalaren garapena eta lehentasunak informatzen dituzte, eta pertsona-talde esanguratsuei informazio zuzena modu egoki batean helaraztea eskatzen dute. Tamalez, gehiegitan, gidalerro nazionalak ez dira hedatzen, eta, beraz, gomendioen ezagutza oso txikia izaten jarrai daiteke, bai publiko profesionalaren artean, bai komunitate orokorraren artean. Eskala handiko hedapenari laguntzeko baliabideak ziurtatzea lehen urrats garrantzitsua da jarduera fisikoa areagotzearen eta sedentarismoa murriztearen garrantziari buruzko kontzientzia eta ezagutza aldatzeko. Jarduera fisikoari eta sedentarismoari buruzko gidalerro nazionalen hedapenean funtsezkoak dira: • Osasun-arloko arduradun politikoak eta beste hainbat arlotakoak (garraioa, plangintza, hezkuntza, lana, kirola, parkeak eta aisialdia barne), helburu hauetarako: a. jakintza areagotzea jarduera fisiko gehiago egiteak eta sedentarismoa murrizteak, osasuna hobetzeaz gain, askotariko eremuak ere hobe ditzakeela, besteak beste, genero-ekitatea, giza eskubideen betebeharrak eta garapen jasangarria; b. jarduera fisikoari eta sedentarismoari buruzko politikak eta programak integratzea politika guztietan; eta c. nazio- eta toki-mailako ekintza koordinatuetan eta zabalagoetan inbertitzea. • Estatuz kanpoko eragileak (gobernuz kanpoko erakundeak, erakunde akademikoak eta ikerketa- erakundeak, sektore pribatua, komunikabideak eta ikerketaren finantzaketa-agentziak barne), helburu hauetarako: a. adin guztietan jarduera fisikoa areagotzearen eta sedentarismoa murriztearen garrantziaz kontzientziatzea; b. politiken lerrokatzea bultzatzea eta ziurtatzea; eta c. tokiko politiken eta ekintzen ezarpenean lankidetza eta inbertsioa handitzea. • Osasun-arloko profesionalak eta beste hainbat arlotakoak (kirola, hezkuntza, garraioa eta plangintza barne), helburu hauetarako: a. jarduera fisikoari eta sedentarismoari buruzko gidalerro nazionalen kontzientzia eta ezagutza areagotzea; b. jarduera fisiko handiagoa sustatzeko eta sedentarismoa murrizteko ezagutza, trebetasunak eta konfiantza areagotzea; eta c. jarduera fisikoaren sustapena ohiko jardunean sartzea, hala dagokionean. • Publiko orokorra eta populazio-azpitalde espezifikoak, helburu hauetarako: a. jarduera fisikoari eta sedentarismoari buruzko gidalerroen kontzientzia eta ezagutza areagotzea; b. jarduera fisikoari eta sedentarismoari buruzko gidalerroak lortzeko modua ezagutzea; eta c. fisikoki aktiboagoa izateko eta sedentarismoa murrizteko asmoak eta motibazioa. KOMUNIKAZIO-KANPAINAK Interesa duten alderdi desberdinek abantailak lortuko dituzte material desberdinetatik; beraz, askotariko publikoari gidalerroak eraginkortasunez ezagutzera emateko, kontuan hartu behar dira edukia, formatua eta bidalketa-kanalak. Komunikazio-estrategia orientagarri bat garatzean, prestakuntza-ikerketak lagun dezake funtsezko publikoak zehazten eta jarduera fisikoaren eta sedentarismoaren mailetan eragiten duten balioak, beharrak eta lehentasunak ulertzen. Horrek barne hartu beharko luke jarduera fisikorako oztopoak aztertzea edo jarduera fisikoa politikan eta praktikan txertatzea, baita mezuen eta materialen zirriborroak hainbat talderekin probatzea ere. Horri esker, erabiltzen diren funtsezko mezuak informatu ahal izango dira, baita komunikaziorako formatu eta kanal egokia(k) ere. Komunikazio-estrategia ulerkor batek publiko desberdinei zuzendutako komunikazioak barne hartuko ditu. Baliteke herrialdeek talde espezifikoak lehenetsi behar izatea eskura dituzten baliabideen arabera (giza baliabideak eta finantza- baliabideak). Publiko orokorrari edo azpipopulazio espezifikoei zuzendutako jarduera fisikoari buruzko komunikazio- kanpainak interbentzio errentagarriak dira (133), eta OMEren 2018-2030 aldirako jarduera fisikoari buruzko ekintza-plan globalean (14) gomendatzen dira. Jarduera fisikoari buruzko kanpaina nazionalek eta azpinazionalek kanpaina orokorreko eslogan bat ezarri ohi dute (adibidez, "Izan aktibo" edo "Mugi zaitez gehiago"), eta diseinu- elementuak edo pertsonaiak garatzen dituzte, publiko desberdinetarako mezu pertsonalizatuak barne har ditzaketenak (adibidez, haurrak, nerabeak, helduak 72 edo adinekoak, gutxien aktibo direnak, desgaitasuna edo gaixotasun kronikoak dituztenak). Ziurrenez, material generikoak baino eraginkorragoak izango dira populazio-talde espezifikoetara egokitzen diren kanpainako mezuak eta baliabideak. Komunikazio- kanpainek kontuan hartu behar dituzte ohiko hedabideetako kanalen (telebista, irratia, publizitate- hesiak, baliabide inprimatuak) eta baliabide digitaletako kanalen (webguneak, telefono mugikorrak, aplikazioak) irismena eta eraginkortasuna. Era berean, baliagarria da gidalerro nazionalei buruzko informazioa hainbat formatutan ematea. Adibidez, jarduera fisikorako gidalerroak komunikatzeko ikuspegi berri samarra baina gero eta ohikoagoa da infografia edo bideo labur animatuak erabiltzea. OMEk material lagungarriak ditu komunikazio-kanpaina horiek garatzeko eta ezartzeko (135). Komunitate akademikoek eta ikerketakoek txosten zientifikoa ezagutu nahi izango dute ziurrenez, gidalerroen oinarri den ebidentzia epidemiologikoa zehazten duena. Hala ere, azpian den ikerketaren xehetasunak beste publiko orokorrago batzuentzat ez dira ziurrenez interesgarriak izango. Arduradun politikoek laburbilduma zientifiko bat edo txosten bat nahiago izango dute. Aldiz, beste publiko batzuek, hala nola osasun-arloko profesionalek eta beste arlo batzuetakoek, bestelako baliabide batzuk nahiago izango dituzte, esate baterako gidalerroei buruzko liburuxka bat edo informazio-orri bat, edo jarduera fisikoaren sustapena ohiko jardunean (adibidez, pazienteen kontsultetan) txertatzeko moduari buruzko bat, edo hiri-inguruneetarako eraikuntza- edo garraio-planak garatzean. Profesionalek beren funtziora egokitzen diren baliabideak beharko dituzte. Osasun-arloko lanbideek, bereziki, hainbat baliabide izan ditzakete, dagozkien jardunean sartzen diren populazio-taldeak islatzeko. POLITIKAK ETA PROGRAMAK EZARTZEA Jarduera fisikoari eta sedentarismoari buruzko gidalerro nazionalek, soilik, ez dute seguru aski populazioaren jarduera fisikoaren maila handituko; beraz, politika- eta plangintza-esparru baten elementutzat hartu behar dira. Funtsezkoa da gidalerro nazionalak xede-publikoei helaraztea eta komunikazio-estrategia nazional iraunkor baten babesa izatea. Estrategia horrek jarduera fisikoa erregulartasunez egitearen eta sedentarismoa murriztearen onurei buruzko kontzientzia eta ezagutza handiagoa izatea ekarriko du. Hala ere, portaera- aldaketa iraunkor bat lortzeko, ekintza horiek politiken babesa izan behar dute, pertsonak aktibo izatea ahalbidetzen eta bultzatzen duten laguntza-inguruneak sortuta, eta horrekin batera, pertsonek jarduera fisikoan parte hartzeko tokiko aukera egokiak areagotuta. Politikek eta programek tokiko testuingurura egokitu behar dute, bai osasun- sistemara, bai jarduera fisikoa sustatzen laguntzeko interesa edo aukera duten sektore anitzeko erakundeen multzora. Neurriak hartu behar dira "gobernantza osoaren" ikuspegia erabilita, eta kontuan hartu behar da politiken eta ekintza ugarien "sistema", alderdi interesdun ugarik parte hartuz, lortu ahal izateko pertsona gehiagok egitea jarduera fisikoa, arlo eta ingurune anitzetan. Komunikazio-estrategia iraunkor batekin lerrokatzen den "sistemen" ikuspegia erabiltzeak ziurtatu egiten du jarduera fisikoa egiteko gero eta eskari handiagoa, komunikazio eraginkorrak sorrarazitakoa, bat etorriko dela pertsonak fisikoki aktibo izateko inguruneak eta aukerak ematearekin. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z 73 Gidalerroak hartzea, hedatzea, ezartzea eta ebaluatzea OMEren 2018-2030 aldirako jarduera fisikoari buruzko ekintza-plan globalak helburu bat ezarri zuen jarduera fisikorik eza % 15 murrizteko 2030erako, eta 20 ekintza eta interbentzio gomendatu nabarmendu zituen (14). Besteak beste, herrialde guztiek hezkuntza eta kontzientziazio publikoko kanpaina iraunkorrak ezartzea gomendatu zen, baita lehen eta bigarren mailako osasun-arretan jarduera fisikoari buruzko aholkularitza-programak integratzea ere. Beste gomendio batzuen arabera, jarduera fisikorako egokiak diren inguruneak sortu beharko ziren, hala nola oinez ibiltzea, bizikletan eta gurpiletan, populazio-talde guztientzat, eta aukera gehiago eta jarduera fisikoko programa gehiago ematea eskoletan, lantokietan, kirol-elkarte eta kiroldegietan. Baliteke 20 gomendioak ez ezartzea epe laburrean herrialde guztietan, baina epe luzerako helburutzat hartu behar da. Berehalako ekintzen multzo egoki eta egingarri bat identifikatzeko, OMEko estatu kideek egungo politiken eta praktiken egoeraren azterketa egin behar dute. Horrek sektore anitzeko lankidetza ahalbidetuko du, eta indarguneak, arrakalak eta aukerak identifikatzen lagundu, eta plan nazionalak eta azpinazionalak garatzeko edo eguneratzeko oinarri gisa erabil daiteke. OMEren gidalerro berri hauek lagungarriak dira talde gehiago sartzeko ekintzen irismena zabaltzen, hala nola desgaitasunak edo gaixotasun kronikoak dituzten pertsonak eta emakumeak haurdunaldian edo erditu ondoren. Politikek babestu egin behar dituzte komunitatearen premiak, eta taldeen eta testuinguruen aniztasuna kontuan hartzen duten programa egokiak gauzatu eta ezarri. Sektore espezifikoetarako zenbait tresna garatzen ari dira ACTIVE pakete teknikoa (135) ezartzen laguntzeko; horiek orientazioa emango diote sektore bakoitzari jarduera fisikoa sustatzeko moduari buruz, adibidez, eskolen bidez, lehen mailako osasun-arretaren bidez edo oinez eta bizikletan ibiltzeko eskaintza hobetuz. ACTIVE tresnek, baita OMEren eskualde- eta nazio-mailako beste baliabide batzuek ere, jarduera fisikoari eta sedentarismoari buruzko gidalerro hauek ezartzen lagunduko dute. GIDALERROAK ZAINTZEA ETA EBALUATZEA OMEren Osasunerako jarduera fisikoari buruzko gomendio globalak erreferentzia gisa erabili dira 2010az geroztik herritarren osasunaren jarraipen eta zaintzarako. Gidalerro eguneratu hauen gomendioetan egindako aldaketek zenbait ondorio izango dituzte gaur egun jarduera fisikoaren mailak kontrolatzeko erabiltzen diren zaintza-sistemetan eta ebaluazio- tresnetan. Gidalerro berri hauek argitaratzeko, egungo tresnak eta txostenak aurkezteko protokoloak berrikusi beharko dira, gidalerro berriei buruzko etorkizuneko txostenak aurkezteari buruzko edozein doikuntza eta gomendio jakinarazteko. Tresnak berrikusiko dira, hala nola jarduera fisikoari buruzko galdetegi globala eta ikasleen osasunari buruzko inkesta globala, eta protokoloak eguneratuko dira gidalerro berri hauekin lerrokatzeko; 2021ean herrialde guztiei laguntzeko orientazioa emango da. OMEren NCDen Gaitasun Nazionalaren Inkesta da (CCS) politikak ezartzeko aurrerapen globala monitorizatzeko erabiltzen den tresna nagusia, eta bi urtean behin egiten da. CCSak jarduera fisikoaren inguruko populazioaren zaintza-sistemei buruzko galdera espezifikoak jasotzen ditu, barnean hartutako adin-talde bakoitzerako eta, 2019tik aurrera, jarduera fisikoari buruzko gidalerro nazionalak ba ote dauden jakiteko galderak ere. OMEko estatu kideei beren erantzuna babesteko dokumentazioa eskatzen zaie. 2019an, OMEko 194 estatu kideetatik 78k ( % 40) jarduera fisikorako gidalerroak zituztela jakinarazi zuten (136).2019an, CCSi emandako erantzunen analisi-dokumentu xehatu bat landu zen, eta identifikatu zen 78 estatu kideen (52/78) bi herenek soilik jasotzen dituztela beren biztanleek egin behar duten jarduera fisikoari buruzko adierazpenak; eta horietatik, 42 herrialdek baino ez zituzten bete OMEren 2010eko Osasunerako jarduera fisikoari buruzko gomendio globalak (1). 2021eko eta ondorengo inkestetako datuek emango dute informazioa gidalerro eguneratu hauek zein neurritan hartu diren jakiteko. 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Assessing national capacity for the prevention and control of noncommunicable diseases: report of the 2019 global survey. Geneva: World Health Organization; 2020. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Erreferentziak 83 84 O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z 85 1. eranskina 1. ERANSKINA: GIDALERROEN GARAPEN-PROZESUAREN KUDEAKETA Kolaboratzaileak gidalerroen garapenean OMEko zuzendaritza-taldea Zuzendaritza Taldeak arlo hauetako adituak hartu zituen barnean: jarduera fisikoa, nerabeen osasuna, zahartzeagatiko desgaitasuna, osasun mentala, lesioen prebentzioa, minbizia, haurdunaldia eta egoitzetako zein eskualde-bulegoetako zaintza. Valentina Baltag Amen, Jaioberrien, Haurren eta Nerabeen Osasuna eta Zahartzea Sailak – nerabeen osasuna Maurice Bucagu Amen, Jaioberrien, Haurren eta Nerabeen Osasuna eta Zahartzea Saila – haurdunaldia Fiona Bull Presidentea Osasunaren Sustatapena Saila – jarduera fisikoa Alex Butchart Osasuneko Determinatzaile Sozialak Saila - lesioen prebentzioa Neerja Chowdhary Gaixotasun Ez Kutsakorren Saila – osasun mentala / dementzia Regina Guthold Amen, Jaioberrien, Haurren eta Nerabeen Osasuna eta Zahartzea Saila – nerbeen zaintza Riitta-Maija Hämäläinen Pazifiko mendebaldeko Eskualde Bulegoa Andre Ilbawi Gaixotasun Ez Kutsakorren Saila – minbizia Wasiq Khan Mediterraneoko ekialdeko Eskualde Bulegoa Lindsay Lee Gaixotasun Ez Kutsakorren Saila –desgaitasuna Alana Officer Zahartzea Leanne Riley Gaixotasun Ez Kutsakorren Saila – zaintza Gojka Roglic Gaixotasun Ez Kutsakorren Saila – diabetesa Juana Willumsen Osasunaren Sustapena Saila – jarduera fisikoa Zuzendaritza Taldeak gidalerroen eta PI/ECOen irismena jaso zuen idatziz. Interesen adierazpena berrikusi zuten, eta gidalerroak idatzi, berrikusi eta amaitu zituzten. 86 Gidalerroak garatzeko taldea (GDG) Gidalerroak Garatzeko Taldea arloko aditu garrantzitsuen, azken erabiltzaileen eta gomendioen eraginpeko pertsonen talde zabal batek osatu zuen. Hauek izan ziren Gidalerroak Garatzeko Taldeko kideak: Salih Saad Al-Ansari dr. (osasunaren sustapenaren eta hezkuntzaren defendatzailea jarduera fisikoa eginez eta ibiliz NCDei aurre egiteko); Stuart Biddle dr. (jarduera fisikoa eta sedentarismoa, eta portaera-aldaketa); Katja Borodulin dr. (jarduera fisikoa haurdunaldian eta adinekoetan); Matthew Buman dr. (loa, sedentarismoa eta jarduera fisikoa gaixotasun kronikoak dituzten pertsonetan); Greet Cardon dr. (jarduera fisikoa haurretan eta nerabeetan); Catherine Carty and. (jarduera fisikoa desgaitasuna duten pertsonetan); Jean-Philippe Chaput dr. (loa, sedentarismoa eta jarduera fisikoa haur eta nerabeetan); Sebastien Chastin dr. (jarduera fisikoa, sedentarismoa eta osasuna, jarduera fisikoaren neurketa objektiboa eta sedentarismoa); Paddy Dempsey dr. (jarduera fisikoa eta sedentarismoa helduetan eta gaixotasun kronikoak dituzten pertsonetan); Loretta DiPietro dr. (jarduera fisikoa haurdunaldian eta adinekoetan); Ulf Ekelund dr. (sedentarismoa eta jarduera fisikoa, jarduera fisikoa haur eta nerabeetan); Joseph Firth dr. (jarduera fisikoa eta osasun mentala); Christine Friedenreich dr. (jarduera fisikoa gaixotasun kronikoak dituzten pertsonetan, jarduera fisikoa eta minbizi-arriskua); Leandro Garcia dr. (jarduera fisikoa eta osasuna helduetan); Muthoni Gichu dr. (politikak ezartzea, gobernu nazionala); Russ Jago dr. (jarduera fisikoa haur eta nerabeetan); Peter Katzmarzyk dr. (jarduera fisikoa eta sedentarismoa); Estelle V. Lambert dr. (jarduera fisikoa eta obesitatea); Michael Leitzmann dr. (sedentarismoa eta jarduera fisikoa gaixotasun kronikoak dituzten pertsonetan); Karen Milton dr. (gomendioak praktikara eramatea); Francisco B. Ortega dr. (jarduera fisikoa haur eta nerabeetan, osasun mentala eta neurketa objektiboa); Chathuranga Ranasinghe dr. (jarduera fisikoa eta osasuna komunitatean, lantokian eta eskolan sustatzea); Emmanuel Stamatakis dr. (jarduera fisikoa eta sedentarismoa eta hainbat osasun- emaitza helduetan); Anne Tiedemann dr. (jarduera fisikoa helduetan); Richard Troiano dr. (politiken garapena); Hidde van der Ploeg dr. (jarduera fisikoa eta sedentarismoa helduetan); Vicky Wari and. (politikak ezartzea - gobernu nazionala); Roger Chou dr. (Pazifikoko ipar- mendebaldea, Ebidentzian Oinarritutako Praktika Zentroa, Medikuntzako Irakaslea, Medikuntza, Informatika Medikoa eta Epidemiologia Klinikoa Sailak, Oregoneko Osasuna eta Zientziak Unibertsitatea) GRADE metodologoa. GDGren xehetasun gehiago 2. eranskinean daude eskuragarri. GDGren lehen bilera bat egin zen 2019ko uztailaren 2tik 4ra. Bilera horretan, PI/ECOren galderetan oinarrituta erabakiak hartu, dauden berrikuspen sistematikoak berrikusi eta beharrezko eguneratzeak identifikatu zituen GDGk. Gomendioei buruzko erabakiak hartzeko prozesua eta GDGren bigarren bileran aplikatuko den ebidentziaren sendotasuna adostu zituen taldeak. Bigarren bilera 2020ko otsailaren 11tik 14ra egin zen; ebidentzia eguneratuak berrikusi ziren eta azken gomendioak aho batez adostu ziren. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z 87 1. eranskina Kanpoko berrikuspen-taldea (ERG) Kidekoen kanpoko zazpi berrikusle hautatu ziren GDGk eta Zuzendaritza Taldeak proposatutako pertsonen zerrenda batetik. Beharrezko ezagutza espezializatua eman zuten, programen inplementazioa barne, eta OMEren sei eskualdeak ordezkatu zituzten. ERGak gidalerroen zirriborroa berrikusi zuen eta Zuzendaritza Taldeari iruzkinak egin zizkion argitasunari eta ezarpenari buruz, eta horiek gehitu egin ziren, zegokionean. Kidekoen kanpoko berrikusleek ez zituzten gomendioak aldatu. 2. eranskinean adierazten dira kidekoen kanpoko berrikusleak. Interes-adierazpenak GDGko kide guztiek eta kanpoko berrikusleek OMEren interesak adierazteko inprimaki bat osatu eta bidali zuten, eta konfidentzialtasun-konpromisoak sinatu zituzten GDGren bileretara joan aurretik. Zuzendaritza Taldeak aurkeztutako curriculum vitaea eta interesen adierazpena berrikusi eta ebaluatu zituen, eta Interneten eta argitalpenetan bilaketa bat egin zuen, egoera konprometigarriak eragin zitzakeen edozein eztabaida edo interes publiko identifikatzeko. GDGK proposatutako kide guztien izenak eta biografia laburrak Jarduera Fisikoaren OMEren webgunean argitaratu ziren, 14 eguneko kontsulta publikorako. Ez zen iruzkinik jaso. Aholkularitza gehiago eskatu izan zenean edozein interes-adierazpen edo -gatazkaren kudeaketari buruz, Betearazpen, Arriskuen Kudeaketa eta Etikako Bulegoko kideei kontsultatu zien Zuzendaritza Taldeak. Beharrezkotzat jo zenean, interes-gatazkak (finantzarioak edo ez finantzarioak) erakutsi zituzten pertsonak baztertu egin ziren edozein gaitan parte hartzetik, gai horietan interes- gatazkak sorraraziz gero. Interes-gatazken kudeaketa prozesu osoan berrikusi zen. GDGko kideek beren interes-adierazpena eguneratu behar zuten, beharrezkoa izanez gero, bilera bakoitzaren aurretik, eta GDGren bilera bakoitzaren hasieran ahozko interes-adierazpen bat eskatu zen. GDGren eta kanpoko berrikusleen interes-adierazpenak 3. eranskinean laburbiltzen dira. Ez zen interes- gatazkarik identifikatu. Kidekoen berrikuspena Gidalerroen zirriborroa GDGk eta Zuzendaritza Taldeak identifikatutako kidekoen kanpoko zazpi berrikuslek berrikusi zuten. Kidekoen kanpoko berrikusleei eskatu zitzaien argitasunari, ebidentziaren aurkezpenari eta ezarpenari buruzko iruzkinak emateko; iruzkinak zegokionean txertatu ziren. Kanpoko berrikusleek ezin zituzten GDGk erabakitako gomendioak aldatu. Kidekoen kanpoko berrikusleak 2. eranskinean zerrendatzen dira; 3. eranskinean interes-adierazpenen laburpena ematen da. Gainera, ekarpenak egiteko eskatu zitzaien OMEren eskualde-bulegoei. 88 2. ERANSKINA: GIDALERROAK GARATZEKO TALDEA, KIDEKOEN KANPOKO BERRIKUSLEAK ETA GIDALERRO HAUEN GARAPENEAN PARTE HARTU DUTEN OME-KO LANGILEAK Gidalerroak garatzeko taldea Salih Al-Ansari dr. Irakasle laguntzailea Familia eta Komunitate Medikuntza Osasunaren Sustapen Zentroaren Fundatzailea eta CEO Riyadh SAUDI ARABIA Stuart Biddle dr. Jarduera Fisiko eta Osasuneko irakaslea Fisikoki Aktibo diren Bizi-estiloen Ikerketa Taldea Osasun Ikerketa Zentroa Eskualde Erresilienteetako Institutua Queensland Hegoaldeko Unibertsitatea Springfield Central AUSTRALIA Katja Borodulin dr. Zahartzaro Institutua Helsinki FINLANDIA Matthew Buman dr. Osasun Soluzioetako Fakultatea Arizonako Unibertsitate Estatala Phoenix AEB Greet Cardon dr. Mugimendu eta Kirol Zientzietako Saila Medikuntzako eta Osasun Zientzietako Fakultatea Ganteko Unibertsitatea Gante BELGIKA Catherine Carty and. Proiektu-kudeatzailea UNESCO katedra Tralee Teknologiako Institutua Co Kerry IRLANDA Jean-Philippe Chaput dr. Zientzialari seniorra, Bizitza Aktibo Osasungarria eta Obesitatea (HALO) Ikerketa Taldea Children's Hospital of Eastern Ontario-ko (CHEO) Ikerketa Institutua Pediatria Saila Ottawako Unibertsitatea Ottawa, Ontario KANADA Sebastien Chastin dr. Osasun Portaeraren Dinamikako irakaslea Osasun eta Bizitza Zientzietako Fakultatea Psikologia, Gizarte Lana eta Loturiko Osasun Zientzia Saila Glasgow Caledonian Unibertsitatea Glasgow ERRESUMA BATUA Roger Chou dr. (GRADE metodologoa) Medikuntzako, Informatika Medikoko eta Epidemiologiako Sailak Oregoneko Osasun eta Zientzietako Unibertsitatea Portland, Oregon AEB Paddy Dempsey dr. MRCko Epidemiologia Unitatea Medikuntza Klinikoko Eskola, Cambridgeko Unibertsitatea Cambridge ERRESUMA BATUA O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z 89 2. eranskina Loretta DiPietro dr. Ariketa eta Nutrizioko Zientziak Saila Osasun Publikoko Fakultatea, Milken Institutua George Washington Unibertsitatea Washington, DC AEB Ulf Ekelund dr. Kirol Medikuntza Saila Norvegiako Kirol Zientzietako Eskola Oslo NORVEGIA Joseph Firth dr. Presidenteordea Osasun Zientzietako Eskola Manchesterreko Unibertsitatea Manchester ERRESUMA BATUA Christine Friedenreich dr. Zuzendari zientifikoa Minbiziaren Epidemiologia eta Prebentzioko Ikerketa Saila Alberta Minbiziaren Kontrola Alberta Osasun Zerbitzuak Calgary KANADA Leandro Garcia dr. Ikertzaile kidea Osasun Publikoko Zentroa Queen's University Belfast Belfast ERRESUMA BATUA Muthoni Gichu dr. Zuzendaria Medikuntza Geriatrikoko Unitatea Gaixotasun Ez Kutsakorren Saila, Osasun Ministerioa Nairobi KENIA Russell Jago dr. Jarduera Fisiko Pediatriko eta Osasun Publikoko irakaslea Ariketa, Nutrizio eta Osasun Zientzietako Zentroa Politika Azterlanetako Eskola Bristoleko Unibertsitatea Bristol ERRESUMA BATUA Peter T. Katzmarzyk dr. Zuzendari Exekutibo kidea Populazio eta Osasun Publikoetako Zientziak Irakaslea eta Marie Edana Corcoran Obesitate eta Diabetes Pediatrikoetako katedraduna Pennington Ikerketa Biomedikoko Zentroa Baton Rouge AEB Estelle V. Lambert dr. Zuzendaria Osasun Ikerketa Zentroa Jarduera Fisikoaren, Bizi-estiloaren eta Kirolaren bidez Cape Towneko Unibertsitatea Cape Town HEGO AFRIKA Michael Leitzmann dr. Epidemiologiako irakaslea Epidemiologia eta Prebentzio Medikuntza Saila Regensburgeko Unibertsitatea Regensburg ALEMANIA Karen Milton dr. Osasun Publikoko irakasle elkartua Norwicheko Medikuntza Eskola Anglia ekialdeko Unibertsitatea Norwich ERRESUMA BATUA Francisco B. Ortega dr. Zuzendaria Jarduera Fisikoa eta Osasunaren Sustapena Unitatea Kirol eta Osasun Ikerketako Institutua (iMUDS) Gorputz Hezkuntza eta Kirolak Saila Granadako Unibertsitatea Granada ESPAINIA Chathuranga Ranasinghe dr. Presidentea NIROGI Lanka proiektua Sri Lankako Medikuntza Elkartea Irakasle titularra Kirol eta Ariketako Medikuntza Unitatea Medikuntzako Fakultatea C Colomboko Unibertsitatea Colombo SRI LANKA Emmanuel Stamatakis dr. Charles Perkins Zentroa Medikuntza eta Osasun Fakultatea, Osasun Publikoko Eskola Sydneyko Unibertsitatea Sydney AUSTRALIA Anne Tiedemann dr. Irakasle elkartua Osasun Muskuloeskeletikoko Institutua, Osasun Publikoko Eskola Medikuntza eta Osasun Fakultatea Sydneyko Unibertsitatea Sydney AUSTRALIA Richard Troiano dr. Epidemiologia eta Genomikak Ikerketa Programa Minbiziaren Institutu Nazionala Osasun Institutu Nazionala Rockville AEB Hidde van der Ploeg dr. Irakasle elkartua Osasun Publikoa eta Lanekoa Saila Amsterdameko Osasun Publikoko Ikerketa Institutua Amsterdameko Unibertsitateko Medikuntza Zentroak Amsterdam HERBEHEREAK Vicky Wari and.* Programa Kudeatzailea, NCD Osasun Sail Nazionala Port Moresby PAPUA GINEA BERRIA Kanpoko berrikuspen-taldea Kingsley Akinroye dr. Nigeriako GET Aliantza NIGERIA Huda Alsiyabi dr. Zuzendaria Ekimen Komunitarioak Saila Osasun Ministerioa OMAN Alberto Flórez-Pregonero dr. Pontificia Universidad Javeriana KOLONBIA Shigeru Inoue dr. Prebentzio Medikuntza eta Osasun Publikoa Saila Tokioko Medikuntza Unibertsitatea JAPONIA Agus Mahendra dr. Gorputz Hezkuntza Saila Universitas Pendidikan INDONESIA Deborah Salvo dr. Prebentziorako Ikerketa Zentroa St. Louisen Brown School Washingtoneko Unibertsitatea AEB Jasper Schipperijn dr. Presidente hautatua 2020-2022 Jarduera Fisikoko eta Osasuneko Nazioarteko Elkartea Kirol Zientziak eta Biomekanika Klinikoa Saila Hego Danimarkako Unibertsitatea DANIMARKA 90 * bertaratu ezin izana O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z 91 2. eranskina OMEko zuzendaritza-taldea Valentina Baltag dr. Zuzendaria Nerabeen eta Heldu Gazteen Osasuna, Amen, Jaioberrien, Haurren eta Nerabeen Osasuna eta Zahartzea Saila OMEren egoitza Geneva SUITZA Maurice Bucagu dr. Medikuntzako Zuzendaria Amen Osasuna Nerabeen eta Heldu Gazteen Osasuna Amen, Jaioberrien, Haurren eta Nerabeen Osasuna eta Zahartzea Saila OMEren egoitza Geneva SUITZA Alexander Buchart dr. Zuzendaria Indarkeriaren Prebentzioa Osasuneko Determinatzaile Sozialak Saila OMEren egoitza Geneva SUITZA Fiona Bull dr. Zuzendaria Jarduera Fisikoa Osasunaren Sustapena Saila OMEren egoitza Geneva SUITZA Regina Guthold dr. Zientzialaria Nerabeen eta Heldu Gazteen Osasuna Amen, Jaioberrien, Haurren eta Nerabeen Osasuna eta Zahartzea Saila OMEren egoitza Geneva SUITZA Riitta-Maija Hämäläinen dr. Zuzendari Teknikoa Gaixotasun Ez Kutsakorren eta Osasunaren Sustapena OMEren eskualde-bulegoa Pazifikoko mendebaldea Manila FILIPINAK Andre Ilbawi dr. Zuzendari Teknikoa Gaixotasun Ez Kutsakorren Saila OMEren egoitza Geneva SUITZA Wasiq Khan dr.* Eskualde Aholkularia Osasun Hezkuntza eta Sustapena OMEren eskualde-bulegoa Mediterraneoko ekialdea Kairo EGIPTO Lindsay Lee and. Zuzendari Teknikoa Zentzumen Funtzioak, Desgaitasuna eta Errehabilitazioa Gaixotasun Ez Kutsakorren Saila OMEren egoitza Geneva SUITZA Alana Officer and. Osasun Aholkulari seniorra Zahartze Osasungarria Zuzendari Nagusiaren Bulegoa OMEren egoitza Geneva SUITZA Leanne Riley and. Zuzendaria Gaixotasun Ez Kutsakorren Zaintza Saila OMEren egoitza Geneva SUITZA Gojka Roglic dr. Medikuntzako Zuzendaria Gaixotasun Ez Kutsakorren Kudeaketa Gaixotasun Ez Kutsakorren Saila OMEren egoitza Geneva SUITZA Juana Willumsen dr. Zuzendari Teknikoa Jarduera Fisikoa Osasunaren Sustapena Saila OMEren egoitza Geneva SUITZA * bertaratu ezin izana 3. ERANSKINA: INTERES-ADIERAZPENEN LABURPENA ETA KUDEATZEKO MODUA Gidalerroak garatzeko taldeko kideak Izena Generoa Arloa Interes adierazpena Interes gatazka eta kudeaketa Salih Saad Al-Ansari dr. Gizon Osasun-hezkuntzaren eta -sustapenaren defentsa, jarduera fisikoa eginez eta ibiliz NCDei aurre egiteko Osasuna Sustatzeko Zentroaren jabe eta zuzendari exekutibo nagusia Ez da interes gatazkarik identifikatu Stuart Biddle dr. Gizon Jarduera fisikoa gazteetan Ikerketa-funtsak eta aholkularitza ordaindua Ez da interes gatazkarik identifikatu Katja Borodulin dr. Emakume Jarduera fisikoa haurdunaldian Enplegua Osasun e t a Ongizate Institutu Nazionalean eta Zahartzaroko Institutua; ikerketa-funtsak Ez da interes gatazkarik identifikatu Matthew Buman dr. Gizon Loa eta jarduera fisikoa gaixotasun kronikoak dituzten pertsonetan Ez da ezer adierazi Ez da interes gatazkarik identifikatu Greet Cardon dr. Emakume Jarduera fisikoa gazteetan Ez da ezer adierazi Ez da interes gatazkarik identifikatu Catherine Carty and. Emakume Jarduera fisikoa desgaitasuna duten pertsonetan Ikerketa-funtsak Ez da interes gatazkarik identifikatu Jean-Philippe Chaput dr. Gizon Loa Ez da ezer adierazi Ez da interes gatazkarik identifikatu Sebastien Chastin dr. Gizon Jarduera fisikoa eta osasuna, jarduera fisikoaren neurketa objektiboa Ikerketa-funtsak Ez da interes gatazkarik identifikatu Paddy Dempsey dr. Gizon Jarduera fisikoa eta sedentarismoa helduetan eta gaixotasun kronikoak dituzten pertsonetan Enplegua eta Ikerketa-funtsak Ez da interes gatazkarik identifikatu Loretta DiPietro dr. Emakume Jarduera fisikoa adinekoetan Ez da ezer adierazi Ez da interes gatazkarik identifikatu Ulf Ekelund dr. Gizon Sedentarismoa eta jarduera fisikoa gazteetan Ez da ezer adierazi Ez da interes gatazkarik identifikatu Joseph Firth dr. Gizon Jarduera fisikoa eta osasun mentala Ez da ezer adierazi Ez da interes gatazkarik identifikatu Christine Friedenreich dr. Emakume Jarduera fisikoa gaixotasun kronikoak dituzten pertsonetan, jarduera fisikoa eta minbizi- arriskua Ez da ezer adierazi Ez da interes gatazkarik identifikatu Leandro Garcia dr. Gizon Jarduera fisikoa eta osasun mentala Enplegua eta aholkularitza ordaindua Ez da interes gatazkarik identifikatu Muthoni Gichu dr. Emakume Politiken ezarpena (gobernu nazionala Ez da ezer adierazi Ez da interes gatazkarik identifikatu Russ Jago dr. Gizon Jarduera fisikoa gazteetan Ez da ezer adierazi Ez da interes gatazkarik identifikatu 92 O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z 93 2. eranskina Izena Generoa Arloa Interes adierazpena Interes gatazka eta kudeaketa Peter Katzmarzyk dr. Gizon Jarduera fisikoa eta sedentarismoa gazteetan Bidaia-laguntza gidalerroen batzordeetara joateko Ez da interes gatazkarik identifikatu Estelle V. Lambert dr. Emakume Jarduera fisikoa eta obesitatea Ez da ezer adierazi Ez da interes gatazkarik identifikatu Michael Leitzmann dr. Gizon Sedentarismoa eta gaixotasun kronikoak Ez da ezer adierazi Ez da interes gatazkarik identifikatu Karen Milton dr. Emakume Gomendioak praktikara eramatea Bidaia-laguntza gidalerroen batzordera joateko Ez da interes gatazkarik identifikatu Francisco Ortega dr. Gizon Jarduera fisikoa gazteetan, osasun mentala eta neurketa objektiboa Ez da ezer adierazi Ez da interes gatazkarik identifikatu Chathuranga Ranasinghe dr. Emakume Jarduera fisikoa eta osasuna sustatzea komunitatean, lantokian eta eskolan Ikerketa-funtsak Ez da interes gatazkarik identifikatu Emmanuel Stamatakis dr Gizon Jarduera fisikoa eta osasun-emaitza anitzak helduetan Diru-laguntza teknologia- enpresari, jarduera fisikoaren neurketa objektiborako Ez da interes gatazkarik identifikatu Anne Tiedemann dr. Emakume Jarduera fisikoa eta osasun-emaitzak adinekoetan Ez da ezer adierazi Ez da interes gatazkarik identifikatu Richard Troiano dr. Gizon Politiken garapena Ez da ezer adierazi Ez da interes gatazkarik identifikatu Hidde van der Ploeg dr. Gizon Jarduera fisikoa, sedentarismoa eta osasun-emaitzak helduetan Bidaia-laguntza 2017ko Holandako Jarduera Fisikorako Gidalerroen batzordera joateko; ikerketa-funtsak Ez da interes gatazkarik identifikatu Vicky Wari and. Emakume Politiken ezarpena (gobernu nazionala) Akzioak (garrantzirik gabeak gidalerroetarako) Ez da interes gatazkarik identifikatu Kidekoen kanpoko berrikusleak Izena Generoa Arloa Interes adierazpena Interes gatazka eta kudeaketa Kingsley Akinroye Gizon Defentsa, gaixotasun ez kutsakorrak Ez da ezer adierazi Ez da interes gatazkarik identifikatu Huda Alsiyabi dr. Emakume Politiken eta programen ezarpena Ez da ezer adierazi Ez da interes gatazkarik identifikatu Alberto Flórez- Pregonero dr. Gizon Jarduera fisikoa eta sedentarismoaren neurketa eta zaintza Ez da ezer adierazi Ez da interes gatazkarik identifikatu Shigeru Inoue dr. Gizon Epidemiologia eta jarduera fisikoaren sustapena Ez da ezer adierazi Ez da interes gatazkarik identifikatu Agus Mahendra dr. Gizon Jarduera fisikoa eta gaitasun motorrak haurretan Ez da ezer adierazi Ez da interes gatazkarik identifikatu Deborah Salvo dr. Emakume Desberdintasun sozio- sanitarioak, arreta berezia gaixotasun kronikoen prebentzioan Ez da ezer adierazi Ez da interes gatazkarik identifikatu Jasper Schipperijn dr. Gizon Jarduera fisikoa eta ingurune eraikia Presidente-Hautatua Jarduera Fisiko eta Osasuneko Nazioarteko Elkartean (ISPAH) Ez da interes gatazkarik identifikatu

OME-REN GIDALERROAK JARDUERA FISIKOARI ETA SEDENTARISMOARI BURUZ OME-REN GIDALERROAK JARDUERA FISIKOARI ETA SEDENTARISMOARI BURUZ ii OME-ren gidalerroak jarduera fisikoari eta sedentarismoari buruz. Vitoria-Gasteiz: Eusko Jaurlaritza, 2021. Zenbait eskubide erreserbatuta. Lan hau Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International lizentziapean dago eskuragarri (CC BY-NC-SA 4.0; https://creativecommons.org/licenses/by-nc-sa/4.0/) © Eusko Jaurlaritza. 2021 Osasunaren Mundu Erakundeak (OME) ez du itzulpen hau burutu. OMEk ez du inolako erantzukizunik izango itzulpen honen eduki edo zehaztasunari dagokienez. Ingelesezko jatorrizko testua (WHO guidelines on physical activity and sedentary behaviour) da benetako bertsio loteslea. Jatorrizkoaren lizentzia: CC BY-NC-SA 3.0 IGO. Iradokitzen den aipamena: OME-ren gidalerroak jarduera fisikoari eta sedentarismoari buruz. Vitoria-Gasteiz: Eusko Jaurlaritza, 2021. Lizentzia: CC BY-NC-SA 4.0 IGO. Itzulpena: BITEZ, S.L. Itzulpenaren zuzenketa: Mugiment idazkaritza teknikoa eta Eusko Jaurlaritzaren Jarduera Fisikoaren eta Kirolaren Zuzendaritza. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z iii Edukiak EDUKIAK Eskertza iv Laburdurak eta akronimoak v Terminoen glosarioa vi Laburpena 1 Testuingurua 15 Metodoak 18 Gomendioak 24 Haurrak eta nerabeak (5–17 urte) 25 Jarduera fisikorako gomendioa 25 Portaera sedentariorako gomendioa 29 Helduak (adina 18–64 urte) 32 Jarduera fisikorako gomendioa 32 Portaera sedentariorako gomendioa 38 Adinekoak (adina 65 urte eta gehiago) 43 Jarduera fisikorako gomendioa 43 Portaera sedentariorako gomendioa 46 Emakumeak haurdunaldian eta erditu ondoren 47 Jarduera fisikorako gomendioa 47 Portaera sedentariorako gomendioa 51 Helduak eta adinekoak gaixotasun kronikoekin (adina 18 urte eta gehiago) 52 Jarduera fisikorako gomendioa 52 Portaera sedentariorako gomendioa 58 Haurrak eta nerabeak (adina 5–17 urte) eta helduak (adina 18 urte eta gehiago) desgaitasunarekin 60 Jarduera fisikorako gomendioa 60 Portaera sedentariorako gomendioa 64 Ebidentziatik gomendioetara 66 Ebidentziaren ziurtasunaren ebaluazioa 66 Onurak eta kalteak 67 Balioak eta lehentasunak 67 Baliabideen inplikazioak 67 Ekitatea, onargarritasuna eta bideragarritasuna 68 Ikerketa-premiak 69 Gomendioak hartzea, hedatzea, ezartzea eta ebaluatzea 70 Gomendioak hartzea 70 Hedatzea 71 Komunikazio-kanpainak 71 Politikak eta programak ezartzea 72 Gomendioak zaintzea eta ebaluatzea 73 Eguneratzea 73 Erreferentziak 75 1. eranskina: Gidalerroen garapen-prozesuaren kudeaketa 85 2. eranskina: Gidalerroak garatzeko taldea, kidekoen kanpoko berrikusleak, eta gidalerro hauen garapenean parte hartu duten OMEko kideak 88 3. eranskina: Interes-adierazpenen laburpena eta kudeatzeko modua 92 Web-eranskina: Ebidentzia-profilak https://apps.who.int/iris/bitstream/handle/ 10665/336657/9789240015111-eng.pdf O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z ESKERTZA Osasunaren Mundu Erakundeak (OME) eskerrak eman nahi dizkie honako pertsona eta erakunde hauei dokumentu hau lantzen laguntzeagatik eta berengandik jasotako babesagatik: Fiona Bull eta Juana Willumsen izan ziren gidalerro hauek lantzeko prozesuaren zuzendari, eta OMEko Zuzendaritza Taldeko kide hauek kudeatu zuten prozesua: Valentina Baltag,Maurice Bucagu, Alex Butchart, Neerja Chowdhary, Regina Guthold, Riitta-Maija Hämäläinen, Andre Ilbawi, Wasiq Khan, Lindsay Lee, Alana Officer, Leanne Riley eta Gojka Roglic. Gidalerroak Lantzeko Taldea (GLT) osatu zuten kideak hauek izan ziren: Salih Saad Al-Ansari, Stuart Biddle, Katja Borodulin, Matthew Buman, Greet Cardon (zuzendarikidea), Catherine Carty, Jean-Philippe Chaput, Sebastien Chastin, Paddy Dempsey, Loretta DiPietro, Ulf Ekelund, Joseph Firth, Christine Friedenreich, Leandro Garcia, Muthoni Gichu, Russ Jago, Peter Katzmarzyk, Estelle V. Lambert, Michael Leitzmann, Karen Milton, Francisco B. Ortega, Chathuranga Ranasinghe, Emmanuel Stamatakis (zuzendarikidea), Anne Tiedemann, Richard Troiano, Hidde van der Ploeg, Vicky Wari. Roger Chou izan zen GRADE metodologiaren arduraduna. Kanpoko berrikuspen-taldea hauek osatu zuten: Kingsley Akinroye, Huda Alsiyabi, Alberto Flórez-Pregonero, Shigeru Inoue, Agus Mahendra, Deborah Salvo eta Jasper Schipperijn. 2018ko AEBetako Jarduera Fisikorako Gidalerroen Aholkularitza BatzordearenTxosten Zientifikoa Osasun eta Giza Zerbitzuetako Idazkaritzari txostenerako prestatu zen ebidentziaren berrikuspen sistematikoak eguneratu egin ziren Kyle Sprowek (Minbiziaren Institutu Nazionalak, Osasunaren Institutu Nazionalak, Maryland, AEB) egindako bilaketa bibliografiko gehigarriei esker. Identifikatutako artikuluen berrikuspen- lanean honako hauek ere lagundu zuten: Elif Eroglu (Sydneyko Unibertsitatea), Andrea Hillreiner (Regensburgeko Unibertsitatea), Bo-Huei Huang (Sydneyko Unibertsitatea), Carmen Jochem (Regensburgeko Unibertsitatea), Jairo H. Migueles (Granadako Unibertsitatea), Chelsea Stone (Calgaryko Unibertsitatea) eta Léonie Uijtdewilligen (Amsterdam UMC). Ebidentziaren laburbilketak eta GRADE taulak Carrie Patnodek eta Michelle Henningerrek prestatu zituzten (Kaiser Fundazioaren Ospitaleak, Osasun Ikerketarako Zentroa, Portland, Oregon, AEB). Bestalde, ondokoek gidatu zituzten ebidentziaren berrikuspen gehigarriak: N Fairhall, J Oliveira, M Pinheiro, eta C Sherrington (Osasun Muskulueskeletikoko Institutua, Osasun Publikoko Eskola, Sydneyko Unibertsitatea, Sydney, Australia) eta A Bauman (Prebentzioaren Ikerketarako Kolaborazioa, Osasun Publikoko Eskola, Sydneyko Unibertsitatea, Sydney, Australia; eta OMEren Zentro Kolaboratzailea Jarduera Fisikoaren, Nutrizioren eta Obesitatearen arloetan); S Mabweazara, M-J Laguette, K Larmuth, F Odunitan- Wayas (Osasunari buruzko Ikerketa Zentroa, Jarduera Fisikoaren, Bizi-estiloaren eta Kirol Medikuntzaren bidez, Osasun Zientzietako Fakultatea, Cape Town-eko Unibertsitatea, Cape Town, Hego Afrika), L Leach, S Onagbiye (Kiroleko, Aisialdiko eta Ariketa Zientziako Saila, Osasun Zientzietako Fakultatea, Western Cape-ko Unibertsitatea, Cape Town, Hego Africa), M Mthethwa (Gaixotasun Kronikoetarako Ekimena Afrikan, Cape Town-eko Unibertsitatea, Cape Town, Hego Africa), P Smith (Desmond Tutu GIB Zentroa, Gaixotasun Infekziosoetako eta Medikuntza Molekularreko Institutua, Osasun Zientzietako Fakultatea, Cape Town-eko Unibertsitatea, Cape Town, Hego Africa) eta F Mashili (Fisiologiako Saila, Muhimbili-ko Osasuneko eta Loturiko Zientzietako Unibertsitatea, Dar Es Salaam, Tanzaniako Errepublika BAtua); B Cillekens, M Lang, W van Mechelen, E Verhagen, M Huysmans, A van der Beek, P Coenen (Osasun Publiko eta Laneko Osasuneko Saila, Amsterdameko Unibertsitatearen Medikuntza Zentroa, Amsterdam, Herbehereak). Kanadako Osasun Publikoko Erakundeak eta Norvegiako Gobernuak emandako babes finantzarioari esker gauzatu ahal izan da lan hau. iv Laburdurak eta akronimoak v LABURDURAK ETA AKRONIMOAK ADHN arreta-defizitaren eta hiperaktibitatearen nahasmendua AOR momio-ratio egokitua BMI gorputz-masaren indizea CI konfiantza-tartea CVD gaixotasun kardiobaskularrak DBP tentsio arterial diastolikoa EtD Ebidentziatik Erabakietara GDG Gidalerroak Garatzeko Taldea GRADE Gomendioak Baliozkotzeko, Garatzeko eta Ebaluatzeko Kalifikazioa HR arrisku-zatidura MET Jardueraren Baliokide Metabolikoa MD batez besteko diferentzia MICT intentsitate ertaineko entrenamendu jarraitua NCD gaixotasun ez kutsakorra OR momio-ratioa PA jarduera fisikoa PAGAC Estatu Batuetako Jarduera Fisikorako Gidalerroen Aholkularitza Batzordea PI/ECO Populazioa, Interbentzioa/Esposioa, Konparazioa, Emaitza RaR arrisku erlatibo egozgarria RCT proba kontrolatu aleatorizatua RR arrisku erlatiboa SBP presio arterial sistolikoa SMD batez besteko diferentzia estandarizatua SPPB errendimendu fisikoaren bateria laburra TB telebista WHA Osasunaren Mundu Batzarra WHO Osasunaren Mundu Erakundea vi TERMINOEN GLOSARIOA Terminoa Definizioa Jarduera fisiko aerobikoa Gorputzaren muskulu handiak erritmikoki mugitzen diren jarduera denbora-tarte iraunkor batean. Jarduera aerobikoak –erresistentzia-jarduera ere deitua– hobetu egiten du bihotzaren eta arnas sistemaren gaitasuna. Adibideak: ibiltzea, korrika egitea, igeri egitea, bizikletan ibiltzea. Jarduera fisiko anaerobikoa Jarduera fisiko anaerobikoa, oldarrez eta denbora-tarte laburretan egiten den ariketa da, besteak beste, pisu- jasotzea eta esprintak, non oxigeno-eskariak gainditu egiten duen oxigeno-hornidura. Oreka-entrenamendua Ariketa estatikoak eta dinamikoak, norberak estimulu ez-egonkorrek eragindako erronkei aurre egiteko duen gaitasuna hobetzeko diseinatuak, norbere mugimenduaren, ingurunearen, edo hainbat objekturen ondorioz. Gorputz-masaren indizea (GMI) Pisua (kg) / garaiera (m)2 GMI/adina edo GMI z- balioa GMI adinera egokitua, haurrentzat estandarizatua. GMI desbideratze-aldagai aldakorrak haurren adin eta sexuaren arabera egokitutako pisu erlatiboen neurriak dira. Haur baten adina, sexua, GMI, eta erreferentzia-estandar egoki bat kontuan hartuta, GMI z-balioa (edo bere baliokide GMI/adina pertzentila) zehaz daiteke. Hezurrak indartzeko jarduera Jarduera fisikoa, batez ere eskeleto-sistema osatzen duten hezur-gune espezifikoen indarra areagotzeko diseinatua. Hezurrak indartzeko jarduerek inpaktua edo indar-tentsioa sortzen dute hezurretan, hezurrak garatzeko eta indartzeko onuragarriak. Korrika egitea, soka-saltoa, eta pisu-jasotzea dira hezurrak indartzeko jardueren adibide batzuk. Gaitasun kardiometabolikoa Presio arterialaren, odoleko lipidoen, odoleko gluklosaren eta intsulinaren interakzioa osasunean. Bihotz eta arnas sistemaren gaitasuna (erresistentzia) Osasunarekin lotutako egoera fisikoaren osagai bat. Zirkulazio- eta arnas sistemek jarduera fisiko iraunkorrean oxigenoa emateko duten gaitasuna. Oro har, neurtu edo kalkulatutako oxigeno-kontsumo maximo gisa adierazten da (VO2 max.). Funtzio kognitiboa Garuneko jarduerak, hau da, informazioa eta ezagutza lortzera daramaten arrazoiketa, oroimena, arreta eta hizkuntza. Horrek ikaskuntza ere barne har dezake. Desgaitasuna Termino orokorra, Funtzionamenduaren, Desgaitasunaren eta Osasunaren Nazioarteko Sailkapenetik, urritasunetarako, jarduera-mugetarako eta parte hartzeko murrizketetarako, gizabanako baten (gaixotasun batekin) eta haren testuinguruko faktoreen (inguruneko faktoreak eta faktore pertsonalak) arteko elkarreraginaren alderdi negatiboak adierazten dituena. Jarduera fisikoaren eremuak Jarduera fisikoaren mailak hainbat eremutan ebalua daitezke, hauetako batean edo gehiagotan: aisialdia, lanbidea, hezkuntza, etxea eta/edo garraioa. Ariketa Jarduera fisikoaren azpikategoria planifikatua, egituratua, errepikakorra, eta irmoa, helburua denean gaitasun fisikoaren osagai bat edo gehiago hobetzea edo mantentzea. “Ariketa” eta “entrenamendua ariketekin” maiz erabiltzen dira txandakatzeko moduan, eta batez ere gaitasun fisikoa, errendimendu fisikoa edo osasuna hobetzeko edo mantentzeko asmoz aisialdian egiten den jarduera fisikoa esan nahi du oro har . Exekuzio-funtzioa Besteak beste: oroimen funtzionala, malgutasun kognitiboa (pentsamendu malgua ere esaten zaio) eta kontrol inhibitorioa (autokontrola barne). Egoera fisiko ona Gorputzak lanean eta aisialdiko jardueretan modu egoki eta eraginkor batean funtzionatzeko duen gaitasuna; gaitasun fisikoa eta bihotz eta arnas sistemarena barne hartzen ditu, besteren artean. Malgutasuna Osasunarekin eta errendimenduarekin lotutako egoera fisikoaren osagai bat, artikulazio batean izan daitekeen mugimendu-tartea. Malgutasuna espezifikoa da artikulazio bakoitzean, eta zenbait aldagai espezifikoren mende dago, besteak beste, lotailuen eta tendoi espezifikoen tentsioa. Malgutasun-ariketek hobetu egiten dute artikulazio batek bere mugimen-maila osoan mugitzeko duen gaitasuna. Ariketa funtzionalak Gorputzaren beheko aldearen indarra, oreka eta errendimendu motorra hobetzeko eguneroko zereginetan sar daitezkeen ariketak. Adibideak: tandem-jarrera, bi edo hanka baten gainean zutik, kukubilko-jarrera, aulki-ariketak, behatzak altxatzea eta oztopoen gainetik ibiltzea. Jarduera fisikoa etxe- eremuan Etxeko zereginetan egiten den jarduera fisikoa (garbiketa, ume-zaintza, lorezaintza…). Jarduera fisikoa aisia- eremuan Norberak egiten duen jarduera fisikoa, eguneroko bizitzan ezinbestekotzat jo gabe, bakoitzaren nahierara egina (kiroletan parte hartzea, sasoian egoteko ariketa edo entrenamenduak, eta ibiltzea, dantza egitea, loretzaintza…). O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z vii Terminoen glosarioa Terminoa Definizioa Intentsitate baxuko jarduera fisikoa Intentsitate baxuko jarduera fisikoa 1,5 eta 3 MET artekoa da, hau da, pertsonak pausagunean egiten duen energia-gastua halako 3 baino kostu energetiko txikiagoa duten jarduerak. Horren barruan sar daitezke poliki ibiltzea, bainatzea edo bihotz-maiztasuna edo arnas maiztasuna nabarmen handitzea eragiten ez duten beste jarduera batzuk. Muskulu-talde nagusiak Muskulu-talde nagusiak hankak, bizkarra, sabelaldea, bularra, sorbaldak eta besoak dira. Zereginaren baliokide metabolikoa (MET) Zereginaren baliokide metabolikoa, edo, besterik gabe, baliokide metabolikoa, jarduera fisikoen intentsitatea adierazten duen neurri fisiologiko bat da. MET bat pertsona batek eserita edo atseden hartzen dagoen bitartean gastatzen duen energia baliokidea da. Intentsitate ertaineko jarduera fisikoa Eskala absolutu batean, intentsitate ertainak esan nahi du jarduera fisikoa egitean 3 aldiz eta 6 alditik behera dela atsedenaren intentsitatea. Norbanako baten gaitasunari buruzko eskala batean, intentsitate ertaineko jarduera fisikoa 5 edo 6koa izaten da 0 eta 10 bitarteko eskala batean. Muskuluak indartzeko jarduera Muskulu eskeletikoaren indarra, potentzia, erresistentzia eta masa areagotzen duten jarduera fisikoa eta ariketa (adibidez, indar-entrenamendua, erresistentzia-entrenamendua edo muskuluen indar- eta erresistentzia-ariketak). Osagai anitzeko jarduera fisikoa Adinekoentzat, osagai anitzeko jarduera fisikoa garrantzitsua da funtzio fisikoa hobetzeko eta erorikoen ondorioz lesioak izateko arriskua murrizteko. Jarduera horiek etxean edo talde egituratu batean egin daitezke. Aztertutako interbentzio askok ariketa-mota guztiak konbinatzen dituzte saio batean (aerobikoa, muskuluen indartzea eta orekaren entrenamendua), eta hori eraginkorra dela frogatu da. Osagai anitzeko jarduera fisikoko programa baten adibide bat oinez ibiltzea (jarduera aerobikoa), pisuak altxatzea (muskuluak indartzea) eta oreka entrenatzea izan daitezke. Oreka entrenatzeko adibideetan sar daiteke atzeraka edo alboz ibiltzea edo oin baten gainean gelditzea gorputzaren goiko aldeko muskuluak indartzeko jarduera egiten den bitartean, hala nola bizeps-flexioak. Dantzak osagai aerobikoak eta orekazkoak ere lantzen ditu. Jarduera fisikoa lanbide-eremuan Ikus jarduera fisikoa lan-eremuan. Jarduera fisikoa Muskulu eskeletikoek eragindako edozein gorputz-mugimendu, energia-gastua eskatzen duena. Jarduera fisikoaren eza Jarduera fisikoaren egungo gomendioak betetzeko nahikoa ez den jarduera fisikoa. Gaitasun psikosoziala Osasunaren dimentsio mentala, emozionala eta soziala barne hartzen ditu. Pantaila aurreko aisialdiko denbora Pantailak (telebista, ordenagailua, gailu mugikorrak) begiratzen emandako denbora, hezkuntza/ikasketekin edo lanarekin zerikusia ez duten helburuekin. Pantailako denbora sedentarioa Pantailan entretenimendua ikusten emandako denbora (telebista, ordenagailua, gailu mugikorrak). Ez dira sartzen pantailan oinarritutako joko aktiboak, jarduera fisikoa edo mugimendua eskatzen dutenak. Sedentarismoa Eserita, erdi etzanda edo etzanda egon bitartean 1,5 METeko edo gutxiagoko energia-gastua duen edozein portaera esna gaudenean. Bulegoko zeregin gehienak, autoa gidatzea eta telebista ikustea, sedentarismoaren adibideak dira; zutik egon ezin duten pertsonak ere hartzen dira barnean, gurpil-aulkien erabiltzaileak, esaterako. Gidalerroek, sedentarismoaren definizioan, autoinformatutako mugimendu-maila baxua sartzen dute, eserita (aisialdian, lanean eta guztira), telebista ikusten (denbora TB edo pantaila aurrean) eta mugimendua edo jarrera ebaluatzen duten gailuen bidez neurtutako maila baxuak ere. Kirola Kirolak arau zehatzei jarraituta eta aisialdiaren edo lehiaketaren parte gisa egindako jarduera-sorta bat hartzen du barnean. Kirol-jardueretan sartzen da taldeek edo norbanakoek egindako jarduera fisikoa, eta esparru instituzional baten babesa izan dezakete, kirol-elkarte batena, adibidez. Jarduera fisikoa garraio-eremuan Lekualdatzeko egiten den jarduera fisikoa, oinez, bizikletan edo gurpiletan (motordunak ez diren ibilgailuak gurpilekin, besteak beste, patineteak, patinak, eskuzko gurpil-aulkiak). Intentsitate biziko jarduera fisikoa Eskala absolutu batean, intentsitate bizia 6.0 MET edo gehiagotan egindako jarduera fisikoa da. Norbanakoaren gaitasunari buruzko eskala batean, intentsitate biziko jarduera fisikoa 7 edo 8 izan ohi da 0–10 eskalan. Jarduera fisikoa lan- eremuan Ordaindutako edo borondatezko lanean egindako jarduera fisikoa. viii LABURPENA OMEren Jarduera fisikoari eta sedentarismoari buruzko gidalerroek osasun publikoko gomendioak ematen dituzte, haur, nerabe, heldu eta adinekoentzako ebidentzietan oinarrituta, osasunerako onura garrantzitsuak eskaintzeko eta osasunerako arriskuak arintzeko behar den jarduera fisikoaren kopuruari buruz (maiztasuna, intentsitatea eta iraupena). Lehen aldiz, gomendioak ematen dira jokabide sedentarioaren eta osasun-emaitzen arteko loturei buruz, bai eta azpipopulazioentzat ere, hala nola emakume haurdunak eta erditze ondokoak, eta gaixotasun kronikoekin edo desgaitasunarekin bizi diren pertsonak. Osasun, hezkuntza, gazteria, kirol eta/edo gizarte- edo familia-ongizateko ministerioetan diru-sarrera altuak, ertainak eta baxuak dituzten herrialdeetan politikak diseinatzearen arduradunei zuzenduta daude gidalerroak; orientazio-dokumentuen bidez, jarduera fisikoa areagotzeko eta populazio- taldeetan sedentarismoa murrizteko plan nazionalak, azpieskualdekoak edo udaletakoak garatzeaz arduratzen diren gobernu-funtzionarioei; gobernuz kanpoko erakundeei, hezkuntza- sektoreari, sektore pribatuari, Ikertzaileei eta osasun-arretako profesionalei. Gidalerroak garatzeko OMEren gidaliburuaren arabera prestatu ziren gidalerroak. Emaitza kritiko eta garrantzitsuetarako ebidentzia-berrikuspen sistematikoak egin ziren, eta onurak eta kalteak, balioak, lehentasunak, bideragarritasuna eta onargarritasuna eta ekitaterako eta baliabideetarako inplikazioak kontuan hartu ondoren garatu ziren. Aurkeztutako osasun publikoko azken gomendioak 5 urtetik 65 urte edo gehiago dituzten populazio eta adin-talde guztientzat dira, sexua, kultura- aurrekariak edo maila sozioekonomikoa edozein izanik ere, eta garrantzitsuak dira gaitasun guztietako pertsonentzat. Baldintza mediko kronikoak eta/edo desgaituak dituztenek eta haurdun dauden eta erditu ondoren dauden emakumeek gomendioak betetzen saiatu behar dute, ahal den guztietan. Gidalerro hauek garatzeak hainbat gomendio ematen ditu, gobernuek beren politika nazionalen esparruetan har ditzaketen ebidentzietan oinarrituta, jarduera fisikoaren populazio-mailak handitzeko ikuspegi integralak bultzatzeko. Adopzio-prozesuaren barruan, kontuan hartu behar da gidalerroak testuinguruan kokatzeko beharra. Adopzioa, zabalkundea, komunikazio- kanpainak eta gidalerroen ezarpena bultzatzeko tresna praktikoek lagunduko diete gobernuei eta interesa duten alderdiei elkarrekin lan egiten, jarduera fisikoa areagotzeko eta jokabide sedentarioak murrizteko bizialdian zehar. Laguntza-baliabide horiek OMEren webgunean egongo dira eskuragarri, gidalerroak argitaratu ondoren. Jarduera fisikoa eta jokabide sedentarioak bizitza osoko osasun-emaitzekin lotzen dituzten laguntza- datu asko egon arren, ebidentzian hutsune handiak daude oraindik. Bereziki, diru-sarrera txikiko eta ertaineko herrialdeen eta ekonomikoki ahulak diren edo arretarik ez duten komunitateen ebidentzia txikiagoa dago, eta azpipopulazioen proba gutxi daude, desgaitasunak dituzten pertsonak barne. Ikerketa gehiagotan inbertitu behar da ebidentzia sortzeko, bereziki arlo horietan. Gainera, gomendio horietan egindako aldaketek zenbait ondorio izango dituzte gaur egun jarduera fisikoaren maila nazionalak monitorizatzeko erabiltzen diren zaintza- sistemetan eta ebaluazio-tresnetan. Dauden tresna nazionalak eta mundukoak berrikusi behar dira, eta txostenak aurkezteko protokoloak eguneratu, etorkizuneko txostenen aurkezpena gidalerro berrien arabera oinarritzeko. 2018-2030 aldirako jarduera fisikoari buruzko munduko ekintza-planak jarduera fisikorik eza % 15 murrizteko helburua ezarri zuen 2030erako, eta gomendatutako politikako 20 ekintza eta esku- hartze deskribatu zituen. Gidalerro horiek herrialde guztiei laguntzen diete GAPPAren gomendioak inplementatzen eta “ACTIVE” tresna-sorta teknikoa ezartzen, bizialdian zehar eta hainbat ingurunetan jarduera fisikoa sustatzeko orientazioa ematen duena. O M E re n gi da le rr oa k ja rd ue ra fi si ko ar i e ta s ed en ta ris m oa ri bu ru z HAURRAK ETA NERABEAK (adina 5–17 urte) Haur eta nerabeetan, jarduera fisikoak onurak dakartza osasun-emaitza hauetarako: hobekuntza osasun fisikoan (bihotz eta arnas sistemaren eta muskuluen gaitasuna), osasun kardiometabolikoan (presio arteriala, dislipidemia, glukosa eta intsulinarekiko erresistentzia), hezurren osasunean, emaitza kongitiboetan (errendimendu akademikoa, exekuzio-funtzioa), osasun mentalean (depresio-sintoma murriztuak); eta adipositate murriztua. Hau gomendatzen da: Haur eta nerabeek, batez beste astean 60 minutu gutxienez egin behar dute jarduera fisikoa ‒ intentsitate ertainetik bizira‒, aerobikoa batez ere. Gomendio sendoa, ziurtasun ertaineko ebidentzia Intentsitate biziko jarduera aerobikoak, baita muskuluak eta hezurrak indartzekoak ere, astean gutxienez 3 egunetan egin behar dira. Gomendio sendoa, ziurtasun ertaineko ebidentzia Haurren eta nerabeen sedentarismo maila altuak harremana du osasun ondorio hauekin: adipositate handiagoa; osasun kardiometaboliko, gaitasun fisiko, portaera/jokabide prosozial urriagoak; eta loaldia murriztea. Hau gomendatzen da: Haurrek eta nerabeek mugatu egin behar dute sedentario izaten emandako denbora, batez ere pantaila aurreko aisialdiarekin. Gomendio sendoa, ziurtasun baxuko ebidentzia Gutxienez 60 minutu egunean J A R D U N B ID E E G O K IA K S T A T E M E N T S Gutxienez 3 egun astean 2 e c glan a at : vi ou r beha y sedentar d an y tiv it c a sical y p h o n es G ui de lin 2 Site-specific cancers of: bladder, breast, colon, endometrial, oesophageal adenocarcinoma, gastric, and renal. In adults, physical activity confers benefits for the following health outcomes: improved all-cause mortality, cardiovascula disease mortality, incident hypertension, incident site-specifi cancers,2 incident type-2 diabetes, mental health (reduced sy of anxiety and depression); cognitive health, and sleep; meas of adiposity may also improve. Hel etan, jarduer fisikoak onu ak dakartza osasun-emaitza hauetarako: gutxitu egiten ditu kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eragindakoa, hipertentsioaren, minbizi espezifikoen , II motako diabetesaren intzidentzia; eta hobetu egiten ditu osasun mentala (antsietate- eta depresio- sintoma gutxiago), osasun kognitiboa eta loa; adipositate-mailak ere hobe ditzake. Hau gomendatzen da: Heldu guztiek erregulartasunez egin behar dute jarduera fisikoa. Gomendio sendoa, ziurtasun ertaineko ebidentzia Helduek intentsitate ertaineko jarduera fisiko aerobikoa egin behar dute, gutxienez 150-300 minutu; edo intentsitate biziko jarduera fisiko aerobikoa, gutxienez 75-150 minutu; edo astean zehar intentsitate ertain eta biziko jardueren konbinazio baliokide bat, osasunerako onura handiak lortzeko. Gomendio sendoa,ziurtasun ertaineko ebidentzia Helduek muskuluak indartzeko jarduerak egin behar dituzte ‒ intentsitate ertaina edo handiagoa‒ astean 2 egunetan edo gehiagotan, muskulu-talde nagusi guztiak landu eta osasun-onura gehigarriak ematen baitituzte. Gomendio sendoa, ziurtasun ertaineko ebidentzia 1 Minbizi espezifiko hauek: maskurikoa, bularr koa, kol nekoa, endometrioko , hestegorrikoa, gastrikoa eta giltzurrunekoa. Gutxienez Gutxienez O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Recommendations 5 Helduek intentsitate ertaineko jarduera fisiko aerobikoa 300 minututik gora egin dezakete; eta intentsitate biziko jarduera fisiko aerobikoa 150 minututik gora; edo astean zehar intentsitate ertain eta biziko jardueren konbinazio baliokide bat egin dezakete osasunerako onura gehigarriak lortzeko. Baldintzapeko gomendioa, ziurtasun ertaineko ebidentzia Helduetan, zenbat eta handiagoa sedentarismoa, orduan eta emaitza okerragoak osasunarentzat: handitu egiten da kausa guztiengatiko hilkortasuna, eta gaixotasun kardiobaskularrek eta minbiziak eragindakoa, baita gaixotasun kardiobaskularren, minbiziaren eta II motako diabetesaren intzidentzia ere. Hau gomendatzen da: Helduek mugatu egin behar dute sedentario izaten emandako denbora. Denbora sedentarioa edozein intentsitateko jarduera fisikoarekin ordezteak (intentsitatea baxua izanda ere) osasunerako onurak dakartza. Gomendio sendoa, ziurtasun ertaineko ebidentzia Helduek, sedentarismoaren maila handiek osasunean dituzten ondorio kaltegarriak murrizten laguntzeko, saiatu egin behar dute igotzen jarduera fisikorako gomendatzen diren mailak, intentsitate ertainekoak eta intentsitate bizikoak. Gomendio sendoa, ziurtasun ertaineko ebidentzia Laburpena J A R D U N B ID E E G O K IA K edo 150 minutu baino gehiago 6 4 ADINEKOAK (adina 65 urte eta gehiago) Adinekoetan, jarduera fisikoak onurak dakartza osasun-emaitza hauetarako: gutxitu egiten ditu kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eragindakoa, hipertentsioaren, minbizi espezifikoen, II motako diabetesaren intzidentzia; eta hobetu egiten ditu osasun mentala (antsietate-eta depresio-sintoma gutxiago), osasun kognitiboa eta loa; adipositate-mailak ere hobe ditzake. Adinekoetan, jarduera fisikoak lagundu egiten du prebenitzen erorikoak eta hezurren osasunaren eta gaitasun funtzionalaren narriadurari eta erorikoei lotutako lesioak. Hau gomendatzen da: Adineko guztiek erregulartasunez egin behar dute jarduera fisikoa. Gomendio sendoa, ziurtasun ertaineko ebidentzia Adinekoek intentsitate ertaineko 150-300 minutuko jarduera fisiko aerobikoa egin behar dute gutxienez; edo intentsitate biziko 75-150 minutuko jarduera fisiko aerobikoa; edo astean zehar intentsitate ertain eta biziko jardueren konbinazio baliokide bat, osasunerako onura esanguratsuak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Adinekoek muskuluak indartzeko jarduerak egin behar dituzte ‒ intentsitate ertaina edo handiagoa‒ astean 2 egunetan edo gehiagotan, muskulu-talde nagusi guztiak landu eta osasun-onura gehigarriak ematen baitituzte. Gomendio sendoa, ziurtasun ertaineko ebidentzia Adinekoek astero egindako jarduera fisikoak askotarikoa izan behar du, oreka funtzionala eta indar- entrenamendua batez ere, intentsitate ertain edo handiagokoa, astean 3 egun edo gehiagotan, gaitasun funtzionala hobetzeko eta erorikoak prebenitzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Gutxienez 150- 300 minutu Gutxienez 75- 300 minutu edo Adinekoek 300 minututik gora egin dezakete intentsitate ertaineko jarduera fisiko aerobikoa; edo 150 minututik gora intentsitate biziko jarduera fisiko aerobikoa; edo astean zehar intentsitate ertain eta biziko jardueren konbinazio baliokide bat egin dezakete, osasunerako onura gehigarriak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Adinekoetan, zenbat eta handiagoa sedentarismoa, orduan eta osasun-emaitza okerragoak: handitu egiten da kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eta minbiziak eragindakoa, baita gaixotasun kardiobaskularren, minbiziaren eta II motako diabetesaren intzidentzia ere. Hau gomendatzen da: Adinekoek mugatu egin behar dute sedentario izaten emandako denbora. Denbora sedentarioa edozein intentsitateko jarduera fisikoarekin ordezkatzeak (intentsitatea txikia izanda ere) osasunerako onurak dakartza. Gomendio sendoa, ziurtasun ertaineko ebidentzia Adinekoek, sedentarismoaren maila handiek osasunean dituzten ondorio kaltegarriak murrizten laguntzeko, saiatu egin behar dute igotzen jarduera fisikorako gomendatzen diren mailak, intentsitate ertain eta bizikoak. Gomendio sendoa, ziurtasun ertaineko ebidentzia J A R D U N B ID E E G O K IA K 300 minutu baino gehiago 150 minutu baino gehiago edo Laburpena 8 6 e c glan a at : vi ou r beha y sedentar d an y tiv it c a sical y p h o n es G ui de lin Emakumeek, haurdunaldian eta erditu ondoren, jarduera fisikoa egiteak onura hauek dakartza amaren eta fetuaren osasunerako: arriskua gutxitzen du aurre-eklanpsia, haurdunaldiko hipertentsioa, haurdunaldiko diabetesa, haurdunaldiko gainpisua izateko, konplikazioak erditzean, depresioa erditu ondoren, konplikazioak jaioberriarengan, eta eragin kaltegarriak jaiotza- pisuan; eta ez du fetu hila erditzeko arriskua handitzen. Emakume ororentzat, haurdunaldian eta erditu ondoren, kontraindikaziorik ezean, gomendatzen da: Jarduera fisikoa erregulartasunez egitea haurdunaldian eta erditu ondoren. Gomendio sendoa, ziurtasun ertaineko ebidentzia Astean zehar intentsitate ertaineko 150 minutuko jarduera fisiko aerobikoa egin, osasunerako funtsezko onurak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Askotariko jarduera aerobikoak eta muskuluak indartzekoak sartu. Luzaketa leunak gehitzea ere onuragarria izan daiteke. Gomendio sendoa, ziurtasun ertaineko ebidentzia Horrez gain: Haurdunaldiaren aurretik intentsitate biziko jarduera aerobikoak egiten zituzten edo fisikoki aktiboak ziren emakumeek jarduera horiekin jarrai dezakete haurdunaldian eta erditu ondorengo aldian. Gomendio sendoa, ziurtasun ertaineko ebidentzia O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z EMAKUMEAK HAURDUNALDIAN ETA ERDITU ONDOREN Gutxienez 150 minutu Recommendations 9 • Jarduera fisiko pixka bat egitea ezer ez egitea baino hobe da. Jarduera fisikoa egitean haurdun dauden emakumeentzako segurtasun-ohar gehigarriak: • Haurdun dauden eta erditu ondoren dauden emakumeek gomendioak betetzen ez badituzte, jarduera fisikoren bat egitea onuragarria izango da haien osasunerako. • Emakumeek, haurdunaldian eta erditu ondoren, gutxika hasi behar dute jarduera fisikoa egiten, eta denborarekin maiztasuna, intentsitatea eta iraupena pixkanaka handitu. • Zoru pelbikoko muskuluen entrenamendua egunero egin daiteke, inkontinentzia- arriskua murrizteko. • Saihestu jarduera fisikoa gehiegizko beroan, batez ere hezetasun handiarekin. • Hidratatuta eduki ura edaten jarduera fisikoaren aurretik, bitartean eta ondoren. • Saihestu kontaktu fisikoa dakarten jardueretan parte hartzea; erortzeko arrisku handia dakarte, edo oxigenazioa murriztu dezakete (altitude handiko jarduerak, normalean altitude handian bizi ez direnean). • Saihestu ahoz gorako jarduerak haurdunaldiaren lehen hiruhilekoaren ondoren. • Emakume haurdunek, atletismoko leihaketetan parte hartzeko edo gidalerro gomendatuen gainetik ariketa esanguratsua egiteko asmoa badute, osasun-arloko profesional batengana jo behar dute azter ditzan. • Haurdun dauden emakumeei osasun- arretako profesionalak jarduera eteteko edo mugatzeko ohartarazten dien arrisku-seinaleen berri eman behar die; arrisku-seinale horiek izanez gero, berehala kontsultatu behar die osasun-arretako profesional bati. • Erditu ondoren pixkanaka jarduera fisikora itzultzea, eta osasun-arloko profesional batekin kontsultatuta, zesarea bidez erdituz gero. Emakumeetan, haurdunaldian eta erditu ondoren, heldu guztietan bezala, jokabide sedentario handiagoa osasun txarreko emaitza hauekin lotzen da: kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eta minbiziak eragindakoa eta gaixotasun kardiobaskularren, minbiziaren eta II motako diabetesaren intzidentzia. MUGATU sedentario izaten emandako denbora ORDEZTU edozein intentsitateko jarduera fisikoarekin (intentsitate baxua barne). Hau gomendatzen da: Emakumeek, haurdunaldian eta erditu ondoren, mugatu egin behar dute sedentario izaten emandako denbora. Denbora sedentarioa edozein intentsitateko jarduera fisikoarekin ordezteak (intentsitate baxua barne) osasunerako onurak dakartza. Gomendio sendoa, ziurtasun baxuko ebidentzia Jarduera fisiko pixka bat egitea ezer ez egitea baino hobe da. J A R D U N B ID E E G O K IA K 8 e c glan a at : vi ou r beha y sedentar d an y tiv it c a sical y p h o n es G ui de lin 10 HELDUAK ETA ADINEKOAK GAIXOTASUN KRONIKOEKIN (adina 18 urte eta gehiago) Jarduera fisikoak gaixotasun kroniko hauek dituzten heldu eta adinekoen osasunerako onurak ekar ditzake: minbizitik bizirik irtendakoentzat – jarduera fisikoak hobetu egiten ditu kausa guztiengatiko hilkortasuna, minbizi espezifikoek eragindakoa eta minbizia errepikatzeko edo bigarren minbizi primarioa izateko arriskua; hipertentsioa dutenentzat – jarduera fisikoak hobetu egiten ditu gaixotasun kardiobaskularrengatiko hilkortasuna, gaixotasunen progresioa, funtzio fisikoa, osasunarekin lotutako bizi-kalitatea; II motako diabetesa dutenentzat – jarduera fisikoak murriztu egiten ditu gaixotasun kardiobaskularrengatiko hilkortasun-tasak, eta gaixotasun-progresioaren adierazleak; eta GIBa dutenentzat – jarduera fisikoak egoera fisikoa eta osasun mentala hobe ditzake (antsietate- eta depresio-sintomak murriztea), eta ez du eragin negatiborik gaixotasunaren progresioan (CD4 zenbaketa eta karga birala) edo gorputz-osaeran. Hau gomendatzen da: Aipatutako gaixotasun kronikoak dituzten heldu guztiek erregulartasunez egin behar dute jarduera fisikoa. Gomendio sendoa, ziurtasun ertaineko ebidentzia Gaixotasun kroniko horiek dituzten helduek intentsitate ertaineko jarduera fisiko aerobikoa egin behar dute gutxienez 150 -300 minutu; edo intentsitate biziko jarduera fisiko aerobikoa gutxienez 75-150 minutu; edo astean zehar intentsitate ertain eta biziko jardueren konbinazio baliokide bat, osasunerako onura nabarmenak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Gaixotasun kroniko horiek dituzten helduek eta adinekoek muskuluak indartzeko jarduerak egin behar dituzte ‒intentsitate ertaina edo handiagoa‒ astean 2 egun edo gehiagotan, muskulu-talde nagusi guztiak landu eta osasun-onura gehigarriak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Gaixotasun kroniko horiek dituzten adinekoek askotariko jarduera fisikoa egin behar dute, osagai anitzekoa, astean 3 egun edo gehiagotan, intentsitate ertain edo handiagoan, nagusiki oreka funtzionala eta indar- entrenamendua, gaitasun funtzionala indartzeko eta erorikoak prebenitzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Gutxienez 150- 300 minutu Gutxienez 75- 150 minutu edo 8 Recommendations 11 Kontraindikaziorik ezean, gaixotasun kroniko horiek dituzten helduek eta adinekoek intentsitate ertaineko jarduera fisiko aerobikoa 300 minututik gora egin dezakete; edo intentsitate biziko jarduera fisiko aerobikoa 150 minututik gora; edo astean zehar intentsitate ertain eta biziko jardueren konbinazio baliokide bat egin dezakete, osasunerako onura gehigarriak lortzeko. Baldintzapeko gomendioa, ziurtasun ertaineko ebidentzia • Aurreko gomendioak bete ezin dituztenean, gaixotasun kroniko horiek dituzten helduek beren gaitasunen arabera saiatu behar dute jarduera fisikoa egiten. • Gaixotasun kroniko horiek dituzten helduek jarduera fisikoa gutxika egiten hasi behar dute, eta denborarekin maiztasuna, intentsitatea eta iraupena pixkanaka handitu. • Gaixotasun kroniko horiek dituzten helduentzat komeni da jarduera fisikoko espezialista bati edo osasun-arloko profesional bati kontsultatzea, norbere premia indibidualak, trebetasunak, muga/konplikazio funtzionalak, hartzen dituzten medikamentuak eta tratamenduak kontuan hartuta, jarduera-mota eta -kantitate egokiei buruzko aholkularitza jasotzeko. • Ariketa egin aurreko baimen medikoa ez da beharrezkoa izaten kontraindikaziorik ez duten pertsonentzat, intentsitate arineko edo ertaineko jarduera fisiko bat hasi aurretik, ibilaldi azkar baten edo eguneroko bizitzaren eskakizunak gainditzen ez baditu. Helduetan, minbizitik irtendakoak eta hipertentsioa, II motako diabetesa eta GIBa duten pertsonak barne, sedentarismo handiagoa osasun-emaitza txar hauekin lotzen da: kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eta minbiziak eragindakoa, eta gaixotasun kardiobaskularren, minbiziaren eta II motako diabetesaren intzidentzia. Helduetan, minbizitik bizirik irtendakoei eta hipertentsioa, II motako diabetesa eta GIBa dutenei gomendatzen zaie: Gaixotasun kronikoak dituzten helduek eta adinekoek mugatu egin behar dute sedentario izaten emandako denbora. Denbora sedentarioa edozein intentsitateko jarduera fisikoarekin ordezteak (intentsitate baxua barne) osasunerako onurak dakartza. Gomendio sendoa, ziurtasun baxuko ebidentzia Sedentarismoaren maila handiek osasunean dituzten ondorio kaltegarriak murrizten laguntzeko, gaixotasun kronikoak dituzten heldu eta adinekoek saiatu egin behar dute maila gomendatuak gainditzen intentsitate ertainetik bizirako jarduera fisikoa egitean. Gomendio sendoa, ziurtasun baxuko ebidentzia J A R D U N B ID E E G O K IA K 300 minutu baino gehiago 150 minutu baino gehiago 12 0 e c glan a at : vi o ur beha y sedentar d an y tiv it c a sical y p h o n es g ui d eli n HO W HAURRAK ETA NERABEAK (adina 5–17 urte) DESGAITASUNAREKIN Jarduera fisikoak haurren eta nerabeen osasunerako dituen onura ugari, aurreko atalean adierazi bezala, desgaitasunen bat duten haur eta nerabeekin ere daude lotuta. Jarduera fisikoak desgaitasuna duten pertsonen osasun-emaitzetarako dituen onura gehigarriak honako hauek dira: hobetu egiten du kognizioa, funtzio kognitiboa narriatzen duten gaixotasunak edo nahasmenduak dituzten pertsonetan, arreta- defizitaren/hiperaktibitatearen nahasmendua (ADHN) barne; funtzio fisikoan hobekuntzak ekar ditzake desgaitasun intelektuala duten haurretan. Hau gomendatzen da: Desgaitasuna duten haur eta nerabeek egunero batez beste 60 minutu egin behar dute jarduera fisikoa astean zehar, intentsitate ertain eta handiagokoa, eta batez ere aerobikoa. Gomendio sendoa, ziurtasun ertaineko ebidentzia Intentsitate handiko jarduera aerobikoak, baita muskuluak eta hezurrak indartzen dituztenak ere, gutxienez astean 3 egunetan egin behar dira. Gomendio sendoa, ziurtasun ertaineko ebidentzia O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z 5 10 Recommendations 13 Haurren eta nerabeen sedentarismoa zenbat eta handiagoa, orduan eta txarragoak haien osasun-emaitzak: areagotu egiten da adipositatea; urritu egiten da bihotz eta arnas sistemaren gaitasuna, gaitasun fisikoa, portaera/jokabide prosoziala; eta murriztu egiten da loa. Hau gomendatzen da: Desgaitasuna duten haur eta nerabeek mugatu egin behar dute sedentario izaten emandako denbora, batez ere pantaila aurreko aisialdiko denbora. Gomendio sendoa, ziurtasun baxuko ebidentzia 1 J A R D U N B ID E E G O K IA K Has zaitez gutxika jarduera fisikoa egiten. 14 2 e c glan a at : vi ou r beha y sedentar d an y tiv it c a sical y p h o n es G ui de lin HELDUAK (adina 18 urte eta gehiago) DESGAITASUNAREKIN Aurreko atalean adierazi bezala, jarduera fisikoak helduen osasunean dituen onuretako asko desgaitasuna duten helduei dagozkie. Desgaitasuna duten pertsonen osasun-emaitzetarako jarduera fisikoak dituen onura gehigarriak honako hauek dira: esklerosi anizkoitza duten helduentzat – funtzio fisikoa hobetzea, baita osasunarekin lotutako bizi-kalitaterako gaitasun fisikoa, mentala eta soziala ere; bizkarrezur-muineko lesioa dutenentzat – hobetu egiten ditu ibiltzeko funtzioa, muskuluen indarra eta goiko gorputz-adarraren funtzioa; eta osasunarekin lotutako bizi-kalitatea; funtzio kognitiboa narriatzen duten gaixotasunak edo nahasmenduak dituztenentzat – funtzio fisiko eta kognizio hobea (Parkinsonen gaixotasuna duten eta istripu zerebrobaskularren aurrekariak dituzten pertsonetan); kognizioaren gaineko ondorio onuragarriak; eta bizi-kalitatea hobe dezake (eskizofrenia duten helduak); baita funtzio fisikoa (desgaitasun intelektuala duten helduetan) eta bizi-kalitatea ere (depresio klinikoa duten helduetan). Hau gomendatzen da: Desgaitasuna duten heldu guztiek erregulartasunez egin behar dute jarduera fisikoa. Gomendio sendoa, ziurtasun ertaineko ebidentzia Desgaitasuna duten helduek gutxienez intentsitate ertaineko 150-300 minutuko jarduera fisiko aerobikoa egin behar dute; edo intentsitate biziko jarduera fisiko aerobikoa, gutxienez 75-150 minutukoa; edo astean zehar intentsitate ertaineko eta biziko jardueren konbinazio baliokide bat, osasunerako onura nabarmenak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Desgaitasuna duten helduek ere muskuluak indartzeko jarduerak egin behar dituzte ‒intentsitate ertaina edo handiagoa‒ astean 2 egun edo gehiagotan, muskulu- talde nagusi guztiak landu eta osasun-onura gehigarriak ematen baitituzte. Gomendio sendoa, ziurtasun ertaineko ebidentzia edo konbinazio baliokide bat astean zehar O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Gutxienez 150- 300 minutu intentsitate ertaineko jarduera fisikoaerobikoa intentsitate biziko jarduera fisiko aerobikoa Gutxienez 75- 150 minutu edo 3 Gutxienez osagai anitzeko askotariko jarduera fisikoa, oreka funtzionala eta indar- entrenamendua nagusiki, intentsitate ertain edo handiagoan Astean egiten duten jarduera fisikoaren barruan, desgaitasuna duten adinekoek askotariko jarduera fisikoa egin behar dute, oreka funtzionala eta indar-entrenamendua batez ere, intentsitate ertain edo handiagoan, astean 3 egunetan edo gehiagotan, gaitasun funtzionala hobetzeko eta erorikoak prebenitzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Osasun-onura gehigarrietarako: Desgaitasuna duten helduek intentsitate ertaineko jarduera fisiko aerobikoa 300 minututik gora igo dezakete; eta intentsitate biziko jarduera fisiko aerobikoa 150 minututik gora; edo astean zehar intentsitate ertain eta biziko jardueraren konbinazio baliokide bat egin dezakete, osasun-onura gehigarriak lortzeko. intentsitate ertaineko jarduera fisiko aerobikoa intentsitate biziko jarduera fisiko aerobikoa Baldintzapeko gomendioa, ziurtasun ertaineko ebidentzia edo konbinazio bakoikide bat astean zehar • Jarduera fisiko pixka bat egitea ezer ez egitea baino hobe da. • Desgaitasuna duten helduek ez badituzte gomendio hauek betetzen, jarduera fisikoren bat egitea onuragarria izango da beren osasunarentzat. • Desgaitasun bat duten helduek gutxika hasi behar dute jarduera fisikoa egiten, eta denborarekin maiztasuna, intentsitatea eta iraupena pixkanaka handitu. • Ez dago arrisku esanguratsurik desgaitasuna duten helduek jarduera fisikoa egiten dutenean, baldin eta egokia bada norberaren unean-uneko jarduera-mailarako, osasun- egoerarako eta funtzio fisikorako; eta osasun-onurek arriskuak gainditzen dituzte. • Baliteke desgaitasuna duten helduek osasun-arloko profesional bati edo jarduera fisikoko eta desgaitasuneko espezialista bati kontsultatu behar izatea, haientzat egokia den jarduera-mota eta -maila zehazten laguntzeko. Helduetan, zenbat eta handiagoa sedentarismoa, orduan eta osasun-emaitza txarragoak, ondokoei lotuta: kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eta minbiziak eragindakoa; eta gaixotasun kardiobaskularren, minbiziaren eta II motako diabetesaren intzidentzia. Hau gomendatzen da: Desgaitasuna duten helduek mugatu egin behar dute sedentario izaten emandako denbora. Denbora sedentarioa edozein intentsitateko jarduera fisikoarekin ordezteak (intentsitate baxua barne) onurak dakartza osasunarentzat. Gomendio sendoa, ziurtasun baxuko ebidentzia Sedentarismoaren maila handiek osasunean dituzten ondorio kaltegarriak murrizten laguntzeko, desgaitasuna duten helduek saiatu egin behar dute intentsitate ertainetik bizirako jarduera fisikoaren maila gomendatuak igotzen. Gomendio sendoa, ziurtasun baxuko ebidentzia 13 J A R D U N B ID E E G O K IA K egun astean 300 minutu baino gehiago 150 minutu baino gehiago edo 14 O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z TESTUINGURUA Jakina da jarduera fisikoa erregulartasunez egiteak lagundu egiten duela gaixotasun ez- transmitigarriak prebenitzen eta tratatzen, besteak beste, gaixotasun kardiobaskularrak, II motako diabetesa, bularreko eta koloneko minbizia (1-3). Jarduera fisikoak osasun mentalerako ere baditu onurak (4), dementziaren agerpena atzeratzen du (5) eta lagungarria izan daiteke pisu osasungarriari eusteko (1) eta ongizate orokorrerako (6). Jarduera fisikoa honela definitzen da: muskulu eskeletikoek eragindako gorputz-mugimendu oro, energia-gastua eskatzen duena (1) eta hainbat intentsitatetan egin daitekeena, lan-jardunean, etxeko lanetan, garraiatzean edo aisialdian, edo ariketan edo kiroletan parte hartzean. Intentsitate- tartearen beheko muturrean, sedentarismoa honela definitzen da: esna gauden bitartean, eserita, erdi etzanda edo etzanda, energia-gastu gutxi eskatzen duen portaera oro (7). Agertzen ari den ebidentzia berriak adierazten du sedentarismoaren maila altuak gaixotasun kardiobaskularrekin eta II motako diabetesarekin lotuta daudela, baita hilkortasun kardiobaskularrarekin eta minbiziak eta kausa guztiek eragindakoarekin ere (8-10). Jarduera fisikoaren eza honela definitzen da: 2010eko Osasunerako jarduera fisikoari buruzko gomendio globalak (1) ez betetzea, eta munduko hilkortasunaren eragile nagusietako bat da. Kalkuluen arabera, urtean lau miliotik bostera arteko heriotza saihes daitezke munduko populazio aktiboagoa balitz (2, 11). Jarduera fisikorik ezaren inguruko kalkulu globalek adierazten dutenez, 2016an, helduen % 27,5ek (12) eta nerabeen % 81ek (13) ez zituzten bete OMEren 2010eko gomendioak (1), eta joeren datuek erakusten dute hobekuntza orokorra mugatua izan dela azken hamarkadan. Datuek nabarmentzen dute, halaber, emakumeak ez direla gizonak bezain aktiboak herrialde gehienetan, eta alde nabarmenak daudela jarduera fisikoaren mailetan herrialdeen eta eskualdeen artean. Desberdintasun horiek jarduera fisikoa egiteko aukeretan dauden desberdintasunen ondorioz azal daitezke, eta horrek are gehiago handitzen ditu osasun-arloko desberdintasunak. Gaur egun ez dago sedentarismoaren kalkulu globalik, baina, besteren artean, berrikuntza teknologikoa, trantsizio sedentarioagoa lanean eta aisialdian, eta motordun garraio pertsonalaren erabilera gero eta handiagoa mundu osoan ari dira jarduera fisikoaren ereduak aldatzen eta sedentarismoa areagotzen. Jarduera fisikoari buruzko ekintza-plan globalak 2018-2030 (14) 4 helburu estrategiko eta 20 politika-ekintza ezartzen ditu, 2030erako helduen eta nerabeen jarduera fisikorik ezaren prebalentzi globalean % 15eko murrizketa erlatiboa lortzeko. 2010ean OMEk Osasunerako jarduera fisikoari buruzko gomendio globalak (1) argitaratu zituen; populazion oinarritutako osasun publikoko lehen gidalerroak haurrentzat eta nerabeentzat, eta helduentzat eta adinekoentzat. 2018an, Osasunaren Mundu Batzarrak, WHA71.61 ebazpenean, 2010eko gomendioak eguneratzeko eskatu zion OMEri. 2019an OMEk 5 urtetik beherako haurrentzako jarduera fisikoari, sedentarismoari eta loari buruzko gidalerroak (15) argitaratu zituen. Haurren obesitateari azkena emateko (4.12 gomendioa) Batzordeak eskatu zituen (16) gidalerroak, eta 2010eko Osasunerako jarduera fisikoari buruzko gomendio globaletan (1) adin-talde gazteago horren omisioari heltzen diote. 2020ko OMEren Jarduera fisikoari eta sedentarismoari buruzko gidalerroek 2010ekoak ordezten dituzte, eta hautatutako portaeren ebidentzian eta osasunari lotutako ondorioetan izandako azkenaldiko aurrerapenetan oinarritzen dira. Jarduera fisikoari eta sedentarismoari buruzko gomendio globalen multzo orokorraren parte izango dira. 1 WHA71.6 OME Jarduera fisikoari buruzko ekintza-plan globala 2018–2030. Testuingurua 15 16 OME-REN FUNTSEZKO BESTE GIDALERRO BATZUK Jarduera fisikoak osasunerako duen garrantzia OMEren beste gidalerro batzuetan aitortzen da. OMEren Baliabide urriko inguruneetako lehen mailako osasun-arretarako gaixotasun ez kutsakorren funtsezko intebentzio-paketeak (17) protokolo bat ematen du hipertentsioaren, II motako diabetesaren, arrisku kardiobaskular handiaren, asmaren eta biriketako gaixotasun buxatzaile kronikoaren tratamendu klinikorako, eta gomendatu egiten du jarduera fisikoa pixkanaka maila ertainera (adibidez, bizkor ibiltzea) eta astean gutxienez 150 minutura handitzea. Narriadura kognitiboaren eta dementziaren arriskua murriztea (18) OMEren gida berriak ezartzen duenez, narriadura kognitiboaren arriskua murrizteko jarduera fisikoa gomendatu behar da hauentzat: kognizio normala duten helduak (gomendio sendoa) eta narriadura kognitibo arina dutenak (baldintzapeko gomendioa). OMEren Arreta integratua adinekoentzat: funtsezko gaitasun-murrizketak zuzentzeko komunitate-mailako interbentzioei buruzko gidalerroek (19) erorikoak prebenitzeko mota anitzeko ariketak gomendatzen dituzte mugikortasuna urritzen ari zaien adinekoentzat. OMEren Haurdunaldiaren esperientzia positiboa izateko jaiotza aurreko arretari buruz gomendioek (20) aholkularitza gomendatzen dute elikadura osasungarriari eta haurdunaldiko jarduera fisikoari buruz, osasuntsu mantentzeko eta pisua gehiegi ez handitzeko, baina ez diete heltzen haurdunaldian eta erditu ondoren jarduera fisikoak osasunerako dituen onura gehigarriei. OMEren gidalerroek, eguneratutako gidalerro hauekin batera, aholku osatuagoak ematen dituzte jarduera fisikoari eta sedentarismoari buruz, funtsezko gaixotasunak prebenitzen eta tratatzen, eta bizitzan zehar osasuna eta ongizatea sustatzen laguntzeko. OINARRIA ETA HELBURUA Azken 10 urteetan, jarduera fisikoaren mota, kantitate eta iraupen desberdinek osasunean duten eraginari buruzko ebidentzia-multzoak nabarmen gora egin duela ikusi da, baita sedentarismoaren eraginari eta jarduera fisikoaren eta osasunaren mailekin duen erlazioari buruz ere. Gainera, jarduera fisikorako ebidentzia-oinarriak azpipopulazioetan, hala nola haurdun dauden emakumeetan eta gaixotasun kronikoak eta/edo desgaitasuna dutenetan, orain aukera ematen du jarduera fisikoaren eta talde horietako osasun-emaitzen arteko lotura aztertzeko. Jarduera fisikoari buruzko ekintza-plan globalean 2018- 2030 (14), 4.1 ekintzak OMEri eskatzen dio egin eta zabal ditzala jarduera fisikoari eta sedentarismoari buruzko gomendio globalak 5 urtetik beherako haurrentzat, gazteentzat, helduentzat, adinekoentzat eta azpipopulazio espezifikoentzat (besteak beste, emakume haurdunak, gaixotasun kronikoak eta desgaitasuna duten pertsonak). Osasunaren Mundu Batzarrak eskatu bezala, gidalerroen irismena eguneratu eta zabaltzeak bermatu egiten du 2010eko gomendioetan sartzen ez diren populazio- taldeek jarduera fisikorako gomendio espezifikoak jasoko dituztela. Hori bat dator jarduera fisikoari buruzko ekintza-plan globalaren funtsezko printzipio eta helburuekin, hau da: desberdintasunak murriztea eta pertsona guztiei fisikoki aktiboagoak izaten laguntzea egunetik egunera. Gidalerro hauen helburu orokorra da osasun publikoko gomendioak ematea, jarduera fisikoaren neurriari eta motari buruzko ebidentzian oinarrituta. Haur eta nerabeei, helduei, adinekoei eta Azpipopulazioei (besteak beste, emakume haurdunak eta gaixotasun kronikoak edo desgaitasuna duten pertsonak) zuzendutako gomendioak dira, osasun-onura nabarmenak lortzeko eta osasun-arriskuak arintzeko bete beharrekoak. Gidalerroetan sedentarismoaren eta osasun-emaitzen arteko loturei buruzko ebidentzian oinarritutako gomendioak ere ematen dira. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Gidalerroak haur eta nerabeentzat (5-17 urte), helduentzat (18-64 urte) eta adinekoentzat (65 urtetik aurrera) garatu dira, eta lehen aldiz jarduera fisikoari buruzko gomendio espezifikoak jasotzen dituzte azpipopulazioentzat, besteak beste, haurdun dauden emakumeentzat eta gaixotasun kronikoak edo desgaitasuna duten pertsonentzat. Adin-talde eta azpipopulazio espezifiko bakoitzerako egiten dira gomendioak, komunitate bereziekin lan egiten dutenei informazio garrantzitsua erraz eskuratzeko aukera emateko. Azpipopulazioentzat gomendio espezifikoak emateak, batez ere gaixotasun kronikoak edo desgaitasuna dutenentzat, nabarmendu egiten du azpipopulazio horiek jarduera fisikoko eta sedentarismoko interbentzio-politiketan eta plangintzan sartzearen garrantzia. Gidalerro hauek ez du loa portaeratzat hartzen. Loa osasunarekin lotutako alderdi garrantzitsua da, populazioaren osasun-zientzien barruan jorratzen ari den gaia, baina aginteen irismenetik kanpo geratu zen gomendioak eguneratzean. Hala ere, aitortu egiten da loaren garrantzia, eta garrantzizko osasun- emaitza gisa barne hartu zen jarduera fisikoaren eta sedentarismoaren eragina kontuan hartzean. NORI ZUZENDUAK Dokumentu honek prozesuaren berri ematen du eta gomendioak garatzeko berrikusitako ebidentzia-oinarria laburbiltzen du. Hauei dago nagusiki zuzendua: 1. Politiken diseinuaren arduradunak osasun, hezkuntza, gazteria, kirol eta/edo gizarte- edo familia-ongizateko ministerioetan, diru-sarrera altu, baxu eta ertaineko herrialdeetan lan egiten dutenak herrialde bakoitzerako gidalerro espezifikoak emateko, eta bizitza osoan zehar interbentzio-programak planifikatzen dituztenak eremu hauetan: osasuna, hezkuntza, lana, familia edo komunitatea. 2. Gobernu-funtzionarioak, populazio-taldeetan jarduera fisikoa areagotzeko eta sedentarismoa murrizteko plan nazionalak, eskualde azpikoak edo udalekoak garatzen dituztenak orientazio- agirien bidez. 3. Gobernuz kanpoko erakundeetan, hezkuntza- eta lan-erakundeetan edo ikerketa-erakundeetan lan egiten duten pertsonak. 4. Osasun-zerbitzuetan lan egiten duten pertsonak eta aholkularitza eta orientazioa ematen dutenak, besteak beste, erizain edo mediku komunitarioak, familiakoak, lehen arretakoak edo espezializatuak, edo osasunari eta ariketari lotutako bestelako profesionalak, osasun-sektoretik harago lan egiten dutenak. Gidalerro hauek gai horiei buruzko aholkuen edukiaren berri eman dezakete, gidalerro nazionalik ez badago. Gidalerroetan jarduera fisikoari eta sedentarismoari buruz jasotako gomendioak zerbitzua eman aurreko prestakuntzarako eta lanbide-garapenerako ikastaroetan informazioa emateko erabili behar dira osasun-arloko langileentzat, jarduera fisikoko espezialistentzat eta hezkuntzako profesionalentzat. Produktu eratorriak behar dira gidalerro hauek azken erabiltzaile espezifikoei, osasunetik kanpoko sektoreetan interesa duten aldeei eta, oro har, komunitateari transmititzeko, komunikazio pertsonalizatuak erabiltzen dituztenei hartzaile bakoitzaren behar espezifikoei erantzuteko. Testuingurua 17 18 METODOAK Gidalerro hauek OMEren Gidalerroak garatzeko eskuliburuaren (bigarren edizioa) (21) arabera garatu ziren. OMEren zuzendaritza-talde bat ezarri zen, Osasuna Sustatzeko Sailak zuzendua, OMEren eskualde- bulegoen eta dagokien OMEren sailen ordezkaritzarekin. Gidalerroak Garatzeko Taldea (GDG) eratu zen, 27 adituk eta alderdi interesatuk osatua, genero-oreka eta geografia-aniztasuna kontuan hartuta. Gidalerroen zirriborroa kanpotik berrikusi zuten zazpi ikuskatzaile independentek, eta ebidentzia zientifikoari, haren interpretazioari eta edukiari buruzko iruzkinak egin zituzten. Gainera, gidalerroen zirriborroari buruzko online kontsulta publiko bat egin zen, eta 400 kolaboratzailek baino gehiagok egindako iruzkinak jaso ziren. Zientzialari, mediku eta publiko orokorraren ekarpen horiek GDGk bildu eta erabili zituen gidalerroak amaitzeko. Gidalerroak garatzeko prozesuaren kudeaketari buruzko xehetasun guztiak 1. eranskinean daude eskuragarri. GIDALERROEN IRISMENA ETA INTERESEKO GALDERAK GDGk gidalerroen irismena berrikusi zuen eta, lehen bileran, PI/ECO (Populazioa, Interbentzioa/Esposizioa, Konparazioa, Emaitza) galdera garrantzitsuenak adostu zituen. Azpipopulazio bakoitzerako landutako funtsezko galderak jarraian laburbiltzen dira: Jarduera fisikorako: a. Zein da jarduera fisikoaren eta osasun- emaitzen arteko lotura? b. Badago dosi-erantzun loturarik (guztizko kantitatea, iraupena, maiztasuna, etenaldiaren intentsitatea)? c. Lotura aldatzen da jarduera fisikoaren motaren edo eremuaren arabera? Sedentarismorako: a. Zein da sedentarismoaren eta osasun- emaitzen arteko lotura? b. Badago dosi-erantzun loturarik (guztizko kantitatea, maiztasuna, iraupena eta intentsitatea)? c. Lotura aldatzen da sedentarismoaren motaren eta eremuaren arabera? d. Helduetan soilik: Jarduera fisikoak aldatzen du sedentarismoak hilkortasunean duen eragina? Populazio (P) bakoitzarentzat, esposizioa (E) hau izan zen: jarduera fisikoaren kantitate, iraupen, maiztasun edo intentsitate handiagoa; konparazioa (K) hau izan zen: jarduera fisikorik eza edo jarduera fisikoaren kantitate, maiztasun, intentsitate edo iraupen gutxiago. Populazio bakoitzaren emaitza kritiko eta garrantzitsuak 1. taulan laburbiltzen dira, eta PI/ECO galdera bakoitzaren xehetasunak web-eranskinean, dagokion atalean: ebidentzia-profilak .. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Metodoak 19 1. taula: Osasun-emaitza kritiko eta garrantzitsuen laburpena* populazio-taldeen araberagroups Emaitzak (ordena alfabetikoan) Haur eta nerabeak adina 5–17 urte: PA eta sedentarioa Helduak adina 18– 64 urte: PA Helduak 18 urte eta gehiago sedentarioa Gaixotasun kronikoakb Haurrak eta helduak desgaitasunarekinc Adipositatea (pisu gehitzea, pisu aldatzea, pisu kontrola, pisu egonkortasuna, pisu egoera eta pisu mantentzea) Kritikoa Kritikoa Kritikoa Kritikoaa Kritikoa Kritikoa – GIB – Gertakari kaltegarriak Kritikoa Kritikoa – Kritikoaa Kritikoa (emaitzak fetuan) – – Hilkortasuna kausa guztiengatik eta kausa espezifikoengatik – Kritikoa (minbizi eta CVD espezifikoa) Kritikoa Kritikoaa – Kritikoa – Hezurren osasuna Kritikoa – Garrantzitsua – – – – Osasun kardiometabolikoa Kritikoa – – – – – – Emaitza kognitiboak Kritikoa Kritikoa Garrantzitsua Kritikoaa – – Kritikoa – MS, PD, Stk, Sch, ADHD Konplikazioak erditzean – – – – Garrantzits ua – – Gaixotasunaren progresioa – – – – – Kritikoa – HT, T2D, HIV, Kritikoa – minbizi errekurrentzia – Erorikoak eta haiei lotutako lesioak – – – Kritikoa – – – Fetuen emaitzak (jaiotza-pisua, jaiotza goiztiarra) – – – – Kritikoa – – Gaitasun funtzionala – – – Kritikoa – – – Diabetes mellitus gestazionala – – – – Kritikoa – – Haurdunaldiko hipertentsioa/ aurre- eklanpsia – – – – Kritikoa – – Osasunarekin lotutako bizi- kalitatea – Garrantzitsua Garrantzitsua Garrantzitsuaa – Kritikoa – HT, T2D, HIV Kritikoa – MS, SCI, ID, MCD, Sch Minbizi-intzidentzia – Kritikoa Kritikoa Kritikoaa – – – CVD intzidentzia – Kritikoa Kritikoa Kritikoaa – – – Hipertentsio-intzidentzia – Garrantzitsua Garrantzitsuaa – – – II motako diabetes-intzidentzia – Kritikoa Kritikoa Kritikoaa – – – Osasun mentala (antsietate- eta depresio-sintomak) Kritikoa Kritikoa Garrantzitsua Kritikoaa Kritikoa – – Osteoporosia – – – Kritikoa – – – Gaitasun fisikoa Kritikoa – Garrantzitsua – – – – Funtzio fisikoa – – Garrantzitsua – – Kritikoa – HT, T2D, HIV Kritikoa – MS, SCI, ID, PD, Stk Jokabide prosoziala Garrantzitsua – – – – – – Emaitza psikosozialak – – – Garrantzitsua – – – Gaixotasun komorbidoen arriskua – – – – – Kritikoa – HT, T2D, HIV Kritikoa – MS, SCI, ID Loa Garrantzitsua Garrantzitsua Garrantzitsua Garrantzitsuaa – – – * Emaitza kritikoa: erabakiak hartzeko funtsezkoa den emaitza; Emaitza garrantzitsua: emaitza garrantzitsua da, baina ez da kritikoa erabakiak hartzeko a Helduentzat, adinekoak barne, kontuan hartutako emaitza kritiko eta garrantzitsuak. b Emaitzak azpipopulazioaren gaixotasunei dagozkie, zerrendaren arabera: minbizia – minbizitik bizirik irtendakoak; HT – hipertentsioa; T2D – II motako diabetesa; GIB c Emaitzak azpipopulazioaren gaixotasunei dagozkie, zerrendaren arabera: ME – esklerosi muskularra; SCI – bizkarrezur-muineko lesioa; ID – desgaitasun intelektuala; PD – Parkinsonen gaixotasuna; Stk – istripu zerebrobaskularretatik bizirik irtendakoak; Sch – eskizofrenia; ADHN –arreta-defizit/hiperaktibitate nahasmendua. Helduak 65 urte eta gehiago: PA* Haurdunaldia eta erditu ondoren 20 Online eskuragarri, hemen: https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf EBIDENTZIA Jarduera fisikoari buruzko OMEren 2010eko gomendioen berrikuspena egiteko, gidalerro hauen irismenarekin lotutako berrikuspen orokor esanguratsuenak eta berrienak identifikatu eta eguneratu ziren. Jarduera fisikoari buruzko zenbait gidalerro nazionalen garapenaz informatzeko aurrera eramandako berrikuspen sistematiko berrien ugaritasunagatik egin zen hurbilketa hori. Eta eguneratze gehigarriari ekin zitzaion, bermatzeko OMEren gidalerro berriek jaso egiten dituztela bizkor garatzen ari den osasun publikoaren eremu zehatz honetan eskuragarri dauden datu berrienak. Berrikuspen orokorrak hautatu ziren, baldin eta honako hiru irizpide hauek betetzen bazituzten: i) ebidentziaren berrikuspenak ondo dokumentatutako prozesu sistematiko estandarren arabera egin ziren; ii) ebidentziaren ziurtasuna ebaluatzeko Gomendioak Baliozkotzeko, Garatzeko eta Ebaluatzeko Kalifikazioa (GRADE) metodoa edo argi deskribatu eta dokumentatutako metodologia baliokide bat erabili zen; eta iii) ebidentziaren berrikuspenak intereseko populazioei zuzendu zitzaizkien, herrialdeari edo herrialdeko diru-sarreren mailari mugarik ezarri gabe. PI/ECOren galderak eta osasun-emaitza kritiko eta garrantzitsuak alderatu ziren dauden ebidentzia- berrikuspenekin, eta, beharrezkoa izan zenean, beste berrikuspen batzuk eskatu ziren arrakalei heltzeko. GDGk ebidentzia-berrikuspenak eguneratzeko eskatu zuen, jatorrizko berrikuspenen ikerketa-termino berak, hizkuntza- termino berak eta datu-base berak erabilita. Ondoko ebidentzia-berrikuspenek aurreko hiru irizpideak betetzen zituztela identifikatu zen, eta haien gaurkotasun eta zabaltasunaren arabera hautatu ziren: • Literaturaren berrikuspen sistematikoa jarduera fisikoaren eta eskola-adineko haur eta gazteen osasun- adierazleen arteko loturari buruz (22), Poitras et al.-ek (2016) egina, Kanadako haur eta gazteentzako 24 orduko mugimendu-gidalerroak (23) garatzeko prozesuaren barruan. Berrikuspen hori jarduera fisikoaren neurketa objektiboak erabili zituzten azterlanetan soilik oinarritu zen. Guztira 162 azterlan bildu ziren, 31 herrialdetako 204.171 parte-hartzaile ordezkatzen zituztenak. • Literaturaren berrikuspen sistematikoa, eskola-adineko haurren sedentarismoaren eta osasun-adierazleen arteko loturari buruz, Carson et al.-ek (2016) (24) egina, Kanadako haur eta gazteentzako 24 orduko mugimendu- gidalerroak (23) garatzeko prozesuaren barruan. Guztira 235 azterlan sartu ziren (194 lagin bakar), 71 herrialdetako 1.657.064 parte-hartzaile ordezkatzen zituztenak. • Berrikuspen sistematikoa, Okely et al.-ek (2019) (25) egina, Poitras et al. (2016) (22) eta Carson et al. (2018) (24) eguneratzeko, 2019ko Australiako haur eta gazteentzako 24 orduko mugimendu-gidalerroen (adina 5-17 urte) (26) garapenaren barruan. Txosten horrek jarduera fisikoari buruzko 42 azterlan eta sedentarismoari buruzko 32 azterlan identifikatu zituen, 2018ko uztailaren 29ra arte argitaratuak (25). Okely et al.-ek garatutako GRADE taulak OMErentzat egindako eguneratzearen oinarri gisa erabili ziren. GRADE taulak eta ebidentzia-profilak web- eranskinean daude: Ebidentzia-profilak. • 12 berrikuspen sistematikoak, 2019ko Haurdunaldiko jarduera fisikorako Kanadako gidalerroen (27) garapenaren barruan eginak eta laburbilduak. 12 berrikuspen horiek haurdunaldiko jarduera fisikoari buruzko 25.000 azterlan (ingelesez, gaztelaniaz eta frantsesez) baino gehiago ebaluatu zituzten amaren, fetuaren edo jaioberriaren morbilitateari edo fetuaren heriotza-tasari buruz informatzeko. Berrikuspen sistematiko horietatik zazpik GDGk kritikotzat eta garrantzitsutzat jotako emaitzak jorratu zituzten (28- 34). Ebidentzia-berrikuspen horien GRADE taulak OMEren gomendioen garapena eguneratzeko eta informatzeko egindako bilaketa bibliografikorako oinarri gisa erabili ziren. Ebidentzia-profil eguneratuak web-eranskinean aurkezten dira: Ebidentzia-profilak. • Jarduera Fisikorako Gidalerroen Aholkularitza Batzordearen (PAGAC) (35) txosten zientifikoa, 2018ko Estatubatuarren jarduera fisikorako gidalerroen ( 2. edizioa) (36) garapenaren barruan 2008-2016 artean argitaratutako jarduera fisikoari eta sedentarismoari buruzko ebidentziaren eta osasun- emaitzen eguneratze sistematikoa ematen duena. Ebidentzia-sintesiak ikerketako 38 galdera nagusi eta 104 azpigaldera jorratu zituen, osasun publikoan duten garrantziagatik hautatuak. Ebidentziak emaitzak jaso zituen berrikuspen sistematikoetatik: 1.130 artikulu guztira, bakoitza ikerketako 38 galderei erantzuteko laburtua (35). Protokoloek "Berrikuspen Sistematikoak Ebaluatzeko Neurketa Tresna"-ren (AMSTARExBP) bertsio aldatua erabili zuten berrikuspen sistematikoen eta metanalisien kalitate metodologikoa ebaluatzeko. Alborapen-arriskua, edo barne-baliozkotasuna, jatorrizko azterlan bakoitzean ebaluatu zen, USDAren NEL Alborapena Ebaluatzeko Tresnaren (BAT) (37) bertsio egokitua erabilita. OMEren gidalerro hauetarako egindako bilaketa eguneratuetan identifikatutako ebidentzia berria ebidentzia-profiletan aurkezten da web-eranskinean: Ebidentzia- profilak; txostenerako estekak eta PAGACen material osagarriak ematen dira (35). O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Metodoak 21 Ebidentzia eguneratzeko eta datuak erauzteko metodoak Berrikuspen sistematikoen bilaketa egin zen, baita kohorte- azterlanen analisi konbinatuak ere, barne hartutako berrikuspen bakoitzari dagozkion azken bilaketen datatik (goian adieraziak) 2019ko irailera arte argitaratutako azterlanetarako; datuak ateratzeko protokolo estandarizatuak garatu eta erabili ziren. Poitras et al-ek (2016) (22), Carson et al.-ek (2016) (24) eta Okely et al.-ek (2019) (25) egindako bilaketak eguneratzeko, bilaketak egin ziren MEDLINE, EMBASE, PsycINFO eta SportDiscus datu-baseetan, kidekoek egindako berrikuspenak, ingelesez edo frantsesez idatziak, identifikatzeko. PAGACek (35) egindako bilaketak eguneratzeko, PubMed, CINAHL eta Cochrane datu- baseetan egin ziren bilaketak, kidekoen berrikuspenak, ingelesez idatziak, identifikatzeko. Ez zen emaitza garrantzitsuen bilaketa berririk egin, PAGACek (35) barne hartu ez zituen horienak baliabideetan mugak ezarri zirelako. Bilaketak egitean ez zen mugarik ezarri herrialdeei edo haien diru-sarreren mailari dagokienez, eta subjektiboki edo objektiboki neurtutako edozein jarduera fisiko edo portaera sedentario jorratzen duten berrikuspenak barnean hartuta. Bilaketak jatorrizko hizkuntzetan bakarrik egitea erabaki zen, baliabideak mugatuta zeudelako eta, aurrez izandako esperientziak kontuan hartuta, bilaketa horiek oso berrikuspen gehigarri gutxi (edo batere ez) izan zutelako. Jarduera fisikoaren edo sedentarismoaren eta osasun- emaitzen arteko lotura aztertu zuten berrikuspenak hartu ziren kontuan (jarduera fisikoaren edo sedentarismoaren atalase batetik gorako edo beherako mailetan oinarrituta), eta horien eta osasun-emaitzen arteko dosi-erantzun erlazioa aztertu ziren. Kanpoko ikuskatzaile-talde batek AMSTAR 2 (Berrikuspen Sistematiko Anizkoitzen Ebaluazioa) tresna erabili zuen barnean hartzeko xedez kontuan hartu ziren berrikuspen sistematikoen sinesgarritasuna kalifikatzeko (38). AMSTAR 2 tresnak 16 elementu biltzen ditu, berrikuspena planifikatzearekin eta egitearekin lotuak. Berrikuspen bakoitzaren emaitzekiko konfiantza orokorra argitaratutako gidaren arabera kalifikatu zen: "altua", berrikuspenaren ahultasun ez kritikoa zero edo bat denean; "ertaina", berrikuspenaren ahultasun ez kritikoa bat baino gehiago dela uste denean; "baxua", berrikuspenaren akats kritikoa bat dela uste denean, ahultasun ez kritikoekin edo gabe, edo ahultasun ez kritiko anitzekin; eta "kritikoki baxua" akats kritiko bat baino gehiago ageri denean. Berrikusle batek AMSTAR 2 tresna osatu zuen behin-behinean barne hartutako berrikuspen guztietarako. Ikuskatzaile batek kritikoki baxutzat jo zituen berrikuspenak tresna bera erabilita berrikusi zituen bigarren ikuskatzaile batek. Azkenean baztertu egin ziren kritikoki baxutzat jotako berrikuspenak, uste zelako ez zirela fidagarriegiak eskura zegoen ebidentziaren laburpen zehatza eta osoa emateko, emaitza jakin baterako eskuragarri zegoen berrikuspen bakarra izan ezean. Ebidentzia-multzo horretan kohorte-azterlan partekatuak ere sartu ziren. Kanpoko ikuskatzaile talde batek Newcastle-Ottawa eskala erabili zuen azterlanen kalitatea ebaluatzeko (39). Azterlan bakoitzak "altua", "ertaina" edo "baxua" kalifikazioa jaso zuen. Oro har, kalitate oneko azterlan batek Newcastle-Ottawa eskalako irizpide guztiak betetzen zituen. Kalitate ertaineko azterlan batek ez zuen betetzen, edo ez zegoen argi irizpide bat gutxienez betetzen zuenik, baina ez zuen bere emaitzak baliogabetzeko muga garrantzitsu jakinik ere. Kalitate txarreko azterlan batek akats nabarmen bakar bat zuen, edo muga garrantzitsu ugari. Baztertu egin ziren kalitate txarreko azterlanak. Gainjartzeak ebaluatu ziren, berrikuspen anitzetan azterlanen bikoizketa-potentziala aintzat hartuta. Baztertu egin ziren ebidentzia-multzo erredundanteak zituzten berrikuspenak, berrikuspenen laburpenak eta kohorte-azterlanen analisi konbinatu batzuk, non beste berrikuspen osatuagoak eta/edo berriagoak identifikatu baitziren. Berrikuspen berrietarako metodoak Ebidentzian hutsuneak identifikatu zirenean, berrikuspen orokor berriak egiteko eskatu zen, honako hauek aztertzeko: 1. lan-eremuko jarduera fisikoaren (hau da, lanarekin lotua) eta osasun-emaitzen arteko lotura (40); eta 2. aisia-eremuko jarduera fisikoaren eta osasun- emaitza kaltegarrien arteko lotura (41). (Aurreko 1. eta 2. zenbakietarako, PubMed, SportDiscus eta EMBASE erabilita egin ziren bilaketak, 2009tik 2019ko abendura arte argitaratutako berrikuspenetarako) 3. jarduera fisikoaren eta erorikoen prebentzioaren arteko lotura; Sherrington et al.-en (42) 2019ko Cochrane Collaboration Systematic Review berrikuspena erabili zen, eta haien jatorrizko berrikuspenaren azken bilaketaren datatik 2019ko azarora arte argitaratutako ebidentziarekin eguneratu zen. 4. jarduera fisikoaren eta osteoporosiaren eta sarkopeniaren arteko lotura. Osteoporosiari eta sarkopeniari buruzko berrikuspen sistematikoen bilaketak, PubMed-en egina 2008tik 2019ko azarora arte argitaratutako berrikuspenetarako, ez zuen identifikatu berrikuspen berririk bai, ordea, lehen mailako zortzi azterlan berri. 5. jarduera fisikoaren eta osasun-emaitzen arteko loturei buruzko ebidentzia GIBa duten pertsonetan. GIBa duten pertsonen artean, jarduera fisikoari eta osasun-emaitzei buruzko 22 ebidentziaren eskuragarritasuna aurretiko berrikuspen batek zehaztu zuen, berrikuspen orokor bat egiten laguntzeko, hasiera-datan mugarik ezarri gabe 2019ko urrira arte argitaratutako ebidentziarako, PubMed, CINAHL eta Web of Science erabilita. Ebidentziaren ezaugarrien laburpena eta jarduera fisikoa eta sedentarismoa ebaluatzeko metodoak Duela gutxi arte, helduen kasuan, jarduera fisikoa eta sedentarismoa neurtzeko metodo nagusiak autoinformea (hau da, inkesta) izan da, eta, haurren kasuan, autoinformea edo gurasoen oroimena. Metodo horiek ondo ezarritako indarguneak dituzten arren, mugek oroimen- alborapenak eta neurketa-akatsak jakinarazteko joera hartzen dute barne (43). Azken urteotan, arlo horretan teknologia digitala azkar hazi denez, handitu egin da jarduera fisikoa eta denbora sedentarioa ebaluatzeko gailuetan oinarritutako neurrien erabilera, bai eta osasun- emaitzekin dituen loturak ere. Hala ere, oraindik ere badaude erronkak azterlanen arteko emaitzak alderatzeko, ezaugarri teknikoen eta gailuen kokapenaren (azelerometroak) eta datuen analisien eta txostenen arteko aldeak direla eta. Adibidez, denbora sedentarioa gailuetan oinarritutako neurriekin neurtzean, kalkulu-akatsak gerta daitezke, gaur egun gailu askok ez baitituzte jarrerak bereizten (adibidez, etzanda, eserita eta geldirik). Zailtasunak daude, halaber, gailuetan oinarritutako neurriak erabiltzen dituzten azterlanen emaitzak autoinforme- neurrien emaitzak informatzen dituztenekin alderatzean. Autoinforme-tresnak edukiz aldatzen dira, jarduera fisikoaren adibideetan, erantzun-aukeretan eta barne hartutako arloetan. Duela gutxi arte, azterlanek guztizko jarduera fisikoa edo jarduera fisikoa aisia/jolas eremuan soilik ebaluatzen zuten nagusiki, baina orain gero eta eremu gehiago sartzen dituzte, hala nola garraiatzeko jarduera fisikoa (adibidez, oinez eta bizikletaz ibiltzea), lanean eta etxean. Ebidentzia gehienek jarduera fisiko aerobikoaren eta osasun-emaitzen arteko loturei buruzko informazioa ematen dute; hala ere, orain, muskuluak indartzearen onurak ebaluatzen ari dira, baita jarduera- mota desberdinen eta beste eremu batzuen konbinazioak ere. Jarduera fisikoaren mailen eta osasun-emaitzen arteko loturari buruzko emaitzak hainbat modutara informatzen eta alderatzen dira. Ikerketa askok jarduera fisikoaren kuartilen edo kintilen arteko alderaketak egiten dituzte, eta beste ikerketa batzuek gidalerro nazionalak "betetzen ez" dituztenak alderatzen dituzte. Jarduera fisikoaren mailen eta osasun-emaitzen arteko loturari buruzko emaitzak hainbat modutara informatzen eta alderatzen dira. Ikerketa askok jarduera fisikoaren kuartilen edo kintilen arteko alderaketak egiten dituzte, eta beste ikerketa batzuek gidalerro nazionalak "betetzen ez" dituztenak alderatzen dituzte. Informatzen denean, guztizko jarduera fisikoaren kalkulua asteko MET orduetan kalkulatzen da oro har, eta zenbait azterlanek "altuena" eta "baxuena" alderatzen dituzte, nahiz eta kategoriak ere aldatu egiten diren azterlanen artean. Literaturak sarritan ematen ditu datuen ebaki-puntuak aplikatzen dituzten analisien emaitzen berri, dagoen gida batean oinarrituta, edo OMEren gaur egungo gomendio globalean, edo aurreko ikerketen metriketan (adibidez, eguneko 60 minutuko ebaki-puntuak populazio gazteei buruzko ikerketan, edo astean 2-3 aldiko maiztasuna indar-entrenamenduaren interbentzioan). Ebaki-puntu horiek ohikoak bilakatzen direnean, mugatu egin daiteke jarduera fisikoaren esposizio-maila altuenak edo baxuenak osasun-emaitzekin lotzen dituzten ebidentzien metaketa. Haur eta nerabeen sedentarismoaren eta osasun- emaitzen arteko loturak ebaluatzen dituen ebidentzia gehiena zeharkakoa da, eta azterlan gehienak gurasoek jakinarazitako denbora sedentarioaren neurrietan oinarritzen dira, neurketa-akatsak eta oroimen- alborapenak dituztela kontuan hartuta. Luzetarako behaketa-azterlanen eta interbentzio- proben ebidentzia lehenetsi zen, eta ez ziren kontuan hartu zeharkako ebidentzia bakarrik edo nagusiki laburbiltzen zuten berrikuspenak. Garrantzi handiagoa eman zitzaion ziurtasun ertaineko edo altuagoko berrikuspenek emandako ebidentziari, baita gailuetan oinarritutako esposizio-neurriak erabiltzen dituzten azterlanen ebidentzia eman zutenei ere. Ebidentzia-multzoaren kalifikazioa Gomendioak Baliozkotzeko, Garatzeko eta Ebaluatzeko Kalifikazioa (GRADE) metodoa erabili zen ebidentziaren ziurtasuna kalifikatzeko IP/ECO (44) bakoitzerako, berrikuspenen azpiko ebidentzian oinarrituta. Eskuragarri egon zirenean, berrikuspen bakoitzeko "Ebidentzia-profilak" edo "Aurkikuntzen laburpena" GRADE taulak erabili ziren abiapuntu gisa. Dauden berrikuspen sistematikoen barruan taula eskuragarririk ez bazegoen, "Ebidentzia-profila" taulak egin ziren populazio eta emaitza interesgarri bakoitzerako. GRADE metodoa erabili zen IP/ECO (44) bakoitzerako ebidentziaren ziurtasuna kalifikatzeko, irizpide hauek kontuan hartuta: azterlanaren diseinua; alborapen- arriskua; eraginaren sendotasuna; zeharkakotasuna; eraginaren zehaztasuna; eta beste muga batzuk, joeren eta faktoreen argitalpena barne, behaketa-ebidentzia eguneratzeko (eraginaren magnitudea, dosi-erantzuna eta nahaste-faktoreen eraginak) barne. Ondo burututako luzetarako azterlanen behaketa-ebidentzia ere eguneratu zen, egokiago islatzeko aurkikuntzetan ziurtasuna altuagoa dela jarduera fisikoaren edo sedentarismoaren eta azterlan horien emaitzen arteko loturei dagokienez. Tarteko/zeharkako emaitzak ebaluatu zituzten azterlanak ez ziren baztertu, GDGk O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Metodoak 23 emaitzak lehenetsi baitzituen (tarteko emaitzak barne); GRADE kalifikazioak emaitza horien gaineko eraginen ziurtasuna islatzen du. Kasu batzuetan, berrikuspenen GRADE kalifikazioak aldatu egin ziren GRADE metodoen aplikazioan koherentzia bermatzeko. Emaitza bakoitzerako ebidentzia-multzoaren ziurtasuna gida honetan oinarrituta eman zen (45): Altua Ziurtasun handia eragin erreala hurbildu egiten dela eraginaren kalkulura. Ertaina Ziurtasun ertaina eraginaren kalkuluan: litekeena da eragin erreala eraginaren kalkulura hurbiltzea, baina gerta daiteke ere desberdintasuna nabarmena izatea. Baxua Ziurtasun mugatua eraginaren kalkuluan: desberdintasuna nabarmena izan daiteke eragin errealaren eta eraginaren kalkuluaren artean. Oso baxua Ziurtasun oso urria eraginaren kalkuluan: litekeena da eragin errealaren eta eraginaren kakuluaren arteko desberdintasuna nabarmena izatea. Ebidentziatik gomendioetara GRADE Ebidentziatik Erabakira (EtD) esparrua erabili zuen GDGk, galdera espezifikoetarako gomendioak sortzeko. EtD esparrua erabakiak hartzeko ikuspegi sistematikoa, egituratua eta gardena da. Esparruak irizpide esplizituak erabiltzen ditu gidalerroen gomendioak sortzeko, kontuan hartuta ikerketaren ebidentzia, ebidentziaren ziurtasuna eta, beharrezkoa denean, adituen iritzia eta gaiari buruzko ezagutza xede-publikoaren ikuspegitik. Irizpideek honako hauen arteko orekari buruzko iritziak sortzen dituzte: behatutako emaitza desiragarri eta ez desiragarrien ebidentzia, ebidentziaren ziurtasun orokorra, pazienteen balio erlatiboak emaitza desiragarri eta ez desiragarrietarako, baliabideen erabilera (kostuei buruzko kontsiderazioak) hala dagokionean, inpaktu potentziala osasun-arloko ekitaterik ezean, gomendioen onargarritasuna eta bideragarritasuna. GDGk gomendio bakoitzerako ebidentzia-multzoa bere osotasunean aztertu zuen emaitza kritiko guztietarako eta eskura zeuden emaitza garrantzitsu guztietarako. Esposizio/interbentzioaren eta emaitzaren arteko lotura jakin baterako, azterlanek alde handiak izan zituzten ebaluatutako esposizio/interbentzio espezifikoan, ebaluatutako emaitzetan, azterlan eta metodo analitikoen diseinuan, eta horrek heterogeneotasuna ematen dio eskura dagoen ebidentziari. Beraz, ezin izan zen ohiko GRADE hurbilketa aplikatu esposizio/interbentzio espezifiko eta emaitza arteko lotura bakoitzean; aitzitik, esposizio/interbentzio eta emaitza arteko lotura espezifikoari heltzen dioten ebidentzia-multzo orokorrerako GRADE aplikatu zen, azterlanen diseinu- motetan eta esposizio/interbentzioaren neurketen eta analisien aldagaietan. Faktore horiek ebidentziaren koherentziari buruzko kezkak sortu zituztenean (hau da, esposizio/interbentzio jakin baten eta emaitzaren arteko loturaren ebidentzia ez zetorrenean bat modu desberdinetan behatuta), panelak ebidentziaren ziurtasuna murriztu zuen (21). GDGk, jarduera fisikoaren eta sedentarismoaren eraginak jorratzeko, osasun-emaitza hauek lehenetsi zituen: hilkortasuna txikiagoa kausa guztiek eta espezifikoek (gaixotasun kardiobaskularrak eta minbizia) eraginda; intzidentzia gutxiago gaixotasun kardiobaskularretan; minbizi espezifikoetan; II motako diabetesean; hobekuntza gaitasun fisikoan (adibidez, bihotz eta arnas sistema, garapen motorra, muskuluen gaitasuna); hobekuntza osasun kardiometabolikoan (adibidez, presio arteriala, dislipidemia, glukosa, erresistentzia insulinarekiko); hezurren osasunean; osasun mentalean (adibidez, depresio-eta antsietate- sintoma, autoestimu-arazo, ADHN murriztuak); eta emaitza kognitibo hobeak (adibidez, errendimendu akademikoa, funtzio exekutiboa); eta adipositate murriztua. Ondorio kaltegarriak ere kontuan hartu ziren (adibidez, lesioak eta minak). Ohar gehigarriak Populazio bakoitzerako eta PI/ECOren galdera guztietarako, GDGk ondokoak kontuan hartu zituen: gidalerroak zuzentzen zaizkien pertsonen balioak eta lehentasunak; gomendioen inplikazioak baliabideetan; eragina osasun-arloko ekitatean; eta gomendioen onargarritasuna eta bideragarritasuna. Populazio-talde bakoitzerako nabarmena izan zenez bikoizketa kontsiderazio horietan, eta GDGren ebaluazioan, elementu horien ebaluazioari buruzko eztabaiden laburpen bat azaltzen da "Ebidentziatik gomendioetara" atalean. 24 GOMENDIOAK OMEren Jarduera fisikoari eta sedentarismoari buruzko gidalerroetan aurkeztutako osasun publikoko gomendioak populazio guztientzat dira, eta adin- taldeak 5 urtetik hasi eta 65 urte edo gehiagora, generoa, jatorri kulturala edo egoera sozioekonomikoa edozein dela ere, eta garrantzitsuak dira gaitasun oro dituzten pertsonentzat. Gidalerro berriak adin-taldearen eta portaeraren (jarduera fisikoa eta sedentarismoa) arabera aurkezten dira. Gomendio-multzo bakoitzerako, sarrerako adierazpen batek jarduera fisikoarekin eta sedentarismoarekin lotutako osasun-emaitzak laburbiltzen ditu, hurrenez hurren; ondoren, gomendioak agertzen dira. Jardunbide egokien adierazpen-multzo bat ematen da, xede-populazioak gomendioa modu seguru batean nola bete dezakeen argitzeko. Jardunbide egokien adierazpen horiek ez dira, berez, "gomendio sailkatuak", baizik eta ebidentzia zientifikotik eta GDGk berrikusi eta gomendatutako kontsiderazio praktikoetatik eratorriak. Gomendio multzo bakoitzerako, ebidentzia zientifikoen laburpen bat ematen da, PI/ECO hiru galderen bidez egituratua; lehenik eta behin, osasun-emaitza kritikoekin lotutako ebidentzia aurkezten da eta, ondoren, dosi- erantzunari buruzko ebidentziaren laburpen bat. Azkenik, esposizio-mota edo -eremu desberdinen eta osasun- emaitzen arteko loturari buruzko ebidentziaren laburpena aurkezten da, halakorik dagoenean. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Gomendioak 25 Haur eta nerabeentzat, jarduera fisikoa ondokoetan sar daiteke: aisialdian (jolasa, jokoak, kirolak edo ariketa planifikatua), gorputz-heziketan, garraiatzean (gurpiletan, oinez eta bizikletan ibiltzea) edo etxeko zereginetan, eta hezkuntzako, familiako eta komunitateko inguruneetan. Aldeko ebidentzia eta oinarria Haur eta nerabeentzako gidalerro hauetarako berrikuspen sistematikoak erabili ziren (22, 25, 35), eta 16 berrikuspen identifikaturekin eguneratu ziren, inklusio-irizpideak betez. Metodoen, datu-erauzketaren eta ebidentzia-profilen xehetasun guztiak web-eranskinean aurki daitezke: ebidentzia-profilak . Online eskuragarri, hemen: https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf J A R D U IN B ID E E G O K IA K Haur eta nerabeetan, jarduera fisikoak onurak dakartza osasun-emaitza hauetarako: hobetu egiten ditu gaitasun fisikoa (bihotz eta arnas sistemaren gaitasuna eta muskuluena), osasun kardiometabolikoa (presio arteriala, dislipidemia, glukosa eta intsulinarekiko erresistentzia), hezurren osasuna, emaitza kognitiboak (errendimendu akademikoa, funtzio exekutiboa), osasun mentala (depresio-sintoma gutxiago); eta murriztu egiten du adipositatea. Hau gomendatzen da:  Haur eta nerabeek eguneko batez beste 60 minutu egin behar dute jarduera fisikoa intentsitate ertaina eta bizia batez ere aerobikoa, astean zehar. Gomendio sendoa, ziurtasun ertaineko ebidentzia  Intentsitate biziko jarduera aerobikoak, baita muskuluak eta hezurrak indartzekoak ere, gutxienez astean 3 egunetan egin behar dira. Gomendio sendoa, ziurtasun ertaineko ebidentzia 26 Haur eta nerabeetan (5-17 urte) zein da jarduera fisikoaren eta osasun-emaitzen arteko lotura? Ebidentzia askok aldez aurretik ezarri zuten, haur eta nerabeetan, jarduera fisikoaren kantitate eta intentsitate handiagoak osasunerako emaitza onuragarri ugarirekin lotzen direla (1). Oraintsuko ebidentziak berresten du jarduera fisikoa areagotzeak hobetu egiten dituela bihotz eta arnas sistemaren gaitasuna eta gaitasun muskulueskeletikoa haur eta nerabeetan (22, 35). Adibidez, eragin positiboak lortzen dira intentsitate ertain eta biziko jarduera fisiko batean parte hartzean astean 3 egunetan edo gehiagotan, 30-60 minutuz (22, 35). Jarduera fisiko erregularra, batez ere aerobikoa, positiboki lotzen da haur eta nerabeen osasun kardiometabolikorako onuragarriak diren emaitzekin, presio arteriala, lipidoen profila, glukosaren kontrola eta intsulinarekiko erresistentzia hobetzea barne (35). Berriki egindako azterlanek eskolako jarduera fisikoko programen (46), intentsitate biziko entrenamendua pausaldiekin (47) eta erresistentzia-entrenamenduaren (48) eraginkortasuna aztertu zuten, inolako interbentziorekin alderatuta bihotz eta arnas sistemaren osasunaren neurrietan. Hiru berrikuspenetan, argi geratu zen interbentzioak emaitza kardiometabolikoko neurri hobeekin lotu zirela, baina askotariko zehaztasunak egon ziren eraginaren tamainan, eta proba indibidual gutxik aurkitu zituzten jarduera fisikoaren onurak, estatistikoki esanguratsuak, emaitza kardiometaboliko guztietan. 19 RCTtako (n = 11988) (46) berrikuspen batek jakinarazi zuen jarduera fisikoko eskola-programak estatistikoki esanguratsuak diren hobekuntzekin lotu zirela presio arterial diastolikoan (ES= 0.21 [% 95eko CI: 0.42tik 0.01era]; p= 0.04) eta intsulina-baraualdian(es = 0,12 [ % 95eko CI: 0,42tik 0,04ra]; p = 0,03), jarduera fisikoko inolako interbentziorekin alderatuta. Jakinarazi da jarduera fisikoa onuragarria dela adipositaterako, eta jarduera-maila handiagoak haurren eta nerabeen pisu osasungarriarekin lotuta egon daitezke (22, 35). Emaitzak, oro har, sendoagoak dira zeharkako azterlanetan; emaitzak, berriz, nahasiagoak dira behaketa-azterlan prospektiboekin, eta horrek mugatu egiten du informatutako loturen norabidea ulertzea. Jarduera fisikoko interbentzioen proben berrikuspen berriagoek (intentsitate biziko tartekako entrenamendua [HIIT] laborategian oinarritua, ikasketa aktiboa ikasgelan oinarritua, erresistentzia- entrenamendua) sendotasunik gabeko emaitzen berri eman zuten, eta berrikuspenetan sartutako azterlan gehienek ez zuten eraginik jakinarazi (47, 49, 50). Hala ere, luzetarako eta zeharkako azterlanen berrikuspen batek jakinarazi zuen lotura negatiboa dagoela podometroak neurtutako jarduera fisikoaren eta adipositate, BMI edo gerriaren zirkunferentziaren neurrien artean (51). Oro har, ziurtasun baxuko ebidentzia dago jarduera fisikoa pisu osasungarri bati eustearekin lotuta dagoela eta ikerketa gehiago behar da lotura horren norabidea eta indarra zehazteko. Ebidentzia gutxiagok aztertzen du haur eta nerabeen jarduera fisikoaren eta haien trebetasun motorren garapenaren arteko lotura, eta egungo berrikuspenek emaitza nuluak erakusten dituzte (22). Ikerketa gehiago egin behar da garapen motorraren inguruan, etorkizuneko gidalerroen berri emateko. Haur eta nerabeetan, hezur-kargako jarduerak sar daitezke jolasetan, korrika egitean, biraketetan edo salto egitean. Jarduera fisikoa positiboki lotzen da hezur- masaren metaketarekin eta/edo hezur-egiturarekin, eta oraintsuko ebidentziaren arabera, fisikoki beren parekoak baino aktiboagoak diren haur eta nerabeek hezur-masa sendoagoa, hezur-eduki edo -dentsitate altuagoa eta hezur-erresistentzia handiagoa dute (35). Haurtzaroan eta nerabezaroan hezurren osasuna maximizatuz gero, osteoporosiaren eta gerora bizitzan izandako hausturen aurka babesten lagun dezake. Funtzio kognitiboa garatzea eta mantentzea funtsezkoa da bizitza osoan zehar. Haur eta nerabeetan, jarduera fisikoak ondorio positiboak ditu funtzio kognitiboan eta emaitza akademikoetan (adibidez, eskola- errendimendua, oroimena eta funtzioa) (22, 35). Berriki egindako berrikuspen batek (19 RCT; n = 5038) frogatu zuen ariketa-interbentzioak, asteko saio ugarirekin, 6 aste edo gehiagotan, aldaketa handiagoarekin lotu zirela funtzio kognitiboaren neurrietan, hala nola: kontrol inhibitorioa (SMD 0,26 [% 95eko IC: 0,08tik 0,45era], p = < 0,01); oroimen funtzionala (SMD 0,10 [% 95eko IC: 0,5), p= < 0.02), eta malgutasun kognitiboa (SMD 0.14 [95% CI: -0.03 to 0.31], p= < 0.04), inolako ariketa- interbetziorekin alderatuta (52). Jarduera fisikoak depresioa eta sintoma depresiboak izateko arriskua murrizten du depresio larria duten eta ez duten haur eta nerabeetan (35), eta terapia psikologiko eta farmazeutikoekin aldera daiteke sintomak murrizteko. Jarduera fisiko oro gertakari kaltegarrien arriskuren batekin badator ere (53), mugatua da ebidentzia, kalteen berri ematen duena osasunaren onurarako gomendatutako jarduera fisikoaren mailekin lotua (35). Eskura dagoen ebidentziaren eta adituen iritziaren arabera, haur eta nerabeentzat gomendatutako jarduera fisikoaren kantitate eta motei lotutako arrisku O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z 27 Gomendioak potentzialak baxutzat jo ziren (35), eta murriztu egin daitezke jarduera-maila eta intentsitatea pixkanaka handituz, batez ere haur eta nerabe ez aktiboetan. Jakina da kirol batzuetan parte hartzeak lesioak izateko arriskua areagotzen duela, baita ariketaren intentsitatea handitzeak ere (53). Ikerketa gehiago behar da arlo honetako ezagutzen oinarria sendotzeko. OMEk honako hau ondorioztatu zuen: • Ziurtasun ertaineko ebidentzia dago haur eta nerabeetan intentsitate ertain eta biziko jarduera fisiko gehiago onura hauekin lotzen dela: hobetu egiten da bihotz eta asnas sistemaren gaitasuna, muskuluen gaitasuna, bihotz eta arnas sistemaren osasuna eta hezurren osasuna. • Ziurtasun ertaineko ebidentzia dago intentsitate ertaineko jarduera fisikoak, epe laburrera zein luzera, ondorio positiboak dituela funtzio kognitiboan, emaitza akademikoetan eta osasun mentalean. • Ziurtasuna baxua da jarduera fisikoa haur eta nerabeentzat onuragarria dela pisu osasungarriari eusteko. • Ziurtasun baxuko ebidentzia dago haur eta nerabeentzat gomendatutako jarduera fisikoaren kantitate eta motetarako arriskuak urriak direla eta onurek konpentsatzen dituztela. Badago dosi-erantzun loturarik (kantitatea, iraupena, maiztasuna, intentsitatea)? Jarduera fisikoaren eta haur eta nerabeen osasun- emaitzen arteko lotura positiboa erakusten duen funtsezko ebidentzia-multzo bat dagoen arren, oso azterlan gutxik jorratu dute dosi-erantzunaren gaia. Beraz, jarduera fisikorako eta osasun-emaitza espezifikoetarako dosi-erantzun kurbaren eta/edo atalase-balioen (arrisku baxuagoa eta altuagoa bereizten dutenak) presentziaren forma zehatza ez da hain ondo ulertzen haur eta nerabeetan, populazio helduekin alderatuta. Hala ere, funtsezko ebidentzia-multzo batek erakusten du osasunerako onura ugari egunean 60 minutuko jarduera fisikoa eginez lortzen dela (22, 35), eta ebidentzia kontraesankorrik gabe, ondorioztatu zen ebidentzia eguneratuak berretsi egiten duela OMEren gaur egungo gomendioa: eguneko 60 minutuko jarduera fisikoa egitea, intentsitate ertainetik bizira (1). Hala ere, ebidentzia guztiaren berrikuspena, gailuetan onarritutako jarduera fisikoaren neurriak erabiltzen dituzten azterlanen azken emaitzak barne, ez zen eguneroko atalase "minimo" baten zehaztapena mantentzearen alde agertu, osasun-onurak lortzeko 60 minutuko jarduera fisikoa, intentsitate ertain eta bizikoa, egiteari dagokiona. Izan ere, azterlanek nabarmen erabili zuten eguneko 60 minutuko "batez besteko" atalasea, eta ez eguneko 60 minutuko gutxieneko atalasea, jarduera fisikoak osasun-emaitzetan dituen onurak ebaluatzeko. Berrikuspenak ondorioztatu zuen gidalerro berria aldatu egin beharko litzatekeela ebidentzia hori hurbilagotik islatzeko. Osasun kardiometabolikoaren emaitzen gaineko intentsitate biziko jarduera erregularraren onurak aldez aurretik ezarri ziren (1), eta berriki egindako berrikuspenek aldeko ebidentzia gehigarria eman zuten (35). Adibidez, duela gutxiko berrikuspen batek (54) frogatu zuen intentsitate biziko aldizkako entrenamenduak, intentsitate ertaineko etengabeko entrenamenduarekin alderatuta, eragin onuragarri ertaina izan zuela bihotz eta asnas sistemaren osasunean (SMD = 0,51 [ % 95eko CI: 0,33tik 0,69ra], p = < 0,01; I2 = % 0). Ez zen ebidentziarik egon bihotz eta arnas sistemaren osasunaren gaineko eragina aldatu zutenik interbentzioaren iraupenak, ariketa-motak, ariketa- eta atseden-ratioak, eta guztizko saioek. Emaitza horiek, oro har, duela gutxiko beste berrikuspen batzuekin bat etorri ziren (22, 35, 47), eta lagundu egiten dute gomendio hau mantentzen: gazteek eta nerabeek intentsitate biziko jarduera erregularrak egin behar dituzte bihotz eta arnas sistemaren gaitasuna hobetzeko. GDGk honako hau ondorioztatu zuen: • Ebidentziak OMEren aurreko gomendioa berresten du: eguneko 60 minutuko jarduera fisikoa egitea, intentsitate ertain eta bizikoa. • Ebidentziak aurreko zehaztapenaren aldaketa babesten du, hau da, jarduera fisikoaren 60 minutuko eguneko gutxieneko atalasearen ordez jarduera fisikoaren 60 minutuko eguneko/asteko batez bestekoa erabiltzea, eta horrek ebidentzia zehatzagoa islatzen du. • Ziurtasun ertaineko ebidentzia dago intentsitate biziko jarduera fisiko gehiagok lotura duela bihotz eta asnas sistemaren gaitasun hobearekin. Lotura aldatzen da jarduera fisikoaren motaren edo eremuaren arabera? Haur eta nerabeetan, jarduera fisikoak barne hartzen ditu jolasa, jokoak, kirolak, garraiatzea, aisialdia, gorputz- heziketa edo ariketa planifikatua, familiako, eskolako eta komunitateko eremuen testuinguruan. Hala ere, azterlan gutxik alderatu dituzte zuzenean haur eta nerabeen jarduera fisikoaren mota edo eremu desberdinak, eta, beraz, ez dago ebidentzia nahikorik erabakitzeko jarduera fisikoaren eta osasun-emaitzen arteko lotura aldatzen den jarduera-motaren arabera (adib., ariketa aerobikoa versus muskuluak indartzeko ariketa) edo jarduera fisikoaren 28 eremuaren arabera (adib., garraiatzea (oinez eta bizikletan ibiltzea) versus gorputz-heziketa, versus kirola/jolasa). Ebidentzia batek erakusten du intentsitate ertaineko eta biziko jarduera fisiko aerobikoaren maila handiagoak bihotz eta arnas sistemaren gaitasun handiagoarekin lotzen direla, eta muskuluak indartzeko jarduera-maila handiagoak muskuluen gaitasun handiagoarekin lotzen direla haur eta nerabeetan. OMEren 2010eko Osasunerako jarduera fisikoari buruzko gomendio globalen (1) berri eman zuen ebidentzia horrek. Gomendio horien arabera, muskuluak eta hezurrak indartzeko jarduerak egitea gomendatzen zen, gutxienez astean 3 egunetan. Eguneratutako ebidentziak berretsi zuen muskuluak astean 3 aldiz indartzeko jarduera erregularra eraginkorra dela muskulu-gaitasunaren adierazleak hobetzeko; hala ere, ez dago ebidentzia nahikorik saioaren iraupenari eta intentsitateari buruzko xehetasun espezifikoak ezartzeko, neurri handi batean literaturan ebaluatutako esposizioen heterogeneotasuna dela eta (22, 35). Ebidentzia gutxiago dago osasun kardiometabolikoaren gaineko erresistentzia-entrenamenduaren babes-efektuaren inguruan. Haur eta nerabeetan, muskuluak indartzeko jardueren maiztasunaz bestelako ezaugarriei buruzko ebidentzia berririk ez zegoenez (iraupena, adibidez), ezin izan zen xehetasun gehiago zehaztu. Etorkizuneko ikerketek jarduera fisikoaren mota eta eremu espezifikoek osasunerako dituzten onurei heldu behar diete, gidalerroen osagai honi espezifikotasun handiagoa emateko. GDGk honako hau ondorioztatu zuen: • Ziurtasun ertaineko ebidentzia dago muskuluak indartzeko jarduerak gutxienez astean 3 egunetan sartu behar direla. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Haur eta nerabeetan, sedentarismo handiagoa osasun-emaitza txar hauekin lotzen da: adipositate handiagoa; osasun kardiometaboliko, gaitasun fisiko, portaera/jokabide prosozial urriagoa; eta loa murriztea. Hau gomendatzen da: 29 Gomendioak Sedentarismoa honela definitzen da: esna gauden bitartean, eserita edo etzanda igarotzen dugun denbora, energia-gastu gutxirekin, hezkuntza-ingurunearen, etxearen, komunitatearen eta garraioaren testuinguruan. Aldeko ebidentzia eta oinarria Sedentarismoa ez zen sartu OMEren 2010eko gomendioetan; hala ere, azken hamarkadan, gero eta gehiago dira ikerketak sedentarismoaren maila eta mota desberdinei lotutako osasun-emaitzak aztertzen dituztenak. Teknologiak eta komunikazio digitalek eragina izan dute pertsonek lan egiteko, ikasteko, bidaiatzeko eta aisialdia igarotzeko moduan. Herrialde gehienetan, haurrek eta nerabeek denbora gehiago ematen dute portaera sedentarioetan, bereziki aisialdian: pantailako entretenimendua (telebista eta ordenagailuak) eta komunikazio digitalekoa (telefono mugikorretan). Haur eta nerabeentzako gidalerro hauetarako, berrikuspen sistematikoak erabili ziren (24, 25), eta zazpi berrikuspen identifikaturekin eguneratu ziren, inklusio-irizpideak betez. Metodoen, datu-erauzketaren eta ebidentzia-profilen xehetasun guztiak web-eranskinean aurki daitezke: ebidentzia-profilak . Online eskuragarri, hemen: https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 30 HAURRAK ETA NERABEAK (ADINA 5–17 URTE) Haur eta nerabeetan (5-17 urte) zein da sedentarismoaren eta osasun-emaitzen arteko lotura? Ebidentziak adierazten duenez, zenbat eta denbora gehiago eman portaera sedentarioetan (batez ere pantailako jolas-denbora) orduan eta txarragoak dira osasun-emaitzak (24, 35). Adibidez, zenbat eta denbora gehiago pantailarekin (telebista barne) orduan eta okerragoa haur eta nerabeen egoera fisikoa eta osasun kardiometabolikoa (24, 25). Sedentarismoaren eta interbentzio-azterlanen loturari buruzko ebaluazioaren (gailuetan oinarritua) ebidentziak eragin urriak erakutsi zituen, baina eragin sendoagoak jada obesitatea dutenentzat (55). Ebidentzia mugatua da iradokitzen duena sedentarismoak ez duela loturarik haurren eta nerabeen hezur-osasunarekin. Emaitzak mistoagoak izan arren, ebidentziak iradokitzen du sedentarismoa adipositate-neurri kaltegarriekin lotuta egon daitekeela (24, 25). Zeharkako azterlanen berrikuspen batek, jakinarazi zuen egunean 2 ordutik gorako sedentarismo-maila (pantailako guztizko denbora gisa neurtua) haurren gehiegizko pisuarekin/obesitatearekin lotzen zela, maila txikiagoekin alderatuta (< 2 ordu/egun) (56). Hala ere, zeharkako 20 azterlanen beste berrikuspen batek (57) ez zuen estatistikoki esanguratsua den loturarik aurkitu bideo-joko sedentarioen eta haurren edo nerabeen gorputz-masaren indizearen artean. Berrikuspen zabal batek, 29 berrikuspen sistematikok osatuak, ondorioztatu zuen azterlan askok gazteen sedentarismoaren eta adipositate-adierazleen arteko lotura negatiboak adierazten dituztela, sedentarismoa autoinformatzen denean pantailako denborarekin lotuta (55). Hala ere, berrikuspenak adierazi zuen lotura horien garrantzia txikia zela eta, gailuetan oinarritutako denbora sedentarioaren ebaluazioa erabiltzen duten azterlanetan, neurri handi batean, garrantzirik gabea (55). Interbentzio- azterlanek eragin urria erakutsi zuten, baina ondorio nabarmenagoak lehendik obesitatea zutenentzat (55). Ikerketa gehiago behar dira sedentarismoaren eta adipositate-neurrien arteko loturaren berri emateko. Agertu berri den ikerketa-arloa bada ere, ebidentziaren batek erakusten du lotura negatiboa egon daitekeela sedentarismoaren eta ongizatearen eta bizi-kalitatearen artean, baita erlazio kaltegarria ere depresioaren eta pantaila aurreko aisialdiko denboraren artean, haur eta nerabeetan (58, 59). Adibidez, portaera sedentarioaren iraunaldi luzeagoak, pantailako denbora gisa ebaluatuak, eta ordenagailuaren erabileraren zenbait alderdi, lotuta (24). egon daitezke osasun mental urriagoarekin Duela gutxi egindako beste berrikuspen batean, 8 azterlanetik 5etan sedentarismoaren eta antsietate-sintomen arteko lotura bat aurkitu zen, baina azterlanetan emaitzak ez zetozen bat sedentarismoaren neurrietan (60). Beste ebidentzia batek erakusten du telebista ikusten eta bideo-jokoetan denbora gehiago ematea lotura nabarmena izan zuela portaera/jokabide prosozialaren neurri negatiboekin (24); eta pantailaren eta telebistaren aurrean denbora gehiago ematea lotuta dago loaren iraupen urriagoarekin, nahiz eta ez zen loturarik egon ordenagailuaren/jokoen erabileraren eta loaren iraupenaren artean (61). Sedentarismoaren eta osasun mentalaren arteko loturari buruzko ikerketak oso azkar garatzen ari dira, eta litekeena da ebidentzian alderantzizko kausalitatea egotea. Ikerketa gehiago behar da lotura horren norabidearen eta indarraren berri emateko. GDGk honako hau ondorioztatu zuen: • Ziurtasuna baxuko ebidentzia dago portaera sedentarioaren iraupen handiagoa (pantailako denbora) nabarmen lotzen dela haurren eta nerabeen egoera fisiko eta osasun kardiometaboliko okerragoarekin. • Ziurtasun oso baxutik ertainera bitarteko ebidentzia dago portaera sedentarioaren iraupen handiagoa (pantailako denbora, telebista ikusten eta bideo- jokoetan) nabarmen lotzen dela osasun mentalaren eta portaera/jokabide prosozialaren neurri negatiboekin, haur eta nerabeetan. • Ziurtasun baxuko ebidentzia dago portaera sedentarioaren iraupen handiagoa (pantailako denbora eta telebista ikusten) lotuta dagoela haur eta nerabeen loaren iraupenaren gaineko eragin kaltegarriekin. • Haurren eta nerabeen sedentarismoa zenbat eta mugatuagoa, orduan eta urriagoak kalteak. Badago dosi-erantzun loturarik (guztizko kantitatea, iraupena, maiztasuna, etenaldiaren intentsitatea)? Ez dago ebidentzia nahikorik zehazteko dosi-erantzun erlaziorik dagoen haur eta nerabeen denbora sedentarioaren (pantailako jolas-denbora barne) eta haien osasun-emaitzen artean. Haurren eta nerabeen sedentarismoaren eta osasun-emaitzen arteko loturak ebaluatzen dituen ebidentzia gehiena, berez, zeharkakoa da, eta ziurtasun baxuko ebidentzia erakusten du GRADEren arabera, eta azterlan gehienak autoinformatutako edo gurasoek O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z 31 Gomendioak jakinarazitako denbora sedentarioaren neurrietan oinarritu ziren, kontuan hartuta neurketa-akatsak eta oroimen-alborapenak izan ditzaketela. Hala ere, ebidentzia dago zenbat eta denbora gutxiago eman sedentario izaten, orduan eta hobeak direla osasun- emaitzak eta, oro har, sedentarismoaren eta osasun- emaitza txarren arteko lotura sendoagoa da telebistako eta pantaila aurreko aisialdiko denbora ebaluatzen denean esposizio-aldagaitzat, guztizko denbora sedentariorako baino. Hala ere, oro har, ebidentzia ez zen nahikotzat jo denbora-mugen zehaztapena babesteko. Sedentarismoa osasun-emaitza txarrekin lotuta dagoelako ebidentzia izan daiteke portaera sedentarioen eragin zuzenen emaitza, portaera fisiko aktiboagoetan emandako denboraren desplazamenduarena, edo biena. Zenbait azterlanek pantailako denboraren eta haur eta nerabeen osasun- emaitza txarren arteko lotura adierazi duten arren, guztizko denbora sedentarioa (gailuetan oinarritutako sedentarismoaren neurketak erabiltzen dituzten azterlanetan ebaluatutakoaren arabera) ez da sendotasunez lotu osasun-emaitzekin jarduera fisikoa intentsitate ertainetik bizira egiten emandako denbora kontuan hartzen denean (62). Aitzitik, jarduera fisikoa ‒ intentsitate ertainetik bizira‒ osasun-emaitza positiboekin lotzen duen ebidentzia sendoa da eta ondo dokumentatuta dago hainbat ingurunetan; portaera sedentario batzuk jarduera fisikoarekin (bereziki intentsitate ertainetik bizira) ordezkatzeak osasun-emaitza hobeak ekar ditzake. Sedentarismoaren, jarduera fisikoaren eta osasun- emaitzen arteko loturak eta elkarrekintza aztertzen dituen ikerlana bizkor ari dira hazten, eta sedentarismoaren eta osasun kardiometabolikoaren neurrien (gailuetan oinarrituta) ebidentziak erakusten du lotura arindu egiten dela jarduera fisikoa ‒ intentsitate ertainetik bizira‒ kontuan hartzen denean (hau da, estatistikoki doituta) (62 – 64). Beraz, gailuetan oinarritutako esposizio-neurriak erabiltzen dituzten azterlan prospektibo gehiago behar dira lotura horien ezagutzan aurrera egiteko eta etorkizuneko gomendioen berri emateko. GDGk honako hau ondorioztatu zuen: • Ziurtasun baxuko ebidentzia dago sedentario izaten denbora gehiago ematea osasun-emaitza okerragoekin lotuta dagoela. • Ez dago ebidentzia nahikorik sedentarismoan denbora-mugak zehazteko. • Denbora sedentarioa jarduera fisikoarekin ‒ intentsitate ertainetik bizira‒ ordezkatzeak osasun- onurak ekar ditzake. Lotura aldatzen da sedentarismoaren motaren edo eremuaren arabera? Sedentarismoak osasunean dituen ondorioen azterketa nahiko ikerketa-eremu berria da. Hala, aurkikuntzak esposizio-tresna eta -neurri desberdinak erabiltzen dituzten azterlanetatik datoz. "Sedentario izaten emandako guztizko denbora" gisa ebaluatutako esposizioa maiz erabiltzen da, baina baita "pantailak" erabiltzen edo "telebista ikusten" emandako denbora sedentario gisa ere. Eskuragarri dagoen ebidentziak iradokitzen du sedentarismoaren eta osasun-emaitza kaltegarrien arteko lotura, oro har, sendoagoa dela telebista ikusten edo pantaila aurreko aisialdian emandako denborarako, guztizko denbora sedentariorako baino (24, 35). Ikerketa berrienetan sedentarismoa gailuetan oinarrituta ebaluatzeak areagotu egin du ezagutza, eta, txosten estandarizatuekin konbinatzen bada, etorkizuneko gidalerroen berri ematen lagunduko du horrek. Onartzen da portaera sedentario oro ez dela kaltegarria. Ebidentziak iradokitzen du portaera sedentario mota batzuk, hala nola irakurtzea eta atazak eskolatik kanpo egitea, errendimendu akademiko handiagoarekin lotzen direla, eta horrek adierazten du emaitzak desberdinak direla jardueraren arabera (24, 25). Portaera sedentarioak hauek barne har ditzake: hezkuntza- jardueretan/ikasketetan edo jolas lasaian emandako denbora, edo interakzio soziala baliabide elektronikorik gabe. Jarduera horiek (adibidez, irakurtzea, buruhausgarriak egitea, marraztea, eskulanak egitea, abestea, musika entzutea) garrantzitsuak dira haurraren garapenerako, eta onura kognitiboak eta bestelakoak ekartzen dituzte. GDGk honako hau onartu zuen: • Jarduera sedentario batzuek onurak dakartzate haur eta nerabeen funtzio kognitiborako eta interakzio sozialerako. • Sedentarismoak osasunean dituen eragin kaltegarriei buruzko ebidentzia, oro har, sendoagoa da telebista ikusten edo pantaila aurreko aisialdian emandako denborarako, guztizko denbora sedentariorako baino. 32 Helduentzat, jarduera fisikoa ondokoetan sar daiteke: aisialdian (jolasa, jokoak, kirolak edo ariketa planifikatua), garraiatzean (gurpiletan, oinez eta bizikletan ibiltzea), laneko eta etxeko zereginetan, lanbideko, hezkuntzako, familiako eta komunitateko eguneroko jardueren testuinguruan. Helduetan, jarduera fisikoak onurak dakartza osasun-emaitza hauetarako: kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eragindakoa, hipertentsioa, minbizi espezifikoak1, II motako diabetesa, osasun mentala (antsietate eta depresioaren sintomak gutxitzen ditu); osasun kognitiboa eta loa, eta adipositate-neurriak ere hobe ditzake. Hau gomendatzen da: Heldu guztiek erregulartasunez egin behar dute jarduera fisikoa. Gomendio sendoa, ziurtasun ertaineko ebidentzia Helduek intentsitate ertaineko jarduera fisiko aerobikoa egin behar dute, gutxienez 150-300 minutukoa; edo intentsitate biziko jarduera fisiko aerobikoa, gutxienez 75-150 minutukoa; edo astean zehar intentsitate ertain eta biziko jardueraren konbinazio baliokide bat, osasun-onura esanguratsuak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Helduek, astean 2 egunetan edo gehiagotan, muskuluak indartzeko jarduerak ere egin behar dituzte, intentsitate ertain edo handiagokoak, muskulu-talde nagusi guztiak landu eta osasunerako onura gehigarriak ematen baitituzte. Gomendio sendoa, ziurtasun ertaineko ebidentzia Helduek intentsitate ertaineko jarduera fisiko aerobikoa 300 minutu baino gehiagora igo dezakete; edo intentsitate biziko 150 minutu baino gehiagoko ariketa fisiko aerobikoa egin dezakete; edo intentsitate ertain eta biziko jardueren konbinazio baliokide bat astean zehar, osasun-onura gehigarriak lortzeko. Baldintzapeko gomendioa, ziurtasun ertaineko ebidentzia 1 Minbizi espezifikoak: maskurikoa, bularrekoa, kolonekoa, endometriaal, esofago-adenokartzinoma, gastrikoa, eta giltzurrunekoa. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z J A R D U N B ID E E G O K IA K     33 33 Gomendioak Aldeko ebidentzia eta oinarria Gidalerro hauetarako, Estatu Batuetako Jarduera Fisikorako Gidalerroen Aholku Batzordeak (PAGAC) egindako ebidentzia-sintesia erabili eta eguneratu zen (35). GDGk ebidentzia-multzo osoa kontuan hartu zuen, PAGACek jakinarazitako aurkikuntzak eta 2017tik 2019ko azarora arte argitaratutako 28 berrikuspenak eta 3 kohorte-analisi konbinatuak barne. Horiek guztiek inklusio-irizpideak bete zituzten eta helduen jarduera fisikoaren eta osasun-emaitzen arteko loturari buruzko ebidentzia eman zuten. Gainera, bi berrikuspen orokor egin ziren, ebidentzia-hutsuneei heltzeko eta i) lan-eremuko jarduera fisikoa (hau da, lanarekin lotua) eta osasun-emaitzen arteko lotura aztertzeko (40); eta ii) aisialdiko jarduera fisikoaren eta osasun-emaitza kaltegarrien arteko lotura aztertzeko (41). Berrikuspen orokorrek 36 eta 15 berrikuspen sistematiko identifikatu zituzten, hurrenez hurren. Luzetarako behaketa-azterketen eta interbentzio-proben ebidentzia lehenetsi zen, eta ez ziren kontuan hartu zeharkako ebidentzia bakarrik edo nagusiki laburbildu zuten berrikuspenak. Garrantzi handiagoa eman zitzaion ziurtasun ertaineko edo handiagoko berrikuspenek emandako ebidentziari, baita gailuetan oinarritutako esposizio-neurriak erabiltzen dituzten azterlanen ebidentzia eman zutenei ere. Metodoen, datu-erauzketaren eta ebidentzia-profilen xehetasun guztiak web-eranskinean aurki daitezke: ebidentzia-profilak . Helduetan (18-64 urte), zein da jarduera fisikoaren eta osasun-emaitzen arteko lotura? Helduetan, jarduera fisikoaren eta kausa guztiengatiko hilkortasunaren eta gaixotasun kardiobaskularrek eragindakoen arteko lotura ondo ezarrita dago (1). Azkenaldiko berrikuspenen emaitzek berretsi zuten jarduera fisikoaren mailarik baxuenekin alderatuta, jarduera fisikoaren mailarik altuenak hilkortasun-arrisku gutxiagorekin lotuta zeudela. Jarduera fisikoaren neurriak gailuetan oinarrituta erabiltzen dituzten azterlanen ebidentzia berriak berretsi eta zabaldu egin zuen ebidentzia, erakutsiz jarduera fisikoaren mailarik baxuenekin alderatuta, jarduera fisikoaren edozein maila eta intentsitate guztiak (intentsitate arina barne) hilkortasun-arrisku gutxiagorekin lotuta zeudela (65). Adibidez, gutxien aktibo dagoenarekin alderatuta (erreferentea, 1,00), guztizko jarduera fisikoaren kuartiletarako doitutako HRa hobetu egin zen jarduera fisikoaren kuartiletan: 2. kuartila (0,48 [ % 95eko CI: 0,43tik 0,54ra]); 3. kuartila (0,34 [ % 95eko CI: 0,26tik 0,45era]); eta 4. kuartila ( % 0,27 [ % 95eko CI: Ebidentzia berriak ondo ezarritako alderantzizko erlazioa berretsi zuen (1) jarduera fisikoaren eta gaixotasun kardiobaskularrengatiko hilkortasunaren artean (66). Ondo dokumentatuta daude jarduera fisikoak gaixotasun kardiobaskularrak eta hipertentsioaren intzidentzia murrizteko dituen onurak (1). Jarduera fisikoak erantzun fisiologiko ugari sustatzen ditu, eta horiek egokitzapen onuragarriak eragiten dituzte epe labur eta luzera; horren ondorioz, hipertentsioa izateko arriskua urriagoa da, kontuan hartuta funtsezko arrisku-faktorea dela gaixotasun kardiobaskularretarako. Ebidentziak berretsi zuen alderantzizko erlazioa zegoela jarduera fisikoaren eta hipertentsioaren intzidentziaren artean presio arterial normala duten helduen artean, eta jarduera fisikoak presio arteriala murrizten duela prehipertentsio eta presio arterial normala duten helduen artean (35). Jarduera fisikoaren eta helduen II motako diabetesaren garapenaren arteko alderantzizko lotura ondo ezarrita dago (1). Oraintsuko ebidentziak alderantzizko erlazio lerromakurra berretsi zuen jarduera fisikoaren kantitate handiagoen eta II motako diabetesaren intzidentziaren artean (35), eta beheranzko maldarekin jarduera fisikoaren maila altuagoetan. Beste berrikuspen batek ikusi zuen eragin hori bat datorrela jatorri desberdinetako gizabanakoen artean, II motako diabetesa garatzeko arrisku urriarekin, jarduera fisikoaren maila “altuenetan” versus “baxuenetan”, hauengan: zuri ez hispanoak (RR = 0,71 [ % 95eko CI: 0,60tik 0,85era]); Asiakoak (RR = 0,76 [ % 95eko CI: 0,67tik 0,85era]); Hispanoak (RR = 0.74 [% 95eko CI: 0.64tik 0.84ra]); eta AEBetako Indiarrak (RR = 0.73 [95% CI: 0.60tik 0.88ra]), nahiz eta beltz ez hispanoen artean eragina ez zen esanguratsua izan (RR = 0.91 [95% CI: 0.76 to 1.08]) (67). Ebidentziak iradokitzen du ez dagoela eragin-aldaketarik pisu-egoeragatik, eta alderantzizko erlazioa dagoela jarduera fisikoaren kantitate handiagoaren eta II motako diabetesaren intzidentzia txikiagoaren artean, pisu normala, gainpisua edo obesitatea duten pertsonentzat (35). Ondo ezarrita daude jarduera fisikoaren maila altuenen eta koloneko minbiziaren eta bularreko minbiziaren arrisku txikiagoen arteko loturak (1). Ebidentziaren aurreko berrikuspenetan ikusi da Online eskuragarri, hemen:https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 34 jarduera fisikoaren maila altuenak bularreko minbizia eta koloneko minbizia garatzeko arrisku txikiarekin lotzen direla (1) Gero eta gehiago dira jarduera fisikoari eta minbiziari buruzko ikerketak, eta ebidentzia berri batek erakusten du jarduera fisikoaren maila altuagoak maskuriko adenokartzinoma, endometrioa, esofagoa, urdaileko minbizia eta giltzurrunekoa garatzeko arriskuak murriztearekin lotzen direla, eta berretsi egiten du jarduera fisikoa faktore babeslea dela bularreko eta koloneko minbizietarako (35). Jarduera fisikoaren mailarik altuenak % 10 eta % 20 bitarteko arrisku- murrizketekin lotzen dira (35). Adibidez, berrikuspen batek alderantzizko lotura bat jakinarazi zuen gibeleko minbiziaren arriskuarekin, jarduera fisikoaren maila altuak eta baxuak alderatu zirenean (HR = 0,75 [ % 95eko CI: 0,63tik 0,89ra]) (68). Ez dago ebidentzia nahikorik jarduera fisikoa handitzearen eta minbizi hematologikoaren, buruko eta lepoko minbiziaren, obario, pankrea, prostata, tiroide, ondeste eta garuneko minbiziaren arriskuak murriztearen arteko loturari buruz (35). Ebidentziak iradokitzen du biriketako minbiziaren arriskua murriztu egiten dela jarduera fisikoaren maila altuenen eta baxuenen artean, baina aurkikuntza horiek tabakoaren kontsumoarekin nahas daitezke, eta, oro har, lotura bat ezartzeko froga nahikorik ez dagoela erabaki zen. Populazio helduetan jarduera fisikoaren eta adipositatearen arteko lotura ez dago hain ondo ezarrita ebidentzia-multzoa handia izan arren; heterogeneoa da eta erlazio hori hainbat emaitza-neurritan ebaluatzen du (pisua handitzea, pisua aldatzea, pisua kontrolatzea, pisu- egonkortasuna, pisu-egoera eta pisuari eustea) (35, 69, 70). Oro har, ebidentziak erakusten du jarduera fisikoaren maila altuagoak lotuta egon daitezkeela helduen adipositate-neurri hobeekin eta gainpisua arintzearekin (35). Ikerketa gehiago behar da emaitza sendoak eta loturen indarra ezartzeko. Jarduera fisikoari eta osasun mentalari, kognizioari eta loari buruzko ikerketak nabarmen egin du gora osasunerako jarduera fisikoari buruzko 2010eko Gomendio globalak garatu zirenetik (1). Une horretan, nahikoa froga egon zen ondorioztatzeko jarduera fisikoak helduen depresioa eta narriadura kognitiboa izateko arriskua murriz dezakeela. Gidalerro hauetarako berrikusitako ebidentzia berriak erakutsi zuen adingabeko batekin alderatuta jarduera fisiko handiagoa egiten duten helduek antsietatea eta depresioa garatzeko arrisku txikia dutela. Adibidez, helduek, maila altuko versus baxuko jarduera fisikoa eginda, joera gutxiago zuten antsietatea (AOR = 0,81 [ % 95eko CI: 0,69tik 0,95era]) (71) edo depresioa (AOR = 0,78 [ % 95eko CI: 0,70etik 0,87ra) (72) garatzeko. Intentsitate ertain eta biziko jarduera fisiko gehiago kognizioaren hobekuntzarekin lotzen da (adibidez, prozesamendu-abiadura, oroimena eta funtzio exekutiboa) (35), garunaren funtzioa eta egitura, eta narriadura kognitiboa garatzeko arrisku txikia, Alzheimerren gaixotasuna barne (73 – 76). Ebidentziaren arabera, populazio heldu batzuek osasun-egoera kognitiboaren gradiente normala eta narriatua adierazten dute, eta jarduera fisikoaren ondorio onuragarriak hainbat motatakoak izan ziren, jarduera aerobikoa, ibilaldiak, muskuluak indartzeko jarduera eta yoga barne (74). Frogatuta dago bai gertakari akutuek bai jarduera fisiko erregularrak loaren emaitzak eta eta osasunarekin lotutako bizi-kalitatea hobetzen dituztela helduetan (35). Depresio-sintomak, antsietate-sintomak eta antsietatearen eta depresioaren garapena aztertu zituen ebidentzia batek adierazi zuen jarduera fisikoa antsietate-sintomak murriztearekin (77, 78) eta depresio- sintomak murriztearekin (77, 79) lotu zela. Jarduera fisiko orok dakar arriskuren bat. Helduen aisialdiko jarduera fisikoarekin lotutako ondorio kaltegarriei, lesioei eta kalteei buruzko azterketa baten ebidentziak (41) iradokitzen du lotura negatiboa dagoela aisialdiko jarduera fisikoaren mailaren eta lesio muskulueskeletikoen artean, eta lotura positiboa aisialdiko jarduera fisikoaren eta haustura-arriskuaren eta belauneko edo aldakako artrosiaren agerpenaren artean. Dagoen ebidentzia gehigarriak (35) adierazten du bat-bateko bihotzeko gertakari kaltegarriak gutxitan izaten direla eta nahiko intentsitate biziko jarduera fisikoko saio gogorrekin lotuta daudela. Oro har, gertakari kaltegarrien arriskuak oso txikiak dira jarduera fisikoa intentsitate ertainekoa denean eta jarduera fisikoaren maiztasun, intentsitate eta iraupenaren igoerak mailakatuak direnean (35) GDGk honako hau ondorioztatu zuen: • Ziurtasun handiko ebidentzia dago jarduera fisikoaren edozein maila eta intentsitate lotuta dagoela ondokoen arrisku gutxiagorekin: kausa guztiengatiko hilkoltasuna eta gaixotasun kardiobaskularrek eragindakoa, eta hipertentsioaren, gaixotasun kardiobaskularren eta II motako diabetesaren intzidentzia. • Ziurtasun ertain eta altuko ebidentzia dago jarduera fisikoaren maila altuagoen eta minbizi espezifikoen intzidentzia-arrisku txikiagoaren arteko loturei dagokienez. • Ziurtasun ertaineko ebidentzia dago babesten duena lotura dagoela jarduera fisikoaren eta osasun mentala, osasun kognitiboa eta loa hobetzearen artean. • Ebidentzia dago lotura dagoela jarduera fisikoaren maila altuagoen eta helduen adipositate-neurri hobeen eta pisua gutxiago gehitzearen artean. • Ziurtasun baxuko ebidentzia dago helduentzat gomendatutako jarduera fisikoa ez dela kaltegarria izango eta jarduera horren ondoriozko osasun- onurak arriskuak baino handiagoak direla. 35 Gomendioak 1. irudia: Dosi erantzun kurba Badago dosi-erantzun loturarik (kantitatea, iraupena, maiztasuna, intentsitatea)? Oro har, osasun kardiobaskularraren eta metabolikoaren emaitzen ebidentziak alderantzizko dosi-erantzun lotura lerromakur nabarmen bat erakusten du jarduera fisikoaren eta emaitza nagusien artean (kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eragindakoa, II motako diabetesaren intzidentzia (67) eta minbizi espezifikoena). 1. irudian adierazi bezala, dosi-erantzun kurbaren formak adierazten du ez dagoela onurarako atalase baxuagorik, eta onura handienak dosi-erantzun kurbaren beheko muturrean ikusten dira (65). Alderantzizko lotura lerrokamurra modu sendo batean agertzen da, eta jarduera fisikoaren neurri desberdinak erabiltzen dituzten azterlanetan. Beste ebidentzia garrantzitsu bat eman zen prospekzio-kohorteen zortzi azterlanen metanalisi batean, 5,8 urteko batez besteko jarraipenarekin (3 eta 14,5 urte arteko tartea) (65). Horiek jarduera fisiko osoaren kuartiletarako doitutako HRren berri eman zuten, esposizioaren eta kausa guztiengatiko hilkortasunaren neurriak erabiliz, gailuetan oinarrituta. Emaitzek dosi-erantzun bat erakutsi zuten, jarduera fisikoaren gero eta kantitate handiagoarekin eta jarduera fisikoren edozein intentsitateren maila altuagoen onurekin, gutxien aktibo direnekin alderatuta (erreferentea, 1,00): 2. kuartila (HR doitua =0,48 [ % 95eko CI: 0,43tik 0,54ra]); 3. kuartila (HR doitua = 0,34 [ % 95eko CI: 0,26tik 0,45era]); eta 4. kuartila(HR doitua= 0.27 [% 95eko CI: 0.23tik 0.32ra]). Intentsitate ertain eta biziko jarduera fisikorako arrisku murrizketa maximoak ikusi ziren eguneko 24 minututan (asteko 168 minuturen baliokidea), eta horrek oso gertutik islatzen du asteko 150 minutuko gomendioa, eta gailuetan oinarritutako ebidentzia berri bat ematen du, orain helduei zuzendutako gomendio globala sendotzen duena: jarduera fisikoa egitea 150-300 minutu asteko (65). Aurkikuntza horiek bat datoz dauden berrikuspenen ebidentziarekin (35) eta identifikatutako beste berrikuspen berriekin (66). Goiko muturrean, jarduera fisikoaren mailarik altuenek onurak ematen jarraitzen dute hilkortasun-arriskua murrizteari dagokionez, kalte-arrisku handiagorik gabe. Adibidez, gailuetan oinarritutako esposizio-neurriei buruzko datu indibidualen metanalisitik aurkikuntzak lortu zituen berrikuspen bateko (65) ebidentziak adierazten duenez, hilkortasun-arrisku baxua ikusten den arren asteko 750 minutura arteko jarduera fisikoan ‒intentsitate ertainetik bizira‒, hilkortasun-arrisku erlatiboa egonkortu egiten da asteko 300 minututatik gora. Emaitza horiek bat datoz jarduera fisiko handiagoa osasun-onura gehiagorekin lotzen dela erakutsi zuen aurretiazko ebidentziarekin, nahiz eta onura erlatiboak murriztu egiten diren jarduera fisikoaren maila altuagoetan (35, 80, 81). Hala ere, ez dago ebidentzia nahikorik jarduera fisikoaren maila zehatza identifikatzeko helduentzako osasun-onurak murrizten hasten direnean. Ebidentziak, halaber, jarduera fisikoaren eta gaixotasun kardiobaskularrengatiko hilkortasunaren artean ondo ezarritako alderantzizko erlazioa berretsi zuen, eta horrek dosi-erantzun erlazio baten ebidentzia gehigarria ematen du, gaur egun gomendatzen diren jarduera fisikoaren kantitateetatik askoz harago. O n u ra k o s a s u n e ta g a it a s u n f is ik o ra k o Maila gomendatuak Asteroko jarduera fisikoa (minutu) Sedentario 36 Jarduera fisikoa (guztizkoa, aisialdikoa eta lan- eremukoa) ebaluatzen duten 48 azterlan prospektiboren metaanalisiak dosi-erantzun erlazio baten ebidentzia gehigarria eman zuen (66), gaur egun gomendatzen diren jarduera fisikoaren kantitateetatik askoz harago. Gomendatutako asteko 750 MET minutuko mailarekin alderatuta, asteko 5.000 MET minututan parte hartzeak (1.000 minutuko intentsitate ertaineko jarduera) gaixotasun kardiobaskularraren ondoriozko hilkortasun-arrisku nabarmen txikiagoa eragin zuen (HR = 0,73 [ % 95eko CI: 0,56tik 0,95era]) (66). OMEren aurreko gomendioek (1) ondorioztatu zuten jarduera aerobikoa gutxienez 10 minutuko serieetan egin behar dela. Hala ere, gailuetan oinarritutako ebaluazioak erabiltzen dituzten proba berriek erakusten dute edozein iraupeneko jarduera fisikoa, gutxieneko atalaserik gabe, osasun-emaitza hobeekin lotzen dela, kausa guztiengatiko hilkortasuna barne (65, 82). Adibidez, jarduera fisikoa azelerometriaren bidez ebaluatzen duten azterlanen berrikuspenen ebidentzia berriak berretsi egiten du antzeko loturak daudela jarduera fisikoaren indize guztien eta kausa guztiengatiko hilkortasunaren artean, 0,27ko arrisku-zatidurarekin guztizko jarduera fisikorako, 0,28koa 5 minutuko tarteetarako eta 0,35ekoa 10 minutuko tarteetarako, kuartilik altuenak baxuenekin alderatuta (83). Emaitza horiek Ekelund et al.-k 2019 (65) egindako berrikuspen berrian jasotako aurkikuntzek berretsi ditu, zeinak ebidentzia ematen duen edozein iraupeneko jarduera fisikoa osasun- emaitza hobeekin lotzen dela, kausa guztiengatiko hilkortasuna barne (82). Ebidentzia berrian oinarrituta, berriz, gutxienez 10 minutu irauten duten tarteen gomendioa baztertu da. Jarduera fisikoaren maila altuagoen eta mibizi espezifikoen intzidentzia-arrisku baxuagoaren arteko loturak erakusten dituen ebidentzia oro har sendotzat jo izan arren, ez dago nahikoa ebidentzia zehazteko jarduera fisikoaren maila espezifikoak, informatutako arriskuaren murrizketari dagozkionak, azterlanen arteko esposizioaren ebaluazioan eta sailkapenean heterogeneotasun handia dagoelako. Hala ere, ez dago ebidentziarik iradokitzen duenik atalase baxuago bat dagoela, eta horren azpitik ez dagoela jarduera fisikoaren eragin onuragarri nabarmenik; horrek iradokitzen du edozein jarduera fisikok onurak ekar ditzakeela minbizi espezifikoen arriskua murrizteko. Etorkizuneko ikerketak behar dira, dosi-erantzunaren izaera ebaluatzeko eta neurri eta txosten sendoagoak erabiltzeko, etorkizuneko gidalerroen berri emateko. Nahiz eta ebidentzia-multzo zabal bat dagoen jarduera fisikoaren eta hainbat adipositate-neurriren, pisua gehitzearen eta pisu-egoera osasungarria eustearen (35) arteko loturei buruz, gaur egun ez dago ebidentzia nahikorik dosi-erantzun erlazioa zehatzago adierazteko edo eragin-atalasea identifikatzeko. Ikerketa gehiago behar da etorkizuneko gidalerroen berri emateko. Ikerketa gehiago behar da etorkizuneko gidalerroen berri emateko. Jarduera fisiko gehiago ‒intentsitate ertainetik bizira‒ osasun- onura hauekin lotzen da: kognizioaren (adibidez, prozesamendu-abiadura, oroimena eta funtzio exekutiboa) (35) eta garunaren funtzio eta egituraren hobekuntza, eta narriadura kognitiboa garatzeko arrisku gutxiago, Alzheimerren gaixotasuna barne (73 – 76). Ebidentzia dago, helduetan, loaren eta osasunarekin lotutako bizi- kalitatearen emaitzak hobetzen dituztela bai jarduera fisikoa erregularrak, bai tarte bizkorretan egiten denak (35). Hala ere, ez dago ebidentzia nahikorik jarduera fisikoaren eta osasun mentalaren eta kognitiboaren banakako emaitzen arteko dosi- erantzun erlazioa zehatzago deskribatzeko. Era berean, proba gehiago behar dira jarduera fisiko aerobikoaren kantitatearen eta/edo intentsitatearen eta muskuluak indartzeko entrenamenduaren eta osasun-emaitza espezifikoen arteko dosi-erantzun erlazioa zehatzago deskribatzeko. Informazio hori funtsezkoa da gutxieneko dosia eta jarduera fisikoaren gehieneko segurtasun-atalaseak ezartzeko azpipopulazio desberdinentzat. GDGk honako hau ondorioztatu zuen: • Ebidentzia dago jarduera fisiko handiagoa osasun-emaitzetan eragin handiagoarekin lotzen dela, nahiz eta onura erlatiboak jarduera fisikoaren maila altuagoetan egonkortzen diren. Ez zen ebidentzia nahikorik egon errendimendu murriztuak gertatzen hasten diren maila zehatza identifikatzeko. • Ziurtasun handiko ebidentzia dago jarduera fisikoaren maila altuagoak ondokoen arrisku txikiagoarekin lotuta daudela: kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eta minbiziak eragindakoa, gaixotasun kardiobaskularren intzidentzia eta II motako hipertentsio eta diabetesaren intzidentzia, kalteen arrisku handiagorik gabe. • Ziurtasun ertaineko ebidentzia dago edozein iraupeneko jarduera fisikoa osasun-emaitza hobeekin lotzen dela, eta baztertu egin behar da jarduera aerobikoa gutxienez 10 minutuko tarteetan egin behar dela dioen aldez aurreko zehaztapena. • Ebidentzia dago jarduera fisikoaren kantitate handiagoak lotuta egon daitezkeela helduen adipositate-neurri hobeekin eta gainpisua arintzearekin, eta arrisku baxua dagoela helduetan jarduera fisikoa kaltegarria izateko pisu osasungarriari eusteko. • Ziurtasun ertaineko ebidentzia dago intentsitate ertaineko jarduera fisiko aerobikoak, 150-300 minutu astean, edo baliokideak, murriztu egiten duela osasun-emaitza negatibo ugari izateko arriskua, eta arriskuak murrizten jarraitzen duela, baina egonkortzen hasten dela, astean 300 minututik gora. Gomendioak 37 Lotura aldatzen da jarduera fisikoaren motaren edo eremuaren arabera? Ebidentziak erakusten duenez, jarduera fisiko mota desberdinek eta hainbat eremutan (hau da, lanean, garraiatzean edo aisialdian) egiten den jarduera fisikoak osasun-emaitza onak ekar ditzakete. Kausa guztiengatiko eta gaixotasun kardiobaskularrengatiko hilkortasunerako, jarduera fisiko aerobikoa bakarrik egiteak, edo indar- ariketarekin konbinatzeak, lotura onuragarriak erakusten ditu, eta hobetu egiten dira emaitzak bi motetako maila gomendatuak egiten direnean (84). Ziurtasun ertaineko ebidentzia berrienak adierazten du muskuluak indartzeko jarduera fisikoa, jarduera fisiko aerobikoaz aparte, kausa guztiengatiko hilkortasun- arrisku txikiagoarekin lotzen dela. Stamatakis et al.-ek (2018) aurkeztutako emaitzek, kausa guztiengatiko hilkortasunaren aurrean astean 2 egunez muskuluak indartzeko gomendioa aztertzen zuten 11 kohorteen analisi konbinatu batekoek, erakutsi zuten jarduera fisiko aerobikoa eta maila gomendatuetan muskuluak indartzeko jarduera fisikoa egitea (1) versus gomendio bat ere ez betetzea (HR doitua = 0,71 [ % 95eko CI: 0,57tik 0,87ra], baita indar-ariketaren gomendioa bakarrik betetzea versus ez betetzea ere (HR = 0,80 [ % 95eko CI: 0,70etik 0,91ra]) kausa guztiengatiko hilkortasun- arriskuaren murrizketa nabarmenarekin lotuta zeudela (84). Datu horiek baieztatzen dute muskuluak indartzearekin lotutako osasun-onurak jarduera fisiko aerobikotik independenteak zirela, eta ebidentzia ematen dute, halaber, muskuluen indartze-ariketaren astean 2 eguneko maiztasunaren gomendioa babesteko. Dinu et al.-ek (2019) aurkeztutako beste aurkikuntza batzuk babes-ebidentzia eman zuen, aisialdiaz (edo jolasaz) bestelako eremuetan egindako jarduera fisikoa onuragarria izan daitekeela berresten duena, eta berariaz erakutsi zuen garraiatze aktiboak (hau da, bizikletaz eta oinez lekualdatzea) nabarmen murriztu dezaketela kausa guztiengatiko hilkortasun-arriskua (RR = 0,92). [ % 95eko CI: 0,85-0,98]) (85). Oraintsuko ikerketek ebidentzia ematen dute frogatzeko garraiatze aktiboan (hau da, oinez edo bizikletaz lekualdatzea) parte hartzen dutenek gaixotasun kardiobaskularrak (gutxiegitasun koronarioa, istripu zerebrobaskularra eta bihotz-hutsegitea) izateko arrisku txikiagoa dutela garraiatze ez aktiboetan parte hartzen dutenekin alderatuta (RR = 0,91 [IC % 95: 0,83-0,99]) (85); eta osasun-emaitza horien ebidentzia nahikoa dagoela ondorioztatzeko eremu derberdinetan aktibo izatea onuragarria izan daitekeela. Hala ere, ez dago ebidentzia nahikorik bereizteko jarduera fisikoaren eremu desberdinek osasun-emaitza bakoitzean duten eragina. Adibidez, ez dago ebidentzia nahikorik jarduera fisikoaren eta minbizi-arriskuaren arteko lotura edo II motako diabetesaren intzidentzia jarduera fisikoaren motaren edo eremuaren arabera aldatzen den zehazteko. Osasun mentalaren emaitzetarako, ebidentziak (35) erakusten du jarduera fisiko mota askok, jarduera aerobikoak, ibiltzeak, muskuluak indartzeko jarduerak eta yogak barne, ondorio onuragarriak izan ditzaketela depresio-sintomak eta antsietatearen garapena murrizteko (74, 79, 86). Adibidez, erresistentzia-ariketek osasun mentalean eragin onuragarria dutela babesten duen ebidentzia berria bi berrikuspenek eman zuten. Berrikuspen horiek depresio-sintomen murrizketa nahiko handiak (77) eta antsietate-sintomen murrizketa txikiak (78) aurkeztu zituzten kontrol-egoerekin alderatuta. Berrikuspen berri baten ebidentziak baieztatu zuen lan- eremuko jarduera fisikoaren maila altuak lotuta daudela minbizi askoren, gaixotasun koronarioaren eta II motako diabetesaren arrisku murriztuarekin (40). Hala ere, lan- eremuko jarduera fisikoaren mailarik altuenak lotuta egon daitezke osteoartritisaren arrisku handiagoarekin, loaren kalitate txarrarekin eta kausa guztiengatiko hilkortasunarekin gizonen artean (baina ez emakumeen artean). Ez dago ebidentzia nahikorik zehazteko zer lotura dagoen lan-eremuko jarduera fisikoaren eta adipositatearen, gorputzaren pisua handitzearen prebentzioaren, osasun mentalaren eta osasunarekin lotutako bizi-kalitatearen artean (40). Era berean, ez dago ebidentzia nahikorik jarduera fisikoaren eta minbizi- arriskuaren arteko lotura jarduera fisikoaren motaren edo eremuaren arabera aldatzen den zehazteko. Ebidentzia gutxiago dago jarduera fisikoaren loturei buruz eremu desberdinetan eta, beraz, zaila izan zen bereiztea jarduera fisikoaren eremu desberdinek osasun-emaitza desberdinetan duten eragina. GDGk honako hau ondorioztatu zuen: • Ziurtasun ertaineko ebidentzia dago muskuluak indartzeko astean 2 egunetan edo gehiagotan egindako jarduerek osasun-onura gehigarriak ematen dituztela, baina ez dago ebidentzia nahikorik iraupen espezifiko bat zehazteko osasun-onura optimoak lortzeko. • Ziurtasun ertaineko ebidentzia dago hainbat eremutan egindako jarduera fisikoak (adibidez, aisialdian, garraiatzean, lanean) osasun-onurak ekar ditzakeela, nahiz eta gaur egun ezin den bereizi jarduera fisikoaren eremu desberdinen eragina zenbait osasun-emaitzatan. • Nahiz eta lan-eremuko jarduera fisikoaren mailarik altuenak lotuta egon daitezkeen osteoartritis-arrisku handiagoarekin, loaren kalitate txarrarekin eta kausa guztiengatiko hilkortasunarekin gizonen artean (baina ez emakumeen artean), oro har, ziurtasun ertaineko ebidentzia dago lan-eremuko jarduera fisikoak osasun- onurak ekar ditzakeela. 38 Helduentzat, sedentarismoa honela definitzen da: esna egon bitartean, eserita edo etzanda emandako denbora, energia-gastu gutxirekin, lanbideko, hezkuntzako, familiako eta komunitateko inguruneetan eta garraioaren testuinguruan. Aldeko ebidentzia eta oinarria Gidalerro hauetarako, PAGACek egindako ebidentzia-sintesia erabili eta eguneratu zen (35). GDGk ebidentzia-multzo osoa hartu zuen kontuan, PAGACek jakinarazitako aurkikuntzak eta inklusio-irizpideak bete zituzten 13 berrikuspen berriak barne, sedentarismoaren eta helduen osasun-emaitzen arteko loturari buruzko ebidentzia emateko. Sedentarismoaren eta osasun-emaitzen arteko loturaren ikerketa nahiko eremu berria da osasun publikoan, jarduera fisikorik ezarekin alderatuta egindakoaren aldean, baina azkar garatu da azken hamarkadan. Ikerketek sedentarismoa honela neurtu dute: i) autoinforme-galdetegiak erabilita portaera sedentarioetan emandako "guztizko denborari" edo portaera espezifikoetan (telebista ikustea, ordenagailua/pantaila erabiltzea eta eserita egotea) emandako denborari buruz; edo ii) gailuetan oinarritutako ebaluazioak erabilita. Ez dago neurri estandarizaturik edo protokolo analitikorik sedentarismorako eta, beraz, emaitzen txostena heterogeneoa da. Oraintsuko garapen metodologikoen barruan sartzen da sedentario izaten emandako denbora gailuetan oinarrituta ebaluatzea, neurketa-akatsak eta oroimen- alborapenak murritz ditzakeelako autoinformeetan. Ebidentzia-multzo osoa aztertzean, GDGk garrantzi handiagoa eman zion ertainetik gorako berrikuspenek emandako ebidentziari. Berrikuspen horiek guztizko denbora sedentarioaren edo eserita emandakoaren neurriak erabiltzen dituzten azterlanen ebidentzia ematen dute, edo gailuetan oinarritutako sedentarismoaren neurriak, eskuragarri daudenean. Metodoen, datu-erauzketaren eta ebidentzia-profilen xehetasun guztiak web-eranskinean aurki daitezke: ebidentzia- profilak . Sedentarismoarekin lotutako osasun-emaitza kaltegarriei buruzko ikerketa azkar ugaritu da azken hamarkadan. Ikerketa berriagoetan, garapen nabarmenen artean, areagotu egin da sedentarismoaren eta osasun-emaitza ugarien arteko dosi-erantzun erlazioei buruzko ebidentzia eta sedentarismoaren eta jarduera fisikoaren arteko interakzioaren berri ematen duena. Online eskuragarri, hemen: https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Helduetan, sedentarismo handiagoa osasun-emaitza txar hauekin lotzen da: kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eta minbiziak eragindakoa, eta gaixotasun kardiobaskularren, minbiziaren eta II motako diabetesaren intzidentzia. Hau gomendatzen da:  Helduek mugatu egin behar dute sedentario izaten ematen duten denbora. Denbora sedentarioa edozein intentsitateko jarduera fisikoarekin ordezkatzeak (intentsitatea baxua barne) osasun-onurak dakartza. Gomendio sendoa, ziurtasun ertaineko ebidentzia  Sedentarismo maila handiek osasunean dituzten eragin kaltegarriak murrizten laguntzeko, gomendatutako jarduera fisikoko mailak ‒intentsitate ertainetik bizira) baino gehiago egiten saiatu behar dute helduek. Gomendio sendoa, ziurtasun ertaineko ebidentzia ADULTS (aged 18–64 years) 39 Gomendioak Helduetan (adina 18 urtetik gora), zein da sedentarismoaren eta osasun-emaitzen artean dagoen lotura? Oro har, ebidentzia dago lotura bat dagoela sedentario izaten emandako denbora gehiagoren (batez ere, autoinformeen bidez edo gailuetan oinarritutako ebaluazioen bidez aztertu da eserita edo telebista ikusten emandako denbora) eta kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eragindakoa, eta gaixotasun kardiobaskularren eta II motako diabetesaren intzidentzia handitzearen artean (8, 35, 65, 87). Adibidez, aldeko ebidentziak berriki egindako metanalisi handi baten emaitzak biltzen ditu (n = 36 383; batez besteko adina: 62,6 urte; % 72,8 emakumeak); azelerometro batek ebaluatutako guztizko denbora sedentarioa eta kausa guztiengatiko hilkortasuna jasotzen ditu (65), eta sedentario izaten emandako denboraren igoera kausa guztiengatiko hilkortasunarekin nabarmen lotu zela erakutsi zuen. Milioi bat parte- hartzaile baino gehiago sartu zituen metanalisi baten antzeko emaitzek (87) erakutsi zuten lotura zegoela guztizko sedentarismoaren eta kausa guztiengatiko hilkortasunaren eta gaixotasun kardiobaskularrek eragindakoaren artean, jarduera fisikorako doikuntzak egin ondoren (87), nahiz eta azterlan honetan minbiziagatiko hilkortasunarekin lotutako asoziazioak ez ziren estatistikoki esanguratsuak izan jarduera fisikoa egokitu ondoren (87). Oraintsuko beste metanalisi batek (8) sedentarismoaren (eserita gisa ebaluatua) eta gaixotasun kardiobaskularrengatiko eta minbiziagatiko hilkortasunaren arteko lotura esanguratsuei buruzko informazioa eman zuen. Emaitza horien arabera, gaixotasun kardiobaskularren ondoriozko heriotza- arriskua handiagoa da (p < 0,001 joerarako) sedentarismoaren mailak altuak direnean, jarduera fisikoko kuartil baxuenean eserita emandako denbora honela neurtzen denean: "inaktiboa" (~ 5 min/egun). Azterlanaren arabera, heldu sedentarioek (egunean 8 ordu baino gehiago eserita) gaixotasun kardiobaskularren ondoriozko heriotza-arrisku handiagoa zuten; "aktiboagoak" zirenetan, berriz, (hau da, > 35,5 MET-ordu astean edo ~ 60-75 minutu egunean) arindu egin zen lotura. Sedentarismoaren eta minbiziagatiko hilkortasunaren arteko loturei buruzko emaitzak, oro har, ahulagoak izan ziren; behatutakoaren arabera, ordea, dosiari lotutako arriskua % 6-% 21 handitzen zen eserita denbora gehiago emanda (bereziki > 8 ordu egunean), baina soilik jarduera fisikoaren kuartilik baxuenean (< 2.5 MET-ordu astean) (8). Ebidentziak sedentarismoaren (eserita emandako guztizko denbora gisa neurtua) eta gaixotasun kardiobaskularren intzidentziaren (HR = 1,29 [ % 95eko CI: 1,27tik 1,30era]) arteko lotura bat bermatzen du, koaldagai potentzialetarako doikuntzaren ondoren arindu zena, jarduera fisikoaren maila barne (HR = 1,14 [ % 95eko CI: 1,04tik 1,23ra]) (88). Asiako hego-ekialdeko populazioetan egindako azterlanen berrikuspen batek ziurtasun baxuko ebidentzia eman zuen denbora sedentario handiagoa adierazle kardiometaboliko kaltegarrien probabilitate handiagoarekin lotzen dela (II motako diabetesa, BMI handiagoa, presio arterial handiagoa barne) (89). Oraintsuko bi azterlanek lotura baten berri ematen dute eguneko guztizko denbora eserita (88) eta guztizko denbora sedentarioa telebista ikusten (87) eta II motako diabetesaren intzidentziaren artean. Bi azterlanek aurkitu zuten sedentarismo handiagoa II motako diabetesaren intzidentzia-arrisku handiagoarekin lotzen zela. Adibidez, II motako diabetesarekin lotura lineal bat ikusi zen jarduera fisikorako doitzean (87) guztizko denbora sedentarioa (RR = 1,01 [ % 95eko CI: 1,00etatik 1,01era] p = < 0,001) eta telebista ikusten (RR = 1,09 [ % 95eko CI: 1,07tik 1,12ra] p = < 0,001). Gainera, lotura esanguratsu baten aldeko ebidentzia dago sedentarismoaren (telebista ikusten emandako denbora gisa neurtua) eta minbiziagatiko hilkortasunaren (35, 87) artean. Berrikuspen berriago batzuek, ziurtasun baxu eta oso baxukoek, sedentarismoaren eta kolon eta ondesteko minbiziaren (90) arteko lotura babesten duen ebidentzia ematen dute, baina ez prostatako, bularreko edo ondesteko minbiziaren intzidentziarenik (90-93). Ebidentzia gehigarriak (35) lotura esanguratsuen berri eman zuen, sedentario izaten emandako denboraren eta endometrioko, koloneko eta biriketako minbiziak garatzeko arrisku handiagoaren artean (35). Ziurtasun baxuko ebidentzia dago denbora sedentarioaren eta adipositatearen eta pisu-egoeraren beste adierazle batzuen arteko erlazio kaltegarriaren ziurtasunari dagokionez, eta sedentarismoaren eta pisu-egoeraren arteko erlazioa jarduera fisikoaren ‒intentsitate ertainetik bizira‒ kantitatearen arabera aldatzen den ala ez. Oro har, gomendio/gidalerro hauen berri emateko ebidentzia nahikorik ez zegoela eta ikerketa gehiago behar zela ondorioztatu zen. Ebidentzia mugatua dago denbora sedentarioaren murrizketaren eragin kaltegarriak ebaluatzen dituena. Adituen arabera, denbora sedentarioaren murrizketa gomendatzeak ez luke lesio-arriskurik handituko, batez ere intentsitate baxuko jarduera fisikoarekin ordezkatuz gero. ADULTS (aged 18–64 years) 40 GDGk honako hau ondorioztatu zuen: • Oro har, nahikoa ebidentzia dago OMEren gomendio berri bat garatzen laguntzeko, sedentarismoa mugatzeko eta osasunerako arriskuak murrizteko. • Ziurtasun ertaineko ebidentzia dago lotura bat dagoela denbora sedentario handiagoaren eta kausa guztiengatiko hilkortasuna eta gaixotasun kardiobaskularrek eta minbiziak eragindakoa, eta gaixotasun kardiobaskularren eta II motako diabetesaren intzidentzia handitzearen artean. • Ziurtasun baxutik ertainera arteko ebidentzia dago denbora sedentario handiagoaren eta endometrioko, koloneko eta biriketako minbizia izateko arriskua handitzearen artean. • Ez dago ebidentzia nahikorik sedentarismoaren eta adipositate-neurrien arteko loturari buruz, eta ikerketa gehiago behar da. • Sedentarismoa mugatzearen onurek edozein arrisku potentzial gainditzen dute. Badago dosi-erantzun loturarik (guztizko kantitatea, maiztasuna, iraupena, etenaldien intentsitatea)? Oro har, ziurtasun ertaineko ebidentziak dosi-erantzun erlazio ez lineala adierazten du denbora sedentarioaren (eserita edo telebista ikusten, autoinforme bidez edo gailuetan oinarrituta ebaluatua) eta kausa guztiengatiko hilkortasunaren eta gaixotasun kardiobaskularrek eta minbiziak eragindakoaren, eta gaixotasun kardiobaskularren indizearen artean (8, 35, 87). Oraintsuko metanalisi batek ziurtasun handiko ebidentzia eman zuen, azelerometroak ebaluatutako guztizko denbora sedentarioaren eta kausa kausa guztiengatiko hilkortasunaren arteko dosi-erantzun erlazioari buruz (65). Horrek adierazten du denbora sedentarioaren igoera nabarmen lotu zela kausa guztiengatiko hilkortasunarekin. Denbora sedentario gero eta handiagoetarako arrisku- zatidurak hauek izan ziren: 1,00 (erreferentea; ez hain sedentarioa); 1,28 (1,09-1,51); 1,71 (1,36-2,15); and 2.63 (1.94–3.56), balizko nahasmendu-faktoreen ondoriozko doikuntzaren ondoren, intentsitate ertainetik bizira bitarteko jarduera fisikoan emandako denbora barne (65). Sedentarismoaren eta hilkortasunaren arteko dosi-erantzun erlazioen azterketa horrek erakutsi zuen arriskua pixkanaka handitzen ari zela 7,5 ordutik 9 ordura, eta nabarmenagoa zela 9,5 ordutik gora. Egunean 10 ordu eta 12 orduko sedentarismoa 1,48 (1,22-1,79) eta 2,92 (2,24-3,83) hiltzeko arriskuarekin lotu zen, hurrenez hurren (65). Oraintsuko beste metanalisi batek dosi-erantzuna ebaluatu zuen eta lotura ez linealen berri eman zuen guztizko denbora sedentariorako eta kausa guztiengatiko hilkortasunerako (RR = 1 ordu/egun = 1,01 (1,00-1,01) ≤ 8 ordu/eguneko; eta 1,04 (1,03 – 1.05) > 8 ordu/esposizio-eguneko; eta gaixotasun kardiobaskularrengatiko hilkortasunerako (RR= 1.01 (0.99–1.02) ≤ 6 ordu/eguneko; eta RR= 1.04 (1.03–1.04) > 6 ordu/eguneko) jarduera fisikorako doikuntza egin ondoren (87). Azterlan berean, ikusi zen dosi-erantzun lotura lineal txiki bat zegoela II motako diabetesaren eta guztizko denbora sedentarioaren (1.01 (1.00 – 1.01)) artean, jarduera fisikorako eta telebista ikusteko denborarako doitu zenean (1.09 (1.07 – 1.12)) (87). Oro har, ebidentziaren arabera, sedentarismo handiagoa osasun-emaitza txarrarekin lotzen da, eta ondorioztatu zen ebidentzia nahikoa dagoela denbora sedentarioa minimizatzeko, osasunerako arriskuak murrizte aldera. Hala ere, kontuan hartuta berrikuspenetan sedentarismoa ebaluatzeko moduan aldaketa nabarmenak izan zirela (eseritako denbora, telebista ikusteko denbora autoinformatua edo gailuetan oinarrituta (azelerometroa) ebaluatua), eta denbora sedentariorako atalaseak desberdinak izan daitezkeela osasun-emaitzetan, jarduera fisikoaren mailen arabera ‒intentsitate ertainetik bizira‒ eta populazio-azpitaldeen artean, ez dago nahikoa ebidentzia denboran oinarritutako gomendio bat finkatzeko. Sedentarismoaren kantitate orokorraz gain, sedentarismoa metatzen duten patroiei buruzko ebidentzia berrikusi zen. Hala ere, ebidentzia mugatua egon zen sedentarismoan etenaldien maiztasunari eta/edo iraupenari buruzko gomendioak egiteko. GDGko honako hau ondorioztatu zuen: • Ez dago ebidentzia nahikorik sedentarismoari buruzko gomendio kuantifikatuak (denboran oinarrituak) finkatzeko. • Ez dago ebidentzia nahikorik sedentarismoan etenaldien maiztasunari eta/edo iraupenari buruzko gomendioak egiteko. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z ADULTS (aged 18–64 years) Lotura aldatzen da sedentarismoaren motaren eta eremuaren arabera? Sedentarismoaren eremu edo mota batzuk beste batzuk baino kaltegarriagoak izan daitezke, bai beren lotura zuzenei dagokienez, bai jarduera fisiko osasungarriago batean emandako denbora ordezteko potentzialari dagokionez. Sedentarismoari buruzko ikerketan hazkunde azkarra egon den arren, ebidentzia mugatuak daude, sedentarismoaren mota desberdinen eta osasun-emaitza desberdinen arteko lotura zuzenean alderatzen dutenak. Adibidez, ikerketa batzuek emaitza sendoagoak ematen dituzte sedentarismoa neurtzen denean telebista ikustearekin eta eserita emandako guztizko denborarekin alderatuta (87). Hori neurketa-akats diferentzialaren edo autoinformeko neurri eta tresnekin lotutako hondar- nahastearen ondorio izan liteke. Gaur egun, ez dago ebidentzia nahikorik osasun-emaitza desberdinekiko lotura desberdinak eta azpipopulazioaren arabera aldatzen diren modua zehazteko. Gero eta azterlan gehiagok gailuetan oinarrituta neurtzen dituzte jarduera fisikoa eta denbora sedentarioa osasun-emaitzekin lotzeko. Hala ere, gailuetan oinarritutako denbora sedentarioaren neurketatik abiatuta, sailkapen okerra gerta daiteke; izan ere, gailuen kokapen askok (adibidez, eskumuturra, gerria) ez dituzte jarrerak bereizten (adibidez, etzanda, eserita eta geldirik). Etorkizuneko ikerketek, txosten konbinatuak eta jarrerak bereizten dituzten metodoak erabilita, sedentarismorako patroiei buruzko ezagutza indartzen lagunduko dute. GDGk honako hau ondorioztatu zuen: • Ez dago ebidentzia nahikorik sedentarismoaren mota edo eremu desberdinei buruzko gomendioak egiteko. Jarduera fisikoaren mailak aldatzen du sedentarismoak hilkortasunean duen eragina? Sedentarismoak osasun-emaitzetan duen eraginean gero eta interes handiagoa dagoenez, jarduera fisikoaren mailen eta sedentarismoaren mailen arteko elkarreragin potentzialari buruzko ikerketa bultzatu da. Eskuragarri dagoen ikerketaren arabera, ziurtasun ertaineko ebidentzia dago sedentarismoaren eta kausa guztiengatiko hilkortasunaren, gaixotasun kardiobaskularrek eta minbiziak eragindakoaren arteko erlazioa aldatu egiten dela intentsitate ertaineko jarduera fisikoaren kantitatearen eta intentsitate bizikoaren artean (8, 9, 35). Aurkikuntza orokorrek erakusten dute sedentarismoaren eragina sendoagoa dela intentsitate ertainetik bizira bitarteko jarduera fisikoa kantitate baxuak egiten dituztenetan, edo, alderantziz, intentsitate ertainetik bizira bitarteko jarduera fisikoaren kantitate altuagoek arindu ditzaketela sedentarismoaren maila handiagoekin lotutako osasun- emaitza kaltegarriak. Frogatu da denbora sedentarioarekin eta kausa guztiengatiko hilkortasunarekin lotutako arriskua nabarmenagoa dela jarduera fisikoaren maila baxuagoetan maila altuagoetan baino (35). Metanalisi konbinatu batean, Ekelund et al.-ek sedentarismoaren eta jarduera fisikoaren eragin konbinatuak eta estratifikatuak ikertu zituzten kausa guztiengatiko hilkortasunean, milioi bat gizon eta emakume baino gehiagorengan, eta loturak jarduera fisikoaren mailaren arabera desberdinak zirela erakutsi zuten (9). Analisiek sedentarismoaren ‒eserita‒ eta jarduera fisikoaren ‒intentsitate ertainetik bizira‒ kuartilak erabili zituzten, eta ikusi zuten erreferentearekin alderatuta (< 4 ordu eserita eguneko eta jarduera fisikoaren ‒intentsitate ertainik bizira‒ kuartil altuena [> 35,5 MET-ordu astean]) alderatuta, ez zegoela heriotza-arrisku handiagorik 8 ordu baino gehiago eserita egoten zirenen jarraipenean, haien jarduera fisikoa 35,5 MET-ordu asteko (HR = 1,04 [ % 95eko CI: 0,99tik 1,10era]) baino gehiago izanik. Aldiz, gutxiago esertzen ziren (< 4 ordu/egun) haien jarraipenean, jarduera fisikoaren kuartilik baxuenean egonda (< 2,5 MET-ordu/aste) askoz ere heriotza-arrisku handiagoa ikusten zen (HR = 1,27 [ % 95 ik: 1,22tik 1,31ra]). Azterlanak ondorioztatu zuen, eguneko 60-75 minutu inguruko (kuartilik altuena) jarduera fisikoaren mailek ‒intentsitate ertainetik bizira‒ arindu egin dezaketela sedentarismoaren eta osasun-emaitzen arteko lotura kaltegarria, baita ezabatu ere. (9). Gomendioak 41 ADULTS (aged 18–64 years) 42 ARRISKU ALTUA 2. irudia: Sedentarismoaren eta jarduera fisikoaren arteko erlazioa PAGACetik egokitua ARRISKU BAXUA Jarduera fisiko gehiago Sedentarismoaren mailen eta jarduera fisikoaren ‒ intentsitate ertainetik bizira‒ arteko erlazio hori PAGACen berrikuspen sistematikoan laburbildu zen (35), 2. irudian erakusten den bezala. Azterlan berri batek beste ebidentzia bat eman zuen, kausa espezifikoengatiko hilkortasunarekin lotutako lotura berak aztertzean, eta antzeko aurkikuntzak erakutsi ziren (8). Metanalisi konbinatu handi batean (9 azterlan, n = 850.000, CVD hilkortasuna; 8 azterlan, n = 777.000, minbiziagatiko hilkortasuna), emaitzek erakutsi zuten, intentsitate ertainetik bizira, jarduera fisikoaren mailarik altuenek arindu egin zutela gaixotasun kardiobaskularrengatiko hilkortasun-arrisku handiagoa sedentarismoaren maila handiekin, bai eserita emandako denbora gisa neurtuta, bai telebista ikusten emandako denbora gisa neurtuta (8). Ikerketaren arabera, egunean 8 ordu baino gehiagoz eserita zeuden pertsonen artean, lotura bat zegoen heriotza-arrisku handiagoarekin, kuartil aktiboenean izan ezik, non lotura arindu egin zen. Zehatzago esanda, gaixotasun kardiobaskularrengatiko hilkortasun-arriskua % 32 handiagoa zen egunean 8 ordu baino gehiagoz eserita zeudenen artean,erreferentziazko taldearekin alderatuta (< 4 ordu/egun)(p < 0,001eko joerarako). Emaitzak ez ziren hain nabarmenak izan, baina adierazgarriak izaten jarraitu zuten, jarduera fisikoaren ziren telebista-denborarako eta gaixotasun kardiobaskularrengatiko hilkortasunerako, intentsitate ertainetik bizira bitarteko jarduera fisikoko estratuetan (8). Minbiziagatiko hilkortasunerako loturak mistoagoak izan ziren, nahiz eta, oro har, frogatu zuten jarduera fisikoaren maila altuagoek arindu egin zituztela sedentarismoaren eragin kaltegarriak, eserita emandako guztizko denbora gisa ebaluatu zirenean. Ebidentzia hori oinarri hartuta, erabaki zen jarduera fisikoaren maila altuagoak gomendatu beharko liratekeela, intentsitate ertainetik bizira, sedentarismo handia duten eta onurek arriskuak gaindituko lituzketen pertsonentzat. GDGk honako hau ondorioztatu zuen: • Ziurtasun ertaineko ebidentzia dago sedentarismoaren eta kausa guztiengatiko hilkortasunaren, eta gaixotasun kardiobaskularrek eta minbiziak eragindakoaren arteko erlazioa aldatu egiten dela jarduera fisikoaren ‒intentsitate ertainetik bizira‒ kantitatearen arabera. • Jarduera fisiko gehiago ‒intentsitate ertainetik bizira‒ egiteak arindu egin dezake sedentarismoaren eta osasun-emaitzen arteko lotura kaltegarria. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z M o re s e d e n ta ry t im e D e n b o ra s e n d e n ta ri o g e h ia g o Adinekoentzat, jarduera fisikoa ondokoetan sar daiteke: aisialdian (jolasa, jolasak, kirolak edo ariketa planifikatua), garraioatzean (bizikletan ibiltzea, oinez ibiltzea eta bizikletan ibiltzea), lanaren edo etxeko lanen zati gisa egin daiteke, eguneroko zereginei, hezkuntzari, etxeko edo komunitateko inguruneei dagokienez. Adinekoetan, jarduera fisikoak onurak dakartza osasun-emaitza hauetarako: hobetu egiten du kausa guztiengatiko hilkortasuna eta gaixotasun kardiobaskularrek eragindakoa, hipertentsioren, minbizi espezifikoen eta II motako diabetesaren intzidentzia, osasun mentala (antsietate eta depresioaren sintoma txikiak), osasun kognitiboa eta loa; adipositate-neurriak ere hobetu ditzakete. Adinekoetan, jarduera fisikoak erorikoak prebenitzen laguntzen du, eta hezur-osasunaren eta gaitasun funtzionalaren narriaduraren ondoriozko erorikoekin lotutako lesioak. Hau gomendatzen da:  Adineko guztiek erregulartasunez egin behar dute jarduera fisikoa. Gomendio sendoa, ziurtasun ertaineko ebidentzia  Adinekoek gutxienez 150-300 minutuko intentsitate ertaineko jarduera fisiko aerobikoa egin behar dute; edo intentsitate biziko jarduera fisiko aerobikoa, gutxienez 75-150 minutukoa; edo astean zehar intentsitate ertainetik bizirako jardueraren konbinazio baliokide bat, osasun-onura esanguratsuak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia  Adinekoek gutxienez 150-300 minutuko intentsitate ertaineko jarduera fisiko aerobikoa egin behar dute; edo intentsitate biziko jarduera fisiko aerobikoa, gutxienez 75-150 minutukoa; edo astean zehar intentsitate ertainetik bizirako jardueraren konbinazio baliokide bat, osasun-onura esanguratsuak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia  Asteko jarduera fisikoaren barruan, adinekoek, astean 3 egunetan edo gehiagotan, oreka funtzionala eta indar-entrenamendua nabarmentzen dituen osagai anitzeko jarduera fisikoa ‒intentsitate ertaina edo handiagoa‒ egin behar dute gaitasun funtzionala hobetzeko eta erorikoak prebenitzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia  Adinekoek 300 minutu baino gehiagora igo dezakete intentsitate ertaineko jarduera fisiko aerobikoa; edo 150 minututik gora egin intentsitate biziko jarduera fisiko aerobikoa; edo astean zehar intentsitate ertain eta biziko jardueraren konbinazio baliokide bat egin dezakete, osasunerako onura gehigarriak lortzeko. Baldintzapeko gomendioa, ziurtasun ertaineko ebidentzia Gomendioak 43 J A R D U N B ID E E G O K IA K OLDER ADULTS (aged 65 years and over) 44 Online eskuragarri, hemen: https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Aldeko ebidentzia eta oinarria Gidalerro hauetarako, adinekoentzat, PAGACek egindako ebidentziaren sintesi osoa erabili eta eguneratu zen (35). Hamabost berrikuspenek inklusio-irizpideak bete zituzten, eta loturaren berri eman zuten jarduera fisikoaren eta adinekoen osasun-emaitza espezifikoen artean (erorikoen prebentzioa eta erorikoekin, funtzio fisikoarekin, hauskortasunarekin eta osteoporosiarekin lotutako lesioak). Erorikoak prebenitzeko ebidentziak Sherrington et al-en 2019ko Cochrane Collaboration Systematic Review (42) berrikuspena erabili eta eguneratu zuen, bere jatorrizko berrikuspenaren azken bilaketa-datatik 2019ko azarora arte (bederatzi azterlan berri) argitaratutako ebidentziarekin. PubMed-en egin ziren osteoporosiari eta sarkopeniari buruz dauden berrikuspen sistematikoen bilaketak (2008tik 2019ko azarora arte argitaratuak) eta berrikuspen berririk ez eta 8 azterlan berri identifikatu ziren. Metodoen, datu-erauzketaren eta ebidentzia-profilen xehetasun guztiak web-eranskinean aurki daitezke: ebidentzia- profilak . Adinekoetan (adina 65 urte eta gehiago), zein da jarduera fisikoaren eta osasun-emaitzen arteko lotura? Ebidentzia primarioaren oinarria adinekoen populazioetan osasun-emaitzek (besteak beste, kausa guztiengatiko eta kausa espezifikoengatiko hilkortasuna, gaixotasun kardiobaskularren, II motako diabetesaren eta minbiziaren intzidentzia, adipositatea, osasun mentala eta emaitza kognitiboak) eta jarduera fisikoak dituzten loturak ebaluatzeko, helduen populazioetan bildu eta berrikusi zen literatura zientifiko bera izan zen. Ebidentzia-multzo hori bera onartu eta estrapolatu zen adinekoentzat, azterlan gehienek ez zutelako ezarri goragoko adin-mugaren irizpiderik, eta, beraz, 65 urtetik gorako helduak barne hartu zituzten. Ebidentziaren berrikuspen gehigarri bat egin zen, loturak aztertzeko eta jakinarazteko jarduera fisikoaren eta adinekoen osasun-emaitza espezifikoen artean, erorikoen prebentzioa, eta erorikoekin, funtzio fisikoarekin, hauskortasunarekin eta osteoporosiarekin lotutako lesioak barne. Adinekoen gaitasun fisikoaren murrizketaren eraginez, askotan, erorikoak eta erorikoekin lotutako lesioak gertatu ohi dira, eta ondorio larriak izan ditzakete. Istripuzko erorikoak kanpo-faktoreen (ingurunekoak) eta barne-faktoreen (adibidez, kontrol posturalean eragina duten anomalia muskuloeskeletikoak edo nerbio-sistemakoak) konbinazioaren ondorio dira. Ebidentziak erakusten duenez, jarduera fisikoa, bereziki osagai anitzeko jarduera fisikoko programak, orekaren, indarraren, erresistentziaren, ibilketaren eta funtzio fisikoaren entrenamenduaren konbinazioak barne hartzen dituztenak, erorikoen tasa murriztuarekin eta erorikoengatiko lesio-arrisku gutxiagorekin lotzen da. Oraintsuko ebidentziak erakusten du, adinekoetan, ariketa fisikoak erorikoen tasa % 23raino murriz dezakeela (tasa-arrazoi konbinatua (RaR) 0,77 [ % 95eko CI: 0,71tik 0,83ra]); horrek nabarmen murriz dezake erorikoen ondoriozko lesio-arriskua, hauek barne: hezur-hausturak, traumatismo kraneoentzefalikoa, zauri irekia, ehun bigunetako lesioa eragiten duten eroriko larriak, edo arreta medikoa edo ospitalizazioa eskatzen duen beste edozein lesio. Ebidentzia hau sendoa izan zen eta beste berrikuspen batzuen aurkikuntzak berretsi zituen (35). Helduaro goiztiarrean goren maila batera iritsi ondoren, muskulu- eta hezur-masa murriztu egiten da adinean aurrera egin ahala (hau da, sarkopenia eta osteopenia/osteoporosia) eta hori indar eta funtzio fisikoaren murrizketarekin lotuta egon daiteke. Ebidentziak erakusten du jarduera fisiko erregularrak funtzio fisikoa hobetzen duela eta adinarekin lotutako funtzio fisikoa galtzeko arriskua murrizten duela adinekoen artean. Emaitzek ondorio onuragarriak erakusten dituzte oreka dinamikoan (SMD = 1,10 [ % 95eko CI: 0,29tik 1,90era]); muskulu-indarrean (SMD = 1,13 [ % 95eko CI: 0,30etik 1,96ra]); malgutasunean (SMD = 1,22 [ % 95eko CI: 0,39tik 2,04ra]); eta bihotz eta arnas sistemen gaitasunean (SMD = 1,48 [IC del 95%: 0,42 a 2,54]) (94). Ebidentziak erakusten du, halaber, jarduera fisikoaren maila altuagoek hezurren osasuna hobetu dezaketela, eta, beraz, adinekoen osteoporosia prebenitu (eraginaren tamaina estandarizatu konbinatua 0,21 [ % 95eko CI: 0,06tik 0,36ra]) (95). Jarduera fisikoko interbentzioek bizkarrezurraren eta lepo femoralaren (aldaka) hezur-dentsitate minerala hobetu dezakete. GDGk honako hau ondorioztatu zuen: • Ziurtasun ertaineko ebidentzia dago jarduera fisikoak funtzio fisikoa hobetzen duela eta adinarekin lotutako funtzio fisikoa galtzeko arriskua murrizten duela oro har zahartzen ari den populazioan. • Ziurtasun baxuko ebidentzia dago adinekoentzat gomendatutako jarduera fisikoaren kantitateetarako eta motetarako arriskuak baxuak direla eta onurek gainditzen dituztela. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Badago dosi-erantzun loturarik (kantitatea, iraupena, maiztasuna, intentsitatea)? Ebidentziak alderantzizko erlazioa erakusten du adinekoek egindako jarduera fisikoaren kantitatearen eta funtzio fisikoa murrizteko arriskuaren artean. Oro har, jarduera fisiko handiagoa (maiztasuna, iraupena eta/edo kantitatea) onura handiagoekin lotzen da (35). Ebidentziaren arabera, nahita egindako abiadura azkarreko erresistentzia-entrenamendua gaitasun funtzional orokorra hobetzeko abiadura ertaineko erresistentzia-entrenamendua baino handiagoa izan daiteke (SMD= 0.41 [% 95 CI: 0.18 - 0.65]; eta SPPB (SMD= 0.52 [% 95 CI: 0.10 - 0.94])) (96). Jarduera fisikoaren eta erorikoen prebentzioaren arteko dosi-erantzun erlazioa aztertzen duen ebidentzia mugatua dago; hala ere, babes-ebidentzia ematen duten azterlan gehienek aurkezten dute astean 3 egunekin bat datorren programa bat. GDGk honako hau ondorioztatu zuen: • Ziurtasun altuko ebidentzia dago dosi-erantzun erlazioa alderantzizkoa dela jarduera fisiko aerobikoaren kantitatearen eta funtzio fisikoa murrizteko arriskuaren artean, adinekoen populazio orokorrean. Lotura aldatzen da jarduera fisikoaren motaren edo eremuaren arabera? Oreka, indarra, erresistentzia, ibilketa eta funtzio fisikoaren entrenamendua konbinatzen dituzten jarduera fisikoko programak lotuta daude adinekoen erorikoen tasa baxuarekin eta erorikoen ondoriozko lesioen arriskuarekin. 11 ECAren berrikuspen baten ebidentziak erakutsi zuen jarduera fisikoko hainbat interbentziotan parte hartzean (oro har, oreka- eta funtzio-ariketak gehi erresistentzia- ariketak), adinekoetan % 28ra murriz daitekeela eroriko- tasa (RaR= 0.72 [% 95 CI: 0.56 - 0.93]) (42). Erresistentzia- ariketen eragina zalantzazkoa izan zen eta datu mugatuetan oinarritu zen (RR= 0.97 [% 95 CI: 0.14 - 6.49]; proba 1; n= 73) (42). Ebidentziak iradokitzen du, halaber, askotariko ariketa- programek eragin positibo handiagoak dituztela hezurren osasunean (eraginaren tamaina estandarizatua: 0,45 [% 95 CI: 0,20 - 0,71]; p = 0,001), ariketarik egiten ez dutenekin alderatuta (95). GDGk honako hau ondorioztatu zuen: • Ziurtasun handiko ebidentzia dago oreka, indarra, martxa eta entrenamendu funtzionala (adibidez, osagai anitzeko jarduera fisikoa) konbinatzen dituzten jarduera fisikoaren mailarik altuenak adinekoen eroriko-tasa baxuarekin eta erorikoen ondoriozko lesio-arrisku gutxiagorekin lotzen direla. • Ziurtasun ertaineko ebidentzia dago askotariko ariketak sartzen dituzten programek ondorio esanguratsuak izan ditzaketela hezurren osasunean eta osteoporosiaren prebentzioan. 45 46 Online eskuragarri, hemen: https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Adinekoentzat, honela definitzen da sedentarismoa: esna egon bitartean, eserita edo etzanda emandako denbora, energia-gastu gutxirekin, lanbideko, hezkuntzako, familiako eta komunitateko inguruneetan eta garraioaren testuinguruan. Aldeko ebidentzia eta oinarria Sedentarismoa ez zen sartu 2010eko osasunerako jarduera fisikoari buruzko gomendio orokorretan (1). Populazioaren ebidentzia espezifikorik eza dela eta, adinekoen populazioen sedentarismoaren eta osasun- emaitzen arteko loturak ebaluatzeko ebidentzia-oinarri nagusia helduen populazioentzat bildutako eta berraztertutako literatura zientifiko bera izan zen, azterlan gehienek ez baitzuten adin-muga handiagoko irizpiderik ezarri, eta, beraz, 65 urtetik gorako helduak sartu ziren. Sedentarismoari buruzko ebidentziaren aurkikuntzak berrikusi ziren helduen populazio orokorrean, eta ebaluatu egin zen ebidentziarik ote zegoen emaitzak desberdinak izango liratekeela, edo ez liratekeela aplikatzekoak edo kontraindikatuta egongo liratekeela adinekoentzat. Metodoen, datu-erauzketaren eta ebidentzia-profilen xehetasun guztiak web-eranskinean aurki daitezke: ebidentzia-profilak . O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Adinekoetan, sedentarismoaren kantitate handiagoa osasun-emaitza txar hauekin lotzen da: kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eta minbiziak eragindakoa, eta gaixotasun kardiobaskularren, minbiziaren eta II motako diabetesaren intzidentzia. Hau gomendatzen da:  Adinekoek mugatu egin behar dute sedentario izaten igarotzen duten denbora. Denbora sedentarioa edozein intentsitateko jarduera fisikoarekin ordezkatzeak (intentsitate baxua barne) osasun-onurak dakartza. Gomendio sendoa, ziurtasun ertaineko ebidentzia  Sedentarismo maila handiek osasunean dituzten ondorio kaltegarriak murrizten laguntzeko, adinekoek saiatu egin behar dute jarduera fisikorako gomendatutako mailak ‒intentsitate ertainetik bizira‒ gainditzen. Gomendio sendoa, ziurtasun ertaineko ebidentzia 47 Gomendioak EMAKUMEAK HAURDUNALDIAN ETA ERDITU ONDOREN Gidalerro hauek jarduera fisikoari eta amaren eta fetuaren osasun-emaitzei heltzen diete haurdunaldian eta erditze ondoko aldian. Emakume haurdun eta erditu ondorengo guztientzat dira, haien adina, testinguru kulturala edo maila sozioekonomikoa edozein izanda ere. Haurdunaldia eta erditu ondorengo aldia emakumearen bizitzako etapak dira, eta helduaroan fisikoki aktiboak izatearen onurak helduei zuzendutako gomendioetan zehazten dira. Emakumeek, haurdunaldian eta erditu ondoren, jaio aurreko eta erditu osteko arreta medikoko espezialista baten zaintzapean egon behar dute. Espezialistak aholkuak eman ahal izango ditu haurdunaldian edo erditu ondoren emakumeek jarduera fisikoan parte hartzeko kontuan hartu beharreko alderdi bereziei buruz, haien historia medikoa eta edozein kontraindikazio kontuan hartuta. Jarraibide horiek osasun publikoan eta populazioan oinarritzen dira. Haurdunaldiarekin edo erditzearekin lotutako konplikazioak dituzten emakumeentzako orientazio klinikoa bilatu behar da. Emakumeek, haurdunaldian eta erditu ondoren, gomendio hauek betetzen saiatu behar dute ahal duten neurrian eta kontraindikaziorik ezean. JARDUERA FISIKORAKO GOMENDIOA Emakumeentzat, haurdunaldian eta erditu ondoren, jarduera fisikoa ondokoetan sar daiteke: aisialdian (jokoa, jolasak, kirolak edo ariketa planifikatua), garraiatzean (gurpiletan, oinez eta bizikletan ibiltzea), laneko eta etxeko zereginetan, eta lanbideko, hezkuntzako, familiako eta komunitateko eguneroko inguruneetan. Emakume haurdunetan eta erditu ondorengoetan, jarduera fisikoak amaren eta fetuaren osasun-onura hauek dakartza: murriztu egiten ditu aurre-eklanpsia izateko arriskua, haurdunaldiko hipertentsioa, diabetesa, gainpisua, erditzearen konplikazioak eta erditu ondorengo depresioa, baita konplikazioak ere jaioberriarengan, jaiotza-pisuan eragin kaltegarririk ekarri gabe; eta ez du handitzen fetu hilaren jaiotza-arriskua. Emakume guztientzat, haurdunaldian eta erditu ondoren, kontraindikaziorik ezean, gomendatzen da:  haurdunaldian eta erditu ondoren jarduera fisikoa erregulartasunez egitea; Gomendio sendoa, ziurtasun ertaineko ebidentzia  astean zehar intentsitate ertaineko 150 minutuko jarduera fisiko aerobikoa egitea, osasun-onura esanguratsuak lortzeko; eta Gomendio sendoa, ziurtasun ertaineko ebidentzia  jarduera aerobiko eta muskuluak indartzeko jarduera askotarikoak txertatzea. Halaber, onuragarria izan daiteke luzaketa-ariketa leunak gehitzea. Gomendio sendoa, ziurtasun ertaineko ebidentzia Horrez gain:  Haurdunaldiaren aurretik intentsitate biziko jarduera aerobikoa egin ohi zuten emakumeek, edo fisikoki aktiboak zirenek, jarduera horiek egiten jarrai dezakete haurdunaldian eta erditu ondoren. Gomendio sendoa, ziurtasun ertaineko ebidentzia PREGNANT AND POSTPARTUM WOMEN 48 Online eskuragarri, hemen: https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf • Jarduera fisiko pixka bat egitea ezer ez egitea baino hobe da. • Emakumeek, haurdunaldian eta erditu ondoren, ez badituzte gomendio hauek betetzen, jarduera fisikoren bat egitea onuragarria izango da beren osasunarentzat. • Emakumeek, haurdunaldian eta erditu ondoren, pixkanaka hasi behar dute jarduera fisikoa egiten, eta maiztasuna, intentsitatea eta iraupena gutxika handitu. • Zoru pelbikoko muskuluen entrenamendua egunero egin daiteke gernu-inkontinentzia arriskua murrizteko. Jarduera fisikoa egitean haurdun dauden emakumeentzako segurtasun-ohar gehigarriak: • Saihestu jarduera fisikoa gehiegizko beroan, batez ere hezetasuna handia denean; • Hidratatuta egon ura edanda jarduera fisikoa egin aurretik, bitartean eta ondoren; • Saihestu kontaktu fisikoa dakarten jardueretan parte hartzea; erorikoen arrisku handia dakarte, edo oxigenazioa murriz dezakete (jarduerak altitude handian, normalean altitude handian bizi ez direnean); • Saihestu, haurdunaldiaren lehen hiruhilekoaren ondoren, ahoz gorako jarreran egiten diren jarduerak; • Emakume haurdunek, kirol leihaketetan parte hartzeko edo gidalerro gomendatuen gainetik ariketa esanguratsua egiteko asmoa badute, osasun- arloko profesional batengana jo behar dute azter ditzan; • Haurdun dauden emakumeei osasun-arretako profesionalak jarduera eteteko edo mugatzeko ohartarazten dien arrisku-seinaleen berri eman behar die; arrisku-seinale horiek izanez gero, berehala kontsultatu behar die osasun-arretako hornitzaile bati • Erditu ondoren pixkanaka jarduera fisikora itzultzea, eta osasun-arloko profesional batekin kontsultatuta, zesarea bidez erdituz gero. Aldeko ebidentzia eta oinarria Emakumeentzat, haurdunaldian eta erditu ondoren, Jarduera fisikoari eta sedentarismoari buruzko gidalerro hauetarako (2020), emaitza kritiko eta garrantzitsuei heltzen dieten 7 berrikuspen sistematikoren ebidentzia- laburpenak erabili eta eguneratu ziren (28-34). 7 berrikuspenetatik lauk inklusio-irizpideak bete zituzten. Metodoen, datu-erauzketaren eta ebidentzia-profilen xehetasun guztiak web-eranskinean aurki daitezke: ebidentzia-profilak . Emakumeetan, haurdunaldian eta erditu ondoren, zein da jarduera fisikoaren eta osasun-emaitzen arteko lotura? Haurdun egon aurretik eta haurdunaldian, jarduera fisikoa egiteak haurdunaldiko konplikazio arruntak izateko arriskua murrizten lagun dezake. Haurdunaldian jarduera fisikoa egitea nabarmen lotzen da haurdunaldiko pisu gehitzea murriztearekin (MD= 1.14 kg [% 95eko CI: 1.67tik 0.62ra]) (97), eta haurdunaldiko diabetesaren arrisku baxuarekin (RR= 0.71 [% 95eko CI: 0.57tik 0.89ra]) (97), haurdunaldiaren aurretik fisikoki aktibo egotean bezala (OR= 0.70 [% 95eko CI: 0.57tik 0.85era]) (31, 34, 97), gainpisua edo obesitatea duten emakumeetan ere (97). Haurdunaldiko jarduera fisikoak ez dirudi areagotu egiten duenik haurdunaldiko hipertentsioaren edo aurre-eklanpsiaren intzidentzia (31). Ebidentziaren arabera, gainpisua edo obesitatea duten emakume haurdunen artean ez dago alde esanguratsurik haurdunaldiko hipertentsioaren intzidentzian (RR = 0,63 [ % 95eko CI: 0,38tik 1,05era]) edo aurre-eklanpsian (RR = 1,39 [ % 95eko CI: 0,66tik 2.93ra]) jarduera fisikoko interbentzio-taldeak versus jaio aurreko arreta estandarra artean (97). Aspaldi batez egon dira kezkak amaren jarduera fisikoak fetuaren garapenean eta erditzean izan ditzakeen ondorio kaltegarriei buruz. Hala ere, oraintsuko ebidentziak erakusten du jarduera fisikoa ez dagoela lotuta ondoko arrisku-intzidentziak areagotzearekin: abortua, hildako fetua erditzea edo konplikazioak erditzean (32). Ebidentziak iradokitzen du ez dagoela alderik zesarea bidezko erditzearen intzidentzian gainpisua edo obesitatea duten emakume haurdunetan jarduera fisikoko interbentzio-taldeen versus jaio aurreko arreta estandarraren artean (97). Haurdunaldiko jarduera fisikoa ez da lotzen jaiotza- pisuan (98) edo jaiotza goiztiarrean (32) eragin kaltegarriak izateko arrisku handiagoarekin, eta are O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z J A R D U N B ID E E G O K IA K 49 Gomendioak gehiago, arrisku orokorra murriz daiteke (98), baita gainpisua edo obesitatea duten emakume haurdunetan ere (RR = 1,02 [% 95eko IC: 0,54tik 1,92ra]) edo haurdunaldian pisua altua duten haurretan (RR= 0.90 [% 95eko CI: 0.65etik 1.25era]) jarduera fisikoko interbentzio-taldeen versus jaio aurreko arreta estandarraren artean (97) Erditze ondoko aldian, amek aldaketa fisiko eta emozional asko izan ditzakete. Ebidentziak erakusten du haurdunaldiko jarduera fisikoa alderantziz lotuta egon daitekeela erditze ondoko depresioarekin (29). Haurdunaldiko jarduera fisikoari buruzko 6 probako eta 11 behaketa-azterketako metanalisiaren ebidentziak (99) alderantzizko erlazio esanguratsua erakutsi zuen haurdunaldiko jarduera fisikoaren eta erditze osteko depresioaren artean (SMD = 0,58 [ % 95eko CI: 1,09tik 0,08ra]). Eragina handiagoa izan zen bost azterlanetara mugatu zenean gutxienez intentsitate ertaineko interbentzioekin (SMD = 0,70 [ % 95eko CI: 1,19tik 0,22ra]) (99). GDGk honako hau ondorioztatu zuen: • Ziurtasun altuko ebidentzia dago haurdunaldiko jarduera fisikoak haurdunaldian pisua gehitzeko eta diabetes mellitusa izateko arriskua murriz dezakeela. • Ziurtasun ertain eta altuko ebidentzia dago jarduera fisikoak ez duela handitzen haurdunaldiko hipertentsioaren intzidentzia. • Ziurtasun ertaineko ebidentzia dago, jarduera fisikoak abortuaren, hildako fetuaren jaiotzaren edo erditzearen konplikazioen intzidentzia handitzen ez duelako; eta ziurtasun ertaineko ebidentzia, intentsitate handiko jarduera fisikoa egiten duten ametan erditze goiztiarra izateko arriskua baxua dela. • Ziurtasun baxu/ertaineko ebidentzia dago jarduera fisikoak ez duela handitzen jaiotza- pisua baxua izateko arriskua, edo haurdunaldian haurraren pisua baxua izateko arriskua, edo haurdunaldian haurraren pisua altua izateko arriskua. • Ziurtasun baxuko ebidentzia dago haurdunaldiko jarduera fisikoa erditze ondoko depresio-maila baxuagoekin lotuta dagoelako. • Arriskuak baxuak dira haurdunaldian eta erditu ondoren emakumeentzat gomendatzen diren jarduera fisikoaren kantitateei eta motei dagokienez, eta onurek konpentsatzen dituzte. Badago dosi-erantzun loturarik (kantitatea, iraupena, maiztasuna, intentsitatea)? Haurdunaldiko eta erditu ondorengo aldiko jarduera fisikoari buruzko ebidentzian zehar, interbentzioak desberdinak ziren jarduera fisikoaren kopuruan (hau da, dosia), bai minutuen araberako iraupenean, bai asteko maiztasunean. Oro har, eskuragarri zegoen ebidentziak astean gutxienez 3 aldiz adierazten zuen jarduera fisiko aerobikoaren maiztasuna, normalean 30- 60 minutukoa. Ebidentzia hori helduentzat oro har gomendatzen den jarduera-kantitatearekin (hau da, astean 150 minutu intentsitate ertainean) bat datorren dosi batek osasunean duen eragina ebaluatzen duten azterlanetatik hartu da. Oro har, jarduera fisiko gehiago (maiztasuna, iraupena eta/edo kantitatea) onura handiagoekin lotzen bada ere, ikerketa gehiago behar da dosi-erantzun erlazioa zehatzago ulertzeko. Haurdunaldiaren aurretik aisialdian jarduera fisikoaren kantitate handiagoa versus txikiagoa egitea lotuta dago haurdunaldiko diabetesaren arriskua nabarmen jaistearekin (OR = 0,54 [ % 95eko CI: 0,34tik 0,87ra]) (100). Era berean, intentsitate biziko jarduera fisikoa egin zuten ametan erditze goiztiarra izateko arriskuaren murrizketa baxua baina esanguratsua dagoela erakusten duen ebidentzia dago (RR = 0,20 [ % 95eko CI: 0,36tik 0,03ra]) (98). Ez zen ebidentziarik identifikatu gomendioen gainetik dauden mailetan ariketa egitearen segurtasunari edo onura gehigarriari buruz. GDGk honako hau ondorioztatu zuen: • Ez dago ebidentzia nahikorik jarduera fisikoaren eta haurdunaldiko eta erditu ondoko osasun-emaitza kritiko espezifikoen arteko dosi-erantzun lotura zehazteko. • Ebidentzia orokorrak onurak erakusten ditu osasun- emaitza kritikoetarako, eta helduentzat oro har gomendatzen den jarduera fisikoaren kantitateekin oso koherenteak diren interbentzioetan oinarritzen da, hau da, astean 150 minutuko jarduera fisikoa, intentsitate ertainekoa. • Ez zegoen inolako oinarririk emakumeentzat, haurdunaldian eta erditu ondoren, gomendatutako intentsitate ertaineko jarduera fisikoaren kantitatea edo maiztasuna aldatzeko, populazio heldu orokorrarekin alderatuta. • Ziurtasun ertaineko ebidentzia dago arriskua baxua dela intentsitate biziko jarduera fisikoa egiten duten ametan erditze goiztiarra izateko. PREGNANT AND POSTPARTUM WOMEN 50 Lotura aldatzen al da jarduera fisikoaren motaren, domeinuaren edo unearen arabera (haurdunaldiaren, jaio aurrekoaren edo jaio ostekoaren aurretik)? Jarduera fisikoa aisialdian batez ere ebaluatu zuten azterlanen ebidentzia dago; jarduera mota aerobikoa zen nagusiki (oinez ibiltzea edo igeri egitea, adibidez), baina bada ebindentzia indar- entrenamendua (adibidez, zirkuituko entrenamendua) edo ariketa aerobikoen eta muskuluak indartzeko ariketen konbinazioak barne hartzen zituzten interbentzioak ebaluatzen dituzten azterlanena. Hala ere, oro har, ez dago ebidentzia nahikorik jarduera fisikoaren eta osasun-emaitzen arteko loturak jarduera fisikoaren motaren, eremuaren edo unearen arabera (haurdunaldiaren aurretik, jaiotza aurretik edo jaiotza ondoren) aldatzen diren zehazteko. GDGk honako hau ondorioztatu zuen: • Ziurtasun ertaineko ebidentzia dago emakumeek, haurdunaldian eta erditu ondoren, askotariko jarduera fisikoak sartu behar dituztela (aerobikoa eta muskuluak indartzekoa). Luzaketa-ariketa leunak ere onuragarriak izan daitezke. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z SEDENTARISMORAKO GOMENDIOA 51 Gomendioak Emakumeentzat, haurdunaldian eta erditu ondoren, honela definitzen da sedentarismoa: esna egon bitartean, eserita edo etzanda emandako denbora, energia-gastu gutxirekin, lanbideko, hezkuntzako, familiako, komunitateko inguruneetan eta garraioaren testuinguruan. Aldeko ebidentzia eta oinarria Sedentarismoa ez zen sartu 2020ko Osasunerako jarduera fisikoari buruzko gomendio globaletan (1). Populazio espezifikoen ebidentziarik ez zegoenez, haurdunaldian eta erditu ondoren emakumeen sedentarismoaren eta osasun-emaitzen arteko loturak ebaluatzeko ebidentzia-oinarri nagusia populazio helduentzat bildutako eta berraztertutako literatura zientifikoa izan zen. Populazio helduaren sedentarismoari buruzko ebidentziaren aurkikuntzak berrikusi ziren, eta ebaluazio bat ere egin zen ikusteko emaitzak desberdinak izango ote ziren, edo esanguratsuak izango ez ote ziren, edo kontraindikatuta egongo ote ziren emakumeentzat, haurdunaldian eta erditu ondoren. Eskura dagoen ebidentzia eta adituen iritzia oinarri hartuta, ebidentzia estrapolatu egin zen, haurdunaldian eta erditu ondoren emakumeentzako osasun-emaitza kritiko arruntetarako sedentarismoari buruz OMEk emandako gomendio berriak informatzeko. Ebidentziaren zeharkakotasuna zela eta, murriztu egin zen ziurtasun-maila. Populazio horrentzako ebidentzia espezifikorik ez zegoenez, eta emakume haurdunak azterlanetatik baztertu zirenez, jarduera fisikoaren mailak igotzeko gomendioa (sedentarismo handiaren eragin kaltegarriari aurre egiteko gomendatutako mailetatik harago) ez zen estrapolatu emakumeentzat haurdunaldian eta erditu ondoren. GDGk honako hau ondorioztatu zuen: • Populazio heldu orokorraren sedentarismoari buruzko ebidentzia estrapolatu egin daiteke gomendioak informatzeko emakumeentzat haurdunaldian eta erditu ondoren, osasun- emaitza kritiko arruntetarako. • Emakumeetan, haurdunaldian eta erditu ondoren, sedentarismoa minimizatzearen onurek gainditu egiten dituzte arriskuak. • Ebidentziaren ziurtasuna murriztu behar da, zeharkakoa delako. EMAKUMEAK HAURDUNALDIAN ETA ERDITU ONDOREN Emakumeetan, haurdunaldian eta erditu ondoren, heldu guztietan bezala, sedentarismo handiagoa honako osasun-emaitza txarrekin lotzen da: kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eta minbiziak eragindakoa, eta gaixotasun kardiobaskularren, minbiziaren eta II motako diabetesaren intzidentzia. Hau gomendatzen da: Emakumeek, haurdunaldian eta erditu ondoren, mugatu egin behar dute sedentario izaten ematen duten denbora. Denbora sedentarioa edozein intentsitateko jarduera fisikoarekin ordezkatzeak ( intentsitate baxua barne) osasunerako onurak dakartza. Gomendio sendoa, ziurtasun baxuko ebidentzia 52 HELDUAK ETA ADINEKOAK GAIXOTASUN KRONIKOEKIN (adina 18 urte eta gehiago) Orain arte, gaixotasun kronikoak dituzten pertsonentzako jarduera fisikoko gidalerro gehienak orientazio kliniko edo terapeutikora mugatu dira. Adibidez, praktika klinikoko gomendioak eta elkarte mediko profesionalek garatutako baliabideak daude onkologiarako (101), II motako diabeteserako (102), hipertentsiorako (103) eta beste gaixotasun kroniko batzuetarako (104).OMEk praktika klinikoko gida bat ere badu, gaixotasun kronikoak dituzten pazienteei jarduera fisikoa gomendatzeko (17). Gidalerro hauek dira OMEk jarduera fisikoari buruz ematen dituen lehenak gaixotasun kronikoak dituzten pertsonen populazioarentzat, bereziki minbizia (aurrerantzean, "minbizitik bizirik irtendakoak"), hipertentsioa, II motako diabetesa eta GIBa dutenentzat. GIBaren tratamendu antirretrobiral eraginkor eta oso erabilgarriaren aurrerapenak direla eta, gaixotasun hori ere kronikotzat jotzen da orain. Tratamendu akutua (kimioterapia, adibidez) jasotzen duten pazienteentzat, edo oraindik medikazioarekin egonkortu ez direnentzat, arreta medikoko profesionalek gaixotasun kroniko bakoitzerako garrantzitsuak diren praktika klinikoko gidak ere kontsultatu behar dituzte. JARDUERA FISIKORAKO GOMENDIOA Gaixotasun kronikoak dituzten helduentzat, ondokoetan sar dezakete jarduera fisikoa: aisialdian (jolasa, jokoak, kirolak edo ariketa planifikatua), garraiatzean (gurpiletan, oinez eta bizikletan ibiltzea), eta laneko edo etxeko zereginetan, lanbideko, hezkuntzako, familiako eta komunitateko eguneroko inguruneetan. Minbizitik bizirik irtendako heldu guztiek, eta hipertentsioa, II motako diabetesa eta GIBa dutenek gomendio hauek betetzen saiatu behar dute, ahal den neurrian eta kontraindikaziorik ezean. Jarduera fisikoak onurak ekar ditzake gaixotasun kroniko hauek dituzten helduen eta adinekoen osasunerako: minbizitik irtendakoentzat, jarduera fisikoak hobetu egiten ditu kausa guztiengatiko hilkortasuna, minbizi espezifikoek eragindakoa, eta minbizia berriro izateko edo bigarren minbizi primarioa izateko arriskua; hipertentsioa dutenentzat, jarduera fisikoak hobetu egiten du gaixotasun kardiobaskularrengatiko hilkortasuna, gaixotasunaren progresioa, funtzio fisikoa eta osasunarekin lotutako bizi- kalitatea; II motako diabetesa dutenentzat, jarduera fisikoak murriztu egiten ditu gaixotasun kardiobaskularrengatiko hilkortasuna eta gaixotasunaren progresio- adierazleak; eta GIBa dutenentzat, jarduera fisikoak hobetu egin ditzake egoera fisikoa eta osasun mentala (antsietate- eta depresio-sintomak murriztea) eta ez du eragin negatiborik gaixotasunaren progresioan (hau da CD4 zenbaketa eta karga birala) edo gorputz-osaeran. Hau gomendatzen da: Gaixotasun kroniko horiek dituzten heldu guztiek erregulartasunez egin behar dute jarduera fisikoa. Gomendio sendoa, ziurtasun ertaineko ebidentzia Gaixotasun kroniko horiek dituzten helduek intentsitate ertaineko jarduera fisiko aerobikoa egin behar dute gutxienez 150-300 minutu; edo intentsitate biziko jarduera fisiko aerobikoa gutxienez 75-150 minutu; edo intentsitate ertain eta biziko jardueren konbinazio baliokide bat astean zehar, osasunerako onura nabarmenak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z HELDUAK ETA ADINEKOAK GAIXOTASUN KRONIKOEKIN (adina 18 urte eta gehiago) Gomendioak 53 Aldeko ebidentzia eta oinarria Gidalerro hauen irismenak jarduera fisikoaren eta osasun-emaitza hauen arteko loturak ebaluatu zituen: minbizitik bizirik irtendakoentzat, kausa guztiengatiko hilkortasuna, minbizi espezifikoek eragindakoa, eta minbizia errepikatzeko edo bigarren minbizi primario bat izateko arriskua; hipertentsioa dutenentzat, gaixotasun kardiobaskularrengatiko hilkortasuna, gaixotasun komorbidoen arriskua, funtzio fisikoa, osasunarekin lotutako bizi- kalitatea eta gaixotasunaren progresioa; II motako diabetesa dutenentzat, gaixotasun kardiobaskularrengatiko hilkortasuna, gaixotasun komorbidoen arriskua, funtzio fisikoa, osasunarekin lotutako bizi-kalitatea eta gaixotasunaren progresioa; eta GIBa dutenentzat, funtzio fisikoa (gaitasun fisikoa, ariketarekiko tolerantzia eta indarra) , osasunarekin lotutako bizi-kalitatea, osasun mentala (antsietate- eta depresio-sintomak) gaixotasun kardiometabolikoaren arrisku- adierazleak (odol-lipidoak, glukoas odolean eta gorputz-konposizioa) eta eragin negatiboak gaixotasunaren progresioan (hau da CD4 zenbaketa eta eta karga birala). Gidalerro hauek azaltzen dituen ebidentzia PAGACen txostena izan zen (35), eta 2017tik 2019ra arte identifikatutako 16 berrikuspen berrirekin eguneratu zen, minbiziari (n = 1), hipertentsioari (n = 2) eta II motako diabetesari (n = 13) dagokienez. Horrez gain, GIBa duten pertsonen jarduera fisikoari eta osasun-emaitzei buruzko berrikuspen orokor batek 2002tik 2018ra argitaratutako 19 berrikuspen hautagarriren ebidentzia eman zuen. Metodoen, datu-erauzketaren eta ebidentzia-profilen xehetasun guztiak web-eranskinean aurki daitezke: ebidentzia-profilak . Online eskuragarri, hemen: https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf J A R D U N B ID E E G O K IA K • Aurreko gomendioak bete ezin dituztenean, gaixutasun kroniko horiek dituzten helduek beren gaitasunen arabera saiatu behar dute jarduera fisikoa egiten. • Gaixotasun kroniko horiek dituzten helduek gutxika egiten hasi behar dute jarduera fisikoa, eta denborarekin maiztasuna, intentsitatea eta iraupena pixkanaka handitu. • Gaixotasun kroniko horiek dituzten helduentzat komeni da jarduera fisikoko espezialista bati edo osasun-arloko profesional bati kontsultatzea, jarduera-motei eta -kantitateei buruzko aholkularitza egokia lortzeko, ondokoei lotuta: beren beharrizan indibidualak, gaitasunak, muga funtzionalak/konplikazioak, medikamentuak eta tratamendu-plan orokorra. • Ariketa egin aurreko baimen medikoa ez da beharrezkoa izaten kontraindikaziorik ez duten pertsonentzat, intentsitate baxu edo ertaineko jarduera fisiko bat hasi aurretik, betiere azkar ibiltzeko edo eguneroko bizitzako zereginak betetzeko eskakizunetara mugatzen denean. Gaixotasun kronikoak dituzten helduek eta adinekoek muskuluak indartzeko jarduerak ere egin behar dituzte ‒intentsitate ertaina edo handiagoa‒ muskulu- talde nagusi guztiak lantzeko, astean 2 alditan edo gehiagotan, osasun-onura gehigarriak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Astean egiten duten jarduera fisikoaren barruan, gaixotasun kronikoak dituzten adinekoek osagai anitzeko askotariko jarduera fisikoa egin behar dute, batez ere oreka funtzionala eta indar-entrenamendua ‒intentsitate ertaina edo handiagoa‒ astean 3 egun edo gehiagotan, gaitasun funtzionala areagotzeko eta erorikoak prebenitzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia  Kontraindikaziorik ezean, gaixotasun kroniko horiek dituzten helduek eta adinekoek 300 minutu baino gehiago egin dezakete intentsitate ertaineko jarduera fisiko aerobikoa; edo 150 minutu baino gehiago intentsitate biziko jarduera fisiko aerobikoa; edo intentsitate ertaineko eta biziko jardueraren konbinazio baliokide bat astean zehar, osasun-onura gehigarriak lortzeko. Baldintzapeko gomendioa, ziurtasun ertaineko ebidentzia 54 HELDUAK ETA ADINEKOAK GAIXOTASUN KRONIKOEKIN (adina 18 urte eta gehiago) Minbizia (minbizitik bizirik irtendakoak), hipertentsioa, II motako diabetesa edo GIBa duten 18 urtetik gorako helduetan, zein da jarduera fisikoaren eta osasun-emaitzen arteko lotura? Jarduera fisikoak aldaketa onuragarriak sustatzen ditu epe laburrera eta luzera bide metaboliko, hormonal eta inflamatorioetan, eta uste da aldaketa horiek minbiziaren intzidentzian eta minbizitik bizirik irteten laguntzen dutela (35). Ebidentziak erakusten duenez, aurkitu zen fisikoaren maila altuagoek, minbiziaren diagnostikoen ondoren, babestu egiten zutela kausa guztiengatiko hilkortasuna eta jarraian bularreko minbizia (HR = 0,58 [ % 95eko CI: 0,52tik 0,65era], 17 azterlan); kolon eta ondesteko minbizia (HR = 0,63 [ % 95eko CI: 0,50etik 0,78ra], 10 azterlan), emakumeen ugalketa-sistemako minbizia (HR= 0.66 [95% CI: 0.49tik 0.88ra]), 4 azterlan); glioma (HR= 0.64 [% 95 CI: 0.46tik 0.91ra], azterlan 1); minbizi hematologikoa (HR = 0,60 [IC % 95: 0,51tik 0,69ra], 2 azterlan ); giltzurruneko minbizia (HR = 0,60 [IC % 95ekoa: 0,38tik 0,95era], azterlan 1); birikako minbizia (HR = 0,76 [IC % 95ekoa: 0,60tik 0,97ra], 2 azterlan); prostatako minbizia (HR = 0,60 [IC del 95%: 0,46 a 0,79], 5 azterlan); eta urdaileko minbizia (HR = 0,75 [CI 95%: 0,61 a 0,93], azterlan 1) (105). Minbiziaren diagnostikoaren ondorengo jarduera fisiko handiagoa lotuta dago gainera kausa espezifikoek eragindako hilkortasunaren arrisku baxuagoarekin, bularreko minbizitik, kolon eta ondestekotik, eta prostatakotik bizirik irtendakoetan. Metanalisiak hilkortasun-arriskuen murrizketa aurkitu zuen diagnostikoaren ondorengo guztizko jarduera fisikoaren mailarik altuenetan versus baxuenean, ondokoetan: minbizi konbinatu guztiak (HR = 0,63 [ % 95eko CI: 0,53tik 0,75era], 4 azterlan); bularreko minbizia (HR = 0,63 [ % 95eko CI: 0,50etik 0,78ra], 13 azterlan); kolon eta ondesteko minbizia (HR= 0.62 [% 95eko CI: 0.44tik 0.86ra], 6 azterlan) eta postatako minbizia (HR= 0.70 [% 95eko CI: 0.55etik 0.90era], 4 azterlan) (105). Hala ere, ez zen ebidentzia nahikorik egon jarduera fisikoa minbiziaren errepikapenarekin edo bigarren minbizi primarioarekin lotuta dagoen zehazteko. Jarduera fisikoa garrantzitsua da hipertentsioaren lehen mailako prebentziorako eta berau maneiatzeko, eta argi dago jarduera fisikoak hobetu egiten dituela funtzio fisikoa, gaixotasun kardiobaskularren progresioa (hau da, presio arterialaren erantzuna jarduera fisikoari) eta hipertentsioa duten pertsonen gaixotasun kardiobaskularrengatiko hilkortasuna (35). Adibidez, ariketa gabeko kontrol-taldeekin alderatuta, fisikoki aktiboak diren pertsona hipertentsoek presio arterial sistolikoa gutxi gorabehera 12 mm Hg murriz dezakete, eta presio arterial diastolikoa 6 mm Hg gutxi gorabehera (SBP MD = 12,26 mm Hg [ % 95eko CI: 15,17tik 9,34ra], p = < 0,05; DBP MD = 6,12 mm Hg [% 95eko CI: 7.76 to 4.48], p= < 0.05) (106). Agertutako ebidentziak erakusten du fisikoki aktiboak diren pertsona hipertentsoek nabarmen hobe dezaketela osasunarekin lotutako bizi-kalitatea, inaktibo dauden pertsona hipertentsoekin alderatuta (54). Jarduera fisikoa, jarduera aerobikoa, muskuluak indartzeko jarduera eta jarduera aerobikoa gehi muskuluak indartzeko jarduera barne, lotuta dago progresio-arriskuaren adierazle sekundario hobeekin (HbA1c, presio arteriala, BMI eta lipidoak) II motako diabetesa duten helduetan (35). Adibidez, berriki egindako ikerketa baten arabera, erresistentzia-entrenamendua lotuta zegoen HbA1c-ren murrizketa handiagoarekin versus kontrol-taldeak, eta intentsitate handiko erresistentzia-entrenamenduak eragin positibo esanguratsuak ditu baraualdiko intsulinan (107). Ez dago ebidentzia nahikorik jarduera fisikoak dituen eraginak ebaluatzeko osasunarekin lotutako bizi-kalitatean eta funtzio fisikoan II motako diabetesa duten helduetan. GIBa duten pertsonetan jarduera fisikoak bihotz eta arnas sistemako gaitasuna hobetzen du. Aztertutako interbentzioek barnean hartu zituzten bai ariketa aerobikoa, bai ariketa muskuluak indartzeko ariketa progresiboarekin konbinatuta, gutxienez 30 minutuz, astean 3 aldiz (108, 109). Era berean, argi dago jarduera fisikoko interbentzioek arrisku kardiometabolikoaren adierazleak hobe ditzaketela (adib., lipidoak), nahiz eta emaitzak mistoak izan; ez zen eraginik ezarri intsulinaren kontzentrazioan, nahiz eta glukosa murriztu egin zen entrenamendu aerobikoaren ondoren (110). Jarduera fisikoa, bai aerobikoa, bai muskuluak indartzeko ariketarekin konbinatua, GIBa duten pertsonetan, osasunarekin lotutako bizi-kalitatearekin (111) eta depresio- eta antsietate-sintomak murriztearekin (112) positiboki lotzen da. Depresiorako metanalisiak (9 azterlan) 0,84ko SMD bat (% 95eko CI: 1,57tik 0,11ra) erakutsi zuen interbentzio-taldeen alde (p = 0,02). Antsietatea murrizteko SMD (5 azterlan) ere estatistikoki esanguratsua izan zen, interbentzioaren alde (1,23 [CI % 95: 2,42tik 0,04ra], p = 0,04) (112). Jarduera fisikoa lotzen da, halaber, batez besteko gehikuntza estandarizatu esanguratsuekin 1,75 kg-ko gorputz-masa baxuetan, eta ariketa egiten duten kontrol-taldeetako parte-hartzaileen gorputz-gantzaren % 1,12ko murrizketa nabarmenarekin, bai eta hanketako eta besoetako muskulu periferikoen eremua handitzearekin ere, ariketa egiten ez duten kontrol-taldeetako kideekin alderatuta (111), baina ez da lotzen GIBa duten pertsonen BMI edo gerriaren zirkunferentziaren aldaketekin (111). Jarduera fisikoak ez du eragin negatiborik GIBaren progresio-adierazleetan, besteak beste, CD4 zenbaketa (zelulak/mm3) edo karga birala (111). Nabarmentzekoa da ebidentzia horrek iradokitzen duena, hau da, jarduera fisikoak ez duela eragin negatiborik izango GIBan, gaixotasun kroniko bat denez gero. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z HELDUAK ETA ADINEKOAK GAIXOTASUN KRONIKOEKIN (adina 18 urte eta gehiago) Gomendioak 55 GDGk honako hau ondorioztatu zuen: • Ziurtasun ertaineko ebidentzia dago minbizia diagnostikatu ondoren jarduera fisiko handiagoa lotu egiten dela hilkortasun-arrisku batxuagoarekin, kausa guztiek, kausa espezifikoek eta minbizi espezifikoek eragindakoa denean, minbizitik bizirik irtendakoetan. • Ziurtasun altuko ebidentzia dago jarduera fisikoak gaixotasun kardiobaskularren progresio-arriskua murrizten duela hipertentsioa duten helduetan. • Ziurtasun ertaineko ebidentzia dago jarduera fisikoak hipertentsioa duten helduen funtzio fisikoa eta osasunarekin lotutako bizi-kalitatearen emaitzak hobetzen dituela. • Ziurtasun altuko ebidentzia dago jarduera fisikoak gaixotasunaren progresio-adierazleak hobetzen dituela (HbA1c, presio arteriala, BMI eta lipidoak) II motako diabetesa duten helduetan. • Ziurtasun ertaineko ebidentzia dago lotura bat dagoela jarduera fisikoaren eta gaitasun fisikoaren (oxigeno-kontsumo maximoa, ariketarekiko tolerantzia) eta muskuluen indarraren hobekuntzaren artean GIBa duten pertsonetan, eta lotura onuragarriak jarduera fisikoaren eta gorputz- osaeraren, osasunarekin lotutako bizi-kalitatearen, depresio- eta antsietate-sintomak murriztearen artean, eta dagoela aldaketarik birus-kargan edo CD4 zenbaketan GIBa duten pertsonetan. • Osasun-emaitza espezifikoei dagokienez, minbizitik bizirik irtendakoek, hipertentsioa, II motako diabetesa eta GIBa dutenek jarduera fisikoa erregulartasunez egitean arriskuak gainditzen dituzte onurek Badago dosi-erantzun loturarik (kantitatea, iraupena, maiztasuna, intentsitatea)? Minbiziaren diagnostikoaren ondoren, jarduera fisiko gehiago egitea lotu egin da kausa guztiengatiko eta minbizi espezifikoek eragindkao hilkortasun-arrisku baxuagoarekin. Ebidentziak erakusten du erlazio ez lineala dagoela diagnostikoaren ondorengo jarduera fisikoaren goranzko mailen eta bularreko minbizi espezifikoagatiko eta kausa guztiengatiko hilkortasunaren artean, astean 10-15 MET-ordu arte egiten denean (jarduera fisikoaren intentsitate ertainetik bizirako 150 minutu/aste), maila altuagoetan izandako kalteen ebidentziarik gabe (105). Beste minbizi espezifiko batzuetarako antzeko dosi-erantzun lotura bat adierazten da, baina oso azterlan gutxi egin ziren metanalisi formala ahalbidetzeko. Ikerketa gehiago behar dira loturaren indarra zehazteko. Dosi-erantzun lotura argia dago jarduera fisikoaren eta gaixotasun kardiobaskularrengatiko hilkortasunaren artean hipertentsioa duten pertsonetan (35). Emaitzek erakusten dutenez, hipertentsio-mailen barruan presio arterial sistolikoak gora egin ahala, gaixotasun kardiobaskularrengatiko hilkortasun-arriskuak gora egiten du, baina arriskuaren igoera hori jarduera fisikoaren maila altuagoekin arintzen da (35). Populazio orokorrarentzako gomendioen antzera, ohiko interbentzio gehienak intentsitate ertaineko jarduera aerobikoan oinarritzen da: 30-60 minutu, astean 3 egunetan, eta/edo 2-3 erresistentzia-entrenamendu saio astean. II motako diabetesa duten helduetan, jarduera fisikoaren kantitatearen eta gaixotasun kardiobaskularrengatiko hilkortasun-arriskuaren arteko alderantzizko lotura baten funtsezko ebidentzia dago (113-115). Jarduera fisikoaren kantitate handiagoek (intentsitate ertaineko jarduera fisikoaren 150 minutu/aste gomendatutako mailetan, azpitik nahiz gainetik) pixkanaka murrizten dute arriskua. Adibidez, jarduerarik ez egitearekin alderatuta, jardueraren bat egitea gaixotasun kardiobaskularrengatiko hilkortasun-arriskua % 32 murriztearekin lotu zen (HR doitua = 0,68 [ % 95eko CI: 0,51tik 0,92ra]); aldiz, jarduera fisikorako gidalerroak edo maila horietatik gora betetzea gaixotasun kardiobaskularrengatiko hilkortasun-arriskua % 40 murriztearekin lotu zen (HR doitua= 0.60 [% 95 CI: 0.44 to 0.82]) (115). Interbentzio gehienak hauetan oinarritzen dira: intentsitate ertaineko 150-300 minutuko jarduera fisiko aerobikoa edo intentsitate biziko 75 minutukoa, edo/eta erresistentzia-entrenamenduko 2 edo 3 saio astean. Emaitza batzuetarako (adibidez, HBA1c eta presio arteriala), II motako diabetesa duten helduetan, jarduera aerobiko handiagoaren eragin sendoago baten ebidentzia dago (hau da, astean 150 minutu baino gehiago versus astean 150 minutu baino gutxiago), baina intentsitaterako ebidentzia mugatua da (35). GIBa duten pertsonetan, ez dago ebidentzia nahikorik jarduera fisikoaren eta gorputz-osaeraren arteko dosi- erantzun erlazioa ezartzeko, edo gaixotasun kardiometabolikoen erdi mailako adierazleetarako (odoleko lipidoen profilak, intsulinarekiko erresistentzia, baraualdiko glukosa-kontzentrazioak edo presio arteriala). Ebidentzia eman zuten azterlan gehienek 12 eta 48 aste bitartean astean gutxienez 3 aldiz egindako jarduera fisikoko interbentzioak barne hartu zituzten, barne hartzen zituztenak gutxienez 30 minutuko ariketa aerobikoa, intentsitate ertainetik bizira, bakarrik edo erresistentzia-entrenamendu progresiboarekin batera. Era berean, ez dago ebidentzia nahikorik osasun mentalaren eta osasunarekin lotutako bizi-kalitatearen emaitzetarako dosi-erantzun erlazioa zehaztasun 56 HELDUAK ETA ADINEKOAK GAIXOTASUN KRONIKOEKIN (adina 18 urte eta gehiago) handiagoz ezartzeko. Eskura dagoen ebidentzia astean 3 aldiz edo gehiagotan jarduera fisikoko interbentzioak ebaluatzen dituzten azterlanetatik dator. Oro har, ziurtasun ertainetik alturako ebidentzia zegoen intentsitate ertaineko (edo baliokidea) 150-300 minutuko jarduera fisikoaren gomendio bat babesteko, gaixotasun kronikoak dituzten pertsonen populazio espezifikoentzat eta osasun-emaitzen multzo espezifikoarentzat. Ebidentzia argiagoa zegoen jardueraren maila altuagoak lotuta zeudela hipertentsioa eta II motako diabetesa dutenen eta minbizitik bizirik irtenden osasun-onura handiagoekin. Ebidentziaren ziurtasunean eta zehaztasunean izandako aldaketak aitortu ziren, gaixotasun kroniko espezifikoaren eta aztertutako emaitza espezifikoen arabera. Ebidentziak indar-entrenamenduaren emaitza positiboak erakutsi zituen, jardueraren maiztasuna erresistentzia-entrenamenduko 2 edo 3 saiokoa izan zenean astean. GDGk honako hau ondorioztatu zuen: • Ziurtasun ertaineko ebidentzia dago dosi-erantzun erlazioa dagoela jarduera fisikoaren eta kausa guztiengatiko hilkortasunaren eta minbizi espezifikoengatiko hilkortasunaren murrizketaren artean minbizitik bizirik irtendakoetan. • Ziurtasun altuko ebidentzia dago dosi-erantzun erlazioa dagoela jarduera fisikoaren eta gaixotasun kardiobaskularrengatiko hilkortasunaren artean hipertentsioa duten helduetan. • Ebidentzia dago dosi-erantzun erlazio alderantzizkoa dagoela jardueraren kantitatearen eta gaixotasun kardiobaskularrengatiko hilkortasun-arriskuaren artean II motako diabetesa duten helduetan. • Ez dago ebidentzia nahikorik dosi-erantzun erlazioa dagoela jarduera fisikoaren eta gaixotasun kardiometabolikoen erdi mailako adierazleen, gorputz- osaeraren, osasunarekin lotutako bizi-kalitatearen eta antsietate- eta depresio-sintomen artean, GIBa duten pertsonetan. • Intentsitate ertaineko 150-300 minutuko jarduera aerobikoko (edo baliokideko) interbentzioek osasun- emaitza onak eta indar-entrenamenduaren emaitza positiboak eman zituzten, ikusi zenean, erresistentzia- entrenamenduko 2 edo 3 saio astean egiten zirenean. Lotura aldatzen da jarduera fisikoaren motaren edo eremuaren arabera? Ebidentzia argia dago jarduera fisikoaren mota eta eremu desberdinek osasun-emaitza onak ematen dituztela. Minbizitik bizirik irtendakoek, jarduera fisiko aerobikoaren eta muskuluak indartzeko ariketen maila gomendatuak betetzen dituztenek, gomendio horiek betetzen ez dituztenen aldean, minbiziagatiko hilkortasun- arrisku baxuagoa dute (HR doitua = 0,70 [% 95eko CI: 0,50etik 0,98ra]) (84). Ebidentziak erakusten du muskuluak indartzeko jarduera fisikorako gomendioa bakarrik betetzea ere, ez betetzearekin alderatuta, onuragarria dela minbiziagatiko hilkortasun-emaitzak hobetzeko (HR = 0,66 [ % 95eko CI: 0,48tik 0,92ra]) (84). Metanalisi batek jarduera fisikoaren eremuaren araberako lotura horien berri eman zuen, eta murrizketa esanguratsuenak minbizi guztiengatiko hilkortasunean, eta bularreko minbiziak, eta kolon eta ondesteko minbiziak eragindakoan aurkitu zituen, aisialdiko jarduera fisikorako (105). Hipertentsioa duten helduetan, ebidentziak babestu egiten ditu jarduera aerobikoa, muskuluak indartzeko jarduera eta bien konbinazioa gaixotasun kardiobaskularren progresioa murrizteko. Hipertentsioa duten pertsonetan ez dirudi nabarmen aldatzen direnik presio arteriala murrizteko dituzten eraginak jarduera fisikoa egiteko ohiko moduek (hau da, jarduera aerobikoa eta erresistentziakoa) (35); hala ere, ebidentzia hori ez da jarduera moten arteko konparazio zuzenetan oinarritzen. Hipertentsioa duten pertsonetan, beste ariketa-mota batzuen (adibidez, Tai Chi, yoga, Qigong) eragin onuragarriak babesteko ere ebidentzia dago; hala ere, ikerketa gehiago behar dira jarduera-mota espezifiko horiek aztertzeko, loturaren indarra zehazteko. Jarduera aerobikoa, muskuluak indartzeko jarduera edo bien arteko konbinazioa, lotuta progresio-arriskuaren (HbA1c, presio arteriala, BMI eta lipidoak) bigarren mailako adierazle hobetuekin II motako diabetesa duten helduetan (35, 107). 24 IKE RCTren (n = 962) berrikuspen batek jakinarazi zuen erresistentzia- entrenamendua HbA1c-ren murrizketa handiagoarekin lotuta zegola, kontrol-taldeekin alderatuta (MD = 0,45 [% 95eko CI: 0,65etik 0,25era], 20 proba; n = 824). Eragin estatistikoki esanguratsuak aurkitu ziren intentsitate biziko erresistentzia entrenatzeko versus kontrol-taldeak intsulinarekin baraualdian (MD = 4,60 [ % 95eko CI: 7,53tik 1,67ra], 5 proba; n = 174) (107). 7 RCTren (n = 189) beste berrikuspen batek jakinarazi zuen entrenamendua pausaldiekin (astean 2-5 aldiz; 1-4 minutuko pausaldiak; saioaren guztizko iraupena 20-60 minutu) lotuta zegoela HbA1c-ren % 0,26ko ( % 95eko CI: % 0,46tik % 0,07ra, 5 RCT) murrizketa estatistiko esanguratsuarekin, MICTekin alderatuta, eta % 0,83ko (95% CI: 1.39% to 0.27%, 4 RCT) murrizketarekin ariketarik egin gabeko kontrol-taldeekin alderatuta (116). Populazio orokorrarentzako gomendioetan bezala, interbentzio gehienak jarduera aerobikoan oinarritzen dira, 150-300 minutuko intentsitate ertaineko jarduera aerobikoaren (edo 75 minutuko intentsitate biziko jardueraren) eta muskuluak indartzeko astean 2-3 saioko jardueraren gomendioaren O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z HELDUAK ETA ADINEKOAK GAIXOTASUN KRONIKOEKIN (adina 18 urte eta gehiago) 57 arabera. Emaitza batzuetarako (adib.: HBA1c eta presio arteriala), eragin sendoagoaren ebidentziak daude jarduera aerobiko gehiago eginda (hau da, astean 150 minutu baino gehiago versus astean 150 minutu baino gutxiago), baina ebidentzia mugatua da intentsitaterako. Ikerketa berriagoek Ariketa txinatar tradizionalek, Tai Chi kasu, onura gluzemikoak izan ditzaketela erakusten dute, baina ziurtasun ertain eta aldakorreko ebidentziak izan ziren (hau da, alborapen-arriskua edo bat ez etortzea). Ikerketa gehiago behar da lotura horiek zehazteko. Ebidentzia dago askotariko jarduera fisikoak, entrenamendu aerobikoak eta erresistentziakoak barne, eragin positiboak dituztela GIBa (111) duten pertsonen osasunarekin lotutako bizi-kalitatean. Ariketa aerobikoari, erresistentzia progresiboari edo bien konbinazioari erantzunez, osasunarekin lotutako bizi-kalitatearen aldaketak aztertzen dituzten ikerketa berriek osasun orokorrean eta osasun mentalean hobekuntza nabarmenak daudela erakusten dute. Era berean, agerikoa da jarduera aerobikoa eta osagai anitzekoa lotuta dagoela GIBa duten pertsonen depresio- eta antsietate-sintomak murriztearekin (112). Jarduera fisikoak osasun mentalaren sintometan dituen eraginen ebidentziak hartu hartu ditu barnean: jarduera aerobikoa, edo aerobikoa eta muskuluak indartzeko jarduera progresiboa konbinatuta, edo yoga. Ebidentziak erakusten du ariketa aerobikoak bakarrik edo erresistentzia- ariketarekin konbinatuta ez duela aldaketa esanguratsurik eragiten GIBa duten pertsonen birus- kargan edo CD4 zenbaketan (111). Literatura eguneratuaren ebidentzia zuzenak II motako diabetesa eta hipertentsioa duten pertsonek jarduera fisiko aerobikoa eta muskuluak indartzekoa egiteko gomendioak sartzea laguntzen du. Ebidentziarik argitaratu ez bada ere, ikuspegi biologikotik onartua dago jarduera fisiko aerobikoak eta muskuluak indartzekoak GIBa duten helduei eta minbizitik bizirik irtendakoei onurak dakarzkiela. Gainera, GDGk adierazi zuenez, ezarritako nazioarteko praktika klinikoko gidalerroek gomendatu egiten dute jarduera fisiko aerobikoa eta muskuluak indartzekoa populazio horietarako (adibidez, ACSM "Moving Through Cancer" gidalerroak (101) ebidentziaren berrikuspen sistematikoan oinarrituta (3). Ebidentzia-oinarri hori oraindik azaleratzen ari dela onartuta, ziurtasun-maila murriztu egin zen. GDGk honako hau ondorioztatu zuen: • Ziurtasun ertaineko ebidentzia dago jarduera aerobikoaren edo muskuluak indartzekoaren eragin konbinatu edo gehigarrietarako, minbiziagatiko hilkortasuna murrizteko eta hipertentsioa duten pertsonen presio arteriala hobetzeko. • Ziurtasun altuko ebidentzia dago jarduera aerobikoak, muskuluak indartzeko jarduerak, eta aerobikoak gehi muskuluak indartzekoak, gaixotasunaren progresio- adierazleak (HbA1C, presio arteriala, BMI eta lipidoak) hobetzen dituztela II motako diabetesa duten helduetan. • Ziurtasun ertaineko ebidentzia dago ariketa aerobiko erregularrak, bakarrik edo erresistentzia-ariketarekin konbinatuta, ez duela aldaketa esanguratsurik eragiten GIBa duten pertsonen birus-kargan edo CD4 zenbaketan. • Ez dago ebidentzia nahikorik indar-entrenamenduak soilik bizi-kalitatean eragina duela GIBa duten pertsonetan. 58 Sedentarismoa ez zen sartu 2010eko Osasunerako jarduera fisikoari buruzko gomendio globaletan (1). Minbizitik irtendakoen eta hipertentsioa, II motako diabetesa eta GIBa dutenen sedentarismoari buruzko gomendio berri honen irismena. Sedentarismoa honela definitzen da: esna egon bitartean, eserita edo etzanda emandako denbora, energia- gastu gutxirekin, lanbideko, hezkuntzako, familiako eta komunitateko inguruneen eta garraioaren testuinguruan. Aldeko ebidentzia eta oinarria Ebidentziarik ez dagoenez populazioaren espezifikoentzat, minbizitik bizirik irtendako heldu eta adinekoetan eta hipertentsioa, II motako diabetesa eta GIBa duten heldu eta adinekoetan, sedentarismoaren eta osasun-emaitzen arteko loturak ebaluatzeko ebidentzia-oinarri nagusia populazio helduentzat bildu eta berrikusitako literatura zientifikoa izan zen. Helduen populazio orokorraren sedentarismoaren inguruko aurkikuntzak berrikusi ziren, eta ebaluatu ere egin zen ebidentziarik egongo ote zen emaitzak desberdinak izango liratekeela edo ez liratekeela aplikatzekoak edo kontraindikatuta egongo liratekeela gaixotasun kronikoak dituzten heldu eta adinekoetan. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Helduetan, minbizitik bizirik irtendakoak eta hipertentsioa, II motako diabetesa eta GIBa dutenak barne, sedentarismo handiagoa osasun-emaitza txar hauekin lotzen da: kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskularrek eta minbiziak eragindakoa; eta gaixotasun kardiobaskularren, minbiziaren eta II motako diabetesaren intzidentzia. Minbizitik irtendako helduentzat, eta hipertentsioa, II motako diabetesa eta GIBa duten helduentzat, honako hau gomendatzen da: Gaixotasun kronikoak dituzten heldu eta adinekoek mugatu egin behar dute sedentario izaten igarotzen duten denbora. Denbora sedentarioa edozein intentsitateko jarduera fisikoarekin ordezkatzeak (intentsitate baxua barne) osasunerako onurak dakartza. Gomendio sendoa, ziurtasun baxuko ebidentzia Sedentarismo maila handiek osasunean dituzten eragin kaltegarriak murrizten laguntzeko, gaixotasun kronikoak dituzten helduek eta adinekoek saiatu egin behar dute jarduera fisikorako ‒intentsitate ertainetik bizira‒ gomendatzen diren mailak gainditzen. Gomendio sendoa, ziurtasun baxuko ebidentzia HELDUAK ETA ADINEKOAK GAIXOTASUN KRONIKOEKIN (adina 18 urte eta gehiago) Eskura dagoen ebidentzia eta adituen iritzia oinarri hartuta, ebidentzia estrapolatu egin zen gaixotasun kronikoak dituzten helduentzako sedentarismoari buruz OMEk emandako gomendio berriei buruz informatzeko, osasun-emaitza kritikoen multzo konbinaturako. Ebidentziaren estrapolazioa, neurri handi batean, honako ebaluazio honek babesten du: azterlan gehienek ez zuten goi-mailako adin- mugaren irizpiderik ezarri, 65 urtetik gorako helduak barne hartu zituzten eta gaixotasun kronikoak dituzten helduak sar zitzaketen, hala nola minbizitik bizirik irtendakoak, eta hipertentsioa edo II motako diabetesa dutenak. GIBa duten pertsonentzat, ez zen identifikatu arrazoirik jakiteko zergatik sedentarismoak osasunean duen eraginari buruzko ebidentzia ez litzatekeen aplikatzekoa. Gomendio horiek garatzeko ebidentzia zeharkakoa zenez, ziurtasun-maila murriztu egin zen. Era berean, intentsitate ertain eta biziko jarduera fisiko gehiago egitearen onurari buruzko ebidentziaren aplikagarritasuna ere kontuan hartu zen, sedentarismo handiaren arrisku potentzialei aurre egiten laguntzeko, eta estrapolatu ere egin zen, gaixotasun kronikoak dituzten helduentzako gomendioen berri emateko, osasun-emaitza kritikoen multzorako. Zeharkakoa zenez, ebidentziaren ziurtasuna murriztu egin zen. GDGk honako hau ondorioztatu zuen: • Populazio heldu orokorraren sedentarismoari buruzko ebidentzia estrapolatu egin daiteke, minbizitik bizirik irtendako heldu eta adinekoentzako eta hipertentsioa, II motako diabetesa eta GIBa duten heldu eta adinekoentzako gomendioak informatzeko, emaitza kritikoen multzo konbinaturako. Ebidentziaren ziurtasun-maila murriztu egin zen zeharkakoa zelako. • Populazio heldu orokorrean, sedentarismo handiaren arrisku potentzialei aurre egiten laguntzeko intentsitate ertain eta biziko jarduera fisiko gehiago egiteak dituen onurei buruzko ebidentzia estrapolatu egin liteke, minbizitik bizirik irtendako heldu eta adinekoentzat eta hipertentsioa, II motako diabetesa eta GIBa duten heldu eta adinekoentzako gomendioak informatzeko, emaitza kritikoen multzo konbinaturako. Ebidentziaren ziurtasun-maila murriztu egin zen zeharkakoa zelako. • Sedentarismoa minimizatzearen onurek gainditu egiten dituzte kalteak minbizitik bizirik irtendakoentzat eta hipertentsioa, II motako diabetesa eta GIBa duten pertsonentzat.. 59 60 Desgaitasuna duten haur, nerabe eta helduek osasun-onura handiak lor ditzakete jarduera fisikoa egiten badute. Desgaitasun bat duten haur, nerabe eta helduek gomendio hauek betetzen saiatu behar dute, ahal duten neurrian. Desgaitasuna duten haur, nerabe eta helduentzat, jarduera fisikoa ondokoetan sar daiteke: aisialdian (jolasa, jokoak, kirolak edo ariketa planifikatua), gorputz-heziketan, garraiatzean (gurpiletan, oinez eta bizikletan ibiltzea) edo etxeko zereginetan, familiako, hezkuntzako, lanbideko eta komunitateko inguruneetan. Garrantzitsua da desgaitasuna duten haur, nerabe eta heldu guztiei beren adinerako eta gaitasunerako egokiak, atseginak eta askotarikoak diren jarduera fisikoetan parte hartzeko aukerak eta pizgarriak ematea. Jarduera fisikoak haur eta nerabeentzat dituen onuretako asko, aurreko atalean adierazi bezala, desgaitasuna duten haur eta nerabeekin ere lotzen dira. Jarduera fisikoak desgaitasun bat duten pertsonen osasun-emaitzei dakarzkien onura gehigarriak honako hauek dira: kognizioa hobetzea funtzio kognitiboa narriatzen duten gaixotasunak edo nahasmenduak dituzten pertsonetan, arreta-defizitaren/hiperaktibitatearen nahasmendua (ADHN) barne; funtzio fisikoan hobekuntzak ekar ditzake desgaitasun intelektuala duten haurretan. Hau gomendatzen da:  Desgaitasuna duten haur eta nerabeek, astean zehar, batez beste eguneko 60 minutu egin behar dute jarduera fisikoa ‒ intentsitate ertainetik bizira ‒ eta batez ere aerobikoa. Gomendio sendoa, ziurtasun ertaineko ebidentzia  Intentsitate biziko jarduera aerobikoak, bai eta muskuluak eta hezurrak indartzen dituztenak ere, gutxienez astean 3 egunetan sartu behar dira. Gomendio sendoa, ziurtasun ertaineko ebidentzia Jarduera fisiko pixka bat egitea ezer ez egitea baino hobe da. Desgaitasuna duten haurrek eta nerabeek ez badituzte gomendio hauek betetzen, jarduera fisikoren bat egitea onuragarria izango da beren osasunarentzat. Desgaitasuna duten haurrek eta nerabeek gutxika hasi behar dute jarduera fisikoa egiten, eta maiztasuna, intentsitatea eta iraupena pixkanaka handitu. Ez dago arrisku esanguratsurik desgaitasuna duten haur eta nerabeentzat jarduera fisikoa egitean, baldin eta egokia bada pertsonaren unean-uneko jarduera-mailarako, osasun-egoerarako eta funtzio fisikorako; eta osasun-onurak gehituta, gutxitu egiten dira arriskuak. Baliteke desgaitasuna duten haurrek eta nerabeek osasun-arloko profesional bati edo jarduera fisikoko eta desgaitasuneko espezialista bati kontsultatu behar izatea, haientzat egokia den jarduera-mota eta -maila zehazten laguntzeko. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z J A R D U N B ID E E G O K IA K HAURRA ETA NERABEAK (adina 5–17 urte) ETA HELDUAK (adina 18 eta gehiago) DESGAITASUNAREKIN Aurreko atalean adierazi bezala, jarduera fisikoak helduentzat dituen osasun-onuretako asko desgaitasuna duten helduekin ere erlazionatzen dira. Desgaitasuna duten pertsonen osasun- emaitzetarako jarduera fisikoak dituen onura gehigarriak honako hauek dira: esklerosi anizkoitza duten helduentzat, hobekuntza funtzio fisikoan, eta gaitasun fisiko, mental eta sozialean, osasunarekin lotutako bizi-kalitateari dagokionez; bizkarrezur-muineko lesioa dutenentzat, hobekuntza ibiltzeko funtzioan, baita muskuluen indarrean eta goiko gorputz- adarren funtzioan ere, eta osasunarekin lotutako bizi-kalitate hobea; funtzio kognitiboa narriatzen duten nahasmenduak dituztenentzat, hobekuntza funtzio fisikoan eta kognitiboan (Parkinsonen gaixotasuna dutenetan eta istripu zerebrobaskularren aurrekariak dituztenetan), kognizioaren gaineko eragin onuragarriak, eta hobetu egin ditzake bizi-kalitatea (eskizofrenia duten helduetan), eta funtzio fisikoa (desgaitasun intelektuala duten helduetan), baita bizi-kalitatea ere (depresio klinikoa duten helduetan). Hau gomendatzen da: Desgaitasuna duten heldu guztiek erregulartasunez egin behar dute jarduera fisikoa. Gomendio sendoa, ziurtasun ertaineko ebidentzia Desgaitasuna duten helduek intentsitate ertaineko 150-300 minutuko jarduera fisiko aerobikoa egin behar dute; edo intentsitate biziko jarduera fisiko aerobikoa 75- 150 minutu gutxienez; edo astean zehar intentsitate ertain eta biziko jardueraren konbinazio baliokide bat, osasun-onura esanguratsuak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Desgaitasuna duten helduek muskuluak indartzeko jarduerak ere egin behar dituzte, intentsitate ertain edo handiagokoak, astean 2 egunetan edo gehigotan, muskulu- talde nagusi guztiak lantzeko, osasun-onura gehigarriak lortzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Asteko jarduera fisikoaren barruan, desgaitasuna duten adinekoek askotariko jarduera fisikoa egin behar dute, osagai anitzekoa, oreka funtzionala eta indar-entrenamendua nabarmenduz, intentsitate ertain edo handiagoan, astean 3 egunetan edo gehiagotan, gaitasun funtzionala hobetzeko eta erorikoak prebenitzeko. Gomendio sendoa, ziurtasun ertaineko ebidentzia Desgaitasuna duten helduek intentsitate ertaineko jarduera fisiko aerobikoa 300 minututik gora igo dezakete; eta intentsitate biziko jarduera fisiko aerobikoa 150 minututik gora; edo astean zehar intentsitate ertain eta biziko jardueraren konbinazio baliokide bat, osasun-onura gehigarriak lortzeko. Baldintzapeko gomendioa, ziurtasun ertaineko ebidentzia Jarduera fisiko pixka bat egitea ezer ez egitea baino hobe da. Desgaitasuna duten helduek ez badituzte gomendio hauek betetzen, jarduera fisikoren bat egitea onuragarria izango da beren osasunarentzat. Desgaitasuna duten helduek gutxika hasi behar dute jarduera fisikoa egiten, eta maiztasuna, intentsitatea eta iraupena pixkanaka handitu. Ez dago arrisku esanguratsurik desgaitasuna duten helduentzat jarduera fisikoa egitean, baldin eta egokia bada pertsonaren unean-uneko jarduera-mailarako, osasun-egoerarako eta funtzio fisikorako; eta osasun-onurak gehituta, gutxitu egiten dira arriskuak. Baliteke desgaitasuna duten helduek osasun-arloko profesional bati edo jarduera fisikoko eta desgaitasuneko espezialista bati kontsultatu behar izatea, haientzat egokia den jarduera-mota eta -maila zehazten laguntzeko. J A R D U N B ID E E G O K IA K > > > > > Gomendioak 61 62 Aldeko ebidentzia eta oinarria Desgaitasuna duten haur, nerabe eta helduentzako gidalerro hauetarako, PAGACek egindako ebidentzia integralaren sintesia erabili eta eguneratu zen (35). Jarduera fisikoari eta osasun-emaitzei buruz dagoen ebidentzia honen taula laburtuak eta metodoen eta datu-erauzketaren xehetasun guztiak eskuragarri daude (35), eta GDGk berrikusi zituen, bilaketa eguneratuaren aurkikuntzez gain. Gidalerro hauetarako egindako eguneratzeak 39 berrikuspen identifikatu zituen, 2017tik 2019ra bitartean argitaratutakoak. Horietatik 27k inklusio-irizpideak bete zituzten, eta jarduera fisikoaren eta desgaitasuna duten haur, nerabe eta helduen osasunarekin lotutako emaitzen arteko loturaren azterketaren berri eman zuten. Metodoen, datu-erauzketaren eta ebidentziaren lan-sorta laburtuak web-eranskinean aurki daitezke: ebidentzia- profilak . Berrikusitako ebidentziak jarduera fisikoaren eta desgaitasuna duten haur, nerabe eta helduen osasun- emaitzen arteko lotura kontuan hartu zuen, honako osasun-egoera hauetatik ondorioztatuta: esklerosi anizkoitza, bizkarrezur-muineko lesioa, desgaitasun intelektuala, Parkinsonen gaixotasuna, istripu zerebrobaskularra, depresio kliniko larria, eskizofrenia eta arreta-defizitaren/hiperaktibitatearen nahasmendua (ADHN). Osasunarekin lotuta azertutako lau emaitzetan, gaixotasun komorbidoak izateko arriskua, funtzio fisikoa, funtzio kognitiboa eta osasunarekin lotutako bizi-kalitatea sartu ziren, baina ez ziren gaixotasun bakoitzerako emaitza guztiak aztertu. Jarduera fisikoaren testuinguruan ingurumen- faktoreek desgaitasunean duten eragina gidalerro hauen irismenetik haratago zegoen eta ez zen aztertu. Desgaitasuna duten haur eta nerabeetan (5- 17 urte) eta helduetan (18 urtetik gorakoak), zein lotura dago jarduera fisikoaren eta osasun-emaitzen artean? Esklerosi anizkoitza duten pertsonentzat, jarduera fisikoak hobetu egiten ditu funtzio fisikoa, mugikortasun funtzionala, abiadura eta ibiltzeko erresistentzia, eta bihotz eta arnas sistemaren gaitasuna, indarra eta oreka. Adibidez, intentsitate handiko entrenamenduak pausaldiekin, 3-12 astez eginda, erakutsi zuen hobekuntzak zekartzala bihotz eta arnas sistemaren gaitasunean edo muskuluen indarrean (117), eta beheko gorputz-adarretako indar- entrenamendua eginda ikusi zen indarra % 23,1 handitu zela ( % 95eko CI: 11,8tik 34,4ra) 13,2 asteko batez besteko entrenamendu-aldian (118), 13 asteko batez besteko entrenamendu aldiaren emaitzaz handitu egiten zen indarra, eta dantza- interbentzioetako azterlanek hobekuntzen berri eman zuten mugikortasun funtzionalean eta orekan. Osasun fisikorako onurez gain, ebidentziak erakusten du jarduera fisikoa mesedegarria izan daitekeela esklerosi anizkoitza duten pertsonen kognizioan (35). Ikerketa berriagoek erakusten dutenez, ariketa aerobikoak eragin txikia baina esangurtsua du osasunarekin lotutako bizi-kalitatearen arlo fisiko, mental eta sozialetan (neke- sintomak eta sintoma depresiboak barne) (35, 120). Bizkarrezur-muineko lesioa duten pertsonentzat, jarduera fisikoak ibiltzearen funtzioa, indar muskularra eta goiko gorputz-adarren funtzioa hobetu ditzake (35). Jarduera fisikoak sorbaldako mina ere murriz dezake, eta funtzio baskularra eta osasunarekin lotutako bizi-kalitatea hobetu (35). Parkinsonen gaixotasuna duten pertsonentzat, jarduera fisikoak hobetu egin ditzake sintoma motorrak, mugikortasun funtzionala eta errendimendua, erresistentzia, ibilera bizkorra mantentzea eta aurrerako eta atzerako mugimenduaren abiadura (35, 121, 122). Ebidentzia berriak iradokitzen du ariketak Parkinsonen gaixotasuna duten pertsonen funtzio kognitibo globalari ere lagun diezaiokeela (123). Istripu zerebrobaskularren aurrekariak dituzten pertsonentzat, jarduera fisikoak funtzio fisikoa hobetu dezake, bereziki goiko gorputz-adarren funtzioa, beheko gorputz-adarraren funtzio sentsorial motorra, oreka, ibileraren abiadura, distantzia, gaitasuna eta erresistentzia, bihotz eta arnas sistemaren gaitasuna, mugikortasuna eta eguneroko bizitzako jarduerak egitekoa. Dagoen ebidentziak iradokitzen du jarduera fisikoak ere eragin onuragarriak izan ditzakeela kognizioan (35). Depresio kliniko larria duten pertsonentzat, berrikuspen berriek (124, 125) babestu egin zuten jarduera fisikoak osasunarekin lotutako bizi-kalitatea hobetu dezakeela erakusten duen ebidentzia (35, 124, 125). Funtzio kognitiboa narriatzen duten gaixotasunak edo nahasmenduak, eskizofrenia barne, dituzten pertsonentzat, jarduera fisikoak eragin onuragarriak izan ditzake kognizioan, oroimen funtzionalean, kognizio sozialean eta arretan/zaintzan (35, 126). Berrikuspen baten arabera, intentsitate ertainetik bizira bitarteko jarduera fisikoak hobekuntza nabarmenak eragin zituen osasunarekin eta desgaitasunarekin lotutako bizi-kalitatean (35, 124). Online eskuragarri, hemen: https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Desgaitasun intelektuala duten pertsonetan, jarduera fisikoak funtzio fisikoa hobetzen duela frogatu da. Berrikusitako interbentzioek jarduera hauetan oinarritu ziren batez ere: oreka- eta indar-jarduerak, 6- 24 astez. Hala, oreka estatikoa, oreka dinamikoa eta oreka estatiko/dinamikoa nabarmen hobetu zirela adierazi zuten, kontrol-taldeekin alderatuta (35, 127, 128). Arreta-defizit eta hiperaktibitatearen nahasmendua duten haurretan, ebidentziak, ADHN barne hartzen duten 5 IKEren RTCren berrikuspena biltzen duenak (129), lotura positiboa erakusten du ariketaren eta ondokoekin lotutako nahasmenduen artean: arreta, funtzio exekutiboa eta kognizio soziala (35, 129). GDGk haurren, nerabeen eta helduen populazio orokorraren ebidentzia hartu zuen kontuan, eta ondorioztatu zuen ez dagoela arrazoirik uste izateko desgaitasunaren eragina aldatuko litzatekeela eta osasun-onura fisiologiko berberak ekarriko lituzkeela fisikoki aktiboa izanda. GDGk aitortu zuen azterlan gutxik jasotzen dituztela desgaitasuna duten pertsonak, eta eraginaren aldaketa gutxitan frogatzen dela. Desgaitasunaren arloko ebidentzia horrek, populazio orokorrarentzako ebidentzia zabalagoarekin batera, babestu egin zuen populazio orokorrean desgaitasuna duten pertsonak barne hartzeko egindako gomendioa, "heldu guztiak", "adineko guztiak" eta "gaitasun guztietako pertsonak" aipatuz. GDGk honako hau ondorioztatu zuen: Bizkarrezur-muineko lesioa duten pertsonetan, ebidentzia hau dago: • ziurtasun baxuko ebidentzia, jarduera fisikoak sorbaldako mina murrizten duela, gorputz-adar geldietako funtzio baskularra hobetzen duela, baita osasunarekin lotutako bizi-kalitatea ere; eta • ziurtasun ertaineko ebidentzia, jarduera fisikoak ibiltzearen funtzioa, indar muskularra eta goiko gorputz-adarren funtzioa hobetzen dituela. Funtzio kognitiboa, Parkinsonen gaixotasuna barne, narriatzen duten gaixotasunak edo nahasmenduak dituzten pertsonetan, ebidentzia hau dago: • ziurtasun altuko ebidentzia, jarduera fisikoak zenbait emaitza funtzional hobetzen dituela, hala nola ibiltzea, orekaren, indarraren eta gaixotasunaren berariazko emaitza motorrak; eta • ziurtasun ertaineko ebidentzia, jarduera fisikoak ‒intentsitate ertainetik bizira‒ kognizioan eragin onuragarriak izan ditzakeela. Istripu zerebrobaskularraren aurrekariak dituzten pertsonetan, ebidentzia hau dago: • ziurtasun ertaineko ebidentzia, mugikortasunera bideratutako jarduera fisikoak funtzio fisikoan eta kognizioan eragin onuragarriak izan ditzakeela. Funtzio kognitiboa, eskizofrenia barne, narriatzen duten gaixotasunak edo nahasmenduak dituzten pertsonetan, ebidentzia hau dago: • ziurtasun ertaineko ebidentzia, jarduera fisikoak bizi- kalitatea hobetzen duela; eta • ziurtasun altuko ebidentzia, jarduera fisikoak ‒intentsitate ertainetik bizira‒ kognizioan, oroimen funtzionalean, kognizio sozialean eta arretan ondorio onuragarriak izan ditzakeela. Depresio kliniko larria duten helduetan, ebidentzia hau dago: • ziurtasun ertaineko ebidentzia, jarduera fisikoak bizi- kalitatea hobetzen duela. Esklerosi anizkoitza duten helduetan, ebidentzia hau dago: • ziurtasun altuko ebidentzia, jarduera fisikoak, bereziki jarduera aerobikoak eta muskuluak indartzekoak, hobetu egiten dituela funtzio fisikoa, mugikortasun funtzionala, abiadura eta ibiltzeko erresistentzia, eta bihotz eta arnas sistemaren gaitasuna, indarra eta oreka; • ziurtasun ertaineko ebidentzia, jarduera fisikoak kognizioan eragin onuragarria izan dezakeela; eta • ziurtasun baxuko ebidentzia, jarduera fisikoak bizi-kalitatea hobetzen duela, nekearen sintomak eta depresio-sintomak barne. Desgaitasun intelektuala duten haur eta helduetan, ebidentzia hau dago: • ziurtasun gutxiko ebidentzia, jarduera fisikoak funtzio fisikoa hobetzen duela. ADHN duten haur eta nerabeetan, ebidentzia hau dago: • ziurtasun ertaineko ebidentzia, jarduera fisikoak ‒ intentsitate ertainetik bizira‒ kognizioan eragin onuragarriak izan ditzakeela, arreta, funtzio exekutiboa eta kognizio soziala barne. GDGk ondorioztatu zuen, gainera, nahikoa ebidentzia zientifiko dagoela jarduera fisikoak desgaitasun-eremu askotan osasun-emaitza anitzetan duen eragin positiboari buruz, eta jarduera fisikoak desgaitasuna duten pertsonentzat dituen onurek kalte potentzialak gainditzen dituztela. Gomendio horiek garatzeko ebidentzia zeharkakoa zenez, ziurtasun-maila murriztu egin zen. Gomendioak 63 64 Desgaitasuna duten haur, nerabe eta helduentzat, honela definitzen da sedentarismoa: esna dauden bitartean, eserita edo etzanda igarotzen duten denbora, energia-gastu gutxirekin, hezkuntzako, familiako eta komunitateko inguruneetan, eta garraiatzean. Posible da sedentarismoa saihestea eta fisikoki aktiboa izatea eserita, erdi etzanda edo etzanda egon bitartean, adibidez, goiko gorputz-adarra lantzeko jarduerak, eta gurpil-aulkientzako jarduera espezifikoak eta kirol inklusiboak eginda. Aldeko ebidentzia eta oinarria Sedentarismoa ez zen sartu Osasunerako jarduera fisikoari buruzko gomendio globaletan (2010). Populazio espezifikoen ebidentziarik ez dagoenez, desgaitasuna duten haur, nerabe eta helduen sedentarismoaren eta osasun-emaitzen arteko loturak ebaluatzeko ebidentzia-oinarri nagusia desgaitasunik gabeko populazioentzat bildutako eta berrikusitako literatura zientifikoa izan zen. Populazio orokorraren sedentarismoari buruzko ebidentziaren aurkikuntzak berrikusi ziren, baita ebaluatu ere ebidentziarik ote zegoen emaitzak desberdinak izango liratekeela, edo ez liratekeela aplikatzekoak izango edo kontraindikatuta egongo liratekeela desgaitasuna duten haur, nerabe eta helduetan. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Helduetan, sedentarismo handiagoa osasun-emaitza txar hauekin lotzen da: kausa guztiengatiko hilkortasuna, gaixotasun kardiobaskulek eta minbiziak eragindakoa, eta gaixotasun kardiobaskularren, minbiziaren eta II motako diabetesaren intzidentzia. Hau gomendatzen da:  Desgaitasuna duten helduek mugatu egin behar dute sedentario izaten igarotzen duten denbora. Denbora sedentarioa edozein intentsitateko jarduera fisikoarekin ordezkatzeak (intentsitate baxua barne) osasun-onurak dakartza. Gomendio sendoa, ziurtasun baxuko ebidentzia  Sedentarismo maila handiek osasunean dituzten eragin kaltegarriak murrizten laguntzeko, desgaitasuna duten helduek jarduera fisikoa egin behar dute intentsitate ertainetik bizira eta gomendatutako mailak gainditzen saiatu. Gomendio sendoa, ziurtasun baxuko ebidentzia Haur eta nerabeetan, sedentarismo handiagoa osasun-emaitza txar hauekin lotzen da: adipositatea handitzen da; bihotz eta arnas sistemaren gaitasuna urritzen da, baita gaitasun fisikoa eta portaera/jokabide prosoziala ere; eta loaren iraupena murrizten da. Hau gomendatzen da:  Desgaitasuna duten haur eta nerabeek mugatu egin behar dute sedentario izaten igarotzen duten denbora, batez ere pantaila aurreko aisialdiko denbora. Gomendio sendoa, ziurtasun baxuko ebidentzia CHILDREN AND ADOLESCENTS (aged 5–17 years) AND ADULTS (aged 18 years and over) LIVING WITH DISABILITY Eskura dagoen ebidentzia eta adituen iritzia oinarri hartuta, ebidentzia estrapolatu egin zen desgaitasuna duten helduentzako sedentarismoari buruz OMEk emandako gomendio berriak informatzeko, osasun-emaitza kritikoen multzo konbinaturako, eta aitortu zen populazio-talde jakin batzuk, gurpil-aulkien erabiltzaileak kasu, ezinbestean esertzen direla denbora-tarte luzeetan, eta, beraz, esertzea litzatekeela araua. Talde horietan, sedentarismoa honela definitu behar da: energia-gastu baxuko denbora, adibidez, aulki elektriko batean mugitzea edo eskuzko gurpil-aulki batean eserita egonda bultzatua izatea. Ez dago ikerketarik sedentarismoaren eta osasun-emaitzen arteko loturari buruz desgaitasuna duten pertsonetan. Hala ere, adituen iritziaren arabera, ez dago arrazoirik uste izateko desgaitasunaren eragina aldatuko litzatekeenik, eta, beraz, osasun-onura fisiologiko berberak lortuko lirateke, desgaitasuna duten pertsonen sedentarismoa mugatuta. Gomendio horiek garatzeko ebidentzia zeharkakoa zenez, ziurtasuna murriztu egin zen. Kontuan hartu zen, halaber, helduek jarduera fisiko gehiago ‒intentsitate ertainetik bizira‒ egitearen onurari buruzko ebidentziaren aplikagarritasuna, sedentarismo handiaren arrisku potentzialei aurre egiten laguntzeko, eta estrapolatu ere egin zen, desgaitasuna duten helduentzako gomendioak informatzeko, osasun-emaitza kritikoen multzo konbinaturako. Zeharkakoa zenez, ebidentziaren ziurtasuna murriztu egin zen. GDGk honako hau ondorioztatu zuen: • Haur eta nerabeen populazioen sedentarismoari buruzko ebidentzia, oro har, desgaitasuna duten haur eta nerabeetara estrapolatu daiteke, haien gaitasun espezifikoaren arabera. • Helduen populazio orokorraren sedentarismoari buruzko ebidentzia, helduentzat jarduera fisikoa ‒ intentsitate ertainetik bizira‒ gehiago egiteak dakartzan onurak barne, sedentarismo handiaren arrisku potentzialak murrizten laguntzeko, oro har estrapolatu egin daiteke desgaitasuna duten heldu eta adinekoetara, beren gaitasun espezifikoaren arabera. Hala ere, ebidentziaren ziurtasuna murriztu egin zen zeharkakoa zelako. • Desgaitasuna duten haur, nerabe, heldu eta adinekoen sedentarismoa minimizatzearen onurek kalteak gainditzen dituzte. 65 HAUR AK ETA NERABEAK (adina 5–17 urte) ETA HELDUAK (adina 18 urte eta gehiago) DESGAITASUNAREKIN 66 EBIDENTZIATIK GOMENDIOETARA GRADE prozesuaren arabera, gomendio eguneratuen idazketa eta haren sendotasunaren kalifikazioa ("sendoa" edo "baldintzapekoa") honako hauetan oinarritu ziren: onuren eta kalteen balantzea; ebidentziaren ziurtasuna; gidalerroen eraginpean daudenen balioekiko eta lehentasunekiko sentikortasuna; generoaren, gizartearen eta osasunaren ekitatean izan dezaketen eragina; eta onargarritasuna, bideragarritasuna eta baliabideen inplikazioak. Hauek populazio talde bakoitzarentzat kontuan hartu ziren, baina eztabaidatutako gaien eta kontsiderazioen antzekotasuna dela eta, hemen finkatu eta aurkezten dira. Gomendioaren sendotasuna onuren eta kalteen balantze ebaluatuan oinarritu zen batez ere. Gomendioak "sendoak" izan ziren onuren eta kalteen arteko oreka funtsezkotzat jo bazen gomendioaren xede-populazioarentzat, eta "baldintzapekotzat" onuren eta kalteen arteko oreka baxua bazen edo xede-populazioan onuretan aldakortasun handia egon bazen. Kalteei buruzko ebidentzia beste berrikuspen sistematiko bat enkargatuz bilatu zen espezifikoki. Hala ere, mugatua izan zen; izan ere, ebidentzia gehienak eliteko atletei eta lehiaketetan parte hartzen dutenei eragindako lesioak eta kalteak dira, populazio orokorrari egindakoak baino gehiago. Oro har, ebidentzia mugatua izanda, eta adituen iritziaren arabera informatua, ondorioztatu zen arriskua ez zela baxuagoa edo altuagoa. Oro har, ebidentziak adierazten du jarduera fisikoaren onurek nabarmen gainditzen dituztela kalteak, eta jarduera fisikoa interbentzio garrantzitsua izan daitekeela dagoen osasun-arrakala bat ixten laguntzeko, batez ere desabantailan dauden populazioentzat. GDGk osasunaren zuzentasunari, bideragarritasunari eta onargarritasunari buruzko gaiak ere hartu zituen kontuan, eta 2020ko martxoaren 31tik 2020ko apirilaren 17ra bitartean egindako gomendioen proiektuari buruzko online kontsulta publikoan parte hartu zuen. Kontsulta publikorako inkestak galdera espezifikoak planteatzen zituen gomendioak ezartzeak norbanakoei eta gobernuei eragiten dizkien kostuen eta osasunerako izan ditzakeen onuren arteko orekari buruz, bai eta gidalerroek osasuneko ekitatea hobetuko ote luketen ere. Gainera, gomendioen proiektua eta iruzkinen formularioa jarduera fisikoari buruzko gidalerro nazionalak idazteko prozesua hasi berri zuten herrialdeei bidali zitzaizkien. Online kontsultaren 420 aurkezpen baino gehiagoren iruzkinak jaso ziren, baita OMEren Europako Eskualde Bulegoaren iruzkinen bilduma gehigarri bat ere,OMEren eta estatu kideen zentro laguntzaileen iruzkinak erantsita. Kontsulta horretako iruzkinak bildu, GDGk berrikusi eta bideragarritasunari, baliabideen inplikazioei eta osasun-ekitateari buruzko iritzia emateko erabili ziren, Zuzendaritza Taldearekin eta GDGrekin egindako kontsulten bidez. Erabakiak adostasunez hartu ziren, eztabaida bidez. GDGk gomendio bakoitzari eta gomendioaren indarrari buruzko adostasuna lortu zuen; ez zen kalifikaziorik edo bozketarik behar izan. EBIDENTZIAREN ZIURTASUNAREN EBALUAZIOA GRADE markoa GDGk erabili zuen IP/ECOetan identifikatutako emaitza bakoitzari laguntzen dion lehen mailako ikerketaren ziurtasuna aztertzeko, eta ebidentziaren ziurtasun orokorra ebaluatu zuen, hauek kontuan hartuta: ebidentziaren alborapen, sendotasun falta, zehaztugabetasun eta zeharkakotasun arriskua eta argitalpenen joera emaitza bakoitzean. Informazio hori IP/ECO bakoitzerako zehazten duten taula grafikoak web-eranskinean daude eskuragarri ebidentzia-profilak . Ebidentziaren ziurtasunaren ebaluazioa ebaluatutako emaitza guztien ebaluazio orokorrean oinarritu zen, eta kausa guztiengatiko hilkortasuna eta hilkortasun kardiobaskularra lehenetsi zituen emaitzarik kritikoenetan, ondoren beste emaitza kliniko batzuk (erorikoak, depresioa, kognizioa, osasunarekin lotutako bizi-kalitatea, etab.), eta gero tarteko emaitzak (adibidez, adierazle kardiometabolikoak, beste adierazle metaboliko batzuk), baita kalteak ere. Ebidentzia espezifikoki berrikusi ez zenean, besteak beste azpipopulazioen sedentarismorako, batez ere talde horien ebidentzia faltagatik, populazio orokorrarentzat ebidentzia estrapolatu eta murriztu egin zen egokitzat jo zenean, zeharkakoa izateagatik. Online eskuragarri, hemen: https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z ONURAK ETA KALTEAK Gomendioak garatzean, inpaktu edo arrisku kaltegarrien ebaluazioa egin zen. Ebidentzia mugatua zenean, erabakiak GDGren esperientzian oinarritu ziren. Oro har, populazio guztientzat ondorioztatu zen jarduera fisikoaren onurak eta sedentarismoa mugatzeak kalte potentzialak gainditzen zituztela. Gidalerro hauek herritar guztientzat dira, eta ez diete heltzen atletek izandako onurei eta kalteei beharrezko jarduera-motak eta kantitatea egiten dutenean lehiaketetarako errendimendu hobea lortzeko. Jarduera fisiko pixka bat egitea ezer ez egitea baino hobe da. Gaur egun pertsonek ez badituzte gomendio hauek betetzen, jarduera fisikoren bat egiteak osasun-onurak ekarriko dizkie. Hasteko, jarduera fisikoa gutxika egiten hasi behar dute, eta denborarekin maiztasuna, intentsitatea eta iraupena pixkanaka handitu. Ariketa egin aurreko baimen medikoa normalean ez da beharrezkoa. Pertsona inaktiboek, intentsitate ertaineko jarduera bati ekiteko pixkanaka hasten direnek, ez dute bat-bateko bihotz-gertakarien arrisku ezagunik, eta arrisku oso baxua dute hezur, muskulu edo artikulazioetako lesioak izateko. Intentsitate ertaineko jarduera egin ohi duen pertsona intentsitate bizira igaro daiteke pixkanaka, osasun-arloko profesional bati kontsultatu beharrik izan gabe. Beren jarduera-maila handitzean sintoma berriak garatzen dituztenek galdetu egin behar diote osasun-arretako profesional bati. Jarduera fisiko mota eta kantitate egokia aukeratzeak eragina izan dezake haurdunaldian, gaixotasun kronikoetan eta desgaitasunetan, eta ahal den neurrian eta kontraindikaziorik ezean egin behar da. Baliteke pertsona horiek jarduera fisikoko espezialista bati edo osasun-arloko profesional bati kontsultatu nahi izatea, aholkularitza jasotzeko ondokoei buruz: haien premia indibidualetarako egokiak diren jarduera-mota eta -kantitatea, haien trebetasunak, muga funtzionalak/konplikazioak, medikamentuak eta tratamendu-plan orokorra. Jarduera fisikoak, intentsitate baxu eta ertainekoak, oro har, ez dakar arrisku handirik, eta denentzat gomendatzen da. BALIOAK ETA LEHENTASUNAK Gidalerroen eraginpean daudenen balioak eta lehentasunak hartu ziren kontuan (kasu honetan, gurasoak eta zaintzaileak, haurrak eta nerabeak, helduak, adinekoak, emakume haurdunak eta erditze ondokoak, gaixotasun kronikoak eta/edo desgaitasunak dituzten pertsonak). Oro har, lehentasunei buruz ziurgabetasun gutxi edo batere ez zegoela ondorioztatu zen, emaitza nagusiei dagokienez, hilkortasuna eta hilkortasun kardiobaskularra barne. Kalkulatutako onura potentzialek kalte potentzial oro gainditu zuten neurri handi batean; beraz, GDGk ikusi zuen gomendioetan ez zutela eraginik lehentasunek. BALIABIDEEN INPLIKAZIOA GDGren iritzi adituak eta ebidentzia-multzo txiki batek, jarduera fisikoaren mailak handitzearen ondoriozko osasun-arretako sistemetarako interbentzioen eta aurrezpenen analisi ekonomikoak informatzen dituenak, gomendioek ingurune desberdinetako baliabideetan zituzten inplikazioei buruzko eztabaidaren berri eman zuten. Gainera, online kontsulta publikoaren emaitzek erakutsi zutenez, inkestatuen % 75 baino gehiago ados edo oso ados zeuden gidalerroak ezartzearen onurek norbanakoarentzat kostua gaindituko zutela, eta % 81 ados edo oso ados zeuden gidalerroak ezartzearen onurek gobernuarentzat kostua konpentsatuko zutela. Eskura dagoen ebidentziak eta adituen iritziak onartzen dute osasun-onura esanguratsuak lor daitezkeela oinez ibiltzearen moduko jarduerak eginda, gizabanakoarentzat ekipamendurik edo kostu espezifikorik behar ez dutenak. Gainera, onartu egin zen beste jarduera fisiko mota batzuek, hala nola kirol egituratuek, bizikletan ibiltzeak eta ariketa-klaseek, kostuak eragin ditzaketela, eta hori oztopo bat izan daiteke pertsona batzuentzat, bereziki diru-sarrera txikienak dituztenentzat. Jarduera fisikoa sustatzeko eta ahalbidetzeko politikak eta programak gobernuak ezartzeko, inbertsioak egin behar dira hainbat arlotan, hala nola giza baliabideetan, politiken garapenean, instalazioen eta zerbitzuen horniduran eta, potentzialki, ekipoetan; horietako batzuk osasun-ministerioek kontratatzen dituzte, baina baita osasunarekin zerikusirik ez duten sektoreetan ere, hala nola kirolean, hezkuntzan, garraioan eta hiri- plangintzan. Beharrezkoak diren baliabideak gobernu- maila batean baino gehiagotan egon daitezke (maila nazionala, azpinazionala eta tokikoa), komunitate guztiek jarduera fisikorako aukera berdinak dituztela bermatzeko. Inbertsio horiek baliabide berriak barne har ditzakete, baina, era berean, lehendik dauden aurrekontuak birbanatu daitezke, populazioaren jarduera fisikoaren mailak handitzeko instalazioen eta programen lehentasuna jasotzeko. Aurrekontuak birbanatzearen adibideetan honako hauetara bideratuak barne har daitezke: batetik, oinez eta bizikletan ibiltzeko azpiegiturak dagoen garraio- aurrekontutik, eta bestetik, "guztiontzako kirolak" dagoen kirol-aurrekontutik. Funtsezko inguruneetan, hala nola eskoletan eta lantokietan, kostu txikiko interbentzioak, ingurune fisikoan izandako aldaketekin batera, baliagarriak izan daitezke jarduera fisikoan parte hartzeko, eta gainera lagungarriak izan daitezke aktibo izateko azpipopulazio- talde batzuen aukera-desberdintasunak murrizteko. Oro Ebidentziatik gomendioetara 67 68 har, ebaluatutakoaren arabera, gomendioen zirriborro hori lortzeko baliabideak behar badira ere, posible da gaur egungo gobernantza-egituren barruan ekintzak ezartzea. Gainera, ebidentziaren arabera, osasun-sistemak aurrezpen nabarmenak lor ditzake, jarduera fisikoaren mailak goratzearen ondorioz. 2013an, jarduera fisikorik ezaren urteko kostua 54.000 milioi dolar INT$ izan zela kalkulatu zen, osasun-kostu zuzenengatik soilik (130); eta maila nazionalean, jarduerarik ezak osasun- arretarako aurrekontuen % 1 - % 3ko kostua duela kalkulatzen da (131). Gaixotasun ez kutsakorren prebentzioaren testuinguru zabalagoaren barruan, gobernuak eta gobernuz kanpoko erakundeek gidalerroak ezartzeko dituzten kostu gehigarriak minimora murriz daitezke, baldin eta gomendatutako jarduera fisikoa beren bizitzan eragozpen handirik gabe ekin ahal badiote pertsonek; eta baldin eta lehen eta bigarren mailako arretan dauden baliabideak, eskolak, lantokiak edo garraioa alda badaitezke jarduera fisiko gehiagoren alde. Jarduera fisikoa sustatzearen kostuen eta onuren analisiek 15 urteko inbertsioaren etekin positiboak adierazten dituzte, NCDen (Gaixotasun Ez Kutsakorrak) prebentzioari dagokionez, inbertsioak egin dituzten herrialde askotan (132). Hainbat interbentzio, besteak beste, kontzientziazio eta hezkuntza publikoko kanpainak, eta jarduera fisikoari buruzko aholkularitza eta erreferentziak, gomendatutako interbentzioen "erosketa onena" eta "erosketa ona" dira, hurrenez hurren, NCDei ekiteko 2013–2020 aldirako NCDak prebenitu eta kontrolatzeko ekintza-plan globaleko (133) 3. eranskinaren eguneraketan oinarrituta. Oro har, GDGk ondorioztatu zuen gomendioak ezartzearen onurek kostuak gainditzen dituztela. Desgaitasuna dutenei zuzendutako jarduera fisikorako gidalerroak betetzeko inbertsioa egin behar izango da, hala nola jardueretako espezialistak gaitzea, ekipamendu egokituak, beharrezkoa denean, eta instalazio irisgarriak. Inbertsio horiek populazio-talde askoren premiak bete ditzakete. Ebidentziak erakusten duenez, jarduera fisikoari dagokionez, parte-hartze malda esanguratsu bat dago desgaitasuna duten eta ez duten pertsonen artean, hainbat oztoporen ondorioz (besteak beste, irisgarritasuna, eskainitako jardueren aukerak eta gainerakoen jarrerak). Diseinu unibertsalaren printzipioak aplikatu behar dira, desgaitasuna duten pertsonek parte-hartze osoa eta eraginkorra izango dutela bermatzeko. Berrikuntzarekin, posible da baliabideen inplikazio horietako askori heltzea. Diseinu unibertsaleko ikuspegiak hartzeak kostu horiek arinduko lituzke etorkizunean. EKITATEA, ONARGARRITASUNA ETA BIDERAGARRITASUNA 2010eko gomendioak eguneratzean, erabaki zen esplizituki sartzea populazio kalteberen kontsiderazioa, hala nola gaixotasun kronikoak eta/edo desgaitasuna duten pertsonena. GDGk eta Zuzendaritza Taldeak talde horiek ordezkatzen zituzten kideak zituzten. GDGk gomendio bakoitza sakon eztabaidatu zuen, eta hausnartu zuen gomendioak ezartzeak murriztuko ote zituen osasun-arloko ekitatea eta ezarpenarekin lotutako arazoak, gomendioek ekitate-arazoak handitzen ez dituztela bermatzeko (adibidez, jarduera fisikoa egiteko instalazio seguruak eta aukera irisgarriak bermatzea guztientzat, desgaitasuna dutenentzat, maila sozioekonomikoan kalteberak direnentzat eta beste desabantaila batzuk dituztenentzat barne; jarduera fisikorako sarbidea eta horietan parte hartzeko aukera murriz ditzaketen genero-aurreiritziei eta beste kultura-aurreiritzi batzuei heltzea eta abar). Online kontsulta publikoari erantzun ziotenen artean, % 76 ados edo oso ados zeuden gidalerroak ezartzeak osasun-arloko ekitate eza murriztea lor dezakeela, guztiak aktibo izateko eta osasun-emaitzak hobetzeko aukerak areagotzean. Adierazi zen laguntza-inguruneak funtsezkoak direla jarduera fisikoan parte hartzeko. Ikuspegi integral bat beharko da hainbat sektoretan politikak diseinatzeko eta ezartzeko, talde kalteberentzat jarduera fisikorako oztopoei heltzeko, hala nola desabantaila sozioekonomikoa duten emakume eta neskentzat eta desgaitasuna duten pertsonentzat. Desgaitasuna duten pertsonek desgaitasunik gabeko pertsonek baino osasun-emaitza txarragoak izaten dituzte; hala ere, jarduera fisikoaren onurek nabarmen gainditzen dituzte kalteak, eta interbentzio garrantzitsua izan daiteke osasun-arrakala hori ixteko. Ebidentziak erakusten duenez, jarduera fisikoari dagokionez, parte-hartze malda esanguratsua dago desgaitasuna duten eta ez duten pertsonen artean, oztopo ugari baitaude, besteak beste, irisgarritasuna, eskainitako jardueren aukerak eta gainerakoen jarrerak. Desgaitasuna duten pertsona askok aukera izan beharko lukete jarduera fisiko mota desberdinak egiteko, egokitutako ekipamendu edo instalaziorik behar izan gabe. Hala ere, desgaitasuna duten pertsonek gainerakoen baldintza beretan jarduera fisikoetan parte hartu ahal izateko, premia hauei erantzun behar izango zaie: ekipamendu egokituak lortzea, instalazioak irisgarri egitea, eta jardueretako espezialistak gaitzea. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z IKERKETA-PREMIAK Jarduera fisikoa eta sedentarismoa bizitza osoko osasun-emaitzekin lotzen dituzten datu asko egon arren, GDGren eztabaidek ebidentzia-hutsune handiak erakutsi zituzten, eta horiek lehenetsi beharko lirateke etorkizuneko gidalerroen berri emateko. Populazio-azpitaldeetako ebidentzia- arrakalek honako hauei buruzko informaziorik eza barne hartu zuten: 1) jarduera fisikoaren eta/edo sedentarismoaren eta aztertutako osasun-emaitza batzuen arteko dosi-erantzun erlazioari buruzko xehetasunik zehatzenak; 2) intentsitate baxuko jarduera fisikoaren osasun- onurak eta denbora sedentarioa intentsitate baxuko jarduerarekin ordezkatzearenak; 3) osasunean mota eta eremu ezberdinek duten eragin ezberdina, jarduera fisikoarenak (aisialdia, lana, joan-etorriak, etxeko-lanak, ikasketak) eta sedentarismoarenak (lana, pantaila aurreko denbora, telebista ikusten); eta 4) jarduera fisikoaren eta denbora sedentarioaren arteko lotura osasun- emaitzekin bizitzan zehar. Halaber, adierazi zenez, ebidentzia mugatua dago diru-sarrera baxu eta ertaineko herrialdeetarako, egoera ekonomiko ahulean dauden edo arreta urria jasotzen duten komunitateetarako, eta desgaitasuna eta/edo gaixotasun kronikoak dituztenentzako. Azterlan asko ez daude diseinatuta edo sustatuta hainbat faktore soziodemografikoren (adina, sexua, arraza/etnia, maila sozioekonomikoa) ondoriozko eragin-aldaketa frogatzeko, jarduera fisikoak osasunean dituen eraginak alda ditzaketen faktoreak izanik. Informazio hori garrantzitsua da osasun publikoko gomendio espezifikoagoak lantzeko eta populazioaren sektore ahulenetan osasun- desberdintasunak murrizteko. Argitaratutako literaturan gidalerro berri hautetatik sortzen diren ikerketa-arrakalei buruzko xehetasun gehiago ere aurki daitezke (134). Ikerketa-premiak 69 70 GIDALERROAK HARTZEA, HEDATZEA, EZARTZEA ETA EBALUATZEA Gidalerro hauen helburua da politikak diseinatzearen arduradunei eta interbentzio-programak garatzen dituztenei (osasun-, hezkuntza-, lan- eta komunitate- eremuetan) gomendioak ematea, jakin dezaten haurrek, nerabeek, helduek eta adinekoek jarduera fisikoa egiten zenbat denbora eman behar duten egunean, baita denbora sedentarioa mugatzeko gomendioak ematea ere. Hala ere, gidalerro globalak garatzea ez da berez helburu bat: hedapenik eta ezarpenik gabe, ez da aldaketarik lortuko jarduera fisikoaren mailetan. GIDALERROAK HARTZEA OMEk prozesu zorrotza eta zabala egiten du gidalerro global (21) garrantzitsuak garatzeko, herrialde guztiek erabil ditzaten. Jarduera fisikoari eta sedentarismoari buruzko gidalerro hauek ebidentzietan oinarritutako gomendioak ematen dituzte jarduera fisikoak eta sedentarismoak osasunean dituzten eraginei buruz, gobernuek euren esparru politiko nazionalaren barruan hartu eta erabil ditzaten. Gidalerro globalen garapenak, kontsulta zabal bat eginda, ezabatu egin beharko luke herrialdeetako bakoitzak baliabideetara jotzeko duen premia prozesu zientifiko luze honi ekiteko. Hala, jarduera fisikoari eta sedentarismoari buruzko gidalerro global hauek berrikusi eta hartuz gero, metodo azkar eta errentagarri bat lortzen da tokiko testuingurura egokitutako gidalerroak garatzeko. OMEren gidalerroak eskualde- edo nazio-mailan hartzeak bermatu egingo du herrialdeek gomendio koherenteak ematea jarduera fisikoari eta sedentarismoari buruz, eskuragarri dauden azken ebidentzia zientifiko sendoenetan oinarrituta. Gainera, herrialdeen artean, gomendioen koherentziak erraztu egingo ditu berrikuspen-lana, jarduera fisikoaren eta sedentarismoaren kalkulu globalak eta herrialdeen arteko konparazioak. Gidalerroak hartzeko prozesuan, kontuan hartu behar da testuinguruan kokatu eta hartara egokitu egin behar direla. Tokiko hizkuntzara itzultzea neurrietako bat da gidalerroak hartu eta testuinguruan kokatzeko. Baliteke jarduera fisikoen adibideak aldatu behar izatea dagokion tokirako esanguratsuak izan daitezen, baita irudien erabilera ere, tokiko kulturak, arauak eta balioak isla ditzaten. Prestaketa-prozesuan da herrialdeei gidalerro Globalak hartzen laguntzeko urratsez urratseko esparru bat, interesdunekin eskualde-mailako tailerrak egin ondoren. Esparru hori garrantzizko datu nazionalekin osa daiteke (adibidez, jarduera fisikoaren prebalentziaren kalkuluak) eta horrek hurbilketa azkar bat emango du gidalerro nazionalen dokumentu bat garatzeko. Laguntza-baliabide horiek eskuragarri egongo dira 2021ean, OMEren webgunean. Gidalerroak hartzea kontuan hartzean, hamar urratseko prozesu hau aplikatzea gomendatzen da: 1. Jarduera fisikoari buruzko egungo gidalerro nazionalak berrikusi daitezen eta OMEren gidalerroak har daitezen defendatzea, gobernuaren baimena bermatzeko. 2. Alderdi interesdun nagusiak inplikatzea, bai osasunaren sektorean, bai beste sektore garrantzitsu batzuetan, hala nola kirolean, hezkuntzan eta garraioan; gaian esperientzia duten elkarte profesional eta zientifiko gailenak inplikatzea. 3. Gomendioen aplikagarritasuna, onargarritasuna eta bideragarritasuna ebaluatzea. 4. Ikustea gidalerroak egokitzen diren tokiko testuingurura, hizkuntza, adibideak eta beste kontsiderazio kultural batzuk barne. 5. Kanpoko berrikuspen bat egitea xede-erabiltzaileekin, politikak diseinatzearen arduradunak, profesionalak eta publiko orokorra barne. 6. Hedapenerako eta komunikaziorako aurrekontu eta plan argi bat ezartzea. 7. Gidalerro nazionalak argitaratzea eta sustatzea, merkaturatzeko ekitaldi batekin batera, publizitatea eta interesa sortzeko. 8. Erakunde profesional garrantzitsuak inplikatzea eta politikak lerrokatzen eta/edo babesten laguntzea. 9. Politika eta praktika nazionalak ezartzea, gidalerro nazionalen ezarpena eta portaera-aldaketa bultzatzeko. 10. Gidalerroak ebaluatzeko, berrikusteko eta eguneratzeko kronograma bat adostea. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z 71 Gidalerroak hartzea, hedatzea, ezartzea eta ebaluatzea HEDAPENA Jarduera fisikorako gidalerro nazionalak gobernantza- egituren funtsezko osagaia dira, populazioaren jarduera fisikoaren mailak handitzeko ikuspegi integral baterako. Gidalerro nazionalek plan estrategiko nazionalaren eta azpinazionalaren garapena eta lehentasunak informatzen dituzte, eta pertsona-talde esanguratsuei informazio zuzena modu egoki batean helaraztea eskatzen dute. Tamalez, gehiegitan, gidalerro nazionalak ez dira hedatzen, eta, beraz, gomendioen ezagutza oso txikia izaten jarrai daiteke, bai publiko profesionalaren artean, bai komunitate orokorraren artean. Eskala handiko hedapenari laguntzeko baliabideak ziurtatzea lehen urrats garrantzitsua da jarduera fisikoa areagotzearen eta sedentarismoa murriztearen garrantziari buruzko kontzientzia eta ezagutza aldatzeko. Jarduera fisikoari eta sedentarismoari buruzko gidalerro nazionalen hedapenean funtsezkoak dira: • Osasun-arloko arduradun politikoak eta beste hainbat arlotakoak (garraioa, plangintza, hezkuntza, lana, kirola, parkeak eta aisialdia barne), helburu hauetarako: a. jakintza areagotzea jarduera fisiko gehiago egiteak eta sedentarismoa murrizteak, osasuna hobetzeaz gain, askotariko eremuak ere hobe ditzakeela, besteak beste, genero-ekitatea, giza eskubideen betebeharrak eta garapen jasangarria; b. jarduera fisikoari eta sedentarismoari buruzko politikak eta programak integratzea politika guztietan; eta c. nazio- eta toki-mailako ekintza koordinatuetan eta zabalagoetan inbertitzea. • Estatuz kanpoko eragileak (gobernuz kanpoko erakundeak, erakunde akademikoak eta ikerketa- erakundeak, sektore pribatua, komunikabideak eta ikerketaren finantzaketa-agentziak barne), helburu hauetarako: a. adin guztietan jarduera fisikoa areagotzearen eta sedentarismoa murriztearen garrantziaz kontzientziatzea; b. politiken lerrokatzea bultzatzea eta ziurtatzea; eta c. tokiko politiken eta ekintzen ezarpenean lankidetza eta inbertsioa handitzea. • Osasun-arloko profesionalak eta beste hainbat arlotakoak (kirola, hezkuntza, garraioa eta plangintza barne), helburu hauetarako: a. jarduera fisikoari eta sedentarismoari buruzko gidalerro nazionalen kontzientzia eta ezagutza areagotzea; b. jarduera fisiko handiagoa sustatzeko eta sedentarismoa murrizteko ezagutza, trebetasunak eta konfiantza areagotzea; eta c. jarduera fisikoaren sustapena ohiko jardunean sartzea, hala dagokionean. • Publiko orokorra eta populazio-azpitalde espezifikoak, helburu hauetarako: a. jarduera fisikoari eta sedentarismoari buruzko gidalerroen kontzientzia eta ezagutza areagotzea; b. jarduera fisikoari eta sedentarismoari buruzko gidalerroak lortzeko modua ezagutzea; eta c. fisikoki aktiboagoa izateko eta sedentarismoa murrizteko asmoak eta motibazioa. KOMUNIKAZIO-KANPAINAK Interesa duten alderdi desberdinek abantailak lortuko dituzte material desberdinetatik; beraz, askotariko publikoari gidalerroak eraginkortasunez ezagutzera emateko, kontuan hartu behar dira edukia, formatua eta bidalketa-kanalak. Komunikazio-estrategia orientagarri bat garatzean, prestakuntza-ikerketak lagun dezake funtsezko publikoak zehazten eta jarduera fisikoaren eta sedentarismoaren mailetan eragiten duten balioak, beharrak eta lehentasunak ulertzen. Horrek barne hartu beharko luke jarduera fisikorako oztopoak aztertzea edo jarduera fisikoa politikan eta praktikan txertatzea, baita mezuen eta materialen zirriborroak hainbat talderekin probatzea ere. Horri esker, erabiltzen diren funtsezko mezuak informatu ahal izango dira, baita komunikaziorako formatu eta kanal egokia(k) ere. Komunikazio-estrategia ulerkor batek publiko desberdinei zuzendutako komunikazioak barne hartuko ditu. Baliteke herrialdeek talde espezifikoak lehenetsi behar izatea eskura dituzten baliabideen arabera (giza baliabideak eta finantza- baliabideak). Publiko orokorrari edo azpipopulazio espezifikoei zuzendutako jarduera fisikoari buruzko komunikazio- kanpainak interbentzio errentagarriak dira (133), eta OMEren 2018-2030 aldirako jarduera fisikoari buruzko ekintza-plan globalean (14) gomendatzen dira. Jarduera fisikoari buruzko kanpaina nazionalek eta azpinazionalek kanpaina orokorreko eslogan bat ezarri ohi dute (adibidez, "Izan aktibo" edo "Mugi zaitez gehiago"), eta diseinu- elementuak edo pertsonaiak garatzen dituzte, publiko desberdinetarako mezu pertsonalizatuak barne har ditzaketenak (adibidez, haurrak, nerabeak, helduak 72 edo adinekoak, gutxien aktibo direnak, desgaitasuna edo gaixotasun kronikoak dituztenak). Ziurrenez, material generikoak baino eraginkorragoak izango dira populazio-talde espezifikoetara egokitzen diren kanpainako mezuak eta baliabideak. Komunikazio- kanpainek kontuan hartu behar dituzte ohiko hedabideetako kanalen (telebista, irratia, publizitate- hesiak, baliabide inprimatuak) eta baliabide digitaletako kanalen (webguneak, telefono mugikorrak, aplikazioak) irismena eta eraginkortasuna. Era berean, baliagarria da gidalerro nazionalei buruzko informazioa hainbat formatutan ematea. Adibidez, jarduera fisikorako gidalerroak komunikatzeko ikuspegi berri samarra baina gero eta ohikoagoa da infografia edo bideo labur animatuak erabiltzea. OMEk material lagungarriak ditu komunikazio-kanpaina horiek garatzeko eta ezartzeko (135). Komunitate akademikoek eta ikerketakoek txosten zientifikoa ezagutu nahi izango dute ziurrenez, gidalerroen oinarri den ebidentzia epidemiologikoa zehazten duena. Hala ere, azpian den ikerketaren xehetasunak beste publiko orokorrago batzuentzat ez dira ziurrenez interesgarriak izango. Arduradun politikoek laburbilduma zientifiko bat edo txosten bat nahiago izango dute. Aldiz, beste publiko batzuek, hala nola osasun-arloko profesionalek eta beste arlo batzuetakoek, bestelako baliabide batzuk nahiago izango dituzte, esate baterako gidalerroei buruzko liburuxka bat edo informazio-orri bat, edo jarduera fisikoaren sustapena ohiko jardunean (adibidez, pazienteen kontsultetan) txertatzeko moduari buruzko bat, edo hiri-inguruneetarako eraikuntza- edo garraio-planak garatzean. Profesionalek beren funtziora egokitzen diren baliabideak beharko dituzte. Osasun-arloko lanbideek, bereziki, hainbat baliabide izan ditzakete, dagozkien jardunean sartzen diren populazio-taldeak islatzeko. POLITIKAK ETA PROGRAMAK EZARTZEA Jarduera fisikoari eta sedentarismoari buruzko gidalerro nazionalek, soilik, ez dute seguru aski populazioaren jarduera fisikoaren maila handituko; beraz, politika- eta plangintza-esparru baten elementutzat hartu behar dira. Funtsezkoa da gidalerro nazionalak xede-publikoei helaraztea eta komunikazio-estrategia nazional iraunkor baten babesa izatea. Estrategia horrek jarduera fisikoa erregulartasunez egitearen eta sedentarismoa murriztearen onurei buruzko kontzientzia eta ezagutza handiagoa izatea ekarriko du. Hala ere, portaera- aldaketa iraunkor bat lortzeko, ekintza horiek politiken babesa izan behar dute, pertsonak aktibo izatea ahalbidetzen eta bultzatzen duten laguntza-inguruneak sortuta, eta horrekin batera, pertsonek jarduera fisikoan parte hartzeko tokiko aukera egokiak areagotuta. Politikek eta programek tokiko testuingurura egokitu behar dute, bai osasun- sistemara, bai jarduera fisikoa sustatzen laguntzeko interesa edo aukera duten sektore anitzeko erakundeen multzora. Neurriak hartu behar dira "gobernantza osoaren" ikuspegia erabilita, eta kontuan hartu behar da politiken eta ekintza ugarien "sistema", alderdi interesdun ugarik parte hartuz, lortu ahal izateko pertsona gehiagok egitea jarduera fisikoa, arlo eta ingurune anitzetan. Komunikazio-estrategia iraunkor batekin lerrokatzen den "sistemen" ikuspegia erabiltzeak ziurtatu egiten du jarduera fisikoa egiteko gero eta eskari handiagoa, komunikazio eraginkorrak sorrarazitakoa, bat etorriko dela pertsonak fisikoki aktibo izateko inguruneak eta aukerak ematearekin. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z 73 Gidalerroak hartzea, hedatzea, ezartzea eta ebaluatzea OMEren 2018-2030 aldirako jarduera fisikoari buruzko ekintza-plan globalak helburu bat ezarri zuen jarduera fisikorik eza % 15 murrizteko 2030erako, eta 20 ekintza eta interbentzio gomendatu nabarmendu zituen (14). Besteak beste, herrialde guztiek hezkuntza eta kontzientziazio publikoko kanpaina iraunkorrak ezartzea gomendatu zen, baita lehen eta bigarren mailako osasun-arretan jarduera fisikoari buruzko aholkularitza-programak integratzea ere. Beste gomendio batzuen arabera, jarduera fisikorako egokiak diren inguruneak sortu beharko ziren, hala nola oinez ibiltzea, bizikletan eta gurpiletan, populazio-talde guztientzat, eta aukera gehiago eta jarduera fisikoko programa gehiago ematea eskoletan, lantokietan, kirol-elkarte eta kiroldegietan. Baliteke 20 gomendioak ez ezartzea epe laburrean herrialde guztietan, baina epe luzerako helburutzat hartu behar da. Berehalako ekintzen multzo egoki eta egingarri bat identifikatzeko, OMEko estatu kideek egungo politiken eta praktiken egoeraren azterketa egin behar dute. Horrek sektore anitzeko lankidetza ahalbidetuko du, eta indarguneak, arrakalak eta aukerak identifikatzen lagundu, eta plan nazionalak eta azpinazionalak garatzeko edo eguneratzeko oinarri gisa erabil daiteke. OMEren gidalerro berri hauek lagungarriak dira talde gehiago sartzeko ekintzen irismena zabaltzen, hala nola desgaitasunak edo gaixotasun kronikoak dituzten pertsonak eta emakumeak haurdunaldian edo erditu ondoren. Politikek babestu egin behar dituzte komunitatearen premiak, eta taldeen eta testuinguruen aniztasuna kontuan hartzen duten programa egokiak gauzatu eta ezarri. Sektore espezifikoetarako zenbait tresna garatzen ari dira ACTIVE pakete teknikoa (135) ezartzen laguntzeko; horiek orientazioa emango diote sektore bakoitzari jarduera fisikoa sustatzeko moduari buruz, adibidez, eskolen bidez, lehen mailako osasun-arretaren bidez edo oinez eta bizikletan ibiltzeko eskaintza hobetuz. ACTIVE tresnek, baita OMEren eskualde- eta nazio-mailako beste baliabide batzuek ere, jarduera fisikoari eta sedentarismoari buruzko gidalerro hauek ezartzen lagunduko dute. GIDALERROAK ZAINTZEA ETA EBALUATZEA OMEren Osasunerako jarduera fisikoari buruzko gomendio globalak erreferentzia gisa erabili dira 2010az geroztik herritarren osasunaren jarraipen eta zaintzarako. Gidalerro eguneratu hauen gomendioetan egindako aldaketek zenbait ondorio izango dituzte gaur egun jarduera fisikoaren mailak kontrolatzeko erabiltzen diren zaintza-sistemetan eta ebaluazio- tresnetan. Gidalerro berri hauek argitaratzeko, egungo tresnak eta txostenak aurkezteko protokoloak berrikusi beharko dira, gidalerro berriei buruzko etorkizuneko txostenak aurkezteari buruzko edozein doikuntza eta gomendio jakinarazteko. Tresnak berrikusiko dira, hala nola jarduera fisikoari buruzko galdetegi globala eta ikasleen osasunari buruzko inkesta globala, eta protokoloak eguneratuko dira gidalerro berri hauekin lerrokatzeko; 2021ean herrialde guztiei laguntzeko orientazioa emango da. OMEren NCDen Gaitasun Nazionalaren Inkesta da (CCS) politikak ezartzeko aurrerapen globala monitorizatzeko erabiltzen den tresna nagusia, eta bi urtean behin egiten da. CCSak jarduera fisikoaren inguruko populazioaren zaintza-sistemei buruzko galdera espezifikoak jasotzen ditu, barnean hartutako adin-talde bakoitzerako eta, 2019tik aurrera, jarduera fisikoari buruzko gidalerro nazionalak ba ote dauden jakiteko galderak ere. OMEko estatu kideei beren erantzuna babesteko dokumentazioa eskatzen zaie. 2019an, OMEko 194 estatu kideetatik 78k ( % 40) jarduera fisikorako gidalerroak zituztela jakinarazi zuten (136).2019an, CCSi emandako erantzunen analisi-dokumentu xehatu bat landu zen, eta identifikatu zen 78 estatu kideen (52/78) bi herenek soilik jasotzen dituztela beren biztanleek egin behar duten jarduera fisikoari buruzko adierazpenak; eta horietatik, 42 herrialdek baino ez zituzten bete OMEren 2010eko Osasunerako jarduera fisikoari buruzko gomendio globalak (1). 2021eko eta ondorengo inkestetako datuek emango dute informazioa gidalerro eguneratu hauek zein neurritan hartu diren jakiteko. 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Assessing national capacity for the prevention and control of noncommunicable diseases: report of the 2019 global survey. Geneva: World Health Organization; 2020. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z Erreferentziak 83 84 O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z 85 1. eranskina 1. ERANSKINA: GIDALERROEN GARAPEN-PROZESUAREN KUDEAKETA Kolaboratzaileak gidalerroen garapenean OMEko zuzendaritza-taldea Zuzendaritza Taldeak arlo hauetako adituak hartu zituen barnean: jarduera fisikoa, nerabeen osasuna, zahartzeagatiko desgaitasuna, osasun mentala, lesioen prebentzioa, minbizia, haurdunaldia eta egoitzetako zein eskualde-bulegoetako zaintza. Valentina Baltag Amen, Jaioberrien, Haurren eta Nerabeen Osasuna eta Zahartzea Sailak – nerabeen osasuna Maurice Bucagu Amen, Jaioberrien, Haurren eta Nerabeen Osasuna eta Zahartzea Saila – haurdunaldia Fiona Bull Presidentea Osasunaren Sustatapena Saila – jarduera fisikoa Alex Butchart Osasuneko Determinatzaile Sozialak Saila - lesioen prebentzioa Neerja Chowdhary Gaixotasun Ez Kutsakorren Saila – osasun mentala / dementzia Regina Guthold Amen, Jaioberrien, Haurren eta Nerabeen Osasuna eta Zahartzea Saila – nerbeen zaintza Riitta-Maija Hämäläinen Pazifiko mendebaldeko Eskualde Bulegoa Andre Ilbawi Gaixotasun Ez Kutsakorren Saila – minbizia Wasiq Khan Mediterraneoko ekialdeko Eskualde Bulegoa Lindsay Lee Gaixotasun Ez Kutsakorren Saila –desgaitasuna Alana Officer Zahartzea Leanne Riley Gaixotasun Ez Kutsakorren Saila – zaintza Gojka Roglic Gaixotasun Ez Kutsakorren Saila – diabetesa Juana Willumsen Osasunaren Sustapena Saila – jarduera fisikoa Zuzendaritza Taldeak gidalerroen eta PI/ECOen irismena jaso zuen idatziz. Interesen adierazpena berrikusi zuten, eta gidalerroak idatzi, berrikusi eta amaitu zituzten. 86 Gidalerroak garatzeko taldea (GDG) Gidalerroak Garatzeko Taldea arloko aditu garrantzitsuen, azken erabiltzaileen eta gomendioen eraginpeko pertsonen talde zabal batek osatu zuen. Hauek izan ziren Gidalerroak Garatzeko Taldeko kideak: Salih Saad Al-Ansari dr. (osasunaren sustapenaren eta hezkuntzaren defendatzailea jarduera fisikoa eginez eta ibiliz NCDei aurre egiteko); Stuart Biddle dr. (jarduera fisikoa eta sedentarismoa, eta portaera-aldaketa); Katja Borodulin dr. (jarduera fisikoa haurdunaldian eta adinekoetan); Matthew Buman dr. (loa, sedentarismoa eta jarduera fisikoa gaixotasun kronikoak dituzten pertsonetan); Greet Cardon dr. (jarduera fisikoa haurretan eta nerabeetan); Catherine Carty and. (jarduera fisikoa desgaitasuna duten pertsonetan); Jean-Philippe Chaput dr. (loa, sedentarismoa eta jarduera fisikoa haur eta nerabeetan); Sebastien Chastin dr. (jarduera fisikoa, sedentarismoa eta osasuna, jarduera fisikoaren neurketa objektiboa eta sedentarismoa); Paddy Dempsey dr. (jarduera fisikoa eta sedentarismoa helduetan eta gaixotasun kronikoak dituzten pertsonetan); Loretta DiPietro dr. (jarduera fisikoa haurdunaldian eta adinekoetan); Ulf Ekelund dr. (sedentarismoa eta jarduera fisikoa, jarduera fisikoa haur eta nerabeetan); Joseph Firth dr. (jarduera fisikoa eta osasun mentala); Christine Friedenreich dr. (jarduera fisikoa gaixotasun kronikoak dituzten pertsonetan, jarduera fisikoa eta minbizi-arriskua); Leandro Garcia dr. (jarduera fisikoa eta osasuna helduetan); Muthoni Gichu dr. (politikak ezartzea, gobernu nazionala); Russ Jago dr. (jarduera fisikoa haur eta nerabeetan); Peter Katzmarzyk dr. (jarduera fisikoa eta sedentarismoa); Estelle V. Lambert dr. (jarduera fisikoa eta obesitatea); Michael Leitzmann dr. (sedentarismoa eta jarduera fisikoa gaixotasun kronikoak dituzten pertsonetan); Karen Milton dr. (gomendioak praktikara eramatea); Francisco B. Ortega dr. (jarduera fisikoa haur eta nerabeetan, osasun mentala eta neurketa objektiboa); Chathuranga Ranasinghe dr. (jarduera fisikoa eta osasuna komunitatean, lantokian eta eskolan sustatzea); Emmanuel Stamatakis dr. (jarduera fisikoa eta sedentarismoa eta hainbat osasun- emaitza helduetan); Anne Tiedemann dr. (jarduera fisikoa helduetan); Richard Troiano dr. (politiken garapena); Hidde van der Ploeg dr. (jarduera fisikoa eta sedentarismoa helduetan); Vicky Wari and. (politikak ezartzea - gobernu nazionala); Roger Chou dr. (Pazifikoko ipar- mendebaldea, Ebidentzian Oinarritutako Praktika Zentroa, Medikuntzako Irakaslea, Medikuntza, Informatika Medikoa eta Epidemiologia Klinikoa Sailak, Oregoneko Osasuna eta Zientziak Unibertsitatea) GRADE metodologoa. GDGren xehetasun gehiago 2. eranskinean daude eskuragarri. GDGren lehen bilera bat egin zen 2019ko uztailaren 2tik 4ra. Bilera horretan, PI/ECOren galderetan oinarrituta erabakiak hartu, dauden berrikuspen sistematikoak berrikusi eta beharrezko eguneratzeak identifikatu zituen GDGk. Gomendioei buruzko erabakiak hartzeko prozesua eta GDGren bigarren bileran aplikatuko den ebidentziaren sendotasuna adostu zituen taldeak. Bigarren bilera 2020ko otsailaren 11tik 14ra egin zen; ebidentzia eguneratuak berrikusi ziren eta azken gomendioak aho batez adostu ziren. O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z 87 1. eranskina Kanpoko berrikuspen-taldea (ERG) Kidekoen kanpoko zazpi berrikusle hautatu ziren GDGk eta Zuzendaritza Taldeak proposatutako pertsonen zerrenda batetik. Beharrezko ezagutza espezializatua eman zuten, programen inplementazioa barne, eta OMEren sei eskualdeak ordezkatu zituzten. ERGak gidalerroen zirriborroa berrikusi zuen eta Zuzendaritza Taldeari iruzkinak egin zizkion argitasunari eta ezarpenari buruz, eta horiek gehitu egin ziren, zegokionean. Kidekoen kanpoko berrikusleek ez zituzten gomendioak aldatu. 2. eranskinean adierazten dira kidekoen kanpoko berrikusleak. Interes-adierazpenak GDGko kide guztiek eta kanpoko berrikusleek OMEren interesak adierazteko inprimaki bat osatu eta bidali zuten, eta konfidentzialtasun-konpromisoak sinatu zituzten GDGren bileretara joan aurretik. Zuzendaritza Taldeak aurkeztutako curriculum vitaea eta interesen adierazpena berrikusi eta ebaluatu zituen, eta Interneten eta argitalpenetan bilaketa bat egin zuen, egoera konprometigarriak eragin zitzakeen edozein eztabaida edo interes publiko identifikatzeko. GDGK proposatutako kide guztien izenak eta biografia laburrak Jarduera Fisikoaren OMEren webgunean argitaratu ziren, 14 eguneko kontsulta publikorako. Ez zen iruzkinik jaso. Aholkularitza gehiago eskatu izan zenean edozein interes-adierazpen edo -gatazkaren kudeaketari buruz, Betearazpen, Arriskuen Kudeaketa eta Etikako Bulegoko kideei kontsultatu zien Zuzendaritza Taldeak. Beharrezkotzat jo zenean, interes-gatazkak (finantzarioak edo ez finantzarioak) erakutsi zituzten pertsonak baztertu egin ziren edozein gaitan parte hartzetik, gai horietan interes- gatazkak sorraraziz gero. Interes-gatazken kudeaketa prozesu osoan berrikusi zen. GDGko kideek beren interes-adierazpena eguneratu behar zuten, beharrezkoa izanez gero, bilera bakoitzaren aurretik, eta GDGren bilera bakoitzaren hasieran ahozko interes-adierazpen bat eskatu zen. GDGren eta kanpoko berrikusleen interes-adierazpenak 3. eranskinean laburbiltzen dira. Ez zen interes- gatazkarik identifikatu. Kidekoen berrikuspena Gidalerroen zirriborroa GDGk eta Zuzendaritza Taldeak identifikatutako kidekoen kanpoko zazpi berrikuslek berrikusi zuten. Kidekoen kanpoko berrikusleei eskatu zitzaien argitasunari, ebidentziaren aurkezpenari eta ezarpenari buruzko iruzkinak emateko; iruzkinak zegokionean txertatu ziren. Kanpoko berrikusleek ezin zituzten GDGk erabakitako gomendioak aldatu. Kidekoen kanpoko berrikusleak 2. eranskinean zerrendatzen dira; 3. eranskinean interes-adierazpenen laburpena ematen da. Gainera, ekarpenak egiteko eskatu zitzaien OMEren eskualde-bulegoei. 88 2. ERANSKINA: GIDALERROAK GARATZEKO TALDEA, KIDEKOEN KANPOKO BERRIKUSLEAK ETA GIDALERRO HAUEN GARAPENEAN PARTE HARTU DUTEN OME-KO LANGILEAK Gidalerroak garatzeko taldea Salih Al-Ansari dr. Irakasle laguntzailea Familia eta Komunitate Medikuntza Osasunaren Sustapen Zentroaren Fundatzailea eta CEO Riyadh SAUDI ARABIA Stuart Biddle dr. Jarduera Fisiko eta Osasuneko irakaslea Fisikoki Aktibo diren Bizi-estiloen Ikerketa Taldea Osasun Ikerketa Zentroa Eskualde Erresilienteetako Institutua Queensland Hegoaldeko Unibertsitatea Springfield Central AUSTRALIA Katja Borodulin dr. Zahartzaro Institutua Helsinki FINLANDIA Matthew Buman dr. Osasun Soluzioetako Fakultatea Arizonako Unibertsitate Estatala Phoenix AEB Greet Cardon dr. Mugimendu eta Kirol Zientzietako Saila Medikuntzako eta Osasun Zientzietako Fakultatea Ganteko Unibertsitatea Gante BELGIKA Catherine Carty and. Proiektu-kudeatzailea UNESCO katedra Tralee Teknologiako Institutua Co Kerry IRLANDA Jean-Philippe Chaput dr. Zientzialari seniorra, Bizitza Aktibo Osasungarria eta Obesitatea (HALO) Ikerketa Taldea Children's Hospital of Eastern Ontario-ko (CHEO) Ikerketa Institutua Pediatria Saila Ottawako Unibertsitatea Ottawa, Ontario KANADA Sebastien Chastin dr. Osasun Portaeraren Dinamikako irakaslea Osasun eta Bizitza Zientzietako Fakultatea Psikologia, Gizarte Lana eta Loturiko Osasun Zientzia Saila Glasgow Caledonian Unibertsitatea Glasgow ERRESUMA BATUA Roger Chou dr. (GRADE metodologoa) Medikuntzako, Informatika Medikoko eta Epidemiologiako Sailak Oregoneko Osasun eta Zientzietako Unibertsitatea Portland, Oregon AEB Paddy Dempsey dr. MRCko Epidemiologia Unitatea Medikuntza Klinikoko Eskola, Cambridgeko Unibertsitatea Cambridge ERRESUMA BATUA O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z 89 2. eranskina Loretta DiPietro dr. Ariketa eta Nutrizioko Zientziak Saila Osasun Publikoko Fakultatea, Milken Institutua George Washington Unibertsitatea Washington, DC AEB Ulf Ekelund dr. Kirol Medikuntza Saila Norvegiako Kirol Zientzietako Eskola Oslo NORVEGIA Joseph Firth dr. Presidenteordea Osasun Zientzietako Eskola Manchesterreko Unibertsitatea Manchester ERRESUMA BATUA Christine Friedenreich dr. Zuzendari zientifikoa Minbiziaren Epidemiologia eta Prebentzioko Ikerketa Saila Alberta Minbiziaren Kontrola Alberta Osasun Zerbitzuak Calgary KANADA Leandro Garcia dr. Ikertzaile kidea Osasun Publikoko Zentroa Queen's University Belfast Belfast ERRESUMA BATUA Muthoni Gichu dr. Zuzendaria Medikuntza Geriatrikoko Unitatea Gaixotasun Ez Kutsakorren Saila, Osasun Ministerioa Nairobi KENIA Russell Jago dr. Jarduera Fisiko Pediatriko eta Osasun Publikoko irakaslea Ariketa, Nutrizio eta Osasun Zientzietako Zentroa Politika Azterlanetako Eskola Bristoleko Unibertsitatea Bristol ERRESUMA BATUA Peter T. Katzmarzyk dr. Zuzendari Exekutibo kidea Populazio eta Osasun Publikoetako Zientziak Irakaslea eta Marie Edana Corcoran Obesitate eta Diabetes Pediatrikoetako katedraduna Pennington Ikerketa Biomedikoko Zentroa Baton Rouge AEB Estelle V. Lambert dr. Zuzendaria Osasun Ikerketa Zentroa Jarduera Fisikoaren, Bizi-estiloaren eta Kirolaren bidez Cape Towneko Unibertsitatea Cape Town HEGO AFRIKA Michael Leitzmann dr. Epidemiologiako irakaslea Epidemiologia eta Prebentzio Medikuntza Saila Regensburgeko Unibertsitatea Regensburg ALEMANIA Karen Milton dr. Osasun Publikoko irakasle elkartua Norwicheko Medikuntza Eskola Anglia ekialdeko Unibertsitatea Norwich ERRESUMA BATUA Francisco B. Ortega dr. Zuzendaria Jarduera Fisikoa eta Osasunaren Sustapena Unitatea Kirol eta Osasun Ikerketako Institutua (iMUDS) Gorputz Hezkuntza eta Kirolak Saila Granadako Unibertsitatea Granada ESPAINIA Chathuranga Ranasinghe dr. Presidentea NIROGI Lanka proiektua Sri Lankako Medikuntza Elkartea Irakasle titularra Kirol eta Ariketako Medikuntza Unitatea Medikuntzako Fakultatea C Colomboko Unibertsitatea Colombo SRI LANKA Emmanuel Stamatakis dr. Charles Perkins Zentroa Medikuntza eta Osasun Fakultatea, Osasun Publikoko Eskola Sydneyko Unibertsitatea Sydney AUSTRALIA Anne Tiedemann dr. Irakasle elkartua Osasun Muskuloeskeletikoko Institutua, Osasun Publikoko Eskola Medikuntza eta Osasun Fakultatea Sydneyko Unibertsitatea Sydney AUSTRALIA Richard Troiano dr. Epidemiologia eta Genomikak Ikerketa Programa Minbiziaren Institutu Nazionala Osasun Institutu Nazionala Rockville AEB Hidde van der Ploeg dr. Irakasle elkartua Osasun Publikoa eta Lanekoa Saila Amsterdameko Osasun Publikoko Ikerketa Institutua Amsterdameko Unibertsitateko Medikuntza Zentroak Amsterdam HERBEHEREAK Vicky Wari and.* Programa Kudeatzailea, NCD Osasun Sail Nazionala Port Moresby PAPUA GINEA BERRIA Kanpoko berrikuspen-taldea Kingsley Akinroye dr. Nigeriako GET Aliantza NIGERIA Huda Alsiyabi dr. Zuzendaria Ekimen Komunitarioak Saila Osasun Ministerioa OMAN Alberto Flórez-Pregonero dr. Pontificia Universidad Javeriana KOLONBIA Shigeru Inoue dr. Prebentzio Medikuntza eta Osasun Publikoa Saila Tokioko Medikuntza Unibertsitatea JAPONIA Agus Mahendra dr. Gorputz Hezkuntza Saila Universitas Pendidikan INDONESIA Deborah Salvo dr. Prebentziorako Ikerketa Zentroa St. Louisen Brown School Washingtoneko Unibertsitatea AEB Jasper Schipperijn dr. Presidente hautatua 2020-2022 Jarduera Fisikoko eta Osasuneko Nazioarteko Elkartea Kirol Zientziak eta Biomekanika Klinikoa Saila Hego Danimarkako Unibertsitatea DANIMARKA 90 * bertaratu ezin izana O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z 91 2. eranskina OMEko zuzendaritza-taldea Valentina Baltag dr. Zuzendaria Nerabeen eta Heldu Gazteen Osasuna, Amen, Jaioberrien, Haurren eta Nerabeen Osasuna eta Zahartzea Saila OMEren egoitza Geneva SUITZA Maurice Bucagu dr. Medikuntzako Zuzendaria Amen Osasuna Nerabeen eta Heldu Gazteen Osasuna Amen, Jaioberrien, Haurren eta Nerabeen Osasuna eta Zahartzea Saila OMEren egoitza Geneva SUITZA Alexander Buchart dr. Zuzendaria Indarkeriaren Prebentzioa Osasuneko Determinatzaile Sozialak Saila OMEren egoitza Geneva SUITZA Fiona Bull dr. Zuzendaria Jarduera Fisikoa Osasunaren Sustapena Saila OMEren egoitza Geneva SUITZA Regina Guthold dr. Zientzialaria Nerabeen eta Heldu Gazteen Osasuna Amen, Jaioberrien, Haurren eta Nerabeen Osasuna eta Zahartzea Saila OMEren egoitza Geneva SUITZA Riitta-Maija Hämäläinen dr. Zuzendari Teknikoa Gaixotasun Ez Kutsakorren eta Osasunaren Sustapena OMEren eskualde-bulegoa Pazifikoko mendebaldea Manila FILIPINAK Andre Ilbawi dr. Zuzendari Teknikoa Gaixotasun Ez Kutsakorren Saila OMEren egoitza Geneva SUITZA Wasiq Khan dr.* Eskualde Aholkularia Osasun Hezkuntza eta Sustapena OMEren eskualde-bulegoa Mediterraneoko ekialdea Kairo EGIPTO Lindsay Lee and. Zuzendari Teknikoa Zentzumen Funtzioak, Desgaitasuna eta Errehabilitazioa Gaixotasun Ez Kutsakorren Saila OMEren egoitza Geneva SUITZA Alana Officer and. Osasun Aholkulari seniorra Zahartze Osasungarria Zuzendari Nagusiaren Bulegoa OMEren egoitza Geneva SUITZA Leanne Riley and. Zuzendaria Gaixotasun Ez Kutsakorren Zaintza Saila OMEren egoitza Geneva SUITZA Gojka Roglic dr. Medikuntzako Zuzendaria Gaixotasun Ez Kutsakorren Kudeaketa Gaixotasun Ez Kutsakorren Saila OMEren egoitza Geneva SUITZA Juana Willumsen dr. Zuzendari Teknikoa Jarduera Fisikoa Osasunaren Sustapena Saila OMEren egoitza Geneva SUITZA * bertaratu ezin izana 3. ERANSKINA: INTERES-ADIERAZPENEN LABURPENA ETA KUDEATZEKO MODUA Gidalerroak garatzeko taldeko kideak Izena Generoa Arloa Interes adierazpena Interes gatazka eta kudeaketa Salih Saad Al-Ansari dr. Gizon Osasun-hezkuntzaren eta -sustapenaren defentsa, jarduera fisikoa eginez eta ibiliz NCDei aurre egiteko Osasuna Sustatzeko Zentroaren jabe eta zuzendari exekutibo nagusia Ez da interes gatazkarik identifikatu Stuart Biddle dr. Gizon Jarduera fisikoa gazteetan Ikerketa-funtsak eta aholkularitza ordaindua Ez da interes gatazkarik identifikatu Katja Borodulin dr. Emakume Jarduera fisikoa haurdunaldian Enplegua Osasun e t a Ongizate Institutu Nazionalean eta Zahartzaroko Institutua; ikerketa-funtsak Ez da interes gatazkarik identifikatu Matthew Buman dr. Gizon Loa eta jarduera fisikoa gaixotasun kronikoak dituzten pertsonetan Ez da ezer adierazi Ez da interes gatazkarik identifikatu Greet Cardon dr. Emakume Jarduera fisikoa gazteetan Ez da ezer adierazi Ez da interes gatazkarik identifikatu Catherine Carty and. Emakume Jarduera fisikoa desgaitasuna duten pertsonetan Ikerketa-funtsak Ez da interes gatazkarik identifikatu Jean-Philippe Chaput dr. Gizon Loa Ez da ezer adierazi Ez da interes gatazkarik identifikatu Sebastien Chastin dr. Gizon Jarduera fisikoa eta osasuna, jarduera fisikoaren neurketa objektiboa Ikerketa-funtsak Ez da interes gatazkarik identifikatu Paddy Dempsey dr. Gizon Jarduera fisikoa eta sedentarismoa helduetan eta gaixotasun kronikoak dituzten pertsonetan Enplegua eta Ikerketa-funtsak Ez da interes gatazkarik identifikatu Loretta DiPietro dr. Emakume Jarduera fisikoa adinekoetan Ez da ezer adierazi Ez da interes gatazkarik identifikatu Ulf Ekelund dr. Gizon Sedentarismoa eta jarduera fisikoa gazteetan Ez da ezer adierazi Ez da interes gatazkarik identifikatu Joseph Firth dr. Gizon Jarduera fisikoa eta osasun mentala Ez da ezer adierazi Ez da interes gatazkarik identifikatu Christine Friedenreich dr. Emakume Jarduera fisikoa gaixotasun kronikoak dituzten pertsonetan, jarduera fisikoa eta minbizi- arriskua Ez da ezer adierazi Ez da interes gatazkarik identifikatu Leandro Garcia dr. Gizon Jarduera fisikoa eta osasun mentala Enplegua eta aholkularitza ordaindua Ez da interes gatazkarik identifikatu Muthoni Gichu dr. Emakume Politiken ezarpena (gobernu nazionala Ez da ezer adierazi Ez da interes gatazkarik identifikatu Russ Jago dr. Gizon Jarduera fisikoa gazteetan Ez da ezer adierazi Ez da interes gatazkarik identifikatu 92 O M E re n g id a le rr o a k j a rd u e ra f is ik o a ri e ta s e d e n ta ri s m o a ri b u ru z 93 2. eranskina Izena Generoa Arloa Interes adierazpena Interes gatazka eta kudeaketa Peter Katzmarzyk dr. Gizon Jarduera fisikoa eta sedentarismoa gazteetan Bidaia-laguntza gidalerroen batzordeetara joateko Ez da interes gatazkarik identifikatu Estelle V. Lambert dr. Emakume Jarduera fisikoa eta obesitatea Ez da ezer adierazi Ez da interes gatazkarik identifikatu Michael Leitzmann dr. Gizon Sedentarismoa eta gaixotasun kronikoak Ez da ezer adierazi Ez da interes gatazkarik identifikatu Karen Milton dr. Emakume Gomendioak praktikara eramatea Bidaia-laguntza gidalerroen batzordera joateko Ez da interes gatazkarik identifikatu Francisco Ortega dr. Gizon Jarduera fisikoa gazteetan, osasun mentala eta neurketa objektiboa Ez da ezer adierazi Ez da interes gatazkarik identifikatu Chathuranga Ranasinghe dr. Emakume Jarduera fisikoa eta osasuna sustatzea komunitatean, lantokian eta eskolan Ikerketa-funtsak Ez da interes gatazkarik identifikatu Emmanuel Stamatakis dr Gizon Jarduera fisikoa eta osasun-emaitza anitzak helduetan Diru-laguntza teknologia- enpresari, jarduera fisikoaren neurketa objektiborako Ez da interes gatazkarik identifikatu Anne Tiedemann dr. Emakume Jarduera fisikoa eta osasun-emaitzak adinekoetan Ez da ezer adierazi Ez da interes gatazkarik identifikatu Richard Troiano dr. Gizon Politiken garapena Ez da ezer adierazi Ez da interes gatazkarik identifikatu Hidde van der Ploeg dr. Gizon Jarduera fisikoa, sedentarismoa eta osasun-emaitzak helduetan Bidaia-laguntza 2017ko Holandako Jarduera Fisikorako Gidalerroen batzordera joateko; ikerketa-funtsak Ez da interes gatazkarik identifikatu Vicky Wari and. Emakume Politiken ezarpena (gobernu nazionala) Akzioak (garrantzirik gabeak gidalerroetarako) Ez da interes gatazkarik identifikatu Kidekoen kanpoko berrikusleak Izena Generoa Arloa Interes adierazpena Interes gatazka eta kudeaketa Kingsley Akinroye Gizon Defentsa, gaixotasun ez kutsakorrak Ez da ezer adierazi Ez da interes gatazkarik identifikatu Huda Alsiyabi dr. Emakume Politiken eta programen ezarpena Ez da ezer adierazi Ez da interes gatazkarik identifikatu Alberto Flórez- Pregonero dr. Gizon Jarduera fisikoa eta sedentarismoaren neurketa eta zaintza Ez da ezer adierazi Ez da interes gatazkarik identifikatu Shigeru Inoue dr. Gizon Epidemiologia eta jarduera fisikoaren sustapena Ez da ezer adierazi Ez da interes gatazkarik identifikatu Agus Mahendra dr. Gizon Jarduera fisikoa eta gaitasun motorrak haurretan Ez da ezer adierazi Ez da interes gatazkarik identifikatu Deborah Salvo dr. Emakume Desberdintasun sozio- sanitarioak, arreta berezia gaixotasun kronikoen prebentzioan Ez da ezer adierazi Ez da interes gatazkarik identifikatu Jasper Schipperijn dr. Gizon Jarduera fisikoa eta ingurune eraikia Presidente-Hautatua Jarduera Fisiko eta Osasuneko Nazioarteko Elkartean (ISPAH) Ez da interes gatazkarik identifikatu

ข้้อแนะนำ�ข้ององค์์ก�รอน�มััยโลก สำำ�หรัับกิิจกิรัรัมท�งกิ�ย และพฤติิกิรัรัมเนืือยนิื�ง WHO GUIDELINES ON PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOUR เอกิสำ�รัแปลจ�กิ WHO Guidelines on physical activity and sedentary behaviour

ข้้อแนะนำ�ข้ององค์์ก�รอน�มััยโลก สำำ�หรัับกิิจกิรัรัมท�งกิ�ย และพฤติิกิรัรัมเนืือยนิื�ง WHO GUIDELINES ON PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOUR เอกิสำ�รัแปลจ�กิ WHO Guidelines on physical activity and sedentary behaviour ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี ข้อ้แนะนำ�ข้ององค์ก์�รอน�มัยัโลกสำำ�หรบักิจกรรมัท�งก�ยและพฤติิกรรมัเนือยนิ�ง WHO GUIDELINES ON PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOUR ผู้้�เขีียน สำำ�นกัง�นใหญ่่องค์ก์�รอน�มัยัโลก ผู้้�แปล ณิิช�ภัทัร แสำงวัฒันะกุล เพ็็ญ่ลด� ไล�เลิศ ผู้้�เรียบเรียง เพ็็ญ่ลด� ไล�เลิศ บรรณิ�ธิิก�ร อรณิ� จันัทรศิริ ผู้้�ออกแบบ ศต�นนัท ์วังัทิพ็ย ์ พิ็ส้ำจันอ์กัษร เพ็็ญ่ลด� ไล�เลิศ พิ็มัพ็ค์์รั�งที� 1 เมัษ�ยน 2564 จัำ�นวัน 133 หน� จัำ�นวันที�พิ็มัพ็ ์ 500 เล่มั จัดัทำ�โดย กองกิจักรรมัท�งก�ยเพ่็�อสุำขีภั�พ็ อ�ค์�ร 7 ชั�น 7 กรมัอน�มัยั กระทรวังสำ�ธิ�รณิสุำขี ตำ�บลตล�ดขีวัญั่ อำ�เภัอเม่ัอง จังัหวัดันนทบุรี 11000 โทรศพั็ท ์ 02-5904585-6 โทรสำ�ร 02-5904584 อีเมัล plan.ex@anamai.mail.go.th เว็ับไซต ์ https://dopah.anamai.moph.go.th/ โรงพิ็มัพ็ ์ บริษทั เดอะ กร�ฟิิโก ซิสำเต็มัสำ ์จัำ�กดั 119/138 เดอะ เทอรเ์รสำ ซอยติวั�นนท ์3 ถนนติวั�นนท ์ตำ�บลตล�ดขีวัญั่ อำ�เภัอเม่ัอง จังัหวัดันนทบุรี 11000 โทรศพั็ท ์ 02-5251121, 02-5254669-70 โทรสำ�ร 02-5251272 อีเมัล thegraphicosys@gmail.com สำนบัสำนุนโดย กองกิจักรรมัท�งก�ยเพ่็�อสุำขีภั�พ็ กรมัอน�มัยั สำำ�นกัง�นกองทุนสำนบัสำนุนก�รสำร� งเสำริมัสุำขีภั�พ็ (สำสำสำ.) ม้ัลนิธิิเพ่็�อก�รพ็ฒัน�นโยบ�ยสุำขีภั�พ็ระหว่ั�งประเทศ ISBN 978-616-11-4600-9 © พิมัพ ์เผยแพร่ และสำงวนลิข้สิำทธิิ์ �โดยกองกิจกรรมัท�งก�ยเพื�อสุำข้ภ�พ 2564 หนังส่ำอแปลฉบับนี�ไม่ัได�จััดทำ�โดยองค์ก์�รอน�มััยโลก (the World Health Organization (WHO) องค์ก์�รอน�มัยัโลกไม่ัมีัส่ำวันรบัผิู้ดชอบค์วั�มัถ้กต�องขีองหนงัส่ำอแปลฉบบันี� ผู้้�อำ�นวัยก�รองค์ก์�รอน�มัยัโลก สำำ�นกัง�นใหญ่่ มัอบลิขีสิำทธิิ �ก�รแปลและตีพิ็มัพ็เ์ป็นภั�ษ�ไทยแก่กองกิจักรรมัท�งก�ยเพ่็�อสุำขีภั�พ็อย่�ง ถ้กต�องต�มักฎหมั�ย ห� มัลอกเลียนแบบหร่อทำ�ซำ � ส่ำวันใดส่ำวันหน่�งขีองหนงัส่ำอเพ่็�อวัตัถุประสำงค์เ์ชิงพ็�ณิิชย ์ โดยไม่ัได�รบัอนุญ่�ต ยกเวั�นเพ่็�อใช�ประกอบก�รศก่ษ�หร่อก�รค์�นค์วั� ท�งวิัช�ก�รเท่�นั�น The original English edition WHO Guidelines on Physical Activity and Sedentary Behaviour. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO shall be the binding and authentic edition. หนงัส่ำอแปลฉบบันี�เผู้ยแพ็ร่ภั�ยใต� CC BY-NC-SA 3.0 iACKNOWLEDGEMENT ii อกัษรย่อและค์ำ�ย่อ iii อภิัธิ�นศพั็ท ์ iv ข้อ้สำรุป 1 ค์ว�มัเป็นมั� 17 ระเบียบวิธีิ์ 22 ข้อ้แนะนำ� 34 > เด็กและวยัรุ่น (อ�ยุ 5-17 ปี) 35 ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย 35 ขี�อแนะนำ�ด� นพ็ฤติกรรมัเน่อยนิ�ง 41 > ผ้ ใ้หญ่่ (อ�ยุ 18–64 ปี) 46 ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย 46 ขี�อแนะนำ�ด� นพ็ฤติกรรมัเน่อยนิ�ง 57 > ผ้ส้้ำงอ�ยุ (อ�ยุ 65 ปีข้้ �นไป) 66 ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย 66 ขี�อแนะนำ�ด� นพ็ฤติกรรมัเน่อยนิ�ง 71 > สำติรีมีัค์รรภแ์ละมั�รด�หลงัค์ลอด 72 ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย 72 ขี�อแนะนำ�ด� นพ็ฤติกรรมัเน่อยนิ�ง 78 > ผ้ ใ้หญ่่และผ้ส้้ำงอ�ยุที�มีัภ�วะเรื �อรงั (อ�ยุ 18 ปีข้้ �นไป) 79 ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย 79 ขี�อแนะนำ�ด� นพ็ฤติกรรมัเน่อยนิ�ง 90 > เด็กและวยัรุ่น (อ�ยุ 5–17 ปี) และผ้ ใ้หญ่่ (อ�ยุ 18 ปีข้้ �นไป) ที�มีัภ�วะทุพพลภ�พ 92 ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย 92 ขี�อแนะนำ�ด� นพ็ฤติกรรมัเน่อยนิ�ง 99 หลกัฐ�นในข้อ้แนะนำ�ต่ิ�ง ๆ 101 ก�รประเมิันค์วั�มัน่�เช่�อถ่อขีองหลกัฐ�น 102 ประโยชนแ์ละโทษ 102 คุ์ณิค่์�และค์วั�มัชอบ 103 ค์วั�มัเกี�ยวัขี�องขีองทรพั็ย�กร 103 ค์วั�มัเท่�เทียมั ก�รเป็นที�ยอมัรบั และค์วั�มัเป็นไปได� 105 ค์ว�มัติอ้งก�รต่ิอง�นวิจยั 107 ก�รเลือกใช้ ้ก�รเผยแพร่ ก�รดำ�เนินก�ร และก�รประเมิันผล 108 ก�รเล่อกใช� 108 ก�รเผู้ยแพ็ร่ 109 ก�รรณิรงค์ผ่์ู้�นก�รส่ำ�อสำ�ร 111 ก�รนำ�นโยบ�ยและร�ยก�รไปใช� 112 ก�รตรวัจัตร�และก�รประเมิัน 113 ก�รปรบัปรุงขี�อม้ัล 114 ร�ยก�รอ�้งอิง 115 ภ�ค์ผนวก 1: Management of guideline development process 125 ภ�ค์ผนวก 2: Guideline development group, external peer reviewers, and who staff involved in the development of these guidelines 128 ภ�ค์ผนวก 3: Summary of declaration of interest and how these were managed 132 ภ�ค์ผนวกเว็บไซติ:์ Evidence profiles https://apps.who.int/iris/bitstream/handle/ 10665/336657/9789240015111-eng.pdf สำ�รับัญ สารบััญ ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี ii The World Health Organization (WHO) gratefully acknowledges the contribution to and support of the following individuals and organizations in the development of these guidelines: Fiona Bull and Juana Willumsen led the process of developing these guidelines. Valentina Baltag, Maurice Bucagu, Alex Butchart, Neerja Chowdhary, Regina Guthold, Riitta-Maija Hämäläinen, Andre Ilbawi, Wasiq Khan, Lindsay Lee, Alana Officer, Leanne Riley and Gojka Roglic were members of the WHO Steering Group that managed the guideline development process. The members of the Guideline Development Group (GDG) included Salih Saad Al-Ansari, Stuart Biddle, Katja Borodulin, Matthew Buman, Greet Cardon (co-chair), Catherine Carty, Jean-Philippe Chaput, Sebastien Chastin, Paddy Dempsey, Loretta DiPietro, Ulf Ekelund, Joseph Firth, Christine Friedenreich, Leandro Garcia, Muthoni Gichu, Russ Jago, Peter Katzmarzyk, Estelle V. Lambert, Michael Leitzmann, Karen Milton, Francisco B. Ortega, Chathuranga Ranasinghe, Emmanuel Stamatakis (co-chair), Anne Tiedemann, Richard Troiano, Hidde van der Ploeg, Vicky Wari. Roger Chou served as GRADE methodologist. The external review group included Kingsley Akinroye, Huda Alsiyabi, Alberto Flórez-Pregonero, Shigeru Inoue, Agus Mahendra, Deborah Salvo and Jasper Schipperijn. Systematic reviews of evidence prepared for 2018 US Physical Activity Guidelines Advisory Committee Scientific Report to the Secretary of Health and Human Services were updated thanks to additional literature searches conducted by Kyle Sprow (National Cancer Institutes, National Institutes of Health, Maryland, USA). Additional support to review papers identified was provided by Elif Eroglu (University of Sydney), Andrea Hillreiner (University of Regensburg), Bo-Huei Huang (University of Sydney), Carmen Jochem (University of Regensburg), Jairo H. Migueles (University of Granada), Chelsea Stone (University of Calgary) and Léonie Uijtdewilligen (Amsterdam UMC). Summaries of evidence and GRADE tables were prepared by Carrie Patnode and Michelle Henninger (The Kaiser Foundation Hospitals, Center for Health Research, Portland, Oregon, USA). Additional reviews of evidence were conducted by N Fairhall, J Oliveira, M Pinheiro, and C Sherrington (Institute for Musculoskeletal Health, School of Public Health, The University of Sydney, Sydney, Australia) and A Bauman (Prevention Research Collaboration, School of Public Health, The University of Sydney, Sydney, Australia; and WHO Collaborating Centre for Physical Activity, Nutrition and Obesity); S Mabweazara, M-J Laguette, K Larmuth, F Odunitan-Wayas (Research Centre for Health through Physical Activity, Lifestyle and Sports Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa), L Leach, S Onagbiye (Department of Sport, Recreation and Exercise Science, Faculty of Health Sciences, University of the Western Cape, Cape Town, South Africa), M Mthethwa (Chronic Disease Initiative for Africa, University of Cape Town, Cape Town, South Africa), P Smith (The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa) and F Mashili (Department of Physiology, Muhimbili University of Allied Sciences, Dar Es Salaam, United Republic of Tanzania); B Cillekens, M Lang, W van Mechelen, E Verhagen, M Huysmans, A van der Beek, P Coenen (Department of Public and Occupational Health at Amsterdam University Medical Centre, Amsterdam, Netherlands). The Public Health Agency of Canada and the Government of Norway provided financial support, without which this work could not have been completed. ACKNOWLEDGEMENT iii อักิษรัย่อและคำำ�ย่อ ADHD attention deficit hyperactive disorder โรค์สำมั�ธิิสำั�น AOR adjusted odds ratio อตัร�ส่ำวันปัจัจัยัในก�รเกิดเหตุที�ถ้กปรบัแต่ง BMI body mass index ดชันีมัวัลก�ย CI confidence interval ช่วังค์วั�มัเช่�อมัั�น CVD cardiovascular disease โรค์หวััใจัและหลอดเล่อด DBP diastolic blood pressure ค์วั�มัดนัโลหิตตำ� EtD Evidence to Decisions หลกัฐ�นประกอบก�รตดัสิำนใจั GDG Guideline Development Group กลุ่มัพ็ฒัน�แนวัปฏิิบติั GRADE Grading of Recommendations Assessment, Development and Evaluationก�รจัดัลำ�ดบัก�รประเมิันขี�อแนะนำ�, ก�รพ็ฒัน� และก�รประเมิันค่์� HR hazards ratio อตัร�ส่ำวันอนัตร�ย MET Metabolic Equivalent of Task หน่วัยวัดัค์วั�มัต�องก�รออกซิเจันขีณิะออกกำ�ลงัก�ย MD mean difference ผู้ลต่�งขีองค่์�เฉลี�ย MICT moderate intensity continuous training ก�รฝึึกฝึนร่�งก�ยอย่�งต่อเน่�องในระดบักล�ง NCD noncommunicable disease โรค์ไม่ัติดต่อเร่ �อรงั OR odds ratio อตัร�ส่ำวันค์วั�มัสำมััพ็นัธิข์ีองค่์�สำองค่์� PA physical activity ก�รเค์ล่�อนไหวัร่�งก�ย ก�รออกกำ�ลงัก�ย PAGAC United States Physical Activity Guidelines Advisory Committee ค์ณิะกรรมัก�รที�ปรก่ษ�แนวัปฏิิบติัก�รออกกำ�ลงัก�ยแห่งสำหรฐัอเมัริก� PI/ECO Population, Intervention/Exposure, Comparison, Outcome ประช�กร, ก�รแทรกแซง, ก�รเปิดเผู้ย, ก�รเปรียบเทียบ, ผู้ลลพั็ธิ ์ RaR Relative attributable risk อตัร�ค์วั�มัเสีำ�ยงในก�รเกิดโรค์ขีองกลุ่มัที�มีัปัจัจัยัเสีำ�ยงเทียบกบักลุ่มัที� ไม่ัมีัค์วั�มัเสีำ�ยง RCT randomized control trial ก�รทดลองแบบสุ่ำมัและมีักลุ่มัค์วับคุ์มั RR relative risk อตัร�ส่ำวันที�บ่งบอกค์วั�มัเสีำ�ยงในก�รเกิดโรค์ SBP systolic blood pressure ค่์�ค์วั�มัดนัโลหิตส้ำงสุำดเม่ั�อหวััใจับีบตวัั SMD standardized mean difference ผู้ลต่�งค่์�เฉลี�ยมั�ตรฐ�น SPPB short physical performance battery แบบประเมิันสำมัรรถภั�พ็ท�งร่�งก�ยในระยะสำั�น TV television โทรทศัน,์ วิัทยุโทรภั�พ็ WHA World Health Assembly สำมัชัช�อน�มัยัโลก WHO World Health Organization องค์ก์�รอน�มัยัโลก อัักษรย่่อัและคำำาย่่อั ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี iv อภิิธ�นืศััพท์ ค์ำ�ศัพัท ์ ค์ว�มัหมั�ย Aerobic physical activity กิิจกิรรมทางกิายแบบแอโรบิกิ กิจักรรมัที� กล� มัเน่�อมััดใหญ่่ขีองร่�งก�ยเค์ล่� อนไหวัอย่�งเป็นจัังหวัะต่อเน่� อง เรียกอีกอย่�งหน่�งว่ั� กิจักรรมัฝึึกค์วั�มัอดทน เพ่็�อพ็ฒัน�สำมัรรถภั�พ็ในก�รหมุันเวีัยน โลหิต ตวััอย่�งเช่น ก�รเดิน วิั�ง ว่ั�ยนำ � และปั� นจักัรย�น Anaerobic physical activity กิิจกิรรมทางกิายแบบแอนแอโรบิกิ ประกอบไปด�วัยกิจักรรมัเขี�มัขี�นใช�แรงหนกั เช่น ก�รยกนำ � หนกั ก�รวิั�งด�วัยค์วั�มัเร็วัส้ำง ซ่�งค์วั�มัต�องก�รออกซิเจันจัะส้ำงกว่ั�ปริมั�ณิก�๊ซออกซิเจันที�มีัอย่้ Balance training กิารฝึึกิเพ่ื่�อสรา้งสมดุุล ก�รออกกำ�ลงัแบบอย่้กบัที�และเค์ล่�อนไหวัที�ถ้กออกแบบมั�เพ่็�อพ็ฒัน�ค์วั�มัสำ�มั�รถขีอง แต่ละบุค์ค์ลที�จัะอดทนต่อค์วั�มัท� ท�ยจั�กท่�ออกกำ�ลงัก�ยที�มีัก�รโค์�งแอ่นหร่อก�ร กระตุ�นที� ไม่ัค์งที�อนัเกิดจั�กก�รเค์ล่�อนไหวัร่�งก�ย, สำภั�พ็แวัดล�อมั หร่อวัตัถุอ่�น ๆ Body mass index (BMI) ดุชันีมวลกิาย นำ � หนกั (กิโลกรมัั) / ส่ำวันส้ำง (เมัตร)2 BMI-for-age or BMI z-score ดุชันีมวลกิายแยกิช่วงอายุ ดชันีมัวัลก�ยที�ปรบัต�มัระดบัอ�ยุ เป็นมั�ตรฐ�นสำำ�หรบัวัยัเด็ก ค่์�มั�ตรฐ�นก�รเบี�ยงเบน ดชันีมัวัลก�ยเป็นก�รวัดันำ � หนกัสำมััพ็ทัธิที์�ปรบัต�มัอ�ยุและเพ็ศขีองเด็ก ก�รระบุอ�ยุ เพ็ศ ดชันีมัวัลก�ย และค่์�มั�ตรฐ�นในก�รอ� งอิงที�เหมั�ะสำมัด�วัยดชันีมัวัลก�ยแยกช่วังอ�ยุ (หร่อค่์�เปอรเ์ซ็นต์ไทลข์ีองดชันีมัวัลก�ยต่ออ�ยุ) จัะเป็นตวัักำ�หนด Bone-strengthening activity กิิจกิรรมเสริมสรา้งความแข็็งแรง กิระดูุกิ กิจักรรมัที� มุ่ังออกแบบมั�เพ่็�อเพิ็�มัค์วั�มัแข็ีงแรงให�กบักระด้กเฉพ็�ะจุัดที�จัะซ่อมัแซมั ระบบกระด้ก กิจักรรมัเสำริมัสำร� งค์วั�มัแข็ีงแรงกระด้กจัะสำร� งผู้ลกระทบหร่อแรงตง่ที� ทำ�ให�กระด้กเจัริญ่เติบโตและแข็ีงแรง ก�รวิั�ง กระโดดเช่อก และยกนำ � หนกัเป็นตวััอย่�ง ขีองกิจักรรมัเสำริมัสำร� งค์วั�มัแข็ีงแรงกระด้ก Cardiometabolic health ภาวะเสี�ยงต่่อโรคหลอดุเล่อดุ และหวัใจ ผู้ลกระทบระหว่ั�งค์วั�มัดนัโลหิต ไขีมันัในเล่อด นำ � ต�ลในเล่อด และอินซ้ลินที�มีัต่อสุำขีภั�พ็ Cardiorespiratory fitness (endurance) ความแข็็งแรงข็องระบบหมุนเวียน โลหิต่ (ความทนทาน) องค์ป์ระกอบท�งสุำขีภั�พ็ที�เกี�ยวัเน่�องกบัค์วั�มัแข็ีงแรงท�งก�ย สำมัรรถนะขีองระบบหมุัน เวีัยนโลหิตและระบบห�ยใจัที�สำร� งก�๊ซออกซิเจันขีณิะออกกำ�ลงัก�ย ปรกติแล�วัจัะแสำดง ค่์�ในร้ปแบบขีองก�รด้ดซม่ัออกซิเจันส้ำงสุำดที�วัดัหร่อประเมิันได� (VO2 max) Cognitive function สมรรถนะดุา้นกิารรูคิ้ดุ กิจักรรมัด� นสำมัอง เช่น ก�รใช�เหตุผู้ล ค์วั�มัจัำ� ค์วั�มัสำนใจั และภั�ษ�ซ่�งนำ�ไปส่้ำก�รบรรลุ ถง่ชุดขี�อม้ัลและค์วั�มัร้� ยงัรวัมัไปถง่ก�รเรียนร้�ด�วัย Disability ทุพื่พื่ลภาพื่ จั�กก�รให�ค์ำ�นิย�มัระดบัสำ�กลเกี�ยวักบั ก�รทำ�ง�น ภั�วัะทุพ็พ็ลภั�พ็ และสุำขีภั�พ็ ภั�วั ะ ทุ พ็ พ็ ล ภั� พ็ อ ย่้ ในก ลุ่มั ค์วั�มั ห มั � ย เ ดี ย วั กับ ค์วั�มั บ ก พ็ ร่ อง ขี�อจัำ � กัด ในก�รทำ�กิจักรรมัต่�ง ๆ และก�รจัำ�กดัก�รมีัส่ำวันร่วัมั แสำดงถง่เกณิฑ์์ในแง่ลบต่อสำมััพ็นัธิ ์ ระหว่ั�งบุค์ค์ล (ที�มีัเง่�อนไขีท�งสุำขีภั�พ็) และปัจัจัยัแวัดล�อมัขีองบุค์ค์ลนั�น (ปัจัจัยัจั�กภั�วัะ แวัดล�อมัและปัจัจัยัเฉพ็�ะบุค์ค์ล) Domains of physical activity ข็อบเข็ต่กิิจกิรรมทางกิาย ระดบัขีองกิจักรรมัท�งก�ยสำ�มั�รถประเมิันได�ด�วัยขีอบเขีตหล�ยร้ปแบบ อ�ทิเช่น เวัล�พ็กัผู่้อน, อ�ชีพ็, ระดบัก�รศก่ษ�, ค์รอบค์รวัั และ/หร่อ ก�รเดินท�งขีนส่ำง Exercise กิารออกิกิำาลงักิาย เป็นประเภัทย่อยขีองกิจักรรมัท�งก�ยซ่�งผู่้�นก�รวั�งแผู้น จัดัโค์รงสำร� ง ทำ�ซำ � และมีั วัตัถุประสำงค์์ในด� นที�จัะปรบัปรุงหร่อรกัษ�ค์วั�มัแข็ีงแรงท�งก�ยด� นใดด� นหน่�ง ก�ร ออกกำ�ลงัก�ยและก�รฝึึกออกกำ�ลงัก�ยอ�จัใช�สำลบัสำบัเปลี�ยนกนั และโดยทั�วัไปมักั หมั�ยถง่กิจักรรมัท�งก�ยที�ทำ�ระหว่ั�งเวัล�พ็กัผู่้อนด�วัยวัตัถุประสำงค์ห์ลกัเพ่็�อพ็ฒัน� หร่อรกัษ�ค์วั�มัแข็ีงแรง สำมัรรถภั�พ็ท�งก�ย หร่อสุำขีภั�พ็ไวั� Executive function ทกัิษะสมอง หมั�ยรวัมัถง่โค์รงสำร� งอ่�น ๆ เช่น ค์วั�มัจัำ�เพ่็�อก�รใช�ง�น, ค์วั�มัย่ดหยุ่นในก�รรบัร้� (หร่อเรียกอีกอย่�งหน่�งว่ั�ก�รคิ์ดแบบย่ดหยุ่น) และก�รค์วับคุ์มัยบัยั�ง (ซ่� งรวัมัถ่ง ก�รค์วับคุ์มัตนเองด�วัย) Fitness ความแข็็งแรง ก�รวัดัค์วั�มัสำ�มั�รถขีองร่�งก�ยในก�รทำ�ง�นอย่�งมีัประสิำทธิิภั�พ็และประสิำทธิิผู้ลทั�ง ด� นกิจักรร�ก�รทำ�ง�นและก�รพ็กัผู่้อน ตวััอย่�งเช่น ค์วั�มัแข็ีงแรงท�งก�ย และค์วั�มั แข็ีงแรงขีองระบบหมุันเวีัยนโลหิต Flexibility ความย่ดุหยุ่น องค์ป์ระกอบขีองค์วั�มัแข็ีงแรงท�งก�ยที� เกี�ยวัเน่�องกบัสุำขีภั�พ็และสำมัรรถนะซ่�งเป็น ค่์�ผู้นัแปรขีองก�รเค์ล่�อนไหวัขีองขี�อต่อ ค์วั�มัย่ดหยุ่นนั�นต่�งกนัไปต�มัขี�อต่อแต่ละส่ำวัน และขี่ �นอย่้กบัตวััแปรหล�ย ๆ อย่�ง และอ�จัมีัตวััแปรอ่�นใดอีก ตวััอย่�งเช่น ค์วั�มัแน่น ขีองเอ็นและเสำ�นเอ็นเฉพ็�ะส่ำวัน ก�รออกกำ�ลงัก�ยแบบเน�นค์วั�มัย่ดหยุ่นจัะทำ�ให�ขี�อต่อ สำ�มั�รถเค์ล่�อนไหวัได�อย่�งค์ล่องตวัั vอัภิิธานศััพท์์ Functional exercises กิารออกิกิำาลงักิายจากิกิารทำางาน ก�รออกกำ�ลงัก�ยที�แฝึงอย่้ในกิจัวัตัรประจัำ�วันัที�จัะพ็ฒัน�ค์วั�มัแข็ีงแรงขีองร่�งก�ย ส่ำวันล่�ง ค์วั�มัสำมัดุล และสำมัรรถนะก�รเค์ล่�อนไหวั ตวััอย่�งเช่น ก�รย่นขี�เดียวั ก�รย่อย่ด ก�รย่นเก�ะเก� อี � ย่นปล�ยเท� หร่อก�รก� วัขี� มัสิำ�งกีดขีวั�ง Household domain physical activity กิิจกิรรมทางกิายในครวัเร่อน กิจักรรมัท�งก�ยในบ� นเร่อน (เช่น ก�รทำ�ค์วั�มัสำะอ�ด ก�รด้แลเด็ก ก�รทำ�สำวัน เป็นต�น) Leisure-domain physical activity กิิจกิรรมทางกิายจากิกิารพื่กัิผ่่อน กิจักรรมัท�งก�ยขีองแต่ละบุค์ค์ลที� ไม่ัใช่สิำ� งจัำ�เป็นในชีวิัตประจัำ�วัันและเป็นไป ต�มัค์วั�มัชอบขีองแต่ละบุค์ค์ล ตัวัอย่�งกิจักรรมัเหล่�นี�ได�แก่ ก�รเล่นกีฬ� ก�รออกกำ�ลงัก�ยหร่อฝึึกก�ยบริห�ร กิจักรรมัสำนัทน�ก�รเล่นก�รเดินเล่น เต�นรำ� หร่อทำ�สำวัน Light-intensity physical activity กิิจกิรรมทางกิายระดุบัเบา กิจักรรมัท�งก�ยแบบเบ�ค่์�ออกซิเจันจัะอย่้ระหว่ั�ง 1.5 และ 3 METs ตวััอย่�งเช่น ก�รส้ำญ่เสีำยพ็ลงัง�นน�อยกว่ั�ค่์�พ็ลงัง�นปรกติขีณิะพ็กัผู่้อนน�อยกว่ั� 3 เท่�ขีอง บุค์ค์ลนั�น ซ่�งรวัมัถง่ก�รเดินช� ๆ ก�รอ�บนำ � หร่อกิจักรรมัเล็ก ๆ น�อย ๆ ที� ไม่ัทำ�ให� อตัร�ก�รเต�นขีองหวััใจั หร่ออตัร�ก�รห�ยใจัเพิ็�มัส้ำงขี่ �นอย่�งมีันยัสำำ�ค์ญั่ Major muscle groups กิลุ่มกิลา้มเน่ �อหลกัิ กลุ่มักล� มัเน่�อหลกัรวัมัถง่ ขี� หลงั ช่องท�อง หน� อก ไหล่ และแขีน Metabolic equivalent of task (MET) หน่วยวดัุความต่อ้งกิารออกิซิิเจน ข็ณะออกิกิำาลงักิาย ห น่วั ย วััด ค์ วั � มั ต�อ ง ก � ร อ อ ก ซิ เจั น ขี ณิ ะ อ อ ก กำ � ลัง ก � ย ห ร่ อ เรี ย ก ง่ � ย ๆ ว่ั�ค่์�เทียบก�รสำนัด�ป เป็นก�รวัดัท�งสำรีรวิัทย�ซ่� ง่แสำดงให�เห็นถง่ค์วั�มัเขี�มัขี�นขีอง กิจักรรมัท�งก�ย ค่์� 1 MET เป็นค่์�พ็ลงัง�นเทียบกบัที�ค์น ๆ หน่�งจัะใช�ขีณิะที�อย่้นิ�ง ๆ Moderate-intensity physical activity กิิจกิรรมทางกิายระดุบัปานกิลาง ในระดบัค่์�สำมัับ้รณิ ์ค์วั�มัหนกัหน่วังพ็อค์วัรหมั�ยถง่กิจักรรมัท�งก�ยที�เกิดขี่ �นระหว่ั�ง 3 ค์รั�งและไม่ัเกิน 6 ค์รั�ง เม่ั�อเทียบกบัค์วั�มัเขี�มัขี�นขีองช่วังพ็กัผู่้อน ในระดบัที�สำมััพ็นัธิก์บั ระดบัค์วั�มัสำ�มั�รถส่ำวันบุค์ค์ล กิจักรรมัท�งก�ยที�มีัค์วั�มัหนกัหน่วังพ็อค์วัรนั�นปรกติจัะ อย่้ที�ระดบั 5 หร่อ 6 จั�กระดบัวัดั 0 ถง่ 10 Muscle-strengthening activity กิิจกิรรมย่ดุหยุ่นกิลา้มเน่ �อ กิจักรรมัท�งก�ยและก�ยบริห�รที�เพิ็�มัค์วั�มัแข็ีงแรงขีองกล� มัเน่�อยด่กระด้ก พ็ละกำ�ลงั ค์วั�มัทนท�น และมัวัล (ตวััอย่�งเช่น ก�รฝึึกค์วั�มัแข็ีงแรง ก�รฝึึกค์วั�มัทนท�น หร่อ ค์วั�มัแข็ีงแรงกล� มัเน่�อและก�ยบริห�รเพ่็�อฝึึกค์วั�มัอดทน) Multicomponent physical activity กิิจกิรรมทางกิายแบบผ่สมผ่สาน กิจักรรมัท�งก�ยแบบผู้สำมัผู้สำ�นนั�นมีัค์วั�มัสำำ�ค์ญั่ต่อผู้้�ส้ำงอ�ยุที�จัะช่วัยพ็ฒัน�ก�รทำ�ง�น ขีองร่�งก�ยและลดค์วั�มัเสีำ�ยงจั�กก�รหกล�มัหร่อบ�ดเจ็ับจั�กก�รหกล�มั กิจักรรมัเหล่�นี� สำ�มั�รถทำ�ได�ที�บ� นหร่อก�รจัดัตั�งกลุ่มั มีัก�รผู้สำมัก�ยบริห�รทุกแขีนงเขี� ด�วัยกนั เป็นช่วัง (ก�รฝึึกแบบแอโรบิก ก�รสำร� งค์วั�มัแข็ีงแรงกล� มัเน่�อ และก�รฝึึกสำมัดุล) และได�ผู้ลเป็นอย่�งดี ตวััอย่�งขีองร�ยก�รออกกำ�ลงัแบบผู้สำมัผู้สำ�นนั�นอ�จัรวัมัถง่ ก�รเดิน (กิจักรรมัแบบแอโรบิก), ก�รยกนำ � หนัก (ก�รเสำริมัสำร� งค์วั�มัแข็ีงแรง กล� มัเน่�อ) รวัมัเขี� กบัก�รฝึึกสำมัดุล ตวััอย่�งขีองก�รฝึึกสำมัดุลก็เช่นก�รเดินถอยหลงั หร่อเดินไปท�งขี� ง หร่อก�รย่นขี�เดียวัขีณิะฝึึกค์วั�มัแข็ีงแรงกล� มัเน่�อร่�งก�ยช่วังบน เช่น ก�รบริห�รกล� มัเน่�อแขีนไปด�วัย ก�รเต�นก็ถ่อเป็นก�รผู้สำมัผู้สำ�นองค์ป์ระกอบแบบ แอโรบิกกบัก�รสำร� งสำมัดุล Occupation domain physical activity กิิจกิรรมทางกิายในกิลุ่มอาชีพื่ ด้หวััขี�อกิจักรรมัท�งก�ยในกลุ่มัก�รทำ�ง�น Physical activity กิิจกิรรมทางกิาย ก�รเค์ล่�อนไหวัร่�งก�ยในร้ปแบบใด ๆ ที� ก่อให�เกิดกล� มัเน่�อย่ดกระด้กซ่�งต�องก�ร ก�รใช�พ็ลงัง�น Physical inactivity กิิจกิรรมทางกิายที�ไม่เพีื่ยงพื่อ ระดบัก�รเค์ล่�อนไหวัร่�งก�ยที� ไม่ัเพี็ยงพ็อต่อระดบัก�รเค์ล่�อนไหวัร่�งก�ยที�แนะนำ� Psychosocial health สุำขีภั�พ็จิัตสำงัค์มั หมั�ยรวั Recreational screen time เวลาจอ้งจอในเชิงสนัทนากิาร เวัล�ที�ใช�ในก�รรบัชมัหน� จัอต่�ง ๆ (โทรทศันห์ร่อทีวีั, ค์อมัพิ็วัเตอร,์ อุปกรณิม่์ัอถ่อ) ด�วัยวัตัถุประสำงค์อ่์�นที�นอกเหน่อไปจั�กก�รเรียนก�รศก่ษ�หร่อก�รทำ�ง�น Sedentary screen time เวลาที�อยู่กิบัหนา้จอโดุย ไม่มีกิารเคล่�อนไหว ระยะเวัล�ที� ใช�ในก�รรบัชมัค์วั�มับนัเทิงผู่้�นจัอ (ทีวีั, ค์อมัพิ็วัเตอร,์ อุปกรณิม่์ัอถ่อ) ไม่ัรวัมัถ่งก�รเล่นเกมัสำผ่์ู้�นหน� จัอที�ต�องใช�ก�รเค์ล่�อนไหวัร่�งก�ยหร่อมีักิจักรรมั ท�งก�ย ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี vi Sedentary behaviour พื่ฤติ่กิรรมเน่อยนิ�ง พ็ฤติกรรมัขีณิะต่�นที�ใช�พ็ลงัง�นไม่ัเกิน 1.5 METS ขีณิะนั�ง นอนเอกขีเนก หร่อนอนเหยียด ก�รทำ�ง�นติดโตะ๊ ก�รขีบัรถ หร่อก�รด้โทรทศันเ์ป็นตวััอย่�งขีองพ็ฤติกรรมัเน่อยยิ�ง อนัอ�จัหมั�ยรวัมัถง่ผู้้�ที� ย่นเองไม่ัได� เช่นผู้้�ต�องนั�งรถเข็ีน แนวัปฏิิบติันี�ได�จัดัค์ำ�นิย�มัขีองพ็ฤติกรรมัเน่อยนิ�งให�รวัมัถง่ก�รนั�งติดที�แบบเค์ล่�อนไห วัน�อย (เวัล�ในก�รพ็กัผู่้อน, สิำ�งที�เกี�ยวักบัอ�ชีพ็ และภั�พ็รวัมัอ่�น), โทรทศัน ์(ก�รชมัร�ย ก�รโทรทศันห์ร่อเวัล�จั�องจัอ และก�รเค์ล่�อนไหวัในระดบัตำ� ที�วัดัได�จั�กค์วั�มัเค์ล่�อนไหวั จับัโดยอุปกรณิที์�ประเมิันค์วั�มัเค์ล่�อนไหวัหร่อก�รออกท่�ท�ง) Sport กีิฬา กีฬ�ค์รอบค์ลุมักิจักรรมัอนัหล�กหล�ยที�กระทำ�ภั�ยใต�กฎต่�ง ๆ และเป็นส่ำวันหน่�งขีอง ก�รพ็กัผู่้อนหร่อก�รแข่ีงขีนั กิจักรรมักีฬ�นั�นค์รอบค์ลุมักิจักรรมัท�งก�ยที�ทำ�เป็นทีมั หร่อเป็นร�ยบุค์ค์ลและอ�จัจัะได�รบัก�รสำนบัสำนุนจั�กสำถ�บนัต่�ง ๆ เช่น สำำ�นกักีฬ� Transport domain physical activity กิิจกิรรมทางกิายในกิลุ่มกิารเดิุนทาง กิจักรรมัท�งก�ยที�เกิดขี่ �นโดยวัตัถุประสำงค์เ์พ่็�อก�รไปจั�กสำถ�นที�หน่�งส่้ำสำถ�นที�อ่�น ๆ ซ่�งหมั�ยถง่ก�รเดิน ก�รปั� นจักัรย�น และก�รขีบัเค์ล่�อนด�วัยล�อ (ก�รใช�วิัถีท�งแบบ ไม่ัมีัเค์ร่� องยนตแ์ต่เค์ล่� อนไหวัด�วัยล�อ ตัวัอย่�งเช่น สำก้ตเตอร,์ โรลเลอรเ์บลด, เก� อี �ล�อเล่�อนด�วัยตนเอง เป็นต�น) Vigorous-intensity physical activity กิิจกิรรมทางกิายระดุบัหนกัิ กิจักรรมัท�งก�ยในระดับแข็ีงแรง ในระดับที� ไ ม่ั มีัก�รผู้ันแปรนั�น หมั�ยถ่ง กิจักรรมัท�งก�ยที�ส้ำงกว่ั� 6 METS หร่อมั�กกว่ั� ในระดบัที�เกี�ยวัขี�องกบัค์วั�มัสำ�มั�รถส่ำวัน บุค์ค์ลนั�น กิจักรรมัท�งก�ยในระดบัแข็ีงแรงนั�นจัะอย่้ที�ระดบั 7 หร่อ 8 ในก�รวัดัระดบัจั�ก 0 ถง่ 10 Work domain physical activity กิิจกิรรมทางกิายในกิลุ่มกิารทำางาน กิจักรรมัท�งก�ยที�เกิดขี่ �นจั�กก�รทำ�ง�นที� ได�รบัค่์�จั� งหร่อง�นอ�สำ� 1ข้้อมูลสำรุัป ขี�อแนะนำ �ขีององค์์ก�รอน�มััยโลก เกี�ยวักบักิจักรรมัท�งก�ยและพ็ฤติกรรมัเน่อย- นิ�งนี�ได�สำร� งเน่�อห�ค์ำ�แนะนำ�ด� นสำ�ธิ�รณิสุำขี ที� มีัหลกัฐ�นรองรบั สำำ�หรบัเด็ก วัยัรุ่น ผู้้�ใหญ่่ แ ล ะ ผู้้� ส้ำ ง อ � ยุ เ กี� ย วั กับ ป ริ มั � ณิ กิ จั ก ร ร มั ท�งก�ย ที�ต�องก�ร (ค์วั�มัถี� , ค์วั�มัหนกัหน่วัง และระยะเวัล�) เพ่็� อ เ ป็นผู้ลดีต่อสุำขีภั�พ็ อ ย่ � ง มีั นัย ย ะ สำำ � ค์ัญ่ แ ล ะ ล ด ค์ วั � มั เ สีำ� ย ง ด� นสุำขีภั�พ็ และถ่อเป็นค์รั�งแรกที�มีัก�รแนะนำ� ที� เช่� อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ� งกับ ผู้ลลพั็ธิด์� นสุำขีภั�พ็ รวัมัถ่งสำำ�หรบัประช�กร กลุ่มัย่อย สำตรีมีัค์รรภัแ์ละมั�รด�หลงัค์ลอด และผู้้�มีัภั�วัะเจ็ับป่วัยเร่ �อรงัหร่อพิ็ก�ร ขี�อ แน ะ นำ � นี�จััด ทำ � ขี่ �น สำำ � หรับ ผู้้�วั�ง นโยบ�ยในประเทศที�มีัร�ยได�ส้ำง กล�ง และตำ� ผู้้�อ ย่้ ในกระทรวังสำ�ธิ�รณิสุำขี ก�รศ่กษ� ก�รเย�วัชน ก�รกีฬ� และ/หร่อสำวัสัำดิก�รสำงัค์มั และค์รอบค์รัวั เจั� หน� ที� รัฐที� รับผิู้ดชอบ แผู้นพ็ฒัน�ระดบัช�ติ ระดบัท�องถิ�น หร่อระดบั เทศบ�ลที�ต�องก�รเพิ็�มักิจักรรมัท�งก�ยและ ลดพ็ฤติกรรมัเน่อยนิ� งในกลุ่มัประช�กรผู่้�น เอกสำ�รแนะแนวั ผู้้�ทำ�ง�นในองค์ก์รที� ไม่ัใช่ หน่วัยง�นขีองรฐั ภั�ค์ก�รศ่กษ� ภั�ค์เอกชน หน่วัยวิัจัยั และผู้้�ให�บริก�รด้แลสุำขีภั�พ็ ขี�อแนะนำ�นี�จัดัเตรียมัขี่ �นต�มัค่้์ม่ัอก�ร พ็ัฒน�ขี�อแนะนำ�ขีององค์ก์�รอน�มััยโลก มีัก�รทบทวันวัรรณิกรรมัอย่�งเป็นระบบเพ่็�อ ผู้ลลพั็ธิที์�สำำ�ค์ญั่ และค์ำ�แนะนำ�นี�ได�พ็ฒัน�ขี่ �น 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ให�รฐับ�ลและผู้้�มีัส่ำวันเกี�ยวัขี�องทำ�ง�นร่วัมักนั เพ่็� อเพิ็� มักิจักรรมัท�งก�ยและลดพ็ฤติกรรมั เน่อยนิ�งในทุก ๆ ช่วังอ�ยุ แหล่งขี�อม้ัลสำนบัสำนุน เหล่�นี�สำ�มั�รถอ่�นได�ที� เว็ับไซตข์ีององค์ก์�ร อน�มััย-โลกหลังจั�กก�รตีพิ็มัพ็์เอกสำ�ร ขี�อแนะนำ�ต่�ง ๆ แมั�จัะมีัขี�อม้ัลสำนบัสำนุนมั�กมั�ยเกี�ยวักบั กิจักรรมัท�งก�ยและพ็ฤติกรรมัเน่อยนิ� งที� เพิ็�มัขี่ �น ซ่�งส่ำงผู้ลต่อสุำขีภั�พ็ในทุกช่วังอ�ยุ แต่ช่อง ว่ั�งท�งหลกัฐ�นที�สำำ�ค์ญั่ยงัค์งมีัอย่้ โดยเฉพ็�ะ ก�รขี�ดหลกัฐ�นจั�กประเทศที�มีัร�ยได�ตำ� และ ร�ยได�ป�นกล�ง ชุมัชนที�ด�อยโอก�สำและด�อย- สิำทธิิ �ท�งเศรษฐกิจั และก�รขี�ดหลกัฐ�นจั�ก ประช�กรกลุ่มัย่อยที�รวัมัถง่กลุ่มัค์นพิ็ก�ร จัง่ค์วัร มีัก�รลงทุนในก�รวิัจััยเพิ็� มัเติมัเพ่็� อสำร� ง ข้้อัมููลสรุป ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 2 หลกัฐ�นขี�อม้ัลในด� นนี�โดยเฉพ็�ะ นอกจั�กนี� ก�รเปลี�ยนแปลงที�เกิดกบัขี�อแนะนำ�เหล่�นี�จัะมีั ค์วั�มัเกี� ยวัขี�องกับระบบก�รตรวัจัสำอบและ เค์ร่� องม่ัอก�รประเมิันผู้ลที� ใช�ตรวัจัสำอบ กิจักรรมัท�งก�ยในระดบัประเทศ เค์ร่�องม่ัอที�มีั อย่้ในระดบัโลกและระดบัประเทศค์วัรได�รบัก�ร ทบทวัน และก�รร�ยง�นก�รปรบัปรุงชุดขี�อม้ัล เพ่็�อจัดัทำ�ร�ยง�นในอน�ค์ตและนำ�มั�เทียบกบั ขี�อแนะนำ� ใหม่ั ขี�อ แน ะ นำ �ร ะ ดับ โ ล ก ด� นกิจั กร ร มั ท�งก�ยในปี 2561-2573 ตั�งเป้�หมั�ยใน ก�รลดพ็ฤติกรรมัเน่อยนิ� งที� ไม่ัเพี็ยงพ็อลง ร�อยละ 15 ภั�ยในปี 2573 และวั�งโค์รงร่�ง ที� จัะร่�งมั�ตรก�รท�งนโยบ�ยและก�รมีั ส่ำวันร่วัมัอีก 20 ร�ยก�ร ขี�อแนะนำ�เหล่�นี� สำ นับ สำ นุ นให� ทุ ก ป ร ะ เท ศ ดำ � เนิ น ก � ร ต � มั ขี�อแนะนำ�ในแผู้นปฏิิบัติก�ร GAPPA และ ACTIVE ซ่�งเป็นชุดแผู้นดำ�เนินก�รเฉพ็�ะท�ง ที� ให� ขี�อแนะ นำ �ด� นก�รส่ำงเสำริมักิจักรรมั ท�งก�ยในแต่ละช่วังอ�ยุและสำภั�พ็แวัดล�อมั ที�หล�กหล�ย 3เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) กิจักรรมัท�งก�ยสำร� งคุ์ณิประโยชนด์� นสุำขีภั�พ็มั�กมั�ยต่อเด็กและวัยัรุ่น ทั�งก�รเสำริมัสำร� งค์วั�มัแข็ีงแรงท�งร่�งก�ร (ค์วั�มัแข็ีงแรงขีองระบบหมุันเวีัยน โลหิตและกล� มัเน่�อ) สุำขีภั�พ็ที� เกี�ยวักบัหลอดเล่อด (ค์วั�มัดนัโลหิต ไขีมันัในเล่อด นำ � ต�ลในเล่อด และก�รต่อต� นอินซ้ลิน) สุำขีภั�พ็กระด้ก ผู้ลต่อประสำ�ทก�รรบัร้� (ก�รเรียนร้� ก�รคิ์ดวิัเค์ร�ะห)์ สุำขีภั�พ็จิัต (ลดอ�ก�รเค์รียด) และลดภั�วัะโรค์อ�วัน • ทำ�กิจักรรมัท�งก�ยสำกันิดย่อมัดีกว่ั�ไม่ัทำ�อะไรเลย • ห�กเด็กหร่อวัยัรุ่นไม่ัสำ�มั�รถทำ�ต�มัขี�อแนะนำ�ได� ก�รทำ�กิจักรรมัท�งก�ยบ� งก็เป็นประโยชน์ ต่อสุำขีภั�พ็ขีองพ็วักเขี�แล�วั • เด็กและวัยัรุ่นค์วัรเริ�มัจั�กกิจักรรมัท�งก�ยเบ� ๆ แล�วัค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มัหนกัหน่วัง และระยะเวัล�ขี่ �นได� • ก�รสำร� งโอก�สำให�กบัเด็กและวัยัรุ่นในก�รทำ�กิจักรรมัท�งก�ยอย่�งปลอดภัยัและมีัโอก�สำ เท่�เทียมักนั และส่ำงเสำริมัให�ทำ�กิจักรรมัท�งก�ยอย่�งสำนุกสำน�น หล�กหล�ย และเหมั�ะสำมักบั อ�ยุกบัค์วั�มัสำ�มั�รถนั�น มีัค์วั�มัสำำ�ค์ญั่อย่�งยิ�ง พ็ฤติกรรมัเน่อยนิ� งในเด็กและวััยรุ่นที� เพิ็� มัขี่ �นจัะต�มัมั�ด�วัยผู้ลลัพ็ธิท์�งสุำขีภั�พ็ที� ไ ม่ั ดี ทั�งโรค์อ�วันที� เพิ็�มัขี่ �น สุำขีภั�พ็หลอดเล่อด ค์วั�มัแข็ีงแรง ค์วั�มัประพ็ฤติ/พ็ฤติกรรมัเอ่ �อสำงัค์มั และระยะเวัล�นอนหลบัที�ลดลง แนะนำ�ให:้ ค์วร ทำ� กิจ กร ร มั ท�ง ก� ย แ บ บ แอ โร บิ ก ใ นร ะ ด ับ ห นัก เ ช่้ น เ ดี ย ว ก ับ ก � ร สำ ร ้� ง ค์ว�มัแข็้งแรงให้กล�้มัเนื �อและกระด้ก อย่�งนอ้ยสำปัด�หล์ะ 3 วนั ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ เด็กและวยัรุ่นค์วรทำ�กิจกรรมัท�งก�ยระดบั ป�นกล�ง-หนกั เฉลี�ยอย่�งนอ้ยวนัละ 60 น�ที ติลอดทั�งสำปัด�ห ์โดยเนน้ไปที�ก�รทำ�กิจกรรมั ท�งก�ยแบบแอโรบิก อย่�งน้ือย สำำ�หรัับกิิจกิรัรัมท�งกิ�ยแบบแอโรับิกิ รัะดัับป�นกิล�ง-หนักิ ตลอดสััปด�ห์์ ควรัทำ�กิิจกิรัรัมท�งกิ�ยแบบแอโรับิกิ ในระดับห์นักและสำร้ั�งคว�มแข็็งแรัง ให้กัิบกิล้�มเน้�อและกิรัะดูักิ ไปด้วยกัน นื�ท่ต่ิอวัันื วัันืต่ิอสัำปด็�ห์ > > แนะนำ�ให:้ เด็กและวยัรุ่นค์วรจำ�กดัเวล�ที� ใช้ ้ ไปกบั พฤติิกรรมัเนือยนิ�ง โดยเฉพ�ะเวล�ที�อย่้กบั หน�้จอเพื�อก�รสำนัทน�ก�ร > ข้้อัมููลสรุป อย่�งน้ือย จำ�กัิด็ รัะยะเวัล�ท่� ใช้้ ไปกัิบ พฤติิกิรัรัมเนืือยนิื�ง โดยเฉพ�ะเวล�ท่ี่�อย่� กับห์น้�จอ ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 4 วััยผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ในวััยผู้้�ใหญ่่ กิจักรรมัท�งก�ยจัะเอ่ �อประโยชน์ต่อผู้ลลัพ็ธิท์�งสุำขีภั�พ็ ทั�งสุำขีภั�พ็ร่�งก�ยโดยรวัมั โรค์หลอดเล่อดหัวัใจั ภั�วัะค์วั�มัดนัโลหิตส้ำง มัะเร็งเฉพ็�ะจุัด1 เบ�หวั�นชนิดที�สำอง สุำขีภั�พ็จิัต (ลดอ�ก�รกงัวัลและเค์รียด) สุำขีภั�พ็ขีองสำมัอง ก�รนอนหลบั มั�ตรวัดัภั�วัะโรค์อ�วันอ�จัจัะดีขี่ �นได�ด�วัย แนะนำ�ให:้ ผ้ ใ้หญ่่ทุกค์นค์วรทำ�กิจกรรมัท�งก�ยท ั�วไปในทุกวนั แนะนำ�อย่�งยิ�ง ค์วั�มัแน่นอนขีองหลกัฐ�น ประกอบเช่�อถ่อได� แนะนำ�อย่�งยิ�ง ค์วั�มัแน่นอนขีองหลกัฐ�น ประกอบเช่�อถ่อได� แนะนำ�อย่�งยิ�ง ค์วั�มัแน่นอนขีองหลกัฐ�น ประกอบเช่�อถ่อได� ผ้ ใ้หญ่่ค์วรทำ�กิจกรรมัท�งก�ยแบบแอโรบิก ระดบัป�นกล�ง อย่�งนอ้ย 150-300 น�ที หรือ ทำ�กิจกรรมัท�งก�ยแบบแอโรบิกระดบัหนกั อย่�งนอ้ย 75-150 น�ที หรือทำ�ผสำมัผสำ�นกนั โดยทำ�ติลอดทั�งสำปัด�ห ์เพื�อผลดีต่ิอสุำข้ภ�พ อย่�งต่ิอเนื�อง วยัผ้ ้ใหญ่่ค์วรทำ�กิจกรรมัสำร�้งค์ว�มั แข็้ง แรงให้ก ับ ก ล�้มั เนื �อ ที� ติ ้องใ ช้ ้ กล�้มัเนื �อส่ำวนหลกัทุกส่ำวนที� ระดบั ป�นกล�งข้้ �นไป อย่�งนอ้ย 2 วนัต่ิอ สำปัด�หเ์พื�อเสำริมัสำร�้งสุำข้ภ�พที�ดี > > > อย่�งน้ือย ถึึง ถึึง หรืัอ150 75 300 150 นาทีี วััน นาทีี อย่�งน้ือย สำำ�หรัับกิิจกิรัรัมท�งกิ�ย แบบแอโรับิกิรัะดัับ ป�นกิล�ง สำำ�หรัับกิิจกิรัรัม ท�งกิ�ย แบบแอโรับิกิ รัะดัับหนักิ หร้ัอทั�งสำองแบบผสำมผสำ�นกัินตลอดัสัำปดั�ห์ สำำ�หรัับกิิจกิรัรัมสำร้ั�งคว�ม แข็็งแรังให้กัิบกิล้�มเน้� อท่� ต้องใช้้กิล้�มเน้� อส่ำวนหลักิ ทุกิส่ำวนท่� รัะดัับป�นกิล�ง ข้็�นไป เพ้ื่�อสุำข็ภ�พื่ท่�ด่ัข้็�น: อย่�งน้ือย สัำปด็�ห์ ต่ิอ 1 มัะเร็งเฉพ�ะจุดได้แก� กระเพ�ะปัสัสั�วะ, ที่รวงอก, ลำ�ไส้ัให์ญ่�, เย่�อบุมัดล่ก, ห์ลอดอ�ห์�ร, กระเพ�ะอ�ห์�ร และไต 5เพ้ื่�อสุำข็ภ�พื่ท่�ด่ัข้็�น: หร้ัอออกิกิำ�ลังแบบผสำมผสำ�นกัินตลอดัสัำปดั�ห์ พ็ฤติกรรมัเน่อยนิ� งที� เพิ็� มัส้ำงขี่ �นในวััยผู้้� ใหญ่่จัะต�มัมั�ด�วัยผู้ลลัพ็ธิท์�งสุำขีภั�พ็ที� ไม่ัดี ได�แก่ ก�รเสีำยชีวิัตจั�กทุกสำ�เหตุ ก�รเสีำยชีวิัตที�เกี�ยวัเน่�องกบัหลอดเล่อดหวััใจั และก�รเสีำยชีวิัตจั�กโรค์มัะเร็ง และโอก�สำในก�รเกิดโรค์หลอดเล่อดหวััใจั โรค์มัะเร็ง และโรค์เบ�หวั�นชนิดที�สำอง ค์ำ�แนะนำ�แบบมีัเง่�อนไขี หลกัฐ�นประกอบเช่�อถ่อได� แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นประกอบเช่�อถ่อได� แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นประกอบเช่�อถ่อได� วััยผูู้้ใหญ่ (อ�ยุ 18-64 ปี) วยัผ้ ้ใหญ่่สำ�มั�รถเพิ�มัระยะเวล�ในก�รทำ� กิจกรรมัท�งก�ยแบบแอโรบิกในระดบั ป�นกล�งใหม้ั�กกว่� 300 น�ที หรือทำ� กิจกรรมัท�งก�ยแบบแอโรบิกในระดบัหนกั ใหม้ั�กกว่� 150 น�ที หรือทำ�ผสำมัผสำ�นกนั ระหว่�งกิจกรรมัท�งก�ยแบบแอโรบิกใน ระดบัป�นกล�งและระดบัหนกัไปติลอดทั�ง สำปัด�ห ์เพื�อสุำข้ภ�พที�ดียิ�งข้้ �น > ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ • ทำ�กิจักรรมัท�งก�ยสำกันิดย่อมัดีกว่ั�ไม่ัทำ�อะไรเลย • ห�กวัยัผู้้�ใหญ่่ไม่ัสำ�มั�รถทำ�ต�มัขี�อแนะนำ�เหล่�นี�ได� ก�รทำ�กิจักรรมัท�งก�ยบ� งก็เป็น ประโยชนต่์อสุำขีภั�พ็ขีองพ็วักเขี�แล�วั • วัยัผู้้�ใหญ่่ค์วัรเริ� มัจั�กกิจักรรมัท�งก�ยเบ� ๆ แล�วัค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มัหนักหน่วัง และระยะเวัล�ขี่ �นได� แนะนำ�ให:้ ในวยัผ้ ้ใหญ่่ ค์วรจะจำ�กดัเวล�ที�ใช้ ้ไปกบั พฤติิกรรมัเนือยนิ�ง และทดแทนเวล�เหล่� นั�นดว้ยก�รทำ�กิจกรรมัท�งก�ยในทุกระดบั (รวมัถง้ระดบัเบ�) เพื�อสำร�้งเสำริมัสุำข้ภ�พที�ดี ในวยัผ้ ้ ใหญ่่ ค์วรทำ�กิจกรรมัท�งก�ย ในระดบัป�นกล�ง-หนักให้มั�กกว่�ที� แนะนำ�ไว ้ เพื�อลดผลกระทบที�เป็นอนัติร�ย ต่ิอสุำข้ภ�พจ�กพฤติิกรรมัเนือยนิ�ง > > ข้้อัมููลสรุป มากกว่ัา มากกว่ัา หรืัอ สำำ�หรัับกิิจกิรัรัม ท�งกิ�ย แบบแอโรับิกิ รัะดัับป�นกิล�ง สำำ�หรัับกิิจกิรัรัมท�ง กิ�ยแบบแอโรับิกิ รัะดัับป�นกิล�ง นาทีี นาทีี จำ�กัิด็ แทนืท่� เวัล�ท่� ใช้้ ไปกัิบ พฤติิกิรัรัมเนืือยนิื�ง ด้็วัยกิิจกิรัรัมท�งกิ�ย ในืทุกิ ๆ รัะดั็บ (รวมัถึึงระดับเบ�) ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 6 ผูู้้สูำงอ�ยุ (อ�ยุ 65 ปีขึ้�นืไป) กิ จั ก ร ร มั ท � ง ก � ย จั ะ เ อ่ �อ ป ร ะ โ ย ช น์ ต่ อ สุำ ขี ภั � พ็ ขี อ ง ผู้้� ส้ำ ง อ � ยุ ทั�งสุำขีภั�พ็ร่�งก�ยโดยรวัมั โรค์หลอดเล่อดหัวัใจั ภั�วัะค์วั�มัดนัโลหิตส้ำง โ ร ค์ มั ะ เ ร็ ง เ ฉ พ็ � ะ จุั ด โ ร ค์ เ บ � ห วั � น ช นิ ด ที� สำ อ ง โ ร ค์ สุำ ขี ภั � พ็ จิั ต (ลดอ�ก�รกงัวัลและเค์รียด) ก�รรบัร้�ขีองสำมัอง ก�รนอนหลบัมั�ตรวัดัภั�วัะ- โรค์อ�วันอ�จัจัะดีขี่ �นด�วัย ก�รทำ�กิจักรรมัท�งก�ยในผู้้�ส้ำงอ�ยุจัะช่วัยป้องกนัก�รหกล�มั และอุบติัเหตุจั�กก�รหกล�มั รวัมัถง่ก�รผุู้กร่อนและค์วั�มัสำ�มั�รถในก�รทำ�ง�นขีองกระด้ก แนะนำ�ให:้ ผ้ส้้ำงอ�ยุค์วรทำ�กิจกรรมัท�งก�ยท ั�วไปในทุกวนั แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� ผ้ ส้้ำงอ�ยุค์วรทำ�กิจกรรมัท�งก�ยแบบ แอโรบิกที� ระด ับป�นกล�ง อย่�งน้อย 150-300 น�ที หรือทำ�กิจกรรมัท�งก�ย แบบแอโรบิกที�ระดบัหนกั หรือทำ�ผสำมัผสำ�น ก ันท ั�งระด ับป�นกล�งและระด ับหนัก อย่�งเท่�เทียมักนั อย่�งนอ้ย 75-150 น�ที ติลอดทั�งสำปัด�ห ์เพื�อสุำข้ภ�พที�ดี แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� > > ผ้ส้้ำงอ�ยุค์วรทำ�กิจกรรมัสำร�้งค์ว�มั แข็้งแรงใหก้บักล�้มัเนื �อที�ใช้ก้ล�้มัเนื �อ หลกัทุกส่ำวนที�ระดบัป�นกล�งข้้ �นไป อย่�งนอ้ย 2 วนัต่ิอสำปัด�หเ์พื�อสุำข้ภ�พ ที�ดีข้้ �น แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� ในก�รทำ� กิจกรรมัท�งก�ยแต่ิละ สำปัด�ห ์ ผ้ส้้ำงอ�ยุค์วรทำ�กิจกรรมัท�ง- ก�ยหล�ยร้ปแบบเพื�อเนน้ไปที�ก�รสำร�้ง ค์ว�มัสำมัดุลและค์ว�มัแข็้งแรงใหร่้�ง ก�ย ที�ระดบัป�นกล�งข้้ �นไป อย่�งนอ้ย 3 วนัต่ิอสำปัด�ห ์ เพื�อสำร�้งเสำริมัค์ว�มั สำ�มั�รถในก�รทำ�ง�นและป้องกนัก�ร หกลม้ั แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� > > อย่�งน้ือย ถึึง ถึึง หรืัอ150 75 300 150 นาทีี นาทีี อย่�งน้ือย สำำ�หรัับกิิจกิรัรัม ท�งกิ�ย แบบแอโรับิกิ รัะดัับป�นกิล�ง หร้ัอผสำมผสำ�นทั�ง 2 รัะดัับอย่�งเท่�เท่ยมกัินตลอดัทั�งสัำปดั�ห์ สำำ�หรัับกิิจกิรัรัม ท�งกิ�ย แบบแอโรับิกิ รัะดัับป�นกิล�ง วััน สำำ�หรัับกิิจกิรัรัม สำร้ั�งคว�มแข็็งแรัง ให้กัิบกิล้�มเน้�อท่� ใช้้ กิล้�มเน้�อหลักิ ทุกิส่ำวนในรัะดัับ ป�นกิล�งข้็�นไป สำำ�หรัับกิิจกิรัรัมท�งกิ�ย ท่�หล�กิหล�ยเพ้ื่�อเน้น ไปท่�กิ�รัสำร้ั�งสำมดุัล กิ�รัทำ�ง�นข็องร่ั�งกิ�ย และกิ�รัฝึึกิคว�มแข็็งแรัง ท่�รัะดัับป�นกิล�งข้็�นไป เพ้ื่�อสุำข็ภ�พื่ท่�ด่ัข้็�น: อย่�งน้ือย อย่�งน้ือย สัำปด็�ห์ ต่ิอ วััน สัำปด็�ห์ ต่ิอ 7ผูู้้สูำงอ�ยุ (65 ปีขึ้�นืไป) ผ้ส้้ำงอ�ยุสำ�มั�รถเพิ�มัระยะเวล�ในก�รทำ� กิจกรรมัท�งก�ยแบบแอโรบิกในระดบั ป�นกล�งใหม้ั�กกว่� 300 น�ที หรือเพิ�มัระยะ เวล�ข้องกิจกรรมัท�งก�ยระดบัหนกัใหม้ั�ก กว่� 150 น�ที หรือท ั�ง 2 ระดบัผสำมักนัติลอด ท ั�งสำปัด�หเ์พื�อสุำข้ภ�พที�ดีข้้ �น ขี�อแนะนำ�ภั�ยใต�เง่�อนไขี มีัหลกัฐ�นย่นยนั > ข้้อัมููลสรุป สำำ �หรับผู้้� ส้ำงอ�ยุ พ็ฤติกรรมัเน่อยนิ� ง ส่ำวันใหญ่่จัะก่อให� เ กิดผู้ลร� ยต่อสุำขี ภั�พ็ ดัง ต่อไปนี� ก�รเสีำยชีวิัตจั�กทุกสำ�เหตุ ก�รเสีำยชีวิัตจั�กโรค์เกี�ยวักบัหลอดเล่อดและหวััใจั และโรค์มัะเร็ง โอก�สำในก�ร เกิดโรค์มัะเร็งและโรค์เบ�หวั�นชนิดที�สำอง ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ • ทำ�กิจักรรมัท�งก�ยสำกันิดย่อมัดีกว่ั�ไม่ัทำ�อะไรเลย • ห�กผู้้�ส้ำงอ�ยุไม่ัสำ�มั�รถทำ�ต�มัค์ำ�แนะนำ�เหล่�นี�ได� ก�รทำ�กิจักรรมัท�งก�ยบ� งก็เป็นประโย ชนต่์อสุำขีภั�พ็ขีองพ็วักเขี�แล�วั • ผู้้�ส้ำงอ�ยุค์วัรเริ�มัจั�กก�รทำ�กิจักรรมัท�งก�ยเบ� ๆ แล�วัค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มัหนกัหน่วัง และระยะเวัล�ขี่ �น • ผู้้�ส้ำงอ�ยุค์วัรทำ�กิจักรรมัท�งก�ยเท่�ที�ค์วั�มัสำ�มั�รถจัะเอ่ �ออำ�นวัย และปรบัระดบัขีองกิจักรรมั ท�งก�รให�สำมััพ็นัธิก์บัระดบัค์วั�มัแข็ีงแรงได� แนะนำ�ให:้ ผ้ส้้ำงอ�ยุค์วรจำ�กดัเวล�ที�ใช้ ้ไปกบัพฤติิกรรมั เนือยนิ� ง และทดแทนเวล�เหล่�นั�นดว้ย กิจ กร ร มั ท � ง ก� ย ในทุ กร ะ ด ับ (ร วมั ถ้ง ระดบัเบ�) ซ้�งจะเอื �อประโยช้นต่์ิอร่�งก�ย แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� ผ้ส้้ำงอ�ยุค์วรทำ�กิจกรรมัท�งก�ยในระดบั ป�นกล�ง-หนกัใหม้ั�กกว่�ข้อ้แนะนำ�ที�ให้ ไว ้ เพื� อลดผลกระทบร�้ยแรงต่ิอสุำข้ภ�พจ�ก พฤติิกรรมัเนือยนิ�ง แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� > > เพ้ื่�อสุำข็ภ�พื่ท่�ด่ัข้็�น: หร้ัอผสำมผสำ�นทั�ง 2 รัะดัับอย่�งเท่�เท่ยมกัินตลอดัทั�งสัำปดั�ห์ มากกว่ัา มากกว่ัา หรืัอ สำำ�หรัับกิิจกิรัรัม ท�งกิ�ย แบบแอโรับิกิ รัะดัับหนักิ นาทีี นาทีี สำำ�หรัับกิิจกิรัรัมท�ง กิ�ยแบบแอโรับิกิ รัะดัับป�นกิล�ง จำ�กัิด็ แทนืท่� รัะยะเวัล�ท่�อยู่เฉยๆ ด้็วัยกิิจกิรัรัมท�งกิ�ย ในืทุกิ ๆ รัะดั็บคำวั�มหนัืกิ (รวมัถึึงก�รออกกำ�ลังเบ�ๆ) ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 8 สำติร่ัม่คำรัรัภ์ิและม�รัด็�หลังคำลอด็ กิจักรรมัท�งก�ยระหว่ั�งก�รตั�งค์รรภัแ์ละหลงัค์ลอดจัะส่ำงผู้ลดีต่อสุำขีภั�พ็ขีอง มั�รด�และท�รกในค์รรภั์ได�ดงันี� ลดค์วั�มัเสีำ�ยงในก�รค์ลอดก่อนกำ�หนด ภั�วัะ ค์วั�มัดนัโลหิตส้ำงจั�กก�รตั�งค์รรภั ์โรค์เบ�หวั�นขีณิะตั�งค์รรภั ์นำ � หนกัเพิ็�มัเกินเกณิฑ์ ์ ขีณิะตั�งค์รรภั ์ก�รค์ลอดย�ก ภั�วัะซม่ัเศร� หลงัหลอด และค์วั�มัซบัซ�อนท�งก�รค์ลอดที�พ็บ ได�น�อย ไม่ัมีัผู้ลลบต่อนำ � หนกัแรกค์ลอด และไม่ัมีัก�รเพิ็�มัค์วั�มัเสีำ�ยงให�กบัท�รกเสีำยชีวิัตในค์รรภั์ แนะนำ�ใหส้ำติรีมีัค์รรภแ์ละมั�รด�หลงัค์ลอดที�ไม่ัมีัข้อ้จำ�กดัใด ๆ ค์วร: ข้อ้ม้ัลเพิ�มัเติิมั ทำ�กิจกรรมัท�งก�ยท ั�วไปในทุกวนั ติลอดระยะเวล�ที�ติ ั�งค์รรภแ์ละหลงัค์ลอด แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� ผ้ห้ญิ่งที�ทำ�กิจกรรมัท�งก�ยแบบแอโรบิกที�ระดบัหนกัเป็นประจำ� หรือมีัก�ร เค์ลื�อนไหวร่�งก�ยเป็นประจำ�ก่อนติ ั�งค์รรภ ์สำ�มั�รถดำ�เนินกิจกรรมัเหล่�นั�น ต่ิอไปไดต้ิลอดก�รติ ั�งค์รรภจ์นหลงัค์ลอด แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� ค์วรทำ�กิจกรรมัท�งก�ยแบบแอโรบิกที�ระดบั ป�นกล�งอย่�งนอ้ย 150 น�ที ติลอดทั�งสำปัด�ห ์ เพื�อสุำข้ภ�พดีอย่�งย ั�งยืน แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� ค์วรทำ�กิจกรรมัประเภทแอโรบิกที�หล�ยหล�ย และกิจกรรมัสำร�้งค์ว�มัแข็้งแรงใหก้บักล�้มัเนื �อ ก�รยืดเหยียดเบ� ๆ ก็เป็นประโยช้นต่์ิอสุำข้ภ�พ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� > > > > อย่�งน้ือย สำำ�หรัับกิิจกิรัรัมท�งกิ�ย แบบแอโรับิกิท่�รัะดัับป�นกิล�ง นื�ท่ ต่ิอสัำปด็�ห์ 150 9สำติร่ัม่คำรัรัภ์ิและม�รัด็�หลังคำลอด็ ข้้อัมููลสรุป ข้อ้ค์วรค์ำ�น้งเพิ�มัเติิมัด�้นค์ว�มัปลอดภยัในก�รทำ� กิจกรรมัท�งก�ย สำำ�หรบัสำติรีมีัค์รรภคื์์อ: ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ ทำ�กิจักรรมัท�งก�ยสำักนิด ย่อมัดีกว่ั�ไม่ัทำ�อะไรเลย ห�กสำตรีมีัค์รรภัห์ร่อมั�รด� หลงัค์ลอดไม่ัสำ�มั�รถทำ�ต�มัค์ำ� แนะนำ�เหล่�นี�ได� ก�รทำ�กิจั- ก ร ร มั ท � ง ก � ย บ� ง ก็ เ ป็ น ป ร ะ โ ย ช น์ต่ อ สุำ ขี ภั � พ็ ขี อ ง พ็วักเขี�แล�วั สำ ต รี มีั ค์ ร ร ภั์ห ร่ อ มั � ร ด � หลังค์ลอดค์วัรเริ� มัจั�กก�ร ทำ�กิจักรรมัท�งก�ยเบ� ๆ แล�วัค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มั หนกัหน่วังและระยะเวัล�ขี่ �น ก � ร บ ริ ห � ร ก ล� มั เ น่� อ อุ� ง เชิงกร�นเป็นประจัำ�ทุกวััน สำ�มั�รถลดค์วั�มัเสีำ� ยงจั�ก อ�ก�รกลั�นปัสำสำ�วัะไม่ัอย่้ หลีกเลี�ยงก�รทำ�กิจักรรมัท�งก�ยในขีณิะที�อ�ก�ศร�อนเกินไป โดยเฉพ็�ะเม่ั�อมีัค์วั�มัช่�นส้ำง รกัษ�ระดบันำ � ในร่�งก�ยด�วัยก�รด่�มันำ � ก่อน ระหว่ั�ง และหลงั ก�รทำ�กิจักรรมัท�งก�ย หลีกเลี�ยงก�รเขี� ร่วัมักิจักรรมัที�ต�องมีัก�รสำมััผู้สัำกนั ท่�ที�เสีำ�ยงต่อ ก�รหกล�มั หร่ออ�จัต�องจัำ�กดัปริมั�ณิออกซิเจัน (เช่น กิจักรรมั ในที�ส้ำง ห�กไม่ัได�พ็กัอ�ศยัในที�ค์วั�มักดอ�ก�ศส้ำงอย่้แล�วั) เลี� ยงกิจักรรมัในท่�นอนหง�ยหลังจั�กช่วัง 3 เด่อนขีอง ก�รตั�งค์รรภั์ ห�กต�องมีัก�รแข่ีงขีนัด� นกีฬ�หร่อก�รบริห�รร่�งก�ยที�เกินกว่ั� ขี�อแนะนำ� สำตรีมีัค์รรภัค์์วัรปรก่ษ�ผู้้�เชี�ยวัช�ญ่ท�งด� นก�รด้แล สุำขีภั�พ็โดยเฉพ็�ะ สำตรีมีัค์รรภัค์์วัรได�รบัขี�อม้ัลจั�กผู้้�ให�บริก�รด� นก�รด้แลสุำขีภั�พ็ ถง่สำญั่ญ่�ณิที� เต่อนให�หยุดหร่อจัำ�กดัก�รทำ�กิจักรรมัท�งก�ย และปรก่ษ�ผู้้�ให�บริก�รสุำขีภั�พ็ทนัทีที�เกิดเหตุนั�น ๆ ค่์อย ๆ กลบัมั�ทำ�กิจักรรมัท�งก�ยช� ๆ หลงัจั�กค์ลอดบุตร และปรก่ษ�ผู้้�ประกอบวิัช�ชีพ็ด� นสุำขีภั�พ็ในกรณีิผู่้�ค์ลอด เช่นเดียวักบัวัยัผู้้�ใหญ่่ทั�วั ๆ ไป พ็ฤติกรรมัเน่อยนิ�งในสำตรีมีัค์รรภัแ์ละมั�รด�หลงัค์ลอดนั�นจัะก่อให�เกิด ผู้ลเ สีำยต่อสุำขีภั�พ็ ทั�งก�รเ สีำยชีวิัตจั�กทุกสำ�เหตุ ก�รเ สีำยชีวิัตจั�กโรค์หลอดเล่อดหัวัใจั ก�รเสีำยชีวิัตจั�กโรค์มัะเร็ง โอก�สำในก�รเกิดโรค์หลอดเล่อดหวััใจั โรค์มัะเร็ง และโรค์เบ�หวั�นชนิดที�สำอง แนะนำ�ให:้ สำติรีมีัค์รรภแ์ละมั�รด�หลงัค์ลอดค์วรจำ�กดั เวล�ข้องพฤติิกรรมัเนือยนิ�ง และทดแทนเวล� เหล่�นั�นดว้ยก�รทำ�กิจกรรมัท�งก�ยในทุก ระดบั (รวมัถง้ระดบัเบ�) เพื�อผลดีต่ิอสุำข้ภ�พ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นสำนบัสำนุนน�อย > ทำ�กิจกรรมั ท�งก�ยบ�้ง ย่อมัดีกว่� ก�รไม่ัข้ยบัเลย จำ�กัิด็ แทนืท่� เวัล�ท่� ใช้้ ไปกัิบ พฤติิกิรัรัมเนืือยนิื�ง ด้็วัยกิิจกิรัรัมท�งกิ�ย ในืทุกิ ๆ รัะดั็บคำวั�มหนัืกิ (รวมัถึึงก�รออกกำ�ลังเบ�ๆ) กิจักรรมัท�งก�ยส่ำงผู้ลดีต่อผู้้�ใหญ่่และผู้้�ส้ำงอ�ยุที�มีัภั�วัะเร่ �อรงัต่�ง ๆ ได�ดงันี� สำำ�หรบัผ้ร้อดชี้วิติจ�กมัะเร็ง กิจักรรมัท�งก�ยจัะทำ�ให�อ�ก�รต่�ง ๆ ดีขี่ �น ทั�งอ�ก�รที� เกิดจั�กโรค์มัะเร็งโดยตรง และค์วั�มัเสีำ�ยงที�มัะเร็งจัะกลบัมั� หร่อมัะเร็งค์รั�งใหญ่่รอบสำอง สำำ�หรบัผ้ที้� มีัอ�ก�รค์ว�มัดนัโลหิติส้ำง กิจักรรมัท�งก�ย ช่วัยให�อ�ก�รที�เกี�ยวัเน่�องกบัหลอดเล่อดหวััใจั ก�รดำ�เนินขีองโรค์อย่�งต่อเน่�อง ก�รทำ�ง�นขีองร่�งก�ย คุ์ณิภั�พ็ชีวิัตที�เกี�ยวัเน่�องกบัสุำขีภั�พ็ ดีขี่ �น สำำ�หรบัผ้ที้�ป่วยเป็นโรค์เบ�หว�นช้นิดที�สำอง กิจักรรมัท�งก�ยจัะลดอตัร� ก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อดหวััใจัและสำญั่ญ่�ณิบ่งชี�ก�รดำ�เนินขีองโรค์อย่�งต่อเน่�อง สำำ�หรบัผ้ป่้วยที�มีัเชื้ �อ HIV กิจักรรมัท�งก�ยจัะทำ�ให�ร่�งก�ยแข็ีงแรงและสุำขีภั�พ็จิัตดีขี่ �น (ลดอ�ก�รกงัวัลและซม่ัเศร� ) และไม่ัมีัผู้ลกระทบ ในด� นลบต่อก�รดำ�เนินขีองโรค์อย่�งต่อเน่�อง (จัำ�นวัน CD4 และเช่�อในเล่อด) หร่อองค์ป์ระกอบขีองร่�งก�ย ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 10 แนะนำ�ให:้ ผ้ ใ้หญ่่และผ้ส้้ำงอ�ยุที�มีัภ�วะเจ็บป่วยเรื �อรงัค์วรทำ�กิจกรรมัท�งก�ยอย่�งสำมัำ� เสำมัอ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� > ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) ผ้ ้ใหญ่่และผ้ส้้ำงอ�ยุที� มีัภ�วะเจ็บป่วยเรื �อรงั ค์ ว ร ทำ � กิจ ก ร ร มั ท � ง ก � ย แ บ บ แ อ โร บิ ก ที� ระดบัป�นกล�งอย่�งนอ้ย 150-300 น�ที หรือที�ระดบัหนกัอย่�งนอ้ย 75-150 น�ที หรือ ผสำมัผสำ�นทั�งสำองระดบัอย่�งเท่�เทียมักนัติลอด สำปัด�ห ์เพื�อสุำข้ภ�พที�ดีอย่�งย ั�งยืน แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� ผ้ ใ้หญ่่และผ้ส้้ำงอ�ยุที�มีัภ�วะเจ็บป่วยเรื �อรงัเหล่� นี �ค์วรทำ�กิจกรรมัเสำริมัสำร�้งกล�้มัเนื �อในระดบั ป�นกล�งข้้ �นไป โดยใช้ก้ล�้มัเนื �อกลุ่มัหลกัอย่�ง นอ้ย 2 วนัต่ิอสำปัด�หเ์พื�อประโยช้นที์�มั�กข้้ �น แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� ก�รทำ�กิจกรรมัท�งก�ยในแต่ิละสำปัด�ห ์ ผ้ส้้ำง- อ�ยุที�มีัโรค์เรื �อรงัค์วรจะทำ�กิจกรรมัท�งก�ยให้ หล�กหล�ย โดยเนน้ไปที�ก�รสำร�้งสำมัดุลและฝึึก ค์ว�มัแข็้งแรงที�ระดบัป�นกล�งข้้ �นไป อย่�งนอ้ย 3 วนัต่ิอสำปัด�ห ์เพื�อเสำริมัสำร�้งค์ว�มัสำ�มั�รถใน ก�รทำ�ง�นข้องร่�งก�ยและป้องกนัก�รหกลม้ั แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� > > > อย่�งน้ือย ถึึง ถึึง หรืัอ150 75 300 150 นาทีี นาทีี อย่�งน้ือย สำำ�หรัับกิิจกิรัรัม ท�งกิ�ยแบบแอโรับิกิ ท่�รัะดัับหนักิ หร้ัอผสำมผสำ�นทั�งสำองรัะดัับอย่�งเท่�เท่ยมกัิน ตลอดัทั�งสัำปดั�ห์ สำำ�หรัับกิิจกิรัรัม ท�งกิ�ยแบบแอโรับิกิ ท่�รัะดัับป�นกิล�ง วััน 2 สำำ�หรัับกิิจกิรัรัมสำร้ั�งคว�มแข็็งแรังให้กัิบกิล้�มเน้�อท่� ใช้้กิล้�มเน้�อหลักิ ทุกิส่ำวนในรัะดัับ ป�นกิล�งข้็�นไป เพ้ื่�อสุำข็ภ�พื่ท่�ด่ัข้็�น: อย่�งน้ือย สัำปด็�ห์ ต่ิอ วััน 3 สำำ�หรัับกิิจกิรัรัมท�งกิ�ย หล�กิหล�ยรูัปแบบท่�เน้น ไปท่�กิ�รัสำร้ั�งสำมดุัล ร่ั�งกิ�ยและฝึึกิคว�ม แข็็งแรังท่�รัะดัับ ป�นกิล�งข้็�นไป อย่�งน้ือย ต่ิอ สัำปด็�ห์ 11ข้้อัมููลสรุป ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) สำำ�หรบัผ้ร้อดชี้วิติจ�กมัะเร็งและผ้ ใ้หญ่่ที�มีัค์ว�มัดนัโลหิติส้ำง เบ�หว�นช้นิดที�สำองและ HIV ข้อ้แนะนำ�คื์อ: ห�กไม่ัมีัข้อ้ห�้มัใด ๆ ผ้ ้ใหญ่่หรือผ้ส้้ำงอ�ยุที�มีั โรค์เรื �อรงัอ�จเพิ�มัก�รทำ�กิจกรรมัท�งก�ยแบบ แอโรบิกที�ระดบัป�นกล�งใหม้ั�กกว่� 300 น�ทีได ้ หรืออ�จเพิ�มัใหม้ั�กกว่� 150 น�ทีไดเ้ช่้นกนั หรือผสำมัผสำ�นทั�งสำองระดบัใหเ้ท่�เทียมักนั ติลอดทั�งสำปัด�ห ์เพื�อสุำข้ภ�พที�ดีข้้ �น ค์ำ�แนะนำ�แบบมีัเง่�อนไขี หลกัฐ�นที�เช่�อถ่อได� > • ห�กไม่ัสำ�มั�รถทำ�ต�มัค์ำ�แนะนำ�ขี� งต�นได� ผู้้�ใหญ่่ที�มีัโรค์เร่�อรงัค์วัรทำ�กิจักรรมัท�งก�ย เท่�ที�ร่�งก�ยเอ่ �ออำ�นวัย • ผู้้�ใหญ่่ที� มีัโรค์เร่�อรงัค์วัรเริ� มัจั�กกิจักรรมั ท�งก�ยเบ� ๆ แล�วัค่์อย ๆ เพิ็� มัค์วั�มัถี� ค์วั�มัหนกัหน่วัง และระยะเวัล�ขี่ �น • ผู้้�ใหญ่่ที� มีัโรค์เร่�อรงัค์วัรปร่กษ�ผู้้�เชี�ยวัช�ญ่ ด� นก�รทำ�กิจักรรมัท�งก�ย หร่อบุค์ล�กร ท�งก�รแพ็ทยเ์พ่็� อขีอค์ำ�แนะนำ�เกี� ยวักับ ประเภัทและระยะเวัล�ขีองกิจักรรมัที�เหมั�ะสำมั ต่อค์วั�มัต�องก�ร ค์วั�มัสำ�มั�รถ ขี�อจัำ�กดัและ ค์วั�มัซบัซ�อนด� นร่�งก�ย ก�รใช�ย� และแผู้น ก�รรกัษ�โดยรวัมัขีองแต่ละบุค์ค์ล • สำำ�หรบับุค์ค์ลที� ไม่ัมีัขี�อห� มัใด ๆ ไม่ัจัำ�เป็นต�อง มีัใบรบัรองท�งก�รแพ็ทยก่์อนก�รทำ�กิจักรรมั ท�งก�ย ทั�งก�รทำ�กิจักรรมัท�งก�ยที�ระดบั เบ�และระดบัป�นกล�งที� ไม่ัมั�กไปกว่ั�ก�ร เดินเร็วัหร่อก�รใช�ชีวิัตประจัำ�วันั ในวััยผู้้�ใหญ่่ รวัมัถ่งผู้้�ที� ห�ยจั�กมัะเร็งและผู้้�มีัค์วั�มัดันโลหิตส้ำง เบ�หวั�นชนิดที� สำอง และ HIV พ็ฤติกรรมัเน่อยนิ�งที�เพิ็�มัส้ำงขี่ �นจัะต�มัมั�ด�วัยสุำขีภั�พ็ที�แย่ลง ดงันี� ก�รเสีำยชีวิัตทุกสำ�เหตุ ก�รเสีำยชีวิัตจั�ก โรค์หลอดเล่อดหวััใจัและมัะเร็ง และโอก�สำก�รเกิดโรค์หลอดเล่อดหวััใจั มัะเร็ง และโรค์เบ�หวั�นชนิดที�สำอง ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ ผ้ ้ใหญ่่และผ้ส้้ำงอ�ยุที� มีัโรค์เรื �อรงันั�นค์วร จำ�กดัระยะเวล�ที� ใช้ ้ไปกบัพฤติิกรรมัเนือย นิ�ง และแทนที�เวล�เหล่�นั�นดว้ยก�รทำ�กิจ- กรรมัท�งก�ยในทุกระดบั (รวมัถง้ระดบัเบ�) เพื�อประโยช้นต่์ิอสุำข้ภ�พ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นประกอบน�อย ผ้ ้ใหญ่่และผ้ส้้ำงอ�ยุที� มีัโรค์เรื �อรงัค์วรจะทำ� กิจกรรมัท�งก�ยให้ไดม้ั�กกว่�ระดบัที�แนะนำ� ท ั�งระดบัป�นกล�งและหนกั เพื�อช่้วยลดผล เสีำยต่ิอสุำข้ภ�พจ�กก�รมีัพฤติิกรรมัเนือยนิ�ง แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นประกอบน�อย > > เพ้ื่�อสุำข็ภ�พื่ท่�ด่ัข้็�น: หร้ัอผสำมผสำ�นทั�ง 2 รัะดัับอย่�งเท่�เท่ยมกัินตลอดัทั�งสัำปดั�ห์ มากกว่ัา มากกว่ัา หรืัอ สำำ�หรัับกิิจกิรัรัม ท�งกิ�ย แบบแอโรับิกิ รัะดัับหนักิ นาทีี นาทีี สำำ�หรัับกิิจกิรัรัมท�ง กิ�ยแบบแอโรับิกิ รัะดัับป�นกิล�ง จำ�กัิด็ แทนืท่� เวัล�ท่� ใช้้ ไปกัิบ พฤติิกิรัรัมเนืือยนิื�ง ด้็วัยกิ�รัทำ�กิิจกิรัรัมท�งกิ�ย เพิ�มขึ้�นืในืทุกิรัะดั็บ (รวมัถึึงระดับเบ�) ทำ�กิจกรรมั ท�งก�ยบ�้ง ย่อมัดีกว่� ก�รไม่ัทำ�อะไรเลย ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 12 กิจักรรมัท�งก�ยมีัประโยชนต่์อเด็กและวัยัรุ่นมั�กมั�ย ต�มัที� ได�กล่�วัไวั�แล�วัใน บทก่อนหน� และยงัเกี�ยวัเน่�องกบัเด็กและวัยัรุ่นที�มีัภั�วัะทุพ็พ็ลภั�พ็ด�วัย ประโยชนข์ีอง กิจักรรมัท�งก�ยต่อสุำขีภั�พ็สำำ�หรบัเด็กและวัยัรุ่นที� มีัภั�วัะทุพ็พ็ลภั�พ็ยงัรวัมัถง่ ก�ร พ็ฒัน�ค์วั�มัจัำ�ในบุค์ค์ลที�มีัโรค์หร่อค์วั�มัผิู้ดปรกติที�ทำ�ล�ยสำมัองส่ำวันก�รรบัร้� โรค์สำมั�ธิิสำั�น (ADHD) ก�รทำ�ง�นขีองร่�งก�ยอ�จัดีขี่ �นสำำ�หรบัเด็กที�มีัค์วั�มับกพ็ร่องท�งสำติปัญ่ญ่� เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) ท่� ม่ภิ�วัะทุพพลภิ�พ แนะนำ�ให:้ เด็กหรือวยัรุ่นที� มีัภ�วะทุพพลภ�พ ค์วรทำ� กิจกรรมัท�งก�ยแบบแอโรบิกที� ระด ับ ป�นกล�ง-หนกั อย่�งนอ้ยเฉลี�ย 60 น�ทีต่ิอวนั ติลอดทั�งสำปัด�ห ์ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นย่นยนัได� ค์วรทำ�กิจกรรมัท�งก�ยแบบแอโรบิกที� ระดบัหนกัร่วมักบัก�รสำร�้งค์ว�มัแข็้งแรง ให้ก ับ ก ล ้�มั เนื �อ แ ล ะ กร ะ ด้ กอ ย่ �ง น้อ ย สำปัด�หล์ะ 3 วนั แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นเช่�อถ่อได� > > อย่�งน้ือย อย่�งน้ือย สำำ�หรัับกิิจกิรัรัมท�งกิ�ยในรัะดัับ ป�นกิล�งหร้ัอหนักิ ตลอดทัี่�งสััปด�ห์์ โดยให้์ที่ำ�กิจกรรมัที่�งก�ยแบบ แอโรบิกเป็นสั�วนให์ญ่� สำำ �หรัับกิิจกิรัรัมท�งกิ�ยแบบแอโรับิกิท่� รัะดัับหนักิ ร�วมักับกิ�รัสำร้ั�งคว�มแข็็งแรัง ให้กัิบกิล้�มเน้�อและกิรัะดูักิ นาทีี ต่่อวััน นาทีี ต่่อสััปดาห์์ เริ�มัติน้ดว้ย กิจกรรมัท�งก�ย ในระดบัเบ� 13ข้้อัมููลสรุป เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) ท่�ม่ภิ�วัะทุพพลภิ�พ • ทำ�กิจักรรมัท�งก�ยบ� งย่อมัดีกว่ั�ไม่ัทำ�อะไรเลย • ห�กเด็กหร่อวัยัรุ่นผู้้�มีัภั�วัะทุพ็พ็ลภั�พ็ไม่ัสำ�มั�รถทำ�ต�มัค์ำ�แนะนำ�เหล่�นี�ได� ก�รได�ทำ� กิจักรรมัท�งก�ยบ� งก็เป็นผู้ลดีต่อสุำขีภั�พ็แล�วั • เด็กหร่อหร่อวัยัรุ่นที� มีัภั�วัะทุพ็พ็ลภั�พ็ค์วัรเริ�มัทำ�กิจักรรมัท�งก�ยอย่�งเบ� ๆ ก่อนแล�วั ค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มัหนกั และระยะเวัล�ขี่ �น • กิจักรรมัท�งก�ยสำำ�หรบัเด็กและวัยัรุ่นที�มีัภั�วัะทุพ็พ็ลภั�พ็นั�นไม่ัมีัค์วั�มัเสีำ�ยงห�กอย่้ในระดบั ที�เหมั�ะสำมักบัระดบักิจักรรมั สำถ�นะด� นสุำขีภั�พ็ และสำภั�พ็ร่�งก�ยขีองบุค์ค์ลนั�น และผู้ลดี ต่อสุำขีภั�พ็มีัมั�กกว่ั�ค์วั�มัเสีำ�ยง • เด็กและวัยัรุ่นที� มีัภั�วัะทุพ็พ็ลภั�พ็อ�จัจัะต�องปร่กษ�บุค์ล�กรท�งแพ็ทยห์ร่อผู้้�เชี�ยวัช�ญ่ ด� นกิจักรรมัท�งก�ยและภั�วัะทุพ็พ็ลภั�พ็เพ่็�อกำ�หนดประเภัทและระยะเวัล�ที� เหมั�ะสำมั ในก�รทำ�กิจักรรมั พ็ฤติกรรมัเน่อยนิ�งที�เพิ็�มัส้ำงขี่ �นในวัยัเด็กและวัยัรุ่นต�มัมั�ด�วัยผู้ลที� ไม่ัดีต่อสุำขีภั�พ็ เช่น โรค์อ�วันที�เพิ็�มัส้ำงขี่ �น โรค์เกี�ยวักบัหลอดเล่อด สำมัรรถภั�พ็ร่�งก�ย และก�รประพ็ฤติตนและพ็ฤติกรรมัเอ่ �อสำงัค์มัที�แย่งลง และระยะเวัล�ในก�รนอนหลบัที�น�อยลง แนะนำ�ให:้ เด็กหรือวยัรุ่นที� ทุพพลภ�พค์วรจะลดระยะ เวล�ที�ใช้ ้ไปกบัพฤติิกรรมัเนือยนิ�ง โดยเฉพ�ะ เวล�ที�อย่้กบัหน�้จอ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นประกอบน�อย > จำ�กัิด็ เวัล�ท่� ใช้้ ไปกัิบ พฤติิกิรัรัมเนืือยนิื�ง โดยเฉพ�ะเวล�ท่ี่�อย่� กับห์น้�จอ ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ ประโยชนข์ีองกิจักรรมัท�งก�ยต่อวัยัผู้้�ใหญ่่หล�ยประก�รได�กล่�วัไวั�แล�วั ขี� งต�น และยงัหมั�ยรวัมัถง่ผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ด�วัย ประโยชนข์ีอง กิจักรรมัท�งก�ยต่อผู้้�ที�มีัทุพ็พ็ลภั�พ็ มีัดงันี� สำาหรบัผู่ใ้หญ่่ที�มีภาวะกิลา้มเน่ �อ อ่อนแรง กิจักรรมัท�งก�ยจัะช่วัยพ็ัฒน�ก�รทำ�ง�นขีองร่�งก�ยและคุ์ณิภั�พ็ชีวิัตที� เกี�ยวัเน่�องกบัสุำขีภั�พ็ทั�งท�งร่�ยก�ย จิัตใจั และสำงัค์มั สำาหรบัผู่ที้�บาดุเจ็บที�เสน้ประสาทไข็สนั- หลงั จัะทำ�ให�ก�รเดิน ค์วั�มัแข็ีงแรงกล� มัเน่�อ ก�รทำ�ง�นขีองร่�งก�ยช่วังบนดีขี่ �น และเสำริมัสำร� ง คุ์ณิภั�พ็ชีวิัตด� นสุำขีภั�พ็ สำาหรบัผู่ที้� มีโรคหร่อความปรกิติ่ในกิารรบัรูบ้กิพื่ร่อง จัะช่วัย ทำ�ให�ก�รทำ�ง�นขีองร่�งก�ยและก�รรบัร้�ดีขี่ �น (สำำ�หรบัผู้้�ที� เป็นโรค์พ็�รกิ์นสำนัหร่อเค์ยมีัประวัติั หัวัใจัวั�ย) มีัผู้ลดีต่อร่�งก�ยด� นประสำ�ทก�รรับร้� และอ�จัพ็ฒัน�คุ์ณิภั�พ็ค์วั�มัเป็นอย่้ (สำำ�หรบัผู้้�ใหญ่่ที�เป็นโรค์จิัตเภัท) พ็ฒัน�ก�รทำ�ง�นขีองร่�งก�ย (สำำ�หรบัผู้้�ใหญ่่ที�มีัค์วั�มับกพ็ร่อง ท�งสำติปัญ่ญ่�) และพ็ฒัน�คุ์ณิภั�พ็ชีวิัต (สำำ�หรบัผู้้�ใหญ่่ที�อย่้ระหว่ั�งก�รรกัษ�โรค์ซม่ัเศร� ) ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 14 ผูู้้ใหญ่ (อ�ยุ 18 ปีขึ้�นืไป) ท่� ม่ภิ�วัะทุพพลภิ�พ แนะนำ�ให:้ ผ้ ใ้หญ่่ที�มีัภ�วะทุพพลภ�พค์วรทำ�กิจกรรมัท�งก�ยเป็นประจำ�ในทุกวนั แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� > ผ้ ใ้หญ่่ที�มีัภ�วะทุพพลภ�พค์วรจะทำ�กิจกรรมั ท�งก�ยแบบแอโรบิกที�ระดบัป�นกล�งอย่�ง นอ้ย 150-300 น�ที หรือที�ระดบัหนกัอย่�งนอ้ย 75-150 น�ที หรือผสำมักนัท ั�ง 2 ระดบั ติลอดสำปัด�ห ์เพื�อสุำข้ภ�พที�ดีอย่�งย ั�งยืน แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นย่นยนัเช่�อถ่อได� > ผ้ ใ้หญ่่ที�มีัภ�วะทุพพลภ�พค์วรทำ�กิจกรรมั สำ ร ้� ง ค์ ว � มั แ ก ข็้ ง แรง ให้ก ับ ล ้� มั เนื �อ โดยใช้ก้ล�้มัเนื �อหล ักทุกส่ำวนที� ระด ับ ป�นกล�งข้้ �นไป อย่�งนอ้ย 2 วนัต่ิอสำปัด�ห ์ เพื�อสุำข้ภ�พที�ดี แนะนำ�อย่�งยิ�ง หลกัฐ�นประกอบเช่�อถ่อได� > อย่�งน้ือย ถึึง ถึึง หรืัอ150 75 300 150 นาทีี นาทีี อย่�งน้ือย สำำ�หรัับกิิจกิรัรัม ท�งกิ�ยแบบแอโรับิกิ ท่�รัะดัับหนักิ หร้ัอผสำมผสำ�นทั�งสำองรัะดัับอย่�งเท่�เท่ยมกัิน ตลอดัทั�งสัำปดั�ห์ สำำ�หรัับกิิจกิรัรัม ท�งกิ�ยแบบแอโรับิกิ ท่�รัะดัับป�นกิล�ง วััน 2 สำำ�หรัับกิิจกิรัรัมสำร้ั�งคว�มแข็็งแรังให้กัิบกิล้�มเน้�อโดัยใช้้กิล้�มเน้�อหลักิ ทุกิส่ำวนในรัะดัับ ป�นกิล�งข้็�นไป เพ้ื่�อสุำข็ภ�พื่ท่�ด่ัข้็�น: อย่�งน้ือย สัำปด็�ห์ ต่ิอ 15 ผูู้้ใหญ่ (อ�ยุ 18 ปีขึ้�นืไป) ท่�ม่ภิ�วัะทุพพลภิ�พ ข้้อัมููลสรุป ผ้ ้ใหญ่่ที� มีัภ�วะทุพพลภ�พสำ�มั�รถเพิ�มักิจ- กรรมัท�งก�ยแบบแอโรบิกที�ระดบัป�นกล�ง ใหม้ั�กกว่� 300 น�ทีได ้หรือทำ�กิจกรรมัท�งก�ย แบบแอโรบิกที�ระดบัหนกัให้มั�กกว่� 150 น�ทีไดเ้ช่้นกนั หรือก�รผสำมัผสำ�นที�เท่�เทียมั กนัระหว่�งกิจกรรมัท�งก�ยแบบแอโรบิกท ั�ง 2 ระดบั ติลอดทั�งสำปัด�หเ์พื�อสุำข้ภ�พที�ดีข้้ �น แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นย่นยนัเช่�อถ่อได� > ก�รทำ�กิจกรรมัท�งก�ยในแต่ิละสำปัด�ห ์ผ้ ใ้หญ่่ที�มีั ภ�วะทุพพลภ�พค์วรทำ�กิจกรรมัท�งก�ยใหห้ล�ก- หล�ย ซ้�งจะช่้วยสำร�้งสำมัดุลร่�งก�ยและฝึึกค์ว�มั แข็้งแรง ดว้ยกิจกรรมัท�งก�ยที�ระดบัป�นกล�ง ข้้ �นไป อย่�งนอ้ยสำปัด�หล์ะ 3 วนั เพื�อเพิ�มัค์ว�มั สำ�มั�รถในก�รทำ�ง�นข้องร่�งก�ยและป้องกนั ก�รหกลม้ั แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อได� > ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ ทำ�กิจักรรมัท�งก�ยบ� งย่อมัดีกว่ั�ไม่ัทำ�อะไรเลย ห�กผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ไม่ัสำ�มั�รถทำ�ต�มัค์ำ�แนะนำ�นี�ได� ก�รทำ�กิจักรรมัท�งก�ยบ� งก็เป็น ผู้ลดีต่อสุำขีภั�พ็แล�วั ผู้้�ใหญ่่ที�มีัค์วั�มัทุพ็พ็ลภั�พ็ค์วัรเริ�มัทำ�กิจักรรมัท�งก�ยเบ� ๆ แล�วัค่์อยเพิ็�มัค์วั�มัถี� ค์วั�มัหนกัหน่วัง และระยะเวัล�ขี่ �น กิจักรรมัท�งก�ยสำำ�หรบัผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็นั�นไม่ัมีัค์วั�มัเสีำ�ยงห�กอย่้ในระดบัที� เหมั�ะสำมักบั ระดบักิจักรรมั สำถ�นะด� นสุำขีภั�พ็ และสำภั�พ็ร่�งก�ยขีองบุค์ค์ลนั�น ผู้ลดีต่อสุำขีภั�พ็มีัมั�กกว่ั�ค์วั�มัเสีำ�ยง ผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็อ�จัจัะต�องปรก่ษ�บุค์ล�กรท�งแพ็ทยห์ร่อผู้้�เชี�ยวัช�ญ่ด� นกิจักรรมัท�งก�ย และภั�วัะทุพ็พ็ลภั�พ็เพ่็�อกำ�หนดประเภัทและระยะเวัล�ที�เหมั�ะสำมัในก�รทำ�กิจักรรมั พ็ฤติกรรมัเน่อยนิ�งที� เพิ็�มัส้ำงขี่ �นในวัยัผู้้�ใหญ่่ต�มัมั�ด�วัยผู้ลที� ไม่ัดีต่อสุำขีภั�พ็ เช่น โรค์อ�วันที� เพิ็�มัส้ำงขี่ �น โรค์เกี�ยวักบัหลอดเล่อด สำมัรรถภั�พ็ร่�งก�ย และก�รประพ็ฤติตนและพ็ฤติกรรมัเอ่ �อสำงัค์มัที�แย่ลง และ ระยะเวัล�ในก�รนอนหลบัที�น�อยลง แนะนำ�ให:้ ผ้ ้ใหญ่่ที�มีัภ�วะทุพพลภ�พค์วรจำ�กดัเวล�ที�ใช้ ้ไป กบัพฤติิกรรมัเนือยนิ�ง และแทนที�เวล�เหล่�นั�นดว้ย กิจกรรมัท�งก�ยในทุกระดบั (รวมัถง้กิจกรรมัท�ง ก�ยที�ระดบัเบ�) เพื�อผลดีต่ิอสุำข้ภ�พ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นอ� งอิงน�อย ผ้ ้ใหญ่่ที� มีัภ�วะทุพพลภ�พค์วรทำ�กิจกรรมัท�ง ก�ยใหม้ั�กกว่�ที�แนะนำ�ไว ้ท ั�งระดบัป�นกล�งและ ระดบัหนกั เพื�อช่้วยลดผลกระทบที�เป็นอนัติร�ยต่ิอ สุำข้ภ�พจ�กพฤติิกรรมัเนือยนิ�งเป็นเวล�น�น แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นอ� งอิงน�อย > > จำ�กัิด็ แทนืท่� เวัล�ท่� ใช้้ ไปกัิบ พฤติิกิรัรัมเนืือยนิื�ง ด้็วัยกิ�รัทำ�กิิจกิรัรัม ท�งกิ�ยในืทุกิรัะดั็บ (รวมัถึึงระดับเบ�) วััน 2 สำำ�หรัับกิิจกิรัรัมท�งกิ�ย อย่�งหล�กิหล�ยท่�เน้ืนื สำร้ั�งสำมดุ็ลร่ั�งกิ�ยและ ฝึึกิคำวั�มแข็้งแรังท่�รัะดั็บ ป�นืกิล�งถึึงหนัืกิ เพ้ื่�อสุำข็ภ�พื่ท่�ด่ัข้็�น: อย่�งน้ือย สัำปด็�ห์ ต่ิอ เพ้ื่�อสุำข็ภ�พื่ท่�ด่ัข้็�น: หรืือผสมผสานท้ั้�ง 2 รืะด้ับอย่่างเท่ั้าเทีั้ย่มก้ันตลอดัท้ั้�งส้ปดัาห์ มากกว่ัา มากกว่ัา หรืัอ สำำ�หรัับกิิจกิรัรัม ท�งกิ�ยแบบแอโรับิกิ ท่�รัะดัับหนักิ สำำ�หรัับกิิจกิรัรัม ท�งกิ�ยแบบแอโรับิกิ ท่�รัะดัับป�นกิล�ง นาทีี นาทีี ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 16 17 คำวั�มเป็นืม� ก�รทำ�กิจักรรมัท�งก�ยเป็นประจัำ� เป็นปัจัจัยัที� ร้�กนัดีกว่ั�เป็นก�รป้องกนั และก�รจัดัก�รโรค์ไม่ัติดต่อต่�ง ๆ เช่น โรค์หลอดเล่อดหวััใจั เบ�หวั�นชนิดที�สำอง มัะเร็งทรวังอก และมัะเร็งลำ�ไสำ� (1-3) กิจักรรมัท�งก�ยยงัมีัผู้ลดีต่อสุำขีภั�พ็จิัต (4) ช่วัยให�เกิดภั�วัะค์วั�มัจัำ�เส่ำ�อมัช� ลง (5) และเอ่ �อต่อก�รรักษ�นำ � หนักที� ดีต่อ สุำขีภั�พ็ (1) และสุำขีภั�พ็ที�ดีด�วัย (6) กิ จั ก ร ร มั ท � ง ก � ย ห มั � ย ถ่ ง ก�รเค์ล่�อนไหวัร่�งก�ยทุกร้ปแบบขีอง กล� มัเน่�อย่ดกระด้กที� ต�องก�รก�รใช� พ็ลังง�น (1) และสำ�มั�รถทำ�ได�ด�วัย ค์วั�มัเขี�มัขี�นหล�ยร้ปแบบ โดยกิจักรรมั ท�งก�ยเป็นส่ำวันหน่� งขีองก�รทำ�ง�น ก�รทำ�ง�นบ� น ระหว่ั�งก�รเดินท�ง หร่อระหว่ั�งเวัล�พ็กัผู่้อน หร่อเม่ั�อเล่น ก�ยบริห�รหร่อกีฬ�ต่�ง ๆ ส่ำวันในระดบั ที�ตำ� สุำดขีองช่วังระดบัค์วั�มัเขี�มัขี�น ค่์อ พ็ฤติกรรมัเน่อยนิ� ง ซ่� งหมั�ยถ่งพ็ฤติ- กรรมัเม่ั�อมีัสำติสำมััปชญั่ญ่ะ ในท่�นั�ง เอน หร่อท่�นอนขีณิะใช�พ็ลงัง�นน�อย หลกั- ฐ�นชิ�นใหม่ัที� พ็บบ่งชี�ว่ั� พ็ฤติกรรมั เน่อยนิ� งในระดบัส้ำงนั�นสำมััพ็นัธิก์บัโรค์ หลอดเล่อดหวััใจัและเบ�หวั�นชนิดที�สำอง เ ช่ น เ ดี ย วั กับ ก � ร เ สีำ ย ชี วิั ต จั � ก โร ค์ หลอดเล่อดหัวัใจั โรค์มัะเร็ง และก�ร เสีำยชีวิัตจั�กทุกสำ�เหตุ (8-10) คำวามูเป็นมูา ก � ร มีั กิ จั ก ร ร มั ท � ง ก � ย ที� ไ ม่ั เพี็ยงพ็อนั�น ไม่ัเป็นไปต�มัค์ำ�แนะนำ� สำำ�หรับกิจักรรมัท�งก�ยเพ่็� อสุำขีภั�พ็ ระดบัโลกประจัำ�ปี 2553 (1) และเป็น สำ�เหตุลำ�ดับต�น ๆ ขีองภั�วัะค์วั�มั เจ็ับป่วัยทั�วัโลก มีัก�รประเมิันว่ั�อตัร�ก�ร เสีำยชีวิัตต่อปีอ�จัลดลงถง่ 4-5 ล� นร�ย ห�กประช�กรโลกขียับตัวักันมั�กขี่ �น (2, 11) ก�รประเมิันกิจักรรมัท�งก�ยที� ไม่ั เพี็ยงพ็อทั�วัโลกชี�ให�เห็นว่ั�ในปีพ็.ศ. 2559 ผู้้�ใหญ่่ร�อยละ 27.5 และวัยัรุ่นร�อยละ 81 นั�นไม่ัเป็นไปต�มัค์ำ�แนะนำ�ขีององค์ก์�ร อ น � มััย โ ล ก ปี 2 5 5 3 แ ล ะ ขี� อ ม้ั ล แนวัโน�มัชี�ให�เห็นว่ั�ตวััเลขีทั� วัโลกกระ- เต่ �องขี่ �นเพี็ยงเล็กน�อยในช่วังทศวัรรษที� ผู่้�นมั� ขี�อม้ัลเหล่�นี�ยงับ่งชี�ให�เห็นว่ั� ผู้้�หญิ่งมีัก�รเค์ล่�อนไหวัร่�งก�ยน�อยกว่ั� ผู้้�ช�ยในเก่อบทุกประเทศ และมีัค์วั�มั แตกต่�งอย่�งมั�กสำำ�หรบัระดบักิจักรรมั ท�งก�ยภั�ยในประเทศและระหว่ั�ง ประเทศและภ้ัมิัภั�ค์ต่�ง ๆ ค์วั�มัแตกต่�ง เหล่�นี�อธิิบ�ยได�ด�วัยค์วั�มัไม่ัเท่�เทียมัใน ก�รเขี� ถง่โอก�สำในก�รทำ�กิจักรรมัท�ง ก�ย ซ่�งทำ�ให�เห็นถง่ค์วั�มัไม่ัเท่�เทียมักนั ด� นสุำขีภั�พ็ ในปัจัจุับนั ยงัไม่ัมีัตวััเลขีประมั�ณิ ก�รด� นพ็ฤติกรรมัเน่อยนิ�งในระดบัโลก แต่นวััตกรรมัด� นเทค์โนโลยีและก�ร เปลี�ยนผู่้�นส่้ำอ�ชีพ็และก�รสำนัทน�ก�ร ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 18 ที� มีัพ็ฤติกรรมัเน่อยนิ�งและก�รใช�ย�น- พ็�หนะที� มีัเค์ร่�องยนตเ์พิ็�มัมั�กขี่ �น เป็น ส่ำวันที� ทำ�ให�ร้ปแบบกิจักรรมัท�งก�ย เปลี� ยนแปลงไปและทำ�ให�พ็ฤติกรรมั เน่อยนิ�งเพิ็�มัขี่ �นทั�วัโลก แผู้นปฏิิบติัก�ร โลกสำำ�หรบักิจักรรมัท�งก�ย พ็.ศ. 2561- 2573 (14) ได�ประก�ศวัตัถุประสำงค์เ์ชิง กลยุทธิ ์4 ขี�อ และแผู้นนโยบ�ยปฎิบติัก�ร 20 ประก�ร เพ่็� อลดค์วั�มัชุกตัวัขีอง กิจักรรมัท�งก�ยที� ไม่ัเพี็ยงพ็อทั� วัโลก ทั�งในผู้้� ใหญ่่และวััยรุ่นลงร�อยละ 15 ให�ได�ภั�ยในปี 2573 ในปี 2553 องค์ก์�ร อน�มััยโลกได�ตีพิ็มัพ็ข์ี�อแนะนำ�เร่� อง กิจักรรมัท�งก�ยเพ่็� อสุำขีภั�พ็ระดับ โลก (1) ซ่�งเป็นขี�อแนะนำ�ด� นสำ�ธิ�รณิสุำขี ฉบับแรกสำำ�หรับเด็ก วััยรุ่น ผู้้� ใหญ่่ และผู้้�ส้ำงอ�ยุ ที� อิงจั�กประช�กร และ ในปี 2561 สำมัชัช�อน�มัยัโลกเรียกร�อง ในมัติฉบบั WHA71.6 ให�องค์ก์�รอน�- มัยัโลกปรบัปรุงแนวัปฏิิบติัฉบบัปี 2553 ในปี 2562 องค์ก์�รอน�มัยัโลก ได�ตีพิ็มัพ็ข์ี�อแนะนำ�ด� นกิจักรรมัท�งก�ย พ็ฤติกรรมัเน่อยนิ� ง และก�รนอนหลบั สำำ�หรบัเด็กอ�ยุตำ� กว่ั� 5 ปี (15) ขี�อแนะนำ� นี�เรียกร�องโดยค์ณิะกรรมัก�รหยุดยั�ง ภั�วัะนำ � หนกัเกินในเด็ก (ขี�อแนะนำ� 4.12) (16) และชี�ให�เห็นถง่ก�รละเลยกลุ่มัที� มีั อ�ยุน�อยนี�ในขี�อแนะนำ�ด� นกิจักรรมั ท�งก�ยเพ่็�อสุำขีภั�พ็ ระดบัโลก ฉบบัปี 2553 ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย และพ็ฤติกรรมัเน่อยนิ� งจั�กองค์ก์�ร อ น�มััย โ ล ก ฉ บับ ปี 2 5 6 3 ตี พิ็ มั พ็ ์ ขี่ �นแทนฉบับปี 2553 ซ่� ง เขีียนจั�ก ค์วั�มัสำำ�ค์ญั่ขีองกิจักรรมัท�งก�ย ต่อสุำขีภั�พ็ได�มีัก�รระบุไวั�ในขี�อแนะนำ� ขีององค์ก์�รอน�มัยัโลกฉบบัอ่�น ๆ ขี�อม้ัล รวัมัขีององค์ก์�รอน�มัยัโลกเร่� องก�ร ป้องกันโรค์ไม่ัติดต่อที� สำำ�ค์ัญ่เพ่็� อก�ร ด้แลสุำขีภั�พ็เบ่ �องต�นในภั�วัะทรพั็ย�ก�ร ก�รด้แลตำ� (17) ได�สำร� งเกณิฑ์วิ์ัธีิก�ร จัดัก�รท�งก�รแพ็ทยส์ำำ�หรบัโรค์ค์วั�มั ดนัโลหิตส้ำง โรค์เบ�หวั�นชนิดที�สำอง ค์วั�มั เสีำ�ยงขีองโรค์หลอดเล่อดหัวัใจัที� เพิ็�มัส้ำง ขี่ �น โรค์ห่ด และโรค์หลอดลมัอุดกั�นเร่ �อรงั และรวัมัถ่งก�รให�ค์ำ�ปร่กษ�เร่� องก�ร เพิ็�มักิจักรรมัท�งก�ยส่้ำระดบัป�นกล�ง (เช่น ก�รเดินเร็วั) และทำ�อย่�งน�อย 150 น�ทีต่อสำัปด�ห์ ซ่� งสำอดค์ล�องกับขี�อ แนะนำ�ระดบัโลกฉบบัปี 2553 ขี�อแนะนำ� ฉบับล่�สุำดขีององค์์ก�รอน�มััยโลก ว่ั�ด�วัยเร่� องก�รลดค์วั�มัเสีำ� ยงขีอง ภั�วัะค์วั�มัจัำ�ถดถอยและสำมัองเส่ำ� อมั (18) โดยระบุไวั�ว่ั� ค์วัรแนะนำ�ให�ผู้้�ใหญ่่ที� มีั ภั � วั ะ ก � ร รับ ร้�ป ร ก ติ ทำ � กิจั ก ร ร มั ท�งก�ย (แนะนำ�อย่�งยิ�ง) และแนะนำ� ให� ผู้้�ที� บกพ็ร่องท�งก�รรับร้�แต่น�อย (แนะนำ�ภั�ยใต�เง่�อนไขี) ทำ�กิจักรรมัท�ง ก�ยเพ่็�อลดค์วั�มัเสีำ�ยงต่อก�รถดถอยขีอง กระบวันก�รรบัร้� องค์ก์�รอน�มัยัโลก รวัมัเอ�ก�รด้แลผู้้�ส้ำงอ�ยุ ค์ำ�แนะนำ�ในก�ร คำำ�แนืะนืำ�หลักิข้้ออื�นื ๆ ข้ององค์ำกิ�รัอนื�มัยโลกิ หลกัฐ�นด� นพ็ฤติกรรมัที�เล่อกสำรรและ ผู้ลต่อเน่�องท�งสุำขีภั�พ็ที�ทนัสำมัยัขี่ �น และ เป็นส่ำวันหน่�งขีองค์ำ�แนะนำ�องค์ร์วัมัด� น กิจักรรมัท�งก�ยและพ็ฤติกรรมัเน่อยนิ�ง ทั�วัโลก 19 เขี� จัดัก�รระดบัชุมัชนที�จัะจัดัก�รก�ร ถดถอยขีองค์วั�มัสำ�มั�รถภั�ยใน (19) ทั�งยงัแนะนำ�ให�มีัก�รบริห�รร่�งก�ย หล�ยร้ปแบบเพ่็�อป้องกนัก�รหกล�มั และ ก�รออกกำ�ลังก�ยสำำ�หรับผู้้�ส้ำงอ�ยุที� เค์ล่�อนไหวัร่�งก�ยได�น�อยลง ค์ำ�แนะนำ� ขีององค์ก์�รอน�มััยโลกเพ่็� อก�รด้แล ก่อนค์ลอดสำำ�หรับประสำบก�รณิ์ก�ร ตั�งค์รรภัที์�ดี (20) แนะนำ�ให�มีัก�รปรก่ษ� เร่�องอ�ห�รที�ดีต่อสุำขีภั�พ็และมีักิจักรรมั ท�งก�ยระหว่ั�งตั�งค์รรภัเ์พ่็�อสุำขีภั�พ็ที� ดีและป้องกนันำ � หนกัเพิ็�มัเกินเกณิฑ์ ์ แต่ มิั ได�กล่�วัถ่งผู้ลดีต่อสุำขีภั�พ็ระหว่ั�ง ตั�งค์รรภัแ์ละหลงัค์ลอดในภั�พ็กวั� ง ขี�อแนะนำ�ขีององค์ก์�รอน�มัยัโลก ฉบบัที�มีัอย่้ผู้นวักรวัมักบัขี�อแนะนำ�ที�ปรบั ปรุงเพิ็�มัเติมัเหล่�นี� เป็นค์ำ�แนะนำ�ระดบั สำ�กลในร้ปแบบที� เขี� ใจัง่�ยขี่ �นเกี�ยวักบั เร่� องขีองกิจักรรมัท�งก�ยและพ็ฤติ- กรรมัเน่อยนิ�ง เพ่็�อก�รป้องกนัและก�ร จัดัก�รโรค์ภัยัหลกั ก�รส่ำงเสำริมัสุำขีภั�พ็ และค์วั�มัเป็นอย่้ที�ดีในทุกช่วังอ�ยุ ช่วัง 10 ปีที� ผู่้�นมั�นั�นมีัหลกัฐ�น เร่� องผู้ลกระทบต่อสุำขีภั�พ็จั�กค์วั�มั หล�กหล�ยในร้ปแบบ ปริมั�ณิ และระยะ เวัล�ขีองกิจักรรมัท�งก�ยเพิ็�มัขี่ �นอย่�ง เห็นได�ชดั รวัมัถ่งผู้ลกระทบจั�กพ็ฤติ- กรรมัเน่อยนิ� ง และค์วั�มัสำมััพ็นัธิเ์กี�ยวั เน่� องระหว่ั�งระดับกิจักรรมัท�งก�ย กบัสุำขีภั�พ็ นอกเหน่อจั�กนั�น หลกัฐ�น เหตุิผู้ลและคำวั�มมุ่งหม�ย ประกอบด� นกิจักรรมัท�งก�ยสำำ�หรบั ประช�กรกลุ่มัย่อย เช่น มีัก�รเปิดโอก�สำ ให�มีัก�รตรวัจัสำอบค์วั�มัสำมััพ็นัธิร์ะหว่ั�ง กิจักรรมัท�งก�ยและผู้ลลพั็ธิด์� นสุำขีภั�พ็ ในกลุ่มัสำตรีมีัค์รรภัแ์ละผู้้�มีัโรค์เร่�อรงั และ/หร่อภั�วัะทุพ็พ็ลภั�พ็ ใ น ขี� อ แ น ะ นำ � ร ะ ดับ โ ล ก ด� น กิจักรรมัท�งก�ย ปี 2561-2573 (14) ขี�อที� 4.1 เรียกร�องให�องค์ก์�รอน�มัยัโลก พ็ัฒน�และเผู้ยแพ็ร่ขี�อแนะนำ�ระดับ โ ล ก ว่ั� ด�วั ย กิจั ก ร ร มั ท�ง ก� ย แ ล ะ พ็ฤติกรรมัเน่อยนิ�งในเด็กอ�ยุตำ� กว่ั� 5 ปี เย�วัชน ผู้้�ใหญ่่ ผู้้�ส้ำงอ�ยุ และประช�กร กลุ่มัย่อยที�เฉพ็�ะเจั�ะจัง เช่น สำตรีมีัค์รรภั ์ ผู้้�เป็นโรค์เร่�อรงัและทุพ็พ็ลภั�พ็ ก�รปรบั- ปรุงและขีย�ยขีอบข่ี�ยขีองขี�อแนะนำ�ให� กวั� งขี่ �นดงัที�สำมัชัช�อน�มัยัโลกร�องขีอ ทำ�ให�แน่ใจัได�ว่ั�ประช�กรกลุ่มัที� ไม่ัได� กล่�วัถ่งไวั�ในค์ำ�แนะนำ�ฉบับปี 2553 จัะได�รบัขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย โดยเฉพ็�ะ ซ่� งพ็�องกับหลักก�รและ เ ป้ � ห มั � ย ห ลัก ๆ ขี อ ง ขี�อ แน ะ นำ � ระดบัโลกด� นกิจักรรมัท�งก�ย ค่์อเพ่็�อ ลดค์วั�มัไม่ัเท่�เทียมัและสำนบัสำนุนให�ผู้้�ค์น ทำ�กิจักรรมัท�งก�ยเพิ็�มัขี่ �นในทุกวันั เป้�หมั�ยโดยรวัมัขีองขี�อแนะนำ� เหล่�นี�ค่์อก�รจััดทำ�ขี�อแนะนำ �ด� น สำ�ธิ�รณิสุำขีที� มีัหลกัฐ�นรองรบั ว่ั�ด�วัย กิจักรรมัท�งก�ยชนิดใดและในปริมั�ณิ เท่�ใด ที� เด็ก วััยรุ่น ผู้้�ใหญ่่ ผู้้�ส้ำงอ�ยุ และประช�กรกลุ่มัย่อย เช่น สำตรีมีัค์รรภั ์ และผู้้�มีัภั�วัะเร่ �อรังหร่อทุพ็พ็ลภั�พ็ ค์วัรทำ�เพ่็�อประโยชนแ์ละลดค์วั�มัเสีำ�ยง ต่อสุำขีภั�พ็ ขี�อแนะนำ�นี�ยังก่อให�เกิด คำวามูเป็นมูา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 20 ขี�อแนะนำ�ที� มีัหลกัฐ�นรองรบัเกี�ยวักบั ค์วั�มัเช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อย- นิ�งและผู้ลต่อสุำขีภั�พ็อีกด�วัย ขี�อแนะนำ�นี�ได�พ็ฒัน�ขี่ �นสำำ�หรับ เด็กและวัยัรุ่น (อ�ยุ 5-17 ปี) ผู้้�ใหญ่่ (อ�ยุ 18-64 ปี) ผู้้�ส้ำงอ�ยุ (อ�ยุ 65 ปีขี่ �นไป) และ เป็นค์รั�งแรกที�รวัมัเอ�ค์ำ�แนะนำ�ในด� น กิจักรรมัท�งก�ยสำำ�หรบัประช�กรกลุ่มั ย่อย เช่น สำตรีมีัค์รรภัแ์ละผู้้�มีัภั�วัะเร่ �อรงั และทุพ็พ็ลภั�พ็เอ�ไวั�ด�วัย ขี�อแนะนำ�นี�จัดั ทำ�ขี่ �นสำำ�หรับแต่ละกลุ่มัอ�ยุและกลุ่มั ประช�กรย่อย เพ่็�อให�ผู้้�ที�ทำ�ง�นกบัชุมัชน เหล่�นี�เขี� ถง่ขี�อม้ัลที�เกี�ยวัขี�องได�โดยง่�ย ก�รให�ค์ำ�แนะนำ�เฉพ็�ะเจั�ะจังกบักลุ่มั ประช�กรกลุ่มัย่อย โดยเฉพ็�ะกลุ่มัที� มีั โรค์เร่�อรงัหร่อทุพ็พ็ลภั�พ็ แสำดงให�เห็นถง่ ค์วั�มัสำำ�ค์ญั่ขีองก�รรวัมัประช�กรกลุ่มั ย่อยไวั�ในนโยบ�ยและก�รวั�งแผู้นสำำ�หรบั กิจักรรมัท�งก�ยและพ็ฤติกรรมัเน่อยนิ�ง ขี�อแนะนำ�เหล่�นี�ไม่ัได�กล่�วัถง่ก�ร นอนหลบัว่ั�เป็นหน่�งในพ็ฤติกรรมั ก�ร นอนเป็นประเด็นสำำ�ค์ญั่ที� เกี�ยวัเน่�องกบั สุำขีภั�พ็และเป็นหวััขี�อเกิดใหม่ัในศ�สำตร ์ ด� นสุำขีภั�พ็ขีองประช�กร อย่�งไรก็ดี ก�รที�จัะรวัมัก�รนอนหลบัไวั�ในค์ำ�แนะนำ� ที�ปรบัปรุงแล�วัอ�จัถ่อว่ั�อย่้เหน่อขีอบ- ข่ี�ย ถ่งกระนั�นก็ต�มั ค์วั�มัสำำ�ค์ญั่ขีอง ก�รนอนหลบันั�นก็เป็นที�ตระหนกัร้�และ รวัมัไวั�ว่ั�เป็นผู้ลลพั็ธิท์�งสุำขีภั�พ็ที�สำำ�ค์ญั่ เม่ั�อพิ็จั�รณิ�ถง่ผู้ลจั�กกิจักรรมัท�งก�ย และพ็ฤติกรรมัเน่อยนิ�ง 21 เอกสำ�รนี�ร�ยง�นกระบวันก�รและ สำรุปให�เห็นก�รทบทวันขี�อม้ัลที�มีัหลกัฐ�น เพ่็�อพ็ฒัน�ขี�อแนะนำ� ผู้้�รบัสำ�รหลกั ได�แก่ • ผู้้�ร่�งนโยบ�ยในกระทรวังสำ�ธิ�รณิสุำขี ศ่กษ�ธิิก�ร เย�วัชน กีฬ� และ/หร่อ สำวััสำดิก�รค์รอบค์รัวัและสำงัค์มั ซ่� ง ทำ�ง�นอย่้ในประเทศที� มีัร�ยได�ส้ำง ป�นกล�ง และตำ� และมีัหน� ที�กำ�หนด ขี�อแนะนำ�ขีองแต่ละประเทศ และ วั�งแผู้นก�รจััดก�รด� นสุำขีภั�พ็ ก�รศ่กษ� สำถ�นที� ประกอบอ�ชีพ็ แหล่งที� พ็ักอ�ศัยหร่อชุมัชนให�กับ ทุกช่วังวัยั • เจั� หน� ที�ขีองรฐัซ่�งพ็ฒัน�ขี�อแนะนำ� ในระดบัช�ติ ระดบัภ้ัมิัภั�ค์ หร่อระดบั ท�องถิ�นเพ่็�อที�จัะเพิ็�มักิจักรรมัท�งก�ย แ ล ะ ล ด พ็ ฤ ติ ก ร ร มั เ น่ อ ย นิ� ง ใ น กลุ่มัประช�กรต่�ง ๆ ผู่้�นเอกสำ�ร ขี�อแนะนำ�เหล่�นี� • บุค์ค์ลที� ทำ �ง�นในองค์์กรที� ไ ม่ั ใ ช่ องค์ก์รขีองรฐั องค์ก์รด� นก�รศก่ษ� สำถ�นที�ทำ�ง�น หร่อองค์ก์รก�รวิัจัยั • บุค์ค์ลที�ทำ�ง�นในก�รให�บริก�รด� น สุำขีภั�พ็ ให�ค์ำ�ปร่กษ�และค์ำ�แนะนำ� เช่น ชุมัชน ค์รอบค์รวัั พ็ย�บ�ลหร่อ แพ็ทย์ในระดบัหลกัหร่อระดบัตติยภ้ัมิั ห ร่ อ ผู้้� ป ร ะ ก อ บ อ � ชี พ็ ด� น ก � ร ออกกำ�ลงัและสำหเวัชที�ทำ�ง�นอย่้ใน ภั�ค์สุำขีภั�พ็ ขี�อแนะนำ�นี�สำ�มั�รถใช� เป็นค์ำ�แนะนำ�ในหวััขี�อเหล่�นี�ได� ห�ก มิัได�มีัขี�อแนะนำ�ขีองประเทศอย่้แล�วั กิลุ่มเป้�หม�ย ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย และพ็ฤติกรรมัเน่อยนิ� งในเอกสำ�รนี� ค์วัรใช�เพ่็� อแจั�งให�ทร�บถ่งก�รปฏิิบัติ ก่ อ น ก � ร ป ฏิิ บัติ จั ริง แ ล ะ ห ลัก ส้ำ ต ร ก�รพ็ฒัน�อ�ชีพ็สำำ�หรบัพ็นักง�นด� น สำ�ธิ�รณิสุำขี ผู้้�เชี� ยวัช�ญ่ด� นกิจักรรมั ท�งก�ย และผู้้�เชี�ยวัช�ญ่ด� นก�รศก่ษ� ผู้ลิตผู้ลที� ได�มั�เป็นสิำ�งจัำ�เป็นที�จัะ นำ�ขี�อแนะนำ�เหล่�นี�ไปส่้ำประช�กรเฉพ็�ะ กลุ่มั ผู้้�มีัส่ำวันเกี�ยวัขี�องในภั�ค์ส่ำวันที�นอก เหน่อจั�กสุำขีภั�พ็ และชุมัชนที�กวั� งขี่ �น ซ่�งใช�ก�รส่ำ�อสำ�รที�ต�องปรบัให�เหมั�ะกบั ค์วั�มัต�องก�รที� เฉพ็�ะเจั�ะจังขีอง ผู้้�รบัสำ�ร คำวามูเป็นมูา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 22 รัะเบ่ยบวิัธ่ ขี�อ แน ะ นำ � เห ล่ � นี�พ็ัฒ น � ต � มั ค่้์ม่ัอสำำ�หรับก�รพ็ฒัน�ขี�อแนะนำ�ขีอง องค์ก์�รอน�มัยัโลก (ฉบบัตีพิ็มัพ็ค์์รั�งที� 2) (21) กลุ่มัผู้้�วั�งระเบียบวิัธีิดำ�เนินก�ร ขีององค์ก์�รอน�มัยัโลกซ่�งดำ�เนินก�ร โดยแผู้นกส่ำงเสำริมัสุำขีภั�พ็ได�จัดัตั�งขี่ �น ด�วัยผู้้�แทนจั�กสำำ�นักง�นส่ำวันภ้ัมิัภั�ค์ ขีององค์ก์�รอน�มัยัโลกและแผู้นกอ่�น ๆ ที� เกี� ยวัขี�องขีององค์ก์�รอน�มััยโลก ก ลุ่มัพ็ัฒน�ขี�อแนะ นำ � (Guidel ine Development Group: GDG) จัดัตั�งขี่ �นจั�ก ผู้้�เชี�ยวัช�ญ่และผู้้�เกี�ยวัขี�องรวัมั 27 ท่�น โดยค์ำ�น่งถ่งสำมัดุลท�งเพ็ศและค์วั�มั หล�กหล�ยท�งภ้ัมิัศ�สำตร ์ขี�อแนะนำ�ฉบบั ร่�งนั�นตรวัจัโดยผู้้�ตรวัจัสำอบอิสำระจั�ก ภั�ยนอกรวัมั 7 ท่�น ซ่� งเป็นผู้้�ให�ผู้ล ตอบรบัด� นหลกัฐ�นท�งวิัทย�ศ�สำตร ์ ก�รตีค์วั�มั และเน่�อห� นอกจั�กนี� มีัก�รทำ�ประช�พิ็จั�รณิแ์บบออนไลน ์ สำำ�หรบัฉบบัร่�ง และได�รบัขี�อคิ์ดเห็นจั�ก ผู้้�เขี� ร่วัมั 400 ร�ย GDG นำ�ขี�อคิ์ดเห็น จั�กนกัวิัทย�ศ�สำตร ์ ผู้้�ปฏิิบติัง�น และ บุค์ค์ลทั�วัไปมั�สำอบท�นและใช�เพ่็�อทำ�ให� ค์ำ�แนะนำ�นี�สำำ�เร็จัลุล่วัง ร�ยละเอียดก�ร จััดก�รกระบวันก�รพ็ัฒน�ขี�อแนะนำ� อย่�งค์รบถ�วันอย่้ที�ภั�ค์ผู้นวัก 1 23 GDG ได�พิ็จั�รณิ�ขีอบเขีตขีอง ขี�อแนะนำ�ในก�รประชุมัค์รั�งแรก และเห็น พ็�องกนัในค์ำ�ถ�มัที�เกี�ยวัเน่�องกบั PI/ECO (ประช�กร (Population), ก�รแทรกแซง ( I n t e r v e n t i o n ) / ก � ร แ สำ ด ง อ อ ก (Exposure), ก�รเปรียบเทียบ (Compar- ison), ผู้ลลพั็ธิ ์(Outcome)) ประเด็นหลกั ที�กล่�วัถง่สำำ�หรบักลุ่มัประช�กรย่อยสำรุป ได�ดงัต่อไปนี� สำำ�หรบักิจกรรมัท�งก�ย: ก. ค์วั�มัเช่�อมัโยงระหว่ั�งกิจักรรมัท�ง ก�ยและผู้ลลพั็ธิที์� เกี�ยวัขี�องกบัสุำขีภั�พ็ ค่์ออะไร ขี. มีัค์วั�มัเช่�อมัโยงด� นปริมั�ณิที�ทำ�และ ก�รตอบสำนอง (จัำ�นวัน ระยะเวัล� ค์วั�มัถี� ค์วั�มัหนกัหน่วัง) หร่อไม่ั ค์. ค์วั�มัเช่�อมัโยงนี�ผู้นัแปรต�มัชนิดหร่อ ขีอบเขีตขีองกิจักรรมัท�งก�ยหร่อไม่ั สำำ�หรบักิจกรรมัท�งก�ย: ก. ค์วั�มัเช่� อมัโยงระหว่ั�งพ็ฤติกรรมั เน่อยนิ� งและผู้ลลัพ็ธิที์� เ กี� ยวัขี�องกับ สุำขีภั�พ็ค่์ออะไร ขี. มีัค์วั�มัเช่�อมัโยงด� นปริมั�ณิที�ทำ�และ ก�รตอบสำนอง(จัำ�นวันทั�งหมัด ค์วั�มัถี� ระยะเวัล� ค์วั�มัหนกัหน่วังขีองก�รหยุด ชะงกั) หร่อไม่ั ข้อบเข้ติข้องข้้อแนืะนืำ �และ คำำ�ถึ�มท่�น่ื�สำนืใจ ระเบีัย่บัวิธี ค์. ค์วั�มัเช่�อมัโยงนี�ผู้นัแปรต�มัชนิดหร่อ ขีอบเขีตขีองพ็ฤติกรรมัเน่อยนิ�งหร่อไม่ั ง. สำำ�หรับผู้้�ใหญ่่ : กิจักรรมัท�งก�ย เปลี�ยนผู้ลกระทบจั�กพ็ฤติกรรมัเน่อยนิ�ง ที�มีัต่อโรค์ภัยัหร่อไม่ั สำำ�หรบัประช�กร (P) แต่ละกลุ่มั ก�รแสำดงผู้ล (E) ค่์อจัำ�นวันระยะเวัล� ค์วั�มัถี� หร่อค์วั�มัหนักหน่วังขีองกิจั- กรรมัท�งก�ย ที� เพิ็�มัส้ำงขี่ �น ขีณิะที�ก�ร เปรียบเทียบ (C) ค่์อก�รไม่ัทำ�กิจักรรมั ท�งก�ยหร่อ มีัค์วั�มัถี� ค์วั�มัหนัก- หน่วัง หร่อระยะเวัล�ในก�รทำ�กิจักรรมั ท � ง ก � ย ที� น� อ ย ผู้ ล ลัพ็ ธิ ์ที� เ ด่ น ชัด แ ล ะ สำำ � ค์ัญ่ สำำ � หรับ ป ร ะ ช� กร แ ต่ ล ะ กลุ่มัได�สำรุป ไวั�ในต�ร�งหมั�ยเลขี 1 และร�ยละเอียดขีองค์ำ�ถ�มัเกี� ยวักับ PI/ECO สำรุปอย่้ในส่ำวันที� เกี�ยวัขี�องกนันี� ในเว็ับไซตภ์ั�ค์ผู้นวัก : หลกัฐ�นประกอบ2 2 ข้้อม่ัลออนไลน์ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 24 ผู้ลลพั็ธิ ์ (ต�มัลำ�ดบัอกัษร ภัษ�องักฤษ) เด็กและวัยัรุ่น อ�ยุ 5-17 ปี: กิจักรรมั ท�งก�ยและ พ็ฤติกรรมั เน่อยนิ�ง ผู้้� ใ ห ญ่่ อ � ยุ 18-64 ปี : กิจักรรมั ท�งก�ย ผู้้�ใหญ่่อ�ยุ 18 ปีขี่ �นไป : พ็ฤติกรรมั เน่อยนิ�ง ผู้้�ส้ำงอ�ยุ อ�ยุ 65 ปี ขี่ �นไป : กิจักรรมั ท�งก�ยa สำตรีมีัค์รรภั์ และมั�รด� หลงัค์ลอด ภั�วัะโรค์ เร่�อรงัb เด็กและ ผู้้�ใหญ่่ที�มีั ภั�วัะ ทุพ็พ็ลภั�พ็c ความอ้ว้น (นำ �าหนกัขึ้้ �น นำ �าหนกัเปล่ี่�ยน การควบคุมนำ �าหนกั ความเสถ่ียรขึ้อ้งนำ �าหนกั สถีานะขึ้อ้งนำ �าหนกั แลี่ะการรกัษานำ �าหนกั) สำาคญัมาก สำาคญัมาก สำาคญัมาก สำาคญัมากa สำาคญัมาก สำาคญัมาก -HIV - เหตุุการณ์์ไม่พึง้ประสงค ์ สำาคญัมาก สำาคญัมาก - สำาคญัมากa สำาคญัมาก (ม่ผลี่ตุ่อ้ ทารก ในครรภ์)์ - - การเส่ยช่ีวิตุทุกสาเหตุุหรือ้ม่ สาเหตุุเฉพึาะ - สำาคญัมาก (มะเร็งแลี่ะ โรคหวัใจแลี่ะ หลี่อ้ดเลืี่อ้ด) สำาคญัมาก สำาคญัมากa - สำาคญัมาก - สุขึ้ภ์าพึกระดูก สำาคญัมาก - สำาคญั - - - - สุขึ้ภ์าพึหลี่อ้ดเลืี่อ้ดหวัใจ สำาคญัมาก - - - - - - ผลี่ดา้นการรบัรู้ สำาคญัมาก สำาคญัมาก สำาคญั สำาคญัมากa - - สำาคญัมาก - MS, PD, Stk, Sch, ADHD ภ์าระแทรกซ้อ้้นในการคลี่อ้ด - - - - สำาคญั - - การดำาเนินขึ้อ้งโรคอ้ย่าง ตุ่อ้เนื�อ้ง - - - - - สำาคญัมาก - HT, T2D, HIV, สำาคญัมาก - การกลี่บัมา เป็นมะเร็งอ่้ก - การหกลี่ม้แลี่ะการบาดเจ็บเ ก่�ยวเนื�อ้งจากการหกลี่ม้ - - - สำาคญัมาก - - - ผลี่ท่�ม่ตุ่อ้ทารก (นำ �าหนกัแรก เกิด,การคลี่อ้ดก่อ้นกำาหนด) - - - - สำาคญัมาก - - ความสามารถีในการทำางาน - - - สำาคญัมาก - - - เบาหวานระหว่างตุั�งครรภ์ ์ - - - - สำาคญัมาก - - ความดนัโลี่หิตุสูงระหว่างตุั�ง ครรภ์/์ครรภ์เ์ป็นพิึษ - - - - สำาคญัมาก - - คุณ์ภ์าพึช่ีวิตุท่�เก่�ยวเนื�อ้งกบั สุขึ้ภ์าพึ - สำาคญั สำาคญั สำาคญั a - สำาคญัมาก - HT, T2D, HIV สำาคัญมาก- MS, SCI, ID, MCD, Sch การเกิดโรคมะเร็ง - สำาคญัมาก สำาคญัมาก สำาคญัมากa - - - การเกิดโรคหลี่อ้ดเลืี่อ้ดหวัใจ - สำาคญัมาก สำาคญัมาก สำาคญัมากa - - - การเกิดความดนัโลี่หิดสูง - สำาคญั - สำาคญัa - - - การเกิดโรคเบาหวาน ชีนิดท่�สอ้ง - สำาคญัมาก สำาคญัมาก สำาคญัมาก a - - - ต�ร�งที� 1 : สำรุปผลลพัธิ์ด์�้นสุำข้ภ�พที�เด่นช้ดัและสำำ�ค์ญั่ โดยแยกติ�มักลุ่มัประช้�กร 25 ผู้ลลพั็ธิ ์ (ต�มัลำ�ดบัอกัษร ภัษ�องักฤษ) เด็กและวัยัรุ่น อ�ยุ 5-17 ปี: กิจักรรมั ท�งก�ยและ พ็ฤติกรรมั เน่อยนิ�ง ผู้้� ใ ห ญ่่ อ � ยุ 18-64 ปี : กิจักรรมั ท�งก�ย ผู้้�ใหญ่่อ�ยุ 18 ปีขี่ �นไป : พ็ฤติกรรมั เน่อยนิ�ง ผู้้�ส้ำงอ�ยุ อ�ยุ 65 ปี ขี่ �นไป : กิจักรรมั ท�งก�ยa สำตรีมีัค์รรภั์ และมั�รด� หลงัค์ลอด ภั�วัะโรค์ เร่�อรงัb เด็กและ ผู้้�ใหญ่่ที�มีั ภั�วัะ ทุพ็พ็ลภั�พ็c สุขึ้ภ์าพึจิตุ (อ้าการกงัวลี่แลี่ะ ซ้้มเศรา้) สำาคญัมาก สำาคญัมาก สำาคญั สำาคญัมาก สำาคญัมาก - - โรคกระดูกพึรุน - - - สำาคญัมากa - - - ความแข็ึ้งแรงทางกายภ์าพึ สำาคญัมาก - สำาคญั - - - - การทำางานขึ้อ้งร่างกาย - - สำาคญั - - สำาคญัมาก - HT, T2D, HIV สำาคญัมาก - MS, SCI, ID, Stk พึฤติุกรรมเอื้ �อ้สงัคม สำาคญั - - - - - - ผลี่ทางจิตุวิทยาสงัคม - - - สำาคญั - - - ความเส่�ยงขึ้อ้งโรคเกิดร่วม - - - - - สำาคญัมาก - HT, T2D, HIV สำาคญัมาก - MS, SCI, ID การนอ้นหลี่บั สำาคญั สำาคญั สำาคญั สำาคญัa - - - * ผู้ลกระทบสำำ�ค์ญั่มั�ก ค่์อ ผู้ลที� มีัอิทธิิพ็ลอย่�งยิ�งต่อก�รตดัสิำนใจั ส่ำวันผู้ลกระทบสำำ�ค์ญั่ ค่์อ ผู้ลกระทบที�มีัค์วั�มัสำำ�ค์ญั่แต่ไม่ัมีัอิทธิิพ็ลต่อก�รตดัสิำนใจั a ผู้ลลพั็ธิที์�สำำ�ค์ญั่และสำำ�ค์ญั่มั�กนั�นถ้กนำ�มั�พิ็จั�รณิ�สำำ�หรบัประช�กรผู้้�ใหญ่่และผู้้�ส้ำงอ�ยุ b ผู้ลลัพ็ธิส์ำำ�หรับสำภั�วัะขีองประช�กรกลุ่มัย่อยอันได�แก่: มัะเร็ง-ผู้้�รอดชีวิัตจั�กมัะเร็ง, HT - ค์วั�มัดนัโลหิตส้ำง, T2D-เบ�หวั�นชนิดที�สำอง และ HIV c ผู้ลลพั็ธิส์ำำ�หรบัสำภั�วัะขีองประช�กรกลุ่มัย่อยอนัได�แก่ MS – กล� มัเน่�ออ่อนแรง SCI - อ�ก�ร บ�ดเจ็ับขีองไขีสำนัหลงั ID - ค์วั�มับกพ็ร่องท�งสำติปัญ่ญ่� PD-โรค์พ็�รกิ์นสำนั Stk – ผู้้�รอดชีวิัตจั�ก เสำ�นเล่อดในสำมัองแตก Sch – โรค์จิัตเภัท ADHD – โรค์สำมั�ธิิสำั�น โดยนำ�ผู้ลลพั็ธิที์�สำำ�ค์ญั่และสำำ�ค์ญั่มั�ก ต่อประช�กรที�มีัช่วังอ�ยุเฉพ็�ะนั�นมั�พิ็จั�รณิ�และค์�ดก�รณิ์ ระเบีัย่บัวิธี ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 26 ก�รทบทวันขี�อแนะนำ�สำำ�หรบักิจักรรมั ท�งก�ยฉบบัปีพ็.ศ. 2553 ขีององค์ก์�รอน�มัยั โลกนั�น กระทำ�โดยก�รวิัเค์ร�ะหแ์จักแจังและ ปรบัปรุงขี�อทบทวันที�เกี�ยวัเน่�องและเป็นปัจัจุับนั ที� สุำดที� เกี� ยวัขี�องกับขีอบเขีตขีองขี�อแนะนำ� เหล่�นี� ขี�อแนะนำ�นี�ถ้กนำ�มั�ใช�เน่� องจั�กองค์ ์ ค์วั�มัร้�ที� ค์รอบค์ลุมัถ่งก�รทบทวันอย่�งเป็น ระบบและมีัค์วั�มัทนัสำมัยั ซ่�งจัดัทำ�ขี่ �นเพ่็�อแสำดง ให�เห็นถ่งก�รพ็ฒัน�ขี�อแนะนำ�ระดบัช�ติด� น กิจักรรมัท�งก�ยที� มีัอย่�งหล�กหล�ยมีัก�ร ปรบัปรุงเพิ็�มัเติมัเพ่็�อให�มัั�นใจัว่ั�ขี�อแนะนำ�ขีอง องค์ก์�รอน�มัยัโลกฉบบัใหม่ัจัะสำะท�อนขี�อม้ัลที� ทนัเหตุก�รณิที์�สุำดเท่�ที�ห�ได�ในสำ�ขี�สำ�ธิ�รณิ- สุำขีที�พ็ฒัน�อย่�งรวัดเร็วั มีัก�รเล่อกใช�บทปริทศันข์ีองบทปริทศัน ์ อีกชิ�น ห�กบทปริทัศน์นั�นตรงต�มัเกณิฑ์ ์ พิ็จั�รณิ� 3 ประก�ร ได�แก่ 1) มีัก�รทำ�บท- ปริทศันห์ลกัฐ�นต�มักระบวันก�รที� เป็นระบบ มั�ตรฐ�น ซ่�งมีัก�รจัดัเก็บเอกสำ�รเป็นอย่�งดี 2) ก�รประเมิันค์วั�มัน่�เช่�อถ่อขีองหลกัฐ�นนั�นใช� วิัธีิต�มัก�รจัดัเกณิฑ์ต์�มัขี�อแนะนำ�ก�รประมัวัล ผู้ล ก�รพ็ฒัน� และก�รประเมิันค่์� (GRADE) หร่อ กระบวันวิัธีิอ่�นที� เทียบเท่� ซ่�งมีัก�รพ็รรณิ�และ บันท่กไวั�อย่�งแจ่ัมัแจั�ง และ 3) บทปริทัศน ์ หลกัฐ�นนั�นกล่�วัถ่งประช�กรกลุ่มัเป้�หมั�ย โดยไม่ัจัำ�กัดประเทศหร่อระดับร�ยได�ขีอง ประเทศ ค์ำ�ถ�มั PI/ECO และผู้ลลพั็ธิท์�งสุำขีภั�พ็ ที�สำำ�ค์ญั่และสำำ�ค์ญั่มั�กถ้กนำ�มั�จับัค่้์กบับท- ปริทศันห์ลกัฐ�นที� มีัอย่้ และห�กจัำ�เป็น จัะมีั ก�รใช�บทปริทศัน์ใหม่ัเพิ็�มัเติมัเพ่็�อจัดัก�รช่อง- หลักิฐ�นื ว่ั�ง กลุ่มัพ็ัฒน�ขี�อแนะนำ�เรียกร�องให�ปรับ ปรุงบทปริทศันห์ลกัฐ�นให�ทนัสำมัยั ใช�ค์ำ�ค์�นห� ภั�ษ�ในก�รค์�นห� และฐ�นขี�อม้ัลเดียวักนักบั บทปริทศันฉ์บบัดั�งเดิมั บทปริทศันห์ลกัิฐานดุา้นล่างนี �เข็า้เกิณฑ์ท์ ั�ง 3 ข็อ้และถูกิเล่อกิมาจากิความทนัสมยัและ ความเข็า้ใจง่าย • ก�รทบทวันวัรรณิกรรมัอย่�งเป็นระบบที� จัดัทำ�โดยโพ็อิทร�สำและค์ณิะ (2559) เกี�ยวั เน่�องกบัค์วั�มัเช่�อมัโยงระหว่ั�งกิจักรรมัท�ง ก�ยและตวัับ่งชี�สุำขีภั�พ็ในเด็กวัยัเรียนและ เย�วัชน (22) ในฐ�นะที� เป็นส่ำวันขีองกระ บวันก�รสำำ�หรบัก�รพ็ฒัน�ขี�อแนะนำ�ด� น ก�รเค์ล่�อนไหวัร่�งก�ยตลอด 24 ชั� วัโมัง สำำ�หรบัเด็กและเย�วัชนขีองประเทศแค์น�ด� (23) บททบทวันนี�ให�ค์วั�มัสำนใจักบัง�นวิัจัยั ที� ใช�ก�รวัดัผู้ลเชิงวัตัถุประสำงค์์ในก�รทำ� กิจักรรมัท�งก�ย ง�นวิัจััยทั�งหมัด 162 ชิ �นถ้กนำ�มั�ใช�ในก�รณินี์� โดยมีัผู้้�เขี� ร่วัมัวิัจัยั 204, 171 ร�ยจั�ก 31 ประเทศ • ก�รทบทวันวัรรณิกรรมัอย่�งเป็นระบบที� เช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งและตวัั ชี �วั ัดสุำขีภั�พ็ในเด็กวััยเรียนที� จััดทำ�โดย ค์�รส์ำนัและค์ณิะ (2561) (24) ซ่�งเป็นส่ำวันหน่�ง ขีองกระบวันก�รสำำ�หรับก�รพ็ัฒน�ขี�อ แนะนำ�ก�รเค์ล่�อนไหวัร่�งก�ยตลอด 24 ชั�วัโมังสำำ�หรบัเด็กและเย�วัชนขีองประเทศ แค์น�ด� (23) มีัก�รวิัจัยัจัำ�นวัน 235 ชิ �น ( ตัวั อ ย่ � ง ไ ม่ั ซำ � กัน 1 9 4 ตัวั อ ย่ � ง ) ซ่�งมีัผู้้�เขี� ร่วัมัร�ยบุค์ค์ล 1,657,064 ร�ย จั�ก 71 ประเทศทั�วัโลก • ก�รทบทวันวัรรณิกรรมัอย่�งเป็นระบบที�จัดั ทำ�โดยโอค์ลีและค์ณิะ (2562) (25) ซ่�งจัดัทำ� ขี่ �นเพ่็� อปรับปรุงขี�อม้ัลจั�กโพ็อิทร�สำและ ค์ณิะ (2559) (22) และค์�รส์ำนัและค์ณิะ 27 (2561) (24) ในฐ�นะส่ำวันหน่�งขีองก�รพ็ฒัน� ขี�อแนะนำ�ในก�รเค์ล่�อนไหวัร่�งก�ยตลอด 24 ชั�วัโมังสำำ�หรบัเด็กและเย�วัชน (อ�ยุ 5-17 ปี) (26) ขีองประเทศออสำเตรเลียประจัำ�ปี 2562 ร�ยง�นฉบับนี�จัำ �แนกร�ยง�น ก�รวิัจััยเร่� องกิจักรรมัท�งก�ย 42 ชิ �น และพ็ฤติกรรมัเน่อยนิ�ง 32 ชิ �น ซ่�งเผู้ยแพ็ร่ ในเด่อนกรกฎ�ค์มั พ็.ศ. 2561 (25) ต�ร�ง GRADE (ก�รจัดัลำ�ดบัก�รประเมิันขี�อแนะนำ� ก�รพ็ฒัน� และก�รประเมิันค่์�) ที�จัดัทำ�โดย โอค์ลีและค์ณิะได�ถ้กนำ�มั�ใช�เป็นแนวัปฏิิบติั ในก�รปรับปรุงขี�อม้ัลต�มัที� ได�รับมัอบ หมั�ยซ่� งจััดทำ�โดยองค์ก์�รอน�มััยโลก ต�ร�ง GRADE พ็ร�อมัทั�งขี�อม้ัลหลกัฐ�นต่�ง ๆ ได�แสำดงไวั�ในภั�ค์ผู้นวักท�งเว็ับไซต์ : ขี�อม้ัลหลกัฐ�น3 • มีัก�รจัดัทำ�และสำงัเค์ร�ะหบ์ทปริทศันอ์ย่�ง เป็นระบบจัำ�นวัน 12 ชิ �น ซ่�งเป็นส่ำวันหน่�ง ขีองก�รพ็ฒัน�ขี�อแนะนำ�สำำ�หรบักิจักรรมั ท�งก�ยขีณิะตั�งค์รรภัข์ีองประเทศแค์น�ด� ประจัำ�ปี 2562 บทปริทัศนท์ั�ง 12 ชิ �นนี� เขี� ถง่ง�นวิัจัยัที� เกี�ยวัขี�องมั�กกว่ั� 25,000 ชิ �น ทั�งภั�ษ�องักฤษ สำเปน ฝึรั�งเศสำ ว่ั�ด�วัย เร่�องกิจักรรมัท�งก�ยขีองมั�รด�ระหว่ั�ง ตั�งค์รรภั ์ ซ่�งร�ยง�นถง่ค์วั�มัเจ็ับป่วัยขีอง มั�รด� ท�รกในค์รรภั ์หร่อท�รกแรกค์ลอด ห ร่ อ ก � ร เ สีำ ย ชี วิั ต ขี อ ง ท � ร กใ น ค์ ร ร ภั ์ บทปริทศันจ์ัำ�นวัน 7 ชิ �นกล่�วัถง่ผู้ลที�ถ่อว่ั� สำำ�ค์ญั่และสำำ�ค์ญั่มั�กโดย GDG (28-34) ต�ร�ง GRADE จั�กก�รทบทวันหลกัฐ�น เหล่�นี�ใช�เป็นแนวัปฏิิบัติขีองก�รห�ง�น ตีพิ็มัพ็ที์�จัดัทำ�ขี่ �น เพ่็�อปรบัปรุงและชี�ให�เห็น ถ่งก�รพ็ัฒน�ขี�อแนะ นำ �ขีององค์์ก�ร อน�มัยัโลก ขี�อม้ัลหลกัฐ�นที�ปรบัปรุงแล�วัมีั อ ย่้ ในภั�ค์ผู้นวักท�งเว็ับไซต์ : ขี�อม้ัล หลกัฐ�น3 • ร�ยก�รท�งวิัทย�ศ�สำตรข์ีองกลุ่มัที�ปรก่ษ� ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย (PAGAC) (35) ซ่�งจัดัทำ�ก�รปรบัปรุงหลกัฐ�นอย่�ง เป็นระบบเกี� ยวักับกิจักรรมัท�งก�ยและ พ็ฤติกรรมัเน่อยนิ� งและผู้ลขีองสุำขีภั�พ็ที� ตีพิ็มัพ็ร์ะหว่ั�งพ็.ศ. 2551-2559 โดยเป็น ส่ำวันหน่� งขีองก�รพ็ัฒน�ขี�อแนะนำ�ด� น กิจักรรมัท�งก�ยสำำ�หรบัช�วัอเมัริกนัฉบบั พ็.ศ. 2561 ฉบบัพิ็มัพ็ค์์รั�งที� 2 (36) หลกัฐ�น ที� สำรุปมั�นั�นได�กล่�วัถ่งค์ำ�ถ�มัง�นวิัจััย จัำ�นวัน 38 ค์ำ�ถ�มัหลกัและ 104 ค์ำ�ถ�มัย่อย ที� เล่อกสำรรมั�จั�กค์วั�มัเกี� ยวัเน่� องเร่� อง สำ�ธิ�รณิสุำขี หลกัฐ�นนี�ประกอบไปด�วัยผู้ล จั�กก�รปริทศัน ์ ซ่� งทบทวันจั�กง�นวิัจัยั ทั�งสิำ �น 1,130 หวััขี�อ สำรุปมั�เพ่็�อตอบค์ำ�ถ�มั ก�รวิัจัยั 38 ขี�อ (35) เกณิฑ์วิ์ัธีินั�นใช�ร้ปแบบ ที� แก� ไขีจั�ก “เค์ร่� องม่ัอชี�วัดัเพ่็� อประเมิัน บทปริทศันที์� เป็นระบบ” (AMSTARE&BP) เพ่็� อ เ ขี� ถ่ง คุ์ ณิ ภั � พ็ เ กี� ย วั กับ ร ะ เ บี ย บ แบบแผู้นขีองก�รปริทศันอ์ย่�งเป็นระบบ และก�รทบทวันวัรรณิกรรมัระบบเชิง ปริมั�ณิ ค์วั�มัเสีำ�ยงที�จัะมีัอค์ติหร่อค์วั�มั เที�ยงตรงภั�ยในนั�นจัะถ้กประเมิันในง�นวิัจัยั ต�นฉบับแต่ละชิ�นโดยใช�ฉบับที� ปรับจั�ก เค์ร่�องม่ัอประเมิันอค์ติ (BAT) (37) จั�กค์ลงั ขี�อม้ัลหลกัฐ�นด� นโภัชน�ก�รขีองกระทรวัง เกษตรแห่งสำหรฐัอเมัริก� หลกัฐ�นชิ�นใหม่ัที� แจักแจังไวั�ในก�รค์�นห�เพ่็�อพ็ฒัน�ขี�อม้ัลที� จัดัทำ�เพ่็�อขี�อแนะนำ�ขีององค์ก์�รอน�มัยัโลก แสำดงอย่้ที�หน� รวัมัขี�อม้ัลหลกัฐ�นในภั�ค์ ผู้นวักบนเว็ับไซต3์ โดยหน� รวัมัขี�อม้ัล หลักฐ�นจัะเช่� อมัโยงไปยังร�ยง�นและ เอกสำ�รเสำริมัขีอง PAGAC (35) ระเบีัย่บัวิธี 3 ข้้อม่ัลออนไลน์ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 28 วิธีิ์ก�รทำ�ใหข้้อ้ม้ัลทนัสำมัยั และก�รแยกส่ำวนข้อ้ม้ัล ก�รค์�นห�ก�รทบทวันที� เป็นระบบและ ก�รวิัเค์ร�ะหผ์ู้ลรวัมัจั�กก�รวิัจัยัแบบรุ่นปี จั�ก ง�นวิัจัยัที�ตีพิ็มัพ็จ์ั�กวันัที�ค์�นห�ค์รั�งสุำดท� ยที�จัดั ทำ�ขี่ �นเพ่็� อบทปริทศันแ์ต่ละชิ�นที� นำ�มั�รวัมัไวั� (ต�มัที�ระบุด� นบน) มั�จันถ่งเด่อนกนัย�ยน พ็.ศ. 2562 ซ่�งเกณิฑ์วิ์ัธีิก�รแยกส่ำวันขี�อม้ัลที�เป็น มั�ตรฐ�นได�รบัก�รพ็ฒัน�และนำ�มั�ใช� เพ่็� อปรับปรุงขี�อม้ัลจั�กก�รค์�นห�ที� จัดัทำ�โดยโพ็อิทร�สำและค์ณิะ (2559) (22), ค์�รส์ำนัและค์ณิะ (2559) (24) และโอค์ลีและค์ณิะ (2559) (25) ฐ�นขี�อม้ัล MEDLINE, EMBASE, PsycINFO และ SportDiscus ถ้กค์�นห�เพ่็� อ แจักแจังบทปริทศันที์�ทบทวันโดยผู้้�ร้�เสำมัอกนั ที� เขีียนเป็นภั�ษ�อังกฤษหร่อฝึรั� งเศสำ เพ่็� อ ปรบัปรุงก�รค์�นห�ที�ดำ�เนินก�รโดย PAGAC (35) ฐ�นขี�อม้ัล PubMed, CINAHL และ Cochrane ถ้กค์�นห�เพ่็� อแจักแจังบทปริทัศนที์� ทบทวัน โดยผู้้�ร้�เสำมัอกนัและเขีียนเป็นภั�ษ�องักฤษ ไม่ั มีัก�รค์�นห�ผู้ลลพั็ธิส์ำำ�ค์ญั่เสีำยใหม่ัซ่�ง PAGAC ไม่ัได�รวัมัไวั� (35) เน่�องด�วัยขี�อจัำ�กดัด� นแหล่ง ขี�อม้ัล ก�รค์�นห�ไม่ัได�จัำ�กดัต�มัประเทศหร่อ สำถ�นะร�ยได�ขีองประเทศและรวัมัเอ�บท- ปริทัศน์ที� ก ล่�วัถ่ง กิจักรรมัท�งก�ยหร่อ พ็ฤติกรรมัเน่อยนิ�งที�เป็นก�รวัดัเชิงอตัวิัสำยัหร่อ วัดัเชิงวัตัถุวิัสำยั มีัก�รตดัสิำนใจัว่ั�จัะไม่ัมีัก�ร ค์�นห�ขี�อม้ัลในภั�ษ�อ่� น ๆ นอกเหน่อไปจั�ก ภั�ษ�ในก�รค์�นห�ต�นฉบบัเน่� องจั�กขี�อจัำ�กดั ด� นขี�อม้ัลและประสำบก�รณิก่์อนหน� ในสำ�ขี�ที� บ่งชี �ว่ั�ก�รค์�นห�ขี�อม้ัลนั�นทำ�ให� ได�บทปริทศัน ์ เพิ็�มัเติมัน�อยมั�กห�กจัะมีัอย่้ บทปริทศันน์ั�นนำ� มั�พิ็จั�รณิ�เพ่็�อทดสำอบค์วั�มัเช่�อมัโยงระหว่ั�ง กิจักรรมัท�งก�ยหร่อพ็ฤติกรรมัเน่อยนิ�งและ ผู้ลลพั็ธิที์�เกี�ยวัขี�องกบัสุำขีภั�พ็ (ขี่ �นอย่้กบัระดบัส้ำง หร่อตำ� ขีองก�รกระตุ�นกิจักรรมัท�งก�ยหร่อ พ็ฤติกรรมัเน่อยนิ�ง) และสำำ�รวัจัค์วั�มัสำมััพ็นัธิ ์ ขีองก�รตอบสำนองต่อผู้ลที� ได�รบัระหว่ั�งกิจั- กรรมัท�งก�ยและพ็ฤติกรรมัเน่อยนิ� งกับ ผู้ลลพั็ธิที์�เกี�ยวัเน่�องกบัสุำขีภั�พ็ ที มั ง � น ผู้้�ท บ ท วั นวั ร ร ณิ ก ร ร มั จั � ก ภั�ยนอกใช�เค์ร่�องม่ัอ AMSTAR 2 (ก�รประเมิัน บทปริทศันอ์ย่�งมีัระบบหล�ยฉบบั) เพ่็�อจัดัระดบั ค์วั�มัน่�เช่� อถ่อขีองก�รทบทวันวัรรณิกรรมั อย่�งเป็นระบบ ภั�ยใต�ก�รพิ็จั�รณิ�เพ่็� อนำ� มั�รวัมัเขี� ไวั�ด�วัยกนั (38) เค์ร่�องม่ัอ AMSTAR 2 มีัอย่้ 16 ร�ยก�รที� เกี�ยวัขี�องกบัก�รวั�งแผู้น และก�รจัดัทำ�บทปริทศัน ์ ค์วั�มัเช่�อมัั�นโดยรวัมั ในผู้ลขีองบทปริทศันแ์ต่ละชิ�นจัะถ้กจัดัระดบั ต�มัขี�อแนะนำ�ที�ตีพิ็มัพ็แ์ล�วั ห�กได�ระดบั “ส้ำง” สำะท�อนว่ั�บทปริทศันนี์�มีัขี�อบกพ็ร่องที� ไม่ัร� ย- แรงอย่้ 0 หร่อ 1 ขี�อ ระดบั “กล�ง” บ่งชี�ว่ั� บทปริทศันนี์�ตดัสิำนแล�วัว่ั�มีัขี�อบกพ็ร่องที� ไม่ั ร� ยแรงมั�กกว่ั� 1 ขี�อ ระดบั “ตำ� ” หมั�ยค์วั�มัว่ั� บทปริทศันนี์�ถ้กตดัสิำนว่ั�มีัขี�อบกพ็ร่องที�วิักฤติ 1 ประเด็น โดยอ�จัมีัหร่อไม่ัมีัขี�อบกพ็ร่องที� ไม่ั ร� ยแรง หร่อมีัขี�อบกพ็ร่องที� ไม่ัร� ยแรงหล�ย อย่�ง และ “ตำ� อย่�งยิ�ง” แสำดงให�เห็นว่ั�มีัขี�อบก- พ็ร่องมั�กกว่ั� 1 ขี�อเกิดขี่ �น ผู้้�ทบทวันวัรรณิกรรมั 1 ร�ยใช�เค์ร่�องม่ัอ AMSTAR 2 กบับทปริทศันที์� จัดัไวั�ให�ทั�งหมัด บทปริทศันที์�ถ้กจัดัอย่้ระดบัตำ� อย่�งยิ�งจั�กผู้้�ทบทวัน 1 ร�ยจัะนำ�มั�ทบทวัน โดยผู้้�ทบทวันร�ยที� 2 โดยใช�เค์ร่�องม่ัอเดียวักนั ในท� ยที�สุำด บทปริทศันที์�ถ้กจัดัระดบัไวั�ตำ� อย่�ง ยิ�งจัะไม่ันำ�มั�รวัมัไวั� เพ็ร�ะถ้กตดัสิำนว่ั�ไม่ัอ�จัให� บทสำรุปจั�กหลกัฐ�นที� มีัอย่้อนัเที� ยงตรงและ เขี� ใจัได� เวั�นเสีำยแต่ว่ั�มีับทปริทศันเ์พี็ยงชิ�นเดียวั สำำ�หรบัผู้ลเฉพ็�ะเจั�ะจังนั�น 29 ขี�อสำรุปขีองหลกัฐ�นได�รวัมัก�รวิัจัยัแบบ รุ่นปีหล�ยฉบบัไวั� กลุ่มัผู้้�ทบทวันจั�กภั�ยนอก ใช�มั�ตรวััด Newcastle-Ottawa ในก�ร ประเมิันคุ์ณิภั�พ็ขีองง�นวิัจัยั (39) ง�นวิัจัยั แต่ละชิ�นได�ระดบัคุ์ณิภั�พ็ “ดี” “พ็อใช�” หร่อ “แย่” โดยทั�วัไปแล�วั ง�นวิัจัยัคุ์ณิภั�พ็ดีตรงต�มัเกณิฑ์ ์ ขีองก�รวัดัระดบั Newcastle-Ottawa ทุกประก�ร ง�นวิัจัยัคุ์ณิภั�พ็พ็อใช�ไม่ัตรงหร่อไม่ัชดัเจันว่ั� ตรงต�มัเกณิฑ์อ์ย่�งน�อยหน่�งขี�อ แต่ยงัค์งไม่ัมีั ขี�อจัำ�กดัที�สำำ�ค์ญั่เชิงประจักัษซ์่�งอ�จัทำ�ให�ผู้ล เป็นโมัฆะ ได� ง�นวิัจััยคุ์ณิภั�พ็แย่มีัจุัดรั� วัที� วิักฤติมั�กหน่�งอย่�งหร่อมีัขี�อจัำ�กดัสำำ�ค์ญั่หล� ยประเด็น และง�นวิัจัยัคุ์ณิภั�พ็แย่ถ้กตดัออกไป มีัก�รประเมิันห�ค์วั�มัเป็นไปได�ที� ทบั ซ�อนและเป็นที� ตระหนักร้�สำำ�หรับก�รจัำ�ลอง ง�นวิัจัยัในบทปริทศันห์ล�ย ๆ ชิ �น บทปริทศัน ์ เห ล่ � นี� มีั ขี�อ สำ รุ ป ขี อ ง ห ลัก ฐ � น ที� ซำ � ซ� อ น ค์ำ�อธิิบ�ยโดยสำรุปขีองบทปริทศัน ์และก�รวิัจัยั แบบรุ่นปีที�รวัมักนัอย่้หล�ยฉบบัถ้กตดัออก ขีณิะ ที�บทปริทศันอ่์�นที� เขี� ใจัง่�ยกว่ั�และ/หร่อเป็น ปัจัจุับนักว่ั�จัะถ้กนำ�มั�ระบุไวั� วิธีิ์สำำ�หรบับทปริทศััน์ใหม่ั เม่ั�อมีัก�รระบุถ่งช่องว่ั�งในหลกัฐ�นที� มีัอย่้ บททบทวันวัรรณิกรรมัขีองบทปริทศันชิ์�น ใหม่ัมีัหน� ที�ตรวัจัสำอบ ดงันี� 1. ค์วั�มัสำมััพ็นัธิร์ะหว่ั�งกิจักรรมัท�งก�ยเชิง อ�ชีพ็ (เช่น สิำ�งที�เกี�ยวัพ็นักบัก�รทำ�ง�น) และ ผู้ลลพั็ธิที์�เกี�ยวัเน่�องกบัสุำขีภั�พ็ (40) และ 2. ค์วั�มัเกี�ยวัเน่�องเช่�อมัโยงระหว่ั�งกิจักรรมั ท�งก�ยในขีอบเขีตขีองก�รพ็กัผู่้อนและ ผู้ลลบต่อสุำขีภั�พ็ (41) ระเบีัย่บัวิธี (สำำ�หรบัขี�อ 1 และ 2 ขี� งต�น ก�รค์�นห�โดยใช� PubMed, Spor tD iscus และ EMBASE สำำ�หรบับทปริทศันจ์ั�กพ็.ศ. 2552 ถง่ ธินัวั�ค์มั พ็.ศ. 2562) 3. ค์วั�มัเช่�อมัโยงระหว่ั�งกิจักรรมัท�งก�ยและ ก�รป้องกนัก�รหกล�มั มีัก�รใช�บทปริทศัน ์ อ ย่ � ง มีั ร ะ บ บ อัน มั �จั � ก ค์ วั � มั ร่ วั มั ม่ั อ Cochrane ฉบบัพ็.ศ. 2562 โดยเชอริงตนั และค์ณิะ (42) และปรับปรุงขี�อม้ัลด�วัย หลกัฐ�นที� ตีพิ็มัพ็จ์ั�กวันัที�ค์�นห�วันัสุำดท� ย ขีองบททบทวันต�นฉบบัจันถง่เด่อนพ็ฤศจิั- ก�ยน พ็.ศ. 2562 4. ค์วั�มัเช่� อมัโยงระหว่ั�งกิจักรรมัท�งก�ย และ โรค์กระด้กพ็รุนและภั�วัะส้ำญ่เสีำย กล� มัเน่�อ ก�รค์�นห�บททบทวันวัรรณิกรรมั อย่�งเป็นระบบเกี�ยวักบัโรค์กระด้กพ็รุนและ ภั�วัะส้ำญ่เสีำยกล� มัเน่�อที�มีัอย่้ ซ่�งใช� PubMed ห�บทปริทัศน์ที� ตีพิ็มัพ็์ ใน พ็.ศ. 2551 จันถ่งพ็ฤศจิัก�ยน พ็.ศ. 2562 พ็บว่ั�ไม่ัมีั บททบทวันชิ�นใหม่ัและมีัง�นวิัจัยัขีั�นแรกเพิ็�มั ใหม่ั 8 ชิ �น 5. หลักฐ�นเร่� องค์วั�มัเช่� อมัโยงระ หว่ั�ง กิจักรรมัท�งก�ยและผู้ลลพั็ธิด์� นสุำขีภั�พ็ ในผู้้�ที� มีัเช่ �อ HIV บทปริทศัน์ในขีอบข่ี�ยนี� ย่นยันหลักฐ�นที� มีัอย่้เกี� ยวักับกิจักรรมั ท�งก�ยและผู้ลลพั็ธิที์� เกี�ยวัเน่�องกบัสุำขีภั�พ็ ในหม่้ัผู้้�มีัเช่ �อ HIV เพ่็�อสำนบัสำนุนก�รทบทวัน วัรรณิกรรมัที�เกี�ยวัเน่�องซ่�งเป็นก�รทบทวัน ห ลักฐ � นที� ตี พิ็ มั พ็์จั นถ่ง เ ด่อ น ตุ ล� ค์มั พ็.ศ. 2562 โดยใช�ฐ�นขี�อม้ัล PubMed, C I N A H L แ ล ะ W e b o f S c i e n c e ซ่�งมิัได�มีัก�รจัำ�กดัวันัเริ�มัต�น ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 30 ข้อ้สำรุปเกี�ยวกบัคุ์ณลกัษณะข้องหลกัฐ�น และวิธีิ์ก�รประเมิันกิจกรรมัท�งก�ยและ พฤติิกรรมัเนือยนิ�ง วิัธีิเริ� มัแรกในก�รวัดักิจักรรมัท�งก�ย และพ็ฤติกรรมัเน่อยนิ�งในวัยัผู้้�ใหญ่่นั�นยงัเป็น ร้ปแบบก�รร�ยง�นโดยตวััผู้้�ให�ขี�อม้ัลเอง (เช่น ก�รสำำ�รวัจั) และสำำ�หรบัเด็กก็ยงัเป็นก�รร�ยง�น ตัวัหร่อบันท่กผู่้�นพ่็อแม่ั แมั�ว่ั�วิัธีิเหล่�นี�จัะ เ ป็ น ที� ย อ มั รั บ แ ต่ ก็ มีั ขี� อ จัำ � กัด ร วั มั ถ่ ง ค์วั�มัโน�มัเอียงที� จัะแจั�งขี�อม้ัลที� ผิู้ดพ็ล�ด ค์ล�ดเค์ล่�อน และมีัอค์ติ (43) ด�วัยเทค์โนโลยี ดิจิัตลัที� ก� วัหน� อย่�งรวัดเร็วัในด� นนี�ในปีที� ผู่้�น ๆ มั� มีัก�รใช�ก�รวัดัโดยเค์ร่� องม่ัอเพ่็�อ ประเมิันกิจักรรมัท�งก�ย และพ็ฤติกรรมัเน่อย- นิ�ง รวัมัถง่ค์วั�มัสำมััพ็นัธิต่์อผู้ลท�งสุำขีภั�พ็มั�ก ขี่ �น อย่�งไรก็ดี ค์วั�มัท� ท�ยก็ยงัค์งมีัอย่้ในก�ร เปรียบเทียบผู้ลระหว่ั�งก�รวิัจัยัอ่�น ๆ เน่�องมั� จั�กค์วั�มัแตกต่�งระหว่ั�งลกัษณิะเฉพ็�ะท�ง เทค์นิค์และก�รใช�ง�นขีองเค์ร่� องม่ัอที� แตก ต่�งกนั (เค์ร่� องวัดัค์วั�มัเร่ง) และค์วั�มัแตก ต่�งในก�รวิัเค์ร�ะห์และก�รร�ยง�นขี�อม้ัล ตวััอย่�งเช่น เม่ั�อมีัก�รวัดัเวัล�ที�อย่้นิ�งเฉยด�วัย เค์ร่� องม่ัอ อ�จัมีัก�รค์ำ�นวัณิผิู้ดพ็ล�ดเพ็ร�ะ อุปกรณิห์ล�ย ๆ ชิ �นยงัไม่ัสำ�มั�รถแยกระหว่ั�ง ท่�ท�งต่�ง ๆ ขีองร่�งก�ย (เช่น ก�รนอน ก�รนั�ง และก�รย่นนิ� ง) ค์วั�มัย�กเกิดขี่ �นเม่ั� อเปรียบ เทียบผู้ลจั�กก�รวิัจัยัที� ใช�ก�รวัดัด�วัยเค์ร่�องม่ัอ กบัก�รร�ยง�นผู้ลที�วัดัจั�กก�รร�ยง�นตวััเอง ในตวััอย่�งขีองกิจักรรมัท�งก�ย เค์ร่�องม่ัอชนิดก�รร�ยง�นผู้ลด�วัยตนเอง นั�นมีัเน่�อห�ที�หล�กหล�ยท�งเล่อกในก�รตอบ สำนองและขีอบเขีต จันเม่ั�อเร็วั ๆ นี� ก�รวิัจัยันั�นมีั เป้�หมั�ยเบ่ �องต�นในก�รประเมิันทั�งกิจักรรมั ท�งก�ยในภั�พ็รวัมัหร่อกิจักรรมัท�งก�ย ในขีอบข่ี�ยก�รพ็กัผู่้อนเท่�นั�น แต่ปัจัจุับนันี� ได�รวัมัเอ�ขีอบข่ี�ยอ่�น เช่น กิจักรรมัท�งก�ย สำำ�หรับก�รเดินท�ง (เช่น ก�รเดินและก�ร ปั� นจัักรย�น) ขีณิะทำ�ง�น และภั�ยในบ� น เอกสำ�รหลกัฐ�นโดยส่ำวันใหญ่่ชี�ให�เห็นถง่ค์วั�มั เช่�อมัโยงระหว่ั�งกิจักรรมัท�งก�ยแบบแอโรบิก กบัผู้ลลพั็ธิท์�งสุำขีภั�พ็ อย่�งไรก็ดี ก�รวิัจัยัใน ช่วังนี�กำ�ลงัประเมิันขี�อดีขีองกิจักรรมัท�งก�ย เพ่็�อเสำริมัสำร� งกล� มัเน่�อและก�รประสำ�นรวัมั กิจักรรมัที�แตกต่�งหล�กหล�ยและขีอบเขีต ก�รเค์ล่�อนไหวัร่�งก�ยแบบอ่�น มีัก�รร�ยง�นและเปรียบเทียบผู้ลด� น ค์วั�มัเช่�อมัโยงระหว่ั�งระดบักิจักรรมัท�งก�ย และผู้ลลพั็ธิท์�งสุำขีภั�พ็ในหล�ย ๆ ท�ง ง�นวิัจัยั หล�ยชิ�นร�ยง�นถ่งก�รเปรียบเทียบระหว่ั�ง ก�รแจักแจังขี�อม้ัล 4 ส่ำวันหร่อก�รแจักแจังขี�อม้ัล แบบ 5 ส่ำวันในกิจักรรมัท�งก�ย ง�นวิัจัยัชิ �นอ่�น ๆ เปรียบเทียบว่ั� “ตรง” เทียบกับ “ไม่ัตรง” ต�มัขี�อแนะนำ�ระดบัช�ติ เม่ั�อมีัก�รร�ยง�น ก�รค์ำ�นวัณิกิจักรรมั ท�งก�ยทั�งหมัดมักัจัะประมั�ณิโดยใช�อตัร�ก�ร เผู้�ผู้ล�ญ่พ็ลงัง�นในหน่�งชั�วัโมัง (MET-hours) ในแต่ละสำปัด�ห ์ และง�นวิัจัยับ�งชิ�นจัะเปรียบ เทียบระดบั “ส้ำงสุำด” กบั “ตำ� สุำด” แมั�ประเภัท กิจักรรมัท�งก�ยจัะต่�งกนัออกไปในง�นวิัจัยั แต่ละชิ�น วัรรณิกรรมัมักัจัะร�ยง�นผู้ลจั�กก�ร วิัเค์ร�ะหที์�ใช�จุัดตดัขี�อม้ัลจั�กขี�อแนะนำ�ที� มีัอย่้ หร่อขี�อแนะนำ�ระดบัโลกจั�กองค์ก์�รอน�มัยั- โลกฉบบัปัจัจุับนั หร่อมั�ตรวัดัจั�กง�นวิัจััย ชิ �นก่อนหน� (เช่น จุัดตดัที� 60 น�ทีต่อวันัในก�ร 31 วิัจัยัจั�กประช�กรที�เป็นเย�วัชน หร่อค์วั�มัถี� 2-3 ค์รั�งต่อสำปัด�ห์เม่ั� อมีัก�รฝึึกค์วั�มัแข็ีงแกร่ง มั�ร่วัมัด�วัย) เม่ั� อจุัดตดัเหล่�นี�เป็นที� ยอมัรับ กนัทั�วัไป ก�รสำร� งหลกัฐ�นที�มีัค์วั�มัเช่�อมัโยง ระ หว่ั�งก�รเปิดรับกิจักรรมัท�งก�ยต่อ ผู้ลลัพ็ธิท์�งสุำขีภั�พ็ในระดับส้ำงหร่อตำ� ย่อมั สำ�มั�รถจัำ�กดัได� หลักฐ�นส่ำวันใหญ่่ที� ประเ มิั นค์วั�มั เช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งและผู้ลต่อ สุำขีภั�พ็ขีองเด็กและวัยัรุ่นนั�นมักัเป็นก�รศก่ษ� เปรียบเทียบระหว่ั�งกลุ่มั และง�นวิัจัยัส่ำวันใหญ่่ อิงก�รวัดัเวัล�ขีองพ็ฤติกรรมัเน่อยนิ�งจั�กก�ร ร�ยง�นขีองตนเองหร่อร�ยง�นขีองจั�กบิด� มั�รด� ซ่�งอ�จัมีัขี�อผิู้ดพ็ล�ดในก�รวัดัและค์วั�มั เอนเอียงจั�กก�รระลก่ขี�อม้ัล หลกัฐ�นจั�กก�รวิัจััยโดยก�รสำงัเกต ระยะย�วัและเสำ�นท�งขีองก�รแทรกแซงจัะ ไ ด�รับ ค์ วั � มั สำำ � ค์ัญ่ ก่ อ น แ ล ะ บ ท ป ริ ทัศ น ์ ที�รวัมัเอ�หลกัฐ�นจั�กก�รเปรียบเทียบระหว่ั�ง กลุ่มัทั�งหมัดหร่อตั�งต�นจัะไม่ัถ้กนำ�มั�พิ็จั�รณิ� นำ � หนกัเน�นไปที�หลกัฐ�นจั�กบทปริทศันที์�จัดั ระดบัให�มีัค์วั�มัแน่นอนป�นกล�งและส้ำงกว่ั�นั�น และบทที�ให�หลกัฐ�นจั�กก�รศก่ษ�ที�ใช�ก�รวัดั ผู้ลด�วัยอุปกรณิ์ ก�รจดัระดบัใจค์ว�มัข้องหลกัฐ�น วิั ธีิ ขี อ ง ก � ร จััด ร ะ ดับ ก � ร ป ร ะ เ มิั น ก�รพ็ัฒน� และวััดค่์�ขี�อแนะนำ� (GRADE) นำ �มั�ใช�เพ่็� อจััดระดับค์วั�มัน่�เช่� อถ่อขีอง หลกัฐ�นสำำ�หรบัอตัร� PI/ECO แต่ละค์รั�ง (44) อิงจั�กหลกัฐ�นที�ซ่อนอย่้ในบทปริทศันเ์หล่�นั�น ห�กมีัต�ร�งขี�อม้ัลหลกัฐ�นขีอง GRADE หร่อ ขี�อสำรุปก�รร�ยง�นจั�กบทปริทศันแ์ต่ละบทจัะ นำ�มั�ใช�เป็นจุัดตั�งต�น ห�กไม่ัมีัต�ร�งอย่้ในก�ร ทบทวันวัรรณิกรรมัอย่�งเป็นระบบที�มีัอย่้ จัะจัดั ทำ�ต�ร�งขี�อม้ัลหลกัฐ�นสำำ�หรบัประช�กรแต่ละ กลุ่มัและผู้ลลพั็ธิที์�สำนใจั กระบวันวิัธีิขีอง GRADE นั�นใช�เพ่็�อวัดั ระดับค์วั�มัเช่� อถ่อได�ขีองหลักฐ�นสำำ�หรับ PI/ECO (44) แต่ละค์รั�งด�วัยก�รค์ำ�น่งถ่ง กฎเกณิฑ์ต่์�ง ๆ ได�แก่ ก�รออกแบบก�รวิัจัยั ค์วั�มัเสีำ�ยงต่ออค์ติ ค์วั�มัค์งที�ขีองผู้ลกระทบ ค์ วั � มั ไ ม่ั ต ร ง ไ ป ต ร ง มั � ค์ วั � มั แ ม่ั น ยำ � ขีองผู้ลกระทบ และขี�อจัำ�กัดอ่� น ๆ รวัมัถ่ง ค์ วั � มั เ อ น เ อี ย ง ใ น ก � ร ตี พิ็ มั พ็์แ ล ะ ปั จั จััย ในก�รปรับปรุงหลักฐ�นจั�กก�รสำังเกต (ก�รศก่ษ�ผู้ลกระทบ ก�รตอบสำนองต่อขีน�ด และผู้ลกระทบขีองตวััวัดัค่์�ต่�ง ๆ) หลกัฐ�น จั�กก�รสำังเกตที� ได�จั�กง�นวิัจััยจั�กก�ร สำงัเกตระยะย�วัที�จัดัทำ�เป็นอย่�งดีถ้กยกระดบั เพ่็�อสำะท�อนถง่ค์วั�มัน่�เช่�อถ่อขีองผู้ลก�รค์�นพ็บ ที� เพิ็�มัส้ำงขี่ �นอย่�งเหมั�ะสำมั อนัเกี�ยวัเน่� องกบั ค์วั�มัเช่�อมัโยงระหว่ั�งกิจักรรมัท�งก�ยหร่อ พ็ฤติกรรมัเน่อยนิ�งและผู้ลลพั็ธิจ์ั�กง�นวิัจัยันั�น ๆ ง�นวิัจัยัที�ประเมิันผู้ลท�งอ�อมัหร่อผู้ลระหว่ั�ง ท�งไม่ัจัำ�เป็นต�องถ้กลดระดบั เน่�องด�วัยผู้ลลพั็ธิ ์ นั�น (รวัมัถ่งผู้ลลัพ็ธิร์ะหว่ั�งท�ง) จััดลำ�ดับ ค์วั�มัสำำ�ค์ญั่โดย GDG และก�รจัดัระดบัโดย GRADE ที�สำะท�อนค์วั�มัเช่�อถ่อได�ในผู้ลกระทบต่อ ผู้ลลพั็ธิเ์หล่�นั�น ในบ�งกรณีิ ก�รวัดัระดบัขีอง GRADE สำำ�หรับบทปริทัศนที์� มีัอย่้แล�วัได�ถ้ก ปรบัแก�เพ่็�อรบัรองค์วั�มัน่�เช่�อถ่อในก�รใช�วิัธีิ วิัจััยขีอง GRADE ค์วั�มัน่�เช่� อถ่อขีององค์ ์ ประกอบขีองหลกัฐ�นสำำ�หรับผู้ลลพั็ธิแ์ต่ละ ประเด็นจัดัไวั�ต�มัแนวัปฏิิบติัดงัต่อไปนี� (45) ระเบีัย่บัวิธี ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 32 ส้ำง มัั�นใจัได�อย่�งยิ�งว่ั�ผู้ลกระทบที� แท�จัริงใกล�เคี์ยงกบัผู้ลกระทบที� ประเมิันไวั� ป�นกล�ง มัั�นใจัในผู้ลกระทบที�ประเมิันไวั�ได� ป�นกล�ง ผู้ลกระทบที�แท�จัริงมีั ค์วั�มัเป็นไปได�ที�จัะใกล�เคี์ยงกบั ผู้ลกระทบที� ประเมิันไวั� แต่มีั ค์วั�มัเป็นไปได�ที�จัะแตกต่�งกนั อย่�งมั�ก ติำ� ค์วั�มัมัั�นใจัในผู้ลกระทบที�ประเมิัน ไวั�มีัอย่�งจัำ�กดั ผู้ลกระทบที�แท� จัริงอ�จัแตกต่�งจั�กผู้ลกระทบที� ประเมิันไวั�เป็นอย่�งมั�ก ติำ� มั�ก มีัค์วั�มัเช่� อมัั� นเพี็ยงน�อยนิดต่อ ผู้ลกระทบที�ประเมิันไวั� ผู้ลกระทบ ที� แท�จัริงมีัค์วั�มัเป็นไปได�ที� จัะ แตกต่�งจั�กผู้ลที�ประเมิันไวั�เป็น อย่�งยิ�ง จ�กหลกัฐ�นส่้ำข้อ้แนะนำ� G D G ใ ช� ก ร อ บ ห ลั ก ฐ � น ประกอบก�รตดัสิำนใจั (EtD) ขีองค์ณิะทำ�ง�น GRADE ในก�รเขีียนค์ำ�แนะนำ�ที� เจั�ะจังค์ำ�ถ�มั กรอบ EtD เป็นขี�อแนะนำ�ที�เป็นระบบ มีัโค์รงสำร� ง และโปร่งใสำต่อก�รตดัสิำนใจั กรอบก�รวิัจัยัใช� เกณิฑ์ที์� ชัดเจันในก�รจััดทำ�ขี�อแนะนำ�โดย ค์ำ�น่งถ่งหลักฐ�นก�รวิัจััย ค์วั�มัน่�เช่� อถ่อ ขีองหลกัฐ�น และค์วั�มัคิ์ดเห็นจั�กผู้้�เชี�ยวัช�ญ่ ห�กต�องก�ร และยงัมีัค์วั�มัร้�เกี�ยวักบัหวััขี�อนั�น ๆ จั�กมุัมัมัองขีองกลุ่มัเป้�หมั�ย เกณิฑ์วิ์ัธีินั�นโน�มั นำ�ก�รตดัสิำนใจัเกี� ยวักบัค์วั�มัสำมัดุลระหว่ั�ง ห ลัก ฐ � น ที� สำัง เ ก ต ไ ด� เ กี� ย วั กับ ผู้ ล ลัพ็ ธิ ์ที� พ็่งประสำงค์แ์ละไม่ัพ็่งประสำงค์ ์ ค์วั�มัเช่� อมัั� น ขีองหลกัฐ�นโดยรวัมั ก�รประเมิันม้ัลค่์�เชิง เปรียบเทียบขีองประช�กรสำำ�หรบัผู้ลลพั็ธิพ์็่ง ประสำงค์แ์ละไม่ัพ็่งประสำงค์ ์ ก�รใช�ทรพั็ย�กร (ก�รพิ็จั�รณิ�ต�นทุน) ห�กมีัผู้ลกระทบที�อ�จัเกิด ต่อค์วั�มัไม่ัเท่�เทียมัด� นสุำขีภั�พ็ ก�รยอมัรบัได� และค์วั�มัเป็นไปได�ขีองขี�อแนะนำ�เหล่�นั�น ค์ณิะทำ�ง�น GDG พิ็จั�รณิ�ใจัค์วั�มั ขีองหลักฐ�นในภั�พ็รวัมัสำำ�หรับขี�อแนะนำ� แต่ละขี�อเพ่็�อผู้ลลพั็ธิที์�สำำ�ค์ญั่ยิ�ง และผู้ลลพั็ธิ ์ สำำ�ค์ญั่ที� มีัอย่้ทั�งหมัด ก�รวิัจัยัเหล่�นั�นมีัค์วั�มั แตกต่�งอย่�งกวั� ง ๆ สำำ�หรบัก�รเขี� ถง่/ก�ร แทรกแซงเฉพ็�ะและก�รเช่�อมัโยงผู้ลลพั็ธิ ์ใน ด� นขีองก�รเขี� ถง่/ก�รแทรกแซงที�ถ้กประเมิัน ผู้ลลพั็ธิที์� ถ้กประเมิัน ก�รออกแบบก�รวิัจัยั และกระบวันก�รวิัเค์ร�ะห์ซ่� งมีัผู้ลต่อค์วั�มั แตกต่�งที�เกิดขี่ �นในหลกัฐ�นที�ห�ได� ดงันั�น จัง่ เป็นไปไม่ัได�ที�จัะใช�ขี�อแนะนำ�ดั�งเดิมัขีอง GRADE สำำ�หรับก�รเขี� ถ่ง/ก�รแทรกแซงและก�ร เ ช่� อ มั โ ย ง ผู้ ล ลัพ็ ธิ ์ ใ น ท � ง ต ร ง กัน ขี� มั ขี�อแนะนำ�ขีอง GRADE ใช�สำำ�หรบัหลกัฐ�นใน ภั�พ็รวัมัที�กล่�วัถ่งก�รเขี� ถ่ง/ก�รแทรกแซง และค์วั�มัเช่�อมัโยงขีองผู้ลลพั็ธิ ์ในประเภัทก�ร อ อ ก แ บ บ ก � ร วิั จััย ทุ ก ร้ ป แ บ บ แ ล ะ ค์ วั � มั หล�กหล�ยในก�รวัดัและวิัเค์ร�ะหก์�รเขี� ถง่/ ก�รแทรกแซง เม่ั�อปัจัจัยัเหล่�นี�ก่อให�เกิดค์วั�มั สำมััพ็นัธิเ์กี�ยวักบัค์วั�มัเช่�อมัโยงขีองหลกัฐ�น (ตวััอย่�งเช่น เม่ั�อหลกัฐ�นสำำ�หรบัก�รเขี� ถง่/ ก�รแทรกแซงและค์วั�มัเช่�อมัโยงขีองผู้ลลพั็ธิ ์ไม่ั สำอดประสำ�นกนัเม่ั�อมัองด�วัยวิัธีิที�แตกต่�งกนั) ชุดขี�อม้ัลลดค์วั�มัน่�เช่� อถ่อขีองหลกัฐ�นลง (21) GDG จัดัลำ�ดบัค์วั�มัสำำ�ค์ญั่ขีองผู้ลลพั็ธิ ์ ท�งสุำขีภั�พ็เพ่็� อพิ็จั�รณิ�ถ่งผู้ลกระทบขีอง กิจักรรมัท�งก�ยและพ็ฤติกรรมัเน่อยนิ� ง ดงัต่อไปนี� ทั�งก�รลดอตัร�ก�รเสีำยชีวิัตจั�ก ทุกสำ�เหตุและที� มีัสำ�เหตุจัำ�เพ็�ะ ( โรค์หลอด เล่อดหัวัใจัและมัะเร็ง) ลดสำ�เหตุก�รเกิด โรค์หลอดเล่อดหัวัใจั โรค์มัะเร็ง (เฉพ็�ะจุัด) โรค์เบ�หวั�นชนิดที�สำอง พ็ฒัน�ค์วั�มัแข็ีงแรง ขีองร่�งก�ย (เช่น ระบบหมุันเวีัยนโลหิต ก�รพ็ัฒน�ก�รเค์ล่� อนไหวั ค์วั�มัแข็ีงแรง 33 ก ล� มั เน่�อ ) พ็ัฒ น � สุำ ขี ภั � พ็ ห ล อ ด เ ล่ อ ด ( เ ช่ น ค์ วั � มั ดั น โ ล หิ ต ไ ขี มัั น ใ น เ ล่ อ ด นำ � ต�ลในเล่อด ค์วั�มัด่�ออินซ้ลิน) สุำขีภั�พ็กระด้ก สุำ ขี ภั� พ็จิั ต ( เ ช่ นก�ร ล ดอ� ก�ร ซ่มั เ ศ ร� ค์วั�มัมัั�นใจัในตนเอง อ�ก�รกงัวัล สำมั�ธิิสำั�น) พ็ั ฒ น � ผู้ ล ลั พ็ ธิ ์ด� น ก � ร เ รี ย น ร้� ( เ ช่ น ค์วั�มัสำ�มั�รถท�งก�รเรียนร้� ก�รคิ์ดวิัเค์ร�ะห)์ และลดภั�วัะโรค์อ�วัน มีัก�รพิ็จั�รณิ�ถง่อ�ก�ร ไ ม่ัพ็่งประสำงค์์ต่�ง ๆ ( เช่นก�รบ�ดเจ็ัด และอนัตร�ย) เช่นกนั ข้อ้พิจ�รณ�อื�น ๆ ค์ ณิ ะ ทำ � ง � น G D G ยัง พิ็ จั � ร ณิ � ค่์ � นิ ย มั แ ล ะ ค์ วั � มั นิ ย มั ขี อ ง ผู้้� ที� ไ ด� รั บ ผู้ลกระทบจั�กขี�อแนะนำ�สำำ�หรับประช�กร แต่ละกลุ่มัและค์ำ�ถ�มั PI/ECO ทั�งหมัด ทั�งสิำ�งที� เกี�ยวัขี�องกบัแหล่งขี�อม้ัลขีองค์ำ�แนะนำ� ผู้ลกระทบต่อค์วั�มัเสำมัอภั�ค์ด� นสุำขีภั�พ็ และก�รเป็นที�ยอมัรบัและค์วั�มัเป็นไปได�ขีอง ค์ำ�แนะนำ� ด�วัยเหตุที�มีัค์วั�มัซำ � ซ�อนค่์อนขี� งมั�ก ในเกณิฑ์์ก�รพิ็จั�รณิ�เหล่�นี�และ ในก�ร ประเมิันขีอง GDG สำำ�หรบัประช�กรแต่ละกลุ่มั บทสำรุปขีองก�รอภิัปร�ยว่ั�ด�วัยก�รประเมิัน องค์ป์ระกอบต่�ง ๆ เหล่�นี�ได�บรรย�ยไวั�ในส่ำวัน “หลกัฐ�นต่อขี�อแนะนำ�” ระเบีัย่บัวิธี ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 34 ข้้อแนืะนืำ� ขี�อแนะนำ�ด� นสำ�ธิ�รณิสุำขีที� นำ� เสำนอในขี�อแนะนำ�เกี� ยวักับกิจักรรมั ท�งก�ยและพ็ฤติกรรมัเน่อยนิ� งขีอง องค์ก์�รอน�มัยัโลก จััดทำ�ขี่ �นสำำ�หรับ ประช�กรทุกค์นและทุกกลุ่มัอ�ยุตั�งแต่ 5-65 ปีและส้ำงวัยักว่ั�นั�น โดยไม่ัเกี�ยวั- กบัเพ็ศ ภ้ัมิัหลงัท�งวัฒันธิรรมัหร่อสำถ�น- ภั�พ็ท�งเศรษฐศ�สำตรส์ำงัค์มั และเกี�ยวั- ขี�องกบัผู้้�ค์นในสำมัรรถภั�พ็ทุกร้ปแบบ ขี�อแนะนำ�ใหม่ันั�นนำ�เสำนอด�วัย กลุ่มัอ�ยุและพ็ฤติกรรมั (กิจักรรมั ท � ง ก � ย แ ล ะ พ็ ฤ ติ ก ร ร มั เน่ อ ย นิ� ง ) สำำ�หรบัค์ำ�แนะนำ�แต่ละชุด ค์ำ�บรรย�ย ส่ำวันเกริ�นนำ�ได�สำรุปผู้ลลพั็ธิท์�งสุำขีภั�พ็ ที� เช่� อมัโยงกับกิจักรรมัท�งก�ยและ พ็ฤติกรรมัเน่อยนิ�งต�มัลำ�ดบัและต�มั มั�ด�วัยขี�อแนะนำ� มีัชุดขี�อม้ัลขี�อแนะนำ� เพ่็� อแจังว่ั�ประช�กรกลุ่มัเป้�หมั�ย จั ะ ทำ � ต � มั ขี�อ แน ะ นำ � โ ด ย ป ล อ ด ภััย ไ ด� อ ย่ � ง ไ ร ขี� อ แ น ะ นำ � เ ห ล่ � นี� ไ ม่ั ใช่ “ขี�อแนะนำ �ที� มีัก�รวััดระดับ” ด�วัยตวััขีองมันัเอง แต่ได�มั�จั�กหลกัฐ�น ท � ง วิั ท ย � ศ � สำ ต ร์แ ล ะ มั � จั � ก ก � ร พิ็จั�รณิ�ที� ใช� ได�จัริง ซ่� งทบทวันและ แนะนำ�โดยค์ณิะทำ�ง�น GDG บทสำรุปขีองหลกัฐ�นท�งวิัทย�- ศ�สำตร์ที� สำนับสำนุนถ้กจััดไวั�สำำ �หรับ ขี�อแนะนำ�แต่ละชุด มีัค์ำ�ถ�มั PI/ECO เป็นโค์รงสำร� ง นำ�เสำนอหลกัฐ�นที� เช่�อมั โยงกบัผู้ลลพั็ธิท์�งสุำขีภั�พ็ที�สำำ�ค์ญั่ยิ�งเป็น อย่�งแรก ต�มัมั�ด�วัยบทสำรุปขีอง หลกัฐ�นเร่�องก�รตอบสำนองต่อปริมั�ณิ ท� ยที� สุำดค่์อ ก�รนำ�เสำนอบทสำรุปขีอง หลกัฐ�นว่ั�ด�วัยค์วั�มัสำมััพ็นัธิร์ะหว่ั�ง ชนิดหร่อขีอบข่ี�ยที�แตกต่�งกนัขีองก�ร เปิดเผู้ยขี�อม้ัลและผู้ลลัพ็ธิต่์อสุำขีภั�พ็ ต�มัที�มีัอย่้ 35ข้้อัแนะนำา กิจักรรมัท�งก�ยในเด็กและวัยัรุ่นจัะเอ่ �อประโยชนต่์อผู้ลลพั็ธิท์�งสุำขีภั�พ็ดงัต่อไปนี� ช่วัยพ็ฒัน� สุำขีภั�พ็ก�ย (ระบบหมุันเวีัยนโลหิตและค์วั�มัแข็ีงแรงกล� มัเน่�อ) สุำขีภั�พ็ระบบหมุันเวีัยนโลหิต (ระบบค์วั�มัดนัโลหิต ไขีมันัในเล่อด นำ � ต�ลในเล่อด และก�รต� นอินซ้ลิน) ค์วั�มัแข็ีงแรง กระด้ก, ผู้ลลพั็ธิด์� นก�รรบัร้�ขีองสำมัอง (ค์วั�มัสำ�มั�รถด� นก�รเรียนร้� ด� นก�รวิัเค์ร�ะห)์ สุำขีภั�พ็จิัต (ลดอ�ก�รซม่ัเศร� ) และลดภั�วัะโรค์อ�วัน สำำ�หรบัเด็กและวัยัรุ่น กิจักรรมัท�งก�ยเป็นได�ทั�งส่ำวันหน่�งขีองสำนัทน�ก�รและก�ร พ็กัผู่้อน (ก�รละเล่น เกมั กีฬ� หร่อก�ยบริห�รที�มีัก�รวั�งแผู้นไวั�) กิจักรรมัพ็ลศก่ษ� ก�รเดินท�ง (เดินท�งด�วัยอุปกรณิที์�มีัล�อ ก�รเดิน ก�รปั� นจักัรย�น) หร่อก�รทำ�ง�นบ� นในสำภั�พ็แวัดล�อมั ท�งก�รศก่ษ� บ� น และชุมัชน หลกัฐ�นและเหตุิผลสำนบัสำนุน สำำ�หรบัขี�อแนะนำ�เพ่็�อเด็กและวัยัรุ่น มีัก�รใช�บทปริทศันอ์ย่�งเป็นระบบ (22,25,35) และเพิ็�มับทปริทศัน์ใหม่ั อีก 16 ชิ �นที�พิ็ส้ำจันแ์ล�วัว่ั�เขี� เกณิฑ์ก์�รค์ดัอ�สำ�สำมัคั์รเขี� ร�ยละเอียดวิัธีิวิัจัยัที�ค์รบถ�วัน ก�รแยะแยะขี�อม้ัล และชุดขี�อม้ัลหลกัฐ�นมีัอย่้ที�ภั�ค์ผู้นวักในเว็ับไซต ์: ชุดขี�อม้ัลหลกัฐ�น4 • ทำ�กิจักรรมัท�งก�ยบ� งย่อมัดีกว่ั�ไม่ัทำ�อะไรเลย • ห�กเด็กหร่อวัยัรุ่นไม่ัสำ�มั�รถทำ�ต�มัขี�อแนะนำ�ได� ก�รทำ�กิจักรรมัท�งก�ยบ� งจัะเป็นผู้ลดี ต่อสุำขีภั�พ็ • เด็กและวัยัรุ่นค์วัรจัะเริ�มัทำ�กิจักรรมัท�งก�ยที�ระดบัเบ�ก่อนแล�วัค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มัเขี�มัขี�น และระยะเวัล�ขี่ �นเร่�อย ๆ • ก�รจัดัให�เด็กและวัยัรุ่นมีัค์วั�มัปลอดภัยั โอก�สำที�เท่�เทียมั และค์วั�มักล� ห�ญ่ที�จัะเขี� ร่วัมัใน ก�รทำ�กิจักรรมัท�งก�ยที� เพ็ลิดเพ็ลิน มีัค์วั�มัหล�กหล�ย และเหมั�ะสำมักบัอ�ยุและค์วั�มั สำ�มั�รถนั�นเป็นสิำ�งสำำ�ค์ญั่ เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) ข้้อแนืะนืำ�ด้็�นืกิิจกิรัรัมท�งกิ�ย แนะนำ�ให:้ เด็กและวยัรุ่นค์วรทำ�กิจกรรมัท�งก�ยอย่�งนอ้ยเฉลี�ยวนัละ 60 น�ที ติลอดทั�งสำปัด�ห ์ ในระดบัป�นกล�งถง้ระดบัหนกั โดยส่ำวนใหญ่่ค์วรเป็นกิจกรรมัท�งก�ยแบบแอโรบิก แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได�ป�นกล�ง ค์วรทำ�กิจกรรมัท�งก�ยแบบแอโรบิกที�ระดบัหนกั และกิจกรรมัสำร�้งค์ว�มัแข็้งแรงใหก้บั กล�้มัเนื �อและกระด้กอย่�งนอ้ย 3 วนัต่ิอสำปัด�ห์ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได�ป�นกล�ง > > ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ 4 ข้้อม่ัลออนไลน์ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 36 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) ค์ว�มัเชื้�อมัโยงระหว่�งกิจกรรมัท�ง- ก�ยและผลลพัธิ์ด์�้นสุำข้ภ�พในเด็ก และวยัรุ่น (อ�ยุ 5-17 ปี) คื์ออะไร หลักฐ�นกลุ่มัใหญ่่ ได�แสำดงไวั� ก่อนหน� นี�ว่ั� กิจักรรมัท�งก�ยเป็น ระยะเวัล�น�นขี่ �นและหนักหน่วังขี่ �นใน เด็กและวัยัรุ่นนั�น สำมััพ็นัธิก์บัผู้ลลพั็ธิท์�ง สุำขีภั�พ็หล�ยประก�ร (1) หลกัฐ�นเม่ั�อ ไม่ัน�นมั�นี�ย่นยนัว่ั�กิจักรรมัท�งก�ยที� เพิ็�มัขี่ �นจัะพ็ฒัน�สำมัรรถภั�พ็ขีองระบบ หัวัใจัและห�ยใจัและสำมัรรถภั�พ็ขีอง กล� มัเน่�อยด่กระด้กในเด็กและวัยัรุ่น (22, 35) ตวััอย่�งเช่น ผู้ลด� นบวักที� เกิดขี่ �น เ ม่ั� อ ทำ � กิ จั ก ร ร มั ท � ง ก � ย ที� ร ะ ดับ ป�นกล�ง-หนกั 3 วันัต่อสำปัด�หข์ี่ �นไป เป็นระยะเวัล� 30 ถง่ 60 น�ที (22, 35) ในเด็กและวัยัรุ่น กิจักรรมัท�งก�ย ทั� วั ไ ป ที� ส่ำ วั นให ญ่่ เ ป็ นกิจั กร ร มั แ บ บ แอโรบิกกบัผู้ลลพั็ธิ ์ในแง่ดีด� นสุำข้ภ�พ ข้องหัวใจและหลอดเลือด รวัมัถ่ง ปรบัปรุงค์วั�มัดนัโลหิต ไขีมันัในเล่อด ก�ร ค์วับคุ์มันำ � ต�ล และก�รต� นอินซ้ลิน ที�ดีขี่ �น มีัค์วั�มัสำมััพ็นัธิ ์ไปในทิศท�งเดียวั กนั (35) ก�รทบทวันวัรรณิกรรมัเม่ั� อ เร็วั ๆ นี�ได�ตรวัจัสำอบประสิำทธิิภั�พ็ขีองกิจั- กรรมัท�งก�ยที�โรงเรียน (46) ก�รออกกำ�- ลงัที�มีัค์วั�มัเขี�มัขี�นส้ำงในระยะเวัล�สำั�น (47) และก�รออกกำ�ลงัก�ยแบบแรงต� น (48) เปรียบเทียบกบัก�รไม่ัมีัก�รแทรกแซง ใน ก � ร วััด ค่์ � สุำ ขี ภั � พ็ โร ค์ หัวัใจั แ ล ะ หลอดเล่อด จั�กบทปริทัศน์ทั�งหมัด 3 ชิ �น มีัหลกัฐ�นต่อเน่�องว่ั�ก�รแทรก- แซงนั�น เช่�อมัโยงกบัผู้ลลพั็ธิสุ์ำขีภั�พ็หวััใจั และหลอดเล่อดที�วัดัได� แมั�ว่ั�ค์วั�มัแม่ัน- ยำ�จัะแปรผู้นัต�มัขีน�ดขีองผู้ลกระทบ และก�รทดลองขีองแต่ละบุค์ค์ล 2-3 ค์รั�ง พ็บผู้ลดีขีองกิจักรรมัท�งก�ยที� มีันัย- สำำ�ค์ญั่ต่อผู้ลลพั็ธิข์ีองสุำขีภั�พ็หัวัใจัและ หลอดเล่อดในทุกท�ง บทปริทศันฉ์บบั หน่� งที� มีักลุ่มัทดลองแบบสุ่ำมัและมีัก�ร ค์วับคุ์มั 19 ฉบับ (n=11988) (46) ชี �ว่ั �ร � ย ก�ร กิจั กร ร มั ท�ง ก� ย ขีอง โรงเรียนเช่�อมัโยงกบัสำภั�พ็ค์วั�มัดนัโลหิต ที� ดีขี่ �นอย่�งมีันัยสำำ�ค์ัญ่ (ES= 0.21 [95% CI: 0.42 to 0.01]; p= 0.04) และอินซ้ลินขีณิะอดอ�ห�ร (ES= 0.12 [95% CI: 0.42 to 0.04]; p= 0.03) เทียบ กับ ภั � วั ะ ที� ไ ม่ั มีั ก � ร แท ร ก แซ ง จั � ก กิจักรรมัท�งก�ย มีัร�ยง�นพ็บว่ั� กิจักรรมัท�งก�ย มีัค์วั�มัเช่�อมัโยงในท�งที� เอ่ �อประโยชน ์ ต่อภ�วะโรค์อว้น และกิจักรรมัระดบัที�ส้ำง กว่ั�อ�จัจัะเกี� ยวัเน่� องกับสำถ�นะขีอง นำ � หนกัที�เหมั�ะสำมักบัสุำขีภั�พ็ในเด็กและ วัยัรุ่น (22,35) ผู้ลก�รทดลองนี� โดย ทั�วัไปแล�วัจัะชดัเจันที� สุำดในก�รวิัจัยัแบบ ขี� มักลุ่มั ซ่�งผู้ลจัะผู้สำมัปนเปไปจั�กก�ร วิัจััยจั�กก�รสำังเกตแบบค์�ดหวัังผู้ล ซ่�งจัำ�กดัค์วั�มัเขี� ใจัเกี�ยวักบัทิศท�งขีอง ค์ วั � มั เ กี� ย วั โ ย ง ที� ไ ด�รับ ร � ย ง � น มั � บทปริทศันเ์ร่� องก�รทดลองก�รแทรก แซงกิจักรรมัท�งก�ยฉบบัเม่ั�อไม่ัน�นนี� (ก�รออกกำ�ลงัที�มีัค์วั�มัเขี�มัขี�นส้ำงในระยะ เวัล�สำั�น [HIIT] ที� เกิดขี่ �นในห�องทดลอง ก � ร เ รี ย น แ บ บ ก ร ะ ฉั บ ก ร ะ เ ฉ ง ใ น 37 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) ห� องเรียน ก�รออกกำ�ลังก�ยแบบ มีัแรงต� น) แสำดงผู้ลที� ไม่ัค์งที� โดยง�น วิัจัยัส่ำวันใหญ่่ที�รวัมัไวั�ในบทปริทศัน์ ไม่ั ได�ร�ยง�นถ่งผู้ลกระทบ (47, 49, 50) แมั�กระนั�น บทปริทศันที์�มั�จั�กง�นวิัจัยั ที� มีัก�รสำงัเกตระยะย�วัและก�รทดลอง แบบขี� มักลุ่มัแสำดงให� เห็นถ่งผู้ลใน ท�งลบต่อค์วั�มัสำมััพ็นัธิร์ะหว่ั�งกิจักรรมั ท�งก�ยที� มีัก�รใช�เค์ร่� องม่ัอวััดก� วั ก�รวััดภั�วัะโรค์อ�วัน ดัชนีมัวัลก�ย หร่อขีน�ดรอบเอวั (51) โดยภั�พ็รวัมัแล�วั มีัหลกัฐ�นที� มีัค์วั�มัเช่� อถ่อเป็นจัำ�นวัน น�อยที�ว่ั� กิจักรรมัท�งก�ยนั�นเกี�ยวัเน่�อง กบัก�รจัดัก�รให�มีันำ � หนกัเหมั�ะสำมั และ ต�องก�รก�รวิัจััยเพิ็� มัเติมัเพ่็� อกำ�หนด ทิศท�งและค์วั�มัแข็ีงแรงขีองค์วั�มั เช่�อมัโยง มีัหลักฐ�นน�อยชิ�นที� ตรวัจัสำอบ ค์วั�มัเกี�ยวัเน่�องระหว่ั�งกิจักรรมัท�งก�ย แ ล ะ ก � ร พัฒ น� ท ัก ษ ะ ก � ร พัฒ น� กล�้มัเนื �อในเด็กและวัยัรุ่น บทปริทศัน ์ ที� มีัอย่้ปัจัจุับนั ชี �ว่ั�ไม่ัมีัก�รค์�นพ็บใด ๆ ( 2 2 ) ง � น วิั จััย เพิ็� มั เ ติ มั ที� เ กี� ย วั กับ ก � ร พ็ั ฒ น � ก ล� มั เ น่� อ เ พ่็� อ พ็ั ฒ น � ขี�อแนะนำ�ในอน�ค์ตเป็นสิำ�งจัำ�เป็น สำำ�หรบัเด็กและวัยัรุ่น กิจักรรมัที� เสำริมัสำร� งกระด้กสำ�มั�รถเกิดร่วัมักบั ก � ร เ ล่ น เ ก มั ก � ร วิั� ง ก � ร ห มุั น ตัวั หร่อกระโดด กิจักรรมัท�งก�ยนั�นเกี�ยวั เน่�องในท�งบวักกบัก�รสำะสำมัมัวัลกระด้ก และ/หร่อโค์รงสำร� งกระด้ก และหลกัฐ�น ฉบบัเม่ั� อไม่ัน�นมั�นี�ก็สำนับสำนุนว่ั�เด็ก และวัยัรุ่นที� มีัก�รทำ�กิจักรรมัท�งก�ย มั�กกว่ั�เพ่็� อนจัะมีัมัวัลกระด้กที� ดีกว่ั� ปริมั�ณิแร่ธิ�ตุในกระด้กหร่อค์วั�มั หน�แน่นกระด้กส้ำงกว่ั� และค์วั�มัแข็ีงแรง ขีองกระด้กที�มั�กกว่ั� (35) ก�รทำ�ให� สุำข้ภ�พกระด้กแข็ีงแรงที� สุำดในวัยัเด็ก และวัยัรุ่นจัะช่วัยป้องกนัโรค์กระด้กพ็รุน และกระด้กร� วัในช่วังต่อ ๆ มั�ขีองชีวิัต ก�รพ็ฒัน�และค์งหน� ที�ท�งก�ร รบัร้�เอ�ไวั�เป็นสิำ�งจัำ�เป็นสำำ�หรบัทุกช่วัง ขีองชีวิัต กิจักรรมัท�งก�ยในเด็กและ วัยัรุ่น มีัผู้ลในท�งบวักกบัก�รรบัร้แ้ละ ผลก�รเรียน (ตวััอย่�งเช่น ก�รเรียนร้� ค์วั�มัจัำ� และหน� ที� ในก�รวิัเค์ร�ะห์) (22,35) ในง�นวิัจัยัล่�สุำดชิ�นหน่� ง (19 RCTs; n= 5038) ชี �ให�เห็นว่ั�ก�รแทรก ก�ร ออ ก กำ � ลัง ก� ย ไวั�ห ล� ย ช่วัง ต่ อ สำปัด�ห ์เป็นเวัล� 6 สำปัด�หห์ร่อมั�กกว่ั�นั�น มีัค์วั�มัสำัมัพ็ันธิก์ับก�รเปลี� ยนแปลง เป็นอย่�งยิ�งในก�รวัดัผู้ลด� นก�รเรียนร้� เช่น ก�รค์วับคุ์มัยับยั�ง (SMD 0.26 [95% CI: 0.08 to 0.45], p= < 0.01) หน่วัยค์วั�มัจัำ�ในก�รทำ�ง�น (SMD 0.10 [95% CI: -0.05 to 0.25], p= < 0.02) และค์วั�มัย่ดหยุ่นท�งค์วั�มัคิ์ด (SMD 0.14 [95% CI: -0.03 to 0.31], p= < 0.04) เปรียบเทียบกบัเม่ั�อไม่ัมีัก�ร ออกกำ�ลงัก�ยมั�แทรกแซง กิจักรรมัท�ง ก�ยยงัช่วัยลดค์วั�มัเสีำ�ยงที�จัะเผู้ชิญ่กบั ภั�วัะซม่ัเศร� และอ�ก�รซม่ัเศร� ในเด็ก และวัยัรุ่นที� เป็นและไม่ัเป็นโรค์ซม้ัเศัร�้ (35) และอ�จัเปรียบได�กับก�รบำ�บัด ท�งจิัตและท�งย�เพ่็�อลดอ�ก�รนั�น ๆ ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 38 แมั�ว่ั�กิจักรรมัท�งก�ยอ�จัมีัค์ว�มั เสีำ�ยงจ�กเหตุิไม่ัพง้ประสำงค์ ์(53) แต่ก็มีั ห ลัก ฐ � น อ ย่ � ง จัำ � กัด ที� ร � ย ง � น ถ่ง อันตร�ยที� เ กี� ยวัเน่� องกับระดับขีอง กิจักรรมัท�งก�ยที�แนะนำ�เพ่็�อสุำขีภั�พ็ที�ดี (35) จั�กหลกัฐ�นที� มีัอย่้และค์ำ�แนะนำ� ขีองผู้้�เชี�ยวัช�ญ่ ค์วั�มัเสีำ�ยงที�อ�จัเกิดขี่ �น นั�นเช่� อมัโยงกับปริมั�ณิและชนิดขีอง กิจักรรมัท�งก�ยที�แนะนำ�สำำ�หรบัเด็กและ วัยัรุ่นนั�นน�อยมั�ก และลดได�ด�วัยก�รเพิ็�มั ระดบักิจักรรมัและค์วั�มัหนกัหน่วังอย่�ง ต่อเน่�อง โดยเฉพ็�ะเด็กและวัยัรุ่นที�ไม่ัค่์อย ขียบัร่�งก�ย เป็นที� ร้�กนัว่ั�ก�รเขี� ร่วัมั กีฬ�บ�งประเภัทนั�นเพิ็�มัค์วั�มัเสีำ�ยงในก�ร บ�ดเจ็ับและเพิ็�มัค์วั�มัหนกัหน่วังในก�ร ออกกำ�ลงัก�ยด�วัย (53) เร�ต�องก�รง�น วิัจัยัเพิ็�มัเพ่็�อเสำริมัฐ�นค์วั�มัร้�ในเน่�อห�นี� ค์ณะทำ�ง�น GDG สำรุปว่� • มีั ห ลั ก ฐ � น ที� มีั ค์ วั � มั เ ช่� อ ถ่ อ ไ ด� ป�นกล�งว่ั� กิจักรรมัท�งก�ยที� ระดบัป�นกล�งและหนักเป็นระยะ เวัล�น�นเกี�ยวัโยงกบัค์วั�มัแข็ีงแรง ขี อ ง ก � ร ห มุั น เ วีั ย น โ ล หิ ต แ ล ะ กล� มัเน่�อ สุำขีภั�พ็หลอดเล่อดหัวัใจั และสุำขีภั�พ็กระด้กในเด็กและวัยัรุ่น • มีั ห ลั ก ฐ � น ที� มีั ค์ วั � มั เ ช่� อ ถ่ อ ไ ด� ป�นกล�งว่ั� กิจักรรมัท�งก�ยที�ระดบั ป�นกล�งและหนักทั�งระยะสำั�นและ ระยะย�วัมีัผู้ลดีต่อค์วั�มัสำ�มั�รถใน ก�รรบัร้�ผู้ลก�รเรียน และสุำขีภั�พ็จิัต • มีัหลกัฐ�นที� มีัค์วั�มัเช่�อถ่อได�น�อยว่ั� กิจักรรมัท�งก�ยมีัค์วั�มัเกี�ยวัเน่�องที� เอ่ �อต่อก�รจัดัก�รต่อสำภั�พ็นำ � หนกัที� เหมั�ะสำมัในเด็กและวัยัรุ่น เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) • มีัหลกัฐ�นที� มีัค์วั�มัเช่�อถ่อได�น�อยว่ั� ค์วั�มัเสีำ�ยงสำำ�หรบัปริมั�ณิและชนิด ขีองกิจักรรมัท�งก�ยที�แนะนำ�สำำ�หรบั เด็กและวััยรุ่นนั�นตำ� และมีันำ � หนัก เทียบไม่ัได�กบัคุ์ณิประโยชน์ มีัค์ว�มัเกี�ยวเนื�องเรื�องปริมั�ณหรือไม่ั ( ป ริ มั � ณ ร ะ ย ะ เ ว ล � ค์ ว � มั ถี� ค์ว�มัหนกัหน่วง) แมั�จัะมีัหลกัฐ�นมั�กมั�ยแสำดงให� เห็นว่ั�มีัก�รเช่�อมัโยงในท�งบวักระหว่ั�ง กิจักรรมัท�งก�ยและผู้ลลพั็ธิท์�งสุำขีภั�พ็ ในเด็กและวัยัรุ่น ง�นวิัจัยัน�อยชิ�นมั�กที� จัะกล่�วัถ่งประเด็นขีองก�รตอบสำนอง ต่อปริมั�ณิ แมั�กระนั�น ร้ปร่�งที�แน่นอน ขีองเสำ�นโค์�งก�รตอบสำนองต่อปริมั�ณิ และ/หร่อก�รมีัอย่้ขีองค่์�ขีีดจัำ�กัด (ที�แยกค์วั�มัแตกต่�งระหว่ั�งค์วั�มัเสีำ�ยง ที� ตำ� กว่ั�และส้ำงกว่ั�) สำำ�หรับกิจักรรมั ท�งก�ยและผู้ลลัพ็ธิต่์อสุำขีภั�พ็โดย เฉพ็�ะนั�น ยังมีัค์วั�มัเขี� ใจัน�อยกว่ั� สำำ �หรับเ ด็ กและวััย รุ่นเ ม่ั� อ เที ยบกับ ประช�กรผู้้� ใหญ่่ แต่อย่�งไรก็ต�มั มีัหลักฐ�นมั�กมั�ยแสำดงให� เห็นว่ั�มีั ประโยชนท์�งสุำขีภั�พ็มั�กมั�ยที� เกิดขี่ �น เม่ั�อทำ�กิจักรรมัท�งก�ยทุกวันัเป็นเวัล� 60 น�ที (22,35) และไม่ัมีัหลกัฐ�นแย�ง ในท�งอ่� น จั่งสำ รุป ได� ว่ั�หลักฐ�นที� ทัน สำ มััย นี� ไ ด� ย่ น ยัน ค์ำ � แน ะ นำ � ขี อ ง องค์ก์�รอน�มัยัโลกฉบบัปัจัจุับนั สำำ�หรบั กิจักรรมัท�งก�ยที�ระดบัป�นกล�ง-หนกั อย่�งน�อย 60 น�ทีต่อวันั 39 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) อย่�งไรก็ดี ก�รทบทวันหลกัฐ�น ทั�งหมัด ซ่�งรวัมัทั�งผู้ลล่�สุำดจั�กก�รวิัจัยัที� ใช�เค์ร่�องม่ัอวัดักิจักรรมัท�งก�ยด�วัยนั�น ไม่ัได�รับรองก�รรักษ�ขี�อกำ�หนดขีอง กิจั ก ร ร มั ท � ง ก � ย ขีั�น ตำ� � อ ย่ � ง น� อ ย 60 น�ที ทั�งในระดบักล�งและระดบัหนกั เพ่็�อสุำขีภั�พ็ที�ดี ชี �ให�เห็นว่ั�ง�นวิัจัยันั�นใช� “ค่์�เฉลี�ย” โดยกวั� ง 60 น�ทีต่อวันั ไม่ัใช่ ค่์�ขีอบเขีตขีั�นตำ� ประจัำ�วันัที� 60 น�ที เพ่็�อประเมิันประโยชนข์ีองกิจักรรมัท�ง- ก�ยต่อผู้ลลพั็ธิท์�งสุำขีภั�พ็ ก�รทบทวัน วัรรณิกรรมัสำรุปว่ั� ค์วัรแก�ไขีขี�อแนะนำ� ใหม่ัให�สำะท�อนหลกัฐ�นนี�อย่�งใกล�เคี์ยง ขี่ �น ประโยชนต่์อสุำขีภั�พ็หลอดเล่อด และหวััใจัจั�กก�รทำ�กิจักรรมัท�งก�ยที� ระดับหนักเป็นประจัำ�นั�นเป็นที� ร้�กันดี อย่้แล�วั และบทปริทัศนเ์ม่ั� อไม่ัน�นมั� นี�ยงัมีัหลกัฐ�นสำนับสำนุนเพิ็�มัเติมั (35) ตวััอย่�งเช่น บทปริทศัน ์(54) แสำดงให�เห็น ว่ั�ก�รออกกำ�ลงัที� มีัค์วั�มัเขี�มัขี�นส้ำงใน ระยะเวัล�สำั�น เทียบกบัก�รออกกำ�ลงัก�ย แบบต่อเน่�องที�ค์วั�มัเขี�มัขี�นป�นกล�งมีั ผู้ลในท�งบวักระดบัป�นกล�งต่อสุำขีภั�พ็ ก�รไหลเวีัยนโลหิต (SMD= 0.51 [95% CI: 0.33 to 0.69], p= < 0.01; I 2= 0%) ไม่ัมีัหลกัฐ�นว่ั�ระยะเวัล�ก�รแทรกแซง วิัธีิก�รออกกำ�ลงัก�ย อตัร�ก�รออกกำ�ลงั ก�ยและก�รพ็กัผู่้อน และช่วังขีองก�ร ออกกำ�ลงัก�ยจัะเปลี� ยนผู้ลขีองค์วั�มั แข็ีงแรงในก�รหมุันเวีัยนโลหิตได� ผู้ลก�ร ทดลองนี�สำอดค์ล�องกบับทปริทศันอ่์�น ๆ (22, 35, 47) และยิ�งรบัรองขี�อแนะนำ�ที�ว่ั� เด็กและวัยัรุ่นนั�นค์วัรทำ�กิจักรรมัที�ระดบั หนักเป็นประจัำ� เพ่็� อเสำริมัสำร� งค์วั�มั แข็ีงแรงขีองระบบไหลเวีัยนโลหิต ค์ณะทำ�ง�น GDG สำรุปว่� • หลกัฐ�นย่นยนัขี�อแนะนำ�ขีององค์ก์�ร อน�มััยโลกว่ั�ด�วัยก�รทำ�กิจักรรมั ท�งก�ยที�ระดบัป�นกล�งถง่หนกั 60 น�ทีต่อวันั • หลกัฐ�นรบัรองก�รแก�ไขีขี�อกำ�หนด เกี� ยวักับกิจักรรมัท�งก�ยตำ� � สุำด 60 น�ทีต่อวันัก่อนหน� นี�เป็นค่์�เฉลี�ย อย่�งน�อย 60 น�ทีต่อวันัต่อสำปัด�ห ์ ซ่�งสำะท�อนให�เห็นหลกัฐ�นได�ใกล�ชิด กว่ั� • มีัหลกัฐ�นที� มีัค์วั�มัน่�เช่�อถ่อระดบั ป�นกล�งว่ั� กิจักรรมัท�งก�ยที�ระดบั หนักเป็นระยะเวัล�น�นสำมััพ็ันธิก์บั ค์วั�มัแข็ีงแรงขีองระบบไหลเวีัยน โลหิตที�เพิ็�มัขี่ �น ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 40 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) ค์ ว � มั สำ ัมั พ ัน ธิ์ ์เ ป ลี� ย น แ ป ล ง ติ � มั ประเภทหรือข้อบข่้�ยข้องก�รทำ� กิจกรรมัท�งก�ยหรือไม่ั สำำ�หรับเด็กและวััยรุ่น กิจักรรมั ท�งก�ยรวัมัถ่ง ก�รละเล่น เกมั กีฬ� ก�รเดินท�ง สำนัทน�ก�ร วิัช�พ็ลศ่กษ� หร่ อ ก�ร ออ ก กำ � ลัง ก� ย วั�ง แ ผู้ นไวั� ในบริบทขีองกิจักรรมัในค์รอบค์รัวั โรงเรียน และชุมัชน อย่�งไรก็ดี ง�นวิัจัยั บ �ง ง � น เ ป รี ย บ เที ย บ ป ร ะ เ ภั ท หร่ อ ขีอบข่ี�ยขีองกิจักรรมัท�งก�ยในเด็ก และวัยัรุ่นโดยตรง ดงันั�นจัง่ไม่ัมีัหลกัฐ�น เพี็ยงพ็อที�จัะกำ�หนดว่ั� ค์วั�มัเกี�ยวัโยง ระหว่ั�งกิจักรรมัท�งก�ยและผู้ลลพั็ธิ ์ ท�งสุำขีภั�พ็ที�หล�กหล�ยเปลี�ยนแปลง ต � มั ป ร ะ เ ภั ท ขี อ ง กิ จั ก ร ร มั ( เ ช่ น ก�รออกกำ�ลังแบบแอโรบิค์กับก�ร ออกกำ�ลังก�ยเพ่็� อเสำริมักล� มัเน่�อ) หร่อขีอบข่ี�ยขีองกิจักรรมัท�งก�ย (เช่น ก�รเดินท�งอย่�งค์ล่องแค์ล่วั (ก�รเดินและก�รปั� นจัักรย�น) และ วิัช�พ็ลศ่กษ�เปรียบเทียบกบัก�รกีฬ�/ สำนัทน�ก�ร) มีัหลักฐ�นที� แสำดงว่ั� ทั�งระดับ กิจักรรมัท�งก�ยแบบแอโรบิกที�ระดบั ป�นกล�งถ่งระดับหนักเช่� อมัโยงกับ ระบบก�รไหลเวีัยนโลหิตที�แข็ีงแรงขี่ �น และกิจักรรมัสำร� งค์วั�มัแข็ีงแรงให�กบั กล� มัเน่�อที� เพิ็� มัขี่ �นนั�น จัะเสำริมัค์วั�มั แข็ีงแรงขีองกล� มัเน่�อในเด็กและวัยัรุ่น หลักฐ�นชิ�นนี�ร�ยง�นว่ั� ขี�อแนะนำ� ระดบัสำ�กลด� นกิจักรรมัท�งก�ยเพ่็� อ สุำขีภั�พ็ขีององค์ก์�รอน�มัยัโลกฉบบัปี 2553 (1) ซ่�งแนะนำ�ก�รรวัมักิจักรรมัสำร� ง ค์วั�มัแข็ีงแรงให�กบักล� มัเน่�อและกระด้ก อย่�งน�อย 3 วันัต่อสำปัด�ห ์หลกัฐ�นที�ปรบั ให�เป็นปัจัจุับนัย่นยนัว่ั�กิจักรรมัย่ดหยุ่น กล� มัเน่�อ 3 วันัต่อสำปัด�หมี์ัประสิำทธิิภั�พ็ ที� จัะปรับปรุงตัวับ่งชี�ค์วั�มัแข็ีงแรง กล� มัเน่�อ อย่�งไรก็ต�มั ไม่ัมีัหลกัฐ�น เพี็ยงพ็อที�จัะแสำดงร�ยละเอียดเฉพ็�ะ ขีองช่วังค์วั�มัต่อเน่� องและค์วั�มัหนัก- หน่วัง ซ่�งเป็นผู้ลส่ำวันใหญ่่มั�จั�กค์วั�มั ต่�งขีองระยะเวัล�ต�มัที� ประเมิันไวั�ใน วัรรณิกรรมั (22, 35) มีัหลักฐ�น น� อ ย ชิ� น ใ น เ ร่� อ ง ขี อ ง ผู้ ล ก ร ะ ท บ เชิงป้องกนัขีองก�รออกกำ�ลงัก�ยแบบ ออกแรงต� นต่อสุำขีภั�พ็หลอดเล่อดและ หวััใจั และเป็นไปไม่ัได�ที�จัะระบุขี�อม้ัลเพิ็�มั เติมั เช่น เร่�องระยะเวัล� ด�วัยก�รให�ค์วั�มั สำำ�ค์ัญ่ส่ำวันที� ห�ยไปสำำ�หรับขี�อม้ัลใหม่ั ในเร่�องขีองบุค์ลิกลกัษณิะมั�กกว่ั�ค์วั�มั- ถี� ในก�รทำ�กิจักรรมัสำร� งค์วั�มัแข็ีงแรง ให�กับกล� มัเน่�อสำำ�หรับเด็กและวััยรุ่น ง�นวิัจััยในอน�ค์ตค์วัรกล่�วัถ่งคุ์ณิ ประโยชนด์� นสุำขีภั�พ็ขีองกิจักรรมัท�ง ก�ยเฉพ็�ะอย่�งและขีอบข่ี�ย เพ่็�อให�มีั ขี�อม้ัลจัำ�เพ็�ะขีองขี�อแนะนำ�ในส่ำวันนี�เพิ็�มั มั�กขี่ �น ค์ณะทำ�ง�น GDG สำรุปว่� • มีัหลกัฐ�นเช่�อถ่อได�ระดบัป�นกล�ง ว่ั� ค์วัรทำ�กิจักรรสำร� งค์วั�มัแข็ีงแรง ให�กับกล� มัเน่�ออย่�งน�อย 3 วััน ต่อสำปัด�ห์ 41 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) ข้้อแนืะนืำ� ด้็�นืพฤติิกิรัรัมเนืือยนิื�ง พ็ฤติกรรมัเน่อยนิ�ง ค่์อ เวัล�ที�ใช�ไปกบัก�รนั�งนิ�งหร่อนอนลง โดยมีัก�รใช�พ็ลงัง�นแต่น�อย ขีณิะต่�น ในสำภั�พ็แวัดล�อมัที�โรงเรียน บ� น ชุมัชน และก�รเดินท�ง หลกัฐ�นสำนบัสำนุนและเหตุิผล พ็ฤติกรรมัเน่อยนิ�งนั�นไม่ัได�มีัก�รกล่�วัถง่ไวั�ในขี�อแนะนำ�ขีององค์ก์�รอน�มัยัโลกปี 2553 แต่ในช่วังทศวัรรษที�ผู่้�นมั� มีัองค์ก์�รวิัจัยัที�เพิ็�มัขี่ �นในก�รตรวัจัสำอบผู้ลลพั็ธิต่์อสุำขีภั�พ็ที�เกี�ยวัเน่�อง กบัมั�ตรวัดัและชนิดขีองพ็ฤติกรรมัเน่อยนิ�งที�หล�กหล�ย เทค์โนโลยีและก�รส่ำ�อสำ�รแบบดิจิัทลั กำ�หนดว่ั� ผู้้�ค์นจัะทำ�ง�น เรียน เดินท�ง และใช�เวัล�พ็กัผู่้อนอย่�งไร ในประเทศส่ำวันใหญ่่ เด็กและ วัยัรุ่นใช�เวัล�ส่ำวันใหญ่่ไปกบัพ็ฤติกรรมัเน่อยนิ�ง โดยเฉพ็�ะก�รสำนัทน�ก�ร เช่น ค์วั�มับนัเทิง ผู่้�นหน� จัอ (โทรทศันแ์ละค์อมัพิ็วัเตอร)์ และก�รส่ำ�อสำ�รแบบดิจิัทลั เช่น โทรศพั็ทม่์ัอถ่อ สำำ�หรบัขี�อแนะนำ�เพ่็�อเด็กและวัยัรุ่นนี� มีัก�รทบทวันวัรรณิกรรมัอย่�งเป็นระบบ (24, 25) และใช�บทปริทศันเ์พิ็�มัใหม่ัอีก 7 ฉบบัที�ตรวัจัสำอบแล�วัว่ั�เขี� เกณิฑ์ก์�รนำ�ขี�อม้ัลเขี� ร�ยละเอียด ค์รบถ�วันเกี�ยวักบักระบวันวิัธีิ ก�รแยกขี�อม้ัล และชุดขี�อม้ัลหลกัฐ�นอย่้ที�ภั�ค์ผู้นวักบนเว็ับไซต ์ : ชุดขี�อม้ัลหลกัฐ�น5 พ็ฤติกรรมัเน่อยนิ�งในวัยัเด็กและวัยัรุ่นที�เพิ็�มัขี่ �นมั�นั�นต�มัมั�ด�วัยผู้ลเสีำยต่อสุำขีภั�พ็ ดงันี� ภั�วัะโรค์อ�วันที�เพิ็�มัขี่ �น สุำขีภั�พ็หลอดเล่อดหวััใจั ค์วั�มัแข็ีงแรง ค์วั�มัประพ็ฤติ พ็ฤติกรรมั เอ่ �อสำงัค์มัที�แย่ลง และช่วังเวัล�นอนหลบัที�ลดลงด�วัย แนะนำ�ให:้ เด็กและวยัรุ่นค์วรจำ�กดัเวล�ที�มีัพฤติิกรรมัเนือยนิ�ง โดยเฉพ�ะเวล�ที�อย่้กบั หน�้จอเพื�อค์ว�มับนัเทิง แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได�ตำ� > ข้้อัแนะนำา 5 ข้้อม่ัลออนไลน์ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 42 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) อะไรคื์อค์ว�มัสำมััพนัธิ์ร์ะหว่�งพฤติิ- กรรมัเนือยนิ�งและผลต่ิอสุำข้ภ�พในเด็ก และวยัรุ่น (อ�ยุ 5-17 ปี) ห ลัก ฐ � น บ่ ง ชี�ว่ั � เวั ล � ที� ใ ช�กับ พ็ฤติกรรมัเน่อยนิ� งที� เพิ็� มัมั�กขี่ �นนั�น โดยเฉพ็�ะเวัล�ที�อย่้กบัหน� จัอ สำมััพ็นัธิ ์ กบัผู้ลลพั็ธิต่์อสุำขีภั�พ็ที�แย่ลง (24, 35) ตวััอย่�งเช่น เวัล�ที�อย่้กบัหน� จัอที�ย�วั น�นขี่ �น (รวัมัถง่เวัล�ด้โทรทศัน)์ เช่�อมัโยง กบัสุำขีภั�พ็และสุำขีภั�พ็ด� นหลอดเล่อด หัวัใจัที�แย่ลงในเด็กและวัยัรุ่น หลกัฐ�น จั�กก�รประเมิันค์วั�มัเช่� อมัโยงด�วัย อุปกรณิร์ะหว่ั�งก�รศ่กษ�พ็ฤติกรรมั เน่อยนิ�งและก�รแทรกแซงแสำดงให�เห็น ถ่งผู้ลกระ ทบป�นกล�ง แมั� ว่ั�จัะมีั ผู้ลกระทบมั�กกว่ั�กบัผู้้�ที� มีัภั�วัะนำ � หนกั เกิน (55) มีัหลกัฐ�นอย่้จัำ�กดัที� ชี �ให�เห็น ว่ั�พ็ฤติกรรมัเน่อยนิ�งไม่ัมีัผู้ลต่อสุำขีภั�พ็ กระด้กในเด็กและวัยัรุ่น แมั�จัะมีัผู้ลก�รทดลองที� หล�ก- ห ล � ย มั � ก ขี่ �น แ ต่ ห ลักฐ � น ยัง ชี�ว่ั � พ็ฤติกรรมัเน่อยนิ� งอ�จัเช่� อมัโยงกับ ก�รวััดภั�วัะโรค์อ�วันที� ไม่ัน่�พ็่งพ็อใจั (24, 25) บทปริทศันชิ์�นหน่� งเกี� ยวักบั ก�รวิัจััยขี� มักลุ่มัขีน�ดใหญ่่ร�ยง�น ว่ั� พ็ฤติกรรมัเน่อยนิ� งที� มั�กกว่ั� 2 ชั� วัโมังต่อวันั (วัดัจั�กเวัล�ทั�งหมัดที� ใช� อย่้กบัหน� จัอ) นั�นเกี�ยวัเน่�องในเชิงบวัก กบัภั�วัะโรค์อ�วัน/นำ � หนกัเกินในวัยัเด็ก เม่ั�อเทียบกบัระดบัที�ตำ� กว่ั� (น�อยกว่ั� 2 ชั�วัโมังต่อวันั) (56) อย่�งไรก็ดี บทปริทศัน ์ ที�มั�จั�กง�นวิัจัยัแบบขี� มักลุ่มัจัำ�นวัน 20 ชิ �นไม่ัพ็บว่ั�มีัก�รเช่� อมัโยงอย่�งมีันัย- สำำ �ค์ัญ่ท�งสำถิติระหว่ั�งก�รนั� ง เ ล่น วีัดีโอเกมัอย่้เฉย ๆ กับดัชนีมัวัลก�ย ในเด็กและวัยัรุ่น บทปริทศันที์�ทบทวัน ง�นวิัจัยั 29 ชิ �นอย่�งเป็นระบบสำรุปว่ั� ง�นวิัจัยัหล�ยชิ�นร�ยง�นค์วั�มัเช่�อมัโยง ที� ไม่ัน่�พ็ง่พ็อใจัระหว่ั�งพ็ฤติกรรมัเน่อย นิ� งและเค์ร่� องบ่งชี�ภั�วัะ โรค์อ�วันใน เย�วัชน เม่ั�อพ็ฤติกรรมันั�นร�ยง�นด�วัย ก�รบนัท่กด�วัยตนเองระหว่ั�งเวัล�ที�อย่้ กบัหน� จัอ (55) อย่�งไรก็ต�มั บทปริทศัน ์ ระบุว่ั� ค์วั�มัสำำ�ค์ญั่ขีองก�รเช่�อมัโยงยงัมีั อย่้น�อยและแทบจัะเป็น 0 สำำ�หรบัก�ร วิัจัยัที�ประเมิันพ็ฤติกรรมัเน่อยนิ�งโดยใช� เค์ร่� องม่ัอ ก�รวิัจัยัก�รแทรกแซงชี�ให� เห็นผู้ลกระทบน�อยมั�ก แมั�ว่ั�จัะมีัผู้ล กระทบที�ร� ยแรงกว่ั�สำำ�หรบัผู้้�ที� มีัภั�วัะ นำ � หนักเกิน (55) ง�นวิัจััยเพิ็� มัเติมั เ กี� ย วั กั บ ค์ วั � มั เ ช่� อ มั โ ย ง ร ะ ห ว่ั � ง พ็ฤติกรรมัเน่อยนิ�งและก�รวัดัไขีมันันั�น มีัค์วั�มัจัำ�เป็น แมั�ว่ั�จัะยงัอย่้ในขีั�นตอนก�รรวับ รวัมัประเด็นในก�รวิัจัยั หลกัฐ�นบ�งชิ�น ชี �ว่ั�อ�จัมีัค์วั�มัเกี� ยวัเน่� องในท�งลบ ระหว่ั�งพ็ฤติกรรมัเน่อยนิ� งกับค์วั�มั เป็นอย่้และคุ์ณิภั�พ็ชีวิัต รวัมัถ่งค์วั�มั สำมััพ็ันธิที์� ไม่ัน่�พ็่งพ็อใจัระหว่ั�งค์วั�มั ซ่มัเศร� กบัเวัล�พ็กัผู่้อนหน� จัอในเด็ก และวััย รุ่น (58, 59) ตัวัอย่�งเช่น ระยะเวัล�ขีองพ็ฤติกรรมัเน่อยนิ� งที� ย�วัน�นขี่ �น ประเมิันจั�กเวัล�ที�อย่้กบั หน� จัอและก�รใช�ค์อมัพิ็วัเตอร์บ�ง ร้ปแบบ อ�จัสำมััพ็นัธิก์บัสุำขีภั�พ็จิัตที�แย่ลง 43 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) (24) ในบทปริทศันอี์กชิ�นเม่ั� อเร็วั ๆ นี� ค์วั�มัเช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อย นิ�งและอ�ก�รวิัตกกงัวัลนั�นพ็บได�ในง�น วิัจัยั 5 จั�ก 8 ชิ �น แมั�ว่ั�ผู้ลจัะไม่ัค์งที�จั�ก ก�รวัดัพ็ฤติกรรมัเน่อยนิ� งที� ต่�งกนัใน ง�นวิัจัยัเหล่�นั�น(60) หลกัฐ�นอ่�นชี�ว่ั� ระยะเวัล�ก�รด้โทรทศันแ์ละก�รเล่นเกมั วิัดีโอที� ย�วัน�นขี่ �นเกี� ยวัเน่� องอย่�งยิ� ง กับ ก � ร วััด ผู้ ล ขี อ ง ค์ วั � มั ป ร ะ พ็ ฤ ติ / พ็ฤติกรรมัเอ่ �อสำังค์มัที� ไม่ัน่�พ็่งพ็อใจั (24) และก�รใช�เวัล�อย่้กบัหน� จัอและ ด้โทรทัศน์ที� ย�วัน�นขี่ �นนั�นสำัมัพ็ันธิ ์ กับค์วั�มัต่อเน่� องในก�รนอนหลับที� สำั�นลง แมั�ว่ั�จัะ ไม่ัมีัค์วั�มัเกี� ยวัเน่� อง ระหว่ั�งก�รใช�ค์อมัพิ็วัเตอร ์ก�รเล่นเกมั และค์วั�มัต่อเน่�องในก�รนอนหลบั (61) ก�รค์�นห�ค์วั�มัสำมััพ็นัธิร์ะหว่ั�งพ็ฤติ- กรรมัเน่อยนิ�งและสุำขีภั�พ็จิัตเป็นสำ�ขี� วิัช�ที� พ็ัฒน�อย่�งรวัดเร็วั และอ�จัมีั สำ�เหตุกลบักนักบัที� ค์�ดไวั�ในหลกัฐ�น ก�รวิัจััยเพิ็� มัเติมันั�นค์วัรมีัเพ่็� อชี �แนะ ขี�อแนะนำ�และค์วั�มัแข็ีงแกร่งขีองค์วั�มั เกี�ยวัเน่�องนี� ค์ณะทำ�ง�น GDG สำรุปว่�: • มีั ห ลั ก ฐ � น ที� มีั ค์ วั � มั น่ � เ ช่� อ ถ่ อ น�อยที� กล่�วัว่ั� พ็ฤติกรรมัเน่อยนิ� ง (เวัล�ที�อย่้กบัหน� จัอ) ที� มีัระยะเวัล� ย�วัน�นขี่ �นเกี� ยวัเน่� องอย่�งมีันัย สำำ�ค์ญั่กบัค์วั�มัแข็ีงแรงท�งก�ยภั�พ็ และสุำขีภั�พ็หลอดเล่อดหัวัใจัที�ตำ� ลง ในเด็กและวัยัรุ่น • มีัหลกัฐ�นที�มีัค์วั�มัน่�เช่�อถ่อตำ� มั�ก จันถง่ป�นกล�งที�กล่�วัว่ั� พ็ฤติกรรมั เน่อยนิ� ง (เวัล�หน� จัอ ด้โทรทัศน ์ และก�รเล่นวีัดีโอเกมั) ที�มีัระยะเวัล�ที� ย�วัน�นขี่ �นมีัค์วั�มัเกี�ยวัเน่�องอย่�งมีั นัยสำำ�ค์ญั่กบัก�รวัดัผู้ลที� ไม่ัเอ่ �อต่อ สุำขีภั�พ็จิัตและก�รประพ็ฤติตน/ พ็ฤติกรรมัเอ่ �อสำงัค์มัในเด็กและวัยัรุ่น • มีัหลักฐ�นที� มีัค์วั�มัน่�เช่� อถ่อตำ� ที� กล่�วัว่ั� เวัล�ที�ใช�ในพ็ฤติกรรมัเน่อยนิ�ง ( เวั ล � ที� อ ย่้ กับ ห น� จั อ แ ล ะ ก � ร ด้ โทรทศัน)์ ที�มั�กขี่ �นนั�นเกี�ยวัเน่�องกบั ผู้ลกระทบที�เป็นอนัตร�ยต่อค์วั�มัต่อ- เน่�องในก�รนอนในเด็กและวัยัรุ่น • ประโยชนข์ีองก�รจัำ�กดัพ็ฤติกรรมั เน่อยนิ�งสำำ�หรบัเด็กและวัยัรุ่นมีัมั�ก กว่ั�ขี�อเสีำย มีัค์ว�มัสำมััพนัธิ์ข์้องก�รติอบสำนองต่ิอ ปริมั�ณ (ปริมั�ณ ค์ว�มัต่ิอเนื� อง ค์ว�มัถี� ค์ว�มัหนักหน่วงข้องก�ร ข้ดัข้ว�ง) หรือไม่ั มีัหลกัฐ�นไม่ัเพี็ยงพ็อที�จัะกำ�หนด ได�ว่ั�มีัค์วั�มัสำมััพ็นัธิ ์ในก�รตอบสำนอง ระหว่ั�งเวัล�ที�มีัพ็ฤติกรรมัเน่อยนิ�ง (รวัมั ถง่เวัล�หน� จัอเพ่็�อก�รสำนัทน�ก�ร) และ ผู้ลลัพ็ธิต่์อสุำขีภั�พ็ในเด็กและวััยรุ่น หลกัฐ�นส่ำวันใหญ่่ที�ประเมิันค์วั�มัเกี�ยวั- เน่� องระหว่ั�งพ็ฤติกรรมัเน่อยนิ� งและ ผู้ลลพั็ธิต่์อสุำขีภั�พ็ในเด็กและวัยัรุ่นจัะ เป็นก�รวิัจััยขี� มักลุ่มั และมีัหลักฐ�น ที� มีัค์วั�มัน่�เช่� อถ่อตำ� ต�มัขี�อม้ัลขีอง GRADE และง�นวิัจัยัส่ำวันใหญ่่ขี่ �นอย่้กบั ก�รวัดัผู้ลเวัล�ที� มีัพ็ฤติกรรมัเน่อยนิ� ง จั�กก�รร�ยง�นด�วัยตนเองหร่อพ่็อแม่ั ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 44 ซ่�งอ�จัมีัขี�อผิู้ดพ็ล�ดในก�รวัดัและค์วั�มั เอนเอียงในก�รระลก่ขี�อม้ัล อย่�งไรก็ต�มั หลกัฐ�นที� กล่�วัว่ั� ก�รลดพ็ฤติกรรมั เน่อยนิ� งส่ำงผู้ลดีต่อสุำขีภั�พ็และค์วั�มั- สำมััพ็นัธิร์ะหว่ั�งพ็ฤติกรรมัเน่อยนิ�งกบั ผู้ลเสีำยต่อสุำขีภั�พ็นั�น มีั อิทธิิพ็ลต่อ ประเภัทพ็ฤติกรรมัเน่อยนิ�งมั�กกว่ั�ระยะ เวัล�ขีองพ็ฤติกรรมัเน่อยนิ�งทั�งหมัด เม่ั�อ ตวััแปรต�นค่์อก�รด้โทรทศันห์ร่อก�รใช� เวัล�อย่้กบัหน� จัอ อย่�งไรก็ต�มั หลกัฐ�น ทั�งหมัดไม่ัเพี็ยงพ็อที�จัะสำนบัสำนุนก�รระบุ เวัล�ที�จัำ�กดั หลักฐ�นที� พ็ฤติกรรมัเน่อยนิ� ง เช่�อมัโยงกบัผู้ลร� ยต่อสุำขีภั�พ็อ�จัเป็น ผู้ลทั�งจั�กผู้ลกระทบจั�กพ็ฤติกรรมั- เน่อยนิ�งโดยตรง ก�รแทนที�เวัล�ที�ใช�กบั กิจักรรมัท�งก�ยมั�กขี่ �น หร่อทั�งสำอง อย่�ง แมั�จัะมีัก�รวิัจัยัที� ร�ยง�นค์วั�มั เช่�อมัโยงระหว่ั�งเวัล�ที�อย่้กบัหน� จัอและ ผู้ลร� ยต่อสุำขีภั�พ็ในเด็กและผู้้�ใหญ่่ เวัล� ขีองก�รมีัพ็ฤติกรรมัเน่อยนิ� งทั�งหมัด ( ป ร ะ เ มิั นในง � นวิัจััย โ ด ย ใช�ก� ร วััด พ็ฤติกรรมัเน่อยนิ�งด�วัยเค์ร่�องม่ัอ) ไม่ัได�มีั ค์วั�มัเกี�ยวัโยงอย่�งต่อเน่�องกบัผู้ลลพั็ธิ ์ ท�งสุำขีภั�พ็ เม่ั�อนำ�เวัล�ในก�รทำ�กิจักรรมั ท�งก�ยที� ระดับป�นกล�งถ่งหนักมั� พิ็จั�รณิ�ด�วัย (62) ในท�งกลับกัน หลกัฐ�นที� เช่� อมัโยงกิจักรรมัท�งก�ย ระดบักล�งถง่หนกักบัผู้ลลพั็ธิด์� นดีต่อ สุำขีภั�พ็นั�นเด่นชดั และได�รบัก�รบนัท่ก ไวั�เป็นอย่�งดีตลอดสำภั�พ็แวัดล�อมัที�ตรง กันขี� มั เช่น ก�รทดแทนพ็ฤติกรรมั เน่อยนิ� งด�วัยกิจักรรมัท�งก�ย ( โดย เฉพ็�ะอย่�งยิ�งกิจักรรมัท�งก�ยที�ระดบั ป�นกล�ง-หนกั) อ�จัทำ�ให�สุำขีภั�พ็ดีขี่ �นได� ก�รวิัจัยัที�ตรวัจัสำอบค์วั�มัเช่�อมัโยง และผู้ลกระทบระหว่ั�งพ็ฤติกรรมัเน่อย นิ� ง กิจักรรมัท�งก�ย และผู้ลลพั็ธิท์�ง สุำขีภั�พ็นั�นเติบโตขี่ �นอย่�งรวัดเร็วั และ หลกัฐ�นจั�กก�รวัดัพ็ฤติกรรมัเน่อยนิ�ง และสุำขีภั�พ็หลอดเล่อดหวััใจัด�วัยอุปกรณิ ์ ที�แสำดงให�เห็นถง่ค์วั�มัเช่�อมัโยงนั�นน�อย มั�ก เม่ั� อนำ�กิจักรรมัท�งก�ยที� ระดับ ป�นกล�งถง่หนกัมั�พิ็จั�รณิ� (ตวััอย่�ง เช่น ปรบัค่์�ท�งสำถิติ) (62-64) ดงันั�นจัง่ ต�องมีัก�รวิัจัยัต�มัแผู้นโดยใช�ก�รวัดัก�ร เขี� ถง่ด�วัยอุปกรณิเ์พ่็�อทำ�ให�ค์วั�มัร้�เกี�ยวั กับค์วั�มัเกี� ยวัเน่� องนี�ก� วัหน� และให� ค์ำ�แนะนำ�เพิ็�มัเติมัในอน�ค์ตได� ค์ณะทำ�ง�น GDG สำรุปว่�: • มีัหลกัฐ�นที� เช่�อถ่อได�น�อยที�กล่�วัว่ั� เวัล�ขีองพ็ฤติกรรมัเน่อยนิ�งที�มั�กขี่ �น สำมััพ็นัธิก์บัผู้ลลพั็ธิท์�งสุำขีภั�พ็ที�แย่ลง • มีัหลกัฐ�นไม่ัเพี็ยงพ็อที�จัะระบุเจั�ะ จังถ่งระยะเวัล�จัำ�กดัสำำ�หรบัพ็ฤติ- กรรมัเน่อยนิ�ง • ก�รทดแทนเวัล�ขีองพ็ฤติกรรมั เน่อยนิ�งด�วัยกิจักรรมัท�งก�ยที�ระดบั ป�นกล�งถง่หนกัจัะมีัผู้ลดีต่อสุำขีภั�พ็ เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) 45 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) ค์ว�มัสำมััพนัธิ์เ์ปลี� ยนแปลงไปติ�มั ประเภทและข้อบเข้ติข้องพฤติิกรรมั เนือยนิ�งหรือไม่ั ก�รศ่กษ�เร่� องผู้ลกระ ทบต่อ สุำขีภั�พ็จั�กพ็ฤติกรรมัเน่อยนิ�งเป็นก�ร วิัจัยัที� ค่์อนขี� งใหม่ั เช่นนี�แล�วั ผู้ลก�ร ทดลองนี�มั�จั�กก�รวิัจัยัที� ใช�เค์ร่�องม่ัอ และก�รวััดระยะเวัล�ในก�รเปิดรับที� แตกต่�งกนั ก�รเปิดรบัที�ประเมิันเป็น “เวัล�ทั�งหมัดที�ใช�ในพ็ฤติกรรมัเน่อยนิ�ง” มัักจัะถ้กใช�กับเวัล�ขีองก�รทำ�พ็ฤติ- กรรมัเน่อยนิ� งขีณิะใช� “หน� จัอ” หร่อ “ด้โทรทศัน”์ หลกัฐ�นที�มีัอย่้แสำดงให�เห็น ว่ั� ค์วั�มัเช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อย นิ�งและผู้ลลบต่อสุำขีภั�พ็นั�น โดยทั�วัไปแล�วั จัะหนักไปที� ก�รด้โทรทัศน์หร่อเวัล� หน� จัอเพ่็�อค์วั�มับนัเทิงมั�กกว่ั�เวัล�ขีอง ก�รทำ�พ็ฤติกรรมัเน่อยนิ�งทั�งหมัด (24, 35) ก�รใช�ก�รประเมิันพ็ฤติกรรมัเน่อย- นิ�งโดยใช�เค์ร่�องม่ัอที� เพิ็�มัมั�กขี่ �นในง�น วิัจัยัหล�ย ๆ ชิ �นในช่วังนี�เป็นค์วั�มัร้�ที�ก� วั หน� และเม่ั�อผู้นวักกบัก�รร�ยง�นอย่�งมีั มั�ตรฐ�นก็จัะช่วัยแจั�งขี�อม้ัลแก่ขี�อ แนะนำ�ในอน�ค์ตได� เป็นที� ร้�กนัว่ั�พ็ฤติกรรมัเน่อยนิ� ง ไ ม่ั ไ ด� อั น ต ร � ย ไ ป เ สีำ ย ทั� ง ห มั ด มีัหลักฐ�นที� ชี �ว่ั�พ็ฤติกรรมัเน่อยนิ� ง บ�งอย่�ง เช่น ก�รอ่�นหนงัส่ำอ ทำ�ก�รบ� น นอกห�องเรียน เกี�ยวัเน่�องกบัค์วั�มัสำำ�เร็จั ท�งก�รศ่กษ�ที� ส้ำงขี่ �น บ่งชี�ว่ั�มีัค์วั�มั แตกต่�งขีองผู้ลที�ขี่ �นอย่้กบักิจักรรมันั�น ๆ (24, 25) พ็ฤติกรรมัเน่อยนิ� งอ�จัรวัมั ถ่งเวัล�ที� ใช�ในก�รแสำวังห�ก�รศ่กษ�/ ก�รเรียน หร่อก�รเล่นเงียบ ๆ หร่อก�ร มีัปฎิสำมััพ็นัธิท์�งสำงัค์มัโดยปร�ศจั�กส่ำ�อ อิเลค์ทรอนิค์สำ ์ ก�รดำ�เนินก�รเหล่�นี� (เช่น ก�รอ่�นหนงัส่ำอ เล่นเกมัปริศน� ก�รวั�ดร้ป ก�รทำ�ง�นฝีึม่ัอ ก�รร�องเพ็ลง เล่นดนตรี) เป็นสิำ�งสำำ�ค์ญั่สำำ�หรบัพ็ฒัน� ก�รขีองเด็กและมีัประโยชน์ทั�งด� น ค์วั�มัคิ์ดและอ่�น ๆ ค์ณะทำ�ง�น GDG พบว่�: • กิจักรรมัที�มีัก�รทำ�พ็ฤติกรรมัเน่อยนิ�ง บ�งอย่�งนั�น มีัประ โยชน์ต่อก�ร ทำ�ง�นด� นค์วั�มัคิ์ดและปฏิิสำมััพ็นัธิ ์ ท�งสำงัค์มัในเด็กและวัยัรุ่น • หลกัฐ�นเกี�ยวักบัผู้ลเสีำยต่อสุำขีภั�พ็ จั�กพ็ฤติกรรมัเน่อยนิ�งนั�นมักัจัะเน�น ไปที� เวัล�ด้โทรทศันห์ร่อเวัล�ที�อย่้กบั หน� จัอเพ่็�อค์วั�มับนัเทิงมั�กกว่ั�เวัล� ที�มีัก�รทำ�พ็ฤติกรรมัเน่อยนิ�งทั�งหมัด ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 46 กิจักรรมัท�งก�ยในผู้้�ใหญ่่เอ่ �อประโยชนต่์อผู้ลลพั็ธิท์�งสุำขีภั�พ็ดงันี� กิจักรรมัท�งก�ย สำ�มั�รถป้องกนัก�รเสีำยชีวิัตจั�กทุกสำ�เหตุที�รวัมัถ่งโรค์หลอดเล่อดหัวัใจั ภั�วัะค์วั�มั- ดนัโลหิตส้ำง ก�รเกิดมัะเร็งเฉพ็�ะจุัด เบ�หวั�นชนิดที� สำอง สุำขีภั�พ็จิัต (ลดอ�ก�ร กงัวัลและซม่ัเศร� ) สุำขีภั�พ็สำมัอง และก�รนอนหลบั และก�รวัดัภั�วัะโรค์อ�วันก็จัะดีขี่ �นด�วัย กิจักรรมัท�งก�ยสำำ�หรบัผู้้�ใหญ่่อ�จัเป็นได�ทั�งก�รสำนัทน�ก�รและก�ร พ็กัผู่้อน (ก�รละเล่น เกมัสำ ์กีฬ� หร่อก�รออกกำ�ลงัก�ยที�มีัก�รวั�งแผู้น ก�รเดินท�ง (เค์ร่�องยนตติ์ดล�อ ก�รเดิน ก�รปั� นจักัรย�น) ก�รทำ�ง�น หร่อก�รทำ�ง�นบ� น ในปริบทขีอง ก�รประกอบอ�ชีพ็ประจัำ�วันั ก�รเรียน ในพ่็�นที�บ� น หร่อพ่็�นที�ชุมัชน • ทำ�กิจักรรมัท�งก�ยบ� งย่อมัดีกว่ั�ไม่ัทำ�อะไรเลย • ห�กผู้้�ใหญ่่ไม่ัสำ�มั�รถทำ�ต�มัขี�อแนะนำ�ดงักล่�วัได� ก�รทำ�กิจักรรมัท�งก�ยบ� งจัะส่ำงผู้ลดีต่อ สุำขีภั�พ็ • ผู้้�ใหญ่่ค์วัรเริ� มัจั�กกิจักรรมัท�งก�ยที� ระดับเบ� แล�วัค่์อยเพิ็� มัค์วั�มัถี� ค์วั�มัหนักหน่วัง และระยะเวัล�ขี่ �น ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ข้้อแนืะนืำ�ด้็�นืกิิจกิรัรัมท�งกิ�ย แนะนำ�ให:้ ผ้ ใ้หญ่่ทุกค์นค์วรทำ�กิจกรรมัท�งก�ยท ั�วไปเป็นประจำ� แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได�ป�นกล�ง ผ้ ใ้หญ่่ค์วรทำ�กิจกรรมัท�งก�ยแบบแอโรบิกที�ระดบัป�นกล�งอย่�งนอ้ย 150-300 น�ที หรือที�ระดบัหนกัอย่�งนอ้ย 75-150 น�ที หรือผสำมัผสำ�นทั�ง 2 ระดบัอย่�งเท่�เทียมักนั ติลอดสำปัด�ห ์เพื�อสุำข้ภ�พที�ดีอย่�งต่ิอเนื�อง แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได�ป�นกล�ง ผ้ ใ้หญ่่ค์วรทำ�กิจกรรมัสำร�้งค์ว�มัแข็้งแรงใหก้บักล�้มัเนื �อ โดยใช้ก้ล�้มัเนื �อหลกัทุกส่ำวน ที�ระดบัป�นกล�งข้้ �นไป อย่�งนอ้ย 2 วนัต่ิอสำปัด�ห ์เพื�อผลดีต่ิอสุำข้ภ�พ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได�ป�นกล�ง ผ้ ้ใหญ่่สำ�มั�รถเพิ�มักิจกรรมัท�งก�ยแบบแอโรบิกที�ระดบัป�นกล�งใหม้ั�กกว่� 300 น�ที หรือที�ระดบัหนกัใหม้ั�กกว่� 150 น�ที หรือผสำมัทั�งระดบัป�นกล�งและระดบั หนกัอย่�งเท่�เทียมักนัติลอดทั�งสำปัด�ห ์เพื�อสุำข้ภ�พที�ดียิ�งข้้ �น แนะนำ�อย่�งมีัเง่�อนไขี มีัหลกัฐ�นที�เช่�อถ่อได�ป�นกล�ง > > > > ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ 47 หลกัฐ�นและเหตุิผลสำนบัสำนุน ขี�อแนะนำ�เหล่�นี�มีัก�รปรบัและนำ�ก�รสำงัเค์ร�ะหห์ลกัฐ�นที�จัดัทำ�โดยค์ณิะกรร- มั�ธิิก�รที�ปรก่ษ�ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ยขีองสำหรฐัอเมัริก� (PAGAC) มั�ใช� ค์ณิะทำ�ง�น GDG ได�พิ็จั�รณิ�หลกัฐ�นทั�งหมัด รวัมัถง่ผู้ลก�รวิัจัยัที�ร�ยง�นโดย PAGAC รวัมับทปริทศัน ์28 ชิ �น และก�รศก่ษ�ที�มีัก�รติดต�มักลุ่มัตวััอย่�งเป็นเวัล� น�นที�ทำ�ร่วัมักนั 3 ชิ �น ตีพิ็มัพ็จ์ั�กปีพ็.ศ. 2560 ไปจันถง่พ็ฤศจิัก�ยน พ็.ศ. 2562 ซ่�งตรงต�มักฎเกณิฑ์์ในก�รค์ดัขี�อม้ัลเขี� และสำร� งหลกัฐ�นเกี�ยวักบัค์วั�มัเช่�อมัโยง ระหว่ั�งกิจักรรมัท�งก�ยและผู้ลต่อสุำขีภั�พ็ในผู้้�ใหญ่่ นอกจั�กนี�บทปริทศันข์ีอง บทปริทศันอี์กชิ�นได�จัดัทำ�ขี่ �นเพ่็�อชี �ให�เห็นถง่ช่องว่ั�งขีองหลกัฐ�นและก�รตรวัจัสำอบ 1) ค์วั�มัสำมััพ็นัธิร์ะหว่ั�งกิจักรรมัท�งก�ยต�มัอ�ชีพ็ (เช่น กิจักรรมัที�เกี�ยวัขี�องกบัง�น) และผู้ลลพั็ธิเ์กี�ยวัเน่�องกบัสุำขีภั�พ็ (40) และ 2) ค์วั�มัเกี�ยวัเน่�องระหว่ั�งกิจักรรมัท�ง ก�ยในขีอบเขีตขีองก�รพ็กัผู่้อนและผู้ลลบต่อสุำขีภั�พ็ (41) บทปริทศันที์�มั�จั�ก บทปริทศันอ่์� นนั�นแจักแจังบทปริทศันอ์ย่�งเป็นระบบจัำ�นวัน 36 ฉบบัและ 15 ฉบบั ต�มัลำ�ดบั หลกัฐ�นจั�กก�รศก่ษ�แบบสำงัเกตระยะย�วัและทดลองแบบมีัก�ร แทรกแซงนั�นจัะได�รบัค์วั�มัสำำ�ค์ญั่ก่อน และบทปริทศันที์�รวัมัหลกัฐ�นก�รจั�กก�ร เปรียบเทียบขี� มักลุ่มัเพี็ยงอย่�งเดียวัหร่อเป็นหลกัจัะไม่ัถ้กนำ�มั�พิ็จั�รณิ� นำ � หนกั ในก�รเน�นยำ�อย่้ที�หลกัฐ�นที�มั�จั�กบทปริทศันที์� ได�ระดบัค์วั�มัน่�เช่�อถ่อป�นกล�ง และมั�กกว่ั�นั�นและบทปริทศันที์� ได�หลกัฐ�นจั�กง�นวิัจัยัที�ใช�เค์ร่�องม่ัอวัดัก�รเปิดรบั ร�ยละเอียดวิัธีิวิัจัยั ก�รแยกขี�อม้ัล และชุดขี�อม้ัลหลกัฐ�นมีัอย่้ที�ภั�ค์ผู้นวักใน เว็ับไซต ์: ชุดขี�อม้ัลหลกัฐ�น6 ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) อะไรคื์อค์ว�มัเชื้�อมัโยงระหว่�งกิจกรรมั ท�งก�ยและผลที�เกี�ยวเนื�องกบัสุำข้ภ�พ ในผ้ ใ้หญ่่ (อ�ยุ 18-64 ปี) คื์ออะไร ค์วั�มัเช่� อมัโยงระหว่ั�งกิจักรรมั ท�งก�ยและก�รเสีำยชี้วิติจ�กทุกสำ�เหตุิ และก�รเสีำยชี้วิติจ�กโรค์หลอดเลือด หวัใจในผู้้�ใหญ่่นั�นเป็นที�ตระหนกักนัดีอย่้ แล�วั (1) ผู้ลก�รวิัจัยัจั�กบทปริทศันเ์ม่ั�อไม่ั น�นมั�นี�ย่นยนัว่ั� เม่ั�อเปรียบเทียบกบักิจั- กรรมัท�งก�ยในระดบัตำ� สุำด กิจักรรมั ท�งก�ยในระดบัที� ส้ำงกว่ั�จัะเช่�อมัโยงกบั ค์วั�มัเสีำ�ยงในก�รเสีำยชีวิัตที�ตำ� กว่ั� หลกั- ฐ�นชิ�นใหม่ัจั�กก�รวิัจัยัที�ใช�เค์ร่�องม่ัอวัดั กิจักรรมัท�งก�ยย่นยันและขีย�ยผู้ล หลกัฐ�นที�แสำดงว่ั�เม่ั�อเปรียบเทียบกบั กิจักรรมัท�งก�ยในระดบัตำ� สุำด กิจักรรมั ท�งก�ยในทุกระดบัและทุกค์วั�มัหนัก หน่วัง(รวัมัถ่งระดบัเบ�) เกี�ยวัเน่� องกบั ค์วั�มัเสีำ�ยงต่อก�รเสีำยชีวิัตที�ลดลง (65) ตวััอย่�งเปรียบเทียบกบัเม่ั�อเค์ล่�อนไหวั น�อยที�สุำด (referent, 1.00) อตัร�ก�รเต�น ขีองหัวัใจัที� ปรับสำำ�หรับค์วัอไทลข์ีอง กิจักรรมัท�งก�ยทั�งหมัดในทุกค์วัอไทล ์ 6 ข้้อม่ัลออนไลน์ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 48 ขีองกิจักรรมัท�งก�ย ค่์�ค์วัอไทลที์�สำอง (0.48 [95% CI: 0.43 to 0.54]) ค์วัอไทลที์�สำ�มั (0.34 [95% CI: 0.26 to 0.45]) และค์วัอไทลที์� สีำ� (0.27 [95% CI: 0.23 to 0.32]) (65) หลกัฐ�นใหม่ัยงัค์ง ย่นยนัถง่ค์วั�มัสำมััพ็นัธิแ์ปรผู้กผู้นัอย่�ง มัั�นค์ง (1) ระหว่ั�งกิจักรรมัท�งก�ยและ อนัติร�ยจ�กโรค์หลอดเลือดหวัใจ (66) ประโยชนจ์ั�กกิจักรรมัท�งก�ยใน ก�รลดก�รเกิดโรค์หลอดเล่อดหัวัใจั และค์วั�มัดันโลหิตได�มีัก�รบันท่กไวั� อย่�งดี (1) กิจักรรมัท�งก�ยส่ำงเสำริมัก�ร ตอบสำนองก�รทำ�ง�นขีองอวัยัวัะต่�ง ๆ ในร่�งก�ย ซ่� งทำ�ให�มีัก�รปรับระบบ ประสำ�ทส่ำวันกล�งและก�รหมุันเวีัยน โลหิตในระยะสำั�นและระยะย�วัที� เป็น ประโยชน ์เป็นผู้ลให�ค์วั�มัเสีำ�ยงขีองภ�วะ ค์ว�มัดนัโลหิติส้ำงซ่�งเป็นปัจัจัยัเสีำ�ยงหลกั ขีองโรค์หลอดเลือดหวัใจลดลง หลกัฐ�นเน�นยำ � ว่ั�มีัค์วั�มัสำมััพ็นัธิที์� ผู้กผู้ันระหว่ั�งกิจักรรมัท�งก�ยและ ผู้ลจั�กค์วั�มัดนัโลหิตส้ำงในผู้้�ใหญ่่ที� มีั ค์วั�มัดนัโลหิตปรกติ และกิจักรรมัท�ง ก�ยที�ลดค์วั�มัดนัโลหิตในผู้้�ใหญ่่ที�มีัภั�วัะ ก่อนจัะเป็นโรค์โลหิตส้ำงและค์วั�มัดัน โลหิตปรกติ (35) ค์วั�มัเกี�ยวัเน่�องในท�งตรงกนัขี� มั ระหว่ั�งกิจักรรมัท�งก�ยและโรค์เบ� หว�นช้นิดที�สำองที�ก่อตวััขี่ �นในผู้้�ใหญ่่นั�น เป็นที�ทร�บกนัดี (1) หลกัฐ�นเม่ั�อไม่ัน�น มั�นี�ย่นยนัค์วั�มัสำมััพ็นัธิแ์บบเป็นเสำ�นโค์�ง ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) หัวัค์วัำ� ระหว่ั�งกิจักรรมัท�งก�ยใน ปริมั�ณิที�มั�กขี่ �นและก�รเกิดเบ�หวั�น ชนิดที�สำอง (35) ด�วัยเสำ�นโค์�งที�ล�ดลง เม่ั� อมีัระดับกิจักรรมัท�งก�ยที� ส้ำงขี่ �น บทปริทศัน์ใหม่ัพ็บว่ั� ผู้ลกระทบนี�ค์งที� กบัทุกบุค์ค์ลที�มีัภ้ัมิัหลงัต่�งกนัด�วัยก�ร ลดค์วั�มัเสีำ� ยงขีองก�รก่อตัวัขีองโรค์ เบ�หวั�นชนิดที� สำองในระดบั “ส้ำงสุำด” เทียบกับ “ตำ� สุำด” ในกลุ่มัประช�กร ผิู้วัขี�วัที� ไม่ัมีัเช่ �อสำ�ยละติน (RR= 0.71 [95% CI: 0.60 to 0.85]) ช�วัเอเชีย (RR= 0.76 [95% CI: 0.67 to 0.85]) ช�วัละตินอเมัริก� (RR = 0.74 [95% CI 0.64 to 0.84]) และช�วัอเมัริกนัอินเดียน (RR = 0.73 [95% CI: 0.60 to 0.88]) แมั�ว่ั�ผู้ลกระทบสำำ�หรบักลุ่มัประช�กร ผิู้วัสีำ ไม่ัมีันัยสำำ�ค์ญั่ (RR = 0.91 [95% CI: 0.76 to 1.08]) (67) หลกัฐ�นชี�ว่ั� ไม่ัมีัก�รปรบัผู้ลกระทบด�วัยนำ � หนกั และ มีัค์วั�มัสำมััพ็นัธิที์�ผู้กผู้นัระหว่ั�งกิจักรรมั ท�งก�ยในปริมั�ณิที� ส้ำงขี่ �น และก�ร เกิดโรค์เบ�หวั�นชนิดที� สำองที� ลดลง สำำ�หรบัผู้้�ที� มีันำ � หนกัปรกติ นำ � หนกัเกิน หร่อมีัภั�วัะโรค์อ�วัน (35) ค์วั�มัสำมััพ็นัธิร์ะหว่ั�งกิจักรรมัท�ง ก�ยในระดับที� ส้ำงขี่ �นและค์วั�มัเสีำ� ยง ต่อมัะเร็งลำ�ไสำแ้ละมัะเร็งเติ�้นมัที�ลดลง นั�นเป็นที�ทร�บกนัดี (1) ในบททบทวัน หลกัฐ�นก่อนหน� นี�พ็บว่ั� กิจักรรมัท�ง- ก�ยในระดับที� ส้ำงขี่ �นนั�นเช่� อมัโยงกับ ค์วั�มัเสีำ� ยงที� ลดลงในก�รก่อตัวัขีอง มัะเร็งเต� นมัและมัะเร็งลำ�ไสำ� (1) ต�มัมั� ด�วัยก�รเพิ็�มัขี่ �นขีองง�นวิัจัยัในกิจักรรมั 49 ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ท�งก�ยและมัะเร็งอย่�งเจั�ะล่ก มีัหลกั ฐ�นใหม่ัที�แสำดงว่ั� ระดบักิจักรรมัท�งก�ย ส้ำงขี่ �นสำมััพ็นัธิก์บัค์วั�มัเสีำ�ยงที�ลดลงขีอง โรค์มัะเร็งกระเพ็�ะปัสำสำ�วัะ มัะเร็งเย่�อบุ โพ็รงมัดล้กมัะเร็งหลอดอ�ห�ร มัะเร็ง กระเพ็�ะอ�ห�ร มัะเร็งไต รวัมัถง่ย่นยนั ว่ั�กิจักรรมัท�งก�ยเป็นก�รป้องกัน มัะเร็งเต� นมัและมัะเร็งลำ�ไสำ� (35) กิจักรรมั ท�งก�ยในระดบัที�ส้ำงขี่ �นนั�นเกี�ยวัเน่�องกบั ก�รลดค์วั�มัเสีำ�ยงประมั�ณิร�อยละ 10-20 (35) ตวััอย่�งเช่น ในบทปริทศันฉ์บบั หน่�งร�ยง�นค์วั�มัเช่�อมัโยงในท�งตรง กนัขี� มักบัค์วั�มัเสีำ�ยงขีองมัะเร็งตบัเม่ั�อ เปรียบเทียบกิจักรรมัท�งก�ยระดบัส้ำง กบักิจักรรมัท�งก�ยระดบัตำ� (HR= 0.75 [95% CI: 0.63 to 0.89]) (68) มีัหลกัฐ�น ที� ไม่ัเพี็ยงพ็อเกี� ยวักับค์วั�มัเช่� อมัโยง ระหว่ั�งกิจักรรมัท�งก�ยที� เพิ็�มัขี่ �นและ ลดค์วั�มัเสีำ� ยงเกี� ยวักับมัะเร็งในเล่อด ศีรษะและค์อ รงัไข่ี ตบัอ่อน ต่อมัล้กหมั�ก ต่อมัไทรอยด ์ทวั�รหนกั และมัะเร็งสำมัอง (35) ขีณิะที�หลกัฐ�นชี�ให�เห็นว่ั�มีัก�รลด ค์วั�มัเสีำ� ยงขีองมัะเร็งปอดระ หว่ั�ง กิจักรรมัท�งก�ยในระดบัส้ำงสุำดเทียบกบั ระดบัตำ� สุำด ก�รใช�ย�ส้ำบอ�จัทำ�ให�ผู้ลก�ร ทดลองนี�สำบัสำนและระบุว่ั�ไม่ัมีัหลกัฐ�นที� เพี็ยงพ็อที�จัะพิ็ส้ำจันค์์วั�มัเช่�อมัโยง ค์วั�มัสำมััพ็นัธิร์ะหว่ั�งกิจักรรมัท�ง ก�ยและภ�วะโรค์อว้นในประช�กรผู้้�ใหญ่่ นั�นไม่ัเป็นที�ทร�บกนัดีนกั แมั�จัะมีัหลกัฐ�น จัำ�นวันมั�กแต่แตกต่�งกนั หลกัฐ�นที� ประเมิันค์วั�มัสำมััพ็นัธินี์�ผู่้�นตวััวัดัผู้ลที� หล�กหล�ย (นำ � หนกัเพิ็�มั นำ � หนกัเปลี�ยน ก�รคุ์มันำ � หนกั ค์วั�มัค์งที�นำ � หนกั สำถ�นะ นำ � หนกั และก�รด้แลนำ � หนกั) (35, 69, 70) หลกัฐ�นชี�ให�เห็นโดยภั�พ็รวัมัว่ั� กิจักรรมัท�งก�ยในระดบัที� ส้ำงขี่ �นอ�จั เช่�อมัโยงกบัก�รวัดัระดบัค์วั�มัอ�วันและ ก�รลดนำ � หนกัในผู้้�ใหญ่่ (35) จัำ�เป็นต�อง มีัง�นวิัจัยัเพิ็�มัเติมัเพ่็�อสำร� งให�เกิดผู้ลอนั ค์งที�และค์วั�มัเช่�อมัโยงที�แข็ีงแกร่ง ก�รวิัจัยัเร่�องกิจักรรมัท�งก�ยและ สุำข้ภ�พจิติ ก�รรบัร้ ้ และก�รนอนหลบั เพิ็�มัมั�กขี่ �นอย่�งมีัแก่นสำ�ร ตั�งแต่ก�ร พ็ฒัน�ขี�อแนะนำ�ระดบัโลกด� นกิจักรรมั ท�งก�ยเพ่็�อสุำขีภั�พ็ ฉบบั พ็.ศ. 2553 (1) ในขีณิะนั�น มีัหลกัฐ�นเพี็ยงพ็อที�จัะสำรุป ได�เพี็ยงว่ั� กิจักรรมัท�งก�ยอ�จัลดค์วั�มั เสีำ�ยงขีองภั�วัะซม่ัเศร� และค์วั�มัจัำ�เส่ำ�อมั ในผู้้�ใหญ่่ หลกัฐ�นชิ�นใหม่ัที�ทบทวันเพ่็�อ ขี�อแนะนำ�เหล่�นี�แสำดงให�เห็นว่ั� ผู้้�ใหญ่่ ที�ทำ�กิจักรรมัท�งก�ยระดบัที�ส้ำงกว่ั�เทียบ กบัระดบัที�ตำ� กว่ั�นั�น ค์วั�มัเสีำ�ยงขีองก�ร พ็ฒัน�อ�ก�รเค์รียดและซม่ัเศร� จัะลดลง ตวััอย่�งเช่น ผู้้�ใหญ่่ที� ทำ�กิจักรรมัท�ง ก�ยในระดบัส้ำงเทียบกบัระดบัตำ� จัะมีั ค่์�ที� จัะพ็ัฒน�อ�ก�รเค์รียด (AOR= 0.81 [95% CI: 0.69 to 0.95]) (71) หร่อซ่มัเศร� (AOR= 0.78 [95% CI: 0.70 to 0.87) ลดลง (72) กิจักรรมัท�ง ก�ยระดบัป�นกล�งถ่งหนกัที� เพิ็�มัมั�ก ขี่ �นเช่� อมัโยงกับก�รพ็ัฒน�ค์วั�มัคิ์ด (ตวััอย่�งเช่น ก�รประมัวัลผู้ลค์วั�มัเร็วั ค์วั�มัจัำ� และก�รหน� ที� ในก�รคิ์ด) (35) หน� ที�ขีองสำมัองและโค์รงสำร� ง และค์วั�มั เ สีำ� ย ง ที� ล ด ล ง ใน ก � ร พ็ัฒ น� อ � ก � ร ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 50 ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) บกพร่องด�้นก�รรบัร้ ้ รวัมัถ่งโรค์ อัลไซเมัอร ์ (73-76) หลักฐ�นที� รวัมั ประช�กรผู้้�ใหญ่่หล�ยร�ยแสำดงให�เห็น ถง่เสำ�นล�ดโค์�งจั�กสุำขีภั�พ็สำมัองปรกติ จันถง่สำมัองเส่ำ�อมั และผู้ลดีขีองกิจักรรมั ท�งก�ยนั�นมีัก�รบนัท่กไวั�หล�กหล�ย ชนิด รวัมัถ่งกิจักรรมัแบบแอโรบิก ก�รเดิน กิจักรรมัสำร� งค์วั�มัแข็ีงแรงให� กบักล� มัเน่�อ และโยค์ะ (74) มีัหลกัฐ�น ว่ั�กิจักรรมัท�งก�ยแบบฝึึกและแบบ ปรกติจัะทำ�ให�ก�รนอนหลบัและคุ์ณ- ภ�พชี้วิติที�เกี�ยวเนื�องกบัสุำข้ภ�พดีขี่ �นใน วัยัผู้้�ใหญ่่ (35) หลกัฐ�นที�ตรวัจัสำอบกิจักรรมัท�ง ก�ยและอ�ก�รข้องโรค์ซม้ัเศัร�้ อ�ก�ร เค์รียด และก�รพฒัน�ส่้ำค์ว�มัเค์รียด และภ�วะซม้ัเศัร�้ชี �ให�เห็นว่ั� กิจักรรมั ท�งก�ยเช่� อมัโยงกับอ�ก�รเค์รียดที� ลดลง (77, 78) และอ�ก�รซม่ัเศร� ที�ลดลง (77, 79) กิจักรรมัท�งก�ยล�วันมั�พ็ร�อมั ค์วั�มัเสีำ� ยง หลกัฐ�นจั�กบทปริทศันที์� จััดทำ�เกี� ยวักับผู้ลในท�งตรงกันขี� มั อ�ก�รบ�ดเจ็ับและอนัตร�ยที�เกี�ยวัเน่�อง กบักิจักรรมัท�งก�ยเพ่็�อก�รสำนัทน�ก�ร ในผู้้�ใหญ่่ (41) ชี �ว่ั� มีัค์วั�มัเช่�อมัโยงที� ไม่ั พ็่งประสำงค์ร์ะหว่ั�งระดบัขีองกิจักรรมั ท�งก�ยในช่วังเวัล�พ็กัผู่้อนกบัอ�ก�ร บ�ดเจ็ับกล� มัเน่�อและกระด้ก และสำมััพ็นั- ธิภั�พ็ที�พ็ง่ประสำงค์ร์ะหว่ั�งกิจักรรมัท�ง ก�ยขีณิะพ็กัผู่้อนกบัค์วั�มัเสีำ�ยงต่อกระ- ด้กแตกหกัและกระด้กหวััเข่ี�หร่อสำะโพ็ก เ ส่ำ� อมั หลักฐ�นเพิ็� มัเติมั (35) ชี �ว่ั� เหตุก�รณิ์ไม่ัพ็ง่ประสำงค์ฉ์บัพ็ลนัเกี�ยวักบั หัวัใจันั�นเกิดขี่ �นได�ย�กและสำมััพ็นัธิก์บั ภั�วัะฉบัพ็ลนัในกิจักรรมัท�งก�ยระดบั หนกั โดยทั�วัไปแล�วั ค์วั�มัเสีำ�ยงต่อเหตุ- ก�รณิ์ ไ ม่ัพ็่งประสำงค์์จัะมีัน�อยมั�ก เม่ั�อทำ�กิจักรรมัท�งก�ยระดบัป�นกล�ง และเม่ั�อค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มัหนกัหน่วัง และระยะเวัล�ในกิจักรรมัท�งก�ย (35) ค์ณะทำ�ง�น GDG สำรุปว่� : • มีัหลักฐ�นที� เช่� อถ่อได�อย่�งยิ� งว่ั� กิจักรรมัท�งก�ยทุกระดับและทุก ค์วั�มัหนักหน่วังเช่� อมัโยงกบัค์วั�มั เสีำ� ยงที� ลดลงจั�กก�รเสีำยชีวิัตทุก สำ�เหตุและก�รเสีำยชีวิัตจั�กโรค์ ห ล อ ด เ ล่ อ ด หั วั ใ จั ก � ร เ กิ ด โร ค์ ค์วั�มัดนัโลหิตส้ำง โรค์หวััใจัและหลอด เล่อด และโรค์เบ�หวั�นชนิดที�สำอง • มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�งถง่มั�ก ในเร่�องค์วั�มัเช่�อมัโยงระหว่ั�งระดบั กิจักรรมัท�งก�ยที� เพิ็� มัส้ำงขี่ �นกับ ค์วั�มัเสีำ�ยงในก�รเกิดมัะเร็งเฉพ็�ะจุัด ที�ลดลง • มีัหลักฐ�นที� เช่� อถ่อได�ป�นกล�งที� สำนับสำนุนค์วั�มัเช่� อมัโยงระหว่ั�ง กิจักรรมัท�งก�ยและก�รพ็ัฒน� สุำขีภั�พ็จิัต สุำขีภั�พ็สำมัอง และผู้ลลพั็ธิ ์ ด� นก�รนอนหลบั • มีัหลกัฐ�นที�เช่�อมัโยงระหว่ั�งกิจักรรมั ท�งก�ยในระดับที� ส้ำงขี่ �น ก�รวััด ผู้ลโรค์อ�วันอย่�งพ็่งประสำงค์ม์ั�กขี่ �น และก�รลดภั�วัะนำ � หนกัเพิ็�มัในผู้้�ใหญ่่ • มีัหลกัฐ�นที�เช่�อถ่อได�น�อยว่ั� กิจักรรมั ท�งก�ยที�แนะนำ�สำำ�หรบัผู้้�ใหญ่่นั�นจัะ ไม่ัเป็นอนัตร�ย และผู้ลดีต่อสุำขีภั�พ็ จั�กกิจักรรมัเหล่�นั�นจัะมั�กกว่ั� ค์วั�มัเสีำ�ยง 51 ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ร้ปที� 1: เสำ�นโค์�งแสำดงก�รตอบสำนองต่อปริมั�ณิ มีัค์ว�มัสำมััพนัธิ์ ์ในก�รติอบสำนองต่ิอ ปริมั�ณหรือไม่ั (ปริมั�ณ ระยะเวล� ค์ว�มัถี� ค์ว�มัหนกัหน่วง) หลกัฐ�นโดยภั�พ็รวัมัจั�กผู้ลลพั็ธิ ์ ท�งสุำขีภั�พ็หลอดเล่อดหัวัใจัและก�ร เผู้�ผู้ล�ญ่อ�ห�ร แสำดงให�เห็นถง่ค์วั�มั สำมััพ็นัธิข์ีองก�รตอบสำนองต่อปริมั�ณิ ที� เป็นเสำ�นโค์�งหง�ยอย่�งค์งที� ระหว่ั�ง กิจักรรมัท�งก�ยและผู้ลลพั็ธิท์�งสุำขีภั�พ็ ที�สำำ�ค์ญั่ เช่น ก�รเสีำยชีวิัตจั�กทุกสำ�เหตุ ก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อดหัวัใจั ก�รเกิดโรค์เบ�หวั�นชนิดที� สำอง (67) และก�รเกิดมัะเร็งเฉพ็�ะที� ในผู้้� ใหญ่่ ต�มัที�บรรย�ยไวั�ในร้ปที� 1 ร้ปร่�งขีอง เสำ�นโค์�งแสำดงก�รตอบสำนองต่อปริมั�ณิ ชี�ว่ั� ไม่ัมีัจุัดเริ� มัต�นที� ตำ� กว่ั�นี�สำำ�หรับ ประโยชน์ และประโยชน์ที� มั�กที� สุำด อย่้ที�ปล�ยที�ตำ� ลงมั�ขีองเสำ�นโค์�งที�แสำดง ก�รตอบสำนอง (65) ค์วั�มัเช่�อมัโยงขีอง เสำ�นโค์�งหง�ยนี�ถ้กนำ�เสำนออย่�งต่อเน่�อง ข้้อัแนะนำา ทั�วัทั�งง�นวิัจัยัต่�ง ๆ โดยใช�ตวััวัดักิจักรรมั ท�งก�ยที�ต่�งกนั หลกัฐ�นชิ�นใหม่ัอย่้ใน ก�รวิัเค์ร�ะหอ์ภิัมั�นจั�กง�นศก่ษ�ต�มั รุ่นที�ค์�ดค์ะเนไวั�จัำ�นวัน 8 ง�น ซ่�งมีัค่์� กล�งขีองก�รติดต�มัผู้ลที� 5 .8 ปี (ช่วังกวั� ง 3-14.5 ปี) (65) ซ่�งร�ยง�นถง่ อัตร�ก�รเต�นหัวัใจัที� ปรับสำำ�หรับช่วัง ค์วัอไทลข์ีองกิจักรรมัท�งก�ยโดยรวัมั โดยใช�ก�รวัดัตวััแปรและก�รเสีำยชี้วิติ จ�กทุกสำ�เหตุิด�วัยเค์ร่�องม่ัอ ผู้ลแสำดงให� เห็นถง่ก�รตอบสำนองต่อปริมั�ณิที�มีักิจั- กรรมัท�งก�ยมั�กขี่ �นและผู้ลดีจั�กกิจั- กรรมัท�งก�ยในทุกระดบั ด�วัยระดบัที�ส้ำง ขี่ �น เปรียบเทียบกับเม่ั� อเค์ล่� อนไหวั ร่�งก�ยน�อยที� สุำด (referent, 1.00): ค์วัอไทลที์� 2 (อตัร�ก�รเต�นขีองหัวัใจัที� ปรบัแล�วั = 0.48 [95% CI: 0.43 to 0.54]) ค์วัอไทลที์� 3 (อตัร�ก�รเต�นขีองหัวัใจัที� ปรบัแล�วั = 0.34 [95% CI: 0.26 to 0.45]) และค์วัอไทลที์� 4 (อตัร�ก�รเต�นขีองหวััใจั ปรั ะโย ช้น์ื รัะยะท่�แนืะนืำ� กิิจกิรัรัมท�งกิ�ยปรัะจำ�สัำปด็�ห์ (หน่ืวัยเป็นืนื�ท่)พฤติิกิรัรัมเนืือยนิื�ง ปรั ะโย ช้นื ติอ สำข้ ภิ� พแ ละ คำวั �ม แข้ งแ รัง คำวั� มเส่ำ �ยงแ ละอั นืติ รั�ย ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 52 ที�ปรบัแล�วั = 0.27 [95% CI: 0.23 to 0.32]) มีัก�รสำังเกตก�รลดค์วั�มัเสีำ� ยงส้ำงสุำด สำำ�หรบักิจักรรมัท�งก�ยระดบัป�นกล�ง ที� 24 น�ทีต่อวััน (เทียบเท่�กับ 168 น�ทีต่อสำปัด�ห)์ ซ่�งสำะท�อนผู้ลใกล�เคี์ยง กบัค์ำ�แนะนำ�ให�ทำ�กิจักรรมัท�งก�ย 150 น�ทีต่อสำปัด�ห ์และเกิดหลกัฐ�นใหม่ัที�วัดั ด�วัยเค์ร่�องม่ัอ ซ่�งเน�นยำ � ขี�อแนะนำ�ระดบั สำ�กลต่อผู้้�ใหญ่่ที�ให�ทำ�กิจักรรมัท�งก�ย อย่�งน�อย 150-300 น�ทีต่อสำัปด�ห ์ ผู้ลก�รทดลองนี�สำอดค์ล�องกบัหลกัฐ�น จั�กบทปริทศันที์�มีัอย่้ (35) และบทปริทศัน ์ ใหม่ัที�นำ�มั�วิัเค์ร�ะห ์(66) ที�ปล�ยบนสุำด ระดบัขีองกิจักรรมั ท�งก�ยที� ส้ำงขี่ �นจัะส่ำงผู้ลดี โดยลดค์วั�มั เสีำ� ยงจั�กก�รเสีำยชีวิัตและ ไม่ัมีัค์วั�มั เสีำ� ยงที� เป็นอันตร�ยเพิ็� มัขี่ �นตัวัอย่�ง เ ช่ น ห ลั ก ฐ � น จั � ก บ ท ป ริ ทั ศ น ์ พ็ร�อมัผู้ลก�รศก่ษ�จั�กผู้ลก�รวิัเค์ร�ะห ์ อภิัมั�นขีองขี�อม้ัลส่ำวันบุค์ค์ล จั�กก�รวัดั กิจักรรมัท�งก�ยด�วัยเค์ร่� องม่ัอ (65) บ่งชี�ว่ั� แมั�ค์วั�มัเสีำ�ยงในก�รเสีำยชีวิัตที� ล ด ลงจั ะ เ ป็ นที� สำัง เก ต ไ ด� ส้ำ ง สุำ ดจั� ก ก�รทำ�กิจักรรมัท�งก�ย 750 น�ทีต่อ สำปัด�ห ์ในระดบัป�นกล�งถง่หนกั ค์วั�มั เสีำ�ยงในก�รเสีำยชีวิัตโดยเทียบเคี์ยงอย่้ที� ระดบัที�มั�กกว่ั� 300 น�ทีต่อสำปัด�ห ์ ผู้ลเหล่�นี�สำอดค์ล�องกบัหลกัฐ�นก่อน หน� นี�ที� แสำดงให�เห็นอย่�งต่อเน่� องว่ั� กิจักรรมัท�งก�ยสำัมัพ็ันธิก์ับผู้ลดีต่อ สุำขีภั�พ็อ่�น ๆ แมั�ว่ั�ประโยชนอ่์�นที�สำมััพ็นัธิ ์ กนัจัะลดลงเม่ั�อกิจักรรมัท�งก�ยในระดบั ที� ส้ำงขี่ �น (35, 80, 81) อย่�งไรก็ต�มั มีั หลกัฐ�นไม่ัเพี็ยงพ็อที�จัะเจั�ะจังระดบั กิจักรรมัท�งก�ยที� แน่นอนซ่� งผู้ลตอบ กลบัที�ลดลงขีองคุ์ณิค่์�ด� นสุำขีภั�พ็นั�น เริ�มัเกิดขี่ �นในวัยัผู้้�ใหญ่่ หลักฐ�นต่�ง ๆ ยังยำ � เต่อนว่ั� ค์วั�มัสำมััพ็นัธิ ์ในท�งตรงกนัขี� มัที� เป็น ที�ยอมัรบักนัดีระหว่ั�งกิจักรรมัท�งก�ย และก�รเสีำยชี้วิติจ�กโรค์หลอดเลือด หวัใจ และให�หลกัฐ�นเพิ็�มัเติมัเกี�ยวักบั ค์วั�มัสำัมัพ็ันธิข์ีองก�รตอบสำนองต่อ ปริมั�ณิที�เกินขีีดสุำดขีองปริมั�ณิกิจักรรมั ท�งก�ยที� แนะนำ�กนัอย่้ ก�รวิัเค์ร�ะห ์ อนุมั�นจั�กก�รศ่กษ�ต�มัแผู้นจัำ�นวัน 48 ฉบับที� ประเมิันกิจักรรมัท�งก�ย (ทุกประเภัท ก�รพ็กัผู่้อน และเพ่็�ออ�ชีพ็) ซ่�งมีัหลกัฐ�นเพิ็�มัเติมัขีองค์วั�มัสำมััพ็นัธิ ์ ในก�รตอบสำนองต่อปริมั�ณิ (66) ที� เ กินขีีดปริมั�ณิกิจักรรมัท�งก�ยที� แนะนำ�ในปัจัจุับนั เม่ั� อเปรียบเทียบกบั ระดับที� แนะนำ�ที� ใช�พ็ลงัง�นเม่ั� อเทียบ กบัขีณิะพ็กั 750 น�ทีต่อสำปัด�ห ์ ก�ร มีัส่ำวันร่วัมัในกิจักรรมัที� ใช�พ็ลงัง�นเม่ั�อ เทียบกบัขีณิะพ็กั 500 น�ทีต่อสำปัด�ห ์ (กิจักรรมัท�งก�ยระดบัป�นกล�ง 1,000 น�ที) มีัผู้ลให�ค์วั�มัเสีำ�ยงต่อก�รเสีำยชีวิัต จั�กโรค์หลอดเล่อดหัวัใจัตำ� ลงอย่�งมีั นยัสำำ�ค์ญั่ (HR= 0.73 [95% CI: 0.56 to 0.95]) (66) ขี�อแนะนำ�ขีององค์ก์�รอน�มัยั โลกฉบบัก่อนหน� (1) สำรุปว่ั�กิจักรรมั ท�งก�ยแบบแอโรบิกอย่�งต่อเน่�องเป็น ระยะเวัล�อย่�งน�อย 10 น�ที อย่�งไรก็ต�มั หลกัฐ�นใหม่ัที�ประเมิันผู้ลโดยใช�อุปกรณิ ์ แสำดงให�เห็นว่ั� กิจักรรมัท�งก�ยไม่ัว่ั�จัะมีั ระยะเวัล�เท่�ใด และไม่ัมีัขีีดขีั�นตำ� จัำ�กดั ล�วันเกี�ยวัเน่�องกบัผู้ลลพั็ธิสุ์ำขีภั�พ็ที�ดีขี่ �น ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) 53 รวัมัถง่ลดสำ�เหตุก�รเสีำยชีวิัตทุกสำ�เหตุ ด�วัย (65,82) ตวััอย่�งเช่น หลกัฐ�นชิ�น ใหม่ัจั�กบทปริทศันง์�นวิัจัยัที� ประเมิัน กิจักรรมัท�งก�ยโดยเค์ร่�องวัดัค์วั�มัเร่ง ที� ยำ � เต่อนค์วั�มัเช่� อมัโยงที� เหม่ัอนกัน ระหว่ั�งดชันีทั�งมัวัลขีองกิจักรรมัท�ง ก�ยและอนัตร�ยทุกชีวิัตในทุกสำ�เหตุ ด�วัยอตัร�ส่ำวันค์วั�มัเสีำ�ยงอนัตร�ยที� 0.27 สำำ�หรบักิจักรรมัท�งก�ยทั�งหมัด 0.28 สำำ�หรบัช่วังระยะเวัล� 5 น�ที และ 0.35 สำำ�หรบัช่วัง 10 น�ที เปรียบเทียบกบัช่วัง ค์วัอไทลส้์ำงสุำดเทียบกบัช่วังตำ� สุำด ผู้ลเหล่� นี�ยำ � เต่อนโดยผู้ลก�รศก่ษ�ในบทปริทศัน ์ ใหม่ัโดยอีค์ลุนดแ์ละค์ณิะ พ็.ศ. 2562 (65) ซ่�งมีัหลกัฐ�นว่ั� กิจักรรมัท�งก�ยไม่ั ว่ั�ระยะเวัล�ใดนั�นเช่�อมัโยงกบัผู้ลลพั็ธิ ์ ท�งสุำขีภั�พ็ที�ดีขี่ �น รวัมัถง่สำ�เหตุก�รเสีำย ชีวิัตทุกสำ�เหตุ (82) ด�วัยหลกัฐ�นชิ�นใหม่ันี� จั่งนำ�ค์ำ�แนะนำ�สำำ�หรับช่วังระยะเวัล� อย่�งน�อย 10 น�ทีออกไป แมั�ว่ั�หลกัฐ�นแสำดงให�เห็นค์วั�มั เช่� อมัโยงระหว่ั�งกิจักรรมัท�งก�ยใน ระดบัที�ส้ำงขี่ �นและค์วั�มัเสีำ�ยงขีองก�รเกิด มัะเร็งเฉพ�ะจุดซ่�งถ่อว่ั�ค์งที�ในภั�พ็รวัมั มีัหลกัฐ�นไม่ัเพี็ยงพ็อที�จัะกำ�หนดระดบั เฉพ็�ะเจั�ะจังในก�รทำ�กิจักรรมัท�ง ก�ยที� สำอดค์ล�องกบัก�รลดค์วั�มัเสีำ� ยง ที� ร�ยง�นไวั�จั�กค์วั�มัแตกต่�งอย่�ง มั�กในก�รประเมิันและก�รจััดแบ่ง ป ร ะ เ ภั ท ขี อ ง ก � ร เ ปิ ด รั บ ใ น ง � น วิัจััยทุกชิ�น อย่�งไรก็ต�มั ไม่ัมีัหลัก- ฐ�นที� ชี �ว่ั� มีัเกณิฑ์ที์� ตำ� กว่ั�จุัดที� ผู้ลดี ในก�รทำ�กิจักรรมัท�งก�ยนั�นไม่ัชัด- เจัน ดงันั�นกิจักรรมัท�งก�ยในระดับ ใด ๆ ก็ต�มัย่อมัก่อให�เกิดผู้ลดีในก�รลด ค์วั�มัเสีำ�ยงต่อมัะเร็งเฉพ็�ะจุัด ง�นวิัจัยัใน อน�ค์ตเพ่็�อประเมิันธิรรมัช�ติขีองก�ร ตอบสำนองต่อปริมั�ณิ และใช�ก�รวัดัที� ค์งที�มั�กขี่ �น และก�รร�ยง�นผู้ลนั�นจัำ�เป็น สำำ�หรบัขี�อแนะนำ�ในอน�ค์ต แมั�ว่ั�จัะมีัหลกัฐ�นชิ�นใหญ่่เกี�ยวักบั ค์วั�มัเช่�อมัโยงระหว่ั�งกิจักรรมัท�งก�ย และมั�ตรวัดัที�หล�กหล�ยในก�รวัดัผู้ล ค์วั�มัอ�วัน ก�รเพิ็�มันำ � หนกั และก�รจัดั ก�รเพ่็� อนำ � หนักที� ส่ำงผู้ลต่อสุำขีภั�พ็ที� ดี (35) ปัจัจุับนันี�ยงัไม่ัมีัหลกัฐ�นเพี็ยงพ็อที� จัะอธิิบ�ยค์วั�มัสำมััพ็นัธิก์บัก�รตอบสำนอง ต่อปริมั�ณิอย่�งเฉพ็�ะเจั�ะจังมั�กขี่ �น หร่อจัำ�แนกแยกแยะขีีดจัำ�กัดขีองผู้ล กระทบ ง�นวิัจัยัเพิ็�มัเติมัเพ่็�อขี�อแนะนำ�ใน อน�ค์ตนั�น มีัค์วั�มัจัำ�เป็น ก�รทำ�กิจักรรมัท�งก�ยที�ระดบั ป�นกล�งและหนักเป็นระยะเวัล�ย�วั น�นขี่ �นนั�น เช่� อมัโยงกับก�รพฒัน� ก�รรบัร้ ้ (ตวััอย่�งเช่น ค์วั�มัไวัในก�ร ประมัวัลผู้ล ค์วั�มัจัำ� และทกัษะก�รคิ์ด เชิงบริห�ร) (35) ก�รทำ�ง�นและโค์รง สำร� งขีองสำมัองและค์วั�มัเสีำ�ยงที�ลดลง จั � ก ค์ ว � มั บ ก พ ร่ อ ง ใ น ก � ร ร ับ ร้ ้ ที�ก่อตวััขี่ �น รวัมัถง่โรค์อลัไซเมัอร ์(73-76) มีัหลกัฐ�นว่ั�ทั�งระยะเวัล�กิจักรรมัท�ง ก�ยและก�รทำ�กิจักรรมัท�งก�ยเป็น ประจัำ� ทำ�ให�ก�รนอนหลบัและคุ์ณภ�พ ชี้วิติที�เกี�ยวเนื�องกบัสุำข้ภ�พในวัยัผู้้�ใหญ่่ นั�นดีขี่ �น แต่ก็ไม่ัมีัหลกัฐ�นเพี็ยงพ็อที�จัะ อธิิบ�ยค์วั�มัสำมััพ็นัธิ ์ในก�รตอบสำนอง ต่อปริมั�ณิระหว่ั�งกิจักรรมัท�งก�ยและ ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 54 ผู้ลลพั็ธิท์�งสุำขีภั�พ็ด� นจิัตใจัและด� น ก�รรับร้�ขีองแต่ละบุค์ค์ลอย่�งเฉพ็�ะ เจั�ะจังมั�กขี่ �น เฉกเช่นเดียวักนั หลกัฐ�น เพิ็�มัเติมัที�อธิิบ�ยค์วั�มัสำมััพ็นัธิร์ะหว่ั�ง ปริมั�ณิและ/หร่อค์วั�มัหนกัหน่วังขีอง กิจักรรมัท�งก�ยแบบแอโรบิก และก�ร ฝึึ ก ค์ วั � มั แ ข็ี ง แร ง ก ล� มั เน่�อ แ ล ะ ผู้ลลพั็ธิสุ์ำขีภั�พ็ที� เฉพ็�ะเจั�ะจัง ขี�อม้ัลนี� เป็นกุญ่แจัในก�รบญั่ญ่ติัปริมั�ณิที�น�อย ที� สุำดที�จัะเกิดผู้ล และเกณิฑ์ค์์วั�มัปลอด- ภัยัที� ส้ำงที� สุำดในก�รทำ�กิจักรรมัท�งก�ย สำำ�หรบัประช�กรกลุ่มัย่อยที�แตกต่�งกนั ค์ณะทำ�ง�น GDG สำรุปว่� : • มีัหลกัฐ�นว่ั�กิจักรรมัท�งก�ยที� เพิ็�มั ขี่ �นเช่�อมัโยงกบัผู้ลลพั็ธิท์�งสุำขีภั�พ็ที� มั�กขี่ �น แมั�ว่ั�คุ์ณิประโยชนที์� เกี� ยวั เน่�องจัะรกัษ�ระดบัขีองกิจักรรมัท�ง ก�ยที�มีัระดบัส้ำงขี่ �น ยงัไม่ัมีัหลกัฐ�นที� เพี็ยงพ็อที�จัะระบุระดบัที� แน่นอนว่ั� ผู้ลตอบกลบัที�ลดลงนั�นเริ�มัเกิดขี่ �น • มีัหลกัฐ�นที� มีัค์วั�มัน่�เช่� อถ่อส้ำงว่ั� กิจักรรมัท�งก�ยในระดับที� ส้ำงขี่ �น เ ช่� อ มั โ ย ง กับ ค์ วั � มั เ สีำ� ย ง ที� ล ด ล ง จั�กก�รเสีำยชีวิัตทุกสำ�เหตุ ก�ร เสีำยชีวิัตจั�กโรค์หลอดเล่อดหัวัใจั ก�รเสีำยชีวิัตจั�กโรค์มัะเร็ง ก�รเกิดโรค์ หลอดเล่อดหัวัใจั และก�รเกิดภั�วัะ ค์วั�มั ดัน โ ล หิ ต ส้ำ ง แ ล ะ เ บ � ห วั� น ประเภัทที� สำอง โดยไม่ัมีัค์วั�มัเสีำ� ยง อนัตร�ยที�เพิ็�มัขี่ �น • มีัหลักฐ�นเช่� อถ่อได�ป�นกล�งว่ั� กิจักรรมัท�งก�ยในระยะใด ๆ นั�น เช่� อมัโยงกับผู้ลลัพ็ธิท์�งสุำขีภั�พ็ที� ดีขี่ �น และก�รเจั�ะจังก่อนหน� นี�ว่ั�ค์วัร มีักิจักรรมัท�งก�ยแบบแอโรบิก เป็นช่วังต่อเน่� องอย่�งน�อย 10 น�ที นั�น ค์วัรเอ�ออกเสีำย • มีัหลกัฐ�นว่ั�กิจักรรมัท�งก�ยที�มั�ก ขี่ �นอ�จัเช่�อมัโยงกบัก�รวัดัที� เหมั�ะ สำมัมั�กขี่ �น ทั�งภั�วัะโรค์อ�วันและก�ร ลดนำ � หนกัในผู้้�ใหญ่่ และมีัค์วั�มัเสีำ�ยง ตำ� ที� กิจักรรมัท�งก�ยจัะเป็นอนัตร�ย สำำ�หรบัก�รจัดัก�รนำ � หนกัที� ส่ำงผู้ลต่อ สุำขีภั�พ็ดีในผู้้�ใหญ่่ • มีัหลักฐ�นเช่� อถ่อได�ป�นกล�งว่ั� กิจักรรมัท�งก�ยแบบแอโรบิกที� ระดับป�นกล�ง 150-300 น�ที หร่อเทียบเท่�ต่อสำปัด�หน์ั�น ลดค์วั�มั เสีำ�ยงสำำ�หรบัผู้ลลพั็ธิสุ์ำขีภั�พ็อย่�งทวีั- ค้์ณิ และก�รลดค์วั�มัเสีำ�ยงจัะดำ�เนินไป แต่เริ� มัที� จัะนิ� งเม่ั� อเกิน 300 น�ที ต่อสำปัด�ห์ ค์ว�มัสำมััพนัธิ์เ์ปลี�ยนแปลงไปติ�มัช้นิด หรือข้อบเข้ติข้องกิจกรรมัท�งก�ย หรือไม่ั หลกัฐ�นแสำดงว่ั�กิจักรรมัท�งก�ย ชนิดต่�ง ๆ และกิจักรรมัท�งก�ยที� เกิด ขี่ �นในขีอบเขีตที�แตกต่�งกนั (เช่น อ�ชีพ็ ก�รเดินท�ง หร่อก�รพ็กัผู่้อน) ทำ�ให�เกิด ผู้ลลพั็ธิท์�งสุำขีภั�พ็ที� น่�พ็อใจั สำำ�หรบั สำ�เหตุก�รเสีำยชีวิัตทุกสำ�เหตุและโรค์ หลอดเล่อดหวััใจั กิจักรรมัท�งก�ยแบบ แอโรบิกแต่เพี็ยงอย่�งเดียวัหร่อผู้สำมักบั ก�ยบริห�รเพ่็�อสำร� งเสำริมัค์วั�มัแข็ีงแรง แสำดงให�เห็นถ่งค์วั�มัเช่� อมัโยงที� มีัส่ำวัน เสำริมักนั แมั�ว่ั�กิจักรรมัท�งก�ยทั�งสำอง ร้ปแบบในระดบัที� แนะนำ�นั�นเหมั�ะสำมั ที�สุำด (84) ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) 55 หลกัฐ�นที� มีัค์วั�มัน่�เช่�อถ่อป�น- กล�งเม่ั�อไม่ัน�นมั�นี�ชี �ให�เห็นว่ั� กิจักรรมั ท�งก�ยเสำริมัสำร� งกล� มัเน่�อ ค์วั�มัอิสำระ ขีองกิจักรรมัท�งก�ยแบบแอโรบิกนั�น ยงัเช่� อมัโยงกบัค์วั�มัเสีำ� ยงที� ลดลงจั�ก ก�รเสีำยชีวิัตทุกร้ปแบบ ผู้ลก�รวิัจััยที� ร�ยง�นโดยสำต�มั�ต�คิ์สำและค์ณิะ (2561) จั�กผู้ลก�รวิัเค์ร�ะห์โดยรวัมัจั�ก 11 กลุ่มัที� ทดสำอบขี�อแนะนำ�ในก�รทำ� กิจักรรมัท�งก�ยแบบเสำริมักล� มัเน่�อ อย่�งน�อย 2 วันัต่อสำปัด�หเ์ปรียบเทียบ กับก�รเสีำยชีวิัตทุกสำ�เหตุ ชี �ให� เห็น ว่ั� เม่ั� อทำ�กิจักรรมัท�งก�ยทั�งแบบ แอโรบิกและเสำริมัสำร� งกล� มัเน่�อในระดบั ต่�ง ๆ ที�แนะนำ� (1) เทียบกบัเม่ั�อไม่ัทำ�ต�มั ขี�อแนะนำ�ใดเลย (ปรบัที� HR= 0.71 [95% CI: 0.57 to 0.87]) และก�รปฏิิบติัต�มั เพี็ยงแค่์ค์ำ�แนะนำ�ในกิจักรรมัท�งก�ย เพ่็�อค์วั�มัแข็ีงแรงเทียบกบัก�รไม่ัปฎิบติั ต�มั (HR= 0.80 [95% CI: 0.70 to 0.91]) ซ่�งสำมััพ็นัธิก์บัค์วั�มัเสีำ�ยงต่อสำ�เหตุก�ร เสีำยชีวิัตทุกสำ�เหตุที� ลดลงอย่�งมีันัย สำำ�ค์ญั่ (84) ขี�อม้ัลเหล่�นี�ย่นยนัว่ั�ผู้ล ประ โยชน์ต่อสุำขีภั�พ็ที� เช่� อมัโยงกับ กิจักรรมัท�งก�ยเพ่็� อเสำริมัสำร� งกล� มั เน่�อนั�น ไม่ัขี่ �นกบักิจักรรมัท�งก�ยแบบ แอโรบิกและยังสำร� งหลักฐ�นที� สำนับ สำนุนก�รแนะนำ�ค์วั�มัถี�ในก�รทำ�กิจักรรมั ท�งก�ยเพ่็�อเสำริมัสำร� งกล� มัเน่�อ 2 วันั ต่อสำัปด�ห์ ขี�อค์�นพ็บที� ร�ยง�นโดย ดีน้และค์ณิะ (2562) ให�หลกัฐ�นสำนับ สำนุนที� ย่นยันว่ั� กิจักรรมัท�งก�ยที� เ กิ ด ขี่ �น น อ ก ขี อ บ ข่ี � ย ก � ร พ็ัก ผู่้ อ น ( ห ร่ อ สำัน ท น � ก � ร ) สำ � มั � ร ถ เ อ่ �อ ประโยชนแ์ละแสำดงให�เห็นอย่�งเจั�ะจัง ว่ั�ก�รเดินท�งอย่�งค์ล่องแค์ล่วั (เช่น ก�ร เ ดิ น แ ล ะ ก � ร เ ดิ น ท � ง ด�วั ย ก � ร ปั� น จัักรย�น) สำ�มั�รถลดค์วั�มัเสีำ� ยงขีอง สำ�เหตุก�รเสีำยชีวิัตทุกร้ปแบบอย่�งมีั นยัสำำ�ค์ญั่ (RR= 0.92 [95% CI: 0.85– 0.98]) (85) ง�นวิัจััยเม่ั� อเร็วั ๆ นี�ชี �ให�เห็นถ่ง หลกัฐ�นที�แสำดงว่ั� ผู้้�ที�เขี� ร่วัมัในก�รเดิน ท�งโดยมีัก�รเค์ล่�อนไหวัร่�งก�ย (เช่น ก�รเดิน หร่อก�รปั� นจักัรย�นเพ่็�อก�รเดิน ท�ง) จัะมีัค์วั�มัเสีำ�ยงต่อโรค์หลอดเล่อด หวััใจัที�ลดลง (โรค์หลอดเล่อดหวััใจั โรค์ หลอดเล่อดสำมัองและหัวัใจัล�มัเหลวั) เปรียบเทียบกบัค์นที� เขี� ร่วัมัในก�รเดิน ท�งโดยไม่ัมีัก�รเค์ล่�อนไหวัร่�งก�ย (RR= 0.91 [95% CI 0.83 to 0.99]) (85) และมีั หลักฐ�นเพี็ ยงพ็อจั�กผู้ลลัพ็ธิ ์ด� น สุำขีภั�พ็เหล่�นี�ที�จัะสำรุปได�ว่ั� กิจักรรมั ในขีอบเขีตที� หล�กหล�ยนั�นเป็นผู้ลดี อย่�งไรก็ต�มั มีัหลกัฐ�นไม่ัเพี็ยงพ็อที�จัะ แยกแยะผู้ลกระทบขีองขีอบข่ี�ยใน กิจั ก ร ร มั ท�ง ก� ย ที� แ ต ก ต่ �ง กันใน ผู้ลลพั็ธิท์�งสุำขีภั�พ็ทุกอย่�ง ตวััอย่�งเช่น มีัหลักฐ�นไม่ัเพี็ยงพ็อที� จัะกำ�หนดว่ั� ค์วั�มัเช่�อมัโยงระหว่ั�งก�รทำ�กิจักรรมั ท�งก�ยและค์วั�มัเสีำ�ยงในก�รเกิดโรค์ มัะเร็งหร่อก�รเกิดโรค์เบ�หวั�นชนิดที� 2 จัะแปรผู้นัไปต�มัชนิดหร่อขีอบเขีตขีอง กิจักรรมัท�งก�ย สำำ�หรับผู้ลลัพ็ธิท์�งสุำขีภั�พ็จิัต หลักฐ�น (35) แสำดงให�เห็นว่ั�ค์วั�มั หล�กหล�ยชนิดขีองกิจักรรมัท�งก�ย รวัมัถ่งกิจักรรมัแบบแอโรบิก ก�รเดิน ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 56 กิจักรรมัสำร� งค์วั�มัแข็ีงแรงให�กบักล� มั- เน่�อ และโยค์ะนั�น สำ�มั�รถสำร� งผู้ลกระทบ ที�เป็นประโยชนต่์อก�รลดอ�ก�รซม่ัเศร� และก�รก่อตวััขีองค์วั�มักงัวัล (74, 79, 86) ตวััอย่�งจั�กหลกัฐ�นเม่ั� อไม่ัน�น มั�นี� เกี�ยวักบัผู้ลกระทบที� เอ่ �อประโยชน ์ ขีองก�รแทรกแซงจั�กก�รออกกำ�ลงัก�ย แบบใช�แรงต� นและสุำขีภั�พ็จิัตมีัอย่้ ในบทปริทศันส์ำองฉบบัที�ร�ยง�นอ�ก�ร ซ่มัเศร� ที� ลดลงมั�กพ็อสำมัค์วัร (77) และก�รลดลงเล็กน�อยขีองอ�ก�รกงัวัล (78) เม่ั�อเปรียบเทียบกบัสำภั�วัะที� มีัก�ร ค์วับคุ์มั หลักฐ�นจั�กบทปริทัศน์ฉบับ ใหม่ัยำ � เต่อนว่ั�กิจักรรมัท�งก�ยเพ่็� อ อ�ชีพ็ในระดบัส้ำงนั�น เช่�อมัโยงกบัค์วั�มั เสีำ�ยงขีองโรค์มัะเร็ง โรค์หลอดเล่อดหวััใจั และโรค์เบ�หวั�นชนิดที� 2 ที�ลดลง (40) อย่�งไรก็ต�มั กิจักรรมัท�งก�ยเพ่็� อ อ�ชีพ็ที�ระดบัส้ำงขี่ �นอ�จัจัะเช่�อมัโยงกบั ค์วั�มัเสีำ�ยงต่อโรค์กระด้กพ็รุนที� เพิ็�มัขี่ �น คุ์ ณิ ภั � พ็ ก � ร น อ น ห ลับ ที� ไ ม่ั ดี แ ล ะ สำ�เหตุก�รเสีำยชีวิัตทุกสำ�เหตุในผู้้�ช�ย (แต่ไม่ัใช่ในผู้้�หญิ่ง) ไม่ัมีัหลกัฐ�นเพี็ยงพ็อ ที� จั ะ กำ � ห น ด ค์ วั � มั สำัมั พ็ัน ธิ ์ร ะ ห ว่ั � ง กิจักรรมัท�งก�ยเพ่็�ออ�ชีพ็และค์วั�มัอ�วัน ก�รป้องกนันำ � หนกัเพิ็�มั สุำขีภั�พ็จิัต และ คุ์ณิภั�พ็ชีวิัตที�เกี�ยวักบัสุำขีภั�พ็ (40) และ ยงัมีัหลกัฐ�นไม่ัเพี็ยงพ็อที�จัะแยกแยะ ห�กค์วั�มัเช่� อมัโยงระหว่ั�งกิจักรรมั ท�งก�ยและค์วั�มัเสีำ� ยงต่อโรค์มัะเร็ง จัะผู้นัแปรต�มัชนิดหร่อขีอบเขีตขีอง กิจักรรมัท�งก�ย มีัหลกัฐ�นน�อยชิ�นเกี�ยวั กบัค์วั�มัเช่�อมัโยงกบัขีอบเขีตที� ต่�งกนั ขีองกิจักรรมัท�งก�ย ดงันั�นจัง่ย�กที�จัะ แ ย ก แ ย ะ ผู้ ล กร ะ ท บ ขีอง ขีอ บ เขี ต ที� แตกต่�งกนัขีองกิจักรรมัท�งก�ยต่อ ผู้ลกระทบท�งสุำขีภั�พ็ที�หล�กหล�ย ค์ณิะทำ�ง�น GDG สำรุปว่ั� : • มีัหลักฐ�นเช่� อถ่อได�ป�นกล�งว่ั� กิจักรรมัท�งก�ยที�สำร� งค์วั�มัแข็ีงแรง ให�กับกล� มัเน่�ออย่�งน�อย 2 วััน ต่อสำปัด�หห์ร่อมั�กกว่ั� จัะช่วัยสำร� ง เสำริมัสุำขีภั�พ็มั�กขี่ �น แต่ไม่ัมีัหลกัฐ�น เพี็ยงพ็อที�จัะระบุช่วังเวัล�ที�แน่นอน สำำ�หรบัผู้ลดีต่อสุำขีภั�พ็ที�น่�พ็อใจัที�สุำด • มีัหลกัฐ�นที� เช่� อถ่อได�ป�นกล�งว่ั� กิจักรรมัท�งก�ยในขีอบเขีตที�แตก ต่�งกนั (ตวััอย่�งเช่น ก�รพ็กัผู่้อน ก�รเดินท�ง เกี�ยวักบัอ�ชีพ็) เสำริมัสำร� ง ประโยชนต่์อสุำขีภั�พ็ แมั�ว่ั�ในปัจัจุับนั จัะเป็นไปไม่ัได�ที� จัะแยกผู้ลกระทบ จั�กขีอบข่ี�ยในก�รทำ�กิจักรรมัท�ง ก�ยที� แตกต่�งกันต่อผู้ลลัพ็ธิท์�ง สุำขีภั�พ็ที�หล�กหล�ย • แมั�ว่ั�กิจักรรมัท�งก�ยเกี�ยวักบัอ�ชีพ็ ในระดับที� ส้ำงขี่ �นอ�จัจัะเกี� ยวัโยง กบัค์วั�มัเสีำ� ยงขีองโรค์กระด้กพ็รุน คุ์ณิภั�พ็ก�รนอนหลับที� ไม่ัดี และ สำ�เหตุก�รเสีำยชีวิัตทุกสำ�เหตุที�เพิ็�มัขี่ �น ในหม่้ัผู้้�ช�ย (แต่ไม่ัใช่ในผู้้�หญิ่ง) โดย ภั�พ็รวัมัแล�วั มีัหลักฐ�นที� มีัค์วั�มั แน่นอนป�นกล�งที� กิจักรรมัท�งก�ย เพ่็�ออ�ชีพ็นั�นส่ำงผู้ลดีต่อสุำขีภั�พ็ ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) 57 วััยผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ข้้อแนืะนืำ� ด้็�นืพฤติิกิรัรัมเนืือยนิื�ง สำำ�หรบัผู้้�ใหญ่่ พ็ฤติกรรมัเน่อยนิ�งค่์อเวัล�ที�ใช�ไปกบัก�รนั�งหร่อนอนเฉย ๆ ด�วัยก�รใช�พ็ลงัง�นแต่น�อยขีณิะต่�นอย่้ ในปริบทที�เกี�ยวักบัก�รทำ�ง�น ก�รเรียน ในสำภั�พ็แวัดล�อมัที�บ� นและชุมัชน รวัมัทั�งก�รค์มัน�ค์มั หลกัฐ�นสำนบัสำนุนและเหตุิผล สำำ�หรบัขี�อแนะนำ�เหล่�นี� ก�รสำงัเค์ร�ะหห์ลกัฐ�นที�ได�จั�ก PAGAC (35) ถ้กนำ�มั�ใช�และปรบัปรุง ค์ณิะทำ�ง�น GDG พิ็จั�รณิ�องค์ป์ระกอบทั�งหมัดขีองหลกัฐ�น รวัมัถง่ผู้ลก�รศก่ษ�ที�ร�ยง�นโดย PAGAC และบทปริทศัน์ใหม่ัจัำ�นวัน 13 บทที�เป็นไปต�มัหลกัเกณิฑ์ก์�รนำ�ผู้ลเขี� เพ่็�อสำร� งหลกัฐ�น เกี�ยวักบัค์วั�มัเช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งและผู้ลลพั็ธิเ์กี�ยวัเน่� องกบัสุำขีภั�พ็ในผู้้�ใหญ่่ ก�รค์�นห�ค์วั�มัต่อเน่�องระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งและผู้ลลพั็ธิท์�งสุำขีภั�พ็เป็นสำ�ขี�ท�งสำ�ธิ�รณิสุำขี ที� ค่์อนขี� งใหม่ั เม่ั�อเทียบกบัเร่�องกิจักรรมัท�งก�ยที� ไม่ัเพี็ยงพ็อ แต่ยงัมีัก�รพ็ฒัน�อย่�งรวัดเร็วั ในทศวัรรษที�ผู่้�นมั� ง�นวิัจัยันั�นได�วัดัพ็ฤติกรรมัเน่อยนิ�งอย่�งเป็นระบบโดยใช�ทั�ง 1) แบบสำอบ- ถ�มัเพ่็�อร�ยง�นผู้ลด�วัยตนเองที�ถ�มัทั�ง “เวัล�โดยรวัมั” ที�ใช�ไปกบัพ็ฤติกรรมัเน่อยนิ�งหร่อเวัล�ที� ใช�กบัพ็ฤติกรรมัเฉพ็�ะ เช่น ก�รด้โทรทศัน ์เวัล�ที�อย่้กบัหน� จัอ/หน� จัอค์อมัพิ็วัเตอร ์และก�รนั�ง 2) ก�รวัดัด�วัยอุปกรณิ ์ ไม่ัมีัก�รวัดัที� เป็นมั�ตรฐ�นหร่อต�นแบบในก�รวิัเค์ร�ะหพ์็ฤติกรรมัเน่อยนิ�ง ดงันั�นก�รร�ยง�นผู้ลจั่งแตกต่�งกนัไป ก�รพ็ฒัน�ระเบียบวิัธีิวิัจัยัเม่ั�อไม่ัน�นนี�ได�รวัมัเอ�ก�ร ประเมิันก�รใช�เวัล�ขีองพ็ฤติกรรมัเน่อยนิ�งด�วัยเค์ร่�องม่ัอเอ�ไวั� ซ่�งสำ�มั�รถลดขี�อผิู้ดพ็ล�ดในก�ร วัดัและค์วั�มัโน�มัเอียงที� ได�จั�กก�รระลก่ขี�อม้ัลที�ร�ยง�นผู้ลด�วัยตนเอง ในวัยัผู้้�ใหญ่่นั�น เวัล�ขีองพ็ฤติกรรมัเน่อยนิ�งที�มั�กขี่ �นจัะต�มัมั�ด�วัยผู้ลเสีำยด� นสุำขีภั�พ็ อ�ทิเช่น สำ�เหตุก�รเสีำยชีวิัตทุกประก�ร สำ�เหตุก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อดหวััใจั และก�รเสีำยชีวิัตจั�กโรค์มัะเร็ง และสำ�เหตุก�รเกิดโรค์หลอดเล่อดหัวัใจั มัะเร็ง และโรค์เบ�หวั�นชนิดที�สำอง แนะนำ�ให:้ ผ้ ใ้หญ่่ค์วรจำ�กดัระยะเวล�ข้องพฤติิกรรมัเนือยนิ�ง และทดแทนเวล�เหล่�นั�น ดว้ยกิจกรรมัท�งก�ยในทุกระดบัที�มีัประโยช้นด์�้นสุำข้ภ�พ (รวมัถง้ระดบัเบ�) แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�ง เพื�อช่้วยลดผลเสีำยต่ิอสุำข้ภ�พจ�กพฤติิกรรมัเนือยนิ�งในระดบัส้ำง ผ้ ใ้หญ่่ค์วรจะมุ่ังทำ� กิจกรรมัท�งก�ยที�ระดบัป�นกล�งหรือหนกัใหม้ั�กกว่�ระดบัที�แนะนำ� แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได�ป�นกล�ง > > ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 58 ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ในก�รพิ็จั�รณิ�องค์ร์วัมัขีองหลกัฐ�น ค์ณิะทำ�ง�น GDG ให�นำ � หนกัส่ำวันใหญ่่ไปที�หลกัฐ�นที� บทปริทศัน์ให�ค์ะแนนระดบักล�งและส้ำงกว่ั� โดยมั�จั�กบทปริทศันที์� ได�หลกัฐ�นจั�กก�รศก่ษ�ที� ใช�ก�รวัดัเวัล�ที�มีัพ็ฤติกรรมัเน่อยนิ�งหร่อนั�งอย่้เฉย ๆ หร่อก�รวัดัพ็ฤติกรรมัเน่อยนิ�งด�วัยอุปกรณิ ์ เม่ั�อห�ได� ร�ยละเอียดที�ค์รบถ�วันเกี�ยวักบัวิัธีิวิัจัยั ก�รแยกส่ำวันขี�อม้ัล และชุดขี�อม้ัลหลกัฐ�นอย่้ที� ภั�ค์ผู้นวักบนเว็ับไซต ์: ชุดหลกัฐ�น7 ง�นวิัจัยัเกี�ยวักบัผู้ลเสีำยต่อสุำขีภั�พ็ที� เช่�อมัโยงกบัพ็ฤติกรรมัเน่อยนิ�งได�เพิ็�มัพ้็นขี่ �นอย่�ง รวัดเร็วัตลอดทศวัรรษที�ผู่้�นมั� ในง�นวิัจัยัที�ทนัสำมัยักว่ั� พ็บก�รพ็ฒัน�ที�โดดเด่น ดงันี� ก�รเพิ็�มัขี่ �น ขีองหลกัฐ�นที�ร�ยง�นเร่�องค์วั�มัสำมััพ็นัธิร์ะหว่ั�งก�รตอบสำนองต่อปริมั�ณิระหว่ั�งพ็ฤติกรรมั เน่อยนิ�งและผู้ลลพั็ธิต่์อสุำขีภั�พ็หล�ยประก�ร และผู้ลกระทบระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งและ กิจักรรมัท�งก�ย 7 ข้้อม่ัลออนไลน์ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ในผ้ใ้หญ่่ (อ�ยุ 18 ปีข้้ �นไป) ค์ว�มัสำมััพนัธิ์ ์ ระหว่�งพฤติิกรรมัเนือยนิ�งและผลลพัธิ์ ์ ที�เกี�ยวเนื�องกบัสุำข้ภ�พคื์ออะไร โดยรวัมัแล�วั มีัหลกัฐ�นเกี�ยวักบั ค์วั�มัเช่� อมัโยงระหว่ั�งเวัล�ที� ใช� ไปกบั พ็ฤติกรรมัเน่อยนิ� งที�มั�กขี่ �น (วัดัผู่้�น ก�รประเมิันจั�กก�รร�ยง�นด�วัยตนเอง หร่อประเมิันด�วัยเค์ร่องม่ัอจั�กเวัล� ที� นั� ง เ ฉ ย ๆ ห ร่ อ เวั ล � ด้ โท ร ทัศ น์) แ ล ะ สำ � เห ตุ ก� ร เ สีำ ย ชี วิั ต ทุ ก สำ � เห ตุ ก�รเสีำยชีวิัตจั�กหลอดเล่อดหัวัใจั และ โอก�สำในก�รเกิดโรค์หลอดเล่อดหัวัใจั และเบ�หวั�นชนิดที�สำองที�มั�กขี่ �น (8, 35, 65, 87) ตวััอย่�งเช่น หลกัฐ�นสำนบัสำนุน รวัมัผู้ลจั�กก�รวิัเค์ร�ะห์อภิัมั�นชิ�น ใหญ่่และทนัสำมัยั (n= 36 383; อ�ยุเฉลี�ย 62.6 years; 72.8% เพ็ศหญิ่ง) ขีองเค์ร่�อง วัดัค์วั�มัเร่งที�ประเมิันเวัล�ขีองพ็ฤติกรรมั เน่อยนิ�งโดยรวัมัและสำ�เหตุิก�รเสีำยชี้วิติ ทุกสำ�เหตุิ (65) และชี�ว่ั� เวัล�ที�ใช�กบัพ็ฤติ- กรรมัเน่อยนิ�งที�เพิ็�มัมั�กขี่ �นนั�น เช่�อมัโยง อย่�งมีันัยสำำ�ค์ญั่กบัภั�วัะก�รเสีำยชีวิัต จั�กทุกสำ�เหตุ ผู้ลก�รศก่ษ�ที�ค์ล� ยค์ลง่ กนั จั�กก�รวิัเค์ร�ะหอ์ภิัมั�นที�มีัผู้้�เขี� ร่วัมั มั�กกว่ั� 1 ล� นค์น (87) แสำดงให�เห็นถง่ ค์วั�มัเช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อย นิ� งทุกแบบกับภั�วัะก�รเสีำยชี้วิติทุก สำ�เหตุิ และภั�วัะก�รเสีำยชี้วิติจ�กโรค์ หลอดเลือดหัวใจหลังจั�กก�รปรับ กิจักรรมัท�งก�ย (87) แมั�ว่ั�ในง�นวิัจัยั ฉบบันี� ก�รเช่�อมัโยงกบัภั�วัะก�รเสีำยชี้วิติ จ�กโรค์มัะเร็งจัะไม่ัมีันยัสำำ�ค์ญั่ท�งสำถิติ หลงัจั�กก�รปรบักิจักรรมัท�งก�ย (87) ก�รวิัเค์ร�ะหอ์ภิัมั�นอีกชิ�นหน่� ง เม่ั�อไม่ัน�นมั�นี� (8) ร�ยง�นถง่ค์วั�มัเช่�อมั โยงที�สำำ�ค์ญั่ระหว่ั�งพ็ฤติกรรมัเน่อยนิ�ง (ประเมิันขีณิะนั�ง) และก�รเสีำยชี้วิติจ�ก โรค์หลอดเลือดหวัใจแลโรค์กมัะเร็ง 59 ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ซ่�งผู้ลที� ได� ชี �ถ่งค์วั�มัเสีำ�ยงต่อภั�วัะก�ร เสีำยชีวิัตจั�กโรค์หลอดเล่อดหัวัใจัที� ส้ำง ขี่ �น 9-32% (p for trend < 0.001) ด�วัย พ็ฤติกรรมัเน่อยนิ�งในระดบัที� ส้ำงขี่ �น เม่ั�อ วัดัขีณิะนั�ง “นิ�ง ๆ” มีักิจักรรมัท�งก�ย ในช่วังค์วัอไทลที์�ตำ� สุำด (~ 5 น�ที/วันั) ผู้ลวิัจััยบอกว่ั�ผู้้� ใหญ่่ที� มีัพ็ฤติกรรมั เน่อยนิ�ง (นั�งนิ�ง ๆ ) มั�กกว่ั� 8 ชั�วัโมังต่อวันั จัะมีัค์วั�มัเสีำ�ยงต่อภั�วัะก�รเสีำยชีวิัตจั�ก โรค์ หลอดเล่อดหวััใจัส้ำงกว่ั� ยกเวั�นผู้้�ที� “ค์ล่องแค์ล่วัที� สุำด” ( ตัวัอย่�งเช่น > 3 5 . 5 M E T- ชั� วั โ มั ง ต่ อ สำัป ด � ห ์ หร่อ ~ 60–75 น�ทีต่อวััน) ซ่� งค์วั�มั เช่�อมัโยงนั�นผู่้อนปรนลง ผู้ลจั�กค์วั�มั เช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งและ ภั�วัะก�รเสีำยชี้วิติจ�กโรค์มัะเร็งยิ�งอ่อน กว่ั� แมั�ว่ั�จัะสำงัเกตเห็นได�ถง่ค์วั�มัเสีำ�ยงที� เกี�ยวัเน่�องกบัปริมั�ณิที� ส้ำงขี่ �นถง่ร�อยละ 6 ถ่ง 21 เม่ั�อเวัล�ที�นั� งเฉยย�วัน�นขี่ �น ( โดยเฉพ็�ะอย่�งยิ� งเม่ั� อมั�กกว่ั� 8 ชั�วัโมังต่อวันั) แต่เฉพ็�ะกบัผู้้�ที�มีักิจักรรมั ท�งก�ยในช่วังค์วัอไทลที์�ตำ� ที� สุำดเท่�นั�น (< 2.5 MET-ชั�วัโมังต่อสำปัด�ห)์ (8) หลกัฐ�นสำนบัสำนุนค์วั�มัเช่�อมัโยง ระหว่ั�งพ็ฤติกรรมัเน่อยนิ� ง (วััดจั�ก เวัล�ที�นั� งทั�งหมัด) และสำ�เหตุก�รเกิด โรค์หลอดเลือดหวัใจที� เพิ็� มัขี่ �น (HR= 1.29 [95% CI: 1.27 to 1.30]) ซ่�งลดลง จั�กก�รปรับตวััแปรร่วัมัที� อ�จัเป็นไป ได� รวัมัถ่งปรบัระดบักิจักรรมัท�งก�ย (HR= 1.14 [95% CI: 1.04 to 1.23]) (88) บทปริทัศนข์ีองก�รวิัจััยในกลุ่มั ประช�กรช�วัเอเชียตะวันัออกเฉียงใต� แสำดงหลกัฐ�นว่ั� มีัค์วั�มัน่�เช่�อถ่อตำ� ขีองเวัล�ในก�รมีัพ็ฤติกรรมัเน่อยนิ� งที� ย�วัน�นขี่ �นจัะเช่�อมัโยงกบัค์วั�มัเป็นไป ได�ที� เพิ็� มัส้ำงขี่ �นกบัติวัชี้ �วดัภยัเสีำ�ยงโรค์ หวัใจและหลอดเลือด (รวัมัถง่เบ�หวั�น ชนิดที� 2, ดชันีมัวัลก�ยเพิ็� มัขี่ �น ค์วั�มั ดนัโลหิตที�ส้ำงขี่ �น) (89) ง�นวิัจััย 2 ฉบับล่�สุำดร�ยง�น ถง่ค์วั�มัเช่�อมัโยงขีองระยะเวัล�ที�นั�งเฉย ๆ ในแต่ละวัันโดยรวัมั (88) และพ็ฤติ- กรรมัเน่อยนิ�งทั�งหมัด และเวัล�ด้โทรทศัน ์ (87) กับกิารเกิิดุเบาหวานชนิดุที� 2 ง�นวิัจัยัทั�ง 2 ชิ �นพ็บว่ั� พ็ฤติกรรมัเน่อย- นิ� งในระดับที� ส้ำงขี่ �นเช่� อมัโยงกับค์วั�มั เสีำ� ยงต่อก�รเกิดเบ�หวั�นชนิดที� 2 ที�เพิ็�มัขี่ �น ตวััอย่�งเช่น ค์วั�มัเช่�อมัโยงที�เป็น เสำ�นตรงกบัเบ�หวั�นชนิดที� 2 นั�นสำงัเกต เห็นได�สำำ�หรบัพ็ฤติกรรมัเน่อยนิ�งโดยรวัมั (RR= 1.01 [95% CI: 1.00 to 1.01] p= < 0.001) และก�รด้โทรทศัน ์(RR= 1.09 [95% CI: 1.07 to 1.12] p= < 0.001) เม่ั�อปรบัเพ่็�อกิจักรรมัท�งก�ย (87) มีัหลกัฐ�นสำนบัสำนุนค์วั�มัเช่�อมัโยง ที� มีั นั ย สำำ � ค์ั ญ่ ร ะ ห ว่ั � ง พ็ ฤ ติ ก ร ร มั เน่อยนิ�ง (เม่ั�อวัดัขีณิะใช�เวัล�ด้โทรทศัน)์ และภาวะอนัต่รายจากิโรคมะเร็ง (35, 87) บทปริทศันฉ์บบัล่�สุำดหล�ยชิ�นที� มีั ค์วั�มัน่�เช่�อถ่อตำ� และตำ� มั�กให�หลกัฐ�น สำนับสำนุนถ่งค์วั�มัเช่� อมัโยงระหว่ั�ง พ็ฤติกรรมัเน่อยนิ�งและโรค์มัะเร็งลำ�ไสำ� (90) แต่ไม่ัมีัค์วั�มัเช่�อมัโยงกบัโรค์มัะเร็ง ต่อมัล้กหมั�ก โรค์มัะเร็งเต� นมั หร่อโรค์ มัะเร็งลำ�ไสำ�ตรง (90-93) หลกัฐ�นเพิ็�มัเติมั (35) ร�ยง�นค์วั�มัเช่�อมัโยงที�มีันยัสำำ�ค์ญั่ ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 60 ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ระหว่ั�งระยะเวัล�ที� ใช�ไปกบัพ็ฤติกรรมั เน่อยนิ�งที�มั�กขี่ �นและค์วั�มัเสีำ�ยงที� ส้ำงขี่ �น ที�จัะก่อให�เกิดโรค์มัะเร็งเย่�อบุโพ็รงมัดล้ก โรค์มัะเร็งลำ�ไสำ� และมัะเร็งปอด (35) มีัหลักฐ�นที� เช่� อถ่อได�น�อยขีอง ค์วั�มัสำมััพ็นัธิที์� เป็นภัยัระหว่ั�งเวัล�ที� ใช� ไปกบัพ็ฤติกรรมัเน่อยนิ� งและโรค์อว้น และตวัับ่งชี�สำถ�นะขีองนำ � หนกั และไม่ัว่ั� ค์วั�มัสำมััพ็นัธิร์ะหว่ั�งพ็ฤติกรรมัเน่อยนิ�ง และสำถ�นะขีองนำ � หนักจัะผู้ันแปรไป ต�มัปริมั�ณิขีองกิจักรรมัท�งก�ยระดบั ป�นกล�งถง่หนกั โดยรวัมัแล�วั สำรุปได�ว่ั� มีั ห ลัก ฐ � น ไ ม่ั เพี็ ย ง พ็ อ ที� จั ะ แจั�ง ถ่ง ค์ำ�แนะนำ�/ขี�อแนะนำ�เหล่�นี�และต�องก�ร ก�รวิัจัยัเพิ็�มัเติมั มีัหลักฐ�นที� จัำ�กัดที� ประเมิันผู้ล ด� นตรงกันขี� มัจั�กก�รลดเวัล�ขีอง พ็ฤติกรรมัเน่อยนิ�ง ค์วั�มัคิ์ดเห็นจั�กผู้้� เชี�ยวัช�ญ่ร�ยง�นบทสำรุปว่ั� ขี�อแนะนำ� ก�รลดเวัล�ที�มีัพ็ฤติกรรมัเน่อยนิ�งไม่ัน่� จัะเพิ็�มัค์วั�มัเสีำ�ยงจั�กอ�ก�รบ�ดเจ็ับ โดย เฉพ็�ะเม่ั�อทดแทนด�วัยกิจักรรมัท�งก�ย ในระดบัเบ� ค์ณะทำ�ง�น GDG สำรุปว่� • โดยรวัมัแล�วั มีัหลกัฐ�นเพี็ยงพ็อที�จัะ สำนับสำนุนก�รพ็ฒัน�ขี�อแนะนำ�ขีอง องค์ก์�รอน�มััยโลกฉบับใหม่ั เพ่็� อ จัำ�กดัพ็ฤติกรรมัเน่อยนิ�งเพ่็�อลดค์วั�มั เสีำ�ยงต่อสุำขีภั�พ็ • มีัหลกัฐ�นที� เช่� อถ่อได�ป�นกล�งถ่ง ก�รเช่�อมัโยงระหว่ั�งเวัล�ที�มั�กขี่ �น ที� ใช�กบัพ็ฤติกรรมัเน่อยนิ�งและภั�วัะ ก�รเสีำยชีวิัตทุกสำ�เหตุ ภั�วัะก�ร เสีำยชีวิัตจั�กโรค์หลอดเล่อดหัวัใจั ภั�วัะก�รเสีำยชีวิัตจั�โรค์กมัะเร็ง และ ก�รเกิดโรค์หลอดเล่อดหวััใจัและโรค์ เบ�หวั�นชนิดที� 2 ที� ส้ำงขี่ �น • มีัหลกัฐ�นที� เช่�อถ่อตำ� ไปจันถง่ระดบั กล�งขีองก�รเช่�อมัโยงระหว่ั�งก�ร ใช�เวัล�กบัพ็ฤติกรรมัเน่อยนิ�งที�มั�ก ขี่ �นและค์วั�มัเสีำ� ยงที�มั�กขี่ �นต่อก�ร เกิดโรค์มัะเร็งเย่�อบุมัดล้ก โรค์มัะเร็ง ลำ�ไสำ� และโรค์มัะเร็งปอด • มีัหลกัฐ�นไม่ัเพี็ยงพ็อเกี�ยวักบัค์วั�มั เช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ�ง และก�รวัดัภั�วัะโรค์อ�วัน และต�องก�ร ง�นวิัจัยัเพิ็�มัเติมั • ประโยชนข์ีองก�รจัำ�กดัพ็ฤติกรรมั เน่อยนิ� งมีัมั�กกว่ั�ค์วั�มัเสีำ� ยงใด ๆ ที�อ�จัเกิดขี่ �น มีัค์ว�มัสำ ัมัพ ันธิ์ที์� เ ชื้� อมัโยงก ับก�ร ติอบสำนองต่ิอปริมั�ณหรือไม่ั (ปริมั�ณ ท ั�งหมัด ค์ว�มัถี� ระยะเวล� ค์ว�มัรุนแรง ข้องก�รหยุดช้ะงกั) หลกัฐ�นทั�งหมัดทั�งมัวัลที�เช่�อถ่อได� ป�นกล�งบ่งชี�ว่ั� ค์วั�มัสำมััพ็นัธิก์�รตอบ สำ นอง ต่ อ ป ริ มั � ณิที� ไ ม่ั เ ป็ น เ สำ�น ต รง ระหว่ั�งเวัล�ที�มีัก�รทำ�พ็ฤติกรรมัเน่อย- นิ�ง (ก�รนั�ง หร่อ เวัล�ด้โทรทศันที์�ประเมิัน โดยก�รร�ยง�นตนเอง หร่อก�รประเมิัน โดยเค์ร่�องม่ัอ) และ ภั�วัะก�รเสีำยชีวิัตทุก สำ�เหตุ ภั�วัะก�รเสีำยชีวิัตจั�กโรค์หลอด- เ ล่อดหัวัใจั ภั�วัะก�รเ สีำ ยชีวิัตจั�ก โรค์มัะเร็ง และก�รเกิดโรค์หลอดเล่อด หวััใจั (8, 35, 87) 61 ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ก�รวิัเค์ร�ะหอ์ภิัมั�นเม่ั� อไม่ัน�น มั�นี� ทำ�ให�มีัหลกัฐ�นที�มีัค์วั�มัน่�เช่�อถ่อส้ำง ในด� นค์วั�มัสำมััพ็นัธิข์ีองก�รตอบสำนอง ต่อปริมั�ณิระหว่ั�งเค์ร่�องวัดัค์วั�มัเร่งที� ประเมิันเวัล�ขีองก�รมีัพ็ฤติกรรมัเน่อย นิ� งทั�งหมัดและภาวะกิารเสียชีวิต่ทุกิ สาเหตุ่ (65) ที� ร�ยง�นว่ั�เวัล�ที� ใช�ใน พ็ฤติกรรมัเน่อยนิ� งที� เพิ็� มัมั�กขี่ �นนั�น เช่�อมัโยงอย่�งมีันัยสำำ�ค์ญั่กบัภั�วัะก�ร เสีำยชีวิัตทุกสำ�เหตุ อตัร�ส่ำวันค์วั�มัเสีำ�ยง อนัตร�ยสำำ�หรบัค่์�ค์วัอไทลที์� เพิ็�มัส้ำงขี่ �น สำำ�หรบัเวัล�ขีองพ็ฤติกรรมัเน่อยนิ�ง ค่์อ 1.00 (ผู้้�อ� งอิง นิ�งเฉยน�อยที� สุำด) 1.28 (1.09– 1.51) 1.71 (1.36–2.15) และ 2.63 (1.94–3.56) หลงัจั�กก�รปรบัตวัั วัดัที�เป็นไปได� รวัมัทั�งเวัล�ที�ใช�กบักิจักรรมั ท�งก�ยที�ระดบัป�นกล�งถง่หนกั (65) ก�รวิัเค์ร�ะหค์์วั�มัสำมััพ็นัธิ ์ในก�รตอบ สำนองต่อปริมั�ณิระ หว่ั�งเวัล�ขีอง พ็ฤติกรรมัเน่อยนิ�งและภั�วัะก�รเสีำยชีวิัต แสำดงถ่งค์วั�มัเสีำ� ยงที� ค่์อย ๆ เพิ็� มัขี่ �น จั�กประมั�ณิ 7.5-9 ชั� วัโมัง และยิ� ง ชัด เจั น เ ม่ั� อ มั � ก ก ว่ั � 9 . 5 ชั� วั โ มั ง พ็ฤติกรรมัเน่อยนิ�งที� 10 ชั�วัโมังและ 12 ชั� วั โ มั ง ใน แ ต่ ล ะ วััน เ ช่� อ มั โ ย ง กับ ค่์ � ค์วั�มัเสีำ�ยงในก�รเสีำยชีวิัตที�ส้ำงขี่ �น ที� 1.48 (1.22–1.79) และ 2.92 (2.24–3.83) ต�มัลำ�ดบั บทวิัเค์ร�ะห์อภิัมั�นอีกชิ�นหน่� ง ประเมิันก�รตอบสำนองต่อปริมั�ณิและ ร�ยง�นค์วั�มัเช่� อมัโยงที� ไม่ัอย่้บนเสำ�น ตรงเดียวักนั สำำ�หรบัเวัล�ขีองพ็ฤติกรรมั เน่อยนิ�งทั�งหมัดและภาวะกิารเสียชีวิต่ ทุกิสาเหตุ่ (RR ต่อ 1 ชั�วัโมัง/วันั = 1.01 (1.00–1.01) สำำ�หรบั ≤ 8 ชั�วัโมัง/วันั และ 1.04 (1.03–1.05) สำำ�หรบั > 8 ชั�วัโมัง/ วันัที� เขี� ถง่) และภาวะกิารเสียชีวิต่จากิ โรคหลอดุเล่อดุหวัใจ (RR= 1.01 (0.99– 1.02) สำำ�หรบั ≤ 6 ชั�วัโมัง/วันั และ RR= 1.04 (1.03–1.04) สำำ�หรบั > 6 ชั�วัโมัง/ วันั) หลงัจั�กก�รปรบักิจักรรมัท�งก�ย (87) ในง�นวิัจัยัชิ �นเดียวักนันี� มีัค์วั�มั เช่�อมัโยงต่อก�รตอบสำนองต่อปริมั�ณิ เป็นเสำ�นตรงเล็กระหว่ั�งโรคเบาหวาน ชนิดุที� 2 กบัพ็ฤติกรรมัเน่อยนิ�งโดยรวัมั (1.01 (1.00– 1.01)) เม่ั�อปรบักิจักรรมั ท�งก�ยและก�รด้โทรทศัน ์(1.09 (1.07– 1.12)) (87) โดยรวัมัแล�วั หลกัฐ�นสำนบัสำนุนว่ั� พ็ฤติกรรมัเน่อยนิ�งในปริมั�ณิมั�กเช่�อมั- โ ยง กับ ผู้ ล ลัพ็ ธิ ์ท�ง สุำ ขี ภั� พ็ ที� แ ย่ ลง และมีัหลักฐ�นเพี็ยงพ็อที� จัะสำนับสำนุน ว่ั� ก�รลดเวัล�ขีองพ็ฤติกรรมัเน่อย- นิ� ง ใ ห� น� อ ย ล ง จั ะ ล ด ค์ วั � มั เ สีำ� ย ง ต่ อ สุำขีภั�พ็ อย่�งไรก็ดี ก�รให�ตัวัแปรที� เหมั�ะสำมัว่ั�ค์วัรจัะประเมิันพ็ฤติกรรมั เน่อยนิ�งอย่�งไรในบทปริทศันน์ั�น ๆ (ผู่้�น เวัล�นั� งที� มั�จั�กก�รร�ยง�นผู้ลด�วัย ตนเอง เวัล�ในก�รด้โทรทศัน ์ หร่อก�ร ประเมิันด�วัยอุปกรณิห์ร่อเค์ร่�องวัดัค์วั�มั เร่ง) และค์วั�มัเป็นไปได�ที� ขีีดจัำ�กดัขีอง เวัล�ที�มีัพ็ฤติกรรมัเน่อยนิ�งอ�จัจัะหล�ก- หล�ยไปต�มัผู้ลลพั็ธิท์�งสุำขีภั�พ็ต่�ง ๆ ด�วัยระดบัขีองกิจักรรมัท�งก�ยตั�งแต่ ป � น ก ล � ง ไ ป จั น ห นั ก แ ล ะ ก ลุ่ มั ป ร ะ ช� ก ร ก ลุ่ มั ย่ อ ย ไ ม่ั มีั ห ลัก ฐ � น เพี็ยงพ็อที� จัะกำ�หนดค์ำ�แนะนำ�เร่� อง เวัล� (ระบุเวัล�) ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 62 นอกจั�กปริมั�ณิทั�งหมัดขีองพ็ฤติกรรมั เน่อยนิ�งแล�วั มีัก�รทบทวันหลกัฐ�นเกี�ยวั กบัร้ปแบบที�พ็ฤติกรรมัเน่อยนิ�งพ็อกพ้็น ขี่ �นด�วัย อย่�งไรก็ต�มั ยงัมีัหลกัฐ�นจัำ�นวัน จัำ�กดัที�จัะสำร� งขี�อแนะนำ�เกี�ยวักบัค์วั�มัถี� และ/หร่อระยะเวัล�ขีองก�รหยุดพ็กัใน ก�รทำ�พ็ฤติกรรมัเน่อยนิ�ง ค์ณะทำ�ง�น GDG สำรุปว่� • ไม่ัมีัหลกัฐ�นเพี็ยงพ็อที�จัะกำ�หนดขี�อ แนะนำ�ต�มัปริมั�ณิ (ต�มัระยะเวัล�) เกี�ยวักบัพ็ฤติกรรมัเน่อยนิ�ง • ไม่ัมีัหลกัฐ�นเพี็ยงพ็อที�จัะกำ�หนดขี�อ แนะนำ�เร่�องค์วั�มัถี� และ/หร่อ ระยะเวัล� หยุดพ็กัในก�รทำ�พ็ฤติกรรมัเน่อยนิ�ง ค์ว�มัสำมััพนัธิ์ผ์นัแปรติ�มัประเภทและ ข้อบเข้ติข้องพฤติิกรรมัเนือยนิ�งหรือไม่ั ขีอบเขีตหร่อชนิดขีองพ็ฤติกรรมั เน่อยนิ�งที�ต่�งกนับ�งชนิดอ�จัจัะเป็นภัยั กว่ั�ชนิดอ่�น ๆ ทั�งในส่ำวันขีองก�รเช่�อมัโยง ต่อกนัโดยตรงและค์วั�มัเป็นไปได�ที�จัะ หักล� งเวัล�ที� ค์วัรใช�กับกิจักรรมัท�ง ก�ย ที� มีัผู้ลดีต่อสุำขีภั�พ็มั�กกว่ั� แมั�ว่ั� ง�นวิัจััยเร่� องพ็ฤติกรรมัเน่อยนิ� งจัะ เพิ็�มัมั�กขี่ �นอย่�งรวัดเร็วั แต่มีัหลกัฐ�น อย่้จัำ�กดัที� เปรียบเทียบค์วั�มัเช่�อมัโยง ระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งต่�งชนิดกนั และผู้ลลัพ็ธิท์�งสุำขีภั�พ็ที� ต่�งกันไป ตวััอย่�งเช่น ง�นวิัจัยับ�งชิ�นร�ยง�นผู้ล ที� น่�เช่� อถ่อยิ� งขี่ �นเกี� ยวักับพ็ฤติกรรมั เน่อยนิ�งที�วัดัขีณิะด้โทรทศันเ์ปรียบเทียบ กับเวัล�ที� นั� งทั�งหมัด (87) นี� อ�จัเป็น เพ็ร�ะค์วั�มัผิู้ดพ็ล�ดจั�กก�รวััดที� แตกต่�งกันหร่อตัวัวััดที� เหล่ออย่้ ที� เช่�อมัโยงกบัก�รวัดัแบบร�ยง�นตนเอง และเค์ร่�องม่ัอต่�ง ๆ ณิ ขีณิะนี� ยงัไม่ัมีั หลักฐ�นเพี็ยงพ็อที� จัะกำ�หนดค์วั�มั เ ช่� อ มั โ ยง กับ ผู้ ล ลัพ็ ธิ ์ท � ง สุำ ขี ภั � พ็ ที� แตกต่�งกนั และสิำ�งที�อ�จัผู้นัแปรต�มั กลุ่มัประช�กรย่อย จัำ�นวันง�นวิัจัยัที� ใช�เค์ร่� องม่ัอใน ก�รวัดักิจักรรมัท�งก�ยและเวัล�ในก�ร ทำ�พ็ฤติกรรมัเน่อยนิ� งต่อผู้ลลพั็ธิด์� น สุำขีภั�พ็มีัเพิ็� มัมั�กขี่ �น อย่�งไรก็ต�มั อ�จัมีัก�รจัดัประเภัทผิู้ดจั�กก�รวัดัเวัล� ในก�รทำ�พ็ฤติกรรมัเน่อยนิ�งเม่ั�อวัดัด�วัย อุปกรณิเ์พ็ร�ะตำ�แหน่งที� วั�งอุปกรณิ ์ เหล่�นี� (เช่น ขี�อม่ัอ รอบเอวั) ยงัไม่ัสำ�มั�รถ แยกแยะท่�ท�งต่�ง ๆ ได� (เช่น ก�รนอน ก�รนั�ง ก�รย่นเฉย ๆ) ง�นวิัจัยัในอน�ค์ต ที�ใช�ก�รร�ยง�นที�สำอดค์ล�องกนัและวิัธีิที� แยกแยะท่�ท�งได� จัะช่วัยเสำริมัสำร� งค์วั�มั ร้�เร่�องร้ปแบบขีองพ็ฤติกรรมัเน่อยนิ�ง ค์ณะทำ�ง�น GDG สำรุปว่� • ไม่ัมีัหลกัฐ�นเพี็ยงพ็อที�จัะให�ค์ำ�แนะนำ� เร่�องประเภัทและขีอบเขีตที�แตกต่�ง กนัขีองพ็ฤติกรรมัเน่อยนิ�ง ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) 63 ระดบัข้องกิจกรรมัท�งก�ยเปลี� ยน แปลงผลกระทบข้องพฤติิกรรมัเนือย นิ�งต่ิอก�รเสีำยชี้วิติไดห้รือไม่ั ค์ วั � มั สำ น ใ จั ที� เ พิ็� มั มั � ก ขี่ �น ต่ อ ผู้ลกระทบขีองพ็ฤติกรรมัเน่อยนิ� งต่อ ผู้ลลัพ็ธิด์� นสุำขีภั�พ็ได�กระตุ�นให�เกิด ก�รค์�นห�ค์วั�มัสำมััพ็นัธิที์�อ�จัเช่�อมัโยง ระหว่ั�งระดบักิจักรรมัท�งก�ยที� ต่�ง กันและระดับขีองพ็ฤติกรรมัเน่อยนิ� ง จั�กวิัจััยที� มีัอย่้ มีัหลกัฐ�นที� เช่� อถ่อได� ป�นกล�งว่ั� ค์วั�มัสำมััพ็นัธิร์ะหว่ั�งพ็ฤติ- กรรมัเน่อยนิ�งและกิารเสียชีวิต่ทุกิสาเหตุ่ กิารเสียชีวิต่จากิโรคหลอดุเล่อดุหวัใจ แ ล ะ กิ า ร เ สี ย ชี วิ ต่ จ า กิ โ ร ค ม ะ เ ร็ ง แปรไปต�มัปริมั�ณิกิจักรรมัท�งก�ย ที� ระดับป�นกล�งจันถ่งระดับหนัก (8, 9, 35) ผู้ลก�รศก่ษ�โดยรวัมัแสำดงให� เห็นว่ั� ผู้ลกระทบจั�กพ็ฤติกรรมัเน่อย- นิ�งมีัมั�กกว่ั�ในผู้้�ที�ทำ�กิจักรรมัท�งก�ย ระดบัป�นกล�งจันถ่งหนักในปริมั�ณิ น�อย หร่อกล่�วัอีกท�งหน่� ง กิจักรรมั ท�งก�ยระดับป�นกล�งหร่อหนักใน ปริมั�ณิส้ำงจัะสำ�มั�รถบรรเท�ผู้ลเสีำยต่อ สุำขีภั�พ็ที�เกี�ยวัโยงกบัพ็ฤติกรรมัเน่อยนิ�ง ในระดบัที�ส้ำงขี่ �นได� ค์วั�มัเสีำ�ยงที� เช่�อมัโยงระหว่ั�งเวัล� ในก�รทำ�พ็ฤติกรรมัเน่อยนิ� งและก�ร เ สีำยชีวิัตในทุกสำ�เหตุนั�นชัดเจันขี่ �น เม่ั�อมีัก�รทำ�กิจักรรมัท�งก�ยในระดบัตำ� กว่ั�มั�กกว่ั�ระดบัส้ำงกว่ั� (35) ในบท วิัเค์ร�ะหอ์ภิัมั�นที�สำอดค์ล�องกนั อีค์ลุนด ์ และค์ณิะได�ตรวัจัสำอบผู้ลกระทบที�มีัร่วัมั กนัและผู้ลกระทบที�แยกเป็นชั�น ๆ จั�ก ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) พ็ฤติกรรมัเน่อยนิ�งและกิจักรรมัท�งก�ย กบัภั�วัะก�รเสีำยชีวิัตทุกสำ�เหตุในผู้้�ช�ย และผู้้�หญิ่งมั�กกว่ั� 1 ล� นร�ย และแสำดง ให�เห็นว่ั� ค์วั�มัเช่�อมัโยงนั�นต่�งกนัออกไป ขี่ �นอย่้กบัระดบัขีองก�รทำ�กิจักรรมัท�ง- ก�ย (9) ก�รวิัเค์ร�ะหน์ั�นใช�ช่วังขี�อม้ัล ค์วัอไทลข์ีองพ็ฤติกรรมัเน่อยนิ�ง (ก�รนั�ง) และช่วังขี�อม้ัลค์วัอไทลข์ีองกิจักรรมัท�ง ก�ยระดบัป�นกล�งจันถง่หนกั และพ็บว่ั� เม่ั�อเปรียบเทียบกบัร�ยก�รอ� งอิง (< 4 ชั�วัโมังขีองก�รนั�งต่อวันัและค่์�ค์วัอไทล ์ ส้ำงสุำดสำำ�หรับกิจักรรมัท�งก�ยระดับ ป�นกล�งจันถ่งหนัก [> 35.5 MET- ชั� วัโมัง/ สำัปด�ห์]) ไม่ัมีัค์วั�มัเสีำ� ยงต่อ ก�รเสีำยชีวิัตที� เพิ็� มัส้ำงขี่ �นระหว่ั�งก�ร ติดต�มัอ�ก�รกับผู้้�ที� นั� งมั�กกว่ั� 8 ชั�วัโมังต่อวันั แต่ยงัร�ยง�นว่ั�มีัก�รทำ� กิจักรรมัมั�กกว่ั� 35.5 ชั�วัโมัง (MET hour) ต่อสำปัด�ห ์(HR= 1.04 [95% CI: 0.99 to 1.10]) ในท�งกลบักนั ผู้้�ที�นั� งน�อยที� สุำด (< 4 ชั�วัโมัง/วันั) และอย่้ในช่วังค์วัอไทล ์ ขีองก�รทำ�กิจักรรมัท�งก�ยที�ตำ� ที� สุำด (< 2.5 MET-ชั�วัโมัง/สำปัด�ห)์ จัะมีัค์วั�มั เสีำ�ยงต่อก�รเสีำยชีวิัตเพิ็�มัขี่ �นอย่�งมีันัย สำำ�ค์ญั่ระหว่ั�งก�รติดต�มัอ�ก�ร (HR= 1.27 [95% CI: 1.22 to 1.31]) ง�นวิัจัยั สำรุปว่ั� ระดับขีองกิจักรรมัท�งก�ย ทั�งระดับป�นกล�งและหนักเป็นเวัล� ประมั�ณิ 60-75 น�ทีต่อวััน (ช่วัง ค์วัอไทลส้์ำงสุำด) อ�จัลดและกระทั�งจัำ�กดั ค์วั�มัเช่� อมัโยงที� เป็นอนัตร�ยระหว่ั�ง พ็ฤติกรรมัเน่อยนิ� งและผู้ลลัพ็ธิต่์อ สุำขีภั�พ็ได� ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 64 ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) พฤ ติกิ รัรั มเ นือ ยนื �งม �กิ ข้� นื กิิจกิรัรัมท�งกิ�ยท่�ม�กิขึ้�นื เวัล�ข้องพฤติิกิรัรัมเนืือยนิื� งลด็ลง และกิิจกิรัรัมท�งกิ�ยม�กิขึ้�นื คำวั�มเส่ำ�ยงสูำง คำวั�มเส่ำ�ยงติำ� เพิ�มกิ�รัออกิกิำ�ลังกิ�ยลด็เวัล�ในืกิ�รัทำ�พฤติิกิรัรัมเนืือยนิื�ง ร้ปที� 2: ค์ว�มัสำมััพนัธิ์ ์ ระหว่�งระดบัพฤติิกรรมัเนือยนิ�ง และกิจกรรมัท�งก�ย ประยุกตจ์ั�ก PAGAC ค์วั�มัสำมััพ็นัธิร์ะหว่ั�งระดบัขีอง พ็ฤติกรรมัเน่อยนิ�งและกิจักรรมัท�งก�ย ในระดบัป�นกล�งไปจันถ่งหนกัได�สำรุป ไวั�ในก�รทบทวันวัรรณิกรรมัอย่�งเป็น ระบบโดย PAGAC (35) ต�มัที� แสำดง ไวั�ในร้ปที� 2 ก�รวิัจััยอีกฉบบัเม่ั� อไม่ัน�นมั�นี� ได�สำร� งหลกัฐ�นฉบบัใหม่ัที�ตรวัจัสำอบ ค์วั�มัเช่� อมัโยงแบบเดิมักับก�รเสีำย ชี วิั ต ที� มีั สำ � เ ห ตุ เ ฉ พ็ � ะ แ ล ะ แ สำ ด ง ผู้ลก�รศ่กษ�ที� เหม่ัอนกัน (8) ในบท วิัเค์ร�ะหอ์ภิัมั�นจัำ�นวันมั�กที�สำอดค์ล�อง กนั (ง�นวิัจัยั 9 ชิ �น n = 850,000 กิาร เ สียชีวิต่จากิโรคหลอดุเล่อดุหัวใจ และง�นวิัจััย 8 ชิ �น n= 777,000 ภั�วัะก�รเสีำยชีวิัตจั�กโรค์มัะเร็ง) ผู้ล ปร�กฎว่ั�ก�รทำ�กิจักรรมัท�งก�ยที�ระดบั ป�นกล�งและหนกัในระดบัที�ส้ำงขี่ �น ทำ�ให� ค์วั�มัเสีำ�ยงต่อภั�วัะก�รเสีำยชีวิัตจั�กโรค์ หวััใจัเม่ั�อมีัพ็ฤติกรรมัเน่อยนิ�งในระดบัส้ำง ลดน�อยลง ไม่ัว่ั�จัะวัดัด�วัยเวัล�ที�นั�งเฉย ๆ หร่อเวัล�ด้โทรทศัน ์(8) ง�นวิัจัยัแสำดงว่ั� ในบุค์ค์ลที�นั�งนิ�งมั�กกว่ั� 8 ชั�วัโมังต่อวันั มีัค์วั�มัเช่�อมัโยงกบัค์วั�มัเสีำ�ยงต่อก�รเสีำย ชีวิัตที� เพิ็� มัขี่ �น ยกเวั�นในช่วังค์วัอไทลที์� ค์ล่องแค์ล่วัที� สุำดที� ค์วั�มัเช่� อมัโยงนี�จัะ ลดลง และเจั�ะจังลงไปกว่ั�นั�น อนัตร�ย จั�กก�รเสีำยชีวิัตด�วัยโรค์หลอดเล่อด หัวัใจัจัะส้ำงกว่ั�ถ่งร�อยละ 32 สำำ�หรับ ผู้้�ที� นั� งมั�กกว่ั� 8 ชั� วัโมังต่อวันัเปรียบ เทียบกบักลุ่มัอ� งอิง (< 4 ชั�วัโมังต่อวันั) (p สำำ�หรับแนวัโน�มั < 0.001) ผู้ลก�ร ทดลองชดัเจันน�อยลงแต่ยงัมีันยัสำำ�ค์ญั่ เม่ั�อเทียบกบักลุ่มัอ� งอิงในช่วังค์วัอไทล ์ อ่�นขีองก�รทำ�กิจักรรมัท�งก�ย (ค์วัอไทล ์ ที� 2 HR= 1.11 [95% CI: 1.03 to 1.20] ค์วัอไทลที์� 3 HR= 1.14 [95% CI: 1.03 to 65 ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) 1.26]) มีัก�รสำังเกตค์วั�มัเช่� อมัโยงที� ค์ล� ยค์ลง่กนัระหว่ั�งเวัล�ในก�รด้โทร- ทศันแ์ละก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อด หัวัใจัระหว่ั�งก�รทำ�กิจักรรมัท�งก�ย ที� ระดับป�นกล�งกับหนัก (8) ค์วั�มั เช่� อมัโยงระ หว่ั�งกิารเสียชีวิต่จากิ ม ะ เ ร็ ง นั�น ผู้ สำ มั ผู้ สำ � น กัน มั � ก ก ว่ั � แมั�ว่ั�จัะแสำดงให�เห็นว่ั� โดยทั�วัไปแล�วัก�ร ทำ�กิจักรรมัท�งก�ยในระดบัที� ส้ำงขี่ �นจัะ ลดภัยัอนัตร�ยจั�กพ็ฤติกรรมัเน่อยนิ�ง เม่ั�อประเมิันจั�กเวัล�ที�นั�งเฉย ๆ ทั�งหมัด จั�กหลกัฐ�นนี� เป็นที�ยอมัรบัว่ั�ค์วัร แนะนำ�ให�ทำ�กิจักรรมัท�งก�ยที� ระดบั ป�นกล�งและหนกัในระดบัที� ส้ำงขี่ �นกบั กลุ่มัค์นที�มีัพ็ฤติกรรมัเน่อยนิ�งในระดบัส้ำง และผู้ลดีที� ได�จัะมีัมั�กกว่ั�ค์วั�มัเสีำ�ยง ค์ณะทำ�ง�น GDG สำรุปว่� • มีัหลกัฐ�นที� เช่� อถ่อได�ป�นกล�งว่ั� ค์วั�มัเช่� อมัโยงระหว่ั�งพ็ฤติกรรมั เน่อยนิ� งและก�รเสีำยชีวิัตทุกสำ�เหตุ ก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อดหวััใจั และก�รเสีำยชีวิัตจั�กมัะเร็งผู้นัแปรไป ต�มัปริมั�ณิในก�รทำ�กิจักรรมัท�ง- ก�ยทั�งระดบัป�นกล�งและหนกั • กิจักรรมัท�งก�ยในระดบัป�นกล�ง จันถง่หนกัในปริมั�ณิที�ส้ำงขี่ �นสำ�มั�รถ ลดอนัตร�ยต่อผู้ลลพั็ธิท์�งสุำขีภั�พ็ จั�กพ็ฤติกรรมัเน่อยนิ�งได� ข้้อัแนะนำา >> > > > ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 66 ในผู้้�ส้ำงอ�ยุ กิจักรรมัท�งก�ยเอ่ �อประโยชน์ต่อสุำขีภั�พ็ ดังต่อไปนี� ลดโอก�สำในก�ร เสีำยชีวิัตทุกสำ�เหตุ ก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อดหัวัใจั ก�รเกิดโรค์ค์วั�มัดนัโลหิตส้ำง เกิดโรค์มัะเร็งเฉพ็�ะที� ก�รเกิดโรค์เบ�หวั�นชนิดที� 2 สุำขีภั�พ็จิัต (อ�ก�รกงัวัลและซม่ัเศร� ลดลง) สุำขีภั�พ็ด� นก�รรบัร้� และก�รนอนหลบั ก�รวัดัภั�วัะโรค์อ�วันอ�จัจัะดีขี่ �นได� กิจักรรมัท�งก�ย จัะช่วัยป้องกนัก�รหกล�มัและอ�ก�รบ�ดเจ็ับที�เกี�ยวัเน่�องกบัก�รหกล�มั และรวัมัถง่ช่วัยป้องกนั สุำขีภั�พ็กระด้กและก�รทำ�ง�นขีองร่�งก�ยที�ถดถอยไป สำำ�หรบัผู้้�ส้ำงอ�ยุ กิจักรรมัท�งก�ยสำ�มั�รถเป็นส่ำวันหน่�งขีองก�รสำนัทน�ก�ร และก�รพ็กัผู่้อน (ก�รละเล่น เกมัสำ ์กีฬ� หร่อก�รออกกำ�ลงัก�ยที�วั�งแผู้นไวั�) ก�รเดินท�ง (เดินท�งด�วัยล�อ ก�รเดิน และก�รปั� นจักัรย�น) ก�รทำ�ง�น หร่อทำ�ง�นบ� น ในปริบท ประจัำ�วันัเกี�ยวักบัก�รทำ�ง�น ก�รเรียน บ� น หร่อสำภั�พ็แวัดล�อมัในชุมัชน • ทำ�กิจักรรมัท�งก�ยบ� งดีกว่ั�ไม่ัทำ�อะไรเลย • ห�กผู้้�ส้ำงอ�ยุไม่ัสำ�มั�รถทำ�ต�มัค์ำ�แนะนำ�ได� ก�รทำ�กิจักรรมัท�งก�ยบ� งจัะให�ประโยชน ์ แก่สุำขีภั�พ็ • ผู้้�ส้ำงอ�ยุค์วัรเริ�มัทำ�กิจักรรมัท�งก�ยในระดบัเบ�แล�วัค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มัหนกัหน่วัง และระยะเวัล�ขี่ �น • ผู้้�ส้ำงอ�ยุค์วัรจัะเค์ล่�อนไหวัให�มั�กเท่�ที�ค์วั�มัสำ�มั�รถท�งก�ยจัะอำ�นวัย และปรบัระดบัสำำ�หรบั ก�รทำ�กิจักรรมัท�งก�ยต�มัระดบัขีองค์วั�มัแข็ีงแรงขีองตน ผูู้้สูำงอ�ยุ (อ�ยุ 65 ปีขึ้�นืไป) ข้้อแนืะนืำ�ด้็�นืกิิจกิรัรัมท�งกิ�ย แนะนำ�ให:้ ผ้ส้้ำงอ�ยุค์วรทำ�กิจกรรมัท�งก�ยเป็นประจำ� แนะนำ�อย่�งยิ�ง หลกัฐ�นน่�เช่�อถ่อได�ป�นกล�ง ผ้ส้้ำงอ�ยุค์วรทำ�กิจกรรมัท�งก�ยแบบแอโร- บิกที�ระดบัป�นกล�งอย่�งนอ้ย 150-300 น�ที หรืออย่�งนอ้ย 75-150 น�ทีที�ระดบัหนกั หรือก�รผสำมัผสำ�นทั�ง 2 ระดบัอย่�งเท่�เทียมั กนัติลอดทั�งสำปัด�ห ์เพื�อสุำข้ภ�พที�แข็้งแรง แนะนำ�อย่�งยิ�ง หลกัฐ�นน่�เช่�อถ่อได�ป�นกล�ง ผ้ส้้ำงอ�ยุค์วรทำ�กิจกรรมัสำร�้งค์ว�มัแข็้งแรง ใหก้บักล�้มัเนื �อ ที�มีัก�รใช้ก้ล�้มัเนื �อหลกัทุก ส่ำวน ในระดบัป�นกล�งข้้ �นไป อย่�งนอ้ย 2 วนัต่ิอสำปัด�หห์รือมั�กกว่� เนื�องจ�กกิจกรรมั เหล่�นี �จะส่ำงผลดีต่ิอสุำข้ภ�พมั�กยิ�งข้้ �น แนะนำ�อย่�งยิ�ง หลกัฐ�นน่�เช่�อถ่อได�ป�นกล�ง ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ ก�รทำ�กิจกรรมัท�งก�ยในแต่ิละสำปัด�ห ์ผ้ส้้ำง อ�ยุค์วรทำ�กิจกรรมัท�งก�ยหล�ย ๆ ส่ำวน ที�ระดบัป�นกล�งข้้ �นไป เพื�อเนน้ก�รสำร�้งสำมั ดุลก�รทำ�ง�นและฝึึกค์ว�มัแข็้งแรงอย่�งนอ้ย 3 วนัต่ิอสำปัด�ห ์เพื�อเสำริมัค์ว�มัสำ�มั�รถในก�ร ทำ�ง�นข้องร่�งก�ยและป้องกนัก�รหกลม้ั แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อได�ป�นกล�ง ผ้ส้้ำงอ�ยุสำ�มั�รถเพิ�มัก�รทำ�กิจกรรมัท�งก�ย แบบแอโรบิกที�ระดบัป�นกล�งใหม้ั�กกว่� 300 น�ที หรือที�ระดบัหนกัมั�กกว่� 150 น�ที หรือ ก�รผสำมัผสำ�นที�เท่�เทียมักนัท ั�ง 2 ระดบั ติลอด สำปัด�หเ์พื�อสำร�้งผลลพัธิ์ท์�งสุำข้ภ�พที�ดีข้้ �น แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อได�ป�นกล�ง 67ข้้อัแนะนำา ผูู้้สูำงอ�ยุ (อ�ยุ 65 ปีขึ้�นืไป) หลกัฐ�นสำนบัสำนุนและเหตุิผล สำำ�หรบัขี�อแนะนำ�เพ่็�อผู้้�ส้ำงอ�ยุเหล่�นี� ก�รรวับรวัมัหลกัฐ�นอย่�งค์รอบค์ลุมัที�จัดัทำ�โดย PAGAC (35) ถ้กนำ�มั�ใช�และปรบัปรุง บทปริทศัน ์15 ฉบบันั�นตรงต�มัเกณิฑ์ก์�รค์ดัเขี� และบอก กล่�วัถง่ก�รตรวัจัสำอบค์วั�มัเช่�อมัโยงระหว่ั�งกิจักรรมัท�งก�ยและผู้ลที� เกี�ยวัเน่�องกบัสุำขีภั�พ็ที� เจั�ะจังกบัผู้้�ส้ำงอ�ยุ (ก�รป้องกนัก�รหกล�มั อ�ก�รบ�ดเจ็ับเกี�ยวัเน่�องกบัก�รล�มั หน� ที�ท�งก�ยภั�พ็ ค์วั�มัเปร�ะบ�ง และโรค์กระด้กพ็รุน) หลกัฐ�นเกี�ยวักบัก�รป้องกนัก�รหกล�มัใช�และปรบัปรุงขี�อม้ัลจั�กบทปริทศันเ์ป็นระบบจั�ก ค์วั�มัร่วัมัม่ัอ Cochrane พ็.ศ. 2562 โดยเชอริงตนัและค์ณิะ (42) ด�วัยหลกัฐ�นที�ตีพิ็มัพ็จ์ั�กวันัที� ค์�นห�วันัสุำดท� ยจั�กบทปริทศันต์�นฉบบั จันถง่พ็ฤศจิัก�ยน พ็.ศ. 2562 (ง�นวิัจัยัใหม่ั 9 ชิ �น) ก�รค์�นห� บทปริทศันอ์ย่�งเป็นระบบที� มีัอย่้เกี�ยวักบัโรค์กระด้กพ็รุนและก�รส้ำญ่เสีำยมัวัลกล� มัเน่�อในผู้้�ส้ำง อ�ยุซ่�งจัดัทำ�ในฐ�นขี�อม้ัล PubMed สำำ�หรบับทปริทศันที์�ตีพิ็มัพ็จ์ั�ก พ็.ศ. 2551 จันถง่พ็ฤศจิัก�ยน พ็.ศ. 2562 และระบุว่ั�ไม่ัมีัรีวิัวัฉบบัใหม่ัและง�นวิัจัยัใหม่ั 8 ฉบบั ขี�อม้ัลเต็มัเร่�องวิัธีิวิัจัยั ก�รแยกส่ำวันขี�อม้ัล และชุดขี�อม้ัลหลกัฐ�นมีัอย่้ที�ภั�ค์ผู้นวักบนเว็ัปไซต ์ : ชุดขี�อม้ัลหลกัฐ�น8 8 ข้้อม่ัลออนไลน์อย่� ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ในผ้ส้้ำงอ�ยุ (อ�ยุ 65 ปีข้้ �นไป) ค์ว�มั สำมััพนัธิ์ร์ะหว่�งกิจกรรมัท�งก�ยและ ผลที�เกี�ยวเนื�องกบัสุำข้ภ�พคื์ออะไร ชุดหลกัฐ�นเบ่ �องต�นสำำ�หรบัก�ร ประเมิันค์วั�มัเช่�อมัโยงระหว่ั�งกิจักรรมั ท�งก�ยและผู้ลลัพ็ธิต่์อสุำขีภั�พ็ เช่น ก � ร เ สีำ ย ชี วิั ต จั � ก ทุ ก สำ � เ ห ตุ แ ล ะ ก�รเ สีำยชีวิัตที� มีัสำ�เหตุเฉพ็�ะ โรค์ หลอดเล่อดหัวัใจั เบ�หวั�นชนิดที�สำอง ก�รเกิดมัะเร็ง โรค์อ�วัน สุำขีภั�พ็จิัต และ ผู้ลต่อก�รรบัร้�ในประช�กรผู้้�ส้ำงอ�ยุ ซ่�ง เป็นสิำ�งตีพิ็มัพ็ท์�งวิัทย�ศ�สำตรฉ์บบัเดียวั กบัที�ตรวัจัท�นและทบทวันสำำ�หรบัประ- ช�กรผู้้�ใหญ่่ใจัค์วั�มัขีองหลกัฐ�นเดิมั เป็นที�ยอมัรบัและนำ�มั�เกี�ยวัโยงกบัผู้้�ส้ำง อ�ยุเพ็ร�ะง�นวิัจัยัส่ำวันใหญ่่ไม่ัมีัเกณิฑ์ ์ กำ�หนดอ�ยุขีั�นกว่ั�และรวัมัผู้้�ใหญ่่อ�ยุ 65 ปีไวั�ด�วัย มีั ก � ร จัั ด ทำ � บ ท ป ริ ทัศ น์ขี อ ง หลักฐ�นเพิ็� มัเติมัเพ่็� อตรวัจัสำอบและ อธิิบ�ยเกี�ยวักบัค์วั�มัเช่�อมัโยงระหว่ั�ง กิจักรรมัท�งก�ยและผู้ลเกี�ยวัเน่� องต่อ สุำขีภั�พ็ที� เจั�ะจังผู้้�ส้ำงอ�ยุ รวัมัทั�งก�ร ป้องกนัก�รหกล�มั อ�ก�รบ�ดเจ็ับจั�กก�ร หกล�มั หน� ที�ท�งก�ยภั�พ็ ค์วั�มัเปร�ะบ�ง และโรค์กระด้กพ็รุน สำมัรรถภั�พ็ท�งร่�งก�ยที�ถดถอย สำำ�หรับผู้้�ส้ำงอ�ยุมัักจัะเกิดในร้ปแบบ ขีองก�รหกล�มัและอ�ก�รบ�ดเจ็ับจั�ก ก�รหกล�มั ซ่� งอ�จัมีัผู้ลที�ร� ยแรง ก�ร หกล�มัจั�กอุบติัเหตุมั�จั�กก�รผู้สำมัผู้สำ�น กับ ปั จั จััย ภั � ย น อ ก ( สิำ� ง แวั ด ล�อ มั ) และปัจัจัยัภั�ยใน (ตวััอย่�งเช่น ค์วั�มัผิู้ด ปรกติขีองกล� มัเน่�อติดกระด้กหร่อระบบ ประสำ�ท) หลักฐ�นบ่งชี�ว่ั�กิจักรรมั ท�งก�ย โดยเฉพ็�ะอย่�งยิ� งขีองก�ร ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 68 ทำ � กิจั ก ร ร มั ท� ง ก� ย ที� ห ล� ก ห ล� ย ซ่� ง ร วั มั ถ่ ง กิ จั ก ร ร มั ท � ง ก � ย แ บ บ สำ ร� ง สำ มั ดุ ล สำ ร� ง ค์ วั � มั แ ข็ี ง แ ร ง ฝึึ ก ค์ วั � มั อ ด ท น ก � ร เ ค์ ล่� อ น ที� เ ร็ วั และก�รฝึึกก�รเค์ล่�อนไหวั ซ่�งเช่�อมัโยง กบัอตัร�ก�รหกลม้ัที�ลดลงและอ�ก�ร เสีำ�ยงจั�กก�รบ�ดเจ็บจ�กก�รหกลม้ัใน ผู้้�ส้ำงอ�ยุ หลกัฐ�นล่�สุำดชี�ว่ั� กิจักรรมัท�ง ก�ยอ�จัลดอตัร�ก�รหกล�มัได�มั�กถ่ง ร�อยละ 23 (อตัร�รวัมั (RaR) 0.77 [95% CI: 0.71 to 0.83]) ในผู้้�ส้ำงอ�ยุ ซ่�งสำ�มั�รถลด ค์วั�มัเสีำ� ยงขีองก�รบ�ดเจ็ับจั�กก�ร หกล�มัได�อย่�งมีันยัสำำ�ค์ญั่ รวัมัถง่ก�รล�มั รุนแรงที� มีัผู้ลทำ�ให�กระด้กหักบ�ดเจ็ับ ที� ศีรษะอย่�งรุนแรง แผู้ลเปิดบ�ดเจ็ับที� เน่�อเย่�ออ่อนหร่ออ�ก�รบ�ดเจ็ับอ่�น ๆ ที� ต�องก�รก�รด้แลท�งก�รแพ็ทยห์ร่อเขี� โรงพ็ย�บ�ล (42) หลกัฐ�นนี�สำอดค์ล�อง และยำ � ผู้ลก�รศ่กษ�ในบทปริทศันฉ์บบั อ่�น (35) หลงัจั�กที� ถ่งจุัดที� ส้ำงที� สุำดในช่วัง แรกวัยัผู้้�ใหญ่่ กล� มัเน่�อและมัวัลกระด้ก มีัแนวัโน�มัที� จัะลดลงเม่ั� ออ�ยุมั�กขี่ �น (ตวััอย่�ง เช่น ก�รส้ำญ่เสีำยมัวัลกล� มัเน่�อ และภั�วัะกระด้กพ็รุน) และอ�จัเช่�อมัโยง กบัค์วั�มัแข็ีงแรงที�ลดลงและสำมัรรถภั�พ็ ท�งก�ย หลกัฐ�นชี�ให�เห็นว่ั� กิจักรรมั ท�งก�ยเป็นกิจัวัตัรนั�น พ็ฒัน�สำมัรรถ- ภ�พท�งร่�งก�ยและลดค์วั�มัเสีำ� ยง จั�กก�รส้ำญ่เสีำยที� เกี� ยวัเน่� องกับอ�ยุ ผูู้้สูำงอ�ยุ (อ�ยุ 65 ปีขึ้�นืไป) สำำ�หรบัสำมัรรถภั�พ็ท�งร่�งก�ยในผู้้�ส้ำง- อ�ยุ ผู้ลก�รศก่ษ�แสำดงให�เห็นถง่ผู้ลอนั เป็นประโยชนจ์ั�กสำมัดุลในก�รเค์ล่�อนที� (SMD= 1.10 [95% CI: 0.29 to 1.90]) ค์วั�มัแข็ีงแรงกล� มัเน่�อ (SMD= 1.13 [95% CI: 0.30 to 1.96]) ค์วั�มัย่ดหยุ่น (SMD= 1.22 [95% CI: 0.39 to 2.04]) และสำมัรรถภั�พ็ด� นก�รหมุันเวีัยน โลหิต (SMD= 1.48 [95% CI: 0.42 to 2.54]) (94) หลกัฐ�นยงัแสำดงอีกว่ั� กิจั กรรมัท�งก�ยในระดบัที� ส้ำงขี่ �นจัะทำ�ให� สุำขีภั�พ็กระด้กดีขี่ �นและป้องกันภั�วัะ กระด้กพรุนในผู้้�ส้ำงอ�ยุ (ขีน�ดขีองผู้ล ที�เป็นมั�ตรฐ�นรวัมั 0.21 [95% CI: 0.06 to 0.36]) (95) ก�รแทรกแซงขีองกิจักรรมั ท�งก�ยอ�จัทำ�ให�ค์วั�มัหน�แน่นขีองแร่ ธิ�ตุในกระด้กสำนัหลงัส่ำวันเอวัและกระด้ก โค์นขี�ส่ำวันค์อ (สำะโพ็ก) ดีขี่ �น ค์ณะทำ�ง�น GDG สำรุปว่� • มีั ห ลั ก ฐ � น ที� มีั ค์ วั � มั เ ช่� อ ถ่ อ ไ ด� ป�นกล�งว่ั� กิจักรรมัท�งก�ยทำ�ให� สำมัรรถภั�พ็ท�งก�ยดีขี่ �นและลดค์วั�มั เสีำ� ยงขีองก�รส้ำญ่เสีำยสำมัรรถภั�พ็ที� เกี�ยวัขี�องกบัอ�ยุ ในประช�กรส้ำงวัยั โดยทั�วัไป • มีัหลกัฐ�นที� มีัค์วั�มัน่�เช่� อถ่อตำ� ว่ั� ค์ วั � มั เ สีำ� ย ง สำำ � ห รับ ป ริ มั � ณิ แ ล ะ ประเภัทขีองกิจักรรมัท�งก�ยที� แนะนำ�สำำ�หรบัผู้้�ส้ำงอ�ยุอย่้ในระดบัตำ� และประโยชนมี์ัมั�กกว่ั� 69 มีัค์ว�มัเชื้� อมัโยงต่ิอก�รติอบสำนอง ต่ิอปริมั�ณ (ปริมั�ณ ระยะเวล� ค์ว�มัถี� ค์ว�มัหนกัหน่วง) หรือไม่ั หลักฐ�นแสำดงให� เห็นถ่งค์วั�มั สำมััพ็นัธิที์� แปรผู้กผู้นัระหว่ั�งกิจักรรมั ท�งก�ยที�กระทำ�โดยผู้้�ส้ำงอ�ยุและค์วั�มั เสีำ�ยงต่อขี�อจัำ�กดัด� นสำมัรรถภั�พ็ร่�ง- ก�ย โดยทั� วัไปแล�วั กิจักรรมัท�งก�ย ที� มั�กขี่ �น (ค์วั�มัถี� ระยะเวัล� และ/ หร่ อ ป ริ มั � ณิ ) นั�น เ ช่� อ มั โ ยง กับ ผู้ ล ประโยชนที์�มั�กขี่ �น หลกัฐ�นชี�ว่ั� ก�ร ออกกำ�ลงัก�ยแบบมีัแรงต� นแบบเน�น ค์วั�มัเร็วัที�เขี� ถง่ได�อย่�งรวัดเร็วั อ�จัจัะมีั ผู้ลเหน่อก�รออกกำ�ลงัก�ยแบบมีัแรง ต� นแบบเน�นค์วั�มัเร็วัป�นกล�งสำำ�หรบั ก�รพ็ัฒน�สำมัรรถภั�พ็ทั� วัไป (SMD= 0.41 [95% CI: 0.18 to 0.65]; และ SPPB (SMD= 0.52 [95% CI: 0.10 to 0.94])) (96) มีัหลักฐ�นจัำ�กัดที� จัะตรวัจัสำอบ ค์วั�มัสำมััพ็นัธิร์ะหว่ั�งก�รตอบสำนองต่อ ปริมั�ณิระหว่ั�งกิจักรรมัท�งก�ยและ ก�รป้องกนัก�รหกล�มั อย่�งไรก็ต�มั ผู้ล วิัจัยัส่ำวันใหญ่่สำร� งหลกัฐ�นสำนับสำนุนที� แสำดงก�รทดสำอบก�รทำ�กิจักรรมัท�ง- ก�ยที�ต่อเน่�อง 3 วันัต่อสำปัด�ห์ ค์ณะทำ�ง�น GDG สำรุปว่� • มีัหลักฐ�นที� เช่� อถ่อได�ส้ำงถ่งค์วั�มั สำมััพ็นัธิต่์อก�รตอบสำนองต่อปริมั�ณิ ในด� นตรงขี� มั ระหว่ั�งปริมั�ณิขีอง ก�รทำ�กิจักรรมัท�งก�ยแบบแอโรบิก และค์วั�มัเ สีำ� ยงต่อขี�อจัำ �กัดด� น สำมัรรถภั�พ็ร่�งก�ยในประช�กร ส้ำงวัยัโดยทั�วัไป ค์ว�มัสำมััพนัธิ์ผ์นัแปรติ�มัประเภทหรือ ข้อบเข้ติข้องกิจกรรมัท�งก�ยหรือไม่ั ใน ผู้้� ส้ำ ง อ � ยุ ก � ร ทำ � กิจั ก ร ร มั ท�งก�ยที� มีัก�รผู้สำมัผู้สำ�นระหว่ั�ง สำมัดุล ค์วั�มัแข็ีงแรง ค์วั�มัทนท�น ก�รเค์ล่�อนที� เร็วั และก�รออกกำ�ลงัเพ่็�อ ฝึึกก�รเค์ล่�อนไหวันั�น เช่�อมัโยงกบัอตัร� ก�รหกล�มัและค์วั�มัเสีำ�ยงจั�กก�รบ�ด- เจ็ับจั�กก�รหกล�มัที�ลดลง หลกัฐ�นจั�กง�นวิัจัยักลุ่มัทดลอง ที� มีัก�รค์วับคุ์มัแบบสุ่ำมั 11 ชิ �นแสำดง ให�เห็นว่ั� ผู้้�ส้ำงอ�ยุสำ�มั�รถลดอตัร�ก�ร หกล�มัได�ถง่ร�อยละ 28 (RaR= 0.72 [95% CI: 0.56 to 0.93]) (42) ด�วัยก�รเขี� ร่วัมั ก�รผู้สำ�นกิจักรรมัท�งก�ยที�แตกต่�งกนั (ก�รออกกำ�ลงัก�ยแบบฝึึกก�รทรงตวัั และฝึึกก�รเค์ล่�อนไหวัเป็นประจัำ�รวัมั กบัก�รออกกำ�ลงัก�ยแบบมีัแรงต� น) ผู้ลจั�กก�รออกกำ�ลังก�ยแบบมีัแรง ต� นนั�นยังไม่ัแน่นอนและยังมีัขี�อม้ัล จัำ�กดั (RR= 0.97 [95% CI: 0.14 to 6.49]; ก�รทดลอง 1 ค์รั�ง; n= 73) (42) ผูู้้สูำงอ�ยุ (อ�ยุ 65 ปีขึ้�นืไป) ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 70 ห ลั ก ฐ � น ยั ง แ สำ ด ง ใ ห� เ ห็ น ว่ั�ก�รทำ�กิจักรรมัท�งก�ยที� รวัมัเอ� ก�รออกกำ�ลังก�ยหล�ยชนิดไวั�ด�วัย กันมีัผู้ลดีต่อสุำขีภั�พ็กระด้กมั�กกว่ั� (ขีน�ดขีองผู้ลที�ทำ�ให�เป็นมั�ตรฐ�น 0.45 [95% CI: 0.20 to 0.71]; p= 0.001) เม่ั�อ เทียบกบัผู้้�ที� ไม่ัได�ทำ� (95) ค์ณะทำ�ง�น GDG สำรุปว่� • มีัหลกัฐ�นเช่�อถ่อได�อย่�งส้ำงว่ั�กิจั- กรรมัท�งก�ยในระดับที� ส้ำงขี่ �นที� ผู้สำมัผู้สำ�นก�รออกกำ�ลังก�ยเพ่็� อ สำร� งสำมัดุล ค์วั�มัแข็ีงแรง ค์วั�มัเร็วัใน ผูู้้สูำงอ�ยุ (อ�ยุ 65 ปีขึ้�นืไป) ก�รเค์ล่� อนที� และก�รเค์ล่� อนไหวั ร่�งก�ย (ตวััอย่�งเช่น ร้ปแบบกิจักรรมั ท�งก�ยแบบผู้สำมัผู้สำ�น) นั�นเกี�ยวัเน่�อง กบัอัตร�ก�รหกล�มัและค์วั�มัเสีำ� ยง จั�กอ�ก�รบ�ดเจ็ับจั�กก�รหกล�มัใน ผู้้�ส้ำงอ�ยุที�ลดลง • มีัหลกัฐ�นที� เช่� อถ่อได�ป�นกล�งว่ั� ก�รทำ�กิจักรรมัท�งก�ยที�รวัมัเอ�ก�ร ออกกำ�ลงัก�ยหล�ยร้ปแบบไวั�ด�วัยกนั จัะมีัผู้ลกระทบสำำ�ค์ัญ่ต่อสุำขีภั�พ็ กระด้กและก�รป้องกนักระด้กพ็รุน 71 ผูู้้สูำงอ�ยุ (อ�ยุ 65 ปีขึ้�นืไป) ข้้อแนืะนืำ� ด้็�นืพฤติิกิรัรัมเนืือยนิื�ง สำำ�หรบัผู้้�ส้ำงอ�ยุ พ็ฤติกรรมัเน่อยนิ�งค่์อเวัล�ที�ใช�กบัก�รนั�งเฉย ๆ หร่อนอนด�วัยก�รใช�พ็ลงัง�นตำ� ขีณิะต่�นอย่้ ในปริบทท�งอ�ชีพ็ ก�รเรียน สำภั�พ็แวัดล�อมัที�บ� นหร่อในชุมัชน และก�รเดินท�ง หลกัฐ�นสำนบัสำนุนและเหตุิผล พ็ฤติกรรมัเน่อยนิ�งไม่ัได�ระบุไวั�ในขี�อแนะนำ�ระดบัโลกด� นกิจักรรมัท�งก�ยเพ่็�อสุำขีภั�พ็ พ็.ศ. 2553 (1) เน่�องจั�กก�รขี�ดหลกัฐ�นที�เจั�ะจังกลุ่มัประช�กร หลกัฐ�นเบ่ �องต�นที�ประเมิันค์วั�มั เช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งและผู้ลลพั็ธิต่์อสุำขีภั�พ็ในประช�กรผู้้�ส้ำงอ�ยุเป็นง�นวิัจัยัท�ง วิัทย�ศ�สำตรชิ์�นเดียวักบัที�เปรียบเทียบและทบทวันสำำ�หรบัประช�กรผู้้�ใหญ่่ เพ็ร�ะง�นวิัจัยัส่ำวันใหญ่่ ไม่ัได�ระบุเกณิฑ์จ์ัำ�กดัอ�ยุที�ส้ำงกว่ั� จัง่มีัก�รรวัมัผู้้�ใหญ่่อ�ยุมั�กกว่ั� 65 ปีไวั� มีัก�รทบทวันก�รค์�นพ็บ จั�กหลกัฐ�นเกี�ยวักบัพ็ฤติกรรมัเน่อยนิ�งในประช�กรผู้้�ใหญ่่ทั�วัไป รวัมัถง่ประเมิันว่ั�หลกัฐ�นนั�นมีั ผู้ลที�ต่�งกนัหร่อไม่ั หร่ออ�จัไม่ัรวัมัถง่ หร่ออ�จัให�ผู้ลที�ขีดัแย�งกนั สำำ�หรบัผู้้�ส้ำงอ�ยุ ร�ยละเอียดค์รบถ�วันสำำ�หรบัวิัธีิก�รวิัจัยั ก�รแยกส่ำวันขี�อม้ัล และชุดขี�อม้ัลหลกัฐ�นมีัอย่้ที�ภั�ค์ผู้นวัก ขีองเว็ับไซต ์: ชุดขี�อม้ัลหลกัฐ�น9 สำำ�หรับผู้้�ส้ำงอ�ยุ พ็ฤติกรรมัเน่อยนิ� งในปริมั�ณิที� ส้ำงขี่ �นนั�นต�มัมั�ด�วัยผู้ลเสีำยต่อ สุำขีภั�พ็ ได�แก่ ก�รเสีำยชีวิัตทุกสำ�เหตุ ก�รเสีำยชีวิัตจั�กโรค์หัวัใจัหลอดเล่อด และก�รเสีำยชีวิัตจั�กโรค์มัะเร็ง และสำ�เหตุก�รเกิดโรค์หลอดเล่อดหัวัใจั โรค์มัะเร็ง และโรค์เบ�หวั�นชนิดที�สำอง แนะนำ�ให:้ ผ้ส้้ำงอ�ยุค์วรจำ�กดัเวล�ที�มีัก�รทำ�พฤติิกรรมัเนือยนิ�ง และทดแทนเวล� เหล่�นั�น ดว้ยกิจกรรมัท�งก�ยทุกระดบัเพื�อผลดีต่ิอสุำข้ภ�พ (รวมัถง้ระดบัเบ�) แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อได�ป�นกล�ง ผ้ส้้ำงอ�ยุค์วรมุ่ังทำ�กิจกรรมัท�งก�ยใหม้ั�กกว่�ระดบัที�แนะนำ� ท ั�งในระดบั ป�นกล�ง และระดบัหนกั เพื�อช่้วยลดอนัติร�ยต่ิอสุำข้ภ�พ จ�กพฤติิกรรมั- เนือยนิ�งในระดบัส้ำง แนะนำ�อย่�งยิ�ง หลกัฐ�นที�เช่�อถ่อได�ป�นกล�ง > > 9 ข้้อม่ัลออนไลน์อย่� ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 72 > > > ในหญิ่งมีัค์รรภัแ์ละมั�รด�หลงัค์ลอด กิจักรรมัท�งก�ยระหว่ั�งตั�งค์รรภัแ์ละช่วังหลงัค์ลอดก่อให� เกิดประโยชนด์� นสุำขีภั�พ็ทั�งต่อแม่ัและท�รกในค์รรภั ์ ได�แก่ ค์วั�มัเสีำ�ยงที�ลดลงในก�รเกิดภั�วัะ- ค์รรภัเ์ป็นพิ็ษ รวัมัทั�งค์วั�มัดนัโลหิตส้ำงขีณิะมีัค์รรภั ์เบ�หวั�นขีณิะตั�งค์รรภั ์ภั�วัะนำ � หนกัเพิ็�มัส้ำง ระหว่ั�งตั�งค์รรภั ์ภั�วัะแทรกซ�อนในก�รค์ลอด อ�ก�รซม่ัเศร� หลงัค์ลอด และภั�วัะแทรกซ�อน สำำ�หรบัท�รกแรกเกิด ไม่ัมีัผู้ลลบต่อนำ � หนกัแรกเกิด และไม่ัมีัค์วั�มัเสีำ�ยงต่อก�รเสีำยชีวิัตในค์รรภั์ สำำ�หรบัหญิ่งมีัค์รรภัแ์ละมั�รด�หลงัค์ลอด กิจักรรมัท�งก�ยสำ�มั�รถทำ�ได�ในฐ�นะส่ำวันหน่�ง ขีองสำนัทน�ก�รและก�รพ็กัผู่้อน (ก�รละเล่น เกมัสำ ์ กีฬ� และก�รออกกำ�ลงัก�ยต�มัแผู้น) ก�รเดินท�ง (ก�รเล่นเค์ร่� องที� มีัล�อ ก�รเดิน และก�รปั� นจัักรย�น) ก�รทำ�ง�น ทำ�ง�นบ� น ในปริบทขีองก�รทำ�ง�นประจัำ�วันั ก�รศก่ษ� บ� น หร่อในชุมัชน ขี�อแนะนำ�นี�กล่�วัถง่กิจักรรมัท�งก�ยและผู้ลลพั็ธิด์� นสุำขีภั�พ็ขีองมั�รด� และท�รกในค์รรภัร์ะหว่ั�งก�รตั�งค์รรภัแ์ละระยะหลงัค์ลอด ขี�อแนะนำ�นี�สำำ�หรบั หญิ่งตั�งค์รรภัแ์ละมั�รด�หลงัค์ลอด ไม่ัจัำ�กดัอ�ยุ พ่็ �นหลงัท�งวัฒันธิรรมั หร่อ สำถ�นะท�งสำงัค์มัเศรษฐกิจัใด ๆ ก�รตั�งค์รรภัแ์ละระยะหลงัค์ลอดเป็นขีั�นหน่�งขีองชีวิัต ผู้้�หญิ่ง และคุ์ณิประโยชนข์ีองก�รเค์ล่�อนไหวัร่�งก�ยอย่�งค์ล่องแค์ล่วัตลอดช่วังวัยัผู้้�ใหญ่่นั�นระบุ ร�ยละเอียดไวั�ในขี�อแนะนำ�ที�จัดัทำ�สำำ�หรบัวัยัผู้้�ใหญ่่ หญิ่งตั�งค์รรภัแ์ละมั�รด�หลงัค์ลอดค์วัรอย่้ภั�ยใต�ก�รด้แลทั�งก่อนค์ลอดและหลงัค์ลอดจั�กบุค์ล�กร ท�งก�รแพ็ทยที์�สำ�มั�รถให�ค์ำ�แนะนำ�เกี�ยวักบักรณีิพิ็เศษจั�กภ้ัมิัหลงัท�งก�รแพ็ทยแ์ละขี�อบ่งห� มัในก�รทำ� กิจักรรมัท�งก�ยระหว่ั�งก�รตั�งค์รรภัห์ร่อช่วังหลงัค์ลอด ขี�อแนะนำ�นี�เน�นต�มัแนวัสำ�ธิ�รณิสุำขีและต�มักลุ่มั ประช�กร แนวัปฏิิบติัท�งก�รแพ็ทยค์์วัรมีัขี่ �นเพ่็�อผู้้�หญิ่งที�มีัภั�วัะซบัซ�อนที� เช่�อมัโยงกบัก�รตั�งค์รรภัห์ร่อ ก�รค์ลอดบุตร หญิ่งตั�งค์รรภัห์ร่อมั�รด�หลงัค์ลอดค์วัรพ็ย�ย�มัที�จัะทำ�ต�มัค์ำ�แนะนำ�เหล่�นี�เม่ั�อเป็นไปได� และเท่�ที�สำ�มั�รถทำ�ได�โดยปร�ศจั�กขี�อค์วัรระวังั สำติร่ัม่คำรัรัภ์ิและม�รัด็�หลังคำลอด็ ข้้อแนืะนืำ�ด้็�นืกิิจกิรัรัมท�งกิ�ย แนะนำ�ว่�หญิ่งมีัค์รรภแ์ละมั�รด�หลงัค์ลอดที�ไม่ัมีัข้อ้ห�้มัใด ๆ นั�นค์วรจะ: ทำ�กิจกรรมัท�งก�ยเป็นประจำ�ติลอดทั�งช่้วงก�รติ ั�งค์รรภแ์ละหลงัค์ลอด แนะนำ�อย่�งยิ�ง หลกัฐ�นน่�เช่�อถ่อได�ป�นกล�ง ทำ�กิจกรรมัท�งก�ยแบบแอโรบิกที�ระดบัป�นกล�งอย่�งนอ้ย 150 น�ทีติลอดสำปัด�ห ์ เพื�อสุำข้ภ�พที�ดี แนะนำ�อย่�งยิ�ง หลกัฐ�นน่�เช่�อถ่อได�ป�นกล�ง และทำ�กิจกรรมัท�งก�ยแบบแอโรบิกที�หล�กหล�ยและก�รสำร�้งค์ว�มัแข็้งแรงใหก้บั กล�้มัเนื �อร่วมักนั และเพิ�มัก�รยืดเหยียดร่�งก�ยในระดบัเบ�จะก่อใหเ้กิดผลดี แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�ง 73 ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ • ทำ�กิจักรรมัท�งก�ยบ� งย่อมัดี กว่ั�ไม่ัทำ�อะไรเลย • ห�กหญิ่งมีัค์รรภัห์ร่อมั�รด� หลงัค์ลอดไม่ัสำ�มั�รถทำ�ต�มั ขี�อแนะนำ�ได� ก�รทำ�กิจักรรมั ท�งก�ยบ� งย่อมัเป็นผู้ลดี ต่อสุำขีภั�พ็ • หญิ่งมีัค์รรภัแ์ละมั�รด�หลงั ค์ลอดค์วัรเริ� มัทำ�กิจักรรมั ท�งก�ยแต่น�อยแล�วัค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มัหนกัหน่วัง และระยะเวัล� • ค์วัรมีัก�รทำ�กิจักรรมัย่ดหยุ่น กล� มัเน่�ออุ�งเชิงกร�นทุกวันั เพ่็� อลดค์วั�มัเสีำ� ยงขีองก�ร กลั�นปัสำสำ�วัะไม่ัอย่้ ข้อ้พิจ�รณ�เรื�องค์ว�มัปลอดภยัเพิ�มัเติิมัสำำ�หรบัหญิ่ง มีัค์รรภ ์เมืั�อทำ�กิจกรรมัท�งก�ย คื์อ: • หลีกเลี�ยงก�รทำ�กิจักรรมัท�งก�ยเม่ั�ออย่้ในที�ที�มีัค์วั�มัร�อน มั�กเกินไป โดยเฉพ็�ะเม่ั�อมีัค์วั�มัช่�นส้ำง • ด่�มันำ � ให�เพี็ยงพ็อ โดยค์วัรด่�มันำ � ก่อน ระหว่ั�ง และหลงัก�ร ทำ�กิจักรรมัท�งก�ย • หลีกเลี�ยงก�รเขี� ร่วัมักิจักรรมัที� เกี�ยวัเน่� องกบัก�รสำมััผู้สัำ ท�งก�ยภั�พ็ มีัค์วั�มัเสีำ� ยงในก�รหกล�มัส้ำง หร่ออ�จัมีั ปริมั�ณิอ็อกซิเจันจัำ�กดั (เช่น กิจักรรมับนพ่็�นที�ส้ำง เม่ั�อไม่ัได� อย่้อ�ศยับนพ่็�นที�ส้ำงเป็นปกติ) • หลีกเลี� ยงกิจักรรมัที� อย่้ในท่�นอนหง�ย หลังจั�กสำ�มั เด่อนแรกขีองก�รตั�งค์รรภั์ • เม่ั�อเป็นก�รแข่ีงขีนักีฬ� หร่อก�รออกกำ�ลงัก�ยเกินไปจั�ก ขี�อแนะนำ�อย่�งมั�ก หญิ่งตั�งค์รรภัค์์วัรปร่กษ�ผู้้�ให�บริก�ร ท�งก�รแพ็ทยที์�เชี�ยวัช�ญ่เฉพ็�ะ • หญิ่งมีัค์รรภัค์์วัรได�รบัขี�อม้ัลจั�กผู้้�ให�บริก�รท�งก�รแพ็ทย ์ ถง่สำญั่ญ่�ณิอนัตร�ยที�จัะเต่อนให�พ็วักเขี�หยุด หร่อจัำ�กดั กิจักรรมัท�งก�ย และปร่กษ�ผู้้�ให�บริก�รท�งก�รแพ็ทย ์ หร่อผู้้�ทรงคุ์ณิวุัฒิทนัทีที�เกิดเหตุ • ค่์อย ๆ กลบัมั�ทำ�กิจักรรมัท�งก�ยหลงัจั�กค์ลอดโดย ค์วัรปร่กษ�ผู้้� ให�บริก�รด้แลสุำขีภั�พ็ ในกรณีิค์ลอด โดยก�รผู่้�ค์ลอด สำติร่ัม่คำรัรัภ์ิและม�รัด็�หลังคำลอด็ หลกัฐ�นสำนบัสำนุนและเหตุิผล สำำ�หรบัขี�อแนะนำ�ในก�รทำ�กิจักรรมัท�งก�ยและพ็ฤติกรรมัเน่อยนิ�ง (2563) สำำ�หรบัหญิ่ง มีัค์รรภัแ์ละมั�รด�หลงัค์ลอด หลกัฐ�นที�รวับรวัมัจั�กบทปริทศันอ์ย่�งเป็นระบบที�กล่�วัถง่ผู้ลลพั็ธิที์� สำำ�ค์ญั่มั�กและสำำ�ค์ญั่ถ้กนำ�มั�ใช�และปรบัขี�อม้ัล บทปริทศัน ์4 ใน 7 ฉบบัเขี� เกณิฑ์ก์�รนำ�ขี�อม้ัลเขี� ขี�อม้ัลเต็มัเกี�ยวักบัระเบียบวิัธีิ ก�รแยกส่ำวันขี�อม้ัลและชุดขี�อม้ัลหลกัฐ�นสำ�มั�รถด้ได�ที�ภั�ค์ผู้นวัก บนเว็ับไซต ์: ชุดขี�อม้ัลหลกัฐ�น10 10 ข้้อม่ัลออนไลน์อย่� ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 74 สำติร่ัม่คำรัรัภ์ิและม�รัด็�หลังคำลอด็ ค์ว�มัสำมััพนัธิ์ร์ะหว่�งกิจกรรมัท�งก�ย และผลลพัธิ์ที์�เกี�ยวเนื�องกบัสุำข้ภ�พใน หญิ่งมีัค์รรภแ์ละมั�รด�หลงัค์ลอดคื์อ อะไร ก�รทำ�กิจักรรมัท�งก�ยก่อนและ ระหว่ั�งก�รตั�งค์รรภัส์ำ�มั�รถลดค์วั�มั เสีำ� ยงขีองภั�วัะแทรกซ�อนระหว่ั�งตั�ง ค์รรภัที์� ร้�กนัดี ก�รทำ�กิจักรรมัท�งก�ย ระหว่ั�งตั�งค์รรภัจ์ัะเช่�อมัโยงอย่�งมีันยั- สำำ�ค์ญั่กบัก�รลดค์วั�มัเสีำ�ยงภ�วะนำ � หนกั เพิ�มัข้ณะติั�งค์รรภ ์(MD= 1.14 กิโลกรมัั [95% CI: 1.67 to 0.62]) (97) และลด ค์วั�มัเสีำ�ยงขีองเบ�หวั�นขีณิะตั�งค์รรภั ์ (RR= 0.71 [95% CI: 0.57 ถง่ 0.89]) (97) ขีณิะที� มีัก�รทำ�กิจักรรมัท�งก�ยตั�งแต่ ก่อนตั�งค์รรภั ์(OR= 0.70 [95% CI: 0.57 ถง่ 0.85]) (31, 34, 97) รวัมัถง่ผู้้�หญิ่งที�มีั นำ � หนกัเกินหร่อโรค์อ�วัน (97) ก�รทำ�กิจักรรมัท�งก�ยระหว่ั�ง ตั�งค์รรภั ์ ไม่ัใช่สำ�เหตุที�ทำ�ให�เกิดค์ว�มั ดนัโลหิติส้ำงระหว่�งติ ั�งค์รรภห์รือภ�วะ ค์รรภเ์ป็นพิษ (31) หลกัฐ�นชี�ให�เห็นว่ั� ในหม่้ัหญิ่งตั�งค์รรภัที์�มีันำ � หนกัเกินหร่อมีั ภั�วัะโรค์อ�วัน ไม่ัมีัค์วั�มัแตกต่�งอย่�งมีั นัยสำำ�ค์ญั่ในก�รเกิดค์วั�มัดนัโลหิตส้ำง ระหว่ั�งตั�งค์รรภั ์ (RR= 0.63 [95% CI: 0.38 ถง่ 1.05]) หร่อภั�วัะค์รรภัเ์ป็นพิ็ษ (RR= 1.39 [95% CI: 0.66 ถง่ 2.93]) ระหว่ั�งก�รแทรกแซงก�รทำ�กิจักรรมั ท � ง ก � ย แ ล ะ ก � ร ฝึ � ก ค์ ร ร ภั์แ บ บ มั�ตรฐ�น (97) มีัขี�อกงัวัลอย่�งย�วัน�นเกี�ยวักบั ผู้ลลบที�อ�จัมีัขีองกิจักรรมัท�งก�ยขีอง มั�รด�ในช่วังที�ท�รกในค์รรภัเ์ริ�มัมีัก�ร พ็ฒัน�จันค์ลอด อย่�งไรก็ต�มัหลกัฐ�น ล่�สุำดแสำดงให�เห็นว่ั� กิจักรรมัท�งก�ยไม่ั เช่� อมัโยงกับค์วั�มัเสีำ� ยงที� เพิ็� มัขี่ �นกับ สำ�เหตุก�รแทง้บุติรก�รค์ลอดที�ท�รก เสีำยชี้วิติในค์รรภ ์ หรือภ�วะแทรกซอ้น ในก�รค์ลอด (32) หลกัฐ�นชี�ว่ั� ไม่ัมีั ค์วั�มัแตกต่�งในก�รเกิดก�รผู่้�ค์ลอด ในหม่้ัหญิ่งมีัค์รรภัที์�มีันำ � หนกัเกินหร่อมีั ภั�วัะโรค์อ�วันระหว่ั�งกลุ่มัที�มีัก�รแทรก- แซงด�วัยก�รทำ�กิจักรรมัท�งก�ยเทียบกบั ก�รฝึ�กค์รรภัต์�มัมั�ตรฐ�น (97) ก�รทำ�กิจักรรมัท�งก�ยระหว่ั�งตั�ง ค์รรภั์ไม่ัเกี� ยวัเน่� องกับก�รเพิ็� มัค์วั�มั เสีำ� ยงขีองผู้ลเสีำยเกี� ยวักบันำ � หนกัข้อง ท�รกแรกเกิดหร่อก�รค์ลอดก่อนกำ�- หนด (32)หร่ออ�จัเป็นก�รป้องกนัลด ค์วั�มัเสีำ�ยงทั�งมัวัล (98) แมั�แต่ในกลุ่มัหญิ่ งมีัค์รรภัที์�มีันำ � หนกัเกินเกณิฑ์ห์ร่อภั�วัะ โรค์อ�วัน (RR= 1.02 [95% CI: 0.54 ถง่ 1.92]) หร่อท�รกที�ตวััใหญ่่เกินอ�ยุค์รรภั ์ (RR= 0.90 [95% CI: 0.65 ถง่ 1.25]) ระหว่ั�งก�รแทรกแซงก�รทำ�กิจักรรมั- ท�งก�ยเทียบกับก�รฝึ�กค์รรภัต์�มั มั�ตรฐ�น (97) สำำ�หรบัช่วังหลงัค์ลอด มั�รด�อ�จั ประสำบค์วั�มัเปลี� ยนแปลงหล�ยอย่�ง ท�งร่�งก�ยและอ�รมัณิ ์ หลกัฐ�นแสำดง ให�เห็นว่ั�ก�รทำ�กิจักรรมัท�งก�ยระหว่ั�ง ตั�งค์รรภัน์ั�นอ�จัจัะเช่�อมัโยงอย่�งผู้กผู้นั กับภ�วะซ้มัเศัร�้หล ังค์ลอด (29) หลกัฐ�น 75 สำติร่ัม่คำรัรัภ์ิและม�รัด็�หลังคำลอด็ ข้้อัแนะนำา จั�กบทวิัเค์ร�ะหอ์ภิัมั�นจั�กก�รทดลอง 6 ชิ �นและง�นวิัจัยัจั�กก�รสำงัเกตุ 11 ชิ �น เกี�ยวักบัก�รทำ�กิจักรรมัท�งก�ยระหว่ั�ง ตั�งค์รรภั ์ (99) แสำดงให�เห็นว่ั� มีัค์วั�มั สำมััพ็นัธิที์� แปรผู้กผู้นัอย่�งมีันัยสำำ�ค์ญั่ ระหว่ั�งก�รทำ�กิจักรรมัท�งก�ยระหว่ั�ง ตั�งค์รรภัแ์ละภั�วัะซ่มัเศร� หลงัค์ลอด (SMD= 0.58 [95% CI: 1.09 ถง่ 0.08]) ผู้ลนั�นรุนแรงขี่ �นเม่ั� อจัำ�กัดง�นวิัจััยที� จัำ�นวัน 5 ชิ �นที� มีัก�รแทรกแซงด�วัยก�ร ทำ�กิจักรรมัท�งก�ยที�ระดบัป�นกล�ง เป็นอย่�งน�อย (SMD= 0.70 [95% CI:1.19 ถง่ 0.22]) (99) ค์ณะทำ�ง�น GDG สำรุปว่� • มีัหลกัฐ�นที� มีัค์วั�มัน่�เช่� อถ่อส้ำงว่ั� กิจักรรมัท�งก�ยระหว่ั�งตั�งค์รรภั ์ อ�จัลดค์วั�มัเสีำ�ยงขีองภั�วัะนำ � หนกั เพิ็�มัระหว่ั�งตั�งค์รรภัแ์ละค์วั�มัเสีำ�ยง จั�กโรค์เบ�หวั�นขีณิะตั�งค์รรภั์ • มีัหลกัฐ�นที� เช่�อถ่อได�ป�นกล�งจัน ถ่งเช่�อถ่อได�ส้ำงว่ั� กิจักรรมัท�งก�ย จัะไม่ัเพิ็� มัโอก�สำขีองก�รแท�งบุตร ท� ร ก เ สีำ ย ชี วิั ต ขี ณิ ะ ค์ ล อ ด หร่ อ ภั�วัะแทรกซ�อนขีณิะค์ลอด และมีัหลกั ฐ�นเช่�อถ่อได�ป�นกล�งเกี�ยวักบัค์วั�มั เสีำ�ยงในก�รค์ลอดก่อนกำ�หนดที�ลดลง สำำ�หรบัมั�รด�ที�มีัก�รทำ�กิจักรรมัท�ง ก�ยในระดบัหนกั • มีัหลักฐ�นที� เช่� อถ่อได�ตำ� ไปจันถ่ง ป�นกล�งว่ั� กิจักรรมัท�งก�ยจัะไม่ั เพิ็�มัค์วั�มัเสีำ�ยงเร่�องนำ � หนกัขีองท�ร กแรกเกิดที�ตำ� หร่อภั�วัะท�รกโตช� ในค์รรภั ์หร่อภั�วัะท�รกตวััโต • มีัหลกัฐ�นที� มีัค์วั�มัน่�เช่� อถ่อตำ� ว่ั� ก�รทำ�กิจักรรมัท�งก�ยระหว่ั�งตั�ง- ค์รรภัเ์ช่�อมัโยงกบัภั�วัะซม่ัเศร� หลงั ค์ลอดในระดบัที�ลดลง • ค์ วั � มั เ สีำ� ย ง สำำ � ห รับ ป ริ มั � ณิ แ ล ะ ประเภัทขีองกิจักรรมัท�งก�ยที� แนะนำ�สำำ�หรบัหญิ่งมีัค์รรภัแ์ละหญิ่ง หลังค์ลอดนั�นตำ� และ ไม่ัมีันำ � หนัก เหน่อประโยชน์ มีัค์ว�มัเชื้�อมัโยงในก�รติอบสำนองปริ- มั�ณหรือไม่ั (ปริมั�ณ ระยะเวล� ค์ว�มัถี� ค์ว�มัหนกัหน่วง) จั�กหลักฐ�นเกี� ยวักับกิจักรรมั ท�งก�ยระหว่ั�งตั�งค์รรภัแ์ละช่วังหลงั ค์ลอด ก�รแทรกแซงนั�นหล�กหล�ย ไปต�มัจัำ�นวัน (ตวััอย่�งเช่น ปริมั�ณิ) ขีองกิจักรรมัท�งก�ย ทั�งค์วั�มัต่อเน่�อง เป็นน�ทีและค์วั�มัถี�ต่อสำปัด�ห ์โดยทั�วัไป หลกัฐ�นที� มีัจัะสำะท�อนค์วั�มัถี�ขีองก�ร ทำ�กิจักรรมัท�งก�ยแบบแอโรบิกอย่�ง น�อย 3 ค์รั�งต่อสำปัด�ห ์เป็นปรกติระหว่ั�ง 30 และ 60 น�ที หลกัฐ�นนี�ได�จั�กง�น วิัจัยัที�ประเมิันผู้ลท�งสุำขีภั�พ็ขีองปริมั�ณิ ที�ค์งที�กบัปริมั�ณิขีองกิจักรรมัที�แนะนำ� สำำ�หรับประช�กรวััยผู้้� ใหญ่่โดยทั� วัไป กล่�วัค่์อ ก�รทำ�กิจักรรมัท�งก�ยที�ระดบั ป�นกล�ง 150 น�ทีต่อสำปัด�ห์ ขีณิะที� ก�รทำ�กิจักรรมัท�งก�ย ที� เพิ็�มัมั�กขี่ �น (ค์วั�มัถี� ระยะเวัล� และ/ หร่อปริมั�ณิ) อ�จัพ็บโดยทั�วัไปว่ั� เช่�อมั โยงกับประโยชน์ที� มั�กขี่ �น ง�นวิัจััย เพิ็�มัเติมัเป็นที�ต�องก�ร เพ่็�อให�เขี� ใจัร�ย- ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 76 ละเอียดค์วั�มัสำมััพ็นัธิ ์ในก�รตอบสำนอง ต่อปริมั�ณิให�มั�กขี่ �น ก�รเขี� ร่วัมัใน กิจักรรมัท�งก�ยระหว่ั�งเวัล�พ็กัผู่้อนใน ปริมั�ณิที� ส้ำงกว่ั�หร่อตำ� กว่ั�ก่อนก�ร ตั�งค์รรภัน์ั�น เช่�อมัโยงกบัค์วั�มัเสีำ�ยงขีอง อ�ก�รเบ�หวั�นขีณิะตั�งค์รรภัที์�ลดลง (OR= 0.54 [95% CI: 0.34 ถง่ 0.87]) (100) ยังมีัหลักฐ�นที� เกี� ยวักับก�รลด ค์วั�มัเสีำ� ยงเล็กน�อยแต่สำำ�ค์ัญ่ต่อก�ร ค์ ล อ ด ก่ อ น กำ � ห น ด สำำ � หรับ แ ม่ั ที� ทำ � กิจักรรมัท�งก�ยที�ระดบัมั�ก (RR= 0.20 [95% CI: 0.36 ถ่ง 0.03]) (98) ไม่ัมีั หลกัฐ�นที� ชี �ถง่ค์วั�มัปลอดภัยัหร่อประ- โยชนเ์พิ็�มัเติมัจั�กกิจักรรมัท�งก�ยใน ระดบัที�มั�กกว่ั�ระดบัที� แนะนำ�อย่�งมีั นยัสำำ�ค์ญั่ ค์ณะทำ�ง�น GDG สำรุปว่� : • มีัหลักฐ�นไม่ัเพี็ยงพ็อที� จัะกำ�หนด ค์วั�มัเช่�อมัโยงในก�รตอบสำนองต่อ ปริมั�ณิระหว่ั�งกิจักรรมัท�งก�ยและ ผู้ลลพั็ธิท์�งสุำขีภั�พ็ที�สำำ�ค์ญั่เป็นอย่�ง ยิ� งระหว่ั�งตั�งค์รรภัแ์ละระยะหลัง ค์ลอด • มีัหลกัฐ�นโดยรวัมัที�แสำดงให�เห็นถ่ง ประโยชนต่์อผู้ลลพั็ธิท์�งสุำขีภั�พ็ที� สำำ�ค์ญั่และมีัพ่็ �นฐ�นอย่้บนก�รแทรก แซงที�ค์งที�อย่�งกวั� ง ๆ กบัปริมั�ณิ ก�รทำ�กิจักรรมัท�งก�ยที� แนะนำ� สำำ �หรับประช�กรวััยผู้้� ใหญ่่ทั� วัไป กล่�วัค่์อ กิจักรรมัท�งก�ยในระดบั ป�นกล�ง 150 น�ทีต่อสำปัด�ห์ • ไม่ัมีัเหตุผู้ลที�จัะเปลี�ยนปริมั�ณิหร่อ ค์วั�มัถี�ขีองกิจักรรมัท�งก�ยในระดบั ป�นกล�งที� แนะนำ�สำำ�หรับหญิ่งมีั ค์รรภัแ์ละมั�รด�หลังค์ลอด เม่ั� อ เปรียบเทียบกบัประช�กรผู้้�ใหญ่่ทั�วัไป • มีัหลักฐ�นเช่� อถ่อได�ป�นกล�งถ่ง ค์วั�มัเสีำ�ยงที�ลดลงจั�กก�รค์ลอดก่อน กำ�หนด สำำ�หรบัมั�รด�ที�ทำ�กิจักรรมั ท�งก�ยในระดบัมั�ก • ค์ว�มัสำมััพนัธิ์ผ์นัแปรติ�มัประเภทหรือ ข้อบข่้�ยหรือช่้วงเวล� (ก่อนติ ั�งค์รรภ ์ ระหว่�งติ ั�งค์รรภ ์ หรือหลงัติ ั�งค์รรภ)์ ข้องก�รทำ�กิจกรรมัท�งก�ยหรือไม่ั ห ลักฐ � นที� ไ ด�จั� กง � นวิัจััย ซ่� ง ประเมิันก�รทำ�กิจักรรมัท�งก�ยในขีอบ ข่ี�ยก�รพ็กัผู่้อนเป็นส่ำวันใหญ่่ ชนิดขีอง กิจักรรมัส่ำวันใหญ่่จัะเป็นแบบแอโรบิก (เช่น ก�รเดินหร่อก�รว่ั�ยนำ � ) แมั�จัะมีั หลกัฐ�นบ�งชิ�นจั�กง�นวิัจัยัที�ประเมิัน ก�รแทรกแซงที� รวัมัถ่งก�รฝึึกค์วั�มั แข็ีงแรง ( เช่น ก�รออกกำ�ลังก�ย แบบหมุันเวีัยน) หร่อก�รผู้สำมัผู้สำ�น ระหว่ั�งกิจักรรมัท�งก�ยแบบแอโรบิก กบัก�รสำร� งค์วั�มัแข็ีงแรงให�กบักล� มั- เน่�อ อย่�งไรก็ต�มั โดยภั�พ็รวัมัแล�วั ยงัไม่ัมีั หลกัฐ�นเพี็ยงพ็อที�จัะกำ�หนดว่ั� ค์วั�มั เช่�อมัโยงระหว่ั�งกิจักรรมัท�งก�ยและ ผู้ลลพั็ธิต่์อสุำขีภั�พ็จัะผู้นัแปรไปต�มัชนิด หร่อขีอบเขีตหร่อช่วังเวัล� (ก่อนตั�งค์รรภั ์ ระหว่ั�งตั�งค์รรภั ์ หร่อหลงัตั�งค์รรภั)์ ขีองก�รทำ�กิจักรรมัท�งก�ย สำติร่ัม่คำรัรัภ์ิและม�รัด็�หลังคำลอด็ 77 ค์ณะทำ�ง�น GDG สำรุปว่� • มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�งว่ั� หญิ่ง มีัค์รรภัแ์ละมั�รด�หลงัค์ลอดค์วัรผู้สำมั กิจักรรมัแบบแอโรบิกที�หล�กหล�ย และกิจักรรมัสำร� งค์วั�มัแข็ีงแรงให�กบั กล� มัเน่�อ และก�รย่ดเหยียดกล� มัเน่�อ ในระดบัเบ�นั�นมีัประโยชนเ์ช่นกนั สำติร่ัม่คำรัรัภ์ิและม�รัด็�หลังคำลอด็ ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 78 สำติร่ัม่คำรัรัภ์ิและม�รัด็�หลังคำลอด็ ข้้อแนืะนืำ� ด้็�นืพฤติิกิรัรัมเนืือยนิื�ง สำำ�หรบัหญิ่งมีัค์รรภัแ์ละมั�รด�หลงัค์ลอด พ็ฤติกรรมัเน่อยนิ�งค่์อเวัล�ที� ใช�กบัก�รนั�งหร่อนอนโดยมีัก�รใช� พ็ลงัง�นตำ� ขีณิะที�ต่�นอย่้ ในปริบทขีองสำภั�พ็แวัดล�อมัด� นอ�ชีพ็ ก�รศก่ษ� บ� น และชุมัชน และก�รเดินท�ง หลกัฐ�นสำนบัสำนุนและเหตุิผล พ็ฤติกรรมัเน่อยนิ�งไม่ัได�ถ้กรวัมัไวั�ในขี�อแนะนำ�ระดบัโลกด� นกิจักรรมัท�งก�ยเพ่็�อสุำขีภั�พ็ ฉบบั พ็.ศ. 2563 (1) เน่�องจั�กขี�ดหลกัฐ�นเฉพ็�ะกลุ่มัประช�กร ฐ�นขี�อม้ัลหลกัฐ�นเบ่ �องต�นเพ่็�อประเมิันค์วั�มั เช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งและผู้ลลพั็ธิต่์อสุำขีภั�พ็ในหญิ่งมีัค์รรภัแ์ละมั�รด�หลงัค์ลอดนั�นเป็น ง�นวิัจัยัด� นวิัทย�ศ�สำตรที์�รวับรวัมัและทบทวันสำำ�หรบัประช�กรวัยัผู้้�ใหญ่่ มีัก�รทบทวันผู้ลก�รวิัจัยัจั�กหลกัฐ�นเกี�ยวักบัพ็ฤติกรรมัเน่อยนิ�งในประช�กรวัยัผู้้�ใหญ่่โดยทั�วัไป รวัมัถง่ประเมิันว่ั�ผู้ลที� ได�แตกต่�งกนับ� งหร่อไม่ั หร่ออ�จัไม่ัประยุกต์ใช� หร่ออ�จัขีดัแย�งกนัสำำ�หรบัหญิ่ง มีัค์รรภัแ์ละมั�รด�หลงัค์ลอด จั�กหลกัฐ�นและค์วั�มัคิ์ดเห็นจั�กผู้้�เชี�ยวั- ช�ญ่ที�มีัอย่้ หลกัฐ�นได�ถ้กนำ�มั�อ� งอิงใช�จัดัทำ�ขี�อ แนะนำ�ขีององค์ก์�รอน�มัยัโลกฉบบัใหม่ัที� เกี�ยวักบั พ็ฤติกรรมัเน่อยนิ�ง สำำ�หรบัหญิ่งมีัค์รรภัแ์ละมั�รด� หลงัค์ลอด เพ่็� อชุดขี�อม้ัลสำ�มััญ่ขีองผู้ลลัพ็ธิต่์อ สุำขีภั�พ็ที�สำำ�ค์ญั่มั�ก เน่�องจั�กขี�อม้ัลโดยอ�อมัขีอง หลกัฐ�น ระดบัขีองค์วั�มัน่�เช่�อถ่อจัง่ถ้กลดลงมั� เน่�องจั�กขี�ดหลกัฐ�นเฉพ็�ะกลุ่มัประช�กร นี� และหญิ่งมีัค์รรภัถ้์กนำ�ออกจั�กง�นวิัจัยั ขี�อแนะนำ� ที�จัะเพิ็�มัระดบัก�รทำ�กิจักรรมัท�งก�ยให�มั�กกว่ั�ระ- ดบัที�แนะนำ�เพ่็�อต่อต� นผู้ลร� ยจั�กพ็ฤติกรรมัเน่อย นิ�งในระดบัส้ำงไม่ัอ�จัค์�ดก�รณิส์ำำ�หรบัผู้้�หญิ่งในช่วัง ตั�งค์รรภัแ์ละช่วังหลงัค์ลอดได� ค์ณะทำ�ง�น GDG สำรุปว่� • หลกัฐ�นเกี� ยวักบัพ็ฤติกรรมัเน่อยนิ� งในกลุ่มั ประช�กรวััยผู้้�ใหญ่่โดยทั� วัไปสำ�มั�รถนำ�มั� อนุมั�นเพ่็�อร่�งขี�อแนะนำ�สำำ�หรบัหญิ่งมีัค์รรภั ์ และมั�รด�หลงัค์ลอดเพ่็�อชุดขี�อม้ัลทั� วัไปขีอง ผู้ลลพั็ธิท์�งสุำขีภั�พ็ที�สำำ�ค์ญั่ • ประโยชน์ขีองก�รลดพ็ฤติกรรมัเน่อยนิ� งมีั มั�กว่ั�ค์วั�มัเสีำ� ยง สำำ�หรับหญิ่งมีัค์รรภัแ์ละ มั�รด�หลงัค์ลอด • ค์วั�มัเช่�อถ่อได�ขีองหลกัฐ�นค์วัรจัะลดลงเน่�อง จั�กเป็นขี�อม้ัลโดยอ�อมั ในหญิ่งมีัค์รรภัแ์ละมั�รด�หลงัค์ลอด เช่นเดียวักบัวัยัผู้้�ใหญ่่ทุกค์น พ็ฤติกรรมัเน่อยนิ�งในปริมั�ณิ มั�กนั�นเช่�อมัโยงกบัผู้ลลบต่อสุำขีภั�พ็ ได�แก่ก�รเสีำยชีวิัตทุกสำ�เหตุ ก�รเสีำยชีวิัตจั�กโรค์หลอด- เล่อดหัวัใจั ก�รเสีำยชีวิัตจั�กโรค์มัะเร็ง และโอก�สำในก�รเกิดโรค์หลอดเล่อดหัวัใจั โรค์มัะเร็ง และก�รเกิดโรค์เบ�หวั�นชนิดที�สำอง แนะนำ�ให:้ หญิ่งมีัค์รรภแ์ละมั�รด�หลงัค์ลอดค์วรจะจำ�กดัระยะเวล�ในก�รทำ�พฤติิกรรมัเนือยนิ�ง และทดแทนเวล�เหล่�นั�นดว้ยกิจกรรมัท�งก�ยที�ระดบัใดก็ได ้ (รวมัถ้งระดบัเบ�) ซ้�งมีัประโยช้นต่์ิอสุำข้ภ�พ แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อได�ตำ� > 79ข้้อัแนะนำา > > กิจักรรมัท�งก�ยนำ�มั�ซ่�งสุำขีภั�พ็ที� ดี สำำ�หรบัผู้้�ใหญ่่และผู้้�ส้ำงอ�ยุที� มีัภั�วัะเร่ �อรงั ดงัต่อไปนี� สำำ�หรับผ้ร้อดชี้วิติจ�กมัะเร็ง กิจักรรมัท�งก�ยจัะทำ�ให�ก�รเสีำยชีวิัตจั�กทุกสำ�เหตุ ก�รเสีำยชีวิัตจั�กมัะเร็ง และค์วั�มัเสีำ�ยงในก�รเกิดใหม่ัขีองมัะเร็งหร่อมัะเร็งขีั�นปฐมัภ้ัมิัค์รั�งที�สำอง นั�นดีขี่ �น สำำ�หรบัผ้ที้�มีัค์ว�มัดนัโลหิติส้ำง กิจักรรมัท�งก�ยจัะช่วัยลดค์วั�มัเสีำ�ยงจั�กก�รเสีำยชีวิัต จั�กโรค์หลอดเล่อดหวััใจัรวัมัทั�งก�รดำ�เนินขีองโรค์ สำมัรรถภั�พ็ร่�งก�ย คุ์ณิภั�พ็ชีวิัตที�เกี�ยวัเน่�อง กบัสุำขีภั�พ็ดีขี่ �นอีกด�วัย สำำ�หรบัผ้เ้ป็นเบ�หว�นช้นิดที� 2กิจักรรมัท�งก�ยจัะลดอตัร�ก�รเสีำยชีวิัต จั�กโรค์หลอดเล่อดหัวัใจัและตวัับ่งชี�ก�รดำ�เนินขีองโรค์ และสำำ�หรบัผ้มี้ัเชื้ �อ HIV กิจักรรมั ท�งก�ยจัะทำ�ให�ค์วั�มัแข็ีงแรงขีองร่�งก�ยและสุำขีภั�พ็จิัตดีขี่ �น (ลดอ�ก�รกงัวัลและซม่ัเศร� ) และไม่ัมีัผู้ลที�ผู้กผู้นัต่อก�รดำ�เนินขีองโรค์ (ค่์� CD4 และค่์� Viral load ในก�รวัดัปริมั�ณิเช่�อ) หร่อองค์ป์ระกอบร่�งก�ย สำำ�หรบัผู้้�ใหญ่่ที�มีัภั�วัะเร่ �อรงั กิจักรรมัท�งก�ยค์วัรเป็นส่ำวันหน่�งขีองก�รสำนัทน�ก�รและก�รพ็กั ผู่้อน (ก�รละเล่น เกมัสำ ์กีฬ� หร่อก�รออกกำ�ลงัก�ยที�มีัก�รวั�งแผู้น) ก�รเดินท�ง (ก�รขีบัเค์ล่�อนด�วัยล�อ ก�รเดิน และก�รปั� นจักัรย�น) ก�รทำ�ง�น หร่อทำ�ง�นบ� น ในปริบทขีองสำภั�พ็แวัดล�อมัประจัำ�วันัด� น ก�รทำ�ง�น ก�รเรียน อย่้บ� น หร่อในชุมัชน ผู้้�ใหญ่่ที�รอดชีวิัตจั�กมัะเร็ง และผู้้�ที�มีัค์วั�มัดนัโลหิตส้ำง เบ�หวั�นชนิดที� 2 และHIV ค์วัรจัะทำ� ต�มัขี�อแนะนำ�นี�เม่ั�อเป็นไปได�และทำ�เท่�ที�ทำ�ได� ห�กไม่ัมีัขี�อบ่งห� มัใด ๆ จันถง่ปัจัจุับนั ขี�อแนะนำ�ในก�รทำ�กิจักรรมัท�งก�ยสำำ�หรบัผู้้�มีัภั�วัะเร่ �อรงั ส่ำวันใหญ่่จัะจัำ�กดัอย่้ในค์ำ�แนะนำ�ท�งก�รแพ็ทยห์ร่อก�รบำ�บดัโรค์ ตวััอย่�งเช่น มีัขี�อแนะนำ�ท�งก�รแพ็ทยแ์ละแหล่งขี�อม้ัลที�พ็ฒัน�โดยสำมั�ค์มัแพ็ทยอ์�ชีพ็สำำ�หรบั มัะเร็งวิัทย� (101) เบ�หวั�นชนิดที� 2 (102) ค์วั�มัดนัโลหิตส้ำง (103) และโรค์เร่�อรงัอ่�น ๆ (104) องค์ก์�รอน�มัยัโลกมีัขี�อแนะนำ�ท�งก�รแพ็ทยซ์่�งรวัมัค์ำ�แนะนำ�ในก�รทำ�กิจักรรมัท�งก�ยสำำ�หรบั ผู้้�ป่วัยโรค์เร่�อรงัเอ�ไวั�ด�วัย (17) ขี�อแนะนำ�เหล่�นี�เป็นขี�อแนะนำ�ที� อิงต�มัประช�กรฉบบัแรกขีององค์ก์�รอน�มัยัโลก ว่ั�ด�วัยก�ร ทำ�กิจักรรมัท�งก�ยสำำ�หรบัผู้้�มีัภั�วัะเร่ �อรงั โดยเฉพ็�ะผู้้�ที� เป็นโรค์มัะเร็ง (จั�กนี�จัะไปกล่�วัถ่งในฐ�นะ “ผู้้�รอดจั�กมัะเร็ง”) โรค์ค์วั�มัดนัโลหิตส้ำง โรค์เบ�หวั�นชนิดที� 2 และโรค์ HIV โรค์ HIV ถ้กมัองเป็นภั�วัะเร่ �อรงั ด�วัยค์วั�มัก� วัหน� ขีองก�รรักษ�ด�วัยย�ต� นไวัรัสำ HIV ที�มีัประสิำทธิิภั�พ็และมีัอย่้ทั�วัไป ผู้้�ป่วัยที�เขี� รบัก�รรกัษ�ต่อเน่�อง (เช่น ก�รทำ�คี์โมับำ�บดั) หร่อยงัไม่ัเสำถียร กบัก�รรกัษ�โรค์เร่�อรงั ผู้้�ให�บริก�รด� นก�รด้แลสุำขีภั�พ็ค์วัรจัะอ� งอิงขี�อแนะนำ�ท�งก�รแพ็ทยที์�เกี�ยวัเน่�อง กบัอ�ก�รเร่�อรงัแต่ละอย่�งด�วัย ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) ข้้อแนืะนืำ�ด้็�นืกิิจกิรัรัมท�งกิ�ย แนะนำ�ให:้ ผ้ ใ้หญ่่หรือผ้ส้้ำงอ�ยุที�มีัภ�วะเรื �อรงัเหล่�นี � ค์วรทำ�กิจกรรมัท�งก�ยเป็นประจำ� แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�ง ผ้ ้ใหญ่่และผ้ส้้ำงอ�ยุที�มีัภ�วะเรื �อรงัเหล่�นี � ค์วรทำ�กิจกรรมัท�งก�ยแบบแอโรบิกที�ระดบั ป�นกล�ง อย่�งนอ้ย 150-300 น�ที หรือที�ระดบัหนกั อย่�งนอ้ย 75-150 น�ที หรือผสำมัทั�ง 2 ระดบัอย่�งเท่�เทียมักนั ติลอดทั�งสำปัด�หเ์พื�อสุำข้ภ�พที�ดีอย่�งต่ิอเนื�อง แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อได�ป�นกล�ง ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 80 ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ • ห�กไม่ัสำ�มั�รถทำ�ต�มัค์ำ�แนะนำ�ด� นบนนี�ได� ผู้้�ใหญ่่ที� มีัภั�วัะเร่ �อรงัค์วัรมุ่ังที�จัะเขี� ร่วัมั กิจักรรมัท�งก�ยต�มัค์วั�มัสำ�มั�รถขีองตน • ผู้้�ใหญ่่ที�มีัภั�วัะเร่ �อรงัเหล่�นี�ค์วัรจัะเริ�มัทำ�กิจักรรมัท�งก�ยแต่น�อยก่อนและค่์อยเพิ็�มัค์วั�มัถี� ค์วั�มัหนกัหน่วัง และระยะเวัล�ขี่ �น • ผู้้�ใหญ่่ที�มีัภั�วัะเร่ �อรงัเหล่�นี�ค์วัรปร่กษ�ผู้้�เชี�ยวัช�ญ่ด� นกิจักรรมัท�งก�ยหร่อผู้้�เชี�ยวัช�ญ่ ด� นก�รด้แลสุำขีภั�พ็ เพ่็�อค์ำ�แนะนำ�เกี�ยวักบัประเภัทและปริมั�ณิขีองกิจักรรมัที� เหมั�ะกบั ค์วั�มัต�องก�ร ค์วั�มัสำ�มั�รถ ขีีดจัำ�กดัและค์วั�มัซบัซ�อนขีองร่�งก�ย ก�รใช�ย� และแผู้นก�ร รกัษ�โดยรวัมัขีองแต่ละบุค์ค์ล • ใบอนุญ่�ตจั�กแพ็ทยก่์อนก�รทำ�กิจักรรมัท�งก�ยนั�นไม่ัจัำ�เป็นต่อบุค์ค์ลที� มิั ได�มีัขี�อ บ่งห� มัในก�รเริ�มัทำ�กิจักรรมัท�งก�ยในระดบัเบ�จันถง่ป�นกล�ง ที� ไม่ัเกินขีีดขีองก�รเดินเร็วั หร่อก�รใช�ชีวิัตประจัำ�วันั ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) > > > ผ้ ้ใหญ่่และผ้ส้้ำงอ�ยุที�มีัภ�วะเรื �อรงัเหล่�นี �ค์วรทำ�กิจกรรมัสำร�้งค์ว�มัแข็้งแรงใหก้บักล�้มั- เนื �อที�ใช้ก้ล�้มัเนื �อหลกัทุกส่ำวน ในระดบัป�นกล�งหรือหนกัที� อย่�งนอ้ย 2 วนัต่ิอสำปัด�ห ์ เพื�อประโยช้นต่์ิอสุำข้ภ�พ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�ง ก�รทำ�กิจกรรมัท�งก�ยในแต่ิละสำปัด�ห ์ ผ้ส้้ำงอ�ยุที�มีัภ�วะเรื �อรงัเหล่�นี �ค์วรทำ�กิจกรรมั ท�งก�ยแบบผสำมัผสำ�นที�เนน้ก�รทรงติวัและเสำริมัสำร�้งค์ว�มัแข็้งแรงที�ระดบัป�นกล�ง ข้้ �นไป อย่�งนอ้ย 3 วนัต่ิอสำปัด�ห ์เพื�อเสำริมัสำร�้งสำมัรรถภ�พร่�งก�ยและป้องกนัก�รหกลม้ัดี แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�ง ห�กไม่ัมีัข้อ้บ่งห�้มัใด ๆ ผ้ ้ใหญ่่และผ้ส้้ำงอ�ยุที�มีัภ�วะเรื �อรงัเหล่�นี �สำ�มั�รถเพิ�มัก�รทำ� กิจกรรมัท�งก�ยแบบแอโรบิกที�ระดบัป�นกล�งใหม้ั�กกว่� 300 น�ที หรือที�ระดบั มั�กใหม้ั�กกว่� 150 น�ที หรือรวมัท ั�งสำองแบบเท่� ๆ กนัติลอดทั�งสำปัด�หเ์พื�อสุำข้ภ�พที�ดี แนะนำ�โดยมีัเง่�อนไขี มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�ง หลกัฐ�นสำนบัสำนุนและเหตุิผล ขีอบเขีตขีองขี�อแนะนำ�เหล่�นี�ค่์อ ประเมิันค์วั�มัเช่�อมัโยงระหว่ั�งกิจักรรมัท�งก�ยและผู้ลลพั็ธิ ์ ท�งสุำขีภั�พ็ ดังนี� สำำ�หรบัผ้ร้อดชี้วิติจ�กมัะเร็ง ค่์อ ก�รเสีำยชีวิัตทุกสำ�เหตุ ก�รเสีำยชีวิัตจั�ก มัะเร็งโดยเฉพ็�ะ และค์วั�มัเสีำ�ยงต่อก�รเกิดใหม่ัขีองมัะเร็งหร่อมัะเร็งขีั�นปฐมัภ้ัมิัในจุัดที�สำอง สำำ�หรบัผ้ที้� มีัค์ว�มัดนัโลหิติส้ำง ค่์อ ก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อดหัวัใจั ค์วั�มัเสีำ� ยงต่อภั�วัะที� มีัโรค์วิันิจัฉัย ร่วัมั สำมัรรถภั�พ็ท�งก�ย คุ์ณิภั�พ็ชีวิัตที� เกี�ยวัเน่�องกบัสุำขีภั�พ็ และก�รดำ�เนินขีองโรค์ (ณิ ที� นี�จัะนิย�มั เป็นก�รตอบสำนองขีองค์วั�มัดนัโลหิตต่อกิจักรรมัท�งก�ย) สำำ�หรบัผ้ป่้วยเบ�หว�นช้นิดที� 2 ค่์อ ก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อดหวััใจั ค์วั�มัเสีำ�ยงต่อภั�วัะโรค์วิันิจัฉยัร่วัมั สำมัรรถภั�พ็ท�งก�ย คุ์ณิภั�พ็ ชีวิัตที�เกี�ยวัเน่�องกบัสุำขีภั�พ็ และก�รดำ�เนินขีองโรค์ และสำำ�หรบัผ้ที้�มีัเชื้ �อ HIV ค่์อ ก�รทำ�ง�นขีองร่�งก�ย (สำมัรรถภั�พ็ ค์วั�มัทนท�นในก�รออกกำ�ลงัก�ย และค์วั�มัแข็ีงแรง) คุ์ณิภั�พ็ชีวิัตที� เกี�ยวัเน่�องกบัสุำขีภั�พ็ สุำขีภั�พ็จิัต (อ�ก�รกงัวัลและซม่ัเศร� ) ตวัับ่งชี�ค์วั�มัเสีำ�ยงโรค์หลอดเล่อดหวััใจั (ไขีมันัในเล่อด นำ � ต�ลในเล่อด และส่ำวันประกอบขีองเล่อด) และผู้ลเสีำยต่อก�รดำ�เนินขีองโรค์ (กล่�วัค่์อก�รนบั CD4 และ Viral load) 81 ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) หลกัฐ�นที�ใช�อ� งอิงขี�อแนะนำ�เหล่�นี�ค่์อ ร�ยง�นขีอง PAGAC (35) ซ่�งปรบัปรุงโดยบทปริทศัน์ใหม่ั จัำ�นวัน 16 ฉบบัที�วิันิจัฉยัมั�จั�ก พ็.ศ. 2560 ถง่ พ็.ศ. 2562 ในเร่�องมัะเร็ง (n= 1) ค์วั�มัดนัโลหิตส้ำง (n= 2) และเบ�หวั�นชนิดที� สำอง (n= 13) นอกจั�กนี� มีับทปริทัศน์ที� ว่ั�ด�วัยก�รทำ�กิจักรรมัท�งก�ย และผู้ลลพั็ธิที์� เกี�ยวัเน่� องกบัสุำขีภั�พ็ในหม่้ัผู้้�มีัเช่ �อ HIV ซ่�งได�หลกัฐ�นจั�กบทปริทศันที์� เหมั�ะสำมัจัำ�นวัน 19 ฉบบั ที�ตีพิ็มัพ็ร์ะหว่ั�ง พ็.ศ. 2545 ถง่ พ็.ศ. 2561 ขี�อม้ัลค์รบถ�วันเกี�ยวักบัวิัธีิวิัจัยั ก�รแยกส่ำวันขี�อม้ัล และชุดขี�อม้ัลหลกัฐ�นนั�นมีัอย่้ที�ภั�ค์ผู้นวักเว็ับไซต ์: ชุดขี�อม้ัลหลกัฐ�น11 ข้้อัแนะนำา 11 ข้้อม่ัลออนไลน์ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ค์ว�มัสำมััพนัธิ์ร์ะหว่�งกิจกรรมัท�ง ก�ยและผลที� เกี� ยวเนื� องกบัสุำข้ภ�พ ในผ้ใ้หญ่่และผ้ส้้ำงอ�ยุ (อ�ยุ 18 ปีข้้ �นไป) ที�มีัเชื้ �อมัะเร็ง (ผ้ร้อดชี้วิติจ�กมัะเร็ง) ค์ว�มัดนัโลหิติส้ำง เบ�หว�นช้นิดที� 2 หรือ HIV คื์ออะไร ก�รทำ�กิจักรรมัท�งก�ยทำ�ให�เกิด ก�รเปลี�ยนแปลงที� เป็นผู้ลดีในระยะสำั�น และระยะย�วัต่อกระบวันก�รเผู้�ผู้ล�ญ่ อ�ห�ร กระบวันก�รเกี�ยวักบัฮอร์โมัน และกระบวันก�รอกัเสำบ ซ่�งถ้กมัองว่ั�เป็น ก�รป้องกนัก�รเกิดมัะเร็งและก�รอย่้ รอดจั�กมัะเร็ง (35) หลกัฐ�นแสำดงให� เห็นว่ั� ก�รทำ�กิจักรรมัท�งก�ยในระดบั ที� ส้ำงขี่ �นหลังจั�กตรวัจัพ็บมัะเร็งเป็น ก�รป้องกันจั�กก�รเ สีำยชีวิัตในทุก สำ�เหตุหลงัจั�กเป็นมัะเร็งเต� นมั (HR= 0.58 [95% CI: 0.52 ถง่ 0.65] ง�นวิัจัยั 17 ฉบบั) มัะเร็งลำ�ไสำ� (HR= 0.63 [95% CI: 0.50 ถง่ 0.78] ง�นวิัจัยั 10 ฉบบั) มัะเร็งระบบส่ำบพ็นัธุิเ์พ็ศหญิ่ง (HR= 0.66 [95% CI: 0.49 ถ่ง 0.88] ง�นวิัจัยั 4 ฉบบั) มัะเร็งสำมัองชนิดกลิโอมั� (HR= 0.64 [95% CI: 0.46 ถง่ 0.91] ง�นวิัจัยั 1 ฉบบั) มัะเร็งเม็ัดเล่อด (HR= 0.60 [95% CI: 0.51 ถ่ง 0.69] ง�นวิัจัยั 2 ฉบบั) มัะเร็งไต (HR= 0.60 [95% CI: 0.38 ถง่ 0.95] ง�นวิัจัยั 1 ฉบบั) มัะเร็งปอด (HR= 0.76 [95% CI: 0.60 ถง่ 0.97] ง�นวิัจัยั 2 ฉบบั) มัะเร็งต่อมัล้กหมั�ก (HR= 0.60 [95% CI: 0.46 ถ่ง 0. 79] ง�นวิัจัยั 5 ฉบบั) และมัะเร็งกระเพ็�ะอ�ห�ร (HR= 0.75 [95% CI: 0.61 ถง่ 0.93] ง�นวิัจัยั 1 ฉบบั) (105) ก�รทำ�กิจักรรมัท�งก�ยในปริมั�ณิ ที�มั�กขี่ �นหลงัก�รตรวัจัพ็บมัะเร็งเช่�อมั โ ยง กับ ค์วั�มั เ สีำ� ยง ที� ล ด ลง ขีอง ก�ร เสีำยชีวิัตจั�กสำ�เหตุเฉพ็�ะในผู้้�รอดชีวิัต จั�กมัะเร็งเต� นมั มัะเร็งกระเพ็�ะอ�ห�ร และมัะเร็งต่อมัล้กหมั�ก บทวิัเค์ร�ะห ์ อภิัมั�นค์�นพ็บอนัตร�ยจั�กภั�วัะก�รเสีำย ชีวิัตที�ลดลง สำำ�หรบัผู้้�ที�ทำ�กิจักรรมัท�ง ก�ยทุกร้ปแบบ หลงัก�รวิันิจัฉยัโรค์มัะเร็ง ทุกประเภัทในระดบัส้ำงสุำดเทียบกบัตำ� สุำด (HR= 0.63 [95% CI: 0.53 ถง่ 0.75] ง�นวิัจัยั 4 ฉบบั ) มัะเร็งเต� นมั (HR= 0.63 [95% CI: 0.50 ถง่ 0.78] ง�นวิัจัยั 13 ฉบบั) มัะเร็งลำ�ไสำ� (HR= 0.62 [95% CI: 0.44 ถ่ง 0.86] ง�นวิัจัยั 6 ฉบบั) และมัะเร็งต่อมัล้กหมั�ก (HR= 0.70 ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 82 [95% CI: 0.55 ถง่ 0.90] ง�นวิัจัยั 4 ฉบบั) (105) อย่�งไรก็ดี มีัหลกัฐ�นไม่ัเพี็ยงพ็อที� จัะระบุว่ั� กิจักรรมัท�งก�ยจัะเกี�ยวัเน่�อง กบัก�รกลบัมั�เกิดใหม่ัขีองมัะเร็งหร่อ มัะเร็งขีั�นปฐมัภ้ัมิัในจุัดที�สำอง กิจักรรมัท�งก�ยมีัค์วั�มัสำำ�ค์ัญ่ สำำ�หรับก�รป้องกันเบ่ �องต�นและก�ร จัดัก�รค์ว�มัดนัโลหิติส้ำง ด�วัยหลกัฐ�น ที� แสำดงว่ั� ก�รทำ�กิจักรรมัท�งก�ย สำร� งเสำริมัสำมัรรถภั�พ็ท�งร่�งก�ย ก�รดำ�เนินขีองโรค์หลอดเล่อดหวััใจั (เช่น ก�รตอบสำนองขีองค์วั�มัดนัโลหิตต่อ กิจักรรมัท�งก�ย) และก�รเสีำยชีวิัตจั�ก โรค์หลอดเล่อดหัวัใจัในผู้้�ป่วัยค์วั�มัดนั โลหิตส้ำง (35) ตวััอย่�งเช่น เม่ั�อเปรียบ- เที ย บ กับ ก ลุ่มั ค์วั บ คุ์มั ที� ไ ม่ั มีั ก�ร ทำ � กิจักรรมัท�งก�ย ผู้้�มีัค์วั�มัดนัโลหิตส้ำง และมีัก�รเค์ล่�อนไหวัร่�งก�ยค์ล่องแค์ล่วั จัะสำ�มั�รถลดค์วั�มัดนัช่วังหัวัใจับีบลง ได�ประมั�ณิ12มิัลลิเมัตรปรอท และค์วั�มั ดนัโลหิตเม่ั�อหัวัใจัค์ล�ยตวััประมั�ณิ 6 มิัลลิเมัตรปรอท (SBP MD= 12.26 mm Hg [95% CI: 15.17 ถง่ 9.34] p= < 0.05; DBP MD= 6.12 mm Hg [95% CI: 7.76 ถง่ 4.48] p= < 0.05) (106) หลกัฐ�นที� ปร�กฎขี่ �นแสำดงให�เห็นว่ั�ผู้้�ที� มีัโรค์ค์วั�มั ดนัโลหิตส้ำงและทำ�กิจักรรมัท�งก�ยนั�น จัะทำ�ให�คุ์ณิภั�พ็ชีวิัตด� นสุำขีภั�พ็ดีขี่ �นได� อย่�งมีันยัสำำ�ค์ญั่ เม่ั�อเปรียบเทียบกบัผู้้� ไม่ัทำ�กิจักรรมัท�งก�ย (54) กิจักรรมัท�งก�ย รวัมัถง่กิจักรรมั แบบแอโรบิก กิจักรรมัสำร� งค์วั�มัแข็ีงแรง ให�กบักล� มัเน่�อและก�รทำ�กิจักรรมัแบบ แอโรบิกผู้นวักกบัเสำริมัสำร� งค์วั�มัแข็ีง- แรงกล� มัเน่�อนั�น เช่� อมัโยงกบัตวัับ่งชี� ทุติยภ้ัมิัขีองค์วั�มัเสีำ� ยงในก�รดำ�เนิน โรค์ที� ดีขี่ �น (HbA1c ค์วั�มัดันโลหิต ดัช นี มั วั ล ก � ย แ ล ะ ไขี มัันใน เ ล่ อ ด ) ในผู้้�ใหญ่่ที� เป็นเบ�หว�นช้นิดที� 2 (35) ตวััอย่�งเช่น ง�นวิัจัยัเม่ั�อไม่ัน�นมั�นี�พ็บ ว่ั� ก�รออกกำ�ลงัก�ยแบบมีัแรงต� นนั�น เช่�อมัโยงกบัก�รลด HbA1c ลงอย่�งมั�ก เม่ั�อเทียบกบักลุ่มัค์วับคุ์มั และก�รออก กำ�ลงัก�ยแบบมีัแรงต� นส้ำงมีัผู้ลในท�ง บวักอย่�งมีันยัสำำ�ค์ญั่กบัปริมั�ณิอินซ้ลิน ขีณิะอดอ�ห�ร (107) มีัหลกัฐ�นไม่ัเพี็ยง พ็อที�จัะประเมิันผู้ลกระทบขีองก�รออก กำ�ลงัก�ยกบัคุ์ณิภั�พ็ชีวิัตที�เกี�ยวัเน่�องกบั สุำขีภั�พ็และสำมัรรถภั�พ็ร่�งก�ยขีอง ผู้้�ใหญ่่ที�เป็นโรค์เบ�หวั�นชนิดที�สำอง กิจักรรมัท�งก�ยสำำ�หรบัผ้มี้ัเชื้ �อ HIV นั�น ช่วัยพ็ฒัน�ค์วั�มัแข็ีงแรงขีอง ปอดและหัวัใจั ก�รแทรกแซงที� นำ�มั� วิัจััยนั�นรวัมัเอ�ทั�งก�รออกกำ�ลงัก�ย แบบแอโรบิกหร่อก�รออกกำ�ลงัก�ยที� ผู้สำ�นก�รออกกำ�ลงัก�ยย่ดหยุ่นกล� มั เน่�ออย่�งต่อเน่�อง อย่�งน�อย 30 น�ที 3 ค์รั�งต่อสำปัด�ห ์(108,109) มีัหลกัฐ�นเช่น กนัว่ั� ก�รแทรกแซงกิจักรรมัท�งก�ยช่วัย ปรบัปรุงตวัับ่งชี�ค์วั�มัเสีำ�ยงต่อโรค์ระบบ หัวัใจัหลอดเล่อด (เช่น ไขีมันัในเล่อด) แมั�ว่ั�ผู้ลที� ได�จัะผู้สำมักนัไป ไม่ัมีัผู้ลกระทบ ย่นยนัเร่�องค์วั�มัเขี�มัขี�นขีองอินซ้ลินแมั� ระดบักล้โค์สำจัะลดลงหลงัก�รออกกำ�ลงั- ก�ยแบบแอโรบิก (110) กิจักรรมัท�ง- ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) 83 ก�ยไม่ัว่ั�จัะเป็นแบบแอโรบิกหร่อแบบ ผู้สำมักบัก�รออกกำ�ลงัก�ยสำร� งค์วั�มั แข็ีงแรงกล� มัเน่�อในผู้้�ที� มีัเช่ �อ HIV นั�น เช่�อมัโยงในท�งบวักกบัคุ์ณิภั�พ็ชีวิัตที� เกี�ยวัเน่�องกบัสุำขีภั�พ็ (111) และก�รลด อ�ก�รซม่ัเศร� และค์วั�มักงัวัล (112) บท วิัเค์ร�ะห์อภิัมั�นสำำ�หรับโรค์ซ่มัเศร� (ง�นวิัจััย 9 ฉบบั) แสำดงค่์�เบี� ยงเบน มั�ตรฐ�นที� 0.84 (95% CI: 1.57 ถ่ง 0.11) เอ่ �อกบักลุ่มัที�มีัก�รแทรกแซง (p= 0.02) ค่์�เบี�ยงเบนมั�ตรฐ�นสำำ�หรบัก�ร ลดอ�ก�รกงัวัล (ง�นวิัจัยั 5 ฉบบั) มีันยั สำำ�ค์ญั่ท�งสำถิติที� เอ่ �อต่อก�รแทรกแซง (1.23 [95% CI: 2.42 ถง่ 0.04], p= 0.04) (112) กิจักรรมัท�งก�ยยงัเช่�อมัโยงกบัค่์� เฉลี�ยมั�ตรฐ�นที�มีันยัสำำ�ค์ญั่ที� เพิ็�มัขี่ �นใน นำ � หนกัขีองร่�งก�ยที� ไม่ัมีัไขีมันัถง่ 1.75 กิโลกรัมั และมีัก�รลดลงอย่�งมีันัย สำำ�ค์ัญ่ขีองไขีมัันในร่�งก�ยที� ร�อยละ 1 . 1 2 สำำ � ห รั บ ผู้้� เ ขี� � ร่ วั มั ใ น ก ลุ่ มั ค์วับคุ์มัที� มีัก�รออกกำ�ลงัก�ย รวัมัถ่ง ก�รเพิ็� มัเสำ�นรอบวังกล� มัเน่�อขี�และ แขีน เปรียบเทียบกบัผู้้�เขี� ร่วัมัที�อย่้ใน กลุ่มัค์วับคุ์มัที� ไม่ัมีัก�รออกกำ�ลงัก�ย (111) แต่ไม่ัเช่� อมัโยงกับก�รเปลี� ยน แปลงดชันีมัวัลก�ยหร่อรอบเอวัในผู้้�ที� มีัเช่ �อ HIV (111) กิจักรรมัท�งก�ยไม่ัมีั อิทธิิพ็ลในท�งตรงกันขี� มักับเค์ร่� อง บ่งชี�กบัก�รดำ�เนินโรค์ HIV ตวััอย่�งเช่น ก�รนับ CD4 (เซลสำต่์อล้กบ�ศกเ์มัตร) หร่อปริมั�ณิเช่�อ HIV ในเล่อด ที�สำำ�ค์ญั่ค่์อ หลกัฐ�นชิ�นนี�แนะนำ�ว่ั� HIV ในฐ�นะที�เป็น โรค์เร่�อรงัจัะไม่ัมีัผู้ลกระทบในท�งตรงกนั ขี� มัจั�กก�รทำ�กิจักรรมัท�งก�ย คณะทำางาน GDG สรุปว่า : • มีัหลักฐ�นเช่� อถ่อได�ป�นกล�งว่ั� ปริมั�ณิขีองก�รทำ�กิจักรรมัท�งก�ย ที�มั�กขี่ �นหลงัตรวัจัพ็บมัะเร็งนั�นจัะ เช่�อมัโยงกบัค์วั�มัเสีำ�ยงที� ลดลงขีอง ก�รเสีำยชีวิัตในทุกสำ�เหตุ ก�รเสีำยชีวิัต จั�กสำ�เหตเฉพ็�ะและมัะเร็งเฉพ็�ะจุัด ในผู้้�รอดชีวิัตจั�กมัะเร็ง • มีัหลักฐ�นเช่� อถ่อได�ป�นกล�งว่ั� กิจักรรมัท�งก�ยลดค์วั�มัเสีำ�ยงต่อก�ร ดำ�เนินโรค์ขีองโรค์หัวัใจัและหลอด เ ล่อดในผู้้� ใหญ่่ที� มีัภั�วัะค์วั�มัดัน โลหิตส้ำง • มีัหลกัฐ�นที� มีัค์วั�มัน่�เช่� อถ่อป�น- กล�งว่ั� กิจักรรมัท�งก�ยจัะทำ�ให� สำมัรรถภั�พ็ร่�งก�ยดีขี่ �นและผู้ลลพั็ธิ ์ ขีองคุ์ณิภั�พ็ชีวิัตที� เกี� ยวัเน่� องกับ สุำขีภั�พ็ในผู้้�ใหญ่่ที� มีัภั�วัะค์วั�มัดัน โลหิตส้ำง • มีัหลกัฐ�นที� มีัค์วั�มัน่�เช่�อถ่อมั�กว่ั� กิจักรรมัท�งก�ยจัะปรับปรุงตัวั บ่งชี�ก�รดำ�เนินขีองโรค์ (HbA1c ค์วั�มัดนัโลหิต ดชันีมัวัลก�ย และไขีมันั ในเล่อด) ในผู้้�ใหญ่่ที�มีัเบ�หวั�นชนิดที� 2 • มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�งว่ั� ก�ร เช่� อมัโยงระหว่ั�งกิจักรรมัท�งก�ย และก�รฟ้ิ�นฟ้ิค์วั�มัแข็ีงแรงขีองร่�ง ก�ย (ก�รรบัออกซิเจันระดบัส้ำงสุำด ค์วั�มัทนท�นในก�รออกกำ�ลงัก�ย) แ ล ะ ค์ วั � มั แ ข็ี ง แ ร ง ก ล� � มั เ น่� อ สำำ�หรับค์นที� มีัเช่ �อ HIV และค์วั�มั เช่�อมัโยงที� เอ่ �อระหว่ั�งกิจักรรมัท�ง ก�ยและองค์ป์ระกอบขีองร่�งก�ย ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 84 คุ์ณิภั�พ็ชีวิัตที� เกี�ยวัเน่� องกบัสุำขีภั�พ็ อ�ก�รซม่ัเศร� และกงัวัลที�ลดลง และ ไม่ัมีัก�รเปลี�ยนแปลงจัำ�นวันเช่�อ HIV ในเล่อดหร่อก�รนบั CD4 ในค์นที�มีัเช่ �อ HIV • ประโยชนเ์ช่� อมัโยงกับก�รเขี� ร่วัมั กิจักรรมัท�งก�ยเป็นกิจัวัตัรสำำ�หรบัผู้้� รอดชีวิัตจั�กมัะเร็งและผู้้�มีัค์วั�มัดนั โลหิตส้ำง เบ�หวั�นชนิดที� 2 และ HIV ที� สำัมัพ็ันธิก์ับผู้ลลัพ็ธิท์�งสุำขีภั�พ็ เฉพ็�ะอย่�งมีัมั�กกว่ั�ค์วั�มัเสีำ�ยง มีัค์ว�มัเชื้�อมัโยงในก�รติอบสำนองต่ิอ ปริมั�ณหรือไม่ั (ปริมั�ณ ระยะเวล� ค์ว�มัถี� ค์ว�มัหนกัหน่วง) ก�รทำ�กิจักรรมัท�งก�ยในปริมั�ณิ ที� มั�กขี่ �นหลงัก�รตรวัจัพ็บมัะเร็งนั�น เช่�อมัโยงกบัค์วั�มัเสีำ�ยงที�ลดลงขีองภั�วัะ ก�รเสีำยชีวิัตจั�กมัะเร็งทุกสำ�เหตุ และ ก�รเสีำยชีวิัตที� เจั�ะจังเฉพ็�ะมัะเร็ง หลกัฐ�นชี�ให�เห็นค์วั�มัสำมััพ็นัธิที์� ไม่ัเป็น เสำ�นตรงระหว่ั�งระดบัที� เพิ็�มัส้ำงขี่ �นขีอง ก�รทำ�กิจักรรมัท�งก�ยหลงัตรวัจัพ็บ มัะเร็ง และภั�วัะก�รเสีำยชีวิัตเจั�ะจัง เฉพ็�ะมัะเร็งเต� นมั และภั�วัะก�รเสีำย ชีวิัตทุกสำ�เหตุไปจันถ่ง 10-15 MET- hours ต่อสำปัด�ห ์ (ค์งที� เป็นเวัล� 150 น�ทีต่อสำัปด�ห์ด�วัยก�รทำ�กิจักรรมั ท�งก�ยที� ระดับป�นกล�งถ่งมั�ก) โดยไม่ัมีัหลักฐ�นถ่งอันตร�ยต่�ง ๆ ในระดบัที� ส้ำงขี่ �น (105) มีัขี�อแนะนำ�ถ่ง ค์วั�มัเช่� อมัโยงกับก�รตอบสำนองต่อ ปริมั�ณิในทำ�นองเดียวักนัสำำ�หรบัมัะเร็ง ในจุัดอ่�น ๆ แต่ก็ยงัมีัง�นวิัจัยัน�อยเกินไป ที�จัะสำร� งบทวิัเค์ร�ะหอ์ภิัมั�นอย่�งเป็น ท�งก�รได� ง�นวิัจัยัเพิ็�มัเติมัเป็นที�ต�อง ก�ร เพ่็�อกำ�หนดพ็ลงัขีองค์วั�มัเช่�อมัโยงนี� มีัค์วั�มัสำมััพ็นัธิ ์ในก�รตอบสำนอง ต่อปริมั�ณิที�ชดัเจันระหว่ั�งกิจักรรมัท�ง ก�ยและภั�วัะก�รเสีำยชีวิัตจั�กโรค์หวััใจั และหลอดเล่อดสำำ�หรบัผู้้�ที� มีัภั�วัะค์ว�มั ดนัโลหิติส้ำง (35) ผู้ลก�รศก่ษ�แสำดงให� เห็นว่ั�ค์วั�มัดนัโลหิตหลงัก�รบีบตวััขีอง หัวัใจัจัะเพิ็�มัขี่ �นในช่วังค์วั�มัดนัโลหิตส้ำง ค์วั�มัเสีำ�ยงต่อภั�วัะก�รเสีำยชีวิัตจั�กโรค์ หลอดเล่อดหวััใจัเพิ็�มัขี่ �น แต่ค์วั�มัเสีำ�ยงที� เพิ็�มัขี่ �นนั�นลดลงด�วัยก�รทำ�กิจักรรมัท�ง- ก�ยในระดบัที� ส้ำงขี่ �น (35) เช่นเดียวักบั ค์ำ�แนะนำ�สำำ�หรับประช�กรทั� วัไป ก�ร แทรกแซงต�มัแบบแผู้นโดยส่ำวันใหญ่่ จัะเป็นก�รทำ�กิจักรรมัท�งก�ยแบบ แอโรบิกที�ระดบัป�นกล�งด�วัยเวัล�ประ- มั�ณิ 30-60 น�ที 3 วันัต่อสำปัด�ห ์และ/ หร่อออกกำ�ลงัก�ยแบบมีัแรงต� น 2-3 ชุดต่อสำปัด�ห์ มีั ห ลัก ฐ � น ที� เ ป็ น ร้ ป ธิ ร ร มั ถ่ ง ค์วั�มัเช่�อมัโยงที�เป็นเสำ�นโค์�งค์วัำ� ระหว่ั�ง ปริมั�ณิก�รทำ�กิจักรรมัท�งก�ยและ ค์วั�มัเสีำ�ยงขีองภั�วัะก�รเสีำยชีวิัตจั�กโรค์ หลอดเล่อดหัวัใจัในผู้้�ป่วัยที� เ ป็นเบ� หว�นช้นิดที� 2 (113-115) ก�รทำ� กิจักรรมัท�งก�ยในปริมั�ณิที� มั�กขี่ �น (จั�กทั�งตำ� กว่ั� หร่อเทียบเท่� หร่อมั�ก กว่ั�ระดบัที�แนะนำ�ที� 150 น�ทีต่อสำปัด�ห ์ ด�วัยก�รทำ�กิจักรรมัท�งก�ยที� ระดับ ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) 85 ป�นกล�ง) ลดค์วั�มัเสีำ�ยงได�อย่�งต่อเน่�อง ตวััอย่�งเช่น เม่ั� อเปรียบเทียบกบัก�ร ไม่ัทำ�กิจักรรมัใด ๆ เลย ก�รเขี� ร่วัมั กิจักรรมับ�งประเภัทเช่�อมัโยงกบัก�ร ลดค์วั�มัเสีำ� ยงต่อภั�วัะก�รเสีำยชีวิัต จั�กโรค์หลอดเล่อดหัวัใจัที�ร�อยละ 32 (อตัร�ก�รเต�นหัวัใจัที�ปรบัแล�วั = 0.68 [95% CI: 0.51 ถง่ 0.92]) ขีณิะที�ก�รทำ� กิจักรรมัในปริมั�ณิที� เป็นไปต�มัขี�อ แนะนำ�หร่อมั�กกว่ั� เช่� อมัโยงกบัก�ร ลดค์วั�มัเสีำ� ยงต่อภั�วัะก�รเสีำยชีวิัต จั � ก โร ค์ ห ล อ ด เ ล่ อ ด หัวัใจั ( อัต ร � ก�รเต�นหวััใจัที�ปรบัแล�วั = 0.60 [95% CI: 0.44 ถ่ง 0.82]) ในปริมั�ณิที� มั�ก ขี่ �นที�ร�อยละ 40 (115) ก�รแทรกแซง อย่้ที�ร�วั ๆ ก�รทำ�กิจักรรมัแบบแอโรบิก ที� ระดับป�นกล�ง 150-300 น�ที หร่อที�ระดบัหนกัเป็นเวัล� 75 น�ที และ/ หร่อออกกำ�ลงัก�ยแบบมีัแรงต� น 2-3 ชุดต่อสำปัด�ห ์ สำำ�หรบัผู้ลลพั็ธิบ์�งอย่�ง (ตัวัอย่�งเช่น HBA1c และค์วั�มัดัน โลหิต) ในผู้้�ใหญ่่ที� เป็นเบ�หวั�นชนิดที� สำอง มีัหลกัฐ�นว่ั�มีัผู้ลที� เห็นได�ชดัเจัน ขี่ �นจั�กก�รทำ�กิจักรรมัแบบแอโรบิก ที� มั�กขี่ �น (เช่น มั�กกว่ั� 150 น�ที ต่อสำปัด�หเ์ทียบกบัน�อยกว่ั� 150 น�ที ต่อสำปัด�ห)์ แต่ยงัมีัหลกัฐ�นจัำ�กดัสำำ�หรบั ค์วั�มัหนกัหน่วัง (35) มีัหลักฐ�นไม่ัเพี็ยงพ็อที� จัะบัญ่ ญ่ัติค์วั�มัสำัมัพ็ันธิ ์ ในก�รตอบสำนอง ต่อปริมั�ณิระหว่ั�งกิจักรรมัท�งก�ย และองค์ป์ระกอบร่�งก�ย หร่อตวัับ่งชี� ที� เป็นตวัักล�งขีองโรค์หลอดเล่อดหวััใจั (เช่น ขี�อม้ัลไขีมันัในเล่อด ก�รต� นอินซ้ลิน ค์วั�มัเขี�มัขี�นขีองกล้โค์สำขีณิะอดอ�ห�ร หร่อค์วั�มัดนัโลหิต) ในผู้้�ที�มีัเช่ �อ HIV ง�น วิัจััยส่ำวันใหญ่่ที� สำร� งหลักฐ�นต่�ง ๆ นั�น เกี�ยวัเน่�องกบัก�รแทรกแซงกิจักรรมั ท�งก�ย อย่�งน�อย 3 ค์รั�งต่อสำปัด�ห ์ เป็นระยะเวัล� 12-48 สำปัด�ห ์และกิจักรรมั แบบแอโรบิกในระดบัป�นกล�งจันถ่ง หนกัแต่เพี็ยงอย่�งเดียวั อย่�งน�อย 30 น�ที หร่อผู้สำมัผู้สำ�นไปกบัก�รออกกำ�ลงั ก�ยแบบมีัแรงต� นอย่�งต่อเน่� อง มีั หลกัฐ�นไม่ัเพี็ยงพ็อที�จัะบญั่ญ่ติัอย่�งแน่ ชดัถง่ค์วั�มัสำมััพ็นัธิต่์อก�รตอบสำนองต่อ ปริมั�ณิกบัสุำขีภั�พ็จิัตและผู้ลลพั็ธิที์�เกี�ยวั เน่�องกบัคุ์ณิภั�พ็ชีวิัต หลกัฐ�นที�มีัอย่้นั�น มั�จั�กง�นวิัจัยัที�ประเมิันก�รแทรกแซง กิจักรรมัท�งก�ย 3 ค์รั�งต่อสำปัด�หห์ร่อ มั�กกว่ั�นั�นอย่�งเป็นแบบแผู้น โดยรวัมัแล�วันั�น มีัหลกัฐ�นที�จัดั ลำ � ดับ จั � ก ร ะ ดับ ค์ วั � มั ห นั ก ห น่ วั ง ป�นกล�งจันถง่หนกัหน่วังส้ำงเพ่็�อสำนบั- สำนุนขี�อแนะนำ�ขีองกิจักรรมัท�งก�ย ที� ระดับป�นกล�ง 150-300 น�ที (หร่อเทียบเท่�) สำำ�หรบักลุ่มัประช�กรที�มีั ภั�วัะเร่ �อรงัที�ระบุและมีัผู้ลลพั็ธิท์�งสุำขี- ภั�พ็เฉพ็�ะกลุ่มั มีัหลกัฐ�นที�ชดัเจันขี่ �น ว่ั� ระดบัขีองกิจักรรมัที�ส้ำงขี่ �นนั�นสำมััพ็นัธิ ์ กบัประโยชนที์�มั�กขี่ �น ในหลกัฐ�นที�กล่�วั ถง่ผู้้�ที�มีัภั�วัะค์วั�มัดนัโลหิตส้ำง เบ�หวั�น ชนิดที� 2 และผู้้�รอดชีวิัตจั�กมัะเร็งยอมัรบั ว่ั�มีั ก�รผู้ันแปรจั�กค์วั�มัน่�เช่� อถ่อ และค์วั�มัตรงไปตรงมั�ขีองหลกัฐ�น ต�มัสำภั�วัะเร่ �อรงัเฉพ็�ะและผู้ลลัพ็ธิ ์ ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 86 เฉพ็�ะที�นำ�มั�ทดสำอบ ขีณิะที�หลกัฐ�น แสำดงถง่ผู้ลในท�งบวักจั�กก�รออกกำ�- ลงัก�ยแบบฝึึกค์วั�มัแข็ีงแรง ค์วั�มัถี�ขีอง ก�รออกกำ�ลงัก�ยแบบมีัแรงต� น ค่์อ 2 หร่อ 3 ชุดต่อสำปัด�ห์ ค์ณะทำ�ง�น GDG สำรุปว่� • มีัหลกัฐ�นที� มีัค์วั�มัน่�เช่� อถ่อป�น- กล�งเกี� ยวักบัค์วั�มัสำมััพ็ันธิ ์ในก�ร ตอบสำนองต่อปริมั�ณิระหว่ั�งก�รทำ� กิจักรรมัท�งก�ยและภั�วัะก�รเสีำย ชีวิัตจั�กทุกสำ�เหตุที� ลดลง รวัมัถ่ง ภั�วัะก�รเสีำยชีวิัตจั�กมัะเร็งโดยเฉพ็�ะ ในผู้้�รอดชีวิัตจั�กมัะเร็ง • มีัหลักฐ�นเช่� อ ถ่อได� ส้ำงถ่งค์วั�มั สำัมั พ็ัน ธิ ์ขี อ ง ก � ร ต อ บ สำ น อ ง ต่ อ ปริมั�ณิระหว่ั�งก�รทำ�กิจักรรมัท�ง ก�ยและภั�วัะก�รเสีำยชีวิัตจั�กโรค์ หลอดเล่อดหัวัใจั สำำ�หรบัผู้้�ใหญ่่ที� มีั ภั�วัะค์วั�มัดนัโลหิตส้ำง • มีัหลกัฐ�นขีองค์วั�มัสำมััพ็นัธิ ์ในก�ร ตอบสำนองต่อปริมั�ณิเป็นเสำ�นโค์�งค์วัำ� ระหว่ั�งปริมั�ณิขีองกิจักรรมัและ ค์วั�มัเสีำ� ยงต่อก�รเสีำยชีวิัตจั�กโรค์ หลอดเล่อดหวััใจัในกลุ่มัผู้้�ใหญ่่ที� เป็น เบ�หวั�นชนิดที� 2 • มีัหลกัฐ�นไม่ัเพี็ยงพ็อเกี�ยวักบัค์วั�มั สำมััพ็นัธิ ์ในก�รตอบสำนองต่อปริมั�ณิ ระหว่ั�งกิจักรรมัท�งก�ยและตวัับ่งชี� ที� เป็นตวัักล�งขีองโรค์ระบบท�งเดิน ห�ยใจั องค์ป์ระกอบขีองร่�งก�ย และคุ์ณิภั�พ็ชีวิัตที� เกี� ยวัเน่� องกับ สุำขีภั�พ็ อ�ก�รกงัวัลและโรค์ซม่ัเศร� ในผู้้�ที�มีัเช่ �อ HIV • ก�รแทรกแซงด�วัยกิจักรรมัแบบ แอโรบิกที�ระดบัป�นกล�งในช่วัง 150- 300 น�ที (หร่อเทียบเท่�) สำร� งผู้ลลพั็ธิ ์ ที�เอ่ �อประโยชนต่์อสุำขีภั�พ็และผู้ลลพั็ธิ ์ ในท�งบวักจั�กก�รออกกำ�ลงัก�ย เพ่็� อเสำริมัค์วั�มัแข็ีงแรงพ็ร�อมัก�ร ออกกำ�ลงัก�ยแบบมีัแรงต� น 2 หร่อ 3 ชุดต่อสำปัด�หต์�มัที�ระบุไวั� ค์ว�มัเชื้�อมัโยงผนัแปรติ�มัช้นิดหรือ ข้อบเข้ติข้องกิจกรรมัท�งก�ยภ�พ หรือไม่ั มีัหลกัฐ�นว่ั�กิจักรรมัท�งก�ยต่�ง ชนิดและต่�งขีอบเขีตนั�น เ อ่ �อประ โยชนต่์อผู้ลลพั็ธิท์�งสุำขีภั�พ็ ผ้ร้อดชี้วิติ จ�กมัะเร็งที� ทำ�กิจักรรมัแบบแอโรบิก และสำร� งค์วั�มัแข็ีงแรงให�กบักล� มัเน่�อ ในระดบัที� แนะนำ�เทียบกบัผู้้�ที� ทำ�ไม่ัถ่ง ระดบัที�แนะนำ�นั�นมีัอตัร�เสีำ�ยงต่อภั�วัะ ก�รเสีำยชีวิัตจั�กโรค์มัะเร็งลดลงอย่�งมีั นัยสำำ�ค์ัญ่ (อัตร�ก�รเต�นขีองหัวัใจั ที� ถ้ ก ป รั บ = 0 . 7 0 [ 9 5 % C I : 0 . 5 0 ถ่ง 0 . 9 8 ] ) ( 8 4 ) ห ลักฐ � น แสำดงให�เห็นว่ั� ก�รย่ดมัั�นกบัขี�อแนะนำ� ในก�รทำ�กิจักรรมัท�งก�ยเพ่็�อย่ดหยุ่น กล� มัเน่�อเพี็ยงอย่�งเดียวั เทียบกบัก�ร ไม่ัย่ดติด ยงัค์งมีัประโยชน์ในก�รปรบั ปรุงผู้ลขีองก�รเสีำยชีวิัตจั�กมัะเร็งให�ดี ขี่ �น ( อตัร�ก�รเต�นขีองหวััใจั = 0.66 [95% CI: 0.48 ถ่ง 0.92]) (84) บทวิัเค์ร�ะห ์ อภิัมั�นยงัได�ร�ยง�นถง่ค์วั�มัเช่�อมัโยงนี� โดยขีอบเขีตในก�รทำ�กิจักรรมัท�งก�ย แ ล ะ พ็ บ ก � ร เ สีำ ย ชี วิั ต ที� ล ด ล ง อ ย่ � ง ต่อเน่� องที� สุำด ทั�งจั�กมัะเร็งทุกจุัด ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) 87 ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) มัะเร็งเต� นมั และภั�วัะก�รต�ยจั�ก มัะเร็งลำ�ไสำ�โดยเฉพ็�ะ สำำ�หรบักิจักรรมั ท�งก�ยเชิงสำนัทน�ก�ร (105) สำำ�หรบั ผู้้�ใหญ่่ที�มีัภั�วัะค์ว�มัดนัโลหิติส้ำง หลกั- ฐ�นสำนับสำนุนกิจักรรมัแบบแอโรบิก ก�รสำร� งค์วั�มัแข็ีงแรงให�กับกล� มั เน่�อ และก�รผู้สำมัผู้สำ�นทั�งสำองร้ปแบบ เพ่็� อแก� ไขีก�รดำ�เนินโรค์หลอดเล่อด หัวัใจั ผู้ลต่อค์วั�มัดันโลหิตที� ลดลง ระหว่ั�งก�รทำ�กิจักรรมัท�งก�ยร้ป แบบดั�งเดิมั (เช่น กิจักรรมัแบบแอ- โรบิกและแบบมีัแรงต� น) ไม่ัผู้ันแปร อย่�งมีันัยสำำ�ค์ญั่ในหม่้ัค์นที� มีัค์วั�มัดนั โลหิตส้ำง (35) อย่�งไรก็ต�มั หลกัฐ�นนี� ไม่ัได�เปรียบเทียบชนิดขีองกิจักรรมัโดย ตรง มีัหลกัฐ�นเพิ็�มัเติมัที�จัะสำนบัสำนุนผู้ล ที�เป็นประโยชนจ์ั�กก�รออกกำ�ลงัก�ยใน ร้ปแบบอ่�น สำำ�หรบัผู้้�มีัภั�วัะค์วั�มัดนัโลหิต ส้ำง (เช่น ไทชี� โยค์ะ ชี�กง) อย่�งไรก็ดีง�น วิัจัยัเพิ็�มัเติมัเพ่็�อวิันิจัฉยักิจักรรมัเหล่�นี� นั�นมีัค์วั�มัต�องก�ร เพ่็� อกำ�หนดค์วั�มั เขี�มัขี�นขีองค์วั�มัเช่�อมัโยง กิจักรรมัแบบแอโรบิก กิจักรรมั สำร� งค์วั�มัแข็ีงแรงให�กับกล� มัเน่�อ หร่อก�รผู้สำมัผู้สำ�นทั�งสำองประเภัทนั�น เช่� อมัโยงกับตัวับ่งชี�ทุติยภ้ัมิัในเร่� อง ค์วั�มัเสีำ� ยงต่อก�รดำ�เนินโรค์ที� ดีขี่ �น (HbA1c, ค์วั�มัดนัโลหิตดชันีมัวัลก�ย แ ล ะ ไ ขี มััน ใ น เ ล่ อ ด ) ใ น ผู้้� ใ ห ญ่่ ที� มีั เบ�หว�นช้นิดที� 2 (35, 107) บทปริทศัน ์ ฉบบัหน่�งที�มีักลุ่มัค์วับคุ์มัแบบสุ่ำมั 24 ร�ย (n= 962) ระบุว่ั� ก�รออกกำ�ลงัก�ยแบบมีั แ ร ง ต� น นั� น เ ช่� อ มั โ ย ง กั บ ก � ร ล ด จัำ�นวัน HbA1c เป็นอย่�งมั�กเทียบกบั ก ลุ่มั ค์วั บ คุ์มั ( ส่ำ วั น เ บี� ยง เ บ น เฉ ลี� ย = 0 . 4 5 [ 9 5 % C I : 0 . 6 5 ถ่ ง 0 . 2 5 ] , ก � ร ท ด ล อ ง 2 0 ค์ รั�ง ; n = 824) ผู้ลที� ได�ระหว่ั�งก�รออกกำ�ลงัก�ย แบบมีัแรงต� นด�วัยค์วั�มัหนกัหน่วังส้ำง เทียบกับกลุ่มัค์วับคุ์มัอินซ้ลินขีณิะอด อ�ห�รนั�น ได�ผู้ลที� มีันัยสำำ�ค์ญั่ท�งสำถิติ (ส่ำวันเบี�ยงเบนเฉลี�ย = 4.60 [95% CI: 7.53 ถง่ 1.67] ก�รทดลอง 5 ค์รั�ง; n= 174) (107) บทปริทศันอี์กฉบบัหน่�งที� มีักลุ่มัค์วับคุ์มัแบบสุ่ำมั 7 ร�ย (n= 189) ร�ยง�นว่ั� ก�รออกกำ�ลงัก�ยแบบสำลบั ช่วัง (2-5 ค์รั�งต่อสำัปด�ห์ ระยะช่วัง 1-4 น�ทีโดยช่วังเวัล�ทั�งหมัดย�วั 20- 60 น�ที) นั�นเช่� อมัโยงกับฮีโมัโกลบิน HbA1c ที� ลดลงอย่�งมีันัยสำำ�ค์ัญ่ท�ง สำถิติถ่งร�อยละ 0.26 (95% CI: 0.46 ถ่ ง 0 . 0 7 % ก ลุ่ มั ค์ วั บ คุ์ มั แ บ บ สุ่ำ มั 5 กลุ่มั) เปรียบเทียบกับกลุ่มั MICT และลดลงร�อยละ 0.83 (95% CI: 1.39% ถง่ 0.27% กลุ่มัค์วับคุ์มัแบบสุ่ำมั 5 กลุ่มั) เปรียบเทียบกบักลุ่มัค์วับคุ์มัที� ไม่ัมีัก�ร ออกกำ�ลังก�ย (116) ในฐ�นะที� เป็น ขี�อแนะนำ�สำำ�หรบัประช�กรทั� วัไป ก�ร แทรกแซงส่ำวันใหญ่่เหล่�นี�มีัที�มั�จั�กก�ร ทำ�กิจักรรมัแบบแอโรบิกที�สำอดค์ล�องกบั ค์ำ�แนะนำ�ให�ทำ�กิจักรรมัแบบแอโรบิก ที�ค์วั�มัหนักหน่วังระดบัป�นกล�งเป็น เวัล� 150-300 น�ที (หร่อกิจักรรมัระดบั หนักเป็นเวัล� 75 น�ที) และกิจักรรมั สำร� งค์วั�มัแข็ีงแรงให�กับกล� มัเน่�อ อ ย่ � ง น� อ ย 2 - 3 ช่ วั ง ต่ อ สำัป ด � ห ์ สำำ�หรบัผู้ลลพั็ธิบ์�งอย่�ง (เช่น HBA1c ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 88 และค์วั�มัดนัโลหิต) มีัหลกัฐ�นว่ั� มีัผู้ล ที� ชัดเจันขี่ �นด�วัยก�รทำ�กิจักรรมัแบบ แอโรบิกที�มั�กขี่ �น (เช่น มั�กกว่ั� 150 น�ทีต่อสำปัด�ห ์ เทียบกบัน�อยกว่ั� 150 น�ทีต่อสำปัด�ห ์ แต่มีัหลกัฐ�นอย่้จัำ�กดั ในเร่�องค์วั�มัหนกัหน่วัง ง�นวิัจัยัล่�สุำด หล�ยชิ�นแสำดงหลกัฐ�นว่ั� ก�รออกกำ�ลงั ก�ยแบบจีันดั�งเดิมั ตวััอย่�งเช่น ไท่ชี� อ�จั จัะมีัประโยชนต่์อระดบันำ � ต�ลในเล่อด แต่ ยงัมีัค์วั�มัน่�เช่�อถ่อป�นกล�งและผู้นัต�มั ตวััแปร (เช่น ค์วั�มัเสีำ�ยงต่อค์วั�มัเอนเอียง หร่อค์วั�มัไม่ัค์งที�) จัำ�เป็นต�องมีัก�รวิัจัยั เพิ็�มัเติมัเพ่็�อกำ�หนดค์วั�มัสำมััพ็นัธิเ์หล่�นี� กิจักรรมัท�งก�ยหล�กหล�ย ประเภัท รวัมัถ่งกิจักรรมัแบบแอโรบิก และก�รออกกำ�ลงัก�ยแบบมีัแรงต� น แสำดงถง่ผู้ลดีต่อคุ์ณิภั�พ็ชีวิัตที�เกี�ยวัขี�อง กบัสุำขีภั�พ็ขีองผู้้�ติดเช่ �อ HIV (111) ง�น วิัจัยัล่�สุำดที�ตรวัจัสำอบก�รเปลี�ยนแปลง คุ์ณิภั�พ็ชีวิัตที�เกี�ยวัขี�องกบัสุำขีภั�พ็ในก�ร ตอบสำนองต่อกิจักรรมัแบบแอโรบิก ก�ร ออกกำ�ลงัก�ยแบบมีัแรงต� นอย่�งต่อ เน่� องหร่อก�รผู้สำมัผู้สำ�นทั�งสำองแบบ แสำดงให�เห็นถ่ง ก�รทำ�ให�สุำขีภั�พ็โดย ทั� วัไปและสุำขีภั�พ็จิัตดีขี่ �นอย่�งมีันัย สำำ�ค์ญั่ และยงัมีัหลกัฐ�นว่ั�กิจักรรมัทั�ง แบบแอโรบิค์และกิจักรรมัหล�ยองค์ ์ ประกอบนั�น เกี�ยวัขี�องกบัก�รลดอ�ก�ร ซม่ัเศร� และค์วั�มัวิัตกกงัวัลในผู้้�ติดเช่ �อ HIV (112) หลกัฐ�นเกี�ยวักบัผู้ลขีองก�ร ทำ�กิจักรรมัท�งก�ยที� มีัต่ออ�ก�รท�ง สุำขีภั�พ็จิัต เกี�ยวัขี�องกบักิจักรรมัแบบ แอโรบิกหร่อแอโรบิกร่วัมักบักิจักรรมั สำร� งค์วั�มัแข็ีงแรงให�กับกล� มัเน่�อ แบบต่อเน่�อง หร่อโยค์ะ หลกัฐ�นยงัแสำดง ให�เห็นว่ั� ก�รออกกำ�ลงัก�ยแบบแอโรบิก แต่เพี็ยงอย่�งเดียวั หร่อเม่ั�อรวัมักบัก�ร ออกกำ�ลงัก�ยแบบมีัแรงต� น ไม่ัได�ส่ำงผู้ ลให�ปริมั�ณิไวัรสัำหร่อจัำ�นวัน CD4 เปลี�ย นแปลงอย่�งมีันยัสำำ�ค์ญั่ในผู้้�ติดเช่ �อ HIV (111) หลกัฐ�นโดยตรงจั�กง�นวิัจัยัที� มีั อย่้และฉบบัปรบัปรุงสำนับสำนุนก�รรวัมั ขี�อแนะนำ�สำำ�หรบัผู้้�ที� เป็นเบ�หวั�นชนิด ที� 2 และค์วั�มัดนัโลหิตส้ำง ให�ทำ�กิจักรรมั ท�งก�ยแบบแอโรบิก และแบบสำร� งค์วั�มั แข็ีงแรงให�กับกล� มัเน่�อแมั�ว่ั�จัะขี�ด หลกัฐ�นตีพิ็มัพ็ ์แต่ก็มีัค์วั�มัเป็นไปได�ท�ง ชีวัภั�พ็ สำำ�หรับประโยชนข์ีองก�รทำ� กิจักรรมัท�งก�ยแบบแอโรบิกและ แบบสำร� งค์วั�มัแข็ีงแรงให�กบักล� มัเน่�อ สำำ�หรบัผู้้�ใหญ่่ที� ติดเช่ �อ HIV และผู้้�รอด ชีวิัตจั�กมัะเร็ง นอกจั�กนี�ต�มัที� ระบุ ไวั� โดยค์ณิะทำ�ง�น GDG ขี�อแนะนำ� ท�งก�รแพ็ทยร์ะหว่ั�งประเทศที�จัดัตั�ง ขี่ �นแนะนำ�ให�ทำ�กิจักรรมัท�งก�ยแบบ แอโรบิกและแบบสำร� งค์วั�มัแข็ีงแรง ใ ห� กับ ก ล� มั เน่�อ สำำ � ห รับ ป ร ะ ช � ก ร ก ลุ่ มั นี� ( ตั วั อ ย่ � ง เ ช่ น แ น วั ป ฏิิ บั ติ ACSM “ก�รก� วัขี� มัมัะเร็ง” (101) จั�กก�รทบทวันหลกัฐ�นอย่�งเป็นระบบ (3)) ก�รตระหนักถ่งหลักฐ�นนี�ยัง เพิ็� งเริ� มัต�นระดับค์วั�มัน่�เช่� อถ่อจั่ง ถ้กลดลง ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) 89 ค์ณะทำ�ง�น GDG สำรุปว่�: • มีัหลกัฐ�นเช่�อถ่อได�ระดบัป�นกล�ง สำำ�หรบัผู้ลจั�กก�รรวัมัหร่อผู้ลเพิ็� มั เติมัขีองก�รทำ�กิจักรรมัแบบแอโรบิก หร่อแบบสำร� งค์วั�มัแข็ีงแรงให�กบั กล� มัเน่�อ เพ่็� อลดก�รเสีำยชีวิัตจั�ก มัะเร็ง ปรบัปรุงค์วั�มัดนัโลหิตสำำ�หรบั ผู้้�มีัค์วั�มัดนัโลหิตส้ำง • มีัหลกัฐ�นเช่�อถ่อได�อย่�งส้ำงว่ั� ก�ร ทำ�กิจักรรมัแบบแอโรบิค์ แบบสำร� ง ค์วั�มัแข็ีงแรงให�กบั กล� มัเน่�อ และ ทั�ง 2 แบบผู้สำมัผู้สำ�นกัน จัะช่วัย ปรับปรุงตัวั บ่งชี�ขีองก�รดำ� เนิน โ ร ค์ ( H b A 1 C ค์ วั � มั ดัน โ ล หิ ต ดัชนีมัวัลก�ย และ ไขีมัันในเล่อด) ในผู้้�ใหญ่่ที�เป็นเบ�หวั�นชนิดที� 2 ข้้อัแนะนำา • มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�งว่ั� ก�ร ออกกำ�ลังก�ยแบบแอโรบิกต�มั ปรกติแต่เพี็ยงอย่�งเดียวั หร่อผู้สำมักบั ก�รออกกำ�ลงัก�ยแบบมีัแรงต� น มิัได� มีัผู้ลให�มีัก�รเปลี�ยนแปลงระดบัไวัรสัำ ในเล่อดหร่อก�รนบั CD4 อย่�งมีันยั- สำำ�ค์ญั่สำำ�หรบัผู้้�ที�มีัเช่ �อ HIV • มีัหลักฐ�นไม่ัเพี็ยงพ็อเกี� ยวักับผู้ล ขีองก�รฝึึกค์วั�มัแข็ีงแรงแต่เพี็ยง อย่�งเดียวัต่อคุ์ณิภั�พ็ชีวิัตที� เกี� ยวั เน่�องกบัสุำขีภั�พ็ขีองผู้้�มีัเช่ �อ HIV ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 90 ข้้อแนืะนืำ� ด้็�นืพฤติิกิรัรัมเนืือยนิื�ง ขี�อแนะนำ�ระดบัโลกด� นกิจักรรมัท�งก�ยเพ่็�อสุำขีภั�พ็ ปีพ็.ศ. 2553 ไม่ัได�มีัก�รรวัมัขี�อแนะนำ�พ็ฤติกรรมัเน่อยนิ�งไวั� (1) ขีอบเขีตขีองขี�อแนะนำ�ใหม่ันี�เกี�ยวักบัพ็ฤติกรรมัเน่อยนิ�งในผู้้�รอดชีวิัตจั�กมัะเร็งและผู้้�ที� มีัค์วั�มัดนัโลหิตส้ำง เบ�หวั�นชนิดที� 2 และ HIV พ็ฤติกรรมัเน่อยนิ�งค่์อเวัล�ที�ใช�ไปกบัก�รนั�งนิ�งหร่อนอนลงด�วัยก�รใช�พ็ลงัง�นด�วัย ขีณิะที�ต่�นอย่้ ในปริบทเกี�ยวักบั อ�ชีพ็ ก�รเรียน ที�บ� น ในชุมัชน และก�รเดินท�ง หลกัฐ�นสำนบัสำนุนและเหตุิผล เน่�องจั�กขี�ดหลกัฐ�นที� เจั�ะจังกลุ่มัประช�กรหลกัฐ�นหลกัในก�รประเมิัน ค์วั�มัเช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งและผู้ลลพั็ธิท์�งสุำขีภั�พ็ในผู้้�ใหญ่่และ ผู้้�ส้ำงอ�ยุที�รอดชีวิัตจั�กมัะเร็ง และผู้้�ใหญ่่และผู้้�ส้ำงอ�ยุที� มีัภั�วัะค์วั�มัดนัโลหิตส้ำง เบ�หวั�นชนิดที� 2 และ HIV เป็นง�นวิัจัยัท�งวิัทย�ศ�สำตรที์�รวัมัรวัมัและทบทวัน สำำ�หรบักลุ่มัประช�กรผู้้�ใหญ่่ มีัก�รทบทวันขี�อค์�นพ็บจั�กหลกัฐ�นเกี� ยวักบัพ็ฤติกรรมัเน่อยนิ� งในกลุ่มั ประช�กรผู้้�ใหญ่่ทั� วัไป รวัมัถ่งประเมิันห�กมีัหลกัฐ�นที� ผู้ลอ�จัต่�งกนัออกไป หร่ออ�จัไม่ัสำ�มั�รถรวัมัได� หร่ออ�จัขีดัแย�งกนั สำำ�หรบัผู้้�ใหญ่่และผู้้�ส้ำงอ�ยุที�มีัภั�วัะ เร่ �อรงั ในผู้้�ใหญ่่ ทั�งผู้้�ที�รอดชีวิัตจั�กมัะเร็ง และผู้้�ที�มีัค์วั�มัดนัโลหิตส้ำง เบ�หวั�นชนิดที�สำอง และ HIV พ็ฤติ- กรรมัเน่อยนิ�งที�มั�กขี่ �นเช่�อมัโยงกบัผู้ลลพั็ธิต่์อสุำขีภั�พ็ที�ไม่ัดีดงัต่อไปนี� ภั�วัะก�รเสีำยชีวิัตทุกสำ�เหตุ ภั�วัะก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อดหัวัใจั มัะเร็ง ก�รเกิดโรค์หลอดเล่อดหัวัใจั มัะเร็ง และเบ�หวั�นชนิดที� 2 ข้อ้แนะนำ�สำำ�หรบัผ้ร้อดชี้วิติจ�กมัะเร็ง และผ้มี้ัโรค์ค์ว�มัดนัโลหิติส้ำง เบ�หว�นช้นิดที� 2 และ HIV ดงันี �: ผ้ ้ใหญ่่และผ้ส้้ำงอ�ยุที�มีัโรค์เรื �อรงัค์วรจำ�กดัเวล�ที�มีัก�รทำ�พฤติิกรรมัเนือยนิ�ง แทนที�เวล� เหล่�นั�นดว้ยกิจกรรมัท�งก�ยในทุกระดบั (รวมัถง้ระดบัเบ�) เพื�อผลดีต่ิอสุำข้ภ�พ แนะนำ�อย่�งยิ�ง หลกัฐ�นมีัค์วั�มัแน่นอนตำ� ผ้ ้ใหญ่่และผ้ส้้ำงอ�ยุที�มีัภ�วะเรื �อรงัค์วรทำ�กิจกรรมัท�งก�ยให้ไดม้ั�กกว่�ระดบัที�แนะนำ� ท ั�งระดบัป�นกล�งและหนกั เพื�อลดผลเสีำยต่ิอสุำข้ภ�พจ�กพฤติิกรรมัเนือยนิ�งในระดบัส้ำง แนะนำ�อย่�งยิ�ง หลกัฐ�นมีัค์วั�มัแนะนำ�ตำ� > ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) > 91ข้้อัแนะนำา จั�กหลกัฐ�นที� มีัอย่้และค์วั�มัคิ์ด เห็นจั�กผู้้�เชี�ยวัช�ญ่ มีัก�รพ็�ดพิ็งหลกั- ฐ�นเพ่็� อร�ยง�นขี�อแนะนำ�ฉบับใหม่ั ขีององค์ก์�รอน�มัยัโลก เกี�ยวักบัพ็ฤติ- กรรมัเน่อยนิ� ง สำำ�หรับผู้้�ใหญ่่ที� มีัภั�วัะ เร่ �อรัง สำำ�หรับผู้ลลัพ็ธิต่์อสุำขีภั�พ็ที� สำำ�ค์ญั่มั�ก ก�รค์�ดค์ะเนหลกัฐ�นนั�น ได�รบัก�รสำนบัสำนุนอย่�งกวั� งขีวั�งโดย ก�รประเมิันผู้ลที� ก�รวิัจััยส่ำวันใหญ่่ มิัได�จัำ�กดัเกณิฑ์อ์�ยุและรวัมัถ่งผู้้�ใหญ่่ ที�อ�ยุเกิน 65 ปี และอ�จัรวัมัเอ�ผู้้�ใหญ่่ที� มีัภั�วัะเร่ �อรงั เช่น ผู้้�รอดชีวิัตจั�กมัะเร็ง ผู้้� มีั ภั � วั ะ ค์ วั � มั ดั น โ ล หิ ต ส้ำ ง ห ร่ อ เ บ � ห วั � น ช นิ ด ที� 2 ไ วั� ด� วั ย สำำ�หรบัผู้้�มีัเช่ �อ HIV ไม่ัมีัเหตุผู้ลระบุว่ั� เหตุใดหลกัฐ�นต่อผู้ลกระทบต่อสุำขีภั�พ็ เกี�ยวักบัพ็ฤติกรรมัเน่อยนิ� งไม่ันำ�มั�ใช� เน่�องด�วัยค์วั�มัไม่ัตรงจุัดขีองหลกัฐ�นที� จัะพ็ฒัน�ขี�อแนะนำ�เหล่�นี� ระดบัค์วั�มั น่�เช่�อถ่อจัง่ถ้กลดลงมั� ก�รใช�ประโยชนจ์ั�กหลกัฐ�นเกี�ยวั กับประโยชนข์ีองกิจักรรมัท�งก�ยที� ระดบัป�นกล�งและหนกัให�มั�กขี่ �น เพ่็�อ ช่วัยลดผู้ลกระทบจั�กค์วั�มัเสีำ�ยงที�อ�จั เกิดขี่ �นจั�กพ็ฤติกรรมัเน่อยนิ�งในระดบั ส้ำง ได�นำ�มั�พิ็จั�รณิ�และค์�ดก�รณิเ์พ่็�อ ร่�งขี�อแนะนำ�สำำ�หรับผู้้�ใหญ่่ที� มีัภั�วัะ เร่ �อรงั เพ่็�อชุดขี�อม้ัลสำำ�หรบัผู้ลลพั็ธิต่์อ สุำขีภั�พ็ที�สำำ�ค์ญั่มั�กที�มีัร่วัมักนั เน่�องด�วัย ค์วั�มัไม่ัตรงจุัดขีองหลกัฐ�น ค์วั�มัน่� เช่�อถ่อขีองหลกัฐ�นจัง่ถ้กลดลงมั� ค์ณะทำ�ง�น GDG สำรุปว่� • หลกัฐ�นเกี�ยวักบัพ็ฤติกรรมัเน่อยนิ�ง ในประช�กรผู้้�ใหญ่่โดยทั�วัไป ค์วัรจัะ นำ �มั�ค์�ดก�รณิ์เพ่็� อสำร� งขี�อม้ัล ขี�อแนะนำ�สำำ�หรับผู้้�รอดชีวิัตจั�ก มัะเร็งที� เ ป็ นผู้้� ใหญ่่ และผู้้� ส้ำงอ�ยุ แ ล ะ ผู้้� มีั ภั � วั ะ ค์ วั � มั ดัน โ ล หิ ต ส้ำ ง เบ�หวั�นชนิดที� 2 และเช่ �อ HIV ที� เ ป็นผู้้� ใหญ่่และผู้้� ส้ำงอ�ยุ เพ่็� อชุด ขี�อม้ัลสำำ�หรบัผู้ลลพั็ธิที์�สำำ�ค์ญั่มั�กที�มีั ร่วัมักนั พ็ร�อมัระดบัค์วั�มัน่�เช่�อถ่อ ขีองหลกัฐ�นที�ลดระดบัลง เน่�องจั�ก เป็นขี�อม้ัลโดยอ�อมั • สำำ�หรบัผู้้�รอดชีวิัตจั�กมัะเร็งและผู้้�ที� มีัค์วั�มัดนัโลหิตส้ำง เบ�หวั�นชนิดที� 2 และ HIV ประโยชนจ์ั�กก�รลดพ็ฤติ- กรรมัเน่อยนิ�งนั�นมีัมั�กกว่ั�อนัตร�ย ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 92 ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ • ทำ�กิจักรรมัท�งก�ยบ� งย่อมัดีกว่ั�ไม่ัทำ�อะไรเลย • ห�กเด็กหร่อวัยัรุ่นที� มีัภั�วัะทุพ็พ็ลภั�พ็ไม่ัสำ�มั�รถทำ�ต�มัขี�อแนะนำ�นี�ได� ก�รทำ�กิจักรรมั ท�งก�ยบ� งย่อมัเป็นผู้ลดีต่อสุำขีภั�พ็ • เด็กและวัยัรุ่นที� มีัภั�วัะทุพ็พ็ลภั�พ็ค์วัรเริ� มัทำ�กิจักรรมัท�งก�ยแต่น�อยก่อนแล�วัค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มัหนกัหน่วัง และระยะเวัล�ขี่ �น • ไม่ัมีัค์วั�มัเสีำ�ยงใด ๆ สำำ�หรบัเด็กและวัยัรุ่นที� มีัภั�วัะทุพ็พ็ลภั�พ็ในก�รทำ�กิจักรรมัท�งก�ย ในระดบัที� เหมั�ะสำมักบัระดบักิจักรรมัที� ดำ�เนินอย่้ สำถ�นะท�งสุำขีภั�พ็ และสำมัรรถภั�พ็ ขีองแต่ละบุค์ค์ล และประโยชนต่์อสุำขีภั�พ็ที�เพิ็�มัพ้็นขี่ �นนั�นมีันำ � หนกัเหน่อค์วั�มัเสีำ�ยง • เด็กและวัยัรุ่นที� มีัภั�วัะทุพ็พ็ลภั�พ็อ�จัจัำ�เป็นต�องปร่กษ�ผู้้�เชี�ยวัช�ญ่ด� นก�รด้แลสุำขีภั�พ็ หร่อผู้้�เชี� ยวัช�ญ่ด� นกิจักรรมัท�งก�ยและภั�วัะทุพ็พ็ลภั�พ็เพ่็� อช่วัยกำ�หนดชนิดและ ปริมั�ณิขีองกิจักรรมัที�เหมั�ะสำมักบัตน เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปีขึ้�นืไป) และผูู้้ใหญ่ (อ�ยุ 18 ปีขึ้�นืไป) ท่� ม่ภิ�วัะทุพพลภิ�พ ผู้ลดีขีองก�รทำ�กิจักรรมัท�งก�ยสำำ�หรบัเด็กและวัยัรุ่นมีัหล�ยประก�ร ต�มัที� ได�กล่�วัถง่ไวั�ใน บทก่อนหน� ยงัเช่�อมัโยงกบัเด็กและวัยัรุ่นที�มีัภั�วัะทุพ็พ็ลภั�พ็ด�วัย ผู้ลดีต่อสุำขีภั�พ็ขีองก�รทำ� กิจักรรมัท�งก�ยขีองผู้้�มีัภั�วัะทุพ็พ็ลภั�พ็นั�นรวัมัถง่ ก�รรบัร้�ที� ดีขี่ �นในบุค์ค์ลที�มีัโรค์หร่อค์วั�มั ผิู้ดปรกติที�ทำ�ให�หน� ที�ในก�รรบัร้�บกพ็ร่อง รวัมัถง่อ�ก�รสำมั�ธิิสำั�น (ADHD) ก�รพ็ฒัน�สำมัรรถ ภั�พ็ท�งก�ยอ�จัเกิดขี่ �นได�กบัเด็กที�มีัค์วั�มับกพ็ร่องท�งสำติปัญ่ญ่� เด็ก วัยัรุ่น และผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็สำ�มั�รถบรรลุถง่ผู้ลดีต่อสุำขีภั�พ็ที�สำำ�ค์ญั่จั�กกิจักรรรมั ท�งก�ย เด็ก วัยัรุ่น และผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ค์วัรจัะทำ�ต�มัขี�อแนะนำ�เหล่�นี� เม่ั�อเป็นไปได�และ เท่�ที�สำ�มั�รถทำ�ได� สำำ�หรบัเด็ก วัยัรุ่น และผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็นั�น กิจักรรมัท�งก�ยสำ�มั�รถเป็นส่ำวันหน่�ง ขีองก�รสำนัทน�ก�รและก�รพ็กัผู่้อน (ก�รละเล่น เกมัสำ ์ กีฬ� และก�รออกกำ�ลงัก�ยที�วั�งแผู้นไวั�) ก�รเรียนพ็ลศก่ษ� ก�รเดินท�ง (ก�รเค์ล่�อนที�ด�วัยล�อ, ก�รเดิน และก�รปั� นจักัรย�น) หร่อก�รทำ�ง�นบ� น ในสำภั�พ็แวัดล�อมัเกี�ยวักบับ� น ก�รศก่ษ� ด� นอ�ชีพ็ และชุมัชน เป็นเร่�องสำำ�ค์ญั่ที�จัะสำร� งโอก�สำและ กำ�ลงัใจัให�แก่เด็ก วัยัรุ่น และผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ที�จัะเขี� ร่วัมักิจักรรมัท�งก�ยที� เหมั�ะสำมักบั อ�ยุและค์วั�มัสำ�มั�รถขีองพ็วักเขี� ให�มีัค์วั�มัสำนุกสำน�นและค์วั�มัหล�กหล�ย ข้้อแนืะนืำ�ด้็�นืกิิจกิรัรัมท�งกิ�ย แนะนำ�ให:้ เด็กและผ้ ใ้หญ่่ที�มีัภ�วะทุพพลภ�พค์วรทำ� กิจกรรมัท�งก�ยเฉลี�ยอย่�งนอ้ย 60 น�ที ต่ิอวนั ติลอดสำปัด�ห ์ ดว้ยก�รทำ�กิจกรรมั ส่ำวนใหญ่่แบบแอโรบิก ที�ระดบัป�นกล�ง แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อป�นกล�ง > > ค์วรทำ�กิจกรรมัท�งก�ยที�ระดบัหนกั รวมัถง้ ก�รสำร�้งค์ว�มัแข็้งแรงใหก้บักล�้มัเนื �อและ กระด้กร่วมักนัอย่�งนอ้ย 3 วนัต่ิอสำปัด�ห์ แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อป�นกล�ง เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) และผูู้้ใหญ่ (อ�ยุ 18 ปีขึ้�นืไป) ท่�ม่ภิ�วัะทุพพลภิ�พ 93 ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ ในวัยัผู้้�ใหญ่่ ประโยชนต่์อสุำขีภั�พ็จั�กก�รทำ�กิจักรรมัท�งก�ยมีัหล�กหล�ย เช่นเดียวักบัที�กล่�วัไป ขี� งต�นแล�วั ซ่�งสำ�มั�รถนำ�มั�ใช�กบัผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ได� ประโยชนต่์อสุำขีภั�พ็เพิ็�มัเติมัจั�กก�รทำ� กิจักรรมัท�งก�ย สำำ�หรบัผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ มีัดงันี� สำำ�หรบัผู้้�ใหญ่่ที�ป่วัยเป็นโรค์ปลอกประสำ�ทเส่ำ�อมั- แข็ีง กิจักรรมัท�งก�ยสำ�มั�รถช่วัยพ็ฒัน�ก�รทำ�ง�นขีองร่�งก�ย รวัมัถง่สุำขีภั�พ็ก�ย สุำขีภั�พ็จิัต และพ็ฤติ- กรรมัท�งสำงัค์มัที�เกี�ยวัเน่�องกบัคุ์ณิภั�พ็ชีวิัต สำำ�หรบัผู้้�ที�มีัอ�ก�รบ�ดเจ็ับไขีสำนัหลงั กิจักรรมัท�งก�ยจัะช่วัย พ็ฒัน�ด� นก�รเดิน ค์วั�มัแข็ีงแรงขีองกล� มัเน่�อและก�รทำ�ง�นขีองร่�งก�ยส่ำวันบน และช่วัยพ็ฒัน�สุำขีภั�พ็ ที� เกี�ยวัเน่�องกบัคุ์ณิภั�พ็ชีวิัตสำำ�หรบัผู้้�ที� ป่วัยเป็นโรค์หร่อมีัภั�วัะบกพ็ร่องท�งสำมัอง กิจักรรมัท�งก�ยช่วัย พ็ฒัน�ก�รทำ�ง�นขีองร่�งก�ยและสำมัอง (ในผู้้�ป่วัยที� เป็นโรค์พ็�รกิ์นสำนัและมีัประวัติัเป็นโรค์หลอดเล่อด สำมัอง) และส่ำงผู้ลดีต่อก�รรบัร้� และอ�จัช่วัยพ็ฒัน�คุ์ณิภั�พ็ชีวิัตได� (ในผู้้�ใหญ่่ที�บกพ็ร่องท�งสำติปัญ่ญ่�) และช่วัยพ็ฒัน�คุ์ณิภั�พ็ชีวิัต (ในผู้้�ใหญ่่ที�ป่วัยเป็นโรค์ซม่ัเศร� ท�งค์ลีนิค์) • ทำ�กิจักรรมัท�งก�ยบ� งย่อมัดีกว่ั�ไม่ัทำ�อะไรเลย • ห�กผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ไม่ัสำ�มั�รถทำ�ต�มัขี�อแนะนำ�ได� ก�รทำ�กิจักรรมัท�งก�ยบ� ง ย่อมัเป็นผู้ลดีต่อสุำขีภั�พ็ • ผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ค์วัรเริ�มัทำ�กิจักรรมัท�งก�ยแต่น�อยก่อน แล�วัค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มัหนกัหน่วัง และระยะเวัล�ขี่ �น • ไม่ัมีัค์วั�มัเสีำ�ยงใด ๆ สำำ�หรบัผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ในก�รทำ�กิจักรรมัท�งก�ย ในระดบัที� เหมั�ะสำมักบัระดบักิจักรรที�ดำ�เนินอย่้ สำถ�นะท�งสุำขีภั�พ็ และสำมัรรถภั�พ็ขีองแต่ละบุค์ค์ล และ ประโยชนต่์อสุำขีภั�พ็ที�เพิ็�มัพ้็นขี่ �นนั�น มีัมั�กกว่ั�ค์วั�มัเสีำ�ยง • ผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ อ�จัจัำ�เป็นต�องปรก่ษ�ผู้้�เชี�ยวัช�ญ่ด� นก�รด้แลสุำขีภั�พ็ หร่อผู้้�เชี�ยวั- ช�ญ่ด� นกิจักรรมัท�งก�ยและภั�วัะทุพ็พ็ลภั�พ็ เพ่็�อช่วัยกำ�หนดชนิดและปริมั�ณิขีองกิจักรรมั ที�เหมั�ะสำมักบัตน ข้้อัแนะนำา แนะนำ�ให:้ ผ้ ใ้หญ่่ทุกค์นที�มีัภ�วะทุพพลภ�พค์วรทำ�กิจกรรมัท�งก�ยเป็นประจำ�ทุกวนั แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อป�นกล�ง ผ้ ใ้หญ่่ที�มีัภ�วะทุพพลภ�พค์วรทำ�กิจกรรมัท�งก�ยแบบแอโรบิก ที�ระดบัป�นกล�ง อย่�งนอ้ย 150-300 น�ที หรือที�ระดบัหนกั อย่�งนอ้ย 75-150 น�ที หรือทำ�ผสำมัผสำ�นกนัท ั�ง 2 ร้ปแบบ ติลอดทั�งสำปัด�ห ์ เพื�อประโยช้นต่์ิอสุำข้ภ�พ แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อป�นกล�ง ผ้ ้ใหญ่่ที�มีัภ�วะทุพพลภ�พค์วรทำ�กิจกรรมัสำร�้งค์ว�มัแข็้งแรงใหก้บักล�้มัเนื �อ ที�ระดบัป�นกล�งข้้ �นไป และมีัก�รใช้ก้ล�้มัเนื �อหลกัเป็นส่ำวนใหญ่่ อย่�งนอ้ย 2 วนัต่ิอสำปัด�ห ์เพื�อสุำข้ภ�พที�ดี แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อป�นกล�ง ในก�รทำ�กิจกรรมัท�งก�ยแต่ิละสำปัด�ห ์ผ้ส้้ำงอ�ยุที�มีัภ�วะทุพพลภ�พค์วรทำ�กิจกรรมัท�งที�หล�กหล�ย เพื�อช่้วยพฒัน�ก�รทรงติวัและค์ว�มัแข็้งแรง ที�ระดบัป�นกล�งข้้ �นไป อย่�งนอ้ย 3 วนัต่ิอสำปัด�ห ์เพื�อ พฒัน�ค์ว�มัแข็้งแรงและป้องกนัก�รหกลม้ั แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อป�นกล�ง ผ้ ใ้หญ่่ที�มีัภ�วะทุพพลภ�พสำ�มั�รถเพิ�มัก�รทำ�กิจกรรมัท�งก�ยแบบแอโรบิกในระดบัป�นกล�งใหม้ั�ก กว่� 300 น�ทีได ้หรือมั�กกว่� 150 น�ที ในระดบัหนกั หรือท ั�ง 2 ระดบัผสำมัผสำ�นกนัติลอดทั�งสำปัด�ห ์ เพื�อสุำข้ภ�พที�ดี แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อป�นกล�ง > > > > > ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 94 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) และผูู้้ใหญ่ (อ�ยุ 18 ปีขึ้�นืไป) ท่�ม่ภิ�วัะทุพพลภิ�พ หลกัฐ�นสำนบัสำนุนและเหตุิผล ก�รสำงัเค์ร�ะหห์ลกัฐ�นองค์ร์วัมัที�จัดัทำ�โดย PAGAC (35) ได�นำ�มั�ใช�และปรบัปรุง ขี�อแนะนำ�สำำ�หรบัเด็ก วัยัรุ่นและผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็นี� ร�ยละเอียดค์รบถ�วันเร่�อง วิัธีิวิัจัยั ก�รแยกส่ำวันขี�อม้ัล และต�ร�งหลกัฐ�นโดยสำรุปขีองหลกัฐ�นที�มีัอย่้เกี�ยวักบั กิจักรรมัท�งก�ยและผู้ลลพั็ธิต่์อสุำขีภั�พ็นั�นมีัอย่้ (35) และทบทวันโดยโดยค์ณิะทำ�ง�น GDG เพิ็�มัเติมัจั�กขี�อค์�นพ็บในก�รค์�นห�ที�ปรบัปรุงแล�วั ก�รปรบัปรุงขี�อม้ัลสำำ�หรบัขี�อแนะนำ�เหล่�นี�ได�จัำ�แนกแยกแยะบทปริทศันจ์ัำ�นวัน 39 ฉบบัที�ตีพิ็มัพ็จ์ั�ก พ็.ศ. 2560 ถง่พ็.ศ. 2562 จั�กทั�งหมัดนี� มีั 27 ฉบบัที�ตรงกบั เกณิฑ์ก์�รนำ�เขี� ขี�อม้ัลและชี�ให�เห็นถง่ก�รตรวัจัสำอบก�รเช่�อมัโยงระหว่ั�งกิจักรรมั ท�งก�ยและผู้ลที�เกี�ยวัเน่�องกบัสุำขีภั�พ็ในหม่้ัเด็ก วัยัรุ่น และผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ ร�ยละเอียดค์รบถ�วันเกี�ยวักบัวิัธีิวิัจัยั ก�รแยกส่ำวันขี�อม้ัล และชุดขี�อม้ัลสำรุปนั�น มีัอย่้ที�ภั�ค์ผู้นวักเว็ับไซต ์: ชุดขี�อม้ัลหลกัฐ�น12 ก�รทบทวันหลกัฐ�นพิ็จั�รณิ�ถง่ ค์วั�มัสำมััพ็นัธิร์ะหว่ั�งกิจักรรมัท�งก�ย และผู้ลลพั็ธิที์�เกี�ยวัเน่�องกบัสุำขีภั�พ็ในเด็ก วััยรุ่น และผู้้�ใหญ่่ที� มีัภั�วัะทุพ็พ็ลภั�พ็ จั�กโรค์และอ�ก�รต่�ง ๆ ดงันี� โรค์ปลอก- ประสำ�ทเส่ำ�อมัแข็ีงอ�ก�รบ�ดเจ็ับไขีสำนั- หลัง ค์วั�มับกพ็ร่องท�งสำติปัญ่ญ่� โรค์พ็�รกิ์นสำัน โรค์หลอดเล่อดสำมัอง โรค์ซ่มัเศร� ท�งค์ลีนิค์ โรค์จิัตเภัท โรค์สำมั�ธิิสำั�น (ADHD) มีัก�รตรวัจัสำอบ ผู้ลลพั็ธิที์�เกี�ยวัเน่�องกบัสุำขีภั�พ็ 4 ประก�ร ค่์อ ค์วั�มัเสีำ� ยงขีองโรค์วิันิจัฉัยร่วัมั ก�รทำ�ง�นขีองร่�งก�ย ก�รทำ�ง�นขีอง สำมัอง และสุำขีภั�พ็ที� เกี�ยวัเน่� องกบัคุ์ณิ- ภั�พ็ชีวิัต แมั�จัะไม่ัมีัก�รตรวัจัสำอบทุก ผู้ลลพั็ธิใ์นแต่ละเง่�อนไขีก็ต�มั ผู้ลกระทบ ต่อปัจัจัยัท�งสิำ�งแวัดล�อมัขีองภั�วัะทุพ็พ็- 12 ข้้อม่ัลออนไลน์ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ลภั�พ็ในบริบทขีองกิจักรรมัท�งก�ยนั�น อย่้เหน่อขีอบเขีตขีองขี�อแนะนำ�เหล่�นี� และไม่ัได�มีัก�รวิัเค์ร�ะห์ใด ๆ ค์ว�มัสำมััพนัธิ์ร์ะหว่�งกิจกรรมัท�ง ก�ยและผลลพัธิ์ที์�เกี�ยวเนื�องกบัสุำข้ภ�พ ในเด็กและวยัรุ่น (อ�ยุ 5-17 ปี) และ ผ้ ้ใหญ่่ (อ�ยุ 18 ปีข้้ �นไป) ที� มีัภ�วะ ทุพพลภ�พ คื์ออะไร สำำ�หรบัผู้้�ที� เป็นโรค์ปลอกประสำ�ท เสืำ�อมัแข็้ง กิจักรรมัท�งก�ยสำ�มั�รถ พ็ัฒน�ก�รทำ�ง�นขีองร่�งก�ย ค์วั�มั สำ�มั�รถด� นก�รเค์ล่�อนไหวั ค์วั�มัเร็วั และค์วั�มัทนท�นในก�รเดิน และค์วั�มั แข็ีงแรงขีองระบบหมุันเวีัยนโลหิต ค์วั�มัแข็ีงแรงและสำมัดุล ตวััอย่�งเช่น ก�รออกกำ�ลงัก�ยแบบสำลบัหนกัเบ�ที� เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) และผูู้้ใหญ่ (อ�ยุ 18 ปีขึ้�นืไป) ท่�ม่ภิ�วัะทุพพลภิ�พ 95ข้้อัแนะนำา ระดบัส้ำงมั�กกว่ั� 3-12 สำปัด�ห ์ชี �ให�เห็น ถง่ก�รปรบัปรุงค์วั�มัแข็ีงแรงขีองระบบ ไหลเวีัยนโลหิตหร่อค์วั�มัแข็ีงแรงกล� มั เน่�อ (117) และก�รฝึึกค์วั�มัแข็ีงแรง ขีองแขีนขี�ส่ำวันล่�ง พ็บว่ั� มีัค์วั�มัแข็ีงแรง ขี่ �นร�อยละ 23.1 (95% CI: 11.8 ถง่ 34.4) จั�กก�รฝึึกเฉลี�ย 13.2 สำปัด�ห ์ (118) และเฉลี� ย 13 สำปัด�ห์ที� มีัผู้ลต่อค์วั�มั แข็ีงแรงที�เพิ็�มัขี่ �น ก�รวิัจัยัก�รแทรกแซง ด�วัยก�รเต�น ร�ยง�นว่ั� มีัก�รพ็ฒัน�ใน ก�รเค์ล่�อนไหวัร่�งก�ยและสำมัดุลที� ดีขี่ �น (119) ทั�งประโยชนต่์อสุำขีภั�พ็ร่�งก�ย หลกัฐ�นที�มีัอย่้ชี �ให�เห็นว่ั� กิจักรรมัท�ง ก�ยสำ�มั�รถเอ่ �อประโยชนต่์อก�รรบัร้�ใน ผู้้�ที� เป็นโรค์ปลอกประสำ�ทเส่ำ�อมัแข็ีง (35) ง�นวิัจัยัชิ �นใหม่ักว่ั�นั�นเปิดเผู้ยว่ั� ก�ร ออกกำ�ลงัก�ยแบบแอโรบิกมีัผู้ลเล็กน�อย แต่มีันยัสำำ�ค์ญั่ต่อขีอบเขีตขีองคุ์ณิภั�พ็ ที� เกี�ยวัเน่� องกบัสุำขีภั�พ็ในด� นก�ยภั�พ็ ด� นจิัตใจั และสำังค์มั (รวัมัถ่งอ�ก�ร อ่อนล� และอ�ก�รซม่ัเศร� ) (35, 120) ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 96 สำำ�หรบัผู้้�ที� มีัอ�ก�รบ�ดเจ็บข้อง ไข้สำนัหลงั กิจักรรมัท�งก�ยช่วัยทำ�ให� ค์วั�มัสำ�มั�รถในก�รเดิน ค์วั�มัแข็ีงแรง กล� มัเน่�อ และค์วั�มัสำ�มั�รถในก�ร ทำ�ง�นขีองร่�งก�ยส่ำวันบนดีขี่ �น ก�ร ออกกำ�ลงัก�ยอ�จับรรเท�อ�ก�รปวัด ไหล่ ทำ�ให�ก�รทำ�ง�นขีองหลอดเล่อดดีขี่ �น และเสำริมัสำร� งคุ์ณิภั�พ็ชีวิัตที� เกี�ยวัเน่�อง กบัสุำขีภั�พ็ (35) สำำ�หรับผู้้�ที� เ ป็นโรค์พ�รกิ์นสำนั กิจักรรมัท�งก�ยสำ�มั�รถทำ�ให�อ�ก�ร เกี�ยวักบัก�รเค์ล่�อนไหวั ค์วั�มัค์ล่องตวัั และศกัยภั�พ็ขีองร่�งก�ย ค์วั�มัทนท�น ปัญ่ห�ก�รเดินติดขีดั และอตัร�ค์วั�มัเร็วั ในก�รเค์ล่�อนที� ไปขี� งหน� และถอยหลงั (35, 121, 122) หลกัฐ�นชิ�นใหม่ัชี�ให�เห็น ว่ั�กิจักรรมัท�งก�ยจัะช่วัยให�ค์วั�มั สำ�มั�รถในก�รรบัร้�ต่อโลกภั�ยนอกขีอง ผู้้�ป่วัยพ็�รกิ์นสำนันั�นดีขี่ �นได� (123) สำำ�หรบัผู้้�ที� เค์ยมีัประวัติัโรค์หลอด เลือดสำมัอง กิจักรรมัท�งก�ยสำ�มั�รถ ทำ�ให�ก�รทำ�ง�นขีองร่�งก�ย ก�รทำ�ง�น ขีองร่�งก�ยส่ำวันบนที�มัองเห็นได� ก�ร ทำ�ง�นขีองประสำ�ทสำมััผู้สัำก�รเค์ล่�อนไหวั ขีองร่�งก�ยส่ำวันล่�ง สำมัดุลร่�งก�ย ค์วั�มัเร็วัในก�รเดิน ระยะท�ง ค์วั�มั สำ�มั�รถและค์วั�มัทนท�น ค์วั�มัแข็ีงแรง ขีองระบบไหลเวีัยนโลหิต ก�รเค์ล่�อนไหวั และกิจักรรมัในชีวิัตประจัำ�วัันดีขี่ �นได� หลกัฐ�นที� มีัอย่้ชี �ให�เห็นว่ั�กิจักรรมัท�ง ก�ยอ�จัจัะมีัผู้ลดีต่อก�รรบัร้�ขีองสำมัอง ด�วัย (35) เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) และผูู้้ใหญ่ (อ�ยุ 18 ปีขึ้�นืไป) ท่�ม่ภิ�วัะทุพพลภิ�พ สำำ�หรับผู้้�ที� เป็นโรค์ซ้มัเศัร�้ท�ง ค์ลีนิค์อย่�งรุนแรง บทปริทศันชิ์�นใหม่ั (124,125) สำนบัสำนุนหลกัฐ�นที� มีัอย่้ว่ั� กิจักรรมัท�งก�ยนั�นช่วัยพ็ฒัน�คุ์ณิภั�พ็ ชีวิัตที�เกี�ยวัเน่�องกบัสุำขีภั�พ็ได� (35, 124, 125) สำำ�หรับผู้้�ป่วยหรือมีัค์ว�มัผิดปรกติิ ที�ทำ�ใหค้์ว�มัสำ�มั�รถในก�รรบัร้แ้ย่ลง รวัมัถ่งโรค์จิัตเภัท กิจักรรมัท�งก�ย มีัผู้ลดีต่อก�รรบัร้� หน่วัยค์วั�มัจัำ� ก�รรบัร้� ท�งสำงัค์มั และค์วั�มัสำนใจัและค์วั�มัระมัดั ระวังั (35,126) บทปริทศันชิ์�นหน่�งพ็บว่ั� กิจักรรมัท�งก�ยในระดบัป�นกล�งจัน ถง่หนกันั�น ยงัผู้ลให�เกิดก�รพ็ฒัน�อย่�ง มีันยัสำำ�ค์ญั่ในคุ์ณิภั�พ็ชีวิัตที� เกี�ยวัเน่� อง กับสุำขีภั�พ็และภั�วัะทุพ็พ็ลภั�พ็ (35, 124) สำำ�หรับผู้้�ที� มีัค์วั�มับกพร่องท�ง สำติิปัญ่ญ่� กิจักรรมัท�งก�ยนั�นทำ�ให� ก�รทำ�ง�นขีองร่�งก�ยดีขี่ �น ก�รแทรก แซงที�นำ�มั�ทบทวันนี� จัะพุ่็งเป้�โดยหลกั ไปที�กิจักรรมัที�สำร� งสำมัดุลและค์วั�มัแข็ีง แรงมั�กกว่ั� 6-24 สำปัด�ห ์ และร�ยง�น ก�รพ็ฒัน�อย่�งมีันยัสำำ�ค์ญั่ในก�รทรง ตวัั สำมัดุลในก�รเค์ล่�อนไหวั และสำมัดุลใน ก�รทรงตวััผู้สำมัเค์ล่�อนไหวัเปรียบเทียบ กบักลุ่มัที�มีัก�รค์วับคุ์มั (35, 127, 128) สำำ�หรบัเด็กสำมั�ธิิ์สำ ั�น หลกัฐ�นรวัมั ถง่บทปริทศันห์น่�งชิ �นที�มีัก�รทดลองแบบ สุ่ำมัและมีักลุ่มัค์วับคุ์มัที�เกี�ยวัขี�องกบัภั�วัะ สำมั�ธิิสำั�น (ADHD) (129) แสำดงถง่ค์วั�มั 97 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) และผูู้้ใหญ่ (อ�ยุ 18 ปีขึ้�นืไป) ท่�ม่ภิ�วัะทุพพลภิ�พ เช่�อมัโยงที�เป็นบวักระหว่ั�งกิจักรรมัท�ง ก�ยและค์วั�มัสำนใจั ค์วั�มัสำ�มั�รถในก�ร คิ์ดวิัเค์ร�ะหแ์ละค์วั�มัผิู้ดปรกติในก�ร เขี� สำงัค์มั (35, 129) ค์ณิะทำ�ง�น GDG พิ็จั�รณิ�หลกั ฐ�นจั�กประช�กรทั�วัไปในวัยัเด็ก วัยัรุ่น และผู้้�ใหญ่่ และได�สำรุปไวั�ว่ั� ไม่ัมีัเหตุผู้ลที� จัะเช่�อได�ว่ั�จัะมีัก�รเปลี�ยนแปลงผู้ลอนั เน่� องมั�จั�กค์วั�มับกพ็ร่องและผู้ลต่อ สำรีรวิัทย�ด� นสุำขีภั�พ็เช่นเดียวักนันี�จัะ ได�รบัจั�กก�รเค์ล่�อนไหวัร่�งก�ยอย่�ง ค์ล่องแค์ล่วั ค์ณิะทำ�ง�น GDG รบัร้�ว่ั� มีั ง�นวิัจัยัน�อยชิ�นที�รวัมัเอ�ผู้้�มีัภั�วัะทุพ็พ็ล ภั�พ็เอ�ไวั�และก�รเปลี� ยนแปลงผู้ล กระทบก็มีัก�รทดสำอบน�อยค์รั�ง หลักฐ�นในขีอบข่ี�ยขีองภั�วัะ ทุพ็พ็ลภั�พ็ ผู้สำมัผู้สำ�นกับหลักฐ�นที� กวั� งขี่ �นสำำ�หรบัประช�กรทั�วัไป สำนบัสำนุน ขี�อแนะนำ�สำำ�หรบัประช�กรทั�วัไปรวัมัถง่ ผู้้�มีัภั�วัะทุพ็พ็ลภั�พ็ มีัก�รอ� งอิงที�สำงัเกตุ ได�ถง่ “ผู้้�ใหญ่่ทั�งหมัด” “ผู้้�ส้ำงอ�ยุทั�งหมัด” และ “ผู้้�ค์นในทุกภั�วัะค์วั�มัสำ�มั�รถ” ค์ณะทำ�ง�น GDG สำรุปว่� ในบุค์ค์ลที�มีัอ�ก�รบ�ดเจ็บไข้สำนัหลงั นั�นมีั: • หลกัฐ�นน่�เช่�อถ่อตำ� ว่ั� กิจักรรมัท�ง ก�ยจัะลดอ�ก�รปวัดไหล่และทำ�ให� ก�รทำ�ง�นขีองหลอดเล่อดดีขี่ �น ในผู้้� ที� เป็นอมััพ็�ตแขีนหร่อขี� และเสำริมั สำร� งคุ์ณิภั�พ็ชีวิัตที� เกี� ยวัเน่� องกับ สุำขีภั�พ็ และ • หลักฐ�นที� เช่� อถ่อได�ป�นกล�งว่ั� กิจักรรมัท�งก�ยทำ�ให�ค์วั�มัสำ�มั�รถ ในก�รเดิน ค์วั�มัแข็ีงแรงกล� มัเน่�อ และ ก�รทำ�ง�นขีองร่�งก�ยส่ำวันบนดีขี่ �น ในบุค์ค์ลที�มีัโรค์หรือค์ว�มัผิดปรกติิที� ทำ�ใหค้์ว�มัสำ�มั�รถในก�รรบัร้บ้กพร่อง รวมัถง้โรค์พ�รกิ์นสำนั นั�นมีั: • หลกัฐ�นเช่�อถ่อได�ส้ำงว่ั� กิจักรรมัท�ง ก�ยจัะปรับปรุงให�ผู้ลลัพ็ธิ ์ในก�ร ทำ�ง�นขีองร่�งก�ยหล�ย ๆ อย่�งดีขี่ �น รวัมัถ่ง ก�รเดิน สำมัดุลร่�งก�ย ค์วั�มัแข็ีงแรง และก�รเค์ล่� อนไหวั เฉพ็�ะจุัดและ • หลักฐ�นเช่� อถ่อได�ป�นกล�งที� ว่ั� กิจักรรมัท�งก�ยที�ระดบัป�นกล�งถง่ มั�ก อ�จัมีัผู้ลดีต่อสุำขีภั�พ็ ในบุค์ค์ลที� มีัประวติัิโรค์หลอดเลือด สำมัอง นั�นมีั: • หลกัฐ�นเช่�อถ่อได�ป�นกล�งว่ั�กิจั- กรรมัท�งก�ยแบบเน�นก�รเค์ล่�อนไหวั จัะมีัผู้ลในด� นดีต่อสำมัรรถภั�พ็ร่�ง- ก�ยและก�รรบัร้� ในบุค์ค์ลที�มีัโรค์หรือค์ว�มัผิดปรกติิที� ทำ�ใหค้์ว�มัสำ�มั�รถในก�รรบัร้บ้กพร่อง รวมัถง้โรค์จิติเภท นั�นมีั: • ห ลักฐ � น เช่� อ ถ่อไ ด�ป � นก ล�ง ว่ั� กิจักรรมัท�งก�ยปรบัปรุงคุ์ณิภั�พ็ ชีวิัต และ ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 98 • หลกัฐ�นเช่�อถ่อได�ส้ำงว่ั� กิจักรรมัท�ง ก � ย ที� ร ะ ดับ ป � น ก ล � ง แ ล ะ ห นัก มีั ผู้ ล ดี ต่ อ สุำ ขี ภั � พ็ ต่ อ ก � ร รั บ ร้� หน่วัยค์วั�มัจัำ� ก�รรับร้�ท�งสำังค์มั และค์วั�มัสำนใจั ในผ้ ้ใหญ่่ที�เป็นโรค์ซม้ัเศัร�้ท�งค์ลีนิค์ อย่�งรุนแรง นั�นมีั: • หลกัฐ�นเช่�อถ่อได�ป�นกล�งว่ั� กิจั- กรรมัท�งก�ยปรบัปรุงคุ์ณิภั�พ็ชีวิัต ในผ้ ใ้หญ่่ที�เป็นโรค์ปลอกประสำ�ทเสืำ�อมั นั�นมีั: • หลักฐ�นเช่� อถ่อได�ส้ำงว่ั� กิจักรรมั ท�งก�ย โดยเฉพ็�ะกิจักรรมัแบบ แอโรบิกและสำร� งค์วั�มัแข็ีงแรงให�กบั กล� มัเน่�อ สำ�มั�รถปรบัปรุงสำมัรรถ- ภั�พ็ร่�งก�ย ค์วั�มัสำ�มั�รถในก�ร เค์ล่�อนไหวั ค์วั�มัเร็วัและค์วั�มัทนท�น ในก�รเดิน สำมัรรถภั�พ็ขีองระบบไหล- เวีัยนโลหิต ค์วั�มัแข็ีงแรงและสำมัดุล • หลกัฐ�นเช่�อถ่อได�ป�นกล�งว่ั� กิจั- กรรมัท�งก�ยมีัผู้ลดีต่อก�รรบัร้� และ • หลกัฐ�นเช่�อถ่อได�ตำ� ว่ั� กิจักรรมัท�ง ก�ยปรับปรุงคุ์ณิภั�พ็ชีวิัตรวัมัถ่ง อ�ก�รเหน่�อยล� และอ�ก�รซม่ัเศร� ในเด็กและผ้ใ้หญ่่ที�มีัค์ว�มับกพร่องท�ง สำติิปัญ่ญ่� นั�นมีั: • หลกัฐ�นเช่�อถ่อได�ตำ� ว่ั� กิจักรรมัท�ง ก�ยนั�นพ็ฒัน�สำมัรรถภั�พ็ร่�งก�ย ในเด็กและผ้ ้ใหญ่่ที� มีัภ�วะสำมั�ธิิ์สำ ั�น นั�นมีั: • ห ลักฐ � น เช่� อ ถ่อไ ด�ป � นก ล�ง ว่ั� กิจักรรมัท�งก�ยที�ระดบัป�นกล�ง และหนกั มีัผู้ลดีต่อก�รรบัร้� รวัมัถ่ง ค์วั�มัสำนใจั ก�รคิ์ดวิัเค์ร�ะห์ และ ค์วั�มัผิู้ดปรกติท�งสำงัค์มั ค์ณิะทำ�ง�น GDG สำรุปเพิ็�มัเติมัว่ั� มีัหลกัฐ�นท�งวิัทย�ศ�สำตรอ์ย่�งเพี็ยง- พ็อเกี� ยวักับผู้ลกระทบด� นบวักขีอง กิจักรรมัท�งก�ยต่อค์วั�มัหล�กหล�ย ขีองผู้ลลพั็ธิต่์อสุำขีภั�พ็ที�ค์รอบค์ลุมัขีอบ เขีตขีองค์วั�มับกพ็ร่องอย่�งกวั� ง และ ประโยชนข์ีองกิจักรรมัท�งก�ยสำำ�หรบั ผู้้�มีัภั�วัะทุพ็พ็ลภั�พ็นั�นมีันำ � หนกัมั�กกว่ั� ค์วั�มัเสีำ�ยงที�อ�จัเกิดขี่ �นได� เน่� องจั�กค์วั�มัไม่ัตรงไปตรงมั� ขีองหลักฐ�นในก�รพ็ัฒน�ขี�อแนะนำ� เหล่�นี�ระดับค์วั�มัน่�เช่� อถ่อจั่งถ้กลด ระดบัลง เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) และผูู้้ใหญ่ (อ�ยุ 18 ปีขึ้�นืไป) ท่�ม่ภิ�วัะทุพพลภิ�พ 99 ข้้อแนืะนืำ� ด้็�นืพฤติิกิรัรัมเนืือยนิื�ง สำำ�หรบัเด็ก วัยัรุ่น และผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ พ็ฤติกรรมัเน่อยนิ�งค่์อ เวัล�ที�ใช�ไปกบัก�รนั�งนิ�ง ๆ หร่อนอน ด�วัยก�รใช�พ็ลงัง�นตำ� ขีณิะที�ต่�นอย่้ ในสำภั�พ็แวัดล�อมัท�งก�รศก่ษ� สำภั�พ็แวัดล�อมัที�บ� น ชุมัชน และก�รเดินท�ง เป็นไปได�ที�จัะหลีกเลี�ยงพ็ฤติกรรมันิ�งเฉยและขียบัร่�งก�ยอย่�งกระฉบักระเฉงขีณิะนั�งหร่อนอนอย่้ ตวััอย่�งเช่น กิจักรรมัที�ใช�ร่�งก�ยท่อนบน รวัมัถง่ และ/หร่อ กีฬ�หร่อกิจักรรมัที�ใช�รถเข็ีนโดยเฉพ็�ะ หลกัฐ�นสำนบัสำนุนและเหตุิผล พ็ฤติกรรมัเน่อยนิ�งไม่ัถ้กรวัมัไวั�ในขี�อแนะนำ�ระดบัโลกด� นกิจักรรมัท�งก�ยเพ่็�อสุำขีภั�พ็ (2553) เน่�องจั�กขี�ดหลกัฐ�นที�เจั�ะจังกลุ่มัประช�กร ฐ�นขี�อม้ัลขีองหลกัฐ�นเบ่ �องต�นสำำ�หรบัก�รประเมิันค์วั�มั เช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งและผู้ลลพั็ธิต่์อสุำขีภั�พ็ในเด็ก วัยัรุ่น และผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็นั�น เป็นก�รวิัจัยัท�งวิัทย�ศ�สำตรที์�รวับรวัมัและทบทวันสำำ�หรบักลุ่มัประช�กรที� ไม่ัมีัภั�วัะทุพ็พ็ลภั�พ็ ได�มีัก�รนำ�ผู้ลก�รวิัจัยัจั�กหลกัฐ�นขีองพ็ฤติกรรมัเน่อยนิ�งในกลุ่มัประช�กรทั�วัไปมั�ทบทวัน รวัมัถง่ ก�รประเมิันห�กมีัหลกัฐ�น ว่ั�ผู้ลที� ได�จัะต่�งกนัหร่อไม่ั หร่ออ�จัไม่ัหมั�ยรวัมัถ่ง และอ�จัจัะมีัขี�อห� มั สำำ�หรบัเด็ก วัยัรุ่น และผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ พ็ฤติกรรมัเน่อยนิ� งที� มั�กขี่ �นในเด็กและวััยรุ่นนั�นต�มัมั�ด�วัยผู้ลเสีำยต่อสุำขีภั�พ็ ได�แก่ ภั�วัะโรค์อ�วันที�เพิ็�มัขี่ �น สุำขีภั�พ็หวััใจัและหลอดเล่อดที�แย่ลง ค์วั�มัแข็ีงแรงน�อยลง และพ็ฤติกรรมั เอ่ �อสำงัค์มัหร่อก�รประพ็ฤติตนที�แย่ลง และลดระยะเวัล�ในก�รนอนหลบัด�วัย พ็ฤติกรรมัเน่อยนิ�งในผู้้�ใหญ่่ที�เพิ็�มัส้ำงขี่ �นต�มัมั�ด�วัยผู้ลเสีำยต่อสุำขีภั�พ็ ได�แก่ ก�รเสีำยชีวิัตทุกสำ�เหตุ ก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อดหวััใจัและมัะเร็ง และสำ�เหตุก�รเกิด โรค์หลอดเล่อดหวััใจั มัะเร็ง และเบ�หวั�นชนิดที� 2 แนะนำ�ให:้ แนะนำ�ให:้ เด็กและวยัรุ่นที�มีัภ�วะทุพพลภ�พค์วรจำ�กดัเวล�ในก�รทำ�พฤติิกรรมัเนือยนิ�ง โดยเฉพ�ะ เวล�ที�อย่้กบัหน�้จอในเชิ้งสำนัทน�ก�ร แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อได�ตำ� ผ้ ใ้หญ่่ที�มีัภ�วะทุพพลภ�พค์วรจำ�กดัเวล�ในก�รทำ�พฤติิกรรมัเนือยนิ�ง ทดแทนเวล�เหล่�นั�น ดว้ยก�รทำ�กิจกรรมัท�งก�ยทุกระดบั (รวมัถง้ระดบัเบ�) เพื�อผลดีต่ิอสุำข้ภ�พ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�ง ผ้ ้ใหญ่่ที�มีัภ�วะทุพพลภ�พ ค์วรมุ่ังที�จะทำ�กิจกรรมัท�งก�ยที�ระดบัป�นกล�งและหนกัให ้ ไดม้ั�กกว่�ระดบัที�แนะนำ� เพื�อช่้วยลดผลเสีำยต่ิอสุำข้ภ�พจ�กพฤติิกรรมัเนือยนิ�งในระดบัส้ำง แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�ง > > > เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปีขึ้�นืไป) และผูู้้ใหญ่ (อ�ยุ 18 ปีขึ้�นืไป) ท่� ม่ภิ�วัะทุพพลภิ�พ ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 100 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) และผูู้้ใหญ่ (อ�ยุ 18 ปีขึ้�นืไป) ท่�ม่ภิ�วัะทุพพลภิ�พ ต�มัหลกัฐ�นที� มีัอย่้และค์วั�มัคิ์ด เห็นจั�กผู้้�เชี�ยวัช�ญ่ หลกัฐ�นนั�นนำ�มั� ค์�ดก�รณิเ์พ่็�อสำร� งขี�อม้ัลให�ขี�อแนะนำ� ขีององค์ก์�รอน�มััยโลกว่ั�ด�วัยพ็ฤติ- กรรมัเน่อยนิ� ง สำำ�หรับบุค์ค์ลที� มีัภั�วัะ ทุพ็พ็ลภั�พ็ เพ่็� อชุดขี�อม้ัลขีองผู้ลลพั็ธิ ์ ต่อสุำขีภั�พ็ที�สำำ�ค์ญั่ยิ�ง โดยระลก่ได�ว่ั� ใน กลุ่มัประช�กรบ�งกลุ่มั เช่น ผู้้�ใช�รถเข็ีนนั�น หลีกเลี�ยงไม่ัได�ที�ต�องนั� งเป็นระยะเวัล� น�นและก�รนั�งอ�จัเป็นสิำ�งปรกติไปแล�วั สำำ�หรบักลุ่มันี� พ็ฤติกรรมัเน่อยนิ� งค์วัร จัะนิย�มัว่ั� เป็นเวัล�ที�ใช�พ็ลงัง�นแต่น�อย ตวััอย่�งเช่น ก�รเค์ล่�อนที�ด�วัยเก� อี �ไฟิฟ้ิ� หร่อก�รถ้กดนัขีณิะนั� งในเก� อี �รถเข็ีน ธิรรมัด� ง�นวิัจััยเกี� ยวักบัค์วั�มัเช่� อมั โยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ� งและ ผู้ลลพั็ธิต่์อสุำขีภั�พ็ในผู้้�ที� มีัภั�วัะทุพ็พ็ล- ภั�พ็นั�นยงัค์งขี�ดแค์ลนอย่้ อย่�งไรก็ดี ต�มัค์ำ�แนะนำ�ขีองผู้้�เชี�ยวัช�ญ่ ไม่ัมีัเหตุ- ผู้ลที�จัะเช่�อว่ั� จัะมีัก�รแก�ไขีผู้ลกระทบ เน่� องจั�กค์วั�มับกพ็ร่อง และผู้ลดีต่อ สุำขีภั�พ็ร่�งก�ยในทำ�นองเดียวักนัจัะเกิด ขี่ �นโดยก�รจัำ�กดัพ็ฤติกรรมัเน่อยนิ�งใน บุค์ค์ลที�มีัภั�วัะทุพ็พ็ลภั�พ็ ด�วัยค์วั�มัไม่ั ตรงไปตรงมั�ขีองหลกัฐ�นที�จัะพ็ฒัน� ขี�อแนะนำ�เหล่�นี� ระดบัค์วั�มัน่�เช่�อถ่อ จัง่ถ้กลดระดบั ก�รประยุกต์ใช�หลกัฐ�นเกี�ยวักบั ประโยชนข์ีองผู้้�ใหญ่่ที�มีัก�รทำ�กิจักรรมั ท�งก�ยในระดบัป�นกล�งและหนักที� มั�กขี่ �นเพ่็�อช่วัยต่อต� นค์วั�มัเสีำ�ยงที�อ�จั เกิดจั�กพ็ฤติกรรมัเน่อยนิ�งในระดบัส้ำง ได� ถ้กนำ�มั�พิ็จั�รณิ�และค์�ดก�รณิเ์พ่็�อระบุ ขี�อแนะนำ�สำำ�หรบัผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ล- ภั�พ็ เพ่็�อชุดขี�อม้ัลร่วัมัขีองผู้ลลพั็ธิต่์อ สุำขีภั�พ็ที�สำำ�ค์ญั่มั�ก ด�วัยค์วั�มัไม่ัตรง ไปตรงมั� ค์วั�มัน่�เช่�อถ่อขีองขี�อม้ัลจั่ง ถ้กลดระดบั ค์ณะทำ�ง�น GDG สำรุปว่� • หลักฐ�นต่อพ็ฤติกรรมัเน่อยนิ� งใน ประช�กรเด็กและวัยัรุ่นนั�นอ�จันำ�มั� ใช�ค์�ดก�รณิส์ำำ�หรบัเด็กและวัยัรุ่นที� มีั ภั � วั ะ ทุ พ็ พ็ ล ภั � พ็ ไ ด�ต � มั ค์ วั � มั สำ�มั�รถเฉพ็�ะตวัั • หลกัฐ�นเกี�ยวักบัพ็ฤติกรรมัเน่อยนิ�ง ในกลุ่มัประช�กรผู้้�ใหญ่่โดยทั�วัไป รวัมั ถ่ง ป ร ะ โ ย ช น์สำำ � หรับ ผู้้� ให ญ่่ ที� ทำ � กิจักรรมัท�งก�ยในระดบัป�นกล�ง และหนกัเพ่็�อช่วัยต่อต� นค์วั�มัเสีำ�ยงที� อ�จัเกิดขี่ �นกบัพ็ฤติกรรมัเน่อยนิ�งใน ปริมั�ณิมั�ก อ�จันำ�มั�ค์�ดก�รณิก์บั ผู้้�ใหญ่่และผู้้�ส้ำงอ�ยุที� มีัภั�วัะทุพ็พ็ล- ภั�พ็ได�โดยทั� วัไปต�มัค์วั�มัสำ�มั�รถ เฉพ็�ะบุค์ค์ลนั�น อย่�งไรก็ต�มั ค์วั�มั น่�เช่�อถ่อขีองหลกัฐ�นนั�นถ้กลดระดบั เน่�องด�วัยค์วั�มัไม่ัตรงไปตรงมั� • ประโยชน์ขีองก�รลดพ็ฤติกรรมั เน่อยนิ�งในเด็ก วัยัรุ่น ผู้้�ใหญ่่ และผู้้�ส้ำง อ�ยุที� มีัภั�วัะทุพ็พ็ลภั�พ็มีัมั�กกว่ั� อนัตร�ย 101 หลักิฐ�นืในืข้้อแนืะนืำ�ต่ิ�ง ๆ ต�มักระบวันก�รขีอง GRADE ค์ำ � นิ ย �มั ขี อง ขี�อ แน ะ นำ � ที� ป รับ ป รุง และระดบัค์วั�มัหนกัแน่น (“หนกัแน่น” หร่อ “มีัเง่� อนไขี”) นั�น ขี่ �นอย่้กับก�ร พิ็จั�รณิ�ถ่งสำมัดุลขีองประโยชน์และ อนัตร�ย ค์วั�มัน่�เช่�อถ่อขีองหลกัฐ�น ค์วั�มัอ่อนไหวัต่อคุ์ณิค่์� และค์วั�มั นิยมัขีองผู้้�ที� ได�รับผู้ลกระทบจั�กขี�อ แนะนำ� ผู้ลกระทบที�อ�จัเป็นไปได�ต่อเพ็ศ สำงัค์มั และค์วั�มัเสำมัอภั�ค์ต่อสุำขีภั�พ็ แ ล ะ ก � ร ย อ มั รับ ค์ วั � มั เ ป็ น ไ ป ไ ด� และค์วั�มัเกี� ยวัขี�องขีองทรัพ็ย�กร สิำ� ง เหล่�นี�ถ้กนำ�มั�พิ็จั�รณิ�ในกลุ่มัประช�กร แต่ละกลุ่มั แต่เม่ั� อพิ็จั�รณิ�ถ่งค์วั�มั ค์ ล� ย ค์ ล่ง กัน ขี อ ง ป ร ะ เ ด็ น แ ล ะ ขี�อ พิ็จั�รณิ�ที�นำ�มั�อภิัปร�ย จัง่มีัก�รรวับ- รวัมัและนำ�เสำนอในเอกสำ�รนี� จุัดแข็ีงขีองขี�อแนะนำ�ค่์อ มีัพ่็ �นฐ�น เ บ่ �องต�นมั�จั�กก�รประเมิันสำมัดุล ระหว่ั�งประโยชนก์บัอนัตร�ย ขี�อแนะนำ� ถ้กจัดัระดบัให� “หนกัแน่น” ห�กสำมัดุล ระหว่ั�งประโยชนแ์ละอันตร�ยถ้กนำ� มั�ประเมิันในฐ�นะสำ�ระสำำ�ค์ญั่สำำ�หรบั ก ลุ่ มั ป ร ะ ช � ก ร เ ป้ � ห มั � ย แ ล ะ “มีัเง่�อนไขี” ห�กสำมัดุลระหว่ั�งประโยชน ์ ต่ออันตร�ยนั�นเล็กน�อยหร่อมีัค์วั�มั แปรปรวันที� สำำ �ค์ัญ่และเป็นไป ได�ใน ผู้ลประโยชน์ ในกลุ่มัประช�ก�รเป้� หมั�ย มีัก�รค์�นห�หลักฐ�นเกี� ยวักับ อันตร�ยโดยเฉพ็�ะผู่้�นก�รสำั� งก�ร ขีองบทปริทศันอ์ย่�งเป็นระบบอนัใหม่ั อย่�งไรก็ต�มั ขี�อแนะนำ�ยงัมีัขี�อจัำ�กดัอย่้ เพ็ร�ะหลกัฐ�นส่ำวันใหญ่่เพ่็งค์วั�มัสำนใจั ไปที�อ�ก�รบ�ดเจ็ับและอนัตร�ยสำำ�หรบั อภิัสิำทธิิ �ชนและนักกีฬ�มั�กกว่ั�กลุ่มั ประช�กรทั�วัไป ทั�ง ๆ ที�มีัหลกัฐ�นจัำ�กดั และแจั�งโดยค์วั�มัคิ์ดเห็นขีองผู้้�เชี�ยวัช�ญ่ จัง่สำรุปได�ว่ั� ค์วั�มัเสีำ�ยงนั�นมีัเพี็ยงน�อยนิด โดยภั�พ็รวัมั โดยทั�วัไปแล�วั หลกัฐ�นบ่ง ชี �ว่ั�ประโยชนข์ีองกิจักรรมัท�งก�ยมีั มั�กกว่ั�อนัตร�ยอย่�งมั�ก และกิจักรรมั ท�งก�ยอ�จัเป็นก�รแทรกแซงสำำ�ค์ญั่ที� สำนับสำนุนก�รปิดช่องโหว่ัด� นสุำขีภั�พ็ที� มีัอย่้ โดยเฉพ็�ะอย่�งยิ�งประช�กรกลุ่มั ด�อยโอก�สำ ค์ณิะทำ�ง�น GDG พิ็จั�รณิ� ประเด็นเร่�องค์วั�มัเท่�เทียมัด� นสุำขีภั�พ็ ค์วั�มัเป็นไปได� และค์วั�มัเป็นที�ยอมัรบั และเป็นส่ำวันหน่�งขีองก�รให�ก�รปร่กษ� ห�ร่อเพ่็�อรบัฟัิงค์วั�มัคิ์ดเห็นสำ�ธิ�รณิะ ในช่องท�งออนไลน ์ ในร่�งขี�อแนะนำ�ที� จัดัขี่ �นระหว่ั�ง 31 มีัน�ค์มั พ็.ศ. 2563 และ 17 เมัษ�ยน พ็.ศ. 2563 ก�รสำำ�รวัจั สำำ�หรบัค์ำ�ปร่กษ�โดยเปิดเผู้ยนี� ถ�มัค์ำ� ถ�มัที� เจั�ะจังเร่� องสำมัดุลระหว่ั�งค่์�ใช� จ่ั�ยขีองบุค์ค์ลและรฐับ�ลในก�รนำ�ขี�อ แนะนำ�ไปใช� ผู้ลดีต่อสุำขีภั�พ็ที�อ�จัเกิดขี่ �น และขี�อแนะนำ�นี�จัะพ็ฒัน�ค์วั�มัเท่�เทียมั ด� นสุำขีภั�พ็ได�หร่อไม่ั ยิ� งไปกว่ั�นั�น ขี�อแนะนำ�ฉบบัร่�งและเอกสำ�รผู้ลตอบ รบัถ้กส่ำงไปยงัประเทศต่�งๆที�สำนใจัจัะ พ็ัฒน�หร่อริเริ� มักระบวันก�รร่�งขี�อ แนะนำ�แห่งช�ติ ว่ั�ด�วัยกิจักรรมัท�งก�ย และได�รบัผู้ลตอบรบัมั�กกว่ั� 420 ร�ย หลักฐานในข้้อัแนะนำาต่่าง ๆ ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 102 จั�กก�รปร่กษ�ห�ร่อแบบออนไลน ์ และก�รรวับรวัมัผู้ลตอบรบัเพิ็�มัเติมัจั�ก สำำ�นักง�นภั�ค์พ่็�นยุโรปขีององค์ก์�ร อน�มัยัโลก ร่วัมักบัขี�อคิ์ดเห็นจั�กศ้นย ์ ค์วั�มัร่วัมัม่ัอขีององค์ก์�รสำหประช�ช�ติ และประเทศสำมั�ชิก ค์ณิะทำ�ง�น GDG ได� รวับรวัมัและทบทวันผู้ลตอบรบัจั�กก�ร ปรก่ษ� และนำ�มั�ใช�เพ่็�อให�ทร�บเกี�ยวักบั พิ็จั�รณิ�ในส่ำวันขีองค์วั�มัเป็นไป ได� ผู้ลด� นค์วั�มัเกี� ยวัขี�องขีองทรัพ็ย�กร และค์วั�มัเท่�เทียมัด� นสุำขีภั�พ็ผู่้�นก�ร ปร่กษ�กบักลุ่มันำ�ร่องและค์ณิะทำ�ง�น GDG ก�รตดัสิำนใจัเกิดขี่ �นโดยฉนัท�มัติ จั�กก�รอภิัปร�ย ค์ณิะทำ�ง�น GDG ลง มัติในขี�อแนะนำ�แต่ละขี�อและนำ � หนัก ขีองค์ำ�แนะนำ� โดยไม่ัมีัก�รจัดัระดบัหร่อ ลงค์ะแนนเสีำยง กรอบก�รทำ�ง�นขีอง GRADE ใช� โดยค์ณิะทำ�ง�น GDG เพ่็� อตรวัจั- สำ อ บ ค์ วั � มั น่ � เ ช่� อ ถ่ อ ขี อ ง ง � น วิั จััย เบ่ �องต�นที� นำ�ไปส่้ำผู้ลลัพ็ธิแ์ต่ละอย่�ง ที�แยกแยะไวั�ในอตัร� PI/ECO และประ- เมิันค์วั�มัน่�เช่� อถ่อขีองหลักฐ�นโดย รวัมัที�นำ�มั�พิ็จั�รณิ�ค์วั�มัเสีำ�ยงต่อค์วั�มั เอนเอียง ค์วั�มัไม่ัค์งที� ค์วั�มัไม่ัแม่ันยำ� ค์วั�มัไม่ัตรงไปตรงมั�ขีองขี�อม้ัลและ ค์วั�มัเอนเอียงในก�รตีพิ็มัพ็ค์์รอบค์ลุมั ผู้ลลพั็ธิแ์ต่ละขี�อ ต�ร�งขีอง GRADE แจังร�ยละเอียดสำำ�หรบัแต่ละกลุ่มัขีอง ก�รพ็ัฒน�ขี�อแนะนำ �รวัมัก�ร ป ร ะ เ มิั น ผู้ ล ก ร ะ ท บ ใน ท � ง ล บ ห ร่ อ ค์วั�มัเสีำ� ยง ก�รตัดสิำนใจันั�นขี่ �นอย่้กับ ค์วั�มัเชี� ยวัช�ญ่ขีองค์ณิะทำ�ง�น GDG เม่ั�อมีัหลกัฐ�นจัำ�กดั โดยภั�พ็รวัมัสำำ�หรบั กลุ่มัประช�กรทั�งหมัดนั�นสำ�มั�รถสำรุปได� ว่ั�ประโยชนข์ีองกิจักรรมัท�งก�ยและ ก�รจัำ�กดัพ็ฤติกรรมัเน่อยนิ�งนั�นมีัมั�ก กว่ั�โทษที�อ�จัจัะเกิดขี่ �น ขี�อแนะนำ�นี�มีัไวั� สำำ�หรบัประช�กรทั�วัไป และไม่ัได�กล่�วั กิ�รัปรัะเมินืคำวั�มน่ื�เชื้�อถืึอ ข้องหลักิฐ�นื ปรัะโยช้น์ืและโทษ PI/ECO มีัอย่้ที�ภั�ค์ผู้นวักขีองเว็ับไซต ์ : ชุ ด ขี�อ ม้ั ล ห ลักฐ � น 1 3 ก � ร ป ร ะ เ มิั น ค์วั�มัน่�เช่� อขีองหลักฐ�นนั�น มั�จั�ก ก�รประเมิันโดยภั�พ็รวัมัค์รอบค์ลุมั ผู้ลลัพ็ธิที์� ถ้กประเมิันทั�งหมัด และให� ค์วั�มัสำำ�ค์ญั่กบัก�รเสีำยชีวิัตทุกสำ�เหตุ และก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อด หัวัใจัเป็นผู้ลลพั็ธิที์�สำำ�ค์ญั่ที� สุำด ต�มัมั� ด� วั ย ผู้ ล ลัพ็ ธิ ์ท � ง ก � ร แพ็ ท ย์อ่� น ๆ (ก�รหกล�มั อ�ก�รซ่มัเศร� ก�รรับร้� คุ์ณิภั�พ็ชีวิัตที� เกี� ยวัเน่� องกับสุำขีภั�พ็ และอ่� น ๆ) และผู้ลลัพ็ธิร์ะดับกล�ง (เช่น ตวัับ่งชี�โรค์หลอดเล่อดและหัวัใจั ตวัับ่งชี�ก�รเผู้�ผู้ล�ญ่อ�ห�ร) รวัมัถ่ง ภัยัอนัตร�ย ในจุัดที�ยงัไม่ัมีัก�รทบทวัน หลกัฐ�นโดยเฉพ็�ะเจั�ะจัง เช่น พ็ฤติ- กรรมัเน่อยนิ�งในประช�กรกลุ่มัย่อย เน่�อง จั�กขี�ดหลกัฐ�นสำำ�หรบักลุ่มันี�ในเบ่ �อง ต�น หลกัฐ�นสำำ�หรบัประช�กรทั�วัไปถ้กนำ� มั�ใช�ค์�ดก�รณิแ์ละลดระดบัค์วั�มัสำำ�ค์ญั่ ลง เม่ั�อเห็นค์วัรด�วัยค์วั�มัเป็นผู้ลท�งอ�อมั 13 ข้้อม่ัลออนไลน์ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 103 ถ่งประโยชนแ์ละโทษที�นักกีฬ�ประสำบ เม่ั�อทำ�กิจักรรมัทั�งประเภัทและปริมั�ณิ ที�จัำ�เป็นที�จัะพ็ฒัน�ค์วั�มัแข็ีงแรงที�เกี�ยวั เน่� องกบัค์วั�มัสำ�มั�รถเพ่็�อเขี� ร่วัมัก�ร แข่ีงขีนั ก�รทำ�กิจักรรมัท�งก�ยบ� งย่อมั ดีกว่ั�ไม่ัทำ�เลย ห�กบุค์ค์ลนั�นไม่ัสำ�มั�รถ ทำ�ต�มัขี�อแนะนำ�เหล่�นี� ก�รทำ�กิจักรรมั ท�งก�ยบ� ง จัะนำ �มั�ซ่� งประโยชน ์ ต่อสุำขีภั�พ็ โดยค์วัรเริ�มัจั�กกิจักรรมัท�ง ก�ยเพี็ยงแต่น�อย แล�วัค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มัหนกัหน่วัง และระยะเวัล�ขี่ �นเร่�อย ๆ โดยทั� วัไปแล�วั ใบอนุญ่�ตจั�กแพ็ทย ์ ก่อนก�รทำ�กิจักรรมัท�งก�ยนั�นไม่ั จัำ�เป็น บุค์ค์ลที� ไม่ัขียบัร่�งก�ยที� ค่์อย ๆ ทำ�กิจักรรมัท�งก�ยในระดบัป�นกล�ง ไม่ัมีับนัท่กค์วั�มัเสีำ�ยงต่อภั�วัะหัวัใจัล�มั เหลวักะทนัหนั และมีัค์วั�มัเสีำ�ยงที�ตำ� มั�ก สำำ�หรบัก�รบ�ดเจ็ับที�กระด้ก กล� มัเน่�อ หร่อขี�อต่อ ผู้้�ที� ทำ�กิจักรรมัท�งก�ยใน ระดบัป�นกล�งอย่�งเป็นนิสำยั สำ�มั�รถ เพิ็�มัระดบัเป็นระดบัหนกัได�ทีละน�อย โดย ไม่ัจัำ�เป็นต�องปร่กษ�ผู้้�ให�บริก�รด� น ก�รแพ็ทย ์ ผู้้�ที� มีัอ�ก�รใหม่ั ๆ เม่ั�อเพิ็�มั ระดบักิจักรรมัค์วัรปร่กษ�ผู้้�ให�บริก�ร ด� นก�รแพ็ทย์ ท�งเล่อกขีองประเภัทและปริมั�ณิ ก�รทำ�กิจักรรมัท�งก�ยที� เหมั�ะสำมั อ�จัมีั ผู้ ล กร ะ ท บจั� ก ก�ร ตั�ง ค์ร ร ภั ์ ภั�วัะโรค์เร่�อรงั และภั�วัะทุพ็พ็ลภั�พ็ และ ค์วัรจัะได�รบัก�รด้แลเหม่ัอนบุค์ค์ลปรกติ และไม่ัมีัขี�อบ่งห� มั บุค์ค์ลเหล่�นี�ค์วัร ต�องปร่กษ�ผู้้�เชี� ยวัช�ญ่ด� นกิจักรรมั ท�งก�ยหร่อบุค์ล�กรด� นก�รแพ็ทย ์ สำำ�หรับค์ำ�แนะนำ�เร่� องขีองชนิดและ ปริมั�ณิกิจักรรมัที� เหมั�ะสำมักับค์วั�มั ต�องก�ร ค์วั�มัสำ�มั�รถ ขี�อจัำ�กดัท�ง ร่�งก�ยและภั�วัะแทรกซ�อน ก�รให�ย� และแผู้นก�รรกัษ�โดยรวัมั กิจักรรมัท�ง ก�ยในระดบัเบ�และป�นกล�งมีัค์วั�มั เสีำ�ยงตำ� และแนะนำ�สำำ�หรบัทุกค์น มีัก�รนำ�คุ์ณิค่์�และค์วั�มัชอบ ขีองผู้้�ได�รบัผู้ลกระทบจั�กขี�อแนะนำ�นี� (ในกรณีินี�ได�แก่ บิด�มั�รด�และผู้้�ด้แล เ ด็ ก แ ล ะ วััย รุ่ น ผู้้� ใ ห ญ่่ ผู้้� ส้ำ ง อ � ยุ หญิ่งมีัค์รรภั์และมั�รด�หลังค์ลอด ผู้้�ที� โรค์เร่�อรงั และ/หร่อทุพ็พ็ลภั�พ็) มั�พิ็จั�รณิ� โดยรวัมัแล�วัสำรุป ได�ว่ั� มีัค์วั�มัแน่นอนน�อยหร่ออ�จัไม่ัมีัเลย เกี�ยวักบัค์วั�มันิยมัที�เกี�ยวัเน่�องกบัผู้ลลพั็ธิ ์ หลกั รวัมัถง่ก�รเสีำยชีวิัตและก�รเสีำยชีวิัต จั�กโรค์หลอดเล่อดหวััใจั ประโยชนที์� ได�นั�นมีัมั�กกว่ั�โทษที� อ�จัเกิดขี่ �น และด�วัยเหตุนี� ค์ณิะทำ�ง�น GDG พิ็จั�รณิ�ว่ั�ค์ำ�แนะนำ�นั�นไม่ัไวัต่อ ค์วั�มัชอบใด ๆ ค์วั�มัเห็นขีองผู้้�เชี�ยวัช�ญ่ขีองค์ณิะ ทำ�ง�น GDG และองค์ข์ี�อม้ัลหลกัฐ�นชิ�น เล็กที�ร�ยง�นเกี�ยวักบัก�รวิัเค์ร�ะหก์�ร แทรกแซงท�งเศรษฐกิจัและก�รเก็บออมั ต่อระบบสำ�ธิ�รณิสุำขีจั�กก�รเพิ็�มัระดบั กิจักรรมัท�งก�ย ร�ยง�นถง่ก�รอภิัปร�ย เร่�องค์วั�มัเกี�ยวัขี�องขีองทรพั็ย�กรขีอง ขี�อแนะนำ�ในสำภั�พ็แวัดล�อมัที�แตกต่�งกนั นอกจั�กนี� ผู้ลจั�กก�รปร่กษ�ห�ร่อเพ่็�อ คุำณค่ำ�และคำวั�มช้อบ คำวั�มเก่ิ�ยวัข้้องข้องทรััพย�กิรั หลักฐานในข้้อัแนะนำาต่่าง ๆ ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 104 รบัฟัิงค์วั�มัคิ์ดเห็นสำ�ธิ�รณิะแสำดงให�เห็น ว่ั� ผู้้�ตอบค์ำ�ถ�มัมั�กกว่ั�ร�อยละ 75 เห็น ด�วัยหร่อเห็นด�วัยอย่�งยิ�งว่ั� ประโยชน์ใน ก�รนำ�ขี�อแนะนำ�ไปใช�มีัมั�กกว่ั�ค่์�ใช� จ่ั�ยต่อตวัับุค์ค์ล และร�อยละ 81 เห็นด�วัย หร่อเห็นด�วัยอย่�งยิ�งว่ั� ประโยชน์ในก�ร นำ�ขี�อแนะนำ�ไปใช�มีัมั�กกว่ั�ค่์�ใช�จ่ั�ย ขีองรฐั หลกัฐ�นที� มีัอย่้และค์วั�มัคิ์ดเห็น จั�กผู้้�เชี�ยวัช�ญ่ตระหนกัว่ั� เร�สำ�มั�รถ บรรลุถ่งผู้ลดีต่อสุำขีภั�พ็อย่�งมั�กมั�ย ด�วัยค์วั�มัเสีำ�ยงน�อย จั�กกิจักรรมัต่�ง ๆ เช่น ก�รเดิน ซ่� งไม่ัต�องก�รอุปกรณิ ์ เฉพ็�ะหร่อค่์�ใช�จ่ั�ยใด ๆ ยิ�งกว่ั�นั�นเป็น ที� ต ร ะ ห นั ก ว่ั � กิ จั ก ร ร มั ท � ง ก � ย ในร้ปแบบอ่� น เช่น กีฬ�ที� มีัโค์รงสำร� ง ก�รปั� นจักัรย�น และชั�นเรียนก�ยบริห�ร ต่�ง ๆ อ�จัมีัค่์�ใช�จ่ั�ย ซ่� งอ�จัเป็น อุปสำรรค์ต่อบ�งค์น โดยเฉพ็�ะผู้้�มีั ร � ย ไ ด� น� อ ย ก � ร นำ � น โ ย บ � ย แ ล ะ ร�ยก�รต่�ง ๆ มั�ใช�โดยรฐับ�ล เพ่็�อส่ำง เสำริมัและสำร� งเสำริมักิจักรรมัท�งก�ย ยงัต�องก�รก�รลงทุนในหล�ยส่ำวัน เช่น ทรัพ็ย�กรบุค์ค์ล ก�รพ็ัฒน�นโยบ�ย ก�รจััดห�สิำ� งอำ�นวัยค์วั�มัสำะดวักและ บริก�ร และอ�จัรวัมัอุปกรณิด์�วัย บ�ง สิำ�งค์วัรจัดัห�โดยกระทรวังสำ�ธิ�รณิสุำขี แ ล ะ ภั� ค์ ส่ำ วั นอ่� นนอ ก ขีอ บ ข่ี � ย ขีอง สุำขีภั�พ็ เช่น กีฬ� ก�รศก่ษ� ก�รเดินท�ง และก�รวั�งผู้งัเม่ัอง ทรพั็ย�กรที� ต�อง ก�รนั�น อ�จัจัะต�องก�รรฐับ�ลมั�กกว่ั� หน่�งระดบั (ระดบัประเทศ ระดบัภั�ยใน ประเทศ และระดบัท�องถิ�น) เพ่็�อให�มัั�นใจั ว่ั�ทุกชุมัชนจัะเขี� ถ่งโอก�สำในก�รทำ� กิจักรรมัท�งก�ยอย่�งเท่�เทียมั ก�ร ลง ทุ นนี�อ�จั เกี� ย วั ขี�อง กับ ทรพั็ย�กรใหม่ั แต่อ�จัเป็นก�รจัดัสำรร งบประมั�ณิที�มีัอย่้เสีำยใหม่ัเพ่็�อให�สำะท�อน ถ่งก�รจััดลำ�ดับค์วั�มัสำำ�ค์ัญ่ขีองสิำ� ง อำ�นวัยค์วั�มัสำะดวักและร�ยก�รต่�ง ๆ ที� มุ่ังเพิ็�มักิจักรรมัท�งก�ยขีองประช�กร ตัวัอย่�งขีองก�รจััดสำรรงบประมั�ณิ เช่น สำ�ธิ�รณ้ิปโภัค์สำำ�หรบัก�รเดินและ ก�รปั� นจัักรย�นจั�กงบประมั�ณิด� น ก�รค์มัน�ค์มัที� มีัอ ย่้ และ โค์รงก�ร “กีฬ�สำำ�หรบัทุกค์น” จั�กงบประมั�ณิ ด� นกีฬ� ในสำภั�พ็แวัดล�อมัหลัก เช่น โรงเรียนและที�ทำ�ง�น ก�รแทรกแซงที� ค่์�ใช�จ่ั�ยตำ� ผู้สำ�นกบัก�รเปลี�ยนแปลง สิำ� งแวัดล�อมัท�งก�ยภั�พ็สำ�มั�รถสำนับ สำนุนก�รมีัส่ำวันร่วัมัในก�รทำ�กิจักรรมั ท�งก�ย และอ�จัมีัส่ำวันช่วัยลดค์วั�มัไม่ั เท่�เทียมัด� นโอก�สำในก�รทำ�กิจักรรมั ท�งก�ยที� ประช�กรกลุ่มัย่อยบ�งกลุ่มั ประสำบอย่้ โดยรวัมัแล�วั มีัก�รประเมิันว่ั� แมั�จัะมีัค์วั�มัเกี� ยวัขี�องขีองทรัพ็ย�กร เพ่็�อที�จัะทำ�ร่�งขี�อแนะนำ�ให�สำำ�เร็จั ก�รนำ� มั�ปฏิิบติันั�นเป็นไปได�ภั�ยใต�โค์รงสำร� ง ก�รกำ�กบัด้แลปัจัจุับนั ยิ� งกว่ั�นั�น หลกัฐ�นสำนับสำนุนว่ั� ก�รออมัเงินเพ่็�อสุำขีภั�พ็อย่�งต่อเน่� อง นั�นเ ป็นไป ได�สำำ �หรับระบบก�รด้แล สุำขีภั�พ็ที� เ ป็นผู้ลจั�กก�รเพิ็� มัระดับ กิจักรรมัท�งก�ย ในพ็.ศ. 2556 ค่์� ใช�จ่ั�ยประจัำ�ปีทั�วัโลกขีองกิจักรรมัท�ง ก�ยที� ไม่ัเพี็ยงพ็อนั�นประเมิันไวั�ที� 54 พ็ันล� นดอลล�ร์สำ�กล อันเป็นค่์�ใช� จ่ั�ยด� นสุำขีภั�พ็โดยตรงเท่�นั�น (130) และในระดับประเทศ และประเมิัน ว่ั�กิจักรรมัท�งก�ยที� ไม่ัเพี็ยงพ็อคิ์ด 105 เป็นค่์�ใช�จ่ั�ยร�อยละ 1 ถ่งร�อยละ 3 ขีองงบประมั�ณิด� นก�รด้และสุำขีภั�พ็ (131) ภั�ยใต�ปริบทขีองก�รป้องกนัโรค์ ไม่ัติดต่อเร่ �อรงั (NCD) ค่์�ใช�จ่ั�ยเพิ็�มัเติมั ขีองรฐับ�ลและองค์ก์รที� ไม่ัใช่ขีองรฐัจั�ก ก�รนำ�ขี�อแนะนำ�ไปใช�อ�จัจัะลดน�อยลง ได� ห�กก�รทำ�กิจักรรมัท�งก�ยต�มัที� แนะนำ�สำ�มั�รถรวัมัเขี� กับชีวิัตขีอง ผู้้�ค์นได�โดยง่�ย ในทำ�นองเดียวักนั ห�ก ทรพั็ย�กรที�มีัอย่้ในก�รด้แลเบ่ �องต�นและ ขีั�นทุติยภ้ัมิั โรงเรียน ที�ทำ�ง�น หร่อก�ร เดินท�งสำ�มั�รถเปลี�ยนแปลงให�มีักิจั- กรรมัท�งก�ยมั�กขี่ �น ก�รวิัเค์ร�ะหค่์์�ใช�จ่ั�ยและประ- โยชน์ขีองก�รส่ำงเสำริมักิจักรรมัท�ง- ก�ย ชี �ให�เห็นผู้ลตอบกลบัในท�งบวัก ในก�รลงทุนด� นก�รป้องกนัโรค์ไม่ัติด- ต่อเร่ �องรงัมั�มั�กกว่ั� 15 ปีในหล�ย ๆ ประเทศที�มีักรณีิก�รลงทุนเกิดขี่ �น (132) ก�รแทรกแซง เช่น ก�รให�ก�รศ่กษ� สำ�ธิ�รณิะ ก�รรณิรงค์์สำร� งค์วั�มั ต ร ะ ห นัก ร้� แ ล ะ ก � ร ใ ห� ค์ำ � ป ร่ ก ษ � ด� นกิจักรรมัท�งก�ย และก�รอ� งอิง ถง่ก�รแทรกแซงที�แนะนำ�ว่ั� “คุ์�มัค่์�ที�สุำด” และ “คุ์�มัมั�ก” ต�มัลำ�ดบัเม่ั�อกล่�วัถ่ง โรค์ไม่ัติดต่อเร่ �อรงัต่�ง ๆ ต�มัขี�อม้ัล ปรบัปรุงในภั�ค์ผู้นวักที� 3 ขีองขี�อแนะนำ� สำ�กลว่ั�ด�วัยก�รป้องกันและค์วับคุ์มั โรค์ไม่ัติดต่อ พ็.ศ. 2556 ถง่ พ็.ศ. 2563 (133) โดยรวัมันั�น ค์ณิะทำ�ง�น GDG สำรุปว่ั� ประโยชนจ์ั�กก�รนำ�ขี�อแนะนำ�ไป ใช�นั�นมีัมั�กกว่ั�ค่์�ใช�จ่ั�ย ก�รนำ�ขี�อแนะนำ�ในก�รทำ�กิจั- กรรมัท�งก�ยไปใช�กับผู้้�มีัภั�วัะทุพ็- พ็ลภั�พ็อ�จัต�องก�รก�รลงทุน เช่น ก�รฝึึกอบรมัผู้้�เชี�ยวัช�ญ่ด� นกิจักรรมั ก�รปรับเปลี� ยนอุปกรณิ์ห�กจัำ�เป็น และสิำ�งอำ�นวัยค์วั�มัสำะดวักต่�ง ๆ ที�ต�อง ทำ�ให�เขี� ถง่ได� ก�รลงทุนเหล่�นี�สำ�มั�รถ ตอบสำนองต่อค์วั�มัจัำ�เป็นที�หล�กหล�ย ขีองกลุ่มัประช�กร หลกัฐ�นออกมั�ใน ร้ปขีองเสำ�นล�ดชันขีองก�รมีัส่ำวันร่วัมั อย่�งมีันยัสำำ�ค์ญั่ ระหว่ั�งผู้้�ที� มีัและไม่ัมีั ภั�วัะทุพ็พ็ลภั�พ็ ที�เกี�ยวัขี�องกบักิจักรรมั ท�งก�ย อนัเน่�องมั�จั�กอุปสำรรค์ในก�ร เขี� ถ่งหล�ยประก�ร ตัวัเ ล่อกขีอง กิจักรรมัที� เสำนอ และทศันค์ติขีองผู้้�อ่�น ค์วัรใช�หลกัก�รที�ออกแบบในระดบัสำ�กล เพ่็�อให�ผู้้�ที� มีัภั�วัะทุพ็พ็ลภั�พ็เขี� ร่วัมัได� อย่�งเต็มัที� และมีัประสิำทธิิภั�พ็ ด�วัย นวัตักรรมั จัง่เป็นไปได�ที�จัะกล่�วัถง่ค์วั�มั เกี�ยวัขี�องด� นทรพั็ย�กรหล�ยอย่�งก�ร นำ�แนวัท�งก�รออกแบบระดบัสำ�กลมั�ใช� อ�จัลดค่์�ใช�จ่ั�ยเหล่�นี�ได�ในอน�ค์ต ในก�รปรับปรุงขี�อแนะนำ�ขีอง พ็.ศ. 2553 มีัก�รตัดสิำนใจัให�รวัมัขี�อ พิ็จั�รณิ�สำำ �หรับกลุ่มัประช�กรที� มีั ค์วั�มัเปร�ะบ�ง เช่น ผู้้�ที�มีัโรค์เร่�อรงัและ/ หร่อค์วั�มัทุพ็พ็ลภั�พ็ ค์ณิะทำ�ง�น GDG และค์ณิะนำ�ร่องได�รวัมัสำมั�ชิกที� เป็นตวัั แทนขีองกลุ่มัเหล่�นี� ค์ณิะทำ�ง�น GDG อภิัปร�ยขี�อแนะนำ�แต่ละขี�อด�วัยเร่� อง ค์วั�มัย�วัน�น พิ็จั�รณิ�ว่ั�ก�รนำ�ขี�อ คำวั�มเท่�เท่ยม กิ�รัเป็นืท่� ยอมรัับ และคำวั�มเป็นืไปได้็ หลักฐานในข้้อัแนะนำาต่่าง ๆ ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 106 แนะนำ�มั�ใช�จัะลดค์วั�มัเท่�เทียมัด� น สุำขีภั�พ็หร่อไม่ั และประเด็นที� เกี�ยวัเน่�อง กบัก�รนำ�มั�ใช� เพ่็�อให�มัั�นใจัว่ั�ขี�อแนะนำ� นั�น ไม่ัทำ�ให�ประเด็นเร่�องค์วั�มัเท่�เทียมั แย่ลง (ตวััอย่�งเช่น ทำ�ให�แน่ใจัว่ั�มีัสิำ� ง อำ�นวัยค์วั�มัสำะดวักที�ปลอดภัยัและโอก�สำ เป็นสิำ�งที�ทุกค์นเขี� ถง่ได� รวัมัถง่ผู้้�มีัภั�วัะ ทุพ็พ็ลภั�พ็ และกลุ่มัผู้้�ด�อยโอก�สำ ทั�งท�ง ด� นเศรษฐกิจั สำงัค์มั และด� นอ่�น ๆ ให�เขี� ร่วัมักบัก�รทำ�กิจักรรมัท�งก�ย โดยกล่�วั ถง่เพ็ศและค์วั�มัเอนเอียงท�งวัฒันธิรรมั อ่�น ๆ ที�จัะจัำ�กดัก�รเขี� ถง่และโอก�สำใน ก�รเขี� ร่วัมัทำ�กิจักรรมัท�งก�ย และอ่�น ๆ ) ผู้้�ตอบแบบสำอบถ�มัจั�กก�รปร่กษ� ห�ร่อสำ�ธิ�รณิะแบบออนไลนร์�อยละ 76 เห็นด�วัยหร่อเห็นด�วัยอย่�งยิ� งว่ั� ก�ร นำ�ขี�อแนะนำ�มั�ใช�สำ�มั�รถลดค์วั�มัไม่ั เท่�เทียมัด� นสุำขีภั�พ็ได� โดยก�รเพิ็� มั โอก�สำให�แก่ทุกค์นในก�รเค์ล่�อนไหวัร่�ง ก�ยและปรบัปรุงผู้ลต่อสุำขีภั�พ็ เป็นที� ยอมัรับว่ั� สิำ� งแวัดล�อมัที� สำนับสำนุนเป็น กุญ่แจันำ�ไปส่้ำก�รเขี� ร่วัมักิจักรรมัท�ง ก�ย มีัค์วั�มัต�องก�รแนวัท�งที� เขี� ใจัถง่ ก�รออกแบบและก�รนำ�นโยบ�ยไปใช� ทั�วัทุกภั�ค์ส่ำวัน เพ่็�อชี �ให�เห็นถง่อุปสำรรค์ ต่อก�รทำ�กิจักรรมัท�งก�ยสำำ�หรบักลุ่มั ที�ด�อยกว่ั� เช่น เด็กและสำตรีที�ด�อยโอก�สำ ท�งเศรษฐกิจัและสำงัค์มั และผู้้�มีัภั�วัะ ทุพ็พ็ลภั�พ็ ผู้้�มีัภั�วัะทุพ็พ็ลภั�พ็ประสำบผู้ลลพั็ธิ ์ ท�งสุำขีภั�พ็ที� เลวัร� ยกว่ั�ผู้้� ไม่ัมีัภั�วัะ ทุพ็พ็ลภั�พ็ แต่ประโยชนข์ีองกิจักรรมั ท�งก�ยยงัมีัมั�กกว่ั�โทษอย่้มั�ก และ สำ�มั�รถเป็นก�รแทรกแซงที�สำำ�ค์ญั่ที�จัะ อุดช่องโหว่ัท�งสุำขีภั�พ็นี�ได� หลกัฐ�นชี�ว่ั� ค่์�ค์วั�มัล�ดชนัขีองก�รเขี� ร่วัมัอย่�งมีั นัยสำำ�ค์ัญ่ระหว่ั�งผู้้�ที� มีัและ ไม่ัมีัภั�วัะ ทุพ็พ็ลภั�พ็ที� เกี� ยวัเน่� องกบัก�รทำ�กิจั- กรรมัท�งก�ย ด�วัยอุปสำรรค์ต่อก�ร เขี� ถ่งที� หล�กหล�ย ท�งเล่อกขีอง กิจั กร ร มั ที� เ สำ นอ แ ล ะ ทัศ น ค์ ติ ขีอง ผู้้�ค์นมั�กมั�ยที�มีัภั�วัะทุพ็พ็ลภั�พ็ค์วัรจัะ เป็นไปได� ที�จัะเขี� ร่วัมัทำ�กิจักรรมัท�ง ก�ยหล�ยร้ปแบบโดยไม่ัจัำ�เป็นต�องมีัก�ร ปรบัเปลี�ยนอุปกรณิห์ร่อสิำ�งอำ�นวัยค์วั�มั สำะดวัก อย่�งไรก็ต�มั เพ่็� อให�ผู้้�มีัภั�วัะ ทุพ็พ็ลภั�พ็เขี� ร่วัมัทำ�กิจักรรมัท�งก�ย ได�เท่�เทียมัผู้้�อ่�น อุปกรณิจ์ั่งอ�จัต�องมีั ก�รปรบัเปลี�ยน สิำ�งอำ�นวัยค์วั�มัสำะดวัก ต�องเขี� ถ่งได� และผู้้�เชี�ยวัช�ญ่ด� นกิจั- กรรมัอ�จัต�องได�รบัก�รฝึึกฝึน 107 คำวั�มต้ิองกิ�รัต่ิอง�นืวิัจัย ทั�ง ที� มีัขี�อม้ัลเกี� ยวักับกิจักรรมั ท�งก�ยและพ็ฤติกรรมัเน่อยนิ� งต่อ ผู้ลลัพ็ธิด์� นสุำขีภั�พ็ที� ค์รอบค์ลุมัทุก ช่วังอ�ยุในปริมั�ณิมั�กและเพิ็�มัมั�กขี่ �น ก�รอภิัปร�ยขีองค์ณิะทำ�ง�น GDG เปิด เผู้ยช่องว่ั�งขีองหลกัฐ�นที�สำำ�ค์ญั่ ซ่�งค์วัร จัะถ้กจัดัลำ�ดบัค์วั�มัสำำ�ค์ญั่เพ่็�อร�ยง�น ขี�อ แน ะ นำ �ในอ น� ค์ ต ช่อง ว่ั�ง ขีอง หลกัฐ�นสำำ�หรบัประช�กรกลุ่มัย่อยยงั ขี�ดขี�อม้ัล ดงัต่อไปนี� 1. ขี�อม้ัลที�แน่นอนเกี�ยวักบัค์วั�มัสำมััพ็นัธิ ์ ขี อ ง ก � ร ต อ บ สำ น อ ง ต่ อ ป ริ มั � ณิ ระหว่ั�งกิจักรรมัท�งก�ย และ/หร่อ พ็ฤติกรรมัเน่อยนิ�ง และผู้ลลพั็ธิต่์อ สุำขีภั�พ็หล�ยประก�รที�ศก่ษ�มั� 2. ผู้ ล ลัพ็ ธิ ์ต่ อ สุำ ขี ภั � พ็ จั � ก ก � ร ทำ � กิจักรรมัท�งก�ยในระดบัเบ� และเลิก ทำ�พ็ฤติกรรมัเน่อยนิ� งด�วัยก�รทำ� กิจักรรมัท�งก�ยที�ระดบัเบ� 3. ค์วั�มัแตกต่�งในผู้ลลพั็ธิต่์อสุำขีภั�พ็ จั�กชนิดและขีอบเขีตขีองกิจักรรมั ท�งก�ยที�แตกต่�งกนั (เวัล�พ็กัผู่้อน เกี�ยวักบัอ�ชีพ็ ก�รเดินท�ง ในค์รวัั- เร่อน ก�รศ่กษ�) และกบัพ็ฤติกรรมั เน่อยนิ� ง (เกี�ยวักบัก�รนิ� งเฉย เวัล� ที�ใช�ไปกบัหน� จัอ เวัล�ด้โทรทศัน)์ และ 4. ค์ วั � มั เ ช่� อ มั โ ย ง ร่ วั มั กัน ร ะ ห ว่ั � ง กิจักรรมัท�งก�ยและพ็ฤติกรรมัเน่อย นิ�งกบัผู้ลลพั็ธิต่์อสุำขีภั�พ็ค์รอบค์ลุมั ทุกช่วังอ�ยุ นอกจั�กนี� ยงัมีัขี�อสำังเกตุว่ั� มีั หลกัฐ�นจัำ�กดัจั�กประเทศที� มีัร�ยได� ตำ� และร�ยได�ป�นกล�ง ชุมัชนที� ด�อย โอก�สำหร่อด�อยโอก�สำท�งเศรษฐกิจั และ ในผู้้� ที� มีัภั�วัะ ทุพ็พ็ลภั�พ็ และ/ หร่อมีัโรค์เร่�อรงั ง�นวิัจัยัหล�ยชิ�นนั�นไม่ั ได�ถ้กออกแบบหร่อเสำริมัแรงเพ่็� อก�ร ปรับผู้ลที� ได�โดยปัจัจัยัท�งสำงัค์มัประ- ช�กรที�หล�กหล�ย (อ�ยุ เพ็ศ เช่ �อช�ติ/ ช�ติพ็นัธุิ ์สำถ�นะท�งเศรษฐกิจัและสำงัค์มั) ที� อ�จัจัะเปลี� ยนแปลงผู้ลกระทบต่อ สุำขีภั�พ็ขีองกิจักรรมัท�งก�ย ขี�อม้ัลนี�มีั ค์วั�มัสำำ�ค์ญั่เพ่็�อนำ�ก�รจัดัทำ�ค์ำ�แนะนำ� ด� นสำ�ธิ�รณิสุำขีที� เจั�ะจังมั�กขี่ �นและ เพ่็�อลดค์วั�มัไม่ัเท่�เทียมัด� นสุำขีภั�พ็ใน ประช�กรที� สุำขีภั�พ็อ่อนแอ ร�ยละเอียด เพิ็�มัเติมัเกี�ยวักบัช่องว่ั�งในก�รวิัจัยัที� ได� จั�กขี�อแนะนำ�ฉบบัใหม่ันั�นค์�นห�ได�ใน ง�นวิัจัยัที�ตีพิ็มัพ็ ์(134) คำวามูต้่อังงานต่่อังานวิจััย่ ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 108 กิ�รัเลือกิใช้้ กิ�รัเผู้ยแพร่ั กิ�รัด็ำ�เนิืนืกิ�รั และกิ�รัปรัะเมินืผู้ล เป้�หมั�ยขีองขี�อแนะนำ�เหล่�นี�ค่์อ เพ่็�อจัดัห�ให�ผู้้�ร่�งนโยบ�ย และผู้้�พ็ฒัน� แทรกแซงในก�รด้แลสุำขีภั�พ็ ก�รศก่ษ� สำ ถ � น ที� ทำ � ง � น แ ล ะ ชุ มั ช น ด� วั ย ค์ำ�แนะนำ�ว่ั�ด�วัยเร่�องเด็ก วัยัรุ่น ผู้้�ใหญ่่ และผู้้�ส้ำงอ�ยุค์วัรใช�เวัล�เท่�ไร ในแต่ละวันั ในก�รทำ�กิจักรรมัท�งก�ย และขี�อแนะนำ� ในก�รจัำ�กดัเวัล�ขีองพ็ฤติกรรมัเน่อยนิ�ง อย่�งไรก็ต�มั ก�รพ็ัฒน�ขี�อแนะนำ� ระดับโลกนี�ยังไม่ัจับสิำ�นในตัวัมัันเอง ห�กไม่ัมีัก�รเผู้ยแพ็ร่และนำ�ไปใช� ก�ร เปลี�ยนแปลงระดบัก�รทำ�กิจักรรมัท�ง- ก�ยก็จัะไม่ัเป็นผู้ล กิ�รัเลือกิใช้้ องค์ก์�รอน�มัยัโลกนำ�เอ�กระบวัน ก�รที�แม่ันยำ�และค์รอบค์ลุมัเป็นวังกวั� ง มั � พ็ัฒ น� ขี�อ แน ะ นำ � ที� เ กี� ย วั ขี�อ ง ใน ระดบัโลก (21) เพ่็�อใช�โดยน�น�ประเทศ ขี�อแนะนำ�เกี�ยวักบักิจักรรมัท�งก�ยและ พ็ฤติกรรมัเน่อยนิ�ง สำร� งขี�อแนะนำ�ที�มั� จั�กหลักฐ�นเกี� ยวักับผู้ลกระทบต่อ สุำขีภั�พ็ขีองก�รทำ�กิจักรรมัท�งก�ยและ พ็ฤติกรรมัเน่อยนิ�ง ที�รฐับ�ลระดบัช�ติ สำ�มั�รถเล่อกนำ�ไปใช�เป็นส่ำวันหน่�งขีอง กรอบนโยบ�ยแห่งช�ติเหล่�นั�น โดยส่ำวัน ใหญ่่แล�วั ก�รพ็ฒัน�ขี�อแนะนำ�ระดบัโลก พ็ร�อมัด�วัยก�รให�ค์ำ�ปรก่ษ�อย่�งละเอียด ค์วัรจัะขีจััดค์วั�มัจัำ � เ ป็นขีองแต่ละ ประเทศที�จัะใช�ทรพั็ย�กรเพ่็�อดำ�เนินกระ บวันก�รท�งวิัทย�ศ�สำตรอ์ันย�วัน�น ออกไป ก�รทบทวันและก�รเล่อกขี�อ แนะนำ�สำ�กลด� นกิจักรรมัท�งก�ยและ พ็ฤติกรรมัเน่อยนิ�งนี�ไปใช� นำ�มั�ซ่�งวิัธีิก�ร ที�รวัดเร็วัและคุ์�มัค่์�ในก�รพ็ฒัน�ขี�อแนะ- นำ�ที�ปรบัไปต�มับริบทท�องถิ�น ก�รเล่อกใช�ขี�อแนะนำ�ขีององค์ก์�ร อน�มัยัโลกในระดบัภ้ัมิัภั�ค์หร่อระดบั ช�ติจัะทำ�ให�มัั�นใจัได�ว่ั�ประเทศเหล่�นั�น จัะจัดัห�ขี�อแนะนำ�ในก�รทำ�กิจักรรมัท�ง ก�ยและพ็ฤติกรรมัเน่อยนิ�งที�ค์งที� ซ่�งได� รบัมั�จั�กหลกัฐ�นท�งวิัทย�ศ�สำตรที์� ดี ที� สุำดและทนัสำมัยัที� สุำดที�ห�ได� นอกจั�กนี� ค์วั�มัค์งที�ขีองขี�อแนะนำ�ในหล�ยประเทศ จัะอำ�นวัยค์วั�มัสำะดวักต่อก�รด้แล ระดบัประเทศ ก�รประเมิันกิจักรรมัท�ง ก�ยและพ็ฤติกรรมัเน่อยนิ�งในระดบัโลก และก�รเปรียบเทียบขี� มัประเทศ ค์วัรมีั ก�รพิ็จั�รณิ�ค์วั�มัต�องก�รในก�รปรบั ขี�อแนะนำ�ต�มับริบทและปรบัให�เหมั�ะ- สำมัตลอดกระบวันก�รนำ�มั�ใช� ก�รแปล เป็นภั�ษ�ท�องถิ� นเป็นองค์์ประกอบ หน่�งขีองก�รนำ�มั�ใช�และก�รปรบัต�มั ปริบท อ�จัจัำ�เป็นต�องมีัก�รเปลี�ยนตวัั อย่�งขีองกิจักรรมัท�งก�ยให�เกี�ยวัเน่�อง กบัท�องถิ�นและใช�ร้ปภั�พ็ที�ปรบัให�สำะท�อน วัฒันธิรรมั ธิรรมัเนียมั และค่์�นิยมัท�องถิ�น 109 กรอบแนวัท�งแบบขีั�นต่อขีั�นเพ่็�อรองรบั ก�รนำ �ขี�อแนะนำ �ระดับโลกไป ใช� ใน ประเทศยงัค์งพ็ฒัน�อย่้ ต�มัด�วัยชุดก�ร ประชุมัปฏิิบติัก�รกบัผู้้�มีัส่ำวันเกี�ยวัขี�อง กรอบค์วั�มัคิ์ดนี� อ�จัสำร� งขี่ �นด�วัยขี�อม้ัล ระดบัประเทศที� เกี�ยวัขี�อง (ตวััอย่�งเช่น ก�รประเมิันค์วั�มัชุกขีองกิจักรรมั ท�งก�ย) และจัะทำ�ให� มีัก�รเขี� ถ่ง ก�รพ็ัฒน�เอกสำ�รขี�อแนะนำ�ระดับ ช�ติอย่�งรวัดเร็วั แหล่งขี�อม้ัลสำนบัสำนุน นี�จัะพ็ร�อมัใช�ง�นใน พ็.ศ. 2564 บน เว็ับไซตข์ีององค์ก์�รอน�มัยัโลก เมืั�อพิจ�รณ�ก�รนำ�ข้อ้แนะนำ�มั�ปฏิิบติัิ มีัข้อ้แนะนำ�ให้ ใช้ก้ระบวนก�ร 10 ข้ ั�นติอน ดงัต่ิอไปนี �: 1. สำนับสำนุนให�มีัก�รทบทวันขี�อแนะนำ� ระดับช�ติฉบับปัจัจุับันว่ั�ด�วัยกิจั- กรรมัท�งก�ยและก�รนำ�ขี�อแนะนำ� ขีององค์ก์�รอน�มัยัโลกมั�ใช� เพ่็�อให� ได�มั�ซ่�งค์ำ�อนุญ่�ตจั�กรฐับ�ล 2. ให�ผู้้�มีัส่ำวันเกี� ยวัขี�องหลกัทั�งในภั�ค์ สุำขีภั�พ็และภั�ค์ส่ำวันอ่�นๆที� เกี�ยวัขี�อง เช่น กีฬ� ก�รศ่กษ� ก�รค์มัน�ค์มั มีัส่ำวันร่วัมั และให�มีัสำมั�ค์มัอ�ชีพ็ต่�ง ๆ ที�เกี�ยวัขี�องและนกัวิัทย�ศ�สำตรต่์�ง ๆ ผู้้�มีัค์วั�มัเชี�ยวัช�ญ่ต�มัหวััขี�อ 3. ประเมิันก�รใช�ประโยชน ์ ค์วั�มัเป็นที� ยอมัรับ และค์วั�มัเป็นไป ได�ขีอง ค์ำ�แนะนำ� 4. ปรบัขี�อแนะนำ�ต�มับริบทขีองท�องถิ�น รวัมัถง่ภั�ษ� ตวััอย่�ง และขี�อค์วัรค์ำ�น่ง ด� นวัฒันธิรรมัต่�ง ๆ 5. จััดทำ�บทปริทัศน์ภั�ยนอกกับผู้้�ใช� กลุ่มัเป้�หมั�ย รวัมัถง่ผู้้�ร่�งนโยบ�ย นกัปฎิบติั และสำ�ธิ�รณิชนทั�วัไป 6. จััดสำรรงบประมั�ณิและจััดเตรียมั แผู้นในก�รเผู้ยแพ็ร่และก�รส่ำ�อสำ�ร 7. เผู้ยแพ็ร่และส่ำงเสำริมัขี�อแนะนำ�ระดบั ช�ติ อย่�งสำมับ้รณิแ์บบ โดยค์วับค่้์ไป กบัง�นเปิดตวััเพ่็�อประช�สำมััพ็นัธิแ์ละ ค์วั�มัสำนใจั 8. มีัส่ำวันร่วัมักบัหน่วัยง�นวิัช�ชีพ็หร่อ องค์์กรที� เ กี� ยวัขี�องและสำนับสำนุน ก�รวั�งแผู้นนโยบ�ย และ/หร่อก�ร รบัรองผู้ล 9. ก�รนำ�นโยบ�ยและแนวัปฏิิบติัระดบั ช�ติไปใช�เพ่็�อสำนบัสำนุนให�เกิดก�รนำ� ขี�อแนะนำ�ระดบัช�ติและก�รเปลี�ยน แปลงพ็ฤติกรรมัมั�ใช� 10. ตกลงกรอบเวัล�ขีองก�รประเมิัน ก�รทบทวัน และก�รปรบัปรุงขี�อแนะนำ� กิ�รัเผู้ยแพร่ั ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย ระดับช�ติเป็นองค์ป์ระกอบหลักขีอง โค์รงสำร� งธิรรมั�ภิับ�ล สำำ�หรบัแนวัท�ง เพ่็�อค์วั�มัเขี� ใจัที�จัะเพิ็�มัระดบักิจักรรมั ท�งก�ยขีองประช�กร ขี�อแนะนำ�แห่ง ช�ติชี�ถ่งก�รพ็ฒัน�และก�รจััดลำ�ดบั ค์วั�มัสำำ�ค์ัญ่ขีองก�รวั�งแผู้นกลยุทธิ ์ ระดบัช�ติและภั�ยในประเทศ และต�อง ก�รก�รเผู้ยแพ็ร่ขี�อม้ัลที� ถ้กต�องให�กบั กลุ่มัค์นที�เกี�ยวัขี�องในแนวัท�งที�เหมั�ะสำมั เป็นที� น่�เสีำยด�ยที� บ่อยค์รั�งขี�อแนะนำ� ระดบัช�ติไม่ัได�ถ้กเผู้ยแพ็ร่ ดงันั�น ค์วั�มั ตระหนกัร้�ถง่ขี�อแนะนำ�ทั�งในหม่้ัผู้้�เชี�ยวั- ช�ญ่และชุมัชนที�กวั� งขี่ �นนั�น ยงัค์งอย่้ใน ระดับตำ� ก�รรักษ�แหล่งขี�อม้ัลเพ่็� อ รองรบัก�รเผู้ยแพ็ร่ในภั�พ็ที�กวั� งขี่ �นนั�น การเลือักใช้้ การเผย่แพร่ การดำำาเนินการ และการประเมิูนผล ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 110 เป็นก� วัแรกที�สำำ�ค์ญั่ที�จัะเปลี�ยนก�รตระ- หนักร้�และค์วั�มัร้�เกี�ยวักบัค์วั�มัสำำ�ค์ญั่ ขีองก�รเพิ็� มักิจักรรมัท�งก�ยและลด พ็ฤติกรรมัเน่อยนิ�ง ผ้เ้กี�ยวข้อ้งหลกัสำำ�หรบัก�รเผยแพร่ ข้อ้แนะนำ�แห่งช้�ติิ ว่�ดว้ยกิจกรรมั ท � ง ก � ย แ ล ะ พ ฤ ติิ ก ร ร มั เนื อ ย นิ� ง ประกอบไปดว้ย • ผู้้�ร่�งนโยบ�ยทั�งในและนอกภั�ค์ส่ำวัน ด� นสุำขีภั�พ็ (รวัมัทั�ง ค์มัน�ค์มั ก�รวั�งแผู้น ก�รศ่กษ� ที� ทำ�ง�น ก�รกีฬ� สำวันต่�ง ๆ และสำนัทน�ก�ร) เพ่็�อเพิ็�มั ก. ค์วั�มัร้�ขีองก�รสำนับสำนุนที�จัะ เพิ็�มักิจักรรมัท�งก�ยและลดพ็ฤติกรรมั เ น่ อ ย นิ� ง อ � จั ไ ม่ั ไ ด� ป รั บ ป รุ ง เ พี็ ย ง สุำขีภั�พ็เท่�นั�น แต่ยังรวัมัประเด็นที� แ ต ก ต่ � ง ห ล � ก ห ล � ย แ ต่ ท ว่ั � เ กี� ย วั เน่�องกนั รวัมัถง่ค์วั�มัเท่�เทียมัท�งเพ็ศ พ็ันธิกิจัด� นสิำทธิิมันุษยชน และก�ร พ็ฒัน�อย่�งยั�งย่น ขี. ก�รรวัมันโยบ�ยและโค์รงก�รว่ั� ด�วัยกิจักรรมัท�งก�ยและพ็ฤติกรรมั เน่อยนิ�งไวั�ในนโยบ�ยที�เกี�ยวัขี�องทั�งหมัด และ ค์. ก�รลงทุนในก�รดำ�เนินก�ร ระดับท�องถิ� นและระดับช�ติที� สำอด ประสำ�นกนั • ภั�ค์ส่ำวันที� ไม่ัใช่รฐั (รวัมัถง่องค์ก์รที� ไม่ัใช่รัฐบ�ล องค์ก์รด� นวิัช�ก�ร และก�รวิัจัยั ภั�ค์เอกชน รวัมัทั�งหน่วัย ง�นด� นส่ำ�อและกองทุนวิัจัยั) ที�จัะ ก. สำร� งค์วั�มัตระหนกัร้�ถง่ค์วั�มั สำำ�ค์ญั่ในก�รเพิ็�มักิจักรรมัท�งก�ยและ ลดพ็ฤติกรรมัเน่อยนิ�งในทุกช่วังอ�ยุ ขี. ส่ำงเสำริมัและทำ�ให�มัั�นใจัในก�รวั�ง นโยบ�ย และ ค์. เพิ็�มัค์วั�มัร่วัมัม่ัอและก�รลงทุน ในก�รนำ�นโยบ�ยไปใช�และก�รดำ�เนิน ก�รขีองท�องถิ�น • ผู้้�ป ฏิิ บัติ ง � นใน ภั� ค์ สุำ ขี ภั� พ็ แ ล ะ ภั�ค์ส่ำวันที� ไม่ัเกี� ยวัเน่� องกับสุำขีภั�พ็ (รวัมัถ่งกีฬ� ก�รศ่กษ� ค์มัน�ค์มั และก�รวั�งแผู้น) เพ่็�อเพิ็�มั ก. ค์วั�มัตระหนกัร้�และค์วั�มัร้�เกี�ยวั กบัแนวัปฏิิบติัระดบัช�ติว่ั�ด�วัยกิจักรรมั ท�งก�ยและพ็ฤติกรรมัเน่อยนิ�ง ขี. ค์วั�มัร้� ทกัษะ และค์วั�มัมัั�นใจัใน ก�รส่ำงเสำริมัให�มีัก�รเพิ็� มักิจักรรมัท�ง ก�ยและลดพ็ฤติกรรมัเน่อยนิ�ง และ ค์. ก�รผู้สำ�นก�รส่ำงเสำริมักิจักรรมั ท�งก�ยลงในก�รฝึึกฝึน อนัเป็นกิจัวัตัร เม่ั�อสำ�มั�รถทำ�ได� • สำ�ธิ�รณิชนทั�วัไปและประช�กรกลุ่มั ย่อยโดยเฉพ็�ะเจั�ะจัง เพ่็�อเพิ็�มั ก. ค์วั�มัตระหนกัร้�และค์วั�มัร้�เกี�ยวั กบัขี�อแนะนำ� ว่ั�ด�วัยกิจักรรมัท�งก�ย และพ็ฤติกรรมัเน่อยนิ�ง ขี. ค์วั�มัร้�ถ่งวิัธีิก�รที�จัะบรรลุขี�อ แนะนำ�ด� นกิจักรรมัท�งก�ยและพ็ฤติ- กรรมัเน่อยนิ�ง ค์. ค์วั�มัตั�งใจัและแรงจ้ังใจัในก�ร เพิ็�มักิจักรรมัท�งก�ยและลดพ็ฤติกรรมั เน่อยนิ�ง 111 กิ�รัรัณรังค์ำผู่้�นืกิ�รัสืำ� อสำ�รั ผู้้�มีัส่ำวันเกี� ยวัขี�องที� ต่�งกนัจัะได� ประโยชนจ์ั�กเร่�องร�วัที� ต่�งกนั ดงันั�น เพ่็� อจัะส่ำ� อสำ�รขี�อแนะนำ�ไปยังกลุ่มัผู้้� ฟัิงที�หล�กหล�ยได�อย่�งมีัประสิำทธิิภั�พ็ ค์วัรมีัก�รค์ำ�น่งถง่เน่�อห� ร้ปแบบ และช่อง ท�งก�รส่ำงสำ�รสำำ�หรับก�รส่ำ� อสำ�รขี�อ แนะนำ� ค์วัรรวัมัเอ�ก�รสำำ�รวัจัอุปสำรรค์ ในก�รทำ�กิจักรรมัท�งก�ย หร่อก�รรวัมั กิจักรรมัท�งก�ยไวั� ในนโยบ�ยและ ก�รปฏิิบัติรวัมัถ่งทดสำอบเน่�อห�และ ขี�อม้ัลกับกลุ่มับุค์ค์ลที� ต่�งกัน อันจัะ ช่วัยส่ำ�อใจัค์วั�มัสำำ�ค์ญั่ อีกทั�งร้ปแบบที� เหมั�ะสำมั และช่องท�งก�รส่ำ�อสำ�ร กลยุทธิ ์ ก�รส่ำ�อสำ�รที�เขี� ใจัได� จัะรวัมัเอ�ช่วังขีอง ก�รส่ำ� อสำ�รที� มุ่ังไปยงักลุ่มัผู้้�ฟัิงที� แตก ต่�งกนั หล�ยประเทศอ�จัให�ค์วั�มัลำ�ดบั ค์วั�มัสำำ�ค์ัญ่กับกลุ่มัเฉพ็�ะขี่ �นอย่้กับ ทรพั็ย�กรที�มีัอย่้ (ผู้้�ค์นและก�รค์ลงั) ก�รรณิรงค์ผ่์ู้�นก�รส่ำ�อสำ�ร ว่ั�ด�วัย ก�รทำ�กิจักรรมัท�งก�ยที�มีัเป้�หมั�ยเป็น สำ�ธิ�รณิชนทั�วัไปหร่อประช�กรกลุ่มัย่อย ที� เฉพ็�ะเจั�ะจังเป็นก�รแทรกแซงที� คุ์�มั ค่์�ใช�จ่ั�ย (133) และได�รบัก�รแนะนำ�ไวั�ใน ขี�อแนะนำ�ระดบัโลกด� นกิจักรรมัท�งก�ย ขีององค์ก์�รอน�มัยัโลก พ็.ศ. 2561- 2573 (14) ก�รรณิรงค์เ์ร่� องกิจักรรมั ท�งก�ยระดบัประเทศและภั�ยในประเทศ นั�น ค์วัรสำร� งค์ำ�ขีวัญั่ในก�รรณิรงค์ที์� ค์รอบค์ลุมั (ตวััอย่�งเช่น “จังกระฉับ กระเฉง” หร่อ “เค์ล่�อนไปให�มั�กขี่ �น”) และพ็ฒัน�องค์ป์ระกอบในก�รออกแบบ หร่อตัวัละค์รที� อ�จัจัะรวัมัขี�อค์วั�มัที� ปรบัแต่งสำำ�หรบักลุ่มัผู้้�รบัสำ�รที�หล�ก- หล�ย (ตัวัอย่�งเช่น เด็กเล็ก วััยรุ่น ผู้้� ใหญ่่หร่อผู้้� ส้ำงอ�ยุ ผู้้� ที� ไ ม่ั ค่์อย ได� เค์ล่�อนไหวั ผู้้�ที� มีัภั�วัะทุพ็พ็ลภั�พ็หร่อ ภั�วัะเร่ �อรงั) ขี�อค์วั�มัและแหล่งขี�อม้ัล ในก�รรณิรงค์์ที� ปรับให� เขี� กับกลุ่มั ประช�กรเฉพ็�ะนั�น อ�จัจัะมีัประสิำทธิิภั�พ็ มั�กกว่ั�ขี�อค์วั�มัทั�วั ๆ ไป ก�รรณิรงค์ ์ ผู่้�นก�รส่ำ�อสำ�รค์วัรพิ็จั�รณิ�ก�รเขี� ถง่ และประสิำทธิิผู้ลขีองช่องท�งส่ำ� อแบบ ดั�งเดิมั (เช่น โทรทศัน ์วิัทยุ ป้�ยประก�ศ สิำ� งตีพิ็มัพ็์) และช่องท�งก�รส่ำ� อสำ�ร แบบดิจิัทัล (เว็ับไซต ์ โทรศัพ็ทม่์ัอถ่อ แอปพ็ลิเค์ชั�นต่�ง ๆ) ก�รให�ขี�อม้ัลเร่�อง ขี�อแนะนำ�ระดบัช�ติในร้ปแบบที�หล�ก- หล�ยนั�นมีัประโยชนม์ั�ก ตวััอย่�งเช่น แนวัท�งที� ด้ใหม่ัแต่มีัค์วั�มัเกี�ยวัเน่�องกนั อย่�งมั�กกบัก�รส่ำ�อสำ�รขี�อแนะนำ�ในก�ร ทำ�กิจักรรมัท�งก�ย ค่์อ ก�รใช�แผู้นภั�พ็ อินโฟิกร�ฟิฟิิค์หร่อวิัดีโอภั�พ็เค์ล่�อนไหวั ขีน�ดสำั�น องค์ก์�รอน�มััยโลกมีัวััตถุ สำนับสำนุนก�รพ็ัฒน�และก�รนำ�ก�ร รณิรงค์ผ่์ู้�นก�รส่ำ�อสำ�รในร้ปแบบเหล่�นี� ไปใช� (135) ชุมัชนวิัช�ก�รและก�รวิัจัยัให�ค์วั�มั สำนใจักบัร�ยง�นท�งวิัทย�ศ�สำตร ์ ซ่�งให� ร�ยละเอียดหลกัฐ�นด� นระบ�ดวิัทย� ซ่� งเป็นไปต�มัขี�อแนะนำ� อย่�งไรก็ดี ร�ยละเอียดที�เฉพ็�ะเจั�ะจังขีองก�รวิัจัยั อ�จัไม่ัเป็นที�สำนใจัขีองผู้้�ชมัทั�วัไป ผู้้�กำ�หนด นโยบ�ยอ�จันิยมัก�รสำรุปท�งวิัทย�- ศ�สำตรห์ร่อกระทั� งเอกสำ�รย่อแบบสำั�น ผู้้�ชมัอ่�น ๆ เช่น บุค์ค์ล�กรด� นสุำขีภั�พ็ หร่อนอกจั�กนั�น อ�จันิยมัแหล่งขี�อม้ัลที�มีั ชนิดต่�ง ๆ กนั ตวััอย่�งเช่น แผู่้นพ็บัหร่อ เอกสำ�รร�ยง�นขี�อเท็จัจัริงเกี�ยวักบัขี�อ การเลือักใช้้ การเผย่แพร่ การดำำาเนินการ และการประเมิูนผล ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 112 แนะนำ� หร่อวิัธีิก�รรวัมัเอ�ก�รส่ำงเสำริมั กิจักรรมัท�งก�ยเขี� กบักิจักรรมัอนัเป็น กิจัวัตัร (ตวััอย่�งเช่น ในก�รให�ค์ำ�ปรก่ษ� แก่ผู้้�ป่วัยในสำภั�พ็แวัดล�อมัขีองก�รด้แล สุำขีภั�พ็ หร่อก�รพ็ฒัน�ตก่อ�ค์�ร หร่อ แผู้นก�รค์มัน�ค์มัในสำภั�พ็แวัดล�อมัขีอง เม่ัอง) ผู้้�ค์นในสำ�ขี�อ�ชีพ็ที� ต่�งกนัต�อง ก�รแหล่งขี�อม้ัลที�ปรบัต�มับทบ�ทขีอง ผู้้�นั�น โดยเฉพ็�ะอย่�งยิ�ง บุค์ค์ล�กรด� น สุำขีภั�พ็อ�จัได�รบัประโยชนจ์ั�กชุดขี�อม้ัล ที� สำะท�อนถ่งกลุ่มัประช�กรที� แตกต่�ง หล�กหล�ยที�พ็วักเขี�ทำ�ง�นด�วัยอย่้ กิ�รันืำ�นืโยบ�ย และโคำรังกิ�รัไปใช้้ ขี�อแนะนำ�แห่งช�ติว่ั�ด�วัยกิจักรรมั ท�งก�ยและพ็ฤติกรรมัเน่อยนิ�งแต่เพี็ยง ลำ�พ็ังนั�นอ�จัไม่ันำ�ไปส่้ำก�รเพิ็� มัระดับ กิจักรรมัท�งก�ยขีองประช�กร ดงันั�น จัง่ ค์วัรมัองว่ั�เป็นส่ำวันหน่�งขีองนโยบ�ยและ กรอบก�รวั�งแผู้น ก�รจัะเผู้ยแพ็ร่ขี�อ แนะนำ�แห่งช�ติไปยงัผู้้�รบัสำ�รกลุ่มัหลกั และก�รสำนบัสำนุนโดยกลยุทธิชุ์มัชนระดบั ประเทศที�เอ่ �อต่อกนัเป็นเร่�องที�สำำ�ค์ญั่ ซ่�ง จัะนำ�ไปส่้ำก�รตระหนกัร้�และค์วั�มัร้�ที�เพิ็�มั มั�กขี่ �น เกี�ยวักบัประโยชนอ์นัหล�กหล�ย จั�กก�รทำ�กิจักรรมัท�งก�ยเป็นประจัำ� และก�รลดพ็ฤติกรรมัเน่อยนิ�ง อย่�งไร ก็ต�มั เพ่็�อที�จัะเปลี�ยนแปลงพ็ฤติกรรมั อย่�งยั�งย่น ก�รกระทำ�เหล่�นี�ค์วัรได�รบั ก�รสำนับสำนุนโดยนโยบ�ยที� สำร� งสิำ� ง แวัดล�อมัที� เป็นใจัอนัก่อให�หร่อกระตุ�น ให� ผู้้�ค์นไม่ัอย่้เฉย และเพิ็� มัโอก�สำใน ท�องถิ�นที�เหมั�ะสำมัให�ผู้้�ค์นเขี� ร่วัมัทำ�กิจั- กรรมัท�งก�ย นโยบ�ยและร�ยก�รต่�ง ๆ จัะต�องพิ็จั�รณิ�และสำ�มั�รถปรบัให�เขี� กบับริบทท�องถิ�นได� ทั�งในเร่�องขีองระบบ สุำขีภั�พ็และสำถ�บนัเชิงซ�อนต่�ง ๆ ที� มีั หล�ยภั�ค์ส่ำวัน ซ่�งสำนใจัหร่อมีัโอก�สำที� จัะสำนับสำนุนก�รส่ำงเสำริมักิจักรรมัท�ง ก�ย ค์วัรมีัก�รดำ�เนินก�รโดยใช�แนวัท�ง “ก�รบ้รณิ�ก�รก�รทำ�ง�นขีองหน่วัย ง�นภั�ค์รฐัให�เป็นไปในทิศท�งเดียวักนั” และพิ็จั�รณิ� “ระบบ” ขีองนโยบ�ยและ ก�รกระทำ�หล�ยประก�รที� สำ�มั�รถ สำนับสำนุนผู้้�ค์นจัำ�นวันมั�กให�มีัก�รทำ� กิจักรรมัท�งก�ย ผู่้�นก�รมีัส่ำวันร่วัมัขีอง ผู้้�มีัส่ำวันเกี�ยวัขี�องมั�กมั�ยที�ค์รอบค์ลุมั ภั�ค์ส่ำวันและสำภั�พ็แวัดล�อมัที� หล�ก หล�ย ก�รใช�แนวัท�งด� น “ระบบ” ซ่�งเป็น ไปต�มักลยุทธิก์�รส่ำ�อสำ�รอย่�งยั�งย่นนั�น ทำ�ให�มัั� นใจัได�ว่ั�อุปสำงค์์ในก�รทำ�กิจั- กรรมัท�งก�ยที�เพิ็�มัส้ำงขี่ �นจั�กก�รส่ำ�อสำ�ร ที�สำมััฤทธิิ �ผู้ลนั�น เขี� ค่้์กบัก�รจัดัห�สำภั�พ็- แวัดล�อมัและ โอก�สำให� ผู้้�ค์นมีัค์วั�มั กระฉบักระเฉงมั�กยิ�งขี่ �น ขี�อแนะนำ�ระดบัโลกด� นกิจักรรมั ท�งก�ยขีององค์ก์�รอน�มัยัโลก พ็.ศ. 2561-2573 ตั�งเป้�ที�จัะลดกิจักรรมัท�ง ก�ยที� ไม่ัเพี็ยงพ็อลงร�อยละ 15 ภั�ยใน พ็.ศ. 2573 และสำรุปก�รดำ�เนินก�รต�มั นโยบ�ยและก�รแทรกแซงที�แนะนำ� 20 ประก�ร (14) รวัมัถ่งก�รแนะนำ�ให�ทุก ประเทศนำ�ก�รศ่กษ�สำ�ธิ�รณิะระดบั ช�ติที�ยั�งย่น และก�รรณิรงค์ส์ำร� งค์วั�มั ตระหนกัร้� ตลอดจันก�รรวัมัเอ�ร�ยก�ร ก�รให�ค์ำ�ปร่กษ�ด� นกิจักรรมัท�งก�ย เขี� ไปใช�ร่วัมักบัก�รด้แลสุำขีภั�พ็ขีั�นต�น และขีั�นทุติยภ้ัมิั ขี�อแนะนำ�อ่�น ๆ นั�นรวัมัถ่ งก�รสำร� งสำภั�พ็แวัดล�อมัที�เหมั�ะสำมัสำำ�- หรับก�รทำ�กิจักรรมัท�งก�ยรวัมัถ่ง 113 ก�รเดิน ก�รปั� นจักัรย�นและก�รเค์ล่�อนที� ด�วัยล�อ สำำ�หรบักลุ่มัประช�กรทุกกลุ่มั และก�รสำร� งโอก�สำและร�ยก�รที�มั�ก ขี่ �นให�มีัก�รทำ�กิจักรรมัท�งก�ยในโรง- เรียน ที�ทำ�ง�น สำโมัสำรกีฬ� และสำถ�นที�พ็บ- ปะก�รนำ�ขี�อแนะนำ�ทั�ง 20 ประก�รไปใช� อ�จัเป็นไป ได�ย�กในระยะสำั�นในทุก ประเทศ และค์วัรมัองเป็นเป้�หมั�ย ระยะย�วั เพ่็�อแยกแยะระหว่ั�งก�รกระทำ� ที�ทำ�ได�ทนัทีอนัมีัค์วั�มัเหมั�ะสำมัและเป็น ไปได� ประเทศสำมั�ชิกขีององค์ก์�รอน�- มััยโลกค์วัรวิัเค์ร�ะห์สำถ�นก�รณิข์ีอง นโยบ�ยและขี�อแนะนำ�ปัจัจุับนั สิำ� งนี�จัะ ช่วัยสำร� งค์วั�มัร่วัมัม่ัอหล�ยภั�ค์ส่ำวันและ ช่วัยบ่งชี�จุัดแข็ีง ตลอดจันช่องว่ั�ง และ โอก�สำที�อ�จัใช�เป็นพ่็�นฐ�นในก�รพ็ฒัน� หร่อปรับปรุงแผู้นระดบัช�ติและแผู้น ภั�ยในช�ติได� ขี�อแนะนำ�ขีององค์ก์�รอน�มัยัโลก ฉบบัใหม่ันี� สำนบัสำนุนก�รขีย�ยขีอบเขีต ขีองก�รปฏิิบติัที�ค์รอบค์ลุมักลุ่มัเพิ็�มัเติมั เช่น ผู้้�มีัภั�วัะทุพ็พ็ลภั�พ็หร่อมีัโรค์เร่�อรงั และหญิ่งมีัค์รรภัห์ร่อมั�รด�หลงัค์ลอด นโยบ�ยค์วัรสำนบัสำนุนก�รนำ�ส่ำงร�ยก�ร ที�เหมั�ะสำมัและขี�อแนะนำ�ที�ตระหนกัร้�ถง่ ค์วั�มัต�องก�รขีองชุมัชน ค์วั�มัหล�ก หล�ยขีองกลุ่มัค์น และสำภั�พ็แวัดล�อมั ชุดเค์ร่�องม่ัอเฉพ็�ะภั�ค์ส่ำวันยงัอย่้ในช่วัง พ็ฒัน�เพ่็�อรองรบัก�รนำ�ชุดเค์ร่� องม่ัอ ท�งเทค์นิค์ต�มัแนวัท�ง ACTIVE ไปใช� (135) ซ่�งจัะนำ�ค์ำ�แนะแนวัในก�รส่ำงเสำริมั กิจักรรมัท�งก�ยให�แก่ทุกภั�ค์ส่ำวัน ตัวัอย่�งเช่น ในโรงเรียน ผู่้�นก�ร ด้แลสุำขีภั�พ็เบ่ �องต�น หร่อโดยก�รปรบั- ปรุงก�รจัดัห�พ่็�นที�สำำ�หรบัก�รเดินและ ก�รปั� นจักัรย�น ชุดเค์ร่�องม่ัอต�มัแนวั- ท�ง ACTIVE รวัมัถง่ทรพั็ย�กรขีององค์-์ ก�รอน�มััยโลกในระดับภ้ัมิัภั�ค์หร่อ ระดบัช�ติ จัะสำนบัสำนุนก�รนำ�ขี�อแนะนำ� ขีองกิจักรรมัท�งก�ยและพ็ฤติกรรมั เน่อยนิ�งนี�ไปใช� กิ�รัติรัวัจติรั� และกิ�รัปรัะเมินื ขี�อแนะนำ�ระดบัโลกขีององค์ก์�ร- อน�มััยโลกด� นกิจักรรมัท�งก�ยเพ่็� อ สุำขีภั�พ็นั�น ใช�เป็นเกณิฑ์ม์ั�ตรฐ�นสำำ�หรบั ก�รด้แลและตรวัจัตร�สุำขีภั�พ็ประช�กร มั�ตั�งแต่ พ็.ศ. 2553 ก�รเปลี�ยนแปลง สำำ�หรบัขี�อแนะนำ�ฉบบัปรบัปรุงนี�อ�จัจัะ มีัก�รอ� งถ่งระบบก�รตรวัจัตร�และ เค์ร่�องม่ัอประเมิันที�ใช�อย่้ขีณิะนี� เพ่็�อด้แล กิจักรรมัท�งก�ยในระดบัช�ติ ก�รเผู้ย- แพ็ร่ขี�อแนะนำ�ใหม่ันี� จัะเรียกร�องให�มีัก�ร ทบทวันเค์ร่�องม่ัอที�ใช�ในปัจัจุับนัและร�ย ง�นร้ปแบบสำำ�หรบัก�รปรบัแก� และขี�อ แนะนำ�ในอน�ค์ตที�ร�ยง�นผู้ลตรงกนั ขี� มักบัขี�อแนะนำ�ใหม่ั จัะต�องทบทวันและ ปรบัปรุงในเค์ร่� องม่ัอต่�ง ๆ เช่น แบบ สำอบถ�มัเกี� ยวักบักิจักรรมัท�งก�ยใน ระดบัโลกและแบบสำำ�รวัจัสุำขีภั�พ็นัก- เรียนโลก ให�สำอดค์ล�องกบัขี�อแนะนำ�ใหม่ั เหล่�นี� แนวัท�งสำนับสำนุนสำำ�หรับทุก ประเทศจัะพ็ร�อมัใน พ็.ศ. 2564 แบบสำำ�รวัจัค์วั�มัสำ�มั�รถระดบั ประเทศด� นโรค์ไม่ัติดต่อเร่ �อรงัขีององค์ ์ ก�รอน�มัยัโลก (CCS) เป็นเค์ร่�องม่ัอหลกัที� ใช�ในก�รตรวัจัตร�ค์วั�มัค่์บหน� ระดบั โลก ในก�รนำ�นโยบ�ยเกี� ยวักบัโรค์ไม่ั ติดต่อเร่ �อรงัไปใช� และมีัก�รสำำ�รวัจัทุก ๆ สำองปี แบบสำำ�รวัจั CCS นั�นมีัค์ำ�ถ�มัที� การเลือักใช้้ การเผย่แพร่ การดำำาเนินการ และการประเมิูนผล ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 114 เฉพ็�ะเจั�ะจังไปยงัระบบก�รตรวัจัตร� กิจักรรมัท�งก�ยขีองประช�กรในแต่ละ กลุ่มัอ�ยุที�ค์รอบค์ลุมัโดยขี�อแนะนำ�ขีอง องค์ก์�รอน�มัยัโลกด� นกิจักรรมัท�ง- ก�ยและพ็ฤติกรรมัเน่อยนิ� ง และก�ร ตรวัจัตร�ขี�อแนะนำ�ด� นกิจักรรมัท�ง- ก�ยระดบัช�ติที� มีัอย่้ตั�งแต่พ็.ศ. 2562 ประเทศสำมั�ชิกขีององค์ก์�รอน�มัยัโลก ต�องนำ�เขี� เอกสำ�รเพ่็� อสำนับสำนุนก�ร ตอบก�รสำำ�รวัจันี� ในพ็.ศ. 2562 ประ- เทศสำมั�ชิกขีององค์ก์�รอน�มััยโลก จัำ�นวัน 78 ประเทศ (ร�อยละ 40) จั�กทั�งสิำ �น 194 ประเทศ ร�ยง�นว่ั� มีัขี�อแนะนำ�ด� น กิจักรรมัท�งก�ย (136) มีัก�รวิัเค์ร�ะห ์ เ อ ก สำ � ร โ ด ย ล ะ เ อี ย ด เ กี� ย วั กับ ก � ร ตอบแบบสำำ�รวัจั CCS ในพ็.ศ. 2562 และระบุว่ั�มีัเพี็ยง 2 ใน 3 จั�กประเทศ สำมั�ชิก 78 ประเทศที� มีัขี�อแนะ นำ � ระดบัช�ติ ได�แนบขี�อแถลงว่ั� ประช�กร ขีองตนค์วัรทำ�กิจักรรมัท�งก�ยเท่�ใด และจั�กกลุ่มันี� มีัเพี็ยง 42 ประเทศที�ทำ� ต�มัขี�อแนะนำ�ระดบัโลกขีององค์ก์�ร อน�มััยโลกด� นกิจักรรมัท�งก�ยเพ่็� อ สุำขีภั�พ็ประจัำ� พ็.ศ. 2553 อย่�งค์รบถ�วัน ขี�อม้ัลจั�ก พ็.ศ. 2564 และก�รสำำ�รวัจัที� จัะต�มัมั�จัะให�ขี�อม้ัลเกี� ยวักับก�รใช� ขี�อแนะนำ�ที�ปรบัปรุงแล�วั กิ�รัปรัับปรุังข้้อมูล จัะมีัก�รปรบัปรุงขี�อแนะนำ�นี�หลงั จั�ก 10 ปีไปแล�วั เวั�นแต่ว่ั�ค์วั�มัก� วัหน� ท�งวิัทย�ศ�สำตร์ในก�รประเมิันกิจักรรมั ท�งก�ยด�วัยเค์ร่� องม่ัอวััด และวิัทย�- ศ�สำตรเ์กี� ยวักับพ็ฤติกรรมัเน่อยนิ� งที� วิัวัฒัน�ก�รรุดหน� จัะกระตุ�นให�เกิดก�ร ปรบัปรุงขี�อม้ัลที�กระชั�นขี่ �น 115 รั�ยกิ�รัอ้�งอิง 1. 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Geneva: World Health Organization; 2020. ราย่การอ้ัางอิัง ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 124 125 ภาคผนวัก 1: MANAGEMENT OF GUIDELINE DEVELOPMENT PROCESS Contributors to guideline development Valentina Baltag Department of Maternal, Newborn, Child and Adolescent Health and Ageing – adolescent health Maurice Bucagu Department of Maternal, Newborn, Child and Adolescent Health and Ageing – pregnancy Fiona Bull Chairperson Department for Health Promotion – physical activity Alex Butchart Department of Social Determinants of Health – injury prevention Neerja Chowdhary Department of Noncommunicable Diseases – mental health/dementia Regina Guthold Department of Maternal, Newborn, Child and Adolescent Health and Ageing – adolescent surveillance WHO Steering Group The Steering Group included experts in the areas of physical activity, adolescent health, ageing disability, mental health, injury prevention, cancer, pregnancy and surveillance from both headquarters and regional offices. The Steering Group drafted the scope of the guidelines, and the PI/ECOs. They reviewed the declaration of interests; and drafted, reviewed and finalized the guidelines. Riitta-Maija Hämäläinen Western Pacific Regional Office Andre Ilbawi Department of Noncommunicable Diseases – cancer Wasiq Khan Eastern Mediterranean Regional Office Lindsay Lee Department of Noncommunicable Diseases – disability Alana Officer Ageing Leanne Riley Department for Noncommunicable Diseases – surveillance Gojka Roglic Department for Noncommunicable Diseases – diabetes Juana Willumsen Department for Health Promotion – physical activity ภิาคำผนวก 1 ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 126 Guideline Development Group (GDG) The Guideline Development Group consisted of a broad group of relevant experts in the field and end users of, and persons affected by, the recommendations. The members of the Guideline Development Group included: A first GDG meeting was held 2–4 July 2019, at which the GDG decided on the PI/ECO questions, reviewed the existing systematic reviews, and identified updates required. The Group agreed on the process for decision-making on recommendations and the strength of the evidence to be applied at the second GDG meeting. The second meeting was held 11–14 February 2020; updated evidence was reviewed and final recommendations agreed upon by consensus. Dr Salih Saad Al-Ansari (advocate in health promotion and education to combat NCDs through physical activity and walking); Dr Stuart Biddle (physical activity and sedentary behaviour, and behaviour change); Dr Katja Borodulin (physical activity in pregnancy and older adults); Dr Matthew Buman (sleep, sedentary behaviour, and physical activity in people living with chronic conditions); Dr Greet Cardon (physical activity in children and adolescents); Ms Catherine Carty (physical activity in people living with disability); Dr Jean-Philippe Chaput (sleep, sedentary behaviour and physical activity in children and adolescents); Dr Sebastien Chastin (physical activity, sedentary behaviour and health, objective measurement of physical activity and sedentary behaviour); Dr Paddy Dempsey (physical activity and sedentary behaviour in adults and people living with chronic conditions); Dr Loretta DiPietro (physical activity in pregnancy and older adults); Dr Ulf Ekelund (sedentary behaviour and physical activity, physical activity in children and adolescents); Dr Joseph Firth (physical activity and mental health); Dr Christine Friedenreich (physical activity in people living with chronic conditions, physical activity and cancer risk); Dr Leandro Garcia (physical activity and health in adults); Dr Muthoni Gichu (policy implementation, national government); Dr Russ Jago (physical activity in children and adolescents); Dr Peter Katzmarzyk (physical activity and sedentary behaviour); Dr Estelle V. Lambert (physical activity and obesity); Dr Michael Leitzmann (sedentary behaviour and physical activity in people living with chronic conditions); Dr Karen Milton (translating recommendations into practice); Dr Francisco B. Ortega (physical activity in children and adolescents, mental health and objective measurement); Dr Chathuranga Ranasinghe (promotion of physical activity and health in the community, workplace and school settings); Dr Emmanuel Stamatakis (physical activity and sedentary behaviour and multiple health outcomes in adults); Dr Anne Tiedemann (physical activity in older adults); Dr Richard Troiano (policy development); Dr Hidde van der Ploeg (physical activity and sedentary behaviour in adults); Ms Vicky Wari (policy implementation – national government); Dr Roger Chou (Pacific Northwest Evidencebased Practice Center and Professor of Medicine, Departments of Medicine, Medical Informatics and Clinical Epidemiology of the Oregon Health and Science University) served as GRADE methodologist. Further details of the GDG are available in Annex 2. 127ภิาคำผนวก 1 External Review Group (ERG) Seven peer reviewers were drawn from a list of individuals suggested by the GDG and Steering Group. They provided relevant expertise, including programme implementation and represented all six WHO regions. The ERG reviewed the draft guidelines and provided feedback to the Steering Group on issues of clarity and implementation, which was incorporated, as appropriate. External peer reviewers did not make changes to the recommendations. External peer reviewers are listed in Annex 2. Declarations of Interest All GDG members and external peer reviewers completed and submitted a WHO Declaration of Interests form and signed confidentiality undertakings prior to attending any GDG meetings. The Steering Group reviewed and assessed the submitted curriculum vitae and declarations of interest and performed an internet and publications search to identify any obvious public controversies or interests that may lead to compromising situations. The names and brief biographies of all proposed GDG members were published on the WHO Physical Activity webpage for public consultation for a period of 14 days. No comments were received. If additional guidance on management of any declaration or conflicts of interest had been required, the Steering Group would have consulted with colleagues in Office of Compliance, Risk Management and Ethics. If deemed necessary, individuals found to have conflicts of interest, financial or non-financial, would have been excluded from participation on any topics where interests were conflicting. The management of conflicts of interest was reviewed throughout the process. GDG members were required to update their Declaration of Interest, if necessary, before each meeting and a verbal declaration of interest was solicited at the beginning of each GDG meeting. Declared interests of the GDG and of the external peer reviewers are summarized in Annex 3. No conflict of interest was identified. Peer review The draft guidelines were reviewed by seven external peer reviewers identified by the GDG and Steering Group. External peer reviewers were requested to provide comments on issues of clarity, presentation of the evidence, and implementation; comments were incorporated as appropriate. External peer reviewers could not change the recommendations decided upon by the GDG. External peer reviewers are listed in Annex 2; a summary of declarations of interest are provided in Annex 3. In addition, inputs were actively sought from WHO regional offices. ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 128 ภาคผนวัก 2: GUIDELINE DEVELOPMENT GROUP, EXTERNAL PEER REVIEWERS, AND WHO STAFF INVOLVED IN THE DEVELOPMENT OF THESE GUIDELINES Guideline Development Group Dr Salih Al-Ansari Assistant Professor Family & Community Medicine Founder and CEO Health Promotion Center Riyadh SAUDI ARABIA Dr Stuart Biddle Professor of Physical Activity & Health Physically Active Lifestyles Research Group Centre for Health Research Institute for Resilient Regions University of Southern Queensland Springfield Central AUSTRALIA Dr Katja Borodulin The Age Institute Helsinki FINLAND Dr Matthew Buman College of Health Solutions Arizona State University Phoenix USA Dr Greet Cardon Department of Movement and Sports Sciences Faculty of Medicine and Health Sciences Ghent University Gent BELGIUM Ms Catherine Carty UNESCO Chair Project Manager Institute of Technology Tralee Co Kerry IRELAND Dr Jean-Philippe Chaput Senior Scientist, Healthy Active Living and Obesity (HALO) Research Group Children’s Hospital of Eastern Ontario (CHEO) Research Institute Department of Pediatrics University of Ottawa Ottawa, Ontario CANADA Dr Sebastien Chastin Professor of Health Behaviour Dynamics School of Health and Life Sciences Department of Psychology, Social Work and Allied Health Sciences Glasgow Caledonian University Glasgow UNITED KINGDOM Dr Roger Chou (GRADE Methodologist) Departments of Medicine, and Medical Informatics & Clinical Epidemiology Oregon Health & Science University Portland, Oregon USA Dr Paddy Dempsey MRC Epidemiology Unit University of Cambridge School of Clinical Medicine Institute of Metabolic Science Cambridge UNITED KINGDOM 129ภิาคำผนวก 2 Dr Loretta DiPietro Department of Exercise and Nutrition Sciences Milken Institute School of Public Health The George Washington University Washington, DC USA Dr Ulf Ekelund Department of Sport Medicine Norwegian School of Sport Science Oslo NORWAY Dr Joseph Firth Presidential Fellow School of Health Sciences University of Manchester Manchester UNITED KINGDOM Dr Christine Friedenreich Scientific Director Department of Cancer Epidemiology and Prevention Research Cancer Control Alberta Alberta Health Services Calgary CANADA Dr Leandro Garcia Research Associate Centre for Public Health Queen’s University Belfast Belfast UNITED KINGDOM Dr Muthoni Gichu Head Division of Geriatric Medicine Department of Non-Communicable Diseases Ministry of Health Nairobi KENYA Dr Russell Jago Professor of Paediatric Physical Activity & Public Health Centre for Exercise, Nutrition & Health Sciences School for Policy Studies University of Bristol Bristol UNITED KINGDOM Dr Peter T. Katzmarzyk Associate Executive Director for Population and Public Health Sciences Professor and Marie Edana Corcoran Endowed Chair in Pediatric Obesity and Diabetes Pennington Biomedical Research Center Baton Rouge USA Dr Estelle V. Lambert Director Research Centre for Health Through Physical Activity, Lifestyle and Sport University of Cape Town Cape Town SOUTH AFRICA Dr Michael Leitzmann Professor of Epidemiology Department of Epidemiology and Preventive Medicine University of Regensburg Regensburg GERMANY Dr Karen Milton Associate Professor in Public Health Norwich Medical School University of East Anglia Norwich UNITED KINGDOM Dr Francisco B. Ortega Head Unit of Physical Activity and Health Promotion Research Institute of Sport and Health (iMUDS) Department of Physical Education and Sports University of Granada Granada SPAIN ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 130 Dr Chathuranga Ranasinghe Chairperson NIROGI Lanka project Sri Lanka Medical Association Senior lecturer Sports and Exercise Medicine Unit Faculty of Medicine University of Colombo C Colombo SRI LANKA Dr Emmanuel Stamatakis Charles Perkins Centre Faculty of Medicine and Health School of Public Health University of Sydney Sydney AUSTRALIA Dr Anne Tiedemann Associate Professor Institute for Musculoskeletal Health School of Public Health Faculty of Medicine and Health University of Sydney Sydney AUSTRALIA Dr Richard Troiano Epidemiology and Genomics Research Program National Cancer Institute National Institutes of Health Rockville USA Dr Hidde van der Ploeg Associate Professor Department of Public and Occupational Health Amsterdam Public Health Research Institute Amsterdam University Medical Centres Amsterdam NETHERLANDS Ms Vicky Wari* Programme Manager, NCD National Department of Health Port Moresby PAPUA NEW GUINEA * unable to attend External review group Dr Kingsley Akinroye NCD Alliance Nigeria NIGERIA Dr Huda Alsiyabi Director Department of Community Based Initiatives Ministry of Health OMAN Dr Alberto Flórez-Pregonero Pontificia Universidad Javeriana COLOMBIA Dr Shigeru Inoue Department of Preventive Medicine and Public Health Tokyo Medical University JAPAN Dr Agus Mahendra Department of Physical education Universitas Pendidikan INDONESIA Dr Deborah Salvo Prevention Research Center in St. Louis Brown School Washington University USA Dr Jasper Schipperijn President-Elect 2020–2022 International Society of Physical Activity and Health Department of Sports Science and Clinical Biome- chanics University of Southern Denmark DENMARK 131ภิาคำผนวก 2 WHO Steering Group Dr Valentina Baltag Head Adolescent and Young Adult Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND Dr Maurice Bucagu Medical Officer Maternal Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND Dr Alexander Buchart Head Violence Prevention Social Determinants of Health Department WHO Headquarters Geneva SWITZERLAND Dr Fiona Bull Head Physical Activity Department of Health Promotion WHO Headquarters Geneva SWITZERLAND Dr Regina Guthold Scientist Adolescent and Young Adult Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND Dr Riitta-Maija Hämäläinen Technical Officer Noncommunicable Diseases and Health Promotion WHO Regional Office for the Western Pacific Manila PHILIPPINES Dr Andre Ilbawi Technical Officer Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Dr Wasiq Khan* Regional Adviser Health Education and Promotion WHO Regional Office for the Eastern Mediterranean Cairo EGYPT Ms Lindsay Lee Technical Officer Sensory Functions, Disability and Rehabilitation Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Ms Alana Officer Senior Health Adviser Healthy Ageing Office of the Director-General WHO Headquarters Geneva SWITZERLAND Ms Leanne Riley Head Surveillance Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Dr Gojka Roglic Medical Officer Noncommunicable Diseases Management Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Dr Juana Willumsen Technical Officer Physical Activity Department of Health Promotion WHO Headquarters Geneva SWITZERLAND * unable to attend ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 132 ภาคผนวัก 3: GUIDELINE DEVELOPMENT GROUP, EXTERNAL PEER REVIEWERS, AND WHO STAFF INVOLVED IN THE DEVELOPMENT OF THESE GUIDELINES Guideline Development Group members Name Gender Expertise Disclosure of interest Conflict of interest and management Dr Salih Saad Al-Ansari Male Advocate in health promotion and education to combat NCDs through physical activity and walking Owner and Chief Executive Officer of the Health Promotion Center No conflict of interest identified Dr Stuart Biddle Male Physical activity in youth Research funds and paid consultancy No conflict of interest identified Dr Katja Borodulin Female Physical activity in pregnancy Employment at National Institute for Health and Welfare and Age Institute; research funds No conflict of interest identified Dr Matthew Buman Male Sleep and physical activity in people living with chronic conditions None declared No conflict of interest identified Dr Greet Cardon Female Physical activity in youth None declared No conflict of interest identified Ms Catherine Carty Female Physical activity in people living with disability Research funds No conflict of interest identified Dr Jean-Philippe Chaput Male Sleep None declared No conflict of interest identified Dr Sebastien Chastin Male Physical activity and health, objective measurement of physical activity Research funds No conflict of interest identified Dr Paddy Dempsey Male Physical activity and sedentary behaviour in adults and people living with chronic conditions Employment and research funds No conflict of interest identified Dr Loretta DiPietro Female Physical activity in older adults None declared No conflict of interest identified Dr Ulf Ekelund Male Sedentary behaviour and physical activity in youth None declared No conflict of interest identified Dr Joseph Firth Male Physical activity and mental health None declared No conflict of interest identified Dr Christine Friedenreich Female Physical activity in people living with chronic conditions, physical activity and cancer risk None declared No conflict of interest identified Dr Leandro Garcia Male Physical activity and mental health Employment and paid consultancy No conflict of interest identified Dr Muthoni Gichu Female Policy implementation (national government) None declared No conflict of interest identified Dr Russ Jago Male Physical activity in youth None declared No conflict of interest identified 133 Name Gender Expertise Disclosure of interest Conflict of interest and management Dr Peter Katzmarzyk Male Physical activity and sedentary behaviour in youth Travel support to assist guideline committees No conflict of interest identified Dr Estelle V. Lambert Female Physical activity and obesity None declared No conflict of interest identified Dr Michael Leitzmann Male Sedentary behaviour and chronic conditions None declared No conflict of interest identified Dr Karen Milton Female Translating recommendations into practice Travel support to assist guideline committee No conflict of interest identified Dr Francisco Ortega Male Physical activity in youth, mental health and objective measurement None declared No conflict of interest identified Dr Chathuranga Ranasinghe Male Promotion of physical activity and health in the community, workplace and school settings Research funds No conflict of interest identified Dr Emmanuel Stamatakis Male Physical activity and multiple health outcomes in adults Grant for technology company for objective measurement of physical activity No conflict of interest identified Dr Anne Tiedemann Female Physical activity and health outcomes in older adults None declared No conflict of interest identified Dr Richard Troiano Male Policy development None declared No conflict of interest identified Dr Hidde van der Ploeg Male Physical activity, sedentary behaviour and health outcomes in adults Travel support to assist 2017 Dutch Physical Activity Guidelines committee and research funds No conflict of interest identified Ms Vicky Wari Female Policy implementation (national government) Shares (not relevant to guideline) No conflict of interest identified Name Gender Expertise Disclosure of interest Conflict of interest and management Kingsley Akinroye Male Advocacy, noncommunicable diseases None declared No conflict of interest identified Dr Huda Alsiyabi Female Policy and programme implementation None declared No conflict of interest identified Dr Alberto Flórez- Pregonero Male Physical activity and sedentary behaviour measurement and surveillance None declared No conflict of interest identified Dr Shigeru Inoue Male Epidemiology and physical activity promotion None declared No conflict of interest identified Dr Agus Mahendra Male Physical activity and movement skills in children None declared No conflict of interest identified Dr Deborah Salvo Female Health and social disparities, with a particular emphasis on chronic disease prevention None declared No conflict of interest identified Dr Jasper Schipperijn Male Physical activity and the built environment President-Elect of the International Society for Physical Activity and Health (ISPAH) No conflict of interest identified External peer reviewers ภิาคำผนวก 3 เอักสารแปลจัาก WHO Guidelines on physical activity and sedentary behaviour

ข้้อแนะนำ�ข้ององค์์ก�รอน�มััยโลก สำำ�หรัับกิิจกิรัรัมท�งกิ�ย และพฤติิกิรัรัมเนืือยนิื�ง WHO GUIDELINES ON PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOUR เอกิสำ�รัแปลจ�กิ WHO Guidelines on physical activity and sedentary behaviour

ข้้อแนะนำ�ข้ององค์์ก�รอน�มััยโลก สำำ�หรัับกิิจกิรัรัมท�งกิ�ย และพฤติิกิรัรัมเนืือยนิื�ง WHO GUIDELINES ON PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOUR เอกิสำ�รัแปลจ�กิ WHO Guidelines on physical activity and sedentary behaviour ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี ข้อ้แนะนำ�ข้ององค์ก์�รอน�มัยัโลกสำำ�หรบักิจกรรมัท�งก�ยและพฤติิกรรมัเนือยนิ�ง WHO GUIDELINES ON PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOUR ผู้้�เขีียน สำำ�นกัง�นใหญ่่องค์ก์�รอน�มัยัโลก ผู้้�แปล ณิิช�ภัทัร แสำงวัฒันะกุล เพ็็ญ่ลด� ไล�เลิศ ผู้้�เรียบเรียง เพ็็ญ่ลด� ไล�เลิศ บรรณิ�ธิิก�ร อรณิ� จันัทรศิริ ผู้้�ออกแบบ ศต�นนัท ์วังัทิพ็ย ์ พิ็ส้ำจันอ์กัษร เพ็็ญ่ลด� ไล�เลิศ พิ็มัพ็ค์์รั�งที� 1 เมัษ�ยน 2564 จัำ�นวัน 133 หน� จัำ�นวันที�พิ็มัพ็ ์ 500 เล่มั จัดัทำ�โดย กองกิจักรรมัท�งก�ยเพ่็�อสุำขีภั�พ็ อ�ค์�ร 7 ชั�น 7 กรมัอน�มัยั กระทรวังสำ�ธิ�รณิสุำขี ตำ�บลตล�ดขีวัญั่ อำ�เภัอเม่ัอง จังัหวัดันนทบุรี 11000 โทรศพั็ท ์ 02-5904585-6 โทรสำ�ร 02-5904584 อีเมัล plan.ex@anamai.mail.go.th เว็ับไซต ์ https://dopah.anamai.moph.go.th/ โรงพิ็มัพ็ ์ บริษทั เดอะ กร�ฟิิโก ซิสำเต็มัสำ ์จัำ�กดั 119/138 เดอะ เทอรเ์รสำ ซอยติวั�นนท ์3 ถนนติวั�นนท ์ตำ�บลตล�ดขีวัญั่ อำ�เภัอเม่ัอง จังัหวัดันนทบุรี 11000 โทรศพั็ท ์ 02-5251121, 02-5254669-70 โทรสำ�ร 02-5251272 อีเมัล thegraphicosys@gmail.com สำนบัสำนุนโดย กองกิจักรรมัท�งก�ยเพ่็�อสุำขีภั�พ็ กรมัอน�มัยั สำำ�นกัง�นกองทุนสำนบัสำนุนก�รสำร� งเสำริมัสุำขีภั�พ็ (สำสำสำ.) ม้ัลนิธิิเพ่็�อก�รพ็ฒัน�นโยบ�ยสุำขีภั�พ็ระหว่ั�งประเทศ ISBN 978-616-11-4600-9 © พิมัพ ์เผยแพร่ และสำงวนลิข้สิำทธิิ์ �โดยกองกิจกรรมัท�งก�ยเพื�อสุำข้ภ�พ 2564 หนังส่ำอแปลฉบับนี�ไม่ัได�จััดทำ�โดยองค์ก์�รอน�มััยโลก (the World Health Organization (WHO) องค์ก์�รอน�มัยัโลกไม่ัมีัส่ำวันรบัผิู้ดชอบค์วั�มัถ้กต�องขีองหนงัส่ำอแปลฉบบันี� ผู้้�อำ�นวัยก�รองค์ก์�รอน�มัยัโลก สำำ�นกัง�นใหญ่่ มัอบลิขีสิำทธิิ �ก�รแปลและตีพิ็มัพ็เ์ป็นภั�ษ�ไทยแก่กองกิจักรรมัท�งก�ยเพ่็�อสุำขีภั�พ็อย่�ง ถ้กต�องต�มักฎหมั�ย ห� มัลอกเลียนแบบหร่อทำ�ซำ � ส่ำวันใดส่ำวันหน่�งขีองหนงัส่ำอเพ่็�อวัตัถุประสำงค์เ์ชิงพ็�ณิิชย ์ โดยไม่ัได�รบัอนุญ่�ต ยกเวั�นเพ่็�อใช�ประกอบก�รศก่ษ�หร่อก�รค์�นค์วั� ท�งวิัช�ก�รเท่�นั�น The original English edition WHO Guidelines on Physical Activity and Sedentary Behaviour. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO shall be the binding and authentic edition. หนงัส่ำอแปลฉบบันี�เผู้ยแพ็ร่ภั�ยใต� CC BY-NC-SA 3.0 iACKNOWLEDGEMENT ii อกัษรย่อและค์ำ�ย่อ iii อภิัธิ�นศพั็ท ์ iv ข้อ้สำรุป 1 ค์ว�มัเป็นมั� 17 ระเบียบวิธีิ์ 22 ข้อ้แนะนำ� 34 > เด็กและวยัรุ่น (อ�ยุ 5-17 ปี) 35 ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย 35 ขี�อแนะนำ�ด� นพ็ฤติกรรมัเน่อยนิ�ง 41 > ผ้ ใ้หญ่่ (อ�ยุ 18–64 ปี) 46 ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย 46 ขี�อแนะนำ�ด� นพ็ฤติกรรมัเน่อยนิ�ง 57 > ผ้ส้้ำงอ�ยุ (อ�ยุ 65 ปีข้้ �นไป) 66 ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย 66 ขี�อแนะนำ�ด� นพ็ฤติกรรมัเน่อยนิ�ง 71 > สำติรีมีัค์รรภแ์ละมั�รด�หลงัค์ลอด 72 ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย 72 ขี�อแนะนำ�ด� นพ็ฤติกรรมัเน่อยนิ�ง 78 > ผ้ ใ้หญ่่และผ้ส้้ำงอ�ยุที�มีัภ�วะเรื �อรงั (อ�ยุ 18 ปีข้้ �นไป) 79 ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย 79 ขี�อแนะนำ�ด� นพ็ฤติกรรมัเน่อยนิ�ง 90 > เด็กและวยัรุ่น (อ�ยุ 5–17 ปี) และผ้ ใ้หญ่่ (อ�ยุ 18 ปีข้้ �นไป) ที�มีัภ�วะทุพพลภ�พ 92 ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย 92 ขี�อแนะนำ�ด� นพ็ฤติกรรมัเน่อยนิ�ง 99 หลกัฐ�นในข้อ้แนะนำ�ต่ิ�ง ๆ 101 ก�รประเมิันค์วั�มัน่�เช่�อถ่อขีองหลกัฐ�น 102 ประโยชนแ์ละโทษ 102 คุ์ณิค่์�และค์วั�มัชอบ 103 ค์วั�มัเกี�ยวัขี�องขีองทรพั็ย�กร 103 ค์วั�มัเท่�เทียมั ก�รเป็นที�ยอมัรบั และค์วั�มัเป็นไปได� 105 ค์ว�มัติอ้งก�รต่ิอง�นวิจยั 107 ก�รเลือกใช้ ้ก�รเผยแพร่ ก�รดำ�เนินก�ร และก�รประเมิันผล 108 ก�รเล่อกใช� 108 ก�รเผู้ยแพ็ร่ 109 ก�รรณิรงค์ผ่์ู้�นก�รส่ำ�อสำ�ร 111 ก�รนำ�นโยบ�ยและร�ยก�รไปใช� 112 ก�รตรวัจัตร�และก�รประเมิัน 113 ก�รปรบัปรุงขี�อม้ัล 114 ร�ยก�รอ�้งอิง 115 ภ�ค์ผนวก 1: Management of guideline development process 125 ภ�ค์ผนวก 2: Guideline development group, external peer reviewers, and who staff involved in the development of these guidelines 128 ภ�ค์ผนวก 3: Summary of declaration of interest and how these were managed 132 ภ�ค์ผนวกเว็บไซติ:์ Evidence profiles https://apps.who.int/iris/bitstream/handle/ 10665/336657/9789240015111-eng.pdf สำ�รับัญ สารบััญ ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี ii The World Health Organization (WHO) gratefully acknowledges the contribution to and support of the following individuals and organizations in the development of these guidelines: Fiona Bull and Juana Willumsen led the process of developing these guidelines. Valentina Baltag, Maurice Bucagu, Alex Butchart, Neerja Chowdhary, Regina Guthold, Riitta-Maija Hämäläinen, Andre Ilbawi, Wasiq Khan, Lindsay Lee, Alana Officer, Leanne Riley and Gojka Roglic were members of the WHO Steering Group that managed the guideline development process. The members of the Guideline Development Group (GDG) included Salih Saad Al-Ansari, Stuart Biddle, Katja Borodulin, Matthew Buman, Greet Cardon (co-chair), Catherine Carty, Jean-Philippe Chaput, Sebastien Chastin, Paddy Dempsey, Loretta DiPietro, Ulf Ekelund, Joseph Firth, Christine Friedenreich, Leandro Garcia, Muthoni Gichu, Russ Jago, Peter Katzmarzyk, Estelle V. Lambert, Michael Leitzmann, Karen Milton, Francisco B. Ortega, Chathuranga Ranasinghe, Emmanuel Stamatakis (co-chair), Anne Tiedemann, Richard Troiano, Hidde van der Ploeg, Vicky Wari. Roger Chou served as GRADE methodologist. The external review group included Kingsley Akinroye, Huda Alsiyabi, Alberto Flórez-Pregonero, Shigeru Inoue, Agus Mahendra, Deborah Salvo and Jasper Schipperijn. Systematic reviews of evidence prepared for 2018 US Physical Activity Guidelines Advisory Committee Scientific Report to the Secretary of Health and Human Services were updated thanks to additional literature searches conducted by Kyle Sprow (National Cancer Institutes, National Institutes of Health, Maryland, USA). Additional support to review papers identified was provided by Elif Eroglu (University of Sydney), Andrea Hillreiner (University of Regensburg), Bo-Huei Huang (University of Sydney), Carmen Jochem (University of Regensburg), Jairo H. Migueles (University of Granada), Chelsea Stone (University of Calgary) and Léonie Uijtdewilligen (Amsterdam UMC). Summaries of evidence and GRADE tables were prepared by Carrie Patnode and Michelle Henninger (The Kaiser Foundation Hospitals, Center for Health Research, Portland, Oregon, USA). Additional reviews of evidence were conducted by N Fairhall, J Oliveira, M Pinheiro, and C Sherrington (Institute for Musculoskeletal Health, School of Public Health, The University of Sydney, Sydney, Australia) and A Bauman (Prevention Research Collaboration, School of Public Health, The University of Sydney, Sydney, Australia; and WHO Collaborating Centre for Physical Activity, Nutrition and Obesity); S Mabweazara, M-J Laguette, K Larmuth, F Odunitan-Wayas (Research Centre for Health through Physical Activity, Lifestyle and Sports Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa), L Leach, S Onagbiye (Department of Sport, Recreation and Exercise Science, Faculty of Health Sciences, University of the Western Cape, Cape Town, South Africa), M Mthethwa (Chronic Disease Initiative for Africa, University of Cape Town, Cape Town, South Africa), P Smith (The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa) and F Mashili (Department of Physiology, Muhimbili University of Allied Sciences, Dar Es Salaam, United Republic of Tanzania); B Cillekens, M Lang, W van Mechelen, E Verhagen, M Huysmans, A van der Beek, P Coenen (Department of Public and Occupational Health at Amsterdam University Medical Centre, Amsterdam, Netherlands). The Public Health Agency of Canada and the Government of Norway provided financial support, without which this work could not have been completed. ACKNOWLEDGEMENT iii อักิษรัย่อและคำำ�ย่อ ADHD attention deficit hyperactive disorder โรค์สำมั�ธิิสำั�น AOR adjusted odds ratio อตัร�ส่ำวันปัจัจัยัในก�รเกิดเหตุที�ถ้กปรบัแต่ง BMI body mass index ดชันีมัวัลก�ย CI confidence interval ช่วังค์วั�มัเช่�อมัั�น CVD cardiovascular disease โรค์หวััใจัและหลอดเล่อด DBP diastolic blood pressure ค์วั�มัดนัโลหิตตำ� EtD Evidence to Decisions หลกัฐ�นประกอบก�รตดัสิำนใจั GDG Guideline Development Group กลุ่มัพ็ฒัน�แนวัปฏิิบติั GRADE Grading of Recommendations Assessment, Development and Evaluationก�รจัดัลำ�ดบัก�รประเมิันขี�อแนะนำ�, ก�รพ็ฒัน� และก�รประเมิันค่์� HR hazards ratio อตัร�ส่ำวันอนัตร�ย MET Metabolic Equivalent of Task หน่วัยวัดัค์วั�มัต�องก�รออกซิเจันขีณิะออกกำ�ลงัก�ย MD mean difference ผู้ลต่�งขีองค่์�เฉลี�ย MICT moderate intensity continuous training ก�รฝึึกฝึนร่�งก�ยอย่�งต่อเน่�องในระดบักล�ง NCD noncommunicable disease โรค์ไม่ัติดต่อเร่ �อรงั OR odds ratio อตัร�ส่ำวันค์วั�มัสำมััพ็นัธิข์ีองค่์�สำองค่์� PA physical activity ก�รเค์ล่�อนไหวัร่�งก�ย ก�รออกกำ�ลงัก�ย PAGAC United States Physical Activity Guidelines Advisory Committee ค์ณิะกรรมัก�รที�ปรก่ษ�แนวัปฏิิบติัก�รออกกำ�ลงัก�ยแห่งสำหรฐัอเมัริก� PI/ECO Population, Intervention/Exposure, Comparison, Outcome ประช�กร, ก�รแทรกแซง, ก�รเปิดเผู้ย, ก�รเปรียบเทียบ, ผู้ลลพั็ธิ ์ RaR Relative attributable risk อตัร�ค์วั�มัเสีำ�ยงในก�รเกิดโรค์ขีองกลุ่มัที�มีัปัจัจัยัเสีำ�ยงเทียบกบักลุ่มัที� ไม่ัมีัค์วั�มัเสีำ�ยง RCT randomized control trial ก�รทดลองแบบสุ่ำมัและมีักลุ่มัค์วับคุ์มั RR relative risk อตัร�ส่ำวันที�บ่งบอกค์วั�มัเสีำ�ยงในก�รเกิดโรค์ SBP systolic blood pressure ค่์�ค์วั�มัดนัโลหิตส้ำงสุำดเม่ั�อหวััใจับีบตวัั SMD standardized mean difference ผู้ลต่�งค่์�เฉลี�ยมั�ตรฐ�น SPPB short physical performance battery แบบประเมิันสำมัรรถภั�พ็ท�งร่�งก�ยในระยะสำั�น TV television โทรทศัน,์ วิัทยุโทรภั�พ็ WHA World Health Assembly สำมัชัช�อน�มัยัโลก WHO World Health Organization องค์ก์�รอน�มัยัโลก อัักษรย่่อัและคำำาย่่อั ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี iv อภิิธ�นืศััพท์ ค์ำ�ศัพัท ์ ค์ว�มัหมั�ย Aerobic physical activity กิิจกิรรมทางกิายแบบแอโรบิกิ กิจักรรมัที� กล� มัเน่�อมััดใหญ่่ขีองร่�งก�ยเค์ล่� อนไหวัอย่�งเป็นจัังหวัะต่อเน่� อง เรียกอีกอย่�งหน่�งว่ั� กิจักรรมัฝึึกค์วั�มัอดทน เพ่็�อพ็ฒัน�สำมัรรถภั�พ็ในก�รหมุันเวีัยน โลหิต ตวััอย่�งเช่น ก�รเดิน วิั�ง ว่ั�ยนำ � และปั� นจักัรย�น Anaerobic physical activity กิิจกิรรมทางกิายแบบแอนแอโรบิกิ ประกอบไปด�วัยกิจักรรมัเขี�มัขี�นใช�แรงหนกั เช่น ก�รยกนำ � หนกั ก�รวิั�งด�วัยค์วั�มัเร็วัส้ำง ซ่�งค์วั�มัต�องก�รออกซิเจันจัะส้ำงกว่ั�ปริมั�ณิก�๊ซออกซิเจันที�มีัอย่้ Balance training กิารฝึึกิเพ่ื่�อสรา้งสมดุุล ก�รออกกำ�ลงัแบบอย่้กบัที�และเค์ล่�อนไหวัที�ถ้กออกแบบมั�เพ่็�อพ็ฒัน�ค์วั�มัสำ�มั�รถขีอง แต่ละบุค์ค์ลที�จัะอดทนต่อค์วั�มัท� ท�ยจั�กท่�ออกกำ�ลงัก�ยที�มีัก�รโค์�งแอ่นหร่อก�ร กระตุ�นที� ไม่ัค์งที�อนัเกิดจั�กก�รเค์ล่�อนไหวัร่�งก�ย, สำภั�พ็แวัดล�อมั หร่อวัตัถุอ่�น ๆ Body mass index (BMI) ดุชันีมวลกิาย นำ � หนกั (กิโลกรมัั) / ส่ำวันส้ำง (เมัตร)2 BMI-for-age or BMI z-score ดุชันีมวลกิายแยกิช่วงอายุ ดชันีมัวัลก�ยที�ปรบัต�มัระดบัอ�ยุ เป็นมั�ตรฐ�นสำำ�หรบัวัยัเด็ก ค่์�มั�ตรฐ�นก�รเบี�ยงเบน ดชันีมัวัลก�ยเป็นก�รวัดันำ � หนกัสำมััพ็ทัธิที์�ปรบัต�มัอ�ยุและเพ็ศขีองเด็ก ก�รระบุอ�ยุ เพ็ศ ดชันีมัวัลก�ย และค่์�มั�ตรฐ�นในก�รอ� งอิงที�เหมั�ะสำมัด�วัยดชันีมัวัลก�ยแยกช่วังอ�ยุ (หร่อค่์�เปอรเ์ซ็นต์ไทลข์ีองดชันีมัวัลก�ยต่ออ�ยุ) จัะเป็นตวัักำ�หนด Bone-strengthening activity กิิจกิรรมเสริมสรา้งความแข็็งแรง กิระดูุกิ กิจักรรมัที� มุ่ังออกแบบมั�เพ่็�อเพิ็�มัค์วั�มัแข็ีงแรงให�กบักระด้กเฉพ็�ะจุัดที�จัะซ่อมัแซมั ระบบกระด้ก กิจักรรมัเสำริมัสำร� งค์วั�มัแข็ีงแรงกระด้กจัะสำร� งผู้ลกระทบหร่อแรงตง่ที� ทำ�ให�กระด้กเจัริญ่เติบโตและแข็ีงแรง ก�รวิั�ง กระโดดเช่อก และยกนำ � หนกัเป็นตวััอย่�ง ขีองกิจักรรมัเสำริมัสำร� งค์วั�มัแข็ีงแรงกระด้ก Cardiometabolic health ภาวะเสี�ยงต่่อโรคหลอดุเล่อดุ และหวัใจ ผู้ลกระทบระหว่ั�งค์วั�มัดนัโลหิต ไขีมันัในเล่อด นำ � ต�ลในเล่อด และอินซ้ลินที�มีัต่อสุำขีภั�พ็ Cardiorespiratory fitness (endurance) ความแข็็งแรงข็องระบบหมุนเวียน โลหิต่ (ความทนทาน) องค์ป์ระกอบท�งสุำขีภั�พ็ที�เกี�ยวัเน่�องกบัค์วั�มัแข็ีงแรงท�งก�ย สำมัรรถนะขีองระบบหมุัน เวีัยนโลหิตและระบบห�ยใจัที�สำร� งก�๊ซออกซิเจันขีณิะออกกำ�ลงัก�ย ปรกติแล�วัจัะแสำดง ค่์�ในร้ปแบบขีองก�รด้ดซม่ัออกซิเจันส้ำงสุำดที�วัดัหร่อประเมิันได� (VO2 max) Cognitive function สมรรถนะดุา้นกิารรูคิ้ดุ กิจักรรมัด� นสำมัอง เช่น ก�รใช�เหตุผู้ล ค์วั�มัจัำ� ค์วั�มัสำนใจั และภั�ษ�ซ่�งนำ�ไปส่้ำก�รบรรลุ ถง่ชุดขี�อม้ัลและค์วั�มัร้� ยงัรวัมัไปถง่ก�รเรียนร้�ด�วัย Disability ทุพื่พื่ลภาพื่ จั�กก�รให�ค์ำ�นิย�มัระดบัสำ�กลเกี�ยวักบั ก�รทำ�ง�น ภั�วัะทุพ็พ็ลภั�พ็ และสุำขีภั�พ็ ภั�วั ะ ทุ พ็ พ็ ล ภั� พ็ อ ย่้ ในก ลุ่มั ค์วั�มั ห มั � ย เ ดี ย วั กับ ค์วั�มั บ ก พ็ ร่ อง ขี�อจัำ � กัด ในก�รทำ�กิจักรรมัต่�ง ๆ และก�รจัำ�กดัก�รมีัส่ำวันร่วัมั แสำดงถง่เกณิฑ์์ในแง่ลบต่อสำมััพ็นัธิ ์ ระหว่ั�งบุค์ค์ล (ที�มีัเง่�อนไขีท�งสุำขีภั�พ็) และปัจัจัยัแวัดล�อมัขีองบุค์ค์ลนั�น (ปัจัจัยัจั�กภั�วัะ แวัดล�อมัและปัจัจัยัเฉพ็�ะบุค์ค์ล) Domains of physical activity ข็อบเข็ต่กิิจกิรรมทางกิาย ระดบัขีองกิจักรรมัท�งก�ยสำ�มั�รถประเมิันได�ด�วัยขีอบเขีตหล�ยร้ปแบบ อ�ทิเช่น เวัล�พ็กัผู่้อน, อ�ชีพ็, ระดบัก�รศก่ษ�, ค์รอบค์รวัั และ/หร่อ ก�รเดินท�งขีนส่ำง Exercise กิารออกิกิำาลงักิาย เป็นประเภัทย่อยขีองกิจักรรมัท�งก�ยซ่�งผู่้�นก�รวั�งแผู้น จัดัโค์รงสำร� ง ทำ�ซำ � และมีั วัตัถุประสำงค์์ในด� นที�จัะปรบัปรุงหร่อรกัษ�ค์วั�มัแข็ีงแรงท�งก�ยด� นใดด� นหน่�ง ก�ร ออกกำ�ลงัก�ยและก�รฝึึกออกกำ�ลงัก�ยอ�จัใช�สำลบัสำบัเปลี�ยนกนั และโดยทั�วัไปมักั หมั�ยถง่กิจักรรมัท�งก�ยที�ทำ�ระหว่ั�งเวัล�พ็กัผู่้อนด�วัยวัตัถุประสำงค์ห์ลกัเพ่็�อพ็ฒัน� หร่อรกัษ�ค์วั�มัแข็ีงแรง สำมัรรถภั�พ็ท�งก�ย หร่อสุำขีภั�พ็ไวั� Executive function ทกัิษะสมอง หมั�ยรวัมัถง่โค์รงสำร� งอ่�น ๆ เช่น ค์วั�มัจัำ�เพ่็�อก�รใช�ง�น, ค์วั�มัย่ดหยุ่นในก�รรบัร้� (หร่อเรียกอีกอย่�งหน่�งว่ั�ก�รคิ์ดแบบย่ดหยุ่น) และก�รค์วับคุ์มัยบัยั�ง (ซ่� งรวัมัถ่ง ก�รค์วับคุ์มัตนเองด�วัย) Fitness ความแข็็งแรง ก�รวัดัค์วั�มัสำ�มั�รถขีองร่�งก�ยในก�รทำ�ง�นอย่�งมีัประสิำทธิิภั�พ็และประสิำทธิิผู้ลทั�ง ด� นกิจักรร�ก�รทำ�ง�นและก�รพ็กัผู่้อน ตวััอย่�งเช่น ค์วั�มัแข็ีงแรงท�งก�ย และค์วั�มั แข็ีงแรงขีองระบบหมุันเวีัยนโลหิต Flexibility ความย่ดุหยุ่น องค์ป์ระกอบขีองค์วั�มัแข็ีงแรงท�งก�ยที� เกี�ยวัเน่�องกบัสุำขีภั�พ็และสำมัรรถนะซ่�งเป็น ค่์�ผู้นัแปรขีองก�รเค์ล่�อนไหวัขีองขี�อต่อ ค์วั�มัย่ดหยุ่นนั�นต่�งกนัไปต�มัขี�อต่อแต่ละส่ำวัน และขี่ �นอย่้กบัตวััแปรหล�ย ๆ อย่�ง และอ�จัมีัตวััแปรอ่�นใดอีก ตวััอย่�งเช่น ค์วั�มัแน่น ขีองเอ็นและเสำ�นเอ็นเฉพ็�ะส่ำวัน ก�รออกกำ�ลงัก�ยแบบเน�นค์วั�มัย่ดหยุ่นจัะทำ�ให�ขี�อต่อ สำ�มั�รถเค์ล่�อนไหวัได�อย่�งค์ล่องตวัั vอัภิิธานศััพท์์ Functional exercises กิารออกิกิำาลงักิายจากิกิารทำางาน ก�รออกกำ�ลงัก�ยที�แฝึงอย่้ในกิจัวัตัรประจัำ�วันัที�จัะพ็ฒัน�ค์วั�มัแข็ีงแรงขีองร่�งก�ย ส่ำวันล่�ง ค์วั�มัสำมัดุล และสำมัรรถนะก�รเค์ล่�อนไหวั ตวััอย่�งเช่น ก�รย่นขี�เดียวั ก�รย่อย่ด ก�รย่นเก�ะเก� อี � ย่นปล�ยเท� หร่อก�รก� วัขี� มัสิำ�งกีดขีวั�ง Household domain physical activity กิิจกิรรมทางกิายในครวัเร่อน กิจักรรมัท�งก�ยในบ� นเร่อน (เช่น ก�รทำ�ค์วั�มัสำะอ�ด ก�รด้แลเด็ก ก�รทำ�สำวัน เป็นต�น) Leisure-domain physical activity กิิจกิรรมทางกิายจากิกิารพื่กัิผ่่อน กิจักรรมัท�งก�ยขีองแต่ละบุค์ค์ลที� ไม่ัใช่สิำ� งจัำ�เป็นในชีวิัตประจัำ�วัันและเป็นไป ต�มัค์วั�มัชอบขีองแต่ละบุค์ค์ล ตัวัอย่�งกิจักรรมัเหล่�นี�ได�แก่ ก�รเล่นกีฬ� ก�รออกกำ�ลงัก�ยหร่อฝึึกก�ยบริห�ร กิจักรรมัสำนัทน�ก�รเล่นก�รเดินเล่น เต�นรำ� หร่อทำ�สำวัน Light-intensity physical activity กิิจกิรรมทางกิายระดุบัเบา กิจักรรมัท�งก�ยแบบเบ�ค่์�ออกซิเจันจัะอย่้ระหว่ั�ง 1.5 และ 3 METs ตวััอย่�งเช่น ก�รส้ำญ่เสีำยพ็ลงัง�นน�อยกว่ั�ค่์�พ็ลงัง�นปรกติขีณิะพ็กัผู่้อนน�อยกว่ั� 3 เท่�ขีอง บุค์ค์ลนั�น ซ่�งรวัมัถง่ก�รเดินช� ๆ ก�รอ�บนำ � หร่อกิจักรรมัเล็ก ๆ น�อย ๆ ที� ไม่ัทำ�ให� อตัร�ก�รเต�นขีองหวััใจั หร่ออตัร�ก�รห�ยใจัเพิ็�มัส้ำงขี่ �นอย่�งมีันยัสำำ�ค์ญั่ Major muscle groups กิลุ่มกิลา้มเน่ �อหลกัิ กลุ่มักล� มัเน่�อหลกัรวัมัถง่ ขี� หลงั ช่องท�อง หน� อก ไหล่ และแขีน Metabolic equivalent of task (MET) หน่วยวดัุความต่อ้งกิารออกิซิิเจน ข็ณะออกิกิำาลงักิาย ห น่วั ย วััด ค์ วั � มั ต�อ ง ก � ร อ อ ก ซิ เจั น ขี ณิ ะ อ อ ก กำ � ลัง ก � ย ห ร่ อ เรี ย ก ง่ � ย ๆ ว่ั�ค่์�เทียบก�รสำนัด�ป เป็นก�รวัดัท�งสำรีรวิัทย�ซ่� ง่แสำดงให�เห็นถง่ค์วั�มัเขี�มัขี�นขีอง กิจักรรมัท�งก�ย ค่์� 1 MET เป็นค่์�พ็ลงัง�นเทียบกบัที�ค์น ๆ หน่�งจัะใช�ขีณิะที�อย่้นิ�ง ๆ Moderate-intensity physical activity กิิจกิรรมทางกิายระดุบัปานกิลาง ในระดบัค่์�สำมัับ้รณิ ์ค์วั�มัหนกัหน่วังพ็อค์วัรหมั�ยถง่กิจักรรมัท�งก�ยที�เกิดขี่ �นระหว่ั�ง 3 ค์รั�งและไม่ัเกิน 6 ค์รั�ง เม่ั�อเทียบกบัค์วั�มัเขี�มัขี�นขีองช่วังพ็กัผู่้อน ในระดบัที�สำมััพ็นัธิก์บั ระดบัค์วั�มัสำ�มั�รถส่ำวันบุค์ค์ล กิจักรรมัท�งก�ยที�มีัค์วั�มัหนกัหน่วังพ็อค์วัรนั�นปรกติจัะ อย่้ที�ระดบั 5 หร่อ 6 จั�กระดบัวัดั 0 ถง่ 10 Muscle-strengthening activity กิิจกิรรมย่ดุหยุ่นกิลา้มเน่ �อ กิจักรรมัท�งก�ยและก�ยบริห�รที�เพิ็�มัค์วั�มัแข็ีงแรงขีองกล� มัเน่�อยด่กระด้ก พ็ละกำ�ลงั ค์วั�มัทนท�น และมัวัล (ตวััอย่�งเช่น ก�รฝึึกค์วั�มัแข็ีงแรง ก�รฝึึกค์วั�มัทนท�น หร่อ ค์วั�มัแข็ีงแรงกล� มัเน่�อและก�ยบริห�รเพ่็�อฝึึกค์วั�มัอดทน) Multicomponent physical activity กิิจกิรรมทางกิายแบบผ่สมผ่สาน กิจักรรมัท�งก�ยแบบผู้สำมัผู้สำ�นนั�นมีัค์วั�มัสำำ�ค์ญั่ต่อผู้้�ส้ำงอ�ยุที�จัะช่วัยพ็ฒัน�ก�รทำ�ง�น ขีองร่�งก�ยและลดค์วั�มัเสีำ�ยงจั�กก�รหกล�มัหร่อบ�ดเจ็ับจั�กก�รหกล�มั กิจักรรมัเหล่�นี� สำ�มั�รถทำ�ได�ที�บ� นหร่อก�รจัดัตั�งกลุ่มั มีัก�รผู้สำมัก�ยบริห�รทุกแขีนงเขี� ด�วัยกนั เป็นช่วัง (ก�รฝึึกแบบแอโรบิก ก�รสำร� งค์วั�มัแข็ีงแรงกล� มัเน่�อ และก�รฝึึกสำมัดุล) และได�ผู้ลเป็นอย่�งดี ตวััอย่�งขีองร�ยก�รออกกำ�ลงัแบบผู้สำมัผู้สำ�นนั�นอ�จัรวัมัถง่ ก�รเดิน (กิจักรรมัแบบแอโรบิก), ก�รยกนำ � หนัก (ก�รเสำริมัสำร� งค์วั�มัแข็ีงแรง กล� มัเน่�อ) รวัมัเขี� กบัก�รฝึึกสำมัดุล ตวััอย่�งขีองก�รฝึึกสำมัดุลก็เช่นก�รเดินถอยหลงั หร่อเดินไปท�งขี� ง หร่อก�รย่นขี�เดียวัขีณิะฝึึกค์วั�มัแข็ีงแรงกล� มัเน่�อร่�งก�ยช่วังบน เช่น ก�รบริห�รกล� มัเน่�อแขีนไปด�วัย ก�รเต�นก็ถ่อเป็นก�รผู้สำมัผู้สำ�นองค์ป์ระกอบแบบ แอโรบิกกบัก�รสำร� งสำมัดุล Occupation domain physical activity กิิจกิรรมทางกิายในกิลุ่มอาชีพื่ ด้หวััขี�อกิจักรรมัท�งก�ยในกลุ่มัก�รทำ�ง�น Physical activity กิิจกิรรมทางกิาย ก�รเค์ล่�อนไหวัร่�งก�ยในร้ปแบบใด ๆ ที� ก่อให�เกิดกล� มัเน่�อย่ดกระด้กซ่�งต�องก�ร ก�รใช�พ็ลงัง�น Physical inactivity กิิจกิรรมทางกิายที�ไม่เพีื่ยงพื่อ ระดบัก�รเค์ล่�อนไหวัร่�งก�ยที� ไม่ัเพี็ยงพ็อต่อระดบัก�รเค์ล่�อนไหวัร่�งก�ยที�แนะนำ� Psychosocial health สุำขีภั�พ็จิัตสำงัค์มั หมั�ยรวั Recreational screen time เวลาจอ้งจอในเชิงสนัทนากิาร เวัล�ที�ใช�ในก�รรบัชมัหน� จัอต่�ง ๆ (โทรทศันห์ร่อทีวีั, ค์อมัพิ็วัเตอร,์ อุปกรณิม่์ัอถ่อ) ด�วัยวัตัถุประสำงค์อ่์�นที�นอกเหน่อไปจั�กก�รเรียนก�รศก่ษ�หร่อก�รทำ�ง�น Sedentary screen time เวลาที�อยู่กิบัหนา้จอโดุย ไม่มีกิารเคล่�อนไหว ระยะเวัล�ที� ใช�ในก�รรบัชมัค์วั�มับนัเทิงผู่้�นจัอ (ทีวีั, ค์อมัพิ็วัเตอร,์ อุปกรณิม่์ัอถ่อ) ไม่ัรวัมัถ่งก�รเล่นเกมัสำผ่์ู้�นหน� จัอที�ต�องใช�ก�รเค์ล่�อนไหวัร่�งก�ยหร่อมีักิจักรรมั ท�งก�ย ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี vi Sedentary behaviour พื่ฤติ่กิรรมเน่อยนิ�ง พ็ฤติกรรมัขีณิะต่�นที�ใช�พ็ลงัง�นไม่ัเกิน 1.5 METS ขีณิะนั�ง นอนเอกขีเนก หร่อนอนเหยียด ก�รทำ�ง�นติดโตะ๊ ก�รขีบัรถ หร่อก�รด้โทรทศันเ์ป็นตวััอย่�งขีองพ็ฤติกรรมัเน่อยยิ�ง อนัอ�จัหมั�ยรวัมัถง่ผู้้�ที� ย่นเองไม่ัได� เช่นผู้้�ต�องนั�งรถเข็ีน แนวัปฏิิบติันี�ได�จัดัค์ำ�นิย�มัขีองพ็ฤติกรรมัเน่อยนิ�งให�รวัมัถง่ก�รนั�งติดที�แบบเค์ล่�อนไห วัน�อย (เวัล�ในก�รพ็กัผู่้อน, สิำ�งที�เกี�ยวักบัอ�ชีพ็ และภั�พ็รวัมัอ่�น), โทรทศัน ์(ก�รชมัร�ย ก�รโทรทศันห์ร่อเวัล�จั�องจัอ และก�รเค์ล่�อนไหวัในระดบัตำ� ที�วัดัได�จั�กค์วั�มัเค์ล่�อนไหวั จับัโดยอุปกรณิที์�ประเมิันค์วั�มัเค์ล่�อนไหวัหร่อก�รออกท่�ท�ง) Sport กีิฬา กีฬ�ค์รอบค์ลุมักิจักรรมัอนัหล�กหล�ยที�กระทำ�ภั�ยใต�กฎต่�ง ๆ และเป็นส่ำวันหน่�งขีอง ก�รพ็กัผู่้อนหร่อก�รแข่ีงขีนั กิจักรรมักีฬ�นั�นค์รอบค์ลุมักิจักรรมัท�งก�ยที�ทำ�เป็นทีมั หร่อเป็นร�ยบุค์ค์ลและอ�จัจัะได�รบัก�รสำนบัสำนุนจั�กสำถ�บนัต่�ง ๆ เช่น สำำ�นกักีฬ� Transport domain physical activity กิิจกิรรมทางกิายในกิลุ่มกิารเดิุนทาง กิจักรรมัท�งก�ยที�เกิดขี่ �นโดยวัตัถุประสำงค์เ์พ่็�อก�รไปจั�กสำถ�นที�หน่�งส่้ำสำถ�นที�อ่�น ๆ ซ่�งหมั�ยถง่ก�รเดิน ก�รปั� นจักัรย�น และก�รขีบัเค์ล่�อนด�วัยล�อ (ก�รใช�วิัถีท�งแบบ ไม่ัมีัเค์ร่� องยนตแ์ต่เค์ล่� อนไหวัด�วัยล�อ ตัวัอย่�งเช่น สำก้ตเตอร,์ โรลเลอรเ์บลด, เก� อี �ล�อเล่�อนด�วัยตนเอง เป็นต�น) Vigorous-intensity physical activity กิิจกิรรมทางกิายระดุบัหนกัิ กิจักรรมัท�งก�ยในระดับแข็ีงแรง ในระดับที� ไ ม่ั มีัก�รผู้ันแปรนั�น หมั�ยถ่ง กิจักรรมัท�งก�ยที�ส้ำงกว่ั� 6 METS หร่อมั�กกว่ั� ในระดบัที�เกี�ยวัขี�องกบัค์วั�มัสำ�มั�รถส่ำวัน บุค์ค์ลนั�น กิจักรรมัท�งก�ยในระดบัแข็ีงแรงนั�นจัะอย่้ที�ระดบั 7 หร่อ 8 ในก�รวัดัระดบัจั�ก 0 ถง่ 10 Work domain physical activity กิิจกิรรมทางกิายในกิลุ่มกิารทำางาน กิจักรรมัท�งก�ยที�เกิดขี่ �นจั�กก�รทำ�ง�นที� ได�รบัค่์�จั� งหร่อง�นอ�สำ� 1ข้้อมูลสำรุัป ขี�อแนะนำ �ขีององค์์ก�รอน�มััยโลก เกี�ยวักบักิจักรรมัท�งก�ยและพ็ฤติกรรมัเน่อย- นิ�งนี�ได�สำร� งเน่�อห�ค์ำ�แนะนำ�ด� นสำ�ธิ�รณิสุำขี ที� มีัหลกัฐ�นรองรบั สำำ�หรบัเด็ก วัยัรุ่น ผู้้�ใหญ่่ แ ล ะ ผู้้� ส้ำ ง อ � ยุ เ กี� ย วั กับ ป ริ มั � ณิ กิ จั ก ร ร มั ท�งก�ย ที�ต�องก�ร (ค์วั�มัถี� , ค์วั�มัหนกัหน่วัง และระยะเวัล�) เพ่็� อ เ ป็นผู้ลดีต่อสุำขีภั�พ็ อ ย่ � ง มีั นัย ย ะ สำำ � ค์ัญ่ แ ล ะ ล ด ค์ วั � มั เ สีำ� ย ง ด� นสุำขีภั�พ็ และถ่อเป็นค์รั�งแรกที�มีัก�รแนะนำ� ที� เช่� อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ� งกับ ผู้ลลพั็ธิด์� นสุำขีภั�พ็ รวัมัถ่งสำำ�หรบัประช�กร กลุ่มัย่อย สำตรีมีัค์รรภัแ์ละมั�รด�หลงัค์ลอด และผู้้�มีัภั�วัะเจ็ับป่วัยเร่ �อรงัหร่อพิ็ก�ร ขี�อ แน ะ นำ � นี�จััด ทำ � ขี่ �น สำำ � หรับ ผู้้�วั�ง นโยบ�ยในประเทศที�มีัร�ยได�ส้ำง กล�ง และตำ� ผู้้�อ ย่้ ในกระทรวังสำ�ธิ�รณิสุำขี ก�รศ่กษ� ก�รเย�วัชน ก�รกีฬ� และ/หร่อสำวัสัำดิก�รสำงัค์มั และค์รอบค์รัวั เจั� หน� ที� รัฐที� รับผิู้ดชอบ แผู้นพ็ฒัน�ระดบัช�ติ ระดบัท�องถิ�น หร่อระดบั เทศบ�ลที�ต�องก�รเพิ็�มักิจักรรมัท�งก�ยและ ลดพ็ฤติกรรมัเน่อยนิ� งในกลุ่มัประช�กรผู่้�น เอกสำ�รแนะแนวั ผู้้�ทำ�ง�นในองค์ก์รที� ไม่ัใช่ หน่วัยง�นขีองรฐั ภั�ค์ก�รศ่กษ� ภั�ค์เอกชน หน่วัยวิัจัยั และผู้้�ให�บริก�รด้แลสุำขีภั�พ็ ขี�อแนะนำ�นี�จัดัเตรียมัขี่ �นต�มัค่้์ม่ัอก�ร พ็ัฒน�ขี�อแนะนำ�ขีององค์ก์�รอน�มััยโลก มีัก�รทบทวันวัรรณิกรรมัอย่�งเป็นระบบเพ่็�อ ผู้ลลพั็ธิที์�สำำ�ค์ญั่ และค์ำ�แนะนำ�นี�ได�พ็ฒัน�ขี่ �น 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ให�รฐับ�ลและผู้้�มีัส่ำวันเกี�ยวัขี�องทำ�ง�นร่วัมักนั เพ่็� อเพิ็� มักิจักรรมัท�งก�ยและลดพ็ฤติกรรมั เน่อยนิ�งในทุก ๆ ช่วังอ�ยุ แหล่งขี�อม้ัลสำนบัสำนุน เหล่�นี�สำ�มั�รถอ่�นได�ที� เว็ับไซตข์ีององค์ก์�ร อน�มััย-โลกหลังจั�กก�รตีพิ็มัพ็์เอกสำ�ร ขี�อแนะนำ�ต่�ง ๆ แมั�จัะมีัขี�อม้ัลสำนบัสำนุนมั�กมั�ยเกี�ยวักบั กิจักรรมัท�งก�ยและพ็ฤติกรรมัเน่อยนิ� งที� เพิ็�มัขี่ �น ซ่�งส่ำงผู้ลต่อสุำขีภั�พ็ในทุกช่วังอ�ยุ แต่ช่อง ว่ั�งท�งหลกัฐ�นที�สำำ�ค์ญั่ยงัค์งมีัอย่้ โดยเฉพ็�ะ ก�รขี�ดหลกัฐ�นจั�กประเทศที�มีัร�ยได�ตำ� และ ร�ยได�ป�นกล�ง ชุมัชนที�ด�อยโอก�สำและด�อย- สิำทธิิ �ท�งเศรษฐกิจั และก�รขี�ดหลกัฐ�นจั�ก ประช�กรกลุ่มัย่อยที�รวัมัถง่กลุ่มัค์นพิ็ก�ร จัง่ค์วัร มีัก�รลงทุนในก�รวิัจััยเพิ็� มัเติมัเพ่็� อสำร� ง ข้้อัมููลสรุป ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 2 หลกัฐ�นขี�อม้ัลในด� นนี�โดยเฉพ็�ะ นอกจั�กนี� ก�รเปลี�ยนแปลงที�เกิดกบัขี�อแนะนำ�เหล่�นี�จัะมีั ค์วั�มัเกี� ยวัขี�องกับระบบก�รตรวัจัสำอบและ เค์ร่� องม่ัอก�รประเมิันผู้ลที� ใช�ตรวัจัสำอบ กิจักรรมัท�งก�ยในระดบัประเทศ เค์ร่�องม่ัอที�มีั อย่้ในระดบัโลกและระดบัประเทศค์วัรได�รบัก�ร ทบทวัน และก�รร�ยง�นก�รปรบัปรุงชุดขี�อม้ัล เพ่็�อจัดัทำ�ร�ยง�นในอน�ค์ตและนำ�มั�เทียบกบั ขี�อแนะนำ� ใหม่ั ขี�อ แน ะ นำ �ร ะ ดับ โ ล ก ด� นกิจั กร ร มั ท�งก�ยในปี 2561-2573 ตั�งเป้�หมั�ยใน ก�รลดพ็ฤติกรรมัเน่อยนิ� งที� ไม่ัเพี็ยงพ็อลง ร�อยละ 15 ภั�ยในปี 2573 และวั�งโค์รงร่�ง ที� จัะร่�งมั�ตรก�รท�งนโยบ�ยและก�รมีั ส่ำวันร่วัมัอีก 20 ร�ยก�ร ขี�อแนะนำ�เหล่�นี� สำ นับ สำ นุ นให� ทุ ก ป ร ะ เท ศ ดำ � เนิ น ก � ร ต � มั ขี�อแนะนำ�ในแผู้นปฏิิบัติก�ร GAPPA และ ACTIVE ซ่�งเป็นชุดแผู้นดำ�เนินก�รเฉพ็�ะท�ง ที� ให� ขี�อแนะ นำ �ด� นก�รส่ำงเสำริมักิจักรรมั ท�งก�ยในแต่ละช่วังอ�ยุและสำภั�พ็แวัดล�อมั ที�หล�กหล�ย 3เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) กิจักรรมัท�งก�ยสำร� งคุ์ณิประโยชนด์� นสุำขีภั�พ็มั�กมั�ยต่อเด็กและวัยัรุ่น ทั�งก�รเสำริมัสำร� งค์วั�มัแข็ีงแรงท�งร่�งก�ร (ค์วั�มัแข็ีงแรงขีองระบบหมุันเวีัยน โลหิตและกล� มัเน่�อ) สุำขีภั�พ็ที� เกี�ยวักบัหลอดเล่อด (ค์วั�มัดนัโลหิต ไขีมันัในเล่อด นำ � ต�ลในเล่อด และก�รต่อต� นอินซ้ลิน) สุำขีภั�พ็กระด้ก ผู้ลต่อประสำ�ทก�รรบัร้� (ก�รเรียนร้� ก�รคิ์ดวิัเค์ร�ะห)์ สุำขีภั�พ็จิัต (ลดอ�ก�รเค์รียด) และลดภั�วัะโรค์อ�วัน • ทำ�กิจักรรมัท�งก�ยสำกันิดย่อมัดีกว่ั�ไม่ัทำ�อะไรเลย • ห�กเด็กหร่อวัยัรุ่นไม่ัสำ�มั�รถทำ�ต�มัขี�อแนะนำ�ได� ก�รทำ�กิจักรรมัท�งก�ยบ� งก็เป็นประโยชน์ ต่อสุำขีภั�พ็ขีองพ็วักเขี�แล�วั • เด็กและวัยัรุ่นค์วัรเริ�มัจั�กกิจักรรมัท�งก�ยเบ� ๆ แล�วัค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มัหนกัหน่วัง และระยะเวัล�ขี่ �นได� • ก�รสำร� งโอก�สำให�กบัเด็กและวัยัรุ่นในก�รทำ�กิจักรรมัท�งก�ยอย่�งปลอดภัยัและมีัโอก�สำ เท่�เทียมักนั และส่ำงเสำริมัให�ทำ�กิจักรรมัท�งก�ยอย่�งสำนุกสำน�น หล�กหล�ย และเหมั�ะสำมักบั อ�ยุกบัค์วั�มัสำ�มั�รถนั�น มีัค์วั�มัสำำ�ค์ญั่อย่�งยิ�ง พ็ฤติกรรมัเน่อยนิ� งในเด็กและวััยรุ่นที� เพิ็� มัขี่ �นจัะต�มัมั�ด�วัยผู้ลลัพ็ธิท์�งสุำขีภั�พ็ที� ไ ม่ั ดี ทั�งโรค์อ�วันที� เพิ็�มัขี่ �น สุำขีภั�พ็หลอดเล่อด ค์วั�มัแข็ีงแรง ค์วั�มัประพ็ฤติ/พ็ฤติกรรมัเอ่ �อสำงัค์มั และระยะเวัล�นอนหลบัที�ลดลง แนะนำ�ให:้ ค์วร ทำ� กิจ กร ร มั ท�ง ก� ย แ บ บ แอ โร บิ ก ใ นร ะ ด ับ ห นัก เ ช่้ น เ ดี ย ว ก ับ ก � ร สำ ร ้� ง ค์ว�มัแข็้งแรงให้กล�้มัเนื �อและกระด้ก อย่�งนอ้ยสำปัด�หล์ะ 3 วนั ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ เด็กและวยัรุ่นค์วรทำ�กิจกรรมัท�งก�ยระดบั ป�นกล�ง-หนกั เฉลี�ยอย่�งนอ้ยวนัละ 60 น�ที ติลอดทั�งสำปัด�ห ์โดยเนน้ไปที�ก�รทำ�กิจกรรมั ท�งก�ยแบบแอโรบิก อย่�งน้ือย สำำ�หรัับกิิจกิรัรัมท�งกิ�ยแบบแอโรับิกิ รัะดัับป�นกิล�ง-หนักิ ตลอดสััปด�ห์์ ควรัทำ�กิิจกิรัรัมท�งกิ�ยแบบแอโรับิกิ ในระดับห์นักและสำร้ั�งคว�มแข็็งแรัง ให้กัิบกิล้�มเน้�อและกิรัะดูักิ ไปด้วยกัน นื�ท่ต่ิอวัันื วัันืต่ิอสัำปด็�ห์ > > แนะนำ�ให:้ เด็กและวยัรุ่นค์วรจำ�กดัเวล�ที� ใช้ ้ ไปกบั พฤติิกรรมัเนือยนิ�ง โดยเฉพ�ะเวล�ที�อย่้กบั หน�้จอเพื�อก�รสำนัทน�ก�ร > ข้้อัมููลสรุป อย่�งน้ือย จำ�กัิด็ รัะยะเวัล�ท่� ใช้้ ไปกัิบ พฤติิกิรัรัมเนืือยนิื�ง โดยเฉพ�ะเวล�ท่ี่�อย่� กับห์น้�จอ ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 4 วััยผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ในวััยผู้้�ใหญ่่ กิจักรรมัท�งก�ยจัะเอ่ �อประโยชน์ต่อผู้ลลัพ็ธิท์�งสุำขีภั�พ็ ทั�งสุำขีภั�พ็ร่�งก�ยโดยรวัมั โรค์หลอดเล่อดหัวัใจั ภั�วัะค์วั�มัดนัโลหิตส้ำง มัะเร็งเฉพ็�ะจุัด1 เบ�หวั�นชนิดที�สำอง สุำขีภั�พ็จิัต (ลดอ�ก�รกงัวัลและเค์รียด) สุำขีภั�พ็ขีองสำมัอง ก�รนอนหลบั มั�ตรวัดัภั�วัะโรค์อ�วันอ�จัจัะดีขี่ �นได�ด�วัย แนะนำ�ให:้ ผ้ ใ้หญ่่ทุกค์นค์วรทำ�กิจกรรมัท�งก�ยท ั�วไปในทุกวนั แนะนำ�อย่�งยิ�ง ค์วั�มัแน่นอนขีองหลกัฐ�น ประกอบเช่�อถ่อได� แนะนำ�อย่�งยิ�ง ค์วั�มัแน่นอนขีองหลกัฐ�น ประกอบเช่�อถ่อได� แนะนำ�อย่�งยิ�ง ค์วั�มัแน่นอนขีองหลกัฐ�น ประกอบเช่�อถ่อได� ผ้ ใ้หญ่่ค์วรทำ�กิจกรรมัท�งก�ยแบบแอโรบิก ระดบัป�นกล�ง อย่�งนอ้ย 150-300 น�ที หรือ ทำ�กิจกรรมัท�งก�ยแบบแอโรบิกระดบัหนกั อย่�งนอ้ย 75-150 น�ที หรือทำ�ผสำมัผสำ�นกนั โดยทำ�ติลอดทั�งสำปัด�ห ์เพื�อผลดีต่ิอสุำข้ภ�พ อย่�งต่ิอเนื�อง วยัผ้ ้ใหญ่่ค์วรทำ�กิจกรรมัสำร�้งค์ว�มั แข็้ง แรงให้ก ับ ก ล�้มั เนื �อ ที� ติ ้องใ ช้ ้ กล�้มัเนื �อส่ำวนหลกัทุกส่ำวนที� ระดบั ป�นกล�งข้้ �นไป อย่�งนอ้ย 2 วนัต่ิอ สำปัด�หเ์พื�อเสำริมัสำร�้งสุำข้ภ�พที�ดี > > > อย่�งน้ือย ถึึง ถึึง หรืัอ150 75 300 150 นาทีี วััน นาทีี อย่�งน้ือย สำำ�หรัับกิิจกิรัรัมท�งกิ�ย แบบแอโรับิกิรัะดัับ ป�นกิล�ง สำำ�หรัับกิิจกิรัรัม ท�งกิ�ย แบบแอโรับิกิ รัะดัับหนักิ หร้ัอทั�งสำองแบบผสำมผสำ�นกัินตลอดัสัำปดั�ห์ สำำ�หรัับกิิจกิรัรัมสำร้ั�งคว�ม แข็็งแรังให้กัิบกิล้�มเน้� อท่� ต้องใช้้กิล้�มเน้� อส่ำวนหลักิ ทุกิส่ำวนท่� รัะดัับป�นกิล�ง ข้็�นไป เพ้ื่�อสุำข็ภ�พื่ท่�ด่ัข้็�น: อย่�งน้ือย สัำปด็�ห์ ต่ิอ 1 มัะเร็งเฉพ�ะจุดได้แก� กระเพ�ะปัสัสั�วะ, ที่รวงอก, ลำ�ไส้ัให์ญ่�, เย่�อบุมัดล่ก, ห์ลอดอ�ห์�ร, กระเพ�ะอ�ห์�ร และไต 5เพ้ื่�อสุำข็ภ�พื่ท่�ด่ัข้็�น: หร้ัอออกิกิำ�ลังแบบผสำมผสำ�นกัินตลอดัสัำปดั�ห์ พ็ฤติกรรมัเน่อยนิ� งที� เพิ็� มัส้ำงขี่ �นในวััยผู้้� ใหญ่่จัะต�มัมั�ด�วัยผู้ลลัพ็ธิท์�งสุำขีภั�พ็ที� ไม่ัดี ได�แก่ ก�รเสีำยชีวิัตจั�กทุกสำ�เหตุ ก�รเสีำยชีวิัตที�เกี�ยวัเน่�องกบัหลอดเล่อดหวััใจั และก�รเสีำยชีวิัตจั�กโรค์มัะเร็ง และโอก�สำในก�รเกิดโรค์หลอดเล่อดหวััใจั โรค์มัะเร็ง และโรค์เบ�หวั�นชนิดที�สำอง ค์ำ�แนะนำ�แบบมีัเง่�อนไขี หลกัฐ�นประกอบเช่�อถ่อได� แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นประกอบเช่�อถ่อได� แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นประกอบเช่�อถ่อได� วััยผูู้้ใหญ่ (อ�ยุ 18-64 ปี) วยัผ้ ้ใหญ่่สำ�มั�รถเพิ�มัระยะเวล�ในก�รทำ� กิจกรรมัท�งก�ยแบบแอโรบิกในระดบั ป�นกล�งใหม้ั�กกว่� 300 น�ที หรือทำ� กิจกรรมัท�งก�ยแบบแอโรบิกในระดบัหนกั ใหม้ั�กกว่� 150 น�ที หรือทำ�ผสำมัผสำ�นกนั ระหว่�งกิจกรรมัท�งก�ยแบบแอโรบิกใน ระดบัป�นกล�งและระดบัหนกัไปติลอดทั�ง สำปัด�ห ์เพื�อสุำข้ภ�พที�ดียิ�งข้้ �น > ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ • ทำ�กิจักรรมัท�งก�ยสำกันิดย่อมัดีกว่ั�ไม่ัทำ�อะไรเลย • ห�กวัยัผู้้�ใหญ่่ไม่ัสำ�มั�รถทำ�ต�มัขี�อแนะนำ�เหล่�นี�ได� ก�รทำ�กิจักรรมัท�งก�ยบ� งก็เป็น ประโยชนต่์อสุำขีภั�พ็ขีองพ็วักเขี�แล�วั • วัยัผู้้�ใหญ่่ค์วัรเริ� มัจั�กกิจักรรมัท�งก�ยเบ� ๆ แล�วัค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มัหนักหน่วัง และระยะเวัล�ขี่ �นได� แนะนำ�ให:้ ในวยัผ้ ้ใหญ่่ ค์วรจะจำ�กดัเวล�ที�ใช้ ้ไปกบั พฤติิกรรมัเนือยนิ�ง และทดแทนเวล�เหล่� นั�นดว้ยก�รทำ�กิจกรรมัท�งก�ยในทุกระดบั (รวมัถง้ระดบัเบ�) เพื�อสำร�้งเสำริมัสุำข้ภ�พที�ดี ในวยัผ้ ้ ใหญ่่ ค์วรทำ�กิจกรรมัท�งก�ย ในระดบัป�นกล�ง-หนักให้มั�กกว่�ที� แนะนำ�ไว ้ เพื�อลดผลกระทบที�เป็นอนัติร�ย ต่ิอสุำข้ภ�พจ�กพฤติิกรรมัเนือยนิ�ง > > ข้้อัมููลสรุป มากกว่ัา มากกว่ัา หรืัอ สำำ�หรัับกิิจกิรัรัม ท�งกิ�ย แบบแอโรับิกิ รัะดัับป�นกิล�ง สำำ�หรัับกิิจกิรัรัมท�ง กิ�ยแบบแอโรับิกิ รัะดัับป�นกิล�ง นาทีี นาทีี จำ�กัิด็ แทนืท่� เวัล�ท่� ใช้้ ไปกัิบ พฤติิกิรัรัมเนืือยนิื�ง ด้็วัยกิิจกิรัรัมท�งกิ�ย ในืทุกิ ๆ รัะดั็บ (รวมัถึึงระดับเบ�) ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 6 ผูู้้สูำงอ�ยุ (อ�ยุ 65 ปีขึ้�นืไป) กิ จั ก ร ร มั ท � ง ก � ย จั ะ เ อ่ �อ ป ร ะ โ ย ช น์ ต่ อ สุำ ขี ภั � พ็ ขี อ ง ผู้้� ส้ำ ง อ � ยุ ทั�งสุำขีภั�พ็ร่�งก�ยโดยรวัมั โรค์หลอดเล่อดหัวัใจั ภั�วัะค์วั�มัดนัโลหิตส้ำง โ ร ค์ มั ะ เ ร็ ง เ ฉ พ็ � ะ จุั ด โ ร ค์ เ บ � ห วั � น ช นิ ด ที� สำ อ ง โ ร ค์ สุำ ขี ภั � พ็ จิั ต (ลดอ�ก�รกงัวัลและเค์รียด) ก�รรบัร้�ขีองสำมัอง ก�รนอนหลบัมั�ตรวัดัภั�วัะ- โรค์อ�วันอ�จัจัะดีขี่ �นด�วัย ก�รทำ�กิจักรรมัท�งก�ยในผู้้�ส้ำงอ�ยุจัะช่วัยป้องกนัก�รหกล�มั และอุบติัเหตุจั�กก�รหกล�มั รวัมัถง่ก�รผุู้กร่อนและค์วั�มัสำ�มั�รถในก�รทำ�ง�นขีองกระด้ก แนะนำ�ให:้ ผ้ส้้ำงอ�ยุค์วรทำ�กิจกรรมัท�งก�ยท ั�วไปในทุกวนั แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� ผ้ ส้้ำงอ�ยุค์วรทำ�กิจกรรมัท�งก�ยแบบ แอโรบิกที� ระด ับป�นกล�ง อย่�งน้อย 150-300 น�ที หรือทำ�กิจกรรมัท�งก�ย แบบแอโรบิกที�ระดบัหนกั หรือทำ�ผสำมัผสำ�น ก ันท ั�งระด ับป�นกล�งและระด ับหนัก อย่�งเท่�เทียมักนั อย่�งนอ้ย 75-150 น�ที ติลอดทั�งสำปัด�ห ์เพื�อสุำข้ภ�พที�ดี แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� > > ผ้ส้้ำงอ�ยุค์วรทำ�กิจกรรมัสำร�้งค์ว�มั แข็้งแรงใหก้บักล�้มัเนื �อที�ใช้ก้ล�้มัเนื �อ หลกัทุกส่ำวนที�ระดบัป�นกล�งข้้ �นไป อย่�งนอ้ย 2 วนัต่ิอสำปัด�หเ์พื�อสุำข้ภ�พ ที�ดีข้้ �น แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� ในก�รทำ� กิจกรรมัท�งก�ยแต่ิละ สำปัด�ห ์ ผ้ส้้ำงอ�ยุค์วรทำ�กิจกรรมัท�ง- ก�ยหล�ยร้ปแบบเพื�อเนน้ไปที�ก�รสำร�้ง ค์ว�มัสำมัดุลและค์ว�มัแข็้งแรงใหร่้�ง ก�ย ที�ระดบัป�นกล�งข้้ �นไป อย่�งนอ้ย 3 วนัต่ิอสำปัด�ห ์ เพื�อสำร�้งเสำริมัค์ว�มั สำ�มั�รถในก�รทำ�ง�นและป้องกนัก�ร หกลม้ั แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� > > อย่�งน้ือย ถึึง ถึึง หรืัอ150 75 300 150 นาทีี นาทีี อย่�งน้ือย สำำ�หรัับกิิจกิรัรัม ท�งกิ�ย แบบแอโรับิกิ รัะดัับป�นกิล�ง หร้ัอผสำมผสำ�นทั�ง 2 รัะดัับอย่�งเท่�เท่ยมกัินตลอดัทั�งสัำปดั�ห์ สำำ�หรัับกิิจกิรัรัม ท�งกิ�ย แบบแอโรับิกิ รัะดัับป�นกิล�ง วััน สำำ�หรัับกิิจกิรัรัม สำร้ั�งคว�มแข็็งแรัง ให้กัิบกิล้�มเน้�อท่� ใช้้ กิล้�มเน้�อหลักิ ทุกิส่ำวนในรัะดัับ ป�นกิล�งข้็�นไป สำำ�หรัับกิิจกิรัรัมท�งกิ�ย ท่�หล�กิหล�ยเพ้ื่�อเน้น ไปท่�กิ�รัสำร้ั�งสำมดุัล กิ�รัทำ�ง�นข็องร่ั�งกิ�ย และกิ�รัฝึึกิคว�มแข็็งแรัง ท่�รัะดัับป�นกิล�งข้็�นไป เพ้ื่�อสุำข็ภ�พื่ท่�ด่ัข้็�น: อย่�งน้ือย อย่�งน้ือย สัำปด็�ห์ ต่ิอ วััน สัำปด็�ห์ ต่ิอ 7ผูู้้สูำงอ�ยุ (65 ปีขึ้�นืไป) ผ้ส้้ำงอ�ยุสำ�มั�รถเพิ�มัระยะเวล�ในก�รทำ� กิจกรรมัท�งก�ยแบบแอโรบิกในระดบั ป�นกล�งใหม้ั�กกว่� 300 น�ที หรือเพิ�มัระยะ เวล�ข้องกิจกรรมัท�งก�ยระดบัหนกัใหม้ั�ก กว่� 150 น�ที หรือท ั�ง 2 ระดบัผสำมักนัติลอด ท ั�งสำปัด�หเ์พื�อสุำข้ภ�พที�ดีข้้ �น ขี�อแนะนำ�ภั�ยใต�เง่�อนไขี มีัหลกัฐ�นย่นยนั > ข้้อัมููลสรุป สำำ �หรับผู้้� ส้ำงอ�ยุ พ็ฤติกรรมัเน่อยนิ� ง ส่ำวันใหญ่่จัะก่อให� เ กิดผู้ลร� ยต่อสุำขี ภั�พ็ ดัง ต่อไปนี� ก�รเสีำยชีวิัตจั�กทุกสำ�เหตุ ก�รเสีำยชีวิัตจั�กโรค์เกี�ยวักบัหลอดเล่อดและหวััใจั และโรค์มัะเร็ง โอก�สำในก�ร เกิดโรค์มัะเร็งและโรค์เบ�หวั�นชนิดที�สำอง ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ • ทำ�กิจักรรมัท�งก�ยสำกันิดย่อมัดีกว่ั�ไม่ัทำ�อะไรเลย • ห�กผู้้�ส้ำงอ�ยุไม่ัสำ�มั�รถทำ�ต�มัค์ำ�แนะนำ�เหล่�นี�ได� ก�รทำ�กิจักรรมัท�งก�ยบ� งก็เป็นประโย ชนต่์อสุำขีภั�พ็ขีองพ็วักเขี�แล�วั • ผู้้�ส้ำงอ�ยุค์วัรเริ�มัจั�กก�รทำ�กิจักรรมัท�งก�ยเบ� ๆ แล�วัค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มัหนกัหน่วัง และระยะเวัล�ขี่ �น • ผู้้�ส้ำงอ�ยุค์วัรทำ�กิจักรรมัท�งก�ยเท่�ที�ค์วั�มัสำ�มั�รถจัะเอ่ �ออำ�นวัย และปรบัระดบัขีองกิจักรรมั ท�งก�รให�สำมััพ็นัธิก์บัระดบัค์วั�มัแข็ีงแรงได� แนะนำ�ให:้ ผ้ส้้ำงอ�ยุค์วรจำ�กดัเวล�ที�ใช้ ้ไปกบัพฤติิกรรมั เนือยนิ� ง และทดแทนเวล�เหล่�นั�นดว้ย กิจ กร ร มั ท � ง ก� ย ในทุ กร ะ ด ับ (ร วมั ถ้ง ระดบัเบ�) ซ้�งจะเอื �อประโยช้นต่์ิอร่�งก�ย แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� ผ้ส้้ำงอ�ยุค์วรทำ�กิจกรรมัท�งก�ยในระดบั ป�นกล�ง-หนกัใหม้ั�กกว่�ข้อ้แนะนำ�ที�ให้ ไว ้ เพื� อลดผลกระทบร�้ยแรงต่ิอสุำข้ภ�พจ�ก พฤติิกรรมัเนือยนิ�ง แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� > > เพ้ื่�อสุำข็ภ�พื่ท่�ด่ัข้็�น: หร้ัอผสำมผสำ�นทั�ง 2 รัะดัับอย่�งเท่�เท่ยมกัินตลอดัทั�งสัำปดั�ห์ มากกว่ัา มากกว่ัา หรืัอ สำำ�หรัับกิิจกิรัรัม ท�งกิ�ย แบบแอโรับิกิ รัะดัับหนักิ นาทีี นาทีี สำำ�หรัับกิิจกิรัรัมท�ง กิ�ยแบบแอโรับิกิ รัะดัับป�นกิล�ง จำ�กัิด็ แทนืท่� รัะยะเวัล�ท่�อยู่เฉยๆ ด้็วัยกิิจกิรัรัมท�งกิ�ย ในืทุกิ ๆ รัะดั็บคำวั�มหนัืกิ (รวมัถึึงก�รออกกำ�ลังเบ�ๆ) ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 8 สำติร่ัม่คำรัรัภ์ิและม�รัด็�หลังคำลอด็ กิจักรรมัท�งก�ยระหว่ั�งก�รตั�งค์รรภัแ์ละหลงัค์ลอดจัะส่ำงผู้ลดีต่อสุำขีภั�พ็ขีอง มั�รด�และท�รกในค์รรภั์ได�ดงันี� ลดค์วั�มัเสีำ�ยงในก�รค์ลอดก่อนกำ�หนด ภั�วัะ ค์วั�มัดนัโลหิตส้ำงจั�กก�รตั�งค์รรภั ์โรค์เบ�หวั�นขีณิะตั�งค์รรภั ์นำ � หนกัเพิ็�มัเกินเกณิฑ์ ์ ขีณิะตั�งค์รรภั ์ก�รค์ลอดย�ก ภั�วัะซม่ัเศร� หลงัหลอด และค์วั�มัซบัซ�อนท�งก�รค์ลอดที�พ็บ ได�น�อย ไม่ัมีัผู้ลลบต่อนำ � หนกัแรกค์ลอด และไม่ัมีัก�รเพิ็�มัค์วั�มัเสีำ�ยงให�กบัท�รกเสีำยชีวิัตในค์รรภั์ แนะนำ�ใหส้ำติรีมีัค์รรภแ์ละมั�รด�หลงัค์ลอดที�ไม่ัมีัข้อ้จำ�กดัใด ๆ ค์วร: ข้อ้ม้ัลเพิ�มัเติิมั ทำ�กิจกรรมัท�งก�ยท ั�วไปในทุกวนั ติลอดระยะเวล�ที�ติ ั�งค์รรภแ์ละหลงัค์ลอด แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� ผ้ห้ญิ่งที�ทำ�กิจกรรมัท�งก�ยแบบแอโรบิกที�ระดบัหนกัเป็นประจำ� หรือมีัก�ร เค์ลื�อนไหวร่�งก�ยเป็นประจำ�ก่อนติ ั�งค์รรภ ์สำ�มั�รถดำ�เนินกิจกรรมัเหล่�นั�น ต่ิอไปไดต้ิลอดก�รติ ั�งค์รรภจ์นหลงัค์ลอด แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� ค์วรทำ�กิจกรรมัท�งก�ยแบบแอโรบิกที�ระดบั ป�นกล�งอย่�งนอ้ย 150 น�ที ติลอดทั�งสำปัด�ห ์ เพื�อสุำข้ภ�พดีอย่�งย ั�งยืน แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� ค์วรทำ�กิจกรรมัประเภทแอโรบิกที�หล�ยหล�ย และกิจกรรมัสำร�้งค์ว�มัแข็้งแรงใหก้บักล�้มัเนื �อ ก�รยืดเหยียดเบ� ๆ ก็เป็นประโยช้นต่์ิอสุำข้ภ�พ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� > > > > อย่�งน้ือย สำำ�หรัับกิิจกิรัรัมท�งกิ�ย แบบแอโรับิกิท่�รัะดัับป�นกิล�ง นื�ท่ ต่ิอสัำปด็�ห์ 150 9สำติร่ัม่คำรัรัภ์ิและม�รัด็�หลังคำลอด็ ข้้อัมููลสรุป ข้อ้ค์วรค์ำ�น้งเพิ�มัเติิมัด�้นค์ว�มัปลอดภยัในก�รทำ� กิจกรรมัท�งก�ย สำำ�หรบัสำติรีมีัค์รรภคื์์อ: ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ ทำ�กิจักรรมัท�งก�ยสำักนิด ย่อมัดีกว่ั�ไม่ัทำ�อะไรเลย ห�กสำตรีมีัค์รรภัห์ร่อมั�รด� หลงัค์ลอดไม่ัสำ�มั�รถทำ�ต�มัค์ำ� แนะนำ�เหล่�นี�ได� ก�รทำ�กิจั- ก ร ร มั ท � ง ก � ย บ� ง ก็ เ ป็ น ป ร ะ โ ย ช น์ต่ อ สุำ ขี ภั � พ็ ขี อ ง พ็วักเขี�แล�วั สำ ต รี มีั ค์ ร ร ภั์ห ร่ อ มั � ร ด � หลังค์ลอดค์วัรเริ� มัจั�กก�ร ทำ�กิจักรรมัท�งก�ยเบ� ๆ แล�วัค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มั หนกัหน่วังและระยะเวัล�ขี่ �น ก � ร บ ริ ห � ร ก ล� มั เ น่� อ อุ� ง เชิงกร�นเป็นประจัำ�ทุกวััน สำ�มั�รถลดค์วั�มัเสีำ� ยงจั�ก อ�ก�รกลั�นปัสำสำ�วัะไม่ัอย่้ หลีกเลี�ยงก�รทำ�กิจักรรมัท�งก�ยในขีณิะที�อ�ก�ศร�อนเกินไป โดยเฉพ็�ะเม่ั�อมีัค์วั�มัช่�นส้ำง รกัษ�ระดบันำ � ในร่�งก�ยด�วัยก�รด่�มันำ � ก่อน ระหว่ั�ง และหลงั ก�รทำ�กิจักรรมัท�งก�ย หลีกเลี�ยงก�รเขี� ร่วัมักิจักรรมัที�ต�องมีัก�รสำมััผู้สัำกนั ท่�ที�เสีำ�ยงต่อ ก�รหกล�มั หร่ออ�จัต�องจัำ�กดัปริมั�ณิออกซิเจัน (เช่น กิจักรรมั ในที�ส้ำง ห�กไม่ัได�พ็กัอ�ศยัในที�ค์วั�มักดอ�ก�ศส้ำงอย่้แล�วั) เลี� ยงกิจักรรมัในท่�นอนหง�ยหลังจั�กช่วัง 3 เด่อนขีอง ก�รตั�งค์รรภั์ ห�กต�องมีัก�รแข่ีงขีนัด� นกีฬ�หร่อก�รบริห�รร่�งก�ยที�เกินกว่ั� ขี�อแนะนำ� สำตรีมีัค์รรภัค์์วัรปรก่ษ�ผู้้�เชี�ยวัช�ญ่ท�งด� นก�รด้แล สุำขีภั�พ็โดยเฉพ็�ะ สำตรีมีัค์รรภัค์์วัรได�รบัขี�อม้ัลจั�กผู้้�ให�บริก�รด� นก�รด้แลสุำขีภั�พ็ ถง่สำญั่ญ่�ณิที� เต่อนให�หยุดหร่อจัำ�กดัก�รทำ�กิจักรรมัท�งก�ย และปรก่ษ�ผู้้�ให�บริก�รสุำขีภั�พ็ทนัทีที�เกิดเหตุนั�น ๆ ค่์อย ๆ กลบัมั�ทำ�กิจักรรมัท�งก�ยช� ๆ หลงัจั�กค์ลอดบุตร และปรก่ษ�ผู้้�ประกอบวิัช�ชีพ็ด� นสุำขีภั�พ็ในกรณีิผู่้�ค์ลอด เช่นเดียวักบัวัยัผู้้�ใหญ่่ทั�วั ๆ ไป พ็ฤติกรรมัเน่อยนิ�งในสำตรีมีัค์รรภัแ์ละมั�รด�หลงัค์ลอดนั�นจัะก่อให�เกิด ผู้ลเ สีำยต่อสุำขีภั�พ็ ทั�งก�รเ สีำยชีวิัตจั�กทุกสำ�เหตุ ก�รเ สีำยชีวิัตจั�กโรค์หลอดเล่อดหัวัใจั ก�รเสีำยชีวิัตจั�กโรค์มัะเร็ง โอก�สำในก�รเกิดโรค์หลอดเล่อดหวััใจั โรค์มัะเร็ง และโรค์เบ�หวั�นชนิดที�สำอง แนะนำ�ให:้ สำติรีมีัค์รรภแ์ละมั�รด�หลงัค์ลอดค์วรจำ�กดั เวล�ข้องพฤติิกรรมัเนือยนิ�ง และทดแทนเวล� เหล่�นั�นดว้ยก�รทำ�กิจกรรมัท�งก�ยในทุก ระดบั (รวมัถง้ระดบัเบ�) เพื�อผลดีต่ิอสุำข้ภ�พ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นสำนบัสำนุนน�อย > ทำ�กิจกรรมั ท�งก�ยบ�้ง ย่อมัดีกว่� ก�รไม่ัข้ยบัเลย จำ�กัิด็ แทนืท่� เวัล�ท่� ใช้้ ไปกัิบ พฤติิกิรัรัมเนืือยนิื�ง ด้็วัยกิิจกิรัรัมท�งกิ�ย ในืทุกิ ๆ รัะดั็บคำวั�มหนัืกิ (รวมัถึึงก�รออกกำ�ลังเบ�ๆ) กิจักรรมัท�งก�ยส่ำงผู้ลดีต่อผู้้�ใหญ่่และผู้้�ส้ำงอ�ยุที�มีัภั�วัะเร่ �อรงัต่�ง ๆ ได�ดงันี� สำำ�หรบัผ้ร้อดชี้วิติจ�กมัะเร็ง กิจักรรมัท�งก�ยจัะทำ�ให�อ�ก�รต่�ง ๆ ดีขี่ �น ทั�งอ�ก�รที� เกิดจั�กโรค์มัะเร็งโดยตรง และค์วั�มัเสีำ�ยงที�มัะเร็งจัะกลบัมั� หร่อมัะเร็งค์รั�งใหญ่่รอบสำอง สำำ�หรบัผ้ที้� มีัอ�ก�รค์ว�มัดนัโลหิติส้ำง กิจักรรมัท�งก�ย ช่วัยให�อ�ก�รที�เกี�ยวัเน่�องกบัหลอดเล่อดหวััใจั ก�รดำ�เนินขีองโรค์อย่�งต่อเน่�อง ก�รทำ�ง�นขีองร่�งก�ย คุ์ณิภั�พ็ชีวิัตที�เกี�ยวัเน่�องกบัสุำขีภั�พ็ ดีขี่ �น สำำ�หรบัผ้ที้�ป่วยเป็นโรค์เบ�หว�นช้นิดที�สำอง กิจักรรมัท�งก�ยจัะลดอตัร� ก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อดหวััใจัและสำญั่ญ่�ณิบ่งชี�ก�รดำ�เนินขีองโรค์อย่�งต่อเน่�อง สำำ�หรบัผ้ป่้วยที�มีัเชื้ �อ HIV กิจักรรมัท�งก�ยจัะทำ�ให�ร่�งก�ยแข็ีงแรงและสุำขีภั�พ็จิัตดีขี่ �น (ลดอ�ก�รกงัวัลและซม่ัเศร� ) และไม่ัมีัผู้ลกระทบ ในด� นลบต่อก�รดำ�เนินขีองโรค์อย่�งต่อเน่�อง (จัำ�นวัน CD4 และเช่�อในเล่อด) หร่อองค์ป์ระกอบขีองร่�งก�ย ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 10 แนะนำ�ให:้ ผ้ ใ้หญ่่และผ้ส้้ำงอ�ยุที�มีัภ�วะเจ็บป่วยเรื �อรงัค์วรทำ�กิจกรรมัท�งก�ยอย่�งสำมัำ� เสำมัอ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� > ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) ผ้ ้ใหญ่่และผ้ส้้ำงอ�ยุที� มีัภ�วะเจ็บป่วยเรื �อรงั ค์ ว ร ทำ � กิจ ก ร ร มั ท � ง ก � ย แ บ บ แ อ โร บิ ก ที� ระดบัป�นกล�งอย่�งนอ้ย 150-300 น�ที หรือที�ระดบัหนกัอย่�งนอ้ย 75-150 น�ที หรือ ผสำมัผสำ�นทั�งสำองระดบัอย่�งเท่�เทียมักนัติลอด สำปัด�ห ์เพื�อสุำข้ภ�พที�ดีอย่�งย ั�งยืน แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� ผ้ ใ้หญ่่และผ้ส้้ำงอ�ยุที�มีัภ�วะเจ็บป่วยเรื �อรงัเหล่� นี �ค์วรทำ�กิจกรรมัเสำริมัสำร�้งกล�้มัเนื �อในระดบั ป�นกล�งข้้ �นไป โดยใช้ก้ล�้มัเนื �อกลุ่มัหลกัอย่�ง นอ้ย 2 วนัต่ิอสำปัด�หเ์พื�อประโยช้นที์�มั�กข้้ �น แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� ก�รทำ�กิจกรรมัท�งก�ยในแต่ิละสำปัด�ห ์ ผ้ส้้ำง- อ�ยุที�มีัโรค์เรื �อรงัค์วรจะทำ�กิจกรรมัท�งก�ยให้ หล�กหล�ย โดยเนน้ไปที�ก�รสำร�้งสำมัดุลและฝึึก ค์ว�มัแข็้งแรงที�ระดบัป�นกล�งข้้ �นไป อย่�งนอ้ย 3 วนัต่ิอสำปัด�ห ์เพื�อเสำริมัสำร�้งค์ว�มัสำ�มั�รถใน ก�รทำ�ง�นข้องร่�งก�ยและป้องกนัก�รหกลม้ั แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� > > > อย่�งน้ือย ถึึง ถึึง หรืัอ150 75 300 150 นาทีี นาทีี อย่�งน้ือย สำำ�หรัับกิิจกิรัรัม ท�งกิ�ยแบบแอโรับิกิ ท่�รัะดัับหนักิ หร้ัอผสำมผสำ�นทั�งสำองรัะดัับอย่�งเท่�เท่ยมกัิน ตลอดัทั�งสัำปดั�ห์ สำำ�หรัับกิิจกิรัรัม ท�งกิ�ยแบบแอโรับิกิ ท่�รัะดัับป�นกิล�ง วััน 2 สำำ�หรัับกิิจกิรัรัมสำร้ั�งคว�มแข็็งแรังให้กัิบกิล้�มเน้�อท่� ใช้้กิล้�มเน้�อหลักิ ทุกิส่ำวนในรัะดัับ ป�นกิล�งข้็�นไป เพ้ื่�อสุำข็ภ�พื่ท่�ด่ัข้็�น: อย่�งน้ือย สัำปด็�ห์ ต่ิอ วััน 3 สำำ�หรัับกิิจกิรัรัมท�งกิ�ย หล�กิหล�ยรูัปแบบท่�เน้น ไปท่�กิ�รัสำร้ั�งสำมดุัล ร่ั�งกิ�ยและฝึึกิคว�ม แข็็งแรังท่�รัะดัับ ป�นกิล�งข้็�นไป อย่�งน้ือย ต่ิอ สัำปด็�ห์ 11ข้้อัมููลสรุป ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) สำำ�หรบัผ้ร้อดชี้วิติจ�กมัะเร็งและผ้ ใ้หญ่่ที�มีัค์ว�มัดนัโลหิติส้ำง เบ�หว�นช้นิดที�สำองและ HIV ข้อ้แนะนำ�คื์อ: ห�กไม่ัมีัข้อ้ห�้มัใด ๆ ผ้ ้ใหญ่่หรือผ้ส้้ำงอ�ยุที�มีั โรค์เรื �อรงัอ�จเพิ�มัก�รทำ�กิจกรรมัท�งก�ยแบบ แอโรบิกที�ระดบัป�นกล�งใหม้ั�กกว่� 300 น�ทีได ้ หรืออ�จเพิ�มัใหม้ั�กกว่� 150 น�ทีไดเ้ช่้นกนั หรือผสำมัผสำ�นทั�งสำองระดบัใหเ้ท่�เทียมักนั ติลอดทั�งสำปัด�ห ์เพื�อสุำข้ภ�พที�ดีข้้ �น ค์ำ�แนะนำ�แบบมีัเง่�อนไขี หลกัฐ�นที�เช่�อถ่อได� > • ห�กไม่ัสำ�มั�รถทำ�ต�มัค์ำ�แนะนำ�ขี� งต�นได� ผู้้�ใหญ่่ที�มีัโรค์เร่�อรงัค์วัรทำ�กิจักรรมัท�งก�ย เท่�ที�ร่�งก�ยเอ่ �ออำ�นวัย • ผู้้�ใหญ่่ที� มีัโรค์เร่�อรงัค์วัรเริ� มัจั�กกิจักรรมั ท�งก�ยเบ� ๆ แล�วัค่์อย ๆ เพิ็� มัค์วั�มัถี� ค์วั�มัหนกัหน่วัง และระยะเวัล�ขี่ �น • ผู้้�ใหญ่่ที� มีัโรค์เร่�อรงัค์วัรปร่กษ�ผู้้�เชี�ยวัช�ญ่ ด� นก�รทำ�กิจักรรมัท�งก�ย หร่อบุค์ล�กร ท�งก�รแพ็ทยเ์พ่็� อขีอค์ำ�แนะนำ�เกี� ยวักับ ประเภัทและระยะเวัล�ขีองกิจักรรมัที�เหมั�ะสำมั ต่อค์วั�มัต�องก�ร ค์วั�มัสำ�มั�รถ ขี�อจัำ�กดัและ ค์วั�มัซบัซ�อนด� นร่�งก�ย ก�รใช�ย� และแผู้น ก�รรกัษ�โดยรวัมัขีองแต่ละบุค์ค์ล • สำำ�หรบับุค์ค์ลที� ไม่ัมีัขี�อห� มัใด ๆ ไม่ัจัำ�เป็นต�อง มีัใบรบัรองท�งก�รแพ็ทยก่์อนก�รทำ�กิจักรรมั ท�งก�ย ทั�งก�รทำ�กิจักรรมัท�งก�ยที�ระดบั เบ�และระดบัป�นกล�งที� ไม่ัมั�กไปกว่ั�ก�ร เดินเร็วัหร่อก�รใช�ชีวิัตประจัำ�วันั ในวััยผู้้�ใหญ่่ รวัมัถ่งผู้้�ที� ห�ยจั�กมัะเร็งและผู้้�มีัค์วั�มัดันโลหิตส้ำง เบ�หวั�นชนิดที� สำอง และ HIV พ็ฤติกรรมัเน่อยนิ�งที�เพิ็�มัส้ำงขี่ �นจัะต�มัมั�ด�วัยสุำขีภั�พ็ที�แย่ลง ดงันี� ก�รเสีำยชีวิัตทุกสำ�เหตุ ก�รเสีำยชีวิัตจั�ก โรค์หลอดเล่อดหวััใจัและมัะเร็ง และโอก�สำก�รเกิดโรค์หลอดเล่อดหวััใจั มัะเร็ง และโรค์เบ�หวั�นชนิดที�สำอง ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ ผ้ ้ใหญ่่และผ้ส้้ำงอ�ยุที� มีัโรค์เรื �อรงันั�นค์วร จำ�กดัระยะเวล�ที� ใช้ ้ไปกบัพฤติิกรรมัเนือย นิ�ง และแทนที�เวล�เหล่�นั�นดว้ยก�รทำ�กิจ- กรรมัท�งก�ยในทุกระดบั (รวมัถง้ระดบัเบ�) เพื�อประโยช้นต่์ิอสุำข้ภ�พ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นประกอบน�อย ผ้ ้ใหญ่่และผ้ส้้ำงอ�ยุที� มีัโรค์เรื �อรงัค์วรจะทำ� กิจกรรมัท�งก�ยให้ไดม้ั�กกว่�ระดบัที�แนะนำ� ท ั�งระดบัป�นกล�งและหนกั เพื�อช่้วยลดผล เสีำยต่ิอสุำข้ภ�พจ�กก�รมีัพฤติิกรรมัเนือยนิ�ง แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นประกอบน�อย > > เพ้ื่�อสุำข็ภ�พื่ท่�ด่ัข้็�น: หร้ัอผสำมผสำ�นทั�ง 2 รัะดัับอย่�งเท่�เท่ยมกัินตลอดัทั�งสัำปดั�ห์ มากกว่ัา มากกว่ัา หรืัอ สำำ�หรัับกิิจกิรัรัม ท�งกิ�ย แบบแอโรับิกิ รัะดัับหนักิ นาทีี นาทีี สำำ�หรัับกิิจกิรัรัมท�ง กิ�ยแบบแอโรับิกิ รัะดัับป�นกิล�ง จำ�กัิด็ แทนืท่� เวัล�ท่� ใช้้ ไปกัิบ พฤติิกิรัรัมเนืือยนิื�ง ด้็วัยกิ�รัทำ�กิิจกิรัรัมท�งกิ�ย เพิ�มขึ้�นืในืทุกิรัะดั็บ (รวมัถึึงระดับเบ�) ทำ�กิจกรรมั ท�งก�ยบ�้ง ย่อมัดีกว่� ก�รไม่ัทำ�อะไรเลย ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 12 กิจักรรมัท�งก�ยมีัประโยชนต่์อเด็กและวัยัรุ่นมั�กมั�ย ต�มัที� ได�กล่�วัไวั�แล�วัใน บทก่อนหน� และยงัเกี�ยวัเน่�องกบัเด็กและวัยัรุ่นที�มีัภั�วัะทุพ็พ็ลภั�พ็ด�วัย ประโยชนข์ีอง กิจักรรมัท�งก�ยต่อสุำขีภั�พ็สำำ�หรบัเด็กและวัยัรุ่นที� มีัภั�วัะทุพ็พ็ลภั�พ็ยงัรวัมัถง่ ก�ร พ็ฒัน�ค์วั�มัจัำ�ในบุค์ค์ลที�มีัโรค์หร่อค์วั�มัผิู้ดปรกติที�ทำ�ล�ยสำมัองส่ำวันก�รรบัร้� โรค์สำมั�ธิิสำั�น (ADHD) ก�รทำ�ง�นขีองร่�งก�ยอ�จัดีขี่ �นสำำ�หรบัเด็กที�มีัค์วั�มับกพ็ร่องท�งสำติปัญ่ญ่� เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) ท่� ม่ภิ�วัะทุพพลภิ�พ แนะนำ�ให:้ เด็กหรือวยัรุ่นที� มีัภ�วะทุพพลภ�พ ค์วรทำ� กิจกรรมัท�งก�ยแบบแอโรบิกที� ระด ับ ป�นกล�ง-หนกั อย่�งนอ้ยเฉลี�ย 60 น�ทีต่ิอวนั ติลอดทั�งสำปัด�ห ์ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นย่นยนัได� ค์วรทำ�กิจกรรมัท�งก�ยแบบแอโรบิกที� ระดบัหนกัร่วมักบัก�รสำร�้งค์ว�มัแข็้งแรง ให้ก ับ ก ล ้�มั เนื �อ แ ล ะ กร ะ ด้ กอ ย่ �ง น้อ ย สำปัด�หล์ะ 3 วนั แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นเช่�อถ่อได� > > อย่�งน้ือย อย่�งน้ือย สำำ�หรัับกิิจกิรัรัมท�งกิ�ยในรัะดัับ ป�นกิล�งหร้ัอหนักิ ตลอดทัี่�งสััปด�ห์์ โดยให้์ที่ำ�กิจกรรมัที่�งก�ยแบบ แอโรบิกเป็นสั�วนให์ญ่� สำำ �หรัับกิิจกิรัรัมท�งกิ�ยแบบแอโรับิกิท่� รัะดัับหนักิ ร�วมักับกิ�รัสำร้ั�งคว�มแข็็งแรัง ให้กัิบกิล้�มเน้�อและกิรัะดูักิ นาทีี ต่่อวััน นาทีี ต่่อสััปดาห์์ เริ�มัติน้ดว้ย กิจกรรมัท�งก�ย ในระดบัเบ� 13ข้้อัมููลสรุป เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) ท่�ม่ภิ�วัะทุพพลภิ�พ • ทำ�กิจักรรมัท�งก�ยบ� งย่อมัดีกว่ั�ไม่ัทำ�อะไรเลย • ห�กเด็กหร่อวัยัรุ่นผู้้�มีัภั�วัะทุพ็พ็ลภั�พ็ไม่ัสำ�มั�รถทำ�ต�มัค์ำ�แนะนำ�เหล่�นี�ได� ก�รได�ทำ� กิจักรรมัท�งก�ยบ� งก็เป็นผู้ลดีต่อสุำขีภั�พ็แล�วั • เด็กหร่อหร่อวัยัรุ่นที� มีัภั�วัะทุพ็พ็ลภั�พ็ค์วัรเริ�มัทำ�กิจักรรมัท�งก�ยอย่�งเบ� ๆ ก่อนแล�วั ค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มัหนกั และระยะเวัล�ขี่ �น • กิจักรรมัท�งก�ยสำำ�หรบัเด็กและวัยัรุ่นที�มีัภั�วัะทุพ็พ็ลภั�พ็นั�นไม่ัมีัค์วั�มัเสีำ�ยงห�กอย่้ในระดบั ที�เหมั�ะสำมักบัระดบักิจักรรมั สำถ�นะด� นสุำขีภั�พ็ และสำภั�พ็ร่�งก�ยขีองบุค์ค์ลนั�น และผู้ลดี ต่อสุำขีภั�พ็มีัมั�กกว่ั�ค์วั�มัเสีำ�ยง • เด็กและวัยัรุ่นที� มีัภั�วัะทุพ็พ็ลภั�พ็อ�จัจัะต�องปร่กษ�บุค์ล�กรท�งแพ็ทยห์ร่อผู้้�เชี�ยวัช�ญ่ ด� นกิจักรรมัท�งก�ยและภั�วัะทุพ็พ็ลภั�พ็เพ่็�อกำ�หนดประเภัทและระยะเวัล�ที� เหมั�ะสำมั ในก�รทำ�กิจักรรมั พ็ฤติกรรมัเน่อยนิ�งที�เพิ็�มัส้ำงขี่ �นในวัยัเด็กและวัยัรุ่นต�มัมั�ด�วัยผู้ลที� ไม่ัดีต่อสุำขีภั�พ็ เช่น โรค์อ�วันที�เพิ็�มัส้ำงขี่ �น โรค์เกี�ยวักบัหลอดเล่อด สำมัรรถภั�พ็ร่�งก�ย และก�รประพ็ฤติตนและพ็ฤติกรรมัเอ่ �อสำงัค์มัที�แย่งลง และระยะเวัล�ในก�รนอนหลบัที�น�อยลง แนะนำ�ให:้ เด็กหรือวยัรุ่นที� ทุพพลภ�พค์วรจะลดระยะ เวล�ที�ใช้ ้ไปกบัพฤติิกรรมัเนือยนิ�ง โดยเฉพ�ะ เวล�ที�อย่้กบัหน�้จอ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นประกอบน�อย > จำ�กัิด็ เวัล�ท่� ใช้้ ไปกัิบ พฤติิกิรัรัมเนืือยนิื�ง โดยเฉพ�ะเวล�ท่ี่�อย่� กับห์น้�จอ ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ ประโยชนข์ีองกิจักรรมัท�งก�ยต่อวัยัผู้้�ใหญ่่หล�ยประก�รได�กล่�วัไวั�แล�วั ขี� งต�น และยงัหมั�ยรวัมัถง่ผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ด�วัย ประโยชนข์ีอง กิจักรรมัท�งก�ยต่อผู้้�ที�มีัทุพ็พ็ลภั�พ็ มีัดงันี� สำาหรบัผู่ใ้หญ่่ที�มีภาวะกิลา้มเน่ �อ อ่อนแรง กิจักรรมัท�งก�ยจัะช่วัยพ็ัฒน�ก�รทำ�ง�นขีองร่�งก�ยและคุ์ณิภั�พ็ชีวิัตที� เกี�ยวัเน่�องกบัสุำขีภั�พ็ทั�งท�งร่�ยก�ย จิัตใจั และสำงัค์มั สำาหรบัผู่ที้�บาดุเจ็บที�เสน้ประสาทไข็สนั- หลงั จัะทำ�ให�ก�รเดิน ค์วั�มัแข็ีงแรงกล� มัเน่�อ ก�รทำ�ง�นขีองร่�งก�ยช่วังบนดีขี่ �น และเสำริมัสำร� ง คุ์ณิภั�พ็ชีวิัตด� นสุำขีภั�พ็ สำาหรบัผู่ที้� มีโรคหร่อความปรกิติ่ในกิารรบัรูบ้กิพื่ร่อง จัะช่วัย ทำ�ให�ก�รทำ�ง�นขีองร่�งก�ยและก�รรบัร้�ดีขี่ �น (สำำ�หรบัผู้้�ที� เป็นโรค์พ็�รกิ์นสำนัหร่อเค์ยมีัประวัติั หัวัใจัวั�ย) มีัผู้ลดีต่อร่�งก�ยด� นประสำ�ทก�รรับร้� และอ�จัพ็ฒัน�คุ์ณิภั�พ็ค์วั�มัเป็นอย่้ (สำำ�หรบัผู้้�ใหญ่่ที�เป็นโรค์จิัตเภัท) พ็ฒัน�ก�รทำ�ง�นขีองร่�งก�ย (สำำ�หรบัผู้้�ใหญ่่ที�มีัค์วั�มับกพ็ร่อง ท�งสำติปัญ่ญ่�) และพ็ฒัน�คุ์ณิภั�พ็ชีวิัต (สำำ�หรบัผู้้�ใหญ่่ที�อย่้ระหว่ั�งก�รรกัษ�โรค์ซม่ัเศร� ) ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 14 ผูู้้ใหญ่ (อ�ยุ 18 ปีขึ้�นืไป) ท่� ม่ภิ�วัะทุพพลภิ�พ แนะนำ�ให:้ ผ้ ใ้หญ่่ที�มีัภ�วะทุพพลภ�พค์วรทำ�กิจกรรมัท�งก�ยเป็นประจำ�ในทุกวนั แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได� > ผ้ ใ้หญ่่ที�มีัภ�วะทุพพลภ�พค์วรจะทำ�กิจกรรมั ท�งก�ยแบบแอโรบิกที�ระดบัป�นกล�งอย่�ง นอ้ย 150-300 น�ที หรือที�ระดบัหนกัอย่�งนอ้ย 75-150 น�ที หรือผสำมักนัท ั�ง 2 ระดบั ติลอดสำปัด�ห ์เพื�อสุำข้ภ�พที�ดีอย่�งย ั�งยืน แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นย่นยนัเช่�อถ่อได� > ผ้ ใ้หญ่่ที�มีัภ�วะทุพพลภ�พค์วรทำ�กิจกรรมั สำ ร ้� ง ค์ ว � มั แ ก ข็้ ง แรง ให้ก ับ ล ้� มั เนื �อ โดยใช้ก้ล�้มัเนื �อหล ักทุกส่ำวนที� ระด ับ ป�นกล�งข้้ �นไป อย่�งนอ้ย 2 วนัต่ิอสำปัด�ห ์ เพื�อสุำข้ภ�พที�ดี แนะนำ�อย่�งยิ�ง หลกัฐ�นประกอบเช่�อถ่อได� > อย่�งน้ือย ถึึง ถึึง หรืัอ150 75 300 150 นาทีี นาทีี อย่�งน้ือย สำำ�หรัับกิิจกิรัรัม ท�งกิ�ยแบบแอโรับิกิ ท่�รัะดัับหนักิ หร้ัอผสำมผสำ�นทั�งสำองรัะดัับอย่�งเท่�เท่ยมกัิน ตลอดัทั�งสัำปดั�ห์ สำำ�หรัับกิิจกิรัรัม ท�งกิ�ยแบบแอโรับิกิ ท่�รัะดัับป�นกิล�ง วััน 2 สำำ�หรัับกิิจกิรัรัมสำร้ั�งคว�มแข็็งแรังให้กัิบกิล้�มเน้�อโดัยใช้้กิล้�มเน้�อหลักิ ทุกิส่ำวนในรัะดัับ ป�นกิล�งข้็�นไป เพ้ื่�อสุำข็ภ�พื่ท่�ด่ัข้็�น: อย่�งน้ือย สัำปด็�ห์ ต่ิอ 15 ผูู้้ใหญ่ (อ�ยุ 18 ปีขึ้�นืไป) ท่�ม่ภิ�วัะทุพพลภิ�พ ข้้อัมููลสรุป ผ้ ้ใหญ่่ที� มีัภ�วะทุพพลภ�พสำ�มั�รถเพิ�มักิจ- กรรมัท�งก�ยแบบแอโรบิกที�ระดบัป�นกล�ง ใหม้ั�กกว่� 300 น�ทีได ้หรือทำ�กิจกรรมัท�งก�ย แบบแอโรบิกที�ระดบัหนกัให้มั�กกว่� 150 น�ทีไดเ้ช่้นกนั หรือก�รผสำมัผสำ�นที�เท่�เทียมั กนัระหว่�งกิจกรรมัท�งก�ยแบบแอโรบิกท ั�ง 2 ระดบั ติลอดทั�งสำปัด�หเ์พื�อสุำข้ภ�พที�ดีข้้ �น แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นย่นยนัเช่�อถ่อได� > ก�รทำ�กิจกรรมัท�งก�ยในแต่ิละสำปัด�ห ์ผ้ ใ้หญ่่ที�มีั ภ�วะทุพพลภ�พค์วรทำ�กิจกรรมัท�งก�ยใหห้ล�ก- หล�ย ซ้�งจะช่้วยสำร�้งสำมัดุลร่�งก�ยและฝึึกค์ว�มั แข็้งแรง ดว้ยกิจกรรมัท�งก�ยที�ระดบัป�นกล�ง ข้้ �นไป อย่�งนอ้ยสำปัด�หล์ะ 3 วนั เพื�อเพิ�มัค์ว�มั สำ�มั�รถในก�รทำ�ง�นข้องร่�งก�ยและป้องกนั ก�รหกลม้ั แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อได� > ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ ทำ�กิจักรรมัท�งก�ยบ� งย่อมัดีกว่ั�ไม่ัทำ�อะไรเลย ห�กผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ไม่ัสำ�มั�รถทำ�ต�มัค์ำ�แนะนำ�นี�ได� ก�รทำ�กิจักรรมัท�งก�ยบ� งก็เป็น ผู้ลดีต่อสุำขีภั�พ็แล�วั ผู้้�ใหญ่่ที�มีัค์วั�มัทุพ็พ็ลภั�พ็ค์วัรเริ�มัทำ�กิจักรรมัท�งก�ยเบ� ๆ แล�วัค่์อยเพิ็�มัค์วั�มัถี� ค์วั�มัหนกัหน่วัง และระยะเวัล�ขี่ �น กิจักรรมัท�งก�ยสำำ�หรบัผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็นั�นไม่ัมีัค์วั�มัเสีำ�ยงห�กอย่้ในระดบัที� เหมั�ะสำมักบั ระดบักิจักรรมั สำถ�นะด� นสุำขีภั�พ็ และสำภั�พ็ร่�งก�ยขีองบุค์ค์ลนั�น ผู้ลดีต่อสุำขีภั�พ็มีัมั�กกว่ั�ค์วั�มัเสีำ�ยง ผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็อ�จัจัะต�องปรก่ษ�บุค์ล�กรท�งแพ็ทยห์ร่อผู้้�เชี�ยวัช�ญ่ด� นกิจักรรมัท�งก�ย และภั�วัะทุพ็พ็ลภั�พ็เพ่็�อกำ�หนดประเภัทและระยะเวัล�ที�เหมั�ะสำมัในก�รทำ�กิจักรรมั พ็ฤติกรรมัเน่อยนิ�งที� เพิ็�มัส้ำงขี่ �นในวัยัผู้้�ใหญ่่ต�มัมั�ด�วัยผู้ลที� ไม่ัดีต่อสุำขีภั�พ็ เช่น โรค์อ�วันที� เพิ็�มัส้ำงขี่ �น โรค์เกี�ยวักบัหลอดเล่อด สำมัรรถภั�พ็ร่�งก�ย และก�รประพ็ฤติตนและพ็ฤติกรรมัเอ่ �อสำงัค์มัที�แย่ลง และ ระยะเวัล�ในก�รนอนหลบัที�น�อยลง แนะนำ�ให:้ ผ้ ้ใหญ่่ที�มีัภ�วะทุพพลภ�พค์วรจำ�กดัเวล�ที�ใช้ ้ไป กบัพฤติิกรรมัเนือยนิ�ง และแทนที�เวล�เหล่�นั�นดว้ย กิจกรรมัท�งก�ยในทุกระดบั (รวมัถง้กิจกรรมัท�ง ก�ยที�ระดบัเบ�) เพื�อผลดีต่ิอสุำข้ภ�พ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นอ� งอิงน�อย ผ้ ้ใหญ่่ที� มีัภ�วะทุพพลภ�พค์วรทำ�กิจกรรมัท�ง ก�ยใหม้ั�กกว่�ที�แนะนำ�ไว ้ท ั�งระดบัป�นกล�งและ ระดบัหนกั เพื�อช่้วยลดผลกระทบที�เป็นอนัติร�ยต่ิอ สุำข้ภ�พจ�กพฤติิกรรมัเนือยนิ�งเป็นเวล�น�น แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นอ� งอิงน�อย > > จำ�กัิด็ แทนืท่� เวัล�ท่� ใช้้ ไปกัิบ พฤติิกิรัรัมเนืือยนิื�ง ด้็วัยกิ�รัทำ�กิิจกิรัรัม ท�งกิ�ยในืทุกิรัะดั็บ (รวมัถึึงระดับเบ�) วััน 2 สำำ�หรัับกิิจกิรัรัมท�งกิ�ย อย่�งหล�กิหล�ยท่�เน้ืนื สำร้ั�งสำมดุ็ลร่ั�งกิ�ยและ ฝึึกิคำวั�มแข็้งแรังท่�รัะดั็บ ป�นืกิล�งถึึงหนัืกิ เพ้ื่�อสุำข็ภ�พื่ท่�ด่ัข้็�น: อย่�งน้ือย สัำปด็�ห์ ต่ิอ เพ้ื่�อสุำข็ภ�พื่ท่�ด่ัข้็�น: หรืือผสมผสานท้ั้�ง 2 รืะด้ับอย่่างเท่ั้าเทีั้ย่มก้ันตลอดัท้ั้�งส้ปดัาห์ มากกว่ัา มากกว่ัา หรืัอ สำำ�หรัับกิิจกิรัรัม ท�งกิ�ยแบบแอโรับิกิ ท่�รัะดัับหนักิ สำำ�หรัับกิิจกิรัรัม ท�งกิ�ยแบบแอโรับิกิ ท่�รัะดัับป�นกิล�ง นาทีี นาทีี ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 16 17 คำวั�มเป็นืม� ก�รทำ�กิจักรรมัท�งก�ยเป็นประจัำ� เป็นปัจัจัยัที� ร้�กนัดีกว่ั�เป็นก�รป้องกนั และก�รจัดัก�รโรค์ไม่ัติดต่อต่�ง ๆ เช่น โรค์หลอดเล่อดหวััใจั เบ�หวั�นชนิดที�สำอง มัะเร็งทรวังอก และมัะเร็งลำ�ไสำ� (1-3) กิจักรรมัท�งก�ยยงัมีัผู้ลดีต่อสุำขีภั�พ็จิัต (4) ช่วัยให�เกิดภั�วัะค์วั�มัจัำ�เส่ำ�อมัช� ลง (5) และเอ่ �อต่อก�รรักษ�นำ � หนักที� ดีต่อ สุำขีภั�พ็ (1) และสุำขีภั�พ็ที�ดีด�วัย (6) กิ จั ก ร ร มั ท � ง ก � ย ห มั � ย ถ่ ง ก�รเค์ล่�อนไหวัร่�งก�ยทุกร้ปแบบขีอง กล� มัเน่�อย่ดกระด้กที� ต�องก�รก�รใช� พ็ลังง�น (1) และสำ�มั�รถทำ�ได�ด�วัย ค์วั�มัเขี�มัขี�นหล�ยร้ปแบบ โดยกิจักรรมั ท�งก�ยเป็นส่ำวันหน่� งขีองก�รทำ�ง�น ก�รทำ�ง�นบ� น ระหว่ั�งก�รเดินท�ง หร่อระหว่ั�งเวัล�พ็กัผู่้อน หร่อเม่ั�อเล่น ก�ยบริห�รหร่อกีฬ�ต่�ง ๆ ส่ำวันในระดบั ที�ตำ� สุำดขีองช่วังระดบัค์วั�มัเขี�มัขี�น ค่์อ พ็ฤติกรรมัเน่อยนิ� ง ซ่� งหมั�ยถ่งพ็ฤติ- กรรมัเม่ั�อมีัสำติสำมััปชญั่ญ่ะ ในท่�นั�ง เอน หร่อท่�นอนขีณิะใช�พ็ลงัง�นน�อย หลกั- ฐ�นชิ�นใหม่ัที� พ็บบ่งชี�ว่ั� พ็ฤติกรรมั เน่อยนิ� งในระดบัส้ำงนั�นสำมััพ็นัธิก์บัโรค์ หลอดเล่อดหวััใจัและเบ�หวั�นชนิดที�สำอง เ ช่ น เ ดี ย วั กับ ก � ร เ สีำ ย ชี วิั ต จั � ก โร ค์ หลอดเล่อดหัวัใจั โรค์มัะเร็ง และก�ร เสีำยชีวิัตจั�กทุกสำ�เหตุ (8-10) คำวามูเป็นมูา ก � ร มีั กิ จั ก ร ร มั ท � ง ก � ย ที� ไ ม่ั เพี็ยงพ็อนั�น ไม่ัเป็นไปต�มัค์ำ�แนะนำ� สำำ�หรับกิจักรรมัท�งก�ยเพ่็� อสุำขีภั�พ็ ระดบัโลกประจัำ�ปี 2553 (1) และเป็น สำ�เหตุลำ�ดับต�น ๆ ขีองภั�วัะค์วั�มั เจ็ับป่วัยทั�วัโลก มีัก�รประเมิันว่ั�อตัร�ก�ร เสีำยชีวิัตต่อปีอ�จัลดลงถง่ 4-5 ล� นร�ย ห�กประช�กรโลกขียับตัวักันมั�กขี่ �น (2, 11) ก�รประเมิันกิจักรรมัท�งก�ยที� ไม่ั เพี็ยงพ็อทั�วัโลกชี�ให�เห็นว่ั�ในปีพ็.ศ. 2559 ผู้้�ใหญ่่ร�อยละ 27.5 และวัยัรุ่นร�อยละ 81 นั�นไม่ัเป็นไปต�มัค์ำ�แนะนำ�ขีององค์ก์�ร อ น � มััย โ ล ก ปี 2 5 5 3 แ ล ะ ขี� อ ม้ั ล แนวัโน�มัชี�ให�เห็นว่ั�ตวััเลขีทั� วัโลกกระ- เต่ �องขี่ �นเพี็ยงเล็กน�อยในช่วังทศวัรรษที� ผู่้�นมั� ขี�อม้ัลเหล่�นี�ยงับ่งชี�ให�เห็นว่ั� ผู้้�หญิ่งมีัก�รเค์ล่�อนไหวัร่�งก�ยน�อยกว่ั� ผู้้�ช�ยในเก่อบทุกประเทศ และมีัค์วั�มั แตกต่�งอย่�งมั�กสำำ�หรบัระดบักิจักรรมั ท�งก�ยภั�ยในประเทศและระหว่ั�ง ประเทศและภ้ัมิัภั�ค์ต่�ง ๆ ค์วั�มัแตกต่�ง เหล่�นี�อธิิบ�ยได�ด�วัยค์วั�มัไม่ัเท่�เทียมัใน ก�รเขี� ถง่โอก�สำในก�รทำ�กิจักรรมัท�ง ก�ย ซ่�งทำ�ให�เห็นถง่ค์วั�มัไม่ัเท่�เทียมักนั ด� นสุำขีภั�พ็ ในปัจัจุับนั ยงัไม่ัมีัตวััเลขีประมั�ณิ ก�รด� นพ็ฤติกรรมัเน่อยนิ�งในระดบัโลก แต่นวััตกรรมัด� นเทค์โนโลยีและก�ร เปลี�ยนผู่้�นส่้ำอ�ชีพ็และก�รสำนัทน�ก�ร ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 18 ที� มีัพ็ฤติกรรมัเน่อยนิ�งและก�รใช�ย�น- พ็�หนะที� มีัเค์ร่�องยนตเ์พิ็�มัมั�กขี่ �น เป็น ส่ำวันที� ทำ�ให�ร้ปแบบกิจักรรมัท�งก�ย เปลี� ยนแปลงไปและทำ�ให�พ็ฤติกรรมั เน่อยนิ�งเพิ็�มัขี่ �นทั�วัโลก แผู้นปฏิิบติัก�ร โลกสำำ�หรบักิจักรรมัท�งก�ย พ็.ศ. 2561- 2573 (14) ได�ประก�ศวัตัถุประสำงค์เ์ชิง กลยุทธิ ์4 ขี�อ และแผู้นนโยบ�ยปฎิบติัก�ร 20 ประก�ร เพ่็� อลดค์วั�มัชุกตัวัขีอง กิจักรรมัท�งก�ยที� ไม่ัเพี็ยงพ็อทั� วัโลก ทั�งในผู้้� ใหญ่่และวััยรุ่นลงร�อยละ 15 ให�ได�ภั�ยในปี 2573 ในปี 2553 องค์ก์�ร อน�มััยโลกได�ตีพิ็มัพ็ข์ี�อแนะนำ�เร่� อง กิจักรรมัท�งก�ยเพ่็� อสุำขีภั�พ็ระดับ โลก (1) ซ่�งเป็นขี�อแนะนำ�ด� นสำ�ธิ�รณิสุำขี ฉบับแรกสำำ�หรับเด็ก วััยรุ่น ผู้้� ใหญ่่ และผู้้�ส้ำงอ�ยุ ที� อิงจั�กประช�กร และ ในปี 2561 สำมัชัช�อน�มัยัโลกเรียกร�อง ในมัติฉบบั WHA71.6 ให�องค์ก์�รอน�- มัยัโลกปรบัปรุงแนวัปฏิิบติัฉบบัปี 2553 ในปี 2562 องค์ก์�รอน�มัยัโลก ได�ตีพิ็มัพ็ข์ี�อแนะนำ�ด� นกิจักรรมัท�งก�ย พ็ฤติกรรมัเน่อยนิ� ง และก�รนอนหลบั สำำ�หรบัเด็กอ�ยุตำ� กว่ั� 5 ปี (15) ขี�อแนะนำ� นี�เรียกร�องโดยค์ณิะกรรมัก�รหยุดยั�ง ภั�วัะนำ � หนกัเกินในเด็ก (ขี�อแนะนำ� 4.12) (16) และชี�ให�เห็นถง่ก�รละเลยกลุ่มัที� มีั อ�ยุน�อยนี�ในขี�อแนะนำ�ด� นกิจักรรมั ท�งก�ยเพ่็�อสุำขีภั�พ็ ระดบัโลก ฉบบัปี 2553 ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย และพ็ฤติกรรมัเน่อยนิ� งจั�กองค์ก์�ร อ น�มััย โ ล ก ฉ บับ ปี 2 5 6 3 ตี พิ็ มั พ็ ์ ขี่ �นแทนฉบับปี 2553 ซ่� ง เขีียนจั�ก ค์วั�มัสำำ�ค์ญั่ขีองกิจักรรมัท�งก�ย ต่อสุำขีภั�พ็ได�มีัก�รระบุไวั�ในขี�อแนะนำ� ขีององค์ก์�รอน�มัยัโลกฉบบัอ่�น ๆ ขี�อม้ัล รวัมัขีององค์ก์�รอน�มัยัโลกเร่� องก�ร ป้องกันโรค์ไม่ัติดต่อที� สำำ�ค์ัญ่เพ่็� อก�ร ด้แลสุำขีภั�พ็เบ่ �องต�นในภั�วัะทรพั็ย�ก�ร ก�รด้แลตำ� (17) ได�สำร� งเกณิฑ์วิ์ัธีิก�ร จัดัก�รท�งก�รแพ็ทยส์ำำ�หรบัโรค์ค์วั�มั ดนัโลหิตส้ำง โรค์เบ�หวั�นชนิดที�สำอง ค์วั�มั เสีำ�ยงขีองโรค์หลอดเล่อดหัวัใจัที� เพิ็�มัส้ำง ขี่ �น โรค์ห่ด และโรค์หลอดลมัอุดกั�นเร่ �อรงั และรวัมัถ่งก�รให�ค์ำ�ปร่กษ�เร่� องก�ร เพิ็�มักิจักรรมัท�งก�ยส่้ำระดบัป�นกล�ง (เช่น ก�รเดินเร็วั) และทำ�อย่�งน�อย 150 น�ทีต่อสำัปด�ห์ ซ่� งสำอดค์ล�องกับขี�อ แนะนำ�ระดบัโลกฉบบัปี 2553 ขี�อแนะนำ� ฉบับล่�สุำดขีององค์์ก�รอน�มััยโลก ว่ั�ด�วัยเร่� องก�รลดค์วั�มัเสีำ� ยงขีอง ภั�วัะค์วั�มัจัำ�ถดถอยและสำมัองเส่ำ� อมั (18) โดยระบุไวั�ว่ั� ค์วัรแนะนำ�ให�ผู้้�ใหญ่่ที� มีั ภั � วั ะ ก � ร รับ ร้�ป ร ก ติ ทำ � กิจั ก ร ร มั ท�งก�ย (แนะนำ�อย่�งยิ�ง) และแนะนำ� ให� ผู้้�ที� บกพ็ร่องท�งก�รรับร้�แต่น�อย (แนะนำ�ภั�ยใต�เง่�อนไขี) ทำ�กิจักรรมัท�ง ก�ยเพ่็�อลดค์วั�มัเสีำ�ยงต่อก�รถดถอยขีอง กระบวันก�รรบัร้� องค์ก์�รอน�มัยัโลก รวัมัเอ�ก�รด้แลผู้้�ส้ำงอ�ยุ ค์ำ�แนะนำ�ในก�ร คำำ�แนืะนืำ�หลักิข้้ออื�นื ๆ ข้ององค์ำกิ�รัอนื�มัยโลกิ หลกัฐ�นด� นพ็ฤติกรรมัที�เล่อกสำรรและ ผู้ลต่อเน่�องท�งสุำขีภั�พ็ที�ทนัสำมัยัขี่ �น และ เป็นส่ำวันหน่�งขีองค์ำ�แนะนำ�องค์ร์วัมัด� น กิจักรรมัท�งก�ยและพ็ฤติกรรมัเน่อยนิ�ง ทั�วัโลก 19 เขี� จัดัก�รระดบัชุมัชนที�จัะจัดัก�รก�ร ถดถอยขีองค์วั�มัสำ�มั�รถภั�ยใน (19) ทั�งยงัแนะนำ�ให�มีัก�รบริห�รร่�งก�ย หล�ยร้ปแบบเพ่็�อป้องกนัก�รหกล�มั และ ก�รออกกำ�ลังก�ยสำำ�หรับผู้้�ส้ำงอ�ยุที� เค์ล่�อนไหวัร่�งก�ยได�น�อยลง ค์ำ�แนะนำ� ขีององค์ก์�รอน�มััยโลกเพ่็� อก�รด้แล ก่อนค์ลอดสำำ�หรับประสำบก�รณิ์ก�ร ตั�งค์รรภัที์�ดี (20) แนะนำ�ให�มีัก�รปรก่ษ� เร่�องอ�ห�รที�ดีต่อสุำขีภั�พ็และมีักิจักรรมั ท�งก�ยระหว่ั�งตั�งค์รรภัเ์พ่็�อสุำขีภั�พ็ที� ดีและป้องกนันำ � หนกัเพิ็�มัเกินเกณิฑ์ ์ แต่ มิั ได�กล่�วัถ่งผู้ลดีต่อสุำขีภั�พ็ระหว่ั�ง ตั�งค์รรภัแ์ละหลงัค์ลอดในภั�พ็กวั� ง ขี�อแนะนำ�ขีององค์ก์�รอน�มัยัโลก ฉบบัที�มีัอย่้ผู้นวักรวัมักบัขี�อแนะนำ�ที�ปรบั ปรุงเพิ็�มัเติมัเหล่�นี� เป็นค์ำ�แนะนำ�ระดบั สำ�กลในร้ปแบบที� เขี� ใจัง่�ยขี่ �นเกี�ยวักบั เร่� องขีองกิจักรรมัท�งก�ยและพ็ฤติ- กรรมัเน่อยนิ�ง เพ่็�อก�รป้องกนัและก�ร จัดัก�รโรค์ภัยัหลกั ก�รส่ำงเสำริมัสุำขีภั�พ็ และค์วั�มัเป็นอย่้ที�ดีในทุกช่วังอ�ยุ ช่วัง 10 ปีที� ผู่้�นมั�นั�นมีัหลกัฐ�น เร่� องผู้ลกระทบต่อสุำขีภั�พ็จั�กค์วั�มั หล�กหล�ยในร้ปแบบ ปริมั�ณิ และระยะ เวัล�ขีองกิจักรรมัท�งก�ยเพิ็�มัขี่ �นอย่�ง เห็นได�ชดั รวัมัถ่งผู้ลกระทบจั�กพ็ฤติ- กรรมัเน่อยนิ� ง และค์วั�มัสำมััพ็นัธิเ์กี�ยวั เน่� องระหว่ั�งระดับกิจักรรมัท�งก�ย กบัสุำขีภั�พ็ นอกเหน่อจั�กนั�น หลกัฐ�น เหตุิผู้ลและคำวั�มมุ่งหม�ย ประกอบด� นกิจักรรมัท�งก�ยสำำ�หรบั ประช�กรกลุ่มัย่อย เช่น มีัก�รเปิดโอก�สำ ให�มีัก�รตรวัจัสำอบค์วั�มัสำมััพ็นัธิร์ะหว่ั�ง กิจักรรมัท�งก�ยและผู้ลลพั็ธิด์� นสุำขีภั�พ็ ในกลุ่มัสำตรีมีัค์รรภัแ์ละผู้้�มีัโรค์เร่�อรงั และ/หร่อภั�วัะทุพ็พ็ลภั�พ็ ใ น ขี� อ แ น ะ นำ � ร ะ ดับ โ ล ก ด� น กิจักรรมัท�งก�ย ปี 2561-2573 (14) ขี�อที� 4.1 เรียกร�องให�องค์ก์�รอน�มัยัโลก พ็ัฒน�และเผู้ยแพ็ร่ขี�อแนะนำ�ระดับ โ ล ก ว่ั� ด�วั ย กิจั ก ร ร มั ท�ง ก� ย แ ล ะ พ็ฤติกรรมัเน่อยนิ�งในเด็กอ�ยุตำ� กว่ั� 5 ปี เย�วัชน ผู้้�ใหญ่่ ผู้้�ส้ำงอ�ยุ และประช�กร กลุ่มัย่อยที�เฉพ็�ะเจั�ะจัง เช่น สำตรีมีัค์รรภั ์ ผู้้�เป็นโรค์เร่�อรงัและทุพ็พ็ลภั�พ็ ก�รปรบั- ปรุงและขีย�ยขีอบข่ี�ยขีองขี�อแนะนำ�ให� กวั� งขี่ �นดงัที�สำมัชัช�อน�มัยัโลกร�องขีอ ทำ�ให�แน่ใจัได�ว่ั�ประช�กรกลุ่มัที� ไม่ัได� กล่�วัถ่งไวั�ในค์ำ�แนะนำ�ฉบับปี 2553 จัะได�รบัขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย โดยเฉพ็�ะ ซ่� งพ็�องกับหลักก�รและ เ ป้ � ห มั � ย ห ลัก ๆ ขี อ ง ขี�อ แน ะ นำ � ระดบัโลกด� นกิจักรรมัท�งก�ย ค่์อเพ่็�อ ลดค์วั�มัไม่ัเท่�เทียมัและสำนบัสำนุนให�ผู้้�ค์น ทำ�กิจักรรมัท�งก�ยเพิ็�มัขี่ �นในทุกวันั เป้�หมั�ยโดยรวัมัขีองขี�อแนะนำ� เหล่�นี�ค่์อก�รจััดทำ�ขี�อแนะนำ �ด� น สำ�ธิ�รณิสุำขีที� มีัหลกัฐ�นรองรบั ว่ั�ด�วัย กิจักรรมัท�งก�ยชนิดใดและในปริมั�ณิ เท่�ใด ที� เด็ก วััยรุ่น ผู้้�ใหญ่่ ผู้้�ส้ำงอ�ยุ และประช�กรกลุ่มัย่อย เช่น สำตรีมีัค์รรภั ์ และผู้้�มีัภั�วัะเร่ �อรังหร่อทุพ็พ็ลภั�พ็ ค์วัรทำ�เพ่็�อประโยชนแ์ละลดค์วั�มัเสีำ�ยง ต่อสุำขีภั�พ็ ขี�อแนะนำ�นี�ยังก่อให�เกิด คำวามูเป็นมูา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 20 ขี�อแนะนำ�ที� มีัหลกัฐ�นรองรบัเกี�ยวักบั ค์วั�มัเช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อย- นิ�งและผู้ลต่อสุำขีภั�พ็อีกด�วัย ขี�อแนะนำ�นี�ได�พ็ฒัน�ขี่ �นสำำ�หรับ เด็กและวัยัรุ่น (อ�ยุ 5-17 ปี) ผู้้�ใหญ่่ (อ�ยุ 18-64 ปี) ผู้้�ส้ำงอ�ยุ (อ�ยุ 65 ปีขี่ �นไป) และ เป็นค์รั�งแรกที�รวัมัเอ�ค์ำ�แนะนำ�ในด� น กิจักรรมัท�งก�ยสำำ�หรบัประช�กรกลุ่มั ย่อย เช่น สำตรีมีัค์รรภัแ์ละผู้้�มีัภั�วัะเร่ �อรงั และทุพ็พ็ลภั�พ็เอ�ไวั�ด�วัย ขี�อแนะนำ�นี�จัดั ทำ�ขี่ �นสำำ�หรับแต่ละกลุ่มัอ�ยุและกลุ่มั ประช�กรย่อย เพ่็�อให�ผู้้�ที�ทำ�ง�นกบัชุมัชน เหล่�นี�เขี� ถง่ขี�อม้ัลที�เกี�ยวัขี�องได�โดยง่�ย ก�รให�ค์ำ�แนะนำ�เฉพ็�ะเจั�ะจังกบักลุ่มั ประช�กรกลุ่มัย่อย โดยเฉพ็�ะกลุ่มัที� มีั โรค์เร่�อรงัหร่อทุพ็พ็ลภั�พ็ แสำดงให�เห็นถง่ ค์วั�มัสำำ�ค์ญั่ขีองก�รรวัมัประช�กรกลุ่มั ย่อยไวั�ในนโยบ�ยและก�รวั�งแผู้นสำำ�หรบั กิจักรรมัท�งก�ยและพ็ฤติกรรมัเน่อยนิ�ง ขี�อแนะนำ�เหล่�นี�ไม่ัได�กล่�วัถง่ก�ร นอนหลบัว่ั�เป็นหน่�งในพ็ฤติกรรมั ก�ร นอนเป็นประเด็นสำำ�ค์ญั่ที� เกี�ยวัเน่�องกบั สุำขีภั�พ็และเป็นหวััขี�อเกิดใหม่ัในศ�สำตร ์ ด� นสุำขีภั�พ็ขีองประช�กร อย่�งไรก็ดี ก�รที�จัะรวัมัก�รนอนหลบัไวั�ในค์ำ�แนะนำ� ที�ปรบัปรุงแล�วัอ�จัถ่อว่ั�อย่้เหน่อขีอบ- ข่ี�ย ถ่งกระนั�นก็ต�มั ค์วั�มัสำำ�ค์ญั่ขีอง ก�รนอนหลบันั�นก็เป็นที�ตระหนกัร้�และ รวัมัไวั�ว่ั�เป็นผู้ลลพั็ธิท์�งสุำขีภั�พ็ที�สำำ�ค์ญั่ เม่ั�อพิ็จั�รณิ�ถง่ผู้ลจั�กกิจักรรมัท�งก�ย และพ็ฤติกรรมัเน่อยนิ�ง 21 เอกสำ�รนี�ร�ยง�นกระบวันก�รและ สำรุปให�เห็นก�รทบทวันขี�อม้ัลที�มีัหลกัฐ�น เพ่็�อพ็ฒัน�ขี�อแนะนำ� ผู้้�รบัสำ�รหลกั ได�แก่ • ผู้้�ร่�งนโยบ�ยในกระทรวังสำ�ธิ�รณิสุำขี ศ่กษ�ธิิก�ร เย�วัชน กีฬ� และ/หร่อ สำวััสำดิก�รค์รอบค์รัวัและสำงัค์มั ซ่� ง ทำ�ง�นอย่้ในประเทศที� มีัร�ยได�ส้ำง ป�นกล�ง และตำ� และมีัหน� ที�กำ�หนด ขี�อแนะนำ�ขีองแต่ละประเทศ และ วั�งแผู้นก�รจััดก�รด� นสุำขีภั�พ็ ก�รศ่กษ� สำถ�นที� ประกอบอ�ชีพ็ แหล่งที� พ็ักอ�ศัยหร่อชุมัชนให�กับ ทุกช่วังวัยั • เจั� หน� ที�ขีองรฐัซ่�งพ็ฒัน�ขี�อแนะนำ� ในระดบัช�ติ ระดบัภ้ัมิัภั�ค์ หร่อระดบั ท�องถิ�นเพ่็�อที�จัะเพิ็�มักิจักรรมัท�งก�ย แ ล ะ ล ด พ็ ฤ ติ ก ร ร มั เ น่ อ ย นิ� ง ใ น กลุ่มัประช�กรต่�ง ๆ ผู่้�นเอกสำ�ร ขี�อแนะนำ�เหล่�นี� • บุค์ค์ลที� ทำ �ง�นในองค์์กรที� ไ ม่ั ใ ช่ องค์ก์รขีองรฐั องค์ก์รด� นก�รศก่ษ� สำถ�นที�ทำ�ง�น หร่อองค์ก์รก�รวิัจัยั • บุค์ค์ลที�ทำ�ง�นในก�รให�บริก�รด� น สุำขีภั�พ็ ให�ค์ำ�ปร่กษ�และค์ำ�แนะนำ� เช่น ชุมัชน ค์รอบค์รวัั พ็ย�บ�ลหร่อ แพ็ทย์ในระดบัหลกัหร่อระดบัตติยภ้ัมิั ห ร่ อ ผู้้� ป ร ะ ก อ บ อ � ชี พ็ ด� น ก � ร ออกกำ�ลงัและสำหเวัชที�ทำ�ง�นอย่้ใน ภั�ค์สุำขีภั�พ็ ขี�อแนะนำ�นี�สำ�มั�รถใช� เป็นค์ำ�แนะนำ�ในหวััขี�อเหล่�นี�ได� ห�ก มิัได�มีัขี�อแนะนำ�ขีองประเทศอย่้แล�วั กิลุ่มเป้�หม�ย ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย และพ็ฤติกรรมัเน่อยนิ� งในเอกสำ�รนี� ค์วัรใช�เพ่็� อแจั�งให�ทร�บถ่งก�รปฏิิบัติ ก่ อ น ก � ร ป ฏิิ บัติ จั ริง แ ล ะ ห ลัก ส้ำ ต ร ก�รพ็ฒัน�อ�ชีพ็สำำ�หรบัพ็นักง�นด� น สำ�ธิ�รณิสุำขี ผู้้�เชี� ยวัช�ญ่ด� นกิจักรรมั ท�งก�ย และผู้้�เชี�ยวัช�ญ่ด� นก�รศก่ษ� ผู้ลิตผู้ลที� ได�มั�เป็นสิำ�งจัำ�เป็นที�จัะ นำ�ขี�อแนะนำ�เหล่�นี�ไปส่้ำประช�กรเฉพ็�ะ กลุ่มั ผู้้�มีัส่ำวันเกี�ยวัขี�องในภั�ค์ส่ำวันที�นอก เหน่อจั�กสุำขีภั�พ็ และชุมัชนที�กวั� งขี่ �น ซ่�งใช�ก�รส่ำ�อสำ�รที�ต�องปรบัให�เหมั�ะกบั ค์วั�มัต�องก�รที� เฉพ็�ะเจั�ะจังขีอง ผู้้�รบัสำ�ร คำวามูเป็นมูา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 22 รัะเบ่ยบวิัธ่ ขี�อ แน ะ นำ � เห ล่ � นี�พ็ัฒ น � ต � มั ค่้์ม่ัอสำำ�หรับก�รพ็ฒัน�ขี�อแนะนำ�ขีอง องค์ก์�รอน�มัยัโลก (ฉบบัตีพิ็มัพ็ค์์รั�งที� 2) (21) กลุ่มัผู้้�วั�งระเบียบวิัธีิดำ�เนินก�ร ขีององค์ก์�รอน�มัยัโลกซ่�งดำ�เนินก�ร โดยแผู้นกส่ำงเสำริมัสุำขีภั�พ็ได�จัดัตั�งขี่ �น ด�วัยผู้้�แทนจั�กสำำ�นักง�นส่ำวันภ้ัมิัภั�ค์ ขีององค์ก์�รอน�มัยัโลกและแผู้นกอ่�น ๆ ที� เกี� ยวัขี�องขีององค์ก์�รอน�มััยโลก ก ลุ่มัพ็ัฒน�ขี�อแนะ นำ � (Guidel ine Development Group: GDG) จัดัตั�งขี่ �นจั�ก ผู้้�เชี�ยวัช�ญ่และผู้้�เกี�ยวัขี�องรวัมั 27 ท่�น โดยค์ำ�น่งถ่งสำมัดุลท�งเพ็ศและค์วั�มั หล�กหล�ยท�งภ้ัมิัศ�สำตร ์ขี�อแนะนำ�ฉบบั ร่�งนั�นตรวัจัโดยผู้้�ตรวัจัสำอบอิสำระจั�ก ภั�ยนอกรวัมั 7 ท่�น ซ่� งเป็นผู้้�ให�ผู้ล ตอบรบัด� นหลกัฐ�นท�งวิัทย�ศ�สำตร ์ ก�รตีค์วั�มั และเน่�อห� นอกจั�กนี� มีัก�รทำ�ประช�พิ็จั�รณิแ์บบออนไลน ์ สำำ�หรบัฉบบัร่�ง และได�รบัขี�อคิ์ดเห็นจั�ก ผู้้�เขี� ร่วัมั 400 ร�ย GDG นำ�ขี�อคิ์ดเห็น จั�กนกัวิัทย�ศ�สำตร ์ ผู้้�ปฏิิบติัง�น และ บุค์ค์ลทั�วัไปมั�สำอบท�นและใช�เพ่็�อทำ�ให� ค์ำ�แนะนำ�นี�สำำ�เร็จัลุล่วัง ร�ยละเอียดก�ร จััดก�รกระบวันก�รพ็ัฒน�ขี�อแนะนำ� อย่�งค์รบถ�วันอย่้ที�ภั�ค์ผู้นวัก 1 23 GDG ได�พิ็จั�รณิ�ขีอบเขีตขีอง ขี�อแนะนำ�ในก�รประชุมัค์รั�งแรก และเห็น พ็�องกนัในค์ำ�ถ�มัที�เกี�ยวัเน่�องกบั PI/ECO (ประช�กร (Population), ก�รแทรกแซง ( I n t e r v e n t i o n ) / ก � ร แ สำ ด ง อ อ ก (Exposure), ก�รเปรียบเทียบ (Compar- ison), ผู้ลลพั็ธิ ์(Outcome)) ประเด็นหลกั ที�กล่�วัถง่สำำ�หรบักลุ่มัประช�กรย่อยสำรุป ได�ดงัต่อไปนี� สำำ�หรบักิจกรรมัท�งก�ย: ก. ค์วั�มัเช่�อมัโยงระหว่ั�งกิจักรรมัท�ง ก�ยและผู้ลลพั็ธิที์� เกี�ยวัขี�องกบัสุำขีภั�พ็ ค่์ออะไร ขี. มีัค์วั�มัเช่�อมัโยงด� นปริมั�ณิที�ทำ�และ ก�รตอบสำนอง (จัำ�นวัน ระยะเวัล� ค์วั�มัถี� ค์วั�มัหนกัหน่วัง) หร่อไม่ั ค์. ค์วั�มัเช่�อมัโยงนี�ผู้นัแปรต�มัชนิดหร่อ ขีอบเขีตขีองกิจักรรมัท�งก�ยหร่อไม่ั สำำ�หรบักิจกรรมัท�งก�ย: ก. ค์วั�มัเช่� อมัโยงระหว่ั�งพ็ฤติกรรมั เน่อยนิ� งและผู้ลลัพ็ธิที์� เ กี� ยวัขี�องกับ สุำขีภั�พ็ค่์ออะไร ขี. มีัค์วั�มัเช่�อมัโยงด� นปริมั�ณิที�ทำ�และ ก�รตอบสำนอง(จัำ�นวันทั�งหมัด ค์วั�มัถี� ระยะเวัล� ค์วั�มัหนกัหน่วังขีองก�รหยุด ชะงกั) หร่อไม่ั ข้อบเข้ติข้องข้้อแนืะนืำ �และ คำำ�ถึ�มท่�น่ื�สำนืใจ ระเบีัย่บัวิธี ค์. ค์วั�มัเช่�อมัโยงนี�ผู้นัแปรต�มัชนิดหร่อ ขีอบเขีตขีองพ็ฤติกรรมัเน่อยนิ�งหร่อไม่ั ง. สำำ�หรับผู้้�ใหญ่่ : กิจักรรมัท�งก�ย เปลี�ยนผู้ลกระทบจั�กพ็ฤติกรรมัเน่อยนิ�ง ที�มีัต่อโรค์ภัยัหร่อไม่ั สำำ�หรบัประช�กร (P) แต่ละกลุ่มั ก�รแสำดงผู้ล (E) ค่์อจัำ�นวันระยะเวัล� ค์วั�มัถี� หร่อค์วั�มัหนักหน่วังขีองกิจั- กรรมัท�งก�ย ที� เพิ็�มัส้ำงขี่ �น ขีณิะที�ก�ร เปรียบเทียบ (C) ค่์อก�รไม่ัทำ�กิจักรรมั ท�งก�ยหร่อ มีัค์วั�มัถี� ค์วั�มัหนัก- หน่วัง หร่อระยะเวัล�ในก�รทำ�กิจักรรมั ท � ง ก � ย ที� น� อ ย ผู้ ล ลัพ็ ธิ ์ที� เ ด่ น ชัด แ ล ะ สำำ � ค์ัญ่ สำำ � หรับ ป ร ะ ช� กร แ ต่ ล ะ กลุ่มัได�สำรุป ไวั�ในต�ร�งหมั�ยเลขี 1 และร�ยละเอียดขีองค์ำ�ถ�มัเกี� ยวักับ PI/ECO สำรุปอย่้ในส่ำวันที� เกี�ยวัขี�องกนันี� ในเว็ับไซตภ์ั�ค์ผู้นวัก : หลกัฐ�นประกอบ2 2 ข้้อม่ัลออนไลน์ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 24 ผู้ลลพั็ธิ ์ (ต�มัลำ�ดบัอกัษร ภัษ�องักฤษ) เด็กและวัยัรุ่น อ�ยุ 5-17 ปี: กิจักรรมั ท�งก�ยและ พ็ฤติกรรมั เน่อยนิ�ง ผู้้� ใ ห ญ่่ อ � ยุ 18-64 ปี : กิจักรรมั ท�งก�ย ผู้้�ใหญ่่อ�ยุ 18 ปีขี่ �นไป : พ็ฤติกรรมั เน่อยนิ�ง ผู้้�ส้ำงอ�ยุ อ�ยุ 65 ปี ขี่ �นไป : กิจักรรมั ท�งก�ยa สำตรีมีัค์รรภั์ และมั�รด� หลงัค์ลอด ภั�วัะโรค์ เร่�อรงัb เด็กและ ผู้้�ใหญ่่ที�มีั ภั�วัะ ทุพ็พ็ลภั�พ็c ความอ้ว้น (นำ �าหนกัขึ้้ �น นำ �าหนกัเปล่ี่�ยน การควบคุมนำ �าหนกั ความเสถ่ียรขึ้อ้งนำ �าหนกั สถีานะขึ้อ้งนำ �าหนกั แลี่ะการรกัษานำ �าหนกั) สำาคญัมาก สำาคญัมาก สำาคญัมาก สำาคญัมากa สำาคญัมาก สำาคญัมาก -HIV - เหตุุการณ์์ไม่พึง้ประสงค ์ สำาคญัมาก สำาคญัมาก - สำาคญัมากa สำาคญัมาก (ม่ผลี่ตุ่อ้ ทารก ในครรภ์)์ - - การเส่ยช่ีวิตุทุกสาเหตุุหรือ้ม่ สาเหตุุเฉพึาะ - สำาคญัมาก (มะเร็งแลี่ะ โรคหวัใจแลี่ะ หลี่อ้ดเลืี่อ้ด) สำาคญัมาก สำาคญัมากa - สำาคญัมาก - สุขึ้ภ์าพึกระดูก สำาคญัมาก - สำาคญั - - - - สุขึ้ภ์าพึหลี่อ้ดเลืี่อ้ดหวัใจ สำาคญัมาก - - - - - - ผลี่ดา้นการรบัรู้ สำาคญัมาก สำาคญัมาก สำาคญั สำาคญัมากa - - สำาคญัมาก - MS, PD, Stk, Sch, ADHD ภ์าระแทรกซ้อ้้นในการคลี่อ้ด - - - - สำาคญั - - การดำาเนินขึ้อ้งโรคอ้ย่าง ตุ่อ้เนื�อ้ง - - - - - สำาคญัมาก - HT, T2D, HIV, สำาคญัมาก - การกลี่บัมา เป็นมะเร็งอ่้ก - การหกลี่ม้แลี่ะการบาดเจ็บเ ก่�ยวเนื�อ้งจากการหกลี่ม้ - - - สำาคญัมาก - - - ผลี่ท่�ม่ตุ่อ้ทารก (นำ �าหนกัแรก เกิด,การคลี่อ้ดก่อ้นกำาหนด) - - - - สำาคญัมาก - - ความสามารถีในการทำางาน - - - สำาคญัมาก - - - เบาหวานระหว่างตุั�งครรภ์ ์ - - - - สำาคญัมาก - - ความดนัโลี่หิตุสูงระหว่างตุั�ง ครรภ์/์ครรภ์เ์ป็นพิึษ - - - - สำาคญัมาก - - คุณ์ภ์าพึช่ีวิตุท่�เก่�ยวเนื�อ้งกบั สุขึ้ภ์าพึ - สำาคญั สำาคญั สำาคญั a - สำาคญัมาก - HT, T2D, HIV สำาคัญมาก- MS, SCI, ID, MCD, Sch การเกิดโรคมะเร็ง - สำาคญัมาก สำาคญัมาก สำาคญัมากa - - - การเกิดโรคหลี่อ้ดเลืี่อ้ดหวัใจ - สำาคญัมาก สำาคญัมาก สำาคญัมากa - - - การเกิดความดนัโลี่หิดสูง - สำาคญั - สำาคญัa - - - การเกิดโรคเบาหวาน ชีนิดท่�สอ้ง - สำาคญัมาก สำาคญัมาก สำาคญัมาก a - - - ต�ร�งที� 1 : สำรุปผลลพัธิ์ด์�้นสุำข้ภ�พที�เด่นช้ดัและสำำ�ค์ญั่ โดยแยกติ�มักลุ่มัประช้�กร 25 ผู้ลลพั็ธิ ์ (ต�มัลำ�ดบัอกัษร ภัษ�องักฤษ) เด็กและวัยัรุ่น อ�ยุ 5-17 ปี: กิจักรรมั ท�งก�ยและ พ็ฤติกรรมั เน่อยนิ�ง ผู้้� ใ ห ญ่่ อ � ยุ 18-64 ปี : กิจักรรมั ท�งก�ย ผู้้�ใหญ่่อ�ยุ 18 ปีขี่ �นไป : พ็ฤติกรรมั เน่อยนิ�ง ผู้้�ส้ำงอ�ยุ อ�ยุ 65 ปี ขี่ �นไป : กิจักรรมั ท�งก�ยa สำตรีมีัค์รรภั์ และมั�รด� หลงัค์ลอด ภั�วัะโรค์ เร่�อรงัb เด็กและ ผู้้�ใหญ่่ที�มีั ภั�วัะ ทุพ็พ็ลภั�พ็c สุขึ้ภ์าพึจิตุ (อ้าการกงัวลี่แลี่ะ ซ้้มเศรา้) สำาคญัมาก สำาคญัมาก สำาคญั สำาคญัมาก สำาคญัมาก - - โรคกระดูกพึรุน - - - สำาคญัมากa - - - ความแข็ึ้งแรงทางกายภ์าพึ สำาคญัมาก - สำาคญั - - - - การทำางานขึ้อ้งร่างกาย - - สำาคญั - - สำาคญัมาก - HT, T2D, HIV สำาคญัมาก - MS, SCI, ID, Stk พึฤติุกรรมเอื้ �อ้สงัคม สำาคญั - - - - - - ผลี่ทางจิตุวิทยาสงัคม - - - สำาคญั - - - ความเส่�ยงขึ้อ้งโรคเกิดร่วม - - - - - สำาคญัมาก - HT, T2D, HIV สำาคญัมาก - MS, SCI, ID การนอ้นหลี่บั สำาคญั สำาคญั สำาคญั สำาคญัa - - - * ผู้ลกระทบสำำ�ค์ญั่มั�ก ค่์อ ผู้ลที� มีัอิทธิิพ็ลอย่�งยิ�งต่อก�รตดัสิำนใจั ส่ำวันผู้ลกระทบสำำ�ค์ญั่ ค่์อ ผู้ลกระทบที�มีัค์วั�มัสำำ�ค์ญั่แต่ไม่ัมีัอิทธิิพ็ลต่อก�รตดัสิำนใจั a ผู้ลลพั็ธิที์�สำำ�ค์ญั่และสำำ�ค์ญั่มั�กนั�นถ้กนำ�มั�พิ็จั�รณิ�สำำ�หรบัประช�กรผู้้�ใหญ่่และผู้้�ส้ำงอ�ยุ b ผู้ลลัพ็ธิส์ำำ�หรับสำภั�วัะขีองประช�กรกลุ่มัย่อยอันได�แก่: มัะเร็ง-ผู้้�รอดชีวิัตจั�กมัะเร็ง, HT - ค์วั�มัดนัโลหิตส้ำง, T2D-เบ�หวั�นชนิดที�สำอง และ HIV c ผู้ลลพั็ธิส์ำำ�หรบัสำภั�วัะขีองประช�กรกลุ่มัย่อยอนัได�แก่ MS – กล� มัเน่�ออ่อนแรง SCI - อ�ก�ร บ�ดเจ็ับขีองไขีสำนัหลงั ID - ค์วั�มับกพ็ร่องท�งสำติปัญ่ญ่� PD-โรค์พ็�รกิ์นสำนั Stk – ผู้้�รอดชีวิัตจั�ก เสำ�นเล่อดในสำมัองแตก Sch – โรค์จิัตเภัท ADHD – โรค์สำมั�ธิิสำั�น โดยนำ�ผู้ลลพั็ธิที์�สำำ�ค์ญั่และสำำ�ค์ญั่มั�ก ต่อประช�กรที�มีัช่วังอ�ยุเฉพ็�ะนั�นมั�พิ็จั�รณิ�และค์�ดก�รณิ์ ระเบีัย่บัวิธี ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 26 ก�รทบทวันขี�อแนะนำ�สำำ�หรบักิจักรรมั ท�งก�ยฉบบัปีพ็.ศ. 2553 ขีององค์ก์�รอน�มัยั โลกนั�น กระทำ�โดยก�รวิัเค์ร�ะหแ์จักแจังและ ปรบัปรุงขี�อทบทวันที�เกี�ยวัเน่�องและเป็นปัจัจุับนั ที� สุำดที� เกี� ยวัขี�องกับขีอบเขีตขีองขี�อแนะนำ� เหล่�นี� ขี�อแนะนำ�นี�ถ้กนำ�มั�ใช�เน่� องจั�กองค์ ์ ค์วั�มัร้�ที� ค์รอบค์ลุมัถ่งก�รทบทวันอย่�งเป็น ระบบและมีัค์วั�มัทนัสำมัยั ซ่�งจัดัทำ�ขี่ �นเพ่็�อแสำดง ให�เห็นถ่งก�รพ็ฒัน�ขี�อแนะนำ�ระดบัช�ติด� น กิจักรรมัท�งก�ยที� มีัอย่�งหล�กหล�ยมีัก�ร ปรบัปรุงเพิ็�มัเติมัเพ่็�อให�มัั�นใจัว่ั�ขี�อแนะนำ�ขีอง องค์ก์�รอน�มัยัโลกฉบบัใหม่ัจัะสำะท�อนขี�อม้ัลที� ทนัเหตุก�รณิที์�สุำดเท่�ที�ห�ได�ในสำ�ขี�สำ�ธิ�รณิ- สุำขีที�พ็ฒัน�อย่�งรวัดเร็วั มีัก�รเล่อกใช�บทปริทศันข์ีองบทปริทศัน ์ อีกชิ�น ห�กบทปริทัศน์นั�นตรงต�มัเกณิฑ์ ์ พิ็จั�รณิ� 3 ประก�ร ได�แก่ 1) มีัก�รทำ�บท- ปริทศันห์ลกัฐ�นต�มักระบวันก�รที� เป็นระบบ มั�ตรฐ�น ซ่�งมีัก�รจัดัเก็บเอกสำ�รเป็นอย่�งดี 2) ก�รประเมิันค์วั�มัน่�เช่�อถ่อขีองหลกัฐ�นนั�นใช� วิัธีิต�มัก�รจัดัเกณิฑ์ต์�มัขี�อแนะนำ�ก�รประมัวัล ผู้ล ก�รพ็ฒัน� และก�รประเมิันค่์� (GRADE) หร่อ กระบวันวิัธีิอ่�นที� เทียบเท่� ซ่�งมีัก�รพ็รรณิ�และ บันท่กไวั�อย่�งแจ่ัมัแจั�ง และ 3) บทปริทัศน ์ หลกัฐ�นนั�นกล่�วัถ่งประช�กรกลุ่มัเป้�หมั�ย โดยไม่ัจัำ�กัดประเทศหร่อระดับร�ยได�ขีอง ประเทศ ค์ำ�ถ�มั PI/ECO และผู้ลลพั็ธิท์�งสุำขีภั�พ็ ที�สำำ�ค์ญั่และสำำ�ค์ญั่มั�กถ้กนำ�มั�จับัค่้์กบับท- ปริทศันห์ลกัฐ�นที� มีัอย่้ และห�กจัำ�เป็น จัะมีั ก�รใช�บทปริทศัน์ใหม่ัเพิ็�มัเติมัเพ่็�อจัดัก�รช่อง- หลักิฐ�นื ว่ั�ง กลุ่มัพ็ัฒน�ขี�อแนะนำ�เรียกร�องให�ปรับ ปรุงบทปริทศันห์ลกัฐ�นให�ทนัสำมัยั ใช�ค์ำ�ค์�นห� ภั�ษ�ในก�รค์�นห� และฐ�นขี�อม้ัลเดียวักนักบั บทปริทศันฉ์บบัดั�งเดิมั บทปริทศันห์ลกัิฐานดุา้นล่างนี �เข็า้เกิณฑ์ท์ ั�ง 3 ข็อ้และถูกิเล่อกิมาจากิความทนัสมยัและ ความเข็า้ใจง่าย • ก�รทบทวันวัรรณิกรรมัอย่�งเป็นระบบที� จัดัทำ�โดยโพ็อิทร�สำและค์ณิะ (2559) เกี�ยวั เน่�องกบัค์วั�มัเช่�อมัโยงระหว่ั�งกิจักรรมัท�ง ก�ยและตวัับ่งชี�สุำขีภั�พ็ในเด็กวัยัเรียนและ เย�วัชน (22) ในฐ�นะที� เป็นส่ำวันขีองกระ บวันก�รสำำ�หรบัก�รพ็ฒัน�ขี�อแนะนำ�ด� น ก�รเค์ล่�อนไหวัร่�งก�ยตลอด 24 ชั� วัโมัง สำำ�หรบัเด็กและเย�วัชนขีองประเทศแค์น�ด� (23) บททบทวันนี�ให�ค์วั�มัสำนใจักบัง�นวิัจัยั ที� ใช�ก�รวัดัผู้ลเชิงวัตัถุประสำงค์์ในก�รทำ� กิจักรรมัท�งก�ย ง�นวิัจััยทั�งหมัด 162 ชิ �นถ้กนำ�มั�ใช�ในก�รณินี์� โดยมีัผู้้�เขี� ร่วัมัวิัจัยั 204, 171 ร�ยจั�ก 31 ประเทศ • ก�รทบทวันวัรรณิกรรมัอย่�งเป็นระบบที� เช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งและตวัั ชี �วั ัดสุำขีภั�พ็ในเด็กวััยเรียนที� จััดทำ�โดย ค์�รส์ำนัและค์ณิะ (2561) (24) ซ่�งเป็นส่ำวันหน่�ง ขีองกระบวันก�รสำำ�หรับก�รพ็ัฒน�ขี�อ แนะนำ�ก�รเค์ล่�อนไหวัร่�งก�ยตลอด 24 ชั�วัโมังสำำ�หรบัเด็กและเย�วัชนขีองประเทศ แค์น�ด� (23) มีัก�รวิัจัยัจัำ�นวัน 235 ชิ �น ( ตัวั อ ย่ � ง ไ ม่ั ซำ � กัน 1 9 4 ตัวั อ ย่ � ง ) ซ่�งมีัผู้้�เขี� ร่วัมัร�ยบุค์ค์ล 1,657,064 ร�ย จั�ก 71 ประเทศทั�วัโลก • ก�รทบทวันวัรรณิกรรมัอย่�งเป็นระบบที�จัดั ทำ�โดยโอค์ลีและค์ณิะ (2562) (25) ซ่�งจัดัทำ� ขี่ �นเพ่็� อปรับปรุงขี�อม้ัลจั�กโพ็อิทร�สำและ ค์ณิะ (2559) (22) และค์�รส์ำนัและค์ณิะ 27 (2561) (24) ในฐ�นะส่ำวันหน่�งขีองก�รพ็ฒัน� ขี�อแนะนำ�ในก�รเค์ล่�อนไหวัร่�งก�ยตลอด 24 ชั�วัโมังสำำ�หรบัเด็กและเย�วัชน (อ�ยุ 5-17 ปี) (26) ขีองประเทศออสำเตรเลียประจัำ�ปี 2562 ร�ยง�นฉบับนี�จัำ �แนกร�ยง�น ก�รวิัจััยเร่� องกิจักรรมัท�งก�ย 42 ชิ �น และพ็ฤติกรรมัเน่อยนิ�ง 32 ชิ �น ซ่�งเผู้ยแพ็ร่ ในเด่อนกรกฎ�ค์มั พ็.ศ. 2561 (25) ต�ร�ง GRADE (ก�รจัดัลำ�ดบัก�รประเมิันขี�อแนะนำ� ก�รพ็ฒัน� และก�รประเมิันค่์�) ที�จัดัทำ�โดย โอค์ลีและค์ณิะได�ถ้กนำ�มั�ใช�เป็นแนวัปฏิิบติั ในก�รปรับปรุงขี�อม้ัลต�มัที� ได�รับมัอบ หมั�ยซ่� งจััดทำ�โดยองค์ก์�รอน�มััยโลก ต�ร�ง GRADE พ็ร�อมัทั�งขี�อม้ัลหลกัฐ�นต่�ง ๆ ได�แสำดงไวั�ในภั�ค์ผู้นวักท�งเว็ับไซต์ : ขี�อม้ัลหลกัฐ�น3 • มีัก�รจัดัทำ�และสำงัเค์ร�ะหบ์ทปริทศันอ์ย่�ง เป็นระบบจัำ�นวัน 12 ชิ �น ซ่�งเป็นส่ำวันหน่�ง ขีองก�รพ็ฒัน�ขี�อแนะนำ�สำำ�หรบักิจักรรมั ท�งก�ยขีณิะตั�งค์รรภัข์ีองประเทศแค์น�ด� ประจัำ�ปี 2562 บทปริทัศนท์ั�ง 12 ชิ �นนี� เขี� ถง่ง�นวิัจัยัที� เกี�ยวัขี�องมั�กกว่ั� 25,000 ชิ �น ทั�งภั�ษ�องักฤษ สำเปน ฝึรั�งเศสำ ว่ั�ด�วัย เร่�องกิจักรรมัท�งก�ยขีองมั�รด�ระหว่ั�ง ตั�งค์รรภั ์ ซ่�งร�ยง�นถง่ค์วั�มัเจ็ับป่วัยขีอง มั�รด� ท�รกในค์รรภั ์หร่อท�รกแรกค์ลอด ห ร่ อ ก � ร เ สีำ ย ชี วิั ต ขี อ ง ท � ร กใ น ค์ ร ร ภั ์ บทปริทศันจ์ัำ�นวัน 7 ชิ �นกล่�วัถง่ผู้ลที�ถ่อว่ั� สำำ�ค์ญั่และสำำ�ค์ญั่มั�กโดย GDG (28-34) ต�ร�ง GRADE จั�กก�รทบทวันหลกัฐ�น เหล่�นี�ใช�เป็นแนวัปฏิิบัติขีองก�รห�ง�น ตีพิ็มัพ็ที์�จัดัทำ�ขี่ �น เพ่็�อปรบัปรุงและชี�ให�เห็น ถ่งก�รพ็ัฒน�ขี�อแนะ นำ �ขีององค์์ก�ร อน�มัยัโลก ขี�อม้ัลหลกัฐ�นที�ปรบัปรุงแล�วัมีั อ ย่้ ในภั�ค์ผู้นวักท�งเว็ับไซต์ : ขี�อม้ัล หลกัฐ�น3 • ร�ยก�รท�งวิัทย�ศ�สำตรข์ีองกลุ่มัที�ปรก่ษ� ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย (PAGAC) (35) ซ่�งจัดัทำ�ก�รปรบัปรุงหลกัฐ�นอย่�ง เป็นระบบเกี� ยวักับกิจักรรมัท�งก�ยและ พ็ฤติกรรมัเน่อยนิ� งและผู้ลขีองสุำขีภั�พ็ที� ตีพิ็มัพ็ร์ะหว่ั�งพ็.ศ. 2551-2559 โดยเป็น ส่ำวันหน่� งขีองก�รพ็ัฒน�ขี�อแนะนำ�ด� น กิจักรรมัท�งก�ยสำำ�หรบัช�วัอเมัริกนัฉบบั พ็.ศ. 2561 ฉบบัพิ็มัพ็ค์์รั�งที� 2 (36) หลกัฐ�น ที� สำรุปมั�นั�นได�กล่�วัถ่งค์ำ�ถ�มัง�นวิัจััย จัำ�นวัน 38 ค์ำ�ถ�มัหลกัและ 104 ค์ำ�ถ�มัย่อย ที� เล่อกสำรรมั�จั�กค์วั�มัเกี� ยวัเน่� องเร่� อง สำ�ธิ�รณิสุำขี หลกัฐ�นนี�ประกอบไปด�วัยผู้ล จั�กก�รปริทศัน ์ ซ่� งทบทวันจั�กง�นวิัจัยั ทั�งสิำ �น 1,130 หวััขี�อ สำรุปมั�เพ่็�อตอบค์ำ�ถ�มั ก�รวิัจัยั 38 ขี�อ (35) เกณิฑ์วิ์ัธีินั�นใช�ร้ปแบบ ที� แก� ไขีจั�ก “เค์ร่� องม่ัอชี�วัดัเพ่็� อประเมิัน บทปริทศันที์� เป็นระบบ” (AMSTARE&BP) เพ่็� อ เ ขี� ถ่ง คุ์ ณิ ภั � พ็ เ กี� ย วั กับ ร ะ เ บี ย บ แบบแผู้นขีองก�รปริทศันอ์ย่�งเป็นระบบ และก�รทบทวันวัรรณิกรรมัระบบเชิง ปริมั�ณิ ค์วั�มัเสีำ�ยงที�จัะมีัอค์ติหร่อค์วั�มั เที�ยงตรงภั�ยในนั�นจัะถ้กประเมิันในง�นวิัจัยั ต�นฉบับแต่ละชิ�นโดยใช�ฉบับที� ปรับจั�ก เค์ร่�องม่ัอประเมิันอค์ติ (BAT) (37) จั�กค์ลงั ขี�อม้ัลหลกัฐ�นด� นโภัชน�ก�รขีองกระทรวัง เกษตรแห่งสำหรฐัอเมัริก� หลกัฐ�นชิ�นใหม่ัที� แจักแจังไวั�ในก�รค์�นห�เพ่็�อพ็ฒัน�ขี�อม้ัลที� จัดัทำ�เพ่็�อขี�อแนะนำ�ขีององค์ก์�รอน�มัยัโลก แสำดงอย่้ที�หน� รวัมัขี�อม้ัลหลกัฐ�นในภั�ค์ ผู้นวักบนเว็ับไซต3์ โดยหน� รวัมัขี�อม้ัล หลักฐ�นจัะเช่� อมัโยงไปยังร�ยง�นและ เอกสำ�รเสำริมัขีอง PAGAC (35) ระเบีัย่บัวิธี 3 ข้้อม่ัลออนไลน์ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 28 วิธีิ์ก�รทำ�ใหข้้อ้ม้ัลทนัสำมัยั และก�รแยกส่ำวนข้อ้ม้ัล ก�รค์�นห�ก�รทบทวันที� เป็นระบบและ ก�รวิัเค์ร�ะหผ์ู้ลรวัมัจั�กก�รวิัจัยัแบบรุ่นปี จั�ก ง�นวิัจัยัที�ตีพิ็มัพ็จ์ั�กวันัที�ค์�นห�ค์รั�งสุำดท� ยที�จัดั ทำ�ขี่ �นเพ่็� อบทปริทศันแ์ต่ละชิ�นที� นำ�มั�รวัมัไวั� (ต�มัที�ระบุด� นบน) มั�จันถ่งเด่อนกนัย�ยน พ็.ศ. 2562 ซ่�งเกณิฑ์วิ์ัธีิก�รแยกส่ำวันขี�อม้ัลที�เป็น มั�ตรฐ�นได�รบัก�รพ็ฒัน�และนำ�มั�ใช� เพ่็� อปรับปรุงขี�อม้ัลจั�กก�รค์�นห�ที� จัดัทำ�โดยโพ็อิทร�สำและค์ณิะ (2559) (22), ค์�รส์ำนัและค์ณิะ (2559) (24) และโอค์ลีและค์ณิะ (2559) (25) ฐ�นขี�อม้ัล MEDLINE, EMBASE, PsycINFO และ SportDiscus ถ้กค์�นห�เพ่็� อ แจักแจังบทปริทศันที์�ทบทวันโดยผู้้�ร้�เสำมัอกนั ที� เขีียนเป็นภั�ษ�อังกฤษหร่อฝึรั� งเศสำ เพ่็� อ ปรบัปรุงก�รค์�นห�ที�ดำ�เนินก�รโดย PAGAC (35) ฐ�นขี�อม้ัล PubMed, CINAHL และ Cochrane ถ้กค์�นห�เพ่็� อแจักแจังบทปริทัศนที์� ทบทวัน โดยผู้้�ร้�เสำมัอกนัและเขีียนเป็นภั�ษ�องักฤษ ไม่ั มีัก�รค์�นห�ผู้ลลพั็ธิส์ำำ�ค์ญั่เสีำยใหม่ัซ่�ง PAGAC ไม่ัได�รวัมัไวั� (35) เน่�องด�วัยขี�อจัำ�กดัด� นแหล่ง ขี�อม้ัล ก�รค์�นห�ไม่ัได�จัำ�กดัต�มัประเทศหร่อ สำถ�นะร�ยได�ขีองประเทศและรวัมัเอ�บท- ปริทัศน์ที� ก ล่�วัถ่ง กิจักรรมัท�งก�ยหร่อ พ็ฤติกรรมัเน่อยนิ�งที�เป็นก�รวัดัเชิงอตัวิัสำยัหร่อ วัดัเชิงวัตัถุวิัสำยั มีัก�รตดัสิำนใจัว่ั�จัะไม่ัมีัก�ร ค์�นห�ขี�อม้ัลในภั�ษ�อ่� น ๆ นอกเหน่อไปจั�ก ภั�ษ�ในก�รค์�นห�ต�นฉบบัเน่� องจั�กขี�อจัำ�กดั ด� นขี�อม้ัลและประสำบก�รณิก่์อนหน� ในสำ�ขี�ที� บ่งชี �ว่ั�ก�รค์�นห�ขี�อม้ัลนั�นทำ�ให� ได�บทปริทศัน ์ เพิ็�มัเติมัน�อยมั�กห�กจัะมีัอย่้ บทปริทศันน์ั�นนำ� มั�พิ็จั�รณิ�เพ่็�อทดสำอบค์วั�มัเช่�อมัโยงระหว่ั�ง กิจักรรมัท�งก�ยหร่อพ็ฤติกรรมัเน่อยนิ�งและ ผู้ลลพั็ธิที์�เกี�ยวัขี�องกบัสุำขีภั�พ็ (ขี่ �นอย่้กบัระดบัส้ำง หร่อตำ� ขีองก�รกระตุ�นกิจักรรมัท�งก�ยหร่อ พ็ฤติกรรมัเน่อยนิ�ง) และสำำ�รวัจัค์วั�มัสำมััพ็นัธิ ์ ขีองก�รตอบสำนองต่อผู้ลที� ได�รบัระหว่ั�งกิจั- กรรมัท�งก�ยและพ็ฤติกรรมัเน่อยนิ� งกับ ผู้ลลพั็ธิที์�เกี�ยวัเน่�องกบัสุำขีภั�พ็ ที มั ง � น ผู้้�ท บ ท วั นวั ร ร ณิ ก ร ร มั จั � ก ภั�ยนอกใช�เค์ร่�องม่ัอ AMSTAR 2 (ก�รประเมิัน บทปริทศันอ์ย่�งมีัระบบหล�ยฉบบั) เพ่็�อจัดัระดบั ค์วั�มัน่�เช่� อถ่อขีองก�รทบทวันวัรรณิกรรมั อย่�งเป็นระบบ ภั�ยใต�ก�รพิ็จั�รณิ�เพ่็� อนำ� มั�รวัมัเขี� ไวั�ด�วัยกนั (38) เค์ร่�องม่ัอ AMSTAR 2 มีัอย่้ 16 ร�ยก�รที� เกี�ยวัขี�องกบัก�รวั�งแผู้น และก�รจัดัทำ�บทปริทศัน ์ ค์วั�มัเช่�อมัั�นโดยรวัมั ในผู้ลขีองบทปริทศันแ์ต่ละชิ�นจัะถ้กจัดัระดบั ต�มัขี�อแนะนำ�ที�ตีพิ็มัพ็แ์ล�วั ห�กได�ระดบั “ส้ำง” สำะท�อนว่ั�บทปริทศันนี์�มีัขี�อบกพ็ร่องที� ไม่ัร� ย- แรงอย่้ 0 หร่อ 1 ขี�อ ระดบั “กล�ง” บ่งชี�ว่ั� บทปริทศันนี์�ตดัสิำนแล�วัว่ั�มีัขี�อบกพ็ร่องที� ไม่ั ร� ยแรงมั�กกว่ั� 1 ขี�อ ระดบั “ตำ� ” หมั�ยค์วั�มัว่ั� บทปริทศันนี์�ถ้กตดัสิำนว่ั�มีัขี�อบกพ็ร่องที�วิักฤติ 1 ประเด็น โดยอ�จัมีัหร่อไม่ัมีัขี�อบกพ็ร่องที� ไม่ั ร� ยแรง หร่อมีัขี�อบกพ็ร่องที� ไม่ัร� ยแรงหล�ย อย่�ง และ “ตำ� อย่�งยิ�ง” แสำดงให�เห็นว่ั�มีัขี�อบก- พ็ร่องมั�กกว่ั� 1 ขี�อเกิดขี่ �น ผู้้�ทบทวันวัรรณิกรรมั 1 ร�ยใช�เค์ร่�องม่ัอ AMSTAR 2 กบับทปริทศันที์� จัดัไวั�ให�ทั�งหมัด บทปริทศันที์�ถ้กจัดัอย่้ระดบัตำ� อย่�งยิ�งจั�กผู้้�ทบทวัน 1 ร�ยจัะนำ�มั�ทบทวัน โดยผู้้�ทบทวันร�ยที� 2 โดยใช�เค์ร่�องม่ัอเดียวักนั ในท� ยที�สุำด บทปริทศันที์�ถ้กจัดัระดบัไวั�ตำ� อย่�ง ยิ�งจัะไม่ันำ�มั�รวัมัไวั� เพ็ร�ะถ้กตดัสิำนว่ั�ไม่ัอ�จัให� บทสำรุปจั�กหลกัฐ�นที� มีัอย่้อนัเที� ยงตรงและ เขี� ใจัได� เวั�นเสีำยแต่ว่ั�มีับทปริทศันเ์พี็ยงชิ�นเดียวั สำำ�หรบัผู้ลเฉพ็�ะเจั�ะจังนั�น 29 ขี�อสำรุปขีองหลกัฐ�นได�รวัมัก�รวิัจัยัแบบ รุ่นปีหล�ยฉบบัไวั� กลุ่มัผู้้�ทบทวันจั�กภั�ยนอก ใช�มั�ตรวััด Newcastle-Ottawa ในก�ร ประเมิันคุ์ณิภั�พ็ขีองง�นวิัจัยั (39) ง�นวิัจัยั แต่ละชิ�นได�ระดบัคุ์ณิภั�พ็ “ดี” “พ็อใช�” หร่อ “แย่” โดยทั�วัไปแล�วั ง�นวิัจัยัคุ์ณิภั�พ็ดีตรงต�มัเกณิฑ์ ์ ขีองก�รวัดัระดบั Newcastle-Ottawa ทุกประก�ร ง�นวิัจัยัคุ์ณิภั�พ็พ็อใช�ไม่ัตรงหร่อไม่ัชดัเจันว่ั� ตรงต�มัเกณิฑ์อ์ย่�งน�อยหน่�งขี�อ แต่ยงัค์งไม่ัมีั ขี�อจัำ�กดัที�สำำ�ค์ญั่เชิงประจักัษซ์่�งอ�จัทำ�ให�ผู้ล เป็นโมัฆะ ได� ง�นวิัจััยคุ์ณิภั�พ็แย่มีัจุัดรั� วัที� วิักฤติมั�กหน่�งอย่�งหร่อมีัขี�อจัำ�กดัสำำ�ค์ญั่หล� ยประเด็น และง�นวิัจัยัคุ์ณิภั�พ็แย่ถ้กตดัออกไป มีัก�รประเมิันห�ค์วั�มัเป็นไปได�ที� ทบั ซ�อนและเป็นที� ตระหนักร้�สำำ�หรับก�รจัำ�ลอง ง�นวิัจัยัในบทปริทศันห์ล�ย ๆ ชิ �น บทปริทศัน ์ เห ล่ � นี� มีั ขี�อ สำ รุ ป ขี อ ง ห ลัก ฐ � น ที� ซำ � ซ� อ น ค์ำ�อธิิบ�ยโดยสำรุปขีองบทปริทศัน ์และก�รวิัจัยั แบบรุ่นปีที�รวัมักนัอย่้หล�ยฉบบัถ้กตดัออก ขีณิะ ที�บทปริทศันอ่์�นที� เขี� ใจัง่�ยกว่ั�และ/หร่อเป็น ปัจัจุับนักว่ั�จัะถ้กนำ�มั�ระบุไวั� วิธีิ์สำำ�หรบับทปริทศััน์ใหม่ั เม่ั�อมีัก�รระบุถ่งช่องว่ั�งในหลกัฐ�นที� มีัอย่้ บททบทวันวัรรณิกรรมัขีองบทปริทศันชิ์�น ใหม่ัมีัหน� ที�ตรวัจัสำอบ ดงันี� 1. ค์วั�มัสำมััพ็นัธิร์ะหว่ั�งกิจักรรมัท�งก�ยเชิง อ�ชีพ็ (เช่น สิำ�งที�เกี�ยวัพ็นักบัก�รทำ�ง�น) และ ผู้ลลพั็ธิที์�เกี�ยวัเน่�องกบัสุำขีภั�พ็ (40) และ 2. ค์วั�มัเกี�ยวัเน่�องเช่�อมัโยงระหว่ั�งกิจักรรมั ท�งก�ยในขีอบเขีตขีองก�รพ็กัผู่้อนและ ผู้ลลบต่อสุำขีภั�พ็ (41) ระเบีัย่บัวิธี (สำำ�หรบัขี�อ 1 และ 2 ขี� งต�น ก�รค์�นห�โดยใช� PubMed, Spor tD iscus และ EMBASE สำำ�หรบับทปริทศันจ์ั�กพ็.ศ. 2552 ถง่ ธินัวั�ค์มั พ็.ศ. 2562) 3. ค์วั�มัเช่�อมัโยงระหว่ั�งกิจักรรมัท�งก�ยและ ก�รป้องกนัก�รหกล�มั มีัก�รใช�บทปริทศัน ์ อ ย่ � ง มีั ร ะ บ บ อัน มั �จั � ก ค์ วั � มั ร่ วั มั ม่ั อ Cochrane ฉบบัพ็.ศ. 2562 โดยเชอริงตนั และค์ณิะ (42) และปรับปรุงขี�อม้ัลด�วัย หลกัฐ�นที� ตีพิ็มัพ็จ์ั�กวันัที�ค์�นห�วันัสุำดท� ย ขีองบททบทวันต�นฉบบัจันถง่เด่อนพ็ฤศจิั- ก�ยน พ็.ศ. 2562 4. ค์วั�มัเช่� อมัโยงระหว่ั�งกิจักรรมัท�งก�ย และ โรค์กระด้กพ็รุนและภั�วัะส้ำญ่เสีำย กล� มัเน่�อ ก�รค์�นห�บททบทวันวัรรณิกรรมั อย่�งเป็นระบบเกี�ยวักบัโรค์กระด้กพ็รุนและ ภั�วัะส้ำญ่เสีำยกล� มัเน่�อที�มีัอย่้ ซ่�งใช� PubMed ห�บทปริทัศน์ที� ตีพิ็มัพ็์ ใน พ็.ศ. 2551 จันถ่งพ็ฤศจิัก�ยน พ็.ศ. 2562 พ็บว่ั�ไม่ัมีั บททบทวันชิ�นใหม่ัและมีัง�นวิัจัยัขีั�นแรกเพิ็�มั ใหม่ั 8 ชิ �น 5. หลักฐ�นเร่� องค์วั�มัเช่� อมัโยงระ หว่ั�ง กิจักรรมัท�งก�ยและผู้ลลพั็ธิด์� นสุำขีภั�พ็ ในผู้้�ที� มีัเช่ �อ HIV บทปริทศัน์ในขีอบข่ี�ยนี� ย่นยันหลักฐ�นที� มีัอย่้เกี� ยวักับกิจักรรมั ท�งก�ยและผู้ลลพั็ธิที์� เกี�ยวัเน่�องกบัสุำขีภั�พ็ ในหม่้ัผู้้�มีัเช่ �อ HIV เพ่็�อสำนบัสำนุนก�รทบทวัน วัรรณิกรรมัที�เกี�ยวัเน่�องซ่�งเป็นก�รทบทวัน ห ลักฐ � นที� ตี พิ็ มั พ็์จั นถ่ง เ ด่อ น ตุ ล� ค์มั พ็.ศ. 2562 โดยใช�ฐ�นขี�อม้ัล PubMed, C I N A H L แ ล ะ W e b o f S c i e n c e ซ่�งมิัได�มีัก�รจัำ�กดัวันัเริ�มัต�น ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 30 ข้อ้สำรุปเกี�ยวกบัคุ์ณลกัษณะข้องหลกัฐ�น และวิธีิ์ก�รประเมิันกิจกรรมัท�งก�ยและ พฤติิกรรมัเนือยนิ�ง วิัธีิเริ� มัแรกในก�รวัดักิจักรรมัท�งก�ย และพ็ฤติกรรมัเน่อยนิ�งในวัยัผู้้�ใหญ่่นั�นยงัเป็น ร้ปแบบก�รร�ยง�นโดยตวััผู้้�ให�ขี�อม้ัลเอง (เช่น ก�รสำำ�รวัจั) และสำำ�หรบัเด็กก็ยงัเป็นก�รร�ยง�น ตัวัหร่อบันท่กผู่้�นพ่็อแม่ั แมั�ว่ั�วิัธีิเหล่�นี�จัะ เ ป็ น ที� ย อ มั รั บ แ ต่ ก็ มีั ขี� อ จัำ � กัด ร วั มั ถ่ ง ค์วั�มัโน�มัเอียงที� จัะแจั�งขี�อม้ัลที� ผิู้ดพ็ล�ด ค์ล�ดเค์ล่�อน และมีัอค์ติ (43) ด�วัยเทค์โนโลยี ดิจิัตลัที� ก� วัหน� อย่�งรวัดเร็วัในด� นนี�ในปีที� ผู่้�น ๆ มั� มีัก�รใช�ก�รวัดัโดยเค์ร่� องม่ัอเพ่็�อ ประเมิันกิจักรรมัท�งก�ย และพ็ฤติกรรมัเน่อย- นิ�ง รวัมัถง่ค์วั�มัสำมััพ็นัธิต่์อผู้ลท�งสุำขีภั�พ็มั�ก ขี่ �น อย่�งไรก็ดี ค์วั�มัท� ท�ยก็ยงัค์งมีัอย่้ในก�ร เปรียบเทียบผู้ลระหว่ั�งก�รวิัจัยัอ่�น ๆ เน่�องมั� จั�กค์วั�มัแตกต่�งระหว่ั�งลกัษณิะเฉพ็�ะท�ง เทค์นิค์และก�รใช�ง�นขีองเค์ร่� องม่ัอที� แตก ต่�งกนั (เค์ร่� องวัดัค์วั�มัเร่ง) และค์วั�มัแตก ต่�งในก�รวิัเค์ร�ะห์และก�รร�ยง�นขี�อม้ัล ตวััอย่�งเช่น เม่ั�อมีัก�รวัดัเวัล�ที�อย่้นิ�งเฉยด�วัย เค์ร่� องม่ัอ อ�จัมีัก�รค์ำ�นวัณิผิู้ดพ็ล�ดเพ็ร�ะ อุปกรณิห์ล�ย ๆ ชิ �นยงัไม่ัสำ�มั�รถแยกระหว่ั�ง ท่�ท�งต่�ง ๆ ขีองร่�งก�ย (เช่น ก�รนอน ก�รนั�ง และก�รย่นนิ� ง) ค์วั�มัย�กเกิดขี่ �นเม่ั� อเปรียบ เทียบผู้ลจั�กก�รวิัจัยัที� ใช�ก�รวัดัด�วัยเค์ร่�องม่ัอ กบัก�รร�ยง�นผู้ลที�วัดัจั�กก�รร�ยง�นตวััเอง ในตวััอย่�งขีองกิจักรรมัท�งก�ย เค์ร่�องม่ัอชนิดก�รร�ยง�นผู้ลด�วัยตนเอง นั�นมีัเน่�อห�ที�หล�กหล�ยท�งเล่อกในก�รตอบ สำนองและขีอบเขีต จันเม่ั�อเร็วั ๆ นี� ก�รวิัจัยันั�นมีั เป้�หมั�ยเบ่ �องต�นในก�รประเมิันทั�งกิจักรรมั ท�งก�ยในภั�พ็รวัมัหร่อกิจักรรมัท�งก�ย ในขีอบข่ี�ยก�รพ็กัผู่้อนเท่�นั�น แต่ปัจัจุับนันี� ได�รวัมัเอ�ขีอบข่ี�ยอ่�น เช่น กิจักรรมัท�งก�ย สำำ�หรับก�รเดินท�ง (เช่น ก�รเดินและก�ร ปั� นจัักรย�น) ขีณิะทำ�ง�น และภั�ยในบ� น เอกสำ�รหลกัฐ�นโดยส่ำวันใหญ่่ชี�ให�เห็นถง่ค์วั�มั เช่�อมัโยงระหว่ั�งกิจักรรมัท�งก�ยแบบแอโรบิก กบัผู้ลลพั็ธิท์�งสุำขีภั�พ็ อย่�งไรก็ดี ก�รวิัจัยัใน ช่วังนี�กำ�ลงัประเมิันขี�อดีขีองกิจักรรมัท�งก�ย เพ่็�อเสำริมัสำร� งกล� มัเน่�อและก�รประสำ�นรวัมั กิจักรรมัที�แตกต่�งหล�กหล�ยและขีอบเขีต ก�รเค์ล่�อนไหวัร่�งก�ยแบบอ่�น มีัก�รร�ยง�นและเปรียบเทียบผู้ลด� น ค์วั�มัเช่�อมัโยงระหว่ั�งระดบักิจักรรมัท�งก�ย และผู้ลลพั็ธิท์�งสุำขีภั�พ็ในหล�ย ๆ ท�ง ง�นวิัจัยั หล�ยชิ�นร�ยง�นถ่งก�รเปรียบเทียบระหว่ั�ง ก�รแจักแจังขี�อม้ัล 4 ส่ำวันหร่อก�รแจักแจังขี�อม้ัล แบบ 5 ส่ำวันในกิจักรรมัท�งก�ย ง�นวิัจัยัชิ �นอ่�น ๆ เปรียบเทียบว่ั� “ตรง” เทียบกับ “ไม่ัตรง” ต�มัขี�อแนะนำ�ระดบัช�ติ เม่ั�อมีัก�รร�ยง�น ก�รค์ำ�นวัณิกิจักรรมั ท�งก�ยทั�งหมัดมักัจัะประมั�ณิโดยใช�อตัร�ก�ร เผู้�ผู้ล�ญ่พ็ลงัง�นในหน่�งชั�วัโมัง (MET-hours) ในแต่ละสำปัด�ห ์ และง�นวิัจัยับ�งชิ�นจัะเปรียบ เทียบระดบั “ส้ำงสุำด” กบั “ตำ� สุำด” แมั�ประเภัท กิจักรรมัท�งก�ยจัะต่�งกนัออกไปในง�นวิัจัยั แต่ละชิ�น วัรรณิกรรมัมักัจัะร�ยง�นผู้ลจั�กก�ร วิัเค์ร�ะหที์�ใช�จุัดตดัขี�อม้ัลจั�กขี�อแนะนำ�ที� มีัอย่้ หร่อขี�อแนะนำ�ระดบัโลกจั�กองค์ก์�รอน�มัยั- โลกฉบบัปัจัจุับนั หร่อมั�ตรวัดัจั�กง�นวิัจััย ชิ �นก่อนหน� (เช่น จุัดตดัที� 60 น�ทีต่อวันัในก�ร 31 วิัจัยัจั�กประช�กรที�เป็นเย�วัชน หร่อค์วั�มัถี� 2-3 ค์รั�งต่อสำปัด�ห์เม่ั� อมีัก�รฝึึกค์วั�มัแข็ีงแกร่ง มั�ร่วัมัด�วัย) เม่ั� อจุัดตดัเหล่�นี�เป็นที� ยอมัรับ กนัทั�วัไป ก�รสำร� งหลกัฐ�นที�มีัค์วั�มัเช่�อมัโยง ระ หว่ั�งก�รเปิดรับกิจักรรมัท�งก�ยต่อ ผู้ลลัพ็ธิท์�งสุำขีภั�พ็ในระดับส้ำงหร่อตำ� ย่อมั สำ�มั�รถจัำ�กดัได� หลักฐ�นส่ำวันใหญ่่ที� ประเ มิั นค์วั�มั เช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งและผู้ลต่อ สุำขีภั�พ็ขีองเด็กและวัยัรุ่นนั�นมักัเป็นก�รศก่ษ� เปรียบเทียบระหว่ั�งกลุ่มั และง�นวิัจัยัส่ำวันใหญ่่ อิงก�รวัดัเวัล�ขีองพ็ฤติกรรมัเน่อยนิ�งจั�กก�ร ร�ยง�นขีองตนเองหร่อร�ยง�นขีองจั�กบิด� มั�รด� ซ่�งอ�จัมีัขี�อผิู้ดพ็ล�ดในก�รวัดัและค์วั�มั เอนเอียงจั�กก�รระลก่ขี�อม้ัล หลกัฐ�นจั�กก�รวิัจััยโดยก�รสำงัเกต ระยะย�วัและเสำ�นท�งขีองก�รแทรกแซงจัะ ไ ด�รับ ค์ วั � มั สำำ � ค์ัญ่ ก่ อ น แ ล ะ บ ท ป ริ ทัศ น ์ ที�รวัมัเอ�หลกัฐ�นจั�กก�รเปรียบเทียบระหว่ั�ง กลุ่มัทั�งหมัดหร่อตั�งต�นจัะไม่ัถ้กนำ�มั�พิ็จั�รณิ� นำ � หนกัเน�นไปที�หลกัฐ�นจั�กบทปริทศันที์�จัดั ระดบัให�มีัค์วั�มัแน่นอนป�นกล�งและส้ำงกว่ั�นั�น และบทที�ให�หลกัฐ�นจั�กก�รศก่ษ�ที�ใช�ก�รวัดั ผู้ลด�วัยอุปกรณิ์ ก�รจดัระดบัใจค์ว�มัข้องหลกัฐ�น วิั ธีิ ขี อ ง ก � ร จััด ร ะ ดับ ก � ร ป ร ะ เ มิั น ก�รพ็ัฒน� และวััดค่์�ขี�อแนะนำ� (GRADE) นำ �มั�ใช�เพ่็� อจััดระดับค์วั�มัน่�เช่� อถ่อขีอง หลกัฐ�นสำำ�หรบัอตัร� PI/ECO แต่ละค์รั�ง (44) อิงจั�กหลกัฐ�นที�ซ่อนอย่้ในบทปริทศันเ์หล่�นั�น ห�กมีัต�ร�งขี�อม้ัลหลกัฐ�นขีอง GRADE หร่อ ขี�อสำรุปก�รร�ยง�นจั�กบทปริทศันแ์ต่ละบทจัะ นำ�มั�ใช�เป็นจุัดตั�งต�น ห�กไม่ัมีัต�ร�งอย่้ในก�ร ทบทวันวัรรณิกรรมัอย่�งเป็นระบบที�มีัอย่้ จัะจัดั ทำ�ต�ร�งขี�อม้ัลหลกัฐ�นสำำ�หรบัประช�กรแต่ละ กลุ่มัและผู้ลลพั็ธิที์�สำนใจั กระบวันวิัธีิขีอง GRADE นั�นใช�เพ่็�อวัดั ระดับค์วั�มัเช่� อถ่อได�ขีองหลักฐ�นสำำ�หรับ PI/ECO (44) แต่ละค์รั�งด�วัยก�รค์ำ�น่งถ่ง กฎเกณิฑ์ต่์�ง ๆ ได�แก่ ก�รออกแบบก�รวิัจัยั ค์วั�มัเสีำ�ยงต่ออค์ติ ค์วั�มัค์งที�ขีองผู้ลกระทบ ค์ วั � มั ไ ม่ั ต ร ง ไ ป ต ร ง มั � ค์ วั � มั แ ม่ั น ยำ � ขีองผู้ลกระทบ และขี�อจัำ�กัดอ่� น ๆ รวัมัถ่ง ค์ วั � มั เ อ น เ อี ย ง ใ น ก � ร ตี พิ็ มั พ็์แ ล ะ ปั จั จััย ในก�รปรับปรุงหลักฐ�นจั�กก�รสำังเกต (ก�รศก่ษ�ผู้ลกระทบ ก�รตอบสำนองต่อขีน�ด และผู้ลกระทบขีองตวััวัดัค่์�ต่�ง ๆ) หลกัฐ�น จั�กก�รสำังเกตที� ได�จั�กง�นวิัจััยจั�กก�ร สำงัเกตระยะย�วัที�จัดัทำ�เป็นอย่�งดีถ้กยกระดบั เพ่็�อสำะท�อนถง่ค์วั�มัน่�เช่�อถ่อขีองผู้ลก�รค์�นพ็บ ที� เพิ็�มัส้ำงขี่ �นอย่�งเหมั�ะสำมั อนัเกี�ยวัเน่� องกบั ค์วั�มัเช่�อมัโยงระหว่ั�งกิจักรรมัท�งก�ยหร่อ พ็ฤติกรรมัเน่อยนิ�งและผู้ลลพั็ธิจ์ั�กง�นวิัจัยันั�น ๆ ง�นวิัจัยัที�ประเมิันผู้ลท�งอ�อมัหร่อผู้ลระหว่ั�ง ท�งไม่ัจัำ�เป็นต�องถ้กลดระดบั เน่�องด�วัยผู้ลลพั็ธิ ์ นั�น (รวัมัถ่งผู้ลลัพ็ธิร์ะหว่ั�งท�ง) จััดลำ�ดับ ค์วั�มัสำำ�ค์ญั่โดย GDG และก�รจัดัระดบัโดย GRADE ที�สำะท�อนค์วั�มัเช่�อถ่อได�ในผู้ลกระทบต่อ ผู้ลลพั็ธิเ์หล่�นั�น ในบ�งกรณีิ ก�รวัดัระดบัขีอง GRADE สำำ�หรับบทปริทัศนที์� มีัอย่้แล�วัได�ถ้ก ปรบัแก�เพ่็�อรบัรองค์วั�มัน่�เช่�อถ่อในก�รใช�วิัธีิ วิัจััยขีอง GRADE ค์วั�มัน่�เช่� อถ่อขีององค์ ์ ประกอบขีองหลกัฐ�นสำำ�หรับผู้ลลพั็ธิแ์ต่ละ ประเด็นจัดัไวั�ต�มัแนวัปฏิิบติัดงัต่อไปนี� (45) ระเบีัย่บัวิธี ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 32 ส้ำง มัั�นใจัได�อย่�งยิ�งว่ั�ผู้ลกระทบที� แท�จัริงใกล�เคี์ยงกบัผู้ลกระทบที� ประเมิันไวั� ป�นกล�ง มัั�นใจัในผู้ลกระทบที�ประเมิันไวั�ได� ป�นกล�ง ผู้ลกระทบที�แท�จัริงมีั ค์วั�มัเป็นไปได�ที�จัะใกล�เคี์ยงกบั ผู้ลกระทบที� ประเมิันไวั� แต่มีั ค์วั�มัเป็นไปได�ที�จัะแตกต่�งกนั อย่�งมั�ก ติำ� ค์วั�มัมัั�นใจัในผู้ลกระทบที�ประเมิัน ไวั�มีัอย่�งจัำ�กดั ผู้ลกระทบที�แท� จัริงอ�จัแตกต่�งจั�กผู้ลกระทบที� ประเมิันไวั�เป็นอย่�งมั�ก ติำ� มั�ก มีัค์วั�มัเช่� อมัั� นเพี็ยงน�อยนิดต่อ ผู้ลกระทบที�ประเมิันไวั� ผู้ลกระทบ ที� แท�จัริงมีัค์วั�มัเป็นไปได�ที� จัะ แตกต่�งจั�กผู้ลที�ประเมิันไวั�เป็น อย่�งยิ�ง จ�กหลกัฐ�นส่้ำข้อ้แนะนำ� G D G ใ ช� ก ร อ บ ห ลั ก ฐ � น ประกอบก�รตดัสิำนใจั (EtD) ขีองค์ณิะทำ�ง�น GRADE ในก�รเขีียนค์ำ�แนะนำ�ที� เจั�ะจังค์ำ�ถ�มั กรอบ EtD เป็นขี�อแนะนำ�ที�เป็นระบบ มีัโค์รงสำร� ง และโปร่งใสำต่อก�รตดัสิำนใจั กรอบก�รวิัจัยัใช� เกณิฑ์ที์� ชัดเจันในก�รจััดทำ�ขี�อแนะนำ�โดย ค์ำ�น่งถ่งหลักฐ�นก�รวิัจััย ค์วั�มัน่�เช่� อถ่อ ขีองหลกัฐ�น และค์วั�มัคิ์ดเห็นจั�กผู้้�เชี�ยวัช�ญ่ ห�กต�องก�ร และยงัมีัค์วั�มัร้�เกี�ยวักบัหวััขี�อนั�น ๆ จั�กมุัมัมัองขีองกลุ่มัเป้�หมั�ย เกณิฑ์วิ์ัธีินั�นโน�มั นำ�ก�รตดัสิำนใจัเกี� ยวักบัค์วั�มัสำมัดุลระหว่ั�ง ห ลัก ฐ � น ที� สำัง เ ก ต ไ ด� เ กี� ย วั กับ ผู้ ล ลัพ็ ธิ ์ที� พ็่งประสำงค์แ์ละไม่ัพ็่งประสำงค์ ์ ค์วั�มัเช่� อมัั� น ขีองหลกัฐ�นโดยรวัมั ก�รประเมิันม้ัลค่์�เชิง เปรียบเทียบขีองประช�กรสำำ�หรบัผู้ลลพั็ธิพ์็่ง ประสำงค์แ์ละไม่ัพ็่งประสำงค์ ์ ก�รใช�ทรพั็ย�กร (ก�รพิ็จั�รณิ�ต�นทุน) ห�กมีัผู้ลกระทบที�อ�จัเกิด ต่อค์วั�มัไม่ัเท่�เทียมัด� นสุำขีภั�พ็ ก�รยอมัรบัได� และค์วั�มัเป็นไปได�ขีองขี�อแนะนำ�เหล่�นั�น ค์ณิะทำ�ง�น GDG พิ็จั�รณิ�ใจัค์วั�มั ขีองหลักฐ�นในภั�พ็รวัมัสำำ�หรับขี�อแนะนำ� แต่ละขี�อเพ่็�อผู้ลลพั็ธิที์�สำำ�ค์ญั่ยิ�ง และผู้ลลพั็ธิ ์ สำำ�ค์ญั่ที� มีัอย่้ทั�งหมัด ก�รวิัจัยัเหล่�นั�นมีัค์วั�มั แตกต่�งอย่�งกวั� ง ๆ สำำ�หรบัก�รเขี� ถง่/ก�ร แทรกแซงเฉพ็�ะและก�รเช่�อมัโยงผู้ลลพั็ธิ ์ใน ด� นขีองก�รเขี� ถง่/ก�รแทรกแซงที�ถ้กประเมิัน ผู้ลลพั็ธิที์� ถ้กประเมิัน ก�รออกแบบก�รวิัจัยั และกระบวันก�รวิัเค์ร�ะห์ซ่� งมีัผู้ลต่อค์วั�มั แตกต่�งที�เกิดขี่ �นในหลกัฐ�นที�ห�ได� ดงันั�น จัง่ เป็นไปไม่ัได�ที�จัะใช�ขี�อแนะนำ�ดั�งเดิมัขีอง GRADE สำำ�หรับก�รเขี� ถ่ง/ก�รแทรกแซงและก�ร เ ช่� อ มั โ ย ง ผู้ ล ลัพ็ ธิ ์ ใ น ท � ง ต ร ง กัน ขี� มั ขี�อแนะนำ�ขีอง GRADE ใช�สำำ�หรบัหลกัฐ�นใน ภั�พ็รวัมัที�กล่�วัถ่งก�รเขี� ถ่ง/ก�รแทรกแซง และค์วั�มัเช่�อมัโยงขีองผู้ลลพั็ธิ ์ในประเภัทก�ร อ อ ก แ บ บ ก � ร วิั จััย ทุ ก ร้ ป แ บ บ แ ล ะ ค์ วั � มั หล�กหล�ยในก�รวัดัและวิัเค์ร�ะหก์�รเขี� ถง่/ ก�รแทรกแซง เม่ั�อปัจัจัยัเหล่�นี�ก่อให�เกิดค์วั�มั สำมััพ็นัธิเ์กี�ยวักบัค์วั�มัเช่�อมัโยงขีองหลกัฐ�น (ตวััอย่�งเช่น เม่ั�อหลกัฐ�นสำำ�หรบัก�รเขี� ถง่/ ก�รแทรกแซงและค์วั�มัเช่�อมัโยงขีองผู้ลลพั็ธิ ์ไม่ั สำอดประสำ�นกนัเม่ั�อมัองด�วัยวิัธีิที�แตกต่�งกนั) ชุดขี�อม้ัลลดค์วั�มัน่�เช่� อถ่อขีองหลกัฐ�นลง (21) GDG จัดัลำ�ดบัค์วั�มัสำำ�ค์ญั่ขีองผู้ลลพั็ธิ ์ ท�งสุำขีภั�พ็เพ่็� อพิ็จั�รณิ�ถ่งผู้ลกระทบขีอง กิจักรรมัท�งก�ยและพ็ฤติกรรมัเน่อยนิ� ง ดงัต่อไปนี� ทั�งก�รลดอตัร�ก�รเสีำยชีวิัตจั�ก ทุกสำ�เหตุและที� มีัสำ�เหตุจัำ�เพ็�ะ ( โรค์หลอด เล่อดหัวัใจัและมัะเร็ง) ลดสำ�เหตุก�รเกิด โรค์หลอดเล่อดหัวัใจั โรค์มัะเร็ง (เฉพ็�ะจุัด) โรค์เบ�หวั�นชนิดที�สำอง พ็ฒัน�ค์วั�มัแข็ีงแรง ขีองร่�งก�ย (เช่น ระบบหมุันเวีัยนโลหิต ก�รพ็ัฒน�ก�รเค์ล่� อนไหวั ค์วั�มัแข็ีงแรง 33 ก ล� มั เน่�อ ) พ็ัฒ น � สุำ ขี ภั � พ็ ห ล อ ด เ ล่ อ ด ( เ ช่ น ค์ วั � มั ดั น โ ล หิ ต ไ ขี มัั น ใ น เ ล่ อ ด นำ � ต�ลในเล่อด ค์วั�มัด่�ออินซ้ลิน) สุำขีภั�พ็กระด้ก สุำ ขี ภั� พ็จิั ต ( เ ช่ นก�ร ล ดอ� ก�ร ซ่มั เ ศ ร� ค์วั�มัมัั�นใจัในตนเอง อ�ก�รกงัวัล สำมั�ธิิสำั�น) พ็ั ฒ น � ผู้ ล ลั พ็ ธิ ์ด� น ก � ร เ รี ย น ร้� ( เ ช่ น ค์วั�มัสำ�มั�รถท�งก�รเรียนร้� ก�รคิ์ดวิัเค์ร�ะห)์ และลดภั�วัะโรค์อ�วัน มีัก�รพิ็จั�รณิ�ถง่อ�ก�ร ไ ม่ัพ็่งประสำงค์์ต่�ง ๆ ( เช่นก�รบ�ดเจ็ัด และอนัตร�ย) เช่นกนั ข้อ้พิจ�รณ�อื�น ๆ ค์ ณิ ะ ทำ � ง � น G D G ยัง พิ็ จั � ร ณิ � ค่์ � นิ ย มั แ ล ะ ค์ วั � มั นิ ย มั ขี อ ง ผู้้� ที� ไ ด� รั บ ผู้ลกระทบจั�กขี�อแนะนำ�สำำ�หรับประช�กร แต่ละกลุ่มัและค์ำ�ถ�มั PI/ECO ทั�งหมัด ทั�งสิำ�งที� เกี�ยวัขี�องกบัแหล่งขี�อม้ัลขีองค์ำ�แนะนำ� ผู้ลกระทบต่อค์วั�มัเสำมัอภั�ค์ด� นสุำขีภั�พ็ และก�รเป็นที�ยอมัรบัและค์วั�มัเป็นไปได�ขีอง ค์ำ�แนะนำ� ด�วัยเหตุที�มีัค์วั�มัซำ � ซ�อนค่์อนขี� งมั�ก ในเกณิฑ์์ก�รพิ็จั�รณิ�เหล่�นี�และ ในก�ร ประเมิันขีอง GDG สำำ�หรบัประช�กรแต่ละกลุ่มั บทสำรุปขีองก�รอภิัปร�ยว่ั�ด�วัยก�รประเมิัน องค์ป์ระกอบต่�ง ๆ เหล่�นี�ได�บรรย�ยไวั�ในส่ำวัน “หลกัฐ�นต่อขี�อแนะนำ�” ระเบีัย่บัวิธี ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 34 ข้้อแนืะนืำ� ขี�อแนะนำ�ด� นสำ�ธิ�รณิสุำขีที� นำ� เสำนอในขี�อแนะนำ�เกี� ยวักับกิจักรรมั ท�งก�ยและพ็ฤติกรรมัเน่อยนิ� งขีอง องค์ก์�รอน�มัยัโลก จััดทำ�ขี่ �นสำำ�หรับ ประช�กรทุกค์นและทุกกลุ่มัอ�ยุตั�งแต่ 5-65 ปีและส้ำงวัยักว่ั�นั�น โดยไม่ัเกี�ยวั- กบัเพ็ศ ภ้ัมิัหลงัท�งวัฒันธิรรมัหร่อสำถ�น- ภั�พ็ท�งเศรษฐศ�สำตรส์ำงัค์มั และเกี�ยวั- ขี�องกบัผู้้�ค์นในสำมัรรถภั�พ็ทุกร้ปแบบ ขี�อแนะนำ�ใหม่ันั�นนำ�เสำนอด�วัย กลุ่มัอ�ยุและพ็ฤติกรรมั (กิจักรรมั ท � ง ก � ย แ ล ะ พ็ ฤ ติ ก ร ร มั เน่ อ ย นิ� ง ) สำำ�หรบัค์ำ�แนะนำ�แต่ละชุด ค์ำ�บรรย�ย ส่ำวันเกริ�นนำ�ได�สำรุปผู้ลลพั็ธิท์�งสุำขีภั�พ็ ที� เช่� อมัโยงกับกิจักรรมัท�งก�ยและ พ็ฤติกรรมัเน่อยนิ�งต�มัลำ�ดบัและต�มั มั�ด�วัยขี�อแนะนำ� มีัชุดขี�อม้ัลขี�อแนะนำ� เพ่็� อแจังว่ั�ประช�กรกลุ่มัเป้�หมั�ย จั ะ ทำ � ต � มั ขี�อ แน ะ นำ � โ ด ย ป ล อ ด ภััย ไ ด� อ ย่ � ง ไ ร ขี� อ แ น ะ นำ � เ ห ล่ � นี� ไ ม่ั ใช่ “ขี�อแนะนำ �ที� มีัก�รวััดระดับ” ด�วัยตวััขีองมันัเอง แต่ได�มั�จั�กหลกัฐ�น ท � ง วิั ท ย � ศ � สำ ต ร์แ ล ะ มั � จั � ก ก � ร พิ็จั�รณิ�ที� ใช� ได�จัริง ซ่� งทบทวันและ แนะนำ�โดยค์ณิะทำ�ง�น GDG บทสำรุปขีองหลกัฐ�นท�งวิัทย�- ศ�สำตร์ที� สำนับสำนุนถ้กจััดไวั�สำำ �หรับ ขี�อแนะนำ�แต่ละชุด มีัค์ำ�ถ�มั PI/ECO เป็นโค์รงสำร� ง นำ�เสำนอหลกัฐ�นที� เช่�อมั โยงกบัผู้ลลพั็ธิท์�งสุำขีภั�พ็ที�สำำ�ค์ญั่ยิ�งเป็น อย่�งแรก ต�มัมั�ด�วัยบทสำรุปขีอง หลกัฐ�นเร่�องก�รตอบสำนองต่อปริมั�ณิ ท� ยที� สุำดค่์อ ก�รนำ�เสำนอบทสำรุปขีอง หลกัฐ�นว่ั�ด�วัยค์วั�มัสำมััพ็นัธิร์ะหว่ั�ง ชนิดหร่อขีอบข่ี�ยที�แตกต่�งกนัขีองก�ร เปิดเผู้ยขี�อม้ัลและผู้ลลัพ็ธิต่์อสุำขีภั�พ็ ต�มัที�มีัอย่้ 35ข้้อัแนะนำา กิจักรรมัท�งก�ยในเด็กและวัยัรุ่นจัะเอ่ �อประโยชนต่์อผู้ลลพั็ธิท์�งสุำขีภั�พ็ดงัต่อไปนี� ช่วัยพ็ฒัน� สุำขีภั�พ็ก�ย (ระบบหมุันเวีัยนโลหิตและค์วั�มัแข็ีงแรงกล� มัเน่�อ) สุำขีภั�พ็ระบบหมุันเวีัยนโลหิต (ระบบค์วั�มัดนัโลหิต ไขีมันัในเล่อด นำ � ต�ลในเล่อด และก�รต� นอินซ้ลิน) ค์วั�มัแข็ีงแรง กระด้ก, ผู้ลลพั็ธิด์� นก�รรบัร้�ขีองสำมัอง (ค์วั�มัสำ�มั�รถด� นก�รเรียนร้� ด� นก�รวิัเค์ร�ะห)์ สุำขีภั�พ็จิัต (ลดอ�ก�รซม่ัเศร� ) และลดภั�วัะโรค์อ�วัน สำำ�หรบัเด็กและวัยัรุ่น กิจักรรมัท�งก�ยเป็นได�ทั�งส่ำวันหน่�งขีองสำนัทน�ก�รและก�ร พ็กัผู่้อน (ก�รละเล่น เกมั กีฬ� หร่อก�ยบริห�รที�มีัก�รวั�งแผู้นไวั�) กิจักรรมัพ็ลศก่ษ� ก�รเดินท�ง (เดินท�งด�วัยอุปกรณิที์�มีัล�อ ก�รเดิน ก�รปั� นจักัรย�น) หร่อก�รทำ�ง�นบ� นในสำภั�พ็แวัดล�อมั ท�งก�รศก่ษ� บ� น และชุมัชน หลกัฐ�นและเหตุิผลสำนบัสำนุน สำำ�หรบัขี�อแนะนำ�เพ่็�อเด็กและวัยัรุ่น มีัก�รใช�บทปริทศันอ์ย่�งเป็นระบบ (22,25,35) และเพิ็�มับทปริทศัน์ใหม่ั อีก 16 ชิ �นที�พิ็ส้ำจันแ์ล�วัว่ั�เขี� เกณิฑ์ก์�รค์ดัอ�สำ�สำมัคั์รเขี� ร�ยละเอียดวิัธีิวิัจัยัที�ค์รบถ�วัน ก�รแยะแยะขี�อม้ัล และชุดขี�อม้ัลหลกัฐ�นมีัอย่้ที�ภั�ค์ผู้นวักในเว็ับไซต ์: ชุดขี�อม้ัลหลกัฐ�น4 • ทำ�กิจักรรมัท�งก�ยบ� งย่อมัดีกว่ั�ไม่ัทำ�อะไรเลย • ห�กเด็กหร่อวัยัรุ่นไม่ัสำ�มั�รถทำ�ต�มัขี�อแนะนำ�ได� ก�รทำ�กิจักรรมัท�งก�ยบ� งจัะเป็นผู้ลดี ต่อสุำขีภั�พ็ • เด็กและวัยัรุ่นค์วัรจัะเริ�มัทำ�กิจักรรมัท�งก�ยที�ระดบัเบ�ก่อนแล�วัค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มัเขี�มัขี�น และระยะเวัล�ขี่ �นเร่�อย ๆ • ก�รจัดัให�เด็กและวัยัรุ่นมีัค์วั�มัปลอดภัยั โอก�สำที�เท่�เทียมั และค์วั�มักล� ห�ญ่ที�จัะเขี� ร่วัมัใน ก�รทำ�กิจักรรมัท�งก�ยที� เพ็ลิดเพ็ลิน มีัค์วั�มัหล�กหล�ย และเหมั�ะสำมักบัอ�ยุและค์วั�มั สำ�มั�รถนั�นเป็นสิำ�งสำำ�ค์ญั่ เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) ข้้อแนืะนืำ�ด้็�นืกิิจกิรัรัมท�งกิ�ย แนะนำ�ให:้ เด็กและวยัรุ่นค์วรทำ�กิจกรรมัท�งก�ยอย่�งนอ้ยเฉลี�ยวนัละ 60 น�ที ติลอดทั�งสำปัด�ห ์ ในระดบัป�นกล�งถง้ระดบัหนกั โดยส่ำวนใหญ่่ค์วรเป็นกิจกรรมัท�งก�ยแบบแอโรบิก แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได�ป�นกล�ง ค์วรทำ�กิจกรรมัท�งก�ยแบบแอโรบิกที�ระดบัหนกั และกิจกรรมัสำร�้งค์ว�มัแข็้งแรงใหก้บั กล�้มัเนื �อและกระด้กอย่�งนอ้ย 3 วนัต่ิอสำปัด�ห์ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได�ป�นกล�ง > > ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ 4 ข้้อม่ัลออนไลน์ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 36 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) ค์ว�มัเชื้�อมัโยงระหว่�งกิจกรรมัท�ง- ก�ยและผลลพัธิ์ด์�้นสุำข้ภ�พในเด็ก และวยัรุ่น (อ�ยุ 5-17 ปี) คื์ออะไร หลักฐ�นกลุ่มัใหญ่่ ได�แสำดงไวั� ก่อนหน� นี�ว่ั� กิจักรรมัท�งก�ยเป็น ระยะเวัล�น�นขี่ �นและหนักหน่วังขี่ �นใน เด็กและวัยัรุ่นนั�น สำมััพ็นัธิก์บัผู้ลลพั็ธิท์�ง สุำขีภั�พ็หล�ยประก�ร (1) หลกัฐ�นเม่ั�อ ไม่ัน�นมั�นี�ย่นยนัว่ั�กิจักรรมัท�งก�ยที� เพิ็�มัขี่ �นจัะพ็ฒัน�สำมัรรถภั�พ็ขีองระบบ หัวัใจัและห�ยใจัและสำมัรรถภั�พ็ขีอง กล� มัเน่�อยด่กระด้กในเด็กและวัยัรุ่น (22, 35) ตวััอย่�งเช่น ผู้ลด� นบวักที� เกิดขี่ �น เ ม่ั� อ ทำ � กิ จั ก ร ร มั ท � ง ก � ย ที� ร ะ ดับ ป�นกล�ง-หนกั 3 วันัต่อสำปัด�หข์ี่ �นไป เป็นระยะเวัล� 30 ถง่ 60 น�ที (22, 35) ในเด็กและวัยัรุ่น กิจักรรมัท�งก�ย ทั� วั ไ ป ที� ส่ำ วั นให ญ่่ เ ป็ นกิจั กร ร มั แ บ บ แอโรบิกกบัผู้ลลพั็ธิ ์ในแง่ดีด� นสุำข้ภ�พ ข้องหัวใจและหลอดเลือด รวัมัถ่ง ปรบัปรุงค์วั�มัดนัโลหิต ไขีมันัในเล่อด ก�ร ค์วับคุ์มันำ � ต�ล และก�รต� นอินซ้ลิน ที�ดีขี่ �น มีัค์วั�มัสำมััพ็นัธิ ์ไปในทิศท�งเดียวั กนั (35) ก�รทบทวันวัรรณิกรรมัเม่ั� อ เร็วั ๆ นี�ได�ตรวัจัสำอบประสิำทธิิภั�พ็ขีองกิจั- กรรมัท�งก�ยที�โรงเรียน (46) ก�รออกกำ�- ลงัที�มีัค์วั�มัเขี�มัขี�นส้ำงในระยะเวัล�สำั�น (47) และก�รออกกำ�ลงัก�ยแบบแรงต� น (48) เปรียบเทียบกบัก�รไม่ัมีัก�รแทรกแซง ใน ก � ร วััด ค่์ � สุำ ขี ภั � พ็ โร ค์ หัวัใจั แ ล ะ หลอดเล่อด จั�กบทปริทัศน์ทั�งหมัด 3 ชิ �น มีัหลกัฐ�นต่อเน่�องว่ั�ก�รแทรก- แซงนั�น เช่�อมัโยงกบัผู้ลลพั็ธิสุ์ำขีภั�พ็หวััใจั และหลอดเล่อดที�วัดัได� แมั�ว่ั�ค์วั�มัแม่ัน- ยำ�จัะแปรผู้นัต�มัขีน�ดขีองผู้ลกระทบ และก�รทดลองขีองแต่ละบุค์ค์ล 2-3 ค์รั�ง พ็บผู้ลดีขีองกิจักรรมัท�งก�ยที� มีันัย- สำำ�ค์ญั่ต่อผู้ลลพั็ธิข์ีองสุำขีภั�พ็หัวัใจัและ หลอดเล่อดในทุกท�ง บทปริทศันฉ์บบั หน่� งที� มีักลุ่มัทดลองแบบสุ่ำมัและมีัก�ร ค์วับคุ์มั 19 ฉบับ (n=11988) (46) ชี �ว่ั �ร � ย ก�ร กิจั กร ร มั ท�ง ก� ย ขีอง โรงเรียนเช่�อมัโยงกบัสำภั�พ็ค์วั�มัดนัโลหิต ที� ดีขี่ �นอย่�งมีันัยสำำ�ค์ัญ่ (ES= 0.21 [95% CI: 0.42 to 0.01]; p= 0.04) และอินซ้ลินขีณิะอดอ�ห�ร (ES= 0.12 [95% CI: 0.42 to 0.04]; p= 0.03) เทียบ กับ ภั � วั ะ ที� ไ ม่ั มีั ก � ร แท ร ก แซ ง จั � ก กิจักรรมัท�งก�ย มีัร�ยง�นพ็บว่ั� กิจักรรมัท�งก�ย มีัค์วั�มัเช่�อมัโยงในท�งที� เอ่ �อประโยชน ์ ต่อภ�วะโรค์อว้น และกิจักรรมัระดบัที�ส้ำง กว่ั�อ�จัจัะเกี� ยวัเน่� องกับสำถ�นะขีอง นำ � หนกัที�เหมั�ะสำมักบัสุำขีภั�พ็ในเด็กและ วัยัรุ่น (22,35) ผู้ลก�รทดลองนี� โดย ทั�วัไปแล�วัจัะชดัเจันที� สุำดในก�รวิัจัยัแบบ ขี� มักลุ่มั ซ่�งผู้ลจัะผู้สำมัปนเปไปจั�กก�ร วิัจััยจั�กก�รสำังเกตแบบค์�ดหวัังผู้ล ซ่�งจัำ�กดัค์วั�มัเขี� ใจัเกี�ยวักบัทิศท�งขีอง ค์ วั � มั เ กี� ย วั โ ย ง ที� ไ ด�รับ ร � ย ง � น มั � บทปริทศันเ์ร่� องก�รทดลองก�รแทรก แซงกิจักรรมัท�งก�ยฉบบัเม่ั�อไม่ัน�นนี� (ก�รออกกำ�ลงัที�มีัค์วั�มัเขี�มัขี�นส้ำงในระยะ เวัล�สำั�น [HIIT] ที� เกิดขี่ �นในห�องทดลอง ก � ร เ รี ย น แ บ บ ก ร ะ ฉั บ ก ร ะ เ ฉ ง ใ น 37 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) ห� องเรียน ก�รออกกำ�ลังก�ยแบบ มีัแรงต� น) แสำดงผู้ลที� ไม่ัค์งที� โดยง�น วิัจัยัส่ำวันใหญ่่ที�รวัมัไวั�ในบทปริทศัน์ ไม่ั ได�ร�ยง�นถ่งผู้ลกระทบ (47, 49, 50) แมั�กระนั�น บทปริทศันที์�มั�จั�กง�นวิัจัยั ที� มีัก�รสำงัเกตระยะย�วัและก�รทดลอง แบบขี� มักลุ่มัแสำดงให� เห็นถ่งผู้ลใน ท�งลบต่อค์วั�มัสำมััพ็นัธิร์ะหว่ั�งกิจักรรมั ท�งก�ยที� มีัก�รใช�เค์ร่� องม่ัอวััดก� วั ก�รวััดภั�วัะโรค์อ�วัน ดัชนีมัวัลก�ย หร่อขีน�ดรอบเอวั (51) โดยภั�พ็รวัมัแล�วั มีัหลกัฐ�นที� มีัค์วั�มัเช่� อถ่อเป็นจัำ�นวัน น�อยที�ว่ั� กิจักรรมัท�งก�ยนั�นเกี�ยวัเน่�อง กบัก�รจัดัก�รให�มีันำ � หนกัเหมั�ะสำมั และ ต�องก�รก�รวิัจััยเพิ็� มัเติมัเพ่็� อกำ�หนด ทิศท�งและค์วั�มัแข็ีงแรงขีองค์วั�มั เช่�อมัโยง มีัหลักฐ�นน�อยชิ�นที� ตรวัจัสำอบ ค์วั�มัเกี�ยวัเน่�องระหว่ั�งกิจักรรมัท�งก�ย แ ล ะ ก � ร พัฒ น� ท ัก ษ ะ ก � ร พัฒ น� กล�้มัเนื �อในเด็กและวัยัรุ่น บทปริทศัน ์ ที� มีัอย่้ปัจัจุับนั ชี �ว่ั�ไม่ัมีัก�รค์�นพ็บใด ๆ ( 2 2 ) ง � น วิั จััย เพิ็� มั เ ติ มั ที� เ กี� ย วั กับ ก � ร พ็ั ฒ น � ก ล� มั เ น่� อ เ พ่็� อ พ็ั ฒ น � ขี�อแนะนำ�ในอน�ค์ตเป็นสิำ�งจัำ�เป็น สำำ�หรบัเด็กและวัยัรุ่น กิจักรรมัที� เสำริมัสำร� งกระด้กสำ�มั�รถเกิดร่วัมักบั ก � ร เ ล่ น เ ก มั ก � ร วิั� ง ก � ร ห มุั น ตัวั หร่อกระโดด กิจักรรมัท�งก�ยนั�นเกี�ยวั เน่�องในท�งบวักกบัก�รสำะสำมัมัวัลกระด้ก และ/หร่อโค์รงสำร� งกระด้ก และหลกัฐ�น ฉบบัเม่ั� อไม่ัน�นมั�นี�ก็สำนับสำนุนว่ั�เด็ก และวัยัรุ่นที� มีัก�รทำ�กิจักรรมัท�งก�ย มั�กกว่ั�เพ่็� อนจัะมีัมัวัลกระด้กที� ดีกว่ั� ปริมั�ณิแร่ธิ�ตุในกระด้กหร่อค์วั�มั หน�แน่นกระด้กส้ำงกว่ั� และค์วั�มัแข็ีงแรง ขีองกระด้กที�มั�กกว่ั� (35) ก�รทำ�ให� สุำข้ภ�พกระด้กแข็ีงแรงที� สุำดในวัยัเด็ก และวัยัรุ่นจัะช่วัยป้องกนัโรค์กระด้กพ็รุน และกระด้กร� วัในช่วังต่อ ๆ มั�ขีองชีวิัต ก�รพ็ฒัน�และค์งหน� ที�ท�งก�ร รบัร้�เอ�ไวั�เป็นสิำ�งจัำ�เป็นสำำ�หรบัทุกช่วัง ขีองชีวิัต กิจักรรมัท�งก�ยในเด็กและ วัยัรุ่น มีัผู้ลในท�งบวักกบัก�รรบัร้แ้ละ ผลก�รเรียน (ตวััอย่�งเช่น ก�รเรียนร้� ค์วั�มัจัำ� และหน� ที� ในก�รวิัเค์ร�ะห์) (22,35) ในง�นวิัจัยัล่�สุำดชิ�นหน่� ง (19 RCTs; n= 5038) ชี �ให�เห็นว่ั�ก�รแทรก ก�ร ออ ก กำ � ลัง ก� ย ไวั�ห ล� ย ช่วัง ต่ อ สำปัด�ห ์เป็นเวัล� 6 สำปัด�หห์ร่อมั�กกว่ั�นั�น มีัค์วั�มัสำัมัพ็ันธิก์ับก�รเปลี� ยนแปลง เป็นอย่�งยิ�งในก�รวัดัผู้ลด� นก�รเรียนร้� เช่น ก�รค์วับคุ์มัยับยั�ง (SMD 0.26 [95% CI: 0.08 to 0.45], p= < 0.01) หน่วัยค์วั�มัจัำ�ในก�รทำ�ง�น (SMD 0.10 [95% CI: -0.05 to 0.25], p= < 0.02) และค์วั�มัย่ดหยุ่นท�งค์วั�มัคิ์ด (SMD 0.14 [95% CI: -0.03 to 0.31], p= < 0.04) เปรียบเทียบกบัเม่ั�อไม่ัมีัก�ร ออกกำ�ลงัก�ยมั�แทรกแซง กิจักรรมัท�ง ก�ยยงัช่วัยลดค์วั�มัเสีำ�ยงที�จัะเผู้ชิญ่กบั ภั�วัะซม่ัเศร� และอ�ก�รซม่ัเศร� ในเด็ก และวัยัรุ่นที� เป็นและไม่ัเป็นโรค์ซม้ัเศัร�้ (35) และอ�จัเปรียบได�กับก�รบำ�บัด ท�งจิัตและท�งย�เพ่็�อลดอ�ก�รนั�น ๆ ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 38 แมั�ว่ั�กิจักรรมัท�งก�ยอ�จัมีัค์ว�มั เสีำ�ยงจ�กเหตุิไม่ัพง้ประสำงค์ ์(53) แต่ก็มีั ห ลัก ฐ � น อ ย่ � ง จัำ � กัด ที� ร � ย ง � น ถ่ง อันตร�ยที� เ กี� ยวัเน่� องกับระดับขีอง กิจักรรมัท�งก�ยที�แนะนำ�เพ่็�อสุำขีภั�พ็ที�ดี (35) จั�กหลกัฐ�นที� มีัอย่้และค์ำ�แนะนำ� ขีองผู้้�เชี�ยวัช�ญ่ ค์วั�มัเสีำ�ยงที�อ�จัเกิดขี่ �น นั�นเช่� อมัโยงกับปริมั�ณิและชนิดขีอง กิจักรรมัท�งก�ยที�แนะนำ�สำำ�หรบัเด็กและ วัยัรุ่นนั�นน�อยมั�ก และลดได�ด�วัยก�รเพิ็�มั ระดบักิจักรรมัและค์วั�มัหนกัหน่วังอย่�ง ต่อเน่�อง โดยเฉพ็�ะเด็กและวัยัรุ่นที�ไม่ัค่์อย ขียบัร่�งก�ย เป็นที� ร้�กนัว่ั�ก�รเขี� ร่วัมั กีฬ�บ�งประเภัทนั�นเพิ็�มัค์วั�มัเสีำ�ยงในก�ร บ�ดเจ็ับและเพิ็�มัค์วั�มัหนกัหน่วังในก�ร ออกกำ�ลงัก�ยด�วัย (53) เร�ต�องก�รง�น วิัจัยัเพิ็�มัเพ่็�อเสำริมัฐ�นค์วั�มัร้�ในเน่�อห�นี� ค์ณะทำ�ง�น GDG สำรุปว่� • มีั ห ลั ก ฐ � น ที� มีั ค์ วั � มั เ ช่� อ ถ่ อ ไ ด� ป�นกล�งว่ั� กิจักรรมัท�งก�ยที� ระดบัป�นกล�งและหนักเป็นระยะ เวัล�น�นเกี�ยวัโยงกบัค์วั�มัแข็ีงแรง ขี อ ง ก � ร ห มุั น เ วีั ย น โ ล หิ ต แ ล ะ กล� มัเน่�อ สุำขีภั�พ็หลอดเล่อดหัวัใจั และสุำขีภั�พ็กระด้กในเด็กและวัยัรุ่น • มีั ห ลั ก ฐ � น ที� มีั ค์ วั � มั เ ช่� อ ถ่ อ ไ ด� ป�นกล�งว่ั� กิจักรรมัท�งก�ยที�ระดบั ป�นกล�งและหนักทั�งระยะสำั�นและ ระยะย�วัมีัผู้ลดีต่อค์วั�มัสำ�มั�รถใน ก�รรบัร้�ผู้ลก�รเรียน และสุำขีภั�พ็จิัต • มีัหลกัฐ�นที� มีัค์วั�มัเช่�อถ่อได�น�อยว่ั� กิจักรรมัท�งก�ยมีัค์วั�มัเกี�ยวัเน่�องที� เอ่ �อต่อก�รจัดัก�รต่อสำภั�พ็นำ � หนกัที� เหมั�ะสำมัในเด็กและวัยัรุ่น เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) • มีัหลกัฐ�นที� มีัค์วั�มัเช่�อถ่อได�น�อยว่ั� ค์วั�มัเสีำ�ยงสำำ�หรบัปริมั�ณิและชนิด ขีองกิจักรรมัท�งก�ยที�แนะนำ�สำำ�หรบั เด็กและวััยรุ่นนั�นตำ� และมีันำ � หนัก เทียบไม่ัได�กบัคุ์ณิประโยชน์ มีัค์ว�มัเกี�ยวเนื�องเรื�องปริมั�ณหรือไม่ั ( ป ริ มั � ณ ร ะ ย ะ เ ว ล � ค์ ว � มั ถี� ค์ว�มัหนกัหน่วง) แมั�จัะมีัหลกัฐ�นมั�กมั�ยแสำดงให� เห็นว่ั�มีัก�รเช่�อมัโยงในท�งบวักระหว่ั�ง กิจักรรมัท�งก�ยและผู้ลลพั็ธิท์�งสุำขีภั�พ็ ในเด็กและวัยัรุ่น ง�นวิัจัยัน�อยชิ�นมั�กที� จัะกล่�วัถ่งประเด็นขีองก�รตอบสำนอง ต่อปริมั�ณิ แมั�กระนั�น ร้ปร่�งที�แน่นอน ขีองเสำ�นโค์�งก�รตอบสำนองต่อปริมั�ณิ และ/หร่อก�รมีัอย่้ขีองค่์�ขีีดจัำ�กัด (ที�แยกค์วั�มัแตกต่�งระหว่ั�งค์วั�มัเสีำ�ยง ที� ตำ� กว่ั�และส้ำงกว่ั�) สำำ�หรับกิจักรรมั ท�งก�ยและผู้ลลัพ็ธิต่์อสุำขีภั�พ็โดย เฉพ็�ะนั�น ยังมีัค์วั�มัเขี� ใจัน�อยกว่ั� สำำ �หรับเ ด็ กและวััย รุ่นเ ม่ั� อ เที ยบกับ ประช�กรผู้้� ใหญ่่ แต่อย่�งไรก็ต�มั มีัหลักฐ�นมั�กมั�ยแสำดงให� เห็นว่ั�มีั ประโยชนท์�งสุำขีภั�พ็มั�กมั�ยที� เกิดขี่ �น เม่ั�อทำ�กิจักรรมัท�งก�ยทุกวันัเป็นเวัล� 60 น�ที (22,35) และไม่ัมีัหลกัฐ�นแย�ง ในท�งอ่� น จั่งสำ รุป ได� ว่ั�หลักฐ�นที� ทัน สำ มััย นี� ไ ด� ย่ น ยัน ค์ำ � แน ะ นำ � ขี อ ง องค์ก์�รอน�มัยัโลกฉบบัปัจัจุับนั สำำ�หรบั กิจักรรมัท�งก�ยที�ระดบัป�นกล�ง-หนกั อย่�งน�อย 60 น�ทีต่อวันั 39 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) อย่�งไรก็ดี ก�รทบทวันหลกัฐ�น ทั�งหมัด ซ่�งรวัมัทั�งผู้ลล่�สุำดจั�กก�รวิัจัยัที� ใช�เค์ร่�องม่ัอวัดักิจักรรมัท�งก�ยด�วัยนั�น ไม่ัได�รับรองก�รรักษ�ขี�อกำ�หนดขีอง กิจั ก ร ร มั ท � ง ก � ย ขีั�น ตำ� � อ ย่ � ง น� อ ย 60 น�ที ทั�งในระดบักล�งและระดบัหนกั เพ่็�อสุำขีภั�พ็ที�ดี ชี �ให�เห็นว่ั�ง�นวิัจัยันั�นใช� “ค่์�เฉลี�ย” โดยกวั� ง 60 น�ทีต่อวันั ไม่ัใช่ ค่์�ขีอบเขีตขีั�นตำ� ประจัำ�วันัที� 60 น�ที เพ่็�อประเมิันประโยชนข์ีองกิจักรรมัท�ง- ก�ยต่อผู้ลลพั็ธิท์�งสุำขีภั�พ็ ก�รทบทวัน วัรรณิกรรมัสำรุปว่ั� ค์วัรแก�ไขีขี�อแนะนำ� ใหม่ัให�สำะท�อนหลกัฐ�นนี�อย่�งใกล�เคี์ยง ขี่ �น ประโยชนต่์อสุำขีภั�พ็หลอดเล่อด และหวััใจัจั�กก�รทำ�กิจักรรมัท�งก�ยที� ระดับหนักเป็นประจัำ�นั�นเป็นที� ร้�กันดี อย่้แล�วั และบทปริทัศนเ์ม่ั� อไม่ัน�นมั� นี�ยงัมีัหลกัฐ�นสำนับสำนุนเพิ็�มัเติมั (35) ตวััอย่�งเช่น บทปริทศัน ์(54) แสำดงให�เห็น ว่ั�ก�รออกกำ�ลงัที� มีัค์วั�มัเขี�มัขี�นส้ำงใน ระยะเวัล�สำั�น เทียบกบัก�รออกกำ�ลงัก�ย แบบต่อเน่�องที�ค์วั�มัเขี�มัขี�นป�นกล�งมีั ผู้ลในท�งบวักระดบัป�นกล�งต่อสุำขีภั�พ็ ก�รไหลเวีัยนโลหิต (SMD= 0.51 [95% CI: 0.33 to 0.69], p= < 0.01; I 2= 0%) ไม่ัมีัหลกัฐ�นว่ั�ระยะเวัล�ก�รแทรกแซง วิัธีิก�รออกกำ�ลงัก�ย อตัร�ก�รออกกำ�ลงั ก�ยและก�รพ็กัผู่้อน และช่วังขีองก�ร ออกกำ�ลงัก�ยจัะเปลี� ยนผู้ลขีองค์วั�มั แข็ีงแรงในก�รหมุันเวีัยนโลหิตได� ผู้ลก�ร ทดลองนี�สำอดค์ล�องกบับทปริทศันอ่์�น ๆ (22, 35, 47) และยิ�งรบัรองขี�อแนะนำ�ที�ว่ั� เด็กและวัยัรุ่นนั�นค์วัรทำ�กิจักรรมัที�ระดบั หนักเป็นประจัำ� เพ่็� อเสำริมัสำร� งค์วั�มั แข็ีงแรงขีองระบบไหลเวีัยนโลหิต ค์ณะทำ�ง�น GDG สำรุปว่� • หลกัฐ�นย่นยนัขี�อแนะนำ�ขีององค์ก์�ร อน�มััยโลกว่ั�ด�วัยก�รทำ�กิจักรรมั ท�งก�ยที�ระดบัป�นกล�งถง่หนกั 60 น�ทีต่อวันั • หลกัฐ�นรบัรองก�รแก�ไขีขี�อกำ�หนด เกี� ยวักับกิจักรรมัท�งก�ยตำ� � สุำด 60 น�ทีต่อวันัก่อนหน� นี�เป็นค่์�เฉลี�ย อย่�งน�อย 60 น�ทีต่อวันัต่อสำปัด�ห ์ ซ่�งสำะท�อนให�เห็นหลกัฐ�นได�ใกล�ชิด กว่ั� • มีัหลกัฐ�นที� มีัค์วั�มัน่�เช่�อถ่อระดบั ป�นกล�งว่ั� กิจักรรมัท�งก�ยที�ระดบั หนักเป็นระยะเวัล�น�นสำมััพ็ันธิก์บั ค์วั�มัแข็ีงแรงขีองระบบไหลเวีัยน โลหิตที�เพิ็�มัขี่ �น ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 40 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) ค์ ว � มั สำ ัมั พ ัน ธิ์ ์เ ป ลี� ย น แ ป ล ง ติ � มั ประเภทหรือข้อบข่้�ยข้องก�รทำ� กิจกรรมัท�งก�ยหรือไม่ั สำำ�หรับเด็กและวััยรุ่น กิจักรรมั ท�งก�ยรวัมัถ่ง ก�รละเล่น เกมั กีฬ� ก�รเดินท�ง สำนัทน�ก�ร วิัช�พ็ลศ่กษ� หร่ อ ก�ร ออ ก กำ � ลัง ก� ย วั�ง แ ผู้ นไวั� ในบริบทขีองกิจักรรมัในค์รอบค์รัวั โรงเรียน และชุมัชน อย่�งไรก็ดี ง�นวิัจัยั บ �ง ง � น เ ป รี ย บ เที ย บ ป ร ะ เ ภั ท หร่ อ ขีอบข่ี�ยขีองกิจักรรมัท�งก�ยในเด็ก และวัยัรุ่นโดยตรง ดงันั�นจัง่ไม่ัมีัหลกัฐ�น เพี็ยงพ็อที�จัะกำ�หนดว่ั� ค์วั�มัเกี�ยวัโยง ระหว่ั�งกิจักรรมัท�งก�ยและผู้ลลพั็ธิ ์ ท�งสุำขีภั�พ็ที�หล�กหล�ยเปลี�ยนแปลง ต � มั ป ร ะ เ ภั ท ขี อ ง กิ จั ก ร ร มั ( เ ช่ น ก�รออกกำ�ลังแบบแอโรบิค์กับก�ร ออกกำ�ลังก�ยเพ่็� อเสำริมักล� มัเน่�อ) หร่อขีอบข่ี�ยขีองกิจักรรมัท�งก�ย (เช่น ก�รเดินท�งอย่�งค์ล่องแค์ล่วั (ก�รเดินและก�รปั� นจัักรย�น) และ วิัช�พ็ลศ่กษ�เปรียบเทียบกบัก�รกีฬ�/ สำนัทน�ก�ร) มีัหลักฐ�นที� แสำดงว่ั� ทั�งระดับ กิจักรรมัท�งก�ยแบบแอโรบิกที�ระดบั ป�นกล�งถ่งระดับหนักเช่� อมัโยงกับ ระบบก�รไหลเวีัยนโลหิตที�แข็ีงแรงขี่ �น และกิจักรรมัสำร� งค์วั�มัแข็ีงแรงให�กบั กล� มัเน่�อที� เพิ็� มัขี่ �นนั�น จัะเสำริมัค์วั�มั แข็ีงแรงขีองกล� มัเน่�อในเด็กและวัยัรุ่น หลักฐ�นชิ�นนี�ร�ยง�นว่ั� ขี�อแนะนำ� ระดบัสำ�กลด� นกิจักรรมัท�งก�ยเพ่็� อ สุำขีภั�พ็ขีององค์ก์�รอน�มัยัโลกฉบบัปี 2553 (1) ซ่�งแนะนำ�ก�รรวัมักิจักรรมัสำร� ง ค์วั�มัแข็ีงแรงให�กบักล� มัเน่�อและกระด้ก อย่�งน�อย 3 วันัต่อสำปัด�ห ์หลกัฐ�นที�ปรบั ให�เป็นปัจัจุับนัย่นยนัว่ั�กิจักรรมัย่ดหยุ่น กล� มัเน่�อ 3 วันัต่อสำปัด�หมี์ัประสิำทธิิภั�พ็ ที� จัะปรับปรุงตัวับ่งชี�ค์วั�มัแข็ีงแรง กล� มัเน่�อ อย่�งไรก็ต�มั ไม่ัมีัหลกัฐ�น เพี็ยงพ็อที�จัะแสำดงร�ยละเอียดเฉพ็�ะ ขีองช่วังค์วั�มัต่อเน่� องและค์วั�มัหนัก- หน่วัง ซ่�งเป็นผู้ลส่ำวันใหญ่่มั�จั�กค์วั�มั ต่�งขีองระยะเวัล�ต�มัที� ประเมิันไวั�ใน วัรรณิกรรมั (22, 35) มีัหลักฐ�น น� อ ย ชิ� น ใ น เ ร่� อ ง ขี อ ง ผู้ ล ก ร ะ ท บ เชิงป้องกนัขีองก�รออกกำ�ลงัก�ยแบบ ออกแรงต� นต่อสุำขีภั�พ็หลอดเล่อดและ หวััใจั และเป็นไปไม่ัได�ที�จัะระบุขี�อม้ัลเพิ็�มั เติมั เช่น เร่�องระยะเวัล� ด�วัยก�รให�ค์วั�มั สำำ�ค์ัญ่ส่ำวันที� ห�ยไปสำำ�หรับขี�อม้ัลใหม่ั ในเร่�องขีองบุค์ลิกลกัษณิะมั�กกว่ั�ค์วั�มั- ถี� ในก�รทำ�กิจักรรมัสำร� งค์วั�มัแข็ีงแรง ให�กับกล� มัเน่�อสำำ�หรับเด็กและวััยรุ่น ง�นวิัจััยในอน�ค์ตค์วัรกล่�วัถ่งคุ์ณิ ประโยชนด์� นสุำขีภั�พ็ขีองกิจักรรมัท�ง ก�ยเฉพ็�ะอย่�งและขีอบข่ี�ย เพ่็�อให�มีั ขี�อม้ัลจัำ�เพ็�ะขีองขี�อแนะนำ�ในส่ำวันนี�เพิ็�มั มั�กขี่ �น ค์ณะทำ�ง�น GDG สำรุปว่� • มีัหลกัฐ�นเช่�อถ่อได�ระดบัป�นกล�ง ว่ั� ค์วัรทำ�กิจักรรสำร� งค์วั�มัแข็ีงแรง ให�กับกล� มัเน่�ออย่�งน�อย 3 วััน ต่อสำปัด�ห์ 41 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) ข้้อแนืะนืำ� ด้็�นืพฤติิกิรัรัมเนืือยนิื�ง พ็ฤติกรรมัเน่อยนิ�ง ค่์อ เวัล�ที�ใช�ไปกบัก�รนั�งนิ�งหร่อนอนลง โดยมีัก�รใช�พ็ลงัง�นแต่น�อย ขีณิะต่�น ในสำภั�พ็แวัดล�อมัที�โรงเรียน บ� น ชุมัชน และก�รเดินท�ง หลกัฐ�นสำนบัสำนุนและเหตุิผล พ็ฤติกรรมัเน่อยนิ�งนั�นไม่ัได�มีัก�รกล่�วัถง่ไวั�ในขี�อแนะนำ�ขีององค์ก์�รอน�มัยัโลกปี 2553 แต่ในช่วังทศวัรรษที�ผู่้�นมั� มีัองค์ก์�รวิัจัยัที�เพิ็�มัขี่ �นในก�รตรวัจัสำอบผู้ลลพั็ธิต่์อสุำขีภั�พ็ที�เกี�ยวัเน่�อง กบัมั�ตรวัดัและชนิดขีองพ็ฤติกรรมัเน่อยนิ�งที�หล�กหล�ย เทค์โนโลยีและก�รส่ำ�อสำ�รแบบดิจิัทลั กำ�หนดว่ั� ผู้้�ค์นจัะทำ�ง�น เรียน เดินท�ง และใช�เวัล�พ็กัผู่้อนอย่�งไร ในประเทศส่ำวันใหญ่่ เด็กและ วัยัรุ่นใช�เวัล�ส่ำวันใหญ่่ไปกบัพ็ฤติกรรมัเน่อยนิ�ง โดยเฉพ็�ะก�รสำนัทน�ก�ร เช่น ค์วั�มับนัเทิง ผู่้�นหน� จัอ (โทรทศันแ์ละค์อมัพิ็วัเตอร)์ และก�รส่ำ�อสำ�รแบบดิจิัทลั เช่น โทรศพั็ทม่์ัอถ่อ สำำ�หรบัขี�อแนะนำ�เพ่็�อเด็กและวัยัรุ่นนี� มีัก�รทบทวันวัรรณิกรรมัอย่�งเป็นระบบ (24, 25) และใช�บทปริทศันเ์พิ็�มัใหม่ัอีก 7 ฉบบัที�ตรวัจัสำอบแล�วัว่ั�เขี� เกณิฑ์ก์�รนำ�ขี�อม้ัลเขี� ร�ยละเอียด ค์รบถ�วันเกี�ยวักบักระบวันวิัธีิ ก�รแยกขี�อม้ัล และชุดขี�อม้ัลหลกัฐ�นอย่้ที�ภั�ค์ผู้นวักบนเว็ับไซต ์ : ชุดขี�อม้ัลหลกัฐ�น5 พ็ฤติกรรมัเน่อยนิ�งในวัยัเด็กและวัยัรุ่นที�เพิ็�มัขี่ �นมั�นั�นต�มัมั�ด�วัยผู้ลเสีำยต่อสุำขีภั�พ็ ดงันี� ภั�วัะโรค์อ�วันที�เพิ็�มัขี่ �น สุำขีภั�พ็หลอดเล่อดหวััใจั ค์วั�มัแข็ีงแรง ค์วั�มัประพ็ฤติ พ็ฤติกรรมั เอ่ �อสำงัค์มัที�แย่ลง และช่วังเวัล�นอนหลบัที�ลดลงด�วัย แนะนำ�ให:้ เด็กและวยัรุ่นค์วรจำ�กดัเวล�ที�มีัพฤติิกรรมัเนือยนิ�ง โดยเฉพ�ะเวล�ที�อย่้กบั หน�้จอเพื�อค์ว�มับนัเทิง แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได�ตำ� > ข้้อัแนะนำา 5 ข้้อม่ัลออนไลน์ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 42 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) อะไรคื์อค์ว�มัสำมััพนัธิ์ร์ะหว่�งพฤติิ- กรรมัเนือยนิ�งและผลต่ิอสุำข้ภ�พในเด็ก และวยัรุ่น (อ�ยุ 5-17 ปี) ห ลัก ฐ � น บ่ ง ชี�ว่ั � เวั ล � ที� ใ ช�กับ พ็ฤติกรรมัเน่อยนิ� งที� เพิ็� มัมั�กขี่ �นนั�น โดยเฉพ็�ะเวัล�ที�อย่้กบัหน� จัอ สำมััพ็นัธิ ์ กบัผู้ลลพั็ธิต่์อสุำขีภั�พ็ที�แย่ลง (24, 35) ตวััอย่�งเช่น เวัล�ที�อย่้กบัหน� จัอที�ย�วั น�นขี่ �น (รวัมัถง่เวัล�ด้โทรทศัน)์ เช่�อมัโยง กบัสุำขีภั�พ็และสุำขีภั�พ็ด� นหลอดเล่อด หัวัใจัที�แย่ลงในเด็กและวัยัรุ่น หลกัฐ�น จั�กก�รประเมิันค์วั�มัเช่� อมัโยงด�วัย อุปกรณิร์ะหว่ั�งก�รศ่กษ�พ็ฤติกรรมั เน่อยนิ�งและก�รแทรกแซงแสำดงให�เห็น ถ่งผู้ลกระ ทบป�นกล�ง แมั� ว่ั�จัะมีั ผู้ลกระทบมั�กกว่ั�กบัผู้้�ที� มีัภั�วัะนำ � หนกั เกิน (55) มีัหลกัฐ�นอย่้จัำ�กดัที� ชี �ให�เห็น ว่ั�พ็ฤติกรรมัเน่อยนิ�งไม่ัมีัผู้ลต่อสุำขีภั�พ็ กระด้กในเด็กและวัยัรุ่น แมั�จัะมีัผู้ลก�รทดลองที� หล�ก- ห ล � ย มั � ก ขี่ �น แ ต่ ห ลักฐ � น ยัง ชี�ว่ั � พ็ฤติกรรมัเน่อยนิ� งอ�จัเช่� อมัโยงกับ ก�รวััดภั�วัะโรค์อ�วันที� ไม่ัน่�พ็่งพ็อใจั (24, 25) บทปริทศันชิ์�นหน่� งเกี� ยวักบั ก�รวิัจััยขี� มักลุ่มัขีน�ดใหญ่่ร�ยง�น ว่ั� พ็ฤติกรรมัเน่อยนิ� งที� มั�กกว่ั� 2 ชั� วัโมังต่อวันั (วัดัจั�กเวัล�ทั�งหมัดที� ใช� อย่้กบัหน� จัอ) นั�นเกี�ยวัเน่�องในเชิงบวัก กบัภั�วัะโรค์อ�วัน/นำ � หนกัเกินในวัยัเด็ก เม่ั�อเทียบกบัระดบัที�ตำ� กว่ั� (น�อยกว่ั� 2 ชั�วัโมังต่อวันั) (56) อย่�งไรก็ดี บทปริทศัน ์ ที�มั�จั�กง�นวิัจัยัแบบขี� มักลุ่มัจัำ�นวัน 20 ชิ �นไม่ัพ็บว่ั�มีัก�รเช่� อมัโยงอย่�งมีันัย- สำำ �ค์ัญ่ท�งสำถิติระหว่ั�งก�รนั� ง เ ล่น วีัดีโอเกมัอย่้เฉย ๆ กับดัชนีมัวัลก�ย ในเด็กและวัยัรุ่น บทปริทศันที์�ทบทวัน ง�นวิัจัยั 29 ชิ �นอย่�งเป็นระบบสำรุปว่ั� ง�นวิัจัยัหล�ยชิ�นร�ยง�นค์วั�มัเช่�อมัโยง ที� ไม่ัน่�พ็ง่พ็อใจัระหว่ั�งพ็ฤติกรรมัเน่อย นิ� งและเค์ร่� องบ่งชี�ภั�วัะ โรค์อ�วันใน เย�วัชน เม่ั�อพ็ฤติกรรมันั�นร�ยง�นด�วัย ก�รบนัท่กด�วัยตนเองระหว่ั�งเวัล�ที�อย่้ กบัหน� จัอ (55) อย่�งไรก็ต�มั บทปริทศัน ์ ระบุว่ั� ค์วั�มัสำำ�ค์ญั่ขีองก�รเช่�อมัโยงยงัมีั อย่้น�อยและแทบจัะเป็น 0 สำำ�หรบัก�ร วิัจัยัที�ประเมิันพ็ฤติกรรมัเน่อยนิ�งโดยใช� เค์ร่� องม่ัอ ก�รวิัจัยัก�รแทรกแซงชี�ให� เห็นผู้ลกระทบน�อยมั�ก แมั�ว่ั�จัะมีัผู้ล กระทบที�ร� ยแรงกว่ั�สำำ�หรบัผู้้�ที� มีัภั�วัะ นำ � หนักเกิน (55) ง�นวิัจััยเพิ็� มัเติมั เ กี� ย วั กั บ ค์ วั � มั เ ช่� อ มั โ ย ง ร ะ ห ว่ั � ง พ็ฤติกรรมัเน่อยนิ�งและก�รวัดัไขีมันันั�น มีัค์วั�มัจัำ�เป็น แมั�ว่ั�จัะยงัอย่้ในขีั�นตอนก�รรวับ รวัมัประเด็นในก�รวิัจัยั หลกัฐ�นบ�งชิ�น ชี �ว่ั�อ�จัมีัค์วั�มัเกี� ยวัเน่� องในท�งลบ ระหว่ั�งพ็ฤติกรรมัเน่อยนิ� งกับค์วั�มั เป็นอย่้และคุ์ณิภั�พ็ชีวิัต รวัมัถ่งค์วั�มั สำมััพ็ันธิที์� ไม่ัน่�พ็่งพ็อใจัระหว่ั�งค์วั�มั ซ่มัเศร� กบัเวัล�พ็กัผู่้อนหน� จัอในเด็ก และวััย รุ่น (58, 59) ตัวัอย่�งเช่น ระยะเวัล�ขีองพ็ฤติกรรมัเน่อยนิ� งที� ย�วัน�นขี่ �น ประเมิันจั�กเวัล�ที�อย่้กบั หน� จัอและก�รใช�ค์อมัพิ็วัเตอร์บ�ง ร้ปแบบ อ�จัสำมััพ็นัธิก์บัสุำขีภั�พ็จิัตที�แย่ลง 43 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) (24) ในบทปริทศันอี์กชิ�นเม่ั� อเร็วั ๆ นี� ค์วั�มัเช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อย นิ�งและอ�ก�รวิัตกกงัวัลนั�นพ็บได�ในง�น วิัจัยั 5 จั�ก 8 ชิ �น แมั�ว่ั�ผู้ลจัะไม่ัค์งที�จั�ก ก�รวัดัพ็ฤติกรรมัเน่อยนิ� งที� ต่�งกนัใน ง�นวิัจัยัเหล่�นั�น(60) หลกัฐ�นอ่�นชี�ว่ั� ระยะเวัล�ก�รด้โทรทศันแ์ละก�รเล่นเกมั วิัดีโอที� ย�วัน�นขี่ �นเกี� ยวัเน่� องอย่�งยิ� ง กับ ก � ร วััด ผู้ ล ขี อ ง ค์ วั � มั ป ร ะ พ็ ฤ ติ / พ็ฤติกรรมัเอ่ �อสำังค์มัที� ไม่ัน่�พ็่งพ็อใจั (24) และก�รใช�เวัล�อย่้กบัหน� จัอและ ด้โทรทัศน์ที� ย�วัน�นขี่ �นนั�นสำัมัพ็ันธิ ์ กับค์วั�มัต่อเน่� องในก�รนอนหลับที� สำั�นลง แมั�ว่ั�จัะ ไม่ัมีัค์วั�มัเกี� ยวัเน่� อง ระหว่ั�งก�รใช�ค์อมัพิ็วัเตอร ์ก�รเล่นเกมั และค์วั�มัต่อเน่�องในก�รนอนหลบั (61) ก�รค์�นห�ค์วั�มัสำมััพ็นัธิร์ะหว่ั�งพ็ฤติ- กรรมัเน่อยนิ�งและสุำขีภั�พ็จิัตเป็นสำ�ขี� วิัช�ที� พ็ัฒน�อย่�งรวัดเร็วั และอ�จัมีั สำ�เหตุกลบักนักบัที� ค์�ดไวั�ในหลกัฐ�น ก�รวิัจััยเพิ็� มัเติมันั�นค์วัรมีัเพ่็� อชี �แนะ ขี�อแนะนำ�และค์วั�มัแข็ีงแกร่งขีองค์วั�มั เกี�ยวัเน่�องนี� ค์ณะทำ�ง�น GDG สำรุปว่�: • มีั ห ลั ก ฐ � น ที� มีั ค์ วั � มั น่ � เ ช่� อ ถ่ อ น�อยที� กล่�วัว่ั� พ็ฤติกรรมัเน่อยนิ� ง (เวัล�ที�อย่้กบัหน� จัอ) ที� มีัระยะเวัล� ย�วัน�นขี่ �นเกี� ยวัเน่� องอย่�งมีันัย สำำ�ค์ญั่กบัค์วั�มัแข็ีงแรงท�งก�ยภั�พ็ และสุำขีภั�พ็หลอดเล่อดหัวัใจัที�ตำ� ลง ในเด็กและวัยัรุ่น • มีัหลกัฐ�นที�มีัค์วั�มัน่�เช่�อถ่อตำ� มั�ก จันถง่ป�นกล�งที�กล่�วัว่ั� พ็ฤติกรรมั เน่อยนิ� ง (เวัล�หน� จัอ ด้โทรทัศน ์ และก�รเล่นวีัดีโอเกมั) ที�มีัระยะเวัล�ที� ย�วัน�นขี่ �นมีัค์วั�มัเกี�ยวัเน่�องอย่�งมีั นัยสำำ�ค์ญั่กบัก�รวัดัผู้ลที� ไม่ัเอ่ �อต่อ สุำขีภั�พ็จิัตและก�รประพ็ฤติตน/ พ็ฤติกรรมัเอ่ �อสำงัค์มัในเด็กและวัยัรุ่น • มีัหลักฐ�นที� มีัค์วั�มัน่�เช่� อถ่อตำ� ที� กล่�วัว่ั� เวัล�ที�ใช�ในพ็ฤติกรรมัเน่อยนิ�ง ( เวั ล � ที� อ ย่้ กับ ห น� จั อ แ ล ะ ก � ร ด้ โทรทศัน)์ ที�มั�กขี่ �นนั�นเกี�ยวัเน่�องกบั ผู้ลกระทบที�เป็นอนัตร�ยต่อค์วั�มัต่อ- เน่�องในก�รนอนในเด็กและวัยัรุ่น • ประโยชนข์ีองก�รจัำ�กดัพ็ฤติกรรมั เน่อยนิ�งสำำ�หรบัเด็กและวัยัรุ่นมีัมั�ก กว่ั�ขี�อเสีำย มีัค์ว�มัสำมััพนัธิ์ข์้องก�รติอบสำนองต่ิอ ปริมั�ณ (ปริมั�ณ ค์ว�มัต่ิอเนื� อง ค์ว�มัถี� ค์ว�มัหนักหน่วงข้องก�ร ข้ดัข้ว�ง) หรือไม่ั มีัหลกัฐ�นไม่ัเพี็ยงพ็อที�จัะกำ�หนด ได�ว่ั�มีัค์วั�มัสำมััพ็นัธิ ์ในก�รตอบสำนอง ระหว่ั�งเวัล�ที�มีัพ็ฤติกรรมัเน่อยนิ�ง (รวัมั ถง่เวัล�หน� จัอเพ่็�อก�รสำนัทน�ก�ร) และ ผู้ลลัพ็ธิต่์อสุำขีภั�พ็ในเด็กและวััยรุ่น หลกัฐ�นส่ำวันใหญ่่ที�ประเมิันค์วั�มัเกี�ยวั- เน่� องระหว่ั�งพ็ฤติกรรมัเน่อยนิ� งและ ผู้ลลพั็ธิต่์อสุำขีภั�พ็ในเด็กและวัยัรุ่นจัะ เป็นก�รวิัจััยขี� มักลุ่มั และมีัหลักฐ�น ที� มีัค์วั�มัน่�เช่� อถ่อตำ� ต�มัขี�อม้ัลขีอง GRADE และง�นวิัจัยัส่ำวันใหญ่่ขี่ �นอย่้กบั ก�รวัดัผู้ลเวัล�ที� มีัพ็ฤติกรรมัเน่อยนิ� ง จั�กก�รร�ยง�นด�วัยตนเองหร่อพ่็อแม่ั ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 44 ซ่�งอ�จัมีัขี�อผิู้ดพ็ล�ดในก�รวัดัและค์วั�มั เอนเอียงในก�รระลก่ขี�อม้ัล อย่�งไรก็ต�มั หลกัฐ�นที� กล่�วัว่ั� ก�รลดพ็ฤติกรรมั เน่อยนิ� งส่ำงผู้ลดีต่อสุำขีภั�พ็และค์วั�มั- สำมััพ็นัธิร์ะหว่ั�งพ็ฤติกรรมัเน่อยนิ�งกบั ผู้ลเสีำยต่อสุำขีภั�พ็นั�น มีั อิทธิิพ็ลต่อ ประเภัทพ็ฤติกรรมัเน่อยนิ�งมั�กกว่ั�ระยะ เวัล�ขีองพ็ฤติกรรมัเน่อยนิ�งทั�งหมัด เม่ั�อ ตวััแปรต�นค่์อก�รด้โทรทศันห์ร่อก�รใช� เวัล�อย่้กบัหน� จัอ อย่�งไรก็ต�มั หลกัฐ�น ทั�งหมัดไม่ัเพี็ยงพ็อที�จัะสำนบัสำนุนก�รระบุ เวัล�ที�จัำ�กดั หลักฐ�นที� พ็ฤติกรรมัเน่อยนิ� ง เช่�อมัโยงกบัผู้ลร� ยต่อสุำขีภั�พ็อ�จัเป็น ผู้ลทั�งจั�กผู้ลกระทบจั�กพ็ฤติกรรมั- เน่อยนิ�งโดยตรง ก�รแทนที�เวัล�ที�ใช�กบั กิจักรรมัท�งก�ยมั�กขี่ �น หร่อทั�งสำอง อย่�ง แมั�จัะมีัก�รวิัจัยัที� ร�ยง�นค์วั�มั เช่�อมัโยงระหว่ั�งเวัล�ที�อย่้กบัหน� จัอและ ผู้ลร� ยต่อสุำขีภั�พ็ในเด็กและผู้้�ใหญ่่ เวัล� ขีองก�รมีัพ็ฤติกรรมัเน่อยนิ� งทั�งหมัด ( ป ร ะ เ มิั นในง � นวิัจััย โ ด ย ใช�ก� ร วััด พ็ฤติกรรมัเน่อยนิ�งด�วัยเค์ร่�องม่ัอ) ไม่ัได�มีั ค์วั�มัเกี�ยวัโยงอย่�งต่อเน่�องกบัผู้ลลพั็ธิ ์ ท�งสุำขีภั�พ็ เม่ั�อนำ�เวัล�ในก�รทำ�กิจักรรมั ท�งก�ยที� ระดับป�นกล�งถ่งหนักมั� พิ็จั�รณิ�ด�วัย (62) ในท�งกลับกัน หลกัฐ�นที� เช่� อมัโยงกิจักรรมัท�งก�ย ระดบักล�งถง่หนกักบัผู้ลลพั็ธิด์� นดีต่อ สุำขีภั�พ็นั�นเด่นชดั และได�รบัก�รบนัท่ก ไวั�เป็นอย่�งดีตลอดสำภั�พ็แวัดล�อมัที�ตรง กันขี� มั เช่น ก�รทดแทนพ็ฤติกรรมั เน่อยนิ� งด�วัยกิจักรรมัท�งก�ย ( โดย เฉพ็�ะอย่�งยิ�งกิจักรรมัท�งก�ยที�ระดบั ป�นกล�ง-หนกั) อ�จัทำ�ให�สุำขีภั�พ็ดีขี่ �นได� ก�รวิัจัยัที�ตรวัจัสำอบค์วั�มัเช่�อมัโยง และผู้ลกระทบระหว่ั�งพ็ฤติกรรมัเน่อย นิ� ง กิจักรรมัท�งก�ย และผู้ลลพั็ธิท์�ง สุำขีภั�พ็นั�นเติบโตขี่ �นอย่�งรวัดเร็วั และ หลกัฐ�นจั�กก�รวัดัพ็ฤติกรรมัเน่อยนิ�ง และสุำขีภั�พ็หลอดเล่อดหวััใจัด�วัยอุปกรณิ ์ ที�แสำดงให�เห็นถง่ค์วั�มัเช่�อมัโยงนั�นน�อย มั�ก เม่ั� อนำ�กิจักรรมัท�งก�ยที� ระดับ ป�นกล�งถง่หนกัมั�พิ็จั�รณิ� (ตวััอย่�ง เช่น ปรบัค่์�ท�งสำถิติ) (62-64) ดงันั�นจัง่ ต�องมีัก�รวิัจัยัต�มัแผู้นโดยใช�ก�รวัดัก�ร เขี� ถง่ด�วัยอุปกรณิเ์พ่็�อทำ�ให�ค์วั�มัร้�เกี�ยวั กับค์วั�มัเกี� ยวัเน่� องนี�ก� วัหน� และให� ค์ำ�แนะนำ�เพิ็�มัเติมัในอน�ค์ตได� ค์ณะทำ�ง�น GDG สำรุปว่�: • มีัหลกัฐ�นที� เช่�อถ่อได�น�อยที�กล่�วัว่ั� เวัล�ขีองพ็ฤติกรรมัเน่อยนิ�งที�มั�กขี่ �น สำมััพ็นัธิก์บัผู้ลลพั็ธิท์�งสุำขีภั�พ็ที�แย่ลง • มีัหลกัฐ�นไม่ัเพี็ยงพ็อที�จัะระบุเจั�ะ จังถ่งระยะเวัล�จัำ�กดัสำำ�หรบัพ็ฤติ- กรรมัเน่อยนิ�ง • ก�รทดแทนเวัล�ขีองพ็ฤติกรรมั เน่อยนิ�งด�วัยกิจักรรมัท�งก�ยที�ระดบั ป�นกล�งถง่หนกัจัะมีัผู้ลดีต่อสุำขีภั�พ็ เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) 45 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) ค์ว�มัสำมััพนัธิ์เ์ปลี� ยนแปลงไปติ�มั ประเภทและข้อบเข้ติข้องพฤติิกรรมั เนือยนิ�งหรือไม่ั ก�รศ่กษ�เร่� องผู้ลกระ ทบต่อ สุำขีภั�พ็จั�กพ็ฤติกรรมัเน่อยนิ�งเป็นก�ร วิัจัยัที� ค่์อนขี� งใหม่ั เช่นนี�แล�วั ผู้ลก�ร ทดลองนี�มั�จั�กก�รวิัจัยัที� ใช�เค์ร่�องม่ัอ และก�รวััดระยะเวัล�ในก�รเปิดรับที� แตกต่�งกนั ก�รเปิดรบัที�ประเมิันเป็น “เวัล�ทั�งหมัดที�ใช�ในพ็ฤติกรรมัเน่อยนิ�ง” มัักจัะถ้กใช�กับเวัล�ขีองก�รทำ�พ็ฤติ- กรรมัเน่อยนิ� งขีณิะใช� “หน� จัอ” หร่อ “ด้โทรทศัน”์ หลกัฐ�นที�มีัอย่้แสำดงให�เห็น ว่ั� ค์วั�มัเช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อย นิ�งและผู้ลลบต่อสุำขีภั�พ็นั�น โดยทั�วัไปแล�วั จัะหนักไปที� ก�รด้โทรทัศน์หร่อเวัล� หน� จัอเพ่็�อค์วั�มับนัเทิงมั�กกว่ั�เวัล�ขีอง ก�รทำ�พ็ฤติกรรมัเน่อยนิ�งทั�งหมัด (24, 35) ก�รใช�ก�รประเมิันพ็ฤติกรรมัเน่อย- นิ�งโดยใช�เค์ร่�องม่ัอที� เพิ็�มัมั�กขี่ �นในง�น วิัจัยัหล�ย ๆ ชิ �นในช่วังนี�เป็นค์วั�มัร้�ที�ก� วั หน� และเม่ั�อผู้นวักกบัก�รร�ยง�นอย่�งมีั มั�ตรฐ�นก็จัะช่วัยแจั�งขี�อม้ัลแก่ขี�อ แนะนำ�ในอน�ค์ตได� เป็นที� ร้�กนัว่ั�พ็ฤติกรรมัเน่อยนิ� ง ไ ม่ั ไ ด� อั น ต ร � ย ไ ป เ สีำ ย ทั� ง ห มั ด มีัหลักฐ�นที� ชี �ว่ั�พ็ฤติกรรมัเน่อยนิ� ง บ�งอย่�ง เช่น ก�รอ่�นหนงัส่ำอ ทำ�ก�รบ� น นอกห�องเรียน เกี�ยวัเน่�องกบัค์วั�มัสำำ�เร็จั ท�งก�รศ่กษ�ที� ส้ำงขี่ �น บ่งชี�ว่ั�มีัค์วั�มั แตกต่�งขีองผู้ลที�ขี่ �นอย่้กบักิจักรรมันั�น ๆ (24, 25) พ็ฤติกรรมัเน่อยนิ� งอ�จัรวัมั ถ่งเวัล�ที� ใช�ในก�รแสำวังห�ก�รศ่กษ�/ ก�รเรียน หร่อก�รเล่นเงียบ ๆ หร่อก�ร มีัปฎิสำมััพ็นัธิท์�งสำงัค์มัโดยปร�ศจั�กส่ำ�อ อิเลค์ทรอนิค์สำ ์ ก�รดำ�เนินก�รเหล่�นี� (เช่น ก�รอ่�นหนงัส่ำอ เล่นเกมัปริศน� ก�รวั�ดร้ป ก�รทำ�ง�นฝีึม่ัอ ก�รร�องเพ็ลง เล่นดนตรี) เป็นสิำ�งสำำ�ค์ญั่สำำ�หรบัพ็ฒัน� ก�รขีองเด็กและมีัประโยชน์ทั�งด� น ค์วั�มัคิ์ดและอ่�น ๆ ค์ณะทำ�ง�น GDG พบว่�: • กิจักรรมัที�มีัก�รทำ�พ็ฤติกรรมัเน่อยนิ�ง บ�งอย่�งนั�น มีัประ โยชน์ต่อก�ร ทำ�ง�นด� นค์วั�มัคิ์ดและปฏิิสำมััพ็นัธิ ์ ท�งสำงัค์มัในเด็กและวัยัรุ่น • หลกัฐ�นเกี�ยวักบัผู้ลเสีำยต่อสุำขีภั�พ็ จั�กพ็ฤติกรรมัเน่อยนิ�งนั�นมักัจัะเน�น ไปที� เวัล�ด้โทรทศันห์ร่อเวัล�ที�อย่้กบั หน� จัอเพ่็�อค์วั�มับนัเทิงมั�กกว่ั�เวัล� ที�มีัก�รทำ�พ็ฤติกรรมัเน่อยนิ�งทั�งหมัด ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 46 กิจักรรมัท�งก�ยในผู้้�ใหญ่่เอ่ �อประโยชนต่์อผู้ลลพั็ธิท์�งสุำขีภั�พ็ดงันี� กิจักรรมัท�งก�ย สำ�มั�รถป้องกนัก�รเสีำยชีวิัตจั�กทุกสำ�เหตุที�รวัมัถ่งโรค์หลอดเล่อดหัวัใจั ภั�วัะค์วั�มั- ดนัโลหิตส้ำง ก�รเกิดมัะเร็งเฉพ็�ะจุัด เบ�หวั�นชนิดที� สำอง สุำขีภั�พ็จิัต (ลดอ�ก�ร กงัวัลและซม่ัเศร� ) สุำขีภั�พ็สำมัอง และก�รนอนหลบั และก�รวัดัภั�วัะโรค์อ�วันก็จัะดีขี่ �นด�วัย กิจักรรมัท�งก�ยสำำ�หรบัผู้้�ใหญ่่อ�จัเป็นได�ทั�งก�รสำนัทน�ก�รและก�ร พ็กัผู่้อน (ก�รละเล่น เกมัสำ ์กีฬ� หร่อก�รออกกำ�ลงัก�ยที�มีัก�รวั�งแผู้น ก�รเดินท�ง (เค์ร่�องยนตติ์ดล�อ ก�รเดิน ก�รปั� นจักัรย�น) ก�รทำ�ง�น หร่อก�รทำ�ง�นบ� น ในปริบทขีอง ก�รประกอบอ�ชีพ็ประจัำ�วันั ก�รเรียน ในพ่็�นที�บ� น หร่อพ่็�นที�ชุมัชน • ทำ�กิจักรรมัท�งก�ยบ� งย่อมัดีกว่ั�ไม่ัทำ�อะไรเลย • ห�กผู้้�ใหญ่่ไม่ัสำ�มั�รถทำ�ต�มัขี�อแนะนำ�ดงักล่�วัได� ก�รทำ�กิจักรรมัท�งก�ยบ� งจัะส่ำงผู้ลดีต่อ สุำขีภั�พ็ • ผู้้�ใหญ่่ค์วัรเริ� มัจั�กกิจักรรมัท�งก�ยที� ระดับเบ� แล�วัค่์อยเพิ็� มัค์วั�มัถี� ค์วั�มัหนักหน่วัง และระยะเวัล�ขี่ �น ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ข้้อแนืะนืำ�ด้็�นืกิิจกิรัรัมท�งกิ�ย แนะนำ�ให:้ ผ้ ใ้หญ่่ทุกค์นค์วรทำ�กิจกรรมัท�งก�ยท ั�วไปเป็นประจำ� แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได�ป�นกล�ง ผ้ ใ้หญ่่ค์วรทำ�กิจกรรมัท�งก�ยแบบแอโรบิกที�ระดบัป�นกล�งอย่�งนอ้ย 150-300 น�ที หรือที�ระดบัหนกัอย่�งนอ้ย 75-150 น�ที หรือผสำมัผสำ�นทั�ง 2 ระดบัอย่�งเท่�เทียมักนั ติลอดสำปัด�ห ์เพื�อสุำข้ภ�พที�ดีอย่�งต่ิอเนื�อง แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได�ป�นกล�ง ผ้ ใ้หญ่่ค์วรทำ�กิจกรรมัสำร�้งค์ว�มัแข็้งแรงใหก้บักล�้มัเนื �อ โดยใช้ก้ล�้มัเนื �อหลกัทุกส่ำวน ที�ระดบัป�นกล�งข้้ �นไป อย่�งนอ้ย 2 วนัต่ิอสำปัด�ห ์เพื�อผลดีต่ิอสุำข้ภ�พ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได�ป�นกล�ง ผ้ ้ใหญ่่สำ�มั�รถเพิ�มักิจกรรมัท�งก�ยแบบแอโรบิกที�ระดบัป�นกล�งใหม้ั�กกว่� 300 น�ที หรือที�ระดบัหนกัใหม้ั�กกว่� 150 น�ที หรือผสำมัทั�งระดบัป�นกล�งและระดบั หนกัอย่�งเท่�เทียมักนัติลอดทั�งสำปัด�ห ์เพื�อสุำข้ภ�พที�ดียิ�งข้้ �น แนะนำ�อย่�งมีัเง่�อนไขี มีัหลกัฐ�นที�เช่�อถ่อได�ป�นกล�ง > > > > ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ 47 หลกัฐ�นและเหตุิผลสำนบัสำนุน ขี�อแนะนำ�เหล่�นี�มีัก�รปรบัและนำ�ก�รสำงัเค์ร�ะหห์ลกัฐ�นที�จัดัทำ�โดยค์ณิะกรร- มั�ธิิก�รที�ปรก่ษ�ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ยขีองสำหรฐัอเมัริก� (PAGAC) มั�ใช� ค์ณิะทำ�ง�น GDG ได�พิ็จั�รณิ�หลกัฐ�นทั�งหมัด รวัมัถง่ผู้ลก�รวิัจัยัที�ร�ยง�นโดย PAGAC รวัมับทปริทศัน ์28 ชิ �น และก�รศก่ษ�ที�มีัก�รติดต�มักลุ่มัตวััอย่�งเป็นเวัล� น�นที�ทำ�ร่วัมักนั 3 ชิ �น ตีพิ็มัพ็จ์ั�กปีพ็.ศ. 2560 ไปจันถง่พ็ฤศจิัก�ยน พ็.ศ. 2562 ซ่�งตรงต�มักฎเกณิฑ์์ในก�รค์ดัขี�อม้ัลเขี� และสำร� งหลกัฐ�นเกี�ยวักบัค์วั�มัเช่�อมัโยง ระหว่ั�งกิจักรรมัท�งก�ยและผู้ลต่อสุำขีภั�พ็ในผู้้�ใหญ่่ นอกจั�กนี�บทปริทศันข์ีอง บทปริทศันอี์กชิ�นได�จัดัทำ�ขี่ �นเพ่็�อชี �ให�เห็นถง่ช่องว่ั�งขีองหลกัฐ�นและก�รตรวัจัสำอบ 1) ค์วั�มัสำมััพ็นัธิร์ะหว่ั�งกิจักรรมัท�งก�ยต�มัอ�ชีพ็ (เช่น กิจักรรมัที�เกี�ยวัขี�องกบัง�น) และผู้ลลพั็ธิเ์กี�ยวัเน่�องกบัสุำขีภั�พ็ (40) และ 2) ค์วั�มัเกี�ยวัเน่�องระหว่ั�งกิจักรรมัท�ง ก�ยในขีอบเขีตขีองก�รพ็กัผู่้อนและผู้ลลบต่อสุำขีภั�พ็ (41) บทปริทศันที์�มั�จั�ก บทปริทศันอ่์� นนั�นแจักแจังบทปริทศันอ์ย่�งเป็นระบบจัำ�นวัน 36 ฉบบัและ 15 ฉบบั ต�มัลำ�ดบั หลกัฐ�นจั�กก�รศก่ษ�แบบสำงัเกตระยะย�วัและทดลองแบบมีัก�ร แทรกแซงนั�นจัะได�รบัค์วั�มัสำำ�ค์ญั่ก่อน และบทปริทศันที์�รวัมัหลกัฐ�นก�รจั�กก�ร เปรียบเทียบขี� มักลุ่มัเพี็ยงอย่�งเดียวัหร่อเป็นหลกัจัะไม่ัถ้กนำ�มั�พิ็จั�รณิ� นำ � หนกั ในก�รเน�นยำ�อย่้ที�หลกัฐ�นที�มั�จั�กบทปริทศันที์� ได�ระดบัค์วั�มัน่�เช่�อถ่อป�นกล�ง และมั�กกว่ั�นั�นและบทปริทศันที์� ได�หลกัฐ�นจั�กง�นวิัจัยัที�ใช�เค์ร่�องม่ัอวัดัก�รเปิดรบั ร�ยละเอียดวิัธีิวิัจัยั ก�รแยกขี�อม้ัล และชุดขี�อม้ัลหลกัฐ�นมีัอย่้ที�ภั�ค์ผู้นวักใน เว็ับไซต ์: ชุดขี�อม้ัลหลกัฐ�น6 ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) อะไรคื์อค์ว�มัเชื้�อมัโยงระหว่�งกิจกรรมั ท�งก�ยและผลที�เกี�ยวเนื�องกบัสุำข้ภ�พ ในผ้ ใ้หญ่่ (อ�ยุ 18-64 ปี) คื์ออะไร ค์วั�มัเช่� อมัโยงระหว่ั�งกิจักรรมั ท�งก�ยและก�รเสีำยชี้วิติจ�กทุกสำ�เหตุิ และก�รเสีำยชี้วิติจ�กโรค์หลอดเลือด หวัใจในผู้้�ใหญ่่นั�นเป็นที�ตระหนกักนัดีอย่้ แล�วั (1) ผู้ลก�รวิัจัยัจั�กบทปริทศันเ์ม่ั�อไม่ั น�นมั�นี�ย่นยนัว่ั� เม่ั�อเปรียบเทียบกบักิจั- กรรมัท�งก�ยในระดบัตำ� สุำด กิจักรรมั ท�งก�ยในระดบัที� ส้ำงกว่ั�จัะเช่�อมัโยงกบั ค์วั�มัเสีำ�ยงในก�รเสีำยชีวิัตที�ตำ� กว่ั� หลกั- ฐ�นชิ�นใหม่ัจั�กก�รวิัจัยัที�ใช�เค์ร่�องม่ัอวัดั กิจักรรมัท�งก�ยย่นยันและขีย�ยผู้ล หลกัฐ�นที�แสำดงว่ั�เม่ั�อเปรียบเทียบกบั กิจักรรมัท�งก�ยในระดบัตำ� สุำด กิจักรรมั ท�งก�ยในทุกระดบัและทุกค์วั�มัหนัก หน่วัง(รวัมัถ่งระดบัเบ�) เกี�ยวัเน่� องกบั ค์วั�มัเสีำ�ยงต่อก�รเสีำยชีวิัตที�ลดลง (65) ตวััอย่�งเปรียบเทียบกบัเม่ั�อเค์ล่�อนไหวั น�อยที�สุำด (referent, 1.00) อตัร�ก�รเต�น ขีองหัวัใจัที� ปรับสำำ�หรับค์วัอไทลข์ีอง กิจักรรมัท�งก�ยทั�งหมัดในทุกค์วัอไทล ์ 6 ข้้อม่ัลออนไลน์ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 48 ขีองกิจักรรมัท�งก�ย ค่์�ค์วัอไทลที์�สำอง (0.48 [95% CI: 0.43 to 0.54]) ค์วัอไทลที์�สำ�มั (0.34 [95% CI: 0.26 to 0.45]) และค์วัอไทลที์� สีำ� (0.27 [95% CI: 0.23 to 0.32]) (65) หลกัฐ�นใหม่ัยงัค์ง ย่นยนัถง่ค์วั�มัสำมััพ็นัธิแ์ปรผู้กผู้นัอย่�ง มัั�นค์ง (1) ระหว่ั�งกิจักรรมัท�งก�ยและ อนัติร�ยจ�กโรค์หลอดเลือดหวัใจ (66) ประโยชนจ์ั�กกิจักรรมัท�งก�ยใน ก�รลดก�รเกิดโรค์หลอดเล่อดหัวัใจั และค์วั�มัดันโลหิตได�มีัก�รบันท่กไวั� อย่�งดี (1) กิจักรรมัท�งก�ยส่ำงเสำริมัก�ร ตอบสำนองก�รทำ�ง�นขีองอวัยัวัะต่�ง ๆ ในร่�งก�ย ซ่� งทำ�ให�มีัก�รปรับระบบ ประสำ�ทส่ำวันกล�งและก�รหมุันเวีัยน โลหิตในระยะสำั�นและระยะย�วัที� เป็น ประโยชน ์เป็นผู้ลให�ค์วั�มัเสีำ�ยงขีองภ�วะ ค์ว�มัดนัโลหิติส้ำงซ่�งเป็นปัจัจัยัเสีำ�ยงหลกั ขีองโรค์หลอดเลือดหวัใจลดลง หลกัฐ�นเน�นยำ � ว่ั�มีัค์วั�มัสำมััพ็นัธิที์� ผู้กผู้ันระหว่ั�งกิจักรรมัท�งก�ยและ ผู้ลจั�กค์วั�มัดนัโลหิตส้ำงในผู้้�ใหญ่่ที� มีั ค์วั�มัดนัโลหิตปรกติ และกิจักรรมัท�ง ก�ยที�ลดค์วั�มัดนัโลหิตในผู้้�ใหญ่่ที�มีัภั�วัะ ก่อนจัะเป็นโรค์โลหิตส้ำงและค์วั�มัดัน โลหิตปรกติ (35) ค์วั�มัเกี�ยวัเน่�องในท�งตรงกนัขี� มั ระหว่ั�งกิจักรรมัท�งก�ยและโรค์เบ� หว�นช้นิดที�สำองที�ก่อตวััขี่ �นในผู้้�ใหญ่่นั�น เป็นที�ทร�บกนัดี (1) หลกัฐ�นเม่ั�อไม่ัน�น มั�นี�ย่นยนัค์วั�มัสำมััพ็นัธิแ์บบเป็นเสำ�นโค์�ง ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) หัวัค์วัำ� ระหว่ั�งกิจักรรมัท�งก�ยใน ปริมั�ณิที�มั�กขี่ �นและก�รเกิดเบ�หวั�น ชนิดที�สำอง (35) ด�วัยเสำ�นโค์�งที�ล�ดลง เม่ั� อมีัระดับกิจักรรมัท�งก�ยที� ส้ำงขี่ �น บทปริทศัน์ใหม่ัพ็บว่ั� ผู้ลกระทบนี�ค์งที� กบัทุกบุค์ค์ลที�มีัภ้ัมิัหลงัต่�งกนัด�วัยก�ร ลดค์วั�มัเสีำ� ยงขีองก�รก่อตัวัขีองโรค์ เบ�หวั�นชนิดที� สำองในระดบั “ส้ำงสุำด” เทียบกับ “ตำ� สุำด” ในกลุ่มัประช�กร ผิู้วัขี�วัที� ไม่ัมีัเช่ �อสำ�ยละติน (RR= 0.71 [95% CI: 0.60 to 0.85]) ช�วัเอเชีย (RR= 0.76 [95% CI: 0.67 to 0.85]) ช�วัละตินอเมัริก� (RR = 0.74 [95% CI 0.64 to 0.84]) และช�วัอเมัริกนัอินเดียน (RR = 0.73 [95% CI: 0.60 to 0.88]) แมั�ว่ั�ผู้ลกระทบสำำ�หรบักลุ่มัประช�กร ผิู้วัสีำ ไม่ัมีันัยสำำ�ค์ญั่ (RR = 0.91 [95% CI: 0.76 to 1.08]) (67) หลกัฐ�นชี�ว่ั� ไม่ัมีัก�รปรบัผู้ลกระทบด�วัยนำ � หนกั และ มีัค์วั�มัสำมััพ็นัธิที์�ผู้กผู้นัระหว่ั�งกิจักรรมั ท�งก�ยในปริมั�ณิที� ส้ำงขี่ �น และก�ร เกิดโรค์เบ�หวั�นชนิดที� สำองที� ลดลง สำำ�หรบัผู้้�ที� มีันำ � หนกัปรกติ นำ � หนกัเกิน หร่อมีัภั�วัะโรค์อ�วัน (35) ค์วั�มัสำมััพ็นัธิร์ะหว่ั�งกิจักรรมัท�ง ก�ยในระดับที� ส้ำงขี่ �นและค์วั�มัเสีำ� ยง ต่อมัะเร็งลำ�ไสำแ้ละมัะเร็งเติ�้นมัที�ลดลง นั�นเป็นที�ทร�บกนัดี (1) ในบททบทวัน หลกัฐ�นก่อนหน� นี�พ็บว่ั� กิจักรรมัท�ง- ก�ยในระดับที� ส้ำงขี่ �นนั�นเช่� อมัโยงกับ ค์วั�มัเสีำ� ยงที� ลดลงในก�รก่อตัวัขีอง มัะเร็งเต� นมัและมัะเร็งลำ�ไสำ� (1) ต�มัมั� ด�วัยก�รเพิ็�มัขี่ �นขีองง�นวิัจัยัในกิจักรรมั 49 ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ท�งก�ยและมัะเร็งอย่�งเจั�ะล่ก มีัหลกั ฐ�นใหม่ัที�แสำดงว่ั� ระดบักิจักรรมัท�งก�ย ส้ำงขี่ �นสำมััพ็นัธิก์บัค์วั�มัเสีำ�ยงที�ลดลงขีอง โรค์มัะเร็งกระเพ็�ะปัสำสำ�วัะ มัะเร็งเย่�อบุ โพ็รงมัดล้กมัะเร็งหลอดอ�ห�ร มัะเร็ง กระเพ็�ะอ�ห�ร มัะเร็งไต รวัมัถง่ย่นยนั ว่ั�กิจักรรมัท�งก�ยเป็นก�รป้องกัน มัะเร็งเต� นมัและมัะเร็งลำ�ไสำ� (35) กิจักรรมั ท�งก�ยในระดบัที�ส้ำงขี่ �นนั�นเกี�ยวัเน่�องกบั ก�รลดค์วั�มัเสีำ�ยงประมั�ณิร�อยละ 10-20 (35) ตวััอย่�งเช่น ในบทปริทศันฉ์บบั หน่�งร�ยง�นค์วั�มัเช่�อมัโยงในท�งตรง กนัขี� มักบัค์วั�มัเสีำ�ยงขีองมัะเร็งตบัเม่ั�อ เปรียบเทียบกิจักรรมัท�งก�ยระดบัส้ำง กบักิจักรรมัท�งก�ยระดบัตำ� (HR= 0.75 [95% CI: 0.63 to 0.89]) (68) มีัหลกัฐ�น ที� ไม่ัเพี็ยงพ็อเกี� ยวักับค์วั�มัเช่� อมัโยง ระหว่ั�งกิจักรรมัท�งก�ยที� เพิ็�มัขี่ �นและ ลดค์วั�มัเสีำ� ยงเกี� ยวักับมัะเร็งในเล่อด ศีรษะและค์อ รงัไข่ี ตบัอ่อน ต่อมัล้กหมั�ก ต่อมัไทรอยด ์ทวั�รหนกั และมัะเร็งสำมัอง (35) ขีณิะที�หลกัฐ�นชี�ให�เห็นว่ั�มีัก�รลด ค์วั�มัเสีำ� ยงขีองมัะเร็งปอดระ หว่ั�ง กิจักรรมัท�งก�ยในระดบัส้ำงสุำดเทียบกบั ระดบัตำ� สุำด ก�รใช�ย�ส้ำบอ�จัทำ�ให�ผู้ลก�ร ทดลองนี�สำบัสำนและระบุว่ั�ไม่ัมีัหลกัฐ�นที� เพี็ยงพ็อที�จัะพิ็ส้ำจันค์์วั�มัเช่�อมัโยง ค์วั�มัสำมััพ็นัธิร์ะหว่ั�งกิจักรรมัท�ง ก�ยและภ�วะโรค์อว้นในประช�กรผู้้�ใหญ่่ นั�นไม่ัเป็นที�ทร�บกนัดีนกั แมั�จัะมีัหลกัฐ�น จัำ�นวันมั�กแต่แตกต่�งกนั หลกัฐ�นที� ประเมิันค์วั�มัสำมััพ็นัธินี์�ผู่้�นตวััวัดัผู้ลที� หล�กหล�ย (นำ � หนกัเพิ็�มั นำ � หนกัเปลี�ยน ก�รคุ์มันำ � หนกั ค์วั�มัค์งที�นำ � หนกั สำถ�นะ นำ � หนกั และก�รด้แลนำ � หนกั) (35, 69, 70) หลกัฐ�นชี�ให�เห็นโดยภั�พ็รวัมัว่ั� กิจักรรมัท�งก�ยในระดบัที� ส้ำงขี่ �นอ�จั เช่�อมัโยงกบัก�รวัดัระดบัค์วั�มัอ�วันและ ก�รลดนำ � หนกัในผู้้�ใหญ่่ (35) จัำ�เป็นต�อง มีัง�นวิัจัยัเพิ็�มัเติมัเพ่็�อสำร� งให�เกิดผู้ลอนั ค์งที�และค์วั�มัเช่�อมัโยงที�แข็ีงแกร่ง ก�รวิัจัยัเร่�องกิจักรรมัท�งก�ยและ สุำข้ภ�พจิติ ก�รรบัร้ ้ และก�รนอนหลบั เพิ็�มัมั�กขี่ �นอย่�งมีัแก่นสำ�ร ตั�งแต่ก�ร พ็ฒัน�ขี�อแนะนำ�ระดบัโลกด� นกิจักรรมั ท�งก�ยเพ่็�อสุำขีภั�พ็ ฉบบั พ็.ศ. 2553 (1) ในขีณิะนั�น มีัหลกัฐ�นเพี็ยงพ็อที�จัะสำรุป ได�เพี็ยงว่ั� กิจักรรมัท�งก�ยอ�จัลดค์วั�มั เสีำ�ยงขีองภั�วัะซม่ัเศร� และค์วั�มัจัำ�เส่ำ�อมั ในผู้้�ใหญ่่ หลกัฐ�นชิ�นใหม่ัที�ทบทวันเพ่็�อ ขี�อแนะนำ�เหล่�นี�แสำดงให�เห็นว่ั� ผู้้�ใหญ่่ ที�ทำ�กิจักรรมัท�งก�ยระดบัที�ส้ำงกว่ั�เทียบ กบัระดบัที�ตำ� กว่ั�นั�น ค์วั�มัเสีำ�ยงขีองก�ร พ็ฒัน�อ�ก�รเค์รียดและซม่ัเศร� จัะลดลง ตวััอย่�งเช่น ผู้้�ใหญ่่ที� ทำ�กิจักรรมัท�ง ก�ยในระดบัส้ำงเทียบกบัระดบัตำ� จัะมีั ค่์�ที� จัะพ็ัฒน�อ�ก�รเค์รียด (AOR= 0.81 [95% CI: 0.69 to 0.95]) (71) หร่อซ่มัเศร� (AOR= 0.78 [95% CI: 0.70 to 0.87) ลดลง (72) กิจักรรมัท�ง ก�ยระดบัป�นกล�งถ่งหนกัที� เพิ็�มัมั�ก ขี่ �นเช่� อมัโยงกับก�รพ็ัฒน�ค์วั�มัคิ์ด (ตวััอย่�งเช่น ก�รประมัวัลผู้ลค์วั�มัเร็วั ค์วั�มัจัำ� และก�รหน� ที� ในก�รคิ์ด) (35) หน� ที�ขีองสำมัองและโค์รงสำร� ง และค์วั�มั เ สีำ� ย ง ที� ล ด ล ง ใน ก � ร พ็ัฒ น� อ � ก � ร ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 50 ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) บกพร่องด�้นก�รรบัร้ ้ รวัมัถ่งโรค์ อัลไซเมัอร ์ (73-76) หลักฐ�นที� รวัมั ประช�กรผู้้�ใหญ่่หล�ยร�ยแสำดงให�เห็น ถง่เสำ�นล�ดโค์�งจั�กสุำขีภั�พ็สำมัองปรกติ จันถง่สำมัองเส่ำ�อมั และผู้ลดีขีองกิจักรรมั ท�งก�ยนั�นมีัก�รบนัท่กไวั�หล�กหล�ย ชนิด รวัมัถ่งกิจักรรมัแบบแอโรบิก ก�รเดิน กิจักรรมัสำร� งค์วั�มัแข็ีงแรงให� กบักล� มัเน่�อ และโยค์ะ (74) มีัหลกัฐ�น ว่ั�กิจักรรมัท�งก�ยแบบฝึึกและแบบ ปรกติจัะทำ�ให�ก�รนอนหลบัและคุ์ณ- ภ�พชี้วิติที�เกี�ยวเนื�องกบัสุำข้ภ�พดีขี่ �นใน วัยัผู้้�ใหญ่่ (35) หลกัฐ�นที�ตรวัจัสำอบกิจักรรมัท�ง ก�ยและอ�ก�รข้องโรค์ซม้ัเศัร�้ อ�ก�ร เค์รียด และก�รพฒัน�ส่้ำค์ว�มัเค์รียด และภ�วะซม้ัเศัร�้ชี �ให�เห็นว่ั� กิจักรรมั ท�งก�ยเช่� อมัโยงกับอ�ก�รเค์รียดที� ลดลง (77, 78) และอ�ก�รซม่ัเศร� ที�ลดลง (77, 79) กิจักรรมัท�งก�ยล�วันมั�พ็ร�อมั ค์วั�มัเสีำ� ยง หลกัฐ�นจั�กบทปริทศันที์� จััดทำ�เกี� ยวักับผู้ลในท�งตรงกันขี� มั อ�ก�รบ�ดเจ็ับและอนัตร�ยที�เกี�ยวัเน่�อง กบักิจักรรมัท�งก�ยเพ่็�อก�รสำนัทน�ก�ร ในผู้้�ใหญ่่ (41) ชี �ว่ั� มีัค์วั�มัเช่�อมัโยงที� ไม่ั พ็่งประสำงค์ร์ะหว่ั�งระดบัขีองกิจักรรมั ท�งก�ยในช่วังเวัล�พ็กัผู่้อนกบัอ�ก�ร บ�ดเจ็ับกล� มัเน่�อและกระด้ก และสำมััพ็นั- ธิภั�พ็ที�พ็ง่ประสำงค์ร์ะหว่ั�งกิจักรรมัท�ง ก�ยขีณิะพ็กัผู่้อนกบัค์วั�มัเสีำ�ยงต่อกระ- ด้กแตกหกัและกระด้กหวััเข่ี�หร่อสำะโพ็ก เ ส่ำ� อมั หลักฐ�นเพิ็� มัเติมั (35) ชี �ว่ั� เหตุก�รณิ์ไม่ัพ็ง่ประสำงค์ฉ์บัพ็ลนัเกี�ยวักบั หัวัใจันั�นเกิดขี่ �นได�ย�กและสำมััพ็นัธิก์บั ภั�วัะฉบัพ็ลนัในกิจักรรมัท�งก�ยระดบั หนกั โดยทั�วัไปแล�วั ค์วั�มัเสีำ�ยงต่อเหตุ- ก�รณิ์ ไ ม่ัพ็่งประสำงค์์จัะมีัน�อยมั�ก เม่ั�อทำ�กิจักรรมัท�งก�ยระดบัป�นกล�ง และเม่ั�อค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มัหนกัหน่วัง และระยะเวัล�ในกิจักรรมัท�งก�ย (35) ค์ณะทำ�ง�น GDG สำรุปว่� : • มีัหลักฐ�นที� เช่� อถ่อได�อย่�งยิ� งว่ั� กิจักรรมัท�งก�ยทุกระดับและทุก ค์วั�มัหนักหน่วังเช่� อมัโยงกบัค์วั�มั เสีำ� ยงที� ลดลงจั�กก�รเสีำยชีวิัตทุก สำ�เหตุและก�รเสีำยชีวิัตจั�กโรค์ ห ล อ ด เ ล่ อ ด หั วั ใ จั ก � ร เ กิ ด โร ค์ ค์วั�มัดนัโลหิตส้ำง โรค์หวััใจัและหลอด เล่อด และโรค์เบ�หวั�นชนิดที�สำอง • มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�งถง่มั�ก ในเร่�องค์วั�มัเช่�อมัโยงระหว่ั�งระดบั กิจักรรมัท�งก�ยที� เพิ็� มัส้ำงขี่ �นกับ ค์วั�มัเสีำ�ยงในก�รเกิดมัะเร็งเฉพ็�ะจุัด ที�ลดลง • มีัหลักฐ�นที� เช่� อถ่อได�ป�นกล�งที� สำนับสำนุนค์วั�มัเช่� อมัโยงระหว่ั�ง กิจักรรมัท�งก�ยและก�รพ็ัฒน� สุำขีภั�พ็จิัต สุำขีภั�พ็สำมัอง และผู้ลลพั็ธิ ์ ด� นก�รนอนหลบั • มีัหลกัฐ�นที�เช่�อมัโยงระหว่ั�งกิจักรรมั ท�งก�ยในระดับที� ส้ำงขี่ �น ก�รวััด ผู้ลโรค์อ�วันอย่�งพ็่งประสำงค์ม์ั�กขี่ �น และก�รลดภั�วัะนำ � หนกัเพิ็�มัในผู้้�ใหญ่่ • มีัหลกัฐ�นที�เช่�อถ่อได�น�อยว่ั� กิจักรรมั ท�งก�ยที�แนะนำ�สำำ�หรบัผู้้�ใหญ่่นั�นจัะ ไม่ัเป็นอนัตร�ย และผู้ลดีต่อสุำขีภั�พ็ จั�กกิจักรรมัเหล่�นั�นจัะมั�กกว่ั� ค์วั�มัเสีำ�ยง 51 ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ร้ปที� 1: เสำ�นโค์�งแสำดงก�รตอบสำนองต่อปริมั�ณิ มีัค์ว�มัสำมััพนัธิ์ ์ในก�รติอบสำนองต่ิอ ปริมั�ณหรือไม่ั (ปริมั�ณ ระยะเวล� ค์ว�มัถี� ค์ว�มัหนกัหน่วง) หลกัฐ�นโดยภั�พ็รวัมัจั�กผู้ลลพั็ธิ ์ ท�งสุำขีภั�พ็หลอดเล่อดหัวัใจัและก�ร เผู้�ผู้ล�ญ่อ�ห�ร แสำดงให�เห็นถง่ค์วั�มั สำมััพ็นัธิข์ีองก�รตอบสำนองต่อปริมั�ณิ ที� เป็นเสำ�นโค์�งหง�ยอย่�งค์งที� ระหว่ั�ง กิจักรรมัท�งก�ยและผู้ลลพั็ธิท์�งสุำขีภั�พ็ ที�สำำ�ค์ญั่ เช่น ก�รเสีำยชีวิัตจั�กทุกสำ�เหตุ ก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อดหัวัใจั ก�รเกิดโรค์เบ�หวั�นชนิดที� สำอง (67) และก�รเกิดมัะเร็งเฉพ็�ะที� ในผู้้� ใหญ่่ ต�มัที�บรรย�ยไวั�ในร้ปที� 1 ร้ปร่�งขีอง เสำ�นโค์�งแสำดงก�รตอบสำนองต่อปริมั�ณิ ชี�ว่ั� ไม่ัมีัจุัดเริ� มัต�นที� ตำ� กว่ั�นี�สำำ�หรับ ประโยชน์ และประโยชน์ที� มั�กที� สุำด อย่้ที�ปล�ยที�ตำ� ลงมั�ขีองเสำ�นโค์�งที�แสำดง ก�รตอบสำนอง (65) ค์วั�มัเช่�อมัโยงขีอง เสำ�นโค์�งหง�ยนี�ถ้กนำ�เสำนออย่�งต่อเน่�อง ข้้อัแนะนำา ทั�วัทั�งง�นวิัจัยัต่�ง ๆ โดยใช�ตวััวัดักิจักรรมั ท�งก�ยที�ต่�งกนั หลกัฐ�นชิ�นใหม่ัอย่้ใน ก�รวิัเค์ร�ะหอ์ภิัมั�นจั�กง�นศก่ษ�ต�มั รุ่นที�ค์�ดค์ะเนไวั�จัำ�นวัน 8 ง�น ซ่�งมีัค่์� กล�งขีองก�รติดต�มัผู้ลที� 5 .8 ปี (ช่วังกวั� ง 3-14.5 ปี) (65) ซ่�งร�ยง�นถง่ อัตร�ก�รเต�นหัวัใจัที� ปรับสำำ�หรับช่วัง ค์วัอไทลข์ีองกิจักรรมัท�งก�ยโดยรวัมั โดยใช�ก�รวัดัตวััแปรและก�รเสีำยชี้วิติ จ�กทุกสำ�เหตุิด�วัยเค์ร่�องม่ัอ ผู้ลแสำดงให� เห็นถง่ก�รตอบสำนองต่อปริมั�ณิที�มีักิจั- กรรมัท�งก�ยมั�กขี่ �นและผู้ลดีจั�กกิจั- กรรมัท�งก�ยในทุกระดบั ด�วัยระดบัที�ส้ำง ขี่ �น เปรียบเทียบกับเม่ั� อเค์ล่� อนไหวั ร่�งก�ยน�อยที� สุำด (referent, 1.00): ค์วัอไทลที์� 2 (อตัร�ก�รเต�นขีองหัวัใจัที� ปรบัแล�วั = 0.48 [95% CI: 0.43 to 0.54]) ค์วัอไทลที์� 3 (อตัร�ก�รเต�นขีองหัวัใจัที� ปรบัแล�วั = 0.34 [95% CI: 0.26 to 0.45]) และค์วัอไทลที์� 4 (อตัร�ก�รเต�นขีองหวััใจั ปรั ะโย ช้น์ื รัะยะท่�แนืะนืำ� กิิจกิรัรัมท�งกิ�ยปรัะจำ�สัำปด็�ห์ (หน่ืวัยเป็นืนื�ท่)พฤติิกิรัรัมเนืือยนิื�ง ปรั ะโย ช้นื ติอ สำข้ ภิ� พแ ละ คำวั �ม แข้ งแ รัง คำวั� มเส่ำ �ยงแ ละอั นืติ รั�ย ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 52 ที�ปรบัแล�วั = 0.27 [95% CI: 0.23 to 0.32]) มีัก�รสำังเกตก�รลดค์วั�มัเสีำ� ยงส้ำงสุำด สำำ�หรบักิจักรรมัท�งก�ยระดบัป�นกล�ง ที� 24 น�ทีต่อวััน (เทียบเท่�กับ 168 น�ทีต่อสำปัด�ห)์ ซ่�งสำะท�อนผู้ลใกล�เคี์ยง กบัค์ำ�แนะนำ�ให�ทำ�กิจักรรมัท�งก�ย 150 น�ทีต่อสำปัด�ห ์และเกิดหลกัฐ�นใหม่ัที�วัดั ด�วัยเค์ร่�องม่ัอ ซ่�งเน�นยำ � ขี�อแนะนำ�ระดบั สำ�กลต่อผู้้�ใหญ่่ที�ให�ทำ�กิจักรรมัท�งก�ย อย่�งน�อย 150-300 น�ทีต่อสำัปด�ห ์ ผู้ลก�รทดลองนี�สำอดค์ล�องกบัหลกัฐ�น จั�กบทปริทศันที์�มีัอย่้ (35) และบทปริทศัน ์ ใหม่ัที�นำ�มั�วิัเค์ร�ะห ์(66) ที�ปล�ยบนสุำด ระดบัขีองกิจักรรมั ท�งก�ยที� ส้ำงขี่ �นจัะส่ำงผู้ลดี โดยลดค์วั�มั เสีำ� ยงจั�กก�รเสีำยชีวิัตและ ไม่ัมีัค์วั�มั เสีำ� ยงที� เป็นอันตร�ยเพิ็� มัขี่ �นตัวัอย่�ง เ ช่ น ห ลั ก ฐ � น จั � ก บ ท ป ริ ทั ศ น ์ พ็ร�อมัผู้ลก�รศก่ษ�จั�กผู้ลก�รวิัเค์ร�ะห ์ อภิัมั�นขีองขี�อม้ัลส่ำวันบุค์ค์ล จั�กก�รวัดั กิจักรรมัท�งก�ยด�วัยเค์ร่� องม่ัอ (65) บ่งชี�ว่ั� แมั�ค์วั�มัเสีำ�ยงในก�รเสีำยชีวิัตที� ล ด ลงจั ะ เ ป็ นที� สำัง เก ต ไ ด� ส้ำ ง สุำ ดจั� ก ก�รทำ�กิจักรรมัท�งก�ย 750 น�ทีต่อ สำปัด�ห ์ในระดบัป�นกล�งถง่หนกั ค์วั�มั เสีำ�ยงในก�รเสีำยชีวิัตโดยเทียบเคี์ยงอย่้ที� ระดบัที�มั�กกว่ั� 300 น�ทีต่อสำปัด�ห ์ ผู้ลเหล่�นี�สำอดค์ล�องกบัหลกัฐ�นก่อน หน� นี�ที� แสำดงให�เห็นอย่�งต่อเน่� องว่ั� กิจักรรมัท�งก�ยสำัมัพ็ันธิก์ับผู้ลดีต่อ สุำขีภั�พ็อ่�น ๆ แมั�ว่ั�ประโยชนอ่์�นที�สำมััพ็นัธิ ์ กนัจัะลดลงเม่ั�อกิจักรรมัท�งก�ยในระดบั ที� ส้ำงขี่ �น (35, 80, 81) อย่�งไรก็ต�มั มีั หลกัฐ�นไม่ัเพี็ยงพ็อที�จัะเจั�ะจังระดบั กิจักรรมัท�งก�ยที� แน่นอนซ่� งผู้ลตอบ กลบัที�ลดลงขีองคุ์ณิค่์�ด� นสุำขีภั�พ็นั�น เริ�มัเกิดขี่ �นในวัยัผู้้�ใหญ่่ หลักฐ�นต่�ง ๆ ยังยำ � เต่อนว่ั� ค์วั�มัสำมััพ็นัธิ ์ในท�งตรงกนัขี� มัที� เป็น ที�ยอมัรบักนัดีระหว่ั�งกิจักรรมัท�งก�ย และก�รเสีำยชี้วิติจ�กโรค์หลอดเลือด หวัใจ และให�หลกัฐ�นเพิ็�มัเติมัเกี�ยวักบั ค์วั�มัสำัมัพ็ันธิข์ีองก�รตอบสำนองต่อ ปริมั�ณิที�เกินขีีดสุำดขีองปริมั�ณิกิจักรรมั ท�งก�ยที� แนะนำ�กนัอย่้ ก�รวิัเค์ร�ะห ์ อนุมั�นจั�กก�รศ่กษ�ต�มัแผู้นจัำ�นวัน 48 ฉบับที� ประเมิันกิจักรรมัท�งก�ย (ทุกประเภัท ก�รพ็กัผู่้อน และเพ่็�ออ�ชีพ็) ซ่�งมีัหลกัฐ�นเพิ็�มัเติมัขีองค์วั�มัสำมััพ็นัธิ ์ ในก�รตอบสำนองต่อปริมั�ณิ (66) ที� เ กินขีีดปริมั�ณิกิจักรรมัท�งก�ยที� แนะนำ�ในปัจัจุับนั เม่ั� อเปรียบเทียบกบั ระดับที� แนะนำ�ที� ใช�พ็ลงัง�นเม่ั� อเทียบ กบัขีณิะพ็กั 750 น�ทีต่อสำปัด�ห ์ ก�ร มีัส่ำวันร่วัมัในกิจักรรมัที� ใช�พ็ลงัง�นเม่ั�อ เทียบกบัขีณิะพ็กั 500 น�ทีต่อสำปัด�ห ์ (กิจักรรมัท�งก�ยระดบัป�นกล�ง 1,000 น�ที) มีัผู้ลให�ค์วั�มัเสีำ�ยงต่อก�รเสีำยชีวิัต จั�กโรค์หลอดเล่อดหัวัใจัตำ� ลงอย่�งมีั นยัสำำ�ค์ญั่ (HR= 0.73 [95% CI: 0.56 to 0.95]) (66) ขี�อแนะนำ�ขีององค์ก์�รอน�มัยั โลกฉบบัก่อนหน� (1) สำรุปว่ั�กิจักรรมั ท�งก�ยแบบแอโรบิกอย่�งต่อเน่�องเป็น ระยะเวัล�อย่�งน�อย 10 น�ที อย่�งไรก็ต�มั หลกัฐ�นใหม่ัที�ประเมิันผู้ลโดยใช�อุปกรณิ ์ แสำดงให�เห็นว่ั� กิจักรรมัท�งก�ยไม่ัว่ั�จัะมีั ระยะเวัล�เท่�ใด และไม่ัมีัขีีดขีั�นตำ� จัำ�กดั ล�วันเกี�ยวัเน่�องกบัผู้ลลพั็ธิสุ์ำขีภั�พ็ที�ดีขี่ �น ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) 53 รวัมัถง่ลดสำ�เหตุก�รเสีำยชีวิัตทุกสำ�เหตุ ด�วัย (65,82) ตวััอย่�งเช่น หลกัฐ�นชิ�น ใหม่ัจั�กบทปริทศันง์�นวิัจัยัที� ประเมิัน กิจักรรมัท�งก�ยโดยเค์ร่�องวัดัค์วั�มัเร่ง ที� ยำ � เต่อนค์วั�มัเช่� อมัโยงที� เหม่ัอนกัน ระหว่ั�งดชันีทั�งมัวัลขีองกิจักรรมัท�ง ก�ยและอนัตร�ยทุกชีวิัตในทุกสำ�เหตุ ด�วัยอตัร�ส่ำวันค์วั�มัเสีำ�ยงอนัตร�ยที� 0.27 สำำ�หรบักิจักรรมัท�งก�ยทั�งหมัด 0.28 สำำ�หรบัช่วังระยะเวัล� 5 น�ที และ 0.35 สำำ�หรบัช่วัง 10 น�ที เปรียบเทียบกบัช่วัง ค์วัอไทลส้์ำงสุำดเทียบกบัช่วังตำ� สุำด ผู้ลเหล่� นี�ยำ � เต่อนโดยผู้ลก�รศก่ษ�ในบทปริทศัน ์ ใหม่ัโดยอีค์ลุนดแ์ละค์ณิะ พ็.ศ. 2562 (65) ซ่�งมีัหลกัฐ�นว่ั� กิจักรรมัท�งก�ยไม่ั ว่ั�ระยะเวัล�ใดนั�นเช่�อมัโยงกบัผู้ลลพั็ธิ ์ ท�งสุำขีภั�พ็ที�ดีขี่ �น รวัมัถง่สำ�เหตุก�รเสีำย ชีวิัตทุกสำ�เหตุ (82) ด�วัยหลกัฐ�นชิ�นใหม่ันี� จั่งนำ�ค์ำ�แนะนำ�สำำ�หรับช่วังระยะเวัล� อย่�งน�อย 10 น�ทีออกไป แมั�ว่ั�หลกัฐ�นแสำดงให�เห็นค์วั�มั เช่� อมัโยงระหว่ั�งกิจักรรมัท�งก�ยใน ระดบัที�ส้ำงขี่ �นและค์วั�มัเสีำ�ยงขีองก�รเกิด มัะเร็งเฉพ�ะจุดซ่�งถ่อว่ั�ค์งที�ในภั�พ็รวัมั มีัหลกัฐ�นไม่ัเพี็ยงพ็อที�จัะกำ�หนดระดบั เฉพ็�ะเจั�ะจังในก�รทำ�กิจักรรมัท�ง ก�ยที� สำอดค์ล�องกบัก�รลดค์วั�มัเสีำ� ยง ที� ร�ยง�นไวั�จั�กค์วั�มัแตกต่�งอย่�ง มั�กในก�รประเมิันและก�รจััดแบ่ง ป ร ะ เ ภั ท ขี อ ง ก � ร เ ปิ ด รั บ ใ น ง � น วิัจััยทุกชิ�น อย่�งไรก็ต�มั ไม่ัมีัหลัก- ฐ�นที� ชี �ว่ั� มีัเกณิฑ์ที์� ตำ� กว่ั�จุัดที� ผู้ลดี ในก�รทำ�กิจักรรมัท�งก�ยนั�นไม่ัชัด- เจัน ดงันั�นกิจักรรมัท�งก�ยในระดับ ใด ๆ ก็ต�มัย่อมัก่อให�เกิดผู้ลดีในก�รลด ค์วั�มัเสีำ�ยงต่อมัะเร็งเฉพ็�ะจุัด ง�นวิัจัยัใน อน�ค์ตเพ่็�อประเมิันธิรรมัช�ติขีองก�ร ตอบสำนองต่อปริมั�ณิ และใช�ก�รวัดัที� ค์งที�มั�กขี่ �น และก�รร�ยง�นผู้ลนั�นจัำ�เป็น สำำ�หรบัขี�อแนะนำ�ในอน�ค์ต แมั�ว่ั�จัะมีัหลกัฐ�นชิ�นใหญ่่เกี�ยวักบั ค์วั�มัเช่�อมัโยงระหว่ั�งกิจักรรมัท�งก�ย และมั�ตรวัดัที�หล�กหล�ยในก�รวัดัผู้ล ค์วั�มัอ�วัน ก�รเพิ็�มันำ � หนกั และก�รจัดั ก�รเพ่็� อนำ � หนักที� ส่ำงผู้ลต่อสุำขีภั�พ็ที� ดี (35) ปัจัจุับนันี�ยงัไม่ัมีัหลกัฐ�นเพี็ยงพ็อที� จัะอธิิบ�ยค์วั�มัสำมััพ็นัธิก์บัก�รตอบสำนอง ต่อปริมั�ณิอย่�งเฉพ็�ะเจั�ะจังมั�กขี่ �น หร่อจัำ�แนกแยกแยะขีีดจัำ�กัดขีองผู้ล กระทบ ง�นวิัจัยัเพิ็�มัเติมัเพ่็�อขี�อแนะนำ�ใน อน�ค์ตนั�น มีัค์วั�มัจัำ�เป็น ก�รทำ�กิจักรรมัท�งก�ยที�ระดบั ป�นกล�งและหนักเป็นระยะเวัล�ย�วั น�นขี่ �นนั�น เช่� อมัโยงกับก�รพฒัน� ก�รรบัร้ ้ (ตวััอย่�งเช่น ค์วั�มัไวัในก�ร ประมัวัลผู้ล ค์วั�มัจัำ� และทกัษะก�รคิ์ด เชิงบริห�ร) (35) ก�รทำ�ง�นและโค์รง สำร� งขีองสำมัองและค์วั�มัเสีำ�ยงที�ลดลง จั � ก ค์ ว � มั บ ก พ ร่ อ ง ใ น ก � ร ร ับ ร้ ้ ที�ก่อตวััขี่ �น รวัมัถง่โรค์อลัไซเมัอร ์(73-76) มีัหลกัฐ�นว่ั�ทั�งระยะเวัล�กิจักรรมัท�ง ก�ยและก�รทำ�กิจักรรมัท�งก�ยเป็น ประจัำ� ทำ�ให�ก�รนอนหลบัและคุ์ณภ�พ ชี้วิติที�เกี�ยวเนื�องกบัสุำข้ภ�พในวัยัผู้้�ใหญ่่ นั�นดีขี่ �น แต่ก็ไม่ัมีัหลกัฐ�นเพี็ยงพ็อที�จัะ อธิิบ�ยค์วั�มัสำมััพ็นัธิ ์ในก�รตอบสำนอง ต่อปริมั�ณิระหว่ั�งกิจักรรมัท�งก�ยและ ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 54 ผู้ลลพั็ธิท์�งสุำขีภั�พ็ด� นจิัตใจัและด� น ก�รรับร้�ขีองแต่ละบุค์ค์ลอย่�งเฉพ็�ะ เจั�ะจังมั�กขี่ �น เฉกเช่นเดียวักนั หลกัฐ�น เพิ็�มัเติมัที�อธิิบ�ยค์วั�มัสำมััพ็นัธิร์ะหว่ั�ง ปริมั�ณิและ/หร่อค์วั�มัหนกัหน่วังขีอง กิจักรรมัท�งก�ยแบบแอโรบิก และก�ร ฝึึ ก ค์ วั � มั แ ข็ี ง แร ง ก ล� มั เน่�อ แ ล ะ ผู้ลลพั็ธิสุ์ำขีภั�พ็ที� เฉพ็�ะเจั�ะจัง ขี�อม้ัลนี� เป็นกุญ่แจัในก�รบญั่ญ่ติัปริมั�ณิที�น�อย ที� สุำดที�จัะเกิดผู้ล และเกณิฑ์ค์์วั�มัปลอด- ภัยัที� ส้ำงที� สุำดในก�รทำ�กิจักรรมัท�งก�ย สำำ�หรบัประช�กรกลุ่มัย่อยที�แตกต่�งกนั ค์ณะทำ�ง�น GDG สำรุปว่� : • มีัหลกัฐ�นว่ั�กิจักรรมัท�งก�ยที� เพิ็�มั ขี่ �นเช่�อมัโยงกบัผู้ลลพั็ธิท์�งสุำขีภั�พ็ที� มั�กขี่ �น แมั�ว่ั�คุ์ณิประโยชนที์� เกี� ยวั เน่�องจัะรกัษ�ระดบัขีองกิจักรรมัท�ง ก�ยที�มีัระดบัส้ำงขี่ �น ยงัไม่ัมีัหลกัฐ�นที� เพี็ยงพ็อที�จัะระบุระดบัที� แน่นอนว่ั� ผู้ลตอบกลบัที�ลดลงนั�นเริ�มัเกิดขี่ �น • มีัหลกัฐ�นที� มีัค์วั�มัน่�เช่� อถ่อส้ำงว่ั� กิจักรรมัท�งก�ยในระดับที� ส้ำงขี่ �น เ ช่� อ มั โ ย ง กับ ค์ วั � มั เ สีำ� ย ง ที� ล ด ล ง จั�กก�รเสีำยชีวิัตทุกสำ�เหตุ ก�ร เสีำยชีวิัตจั�กโรค์หลอดเล่อดหัวัใจั ก�รเสีำยชีวิัตจั�กโรค์มัะเร็ง ก�รเกิดโรค์ หลอดเล่อดหัวัใจั และก�รเกิดภั�วัะ ค์วั�มั ดัน โ ล หิ ต ส้ำ ง แ ล ะ เ บ � ห วั� น ประเภัทที� สำอง โดยไม่ัมีัค์วั�มัเสีำ� ยง อนัตร�ยที�เพิ็�มัขี่ �น • มีัหลักฐ�นเช่� อถ่อได�ป�นกล�งว่ั� กิจักรรมัท�งก�ยในระยะใด ๆ นั�น เช่� อมัโยงกับผู้ลลัพ็ธิท์�งสุำขีภั�พ็ที� ดีขี่ �น และก�รเจั�ะจังก่อนหน� นี�ว่ั�ค์วัร มีักิจักรรมัท�งก�ยแบบแอโรบิก เป็นช่วังต่อเน่� องอย่�งน�อย 10 น�ที นั�น ค์วัรเอ�ออกเสีำย • มีัหลกัฐ�นว่ั�กิจักรรมัท�งก�ยที�มั�ก ขี่ �นอ�จัเช่�อมัโยงกบัก�รวัดัที� เหมั�ะ สำมัมั�กขี่ �น ทั�งภั�วัะโรค์อ�วันและก�ร ลดนำ � หนกัในผู้้�ใหญ่่ และมีัค์วั�มัเสีำ�ยง ตำ� ที� กิจักรรมัท�งก�ยจัะเป็นอนัตร�ย สำำ�หรบัก�รจัดัก�รนำ � หนกัที� ส่ำงผู้ลต่อ สุำขีภั�พ็ดีในผู้้�ใหญ่่ • มีัหลักฐ�นเช่� อถ่อได�ป�นกล�งว่ั� กิจักรรมัท�งก�ยแบบแอโรบิกที� ระดับป�นกล�ง 150-300 น�ที หร่อเทียบเท่�ต่อสำปัด�หน์ั�น ลดค์วั�มั เสีำ�ยงสำำ�หรบัผู้ลลพั็ธิสุ์ำขีภั�พ็อย่�งทวีั- ค้์ณิ และก�รลดค์วั�มัเสีำ�ยงจัะดำ�เนินไป แต่เริ� มัที� จัะนิ� งเม่ั� อเกิน 300 น�ที ต่อสำปัด�ห์ ค์ว�มัสำมััพนัธิ์เ์ปลี�ยนแปลงไปติ�มัช้นิด หรือข้อบเข้ติข้องกิจกรรมัท�งก�ย หรือไม่ั หลกัฐ�นแสำดงว่ั�กิจักรรมัท�งก�ย ชนิดต่�ง ๆ และกิจักรรมัท�งก�ยที� เกิด ขี่ �นในขีอบเขีตที�แตกต่�งกนั (เช่น อ�ชีพ็ ก�รเดินท�ง หร่อก�รพ็กัผู่้อน) ทำ�ให�เกิด ผู้ลลพั็ธิท์�งสุำขีภั�พ็ที� น่�พ็อใจั สำำ�หรบั สำ�เหตุก�รเสีำยชีวิัตทุกสำ�เหตุและโรค์ หลอดเล่อดหวััใจั กิจักรรมัท�งก�ยแบบ แอโรบิกแต่เพี็ยงอย่�งเดียวัหร่อผู้สำมักบั ก�ยบริห�รเพ่็�อสำร� งเสำริมัค์วั�มัแข็ีงแรง แสำดงให�เห็นถ่งค์วั�มัเช่� อมัโยงที� มีัส่ำวัน เสำริมักนั แมั�ว่ั�กิจักรรมัท�งก�ยทั�งสำอง ร้ปแบบในระดบัที� แนะนำ�นั�นเหมั�ะสำมั ที�สุำด (84) ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) 55 หลกัฐ�นที� มีัค์วั�มัน่�เช่�อถ่อป�น- กล�งเม่ั�อไม่ัน�นมั�นี�ชี �ให�เห็นว่ั� กิจักรรมั ท�งก�ยเสำริมัสำร� งกล� มัเน่�อ ค์วั�มัอิสำระ ขีองกิจักรรมัท�งก�ยแบบแอโรบิกนั�น ยงัเช่� อมัโยงกบัค์วั�มัเสีำ� ยงที� ลดลงจั�ก ก�รเสีำยชีวิัตทุกร้ปแบบ ผู้ลก�รวิัจััยที� ร�ยง�นโดยสำต�มั�ต�คิ์สำและค์ณิะ (2561) จั�กผู้ลก�รวิัเค์ร�ะห์โดยรวัมัจั�ก 11 กลุ่มัที� ทดสำอบขี�อแนะนำ�ในก�รทำ� กิจักรรมัท�งก�ยแบบเสำริมักล� มัเน่�อ อย่�งน�อย 2 วันัต่อสำปัด�หเ์ปรียบเทียบ กับก�รเสีำยชีวิัตทุกสำ�เหตุ ชี �ให� เห็น ว่ั� เม่ั� อทำ�กิจักรรมัท�งก�ยทั�งแบบ แอโรบิกและเสำริมัสำร� งกล� มัเน่�อในระดบั ต่�ง ๆ ที�แนะนำ� (1) เทียบกบัเม่ั�อไม่ัทำ�ต�มั ขี�อแนะนำ�ใดเลย (ปรบัที� HR= 0.71 [95% CI: 0.57 to 0.87]) และก�รปฏิิบติัต�มั เพี็ยงแค่์ค์ำ�แนะนำ�ในกิจักรรมัท�งก�ย เพ่็�อค์วั�มัแข็ีงแรงเทียบกบัก�รไม่ัปฎิบติั ต�มั (HR= 0.80 [95% CI: 0.70 to 0.91]) ซ่�งสำมััพ็นัธิก์บัค์วั�มัเสีำ�ยงต่อสำ�เหตุก�ร เสีำยชีวิัตทุกสำ�เหตุที� ลดลงอย่�งมีันัย สำำ�ค์ญั่ (84) ขี�อม้ัลเหล่�นี�ย่นยนัว่ั�ผู้ล ประ โยชน์ต่อสุำขีภั�พ็ที� เช่� อมัโยงกับ กิจักรรมัท�งก�ยเพ่็� อเสำริมัสำร� งกล� มั เน่�อนั�น ไม่ัขี่ �นกบักิจักรรมัท�งก�ยแบบ แอโรบิกและยังสำร� งหลักฐ�นที� สำนับ สำนุนก�รแนะนำ�ค์วั�มัถี�ในก�รทำ�กิจักรรมั ท�งก�ยเพ่็�อเสำริมัสำร� งกล� มัเน่�อ 2 วันั ต่อสำัปด�ห์ ขี�อค์�นพ็บที� ร�ยง�นโดย ดีน้และค์ณิะ (2562) ให�หลกัฐ�นสำนับ สำนุนที� ย่นยันว่ั� กิจักรรมัท�งก�ยที� เ กิ ด ขี่ �น น อ ก ขี อ บ ข่ี � ย ก � ร พ็ัก ผู่้ อ น ( ห ร่ อ สำัน ท น � ก � ร ) สำ � มั � ร ถ เ อ่ �อ ประโยชนแ์ละแสำดงให�เห็นอย่�งเจั�ะจัง ว่ั�ก�รเดินท�งอย่�งค์ล่องแค์ล่วั (เช่น ก�ร เ ดิ น แ ล ะ ก � ร เ ดิ น ท � ง ด�วั ย ก � ร ปั� น จัักรย�น) สำ�มั�รถลดค์วั�มัเสีำ� ยงขีอง สำ�เหตุก�รเสีำยชีวิัตทุกร้ปแบบอย่�งมีั นยัสำำ�ค์ญั่ (RR= 0.92 [95% CI: 0.85– 0.98]) (85) ง�นวิัจััยเม่ั� อเร็วั ๆ นี�ชี �ให�เห็นถ่ง หลกัฐ�นที�แสำดงว่ั� ผู้้�ที�เขี� ร่วัมัในก�รเดิน ท�งโดยมีัก�รเค์ล่�อนไหวัร่�งก�ย (เช่น ก�รเดิน หร่อก�รปั� นจักัรย�นเพ่็�อก�รเดิน ท�ง) จัะมีัค์วั�มัเสีำ�ยงต่อโรค์หลอดเล่อด หวััใจัที�ลดลง (โรค์หลอดเล่อดหวััใจั โรค์ หลอดเล่อดสำมัองและหัวัใจัล�มัเหลวั) เปรียบเทียบกบัค์นที� เขี� ร่วัมัในก�รเดิน ท�งโดยไม่ัมีัก�รเค์ล่�อนไหวัร่�งก�ย (RR= 0.91 [95% CI 0.83 to 0.99]) (85) และมีั หลักฐ�นเพี็ ยงพ็อจั�กผู้ลลัพ็ธิ ์ด� น สุำขีภั�พ็เหล่�นี�ที�จัะสำรุปได�ว่ั� กิจักรรมั ในขีอบเขีตที� หล�กหล�ยนั�นเป็นผู้ลดี อย่�งไรก็ต�มั มีัหลกัฐ�นไม่ัเพี็ยงพ็อที�จัะ แยกแยะผู้ลกระทบขีองขีอบข่ี�ยใน กิจั ก ร ร มั ท�ง ก� ย ที� แ ต ก ต่ �ง กันใน ผู้ลลพั็ธิท์�งสุำขีภั�พ็ทุกอย่�ง ตวััอย่�งเช่น มีัหลักฐ�นไม่ัเพี็ยงพ็อที� จัะกำ�หนดว่ั� ค์วั�มัเช่�อมัโยงระหว่ั�งก�รทำ�กิจักรรมั ท�งก�ยและค์วั�มัเสีำ�ยงในก�รเกิดโรค์ มัะเร็งหร่อก�รเกิดโรค์เบ�หวั�นชนิดที� 2 จัะแปรผู้นัไปต�มัชนิดหร่อขีอบเขีตขีอง กิจักรรมัท�งก�ย สำำ�หรับผู้ลลัพ็ธิท์�งสุำขีภั�พ็จิัต หลักฐ�น (35) แสำดงให�เห็นว่ั�ค์วั�มั หล�กหล�ยชนิดขีองกิจักรรมัท�งก�ย รวัมัถ่งกิจักรรมัแบบแอโรบิก ก�รเดิน ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 56 กิจักรรมัสำร� งค์วั�มัแข็ีงแรงให�กบักล� มั- เน่�อ และโยค์ะนั�น สำ�มั�รถสำร� งผู้ลกระทบ ที�เป็นประโยชนต่์อก�รลดอ�ก�รซม่ัเศร� และก�รก่อตวััขีองค์วั�มักงัวัล (74, 79, 86) ตวััอย่�งจั�กหลกัฐ�นเม่ั� อไม่ัน�น มั�นี� เกี�ยวักบัผู้ลกระทบที� เอ่ �อประโยชน ์ ขีองก�รแทรกแซงจั�กก�รออกกำ�ลงัก�ย แบบใช�แรงต� นและสุำขีภั�พ็จิัตมีัอย่้ ในบทปริทศันส์ำองฉบบัที�ร�ยง�นอ�ก�ร ซ่มัเศร� ที� ลดลงมั�กพ็อสำมัค์วัร (77) และก�รลดลงเล็กน�อยขีองอ�ก�รกงัวัล (78) เม่ั�อเปรียบเทียบกบัสำภั�วัะที� มีัก�ร ค์วับคุ์มั หลักฐ�นจั�กบทปริทัศน์ฉบับ ใหม่ัยำ � เต่อนว่ั�กิจักรรมัท�งก�ยเพ่็� อ อ�ชีพ็ในระดบัส้ำงนั�น เช่�อมัโยงกบัค์วั�มั เสีำ�ยงขีองโรค์มัะเร็ง โรค์หลอดเล่อดหวััใจั และโรค์เบ�หวั�นชนิดที� 2 ที�ลดลง (40) อย่�งไรก็ต�มั กิจักรรมัท�งก�ยเพ่็� อ อ�ชีพ็ที�ระดบัส้ำงขี่ �นอ�จัจัะเช่�อมัโยงกบั ค์วั�มัเสีำ�ยงต่อโรค์กระด้กพ็รุนที� เพิ็�มัขี่ �น คุ์ ณิ ภั � พ็ ก � ร น อ น ห ลับ ที� ไ ม่ั ดี แ ล ะ สำ�เหตุก�รเสีำยชีวิัตทุกสำ�เหตุในผู้้�ช�ย (แต่ไม่ัใช่ในผู้้�หญิ่ง) ไม่ัมีัหลกัฐ�นเพี็ยงพ็อ ที� จั ะ กำ � ห น ด ค์ วั � มั สำัมั พ็ัน ธิ ์ร ะ ห ว่ั � ง กิจักรรมัท�งก�ยเพ่็�ออ�ชีพ็และค์วั�มัอ�วัน ก�รป้องกนันำ � หนกัเพิ็�มั สุำขีภั�พ็จิัต และ คุ์ณิภั�พ็ชีวิัตที�เกี�ยวักบัสุำขีภั�พ็ (40) และ ยงัมีัหลกัฐ�นไม่ัเพี็ยงพ็อที�จัะแยกแยะ ห�กค์วั�มัเช่� อมัโยงระหว่ั�งกิจักรรมั ท�งก�ยและค์วั�มัเสีำ� ยงต่อโรค์มัะเร็ง จัะผู้นัแปรต�มัชนิดหร่อขีอบเขีตขีอง กิจักรรมัท�งก�ย มีัหลกัฐ�นน�อยชิ�นเกี�ยวั กบัค์วั�มัเช่�อมัโยงกบัขีอบเขีตที� ต่�งกนั ขีองกิจักรรมัท�งก�ย ดงันั�นจัง่ย�กที�จัะ แ ย ก แ ย ะ ผู้ ล กร ะ ท บ ขีอง ขีอ บ เขี ต ที� แตกต่�งกนัขีองกิจักรรมัท�งก�ยต่อ ผู้ลกระทบท�งสุำขีภั�พ็ที�หล�กหล�ย ค์ณิะทำ�ง�น GDG สำรุปว่ั� : • มีัหลักฐ�นเช่� อถ่อได�ป�นกล�งว่ั� กิจักรรมัท�งก�ยที�สำร� งค์วั�มัแข็ีงแรง ให�กับกล� มัเน่�ออย่�งน�อย 2 วััน ต่อสำปัด�หห์ร่อมั�กกว่ั� จัะช่วัยสำร� ง เสำริมัสุำขีภั�พ็มั�กขี่ �น แต่ไม่ัมีัหลกัฐ�น เพี็ยงพ็อที�จัะระบุช่วังเวัล�ที�แน่นอน สำำ�หรบัผู้ลดีต่อสุำขีภั�พ็ที�น่�พ็อใจัที�สุำด • มีัหลกัฐ�นที� เช่� อถ่อได�ป�นกล�งว่ั� กิจักรรมัท�งก�ยในขีอบเขีตที�แตก ต่�งกนั (ตวััอย่�งเช่น ก�รพ็กัผู่้อน ก�รเดินท�ง เกี�ยวักบัอ�ชีพ็) เสำริมัสำร� ง ประโยชนต่์อสุำขีภั�พ็ แมั�ว่ั�ในปัจัจุับนั จัะเป็นไปไม่ัได�ที� จัะแยกผู้ลกระทบ จั�กขีอบข่ี�ยในก�รทำ�กิจักรรมัท�ง ก�ยที� แตกต่�งกันต่อผู้ลลัพ็ธิท์�ง สุำขีภั�พ็ที�หล�กหล�ย • แมั�ว่ั�กิจักรรมัท�งก�ยเกี�ยวักบัอ�ชีพ็ ในระดับที� ส้ำงขี่ �นอ�จัจัะเกี� ยวัโยง กบัค์วั�มัเสีำ� ยงขีองโรค์กระด้กพ็รุน คุ์ณิภั�พ็ก�รนอนหลับที� ไม่ัดี และ สำ�เหตุก�รเสีำยชีวิัตทุกสำ�เหตุที�เพิ็�มัขี่ �น ในหม่้ัผู้้�ช�ย (แต่ไม่ัใช่ในผู้้�หญิ่ง) โดย ภั�พ็รวัมัแล�วั มีัหลักฐ�นที� มีัค์วั�มั แน่นอนป�นกล�งที� กิจักรรมัท�งก�ย เพ่็�ออ�ชีพ็นั�นส่ำงผู้ลดีต่อสุำขีภั�พ็ ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) 57 วััยผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ข้้อแนืะนืำ� ด้็�นืพฤติิกิรัรัมเนืือยนิื�ง สำำ�หรบัผู้้�ใหญ่่ พ็ฤติกรรมัเน่อยนิ�งค่์อเวัล�ที�ใช�ไปกบัก�รนั�งหร่อนอนเฉย ๆ ด�วัยก�รใช�พ็ลงัง�นแต่น�อยขีณิะต่�นอย่้ ในปริบทที�เกี�ยวักบัก�รทำ�ง�น ก�รเรียน ในสำภั�พ็แวัดล�อมัที�บ� นและชุมัชน รวัมัทั�งก�รค์มัน�ค์มั หลกัฐ�นสำนบัสำนุนและเหตุิผล สำำ�หรบัขี�อแนะนำ�เหล่�นี� ก�รสำงัเค์ร�ะหห์ลกัฐ�นที�ได�จั�ก PAGAC (35) ถ้กนำ�มั�ใช�และปรบัปรุง ค์ณิะทำ�ง�น GDG พิ็จั�รณิ�องค์ป์ระกอบทั�งหมัดขีองหลกัฐ�น รวัมัถง่ผู้ลก�รศก่ษ�ที�ร�ยง�นโดย PAGAC และบทปริทศัน์ใหม่ัจัำ�นวัน 13 บทที�เป็นไปต�มัหลกัเกณิฑ์ก์�รนำ�ผู้ลเขี� เพ่็�อสำร� งหลกัฐ�น เกี�ยวักบัค์วั�มัเช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งและผู้ลลพั็ธิเ์กี�ยวัเน่� องกบัสุำขีภั�พ็ในผู้้�ใหญ่่ ก�รค์�นห�ค์วั�มัต่อเน่�องระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งและผู้ลลพั็ธิท์�งสุำขีภั�พ็เป็นสำ�ขี�ท�งสำ�ธิ�รณิสุำขี ที� ค่์อนขี� งใหม่ั เม่ั�อเทียบกบัเร่�องกิจักรรมัท�งก�ยที� ไม่ัเพี็ยงพ็อ แต่ยงัมีัก�รพ็ฒัน�อย่�งรวัดเร็วั ในทศวัรรษที�ผู่้�นมั� ง�นวิัจัยันั�นได�วัดัพ็ฤติกรรมัเน่อยนิ�งอย่�งเป็นระบบโดยใช�ทั�ง 1) แบบสำอบ- ถ�มัเพ่็�อร�ยง�นผู้ลด�วัยตนเองที�ถ�มัทั�ง “เวัล�โดยรวัมั” ที�ใช�ไปกบัพ็ฤติกรรมัเน่อยนิ�งหร่อเวัล�ที� ใช�กบัพ็ฤติกรรมัเฉพ็�ะ เช่น ก�รด้โทรทศัน ์เวัล�ที�อย่้กบัหน� จัอ/หน� จัอค์อมัพิ็วัเตอร ์และก�รนั�ง 2) ก�รวัดัด�วัยอุปกรณิ ์ ไม่ัมีัก�รวัดัที� เป็นมั�ตรฐ�นหร่อต�นแบบในก�รวิัเค์ร�ะหพ์็ฤติกรรมัเน่อยนิ�ง ดงันั�นก�รร�ยง�นผู้ลจั่งแตกต่�งกนัไป ก�รพ็ฒัน�ระเบียบวิัธีิวิัจัยัเม่ั�อไม่ัน�นนี�ได�รวัมัเอ�ก�ร ประเมิันก�รใช�เวัล�ขีองพ็ฤติกรรมัเน่อยนิ�งด�วัยเค์ร่�องม่ัอเอ�ไวั� ซ่�งสำ�มั�รถลดขี�อผิู้ดพ็ล�ดในก�ร วัดัและค์วั�มัโน�มัเอียงที� ได�จั�กก�รระลก่ขี�อม้ัลที�ร�ยง�นผู้ลด�วัยตนเอง ในวัยัผู้้�ใหญ่่นั�น เวัล�ขีองพ็ฤติกรรมัเน่อยนิ�งที�มั�กขี่ �นจัะต�มัมั�ด�วัยผู้ลเสีำยด� นสุำขีภั�พ็ อ�ทิเช่น สำ�เหตุก�รเสีำยชีวิัตทุกประก�ร สำ�เหตุก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อดหวััใจั และก�รเสีำยชีวิัตจั�กโรค์มัะเร็ง และสำ�เหตุก�รเกิดโรค์หลอดเล่อดหัวัใจั มัะเร็ง และโรค์เบ�หวั�นชนิดที�สำอง แนะนำ�ให:้ ผ้ ใ้หญ่่ค์วรจำ�กดัระยะเวล�ข้องพฤติิกรรมัเนือยนิ�ง และทดแทนเวล�เหล่�นั�น ดว้ยกิจกรรมัท�งก�ยในทุกระดบัที�มีัประโยช้นด์�้นสุำข้ภ�พ (รวมัถง้ระดบัเบ�) แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�ง เพื�อช่้วยลดผลเสีำยต่ิอสุำข้ภ�พจ�กพฤติิกรรมัเนือยนิ�งในระดบัส้ำง ผ้ ใ้หญ่่ค์วรจะมุ่ังทำ� กิจกรรมัท�งก�ยที�ระดบัป�นกล�งหรือหนกัใหม้ั�กกว่�ระดบัที�แนะนำ� แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นที�เช่�อถ่อได�ป�นกล�ง > > ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 58 ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ในก�รพิ็จั�รณิ�องค์ร์วัมัขีองหลกัฐ�น ค์ณิะทำ�ง�น GDG ให�นำ � หนกัส่ำวันใหญ่่ไปที�หลกัฐ�นที� บทปริทศัน์ให�ค์ะแนนระดบักล�งและส้ำงกว่ั� โดยมั�จั�กบทปริทศันที์� ได�หลกัฐ�นจั�กก�รศก่ษ�ที� ใช�ก�รวัดัเวัล�ที�มีัพ็ฤติกรรมัเน่อยนิ�งหร่อนั�งอย่้เฉย ๆ หร่อก�รวัดัพ็ฤติกรรมัเน่อยนิ�งด�วัยอุปกรณิ ์ เม่ั�อห�ได� ร�ยละเอียดที�ค์รบถ�วันเกี�ยวักบัวิัธีิวิัจัยั ก�รแยกส่ำวันขี�อม้ัล และชุดขี�อม้ัลหลกัฐ�นอย่้ที� ภั�ค์ผู้นวักบนเว็ับไซต ์: ชุดหลกัฐ�น7 ง�นวิัจัยัเกี�ยวักบัผู้ลเสีำยต่อสุำขีภั�พ็ที� เช่�อมัโยงกบัพ็ฤติกรรมัเน่อยนิ�งได�เพิ็�มัพ้็นขี่ �นอย่�ง รวัดเร็วัตลอดทศวัรรษที�ผู่้�นมั� ในง�นวิัจัยัที�ทนัสำมัยักว่ั� พ็บก�รพ็ฒัน�ที�โดดเด่น ดงันี� ก�รเพิ็�มัขี่ �น ขีองหลกัฐ�นที�ร�ยง�นเร่�องค์วั�มัสำมััพ็นัธิร์ะหว่ั�งก�รตอบสำนองต่อปริมั�ณิระหว่ั�งพ็ฤติกรรมั เน่อยนิ�งและผู้ลลพั็ธิต่์อสุำขีภั�พ็หล�ยประก�ร และผู้ลกระทบระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งและ กิจักรรมัท�งก�ย 7 ข้้อม่ัลออนไลน์ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ในผ้ใ้หญ่่ (อ�ยุ 18 ปีข้้ �นไป) ค์ว�มัสำมััพนัธิ์ ์ ระหว่�งพฤติิกรรมัเนือยนิ�งและผลลพัธิ์ ์ ที�เกี�ยวเนื�องกบัสุำข้ภ�พคื์ออะไร โดยรวัมัแล�วั มีัหลกัฐ�นเกี�ยวักบั ค์วั�มัเช่� อมัโยงระหว่ั�งเวัล�ที� ใช� ไปกบั พ็ฤติกรรมัเน่อยนิ� งที�มั�กขี่ �น (วัดัผู่้�น ก�รประเมิันจั�กก�รร�ยง�นด�วัยตนเอง หร่อประเมิันด�วัยเค์ร่องม่ัอจั�กเวัล� ที� นั� ง เ ฉ ย ๆ ห ร่ อ เวั ล � ด้ โท ร ทัศ น์) แ ล ะ สำ � เห ตุ ก� ร เ สีำ ย ชี วิั ต ทุ ก สำ � เห ตุ ก�รเสีำยชีวิัตจั�กหลอดเล่อดหัวัใจั และ โอก�สำในก�รเกิดโรค์หลอดเล่อดหัวัใจั และเบ�หวั�นชนิดที�สำองที�มั�กขี่ �น (8, 35, 65, 87) ตวััอย่�งเช่น หลกัฐ�นสำนบัสำนุน รวัมัผู้ลจั�กก�รวิัเค์ร�ะห์อภิัมั�นชิ�น ใหญ่่และทนัสำมัยั (n= 36 383; อ�ยุเฉลี�ย 62.6 years; 72.8% เพ็ศหญิ่ง) ขีองเค์ร่�อง วัดัค์วั�มัเร่งที�ประเมิันเวัล�ขีองพ็ฤติกรรมั เน่อยนิ�งโดยรวัมัและสำ�เหตุิก�รเสีำยชี้วิติ ทุกสำ�เหตุิ (65) และชี�ว่ั� เวัล�ที�ใช�กบัพ็ฤติ- กรรมัเน่อยนิ�งที�เพิ็�มัมั�กขี่ �นนั�น เช่�อมัโยง อย่�งมีันัยสำำ�ค์ญั่กบัภั�วัะก�รเสีำยชีวิัต จั�กทุกสำ�เหตุ ผู้ลก�รศก่ษ�ที�ค์ล� ยค์ลง่ กนั จั�กก�รวิัเค์ร�ะหอ์ภิัมั�นที�มีัผู้้�เขี� ร่วัมั มั�กกว่ั� 1 ล� นค์น (87) แสำดงให�เห็นถง่ ค์วั�มัเช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อย นิ� งทุกแบบกับภั�วัะก�รเสีำยชี้วิติทุก สำ�เหตุิ และภั�วัะก�รเสีำยชี้วิติจ�กโรค์ หลอดเลือดหัวใจหลังจั�กก�รปรับ กิจักรรมัท�งก�ย (87) แมั�ว่ั�ในง�นวิัจัยั ฉบบันี� ก�รเช่�อมัโยงกบัภั�วัะก�รเสีำยชี้วิติ จ�กโรค์มัะเร็งจัะไม่ัมีันยัสำำ�ค์ญั่ท�งสำถิติ หลงัจั�กก�รปรบักิจักรรมัท�งก�ย (87) ก�รวิัเค์ร�ะหอ์ภิัมั�นอีกชิ�นหน่� ง เม่ั�อไม่ัน�นมั�นี� (8) ร�ยง�นถง่ค์วั�มัเช่�อมั โยงที�สำำ�ค์ญั่ระหว่ั�งพ็ฤติกรรมัเน่อยนิ�ง (ประเมิันขีณิะนั�ง) และก�รเสีำยชี้วิติจ�ก โรค์หลอดเลือดหวัใจแลโรค์กมัะเร็ง 59 ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ซ่�งผู้ลที� ได� ชี �ถ่งค์วั�มัเสีำ�ยงต่อภั�วัะก�ร เสีำยชีวิัตจั�กโรค์หลอดเล่อดหัวัใจัที� ส้ำง ขี่ �น 9-32% (p for trend < 0.001) ด�วัย พ็ฤติกรรมัเน่อยนิ�งในระดบัที� ส้ำงขี่ �น เม่ั�อ วัดัขีณิะนั�ง “นิ�ง ๆ” มีักิจักรรมัท�งก�ย ในช่วังค์วัอไทลที์�ตำ� สุำด (~ 5 น�ที/วันั) ผู้ลวิัจััยบอกว่ั�ผู้้� ใหญ่่ที� มีัพ็ฤติกรรมั เน่อยนิ�ง (นั�งนิ�ง ๆ ) มั�กกว่ั� 8 ชั�วัโมังต่อวันั จัะมีัค์วั�มัเสีำ�ยงต่อภั�วัะก�รเสีำยชีวิัตจั�ก โรค์ หลอดเล่อดหวััใจัส้ำงกว่ั� ยกเวั�นผู้้�ที� “ค์ล่องแค์ล่วัที� สุำด” ( ตัวัอย่�งเช่น > 3 5 . 5 M E T- ชั� วั โ มั ง ต่ อ สำัป ด � ห ์ หร่อ ~ 60–75 น�ทีต่อวััน) ซ่� งค์วั�มั เช่�อมัโยงนั�นผู่้อนปรนลง ผู้ลจั�กค์วั�มั เช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งและ ภั�วัะก�รเสีำยชี้วิติจ�กโรค์มัะเร็งยิ�งอ่อน กว่ั� แมั�ว่ั�จัะสำงัเกตเห็นได�ถง่ค์วั�มัเสีำ�ยงที� เกี�ยวัเน่�องกบัปริมั�ณิที� ส้ำงขี่ �นถง่ร�อยละ 6 ถ่ง 21 เม่ั�อเวัล�ที�นั� งเฉยย�วัน�นขี่ �น ( โดยเฉพ็�ะอย่�งยิ� งเม่ั� อมั�กกว่ั� 8 ชั�วัโมังต่อวันั) แต่เฉพ็�ะกบัผู้้�ที�มีักิจักรรมั ท�งก�ยในช่วังค์วัอไทลที์�ตำ� ที� สุำดเท่�นั�น (< 2.5 MET-ชั�วัโมังต่อสำปัด�ห)์ (8) หลกัฐ�นสำนบัสำนุนค์วั�มัเช่�อมัโยง ระหว่ั�งพ็ฤติกรรมัเน่อยนิ� ง (วััดจั�ก เวัล�ที�นั� งทั�งหมัด) และสำ�เหตุก�รเกิด โรค์หลอดเลือดหวัใจที� เพิ็� มัขี่ �น (HR= 1.29 [95% CI: 1.27 to 1.30]) ซ่�งลดลง จั�กก�รปรับตวััแปรร่วัมัที� อ�จัเป็นไป ได� รวัมัถ่งปรบัระดบักิจักรรมัท�งก�ย (HR= 1.14 [95% CI: 1.04 to 1.23]) (88) บทปริทัศนข์ีองก�รวิัจััยในกลุ่มั ประช�กรช�วัเอเชียตะวันัออกเฉียงใต� แสำดงหลกัฐ�นว่ั� มีัค์วั�มัน่�เช่�อถ่อตำ� ขีองเวัล�ในก�รมีัพ็ฤติกรรมัเน่อยนิ� งที� ย�วัน�นขี่ �นจัะเช่�อมัโยงกบัค์วั�มัเป็นไป ได�ที� เพิ็� มัส้ำงขี่ �นกบัติวัชี้ �วดัภยัเสีำ�ยงโรค์ หวัใจและหลอดเลือด (รวัมัถง่เบ�หวั�น ชนิดที� 2, ดชันีมัวัลก�ยเพิ็� มัขี่ �น ค์วั�มั ดนัโลหิตที�ส้ำงขี่ �น) (89) ง�นวิัจััย 2 ฉบับล่�สุำดร�ยง�น ถง่ค์วั�มัเช่�อมัโยงขีองระยะเวัล�ที�นั�งเฉย ๆ ในแต่ละวัันโดยรวัมั (88) และพ็ฤติ- กรรมัเน่อยนิ�งทั�งหมัด และเวัล�ด้โทรทศัน ์ (87) กับกิารเกิิดุเบาหวานชนิดุที� 2 ง�นวิัจัยัทั�ง 2 ชิ �นพ็บว่ั� พ็ฤติกรรมัเน่อย- นิ� งในระดับที� ส้ำงขี่ �นเช่� อมัโยงกับค์วั�มั เสีำ� ยงต่อก�รเกิดเบ�หวั�นชนิดที� 2 ที�เพิ็�มัขี่ �น ตวััอย่�งเช่น ค์วั�มัเช่�อมัโยงที�เป็น เสำ�นตรงกบัเบ�หวั�นชนิดที� 2 นั�นสำงัเกต เห็นได�สำำ�หรบัพ็ฤติกรรมัเน่อยนิ�งโดยรวัมั (RR= 1.01 [95% CI: 1.00 to 1.01] p= < 0.001) และก�รด้โทรทศัน ์(RR= 1.09 [95% CI: 1.07 to 1.12] p= < 0.001) เม่ั�อปรบัเพ่็�อกิจักรรมัท�งก�ย (87) มีัหลกัฐ�นสำนบัสำนุนค์วั�มัเช่�อมัโยง ที� มีั นั ย สำำ � ค์ั ญ่ ร ะ ห ว่ั � ง พ็ ฤ ติ ก ร ร มั เน่อยนิ�ง (เม่ั�อวัดัขีณิะใช�เวัล�ด้โทรทศัน)์ และภาวะอนัต่รายจากิโรคมะเร็ง (35, 87) บทปริทศันฉ์บบัล่�สุำดหล�ยชิ�นที� มีั ค์วั�มัน่�เช่�อถ่อตำ� และตำ� มั�กให�หลกัฐ�น สำนับสำนุนถ่งค์วั�มัเช่� อมัโยงระหว่ั�ง พ็ฤติกรรมัเน่อยนิ�งและโรค์มัะเร็งลำ�ไสำ� (90) แต่ไม่ัมีัค์วั�มัเช่�อมัโยงกบัโรค์มัะเร็ง ต่อมัล้กหมั�ก โรค์มัะเร็งเต� นมั หร่อโรค์ มัะเร็งลำ�ไสำ�ตรง (90-93) หลกัฐ�นเพิ็�มัเติมั (35) ร�ยง�นค์วั�มัเช่�อมัโยงที�มีันยัสำำ�ค์ญั่ ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 60 ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ระหว่ั�งระยะเวัล�ที� ใช�ไปกบัพ็ฤติกรรมั เน่อยนิ�งที�มั�กขี่ �นและค์วั�มัเสีำ�ยงที� ส้ำงขี่ �น ที�จัะก่อให�เกิดโรค์มัะเร็งเย่�อบุโพ็รงมัดล้ก โรค์มัะเร็งลำ�ไสำ� และมัะเร็งปอด (35) มีัหลักฐ�นที� เช่� อถ่อได�น�อยขีอง ค์วั�มัสำมััพ็นัธิที์� เป็นภัยัระหว่ั�งเวัล�ที� ใช� ไปกบัพ็ฤติกรรมัเน่อยนิ� งและโรค์อว้น และตวัับ่งชี�สำถ�นะขีองนำ � หนกั และไม่ัว่ั� ค์วั�มัสำมััพ็นัธิร์ะหว่ั�งพ็ฤติกรรมัเน่อยนิ�ง และสำถ�นะขีองนำ � หนักจัะผู้ันแปรไป ต�มัปริมั�ณิขีองกิจักรรมัท�งก�ยระดบั ป�นกล�งถง่หนกั โดยรวัมัแล�วั สำรุปได�ว่ั� มีั ห ลัก ฐ � น ไ ม่ั เพี็ ย ง พ็ อ ที� จั ะ แจั�ง ถ่ง ค์ำ�แนะนำ�/ขี�อแนะนำ�เหล่�นี�และต�องก�ร ก�รวิัจัยัเพิ็�มัเติมั มีัหลักฐ�นที� จัำ�กัดที� ประเมิันผู้ล ด� นตรงกันขี� มัจั�กก�รลดเวัล�ขีอง พ็ฤติกรรมัเน่อยนิ�ง ค์วั�มัคิ์ดเห็นจั�กผู้้� เชี�ยวัช�ญ่ร�ยง�นบทสำรุปว่ั� ขี�อแนะนำ� ก�รลดเวัล�ที�มีัพ็ฤติกรรมัเน่อยนิ�งไม่ัน่� จัะเพิ็�มัค์วั�มัเสีำ�ยงจั�กอ�ก�รบ�ดเจ็ับ โดย เฉพ็�ะเม่ั�อทดแทนด�วัยกิจักรรมัท�งก�ย ในระดบัเบ� ค์ณะทำ�ง�น GDG สำรุปว่� • โดยรวัมัแล�วั มีัหลกัฐ�นเพี็ยงพ็อที�จัะ สำนับสำนุนก�รพ็ฒัน�ขี�อแนะนำ�ขีอง องค์ก์�รอน�มััยโลกฉบับใหม่ั เพ่็� อ จัำ�กดัพ็ฤติกรรมัเน่อยนิ�งเพ่็�อลดค์วั�มั เสีำ�ยงต่อสุำขีภั�พ็ • มีัหลกัฐ�นที� เช่� อถ่อได�ป�นกล�งถ่ง ก�รเช่�อมัโยงระหว่ั�งเวัล�ที�มั�กขี่ �น ที� ใช�กบัพ็ฤติกรรมัเน่อยนิ�งและภั�วัะ ก�รเสีำยชีวิัตทุกสำ�เหตุ ภั�วัะก�ร เสีำยชีวิัตจั�กโรค์หลอดเล่อดหัวัใจั ภั�วัะก�รเสีำยชีวิัตจั�โรค์กมัะเร็ง และ ก�รเกิดโรค์หลอดเล่อดหวััใจัและโรค์ เบ�หวั�นชนิดที� 2 ที� ส้ำงขี่ �น • มีัหลกัฐ�นที� เช่�อถ่อตำ� ไปจันถง่ระดบั กล�งขีองก�รเช่�อมัโยงระหว่ั�งก�ร ใช�เวัล�กบัพ็ฤติกรรมัเน่อยนิ�งที�มั�ก ขี่ �นและค์วั�มัเสีำ� ยงที�มั�กขี่ �นต่อก�ร เกิดโรค์มัะเร็งเย่�อบุมัดล้ก โรค์มัะเร็ง ลำ�ไสำ� และโรค์มัะเร็งปอด • มีัหลกัฐ�นไม่ัเพี็ยงพ็อเกี�ยวักบัค์วั�มั เช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ�ง และก�รวัดัภั�วัะโรค์อ�วัน และต�องก�ร ง�นวิัจัยัเพิ็�มัเติมั • ประโยชนข์ีองก�รจัำ�กดัพ็ฤติกรรมั เน่อยนิ� งมีัมั�กกว่ั�ค์วั�มัเสีำ� ยงใด ๆ ที�อ�จัเกิดขี่ �น มีัค์ว�มัสำ ัมัพ ันธิ์ที์� เ ชื้� อมัโยงก ับก�ร ติอบสำนองต่ิอปริมั�ณหรือไม่ั (ปริมั�ณ ท ั�งหมัด ค์ว�มัถี� ระยะเวล� ค์ว�มัรุนแรง ข้องก�รหยุดช้ะงกั) หลกัฐ�นทั�งหมัดทั�งมัวัลที�เช่�อถ่อได� ป�นกล�งบ่งชี�ว่ั� ค์วั�มัสำมััพ็นัธิก์�รตอบ สำ นอง ต่ อ ป ริ มั � ณิที� ไ ม่ั เ ป็ น เ สำ�น ต รง ระหว่ั�งเวัล�ที�มีัก�รทำ�พ็ฤติกรรมัเน่อย- นิ�ง (ก�รนั�ง หร่อ เวัล�ด้โทรทศันที์�ประเมิัน โดยก�รร�ยง�นตนเอง หร่อก�รประเมิัน โดยเค์ร่�องม่ัอ) และ ภั�วัะก�รเสีำยชีวิัตทุก สำ�เหตุ ภั�วัะก�รเสีำยชีวิัตจั�กโรค์หลอด- เ ล่อดหัวัใจั ภั�วัะก�รเ สีำ ยชีวิัตจั�ก โรค์มัะเร็ง และก�รเกิดโรค์หลอดเล่อด หวััใจั (8, 35, 87) 61 ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) ก�รวิัเค์ร�ะหอ์ภิัมั�นเม่ั� อไม่ัน�น มั�นี� ทำ�ให�มีัหลกัฐ�นที�มีัค์วั�มัน่�เช่�อถ่อส้ำง ในด� นค์วั�มัสำมััพ็นัธิข์ีองก�รตอบสำนอง ต่อปริมั�ณิระหว่ั�งเค์ร่�องวัดัค์วั�มัเร่งที� ประเมิันเวัล�ขีองก�รมีัพ็ฤติกรรมัเน่อย นิ� งทั�งหมัดและภาวะกิารเสียชีวิต่ทุกิ สาเหตุ่ (65) ที� ร�ยง�นว่ั�เวัล�ที� ใช�ใน พ็ฤติกรรมัเน่อยนิ� งที� เพิ็� มัมั�กขี่ �นนั�น เช่�อมัโยงอย่�งมีันัยสำำ�ค์ญั่กบัภั�วัะก�ร เสีำยชีวิัตทุกสำ�เหตุ อตัร�ส่ำวันค์วั�มัเสีำ�ยง อนัตร�ยสำำ�หรบัค่์�ค์วัอไทลที์� เพิ็�มัส้ำงขี่ �น สำำ�หรบัเวัล�ขีองพ็ฤติกรรมัเน่อยนิ�ง ค่์อ 1.00 (ผู้้�อ� งอิง นิ�งเฉยน�อยที� สุำด) 1.28 (1.09– 1.51) 1.71 (1.36–2.15) และ 2.63 (1.94–3.56) หลงัจั�กก�รปรบัตวัั วัดัที�เป็นไปได� รวัมัทั�งเวัล�ที�ใช�กบักิจักรรมั ท�งก�ยที�ระดบัป�นกล�งถง่หนกั (65) ก�รวิัเค์ร�ะหค์์วั�มัสำมััพ็นัธิ ์ในก�รตอบ สำนองต่อปริมั�ณิระ หว่ั�งเวัล�ขีอง พ็ฤติกรรมัเน่อยนิ�งและภั�วัะก�รเสีำยชีวิัต แสำดงถ่งค์วั�มัเสีำ� ยงที� ค่์อย ๆ เพิ็� มัขี่ �น จั�กประมั�ณิ 7.5-9 ชั� วัโมัง และยิ� ง ชัด เจั น เ ม่ั� อ มั � ก ก ว่ั � 9 . 5 ชั� วั โ มั ง พ็ฤติกรรมัเน่อยนิ�งที� 10 ชั�วัโมังและ 12 ชั� วั โ มั ง ใน แ ต่ ล ะ วััน เ ช่� อ มั โ ย ง กับ ค่์ � ค์วั�มัเสีำ�ยงในก�รเสีำยชีวิัตที�ส้ำงขี่ �น ที� 1.48 (1.22–1.79) และ 2.92 (2.24–3.83) ต�มัลำ�ดบั บทวิัเค์ร�ะห์อภิัมั�นอีกชิ�นหน่� ง ประเมิันก�รตอบสำนองต่อปริมั�ณิและ ร�ยง�นค์วั�มัเช่� อมัโยงที� ไม่ัอย่้บนเสำ�น ตรงเดียวักนั สำำ�หรบัเวัล�ขีองพ็ฤติกรรมั เน่อยนิ�งทั�งหมัดและภาวะกิารเสียชีวิต่ ทุกิสาเหตุ่ (RR ต่อ 1 ชั�วัโมัง/วันั = 1.01 (1.00–1.01) สำำ�หรบั ≤ 8 ชั�วัโมัง/วันั และ 1.04 (1.03–1.05) สำำ�หรบั > 8 ชั�วัโมัง/ วันัที� เขี� ถง่) และภาวะกิารเสียชีวิต่จากิ โรคหลอดุเล่อดุหวัใจ (RR= 1.01 (0.99– 1.02) สำำ�หรบั ≤ 6 ชั�วัโมัง/วันั และ RR= 1.04 (1.03–1.04) สำำ�หรบั > 6 ชั�วัโมัง/ วันั) หลงัจั�กก�รปรบักิจักรรมัท�งก�ย (87) ในง�นวิัจัยัชิ �นเดียวักนันี� มีัค์วั�มั เช่�อมัโยงต่อก�รตอบสำนองต่อปริมั�ณิ เป็นเสำ�นตรงเล็กระหว่ั�งโรคเบาหวาน ชนิดุที� 2 กบัพ็ฤติกรรมัเน่อยนิ�งโดยรวัมั (1.01 (1.00– 1.01)) เม่ั�อปรบักิจักรรมั ท�งก�ยและก�รด้โทรทศัน ์(1.09 (1.07– 1.12)) (87) โดยรวัมัแล�วั หลกัฐ�นสำนบัสำนุนว่ั� พ็ฤติกรรมัเน่อยนิ�งในปริมั�ณิมั�กเช่�อมั- โ ยง กับ ผู้ ล ลัพ็ ธิ ์ท�ง สุำ ขี ภั� พ็ ที� แ ย่ ลง และมีัหลักฐ�นเพี็ยงพ็อที� จัะสำนับสำนุน ว่ั� ก�รลดเวัล�ขีองพ็ฤติกรรมัเน่อย- นิ� ง ใ ห� น� อ ย ล ง จั ะ ล ด ค์ วั � มั เ สีำ� ย ง ต่ อ สุำขีภั�พ็ อย่�งไรก็ดี ก�รให�ตัวัแปรที� เหมั�ะสำมัว่ั�ค์วัรจัะประเมิันพ็ฤติกรรมั เน่อยนิ�งอย่�งไรในบทปริทศันน์ั�น ๆ (ผู่้�น เวัล�นั� งที� มั�จั�กก�รร�ยง�นผู้ลด�วัย ตนเอง เวัล�ในก�รด้โทรทศัน ์ หร่อก�ร ประเมิันด�วัยอุปกรณิห์ร่อเค์ร่�องวัดัค์วั�มั เร่ง) และค์วั�มัเป็นไปได�ที� ขีีดจัำ�กดัขีอง เวัล�ที�มีัพ็ฤติกรรมัเน่อยนิ�งอ�จัจัะหล�ก- หล�ยไปต�มัผู้ลลพั็ธิท์�งสุำขีภั�พ็ต่�ง ๆ ด�วัยระดบัขีองกิจักรรมัท�งก�ยตั�งแต่ ป � น ก ล � ง ไ ป จั น ห นั ก แ ล ะ ก ลุ่ มั ป ร ะ ช� ก ร ก ลุ่ มั ย่ อ ย ไ ม่ั มีั ห ลัก ฐ � น เพี็ยงพ็อที� จัะกำ�หนดค์ำ�แนะนำ�เร่� อง เวัล� (ระบุเวัล�) ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 62 นอกจั�กปริมั�ณิทั�งหมัดขีองพ็ฤติกรรมั เน่อยนิ�งแล�วั มีัก�รทบทวันหลกัฐ�นเกี�ยวั กบัร้ปแบบที�พ็ฤติกรรมัเน่อยนิ�งพ็อกพ้็น ขี่ �นด�วัย อย่�งไรก็ต�มั ยงัมีัหลกัฐ�นจัำ�นวัน จัำ�กดัที�จัะสำร� งขี�อแนะนำ�เกี�ยวักบัค์วั�มัถี� และ/หร่อระยะเวัล�ขีองก�รหยุดพ็กัใน ก�รทำ�พ็ฤติกรรมัเน่อยนิ�ง ค์ณะทำ�ง�น GDG สำรุปว่� • ไม่ัมีัหลกัฐ�นเพี็ยงพ็อที�จัะกำ�หนดขี�อ แนะนำ�ต�มัปริมั�ณิ (ต�มัระยะเวัล�) เกี�ยวักบัพ็ฤติกรรมัเน่อยนิ�ง • ไม่ัมีัหลกัฐ�นเพี็ยงพ็อที�จัะกำ�หนดขี�อ แนะนำ�เร่�องค์วั�มัถี� และ/หร่อ ระยะเวัล� หยุดพ็กัในก�รทำ�พ็ฤติกรรมัเน่อยนิ�ง ค์ว�มัสำมััพนัธิ์ผ์นัแปรติ�มัประเภทและ ข้อบเข้ติข้องพฤติิกรรมัเนือยนิ�งหรือไม่ั ขีอบเขีตหร่อชนิดขีองพ็ฤติกรรมั เน่อยนิ�งที�ต่�งกนับ�งชนิดอ�จัจัะเป็นภัยั กว่ั�ชนิดอ่�น ๆ ทั�งในส่ำวันขีองก�รเช่�อมัโยง ต่อกนัโดยตรงและค์วั�มัเป็นไปได�ที�จัะ หักล� งเวัล�ที� ค์วัรใช�กับกิจักรรมัท�ง ก�ย ที� มีัผู้ลดีต่อสุำขีภั�พ็มั�กกว่ั� แมั�ว่ั� ง�นวิัจััยเร่� องพ็ฤติกรรมัเน่อยนิ� งจัะ เพิ็�มัมั�กขี่ �นอย่�งรวัดเร็วั แต่มีัหลกัฐ�น อย่้จัำ�กดัที� เปรียบเทียบค์วั�มัเช่�อมัโยง ระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งต่�งชนิดกนั และผู้ลลัพ็ธิท์�งสุำขีภั�พ็ที� ต่�งกันไป ตวััอย่�งเช่น ง�นวิัจัยับ�งชิ�นร�ยง�นผู้ล ที� น่�เช่� อถ่อยิ� งขี่ �นเกี� ยวักับพ็ฤติกรรมั เน่อยนิ�งที�วัดัขีณิะด้โทรทศันเ์ปรียบเทียบ กับเวัล�ที� นั� งทั�งหมัด (87) นี� อ�จัเป็น เพ็ร�ะค์วั�มัผิู้ดพ็ล�ดจั�กก�รวััดที� แตกต่�งกันหร่อตัวัวััดที� เหล่ออย่้ ที� เช่�อมัโยงกบัก�รวัดัแบบร�ยง�นตนเอง และเค์ร่�องม่ัอต่�ง ๆ ณิ ขีณิะนี� ยงัไม่ัมีั หลักฐ�นเพี็ยงพ็อที� จัะกำ�หนดค์วั�มั เ ช่� อ มั โ ยง กับ ผู้ ล ลัพ็ ธิ ์ท � ง สุำ ขี ภั � พ็ ที� แตกต่�งกนั และสิำ�งที�อ�จัผู้นัแปรต�มั กลุ่มัประช�กรย่อย จัำ�นวันง�นวิัจัยัที� ใช�เค์ร่� องม่ัอใน ก�รวัดักิจักรรมัท�งก�ยและเวัล�ในก�ร ทำ�พ็ฤติกรรมัเน่อยนิ� งต่อผู้ลลพั็ธิด์� น สุำขีภั�พ็มีัเพิ็� มัมั�กขี่ �น อย่�งไรก็ต�มั อ�จัมีัก�รจัดัประเภัทผิู้ดจั�กก�รวัดัเวัล� ในก�รทำ�พ็ฤติกรรมัเน่อยนิ�งเม่ั�อวัดัด�วัย อุปกรณิเ์พ็ร�ะตำ�แหน่งที� วั�งอุปกรณิ ์ เหล่�นี� (เช่น ขี�อม่ัอ รอบเอวั) ยงัไม่ัสำ�มั�รถ แยกแยะท่�ท�งต่�ง ๆ ได� (เช่น ก�รนอน ก�รนั�ง ก�รย่นเฉย ๆ) ง�นวิัจัยัในอน�ค์ต ที�ใช�ก�รร�ยง�นที�สำอดค์ล�องกนัและวิัธีิที� แยกแยะท่�ท�งได� จัะช่วัยเสำริมัสำร� งค์วั�มั ร้�เร่�องร้ปแบบขีองพ็ฤติกรรมัเน่อยนิ�ง ค์ณะทำ�ง�น GDG สำรุปว่� • ไม่ัมีัหลกัฐ�นเพี็ยงพ็อที�จัะให�ค์ำ�แนะนำ� เร่�องประเภัทและขีอบเขีตที�แตกต่�ง กนัขีองพ็ฤติกรรมัเน่อยนิ�ง ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) 63 ระดบัข้องกิจกรรมัท�งก�ยเปลี� ยน แปลงผลกระทบข้องพฤติิกรรมัเนือย นิ�งต่ิอก�รเสีำยชี้วิติไดห้รือไม่ั ค์ วั � มั สำ น ใ จั ที� เ พิ็� มั มั � ก ขี่ �น ต่ อ ผู้ลกระทบขีองพ็ฤติกรรมัเน่อยนิ� งต่อ ผู้ลลัพ็ธิด์� นสุำขีภั�พ็ได�กระตุ�นให�เกิด ก�รค์�นห�ค์วั�มัสำมััพ็นัธิที์�อ�จัเช่�อมัโยง ระหว่ั�งระดบักิจักรรมัท�งก�ยที� ต่�ง กันและระดับขีองพ็ฤติกรรมัเน่อยนิ� ง จั�กวิัจััยที� มีัอย่้ มีัหลกัฐ�นที� เช่� อถ่อได� ป�นกล�งว่ั� ค์วั�มัสำมััพ็นัธิร์ะหว่ั�งพ็ฤติ- กรรมัเน่อยนิ�งและกิารเสียชีวิต่ทุกิสาเหตุ่ กิารเสียชีวิต่จากิโรคหลอดุเล่อดุหวัใจ แ ล ะ กิ า ร เ สี ย ชี วิ ต่ จ า กิ โ ร ค ม ะ เ ร็ ง แปรไปต�มัปริมั�ณิกิจักรรมัท�งก�ย ที� ระดับป�นกล�งจันถ่งระดับหนัก (8, 9, 35) ผู้ลก�รศก่ษ�โดยรวัมัแสำดงให� เห็นว่ั� ผู้ลกระทบจั�กพ็ฤติกรรมัเน่อย- นิ�งมีัมั�กกว่ั�ในผู้้�ที�ทำ�กิจักรรมัท�งก�ย ระดบัป�นกล�งจันถ่งหนักในปริมั�ณิ น�อย หร่อกล่�วัอีกท�งหน่� ง กิจักรรมั ท�งก�ยระดับป�นกล�งหร่อหนักใน ปริมั�ณิส้ำงจัะสำ�มั�รถบรรเท�ผู้ลเสีำยต่อ สุำขีภั�พ็ที�เกี�ยวัโยงกบัพ็ฤติกรรมัเน่อยนิ�ง ในระดบัที�ส้ำงขี่ �นได� ค์วั�มัเสีำ�ยงที� เช่�อมัโยงระหว่ั�งเวัล� ในก�รทำ�พ็ฤติกรรมัเน่อยนิ� งและก�ร เ สีำยชีวิัตในทุกสำ�เหตุนั�นชัดเจันขี่ �น เม่ั�อมีัก�รทำ�กิจักรรมัท�งก�ยในระดบัตำ� กว่ั�มั�กกว่ั�ระดบัส้ำงกว่ั� (35) ในบท วิัเค์ร�ะหอ์ภิัมั�นที�สำอดค์ล�องกนั อีค์ลุนด ์ และค์ณิะได�ตรวัจัสำอบผู้ลกระทบที�มีัร่วัมั กนัและผู้ลกระทบที�แยกเป็นชั�น ๆ จั�ก ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) พ็ฤติกรรมัเน่อยนิ�งและกิจักรรมัท�งก�ย กบัภั�วัะก�รเสีำยชีวิัตทุกสำ�เหตุในผู้้�ช�ย และผู้้�หญิ่งมั�กกว่ั� 1 ล� นร�ย และแสำดง ให�เห็นว่ั� ค์วั�มัเช่�อมัโยงนั�นต่�งกนัออกไป ขี่ �นอย่้กบัระดบัขีองก�รทำ�กิจักรรมัท�ง- ก�ย (9) ก�รวิัเค์ร�ะหน์ั�นใช�ช่วังขี�อม้ัล ค์วัอไทลข์ีองพ็ฤติกรรมัเน่อยนิ�ง (ก�รนั�ง) และช่วังขี�อม้ัลค์วัอไทลข์ีองกิจักรรมัท�ง ก�ยระดบัป�นกล�งจันถง่หนกั และพ็บว่ั� เม่ั�อเปรียบเทียบกบัร�ยก�รอ� งอิง (< 4 ชั�วัโมังขีองก�รนั�งต่อวันัและค่์�ค์วัอไทล ์ ส้ำงสุำดสำำ�หรับกิจักรรมัท�งก�ยระดับ ป�นกล�งจันถ่งหนัก [> 35.5 MET- ชั� วัโมัง/ สำัปด�ห์]) ไม่ัมีัค์วั�มัเสีำ� ยงต่อ ก�รเสีำยชีวิัตที� เพิ็� มัส้ำงขี่ �นระหว่ั�งก�ร ติดต�มัอ�ก�รกับผู้้�ที� นั� งมั�กกว่ั� 8 ชั�วัโมังต่อวันั แต่ยงัร�ยง�นว่ั�มีัก�รทำ� กิจักรรมัมั�กกว่ั� 35.5 ชั�วัโมัง (MET hour) ต่อสำปัด�ห ์(HR= 1.04 [95% CI: 0.99 to 1.10]) ในท�งกลบักนั ผู้้�ที�นั� งน�อยที� สุำด (< 4 ชั�วัโมัง/วันั) และอย่้ในช่วังค์วัอไทล ์ ขีองก�รทำ�กิจักรรมัท�งก�ยที�ตำ� ที� สุำด (< 2.5 MET-ชั�วัโมัง/สำปัด�ห)์ จัะมีัค์วั�มั เสีำ�ยงต่อก�รเสีำยชีวิัตเพิ็�มัขี่ �นอย่�งมีันัย สำำ�ค์ญั่ระหว่ั�งก�รติดต�มัอ�ก�ร (HR= 1.27 [95% CI: 1.22 to 1.31]) ง�นวิัจัยั สำรุปว่ั� ระดับขีองกิจักรรมัท�งก�ย ทั�งระดับป�นกล�งและหนักเป็นเวัล� ประมั�ณิ 60-75 น�ทีต่อวััน (ช่วัง ค์วัอไทลส้์ำงสุำด) อ�จัลดและกระทั�งจัำ�กดั ค์วั�มัเช่� อมัโยงที� เป็นอนัตร�ยระหว่ั�ง พ็ฤติกรรมัเน่อยนิ� งและผู้ลลัพ็ธิต่์อ สุำขีภั�พ็ได� ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 64 ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) พฤ ติกิ รัรั มเ นือ ยนื �งม �กิ ข้� นื กิิจกิรัรัมท�งกิ�ยท่�ม�กิขึ้�นื เวัล�ข้องพฤติิกิรัรัมเนืือยนิื� งลด็ลง และกิิจกิรัรัมท�งกิ�ยม�กิขึ้�นื คำวั�มเส่ำ�ยงสูำง คำวั�มเส่ำ�ยงติำ� เพิ�มกิ�รัออกิกิำ�ลังกิ�ยลด็เวัล�ในืกิ�รัทำ�พฤติิกิรัรัมเนืือยนิื�ง ร้ปที� 2: ค์ว�มัสำมััพนัธิ์ ์ ระหว่�งระดบัพฤติิกรรมัเนือยนิ�ง และกิจกรรมัท�งก�ย ประยุกตจ์ั�ก PAGAC ค์วั�มัสำมััพ็นัธิร์ะหว่ั�งระดบัขีอง พ็ฤติกรรมัเน่อยนิ�งและกิจักรรมัท�งก�ย ในระดบัป�นกล�งไปจันถ่งหนกัได�สำรุป ไวั�ในก�รทบทวันวัรรณิกรรมัอย่�งเป็น ระบบโดย PAGAC (35) ต�มัที� แสำดง ไวั�ในร้ปที� 2 ก�รวิัจััยอีกฉบบัเม่ั� อไม่ัน�นมั�นี� ได�สำร� งหลกัฐ�นฉบบัใหม่ัที�ตรวัจัสำอบ ค์วั�มัเช่� อมัโยงแบบเดิมักับก�รเสีำย ชี วิั ต ที� มีั สำ � เ ห ตุ เ ฉ พ็ � ะ แ ล ะ แ สำ ด ง ผู้ลก�รศ่กษ�ที� เหม่ัอนกัน (8) ในบท วิัเค์ร�ะหอ์ภิัมั�นจัำ�นวันมั�กที�สำอดค์ล�อง กนั (ง�นวิัจัยั 9 ชิ �น n = 850,000 กิาร เ สียชีวิต่จากิโรคหลอดุเล่อดุหัวใจ และง�นวิัจััย 8 ชิ �น n= 777,000 ภั�วัะก�รเสีำยชีวิัตจั�กโรค์มัะเร็ง) ผู้ล ปร�กฎว่ั�ก�รทำ�กิจักรรมัท�งก�ยที�ระดบั ป�นกล�งและหนกัในระดบัที�ส้ำงขี่ �น ทำ�ให� ค์วั�มัเสีำ�ยงต่อภั�วัะก�รเสีำยชีวิัตจั�กโรค์ หวััใจัเม่ั�อมีัพ็ฤติกรรมัเน่อยนิ�งในระดบัส้ำง ลดน�อยลง ไม่ัว่ั�จัะวัดัด�วัยเวัล�ที�นั�งเฉย ๆ หร่อเวัล�ด้โทรทศัน ์(8) ง�นวิัจัยัแสำดงว่ั� ในบุค์ค์ลที�นั�งนิ�งมั�กกว่ั� 8 ชั�วัโมังต่อวันั มีัค์วั�มัเช่�อมัโยงกบัค์วั�มัเสีำ�ยงต่อก�รเสีำย ชีวิัตที� เพิ็� มัขี่ �น ยกเวั�นในช่วังค์วัอไทลที์� ค์ล่องแค์ล่วัที� สุำดที� ค์วั�มัเช่� อมัโยงนี�จัะ ลดลง และเจั�ะจังลงไปกว่ั�นั�น อนัตร�ย จั�กก�รเสีำยชีวิัตด�วัยโรค์หลอดเล่อด หัวัใจัจัะส้ำงกว่ั�ถ่งร�อยละ 32 สำำ�หรับ ผู้้�ที� นั� งมั�กกว่ั� 8 ชั� วัโมังต่อวันัเปรียบ เทียบกบักลุ่มัอ� งอิง (< 4 ชั�วัโมังต่อวันั) (p สำำ�หรับแนวัโน�มั < 0.001) ผู้ลก�ร ทดลองชดัเจันน�อยลงแต่ยงัมีันยัสำำ�ค์ญั่ เม่ั�อเทียบกบักลุ่มัอ� งอิงในช่วังค์วัอไทล ์ อ่�นขีองก�รทำ�กิจักรรมัท�งก�ย (ค์วัอไทล ์ ที� 2 HR= 1.11 [95% CI: 1.03 to 1.20] ค์วัอไทลที์� 3 HR= 1.14 [95% CI: 1.03 to 65 ผูู้้ใหญ่ (อ�ยุ 18-64 ปี) 1.26]) มีัก�รสำังเกตค์วั�มัเช่� อมัโยงที� ค์ล� ยค์ลง่กนัระหว่ั�งเวัล�ในก�รด้โทร- ทศันแ์ละก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อด หัวัใจัระหว่ั�งก�รทำ�กิจักรรมัท�งก�ย ที� ระดับป�นกล�งกับหนัก (8) ค์วั�มั เช่� อมัโยงระ หว่ั�งกิารเสียชีวิต่จากิ ม ะ เ ร็ ง นั�น ผู้ สำ มั ผู้ สำ � น กัน มั � ก ก ว่ั � แมั�ว่ั�จัะแสำดงให�เห็นว่ั� โดยทั�วัไปแล�วัก�ร ทำ�กิจักรรมัท�งก�ยในระดบัที� ส้ำงขี่ �นจัะ ลดภัยัอนัตร�ยจั�กพ็ฤติกรรมัเน่อยนิ�ง เม่ั�อประเมิันจั�กเวัล�ที�นั�งเฉย ๆ ทั�งหมัด จั�กหลกัฐ�นนี� เป็นที�ยอมัรบัว่ั�ค์วัร แนะนำ�ให�ทำ�กิจักรรมัท�งก�ยที� ระดบั ป�นกล�งและหนกัในระดบัที� ส้ำงขี่ �นกบั กลุ่มัค์นที�มีัพ็ฤติกรรมัเน่อยนิ�งในระดบัส้ำง และผู้ลดีที� ได�จัะมีัมั�กกว่ั�ค์วั�มัเสีำ�ยง ค์ณะทำ�ง�น GDG สำรุปว่� • มีัหลกัฐ�นที� เช่� อถ่อได�ป�นกล�งว่ั� ค์วั�มัเช่� อมัโยงระหว่ั�งพ็ฤติกรรมั เน่อยนิ� งและก�รเสีำยชีวิัตทุกสำ�เหตุ ก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อดหวััใจั และก�รเสีำยชีวิัตจั�กมัะเร็งผู้นัแปรไป ต�มัปริมั�ณิในก�รทำ�กิจักรรมัท�ง- ก�ยทั�งระดบัป�นกล�งและหนกั • กิจักรรมัท�งก�ยในระดบัป�นกล�ง จันถง่หนกัในปริมั�ณิที�ส้ำงขี่ �นสำ�มั�รถ ลดอนัตร�ยต่อผู้ลลพั็ธิท์�งสุำขีภั�พ็ จั�กพ็ฤติกรรมัเน่อยนิ�งได� ข้้อัแนะนำา >> > > > ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 66 ในผู้้�ส้ำงอ�ยุ กิจักรรมัท�งก�ยเอ่ �อประโยชน์ต่อสุำขีภั�พ็ ดังต่อไปนี� ลดโอก�สำในก�ร เสีำยชีวิัตทุกสำ�เหตุ ก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อดหัวัใจั ก�รเกิดโรค์ค์วั�มัดนัโลหิตส้ำง เกิดโรค์มัะเร็งเฉพ็�ะที� ก�รเกิดโรค์เบ�หวั�นชนิดที� 2 สุำขีภั�พ็จิัต (อ�ก�รกงัวัลและซม่ัเศร� ลดลง) สุำขีภั�พ็ด� นก�รรบัร้� และก�รนอนหลบั ก�รวัดัภั�วัะโรค์อ�วันอ�จัจัะดีขี่ �นได� กิจักรรมัท�งก�ย จัะช่วัยป้องกนัก�รหกล�มัและอ�ก�รบ�ดเจ็ับที�เกี�ยวัเน่�องกบัก�รหกล�มั และรวัมัถง่ช่วัยป้องกนั สุำขีภั�พ็กระด้กและก�รทำ�ง�นขีองร่�งก�ยที�ถดถอยไป สำำ�หรบัผู้้�ส้ำงอ�ยุ กิจักรรมัท�งก�ยสำ�มั�รถเป็นส่ำวันหน่�งขีองก�รสำนัทน�ก�ร และก�รพ็กัผู่้อน (ก�รละเล่น เกมัสำ ์กีฬ� หร่อก�รออกกำ�ลงัก�ยที�วั�งแผู้นไวั�) ก�รเดินท�ง (เดินท�งด�วัยล�อ ก�รเดิน และก�รปั� นจักัรย�น) ก�รทำ�ง�น หร่อทำ�ง�นบ� น ในปริบท ประจัำ�วันัเกี�ยวักบัก�รทำ�ง�น ก�รเรียน บ� น หร่อสำภั�พ็แวัดล�อมัในชุมัชน • ทำ�กิจักรรมัท�งก�ยบ� งดีกว่ั�ไม่ัทำ�อะไรเลย • ห�กผู้้�ส้ำงอ�ยุไม่ัสำ�มั�รถทำ�ต�มัค์ำ�แนะนำ�ได� ก�รทำ�กิจักรรมัท�งก�ยบ� งจัะให�ประโยชน ์ แก่สุำขีภั�พ็ • ผู้้�ส้ำงอ�ยุค์วัรเริ�มัทำ�กิจักรรมัท�งก�ยในระดบัเบ�แล�วัค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มัหนกัหน่วัง และระยะเวัล�ขี่ �น • ผู้้�ส้ำงอ�ยุค์วัรจัะเค์ล่�อนไหวัให�มั�กเท่�ที�ค์วั�มัสำ�มั�รถท�งก�ยจัะอำ�นวัย และปรบัระดบัสำำ�หรบั ก�รทำ�กิจักรรมัท�งก�ยต�มัระดบัขีองค์วั�มัแข็ีงแรงขีองตน ผูู้้สูำงอ�ยุ (อ�ยุ 65 ปีขึ้�นืไป) ข้้อแนืะนืำ�ด้็�นืกิิจกิรัรัมท�งกิ�ย แนะนำ�ให:้ ผ้ส้้ำงอ�ยุค์วรทำ�กิจกรรมัท�งก�ยเป็นประจำ� แนะนำ�อย่�งยิ�ง หลกัฐ�นน่�เช่�อถ่อได�ป�นกล�ง ผ้ส้้ำงอ�ยุค์วรทำ�กิจกรรมัท�งก�ยแบบแอโร- บิกที�ระดบัป�นกล�งอย่�งนอ้ย 150-300 น�ที หรืออย่�งนอ้ย 75-150 น�ทีที�ระดบัหนกั หรือก�รผสำมัผสำ�นทั�ง 2 ระดบัอย่�งเท่�เทียมั กนัติลอดทั�งสำปัด�ห ์เพื�อสุำข้ภ�พที�แข็้งแรง แนะนำ�อย่�งยิ�ง หลกัฐ�นน่�เช่�อถ่อได�ป�นกล�ง ผ้ส้้ำงอ�ยุค์วรทำ�กิจกรรมัสำร�้งค์ว�มัแข็้งแรง ใหก้บักล�้มัเนื �อ ที�มีัก�รใช้ก้ล�้มัเนื �อหลกัทุก ส่ำวน ในระดบัป�นกล�งข้้ �นไป อย่�งนอ้ย 2 วนัต่ิอสำปัด�หห์รือมั�กกว่� เนื�องจ�กกิจกรรมั เหล่�นี �จะส่ำงผลดีต่ิอสุำข้ภ�พมั�กยิ�งข้้ �น แนะนำ�อย่�งยิ�ง หลกัฐ�นน่�เช่�อถ่อได�ป�นกล�ง ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ ก�รทำ�กิจกรรมัท�งก�ยในแต่ิละสำปัด�ห ์ผ้ส้้ำง อ�ยุค์วรทำ�กิจกรรมัท�งก�ยหล�ย ๆ ส่ำวน ที�ระดบัป�นกล�งข้้ �นไป เพื�อเนน้ก�รสำร�้งสำมั ดุลก�รทำ�ง�นและฝึึกค์ว�มัแข็้งแรงอย่�งนอ้ย 3 วนัต่ิอสำปัด�ห ์เพื�อเสำริมัค์ว�มัสำ�มั�รถในก�ร ทำ�ง�นข้องร่�งก�ยและป้องกนัก�รหกลม้ั แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อได�ป�นกล�ง ผ้ส้้ำงอ�ยุสำ�มั�รถเพิ�มัก�รทำ�กิจกรรมัท�งก�ย แบบแอโรบิกที�ระดบัป�นกล�งใหม้ั�กกว่� 300 น�ที หรือที�ระดบัหนกัมั�กกว่� 150 น�ที หรือ ก�รผสำมัผสำ�นที�เท่�เทียมักนัท ั�ง 2 ระดบั ติลอด สำปัด�หเ์พื�อสำร�้งผลลพัธิ์ท์�งสุำข้ภ�พที�ดีข้้ �น แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อได�ป�นกล�ง 67ข้้อัแนะนำา ผูู้้สูำงอ�ยุ (อ�ยุ 65 ปีขึ้�นืไป) หลกัฐ�นสำนบัสำนุนและเหตุิผล สำำ�หรบัขี�อแนะนำ�เพ่็�อผู้้�ส้ำงอ�ยุเหล่�นี� ก�รรวับรวัมัหลกัฐ�นอย่�งค์รอบค์ลุมัที�จัดัทำ�โดย PAGAC (35) ถ้กนำ�มั�ใช�และปรบัปรุง บทปริทศัน ์15 ฉบบันั�นตรงต�มัเกณิฑ์ก์�รค์ดัเขี� และบอก กล่�วัถง่ก�รตรวัจัสำอบค์วั�มัเช่�อมัโยงระหว่ั�งกิจักรรมัท�งก�ยและผู้ลที� เกี�ยวัเน่�องกบัสุำขีภั�พ็ที� เจั�ะจังกบัผู้้�ส้ำงอ�ยุ (ก�รป้องกนัก�รหกล�มั อ�ก�รบ�ดเจ็ับเกี�ยวัเน่�องกบัก�รล�มั หน� ที�ท�งก�ยภั�พ็ ค์วั�มัเปร�ะบ�ง และโรค์กระด้กพ็รุน) หลกัฐ�นเกี�ยวักบัก�รป้องกนัก�รหกล�มัใช�และปรบัปรุงขี�อม้ัลจั�กบทปริทศันเ์ป็นระบบจั�ก ค์วั�มัร่วัมัม่ัอ Cochrane พ็.ศ. 2562 โดยเชอริงตนัและค์ณิะ (42) ด�วัยหลกัฐ�นที�ตีพิ็มัพ็จ์ั�กวันัที� ค์�นห�วันัสุำดท� ยจั�กบทปริทศันต์�นฉบบั จันถง่พ็ฤศจิัก�ยน พ็.ศ. 2562 (ง�นวิัจัยัใหม่ั 9 ชิ �น) ก�รค์�นห� บทปริทศันอ์ย่�งเป็นระบบที� มีัอย่้เกี�ยวักบัโรค์กระด้กพ็รุนและก�รส้ำญ่เสีำยมัวัลกล� มัเน่�อในผู้้�ส้ำง อ�ยุซ่�งจัดัทำ�ในฐ�นขี�อม้ัล PubMed สำำ�หรบับทปริทศันที์�ตีพิ็มัพ็จ์ั�ก พ็.ศ. 2551 จันถง่พ็ฤศจิัก�ยน พ็.ศ. 2562 และระบุว่ั�ไม่ัมีัรีวิัวัฉบบัใหม่ัและง�นวิัจัยัใหม่ั 8 ฉบบั ขี�อม้ัลเต็มัเร่�องวิัธีิวิัจัยั ก�รแยกส่ำวันขี�อม้ัล และชุดขี�อม้ัลหลกัฐ�นมีัอย่้ที�ภั�ค์ผู้นวักบนเว็ัปไซต ์ : ชุดขี�อม้ัลหลกัฐ�น8 8 ข้้อม่ัลออนไลน์อย่� ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ในผ้ส้้ำงอ�ยุ (อ�ยุ 65 ปีข้้ �นไป) ค์ว�มั สำมััพนัธิ์ร์ะหว่�งกิจกรรมัท�งก�ยและ ผลที�เกี�ยวเนื�องกบัสุำข้ภ�พคื์ออะไร ชุดหลกัฐ�นเบ่ �องต�นสำำ�หรบัก�ร ประเมิันค์วั�มัเช่�อมัโยงระหว่ั�งกิจักรรมั ท�งก�ยและผู้ลลัพ็ธิต่์อสุำขีภั�พ็ เช่น ก � ร เ สีำ ย ชี วิั ต จั � ก ทุ ก สำ � เ ห ตุ แ ล ะ ก�รเ สีำยชีวิัตที� มีัสำ�เหตุเฉพ็�ะ โรค์ หลอดเล่อดหัวัใจั เบ�หวั�นชนิดที�สำอง ก�รเกิดมัะเร็ง โรค์อ�วัน สุำขีภั�พ็จิัต และ ผู้ลต่อก�รรบัร้�ในประช�กรผู้้�ส้ำงอ�ยุ ซ่�ง เป็นสิำ�งตีพิ็มัพ็ท์�งวิัทย�ศ�สำตรฉ์บบัเดียวั กบัที�ตรวัจัท�นและทบทวันสำำ�หรบัประ- ช�กรผู้้�ใหญ่่ใจัค์วั�มัขีองหลกัฐ�นเดิมั เป็นที�ยอมัรบัและนำ�มั�เกี�ยวัโยงกบัผู้้�ส้ำง อ�ยุเพ็ร�ะง�นวิัจัยัส่ำวันใหญ่่ไม่ัมีัเกณิฑ์ ์ กำ�หนดอ�ยุขีั�นกว่ั�และรวัมัผู้้�ใหญ่่อ�ยุ 65 ปีไวั�ด�วัย มีั ก � ร จัั ด ทำ � บ ท ป ริ ทัศ น์ขี อ ง หลักฐ�นเพิ็� มัเติมัเพ่็� อตรวัจัสำอบและ อธิิบ�ยเกี�ยวักบัค์วั�มัเช่�อมัโยงระหว่ั�ง กิจักรรมัท�งก�ยและผู้ลเกี�ยวัเน่� องต่อ สุำขีภั�พ็ที� เจั�ะจังผู้้�ส้ำงอ�ยุ รวัมัทั�งก�ร ป้องกนัก�รหกล�มั อ�ก�รบ�ดเจ็ับจั�กก�ร หกล�มั หน� ที�ท�งก�ยภั�พ็ ค์วั�มัเปร�ะบ�ง และโรค์กระด้กพ็รุน สำมัรรถภั�พ็ท�งร่�งก�ยที�ถดถอย สำำ�หรับผู้้�ส้ำงอ�ยุมัักจัะเกิดในร้ปแบบ ขีองก�รหกล�มัและอ�ก�รบ�ดเจ็ับจั�ก ก�รหกล�มั ซ่� งอ�จัมีัผู้ลที�ร� ยแรง ก�ร หกล�มัจั�กอุบติัเหตุมั�จั�กก�รผู้สำมัผู้สำ�น กับ ปั จั จััย ภั � ย น อ ก ( สิำ� ง แวั ด ล�อ มั ) และปัจัจัยัภั�ยใน (ตวััอย่�งเช่น ค์วั�มัผิู้ด ปรกติขีองกล� มัเน่�อติดกระด้กหร่อระบบ ประสำ�ท) หลักฐ�นบ่งชี�ว่ั�กิจักรรมั ท�งก�ย โดยเฉพ็�ะอย่�งยิ� งขีองก�ร ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 68 ทำ � กิจั ก ร ร มั ท� ง ก� ย ที� ห ล� ก ห ล� ย ซ่� ง ร วั มั ถ่ ง กิ จั ก ร ร มั ท � ง ก � ย แ บ บ สำ ร� ง สำ มั ดุ ล สำ ร� ง ค์ วั � มั แ ข็ี ง แ ร ง ฝึึ ก ค์ วั � มั อ ด ท น ก � ร เ ค์ ล่� อ น ที� เ ร็ วั และก�รฝึึกก�รเค์ล่�อนไหวั ซ่�งเช่�อมัโยง กบัอตัร�ก�รหกลม้ัที�ลดลงและอ�ก�ร เสีำ�ยงจั�กก�รบ�ดเจ็บจ�กก�รหกลม้ัใน ผู้้�ส้ำงอ�ยุ หลกัฐ�นล่�สุำดชี�ว่ั� กิจักรรมัท�ง ก�ยอ�จัลดอตัร�ก�รหกล�มัได�มั�กถ่ง ร�อยละ 23 (อตัร�รวัมั (RaR) 0.77 [95% CI: 0.71 to 0.83]) ในผู้้�ส้ำงอ�ยุ ซ่�งสำ�มั�รถลด ค์วั�มัเสีำ� ยงขีองก�รบ�ดเจ็ับจั�กก�ร หกล�มัได�อย่�งมีันยัสำำ�ค์ญั่ รวัมัถง่ก�รล�มั รุนแรงที� มีัผู้ลทำ�ให�กระด้กหักบ�ดเจ็ับ ที� ศีรษะอย่�งรุนแรง แผู้ลเปิดบ�ดเจ็ับที� เน่�อเย่�ออ่อนหร่ออ�ก�รบ�ดเจ็ับอ่�น ๆ ที� ต�องก�รก�รด้แลท�งก�รแพ็ทยห์ร่อเขี� โรงพ็ย�บ�ล (42) หลกัฐ�นนี�สำอดค์ล�อง และยำ � ผู้ลก�รศ่กษ�ในบทปริทศันฉ์บบั อ่�น (35) หลงัจั�กที� ถ่งจุัดที� ส้ำงที� สุำดในช่วัง แรกวัยัผู้้�ใหญ่่ กล� มัเน่�อและมัวัลกระด้ก มีัแนวัโน�มัที� จัะลดลงเม่ั� ออ�ยุมั�กขี่ �น (ตวััอย่�ง เช่น ก�รส้ำญ่เสีำยมัวัลกล� มัเน่�อ และภั�วัะกระด้กพ็รุน) และอ�จัเช่�อมัโยง กบัค์วั�มัแข็ีงแรงที�ลดลงและสำมัรรถภั�พ็ ท�งก�ย หลกัฐ�นชี�ให�เห็นว่ั� กิจักรรมั ท�งก�ยเป็นกิจัวัตัรนั�น พ็ฒัน�สำมัรรถ- ภ�พท�งร่�งก�ยและลดค์วั�มัเสีำ� ยง จั�กก�รส้ำญ่เสีำยที� เกี� ยวัเน่� องกับอ�ยุ ผูู้้สูำงอ�ยุ (อ�ยุ 65 ปีขึ้�นืไป) สำำ�หรบัสำมัรรถภั�พ็ท�งร่�งก�ยในผู้้�ส้ำง- อ�ยุ ผู้ลก�รศก่ษ�แสำดงให�เห็นถง่ผู้ลอนั เป็นประโยชนจ์ั�กสำมัดุลในก�รเค์ล่�อนที� (SMD= 1.10 [95% CI: 0.29 to 1.90]) ค์วั�มัแข็ีงแรงกล� มัเน่�อ (SMD= 1.13 [95% CI: 0.30 to 1.96]) ค์วั�มัย่ดหยุ่น (SMD= 1.22 [95% CI: 0.39 to 2.04]) และสำมัรรถภั�พ็ด� นก�รหมุันเวีัยน โลหิต (SMD= 1.48 [95% CI: 0.42 to 2.54]) (94) หลกัฐ�นยงัแสำดงอีกว่ั� กิจั กรรมัท�งก�ยในระดบัที� ส้ำงขี่ �นจัะทำ�ให� สุำขีภั�พ็กระด้กดีขี่ �นและป้องกันภั�วัะ กระด้กพรุนในผู้้�ส้ำงอ�ยุ (ขีน�ดขีองผู้ล ที�เป็นมั�ตรฐ�นรวัมั 0.21 [95% CI: 0.06 to 0.36]) (95) ก�รแทรกแซงขีองกิจักรรมั ท�งก�ยอ�จัทำ�ให�ค์วั�มัหน�แน่นขีองแร่ ธิ�ตุในกระด้กสำนัหลงัส่ำวันเอวัและกระด้ก โค์นขี�ส่ำวันค์อ (สำะโพ็ก) ดีขี่ �น ค์ณะทำ�ง�น GDG สำรุปว่� • มีั ห ลั ก ฐ � น ที� มีั ค์ วั � มั เ ช่� อ ถ่ อ ไ ด� ป�นกล�งว่ั� กิจักรรมัท�งก�ยทำ�ให� สำมัรรถภั�พ็ท�งก�ยดีขี่ �นและลดค์วั�มั เสีำ� ยงขีองก�รส้ำญ่เสีำยสำมัรรถภั�พ็ที� เกี�ยวัขี�องกบัอ�ยุ ในประช�กรส้ำงวัยั โดยทั�วัไป • มีัหลกัฐ�นที� มีัค์วั�มัน่�เช่� อถ่อตำ� ว่ั� ค์ วั � มั เ สีำ� ย ง สำำ � ห รับ ป ริ มั � ณิ แ ล ะ ประเภัทขีองกิจักรรมัท�งก�ยที� แนะนำ�สำำ�หรบัผู้้�ส้ำงอ�ยุอย่้ในระดบัตำ� และประโยชนมี์ัมั�กกว่ั� 69 มีัค์ว�มัเชื้� อมัโยงต่ิอก�รติอบสำนอง ต่ิอปริมั�ณ (ปริมั�ณ ระยะเวล� ค์ว�มัถี� ค์ว�มัหนกัหน่วง) หรือไม่ั หลักฐ�นแสำดงให� เห็นถ่งค์วั�มั สำมััพ็นัธิที์� แปรผู้กผู้นัระหว่ั�งกิจักรรมั ท�งก�ยที�กระทำ�โดยผู้้�ส้ำงอ�ยุและค์วั�มั เสีำ�ยงต่อขี�อจัำ�กดัด� นสำมัรรถภั�พ็ร่�ง- ก�ย โดยทั� วัไปแล�วั กิจักรรมัท�งก�ย ที� มั�กขี่ �น (ค์วั�มัถี� ระยะเวัล� และ/ หร่ อ ป ริ มั � ณิ ) นั�น เ ช่� อ มั โ ยง กับ ผู้ ล ประโยชนที์�มั�กขี่ �น หลกัฐ�นชี�ว่ั� ก�ร ออกกำ�ลงัก�ยแบบมีัแรงต� นแบบเน�น ค์วั�มัเร็วัที�เขี� ถง่ได�อย่�งรวัดเร็วั อ�จัจัะมีั ผู้ลเหน่อก�รออกกำ�ลงัก�ยแบบมีัแรง ต� นแบบเน�นค์วั�มัเร็วัป�นกล�งสำำ�หรบั ก�รพ็ัฒน�สำมัรรถภั�พ็ทั� วัไป (SMD= 0.41 [95% CI: 0.18 to 0.65]; และ SPPB (SMD= 0.52 [95% CI: 0.10 to 0.94])) (96) มีัหลักฐ�นจัำ�กัดที� จัะตรวัจัสำอบ ค์วั�มัสำมััพ็นัธิร์ะหว่ั�งก�รตอบสำนองต่อ ปริมั�ณิระหว่ั�งกิจักรรมัท�งก�ยและ ก�รป้องกนัก�รหกล�มั อย่�งไรก็ต�มั ผู้ล วิัจัยัส่ำวันใหญ่่สำร� งหลกัฐ�นสำนับสำนุนที� แสำดงก�รทดสำอบก�รทำ�กิจักรรมัท�ง- ก�ยที�ต่อเน่�อง 3 วันัต่อสำปัด�ห์ ค์ณะทำ�ง�น GDG สำรุปว่� • มีัหลักฐ�นที� เช่� อถ่อได�ส้ำงถ่งค์วั�มั สำมััพ็นัธิต่์อก�รตอบสำนองต่อปริมั�ณิ ในด� นตรงขี� มั ระหว่ั�งปริมั�ณิขีอง ก�รทำ�กิจักรรมัท�งก�ยแบบแอโรบิก และค์วั�มัเ สีำ� ยงต่อขี�อจัำ �กัดด� น สำมัรรถภั�พ็ร่�งก�ยในประช�กร ส้ำงวัยัโดยทั�วัไป ค์ว�มัสำมััพนัธิ์ผ์นัแปรติ�มัประเภทหรือ ข้อบเข้ติข้องกิจกรรมัท�งก�ยหรือไม่ั ใน ผู้้� ส้ำ ง อ � ยุ ก � ร ทำ � กิจั ก ร ร มั ท�งก�ยที� มีัก�รผู้สำมัผู้สำ�นระหว่ั�ง สำมัดุล ค์วั�มัแข็ีงแรง ค์วั�มัทนท�น ก�รเค์ล่�อนที� เร็วั และก�รออกกำ�ลงัเพ่็�อ ฝึึกก�รเค์ล่�อนไหวันั�น เช่�อมัโยงกบัอตัร� ก�รหกล�มัและค์วั�มัเสีำ�ยงจั�กก�รบ�ด- เจ็ับจั�กก�รหกล�มัที�ลดลง หลกัฐ�นจั�กง�นวิัจัยักลุ่มัทดลอง ที� มีัก�รค์วับคุ์มัแบบสุ่ำมั 11 ชิ �นแสำดง ให�เห็นว่ั� ผู้้�ส้ำงอ�ยุสำ�มั�รถลดอตัร�ก�ร หกล�มัได�ถง่ร�อยละ 28 (RaR= 0.72 [95% CI: 0.56 to 0.93]) (42) ด�วัยก�รเขี� ร่วัมั ก�รผู้สำ�นกิจักรรมัท�งก�ยที�แตกต่�งกนั (ก�รออกกำ�ลงัก�ยแบบฝึึกก�รทรงตวัั และฝึึกก�รเค์ล่�อนไหวัเป็นประจัำ�รวัมั กบัก�รออกกำ�ลงัก�ยแบบมีัแรงต� น) ผู้ลจั�กก�รออกกำ�ลังก�ยแบบมีัแรง ต� นนั�นยังไม่ัแน่นอนและยังมีัขี�อม้ัล จัำ�กดั (RR= 0.97 [95% CI: 0.14 to 6.49]; ก�รทดลอง 1 ค์รั�ง; n= 73) (42) ผูู้้สูำงอ�ยุ (อ�ยุ 65 ปีขึ้�นืไป) ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 70 ห ลั ก ฐ � น ยั ง แ สำ ด ง ใ ห� เ ห็ น ว่ั�ก�รทำ�กิจักรรมัท�งก�ยที� รวัมัเอ� ก�รออกกำ�ลังก�ยหล�ยชนิดไวั�ด�วัย กันมีัผู้ลดีต่อสุำขีภั�พ็กระด้กมั�กกว่ั� (ขีน�ดขีองผู้ลที�ทำ�ให�เป็นมั�ตรฐ�น 0.45 [95% CI: 0.20 to 0.71]; p= 0.001) เม่ั�อ เทียบกบัผู้้�ที� ไม่ัได�ทำ� (95) ค์ณะทำ�ง�น GDG สำรุปว่� • มีัหลกัฐ�นเช่�อถ่อได�อย่�งส้ำงว่ั�กิจั- กรรมัท�งก�ยในระดับที� ส้ำงขี่ �นที� ผู้สำมัผู้สำ�นก�รออกกำ�ลังก�ยเพ่็� อ สำร� งสำมัดุล ค์วั�มัแข็ีงแรง ค์วั�มัเร็วัใน ผูู้้สูำงอ�ยุ (อ�ยุ 65 ปีขึ้�นืไป) ก�รเค์ล่� อนที� และก�รเค์ล่� อนไหวั ร่�งก�ย (ตวััอย่�งเช่น ร้ปแบบกิจักรรมั ท�งก�ยแบบผู้สำมัผู้สำ�น) นั�นเกี�ยวัเน่�อง กบัอัตร�ก�รหกล�มัและค์วั�มัเสีำ� ยง จั�กอ�ก�รบ�ดเจ็ับจั�กก�รหกล�มัใน ผู้้�ส้ำงอ�ยุที�ลดลง • มีัหลกัฐ�นที� เช่� อถ่อได�ป�นกล�งว่ั� ก�รทำ�กิจักรรมัท�งก�ยที�รวัมัเอ�ก�ร ออกกำ�ลงัก�ยหล�ยร้ปแบบไวั�ด�วัยกนั จัะมีัผู้ลกระทบสำำ�ค์ัญ่ต่อสุำขีภั�พ็ กระด้กและก�รป้องกนักระด้กพ็รุน 71 ผูู้้สูำงอ�ยุ (อ�ยุ 65 ปีขึ้�นืไป) ข้้อแนืะนืำ� ด้็�นืพฤติิกิรัรัมเนืือยนิื�ง สำำ�หรบัผู้้�ส้ำงอ�ยุ พ็ฤติกรรมัเน่อยนิ�งค่์อเวัล�ที�ใช�กบัก�รนั�งเฉย ๆ หร่อนอนด�วัยก�รใช�พ็ลงัง�นตำ� ขีณิะต่�นอย่้ ในปริบทท�งอ�ชีพ็ ก�รเรียน สำภั�พ็แวัดล�อมัที�บ� นหร่อในชุมัชน และก�รเดินท�ง หลกัฐ�นสำนบัสำนุนและเหตุิผล พ็ฤติกรรมัเน่อยนิ�งไม่ัได�ระบุไวั�ในขี�อแนะนำ�ระดบัโลกด� นกิจักรรมัท�งก�ยเพ่็�อสุำขีภั�พ็ พ็.ศ. 2553 (1) เน่�องจั�กก�รขี�ดหลกัฐ�นที�เจั�ะจังกลุ่มัประช�กร หลกัฐ�นเบ่ �องต�นที�ประเมิันค์วั�มั เช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งและผู้ลลพั็ธิต่์อสุำขีภั�พ็ในประช�กรผู้้�ส้ำงอ�ยุเป็นง�นวิัจัยัท�ง วิัทย�ศ�สำตรชิ์�นเดียวักบัที�เปรียบเทียบและทบทวันสำำ�หรบัประช�กรผู้้�ใหญ่่ เพ็ร�ะง�นวิัจัยัส่ำวันใหญ่่ ไม่ัได�ระบุเกณิฑ์จ์ัำ�กดัอ�ยุที�ส้ำงกว่ั� จัง่มีัก�รรวัมัผู้้�ใหญ่่อ�ยุมั�กกว่ั� 65 ปีไวั� มีัก�รทบทวันก�รค์�นพ็บ จั�กหลกัฐ�นเกี�ยวักบัพ็ฤติกรรมัเน่อยนิ�งในประช�กรผู้้�ใหญ่่ทั�วัไป รวัมัถง่ประเมิันว่ั�หลกัฐ�นนั�นมีั ผู้ลที�ต่�งกนัหร่อไม่ั หร่ออ�จัไม่ัรวัมัถง่ หร่ออ�จัให�ผู้ลที�ขีดัแย�งกนั สำำ�หรบัผู้้�ส้ำงอ�ยุ ร�ยละเอียดค์รบถ�วันสำำ�หรบัวิัธีิก�รวิัจัยั ก�รแยกส่ำวันขี�อม้ัล และชุดขี�อม้ัลหลกัฐ�นมีัอย่้ที�ภั�ค์ผู้นวัก ขีองเว็ับไซต ์: ชุดขี�อม้ัลหลกัฐ�น9 สำำ�หรับผู้้�ส้ำงอ�ยุ พ็ฤติกรรมัเน่อยนิ� งในปริมั�ณิที� ส้ำงขี่ �นนั�นต�มัมั�ด�วัยผู้ลเสีำยต่อ สุำขีภั�พ็ ได�แก่ ก�รเสีำยชีวิัตทุกสำ�เหตุ ก�รเสีำยชีวิัตจั�กโรค์หัวัใจัหลอดเล่อด และก�รเสีำยชีวิัตจั�กโรค์มัะเร็ง และสำ�เหตุก�รเกิดโรค์หลอดเล่อดหัวัใจั โรค์มัะเร็ง และโรค์เบ�หวั�นชนิดที�สำอง แนะนำ�ให:้ ผ้ส้้ำงอ�ยุค์วรจำ�กดัเวล�ที�มีัก�รทำ�พฤติิกรรมัเนือยนิ�ง และทดแทนเวล� เหล่�นั�น ดว้ยกิจกรรมัท�งก�ยทุกระดบัเพื�อผลดีต่ิอสุำข้ภ�พ (รวมัถง้ระดบัเบ�) แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อได�ป�นกล�ง ผ้ส้้ำงอ�ยุค์วรมุ่ังทำ�กิจกรรมัท�งก�ยใหม้ั�กกว่�ระดบัที�แนะนำ� ท ั�งในระดบั ป�นกล�ง และระดบัหนกั เพื�อช่้วยลดอนัติร�ยต่ิอสุำข้ภ�พ จ�กพฤติิกรรมั- เนือยนิ�งในระดบัส้ำง แนะนำ�อย่�งยิ�ง หลกัฐ�นที�เช่�อถ่อได�ป�นกล�ง > > 9 ข้้อม่ัลออนไลน์อย่� ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 72 > > > ในหญิ่งมีัค์รรภัแ์ละมั�รด�หลงัค์ลอด กิจักรรมัท�งก�ยระหว่ั�งตั�งค์รรภัแ์ละช่วังหลงัค์ลอดก่อให� เกิดประโยชนด์� นสุำขีภั�พ็ทั�งต่อแม่ัและท�รกในค์รรภั ์ ได�แก่ ค์วั�มัเสีำ�ยงที�ลดลงในก�รเกิดภั�วัะ- ค์รรภัเ์ป็นพิ็ษ รวัมัทั�งค์วั�มัดนัโลหิตส้ำงขีณิะมีัค์รรภั ์เบ�หวั�นขีณิะตั�งค์รรภั ์ภั�วัะนำ � หนกัเพิ็�มัส้ำง ระหว่ั�งตั�งค์รรภั ์ภั�วัะแทรกซ�อนในก�รค์ลอด อ�ก�รซม่ัเศร� หลงัค์ลอด และภั�วัะแทรกซ�อน สำำ�หรบัท�รกแรกเกิด ไม่ัมีัผู้ลลบต่อนำ � หนกัแรกเกิด และไม่ัมีัค์วั�มัเสีำ�ยงต่อก�รเสีำยชีวิัตในค์รรภั์ สำำ�หรบัหญิ่งมีัค์รรภัแ์ละมั�รด�หลงัค์ลอด กิจักรรมัท�งก�ยสำ�มั�รถทำ�ได�ในฐ�นะส่ำวันหน่�ง ขีองสำนัทน�ก�รและก�รพ็กัผู่้อน (ก�รละเล่น เกมัสำ ์ กีฬ� และก�รออกกำ�ลงัก�ยต�มัแผู้น) ก�รเดินท�ง (ก�รเล่นเค์ร่� องที� มีัล�อ ก�รเดิน และก�รปั� นจัักรย�น) ก�รทำ�ง�น ทำ�ง�นบ� น ในปริบทขีองก�รทำ�ง�นประจัำ�วันั ก�รศก่ษ� บ� น หร่อในชุมัชน ขี�อแนะนำ�นี�กล่�วัถง่กิจักรรมัท�งก�ยและผู้ลลพั็ธิด์� นสุำขีภั�พ็ขีองมั�รด� และท�รกในค์รรภัร์ะหว่ั�งก�รตั�งค์รรภัแ์ละระยะหลงัค์ลอด ขี�อแนะนำ�นี�สำำ�หรบั หญิ่งตั�งค์รรภัแ์ละมั�รด�หลงัค์ลอด ไม่ัจัำ�กดัอ�ยุ พ่็ �นหลงัท�งวัฒันธิรรมั หร่อ สำถ�นะท�งสำงัค์มัเศรษฐกิจัใด ๆ ก�รตั�งค์รรภัแ์ละระยะหลงัค์ลอดเป็นขีั�นหน่�งขีองชีวิัต ผู้้�หญิ่ง และคุ์ณิประโยชนข์ีองก�รเค์ล่�อนไหวัร่�งก�ยอย่�งค์ล่องแค์ล่วัตลอดช่วังวัยัผู้้�ใหญ่่นั�นระบุ ร�ยละเอียดไวั�ในขี�อแนะนำ�ที�จัดัทำ�สำำ�หรบัวัยัผู้้�ใหญ่่ หญิ่งตั�งค์รรภัแ์ละมั�รด�หลงัค์ลอดค์วัรอย่้ภั�ยใต�ก�รด้แลทั�งก่อนค์ลอดและหลงัค์ลอดจั�กบุค์ล�กร ท�งก�รแพ็ทยที์�สำ�มั�รถให�ค์ำ�แนะนำ�เกี�ยวักบักรณีิพิ็เศษจั�กภ้ัมิัหลงัท�งก�รแพ็ทยแ์ละขี�อบ่งห� มัในก�รทำ� กิจักรรมัท�งก�ยระหว่ั�งก�รตั�งค์รรภัห์ร่อช่วังหลงัค์ลอด ขี�อแนะนำ�นี�เน�นต�มัแนวัสำ�ธิ�รณิสุำขีและต�มักลุ่มั ประช�กร แนวัปฏิิบติัท�งก�รแพ็ทยค์์วัรมีัขี่ �นเพ่็�อผู้้�หญิ่งที�มีัภั�วัะซบัซ�อนที� เช่�อมัโยงกบัก�รตั�งค์รรภัห์ร่อ ก�รค์ลอดบุตร หญิ่งตั�งค์รรภัห์ร่อมั�รด�หลงัค์ลอดค์วัรพ็ย�ย�มัที�จัะทำ�ต�มัค์ำ�แนะนำ�เหล่�นี�เม่ั�อเป็นไปได� และเท่�ที�สำ�มั�รถทำ�ได�โดยปร�ศจั�กขี�อค์วัรระวังั สำติร่ัม่คำรัรัภ์ิและม�รัด็�หลังคำลอด็ ข้้อแนืะนืำ�ด้็�นืกิิจกิรัรัมท�งกิ�ย แนะนำ�ว่�หญิ่งมีัค์รรภแ์ละมั�รด�หลงัค์ลอดที�ไม่ัมีัข้อ้ห�้มัใด ๆ นั�นค์วรจะ: ทำ�กิจกรรมัท�งก�ยเป็นประจำ�ติลอดทั�งช่้วงก�รติ ั�งค์รรภแ์ละหลงัค์ลอด แนะนำ�อย่�งยิ�ง หลกัฐ�นน่�เช่�อถ่อได�ป�นกล�ง ทำ�กิจกรรมัท�งก�ยแบบแอโรบิกที�ระดบัป�นกล�งอย่�งนอ้ย 150 น�ทีติลอดสำปัด�ห ์ เพื�อสุำข้ภ�พที�ดี แนะนำ�อย่�งยิ�ง หลกัฐ�นน่�เช่�อถ่อได�ป�นกล�ง และทำ�กิจกรรมัท�งก�ยแบบแอโรบิกที�หล�กหล�ยและก�รสำร�้งค์ว�มัแข็้งแรงใหก้บั กล�้มัเนื �อร่วมักนั และเพิ�มัก�รยืดเหยียดร่�งก�ยในระดบัเบ�จะก่อใหเ้กิดผลดี แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�ง 73 ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ • ทำ�กิจักรรมัท�งก�ยบ� งย่อมัดี กว่ั�ไม่ัทำ�อะไรเลย • ห�กหญิ่งมีัค์รรภัห์ร่อมั�รด� หลงัค์ลอดไม่ัสำ�มั�รถทำ�ต�มั ขี�อแนะนำ�ได� ก�รทำ�กิจักรรมั ท�งก�ยบ� งย่อมัเป็นผู้ลดี ต่อสุำขีภั�พ็ • หญิ่งมีัค์รรภัแ์ละมั�รด�หลงั ค์ลอดค์วัรเริ� มัทำ�กิจักรรมั ท�งก�ยแต่น�อยแล�วัค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มัหนกัหน่วัง และระยะเวัล� • ค์วัรมีัก�รทำ�กิจักรรมัย่ดหยุ่น กล� มัเน่�ออุ�งเชิงกร�นทุกวันั เพ่็� อลดค์วั�มัเสีำ� ยงขีองก�ร กลั�นปัสำสำ�วัะไม่ัอย่้ ข้อ้พิจ�รณ�เรื�องค์ว�มัปลอดภยัเพิ�มัเติิมัสำำ�หรบัหญิ่ง มีัค์รรภ ์เมืั�อทำ�กิจกรรมัท�งก�ย คื์อ: • หลีกเลี�ยงก�รทำ�กิจักรรมัท�งก�ยเม่ั�ออย่้ในที�ที�มีัค์วั�มัร�อน มั�กเกินไป โดยเฉพ็�ะเม่ั�อมีัค์วั�มัช่�นส้ำง • ด่�มันำ � ให�เพี็ยงพ็อ โดยค์วัรด่�มันำ � ก่อน ระหว่ั�ง และหลงัก�ร ทำ�กิจักรรมัท�งก�ย • หลีกเลี�ยงก�รเขี� ร่วัมักิจักรรมัที� เกี�ยวัเน่� องกบัก�รสำมััผู้สัำ ท�งก�ยภั�พ็ มีัค์วั�มัเสีำ� ยงในก�รหกล�มัส้ำง หร่ออ�จัมีั ปริมั�ณิอ็อกซิเจันจัำ�กดั (เช่น กิจักรรมับนพ่็�นที�ส้ำง เม่ั�อไม่ัได� อย่้อ�ศยับนพ่็�นที�ส้ำงเป็นปกติ) • หลีกเลี� ยงกิจักรรมัที� อย่้ในท่�นอนหง�ย หลังจั�กสำ�มั เด่อนแรกขีองก�รตั�งค์รรภั์ • เม่ั�อเป็นก�รแข่ีงขีนักีฬ� หร่อก�รออกกำ�ลงัก�ยเกินไปจั�ก ขี�อแนะนำ�อย่�งมั�ก หญิ่งตั�งค์รรภัค์์วัรปร่กษ�ผู้้�ให�บริก�ร ท�งก�รแพ็ทยที์�เชี�ยวัช�ญ่เฉพ็�ะ • หญิ่งมีัค์รรภัค์์วัรได�รบัขี�อม้ัลจั�กผู้้�ให�บริก�รท�งก�รแพ็ทย ์ ถง่สำญั่ญ่�ณิอนัตร�ยที�จัะเต่อนให�พ็วักเขี�หยุด หร่อจัำ�กดั กิจักรรมัท�งก�ย และปร่กษ�ผู้้�ให�บริก�รท�งก�รแพ็ทย ์ หร่อผู้้�ทรงคุ์ณิวุัฒิทนัทีที�เกิดเหตุ • ค่์อย ๆ กลบัมั�ทำ�กิจักรรมัท�งก�ยหลงัจั�กค์ลอดโดย ค์วัรปร่กษ�ผู้้� ให�บริก�รด้แลสุำขีภั�พ็ ในกรณีิค์ลอด โดยก�รผู่้�ค์ลอด สำติร่ัม่คำรัรัภ์ิและม�รัด็�หลังคำลอด็ หลกัฐ�นสำนบัสำนุนและเหตุิผล สำำ�หรบัขี�อแนะนำ�ในก�รทำ�กิจักรรมัท�งก�ยและพ็ฤติกรรมัเน่อยนิ�ง (2563) สำำ�หรบัหญิ่ง มีัค์รรภัแ์ละมั�รด�หลงัค์ลอด หลกัฐ�นที�รวับรวัมัจั�กบทปริทศันอ์ย่�งเป็นระบบที�กล่�วัถง่ผู้ลลพั็ธิที์� สำำ�ค์ญั่มั�กและสำำ�ค์ญั่ถ้กนำ�มั�ใช�และปรบัขี�อม้ัล บทปริทศัน ์4 ใน 7 ฉบบัเขี� เกณิฑ์ก์�รนำ�ขี�อม้ัลเขี� ขี�อม้ัลเต็มัเกี�ยวักบัระเบียบวิัธีิ ก�รแยกส่ำวันขี�อม้ัลและชุดขี�อม้ัลหลกัฐ�นสำ�มั�รถด้ได�ที�ภั�ค์ผู้นวัก บนเว็ับไซต ์: ชุดขี�อม้ัลหลกัฐ�น10 10 ข้้อม่ัลออนไลน์อย่� ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 74 สำติร่ัม่คำรัรัภ์ิและม�รัด็�หลังคำลอด็ ค์ว�มัสำมััพนัธิ์ร์ะหว่�งกิจกรรมัท�งก�ย และผลลพัธิ์ที์�เกี�ยวเนื�องกบัสุำข้ภ�พใน หญิ่งมีัค์รรภแ์ละมั�รด�หลงัค์ลอดคื์อ อะไร ก�รทำ�กิจักรรมัท�งก�ยก่อนและ ระหว่ั�งก�รตั�งค์รรภัส์ำ�มั�รถลดค์วั�มั เสีำ� ยงขีองภั�วัะแทรกซ�อนระหว่ั�งตั�ง ค์รรภัที์� ร้�กนัดี ก�รทำ�กิจักรรมัท�งก�ย ระหว่ั�งตั�งค์รรภัจ์ัะเช่�อมัโยงอย่�งมีันยั- สำำ�ค์ญั่กบัก�รลดค์วั�มัเสีำ�ยงภ�วะนำ � หนกั เพิ�มัข้ณะติั�งค์รรภ ์(MD= 1.14 กิโลกรมัั [95% CI: 1.67 to 0.62]) (97) และลด ค์วั�มัเสีำ�ยงขีองเบ�หวั�นขีณิะตั�งค์รรภั ์ (RR= 0.71 [95% CI: 0.57 ถง่ 0.89]) (97) ขีณิะที� มีัก�รทำ�กิจักรรมัท�งก�ยตั�งแต่ ก่อนตั�งค์รรภั ์(OR= 0.70 [95% CI: 0.57 ถง่ 0.85]) (31, 34, 97) รวัมัถง่ผู้้�หญิ่งที�มีั นำ � หนกัเกินหร่อโรค์อ�วัน (97) ก�รทำ�กิจักรรมัท�งก�ยระหว่ั�ง ตั�งค์รรภั ์ ไม่ัใช่สำ�เหตุที�ทำ�ให�เกิดค์ว�มั ดนัโลหิติส้ำงระหว่�งติ ั�งค์รรภห์รือภ�วะ ค์รรภเ์ป็นพิษ (31) หลกัฐ�นชี�ให�เห็นว่ั� ในหม่้ัหญิ่งตั�งค์รรภัที์�มีันำ � หนกัเกินหร่อมีั ภั�วัะโรค์อ�วัน ไม่ัมีัค์วั�มัแตกต่�งอย่�งมีั นัยสำำ�ค์ญั่ในก�รเกิดค์วั�มัดนัโลหิตส้ำง ระหว่ั�งตั�งค์รรภั ์ (RR= 0.63 [95% CI: 0.38 ถง่ 1.05]) หร่อภั�วัะค์รรภัเ์ป็นพิ็ษ (RR= 1.39 [95% CI: 0.66 ถง่ 2.93]) ระหว่ั�งก�รแทรกแซงก�รทำ�กิจักรรมั ท � ง ก � ย แ ล ะ ก � ร ฝึ � ก ค์ ร ร ภั์แ บ บ มั�ตรฐ�น (97) มีัขี�อกงัวัลอย่�งย�วัน�นเกี�ยวักบั ผู้ลลบที�อ�จัมีัขีองกิจักรรมัท�งก�ยขีอง มั�รด�ในช่วังที�ท�รกในค์รรภัเ์ริ�มัมีัก�ร พ็ฒัน�จันค์ลอด อย่�งไรก็ต�มัหลกัฐ�น ล่�สุำดแสำดงให�เห็นว่ั� กิจักรรมัท�งก�ยไม่ั เช่� อมัโยงกับค์วั�มัเสีำ� ยงที� เพิ็� มัขี่ �นกับ สำ�เหตุก�รแทง้บุติรก�รค์ลอดที�ท�รก เสีำยชี้วิติในค์รรภ ์ หรือภ�วะแทรกซอ้น ในก�รค์ลอด (32) หลกัฐ�นชี�ว่ั� ไม่ัมีั ค์วั�มัแตกต่�งในก�รเกิดก�รผู่้�ค์ลอด ในหม่้ัหญิ่งมีัค์รรภัที์�มีันำ � หนกัเกินหร่อมีั ภั�วัะโรค์อ�วันระหว่ั�งกลุ่มัที�มีัก�รแทรก- แซงด�วัยก�รทำ�กิจักรรมัท�งก�ยเทียบกบั ก�รฝึ�กค์รรภัต์�มัมั�ตรฐ�น (97) ก�รทำ�กิจักรรมัท�งก�ยระหว่ั�งตั�ง ค์รรภั์ไม่ัเกี� ยวัเน่� องกับก�รเพิ็� มัค์วั�มั เสีำ� ยงขีองผู้ลเสีำยเกี� ยวักบันำ � หนกัข้อง ท�รกแรกเกิดหร่อก�รค์ลอดก่อนกำ�- หนด (32)หร่ออ�จัเป็นก�รป้องกนัลด ค์วั�มัเสีำ�ยงทั�งมัวัล (98) แมั�แต่ในกลุ่มัหญิ่ งมีัค์รรภัที์�มีันำ � หนกัเกินเกณิฑ์ห์ร่อภั�วัะ โรค์อ�วัน (RR= 1.02 [95% CI: 0.54 ถง่ 1.92]) หร่อท�รกที�ตวััใหญ่่เกินอ�ยุค์รรภั ์ (RR= 0.90 [95% CI: 0.65 ถง่ 1.25]) ระหว่ั�งก�รแทรกแซงก�รทำ�กิจักรรมั- ท�งก�ยเทียบกับก�รฝึ�กค์รรภัต์�มั มั�ตรฐ�น (97) สำำ�หรบัช่วังหลงัค์ลอด มั�รด�อ�จั ประสำบค์วั�มัเปลี� ยนแปลงหล�ยอย่�ง ท�งร่�งก�ยและอ�รมัณิ ์ หลกัฐ�นแสำดง ให�เห็นว่ั�ก�รทำ�กิจักรรมัท�งก�ยระหว่ั�ง ตั�งค์รรภัน์ั�นอ�จัจัะเช่�อมัโยงอย่�งผู้กผู้นั กับภ�วะซ้มัเศัร�้หล ังค์ลอด (29) หลกัฐ�น 75 สำติร่ัม่คำรัรัภ์ิและม�รัด็�หลังคำลอด็ ข้้อัแนะนำา จั�กบทวิัเค์ร�ะหอ์ภิัมั�นจั�กก�รทดลอง 6 ชิ �นและง�นวิัจัยัจั�กก�รสำงัเกตุ 11 ชิ �น เกี�ยวักบัก�รทำ�กิจักรรมัท�งก�ยระหว่ั�ง ตั�งค์รรภั ์ (99) แสำดงให�เห็นว่ั� มีัค์วั�มั สำมััพ็นัธิที์� แปรผู้กผู้นัอย่�งมีันัยสำำ�ค์ญั่ ระหว่ั�งก�รทำ�กิจักรรมัท�งก�ยระหว่ั�ง ตั�งค์รรภัแ์ละภั�วัะซ่มัเศร� หลงัค์ลอด (SMD= 0.58 [95% CI: 1.09 ถง่ 0.08]) ผู้ลนั�นรุนแรงขี่ �นเม่ั� อจัำ�กัดง�นวิัจััยที� จัำ�นวัน 5 ชิ �นที� มีัก�รแทรกแซงด�วัยก�ร ทำ�กิจักรรมัท�งก�ยที�ระดบัป�นกล�ง เป็นอย่�งน�อย (SMD= 0.70 [95% CI:1.19 ถง่ 0.22]) (99) ค์ณะทำ�ง�น GDG สำรุปว่� • มีัหลกัฐ�นที� มีัค์วั�มัน่�เช่� อถ่อส้ำงว่ั� กิจักรรมัท�งก�ยระหว่ั�งตั�งค์รรภั ์ อ�จัลดค์วั�มัเสีำ�ยงขีองภั�วัะนำ � หนกั เพิ็�มัระหว่ั�งตั�งค์รรภัแ์ละค์วั�มัเสีำ�ยง จั�กโรค์เบ�หวั�นขีณิะตั�งค์รรภั์ • มีัหลกัฐ�นที� เช่�อถ่อได�ป�นกล�งจัน ถ่งเช่�อถ่อได�ส้ำงว่ั� กิจักรรมัท�งก�ย จัะไม่ัเพิ็� มัโอก�สำขีองก�รแท�งบุตร ท� ร ก เ สีำ ย ชี วิั ต ขี ณิ ะ ค์ ล อ ด หร่ อ ภั�วัะแทรกซ�อนขีณิะค์ลอด และมีัหลกั ฐ�นเช่�อถ่อได�ป�นกล�งเกี�ยวักบัค์วั�มั เสีำ�ยงในก�รค์ลอดก่อนกำ�หนดที�ลดลง สำำ�หรบัมั�รด�ที�มีัก�รทำ�กิจักรรมัท�ง ก�ยในระดบัหนกั • มีัหลักฐ�นที� เช่� อถ่อได�ตำ� ไปจันถ่ง ป�นกล�งว่ั� กิจักรรมัท�งก�ยจัะไม่ั เพิ็�มัค์วั�มัเสีำ�ยงเร่�องนำ � หนกัขีองท�ร กแรกเกิดที�ตำ� หร่อภั�วัะท�รกโตช� ในค์รรภั ์หร่อภั�วัะท�รกตวััโต • มีัหลกัฐ�นที� มีัค์วั�มัน่�เช่� อถ่อตำ� ว่ั� ก�รทำ�กิจักรรมัท�งก�ยระหว่ั�งตั�ง- ค์รรภัเ์ช่�อมัโยงกบัภั�วัะซม่ัเศร� หลงั ค์ลอดในระดบัที�ลดลง • ค์ วั � มั เ สีำ� ย ง สำำ � ห รับ ป ริ มั � ณิ แ ล ะ ประเภัทขีองกิจักรรมัท�งก�ยที� แนะนำ�สำำ�หรบัหญิ่งมีัค์รรภัแ์ละหญิ่ง หลังค์ลอดนั�นตำ� และ ไม่ัมีันำ � หนัก เหน่อประโยชน์ มีัค์ว�มัเชื้�อมัโยงในก�รติอบสำนองปริ- มั�ณหรือไม่ั (ปริมั�ณ ระยะเวล� ค์ว�มัถี� ค์ว�มัหนกัหน่วง) จั�กหลักฐ�นเกี� ยวักับกิจักรรมั ท�งก�ยระหว่ั�งตั�งค์รรภัแ์ละช่วังหลงั ค์ลอด ก�รแทรกแซงนั�นหล�กหล�ย ไปต�มัจัำ�นวัน (ตวััอย่�งเช่น ปริมั�ณิ) ขีองกิจักรรมัท�งก�ย ทั�งค์วั�มัต่อเน่�อง เป็นน�ทีและค์วั�มัถี�ต่อสำปัด�ห ์โดยทั�วัไป หลกัฐ�นที� มีัจัะสำะท�อนค์วั�มัถี�ขีองก�ร ทำ�กิจักรรมัท�งก�ยแบบแอโรบิกอย่�ง น�อย 3 ค์รั�งต่อสำปัด�ห ์เป็นปรกติระหว่ั�ง 30 และ 60 น�ที หลกัฐ�นนี�ได�จั�กง�น วิัจัยัที�ประเมิันผู้ลท�งสุำขีภั�พ็ขีองปริมั�ณิ ที�ค์งที�กบัปริมั�ณิขีองกิจักรรมัที�แนะนำ� สำำ�หรับประช�กรวััยผู้้� ใหญ่่โดยทั� วัไป กล่�วัค่์อ ก�รทำ�กิจักรรมัท�งก�ยที�ระดบั ป�นกล�ง 150 น�ทีต่อสำปัด�ห์ ขีณิะที� ก�รทำ�กิจักรรมัท�งก�ย ที� เพิ็�มัมั�กขี่ �น (ค์วั�มัถี� ระยะเวัล� และ/ หร่อปริมั�ณิ) อ�จัพ็บโดยทั�วัไปว่ั� เช่�อมั โยงกับประโยชน์ที� มั�กขี่ �น ง�นวิัจััย เพิ็�มัเติมัเป็นที�ต�องก�ร เพ่็�อให�เขี� ใจัร�ย- ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 76 ละเอียดค์วั�มัสำมััพ็นัธิ ์ในก�รตอบสำนอง ต่อปริมั�ณิให�มั�กขี่ �น ก�รเขี� ร่วัมัใน กิจักรรมัท�งก�ยระหว่ั�งเวัล�พ็กัผู่้อนใน ปริมั�ณิที� ส้ำงกว่ั�หร่อตำ� กว่ั�ก่อนก�ร ตั�งค์รรภัน์ั�น เช่�อมัโยงกบัค์วั�มัเสีำ�ยงขีอง อ�ก�รเบ�หวั�นขีณิะตั�งค์รรภัที์�ลดลง (OR= 0.54 [95% CI: 0.34 ถง่ 0.87]) (100) ยังมีัหลักฐ�นที� เกี� ยวักับก�รลด ค์วั�มัเสีำ� ยงเล็กน�อยแต่สำำ�ค์ัญ่ต่อก�ร ค์ ล อ ด ก่ อ น กำ � ห น ด สำำ � หรับ แ ม่ั ที� ทำ � กิจักรรมัท�งก�ยที�ระดบัมั�ก (RR= 0.20 [95% CI: 0.36 ถ่ง 0.03]) (98) ไม่ัมีั หลกัฐ�นที� ชี �ถง่ค์วั�มัปลอดภัยัหร่อประ- โยชนเ์พิ็�มัเติมัจั�กกิจักรรมัท�งก�ยใน ระดบัที�มั�กกว่ั�ระดบัที� แนะนำ�อย่�งมีั นยัสำำ�ค์ญั่ ค์ณะทำ�ง�น GDG สำรุปว่� : • มีัหลักฐ�นไม่ัเพี็ยงพ็อที� จัะกำ�หนด ค์วั�มัเช่�อมัโยงในก�รตอบสำนองต่อ ปริมั�ณิระหว่ั�งกิจักรรมัท�งก�ยและ ผู้ลลพั็ธิท์�งสุำขีภั�พ็ที�สำำ�ค์ญั่เป็นอย่�ง ยิ� งระหว่ั�งตั�งค์รรภัแ์ละระยะหลัง ค์ลอด • มีัหลกัฐ�นโดยรวัมัที�แสำดงให�เห็นถ่ง ประโยชนต่์อผู้ลลพั็ธิท์�งสุำขีภั�พ็ที� สำำ�ค์ญั่และมีัพ่็ �นฐ�นอย่้บนก�รแทรก แซงที�ค์งที�อย่�งกวั� ง ๆ กบัปริมั�ณิ ก�รทำ�กิจักรรมัท�งก�ยที� แนะนำ� สำำ �หรับประช�กรวััยผู้้� ใหญ่่ทั� วัไป กล่�วัค่์อ กิจักรรมัท�งก�ยในระดบั ป�นกล�ง 150 น�ทีต่อสำปัด�ห์ • ไม่ัมีัเหตุผู้ลที�จัะเปลี�ยนปริมั�ณิหร่อ ค์วั�มัถี�ขีองกิจักรรมัท�งก�ยในระดบั ป�นกล�งที� แนะนำ�สำำ�หรับหญิ่งมีั ค์รรภัแ์ละมั�รด�หลังค์ลอด เม่ั� อ เปรียบเทียบกบัประช�กรผู้้�ใหญ่่ทั�วัไป • มีัหลักฐ�นเช่� อถ่อได�ป�นกล�งถ่ง ค์วั�มัเสีำ�ยงที�ลดลงจั�กก�รค์ลอดก่อน กำ�หนด สำำ�หรบัมั�รด�ที�ทำ�กิจักรรมั ท�งก�ยในระดบัมั�ก • ค์ว�มัสำมััพนัธิ์ผ์นัแปรติ�มัประเภทหรือ ข้อบข่้�ยหรือช่้วงเวล� (ก่อนติ ั�งค์รรภ ์ ระหว่�งติ ั�งค์รรภ ์ หรือหลงัติ ั�งค์รรภ)์ ข้องก�รทำ�กิจกรรมัท�งก�ยหรือไม่ั ห ลักฐ � นที� ไ ด�จั� กง � นวิัจััย ซ่� ง ประเมิันก�รทำ�กิจักรรมัท�งก�ยในขีอบ ข่ี�ยก�รพ็กัผู่้อนเป็นส่ำวันใหญ่่ ชนิดขีอง กิจักรรมัส่ำวันใหญ่่จัะเป็นแบบแอโรบิก (เช่น ก�รเดินหร่อก�รว่ั�ยนำ � ) แมั�จัะมีั หลกัฐ�นบ�งชิ�นจั�กง�นวิัจัยัที�ประเมิัน ก�รแทรกแซงที� รวัมัถ่งก�รฝึึกค์วั�มั แข็ีงแรง ( เช่น ก�รออกกำ�ลังก�ย แบบหมุันเวีัยน) หร่อก�รผู้สำมัผู้สำ�น ระหว่ั�งกิจักรรมัท�งก�ยแบบแอโรบิก กบัก�รสำร� งค์วั�มัแข็ีงแรงให�กบักล� มั- เน่�อ อย่�งไรก็ต�มั โดยภั�พ็รวัมัแล�วั ยงัไม่ัมีั หลกัฐ�นเพี็ยงพ็อที�จัะกำ�หนดว่ั� ค์วั�มั เช่�อมัโยงระหว่ั�งกิจักรรมัท�งก�ยและ ผู้ลลพั็ธิต่์อสุำขีภั�พ็จัะผู้นัแปรไปต�มัชนิด หร่อขีอบเขีตหร่อช่วังเวัล� (ก่อนตั�งค์รรภั ์ ระหว่ั�งตั�งค์รรภั ์ หร่อหลงัตั�งค์รรภั)์ ขีองก�รทำ�กิจักรรมัท�งก�ย สำติร่ัม่คำรัรัภ์ิและม�รัด็�หลังคำลอด็ 77 ค์ณะทำ�ง�น GDG สำรุปว่� • มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�งว่ั� หญิ่ง มีัค์รรภัแ์ละมั�รด�หลงัค์ลอดค์วัรผู้สำมั กิจักรรมัแบบแอโรบิกที�หล�กหล�ย และกิจักรรมัสำร� งค์วั�มัแข็ีงแรงให�กบั กล� มัเน่�อ และก�รย่ดเหยียดกล� มัเน่�อ ในระดบัเบ�นั�นมีัประโยชนเ์ช่นกนั สำติร่ัม่คำรัรัภ์ิและม�รัด็�หลังคำลอด็ ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 78 สำติร่ัม่คำรัรัภ์ิและม�รัด็�หลังคำลอด็ ข้้อแนืะนืำ� ด้็�นืพฤติิกิรัรัมเนืือยนิื�ง สำำ�หรบัหญิ่งมีัค์รรภัแ์ละมั�รด�หลงัค์ลอด พ็ฤติกรรมัเน่อยนิ�งค่์อเวัล�ที� ใช�กบัก�รนั�งหร่อนอนโดยมีัก�รใช� พ็ลงัง�นตำ� ขีณิะที�ต่�นอย่้ ในปริบทขีองสำภั�พ็แวัดล�อมัด� นอ�ชีพ็ ก�รศก่ษ� บ� น และชุมัชน และก�รเดินท�ง หลกัฐ�นสำนบัสำนุนและเหตุิผล พ็ฤติกรรมัเน่อยนิ�งไม่ัได�ถ้กรวัมัไวั�ในขี�อแนะนำ�ระดบัโลกด� นกิจักรรมัท�งก�ยเพ่็�อสุำขีภั�พ็ ฉบบั พ็.ศ. 2563 (1) เน่�องจั�กขี�ดหลกัฐ�นเฉพ็�ะกลุ่มัประช�กร ฐ�นขี�อม้ัลหลกัฐ�นเบ่ �องต�นเพ่็�อประเมิันค์วั�มั เช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งและผู้ลลพั็ธิต่์อสุำขีภั�พ็ในหญิ่งมีัค์รรภัแ์ละมั�รด�หลงัค์ลอดนั�นเป็น ง�นวิัจัยัด� นวิัทย�ศ�สำตรที์�รวับรวัมัและทบทวันสำำ�หรบัประช�กรวัยัผู้้�ใหญ่่ มีัก�รทบทวันผู้ลก�รวิัจัยัจั�กหลกัฐ�นเกี�ยวักบัพ็ฤติกรรมัเน่อยนิ�งในประช�กรวัยัผู้้�ใหญ่่โดยทั�วัไป รวัมัถง่ประเมิันว่ั�ผู้ลที� ได�แตกต่�งกนับ� งหร่อไม่ั หร่ออ�จัไม่ัประยุกต์ใช� หร่ออ�จัขีดัแย�งกนัสำำ�หรบัหญิ่ง มีัค์รรภัแ์ละมั�รด�หลงัค์ลอด จั�กหลกัฐ�นและค์วั�มัคิ์ดเห็นจั�กผู้้�เชี�ยวั- ช�ญ่ที�มีัอย่้ หลกัฐ�นได�ถ้กนำ�มั�อ� งอิงใช�จัดัทำ�ขี�อ แนะนำ�ขีององค์ก์�รอน�มัยัโลกฉบบัใหม่ัที� เกี�ยวักบั พ็ฤติกรรมัเน่อยนิ�ง สำำ�หรบัหญิ่งมีัค์รรภัแ์ละมั�รด� หลงัค์ลอด เพ่็� อชุดขี�อม้ัลสำ�มััญ่ขีองผู้ลลัพ็ธิต่์อ สุำขีภั�พ็ที�สำำ�ค์ญั่มั�ก เน่�องจั�กขี�อม้ัลโดยอ�อมัขีอง หลกัฐ�น ระดบัขีองค์วั�มัน่�เช่�อถ่อจัง่ถ้กลดลงมั� เน่�องจั�กขี�ดหลกัฐ�นเฉพ็�ะกลุ่มัประช�กร นี� และหญิ่งมีัค์รรภัถ้์กนำ�ออกจั�กง�นวิัจัยั ขี�อแนะนำ� ที�จัะเพิ็�มัระดบัก�รทำ�กิจักรรมัท�งก�ยให�มั�กกว่ั�ระ- ดบัที�แนะนำ�เพ่็�อต่อต� นผู้ลร� ยจั�กพ็ฤติกรรมัเน่อย นิ�งในระดบัส้ำงไม่ัอ�จัค์�ดก�รณิส์ำำ�หรบัผู้้�หญิ่งในช่วัง ตั�งค์รรภัแ์ละช่วังหลงัค์ลอดได� ค์ณะทำ�ง�น GDG สำรุปว่� • หลกัฐ�นเกี� ยวักบัพ็ฤติกรรมัเน่อยนิ� งในกลุ่มั ประช�กรวััยผู้้�ใหญ่่โดยทั� วัไปสำ�มั�รถนำ�มั� อนุมั�นเพ่็�อร่�งขี�อแนะนำ�สำำ�หรบัหญิ่งมีัค์รรภั ์ และมั�รด�หลงัค์ลอดเพ่็�อชุดขี�อม้ัลทั� วัไปขีอง ผู้ลลพั็ธิท์�งสุำขีภั�พ็ที�สำำ�ค์ญั่ • ประโยชน์ขีองก�รลดพ็ฤติกรรมัเน่อยนิ� งมีั มั�กว่ั�ค์วั�มัเสีำ� ยง สำำ�หรับหญิ่งมีัค์รรภัแ์ละ มั�รด�หลงัค์ลอด • ค์วั�มัเช่�อถ่อได�ขีองหลกัฐ�นค์วัรจัะลดลงเน่�อง จั�กเป็นขี�อม้ัลโดยอ�อมั ในหญิ่งมีัค์รรภัแ์ละมั�รด�หลงัค์ลอด เช่นเดียวักบัวัยัผู้้�ใหญ่่ทุกค์น พ็ฤติกรรมัเน่อยนิ�งในปริมั�ณิ มั�กนั�นเช่�อมัโยงกบัผู้ลลบต่อสุำขีภั�พ็ ได�แก่ก�รเสีำยชีวิัตทุกสำ�เหตุ ก�รเสีำยชีวิัตจั�กโรค์หลอด- เล่อดหัวัใจั ก�รเสีำยชีวิัตจั�กโรค์มัะเร็ง และโอก�สำในก�รเกิดโรค์หลอดเล่อดหัวัใจั โรค์มัะเร็ง และก�รเกิดโรค์เบ�หวั�นชนิดที�สำอง แนะนำ�ให:้ หญิ่งมีัค์รรภแ์ละมั�รด�หลงัค์ลอดค์วรจะจำ�กดัระยะเวล�ในก�รทำ�พฤติิกรรมัเนือยนิ�ง และทดแทนเวล�เหล่�นั�นดว้ยกิจกรรมัท�งก�ยที�ระดบัใดก็ได ้ (รวมัถ้งระดบัเบ�) ซ้�งมีัประโยช้นต่์ิอสุำข้ภ�พ แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อได�ตำ� > 79ข้้อัแนะนำา > > กิจักรรมัท�งก�ยนำ�มั�ซ่�งสุำขีภั�พ็ที� ดี สำำ�หรบัผู้้�ใหญ่่และผู้้�ส้ำงอ�ยุที� มีัภั�วัะเร่ �อรงั ดงัต่อไปนี� สำำ�หรับผ้ร้อดชี้วิติจ�กมัะเร็ง กิจักรรมัท�งก�ยจัะทำ�ให�ก�รเสีำยชีวิัตจั�กทุกสำ�เหตุ ก�รเสีำยชีวิัตจั�กมัะเร็ง และค์วั�มัเสีำ�ยงในก�รเกิดใหม่ัขีองมัะเร็งหร่อมัะเร็งขีั�นปฐมัภ้ัมิัค์รั�งที�สำอง นั�นดีขี่ �น สำำ�หรบัผ้ที้�มีัค์ว�มัดนัโลหิติส้ำง กิจักรรมัท�งก�ยจัะช่วัยลดค์วั�มัเสีำ�ยงจั�กก�รเสีำยชีวิัต จั�กโรค์หลอดเล่อดหวััใจัรวัมัทั�งก�รดำ�เนินขีองโรค์ สำมัรรถภั�พ็ร่�งก�ย คุ์ณิภั�พ็ชีวิัตที�เกี�ยวัเน่�อง กบัสุำขีภั�พ็ดีขี่ �นอีกด�วัย สำำ�หรบัผ้เ้ป็นเบ�หว�นช้นิดที� 2กิจักรรมัท�งก�ยจัะลดอตัร�ก�รเสีำยชีวิัต จั�กโรค์หลอดเล่อดหัวัใจัและตวัับ่งชี�ก�รดำ�เนินขีองโรค์ และสำำ�หรบัผ้มี้ัเชื้ �อ HIV กิจักรรมั ท�งก�ยจัะทำ�ให�ค์วั�มัแข็ีงแรงขีองร่�งก�ยและสุำขีภั�พ็จิัตดีขี่ �น (ลดอ�ก�รกงัวัลและซม่ัเศร� ) และไม่ัมีัผู้ลที�ผู้กผู้นัต่อก�รดำ�เนินขีองโรค์ (ค่์� CD4 และค่์� Viral load ในก�รวัดัปริมั�ณิเช่�อ) หร่อองค์ป์ระกอบร่�งก�ย สำำ�หรบัผู้้�ใหญ่่ที�มีัภั�วัะเร่ �อรงั กิจักรรมัท�งก�ยค์วัรเป็นส่ำวันหน่�งขีองก�รสำนัทน�ก�รและก�รพ็กั ผู่้อน (ก�รละเล่น เกมัสำ ์กีฬ� หร่อก�รออกกำ�ลงัก�ยที�มีัก�รวั�งแผู้น) ก�รเดินท�ง (ก�รขีบัเค์ล่�อนด�วัยล�อ ก�รเดิน และก�รปั� นจักัรย�น) ก�รทำ�ง�น หร่อทำ�ง�นบ� น ในปริบทขีองสำภั�พ็แวัดล�อมัประจัำ�วันัด� น ก�รทำ�ง�น ก�รเรียน อย่้บ� น หร่อในชุมัชน ผู้้�ใหญ่่ที�รอดชีวิัตจั�กมัะเร็ง และผู้้�ที�มีัค์วั�มัดนัโลหิตส้ำง เบ�หวั�นชนิดที� 2 และHIV ค์วัรจัะทำ� ต�มัขี�อแนะนำ�นี�เม่ั�อเป็นไปได�และทำ�เท่�ที�ทำ�ได� ห�กไม่ัมีัขี�อบ่งห� มัใด ๆ จันถง่ปัจัจุับนั ขี�อแนะนำ�ในก�รทำ�กิจักรรมัท�งก�ยสำำ�หรบัผู้้�มีัภั�วัะเร่ �อรงั ส่ำวันใหญ่่จัะจัำ�กดัอย่้ในค์ำ�แนะนำ�ท�งก�รแพ็ทยห์ร่อก�รบำ�บดัโรค์ ตวััอย่�งเช่น มีัขี�อแนะนำ�ท�งก�รแพ็ทยแ์ละแหล่งขี�อม้ัลที�พ็ฒัน�โดยสำมั�ค์มัแพ็ทยอ์�ชีพ็สำำ�หรบั มัะเร็งวิัทย� (101) เบ�หวั�นชนิดที� 2 (102) ค์วั�มัดนัโลหิตส้ำง (103) และโรค์เร่�อรงัอ่�น ๆ (104) องค์ก์�รอน�มัยัโลกมีัขี�อแนะนำ�ท�งก�รแพ็ทยซ์่�งรวัมัค์ำ�แนะนำ�ในก�รทำ�กิจักรรมัท�งก�ยสำำ�หรบั ผู้้�ป่วัยโรค์เร่�อรงัเอ�ไวั�ด�วัย (17) ขี�อแนะนำ�เหล่�นี�เป็นขี�อแนะนำ�ที� อิงต�มัประช�กรฉบบัแรกขีององค์ก์�รอน�มัยัโลก ว่ั�ด�วัยก�ร ทำ�กิจักรรมัท�งก�ยสำำ�หรบัผู้้�มีัภั�วัะเร่ �อรงั โดยเฉพ็�ะผู้้�ที� เป็นโรค์มัะเร็ง (จั�กนี�จัะไปกล่�วัถ่งในฐ�นะ “ผู้้�รอดจั�กมัะเร็ง”) โรค์ค์วั�มัดนัโลหิตส้ำง โรค์เบ�หวั�นชนิดที� 2 และโรค์ HIV โรค์ HIV ถ้กมัองเป็นภั�วัะเร่ �อรงั ด�วัยค์วั�มัก� วัหน� ขีองก�รรักษ�ด�วัยย�ต� นไวัรัสำ HIV ที�มีัประสิำทธิิภั�พ็และมีัอย่้ทั�วัไป ผู้้�ป่วัยที�เขี� รบัก�รรกัษ�ต่อเน่�อง (เช่น ก�รทำ�คี์โมับำ�บดั) หร่อยงัไม่ัเสำถียร กบัก�รรกัษ�โรค์เร่�อรงั ผู้้�ให�บริก�รด� นก�รด้แลสุำขีภั�พ็ค์วัรจัะอ� งอิงขี�อแนะนำ�ท�งก�รแพ็ทยที์�เกี�ยวัเน่�อง กบัอ�ก�รเร่�อรงัแต่ละอย่�งด�วัย ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) ข้้อแนืะนืำ�ด้็�นืกิิจกิรัรัมท�งกิ�ย แนะนำ�ให:้ ผ้ ใ้หญ่่หรือผ้ส้้ำงอ�ยุที�มีัภ�วะเรื �อรงัเหล่�นี � ค์วรทำ�กิจกรรมัท�งก�ยเป็นประจำ� แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�ง ผ้ ้ใหญ่่และผ้ส้้ำงอ�ยุที�มีัภ�วะเรื �อรงัเหล่�นี � ค์วรทำ�กิจกรรมัท�งก�ยแบบแอโรบิกที�ระดบั ป�นกล�ง อย่�งนอ้ย 150-300 น�ที หรือที�ระดบัหนกั อย่�งนอ้ย 75-150 น�ที หรือผสำมัทั�ง 2 ระดบัอย่�งเท่�เทียมักนั ติลอดทั�งสำปัด�หเ์พื�อสุำข้ภ�พที�ดีอย่�งต่ิอเนื�อง แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อได�ป�นกล�ง ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 80 ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ • ห�กไม่ัสำ�มั�รถทำ�ต�มัค์ำ�แนะนำ�ด� นบนนี�ได� ผู้้�ใหญ่่ที� มีัภั�วัะเร่ �อรงัค์วัรมุ่ังที�จัะเขี� ร่วัมั กิจักรรมัท�งก�ยต�มัค์วั�มัสำ�มั�รถขีองตน • ผู้้�ใหญ่่ที�มีัภั�วัะเร่ �อรงัเหล่�นี�ค์วัรจัะเริ�มัทำ�กิจักรรมัท�งก�ยแต่น�อยก่อนและค่์อยเพิ็�มัค์วั�มัถี� ค์วั�มัหนกัหน่วัง และระยะเวัล�ขี่ �น • ผู้้�ใหญ่่ที�มีัภั�วัะเร่ �อรงัเหล่�นี�ค์วัรปร่กษ�ผู้้�เชี�ยวัช�ญ่ด� นกิจักรรมัท�งก�ยหร่อผู้้�เชี�ยวัช�ญ่ ด� นก�รด้แลสุำขีภั�พ็ เพ่็�อค์ำ�แนะนำ�เกี�ยวักบัประเภัทและปริมั�ณิขีองกิจักรรมัที� เหมั�ะกบั ค์วั�มัต�องก�ร ค์วั�มัสำ�มั�รถ ขีีดจัำ�กดัและค์วั�มัซบัซ�อนขีองร่�งก�ย ก�รใช�ย� และแผู้นก�ร รกัษ�โดยรวัมัขีองแต่ละบุค์ค์ล • ใบอนุญ่�ตจั�กแพ็ทยก่์อนก�รทำ�กิจักรรมัท�งก�ยนั�นไม่ัจัำ�เป็นต่อบุค์ค์ลที� มิั ได�มีัขี�อ บ่งห� มัในก�รเริ�มัทำ�กิจักรรมัท�งก�ยในระดบัเบ�จันถง่ป�นกล�ง ที� ไม่ัเกินขีีดขีองก�รเดินเร็วั หร่อก�รใช�ชีวิัตประจัำ�วันั ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) > > > ผ้ ้ใหญ่่และผ้ส้้ำงอ�ยุที�มีัภ�วะเรื �อรงัเหล่�นี �ค์วรทำ�กิจกรรมัสำร�้งค์ว�มัแข็้งแรงใหก้บักล�้มั- เนื �อที�ใช้ก้ล�้มัเนื �อหลกัทุกส่ำวน ในระดบัป�นกล�งหรือหนกัที� อย่�งนอ้ย 2 วนัต่ิอสำปัด�ห ์ เพื�อประโยช้นต่์ิอสุำข้ภ�พ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�ง ก�รทำ�กิจกรรมัท�งก�ยในแต่ิละสำปัด�ห ์ ผ้ส้้ำงอ�ยุที�มีัภ�วะเรื �อรงัเหล่�นี �ค์วรทำ�กิจกรรมั ท�งก�ยแบบผสำมัผสำ�นที�เนน้ก�รทรงติวัและเสำริมัสำร�้งค์ว�มัแข็้งแรงที�ระดบัป�นกล�ง ข้้ �นไป อย่�งนอ้ย 3 วนัต่ิอสำปัด�ห ์เพื�อเสำริมัสำร�้งสำมัรรถภ�พร่�งก�ยและป้องกนัก�รหกลม้ัดี แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�ง ห�กไม่ัมีัข้อ้บ่งห�้มัใด ๆ ผ้ ้ใหญ่่และผ้ส้้ำงอ�ยุที�มีัภ�วะเรื �อรงัเหล่�นี �สำ�มั�รถเพิ�มัก�รทำ� กิจกรรมัท�งก�ยแบบแอโรบิกที�ระดบัป�นกล�งใหม้ั�กกว่� 300 น�ที หรือที�ระดบั มั�กใหม้ั�กกว่� 150 น�ที หรือรวมัท ั�งสำองแบบเท่� ๆ กนัติลอดทั�งสำปัด�หเ์พื�อสุำข้ภ�พที�ดี แนะนำ�โดยมีัเง่�อนไขี มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�ง หลกัฐ�นสำนบัสำนุนและเหตุิผล ขีอบเขีตขีองขี�อแนะนำ�เหล่�นี�ค่์อ ประเมิันค์วั�มัเช่�อมัโยงระหว่ั�งกิจักรรมัท�งก�ยและผู้ลลพั็ธิ ์ ท�งสุำขีภั�พ็ ดังนี� สำำ�หรบัผ้ร้อดชี้วิติจ�กมัะเร็ง ค่์อ ก�รเสีำยชีวิัตทุกสำ�เหตุ ก�รเสีำยชีวิัตจั�ก มัะเร็งโดยเฉพ็�ะ และค์วั�มัเสีำ�ยงต่อก�รเกิดใหม่ัขีองมัะเร็งหร่อมัะเร็งขีั�นปฐมัภ้ัมิัในจุัดที�สำอง สำำ�หรบัผ้ที้� มีัค์ว�มัดนัโลหิติส้ำง ค่์อ ก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อดหัวัใจั ค์วั�มัเสีำ� ยงต่อภั�วัะที� มีัโรค์วิันิจัฉัย ร่วัมั สำมัรรถภั�พ็ท�งก�ย คุ์ณิภั�พ็ชีวิัตที� เกี�ยวัเน่�องกบัสุำขีภั�พ็ และก�รดำ�เนินขีองโรค์ (ณิ ที� นี�จัะนิย�มั เป็นก�รตอบสำนองขีองค์วั�มัดนัโลหิตต่อกิจักรรมัท�งก�ย) สำำ�หรบัผ้ป่้วยเบ�หว�นช้นิดที� 2 ค่์อ ก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อดหวััใจั ค์วั�มัเสีำ�ยงต่อภั�วัะโรค์วิันิจัฉยัร่วัมั สำมัรรถภั�พ็ท�งก�ย คุ์ณิภั�พ็ ชีวิัตที�เกี�ยวัเน่�องกบัสุำขีภั�พ็ และก�รดำ�เนินขีองโรค์ และสำำ�หรบัผ้ที้�มีัเชื้ �อ HIV ค่์อ ก�รทำ�ง�นขีองร่�งก�ย (สำมัรรถภั�พ็ ค์วั�มัทนท�นในก�รออกกำ�ลงัก�ย และค์วั�มัแข็ีงแรง) คุ์ณิภั�พ็ชีวิัตที� เกี�ยวัเน่�องกบัสุำขีภั�พ็ สุำขีภั�พ็จิัต (อ�ก�รกงัวัลและซม่ัเศร� ) ตวัับ่งชี�ค์วั�มัเสีำ�ยงโรค์หลอดเล่อดหวััใจั (ไขีมันัในเล่อด นำ � ต�ลในเล่อด และส่ำวันประกอบขีองเล่อด) และผู้ลเสีำยต่อก�รดำ�เนินขีองโรค์ (กล่�วัค่์อก�รนบั CD4 และ Viral load) 81 ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) หลกัฐ�นที�ใช�อ� งอิงขี�อแนะนำ�เหล่�นี�ค่์อ ร�ยง�นขีอง PAGAC (35) ซ่�งปรบัปรุงโดยบทปริทศัน์ใหม่ั จัำ�นวัน 16 ฉบบัที�วิันิจัฉยัมั�จั�ก พ็.ศ. 2560 ถง่ พ็.ศ. 2562 ในเร่�องมัะเร็ง (n= 1) ค์วั�มัดนัโลหิตส้ำง (n= 2) และเบ�หวั�นชนิดที� สำอง (n= 13) นอกจั�กนี� มีับทปริทัศน์ที� ว่ั�ด�วัยก�รทำ�กิจักรรมัท�งก�ย และผู้ลลพั็ธิที์� เกี�ยวัเน่� องกบัสุำขีภั�พ็ในหม่้ัผู้้�มีัเช่ �อ HIV ซ่�งได�หลกัฐ�นจั�กบทปริทศันที์� เหมั�ะสำมัจัำ�นวัน 19 ฉบบั ที�ตีพิ็มัพ็ร์ะหว่ั�ง พ็.ศ. 2545 ถง่ พ็.ศ. 2561 ขี�อม้ัลค์รบถ�วันเกี�ยวักบัวิัธีิวิัจัยั ก�รแยกส่ำวันขี�อม้ัล และชุดขี�อม้ัลหลกัฐ�นนั�นมีัอย่้ที�ภั�ค์ผู้นวักเว็ับไซต ์: ชุดขี�อม้ัลหลกัฐ�น11 ข้้อัแนะนำา 11 ข้้อม่ัลออนไลน์ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ค์ว�มัสำมััพนัธิ์ร์ะหว่�งกิจกรรมัท�ง ก�ยและผลที� เกี� ยวเนื� องกบัสุำข้ภ�พ ในผ้ใ้หญ่่และผ้ส้้ำงอ�ยุ (อ�ยุ 18 ปีข้้ �นไป) ที�มีัเชื้ �อมัะเร็ง (ผ้ร้อดชี้วิติจ�กมัะเร็ง) ค์ว�มัดนัโลหิติส้ำง เบ�หว�นช้นิดที� 2 หรือ HIV คื์ออะไร ก�รทำ�กิจักรรมัท�งก�ยทำ�ให�เกิด ก�รเปลี�ยนแปลงที� เป็นผู้ลดีในระยะสำั�น และระยะย�วัต่อกระบวันก�รเผู้�ผู้ล�ญ่ อ�ห�ร กระบวันก�รเกี�ยวักบัฮอร์โมัน และกระบวันก�รอกัเสำบ ซ่�งถ้กมัองว่ั�เป็น ก�รป้องกนัก�รเกิดมัะเร็งและก�รอย่้ รอดจั�กมัะเร็ง (35) หลกัฐ�นแสำดงให� เห็นว่ั� ก�รทำ�กิจักรรมัท�งก�ยในระดบั ที� ส้ำงขี่ �นหลังจั�กตรวัจัพ็บมัะเร็งเป็น ก�รป้องกันจั�กก�รเ สีำยชีวิัตในทุก สำ�เหตุหลงัจั�กเป็นมัะเร็งเต� นมั (HR= 0.58 [95% CI: 0.52 ถง่ 0.65] ง�นวิัจัยั 17 ฉบบั) มัะเร็งลำ�ไสำ� (HR= 0.63 [95% CI: 0.50 ถง่ 0.78] ง�นวิัจัยั 10 ฉบบั) มัะเร็งระบบส่ำบพ็นัธุิเ์พ็ศหญิ่ง (HR= 0.66 [95% CI: 0.49 ถ่ง 0.88] ง�นวิัจัยั 4 ฉบบั) มัะเร็งสำมัองชนิดกลิโอมั� (HR= 0.64 [95% CI: 0.46 ถง่ 0.91] ง�นวิัจัยั 1 ฉบบั) มัะเร็งเม็ัดเล่อด (HR= 0.60 [95% CI: 0.51 ถ่ง 0.69] ง�นวิัจัยั 2 ฉบบั) มัะเร็งไต (HR= 0.60 [95% CI: 0.38 ถง่ 0.95] ง�นวิัจัยั 1 ฉบบั) มัะเร็งปอด (HR= 0.76 [95% CI: 0.60 ถง่ 0.97] ง�นวิัจัยั 2 ฉบบั) มัะเร็งต่อมัล้กหมั�ก (HR= 0.60 [95% CI: 0.46 ถ่ง 0. 79] ง�นวิัจัยั 5 ฉบบั) และมัะเร็งกระเพ็�ะอ�ห�ร (HR= 0.75 [95% CI: 0.61 ถง่ 0.93] ง�นวิัจัยั 1 ฉบบั) (105) ก�รทำ�กิจักรรมัท�งก�ยในปริมั�ณิ ที�มั�กขี่ �นหลงัก�รตรวัจัพ็บมัะเร็งเช่�อมั โ ยง กับ ค์วั�มั เ สีำ� ยง ที� ล ด ลง ขีอง ก�ร เสีำยชีวิัตจั�กสำ�เหตุเฉพ็�ะในผู้้�รอดชีวิัต จั�กมัะเร็งเต� นมั มัะเร็งกระเพ็�ะอ�ห�ร และมัะเร็งต่อมัล้กหมั�ก บทวิัเค์ร�ะห ์ อภิัมั�นค์�นพ็บอนัตร�ยจั�กภั�วัะก�รเสีำย ชีวิัตที�ลดลง สำำ�หรบัผู้้�ที�ทำ�กิจักรรมัท�ง ก�ยทุกร้ปแบบ หลงัก�รวิันิจัฉยัโรค์มัะเร็ง ทุกประเภัทในระดบัส้ำงสุำดเทียบกบัตำ� สุำด (HR= 0.63 [95% CI: 0.53 ถง่ 0.75] ง�นวิัจัยั 4 ฉบบั ) มัะเร็งเต� นมั (HR= 0.63 [95% CI: 0.50 ถง่ 0.78] ง�นวิัจัยั 13 ฉบบั) มัะเร็งลำ�ไสำ� (HR= 0.62 [95% CI: 0.44 ถ่ง 0.86] ง�นวิัจัยั 6 ฉบบั) และมัะเร็งต่อมัล้กหมั�ก (HR= 0.70 ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 82 [95% CI: 0.55 ถง่ 0.90] ง�นวิัจัยั 4 ฉบบั) (105) อย่�งไรก็ดี มีัหลกัฐ�นไม่ัเพี็ยงพ็อที� จัะระบุว่ั� กิจักรรมัท�งก�ยจัะเกี�ยวัเน่�อง กบัก�รกลบัมั�เกิดใหม่ัขีองมัะเร็งหร่อ มัะเร็งขีั�นปฐมัภ้ัมิัในจุัดที�สำอง กิจักรรมัท�งก�ยมีัค์วั�มัสำำ�ค์ัญ่ สำำ�หรับก�รป้องกันเบ่ �องต�นและก�ร จัดัก�รค์ว�มัดนัโลหิติส้ำง ด�วัยหลกัฐ�น ที� แสำดงว่ั� ก�รทำ�กิจักรรมัท�งก�ย สำร� งเสำริมัสำมัรรถภั�พ็ท�งร่�งก�ย ก�รดำ�เนินขีองโรค์หลอดเล่อดหวััใจั (เช่น ก�รตอบสำนองขีองค์วั�มัดนัโลหิตต่อ กิจักรรมัท�งก�ย) และก�รเสีำยชีวิัตจั�ก โรค์หลอดเล่อดหัวัใจัในผู้้�ป่วัยค์วั�มัดนั โลหิตส้ำง (35) ตวััอย่�งเช่น เม่ั�อเปรียบ- เที ย บ กับ ก ลุ่มั ค์วั บ คุ์มั ที� ไ ม่ั มีั ก�ร ทำ � กิจักรรมัท�งก�ย ผู้้�มีัค์วั�มัดนัโลหิตส้ำง และมีัก�รเค์ล่�อนไหวัร่�งก�ยค์ล่องแค์ล่วั จัะสำ�มั�รถลดค์วั�มัดนัช่วังหัวัใจับีบลง ได�ประมั�ณิ12มิัลลิเมัตรปรอท และค์วั�มั ดนัโลหิตเม่ั�อหัวัใจัค์ล�ยตวััประมั�ณิ 6 มิัลลิเมัตรปรอท (SBP MD= 12.26 mm Hg [95% CI: 15.17 ถง่ 9.34] p= < 0.05; DBP MD= 6.12 mm Hg [95% CI: 7.76 ถง่ 4.48] p= < 0.05) (106) หลกัฐ�นที� ปร�กฎขี่ �นแสำดงให�เห็นว่ั�ผู้้�ที� มีัโรค์ค์วั�มั ดนัโลหิตส้ำงและทำ�กิจักรรมัท�งก�ยนั�น จัะทำ�ให�คุ์ณิภั�พ็ชีวิัตด� นสุำขีภั�พ็ดีขี่ �นได� อย่�งมีันยัสำำ�ค์ญั่ เม่ั�อเปรียบเทียบกบัผู้้� ไม่ัทำ�กิจักรรมัท�งก�ย (54) กิจักรรมัท�งก�ย รวัมัถง่กิจักรรมั แบบแอโรบิก กิจักรรมัสำร� งค์วั�มัแข็ีงแรง ให�กบักล� มัเน่�อและก�รทำ�กิจักรรมัแบบ แอโรบิกผู้นวักกบัเสำริมัสำร� งค์วั�มัแข็ีง- แรงกล� มัเน่�อนั�น เช่� อมัโยงกบัตวัับ่งชี� ทุติยภ้ัมิัขีองค์วั�มัเสีำ� ยงในก�รดำ�เนิน โรค์ที� ดีขี่ �น (HbA1c ค์วั�มัดันโลหิต ดัช นี มั วั ล ก � ย แ ล ะ ไขี มัันใน เ ล่ อ ด ) ในผู้้�ใหญ่่ที� เป็นเบ�หว�นช้นิดที� 2 (35) ตวััอย่�งเช่น ง�นวิัจัยัเม่ั�อไม่ัน�นมั�นี�พ็บ ว่ั� ก�รออกกำ�ลงัก�ยแบบมีัแรงต� นนั�น เช่�อมัโยงกบัก�รลด HbA1c ลงอย่�งมั�ก เม่ั�อเทียบกบักลุ่มัค์วับคุ์มั และก�รออก กำ�ลงัก�ยแบบมีัแรงต� นส้ำงมีัผู้ลในท�ง บวักอย่�งมีันยัสำำ�ค์ญั่กบัปริมั�ณิอินซ้ลิน ขีณิะอดอ�ห�ร (107) มีัหลกัฐ�นไม่ัเพี็ยง พ็อที�จัะประเมิันผู้ลกระทบขีองก�รออก กำ�ลงัก�ยกบัคุ์ณิภั�พ็ชีวิัตที�เกี�ยวัเน่�องกบั สุำขีภั�พ็และสำมัรรถภั�พ็ร่�งก�ยขีอง ผู้้�ใหญ่่ที�เป็นโรค์เบ�หวั�นชนิดที�สำอง กิจักรรมัท�งก�ยสำำ�หรบัผ้มี้ัเชื้ �อ HIV นั�น ช่วัยพ็ฒัน�ค์วั�มัแข็ีงแรงขีอง ปอดและหัวัใจั ก�รแทรกแซงที� นำ�มั� วิัจััยนั�นรวัมัเอ�ทั�งก�รออกกำ�ลงัก�ย แบบแอโรบิกหร่อก�รออกกำ�ลงัก�ยที� ผู้สำ�นก�รออกกำ�ลงัก�ยย่ดหยุ่นกล� มั เน่�ออย่�งต่อเน่�อง อย่�งน�อย 30 น�ที 3 ค์รั�งต่อสำปัด�ห ์(108,109) มีัหลกัฐ�นเช่น กนัว่ั� ก�รแทรกแซงกิจักรรมัท�งก�ยช่วัย ปรบัปรุงตวัับ่งชี�ค์วั�มัเสีำ�ยงต่อโรค์ระบบ หัวัใจัหลอดเล่อด (เช่น ไขีมันัในเล่อด) แมั�ว่ั�ผู้ลที� ได�จัะผู้สำมักนัไป ไม่ัมีัผู้ลกระทบ ย่นยนัเร่�องค์วั�มัเขี�มัขี�นขีองอินซ้ลินแมั� ระดบักล้โค์สำจัะลดลงหลงัก�รออกกำ�ลงั- ก�ยแบบแอโรบิก (110) กิจักรรมัท�ง- ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) 83 ก�ยไม่ัว่ั�จัะเป็นแบบแอโรบิกหร่อแบบ ผู้สำมักบัก�รออกกำ�ลงัก�ยสำร� งค์วั�มั แข็ีงแรงกล� มัเน่�อในผู้้�ที� มีัเช่ �อ HIV นั�น เช่�อมัโยงในท�งบวักกบัคุ์ณิภั�พ็ชีวิัตที� เกี�ยวัเน่�องกบัสุำขีภั�พ็ (111) และก�รลด อ�ก�รซม่ัเศร� และค์วั�มักงัวัล (112) บท วิัเค์ร�ะห์อภิัมั�นสำำ�หรับโรค์ซ่มัเศร� (ง�นวิัจััย 9 ฉบบั) แสำดงค่์�เบี� ยงเบน มั�ตรฐ�นที� 0.84 (95% CI: 1.57 ถ่ง 0.11) เอ่ �อกบักลุ่มัที�มีัก�รแทรกแซง (p= 0.02) ค่์�เบี�ยงเบนมั�ตรฐ�นสำำ�หรบัก�ร ลดอ�ก�รกงัวัล (ง�นวิัจัยั 5 ฉบบั) มีันยั สำำ�ค์ญั่ท�งสำถิติที� เอ่ �อต่อก�รแทรกแซง (1.23 [95% CI: 2.42 ถง่ 0.04], p= 0.04) (112) กิจักรรมัท�งก�ยยงัเช่�อมัโยงกบัค่์� เฉลี�ยมั�ตรฐ�นที�มีันยัสำำ�ค์ญั่ที� เพิ็�มัขี่ �นใน นำ � หนกัขีองร่�งก�ยที� ไม่ัมีัไขีมันัถง่ 1.75 กิโลกรัมั และมีัก�รลดลงอย่�งมีันัย สำำ�ค์ัญ่ขีองไขีมัันในร่�งก�ยที� ร�อยละ 1 . 1 2 สำำ � ห รั บ ผู้้� เ ขี� � ร่ วั มั ใ น ก ลุ่ มั ค์วับคุ์มัที� มีัก�รออกกำ�ลงัก�ย รวัมัถ่ง ก�รเพิ็� มัเสำ�นรอบวังกล� มัเน่�อขี�และ แขีน เปรียบเทียบกบัผู้้�เขี� ร่วัมัที�อย่้ใน กลุ่มัค์วับคุ์มัที� ไม่ัมีัก�รออกกำ�ลงัก�ย (111) แต่ไม่ัเช่� อมัโยงกับก�รเปลี� ยน แปลงดชันีมัวัลก�ยหร่อรอบเอวัในผู้้�ที� มีัเช่ �อ HIV (111) กิจักรรมัท�งก�ยไม่ัมีั อิทธิิพ็ลในท�งตรงกันขี� มักับเค์ร่� อง บ่งชี�กบัก�รดำ�เนินโรค์ HIV ตวััอย่�งเช่น ก�รนับ CD4 (เซลสำต่์อล้กบ�ศกเ์มัตร) หร่อปริมั�ณิเช่�อ HIV ในเล่อด ที�สำำ�ค์ญั่ค่์อ หลกัฐ�นชิ�นนี�แนะนำ�ว่ั� HIV ในฐ�นะที�เป็น โรค์เร่�อรงัจัะไม่ัมีัผู้ลกระทบในท�งตรงกนั ขี� มัจั�กก�รทำ�กิจักรรมัท�งก�ย คณะทำางาน GDG สรุปว่า : • มีัหลักฐ�นเช่� อถ่อได�ป�นกล�งว่ั� ปริมั�ณิขีองก�รทำ�กิจักรรมัท�งก�ย ที�มั�กขี่ �นหลงัตรวัจัพ็บมัะเร็งนั�นจัะ เช่�อมัโยงกบัค์วั�มัเสีำ�ยงที� ลดลงขีอง ก�รเสีำยชีวิัตในทุกสำ�เหตุ ก�รเสีำยชีวิัต จั�กสำ�เหตเฉพ็�ะและมัะเร็งเฉพ็�ะจุัด ในผู้้�รอดชีวิัตจั�กมัะเร็ง • มีัหลักฐ�นเช่� อถ่อได�ป�นกล�งว่ั� กิจักรรมัท�งก�ยลดค์วั�มัเสีำ�ยงต่อก�ร ดำ�เนินโรค์ขีองโรค์หัวัใจัและหลอด เ ล่อดในผู้้� ใหญ่่ที� มีัภั�วัะค์วั�มัดัน โลหิตส้ำง • มีัหลกัฐ�นที� มีัค์วั�มัน่�เช่� อถ่อป�น- กล�งว่ั� กิจักรรมัท�งก�ยจัะทำ�ให� สำมัรรถภั�พ็ร่�งก�ยดีขี่ �นและผู้ลลพั็ธิ ์ ขีองคุ์ณิภั�พ็ชีวิัตที� เกี� ยวัเน่� องกับ สุำขีภั�พ็ในผู้้�ใหญ่่ที� มีัภั�วัะค์วั�มัดัน โลหิตส้ำง • มีัหลกัฐ�นที� มีัค์วั�มัน่�เช่�อถ่อมั�กว่ั� กิจักรรมัท�งก�ยจัะปรับปรุงตัวั บ่งชี�ก�รดำ�เนินขีองโรค์ (HbA1c ค์วั�มัดนัโลหิต ดชันีมัวัลก�ย และไขีมันั ในเล่อด) ในผู้้�ใหญ่่ที�มีัเบ�หวั�นชนิดที� 2 • มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�งว่ั� ก�ร เช่� อมัโยงระหว่ั�งกิจักรรมัท�งก�ย และก�รฟ้ิ�นฟ้ิค์วั�มัแข็ีงแรงขีองร่�ง ก�ย (ก�รรบัออกซิเจันระดบัส้ำงสุำด ค์วั�มัทนท�นในก�รออกกำ�ลงัก�ย) แ ล ะ ค์ วั � มั แ ข็ี ง แ ร ง ก ล� � มั เ น่� อ สำำ�หรับค์นที� มีัเช่ �อ HIV และค์วั�มั เช่�อมัโยงที� เอ่ �อระหว่ั�งกิจักรรมัท�ง ก�ยและองค์ป์ระกอบขีองร่�งก�ย ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 84 คุ์ณิภั�พ็ชีวิัตที� เกี�ยวัเน่� องกบัสุำขีภั�พ็ อ�ก�รซม่ัเศร� และกงัวัลที�ลดลง และ ไม่ัมีัก�รเปลี�ยนแปลงจัำ�นวันเช่�อ HIV ในเล่อดหร่อก�รนบั CD4 ในค์นที�มีัเช่ �อ HIV • ประโยชนเ์ช่� อมัโยงกับก�รเขี� ร่วัมั กิจักรรมัท�งก�ยเป็นกิจัวัตัรสำำ�หรบัผู้้� รอดชีวิัตจั�กมัะเร็งและผู้้�มีัค์วั�มัดนั โลหิตส้ำง เบ�หวั�นชนิดที� 2 และ HIV ที� สำัมัพ็ันธิก์ับผู้ลลัพ็ธิท์�งสุำขีภั�พ็ เฉพ็�ะอย่�งมีัมั�กกว่ั�ค์วั�มัเสีำ�ยง มีัค์ว�มัเชื้�อมัโยงในก�รติอบสำนองต่ิอ ปริมั�ณหรือไม่ั (ปริมั�ณ ระยะเวล� ค์ว�มัถี� ค์ว�มัหนกัหน่วง) ก�รทำ�กิจักรรมัท�งก�ยในปริมั�ณิ ที� มั�กขี่ �นหลงัก�รตรวัจัพ็บมัะเร็งนั�น เช่�อมัโยงกบัค์วั�มัเสีำ�ยงที�ลดลงขีองภั�วัะ ก�รเสีำยชีวิัตจั�กมัะเร็งทุกสำ�เหตุ และ ก�รเสีำยชีวิัตที� เจั�ะจังเฉพ็�ะมัะเร็ง หลกัฐ�นชี�ให�เห็นค์วั�มัสำมััพ็นัธิที์� ไม่ัเป็น เสำ�นตรงระหว่ั�งระดบัที� เพิ็�มัส้ำงขี่ �นขีอง ก�รทำ�กิจักรรมัท�งก�ยหลงัตรวัจัพ็บ มัะเร็ง และภั�วัะก�รเสีำยชีวิัตเจั�ะจัง เฉพ็�ะมัะเร็งเต� นมั และภั�วัะก�รเสีำย ชีวิัตทุกสำ�เหตุไปจันถ่ง 10-15 MET- hours ต่อสำปัด�ห ์ (ค์งที� เป็นเวัล� 150 น�ทีต่อสำัปด�ห์ด�วัยก�รทำ�กิจักรรมั ท�งก�ยที� ระดับป�นกล�งถ่งมั�ก) โดยไม่ัมีัหลักฐ�นถ่งอันตร�ยต่�ง ๆ ในระดบัที� ส้ำงขี่ �น (105) มีัขี�อแนะนำ�ถ่ง ค์วั�มัเช่� อมัโยงกับก�รตอบสำนองต่อ ปริมั�ณิในทำ�นองเดียวักนัสำำ�หรบัมัะเร็ง ในจุัดอ่�น ๆ แต่ก็ยงัมีัง�นวิัจัยัน�อยเกินไป ที�จัะสำร� งบทวิัเค์ร�ะหอ์ภิัมั�นอย่�งเป็น ท�งก�รได� ง�นวิัจัยัเพิ็�มัเติมัเป็นที�ต�อง ก�ร เพ่็�อกำ�หนดพ็ลงัขีองค์วั�มัเช่�อมัโยงนี� มีัค์วั�มัสำมััพ็นัธิ ์ในก�รตอบสำนอง ต่อปริมั�ณิที�ชดัเจันระหว่ั�งกิจักรรมัท�ง ก�ยและภั�วัะก�รเสีำยชีวิัตจั�กโรค์หวััใจั และหลอดเล่อดสำำ�หรบัผู้้�ที� มีัภั�วัะค์ว�มั ดนัโลหิติส้ำง (35) ผู้ลก�รศก่ษ�แสำดงให� เห็นว่ั�ค์วั�มัดนัโลหิตหลงัก�รบีบตวััขีอง หัวัใจัจัะเพิ็�มัขี่ �นในช่วังค์วั�มัดนัโลหิตส้ำง ค์วั�มัเสีำ�ยงต่อภั�วัะก�รเสีำยชีวิัตจั�กโรค์ หลอดเล่อดหวััใจัเพิ็�มัขี่ �น แต่ค์วั�มัเสีำ�ยงที� เพิ็�มัขี่ �นนั�นลดลงด�วัยก�รทำ�กิจักรรมัท�ง- ก�ยในระดบัที� ส้ำงขี่ �น (35) เช่นเดียวักบั ค์ำ�แนะนำ�สำำ�หรับประช�กรทั� วัไป ก�ร แทรกแซงต�มัแบบแผู้นโดยส่ำวันใหญ่่ จัะเป็นก�รทำ�กิจักรรมัท�งก�ยแบบ แอโรบิกที�ระดบัป�นกล�งด�วัยเวัล�ประ- มั�ณิ 30-60 น�ที 3 วันัต่อสำปัด�ห ์และ/ หร่อออกกำ�ลงัก�ยแบบมีัแรงต� น 2-3 ชุดต่อสำปัด�ห์ มีั ห ลัก ฐ � น ที� เ ป็ น ร้ ป ธิ ร ร มั ถ่ ง ค์วั�มัเช่�อมัโยงที�เป็นเสำ�นโค์�งค์วัำ� ระหว่ั�ง ปริมั�ณิก�รทำ�กิจักรรมัท�งก�ยและ ค์วั�มัเสีำ�ยงขีองภั�วัะก�รเสีำยชีวิัตจั�กโรค์ หลอดเล่อดหัวัใจัในผู้้�ป่วัยที� เ ป็นเบ� หว�นช้นิดที� 2 (113-115) ก�รทำ� กิจักรรมัท�งก�ยในปริมั�ณิที� มั�กขี่ �น (จั�กทั�งตำ� กว่ั� หร่อเทียบเท่� หร่อมั�ก กว่ั�ระดบัที�แนะนำ�ที� 150 น�ทีต่อสำปัด�ห ์ ด�วัยก�รทำ�กิจักรรมัท�งก�ยที� ระดับ ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) 85 ป�นกล�ง) ลดค์วั�มัเสีำ�ยงได�อย่�งต่อเน่�อง ตวััอย่�งเช่น เม่ั� อเปรียบเทียบกบัก�ร ไม่ัทำ�กิจักรรมัใด ๆ เลย ก�รเขี� ร่วัมั กิจักรรมับ�งประเภัทเช่�อมัโยงกบัก�ร ลดค์วั�มัเสีำ� ยงต่อภั�วัะก�รเสีำยชีวิัต จั�กโรค์หลอดเล่อดหัวัใจัที�ร�อยละ 32 (อตัร�ก�รเต�นหัวัใจัที�ปรบัแล�วั = 0.68 [95% CI: 0.51 ถง่ 0.92]) ขีณิะที�ก�รทำ� กิจักรรมัในปริมั�ณิที� เป็นไปต�มัขี�อ แนะนำ�หร่อมั�กกว่ั� เช่� อมัโยงกบัก�ร ลดค์วั�มัเสีำ� ยงต่อภั�วัะก�รเสีำยชีวิัต จั � ก โร ค์ ห ล อ ด เ ล่ อ ด หัวัใจั ( อัต ร � ก�รเต�นหวััใจัที�ปรบัแล�วั = 0.60 [95% CI: 0.44 ถ่ง 0.82]) ในปริมั�ณิที� มั�ก ขี่ �นที�ร�อยละ 40 (115) ก�รแทรกแซง อย่้ที�ร�วั ๆ ก�รทำ�กิจักรรมัแบบแอโรบิก ที� ระดับป�นกล�ง 150-300 น�ที หร่อที�ระดบัหนกัเป็นเวัล� 75 น�ที และ/ หร่อออกกำ�ลงัก�ยแบบมีัแรงต� น 2-3 ชุดต่อสำปัด�ห ์ สำำ�หรบัผู้ลลพั็ธิบ์�งอย่�ง (ตัวัอย่�งเช่น HBA1c และค์วั�มัดัน โลหิต) ในผู้้�ใหญ่่ที� เป็นเบ�หวั�นชนิดที� สำอง มีัหลกัฐ�นว่ั�มีัผู้ลที� เห็นได�ชดัเจัน ขี่ �นจั�กก�รทำ�กิจักรรมัแบบแอโรบิก ที� มั�กขี่ �น (เช่น มั�กกว่ั� 150 น�ที ต่อสำปัด�หเ์ทียบกบัน�อยกว่ั� 150 น�ที ต่อสำปัด�ห)์ แต่ยงัมีัหลกัฐ�นจัำ�กดัสำำ�หรบั ค์วั�มัหนกัหน่วัง (35) มีัหลักฐ�นไม่ัเพี็ยงพ็อที� จัะบัญ่ ญ่ัติค์วั�มัสำัมัพ็ันธิ ์ ในก�รตอบสำนอง ต่อปริมั�ณิระหว่ั�งกิจักรรมัท�งก�ย และองค์ป์ระกอบร่�งก�ย หร่อตวัับ่งชี� ที� เป็นตวัักล�งขีองโรค์หลอดเล่อดหวััใจั (เช่น ขี�อม้ัลไขีมันัในเล่อด ก�รต� นอินซ้ลิน ค์วั�มัเขี�มัขี�นขีองกล้โค์สำขีณิะอดอ�ห�ร หร่อค์วั�มัดนัโลหิต) ในผู้้�ที�มีัเช่ �อ HIV ง�น วิัจััยส่ำวันใหญ่่ที� สำร� งหลักฐ�นต่�ง ๆ นั�น เกี�ยวัเน่�องกบัก�รแทรกแซงกิจักรรมั ท�งก�ย อย่�งน�อย 3 ค์รั�งต่อสำปัด�ห ์ เป็นระยะเวัล� 12-48 สำปัด�ห ์และกิจักรรมั แบบแอโรบิกในระดบัป�นกล�งจันถ่ง หนกัแต่เพี็ยงอย่�งเดียวั อย่�งน�อย 30 น�ที หร่อผู้สำมัผู้สำ�นไปกบัก�รออกกำ�ลงั ก�ยแบบมีัแรงต� นอย่�งต่อเน่� อง มีั หลกัฐ�นไม่ัเพี็ยงพ็อที�จัะบญั่ญ่ติัอย่�งแน่ ชดัถง่ค์วั�มัสำมััพ็นัธิต่์อก�รตอบสำนองต่อ ปริมั�ณิกบัสุำขีภั�พ็จิัตและผู้ลลพั็ธิที์�เกี�ยวั เน่�องกบัคุ์ณิภั�พ็ชีวิัต หลกัฐ�นที�มีัอย่้นั�น มั�จั�กง�นวิัจัยัที�ประเมิันก�รแทรกแซง กิจักรรมัท�งก�ย 3 ค์รั�งต่อสำปัด�หห์ร่อ มั�กกว่ั�นั�นอย่�งเป็นแบบแผู้น โดยรวัมัแล�วันั�น มีัหลกัฐ�นที�จัดั ลำ � ดับ จั � ก ร ะ ดับ ค์ วั � มั ห นั ก ห น่ วั ง ป�นกล�งจันถง่หนกัหน่วังส้ำงเพ่็�อสำนบั- สำนุนขี�อแนะนำ�ขีองกิจักรรมัท�งก�ย ที� ระดับป�นกล�ง 150-300 น�ที (หร่อเทียบเท่�) สำำ�หรบักลุ่มัประช�กรที�มีั ภั�วัะเร่ �อรงัที�ระบุและมีัผู้ลลพั็ธิท์�งสุำขี- ภั�พ็เฉพ็�ะกลุ่มั มีัหลกัฐ�นที�ชดัเจันขี่ �น ว่ั� ระดบัขีองกิจักรรมัที�ส้ำงขี่ �นนั�นสำมััพ็นัธิ ์ กบัประโยชนที์�มั�กขี่ �น ในหลกัฐ�นที�กล่�วั ถง่ผู้้�ที�มีัภั�วัะค์วั�มัดนัโลหิตส้ำง เบ�หวั�น ชนิดที� 2 และผู้้�รอดชีวิัตจั�กมัะเร็งยอมัรบั ว่ั�มีั ก�รผู้ันแปรจั�กค์วั�มัน่�เช่� อถ่อ และค์วั�มัตรงไปตรงมั�ขีองหลกัฐ�น ต�มัสำภั�วัะเร่ �อรงัเฉพ็�ะและผู้ลลัพ็ธิ ์ ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 86 เฉพ็�ะที�นำ�มั�ทดสำอบ ขีณิะที�หลกัฐ�น แสำดงถง่ผู้ลในท�งบวักจั�กก�รออกกำ�- ลงัก�ยแบบฝึึกค์วั�มัแข็ีงแรง ค์วั�มัถี�ขีอง ก�รออกกำ�ลงัก�ยแบบมีัแรงต� น ค่์อ 2 หร่อ 3 ชุดต่อสำปัด�ห์ ค์ณะทำ�ง�น GDG สำรุปว่� • มีัหลกัฐ�นที� มีัค์วั�มัน่�เช่� อถ่อป�น- กล�งเกี� ยวักบัค์วั�มัสำมััพ็ันธิ ์ในก�ร ตอบสำนองต่อปริมั�ณิระหว่ั�งก�รทำ� กิจักรรมัท�งก�ยและภั�วัะก�รเสีำย ชีวิัตจั�กทุกสำ�เหตุที� ลดลง รวัมัถ่ง ภั�วัะก�รเสีำยชีวิัตจั�กมัะเร็งโดยเฉพ็�ะ ในผู้้�รอดชีวิัตจั�กมัะเร็ง • มีัหลักฐ�นเช่� อ ถ่อได� ส้ำงถ่งค์วั�มั สำัมั พ็ัน ธิ ์ขี อ ง ก � ร ต อ บ สำ น อ ง ต่ อ ปริมั�ณิระหว่ั�งก�รทำ�กิจักรรมัท�ง ก�ยและภั�วัะก�รเสีำยชีวิัตจั�กโรค์ หลอดเล่อดหัวัใจั สำำ�หรบัผู้้�ใหญ่่ที� มีั ภั�วัะค์วั�มัดนัโลหิตส้ำง • มีัหลกัฐ�นขีองค์วั�มัสำมััพ็นัธิ ์ในก�ร ตอบสำนองต่อปริมั�ณิเป็นเสำ�นโค์�งค์วัำ� ระหว่ั�งปริมั�ณิขีองกิจักรรมัและ ค์วั�มัเสีำ� ยงต่อก�รเสีำยชีวิัตจั�กโรค์ หลอดเล่อดหวััใจัในกลุ่มัผู้้�ใหญ่่ที� เป็น เบ�หวั�นชนิดที� 2 • มีัหลกัฐ�นไม่ัเพี็ยงพ็อเกี�ยวักบัค์วั�มั สำมััพ็นัธิ ์ในก�รตอบสำนองต่อปริมั�ณิ ระหว่ั�งกิจักรรมัท�งก�ยและตวัับ่งชี� ที� เป็นตวัักล�งขีองโรค์ระบบท�งเดิน ห�ยใจั องค์ป์ระกอบขีองร่�งก�ย และคุ์ณิภั�พ็ชีวิัตที� เกี� ยวัเน่� องกับ สุำขีภั�พ็ อ�ก�รกงัวัลและโรค์ซม่ัเศร� ในผู้้�ที�มีัเช่ �อ HIV • ก�รแทรกแซงด�วัยกิจักรรมัแบบ แอโรบิกที�ระดบัป�นกล�งในช่วัง 150- 300 น�ที (หร่อเทียบเท่�) สำร� งผู้ลลพั็ธิ ์ ที�เอ่ �อประโยชนต่์อสุำขีภั�พ็และผู้ลลพั็ธิ ์ ในท�งบวักจั�กก�รออกกำ�ลงัก�ย เพ่็� อเสำริมัค์วั�มัแข็ีงแรงพ็ร�อมัก�ร ออกกำ�ลงัก�ยแบบมีัแรงต� น 2 หร่อ 3 ชุดต่อสำปัด�หต์�มัที�ระบุไวั� ค์ว�มัเชื้�อมัโยงผนัแปรติ�มัช้นิดหรือ ข้อบเข้ติข้องกิจกรรมัท�งก�ยภ�พ หรือไม่ั มีัหลกัฐ�นว่ั�กิจักรรมัท�งก�ยต่�ง ชนิดและต่�งขีอบเขีตนั�น เ อ่ �อประ โยชนต่์อผู้ลลพั็ธิท์�งสุำขีภั�พ็ ผ้ร้อดชี้วิติ จ�กมัะเร็งที� ทำ�กิจักรรมัแบบแอโรบิก และสำร� งค์วั�มัแข็ีงแรงให�กบักล� มัเน่�อ ในระดบัที� แนะนำ�เทียบกบัผู้้�ที� ทำ�ไม่ัถ่ง ระดบัที�แนะนำ�นั�นมีัอตัร�เสีำ�ยงต่อภั�วัะ ก�รเสีำยชีวิัตจั�กโรค์มัะเร็งลดลงอย่�งมีั นัยสำำ�ค์ัญ่ (อัตร�ก�รเต�นขีองหัวัใจั ที� ถ้ ก ป รั บ = 0 . 7 0 [ 9 5 % C I : 0 . 5 0 ถ่ง 0 . 9 8 ] ) ( 8 4 ) ห ลักฐ � น แสำดงให�เห็นว่ั� ก�รย่ดมัั�นกบัขี�อแนะนำ� ในก�รทำ�กิจักรรมัท�งก�ยเพ่็�อย่ดหยุ่น กล� มัเน่�อเพี็ยงอย่�งเดียวั เทียบกบัก�ร ไม่ัย่ดติด ยงัค์งมีัประโยชน์ในก�รปรบั ปรุงผู้ลขีองก�รเสีำยชีวิัตจั�กมัะเร็งให�ดี ขี่ �น ( อตัร�ก�รเต�นขีองหวััใจั = 0.66 [95% CI: 0.48 ถ่ง 0.92]) (84) บทวิัเค์ร�ะห ์ อภิัมั�นยงัได�ร�ยง�นถง่ค์วั�มัเช่�อมัโยงนี� โดยขีอบเขีตในก�รทำ�กิจักรรมัท�งก�ย แ ล ะ พ็ บ ก � ร เ สีำ ย ชี วิั ต ที� ล ด ล ง อ ย่ � ง ต่อเน่� องที� สุำด ทั�งจั�กมัะเร็งทุกจุัด ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) 87 ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) มัะเร็งเต� นมั และภั�วัะก�รต�ยจั�ก มัะเร็งลำ�ไสำ�โดยเฉพ็�ะ สำำ�หรบักิจักรรมั ท�งก�ยเชิงสำนัทน�ก�ร (105) สำำ�หรบั ผู้้�ใหญ่่ที�มีัภั�วัะค์ว�มัดนัโลหิติส้ำง หลกั- ฐ�นสำนับสำนุนกิจักรรมัแบบแอโรบิก ก�รสำร� งค์วั�มัแข็ีงแรงให�กับกล� มั เน่�อ และก�รผู้สำมัผู้สำ�นทั�งสำองร้ปแบบ เพ่็� อแก� ไขีก�รดำ�เนินโรค์หลอดเล่อด หัวัใจั ผู้ลต่อค์วั�มัดันโลหิตที� ลดลง ระหว่ั�งก�รทำ�กิจักรรมัท�งก�ยร้ป แบบดั�งเดิมั (เช่น กิจักรรมัแบบแอ- โรบิกและแบบมีัแรงต� น) ไม่ัผู้ันแปร อย่�งมีันัยสำำ�ค์ญั่ในหม่้ัค์นที� มีัค์วั�มัดนั โลหิตส้ำง (35) อย่�งไรก็ต�มั หลกัฐ�นนี� ไม่ัได�เปรียบเทียบชนิดขีองกิจักรรมัโดย ตรง มีัหลกัฐ�นเพิ็�มัเติมัที�จัะสำนบัสำนุนผู้ล ที�เป็นประโยชนจ์ั�กก�รออกกำ�ลงัก�ยใน ร้ปแบบอ่�น สำำ�หรบัผู้้�มีัภั�วัะค์วั�มัดนัโลหิต ส้ำง (เช่น ไทชี� โยค์ะ ชี�กง) อย่�งไรก็ดีง�น วิัจัยัเพิ็�มัเติมัเพ่็�อวิันิจัฉยักิจักรรมัเหล่�นี� นั�นมีัค์วั�มัต�องก�ร เพ่็� อกำ�หนดค์วั�มั เขี�มัขี�นขีองค์วั�มัเช่�อมัโยง กิจักรรมัแบบแอโรบิก กิจักรรมั สำร� งค์วั�มัแข็ีงแรงให�กับกล� มัเน่�อ หร่อก�รผู้สำมัผู้สำ�นทั�งสำองประเภัทนั�น เช่� อมัโยงกับตัวับ่งชี�ทุติยภ้ัมิัในเร่� อง ค์วั�มัเสีำ� ยงต่อก�รดำ�เนินโรค์ที� ดีขี่ �น (HbA1c, ค์วั�มัดนัโลหิตดชันีมัวัลก�ย แ ล ะ ไ ขี มััน ใ น เ ล่ อ ด ) ใ น ผู้้� ใ ห ญ่่ ที� มีั เบ�หว�นช้นิดที� 2 (35, 107) บทปริทศัน ์ ฉบบัหน่�งที�มีักลุ่มัค์วับคุ์มัแบบสุ่ำมั 24 ร�ย (n= 962) ระบุว่ั� ก�รออกกำ�ลงัก�ยแบบมีั แ ร ง ต� น นั� น เ ช่� อ มั โ ย ง กั บ ก � ร ล ด จัำ�นวัน HbA1c เป็นอย่�งมั�กเทียบกบั ก ลุ่มั ค์วั บ คุ์มั ( ส่ำ วั น เ บี� ยง เ บ น เฉ ลี� ย = 0 . 4 5 [ 9 5 % C I : 0 . 6 5 ถ่ ง 0 . 2 5 ] , ก � ร ท ด ล อ ง 2 0 ค์ รั�ง ; n = 824) ผู้ลที� ได�ระหว่ั�งก�รออกกำ�ลงัก�ย แบบมีัแรงต� นด�วัยค์วั�มัหนกัหน่วังส้ำง เทียบกับกลุ่มัค์วับคุ์มัอินซ้ลินขีณิะอด อ�ห�รนั�น ได�ผู้ลที� มีันัยสำำ�ค์ญั่ท�งสำถิติ (ส่ำวันเบี�ยงเบนเฉลี�ย = 4.60 [95% CI: 7.53 ถง่ 1.67] ก�รทดลอง 5 ค์รั�ง; n= 174) (107) บทปริทศันอี์กฉบบัหน่�งที� มีักลุ่มัค์วับคุ์มัแบบสุ่ำมั 7 ร�ย (n= 189) ร�ยง�นว่ั� ก�รออกกำ�ลงัก�ยแบบสำลบั ช่วัง (2-5 ค์รั�งต่อสำัปด�ห์ ระยะช่วัง 1-4 น�ทีโดยช่วังเวัล�ทั�งหมัดย�วั 20- 60 น�ที) นั�นเช่� อมัโยงกับฮีโมัโกลบิน HbA1c ที� ลดลงอย่�งมีันัยสำำ�ค์ัญ่ท�ง สำถิติถ่งร�อยละ 0.26 (95% CI: 0.46 ถ่ ง 0 . 0 7 % ก ลุ่ มั ค์ วั บ คุ์ มั แ บ บ สุ่ำ มั 5 กลุ่มั) เปรียบเทียบกับกลุ่มั MICT และลดลงร�อยละ 0.83 (95% CI: 1.39% ถง่ 0.27% กลุ่มัค์วับคุ์มัแบบสุ่ำมั 5 กลุ่มั) เปรียบเทียบกบักลุ่มัค์วับคุ์มัที� ไม่ัมีัก�ร ออกกำ�ลังก�ย (116) ในฐ�นะที� เป็น ขี�อแนะนำ�สำำ�หรบัประช�กรทั� วัไป ก�ร แทรกแซงส่ำวันใหญ่่เหล่�นี�มีัที�มั�จั�กก�ร ทำ�กิจักรรมัแบบแอโรบิกที�สำอดค์ล�องกบั ค์ำ�แนะนำ�ให�ทำ�กิจักรรมัแบบแอโรบิก ที�ค์วั�มัหนักหน่วังระดบัป�นกล�งเป็น เวัล� 150-300 น�ที (หร่อกิจักรรมัระดบั หนักเป็นเวัล� 75 น�ที) และกิจักรรมั สำร� งค์วั�มัแข็ีงแรงให�กับกล� มัเน่�อ อ ย่ � ง น� อ ย 2 - 3 ช่ วั ง ต่ อ สำัป ด � ห ์ สำำ�หรบัผู้ลลพั็ธิบ์�งอย่�ง (เช่น HBA1c ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 88 และค์วั�มัดนัโลหิต) มีัหลกัฐ�นว่ั� มีัผู้ล ที� ชัดเจันขี่ �นด�วัยก�รทำ�กิจักรรมัแบบ แอโรบิกที�มั�กขี่ �น (เช่น มั�กกว่ั� 150 น�ทีต่อสำปัด�ห ์ เทียบกบัน�อยกว่ั� 150 น�ทีต่อสำปัด�ห ์ แต่มีัหลกัฐ�นอย่้จัำ�กดั ในเร่�องค์วั�มัหนกัหน่วัง ง�นวิัจัยัล่�สุำด หล�ยชิ�นแสำดงหลกัฐ�นว่ั� ก�รออกกำ�ลงั ก�ยแบบจีันดั�งเดิมั ตวััอย่�งเช่น ไท่ชี� อ�จั จัะมีัประโยชนต่์อระดบันำ � ต�ลในเล่อด แต่ ยงัมีัค์วั�มัน่�เช่�อถ่อป�นกล�งและผู้นัต�มั ตวััแปร (เช่น ค์วั�มัเสีำ�ยงต่อค์วั�มัเอนเอียง หร่อค์วั�มัไม่ัค์งที�) จัำ�เป็นต�องมีัก�รวิัจัยั เพิ็�มัเติมัเพ่็�อกำ�หนดค์วั�มัสำมััพ็นัธิเ์หล่�นี� กิจักรรมัท�งก�ยหล�กหล�ย ประเภัท รวัมัถ่งกิจักรรมัแบบแอโรบิก และก�รออกกำ�ลงัก�ยแบบมีัแรงต� น แสำดงถง่ผู้ลดีต่อคุ์ณิภั�พ็ชีวิัตที�เกี�ยวัขี�อง กบัสุำขีภั�พ็ขีองผู้้�ติดเช่ �อ HIV (111) ง�น วิัจัยัล่�สุำดที�ตรวัจัสำอบก�รเปลี�ยนแปลง คุ์ณิภั�พ็ชีวิัตที�เกี�ยวัขี�องกบัสุำขีภั�พ็ในก�ร ตอบสำนองต่อกิจักรรมัแบบแอโรบิก ก�ร ออกกำ�ลงัก�ยแบบมีัแรงต� นอย่�งต่อ เน่� องหร่อก�รผู้สำมัผู้สำ�นทั�งสำองแบบ แสำดงให�เห็นถ่ง ก�รทำ�ให�สุำขีภั�พ็โดย ทั� วัไปและสุำขีภั�พ็จิัตดีขี่ �นอย่�งมีันัย สำำ�ค์ญั่ และยงัมีัหลกัฐ�นว่ั�กิจักรรมัทั�ง แบบแอโรบิค์และกิจักรรมัหล�ยองค์ ์ ประกอบนั�น เกี�ยวัขี�องกบัก�รลดอ�ก�ร ซม่ัเศร� และค์วั�มัวิัตกกงัวัลในผู้้�ติดเช่ �อ HIV (112) หลกัฐ�นเกี�ยวักบัผู้ลขีองก�ร ทำ�กิจักรรมัท�งก�ยที� มีัต่ออ�ก�รท�ง สุำขีภั�พ็จิัต เกี�ยวัขี�องกบักิจักรรมัแบบ แอโรบิกหร่อแอโรบิกร่วัมักบักิจักรรมั สำร� งค์วั�มัแข็ีงแรงให�กับกล� มัเน่�อ แบบต่อเน่�อง หร่อโยค์ะ หลกัฐ�นยงัแสำดง ให�เห็นว่ั� ก�รออกกำ�ลงัก�ยแบบแอโรบิก แต่เพี็ยงอย่�งเดียวั หร่อเม่ั�อรวัมักบัก�ร ออกกำ�ลงัก�ยแบบมีัแรงต� น ไม่ัได�ส่ำงผู้ ลให�ปริมั�ณิไวัรสัำหร่อจัำ�นวัน CD4 เปลี�ย นแปลงอย่�งมีันยัสำำ�ค์ญั่ในผู้้�ติดเช่ �อ HIV (111) หลกัฐ�นโดยตรงจั�กง�นวิัจัยัที� มีั อย่้และฉบบัปรบัปรุงสำนับสำนุนก�รรวัมั ขี�อแนะนำ�สำำ�หรบัผู้้�ที� เป็นเบ�หวั�นชนิด ที� 2 และค์วั�มัดนัโลหิตส้ำง ให�ทำ�กิจักรรมั ท�งก�ยแบบแอโรบิก และแบบสำร� งค์วั�มั แข็ีงแรงให�กับกล� มัเน่�อแมั�ว่ั�จัะขี�ด หลกัฐ�นตีพิ็มัพ็ ์แต่ก็มีัค์วั�มัเป็นไปได�ท�ง ชีวัภั�พ็ สำำ�หรับประโยชนข์ีองก�รทำ� กิจักรรมัท�งก�ยแบบแอโรบิกและ แบบสำร� งค์วั�มัแข็ีงแรงให�กบักล� มัเน่�อ สำำ�หรบัผู้้�ใหญ่่ที� ติดเช่ �อ HIV และผู้้�รอด ชีวิัตจั�กมัะเร็ง นอกจั�กนี�ต�มัที� ระบุ ไวั� โดยค์ณิะทำ�ง�น GDG ขี�อแนะนำ� ท�งก�รแพ็ทยร์ะหว่ั�งประเทศที�จัดัตั�ง ขี่ �นแนะนำ�ให�ทำ�กิจักรรมัท�งก�ยแบบ แอโรบิกและแบบสำร� งค์วั�มัแข็ีงแรง ใ ห� กับ ก ล� มั เน่�อ สำำ � ห รับ ป ร ะ ช � ก ร ก ลุ่ มั นี� ( ตั วั อ ย่ � ง เ ช่ น แ น วั ป ฏิิ บั ติ ACSM “ก�รก� วัขี� มัมัะเร็ง” (101) จั�กก�รทบทวันหลกัฐ�นอย่�งเป็นระบบ (3)) ก�รตระหนักถ่งหลักฐ�นนี�ยัง เพิ็� งเริ� มัต�นระดับค์วั�มัน่�เช่� อถ่อจั่ง ถ้กลดลง ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) 89 ค์ณะทำ�ง�น GDG สำรุปว่�: • มีัหลกัฐ�นเช่�อถ่อได�ระดบัป�นกล�ง สำำ�หรบัผู้ลจั�กก�รรวัมัหร่อผู้ลเพิ็� มั เติมัขีองก�รทำ�กิจักรรมัแบบแอโรบิก หร่อแบบสำร� งค์วั�มัแข็ีงแรงให�กบั กล� มัเน่�อ เพ่็� อลดก�รเสีำยชีวิัตจั�ก มัะเร็ง ปรบัปรุงค์วั�มัดนัโลหิตสำำ�หรบั ผู้้�มีัค์วั�มัดนัโลหิตส้ำง • มีัหลกัฐ�นเช่�อถ่อได�อย่�งส้ำงว่ั� ก�ร ทำ�กิจักรรมัแบบแอโรบิค์ แบบสำร� ง ค์วั�มัแข็ีงแรงให�กบั กล� มัเน่�อ และ ทั�ง 2 แบบผู้สำมัผู้สำ�นกัน จัะช่วัย ปรับปรุงตัวั บ่งชี�ขีองก�รดำ� เนิน โ ร ค์ ( H b A 1 C ค์ วั � มั ดัน โ ล หิ ต ดัชนีมัวัลก�ย และ ไขีมัันในเล่อด) ในผู้้�ใหญ่่ที�เป็นเบ�หวั�นชนิดที� 2 ข้้อัแนะนำา • มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�งว่ั� ก�ร ออกกำ�ลังก�ยแบบแอโรบิกต�มั ปรกติแต่เพี็ยงอย่�งเดียวั หร่อผู้สำมักบั ก�รออกกำ�ลงัก�ยแบบมีัแรงต� น มิัได� มีัผู้ลให�มีัก�รเปลี�ยนแปลงระดบัไวัรสัำ ในเล่อดหร่อก�รนบั CD4 อย่�งมีันยั- สำำ�ค์ญั่สำำ�หรบัผู้้�ที�มีัเช่ �อ HIV • มีัหลักฐ�นไม่ัเพี็ยงพ็อเกี� ยวักับผู้ล ขีองก�รฝึึกค์วั�มัแข็ีงแรงแต่เพี็ยง อย่�งเดียวัต่อคุ์ณิภั�พ็ชีวิัตที� เกี� ยวั เน่�องกบัสุำขีภั�พ็ขีองผู้้�มีัเช่ �อ HIV ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 90 ข้้อแนืะนืำ� ด้็�นืพฤติิกิรัรัมเนืือยนิื�ง ขี�อแนะนำ�ระดบัโลกด� นกิจักรรมัท�งก�ยเพ่็�อสุำขีภั�พ็ ปีพ็.ศ. 2553 ไม่ัได�มีัก�รรวัมัขี�อแนะนำ�พ็ฤติกรรมัเน่อยนิ�งไวั� (1) ขีอบเขีตขีองขี�อแนะนำ�ใหม่ันี�เกี�ยวักบัพ็ฤติกรรมัเน่อยนิ�งในผู้้�รอดชีวิัตจั�กมัะเร็งและผู้้�ที� มีัค์วั�มัดนัโลหิตส้ำง เบ�หวั�นชนิดที� 2 และ HIV พ็ฤติกรรมัเน่อยนิ�งค่์อเวัล�ที�ใช�ไปกบัก�รนั�งนิ�งหร่อนอนลงด�วัยก�รใช�พ็ลงัง�นด�วัย ขีณิะที�ต่�นอย่้ ในปริบทเกี�ยวักบั อ�ชีพ็ ก�รเรียน ที�บ� น ในชุมัชน และก�รเดินท�ง หลกัฐ�นสำนบัสำนุนและเหตุิผล เน่�องจั�กขี�ดหลกัฐ�นที� เจั�ะจังกลุ่มัประช�กรหลกัฐ�นหลกัในก�รประเมิัน ค์วั�มัเช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งและผู้ลลพั็ธิท์�งสุำขีภั�พ็ในผู้้�ใหญ่่และ ผู้้�ส้ำงอ�ยุที�รอดชีวิัตจั�กมัะเร็ง และผู้้�ใหญ่่และผู้้�ส้ำงอ�ยุที� มีัภั�วัะค์วั�มัดนัโลหิตส้ำง เบ�หวั�นชนิดที� 2 และ HIV เป็นง�นวิัจัยัท�งวิัทย�ศ�สำตรที์�รวัมัรวัมัและทบทวัน สำำ�หรบักลุ่มัประช�กรผู้้�ใหญ่่ มีัก�รทบทวันขี�อค์�นพ็บจั�กหลกัฐ�นเกี� ยวักบัพ็ฤติกรรมัเน่อยนิ� งในกลุ่มั ประช�กรผู้้�ใหญ่่ทั� วัไป รวัมัถ่งประเมิันห�กมีัหลกัฐ�นที� ผู้ลอ�จัต่�งกนัออกไป หร่ออ�จัไม่ัสำ�มั�รถรวัมัได� หร่ออ�จัขีดัแย�งกนั สำำ�หรบัผู้้�ใหญ่่และผู้้�ส้ำงอ�ยุที�มีัภั�วัะ เร่ �อรงั ในผู้้�ใหญ่่ ทั�งผู้้�ที�รอดชีวิัตจั�กมัะเร็ง และผู้้�ที�มีัค์วั�มัดนัโลหิตส้ำง เบ�หวั�นชนิดที�สำอง และ HIV พ็ฤติ- กรรมัเน่อยนิ�งที�มั�กขี่ �นเช่�อมัโยงกบัผู้ลลพั็ธิต่์อสุำขีภั�พ็ที�ไม่ัดีดงัต่อไปนี� ภั�วัะก�รเสีำยชีวิัตทุกสำ�เหตุ ภั�วัะก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อดหัวัใจั มัะเร็ง ก�รเกิดโรค์หลอดเล่อดหัวัใจั มัะเร็ง และเบ�หวั�นชนิดที� 2 ข้อ้แนะนำ�สำำ�หรบัผ้ร้อดชี้วิติจ�กมัะเร็ง และผ้มี้ัโรค์ค์ว�มัดนัโลหิติส้ำง เบ�หว�นช้นิดที� 2 และ HIV ดงันี �: ผ้ ้ใหญ่่และผ้ส้้ำงอ�ยุที�มีัโรค์เรื �อรงัค์วรจำ�กดัเวล�ที�มีัก�รทำ�พฤติิกรรมัเนือยนิ�ง แทนที�เวล� เหล่�นั�นดว้ยกิจกรรมัท�งก�ยในทุกระดบั (รวมัถง้ระดบัเบ�) เพื�อผลดีต่ิอสุำข้ภ�พ แนะนำ�อย่�งยิ�ง หลกัฐ�นมีัค์วั�มัแน่นอนตำ� ผ้ ้ใหญ่่และผ้ส้้ำงอ�ยุที�มีัภ�วะเรื �อรงัค์วรทำ�กิจกรรมัท�งก�ยให้ไดม้ั�กกว่�ระดบัที�แนะนำ� ท ั�งระดบัป�นกล�งและหนกั เพื�อลดผลเสีำยต่ิอสุำข้ภ�พจ�กพฤติิกรรมัเนือยนิ�งในระดบัส้ำง แนะนำ�อย่�งยิ�ง หลกัฐ�นมีัค์วั�มัแนะนำ�ตำ� > ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) > 91ข้้อัแนะนำา จั�กหลกัฐ�นที� มีัอย่้และค์วั�มัคิ์ด เห็นจั�กผู้้�เชี�ยวัช�ญ่ มีัก�รพ็�ดพิ็งหลกั- ฐ�นเพ่็� อร�ยง�นขี�อแนะนำ�ฉบับใหม่ั ขีององค์ก์�รอน�มัยัโลก เกี�ยวักบัพ็ฤติ- กรรมัเน่อยนิ� ง สำำ�หรับผู้้�ใหญ่่ที� มีัภั�วัะ เร่ �อรัง สำำ�หรับผู้ลลัพ็ธิต่์อสุำขีภั�พ็ที� สำำ�ค์ญั่มั�ก ก�รค์�ดค์ะเนหลกัฐ�นนั�น ได�รบัก�รสำนบัสำนุนอย่�งกวั� งขีวั�งโดย ก�รประเมิันผู้ลที� ก�รวิัจััยส่ำวันใหญ่่ มิัได�จัำ�กดัเกณิฑ์อ์�ยุและรวัมัถ่งผู้้�ใหญ่่ ที�อ�ยุเกิน 65 ปี และอ�จัรวัมัเอ�ผู้้�ใหญ่่ที� มีัภั�วัะเร่ �อรงั เช่น ผู้้�รอดชีวิัตจั�กมัะเร็ง ผู้้� มีั ภั � วั ะ ค์ วั � มั ดั น โ ล หิ ต ส้ำ ง ห ร่ อ เ บ � ห วั � น ช นิ ด ที� 2 ไ วั� ด� วั ย สำำ�หรบัผู้้�มีัเช่ �อ HIV ไม่ัมีัเหตุผู้ลระบุว่ั� เหตุใดหลกัฐ�นต่อผู้ลกระทบต่อสุำขีภั�พ็ เกี�ยวักบัพ็ฤติกรรมัเน่อยนิ� งไม่ันำ�มั�ใช� เน่�องด�วัยค์วั�มัไม่ัตรงจุัดขีองหลกัฐ�นที� จัะพ็ฒัน�ขี�อแนะนำ�เหล่�นี� ระดบัค์วั�มั น่�เช่�อถ่อจัง่ถ้กลดลงมั� ก�รใช�ประโยชนจ์ั�กหลกัฐ�นเกี�ยวั กับประโยชนข์ีองกิจักรรมัท�งก�ยที� ระดบัป�นกล�งและหนกัให�มั�กขี่ �น เพ่็�อ ช่วัยลดผู้ลกระทบจั�กค์วั�มัเสีำ�ยงที�อ�จั เกิดขี่ �นจั�กพ็ฤติกรรมัเน่อยนิ�งในระดบั ส้ำง ได�นำ�มั�พิ็จั�รณิ�และค์�ดก�รณิเ์พ่็�อ ร่�งขี�อแนะนำ�สำำ�หรับผู้้�ใหญ่่ที� มีัภั�วัะ เร่ �อรงั เพ่็�อชุดขี�อม้ัลสำำ�หรบัผู้ลลพั็ธิต่์อ สุำขีภั�พ็ที�สำำ�ค์ญั่มั�กที�มีัร่วัมักนั เน่�องด�วัย ค์วั�มัไม่ัตรงจุัดขีองหลกัฐ�น ค์วั�มัน่� เช่�อถ่อขีองหลกัฐ�นจัง่ถ้กลดลงมั� ค์ณะทำ�ง�น GDG สำรุปว่� • หลกัฐ�นเกี�ยวักบัพ็ฤติกรรมัเน่อยนิ�ง ในประช�กรผู้้�ใหญ่่โดยทั�วัไป ค์วัรจัะ นำ �มั�ค์�ดก�รณิ์เพ่็� อสำร� งขี�อม้ัล ขี�อแนะนำ�สำำ�หรับผู้้�รอดชีวิัตจั�ก มัะเร็งที� เ ป็ นผู้้� ใหญ่่ และผู้้� ส้ำงอ�ยุ แ ล ะ ผู้้� มีั ภั � วั ะ ค์ วั � มั ดัน โ ล หิ ต ส้ำ ง เบ�หวั�นชนิดที� 2 และเช่ �อ HIV ที� เ ป็นผู้้� ใหญ่่และผู้้� ส้ำงอ�ยุ เพ่็� อชุด ขี�อม้ัลสำำ�หรบัผู้ลลพั็ธิที์�สำำ�ค์ญั่มั�กที�มีั ร่วัมักนั พ็ร�อมัระดบัค์วั�มัน่�เช่�อถ่อ ขีองหลกัฐ�นที�ลดระดบัลง เน่�องจั�ก เป็นขี�อม้ัลโดยอ�อมั • สำำ�หรบัผู้้�รอดชีวิัตจั�กมัะเร็งและผู้้�ที� มีัค์วั�มัดนัโลหิตส้ำง เบ�หวั�นชนิดที� 2 และ HIV ประโยชนจ์ั�กก�รลดพ็ฤติ- กรรมัเน่อยนิ�งนั�นมีัมั�กกว่ั�อนัตร�ย ผูู้้ใหญ่และผูู้้สูำงอ�ยุท่�ม่ภิ�วัะเรืั�อรััง (อ�ยุ 18 ปีขึ้�นืไป) ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 92 ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ • ทำ�กิจักรรมัท�งก�ยบ� งย่อมัดีกว่ั�ไม่ัทำ�อะไรเลย • ห�กเด็กหร่อวัยัรุ่นที� มีัภั�วัะทุพ็พ็ลภั�พ็ไม่ัสำ�มั�รถทำ�ต�มัขี�อแนะนำ�นี�ได� ก�รทำ�กิจักรรมั ท�งก�ยบ� งย่อมัเป็นผู้ลดีต่อสุำขีภั�พ็ • 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กิจักรรมัท�งก�ยขีองผู้้�มีัภั�วัะทุพ็พ็ลภั�พ็นั�นรวัมัถง่ ก�รรบัร้�ที� ดีขี่ �นในบุค์ค์ลที�มีัโรค์หร่อค์วั�มั ผิู้ดปรกติที�ทำ�ให�หน� ที�ในก�รรบัร้�บกพ็ร่อง รวัมัถง่อ�ก�รสำมั�ธิิสำั�น (ADHD) ก�รพ็ฒัน�สำมัรรถ ภั�พ็ท�งก�ยอ�จัเกิดขี่ �นได�กบัเด็กที�มีัค์วั�มับกพ็ร่องท�งสำติปัญ่ญ่� เด็ก วัยัรุ่น และผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็สำ�มั�รถบรรลุถง่ผู้ลดีต่อสุำขีภั�พ็ที�สำำ�ค์ญั่จั�กกิจักรรรมั ท�งก�ย เด็ก วัยัรุ่น และผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ค์วัรจัะทำ�ต�มัขี�อแนะนำ�เหล่�นี� เม่ั�อเป็นไปได�และ เท่�ที�สำ�มั�รถทำ�ได� สำำ�หรบัเด็ก วัยัรุ่น และผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็นั�น กิจักรรมัท�งก�ยสำ�มั�รถเป็นส่ำวันหน่�ง ขีองก�รสำนัทน�ก�รและก�รพ็กัผู่้อน (ก�รละเล่น เกมัสำ ์ กีฬ� และก�รออกกำ�ลงัก�ยที�วั�งแผู้นไวั�) ก�รเรียนพ็ลศก่ษ� ก�รเดินท�ง (ก�รเค์ล่�อนที�ด�วัยล�อ, ก�รเดิน และก�รปั� นจักัรย�น) หร่อก�รทำ�ง�นบ� น ในสำภั�พ็แวัดล�อมัเกี�ยวักบับ� น ก�รศก่ษ� ด� นอ�ชีพ็ และชุมัชน เป็นเร่�องสำำ�ค์ญั่ที�จัะสำร� งโอก�สำและ กำ�ลงัใจัให�แก่เด็ก วัยัรุ่น และผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ที�จัะเขี� ร่วัมักิจักรรมัท�งก�ยที� เหมั�ะสำมักบั อ�ยุและค์วั�มัสำ�มั�รถขีองพ็วักเขี� ให�มีัค์วั�มัสำนุกสำน�นและค์วั�มัหล�กหล�ย ข้้อแนืะนืำ�ด้็�นืกิิจกิรัรัมท�งกิ�ย แนะนำ�ให:้ เด็กและผ้ ใ้หญ่่ที�มีัภ�วะทุพพลภ�พค์วรทำ� กิจกรรมัท�งก�ยเฉลี�ยอย่�งนอ้ย 60 น�ที ต่ิอวนั ติลอดสำปัด�ห ์ ดว้ยก�รทำ�กิจกรรมั ส่ำวนใหญ่่แบบแอโรบิก ที�ระดบัป�นกล�ง แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อป�นกล�ง > > ค์วรทำ�กิจกรรมัท�งก�ยที�ระดบัหนกั รวมัถง้ ก�รสำร�้งค์ว�มัแข็้งแรงใหก้บักล�้มัเนื �อและ กระด้กร่วมักนัอย่�งนอ้ย 3 วนัต่ิอสำปัด�ห์ แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อป�นกล�ง เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) และผูู้้ใหญ่ (อ�ยุ 18 ปีขึ้�นืไป) ท่�ม่ภิ�วัะทุพพลภิ�พ 93 ข้อ แนื ะนื ำ�สำ ำ�ห รับ กิ� รัป ฏิบั ติติ �ม ท่�ด็ ในวัยัผู้้�ใหญ่่ ประโยชนต่์อสุำขีภั�พ็จั�กก�รทำ�กิจักรรมัท�งก�ยมีัหล�กหล�ย เช่นเดียวักบัที�กล่�วัไป ขี� งต�นแล�วั ซ่�งสำ�มั�รถนำ�มั�ใช�กบัผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ได� ประโยชนต่์อสุำขีภั�พ็เพิ็�มัเติมัจั�กก�รทำ� กิจักรรมัท�งก�ย 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ก�รทำ�กิจักรรมัท�งก�ยบ� ง ย่อมัเป็นผู้ลดีต่อสุำขีภั�พ็ • ผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ค์วัรเริ�มัทำ�กิจักรรมัท�งก�ยแต่น�อยก่อน แล�วัค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มัหนกัหน่วัง และระยะเวัล�ขี่ �น • ไม่ัมีัค์วั�มัเสีำ�ยงใด ๆ สำำ�หรบัผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ในก�รทำ�กิจักรรมัท�งก�ย ในระดบัที� เหมั�ะสำมักบัระดบักิจักรรที�ดำ�เนินอย่้ สำถ�นะท�งสุำขีภั�พ็ และสำมัรรถภั�พ็ขีองแต่ละบุค์ค์ล และ ประโยชนต่์อสุำขีภั�พ็ที�เพิ็�มัพ้็นขี่ �นนั�น มีัมั�กกว่ั�ค์วั�มัเสีำ�ยง • ผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ อ�จัจัำ�เป็นต�องปรก่ษ�ผู้้�เชี�ยวัช�ญ่ด� นก�รด้แลสุำขีภั�พ็ หร่อผู้้�เชี�ยวั- ช�ญ่ด� นกิจักรรมัท�งก�ยและภั�วัะทุพ็พ็ลภั�พ็ เพ่็�อช่วัยกำ�หนดชนิดและปริมั�ณิขีองกิจักรรมั ที�เหมั�ะสำมักบัตน ข้้อัแนะนำา แนะนำ�ให:้ ผ้ ใ้หญ่่ทุกค์นที�มีัภ�วะทุพพลภ�พค์วรทำ�กิจกรรมัท�งก�ยเป็นประจำ�ทุกวนั แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อป�นกล�ง ผ้ ใ้หญ่่ที�มีัภ�วะทุพพลภ�พค์วรทำ�กิจกรรมัท�งก�ยแบบแอโรบิก ที�ระดบัป�นกล�ง อย่�งนอ้ย 150-300 น�ที หรือที�ระดบัหนกั อย่�งนอ้ย 75-150 น�ที หรือทำ�ผสำมัผสำ�นกนัท ั�ง 2 ร้ปแบบ ติลอดทั�งสำปัด�ห ์ เพื�อประโยช้นต่์ิอสุำข้ภ�พ แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อป�นกล�ง ผ้ ้ใหญ่่ที�มีัภ�วะทุพพลภ�พค์วรทำ�กิจกรรมัสำร�้งค์ว�มัแข็้งแรงใหก้บักล�้มัเนื �อ ที�ระดบัป�นกล�งข้้ �นไป และมีัก�รใช้ก้ล�้มัเนื �อหลกัเป็นส่ำวนใหญ่่ อย่�งนอ้ย 2 วนัต่ิอสำปัด�ห ์เพื�อสุำข้ภ�พที�ดี แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อป�นกล�ง ในก�รทำ�กิจกรรมัท�งก�ยแต่ิละสำปัด�ห ์ผ้ส้้ำงอ�ยุที�มีัภ�วะทุพพลภ�พค์วรทำ�กิจกรรมัท�งที�หล�กหล�ย เพื�อช่้วยพฒัน�ก�รทรงติวัและค์ว�มัแข็้งแรง ที�ระดบัป�นกล�งข้้ �นไป อย่�งนอ้ย 3 วนัต่ิอสำปัด�ห ์เพื�อ พฒัน�ค์ว�มัแข็้งแรงและป้องกนัก�รหกลม้ั แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อป�นกล�ง ผ้ ใ้หญ่่ที�มีัภ�วะทุพพลภ�พสำ�มั�รถเพิ�มัก�รทำ�กิจกรรมัท�งก�ยแบบแอโรบิกในระดบัป�นกล�งใหม้ั�ก กว่� 300 น�ทีได ้หรือมั�กกว่� 150 น�ที ในระดบัหนกั หรือท ั�ง 2 ระดบัผสำมัผสำ�นกนัติลอดทั�งสำปัด�ห ์ เพื�อสุำข้ภ�พที�ดี แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อป�นกล�ง > > > > > ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 94 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) และผูู้้ใหญ่ (อ�ยุ 18 ปีขึ้�นืไป) ท่�ม่ภิ�วัะทุพพลภิ�พ หลกัฐ�นสำนบัสำนุนและเหตุิผล ก�รสำงัเค์ร�ะหห์ลกัฐ�นองค์ร์วัมัที�จัดัทำ�โดย PAGAC (35) ได�นำ�มั�ใช�และปรบัปรุง ขี�อแนะนำ�สำำ�หรบัเด็ก วัยัรุ่นและผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็นี� ร�ยละเอียดค์รบถ�วันเร่�อง วิัธีิวิัจัยั ก�รแยกส่ำวันขี�อม้ัล และต�ร�งหลกัฐ�นโดยสำรุปขีองหลกัฐ�นที�มีัอย่้เกี�ยวักบั กิจักรรมัท�งก�ยและผู้ลลพั็ธิต่์อสุำขีภั�พ็นั�นมีัอย่้ (35) และทบทวันโดยโดยค์ณิะทำ�ง�น GDG เพิ็�มัเติมัจั�กขี�อค์�นพ็บในก�รค์�นห�ที�ปรบัปรุงแล�วั ก�รปรบัปรุงขี�อม้ัลสำำ�หรบัขี�อแนะนำ�เหล่�นี�ได�จัำ�แนกแยกแยะบทปริทศันจ์ัำ�นวัน 39 ฉบบัที�ตีพิ็มัพ็จ์ั�ก พ็.ศ. 2560 ถง่พ็.ศ. 2562 จั�กทั�งหมัดนี� มีั 27 ฉบบัที�ตรงกบั เกณิฑ์ก์�รนำ�เขี� ขี�อม้ัลและชี�ให�เห็นถง่ก�รตรวัจัสำอบก�รเช่�อมัโยงระหว่ั�งกิจักรรมั ท�งก�ยและผู้ลที�เกี�ยวัเน่�องกบัสุำขีภั�พ็ในหม่้ัเด็ก วัยัรุ่น และผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ ร�ยละเอียดค์รบถ�วันเกี�ยวักบัวิัธีิวิัจัยั ก�รแยกส่ำวันขี�อม้ัล และชุดขี�อม้ัลสำรุปนั�น มีัอย่้ที�ภั�ค์ผู้นวักเว็ับไซต ์: ชุดขี�อม้ัลหลกัฐ�น12 ก�รทบทวันหลกัฐ�นพิ็จั�รณิ�ถง่ ค์วั�มัสำมััพ็นัธิร์ะหว่ั�งกิจักรรมัท�งก�ย และผู้ลลพั็ธิที์�เกี�ยวัเน่�องกบัสุำขีภั�พ็ในเด็ก วััยรุ่น และผู้้�ใหญ่่ที� มีัภั�วัะทุพ็พ็ลภั�พ็ จั�กโรค์และอ�ก�รต่�ง ๆ ดงันี� โรค์ปลอก- ประสำ�ทเส่ำ�อมัแข็ีงอ�ก�รบ�ดเจ็ับไขีสำนั- หลัง ค์วั�มับกพ็ร่องท�งสำติปัญ่ญ่� โรค์พ็�รกิ์นสำัน โรค์หลอดเล่อดสำมัอง โรค์ซ่มัเศร� ท�งค์ลีนิค์ โรค์จิัตเภัท โรค์สำมั�ธิิสำั�น (ADHD) มีัก�รตรวัจัสำอบ ผู้ลลพั็ธิที์�เกี�ยวัเน่�องกบัสุำขีภั�พ็ 4 ประก�ร ค่์อ ค์วั�มัเสีำ� ยงขีองโรค์วิันิจัฉัยร่วัมั ก�รทำ�ง�นขีองร่�งก�ย ก�รทำ�ง�นขีอง สำมัอง และสุำขีภั�พ็ที� เกี�ยวัเน่� องกบัคุ์ณิ- ภั�พ็ชีวิัต แมั�จัะไม่ัมีัก�รตรวัจัสำอบทุก ผู้ลลพั็ธิใ์นแต่ละเง่�อนไขีก็ต�มั ผู้ลกระทบ ต่อปัจัจัยัท�งสิำ�งแวัดล�อมัขีองภั�วัะทุพ็พ็- 12 ข้้อม่ัลออนไลน์ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ลภั�พ็ในบริบทขีองกิจักรรมัท�งก�ยนั�น อย่้เหน่อขีอบเขีตขีองขี�อแนะนำ�เหล่�นี� และไม่ัได�มีัก�รวิัเค์ร�ะห์ใด ๆ ค์ว�มัสำมััพนัธิ์ร์ะหว่�งกิจกรรมัท�ง ก�ยและผลลพัธิ์ที์�เกี�ยวเนื�องกบัสุำข้ภ�พ ในเด็กและวยัรุ่น (อ�ยุ 5-17 ปี) และ ผ้ ้ใหญ่่ (อ�ยุ 18 ปีข้้ �นไป) ที� มีัภ�วะ ทุพพลภ�พ คื์ออะไร สำำ�หรบัผู้้�ที� เป็นโรค์ปลอกประสำ�ท เสืำ�อมัแข็้ง กิจักรรมัท�งก�ยสำ�มั�รถ พ็ัฒน�ก�รทำ�ง�นขีองร่�งก�ย ค์วั�มั สำ�มั�รถด� นก�รเค์ล่�อนไหวั ค์วั�มัเร็วั และค์วั�มัทนท�นในก�รเดิน และค์วั�มั แข็ีงแรงขีองระบบหมุันเวีัยนโลหิต ค์วั�มัแข็ีงแรงและสำมัดุล ตวััอย่�งเช่น ก�รออกกำ�ลงัก�ยแบบสำลบัหนกัเบ�ที� เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) และผูู้้ใหญ่ (อ�ยุ 18 ปีขึ้�นืไป) ท่�ม่ภิ�วัะทุพพลภิ�พ 95ข้้อัแนะนำา ระดบัส้ำงมั�กกว่ั� 3-12 สำปัด�ห ์ชี �ให�เห็น ถง่ก�รปรบัปรุงค์วั�มัแข็ีงแรงขีองระบบ ไหลเวีัยนโลหิตหร่อค์วั�มัแข็ีงแรงกล� มั เน่�อ (117) และก�รฝึึกค์วั�มัแข็ีงแรง ขีองแขีนขี�ส่ำวันล่�ง พ็บว่ั� มีัค์วั�มัแข็ีงแรง ขี่ �นร�อยละ 23.1 (95% CI: 11.8 ถง่ 34.4) จั�กก�รฝึึกเฉลี�ย 13.2 สำปัด�ห ์ (118) และเฉลี� ย 13 สำปัด�ห์ที� มีัผู้ลต่อค์วั�มั แข็ีงแรงที�เพิ็�มัขี่ �น ก�รวิัจัยัก�รแทรกแซง ด�วัยก�รเต�น ร�ยง�นว่ั� มีัก�รพ็ฒัน�ใน ก�รเค์ล่�อนไหวัร่�งก�ยและสำมัดุลที� ดีขี่ �น (119) ทั�งประโยชนต่์อสุำขีภั�พ็ร่�งก�ย หลกัฐ�นที�มีัอย่้ชี �ให�เห็นว่ั� กิจักรรมัท�ง ก�ยสำ�มั�รถเอ่ �อประโยชนต่์อก�รรบัร้�ใน ผู้้�ที� เป็นโรค์ปลอกประสำ�ทเส่ำ�อมัแข็ีง (35) ง�นวิัจัยัชิ �นใหม่ักว่ั�นั�นเปิดเผู้ยว่ั� ก�ร ออกกำ�ลงัก�ยแบบแอโรบิกมีัผู้ลเล็กน�อย แต่มีันยัสำำ�ค์ญั่ต่อขีอบเขีตขีองคุ์ณิภั�พ็ ที� เกี�ยวัเน่� องกบัสุำขีภั�พ็ในด� นก�ยภั�พ็ ด� นจิัตใจั และสำังค์มั (รวัมัถ่งอ�ก�ร อ่อนล� และอ�ก�รซม่ัเศร� ) (35, 120) ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 96 สำำ�หรบัผู้้�ที� มีัอ�ก�รบ�ดเจ็บข้อง ไข้สำนัหลงั กิจักรรมัท�งก�ยช่วัยทำ�ให� ค์วั�มัสำ�มั�รถในก�รเดิน ค์วั�มัแข็ีงแรง กล� มัเน่�อ และค์วั�มัสำ�มั�รถในก�ร ทำ�ง�นขีองร่�งก�ยส่ำวันบนดีขี่ �น ก�ร ออกกำ�ลงัก�ยอ�จับรรเท�อ�ก�รปวัด ไหล่ ทำ�ให�ก�รทำ�ง�นขีองหลอดเล่อดดีขี่ �น และเสำริมัสำร� งคุ์ณิภั�พ็ชีวิัตที� เกี�ยวัเน่�อง กบัสุำขีภั�พ็ (35) สำำ�หรับผู้้�ที� เ ป็นโรค์พ�รกิ์นสำนั กิจักรรมัท�งก�ยสำ�มั�รถทำ�ให�อ�ก�ร เกี�ยวักบัก�รเค์ล่�อนไหวั ค์วั�มัค์ล่องตวัั และศกัยภั�พ็ขีองร่�งก�ย ค์วั�มัทนท�น ปัญ่ห�ก�รเดินติดขีดั และอตัร�ค์วั�มัเร็วั ในก�รเค์ล่�อนที� ไปขี� งหน� และถอยหลงั (35, 121, 122) หลกัฐ�นชิ�นใหม่ัชี�ให�เห็น ว่ั�กิจักรรมัท�งก�ยจัะช่วัยให�ค์วั�มั สำ�มั�รถในก�รรบัร้�ต่อโลกภั�ยนอกขีอง ผู้้�ป่วัยพ็�รกิ์นสำนันั�นดีขี่ �นได� (123) สำำ�หรบัผู้้�ที� เค์ยมีัประวัติัโรค์หลอด เลือดสำมัอง กิจักรรมัท�งก�ยสำ�มั�รถ ทำ�ให�ก�รทำ�ง�นขีองร่�งก�ย ก�รทำ�ง�น ขีองร่�งก�ยส่ำวันบนที�มัองเห็นได� ก�ร ทำ�ง�นขีองประสำ�ทสำมััผู้สัำก�รเค์ล่�อนไหวั ขีองร่�งก�ยส่ำวันล่�ง สำมัดุลร่�งก�ย ค์วั�มัเร็วัในก�รเดิน ระยะท�ง ค์วั�มั สำ�มั�รถและค์วั�มัทนท�น ค์วั�มัแข็ีงแรง ขีองระบบไหลเวีัยนโลหิต ก�รเค์ล่�อนไหวั และกิจักรรมัในชีวิัตประจัำ�วัันดีขี่ �นได� หลกัฐ�นที� มีัอย่้ชี �ให�เห็นว่ั�กิจักรรมัท�ง ก�ยอ�จัจัะมีัผู้ลดีต่อก�รรบัร้�ขีองสำมัอง ด�วัย (35) เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) และผูู้้ใหญ่ (อ�ยุ 18 ปีขึ้�นืไป) ท่�ม่ภิ�วัะทุพพลภิ�พ สำำ�หรับผู้้�ที� เป็นโรค์ซ้มัเศัร�้ท�ง ค์ลีนิค์อย่�งรุนแรง บทปริทศันชิ์�นใหม่ั (124,125) สำนบัสำนุนหลกัฐ�นที� มีัอย่้ว่ั� กิจักรรมัท�งก�ยนั�นช่วัยพ็ฒัน�คุ์ณิภั�พ็ ชีวิัตที�เกี�ยวัเน่�องกบัสุำขีภั�พ็ได� (35, 124, 125) สำำ�หรับผู้้�ป่วยหรือมีัค์ว�มัผิดปรกติิ ที�ทำ�ใหค้์ว�มัสำ�มั�รถในก�รรบัร้แ้ย่ลง รวัมัถ่งโรค์จิัตเภัท กิจักรรมัท�งก�ย มีัผู้ลดีต่อก�รรบัร้� หน่วัยค์วั�มัจัำ� ก�รรบัร้� ท�งสำงัค์มั และค์วั�มัสำนใจัและค์วั�มัระมัดั ระวังั (35,126) บทปริทศันชิ์�นหน่�งพ็บว่ั� กิจักรรมัท�งก�ยในระดบัป�นกล�งจัน ถง่หนกันั�น ยงัผู้ลให�เกิดก�รพ็ฒัน�อย่�ง มีันยัสำำ�ค์ญั่ในคุ์ณิภั�พ็ชีวิัตที� เกี�ยวัเน่� อง กับสุำขีภั�พ็และภั�วัะทุพ็พ็ลภั�พ็ (35, 124) สำำ�หรับผู้้�ที� มีัค์วั�มับกพร่องท�ง สำติิปัญ่ญ่� กิจักรรมัท�งก�ยนั�นทำ�ให� ก�รทำ�ง�นขีองร่�งก�ยดีขี่ �น ก�รแทรก แซงที�นำ�มั�ทบทวันนี� จัะพุ่็งเป้�โดยหลกั ไปที�กิจักรรมัที�สำร� งสำมัดุลและค์วั�มัแข็ีง แรงมั�กกว่ั� 6-24 สำปัด�ห ์ และร�ยง�น ก�รพ็ฒัน�อย่�งมีันยัสำำ�ค์ญั่ในก�รทรง ตวัั สำมัดุลในก�รเค์ล่�อนไหวั และสำมัดุลใน ก�รทรงตวััผู้สำมัเค์ล่�อนไหวัเปรียบเทียบ กบักลุ่มัที�มีัก�รค์วับคุ์มั (35, 127, 128) สำำ�หรบัเด็กสำมั�ธิิ์สำ ั�น หลกัฐ�นรวัมั ถง่บทปริทศันห์น่�งชิ �นที�มีัก�รทดลองแบบ สุ่ำมัและมีักลุ่มัค์วับคุ์มัที�เกี�ยวัขี�องกบัภั�วัะ สำมั�ธิิสำั�น (ADHD) (129) แสำดงถง่ค์วั�มั 97 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) และผูู้้ใหญ่ (อ�ยุ 18 ปีขึ้�นืไป) ท่�ม่ภิ�วัะทุพพลภิ�พ เช่�อมัโยงที�เป็นบวักระหว่ั�งกิจักรรมัท�ง ก�ยและค์วั�มัสำนใจั ค์วั�มัสำ�มั�รถในก�ร คิ์ดวิัเค์ร�ะหแ์ละค์วั�มัผิู้ดปรกติในก�ร เขี� สำงัค์มั (35, 129) ค์ณิะทำ�ง�น GDG พิ็จั�รณิ�หลกั ฐ�นจั�กประช�กรทั�วัไปในวัยัเด็ก วัยัรุ่น และผู้้�ใหญ่่ และได�สำรุปไวั�ว่ั� ไม่ัมีัเหตุผู้ลที� จัะเช่�อได�ว่ั�จัะมีัก�รเปลี�ยนแปลงผู้ลอนั เน่� องมั�จั�กค์วั�มับกพ็ร่องและผู้ลต่อ สำรีรวิัทย�ด� นสุำขีภั�พ็เช่นเดียวักนันี�จัะ ได�รบัจั�กก�รเค์ล่�อนไหวัร่�งก�ยอย่�ง ค์ล่องแค์ล่วั ค์ณิะทำ�ง�น GDG รบัร้�ว่ั� มีั ง�นวิัจัยัน�อยชิ�นที�รวัมัเอ�ผู้้�มีัภั�วัะทุพ็พ็ล ภั�พ็เอ�ไวั�และก�รเปลี� ยนแปลงผู้ล กระทบก็มีัก�รทดสำอบน�อยค์รั�ง หลักฐ�นในขีอบข่ี�ยขีองภั�วัะ ทุพ็พ็ลภั�พ็ ผู้สำมัผู้สำ�นกับหลักฐ�นที� กวั� งขี่ �นสำำ�หรบัประช�กรทั�วัไป สำนบัสำนุน ขี�อแนะนำ�สำำ�หรบัประช�กรทั�วัไปรวัมัถง่ ผู้้�มีัภั�วัะทุพ็พ็ลภั�พ็ มีัก�รอ� งอิงที�สำงัเกตุ ได�ถง่ “ผู้้�ใหญ่่ทั�งหมัด” “ผู้้�ส้ำงอ�ยุทั�งหมัด” และ “ผู้้�ค์นในทุกภั�วัะค์วั�มัสำ�มั�รถ” ค์ณะทำ�ง�น GDG สำรุปว่� ในบุค์ค์ลที�มีัอ�ก�รบ�ดเจ็บไข้สำนัหลงั นั�นมีั: • หลกัฐ�นน่�เช่�อถ่อตำ� ว่ั� กิจักรรมัท�ง ก�ยจัะลดอ�ก�รปวัดไหล่และทำ�ให� ก�รทำ�ง�นขีองหลอดเล่อดดีขี่ �น ในผู้้� ที� เป็นอมััพ็�ตแขีนหร่อขี� และเสำริมั สำร� งคุ์ณิภั�พ็ชีวิัตที� เกี� ยวัเน่� องกับ สุำขีภั�พ็ และ • หลักฐ�นที� เช่� อถ่อได�ป�นกล�งว่ั� กิจักรรมัท�งก�ยทำ�ให�ค์วั�มัสำ�มั�รถ ในก�รเดิน ค์วั�มัแข็ีงแรงกล� มัเน่�อ และ ก�รทำ�ง�นขีองร่�งก�ยส่ำวันบนดีขี่ �น ในบุค์ค์ลที�มีัโรค์หรือค์ว�มัผิดปรกติิที� ทำ�ใหค้์ว�มัสำ�มั�รถในก�รรบัร้บ้กพร่อง รวมัถง้โรค์พ�รกิ์นสำนั นั�นมีั: • หลกัฐ�นเช่�อถ่อได�ส้ำงว่ั� กิจักรรมัท�ง ก�ยจัะปรับปรุงให�ผู้ลลัพ็ธิ ์ในก�ร ทำ�ง�นขีองร่�งก�ยหล�ย ๆ อย่�งดีขี่ �น รวัมัถ่ง ก�รเดิน สำมัดุลร่�งก�ย ค์วั�มัแข็ีงแรง และก�รเค์ล่� อนไหวั เฉพ็�ะจุัดและ • หลักฐ�นเช่� อถ่อได�ป�นกล�งที� ว่ั� กิจักรรมัท�งก�ยที�ระดบัป�นกล�งถง่ มั�ก อ�จัมีัผู้ลดีต่อสุำขีภั�พ็ ในบุค์ค์ลที� มีัประวติัิโรค์หลอดเลือด สำมัอง นั�นมีั: • หลกัฐ�นเช่�อถ่อได�ป�นกล�งว่ั�กิจั- กรรมัท�งก�ยแบบเน�นก�รเค์ล่�อนไหวั จัะมีัผู้ลในด� นดีต่อสำมัรรถภั�พ็ร่�ง- ก�ยและก�รรบัร้� ในบุค์ค์ลที�มีัโรค์หรือค์ว�มัผิดปรกติิที� ทำ�ใหค้์ว�มัสำ�มั�รถในก�รรบัร้บ้กพร่อง รวมัถง้โรค์จิติเภท นั�นมีั: • ห ลักฐ � น เช่� อ ถ่อไ ด�ป � นก ล�ง ว่ั� กิจักรรมัท�งก�ยปรบัปรุงคุ์ณิภั�พ็ ชีวิัต และ ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 98 • หลกัฐ�นเช่�อถ่อได�ส้ำงว่ั� กิจักรรมัท�ง ก � ย ที� ร ะ ดับ ป � น ก ล � ง แ ล ะ ห นัก มีั ผู้ ล ดี ต่ อ สุำ ขี ภั � พ็ ต่ อ ก � ร รั บ ร้� หน่วัยค์วั�มัจัำ� ก�รรับร้�ท�งสำังค์มั และค์วั�มัสำนใจั ในผ้ ้ใหญ่่ที�เป็นโรค์ซม้ัเศัร�้ท�งค์ลีนิค์ อย่�งรุนแรง นั�นมีั: • หลกัฐ�นเช่�อถ่อได�ป�นกล�งว่ั� กิจั- กรรมัท�งก�ยปรบัปรุงคุ์ณิภั�พ็ชีวิัต ในผ้ ใ้หญ่่ที�เป็นโรค์ปลอกประสำ�ทเสืำ�อมั นั�นมีั: • หลักฐ�นเช่� อถ่อได�ส้ำงว่ั� กิจักรรมั ท�งก�ย โดยเฉพ็�ะกิจักรรมัแบบ แอโรบิกและสำร� งค์วั�มัแข็ีงแรงให�กบั กล� มัเน่�อ สำ�มั�รถปรบัปรุงสำมัรรถ- ภั�พ็ร่�งก�ย ค์วั�มัสำ�มั�รถในก�ร เค์ล่�อนไหวั ค์วั�มัเร็วัและค์วั�มัทนท�น ในก�รเดิน สำมัรรถภั�พ็ขีองระบบไหล- เวีัยนโลหิต ค์วั�มัแข็ีงแรงและสำมัดุล • หลกัฐ�นเช่�อถ่อได�ป�นกล�งว่ั� กิจั- กรรมัท�งก�ยมีัผู้ลดีต่อก�รรบัร้� และ • หลกัฐ�นเช่�อถ่อได�ตำ� ว่ั� กิจักรรมัท�ง ก�ยปรับปรุงคุ์ณิภั�พ็ชีวิัตรวัมัถ่ง อ�ก�รเหน่�อยล� และอ�ก�รซม่ัเศร� ในเด็กและผ้ใ้หญ่่ที�มีัค์ว�มับกพร่องท�ง สำติิปัญ่ญ่� นั�นมีั: • หลกัฐ�นเช่�อถ่อได�ตำ� ว่ั� กิจักรรมัท�ง ก�ยนั�นพ็ฒัน�สำมัรรถภั�พ็ร่�งก�ย ในเด็กและผ้ ้ใหญ่่ที� มีัภ�วะสำมั�ธิิ์สำ ั�น นั�นมีั: • ห ลักฐ � น เช่� อ ถ่อไ ด�ป � นก ล�ง ว่ั� กิจักรรมัท�งก�ยที�ระดบัป�นกล�ง และหนกั มีัผู้ลดีต่อก�รรบัร้� รวัมัถ่ง ค์วั�มัสำนใจั ก�รคิ์ดวิัเค์ร�ะห์ และ ค์วั�มัผิู้ดปรกติท�งสำงัค์มั ค์ณิะทำ�ง�น GDG สำรุปเพิ็�มัเติมัว่ั� มีัหลกัฐ�นท�งวิัทย�ศ�สำตรอ์ย่�งเพี็ยง- พ็อเกี� ยวักับผู้ลกระทบด� นบวักขีอง กิจักรรมัท�งก�ยต่อค์วั�มัหล�กหล�ย ขีองผู้ลลพั็ธิต่์อสุำขีภั�พ็ที�ค์รอบค์ลุมัขีอบ เขีตขีองค์วั�มับกพ็ร่องอย่�งกวั� ง และ ประโยชนข์ีองกิจักรรมัท�งก�ยสำำ�หรบั ผู้้�มีัภั�วัะทุพ็พ็ลภั�พ็นั�นมีันำ � หนกัมั�กกว่ั� ค์วั�มัเสีำ�ยงที�อ�จัเกิดขี่ �นได� เน่� องจั�กค์วั�มัไม่ัตรงไปตรงมั� ขีองหลักฐ�นในก�รพ็ัฒน�ขี�อแนะนำ� เหล่�นี�ระดับค์วั�มัน่�เช่� อถ่อจั่งถ้กลด ระดบัลง เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) และผูู้้ใหญ่ (อ�ยุ 18 ปีขึ้�นืไป) ท่�ม่ภิ�วัะทุพพลภิ�พ 99 ข้้อแนืะนืำ� ด้็�นืพฤติิกิรัรัมเนืือยนิื�ง สำำ�หรบัเด็ก วัยัรุ่น และผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ พ็ฤติกรรมัเน่อยนิ�งค่์อ เวัล�ที�ใช�ไปกบัก�รนั�งนิ�ง ๆ หร่อนอน ด�วัยก�รใช�พ็ลงัง�นตำ� ขีณิะที�ต่�นอย่้ ในสำภั�พ็แวัดล�อมัท�งก�รศก่ษ� สำภั�พ็แวัดล�อมัที�บ� น ชุมัชน และก�รเดินท�ง เป็นไปได�ที�จัะหลีกเลี�ยงพ็ฤติกรรมันิ�งเฉยและขียบัร่�งก�ยอย่�งกระฉบักระเฉงขีณิะนั�งหร่อนอนอย่้ ตวััอย่�งเช่น กิจักรรมัที�ใช�ร่�งก�ยท่อนบน รวัมัถง่ และ/หร่อ กีฬ�หร่อกิจักรรมัที�ใช�รถเข็ีนโดยเฉพ็�ะ หลกัฐ�นสำนบัสำนุนและเหตุิผล พ็ฤติกรรมัเน่อยนิ�งไม่ัถ้กรวัมัไวั�ในขี�อแนะนำ�ระดบัโลกด� นกิจักรรมัท�งก�ยเพ่็�อสุำขีภั�พ็ (2553) เน่�องจั�กขี�ดหลกัฐ�นที�เจั�ะจังกลุ่มัประช�กร ฐ�นขี�อม้ัลขีองหลกัฐ�นเบ่ �องต�นสำำ�หรบัก�รประเมิันค์วั�มั เช่�อมัโยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ�งและผู้ลลพั็ธิต่์อสุำขีภั�พ็ในเด็ก วัยัรุ่น และผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็นั�น เป็นก�รวิัจัยัท�งวิัทย�ศ�สำตรที์�รวับรวัมัและทบทวันสำำ�หรบักลุ่มัประช�กรที� ไม่ัมีัภั�วัะทุพ็พ็ลภั�พ็ ได�มีัก�รนำ�ผู้ลก�รวิัจัยัจั�กหลกัฐ�นขีองพ็ฤติกรรมัเน่อยนิ�งในกลุ่มัประช�กรทั�วัไปมั�ทบทวัน รวัมัถง่ ก�รประเมิันห�กมีัหลกัฐ�น ว่ั�ผู้ลที� ได�จัะต่�งกนัหร่อไม่ั หร่ออ�จัไม่ัหมั�ยรวัมัถ่ง และอ�จัจัะมีัขี�อห� มั สำำ�หรบัเด็ก วัยัรุ่น และผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ลภั�พ็ พ็ฤติกรรมัเน่อยนิ� งที� มั�กขี่ �นในเด็กและวััยรุ่นนั�นต�มัมั�ด�วัยผู้ลเสีำยต่อสุำขีภั�พ็ ได�แก่ ภั�วัะโรค์อ�วันที�เพิ็�มัขี่ �น สุำขีภั�พ็หวััใจัและหลอดเล่อดที�แย่ลง ค์วั�มัแข็ีงแรงน�อยลง และพ็ฤติกรรมั เอ่ �อสำงัค์มัหร่อก�รประพ็ฤติตนที�แย่ลง และลดระยะเวัล�ในก�รนอนหลบัด�วัย พ็ฤติกรรมัเน่อยนิ�งในผู้้�ใหญ่่ที�เพิ็�มัส้ำงขี่ �นต�มัมั�ด�วัยผู้ลเสีำยต่อสุำขีภั�พ็ ได�แก่ ก�รเสีำยชีวิัตทุกสำ�เหตุ ก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อดหวััใจัและมัะเร็ง และสำ�เหตุก�รเกิด โรค์หลอดเล่อดหวััใจั มัะเร็ง และเบ�หวั�นชนิดที� 2 แนะนำ�ให:้ แนะนำ�ให:้ เด็กและวยัรุ่นที�มีัภ�วะทุพพลภ�พค์วรจำ�กดัเวล�ในก�รทำ�พฤติิกรรมัเนือยนิ�ง โดยเฉพ�ะ เวล�ที�อย่้กบัหน�้จอในเชิ้งสำนัทน�ก�ร แนะนำ�อย่�งยิ�ง หลกัฐ�นเช่�อถ่อได�ตำ� ผ้ ใ้หญ่่ที�มีัภ�วะทุพพลภ�พค์วรจำ�กดัเวล�ในก�รทำ�พฤติิกรรมัเนือยนิ�ง ทดแทนเวล�เหล่�นั�น ดว้ยก�รทำ�กิจกรรมัท�งก�ยทุกระดบั (รวมัถง้ระดบัเบ�) เพื�อผลดีต่ิอสุำข้ภ�พ แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�ง ผ้ ้ใหญ่่ที�มีัภ�วะทุพพลภ�พ ค์วรมุ่ังที�จะทำ�กิจกรรมัท�งก�ยที�ระดบัป�นกล�งและหนกัให ้ ไดม้ั�กกว่�ระดบัที�แนะนำ� เพื�อช่้วยลดผลเสีำยต่ิอสุำข้ภ�พจ�กพฤติิกรรมัเนือยนิ�งในระดบัส้ำง แนะนำ�อย่�งยิ�ง มีัหลกัฐ�นเช่�อถ่อได�ป�นกล�ง > > > เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปีขึ้�นืไป) และผูู้้ใหญ่ (อ�ยุ 18 ปีขึ้�นืไป) ท่� ม่ภิ�วัะทุพพลภิ�พ ข้้อัแนะนำา ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 100 เด็็กิและวััยรุ่ันื (อ�ยุ 5-17 ปี) และผูู้้ใหญ่ (อ�ยุ 18 ปีขึ้�นืไป) ท่�ม่ภิ�วัะทุพพลภิ�พ ต�มัหลกัฐ�นที� มีัอย่้และค์วั�มัคิ์ด เห็นจั�กผู้้�เชี�ยวัช�ญ่ หลกัฐ�นนั�นนำ�มั� ค์�ดก�รณิเ์พ่็�อสำร� งขี�อม้ัลให�ขี�อแนะนำ� ขีององค์ก์�รอน�มััยโลกว่ั�ด�วัยพ็ฤติ- กรรมัเน่อยนิ� ง สำำ�หรับบุค์ค์ลที� มีัภั�วัะ ทุพ็พ็ลภั�พ็ เพ่็� อชุดขี�อม้ัลขีองผู้ลลพั็ธิ ์ ต่อสุำขีภั�พ็ที�สำำ�ค์ญั่ยิ�ง โดยระลก่ได�ว่ั� ใน กลุ่มัประช�กรบ�งกลุ่มั เช่น ผู้้�ใช�รถเข็ีนนั�น หลีกเลี�ยงไม่ัได�ที�ต�องนั� งเป็นระยะเวัล� น�นและก�รนั�งอ�จัเป็นสิำ�งปรกติไปแล�วั สำำ�หรบักลุ่มันี� พ็ฤติกรรมัเน่อยนิ� งค์วัร จัะนิย�มัว่ั� เป็นเวัล�ที�ใช�พ็ลงัง�นแต่น�อย ตวััอย่�งเช่น ก�รเค์ล่�อนที�ด�วัยเก� อี �ไฟิฟ้ิ� หร่อก�รถ้กดนัขีณิะนั� งในเก� อี �รถเข็ีน ธิรรมัด� ง�นวิัจััยเกี� ยวักบัค์วั�มัเช่� อมั โยงระหว่ั�งพ็ฤติกรรมัเน่อยนิ� งและ ผู้ลลพั็ธิต่์อสุำขีภั�พ็ในผู้้�ที� มีัภั�วัะทุพ็พ็ล- ภั�พ็นั�นยงัค์งขี�ดแค์ลนอย่้ อย่�งไรก็ดี ต�มัค์ำ�แนะนำ�ขีองผู้้�เชี�ยวัช�ญ่ ไม่ัมีัเหตุ- ผู้ลที�จัะเช่�อว่ั� จัะมีัก�รแก�ไขีผู้ลกระทบ เน่� องจั�กค์วั�มับกพ็ร่อง และผู้ลดีต่อ สุำขีภั�พ็ร่�งก�ยในทำ�นองเดียวักนัจัะเกิด ขี่ �นโดยก�รจัำ�กดัพ็ฤติกรรมัเน่อยนิ�งใน บุค์ค์ลที�มีัภั�วัะทุพ็พ็ลภั�พ็ ด�วัยค์วั�มัไม่ั ตรงไปตรงมั�ขีองหลกัฐ�นที�จัะพ็ฒัน� ขี�อแนะนำ�เหล่�นี� ระดบัค์วั�มัน่�เช่�อถ่อ จัง่ถ้กลดระดบั ก�รประยุกต์ใช�หลกัฐ�นเกี�ยวักบั ประโยชนข์ีองผู้้�ใหญ่่ที�มีัก�รทำ�กิจักรรมั ท�งก�ยในระดบัป�นกล�งและหนักที� มั�กขี่ �นเพ่็�อช่วัยต่อต� นค์วั�มัเสีำ�ยงที�อ�จั เกิดจั�กพ็ฤติกรรมัเน่อยนิ�งในระดบัส้ำง ได� ถ้กนำ�มั�พิ็จั�รณิ�และค์�ดก�รณิเ์พ่็�อระบุ ขี�อแนะนำ�สำำ�หรบัผู้้�ใหญ่่ที�มีัภั�วัะทุพ็พ็ล- ภั�พ็ เพ่็�อชุดขี�อม้ัลร่วัมัขีองผู้ลลพั็ธิต่์อ สุำขีภั�พ็ที�สำำ�ค์ญั่มั�ก ด�วัยค์วั�มัไม่ัตรง ไปตรงมั� ค์วั�มัน่�เช่�อถ่อขีองขี�อม้ัลจั่ง ถ้กลดระดบั ค์ณะทำ�ง�น GDG สำรุปว่� • หลักฐ�นต่อพ็ฤติกรรมัเน่อยนิ� งใน ประช�กรเด็กและวัยัรุ่นนั�นอ�จันำ�มั� ใช�ค์�ดก�รณิส์ำำ�หรบัเด็กและวัยัรุ่นที� มีั ภั � วั ะ ทุ พ็ พ็ ล ภั � พ็ ไ ด�ต � มั ค์ วั � มั สำ�มั�รถเฉพ็�ะตวัั • หลกัฐ�นเกี�ยวักบัพ็ฤติกรรมัเน่อยนิ�ง ในกลุ่มัประช�กรผู้้�ใหญ่่โดยทั�วัไป รวัมั ถ่ง ป ร ะ โ ย ช น์สำำ � หรับ ผู้้� ให ญ่่ ที� ทำ � กิจักรรมัท�งก�ยในระดบัป�นกล�ง และหนกัเพ่็�อช่วัยต่อต� นค์วั�มัเสีำ�ยงที� อ�จัเกิดขี่ �นกบัพ็ฤติกรรมัเน่อยนิ�งใน ปริมั�ณิมั�ก อ�จันำ�มั�ค์�ดก�รณิก์บั ผู้้�ใหญ่่และผู้้�ส้ำงอ�ยุที� มีัภั�วัะทุพ็พ็ล- ภั�พ็ได�โดยทั� วัไปต�มัค์วั�มัสำ�มั�รถ เฉพ็�ะบุค์ค์ลนั�น อย่�งไรก็ต�มั ค์วั�มั น่�เช่�อถ่อขีองหลกัฐ�นนั�นถ้กลดระดบั เน่�องด�วัยค์วั�มัไม่ัตรงไปตรงมั� • ประโยชน์ขีองก�รลดพ็ฤติกรรมั เน่อยนิ�งในเด็ก วัยัรุ่น ผู้้�ใหญ่่ และผู้้�ส้ำง อ�ยุที� มีัภั�วัะทุพ็พ็ลภั�พ็มีัมั�กกว่ั� อนัตร�ย 101 หลักิฐ�นืในืข้้อแนืะนืำ�ต่ิ�ง ๆ ต�มักระบวันก�รขีอง GRADE ค์ำ � นิ ย �มั ขี อง ขี�อ แน ะ นำ � ที� ป รับ ป รุง และระดบัค์วั�มัหนกัแน่น (“หนกัแน่น” หร่อ “มีัเง่� อนไขี”) นั�น ขี่ �นอย่้กับก�ร พิ็จั�รณิ�ถ่งสำมัดุลขีองประโยชน์และ อนัตร�ย ค์วั�มัน่�เช่�อถ่อขีองหลกัฐ�น ค์วั�มัอ่อนไหวัต่อคุ์ณิค่์� และค์วั�มั นิยมัขีองผู้้�ที� ได�รับผู้ลกระทบจั�กขี�อ แนะนำ� ผู้ลกระทบที�อ�จัเป็นไปได�ต่อเพ็ศ สำงัค์มั และค์วั�มัเสำมัอภั�ค์ต่อสุำขีภั�พ็ แ ล ะ ก � ร ย อ มั รับ ค์ วั � มั เ ป็ น ไ ป ไ ด� และค์วั�มัเกี� ยวัขี�องขีองทรัพ็ย�กร สิำ� ง เหล่�นี�ถ้กนำ�มั�พิ็จั�รณิ�ในกลุ่มัประช�กร แต่ละกลุ่มั แต่เม่ั� อพิ็จั�รณิ�ถ่งค์วั�มั ค์ ล� ย ค์ ล่ง กัน ขี อ ง ป ร ะ เ ด็ น แ ล ะ ขี�อ พิ็จั�รณิ�ที�นำ�มั�อภิัปร�ย จัง่มีัก�รรวับ- รวัมัและนำ�เสำนอในเอกสำ�รนี� จุัดแข็ีงขีองขี�อแนะนำ�ค่์อ มีัพ่็ �นฐ�น เ บ่ �องต�นมั�จั�กก�รประเมิันสำมัดุล ระหว่ั�งประโยชนก์บัอนัตร�ย ขี�อแนะนำ� ถ้กจัดัระดบัให� “หนกัแน่น” ห�กสำมัดุล ระหว่ั�งประโยชนแ์ละอันตร�ยถ้กนำ� มั�ประเมิันในฐ�นะสำ�ระสำำ�ค์ญั่สำำ�หรบั ก ลุ่ มั ป ร ะ ช � ก ร เ ป้ � ห มั � ย แ ล ะ “มีัเง่�อนไขี” ห�กสำมัดุลระหว่ั�งประโยชน ์ ต่ออันตร�ยนั�นเล็กน�อยหร่อมีัค์วั�มั แปรปรวันที� สำำ �ค์ัญ่และเป็นไป ได�ใน ผู้ลประโยชน์ ในกลุ่มัประช�ก�รเป้� หมั�ย มีัก�รค์�นห�หลักฐ�นเกี� ยวักับ อันตร�ยโดยเฉพ็�ะผู่้�นก�รสำั� งก�ร ขีองบทปริทศันอ์ย่�งเป็นระบบอนัใหม่ั อย่�งไรก็ต�มั ขี�อแนะนำ�ยงัมีัขี�อจัำ�กดัอย่้ เพ็ร�ะหลกัฐ�นส่ำวันใหญ่่เพ่็งค์วั�มัสำนใจั ไปที�อ�ก�รบ�ดเจ็ับและอนัตร�ยสำำ�หรบั อภิัสิำทธิิ �ชนและนักกีฬ�มั�กกว่ั�กลุ่มั ประช�กรทั�วัไป ทั�ง ๆ ที�มีัหลกัฐ�นจัำ�กดั และแจั�งโดยค์วั�มัคิ์ดเห็นขีองผู้้�เชี�ยวัช�ญ่ จัง่สำรุปได�ว่ั� ค์วั�มัเสีำ�ยงนั�นมีัเพี็ยงน�อยนิด โดยภั�พ็รวัมั โดยทั�วัไปแล�วั หลกัฐ�นบ่ง ชี �ว่ั�ประโยชนข์ีองกิจักรรมัท�งก�ยมีั มั�กกว่ั�อนัตร�ยอย่�งมั�ก และกิจักรรมั ท�งก�ยอ�จัเป็นก�รแทรกแซงสำำ�ค์ญั่ที� สำนับสำนุนก�รปิดช่องโหว่ัด� นสุำขีภั�พ็ที� มีัอย่้ โดยเฉพ็�ะอย่�งยิ�งประช�กรกลุ่มั ด�อยโอก�สำ ค์ณิะทำ�ง�น GDG พิ็จั�รณิ� ประเด็นเร่�องค์วั�มัเท่�เทียมัด� นสุำขีภั�พ็ ค์วั�มัเป็นไปได� และค์วั�มัเป็นที�ยอมัรบั และเป็นส่ำวันหน่�งขีองก�รให�ก�รปร่กษ� ห�ร่อเพ่็�อรบัฟัิงค์วั�มัคิ์ดเห็นสำ�ธิ�รณิะ ในช่องท�งออนไลน ์ ในร่�งขี�อแนะนำ�ที� จัดัขี่ �นระหว่ั�ง 31 มีัน�ค์มั พ็.ศ. 2563 และ 17 เมัษ�ยน พ็.ศ. 2563 ก�รสำำ�รวัจั สำำ�หรบัค์ำ�ปร่กษ�โดยเปิดเผู้ยนี� ถ�มัค์ำ� ถ�มัที� เจั�ะจังเร่� องสำมัดุลระหว่ั�งค่์�ใช� จ่ั�ยขีองบุค์ค์ลและรฐับ�ลในก�รนำ�ขี�อ แนะนำ�ไปใช� ผู้ลดีต่อสุำขีภั�พ็ที�อ�จัเกิดขี่ �น และขี�อแนะนำ�นี�จัะพ็ฒัน�ค์วั�มัเท่�เทียมั ด� นสุำขีภั�พ็ได�หร่อไม่ั ยิ� งไปกว่ั�นั�น ขี�อแนะนำ�ฉบบัร่�งและเอกสำ�รผู้ลตอบ รบัถ้กส่ำงไปยงัประเทศต่�งๆที�สำนใจัจัะ พ็ัฒน�หร่อริเริ� มักระบวันก�รร่�งขี�อ แนะนำ�แห่งช�ติ ว่ั�ด�วัยกิจักรรมัท�งก�ย และได�รบัผู้ลตอบรบัมั�กกว่ั� 420 ร�ย หลักฐานในข้้อัแนะนำาต่่าง ๆ ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 102 จั�กก�รปร่กษ�ห�ร่อแบบออนไลน ์ และก�รรวับรวัมัผู้ลตอบรบัเพิ็�มัเติมัจั�ก สำำ�นักง�นภั�ค์พ่็�นยุโรปขีององค์ก์�ร อน�มัยัโลก ร่วัมักบัขี�อคิ์ดเห็นจั�กศ้นย ์ ค์วั�มัร่วัมัม่ัอขีององค์ก์�รสำหประช�ช�ติ และประเทศสำมั�ชิก ค์ณิะทำ�ง�น GDG ได� รวับรวัมัและทบทวันผู้ลตอบรบัจั�กก�ร ปรก่ษ� และนำ�มั�ใช�เพ่็�อให�ทร�บเกี�ยวักบั พิ็จั�รณิ�ในส่ำวันขีองค์วั�มัเป็นไป ได� ผู้ลด� นค์วั�มัเกี� ยวัขี�องขีองทรัพ็ย�กร และค์วั�มัเท่�เทียมัด� นสุำขีภั�พ็ผู่้�นก�ร ปร่กษ�กบักลุ่มันำ�ร่องและค์ณิะทำ�ง�น GDG ก�รตดัสิำนใจัเกิดขี่ �นโดยฉนัท�มัติ จั�กก�รอภิัปร�ย ค์ณิะทำ�ง�น GDG ลง มัติในขี�อแนะนำ�แต่ละขี�อและนำ � หนัก ขีองค์ำ�แนะนำ� โดยไม่ัมีัก�รจัดัระดบัหร่อ ลงค์ะแนนเสีำยง กรอบก�รทำ�ง�นขีอง GRADE ใช� โดยค์ณิะทำ�ง�น GDG เพ่็� อตรวัจั- สำ อ บ ค์ วั � มั น่ � เ ช่� อ ถ่ อ ขี อ ง ง � น วิั จััย เบ่ �องต�นที� นำ�ไปส่้ำผู้ลลัพ็ธิแ์ต่ละอย่�ง ที�แยกแยะไวั�ในอตัร� PI/ECO และประ- เมิันค์วั�มัน่�เช่� อถ่อขีองหลักฐ�นโดย รวัมัที�นำ�มั�พิ็จั�รณิ�ค์วั�มัเสีำ�ยงต่อค์วั�มั เอนเอียง ค์วั�มัไม่ัค์งที� ค์วั�มัไม่ัแม่ันยำ� ค์วั�มัไม่ัตรงไปตรงมั�ขีองขี�อม้ัลและ ค์วั�มัเอนเอียงในก�รตีพิ็มัพ็ค์์รอบค์ลุมั ผู้ลลพั็ธิแ์ต่ละขี�อ ต�ร�งขีอง GRADE แจังร�ยละเอียดสำำ�หรบัแต่ละกลุ่มัขีอง ก�รพ็ัฒน�ขี�อแนะนำ �รวัมัก�ร ป ร ะ เ มิั น ผู้ ล ก ร ะ ท บ ใน ท � ง ล บ ห ร่ อ ค์วั�มัเสีำ� ยง ก�รตัดสิำนใจันั�นขี่ �นอย่้กับ ค์วั�มัเชี� ยวัช�ญ่ขีองค์ณิะทำ�ง�น GDG เม่ั�อมีัหลกัฐ�นจัำ�กดั โดยภั�พ็รวัมัสำำ�หรบั กลุ่มัประช�กรทั�งหมัดนั�นสำ�มั�รถสำรุปได� ว่ั�ประโยชนข์ีองกิจักรรมัท�งก�ยและ ก�รจัำ�กดัพ็ฤติกรรมัเน่อยนิ�งนั�นมีัมั�ก กว่ั�โทษที�อ�จัจัะเกิดขี่ �น ขี�อแนะนำ�นี�มีัไวั� สำำ�หรบัประช�กรทั�วัไป และไม่ัได�กล่�วั กิ�รัปรัะเมินืคำวั�มน่ื�เชื้�อถืึอ ข้องหลักิฐ�นื ปรัะโยช้น์ืและโทษ PI/ECO มีัอย่้ที�ภั�ค์ผู้นวักขีองเว็ับไซต ์ : ชุ ด ขี�อ ม้ั ล ห ลักฐ � น 1 3 ก � ร ป ร ะ เ มิั น ค์วั�มัน่�เช่� อขีองหลักฐ�นนั�น มั�จั�ก ก�รประเมิันโดยภั�พ็รวัมัค์รอบค์ลุมั ผู้ลลัพ็ธิที์� ถ้กประเมิันทั�งหมัด และให� ค์วั�มัสำำ�ค์ญั่กบัก�รเสีำยชีวิัตทุกสำ�เหตุ และก�รเสีำยชีวิัตจั�กโรค์หลอดเล่อด หัวัใจัเป็นผู้ลลพั็ธิที์�สำำ�ค์ญั่ที� สุำด ต�มัมั� ด� วั ย ผู้ ล ลัพ็ ธิ ์ท � ง ก � ร แพ็ ท ย์อ่� น ๆ (ก�รหกล�มั อ�ก�รซ่มัเศร� ก�รรับร้� คุ์ณิภั�พ็ชีวิัตที� เกี� ยวัเน่� องกับสุำขีภั�พ็ และอ่� น ๆ) และผู้ลลัพ็ธิร์ะดับกล�ง (เช่น ตวัับ่งชี�โรค์หลอดเล่อดและหัวัใจั ตวัับ่งชี�ก�รเผู้�ผู้ล�ญ่อ�ห�ร) รวัมัถ่ง ภัยัอนัตร�ย ในจุัดที�ยงัไม่ัมีัก�รทบทวัน หลกัฐ�นโดยเฉพ็�ะเจั�ะจัง เช่น พ็ฤติ- กรรมัเน่อยนิ�งในประช�กรกลุ่มัย่อย เน่�อง จั�กขี�ดหลกัฐ�นสำำ�หรบักลุ่มันี�ในเบ่ �อง ต�น หลกัฐ�นสำำ�หรบัประช�กรทั�วัไปถ้กนำ� มั�ใช�ค์�ดก�รณิแ์ละลดระดบัค์วั�มัสำำ�ค์ญั่ ลง เม่ั�อเห็นค์วัรด�วัยค์วั�มัเป็นผู้ลท�งอ�อมั 13 ข้้อม่ัลออนไลน์ท่ี่� https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 103 ถ่งประโยชนแ์ละโทษที�นักกีฬ�ประสำบ เม่ั�อทำ�กิจักรรมัทั�งประเภัทและปริมั�ณิ ที�จัำ�เป็นที�จัะพ็ฒัน�ค์วั�มัแข็ีงแรงที�เกี�ยวั เน่� องกบัค์วั�มัสำ�มั�รถเพ่็�อเขี� ร่วัมัก�ร แข่ีงขีนั ก�รทำ�กิจักรรมัท�งก�ยบ� งย่อมั ดีกว่ั�ไม่ัทำ�เลย ห�กบุค์ค์ลนั�นไม่ัสำ�มั�รถ ทำ�ต�มัขี�อแนะนำ�เหล่�นี� ก�รทำ�กิจักรรมั ท�งก�ยบ� ง จัะนำ �มั�ซ่� งประโยชน ์ ต่อสุำขีภั�พ็ โดยค์วัรเริ�มัจั�กกิจักรรมัท�ง ก�ยเพี็ยงแต่น�อย แล�วัค่์อย ๆ เพิ็�มัค์วั�มัถี� ค์วั�มัหนกัหน่วัง และระยะเวัล�ขี่ �นเร่�อย ๆ โดยทั� วัไปแล�วั ใบอนุญ่�ตจั�กแพ็ทย ์ ก่อนก�รทำ�กิจักรรมัท�งก�ยนั�นไม่ั จัำ�เป็น บุค์ค์ลที� ไม่ัขียบัร่�งก�ยที� ค่์อย ๆ ทำ�กิจักรรมัท�งก�ยในระดบัป�นกล�ง ไม่ัมีับนัท่กค์วั�มัเสีำ�ยงต่อภั�วัะหัวัใจัล�มั เหลวักะทนัหนั และมีัค์วั�มัเสีำ�ยงที�ตำ� มั�ก สำำ�หรบัก�รบ�ดเจ็ับที�กระด้ก กล� มัเน่�อ หร่อขี�อต่อ ผู้้�ที� ทำ�กิจักรรมัท�งก�ยใน ระดบัป�นกล�งอย่�งเป็นนิสำยั สำ�มั�รถ เพิ็�มัระดบัเป็นระดบัหนกัได�ทีละน�อย โดย ไม่ัจัำ�เป็นต�องปร่กษ�ผู้้�ให�บริก�รด� น ก�รแพ็ทย ์ ผู้้�ที� มีัอ�ก�รใหม่ั ๆ เม่ั�อเพิ็�มั ระดบักิจักรรมัค์วัรปร่กษ�ผู้้�ให�บริก�ร ด� นก�รแพ็ทย์ ท�งเล่อกขีองประเภัทและปริมั�ณิ ก�รทำ�กิจักรรมัท�งก�ยที� เหมั�ะสำมั อ�จัมีั ผู้ ล กร ะ ท บจั� ก ก�ร ตั�ง ค์ร ร ภั ์ ภั�วัะโรค์เร่�อรงั และภั�วัะทุพ็พ็ลภั�พ็ และ ค์วัรจัะได�รบัก�รด้แลเหม่ัอนบุค์ค์ลปรกติ และไม่ัมีัขี�อบ่งห� มั บุค์ค์ลเหล่�นี�ค์วัร ต�องปร่กษ�ผู้้�เชี� ยวัช�ญ่ด� นกิจักรรมั ท�งก�ยหร่อบุค์ล�กรด� นก�รแพ็ทย ์ สำำ�หรับค์ำ�แนะนำ�เร่� องขีองชนิดและ ปริมั�ณิกิจักรรมัที� เหมั�ะสำมักับค์วั�มั ต�องก�ร ค์วั�มัสำ�มั�รถ ขี�อจัำ�กดัท�ง ร่�งก�ยและภั�วัะแทรกซ�อน ก�รให�ย� และแผู้นก�รรกัษ�โดยรวัมั กิจักรรมัท�ง ก�ยในระดบัเบ�และป�นกล�งมีัค์วั�มั เสีำ�ยงตำ� และแนะนำ�สำำ�หรบัทุกค์น มีัก�รนำ�คุ์ณิค่์�และค์วั�มัชอบ ขีองผู้้�ได�รบัผู้ลกระทบจั�กขี�อแนะนำ�นี� (ในกรณีินี�ได�แก่ บิด�มั�รด�และผู้้�ด้แล เ ด็ ก แ ล ะ วััย รุ่ น ผู้้� ใ ห ญ่่ ผู้้� ส้ำ ง อ � ยุ หญิ่งมีัค์รรภั์และมั�รด�หลังค์ลอด ผู้้�ที� โรค์เร่�อรงั และ/หร่อทุพ็พ็ลภั�พ็) มั�พิ็จั�รณิ� โดยรวัมัแล�วัสำรุป ได�ว่ั� มีัค์วั�มัแน่นอนน�อยหร่ออ�จัไม่ัมีัเลย เกี�ยวักบัค์วั�มันิยมัที�เกี�ยวัเน่�องกบัผู้ลลพั็ธิ ์ หลกั รวัมัถง่ก�รเสีำยชีวิัตและก�รเสีำยชีวิัต จั�กโรค์หลอดเล่อดหวััใจั ประโยชนที์� ได�นั�นมีัมั�กกว่ั�โทษที� อ�จัเกิดขี่ �น และด�วัยเหตุนี� ค์ณิะทำ�ง�น GDG พิ็จั�รณิ�ว่ั�ค์ำ�แนะนำ�นั�นไม่ัไวัต่อ ค์วั�มัชอบใด ๆ ค์วั�มัเห็นขีองผู้้�เชี�ยวัช�ญ่ขีองค์ณิะ ทำ�ง�น GDG และองค์ข์ี�อม้ัลหลกัฐ�นชิ�น เล็กที�ร�ยง�นเกี�ยวักบัก�รวิัเค์ร�ะหก์�ร แทรกแซงท�งเศรษฐกิจัและก�รเก็บออมั ต่อระบบสำ�ธิ�รณิสุำขีจั�กก�รเพิ็�มัระดบั กิจักรรมัท�งก�ย ร�ยง�นถง่ก�รอภิัปร�ย เร่�องค์วั�มัเกี�ยวัขี�องขีองทรพั็ย�กรขีอง ขี�อแนะนำ�ในสำภั�พ็แวัดล�อมัที�แตกต่�งกนั นอกจั�กนี� ผู้ลจั�กก�รปร่กษ�ห�ร่อเพ่็�อ คุำณค่ำ�และคำวั�มช้อบ คำวั�มเก่ิ�ยวัข้้องข้องทรััพย�กิรั หลักฐานในข้้อัแนะนำาต่่าง ๆ ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 104 รบัฟัิงค์วั�มัคิ์ดเห็นสำ�ธิ�รณิะแสำดงให�เห็น ว่ั� ผู้้�ตอบค์ำ�ถ�มัมั�กกว่ั�ร�อยละ 75 เห็น ด�วัยหร่อเห็นด�วัยอย่�งยิ�งว่ั� ประโยชน์ใน ก�รนำ�ขี�อแนะนำ�ไปใช�มีัมั�กกว่ั�ค่์�ใช� จ่ั�ยต่อตวัับุค์ค์ล และร�อยละ 81 เห็นด�วัย หร่อเห็นด�วัยอย่�งยิ�งว่ั� ประโยชน์ในก�ร นำ�ขี�อแนะนำ�ไปใช�มีัมั�กกว่ั�ค่์�ใช�จ่ั�ย ขีองรฐั หลกัฐ�นที� มีัอย่้และค์วั�มัคิ์ดเห็น จั�กผู้้�เชี�ยวัช�ญ่ตระหนกัว่ั� เร�สำ�มั�รถ บรรลุถ่งผู้ลดีต่อสุำขีภั�พ็อย่�งมั�กมั�ย ด�วัยค์วั�มัเสีำ�ยงน�อย จั�กกิจักรรมัต่�ง ๆ เช่น ก�รเดิน ซ่� งไม่ัต�องก�รอุปกรณิ ์ เฉพ็�ะหร่อค่์�ใช�จ่ั�ยใด ๆ ยิ�งกว่ั�นั�นเป็น ที� ต ร ะ ห นั ก ว่ั � กิ จั ก ร ร มั ท � ง ก � ย ในร้ปแบบอ่� น เช่น กีฬ�ที� มีัโค์รงสำร� ง ก�รปั� นจักัรย�น และชั�นเรียนก�ยบริห�ร ต่�ง ๆ อ�จัมีัค่์�ใช�จ่ั�ย ซ่� งอ�จัเป็น อุปสำรรค์ต่อบ�งค์น โดยเฉพ็�ะผู้้�มีั ร � ย ไ ด� น� อ ย ก � ร นำ � น โ ย บ � ย แ ล ะ ร�ยก�รต่�ง ๆ มั�ใช�โดยรฐับ�ล เพ่็�อส่ำง เสำริมัและสำร� งเสำริมักิจักรรมัท�งก�ย ยงัต�องก�รก�รลงทุนในหล�ยส่ำวัน เช่น ทรัพ็ย�กรบุค์ค์ล ก�รพ็ัฒน�นโยบ�ย ก�รจััดห�สิำ� งอำ�นวัยค์วั�มัสำะดวักและ บริก�ร และอ�จัรวัมัอุปกรณิด์�วัย บ�ง สิำ�งค์วัรจัดัห�โดยกระทรวังสำ�ธิ�รณิสุำขี แ ล ะ ภั� ค์ ส่ำ วั นอ่� นนอ ก ขีอ บ ข่ี � ย ขีอง สุำขีภั�พ็ เช่น กีฬ� ก�รศก่ษ� ก�รเดินท�ง และก�รวั�งผู้งัเม่ัอง ทรพั็ย�กรที� ต�อง ก�รนั�น อ�จัจัะต�องก�รรฐับ�ลมั�กกว่ั� หน่�งระดบั (ระดบัประเทศ ระดบัภั�ยใน ประเทศ และระดบัท�องถิ�น) เพ่็�อให�มัั�นใจั ว่ั�ทุกชุมัชนจัะเขี� ถ่งโอก�สำในก�รทำ� กิจักรรมัท�งก�ยอย่�งเท่�เทียมั ก�ร ลง ทุ นนี�อ�จั เกี� ย วั ขี�อง กับ ทรพั็ย�กรใหม่ั แต่อ�จัเป็นก�รจัดัสำรร งบประมั�ณิที�มีัอย่้เสีำยใหม่ัเพ่็�อให�สำะท�อน ถ่งก�รจััดลำ�ดับค์วั�มัสำำ�ค์ัญ่ขีองสิำ� ง อำ�นวัยค์วั�มัสำะดวักและร�ยก�รต่�ง ๆ ที� มุ่ังเพิ็�มักิจักรรมัท�งก�ยขีองประช�กร ตัวัอย่�งขีองก�รจััดสำรรงบประมั�ณิ เช่น สำ�ธิ�รณ้ิปโภัค์สำำ�หรบัก�รเดินและ ก�รปั� นจัักรย�นจั�กงบประมั�ณิด� น ก�รค์มัน�ค์มัที� มีัอ ย่้ และ โค์รงก�ร “กีฬ�สำำ�หรบัทุกค์น” จั�กงบประมั�ณิ ด� นกีฬ� ในสำภั�พ็แวัดล�อมัหลัก เช่น โรงเรียนและที�ทำ�ง�น ก�รแทรกแซงที� ค่์�ใช�จ่ั�ยตำ� ผู้สำ�นกบัก�รเปลี�ยนแปลง สิำ� งแวัดล�อมัท�งก�ยภั�พ็สำ�มั�รถสำนับ สำนุนก�รมีัส่ำวันร่วัมัในก�รทำ�กิจักรรมั ท�งก�ย และอ�จัมีัส่ำวันช่วัยลดค์วั�มัไม่ั เท่�เทียมัด� นโอก�สำในก�รทำ�กิจักรรมั ท�งก�ยที� ประช�กรกลุ่มัย่อยบ�งกลุ่มั ประสำบอย่้ โดยรวัมัแล�วั มีัก�รประเมิันว่ั� แมั�จัะมีัค์วั�มัเกี� ยวัขี�องขีองทรัพ็ย�กร เพ่็�อที�จัะทำ�ร่�งขี�อแนะนำ�ให�สำำ�เร็จั ก�รนำ� มั�ปฏิิบติันั�นเป็นไปได�ภั�ยใต�โค์รงสำร� ง ก�รกำ�กบัด้แลปัจัจุับนั ยิ� งกว่ั�นั�น หลกัฐ�นสำนับสำนุนว่ั� ก�รออมัเงินเพ่็�อสุำขีภั�พ็อย่�งต่อเน่� อง นั�นเ ป็นไป ได�สำำ �หรับระบบก�รด้แล สุำขีภั�พ็ที� เ ป็นผู้ลจั�กก�รเพิ็� มัระดับ กิจักรรมัท�งก�ย ในพ็.ศ. 2556 ค่์� ใช�จ่ั�ยประจัำ�ปีทั�วัโลกขีองกิจักรรมัท�ง ก�ยที� ไม่ัเพี็ยงพ็อนั�นประเมิันไวั�ที� 54 พ็ันล� นดอลล�ร์สำ�กล อันเป็นค่์�ใช� จ่ั�ยด� นสุำขีภั�พ็โดยตรงเท่�นั�น (130) และในระดับประเทศ และประเมิัน ว่ั�กิจักรรมัท�งก�ยที� ไม่ัเพี็ยงพ็อคิ์ด 105 เป็นค่์�ใช�จ่ั�ยร�อยละ 1 ถ่งร�อยละ 3 ขีองงบประมั�ณิด� นก�รด้และสุำขีภั�พ็ (131) ภั�ยใต�ปริบทขีองก�รป้องกนัโรค์ ไม่ัติดต่อเร่ �อรงั (NCD) ค่์�ใช�จ่ั�ยเพิ็�มัเติมั ขีองรฐับ�ลและองค์ก์รที� ไม่ัใช่ขีองรฐัจั�ก ก�รนำ�ขี�อแนะนำ�ไปใช�อ�จัจัะลดน�อยลง ได� ห�กก�รทำ�กิจักรรมัท�งก�ยต�มัที� แนะนำ�สำ�มั�รถรวัมัเขี� กับชีวิัตขีอง ผู้้�ค์นได�โดยง่�ย ในทำ�นองเดียวักนั ห�ก ทรพั็ย�กรที�มีัอย่้ในก�รด้แลเบ่ �องต�นและ ขีั�นทุติยภ้ัมิั โรงเรียน ที�ทำ�ง�น หร่อก�ร เดินท�งสำ�มั�รถเปลี�ยนแปลงให�มีักิจั- กรรมัท�งก�ยมั�กขี่ �น ก�รวิัเค์ร�ะหค่์์�ใช�จ่ั�ยและประ- โยชน์ขีองก�รส่ำงเสำริมักิจักรรมัท�ง- ก�ย ชี �ให�เห็นผู้ลตอบกลบัในท�งบวัก ในก�รลงทุนด� นก�รป้องกนัโรค์ไม่ัติด- ต่อเร่ �องรงัมั�มั�กกว่ั� 15 ปีในหล�ย ๆ ประเทศที�มีักรณีิก�รลงทุนเกิดขี่ �น (132) ก�รแทรกแซง เช่น ก�รให�ก�รศ่กษ� สำ�ธิ�รณิะ ก�รรณิรงค์์สำร� งค์วั�มั ต ร ะ ห นัก ร้� แ ล ะ ก � ร ใ ห� ค์ำ � ป ร่ ก ษ � ด� นกิจักรรมัท�งก�ย และก�รอ� งอิง ถง่ก�รแทรกแซงที�แนะนำ�ว่ั� “คุ์�มัค่์�ที�สุำด” และ “คุ์�มัมั�ก” ต�มัลำ�ดบัเม่ั�อกล่�วัถ่ง โรค์ไม่ัติดต่อเร่ �อรงัต่�ง ๆ ต�มัขี�อม้ัล ปรบัปรุงในภั�ค์ผู้นวักที� 3 ขีองขี�อแนะนำ� สำ�กลว่ั�ด�วัยก�รป้องกันและค์วับคุ์มั โรค์ไม่ัติดต่อ พ็.ศ. 2556 ถง่ พ็.ศ. 2563 (133) โดยรวัมันั�น ค์ณิะทำ�ง�น GDG สำรุปว่ั� ประโยชนจ์ั�กก�รนำ�ขี�อแนะนำ�ไป ใช�นั�นมีัมั�กกว่ั�ค่์�ใช�จ่ั�ย ก�รนำ�ขี�อแนะนำ�ในก�รทำ�กิจั- กรรมัท�งก�ยไปใช�กับผู้้�มีัภั�วัะทุพ็- พ็ลภั�พ็อ�จัต�องก�รก�รลงทุน เช่น ก�รฝึึกอบรมัผู้้�เชี�ยวัช�ญ่ด� นกิจักรรมั ก�รปรับเปลี� ยนอุปกรณิ์ห�กจัำ�เป็น และสิำ�งอำ�นวัยค์วั�มัสำะดวักต่�ง ๆ ที�ต�อง ทำ�ให�เขี� ถง่ได� ก�รลงทุนเหล่�นี�สำ�มั�รถ ตอบสำนองต่อค์วั�มัจัำ�เป็นที�หล�กหล�ย ขีองกลุ่มัประช�กร หลกัฐ�นออกมั�ใน ร้ปขีองเสำ�นล�ดชันขีองก�รมีัส่ำวันร่วัมั อย่�งมีันยัสำำ�ค์ญั่ ระหว่ั�งผู้้�ที� มีัและไม่ัมีั ภั�วัะทุพ็พ็ลภั�พ็ ที�เกี�ยวัขี�องกบักิจักรรมั ท�งก�ย อนัเน่�องมั�จั�กอุปสำรรค์ในก�ร เขี� ถ่งหล�ยประก�ร ตัวัเ ล่อกขีอง กิจักรรมัที� เสำนอ และทศันค์ติขีองผู้้�อ่�น ค์วัรใช�หลกัก�รที�ออกแบบในระดบัสำ�กล เพ่็�อให�ผู้้�ที� มีัภั�วัะทุพ็พ็ลภั�พ็เขี� ร่วัมัได� อย่�งเต็มัที� และมีัประสิำทธิิภั�พ็ ด�วัย นวัตักรรมั จัง่เป็นไปได�ที�จัะกล่�วัถง่ค์วั�มั เกี�ยวัขี�องด� นทรพั็ย�กรหล�ยอย่�งก�ร นำ�แนวัท�งก�รออกแบบระดบัสำ�กลมั�ใช� อ�จัลดค่์�ใช�จ่ั�ยเหล่�นี�ได�ในอน�ค์ต ในก�รปรับปรุงขี�อแนะนำ�ขีอง พ็.ศ. 2553 มีัก�รตัดสิำนใจัให�รวัมัขี�อ พิ็จั�รณิ�สำำ �หรับกลุ่มัประช�กรที� มีั ค์วั�มัเปร�ะบ�ง เช่น ผู้้�ที�มีัโรค์เร่�อรงัและ/ หร่อค์วั�มัทุพ็พ็ลภั�พ็ ค์ณิะทำ�ง�น GDG และค์ณิะนำ�ร่องได�รวัมัสำมั�ชิกที� เป็นตวัั แทนขีองกลุ่มัเหล่�นี� ค์ณิะทำ�ง�น GDG อภิัปร�ยขี�อแนะนำ�แต่ละขี�อด�วัยเร่� อง ค์วั�มัย�วัน�น พิ็จั�รณิ�ว่ั�ก�รนำ�ขี�อ คำวั�มเท่�เท่ยม กิ�รัเป็นืท่� ยอมรัับ และคำวั�มเป็นืไปได้็ หลักฐานในข้้อัแนะนำาต่่าง ๆ ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 106 แนะนำ�มั�ใช�จัะลดค์วั�มัเท่�เทียมัด� น สุำขีภั�พ็หร่อไม่ั และประเด็นที� เกี�ยวัเน่�อง กบัก�รนำ�มั�ใช� เพ่็�อให�มัั�นใจัว่ั�ขี�อแนะนำ� นั�น ไม่ัทำ�ให�ประเด็นเร่�องค์วั�มัเท่�เทียมั แย่ลง (ตวััอย่�งเช่น ทำ�ให�แน่ใจัว่ั�มีัสิำ� ง อำ�นวัยค์วั�มัสำะดวักที�ปลอดภัยัและโอก�สำ เป็นสิำ�งที�ทุกค์นเขี� ถง่ได� รวัมัถง่ผู้้�มีัภั�วัะ ทุพ็พ็ลภั�พ็ และกลุ่มัผู้้�ด�อยโอก�สำ ทั�งท�ง ด� นเศรษฐกิจั สำงัค์มั และด� นอ่�น ๆ ให�เขี� ร่วัมักบัก�รทำ�กิจักรรมัท�งก�ย โดยกล่�วั ถง่เพ็ศและค์วั�มัเอนเอียงท�งวัฒันธิรรมั อ่�น ๆ ที�จัะจัำ�กดัก�รเขี� ถง่และโอก�สำใน ก�รเขี� ร่วัมัทำ�กิจักรรมัท�งก�ย และอ่�น ๆ ) ผู้้�ตอบแบบสำอบถ�มัจั�กก�รปร่กษ� ห�ร่อสำ�ธิ�รณิะแบบออนไลนร์�อยละ 76 เห็นด�วัยหร่อเห็นด�วัยอย่�งยิ� งว่ั� ก�ร นำ�ขี�อแนะนำ�มั�ใช�สำ�มั�รถลดค์วั�มัไม่ั เท่�เทียมัด� นสุำขีภั�พ็ได� โดยก�รเพิ็� มั โอก�สำให�แก่ทุกค์นในก�รเค์ล่�อนไหวัร่�ง ก�ยและปรบัปรุงผู้ลต่อสุำขีภั�พ็ เป็นที� ยอมัรับว่ั� สิำ� งแวัดล�อมัที� สำนับสำนุนเป็น กุญ่แจันำ�ไปส่้ำก�รเขี� ร่วัมักิจักรรมัท�ง ก�ย มีัค์วั�มัต�องก�รแนวัท�งที� เขี� ใจัถง่ ก�รออกแบบและก�รนำ�นโยบ�ยไปใช� ทั�วัทุกภั�ค์ส่ำวัน เพ่็�อชี �ให�เห็นถง่อุปสำรรค์ ต่อก�รทำ�กิจักรรมัท�งก�ยสำำ�หรบักลุ่มั ที�ด�อยกว่ั� เช่น เด็กและสำตรีที�ด�อยโอก�สำ ท�งเศรษฐกิจัและสำงัค์มั และผู้้�มีัภั�วัะ ทุพ็พ็ลภั�พ็ ผู้้�มีัภั�วัะทุพ็พ็ลภั�พ็ประสำบผู้ลลพั็ธิ ์ ท�งสุำขีภั�พ็ที� เลวัร� ยกว่ั�ผู้้� ไม่ัมีัภั�วัะ ทุพ็พ็ลภั�พ็ แต่ประโยชนข์ีองกิจักรรมั ท�งก�ยยงัมีัมั�กกว่ั�โทษอย่้มั�ก และ สำ�มั�รถเป็นก�รแทรกแซงที�สำำ�ค์ญั่ที�จัะ อุดช่องโหว่ัท�งสุำขีภั�พ็นี�ได� หลกัฐ�นชี�ว่ั� ค่์�ค์วั�มัล�ดชนัขีองก�รเขี� ร่วัมัอย่�งมีั นัยสำำ�ค์ัญ่ระหว่ั�งผู้้�ที� มีัและ ไม่ัมีัภั�วัะ ทุพ็พ็ลภั�พ็ที� เกี� ยวัเน่� องกบัก�รทำ�กิจั- กรรมัท�งก�ย ด�วัยอุปสำรรค์ต่อก�ร เขี� ถ่งที� หล�กหล�ย ท�งเล่อกขีอง กิจั กร ร มั ที� เ สำ นอ แ ล ะ ทัศ น ค์ ติ ขีอง ผู้้�ค์นมั�กมั�ยที�มีัภั�วัะทุพ็พ็ลภั�พ็ค์วัรจัะ เป็นไปได� ที�จัะเขี� ร่วัมัทำ�กิจักรรมัท�ง ก�ยหล�ยร้ปแบบโดยไม่ัจัำ�เป็นต�องมีัก�ร ปรบัเปลี�ยนอุปกรณิห์ร่อสิำ�งอำ�นวัยค์วั�มั สำะดวัก อย่�งไรก็ต�มั เพ่็� อให�ผู้้�มีัภั�วัะ ทุพ็พ็ลภั�พ็เขี� ร่วัมัทำ�กิจักรรมัท�งก�ย ได�เท่�เทียมัผู้้�อ่�น อุปกรณิจ์ั่งอ�จัต�องมีั ก�รปรบัเปลี�ยน สิำ�งอำ�นวัยค์วั�มัสำะดวัก ต�องเขี� ถ่งได� และผู้้�เชี�ยวัช�ญ่ด� นกิจั- กรรมัอ�จัต�องได�รบัก�รฝึึกฝึน 107 คำวั�มต้ิองกิ�รัต่ิอง�นืวิัจัย ทั�ง ที� มีัขี�อม้ัลเกี� ยวักับกิจักรรมั ท�งก�ยและพ็ฤติกรรมัเน่อยนิ� งต่อ ผู้ลลัพ็ธิด์� นสุำขีภั�พ็ที� ค์รอบค์ลุมัทุก ช่วังอ�ยุในปริมั�ณิมั�กและเพิ็�มัมั�กขี่ �น ก�รอภิัปร�ยขีองค์ณิะทำ�ง�น GDG เปิด เผู้ยช่องว่ั�งขีองหลกัฐ�นที�สำำ�ค์ญั่ ซ่�งค์วัร จัะถ้กจัดัลำ�ดบัค์วั�มัสำำ�ค์ญั่เพ่็�อร�ยง�น ขี�อ แน ะ นำ �ในอ น� ค์ ต ช่อง ว่ั�ง ขีอง หลกัฐ�นสำำ�หรบัประช�กรกลุ่มัย่อยยงั ขี�ดขี�อม้ัล ดงัต่อไปนี� 1. ขี�อม้ัลที�แน่นอนเกี�ยวักบัค์วั�มัสำมััพ็นัธิ ์ ขี อ ง ก � ร ต อ บ สำ น อ ง ต่ อ ป ริ มั � ณิ ระหว่ั�งกิจักรรมัท�งก�ย และ/หร่อ พ็ฤติกรรมัเน่อยนิ�ง และผู้ลลพั็ธิต่์อ สุำขีภั�พ็หล�ยประก�รที�ศก่ษ�มั� 2. ผู้ ล ลัพ็ ธิ ์ต่ อ สุำ ขี ภั � พ็ จั � ก ก � ร ทำ � กิจักรรมัท�งก�ยในระดบัเบ� และเลิก ทำ�พ็ฤติกรรมัเน่อยนิ� งด�วัยก�รทำ� กิจักรรมัท�งก�ยที�ระดบัเบ� 3. ค์วั�มัแตกต่�งในผู้ลลพั็ธิต่์อสุำขีภั�พ็ จั�กชนิดและขีอบเขีตขีองกิจักรรมั ท�งก�ยที�แตกต่�งกนั (เวัล�พ็กัผู่้อน เกี�ยวักบัอ�ชีพ็ ก�รเดินท�ง ในค์รวัั- เร่อน ก�รศ่กษ�) และกบัพ็ฤติกรรมั เน่อยนิ� ง (เกี�ยวักบัก�รนิ� งเฉย เวัล� ที�ใช�ไปกบัหน� จัอ เวัล�ด้โทรทศัน)์ และ 4. ค์ วั � มั เ ช่� อ มั โ ย ง ร่ วั มั กัน ร ะ ห ว่ั � ง กิจักรรมัท�งก�ยและพ็ฤติกรรมัเน่อย นิ�งกบัผู้ลลพั็ธิต่์อสุำขีภั�พ็ค์รอบค์ลุมั ทุกช่วังอ�ยุ นอกจั�กนี� ยงัมีัขี�อสำังเกตุว่ั� มีั หลกัฐ�นจัำ�กดัจั�กประเทศที� มีัร�ยได� ตำ� และร�ยได�ป�นกล�ง ชุมัชนที� ด�อย โอก�สำหร่อด�อยโอก�สำท�งเศรษฐกิจั และ ในผู้้� ที� มีัภั�วัะ ทุพ็พ็ลภั�พ็ และ/ หร่อมีัโรค์เร่�อรงั ง�นวิัจัยัหล�ยชิ�นนั�นไม่ั ได�ถ้กออกแบบหร่อเสำริมัแรงเพ่็� อก�ร ปรับผู้ลที� ได�โดยปัจัจัยัท�งสำงัค์มัประ- ช�กรที�หล�กหล�ย (อ�ยุ เพ็ศ เช่ �อช�ติ/ ช�ติพ็นัธุิ ์สำถ�นะท�งเศรษฐกิจัและสำงัค์มั) ที� อ�จัจัะเปลี� ยนแปลงผู้ลกระทบต่อ สุำขีภั�พ็ขีองกิจักรรมัท�งก�ย ขี�อม้ัลนี�มีั ค์วั�มัสำำ�ค์ญั่เพ่็�อนำ�ก�รจัดัทำ�ค์ำ�แนะนำ� ด� นสำ�ธิ�รณิสุำขีที� เจั�ะจังมั�กขี่ �นและ เพ่็�อลดค์วั�มัไม่ัเท่�เทียมัด� นสุำขีภั�พ็ใน ประช�กรที� สุำขีภั�พ็อ่อนแอ ร�ยละเอียด เพิ็�มัเติมัเกี�ยวักบัช่องว่ั�งในก�รวิัจัยัที� ได� จั�กขี�อแนะนำ�ฉบบัใหม่ันั�นค์�นห�ได�ใน ง�นวิัจัยัที�ตีพิ็มัพ็ ์(134) คำวามูต้่อังงานต่่อังานวิจััย่ ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 108 กิ�รัเลือกิใช้้ กิ�รัเผู้ยแพร่ั กิ�รัด็ำ�เนิืนืกิ�รั และกิ�รัปรัะเมินืผู้ล เป้�หมั�ยขีองขี�อแนะนำ�เหล่�นี�ค่์อ เพ่็�อจัดัห�ให�ผู้้�ร่�งนโยบ�ย และผู้้�พ็ฒัน� แทรกแซงในก�รด้แลสุำขีภั�พ็ ก�รศก่ษ� สำ ถ � น ที� ทำ � ง � น แ ล ะ ชุ มั ช น ด� วั ย ค์ำ�แนะนำ�ว่ั�ด�วัยเร่�องเด็ก วัยัรุ่น ผู้้�ใหญ่่ และผู้้�ส้ำงอ�ยุค์วัรใช�เวัล�เท่�ไร 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พ็ฤติกรรมัเน่อยนิ�งนี�ไปใช� นำ�มั�ซ่�งวิัธีิก�ร ที�รวัดเร็วัและคุ์�มัค่์�ในก�รพ็ฒัน�ขี�อแนะ- นำ�ที�ปรบัไปต�มับริบทท�องถิ�น ก�รเล่อกใช�ขี�อแนะนำ�ขีององค์ก์�ร อน�มัยัโลกในระดบัภ้ัมิัภั�ค์หร่อระดบั ช�ติจัะทำ�ให�มัั�นใจัได�ว่ั�ประเทศเหล่�นั�น จัะจัดัห�ขี�อแนะนำ�ในก�รทำ�กิจักรรมัท�ง ก�ยและพ็ฤติกรรมัเน่อยนิ�งที�ค์งที� ซ่�งได� รบัมั�จั�กหลกัฐ�นท�งวิัทย�ศ�สำตรที์� ดี ที� สุำดและทนัสำมัยัที� สุำดที�ห�ได� นอกจั�กนี� ค์วั�มัค์งที�ขีองขี�อแนะนำ�ในหล�ยประเทศ จัะอำ�นวัยค์วั�มัสำะดวักต่อก�รด้แล ระดบัประเทศ ก�รประเมิันกิจักรรมัท�ง ก�ยและพ็ฤติกรรมัเน่อยนิ�งในระดบัโลก และก�รเปรียบเทียบขี� มัประเทศ ค์วัรมีั ก�รพิ็จั�รณิ�ค์วั�มัต�องก�รในก�รปรบั ขี�อแนะนำ�ต�มับริบทและปรบัให�เหมั�ะ- สำมัตลอดกระบวันก�รนำ�มั�ใช� ก�รแปล เป็นภั�ษ�ท�องถิ� นเป็นองค์์ประกอบ หน่�งขีองก�รนำ�มั�ใช�และก�รปรบัต�มั ปริบท อ�จัจัำ�เป็นต�องมีัก�รเปลี�ยนตวัั อย่�งขีองกิจักรรมัท�งก�ยให�เกี�ยวัเน่�อง กบัท�องถิ�นและใช�ร้ปภั�พ็ที�ปรบัให�สำะท�อน วัฒันธิรรมั ธิรรมัเนียมั และค่์�นิยมัท�องถิ�น 109 กรอบแนวัท�งแบบขีั�นต่อขีั�นเพ่็�อรองรบั ก�รนำ �ขี�อแนะนำ �ระดับโลกไป ใช� ใน ประเทศยงัค์งพ็ฒัน�อย่้ ต�มัด�วัยชุดก�ร ประชุมัปฏิิบติัก�รกบัผู้้�มีัส่ำวันเกี�ยวัขี�อง กรอบค์วั�มัคิ์ดนี� อ�จัสำร� งขี่ �นด�วัยขี�อม้ัล ระดบัประเทศที� เกี�ยวัขี�อง (ตวััอย่�งเช่น ก�รประเมิันค์วั�มัชุกขีองกิจักรรมั ท�งก�ย) และจัะทำ�ให� มีัก�รเขี� ถ่ง ก�รพ็ัฒน�เอกสำ�รขี�อแนะนำ�ระดับ ช�ติอย่�งรวัดเร็วั แหล่งขี�อม้ัลสำนบัสำนุน นี�จัะพ็ร�อมัใช�ง�นใน พ็.ศ. 2564 บน เว็ับไซตข์ีององค์ก์�รอน�มัยัโลก เมืั�อพิจ�รณ�ก�รนำ�ข้อ้แนะนำ�มั�ปฏิิบติัิ มีัข้อ้แนะนำ�ให้ ใช้ก้ระบวนก�ร 10 ข้ ั�นติอน ดงัต่ิอไปนี �: 1. สำนับสำนุนให�มีัก�รทบทวันขี�อแนะนำ� ระดับช�ติฉบับปัจัจุับันว่ั�ด�วัยกิจั- กรรมัท�งก�ยและก�รนำ�ขี�อแนะนำ� ขีององค์ก์�รอน�มัยัโลกมั�ใช� เพ่็�อให� ได�มั�ซ่�งค์ำ�อนุญ่�ตจั�กรฐับ�ล 2. ให�ผู้้�มีัส่ำวันเกี� ยวัขี�องหลกัทั�งในภั�ค์ สุำขีภั�พ็และภั�ค์ส่ำวันอ่�นๆที� เกี�ยวัขี�อง เช่น กีฬ� ก�รศ่กษ� ก�รค์มัน�ค์มั มีัส่ำวันร่วัมั และให�มีัสำมั�ค์มัอ�ชีพ็ต่�ง ๆ ที�เกี�ยวัขี�องและนกัวิัทย�ศ�สำตรต่์�ง ๆ ผู้้�มีัค์วั�มัเชี�ยวัช�ญ่ต�มัหวััขี�อ 3. ประเมิันก�รใช�ประโยชน ์ ค์วั�มัเป็นที� ยอมัรับ และค์วั�มัเป็นไป ได�ขีอง ค์ำ�แนะนำ� 4. ปรบัขี�อแนะนำ�ต�มับริบทขีองท�องถิ�น รวัมัถง่ภั�ษ� ตวััอย่�ง และขี�อค์วัรค์ำ�น่ง ด� นวัฒันธิรรมัต่�ง ๆ 5. จััดทำ�บทปริทัศน์ภั�ยนอกกับผู้้�ใช� กลุ่มัเป้�หมั�ย รวัมัถง่ผู้้�ร่�งนโยบ�ย นกัปฎิบติั และสำ�ธิ�รณิชนทั�วัไป 6. จััดสำรรงบประมั�ณิและจััดเตรียมั แผู้นในก�รเผู้ยแพ็ร่และก�รส่ำ�อสำ�ร 7. เผู้ยแพ็ร่และส่ำงเสำริมัขี�อแนะนำ�ระดบั ช�ติ อย่�งสำมับ้รณิแ์บบ โดยค์วับค่้์ไป กบัง�นเปิดตวััเพ่็�อประช�สำมััพ็นัธิแ์ละ ค์วั�มัสำนใจั 8. มีัส่ำวันร่วัมักบัหน่วัยง�นวิัช�ชีพ็หร่อ องค์์กรที� เ กี� ยวัขี�องและสำนับสำนุน ก�รวั�งแผู้นนโยบ�ย และ/หร่อก�ร รบัรองผู้ล 9. ก�รนำ�นโยบ�ยและแนวัปฏิิบติัระดบั ช�ติไปใช�เพ่็�อสำนบัสำนุนให�เกิดก�รนำ� ขี�อแนะนำ�ระดบัช�ติและก�รเปลี�ยน แปลงพ็ฤติกรรมัมั�ใช� 10. ตกลงกรอบเวัล�ขีองก�รประเมิัน ก�รทบทวัน และก�รปรบัปรุงขี�อแนะนำ� กิ�รัเผู้ยแพร่ั ขี�อแนะนำ�ด� นกิจักรรมัท�งก�ย ระดับช�ติเป็นองค์ป์ระกอบหลักขีอง โค์รงสำร� งธิรรมั�ภิับ�ล สำำ�หรบัแนวัท�ง เพ่็�อค์วั�มัเขี� ใจัที�จัะเพิ็�มัระดบักิจักรรมั ท�งก�ยขีองประช�กร ขี�อแนะนำ�แห่ง ช�ติชี�ถ่งก�รพ็ฒัน�และก�รจััดลำ�ดบั ค์วั�มัสำำ�ค์ัญ่ขีองก�รวั�งแผู้นกลยุทธิ ์ ระดบัช�ติและภั�ยในประเทศ และต�อง ก�รก�รเผู้ยแพ็ร่ขี�อม้ัลที� ถ้กต�องให�กบั กลุ่มัค์นที�เกี�ยวัขี�องในแนวัท�งที�เหมั�ะสำมั เป็นที� น่�เสีำยด�ยที� บ่อยค์รั�งขี�อแนะนำ� ระดบัช�ติไม่ัได�ถ้กเผู้ยแพ็ร่ ดงันั�น ค์วั�มั ตระหนกัร้�ถง่ขี�อแนะนำ�ทั�งในหม่้ัผู้้�เชี�ยวั- ช�ญ่และชุมัชนที�กวั� งขี่ �นนั�น ยงัค์งอย่้ใน ระดับตำ� ก�รรักษ�แหล่งขี�อม้ัลเพ่็� อ รองรบัก�รเผู้ยแพ็ร่ในภั�พ็ที�กวั� งขี่ �นนั�น การเลือักใช้้ การเผย่แพร่ การดำำาเนินการ และการประเมิูนผล ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 110 เป็นก� วัแรกที�สำำ�ค์ญั่ที�จัะเปลี�ยนก�รตระ- หนักร้�และค์วั�มัร้�เกี�ยวักบัค์วั�มัสำำ�ค์ญั่ ขีองก�รเพิ็� มักิจักรรมัท�งก�ยและลด พ็ฤติกรรมัเน่อยนิ�ง ผ้เ้กี�ยวข้อ้งหลกัสำำ�หรบัก�รเผยแพร่ ข้อ้แนะนำ�แห่งช้�ติิ ว่�ดว้ยกิจกรรมั ท � ง ก � ย แ ล ะ พ ฤ ติิ ก ร ร มั เนื อ ย นิ� ง ประกอบไปดว้ย • ผู้้�ร่�งนโยบ�ยทั�งในและนอกภั�ค์ส่ำวัน ด� นสุำขีภั�พ็ (รวัมัทั�ง ค์มัน�ค์มั ก�รวั�งแผู้น ก�รศ่กษ� ที� ทำ�ง�น ก�รกีฬ� สำวันต่�ง ๆ และสำนัทน�ก�ร) เพ่็�อเพิ็�มั ก. ค์วั�มัร้�ขีองก�รสำนับสำนุนที�จัะ เพิ็�มักิจักรรมัท�งก�ยและลดพ็ฤติกรรมั เ น่ อ ย นิ� ง อ � จั ไ ม่ั ไ ด� ป รั บ ป รุ ง เ พี็ ย ง สุำขีภั�พ็เท่�นั�น แต่ยังรวัมัประเด็นที� แ ต ก ต่ � ง ห ล � ก ห ล � ย แ ต่ ท ว่ั � เ กี� ย วั เน่�องกนั รวัมัถง่ค์วั�มัเท่�เทียมัท�งเพ็ศ พ็ันธิกิจัด� นสิำทธิิมันุษยชน และก�ร พ็ฒัน�อย่�งยั�งย่น ขี. ก�รรวัมันโยบ�ยและโค์รงก�รว่ั� ด�วัยกิจักรรมัท�งก�ยและพ็ฤติกรรมั เน่อยนิ�งไวั�ในนโยบ�ยที�เกี�ยวัขี�องทั�งหมัด และ ค์. ก�รลงทุนในก�รดำ�เนินก�ร ระดับท�องถิ� นและระดับช�ติที� สำอด ประสำ�นกนั • ภั�ค์ส่ำวันที� ไม่ัใช่รฐั (รวัมัถง่องค์ก์รที� ไม่ัใช่รัฐบ�ล องค์ก์รด� นวิัช�ก�ร และก�รวิัจัยั ภั�ค์เอกชน รวัมัทั�งหน่วัย ง�นด� นส่ำ�อและกองทุนวิัจัยั) ที�จัะ ก. สำร� งค์วั�มัตระหนกัร้�ถง่ค์วั�มั สำำ�ค์ญั่ในก�รเพิ็�มักิจักรรมัท�งก�ยและ ลดพ็ฤติกรรมัเน่อยนิ�งในทุกช่วังอ�ยุ ขี. ส่ำงเสำริมัและทำ�ให�มัั�นใจัในก�รวั�ง นโยบ�ย และ ค์. เพิ็�มัค์วั�มัร่วัมัม่ัอและก�รลงทุน ในก�รนำ�นโยบ�ยไปใช�และก�รดำ�เนิน ก�รขีองท�องถิ�น • ผู้้�ป ฏิิ บัติ ง � นใน ภั� ค์ สุำ ขี ภั� พ็ แ ล ะ ภั�ค์ส่ำวันที� ไม่ัเกี� ยวัเน่� องกับสุำขีภั�พ็ (รวัมัถ่งกีฬ� ก�รศ่กษ� ค์มัน�ค์มั และก�รวั�งแผู้น) เพ่็�อเพิ็�มั ก. ค์วั�มัตระหนกัร้�และค์วั�มัร้�เกี�ยวั กบัแนวัปฏิิบติัระดบัช�ติว่ั�ด�วัยกิจักรรมั ท�งก�ยและพ็ฤติกรรมัเน่อยนิ�ง ขี. ค์วั�มัร้� ทกัษะ และค์วั�มัมัั�นใจัใน ก�รส่ำงเสำริมัให�มีัก�รเพิ็� มักิจักรรมัท�ง ก�ยและลดพ็ฤติกรรมัเน่อยนิ�ง และ ค์. ก�รผู้สำ�นก�รส่ำงเสำริมักิจักรรมั ท�งก�ยลงในก�รฝึึกฝึน อนัเป็นกิจัวัตัร เม่ั�อสำ�มั�รถทำ�ได� • สำ�ธิ�รณิชนทั�วัไปและประช�กรกลุ่มั ย่อยโดยเฉพ็�ะเจั�ะจัง เพ่็�อเพิ็�มั ก. ค์วั�มัตระหนกัร้�และค์วั�มัร้�เกี�ยวั กบัขี�อแนะนำ� ว่ั�ด�วัยกิจักรรมัท�งก�ย และพ็ฤติกรรมัเน่อยนิ�ง ขี. ค์วั�มัร้�ถ่งวิัธีิก�รที�จัะบรรลุขี�อ แนะนำ�ด� นกิจักรรมัท�งก�ยและพ็ฤติ- กรรมัเน่อยนิ�ง ค์. ค์วั�มัตั�งใจัและแรงจ้ังใจัในก�ร เพิ็�มักิจักรรมัท�งก�ยและลดพ็ฤติกรรมั เน่อยนิ�ง 111 กิ�รัรัณรังค์ำผู่้�นืกิ�รัสืำ� อสำ�รั ผู้้�มีัส่ำวันเกี� ยวัขี�องที� ต่�งกนัจัะได� ประโยชนจ์ั�กเร่�องร�วัที� ต่�งกนั ดงันั�น เพ่็� อจัะส่ำ� อสำ�รขี�อแนะนำ�ไปยังกลุ่มัผู้้� ฟัิงที�หล�กหล�ยได�อย่�งมีัประสิำทธิิภั�พ็ ค์วัรมีัก�รค์ำ�น่งถง่เน่�อห� ร้ปแบบ และช่อง ท�งก�รส่ำงสำ�รสำำ�หรับก�รส่ำ� อสำ�รขี�อ แนะนำ� ค์วัรรวัมัเอ�ก�รสำำ�รวัจัอุปสำรรค์ ในก�รทำ�กิจักรรมัท�งก�ย หร่อก�รรวัมั กิจักรรมัท�งก�ยไวั� ในนโยบ�ยและ ก�รปฏิิบัติรวัมัถ่งทดสำอบเน่�อห�และ ขี�อม้ัลกับกลุ่มับุค์ค์ลที� ต่�งกัน อันจัะ ช่วัยส่ำ�อใจัค์วั�มัสำำ�ค์ญั่ อีกทั�งร้ปแบบที� เหมั�ะสำมั และช่องท�งก�รส่ำ�อสำ�ร กลยุทธิ ์ ก�รส่ำ�อสำ�รที�เขี� ใจัได� จัะรวัมัเอ�ช่วังขีอง ก�รส่ำ� อสำ�รที� มุ่ังไปยงักลุ่มัผู้้�ฟัิงที� แตก ต่�งกนั หล�ยประเทศอ�จัให�ค์วั�มัลำ�ดบั ค์วั�มัสำำ�ค์ัญ่กับกลุ่มัเฉพ็�ะขี่ �นอย่้กับ ทรพั็ย�กรที�มีัอย่้ (ผู้้�ค์นและก�รค์ลงั) ก�รรณิรงค์ผ่์ู้�นก�รส่ำ�อสำ�ร ว่ั�ด�วัย ก�รทำ�กิจักรรมัท�งก�ยที�มีัเป้�หมั�ยเป็น สำ�ธิ�รณิชนทั�วัไปหร่อประช�กรกลุ่มัย่อย ที� เฉพ็�ะเจั�ะจังเป็นก�รแทรกแซงที� คุ์�มั ค่์�ใช�จ่ั�ย (133) และได�รบัก�รแนะนำ�ไวั�ใน ขี�อแนะนำ�ระดบัโลกด� นกิจักรรมัท�งก�ย ขีององค์ก์�รอน�มัยัโลก พ็.ศ. 2561- 2573 (14) ก�รรณิรงค์เ์ร่� องกิจักรรมั ท�งก�ยระดบัประเทศและภั�ยในประเทศ นั�น ค์วัรสำร� งค์ำ�ขีวัญั่ในก�รรณิรงค์ที์� ค์รอบค์ลุมั (ตวััอย่�งเช่น “จังกระฉับ กระเฉง” หร่อ “เค์ล่�อนไปให�มั�กขี่ �น”) และพ็ฒัน�องค์ป์ระกอบในก�รออกแบบ หร่อตัวัละค์รที� อ�จัจัะรวัมัขี�อค์วั�มัที� ปรบัแต่งสำำ�หรบักลุ่มัผู้้�รบัสำ�รที�หล�ก- หล�ย (ตัวัอย่�งเช่น เด็กเล็ก วััยรุ่น ผู้้� ใหญ่่หร่อผู้้� ส้ำงอ�ยุ ผู้้� ที� ไ ม่ั ค่์อย ได� เค์ล่�อนไหวั ผู้้�ที� มีัภั�วัะทุพ็พ็ลภั�พ็หร่อ ภั�วัะเร่ �อรงั) ขี�อค์วั�มัและแหล่งขี�อม้ัล ในก�รรณิรงค์์ที� ปรับให� เขี� กับกลุ่มั ประช�กรเฉพ็�ะนั�น อ�จัจัะมีัประสิำทธิิภั�พ็ มั�กกว่ั�ขี�อค์วั�มัทั�วั ๆ ไป ก�รรณิรงค์ ์ ผู่้�นก�รส่ำ�อสำ�รค์วัรพิ็จั�รณิ�ก�รเขี� ถง่ และประสิำทธิิผู้ลขีองช่องท�งส่ำ� อแบบ ดั�งเดิมั (เช่น โทรทศัน ์วิัทยุ ป้�ยประก�ศ สิำ� งตีพิ็มัพ็์) และช่องท�งก�รส่ำ� อสำ�ร แบบดิจิัทัล (เว็ับไซต ์ โทรศัพ็ทม่์ัอถ่อ แอปพ็ลิเค์ชั�นต่�ง ๆ) ก�รให�ขี�อม้ัลเร่�อง ขี�อแนะนำ�ระดบัช�ติในร้ปแบบที�หล�ก- หล�ยนั�นมีัประโยชนม์ั�ก ตวััอย่�งเช่น แนวัท�งที� ด้ใหม่ัแต่มีัค์วั�มัเกี�ยวัเน่�องกนั อย่�งมั�กกบัก�รส่ำ�อสำ�รขี�อแนะนำ�ในก�ร ทำ�กิจักรรมัท�งก�ย ค่์อ ก�รใช�แผู้นภั�พ็ อินโฟิกร�ฟิฟิิค์หร่อวิัดีโอภั�พ็เค์ล่�อนไหวั ขีน�ดสำั�น องค์ก์�รอน�มััยโลกมีัวััตถุ สำนับสำนุนก�รพ็ัฒน�และก�รนำ�ก�ร รณิรงค์ผ่์ู้�นก�รส่ำ�อสำ�รในร้ปแบบเหล่�นี� ไปใช� (135) ชุมัชนวิัช�ก�รและก�รวิัจัยัให�ค์วั�มั สำนใจักบัร�ยง�นท�งวิัทย�ศ�สำตร ์ ซ่�งให� ร�ยละเอียดหลกัฐ�นด� นระบ�ดวิัทย� ซ่� งเป็นไปต�มัขี�อแนะนำ� อย่�งไรก็ดี ร�ยละเอียดที�เฉพ็�ะเจั�ะจังขีองก�รวิัจัยั อ�จัไม่ัเป็นที�สำนใจัขีองผู้้�ชมัทั�วัไป ผู้้�กำ�หนด นโยบ�ยอ�จันิยมัก�รสำรุปท�งวิัทย�- ศ�สำตรห์ร่อกระทั� งเอกสำ�รย่อแบบสำั�น ผู้้�ชมัอ่�น ๆ เช่น บุค์ค์ล�กรด� นสุำขีภั�พ็ หร่อนอกจั�กนั�น อ�จันิยมัแหล่งขี�อม้ัลที�มีั ชนิดต่�ง ๆ กนั ตวััอย่�งเช่น แผู่้นพ็บัหร่อ เอกสำ�รร�ยง�นขี�อเท็จัจัริงเกี�ยวักบัขี�อ การเลือักใช้้ การเผย่แพร่ การดำำาเนินการ และการประเมิูนผล ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 112 แนะนำ� หร่อวิัธีิก�รรวัมัเอ�ก�รส่ำงเสำริมั กิจักรรมัท�งก�ยเขี� กบักิจักรรมัอนัเป็น กิจัวัตัร (ตวััอย่�งเช่น ในก�รให�ค์ำ�ปรก่ษ� แก่ผู้้�ป่วัยในสำภั�พ็แวัดล�อมัขีองก�รด้แล สุำขีภั�พ็ หร่อก�รพ็ฒัน�ตก่อ�ค์�ร หร่อ แผู้นก�รค์มัน�ค์มัในสำภั�พ็แวัดล�อมัขีอง เม่ัอง) ผู้้�ค์นในสำ�ขี�อ�ชีพ็ที� ต่�งกนัต�อง ก�รแหล่งขี�อม้ัลที�ปรบัต�มับทบ�ทขีอง ผู้้�นั�น โดยเฉพ็�ะอย่�งยิ�ง บุค์ค์ล�กรด� น สุำขีภั�พ็อ�จัได�รบัประโยชนจ์ั�กชุดขี�อม้ัล ที� สำะท�อนถ่งกลุ่มัประช�กรที� แตกต่�ง หล�กหล�ยที�พ็วักเขี�ทำ�ง�นด�วัยอย่้ กิ�รันืำ�นืโยบ�ย และโคำรังกิ�รัไปใช้้ ขี�อแนะนำ�แห่งช�ติว่ั�ด�วัยกิจักรรมั ท�งก�ยและพ็ฤติกรรมัเน่อยนิ�งแต่เพี็ยง ลำ�พ็ังนั�นอ�จัไม่ันำ�ไปส่้ำก�รเพิ็� มัระดับ กิจักรรมัท�งก�ยขีองประช�กร ดงันั�น จัง่ ค์วัรมัองว่ั�เป็นส่ำวันหน่�งขีองนโยบ�ยและ กรอบก�รวั�งแผู้น ก�รจัะเผู้ยแพ็ร่ขี�อ แนะนำ�แห่งช�ติไปยงัผู้้�รบัสำ�รกลุ่มัหลกั และก�รสำนบัสำนุนโดยกลยุทธิชุ์มัชนระดบั ประเทศที�เอ่ �อต่อกนัเป็นเร่�องที�สำำ�ค์ญั่ ซ่�ง จัะนำ�ไปส่้ำก�รตระหนกัร้�และค์วั�มัร้�ที�เพิ็�มั มั�กขี่ �น เกี�ยวักบัประโยชนอ์นัหล�กหล�ย จั�กก�รทำ�กิจักรรมัท�งก�ยเป็นประจัำ� และก�รลดพ็ฤติกรรมัเน่อยนิ�ง อย่�งไร ก็ต�มั เพ่็�อที�จัะเปลี�ยนแปลงพ็ฤติกรรมั อย่�งยั�งย่น ก�รกระทำ�เหล่�นี�ค์วัรได�รบั ก�รสำนับสำนุนโดยนโยบ�ยที� สำร� งสิำ� ง แวัดล�อมัที� เป็นใจัอนัก่อให�หร่อกระตุ�น ให� ผู้้�ค์นไม่ัอย่้เฉย และเพิ็� มัโอก�สำใน ท�องถิ�นที�เหมั�ะสำมัให�ผู้้�ค์นเขี� ร่วัมัทำ�กิจั- กรรมัท�งก�ย นโยบ�ยและร�ยก�รต่�ง ๆ จัะต�องพิ็จั�รณิ�และสำ�มั�รถปรบัให�เขี� กบับริบทท�องถิ�นได� ทั�งในเร่�องขีองระบบ สุำขีภั�พ็และสำถ�บนัเชิงซ�อนต่�ง ๆ ที� มีั หล�ยภั�ค์ส่ำวัน ซ่�งสำนใจัหร่อมีัโอก�สำที� จัะสำนับสำนุนก�รส่ำงเสำริมักิจักรรมัท�ง ก�ย ค์วัรมีัก�รดำ�เนินก�รโดยใช�แนวัท�ง “ก�รบ้รณิ�ก�รก�รทำ�ง�นขีองหน่วัย ง�นภั�ค์รฐัให�เป็นไปในทิศท�งเดียวักนั” และพิ็จั�รณิ� “ระบบ” ขีองนโยบ�ยและ ก�รกระทำ�หล�ยประก�รที� สำ�มั�รถ สำนับสำนุนผู้้�ค์นจัำ�นวันมั�กให�มีัก�รทำ� กิจักรรมัท�งก�ย ผู่้�นก�รมีัส่ำวันร่วัมัขีอง ผู้้�มีัส่ำวันเกี�ยวัขี�องมั�กมั�ยที�ค์รอบค์ลุมั ภั�ค์ส่ำวันและสำภั�พ็แวัดล�อมัที� หล�ก หล�ย ก�รใช�แนวัท�งด� น “ระบบ” ซ่�งเป็น ไปต�มักลยุทธิก์�รส่ำ�อสำ�รอย่�งยั�งย่นนั�น ทำ�ให�มัั� นใจัได�ว่ั�อุปสำงค์์ในก�รทำ�กิจั- กรรมัท�งก�ยที�เพิ็�มัส้ำงขี่ �นจั�กก�รส่ำ�อสำ�ร ที�สำมััฤทธิิ �ผู้ลนั�น เขี� ค่้์กบัก�รจัดัห�สำภั�พ็- แวัดล�อมัและ โอก�สำให� ผู้้�ค์นมีัค์วั�มั กระฉบักระเฉงมั�กยิ�งขี่ �น ขี�อแนะนำ�ระดบัโลกด� นกิจักรรมั ท�งก�ยขีององค์ก์�รอน�มัยัโลก พ็.ศ. 2561-2573 ตั�งเป้�ที�จัะลดกิจักรรมัท�ง ก�ยที� ไม่ัเพี็ยงพ็อลงร�อยละ 15 ภั�ยใน พ็.ศ. 2573 และสำรุปก�รดำ�เนินก�รต�มั นโยบ�ยและก�รแทรกแซงที�แนะนำ� 20 ประก�ร (14) รวัมัถ่งก�รแนะนำ�ให�ทุก ประเทศนำ�ก�รศ่กษ�สำ�ธิ�รณิะระดบั ช�ติที�ยั�งย่น และก�รรณิรงค์ส์ำร� งค์วั�มั ตระหนกัร้� ตลอดจันก�รรวัมัเอ�ร�ยก�ร ก�รให�ค์ำ�ปร่กษ�ด� นกิจักรรมัท�งก�ย เขี� ไปใช�ร่วัมักบัก�รด้แลสุำขีภั�พ็ขีั�นต�น และขีั�นทุติยภ้ัมิั ขี�อแนะนำ�อ่�น ๆ นั�นรวัมัถ่ งก�รสำร� งสำภั�พ็แวัดล�อมัที�เหมั�ะสำมัสำำ�- หรับก�รทำ�กิจักรรมัท�งก�ยรวัมัถ่ง 113 ก�รเดิน ก�รปั� นจักัรย�นและก�รเค์ล่�อนที� ด�วัยล�อ สำำ�หรบักลุ่มัประช�กรทุกกลุ่มั และก�รสำร� งโอก�สำและร�ยก�รที�มั�ก ขี่ �นให�มีัก�รทำ�กิจักรรมัท�งก�ยในโรง- เรียน ที�ทำ�ง�น สำโมัสำรกีฬ� และสำถ�นที�พ็บ- ปะก�รนำ�ขี�อแนะนำ�ทั�ง 20 ประก�รไปใช� อ�จัเป็นไป ได�ย�กในระยะสำั�นในทุก ประเทศ และค์วัรมัองเป็นเป้�หมั�ย ระยะย�วั เพ่็�อแยกแยะระหว่ั�งก�รกระทำ� ที�ทำ�ได�ทนัทีอนัมีัค์วั�มัเหมั�ะสำมัและเป็น ไปได� ประเทศสำมั�ชิกขีององค์ก์�รอน�- มััยโลกค์วัรวิัเค์ร�ะห์สำถ�นก�รณิข์ีอง นโยบ�ยและขี�อแนะนำ�ปัจัจุับนั สิำ� งนี�จัะ ช่วัยสำร� งค์วั�มัร่วัมัม่ัอหล�ยภั�ค์ส่ำวันและ ช่วัยบ่งชี�จุัดแข็ีง ตลอดจันช่องว่ั�ง และ โอก�สำที�อ�จัใช�เป็นพ่็�นฐ�นในก�รพ็ฒัน� หร่อปรับปรุงแผู้นระดบัช�ติและแผู้น ภั�ยในช�ติได� ขี�อแนะนำ�ขีององค์ก์�รอน�มัยัโลก ฉบบัใหม่ันี� สำนบัสำนุนก�รขีย�ยขีอบเขีต ขีองก�รปฏิิบติัที�ค์รอบค์ลุมักลุ่มัเพิ็�มัเติมั เช่น ผู้้�มีัภั�วัะทุพ็พ็ลภั�พ็หร่อมีัโรค์เร่�อรงั และหญิ่งมีัค์รรภัห์ร่อมั�รด�หลงัค์ลอด นโยบ�ยค์วัรสำนบัสำนุนก�รนำ�ส่ำงร�ยก�ร ที�เหมั�ะสำมัและขี�อแนะนำ�ที�ตระหนกัร้�ถง่ ค์วั�มัต�องก�รขีองชุมัชน ค์วั�มัหล�ก หล�ยขีองกลุ่มัค์น และสำภั�พ็แวัดล�อมั ชุดเค์ร่�องม่ัอเฉพ็�ะภั�ค์ส่ำวันยงัอย่้ในช่วัง พ็ฒัน�เพ่็�อรองรบัก�รนำ�ชุดเค์ร่� องม่ัอ ท�งเทค์นิค์ต�มัแนวัท�ง ACTIVE ไปใช� (135) ซ่�งจัะนำ�ค์ำ�แนะแนวัในก�รส่ำงเสำริมั กิจักรรมัท�งก�ยให�แก่ทุกภั�ค์ส่ำวัน ตัวัอย่�งเช่น ในโรงเรียน ผู่้�นก�ร ด้แลสุำขีภั�พ็เบ่ �องต�น หร่อโดยก�รปรบั- ปรุงก�รจัดัห�พ่็�นที�สำำ�หรบัก�รเดินและ ก�รปั� นจักัรย�น ชุดเค์ร่�องม่ัอต�มัแนวั- ท�ง ACTIVE รวัมัถง่ทรพั็ย�กรขีององค์-์ ก�รอน�มััยโลกในระดับภ้ัมิัภั�ค์หร่อ ระดบัช�ติ จัะสำนบัสำนุนก�รนำ�ขี�อแนะนำ� ขีองกิจักรรมัท�งก�ยและพ็ฤติกรรมั เน่อยนิ�งนี�ไปใช� กิ�รัติรัวัจติรั� และกิ�รัปรัะเมินื ขี�อแนะนำ�ระดบัโลกขีององค์ก์�ร- อน�มััยโลกด� นกิจักรรมัท�งก�ยเพ่็� อ สุำขีภั�พ็นั�น ใช�เป็นเกณิฑ์ม์ั�ตรฐ�นสำำ�หรบั ก�รด้แลและตรวัจัตร�สุำขีภั�พ็ประช�กร มั�ตั�งแต่ พ็.ศ. 2553 ก�รเปลี�ยนแปลง สำำ�หรบัขี�อแนะนำ�ฉบบัปรบัปรุงนี�อ�จัจัะ มีัก�รอ� งถ่งระบบก�รตรวัจัตร�และ เค์ร่�องม่ัอประเมิันที�ใช�อย่้ขีณิะนี� เพ่็�อด้แล กิจักรรมัท�งก�ยในระดบัช�ติ ก�รเผู้ย- แพ็ร่ขี�อแนะนำ�ใหม่ันี� จัะเรียกร�องให�มีัก�ร ทบทวันเค์ร่�องม่ัอที�ใช�ในปัจัจุับนัและร�ย ง�นร้ปแบบสำำ�หรบัก�รปรบัแก� และขี�อ แนะนำ�ในอน�ค์ตที�ร�ยง�นผู้ลตรงกนั ขี� มักบัขี�อแนะนำ�ใหม่ั จัะต�องทบทวันและ ปรบัปรุงในเค์ร่� องม่ัอต่�ง ๆ เช่น แบบ สำอบถ�มัเกี� ยวักบักิจักรรมัท�งก�ยใน ระดบัโลกและแบบสำำ�รวัจัสุำขีภั�พ็นัก- เรียนโลก ให�สำอดค์ล�องกบัขี�อแนะนำ�ใหม่ั เหล่�นี� แนวัท�งสำนับสำนุนสำำ�หรับทุก ประเทศจัะพ็ร�อมัใน พ็.ศ. 2564 แบบสำำ�รวัจัค์วั�มัสำ�มั�รถระดบั ประเทศด� นโรค์ไม่ัติดต่อเร่ �อรงัขีององค์ ์ ก�รอน�มัยัโลก (CCS) เป็นเค์ร่�องม่ัอหลกัที� ใช�ในก�รตรวัจัตร�ค์วั�มัค่์บหน� ระดบั โลก ในก�รนำ�นโยบ�ยเกี� ยวักบัโรค์ไม่ั ติดต่อเร่ �อรงัไปใช� และมีัก�รสำำ�รวัจัทุก ๆ สำองปี แบบสำำ�รวัจั CCS นั�นมีัค์ำ�ถ�มัที� การเลือักใช้้ การเผย่แพร่ การดำำาเนินการ และการประเมิูนผล ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 114 เฉพ็�ะเจั�ะจังไปยงัระบบก�รตรวัจัตร� กิจักรรมัท�งก�ยขีองประช�กรในแต่ละ กลุ่มัอ�ยุที�ค์รอบค์ลุมัโดยขี�อแนะนำ�ขีอง องค์ก์�รอน�มัยัโลกด� นกิจักรรมัท�ง- ก�ยและพ็ฤติกรรมัเน่อยนิ� ง และก�ร ตรวัจัตร�ขี�อแนะนำ�ด� นกิจักรรมัท�ง- ก�ยระดบัช�ติที� มีัอย่้ตั�งแต่พ็.ศ. 2562 ประเทศสำมั�ชิกขีององค์ก์�รอน�มัยัโลก ต�องนำ�เขี� เอกสำ�รเพ่็� อสำนับสำนุนก�ร ตอบก�รสำำ�รวัจันี� ในพ็.ศ. 2562 ประ- เทศสำมั�ชิกขีององค์ก์�รอน�มััยโลก จัำ�นวัน 78 ประเทศ (ร�อยละ 40) จั�กทั�งสิำ �น 194 ประเทศ ร�ยง�นว่ั� มีัขี�อแนะนำ�ด� น กิจักรรมัท�งก�ย (136) มีัก�รวิัเค์ร�ะห ์ เ อ ก สำ � ร โ ด ย ล ะ เ อี ย ด เ กี� ย วั กับ ก � ร ตอบแบบสำำ�รวัจั CCS ในพ็.ศ. 2562 และระบุว่ั�มีัเพี็ยง 2 ใน 3 จั�กประเทศ สำมั�ชิก 78 ประเทศที� มีัขี�อแนะ นำ � ระดบัช�ติ ได�แนบขี�อแถลงว่ั� ประช�กร ขีองตนค์วัรทำ�กิจักรรมัท�งก�ยเท่�ใด และจั�กกลุ่มันี� มีัเพี็ยง 42 ประเทศที�ทำ� ต�มัขี�อแนะนำ�ระดบัโลกขีององค์ก์�ร อน�มััยโลกด� นกิจักรรมัท�งก�ยเพ่็� อ สุำขีภั�พ็ประจัำ� พ็.ศ. 2553 อย่�งค์รบถ�วัน ขี�อม้ัลจั�ก พ็.ศ. 2564 และก�รสำำ�รวัจัที� จัะต�มัมั�จัะให�ขี�อม้ัลเกี� ยวักับก�รใช� ขี�อแนะนำ�ที�ปรบัปรุงแล�วั กิ�รัปรัับปรุังข้้อมูล จัะมีัก�รปรบัปรุงขี�อแนะนำ�นี�หลงั จั�ก 10 ปีไปแล�วั เวั�นแต่ว่ั�ค์วั�มัก� วัหน� ท�งวิัทย�ศ�สำตร์ในก�รประเมิันกิจักรรมั ท�งก�ยด�วัยเค์ร่� องม่ัอวััด และวิัทย�- ศ�สำตรเ์กี� ยวักับพ็ฤติกรรมัเน่อยนิ� งที� วิัวัฒัน�ก�รรุดหน� จัะกระตุ�นให�เกิดก�ร ปรบัปรุงขี�อม้ัลที�กระชั�นขี่ �น 115 รั�ยกิ�รัอ้�งอิง 1. 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Geneva: World Health Organization; 2020. ราย่การอ้ัางอิัง ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 124 125 ภาคผนวัก 1: MANAGEMENT OF GUIDELINE DEVELOPMENT PROCESS Contributors to guideline development Valentina Baltag Department of Maternal, Newborn, Child and Adolescent Health and Ageing – adolescent health Maurice Bucagu Department of Maternal, Newborn, Child and Adolescent Health and Ageing – pregnancy Fiona Bull Chairperson Department for Health Promotion – physical activity Alex Butchart Department of Social Determinants of Health – injury prevention Neerja Chowdhary Department of Noncommunicable Diseases – mental health/dementia Regina Guthold Department of Maternal, Newborn, Child and Adolescent Health and Ageing – adolescent surveillance WHO Steering Group The Steering Group included experts in the areas of physical activity, adolescent health, ageing disability, mental health, injury prevention, cancer, pregnancy and surveillance from both headquarters and regional offices. The Steering Group drafted the scope of the guidelines, and the PI/ECOs. They reviewed the declaration of interests; and drafted, reviewed and finalized the guidelines. Riitta-Maija Hämäläinen Western Pacific Regional Office Andre Ilbawi Department of Noncommunicable Diseases – cancer Wasiq Khan Eastern Mediterranean Regional Office Lindsay Lee Department of Noncommunicable Diseases – disability Alana Officer Ageing Leanne Riley Department for Noncommunicable Diseases – surveillance Gojka Roglic Department for Noncommunicable Diseases – diabetes Juana Willumsen Department for Health Promotion – physical activity ภิาคำผนวก 1 ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 126 Guideline Development Group (GDG) The Guideline Development Group consisted of a broad group of relevant experts in the field and end users of, and persons affected by, the recommendations. The members of the Guideline Development Group included: A first GDG meeting was held 2–4 July 2019, at which the GDG decided on the PI/ECO questions, reviewed the existing systematic reviews, and identified updates required. The Group agreed on the process for decision-making on recommendations and the strength of the evidence to be applied at the second GDG meeting. The second meeting was held 11–14 February 2020; updated evidence was reviewed and final recommendations agreed upon by consensus. Dr Salih Saad Al-Ansari (advocate in health promotion and education to combat NCDs through physical activity and walking); Dr Stuart Biddle (physical activity and sedentary behaviour, and behaviour change); Dr Katja Borodulin (physical activity in pregnancy and older adults); Dr Matthew Buman (sleep, sedentary behaviour, and physical activity in people living with chronic conditions); Dr Greet Cardon (physical activity in children and adolescents); Ms Catherine Carty (physical activity in people living with disability); Dr Jean-Philippe Chaput (sleep, sedentary behaviour and physical activity in children and adolescents); Dr Sebastien Chastin (physical activity, sedentary behaviour and health, objective measurement of physical activity and sedentary behaviour); Dr Paddy Dempsey (physical activity and sedentary behaviour in adults and people living with chronic conditions); Dr Loretta DiPietro (physical activity in pregnancy and older adults); Dr Ulf Ekelund (sedentary behaviour and physical activity, physical activity in children and adolescents); Dr Joseph Firth (physical activity and mental health); Dr Christine Friedenreich (physical activity in people living with chronic conditions, physical activity and cancer risk); Dr Leandro Garcia (physical activity and health in adults); Dr Muthoni Gichu (policy implementation, national government); Dr Russ Jago (physical activity in children and adolescents); Dr Peter Katzmarzyk (physical activity and sedentary behaviour); Dr Estelle V. Lambert (physical activity and obesity); Dr Michael Leitzmann (sedentary behaviour and physical activity in people living with chronic conditions); Dr Karen Milton (translating recommendations into practice); Dr Francisco B. Ortega (physical activity in children and adolescents, mental health and objective measurement); Dr Chathuranga Ranasinghe (promotion of physical activity and health in the community, workplace and school settings); Dr Emmanuel Stamatakis (physical activity and sedentary behaviour and multiple health outcomes in adults); Dr Anne Tiedemann (physical activity in older adults); Dr Richard Troiano (policy development); Dr Hidde van der Ploeg (physical activity and sedentary behaviour in adults); Ms Vicky Wari (policy implementation – national government); Dr Roger Chou (Pacific Northwest Evidencebased Practice Center and Professor of Medicine, Departments of Medicine, Medical Informatics and Clinical Epidemiology of the Oregon Health and Science University) served as GRADE methodologist. Further details of the GDG are available in Annex 2. 127ภิาคำผนวก 1 External Review Group (ERG) Seven peer reviewers were drawn from a list of individuals suggested by the GDG and Steering Group. They provided relevant expertise, including programme implementation and represented all six WHO regions. The ERG reviewed the draft guidelines and provided feedback to the Steering Group on issues of clarity and implementation, which was incorporated, as appropriate. External peer reviewers did not make changes to the recommendations. External peer reviewers are listed in Annex 2. Declarations of Interest All GDG members and external peer reviewers completed and submitted a WHO Declaration of Interests form and signed confidentiality undertakings prior to attending any GDG meetings. The Steering Group reviewed and assessed the submitted curriculum vitae and declarations of interest and performed an internet and publications search to identify any obvious public controversies or interests that may lead to compromising situations. The names and brief biographies of all proposed GDG members were published on the WHO Physical Activity webpage for public consultation for a period of 14 days. No comments were received. If additional guidance on management of any declaration or conflicts of interest had been required, the Steering Group would have consulted with colleagues in Office of Compliance, Risk Management and Ethics. If deemed necessary, individuals found to have conflicts of interest, financial or non-financial, would have been excluded from participation on any topics where interests were conflicting. The management of conflicts of interest was reviewed throughout the process. GDG members were required to update their Declaration of Interest, if necessary, before each meeting and a verbal declaration of interest was solicited at the beginning of each GDG meeting. Declared interests of the GDG and of the external peer reviewers are summarized in Annex 3. No conflict of interest was identified. Peer review The draft guidelines were reviewed by seven external peer reviewers identified by the GDG and Steering Group. External peer reviewers were requested to provide comments on issues of clarity, presentation of the evidence, and implementation; comments were incorporated as appropriate. External peer reviewers could not change the recommendations decided upon by the GDG. External peer reviewers are listed in Annex 2; a summary of declarations of interest are provided in Annex 3. In addition, inputs were actively sought from WHO regional offices. ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 128 ภาคผนวัก 2: GUIDELINE DEVELOPMENT GROUP, EXTERNAL PEER REVIEWERS, AND WHO STAFF INVOLVED IN THE DEVELOPMENT OF THESE GUIDELINES Guideline Development Group Dr Salih Al-Ansari Assistant Professor Family & Community Medicine Founder and CEO Health Promotion Center Riyadh SAUDI ARABIA Dr Stuart Biddle Professor of Physical Activity & Health Physically Active Lifestyles Research Group Centre for Health Research Institute for Resilient Regions University of Southern Queensland Springfield Central AUSTRALIA Dr Katja Borodulin The Age Institute Helsinki FINLAND Dr Matthew Buman College of Health Solutions Arizona State University Phoenix USA Dr Greet Cardon Department of Movement and Sports Sciences Faculty of Medicine and Health Sciences Ghent University Gent BELGIUM Ms Catherine Carty UNESCO Chair Project Manager Institute of Technology Tralee Co Kerry IRELAND Dr Jean-Philippe Chaput Senior Scientist, Healthy Active Living and Obesity (HALO) Research Group Children’s Hospital of Eastern Ontario (CHEO) Research Institute Department of Pediatrics University of Ottawa Ottawa, Ontario CANADA Dr Sebastien Chastin Professor of Health Behaviour Dynamics School of Health and Life Sciences Department of Psychology, Social Work and Allied Health Sciences Glasgow Caledonian University Glasgow UNITED KINGDOM Dr Roger Chou (GRADE Methodologist) Departments of Medicine, and Medical Informatics & Clinical Epidemiology Oregon Health & Science University Portland, Oregon USA Dr Paddy Dempsey MRC Epidemiology Unit University of Cambridge School of Clinical Medicine Institute of Metabolic Science Cambridge UNITED KINGDOM 129ภิาคำผนวก 2 Dr Loretta DiPietro Department of Exercise and Nutrition Sciences Milken Institute School of Public Health The George Washington University Washington, DC USA Dr Ulf Ekelund Department of Sport Medicine Norwegian School of Sport Science Oslo NORWAY Dr Joseph Firth Presidential Fellow School of Health Sciences University of Manchester Manchester UNITED KINGDOM Dr Christine Friedenreich Scientific Director Department of Cancer Epidemiology and Prevention Research Cancer Control Alberta Alberta Health Services Calgary CANADA Dr Leandro Garcia Research Associate Centre for Public Health Queen’s University Belfast Belfast UNITED KINGDOM Dr Muthoni Gichu Head Division of Geriatric Medicine Department of Non-Communicable Diseases Ministry of Health Nairobi KENYA Dr Russell Jago Professor of Paediatric Physical Activity & Public Health Centre for Exercise, Nutrition & Health Sciences School for Policy Studies University of Bristol Bristol UNITED KINGDOM Dr Peter T. Katzmarzyk Associate Executive Director for Population and Public Health Sciences Professor and Marie Edana Corcoran Endowed Chair in Pediatric Obesity and Diabetes Pennington Biomedical Research Center Baton Rouge USA Dr Estelle V. Lambert Director Research Centre for Health Through Physical Activity, Lifestyle and Sport University of Cape Town Cape Town SOUTH AFRICA Dr Michael Leitzmann Professor of Epidemiology Department of Epidemiology and Preventive Medicine University of Regensburg Regensburg GERMANY Dr Karen Milton Associate Professor in Public Health Norwich Medical School University of East Anglia Norwich UNITED KINGDOM Dr Francisco B. Ortega Head Unit of Physical Activity and Health Promotion Research Institute of Sport and Health (iMUDS) Department of Physical Education and Sports University of Granada Granada SPAIN ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 130 Dr Chathuranga Ranasinghe Chairperson NIROGI Lanka project Sri Lanka Medical Association Senior lecturer Sports and Exercise Medicine Unit Faculty of Medicine University of Colombo C Colombo SRI LANKA Dr Emmanuel Stamatakis Charles Perkins Centre Faculty of Medicine and Health School of Public Health University of Sydney Sydney AUSTRALIA Dr Anne Tiedemann Associate Professor Institute for Musculoskeletal Health School of Public Health Faculty of Medicine and Health University of Sydney Sydney AUSTRALIA Dr Richard Troiano Epidemiology and Genomics Research Program National Cancer Institute National Institutes of Health Rockville USA Dr Hidde van der Ploeg Associate Professor Department of Public and Occupational Health Amsterdam Public Health Research Institute Amsterdam University Medical Centres Amsterdam NETHERLANDS Ms Vicky Wari* Programme Manager, NCD National Department of Health Port Moresby PAPUA NEW GUINEA * unable to attend External review group Dr Kingsley Akinroye NCD Alliance Nigeria NIGERIA Dr Huda Alsiyabi Director Department of Community Based Initiatives Ministry of Health OMAN Dr Alberto Flórez-Pregonero Pontificia Universidad Javeriana COLOMBIA Dr Shigeru Inoue Department of Preventive Medicine and Public Health Tokyo Medical University JAPAN Dr Agus Mahendra Department of Physical education Universitas Pendidikan INDONESIA Dr Deborah Salvo Prevention Research Center in St. Louis Brown School Washington University USA Dr Jasper Schipperijn President-Elect 2020–2022 International Society of Physical Activity and Health Department of Sports Science and Clinical Biome- chanics University of Southern Denmark DENMARK 131ภิาคำผนวก 2 WHO Steering Group Dr Valentina Baltag Head Adolescent and Young Adult Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND Dr Maurice Bucagu Medical Officer Maternal Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND Dr Alexander Buchart Head Violence Prevention Social Determinants of Health Department WHO Headquarters Geneva SWITZERLAND Dr Fiona Bull Head Physical Activity Department of Health Promotion WHO Headquarters Geneva SWITZERLAND Dr Regina Guthold Scientist Adolescent and Young Adult Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND Dr Riitta-Maija Hämäläinen Technical Officer Noncommunicable Diseases and Health Promotion WHO Regional Office for the Western Pacific Manila PHILIPPINES Dr Andre Ilbawi Technical Officer Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Dr Wasiq Khan* Regional Adviser Health Education and Promotion WHO Regional Office for the Eastern Mediterranean Cairo EGYPT Ms Lindsay Lee Technical Officer Sensory Functions, Disability and Rehabilitation Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Ms Alana Officer Senior Health Adviser Healthy Ageing Office of the Director-General WHO Headquarters Geneva SWITZERLAND Ms Leanne Riley Head Surveillance Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Dr Gojka Roglic Medical Officer Noncommunicable Diseases Management Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND Dr Juana Willumsen Technical Officer Physical Activity Department of Health Promotion WHO Headquarters Geneva SWITZERLAND * unable to attend ข้อ แน ะน ำ�เ กี่�ย วกี่ บกี่ จกี่ รร มท �ง กี่� ย พฤ ติกี่ รร มเ นือ ยนิ �ง แล ะกี่ �ร นอ นห ลับ สำำ �ห รับ เด็ กี่ท่ �ม่อ �ยุ ติำ� � กี่ว่ � 5 ปี 132 ภาคผนวัก 3: GUIDELINE DEVELOPMENT GROUP, EXTERNAL PEER REVIEWERS, AND WHO STAFF INVOLVED IN THE DEVELOPMENT OF THESE GUIDELINES Guideline Development Group members Name Gender Expertise Disclosure of interest Conflict of interest and management Dr Salih Saad Al-Ansari Male Advocate in health promotion and education to combat NCDs through physical activity and walking Owner and Chief Executive Officer of the Health Promotion Center No conflict of interest identified Dr Stuart Biddle Male Physical activity in youth Research funds and paid consultancy No conflict of interest identified Dr Katja Borodulin Female Physical activity in pregnancy Employment at National Institute for Health and Welfare and Age Institute; research funds No conflict of interest identified Dr Matthew Buman Male Sleep and physical activity in people living with chronic conditions None declared No conflict of interest identified Dr Greet Cardon Female Physical activity in youth None declared No conflict of interest identified Ms Catherine Carty Female Physical activity in people living with disability Research funds No conflict of interest identified Dr Jean-Philippe Chaput Male Sleep None declared No conflict of interest identified Dr Sebastien Chastin Male Physical activity and health, objective measurement of physical activity Research funds No conflict of interest identified Dr Paddy Dempsey Male Physical activity and sedentary behaviour in adults and people living with chronic conditions Employment and research funds No conflict of interest identified Dr Loretta DiPietro Female Physical activity in older adults None declared No conflict of interest identified Dr Ulf Ekelund Male Sedentary behaviour and physical activity in youth None declared No conflict of interest identified Dr Joseph Firth Male Physical activity and mental health None declared No conflict of interest identified Dr Christine Friedenreich Female Physical activity in people living with chronic conditions, physical activity and cancer risk None declared No conflict of interest identified Dr Leandro Garcia Male Physical activity and mental health Employment and paid consultancy No conflict of interest identified Dr Muthoni Gichu Female Policy implementation (national government) None declared No conflict of interest identified Dr Russ Jago Male Physical activity in youth None declared No conflict of interest identified 133 Name Gender Expertise Disclosure of interest Conflict of interest and management Dr Peter Katzmarzyk Male Physical activity and sedentary behaviour in youth Travel support to assist guideline committees No conflict of interest identified Dr Estelle V. Lambert Female Physical activity and obesity None declared No conflict of interest identified Dr Michael Leitzmann Male Sedentary behaviour and chronic conditions None declared No conflict of interest identified Dr Karen Milton Female Translating recommendations into practice Travel support to assist guideline committee No conflict of interest identified Dr Francisco Ortega Male Physical activity in youth, mental health and objective measurement None declared No conflict of interest identified Dr Chathuranga Ranasinghe Male Promotion of physical activity and health in the community, workplace and school settings Research funds No conflict of interest identified Dr Emmanuel Stamatakis Male Physical activity and multiple health outcomes in adults Grant for technology company for objective measurement of physical activity No conflict of interest identified Dr Anne Tiedemann Female Physical activity and health outcomes in older adults None declared No conflict of interest identified Dr Richard Troiano Male Policy development None declared No conflict of interest identified Dr Hidde van der Ploeg Male Physical activity, sedentary behaviour and health outcomes in adults Travel support to assist 2017 Dutch Physical Activity Guidelines committee and research funds No conflict of interest identified Ms Vicky Wari Female Policy implementation (national government) Shares (not relevant to guideline) No conflict of interest identified Name Gender Expertise Disclosure of interest Conflict of interest and management Kingsley Akinroye Male Advocacy, noncommunicable diseases None declared No conflict of interest identified Dr Huda Alsiyabi Female Policy and programme implementation None declared No conflict of interest identified Dr Alberto Flórez- Pregonero Male Physical activity and sedentary behaviour measurement and surveillance None declared No conflict of interest identified Dr Shigeru Inoue Male Epidemiology and physical activity promotion None declared No conflict of interest identified Dr Agus Mahendra Male Physical activity and movement skills in children None declared No conflict of interest identified Dr Deborah Salvo Female Health and social disparities, with a particular emphasis on chronic disease prevention None declared No conflict of interest identified Dr Jasper Schipperijn Male Physical activity and the built environment President-Elect of the International Society for Physical Activity and Health (ISPAH) No conflict of interest identified External peer reviewers ภิาคำผนวก 3 เอักสารแปลจัาก WHO Guidelines on physical activity and sedentary behaviour

世卫组织关于身体活 动和久坐行为的指南

世卫组织关于身体活 动和久坐行为的指南 世卫组织关于身体活动和久坐行为的指南 [WHO guidelines on physical activity and sedentary behaviour] ISBN 978-92-4-003215-6（网络版） ISBN 978-92-4-003216-3（印刷版） © 世界卫生组织 2021年 保留部分版权。本作品可在知识共享署名——非商业性 使用——相同方式共享3.0政府间组织（CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo/deed.zh) 许可协议下使用。 根据该许可协议条款，可为非商业目的复制、重新分 发和改写本作品，但须按以下说明妥善引用。在对本作品 进行任何使用时，均不得暗示世卫组织认可任何特定组 织、产品或服务。不允许使用世卫组织的标识。如果改写 本作品，则必须根据相同或同等的知识共享许可协议对改 写后的作品发放许可。如果对本作品进行翻译，则应与建 议的引用格式一道添加下述免责声明：“本译文不由世界卫 生组织（世卫组织）翻译，世卫组织不对此译文的内容或 准确性负责。原始英文版本为应遵守的正本”。 与许可协议下出现的争端有关的任何调解应根据世界 知识产权组织调解规则进行（http://www.wipo.int/amc/en/ mediation/rules)。 建议的引用格式。世卫组织关于身体活动和久坐 行为的指南 [WHO guidelines on physical activity and sedentary behaviour]。日内瓦：世界卫生组织；2021年。 许可协议：CC BY-NC-SA 3.0 IGO。 在版编目（CIP）数据。在版编目数据可查阅http:// apps.who.int/iris 。 销售、版权和许可。购买世卫组织出版物，参见 http://apps.who.int/bookorders 。提交商业使用请求和查询 版权及许可情况，参见http://www.who.int/about/licensing 。 第三方材料。如果希望重新使用本作品中属于第 三方的材料，如表格、图形或图像等，应自行决定这 种重新使用是否需要获得许可，并相应从版权所有方 获取这一许可。因侵犯本作品中任何属于第三方所有 的内容而导致的索赔风险完全由使用者承担。 一般免责声明。本出版物采用的名称和陈述的材 料并不代表世卫组织对任何国家、领地、城市或地区 或其当局的合法地位，或关于边界或分界线的规定有 任何意见。地图上的虚线表示可能尚未完全达成一致 的大致边界线。 凡提及某些公司或某些制造商的产品时，并不意味 着它们已为世卫组织所认可或推荐，或比其它未提及的 同类公司或产品更好。除差错和疏忽外，凡专利产品名 称均冠以大写字母，以示区别。 世卫组织已采取一切合理的预防措施来核实本出 版物中包含的信息。但是，已出版材料的分发无任何 明确或含蓄的保证。解释和使用材料的责任取决于 读者。世卫组织对于因使用这些材料造成的损失不承 担责任。 设计：Eddy Hill Design Printed in Switzerland ii iii 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 目录 致谢 iv 缩略语 v 术语表 vi 概述 1 背景 15 方法 18 建议 24 儿童与青少年（5-17岁） 25 身体活动建议 25 久坐行为建议 29 成年人（18–64岁） 32 身体活动建议 32 久坐行为建议 38 老年人（65岁以上） 43 身体活动建议 43 久坐行为建议 46 孕妇和产后妇女 47 身体活动建议 47 久坐行为建议 51 患有慢性病的成年人和老年人 （18岁以上） 52 身体活动建议 52 久坐行为建议 58 残疾儿童和青少年（5–17岁） 以及残疾成年人（18岁以上） 60 身体活动建议 60 久坐行为建议 64 证据转化建议 66 证据质量评估 66 收益和危害 67 价值观和偏好 67 涉及资源问题 67 平等、可接受性和可行性 68 研究需求 69 采纳、传播、实施和评估 70 采纳 70 传播 71 宣传活动 71 策和方案实施 72 监测与评估 73 更新 73 参考文献 75 附件1：指南制定程序的管理 85 附件2：指南制定小组、外部同行评审员 以及参与指南制定工作的世卫组织职员 88 附件3：利益申报汇总及其管理方式 92 网络附件：证据简介 https://apps.who.int/iris/bitstream/handle/ 10665/336657/9789240015111-eng.pdf ii iii目录 致谢 世界卫生组织十分感谢以下个人和机构在指南制定过程中做出的贡献和帮助： Fiona Bull和Juana Willumsen领导指南制定程序。管理指南制定程序的世卫组织指导小组成员 有Valentina Baltag、Maurice Bucagu、Alex Butchart、Neerja Chowdhary、Regina Guthold、Riitta-Maija Hämäläinen、Andre Ilbawi、Wasiq Khan、Lindsay Lee、Alana Officer、Leanne Riley和Gojka Roglic。 指南制定小组（GDG）的成员有Salih Saad Al-Ansari、Stuart Biddle、Katja Borodulin、 Matthew  Buman、Greet Cardon（联合主席）、Catherine Carty、Jean-Philippe Chaput、Sebastien Chastin、Paddy Dempsey、Loretta DiPietro、Ulf Ekelund、Joseph Firth、Christine Friedenreich、 Leandro Garcia、Muthoni Gichu、Russ Jago、Peter Katzmarzyk、Estelle V. Lambert、Michael Leitzmann、Karen Milton、Francisco B. Ortega、Chathuranga Ranasinghe、Emmanuel Stamatakis（联合主席）、Anne Tiedemann、Richard Troiano、Hidde van der Ploeg、 Vicky Wari。Roger Chou任GRADE方法学家。外部审查小组成员有 Kingsley Akinroye、 Huda  Alsiyabi、Alberto Flórez-Pregonero、Shigeru Inoue、Agus Mahendra、Deborah Salvo和 Jasper Schipperijn。 对提交给美国卫生和公众服务部部长的《 2 0 1 8年美国身体活动指南顾问委员 会科学报告》所准备的证据再次进行了系统审查，为此要感谢 K y l e S p r o w（美国国 立卫生研究院下属美国国家癌症研究所，美国马里兰州）补充完成的文献搜索工 作。Elif Eroglu（悉尼大学）、Andrea Hillreiner（雷根斯堡大学）、Bo-Huei Huang（悉尼大学）、 Carmen Jochem（雷根斯堡大学）、Jairo H. Migueles（格拉纳达大学）、Chelsea Stone（卡尔加里 大学）和Léonie Uijtdewilligen（阿姆斯特丹大学医学中心）也提供了帮助，负责审查指定论文。 证据与GRADE表格的概述总结由Carrie Patnode和Michelle Henninger（凯撒基金会医院，健康 研究中心，美国俄勒冈州波特兰）完成。 负责补充完成证据审查的还有N Fairhall、J Oliveira、M Pinheiro、C Sherrington（肌肉骨骼健康 研究所，悉尼大学公共卫生学院，澳大利亚悉尼） 及A Bauman（悉尼大学公共卫生学院预防研究 合作项目，澳大利亚悉尼；及世卫组织身体活动、营养与肥胖症合作中心）；S  Mabweazara、M-J Laguette、K Larmuth、F Odunitan-Wayas（开普敦大学卫生科学系身体活动、生活方式和运动医 学健康研究中心，南非开普敦）、L Leach、S Onagbiye（西开普大学卫生科学系运动、娱乐 与训练学部，南非开普敦）、M Mthethwa（开普敦大学非洲慢性病倡议，南非开普敦）、 P Smith（开普敦大学卫生科学系传染病与分子医学研究所德斯蒙德·图图艾滋病中心，南非开普 敦）和F Mashili（穆希比利健康与联合科学大学生理学系，坦桑尼亚达累斯萨拉姆）；B Cillekens、 M Lang、W van Mechelen、E Verhagen、M Huysmans、A van der Beek、P Coenen （阿姆斯特丹大 学医学中心公共卫生与职业健康部，荷兰阿姆斯特丹）。 若非加拿大公共卫生署和挪威政府提供财政支持，本次工作难以完成。 iv v 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 ADHD 注意力缺陷多动障碍 AOR 校正比值比 BMI 身体质量指数 CI 置信区间 CVD 心血管疾病 DBP 舒张压 EtD 证据转化为决策 GDG 指南制定小组 GRADE 推荐分级的评估、制定与评价 HR 风险比 MET 代谢当量 MD 均数差 MICT 中等强度连续训练 NCD 非传染性疾病 OR 比值比 PA 身体活动 PAGAC 美国身体活动指南顾问委员会 PI/ECO 人群、干预/接触、比较和结果 RaR 相对特异危险度 RCT 随机对照试验 RR 相对危险度 SBP 收缩压 SMD 标准均数差 SPPB 简易体能状况量表 TV 电视 WHA 世界卫生大会 WHO 世界卫生组织 缩略语 iv v缩略语 术语 定义 有氧身体活动 人体大肌群有节奏持续运动的活动。有氧活动——又称耐力运动——可以改善 心肺功能健康。 例如散步、跑步、游泳和骑车。 无氧身体活动 无氧身体活动为短暂的剧烈运动，如举重和短跑，其氧气需求超过氧气供应。 平衡性训练 静态和动态练习，旨在提高自发运动、环境或其他物体引起姿势晃动或失稳刺 激时个人的应对能力。 身体质量指数 （BMI ） 体重（公斤）/身高（米）2 年龄别身体质 量指数或BMI 的Z值 根据年龄调整的BMI，针对儿童标准化。 BMI标准差值是根据儿童年龄和性别调整后的相对体重衡量标准。根据儿童 的年龄、性别、BMI和适当参考标准，可以确定BMI的Z值（或等值的年龄别 BMI百分位）。 增强骨骼的活动 主要目的为提高骨骼系统中特定部位强度的身体活动。增强骨骼的活动对骨骼 产生冲击力或张力，促进骨骼生长和强度。 增强骨骼的活动有跑步、跳绳和举重等。 心血管代谢健康 血压、血脂、血糖和胰岛素对健康的相互作用。 心肺健康 （耐力） 身体素质中与健康有关的组成部分。循环系统和呼吸系统在持续身体活动中的 供氧能力。 通常以测量或估计的最大摄氧量表示（VO2 max）。 认知功能 可获得信息和知识的大脑活动，如推理、记忆、注意力和语言。也包括学习。 残疾 根据《国际功能、残疾和健康分类》，残疾为损伤、活动受限以及参与限制的 总称，表示个人（疾病患者）与自己的背景因素（环境和个人因素）之间相互 的负面作用。 身体活动类型 身体活动水平可以按不同类型评估，包括以下一种或几种类型：休闲、职业、 教育、家庭和/或交通。 锻炼 身体活动的子类别之一，有计划、有安排、重复和有针对性，以改善或维持身 体健康的某一方面或多个方面为目标。“锻炼”和“运动训练”往往可以通用， 一般指利用闲暇时间、以改善或维持身体健康、体能或健康为主要目标的身体 活动。 执行功能 包括：工作记忆，认知弹性（又称灵活思维）和抑制控制（包括自我控制）。 身体素质 衡量人体在工作和休闲活动中高效有效运作能力的指标，包括身体素质和心肺 功能等。 柔韧性 身体素质中与健康和表现有关的部分，即各关节活动范围。各关节的柔韧性各 有不同，取决于一些特定变量，包括但不限于特定韧带和肌腱的紧密性。柔韧 性练习可以提高关节在全部活动范围内的运动能力。 功能性练习 可以融入日常任务中、提高下半身力量、平衡能力和运动能力的练习。例如串 联式和单腿站立，下蹲，椅式站立，小腿伸展，以及跨越障碍。 家务类身体活动 在家中为完成家务（如打扫卫生、照料儿童、园艺等）而进行的身体活动。 休闲类身体活动 个人自行决定从事、非日常生活必须的身体活动。这些活动包括参与体育运 动、身体素质锻炼或训练，以及诸如散步、跳舞和园艺等休闲活动。 术语表 vi vii 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 术语 定义 轻微强度身体 活动 轻微强度身体活动的代谢当量为1.5到3之间，也就是说，能量消耗不超过休息 时能量消耗的3倍。 此类活动包括慢走、洗澡或其他不会导致心率或呼吸频率大幅增加的偶然 活动。 主要肌肉群 主要肌肉群包括腿部、背部、腹部、胸部、肩部和手臂。 代谢当量 （MET） 某项任务的代谢当量，或简称为代谢当量，是表示身体活动强度的生理指标。 一个代谢当量等于一个人静坐时消耗的能量。 中等强度身体 活动 从绝对量级上看，中等强度指强度为休息的3倍至6倍以下的身体活动。从个 人能力的标准来看，按分值范围0-10分计算，中等强度身体活动通常为5分或 6分。 肌肉强化活动 增加骨骼肌力量、爆发力、耐力和质量的身体活动和练习（例如力量训练、抗 阻力训练或肌肉力量和耐力练习）。 多样化身体活动 对于老年人来说，多样化身体活动对于改善身体机能和减少跌倒或摔伤的风险 非常重要。这些活动可以在家里或在有组织的小组环境中进行。许多有计划的 干预措施将所有种类的运动（有氧运动、肌肉强化和平衡训练）结合到单次训 练中，已证实有效。例如，多样化身体活动方案可以包括步行（有氧活动）、 举重（肌肉强化），并结合平衡训练。平衡训练的例子包括倒退行走或侧身行 走或单脚站立，同时进行增强上身肌肉的活动，如肱二头肌弯举。舞蹈也结合 了有氧运动和平衡训练的内容。 职业类身体活动 参见工作类身体活动。 身体活动 任何由骨骼肌产生、需要消耗能量的身体运动。 身体活动不足 身体活动水平不足，无法达到当前身体活动建议水平。 社会心理健康 包括心理，情绪和社交方面的健康。 娱乐屏幕时间 除教育/学习或工作需要之外观看屏幕（电视、电脑、移动设备）的时间。 久坐屏幕时间 观看屏幕娱乐（电视、电脑、移动设备）的时间。不包括需要进行身体活动或 运动的活动类屏幕游戏。 久坐行为 任何清醒状态下坐、倚、卧的行为，能量消耗为1.5 MET 或更低。大多数办公 室案头工作、开车和看电视都属于久坐行为；定义也适用于无法站立者，比如 使用轮椅的人士。 指南让久坐行为的定义具有可操作性，包括自我报告的低运动量坐姿（休闲时 间、工作时间和总时间)、看电视（看电视或屏幕时间，以及评估运动或姿态 的设备测量到的低运动量）。 体育运动 体育运动涵盖了遵守特定规则、作为休闲或竞赛进行的各类活动。体育运动为 团队或个人开展的身体活动，可能有体育机构等体制框架的支持。 交通类身体活动 为往返各地而进行的身体活动，指行走、骑自行车和轮式运动（使用非机动的 带轮运动方式，例如滑板车、溜冰鞋、手动轮椅等）。 剧烈强度身体 活动 从绝对量级来看，剧烈强度指的是代谢当量6.0或更高的身体活动。从个人 能力的标准来看，按分值范围0-10分计算，剧烈强度身体活动通常为7分或 8分。 工作类身体活动 有偿或志愿工作时进行的身体活动。 vi vii术语表 《世卫组织关于身体活动和久坐行为的 指南》为儿童、青少年、成年人和老年人提 供基于证据的公共卫生建议，说明获得显著 健康收益和减轻健康风险所需的身体活动量 （频率、强度和持续时间）。首次就久坐行 为与健康结果之间的关系以及对孕妇和产后 妇女等亚群体、慢性病患者或残疾人的意义 提出了建议。 指南针对高收入、中等收入和低收入国 家卫生、教育、青少年、体育和/或社会家庭 福利相关政府部委的政策制定者；负责制定 国家、地区或市级计划、通过指导文件让各 类人群增加身体活动、减少久坐行为的政府 官员；非政府组织、教育行业、私营部门、 科研界从业人员；卫生保健提供者。 指南根据《世卫组织指南制定手册》编 写。针对关键重要结果进行了证据的系统综 述，考虑收益和危害、价值观、偏好、可行 性和接受度，以及对公平和资源的影响后形 成建议。 最终提出的公共卫生建议适用于5至65 岁及以上的所有人群和年龄段，不分性别、 文化背景或社会经济地位，无论个人能力如 何。有慢性病和/或残疾的人以及孕妇和产后 妇女应在条件允许的情况下根据自己的能力 努力完成建议要求。 制定指南的工作形成了一组基于证据的建 议，各国政府可以作为国家政策框架的一部分 采纳，支持采用综合方法提高民众身体活动水 平。采纳过程中应注意指南落实须因地制宜。 关于指南的采纳、传播、宣传活动和落实工 作，有实用工具可以支持各国政府和利益攸关 方共同努力，在生命全程增加身体活动，减少 久坐行为。指南发布后可在世卫组织网站获取 这些支持资源。 尽管有大量数据支持身体活动与整个生命 周期健康结果相关，以及越来越多证据支持久 坐行为与整个生命周期健康结果相关，但依然 存在重要证据空白。尤其是低收入和中等收入 国家以及贫穷社区或服务不足的社区的证据较 少，缺乏来自残疾人等亚群体的证据。需要有 更多科研投入专门积累这些方面的证据。此 外，建议的修改会对目前用于监督各国身体活 动水平的监测系统和评估工具产生影响。应审 查全球和各国的现有工具，更新报告规程，为 将来根据新指南提交报告提供参考。 《2018-2030年促进身体活动全球行 动计划》设定2030年身体活动不足现象减 少15%的目标，并概述了20项建议政策行 动和干预措施。这些指南帮助所有国家执行 GAPPA建议和使用“ACTIVE”，“ACTIVE”是 一套指导在整个生命周期和多种环境促进身体 活动的技术工具包。 概述 viii 1 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 建议： 一周㊥儿童和青少年应平均每天至少进行 60分钟的中等到剧烈强度的身体活动， 有氧运动为主。 强烈推荐，中等质量证据 每周至少应有3天进行剧烈强度有氧运动以 及增强肌肉和骨骼的运动。 强烈推荐，中等质量证据 • 少量身体活动优于不活动。 • 如果儿童和青少年未达到建议活动水平，少量身体活动有益健康。 • 儿童和青少年应从少量身体活动开始，逐渐增加频率、强度和持续时间。 • 应向所有儿童和青少年提供安全平等的机会并鼓励参与有趣、多样、适合其年龄 和能力的身体活动。 良 好 做 法 在儿童和青少年中，身体活动的收益体现于以 下健康结果：改善身体健康（心肺和肌肉健康）、 心血管代谢健康（血压、血脂异常、葡萄糖和胰岛素 抵抗）、骨骼健康、认知结果（学业成绩、执行功能）、 心理健康（抑郁症状减少）；以及肥胖症减轻。 儿童和青少年较多久坐行为与以下不良健康结果有关：更加肥胖；心脏 代谢健康、健康状况、行为品行/亲社会行为较差；以及睡眠时间减少。 建议： 儿童和青少年应该限制久坐时间， 尤其是屏幕娱乐时间。 强烈推荐，低质量证据 1 GRADE: 推荐分级的评估、制定与评价 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 引言 定期进行身体活动是预防和管理非传染性 疾病（NCDS）的关键保护因素，如心血管疾 病、2型糖尿病和部分癌症。身体活动还有利 于心理健康，包括预防认知功能降低和抑郁焦 虑的症状；并有助于维持健康体重和总体幸福 感。据全球估计，27.5%的成年人(1) 和81%的 青少年(2) 没有达到2010年世卫组织建议的身 体活动水平(3)，过去十年中几乎没有任何改 善。不平等现象也很明显：数据显示，大多数 国家，女童和妇女不如男童和男子活跃，经济 水平较高和较低的群体之间以及国家和区域之 间的身体活动水平差异很大。 范围 《世卫组织关于身体活动和久坐行为的指 南》为儿童、青少年、成年人和老年人提供基 于证据的公共卫生建议，说明获得显著健康收 益和减轻健康风险所需的身体活动量（频率、 强度和持续时间）。首次就久坐行为与健康 结果之间的关系以及对孕妇和产后妇女等亚群 体、慢性病患者或残疾人的意义提出了建议。 目标受众 指南针对高收入、中等收入和低收入国家 卫生、教育、青少年、体育和/或社会家庭福 利相关政府部委的政策制定者；负责制定国 家、地区或市级计划、通过指导文件让各类人 群增加身体活动、减少久坐行为的政府官员； 非政府组织、教育行业、私营部门、科研界从 业人员；卫生保健提供者。 指南制定过程 指 南 根 据 《 世 卫 组 织 指 南 制 定 手 册》(4) 编写。2019年成立了指南制定小 组（GDG），成员包括世卫组织所有六个区域 的技术专家和相关利益攸关方。小组于2019 年7月召开会议，确定关键问题，审查证据基 础，商定文献更新方法，以及必要时再做审查 的方法。2020年2月，GDG再次举行会议，审 查关键重要成果的证据，考虑收益和危害、价 值观、偏好、可行性和接受度，以及对公平和 资源的影响。这些建议在达成共识后制定，并 在网上征求公众意见。最终更新的建议摘要如 下。GRADE 1 表格和证据简介作为网络附件 提供。关于指南的采纳、传播、宣传活动和落 实工作，有实用工具可以支持各国政府和利益 攸关方共同努力，在生命全程增加身体活动， 减少久坐行为。 建议 《世卫组织关于身体活动和久坐行为的指 南》中提出的公共卫生建议适用于5至65岁及 以上的所有人群，不分性别、文化背景或社会 经济地位，无论个人能力如何。有慢性病和/ 或残疾的人以及孕妇和产后妇女应在条件允许 的情况下根据自己的能力努力完成建议要求。 儿童与青少年 (5–17岁) 限制 久 坐 不 动 的 时 间 ， 尤其是娱乐性的屏幕 前时间。 3 每星期至少 天 剧烈强度有氧运动， 那些增强肌肉和骨骼的活动 都应包括在内。 60 分钟 一星期每天至少 中等强度到剧烈强度活动， 主要是身体活动，大多数此类身 体活动应为有氧活动。 2 3 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议viii 1概述 建议： 成年人应该限制久坐时间。久坐时间改用 来进行各种强度的身体活动（包括轻微强 度）能带来健康收益。 强烈推荐，中等质量证据 为了帮助减少过多久坐行为对健康的不利 影响，成年人进行中等到剧烈强度身体活 动应力求超过建议水平。 强烈推荐，中等质量证据 建议： 所有成年人应定期进行身体活动。 强烈推荐，中等质量证据 成年人每周应该进行至少150- 300分钟的中等强度有氧活动； 或至少75-150分钟的剧烈强度 有氧活动；或者等量的中等强 度和剧烈强度组合活动，可以 获得巨大健康收益。 强烈推荐，中等质量证据 成年人 (18–64岁) 成年人（18–64岁） • 少量身体活动优于不活动。 • 如果成年人未达到建议活动水平，少量身体活动有益健康。 • 成年人应从少量身体活动开始，逐渐增加频率、强度和持续时间。良 好 做 法 成年人较多久坐行为与下列不良健康结果有关：全因死亡率、心血管疾 病死亡率和癌症死亡率以及心血管疾病、癌症和2型糖尿病发病率。 对于成年人来说，身体活动的收益体现在以下 健康结果：改善全因死亡率、心血管疾病死亡率、 新发高血压、新发位点特异性肿瘤 2、新发2型糖尿病、 心理健康（减少焦虑和抑郁症状）、认知健康和睡眠； 肥胖指数也能改善。 成年人可以将每周中等强度有氧活动 增加到300分钟以上；或进行150分钟 以上的剧烈强度有氧活动；或等量的 中等强度和剧烈强度组合活动，可获 得额外健康收益。 条件性推荐，中等质量证据 成年人还应进行中等强度或更高强 度的肌肉强化活动，锻炼所有主要 肌肉群，每周2天或2天以上，能带 来额外健康收益。 强烈推荐，中等质量证据 2 膀胱癌、乳腺癌、结肠癌、子宫内膜癌、食管腺癌、胃癌和肾癌等特定部位癌症。 中等或更高强度的 肌肉强化活动，涉 及所有主要肌群。 2 每星期至少 天 额外的健康福利： 150 300 150 75或者 中等强度有氧 身体活动 剧烈强度有氧身 体活动 （或一星期内的等量组合） 至少 到 分钟 至少 到 分钟 300 150 额外的健康福利： 或者 分钟以上 分钟以上 中等强度有氧 身体活动 剧烈强度有 氧身体活动 （或一星期内的等量组合） 限制 久坐不动时间 代之以 任何强度的身体活动 （包括轻微强度）。 4 5 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议 1 1 2 3 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 建议： 成年人应该限制久坐时间。久坐时间改用 来进行各种强度的身体活动（包括轻微强 度）能带来健康收益。 强烈推荐，中等质量证据 为了帮助减少过多久坐行为对健康的不利 影响，成年人进行中等到剧烈强度身体活 动应力求超过建议水平。 强烈推荐，中等质量证据 建议： 所有成年人应定期进行身体活动。 强烈推荐，中等质量证据 成年人每周应该进行至少150- 300分钟的中等强度有氧活动； 或至少75-150分钟的剧烈强度 有氧活动；或者等量的中等强 度和剧烈强度组合活动，可以 获得巨大健康收益。 强烈推荐，中等质量证据 成年人 (18–64岁) 成年人（18–64岁） • 少量身体活动优于不活动。 • 如果成年人未达到建议活动水平，少量身体活动有益健康。 • 成年人应从少量身体活动开始，逐渐增加频率、强度和持续时间。良 好 做 法 成年人较多久坐行为与下列不良健康结果有关：全因死亡率、心血管疾 病死亡率和癌症死亡率以及心血管疾病、癌症和2型糖尿病发病率。 对于成年人来说，身体活动的收益体现在以下 健康结果：改善全因死亡率、心血管疾病死亡率、 新发高血压、新发位点特异性肿瘤 2、新发2型糖尿病、 心理健康（减少焦虑和抑郁症状）、认知健康和睡眠； 肥胖指数也能改善。 成年人可以将每周中等强度有氧活动 增加到300分钟以上；或进行150分钟 以上的剧烈强度有氧活动；或等量的 中等强度和剧烈强度组合活动，可获 得额外健康收益。 条件性推荐，中等质量证据 成年人还应进行中等强度或更高强 度的肌肉强化活动，锻炼所有主要 肌肉群，每周2天或2天以上，能带 来额外健康收益。 强烈推荐，中等质量证据 2 膀胱癌、乳腺癌、结肠癌、子宫内膜癌、食管腺癌、胃癌和肾癌等特定部位癌症。 中等或更高强度的 肌肉强化活动，涉 及所有主要肌群。 2 每星期至少 天 额外的健康福利： 150 300 150 75或者 中等强度有氧 身体活动 剧烈强度有氧身 体活动 （或一星期内的等量组合） 至少 到 分钟 至少 到 分钟 300 150 额外的健康福利： 或者 分钟以上 分钟以上 中等强度有氧 身体活动 剧烈强度有 氧身体活动 （或一星期内的等量组合） 限制 久坐不动时间 代之以 任何强度的身体活动 （包括轻微强度）。 4 5 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议2 3概述 建议： 所有老年人应定期进行身体活动。 强烈推荐，中等质量证据 老年人应该每周进行至少 150-300分钟的中等强度有 氧活动；或至少75-150分钟 的剧烈强度有氧活动；或等 量的中等强度和剧烈强度组 合活动，可以获得巨大健康 收益。 强烈推荐，中等质量证据 老年人 (65岁以上) 老年人（65岁以上） • 少量身体活动优于不活动。 • 如果老年人未达到建议活动水平，少量身体活动有益健康。 • 老年人应从少量身体活动开始，逐渐增加频率、强度和持续时间。 • 老年人应该在自身功能性能力允许的范围内进行身体活动，并根据健康水平调整 身体活动强度。 良 好 做 法 老年人较多久坐行为与下列不良健康结果有关：全因死亡率、心血管疾 病死亡率和癌症死亡率、心血管疾病、癌症和2型糖尿病发病率。 建议： 老年人应该限制久坐时间。久坐时间改用 来进行各种强度的身体活动（包括轻微强 度）能带来健康收益。 强烈推荐，中等质量证据 为了帮助减少过多久坐行为对健康的不利 影响，老年人进行中等到剧烈强度身体活 动应力求超过建议水平。 强烈推荐，中等质量证据 对于老年人来说，身体活动的收益体现于以下 健康结果：改善全因死亡率、心血管疾病死亡率、新 发高血压、新发位点特异性肿瘤、新发2型糖尿病、心理 健康（焦虑和抑郁症状减少）、认知健康和睡眠；肥胖指数 也能改善。对于老年人，身体活动有助于预防跌倒和跌倒相关伤害以及 骨骼健康和功能性能力的衰退。 老年人可以将每周中等强度有氧活 动增加到300分钟以上；或者进行 150分钟以上的剧烈强度有氧活动； 或者等量的中等强度和剧烈强度组 合活动，可获得额外健康收益。 条件性推荐，中等质量证据 老年人还应进行中等强度或更高强 度的肌肉强化活动，锻炼所有主要 肌肉群，每周2天或2天以上，能带 来额外健康收益。 强烈推荐，中等质量证据 在每周身体活动中，老年人应该进 行多样化身体活动，侧重于中等 或更高强度的功能性平衡和力量训 练，每周3天或3天以上，以增强功 能性能力和防止跌倒。 强烈推荐，中等质量证据 150 300 150 75或者 中等强度有氧 身体活动 剧烈强度有氧身 体活动 （或一星期内的等量组合） 至少 到 分钟 至少 到 分钟 300 150 额外的健康福利： 或者 分钟以上 分钟以上 中等强度有氧 身体活动 剧烈强度有 氧身体活动 （或一星期内的等量组合） 2 中等或更高强度的肌肉强化活动，涉 及所有主要肌群。 每星期至少 天 额外的健康福利： 各种多成分身体活 动，强调中等或更 高强度的功能平衡 和力量训练。 3 每星期至少 天 额外的健康福利： 限制 久坐不动时间 代之以 任何强度的身体活动 （包括轻微强度）。 6 7 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议4 5 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 建议： 所有老年人应定期进行身体活动。 强烈推荐，中等质量证据 老年人应该每周进行至少 150-300分钟的中等强度有 氧活动；或至少75-150分钟 的剧烈强度有氧活动；或等 量的中等强度和剧烈强度组 合活动，可以获得巨大健康 收益。 强烈推荐，中等质量证据 老年人 (65岁以上) 老年人（65岁以上） • 少量身体活动优于不活动。 • 如果老年人未达到建议活动水平，少量身体活动有益健康。 • 老年人应从少量身体活动开始，逐渐增加频率、强度和持续时间。 • 老年人应该在自身功能性能力允许的范围内进行身体活动，并根据健康水平调整 身体活动强度。 良 好 做 法 老年人较多久坐行为与下列不良健康结果有关：全因死亡率、心血管疾 病死亡率和癌症死亡率、心血管疾病、癌症和2型糖尿病发病率。 建议： 老年人应该限制久坐时间。久坐时间改用 来进行各种强度的身体活动（包括轻微强 度）能带来健康收益。 强烈推荐，中等质量证据 为了帮助减少过多久坐行为对健康的不利 影响，老年人进行中等到剧烈强度身体活 动应力求超过建议水平。 强烈推荐，中等质量证据 对于老年人来说，身体活动的收益体现于以下 健康结果：改善全因死亡率、心血管疾病死亡率、新 发高血压、新发位点特异性肿瘤、新发2型糖尿病、心理 健康（焦虑和抑郁症状减少）、认知健康和睡眠；肥胖指数 也能改善。对于老年人，身体活动有助于预防跌倒和跌倒相关伤害以及 骨骼健康和功能性能力的衰退。 老年人可以将每周中等强度有氧活 动增加到300分钟以上；或者进行 150分钟以上的剧烈强度有氧活动； 或者等量的中等强度和剧烈强度组 合活动，可获得额外健康收益。 条件性推荐，中等质量证据 老年人还应进行中等强度或更高强 度的肌肉强化活动，锻炼所有主要 肌肉群，每周2天或2天以上，能带 来额外健康收益。 强烈推荐，中等质量证据 在每周身体活动中，老年人应该进 行多样化身体活动，侧重于中等 或更高强度的功能性平衡和力量训 练，每周3天或3天以上，以增强功 能性能力和防止跌倒。 强烈推荐，中等质量证据 150 300 150 75或者 中等强度有氧 身体活动 剧烈强度有氧身 体活动 （或一星期内的等量组合） 至少 到 分钟 至少 到 分钟 300 150 额外的健康福利： 或者 分钟以上 分钟以上 中等强度有氧 身体活动 剧烈强度有 氧身体活动 （或一星期内的等量组合） 2 中等或更高强度的肌肉强化活动，涉 及所有主要肌群。 每星期至少 天 额外的健康福利： 各种多成分身体活 动，强调中等或更 高强度的功能平衡 和力量训练。 3 每星期至少 天 额外的健康福利： 限制 久坐不动时间 代之以 任何强度的身体活动 （包括轻微强度）。 6 7 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议4 5概述 孕妇和产后妇女在孕期和产后的身体活动对母 婴健康有以下好处：先兆子痫、妊娠高血压、妊娠糖 尿病、妊娠期过度增重、分娩并发症和产后抑郁症的风 险降低，新生儿并发症减少，对出生体重无不良影响； 死产风险未见增加。 建议所有无禁忌证的孕妇和产后妇女： 整个孕期和产后应定期进行身体活动。 强烈推荐，中等质量证据 此外： 怀孕前习惯进行剧烈强度有氧运动的妇女，或者经常进行 身体活动的妇女，可以在怀孕和产后继续原有活动。 强烈推荐，中等质量证据 每周应该进行至少150分钟中等强度有氧 活动，可以获得巨大健康收益。 强烈推荐，中等质量证据 进行各种有氧和肌肉强化运动。增加轻 柔拉伸运动可能也有益处。 强烈推荐，中等质量证据 孕妇和产后妇女 孕妇和产后妇女 良 好 做 法 • 少量身体活动优于不 活动。 • 如 果 孕 妇 和 产 后 妇 女未达到建议活动水 平，少量身体活动有 益健康。 • 孕妇和产后妇女应从 少量身体活动开始， 逐渐增加频率、强度 和持续时间。 • 盆底肌肉训练可以每 天进行，减少尿失禁 风险。 • 气温过高时避免进行身 体活动，尤其是高湿度 环境下。 • 身体活动之前、期间和 之后饮水保持水分。 • 避 免 参 与 涉 及 身 体 接 触 、 跌 倒 风 险 大 或 可 能限制氧化作用的活动 （例如，平时不在高海 拔地区生活的人应避免 高海拔地区活动）。 • 孕早期过后避免仰卧位 活动。 • 若考虑参加体育比赛或运 动量远高于指南建议标准 时，孕妇应寻求专业卫生 保健人员监督。 • 卫 生 保 健 提 供 者 应 告 知 孕妇出现哪些危险信号时 须停止活动；或者出现此 类信号时限制身体活动并 立即咨询合格卫生保健提 供者。 • 分 娩 后 逐 渐 恢 复 身 体 活 动，剖腹产分娩应咨询卫 生保健提供者。 孕妇进行身体活动时的其他安全注意事项： 和所有成年人一样，孕妇和产后妇女较多久坐行为与下列不良健康结 果有关：全因死亡率、心血管疾病死亡率和癌症死亡率、心血管疾病、癌 症和2型糖尿病发病率。 建议： 孕妇和产后妇女应该限制久坐时间。 久坐时间改用来进行各种强度的身体活 动（包括轻微强度）能带来健康收益。 强烈推荐，低质量证据 身体活动强 于不活动。 150 中等强度有氧身体活动 分钟 每星期至少 限制 久坐不动时间 代之以 任何强度的身体活动 （包括轻微强度）。 8 9 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议6 7 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 孕妇和产后妇女在孕期和产后的身体活动对母 婴健康有以下好处：先兆子痫、妊娠高血压、妊娠糖 尿病、妊娠期过度增重、分娩并发症和产后抑郁症的风 险降低，新生儿并发症减少，对出生体重无不良影响； 死产风险未见增加。 建议所有无禁忌证的孕妇和产后妇女： 整个孕期和产后应定期进行身体活动。 强烈推荐，中等质量证据 此外： 怀孕前习惯进行剧烈强度有氧运动的妇女，或者经常进行 身体活动的妇女，可以在怀孕和产后继续原有活动。 强烈推荐，中等质量证据 每周应该进行至少150分钟中等强度有氧 活动，可以获得巨大健康收益。 强烈推荐，中等质量证据 进行各种有氧和肌肉强化运动。增加轻 柔拉伸运动可能也有益处。 强烈推荐，中等质量证据 孕妇和产后妇女 孕妇和产后妇女 良 好 做 法 • 少量身体活动优于不 活动。 • 如 果 孕 妇 和 产 后 妇 女未达到建议活动水 平，少量身体活动有 益健康。 • 孕妇和产后妇女应从 少量身体活动开始， 逐渐增加频率、强度 和持续时间。 • 盆底肌肉训练可以每 天进行，减少尿失禁 风险。 • 气温过高时避免进行身 体活动，尤其是高湿度 环境下。 • 身体活动之前、期间和 之后饮水保持水分。 • 避 免 参 与 涉 及 身 体 接 触 、 跌 倒 风 险 大 或 可 能限制氧化作用的活动 （例如，平时不在高海 拔地区生活的人应避免 高海拔地区活动）。 • 孕早期过后避免仰卧位 活动。 • 若考虑参加体育比赛或运 动量远高于指南建议标准 时，孕妇应寻求专业卫生 保健人员监督。 • 卫 生 保 健 提 供 者 应 告 知 孕妇出现哪些危险信号时 须停止活动；或者出现此 类信号时限制身体活动并 立即咨询合格卫生保健提 供者。 • 分 娩 后 逐 渐 恢 复 身 体 活 动，剖腹产分娩应咨询卫 生保健提供者。 孕妇进行身体活动时的其他安全注意事项： 和所有成年人一样，孕妇和产后妇女较多久坐行为与下列不良健康结 果有关：全因死亡率、心血管疾病死亡率和癌症死亡率、心血管疾病、癌 症和2型糖尿病发病率。 建议： 孕妇和产后妇女应该限制久坐时间。 久坐时间改用来进行各种强度的身体活 动（包括轻微强度）能带来健康收益。 强烈推荐，低质量证据 身体活动强 于不活动。 150 中等强度有氧身体活动 分钟 每星期至少 限制 久坐不动时间 代之以 任何强度的身体活动 （包括轻微强度）。 8 9 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议6 7概述 患有慢性病的成年人和老年人应限制久 坐时间。久坐时间改用来进行各种强度 的身体活动（包括轻微强度）能带来健 康收益。 强烈推荐，低质量证据 为了帮助减少过多久坐行为对健康的不 利影响，患有慢性病的成年人和老年人 进行中等到剧烈强度身体活动应力求超 过建议水平。 强烈推荐，低质量证据 癌症幸存者和患有高血压、2型糖尿病和艾滋病的成年人，建议： 患有此类慢性病的成年人和老年人每 周应该进行至少150-300分钟的中等 强度有氧活动；或至少75-150分钟的 剧烈强度有氧活动；或等量的中等强 度和剧烈强度组合活动，可以获得巨 大健康收益。 强烈推荐，中等质量证据 无禁忌证的情况下，患有此类慢性病 的成年人和老年人可以将每周中等强 度有氧活动增加到300分钟以上；或 进行150分钟以上的剧烈强度有氧活 动；或等量的中等强度和剧烈强度组 合活动，可获得额外健康收益。 条件性推荐，中等质量证据 在每周身体活动中，患有此类慢性病的老 年人应该进行多样化身体活动，侧重于中 等或更高强度的功能性平衡和力量训练， 每周3天或３天以上，以增强功能性能力和 防止跌倒。 强烈推荐，中等质量证据 患有此类慢性病的成年人和老年人还应进 行中等强度或更高强度的肌肉强化活动， 锻炼所有主要肌肉群，每周2天或2天以 上，能带来额外健康收益。 强烈推荐，中等质量证据 患有慢性病的成年人和老年人 (18岁以上) 患有慢性病的成年人和老年人（18岁以上） 身体活动可以为患有以下慢性病的成年人和老年 人带来健康益处：对癌症幸存者来说，身体活动可以改 善全因死亡率、肿瘤特异性死亡率、肿瘤复发或第二原 发肿瘤的风险；对高血压患者来说，身体活动可以改善心血 管疾病死亡率、病情进展、身体机能、与健康相关的生活质量； 对2型糖尿病患者来说，身体活动可以降低心血管疾病死亡率和病情进展指 标；对艾滋病患者来说，身体活动可以改善身体健康和心理健康（焦虑和抑郁 症状减少），对病情进展（CD4计数和病毒载量）或身体成分无不良影响。 良 好 做 法 • 如无法达到上述建议活动水平，患有 此类慢性病的成年人应根据自身能力 进行身体活动。 • 患有此类慢性病的成年人应从少量身 体活动开始，逐渐增加频率、强度和 持续时间 • 患有此类慢性病的成年人应咨询身 体活动专家或卫生保健专业人员， 听取建议，确定适合自身需求、能 力、功能受限/并发症、用药情况和 整体治疗方案的活动类型和活动量。 • 无禁忌症者进行不超过快走或日常 生活需要的轻微或中等强度身体活 动之前，一般无须通过体检。 包括癌症幸存者和高血压、2型糖尿病和艾滋病患者在内，成年人较多 久坐行为与以下不良健康结果有关：全因死亡率、心血管疾病死亡率和癌症 死亡率以及心血管疾病、癌症和2型糖尿病的发病率。 建议： 患有上述慢性病的所有成年人和老年人应定期进行身体活动。 强烈推荐，中等质量证据 300 150 额外的健康福利： 或者 分钟以上 分钟以上 中等强度有氧 身体活动 剧 烈 强 度 有 氧身体活动 （或一星期内的等量组合） 中等或更高强度的 肌肉强化活动，涉 及所有主要肌群。 2 每星期至少 天 额外的健康福利： 至少 到 分钟 150 300 75 150 或者 中等强度有氧 身体活动 剧烈强度有氧身 体活动 （或一星期内的等量组合） 至少 到 分钟 至少 到 分钟 限制 久坐不动时间 代之以 任何强度的身体活动 （包括轻微强度）。 各种多成分身体活 动，强调中等或更 高强度的功能平衡 和力量训练。 3 每星期至少 天 额外的健康福利： 10 11 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议8 9 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 患有慢性病的成年人和老年人应限制久 坐时间。久坐时间改用来进行各种强度 的身体活动（包括轻微强度）能带来健 康收益。 强烈推荐，低质量证据 为了帮助减少过多久坐行为对健康的不 利影响，患有慢性病的成年人和老年人 进行中等到剧烈强度身体活动应力求超 过建议水平。 强烈推荐，低质量证据 癌症幸存者和患有高血压、2型糖尿病和艾滋病的成年人，建议： 患有此类慢性病的成年人和老年人每 周应该进行至少150-300分钟的中等 强度有氧活动；或至少75-150分钟的 剧烈强度有氧活动；或等量的中等强 度和剧烈强度组合活动，可以获得巨 大健康收益。 强烈推荐，中等质量证据 无禁忌证的情况下，患有此类慢性病 的成年人和老年人可以将每周中等强 度有氧活动增加到300分钟以上；或 进行150分钟以上的剧烈强度有氧活 动；或等量的中等强度和剧烈强度组 合活动，可获得额外健康收益。 条件性推荐，中等质量证据 在每周身体活动中，患有此类慢性病的老 年人应该进行多样化身体活动，侧重于中 等或更高强度的功能性平衡和力量训练， 每周3天或３天以上，以增强功能性能力和 防止跌倒。 强烈推荐，中等质量证据 患有此类慢性病的成年人和老年人还应进 行中等强度或更高强度的肌肉强化活动， 锻炼所有主要肌肉群，每周2天或2天以 上，能带来额外健康收益。 强烈推荐，中等质量证据 患有慢性病的成年人和老年人 (18岁以上) 患有慢性病的成年人和老年人（18岁以上） 身体活动可以为患有以下慢性病的成年人和老年 人带来健康益处：对癌症幸存者来说，身体活动可以改 善全因死亡率、肿瘤特异性死亡率、肿瘤复发或第二原 发肿瘤的风险；对高血压患者来说，身体活动可以改善心血 管疾病死亡率、病情进展、身体机能、与健康相关的生活质量； 对2型糖尿病患者来说，身体活动可以降低心血管疾病死亡率和病情进展指 标；对艾滋病患者来说，身体活动可以改善身体健康和心理健康（焦虑和抑郁 症状减少），对病情进展（CD4计数和病毒载量）或身体成分无不良影响。 良 好 做 法 • 如无法达到上述建议活动水平，患有 此类慢性病的成年人应根据自身能力 进行身体活动。 • 患有此类慢性病的成年人应从少量身 体活动开始，逐渐增加频率、强度和 持续时间 • 患有此类慢性病的成年人应咨询身 体活动专家或卫生保健专业人员， 听取建议，确定适合自身需求、能 力、功能受限/并发症、用药情况和 整体治疗方案的活动类型和活动量。 • 无禁忌症者进行不超过快走或日常 生活需要的轻微或中等强度身体活 动之前，一般无须通过体检。 包括癌症幸存者和高血压、2型糖尿病和艾滋病患者在内，成年人较多 久坐行为与以下不良健康结果有关：全因死亡率、心血管疾病死亡率和癌症 死亡率以及心血管疾病、癌症和2型糖尿病的发病率。 建议： 患有上述慢性病的所有成年人和老年人应定期进行身体活动。 强烈推荐，中等质量证据 300 150 额外的健康福利： 或者 分钟以上 分钟以上 中等强度有氧 身体活动 剧 烈 强 度 有 氧身体活动 （或一星期内的等量组合） 中等或更高强度的 肌肉强化活动，涉 及所有主要肌群。 2 每星期至少 天 额外的健康福利： 至少 到 分钟 150 300 75 150 或者 中等强度有氧 身体活动 剧烈强度有氧身 体活动 （或一星期内的等量组合） 至少 到 分钟 至少 到 分钟 限制 久坐不动时间 代之以 任何强度的身体活动 （包括轻微强度）。 各种多成分身体活 动，强调中等或更 高强度的功能平衡 和力量训练。 3 每星期至少 天 额外的健康福利： 10 11 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议8 9概述 残疾儿童和青少年 (5–17岁) 残疾儿童和青少年（5–17岁） 之前章节介绍了身体活动对儿童和青少年的 健康收益，其中许多也适用于残疾儿童和青少年。 身体活动对残疾人健康结果的其他收益包括：因注意 力缺陷/多动障碍（ADHD）等疾病或障碍认知功能受损者 可以改善认知能力；智力障碍儿童的身体功能也能得到改善。 • 少量身体活动优于不活动。 • 如果残疾儿童和青少年未达到建议活动水平，少量身体活动有益健康。 • 残疾儿童和青少年应从少量身体活动开始，逐渐增加频率、强度和持续时间。 • 在适合当前活动水平、健康状况和身体机能的情况下，残疾儿童和青少年进行身 体活动不存在重大风险；而且健康收益超过风险。 • 残疾儿童和青少年应咨询卫生保健专业人员或其他身体活动和残疾专家，确定适 合他们的活动类型和活动量。 良 好 做 法 儿童和青少年较多久坐行为与以下不良健康结果有关：更加肥胖；心 脏代谢健康、健康状况、行为品行/亲社会行为较差；以及睡眠时间减少。 建议： 残疾儿童和青少年应该限制久坐时 间，尤其是屏幕娱乐时间。 强烈推荐，低质量证据 建议： 一周中，残疾儿童和青少年应该平 均每天至少进行60分钟中等到剧烈 强度身体活动，有氧活动为主。 强烈推荐，中等质量证据 每周至少应有3天进行剧烈强度有氧 运动以及增强肌肉和骨骼的运动。 强烈推荐，中等质量证据 身体活动强 于不活动。 从少量身体 活动开始。 3 剧烈强度有氧运动， 那些增强肌肉和骨骼的活动 都应包括在内。 每星期至少 天 60 中等强度到剧烈强度活动， 主要是身体活动，大多数此类身 体活动应为有氧活动。 分钟 一星期每天至少 限制 久 坐 不 动 的 时 间 ， 尤其是娱乐性的屏幕 前时间。 12 13 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议0 1 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 残疾儿童和青少年 (5–17岁) 残疾儿童和青少年（5–17岁） 之前章节介绍了身体活动对儿童和青少年的 健康收益，其中许多也适用于残疾儿童和青少年。 身体活动对残疾人健康结果的其他收益包括：因注意 力缺陷/多动障碍（ADHD）等疾病或障碍认知功能受损者 可以改善认知能力；智力障碍儿童的身体功能也能得到改善。 • 少量身体活动优于不活动。 • 如果残疾儿童和青少年未达到建议活动水平，少量身体活动有益健康。 • 残疾儿童和青少年应从少量身体活动开始，逐渐增加频率、强度和持续时间。 • 在适合当前活动水平、健康状况和身体机能的情况下，残疾儿童和青少年进行身 体活动不存在重大风险；而且健康收益超过风险。 • 残疾儿童和青少年应咨询卫生保健专业人员或其他身体活动和残疾专家，确定适 合他们的活动类型和活动量。 良 好 做 法 儿童和青少年较多久坐行为与以下不良健康结果有关：更加肥胖；心 脏代谢健康、健康状况、行为品行/亲社会行为较差；以及睡眠时间减少。 建议： 残疾儿童和青少年应该限制久坐时 间，尤其是屏幕娱乐时间。 强烈推荐，低质量证据 建议： 一周中，残疾儿童和青少年应该平 均每天至少进行60分钟中等到剧烈 强度身体活动，有氧活动为主。 强烈推荐，中等质量证据 每周至少应有3天进行剧烈强度有氧 运动以及增强肌肉和骨骼的运动。 强烈推荐，中等质量证据 身体活动强 于不活动。 从少量身体 活动开始。 3 剧烈强度有氧运动， 那些增强肌肉和骨骼的活动 都应包括在内。 每星期至少 天 60 中等强度到剧烈强度活动， 主要是身体活动，大多数此类身 体活动应为有氧活动。 分钟 一星期每天至少 限制 久 坐 不 动 的 时 间 ， 尤其是娱乐性的屏幕 前时间。 12 13 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议0 1概述 建议： 残疾成年人应限制久坐时间。久坐时间改 用来进行各种强度的身体活动（包括轻微 强度）能带来健康收益。 强烈推荐，低质量证据 为了帮助减少过多久坐行为对健康的不利 影响，残疾成年人进行中等到剧烈强度身 体活动应力求超过建议水平。 强烈推荐，低质量证据 建议： 所有残疾成年人应定期进行身体活动。 强烈推荐，中等质量证据 残 疾 成 年 人 每 周 应 该 进 行 至 少 150-300分钟的中等强度有氧活动； 或至少75-150分钟的剧烈强度有氧活 动；或等量的中等强度和剧烈强度组 合活动，可以获得巨大健康收益。 强烈推荐，中等质量证据 残疾成年人还应进行中等强度或 更高强度的肌肉强化活动，锻炼 所有主要肌肉群，每周2天或2天 以上，能带来额外健康收益。 强烈推荐，中等质量证据 之前章节介绍了身体活动对成年人的健康收益， 其中许多也适用于残疾成年人。身体活动对残疾人健 康结果的其他好处包括：对于患有多发性硬化症的成年 人——改善身体功能，在生理、心理和社会方面改善健康相 关生活质量；对于脊髓损伤的成年人——改善步行功能、肌肉力 量和上肢功能; 以及改善健康相关生活质量；对于因疾病或障碍认知功能受损 的患者，改善身体功能和认知（帕金森病患者和中风病史患者）；对认知有正 面作用；可改善生活质量（成年精神分裂症患者）；可改善身体功能（成年智 力障碍者）；以及提高生活质量（成年重度临床抑郁症患者）。 成年人较多久坐行为与以下不良健康结果有关：全因死亡率、心血管疾 病死亡率和癌症死亡率以及心血管疾病、癌症和2型糖尿病的发病率。 残疾成年人可以将每周中等强度 有氧活动增加到300分钟以上； 或进行150分钟以上的剧烈强度 有氧活动；或等量的中等强度和 剧烈强度组合活动，可获得额外 健康收益 条件性推荐，中等质量证据 在每周身体活动中，残疾老年人应该进行 多样化身体活动，侧重于中等或更高强度 的功能性平衡和力量训练，每周3天或3天 以上，以增强功能性能力和防止跌倒。 强烈推荐，中等质量证据 良 好 做 法 • 少量身体活动优于不活动。 • 如果残疾成年人未达到建议活动水 平，少量身体活动有益健康。 • 残疾成年人应从少量身体活动开始， 逐渐增加频率、强度和持续时间。 • 在适合当前活动水平、健康状况和身体机 能的情况下，残疾成年人进行身体活动不 存在重大风险；而且健康收益超过风险。 • 残疾成年人应咨询卫生保健专业人员或其 他身体活动和残疾专家，确定适合他们的 活动类型和活动量。 残疾成年人 (18岁以上) 残疾成年人（18岁以上） 限制 久坐不动时间 代之以 任何强度的身体活动 （包括轻微强度）。 300 150 额外的健康福利： 或者 分钟以上 分钟以上 中等强度有氧 身体活动 剧 烈 强 度 有 氧身体活动 （或一星期内的等量组合） 各 种 多 成 分 身 体 活 动，强调中等或更高 强度的功能平衡和力 量训练。 3 每星期至少 天 额外的健康福利： 150 300 150 中等强度有氧 身体活动 剧烈强度有氧身 体活动 （或一星期内的等量组合） 75 至少 到 分钟 至少 到 分钟 或者 中等或更高强度的肌 肉强化活动，涉及所 有主要肌群。 2 每星期至少 天 额外的健康福利： 14 15 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议2 3 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 建议： 残疾成年人应限制久坐时间。久坐时间改 用来进行各种强度的身体活动（包括轻微 强度）能带来健康收益。 强烈推荐，低质量证据 为了帮助减少过多久坐行为对健康的不利 影响，残疾成年人进行中等到剧烈强度身 体活动应力求超过建议水平。 强烈推荐，低质量证据 建议： 所有残疾成年人应定期进行身体活动。 强烈推荐，中等质量证据 残 疾 成 年 人 每 周 应 该 进 行 至 少 150-300分钟的中等强度有氧活动； 或至少75-150分钟的剧烈强度有氧活 动；或等量的中等强度和剧烈强度组 合活动，可以获得巨大健康收益。 强烈推荐，中等质量证据 残疾成年人还应进行中等强度或 更高强度的肌肉强化活动，锻炼 所有主要肌肉群，每周2天或2天 以上，能带来额外健康收益。 强烈推荐，中等质量证据 之前章节介绍了身体活动对成年人的健康收益， 其中许多也适用于残疾成年人。身体活动对残疾人健 康结果的其他好处包括：对于患有多发性硬化症的成年 人——改善身体功能，在生理、心理和社会方面改善健康相 关生活质量；对于脊髓损伤的成年人——改善步行功能、肌肉力 量和上肢功能; 以及改善健康相关生活质量；对于因疾病或障碍认知功能受损 的患者，改善身体功能和认知（帕金森病患者和中风病史患者）；对认知有正 面作用；可改善生活质量（成年精神分裂症患者）；可改善身体功能（成年智 力障碍者）；以及提高生活质量（成年重度临床抑郁症患者）。 成年人较多久坐行为与以下不良健康结果有关：全因死亡率、心血管疾 病死亡率和癌症死亡率以及心血管疾病、癌症和2型糖尿病的发病率。 残疾成年人可以将每周中等强度 有氧活动增加到300分钟以上； 或进行150分钟以上的剧烈强度 有氧活动；或等量的中等强度和 剧烈强度组合活动，可获得额外 健康收益 条件性推荐，中等质量证据 在每周身体活动中，残疾老年人应该进行 多样化身体活动，侧重于中等或更高强度 的功能性平衡和力量训练，每周3天或3天 以上，以增强功能性能力和防止跌倒。 强烈推荐，中等质量证据 良 好 做 法 • 少量身体活动优于不活动。 • 如果残疾成年人未达到建议活动水 平，少量身体活动有益健康。 • 残疾成年人应从少量身体活动开始， 逐渐增加频率、强度和持续时间。 • 在适合当前活动水平、健康状况和身体机 能的情况下，残疾成年人进行身体活动不 存在重大风险；而且健康收益超过风险。 • 残疾成年人应咨询卫生保健专业人员或其 他身体活动和残疾专家，确定适合他们的 活动类型和活动量。 残疾成年人 (18岁以上) 残疾成年人（18岁以上） 限制 久坐不动时间 代之以 任何强度的身体活动 （包括轻微强度）。 300 150 额外的健康福利： 或者 分钟以上 分钟以上 中等强度有氧 身体活动 剧 烈 强 度 有 氧身体活动 （或一星期内的等量组合） 各 种 多 成 分 身 体 活 动，强调中等或更高 强度的功能平衡和力 量训练。 3 每星期至少 天 额外的健康福利： 150 300 150 中等强度有氧 身体活动 剧烈强度有氧身 体活动 （或一星期内的等量组合） 75 至少 到 分钟 至少 到 分钟 或者 中等或更高强度的肌 肉强化活动，涉及所 有主要肌群。 2 每星期至少 天 额外的健康福利： 14 15 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议2 3概述 14 15 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 定期进行身体活动是预防和管理心血管 疾病、2型糖尿病、乳腺癌和结肠癌等非传 染性疾病的一个已知保护因素(1–3)。身体 活动对心理健康(4)也有好处，延缓痴呆症发 病(5)，还有利于维持健康体重(1)和总体幸福 感(6)。 身体活动的定义是任何由骨骼肌产生、 需要消耗能量的身体运动(1)，可以作为工 作、家务、交通或休闲的一部分，或参加锻 炼或体育活动时进行，有各种强度。久坐行 为属于低强度，定义是任何清醒状态下坐、 倚或卧的行为，能量消耗低(7)。新出现的证 据表明，大量久坐行为与心血管疾病、2型糖 尿病以及心血管病、癌症和全因死亡率(8–10) 相关。 身体活动不足的定义是未能达到2010 年《关于身体活动有益健康的全球建议》 ( 1 )的要求，这是全球死亡率的主要原因 之一。据估计，如果全球民众参加更多身 体活动，每年可以有400万至500万人免于 死亡(2, 11)。全球对于身体活动不足的估测 表明，2016年，27.5%的成年人(12)和81% 的青少年(13)未达到 2010年世卫组织建议 标准(1)，趋势数据显示，过去十年来全球进 步有限。数据还突出表明，大多数国家女性 身体活动少于男性，在身体活动水平方面各 国各地区之间以及各国各地区内部都存在巨 大差异。这些差异的原因可能是体育锻炼机 会的不平等，这又进一步加剧了健康方面的 不平等。 目前对久坐行为尚无全球估测数据，但 由于技术革新，职业和娱乐越来越趋向久 坐，以及越来越多地使用个人机动交通工 具，世界各地的身体活动模式发生变化，久 坐行为增加。《2018-2030年促进身体活动 全球行动计划》(14)设立4项战略目标以及20 项政策行动，到2030年实现全球成人和青少 年身体活动不足的比例相对减少15%。 2010年，世卫组织发布《关于身体活动 有益健康的全球建议》(1)，第一部按人群分 类，针对儿童和青少年、成年人和老年人的 公共卫生指南。2018年，世界卫生大会在 WHA71.6号决议1中呼吁世卫组织更新2010年 的建议。 2019年，世卫组织发布《5岁以下儿童 身体活动、久坐行为及睡眠指南》(15)。指南 在终止儿童肥胖委员会（建议4.12）(16)的呼 吁下出台，弥补2010年《关于身体活动有益 健康的全球建议》(1)未涉及这一低年龄段的 问题。 2020年《世卫组织关于身体活动和久坐 行为的指南》取代2010年指南，以特定行为 及相关健康后果的最新证据为基础。这些建 议将成为关于身体活动和久坐行为的整体全 球建议的一部分。 背景 1 WHA71.6《世卫组织2018-2030年促进身体活动全球行动计划》。 14 15背景 世卫组织的其他关键指南 世卫组织其他指南也认可身体活动的重 要意义。世卫组织的《在资源短缺的设施中 提供初级卫生保健的非传染性疾病必要干预 措施一揽子计划》(17)提供了高血压、2型糖 尿病、心血管风险增加、哮喘和慢性阻塞性 肺病的临床管理规程，根据2010年全球建议 给出咨询意见，逐步将身体活动增加到中等 水平（如快走），每周至少活动150分钟。最 近世卫组织《关于降低认知衰退和痴呆症风 险的指南》(18)指出，应该向认知能力正常的 成年人（强烈推荐）和有轻度认知障碍的成 年人（条件性推荐）推荐身体活动，减少认 知能力下降的风险。世卫组织在《老年人综 合护理规划：管理内在能力衰退的社区一级 干预措施指南》(19)中建议活动能力下降的老 年人从事多样化运动防止跌倒。《世卫组织 关于产前保健促进积极妊娠经历的建议》(20) 推荐辅导健康饮食和孕期身体活动，保持健 康并防止体重过度增加，但未提及孕期和产 后进行身体活动更广泛的健康收益。 世卫组织现有指南与这些更新指南相结 合，为身体活动和久坐行为对预防和管理主 要疾病以及促进生命全程健康福祉的影响提 供了一套日益全面的全球指导文件。 理论基础和目的 过去10年里，关于不同类型的身体活 动、活动量和活动持续时间对健康的影响， 以及久坐行为的后果及其与身体活动水平和 健康的相互关系，这些方面的证据显著增 加。此外，关于孕妇、慢性病患者和（或） 残疾人等亚群体身体活动的证据基础现在可 用于审查这些群体的身体活动与健康结果之 间的关系。 《2018-2030年促进身体活动全球行动 计划》(14)的行动4.1呼吁世卫组织制定和传播 关于5岁以下儿童、年轻人、成年人、老年人 和孕妇、慢性病患者和残疾人等特定亚群体 身体活动和久坐行为的全球建议。按照世界 卫生大会的要求，更新和扩大指南范围，确 保向2010年建议未涵盖的人口群体提供关于 身体活动的具体建议。这与全球身体活动行 动计划的主要原则和目标相一致，即减少不 平等现象，支持全民加强日常身体活动。 这些指南的首要目的是提供基于证据的 公共卫生建议，说明儿童和青少年、成年 人、老年人以及孕妇、慢性病患者或残疾人 等亚群体获得显著健康收益和减轻健康风险 所需的身体活动量和活动类型。该指南还针 对久坐行为与健康结果之间的关系提供了循 证建议。 指 南 为 儿 童 和 青 少 年 （5至 1 7岁）、成年人 （18至64岁）、老年人 （65岁及以上）制定， 并首次针对孕妇、慢性 病患者或残疾人等亚群 16 17 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 体的身体活动提出具体建议。针对每个特定 年龄组和亚群体分别提出建议，让那些为特 定社区工作的人能够轻松获得相关信息。为 亚群体，特别是慢性病患者或残疾人单独提 出建议，强调必须将这些亚群体纳入身体活 动和久坐行为干预措施的政策和规划。 这些指南并未将睡眠视为一种行为。睡 眠是关系到健康的重要问题，也是人口健康 学的一个新兴课题。然而，在最新建议中涵 盖睡眠被视为超出授权范围。尽管如此，睡 眠的重要性已得到承认，在考虑身体活动和 久坐行为的影响时，睡眠被列为重要健康 结果。 目标受众 本文件报告制定建议的过程，并概述审 查的证据基础。主要受众是： 1. 高收入和中低收入国家卫生、教育、青少 年、体育和/或社会家庭福利相关政府部 委、负责编制本国指南、规划生命全程的 卫生、教育、工作场所、住宅或社区干预 方案的政策制定者。 2. 负责制定国家、地区或市级计划、通过指 导文件让各类人群增加身体活动、减少久 坐行为的政府官员。 3. 非政府组织、教育和工作场所组织以及科 研界的从业人员； 4. 在卫生服务机构工作的人员和提供咨询指 导的人员，如社区、家庭、初级或三级护 士或医生，或在卫生部门以外工作的相关 卫生和运动专业人员。如果没有国家指导 文件，他们在提出涉及此类主题的建议时 可以参考这些指南。 向卫生保健工作者、身体活动专家和教 育专业人员提供的职前培训和专业进修课 程应参考指南中关于身体活动和久坐行为的 建议。 需要由衍生产品将这些指南传达给特定 最终用户、卫生部门以外的利益攸关方以及 更广泛的社区，这些产品可利用量身定制的 宣传方法满足各类受众的具体需求。 16 17背景 指南根据《世卫组织指南制定手册》 （第2版）(21)编写。在健康促进司领导下成 立了世卫组织指导小组，由世卫组织各区域 办事处和世卫组织相关部门派代表参加。由 27名专家和利益攸关方组成了指南制定小组 （GDG），成员构成考虑了性别平衡和地域 多样性。指南草案由7名独立评审员进行外部 评审，他们对科学证据、证据解读和内容给 予了反馈。此外还就指南草案进行了一次网 上公众咨询，收到了400多名参与者的反馈意 见。这些科学家、从业人员和公众的意见经 过整理后，被GDG用于指南定稿。指南制定 过程管理的详情参见附件1。 指南范围和相关问题 GDG审议指南范围，在第一次会议上 商定了最为相关的PI/ECO（人群、干预/接 触、比较、结果）问题。针对各亚群体提出 的关键问题概述如下： 身体活动： a. 身体活动与健康相关结果之间有何关联？ b. 是否存在剂量-反应关系（量、持续时 间、频率、强度）？ c. 这种关联是否因身体活动的种类或类型而 异？ 久坐行为： a. 久坐行为与健康相关结果之间有何关联？ b. 是否存在剂量-反应关系（总量、频率、 中断持续时间和强度）？ c. 这种关联是否因久坐行为的种类或类型而 异？ d. 仅针对成年人：身体活动是否会修正久坐 行为对死亡率的影响？ 对于每类人群(P)，接触(E)指身体活动 量、持续时间、频率或强度较多的情况；作 为比较(C)指无身体活动或身体活动量、频 率、强度或持续时间较少。各群体的关键和 重要结果概述见表1，各PI/ECO问题的细节参 见《网络附件：证据简介》 的相关章节。 方法 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 18 19 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 表1：各人群关键和重要*健康结果概述 结果（按字母顺序） 5-17岁儿童与 青少年：身体 活动和久坐 18–64岁成年 人：身体活动 18岁以上成年 人：久坐 65岁以上成 年人：身体 活动a 孕妇和产后 妇女 慢性病 b 残疾儿童和 成年人c 肥胖症（体重增加、体重变 化、体重控制、体重稳定、体 重状态和体重维持） 关键 关键 关键 关键 a 关键 关键 – HIV – 不良事件 关键 关键 – 关键a 关键（胎儿结局） – – 全因和特定病因 死亡率 – 关键（癌症和 心血管疾病 特定） 关键 关键a – 关键 – 骨骼健康 关键 – 重要 – – – – 心血管代谢健康 关键 – – – – – – 认知结果 关键 关键 重要 关键a – – 关键 – MS、PD、 Stk、Sch、 ADHD 分娩并发症 – – – – 重要 – – 病情进展 – – – – – 关键 – HT、T2D、 HIV，关键 – 癌症复发 – 跌倒及相关伤害 – – – 关键 – – – 胎儿结局（出生体重，早产） – – – – 关键 – – 功能性能力 – – – 关键 – – – 妊娠糖尿病 – – – – 关键 – – 妊娠高血压/ 先兆子痫 – – – – 关键 – – 健康相关生活质量 – 重要 重要 重要a – 关键 – HT、 T2D、HIV 关键 – MS、 SCI、ID、 MCD、Sch 癌症发病率 – 关键 关键 关键a – – – CVD发病率 – 关键 关键 关键a – – – 高血压发病率 – 重要 – 重要a – – – 2型糖尿病发病率 – 关键 关键 关键a – – – 心理健康（焦虑和抑郁症状） 关键 关键 重要 关键a 关键 – – 骨质疏松症 – – – 关键 – – – 身体健康 关键 – 重要 – – – – 身体功能 – – 重要 – – 关键 – HT、 T2D、HIV 关键 – MS、 SCI、ID、 PD、Stk 亲社会行为 重要 – – – – – – 社会心理结果 – – – 重要 – – – 共病风险 – – – – – 关键 – HT、 T2D、HIV 关键 – MS、 SCI、ID 睡眠 重要 重要 重要 重要a – – – * 关键结果：对于决策具有关键意义的结果；重要结果：重要但对于决策不具有关键意义的结果。 a 针对包括老年人在内的成年人的关键和重要结果。 b 结果针对所列亚群体病情：癌症 – 癌症幸存者；HT – 高血压；T2D – 2型糖尿病；HIV。 c 结果针对所列亚群体病情：MS – 肌肉硬化症；SCI – 脊髓损伤；ID – 智力障碍；PD – 帕金森氏症；Stk – 中风幸 存者；Sch – 精神分裂症；ADHD – 注意力缺陷/多动障碍；MCD – 重度临床抑郁症。考虑了各年龄段群体的关键和 重要结果并加以类推。 关键 – MS、 SCI、ID 18 19方法 证据 修订2010年世卫组织身体活动建议的方 法是确定并随后更新涉及这些指南范围的最新 相关伞状综述。 之所以采用这种方法，是因为最近多个国 家为制定身体活动指南提供参考而进行了大量 系统综述。进行额外更新的目的是确保世卫组 织的新指南能反映这个迅速发展的公共卫生领 域涌现的最新数据。 中选的伞状综述均符合以下三个标准：i) 证据综述根据有充分文件记录的标准系统程 序进行；ii)使用推荐分级的评估、制定与评价 （GRADE）方法或有明确说明和记录的等效 方法评估证据质量；iii)证据综述针对相关人群 进行，对国家或国家收入水平没有任何限制。 PI/ECO问题以及关键和重要健康结果与 现有证据综述进行了对比，并在必要时委托进 行新的综述填补空白。GDG要求更新证据综 述，使用与原始综述相同的搜索词、搜索语言 和数据库。 以下证据审查确认符合上述三项标准， 因时效性和全面性而中选： • 作为制定《加拿大儿童和青少年24小时运动 指南》(23)的一个环节，Poitras等（2016） 对学龄儿童和青少年身体活动与健康指标之 间关联的文献进行了系统综述(22)。该综述 仅关注使用客观方法测量身体活动的研究。 共包含162项研究，涵盖31个国家的204 171 名参与者。 • 作为制定《加拿大儿童和青少年24小时 运动指南》(23)的一个环节，Carson等 （2016）(24)对学龄儿童久坐行为与健康指 标之间关联的文献进行了系统综述。共包含 235项研究（194个独特样本），涵盖71个国 家的1 657 064名独特参与者。 • 作为制定《2019年澳大利亚儿童和青少年 （5-17岁）24小时运动指南》(26)的一个 环节，Okely等（2019）(25)为更新Poitras 等（2016）(22)和Carson等（2018）(24) 进行的系统综述。该报告确定了截至2018 年7月发表的另外42项关于身体活动的研 究和32项关于久坐行为的研究(25)。Okely 等制定的GRADE表被用作世卫组织委托更 新工作的基础。GRADE表和证据简介见 《网络附件：证据简介》 。 • 作为制定《2019年加拿大孕期身体活动指 南》(27)的一个环节，完成并综合了12项系 统综述。这12篇综述评估了超过25 000篇关 于孕妇孕期身体活动的相关研究，研究使用 语言有英语、西班牙语和法语，这些研究报 告了孕妇、胎儿或新生儿发病率或胎儿死亡 率的结果。其中七项系统综述涉及到GDG视 为关键重要的结果(28–34)。这些证据综述 的GRADE表被用作文献检索的基础，为世 卫组织的建议制定工作提供更新和参考。更 新证据简介见《网络附件：证据简介》 。 • 身体活动指南顾问委员会（PAGAC）(35) 的科学报告对2008-2016年发表的关于身 体活动和久坐行为及健康结果的证据进行 了系统更新，作为2018年《美国人身体活 动指南第2版》(36)制定工作的部分环节。 所总结的证据共涉及38个主要研究问题和 104个根据公共卫生相关性选定的子问题。 证据包括系统综述的结果，共由1130篇文章 组成，对每篇提取摘要回答38个研究问题 (35)。规程使用修改后的“评估系统综述的 测量工具”（AMSTARExBP）来评估系统综 述和荟萃分析的方法学质量。使用美国农业 部NEL偏倚评估工具（BAT）的改编版对每 项原始研究进行偏倚风险或内部有效性评 估(37)。针对这些世卫组织指南进行的最新 搜索中发现的新证据载于证据简介，参见 《网络附件：证据简介》 ；提供PAGAC 报告和补充材料链接(35)。 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 20 21 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 更新证据和提取数据的方法 对所含每项综述（上文所列）最近一次搜 索的日期至2019年9月这段时间发表的所有研 究进行了系统综述和队列研究汇总分析搜索； 制定并采用标准化的数据提取规程。 为了更新 P o i t r a s 等 （ 2 0 1 6 年） ( 2 2 )， C a r s o n 等（ 2 0 1 6 年） ( 2 4 )和 Oke l y等（20 1 9年）(25 )进行的搜索， 对MEDL INE，EMBASE，Psyc INFO和 SportDiscus等数据库进行了搜索，寻找 经过同行评审、使用英语或法语的综述。 为了更新由PAGAC (35 )进行的搜索，在 PubMed、CINAHL和Cochrane数据库搜索 了使用英语、经同行评审的综述。受资源限 制，没有对PAGAC(35)未包括的重要成果进 行重新搜索。 搜索时不限制国家或国家收入状况，涵 盖针对任何主观或客观衡量身体活动或久坐 行为的综述。由于资源有限，而且以前这一 领域的经验表明使用其他语言搜索不会发现 更多综述，即使发现也数量极少，因此决定 仅使用原始搜索的语言。入选的综述审查身 体活动或久坐行为与健康相关结果之间的关 联（以高于或低于身体活动或久坐行为阈值 的水平为基准），并探讨了与健康相关结果 之间的剂量-反应关系。 由外部评审小组使用AMSTAR 2（多系统 综述评估）工具对考虑列入的系统综述可信度 评级(38)。AMSTAR 2工具包含16个与综述规 划和进行有关的项目。根据已公布指南，对每 项综述结果的总体可信度进行评分：“高”评分 表明该综述无或存在一个非关键性缺陷；“中 等”表示判断该综述存在一个以上的非关键性 缺陷；“低”表示判断该综述存在一个关键性缺 陷，伴有或不伴有非关键性缺陷，或存在多个 非关键性缺陷；“极低”表示存在一个以上的关 键性缺陷。由一名评审员针对所有暂时列入的 综述填写AMSTAR 2工具。评分为极低的综述 由另一名评审员使用同一工具审查。除非针对 某特定结果只有一个综述，否则最终评分极低 的综述不会列入，理由是过于不可靠，无法对 现有证据进行准确和全面的总结。 证据还包括汇总的队列研究。由外部 评审小组使用Newcastle-Ottawa量表来评 估研究质量(39)。每项研究都给予质量评 级，“好”、“一般”或“差”。一般来说，质量好 的研究符合Newcastle-Ottawa量表的所有标 准。质量一般的研究至少有一项标准不符合， 或者不能明确是否符合，但也不存在会导致结 果无效的已知重要局限性。质量差的研究存在 一项致命缺陷或是多项重要局限性。质量差的 研究不会列入。 考虑到多份综述中可能出现重复研究，对 重复情况进行了评估。如果发现有其他更全 面和/或日期更近的综述，则排除含有多余证 据、综述概括和部分集合队列研究的综述。 新综述的方法 发现现有证据缺口时，委托开展新的伞状 综述，考察： 1. 职业类（即工作相关）身体活动与健康相 关结果的关系(40)； 2. 休闲类身体活动与不良健康结果的关联 (41)。 (对上述1和2，采用PubMed、SportDiscus 和EMBASE搜索了2009年至2019年12月发表 的综述） 3. 身 体活动和预防跌倒的关联；采用 Sherrington等2019年的Cochrane协作 网系统综述(42)，用原始综述的最终检索 日期到2019年11月以来公布的证据进行 更新。 4. 身体活动与骨质疏松症和肌肉减少症的关 联。使用PubMed在2008年至2019年11月 发表的综述中搜索现有关于骨质疏松症和 肌肉减少症的系统综述，未发现新综述， 有8项新的原始研究。 20 21方法 5. 艾滋病毒感染者的身体活动与健康结果 之间关联的证据。由范围综述确定HIV感 染者身体活动和健康相关结果的证据可用 性，支持进行伞状综述，伞状综述使用 PubMed、CINAHL和Web of Science研 究截至2019年10月发布的证据，没有起始 日期限制。 身体活动和久坐行为的证据和评估方法的 特点总结 一直以来，测量成人身体活动和久坐行为 的主要方法是自行报告（即调查），对于儿童 则是自行报告或父母回忆。虽然这些方法具有 公认的优势，但也有局限性，如容易出现报告 偏倚和测量误差(43)。近年来，随着数字技术 在这一领域的迅速发展，使用基于设备的方法 来评估身体活动和久坐时间及其与健康结果关 联的情况越来越多。然而，由于不同设备（加 速度传感器）的技术特点和放置位置不同，以 及数据分析和报告方面的差异，在比较研究结 果方面仍然存在挑战。例如，在使用设备测量 久坐时间时，可能会出现计算错误，因为许多 设备目前没有区分体位（例如卧、坐和站立不 动）。在比较使用设备测量的研究和从自行报 告数据得出结果的研究时，也存在困难。 自行报告工具的内容、身体活动的例子、 回答选项和涵盖类型各不相同。一直以来研 究主要侧重于评估身体活动总量，或只评估 休闲/娱乐类型的身体活动，但现在越来越 多地涵盖其他类型，如交通（如步行和骑自 行车）、工作和家庭中的身体活动。大多数证 据报告有氧身体活动与健康结果之间的关联， 但目前很多研究正在评估肌肉强化锻炼以及不 同种类的活动和其他类型活动组合的收益。 关于身体活动水平与健康结果关联的结 果，报告和比较的方式各有不同。许多研究报 告了体育活动四分位数或五分位数之间的比 较，其他研究比较“达到”和“未达到”国家指南 建议水平的情况。报告时，身体活动总量通常 以每周MET-小时为单位进行估算，一些研究 比较了“最高”和“最低”值，但不同研究的类别 也有所不同。经常有文献报告应用基于现有指 南或当前世卫组织全球建议的数据临界点， 或以往研究的指标（例如，对青年人群研究中 每天60分钟的临界点，或每周频率2-3次的 力量训练干预）的分析结果。当这样的临界点 变得司空见惯时，关于较高或较低水平身体活 动接触与健康结果关联的证据积累可能会受 到限制。 评估儿童和青少年久坐行为与健康结果关 联的大多数证据为横断面性质，大多数研究依 赖于自行报告或父母报告的久坐时间，测量方 法存在测量误差和回忆偏倚。 来自纵向观察研究和干预试验的证据优先 考虑，而仅仅或主要综合横断面证据的综述不 予考虑。更侧重于被评为中度质量及以上级别 的综述所提供的证据，以及使用设备测量接触 数据的研究所提供的证据。 整体证据评级 使用推荐分级的评估、制定与评价 （GRADE）方法，根据综述的基础证据，对 各项PI/ECO的证据质量评级(44)。每项综述 若有GRADE“证据简介”或“结果摘要”表，则 以之作为起点。如果现有系统综述中没有表 格，则为相关各个人群和结果编制“证据简 介”表。 使用GRADE方法评估各项PI/ECO证据 质量(44)时考虑以下标准：研究设计；偏倚风 险；效果连贯性；间接性；效果精准度，以 及其他局限性，例如发表偏倚和升级观察证据 的因素（效果大小，剂量-反应和混杂因素影 响）。从正常完成的纵向研究中获得的观察 证据也调高级别，以便更恰当地反映在体力活 动或久坐行为与结果关联的方面这些研究结论 的质量提升。评价中间/间接结果的研究不一 定会降级，因为结果（包括中间结果）的优先 次序由GDG决定；GRADE评级反映了对这些 结果产生效果的结论质量。某些情况下为确保 应用GRADE方法的一致性修改了现有综述的 GRADE评级。各项结果的证据质量根据以下 指导意见确定(45)： 22 23 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 高 非常确信真实效果与效果估计值 接近。 中等 对效果估计值中等确信：真实效果很 可能与效果估计值接近，但也有可能 存在很大差异。 低 对效果估计值的确信度有限：真实效 果或许与效果估计值差异很大。 极低 对效果估计值的确信度极低：真实效 果很可能与效果估计值差异很大。 证据转化建议 G D G 采 用 G R A D E 证 据 转 化 为 决 策（E t D）框架生成针对具体问题的建 议。EtD框架是一种系统化、结构化和透明化 的决策方法。该框架采用明确标准生成指南建 议，考虑到研究证据和证据质量，并在必要 时从目标受众的角度考虑专家意见和专题知 识。这些标准要求对以下方面作出判断：所 观察到的理想结果和不理想结果的证据之间 的平衡、证据的总体质量、患者理想结果和 不理想结果的相对值、资源使用（成本因素) (如适用）、对健康不平等的潜在影响、建议 的可接受性和可行性。 GDG审查了各项建议所有关键结果的全 部证据，以及所有现有重要结果。对于具体接 触/干预和结果的联系，研究在评估的接触/干 预、评估的结果、研究设计和分析方法上差异 很大，导致现有证据无法统一。因此不可能将 经典的GRADE 方法应用于每项具体接触/干 预和结果的的联系；相反，GRADE被应用于 每项接触/干预和结果联系的整体证据，涵盖 各类研究设计和各种不同的接触/干预测量和 分析方法。当这些因素引起对证据一致性的顾 虑时（即某一特定接触/干预和结果联系的证 据从不同角度观察时不一致），专家小组下调 证据质量(21)。 GDG考虑身体活动和久坐行为的影响时 以下健康结果优先：全因死亡率和病因特异性 死亡率（心血管疾病和癌症）降低；心血管疾 病发病率降低；癌症（位点特异）；2型糖尿 病；体质（如心肺功能、运动技能发展、肌肉 功能）改善；心血管代谢健康（如血压、血脂 异常、血糖、胰岛素抵抗）改善；骨骼健康； 心理健康（如抑郁症状减轻、自尊、焦虑症 状、ADHD）；认知结果（如学习成绩、执行 功能）改善；肥胖症减轻。还考虑了不良影响 （如受伤和危害）。 附加考虑因素 针对每个人群和所有PI/ECO问题，GDG 还考虑了受指南影响者的价值观和偏好；建议 涉及资源问题；对健康公平的影响；以及建议 的可接受性和可行性。由于这些考虑因素以及 GDG对每个人群的评估中存在相当多重复内 容，“证据转化建议”一节概括说明了对要素评 估的讨论。 22 23方法 《世卫组织关于身体活动和久坐行为的指 南》提出的公共卫生建议适用于5至65岁及以 上的所有人群，不分性别、文化背景或社会经 济地位，无论个人能力如何。 新的指南按年龄组和行为（身体活动和久 坐）分类。每一组建议都有介绍性陈述，分别 总结了与身体活动和久坐行为相关的健康结 果；然后提出建议。指南提供一套良好做法说 明，进一步说明目标人群如何能够安全达到建 议要求。这些良好做法说明本身并非“分级建 议” ，而是源自科学证据和GDG审查并建议的 实用注意事项。 每一组建议都附有一份支持科学证据的摘 要，根据三个PI/ECO问题构成；首先提供与 关键健康结果关联的证据，然后是关于剂量反 应的证据摘要。最后，如有证据表明不同种类 或类型的接触与健康结果之间的关系，则提供 一份证据摘要。 建议 良 好 做 法 24 25 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 支持性证据和理由 针对儿童和青少年的指南采用系统综述(22, 25, 35)，并增加16项符合纳入标准的新综述。 关于方法、数据提取和证据简介的全部细节见《网络附件：证据简介》 。 在儿童和青少年中，身体活动的收益体现于以下健康结果：改善身体健康 （心肺和肌肉健康）、心血管代谢健康（血压、血脂异常、葡萄糖和胰岛素 抵抗）、骨骼健康、认知结果（学业成绩、执行功能）、心理健康（抑郁症 状减少）；以及肥胖症减轻。 建议： 一周中儿童和青少年应平均每天至少进行60分钟的中等到剧烈强度的身体 活动，有氧运动为主。 强烈推荐，中等质量证据 每周至少应有3天进行剧烈强度有氧运动以及增强肌肉和骨骼的运动。 强烈推荐，中等质量证据 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 对于儿童与青少年，身体活动可以作为娱乐休闲（游戏、比赛、运动或有计划的锻 炼）、体育、交通（轮式运动、步行和骑自行车）或家务的一部分，在教育、家庭和社 区环境中进行。 身体活动建议 儿童与青少年 (5–17岁) • 少量身体活动优于不活动。 • 如果儿童和青少年未达到建议活动水平，少量身体活动有益健康。 • 儿童和青少年应从少量身体活动开始，逐渐增加频率、强度和持续时间。 • 应向所有儿童和青少年提供安全平等的机会并鼓励参与有趣、多样、适合其年龄 和能力的身体活动。 良 好 做 法 24 25建议 对于儿童和青少年（5-17岁），身体活 动与健康相关结果之间有何关联？ 大量证据先前已经证实，儿童和青少年 身体活动的总量和强度越大，就越有利于多 种健康结果(1)。最近的证据再度证明，增加 身体活动能改善儿童和青少年的心肺功能和 肌肉骨骼健康(22, 35)。例如，每周至少3天从 事30至60分钟中等到剧烈强度的身体活动就 会产生积极影响(22, 35)。 有规律的身体活动，主要是有氧运动，有 益于儿童和青少年的心血管代谢健康，包括改 善血压、血脂、控制血糖和胰岛素抵抗(35)。 最近的综述对比了校园身体活动计划(46)、高 强度间歇训练(47)和抗阻力训练(48)与无干预 措施对心血管代谢健康的影响。在所有3篇综 述中，有证据一致表明干预措施与更好的心血 管代谢结果有关联，尽管效果强弱的精确度不 同，而且仅有个别试验发现身体活动对所有心 血管代谢结果均具有统计学意义的收益。一项 对19个RCT（n=11 988）的综述(46)报告称， 相比无身体活动干预措施的情况，校园身体活 动计划对于舒张压（ES= 0.21 [95% CI: 0.42 to 0.01]; p= 0.04）和空腹胰岛素（ES= 0.12 [95% CI: 0.42 to 0.04]; p= 0.03）的改善具 有统计学意义。 据报道，身体活动对肥胖症有正面影响， 较高活动水平可能与儿童和青少年的健康体重 状况有关联(22, 35)。一般来说，横断面研究 的结果最为有力，而前瞻性观察研究的结果则 较为参差不齐，导致对报告关联的方向性理解 有限。综述包含的大多数研究未报告效果，最 近身体活动干预试验（实验室高强度间歇训练 [HIIT]、课堂主动学习、抗阻力训练）的综述 报告结果与其不一致(47, 49, 50)。然而，对纵 向和横断面研究的综述报告称，计步器测量的 身体活动与肥胖指标、BMI或腰围之间为负相 关的关系(51)。总的来说，身体活动与健康体 重状态管理之间关联的证据质量不高，需要更 多研究来确定关联的方向性和强度。 研究儿童和青少年身体活动和运动技能 发展之间关联的证据较少，当前综述未发现 任何成果(22)。需要更多研究考察运动技能发 展这一结果，为未来指南提供参考。 对于儿童和青少年来说，骨负荷活动可 以在游戏、跑步、转身或跳跃当中进行。身 体活动有利于骨量积累和/或骨结构，最近的 证据表明，比同龄人活动更多的儿童和青少 年骨量更大、骨矿物质含量或密度更高，骨 强度更高(35)。在儿童和青少年时期尽可能增 进骨骼健康有助于预防成年后的骨质疏松症 和相关骨折。 发展和维持认知功能在生命全程都非 常重要。儿童和青少年的身体活动对认知 功能和学业成绩（如学校成绩、记忆力和 执行功能）有积极影响(22, 35)。最近一 次综述（19个RCT；n= 5038）显示， 相比无运动干预措施的情况，每周进行 多次运动干预，持续6周或更长时间，会 导致以下认知功能量值发生更大变化，如 抑制控制（SMD 0.26 [95% CI：0.08至 0.45]，p= < 0.01）；工作记忆（SMD 0.10 [95% CI：-0.05至0.25]，p=  <  0.02）和 认知弹性（SMD 0.14 [95% CI：-0.03至 0.31]，p= < 0.04）(52)。身体活动还可以降 低患有抑郁症或未患抑郁症的儿童和青少年 陷入抑郁和出现抑郁症状的风险(35)，在减轻 症状方面可与心理和药物疗法媲美。 尽管所有身体活动都伴随某些不良事件 风险(53)，报告称为获得健康收益推荐的身体 活动量有相关危害的证据有限(35)。根据现 有证据和专家意见，推荐儿童和青少年进行 身体活动的总量和种类的相关潜在风险不高 (35)，可以通过活动量和活动强度循序渐进降 低风险，对于活动少的儿童和青少年尤其如 此。众所周知，参加某些运动和增加运动强 度都会增加受伤风险(53)。需要更多研究加强 对这一领域的了解。 儿童与青少年（5–17岁) 26 27 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 GDG的结论是： • 有中等质量证据表明更多中等强度和剧烈 强度的身体活动能改善儿童和青少年的心肺 功能和肌肉功能、心血管代谢健康和骨骼 健康。 • 有中等质量证据表明短期和长期的中等强度 至剧烈强度的身体活动对认知功能、学习成 绩和心理健康都有积极影响。 • 有低质量证据表明身体活动有利于儿童和青 少年的健康体重状况管理。 • 有低质量证据表明建议儿童和青少年进行的 身体活动的总量和种类的风险不高，而收益 更大。 是否存在剂量-反应关系（量、持续时 间、频率、强度）？ 虽然有大量证据表明，儿童和青少年的 身体活动与健康结果之间存在积极关联，但 很少有研究涉及剂量-反应问题。因此，与成 年人相比，对于儿童和青少年身体活动和特 定健康结果的剂量-反应曲线的确切形状和/ 或是否存在阈值（区分较低和较高风险）了 解不多。然而，大量证据表明，每天60分钟 的身体活动能带来多种健康收益(22, 35)，鉴 于无反面证据，得出的结论是，最新证据再 度肯定了世卫组织目前每天60分钟中等至剧 烈强度身体活动的建议(1)。 然而，审查包括最近使用设备测量身体 活动的研究结果在内的所有证据后，不支持 保留每天60分钟中等至剧烈强度身体活动的“ 最低”阈值有益健康的要求，因为各类研究在 评估身体活动对健康结果的收益时普遍使用 每天“平均”60分钟的阈值，而不是每天最低 60分钟的阈值。审查的结论是，应修改新指 南，从而更准确地体现这方面的证据。 定期的剧烈强度活动对于心血管代谢 健康结果的收益已经证实(1)，近期综述进一 步提供了证据支持(35)。例如，最近的一篇 综述(54)显示，与中等强度连续训练相比， 高强度间歇训练对心肺功能有中等程度的 有益影响（SMD= 0.51 [95% CI：0.33至 0.69]，p= < 0.01；I2= 0%）。没有证据表明 干预时间、运动方式、运动休息比以及总次 数会改变对心肺功能的效果。这些结果与最 近的其他综述(22, 35, 47)总体一致，并支持保 留青年和青少年应定期进行剧烈强度活动以 改善心肺功能的建议。 GDG的结论是： • 有证据支持世卫组织先前的建议，即每天 进行60分钟中等强度到剧烈强度的身体活 动。 • 有证据支持将以前规定的每日最低60分钟 身体活动时间改为每周平均每日60分钟， 更贴近证据反映的情况 • 有中等质量证据表明更多剧烈强度身体活动 与心肺功能改善有关联。 这种关联是否因身体活动的种类或类型 而异？ 对于儿童和青少年来说，身体活动包括 在家庭、学校和社区活动中的游戏、比赛、 运动、交通、娱乐、体育或有计划的锻炼。 然而，很少有研究直接比较儿童和青少年不 同种类或类型的身体活动，因此没有足够证 据确定身体活动和健康结果之间的关联是否 因活动种类（例如有氧运动或是肌肉强化练 习）或身体活动类型（例如主动运动（步行 和骑自行车）还是体育或运动/娱乐）而有所 不同。 有证据表明，儿童和青少年中等强度至剧 烈强度的有氧身体活动水平的增加都与心肺 健康改善有关联，而肌肉强化活动的增加也 能提高肌肉功能。这一证据为2010年世卫组 织《关于身体活动有益健康的全球建议》(1) 提供了参考，该建议推荐每周至少有3天从事 能增强肌肉和骨骼的活动。最新的证据再次 儿童与青少年（5–17岁) 26 27建议 证实，每周3次的定期肌肉强化活动可有效改 善肌肉健康指标；但没有足够证据说明锻炼的 具体持续时间和强度，主要由于文献中评估的 接触情况不一致(22, 35)。关于抗阻力训练对 心血管代谢健康的保护作用，相关证据较少。 由于除了儿童和青少年肌肉强化活动的频率之 外，没有关于持续时间等其他方面的新证据， 因此无法具体说明任何进一步的细节。今后的 研究应分析各种类和各类型身体活动的健康收 益，让指南的这一部分更加具体。 GDG的结论是： • 有中等质量证据表明每周至少应有3天进行 增强肌肉的运动。 儿童与青少年（5–17岁) 28 29 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 儿童与青少年 (5–17岁) 支持性证据和理由 久坐行为未列入世卫组织2010年建议，但过去十年有越来越多的研究审查了与不同程度 和不同类型的久坐行为关联的健康结果。技术和数字通信已经影响了人们工作、学习、旅行和 休闲娱乐的方式。在大多数国家，儿童和青少年久坐行为的时间越来越长，主要原因是屏幕娱 乐（电视和电脑）等休闲方式和手机等数字通信手段。 针对儿童和青少年的指南运用了系统综述(24, 25)，更新时增加7项符合纳入标准的新 综述。关于方法、数据提取和证据简介，详情参见《网络附件：证据简介》 。 儿童和青少年较多久坐行为与以下不良健康结果有关联：更加肥胖；心血 管代谢健康、身体素质、行为品行/亲社会行为较差；以及睡眠时间减少。 建议： 儿童和青少年应该限制久坐时间，尤其是屏幕娱乐时间。 强烈推荐，低质量证据 久坐行为的定义是教育、家庭、社区环境和交通中，清醒状态下坐卧的时间， 能量消耗低。 久坐行为建议 28 29建议 对于儿童和青少年（5-17岁），久坐行 为与健康相关结果之间有何关联？ 有证据表明，较长时间的久坐行为，特 别是娱乐性屏幕时间，与较差的健康结果有 关联(24, 35)。例如，儿童和青少年较长屏幕 时间（包括看电视）与较差体质和心血管代 谢健康有关联(24, 25)。使用设备评估久坐行 为关联和干预措施研究的证据显示，效果一 般，但对已经患有肥胖症的人效果更好(55)。 久坐行为与儿童和青少年的骨骼健康无关， 这一点的相关证据有限。 尽管研究结果有所不同，但也有证据 表明久坐行为可能与肥胖指标不良有关 (24, 25)。一项主要针对横断面研究的综述报 告，与较低水平（<2小时/日）相比，每天 超过2小时的久坐行为（以总屏幕时间衡量） 与儿童超重/肥胖呈正相关(56)。但另一项20 项横断面研究 (57)的综述发现久坐电子游戏 时间与儿童或青少年的身体质量指数之间没 有统计学意义上的关联。对29份系统综述的 大规模审查发现，许多研究报告说，当年轻 人的久坐行为自行报告为某种形式屏幕时间 时，久坐行为与肥胖症标志物之间存在不利 关联(55)。但审查结果指出，这种关联程度不 高，使用设备衡量久坐时间的研究体现的关 联基本为零(55)。干预措施研究显示效果一 般，但对那些已经患有肥胖症的人效果更好 (55)。需要开展进一步研究，为久坐行为与肥 胖症程度之间的关联提供参考信息。 虽然仍属新兴研究领域，但一些证据表 明，儿童和青少年的久坐行为与幸福感和生 活质量为负相关，而抑郁症与休闲屏幕时间 之间存在不利关系(58, 59)。例如，评估为屏 幕时间的较长时间久坐行为和某些电脑使用 行为，可能与心理健康较差有关(24)。在最近 的另一项综述中，8项研究中有5项发现久坐 行为与焦虑症状之间存在关联，尽管研究中 使用不同方法衡量久坐行为得出的结果并不 一致(60)。其他证据表明，看电视和电子游戏 的时间较长，与行为举止/亲社会行为的不利 结果显著相关(24)；屏幕时间和看电视时间较 长与睡眠时间较短相关，但使用电脑/游戏与 睡眠时间没有关联(61)。久坐行为与心理健康 的关系这一研究领域发展迅速，有很多未知 因素，可能体现出逆向因果关系。需要进一 步研究，为这种关系的方向和强度提供参考 信息。 GDG的结论是： • 有低质量证据表明时间较长的久坐行为 （屏幕时间）与儿童和青少年较低的身体 素质和心血管代谢健康有显著关联。 • 有极低或中等质量证据表明时间较长的久 坐行为（屏幕时间、看电视和电子游戏） 与儿童和青少年心理健康及行为品行/亲社 会行为较差有显著关联。 • 有低质量证据表明时间较长的久坐行为（ 屏幕时间和看电视）与儿童和青少年睡眠 时间有害影响有显著关联。 • 限制儿童和青少年久坐时间的收益大于危 害。 是否存在剂量-反应关系（总量、持续 时间、频率、中止强度）？ 没有足够证据确定儿童和青少年久坐时 间（包括娱乐性屏幕时间）与健康结果之间 是否存在剂量-反应关系。评估儿童和青少年 久坐行为与健康结果之间关系的大多数证据 具有横断面性质，以GRADE的标准证据质量 较低，大多数研究依赖于自行报告或父母报 告的久坐时间数据，容易出现计量错误和回 忆偏倚。然而，有证据表明，久坐行为时间 越少，对健康结果似乎越有利，而且当接触 变量评估为看电视或娱乐屏幕时间，久坐行 为与不良健康结果之间的关联性一般比评估 为久坐总时间要强。但总体而言，认为证据 不足以支持规定时间限制。 儿童与青少年（5–17岁) 30 31 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 久坐行为与不良健康结果有关的证据可 能是久坐行为的直接影响、替代身体活动占 用时间，或两者兼而有之的结果。虽然有研 究报告说屏幕时间与儿童和青少年不良健康 结果之间存在关联，但如果考虑到中等到剧 烈强度的身体活动时间(62)，久坐总时间（使 用设备衡量久坐行为的研究评估结果）始终 与健康结果无关。相反，将中等强度至剧烈 强度的身体活动与积极健康结果联系起来的 证据有力，并且在各种不同环境中都有充分 证据；用身体活动（特别是中等强度至剧烈 强度的身体活动）取代一些久坐行为会改善 健康结果。 对久坐行为、身体活动和健康结果之间 关联和相互作用的研究迅速增加，用设备衡 量久坐行为和心血管代谢健康的证据表明， 如果考虑中等到剧烈强度身体活动（即经过 统计调整），关联性就会减弱(62–64)。因 此，有必要继续前瞻性研究，使用设备衡量 接触，增进对这些关联的了解，并为今后的 建议提供参考。 GDG的结论是： • 有低质量证据表明久坐时间越长，健康结 果越差。 • 证据不足以明确规定久坐行为的时间限制。 • 久坐时间改为中等强度至剧烈强度身体活 动能带来健康收益。 这种关联是否因身体活动的种类或类型 而异？ 研究久坐行为对健康的影响属于相对较 新的领域。因此，这些研究结果源自使用不 同工具和接触量度的研究。被评估为“久坐行 为总时间”的接触，以及使用“屏幕”或“看电 视”的久坐时间比较常用。现有证据表明，就 久坐行为与不良健康结果的关联而言，看电 视或娱乐屏幕时间一般比久坐总时间关联性 更强(24, 35)。最近的研究越来越多地使用设 备评估久坐行为，增进了解，结合标准化报 告有助于为未来指南提供信息。 人们认为，并非所有久坐行为都有危 害。有证据表明，某些类型的久坐行为， 如阅读和在校外做家庭作业，与较高学业 成绩有关联，说明结果因活动不同而有差异 (24, 25)。久坐行为可能包括从事教育活动/ 学习或安静游戏的时间，或不使用电子媒体 的社交。这些活动（如阅读、拼图、绘画、 手工、唱歌、音乐）对儿童发展具有重要意 义，能带来认知等方面的收益。 GDG认为： • 某些久坐活动在儿童和青少年的认知功能 和社会交往方面带来收益。 • 关于久坐行为对健康不良影响的证据，一 般来说，看电视或娱乐性屏幕时间比久坐 总时间的证据质量更强。 儿童与青少年（5–17岁) 30 31建议 成年人 (18–64岁) 对于成年人来说，身体活动的收益体现在以下健康结果：改善全因死 亡率、心血管疾病死亡率、新发高血压、新发位点特异性肿瘤1、新发2型糖 尿病、心理健康（减少焦虑和抑郁症状）、认知健康和睡眠；肥胖指数也能 改善。 建议： 所有成年人应定期进行身体活动。 强烈推荐，中等质量证据 成年人每周应该进行至少150-300分钟的中等强度有氧活动；或至少75- 150分钟的剧烈强度有氧活动；或者等量的中等强度和剧烈强度组合活动，可 以获得巨大健康收益。 强烈推荐，中等质量证据 成年人还应进行中等强度或更高强度的肌肉强化活动，锻炼所有主要肌肉 群，每周2天或2天以上，能带来额外健康收益。 强烈推荐，中等质量证据 成年人可以将每周中等强度有氧活动增加到300分钟以上；或进行150分钟 以上的剧烈强度有氧活动；或等量的中等强度和剧烈强度组合活动，可获得 额外健康收益。 条件性推荐，中等质量证据 对于成年人，身体活动可以作为娱乐休闲（游戏、比赛、运动或有计划的锻炼）、 交通（轮式运动、步行和骑自行车）、工作或家务的一部分，在日常工作、教育、家庭 和社区环境中进行。 身体活动建议 • 少量身体活动优于不活动。 • 如果成年人未达到建议活动水平，少量身体活动有益健康。 • 成年人应从少量身体活动开始，逐渐增加频率、强度和持续时间。良 好 做 法 1 膀胱癌、乳腺癌、结肠癌、子宫内膜癌、食管腺癌、胃癌和肾癌等特定部位癌症。 32 33 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 支持性证据和理由 为制定这些指南，使用并更新了美国身体活动指南顾问委员会（PAGAC）综合的证据(35)。 GDG考虑了全部证据，包括PAGAC报告的结果和2017年至2019年11月发表的28篇综述和3 项集合队列研究，这些研究符合纳入标准，并提供了成年人体力活动与健康相关结果之间关联 的证据。此外还委托进行了两项伞状综述，以解决证据不足的问题，并研究i)职业（即工作相 关）身体活动与健康相关结果的关联(40)；ii) 休闲类身体活动与不良健康结果的关联(41)。伞状 综述分别发现了36份和15份系统综述。优先考虑来自纵向观察研究和干预试验的证据，而仅仅 或主要综合横断面证据的综述不予考虑。评为中等质量及以上的综述所提供的证据，以及那些 使用设备测量接触的研究所提供的证据更受重视。 关于方法、数据提取和证据简介，详情参见《网络附件：证据简介》 。 对于成年人（18-64岁），身体活动与 健康相关结果之间有何关联？ 身体活动与成年人全因死亡率和心血管 疾病死亡率之间的关联已经得到公认(1)。近 期综述结果再次证实，与最低水平的身体活 动相比，较高水平身体活动意味着较低的死 亡风险。使用设备衡量身体活动的研究提供 的新证据重申并拓展了以下观点的证据：与 最低水平的身体活动相比，任何水平和各种 强度（包括轻微强度）的身体活动都意味着 较低的死亡风险(65)。例如，与活动量最少的 人（参考值，1.00）相比，身体活动总量四分 位数的校正HR在身体活动各四分位点均有所 改善：2nd四分位数（0.48 [95% CI：0.43至 0.54]）；3rd四分位数（0.34 [95% CI：0.26 至0 .45 ]）；4 th四分位数（0.27 [ 95% CI：0.23至0.32]）(65)。新证据也再次确认 了身体活动与心血管疾病死亡率之间得到公 认(1)的反比关系(66)。 身体活动在降低心血管疾病和高血压发病 率方面带来的收益已有充分证据说明(1)。身体 活动促进许多生理反应，引发有益的短期和长 期自主神经和血流动力调节，从而降低高血压 风险，而高血压是心血管疾病的一个关键风 险因素。有证据再次证实，在血压正常的成年 人中，身体活动与新发高血压之间为负相关关 系，而对于血压正常的高血压前期成年人，身 体活动可以降低血压(35)。 身体活动与成年人患2型糖尿病之间的负 相关关系已经得到公认(1)。最近的证据再次确 认了身体活动量增加与2型糖尿病发病率之间 的逆曲线关系(35)，身体活动较多时为下降斜 率。一项新的综述发现，这种影响在不同背 景的个体中表现一致，“最高”与“最低”身体活 动水平时患2型糖尿病风险降低的情况如下， 非西班牙裔白人（RR= 0.71 [95% CI：0.60 至0.85]）；亚裔（RR= 0.76 [95% CI：0.67 至0.85]）；西班牙裔（RR = 0.74 [95% CI：0.64至0.84]）；美国印第安人（RR= 0.73 [95% CI：0.60至0.88]），但对于非 西班牙裔黑人无明显效果（RR= 0.91 [95% CI：0.76至1.08]）(67)。有证据表明，体重状 况没有修饰效应，对于体重正常、超重或肥胖 的人，身体活动量增加与2型糖尿病发病率降 低之间均存在反比关系(35)。 身体活动量增加与结肠癌和乳腺癌风险 降低的关联已经得到公认(1)。先前的证据综述 发现，较高水平的身体活动能降低患乳腺癌 成年人（18–64岁） 32 33建议 和结肠癌的风险(1)。随着对身体活动与癌症 的研究大量增加，有新的证据表明，身体活 动水平越高，患膀胱癌、子宫内膜癌、食管 腺癌、胃癌和肾癌的风险也越低，同时再度 确认身体活动可预防乳腺癌和结肠癌(35)。较 高水平的身体活动相关的风险降低范围约为 10-20%(35)。例如，某篇综述报告，较高水 平身体活动和低水平身体活动相比，肝癌发 病率呈负相关（HR= 0.75 [95% CI：0.63至 0.89]）(68)。没有足够证据表明增加身体活动 与降低血液癌、头颈癌、卵巢癌、胰腺癌、前 列腺癌、甲状腺癌、直肠癌和脑癌的风险之间 存在关联(35)。虽然有证据表明，最高水平与 最低水平身体活动相比肺癌风险降低，但此类 结果可能受到烟草使用的干扰，因此认定总体 而言证据不足以建立关联。 成年人身体活动与肥胖症之间的关联并未 完全得到公认，尽管根据各种结果量度（体重 增加、体重变化、体重控制、体重稳定、体重 状态和体重维持）评估这一关联的证据数量很 大同时又缺乏一致性(35, 69, 70)。总体而言， 证据表明较高的身体活动水平可能会改善成年 人肥胖症量度和减少体重增加的幅度(35)。需 要进一步研究，确定结果连贯一致以及关联的 强度。 2010年《关于身体活动有益健康的全球 建议》制定以来，对身体活动与心理健康、 认知和睡眠的研究大量增加(1)。当时，证据 只能得出成年人身体活动可以降低抑郁症和认 知能力下降风险的结论。为这些指南而审查 的新证据表明，身体活动较多和较少的成年人 相比，前者患焦虑和抑郁症的风险降低。例 如，相对于低水平身体活动者，身体活动水平 高的成年人出现焦虑症状（AOR= 0.81 [95% CI：0.69至0.95](71)或抑郁症状（AOR=0.78 [95% CI：0.70至0.87]）(72)的几率降低。增 加中等至剧烈强度身体活动可改善认知（如处 理速度、记忆和执行功能）(35)、大脑功能和 结构，降低认知受损的风险，如阿尔茨海默 症(73–76)。证据涵盖多个成年人群体，其认 知健康状况有正常到受损的不同梯度，并报告 了各种身体活动的有益影响，包括有氧活动、 步行、肌肉强化活动和瑜伽(74)。有证据表明 短时间剧烈身体活动和有规律的身体活动都能 改善成年人睡眠和健康相关生活质量的结果 (35)。 研究身体活动与抑郁症状、焦虑疾病和 抑郁症焦虑症形成的证据表明，身体活动可 减轻焦虑症状(77, 78)和抑郁症状(77, 79)。 所有身体活动都伴随风险。一项对成年人 休闲类身体活动相关不良影响、损伤和危害的 委托研究(41)有证据表明，休闲时间身体活动 水平与肌肉骨骼损伤有不利关联，而休闲时间 身体活动与骨折风险和膝、髋关节炎发病之间 有正面关联。此外还有证据(35)表明，突发性 心脏不良事件并不多见，与短时间强度相对剧 烈的身体活动有关联。一般而言，身体活动强 度中等，活动频率、强度和持续时间逐渐增加 时，伴随的不良事件风险极低(35)。 GDG的结论是： • 有高质量证据表明，任意水平任意强度的 身体活动都能降低全因死亡率和心血管疾 病死亡率、高血压、心血管疾病和2型糖尿 病发病率的相关风险。 • 有中等至高质量证据表明，较高水平身体 活动可降低位点特异性肿瘤发病风险。 • 有中等质量证据支持身体活动与心理健 康、认知健康和睡眠结果之间的关联。 • 有证据表明较高水平身体活动可改善成年 人肥胖症量度和减小体重增加幅度。 • 有低质量证据表明，向成年人推荐的身体 活动没有危害，此类活动的健康收益大于 风险。 成年人（18–64岁） 34 35 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 是否存在剂量-反应关系（量、持续时 间、频率、强度）？ 总体而言，心血管健康和代谢健康结果的 证据体现出身体活动与成年人全因死亡率、心 血管疾病死亡率、新发2型糖尿病(67)和新发 位点特异性肿瘤等主要结果之间存在一致的逆 曲线剂量-反应关系。如图1所示，剂量-反应 曲线的形状表明收益没有较低阀值，最大收益 见于剂量-反应曲线的较低端(65)。使用不同 方法衡量身体活动的研究对逆曲线关联的报告 一致。对八项前瞻性队列研究的荟萃分析提供 了重要的新证据，平均随访时间为5.8年（范 围为3-14.5年）(65)，报告了使用设备衡量接 触并统计全因死亡率得出的身体活动总量四分 位数的校正HR。结果显示，与活动最少的情 况（参考值1.00）相比，身体活动量增加与较 高水平、任意强度身体活动的收益之间存在剂 量－反应关系：2nd四分位数（校正HR=  0.48 [95% CI：0.43至0.54]）；3rd四分位数（校 正HR= 0.34 [95% CI：0.26至0.45]）；4th 四分位数（校正HR= 0.27 [95% CI：0.23至 0.32]）。当每天中等至剧烈强度身体活动达 到24分钟（相当于每周168分钟）时风险降低 的幅度最大，高度符合建议的每周150分钟， 也提供了使用设备衡量得出的新证据，支持现 有成年人每周150－300分钟身体活动的全球 指导(65)。这些研究结论与源自现有综述(35) 以及其他新发现综述(66)的证据一致。 在上端，较高水平身体活动继续带来死亡 率风险降低的收益，发生危害的风险并未增 加。例如，一项新的综述包含有使用设备衡量 接触获得各项数据的荟萃分析结果(65)，其中 证据表明，尽管每周750分钟以内的中等至剧 烈强度身体活动均可观察到死亡率风险降低， 但每周运动超过300分钟时死亡率相对风险就 趋于平缓。这些结果符合先前证据，这些证据 一致表明，更多身体活动与更多健康收益相 关，但身体活动水平较高时相对收益下降(35, 80, 81)。然而，没有足够证据确定身体活动水 平具体达到何种程度时成年人的健康收益开始 下降。 证据还再度确认了身体活动与心血管疾病 死亡率之间已有公论的反比关系，提供了远远 超出目前建议身体活动量的剂量-反应关系的 额外证据。对48项评估身体活动（总量、休闲 图1：剂量-反应曲线 成年人（18–64岁） 每周身体活动量（分钟） 风险 和危 害 收 益 久坐 150 300 健 康 和 身 体 素 质 收 益 建议范围 34 35建议 类和职业类）的前瞻性研究进行的荟萃分析提 供了远远超出目前建议活动量的剂量-反应关 系(66) 的额外证据。与每周750 MET分钟的建 议水平相比，每周5000 MET分钟的高强度运 动（1000分钟中等强度运动）可以显著降低 心血管疾病死亡率（HR= 0.73 [95%CI：0.56 至0.95]）(66)。之前的世卫组织建议(1)认为， 有氧活动每次持续时间不应少于10分钟。但借 助设备评估得出的新证据表明，任意持续时间 的身体活动都能改善包括全因死亡率在内的 健康结果(65, 82)，不存在最低阀值。例如， 用加速度感应器评估身体活动的研究综述提出 新证据，再度确认所有身体活动均与全因死亡 率有类似关联性，身体活动总量的风险比为 0.27，一次5分钟的活动风险比为0.28，一次 10分钟的活动风险比为0.35，这是最高四分位 数和最低四分位数比较的结果(83)。Ekelund 等2019年的新综述(65)得出的结论再次验证了 上述发现，提出的证据表明，每次任意持续时 间的身体活动都能改善包括全因死亡率在内的 健康结果(82)。根据新证据删除了每次活动至 少持续10分钟的建议。 尽管显示较高水平身体活动与降低位点特 异性肿瘤发病率风险之间关联的证据总体而言 表现出一致性，由于各项研究对接触的评估和 分类差异很大，证据不足以确定报告风险降低 所对应的具体身体活动水平。但也没有证据表 明存在较低阀值，低于此阀值身体活动无有益 效果，因此说明任意水平的身体活动都能带来 降低位点特异性肿瘤风险的收益。未来研究需 要评估剂量-反应关系的性质，并在测量和报 告方面提高一致性，供未来指南参考。 尽管有大量证据体现身体活动和各种肥胖 症量度、体重增加和健康体重状态管理之间的 关联(35)，目前没有足够证据更具体地说明剂 量-反应关系或是确定效果阀值。需要进一步 研究供未来指南参考。 更多中等至剧烈强度身体活动能改善认知 （如处理速度，记忆和执行功能）(35)、大脑 功能和结构，降低认知受损的风险，包括阿 尔兹海默症(73–76)。有证据表明，短时间剧 烈活动和定期身体活动能改善成年人睡眠和健 康相关生活质量(35)。但证据不足以具体说明 身体活动与个人心理和认知健康结果之间的剂 量-反应关系。同样，需要更多证据进一步说 明有氧身体活动和肌肉力量训练的总量和/或 强度与特定健康结果之间的剂量-反应关系。 此类信息具有关键作用，能用于确定各人口 亚群体身体活动的最低有效剂量和最大安全 阀值。 GDG的结论是： • 证据表明，更多身体活动能对健康结果产 生更大效果，但身体活动水平更高时相对 收益趋于平缓。证据不足以确定具体达到 何种活动水平时回报开始减少。 • 有高质量证据表明较高水平身体活动能降 低全因死亡率、心血管疾病死亡率、癌症 死亡率、心血管疾病发病率以及高血压和2 型糖尿病发病率的相关风险，而危害的风 险不会增加。 • 有中等质量证据表明任意持续时间的身体 活动都能改善健康结果，之前关于有氧活 动应每次至少持续10分钟的规定应当删除。 • 证据表明更高水平身体活动可能与成年人 改善肥胖症量度和体重增加幅度减小有关 联，身体活动危害成年人健康体重状态管 理的风险不高。 • 有中等质量证据表明每周150－300分钟中 等强度有氧身体活动或等量活动可降低多 种健康结果的相关风险，每周活动超过300 分钟后风险继续降低但幅度趋于平缓。 成年人（18–64岁） 36 37 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 这种关联是否因身体活动的种类和类型 而异？ 证据表明，不同种类和不同类型（如职 业、交通或休闲）身体活动能带来有益健康结 果。对全因死亡率和心血管疾病死亡率而言， 仅从事有氧身体活动，或结合肌肉强化练习即 有良好效果，但两种活动均达到建议水平效果 最佳(84)。 最近有更多中等质量证据表明，不考虑有 氧身体活动，仅肌肉强化身体活动也能降低全 因死亡率相关风险。Stamatakis等人（2018 年）对11项考察建议每周两天肌肉强化练习与 全因死亡率的研究进行汇总分析，结果显示， 有氧身体活动和肌肉强化身体活动均达到建 议水平(1)与其中一项未达到建议水平的情况 （校正HR= 0.71 [95% CI：0.57至 0.87]） 相比，以及仅坚持达到力量练习建议水平与 未达到相比（校正HR= 0.80 [95% CI：0.70 至 0.91]），均能大大降低全因死亡率相关风 险(84)。这些数据确认，肌肉强化练习的相关 健康收益与有氧身体活动无关，还提供证据 支持每周两天的肌肉强化练习建议。Dinu等 人（2019年）报告的研究结果提供了支持性 证据，再度确认除休闲类（或娱乐类）以外 其他类型的身体活动有益，并具体指出，通 勤运动（如步行和骑自行车的交通方式）可 以大大降低全因死亡率相关风险（RR= 0.92 [95% CI：0.85–0.98]）(85)。 近期研究提供的证据表明，参与通勤运动 （如步行和骑自行车的交通方式）与不参与相 比，可以降低心血管疾病（冠心病、卒中和心 衰）风险（RR= 0.91 [95% CI 0.83至0.99]） (85)；此类健康结果提供了足够证据说明不同 类型活动均有效果。但证据不足以区分不同类 型身体活动对各项健康结果的效果。例如，证 据不足以确定身体活动与癌症风险或2型糖尿 病发病率之间的关联是否因身体活动的种类或 类型而异。 对于心理健康结果，证据(35)显示包括有 氧活动、步行、肌肉强化活动和瑜珈在内的各 类身体活动对减少抑郁症状和焦虑症发病有效 (74, 79, 86)。例如，最近有两项综述提供的证 据体现出抗阻力练习干预措施对心理健康的 良好效果，与对照组相比，抑郁症状适度降低 (77)以及焦虑症状小幅降低(78)。 一项新综述的证据确认，高水平职业类身 体活动可降低多种癌症、冠心病和2型糖尿病 风险(40)。但较高水平职业类身体活动可能也 与骨关节炎风险增加、睡眠质量差和男性全 因死亡率（未见于女性）有关联。证据不足以 确定职业类身体活动与肥胖症、预防体重增 加、心理健康和健康相关生活质量之间的关系 (40)。同样证据也不足以确定身体活动与癌症 风险之间的关联是否因身体活动的种类或类型 而异。关联按照不同类型身体活动分类研究的 证据较少，因此难以区分不同类型身体活动对 各类健康结果的效果。 GDG的结论是： • 有中等质量证据表明每周两天或两天以上 肌肉强化活动能带来额外健康收益，但证 据不足以具体指明达到最佳健康收益需持 续的活动时间。 • 有中等质量证据表明不同类型（如休闲、 交通、职业）身体活动能带来健康收益， 但目前无法区分不同类型身体活动对各类 健康结果的效果。 • 尽管较高水平职业类身体活动可能导致骨 关节炎、睡眠质量差和男性全因死亡率 （未见于女性）相关风险增加，总体而言 有中等质量证据表明职业类身体活动能带 来健康收益。 成年人（18–64岁） 36 37建议 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 成年人 (18–64岁) 久坐行为建议 支持性证据和理由 为编制指南采用并更新了PAGAC综合的证据(35)。GDG考虑了整体证据，包括PAGAC报 告的研究发现和13项符合纳入标准的新综述，向成年人久坐行为与健康相关结果之间的关联 贡献了证据。作为公共卫生研究领域，久坐行为与健康结果之间的关联与活动不足相比相对 较新，但过去十年发展迅速。一般研究会使用i)关于久坐行为“总时间”或看电视、使用电脑/ 屏幕和保持坐姿等具体行为时间的自行报告问卷；或ii)使用设备的评估数据来衡量久坐行为。 久坐行为没有标准化衡量方法或分析规程，因此结果的报告缺乏一致性。近期在方法学上的 发展包括使用设备衡量久坐时间，这种方法可以减少测量误差和其他自行报告回忆固有的偏 倚问题。 考虑整体证据时，GDG更侧重于综述提供的评级中等及以上的证据，源自采用久坐总时 间或坐姿总时间或借助设备测量久坐行为的研究证据综述。 关于方法、数据提取和证据简介的全部细节见《网络附件：证据简介》 。 过去十年关于久坐行为相关潜在不良健康影响的研究快速增加。最近较为突出的进展 是，研究久坐行为与多种健康结果的剂量-反应关系以及久坐行为与身体活动相互作用的证据 有所增加。 成年人较多久坐行为与下列不良健康结果有关：全因死亡率、心血管疾病 死亡率和癌症死亡率以及心血管疾病、癌症和2型糖尿病发病率。 建议： 成年人应该限制久坐时间。久坐时间改用来进行各种强度的身体活动 （包括轻微强度）能带来健康收益。 强烈推荐，中等质量证据 为了帮助减少过多久坐行为对健康的不利影响，成年人进行中等到剧烈强 度身体活动应力求超过建议水平。 强烈推荐，中等质量证据 成年人的久坐行为定义是在职业、教育、家居和社区环境以及交通中，清醒状态 下坐卧的时间，能量消耗低。 38 39 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 对于成年人（18岁以上），久坐行为与 健康相关结果之间有何关联？ 总体而言，有证据表明较长时间久坐行为 （主要通过自行报告或借助设备评估保持坐 姿或看电视的时间）与较高的全因死亡率、 心血管疾病死亡率、心血管疾病发病率和2型 糖尿病发病率有关联(8, 35, 65, 87)。例如， 支持性证据包括近期借助加速度感应器评估 久坐总时间与全因死亡率(65)的大型荟萃分 析（n= 36 383；平均年龄62.6岁；女性占 72.8%）取得的结果，表明久坐行为时间增加 与全因死亡率有显著关联。涵盖超过一百万名 参与者的一项荟萃分析(87)有类似研究发现， 针对身体活动进行校正后，久坐行为总量与全 因死亡率和心血管疾病死亡率有关联(87)，但 在这项研究中，与癌症死亡率的关联经身体 活动校正后不具有统计学意义(87)。 最近还有一项荟萃分析(8)报告称，久坐 行为（评估为坐姿状态）与心血管疾病和癌 症死亡率有显著关联，结果表明当：身体活 动最低四分位数（~5分钟/天）的“活动不足” 者，评估为坐姿时间的较多久坐行为导致心 血管疾病死亡率相关风险提高9-32%（p 趋 势< 0.001）。该研究报告，每天久坐（保持 坐姿）超过8小时的成年人心血管疾病死亡率 相关风险较高，“活动最多”（即>35.5MET小 时/周，或60–75分钟/天）者除外，后者该 项关联减弱。根据研究结果，久坐行为与癌症 死亡率的关联总体较弱，但较长坐姿时间（ 尤其>8小时/天时）意味着剂量相关风险增加 6–21%，但仅见于身体活动最低四分位数人 群（< 2.5 MET小时/周）(8)。 证据支持久坐行为（按总坐姿时间衡量） 与更多新发心血管疾病之间的关联（HR= 1.29[95%CI：1.27至1.30]），而针对包括身 体活动水平在内的潜在协变量校正后关联性减 弱（HR= 1.14 [95% CI：1.04至1.23])(88)。 东南亚人群研究综述提供的低质量证据表明， 久坐时间越长，心血管代谢指标不良的可能 性越高（包括2型糖尿病、BMI更高和血压更 高）(89)。 最近有两项综述报告了每日坐姿总时间 (88)、久坐行为和看电视总时间(87)与2型糖 尿病发病率的关联。两项研究均发现较长 时间久坐行为与2型糖尿病发病率风险增加 有关联。例如，经过身体活动校正后，久坐 行为总量（RR= 1.01 [95% CI：1.00至1.01] p= < 0.001）和看电视（RR= 1.09 [95% CI：1.07至1.12] p= < 0.001）与2型糖尿病之 间有线性关联(87)。 还有支持性证据表明，久坐行为（以看电 视时间计）与癌症死亡率之间有显著关联性 (35, 87)。最近多项研究提供了低质量和极低 质量的支持性证据，表明久坐行为与结肠直肠 癌有关联(90)，但与新发前列腺癌、乳腺癌或 直肠癌无关联(90–93)。另外还有证据(35)报 告较长时间久坐行为与罹患子宫内膜癌、结肠 癌和肺癌较高风险之间有显著关联(35)。 有低质量证据表明，久坐行为时间对肥胖 症及其他体重状态指标有不良影响，久坐行为 与体重状态之间的关系是否随着中等至剧烈强 度身体活动量变化，相关证据同样质量不高。 总体结论是，证据不足以为此类建议/指南提 供参考，需要进一步开展研究。 评估减少久坐时间不良后果的证据有限。 根据专家意见，结论是建议减少久坐时间不大 可能增加受伤的风险，在轻微强度身体活动替 代久坐的情况下尤其如此。 成年人（18–64岁） 38 39建议 GDG的结论是： • 总体而言，有充分证据支持编制世卫组织 新建议，限制久坐行为，降低健康风险。 • 有中等质量证据表明较长时间久坐行为与 较高全因死亡率、心血管疾病死亡率、癌 症死亡率和心血管疾病及2型糖尿病发病率 之间有关联。 • 有低质量和中等质量证据表明较长久坐时 间与新发子宫内膜癌、结肠癌和肺癌的较 高风险有关联。 • 关于久坐行为与肥胖症量度之间的关联， 证据不充分，需要开展进一步研究。 • 限制久坐行为的收益超过潜在风险。 是否存在剂量-反应关系（总量、频 率、持续时间、中断强度）？ 总体而言，有中等质量证据表明久坐时 间（自行报告或借助设备衡量的坐姿或看电 视时间）与全因死亡率、心血管疾病死亡 率、癌症死亡率和新发心血管疾病之间存在 非线性剂量－反应关系(8, 35, 87)。 近期的一项荟萃分析提供了高质量证 据，说明加速度感应器衡量的久坐总时间与 全因死亡率之间的剂量－反应关系(65)，报 告久坐时间增加与全因死亡率之间有显著关 联。针对中等至剧烈强度身体活动时间等潜 在混杂因素进行校正后，久坐时间四分位 数增加的风险比为1.00（参考值；久坐时间 最少）；1.28（1.09–1.51）；1.71（1.36– 2.15）；2.63（1.94–3.56）(65)。对久坐行 为与死亡率之间剂量-反应关系的这项分析 表明，约7.5-9小时起风险逐渐增加，超过 9.5小时风险更为突出。每天10小时或12小时 的久坐行为对应更高死亡风险比分别为1.48 （1.22–1.79）和2.92（2.24–3.83）(65)。 最近另外一项荟萃分析评估了经过身体 活动校正后，久坐总时间与全因死亡率之间 的剂量－反应关系，报告两者之间为非线 性关联（≤8小时/天，RR每小时/天= 1.01 (1.00–1.01)；接触> 8小时/天为1.04（1.03– 1.05））；与心血管疾病死亡率也是非线性关 联（≤6小时/天，RR=1.01(0.99-1.02)；>6小 时/天,RR=1.04（1.03-1.04））(87)。同一研 究中，经过体力活动和看电视（1.09（1.07– 1.12））校正后，2型糖尿病与久坐行为总量 （1.01（1.00-1.01））之间有微小线性剂量- 反应关系(87)。 总体而言，有证据支持较多久坐行为关 联较差健康结果，结论是有充分证据支持尽 量减少久坐时间减少健康风险的做法。但考 虑到各项综述评估久坐行为的方法差异很大 （通过自行报告坐姿时间、看电视时间或是 借助设备（加速度感应器）评估），加上各 项健康结果、中等至剧烈强度身体活动不同 水平和各人口亚群体相关的久坐时间阀值 可能各不相同，证据不足以设定有具体时间 （量化）的建议。 除了久坐行为总量外，还审查了关于久 坐行为累积模式的证据。但证据有限，无法 就中断久坐行为的频率和/或持续时间提出 建议。 TGDG的结论是： • 证据不够充分，无法设定久坐行为的量化 （规定时间）建议。 • 证据不够充分，无法就中断久坐行为的频 率和/或持续时间提出建议。 成年人（18–64岁） 40 41 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 这种关联是否因久坐行为的种类和类型 而异？ 某些类型或不同种类的久坐行为可能比 其他久坐行为更有害，一方面是直接关联的 后果，另一方面是可能占用了更健康的身 体活动时间。虽然对久坐行为的研究迅速增 加，但直接比较不同种类久坐行为与不同健 康结果之间关联的证据有限。例如，一些研 究报告说，以看电视为准的久坐行为与坐姿 总时间相比，其结果更为明显(87)。这可能是 与自行报告措施和工具有关的差分测量误差 或残余混杂的原因。目前，证据不足以确定 不同健康结果在关联上的差异，以及这些关 联对于各亚群体的区别。 越来越多的研究正在借助设备衡量与健 康结果有关的身体活动和久坐时间。然而， 借助设备测量久坐时间可能会出现分类错 误，因为许多情况下这些设备的放置方法（ 如手腕、腰部）目前未能区分不同姿态（如 卧、坐和站立不动）。今后通过统一报告模 式和区分不同姿态的方法进行研究，将有助 于加强了解久坐行为的规律。 GDG的结论是： • 证据不够充分，无法就久坐行为的不同种 类或类型提出建议。 身体活动水平是否会改变久坐行为对死 亡率的影响？ 人们对久坐行为影响健康结果的问题越 来越感兴趣，从而催生了对不同水平身体 活动和久坐行为潜在相互作用的研究。根 据现有研究，有中等质量证据表明久坐行 为与全因死亡率、心血管疾病死亡率和癌症 死亡率的关系会随着中等到剧烈强度身体活 动量变化(8, 9, 35)。总体研究发现显示，久 坐行为对那些中等至剧烈强度身体活动不多 的人影响更大，或者反过来说，较多中等至 剧烈强度身体活动可以减轻与较多久坐行为 相关的不利健康结果。 久坐时间和全因死亡率的相关风险已证 实在身体活动水平较低时比水平较高时更为 突出(35)。Ekelund等人在一项统一荟萃分 析中研究了100多万名男性和女性的久坐行 为和身体活动对全因死亡率的共同和分层效 应，发现关联性因身体活动水平而异(9)。分 析使用久坐行为（坐姿）以及中等至剧烈强 度身体活动的四分位数，发现与参考值（每 天保持坐姿<4小时，中等至剧烈强度身体活 动的最高四分位数[> 35.5 MET-小时/周]） 比较，在随访期间，那些每天保持坐姿8小 时以上，但同时每周报告活动时间超过35.5 MET-小时的人，死亡风险没有增加（HR= 1.04 [95% CI：0.99至1.10]）。相比之下， 坐姿时间最少（<4小时/天）和身体活动四 分位数最低（<2.5 MET-小时/周）的人，随 访期间死亡风险显著增加（HR= 1.27 [95% CI：1.22至1.31]）。该研究得出结论，每天 约60-75分钟的中等强度至剧烈强度身体活 动（最高四分位数）可以减轻甚至消除久坐 行为与健康结果之间的不利关联(9)。PAGAC 的系统综述(35)总结了久坐行为与中等至剧 烈强度身体活动的关系，如图2所示。 成年人（18–64岁） 40 41建议 最近的另一项研究提供了研究与病因 特异死亡率的同一关联性的新证据，得出 类似结果(8)。在一项大型统一荟萃分析中 （9项研究，n= 850 000，CVD死亡率；8 项研究，n= 777 000，癌症死亡率），结 果显示较高水平中等至剧烈强度的身体活 动能减缓大量久坐行为伴随的心血管疾病 死亡率风险上升的问题，无论久坐行为是 保持坐姿还是看电视(8)。研究表明，每天 保持坐姿8小时以上的人死亡风险更高， 但身体活动最多的四分位数除外，后者的 这种关联得到缓解。更具体地说，那些每 天保持坐姿8小时以上的人，心血管疾病死 亡率风险比参照组（< 4小时/天）高32% （p 为趋势< 0.001）。身体活动其他四分 位数方面的结果较不突出，但与参考组相比 仍然显著（2nd四分位数，HR= 1.11 [95% CI：1.03至1.20]；3rd四分位数，HR= 1.14 [95% CI：1.03至1.26]）。在中等强度和剧 烈强度身体活动各分层中，观察到电视时间 和心血管疾病死亡率之间有类似关联(8)。 与癌症死亡率之间的关联情况更为复杂， 但总体而言如果将坐姿总时间作为评估指标， 较高水平身体活动能减少久坐行为的不利 影响。 根据这一证据得出一致意见，应建议有 大量久坐行为的人进行更高水平的中等强度 至剧烈强度的身体活动，这种做法收益大于 风险。 GDG的结论是： • 有中等质量证据表明久坐行为与全因死亡 率、心血管疾病和癌症死亡率的关系随着 中等至剧烈强度身体活动量而变化。 • 增加中等至剧烈强度身体活动量可减缓久 坐行为与健康结果之间的不利关联。 图2：久坐行为与身体活动量的关系 改编自PAGAC 成年人（18–64岁） 良 好 做 法 更多身体活动 更 多 久 坐 时 间 高风险 低风险 更 少 久 坐 时 间 以 及 更 多 身 体 活 动 增加 身 体 活 动 减 少 久 坐 时间 42 43 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 老年人 (65岁以上) 对于成年人来说，身体活动的收益体现在以下健康结果：改善全因死 亡率、心血管疾病死亡率、新发高血压、新发位点特异性肿瘤1、新发2型糖 尿病、心理健康（减少焦虑和抑郁症状）、认知健康和睡眠；肥胖指数也能 改善。 建议： 所有老年人应定期进行身体活动。 强烈推荐，中等质量证据 老年人应该每周进行至少150- 300分钟的中等强度有氧活动；或 至少75-150分钟的剧烈强度有氧活 动；或等量的中等强度和剧烈强度组 合活动，可以获得巨大健康收益。 强烈推荐，中等质量证据 老年人还应进行中等强度或更高 强度的肌肉强化活动，锻炼所有主要 肌肉群，每周2天或2天以上，能带 来额外健康收益。 强烈推荐，中等质量证据 在每周身体活动中，老年人应该 进行多样化身体活动，侧重于中等 或更高强度的功能性平衡和力量训 练，每周3天或3天以上，以增强功 能性能力和防止跌倒。 强烈推荐，中等质量证据 老年人可以将每周中等强度有氧 活动增加到300分钟以上；或进行 150分钟以上的剧烈强度有氧活动； 或等量的中等强度和剧烈强度组合 活动，可获得额外健康收益。 条件性推荐，中等质量证据 对于老年人，身体活动可以作为娱乐休闲（游戏、比赛、运动或有计划的锻炼）、 交通（轮式运动、步行和骑自行车）、工作或家务的一部分，在日常工作、教育、家庭 和社区环境中进行。 身体活动建议 • 少量身体活动优于不活动。 • 如果老年人未达到建议活动水平，少量身体活动有益健康。 • 老年人应从少量身体活动开始，逐渐增加频率、强度和持续时间。 • 老年人应该在自身功能性能力允许的范围内进行身体活动，并根据健康水平调整 身体活动强度。 良 好 做 法 42 43建议 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 支持性证据和理由 为制定这些针对老年人的指南，使用并更新了PAGAC全面证据综合结果(35)。有15项综 述符合纳入标准，为研究老年人身体活动与健康相关结果（预防跌倒、跌倒相关伤害、身体 机能、衰弱和骨质疏松症）的关联提供了参考。 预防跌倒的证据采用并更新了Sherrington等人2019年的Cochrane协作网系统综述 (42)，为原始综述的最终检索日期到2019年11月（9项新研究）以来公布的证据。使用 PubMed在2008年至2019年11月发表的综述中搜索现有关于骨质疏松症和肌肉减少症的系统 综述，未发现新综述，有8项新研究。 关于方法、数据提取和证据简介的全部细节见《网络附件：证据简介》 。 对于老年人（65岁以上），身体活动与 健康相关结果之间有何关联？ 评估老年人身体活动与全因死亡率和病 因特异性死亡率、心血管疾病、2型糖尿病 和癌症发病率、肥胖症、心理健康和认知等 健康结果之间关联的主要证据基础是针对成 年人整理和审查的科学文献。这部分证据被 接受并类推至老年人，因为大多数研究没有 说明年龄上限标准，因此包括65岁以上的成 年人。 对证据进行了进一步审查，研究和了解 身体活动与老年人独有健康相关结果之间的 关联，包括预防跌倒、跌倒相关伤害、身体 机能、虚弱和骨质疏松症。 老年人体质下降往往表现为跌倒和跌倒 相关伤害，可能造成严重后果。意外跌倒是 外在（环境）和内在（如影响姿势控制的肌 肉骨骼或神经系统异常）因素共同造成的结 果。有证据表明，身体活动——特别是包括 平衡、力量、耐力、步态和身体机能组合训 练的多样化身体活动方案——可降低老年 人跌倒几率和跌倒受伤风险。最近的证据表 明，运动可以使老年人跌倒率最多降低23% （汇总率比（RaR）0.77[95% CI：0.71至 0.83]），可以显著降低跌倒受伤的风险，包 括导致骨折、头部外伤、开放性创伤、软组 织损伤或任何其他需要医疗护理或住院的损 伤在内的严重跌倒(42)。这部分证据符合并 再度确认了其他综述的研究发现(35)。 肌肉和骨量在成年早期达到高峰后， 往往会随着年龄增长而下降（即肌肉减少 症和骨质减少症/骨质疏松症），与力量 和身体机能下降或有关联。有证据表明， 定期身体活动可以改善老年人的身体机 能，并降低与年龄相关的身体机能缺失风 险。研究结果显示以下方面的良好效果： 动态平衡（SMD= 1.10 [95% CI：0.29至 1.90]）；肌肉力量（SMD= 1 . 13 [95% CI：0.30至1.96]）；柔韧性（SMD= 1.22 [ 95% C I：0 . 39至2 .04 ]）；心肺功能 （SMD= 1.48 [95% CI：0.42至2.54]） (94)。还有证据表明，较高水平身体活动 可以改善老年人的骨骼健康，从而预防骨 质疏松症（汇总标准化效应为0.21 [95% CI：0.06至0.36]）(95)。身体活动干预措施 可改善腰椎和股骨颈（髋关节）骨密度。 GDG的结论是： • 有中等质量证据表明身体活动可改善一般 老龄人口的身体机能，降低年龄相关的身 体机能缺失风险。 • 有低质量证据表明向老年人推荐的身体活 动量和活动种类的风险不高，而且收益大 于风险。 老年人（65岁以上） 44 45 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 是否存在剂量-反应关系（量、持续时 间、频率、强度）？ 有证据表明，老年人的身体活动量与身 体机能受限的风险成反比关系。一般来说， 更多身体活动（频率、持续时间和/或量） 会带来更大收益(35)。有证据表明，想提高 一般功能性能力，快速阻力训练可能优于中 速阻力训练（SMD= 0.41 [95% CI：0.18至 0.65]；SPPB（SMD= 0.52 [95% CI：0.10 至0.94]））(96)。 研究身体活动和预防跌倒之间剂量-反应 关系的证据有限；但大多数提供支持性证据 的研究都是测试每周3天的运动计划。 GDG的结论是： • 有高质量证据表明一般老年人有氧运动量 与身体机能受限风险之间的反向剂量-反应 关系。 老年人（65岁以上） 这种关联是否因身体活动的种类或类型 而异？ 包括平衡、力量、耐力、步态和身体机能 组合训练在内的身体活动计划，可以降低老年 人跌倒的几率和跌倒受伤的风险。 对11个随机对照试验的综述证据显示，通 过各种不同的身体活动干预措施（通常是平 衡和功能练习加上抗阻力练习），老年人跌倒 的几率最多可以降低28%（RaR= 0.72 [95% CI：0.56至0.93]）(42)。抗阻力练习的效果 不能确定，依赖的数据有限（RR= 0.97 [95% CI：0.14至6.49]；1项试验；n= 73）(42)。 证据还表明，包括多种练习的运动计划与 未包括多种练习的运动计划相比，对骨骼健康 有更大的积极影响（标准化效应为0.45[95% CI：0.20至0.71]；p = 0.001）(95)。 GDG的结论是： • 有高质量证据表明，结合平衡、力量、步态 和功能性训练（如多样化身体活动）的较高 水平身体活动可降低老年人跌倒几率和跌倒 受伤的风险。 • 有中等质量证据表明包含多种练习的运动计 划可能对骨骼健康和预防骨质疏松症有显著 效果。 44 45建议 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 老年人 (65岁以上) 久坐行为建议 支持性证据和理由 2010年《关于身体活动有益健康的全球建议》(1)未涵盖久坐行为。由于缺乏按人群分类 的证据，评估老年人久坐行为与健康结果之间关系的主要证据基础是针对成年人整理和审查 的科学文献，因为大多数研究没有说明年龄上限标准，因此包括65岁以上的成年人。对一般 成年人群久坐行为相关证据的研究发现进行了审查，并评估是否有证据表明老年人会有不同 结果、结果对其不适用或有禁忌。 更多中等和剧烈强度身体活动可抵消大量久坐行为的潜在风险，这方面的证据是否适用 也纳入考虑，并加以类推，为老年人通用关键健康结果的建议提供参考。 在生命的最后几十年中，由于身体机能的原因，可能更难限制久坐行为，但人们承认， 以任何强度的身体活动（包括轻微强度）取代久坐时间仍然能带来健康收益。 关于方法、数据提取和证据简介的全部细节见《网络附件：证据简介》 。 GDG的结论是： • 一般成年人口久坐行为的证据，包括从事更多中等强度到剧烈强度身体活动可抵消大量久坐 行为潜在风险带来的收益，可以类推，为老年人通用关键健康结果的相关建议提供参考。 • 老年人尽量减少久坐行为带来的收益大于风险。 老年人较多久坐行为与下列不良健康结果有关：全因死亡率、心血管疾病 死亡率和癌症死亡率、心血管疾病、癌症和2型糖尿病发病率。 建议： 老年人应该限制久坐时间。久坐时间改用来进行各种强度的身体活动 （包括轻微强度）能带来健康收益。 强烈推荐，中等质量证据 为了帮助减少过多久坐行为对健康的不利影响，老年人进行中等到剧烈强 度身体活动应力求超过建议水平。 强烈推荐，中等质量证据 对于老年人，久坐行为的定义是职业、教育、家庭、社区环境和交通中，清醒状 态下坐卧的时间，能量消耗低。 46 47 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 这些指南涉及孕期和产后期的身体活动和母婴健康结果。指南适用 于所有孕妇和产后妇女，不论年龄、文化背景或社会经济地位。怀孕和分 娩后的时期是妇女生命阶段的一部分，为成年人提供的建议中详细说明了整 个成年时期进行身体活动的收益。 孕妇和产后妇女应接受卫生保健提供者的产前和产后护理，后者可根据其病史提出特别注意事 项，并就孕期或产后期参加身体活动的禁忌提出建议。这些指南以公共卫生和人群的情况为基础。 对于有妊娠或分娩并发症的妇女，应寻求临床指导。 孕妇和产后妇女应在条件允许、无禁忌症的情况下根据自身能力尽力达到建议水平。 孕妇和产后妇女 对于孕妇和产后妇女，身体活动可以作为娱乐休闲（游戏、比赛、运动或有计划的 锻炼）、交通（轮式运动、步行和骑自行车）、工作或家务的一部分，在日常工作、教育、家 庭和社区环境中进行。 身体活动建议 孕妇和产后妇女在孕期和产后的身体活动对母婴健康有以下收益：先兆 子痫、妊娠高血压、妊娠糖尿病、妊娠期过度增重、分娩并发症和产后抑郁 症的风险降低，新生儿并发症减少，对出生体重无不良影响；死产风险未见 增加。 建议所有无禁忌症的孕妇和产后妇女： 整个孕期和产后应定期进行身体活动； 强烈推荐，中等质量证据 每周应该进行至少150分钟中等强度有氧活动，可以获得巨大健康收益； 强烈推荐，中等质量证据 进行各种有氧和肌肉强化运动。增加轻柔拉伸运动可能也有益处。 强烈推荐，中等质量证据 此外： 怀孕前习惯进行剧烈强度有氧运动的妇女，或者经常进行身体活动的 妇女，可以在怀孕和产后继续原有活动。 强烈推荐，中等质量证据 46 47建议 支持性证据和理由 《关于身体活动和久坐行为的指南》（2020年）涉及孕妇和产后妇女的部分采用并更新 了对7项关于关键重要结果的系统综述(28–34)的证据综合。7项中有4项符合纳入标准。 关于方法、数据提取和证据简介的全部细节见《网络附件：证据简介》 。 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 对于孕妇和产后妇女，身体活动与健康 相关结果之间有何关联？ 怀孕前和怀孕期间的身体活动有助于 降低怀孕常见并发症的风险。怀孕期间 进行身体活动与减少妊娠体重增加幅度 （MD= 1.14  kg [95% CI：1.67至 0.62]） (97)和减少妊娠糖尿病风险（RR= 0.71 [95% CI：0.57至0.89]）(97)有显著关联，孕前身 体活动也有关联（OR= 0.70 [95% CI：0.57 至0.85]）(31, 34, 97)，包括超重妇女和患肥 胖症的妇女(97)。 怀孕期间的身体活动似乎不会增加妊娠 高血压或先兆子痫的发病率(31)。证据表明， 对于超重或肥胖症孕妇，身体活动干预组与 标准产前护理组在妊娠高血压（RR= 0.63 [ 9 5% C I：0 . 3 8至1 . 0 5 ]）或先兆子痫 （RR= 1.39 [95% CI：0.66至2.93]）的发病 率上没有显著差异(97)。 长期以来，人们一直顾虑孕妇身体活动 对胎儿发育和分娩可能产生不利影响。然 而，最近的证据表明，身体活动不会增加流 产、死产或分娩并发症发生率的风险(32)。有 证据表明，身体活动干预组与标准产前护理 组之间，超重或肥胖症孕妇的剖腹产率没有 差异(97)。 比较身体活动干预组与标准产前护 理组，怀孕期间的身体活动不会增加对 出生体重 ( 98 ) 或早产(32 )不良影响的风 孕妇和产后妇女 良 好 做 法 • 少量身体活动优于不 活动。 • 如 果 孕 妇 和 产 后 妇 女未达到建议活动水 平，少量身体活动有 益健康。 • 孕妇和产后妇女应从 少量身体活动开始， 逐渐增加频率、强度 和持续时间。 • 盆底肌肉训练可以每 天进行，减少尿失禁 风险。 • 气温过高时避免进行身 体活动，尤其是高湿度 环境下。 • 身体活动之前、期间和 之后饮水保持水分。 • 避免参与涉及身体接 触、跌倒风险大或可 能限制氧化作用的活动 （例如，平时不在高海 拔地区生活的人应避免 高海拔地区活动）。 • 孕早期过后避免仰卧位 活动。 • 若考虑参加体育比赛或运 动量远高于指南建议标准 时，孕妇应寻求专业卫生 保健人员监督。 • 卫生保健提供者应告知 孕妇出现哪些危险信号时 须停止活动；或者出现此 类信号时限制身体活动并 立即咨询合格卫生保健提 供者。 • 分娩后逐渐恢复身体活 动，剖腹产分娩应咨询卫 生保健提供者。 孕妇进行身体活动时的其他安全注意事项： 48 49 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 险，甚至可能具有保护作用，降低了 总体风险 (98 )，即使超重或肥胖症孕妇 （RR=1.02[95% CI：0.54至1.92]）或大于胎 龄儿（RR= 0.90[95% CI：0.65至1.25]）也 是如此(97)。 在产后期间，母亲会经历许多生理和情 绪变化。有证据表明，怀孕期间的身体活动 可能与产后抑郁症有反向关联(29)。对6项 试验和11项孕期身体活动观察性研究(99)的 荟萃分析证据表明，孕期身体活动与产后抑 郁症之间存在显著反向关联（SMD= 0.58 [95% CI：1.09至 0.08]）。限于5项至少 采用中等强度干预措施的研究时，效果更 强（SMD= 0.70 [95%CI：1.19至 0.22]） (99)。 GDG的结论是： • 有高质量证据表明孕期身体活动可减少孕 期体重增加幅度和妊娠糖尿病风险。 • 有中等质量和高质量证据表明身体活动不 会增加妊娠高血压发病率。 • 有中等质量证据表明身体活动不会增加流 产、死产或分娩并发症的发生率；有中等 质量证据表明参加剧烈强度身体活动的孕 妇会减少早产风险。 • 有低质量和中等质量证据表明身体活动不 会增加低出生体重、小于胎龄儿或大于胎 龄儿的风险。 • 有低质量证据表明孕期身体活动会减轻产 后抑郁症状。 • 向孕妇和产后妇女推荐的身体活动量和活 动种类的风险不高，且收益超过风险。 是否存在剂量-反应关系（量、持续时 间、频率、强度）？ 在孕期和产后期间进行身体活动的证据 中，干预措施在身体活动量（即剂量）上存 在差异，持续分钟数和每周的频率都不相 同。一般而言，现有证据反映的情况是每周 至少进行3次有氧身体活动，每次通常持续 30到60分钟。这部分证据来自于评估剂量对 健康影响的研究，该剂量大致符合一般成年 人的建议活动量，即每周进行150分钟中等 强度身体活动。 虽然更多身体活动（频率、持续时间和/ 或量）通常会带来更大收益，但需要进一步 研究来更详细地了解剂量-反应关系。孕前 参加较多和较少的休闲身体活动相对比，可 显著降低妊娠糖尿病风险（OR= 0.54 [95% CI：0.34至0.87]）(100)。还有证据表明，从 事剧烈强度体育活动的孕妇的婴儿早产风险 降低幅度不大，但很明显（RR= 0.20 [95% CI：0.36至 0.03]）(98)。关于锻炼远高于建 议水平是否安全或有额外收益未发现证据。 GDG的结论是： • 证据不足以确定孕期和产后期间身体活动和 特定关键健康结果之间的剂量-反应关系。 • 总体证据显示关键健康结果的收益，证据 的基础是大致符合一般成年人建议身体活 动量的干预措施，即每周150分钟的中等强 度身体活动。 • 向孕妇和产后妇女推荐的中等强度身体活 动量或频率没有理由与一般成年人不同。 • 有中等质量证据表明参与剧烈强度身体活 动的孕妇可降低早产风险。 孕妇和产后妇女 48 49建议 这种关联是否因身体活动的种类或类型 或时间（孕前、产前或产后）而异？ 证据来自主要评估休闲类身体活动的研 究；活动种类主要是有氧运动（如步行或游 泳），但部分证据源自评估干预措施的研 究，这些干预措施也包括力量训练（如循环 训练）或有氧运动和肌肉强化运动的组合训 练。然而，总体而言没有充分证据确定身体 活动与健康结果之间的关联是否因身体活动 的种类或类型或时间（孕前、产前或产后） 而异。 GDG的结论是： • 有中等质量证据表明孕妇和产后妇女应从 事各类有氧运动和肌肉强化运动。轻柔拉 伸运动可能也有益处。 孕妇和产后妇女 50 51 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 支持性证据和理由 2010年《关于身体活动有益健康的全球建议》(1)未涵盖久坐行为。由于缺乏按人群分 类的证据，评估孕妇和产后妇女久坐行为与健康结果之间关系的主要证据基础是针对成年 人整理和审查的科学文献。 对一般成年人群久坐行为相关证据的研究发现进行了审查，并评估是否有证据表明孕 妇和产后妇女会有不同结果、结果对其不适用或有禁忌。 根据现有证据和专家意见对这些证据进 行了类推，以便为世卫组织关于孕妇和产后 妇女久坐行为的新建议提供参考，涵盖通用 的关键健康结果。考虑到所用证据的间接 性，下调了证据质量。 鉴于缺乏专门针对这一群体的证据，而 且研究排除孕妇，因此增加身体活动量、超 过建议水平，以抵消久坐行为不利影响的建 议不适用于孕妇和产后妇女。 GDG的结论是： • 一般成年人久坐行为的证据可以类推， 为孕妇和产后妇女涉及通用关键健康结 果的建议提供参考。 • 孕妇和产后妇女尽量减少久坐行为的收 益大于风险。 • 出于间接性的原因应当下调证据质量。 孕妇和产后妇女 久坐行为建议 对于孕妇和产后妇女，久坐行为的定义是职业、教育、家庭、社区环境和交通中， 清醒状态下坐卧的时间，能量消耗低。 和所有成年人一样，孕妇和产后妇女较多久坐行为与下列不良健康结果有 关：全因死亡率、心血管疾病死亡率和癌症死亡率、心血管疾病、癌症和2 型糖尿病发病率。 建议： 孕妇和产后妇女应该限制久坐时间。久坐时间改用来进行各种强度的身体 活动（包括轻微强度）能带来健康收益。 强烈推荐，低质量证据 50 51建议 迄今为止，大多数针对慢性病患者的身体活动指南仅限于临床或治疗 指导。例如，以下方面的专业医学协会形成了临床实践建议和资源：肿瘤 (101)、2型糖尿病(102)、高血压(103)和其他慢性病(104)。世卫组织的临床实践 指导文件也建议慢性病患者从事身体活动(17)。 这些指南是世卫组织第一批基于人群的慢性病患者身体活动指南，专门针对癌症患者 （下称“癌症幸存者”）、高血压、2型糖尿病和艾滋病患者。 考虑到普及有效的艾滋病抗逆转录病毒治疗已有进展，艾滋病现在也被视为一种慢性病。至于正 接受急性治疗（例如化疗）或慢性病用药尚不稳定的患者，卫生保健提供者亦应参考各种慢性病相关 的临床实践指南。 患有慢性病的成年人和老年人 (18岁以上) 对于患有慢性病的成年人来说，身体活动可以作为娱乐和休闲（游戏、比赛、运动或有计 划的锻炼）、交通（轮式运动、步行和骑自行车)、工作或家务的一部分，在日常职业、教育、 家庭或社区环境中进行。 所有成年癌症幸存者和成年高血压、2型糖尿病和艾滋病患者应根据自身能力，在无禁忌症 的情况下尽力达到建议水平。 身体活动建议 身体活动可以为患有以下慢性病的成年人和老年人带来健康收益：对癌 症幸存者来说，身体活动可以改善全因死亡率、肿瘤特异性死亡率、肿瘤复 发或第二原发肿瘤的风险；对高血压患者来说，身体活动可以改善心血管疾 病死亡率、病情进展、身体机能、与健康相关的生活质量；对2型糖尿病患 者来说，身体活动可以降低心血管疾病死亡率和病情进展指标；对艾滋病患 者来说，身体活动可以改善身体素质和心理健康（焦虑和抑郁症状减少）， 对病情进展（CD4计数和病毒载量）或身体成分无不良影响。 建议： 患有上述慢性病的所有成年人和老年人应定期进行身体活动。 强烈推荐，中等质量证据 患有此类慢性病的成年人和老年人每周应该进行至少150-300分钟的中等 强度有氧活动；或至少75-150分钟的剧烈强度有氧活动；或等量的中等强度 和剧烈强度组合活动，可以获得巨大健康收益。 强烈推荐，中等质量证据 患有此类慢性病的成年人和老年人还应进行中等强度或更高强度的肌肉强 化活动，锻炼所有主要肌肉群，每周2天或2天以上，能带来额外健康收益。 强烈推荐，中等质量证据 良 好 做 法 52 53 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 支持性证据和理由 这些指南评估了身体活动与以下健康结果之间的关联：对于癌症幸存者——全因死亡 率、肿瘤特异性死亡率、肿瘤复发或第二原发肿瘤风险；对于高血压患者——心血管疾病死 亡率、共病风险、身体功能、健康相关生活质量和病情进展(在这里定义为血压对身体活动的 反应）；对于2型糖尿病患者——心血管疾病死亡率，共病风险、身体功能、健康相关生活质 量和病情进展；对于艾滋病患者，身体功能（身体素质、运动耐力和力量）、健康相关生活 质量、心理健康（焦虑和抑郁症状）、心血管代谢疾病风险指标（血脂、血糖和身体成分） 及对病情进展的不良影响（即CD4计数和病毒载量）。 为这些指南提供参考的证据是PAGAC的报告(35)，添加了2017年至2019年确定的16项新 综述，涉及癌症（n=1）、高血压（n=2）和2型糖尿病（n=13）。此外，针对艾滋病患者身 体活动和健康相关结果委托进行的伞状综述提供的证据源自2002-2018年发表的19项合格综 述。关于方法、数据提取和证据简介的全部细节见《网络附件：证据简介》 。 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 患有慢性病的成年人和老年人（18岁以上） 在每周身体活动中，患有此类慢性病的老年人应该进行多样化身体活动， 侧重于中等或更高强度的功能性平衡和力量训练，每周3天或３天以上， 以增强功能性能力和防止跌倒。 强烈推荐，中等质量证据 无禁忌症的情况下，患有此类慢性病的成年人和老年人可以将每周中等强 度有氧活动增加到300分钟以上；或进行150分钟以上的剧烈强度有氧活动； 或等量的中等强度和剧烈强度组合活动，可获得额外健康收益。 条件性推荐，中等质量证据 良 好 做 法 • 如无法达到上述建议活动水平，患有 此类慢性病的成年人应根据自身能力 进行身体活动。 • 患有此类慢性病的成年人应从少量身 体活动开始，逐渐增加频率、强度和 持续时间 • 患有此类慢性病的成年人应咨询身 体活动专家或卫生保健专业人员， 听取建议，确定适合自身需求、能 力、功能受限/并发症、用药情况和 整体治疗方案的活动类型和活动量。 • 无禁忌症者进行不超过快走或日常 生活需要的轻微或中等强度身体活 动之前，一般无须通过体检。 52 53建议 对于成年和老年（18岁以上）癌症患者 （癌症幸存者）、高血压患者、2型糖尿 病患者和艾滋病患者，身体活动与健康 相关结果之间有何关联？ 身体运动能促进新陈代谢、激素和炎症通 路短期和长期的有益变化，肿瘤发病和存活期 有保护作用(35)。证据显示，下列癌症确诊后 较高水平身体活动在全因死亡率方面有保护 作用：乳腺癌（HR= 0.58 [95% CI：0.52至 0.65]，17项研究）；结肠直肠癌（HR= 0.63 [95% CI：0.50至0.78]，10项研究），女性 生殖系统癌（HR= 0.66 [95% CI：0.49至 0.88]，4项研究）；神经胶质瘤（HR=0.64 [95% CI：0.46至0.91]，1项研究）；血癌 （HR= 0.60 [95% CI：0.51至0.69]，2项 研究）；肾癌（HR= 0.60 [95% CI：0.38 至0.95]，1项研究）；肺癌（HR= 0.76 [95% CI：0.60至0.97]，2项研究）；前列腺 癌（HR= 0.60 [95% CI：0.46至0.79]，5项 研究）；胃癌（HR= 0.75 [95% CI：0.61至 0.93]，1项研究）(105)。 癌症确诊后身体活动量增加也可降低 乳腺癌、结肠直肠癌和前列腺癌幸存者的 病因特异性死亡率风险。荟萃分析发现， 确诊癌症后与身体活动总量最低的人群相 比，活动总量最高人群的死亡率风险降低， 具体数据如下，所有癌症总体（HR=0.63 [95% CI：0.53至0.75]，4项研究）；乳腺 癌（HR=0.63 [95% CI：0.50至0.78]，13 项研究）；结肠直肠癌（HR= 0.62 [95% CI：0.44 至0.86]，6项研究）；前列腺癌 （HR= 0.70 [95% CI：0.55至0.90]，4项研 究）(105)。但证据不足以确定身体活动与肿 瘤复发或第二原发肿瘤是否有关联。 身体活动对于高血压的一级预防和管理 都很重要，有证据表明，身体活动改善了高 血压患者的身体机能、心血管疾病进展（ 即血压对身体活动的反应）和心血管疾病 死亡率(35) 。例如，与没有运动的对照组相 比，活动量大的高血压患者可使收缩压降 低约12毫米汞柱，舒张压降低约6毫米汞柱 （SBP MD= 12.26 mm Hg [95% CI：15.17至 9.34]，p= < 0.05；DBP MD= 6.12 mm Hg [95% CI：7.76至 4.48]，p= < 0.05）(106)。 新出现的证据表明，与活动不足的高血压患者 相比，活动量大的高血压患者的健康相关生活 质量显著改善(54)。 包括有氧运动、肌肉强化运动、有氧运动 加肌肉强化运动在内的身体活动，与成年2型 糖尿病患者病情进展风险次级指标（糖化血红 蛋白、血压、身体质量指数和血脂）的改善有 关联(35)。例如，近期研究发现，与对照组相 比，抗阻力训练后糖化血红蛋白降低幅度更 大，高强度抗阻力训练对空腹胰岛素有显著的 积极效果(107)。现有证据不足以评估2型糖尿 病成年患者的身体活动对健康相关生活质量和 身体机能的影响。 艾滋病患者从事身体活动可改善心肺功 能。研究的干预措施包括每周3天、至少30 分钟的有氧练习或结合渐进式肌肉强化练习 的活动(108, 109)。还有证据表明，虽然结果 并非完全一致，身体活动干预措施可以改善 心血管代谢风险标志物（如脂质标志物）； 胰岛素浓度未见影响，但有氧训练后血糖降 低(110)。艾滋病患者进行身体活动，无论是 有氧运动，还是结合肌肉强化练习的运动， 都能改善健康相关生活质量(111)和减轻抑郁 和焦虑症状(112)。对抑郁症的荟萃分析（9 项研究）显示，干预组（p= 0.02）的SMD 为0.84（95% CI：-1.57至-0.11)，更优。 焦虑减轻的SMD（5项研究）也有统计学意 义，干预组更优（1.23 [95% CI：2.42至 0.04]，p= 0.04）(112)。与不锻炼的对照组相 比，锻炼的对照组参与者身体活动也关联以下 变化，去脂体重标准化平均值显著增加1.75公 斤，身体脂肪百分比显著减少1.12%，以及腿 部和臂部周围肌肉面积增加(111)，但艾滋病患 者未见BMI或腰围变化(111)。身体活动对艾滋 病病情进展的标志物无不良影响，如CD4计数 （细胞/mm3）或病毒载量(111)。重要的是， 这一证据表明，艾滋病作为慢性病不会受到身 体活动的不良影响。 患有慢性病的成年人和老年人（18岁以上） 54 55 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 GDG的结论是： • 有中等质量证据表明癌症确诊后身体活动 增加可降低癌症幸存者全因死亡率、病因 特异性死亡率和肿瘤特异性死亡率的相关 风险。 • 有高质量证据表明，身体活动降低高血压 成年患者心血管疾病进展风险。 • 有中等质量证据表明，身体活动改善高血 压成年患者的身体机能和健康相关生活 质量。 • 有高质量证据表明，身体活动可改善2型糖 尿病成年患者病情进展标志物（糖化血红 蛋白、血压、BMI和脂质）。 • 有中等质量证据表明，身体活动与艾滋病 患者的身体素质（最大耗氧量、运动耐 力）和肌肉力量有关联，身体活动有利于 艾滋病患者的身体成分、健康相关生活质 量和抑郁焦虑症状减轻，不会改变病毒载 量和CD4计数。 • 癌症幸存者和高血压、2型糖尿病和艾滋病 患者定期从事身体活动在特定健康结果方 面的收益超过风险。 是否存在剂量-反应关系（量、持续时 间、频率、强度）？ 癌症确诊后增加身体活动可以降低全因 死亡率和肿瘤特异性死亡率的相关风险。证 据显示确诊后增加身体活动与乳腺癌特异死 亡率和全因死亡率之间存在非线性关系，最 多达每周10-15 MET-小时（等于每周150分 钟中等至剧烈强度身体活动），没有证据表 明活动水平提高会带来危害(105)。有迹象表 明，其他癌症位点也存在类似的剂量-反应 关系，但研究数量太少，无法进行正式的荟 萃分析。需要进一步开展研究确定关联性的 强弱。 高血压患者的身体活动与心血管疾病死 亡率之间有明确的剂量-反应关系(35)。研究 结果表明，随着高血压范围内收缩压增加， 心血管疾病死亡率的风险增加，但又随着身 体活动的增加而减缓(35)。与针对一般人群的 建议类似，大多数传统干预措施为每周有3天 进行约30-60分钟的中等强度有氧运动和/或 每周2-3次抗阻力训练。 大量证据表明，2型糖尿病成年患者的 身体活动量与心血管疾病死亡率风险为逆曲 线关系(113–115)。随着身体活动量提高（从 低于、等于到高于建议的每周150分钟中等 强度活动量），风险逐渐降低。例如，与不 活动相比，从事某种活动可以让心血管疾病 死亡率风险下降32%（校正HR=0.68 [95% CI：0.51至0.92]），而活动量达到或超过 身体活动指南要求时，心血管疾病死亡率 风险下降多达40%（校正HR=0.60 [95% CI：0.44至0.82]）(115)。大多数干预措施为 每周150-300分钟中等强度有氧运动或75分 钟剧烈强度运动和/或2-3次抗阻力训练。对 于2型糖尿病成年患者的某些结果（如糖化 血红蛋白和血压），有证据表明增加有氧运 动（即每周超过150分钟，相对于每周不到 150分钟）效果更好，但关于强度的证据有限 (35)。 对于艾滋病患者，证据不足以确定身体 活动与身体成分、或是心血管代谢疾病中间 标志物（如血脂、胰岛素抵抗、空腹血糖浓 度或血压）之间的剂量-反应关系。提供证据 的大多数研究涉及的身体活动干预措施为每 周至少3次、为期12-48周、至少30分钟的中 等至剧烈强度有氧练习或有氧练习结合渐进 式抗阻力训练。也没有充分证据能确定与心 理健康及健康相关生活质量具体的剂量-反应 关系。提供现有证据的研究一般评估的身体 活动干预措施为每周3次或3次以上。 总体而言，有中等质量证据也有高质量 证据支持向特定慢性病患者人群推荐150- 300分钟的中等强度身体活动（或其他等量 活动），关联一系列特定健康结果。高血压 患者、2型糖尿病患者和癌症幸存者的证据表 患有慢性病的成年人和老年人（18岁以上） 54 55建议 明，更高水平的活动与更大收益有更明确的 关系。认定涉及特定慢性病和特定结果的证 据质量和直接性各有不同。力量训练证明有 积极结果的情况下，活动频率为每周2或3次 抗阻力训练。 GDG的结论是： • 有中等质量证据表明，癌症幸存者身体活 动与全因死亡率和肿瘤特异性死亡率降低 存在剂量-反应关系。 • 有高质量证据表明，高血压成年患者身体 活动与心血管疾病死亡率之间存在剂量-反 应关系。 • 有证据表明，2型糖尿病患者的活动量与心 血管疾病死亡风险之间存在逆曲线剂量反 应关系。 • 没有充分证据表明艾滋病患者身体活动与 心血管代谢疾病中间标志物、身体成分、 健康相关生活质量和焦虑抑郁症状之间存 在剂量-反应关系。 • 150-300分钟的中等强度有氧运动（或等 量运动）范围内的干预措施带来有利健康 结果，有力量训练的情况下，每周进行2至 3次抗阻力训练有积极结果。 这种关联是否因身体活动的种类和类型 而异？ 有证据表明，不同种类和类型的身体 活动都能带来有利健康结果。达到有氧 和肌肉强化类活动建议水平的癌症幸存 者与未达到的情况相比，癌症死亡率显 著降低（校正HR=0.70 [95% CI：0.50 至0 . 9 8 ]） ( 8 4 )。证据显示，仅达到肌 肉强化身体活动建议水平者与未达到者 相比，癌症死亡率相关结果也有所改善 （HR=0.66 [95% CI：0.48至0.92]）(84)。 一项荟萃分析也研究了各类型身体活动的关 联情况，发现各类癌症、乳腺癌和结肠直肠 癌的肿瘤特异性死亡率下降情况最为一致的 是娱乐类身体活动(105)。对于高血压成年患 者，有证据支持有氧运动、肌肉强化运动以 及两者的结合能够改善心血管疾病的病情进 展情况。各种传统身体活动（如有氧和抗阻 力类）对于高血压患者的降血压效果并无显 著差别(35)；但得出这一证据时并未直接比较 各种身体活动。还有新的证据支持其他形式 的运动对高血压患者的有益影响（如太极、 瑜珈、气功），但需要进一步研究这些特定 种类的运动才能确定关联性的强弱。 有氧活动、肌肉强化活动或两者结 合，可改善 2型糖尿病成人患者病情进 展风险的次级指标（糖化血红蛋白、血 压、BMI和血脂）(35 , 107 )。一项24个 RCT（n= 962）的综述报告，与对照组相 比，抗阻力训练组的糖化血红蛋白降低幅度 更大（MD= 0.45 [95% CI：0.65至 0.25]，20 次试验；n= 824）。与对照组相比，高强 度抗阻力训练组在空腹胰岛素方面的效果有 统计学意义（MD= 4.60 [95% CI：7.53至 1.67]，5次试验；n= 174）(107)。另外一项7 个RCT的（n= 189）的综述报告，与MICT组 相比，间歇性训练组（每周2–5次；每次训 练期间有1-4分钟的间隔时间；每次训练总时 长为20–60分钟）糖化血红蛋白降低0.26% (95% CI：0.46至 0.07%，5个RCT）， 与无训练对照组相比降低0.83%（95% CI：1.39%至 0.27%，4个RCT），有统计学 意义(116)。与针对一般人群的建议一样，大多 数此类干预措施为每周推荐150-300分钟中 等强度有氧运动（或75分钟剧烈强度活动） 和每周2-3次肌肉强化运动。针对某些结果（ 如糖化血红蛋白和血压），有证据表明增加 有氧活动（如每周超过150分钟，相对于每周 不到150分钟）效果更好，但关于强度的证据 有限。最近研究提供的证据表明，太极等传 统中式运动可能有利于控制血糖，但相关证 据的质量中等且有差异（如偏倚或不一致风 险）。需要进一步研究确定其关联性。 患有慢性病的成年人和老年人（18岁以上） 56 57 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 包括有氧运动和抗阻力训练在内的多种身 体活动已证实对艾滋病患者的健康相关生活 质量有积极影响(111)。近期关于有氧活动、渐 进式抗阻力练习或两者结合改变健康相关生 活质量的研究显示，整体健康状况和心理健 康都出现了显著改善。还有证据表明，有氧 运动和多样化运动都能减轻艾滋病患者的抑 郁和焦虑症状(112)。身体活动对心理健康相关 症状影响的证据包括有氧运动或有氧运动结 合渐进式肌肉强化活动或瑜伽。还有证据显 示，仅从事有氧运动或结合抗阻力练习均不 会导致艾滋病患者的病毒载量或CD4计数出 现显著变化(111)。 来自现有文献和最新文献的直接证据支持 向2型糖尿病和高血压患者推荐有氧和肌肉强 化身体活动。尽管缺乏公开证据，但有氧运 动和肌肉强化运动对于艾滋病患者和癌症幸 存者的收益从生物学角度判断有其合理性。 此外，正如GDG指出的那样，现行国际临床 实践指南建议这些人群进行有氧和肌肉强化 身体活动（例如ACSM根据证据系统综述推出 的“运动战胜癌症”指南(101)）。考虑到证据基 础还在扩大，下调了证据质量。 GDG的结论是： • 有中等质量证据表明，有氧运动或肌肉强 化运动的综合或叠加效应可降低癌症死亡 率，改善高血压患者的血压。 • 有高质量证据表明，有氧运动、肌肉强化 运动、有氧运动结合肌肉强化运动能改 善2型糖尿病成年患者疾病进展的标志物 （糖化血红蛋白、血压、身体质量指数和 脂质）。 • 有中等质量证据表明，仅从事定期有氧运 动，或结合抗阻力练习，不会导致艾滋 病患者的病毒载量或CD4计数发生显著 变化。 • 没有充分证据表明仅进行力量训练会影响 艾滋病患者的健康相关生活质量。 患有慢性病的成年人和老年人（18岁以上） 56 57建议 患有慢性病的成年人和老年人 (18岁以上) 久坐行为建议 支持性证据和理由 由于缺乏按人群分类的证据，评估成年和老年癌症幸存者以及高血压、2型糖尿病和艾滋 病成年和老年患者的久坐行为与健康结果之间关系的主要证据基础是针对成年人整理和审查 的科学文献。 对一般成年人群久坐行为相关证据的研究发现进行了审查，并评估是否有证据表明慢性 病成年和老年患者会有不同结果、结果对其不适用或有禁忌。 包括癌症幸存者和高血压、2型糖尿病和艾滋病患者在内，成年人较多久 坐行为与以下不良健康结果有关：全因死亡率、心血管疾病死亡率；癌症死 亡率；心血管疾病、癌症和2型糖尿病的发病率。 癌症幸存者和患有高血压、2型糖尿病和艾滋病的成年人，建议： 患有慢性病的成年人和老年人应限制久坐时间。久坐时间改用来进行各种 强度的身体活动（包括轻微强度）能带来健康收益。 强烈推荐，低质量证据 为了帮助减少过多久坐行为对健康的不利影响，患有慢性病的成年人和老 年人进行中等到剧烈强度身体活动应力求超过建议水平。 强烈推荐，低质量证据 2010年《关于身体活动有益健康的全球建议》(1)未包括久坐行为。这项关于久坐行为的 新建议适用于癌症幸存者和高血压、2型糖尿病和艾滋病患者。 久坐行为的定义是职业、教育、家庭、社区环境和交通中，清醒状态下坐卧的时间，能量 消耗低。 58 59 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 患有慢性病的成年人和老年人（18岁以上） 根据现有证据和专家意见对这些证据进 行了类推，以便为世卫组织关于慢性病成年 患者久坐行为的新建议提供参考，涵盖通 用的关键健康结果。对证据的类推主要基于 以下判断，大多数研究没有规定年龄上限标 准，涵盖65岁以上成年人，也有慢性病成年 患者，如癌症幸存者、高血压患者或2型糖尿 病患者。关于艾滋病患者久坐行为对健康影 响的证据不适用问题，未能确定原因。考虑 到制定这些建议所用证据的间接性，下调了 证据质量。 更多中等和剧烈强度身体活动可抵消大 量久坐行为的潜在风险，这方面的证据是否 适用也纳入考虑，并加以类推，为慢性病成 年患者通用关键健康结果的建议提供参考。 鉴于证据的间接性，下调了证据质量。 GDG的结论是： • 关于一般成年人久坐行为的证据可以类 推，为成年和老年癌症幸存者以及高血 压、2型糖尿病和艾滋病成年和老年患者的 通用关键结果建议提供参考，出于间接性 的原因下调了证据质量。 • 关于一般成年人更多中等和剧烈强度身体 活动可抵消大量久坐行为潜在风险的证据 可以类推，为成年和老年癌症幸存者以及 高血压、2型糖尿病和艾滋病成年和老年患 者的通用关键结果建议提供参考，出于间 接性的原因下调了证据质量。 • 对于癌症幸存者和高血压、2型糖尿病和艾 滋病患者来说，尽量减少久坐行为的收益 大于危害。 58 59建议 残疾儿童和青少年（5–17岁） 以及残疾成年人（18岁以上） 残疾儿童、青少年和成年人可以从身体活动中获得重要健康收益。残疾儿童、青少年和 成年人应在条件允许的情况下根据自身能力尽量达到这些建议要求。 对于残疾儿童、青少年和成年人，身体活动可以作为娱乐休闲（游戏、比赛、运动或有 计划的锻炼）、体育、交通（轮式运动 、步行和骑自行车）或家务的一部分，在家庭、教 育、职业和社区环境中进行。应向所有残疾儿童、青少年和成年人提供机会并鼓励他们参与 有趣、多样、适合其年龄和能力的身体活动。 身体活动建议 之前章节介绍了身体活动对儿童和青少年的健康收益，其中许多也适用于 残疾儿童和青少年。身体活动对残疾人健康结果的其他收益包括：因注意力 缺陷/多动障碍（ADHD）等疾病或障碍认知功能受损者可以改善认知能力； 智力障碍儿童的身体功能也能得到改善。 建议： 一周中，残疾儿童和青少年应该 平均每天至少进行60分钟中等到剧 烈强度身体活动，有氧活动为主。 强烈推荐，中等质量证据 每周至少应有3天进行剧烈强度有 氧运动以及增强肌肉和骨骼的运动。 强烈推荐，中等质量证据 良 好 做 法 • 少量身体活动优于不活动。 • 如果残疾儿童和青少年未达到建 议活动水平，少量身体活动有益 健康。 • 残疾儿童和青少年应从少量身体活 动开始，逐渐增加频率、强度和持 续时间。 • 在适合当前活动水平、健康状况 和身体机能的情况下，残疾儿童和 青少年进行身体活动不存在重大风 险；而且健康收益超过风险。 • 残疾儿童和青少年应咨询卫生保健 专业人员或其他身体活动和残疾专 家，确定适合他们的活动类型和活 动量。 良 好 做 法 60 61 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 残疾儿童和青少年（5–17岁）以及残疾成年人（18岁以上） 之前章节介绍了身体活动对成年人的健康收益，其中许多也适用于残疾成 年人。身体活动对残疾人健康结果的其他好处包括：对于患有多发性硬化症 的成年人——改善身体功能，在生理、心理和社会方面改善健康相关生活质 量；对于脊髓损伤的成年人——改善步行功能、肌肉力量和上肢功能；以及 改善健康相关生活质量；对于因疾病或障碍认知功能受损的患者，改善身体 功能和认知（帕金森病患者和中风病史患者）；对认知有正面作用；可改善 生活质量（成年精神分裂症患者）；可改善身体功能（成年智力障碍者）； 以及提高生活质量（成年重度临床抑郁症患者）。 建议： 所有残疾成年人应定期进行身体 活动。 强烈推荐，中等质量证据 残疾成年人每周应该进行至少 150-300分钟的中等强度有氧活动； 或至少75-150分钟的剧烈强度有氧 活动；或等量的中等强度和剧烈强度 组合活动，可以获得巨大健康收益。 强烈推荐，中等质量证据 残疾成年人还应进行中等强度或 更高强度的肌肉强化活动，锻炼所有 主要肌肉群，每周2天或2天以上， 能带来额外健康收益。 强烈推荐，中等质量证据 在每周身体活动中，残疾老年人 应该进行多样化身体活动，侧重于 中等或更高强度的功能性平衡和力 量训练，每周3天或3天以上，以增 强功能性能力和防止跌倒。 强烈推荐，中等质量证据 残疾成年人可以将每周中等强度 有氧活动增加到300分钟以上；或 进行150分钟以上的剧烈强度有氧活 动；或等量的中等强度和剧烈强度 组合活动，可获得额外健康收益。 条件性推荐，中等质量证据 良 好 做 法 • 少量身体活动优于不活动。 • 如果残疾成年人未达到建议活动水 平，少量身体活动有益健康。 • 残疾成年人应从少量身体活动开 始，逐渐增加频率、强度和持续 时间。 • 在适合当前活动水平、健康状况和 身体机能的情况下，残疾成年人进 行身体活动不存在重大风险；而且 健康收益超过风险。 • 残疾成年人应咨询卫生保健专业人 员或其他身体活动和残疾专家，确 定适合他们的活动类型和活动量。 60 61建议 支持性证据和理由 为制定残疾儿童、青少年和成年人的指南，使用并更新了PAGAC的全面证据综合结果 (35)。关于身体活动和健康结果现有证据使用的方法、数据提取和证据概要表，全部细节可供 查阅(35)，除最新搜索结果外，GDG也审查了这些内容。 为这些指南进行的更新工作考虑了2017年至2019年发表的39篇综述。其中，27篇符合纳 入标准，为研究残疾儿童、青少年和成年人身体活动与健康相关结果之间的关联提供参考。 关于方法、数据提取和证据简介的全部细节见《网络附件：证据简介》 。 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 审查的证据考虑了因下列疾病致残的儿 童、青少年和成年人身体活动与健康相关结 果之间的关联：多发性硬化症、脊髓损伤、 智力障碍、帕金森症、卒中、重度临床抑 郁症、精神分裂症和注意力缺陷/多动障碍 （ADHD）。审查了四种健康相关结果，包括 共病风险、身体功能、认知功能和健康相关 生活质量，但并非每种疾病的所有结果都有 研究。在身体活动方面，环境因素对残疾的 影响超出了这些指南的范围，未作分析。 对于残疾儿童和青少年（5–17岁）以及 残疾成年人（18岁以上），身体活动与 健康相关结果之间有何关联？ 对于多发性硬化症患者来说，身体活动 可以改善身体机能、功能性移动能力、步行 速度和耐力，以及心肺功能、力量和平衡能 力。例如，为期3-12周的高强度间歇性训练 可以改善心肺功能或肌肉力量(117)，平均为期 13周的下肢力量训练可以让力量提高23.1% （95% CI：11.8至34.4）(118)，研究发现舞 蹈类干预措施可改善功能性移动能力和平衡 能力(119)。除了身体健康方面的收益之外，现 有证据表明，身体活动还有利于多发性硬化 症患者的认知能力(35)。较新的研究显示，有 氧运动对身体、心理和社会领域的健康相关 生活质量（包括疲劳和抑郁症状）有微小而 重要的影响(35, 120)。 对于脊髓损伤患者，身体活动可以改善 步行功能、肌肉力量和上肢功能(35)。身体 活动还可能减轻肩部疼痛，改善血管功能， 提高健康相关生活质量(35)。 对于帕金森症患者，身体活动可以改善 运动症状、功能性移动能力和表现、耐力、 冻结步态和前进后退速度(35, 121, 122)。新证 据显示，锻炼还有助于帕金森症患者的整体 认知功能(123)。 对于卒中史患者，身体活动可以改善身 体机能，尤其是上肢功能、下肢感觉运动功 能、平衡能力、步行速度、距离、能力和耐 力、心肺功能、行动能力和日常生活活动。 现有证据表明身体活动对于认知能力也有积 极影响(35)。 对于重度临床抑郁症患者，新综述(124, 125)支持现有证据(35)，即身体活动可以改善 健康相关生活质量(35, 124, 125)。 对于包括精神分裂症在内的因疾病或障 碍认知功能受损的患者，身体活动对认知、 工作记忆、社会认知和注意力/警觉性有积极 影响(35, 126)。一项综述发现，中等至剧烈强 度身体活动可显著改善健康相关生活质量和 失能 (35, 124)。 残疾儿童和青少年（5–17岁）以及残疾成年人（18岁以上） 62 63 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 对于智力障碍者，身体活动也证实可改 善身体机能。审查的干预措施主要侧重于为 期6-24周的平衡性和力量训练，发现静态平 衡、动态平衡和静动态平衡均显著优于对照 组(35, 127, 128)。 对于注意力缺陷/多动障碍儿童，包括研 究涉及ADHD的5次RCT综述在内的证据(129) 表明，锻炼与注意力、执行功能和社交障碍 之间有积极关联(35, 129)。 GDG研究了一般儿童、青少年和成年人 的证据，得出的结论是，没有理由认为身体 受损会带来效应修饰，因此积极身体活动也 会带来同样的健康生理收益。GDG承认，涵 盖残疾人的研究为数不多，对效应修饰的检 测极少进行。 残疾方面的这部分证据，加上更广泛的 一般人口证据，支持在一般人口建议中涵盖 残疾人，并注意提到“所有成年人”、“所有老 年人”和“各种能力的人”。 GDG的结论是： 对于脊髓损失患者，有： • 低质量证据表明身体活动可减轻肩部疼 痛，改善瘫痪肢体血管功能，提高健康相 关生活质量； • 中等质量证据表明身体活动可改善步行功 能、肌肉力量和上肢功能。 对于包括帕金森症在内的因疾病或障碍认知 功能受损的患者，有： • 高质量证据表明身体活动改善包括步行、 平衡、力量和疾病特异性运动评分在内的 功能性结果； • 中等质量证据表明中等至剧烈强度身体活 动对认知有积极影响。 对于卒中史患者，有： • 中等质量证据表明，侧重于行动能力的身 体活动对身体机能和认知有积极影响。 对于包括精神分裂症在内的因疾病或障碍认 知功能受损的患者，有： • 中等质量证据表明身体活动能改善生活 质量； • 高质量证据表明中等至剧烈强度身体活动 对认知、工作记忆、社会认知和注意力有 积极影响。 对于重度临床抑郁症成年患者，有： • 中等质量证据表明身体活动改善生活质量。 对于多发性硬化症成年患者，有： • 高质量证据表明身体活动，尤其是有氧和 肌肉强化运动，能改善身体机能、功能性 移动能力，步行速度和耐力以及心肺功 能、力量和平衡能力； • 中等质量证据表明身体活动对认知有积极 影响； • 低质量证据表明身体活动能改善生活 质量，包括疲劳和抑郁症状。 对于智力障碍的儿童和成年人，有： • 低质量证据表明身体活动能改善身体机能。 对于患有ADHD的儿童和青少年，有： • 中等质量证据表明，中等至剧烈强度身体 活动对认知有积极影响，包括注意力、执 行功能和社交障碍。 GDG进一步得出结论，有充分科学证据 表明，身体活动对多种受损领域的各种健康 结果有积极影响，身体活动对于残疾人而言 收益大于潜在危害。 考虑到制定这些建议所用证据的间 接性，下调了证据质量。 残疾儿童和青少年（5–17岁）以及残疾成年人（18岁以上） 62 63建议 支持性证据和理由 《关于身体活动有益健康的全球建议》（2010年）未涵盖久坐行为。 由于缺乏按人群分类的证据，评估残疾儿童、青少年和成年人久坐行为与健康结果之间 关系的主要证据基础是针对非残疾人整理和审查的科学文献。 对一般人群久坐行为相关证据的研究发现进行了审查，并评估是否有证据表明残疾儿 童、青少年和成年人会有不同结果、结果对其不适用或有禁忌。 残疾儿童和青少年（5–17岁） 以及残疾成年人（18岁以上） 久坐行为建议 对于残疾儿童、青少年和成年人，久坐行为的定义是教育、家庭、社区环境和交通中， 清醒状态下坐卧的时间，能量消耗低。通过上肢主导的活动和/或轮椅运动和活动等方式可 以在坐卧状态下避免久坐行为，坚持身体活动。 儿童和青少年较多久坐行为与以下不良健康结果有关：更加肥胖；心血管 代谢健康、身体素质、行为品行/亲社会行为较差；以及睡眠时间减少。 建议： 残疾儿童和青少年应该限制久坐时间，尤其是屏幕娱乐时间。 强烈推荐，低质量证据 成年人较多久坐行为与以下不良健康结果有关：全因死亡率、心血管疾病 死亡率和癌症死亡率以及心血管疾病、癌症和2型糖尿病的发病率。 建议： 残疾成年人应限制久坐时间。久坐时间改用来进行各种强度的身体活动 （包括轻微强度）能带来健康收益。 强烈推荐，低质量证据 为了帮助减少过多久坐行为对健康的不利影响，残疾成年人进行中等到剧烈 强度身体活动应力求超过建议水平。 强烈推荐，低质量证据 64 65 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 根据现有证据和专家意见对这些证据进 行了类推，以便为世卫组织关于残疾人久坐 行为的新建议提供参考，涵盖通用的关键健 康结果，承认轮椅使用者等特定人口群体难 免长时间保持坐姿，坐姿因此属于常态。对 于这些群体，久坐行为应定义为能量消耗低 的时间，如使用电动轮椅或使用手动轮椅由 他人推行。对于残疾人久坐行为与健康结果 之间的关联研究不足。但根据专家意见，没 有理由认为身体受损会带来效应修饰，因此 残疾人限制久坐行为也会带来同样的健康生 理收益。考虑到制定这些建议所用证据的间 接性，下调了证据质量。 更多中等和剧烈强度身体活动可抵消成 年人大量久坐行为的潜在风险，这方面的证 据是否适用也纳入考虑，并加以类推，为 残疾成年人通用关键健康结果的建议提供参 考。鉴于证据的间接性，下调了证据质量。 GDG的结论是： • 儿童和青少年群体久坐行为的相关证据一 般可类推至残疾儿童和青少年，同时考虑 后者的具体能力。 • 一般成年人群体久坐行为的相关证据，包 括更多中等和剧烈强度身体活动可抵消成 年人大量久坐行为潜在风险的证据在内， 一般可类推至成年和老年残疾人，同时 考虑后者的具体能力。但出于证据的间接 性，下调了证据质量。 • 残疾儿童、青少年、成年人和老年人尽量 减少久坐行为的收益大于危害。 残疾儿童和青少年（5–17岁）以及残疾成年人（18岁以上） 64 65建议 按照GRADE程序，更新建议的拟议措 辞及推荐程度的评级（“强烈”或“条件性”） 基于以下考虑：收益与危害的平衡；证据质 量；受指南影响者的价值观和偏好是否有影 响；对性别、社会和健康公平的潜在影响； 可接受性、可行性和涉及资源问题。对上述 因素的研究针对各个人口群体分别进行，但 鉴于所讨论问题和注意事项的相似性，本文 为所有内容的汇总说明。 推荐的程度主要基于比较收益和危害的 评估。如果比较后，评估认为对建议的目标 人群而言收益远大于危害，则推荐标为“强 烈”，如果收益相对于危害并不明显，或者目 标人群的收益可能存在重大差异，则推荐标 为“有条件”。委托进行新的系统综述专门寻 找关于危害的证据。但收获有限，因为大多 数证据侧重于精英和竞技运动员受伤和受到 危害的情况，而非广大民众。总体而言，尽 管证据有限，但根据专家意见，得出的结论 是风险不大。证据普遍表明，身体活动的收 益远远超过危害，身体活动可以作为重要干 预措施支持缩小现有健康差距，特别是针对 弱势群体而言。 GDG还审议了健康公平、可行性和可接 受性等问题，2020年3月31日至2020年4月 17日期间举行的建议草案网上公众咨询也包 括这些问题。公众咨询调查提出的具体问题 涉及实施建议个人和政府需要承担的成本与 潜在健康收益之间的平衡，以及指南是否会 改善健康公平。此外，建议草案和反馈表也 发给了最近表示有兴趣制定或已经开始起草 国家身体活动指南的国家。已收到超过420份 网上咨询的反馈意见，此外还整理了世卫组 织欧洲区域办事处的反馈意见，采纳世卫组 织合作中心和会员国的意见。公众咨询获得 的反馈意见经过整理，由GDG审查，在指导 小组和GDG协商下，进一步为审议可行性、 涉及资源问题和健康公平问题提供参考。 讨 论 后 以 协 商 一 致 的 方 式 作 出 决 定。GDG在每项建议和推荐程度上达成共 识；无须评分和表决。 证据质量评估 GDG使用GRADE框架审查针对PI/ECOs 识别的各项结果进行初步研究的质量，并评 估证据的总体质量，同时考虑到每项结果的 偏倚风险、不一致、不精确、证据的间接性 和发表偏倚。详细说明各PI/ECO此类信息的 GRADE表格见《网络附件：证据简介》 。 证据质量评估的基础是对所有评估结果的整 体评估，并将全因死亡率和心血管疾病死亡 率作为最关键的结果排在前面，其次是其他 临床结果（跌倒、抑郁、认知、健康相关的 生活质量等），然后是中间结果（如心血管 代谢标志物、其他代谢标志物）以及危害。 亚群体久坐行为等证据未经专门审查，主要 原因是缺乏此类人群的相关证据，这种情况 下考虑到间接性，酌情采用一般人群证据类 推，证据质量降级。 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 证据转化建议 66 67 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 收益和危害 制定建议时也评估了不良影响或风险。 在证据有限的情况下，决策基于GDG的专业 知识。总体结论是，对于所有人群身体活动 和限制久坐行为的收益都超过潜在危害。这 些指南针对大众，不涉及运动员为提高竞赛 成绩加强体能所需运动类型和总量的收益和 危害。 少量身体活动优于不活动。如果未达到 建议活动水平，少量身体活动有益健康。应 从少量身体活动开始，逐渐增加频率、强度 和持续时间。参加锻炼前一般无须体检。身 体活动不足者逐步发展到中等强度身体活动 没有心脏突发事件的已知风险，骨骼、肌肉 或关节受伤的风险也很低。习惯从事中等强 度活动者可以逐渐增加至剧烈强度活动，无 须咨询卫生保健机构。如果增加活动量时出 现新症状，应咨询卫生保健机构。 选择何种身体活动以及合适的活动量会 受到怀孕、慢性病和残疾的影响，应根据自 身能力在无禁忌证的情况下活动。此类人群 不妨咨询身体活动专家或卫生保健专业人 员，听取建议，确定适合自身需求、能力、 功能受限/并发症、用药情况和整体治疗方案 的活动类型和活动量。以获得适合其个人需 要、能力、功能限制/并发症、药物和整体治 疗计划的活动类型和数量的建议。轻微强度 和中等强度的身体活动一般风险较低，推荐 所有人参加。 价值观和偏好 考虑了指南涉及群体（此处包括父母和 照顾者、儿童和青少年、成年人、老年人、 孕妇和产后妇女、慢性病患者和/或残疾人） 的价值观和偏好。总体结论是，对于全因死 亡率和心血管疾病死亡率等主要结果，与偏 好相关的不确定性很低或不存在。估计的潜 在收益大大超过所有潜在危害，因此GDG认 为这些建议不受偏好影响。 涉及资源问题 GDG的专家意见以及关于干预措施的 经济分析和卫生保健系统因身体活动水平提 高节省费用的少量证据，为不同环境下建议 涉及资源问题的讨论提供了参考。此外，网 上公众咨询的结果显示，超过75%的参与 者赞同或非常赞同，实施指南的收益将超过 个人付出的成本，而81%的参与者赞同或非 常赞同，实施指南的收益将超过政府付出的 成本。 现有证据和专家意见确认，通过步行等 个人不需要特定设备或付费的活动，可以在 低风险的情况下实现巨大健康收益。此外， 人们承认，其他形式的身体活动，例如有组 织的体育运动、骑自行车和训练课程，可能 会产生费用，对于部分人，特别是低收入者 而言是一个障碍因素。政府执行促进和扶持 身体活动的政策和方案时，在人力资源、 政策制定、设施和服务的提供，还有可能在 设备这些领域也需要进行投资，部分投资由 卫生部委承担，卫生领域之外，如体育、教 育、交通和城市规划等部门也会分担。可能 需要不止一级政府（国家、国家以下和地方 各级）投入资源，以确保所有社区都有平等 机会参加身体活动。 这些投资可能需要新的资源，但也可以 通过重新分配现有预算来解决，体现出设施 和方案优先关注提高全民身体活动水平。预 算重新分配的例子有，现有交通预算拨款 转而用于步行和骑自行车的基础设施，以及 体育预算向“全民体育”倾斜。在学校和工作 场所等关键环境中，低成本的干预措施加上 实体环境的调整，可以支持民众参与身体活 动，也有助于减少某些亚群体在身体活动参 与机会方面的不平等。总体评估的结果是， 虽然实现这些建议草案涉及资源问题，但在 目前治理结构内可以采取行动。 66 67证据转化建议 此外，有证据表明，提高身体活动水 平可以让卫生保健系统节省大量卫生保健 费用。2013年，仅直接医疗费用，全球每 年身体活动不足的成本估计为540亿英特币 (130)；在国家一级，身体活动不足的产生的 费用估计占到卫生保健成本的1-3% (131)。 在范围更广的非传染性疾病（NCD）预 防方面，如果建议的身体活动能够相对容易 地纳入民众生活，那么政府和非政府组织执 行指南的额外费用可以尽量减少；同样，如 果初级和二级保健、学校、工作场所或交通 运输的现有资源能够转移，从而增加身体活 动，也能减少费用。 对促进身体活动的成本收益分析表明， 在有投资案例的许多国家，从预防非传染性 疾病的角度而言，15年以上的投资收益为正 (132)。根据《2013-2020年预防和控制非传 染性疾病全球行动计划》附录3(133)的更新 情况，公众教育和宣传活动以及身体活动咨 询和转荐等干预措施，分别是应对非传染性 疾病建议干预措施的“最合算措施”和“合算措 施”。GDG的总体结论是，落实建议的收益大 于成本。 落实残疾人身体活动指南可能需要投 资，如培训活动专家，必要时调整设备，以 及提供无障碍设施。此类投资可以为众多人 口群体的需求提供便利。有证据表明，由于 可及性、可供选择的活动和他人态度构成多 种障碍，残疾人和非残疾人在身体活动方面 存在显著的参与梯度。应运用通用设计原则 确保残疾人充分和有效的参与。通过创新， 有可能解决许多涉及资源的问题。采用通用 设计方法未来能降低此类成本。 平等、可接受性和可行性 更新2010年建议时决定明确纳入弱势 群体的相关内容，如慢性病患者和/或残疾 人。GDG和指导小组的成员有一些为弱势 群体代表。GDG深入讨论各项建议，考虑 实施建议是否会降低健康公平性，以及与实 施有关的问题，确保建议不会导致公平性问 题恶化（例如，确保有安全的设施和机会让 包括残疾人、社会经济等各方面弱势群体在 内的所有人能够从事身体活动；解决可能限 制身体活动参与途径和参与机会的性别和其 他文化偏见等等）。网上公众咨询的受访者 中，76%赞同或非常赞同实施指南可以增 加所有人的身体活动机会从而减少健康不平 等，能够改善健康结果。讨论指出，配套 的环境是促进参与身体活动的关键。需要采 取多部门综合方法设计和执行政策，才能 为社会经济处于不利地位的妇女和女童以及 残疾人等弱势群体解决参加身体活动的障碍 因素。 残疾人的健康结果不如非残疾人，但身 体活动的收益远远超过危害，可以成为缩小 这种健康差距的重要干预措施。证据表明， 由于可及性、可供选择的活动和他人态度构 成多种障碍，残疾人和非残疾人之间在身体 活动方面存在显著的参与梯度。应当让许多 残疾人能够在不需要调整设备或设施的情况 下进行多种形式的身体活动。然而，若要让 残疾人能与他人平等参与身体活动，可能需 要获得经过改造的设备、提供无障碍设施并 培训活动专家。 68 69 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 尽管有大量数据显示身体活动与整个生 命周期健康结果相关，以及越来越多证据支 持久坐行为与整个生命周期健康结果相关， 但通过GDG的讨论发现了重要的证据空白， 应予以优先考虑，为今后的指南提供参考。 各个亚群体存在的证据空白包括以下方面的 信息缺失： 1) 针对身体活动和/或久坐行为与所研究的 若干健康结果之间的剂量-反应关系更精 准的细节信息； 2) 轻微强度身体活动以及久坐时间穿插轻微 强度身体活动的健康收益； 3) 不同种类及类型的身体活动（休闲、职 业、交通、家居、教育）和久坐行为（职 业、屏幕时间、看电视时间）对健康的不 同影响； 4) 身体活动和久坐时间与生命全程健康结果 之间的联系。 讨论也指出，低收入和中等收入国家、 贫穷社区或服务不足社区、残疾人和/或慢 性病患者的相关证据仍然有限。许多研究的 设计或能力没有考虑各种社会人口因素（年 龄、性别、种族/民族、社会经济地位）的 效应修饰，而这些因素可能会改变身体活动 对健康的影响。这类信息对于提出更具体的 公共卫生建议和减少人口中较脆弱群体的 卫生差距具有重要意义。关于这些新指南带 来的研究空白，详情也可参考已发表的文献 (134)。 研究需求 68 69研究需求 这些指南的目标是向政策制定者和卫生 保健、教育、工作场所和社区的干预方案设 计者提供关于儿童、青少年、成年人和老年 人每天身体活动时间的建议，以及限制久坐 时间的建议。然而，制定全球指南本身并不 是目的：在传播和实施方面不做工作，就不 可能改变身体活动水平。 采纳 世卫组织制定全球适用的指南(21)时遵 循严格而广泛的程序，可供所有国家使用。 《关于身体活动和久坐行为的指南》针对身 体活动和久坐行为对健康的影响提供了基于 证据的建议，各国政府可以采纳建议，作为 国家政策框架的一部分。全球指南经过广泛 磋商后制定，大部分国家不必再动用资源展 开漫长的科学进程。审查并采纳身体活动和 久坐行为全球指南，是制定适合本地情况指 南快速而经济的方法。 在区域或国家一级采纳世卫组织指南， 将确保各国在身体活动和久坐行为上提供一 致的建议，这些建议参考了现有最新和最佳 科学证据。此外，各国建议的一致性将有助 于国家监测、对身体活动和久坐行为的全球 估测以及跨国比较。在采纳指南的整个过程 中，应注意根据具体情况调整和修改指南。 将指南翻译成当地语言就属于采纳和适应 背景情况的工作。身体活动举例时可能需要 加以调整适应当地情况，并使用反映当地文 化、规范和价值观的图片。 与相关利益攸关方举办一系列区域研讨 会之后，支持各国采纳全球指南的分步骤 框架正在制定当中。可以用相关国家数据 （例如，身体活动普及率估计值）填充这一 框架，为制定国家指南文件提供了快捷方 式。这些辅助资源将于2021年通过世卫组织 网站提供。 考虑采纳指南时建议通过以下十个 步骤进行： 1. 倡导审查现行身体活动国家指南并采纳世 卫组织指南，确保政府授权。 2. 让卫生部门和体育、教育、交通等其他相 关部门的主要利益攸关方参与进来；让相 关专业协会和科学家参与进来，提供主题 专业知识。 3. 评估建议的适用性、可接受性和可行性。 4. 根据本地情况调整指南，考虑语言、举例 和其他文化因素。 5. 与政策制定者、从业人员和大众等目标用 户进行外部评审。 6. 为传播和宣传工作制定预算和明确计划。 7. 发布并宣传国家指南，最好举办发布会活 动，引起热度和关注。 8. 邀请相关专业组织机构参与，支持政策协 调和/或批准。 9. 落实国家政策和作法，支持国家指南的实 施和行为改变。 10. 商定指南评估、审查和更新的时间表。 采纳、传播、实施和评估 70 71 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 传播 要全面提高全民身体活动水平，国家身 体活动指南是治理结构的核心组成部分。国 家指南为国家和国家以下各级战略规划的发 展和优先事项提供参考，要求以适当方式向 相关群体传播正确信息。遗憾的是，国家指 南往往得不到传播，因此专业人员以及更广 泛的社群对建议仍然很不了解。要改变对增 加身体活动和减少久坐行为重要意义的认识 和了解，首先要采取的重要步骤是获得支持 广泛传播的专用资源。 传播身体活动和久坐行为国家指南的主 要受众包括： • 卫生保健部门内外的政策制定者（包括交 通、规划、教育、工作场所、体育、公园和 娱乐），要加强以下方面工作： a. 了解增加身体活动和减少久坐行为不 仅有助于改善健康，而且有利于改善 范围广泛而又互相关联的问题，如性 别平等、人权义务和可持续发展； b. 将有关身体活动和久坐行为的政策和 方案纳入所有相关政策； c. 投资于规模扩大、协调进行的国家和 地方行动。 • 非国家实体（包括非政府组织、学术科 研机构、私营部门以及媒体和研究资助 机构）应： a. 提高对各年龄段增加身体活动和减少 久坐行为重要意义的认识； b. 鼓励并确保政策相互配合； c. 在政策实施和本地行动方面加强合作 和投资。 • 卫生部门和非卫生部门（包括体育、教育、 交通和规划）的从业人员应加强以下方面： a. 认识和了解身体活动和久坐行为的国 家指南； b. 推动提高身体活动水平和减少久坐行 为的知识、技能和信心； c. 将促进身体活动酌情纳入常规工作。 • 大众和特定亚群体应加强以下方面： a. 认识和了解身体活动和久坐行为指南； b. 了解如何落实身体活动和久坐行为 指南； c. 增加身体活动和减少久坐行为的意愿 和动力。 宣传活动 不同的利益攸关方受益于不同材料；因 此，为了向各类受众有效宣传指南，必须注 意指南传播的内容、格式和渠道。制定指南 传播战略时，形成性研究可以帮助确定关键 受众，了解影响身体活动量和久坐行为的价 值观、需求和偏好。应包括探讨妨碍身体 活动或妨碍将身体活动纳入政策和实践的因 素，以及对各个不同群体测试草拟宣传信息 和材料。这个过程可以帮助确定最终采纳的 关键信息以及适当的沟通格式和渠道。全面 的宣传战略应包括针对不同受众的各类宣传 方法。各国可能需要根据现有资源（人力和 财力）优先考虑特定群体。 针对公众或特定亚群体的身体活动宣传 工作是一种经济有效的干预措施(133)，受到 《2018-2030年促进身体活动全球行动计 划》(14)推荐。国家和国家以下各级的身体活 动宣传工作通常会确定一个总口号（例如“动 起来”或“多运动”），并推出一些设计元素或 角色，其中含有针对不同受众（例如幼儿、 青少年、成年人或老年人、不爱运动的人、 残疾人或慢性病患者）定制的信息。针对特 定人口群体定制的宣传信息和资源可能比通 70 71采纳、传播、实施和评估 用材料更有效。宣传活动应兼顾传统媒体渠 道（如电视、广播、广告牌、印刷资源）和 数字媒体渠道（网站、手机、APP）的覆盖 范围和效果。以各种形式提供国家指南信息 也很有用。例如，一种相对较新但日益普遍 的身体活动指南宣传方法是使用信息可视图 或动画短视频。世卫组织提供设计和实施此 类宣传活动的辅助材料(135)。 学术界和研究界可能会对科学报告感兴 趣，该报告详细介绍了指南所依据的流行病 学证据。但其他普通受众不太可能对基础研 究的具体细节感兴趣。政策制定者可能更喜 欢科学摘要，甚至是一份简短的简报文件。 其他受众，例如卫生保健和非卫生保健专业 人员，更可能喜欢其他不同类型的资源，例 如关于指南或关于如何将促进身体活动纳 入日常实践（例如卫生保健环境中的患者问 诊，或制定城市环境的建筑或交通计划）的 小册子或概况介绍。不同的专业人士需要根 据其职责量身定制的资源。特别是卫生保健 专业人员，可能会受益于能体现所服务的多 种人口群体的一整套资源。 政策和方案实施 仅仅依靠关于身体活动和久坐行为的国 家指南不可能提高民众身体活动水平，因此 应被视为政策和规划框架的一个组成部分。 国家指南必须向主要受众发放，并有长期国 家宣传战略支持，宣传战略能让民众更好地 认识和了解定期身体活动、减少久坐行为 的多重收益。然而，为了实现行为的长期改 变，这些行动必须得到政策支持，创造支 持性的环境让人们能够积极活动并鼓励人们 积极活动，同时增加人们在本地参与身体活 动的适当机会。政策和方案必须考虑并适应 当地卫生系统和有兴趣或有机会支持促进身 体活动的复杂多部门机构的情况。采取行动 时应遵循“全政府”的办法，让政策和多种行 动构成“体系”，通过各方面利益攸关方的参 与，在多个部门和多种环境中鼓励更多民众 参与身体活动。运用与长期宣传战略相配合 的“体系”方法，能确保身体活动的需求因有 效宣传增加后，同时向人们提供参与身体活 动的环境和机会。 72 73 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 世卫组织《2018-2030年促进身体活动 全球行动计划》设定2030年身体活动不足现 象减少15%的目标，并概述了20项建议政策 行动和干预措施(14)。其中包括建议所有国家 实施长期全国公共教育和提高认识活动，并 将身体活动辅导方案纳入初级和中级卫生保 健工作。其他建议包括为所有人口群体创造 适当的身体活动环境，包括步行、骑自行车 和轮式运动，以及在学校、工作场所、体育 俱乐部和体育场所提供更多身体活动机会和 方案。执行所有20项建议在短期内可能并非 所有国家都能实现，但应被视为一项长期目 标。为确定一套可以立刻着手的适当可行的 行动，世卫组织会员国应对现行政策和做法 进行情境分析。这样可以促进多部门协作， 有助于确定优势领域以及差距和机会，并可 作为制定或更新国家和国家以下各级计划的 基础。 世卫组织新指南支持扩大行动范围，涵 盖更多群体，如残疾人或慢性病患者，以及 孕妇和产后妇女。政策扶持的恰当方案执行 工作和做法应考虑社区需求以及群体和背景 的多样性。目前正在开发一些针对具体部门 的工具包，支持ACTIVE一揽子技术措施的 实施(135)；工具包将为各部门提供促进身 体活动的指导，例如在学校或初级卫生保健 层面的工作，或者改善步行和骑自行车的条 件。ACTIVE工具包以及世卫组织在各区域和 各国的其他资源将支持身体活动和久坐行为 指南的落实工作。 监测与评估 2010年以来，世卫组织《关于身体活动 有益健康的全球建议》一直被用作人口健康 监督监测的标准。更新指南中建议的修改将 对目前用于监督各国身体活动水平的监测系 统和评估工具产生一些影响。新指南的发布 将要求对现有工具和报告规程进行审查，以 便为今后根据新指南提交报告的调整和建议 提供参考。全球身体活动问卷和全球学生健 康调查等工具会接受审查，规程配合新指南 进行更新；2021年会向各国提供辅助指导 文件。 世卫组织的非传染性疾病国家能力调查 （CCS）是监测全球非传染性疾病政策执行 进展的主要工具，每两年进行一次。CCS利 用人口监测系统针对世卫组织关于身体活动 和久坐行为的指南所涵盖各个年龄组的身体 活动提出具体问题，2019年后还调查是否存 在国家身体活动指南的问题。世卫组织会员 国须上传文件证实其答复内容。2019年，世 卫组织194个会员国中，78国（40%）报告 已有身体活动指南(136)。对2019年CCS的回 复情况进行了详细的文件分析，发现在78个 有国家指南的会员国中只有三分之二的国家 （52/78）说明了国民身体活动量的要求； 其中，只有42个国家完全符合2010年世卫 组织《关于身体活动有益健康的全球建议》 (1)。2021年及以后调查的数据将提供更新指 南采纳情况的信息。 更新 这些指南将于10年后更新，除非借助设 备测量的方法评估身体活动方面的科学进步 以及关于久坐行为的科学研究快速发展引发 提前更新的要求。 72 73采纳、传播、实施和评估 74 75 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 1. 世界卫生组织。关于身体活动有益健康的全球建 议。日内瓦：世界卫生组织；2010年。 2. 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Copenhagen: World Health Organization (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies); 2015. 132. 世界卫生组织，联合国开发计划署。非传染性疾病 的预防与控制：投资案例指导说明。日内瓦：世界 卫生组织；2019年。 133. 世界卫生组织。应对非传染性疾病：预防和控制 非传染性疾病的“最合算措施”以及其它推荐干预措 施。日内瓦：世界卫生组织；2017年。 134. DiPietro L, Al-Ansari S, Biddle S, Borodulin K, Bull F, Buman M, et al. Advancing the global physical activity agenda: recommendations for future research by the 2020 WHO Physical Activity and Sedentary Behavior Guidelines Development Group. Int J Behav Nutr Phys Act. 2020;In press. 135. 世界卫生组织。ACTIVE：增加身体活动的技术工具 包。日内瓦：世界卫生组织；2018年。 136. 世界卫生组织。评估预防控制非传染性疾病的国家 能力：2019年全球调查报告。日内瓦：世界卫生组 织；2020年。 82 83 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 G lo be b as ed o n io at /S hu tt er st oc k, s ilh ou et te s ha pe s or ig in al ly b as ed o n Sh ut te rs to ck s ou rc es 82 83参考文献 84 85 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 世卫组织指导小组 指导小组由来自总部和各区域办事处的身体活动、青少年健康、老龄、残疾、心理健康、 预防受伤、癌症、妊娠和监测方面的专家组成。 Valentina Baltag（孕产妇、新生儿、儿童和青少年 卫生以及老龄化司——青少年卫生处） Maurice Bucagu（孕产妇、新生儿、儿童和青少年 卫生以及老龄化司——妊娠处） Fiona Bull（组长）（健康促进司——身体活动处） Alex Butchart（健康问题社会决定因素司——预防 伤害处） Neerja Chowdhary（非传染性疾病司——心理健 康/痴呆症处） Regina Guthold（孕产妇、新生儿、儿童和青少年 卫生以及老龄化司——青少年监测处） Riitta-Maija Hämäläinen（西太平洋区域办事处） Andre Ilbawi（非传染性疾病司——癌症处） Wasiq Khan（东地中海区域办事处） Lindsay Lee（非传染性疾病司——残疾处） Alana Officer（老龄化） Leanne Riley（非传染性疾病司——监测处） Gojka Roglic（非传染性疾病司——糖尿病处） Juana Willumsen（健康促进司——身体活动处） 指导小组草拟了指南范围和PI/ECO。他们对利益申报情况进行审核；起草、审查指南 并最后定稿。 指南制定的贡献者 附件1： 指南制定程序的管理 84 85附件1 指南制定小组（GDG） 指南制定小组成员来源广泛，有该领域相关专家、建议的最终用户和受建议影响的人士。 指南制定小组的成员有： Salih Saad Al-Ansari博士（提倡健康促 进和教育，通过身体活动和步行预防非传染性 疾病）；Stuart Biddle博士（身体活动与久坐 行为，以及行为改变）；Katja Borodulin博士 （孕妇和老年人的身体活动）；Matthew Buman 博士（慢性病患者的睡眠、久坐行为和身体活 动）；Greet Cardon博士（儿童和青少年身体 活动）；Catherine Carty女士（残疾人身体活 动）；Jean-Philippe Chaput博士（儿童和青少 年的睡眠、久坐行为和身体活动）；Sebastien Chastin博士（身体活动、久坐行为和健康、身体 活动和久坐行为的客观测量）；Paddy Dempsey 博士（成年人和残疾人的身体活动和久坐行 为）；Loretta DiPietro博士（孕妇和老年人的身 体活动）；Ulf Ekelund博士（久坐行为和身体活 动、儿童和青少年身体活动）；Joseph Firth博士 （身体活动与心理健康）；Christine Friedenreich 博士（慢性病患者的身体活动、身体活动与癌症 风险）；Leandro Garcia博士（成年人身体活 动与健康）；Muthoni Gichu博士（政策实施、 各国政府）；Russ Jago博士（儿童和青少年 身体活动）；Peter Katzmarzyk博士（身体活 动与久坐行为）；Estelle V. Lambert博士（身 体活动与肥胖症）；Michael Leitzmann博士 （慢性病患者的久坐行为和身体活动）；Karen Milton博士（将建议转化为实践）；Francisco B.Ortega博士（儿童和青少年身体活动、心理 健康和客观测量）；Chathuranga Ranasinghe 博士（在社区、工作和学校环境中促进身体活动与 健康）；Emmanuel Stamatakis博士（成年人的 身体活动和久坐行为以及多种健康结果）；Anne Tiedemann博士（老年人身体活动）；Richard Troiano博士（政策制定）；Hidde van der Ploeg 博士（成年人身体活动与久坐行为）；Vicky Wari 女士（政策实施——各国政府）；Roger Chou博士 （太平洋西北地区循证实践中心，俄勒冈健康与科学 大学医学系、医学信息学系与临床流行病学系教授） 任GRADE方法学家。GDG的更多详情参见附件2。 GDG第一次会议于2019年7月2日至4日召开，期间GDG确定了PI/ECO问题，审查了现有系统综 述，并确认了需要完成的更新工作。小组商定了涉及建议的决策程序以及第二次GDG会议将讨论的证据 力度。第二次会议于2020年2月11日至14日举行；会上审查了更新的证据，并以协商一致的方式商定最 终建议。 86 87 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 外部评审小组（ERG） 7名同行评审员选自GDG和指导小组推 荐的人员名单。他们提供包括方案实施在内 的相关专业知识，代表世卫组织所有六个区 域。ERG审查了指南草案，并就明确性和 执行问题向指导小组提供了反馈意见，这些 意见已酌情采纳。外部同行评审员未修改建 议。外部评审员名单见附件2。 利益申报 所有GDG成员和外部同行评审员均完成 并提交了世卫组织利益申报表，并在出席每 次GDG会议之前签署保密承诺书。指导小 组审查评估了提交的简历和利益申报表，并 进行了互联网和出版物搜索，检查是否存在 任何可能造成难堪局面的明显公众争议或利 益。所有提名的GDG成员的姓名和简历都 在世卫组织身体活动网页上公示，供公众咨 询，为期14天。未收到任何意见。如果需要 更多关于申报或利益冲突管理的指导，指导 小组会与合规、风险管理和道德操守办公室 的同事进行协商。如果认为有必要，被发现 有经济或非经济利益冲突者不得参与有利益 冲突的议题。整个过程都审查了利益冲突的 管理。如有必要，GDG成员每次会议前须更 新利益申报表，每次GDG会议开始时都要求 成员口头进行利益申报。GDG和外部同行评 审员的利益申报汇总见附件3。未发现利益 冲突。 同行评审 指南草案由GDG和指导小组确定的7名 外部同行评审员审查。请外部同行评审员就 明确性、证据呈现和执行情况等问题提出意 见；意见酌情采纳。外部同行评审员无法改 变GDG确定的建议内容。外部同行评审员名 单见附件2；利益申报表汇总见附件3。此外 还积极征求了世卫组织区域办事处的意见。 86 87附件1 指南制定小组 Salih Al-Ansari博士 家庭与社区医学副教授 健康促进中心创始人兼CEO 沙特阿拉伯利雅得 Stuart Biddle博士 南昆士兰大学弹性区域研究所卫生研究中心 运动生活方式研究组 身体活动与健康教授 澳大利亚Springfield Central Katja Borodulin博士 老龄研究所 芬兰赫尔辛基 Matthew Buman博士 亚利桑那州立大学健康解决方案学院 美国凤凰城 Greet Cardon博士 根特大学医学与卫生学学院运动与体育学系 比利时根特 Catherine Carty女士 UNESCO教席项目主管 特拉利理工学院 爱尔兰克里郡 Jean-Philippe Chaput博士 健康活跃生活与肥胖症（HALO）研究集团高 级科学家 东安大略儿童医院（CHEO）研究所 渥太华大学儿科系 加拿大渥太华 Sebastien Chastin博士 格拉斯哥卡里多尼亚大学 心理学、社会工作和联合健康学系卫生与生 命科学学院健康行为动力学教授 英国格拉斯哥 Roger Chou （GRADE方法学家）博士 俄勒冈健康与科学大学医学系、医学信息学 系与临床流行病学系 美国俄勒冈州波特兰 Paddy Dempsey博士 MRC流行病学部 剑桥大学临床医学学院 代谢科学研究所 英国剑桥 附件2： 指南制定小组、外部同行评审员以及 参与指南制定工作的世卫组织职员 88 89 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 Loretta DiPietro博士 Milken公共卫生学院运动与营养学系 乔治·华盛顿大学 美国华盛顿特区 Ulf Ekelund博士 挪威运动科学学院运动医学系 挪威奥斯陆 Joseph Firth博士 曼彻斯特大学卫生学院校长级研究员 英国曼彻斯特 Christine Friedenreich博士 阿省卫生服务局癌症控制部门 癌症流行病学和预防研究处科学主管 加拿大卡尔加里 Leandro Garcia博士 贝尔法斯特女王大学公共卫生中心助理研 究员 英国贝尔法斯特 Muthoni Gichu博士 卫生部非传染性疾病司老年医学处主管 肯尼亚内罗毕 Russell Jago博士 布里斯托大学政策研究学院运动、营养学与 保健科学中心 儿童身体活动与公共卫生教授 英国布里斯托 Peter T. Katzmarzyk博士 人口与公共卫生学副院长 潘宁顿生物医学研究中心Marie Edana Corcoran特聘儿童肥胖症与糖尿病教授 美国巴吞鲁日 Estelle V. Lambert博士 开普敦大学身体活动、生活方式和体育促进 健康研究中心主管 南非开普敦 Michael Leitzmann博士 雷根斯堡大学流行病学与预防医学系预防医 学教授 德国雷根斯堡 Karen Milton博士 东英吉利大学诺里奇医学院公共卫生副教授 英国诺里奇 Francisco B. Ortega博士 格拉纳达大学体育教育与运动系 运动与健康研究所（iMUDS）身体活动与健 康促进部负责人 西班牙格拉纳达 88 89附件2 Chathuranga Ranasinghe博士 斯里兰卡医学协会健康兰卡项目主席 科伦坡大学医学系体育与运动医学部高级讲师 斯里兰卡科伦坡 Emmanuel Stamatakis博士 悉尼大学公共卫生学院医学卫生系 Charles Perkins中心 澳大利亚悉尼 Anne Tiedemann博士 悉尼大学医学卫生系公共卫生学院肌骨健康研 究所副教授 澳大利亚悉尼 Richard Troiano博士 美国国立卫生研究院国立癌症研究所流行病学 和基因组学项目 美国罗克维尔 Hidde van der Ploeg博士 阿姆斯特丹大学医学中心阿姆斯特丹公共卫生 研究所公共卫生与职业健康系副教授 荷兰阿姆斯特丹 Vicky Wari女士* 国家卫生部非传染性疾病项目主管 巴布亚新几内亚莫尔兹比港 外部评审小组 Kingsley Akinroye博士 非传染性疾病联盟尼日利亚部 尼日利亚 Huda Alsiyabi博士 卫生部社区工作司主管 阿曼 Alberto Flórez-Pregonero博士 哈维里亚那天主教大学 哥伦比亚 Shigeru Inoue博士 东京医科大学预防医学与公共卫生系 日本 Agus Mahendra博士 教育大学体育系 印度尼西亚 Deborah Salvo博士 圣路易斯预防研究中心 华盛顿大学布朗学院 美国 Jasper Schipperijn博士 身体活动与健康国际学会2020-2022年当选 会长， 南丹麦大学运动科学与临床生物力学系 丹麦 *未能参加 90 91 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 世卫组织指导小组 Valentina Baltag博士 世卫组织总部孕产妇、新生 儿、儿童和青少年卫生以及老 龄化司 青少年与年青人健康处负责人 瑞士日内瓦 Maurice Bucagu博士 世卫组织总部孕产妇、新生 儿、儿童和青少年卫生以及老 龄化司 孕产妇健康处医学官员 瑞士日内瓦 Alexander Buchart博士 世卫组织总部健康问题社会决 定因素司 预防暴力处负责人 瑞士日内瓦 Fiona Bull博士 世卫组织总部健康促进司 身体活动处负责人 瑞士日内瓦 Regina Guthold博士 世卫组织总部孕产妇、新生 儿、儿童和青少年卫生以及老 龄化司 青少年与年青人健康处科学家 瑞士日内瓦 Riitta-Maija Hämäläinen博士 世卫组织西太平洋区域办事处 技术官员 非传染性疾病与健康促进 菲律宾马尼拉 Andre Ilbawi博士 世卫组织总部非传染性疾病司 技术官员 瑞士日内瓦 Wasiq Khan博士* 世卫组织东地中海区域办事处 地区顾问 健康教育与促进 埃及开罗 Lindsay Lee女士 世卫组织总部非传染性疾病司 感觉功能、残疾及康复处技 术官员 瑞士日内瓦 Alana Officer女士 世卫组织总部总干事办公室 健康老龄化处高级卫生顾问 瑞士日内瓦 Leanne Riley女士 世卫组织总部非传染性疾病司 监测处负责人 瑞士日内瓦 Gojka Roglic博士 世卫组织总部非传染性疾病司 非传染性疾病管理处医学官员 瑞士日内瓦 Juana Willumsen博士 世卫组织总部健康促进司 身体活动处技术官员 瑞士日内瓦 *未能参加 附件290 91 指南制定小组成员 姓名 性别 专业 利益披露 利益冲突和管理 Salih Saad Al- Ansari博士 男 倡导健康促进和教育， 利用身体活动和步行应 对非传染性疾病。 健康促进中心所有人兼 首席执行官 未发现利益冲突 Stuart Biddle博士 男 青少年身体活动 研究基金及有偿咨询 未发现利益冲突 Katja Borodulin博士 女 孕期身体活动 就职于国家卫生福利和 老龄研究所；研究基金 未发现利益冲突 Matthew Buman 博士 男 慢性病患者的睡眠和身 体活动 无相关利益 未发现利益冲突 Greet Cardon博士 女 青少年身体活动 无相关利益 未发现利益冲突 Catherine Carty 女士 女 残疾人身体活动 研究基金 未发现利益冲突 Jean-Philippe Chaput博士 男 睡眠 无相关利益 未发现利益冲突 Sebastien Chastin 博士 男 身体活动与健康，身体 活动的客观测量 研究基金 未发现利益冲突 Paddy Dempsey 博士 男 成年人及慢性病患者的 身体活动与久坐行为 就职以及研究基金 未发现利益冲突 Loretta DiPietro 博士 女 老年人身体活动 无相关利益 未发现利益冲突 Ulf Ekelund博士 男 青少年久坐行为与身 体活动 无相关利益 未发现利益冲突 Joseph Firth博士 男 身体活动与心理健康 无相关利益 未发现利益冲突 Christine Friedenreich博士 女 慢性病患者的身体活 动，身体活动与癌症 风险 无相关利益 未发现利益冲突 Leandro Garcia博士 男 身体活动与心理健康 就职以及有偿咨询 未发现利益冲突 Muthoni Gichu博士 女 政策实施（国家政府） 无相关利益 未发现利益冲突 Russ Jago博士 男 青少年身体活动 无相关利益 未发现利益冲突 附件3： 利益申报汇总及其管理方式 92 93 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 姓名 性别 专业 利益披露 利益冲突和管理 Peter Katzmarzyk 博士 男 青少年身体活动与久 坐行为 协助指南委员会的差 旅支持 未发现利益冲突 Estelle V. Lambert 博士 女 身体活动与肥胖症 无相关利益 未发现利益冲突 Michael Leitzmann 博士 男 久坐行为与慢性病 无相关利益 未发现利益冲突 Karen Milton博士 女 建议转化为实践 协助指南委员会的差 旅支持 未发现利益冲突 Francisco Ortega 博士 男 青少年身体活动、心理 健康与客观测量 无相关利益 未发现利益冲突 Chathuranga Ranasinghe博士 男 在社区、工作场所和校 园促进身体活动和健康 研究基金 未发现利益冲突 Emmanuel Stamatakis博士 男 成年人身体活动与多项 健康结果 用于客观测量身体活动 的技术公司资助 未发现利益冲突 Anne Tiedemann 博士 女 老年人身体活动与健 康结果 无相关利益 未发现利益冲突 Richard Troiano 博士 男 政策制定 无相关利益 未发现利益冲突 Hidde van der Ploeg博士 男 成年人身体活动、久坐 行为与健康结果 协助2017年荷兰身体 活动指南委员会的差旅 支持和研究基金 未发现利益冲突 Vicky Wari女士 女 政策实施（国家政府） 股份（与指南无关） 未发现利益冲突 外部同行评审员 姓名 性别 专业 利益披露 利益冲突和管理 Kingsley Akinroye 男 游说，非传染性疾病 无相关利益 未发现利益冲突 Huda Alsiyabi博士 女 政策与方案实施 无相关利益 未发现利益冲突 Alberto Flórez- Pregonero博士 男 身体活动与久坐行为的 测算与监控 无相关利益 未发现利益冲突 Shigeru Inoue博士 男 流行病学与促进身体 活动 无相关利益 未发现利益冲突 Agus Mahendra博士 男 儿童的身体活动与运 动技能 无相关利益 未发现利益冲突 Deborah Salvo博士 女 健康与社会不平等，尤 其侧重于慢性病预防 无相关利益 未发现利益冲突 Jasper Schipperijn 博士 男 身体活动与建筑环境 身体活动与健康国际学 会（ISPAH）当选会长 未发现利益冲突 92 93附件3 ISBN 978-92-4-003216-3I - - - 5-6

世卫组织关于身体活 动和久坐行为的指南

世卫组织关于身体活 动和久坐行为的指南 世卫组织关于身体活动和久坐行为的指南 [WHO guidelines on physical activity and sedentary behaviour] ISBN 978-92-4-003215-6（网络版） ISBN 978-92-4-003216-3（印刷版） © 世界卫生组织 2021年 保留部分版权。本作品可在知识共享署名——非商业性 使用——相同方式共享3.0政府间组织（CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo/deed.zh) 许可协议下使用。 根据该许可协议条款，可为非商业目的复制、重新分 发和改写本作品，但须按以下说明妥善引用。在对本作品 进行任何使用时，均不得暗示世卫组织认可任何特定组 织、产品或服务。不允许使用世卫组织的标识。如果改写 本作品，则必须根据相同或同等的知识共享许可协议对改 写后的作品发放许可。如果对本作品进行翻译，则应与建 议的引用格式一道添加下述免责声明：“本译文不由世界卫 生组织（世卫组织）翻译，世卫组织不对此译文的内容或 准确性负责。原始英文版本为应遵守的正本”。 与许可协议下出现的争端有关的任何调解应根据世界 知识产权组织调解规则进行（http://www.wipo.int/amc/en/ mediation/rules)。 建议的引用格式。世卫组织关于身体活动和久坐 行为的指南 [WHO guidelines on physical activity and sedentary behaviour]。日内瓦：世界卫生组织；2021年。 许可协议：CC BY-NC-SA 3.0 IGO。 在版编目（CIP）数据。在版编目数据可查阅http:// apps.who.int/iris 。 销售、版权和许可。购买世卫组织出版物，参见 http://apps.who.int/bookorders 。提交商业使用请求和查询 版权及许可情况，参见http://www.who.int/about/licensing 。 第三方材料。如果希望重新使用本作品中属于第 三方的材料，如表格、图形或图像等，应自行决定这 种重新使用是否需要获得许可，并相应从版权所有方 获取这一许可。因侵犯本作品中任何属于第三方所有 的内容而导致的索赔风险完全由使用者承担。 一般免责声明。本出版物采用的名称和陈述的材 料并不代表世卫组织对任何国家、领地、城市或地区 或其当局的合法地位，或关于边界或分界线的规定有 任何意见。地图上的虚线表示可能尚未完全达成一致 的大致边界线。 凡提及某些公司或某些制造商的产品时，并不意味 着它们已为世卫组织所认可或推荐，或比其它未提及的 同类公司或产品更好。除差错和疏忽外，凡专利产品名 称均冠以大写字母，以示区别。 世卫组织已采取一切合理的预防措施来核实本出 版物中包含的信息。但是，已出版材料的分发无任何 明确或含蓄的保证。解释和使用材料的责任取决于 读者。世卫组织对于因使用这些材料造成的损失不承 担责任。 设计：Eddy Hill Design Printed in Switzerland ii iii 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 目录 致谢 iv 缩略语 v 术语表 vi 概述 1 背景 15 方法 18 建议 24 儿童与青少年（5-17岁） 25 身体活动建议 25 久坐行为建议 29 成年人（18–64岁） 32 身体活动建议 32 久坐行为建议 38 老年人（65岁以上） 43 身体活动建议 43 久坐行为建议 46 孕妇和产后妇女 47 身体活动建议 47 久坐行为建议 51 患有慢性病的成年人和老年人 （18岁以上） 52 身体活动建议 52 久坐行为建议 58 残疾儿童和青少年（5–17岁） 以及残疾成年人（18岁以上） 60 身体活动建议 60 久坐行为建议 64 证据转化建议 66 证据质量评估 66 收益和危害 67 价值观和偏好 67 涉及资源问题 67 平等、可接受性和可行性 68 研究需求 69 采纳、传播、实施和评估 70 采纳 70 传播 71 宣传活动 71 策和方案实施 72 监测与评估 73 更新 73 参考文献 75 附件1：指南制定程序的管理 85 附件2：指南制定小组、外部同行评审员 以及参与指南制定工作的世卫组织职员 88 附件3：利益申报汇总及其管理方式 92 网络附件：证据简介 https://apps.who.int/iris/bitstream/handle/ 10665/336657/9789240015111-eng.pdf ii iii目录 致谢 世界卫生组织十分感谢以下个人和机构在指南制定过程中做出的贡献和帮助： Fiona Bull和Juana Willumsen领导指南制定程序。管理指南制定程序的世卫组织指导小组成员 有Valentina Baltag、Maurice Bucagu、Alex Butchart、Neerja Chowdhary、Regina Guthold、Riitta-Maija Hämäläinen、Andre Ilbawi、Wasiq Khan、Lindsay Lee、Alana Officer、Leanne Riley和Gojka Roglic。 指南制定小组（GDG）的成员有Salih Saad Al-Ansari、Stuart Biddle、Katja Borodulin、 Matthew  Buman、Greet Cardon（联合主席）、Catherine Carty、Jean-Philippe Chaput、Sebastien Chastin、Paddy Dempsey、Loretta DiPietro、Ulf Ekelund、Joseph Firth、Christine Friedenreich、 Leandro Garcia、Muthoni Gichu、Russ Jago、Peter Katzmarzyk、Estelle V. Lambert、Michael Leitzmann、Karen Milton、Francisco B. Ortega、Chathuranga Ranasinghe、Emmanuel Stamatakis（联合主席）、Anne Tiedemann、Richard Troiano、Hidde van der Ploeg、 Vicky Wari。Roger Chou任GRADE方法学家。外部审查小组成员有 Kingsley Akinroye、 Huda  Alsiyabi、Alberto Flórez-Pregonero、Shigeru Inoue、Agus Mahendra、Deborah Salvo和 Jasper Schipperijn。 对提交给美国卫生和公众服务部部长的《 2 0 1 8年美国身体活动指南顾问委员 会科学报告》所准备的证据再次进行了系统审查，为此要感谢 K y l e S p r o w（美国国 立卫生研究院下属美国国家癌症研究所，美国马里兰州）补充完成的文献搜索工 作。Elif Eroglu（悉尼大学）、Andrea Hillreiner（雷根斯堡大学）、Bo-Huei Huang（悉尼大学）、 Carmen Jochem（雷根斯堡大学）、Jairo H. Migueles（格拉纳达大学）、Chelsea Stone（卡尔加里 大学）和Léonie Uijtdewilligen（阿姆斯特丹大学医学中心）也提供了帮助，负责审查指定论文。 证据与GRADE表格的概述总结由Carrie Patnode和Michelle Henninger（凯撒基金会医院，健康 研究中心，美国俄勒冈州波特兰）完成。 负责补充完成证据审查的还有N Fairhall、J Oliveira、M Pinheiro、C Sherrington（肌肉骨骼健康 研究所，悉尼大学公共卫生学院，澳大利亚悉尼） 及A Bauman（悉尼大学公共卫生学院预防研究 合作项目，澳大利亚悉尼；及世卫组织身体活动、营养与肥胖症合作中心）；S  Mabweazara、M-J Laguette、K Larmuth、F Odunitan-Wayas（开普敦大学卫生科学系身体活动、生活方式和运动医 学健康研究中心，南非开普敦）、L Leach、S Onagbiye（西开普大学卫生科学系运动、娱乐 与训练学部，南非开普敦）、M Mthethwa（开普敦大学非洲慢性病倡议，南非开普敦）、 P Smith（开普敦大学卫生科学系传染病与分子医学研究所德斯蒙德·图图艾滋病中心，南非开普 敦）和F Mashili（穆希比利健康与联合科学大学生理学系，坦桑尼亚达累斯萨拉姆）；B Cillekens、 M Lang、W van Mechelen、E Verhagen、M Huysmans、A van der Beek、P Coenen （阿姆斯特丹大 学医学中心公共卫生与职业健康部，荷兰阿姆斯特丹）。 若非加拿大公共卫生署和挪威政府提供财政支持，本次工作难以完成。 iv v 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 ADHD 注意力缺陷多动障碍 AOR 校正比值比 BMI 身体质量指数 CI 置信区间 CVD 心血管疾病 DBP 舒张压 EtD 证据转化为决策 GDG 指南制定小组 GRADE 推荐分级的评估、制定与评价 HR 风险比 MET 代谢当量 MD 均数差 MICT 中等强度连续训练 NCD 非传染性疾病 OR 比值比 PA 身体活动 PAGAC 美国身体活动指南顾问委员会 PI/ECO 人群、干预/接触、比较和结果 RaR 相对特异危险度 RCT 随机对照试验 RR 相对危险度 SBP 收缩压 SMD 标准均数差 SPPB 简易体能状况量表 TV 电视 WHA 世界卫生大会 WHO 世界卫生组织 缩略语 iv v缩略语 术语 定义 有氧身体活动 人体大肌群有节奏持续运动的活动。有氧活动——又称耐力运动——可以改善 心肺功能健康。 例如散步、跑步、游泳和骑车。 无氧身体活动 无氧身体活动为短暂的剧烈运动，如举重和短跑，其氧气需求超过氧气供应。 平衡性训练 静态和动态练习，旨在提高自发运动、环境或其他物体引起姿势晃动或失稳刺 激时个人的应对能力。 身体质量指数 （BMI ） 体重（公斤）/身高（米）2 年龄别身体质 量指数或BMI 的Z值 根据年龄调整的BMI，针对儿童标准化。 BMI标准差值是根据儿童年龄和性别调整后的相对体重衡量标准。根据儿童 的年龄、性别、BMI和适当参考标准，可以确定BMI的Z值（或等值的年龄别 BMI百分位）。 增强骨骼的活动 主要目的为提高骨骼系统中特定部位强度的身体活动。增强骨骼的活动对骨骼 产生冲击力或张力，促进骨骼生长和强度。 增强骨骼的活动有跑步、跳绳和举重等。 心血管代谢健康 血压、血脂、血糖和胰岛素对健康的相互作用。 心肺健康 （耐力） 身体素质中与健康有关的组成部分。循环系统和呼吸系统在持续身体活动中的 供氧能力。 通常以测量或估计的最大摄氧量表示（VO2 max）。 认知功能 可获得信息和知识的大脑活动，如推理、记忆、注意力和语言。也包括学习。 残疾 根据《国际功能、残疾和健康分类》，残疾为损伤、活动受限以及参与限制的 总称，表示个人（疾病患者）与自己的背景因素（环境和个人因素）之间相互 的负面作用。 身体活动类型 身体活动水平可以按不同类型评估，包括以下一种或几种类型：休闲、职业、 教育、家庭和/或交通。 锻炼 身体活动的子类别之一，有计划、有安排、重复和有针对性，以改善或维持身 体健康的某一方面或多个方面为目标。“锻炼”和“运动训练”往往可以通用， 一般指利用闲暇时间、以改善或维持身体健康、体能或健康为主要目标的身体 活动。 执行功能 包括：工作记忆，认知弹性（又称灵活思维）和抑制控制（包括自我控制）。 身体素质 衡量人体在工作和休闲活动中高效有效运作能力的指标，包括身体素质和心肺 功能等。 柔韧性 身体素质中与健康和表现有关的部分，即各关节活动范围。各关节的柔韧性各 有不同，取决于一些特定变量，包括但不限于特定韧带和肌腱的紧密性。柔韧 性练习可以提高关节在全部活动范围内的运动能力。 功能性练习 可以融入日常任务中、提高下半身力量、平衡能力和运动能力的练习。例如串 联式和单腿站立，下蹲，椅式站立，小腿伸展，以及跨越障碍。 家务类身体活动 在家中为完成家务（如打扫卫生、照料儿童、园艺等）而进行的身体活动。 休闲类身体活动 个人自行决定从事、非日常生活必须的身体活动。这些活动包括参与体育运 动、身体素质锻炼或训练，以及诸如散步、跳舞和园艺等休闲活动。 术语表 vi vii 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 术语 定义 轻微强度身体 活动 轻微强度身体活动的代谢当量为1.5到3之间，也就是说，能量消耗不超过休息 时能量消耗的3倍。 此类活动包括慢走、洗澡或其他不会导致心率或呼吸频率大幅增加的偶然 活动。 主要肌肉群 主要肌肉群包括腿部、背部、腹部、胸部、肩部和手臂。 代谢当量 （MET） 某项任务的代谢当量，或简称为代谢当量，是表示身体活动强度的生理指标。 一个代谢当量等于一个人静坐时消耗的能量。 中等强度身体 活动 从绝对量级上看，中等强度指强度为休息的3倍至6倍以下的身体活动。从个 人能力的标准来看，按分值范围0-10分计算，中等强度身体活动通常为5分或 6分。 肌肉强化活动 增加骨骼肌力量、爆发力、耐力和质量的身体活动和练习（例如力量训练、抗 阻力训练或肌肉力量和耐力练习）。 多样化身体活动 对于老年人来说，多样化身体活动对于改善身体机能和减少跌倒或摔伤的风险 非常重要。这些活动可以在家里或在有组织的小组环境中进行。许多有计划的 干预措施将所有种类的运动（有氧运动、肌肉强化和平衡训练）结合到单次训 练中，已证实有效。例如，多样化身体活动方案可以包括步行（有氧活动）、 举重（肌肉强化），并结合平衡训练。平衡训练的例子包括倒退行走或侧身行 走或单脚站立，同时进行增强上身肌肉的活动，如肱二头肌弯举。舞蹈也结合 了有氧运动和平衡训练的内容。 职业类身体活动 参见工作类身体活动。 身体活动 任何由骨骼肌产生、需要消耗能量的身体运动。 身体活动不足 身体活动水平不足，无法达到当前身体活动建议水平。 社会心理健康 包括心理，情绪和社交方面的健康。 娱乐屏幕时间 除教育/学习或工作需要之外观看屏幕（电视、电脑、移动设备）的时间。 久坐屏幕时间 观看屏幕娱乐（电视、电脑、移动设备）的时间。不包括需要进行身体活动或 运动的活动类屏幕游戏。 久坐行为 任何清醒状态下坐、倚、卧的行为，能量消耗为1.5 MET 或更低。大多数办公 室案头工作、开车和看电视都属于久坐行为；定义也适用于无法站立者，比如 使用轮椅的人士。 指南让久坐行为的定义具有可操作性，包括自我报告的低运动量坐姿（休闲时 间、工作时间和总时间)、看电视（看电视或屏幕时间，以及评估运动或姿态 的设备测量到的低运动量）。 体育运动 体育运动涵盖了遵守特定规则、作为休闲或竞赛进行的各类活动。体育运动为 团队或个人开展的身体活动，可能有体育机构等体制框架的支持。 交通类身体活动 为往返各地而进行的身体活动，指行走、骑自行车和轮式运动（使用非机动的 带轮运动方式，例如滑板车、溜冰鞋、手动轮椅等）。 剧烈强度身体 活动 从绝对量级来看，剧烈强度指的是代谢当量6.0或更高的身体活动。从个人 能力的标准来看，按分值范围0-10分计算，剧烈强度身体活动通常为7分或 8分。 工作类身体活动 有偿或志愿工作时进行的身体活动。 vi vii术语表 《世卫组织关于身体活动和久坐行为的 指南》为儿童、青少年、成年人和老年人提 供基于证据的公共卫生建议，说明获得显著 健康收益和减轻健康风险所需的身体活动量 （频率、强度和持续时间）。首次就久坐行 为与健康结果之间的关系以及对孕妇和产后 妇女等亚群体、慢性病患者或残疾人的意义 提出了建议。 指南针对高收入、中等收入和低收入国 家卫生、教育、青少年、体育和/或社会家庭 福利相关政府部委的政策制定者；负责制定 国家、地区或市级计划、通过指导文件让各 类人群增加身体活动、减少久坐行为的政府 官员；非政府组织、教育行业、私营部门、 科研界从业人员；卫生保健提供者。 指南根据《世卫组织指南制定手册》编 写。针对关键重要结果进行了证据的系统综 述，考虑收益和危害、价值观、偏好、可行 性和接受度，以及对公平和资源的影响后形 成建议。 最终提出的公共卫生建议适用于5至65 岁及以上的所有人群和年龄段，不分性别、 文化背景或社会经济地位，无论个人能力如 何。有慢性病和/或残疾的人以及孕妇和产后 妇女应在条件允许的情况下根据自己的能力 努力完成建议要求。 制定指南的工作形成了一组基于证据的建 议，各国政府可以作为国家政策框架的一部分 采纳，支持采用综合方法提高民众身体活动水 平。采纳过程中应注意指南落实须因地制宜。 关于指南的采纳、传播、宣传活动和落实工 作，有实用工具可以支持各国政府和利益攸关 方共同努力，在生命全程增加身体活动，减少 久坐行为。指南发布后可在世卫组织网站获取 这些支持资源。 尽管有大量数据支持身体活动与整个生命 周期健康结果相关，以及越来越多证据支持久 坐行为与整个生命周期健康结果相关，但依然 存在重要证据空白。尤其是低收入和中等收入 国家以及贫穷社区或服务不足的社区的证据较 少，缺乏来自残疾人等亚群体的证据。需要有 更多科研投入专门积累这些方面的证据。此 外，建议的修改会对目前用于监督各国身体活 动水平的监测系统和评估工具产生影响。应审 查全球和各国的现有工具，更新报告规程，为 将来根据新指南提交报告提供参考。 《2018-2030年促进身体活动全球行 动计划》设定2030年身体活动不足现象减 少15%的目标，并概述了20项建议政策行 动和干预措施。这些指南帮助所有国家执行 GAPPA建议和使用“ACTIVE”，“ACTIVE”是 一套指导在整个生命周期和多种环境促进身体 活动的技术工具包。 概述 viii 1 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 建议： 一周㊥儿童和青少年应平均每天至少进行 60分钟的中等到剧烈强度的身体活动， 有氧运动为主。 强烈推荐，中等质量证据 每周至少应有3天进行剧烈强度有氧运动以 及增强肌肉和骨骼的运动。 强烈推荐，中等质量证据 • 少量身体活动优于不活动。 • 如果儿童和青少年未达到建议活动水平，少量身体活动有益健康。 • 儿童和青少年应从少量身体活动开始，逐渐增加频率、强度和持续时间。 • 应向所有儿童和青少年提供安全平等的机会并鼓励参与有趣、多样、适合其年龄 和能力的身体活动。 良 好 做 法 在儿童和青少年中，身体活动的收益体现于以 下健康结果：改善身体健康（心肺和肌肉健康）、 心血管代谢健康（血压、血脂异常、葡萄糖和胰岛素 抵抗）、骨骼健康、认知结果（学业成绩、执行功能）、 心理健康（抑郁症状减少）；以及肥胖症减轻。 儿童和青少年较多久坐行为与以下不良健康结果有关：更加肥胖；心脏 代谢健康、健康状况、行为品行/亲社会行为较差；以及睡眠时间减少。 建议： 儿童和青少年应该限制久坐时间， 尤其是屏幕娱乐时间。 强烈推荐，低质量证据 1 GRADE: 推荐分级的评估、制定与评价 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 引言 定期进行身体活动是预防和管理非传染性 疾病（NCDS）的关键保护因素，如心血管疾 病、2型糖尿病和部分癌症。身体活动还有利 于心理健康，包括预防认知功能降低和抑郁焦 虑的症状；并有助于维持健康体重和总体幸福 感。据全球估计，27.5%的成年人(1) 和81%的 青少年(2) 没有达到2010年世卫组织建议的身 体活动水平(3)，过去十年中几乎没有任何改 善。不平等现象也很明显：数据显示，大多数 国家，女童和妇女不如男童和男子活跃，经济 水平较高和较低的群体之间以及国家和区域之 间的身体活动水平差异很大。 范围 《世卫组织关于身体活动和久坐行为的指 南》为儿童、青少年、成年人和老年人提供基 于证据的公共卫生建议，说明获得显著健康收 益和减轻健康风险所需的身体活动量（频率、 强度和持续时间）。首次就久坐行为与健康 结果之间的关系以及对孕妇和产后妇女等亚群 体、慢性病患者或残疾人的意义提出了建议。 目标受众 指南针对高收入、中等收入和低收入国家 卫生、教育、青少年、体育和/或社会家庭福 利相关政府部委的政策制定者；负责制定国 家、地区或市级计划、通过指导文件让各类人 群增加身体活动、减少久坐行为的政府官员； 非政府组织、教育行业、私营部门、科研界从 业人员；卫生保健提供者。 指南制定过程 指 南 根 据 《 世 卫 组 织 指 南 制 定 手 册》(4) 编写。2019年成立了指南制定小 组（GDG），成员包括世卫组织所有六个区域 的技术专家和相关利益攸关方。小组于2019 年7月召开会议，确定关键问题，审查证据基 础，商定文献更新方法，以及必要时再做审查 的方法。2020年2月，GDG再次举行会议，审 查关键重要成果的证据，考虑收益和危害、价 值观、偏好、可行性和接受度，以及对公平和 资源的影响。这些建议在达成共识后制定，并 在网上征求公众意见。最终更新的建议摘要如 下。GRADE 1 表格和证据简介作为网络附件 提供。关于指南的采纳、传播、宣传活动和落 实工作，有实用工具可以支持各国政府和利益 攸关方共同努力，在生命全程增加身体活动， 减少久坐行为。 建议 《世卫组织关于身体活动和久坐行为的指 南》中提出的公共卫生建议适用于5至65岁及 以上的所有人群，不分性别、文化背景或社会 经济地位，无论个人能力如何。有慢性病和/ 或残疾的人以及孕妇和产后妇女应在条件允许 的情况下根据自己的能力努力完成建议要求。 儿童与青少年 (5–17岁) 限制 久 坐 不 动 的 时 间 ， 尤其是娱乐性的屏幕 前时间。 3 每星期至少 天 剧烈强度有氧运动， 那些增强肌肉和骨骼的活动 都应包括在内。 60 分钟 一星期每天至少 中等强度到剧烈强度活动， 主要是身体活动，大多数此类身 体活动应为有氧活动。 2 3 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议viii 1概述 建议： 成年人应该限制久坐时间。久坐时间改用 来进行各种强度的身体活动（包括轻微强 度）能带来健康收益。 强烈推荐，中等质量证据 为了帮助减少过多久坐行为对健康的不利 影响，成年人进行中等到剧烈强度身体活 动应力求超过建议水平。 强烈推荐，中等质量证据 建议： 所有成年人应定期进行身体活动。 强烈推荐，中等质量证据 成年人每周应该进行至少150- 300分钟的中等强度有氧活动； 或至少75-150分钟的剧烈强度 有氧活动；或者等量的中等强 度和剧烈强度组合活动，可以 获得巨大健康收益。 强烈推荐，中等质量证据 成年人 (18–64岁) 成年人（18–64岁） • 少量身体活动优于不活动。 • 如果成年人未达到建议活动水平，少量身体活动有益健康。 • 成年人应从少量身体活动开始，逐渐增加频率、强度和持续时间。良 好 做 法 成年人较多久坐行为与下列不良健康结果有关：全因死亡率、心血管疾 病死亡率和癌症死亡率以及心血管疾病、癌症和2型糖尿病发病率。 对于成年人来说，身体活动的收益体现在以下 健康结果：改善全因死亡率、心血管疾病死亡率、 新发高血压、新发位点特异性肿瘤 2、新发2型糖尿病、 心理健康（减少焦虑和抑郁症状）、认知健康和睡眠； 肥胖指数也能改善。 成年人可以将每周中等强度有氧活动 增加到300分钟以上；或进行150分钟 以上的剧烈强度有氧活动；或等量的 中等强度和剧烈强度组合活动，可获 得额外健康收益。 条件性推荐，中等质量证据 成年人还应进行中等强度或更高强 度的肌肉强化活动，锻炼所有主要 肌肉群，每周2天或2天以上，能带 来额外健康收益。 强烈推荐，中等质量证据 2 膀胱癌、乳腺癌、结肠癌、子宫内膜癌、食管腺癌、胃癌和肾癌等特定部位癌症。 中等或更高强度的 肌肉强化活动，涉 及所有主要肌群。 2 每星期至少 天 额外的健康福利： 150 300 150 75或者 中等强度有氧 身体活动 剧烈强度有氧身 体活动 （或一星期内的等量组合） 至少 到 分钟 至少 到 分钟 300 150 额外的健康福利： 或者 分钟以上 分钟以上 中等强度有氧 身体活动 剧烈强度有 氧身体活动 （或一星期内的等量组合） 限制 久坐不动时间 代之以 任何强度的身体活动 （包括轻微强度）。 4 5 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议 1 1 2 3 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 建议： 成年人应该限制久坐时间。久坐时间改用 来进行各种强度的身体活动（包括轻微强 度）能带来健康收益。 强烈推荐，中等质量证据 为了帮助减少过多久坐行为对健康的不利 影响，成年人进行中等到剧烈强度身体活 动应力求超过建议水平。 强烈推荐，中等质量证据 建议： 所有成年人应定期进行身体活动。 强烈推荐，中等质量证据 成年人每周应该进行至少150- 300分钟的中等强度有氧活动； 或至少75-150分钟的剧烈强度 有氧活动；或者等量的中等强 度和剧烈强度组合活动，可以 获得巨大健康收益。 强烈推荐，中等质量证据 成年人 (18–64岁) 成年人（18–64岁） • 少量身体活动优于不活动。 • 如果成年人未达到建议活动水平，少量身体活动有益健康。 • 成年人应从少量身体活动开始，逐渐增加频率、强度和持续时间。良 好 做 法 成年人较多久坐行为与下列不良健康结果有关：全因死亡率、心血管疾 病死亡率和癌症死亡率以及心血管疾病、癌症和2型糖尿病发病率。 对于成年人来说，身体活动的收益体现在以下 健康结果：改善全因死亡率、心血管疾病死亡率、 新发高血压、新发位点特异性肿瘤 2、新发2型糖尿病、 心理健康（减少焦虑和抑郁症状）、认知健康和睡眠； 肥胖指数也能改善。 成年人可以将每周中等强度有氧活动 增加到300分钟以上；或进行150分钟 以上的剧烈强度有氧活动；或等量的 中等强度和剧烈强度组合活动，可获 得额外健康收益。 条件性推荐，中等质量证据 成年人还应进行中等强度或更高强 度的肌肉强化活动，锻炼所有主要 肌肉群，每周2天或2天以上，能带 来额外健康收益。 强烈推荐，中等质量证据 2 膀胱癌、乳腺癌、结肠癌、子宫内膜癌、食管腺癌、胃癌和肾癌等特定部位癌症。 中等或更高强度的 肌肉强化活动，涉 及所有主要肌群。 2 每星期至少 天 额外的健康福利： 150 300 150 75或者 中等强度有氧 身体活动 剧烈强度有氧身 体活动 （或一星期内的等量组合） 至少 到 分钟 至少 到 分钟 300 150 额外的健康福利： 或者 分钟以上 分钟以上 中等强度有氧 身体活动 剧烈强度有 氧身体活动 （或一星期内的等量组合） 限制 久坐不动时间 代之以 任何强度的身体活动 （包括轻微强度）。 4 5 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议2 3概述 建议： 所有老年人应定期进行身体活动。 强烈推荐，中等质量证据 老年人应该每周进行至少 150-300分钟的中等强度有 氧活动；或至少75-150分钟 的剧烈强度有氧活动；或等 量的中等强度和剧烈强度组 合活动，可以获得巨大健康 收益。 强烈推荐，中等质量证据 老年人 (65岁以上) 老年人（65岁以上） • 少量身体活动优于不活动。 • 如果老年人未达到建议活动水平，少量身体活动有益健康。 • 老年人应从少量身体活动开始，逐渐增加频率、强度和持续时间。 • 老年人应该在自身功能性能力允许的范围内进行身体活动，并根据健康水平调整 身体活动强度。 良 好 做 法 老年人较多久坐行为与下列不良健康结果有关：全因死亡率、心血管疾 病死亡率和癌症死亡率、心血管疾病、癌症和2型糖尿病发病率。 建议： 老年人应该限制久坐时间。久坐时间改用 来进行各种强度的身体活动（包括轻微强 度）能带来健康收益。 强烈推荐，中等质量证据 为了帮助减少过多久坐行为对健康的不利 影响，老年人进行中等到剧烈强度身体活 动应力求超过建议水平。 强烈推荐，中等质量证据 对于老年人来说，身体活动的收益体现于以下 健康结果：改善全因死亡率、心血管疾病死亡率、新 发高血压、新发位点特异性肿瘤、新发2型糖尿病、心理 健康（焦虑和抑郁症状减少）、认知健康和睡眠；肥胖指数 也能改善。对于老年人，身体活动有助于预防跌倒和跌倒相关伤害以及 骨骼健康和功能性能力的衰退。 老年人可以将每周中等强度有氧活 动增加到300分钟以上；或者进行 150分钟以上的剧烈强度有氧活动； 或者等量的中等强度和剧烈强度组 合活动，可获得额外健康收益。 条件性推荐，中等质量证据 老年人还应进行中等强度或更高强 度的肌肉强化活动，锻炼所有主要 肌肉群，每周2天或2天以上，能带 来额外健康收益。 强烈推荐，中等质量证据 在每周身体活动中，老年人应该进 行多样化身体活动，侧重于中等 或更高强度的功能性平衡和力量训 练，每周3天或3天以上，以增强功 能性能力和防止跌倒。 强烈推荐，中等质量证据 150 300 150 75或者 中等强度有氧 身体活动 剧烈强度有氧身 体活动 （或一星期内的等量组合） 至少 到 分钟 至少 到 分钟 300 150 额外的健康福利： 或者 分钟以上 分钟以上 中等强度有氧 身体活动 剧烈强度有 氧身体活动 （或一星期内的等量组合） 2 中等或更高强度的肌肉强化活动，涉 及所有主要肌群。 每星期至少 天 额外的健康福利： 各种多成分身体活 动，强调中等或更 高强度的功能平衡 和力量训练。 3 每星期至少 天 额外的健康福利： 限制 久坐不动时间 代之以 任何强度的身体活动 （包括轻微强度）。 6 7 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议4 5 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 建议： 所有老年人应定期进行身体活动。 强烈推荐，中等质量证据 老年人应该每周进行至少 150-300分钟的中等强度有 氧活动；或至少75-150分钟 的剧烈强度有氧活动；或等 量的中等强度和剧烈强度组 合活动，可以获得巨大健康 收益。 强烈推荐，中等质量证据 老年人 (65岁以上) 老年人（65岁以上） • 少量身体活动优于不活动。 • 如果老年人未达到建议活动水平，少量身体活动有益健康。 • 老年人应从少量身体活动开始，逐渐增加频率、强度和持续时间。 • 老年人应该在自身功能性能力允许的范围内进行身体活动，并根据健康水平调整 身体活动强度。 良 好 做 法 老年人较多久坐行为与下列不良健康结果有关：全因死亡率、心血管疾 病死亡率和癌症死亡率、心血管疾病、癌症和2型糖尿病发病率。 建议： 老年人应该限制久坐时间。久坐时间改用 来进行各种强度的身体活动（包括轻微强 度）能带来健康收益。 强烈推荐，中等质量证据 为了帮助减少过多久坐行为对健康的不利 影响，老年人进行中等到剧烈强度身体活 动应力求超过建议水平。 强烈推荐，中等质量证据 对于老年人来说，身体活动的收益体现于以下 健康结果：改善全因死亡率、心血管疾病死亡率、新 发高血压、新发位点特异性肿瘤、新发2型糖尿病、心理 健康（焦虑和抑郁症状减少）、认知健康和睡眠；肥胖指数 也能改善。对于老年人，身体活动有助于预防跌倒和跌倒相关伤害以及 骨骼健康和功能性能力的衰退。 老年人可以将每周中等强度有氧活 动增加到300分钟以上；或者进行 150分钟以上的剧烈强度有氧活动； 或者等量的中等强度和剧烈强度组 合活动，可获得额外健康收益。 条件性推荐，中等质量证据 老年人还应进行中等强度或更高强 度的肌肉强化活动，锻炼所有主要 肌肉群，每周2天或2天以上，能带 来额外健康收益。 强烈推荐，中等质量证据 在每周身体活动中，老年人应该进 行多样化身体活动，侧重于中等 或更高强度的功能性平衡和力量训 练，每周3天或3天以上，以增强功 能性能力和防止跌倒。 强烈推荐，中等质量证据 150 300 150 75或者 中等强度有氧 身体活动 剧烈强度有氧身 体活动 （或一星期内的等量组合） 至少 到 分钟 至少 到 分钟 300 150 额外的健康福利： 或者 分钟以上 分钟以上 中等强度有氧 身体活动 剧烈强度有 氧身体活动 （或一星期内的等量组合） 2 中等或更高强度的肌肉强化活动，涉 及所有主要肌群。 每星期至少 天 额外的健康福利： 各种多成分身体活 动，强调中等或更 高强度的功能平衡 和力量训练。 3 每星期至少 天 额外的健康福利： 限制 久坐不动时间 代之以 任何强度的身体活动 （包括轻微强度）。 6 7 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议4 5概述 孕妇和产后妇女在孕期和产后的身体活动对母 婴健康有以下好处：先兆子痫、妊娠高血压、妊娠糖 尿病、妊娠期过度增重、分娩并发症和产后抑郁症的风 险降低，新生儿并发症减少，对出生体重无不良影响； 死产风险未见增加。 建议所有无禁忌证的孕妇和产后妇女： 整个孕期和产后应定期进行身体活动。 强烈推荐，中等质量证据 此外： 怀孕前习惯进行剧烈强度有氧运动的妇女，或者经常进行 身体活动的妇女，可以在怀孕和产后继续原有活动。 强烈推荐，中等质量证据 每周应该进行至少150分钟中等强度有氧 活动，可以获得巨大健康收益。 强烈推荐，中等质量证据 进行各种有氧和肌肉强化运动。增加轻 柔拉伸运动可能也有益处。 强烈推荐，中等质量证据 孕妇和产后妇女 孕妇和产后妇女 良 好 做 法 • 少量身体活动优于不 活动。 • 如 果 孕 妇 和 产 后 妇 女未达到建议活动水 平，少量身体活动有 益健康。 • 孕妇和产后妇女应从 少量身体活动开始， 逐渐增加频率、强度 和持续时间。 • 盆底肌肉训练可以每 天进行，减少尿失禁 风险。 • 气温过高时避免进行身 体活动，尤其是高湿度 环境下。 • 身体活动之前、期间和 之后饮水保持水分。 • 避 免 参 与 涉 及 身 体 接 触 、 跌 倒 风 险 大 或 可 能限制氧化作用的活动 （例如，平时不在高海 拔地区生活的人应避免 高海拔地区活动）。 • 孕早期过后避免仰卧位 活动。 • 若考虑参加体育比赛或运 动量远高于指南建议标准 时，孕妇应寻求专业卫生 保健人员监督。 • 卫 生 保 健 提 供 者 应 告 知 孕妇出现哪些危险信号时 须停止活动；或者出现此 类信号时限制身体活动并 立即咨询合格卫生保健提 供者。 • 分 娩 后 逐 渐 恢 复 身 体 活 动，剖腹产分娩应咨询卫 生保健提供者。 孕妇进行身体活动时的其他安全注意事项： 和所有成年人一样，孕妇和产后妇女较多久坐行为与下列不良健康结 果有关：全因死亡率、心血管疾病死亡率和癌症死亡率、心血管疾病、癌 症和2型糖尿病发病率。 建议： 孕妇和产后妇女应该限制久坐时间。 久坐时间改用来进行各种强度的身体活 动（包括轻微强度）能带来健康收益。 强烈推荐，低质量证据 身体活动强 于不活动。 150 中等强度有氧身体活动 分钟 每星期至少 限制 久坐不动时间 代之以 任何强度的身体活动 （包括轻微强度）。 8 9 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议6 7 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 孕妇和产后妇女在孕期和产后的身体活动对母 婴健康有以下好处：先兆子痫、妊娠高血压、妊娠糖 尿病、妊娠期过度增重、分娩并发症和产后抑郁症的风 险降低，新生儿并发症减少，对出生体重无不良影响； 死产风险未见增加。 建议所有无禁忌证的孕妇和产后妇女： 整个孕期和产后应定期进行身体活动。 强烈推荐，中等质量证据 此外： 怀孕前习惯进行剧烈强度有氧运动的妇女，或者经常进行 身体活动的妇女，可以在怀孕和产后继续原有活动。 强烈推荐，中等质量证据 每周应该进行至少150分钟中等强度有氧 活动，可以获得巨大健康收益。 强烈推荐，中等质量证据 进行各种有氧和肌肉强化运动。增加轻 柔拉伸运动可能也有益处。 强烈推荐，中等质量证据 孕妇和产后妇女 孕妇和产后妇女 良 好 做 法 • 少量身体活动优于不 活动。 • 如 果 孕 妇 和 产 后 妇 女未达到建议活动水 平，少量身体活动有 益健康。 • 孕妇和产后妇女应从 少量身体活动开始， 逐渐增加频率、强度 和持续时间。 • 盆底肌肉训练可以每 天进行，减少尿失禁 风险。 • 气温过高时避免进行身 体活动，尤其是高湿度 环境下。 • 身体活动之前、期间和 之后饮水保持水分。 • 避 免 参 与 涉 及 身 体 接 触 、 跌 倒 风 险 大 或 可 能限制氧化作用的活动 （例如，平时不在高海 拔地区生活的人应避免 高海拔地区活动）。 • 孕早期过后避免仰卧位 活动。 • 若考虑参加体育比赛或运 动量远高于指南建议标准 时，孕妇应寻求专业卫生 保健人员监督。 • 卫 生 保 健 提 供 者 应 告 知 孕妇出现哪些危险信号时 须停止活动；或者出现此 类信号时限制身体活动并 立即咨询合格卫生保健提 供者。 • 分 娩 后 逐 渐 恢 复 身 体 活 动，剖腹产分娩应咨询卫 生保健提供者。 孕妇进行身体活动时的其他安全注意事项： 和所有成年人一样，孕妇和产后妇女较多久坐行为与下列不良健康结 果有关：全因死亡率、心血管疾病死亡率和癌症死亡率、心血管疾病、癌 症和2型糖尿病发病率。 建议： 孕妇和产后妇女应该限制久坐时间。 久坐时间改用来进行各种强度的身体活 动（包括轻微强度）能带来健康收益。 强烈推荐，低质量证据 身体活动强 于不活动。 150 中等强度有氧身体活动 分钟 每星期至少 限制 久坐不动时间 代之以 任何强度的身体活动 （包括轻微强度）。 8 9 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议6 7概述 患有慢性病的成年人和老年人应限制久 坐时间。久坐时间改用来进行各种强度 的身体活动（包括轻微强度）能带来健 康收益。 强烈推荐，低质量证据 为了帮助减少过多久坐行为对健康的不 利影响，患有慢性病的成年人和老年人 进行中等到剧烈强度身体活动应力求超 过建议水平。 强烈推荐，低质量证据 癌症幸存者和患有高血压、2型糖尿病和艾滋病的成年人，建议： 患有此类慢性病的成年人和老年人每 周应该进行至少150-300分钟的中等 强度有氧活动；或至少75-150分钟的 剧烈强度有氧活动；或等量的中等强 度和剧烈强度组合活动，可以获得巨 大健康收益。 强烈推荐，中等质量证据 无禁忌证的情况下，患有此类慢性病 的成年人和老年人可以将每周中等强 度有氧活动增加到300分钟以上；或 进行150分钟以上的剧烈强度有氧活 动；或等量的中等强度和剧烈强度组 合活动，可获得额外健康收益。 条件性推荐，中等质量证据 在每周身体活动中，患有此类慢性病的老 年人应该进行多样化身体活动，侧重于中 等或更高强度的功能性平衡和力量训练， 每周3天或３天以上，以增强功能性能力和 防止跌倒。 强烈推荐，中等质量证据 患有此类慢性病的成年人和老年人还应进 行中等强度或更高强度的肌肉强化活动， 锻炼所有主要肌肉群，每周2天或2天以 上，能带来额外健康收益。 强烈推荐，中等质量证据 患有慢性病的成年人和老年人 (18岁以上) 患有慢性病的成年人和老年人（18岁以上） 身体活动可以为患有以下慢性病的成年人和老年 人带来健康益处：对癌症幸存者来说，身体活动可以改 善全因死亡率、肿瘤特异性死亡率、肿瘤复发或第二原 发肿瘤的风险；对高血压患者来说，身体活动可以改善心血 管疾病死亡率、病情进展、身体机能、与健康相关的生活质量； 对2型糖尿病患者来说，身体活动可以降低心血管疾病死亡率和病情进展指 标；对艾滋病患者来说，身体活动可以改善身体健康和心理健康（焦虑和抑郁 症状减少），对病情进展（CD4计数和病毒载量）或身体成分无不良影响。 良 好 做 法 • 如无法达到上述建议活动水平，患有 此类慢性病的成年人应根据自身能力 进行身体活动。 • 患有此类慢性病的成年人应从少量身 体活动开始，逐渐增加频率、强度和 持续时间 • 患有此类慢性病的成年人应咨询身 体活动专家或卫生保健专业人员， 听取建议，确定适合自身需求、能 力、功能受限/并发症、用药情况和 整体治疗方案的活动类型和活动量。 • 无禁忌症者进行不超过快走或日常 生活需要的轻微或中等强度身体活 动之前，一般无须通过体检。 包括癌症幸存者和高血压、2型糖尿病和艾滋病患者在内，成年人较多 久坐行为与以下不良健康结果有关：全因死亡率、心血管疾病死亡率和癌症 死亡率以及心血管疾病、癌症和2型糖尿病的发病率。 建议： 患有上述慢性病的所有成年人和老年人应定期进行身体活动。 强烈推荐，中等质量证据 300 150 额外的健康福利： 或者 分钟以上 分钟以上 中等强度有氧 身体活动 剧 烈 强 度 有 氧身体活动 （或一星期内的等量组合） 中等或更高强度的 肌肉强化活动，涉 及所有主要肌群。 2 每星期至少 天 额外的健康福利： 至少 到 分钟 150 300 75 150 或者 中等强度有氧 身体活动 剧烈强度有氧身 体活动 （或一星期内的等量组合） 至少 到 分钟 至少 到 分钟 限制 久坐不动时间 代之以 任何强度的身体活动 （包括轻微强度）。 各种多成分身体活 动，强调中等或更 高强度的功能平衡 和力量训练。 3 每星期至少 天 额外的健康福利： 10 11 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议8 9 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 患有慢性病的成年人和老年人应限制久 坐时间。久坐时间改用来进行各种强度 的身体活动（包括轻微强度）能带来健 康收益。 强烈推荐，低质量证据 为了帮助减少过多久坐行为对健康的不 利影响，患有慢性病的成年人和老年人 进行中等到剧烈强度身体活动应力求超 过建议水平。 强烈推荐，低质量证据 癌症幸存者和患有高血压、2型糖尿病和艾滋病的成年人，建议： 患有此类慢性病的成年人和老年人每 周应该进行至少150-300分钟的中等 强度有氧活动；或至少75-150分钟的 剧烈强度有氧活动；或等量的中等强 度和剧烈强度组合活动，可以获得巨 大健康收益。 强烈推荐，中等质量证据 无禁忌证的情况下，患有此类慢性病 的成年人和老年人可以将每周中等强 度有氧活动增加到300分钟以上；或 进行150分钟以上的剧烈强度有氧活 动；或等量的中等强度和剧烈强度组 合活动，可获得额外健康收益。 条件性推荐，中等质量证据 在每周身体活动中，患有此类慢性病的老 年人应该进行多样化身体活动，侧重于中 等或更高强度的功能性平衡和力量训练， 每周3天或３天以上，以增强功能性能力和 防止跌倒。 强烈推荐，中等质量证据 患有此类慢性病的成年人和老年人还应进 行中等强度或更高强度的肌肉强化活动， 锻炼所有主要肌肉群，每周2天或2天以 上，能带来额外健康收益。 强烈推荐，中等质量证据 患有慢性病的成年人和老年人 (18岁以上) 患有慢性病的成年人和老年人（18岁以上） 身体活动可以为患有以下慢性病的成年人和老年 人带来健康益处：对癌症幸存者来说，身体活动可以改 善全因死亡率、肿瘤特异性死亡率、肿瘤复发或第二原 发肿瘤的风险；对高血压患者来说，身体活动可以改善心血 管疾病死亡率、病情进展、身体机能、与健康相关的生活质量； 对2型糖尿病患者来说，身体活动可以降低心血管疾病死亡率和病情进展指 标；对艾滋病患者来说，身体活动可以改善身体健康和心理健康（焦虑和抑郁 症状减少），对病情进展（CD4计数和病毒载量）或身体成分无不良影响。 良 好 做 法 • 如无法达到上述建议活动水平，患有 此类慢性病的成年人应根据自身能力 进行身体活动。 • 患有此类慢性病的成年人应从少量身 体活动开始，逐渐增加频率、强度和 持续时间 • 患有此类慢性病的成年人应咨询身 体活动专家或卫生保健专业人员， 听取建议，确定适合自身需求、能 力、功能受限/并发症、用药情况和 整体治疗方案的活动类型和活动量。 • 无禁忌症者进行不超过快走或日常 生活需要的轻微或中等强度身体活 动之前，一般无须通过体检。 包括癌症幸存者和高血压、2型糖尿病和艾滋病患者在内，成年人较多 久坐行为与以下不良健康结果有关：全因死亡率、心血管疾病死亡率和癌症 死亡率以及心血管疾病、癌症和2型糖尿病的发病率。 建议： 患有上述慢性病的所有成年人和老年人应定期进行身体活动。 强烈推荐，中等质量证据 300 150 额外的健康福利： 或者 分钟以上 分钟以上 中等强度有氧 身体活动 剧 烈 强 度 有 氧身体活动 （或一星期内的等量组合） 中等或更高强度的 肌肉强化活动，涉 及所有主要肌群。 2 每星期至少 天 额外的健康福利： 至少 到 分钟 150 300 75 150 或者 中等强度有氧 身体活动 剧烈强度有氧身 体活动 （或一星期内的等量组合） 至少 到 分钟 至少 到 分钟 限制 久坐不动时间 代之以 任何强度的身体活动 （包括轻微强度）。 各种多成分身体活 动，强调中等或更 高强度的功能平衡 和力量训练。 3 每星期至少 天 额外的健康福利： 10 11 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议8 9概述 残疾儿童和青少年 (5–17岁) 残疾儿童和青少年（5–17岁） 之前章节介绍了身体活动对儿童和青少年的 健康收益，其中许多也适用于残疾儿童和青少年。 身体活动对残疾人健康结果的其他收益包括：因注意 力缺陷/多动障碍（ADHD）等疾病或障碍认知功能受损者 可以改善认知能力；智力障碍儿童的身体功能也能得到改善。 • 少量身体活动优于不活动。 • 如果残疾儿童和青少年未达到建议活动水平，少量身体活动有益健康。 • 残疾儿童和青少年应从少量身体活动开始，逐渐增加频率、强度和持续时间。 • 在适合当前活动水平、健康状况和身体机能的情况下，残疾儿童和青少年进行身 体活动不存在重大风险；而且健康收益超过风险。 • 残疾儿童和青少年应咨询卫生保健专业人员或其他身体活动和残疾专家，确定适 合他们的活动类型和活动量。 良 好 做 法 儿童和青少年较多久坐行为与以下不良健康结果有关：更加肥胖；心 脏代谢健康、健康状况、行为品行/亲社会行为较差；以及睡眠时间减少。 建议： 残疾儿童和青少年应该限制久坐时 间，尤其是屏幕娱乐时间。 强烈推荐，低质量证据 建议： 一周中，残疾儿童和青少年应该平 均每天至少进行60分钟中等到剧烈 强度身体活动，有氧活动为主。 强烈推荐，中等质量证据 每周至少应有3天进行剧烈强度有氧 运动以及增强肌肉和骨骼的运动。 强烈推荐，中等质量证据 身体活动强 于不活动。 从少量身体 活动开始。 3 剧烈强度有氧运动， 那些增强肌肉和骨骼的活动 都应包括在内。 每星期至少 天 60 中等强度到剧烈强度活动， 主要是身体活动，大多数此类身 体活动应为有氧活动。 分钟 一星期每天至少 限制 久 坐 不 动 的 时 间 ， 尤其是娱乐性的屏幕 前时间。 12 13 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议0 1 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 残疾儿童和青少年 (5–17岁) 残疾儿童和青少年（5–17岁） 之前章节介绍了身体活动对儿童和青少年的 健康收益，其中许多也适用于残疾儿童和青少年。 身体活动对残疾人健康结果的其他收益包括：因注意 力缺陷/多动障碍（ADHD）等疾病或障碍认知功能受损者 可以改善认知能力；智力障碍儿童的身体功能也能得到改善。 • 少量身体活动优于不活动。 • 如果残疾儿童和青少年未达到建议活动水平，少量身体活动有益健康。 • 残疾儿童和青少年应从少量身体活动开始，逐渐增加频率、强度和持续时间。 • 在适合当前活动水平、健康状况和身体机能的情况下，残疾儿童和青少年进行身 体活动不存在重大风险；而且健康收益超过风险。 • 残疾儿童和青少年应咨询卫生保健专业人员或其他身体活动和残疾专家，确定适 合他们的活动类型和活动量。 良 好 做 法 儿童和青少年较多久坐行为与以下不良健康结果有关：更加肥胖；心 脏代谢健康、健康状况、行为品行/亲社会行为较差；以及睡眠时间减少。 建议： 残疾儿童和青少年应该限制久坐时 间，尤其是屏幕娱乐时间。 强烈推荐，低质量证据 建议： 一周中，残疾儿童和青少年应该平 均每天至少进行60分钟中等到剧烈 强度身体活动，有氧活动为主。 强烈推荐，中等质量证据 每周至少应有3天进行剧烈强度有氧 运动以及增强肌肉和骨骼的运动。 强烈推荐，中等质量证据 身体活动强 于不活动。 从少量身体 活动开始。 3 剧烈强度有氧运动， 那些增强肌肉和骨骼的活动 都应包括在内。 每星期至少 天 60 中等强度到剧烈强度活动， 主要是身体活动，大多数此类身 体活动应为有氧活动。 分钟 一星期每天至少 限制 久 坐 不 动 的 时 间 ， 尤其是娱乐性的屏幕 前时间。 12 13 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议0 1概述 建议： 残疾成年人应限制久坐时间。久坐时间改 用来进行各种强度的身体活动（包括轻微 强度）能带来健康收益。 强烈推荐，低质量证据 为了帮助减少过多久坐行为对健康的不利 影响，残疾成年人进行中等到剧烈强度身 体活动应力求超过建议水平。 强烈推荐，低质量证据 建议： 所有残疾成年人应定期进行身体活动。 强烈推荐，中等质量证据 残 疾 成 年 人 每 周 应 该 进 行 至 少 150-300分钟的中等强度有氧活动； 或至少75-150分钟的剧烈强度有氧活 动；或等量的中等强度和剧烈强度组 合活动，可以获得巨大健康收益。 强烈推荐，中等质量证据 残疾成年人还应进行中等强度或 更高强度的肌肉强化活动，锻炼 所有主要肌肉群，每周2天或2天 以上，能带来额外健康收益。 强烈推荐，中等质量证据 之前章节介绍了身体活动对成年人的健康收益， 其中许多也适用于残疾成年人。身体活动对残疾人健 康结果的其他好处包括：对于患有多发性硬化症的成年 人——改善身体功能，在生理、心理和社会方面改善健康相 关生活质量；对于脊髓损伤的成年人——改善步行功能、肌肉力 量和上肢功能; 以及改善健康相关生活质量；对于因疾病或障碍认知功能受损 的患者，改善身体功能和认知（帕金森病患者和中风病史患者）；对认知有正 面作用；可改善生活质量（成年精神分裂症患者）；可改善身体功能（成年智 力障碍者）；以及提高生活质量（成年重度临床抑郁症患者）。 成年人较多久坐行为与以下不良健康结果有关：全因死亡率、心血管疾 病死亡率和癌症死亡率以及心血管疾病、癌症和2型糖尿病的发病率。 残疾成年人可以将每周中等强度 有氧活动增加到300分钟以上； 或进行150分钟以上的剧烈强度 有氧活动；或等量的中等强度和 剧烈强度组合活动，可获得额外 健康收益 条件性推荐，中等质量证据 在每周身体活动中，残疾老年人应该进行 多样化身体活动，侧重于中等或更高强度 的功能性平衡和力量训练，每周3天或3天 以上，以增强功能性能力和防止跌倒。 强烈推荐，中等质量证据 良 好 做 法 • 少量身体活动优于不活动。 • 如果残疾成年人未达到建议活动水 平，少量身体活动有益健康。 • 残疾成年人应从少量身体活动开始， 逐渐增加频率、强度和持续时间。 • 在适合当前活动水平、健康状况和身体机 能的情况下，残疾成年人进行身体活动不 存在重大风险；而且健康收益超过风险。 • 残疾成年人应咨询卫生保健专业人员或其 他身体活动和残疾专家，确定适合他们的 活动类型和活动量。 残疾成年人 (18岁以上) 残疾成年人（18岁以上） 限制 久坐不动时间 代之以 任何强度的身体活动 （包括轻微强度）。 300 150 额外的健康福利： 或者 分钟以上 分钟以上 中等强度有氧 身体活动 剧 烈 强 度 有 氧身体活动 （或一星期内的等量组合） 各 种 多 成 分 身 体 活 动，强调中等或更高 强度的功能平衡和力 量训练。 3 每星期至少 天 额外的健康福利： 150 300 150 中等强度有氧 身体活动 剧烈强度有氧身 体活动 （或一星期内的等量组合） 75 至少 到 分钟 至少 到 分钟 或者 中等或更高强度的肌 肉强化活动，涉及所 有主要肌群。 2 每星期至少 天 额外的健康福利： 14 15 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议2 3 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 建议： 残疾成年人应限制久坐时间。久坐时间改 用来进行各种强度的身体活动（包括轻微 强度）能带来健康收益。 强烈推荐，低质量证据 为了帮助减少过多久坐行为对健康的不利 影响，残疾成年人进行中等到剧烈强度身 体活动应力求超过建议水平。 强烈推荐，低质量证据 建议： 所有残疾成年人应定期进行身体活动。 强烈推荐，中等质量证据 残 疾 成 年 人 每 周 应 该 进 行 至 少 150-300分钟的中等强度有氧活动； 或至少75-150分钟的剧烈强度有氧活 动；或等量的中等强度和剧烈强度组 合活动，可以获得巨大健康收益。 强烈推荐，中等质量证据 残疾成年人还应进行中等强度或 更高强度的肌肉强化活动，锻炼 所有主要肌肉群，每周2天或2天 以上，能带来额外健康收益。 强烈推荐，中等质量证据 之前章节介绍了身体活动对成年人的健康收益， 其中许多也适用于残疾成年人。身体活动对残疾人健 康结果的其他好处包括：对于患有多发性硬化症的成年 人——改善身体功能，在生理、心理和社会方面改善健康相 关生活质量；对于脊髓损伤的成年人——改善步行功能、肌肉力 量和上肢功能; 以及改善健康相关生活质量；对于因疾病或障碍认知功能受损 的患者，改善身体功能和认知（帕金森病患者和中风病史患者）；对认知有正 面作用；可改善生活质量（成年精神分裂症患者）；可改善身体功能（成年智 力障碍者）；以及提高生活质量（成年重度临床抑郁症患者）。 成年人较多久坐行为与以下不良健康结果有关：全因死亡率、心血管疾 病死亡率和癌症死亡率以及心血管疾病、癌症和2型糖尿病的发病率。 残疾成年人可以将每周中等强度 有氧活动增加到300分钟以上； 或进行150分钟以上的剧烈强度 有氧活动；或等量的中等强度和 剧烈强度组合活动，可获得额外 健康收益 条件性推荐，中等质量证据 在每周身体活动中，残疾老年人应该进行 多样化身体活动，侧重于中等或更高强度 的功能性平衡和力量训练，每周3天或3天 以上，以增强功能性能力和防止跌倒。 强烈推荐，中等质量证据 良 好 做 法 • 少量身体活动优于不活动。 • 如果残疾成年人未达到建议活动水 平，少量身体活动有益健康。 • 残疾成年人应从少量身体活动开始， 逐渐增加频率、强度和持续时间。 • 在适合当前活动水平、健康状况和身体机 能的情况下，残疾成年人进行身体活动不 存在重大风险；而且健康收益超过风险。 • 残疾成年人应咨询卫生保健专业人员或其 他身体活动和残疾专家，确定适合他们的 活动类型和活动量。 残疾成年人 (18岁以上) 残疾成年人（18岁以上） 限制 久坐不动时间 代之以 任何强度的身体活动 （包括轻微强度）。 300 150 额外的健康福利： 或者 分钟以上 分钟以上 中等强度有氧 身体活动 剧 烈 强 度 有 氧身体活动 （或一星期内的等量组合） 各 种 多 成 分 身 体 活 动，强调中等或更高 强度的功能平衡和力 量训练。 3 每星期至少 天 额外的健康福利： 150 300 150 中等强度有氧 身体活动 剧烈强度有氧身 体活动 （或一星期内的等量组合） 75 至少 到 分钟 至少 到 分钟 或者 中等或更高强度的肌 肉强化活动，涉及所 有主要肌群。 2 每星期至少 天 额外的健康福利： 14 15 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 : 简 述 建议2 3概述 14 15 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 定期进行身体活动是预防和管理心血管 疾病、2型糖尿病、乳腺癌和结肠癌等非传 染性疾病的一个已知保护因素(1–3)。身体 活动对心理健康(4)也有好处，延缓痴呆症发 病(5)，还有利于维持健康体重(1)和总体幸福 感(6)。 身体活动的定义是任何由骨骼肌产生、 需要消耗能量的身体运动(1)，可以作为工 作、家务、交通或休闲的一部分，或参加锻 炼或体育活动时进行，有各种强度。久坐行 为属于低强度，定义是任何清醒状态下坐、 倚或卧的行为，能量消耗低(7)。新出现的证 据表明，大量久坐行为与心血管疾病、2型糖 尿病以及心血管病、癌症和全因死亡率(8–10) 相关。 身体活动不足的定义是未能达到2010 年《关于身体活动有益健康的全球建议》 ( 1 )的要求，这是全球死亡率的主要原因 之一。据估计，如果全球民众参加更多身 体活动，每年可以有400万至500万人免于 死亡(2, 11)。全球对于身体活动不足的估测 表明，2016年，27.5%的成年人(12)和81% 的青少年(13)未达到 2010年世卫组织建议 标准(1)，趋势数据显示，过去十年来全球进 步有限。数据还突出表明，大多数国家女性 身体活动少于男性，在身体活动水平方面各 国各地区之间以及各国各地区内部都存在巨 大差异。这些差异的原因可能是体育锻炼机 会的不平等，这又进一步加剧了健康方面的 不平等。 目前对久坐行为尚无全球估测数据，但 由于技术革新，职业和娱乐越来越趋向久 坐，以及越来越多地使用个人机动交通工 具，世界各地的身体活动模式发生变化，久 坐行为增加。《2018-2030年促进身体活动 全球行动计划》(14)设立4项战略目标以及20 项政策行动，到2030年实现全球成人和青少 年身体活动不足的比例相对减少15%。 2010年，世卫组织发布《关于身体活动 有益健康的全球建议》(1)，第一部按人群分 类，针对儿童和青少年、成年人和老年人的 公共卫生指南。2018年，世界卫生大会在 WHA71.6号决议1中呼吁世卫组织更新2010年 的建议。 2019年，世卫组织发布《5岁以下儿童 身体活动、久坐行为及睡眠指南》(15)。指南 在终止儿童肥胖委员会（建议4.12）(16)的呼 吁下出台，弥补2010年《关于身体活动有益 健康的全球建议》(1)未涉及这一低年龄段的 问题。 2020年《世卫组织关于身体活动和久坐 行为的指南》取代2010年指南，以特定行为 及相关健康后果的最新证据为基础。这些建 议将成为关于身体活动和久坐行为的整体全 球建议的一部分。 背景 1 WHA71.6《世卫组织2018-2030年促进身体活动全球行动计划》。 14 15背景 世卫组织的其他关键指南 世卫组织其他指南也认可身体活动的重 要意义。世卫组织的《在资源短缺的设施中 提供初级卫生保健的非传染性疾病必要干预 措施一揽子计划》(17)提供了高血压、2型糖 尿病、心血管风险增加、哮喘和慢性阻塞性 肺病的临床管理规程，根据2010年全球建议 给出咨询意见，逐步将身体活动增加到中等 水平（如快走），每周至少活动150分钟。最 近世卫组织《关于降低认知衰退和痴呆症风 险的指南》(18)指出，应该向认知能力正常的 成年人（强烈推荐）和有轻度认知障碍的成 年人（条件性推荐）推荐身体活动，减少认 知能力下降的风险。世卫组织在《老年人综 合护理规划：管理内在能力衰退的社区一级 干预措施指南》(19)中建议活动能力下降的老 年人从事多样化运动防止跌倒。《世卫组织 关于产前保健促进积极妊娠经历的建议》(20) 推荐辅导健康饮食和孕期身体活动，保持健 康并防止体重过度增加，但未提及孕期和产 后进行身体活动更广泛的健康收益。 世卫组织现有指南与这些更新指南相结 合，为身体活动和久坐行为对预防和管理主 要疾病以及促进生命全程健康福祉的影响提 供了一套日益全面的全球指导文件。 理论基础和目的 过去10年里，关于不同类型的身体活 动、活动量和活动持续时间对健康的影响， 以及久坐行为的后果及其与身体活动水平和 健康的相互关系，这些方面的证据显著增 加。此外，关于孕妇、慢性病患者和（或） 残疾人等亚群体身体活动的证据基础现在可 用于审查这些群体的身体活动与健康结果之 间的关系。 《2018-2030年促进身体活动全球行动 计划》(14)的行动4.1呼吁世卫组织制定和传播 关于5岁以下儿童、年轻人、成年人、老年人 和孕妇、慢性病患者和残疾人等特定亚群体 身体活动和久坐行为的全球建议。按照世界 卫生大会的要求，更新和扩大指南范围，确 保向2010年建议未涵盖的人口群体提供关于 身体活动的具体建议。这与全球身体活动行 动计划的主要原则和目标相一致，即减少不 平等现象，支持全民加强日常身体活动。 这些指南的首要目的是提供基于证据的 公共卫生建议，说明儿童和青少年、成年 人、老年人以及孕妇、慢性病患者或残疾人 等亚群体获得显著健康收益和减轻健康风险 所需的身体活动量和活动类型。该指南还针 对久坐行为与健康结果之间的关系提供了循 证建议。 指 南 为 儿 童 和 青 少 年 （5至 1 7岁）、成年人 （18至64岁）、老年人 （65岁及以上）制定， 并首次针对孕妇、慢性 病患者或残疾人等亚群 16 17 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 体的身体活动提出具体建议。针对每个特定 年龄组和亚群体分别提出建议，让那些为特 定社区工作的人能够轻松获得相关信息。为 亚群体，特别是慢性病患者或残疾人单独提 出建议，强调必须将这些亚群体纳入身体活 动和久坐行为干预措施的政策和规划。 这些指南并未将睡眠视为一种行为。睡 眠是关系到健康的重要问题，也是人口健康 学的一个新兴课题。然而，在最新建议中涵 盖睡眠被视为超出授权范围。尽管如此，睡 眠的重要性已得到承认，在考虑身体活动和 久坐行为的影响时，睡眠被列为重要健康 结果。 目标受众 本文件报告制定建议的过程，并概述审 查的证据基础。主要受众是： 1. 高收入和中低收入国家卫生、教育、青少 年、体育和/或社会家庭福利相关政府部 委、负责编制本国指南、规划生命全程的 卫生、教育、工作场所、住宅或社区干预 方案的政策制定者。 2. 负责制定国家、地区或市级计划、通过指 导文件让各类人群增加身体活动、减少久 坐行为的政府官员。 3. 非政府组织、教育和工作场所组织以及科 研界的从业人员； 4. 在卫生服务机构工作的人员和提供咨询指 导的人员，如社区、家庭、初级或三级护 士或医生，或在卫生部门以外工作的相关 卫生和运动专业人员。如果没有国家指导 文件，他们在提出涉及此类主题的建议时 可以参考这些指南。 向卫生保健工作者、身体活动专家和教 育专业人员提供的职前培训和专业进修课 程应参考指南中关于身体活动和久坐行为的 建议。 需要由衍生产品将这些指南传达给特定 最终用户、卫生部门以外的利益攸关方以及 更广泛的社区，这些产品可利用量身定制的 宣传方法满足各类受众的具体需求。 16 17背景 指南根据《世卫组织指南制定手册》 （第2版）(21)编写。在健康促进司领导下成 立了世卫组织指导小组，由世卫组织各区域 办事处和世卫组织相关部门派代表参加。由 27名专家和利益攸关方组成了指南制定小组 （GDG），成员构成考虑了性别平衡和地域 多样性。指南草案由7名独立评审员进行外部 评审，他们对科学证据、证据解读和内容给 予了反馈。此外还就指南草案进行了一次网 上公众咨询，收到了400多名参与者的反馈意 见。这些科学家、从业人员和公众的意见经 过整理后，被GDG用于指南定稿。指南制定 过程管理的详情参见附件1。 指南范围和相关问题 GDG审议指南范围，在第一次会议上 商定了最为相关的PI/ECO（人群、干预/接 触、比较、结果）问题。针对各亚群体提出 的关键问题概述如下： 身体活动： a. 身体活动与健康相关结果之间有何关联？ b. 是否存在剂量-反应关系（量、持续时 间、频率、强度）？ c. 这种关联是否因身体活动的种类或类型而 异？ 久坐行为： a. 久坐行为与健康相关结果之间有何关联？ b. 是否存在剂量-反应关系（总量、频率、 中断持续时间和强度）？ c. 这种关联是否因久坐行为的种类或类型而 异？ d. 仅针对成年人：身体活动是否会修正久坐 行为对死亡率的影响？ 对于每类人群(P)，接触(E)指身体活动 量、持续时间、频率或强度较多的情况；作 为比较(C)指无身体活动或身体活动量、频 率、强度或持续时间较少。各群体的关键和 重要结果概述见表1，各PI/ECO问题的细节参 见《网络附件：证据简介》 的相关章节。 方法 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 18 19 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 表1：各人群关键和重要*健康结果概述 结果（按字母顺序） 5-17岁儿童与 青少年：身体 活动和久坐 18–64岁成年 人：身体活动 18岁以上成年 人：久坐 65岁以上成 年人：身体 活动a 孕妇和产后 妇女 慢性病 b 残疾儿童和 成年人c 肥胖症（体重增加、体重变 化、体重控制、体重稳定、体 重状态和体重维持） 关键 关键 关键 关键 a 关键 关键 – HIV – 不良事件 关键 关键 – 关键a 关键（胎儿结局） – – 全因和特定病因 死亡率 – 关键（癌症和 心血管疾病 特定） 关键 关键a – 关键 – 骨骼健康 关键 – 重要 – – – – 心血管代谢健康 关键 – – – – – – 认知结果 关键 关键 重要 关键a – – 关键 – MS、PD、 Stk、Sch、 ADHD 分娩并发症 – – – – 重要 – – 病情进展 – – – – – 关键 – HT、T2D、 HIV，关键 – 癌症复发 – 跌倒及相关伤害 – – – 关键 – – – 胎儿结局（出生体重，早产） – – – – 关键 – – 功能性能力 – – – 关键 – – – 妊娠糖尿病 – – – – 关键 – – 妊娠高血压/ 先兆子痫 – – – – 关键 – – 健康相关生活质量 – 重要 重要 重要a – 关键 – HT、 T2D、HIV 关键 – MS、 SCI、ID、 MCD、Sch 癌症发病率 – 关键 关键 关键a – – – CVD发病率 – 关键 关键 关键a – – – 高血压发病率 – 重要 – 重要a – – – 2型糖尿病发病率 – 关键 关键 关键a – – – 心理健康（焦虑和抑郁症状） 关键 关键 重要 关键a 关键 – – 骨质疏松症 – – – 关键 – – – 身体健康 关键 – 重要 – – – – 身体功能 – – 重要 – – 关键 – HT、 T2D、HIV 关键 – MS、 SCI、ID、 PD、Stk 亲社会行为 重要 – – – – – – 社会心理结果 – – – 重要 – – – 共病风险 – – – – – 关键 – HT、 T2D、HIV 关键 – MS、 SCI、ID 睡眠 重要 重要 重要 重要a – – – * 关键结果：对于决策具有关键意义的结果；重要结果：重要但对于决策不具有关键意义的结果。 a 针对包括老年人在内的成年人的关键和重要结果。 b 结果针对所列亚群体病情：癌症 – 癌症幸存者；HT – 高血压；T2D – 2型糖尿病；HIV。 c 结果针对所列亚群体病情：MS – 肌肉硬化症；SCI – 脊髓损伤；ID – 智力障碍；PD – 帕金森氏症；Stk – 中风幸 存者；Sch – 精神分裂症；ADHD – 注意力缺陷/多动障碍；MCD – 重度临床抑郁症。考虑了各年龄段群体的关键和 重要结果并加以类推。 关键 – MS、 SCI、ID 18 19方法 证据 修订2010年世卫组织身体活动建议的方 法是确定并随后更新涉及这些指南范围的最新 相关伞状综述。 之所以采用这种方法，是因为最近多个国 家为制定身体活动指南提供参考而进行了大量 系统综述。进行额外更新的目的是确保世卫组 织的新指南能反映这个迅速发展的公共卫生领 域涌现的最新数据。 中选的伞状综述均符合以下三个标准：i) 证据综述根据有充分文件记录的标准系统程 序进行；ii)使用推荐分级的评估、制定与评价 （GRADE）方法或有明确说明和记录的等效 方法评估证据质量；iii)证据综述针对相关人群 进行，对国家或国家收入水平没有任何限制。 PI/ECO问题以及关键和重要健康结果与 现有证据综述进行了对比，并在必要时委托进 行新的综述填补空白。GDG要求更新证据综 述，使用与原始综述相同的搜索词、搜索语言 和数据库。 以下证据审查确认符合上述三项标准， 因时效性和全面性而中选： • 作为制定《加拿大儿童和青少年24小时运动 指南》(23)的一个环节，Poitras等（2016） 对学龄儿童和青少年身体活动与健康指标之 间关联的文献进行了系统综述(22)。该综述 仅关注使用客观方法测量身体活动的研究。 共包含162项研究，涵盖31个国家的204 171 名参与者。 • 作为制定《加拿大儿童和青少年24小时 运动指南》(23)的一个环节，Carson等 （2016）(24)对学龄儿童久坐行为与健康指 标之间关联的文献进行了系统综述。共包含 235项研究（194个独特样本），涵盖71个国 家的1 657 064名独特参与者。 • 作为制定《2019年澳大利亚儿童和青少年 （5-17岁）24小时运动指南》(26)的一个 环节，Okely等（2019）(25)为更新Poitras 等（2016）(22)和Carson等（2018）(24) 进行的系统综述。该报告确定了截至2018 年7月发表的另外42项关于身体活动的研 究和32项关于久坐行为的研究(25)。Okely 等制定的GRADE表被用作世卫组织委托更 新工作的基础。GRADE表和证据简介见 《网络附件：证据简介》 。 • 作为制定《2019年加拿大孕期身体活动指 南》(27)的一个环节，完成并综合了12项系 统综述。这12篇综述评估了超过25 000篇关 于孕妇孕期身体活动的相关研究，研究使用 语言有英语、西班牙语和法语，这些研究报 告了孕妇、胎儿或新生儿发病率或胎儿死亡 率的结果。其中七项系统综述涉及到GDG视 为关键重要的结果(28–34)。这些证据综述 的GRADE表被用作文献检索的基础，为世 卫组织的建议制定工作提供更新和参考。更 新证据简介见《网络附件：证据简介》 。 • 身体活动指南顾问委员会（PAGAC）(35) 的科学报告对2008-2016年发表的关于身 体活动和久坐行为及健康结果的证据进行 了系统更新，作为2018年《美国人身体活 动指南第2版》(36)制定工作的部分环节。 所总结的证据共涉及38个主要研究问题和 104个根据公共卫生相关性选定的子问题。 证据包括系统综述的结果，共由1130篇文章 组成，对每篇提取摘要回答38个研究问题 (35)。规程使用修改后的“评估系统综述的 测量工具”（AMSTARExBP）来评估系统综 述和荟萃分析的方法学质量。使用美国农业 部NEL偏倚评估工具（BAT）的改编版对每 项原始研究进行偏倚风险或内部有效性评 估(37)。针对这些世卫组织指南进行的最新 搜索中发现的新证据载于证据简介，参见 《网络附件：证据简介》 ；提供PAGAC 报告和补充材料链接(35)。 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 20 21 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 更新证据和提取数据的方法 对所含每项综述（上文所列）最近一次搜 索的日期至2019年9月这段时间发表的所有研 究进行了系统综述和队列研究汇总分析搜索； 制定并采用标准化的数据提取规程。 为了更新 P o i t r a s 等 （ 2 0 1 6 年） ( 2 2 )， C a r s o n 等（ 2 0 1 6 年） ( 2 4 )和 Oke l y等（20 1 9年）(25 )进行的搜索， 对MEDL INE，EMBASE，Psyc INFO和 SportDiscus等数据库进行了搜索，寻找 经过同行评审、使用英语或法语的综述。 为了更新由PAGAC (35 )进行的搜索，在 PubMed、CINAHL和Cochrane数据库搜索 了使用英语、经同行评审的综述。受资源限 制，没有对PAGAC(35)未包括的重要成果进 行重新搜索。 搜索时不限制国家或国家收入状况，涵 盖针对任何主观或客观衡量身体活动或久坐 行为的综述。由于资源有限，而且以前这一 领域的经验表明使用其他语言搜索不会发现 更多综述，即使发现也数量极少，因此决定 仅使用原始搜索的语言。入选的综述审查身 体活动或久坐行为与健康相关结果之间的关 联（以高于或低于身体活动或久坐行为阈值 的水平为基准），并探讨了与健康相关结果 之间的剂量-反应关系。 由外部评审小组使用AMSTAR 2（多系统 综述评估）工具对考虑列入的系统综述可信度 评级(38)。AMSTAR 2工具包含16个与综述规 划和进行有关的项目。根据已公布指南，对每 项综述结果的总体可信度进行评分：“高”评分 表明该综述无或存在一个非关键性缺陷；“中 等”表示判断该综述存在一个以上的非关键性 缺陷；“低”表示判断该综述存在一个关键性缺 陷，伴有或不伴有非关键性缺陷，或存在多个 非关键性缺陷；“极低”表示存在一个以上的关 键性缺陷。由一名评审员针对所有暂时列入的 综述填写AMSTAR 2工具。评分为极低的综述 由另一名评审员使用同一工具审查。除非针对 某特定结果只有一个综述，否则最终评分极低 的综述不会列入，理由是过于不可靠，无法对 现有证据进行准确和全面的总结。 证据还包括汇总的队列研究。由外部 评审小组使用Newcastle-Ottawa量表来评 估研究质量(39)。每项研究都给予质量评 级，“好”、“一般”或“差”。一般来说，质量好 的研究符合Newcastle-Ottawa量表的所有标 准。质量一般的研究至少有一项标准不符合， 或者不能明确是否符合，但也不存在会导致结 果无效的已知重要局限性。质量差的研究存在 一项致命缺陷或是多项重要局限性。质量差的 研究不会列入。 考虑到多份综述中可能出现重复研究，对 重复情况进行了评估。如果发现有其他更全 面和/或日期更近的综述，则排除含有多余证 据、综述概括和部分集合队列研究的综述。 新综述的方法 发现现有证据缺口时，委托开展新的伞状 综述，考察： 1. 职业类（即工作相关）身体活动与健康相 关结果的关系(40)； 2. 休闲类身体活动与不良健康结果的关联 (41)。 (对上述1和2，采用PubMed、SportDiscus 和EMBASE搜索了2009年至2019年12月发表 的综述） 3. 身 体活动和预防跌倒的关联；采用 Sherrington等2019年的Cochrane协作 网系统综述(42)，用原始综述的最终检索 日期到2019年11月以来公布的证据进行 更新。 4. 身体活动与骨质疏松症和肌肉减少症的关 联。使用PubMed在2008年至2019年11月 发表的综述中搜索现有关于骨质疏松症和 肌肉减少症的系统综述，未发现新综述， 有8项新的原始研究。 20 21方法 5. 艾滋病毒感染者的身体活动与健康结果 之间关联的证据。由范围综述确定HIV感 染者身体活动和健康相关结果的证据可用 性，支持进行伞状综述，伞状综述使用 PubMed、CINAHL和Web of Science研 究截至2019年10月发布的证据，没有起始 日期限制。 身体活动和久坐行为的证据和评估方法的 特点总结 一直以来，测量成人身体活动和久坐行为 的主要方法是自行报告（即调查），对于儿童 则是自行报告或父母回忆。虽然这些方法具有 公认的优势，但也有局限性，如容易出现报告 偏倚和测量误差(43)。近年来，随着数字技术 在这一领域的迅速发展，使用基于设备的方法 来评估身体活动和久坐时间及其与健康结果关 联的情况越来越多。然而，由于不同设备（加 速度传感器）的技术特点和放置位置不同，以 及数据分析和报告方面的差异，在比较研究结 果方面仍然存在挑战。例如，在使用设备测量 久坐时间时，可能会出现计算错误，因为许多 设备目前没有区分体位（例如卧、坐和站立不 动）。在比较使用设备测量的研究和从自行报 告数据得出结果的研究时，也存在困难。 自行报告工具的内容、身体活动的例子、 回答选项和涵盖类型各不相同。一直以来研 究主要侧重于评估身体活动总量，或只评估 休闲/娱乐类型的身体活动，但现在越来越 多地涵盖其他类型，如交通（如步行和骑自 行车）、工作和家庭中的身体活动。大多数证 据报告有氧身体活动与健康结果之间的关联， 但目前很多研究正在评估肌肉强化锻炼以及不 同种类的活动和其他类型活动组合的收益。 关于身体活动水平与健康结果关联的结 果，报告和比较的方式各有不同。许多研究报 告了体育活动四分位数或五分位数之间的比 较，其他研究比较“达到”和“未达到”国家指南 建议水平的情况。报告时，身体活动总量通常 以每周MET-小时为单位进行估算，一些研究 比较了“最高”和“最低”值，但不同研究的类别 也有所不同。经常有文献报告应用基于现有指 南或当前世卫组织全球建议的数据临界点， 或以往研究的指标（例如，对青年人群研究中 每天60分钟的临界点，或每周频率2-3次的 力量训练干预）的分析结果。当这样的临界点 变得司空见惯时，关于较高或较低水平身体活 动接触与健康结果关联的证据积累可能会受 到限制。 评估儿童和青少年久坐行为与健康结果关 联的大多数证据为横断面性质，大多数研究依 赖于自行报告或父母报告的久坐时间，测量方 法存在测量误差和回忆偏倚。 来自纵向观察研究和干预试验的证据优先 考虑，而仅仅或主要综合横断面证据的综述不 予考虑。更侧重于被评为中度质量及以上级别 的综述所提供的证据，以及使用设备测量接触 数据的研究所提供的证据。 整体证据评级 使用推荐分级的评估、制定与评价 （GRADE）方法，根据综述的基础证据，对 各项PI/ECO的证据质量评级(44)。每项综述 若有GRADE“证据简介”或“结果摘要”表，则 以之作为起点。如果现有系统综述中没有表 格，则为相关各个人群和结果编制“证据简 介”表。 使用GRADE方法评估各项PI/ECO证据 质量(44)时考虑以下标准：研究设计；偏倚风 险；效果连贯性；间接性；效果精准度，以 及其他局限性，例如发表偏倚和升级观察证据 的因素（效果大小，剂量-反应和混杂因素影 响）。从正常完成的纵向研究中获得的观察 证据也调高级别，以便更恰当地反映在体力活 动或久坐行为与结果关联的方面这些研究结论 的质量提升。评价中间/间接结果的研究不一 定会降级，因为结果（包括中间结果）的优先 次序由GDG决定；GRADE评级反映了对这些 结果产生效果的结论质量。某些情况下为确保 应用GRADE方法的一致性修改了现有综述的 GRADE评级。各项结果的证据质量根据以下 指导意见确定(45)： 22 23 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 高 非常确信真实效果与效果估计值 接近。 中等 对效果估计值中等确信：真实效果很 可能与效果估计值接近，但也有可能 存在很大差异。 低 对效果估计值的确信度有限：真实效 果或许与效果估计值差异很大。 极低 对效果估计值的确信度极低：真实效 果很可能与效果估计值差异很大。 证据转化建议 G D G 采 用 G R A D E 证 据 转 化 为 决 策（E t D）框架生成针对具体问题的建 议。EtD框架是一种系统化、结构化和透明化 的决策方法。该框架采用明确标准生成指南建 议，考虑到研究证据和证据质量，并在必要 时从目标受众的角度考虑专家意见和专题知 识。这些标准要求对以下方面作出判断：所 观察到的理想结果和不理想结果的证据之间 的平衡、证据的总体质量、患者理想结果和 不理想结果的相对值、资源使用（成本因素) (如适用）、对健康不平等的潜在影响、建议 的可接受性和可行性。 GDG审查了各项建议所有关键结果的全 部证据，以及所有现有重要结果。对于具体接 触/干预和结果的联系，研究在评估的接触/干 预、评估的结果、研究设计和分析方法上差异 很大，导致现有证据无法统一。因此不可能将 经典的GRADE 方法应用于每项具体接触/干 预和结果的的联系；相反，GRADE被应用于 每项接触/干预和结果联系的整体证据，涵盖 各类研究设计和各种不同的接触/干预测量和 分析方法。当这些因素引起对证据一致性的顾 虑时（即某一特定接触/干预和结果联系的证 据从不同角度观察时不一致），专家小组下调 证据质量(21)。 GDG考虑身体活动和久坐行为的影响时 以下健康结果优先：全因死亡率和病因特异性 死亡率（心血管疾病和癌症）降低；心血管疾 病发病率降低；癌症（位点特异）；2型糖尿 病；体质（如心肺功能、运动技能发展、肌肉 功能）改善；心血管代谢健康（如血压、血脂 异常、血糖、胰岛素抵抗）改善；骨骼健康； 心理健康（如抑郁症状减轻、自尊、焦虑症 状、ADHD）；认知结果（如学习成绩、执行 功能）改善；肥胖症减轻。还考虑了不良影响 （如受伤和危害）。 附加考虑因素 针对每个人群和所有PI/ECO问题，GDG 还考虑了受指南影响者的价值观和偏好；建议 涉及资源问题；对健康公平的影响；以及建议 的可接受性和可行性。由于这些考虑因素以及 GDG对每个人群的评估中存在相当多重复内 容，“证据转化建议”一节概括说明了对要素评 估的讨论。 22 23方法 《世卫组织关于身体活动和久坐行为的指 南》提出的公共卫生建议适用于5至65岁及以 上的所有人群，不分性别、文化背景或社会经 济地位，无论个人能力如何。 新的指南按年龄组和行为（身体活动和久 坐）分类。每一组建议都有介绍性陈述，分别 总结了与身体活动和久坐行为相关的健康结 果；然后提出建议。指南提供一套良好做法说 明，进一步说明目标人群如何能够安全达到建 议要求。这些良好做法说明本身并非“分级建 议” ，而是源自科学证据和GDG审查并建议的 实用注意事项。 每一组建议都附有一份支持科学证据的摘 要，根据三个PI/ECO问题构成；首先提供与 关键健康结果关联的证据，然后是关于剂量反 应的证据摘要。最后，如有证据表明不同种类 或类型的接触与健康结果之间的关系，则提供 一份证据摘要。 建议 良 好 做 法 24 25 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 支持性证据和理由 针对儿童和青少年的指南采用系统综述(22, 25, 35)，并增加16项符合纳入标准的新综述。 关于方法、数据提取和证据简介的全部细节见《网络附件：证据简介》 。 在儿童和青少年中，身体活动的收益体现于以下健康结果：改善身体健康 （心肺和肌肉健康）、心血管代谢健康（血压、血脂异常、葡萄糖和胰岛素 抵抗）、骨骼健康、认知结果（学业成绩、执行功能）、心理健康（抑郁症 状减少）；以及肥胖症减轻。 建议： 一周中儿童和青少年应平均每天至少进行60分钟的中等到剧烈强度的身体 活动，有氧运动为主。 强烈推荐，中等质量证据 每周至少应有3天进行剧烈强度有氧运动以及增强肌肉和骨骼的运动。 强烈推荐，中等质量证据 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 对于儿童与青少年，身体活动可以作为娱乐休闲（游戏、比赛、运动或有计划的锻 炼）、体育、交通（轮式运动、步行和骑自行车）或家务的一部分，在教育、家庭和社 区环境中进行。 身体活动建议 儿童与青少年 (5–17岁) • 少量身体活动优于不活动。 • 如果儿童和青少年未达到建议活动水平，少量身体活动有益健康。 • 儿童和青少年应从少量身体活动开始，逐渐增加频率、强度和持续时间。 • 应向所有儿童和青少年提供安全平等的机会并鼓励参与有趣、多样、适合其年龄 和能力的身体活动。 良 好 做 法 24 25建议 对于儿童和青少年（5-17岁），身体活 动与健康相关结果之间有何关联？ 大量证据先前已经证实，儿童和青少年 身体活动的总量和强度越大，就越有利于多 种健康结果(1)。最近的证据再度证明，增加 身体活动能改善儿童和青少年的心肺功能和 肌肉骨骼健康(22, 35)。例如，每周至少3天从 事30至60分钟中等到剧烈强度的身体活动就 会产生积极影响(22, 35)。 有规律的身体活动，主要是有氧运动，有 益于儿童和青少年的心血管代谢健康，包括改 善血压、血脂、控制血糖和胰岛素抵抗(35)。 最近的综述对比了校园身体活动计划(46)、高 强度间歇训练(47)和抗阻力训练(48)与无干预 措施对心血管代谢健康的影响。在所有3篇综 述中，有证据一致表明干预措施与更好的心血 管代谢结果有关联，尽管效果强弱的精确度不 同，而且仅有个别试验发现身体活动对所有心 血管代谢结果均具有统计学意义的收益。一项 对19个RCT（n=11 988）的综述(46)报告称， 相比无身体活动干预措施的情况，校园身体活 动计划对于舒张压（ES= 0.21 [95% CI: 0.42 to 0.01]; p= 0.04）和空腹胰岛素（ES= 0.12 [95% CI: 0.42 to 0.04]; p= 0.03）的改善具 有统计学意义。 据报道，身体活动对肥胖症有正面影响， 较高活动水平可能与儿童和青少年的健康体重 状况有关联(22, 35)。一般来说，横断面研究 的结果最为有力，而前瞻性观察研究的结果则 较为参差不齐，导致对报告关联的方向性理解 有限。综述包含的大多数研究未报告效果，最 近身体活动干预试验（实验室高强度间歇训练 [HIIT]、课堂主动学习、抗阻力训练）的综述 报告结果与其不一致(47, 49, 50)。然而，对纵 向和横断面研究的综述报告称，计步器测量的 身体活动与肥胖指标、BMI或腰围之间为负相 关的关系(51)。总的来说，身体活动与健康体 重状态管理之间关联的证据质量不高，需要更 多研究来确定关联的方向性和强度。 研究儿童和青少年身体活动和运动技能 发展之间关联的证据较少，当前综述未发现 任何成果(22)。需要更多研究考察运动技能发 展这一结果，为未来指南提供参考。 对于儿童和青少年来说，骨负荷活动可 以在游戏、跑步、转身或跳跃当中进行。身 体活动有利于骨量积累和/或骨结构，最近的 证据表明，比同龄人活动更多的儿童和青少 年骨量更大、骨矿物质含量或密度更高，骨 强度更高(35)。在儿童和青少年时期尽可能增 进骨骼健康有助于预防成年后的骨质疏松症 和相关骨折。 发展和维持认知功能在生命全程都非 常重要。儿童和青少年的身体活动对认知 功能和学业成绩（如学校成绩、记忆力和 执行功能）有积极影响(22, 35)。最近一 次综述（19个RCT；n= 5038）显示， 相比无运动干预措施的情况，每周进行 多次运动干预，持续6周或更长时间，会 导致以下认知功能量值发生更大变化，如 抑制控制（SMD 0.26 [95% CI：0.08至 0.45]，p= < 0.01）；工作记忆（SMD 0.10 [95% CI：-0.05至0.25]，p=  <  0.02）和 认知弹性（SMD 0.14 [95% CI：-0.03至 0.31]，p= < 0.04）(52)。身体活动还可以降 低患有抑郁症或未患抑郁症的儿童和青少年 陷入抑郁和出现抑郁症状的风险(35)，在减轻 症状方面可与心理和药物疗法媲美。 尽管所有身体活动都伴随某些不良事件 风险(53)，报告称为获得健康收益推荐的身体 活动量有相关危害的证据有限(35)。根据现 有证据和专家意见，推荐儿童和青少年进行 身体活动的总量和种类的相关潜在风险不高 (35)，可以通过活动量和活动强度循序渐进降 低风险，对于活动少的儿童和青少年尤其如 此。众所周知，参加某些运动和增加运动强 度都会增加受伤风险(53)。需要更多研究加强 对这一领域的了解。 儿童与青少年（5–17岁) 26 27 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 GDG的结论是： • 有中等质量证据表明更多中等强度和剧烈 强度的身体活动能改善儿童和青少年的心肺 功能和肌肉功能、心血管代谢健康和骨骼 健康。 • 有中等质量证据表明短期和长期的中等强度 至剧烈强度的身体活动对认知功能、学习成 绩和心理健康都有积极影响。 • 有低质量证据表明身体活动有利于儿童和青 少年的健康体重状况管理。 • 有低质量证据表明建议儿童和青少年进行的 身体活动的总量和种类的风险不高，而收益 更大。 是否存在剂量-反应关系（量、持续时 间、频率、强度）？ 虽然有大量证据表明，儿童和青少年的 身体活动与健康结果之间存在积极关联，但 很少有研究涉及剂量-反应问题。因此，与成 年人相比，对于儿童和青少年身体活动和特 定健康结果的剂量-反应曲线的确切形状和/ 或是否存在阈值（区分较低和较高风险）了 解不多。然而，大量证据表明，每天60分钟 的身体活动能带来多种健康收益(22, 35)，鉴 于无反面证据，得出的结论是，最新证据再 度肯定了世卫组织目前每天60分钟中等至剧 烈强度身体活动的建议(1)。 然而，审查包括最近使用设备测量身体 活动的研究结果在内的所有证据后，不支持 保留每天60分钟中等至剧烈强度身体活动的“ 最低”阈值有益健康的要求，因为各类研究在 评估身体活动对健康结果的收益时普遍使用 每天“平均”60分钟的阈值，而不是每天最低 60分钟的阈值。审查的结论是，应修改新指 南，从而更准确地体现这方面的证据。 定期的剧烈强度活动对于心血管代谢 健康结果的收益已经证实(1)，近期综述进一 步提供了证据支持(35)。例如，最近的一篇 综述(54)显示，与中等强度连续训练相比， 高强度间歇训练对心肺功能有中等程度的 有益影响（SMD= 0.51 [95% CI：0.33至 0.69]，p= < 0.01；I2= 0%）。没有证据表明 干预时间、运动方式、运动休息比以及总次 数会改变对心肺功能的效果。这些结果与最 近的其他综述(22, 35, 47)总体一致，并支持保 留青年和青少年应定期进行剧烈强度活动以 改善心肺功能的建议。 GDG的结论是： • 有证据支持世卫组织先前的建议，即每天 进行60分钟中等强度到剧烈强度的身体活 动。 • 有证据支持将以前规定的每日最低60分钟 身体活动时间改为每周平均每日60分钟， 更贴近证据反映的情况 • 有中等质量证据表明更多剧烈强度身体活动 与心肺功能改善有关联。 这种关联是否因身体活动的种类或类型 而异？ 对于儿童和青少年来说，身体活动包括 在家庭、学校和社区活动中的游戏、比赛、 运动、交通、娱乐、体育或有计划的锻炼。 然而，很少有研究直接比较儿童和青少年不 同种类或类型的身体活动，因此没有足够证 据确定身体活动和健康结果之间的关联是否 因活动种类（例如有氧运动或是肌肉强化练 习）或身体活动类型（例如主动运动（步行 和骑自行车）还是体育或运动/娱乐）而有所 不同。 有证据表明，儿童和青少年中等强度至剧 烈强度的有氧身体活动水平的增加都与心肺 健康改善有关联，而肌肉强化活动的增加也 能提高肌肉功能。这一证据为2010年世卫组 织《关于身体活动有益健康的全球建议》(1) 提供了参考，该建议推荐每周至少有3天从事 能增强肌肉和骨骼的活动。最新的证据再次 儿童与青少年（5–17岁) 26 27建议 证实，每周3次的定期肌肉强化活动可有效改 善肌肉健康指标；但没有足够证据说明锻炼的 具体持续时间和强度，主要由于文献中评估的 接触情况不一致(22, 35)。关于抗阻力训练对 心血管代谢健康的保护作用，相关证据较少。 由于除了儿童和青少年肌肉强化活动的频率之 外，没有关于持续时间等其他方面的新证据， 因此无法具体说明任何进一步的细节。今后的 研究应分析各种类和各类型身体活动的健康收 益，让指南的这一部分更加具体。 GDG的结论是： • 有中等质量证据表明每周至少应有3天进行 增强肌肉的运动。 儿童与青少年（5–17岁) 28 29 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 儿童与青少年 (5–17岁) 支持性证据和理由 久坐行为未列入世卫组织2010年建议，但过去十年有越来越多的研究审查了与不同程度 和不同类型的久坐行为关联的健康结果。技术和数字通信已经影响了人们工作、学习、旅行和 休闲娱乐的方式。在大多数国家，儿童和青少年久坐行为的时间越来越长，主要原因是屏幕娱 乐（电视和电脑）等休闲方式和手机等数字通信手段。 针对儿童和青少年的指南运用了系统综述(24, 25)，更新时增加7项符合纳入标准的新 综述。关于方法、数据提取和证据简介，详情参见《网络附件：证据简介》 。 儿童和青少年较多久坐行为与以下不良健康结果有关联：更加肥胖；心血 管代谢健康、身体素质、行为品行/亲社会行为较差；以及睡眠时间减少。 建议： 儿童和青少年应该限制久坐时间，尤其是屏幕娱乐时间。 强烈推荐，低质量证据 久坐行为的定义是教育、家庭、社区环境和交通中，清醒状态下坐卧的时间， 能量消耗低。 久坐行为建议 28 29建议 对于儿童和青少年（5-17岁），久坐行 为与健康相关结果之间有何关联？ 有证据表明，较长时间的久坐行为，特 别是娱乐性屏幕时间，与较差的健康结果有 关联(24, 35)。例如，儿童和青少年较长屏幕 时间（包括看电视）与较差体质和心血管代 谢健康有关联(24, 25)。使用设备评估久坐行 为关联和干预措施研究的证据显示，效果一 般，但对已经患有肥胖症的人效果更好(55)。 久坐行为与儿童和青少年的骨骼健康无关， 这一点的相关证据有限。 尽管研究结果有所不同，但也有证据 表明久坐行为可能与肥胖指标不良有关 (24, 25)。一项主要针对横断面研究的综述报 告，与较低水平（<2小时/日）相比，每天 超过2小时的久坐行为（以总屏幕时间衡量） 与儿童超重/肥胖呈正相关(56)。但另一项20 项横断面研究 (57)的综述发现久坐电子游戏 时间与儿童或青少年的身体质量指数之间没 有统计学意义上的关联。对29份系统综述的 大规模审查发现，许多研究报告说，当年轻 人的久坐行为自行报告为某种形式屏幕时间 时，久坐行为与肥胖症标志物之间存在不利 关联(55)。但审查结果指出，这种关联程度不 高，使用设备衡量久坐时间的研究体现的关 联基本为零(55)。干预措施研究显示效果一 般，但对那些已经患有肥胖症的人效果更好 (55)。需要开展进一步研究，为久坐行为与肥 胖症程度之间的关联提供参考信息。 虽然仍属新兴研究领域，但一些证据表 明，儿童和青少年的久坐行为与幸福感和生 活质量为负相关，而抑郁症与休闲屏幕时间 之间存在不利关系(58, 59)。例如，评估为屏 幕时间的较长时间久坐行为和某些电脑使用 行为，可能与心理健康较差有关(24)。在最近 的另一项综述中，8项研究中有5项发现久坐 行为与焦虑症状之间存在关联，尽管研究中 使用不同方法衡量久坐行为得出的结果并不 一致(60)。其他证据表明，看电视和电子游戏 的时间较长，与行为举止/亲社会行为的不利 结果显著相关(24)；屏幕时间和看电视时间较 长与睡眠时间较短相关，但使用电脑/游戏与 睡眠时间没有关联(61)。久坐行为与心理健康 的关系这一研究领域发展迅速，有很多未知 因素，可能体现出逆向因果关系。需要进一 步研究，为这种关系的方向和强度提供参考 信息。 GDG的结论是： • 有低质量证据表明时间较长的久坐行为 （屏幕时间）与儿童和青少年较低的身体 素质和心血管代谢健康有显著关联。 • 有极低或中等质量证据表明时间较长的久 坐行为（屏幕时间、看电视和电子游戏） 与儿童和青少年心理健康及行为品行/亲社 会行为较差有显著关联。 • 有低质量证据表明时间较长的久坐行为（ 屏幕时间和看电视）与儿童和青少年睡眠 时间有害影响有显著关联。 • 限制儿童和青少年久坐时间的收益大于危 害。 是否存在剂量-反应关系（总量、持续 时间、频率、中止强度）？ 没有足够证据确定儿童和青少年久坐时 间（包括娱乐性屏幕时间）与健康结果之间 是否存在剂量-反应关系。评估儿童和青少年 久坐行为与健康结果之间关系的大多数证据 具有横断面性质，以GRADE的标准证据质量 较低，大多数研究依赖于自行报告或父母报 告的久坐时间数据，容易出现计量错误和回 忆偏倚。然而，有证据表明，久坐行为时间 越少，对健康结果似乎越有利，而且当接触 变量评估为看电视或娱乐屏幕时间，久坐行 为与不良健康结果之间的关联性一般比评估 为久坐总时间要强。但总体而言，认为证据 不足以支持规定时间限制。 儿童与青少年（5–17岁) 30 31 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 久坐行为与不良健康结果有关的证据可 能是久坐行为的直接影响、替代身体活动占 用时间，或两者兼而有之的结果。虽然有研 究报告说屏幕时间与儿童和青少年不良健康 结果之间存在关联，但如果考虑到中等到剧 烈强度的身体活动时间(62)，久坐总时间（使 用设备衡量久坐行为的研究评估结果）始终 与健康结果无关。相反，将中等强度至剧烈 强度的身体活动与积极健康结果联系起来的 证据有力，并且在各种不同环境中都有充分 证据；用身体活动（特别是中等强度至剧烈 强度的身体活动）取代一些久坐行为会改善 健康结果。 对久坐行为、身体活动和健康结果之间 关联和相互作用的研究迅速增加，用设备衡 量久坐行为和心血管代谢健康的证据表明， 如果考虑中等到剧烈强度身体活动（即经过 统计调整），关联性就会减弱(62–64)。因 此，有必要继续前瞻性研究，使用设备衡量 接触，增进对这些关联的了解，并为今后的 建议提供参考。 GDG的结论是： • 有低质量证据表明久坐时间越长，健康结 果越差。 • 证据不足以明确规定久坐行为的时间限制。 • 久坐时间改为中等强度至剧烈强度身体活 动能带来健康收益。 这种关联是否因身体活动的种类或类型 而异？ 研究久坐行为对健康的影响属于相对较 新的领域。因此，这些研究结果源自使用不 同工具和接触量度的研究。被评估为“久坐行 为总时间”的接触，以及使用“屏幕”或“看电 视”的久坐时间比较常用。现有证据表明，就 久坐行为与不良健康结果的关联而言，看电 视或娱乐屏幕时间一般比久坐总时间关联性 更强(24, 35)。最近的研究越来越多地使用设 备评估久坐行为，增进了解，结合标准化报 告有助于为未来指南提供信息。 人们认为，并非所有久坐行为都有危 害。有证据表明，某些类型的久坐行为， 如阅读和在校外做家庭作业，与较高学业 成绩有关联，说明结果因活动不同而有差异 (24, 25)。久坐行为可能包括从事教育活动/ 学习或安静游戏的时间，或不使用电子媒体 的社交。这些活动（如阅读、拼图、绘画、 手工、唱歌、音乐）对儿童发展具有重要意 义，能带来认知等方面的收益。 GDG认为： • 某些久坐活动在儿童和青少年的认知功能 和社会交往方面带来收益。 • 关于久坐行为对健康不良影响的证据，一 般来说，看电视或娱乐性屏幕时间比久坐 总时间的证据质量更强。 儿童与青少年（5–17岁) 30 31建议 成年人 (18–64岁) 对于成年人来说，身体活动的收益体现在以下健康结果：改善全因死 亡率、心血管疾病死亡率、新发高血压、新发位点特异性肿瘤1、新发2型糖 尿病、心理健康（减少焦虑和抑郁症状）、认知健康和睡眠；肥胖指数也能 改善。 建议： 所有成年人应定期进行身体活动。 强烈推荐，中等质量证据 成年人每周应该进行至少150-300分钟的中等强度有氧活动；或至少75- 150分钟的剧烈强度有氧活动；或者等量的中等强度和剧烈强度组合活动，可 以获得巨大健康收益。 强烈推荐，中等质量证据 成年人还应进行中等强度或更高强度的肌肉强化活动，锻炼所有主要肌肉 群，每周2天或2天以上，能带来额外健康收益。 强烈推荐，中等质量证据 成年人可以将每周中等强度有氧活动增加到300分钟以上；或进行150分钟 以上的剧烈强度有氧活动；或等量的中等强度和剧烈强度组合活动，可获得 额外健康收益。 条件性推荐，中等质量证据 对于成年人，身体活动可以作为娱乐休闲（游戏、比赛、运动或有计划的锻炼）、 交通（轮式运动、步行和骑自行车）、工作或家务的一部分，在日常工作、教育、家庭 和社区环境中进行。 身体活动建议 • 少量身体活动优于不活动。 • 如果成年人未达到建议活动水平，少量身体活动有益健康。 • 成年人应从少量身体活动开始，逐渐增加频率、强度和持续时间。良 好 做 法 1 膀胱癌、乳腺癌、结肠癌、子宫内膜癌、食管腺癌、胃癌和肾癌等特定部位癌症。 32 33 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 支持性证据和理由 为制定这些指南，使用并更新了美国身体活动指南顾问委员会（PAGAC）综合的证据(35)。 GDG考虑了全部证据，包括PAGAC报告的结果和2017年至2019年11月发表的28篇综述和3 项集合队列研究，这些研究符合纳入标准，并提供了成年人体力活动与健康相关结果之间关联 的证据。此外还委托进行了两项伞状综述，以解决证据不足的问题，并研究i)职业（即工作相 关）身体活动与健康相关结果的关联(40)；ii) 休闲类身体活动与不良健康结果的关联(41)。伞状 综述分别发现了36份和15份系统综述。优先考虑来自纵向观察研究和干预试验的证据，而仅仅 或主要综合横断面证据的综述不予考虑。评为中等质量及以上的综述所提供的证据，以及那些 使用设备测量接触的研究所提供的证据更受重视。 关于方法、数据提取和证据简介，详情参见《网络附件：证据简介》 。 对于成年人（18-64岁），身体活动与 健康相关结果之间有何关联？ 身体活动与成年人全因死亡率和心血管 疾病死亡率之间的关联已经得到公认(1)。近 期综述结果再次证实，与最低水平的身体活 动相比，较高水平身体活动意味着较低的死 亡风险。使用设备衡量身体活动的研究提供 的新证据重申并拓展了以下观点的证据：与 最低水平的身体活动相比，任何水平和各种 强度（包括轻微强度）的身体活动都意味着 较低的死亡风险(65)。例如，与活动量最少的 人（参考值，1.00）相比，身体活动总量四分 位数的校正HR在身体活动各四分位点均有所 改善：2nd四分位数（0.48 [95% CI：0.43至 0.54]）；3rd四分位数（0.34 [95% CI：0.26 至0 .45 ]）；4 th四分位数（0.27 [ 95% CI：0.23至0.32]）(65)。新证据也再次确认 了身体活动与心血管疾病死亡率之间得到公 认(1)的反比关系(66)。 身体活动在降低心血管疾病和高血压发病 率方面带来的收益已有充分证据说明(1)。身体 活动促进许多生理反应，引发有益的短期和长 期自主神经和血流动力调节，从而降低高血压 风险，而高血压是心血管疾病的一个关键风 险因素。有证据再次证实，在血压正常的成年 人中，身体活动与新发高血压之间为负相关关 系，而对于血压正常的高血压前期成年人，身 体活动可以降低血压(35)。 身体活动与成年人患2型糖尿病之间的负 相关关系已经得到公认(1)。最近的证据再次确 认了身体活动量增加与2型糖尿病发病率之间 的逆曲线关系(35)，身体活动较多时为下降斜 率。一项新的综述发现，这种影响在不同背 景的个体中表现一致，“最高”与“最低”身体活 动水平时患2型糖尿病风险降低的情况如下， 非西班牙裔白人（RR= 0.71 [95% CI：0.60 至0.85]）；亚裔（RR= 0.76 [95% CI：0.67 至0.85]）；西班牙裔（RR = 0.74 [95% CI：0.64至0.84]）；美国印第安人（RR= 0.73 [95% CI：0.60至0.88]），但对于非 西班牙裔黑人无明显效果（RR= 0.91 [95% CI：0.76至1.08]）(67)。有证据表明，体重状 况没有修饰效应，对于体重正常、超重或肥胖 的人，身体活动量增加与2型糖尿病发病率降 低之间均存在反比关系(35)。 身体活动量增加与结肠癌和乳腺癌风险 降低的关联已经得到公认(1)。先前的证据综述 发现，较高水平的身体活动能降低患乳腺癌 成年人（18–64岁） 32 33建议 和结肠癌的风险(1)。随着对身体活动与癌症 的研究大量增加，有新的证据表明，身体活 动水平越高，患膀胱癌、子宫内膜癌、食管 腺癌、胃癌和肾癌的风险也越低，同时再度 确认身体活动可预防乳腺癌和结肠癌(35)。较 高水平的身体活动相关的风险降低范围约为 10-20%(35)。例如，某篇综述报告，较高水 平身体活动和低水平身体活动相比，肝癌发 病率呈负相关（HR= 0.75 [95% CI：0.63至 0.89]）(68)。没有足够证据表明增加身体活动 与降低血液癌、头颈癌、卵巢癌、胰腺癌、前 列腺癌、甲状腺癌、直肠癌和脑癌的风险之间 存在关联(35)。虽然有证据表明，最高水平与 最低水平身体活动相比肺癌风险降低，但此类 结果可能受到烟草使用的干扰，因此认定总体 而言证据不足以建立关联。 成年人身体活动与肥胖症之间的关联并未 完全得到公认，尽管根据各种结果量度（体重 增加、体重变化、体重控制、体重稳定、体重 状态和体重维持）评估这一关联的证据数量很 大同时又缺乏一致性(35, 69, 70)。总体而言， 证据表明较高的身体活动水平可能会改善成年 人肥胖症量度和减少体重增加的幅度(35)。需 要进一步研究，确定结果连贯一致以及关联的 强度。 2010年《关于身体活动有益健康的全球 建议》制定以来，对身体活动与心理健康、 认知和睡眠的研究大量增加(1)。当时，证据 只能得出成年人身体活动可以降低抑郁症和认 知能力下降风险的结论。为这些指南而审查 的新证据表明，身体活动较多和较少的成年人 相比，前者患焦虑和抑郁症的风险降低。例 如，相对于低水平身体活动者，身体活动水平 高的成年人出现焦虑症状（AOR= 0.81 [95% CI：0.69至0.95](71)或抑郁症状（AOR=0.78 [95% CI：0.70至0.87]）(72)的几率降低。增 加中等至剧烈强度身体活动可改善认知（如处 理速度、记忆和执行功能）(35)、大脑功能和 结构，降低认知受损的风险，如阿尔茨海默 症(73–76)。证据涵盖多个成年人群体，其认 知健康状况有正常到受损的不同梯度，并报告 了各种身体活动的有益影响，包括有氧活动、 步行、肌肉强化活动和瑜伽(74)。有证据表明 短时间剧烈身体活动和有规律的身体活动都能 改善成年人睡眠和健康相关生活质量的结果 (35)。 研究身体活动与抑郁症状、焦虑疾病和 抑郁症焦虑症形成的证据表明，身体活动可 减轻焦虑症状(77, 78)和抑郁症状(77, 79)。 所有身体活动都伴随风险。一项对成年人 休闲类身体活动相关不良影响、损伤和危害的 委托研究(41)有证据表明，休闲时间身体活动 水平与肌肉骨骼损伤有不利关联，而休闲时间 身体活动与骨折风险和膝、髋关节炎发病之间 有正面关联。此外还有证据(35)表明，突发性 心脏不良事件并不多见，与短时间强度相对剧 烈的身体活动有关联。一般而言，身体活动强 度中等，活动频率、强度和持续时间逐渐增加 时，伴随的不良事件风险极低(35)。 GDG的结论是： • 有高质量证据表明，任意水平任意强度的 身体活动都能降低全因死亡率和心血管疾 病死亡率、高血压、心血管疾病和2型糖尿 病发病率的相关风险。 • 有中等至高质量证据表明，较高水平身体 活动可降低位点特异性肿瘤发病风险。 • 有中等质量证据支持身体活动与心理健 康、认知健康和睡眠结果之间的关联。 • 有证据表明较高水平身体活动可改善成年 人肥胖症量度和减小体重增加幅度。 • 有低质量证据表明，向成年人推荐的身体 活动没有危害，此类活动的健康收益大于 风险。 成年人（18–64岁） 34 35 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 是否存在剂量-反应关系（量、持续时 间、频率、强度）？ 总体而言，心血管健康和代谢健康结果的 证据体现出身体活动与成年人全因死亡率、心 血管疾病死亡率、新发2型糖尿病(67)和新发 位点特异性肿瘤等主要结果之间存在一致的逆 曲线剂量-反应关系。如图1所示，剂量-反应 曲线的形状表明收益没有较低阀值，最大收益 见于剂量-反应曲线的较低端(65)。使用不同 方法衡量身体活动的研究对逆曲线关联的报告 一致。对八项前瞻性队列研究的荟萃分析提供 了重要的新证据，平均随访时间为5.8年（范 围为3-14.5年）(65)，报告了使用设备衡量接 触并统计全因死亡率得出的身体活动总量四分 位数的校正HR。结果显示，与活动最少的情 况（参考值1.00）相比，身体活动量增加与较 高水平、任意强度身体活动的收益之间存在剂 量－反应关系：2nd四分位数（校正HR=  0.48 [95% CI：0.43至0.54]）；3rd四分位数（校 正HR= 0.34 [95% CI：0.26至0.45]）；4th 四分位数（校正HR= 0.27 [95% CI：0.23至 0.32]）。当每天中等至剧烈强度身体活动达 到24分钟（相当于每周168分钟）时风险降低 的幅度最大，高度符合建议的每周150分钟， 也提供了使用设备衡量得出的新证据，支持现 有成年人每周150－300分钟身体活动的全球 指导(65)。这些研究结论与源自现有综述(35) 以及其他新发现综述(66)的证据一致。 在上端，较高水平身体活动继续带来死亡 率风险降低的收益，发生危害的风险并未增 加。例如，一项新的综述包含有使用设备衡量 接触获得各项数据的荟萃分析结果(65)，其中 证据表明，尽管每周750分钟以内的中等至剧 烈强度身体活动均可观察到死亡率风险降低， 但每周运动超过300分钟时死亡率相对风险就 趋于平缓。这些结果符合先前证据，这些证据 一致表明，更多身体活动与更多健康收益相 关，但身体活动水平较高时相对收益下降(35, 80, 81)。然而，没有足够证据确定身体活动水 平具体达到何种程度时成年人的健康收益开始 下降。 证据还再度确认了身体活动与心血管疾病 死亡率之间已有公论的反比关系，提供了远远 超出目前建议身体活动量的剂量-反应关系的 额外证据。对48项评估身体活动（总量、休闲 图1：剂量-反应曲线 成年人（18–64岁） 每周身体活动量（分钟） 风险 和危 害 收 益 久坐 150 300 健 康 和 身 体 素 质 收 益 建议范围 34 35建议 类和职业类）的前瞻性研究进行的荟萃分析提 供了远远超出目前建议活动量的剂量-反应关 系(66) 的额外证据。与每周750 MET分钟的建 议水平相比，每周5000 MET分钟的高强度运 动（1000分钟中等强度运动）可以显著降低 心血管疾病死亡率（HR= 0.73 [95%CI：0.56 至0.95]）(66)。之前的世卫组织建议(1)认为， 有氧活动每次持续时间不应少于10分钟。但借 助设备评估得出的新证据表明，任意持续时间 的身体活动都能改善包括全因死亡率在内的 健康结果(65, 82)，不存在最低阀值。例如， 用加速度感应器评估身体活动的研究综述提出 新证据，再度确认所有身体活动均与全因死亡 率有类似关联性，身体活动总量的风险比为 0.27，一次5分钟的活动风险比为0.28，一次 10分钟的活动风险比为0.35，这是最高四分位 数和最低四分位数比较的结果(83)。Ekelund 等2019年的新综述(65)得出的结论再次验证了 上述发现，提出的证据表明，每次任意持续时 间的身体活动都能改善包括全因死亡率在内的 健康结果(82)。根据新证据删除了每次活动至 少持续10分钟的建议。 尽管显示较高水平身体活动与降低位点特 异性肿瘤发病率风险之间关联的证据总体而言 表现出一致性，由于各项研究对接触的评估和 分类差异很大，证据不足以确定报告风险降低 所对应的具体身体活动水平。但也没有证据表 明存在较低阀值，低于此阀值身体活动无有益 效果，因此说明任意水平的身体活动都能带来 降低位点特异性肿瘤风险的收益。未来研究需 要评估剂量-反应关系的性质，并在测量和报 告方面提高一致性，供未来指南参考。 尽管有大量证据体现身体活动和各种肥胖 症量度、体重增加和健康体重状态管理之间的 关联(35)，目前没有足够证据更具体地说明剂 量-反应关系或是确定效果阀值。需要进一步 研究供未来指南参考。 更多中等至剧烈强度身体活动能改善认知 （如处理速度，记忆和执行功能）(35)、大脑 功能和结构，降低认知受损的风险，包括阿 尔兹海默症(73–76)。有证据表明，短时间剧 烈活动和定期身体活动能改善成年人睡眠和健 康相关生活质量(35)。但证据不足以具体说明 身体活动与个人心理和认知健康结果之间的剂 量-反应关系。同样，需要更多证据进一步说 明有氧身体活动和肌肉力量训练的总量和/或 强度与特定健康结果之间的剂量-反应关系。 此类信息具有关键作用，能用于确定各人口 亚群体身体活动的最低有效剂量和最大安全 阀值。 GDG的结论是： • 证据表明，更多身体活动能对健康结果产 生更大效果，但身体活动水平更高时相对 收益趋于平缓。证据不足以确定具体达到 何种活动水平时回报开始减少。 • 有高质量证据表明较高水平身体活动能降 低全因死亡率、心血管疾病死亡率、癌症 死亡率、心血管疾病发病率以及高血压和2 型糖尿病发病率的相关风险，而危害的风 险不会增加。 • 有中等质量证据表明任意持续时间的身体 活动都能改善健康结果，之前关于有氧活 动应每次至少持续10分钟的规定应当删除。 • 证据表明更高水平身体活动可能与成年人 改善肥胖症量度和体重增加幅度减小有关 联，身体活动危害成年人健康体重状态管 理的风险不高。 • 有中等质量证据表明每周150－300分钟中 等强度有氧身体活动或等量活动可降低多 种健康结果的相关风险，每周活动超过300 分钟后风险继续降低但幅度趋于平缓。 成年人（18–64岁） 36 37 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 这种关联是否因身体活动的种类和类型 而异？ 证据表明，不同种类和不同类型（如职 业、交通或休闲）身体活动能带来有益健康结 果。对全因死亡率和心血管疾病死亡率而言， 仅从事有氧身体活动，或结合肌肉强化练习即 有良好效果，但两种活动均达到建议水平效果 最佳(84)。 最近有更多中等质量证据表明，不考虑有 氧身体活动，仅肌肉强化身体活动也能降低全 因死亡率相关风险。Stamatakis等人（2018 年）对11项考察建议每周两天肌肉强化练习与 全因死亡率的研究进行汇总分析，结果显示， 有氧身体活动和肌肉强化身体活动均达到建 议水平(1)与其中一项未达到建议水平的情况 （校正HR= 0.71 [95% CI：0.57至 0.87]） 相比，以及仅坚持达到力量练习建议水平与 未达到相比（校正HR= 0.80 [95% CI：0.70 至 0.91]），均能大大降低全因死亡率相关风 险(84)。这些数据确认，肌肉强化练习的相关 健康收益与有氧身体活动无关，还提供证据 支持每周两天的肌肉强化练习建议。Dinu等 人（2019年）报告的研究结果提供了支持性 证据，再度确认除休闲类（或娱乐类）以外 其他类型的身体活动有益，并具体指出，通 勤运动（如步行和骑自行车的交通方式）可 以大大降低全因死亡率相关风险（RR= 0.92 [95% CI：0.85–0.98]）(85)。 近期研究提供的证据表明，参与通勤运动 （如步行和骑自行车的交通方式）与不参与相 比，可以降低心血管疾病（冠心病、卒中和心 衰）风险（RR= 0.91 [95% CI 0.83至0.99]） (85)；此类健康结果提供了足够证据说明不同 类型活动均有效果。但证据不足以区分不同类 型身体活动对各项健康结果的效果。例如，证 据不足以确定身体活动与癌症风险或2型糖尿 病发病率之间的关联是否因身体活动的种类或 类型而异。 对于心理健康结果，证据(35)显示包括有 氧活动、步行、肌肉强化活动和瑜珈在内的各 类身体活动对减少抑郁症状和焦虑症发病有效 (74, 79, 86)。例如，最近有两项综述提供的证 据体现出抗阻力练习干预措施对心理健康的 良好效果，与对照组相比，抑郁症状适度降低 (77)以及焦虑症状小幅降低(78)。 一项新综述的证据确认，高水平职业类身 体活动可降低多种癌症、冠心病和2型糖尿病 风险(40)。但较高水平职业类身体活动可能也 与骨关节炎风险增加、睡眠质量差和男性全 因死亡率（未见于女性）有关联。证据不足以 确定职业类身体活动与肥胖症、预防体重增 加、心理健康和健康相关生活质量之间的关系 (40)。同样证据也不足以确定身体活动与癌症 风险之间的关联是否因身体活动的种类或类型 而异。关联按照不同类型身体活动分类研究的 证据较少，因此难以区分不同类型身体活动对 各类健康结果的效果。 GDG的结论是： • 有中等质量证据表明每周两天或两天以上 肌肉强化活动能带来额外健康收益，但证 据不足以具体指明达到最佳健康收益需持 续的活动时间。 • 有中等质量证据表明不同类型（如休闲、 交通、职业）身体活动能带来健康收益， 但目前无法区分不同类型身体活动对各类 健康结果的效果。 • 尽管较高水平职业类身体活动可能导致骨 关节炎、睡眠质量差和男性全因死亡率 （未见于女性）相关风险增加，总体而言 有中等质量证据表明职业类身体活动能带 来健康收益。 成年人（18–64岁） 36 37建议 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 成年人 (18–64岁) 久坐行为建议 支持性证据和理由 为编制指南采用并更新了PAGAC综合的证据(35)。GDG考虑了整体证据，包括PAGAC报 告的研究发现和13项符合纳入标准的新综述，向成年人久坐行为与健康相关结果之间的关联 贡献了证据。作为公共卫生研究领域，久坐行为与健康结果之间的关联与活动不足相比相对 较新，但过去十年发展迅速。一般研究会使用i)关于久坐行为“总时间”或看电视、使用电脑/ 屏幕和保持坐姿等具体行为时间的自行报告问卷；或ii)使用设备的评估数据来衡量久坐行为。 久坐行为没有标准化衡量方法或分析规程，因此结果的报告缺乏一致性。近期在方法学上的 发展包括使用设备衡量久坐时间，这种方法可以减少测量误差和其他自行报告回忆固有的偏 倚问题。 考虑整体证据时，GDG更侧重于综述提供的评级中等及以上的证据，源自采用久坐总时 间或坐姿总时间或借助设备测量久坐行为的研究证据综述。 关于方法、数据提取和证据简介的全部细节见《网络附件：证据简介》 。 过去十年关于久坐行为相关潜在不良健康影响的研究快速增加。最近较为突出的进展 是，研究久坐行为与多种健康结果的剂量-反应关系以及久坐行为与身体活动相互作用的证据 有所增加。 成年人较多久坐行为与下列不良健康结果有关：全因死亡率、心血管疾病 死亡率和癌症死亡率以及心血管疾病、癌症和2型糖尿病发病率。 建议： 成年人应该限制久坐时间。久坐时间改用来进行各种强度的身体活动 （包括轻微强度）能带来健康收益。 强烈推荐，中等质量证据 为了帮助减少过多久坐行为对健康的不利影响，成年人进行中等到剧烈强 度身体活动应力求超过建议水平。 强烈推荐，中等质量证据 成年人的久坐行为定义是在职业、教育、家居和社区环境以及交通中，清醒状态 下坐卧的时间，能量消耗低。 38 39 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 对于成年人（18岁以上），久坐行为与 健康相关结果之间有何关联？ 总体而言，有证据表明较长时间久坐行为 （主要通过自行报告或借助设备评估保持坐 姿或看电视的时间）与较高的全因死亡率、 心血管疾病死亡率、心血管疾病发病率和2型 糖尿病发病率有关联(8, 35, 65, 87)。例如， 支持性证据包括近期借助加速度感应器评估 久坐总时间与全因死亡率(65)的大型荟萃分 析（n= 36 383；平均年龄62.6岁；女性占 72.8%）取得的结果，表明久坐行为时间增加 与全因死亡率有显著关联。涵盖超过一百万名 参与者的一项荟萃分析(87)有类似研究发现， 针对身体活动进行校正后，久坐行为总量与全 因死亡率和心血管疾病死亡率有关联(87)，但 在这项研究中，与癌症死亡率的关联经身体 活动校正后不具有统计学意义(87)。 最近还有一项荟萃分析(8)报告称，久坐 行为（评估为坐姿状态）与心血管疾病和癌 症死亡率有显著关联，结果表明当：身体活 动最低四分位数（~5分钟/天）的“活动不足” 者，评估为坐姿时间的较多久坐行为导致心 血管疾病死亡率相关风险提高9-32%（p 趋 势< 0.001）。该研究报告，每天久坐（保持 坐姿）超过8小时的成年人心血管疾病死亡率 相关风险较高，“活动最多”（即>35.5MET小 时/周，或60–75分钟/天）者除外，后者该 项关联减弱。根据研究结果，久坐行为与癌症 死亡率的关联总体较弱，但较长坐姿时间（ 尤其>8小时/天时）意味着剂量相关风险增加 6–21%，但仅见于身体活动最低四分位数人 群（< 2.5 MET小时/周）(8)。 证据支持久坐行为（按总坐姿时间衡量） 与更多新发心血管疾病之间的关联（HR= 1.29[95%CI：1.27至1.30]），而针对包括身 体活动水平在内的潜在协变量校正后关联性减 弱（HR= 1.14 [95% CI：1.04至1.23])(88)。 东南亚人群研究综述提供的低质量证据表明， 久坐时间越长，心血管代谢指标不良的可能 性越高（包括2型糖尿病、BMI更高和血压更 高）(89)。 最近有两项综述报告了每日坐姿总时间 (88)、久坐行为和看电视总时间(87)与2型糖 尿病发病率的关联。两项研究均发现较长 时间久坐行为与2型糖尿病发病率风险增加 有关联。例如，经过身体活动校正后，久坐 行为总量（RR= 1.01 [95% CI：1.00至1.01] p= < 0.001）和看电视（RR= 1.09 [95% CI：1.07至1.12] p= < 0.001）与2型糖尿病之 间有线性关联(87)。 还有支持性证据表明，久坐行为（以看电 视时间计）与癌症死亡率之间有显著关联性 (35, 87)。最近多项研究提供了低质量和极低 质量的支持性证据，表明久坐行为与结肠直肠 癌有关联(90)，但与新发前列腺癌、乳腺癌或 直肠癌无关联(90–93)。另外还有证据(35)报 告较长时间久坐行为与罹患子宫内膜癌、结肠 癌和肺癌较高风险之间有显著关联(35)。 有低质量证据表明，久坐行为时间对肥胖 症及其他体重状态指标有不良影响，久坐行为 与体重状态之间的关系是否随着中等至剧烈强 度身体活动量变化，相关证据同样质量不高。 总体结论是，证据不足以为此类建议/指南提 供参考，需要进一步开展研究。 评估减少久坐时间不良后果的证据有限。 根据专家意见，结论是建议减少久坐时间不大 可能增加受伤的风险，在轻微强度身体活动替 代久坐的情况下尤其如此。 成年人（18–64岁） 38 39建议 GDG的结论是： • 总体而言，有充分证据支持编制世卫组织 新建议，限制久坐行为，降低健康风险。 • 有中等质量证据表明较长时间久坐行为与 较高全因死亡率、心血管疾病死亡率、癌 症死亡率和心血管疾病及2型糖尿病发病率 之间有关联。 • 有低质量和中等质量证据表明较长久坐时 间与新发子宫内膜癌、结肠癌和肺癌的较 高风险有关联。 • 关于久坐行为与肥胖症量度之间的关联， 证据不充分，需要开展进一步研究。 • 限制久坐行为的收益超过潜在风险。 是否存在剂量-反应关系（总量、频 率、持续时间、中断强度）？ 总体而言，有中等质量证据表明久坐时 间（自行报告或借助设备衡量的坐姿或看电 视时间）与全因死亡率、心血管疾病死亡 率、癌症死亡率和新发心血管疾病之间存在 非线性剂量－反应关系(8, 35, 87)。 近期的一项荟萃分析提供了高质量证 据，说明加速度感应器衡量的久坐总时间与 全因死亡率之间的剂量－反应关系(65)，报 告久坐时间增加与全因死亡率之间有显著关 联。针对中等至剧烈强度身体活动时间等潜 在混杂因素进行校正后，久坐时间四分位 数增加的风险比为1.00（参考值；久坐时间 最少）；1.28（1.09–1.51）；1.71（1.36– 2.15）；2.63（1.94–3.56）(65)。对久坐行 为与死亡率之间剂量-反应关系的这项分析 表明，约7.5-9小时起风险逐渐增加，超过 9.5小时风险更为突出。每天10小时或12小时 的久坐行为对应更高死亡风险比分别为1.48 （1.22–1.79）和2.92（2.24–3.83）(65)。 最近另外一项荟萃分析评估了经过身体 活动校正后，久坐总时间与全因死亡率之间 的剂量－反应关系，报告两者之间为非线 性关联（≤8小时/天，RR每小时/天= 1.01 (1.00–1.01)；接触> 8小时/天为1.04（1.03– 1.05））；与心血管疾病死亡率也是非线性关 联（≤6小时/天，RR=1.01(0.99-1.02)；>6小 时/天,RR=1.04（1.03-1.04））(87)。同一研 究中，经过体力活动和看电视（1.09（1.07– 1.12））校正后，2型糖尿病与久坐行为总量 （1.01（1.00-1.01））之间有微小线性剂量- 反应关系(87)。 总体而言，有证据支持较多久坐行为关 联较差健康结果，结论是有充分证据支持尽 量减少久坐时间减少健康风险的做法。但考 虑到各项综述评估久坐行为的方法差异很大 （通过自行报告坐姿时间、看电视时间或是 借助设备（加速度感应器）评估），加上各 项健康结果、中等至剧烈强度身体活动不同 水平和各人口亚群体相关的久坐时间阀值 可能各不相同，证据不足以设定有具体时间 （量化）的建议。 除了久坐行为总量外，还审查了关于久 坐行为累积模式的证据。但证据有限，无法 就中断久坐行为的频率和/或持续时间提出 建议。 TGDG的结论是： • 证据不够充分，无法设定久坐行为的量化 （规定时间）建议。 • 证据不够充分，无法就中断久坐行为的频 率和/或持续时间提出建议。 成年人（18–64岁） 40 41 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 这种关联是否因久坐行为的种类和类型 而异？ 某些类型或不同种类的久坐行为可能比 其他久坐行为更有害，一方面是直接关联的 后果，另一方面是可能占用了更健康的身 体活动时间。虽然对久坐行为的研究迅速增 加，但直接比较不同种类久坐行为与不同健 康结果之间关联的证据有限。例如，一些研 究报告说，以看电视为准的久坐行为与坐姿 总时间相比，其结果更为明显(87)。这可能是 与自行报告措施和工具有关的差分测量误差 或残余混杂的原因。目前，证据不足以确定 不同健康结果在关联上的差异，以及这些关 联对于各亚群体的区别。 越来越多的研究正在借助设备衡量与健 康结果有关的身体活动和久坐时间。然而， 借助设备测量久坐时间可能会出现分类错 误，因为许多情况下这些设备的放置方法（ 如手腕、腰部）目前未能区分不同姿态（如 卧、坐和站立不动）。今后通过统一报告模 式和区分不同姿态的方法进行研究，将有助 于加强了解久坐行为的规律。 GDG的结论是： • 证据不够充分，无法就久坐行为的不同种 类或类型提出建议。 身体活动水平是否会改变久坐行为对死 亡率的影响？ 人们对久坐行为影响健康结果的问题越 来越感兴趣，从而催生了对不同水平身体 活动和久坐行为潜在相互作用的研究。根 据现有研究，有中等质量证据表明久坐行 为与全因死亡率、心血管疾病死亡率和癌症 死亡率的关系会随着中等到剧烈强度身体活 动量变化(8, 9, 35)。总体研究发现显示，久 坐行为对那些中等至剧烈强度身体活动不多 的人影响更大，或者反过来说，较多中等至 剧烈强度身体活动可以减轻与较多久坐行为 相关的不利健康结果。 久坐时间和全因死亡率的相关风险已证 实在身体活动水平较低时比水平较高时更为 突出(35)。Ekelund等人在一项统一荟萃分 析中研究了100多万名男性和女性的久坐行 为和身体活动对全因死亡率的共同和分层效 应，发现关联性因身体活动水平而异(9)。分 析使用久坐行为（坐姿）以及中等至剧烈强 度身体活动的四分位数，发现与参考值（每 天保持坐姿<4小时，中等至剧烈强度身体活 动的最高四分位数[> 35.5 MET-小时/周]） 比较，在随访期间，那些每天保持坐姿8小 时以上，但同时每周报告活动时间超过35.5 MET-小时的人，死亡风险没有增加（HR= 1.04 [95% CI：0.99至1.10]）。相比之下， 坐姿时间最少（<4小时/天）和身体活动四 分位数最低（<2.5 MET-小时/周）的人，随 访期间死亡风险显著增加（HR= 1.27 [95% CI：1.22至1.31]）。该研究得出结论，每天 约60-75分钟的中等强度至剧烈强度身体活 动（最高四分位数）可以减轻甚至消除久坐 行为与健康结果之间的不利关联(9)。PAGAC 的系统综述(35)总结了久坐行为与中等至剧 烈强度身体活动的关系，如图2所示。 成年人（18–64岁） 40 41建议 最近的另一项研究提供了研究与病因 特异死亡率的同一关联性的新证据，得出 类似结果(8)。在一项大型统一荟萃分析中 （9项研究，n= 850 000，CVD死亡率；8 项研究，n= 777 000，癌症死亡率），结 果显示较高水平中等至剧烈强度的身体活 动能减缓大量久坐行为伴随的心血管疾病 死亡率风险上升的问题，无论久坐行为是 保持坐姿还是看电视(8)。研究表明，每天 保持坐姿8小时以上的人死亡风险更高， 但身体活动最多的四分位数除外，后者的 这种关联得到缓解。更具体地说，那些每 天保持坐姿8小时以上的人，心血管疾病死 亡率风险比参照组（< 4小时/天）高32% （p 为趋势< 0.001）。身体活动其他四分 位数方面的结果较不突出，但与参考组相比 仍然显著（2nd四分位数，HR= 1.11 [95% CI：1.03至1.20]；3rd四分位数，HR= 1.14 [95% CI：1.03至1.26]）。在中等强度和剧 烈强度身体活动各分层中，观察到电视时间 和心血管疾病死亡率之间有类似关联(8)。 与癌症死亡率之间的关联情况更为复杂， 但总体而言如果将坐姿总时间作为评估指标， 较高水平身体活动能减少久坐行为的不利 影响。 根据这一证据得出一致意见，应建议有 大量久坐行为的人进行更高水平的中等强度 至剧烈强度的身体活动，这种做法收益大于 风险。 GDG的结论是： • 有中等质量证据表明久坐行为与全因死亡 率、心血管疾病和癌症死亡率的关系随着 中等至剧烈强度身体活动量而变化。 • 增加中等至剧烈强度身体活动量可减缓久 坐行为与健康结果之间的不利关联。 图2：久坐行为与身体活动量的关系 改编自PAGAC 成年人（18–64岁） 良 好 做 法 更多身体活动 更 多 久 坐 时 间 高风险 低风险 更 少 久 坐 时 间 以 及 更 多 身 体 活 动 增加 身 体 活 动 减 少 久 坐 时间 42 43 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 老年人 (65岁以上) 对于成年人来说，身体活动的收益体现在以下健康结果：改善全因死 亡率、心血管疾病死亡率、新发高血压、新发位点特异性肿瘤1、新发2型糖 尿病、心理健康（减少焦虑和抑郁症状）、认知健康和睡眠；肥胖指数也能 改善。 建议： 所有老年人应定期进行身体活动。 强烈推荐，中等质量证据 老年人应该每周进行至少150- 300分钟的中等强度有氧活动；或 至少75-150分钟的剧烈强度有氧活 动；或等量的中等强度和剧烈强度组 合活动，可以获得巨大健康收益。 强烈推荐，中等质量证据 老年人还应进行中等强度或更高 强度的肌肉强化活动，锻炼所有主要 肌肉群，每周2天或2天以上，能带 来额外健康收益。 强烈推荐，中等质量证据 在每周身体活动中，老年人应该 进行多样化身体活动，侧重于中等 或更高强度的功能性平衡和力量训 练，每周3天或3天以上，以增强功 能性能力和防止跌倒。 强烈推荐，中等质量证据 老年人可以将每周中等强度有氧 活动增加到300分钟以上；或进行 150分钟以上的剧烈强度有氧活动； 或等量的中等强度和剧烈强度组合 活动，可获得额外健康收益。 条件性推荐，中等质量证据 对于老年人，身体活动可以作为娱乐休闲（游戏、比赛、运动或有计划的锻炼）、 交通（轮式运动、步行和骑自行车）、工作或家务的一部分，在日常工作、教育、家庭 和社区环境中进行。 身体活动建议 • 少量身体活动优于不活动。 • 如果老年人未达到建议活动水平，少量身体活动有益健康。 • 老年人应从少量身体活动开始，逐渐增加频率、强度和持续时间。 • 老年人应该在自身功能性能力允许的范围内进行身体活动，并根据健康水平调整 身体活动强度。 良 好 做 法 42 43建议 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 支持性证据和理由 为制定这些针对老年人的指南，使用并更新了PAGAC全面证据综合结果(35)。有15项综 述符合纳入标准，为研究老年人身体活动与健康相关结果（预防跌倒、跌倒相关伤害、身体 机能、衰弱和骨质疏松症）的关联提供了参考。 预防跌倒的证据采用并更新了Sherrington等人2019年的Cochrane协作网系统综述 (42)，为原始综述的最终检索日期到2019年11月（9项新研究）以来公布的证据。使用 PubMed在2008年至2019年11月发表的综述中搜索现有关于骨质疏松症和肌肉减少症的系统 综述，未发现新综述，有8项新研究。 关于方法、数据提取和证据简介的全部细节见《网络附件：证据简介》 。 对于老年人（65岁以上），身体活动与 健康相关结果之间有何关联？ 评估老年人身体活动与全因死亡率和病 因特异性死亡率、心血管疾病、2型糖尿病 和癌症发病率、肥胖症、心理健康和认知等 健康结果之间关联的主要证据基础是针对成 年人整理和审查的科学文献。这部分证据被 接受并类推至老年人，因为大多数研究没有 说明年龄上限标准，因此包括65岁以上的成 年人。 对证据进行了进一步审查，研究和了解 身体活动与老年人独有健康相关结果之间的 关联，包括预防跌倒、跌倒相关伤害、身体 机能、虚弱和骨质疏松症。 老年人体质下降往往表现为跌倒和跌倒 相关伤害，可能造成严重后果。意外跌倒是 外在（环境）和内在（如影响姿势控制的肌 肉骨骼或神经系统异常）因素共同造成的结 果。有证据表明，身体活动——特别是包括 平衡、力量、耐力、步态和身体机能组合训 练的多样化身体活动方案——可降低老年 人跌倒几率和跌倒受伤风险。最近的证据表 明，运动可以使老年人跌倒率最多降低23% （汇总率比（RaR）0.77[95% CI：0.71至 0.83]），可以显著降低跌倒受伤的风险，包 括导致骨折、头部外伤、开放性创伤、软组 织损伤或任何其他需要医疗护理或住院的损 伤在内的严重跌倒(42)。这部分证据符合并 再度确认了其他综述的研究发现(35)。 肌肉和骨量在成年早期达到高峰后， 往往会随着年龄增长而下降（即肌肉减少 症和骨质减少症/骨质疏松症），与力量 和身体机能下降或有关联。有证据表明， 定期身体活动可以改善老年人的身体机 能，并降低与年龄相关的身体机能缺失风 险。研究结果显示以下方面的良好效果： 动态平衡（SMD= 1.10 [95% CI：0.29至 1.90]）；肌肉力量（SMD= 1 . 13 [95% CI：0.30至1.96]）；柔韧性（SMD= 1.22 [ 95% C I：0 . 39至2 .04 ]）；心肺功能 （SMD= 1.48 [95% CI：0.42至2.54]） (94)。还有证据表明，较高水平身体活动 可以改善老年人的骨骼健康，从而预防骨 质疏松症（汇总标准化效应为0.21 [95% CI：0.06至0.36]）(95)。身体活动干预措施 可改善腰椎和股骨颈（髋关节）骨密度。 GDG的结论是： • 有中等质量证据表明身体活动可改善一般 老龄人口的身体机能，降低年龄相关的身 体机能缺失风险。 • 有低质量证据表明向老年人推荐的身体活 动量和活动种类的风险不高，而且收益大 于风险。 老年人（65岁以上） 44 45 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 是否存在剂量-反应关系（量、持续时 间、频率、强度）？ 有证据表明，老年人的身体活动量与身 体机能受限的风险成反比关系。一般来说， 更多身体活动（频率、持续时间和/或量） 会带来更大收益(35)。有证据表明，想提高 一般功能性能力，快速阻力训练可能优于中 速阻力训练（SMD= 0.41 [95% CI：0.18至 0.65]；SPPB（SMD= 0.52 [95% CI：0.10 至0.94]））(96)。 研究身体活动和预防跌倒之间剂量-反应 关系的证据有限；但大多数提供支持性证据 的研究都是测试每周3天的运动计划。 GDG的结论是： • 有高质量证据表明一般老年人有氧运动量 与身体机能受限风险之间的反向剂量-反应 关系。 老年人（65岁以上） 这种关联是否因身体活动的种类或类型 而异？ 包括平衡、力量、耐力、步态和身体机能 组合训练在内的身体活动计划，可以降低老年 人跌倒的几率和跌倒受伤的风险。 对11个随机对照试验的综述证据显示，通 过各种不同的身体活动干预措施（通常是平 衡和功能练习加上抗阻力练习），老年人跌倒 的几率最多可以降低28%（RaR= 0.72 [95% CI：0.56至0.93]）(42)。抗阻力练习的效果 不能确定，依赖的数据有限（RR= 0.97 [95% CI：0.14至6.49]；1项试验；n= 73）(42)。 证据还表明，包括多种练习的运动计划与 未包括多种练习的运动计划相比，对骨骼健康 有更大的积极影响（标准化效应为0.45[95% CI：0.20至0.71]；p = 0.001）(95)。 GDG的结论是： • 有高质量证据表明，结合平衡、力量、步态 和功能性训练（如多样化身体活动）的较高 水平身体活动可降低老年人跌倒几率和跌倒 受伤的风险。 • 有中等质量证据表明包含多种练习的运动计 划可能对骨骼健康和预防骨质疏松症有显著 效果。 44 45建议 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 老年人 (65岁以上) 久坐行为建议 支持性证据和理由 2010年《关于身体活动有益健康的全球建议》(1)未涵盖久坐行为。由于缺乏按人群分类 的证据，评估老年人久坐行为与健康结果之间关系的主要证据基础是针对成年人整理和审查 的科学文献，因为大多数研究没有说明年龄上限标准，因此包括65岁以上的成年人。对一般 成年人群久坐行为相关证据的研究发现进行了审查，并评估是否有证据表明老年人会有不同 结果、结果对其不适用或有禁忌。 更多中等和剧烈强度身体活动可抵消大量久坐行为的潜在风险，这方面的证据是否适用 也纳入考虑，并加以类推，为老年人通用关键健康结果的建议提供参考。 在生命的最后几十年中，由于身体机能的原因，可能更难限制久坐行为，但人们承认， 以任何强度的身体活动（包括轻微强度）取代久坐时间仍然能带来健康收益。 关于方法、数据提取和证据简介的全部细节见《网络附件：证据简介》 。 GDG的结论是： • 一般成年人口久坐行为的证据，包括从事更多中等强度到剧烈强度身体活动可抵消大量久坐 行为潜在风险带来的收益，可以类推，为老年人通用关键健康结果的相关建议提供参考。 • 老年人尽量减少久坐行为带来的收益大于风险。 老年人较多久坐行为与下列不良健康结果有关：全因死亡率、心血管疾病 死亡率和癌症死亡率、心血管疾病、癌症和2型糖尿病发病率。 建议： 老年人应该限制久坐时间。久坐时间改用来进行各种强度的身体活动 （包括轻微强度）能带来健康收益。 强烈推荐，中等质量证据 为了帮助减少过多久坐行为对健康的不利影响，老年人进行中等到剧烈强 度身体活动应力求超过建议水平。 强烈推荐，中等质量证据 对于老年人，久坐行为的定义是职业、教育、家庭、社区环境和交通中，清醒状 态下坐卧的时间，能量消耗低。 46 47 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 这些指南涉及孕期和产后期的身体活动和母婴健康结果。指南适用 于所有孕妇和产后妇女，不论年龄、文化背景或社会经济地位。怀孕和分 娩后的时期是妇女生命阶段的一部分，为成年人提供的建议中详细说明了整 个成年时期进行身体活动的收益。 孕妇和产后妇女应接受卫生保健提供者的产前和产后护理，后者可根据其病史提出特别注意事 项，并就孕期或产后期参加身体活动的禁忌提出建议。这些指南以公共卫生和人群的情况为基础。 对于有妊娠或分娩并发症的妇女，应寻求临床指导。 孕妇和产后妇女应在条件允许、无禁忌症的情况下根据自身能力尽力达到建议水平。 孕妇和产后妇女 对于孕妇和产后妇女，身体活动可以作为娱乐休闲（游戏、比赛、运动或有计划的 锻炼）、交通（轮式运动、步行和骑自行车）、工作或家务的一部分，在日常工作、教育、家 庭和社区环境中进行。 身体活动建议 孕妇和产后妇女在孕期和产后的身体活动对母婴健康有以下收益：先兆 子痫、妊娠高血压、妊娠糖尿病、妊娠期过度增重、分娩并发症和产后抑郁 症的风险降低，新生儿并发症减少，对出生体重无不良影响；死产风险未见 增加。 建议所有无禁忌症的孕妇和产后妇女： 整个孕期和产后应定期进行身体活动； 强烈推荐，中等质量证据 每周应该进行至少150分钟中等强度有氧活动，可以获得巨大健康收益； 强烈推荐，中等质量证据 进行各种有氧和肌肉强化运动。增加轻柔拉伸运动可能也有益处。 强烈推荐，中等质量证据 此外： 怀孕前习惯进行剧烈强度有氧运动的妇女，或者经常进行身体活动的 妇女，可以在怀孕和产后继续原有活动。 强烈推荐，中等质量证据 46 47建议 支持性证据和理由 《关于身体活动和久坐行为的指南》（2020年）涉及孕妇和产后妇女的部分采用并更新 了对7项关于关键重要结果的系统综述(28–34)的证据综合。7项中有4项符合纳入标准。 关于方法、数据提取和证据简介的全部细节见《网络附件：证据简介》 。 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 对于孕妇和产后妇女，身体活动与健康 相关结果之间有何关联？ 怀孕前和怀孕期间的身体活动有助于 降低怀孕常见并发症的风险。怀孕期间 进行身体活动与减少妊娠体重增加幅度 （MD= 1.14  kg [95% CI：1.67至 0.62]） (97)和减少妊娠糖尿病风险（RR= 0.71 [95% CI：0.57至0.89]）(97)有显著关联，孕前身 体活动也有关联（OR= 0.70 [95% CI：0.57 至0.85]）(31, 34, 97)，包括超重妇女和患肥 胖症的妇女(97)。 怀孕期间的身体活动似乎不会增加妊娠 高血压或先兆子痫的发病率(31)。证据表明， 对于超重或肥胖症孕妇，身体活动干预组与 标准产前护理组在妊娠高血压（RR= 0.63 [ 9 5% C I：0 . 3 8至1 . 0 5 ]）或先兆子痫 （RR= 1.39 [95% CI：0.66至2.93]）的发病 率上没有显著差异(97)。 长期以来，人们一直顾虑孕妇身体活动 对胎儿发育和分娩可能产生不利影响。然 而，最近的证据表明，身体活动不会增加流 产、死产或分娩并发症发生率的风险(32)。有 证据表明，身体活动干预组与标准产前护理 组之间，超重或肥胖症孕妇的剖腹产率没有 差异(97)。 比较身体活动干预组与标准产前护 理组，怀孕期间的身体活动不会增加对 出生体重 ( 98 ) 或早产(32 )不良影响的风 孕妇和产后妇女 良 好 做 法 • 少量身体活动优于不 活动。 • 如 果 孕 妇 和 产 后 妇 女未达到建议活动水 平，少量身体活动有 益健康。 • 孕妇和产后妇女应从 少量身体活动开始， 逐渐增加频率、强度 和持续时间。 • 盆底肌肉训练可以每 天进行，减少尿失禁 风险。 • 气温过高时避免进行身 体活动，尤其是高湿度 环境下。 • 身体活动之前、期间和 之后饮水保持水分。 • 避免参与涉及身体接 触、跌倒风险大或可 能限制氧化作用的活动 （例如，平时不在高海 拔地区生活的人应避免 高海拔地区活动）。 • 孕早期过后避免仰卧位 活动。 • 若考虑参加体育比赛或运 动量远高于指南建议标准 时，孕妇应寻求专业卫生 保健人员监督。 • 卫生保健提供者应告知 孕妇出现哪些危险信号时 须停止活动；或者出现此 类信号时限制身体活动并 立即咨询合格卫生保健提 供者。 • 分娩后逐渐恢复身体活 动，剖腹产分娩应咨询卫 生保健提供者。 孕妇进行身体活动时的其他安全注意事项： 48 49 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 险，甚至可能具有保护作用，降低了 总体风险 (98 )，即使超重或肥胖症孕妇 （RR=1.02[95% CI：0.54至1.92]）或大于胎 龄儿（RR= 0.90[95% CI：0.65至1.25]）也 是如此(97)。 在产后期间，母亲会经历许多生理和情 绪变化。有证据表明，怀孕期间的身体活动 可能与产后抑郁症有反向关联(29)。对6项 试验和11项孕期身体活动观察性研究(99)的 荟萃分析证据表明，孕期身体活动与产后抑 郁症之间存在显著反向关联（SMD= 0.58 [95% CI：1.09至 0.08]）。限于5项至少 采用中等强度干预措施的研究时，效果更 强（SMD= 0.70 [95%CI：1.19至 0.22]） (99)。 GDG的结论是： • 有高质量证据表明孕期身体活动可减少孕 期体重增加幅度和妊娠糖尿病风险。 • 有中等质量和高质量证据表明身体活动不 会增加妊娠高血压发病率。 • 有中等质量证据表明身体活动不会增加流 产、死产或分娩并发症的发生率；有中等 质量证据表明参加剧烈强度身体活动的孕 妇会减少早产风险。 • 有低质量和中等质量证据表明身体活动不 会增加低出生体重、小于胎龄儿或大于胎 龄儿的风险。 • 有低质量证据表明孕期身体活动会减轻产 后抑郁症状。 • 向孕妇和产后妇女推荐的身体活动量和活 动种类的风险不高，且收益超过风险。 是否存在剂量-反应关系（量、持续时 间、频率、强度）？ 在孕期和产后期间进行身体活动的证据 中，干预措施在身体活动量（即剂量）上存 在差异，持续分钟数和每周的频率都不相 同。一般而言，现有证据反映的情况是每周 至少进行3次有氧身体活动，每次通常持续 30到60分钟。这部分证据来自于评估剂量对 健康影响的研究，该剂量大致符合一般成年 人的建议活动量，即每周进行150分钟中等 强度身体活动。 虽然更多身体活动（频率、持续时间和/ 或量）通常会带来更大收益，但需要进一步 研究来更详细地了解剂量-反应关系。孕前 参加较多和较少的休闲身体活动相对比，可 显著降低妊娠糖尿病风险（OR= 0.54 [95% CI：0.34至0.87]）(100)。还有证据表明，从 事剧烈强度体育活动的孕妇的婴儿早产风险 降低幅度不大，但很明显（RR= 0.20 [95% CI：0.36至 0.03]）(98)。关于锻炼远高于建 议水平是否安全或有额外收益未发现证据。 GDG的结论是： • 证据不足以确定孕期和产后期间身体活动和 特定关键健康结果之间的剂量-反应关系。 • 总体证据显示关键健康结果的收益，证据 的基础是大致符合一般成年人建议身体活 动量的干预措施，即每周150分钟的中等强 度身体活动。 • 向孕妇和产后妇女推荐的中等强度身体活 动量或频率没有理由与一般成年人不同。 • 有中等质量证据表明参与剧烈强度身体活 动的孕妇可降低早产风险。 孕妇和产后妇女 48 49建议 这种关联是否因身体活动的种类或类型 或时间（孕前、产前或产后）而异？ 证据来自主要评估休闲类身体活动的研 究；活动种类主要是有氧运动（如步行或游 泳），但部分证据源自评估干预措施的研 究，这些干预措施也包括力量训练（如循环 训练）或有氧运动和肌肉强化运动的组合训 练。然而，总体而言没有充分证据确定身体 活动与健康结果之间的关联是否因身体活动 的种类或类型或时间（孕前、产前或产后） 而异。 GDG的结论是： • 有中等质量证据表明孕妇和产后妇女应从 事各类有氧运动和肌肉强化运动。轻柔拉 伸运动可能也有益处。 孕妇和产后妇女 50 51 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 支持性证据和理由 2010年《关于身体活动有益健康的全球建议》(1)未涵盖久坐行为。由于缺乏按人群分 类的证据，评估孕妇和产后妇女久坐行为与健康结果之间关系的主要证据基础是针对成年 人整理和审查的科学文献。 对一般成年人群久坐行为相关证据的研究发现进行了审查，并评估是否有证据表明孕 妇和产后妇女会有不同结果、结果对其不适用或有禁忌。 根据现有证据和专家意见对这些证据进 行了类推，以便为世卫组织关于孕妇和产后 妇女久坐行为的新建议提供参考，涵盖通用 的关键健康结果。考虑到所用证据的间接 性，下调了证据质量。 鉴于缺乏专门针对这一群体的证据，而 且研究排除孕妇，因此增加身体活动量、超 过建议水平，以抵消久坐行为不利影响的建 议不适用于孕妇和产后妇女。 GDG的结论是： • 一般成年人久坐行为的证据可以类推， 为孕妇和产后妇女涉及通用关键健康结 果的建议提供参考。 • 孕妇和产后妇女尽量减少久坐行为的收 益大于风险。 • 出于间接性的原因应当下调证据质量。 孕妇和产后妇女 久坐行为建议 对于孕妇和产后妇女，久坐行为的定义是职业、教育、家庭、社区环境和交通中， 清醒状态下坐卧的时间，能量消耗低。 和所有成年人一样，孕妇和产后妇女较多久坐行为与下列不良健康结果有 关：全因死亡率、心血管疾病死亡率和癌症死亡率、心血管疾病、癌症和2 型糖尿病发病率。 建议： 孕妇和产后妇女应该限制久坐时间。久坐时间改用来进行各种强度的身体 活动（包括轻微强度）能带来健康收益。 强烈推荐，低质量证据 50 51建议 迄今为止，大多数针对慢性病患者的身体活动指南仅限于临床或治疗 指导。例如，以下方面的专业医学协会形成了临床实践建议和资源：肿瘤 (101)、2型糖尿病(102)、高血压(103)和其他慢性病(104)。世卫组织的临床实践 指导文件也建议慢性病患者从事身体活动(17)。 这些指南是世卫组织第一批基于人群的慢性病患者身体活动指南，专门针对癌症患者 （下称“癌症幸存者”）、高血压、2型糖尿病和艾滋病患者。 考虑到普及有效的艾滋病抗逆转录病毒治疗已有进展，艾滋病现在也被视为一种慢性病。至于正 接受急性治疗（例如化疗）或慢性病用药尚不稳定的患者，卫生保健提供者亦应参考各种慢性病相关 的临床实践指南。 患有慢性病的成年人和老年人 (18岁以上) 对于患有慢性病的成年人来说，身体活动可以作为娱乐和休闲（游戏、比赛、运动或有计 划的锻炼）、交通（轮式运动、步行和骑自行车)、工作或家务的一部分，在日常职业、教育、 家庭或社区环境中进行。 所有成年癌症幸存者和成年高血压、2型糖尿病和艾滋病患者应根据自身能力，在无禁忌症 的情况下尽力达到建议水平。 身体活动建议 身体活动可以为患有以下慢性病的成年人和老年人带来健康收益：对癌 症幸存者来说，身体活动可以改善全因死亡率、肿瘤特异性死亡率、肿瘤复 发或第二原发肿瘤的风险；对高血压患者来说，身体活动可以改善心血管疾 病死亡率、病情进展、身体机能、与健康相关的生活质量；对2型糖尿病患 者来说，身体活动可以降低心血管疾病死亡率和病情进展指标；对艾滋病患 者来说，身体活动可以改善身体素质和心理健康（焦虑和抑郁症状减少）， 对病情进展（CD4计数和病毒载量）或身体成分无不良影响。 建议： 患有上述慢性病的所有成年人和老年人应定期进行身体活动。 强烈推荐，中等质量证据 患有此类慢性病的成年人和老年人每周应该进行至少150-300分钟的中等 强度有氧活动；或至少75-150分钟的剧烈强度有氧活动；或等量的中等强度 和剧烈强度组合活动，可以获得巨大健康收益。 强烈推荐，中等质量证据 患有此类慢性病的成年人和老年人还应进行中等强度或更高强度的肌肉强 化活动，锻炼所有主要肌肉群，每周2天或2天以上，能带来额外健康收益。 强烈推荐，中等质量证据 良 好 做 法 52 53 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 支持性证据和理由 这些指南评估了身体活动与以下健康结果之间的关联：对于癌症幸存者——全因死亡 率、肿瘤特异性死亡率、肿瘤复发或第二原发肿瘤风险；对于高血压患者——心血管疾病死 亡率、共病风险、身体功能、健康相关生活质量和病情进展(在这里定义为血压对身体活动的 反应）；对于2型糖尿病患者——心血管疾病死亡率，共病风险、身体功能、健康相关生活质 量和病情进展；对于艾滋病患者，身体功能（身体素质、运动耐力和力量）、健康相关生活 质量、心理健康（焦虑和抑郁症状）、心血管代谢疾病风险指标（血脂、血糖和身体成分） 及对病情进展的不良影响（即CD4计数和病毒载量）。 为这些指南提供参考的证据是PAGAC的报告(35)，添加了2017年至2019年确定的16项新 综述，涉及癌症（n=1）、高血压（n=2）和2型糖尿病（n=13）。此外，针对艾滋病患者身 体活动和健康相关结果委托进行的伞状综述提供的证据源自2002-2018年发表的19项合格综 述。关于方法、数据提取和证据简介的全部细节见《网络附件：证据简介》 。 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 患有慢性病的成年人和老年人（18岁以上） 在每周身体活动中，患有此类慢性病的老年人应该进行多样化身体活动， 侧重于中等或更高强度的功能性平衡和力量训练，每周3天或３天以上， 以增强功能性能力和防止跌倒。 强烈推荐，中等质量证据 无禁忌症的情况下，患有此类慢性病的成年人和老年人可以将每周中等强 度有氧活动增加到300分钟以上；或进行150分钟以上的剧烈强度有氧活动； 或等量的中等强度和剧烈强度组合活动，可获得额外健康收益。 条件性推荐，中等质量证据 良 好 做 法 • 如无法达到上述建议活动水平，患有 此类慢性病的成年人应根据自身能力 进行身体活动。 • 患有此类慢性病的成年人应从少量身 体活动开始，逐渐增加频率、强度和 持续时间 • 患有此类慢性病的成年人应咨询身 体活动专家或卫生保健专业人员， 听取建议，确定适合自身需求、能 力、功能受限/并发症、用药情况和 整体治疗方案的活动类型和活动量。 • 无禁忌症者进行不超过快走或日常 生活需要的轻微或中等强度身体活 动之前，一般无须通过体检。 52 53建议 对于成年和老年（18岁以上）癌症患者 （癌症幸存者）、高血压患者、2型糖尿 病患者和艾滋病患者，身体活动与健康 相关结果之间有何关联？ 身体运动能促进新陈代谢、激素和炎症通 路短期和长期的有益变化，肿瘤发病和存活期 有保护作用(35)。证据显示，下列癌症确诊后 较高水平身体活动在全因死亡率方面有保护 作用：乳腺癌（HR= 0.58 [95% CI：0.52至 0.65]，17项研究）；结肠直肠癌（HR= 0.63 [95% CI：0.50至0.78]，10项研究），女性 生殖系统癌（HR= 0.66 [95% CI：0.49至 0.88]，4项研究）；神经胶质瘤（HR=0.64 [95% CI：0.46至0.91]，1项研究）；血癌 （HR= 0.60 [95% CI：0.51至0.69]，2项 研究）；肾癌（HR= 0.60 [95% CI：0.38 至0.95]，1项研究）；肺癌（HR= 0.76 [95% CI：0.60至0.97]，2项研究）；前列腺 癌（HR= 0.60 [95% CI：0.46至0.79]，5项 研究）；胃癌（HR= 0.75 [95% CI：0.61至 0.93]，1项研究）(105)。 癌症确诊后身体活动量增加也可降低 乳腺癌、结肠直肠癌和前列腺癌幸存者的 病因特异性死亡率风险。荟萃分析发现， 确诊癌症后与身体活动总量最低的人群相 比，活动总量最高人群的死亡率风险降低， 具体数据如下，所有癌症总体（HR=0.63 [95% CI：0.53至0.75]，4项研究）；乳腺 癌（HR=0.63 [95% CI：0.50至0.78]，13 项研究）；结肠直肠癌（HR= 0.62 [95% CI：0.44 至0.86]，6项研究）；前列腺癌 （HR= 0.70 [95% CI：0.55至0.90]，4项研 究）(105)。但证据不足以确定身体活动与肿 瘤复发或第二原发肿瘤是否有关联。 身体活动对于高血压的一级预防和管理 都很重要，有证据表明，身体活动改善了高 血压患者的身体机能、心血管疾病进展（ 即血压对身体活动的反应）和心血管疾病 死亡率(35) 。例如，与没有运动的对照组相 比，活动量大的高血压患者可使收缩压降 低约12毫米汞柱，舒张压降低约6毫米汞柱 （SBP MD= 12.26 mm Hg [95% CI：15.17至 9.34]，p= < 0.05；DBP MD= 6.12 mm Hg [95% CI：7.76至 4.48]，p= < 0.05）(106)。 新出现的证据表明，与活动不足的高血压患者 相比，活动量大的高血压患者的健康相关生活 质量显著改善(54)。 包括有氧运动、肌肉强化运动、有氧运动 加肌肉强化运动在内的身体活动，与成年2型 糖尿病患者病情进展风险次级指标（糖化血红 蛋白、血压、身体质量指数和血脂）的改善有 关联(35)。例如，近期研究发现，与对照组相 比，抗阻力训练后糖化血红蛋白降低幅度更 大，高强度抗阻力训练对空腹胰岛素有显著的 积极效果(107)。现有证据不足以评估2型糖尿 病成年患者的身体活动对健康相关生活质量和 身体机能的影响。 艾滋病患者从事身体活动可改善心肺功 能。研究的干预措施包括每周3天、至少30 分钟的有氧练习或结合渐进式肌肉强化练习 的活动(108, 109)。还有证据表明，虽然结果 并非完全一致，身体活动干预措施可以改善 心血管代谢风险标志物（如脂质标志物）； 胰岛素浓度未见影响，但有氧训练后血糖降 低(110)。艾滋病患者进行身体活动，无论是 有氧运动，还是结合肌肉强化练习的运动， 都能改善健康相关生活质量(111)和减轻抑郁 和焦虑症状(112)。对抑郁症的荟萃分析（9 项研究）显示，干预组（p= 0.02）的SMD 为0.84（95% CI：-1.57至-0.11)，更优。 焦虑减轻的SMD（5项研究）也有统计学意 义，干预组更优（1.23 [95% CI：2.42至 0.04]，p= 0.04）(112)。与不锻炼的对照组相 比，锻炼的对照组参与者身体活动也关联以下 变化，去脂体重标准化平均值显著增加1.75公 斤，身体脂肪百分比显著减少1.12%，以及腿 部和臂部周围肌肉面积增加(111)，但艾滋病患 者未见BMI或腰围变化(111)。身体活动对艾滋 病病情进展的标志物无不良影响，如CD4计数 （细胞/mm3）或病毒载量(111)。重要的是， 这一证据表明，艾滋病作为慢性病不会受到身 体活动的不良影响。 患有慢性病的成年人和老年人（18岁以上） 54 55 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 GDG的结论是： • 有中等质量证据表明癌症确诊后身体活动 增加可降低癌症幸存者全因死亡率、病因 特异性死亡率和肿瘤特异性死亡率的相关 风险。 • 有高质量证据表明，身体活动降低高血压 成年患者心血管疾病进展风险。 • 有中等质量证据表明，身体活动改善高血 压成年患者的身体机能和健康相关生活 质量。 • 有高质量证据表明，身体活动可改善2型糖 尿病成年患者病情进展标志物（糖化血红 蛋白、血压、BMI和脂质）。 • 有中等质量证据表明，身体活动与艾滋病 患者的身体素质（最大耗氧量、运动耐 力）和肌肉力量有关联，身体活动有利于 艾滋病患者的身体成分、健康相关生活质 量和抑郁焦虑症状减轻，不会改变病毒载 量和CD4计数。 • 癌症幸存者和高血压、2型糖尿病和艾滋病 患者定期从事身体活动在特定健康结果方 面的收益超过风险。 是否存在剂量-反应关系（量、持续时 间、频率、强度）？ 癌症确诊后增加身体活动可以降低全因 死亡率和肿瘤特异性死亡率的相关风险。证 据显示确诊后增加身体活动与乳腺癌特异死 亡率和全因死亡率之间存在非线性关系，最 多达每周10-15 MET-小时（等于每周150分 钟中等至剧烈强度身体活动），没有证据表 明活动水平提高会带来危害(105)。有迹象表 明，其他癌症位点也存在类似的剂量-反应 关系，但研究数量太少，无法进行正式的荟 萃分析。需要进一步开展研究确定关联性的 强弱。 高血压患者的身体活动与心血管疾病死 亡率之间有明确的剂量-反应关系(35)。研究 结果表明，随着高血压范围内收缩压增加， 心血管疾病死亡率的风险增加，但又随着身 体活动的增加而减缓(35)。与针对一般人群的 建议类似，大多数传统干预措施为每周有3天 进行约30-60分钟的中等强度有氧运动和/或 每周2-3次抗阻力训练。 大量证据表明，2型糖尿病成年患者的 身体活动量与心血管疾病死亡率风险为逆曲 线关系(113–115)。随着身体活动量提高（从 低于、等于到高于建议的每周150分钟中等 强度活动量），风险逐渐降低。例如，与不 活动相比，从事某种活动可以让心血管疾病 死亡率风险下降32%（校正HR=0.68 [95% CI：0.51至0.92]），而活动量达到或超过 身体活动指南要求时，心血管疾病死亡率 风险下降多达40%（校正HR=0.60 [95% CI：0.44至0.82]）(115)。大多数干预措施为 每周150-300分钟中等强度有氧运动或75分 钟剧烈强度运动和/或2-3次抗阻力训练。对 于2型糖尿病成年患者的某些结果（如糖化 血红蛋白和血压），有证据表明增加有氧运 动（即每周超过150分钟，相对于每周不到 150分钟）效果更好，但关于强度的证据有限 (35)。 对于艾滋病患者，证据不足以确定身体 活动与身体成分、或是心血管代谢疾病中间 标志物（如血脂、胰岛素抵抗、空腹血糖浓 度或血压）之间的剂量-反应关系。提供证据 的大多数研究涉及的身体活动干预措施为每 周至少3次、为期12-48周、至少30分钟的中 等至剧烈强度有氧练习或有氧练习结合渐进 式抗阻力训练。也没有充分证据能确定与心 理健康及健康相关生活质量具体的剂量-反应 关系。提供现有证据的研究一般评估的身体 活动干预措施为每周3次或3次以上。 总体而言，有中等质量证据也有高质量 证据支持向特定慢性病患者人群推荐150- 300分钟的中等强度身体活动（或其他等量 活动），关联一系列特定健康结果。高血压 患者、2型糖尿病患者和癌症幸存者的证据表 患有慢性病的成年人和老年人（18岁以上） 54 55建议 明，更高水平的活动与更大收益有更明确的 关系。认定涉及特定慢性病和特定结果的证 据质量和直接性各有不同。力量训练证明有 积极结果的情况下，活动频率为每周2或3次 抗阻力训练。 GDG的结论是： • 有中等质量证据表明，癌症幸存者身体活 动与全因死亡率和肿瘤特异性死亡率降低 存在剂量-反应关系。 • 有高质量证据表明，高血压成年患者身体 活动与心血管疾病死亡率之间存在剂量-反 应关系。 • 有证据表明，2型糖尿病患者的活动量与心 血管疾病死亡风险之间存在逆曲线剂量反 应关系。 • 没有充分证据表明艾滋病患者身体活动与 心血管代谢疾病中间标志物、身体成分、 健康相关生活质量和焦虑抑郁症状之间存 在剂量-反应关系。 • 150-300分钟的中等强度有氧运动（或等 量运动）范围内的干预措施带来有利健康 结果，有力量训练的情况下，每周进行2至 3次抗阻力训练有积极结果。 这种关联是否因身体活动的种类和类型 而异？ 有证据表明，不同种类和类型的身体 活动都能带来有利健康结果。达到有氧 和肌肉强化类活动建议水平的癌症幸存 者与未达到的情况相比，癌症死亡率显 著降低（校正HR=0.70 [95% CI：0.50 至0 . 9 8 ]） ( 8 4 )。证据显示，仅达到肌 肉强化身体活动建议水平者与未达到者 相比，癌症死亡率相关结果也有所改善 （HR=0.66 [95% CI：0.48至0.92]）(84)。 一项荟萃分析也研究了各类型身体活动的关 联情况，发现各类癌症、乳腺癌和结肠直肠 癌的肿瘤特异性死亡率下降情况最为一致的 是娱乐类身体活动(105)。对于高血压成年患 者，有证据支持有氧运动、肌肉强化运动以 及两者的结合能够改善心血管疾病的病情进 展情况。各种传统身体活动（如有氧和抗阻 力类）对于高血压患者的降血压效果并无显 著差别(35)；但得出这一证据时并未直接比较 各种身体活动。还有新的证据支持其他形式 的运动对高血压患者的有益影响（如太极、 瑜珈、气功），但需要进一步研究这些特定 种类的运动才能确定关联性的强弱。 有氧活动、肌肉强化活动或两者结 合，可改善 2型糖尿病成人患者病情进 展风险的次级指标（糖化血红蛋白、血 压、BMI和血脂）(35 , 107 )。一项24个 RCT（n= 962）的综述报告，与对照组相 比，抗阻力训练组的糖化血红蛋白降低幅度 更大（MD= 0.45 [95% CI：0.65至 0.25]，20 次试验；n= 824）。与对照组相比，高强 度抗阻力训练组在空腹胰岛素方面的效果有 统计学意义（MD= 4.60 [95% CI：7.53至 1.67]，5次试验；n= 174）(107)。另外一项7 个RCT的（n= 189）的综述报告，与MICT组 相比，间歇性训练组（每周2–5次；每次训 练期间有1-4分钟的间隔时间；每次训练总时 长为20–60分钟）糖化血红蛋白降低0.26% (95% CI：0.46至 0.07%，5个RCT）， 与无训练对照组相比降低0.83%（95% CI：1.39%至 0.27%，4个RCT），有统计学 意义(116)。与针对一般人群的建议一样，大多 数此类干预措施为每周推荐150-300分钟中 等强度有氧运动（或75分钟剧烈强度活动） 和每周2-3次肌肉强化运动。针对某些结果（ 如糖化血红蛋白和血压），有证据表明增加 有氧活动（如每周超过150分钟，相对于每周 不到150分钟）效果更好，但关于强度的证据 有限。最近研究提供的证据表明，太极等传 统中式运动可能有利于控制血糖，但相关证 据的质量中等且有差异（如偏倚或不一致风 险）。需要进一步研究确定其关联性。 患有慢性病的成年人和老年人（18岁以上） 56 57 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 包括有氧运动和抗阻力训练在内的多种身 体活动已证实对艾滋病患者的健康相关生活 质量有积极影响(111)。近期关于有氧活动、渐 进式抗阻力练习或两者结合改变健康相关生 活质量的研究显示，整体健康状况和心理健 康都出现了显著改善。还有证据表明，有氧 运动和多样化运动都能减轻艾滋病患者的抑 郁和焦虑症状(112)。身体活动对心理健康相关 症状影响的证据包括有氧运动或有氧运动结 合渐进式肌肉强化活动或瑜伽。还有证据显 示，仅从事有氧运动或结合抗阻力练习均不 会导致艾滋病患者的病毒载量或CD4计数出 现显著变化(111)。 来自现有文献和最新文献的直接证据支持 向2型糖尿病和高血压患者推荐有氧和肌肉强 化身体活动。尽管缺乏公开证据，但有氧运 动和肌肉强化运动对于艾滋病患者和癌症幸 存者的收益从生物学角度判断有其合理性。 此外，正如GDG指出的那样，现行国际临床 实践指南建议这些人群进行有氧和肌肉强化 身体活动（例如ACSM根据证据系统综述推出 的“运动战胜癌症”指南(101)）。考虑到证据基 础还在扩大，下调了证据质量。 GDG的结论是： • 有中等质量证据表明，有氧运动或肌肉强 化运动的综合或叠加效应可降低癌症死亡 率，改善高血压患者的血压。 • 有高质量证据表明，有氧运动、肌肉强化 运动、有氧运动结合肌肉强化运动能改 善2型糖尿病成年患者疾病进展的标志物 （糖化血红蛋白、血压、身体质量指数和 脂质）。 • 有中等质量证据表明，仅从事定期有氧运 动，或结合抗阻力练习，不会导致艾滋 病患者的病毒载量或CD4计数发生显著 变化。 • 没有充分证据表明仅进行力量训练会影响 艾滋病患者的健康相关生活质量。 患有慢性病的成年人和老年人（18岁以上） 56 57建议 患有慢性病的成年人和老年人 (18岁以上) 久坐行为建议 支持性证据和理由 由于缺乏按人群分类的证据，评估成年和老年癌症幸存者以及高血压、2型糖尿病和艾滋 病成年和老年患者的久坐行为与健康结果之间关系的主要证据基础是针对成年人整理和审查 的科学文献。 对一般成年人群久坐行为相关证据的研究发现进行了审查，并评估是否有证据表明慢性 病成年和老年患者会有不同结果、结果对其不适用或有禁忌。 包括癌症幸存者和高血压、2型糖尿病和艾滋病患者在内，成年人较多久 坐行为与以下不良健康结果有关：全因死亡率、心血管疾病死亡率；癌症死 亡率；心血管疾病、癌症和2型糖尿病的发病率。 癌症幸存者和患有高血压、2型糖尿病和艾滋病的成年人，建议： 患有慢性病的成年人和老年人应限制久坐时间。久坐时间改用来进行各种 强度的身体活动（包括轻微强度）能带来健康收益。 强烈推荐，低质量证据 为了帮助减少过多久坐行为对健康的不利影响，患有慢性病的成年人和老 年人进行中等到剧烈强度身体活动应力求超过建议水平。 强烈推荐，低质量证据 2010年《关于身体活动有益健康的全球建议》(1)未包括久坐行为。这项关于久坐行为的 新建议适用于癌症幸存者和高血压、2型糖尿病和艾滋病患者。 久坐行为的定义是职业、教育、家庭、社区环境和交通中，清醒状态下坐卧的时间，能量 消耗低。 58 59 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 患有慢性病的成年人和老年人（18岁以上） 根据现有证据和专家意见对这些证据进 行了类推，以便为世卫组织关于慢性病成年 患者久坐行为的新建议提供参考，涵盖通 用的关键健康结果。对证据的类推主要基于 以下判断，大多数研究没有规定年龄上限标 准，涵盖65岁以上成年人，也有慢性病成年 患者，如癌症幸存者、高血压患者或2型糖尿 病患者。关于艾滋病患者久坐行为对健康影 响的证据不适用问题，未能确定原因。考虑 到制定这些建议所用证据的间接性，下调了 证据质量。 更多中等和剧烈强度身体活动可抵消大 量久坐行为的潜在风险，这方面的证据是否 适用也纳入考虑，并加以类推，为慢性病成 年患者通用关键健康结果的建议提供参考。 鉴于证据的间接性，下调了证据质量。 GDG的结论是： • 关于一般成年人久坐行为的证据可以类 推，为成年和老年癌症幸存者以及高血 压、2型糖尿病和艾滋病成年和老年患者的 通用关键结果建议提供参考，出于间接性 的原因下调了证据质量。 • 关于一般成年人更多中等和剧烈强度身体 活动可抵消大量久坐行为潜在风险的证据 可以类推，为成年和老年癌症幸存者以及 高血压、2型糖尿病和艾滋病成年和老年患 者的通用关键结果建议提供参考，出于间 接性的原因下调了证据质量。 • 对于癌症幸存者和高血压、2型糖尿病和艾 滋病患者来说，尽量减少久坐行为的收益 大于危害。 58 59建议 残疾儿童和青少年（5–17岁） 以及残疾成年人（18岁以上） 残疾儿童、青少年和成年人可以从身体活动中获得重要健康收益。残疾儿童、青少年和 成年人应在条件允许的情况下根据自身能力尽量达到这些建议要求。 对于残疾儿童、青少年和成年人，身体活动可以作为娱乐休闲（游戏、比赛、运动或有 计划的锻炼）、体育、交通（轮式运动 、步行和骑自行车）或家务的一部分，在家庭、教 育、职业和社区环境中进行。应向所有残疾儿童、青少年和成年人提供机会并鼓励他们参与 有趣、多样、适合其年龄和能力的身体活动。 身体活动建议 之前章节介绍了身体活动对儿童和青少年的健康收益，其中许多也适用于 残疾儿童和青少年。身体活动对残疾人健康结果的其他收益包括：因注意力 缺陷/多动障碍（ADHD）等疾病或障碍认知功能受损者可以改善认知能力； 智力障碍儿童的身体功能也能得到改善。 建议： 一周中，残疾儿童和青少年应该 平均每天至少进行60分钟中等到剧 烈强度身体活动，有氧活动为主。 强烈推荐，中等质量证据 每周至少应有3天进行剧烈强度有 氧运动以及增强肌肉和骨骼的运动。 强烈推荐，中等质量证据 良 好 做 法 • 少量身体活动优于不活动。 • 如果残疾儿童和青少年未达到建 议活动水平，少量身体活动有益 健康。 • 残疾儿童和青少年应从少量身体活 动开始，逐渐增加频率、强度和持 续时间。 • 在适合当前活动水平、健康状况 和身体机能的情况下，残疾儿童和 青少年进行身体活动不存在重大风 险；而且健康收益超过风险。 • 残疾儿童和青少年应咨询卫生保健 专业人员或其他身体活动和残疾专 家，确定适合他们的活动类型和活 动量。 良 好 做 法 60 61 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 残疾儿童和青少年（5–17岁）以及残疾成年人（18岁以上） 之前章节介绍了身体活动对成年人的健康收益，其中许多也适用于残疾成 年人。身体活动对残疾人健康结果的其他好处包括：对于患有多发性硬化症 的成年人——改善身体功能，在生理、心理和社会方面改善健康相关生活质 量；对于脊髓损伤的成年人——改善步行功能、肌肉力量和上肢功能；以及 改善健康相关生活质量；对于因疾病或障碍认知功能受损的患者，改善身体 功能和认知（帕金森病患者和中风病史患者）；对认知有正面作用；可改善 生活质量（成年精神分裂症患者）；可改善身体功能（成年智力障碍者）； 以及提高生活质量（成年重度临床抑郁症患者）。 建议： 所有残疾成年人应定期进行身体 活动。 强烈推荐，中等质量证据 残疾成年人每周应该进行至少 150-300分钟的中等强度有氧活动； 或至少75-150分钟的剧烈强度有氧 活动；或等量的中等强度和剧烈强度 组合活动，可以获得巨大健康收益。 强烈推荐，中等质量证据 残疾成年人还应进行中等强度或 更高强度的肌肉强化活动，锻炼所有 主要肌肉群，每周2天或2天以上， 能带来额外健康收益。 强烈推荐，中等质量证据 在每周身体活动中，残疾老年人 应该进行多样化身体活动，侧重于 中等或更高强度的功能性平衡和力 量训练，每周3天或3天以上，以增 强功能性能力和防止跌倒。 强烈推荐，中等质量证据 残疾成年人可以将每周中等强度 有氧活动增加到300分钟以上；或 进行150分钟以上的剧烈强度有氧活 动；或等量的中等强度和剧烈强度 组合活动，可获得额外健康收益。 条件性推荐，中等质量证据 良 好 做 法 • 少量身体活动优于不活动。 • 如果残疾成年人未达到建议活动水 平，少量身体活动有益健康。 • 残疾成年人应从少量身体活动开 始，逐渐增加频率、强度和持续 时间。 • 在适合当前活动水平、健康状况和 身体机能的情况下，残疾成年人进 行身体活动不存在重大风险；而且 健康收益超过风险。 • 残疾成年人应咨询卫生保健专业人 员或其他身体活动和残疾专家，确 定适合他们的活动类型和活动量。 60 61建议 支持性证据和理由 为制定残疾儿童、青少年和成年人的指南，使用并更新了PAGAC的全面证据综合结果 (35)。关于身体活动和健康结果现有证据使用的方法、数据提取和证据概要表，全部细节可供 查阅(35)，除最新搜索结果外，GDG也审查了这些内容。 为这些指南进行的更新工作考虑了2017年至2019年发表的39篇综述。其中，27篇符合纳 入标准，为研究残疾儿童、青少年和成年人身体活动与健康相关结果之间的关联提供参考。 关于方法、数据提取和证据简介的全部细节见《网络附件：证据简介》 。 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 审查的证据考虑了因下列疾病致残的儿 童、青少年和成年人身体活动与健康相关结 果之间的关联：多发性硬化症、脊髓损伤、 智力障碍、帕金森症、卒中、重度临床抑 郁症、精神分裂症和注意力缺陷/多动障碍 （ADHD）。审查了四种健康相关结果，包括 共病风险、身体功能、认知功能和健康相关 生活质量，但并非每种疾病的所有结果都有 研究。在身体活动方面，环境因素对残疾的 影响超出了这些指南的范围，未作分析。 对于残疾儿童和青少年（5–17岁）以及 残疾成年人（18岁以上），身体活动与 健康相关结果之间有何关联？ 对于多发性硬化症患者来说，身体活动 可以改善身体机能、功能性移动能力、步行 速度和耐力，以及心肺功能、力量和平衡能 力。例如，为期3-12周的高强度间歇性训练 可以改善心肺功能或肌肉力量(117)，平均为期 13周的下肢力量训练可以让力量提高23.1% （95% CI：11.8至34.4）(118)，研究发现舞 蹈类干预措施可改善功能性移动能力和平衡 能力(119)。除了身体健康方面的收益之外，现 有证据表明，身体活动还有利于多发性硬化 症患者的认知能力(35)。较新的研究显示，有 氧运动对身体、心理和社会领域的健康相关 生活质量（包括疲劳和抑郁症状）有微小而 重要的影响(35, 120)。 对于脊髓损伤患者，身体活动可以改善 步行功能、肌肉力量和上肢功能(35)。身体 活动还可能减轻肩部疼痛，改善血管功能， 提高健康相关生活质量(35)。 对于帕金森症患者，身体活动可以改善 运动症状、功能性移动能力和表现、耐力、 冻结步态和前进后退速度(35, 121, 122)。新证 据显示，锻炼还有助于帕金森症患者的整体 认知功能(123)。 对于卒中史患者，身体活动可以改善身 体机能，尤其是上肢功能、下肢感觉运动功 能、平衡能力、步行速度、距离、能力和耐 力、心肺功能、行动能力和日常生活活动。 现有证据表明身体活动对于认知能力也有积 极影响(35)。 对于重度临床抑郁症患者，新综述(124, 125)支持现有证据(35)，即身体活动可以改善 健康相关生活质量(35, 124, 125)。 对于包括精神分裂症在内的因疾病或障 碍认知功能受损的患者，身体活动对认知、 工作记忆、社会认知和注意力/警觉性有积极 影响(35, 126)。一项综述发现，中等至剧烈强 度身体活动可显著改善健康相关生活质量和 失能 (35, 124)。 残疾儿童和青少年（5–17岁）以及残疾成年人（18岁以上） 62 63 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 对于智力障碍者，身体活动也证实可改 善身体机能。审查的干预措施主要侧重于为 期6-24周的平衡性和力量训练，发现静态平 衡、动态平衡和静动态平衡均显著优于对照 组(35, 127, 128)。 对于注意力缺陷/多动障碍儿童，包括研 究涉及ADHD的5次RCT综述在内的证据(129) 表明，锻炼与注意力、执行功能和社交障碍 之间有积极关联(35, 129)。 GDG研究了一般儿童、青少年和成年人 的证据，得出的结论是，没有理由认为身体 受损会带来效应修饰，因此积极身体活动也 会带来同样的健康生理收益。GDG承认，涵 盖残疾人的研究为数不多，对效应修饰的检 测极少进行。 残疾方面的这部分证据，加上更广泛的 一般人口证据，支持在一般人口建议中涵盖 残疾人，并注意提到“所有成年人”、“所有老 年人”和“各种能力的人”。 GDG的结论是： 对于脊髓损失患者，有： • 低质量证据表明身体活动可减轻肩部疼 痛，改善瘫痪肢体血管功能，提高健康相 关生活质量； • 中等质量证据表明身体活动可改善步行功 能、肌肉力量和上肢功能。 对于包括帕金森症在内的因疾病或障碍认知 功能受损的患者，有： • 高质量证据表明身体活动改善包括步行、 平衡、力量和疾病特异性运动评分在内的 功能性结果； • 中等质量证据表明中等至剧烈强度身体活 动对认知有积极影响。 对于卒中史患者，有： • 中等质量证据表明，侧重于行动能力的身 体活动对身体机能和认知有积极影响。 对于包括精神分裂症在内的因疾病或障碍认 知功能受损的患者，有： • 中等质量证据表明身体活动能改善生活 质量； • 高质量证据表明中等至剧烈强度身体活动 对认知、工作记忆、社会认知和注意力有 积极影响。 对于重度临床抑郁症成年患者，有： • 中等质量证据表明身体活动改善生活质量。 对于多发性硬化症成年患者，有： • 高质量证据表明身体活动，尤其是有氧和 肌肉强化运动，能改善身体机能、功能性 移动能力，步行速度和耐力以及心肺功 能、力量和平衡能力； • 中等质量证据表明身体活动对认知有积极 影响； • 低质量证据表明身体活动能改善生活 质量，包括疲劳和抑郁症状。 对于智力障碍的儿童和成年人，有： • 低质量证据表明身体活动能改善身体机能。 对于患有ADHD的儿童和青少年，有： • 中等质量证据表明，中等至剧烈强度身体 活动对认知有积极影响，包括注意力、执 行功能和社交障碍。 GDG进一步得出结论，有充分科学证据 表明，身体活动对多种受损领域的各种健康 结果有积极影响，身体活动对于残疾人而言 收益大于潜在危害。 考虑到制定这些建议所用证据的间 接性，下调了证据质量。 残疾儿童和青少年（5–17岁）以及残疾成年人（18岁以上） 62 63建议 支持性证据和理由 《关于身体活动有益健康的全球建议》（2010年）未涵盖久坐行为。 由于缺乏按人群分类的证据，评估残疾儿童、青少年和成年人久坐行为与健康结果之间 关系的主要证据基础是针对非残疾人整理和审查的科学文献。 对一般人群久坐行为相关证据的研究发现进行了审查，并评估是否有证据表明残疾儿 童、青少年和成年人会有不同结果、结果对其不适用或有禁忌。 残疾儿童和青少年（5–17岁） 以及残疾成年人（18岁以上） 久坐行为建议 对于残疾儿童、青少年和成年人，久坐行为的定义是教育、家庭、社区环境和交通中， 清醒状态下坐卧的时间，能量消耗低。通过上肢主导的活动和/或轮椅运动和活动等方式可 以在坐卧状态下避免久坐行为，坚持身体活动。 儿童和青少年较多久坐行为与以下不良健康结果有关：更加肥胖；心血管 代谢健康、身体素质、行为品行/亲社会行为较差；以及睡眠时间减少。 建议： 残疾儿童和青少年应该限制久坐时间，尤其是屏幕娱乐时间。 强烈推荐，低质量证据 成年人较多久坐行为与以下不良健康结果有关：全因死亡率、心血管疾病 死亡率和癌症死亡率以及心血管疾病、癌症和2型糖尿病的发病率。 建议： 残疾成年人应限制久坐时间。久坐时间改用来进行各种强度的身体活动 （包括轻微强度）能带来健康收益。 强烈推荐，低质量证据 为了帮助减少过多久坐行为对健康的不利影响，残疾成年人进行中等到剧烈 强度身体活动应力求超过建议水平。 强烈推荐，低质量证据 64 65 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 根据现有证据和专家意见对这些证据进 行了类推，以便为世卫组织关于残疾人久坐 行为的新建议提供参考，涵盖通用的关键健 康结果，承认轮椅使用者等特定人口群体难 免长时间保持坐姿，坐姿因此属于常态。对 于这些群体，久坐行为应定义为能量消耗低 的时间，如使用电动轮椅或使用手动轮椅由 他人推行。对于残疾人久坐行为与健康结果 之间的关联研究不足。但根据专家意见，没 有理由认为身体受损会带来效应修饰，因此 残疾人限制久坐行为也会带来同样的健康生 理收益。考虑到制定这些建议所用证据的间 接性，下调了证据质量。 更多中等和剧烈强度身体活动可抵消成 年人大量久坐行为的潜在风险，这方面的证 据是否适用也纳入考虑，并加以类推，为 残疾成年人通用关键健康结果的建议提供参 考。鉴于证据的间接性，下调了证据质量。 GDG的结论是： • 儿童和青少年群体久坐行为的相关证据一 般可类推至残疾儿童和青少年，同时考虑 后者的具体能力。 • 一般成年人群体久坐行为的相关证据，包 括更多中等和剧烈强度身体活动可抵消成 年人大量久坐行为潜在风险的证据在内， 一般可类推至成年和老年残疾人，同时 考虑后者的具体能力。但出于证据的间接 性，下调了证据质量。 • 残疾儿童、青少年、成年人和老年人尽量 减少久坐行为的收益大于危害。 残疾儿童和青少年（5–17岁）以及残疾成年人（18岁以上） 64 65建议 按照GRADE程序，更新建议的拟议措 辞及推荐程度的评级（“强烈”或“条件性”） 基于以下考虑：收益与危害的平衡；证据质 量；受指南影响者的价值观和偏好是否有影 响；对性别、社会和健康公平的潜在影响； 可接受性、可行性和涉及资源问题。对上述 因素的研究针对各个人口群体分别进行，但 鉴于所讨论问题和注意事项的相似性，本文 为所有内容的汇总说明。 推荐的程度主要基于比较收益和危害的 评估。如果比较后，评估认为对建议的目标 人群而言收益远大于危害，则推荐标为“强 烈”，如果收益相对于危害并不明显，或者目 标人群的收益可能存在重大差异，则推荐标 为“有条件”。委托进行新的系统综述专门寻 找关于危害的证据。但收获有限，因为大多 数证据侧重于精英和竞技运动员受伤和受到 危害的情况，而非广大民众。总体而言，尽 管证据有限，但根据专家意见，得出的结论 是风险不大。证据普遍表明，身体活动的收 益远远超过危害，身体活动可以作为重要干 预措施支持缩小现有健康差距，特别是针对 弱势群体而言。 GDG还审议了健康公平、可行性和可接 受性等问题，2020年3月31日至2020年4月 17日期间举行的建议草案网上公众咨询也包 括这些问题。公众咨询调查提出的具体问题 涉及实施建议个人和政府需要承担的成本与 潜在健康收益之间的平衡，以及指南是否会 改善健康公平。此外，建议草案和反馈表也 发给了最近表示有兴趣制定或已经开始起草 国家身体活动指南的国家。已收到超过420份 网上咨询的反馈意见，此外还整理了世卫组 织欧洲区域办事处的反馈意见，采纳世卫组 织合作中心和会员国的意见。公众咨询获得 的反馈意见经过整理，由GDG审查，在指导 小组和GDG协商下，进一步为审议可行性、 涉及资源问题和健康公平问题提供参考。 讨 论 后 以 协 商 一 致 的 方 式 作 出 决 定。GDG在每项建议和推荐程度上达成共 识；无须评分和表决。 证据质量评估 GDG使用GRADE框架审查针对PI/ECOs 识别的各项结果进行初步研究的质量，并评 估证据的总体质量，同时考虑到每项结果的 偏倚风险、不一致、不精确、证据的间接性 和发表偏倚。详细说明各PI/ECO此类信息的 GRADE表格见《网络附件：证据简介》 。 证据质量评估的基础是对所有评估结果的整 体评估，并将全因死亡率和心血管疾病死亡 率作为最关键的结果排在前面，其次是其他 临床结果（跌倒、抑郁、认知、健康相关的 生活质量等），然后是中间结果（如心血管 代谢标志物、其他代谢标志物）以及危害。 亚群体久坐行为等证据未经专门审查，主要 原因是缺乏此类人群的相关证据，这种情况 下考虑到间接性，酌情采用一般人群证据类 推，证据质量降级。 可在线获取：https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 证据转化建议 66 67 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 收益和危害 制定建议时也评估了不良影响或风险。 在证据有限的情况下，决策基于GDG的专业 知识。总体结论是，对于所有人群身体活动 和限制久坐行为的收益都超过潜在危害。这 些指南针对大众，不涉及运动员为提高竞赛 成绩加强体能所需运动类型和总量的收益和 危害。 少量身体活动优于不活动。如果未达到 建议活动水平，少量身体活动有益健康。应 从少量身体活动开始，逐渐增加频率、强度 和持续时间。参加锻炼前一般无须体检。身 体活动不足者逐步发展到中等强度身体活动 没有心脏突发事件的已知风险，骨骼、肌肉 或关节受伤的风险也很低。习惯从事中等强 度活动者可以逐渐增加至剧烈强度活动，无 须咨询卫生保健机构。如果增加活动量时出 现新症状，应咨询卫生保健机构。 选择何种身体活动以及合适的活动量会 受到怀孕、慢性病和残疾的影响，应根据自 身能力在无禁忌证的情况下活动。此类人群 不妨咨询身体活动专家或卫生保健专业人 员，听取建议，确定适合自身需求、能力、 功能受限/并发症、用药情况和整体治疗方案 的活动类型和活动量。以获得适合其个人需 要、能力、功能限制/并发症、药物和整体治 疗计划的活动类型和数量的建议。轻微强度 和中等强度的身体活动一般风险较低，推荐 所有人参加。 价值观和偏好 考虑了指南涉及群体（此处包括父母和 照顾者、儿童和青少年、成年人、老年人、 孕妇和产后妇女、慢性病患者和/或残疾人） 的价值观和偏好。总体结论是，对于全因死 亡率和心血管疾病死亡率等主要结果，与偏 好相关的不确定性很低或不存在。估计的潜 在收益大大超过所有潜在危害，因此GDG认 为这些建议不受偏好影响。 涉及资源问题 GDG的专家意见以及关于干预措施的 经济分析和卫生保健系统因身体活动水平提 高节省费用的少量证据，为不同环境下建议 涉及资源问题的讨论提供了参考。此外，网 上公众咨询的结果显示，超过75%的参与 者赞同或非常赞同，实施指南的收益将超过 个人付出的成本，而81%的参与者赞同或非 常赞同，实施指南的收益将超过政府付出的 成本。 现有证据和专家意见确认，通过步行等 个人不需要特定设备或付费的活动，可以在 低风险的情况下实现巨大健康收益。此外， 人们承认，其他形式的身体活动，例如有组 织的体育运动、骑自行车和训练课程，可能 会产生费用，对于部分人，特别是低收入者 而言是一个障碍因素。政府执行促进和扶持 身体活动的政策和方案时，在人力资源、 政策制定、设施和服务的提供，还有可能在 设备这些领域也需要进行投资，部分投资由 卫生部委承担，卫生领域之外，如体育、教 育、交通和城市规划等部门也会分担。可能 需要不止一级政府（国家、国家以下和地方 各级）投入资源，以确保所有社区都有平等 机会参加身体活动。 这些投资可能需要新的资源，但也可以 通过重新分配现有预算来解决，体现出设施 和方案优先关注提高全民身体活动水平。预 算重新分配的例子有，现有交通预算拨款 转而用于步行和骑自行车的基础设施，以及 体育预算向“全民体育”倾斜。在学校和工作 场所等关键环境中，低成本的干预措施加上 实体环境的调整，可以支持民众参与身体活 动，也有助于减少某些亚群体在身体活动参 与机会方面的不平等。总体评估的结果是， 虽然实现这些建议草案涉及资源问题，但在 目前治理结构内可以采取行动。 66 67证据转化建议 此外，有证据表明，提高身体活动水 平可以让卫生保健系统节省大量卫生保健 费用。2013年，仅直接医疗费用，全球每 年身体活动不足的成本估计为540亿英特币 (130)；在国家一级，身体活动不足的产生的 费用估计占到卫生保健成本的1-3% (131)。 在范围更广的非传染性疾病（NCD）预 防方面，如果建议的身体活动能够相对容易 地纳入民众生活，那么政府和非政府组织执 行指南的额外费用可以尽量减少；同样，如 果初级和二级保健、学校、工作场所或交通 运输的现有资源能够转移，从而增加身体活 动，也能减少费用。 对促进身体活动的成本收益分析表明， 在有投资案例的许多国家，从预防非传染性 疾病的角度而言，15年以上的投资收益为正 (132)。根据《2013-2020年预防和控制非传 染性疾病全球行动计划》附录3(133)的更新 情况，公众教育和宣传活动以及身体活动咨 询和转荐等干预措施，分别是应对非传染性 疾病建议干预措施的“最合算措施”和“合算措 施”。GDG的总体结论是，落实建议的收益大 于成本。 落实残疾人身体活动指南可能需要投 资，如培训活动专家，必要时调整设备，以 及提供无障碍设施。此类投资可以为众多人 口群体的需求提供便利。有证据表明，由于 可及性、可供选择的活动和他人态度构成多 种障碍，残疾人和非残疾人在身体活动方面 存在显著的参与梯度。应运用通用设计原则 确保残疾人充分和有效的参与。通过创新， 有可能解决许多涉及资源的问题。采用通用 设计方法未来能降低此类成本。 平等、可接受性和可行性 更新2010年建议时决定明确纳入弱势 群体的相关内容，如慢性病患者和/或残疾 人。GDG和指导小组的成员有一些为弱势 群体代表。GDG深入讨论各项建议，考虑 实施建议是否会降低健康公平性，以及与实 施有关的问题，确保建议不会导致公平性问 题恶化（例如，确保有安全的设施和机会让 包括残疾人、社会经济等各方面弱势群体在 内的所有人能够从事身体活动；解决可能限 制身体活动参与途径和参与机会的性别和其 他文化偏见等等）。网上公众咨询的受访者 中，76%赞同或非常赞同实施指南可以增 加所有人的身体活动机会从而减少健康不平 等，能够改善健康结果。讨论指出，配套 的环境是促进参与身体活动的关键。需要采 取多部门综合方法设计和执行政策，才能 为社会经济处于不利地位的妇女和女童以及 残疾人等弱势群体解决参加身体活动的障碍 因素。 残疾人的健康结果不如非残疾人，但身 体活动的收益远远超过危害，可以成为缩小 这种健康差距的重要干预措施。证据表明， 由于可及性、可供选择的活动和他人态度构 成多种障碍，残疾人和非残疾人之间在身体 活动方面存在显著的参与梯度。应当让许多 残疾人能够在不需要调整设备或设施的情况 下进行多种形式的身体活动。然而，若要让 残疾人能与他人平等参与身体活动，可能需 要获得经过改造的设备、提供无障碍设施并 培训活动专家。 68 69 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 尽管有大量数据显示身体活动与整个生 命周期健康结果相关，以及越来越多证据支 持久坐行为与整个生命周期健康结果相关， 但通过GDG的讨论发现了重要的证据空白， 应予以优先考虑，为今后的指南提供参考。 各个亚群体存在的证据空白包括以下方面的 信息缺失： 1) 针对身体活动和/或久坐行为与所研究的 若干健康结果之间的剂量-反应关系更精 准的细节信息； 2) 轻微强度身体活动以及久坐时间穿插轻微 强度身体活动的健康收益； 3) 不同种类及类型的身体活动（休闲、职 业、交通、家居、教育）和久坐行为（职 业、屏幕时间、看电视时间）对健康的不 同影响； 4) 身体活动和久坐时间与生命全程健康结果 之间的联系。 讨论也指出，低收入和中等收入国家、 贫穷社区或服务不足社区、残疾人和/或慢 性病患者的相关证据仍然有限。许多研究的 设计或能力没有考虑各种社会人口因素（年 龄、性别、种族/民族、社会经济地位）的 效应修饰，而这些因素可能会改变身体活动 对健康的影响。这类信息对于提出更具体的 公共卫生建议和减少人口中较脆弱群体的 卫生差距具有重要意义。关于这些新指南带 来的研究空白，详情也可参考已发表的文献 (134)。 研究需求 68 69研究需求 这些指南的目标是向政策制定者和卫生 保健、教育、工作场所和社区的干预方案设 计者提供关于儿童、青少年、成年人和老年 人每天身体活动时间的建议，以及限制久坐 时间的建议。然而，制定全球指南本身并不 是目的：在传播和实施方面不做工作，就不 可能改变身体活动水平。 采纳 世卫组织制定全球适用的指南(21)时遵 循严格而广泛的程序，可供所有国家使用。 《关于身体活动和久坐行为的指南》针对身 体活动和久坐行为对健康的影响提供了基于 证据的建议，各国政府可以采纳建议，作为 国家政策框架的一部分。全球指南经过广泛 磋商后制定，大部分国家不必再动用资源展 开漫长的科学进程。审查并采纳身体活动和 久坐行为全球指南，是制定适合本地情况指 南快速而经济的方法。 在区域或国家一级采纳世卫组织指南， 将确保各国在身体活动和久坐行为上提供一 致的建议，这些建议参考了现有最新和最佳 科学证据。此外，各国建议的一致性将有助 于国家监测、对身体活动和久坐行为的全球 估测以及跨国比较。在采纳指南的整个过程 中，应注意根据具体情况调整和修改指南。 将指南翻译成当地语言就属于采纳和适应 背景情况的工作。身体活动举例时可能需要 加以调整适应当地情况，并使用反映当地文 化、规范和价值观的图片。 与相关利益攸关方举办一系列区域研讨 会之后，支持各国采纳全球指南的分步骤 框架正在制定当中。可以用相关国家数据 （例如，身体活动普及率估计值）填充这一 框架，为制定国家指南文件提供了快捷方 式。这些辅助资源将于2021年通过世卫组织 网站提供。 考虑采纳指南时建议通过以下十个 步骤进行： 1. 倡导审查现行身体活动国家指南并采纳世 卫组织指南，确保政府授权。 2. 让卫生部门和体育、教育、交通等其他相 关部门的主要利益攸关方参与进来；让相 关专业协会和科学家参与进来，提供主题 专业知识。 3. 评估建议的适用性、可接受性和可行性。 4. 根据本地情况调整指南，考虑语言、举例 和其他文化因素。 5. 与政策制定者、从业人员和大众等目标用 户进行外部评审。 6. 为传播和宣传工作制定预算和明确计划。 7. 发布并宣传国家指南，最好举办发布会活 动，引起热度和关注。 8. 邀请相关专业组织机构参与，支持政策协 调和/或批准。 9. 落实国家政策和作法，支持国家指南的实 施和行为改变。 10. 商定指南评估、审查和更新的时间表。 采纳、传播、实施和评估 70 71 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 传播 要全面提高全民身体活动水平，国家身 体活动指南是治理结构的核心组成部分。国 家指南为国家和国家以下各级战略规划的发 展和优先事项提供参考，要求以适当方式向 相关群体传播正确信息。遗憾的是，国家指 南往往得不到传播，因此专业人员以及更广 泛的社群对建议仍然很不了解。要改变对增 加身体活动和减少久坐行为重要意义的认识 和了解，首先要采取的重要步骤是获得支持 广泛传播的专用资源。 传播身体活动和久坐行为国家指南的主 要受众包括： • 卫生保健部门内外的政策制定者（包括交 通、规划、教育、工作场所、体育、公园和 娱乐），要加强以下方面工作： a. 了解增加身体活动和减少久坐行为不 仅有助于改善健康，而且有利于改善 范围广泛而又互相关联的问题，如性 别平等、人权义务和可持续发展； b. 将有关身体活动和久坐行为的政策和 方案纳入所有相关政策； c. 投资于规模扩大、协调进行的国家和 地方行动。 • 非国家实体（包括非政府组织、学术科 研机构、私营部门以及媒体和研究资助 机构）应： a. 提高对各年龄段增加身体活动和减少 久坐行为重要意义的认识； b. 鼓励并确保政策相互配合； c. 在政策实施和本地行动方面加强合作 和投资。 • 卫生部门和非卫生部门（包括体育、教育、 交通和规划）的从业人员应加强以下方面： a. 认识和了解身体活动和久坐行为的国 家指南； b. 推动提高身体活动水平和减少久坐行 为的知识、技能和信心； c. 将促进身体活动酌情纳入常规工作。 • 大众和特定亚群体应加强以下方面： a. 认识和了解身体活动和久坐行为指南； b. 了解如何落实身体活动和久坐行为 指南； c. 增加身体活动和减少久坐行为的意愿 和动力。 宣传活动 不同的利益攸关方受益于不同材料；因 此，为了向各类受众有效宣传指南，必须注 意指南传播的内容、格式和渠道。制定指南 传播战略时，形成性研究可以帮助确定关键 受众，了解影响身体活动量和久坐行为的价 值观、需求和偏好。应包括探讨妨碍身体 活动或妨碍将身体活动纳入政策和实践的因 素，以及对各个不同群体测试草拟宣传信息 和材料。这个过程可以帮助确定最终采纳的 关键信息以及适当的沟通格式和渠道。全面 的宣传战略应包括针对不同受众的各类宣传 方法。各国可能需要根据现有资源（人力和 财力）优先考虑特定群体。 针对公众或特定亚群体的身体活动宣传 工作是一种经济有效的干预措施(133)，受到 《2018-2030年促进身体活动全球行动计 划》(14)推荐。国家和国家以下各级的身体活 动宣传工作通常会确定一个总口号（例如“动 起来”或“多运动”），并推出一些设计元素或 角色，其中含有针对不同受众（例如幼儿、 青少年、成年人或老年人、不爱运动的人、 残疾人或慢性病患者）定制的信息。针对特 定人口群体定制的宣传信息和资源可能比通 70 71采纳、传播、实施和评估 用材料更有效。宣传活动应兼顾传统媒体渠 道（如电视、广播、广告牌、印刷资源）和 数字媒体渠道（网站、手机、APP）的覆盖 范围和效果。以各种形式提供国家指南信息 也很有用。例如，一种相对较新但日益普遍 的身体活动指南宣传方法是使用信息可视图 或动画短视频。世卫组织提供设计和实施此 类宣传活动的辅助材料(135)。 学术界和研究界可能会对科学报告感兴 趣，该报告详细介绍了指南所依据的流行病 学证据。但其他普通受众不太可能对基础研 究的具体细节感兴趣。政策制定者可能更喜 欢科学摘要，甚至是一份简短的简报文件。 其他受众，例如卫生保健和非卫生保健专业 人员，更可能喜欢其他不同类型的资源，例 如关于指南或关于如何将促进身体活动纳 入日常实践（例如卫生保健环境中的患者问 诊，或制定城市环境的建筑或交通计划）的 小册子或概况介绍。不同的专业人士需要根 据其职责量身定制的资源。特别是卫生保健 专业人员，可能会受益于能体现所服务的多 种人口群体的一整套资源。 政策和方案实施 仅仅依靠关于身体活动和久坐行为的国 家指南不可能提高民众身体活动水平，因此 应被视为政策和规划框架的一个组成部分。 国家指南必须向主要受众发放，并有长期国 家宣传战略支持，宣传战略能让民众更好地 认识和了解定期身体活动、减少久坐行为 的多重收益。然而，为了实现行为的长期改 变，这些行动必须得到政策支持，创造支 持性的环境让人们能够积极活动并鼓励人们 积极活动，同时增加人们在本地参与身体活 动的适当机会。政策和方案必须考虑并适应 当地卫生系统和有兴趣或有机会支持促进身 体活动的复杂多部门机构的情况。采取行动 时应遵循“全政府”的办法，让政策和多种行 动构成“体系”，通过各方面利益攸关方的参 与，在多个部门和多种环境中鼓励更多民众 参与身体活动。运用与长期宣传战略相配合 的“体系”方法，能确保身体活动的需求因有 效宣传增加后，同时向人们提供参与身体活 动的环境和机会。 72 73 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 世卫组织《2018-2030年促进身体活动 全球行动计划》设定2030年身体活动不足现 象减少15%的目标，并概述了20项建议政策 行动和干预措施(14)。其中包括建议所有国家 实施长期全国公共教育和提高认识活动，并 将身体活动辅导方案纳入初级和中级卫生保 健工作。其他建议包括为所有人口群体创造 适当的身体活动环境，包括步行、骑自行车 和轮式运动，以及在学校、工作场所、体育 俱乐部和体育场所提供更多身体活动机会和 方案。执行所有20项建议在短期内可能并非 所有国家都能实现，但应被视为一项长期目 标。为确定一套可以立刻着手的适当可行的 行动，世卫组织会员国应对现行政策和做法 进行情境分析。这样可以促进多部门协作， 有助于确定优势领域以及差距和机会，并可 作为制定或更新国家和国家以下各级计划的 基础。 世卫组织新指南支持扩大行动范围，涵 盖更多群体，如残疾人或慢性病患者，以及 孕妇和产后妇女。政策扶持的恰当方案执行 工作和做法应考虑社区需求以及群体和背景 的多样性。目前正在开发一些针对具体部门 的工具包，支持ACTIVE一揽子技术措施的 实施(135)；工具包将为各部门提供促进身 体活动的指导，例如在学校或初级卫生保健 层面的工作，或者改善步行和骑自行车的条 件。ACTIVE工具包以及世卫组织在各区域和 各国的其他资源将支持身体活动和久坐行为 指南的落实工作。 监测与评估 2010年以来，世卫组织《关于身体活动 有益健康的全球建议》一直被用作人口健康 监督监测的标准。更新指南中建议的修改将 对目前用于监督各国身体活动水平的监测系 统和评估工具产生一些影响。新指南的发布 将要求对现有工具和报告规程进行审查，以 便为今后根据新指南提交报告的调整和建议 提供参考。全球身体活动问卷和全球学生健 康调查等工具会接受审查，规程配合新指南 进行更新；2021年会向各国提供辅助指导 文件。 世卫组织的非传染性疾病国家能力调查 （CCS）是监测全球非传染性疾病政策执行 进展的主要工具，每两年进行一次。CCS利 用人口监测系统针对世卫组织关于身体活动 和久坐行为的指南所涵盖各个年龄组的身体 活动提出具体问题，2019年后还调查是否存 在国家身体活动指南的问题。世卫组织会员 国须上传文件证实其答复内容。2019年，世 卫组织194个会员国中，78国（40%）报告 已有身体活动指南(136)。对2019年CCS的回 复情况进行了详细的文件分析，发现在78个 有国家指南的会员国中只有三分之二的国家 （52/78）说明了国民身体活动量的要求； 其中，只有42个国家完全符合2010年世卫 组织《关于身体活动有益健康的全球建议》 (1)。2021年及以后调查的数据将提供更新指 南采纳情况的信息。 更新 这些指南将于10年后更新，除非借助设 备测量的方法评估身体活动方面的科学进步 以及关于久坐行为的科学研究快速发展引发 提前更新的要求。 72 73采纳、传播、实施和评估 74 75 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 1. 世界卫生组织。关于身体活动有益健康的全球建 议。日内瓦：世界卫生组织；2010年。 2. 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Int J Behav Nutr Phys Act. 2020;In press. 135. 世界卫生组织。ACTIVE：增加身体活动的技术工具 包。日内瓦：世界卫生组织；2018年。 136. 世界卫生组织。评估预防控制非传染性疾病的国家 能力：2019年全球调查报告。日内瓦：世界卫生组 织；2020年。 82 83 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 G lo be b as ed o n io at /S hu tt er st oc k, s ilh ou et te s ha pe s or ig in al ly b as ed o n Sh ut te rs to ck s ou rc es 82 83参考文献 84 85 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 世卫组织指导小组 指导小组由来自总部和各区域办事处的身体活动、青少年健康、老龄、残疾、心理健康、 预防受伤、癌症、妊娠和监测方面的专家组成。 Valentina Baltag（孕产妇、新生儿、儿童和青少年 卫生以及老龄化司——青少年卫生处） Maurice Bucagu（孕产妇、新生儿、儿童和青少年 卫生以及老龄化司——妊娠处） Fiona Bull（组长）（健康促进司——身体活动处） Alex Butchart（健康问题社会决定因素司——预防 伤害处） Neerja Chowdhary（非传染性疾病司——心理健 康/痴呆症处） Regina Guthold（孕产妇、新生儿、儿童和青少年 卫生以及老龄化司——青少年监测处） Riitta-Maija Hämäläinen（西太平洋区域办事处） Andre Ilbawi（非传染性疾病司——癌症处） Wasiq Khan（东地中海区域办事处） Lindsay Lee（非传染性疾病司——残疾处） Alana Officer（老龄化） Leanne Riley（非传染性疾病司——监测处） Gojka Roglic（非传染性疾病司——糖尿病处） Juana Willumsen（健康促进司——身体活动处） 指导小组草拟了指南范围和PI/ECO。他们对利益申报情况进行审核；起草、审查指南 并最后定稿。 指南制定的贡献者 附件1： 指南制定程序的管理 84 85附件1 指南制定小组（GDG） 指南制定小组成员来源广泛，有该领域相关专家、建议的最终用户和受建议影响的人士。 指南制定小组的成员有： Salih Saad Al-Ansari博士（提倡健康促 进和教育，通过身体活动和步行预防非传染性 疾病）；Stuart Biddle博士（身体活动与久坐 行为，以及行为改变）；Katja Borodulin博士 （孕妇和老年人的身体活动）；Matthew Buman 博士（慢性病患者的睡眠、久坐行为和身体活 动）；Greet Cardon博士（儿童和青少年身体 活动）；Catherine Carty女士（残疾人身体活 动）；Jean-Philippe Chaput博士（儿童和青少 年的睡眠、久坐行为和身体活动）；Sebastien Chastin博士（身体活动、久坐行为和健康、身体 活动和久坐行为的客观测量）；Paddy Dempsey 博士（成年人和残疾人的身体活动和久坐行 为）；Loretta DiPietro博士（孕妇和老年人的身 体活动）；Ulf Ekelund博士（久坐行为和身体活 动、儿童和青少年身体活动）；Joseph Firth博士 （身体活动与心理健康）；Christine Friedenreich 博士（慢性病患者的身体活动、身体活动与癌症 风险）；Leandro Garcia博士（成年人身体活 动与健康）；Muthoni Gichu博士（政策实施、 各国政府）；Russ Jago博士（儿童和青少年 身体活动）；Peter Katzmarzyk博士（身体活 动与久坐行为）；Estelle V. Lambert博士（身 体活动与肥胖症）；Michael Leitzmann博士 （慢性病患者的久坐行为和身体活动）；Karen Milton博士（将建议转化为实践）；Francisco B.Ortega博士（儿童和青少年身体活动、心理 健康和客观测量）；Chathuranga Ranasinghe 博士（在社区、工作和学校环境中促进身体活动与 健康）；Emmanuel Stamatakis博士（成年人的 身体活动和久坐行为以及多种健康结果）；Anne Tiedemann博士（老年人身体活动）；Richard Troiano博士（政策制定）；Hidde van der Ploeg 博士（成年人身体活动与久坐行为）；Vicky Wari 女士（政策实施——各国政府）；Roger Chou博士 （太平洋西北地区循证实践中心，俄勒冈健康与科学 大学医学系、医学信息学系与临床流行病学系教授） 任GRADE方法学家。GDG的更多详情参见附件2。 GDG第一次会议于2019年7月2日至4日召开，期间GDG确定了PI/ECO问题，审查了现有系统综 述，并确认了需要完成的更新工作。小组商定了涉及建议的决策程序以及第二次GDG会议将讨论的证据 力度。第二次会议于2020年2月11日至14日举行；会上审查了更新的证据，并以协商一致的方式商定最 终建议。 86 87 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 外部评审小组（ERG） 7名同行评审员选自GDG和指导小组推 荐的人员名单。他们提供包括方案实施在内 的相关专业知识，代表世卫组织所有六个区 域。ERG审查了指南草案，并就明确性和 执行问题向指导小组提供了反馈意见，这些 意见已酌情采纳。外部同行评审员未修改建 议。外部评审员名单见附件2。 利益申报 所有GDG成员和外部同行评审员均完成 并提交了世卫组织利益申报表，并在出席每 次GDG会议之前签署保密承诺书。指导小 组审查评估了提交的简历和利益申报表，并 进行了互联网和出版物搜索，检查是否存在 任何可能造成难堪局面的明显公众争议或利 益。所有提名的GDG成员的姓名和简历都 在世卫组织身体活动网页上公示，供公众咨 询，为期14天。未收到任何意见。如果需要 更多关于申报或利益冲突管理的指导，指导 小组会与合规、风险管理和道德操守办公室 的同事进行协商。如果认为有必要，被发现 有经济或非经济利益冲突者不得参与有利益 冲突的议题。整个过程都审查了利益冲突的 管理。如有必要，GDG成员每次会议前须更 新利益申报表，每次GDG会议开始时都要求 成员口头进行利益申报。GDG和外部同行评 审员的利益申报汇总见附件3。未发现利益 冲突。 同行评审 指南草案由GDG和指导小组确定的7名 外部同行评审员审查。请外部同行评审员就 明确性、证据呈现和执行情况等问题提出意 见；意见酌情采纳。外部同行评审员无法改 变GDG确定的建议内容。外部同行评审员名 单见附件2；利益申报表汇总见附件3。此外 还积极征求了世卫组织区域办事处的意见。 86 87附件1 指南制定小组 Salih Al-Ansari博士 家庭与社区医学副教授 健康促进中心创始人兼CEO 沙特阿拉伯利雅得 Stuart Biddle博士 南昆士兰大学弹性区域研究所卫生研究中心 运动生活方式研究组 身体活动与健康教授 澳大利亚Springfield Central Katja Borodulin博士 老龄研究所 芬兰赫尔辛基 Matthew Buman博士 亚利桑那州立大学健康解决方案学院 美国凤凰城 Greet Cardon博士 根特大学医学与卫生学学院运动与体育学系 比利时根特 Catherine Carty女士 UNESCO教席项目主管 特拉利理工学院 爱尔兰克里郡 Jean-Philippe Chaput博士 健康活跃生活与肥胖症（HALO）研究集团高 级科学家 东安大略儿童医院（CHEO）研究所 渥太华大学儿科系 加拿大渥太华 Sebastien Chastin博士 格拉斯哥卡里多尼亚大学 心理学、社会工作和联合健康学系卫生与生 命科学学院健康行为动力学教授 英国格拉斯哥 Roger Chou （GRADE方法学家）博士 俄勒冈健康与科学大学医学系、医学信息学 系与临床流行病学系 美国俄勒冈州波特兰 Paddy Dempsey博士 MRC流行病学部 剑桥大学临床医学学院 代谢科学研究所 英国剑桥 附件2： 指南制定小组、外部同行评审员以及 参与指南制定工作的世卫组织职员 88 89 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 Loretta DiPietro博士 Milken公共卫生学院运动与营养学系 乔治·华盛顿大学 美国华盛顿特区 Ulf Ekelund博士 挪威运动科学学院运动医学系 挪威奥斯陆 Joseph Firth博士 曼彻斯特大学卫生学院校长级研究员 英国曼彻斯特 Christine Friedenreich博士 阿省卫生服务局癌症控制部门 癌症流行病学和预防研究处科学主管 加拿大卡尔加里 Leandro Garcia博士 贝尔法斯特女王大学公共卫生中心助理研 究员 英国贝尔法斯特 Muthoni Gichu博士 卫生部非传染性疾病司老年医学处主管 肯尼亚内罗毕 Russell Jago博士 布里斯托大学政策研究学院运动、营养学与 保健科学中心 儿童身体活动与公共卫生教授 英国布里斯托 Peter T. Katzmarzyk博士 人口与公共卫生学副院长 潘宁顿生物医学研究中心Marie Edana Corcoran特聘儿童肥胖症与糖尿病教授 美国巴吞鲁日 Estelle V. Lambert博士 开普敦大学身体活动、生活方式和体育促进 健康研究中心主管 南非开普敦 Michael Leitzmann博士 雷根斯堡大学流行病学与预防医学系预防医 学教授 德国雷根斯堡 Karen Milton博士 东英吉利大学诺里奇医学院公共卫生副教授 英国诺里奇 Francisco B. Ortega博士 格拉纳达大学体育教育与运动系 运动与健康研究所（iMUDS）身体活动与健 康促进部负责人 西班牙格拉纳达 88 89附件2 Chathuranga Ranasinghe博士 斯里兰卡医学协会健康兰卡项目主席 科伦坡大学医学系体育与运动医学部高级讲师 斯里兰卡科伦坡 Emmanuel Stamatakis博士 悉尼大学公共卫生学院医学卫生系 Charles Perkins中心 澳大利亚悉尼 Anne Tiedemann博士 悉尼大学医学卫生系公共卫生学院肌骨健康研 究所副教授 澳大利亚悉尼 Richard Troiano博士 美国国立卫生研究院国立癌症研究所流行病学 和基因组学项目 美国罗克维尔 Hidde van der Ploeg博士 阿姆斯特丹大学医学中心阿姆斯特丹公共卫生 研究所公共卫生与职业健康系副教授 荷兰阿姆斯特丹 Vicky Wari女士* 国家卫生部非传染性疾病项目主管 巴布亚新几内亚莫尔兹比港 外部评审小组 Kingsley Akinroye博士 非传染性疾病联盟尼日利亚部 尼日利亚 Huda Alsiyabi博士 卫生部社区工作司主管 阿曼 Alberto Flórez-Pregonero博士 哈维里亚那天主教大学 哥伦比亚 Shigeru Inoue博士 东京医科大学预防医学与公共卫生系 日本 Agus Mahendra博士 教育大学体育系 印度尼西亚 Deborah Salvo博士 圣路易斯预防研究中心 华盛顿大学布朗学院 美国 Jasper Schipperijn博士 身体活动与健康国际学会2020-2022年当选 会长， 南丹麦大学运动科学与临床生物力学系 丹麦 *未能参加 90 91 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 世卫组织指导小组 Valentina Baltag博士 世卫组织总部孕产妇、新生 儿、儿童和青少年卫生以及老 龄化司 青少年与年青人健康处负责人 瑞士日内瓦 Maurice Bucagu博士 世卫组织总部孕产妇、新生 儿、儿童和青少年卫生以及老 龄化司 孕产妇健康处医学官员 瑞士日内瓦 Alexander Buchart博士 世卫组织总部健康问题社会决 定因素司 预防暴力处负责人 瑞士日内瓦 Fiona Bull博士 世卫组织总部健康促进司 身体活动处负责人 瑞士日内瓦 Regina Guthold博士 世卫组织总部孕产妇、新生 儿、儿童和青少年卫生以及老 龄化司 青少年与年青人健康处科学家 瑞士日内瓦 Riitta-Maija Hämäläinen博士 世卫组织西太平洋区域办事处 技术官员 非传染性疾病与健康促进 菲律宾马尼拉 Andre Ilbawi博士 世卫组织总部非传染性疾病司 技术官员 瑞士日内瓦 Wasiq Khan博士* 世卫组织东地中海区域办事处 地区顾问 健康教育与促进 埃及开罗 Lindsay Lee女士 世卫组织总部非传染性疾病司 感觉功能、残疾及康复处技 术官员 瑞士日内瓦 Alana Officer女士 世卫组织总部总干事办公室 健康老龄化处高级卫生顾问 瑞士日内瓦 Leanne Riley女士 世卫组织总部非传染性疾病司 监测处负责人 瑞士日内瓦 Gojka Roglic博士 世卫组织总部非传染性疾病司 非传染性疾病管理处医学官员 瑞士日内瓦 Juana Willumsen博士 世卫组织总部健康促进司 身体活动处技术官员 瑞士日内瓦 *未能参加 附件290 91 指南制定小组成员 姓名 性别 专业 利益披露 利益冲突和管理 Salih Saad Al- Ansari博士 男 倡导健康促进和教育， 利用身体活动和步行应 对非传染性疾病。 健康促进中心所有人兼 首席执行官 未发现利益冲突 Stuart Biddle博士 男 青少年身体活动 研究基金及有偿咨询 未发现利益冲突 Katja Borodulin博士 女 孕期身体活动 就职于国家卫生福利和 老龄研究所；研究基金 未发现利益冲突 Matthew Buman 博士 男 慢性病患者的睡眠和身 体活动 无相关利益 未发现利益冲突 Greet Cardon博士 女 青少年身体活动 无相关利益 未发现利益冲突 Catherine Carty 女士 女 残疾人身体活动 研究基金 未发现利益冲突 Jean-Philippe Chaput博士 男 睡眠 无相关利益 未发现利益冲突 Sebastien Chastin 博士 男 身体活动与健康，身体 活动的客观测量 研究基金 未发现利益冲突 Paddy Dempsey 博士 男 成年人及慢性病患者的 身体活动与久坐行为 就职以及研究基金 未发现利益冲突 Loretta DiPietro 博士 女 老年人身体活动 无相关利益 未发现利益冲突 Ulf Ekelund博士 男 青少年久坐行为与身 体活动 无相关利益 未发现利益冲突 Joseph Firth博士 男 身体活动与心理健康 无相关利益 未发现利益冲突 Christine Friedenreich博士 女 慢性病患者的身体活 动，身体活动与癌症 风险 无相关利益 未发现利益冲突 Leandro Garcia博士 男 身体活动与心理健康 就职以及有偿咨询 未发现利益冲突 Muthoni Gichu博士 女 政策实施（国家政府） 无相关利益 未发现利益冲突 Russ Jago博士 男 青少年身体活动 无相关利益 未发现利益冲突 附件3： 利益申报汇总及其管理方式 92 93 世 卫 组 织 关 于 身 体 活 动 和 久 坐 行 为 的 指 南 姓名 性别 专业 利益披露 利益冲突和管理 Peter Katzmarzyk 博士 男 青少年身体活动与久 坐行为 协助指南委员会的差 旅支持 未发现利益冲突 Estelle V. Lambert 博士 女 身体活动与肥胖症 无相关利益 未发现利益冲突 Michael Leitzmann 博士 男 久坐行为与慢性病 无相关利益 未发现利益冲突 Karen Milton博士 女 建议转化为实践 协助指南委员会的差 旅支持 未发现利益冲突 Francisco Ortega 博士 男 青少年身体活动、心理 健康与客观测量 无相关利益 未发现利益冲突 Chathuranga Ranasinghe博士 男 在社区、工作场所和校 园促进身体活动和健康 研究基金 未发现利益冲突 Emmanuel Stamatakis博士 男 成年人身体活动与多项 健康结果 用于客观测量身体活动 的技术公司资助 未发现利益冲突 Anne Tiedemann 博士 女 老年人身体活动与健 康结果 无相关利益 未发现利益冲突 Richard Troiano 博士 男 政策制定 无相关利益 未发现利益冲突 Hidde van der Ploeg博士 男 成年人身体活动、久坐 行为与健康结果 协助2017年荷兰身体 活动指南委员会的差旅 支持和研究基金 未发现利益冲突 Vicky Wari女士 女 政策实施（国家政府） 股份（与指南无关） 未发现利益冲突 外部同行评审员 姓名 性别 专业 利益披露 利益冲突和管理 Kingsley Akinroye 男 游说，非传染性疾病 无相关利益 未发现利益冲突 Huda Alsiyabi博士 女 政策与方案实施 无相关利益 未发现利益冲突 Alberto Flórez- Pregonero博士 男 身体活动与久坐行为的 测算与监控 无相关利益 未发现利益冲突 Shigeru Inoue博士 男 流行病学与促进身体 活动 无相关利益 未发现利益冲突 Agus Mahendra博士 男 儿童的身体活动与运 动技能 无相关利益 未发现利益冲突 Deborah Salvo博士 女 健康与社会不平等，尤 其侧重于慢性病预防 无相关利益 未发现利益冲突 Jasper Schipperijn 博士 男 身体活动与建筑环境 身体活动与健康国际学 会（ISPAH）当选会长 未发现利益冲突 92 93附件3 ISBN 978-92-4-003216-3I - - - 5-6

РЕКОМЕНДАЦИИ ВОЗ ПО ВОПРОСАМ ФИЗИЧЕСКОЙ АКТИВНОСТИ И МАЛОПОДВИЖНОГО ОБРАЗА ЖИЗНИ

РЕКОМЕНДАЦИИ ВОЗ ПО ВОПРОСАМ ФИЗИЧЕСКОЙ АКТИВНОСТИ И МАЛОПОДВИЖНОГО ОБРАЗА ЖИЗНИ Рекомендации ВОЗ по вопросам физической активности и малоподвижного образа жизни [WHO guidelines on physical activity and sedentary behaviour] ISBN 978-92-4-003217-0 (Онлайн-версия) ISBN 978-92-4-003218-7 (Версия для печати) © Всемирная организация здравоохранения, 2021 г. Некоторые права защищены. Настоящая публикация распространяется на условиях лицензии Creative Commons 3.0 IGO «С указанием авторства – Некоммерческая – Распространение на тех же условиях» (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo/deed.ru). Лицензией допускается копирование, распространение и адаптация публикации в некоммерческих целях с указанием библиографической ссылки согласно нижеприведенному образцу. Никакое использование публикации не означает одобрения ВОЗ какой-либо организации, товара или услуги. Использование логотипа ВОЗ не допускается. Распространение адаптированных вариантов публикации допускается на условиях указанной или эквивалентной лицензии Creative Commons. При переводе публикации на другие языки приводится библиографическая ссылка согласно нижеприведенному образцу и следующая оговорка: «Настоящий перевод не был выполнен Всемирной организацией здравоохранения (ВОЗ). ВОЗ не несет ответственности за его содержание и точность. Аутентичным подлинным текстом является оригинальное издание на английском языке». Урегулирование споров, связанных с условиями лицензии, производится в соответствии с согласительным регламентом Всемирной организации интеллектуальной собственности (http://www.wipo.int/amc/en/mediation/rules). Образец библиографической ссылки. Рекомендации ВОЗ по вопросам физической активности и малоподвижного образа жизни [WHO guidelines on physical activity and sedentary behaviour]. Женева: Всемирная организация здравоохранения; 2021 г. Лицензия: CC BY-NC-SA 3.0 IGO. Данные каталогизации перед публикацией (CIP). Данные CIP доступны по ссылке: http://apps.who.int/iris. Приобретение, авторские права и лицензирование. По вопросам приобретения публикаций ВОЗ см. http://apps.who.int/bookorders. По вопросам оформления заявок на коммерческое использование и направления запросов, касающихся права пользования и лицензирования, см. http://www.who.int/about/licensing. Материалы третьих сторон. Пользователь, желающий использовать в своих целях содержащиеся в настоящей публикации материалы, принадлежащие третьим сторонам, например таблицы, рисунки или изображения, должен установить, требуется ли для этого разрешение обладателя авторского права, и при необходимости получить такое разрешение. Ответственность за нарушение прав на содержащиеся в публикации материалы третьих сторон несет пользователь. Оговорки общего характера. Используемые в настоящей публикации обозначения и приводимые в ней материалы не означают выражения мнения ВОЗ относительно правового статуса любой страны, территории, города или района или их органов власти или относительно делимитации границ. Штрихпунктирные линии на картах обозначают приблизительные границы, которые могут быть не полностью согласованы. Упоминание определенных компаний или продукции определенных производителей не означает, что они одобрены или рекомендованы ВОЗ в отличие от аналогичных компаний или продукции, не названных в тексте. Названия патентованных изделий, исключая ошибки и пропуски в тексте, выделяются начальными прописными буквами. ВОЗ приняты все разумные меры для проверки точности информации, содержащейся в настоящей публикации. Однако данные материалы публикуются без каких-либо прямых или косвенных гарантий. Ответственность за интерпретацию и использование материалов несет пользователь. ВОЗ не несет никакой ответственности за ущерб, связанный с использованием материалов. Дизайн: Eddy Hill Design Printed in Switzerland ii iii Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и CОДЕРЖАНИЕ Выражение признательности iv Сокращения и акронимы v Глоссарий терминов vi Резюме 1 Справочная информация 15 Методика 18 Рекомендации 24 Дети и подростки (в возрасте 5–17 лет) 25 Pекомендация относительно физической активности 25 Рекомендация относительно малоподвижного образа жизни 29 Взрослые (в возрасте 18–64 лет) 32 Pекомендация относительно физической активности 32 Рекомендация относительно малоподвижного образа жизни 38 Пожилые люди (в возрасте 65 лет и старше) 43 Pекомендация относительно физической активности 43 Рекомендация относительно малоподвижного образа жизни 46 Беременные женщины и женщины в послеродовом периоде 47 Pекомендация относительно физической активности 47 Рекомендация относительно малоподвижного образа жизни 51 Взрослые и пожилые люди с хроническими патологиями (в возрасте 18 лет и старше) 52 Pекомендация относительно физической активности 52 Рекомендация относительно малоподвижного образа жизни 58 Дети и подростки (в возрасте 5–17 лет) и взрослые (в возрасте 18 лет и старше) с ограниченными возможностями 60 Pекомендация относительно физической активности 60 Рекомендация относительно малоподвижного образа жизни 64 Научное обоснование рекомендаций 66 Оценка достоверности фактических данных 66 Польза и вред 66 Ценности и предпочтения 67 Ресурсные последствия 67 Справедливость, приемлемость и целесообразность 68 Потребности в исследованиях 69 Принятие, распространение, осуществление и оценка 70 Принятие 70 Распространение 71 Информационные кампании 71 Осуществление политики и программ 72 Надзор и оценка 73 Обновление 73 Библиография 75 Приложение 1. Управление процессом разработки руководства 85 Приложение 2. Группа по разработке рекомендаций, внешние рецензенты и сотрудники ВОЗ, участвовавшие в работе над настоящими рекомендациями 88 Приложение 3. Резюме деклараций интересов и результаты их рассмотрения 92 Веб-приложение «Профили фактических данных» https://apps.who.int/iris/bitstream/handle/ 10665/336657/9789240015111-eng.pdf ii iiiCодержание ВЫРАЖЕНИЕ ПРИЗНАТЕЛЬНОСТИ Всемирная организация здравоохранения (ВОЗ) с благодарностью отмечает вклад и поддержку следующих лиц и организаций в разработку настоящих рекомендаций. Фиона Булл и Хуана Виллумсен руководили процессом подготовки данных рекомендаций. Валентина Балтаг, Морис Букагу, Алекс Бутчарт, Неерия Чаудхари, Регина Гутхольд, Риитта-Майя Хямяляйнен, Андре Илбави, Васик Хан, Линдси Ли, Алана Оффисер, Лиэнн Райли и Гойка Роглич являлись членами Руководящей группы ВОЗ, возглавившей процесс подготовки рекомендаций. В состав Группы по разработке рекомендаций (ГРР) вошли Салих Саад аль-Ансари, Стюарт Бидль, Катя Бородулин, Мэтью Буман, Грит Кардон (сопредседатель), Кэтрин Карти, Жан-Филипп Чапут, Себастьян Частин, Падди Демпси, Лоретта ДиПьетро, Ульф Экелунд, Джозеф Ферт, Кристина Фриденрайх, Леандро Гарсия, Мутони Гичу, Русс Яго, Питер Кацмарзик, Эстель В. Ламберт, Майкл Лейцман, Карен Мильтон, Франсиско Б. Ортега, Чатуранга Ранасинге, Эммануэль Стаматакис (сопредседатель), Анна Тидеман, Ричард Трояно, Хидде ван дер Плоег, Вики Вари. Роджер Чоу принимал участие в работе в качестве методиста GRADE. В состав группы внешних рецензентов вошли Кингсли Акинройе, Худа Альсияби, Альберто Флорес-Прегонеро, Шигеру Иноуэ, Агус Махендра, Дебора Сальво и Джаспер Шипперийн. Данные систематических обзоров научной информации, подготовленных к научному докладу Консультативного комитета США по рекомендациям в области физической активности, представленного министру здравоохранения и социальных служб, были обновлены в результате поиска по дополнительным источникам, проведенного Кайлом Спроу (Национальный онкологический институт, Национальный институт здравоохранения, Мэриленд, США). Дополнительную поддержку в целях обзора соответствующих документов оказали Элиф Эроглу (Сиднейский университет), Андреа Хилрайнер (Регенсбургский университет), Бо-Хуэй Хуанг (Сиднейский университет), Кармен Йохем (Регенсбургский университет), Джайро Х. Мигельес (Университет Гранады), Челси Стоун (Университет Калгари) и Леони Уйтдевильиген (УМЦ Амстердама). Резюме научных данных и данные таблиц GRADE были подготовлены Кэрри Патнуод и Мишель Хеннингер (госпитали фонда Кайзера, центр исследований в области здравоохранения, Портленд, Орегон, США). Дополнительные обзоры научных данных провели Н. Фэрхолл, Дж. Оливейра, М. Пиньейру и С. Шеррингтон (Институт здоровья опорно-двигательного аппарата, Школа общественного здравоохранения, Сиднейский университет, Сидней, Австралия) и А. Бауман (Исследовательская группа по сотрудничеству в области профилактики, Школа общественного здравоохранения Сиднейского университета, Сидней, Австралия; и Сотрудничающий центр ВОЗ по вопросам физической активности, питания и избыточного веса); С. Мабвазара, М. Дж. Лагетт, К. Лармут, Ф. Одунитан-Вайяс (Научно-исследовательский центр по вопросам укрепления здоровья в результате повышения физической активности, ведения здорового образа жизни и использования возможностей спортивной медицины, факультет медицинских наук, Кейптаунский университет, Кейптаун, Южная Африка), Л. Лич, С. Онагбие (кафедра наук в области спорта, отдыха и физической культуры, факультет медицинских наук, Кейптаунский университет, Южная Африка), М. Мтетва (Инициатива по борьбе с хроническими заболеваниями в странах Африки, Кейптаунский университет, Кейптаун, Южная Африка), П. Смит (Центр Десмонда Туту по борьбе с ВИЧ, Институт инфекционных заболеваний и молекулярной медицины, факультет медицинских наук, Кейптаунский университет, Кейптаун, Южная Африка) и Ф. Машили (факультет физиологии, Медицинский университет смежных наук Мухимбили, Дар-эс-Салам, Объединенная Республика Танзания); Б. Силлекенс, М. Ланг, В. ван Мехелен, Э. Верхаген, М. Гюисманс, А. ван дер Бик, П. Коенен (кафедра общественного здравоохранения и гигиены труда медицинского центра Амстердамского университета, Амстердам, Нидерланды). Агентство общественного здравоохранения Канады и правительство Норвегии оказали финансовую поддержку, без которой эта работа не могла бы быть завершена. iv v Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и СДВГ синдром дефицита внимания и гиперактивности СОШ скорректированное отношение шансов ИМТ индекс массы тела ДИ доверительный интервал ССЗ сердечно-сосудистое заболевание ДАД диастолическое артериальное давление НОР научное обоснование решений ГРР Группа по разработке руководства GRADE Ранжирование оценки, разработки и экспертизы рекомендаций ОР отношение риска MET метаболический эквивалент нагрузки РСЗ различие средних значений НТСИ непрерывный тренинг средней интенсивности НИЗ неинфекционное заболевание OШ отношение шансов ФА физическая активность PAGAC Консультативный комитет США по Руководящим принципам физической активности НМ/ВСР население, мероприятие/воздействие, сравнение, результат ОАР относительный атрибутивный риск РКИ рандомизированное контролируемое испытание ОТР относительный риск САД систолическое артериальное давление СРС стандартизированная разность средних SPPB краткий набор тестов по оценке физической производительности ТВ телевидение ВАЗ Всемирная ассамблея здравоохранения ВОЗ Всемирная организация здравоохранения СОКРАЩЕНИЯ И АКРОНИМЫ iv vСокращения и акронимы Teрмин Определение Аэробная нагрузка Aктивность, при которой большие мышцы тела совершают ритмичные движения в течение продолжительного времени. Aэробная нагрузка, также называемая тренировкой выносливости, улучшает кардиореспираторное здоровье. К примерам такой нагрузки относятся ходьба, бег, плавание и езда на велосипеде. Анаэробная нагрузка Анаэробная нагрузка заключается в выполнении коротких, но интенсивных тренировочных серий, таких как поднятие тяжестей или спринтерский бег, когда организму требуется больше кислорода, чем он получает. Упражнения на равновесие Статические и динамические упражнения для повышения способности человека выдерживать нагрузки, связанные с осаночными колебаниями или дестабилизирующими воздействиями, которые вызваны самопроизвольными движениями, обстановкой или другими предметами. Индекс массы тела (ИМТ) Отношение веса в килограммах к квадрату роста в метрах. ИМТ-возраст, или ИМТ по Z-показателю ИМТ с корректировкой по возрасту, стандартизированный для детей. Стандартные расчеты отклонения ИМТ производятся путем измерения относительного веса, скорректированного с учетом возраста и пола ребенка. Зная возраст, пол, ИМТ ребенка и соответствующий исходный стандарт, можно вычислить ИМТ по Z-показателю (или эквивалентный ему процентиль ИМТ-возраста). Нагрузка для укрепления костной системы Физическая активность, первоочередная цель которой — обеспечить укрепление определенных участков костей, составляющих скелетную систему. Нагрузки для укрепления костной системы воздействуют на кости или сообщают им усилие натяжения, стимулирующее рост и прочность костной системы. Примерами физической активности для укрепления костной системы являются бег, прыжки через скакалку и поднятие тяжестей. Кардиометаболическое здоровье Совокупное воздействие кровяного давления, липидов крови, глюкозы в крови и инсулина на здоровье человека. Кардиореспираторное здоровье (выносливость) Один из компонентов физического состояния, связанный со здравоохранением. Способность органов кровообращения и дыхания обеспечивать организм кислородом во время продолжительной физической активности. Обычно выражается измеряемым или оцениваемым объемом максимального потребления кислорода (VO2 max). Когнитивные функции Умственная деятельность, т. е. рассудительность, память, внимание и речь, приводящие к усвоению информации и знаний. К этим функциям также можно отнести обучение. Ограниченные возможности здоровья Согласно Международной классификации функционирования, инвалидности и здоровья — обобщающее понятие, которое охватывает нарушения здоровья, ограничения физической активности и факторы, препятствующие полноценному участию в общественной жизни, и указывает на негативные аспекты взаимодействия между индивидуумом (с определенным состоянием здоровья) и его конкретными ситуативными обстоятельствами (экологическими и личными факторами). Области физической активности Уровни физической активности можно оценивать в разных областях, включая одну или несколько следующих областей: досуг, профессиональная деятельность, образование, домашнее хозяйство и/или передвижение. Физические упражнения Подкатегория физической активности, которая является планируемой, структурированной, повторяемой и целенаправленной в том смысле, что ее цель заключается в улучшении или поддержании одного или нескольких компонентов физического состояния. Термины «физические упражнения» и «упражнения» нередко используются как взаимозаменяемые и обычно означают физическую нагрузку, которая выполняется в свободное время и нацелена прежде всего на улучшение или поддержание физического состояния, физической работоспособности или здоровья. Управляющая функция Включает такие компоненты, как кратковременная память, когнитивная гибкость (также называемая гибкостью мышления) и ингибиторный контроль (включающий в себя самоконтроль). Физическое здоровье Один из критериев способности тела к эффективному и результативному функционированию во время работы и досуга, включающий в себя, например, физическое состояние и кардиореспираторное здоровье. Гибкость Компонент физического состояния, связанный со здоровьем и работоспособностью, который отражает возможную амплитуду движений того или иного сустава. Гибкость присуща каждому суставу и зависит от ряда определенных регулирующих факторов, в том числе от плотности конкретных связок и сухожилий. Упражнения для гибкости повышают способность сустава к выполнению полного спектра его движений. Функциональные упражнения Упражнения, которые могут быть включены в комплекс ежедневных задач для укрепления нижней части тела, улучшения равновесия и двигательной активности. К числу таких упражнений относятся тандем и баланс на одной ноге, приседания, вставания со стула, подъемы на носки и перешагивание через препятствия. Физическая активность в домашних условиях Физическая активность, проявляемая дома при выполнении домашних обязанностей (таких как уборка, уход за детьми, садоводство и т. п.). Досуговая физическая активность Физическая активность, проявляемая индивидуумом в условиях, когда она не требуется в качестве одного из основных видов деятельности в повседневной жизни и проявляется по собственному желанию индивидуума. К видам такой активности относятся участие в спортивных мероприятиях, физическая подготовка или тренировка и рекреационные занятия – прогулки, танцы и работа в саду. ГЛОССАРИЙ ТЕРМИНОВ vi vii Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Teрмин Определение Физическая активность низкой интенсивности Физическая активность низкой интенсивности выполняется при расходе энергии от 1,5 до 3 MET, т. е. для нее требуется объем энергии, который менее чем в 3 раза превышает энергозатраты соответствующего лица в состоянии покоя. Примерами упражнений такой интенсивности являются медленная ходьба, купание или другие случайные виды деятельности, не приводящие к значительному увеличению частоты сердечных сокращений или учащению дыхания. Основные группы мышц К основным группам мышц относятся мышцы ног, спины, живота, груди, плеч и рук. Meтаболический эквивалент нагрузки (MET) Meтаболический эквивалент нагрузки, или просто метаболический эквивалент, является физиологической мерой интенсивности различных видов физической активности. Один MET – это эквивалент энергии, расходуемой индивидуумом в сидячем положении в состоянии покоя. Физическая активность средней интенсивности По абсолютной шкале средняя интенсивность соответствует физической активности, интенсивность которой выше интенсивности в состоянии покоя от 3 до менее 6 раз. Если рассматривать шкалу личного потенциала индивидуума, то физическая активность средней интенсивности обычно составляет 5–6 по шкале от 0 до 10. Силовые упражнения Вид физической активности и нагрузки, обеспечивающий наращивание силы, мощности, выносливости и массы скелетных мышц (например, отягощения, тренировки на сопротивление или упражнения на развитие силы и выносливости мышц). Комплексные физические упражнения Для пожилых людей комплексные физические упражнения важны с точки зрения улучшения показателей физического функционирования и снижения риска падений и связанного с падениями травматизма. Такие упражнения могут выполняться дома или в составе организованной группы. Согласно целому ряду научно обоснованных систем, одна тренировка объединяет в себе все виды упражнений (аэробные, силовые и на равновесие), и такой опыт показал свою эффективность. Примерная программа комплексных физических упражнений может включать в себя ходьбу (aэробные упражнение), подъем тяжестей (силовое упражение) и упражнения на равновесие. К упражнениям на равновесие могут относиться ходьба задом наперед, ходьба боком или стояние на одной ноге с одновременным выполнением верхней частью тела упражнений на развитие силы, например подъема на бицепсы. Танцы также сочетают в себе аэробные и балансовые компоненты. Физическая активность в профессиональной среде См. «Физическая активность на работе». Физическая активность Любое движение тела, которое производится скелетными мышцами и требует расхода энергии. Недостаточная физическая активность Физическая активность, уровень которой недостаточен для выполнения настоящих рекомендаций в отношении физической активности. Психосоциальное здоровье Включает в себя психический, эмоциональный и социальный аспекты здоровья. Экранное время досуга Время, проводимое перед экраном (телевизора, компьютера или мобильных устройств) в целях, отличных от целей образования/обучения или работы. Экранное время при малоподвижном образе жизни Время, проводимое за просмотром развлекательного контента на экране (ТВ, компьютера или мобильных устройств). Не включает в себя активные экранные игры, требующие физической наргузки или движения. Малоподвижный образ жизни Любая нагрузка в состоянии бодрствования, которая характеризуется расходом энергии не более 1,5 MET в положениях сидя, лежа или полулежа. Примерами малоподвижного образа жизни являются основная часть сидячей офисной работы, вождение автомобиля и просмотр телевизора; такой образ жизни также ведут лица, которые не способны находиться в стоячем положении, например пользователи кресел-колясок. Вводимое в настоящих рекомендациях определение термина «малоподвижный образ жизни» охватывает самостоятельно оцениваемое малоподвижное сидение (во время досуга, на работе и в целом), пребывание у телевизора (просмотр ТВ или экранное время, а также низкие уровни движения, измеряемые устройствами для оценки движения или позы). Спорт Спорт включает в себя ряд видов деятельности, которые регулируются комплексом правил и выполняются в рамках досуга или соревнования. Спортивные занятия предполагают физическую активность, осуществляемую в составе команды или индивидуально, которая может курироваться официальным учреждением, например спортивным клубом. Физическая активность при передвижении Физическая активность, осуществляемая для передвижения в какие-либо пункты и обратно, которая связана с ходьбой, ездой на велосипеде и на других колесных устройствах (немоторизованных колесных средствах передвижения, таких как самокаты, роликовые коньки, кресла-коляски с ручным приводом и т. п.). Физическая активность высокой интенсивности По абсолютной шкале высокая интенсивность соответствует физической активности, выполняемой при 6 МЕТ или выше. Если рассматривать шкалу личного потенциала индивидуума, то физическая активность высокой интенсивности обычно составляет 7 или 8 по шкале от 0 до 10. Физическая активность на работе Физическая активность во время оплачиваемой или волонтерской работы. vi viiГлоссарий терминов Рекомендации ВОЗ по вопросам физической активности и малоподвижного образа жизни содержит научно обоснованные рекомендации в области общественного здравоохранения для детей, подростков, взрослых и пожилых людей в отношении объема физической активности (регулярности, интенсивности и продолжительности), необходимого для того, чтобы обеспечить значительное улучшение состояния здоровья и снизить соответствующие риски. В нем впервые даются рекомендации по вопросам, касающимся взаимосвязи между малоподвижным образом жизни и показателями здоровья, а также рекомендации для отдельных подгрупп населения, таких как беременные женщины, женщины в послеродовом периоде и лица с хроническими патологиями или ограниченными возможностями. Рекомендации предназначены для директивных органов в странах с высоким, средним и низким уровнем дохода, входящих в структуру министерств здравоохранения, образования, по делам молодежи, спорта и/или социального обеспечения и защиты семьи; для государственных должностных лиц, отвечающих за разработку национальных, субрегиональных или муниципальных планов по повышению физической активности и сокращению масштабов малоподвижного образа жизни в отдельных группах населения и за подготовку соответствующей методической документации; для сотрудников неправительственных организаций, работников сектора образования, частного сектора и сектора научных исследований, а также для работников здравоохранения. Рекомендации были подготовлены в соответствии с положениями Пособия ВОЗ по разработке рекомендаций. Проводились систематические обзоры информации о состоянии важнейших и важных показателей здоровья и дискуссии по вопросам, касающимся пользы и вреда, ценностей и предпочтений, целесообразности и приемлемости, а также последствий с точки зрения обеспечения равенства и использования ресурсов, по итогам которых были составлены рекомендации. Окончательные рекомендации в области общественного здравоохранения, содержащиеся в настоящем документе, предназначены для всех групп населения и возрастных групп от 5 до 65 лет и старше вне зависимости от пола, культурной принадлежности или социально-экономического статуса и актуальны для людей с любым уровнем способностей. Лицам с хроническими патологиями и/или ограниченными возможностями, а также беременным женщинам и женщинам в послеродовом периоде, следует стараться выполнять эти рекомендации по мере возможности и сообразно своим способностям. В процессе подготовки настоящих рекомендаций составлен свод научно обоснованных рекомендаций, которые могут включаться правительствами в разрабатываемые ими механизмы национальной политики, направленной на содействие внедрению всеобъемлющих подходов к повышению уровней физической активности населения. При включении рекомендаций следует рассмотреть вопрос о целесообразности корректировки содержания рекомендаций с учетом конкретных условий. Практические инструменты для содействия проведению кампаний по принятию, распространению, популяризации и осуществлению рекомендаций станут для правительств и заинтересованных сторон подспорьем в налаживании взаимодействия в целях повышения физической активности и сокращения малоподвижности на протяжении всего жизненного цикла. Эти вспомогательные ресурсы будут размещены на веб-сайте ВОЗ после опубликования настоящих рекомендаций. Несмотря на многочисленные данные, подтверждающие значение физической активности, и возрастающий объем информации о влиянии малоподвижного образа жизни на показатели здоровья на всех этапах жизненного цикла, в соответствующем фактическом материале сохраняются значительные пробелы. В частности, меньше данных поступает от стран с низким и средним уровнем дохода и экономически неблагополучных и недостаточно обеспеченных услугами общин; кроме того, налицо нехватка информации о различных подгруппах населения, в том числе о лицах с ограниченными возможностями. Необходимы инвестиции в расширение исследований для получения научных данных именно по указанным областям. С другой стороны, изменения, внесенные в эти рекомендации, окажут определенное влияние на системы надзора и инструменты оценки, которые используются в настоящее время для мониторинга национальных уровней физической активности. Следует пересмотреть существующие глобальные и национальные инструменты и обновить протоколы отчетности, чтобы обеспечить ведение будущей отчетности в соответствии с новыми рекомендациями. В Глобальном плане действий ВОЗ по повышению уровня физической активности на 2018–2030 гг. предусмотрена цель — сократить масштабы малоподвижного образа жизни на 15% к 2030 г. — и сформулированы 20 рекомендуемых мер политики и практических мероприятий. Настоящие рекомендации содействуют всем странам в применении рекомендаций ГПДПУФА в сочетании с пакетом технической документации «ACTIVE», где содержатся рекомендации о том, как способствовать поддержанию физической активности на всех этапах жизненного цикла в самых разных условиях. РЕЗЮМЕ viii 1 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) В связи с этим рекомендуется следующее. Детям и подросткам следует еженедельно посвящать в среднем не менее 60 минут в день занятиям физически активной деятельностью средней или высокой интенсивности, в основном с аэробной нагрузкой. Настоятельная рекомендация, средняя степень достоверности данных Физически активной деятельностью высокой интенсивности с аэробной нагрузкой, в том числе направленной на укрепление скелетно- мышечной системы, следует заниматься не реже трех раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных • небольшая физическая активность лучше, чем ее полное отсутствие; • если дети и подростки не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • детям и подросткам следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • важно предоставить всем детям и подросткам безопасные и равные возможности, а также поощрять их к участию в различных занятиях физически активной деятельностью, которые доставляли бы удовольствие, были бы разнообразными и соответствовали бы их возрасту и способностям.П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я Физическая активность детей и подростков благоприятно отражается на следующих показателях, связанных со здоровьем: состоянии физического здоровья (кардиореспираторный и мышечный тонус), состоянии кардиометаболического здоровья (артериальное давление, дислипидемия, содержание глюкозы и инсулинорезистентность), состоянии костной системы, развитии когнитивных способностей (академическая успеваемость, способность к целенаправленной деятельности), состоянии психического здоровья (уменьшение симптомов депрессии); и снижении степени ожирения. Особо малоподвижный образ жизни детей и подростков ведет к следующим негативным последствиям для их здоровья: повышению степени ожирения; ухудшению состояния кардиометаболического здоровья, физического здоровья и эмоционального/социально ориентированного поведения; а также сокращению продолжительности сна. В связи с этим рекомендуется следующее. Детям и подросткам следует сокращать продолжительность малоподвижных периодов, особенно время досуга у экрана телевизора, компьютера или другого устройства. Настоятельная рекомендация, низкая степень достоверности данных 1 GRADE - Ранжирование оценки, разработки и экспертизы рекомендаций. Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ВВЕДЕНИЕ Регулярная физическая активность является одним из ключевых защитных факторов при профилактике и лечении неинфекционных заболеваний (НИЗ), таких как сердечно-сосудистые заболевания, сахарный диабет 2-го типа и ряда онкологических заболеваний. Физическая активность также благотворно влияет на психическое здоровье, включая профилактику снижения когнитивных функций и предупреждение симптомов депрессии и тревоги; и может способствовать поддержанию оптимального веса и общего самочувствия. Глобальные оценки свидетельствуют о том, что 27,5% взрослых (1) и 81% подростков (2) не выполняют рекомендации ВОЗ 2010 г. в отношении физической активности (3), при этом в последнее десятилетие практически не наблюдалось каких-либо улучшений. Сохраняются также заметные диспропорции: данные свидетельствуют о том, что в большинстве стран девочки и женщины проявляют меньшую физическую активность, чем мальчики и мужчины, и что существуют значительные различия в уровнях физической активности между группами населения с более высоким и более низким социально-экономическим статусом, а также между странами и регионами. СФЕРА ОХВАТА Рекомендации ВОЗ по вопросам физической активности и малоподвижного образа жизни представляют собой научно обоснованные рекомендации в области общественного здравоохранения для детей, подростков, взрослых и пожилых людей в отношении уровня физической активности (регулярности, интенсивности и продолжительности), необходимого для того, чтобы обеспечить значительное улучшение состояния здоровья и снизить соответствующие риски. Впервые даются рекомендации по вопросам, касающимся взаимосвязи между малоподвижным образом жизни и показателями здоровья, а также в отношении отдельных подгрупп населения, таких как беременные женщины, женщины в послеродовом периоде и лица с хроническими патологиями и ограниченными возможностями. ЦЕЛЕВАЯ АУДИТОРИЯ Рекомендации предназначены для лиц, ответственных за разработку политики в странах с высоким, средним и низким уровнем дохода и действующих в рамках министерств здравоохранения, образования, по делам молодежи, спорта и/или социального обеспечения и защиты семьи; государственных должностных лиц, отвечающих за разработку национальных, субрегиональных и муниципальных планов по повышению физической активности и снижению распространенности малоподвижного образа жизни в отдельных группах населения и подготовку соответствующей методической документации; сотрудников неправительственных организаций, работников сектора образования, частного сектора и сектора научных исследований; а также работников здравоохранения. ПРОЦЕСС РАЗРАБОТКИ РЕКОМЕНДАЦИЙ Рекомендации были подготовлены в соответствии с положениями Пособия ВОЗ по разработке рекомендаций (4). В 2019 г. была создана группа по разработке рекомендаций (ГРР), в состав которой вошли технические эксперты и соответствующие заинтересованные стороны из всех шести регионов ВОЗ. В июле 2019 г. группа провела совещание в целях формулирования ключевых вопросов, проведения обзора баз научных данных и согласования методов, используемых при обновлении материалов и в случае необходимости при проведении дополнительных новых обзоров. В феврале 2020 г. ГРР вновь провела совещание в целях обзора информации о важнейших и значимых итоговых результатах и обсуждения вопросов, касающихся пользы и вреда, ценностей, предпочтений, осуществимости и приемлемости, а также последствий с точки зрения обеспечения равенства и использования ресурсов. Рекомендации были разработаны на основе достигнутого консенсуса и размещены в интернете для открытого обсуждения. Обновленные рекомендации в окончательном виде обобщены ниже. Таблицы GRADE 1 и профили фактических данных доступны в виде веб- приложения . Практический инструментарий по оказанию содействия принятию, распространению и выполнению рекомендаций и проведению информационных кампаний поможет правительствам и заинтересованным сторонам в их совместной работе по повышению физической активности населения и снижению распространенности малоподвижного образа жизни на всех этапах жизненного цикла. РЕКОМЕНДАЦИИ Рекомендации в области общественного здравоохранения, представленные в Рекомендациях ВОЗ по вопросам физической активности и малоподвижному образу жизни, предназначены для всех групп населения и возрастных групп от 5 до 65 лет и старше, независимо от пола, культурной принадлежности или социально- экономического статуса, и актуальны для людей с любыми способностями. Лицам с хроническими патологиями и/ или ограниченными возможностями, а также беременным женщинам и женщинам в послеродовом периоде следует по мере возможности и в силу своих способностей стараться выполнять эти рекомендации. 60 следует посвящать занятиям физически активной деятельностью средней или высокой интенсивности, в основном с аэробной нагрузкой. минут в день Не менее 3 следует заниматься физически активной деятельностью высокой интенсивности с аэробной нагрузкой, в том числе направленной на укрепление скелетно- мышечной системы. Не реже дней в неделю СЛЕДУЕТ СОКРАТИТЬ продолжительность малоподвижных периодов, особенно время досуга у экрана телевизора, компьютера или другого устройства. 2 3 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации viii 1Резюме В связи с этим рекомендуется следующее. Взрослым следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, средняя степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии взрослым следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней или высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных В связи с этим рекомендуется следующее. Всем взрослым следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Взрослым следует не менее 150-300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75-150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили дополнительную пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных ВЗРОСЛЫЕ (в возрасте 18-64 лет) ВЗРОСЛЫЕ (в возрасте 18-64 лет) 2 К раку отдельных локализаций относятся рак мочевого пузыря, молочной железы, толстой кишки, эндометрия, аденокарцинома пищевода, рак желудка и почек. • небольшая физическая активность лучше, чем ее полное отсутствие; • если взрослые не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • взрослым следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность. П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я Особо малоподвижный образ жизни взрослых ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению распространенности сердечно- сосудистых заболеваний, рака и диабета 2-го типа. Физическая активность взрослых благоприятно отражается на следующих показателях, связанных со здоровьем: снижается смертность от всех причин, в том числе от сердечно-сосудистых заболеваний, снижается заболеваемость гипертонией, раком отдельных локализаций 2, диабетом 2-го типа, улучшается психическое здоровье (снижаются симптомы тревоги и депрессии); улучшаются когнитивное здоровье и сон; также может снижаться степень ожирения. Взрослые могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных Для того, чтобы занятия приносили дополнительную пользу для здоровья, взрослым также следует выполнять силовые упражнения средней и большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных СЛЕДУЕТ СОКРАТИТЬ ЗАМЕНИТЬ НА продолжительность малоподвижных периодов занятия физически более активной деятельностью любой интенсивности (в том числе низкой интенсивности) 150 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут или не менееНе менее 75 - - Дополнительная польза для здоровья: силовые упражнения средней или большей интенсивности на все основные группы мышц. 2 Не реже дней в неделю 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут болееБолее Дополнительная польза для здоровья: или 4 5 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 1 1 2 3 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и В связи с этим рекомендуется следующее. Взрослым следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, средняя степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии взрослым следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней или высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных В связи с этим рекомендуется следующее. Всем взрослым следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Взрослым следует не менее 150-300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75-150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили дополнительную пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных ВЗРОСЛЫЕ (в возрасте 18-64 лет) ВЗРОСЛЫЕ (в возрасте 18-64 лет) 2 К раку отдельных локализаций относятся рак мочевого пузыря, молочной железы, толстой кишки, эндометрия, аденокарцинома пищевода, рак желудка и почек. • небольшая физическая активность лучше, чем ее полное отсутствие; • если взрослые не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • взрослым следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность. П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я Особо малоподвижный образ жизни взрослых ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению распространенности сердечно- сосудистых заболеваний, рака и диабета 2-го типа. Физическая активность взрослых благоприятно отражается на следующих показателях, связанных со здоровьем: снижается смертность от всех причин, в том числе от сердечно-сосудистых заболеваний, снижается заболеваемость гипертонией, раком отдельных локализаций 2, диабетом 2-го типа, улучшается психическое здоровье (снижаются симптомы тревоги и депрессии); улучшаются когнитивное здоровье и сон; также может снижаться степень ожирения. Взрослые могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных Для того, чтобы занятия приносили дополнительную пользу для здоровья, взрослым также следует выполнять силовые упражнения средней и большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных СЛЕДУЕТ СОКРАТИТЬ ЗАМЕНИТЬ НА продолжительность малоподвижных периодов занятия физически более активной деятельностью любой интенсивности (в том числе низкой интенсивности) 150 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут или не менееНе менее 75 - - Дополнительная польза для здоровья: силовые упражнения средней или большей интенсивности на все основные группы мышц. 2 Не реже дней в неделю 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут болееБолее Дополнительная польза для здоровья: или 4 5 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 2 3Резюме В связи с этим рекомендуется следующее. Всем пожилым людям следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Пожилым людям следует не менее 150-300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75-150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили ощутимую пользу для здоровья, уделять в течение недели время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных ПОЖИЛЫЕ ЛЮДИ (в возрасте 65 лет и старше) ПОЖИЛЫЕ ЛЮДИ (в возрасте 65 лет и старше) • небольшая физическая активность лучше, чем ее полное отсутствие; • если пожилые люди не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • пожилым людям следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • пожилым людям следует оставаться настолько физически активными, насколько позволяют их функциональные возможности, и соразмерять интенсивность занятий физически активной деятельностью с уровнем своего физического здоровья.П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я Особо малоподвижный образ жизни пожилых людей ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению распространенности сердечно-сосудистых заболеваний, рака и диабета 2-го типа. В связи с этим рекомендуется следующее. Пожилым людям следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, средняя степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии пожилым людям следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней или высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Физическая активность пожилых людей благоприятно отражается на следующих показателях, связанных со здоровьем: снижается смертность от всех причин, в том числе от сердечно-сосудистых заболеваний, снижается заболеваемость гипертонией, раком отдельных локализаций, диабетом 2-го типа, улучшается психическое здоровье (снижаются симптомы тревоги и депрессии), улучшаются когнитивное здоровье и сон; также может снижаться степень ожирения. У пожилых людей занятия физически активной деятельностью помогают предотвращать падения и связанный с падениями травматизм, а также препятствуют ухудшению состояния костной системы и ее функциональных возможностей. Пожилые люди могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных Для того, чтобы занятия приносили дополнительную пользу для здоровья, пожилым людям также следует выполнять силовые упражнения средней и большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных В ходе еженедельных занятий физически активной деятельностью в целях повышения функциональных возможностей и предотвращения риска падений пожилым людям следует не реже трех раз в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней и большей интенсивности. Настоятельная рекомендация, средняя степень достоверности данных 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут болееБолее Дополнительная польза для здоровья: или 150 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут не менееНе менее 75или - - силовые упражнения средней или большей интенсивности на все основные группы мышц. Дополнительная польза для здоровья: 2 Не реже дней в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней или большей интенсивности. 3 Не реже дней в неделю СЛЕДУЕТ СОКРАТИТЬ ЗАМЕНИТЬ НА продолжительность малоподвижных периодов занятия физически более активной деятельностью любой интенсивности (в том числе низкой интенсивности) 6 7 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 4 5 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и В связи с этим рекомендуется следующее. Всем пожилым людям следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Пожилым людям следует не менее 150-300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75-150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили ощутимую пользу для здоровья, уделять в течение недели время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных ПОЖИЛЫЕ ЛЮДИ (в возрасте 65 лет и старше) ПОЖИЛЫЕ ЛЮДИ (в возрасте 65 лет и старше) • небольшая физическая активность лучше, чем ее полное отсутствие; • если пожилые люди не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • пожилым людям следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • пожилым людям следует оставаться настолько физически активными, насколько позволяют их функциональные возможности, и соразмерять интенсивность занятий физически активной деятельностью с уровнем своего физического здоровья.П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я Особо малоподвижный образ жизни пожилых людей ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению распространенности сердечно-сосудистых заболеваний, рака и диабета 2-го типа. В связи с этим рекомендуется следующее. Пожилым людям следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, средняя степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии пожилым людям следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней или высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Физическая активность пожилых людей благоприятно отражается на следующих показателях, связанных со здоровьем: снижается смертность от всех причин, в том числе от сердечно-сосудистых заболеваний, снижается заболеваемость гипертонией, раком отдельных локализаций, диабетом 2-го типа, улучшается психическое здоровье (снижаются симптомы тревоги и депрессии), улучшаются когнитивное здоровье и сон; также может снижаться степень ожирения. У пожилых людей занятия физически активной деятельностью помогают предотвращать падения и связанный с падениями травматизм, а также препятствуют ухудшению состояния костной системы и ее функциональных возможностей. Пожилые люди могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных Для того, чтобы занятия приносили дополнительную пользу для здоровья, пожилым людям также следует выполнять силовые упражнения средней и большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных В ходе еженедельных занятий физически активной деятельностью в целях повышения функциональных возможностей и предотвращения риска падений пожилым людям следует не реже трех раз в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней и большей интенсивности. Настоятельная рекомендация, средняя степень достоверности данных 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут болееБолее Дополнительная польза для здоровья: или 150 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут не менееНе менее 75или - - силовые упражнения средней или большей интенсивности на все основные группы мышц. Дополнительная польза для здоровья: 2 Не реже дней в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней или большей интенсивности. 3 Не реже дней в неделю СЛЕДУЕТ СОКРАТИТЬ ЗАМЕНИТЬ НА продолжительность малоподвижных периодов занятия физически более активной деятельностью любой интенсивности (в том числе низкой интенсивности) 6 7 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 4 5Резюме Физическая активность беременных женщин и женщин в послеродовом периоде благоприятно отражается на следующих показателях, связанных со здоровьем матери и плода: снижаются риски преэклампсии, гестационной гипертензии, гестационного диабета, чрезмерного гестационного увеличения массы тела, осложнений при родах и послеродовой депрессии, а также уменьшается количество осложнений у новорожденных, исключаются негативные факторы, влияющие на вес ребенка при рождении; и также исключается повышение риска мертворождения. Всем беременным женщинам и женщинам в послеродовом периоде при отсутствии противопоказаний рекомендуется следующее. Следует регулярно заниматься физически активной деятельностью во время беременности и в послеродовой период. Настоятельная рекомендация, средняя степень достоверности данных Кроме того, женщины, которые до наступления беременности регулярно выполняли аэробные физические упражнения высокой интенсивности или занимались физически активной деятельностью, могут продолжать эту практику во время беременности и в послеродовой период. Настоятельная рекомендация, средняя степень достоверности данных Для того, чтобы физическая активность приносила ощутимую пользу для здоровья, следует уделять не менее 150 минут в неделю занятиям физически активной деятельностью средней и высокой интенсивности с аэробной нагрузкой. Настоятельная рекомендация, средняя степень достоверности данных Рекомендуется использовать различные виды аэробных и силовых физических упражнений. Также могут быть полезными дополнительные легкие упражнения на растяжку. Настоятельная рекомендация, средняя степень достоверности данных БЕРЕМЕННЫЕ ЖЕНЩИНЫ И ЖЕНЩИНЫ В ПОСЛЕРОДОВОМ ПЕРИОДЕ БЕРЕМЕННЫЕ ЖЕНЩИНЫ И ЖЕНЩИНЫ В ПОСЛЕРОДОВОМ ПЕРИОДЕ П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я • небольшая физическая активность лучше, чем ее полное отсутствие; • если беременные женщины и женщины в послеродовом периоде не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • беременным женщинам и женщинам в послеродовом периоде следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • в целях снижения риска недержания мочи можно ежедневно делать упражнения для укрепления мышц тазового дна. • Избегайте занятий физически активной деятельностью во время чрезмерной жары, особенно в условиях высокой влажности. • Не допускайте обезвоживания организма и пейте воду до, во время и после физических нагрузок. • Избегайте занятий теми видами деятельности, которые предполагают физические контакты с другими людьми; повышают риск падений; или могут ограничивать насыщение организма кислородом (например, занятия физически активной деятельностью в условиях больших высот над уровнем моря, если они не являются условиями вашей обычной жизнедеятельности). • Избегайте физических нагрузок в положении лежа на спине после первого триместра беременности. • При принятии решений относительно участия в спортивных соревнованиях или выполнения упражнений, значительно превышающих по своим нагрузкам рекомендуемые уровни, беременным женщинам следует обращаться за консультацией к врачу-специалисту. • Беременным женщинам следует проконсультироваться у своего лечащего врача по вопросу об опасных симптомах, свидетельствующих о необходимости приостановить или ограничить занятия физически активной деятельностью, и немедленно проконсультироваться с квалифицированным врачом-специалистом в случае возникновения таких симптомов. • Возвращение к активной физической деятельности после родов следует осуществлять постепенно, а также по согласованию лечащим врачом в случае родов путем кесарева сечения. К дополнительным рекомендациям относительно мер предосторожности, которые необходимо соблюдать беременным женщинам при занятии физически активной деятельностью, относятся следующие. Особо малоподвижный образ жизни беременных женщин и женщин в послеродовом периоде, как и всех взрослых, ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению распространенности сердечно- сосудистых заболеваний, рака и диабета 2-го типа. В связи с этим рекомендуется следующее. Беременным женщинам и женщинам в послеродовом периоде следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, низкая степень достоверности данных Небольшая физическая активность лучше, чем ее полное отсутствие. СЛЕДУЕТ СОКРАТИТЬ ЗАМЕНИТЬ НА продолжительность малоподвижных периодов занятия физически более активной деятельностью любой интенсивности (в том числе низкой интенсивности) 150 занятия физически активной деятельностью средней интенсивности с аэробной нагрузкой Не менее минут в неделю 8 9 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 6 7 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Физическая активность беременных женщин и женщин в послеродовом периоде благоприятно отражается на следующих показателях, связанных со здоровьем матери и плода: снижаются риски преэклампсии, гестационной гипертензии, гестационного диабета, чрезмерного гестационного увеличения массы тела, осложнений при родах и послеродовой депрессии, а также уменьшается количество осложнений у новорожденных, исключаются негативные факторы, влияющие на вес ребенка при рождении; и также исключается повышение риска мертворождения. Всем беременным женщинам и женщинам в послеродовом периоде при отсутствии противопоказаний рекомендуется следующее. Следует регулярно заниматься физически активной деятельностью во время беременности и в послеродовой период. Настоятельная рекомендация, средняя степень достоверности данных Кроме того, женщины, которые до наступления беременности регулярно выполняли аэробные физические упражнения высокой интенсивности или занимались физически активной деятельностью, могут продолжать эту практику во время беременности и в послеродовой период. Настоятельная рекомендация, средняя степень достоверности данных Для того, чтобы физическая активность приносила ощутимую пользу для здоровья, следует уделять не менее 150 минут в неделю занятиям физически активной деятельностью средней и высокой интенсивности с аэробной нагрузкой. Настоятельная рекомендация, средняя степень достоверности данных Рекомендуется использовать различные виды аэробных и силовых физических упражнений. Также могут быть полезными дополнительные легкие упражнения на растяжку. Настоятельная рекомендация, средняя степень достоверности данных БЕРЕМЕННЫЕ ЖЕНЩИНЫ И ЖЕНЩИНЫ В ПОСЛЕРОДОВОМ ПЕРИОДЕ БЕРЕМЕННЫЕ ЖЕНЩИНЫ И ЖЕНЩИНЫ В ПОСЛЕРОДОВОМ ПЕРИОДЕ П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я • небольшая физическая активность лучше, чем ее полное отсутствие; • если беременные женщины и женщины в послеродовом периоде не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • беременным женщинам и женщинам в послеродовом периоде следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • в целях снижения риска недержания мочи можно ежедневно делать упражнения для укрепления мышц тазового дна. • Избегайте занятий физически активной деятельностью во время чрезмерной жары, особенно в условиях высокой влажности. • Не допускайте обезвоживания организма и пейте воду до, во время и после физических нагрузок. • Избегайте занятий теми видами деятельности, которые предполагают физические контакты с другими людьми; повышают риск падений; или могут ограничивать насыщение организма кислородом (например, занятия физически активной деятельностью в условиях больших высот над уровнем моря, если они не являются условиями вашей обычной жизнедеятельности). • Избегайте физических нагрузок в положении лежа на спине после первого триместра беременности. • При принятии решений относительно участия в спортивных соревнованиях или выполнения упражнений, значительно превышающих по своим нагрузкам рекомендуемые уровни, беременным женщинам следует обращаться за консультацией к врачу-специалисту. • Беременным женщинам следует проконсультироваться у своего лечащего врача по вопросу об опасных симптомах, свидетельствующих о необходимости приостановить или ограничить занятия физически активной деятельностью, и немедленно проконсультироваться с квалифицированным врачом-специалистом в случае возникновения таких симптомов. • Возвращение к активной физической деятельности после родов следует осуществлять постепенно, а также по согласованию лечащим врачом в случае родов путем кесарева сечения. К дополнительным рекомендациям относительно мер предосторожности, которые необходимо соблюдать беременным женщинам при занятии физически активной деятельностью, относятся следующие. Особо малоподвижный образ жизни беременных женщин и женщин в послеродовом периоде, как и всех взрослых, ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению распространенности сердечно- сосудистых заболеваний, рака и диабета 2-го типа. В связи с этим рекомендуется следующее. Беременным женщинам и женщинам в послеродовом периоде следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, низкая степень достоверности данных Небольшая физическая активность лучше, чем ее полное отсутствие. СЛЕДУЕТ СОКРАТИТЬ ЗАМЕНИТЬ НА продолжительность малоподвижных периодов занятия физически более активной деятельностью любой интенсивности (в том числе низкой интенсивности) 150 занятия физически активной деятельностью средней интенсивности с аэробной нагрузкой Не менее минут в неделю 8 9 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 6 7Резюме Взрослым и пожилым людям с хроническими патологиями следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, низкая степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии взрослым и пожилым людям с хроническими патологиями следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней или высокой интенсивности. Настоятельная рекомендация, низкая степень достоверности данных Лицам, пережившим онкологические заболевания, а также взрослым, страдающим гипертонией и диабетом 2-го типа, и ВИЧ-инфицированным рекомендуется следующее. В связи с этим рекомендуется следующее. Всем взрослым и пожилым людям с вышеуказанными хроническими патологиями следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Взрослым и пожилым людям с этими хроническими патологиями следует не менее 150-300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75-150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных При отсутствии противопоказаний взрослые и пожилые люди, страдающие этими хроническими патологиями, могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили дополнительную пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных В ходе еженедельных занятий физически активной деятельностью в целях повышения функциональных возможностей и предотвращения риска падений пожилым людям с этими хроническими патологиями следует не реже трех раз в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней и большей интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Для того, чтобы занятия приносили дополнительную пользу для здоровья, взрослым и пожилым людям с этими хроническими патологиями также следует выполнять силовые упражнения средней и большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) Физическая активность может благоприятно отражаться на здоровье взрослых и пожилых людей со следующими хроническими патологиями: благодаря поддержанию физической активности у лиц, переживших онкологические заболевания, снижаются показатели смертности от всех причин и конкретных онкологических заболеваний, а также риск рецидива или второго первичного рака; у лиц, страдающих артериальной гипертонией, благодаря поддержанию физической активности снижаются показатели смертности от сердечно-сосудистых заболеваний, замедляется прогрессирование заболевания, улучшаются показатели физического функционирования, а также повышается качество жизни, обусловленное состоянием здоровья; у лиц, страдающих сахарным диабетом 2-го типа, благодаря поддержанию физической активности снижаются показатели смертности от сердечно-сосудистых заболеваний и замедляется прогрессирование заболевания; лицам с ВИЧ-инфекцией поддержание физической активности может помочь улучшить физическое и психическое здоровье (снизить симптомы тревоги и депрессии), не оказывая при этом негативного воздействия на прогрессирование болезни (на число CD4-клеток и вирусную нагрузку) или состав тканей организма. П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я • если взрослые с этими хроническими патологиями не в состоянии выполнять вышеперечисленные рекомендации, им следует стремиться к тому, чтобы заниматься физически активной деятельностью в соответствии со своими физическими возможностями; • взрослым с этими хроническими патологиями следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • взрослые с этими хроническими патологиями могут получить консультацию у специалиста по вопросам физической активности или медицинского работника относительно видов и объемов физически активной деятельности, соответствующих их индивидуальным потребностям, физическим возможностям, функциональным ограничениям/ осложнениями, принимаемым лекарственным средствам и общему плану лечения; • как правило, для лиц, не имеющих противопоказаний, нет необходимости в прохождении предварительного медосмотра перед началом занятий физически активной деятельностью низкой и средней интенсивности, не требующих физической подготовки дополнительно к той, которая необходима для энергичной ходьбы или в повседневной жизни. Особо малоподвижный образ жизни взрослых, в том числе переживших онкологические заболевания, страдающих артериальной гипертонией и диабетом 2-го типа, а также ВИЧ-инфицированных, ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению распространенности сердечно- сосудистых заболеваний, рака и диабета 2-го типа. выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней или большей интенсивности. 3 Не реже дней в неделю силовые упражнения средней или большей интенсивности на все основные группы мышц. Дополнительная польза для здоровья: 2 Не реже дней в неделю 150 300 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут не менееНе менее 75 150 или - - 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут болееБолее Дополнительная польза для здоровья: или СЛЕДУЕТ СОКРАТИТЬ ЗАМЕНИТЬ НА продолжительность малоподвижных периодов занятия физически более активной деятельностью любой интенсивности (в том числе низкой интенсивности) 10 11 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 8 9 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Взрослым и пожилым людям с хроническими патологиями следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, низкая степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии взрослым и пожилым людям с хроническими патологиями следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней или высокой интенсивности. Настоятельная рекомендация, низкая степень достоверности данных Лицам, пережившим онкологические заболевания, а также взрослым, страдающим гипертонией и диабетом 2-го типа, и ВИЧ-инфицированным рекомендуется следующее. В связи с этим рекомендуется следующее. Всем взрослым и пожилым людям с вышеуказанными хроническими патологиями следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Взрослым и пожилым людям с этими хроническими патологиями следует не менее 150-300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75-150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных При отсутствии противопоказаний взрослые и пожилые люди, страдающие этими хроническими патологиями, могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили дополнительную пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных В ходе еженедельных занятий физически активной деятельностью в целях повышения функциональных возможностей и предотвращения риска падений пожилым людям с этими хроническими патологиями следует не реже трех раз в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней и большей интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Для того, чтобы занятия приносили дополнительную пользу для здоровья, взрослым и пожилым людям с этими хроническими патологиями также следует выполнять силовые упражнения средней и большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) Физическая активность может благоприятно отражаться на здоровье взрослых и пожилых людей со следующими хроническими патологиями: благодаря поддержанию физической активности у лиц, переживших онкологические заболевания, снижаются показатели смертности от всех причин и конкретных онкологических заболеваний, а также риск рецидива или второго первичного рака; у лиц, страдающих артериальной гипертонией, благодаря поддержанию физической активности снижаются показатели смертности от сердечно-сосудистых заболеваний, замедляется прогрессирование заболевания, улучшаются показатели физического функционирования, а также повышается качество жизни, обусловленное состоянием здоровья; у лиц, страдающих сахарным диабетом 2-го типа, благодаря поддержанию физической активности снижаются показатели смертности от сердечно-сосудистых заболеваний и замедляется прогрессирование заболевания; лицам с ВИЧ-инфекцией поддержание физической активности может помочь улучшить физическое и психическое здоровье (снизить симптомы тревоги и депрессии), не оказывая при этом негативного воздействия на прогрессирование болезни (на число CD4-клеток и вирусную нагрузку) или состав тканей организма. П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я • если взрослые с этими хроническими патологиями не в состоянии выполнять вышеперечисленные рекомендации, им следует стремиться к тому, чтобы заниматься физически активной деятельностью в соответствии со своими физическими возможностями; • взрослым с этими хроническими патологиями следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • взрослые с этими хроническими патологиями могут получить консультацию у специалиста по вопросам физической активности или медицинского работника относительно видов и объемов физически активной деятельности, соответствующих их индивидуальным потребностям, физическим возможностям, функциональным ограничениям/ осложнениями, принимаемым лекарственным средствам и общему плану лечения; • как правило, для лиц, не имеющих противопоказаний, нет необходимости в прохождении предварительного медосмотра перед началом занятий физически активной деятельностью низкой и средней интенсивности, не требующих физической подготовки дополнительно к той, которая необходима для энергичной ходьбы или в повседневной жизни. Особо малоподвижный образ жизни взрослых, в том числе переживших онкологические заболевания, страдающих артериальной гипертонией и диабетом 2-го типа, а также ВИЧ-инфицированных, ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению распространенности сердечно- сосудистых заболеваний, рака и диабета 2-го типа. выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней или большей интенсивности. 3 Не реже дней в неделю силовые упражнения средней или большей интенсивности на все основные группы мышц. Дополнительная польза для здоровья: 2 Не реже дней в неделю 150 300 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут не менееНе менее 75 150 или - - 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут болееБолее Дополнительная польза для здоровья: или СЛЕДУЕТ СОКРАТИТЬ ЗАМЕНИТЬ НА продолжительность малоподвижных периодов занятия физически более активной деятельностью любой интенсивности (в том числе низкой интенсивности) 10 11 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 8 9Резюме ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ Во многих случаях физическая активность приносит детям и подросткам с ограниченными возможностями такую же пользу для здоровья, которую, как отмечалось в разделе выше, она приносит всем детям и подросткам. Дополнительная польза физической активности в улучшении показателей здоровья людей с ограниченными возможностями также заключается в том, что улучшаются когнитивные способности лиц с заболеваниями и расстройствами, связанными с нарушением когнитивных функций, в том числе лиц с синдромом дефицита внимания/гиперактивности (СДВГ); у детей с ограниченными интеллектуальными возможностями могут улучшаться показатели физического функционирования. • небольшая физическая активность лучше, чем ее полное отсутствие; • если дети и подростки с ограниченными возможностями не соблюдают эти рекомендации, любые занятия физически активной деятельностью пойдут на пользу их здоровью; • детям и подросткам с ограниченными возможностями следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • занятия физически активной деятельностью для детей и подростков с ограниченными возможностями не связаны с какими-либо серьезными рисками в том случае, когда они соответствуют текущему уровню физической подготовки, состоянию здоровья и показателям физического функционирования конкретного ребенка; при этом полученная в итоге польза для здоровья перевешивает возможные риски; • дети и подростки с ограниченными возможностями могут нуждаться в консультации медицинского работника или другого специалиста по вопросам физической активности и работе с лицами с ограниченными возможностями для определения видов и объема физических нагрузок, которые им подходят. П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я Особо малоподвижный образ жизни детей и подростков ведет к следующим негативным последствиям для их здоровья: повышению степени ожирения; ухудшению состояния кардиометаболического здоровья, физического здоровья и эмоционального/социально ориентированного поведения; а также сокращению продолжительности сна. В связи с этим рекомендуется следующее. Детям и подросткам с ограниченными возможностями следует сокращать продолжительность малоподвижных периодов, особенно время досуга у экрана телевизора, компьютера или другого устройства. Настоятельная рекомендация, низкая степень достоверности данных В связи с этим рекомендуется следующее. Детям и подросткам еженедельно следует посвящать в среднем не менее 60 минут в день занятиям физически активной деятельностью, в основном аэробного типа, средней или высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Физически активной деятельностью с аэробной нагрузкой высокой интенсивности, в том числе направленной на укрепление скелетно-мышечной системы, следует заниматься не реже трех раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных Следует начинать с небольших физических нагрузок. Небольшая физическая активность лучше, чем ее полное отсутствие. 3 следует заниматься физически активной деятельностью высокой интенсивности с аэробной нагрузкой, в том числе направленной на укрепление скелетно- мышечной системы. Не реже дней в неделю 60 следует посвящать занятиям физически активной деятельностью средней или высокой интенсивности, в основном с аэробной нагрузкой. Не менее минут в день СЛЕДУЕТ СОКРАТИТЬ продолжительность малоподвижных периодов, особенно время досуга у экрана телевизора, компьютера или другого устройства. 12 13 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 0 1 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ Во многих случаях физическая активность приносит детям и подросткам с ограниченными возможностями такую же пользу для здоровья, которую, как отмечалось в разделе выше, она приносит всем детям и подросткам. Дополнительная польза физической активности в улучшении показателей здоровья людей с ограниченными возможностями также заключается в том, что улучшаются когнитивные способности лиц с заболеваниями и расстройствами, связанными с нарушением когнитивных функций, в том числе лиц с синдромом дефицита внимания/гиперактивности (СДВГ); у детей с ограниченными интеллектуальными возможностями могут улучшаться показатели физического функционирования. • небольшая физическая активность лучше, чем ее полное отсутствие; • если дети и подростки с ограниченными возможностями не соблюдают эти рекомендации, любые занятия физически активной деятельностью пойдут на пользу их здоровью; • детям и подросткам с ограниченными возможностями следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • занятия физически активной деятельностью для детей и подростков с ограниченными возможностями не связаны с какими-либо серьезными рисками в том случае, когда они соответствуют текущему уровню физической подготовки, состоянию здоровья и показателям физического функционирования конкретного ребенка; при этом полученная в итоге польза для здоровья перевешивает возможные риски; • дети и подростки с ограниченными возможностями могут нуждаться в консультации медицинского работника или другого специалиста по вопросам физической активности и работе с лицами с ограниченными возможностями для определения видов и объема физических нагрузок, которые им подходят. П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я Особо малоподвижный образ жизни детей и подростков ведет к следующим негативным последствиям для их здоровья: повышению степени ожирения; ухудшению состояния кардиометаболического здоровья, физического здоровья и эмоционального/социально ориентированного поведения; а также сокращению продолжительности сна. В связи с этим рекомендуется следующее. Детям и подросткам с ограниченными возможностями следует сокращать продолжительность малоподвижных периодов, особенно время досуга у экрана телевизора, компьютера или другого устройства. Настоятельная рекомендация, низкая степень достоверности данных В связи с этим рекомендуется следующее. Детям и подросткам еженедельно следует посвящать в среднем не менее 60 минут в день занятиям физически активной деятельностью, в основном аэробного типа, средней или высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Физически активной деятельностью с аэробной нагрузкой высокой интенсивности, в том числе направленной на укрепление скелетно-мышечной системы, следует заниматься не реже трех раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных Следует начинать с небольших физических нагрузок. Небольшая физическая активность лучше, чем ее полное отсутствие. 3 следует заниматься физически активной деятельностью высокой интенсивности с аэробной нагрузкой, в том числе направленной на укрепление скелетно- мышечной системы. Не реже дней в неделю 60 следует посвящать занятиям физически активной деятельностью средней или высокой интенсивности, в основном с аэробной нагрузкой. Не менее минут в день СЛЕДУЕТ СОКРАТИТЬ продолжительность малоподвижных периодов, особенно время досуга у экрана телевизора, компьютера или другого устройства. 12 13 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 0 1Резюме В связи с этим рекомендуется следующее. Взрослым с ограниченными возможностями следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, низкая степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии взрослым с ограниченными возможностями следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней и высокой интенсивности. Настоятельная рекомендация, низкая степень достоверности данных В связи с этим рекомендуется следующее. Всем взрослым с ограниченными возможностями следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Взрослым с ограниченными возможностями следует не менее 150-300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75-150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Для того, чтобы занятия приносили дополнительную пользу для здоровья, взрослым с ограниченными возможностями также следует выполнять силовые упражнения средней и большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных ВЗРОСЛЫЕ (в возрасте 18 лет и старше) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ ВЗРОСЛЫЕ (в возрасте 18 лет и старше) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ Во многих случаях физическая активность приносит взрослым с ограниченными возможностями такую же пользу для здоровья, которую, как отмечалось в разделе выше, она приносит всем взрослым. Дополнительная польза физической активности в улучшении показателей здоровья людей с ограниченными возможностями также заключается в следующем: у взрослых, страдающих рассеянным склерозом, улучшаются показатели физического функционирования, а также физические, психологические и социальные аспекты качества жизни, обусловленного состоянием здоровья; у лиц с повреждениями спинного мозга улучшается функция ходьбы, повышается мышечная сила и улучшается функция верхних конечностей; а также улучшается качество жизни, обусловленное состоянием здоровья; у людей с заболеваниями или расстройствами, связанными с нарушением когнитивных функций, улучшаются показатели физического функционирования и когнитивной деятельности (у лиц с болезнью Паркинсона и лиц, имеющих в анамнезе инсульт); оказывается положительное воздействие на когнитивную деятельность; а также может улучшаться качество жизни (у взрослых, страдающих шизофренией); могут улучшаться показатели физического функционирования (у взрослых с ограниченными интеллектуальными возможностями); и улучшается качество жизни (у взрослых, страдающих большим депрессивным расстройством). Особо малоподвижный образ жизни взрослых ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению распространенности сердечно-сосудистых заболеваний, рака и диабета 2-го типа. Взрослые с ограниченными возможностями могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили дополнительную пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных В ходе еженедельных занятий физически активной деятельностью в целях повышения функциональных возможностей и предотвращения риска падений пожилым людям с ограниченными возможностями следует не реже трех раз в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней и большей интенсивности. Настоятельная рекомендация, средняя степень достоверности данных П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я • небольшая физическая активность лучше, чем ее полное отсутствие; • если взрослые с ограниченными возможностями не соблюдают эти рекомендации, любые занятия физически активной деятельностью пойдут на пользу их здоровью; • взрослым с ограниченными возможностями следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • занятия физически активной деятельностью для взрослых с ограниченными возможностями не связаны с какими-либо серьезными рисками в том случае, когда они соответствуют текущему уровню физической подготовки, состоянию здоровья и показателям физического функционирования конкретного человека; при этом полученная в итоге польза для здоровья перевешивает возможные риски; • взрослые с ограниченными возможностями могут нуждаться в консультации медицинского работника или другого специалиста по вопросам физической активности и работе с лицами с ограниченными возможностями для определения видов и объема физических нагрузок, которые им подходят. 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут болееБолее физически активной деятельности высокой интенсивности с аэробной нагрузкой Дополнительная польза для здоровья: или выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней или большей интенсивности. 3 Не реже дней в неделю СЛЕДУЕТ СОКРАТИТЬ ЗАМЕНИТЬ НА продолжительность малоподвижных периодов занятия физически более активной деятельностью любой интенсивности (в том числе низкой интенсивности) силовые упражнения средней или большей интенсивности на все основные группы мышц. Дополнительная польза для здоровья: 2 Не реже дней в неделю 150 300 150 минут - физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут не менееНе менее 75или - 14 15 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 2 3 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и В связи с этим рекомендуется следующее. Взрослым с ограниченными возможностями следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, низкая степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии взрослым с ограниченными возможностями следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней и высокой интенсивности. Настоятельная рекомендация, низкая степень достоверности данных В связи с этим рекомендуется следующее. Всем взрослым с ограниченными возможностями следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Взрослым с ограниченными возможностями следует не менее 150-300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75-150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Для того, чтобы занятия приносили дополнительную пользу для здоровья, взрослым с ограниченными возможностями также следует выполнять силовые упражнения средней и большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных ВЗРОСЛЫЕ (в возрасте 18 лет и старше) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ ВЗРОСЛЫЕ (в возрасте 18 лет и старше) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ Во многих случаях физическая активность приносит взрослым с ограниченными возможностями такую же пользу для здоровья, которую, как отмечалось в разделе выше, она приносит всем взрослым. Дополнительная польза физической активности в улучшении показателей здоровья людей с ограниченными возможностями также заключается в следующем: у взрослых, страдающих рассеянным склерозом, улучшаются показатели физического функционирования, а также физические, психологические и социальные аспекты качества жизни, обусловленного состоянием здоровья; у лиц с повреждениями спинного мозга улучшается функция ходьбы, повышается мышечная сила и улучшается функция верхних конечностей; а также улучшается качество жизни, обусловленное состоянием здоровья; у людей с заболеваниями или расстройствами, связанными с нарушением когнитивных функций, улучшаются показатели физического функционирования и когнитивной деятельности (у лиц с болезнью Паркинсона и лиц, имеющих в анамнезе инсульт); оказывается положительное воздействие на когнитивную деятельность; а также может улучшаться качество жизни (у взрослых, страдающих шизофренией); могут улучшаться показатели физического функционирования (у взрослых с ограниченными интеллектуальными возможностями); и улучшается качество жизни (у взрослых, страдающих большим депрессивным расстройством). Особо малоподвижный образ жизни взрослых ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению распространенности сердечно-сосудистых заболеваний, рака и диабета 2-го типа. Взрослые с ограниченными возможностями могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили дополнительную пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных В ходе еженедельных занятий физически активной деятельностью в целях повышения функциональных возможностей и предотвращения риска падений пожилым людям с ограниченными возможностями следует не реже трех раз в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней и большей интенсивности. Настоятельная рекомендация, средняя степень достоверности данных П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я • небольшая физическая активность лучше, чем ее полное отсутствие; • если взрослые с ограниченными возможностями не соблюдают эти рекомендации, любые занятия физически активной деятельностью пойдут на пользу их здоровью; • взрослым с ограниченными возможностями следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • занятия физически активной деятельностью для взрослых с ограниченными возможностями не связаны с какими-либо серьезными рисками в том случае, когда они соответствуют текущему уровню физической подготовки, состоянию здоровья и показателям физического функционирования конкретного человека; при этом полученная в итоге польза для здоровья перевешивает возможные риски; • взрослые с ограниченными возможностями могут нуждаться в консультации медицинского работника или другого специалиста по вопросам физической активности и работе с лицами с ограниченными возможностями для определения видов и объема физических нагрузок, которые им подходят. 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут болееБолее физически активной деятельности высокой интенсивности с аэробной нагрузкой Дополнительная польза для здоровья: или выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней или большей интенсивности. 3 Не реже дней в неделю СЛЕДУЕТ СОКРАТИТЬ ЗАМЕНИТЬ НА продолжительность малоподвижных периодов занятия физически более активной деятельностью любой интенсивности (в том числе низкой интенсивности) силовые упражнения средней или большей интенсивности на все основные группы мышц. Дополнительная польза для здоровья: 2 Не реже дней в неделю 150 300 150 минут - физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут не менееНе менее 75или - 14 15 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 2 3Резюме 14 15 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Регулярная физическая активность является общепризнанным защитным фактором при профилактике и лечении неинфекционных заболеваний, таких как сердечно-сосудистые заболевания, диабет 2-го типа, рак молочной железы и толстой кишки (1–3). Физическая активность также благотворно влияет на психическое здоровье (4), задерживает начало развития деменции (5), может способствовать поддержанию оптимального веса (1) и общего самочувствия (6). Согласно определению, физическая активность есть любое движение тела, производимое скелетными мышцами, которое требует затрат энергии (1) и может осуществляться с разной степенью интенсивности как часть работы, выполнения домашних обязанностей или передвижения, досуга, а также при занятиях спортом или участии в спортивных мероприятиях. Малоподвижный образ жизни, соответствующий нижней границе шкалы интенсивности, определяется как любая нагрузка во время бодрствования в положении сидя, лежа или полулежа, связанная с низким расходом энергии (7). Появляющиеся новые данные свидетельствуют о том, что высокая распространенность малоподвижного образа жизни приводит к возникновению сердечно- сосудистых заболеваний и диабета 2-го типа, а также к росту смертности от сердечно-сосудистых, онкологических и других заболеваний (8–10). Недостаточная физическая активность определяется как не соответствующая Глобальным рекомендациям по физической активности для здоровья 2010 г. (1) и относится к числу основных факторов, вызывающих глобальную смертность. Согласно оценкам, если бы мировое население вело более активный образ жизни, это позволило бы ежегодно предотвращать 4–5 миллионов случаев смерти (2, 11). Глобальные оценочные данные о масштабах недостаточной физической активности показывают, что в 2016 г. образ жизни 27,5% взрослых (12) и 81% подростков (13) не соответствовал рекомендациям ВОЗ 2010 г. (1), а данные о динамике свидетельствуют об ограниченном характере глобальных улучшений, достигнутых за истекшее десятилетие. Из имеющихся данных также видно, что в большинстве стран образ жизни у женщин менее активен, чем у мужчин, и что как внутри отдельных стран и регионов, так и между ними наблюдаются значительные различия в уровнях физической активности. Эти различия объясняются неравным доступом к возможностям проявления СПРАВОЧНАЯ ИНФОРМАЦИЯ 1 WHA71.6 Глобальный план действий ВОЗ по повышению уровня физической активности на 2018–2030 гг.. физической активности, что еще более усугубляет неравенство в сфере здравоохранения. В настоящее время не имеется глобальных оценочных данных о распространенности малоподвижного образа жизни, но технологические инновации и переход к более статичным видам работы и отдыха наряду с ростом масштабов использования личных автотранспортных средств способствуют изменению моделей физической активности и распространению малоподвижного образа жизни во всем мире. В Глобальном плане действий ВОЗ по повышению уровня физической активности на 2018–2030 гг. (14) предусмотрены четыре стратегические цели и 20 мер политики для достижения относительного сокращения на 15% общей распространенности недостаточной физической активности среди взрослых и подростков к 2030 г. В 2010 г. ВОЗ опубликовала Глобальные рекомендации по физической активности для здоровья (1) — первые популяционные рекомендации по общественному здравоохранению для детей, подростков, взрослых и пожилых людей. В 2018 г. Всемирная ассамблея здравоохранения в своей резолюции WHA71.61 призвала ВОЗ обновить рекомендации 2010 г. В 2019 г. ВОЗ опубликовала Руководство «Физическая активность, малоподвижный образ жизни и сон у детей в возрасте до 5 лет» (15). Цель этого руководства, составленного по инициативе Комиссии по ликвидации детского ожирения (рекомендация 4.12) (16), — восполнить пробел в связи с этой младшей возрастной группой, которая была обойдена вниманием в Глобальных рекомендациях по физической активности для здоровья 2010 г. (1). В основу Рекомендаций ВОЗ по вопросам физической активности и малоподвижного образа жизни 2020 г., заменяющего рекомендации 2010 г., заложены наиболее поздние фактологические наработки по рассматриваемым поведенческим моделям и связанным с ними последствиям для здоровья. Новые рекомендации станут составной частью свода глобальных рекомендаций в отношении физической активности и малоподвижного образа жизни. 14 15Справочная информация ДРУГИЕ КЛЮЧЕВЫЕ РЕКОМЕНДАЦИИ ВОЗ Важность физической активности для здоровья человека признана и в других рекомендациях ВОЗ. Так, в публикации «Пакет основных мероприятий ВОЗ по оказанию первичной медико-санитарной помощи в отношении неинфекционных заболеваний в условиях ограниченных ресурсов» (17), содержащей протокол клинического ведения артериальной гипертонии, диабета 2-го типа, повышенного сердечно-сосудистого риска, астмы и хронического обструктивного легочного заболевания, рекомендуется постепенно увеличивать физическую нагрузку до средних уровней (такую как энергичная ходьба) и практиковать ее как минимум 150 минут в неделю в соответствии с Глобальными рекомендациями 2010 г. Недавнее Руководство ВОЗ по снижению риска развития когнитивных расстройств и деменции (18) гласит, что для уменьшения риска снижения когнитивных способностей физически активную деятельность следует рекомендовать взрослым с нормальными когнитивными функциями (настоятельная рекомендация) и взрослым с умеренным когнитивным нарушением (условная рекомендация). В публикации ВОЗ «Интегрированный уход за пожилыми людьми: руководство по оказанию помощи на уровне местных сообществ по предотвращению снижения физических и умственных возможностей» (19) рекомендуются комплексные упражнения для предотвращения риска падений и упражнения для пожилых людей со снижающейся мобильностью. В Рекомендациях ВОЗ по оказанию дородовой помощи для формирования положительного опыта беременности (20) предлагается проконсультироваться по вопросам здорового питания и физической активности, которые позволяют поддержать хорошее самочувствие и избежать чрезмерной прибавки в весе, но при этом не стремиться во время беременности и в послеродовой период к достижению более значимого оздоровительного эффекта от физической активности. Существующие рекомендации ВОЗ в сочетании с настоящими обновленными рекомендациями составляют более широкоохватный комплекс глобальных выводов о влиянии физической активности и малоподвижного образа жизни на профилактику и ведение основных заболеваний и на улучшение здоровья и благополучия на протяжении всего жизненного цикла. ОБОСНОВАНИЕ И ЦЕЛЬ За последние 10 лет был отмечен значительный прирост фактического материала о влиянии на здоровье человека различных видов, объемов и периодов физической активности, а также о последствиях малоподвижного образа жизни и его взаимосвязи с уровнями физической активности и здоровья. Кроме того, составленная база фактических данных о физической активности в отдельных подгруппах населения, таких как беременные женщины и лица с хроническими заболеваниями и/или с ограниченными возможностями, теперь позволяет рассмотреть взаимосвязь между физической активностью и показателями здоровья в этих подгруппах. Мера 4.1 Глобального плана действий ВОЗ по повышению уровня физической активности на 2018–2030 гг. (14) предусматривает, чтобы ВОЗ разработала и распространила глобальные рекомендации по повышению уровня физической активности и снижению распространенности малоподвижного образа жизни среди детей в возрасте до 5 лет, молодых людей, взрослых, пожилых людей и определенных групп населения, таких как беременные женщины и лица с хроническими заболеваниями или ограниченными возможностями. Процесс обновления и расширения охвата рекомендаций, проводимый согласно поручению Всемирной ассамблеи здравоохранения, обеспечивает включение отдельных рекомендаций о физической активности для тех групп населения, которые не были охвачены рекомендациями 2010 г. Это согласуется с основными принципами и целями Глобального плана действий по повышению уровня физической активности, а именно со стремлением сократить неравенство и ежедневно содействовать всем группам населения в повышении уровня их физической активности. 16 17 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Главная цель настоящего документа — предоставить научно обоснованные рекомендации в области общественного здравоохранения, посвященные тому, какие объемы и виды физической активности следует практиковать детям и подросткам, взрослым, пожилым людям и таким подгруппам, как беременные женщины и лица с хроническими заболеваниями или ограниченными возможностями, чтобы обеспечить значительное улучшение состояния здоровья и снизить соответствующие риски. В нем также даются научно обоснованные рекомендации, касающиеся взаимосвязей между малоподвижным образом жизни и показателями здоровья. Настоящие рекомендации касаются детей и подростков (в возрасте 5–17 лет), взрослых (в возрасте 18–64 лет), пожилых людей (в возрасте 65 лет и старше) и впервые включают в себя отдельные рекомендации по физической активности для подгрупп населения, таких как беременные женщины и лица с хроническими заболеваниями или ограниченными возможностями. Рекомендации даются для каждой отдельной возрастной группы и подгруппы населения, чтобы обеспечить лицам, работающим с определенными общинами, прямой доступ к соответствующей информации. Составление отдельных рекомендаций для подгрупп населения, особенно для лиц с хроническими заболеваниями или ограниченными возможностями, свидетельствует о важности включения этих подгрупп в процесс выработки политики и мероприятий, касающихся физической активности и малоподвижного образа жизни. В настоящих рекомендациях сон не рассматривается в качестве образа жизни. Сон — важный аспект здоровья и новая тема в области науки о здоровье населения, но все же было решено, что включение сна в обновленные рекомендации выходит за рамки предусмотренного мандата. Тем не менее значение сна является общепризнанным, и он был включен в число важных показателей здоровья при рассмотрении вопроса о воздействии физической активности и малоподвижного образа жизни. ЦЕЛЕВАЯ АУДИТОРИЯ В настоящих рекомендациях представлена процедура разработки рекомендаций и обобщена база фактических данных, рассмотренных в ходе их разработки. Первоочередными целевыми аудиториями рекомендаций являются: (1) директивные органы министерств здравоохранения, образования, по делам молодежи, спорта и/или социального обеспечения и защиты семьи в странах с высоким, а также низким и средним уровнем дохода, занимающиеся разработкой страновых инструкций и подготовкой программ действий по вопросам здравоохранения, образования, условий труда, жилища или общин на протяжении всего жизненного цикла; (2) государственные должностные лица, отвечающие за разработку национальных, субрегиональных и муниципальных планов по повышению физической активности и сокращению масштабов малоподвижного образа жизни в отдельных группах населения с помощью методической документации; (3) сотрудники неправительственных организаций, работников сектора образования, профессиональных организаций и сектора научных исследований; (4) лица, занятые в медицинских учреждениях и лица, предоставляющие консультации и рекомендации, такие как общинные представители, члены семьи, медперсонал и врачи как первичной, так и специализированной помощи или представители смежных с медициной профессий, занятые вне сектора здравоохранения. Они могут опираться на настоящий документ при подготовке своих рекомендаций по указанным темам при отсутствии национальных руководящих материалов. Рекомендации в отношении физической активности и малоподвижного образа жизни, изложенные в документе, следует включать в материалы курсов дослужебной подготовки и повышения квалификации медицинских работников, специалистов по вопросам физической активности и работников образования. Налицо необходимость в производных продуктах данных рекомендаций, предназначенных для инструктирования определенных групп пользователей, заинтересованных сторон в секторах за пределами сферы здравоохранения и широкой общественности, которые пользуются адаптированными материалами для удовлетворения специфических потребностей каждой аудитории. 16 17Справочная информация Настоящие рекомендации были составлены в соответствии с Пособием ВОЗ по разработке руководящих принципов (второе издание) (21). Была учреждена Руководящая группа ВОЗ, возглавляемая Департаментом по вопросам укрепления здоровья, в которую вошли представители региональных бюро ВОЗ и соответствующих департаментов ВОЗ. Была также создана Группа по разработке рекомендаций (ГРР) в составе 27 экспертов и заинтересованных сторон; при ее формировании учитывались принципы гендерного равновесия и географического разнообразия. Проект рекомендаций был рассмотрен семью независимыми внешними рецензентами, которые представили свое заключение о качестве научных данных, их толковании и содержании. Кроме того, состоялось онлайновое публичное обсуждение проекта рекомендаций, после чего более 400 участников дискуссии направили свои отзывы. Эти материалы, полученные от ученых, специалистов-практиков и широкой общественности, были обработаны и использованы членами ГРР при окончательной доработке рекомендаций. Подробные сведения о координации процесса работы над рекомендациями содержатся в приложении 1. СФЕРА ОХВАТА РЕКОМЕНДАЦИЙ И РАССМАТРИВАЕМЫЕ ВОПРОСЫ ГРР рассмотрела вопрос о сфере охвата рекомендаций и на своем первом совещании согласовала наиболее актуальные аспекты, обозначенные как ГМ/ВСП (Группа населения, Мероприятие/Воздействие, Coпоставление, Показатель здоровья). Ключевые вопросы, рассмотренные по каждой подгруппе населения, обобщены следующим образом: По физической активности: a. Какова взаимосвязь между физической активностью (ФА) и показателями здоровья? b. Имеет ли место взаимосвязь «доза-реакция» (объем, продолжительность, регулярность, интенсивность)? c. Варьируется ли эта взаимосвязь в зависимости от типа или области физической активности? По малоподвижному образу жизни: a. Какова взаимосвязь между малоподвижным образом жизни (МОЖ) и показателями здоровья? b. Имеет ли место взаимосвязь «доза- реакция» (общий объем, регулярность, продолжительность и интенсивность перерывов)? c. Варьируется ли эта взаимосвязь в зависимости от типа или области малоподвижного образа жизни? d. Только для взрослых: изменяет ли физическая активность влияние малоподвижного образа жизни на смертность? Для каждой группы населения (Г) в качестве воздействия (В) на нее рассматривалось увеличение объема, продолжительности, регулярности или интенсивности физической нагрузки в сопоставлении (С) с отсутствием физической нагрузки или с физической нагрузкой меньшего объема и меньшей регулярности, интенсивности или продолжительности. Важнейшие и важные показатели здоровья для каждой группы населения обобщены в таблице 1, а подробная информация по каждому вопросу комплекса ГМ/ВСП содержится в соответствующем разделе веб-приложения «Профили фактических данных» . METОДИКА Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 18 19 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Taблица 1: Обобщение важнейших и важных* показателей здоровья по группам населения Показатели (в английском алфавитном порядке) Дети и подростки в возрасте 5–17 лет: ФА и МОЖ Взрослые в возрасте 18–64 лет: ФA Взрослые старше 18 лет: МОЖ Взрослые старше 65 лет: ФA a Беременность и послеродовой период Хронические патологии b Дети и взрослые с ограничен-ными возмож-ностями c Ожирение (набор веса, изменение веса, контроль веса, стабильность веса, статус веса и поддержание веса) Важнейший Важнейший Важнейший Важнейшийa Важнейший Важнейший – ВИЧ – Нежелательные явления Важнейший Важнейший – Важнейшийa Важнейший (исходы для плода) – – Смертность от всех причин и от конкретных причин – Важнейший (особенно онкологические заболевания и ССЗ) Важнейший Важнейшийa – Важнейший – Здоровье костной системы Важнейший – Важный – – – – Кардиометаболическое здоровье Важнейший – – – – – – Когнитивные способности Важнейший Важнейший Важный Важнейшийa – – Важнейший – MС, БП, ЛПИ, ШФ, СДВГ Осложнения при родах – – – – Важный – – Прогрессирование заболевания – – – – – Важнейший – ГT, Д2, ВИЧ, Важнейший – рецидив рака – Падения и связанный с падениями травматизм – – – Важнейший – – – Исходы для плода (вес при рождении, преждевременные роды) – – – – Важнейший – – Функциональная способность – – – Важнейший – – – Гестационный сахарный диабет – – – – Важнейший – – Гестационная гипертония/ преэклампсия – – – – Важнейший – – Качество жизни, обусловленное состоянием здоровья – Важный Важный Важный a – Важнейший – ГT, Д2, ВИЧ Важнейший – MС, ПСМ, ОИВ, БДР, ШФ Заболеваемость раком – Важнейший Важнейший Важнейшийa – – – Заболеваемость ССЗ – Важнейший Важнейший Важнейшийa – – – Заболеваемость гипертонией – Важный – Важный a – – – Заболеваемость диабетом 2-го типа – Важнейший Важнейший Важнейший a – – – Психическое здоровье (симптомы тревоги и депрессии) Важнейший Важнейший Важный Важнейший a Важнейший – – Остеопороз – – – Важнейший – – – Физическое состояние Важнейший – Важный – – – – Физическое функционирование – – Важный – – Важнейший – ГT, Д2, ВИЧ Важнейший – MС, ПСМ, ОИВ, БП, ЛПИ Просоциальное поведение Важный – – – – – – Психосоциальные показатели – – – Важный – – – Риск сопутствующих заболеваний – – – – – Важнейший – ГT, Д2, ВИЧ Важнейший – MС, ПСМ, ОИВ Сон Важный Важный Важный Важныйa – – – * Важнейший показатель здоровья: показатель, имеющий критическое значение для принятия решений; важный показатель здоровья: показатель, который важен, но не является критическим для принятия решений. a Важнейшие и важные показатели здоровья рассматриваются для взрослого населения, включая пожилых людей. b Показатели состояния здоровья по подгруппам: онкологические заболевания – лица, пережившие рак; ГT — гипертония; Д2 — диабет 2-го типа; ВИЧ. c Показатели состояния здоровья по подгруппам: MС – мышечный склероз; ПСМ – повреждение спинного мозга; ОИВ — ограниченные интеллектуальные возможности; БП — болезнь Паркинсона; ЛПИ — лица, пережившие инсульт; ШФ — шизофрения; СДВГ — синдром дефицита внимания/гиперактивности; БДР — большое депрессивное расстройство. Важнейшие и важные показатели здоровья по возрастным группам были рассмотрены и экстраполированы. 18 19Методика ФАКТИЧЕСКИЕ ДАННЫЕ В процессе пересмотра рекомендаций ВОЗ по физической активности 2010 г. были выявлены, а затем обновлены наиболее поздние из соответствующих общих обзоров, относящихся к сфере охвата настоящих рекомендаций. Применение такого подхода объяснялось наличием широкого спектра недавних систематических обзоров, проведенных для информирования органов, которые занимались разработкой ряда национальных рекомендацией в отношении физической активности. В ходе дополнительного обновления принимались меры к тому, чтобы в новых рекомендациях ВОЗ были отражены самые последние данные, которые имеются в быстро эволюционирующей сфере общественного здравоохранения. Общие обзоры отбирались по трем следующим критериям: (i) если обзоры фактических данных были проведены в соответствии со стандартными, официально оформленными систематическими процедурами; (ii) если для оценки достоверности фактических данных применялся метод ранжирования оценки, разработки и экспертизы рекомендаций (GRADE) или какая-либо эквивалентная, подробно описанная и задокументированная методика; и (iii) если обзоры фактических данных были посвящены группам населения, представляющим интерес для авторов рекомендаций, и при этом не ограничивались какими-либо странами или уровнем дохода стран. Вопросы комплекса ГМ/ВСП наряду с важнейшими и важными показателями здоровья проецировались на имеющиеся обзоры фактических данных, после чего при необходимости запрашивалось проведение новых, дополнительных обзоров для восполнения обнаруженных пробелов. ГРР поручила обновить обзоры фактических данных, используя те же поисковые запросы, те же языки поиска и базы данных, которые были задействованы в первоначальных обзорах. Следующие обзоры фактических данных были признаны соответствующими трем вышеупомянутым критериям и отобраны за их новизну и всеохватность: • Poitras et al. (2016) Систематический обзор публикаций о взаимосвязи между физической активностью и показателями здоровья среди детей и молодежи школьного возраста (22), проведенный в рамках процесса разработки Канадой рекомендаций относительно подвижности на 24-часовой период для детей и молодежи (23). В этом обзоре рассматривались лишь те исследования, в которых были использованы объективные измерения параметров физической активности. Обзор в целом охватывал 162 исследования, представлявших 204 171 участника из 31 страны. • Carson et al. (2016) Систематический обзор публикаций о взаимосвязи между малоподвижным образом жизни и показателями здоровья среди детей школьного возраста (24), проведенный в рамках процесса разработки Канадой рекомендаций относительно подвижности на 24-часовой период для детей и молодежи (23). Обзор в целом охватывал 235 исследований (194 отдельных выборки), представлявших 1 657 064 участника из 71 cтраны. • Okely et al. (2019) (25) Систематический обзор, проведенный с целью обновления публикаций Poitras et al. (2016) (22) и Carson et al. (2018) (24) в рамках разработки Австралией рекомендаций относительно подвижности на 24-часовой период для детей и молодежи (в возрасте 5–17 лет) 2019 г. (26). В этом докладе было рассмотрено 42 дополнительных исследования о физической активности и 32 — о малоподвижном образе жизни, опубликованных за период до июля 2018 г. (25). Tаблицы, составленные по методу GRADE в ходе исследования Okely et al., были использованы в качестве основы для порученного обновления, проведенного усилиями ВОЗ. Таблицы GRADE вместе с профилями фактических данных представлены в веб-приложении «Профили фактических данных» . • Двенадцать систематических обзоров, проведенных и обобщенных в рамках процесса разработки Канадой рекомендаций относительно физической активности в период беременности 2019 г. (27). В этих 12 обзорах оценено более 25 000 соответствующих исследований на английском, испанском и французском языках по вопросу о физической активности будущих матерей в период беременности, в которых сообщались данные о материнской, внутриутробной или неонатальной заболеваемости или внутриутробной смертности. В семи из упомянутых систематических обзоров рассматривались показатели здоровья, которые ГРР признала важнейшими и важными (28–34). Таблицы GRADE, включенные в эти обзоры фактических данных, были приняты за основу для поиска публикаций, который был проведен в целях обновления данных и передачи информации для разработки рекомендаций ВОЗ. Обновленные профили фактических данных представлены в веб приложении «Профили фактических данных» . • Научный доклад Консультативной группы по руководящим принципам физической активности (PAGAC) (35), в котором проведено систематическое обновление фактических данных о физической активности и малоподвижном образе жизни и показателей здоровья, опубликованных в 2008–2016 гг. в рамках разработки Рекомендаций относительно физической активности для американцев (второе издание) (36). В обобщенном фактическом материале было рассмотрено в общей сложности 38 основных исследовательских вопросов и 104 подвопроса, отобранных в связи с их актуальностью для общественного здравоохранения. Представленный материал включал в себя результаты систематических обзоров, охватывавших в целом 1130 статей, причем из каждой статьи были взяты выдержки для ответов на 38 упомянутых исследовательских вопросов (35). В протоколах была использована модифицированная версия измерительного инструмента для оценки систематических обзоров (AMSTARExBP), с помощью которого оценивалось методологическое качество систематических обзоров и метаанализов. По каждому первоначальному исследованию была проведена оценка риска необъективности, или процедура внутреннего подтверждения, для которой использовалась адаптированная версия инструмента для оценки необъективности USDA NEL (BAT) (37). Новый фактический материал, собранный в результате проведения обновленных поисков для настоящих рекомендаций ВОЗ, представлен в профилях фактических данных в веб-приложении «Профили фактических данных» ; даются ссылки на доклад и на дополнительные материалы PAGAC (35). Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf20 21 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Meтоды обновления фактического материала и извлечение данных Предметом поиска систематических обзоров и сводных анализов когортных исследований являлись исследования, опубликованные с даты последних поисков каждого из отобранных обзоров (перечисленных выше) до сентября 2019 г.; были разработаны и применены стандартизированные протоколы извлечения данных. Для обновления материалов, представленных в публикациях Poitras et al. (2016) (22), Carson et al. (2016) (24) и Okely et al. (2019) (25), были проведены поиски по базам данных MEDLINE, EMBASE, PsycINFO и SportDiscus на предмет выявления рецензированных обзоров на английском или французском языках. Для обновления результатов поиска, проведенного PAGAC (35), были обследованы базы данных PubMed, CINAHL и Cochrane на предмет выявления рецензированных обзоров на английском языке. Новый поиск по важным показателям здоровья в случаях, когда соответствующие данные не фигурировали в материалах PAGAC (35), из-за ограниченности ресурсов провести не удалось. Поиски проводились без ограничений по странам или уровню дохода стран и охватывали обзоры, в которых рассматривались те или иные субъективные или объективные измерения параметров физической активности или малоподвижного образа жизни. Было решено не проводить поисков на других языках, кроме языков первоначальных исследований, учитывая ресурсные ограничения и предшествующий опыт в этой области, согласно которому поиски такого рода весьма редко приводят к выявлению дополнительных обзоров. Принимались во внимание обзоры, в которых была рассмотрена взаимосвязь между физической активностью или малоподвижным образом жизни и показателями здоровья (исходя из уровней, находящихся выше или ниже какой-либо пороговой величины физической активности или малоподвижного образа жизни), a также обзоры, где исследовалась взаимосвязь «доза реакция» между активностью/ малоподвижностью и параметрами состояния здоровья. Для ранжирования степени достоверности рассматриваемых систематических обзоров на предмет их включения в выборку внешняя исследовательская группа использовала инструмент AMSTAR 2 (Оценка множественных систематических обзоров) (38). Инструмент AMSTAR 2 включает в себя 16 критериев, касающихся планирования и проведения обзора. Общее доверие к результатам каждого обзора ранжировалось согласно опубликованной инструкции: «высокий» рейтинг доверия означает, что в обзоре имеется не более одного некритичного недостатка; рейтинг «средний» указывает, что анализ выявил в обзоре более одного некритичного недостатка; рейтинг «низкий» свидетельствует о том, что в обзоре была обнаружена одна серьезная ошибка наряду с некритичными недостатками или без таковых, либо несколько некритичных недостатков; наконец, рейтинг «крайне низкий» означает, что в обзоре выявлено более одной серьезной ошибки. Один из исследователей провел с помощью инструмента AMSTAR 2 оценку всех обзоров, которые были ранее включены в выборку. Обзоры, оцененные одним исследователем как «крайне низкие», были повторно рассмотрены вторым исследователем с помощью того же инструмента. В результате обзоры, получившие «крайне низкий» рейтинг, были изъяты из выборки как признанные слишком ненадежными для предоставления точного и всеобъемлющего обобщения имеющихся фактических данных, за исключением случаев, когда такой обзор был единственным имеющимся источником по какому-либо конкретному показателю. В этот массив фактических данных были также включены сводные когортные исследования. Для оценки качества исследований внешняя исследовательская группа использовала шкалу Ньюкасла-Оттавы (39). Каждому исследованию была присвоена качественная оценка «хорошо», «удовлетворительно» или «неудовлетворительно». Как правило, качественное исследование соответствовало всем критериям шкалы Ньюкасла-Оттавы. Исследование удовлетворительного качества не соответствовало или неявно соответствовало хотя бы одному критерию этой шкалы, а также не имело известных существенных ограничений, которые могли бы обесценить его результаты. Исследование неудовлетворительного качества содержало одну критическую ошибку или несколько существенных ограничений; такие исследования были исключены из выборки. Кроме того, была проведена оценка на дублирование, поскольку не исключалась возможность совпадения исследований в рамках многочисленных обзоров. Обзоры, в которых содержались излишние комплексы фактических данных, краткие описания обзоров и некоторые из сводных когортных исследований исключались из выборки в случаях, когда обнаруживались другие, более полные и/или свежие обзоры. Meтоды проведения новых обзоров При обнаружении пробелов в имеющихся фактических данных назначались новые общие обзоры для рассмотрения: (1) взаимосвязи между профессиональной (т. е. связанной с работой) физической активностью и показателями здоровья (40); и (2) взаимосвязи между досуговой физической активностью и негативными показателями здоровья (41); (По пунктам 1 и 2 выше поиски проводились с использованием PubMed, SportDiscus и EMBASE в отношении обзоров, опубликованных с 2009 г. по декабрь 2019 г.) (3) взаимосвязи между физической активностью и профилактикой падений; при этом были использованы материалы публикации Sherrington et al. «Систематический обзор Кокрейновского сотрудичества» 2019 г. (42), обновленные путем включения данных, опубликованных с даты последнего поиска в этом первоначальном обзоре до ноября 2019 г.; (4) взаимосвязи между физической активностью и остеопорозом и саркопенией; в процессе поиска существующих систематических обзоров по проблемам остеопороза и саркопении, проведенного по базе PubMed среди обзоров, опубликованных с 2008 г. по ноябрь 2019 г., новых обзоров выявлено не было, но при этом удалось обнаружить восемь новых первичных исследований; 20 21Методика (5) фактических данных о взаимосвязи между физической активностью и показателями здоровья лиц с ВИЧ-инфекцией. Обзорный анализ подтвердил наличие фактических данных о физической активности и показателях здоровья среди лиц с ВИЧ-инфекцией и послужил основанием для проведения общего обзора, который охватывал фактические данные, опубликованные до октября 2019 г., без ограничения по исходной дате; поиск осуществлялся по базам PubMed, CINAHL и Web of Science. Резюме характеристик фактических данных и методов оценки физической активности и малоподвижного образа жизни До недавнего времени первичной методикой измерения параметров физической активности и малоподвижного образа жизни среди взрослых являлся анализ данных самооценки респондентов (т. е. обследований), а среди детей — либо их самооценки, либо сведений от родителей. Хотя эти методы пользуются общепризнанным авторитетом, им свойственны ограничения, к числу которых относятся возможная необъективность информации и погрешность измерения (43). В последние годы, отмеченные активным внедрением цифровой технологии в эту сферу, наблюдается рост масштабов использования аппаратных средств оценки физической активности и малоподвижного времяпровождения и их взаимосвязи с показателями здоровья. При этом, однако, остаются проблемы, связанные с сопоставлением результатов исследований, обусловленные различиями между техническими аспектами и размещением разнообразных устройств (акселерометров), a также различиями в процедурах анализа и представления данных. Так, при измерении времени пребывания в малоподвижном состоянии с помощью аппаратных средств возможны ошибки в расчетах, поскольку многие устройства пока не умеют различать положения тела (например, дифференцировать положения лежа, сидя и стоя неподвижно). Трудности встречаются и при сопоставлении выводов исследований, проведенных с применением аппаратных средств, с результатами исследований, основанных на собственных сообщениях респондентов. Инструменты самооценки различаются по своему содержанию, по примерам физической активности, вариантам ответов и охватываемым сферам. До недавнего времени исследования были прежде всего сосредоточены исключительно на оценке либо общей физической активности, либо досуговой/ рекреационной физической активности; теперь же они все чаще охватывают другие области, такие как физическая активность при передвижении (например, ходьба или езда на велосипеде), на работе или дома. Большинство фактических данных касается взаимосвязи между аэробной нагрузкой и показателями здоровья, однако нынешние исследования посвящены оценке благотворного влияния силовых упражнений, а также сочетаниям различных видов нагрузок и другим областям. Результаты исследований о взаимосвязи между уровнями физической активности и показателями здоровья публикуются и сопоставляются в различных странах. Во многих исследованиях даются сравнения между квартилями или квинтилями физической активности; другие исследования посвящены сопоставлению показателей лиц, «выполняющих» и «не выполняющих» национальные рекомендации. Когда сообщаются данные расчета общей физической активности, они обычно выражены в MET-часах в неделю, и в некоторых исследованиях сравниваются «высшие» и «низшие» показатели, хотя соответствующие категории также варьируются в зависимости от исследований. В публикациях нередко сообщаются результаты анализов с применением величин пограничных значений, основанных на какой-либо существующей рекомендации, на нынешних Глобальных рекомендациях ВОЗ или на количественных показателях из предыдущего поиска (например, на пограничных значениях, составляющих 60 минут в день из поиска данных о молодом населении, или на регулярности в 2–3 раза в неделю для силовых тренировок). Когда такие пограничные значения становятся обычной практикой, процесс получения фактических данных o взаимосвязи между влиянием более высоких или более низких уровней физической активности на показатели здоровья может быть ограничен. Основная часть фактических данных об оценке взаимосвязи между малоподвижным образом жизни и показателями здоровья для детей и подростков носит межсекторальный характер, а большинство исследований опирается на данные самооценки или сообщения родителей об измерении времени пребывания в малоподвижном состоянии, которые могут страдать от погрешностей в измерениях и ошибок памяти. Приоритетное внимание уделялось результатам продольных наблюдательных исследований и экспериментальных разработок, а обзоры, где в исключительном или первоочередном порядке были обобщены межсекторальные фактические данные, во внимание не принимались. Повышенный интерес вызывали данные из обзоров, которым был присвоен уровень достоверности от среднего и выше, а также из обзоров, содержащих данные исследований, проведенных с применением аппаратных измерений воздействия. Ранжирование фактических данных Метод ранжирования оценки, разработки и экспертизы рекомендаций (GRADE) был использован для квалификации уровня достоверности фактических данных по каждому аспекту ГМ/ВСП (44) исходя из тех материалов, которые были заложены в основу обзоров. За отправную точку оценки каждого обзора принимались таблицы GRADE «Профили фактических данных» или «Резюме выводов», когда таковые фигурировали в обзоре. В случаях, когда таблицы в существующих систематических обзорах отсутствовали, для каждой группы населения и каждого показателя здоровья, представляющих интерес, были составлены таблицы «Профиль фактических данных». Метод GRADE применялся для ранжирования достоверности фактических данных по каждому аспекту ГМ/ВСП (44) с учетом следующих критериев: плана исследования; риска необъективности; последовательного 22 23 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и характера эффекта; косвенности; точности эффекта; и других ограничений, включая искаженность публикации и факторы повышения рейтинга эмпирических данных (масштабы последствий, «доза-ответ» и влияние неопределенностей). Рейтинг эмпирических данных из успешно проведенных продольных исследований также был повышен, чтобы более адекватно отражать возросший уровень достоверности сформулированных в этих исследованиях выводов о взаимосвязи между физической активностью или малоподвижным образом жизни и показателями здоровья. Результаты исследований, в которых оценивались непосредственные/косвенные показатели здоровья, не всегда понижались в рейтинге, т. к. эти показатели (в том числе промежуточные) являлись предметом приоритетного внимания ГРР; метод ранжирования GRADE отражает достоверность факторов воздействия на эти показатели здоровья. В ряде случаев рейтинги существующих обзоров, присвоенные по методу GRADE, были изменены для обеспечения последовательности в применении методики GRADE. Достоверность фактических данных по каждому показателю здоровья определялась согласно следующей рекомендации (45): Высокая Очень высокая степень доверия к тому, что реальные последствия близки к оценочным данным об этих последствиях. Средняя Средняя степень доверия к оценкам последствий: вероятно, реальные последствия близки к оценочным данным об этих последствиях, но не исключены и существенные отличия. Низкая Доверие к оценке последствий носит ограниченный характер: реальные последствия могут существенно отличаться от оценочных данных об этих последствиях. Очень низкая Весьма незначительное доверие к оценке последствий: вероятно, реальные последствия существенно отличаются от оценочных данных об этих последствиях. От фактических данных к рекомендациям Для разработки рекомендаций по конкретным вопросам ГРР применила механизм GRADE «Обоснование для решений» (ОДР). Механизм ОДР обеспечивает систематический, структурированный и транспарентный подход к принятию решений. В нем используются эксплицитные критерии формулирования рекомендаций для настоящего документа с учетом фактических исследовательских данных, достоверности данных и при необходимости — экспертных заключений и тематических знаний с точки зрения целевой аудитории. Эти критерии позволяют делать осознанные выводы о балансе между наблюдаемыми свидетельствами желательных и нежелательных результатов, общей достоверности фактических данных, относительной значимости желательных и нежелательных результатов для пациентов, в соответствующих случаях – о расходе ресурсов (стоимостных факторах), потенциальном воздействии на проявления неравенства в здравоохранении, приемлемости и целесообразности рекомендаций. ГРР полностью рассмотрела фактические данные для каждой рекомендации по всем важнейшим показателям здоровья и по всем имеющимся важным показателям здоровья. По отдельным случаям связи между воздействием/мероприятием и результатом исследования значительно различались в части, касающейся конкретного оцениваемого воздействия/мероприятия, оцениваемых результатов, плана исследования и методов анализа, что приводило к разнородности получаемых свидетельств. Поэтому было невозможно применять классический подход GRADE к каждому конкретному случаю связи между воздействием/мероприятием и результатом; вместо этого методика GRADE была применена к общему своду фактических данных по каждому случаю связи между воздействием/мероприятием и результатом, по всем типам и вариантам планов исследования измерений и анализов воздействия/мероприятия. Когда эти факторы вызывали беспокойство по поводу согласованности фактических данных (т. е. о том, что данные о связи определенного случая воздействия/мероприятия с результатом при их рассмотрении разными способами не совпадают), Группа понижала рейтинг достоверности таких данных (21). При рассмотрении последствий физической активности и малоподвижного образа жизни ГРР уделяла приоритетное внимание таким параметрам здравоохранения, как снижение показателей смертности от всех причин и смертности от конкретных причин (сердечно- сосудистых и онкологических заболеваний); сокращение масштабов распространения сердечно-сосудистых заболеваний; онкологические заболевания (отдельных локализаций); диабет 2-го типа; улучшение физического состояния (например, кардиореспираторных функций, моторного развития и мышечного тонуса); улучшение кардиометаболического здоровья (например, таких показателей, как артериальное давление, дислипидемия, уровень глюкозы, инсулинорезистентность); здоровье костной системы; психическое здоровье (например, уменьшение симптомов депрессии, чувство собственного достоинства, симптомы тревоги, СДВГ); улучшение когнитивных способностей (например, академической успеваемости, управляющей функции); и снижение ожирения. При этом были рассмотрены и отрицательные последствия (например, травмы и причинение вреда). Дополнительные факторы При рассмотрении каждой группы населения и всех вопросов, связанных с ГМ/ВСП, ГРР также принимала во внимание ценностные ориентиры и предпочтения лиц, охватываемых настоящими рекомендациями; ресурсные потребности для выполнения предлагаемых рекомендаций; последствия с точки зрения справедливости в области здравоохранения; и приемлемость и целесообразность рекомендаций. Учитывая значительную степень дублирования указанных факторов и оценок ГРР, для каждой группы населения в раздел «Обоснование рекомендаций» включено резюме дискуссий, посвященных оценкам этих элементов. 22 23Методика Рекомендации в области общественного здравоохранения, представленные в Рекомендациях ВОЗ по вопросам физической активности и малоподвижного образа жизни, предназначены для всех групп населения и возрастных групп от 5 до 65 лет и старше, независимо от пола, культурной принадлежности или социально-экономического статуса, и актуальны для лиц с ограниченными возможностями. Новые рекомендации структурированы по возрастным группам и образу жизни (физическая активность и малоподвижность). Каждому комплексу рекомендаций предшествует вступление, где обобщаются показатели здоровья, сопряженные соответственно с физической активностью и с малоподвижным образом жизни, после чего следуют сами рекомендации. Далее представлен ряд практических наблюдений для более углубленного пояснения о том, как представители целевой группы населения могут безопасно следовать данным рекомендациям. Эти практические наблюдения не являются «ступенчатыми рекомендациями» per se; они составлены на основе научных данных и практических соображений, пересмотренных и рекомендованных ГРР. Каждый комплекс рекомендаций сопровождается кратким изложением обосновывающих его научных данных, которые распределены по трем вопросам ГМ/ВСП; сначала приводятся данные о связях с важнейшими показателями здоровья, за которыми следует резюме данных о взаимосвязи «доза-ответ». В конце дается резюме данных o взаимосвязи между различными видами или областями воздействия и показателями здоровья, если такая взаимосвязь существует. РЕКОМЕНДАЦИИ П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я 24 25 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Подтверждающие фактические данные и обоснование При подготовке настоящих рекомендаций в отношении детей и подростков были использованы систематические обзоры (22, 25, 35), обновленные материалами 16 новых обзоров, которые были признаны соответствующими критериям включения. С полной информацией о методах, извлечении данных и профилях фактических данных можно ознакомиться в веб-приложении «Профили фактических данных» . Физическая активность детей и подростков благоприятно отражается на следующих показателях здоровья: состоянии физического здоровья (кардиореспираторный и мышечный тонус), кардиометаболическом здоровье (артериальное давление, дислипидемия, содержание глюкозы и инсулинорезистентность), состоянии костной системы, развитии когнитивных способностей (академическая успеваемость, управляющая функция), состоянии психического здоровья (уменьшение симптомов депрессии); и снижении степени ожирения. В этой связи рекомендуется следующее. Детям и подросткам следует еженедельно посвящать в среднем не менее 60 минут в день занятиям физически активной деятельностью средней и высокой интенсивности, в основном с аэробной нагрузкой. Настоятельная рекомендация, средняя степень достоверности данных Физически активной деятельностью высокой интенсивности с аэробной нагрузкой, в том числе направленной на укрепление скелетно-мышечной системы, следует заниматься не реже трех раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Дети и подростки могут заниматься физически активной деятельностью в рамках отдыха и досуга (подвижные игры, занятия спортом или плановые тренировки), физического воспитания, передвижений (использование колесных средств, ходьба и езда на велосипеде) или выполнения домашних обязанностей, то есть в образовательном, домашнем и общинном контексте. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО ФИЗИЧЕСКОЙ АКТИВНОСТИ ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) • небольшая физическая активность лучше, чем ее полное отсутствие; • если дети и подростки не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • детям и подросткам следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • важно предоставить всем детям и подросткам безопасные и равные возможности, а также поощрять их к участию в различных занятиях физически активной деятельностью, которые доставляли бы удовольствие, были бы разнообразными и соответствовали бы их возрасту и способностям.П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я 24 25Рекомендации Какова взаимосвязь между физической активностью и показателями здоровья у детей и подростков (в возрасте 5–17 лет)? Ранее в обширных фактических материалах было установлено, что увеличение объема и повышение интенсивности физических нагрузок приводят к многочисленным улучшениям показателей здоровья у детей и подростков (1). Недавно полученные данные подтверждают, что увеличение физической активности у детей и подростков приводит к улучшению кардиореспираторного здоровья и состояния скелетно-мышечной системы (22, 35). Например, позитивные результаты приносят занятия физически активной деятельностью средней и высокой интенсивности продолжительностью 30–60 минут не реже трех раз в неделю (22, 35). Регулярные, в основном аэробные физические нагрузки у детей и подростков благоприятно отражаются на показателях кардиометаболического здоровья, включая улучшение артериального давления, липидного спектра, содержания глюкозы и инсулинорезистентности (35). В недавно проведенных обзорах была рассмотрена эффективность школьных программ физической активности (46), интервальных тренировок высокой интенсивности (47) и тренировок сопротивления (48) в сравнении с отсутствием мероприятий по поддержанию кардиометаболического здоровья. Во всех трех обзорах были представлены последовательные фактические данные о том, что такие мероприятия приводили к улучшению кардиометаболических показателей, хотя полученные данные варьировались по уровню их эффективности, а ряд индивидуальных исследований показал статистически значимую пользу физической активности для всех кардиометаболических показателей. Согласно одному обзору по 19 РКИ (n= 11 988) (46), школьные программы физической активности приводили к статистически значимым улучшениям показателей диастолического артериального давления (КС= 0,21 [95% ДИ: 0,42 – 0,01]; p= 0,04) и уровня инсулина натощак (КС= 0,12 [95% ДИ: 0,42 – 0,04]; p= 0,03) по сравнению с отсутствием физически активных мероприятий. Сообщалось, что физически активная деятельность благоприятно воздействует на ожирение и что повышение уровней такой деятельности может обеспечивать поддержание нормального веса у детей и подростков (22, 35). Если наиболее высокие результаты обычно свойственны поперечным исследованиям, то результаты проспективных обсервационных исследований более неоднозначны; это ограничивает возможность осмысления направленности сообщаемых взаимосвязей. В более поздних обзорах испытаний, связанных с мероприятиями в сфере физической активности (лабораторные интервальные ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) тренировки высокой интенсивности [ИТВИ], активное классное обучение, тренировки на сопротивление), были представлены результаты, которые не соответствовали большинству исследований, включенных в обзоры, где не сообщалось о каком-либо эффекте (47, 49, 50). При этом в одном обзоре продольных и поперечных исследований было отмечено наличие негативной взаимосвязи между физической нагрузкой, измеренной с помощью шагомера, и замерами ожирения, ИМТ или охвата талии (51). В целом же полученные фактические данные о том, что физическая активность способствует поддержанию нормального веса, имеют низкую достоверность, и для выявления направленности и прочности такой взаимосвязи необходимы дополнительные исследования. Меньший объем фактических данных получен об анализе взаимосвязи между физической активностью и развитием моторики у детей и подростков; при этом в нынешних обзорах показываются нулевые результаты (22). Для подготовки последующих рекомендаций необходимы дополнительные исследования по моторному развитию как показателю здоровья. Физически активной деятельностью для укрепления костной системы дети и подростки могут заниматься во время подвижных игр, бега, вращений или прыжков. Физическая активность позитивно влияет на прирост костной массы и/или костную структуру; недавние фактические материалы свидетельствуют о том, что дети и подростки, которые физически активнее своих сверстников, имеют более значительную костную массу, более высокие показатели содержания костных минералов или плотности костной ткани, а также более высокую прочность кости (35). Maксимальное укрепление здоровья костной системы в детском и подростковом возрасте может способствовать защите от остеопороза и сопутствующих переломов в более поздние периоды жизни. Развитие и поддержание когнитивных функций остается крайне важным на протяжении всей жизни. У детей и подростков физическая активность благотворно сказывается на их когнитивных функциях и академической успеваемости (например, на результатах школьного обучения, памяти и управляющей функции) (22, 35). Как показал один недавний обзор (19 РКИ; n= 5038), спортивные тренировки несколько раз в неделю в течение шести или более недель обеспечивают более заметный прогресс в показателях когнитивных функций, таких как ингибиторный контроль (СРС 0,26 [95% ДИ: 0,08–0,45], p= < 0,01); кратковременная память (СРС 0,10 [95% ДИ: -0,05–0,25], p= < 0,02) и когнитивная гибкость (СРС 0,14 [95% ДИ: -0,03–0,31], p= < 0,04), по сравнению с отсутствием тренировок (52). Кроме того, физическая активность не только снижает риск наступления депрессии и появления депрессивных симптомов у детей и подростков с последующей глубокой депрессией или без таковой (35), но и по своей эффективности в снижении симптомов 26 27 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и она может быть сопоставима с психологической или лекарственной терапией. Хотя любые физические нагрузки сопряжены с определенным риском причинения вреда (53), имеются весьма ограниченные сведения о причинении вреда от физически активной деятельности на уровнях, рекомендуемых для улучшения состояния здоровья (35). На основе имеющихся фактических данных и экспертного заключения был сделан вывод о том, что потенциальные риски в связи с объемами и видами физической активности, рекомендуемыми для детей и подростков, являются незначительными (35) и могут сокращаться при постепенном повышении уровня и интенсивности нагрузки, особенно для неактивных детей и подростков. Известно, что занятие некоторыми видами спорта, как и повышение интенсивности тренировок, увеличивают травмоопасность (53). Для укрепления научной базы в этой области необходимы дополнительные исследования. Выводы ГРР • Получены фактические данные среднего уровня достоверности о том, что увеличение объема физической активности средней и высокой интенсивности у детей и подростков способствует улучшению кардиореспираторного здоровья и мышечного тонуса, кардиометаболического здоровья и состояния костной системы. • Получены фактические данные среднего уровня достоверности о том, что кратко- и долгосрочная физическая активность средней и высокой интенсивности позитивно влияет на когнитивные функции, академическую успеваемость и психическое здоровье. • Получены фактические данные низкого уровня достоверности о том, что физическая активность благотворно влияет на поддержание нормального веса у детей и подростков. • Получены фактические данные низкого уровня достоверности о том, что риски, связанные с объемами и видами физической активности, рекомендуемыми для детей и подростков, являются незначительными и перевешиваются ее позитивными эффектами. Имеется ли взаимосвязь «доза-ответ» (объем, продолжительность, регулярность, интенсивность)? Хотя массив данных, указывающих на наличие позитивной взаимосвязи между физической активностью и показателями здоровья у детей и подростков, является значительным, исследования о рассмотрении взаимосвязи «доза-ответ» весьма немногочисленны. Поэтому вопрос о точной конфигурации кривой «доза-ответ» и/или наличии ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) пороговых величин физической активности (позволяющих дифференцировать низкий и высокий риски) и конкретных показателей здоровья в случае детей и подростков не столь ясен, как для взрослых групп населения. Тем не менее обширный фактический материал показывает, что большинство выгод для здоровья приобретается при ежедневной физической активности продолжительностью 60 минут (22, 35), и при отсутствии свидетельств противного был сделан вывод о том, что обновленные фактические данные подтверждают нынешнюю рекомендацию ВОЗ о целесообразности занятий физически активной деятельностью средней и высокой интенсивности ежедневно в течение 60 минут (1). Однако рассмотрение всех фактических данных, включая результаты недавних исследований, проведенных с помощью аппаратных измерений физической активности, не позволило подтвердить уточнение о «минимальной» 60-минутной ежедневной пороговой величине продолжительности средней и высокой интенсивности физических нагрузок для улучшения здоровья, поскольку в исследованиях для оценки благотворного влияния физической активности на показатели здоровья широко использовалась «средняя» 60-минутная ежедневная пороговая величина, а не минимальный ежедневный порог, составляющий 60 минут. В итоге обзор показал, что формулировку новой рекомендации следует изменить, чтобы она точнее отражала эти фактические данные. Полезное влияние регулярной высокоинтенсивной деятельности на показатели кардиометаболического здоровья уже было установлено в предшествующий период (1), а недавние обзоры позволили получить дополнительные подтверждающие данные (35). Так, один из недавних обзоров (54) показал, что интервальные тренировки высокой интенсивности в сравнении с продолжительными тренировками средней интенсивности оказывают умеренное позитивное воздействие на кардиореспираторное здоровье (СРС= 0,51 [95% ДИ: 0,33– 0,69], p= < 0,01; I2= 0%). Не было получено данных о том, что продолжительность активности, методика тренировок, соотношение «упражнение/отдых» и общее число серий изменяют воздействие на кардиореспираторное здоровье. Эти результаты в целом соответствуют материалам других недавних обзоров (22, 35, 47) и дают основания подтвердить рекомендацию о том, что молодежи и подросткам следует регулярно заниматься физически активной деятельностью высокой интенсивности для улучшения состояния кардиореспираторного здоровья. Выводы ГРР • Фактические данные подтверждают предыдущую рекомендацию ВОЗ о том, что физически активной деятельностью средней и высокой интенсивности следует заниматься 60 минут в день. 26 27Рекомендации • Имеющиеся данные указывают на необходимость замены предыдущего уточнения о «минимальной» 60-минутной ежедневной пороговой величине продолжительности физической активности на еженедельную «среднюю» пороговую величину, составляющую 60 минут в день, что точнее отражает полученный фактический материал. • Получены фактические данные среднего уровня достоверности о том, что увеличение объема физической активности высокой интенсивности способствует улучшению кардиореспираторного здоровья. Варьируется ли эта взаимосвязь в зависимости от вида или области физической активности? У детей и подростков физическая активность включает в себя развлечения и подвижные игры, спорт, передвижения, досуг, физическое воспитание или плановые тренировки в рамках их деятельности в семейной, школьной и общинной среде. Однако, поскольку прямое сопоставление различных видов или областей физической активности детей и подростков проводилось лишь в немногих исследованиях, не удалось получить достаточные фактические данные, с помощью которых можно было бы определить, варьируется ли взаимосвязь между физической активностью и показателями здоровья в зависимости от вида физической активности (например, аэробные упражнения в сравнении с силовыми) или от области такой активности (например, активное передвижение (ходьба и велосипед) в сравнении с физическим воспитанием и спортом/досугом). ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) Получены фактические данные о том, что увеличение объема аэробной физической активности средней и высокой интенсивности приводит к улучшению кардиореспираторного здоровья детей и подростков и что увеличение силовых нагрузок повышает их мышечный тонус. Эти данные были приняты во внимание при подготовке Глобальных рекомендаций ВОЗ по физической активности для здоровья 2010 г. (1), в которых предлагалось заниматься деятельностью, укрепляющей костно-мышечную систему, не реже трех раз в неделю. Обновленные данные подтвердили, что регулярное выполнение силовых упражнений три раза в неделю приводит к эффективному улучшению показателей мышечного тонуса; при этом не удалось получить достаточный фактический материал, позволяющий конкретно указать продолжительность и интенсивность тренировки, что объясняется прежде всего разнородностью нагрузок, которые оценивались в публикациях (22, 35). Меньше фактических данных имеется о защитном воздействии тренировок сопротивления на кардиометаболическое здоровье. Учитывая отсутствие новой информации о характеристиках, помимо регулярности силовых тренировок для детей и подростков, например о продолжительности нагрузки, невозможно уточнить какие-либо дополнительные детали. Дальнейшее исследование следует посвятить оздоровительному воздействию конкретных видов и областей физической активности, чтобы придать этому компоненту рекомендаций более специфический характер. Вывод ГРР • Получены фактические данные среднего уровня достоверности о том, что силовые упражнения следует выполнять не реже трех раз в неделю. 28 29 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Подтверждающие фактические данные и обоснование Малоподвижный образ жизни не был включен в Рекомендации ВОЗ 2010 г., однако в течение прошлого десятилетия наблюдался рост числа исследований, в которых рассматривались показатели здоровья, обусловленные различными мерами и видами малоподвижного образа жизни. Развитие технологий и цифровых средств коммуникации повлияло на работу, учебу, путешествия и досуговое времяпровождение людей. В большинстве стран дети и подростки теперь посвящают больше времени малоподвижному образу жизни, особенно во время досуга, например экранным развлечениям (телевидению и компьютерам) и цифровым средствам коммуникации, таким как мобильные телефоны. При подготовке настоящих рекомендаций в отношении детей и подростков были использованы систематические обзоры (24, 25), обновленные материалами семи новых обзоров, которые были признаны соответствующими критериям включения. С полной информацией о методах, извлечении данных и профилях фактических данных можно ознакомиться в веб-приложении «Профили фактических данных» . Особо малоподвижный образ жизни детей и подростков ведет к следующим негативным последствиям для их здоровья: повышению степени ожирения; ухудшению состояния кардиометаболического здоровья, физического здоровья и эмоционального/социально ориентированного поведения; а также к сокращению продолжительности сна. В этой связи рекомендуется следующее. Детям и подросткам следует сокращать продолжительность малоподвижных периодов, особенно экранное время досуга. Настоятельная рекомендация, низкая степень достоверности данных Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Малоподвижный образ жизни определяется как время, проводимое в состоянии бодрствования в положениях сидя или лежа при низком расходе энергии в учебных, домашних и общинных условиях, а также при передвижении. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО МАЛОПОДВИЖНОГО ОБРАЗА ЖИЗНИ ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) 28 29Рекомендации Какова взаимосвязь между малоподвижным образом жизни и показателями здоровья у детей и подростков (в возрасте 5–17 лет)? Фактические данные показывают, что увеличение времени, посвящаемого малоподвижному образу жизни, особенно экранного времени досуга, приводит к ухудшению показателей здоровья (24 35). Например, увеличение продолжительности экранного времени (включая просмотр телевизора) влечет за собой ухудшение состояния физического здоровья и кардиометаболического здоровья (24, 25) детей и подростков. Фактические материалы исследований, посвященных аппаратной оценке взаимосвязи между малоподвижным образом жизни и активными мероприятиями, дали скромные результаты; при этом более значимый результат был показан в отношении лиц, уже имеющих избыточный вес (55). Получены ограниченные данные, согласно которым малоподвижный образ жизни детей и подростков не имеет отношения к здоровью их костной системы. Несмотря на еще более неоднозначные результаты, фактические данные также показывают, что малоподвижный образ жизни может быть связан с неблагоприятным воздействием ожирения (24, 25). Согласно выводам одного обзора, посвященного в основном поперечным исследованиям, ежедневное малоподвижное состояние (измеряемое как общий объем экранного времени) в течение более двух часов имеет несомненную связь с избыточным весом/ ожирением у детей по сравнению с меньшими уровнями (< 2 часов в день) (56). При этом другой обзор 20 поперечных исследований (57) не выявил статистически значимой взаимосвязи между малоподвижными видеоиграми и индексом массы тела у детей или подростков. Объемный анализ 29 систематических обзоров позволил сделать вывод, что результаты многих исследований указывают на наличие неблагоприятной взаимосвязи между малоподвижным образом жизни и маркерами жировой ткани у молодежи, когда самооценка ее поведения выявляет ту или иную форму экранного времени (55). Однако в анализе отмечалось, что масштаб такой взаимосвязи незначителен, а в исследованиях, проведенных с применением аппаратной оценки малоподвижного времяпровождения, во многих случаях он и вовсе признан нулевым (55). Исследования мероприятий выявили скромный эффект, который, однако, был более значительным в случае лиц, уже имеющих избыточный вес (55). Для установления взаимосвязи между малоподвижным образом жизни и показателями ожирения требуется дополнительное исследование. Хотя эта область исследований все еще нова, некоторые фактические данные уже указывают на возможное наличие негативной взаимосвязи между малоподвижностью детей и подростков и их благополучием и качеством жизни, а также ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) неблагоприятной взаимосвязи между появлением у них депрессии и проведением досуга у экранов (58, 59). Например, особо малоподвижный образ жизни, оцениваемый как объем экранного времени, и некоторые аспекты пользования компьютером могут вызывать ухудшение психического здоровья (24). Согласно еще одному недавнему обзору, в пяти из восьми исследований была обнаружена взаимосвязь между малоподвижным образом жизни и появлением симптомов тревоги, хотя результаты этих исследований различались в зависимости от применяемых измерений малоподвижного образа жизни (60). Другие фактические данные показывают, что особо длительные периоды просмотра телевизора и занятия видеоиграми в значительной степени связаны с неблагоприятными показателями эмоционального/ социально ориентированного поведения (24); и что повышенный объем экранного времени и просмотра телевизора связан с сокращением времени сна, хотя взаимосвязь между использованием компьютера/видеоиграми и продолжительностью сна при этом не обнаружена (61). Исследование взаимосвязи между малоподвижным образом жизни и психическим здоровьем – это динамично развивающее направление с целым рядом неизвестных аспектов, и обратная зависимость здесь, скорее всего, является очевидной. Для установления направленности и прочности этой взаимосвязи необходимо дополнительное исследование. Выводы ГРР • Получены фактические данные низкого уровня достоверности о том, что особо малоподвижный образ жизни (экранное время) является существенной причиной ухудшения физического состояния и кардиометаболического здоровья у детей и подростков. • Получены фактические данные с уровнями достоверности от очень низкого до среднего о том, что особо малоподвижный образ жизни (экранное время, просмотр телевизора и видеоигры) является существенной причиной неблагоприятных показателей психического здоровья и эмоционального/социально ориентированного поведения у детей и подростков. • Получены фактические данные низкого уровня достоверности о том, что увеличение малоподвижных периодов (экранное время и просмотр телевизора) оказывает вредное воздействие на продолжительность сна у детей и подростков. • Позитивный эффект от сокращения малоподвижных периодов у детей и подростков перевешивает негативные аспекты. Имеется ли взаимосвязь «доза-ответ» (общий объем, продолжительность, регулярность, интенсивность прерывания)? Достаточных фактических данных, позволяющих определить, существует ли взаимосвязь «доза-ответ» между временем пребывания детей и подростков в малоподвижном состоянии (включая экранное время досуга) и показателями здоровья, пока не имеется. Данные об оценке взаимосвязи между малоподвижным образом жизни детей и подростков и их показателями здоровья носят в основном поперечный характер 30 31 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и и имеют низкую степень достоверности по рейтингу GRADE; при этом большинство исследований основано на самооценочных или представленных родителями данных о количестве времени пребывания в малоподвижном состоянии, в которых возможны погрешности измерения и ошибки памяти. Однако имеются данные о том, что сокращение времени пребывания в малоподвижном состоянии, по-видимому, позитивно влияет на показатели здоровья, а взаимосвязь между малоподвижным образом жизни и негативными показателями здоровья обычно оказывается прочнее для малоподвижного образа жизни в случаях, когда оно оценивается как время просмотра телевизора или экранное время досуга в качестве переменной величины воздействия, а не как общий объем времени, проведенного в малоподвижном состоянии. При этом фактические данные были признаны в целом недостаточными для указания конкретных ограничений такого времени. Получение фактических данных о том, что малоподвижный образ жизни связан с ухудшением показателей здоровья, может являться результатом либо прямого эффекта малоподвижного образа жизни, либо переключения времяпровождения на более активные виды деятельности, либо обоих этих факторов. Хотя некоторые исследования указывают на наличие взаимосвязи между экранным временем детей и подростков и негативными показателями их здоровья, общее время пребывания в малоподвижном состоянии (оцененное в ходе исследований с применением аппаратного измерения малоподвижного образа жизни) постоянно не увязывается с состоянием показателей здоровья, если при этом учитывать время, затраченное ими на физически активную деятельность средней и высокой интенсивности (62). Верно и обратное: фактические данные, указывающие на связь физической активности средней и высокой интенсивности с позитивными показателями здоровья, убедительны и подробно описаны в различных контекстах; замена части времени пребывания в малоподвижном состоянии на физическую активность (особенно на физически активную деятельность средней и высокой интенсивности) может привести к улучшению показателей здоровья. Исследования по изучению связи и взаимодействия между малоподвижным образом жизни, физической активностью и показателями здоровья динамично развиваются, и результаты аппаратных измерений малоподвижного образа жизни и состояния кардиометаболического здоровья указывают на ослабление этой связи в случаях, когда учитывается физическая активность средней и высокой интенсивности (т. е. при статистической корректировке) (62–64). Таким образом, для получения дополнительных данных об этой взаимосвязи и их учета в будущих рекомендациях необходимы дальнейшие проспективные исследования с проведением аппаратных измерений воздействия. ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) Выводы ГРР • Получены фактические данные низкого уровня достоверности о том, что особо длительный малоподвижный образ жизни приводит к ухудшению показателей здоровья. • Достаточных данных для уточнения ограничений времени, проводимого в малоподвижном состоянии, не имеется. • Замена времени, проводимого в малоподвижном состоянии, на физическую активность средней и высокой интенсивности может привести к улучшению показателей здоровья. Варьируется ли эта взаимосвязь в зависимости от вида или области малоподвижного образа жизни? Изучение влияния малоподвижного образа жизни на здоровье человека является сравнительно новым исследовательским направлением. Выводы, по сути, делаются на основе результатов исследований, проводимых с применением различных инструментов и измерений воздействия. Часто используются такие понятия, как воздействие, оцениваемое как «общее время, проведенное в малоподвижном состоянии», и время пребывания в малоподвижном состоянии за «экранами» или «просмотром телевизора». Имеющиеся фактические данные показывают, что взаимосвязь между малоподвижным образом жизни и негативными показателями здоровья, как правило, более очевидна применительно к просмотру телевизора или экранному времени досуга, чем к общему времени пребывания в малоподвижном состоянии (24, 35). Возросшее применение аппаратной оценки малоподвижного образа жизни при проведении более поздних исследований позволяет наращивать объем знаний и в сочетании со стандартизированной отчетностью будет содействовать подготовке будущих рекомендаций. Общепризнано, что не все виды малоподвижного образа жизни дают негативный результат. Фактические данные показывают, что некоторые из них, например чтение и выполнение домашних заданий вне школы, способствуют повышению академической успеваемости, т. е. результаты деятельности различаются в зависимости от ее вида (24, 25). Малоподвижный образ жизни может включать в себя время, расходуемое на образовательные занятия/учебу, на спокойные игры или на социальное общение без использования электронных средств. Tакие занятия (например, чтение, складывание головоломок, рисование, рукоделие, пение, музицирование) важны для развития ребенка и обеспечивают когнитивный и иной позитивный эффект. ГРР признала следующее. • Некоторые малоподвижные виды деятельности детей и подростков благоприятно отражаются на их когнитивных функциях и социальном взаимодействии. • Объем данных о вредном воздействии малоподвижного образа жизни на здоровье, как правило, более значителен в части просмотра телевизора или экранного времени досуга, чем общего времени пребывания в малоподвижном состоянии. 30 31Рекомендации Физическая активность взрослых благоприятно отражается на следующих показателях здоровья: снижается смертность от всех причин, в том числе от сердечно-сосудистых заболеваний, снижается заболеваемость гипертонией, раком отдельных локализаций 1 и диабетом 2-го типа, улучшается психическое здоровье (снижаются симптомы тревоги и депрессии); улучшаются когнитивное здоровье и сон; также может снижаться степень ожирения. В этой связи рекомендуется следующее. Всем взрослым следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Взрослым следует не менее 150–300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75–150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, чтобы занятия приносили дополнительную пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Чтобы занятия приносили дополнительную пользу для здоровья, взрослым также следует выполнять силовые упражнения средней или большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных Взрослые могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных Взрослые могут заниматься физически активной деятельностью в рамках отдыха и досуга (подвижные игры, занятия спортом или плановые тренировки), передвижений (использование колесных средств, ходьба и езда на велосипеде), работы или выполнения домашних обязанностей, то есть в повседневном профессиональном, образовательном, домашнем и общинном контексте. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО ФИЗИЧЕСКОЙ АКТИВНОСТИ 1 К раку отдельных локализаций относятся рак мочевого пузыря, молочной железы, толстой кишки, эндометрия, аденокарцинома пищевода, рак желудка и почек. ВЗРОСЛЫЕ (в возрасте 18-64 лет) • небольшая физическая активность лучше, чем ее полное отсутствие; • если взрослые не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • взрослым следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность. П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я 32 33 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Подтверждающие фактические данные и обоснование При подготовке настоящих рекомендаций были использованы и обновлены обобщенные фактические данные, собранные Консультативным комитетом Соединенных Штатов по руководящим принципам физической активности (PAGAC) (35). ГРР рассмотрела весь массив фактических данных, включая как выводы самого PAGAC, так и материалы 28 обзоров и трех сводных когортных исследований, опубликованные за период с 2017 по ноябрь 2019 г., которые соответствовали критериям включения и расширяли объем информации о взаимосвязи между физической активностью и показателями здоровья у взрослых. Кроме того, были назначены два общих обзора для восполнения пробелов в фактических данных и рассмотрения (i) взаимосвязи между профессиональной (т. е. связанной с работой) физической активностью и показателями здоровья (40); и (ii) взаимосвязи между досуговой физической активностью и негативными показателями здоровья (41). В ходе этих общих обзоров было выявлено соответственно 36 и 15 систематических обзоров. Приоритетное внимание уделялось результатам продольных наблюдательных исследований и экспериментальных разработок, а обзоры, где в исключительном или первоочередном порядке были обобщены межсекторальные фактические данные, во внимание не принимались. Повышенный интерес вызывали данные из обзоров, которым был присвоен уровень достоверности от среднего и выше, а также из обзоров, содержащих данные исследований, которые были проведены с применением аппаратных измерений воздействия. С полной информацией о методах, извлечении данных и профилях фактических данных можно ознакомиться в веб-приложении «Профили фактических данных» . Какова взаимосвязь между физической активностью и показателями здоровья у взрослых (в возрасте 18–64 лет)? Взаимосвязь между физической активностью и смертностью от всех причин/смертностью от сердечно-сосудистых заболеваний у взрослых уже широко известна (1). Выводы недавних обзоров подтвердили, что в сравнении с самыми низкими уровнями физической активности более высокие уровни нагрузки способствуют снижению риска смертности. Новые данные исследований, проведенных с применением аппаратных измерений физической активности, подтвердили и расширили доказательства того, что в сравнении с самыми низкими уровнями физической активности любой уровень и все степени интенсивности (включая легкую интенсивность) физической активности способствуют снижению риска смертности (65). Например, в сравнении с наименьшей активностью (при эталонном значении 1,00) скорректированный показатель ОР для квартилей общей физической активности снижался по квартилям физической активности следующим образом: 2-й квартиль (0,48 [95% ДИ: 0,43–0,54]); 3-й квартиль (0,34 [95% ДИ: 0,26–0,45]); и 4-й квартиль (0,27 [95% ДИ: 0,23–0,32]) (65). Новые фактические данные также подтвердили широко известную (1) обратную взаимосвязь между физической активностью и смертностью от сердечно-сосудистых заболеваний (66). Полезное воздействие физической активности на снижение заболеваемости сердечно-сосудистыми болезнями и гипертонией тщательно задокументировано (1). Физическая активность стимулирует целый ряд физиологических реакций, способствующих позитивным кратко- и долгосрочным автономным и гемодинамическим адаптациям, что приводит к уменьшению риска гипертонии — одного из ключевых факторов, вызывающих сердечно-сосудистые заболевания. Фактические данные подтвердили наличие обратной взаимосвязи между физической активностью и ВЗРОСЛЫЕ (в возрасте 18-64 лет) заболеваемостью гипертонией среди взрослых с нормальным артериальным давлением и тот факт, что физическая активность способствует снижению артериального давления у взрослых с прегипертонией и нормальным артериальным давлением (35). Широко известно наличие обратной взаимосвязи между физической активностью взрослых и развитием у них диабета 2-го типа (1). Недавно полученные фактические данные подтвердили наличие обратной криволинейной взаимосвязи между большими объемами физической активности и заболеваемостью диабетом 2-го типа (35), с наблюдаемым снижением кривой при росте уровней физической нагрузки. Один из новых обзоров показал, что данный эффект последовательно наблюдается у лиц различного происхождения с пониженным риском развития диабета 2-го типа при «самом высоком» уровне физической активности в сравнении с «самым низким» уровнем среди: неиспаноязычных белых (КР= 0,71 [95% ДИ: 0,60–0,85]); азиатов (КР= 0,76 [95% ДИ: 0,67–0,85]); испаноязычных (КР= 0,74 [95% ДИ: 0,64–0,84]); и американских индейцев (КР= 0,73 [95% ДИ: 0,60–0,88]), хотя эффект среди неиспаноязычных чернокожих был незначительным (КР= 0,91 [95% ДИ: 0,76–1,08]) (67). Данные показывают, что эффект не изменяется в зависимости от веса и что обратная взаимосвязь между ростом физической активности и снижением заболеваемостью диабетом 2-го типа наблюдается у лиц с нормальным весом, избыточным весом или ожирением (35). Широко известна взаимосвязь между высоким уровнем физической активности и снижением рисков рака толстой кишки и рака молочной железы (1). В предыдущих обзорах фактических данных было установлено, что более высокие уровни физической активности способствуют снижению риска развития рака молочной железы и рака толстой кишки (1). После масштабного роста физической активности и проведения онкологических исследований получены новые данные, которые показывают, что более высокие уровни физической активности содействуют еще и уменьшению риска развития рака мочевого пузыря, эндометрии, аденокарциномы пищевода, рака желудка и почек, а также подтверждают, 32 33Рекомендации что физические нагрузки защищают от рака молочной железы и рака толстой кишки (35). Более высокие уровни физической активности приводят к снижению рисков приблизительно на 10–20% (35). Например, в одном обзоре сообщалось о наличии обратной взаимосвязи с риском рака печени при сопоставлении высоких уровней физической активности с ее низкими уровнями (ОР= 0,75 [95% ДИ: 0,63–0,89]) (68). Пока не получено достаточных подтверждений взаимосвязи между ростом физической активности и снижением рисков гемобластоза, рака головы и шеи, яичников, поджелудочной железы, простаты, щитовидной железы, прямой кишки и мозга (35). Хотя фактические данные указывают на снижение риска рака легких при сопоставлении самых высоких уровней физической активности с самыми низкими, такие выводы можно спутать с последствиями употребления табака; поэтому было решено, что имеющихся данных в целом недостаточно для подтверждения такой связи. Взаимосвязь между физической активностью и ожирением во взрослых группах населения подтверждена менее явно, несмотря на наличие крупного, хотя и разнородного массива данных об оценке этой взаимосвязи на основе различных показателей результата (увеличение массы тела, изменение веса, контроль веса, стабильность веса, состояние массы тела и поддержание веса) (35, 69, 70). Фактические материалы в целом показывают, что повышение уровня физической активности может оказывать более благоприятное воздействие на ожирение и замедление увеличение массы тела у взрослых (35). Для получения последовательных результатов и подтверждения установленных взаимосвязей необходимо дополнительное исследование. Объем исследований, посвященных физической активности и психическому здоровью, когнитивным способностям и сну, существенно возрос после составления Глобальных рекомендаций ВОЗ по физической активности для здоровья 2010 г. (1). На тот момент имелись достаточные данные только для вывода о том, что физическая активность может приводить к уменьшению риска депрессии или ослабления когнитивных функций во взрослых группах населения. Новые фактические материалы, пересмотренные в ходе подготовки настоящих рекомендаций, показали, что у взрослых, занимающихся физически активной деятельностью более высокого уровня по сравнению с более низким уровнем, снижается риск развития тревоги и депрессии. Например, у взрослых с высокими уровнями физической активности по сравнению с низкими уровнями наблюдалось снижение шансов развития симптомов тревоги (ССШ= 0,81 [95% ДИ: 0,69–0,95]) (71) или депрессии (ССШ= 0,78 [95% ДИ: 0,70–0,87) (72). Повышенные объемы физических нагрузок средней и высокой интенсивности приводят к улучшению когнитивных способностей (например, скорости обработки информации, памяти и управляющей функции) (35), функций и структуры мозга и к снижению риска развития когнитивных нарушений, в том числе болезни Альцгеймера (73–76). Фактические данные охватывали несколько групп взрослого населения, представляющих спектр состояний от нормального до нарушенного когнитивного здоровья, и позитивные эффекты физической активности наблюдались по целому ряду видов, включая аэробную нагрузку, ходьбу, силовые упражнения и йогу (74). Имеются фактические данные о том, что как интенсивные тренировочные серии, так и регулярная физическая активность улучшают у взрослых показатели сна и качества жизни, обусловленного состоянием здоровья (35). Данные исследований взаимосвязи между физической активностью и симптомами депрессии, симптомами тревоги и развитием тревоги и депрессии показали, что физическая активность приводит к сокращению симптомов тревоги (77, 78) и сокращению симптомов депрессии (77, 79). Все виды физической активности связаны с определенным риском. Фактические данные назначенного обзора, посвященного негативным эффектам, травмам и вреду в связи с досуговой физической активностью у взрослых (41), указывают на наличие неблагоприятной взаимосвязи между уровнями досуговой физической активности и травмами скелетно- мышечной системы, а также на наличие благоприятной взаимосвязи между досуговой физической активностью и риском перелома и началом коленного или бедренного остеоартрита. Дополнительные имеющиеся данные (35) свидетельствуют о том, что внезапные нежелательные сердечно-сосудистые явления носят редкий характер и связаны с активными тренировочными сеансами довольно высокой интенсивности. В целом же риски нежелательных явлений крайне невелики, когда физические нагрузки имеют среднюю интенсивность и когда рост регулярности, интенсивности и продолжительности нагрузок происходит постепенно (35). Выводы ГРР • Получены фактические данные высокого уровня достоверности о том, что физически активная деятельность любого уровня и любой интенсивности способствует снижению риска смертности от всех причин и смертности от сердечно-сосудистых заболеваний, заболеваемости гипертонией, сердечно-сосудистыми заболеваниями и диабетом 2-го типа. • Получены фактические данные от среднего до высокого уровня достоверности о наличии взаимосвязи между ростом уровней физической активности и снижением риска рака отдельных локализаций. • Получены фактические данные среднего уровня достоверности, подтверждающие взаимосвязь между физической активностью и улучшением показателей психического здоровья, когнитивного здоровья и сна. • Получены фактические данные о взаимосвязи между ростом уровней физической активности и более благоприятным воздействием на ожирение и замедлением увеличения массы тела у взрослых. • Получены фактические данные низкого уровня достоверности о том, что физическая активность, рекомендуемая для взрослых, не окажет вредного воздействия и что польза такой активности для здоровья перевешивает риски. ВЗРОСЛЫЕ (в возрасте 18-64 лет) 34 35 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Имеется ли взаимосвязь «доза-ответ» (объем, продолжительность, регулярность, интенсивность)? Общие фактические данные, касающиеся показателей сердечно-сосудистого и метаболического здоровья, демонстрируют наличие последовательной криволинейной обратной взаимосвязи «доза-ответ» между физической активностью и основными конечными результатами, такими как смертность от всех причин, смертность от сердечно-сосудистых заболеваний, заболеваемость диабетом 2-го типа (67) и раком отдельных локализаций у взрослых. Как видно на рисунке 1, форма кривой «доза-ответ» указывает на отсутствие нижнего порога для полезного воздействия, а наибольшая польза просматривается на нижнем конце кривой «доза- ответ» (65). Данные о наличии такой криволинейной обратной взаимосвязи последовательно указываются в исследованиях, проводимых с применением различных измерений физической активности. Важный новый материал был представлен в метаанализе восьми проспективных когортных исследований со средним сроком последующего наблюдения 5,8 года (диапазон 3–14,5 года) (65); в нем были указаны значения относительного риска (ОР) для квартилей oбщей физической активности с использованием аппаратных измерений воздействия и смертности от всех причин. Результаты показали наличие взаимосвязи «доза-ответ» при росте объема физической активности и пользе от более высоких уровней нагрузки при любой интенсивности в сопоставлении с наименьшей активностью (при эталоне 1,00): 2-й квартиль (ОР= 0,48 [95% ДИ: 0,43–0,54]); 3-й квартиль (ОР= 0,34 [95% ДИ: 0,26–0,45]); и 4-й квартиль (ОР= 0.27 [95% ДИ: 0,23–0,32]). Maксимальное снижение рисков в условиях физически активной деятельности средней и высокой интенсивности наблюдалось при нагрузке продолжительностью 24 минуты в день (или 168 минут в неделю), что почти соответствует рекомендуемой продолжительности, составляющей 150 минут в неделю, и обеспечивает новые данные аппаратных измерений, подтверждающие нынешнюю общую установку для взрослых о занятии физически активной деятельностью в течение 150–300 минут в неделю (65). Эти выводы созвучны фактическим материалам, полученным как из имеющихся обзоров (35), так и из новых выявленных обзоров (66). В верхней части кривой более высокие уровни физической активности продолжают оказывать благоприятное воздействие на снижение риска смертности при отсутствии возрастания риска вреда. Например, результаты нового обзора с выводами метаанализа индивидуальных данных, полученных путем аппаратных измерений воздействия (65), показывают, что, хотя сниженный риск смертности наблюдается вплоть до 750 минут еженедельной физической нагрузки средней и высокой интенсивности, относительный риск смертности стабилизируется за пределами 300 минут в неделю. Эти результаты согласуются с предыдущими фактическими данными, которые последовательно указывали, что увеличение физической активности приносит дополнительные выгоды здоровью, хотя на более высоких уровнях нагрузки относительная польза сокращается (35, 80, 81). Однако для точного определения уровня физической активности взрослых, при котором начинается снижение полезного эффекта для здоровья, этих данных недостаточно. Фактические данные также подтвердили наличие широко известной обратной взаимосвязи между физической активностью и смертностью от сердечно- сосудистых заболеваний, обеспечив дополнительные доказательства соотношения «доза-ответ» в значениях, намного превышающих нынешние рекомендуемые объемы физической активности. Метаанализ 48 проспективных исследований оценки физической активности (общий объем, Рисунок 1. Кривая взаимосвязи «доза-реакция» ВЗРОСЛЫЕ (в возрасте 18-64 лет) Еженедельная физическая активность (в минутах) РИ СК И И ВР ЕД ПО ЛЬ ЗА П ол ьз а д л я зд ор ов ья и ф и зи че ск ог о со ст оя н и я Малоподвижный образ жизни Рекомендуемый диапазон 150 300 34 35Рекомендации досуговая и профессиональная активность) позволил получить дополнительные сведения о взаимосвязи «доза-ответ» (66) со значительным превышением объемов физической активности, рекомендуемых в настоящее время. По сравнению с рекомендуемым уровнем, составляющим 750 MET-минут в неделю, участие в физически активной деятельности на уровне 5000 MET минут в неделю (1000 минут активной деятельности средней интенсивности) приводило к значительному снижению риска смертности от сердечно-сосудистых заболеваний (ОР= 0,73 [95% ДИ: 0,56–0,95]) (66). Согласно предыдущей рекомендации ВОЗ (1), аэробную нагрузку следует выполнять сериями продолжительностью не менее 10 минут. Однако новые данные, полученные с помощью аппаратных оценок, показывают, что физическая активность любой продолжительности, без минимальной пороговой величины, приводит к улучшению показателей здоровья, включая смертность от всех причин (65, 82). Например, новые фактические материалы, полученные в результате обзоров исследований, посвященных оценке физической активности методом акселерометрии, подтверждают наличие аналогичных взаимосвязей между всеми показателями физической активности и уровнем смертности от всех причин с относительным риском 0,27 от общей физической активности, 0,28 для 5-минутных серий и 0,35 для 10-минутных серий при сопоставлении высших и низших квартилей (83). Эти результаты, подтвержденные выводами нового обзора Ekelund et al. 2019 (65), свидетельствуют о том, что физическая нагрузка, выполняемая в течение серии любой продолжительности, обеспечивает улучшение показателей здоровья, включая уровень смертности от всех причин (82). На основании новых фактических данных рекомендация о нагрузке сериями по 10 минут была отменена. Хотя было признано, что фактические данные, указывающие на наличие взаимосвязи между ростом уровней физической активности и снижением риска рака отдельных локализаций, в целом согласуются между собой, достаточные доказательства для определения конкретных уровней физической активности, которым соответствуют сообщаемые показатели снижения риска, получить не удалось, поскольку оценки и классификации воздействия в различных исследованиях были весьма неоднородны. В то же время нет фактических данных, позволяющих предположить, что существует какой- либо минимальный порог, ниже которого физическая активность не приносит никакой очевидной пользы; это означает, что физическая нагрузка любого уровня может способствовать снижению риска рака отдельных локализаций. Для подготовки будущих рекомендаций необходимо дополнительное исследование, посвященное оценке характера связи «доза-ответ» и проводимое с использованием более согласованных процедур измерения и отчетности. Несмотря на наличие объемных фактических материалов о взаимосвязи между физической активностью и различной степенью ожирения, увеличением массы тела и удержанием нормального веса (35), в настоящее время не имеется достаточных данных для более конкретного описания взаимосвязи «доза-ответ» или определения порога наступления эффекта. Для подготовки будущих рекомендаций необходимо дополнительное исследование. Рост объемов физически активной деятельности средней и высокой интенсивности приводит к улучшению когнитивных способностей (например, скорости обработки информации, памяти и управляющей функции) (35), функций и структуры мозга и к снижению риска развития когнитивных нарушений, включая болезнь Альцгеймера (73–76). Получены фактические данные о том, что физическая нагрузка у взрослых, осуществляемая как активными сериями, так и на регулярной основе, улучшает показатели сна и качества жизни, обусловленного состоянием здоровья (35). При этом не имеется достаточных материалов для более конкретного описания взаимосвязи «доза-ответ» между физической активностью и индивидуальными показателями психического и когнитивного здоровья. Аналогичным образом необходимы дополнительные данные для дальнейшего описания взаимосвязи «доза-ответ» между объемом и/или интенсивностью аэробной нагрузки и силовых тренировок и отдельными показателями здоровья. Такая информация очень важна для определения минимальных эффективных доз и максимальных порогов безопасности физически активной деятельности для различных подгрупп населения. Выводы ГРР • Получены фактические данные о том, что повышение физической активности приводит к большему эффекту для показателей здоровья, хотя на более высоких уровнях физической активности относительная польза стабилизируется. Достаточных данных для точного определения уровня, на котором начинается снижение пользы для здоровья, не имеется. • Получены фактические данные высокого уровня достоверности о том, что рост физической активности способствует снижению риска смертности от всех причин, смертности от сердечно- сосудистых заболеваний, смертности от рака, заболеваемости сердечно-сосудистых заболеваниями, гипертонией и диабетом 2-го типа при остутствии роста риска причинения вреда. • Получены фактические данные среднего уровня достоверности о том, что физическая активность любой продолжительности приводит к улучшению показателей здоровья, вследствие чего предыдущее уточнение о том, что аэробные нагрузки рекомендуется выполнять сериями продолжительностью не менее 10 минут, следует исключить. • Получены фактические данные о том, что увеличение объемов физической активности может оказывать более благоприятное воздействие на степень ожирения и замедление роста массы тела у взрослых и что риск того, что физические нагрузки будут вредны для поддержания нормального веса у взрослых, является незначительным. • Получены фактические данные среднего уровня достоверности о том, что еженедельная аэробная нагрузка средней интенсивности или эквивалентная ей нагрузка продолжительностью 150–300 минут снижает риск по целому ряду показателей здоровья и что снижение риска продолжается, но при продолжительности свыше 300 минут в неделю начинает стабилизироваться. ВЗРОСЛЫЕ (в возрасте 18-64 лет) 36 37 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Варьируется ли эта взаимосвязь в зависимости от вида или области физической активности? Фактические данные показывают, что различные виды физически активной деятельности и физические нагрузки в различных областях (т. е. на работе, при передвижении и на досуге) могут благотворно сказываться на показателях здоровья. Что касается смертности от всех причин и смертности от сердечно-сосудистых заболеваний, то выполнение аэробной нагрузки отдельно или в сочетании с силовыми упражнениями дает позитивный эффект, хотя в обоих случаях оптимальный режим обеспечивается соблюдением рекомендуемых уровней (84). Согласно более поздним фактическим данным среднего уровня достоверности, силовые упражнения, выполняемые независимо от аэробной нагрузки, также снижают риск смертности от всех причин. Приведенные в публикации Stamatakis et al. (2018) результаты сводного анализа 11 когортных исследований, посвященных изучению рекомендации о выполнении силовых упражнений дважды в неделю в сопоставлении с уровнями смертности от всех причин, показали, что выполнение как аэробных, так и силовых упражнений на рекомендуемых уровнях (1) в сравнении с несоблюдением какой-либо из рекомендаций (скорректированный ОР= 0,71 [95% ДИ: 0,57–0,87]), а также выполнение только рекомендации о силовых упражнениях в сравнении с ее невыполнением (ОР= 0,80 [95% ДИ: 0,70–0,91]), обеспечивает существенное снижение риска смертности от всех причин (84). Эти данные свидетельствуют о том, что польза для здоровья, обеспечиваемая силовыми упражнениями, не зависит от аэробной нагрузки, а также подтверждают рекомендацию о выполнении силовых упражнений дважды в неделю. Другие выводы, изложенные у Dinu et al. (2019), стали подтверждением вывода о том, что занятия физически активной деятельностью в областях, помимо досуга (или отдыха), могут быть полезны, и непосредственно показали, что виды активного перемещения (т. е. ходьба и велосипед для поездок) способны значительно снижать риск смертности от всех причин (КР= 0,92 [95% ДИ: 0,85–0,98]) (85). В недавнем исследовании приведены фактические данные о том, что для лиц, практикующих активное перемещение (т. е. ходьбу или велосипед для поездок), риск сердечно- сосудистых заболеваний (ишемической болезни сердца, инсульта и сердечной недостаточности) ниже, чем для лиц, не участвующих в активном перемещении (КР= 0,91 [95% ДИ: 0,83–0,99]) (85); и что исходя из этих показателей здоровья имеются достаточные подтверждения, позволяющие сделать вывод, что деятельность в разных областях может быть полезна. При этом нет достаточных фактических данных, позволяющих дифференцировать влияние разных областей физической активности на каждый показатель здоровья. Например, не имеется достаточных данных для решения вопроса о том, варьируется ли взаимосвязь между физической активностью и риском возникновения рака или диабета 2-го типа в зависимости от вида или области физической активности. В отношении показателей психического здоровья фактические данные (35) показывают, что широкий спектр видов физической активности, включая аэробные нагрузки, ходьбу, силовые упражнения и йогу, может благотворно влиять на уменьшение симптомов депрессии и на развитие тревоги (74, 79, 86). Например, в двух обзорах недавно были представлены фактические данные о благотворном воздействии упражнений для тренировки сопротивления на психическое здоровье; в них сообщалось о довольно значительном снижении симптомов депрессии (77) и о небольшом уменьшении симптомов тревоги (78) по сравнению с контролируемыми условиями. По данным одного нового исследования, высокие уровни физической активности в профессиональной среде способствуют снижению риска возникновения многих онкологических заболеваний, ишемической болезни сердца и диабета 2-го типа (40). При этом высокие уровни профессиональной физической активности могут также быть связаны с повышением риска остеоартрита, снижения качества сна и смертности от всех причин среди мужского населения (в отличие от женщин). Нет достаточных фактических данных, позволяющих определить взаимосвязь между физической активностью в профессиональной среде и ожирением, профилактикой увеличения массы тела, психическим здоровьем и качеством жизни, обусловленным состоянием здоровья (40). Также не имеется достаточных данных для решения вопроса о том, варьируется ли взаимосвязь между физической активностью и риском возникновения рака в зависимости от типа и области физической активности. Из-за незначительного объема данных о взаимосвязи между разными областями физической активности было трудно дифференцировать влияние тех или иных областей физических нагрузок на различные показатели здоровья. Выводы ГРР • Получены фактические данные среднего уровня достоверности о том, что выполнение силовых упражнений не реже двух раз в неделю приносит дополнительную пользу для здоровья, но достаточных данных для указания конкретной продолжительности сеанса для достижения оптимального полезного эффекта не имеется. • Получены фактические данные среднего уровня достоверности о том, что физически активная деятельность, осуществляемая в различных областях (т. е. на досуге, при передвижении, на работе), может приносить пользу здоровью, хотя пока нет возможности дифференцировать влияние разных областей физической активности на различные показатели здоровья. • Хотя повышение уровней физической активности в профессиональной среде может быть связано с ростом риска возникновения остеоартрита, снижения качества сна и смертности от всех причин среди мужского населения (в отличие от женщин), общие фактические данные среднего уровня достоверности указывают на то, что профессиональная физическая активность может быть полезна для здоровья. ВЗРОСЛЫЕ (в возрасте 18-64 лет) 36 37Рекомендации Подтверждающие фактические данные и обоснование При подготовке настоящих рекомендаций были использованы и обновлены обобщенные фактические данные, собранные PAGAC (35). ГРР рассмотрела весь комплекс фактических данных, включая как выводы самого PAGAC, так и материалы 13 новых обзоров, которые соответствовали критериям включения и расширяли объем информации о взаимосвязи между малоподвижным образом жизни и показателями здоровья у взрослых. Изучение взаимосвязи между малоподвижным образом жизни и показателями здоровья человека является сравнительно новым направлением общественного здравоохранения по сравнению с последствиями недостаточной физической активности, хотя в истекшем десятилетии оно динамично развивалось. Как правило, целью исследований являлось измерение параметров малоподвижного образа жизни на основе либо (i) вопросников для самооценки, содержащих вопросы об «общем объеме времени», проводимом в малоподвижном состоянии, или о времени, уделяемом определенным занятиям, таким как просмотр телевизора, пользование компьютером/экранными устройствами и пребывание в положении сидя; либо (ii) аппаратных оценок. Поскольку стандартизированных методов измерения или протоколов анализа для малоподвижного образа жизни не существует, сообщаемые результаты носят разнородный характер. К числу недавних методологических подвижек относится применение аппаратной оценки времени, проводимого в малоподвижном состоянии, которая позволит уменьшить погрешность измерений и другие отклонения, свойственные данным самооценки, приводимым по памяти. При рассмотрении всего комплекса фактических данных ГРР уделяла особое внимание материалам с уровнем достоверности не ниже среднего, взятым из обзоров о результатах исследований, в которых содержались данные измерений общего времени, проводимого в малоподвижном состоянии или в положении сидя, или данные аппаратных измерений малоподвижного образа жизни. С полной информацией о методах, извлечении данных и профилях фактических данных можно ознакомиться в веб- приложении «Профили фактических данных» . В течение последнего десятилетия активно развивались исследования, посвященные потенциальному вредному воздействию малоподвижного образа жизни на здоровье человека. К числу заметных наработок более поздних исследований относятся увеличение объема фактических данных о взаимосвязи «доза- ответ» между малоподвижностью и несколькими показателями здоровья, а также о взаимодействии между малоподвижным образом жизни и физической активностью. Особо малоподвижный образ жизни взрослых ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также к повышению распространенности сердечно-сосудистых заболеваний, рака и диабета 2-го типа. В этой связи рекомендуется следующее. Взрослым следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, средняя степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии взрослым следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Малоподвижный образ жизни у взрослых определяется как время, проведенное в период бодрствования в положении сидя или лежа при низком расходе энергии в профессиональном, образовательном, домашнем и общинном контексте и при передвижении. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО МАЛОПОДВИЖНОГО ОБРАЗА ЖИЗНИ ВЗРОСЛЫЕ (в возрасте 18-64 лет) 38 39 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Какова взаимосвязь между малоподвижным образом жизни и показателями здоровья у взрослых (старше 18 лет)? В целом имеются фактические данные о взаимосвязи между увеличением продолжительности малоподвижного состояния (полученные главным образом в виде результатов самооценки или аппаратных оценок времени, проводимого в положении сидя или за просмотром телевизора) и ростом смертности от всех причин, в том числе от сердечно-сосудистых заболеваний, а также ростом масштабов распространения сердечно-сосудистых заболеваний и диабета 2-го типа (8, 35, 65, 87). Например, подтверждающие данные включают в себя результаты недавно проведенного крупного метаанализа (n= 36 383; средний возраст —62,6 года; 72,8% — женщины), который предусматривал акселерометрическую оценку общего времени пребывания в малоподвижном состоянии и уровня смертности от всех причин (65) и который показал, что увеличение продолжительности малоподвижного состояния является существенным фактором смертности от всех причин. Аналогичные выводы были изложены в метаанализе, который охватывал более 1 миллиона респондентов (87) и после коррекции по фактору физической активности показал наличие взаимосвязи между общим временем, проводимым в малоподвижном состоянии, и смертностью от всех причин, в том числе смертностью от сердечно- сосудистых заболеваний (87); однако в этом же исследовании данные о взаимосвязи со смертностью от рака после их коррекции по фактору физической активности не оказались статистически значимыми (87). Еще один недавний метаанализ (8) выявил значительную взаимосвязь между малоподвижным образом жизни (оцениваемым как пребывание в положении сидя) и сердечно-сосудистыми заболеваниями и смертностью от рака; его результаты показали, что при повышении уровня малоподвижного образа жизни, измеряемого как время сидения в самом физически «неактивном», нижнем квартиле (~ 5 минут в день), риск смертности от сердечно-сосудистых заболеваний возрастает на 9–32% (p тренда < 0,001). В этом исследовании сообщалось, что взрослым, проявляющим низкую активность (сидящим) более 8 часов в день, грозит повышенный риск смертности от сердечно- сосудистых заболеваний, за исключением случаев, когда речь идет о «наиболее активных» (т. е. > 35,5 MET- часа в неделю, или ~ 60–75 минут в день) и когда такая зависимость сглаживается. Показатели взаимосвязи между малоподвижным образом жизни и смертностью от рака обычно оказывались ниже, хотя при более длительном времени сидения (особенно > 8 часов в день) наблюдался рост дозозависимого риска на 6–21%, но только для лиц, относящихся к нижнему квартилю физической активности (< 2,5 MET-часа в неделю) (8). Фактические данные подтверждают взаимосвязь между малоподвижным образом жизни (измеряемым как общее время сидения) и ростом возникновения сердечно- ВЗРОСЛЫЕ (в возрасте 18-64 лет) сосудистых заболеваний (ОР= 1,29 [95% ДИ: 1,27–1,30]), который снижался после корректировки с учетом потенциальных ковариантов, включая уровень физической активности (ОР= 1,14 [95% ДИ: 1,04–1,23]) (88). В результате обзора исследований населения Юго-Восточной Азии были получены фактические данные низкого уровня достоверности о том, что увеличение продолжительности времени пребывания в малоподвижном состоянии приводит к росту вероятности ухудшения кардиометаболических показателей (включая диабет 2-го типа, повышение ИМТ и артериального давления) (89). Материалы двух недавних обзоров указывают на взаимосвязь между общей продолжительностью дневного времени, проводимого в положении сидя (88), общего малоподвижного образа жизни и просмотра телевизора (87) с возникновением диабета 2-го типа. Согласно обоим этим исследованиям, повышение уровня малоподвижного образа жизни приводит к росту риска диабета 2-го типа. Например, после коррекции по фактору физической активности линейная связь с диабетом 2-го типа наблюдалась при любом малоподвижном образе жизни (КР= 1,01 [95% ДИ: 1,00–1,01] p= < 0,001) и просмотре телевизора (КР= 1,09 [95% ДИ: 1,07–1,12] p= < 0,001) (87). Кроме того, получены фактические данные, подтверждающие значительную взаимосвязь между малоподвижным образом жизни (измеряемым как время просмотра телевизора) и смертностью от рака (35, 87). Несколько более поздних обзоров низкого и очень низкого уровня достоверности содержат материалы, подтверждающие наличие взаимосвязи между малоподвижным образом жизни и колоректальным раком (90); при этом нет данных о связи с возникновением рака простаты, молочной железы или прямой кишки (90–93). В дополнительных данных (35) сообщалось о существенной взаимосвязи между увеличением времени пребывания в малоподвижном состоянии и ростом риска развития рака тела матки, толстой кишки и легких (35). Получены фактические данные низкого уровня достоверности о том, что между временем пребывания в малоподвижном состоянии и ожирением и другими показателями веса существует неблагоприятная взаимосвязь, и о том, варьируется ли взаимосвязь между малоподвижным образом жизни и весом в зависимости от объема физической нагрузки средней и высокой интенсивности. В целом был сделан вывод об отсутствии достаточных данных для подготовки этих рекомендаций/ этого документа и о необходимости проведения дальнейшего исследования. Имеются ограниченные фактические данные об оценке вредных последствий сокращения времени, проводимого в малоподвижном состоянии. На основе экспертного заключения был сделан вывод о том, что сокращение времени, проводимого в малоподвижном состоянии, вряд ли приведет к росту риска травматизма, особенно если это время использовать для физически активной деятельности низкой интенсивности. 38 39Рекомендации Выводы ГРР • Получены в целом достаточные фактические данные для подготовки новой рекомендации ВОЗ об ограничении малоподвижного образа жизни в целях снижения рисков для здоровья. • Получены фактические данные среднего уровня достоверности о наличии взаимосвязи между увеличением времени, проводимого в малоподвижном состоянии, и повышением смертности от всех причин, в том числе от сердечно- сосудистых и онкологических заболеваний, а также ростом масштабов распространения сердечно- сосудистых заболеваний и диабета 2-го типа. • Получены фактические данные от низкого до среднего уровня достоверности о наличии взаимосвязи между увеличением времени, проводимого в малоподвижном состоянии, и ростом риска развития рака тела матки, толстой кишки и легких. • Достаточных данных, подтверждающих взаимосвязь между малоподвижным образом жизни и степенью ожирения, не имеется; необходимо дальнейшее исследование. • Польза от ограничения времени, проводимого в малоподвижном состоянии, перевешивает любые потенциальные риски. Имеется ли взаимосвязь «доза-ответ» (общий объем, регулярность, продолжительность, интенсивность прерывания)? В целом фактические данные среднего уровня достоверности указывают на наличие нелинейной взаимосвязи «доза-ответ» между временем пребывания в малоподвижном состоянии (время, проводимое в положении сидя или за просмотром телевизора, которое определено путем самооценок или аппаратных оценок) и смертностью от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, и возникновением сердечно-сосудистых заболеваний (8, 35, 87). Недавний метаанализ позволил получить данные высокого уровня достоверности о наличии взаимосвязи «доза-ответ» между измерением общего времени пребывания в малоподвижном состоянии, проведенным методом акселерометрии, и смертностью от всех причин (65); в нем сообщалось, что увеличение времени, проводимого в малоподвижном состоянии, является существенным фактором смертности от всех причин. После коррекции по возможным искажающим факторам, включая время занятия физически активной деятельностью средней и высокой интенсивности, коэффициенты риска для квартилей с растущим временем пребывания в малоподвижном состоянии были равны 1,00 (эталон; наименьшая малоподвижность); 1,28 (1,09–1,51); 1,71 (1,36–2,15) и 2,63 (1,94–3,56) (65). В результате такого анализа взаимосвязи «доза-ответ» между временем малоподвижности и смертностью был выявлен ВЗРОСЛЫЕ (в возрасте 18-64 лет) постепенный рост риска, который начинался примерно от 7,5–9 часов и становился более отчетливым после 9,5 часа. Ежедневное пребывание в малоподвижном состоянии в течение 10 часов и 12 часов было связано с ростом риска смерти, составляющим соответственно 1,48 (1,22–1,79) и 2,92 (2,24–3,83) (65). Еще один недавний метаанализ оценки взаимосвязи «доза-ответ» выявил наличие линейной зависимости между общим временем пребывания в малоподвижном состоянии и смертностью от всех причин (КР на 1 час в день = 1,01 (1,00–1,01) для воздействия ≤ 8 часов в день; и 1,04 (1,03–1,05) для > 8 часов в день); а также смертностью от сердечно-сосудистых заболеваний (КР= 1,01 (0,99–1,02) для ≤ 6 часов в день; и КР= 1,04 (1,03–1,04) для > 6 часов в день) после коррекции по фактору физической активности (87). В результатах этого же исследования наблюдалась незначительная линейная взаимосвязь «доза-ответ» с диабетом 2-го типа применительно к общему объему малоподвижного образа жизни (1,01 (1,00–1,01)) после коррекции по факторам физической активности и просмотра телевизора (1,09 (1,07–1,12)) (87). Фактические данные в целом подтверждают, что увеличение времени пребывания в малоподвижном состоянии приводит к ухудшению показателей здоровья; поэтому был сделан вывод о наличии достаточных данных в поддержку минимизации времени пребывания в малоподвижном состоянии для снижения рисков, грозящих здоровью. Тем не менее с учетом высокой степени вариативности методов оценки малоподвижного образа жизни в различных обзорах (путем самооценки времени, проводимого в положении сидя и за просмотром телевизора, или путем аппаратных (акселерометр) оценок) и вероятности того, что пороговые величины времени пребывания в малоподвижном состоянии могут различаться в зависимости от показателей здоровья, от уровней физической нагрузки средней и высокой интенсивности и от подгруппы населения, был сделан вывод об отсутствии достаточных фактических данных для подготовки рекомендации относительно объема времени (с его количественными показателями). Помимо общего объема времени, проводимого в малоподвижном состоянии, были рассмотрены данные о схемах увеличения времени пребывания в малоподвижном состоянии. Однако достаточного объема материалов для подготовки рекомендаций о частотности и/или продолжительности перерывов в малоподвижном образе жизни собрать не удалось. Выводы ГРР • Достаточных фактических данных для подготовки количественных рекомендаций (касающихся объема времени) в отношении малоподвижного образа жизни не имеется. • Достаточных фактических данных для подготовки рекомендаций о частотности и/или продолжительности перерывов в малоподвижном образе жизни не имеется. 40 41 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Варьируется ли эта взаимосвязь в зависимости от вида и области малоподвижного образа жизни? Одни области или виды малоподвижного образа жизни могут причинять больше вреда, чем другие — по причине как их прямых взаимосвязей, так и их потенциала по оттягиванию на себя времени от занятия физически активной деятельностью, более полезной для здоровья. Хотя работа по исследованию малоподвижного образа жизни продвигается вперед быстрыми темпами, имеющихся фактических данных недостаточно для проведения прямого сопоставления взаимосвязи между различными видами малоподвижного образа жизни и всевозможными показателями здоровья. Например, некоторые исследования приводят к более высоким результатам при измерении малоподвижного образа жизни как времени просмотра телевизора в сравнении с общим временем пребывания в положении сидя (87). Возможно, это объясняется дифференциальной погрешностью измерения или остаточным искажением, которое связано с показателями самооценки и применяемым инструментами. В настоящее время не имеется достаточных фактических данных для определения различных взаимосвязей с разнообразными показателями здоровья и для прояснения вопроса о том, как они могут варьироваться в зависимости от подгруппы населения. Растет число исследований, в которых применяются аппаратные измерения физической активности и времени пребывания в малоподвижном состоянии по отношению к показателям здоровья. Однако при аппаратных измерениях времени пребывания в малоподвижном состоянии возможны некоторые классификационные искажения, поскольку многие из размещаемых устройств (например, на запястье или на талии) пока не умеют различать положения тела (например, лежа, сидя и стоя на месте). Будущее исследование с применением согласованного порядка отчетности и методики, позволяющей различать положения, поможет расширить знания о схемах малоподвижного образа жизни. Вывод ГРР • Достаточных фактических данных для составления рекомендаций о различных типах или областях малоподвижного образа жизни не имеется. Приводит ли уровень физической активности к изменению влияния малоподвижного образа жизни на показатели смертности? Возросший интерес к воздействию малоподвижного образа жизни на показатели здоровья послужил стимулом для исследования потенциального взаимодействия между разными уровнями физической активности и уровнями малоподвижности. На основе имеющихся результатов исследований получены фактические данные среднего уровня достоверности о том, что взаимосвязь между малоподвижным образом жизни и смертностью от всех причин, в том числе от сердечно-сосудистых заболеваний и от рака, варьируется в зависимости от объема физических нагрузок средней и высокой интенсивности (8, 9, 35). Общие выводы показывают, что воздействие малоподвижного образа жизни ощутимее для лиц, занимающихся физически активной деятельностью средней и высокой интенсивности в небольших объемах; иначе говоря, более значительные объемы физической нагрузки средней и высокой интенсивности способны сглаживать ухудшение показателей здоровья, вызванное более высокими уровнями малоподвижного образа жизни. Было установлено, что уровень риска, связанного с временем пребывания в малоподвижном состоянии и смертностью от всех причин, является более высоким на низких уровнях физической активности по сравнению с ее высокими уровнями (35). В последовательном метаанализе Ekelund et al. были рассмотрены совокупные и стратифицированные факторы влияния малоподвижного образа жизни и физической активности на смертность от всех причин у более 1 миллиона мужчин и женщин; анализ показал, что эта взаимосвязь дифференцируется в зависимости от уровня физической активности (9). В ходе анализа использовались квартили малоподвижности (сидячий образ жизни) и квартили с физической активностью средней и высокой интенсивности; было установлено, что в сравнении с эталоном (< 4 часов пребывания в сидячем положении в день и верхний квартиль с нагрузкой средней и высокой интенсивности [> 35,5 MET- часа в неделю]) при последующем наблюдении не отмечалось повышенного риска смерти среди лиц, которые проводили сидя более 8 часов в день, но при этом сообщали о занятиях физически активной деятельностью более 35,5 MET-часа в неделю (ОР= 1,04 [95% ДИ: 0,99–1,10]). Напротив, в случае лиц, которые проводили сидя наименьший объем времени (< 4 часов в день) и относились к нижнему (< 2,5 MET-часа в неделю) квартилю физической активности, при последующем наблюдении отмечался значительно возросший риск смерти (ОР= 1,27 [95% ДИ: 1,22–1,31]). Авторы исследования пришли к выводу, что физическая нагрузка средней и высокой ВЗРОСЛЫЕ (в возрасте 18-64 лет) 40 41Рекомендации интенсивности, выполняемая в течение примерно 60–75 минут в день (верхний квартиль), может сглаживать и даже устранять пагубную взаимосвязь между малоподвижным образом жизни и ухудшением показателей здоровья (9). Взаимосвязь между уровнями малоподвижного образа жизни и физической активностью средней и высокой интенсивности была обобщена в систематическом обзоре PAGAC (35), как показано на рисунке 2. Еще одно недавнее исследование обеспечило новые фактические данные о рассмотрении аналогичных связей с показателями смертности от конкретных причин и привело к аналогичным выводам (8). Результаты масштабного последовательного метаанализа (9 исследований, n= 850 000, смертность от ССЗ; 8 исследований, n= 777 000, смертность от рака) показали, что более высокие уровни физической активности средней и высокой интенсивности сглаживают риск смертности от сердечно- сосудистых заболеваний, возрастающий при высоких уровнях малоподвижного образа жизни, измеряемого как время, проводимое сидя, или как время, проводимое за просмотром телевизора (8). Как видно из результатов исследования, в случае лиц, находящихся в положении сидя более 8 часов в день, наблюдается связь с повышенным риском смерти, за исключением верхнего квартиля, где такая связь сглаживается. В более конкретном выражении риск смерти от сердечно-сосудистых заболеваний для лиц, ежедневное время сидения которых превышает 8 часов, на 32% выше по сравнению с референтной группой (< 4 часов в день) (p тренда < 0,001). Рисунок 2. Взаимосвязь между степенью малоподвижного образа жизни и уровнем физической активности Адаптированный график из доклада PAGAC ВЗРОСЛЫЕ (в возрасте 18-64 лет) Менее явные, но все же значительные в сопоставлении с референтной группой результаты были получены по другим квартилям физической активности (2-й квартиль, ОР= 1,11 [95% ДИ: 1,03–1,20]; 3-й квартиль, ОР= 1,14 [95% ДИ: 1,03–1,26]). Аналогичная взаимосвязь наблюдалось между продолжительностью времени просмотра телевизора и смертностью от сердечно-сосудистых заболеваний среди всех групп с физической активностью средней и высокой интенсивности (8). Наличие связи со смертностью от рака было не столь однозначным, хотя исследование в целом показало, что более высокие уровни физической активности снижают вредное воздействие малоподвижного образа жизни, когда он оценивается как общее время сидения. На основе этих фактических данных был сделан вывод, что более высокие уровни физически активной деятельности средней и высокой интенсивности следует рекомендовать лицам, ведущим весьма малоподвижный образ жизни, и что польза от такой деятельности перевесит риски. Выводы ГРР • Получены фактические данные среднего уровня достоверности о том, что взаимосвязь между малоподвижным образом жизни и смертностью от всех причин, в том числе от сердечно-сосудистых заболеваний и от рака, варьируется в зависимости от объема физически активной деятельности средней и высокой интенсивности. • Повышенные объемы физической нагрузки средней и высокой интенсивности могут сглаживать вредную взаимосвязь между малоподвижным образом жизни и показателями здоровья. П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я Больше физической активности Б ол ее м ал оп од ви ж н ы й о б р аз ж и зн и ВЫСОКИЙ РИСК НИЗКИЙ РИСК М енее малоподвижный образ жизни Увеличение физической акти вн ости У м ен ьш ен и е степени м алоподвижного образа жизни и больш е физической активности 42 43 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Пожилые люди могут заниматься физически активной деятельностью в рамках отдыха и досуга (подвижные игры, занятия спортом или плановые тренировки), передвижений (использование колесных средств, ходьба и езда на велосипеде), работы или выполнения домашних обязанностей, то есть в повседневном профессиональном, образовательном, домашнем или общинном контексте. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО ФИЗИЧЕСКОЙ АКТИВНОСТИ ПОЖИЛЫЕ ЛЮДИ (в возрасте 65 лет и старше) • небольшая физическая активность лучше, чем ее полное отсутствие; • если пожилые люди не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • пожилым людям следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • пожилым людям следует оставаться настолько физически активными, насколько позволяют их функциональные возможности, и соразмерять интенсивность занятий физически активной деятельностью с уровнем своего физического здоровья.П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я Физическая активность пожилых людей благоприятно отражается на следующих показателях здоровья: снижается смертность от всех причин, том числе от сердечно- сосудистых заболеваний, снижается заболеваемость гипертонией, раком отдельных локализаций, диабетом 2-го типа, улучшается психическое здоровье (снижаются симптомы тревоги и депрессии), улучшаются когнитивное здоровье и сон; также может снижаться степень ожирения. У пожилых людей занятия физически активной деятельностью помогают предотвращать падения и связанный с падениями травматизм, а также препятствуют ухудшению состояния костной системы и ее функциональных возможностей. В этой связи рекомендуется следующее. Всем пожилым людям следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Пожилым людям следует не менее 150–300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75–150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, чтобы занятия приносили ощутимую пользу для здоровья, уделять в течении недели время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Чтобы занятия приносили дополнительную пользу для здоровья, пожилым людям также следует выполнять силовые упражнения средней или большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных В ходе еженедельных занятий физически активной деятельностью в целях повышения функциональных возможностей и предотвращения риска падений пожилым людям следует не реже трех раз в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней или большей интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Пожилые люди могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных 42 43Рекомендации Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Подтверждающие фактические данные и обоснование При подготовке настоящих рекомендаций в отношении пожилых людей были использованы и обновлены всеобъемлющие обобщенные фактические данные, собранные PAGAC (35); 15 обзоров соответствовали критериям включения и расширяли объем информации о взаимосвязи между физической активностью и специфическими показателями здоровья пожилых людей (профилактика падений, связанный с падениями травматизм, физическое функционирование, дряхлость и остеопороз). При подготовке фактических данных по профилактике падений были использованы и обновлены материалы «Систематический обзор Кокрейновского сотрудничества» 2019 г., содержащийся в публикации Sherrington et al. (42); в нем были опубликованы данные за период с даты последнего поиска в этом первоначальном обзоре до ноября 2019 г. (девять новых исследований). В процессе поиска существующих систематических обзоров по проблемам остеопороза и саркопении, проведенного по базе PubMed среди обзоров, опубликованных с 2008 по ноябрь 2019 г., новых обзоров выявлено не было, но при этом удалось обнаружить восемь новых исследований. С полной информацией о методах, извлечении данных и профилях фактических данных можно ознакомиться в веб-приложении «Профили фактических данных» . Какова взаимосвязь между малоподвижным образом жизни и показателями здоровья у пожилых людей (в возрасте 65 лет и старше)? Базой первичных фактических данных для оценки взаимосвязи между физической активностью и показателями здоровья пожилого населения, такими как смертность от всех причин и от конкретных причин, масштабы распространения сердечно-сосудистых заболеваний, диабета 2-го типа и онкологических заболеваний, ожирение, психическое здоровье и когнитивные способности, являлась та же научная литература, которая была подобрана и пересмотрена для взрослых групп населения. Этот же массив данных был одобрен и экстраполирован для пожилых людей, поскольку охват большинства исследований не предусматривал верхнего возрастного предела и, следовательно, включал в себя взрослых старше 65 лет. Последующий обзор фактического материала был нацелен на рассмотрение и более подробное изучение взаимосвязи между физической активностью и специфическими показателями здоровья пожилых людей, включая профилактику падений, связанный с падениями травматизм, физическое функционирование, дряхлость и остеопороз. Ослабление физических возможностей у пожилых людей нередко проявляется в падениях и в связанном с падениями травматизме, что может повлечь серьезные последствия. Случайные падения происходят под действием совокупности внешних (связанных с окружающей средой) и внутренних (например, обусловленных нарушениями скелетно-мышечной или нервной систем, влияющими на постуральный контроль) факторов. Фактические данные показывают, что физическая активность у пожилых людей — особенно программы комплексных физических упражнений, включающие в себя различные комбинации упражнений на равновесие, развитие силы, выносливости, походки и физического функционирования, — приводит к снижению вероятности падений и риска ПОЖИЛЫЕ ЛЮДИ (в возрасте 65 лет и старше) травмирования при падениях. Недавно полученные данные свидетельствуют о том, что выполнение пожилыми людьми комплекса упражнений может снизить вероятность падений на 23% (совокупный относительный риск (СОР) 0,77 [95% ДИ: 0,71–0,83]), что существенно уменьшит травмирование при падениях, включая тяжелые случаи падений, приводящие к переломам, травмам головы, открытым ранам, повреждениям мягких тканей или другим травмам, требующим медицинской помощи или госпитализации (42). Эти данные соответствовали выводам других обзоров и подтверждали их (35). После достижения пика старшего юношеского возраста мышечная и костная масса с годами начинает уменьшаться (т. е. появляются саркопения и остеопения/ остеопороз), что может привести к ослаблению силы и физического функционирования. Имеющиеся данные показывают, что регулярная физическая активность способствует улучшению физического функционирования и снижению риска возрастного ослабления физических функций у пожилых людей. Полученные выводы свидетельствуют о благотворном воздействии на динамическое равновесие (СМД= 1,10 [95% ДИ: 0,29–1,90]); мышечная сила (СМД= 1,13 [95% ДИ: 0,30–1,96]); гибкость (СМД= 1,22 [95% ДИ: 0,39–2,04]) и кардиореспираторное здоровье (СМД= 1,48 [95% ДИ: 0,42–2,54]) (94). Данные также показывают, что повышенные уровни физической активности могут улучшать здоровье костной системы и тем самым обеспечивать профилактику остеопороза у пожилых людей (сводный стандартизированный размер эффекта 0,21 [95% ДИ: 0,06–0,36]) (95). Физически активная деятельность может приводить к повышению минеральной плотности костной ткани поясничного отдела позвоночника и шейки бедра (тазобедренного сустава). 44 45 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Выводы ГРР • Получены фактические данные среднего уровня достоверности о том, что физические нагрузки улучшают физическое функционирование и снижают риск возрастного ослабления физических функций у стареющих групп населения в целом. • Получены фактические данные низкого уровня достоверности о том, что риски, связанные с объемами и видами физической активности, рекомендуемыми пожилым людям, являются незначительными и перевешиваются приносимой пользой. Имеется ли взаимосвязь «доза-ответ» (объем, продолжительность, регулярность, интенсивность)? Фактические данные указывают на обратную взаимосвязь между объемом физической активности у пожилых людей и риском ограничений физического функционирования. Вообще, повышенная физическая активность (регулярность, продолжительность и/или объем) приносит больше пользы (35). По имеющимся данным, с точки зрения общего повышения функциональных возможностей быстроскоростная тренировка на сопротивление может быть эффективнее среднескоростной (СМД= 0,41 [95% ДИ: 0,18–0,65]; и SPPB (СМД= 0,52 [95% ДИ: 0,10–0,94])) (96). Имеются ограниченные данные о взаимосвязи «доза- ответ» между физической активностью и профилактикой падений; при этом в большинстве исследований, содержащих подтверждающие данные, рассматривается тестовая программа, рассчитанная на тренировки три раза в неделю. Вывод ГРР • Получены фактические данные высокого уровня достоверности о наличии обратной взаимосвязи «доза-ответ» между объемом аэробной нагрузки и риском снижения физического функционирования в группах пожилого населения в целом. ПОЖИЛЫЕ ЛЮДИ (в возрасте 65 лет и старше) Варьируется ли эта взаимосвязь в зависимости от вида или области физической активности? Программы физической активности для пожилых людей, включающие в себя сочетание упражнений на развитие силы, выносливости, походки и физического функционирования, приводят к снижению вероятности падений и риска получения травм в результате падений. Результаты обзора 11 РКИ показали, что пожилые люди, практикующие различные виды физической активности (как правило, упражнения на равновесие и функциональные упражнения наряду с упражнениями для тренировки сопротивления), могут добиться снижения вероятности падений на 28% (СОР= 0,72 [95% ДИ: 0,56–0,93]) (42). Вывод об эффекте от упражнений для тренировки сопротивления остался неопределенным из-за ограниченности полученных данных (КР= 0,97 [95% ДИ: 0,14–6,49]; одно исследование; n= 73) (42). Имеющиеся данные также показывают, что программы, состоящие из упражнений различных видов, оказывают значительное позитивное воздействие на здоровье костной системы (стандартизированный размер эффекта 0,45 [95% ДИ: 0,20–0,71]; p= 0,001) по сравнению с однообразными программами (95). Выводы ГРР • Получены фактические данные высокого уровня достоверности о том, что высокие уровни физически активной деятельности у пожилых людей, сочетающие в себе упражнения на укрепление равновесия, силы, походки и физического функционирования (например, комплексные физические упражнения), приводят к снижению вероятности падений и риска получения травм в результате падений. • Получены фактические данные среднего уровня достоверности о том, что программы, состоящие из упражнений различных видов, могут оказывать значительное позитивное воздействие на здоровье костной системы и предупреждать остеопороз. 44 45Рекомендации Подтверждающие фактические данные и обоснование Малоподвижный образ жизни не был включен в Глобальные рекомендации ВОЗ по физической активности для здоровья 2010 г. (1). Из-за нехватки материалов по отдельным группам населения базой первичных фактических данных для оценки взаимосвязи между малоподвижным образом жизни и показателями здоровья пожилых людей являлась та же научная литература, которая была подобрана и пересмотрена для взрослых групп населения, поскольку охват большинства исследований не предусматривал верхнего возрастного предела и, следовательно, включал в себя взрослых старше 65 лет. Были пересмотрены выводы, сделанные на основе данных о малоподвижном образе жизни по всем группам взрослого населения, включая решение вопроса о том, имеются ли данные, согласно которым соответствующие результаты будут в отношении пожилых людей чем-либо отличаться, окажутся для них неприменимыми или будут им противопоказаны. Кроме того, сведения относительно применимости фактических данных о пользе увеличения объема физически активной деятельности средней и высокой интенсивности для противодействия возможным рискам особо малоподвижного образа жизни были рассмотрены и также экстраполированы с целью учета в рекомендациях для пожилых людей по единому комплексу важнейших показателей здоровья. В последние десятилетия жизни могут возникать трудности при попытках сократить время малоподвижности из-за ухудшения физического функционирования, хотя общеизвестно, что замена пребывания в малоподвижном состоянии физически активной деятельностью (даже низкой интенсивности) по-прежнему полезна для здоровья. С полной информацией о методах, извлечении данных и профилях фактических данных можно ознакомиться в веб- приложении «Профили фактических данных» . Выводы ГРР • Фактические данные о малоподвижном образе жизни во всех группах взрослого населения, в том числе о пользе увеличения объема физически активной деятельности средней и высокой интенсивности для противодействия возможным рискам особо малоподвижного образа жизни, могут экстраполироваться и учитываться при составлении рекомендаций для пожилых людей по единому комплексу важнейших показателей здоровья. • Польза от минимизации объема малоподвижного образа жизни перевешивает риски для пожилых людей. Особо малоподвижный образ жизни пожилых людей ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению масштабов распространения сердечно-сосудистых заболеваний, рака и диабета 2-го типа. В этой связи рекомендуется следующее. Пожилым людям следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, средняя степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии пожилым людям следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Для пожилых людей малоподвижный образ жизни определяется как время, проводимое в состоянии бодрствования в положениях сидя или лежа при низком расходе энергии в профессиональном, образовательном, домашнем и общинном контексте и при передвижении. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО МАЛОПОДВИЖНОГО ОБРАЗА ЖИЗНИ Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ПОЖИЛЫЕ ЛЮДИ (в возрасте 65 лет и старше) 46 47 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и PREGNANT AND POSTPARTUM WOMEN РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО ФИЗИЧЕСКОЙ АКТИВНОСТИ Беременные женщины и женщины в послеродовом периоде могут заниматься физически активной деятельностью в рамках отдыха и досуга (подвижные игры, занятия спортом или плановые тренировки), передвижений (использование колесных средств, ходьба и езда на велосипеде), работы или выполнения домашних обязанностей, то есть в повседневном профессиональном, образовательном, домашнем и общинном контексте. В настоящих рекомендациях рассматриваются физическая активность и показатели здоровья матери и плода во время беременности и в послеродовой период. Рекомендации адресованы всем беременным женщинам и женщинам в послеродовом периоде независимо от их возраста, культурного уровня или социально- экономического статуса. Поскольку беременность и послеродовой период — важные этапы в жизни женщины, благотворное влияние физической активности на протяжении всего периода зрелости организма подробно описано в рекомендациях, предоставляемых взрослым. Беременным женщинам и женщинам в послеродовом периоде следует получать квалифицированную антенатальную и постнатальную помощь врача-специалиста, который может консультировать по специфическим вопросам, учитывая их медицинский анамнез и любые противопоказания для занятия физически активной деятельностью во время беременности или в послеродовой период. Настоящие рекомендации основаны на принципах общественного здравоохранения и носят общепопуляционный характер. Для женщин с осложнениями в связи с беременностью или родами следует запрашивать клинические консультации. Беременным женщинам и женщинам в послеродовом периоде во всех возможных случаях нужно пытаться следовать этим рекомендациям в соответствии со своими способностями и при отсутствии противопоказаний. Физическая активность беременных женщин и женщин в послеродовом периоде благоприятно отражается на следующих показателях здоровья матери и плода: снижаются риски преэклампсии, гестационной гипертонии, гестационного диабета, чрезмерного гестационного увеличения массы тела, осложнений при родах и послеродовой депрессии, а также уменьшается количество осложнений у новорожденных, исключаются негативные факторы, влияющие на вес ребенка при рождении; и также исключается повышение риска мертворождения. Всем беременным женщинам и женщинам в послеродовом периоде при отсутствии противопоказаний рекомендуется следующее. Следует регулярно заниматься физически активной деятельностью во время беременности и в послеродовой период. Настоятельная рекомендация, средняя степень достоверности данных Чтобы физическая активность приносила ощутимую пользу для здоровья, следует уделять не менее 150 минут в неделю занятиям физически активной деятельностью средней и высокой интенсивности с аэробной нагрузкой. Настоятельная рекомендация, средняя степень достоверности данных Рекомендуется использовать различные виды аэробных и силовых физических упражнений. Также могут быть полезны дополнительные легкие упражнения на растяжку. Настоятельная рекомендация, средняя степень достоверности данных Кроме того, женщины, которые до наступления беременности регулярно выполняли аэробные физические упражнения высокой интенсивности или занимались физически активной деятельностью, могут продолжать эту практику во время беременности и в послеродовой период. Настоятельная рекомендация, средняя степень достоверности данных БЕРЕМЕННЫЕ ЖЕНЩИНЫ И ЖЕНЩИНЫ В ПОСЛЕРОДОВОМ ПЕРИОДЕ 46 47Рекомендации Подтверждающие фактические данные и обоснование При подготовке настоящих Рекомендаций по вопросам физической активности и малоподвижного образа жизни (2020 г.) в отношении беременных женщин и женщин в послеродовом периоде были использованы и обновлены обобщенные фактические данные из семи систематических обзоров, в которых рассматривались важнейшие и важные показатели здоровья (28–34). Четыре обзора из семи соответствовали критериям включения. С полной информацией о методах, извлечении данных и профилях фактических данных можно ознакомиться в веб-приложении «Профили фактических данных» . Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Какова взаимосвязь между физической активностью и показателями здоровья у беременных женщин и женщин в послеродовом периоде? Физическая активность до и во время беременности может способствовать снижению риска наиболее частых осложнений беременности. Занятия физически активной деятельностью в период беременности эффективно сокращают гестационное увеличение массы тела (разница= 1,14 кг [95% ДИ: 1,67 – 0,62]) (97) и снижает риск гестационного диабета (КР= 0,71 [95% ДИ: 0,57–0,89]) (97), как и физическая активность до беременности (OШ= 0,70 [95% ДИ: 0,57–0,85]) (31, 34, 97), в том числе среди женщин с избыточным весом или ожирением (97). Как представляется, физическая активность в период беременности не приводит к росту масштабов гестационной гипертонии или преэклампсии (31). Согласно фактическим данным, среди беременных женщин с избыточным весом или ожирением не наблюдается заметных различий в распространенности гестационной гипертонии (КР= 0,63 [95% ДИ: 0,38–1,05]) БЕРЕМЕННЫЕ ЖЕНЩИНЫ И ЖЕНЩИНЫ В ПОСЛЕРОДОВОМ ПЕРИОДЕ П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я • небольшая физическая активность лучше, чем ее полное отсутствие; • если беременные женщины и женщины в послеродовом периоде не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • беременным женщинам и женщинам в послеродовом периоде следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • в целях снижения риска недержания мочи можно ежедневно делать упражнения для укрепления мышц тазового дна. • Избегайте занятий физически активной деятельностью во время чрезмерной жары, особенно в условиях высокой влажности. • Не допускайте обезвоживания организма и пейте воду до, во время и после физических нагрузок. • Избегайте занятий теми видами деятельности, которые предполагают физические контакты с другими людьми; повышают риск падений; или могут ограничивать насыщение организма кислородом (например, занятия физически активной деятельностью в условиях больших высот над уровнем моря, если они не являются условиями вашей обычной жизнедеятельности). • Избегайте физических нагрузок в положении лежа на спине после первого триместра беременности. • При принятии решений относительно участия в спортивных соревнованиях или выполнения упражнений, значительно превышающих по своим нагрузкам рекомендуемые уровни, беременным женщинам следует обращаться за консультацией к врачу-специалисту. • Беременным женщинам следует проконсультироваться у своего лечащего врача по вопросу об опасных симптомах, свидетельствующих о необходимости приостановить или ограничить занятия физически активной деятельностью, и немедленно проконсультироваться с квалифицированным врачом-специалистом в случае возникновения таких симптомов. • Возвращение к активной физической деятельности после родов следует осуществлять постепенно, а также по согласованию лечащим врачом в случае родов путем кесарева сечения. К дополнительным рекомендациям относительно мер предосторожности, которые необходимо соблюдать беременным женщинам при занятии физически активной деятельностью, относятся следующие. или преэклампсии (КР= 1,39 [95% ДИ: 0,66–2,93]), если сравнивать физически активные группы с группами, получающими стандартный дородовой уход (97). Существует давняя озабоченность в связи с потенциальным вредным воздействием физической активности матери на развитие плода и родоразрешение. Однако, как показывают недавно полученные данные, физическая активность не приводит к росту риска выкидыша, мертворождения или осложнений при родах (32). Согласно фактическим материалам, нет никаких различий в частотности применения кесарева сечения среди беременных женщин с избыточным весом или ожирением, если сравнивать физически активные группы с группами, получающими стандартный дородовой уход (97). Физическая активность во время беременности не связана с ростом риска вредного воздействия на вес при рождении (98) или риска преждевременных родов (32); напротив, она может выполнять защитную функцию, снижая уровень общего рискa (98) даже среди беременных женщин с избыточным весом или ожирением (КР= 1,02 [95% ДИ: 0,54–1,92]) или риска 48 49 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и рождения крупных для гестационного возраста младенцев (КР= 0,90 [95% ДИ: 0,65–1,25]), если сравнивать физически активные группы с группами, получающими стандартный дородовой уход (97). В послеродовой период матери могут переживать широкий спектр физических и эмоциональных изменений. Из фактических данных видно, что физическая активность во время беременности может иметь обратную взаимосвязь с послеродовой депрессией (29). Результаты метаанализа шести испытаний и 11 обсервационных исследований физической активности в ходе беременности (99) показали явную обратную взаимосвязь между физической активностью в период беременности и послеродовой депрессией (СМД= 0,58 [95% ДИ: 1,09 – 0,08]). Этот эффект проявлялся еще более отчетливо при ограничении результатов пятью исследованиями групп, занимавшихся физически активной деятельностью как минимум средней интенсивности (СМД= 0,70 [95% ДИ: 1,19 – 0,22]) (99). Выводы ГРР • Получены фактические данные высокого уровня достоверности о том, что физическая активность в период беременности может сокращать гестационное увеличение массы тела и снижать риск гестационного сахарного диабета. • Получены фактические данные от среднего до высокого уровня достоверности о том, что физическая активность не приводит к росту масштабов гестационной гипертонии. • Получены фактические данные среднего уровня достоверности о том, что физическая активность не приводит к росту риска выкидыша, мертворождения или осложнений при родах; и данные среднего уровня достоверности о снижении риска преждевременных родов для матерей, занимающихся физически активной деятельностью высокой интенсивности. • Получены фактические данные от низкого до среднего уровня достоверности о том, что физическая активность не вызывает рост риска низкого веса при рождении или риска рождения маленьких или крупных для гестационного возраста младенцев. • Получены фактические данные низкого уровня достоверности о том, что физическая активность во время беременности приводит к снижению симптомов послеродовой депрессии. • Риски, связанные с объемами и видами физической активности, рекомендуемой беременным женщинам и женщинам в послеродовом периоде, являются незначительными и перевешиваются приносимой пользой. БЕРЕМЕННЫЕ ЖЕНЩИНЫ И ЖЕНЩИНЫ В ПОСЛЕРОДОВОМ ПЕРИОДЕ Имеется ли взаимосвязь «доза-ответ» (объем, продолжительность, регулярность, интенсивность)? Aнализ фактического материала о физической активности во время беременности и в послеродовой период показывает, что проводимые мероприятия варьируются по объему (т. е. дозе) физической активности в части как ее продолжительности в минутах, так и количества занятий в неделю. В целом же имеющиеся данные отражали регулярность аэробной нагрузки, составляющую не реже трех дней в неделю с типичной продолжительностью 30–60 минут. Эти данные заимствованы из исследований, посвященных влиянию на здоровье какой-либо дозы физической нагрузки, в основном соответствующей объему активности, рекомендуемому для всех групп взрослого населения — 150 минут еженедельной физически активной деятельности средней интенсивности. Хотя обычно считается, что увеличение физической активности (регулярности, продолжительности и/или объема) приводит к большему позитивному эффекту, для более детального осмысления взаимосвязи «доза- ответ» необходимо дальнейшее исследование. Занятие в предбеременный период досуговой физически активной деятельностью большего объема по сравнению с меньшим обеспечивает значительное снижение риска гестационного диабета (OШ= 0,54 [95% ДИ: 0,34–0,87]) (100). Имеются также данные о небольшом, но заметном уменьшении риска преждевременных родов у матерей, практиковавших физические нагрузки высокой интенсивности (КР= 0,20 [95% ДИ: 0,36 – 0,03]) (98). При этом не было обнаружено каких-либо данных о безопасности или дополнительной пользе тренировок на уровнях, существенно превышающих рекомендуемые. Выводы ГРР • Достаточных фактических данных для определения взаимосвязи «доза-ответ» между физической активностью и конкретными важнейшими показателями здоровья во время беременности и в послеродовой период не имеется. • Фактические данные в целом свидетельствуют о благотворном влиянии на важнейшие показатели здоровья, которое достигается благодаря занятиям, в целом соответствующим объему физической активности, рекомендуемому для всех групп взрослого населения — 150 минут еженедельной физически активной деятельности средней интенсивности. • Нет оснований изменять объем или регулярность рекомендуемой физической активности средней интенсивности для беременных женщин и женщин в послеродовом периоде по сравнению с остальными группами взрослого населения. • Получены фактические данные среднего уровня достоверности о снижении риска преждевременных родов у матерей, занимающихся физически активной деятельностью высокой интенсивности. 48 49Рекомендации Варьируется ли эта взаимосвязь в зависимости от вида, области или периода (предбеременный, дородовой или послеродовой) физической активности? Фактические данные взяты из исследований, сосредоточенных на оценке досуговой области физической активности; этот вид активности является в основном аэробным (например, ходьба или плавание), хотя, согласно некоторым результатам оценочных исследований, нагрузки этого вида активности также включают в себя силовые упражнения (например, круговой тренинг) или сочетания аэробных и силовых упражнений. Однако в целом не имеется достаточных данных, позволяющих определить, варьируется ли взаимосвязь между физической активностью и показателями здоровья в зависимости от вида, области или периода (предбеременный, дородовой или послеродовой) физической активности. Вывод ГРР • Получены фактические данные среднего уровня достоверности о том, что беременным женщинам и женщинам в послеродовом периоде следует выполнять различные виды аэробных и силовых физических упражнений. Также могут быть полезны дополнительные легкие упражнения на растяжку. БЕРЕМЕННЫЕ ЖЕНЩИНЫ И ЖЕНЩИНЫ В ПОСЛЕРОДОВОМ ПЕРИОДЕ 50 51 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Особо малоподвижный образ жизни беременных женщин и женщин в послеродовом периоде, как и у всех взрослых, ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также росту масштабов распространения сердечно- сосудистых заболеваний, рака и диабета 2-го типа. В этой связи рекомендуется следующее. Беременным женщинам и женщинам в послеродовом периоде следует сокращать продолжительность пребывания в малоподвижном состоянии. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, низкая степень достоверности данных Для беременных женщин и женщин в послеродовом периоде малоподвижный образ жизни определяется как время, проводимое в состоянии бодрствования в положениях сидя или лежа при низком расходе энергии в профессиональном, образовательном, домашнем и общинном контексте и при передвижении. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО МАЛОПОДВИЖНОГО ОБРАЗА ЖИЗНИ Подтверждающие фактические данные и обоснование Малоподвижный образ жизни не был включен в Глобальные рекомендации ВОЗ по физической активности для здоровья 2010 г. (1). Из-за нехватки материалов по отдельным группам населения базой первичных фактических данных для оценки взаимосвязи между малоподвижным образом жизни и показателями здоровья беременных женщин и женщин в послеродовом периоде являлась научная литература, которая была подобрана и пересмотрена для взрослых групп населения. Были пересмотрены выводы, сделанные на основе данных о малоподвижном образе жизни по всем группам взрослого населения, включая решение вопроса о том, имеются ли данные, согласно которым соответствующие результаты будут в отношении беременных женщин и женщин в послеродовом периоде чем-либо отличаться, окажутся для них неприменимыми или будут им противопоказаны. На основе имеющихся материалов и экспертных заключений эти фактические данные были экстраполированы с целью учета в новых рекомендациях ВОЗ относительно малоподвижного образа жизни для беременных женщин и женщин в послеродовом периоде по единому комплексу важнейших показателей здоровья. Ввиду косвенного характера фактических данных уровень их достоверности был понижен. Учитывая нехватку данных по данной группе населения и тот факт, что беременные женщины были исключены из охвата исследований, рекомендация относительно повышения уровня физической активности сверх ее рекомендуемых объемов с целью сглаживания вредного воздействия особо малоподвижного образа жизни не была экстраполирована для женщин во время беременности и в послеродовой период. Выводы ГРР • Фактические данные о малоподвижном образе жизни во всех группах взрослого населения могут экстраполироваться и учитываться при составлении рекомендаций для беременных женщин и женщин в послеродовом периоде по единому комплексу важнейших показателей здоровья. • Польза от минимизации объема малоподвижного образа жизни перевешивает риски для беременных женщин и женщин в послеродовом периоде. • Ввиду косвенного характера фактических данных уровень их достоверности следует понизить. БЕРЕМЕННЫЕ ЖЕНЩИНЫ И ЖЕНЩИНЫ В ПОСЛЕРОДОВОМ ПЕРИОДЕ 50 51Рекомендации На сегодняшний день большинство рекомендаций о физической активности для лиц с хроническими патологиями ограничено рекомендациями клинического или терапевтического характера. Например, имеются рекомендации и ресурсы по клинической практике, разработанные профессиональными медицинскими ассоциациями для онкологических заболеваний (101), диабета 2-го типа (102), гипертонии (103) и других хронических болезней (104). ВОЗ также подготовила руководство по клинической практике, включающее рекомендации относительно физической активности для пациентов с хроническими заболеваниями (17). В настоящих рекомендациях изложены первые популяционные рекомендации ВОЗ, касающиеся физической активности лиц с хроническими патологиями, особенно лиц с онкологическими заболеваниями (далее именуемых лицами, пережившими рак), гипертонией, диабетом 2-го типа и ВИЧ-инфекцией. Учитывая прогресс в деле эффективной и широкодоступной антиретровирусной терапии для ВИЧ, эта патология теперь также считается хронической. При ведении пациентов, которые проходят интенсивное лечение (например, химиотерапию) или еще не стабилизировались после непрерывного приема лекарств, врачам также следует пользоваться рекомендациями по клинической практике, относящимися к каждой хронической патологии. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО ФИЗИЧЕСКОЙ АКТИВНОСТИ Взрослые с хроническими патологиями могут заниматься физически активной деятельностью в рамках отдыха и досуга (подвижные игры, занятия спортом или плановые тренировки), передвижений (использование колесных средств, ходьба и езда на велосипеде), работы или выполнения домашних обязанностей, то есть в повседневном профессиональном, образовательном, домашнем и общинном контексте. Всем взрослым, пережившим рак, а также взрослым, страдающим гипертонией, диабетом 2-го типа и ВИЧ-инфекцией, нужно пытаться следовать этим рекомендациям по мере возможности, сообразно своим способностям и при отсутствии противопоказаний. Физическая активность может благоприятно отражаться на здоровье взрослых и пожилых людей со следующими хроническими патологиями: благодаря поддержанию физической активности у лиц, переживших рак, снижаются показатели смертности от всех причин и от конкретных онкологических заболеваний, а также риск рецидива или второго первичного рака; у лиц, страдающих артериальной гипертонией, благодаря поддержанию физической активности снижаются показатели смертности от сердечно-сосудистых заболеваний, замедляется прогрессирование заболевания, улучшаются показатели физического функционирования, а также повышается качество жизни, обусловленное состоянием здоровья; у лиц, страдающих диабетом 2-го типа, благодаря поддержанию физической активности снижаются показатели смертности от сердечно-сосудистых заболеваний и замедляется прогрессирование заболевания; лицам, страдающим ВИЧ-инфекцией, поддержание физической активности может помочь улучшить физическое и психическое здоровье (снизить симптомы тревоги и депрессии), не оказывая при этом негативного воздействия на прогрессирование болезни (на число CD4-клеток и вирусную нагрузку) или на состав тканей организма. В этой связи рекомендуется следующее. Всем взрослым и пожилым людям с вышеуказанными хроническими патологиями следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Взрослым и пожилым людям с этими хроническими патологиями следует не менее 150–300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75–150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я 52 53 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Чтобы занятия приносили дополнительную пользу для здоровья, взрослым и пожилым людям с этими хроническими патологиями также следует выполнять силовые упражнения средней и большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных В ходе еженедельных занятий физически активной деятельностью в целях повышения функциональных возможностей и предотвращения риска падений пожилым людям с этими хроническими патологиями следует не реже трех раз в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней и большей интенсивности. Настоятельная рекомендация, средняя степень достоверности данных При отсутствии противопоказаний взрослые и пожилые люди, страдающие этими хроническими патологиями, могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, чтобы занятия приносили дополнительную пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных Подтверждающие фактические данные и обоснование Охват настоящих рекомендаций включал в себя оценку взаимосвязи между физической активностью и следующими показателями здоровья: для лиц, переживших рак — смертность от всех причин и от конкретных онкологических заболеваний, а также риск рецидива или второго первичного рака; для лиц, страдающих артериальной гипертонией — смертность от сердечно-сосудистых заболеваний, риск сопутствующих заболеваний, физическое функционирование, качество жизни, обусловленное состоянием здоровья, и прогрессирование заболевания (здесь определено как реакция артериального давления на физическую активность); для лиц, страдающих диабетом 2-го типа — смертность от сердечно-сосудистых заболеваний, риск сопутствующих заболеваний, физическое функционирование, качество жизни, обусловленное состоянием здоровья, и прогрессирование заболевания; и для лиц, страдающих ВИЧ-инфекцией — физическое функционирование (физическое состояние, переносимость нагрузки и сила), качество жизни, обусловленное состоянием здоровья, психическое здоровье (симптомы тревоги и депрессии), кардиометаболические показатели риска заболевания (липиды крови, глюкоза в крови и состав тканей организма) и негативное воздействие на прогрессирование болезни (на число CD4-клеток и вирусную нагрузку). При подготовке настоящих рекомендаций были использованы и обновлены фактические данные из доклада PAGAC (35); были также выявлены 16 новых обзоров за период 2017–2019 гг. по онкологическим заболеваниям (n= 1), гипертонии (n= 2) и диабету 2-го типа (n= 13). Кроме того, из запрошенного общего обзора, посвященного физической активности и показателям здоровья у лиц, страдающих ВИЧ-инфекцией, были взяты данные по 19 признанным приемлемыми обзорам, опубликованным в 2002–2018 гг. С полной информацией о методах, извлечении данных и профилях фактических данных можно ознакомиться в веб-приложении «Профили фактических данных» . Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я • если взрослые с этими хроническими патологиями не в состоянии выполнять вышеперечисленные рекомендации, им следует стремиться к тому, чтобы заниматься физически активной деятельностью в соответствии со своими физическими возможностями; • взрослым с этими хроническими патологиями следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • взрослые с этими хроническими патологиями могут получить консультацию у специалиста по вопросам физической активности или медицинского работника относительно видов и объемов физически активной деятельности, соответствующих их индивидуальным потребностям, физическим возможностям, функциональным ограничениям/ осложнениями, принимаемым лекарственным средствам и общему плану лечения; • как правило, для лиц, не имеющих противопоказаний, нет необходимости в прохождении предварительного медосмотра перед началом занятий физически активной деятельностью низкой и средней интенсивности, не требующих физической подготовки дополнительно к той, которая необходима для энергичной ходьбы или в повседневной жизни. 52 53Рекомендации Какова взаимосвязь между физической активностью и показателями здоровья у взрослых и пожилых людей (в возрасте 18 лет и старше), страдающих онкологическими заболеваниями (лиц, переживших рак), гипертонией, диабетом 2-го типа или ВИЧ-инфекцией? Физическая активность стимулирует в метаболических, гормональных и воспалительных путях благотворные кратко- и долгосрочные изменения, которые считаются факторами защиты от возникновения рака и выживания после него (35). Фактические данные показывают, что повышение уровней физической активности после диагностики рака обеспечивало защиту от смертности от всех причин после рака молочной железы (ОР= 0,58 [95% ДИ: 0,52–0,65], 17 исследований); колоректального рака (ОР= 0,63 [95% ДИ: 0,50–0,78], 10 исследований), рака женской репродуктивной системы (ОР= 0,66 [95% ДИ: 0,49–0,88], 4 исследования); глиомы (ОР= 0,64 [95% ДИ: 0,46–0,91], 1 исследование); гемобластоза (ОР= 0,60 [95% ДИ: 0,51–0,69], 2 исследования); рака почки (ОР= 0,60 [95% ДИ: 0,38–0,95], 1 исследование); рака легких (ОР= 0,76 [95% ДИ: 0,60–0,97], 2 исследования); рака простаты (ОР= 0,60 [95% ДИ: 0,46–0,79], 5 исследований); и рака желудка (ОР= 0,75 [95% ДИ: 0,61–0,93], 1 исследование) (105). Повышенные объемы физической активности после диагностики рака также приводят к снижению риска смертности от конкретных причин у лиц, переживших рак молочной железы, колоректальный рак и рак простаты. Результаты метаанализа показали снижение рисков смерти для лиц верхней группы общей постдиагностической активности в сравнении с нижней группой по всем онкологическим заболеваниям (ОР= 0,63 [95% ДИ: 0,53–0,75], 4 исследования); раку молочной железы (ОР= 0,63 [95% ДИ: 0,50–0,78], 13 исследований); колоректальному раку (ОР= 0,62 [95% ДИ: 0,44–0,86], 6 исследований); и раку простаты (ОР= 0,70 [95% ДИ: 0,55–0,90], 4 исследования) (105). Однако фактические данные оказались недостаточными для решения вопроса о том, существует ли взаимосвязь между физической активностью и рецидивом рака или вторым первичным раком. Физическая активность имеет большое значение как для первичной профилактики гипертонии, так и для ее лечения: фактические данные показывают, что физические нагрузки обеспечивают улучшение физического функционирования, замедляют прогрессирование сердечно-сосудистых заболеваний (т. е. реакцию артериального давления на физическую активность) и снижают смертность от сердечно- сосудистых заболеваний среди лиц, страдающих гипертонией (35). Например, по сравнению с неактивными контрольными группами физически активные лица с гипертонией могут снижать систолическое артериальное давление примерно на 12 мм ртутного столба, а диастолическое артериальное давление – примерно на 6 мм ртутного столба (САР МД= 12,26 мм рт. ст. [95% ДИ: 15,17–9,34], p= < 0,05; ДАР МД= 6,12 мм рт. ст. [95% ДИ: 7,76–4,48], p= < 0,05) (106). Новые фактические материалы свидетельствуют о том, что лица с гипертонией, занимающиеся физически активной деятельностью, способны значительно улучшить свое качество жизни, обусловленное состоянием здоровья, по сравнению со страдающими гипертонией неактивными лицами (54). Физическая активность, включая аэробные нагрузки, силовые упражнения и сочетание аэробных и силовых упражнений, способствует улучшению вторичных показателей риска прогрессирования (HbA1c, артериального давления, ИМТ и липидов) у взрослых, страдающих диабетом 2-го типа (35). Например, недавнее исследование показало, что упражнения на сопротивление помогают активнее снижать HbA1c в сравнении с контрольными группами и что тренировки на сопротивление высокой интенсивности оказывают большое позитивное воздействие на уровень инсулина натощак (107). При этом не имеется достаточных фактических данных для оценки влияния физической активности на качество жизни, обусловленное состоянием здоровья, и на физическое функционирование у взрослых, страдающих диабетом 2-го типа. Физическая активность лиц, страдающих ВИЧ-инфекцией, улучшает их кардиореспираторное здоровье. Рассмотренные мероприятия включали в себя либо аэробные нагрузки, либо тренировки в сочетании с постепенным добавлением силовых упражнений в течение как минимум 30 минут три раза в неделю (108, 109). Имеются также данные о том, что занятия физически активной деятельностью могут улучшить показатели маркеров кардиометаболического риска (например, липидов), хотя полученные результаты неоднозначны; не был установлен факт воздействия на концентрацию инсулина, но при этом содержание глюкозы после аэробной нагрузки снижалось (110). Физическая активность лиц, страдающих ВИЧ-инфекцией, — как аэробная, так и комбинируемая с силовыми упражнениями — имеет несомненную связь с их качеством жизни, обусловленным состоянием здоровья (111), и со снижением симптомов депрессии и тревоги (112). Метаанализ проблем депрессии (9 исследований) показал величину СМД = 0,84 (95% ДИ: 1,57–0,11), благоприятную для физически активных групп (p= 0,02). Показатель СМД для снижения симптомов тревоги (5 исследований) также был статистически значимым и подтверждал целесообразность активности ( 1.23 [95% ДИ: 2,42–0.04], p= 0,04) (112). Кроме того, физическая активность приводит к заметному увеличению разности стандартизированных средних показателей сухой мышечной массы (1,75 кг) и значительному снижению доли телесного жира (на 1,12%) у участников физически активных контрольных групп, а также к росту периферийных мышц ног и рук в сравнении с участниками неактивных контрольных групп (111); при этом она не влечет изменений ИМТ или окружности талии у лиц, страдающих ВИЧ-инфекцией (111). Физическая активность не оказывает вредного воздействия ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) 54 55 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и на маркеры прогрессирования ВИЧ-инфекции, такие как число CD4-клеток (клеток на 1 мм3) или вирусная нагрузка (111). Важно отметить, что, согласно этим данным, физическая активность не будет способствовать подавлению ВИЧ как хронического заболевания. Выводы ГРР • Получены фактические данные среднего уровня достоверности о том, что увеличение объема физической активности после диагностики рака приводит к снижению рисков смертности от всех причин, от конкретных причин и от определенных онкологических заболеваний среди лиц, переживших рак. • Получены фактические данные высокого уровня достоверности о том, что физическая активность снижает риск прогрессирования сердечно- сосудистых заболеваний у взрослых, страдающих гипертонией. • Получены фактические данные среднего уровня достоверности о том, что физическая активность улучшает у взрослых, страдающих гипертонией, показатели физического функционирования и качества жизни, обусловленного состоянием здоровья. • Получены фактические данные высокого уровня достоверности о том, что физическая активность улучшает показатели маркеров прогрессирования заболевания (HbA1c, артериального давления, ИМТ и липидов) у взрослых, страдающих диабетом 2-го типа. • Получены фактические данные среднего уровня достоверности о наличии взаимосвязи между физической активностью и улучшением физического здоровья (максимального потребления кислорода, переносимости нагрузки) и мышечной силы у лиц, страдающих ВИЧ-инфекцией, и о наличии благоприятной взаимосвязи между физической активностью и составом тканей организма, качеством жизни, обусловленным состоянием здоровья, сокращением симптомов депрессии и тревоги и отсутствием изменений в вирусной нагрузке или числе CD4-клеток у лиц, страдающих ВИЧ-инфекцией. • Польза от занятий регулярной физически активной деятельностью для лиц, переживших рак, и лиц, страдающих гипертонией, диабетом 2-го типа и ВИЧ-инфекцией, в части улучшения конкретных показателей здоровья перевешивает смежные риски. Имеется ли взаимосвязь «доза-ответ» (объем, продолжительность, регулярность, интенсивность)? Повышение объема физической активности после диагностики рака приводит к снижению рисков смертности от всех причин и от онкологических заболеваний. Фактические данные указывают на наличие нелинейной взаимосвязи между увеличением постдиагностической физической активности и показателями смертности от рака молочной железы ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) и от всех причин до 10–15 MET-часов в неделю (что согласуется с физической нагрузкой средней и высокой интенсивности продолжительностью 150 минут в неделю) без подтверждения причинения вреда на более высоких уровнях активности (105). Предполагается наличие аналогичной взаимосвязи «доза-ответ» при других локализациях рака, однако немногочисленность состоявшихся исследований не позволяет провести формальный метаанализ. Для выявления степени прочности этой взаимосвязи необходимо дальнейшее исследование. Налицо явная взаимосвязь «доза-ответ» между физической активностью и смертностью от сердечно-сосудистых заболеваний среди лиц, страдающих гипертонией (35). Выводы показывают, что по мере роста систолического артериального давления в гипертонических диапазонах возрастает риск смертности от сердечно-сосудистых заболеваний, однако с наращиванием физической активности этот возросший риск ослабевает (35). По аналогии с рекомендациями для общей популяции основу большинства традиционных мероприятий составляет аэробная нагрузка средней интенсивности продолжительностью 30–60 минут три раза в неделю и/или 2–3 еженедельные тренировки на сопротивление. Получены существенные фактические данные о наличии обратной криволинейной взаимосвязи между объемом физической активности и риском смертности от сердечно- сосудистых заболеваний у взрослых, страдающих диабетом 2-го типа (113–115). Более значительные объемы физической активности (которые ниже, равны или выше рекомендованных 150 минут активной нагрузки средней интенсивности в неделю) постепенно снижают этот риск. Например, в сравнении с полным отсутствием активности занятие той или иной активной деятельностью приводило к снижению риска смертности от сердечно-сосудистых заболеваний на 32% (ОР= 0,68 [95% ДИ: 0,51–0,92]), а занятие физически активной деятельностью в объеме, который соответствует рекомендациям по физической активности или превышает их, обеспечивало снижение риска смертности от сердечно-сосудистых заболеваний на 40% (ОР= 0,60 [95% ДИ: 0,44–0,82]) (115). Основу большинства мероприятий составляет аэробная нагрузка средней интенсивности продолжительностью 150–300 минут или нагрузка высокой интенсивности продолжительностью 75 минут и/или 2–3 тренировки на сопротивление в неделю. По некоторым показателям (например, HBA1c и артериальному давлению) у взрослых, страдающих диабетом 2-го типа, имеются фактические данные о более заметном эффекте большего объема аэробной нагрузки (т. е. более чем 150 минут в неделю в сравнении с менее чем 150 минут в неделю), но при этом данные по интенсивности нагрузки носят ограниченный характер (35). В отношении лиц, страдающих ВИЧ-инфекцией, не было получено достаточных фактических данных для установления взаимосвязи «доза-ответ» между физической активностью и составом тканей организма или косвенными маркерами кардиометаболических заболеваний (такими как липидные профили крови, инсулинорезистентность, 54 55Рекомендации содержание глюкозы в крови натощак или артериальное давление). В большинстве исследований, послуживших источником данных, рассматривались мероприятия по физической активности, которые проводились не реже трех раз в неделю в течение 12–48 недель и представляли собой только аэробную нагрузку средней и высокой интенсивности не менее 30 минут или сочетание аэробной нагрузки с постепенными тренировками на сопротивление. В этом случае также нет достаточных фактических данных для более точного установления взаимосвязи «доза-ответ» между физической нагрузкой и показателями психического здоровья и качества жизни, обусловленного состоянием здоровья. Имеющиеся данные взяты из исследований, которые, как правило, посвящены оценке мероприятий по физической активности, проводимых не реже трех раз в неделю. В целом были получены фактические данные от среднего до высокого уровня достоверности, которые подтверждают рекомендацию о физической активности средней интенсивности (или ее эквивалента) продолжительностью 150–300 минут для определенных групп населения, страдающих хроническими заболеваниями, и конкретного комплекса показателей здоровья. В фактических материалах относительно лиц, страдающих гипертонией и диабетом 2-го типа, и лиц, переживших рак, имелись более конкретные данные о том, что повышенные уровни физической активности приносят больше пользы. Была отмечена вариативность в уровнях достоверности и прямоты данных в зависимости от рассматриваемой конкретной хронической патологии и определенных показателей здоровья. В случаях, когда имеющиеся данные указывали на позитивный эффект силовых упражнений, регулярность нагрузок составляла 2–3 тренировки на сопротивление в неделю. Выводы ГРР • Получены фактические данные среднего уровня достоверности о наличии взаимосвязи «доза-ответ» между физической активностью и снижением смертности от всех причин и смертности от онкологических заболеваний у лиц, переживших рак. • Получены фактические данные высокого уровня достоверности о наличии взаимосвязи «доза-ответ» между физической активностью и смертностью от сердечно-сосудистых заболеваний у взрослых, страдающих гипертонией. • Получены фактические данные о наличии обратной криволинейной взаимосвязи «доза-ответ» между объемом активной деятельности и риском смертности от сердечно-сосудистых заболеваний среди взрослых, страдающих диабетом 2-го типа. • Не имеется достаточных фактических данных о наличии взаимосвязи «доза-ответ» между физической активностью и косвенными маркерами кардиометаболических заболеваний, составом тканей организма и качеством жизни, обусловленным ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) состоянием здоровья, симптомами тревоги и депрессии у лиц, страдающих ВИЧ-инфекцией. • Аэробная физическая активность средней интенсивности (или ее эквивалент) в течение 150–300 минут обеспечивает благоприятные показатели здоровья; были также отмечены позитивные эффекты силовых упражнений при еженедельном проведении 2-3 тренировок на сопротивление. Варьируется ли эта взаимосвязь в зависимости от вида или области физической активности? Имеющиеся фактические данные подтверждают, что различные виды и области физической активности оказывают благоприятное воздействие на показатели здоровья. Лица, пережившие рак, которые соблюдают рекомендуемые уровни аэробной и силовой нагрузки, в сравнении с не соблюдающими никаких рекомендаций лицами значительно снижают риск смертности от рака (ОР= 0,70 [95% ДИ: 0,50–0,98]) (84). Данные показывают, что выполнение одной лишь рекомендации в отношении силовой физической активности в сравнении с невыполнением рекомендаций также приводит к снижению показателей смертности от рака (ОР= 0,66 [95% ДИ: 0,48–0,92]) (84). В результатах одного из метаанализов также сообщалось о наличии таких взаимосвязей в разбивке по областям физической активности; в нем были отмечены наиболее существенные снижения смертности от всех онкологических заболеваний, рака молочной железы и колоректального рака, достигнутые благодаря рекреационной физической активности (105). В отношении взрослых, страдающих от гипертонии, фактические данные подтверждают, что аэробная активность, силовые упражнения и сочетание этих двух видов нагрузки способствуют замедлению прогрессирования сердечно-сосудистых заболеваний. Что касается понижающего воздействия на артериальное давление, обеспечиваемого двумя традиционными видами физической активности (т. е. аэробной активностью и тренировками на сопротивление), то оно, как представляется, не показывает заметной вариативности среди лиц, страдающих гипертонией (35); эти данные, однако, не являются следствием прямого сопоставления двух указанных видов нагрузки. Кроме того, появляются данные, подтверждающие благотворное влияние других видов упражнений для лиц, страдающих гипертоний (например, тайцзи, йога, цигун), однако для изучения этих особых видов активности и определения прочности взаимосвязи необходимо дальнейшее исследование. Aэробная нагрузка, силовые упражнения или их сочетание приводят к улучшению вторичных показателей риска прогрессирования заболевания (HbA1c, артериального давления, ИМТ и липидов) среди взрослых, страдающих диабетом 2-го типа (35, 107). В обзоре материалов 24 РКИ (n= 962) сообщалось, что тренировки на сопротивление позволяют активнее снижать показатель HbA1c по сравнению с контрольными группами (РС= 0,45 [95% ДИ: 0,65–0,25], 20 испытаний; n= 824). При упражнениях на сопротивление высокой интенсивности в сравнении с контрольными группами были обнаружено статистически значимое воздействие на уровень инсулина натощак (РС= 4,60 56 57 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и [95% ДИ: 7,53–1,67], 5 испытаний; n= 174) (107). Еще один обзор, охватывавший 7 РКИ (n= 189), показал, что интервальные тренировки (2–5 раз в неделю, с интервалами 1–4 минуты и общей продолжительностью 20–60 минут) позволяют добиться статистически значимых снижений HbA1c на 0,26% (95% ДИ: 0,46–0,07%, 5 РКИ) по сравнению с группами средней активности и на 0,83% (95% ДИ: 1,39%–0.27%, 4 РКИ) — с неактивными контрольными группами (116). По аналогии с рекомендациями для общей популяции основу большинства этих мероприятий составляют аэробная физическая активность, соответствующая рекомендации относительно аэробной нагрузки средней интенсивности продолжительностью 150–300 минут (или 75 минут высокой интенсивности), и силовые упражнения в виде 2–3 тренировок в неделю. Имеются фактические данные о росте воздействия на некоторые показатели (например, HBA1c и артериальное давление) при увеличении аэробной нагрузки (т. е. более 150 минут в неделю по сравнению с нагрузкой менее 150 минут в неделю), однако сведения об интенсивности носят ограниченный характер. Результаты более поздних исследований показывают, что традиционная китайская гимнастика, например тайцзи, может способствовать снижению уровня глюкозы в крови, однако эти данные имеют средний и вариативный уровень достоверности (т. е. подвержены риску необъективности или непоследовательности). Для определения этих взаимосвязей необходимо дальнейшее исследование. Было доказано, что различные виды физической активности лиц, страдающих ВИЧ-инфекцией, в частности аэробная нагрузка и упражнения на сопротивление, позитивно воздействуют на качество жизни, обусловленное состоянием здоровья (111). Результаты недавнего исследования изменений качества жизни, обусловленного состоянием здоровья, которые были достигнуты благодаря аэробным нагрузкам, постепенному включению упражнений на сопротивление или обоих этих видов нагрузки, указывают на существенные улучшения общего состояния здоровья и психического здоровья. Имеются также фактические данные о том, что как аэробная, так и многокомпонентная физическая активность влияют на снижение симптомов депрессии и тревоги у лиц, страдающих ВИЧ-инфекцией (112). Данные о воздействии физической активности на показатели психического здоровья касались применения только аэробной нагрузки или сочетания аэробной нагрузки ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) с постепенными силовыми упражнениями или йогой. Полученные материалы также показывают, что аэробная нагрузка — отдельно или в сочетании с упражнениями на сопротивление — не вызывает значительных изменений вирусной нагрузки или числа CD4-клеток у лиц, страдающих ВИЧ-инфекцией (111). Непосредственные фактические данные, взятые как из имеющихся, так и из обновленных публикаций, подтверждают целесообразность включения рекомендаций для лиц, страдающих диабетом 2-го типа и гипертонией, согласно которым им следует заниматься аэробной и силовой физически активной деятельностью. Несмотря на нехватку опубликованных данных, налицо биологическое правдоподобие благотворного влияния аэробных и силовых нагрузок на состояние взрослых, страдающих ВИЧ- инфекцией, и лиц, переживших рак. С другой стороны, как отметила ГРР, общепринятые международные рекомендации по клинической практике предписывают этим группам населения занятие аэробной и силовой физически активной деятельностью (например, рекомендации ACSM «Moving Through Cancer» (101), составленные на основе систематического обзора фактических данных (3)). С учетом предварительного характера этих данных уровень их достоверности был понижен. Выводы ГРР • Получены фактические данные среднего уровня достоверности о совокупном или аддитивном воздействии аэробных или силовых упражнений на снижение смертности от рака, а также на улучшение артериального давления у лиц, страдающих гипертонией. • Получены фактические данные высокого уровня достоверности о том, что аэробная нагрузка, силовые упражнения, а также сочетание аэробных и силовых упражнений улучшают состояние маркеров прогрессирования заболевания (HbA1C, артериального давления, ИМТ и липидов) у взрослых, страдающих диабетом 2-го типа. • Получены фактические данные среднего уровня достоверности о том, что регулярные занятия аэробной физически активной деятельностью отдельно или в сочетании с упражнениями на сопротивление не вызывают значительных изменений вирусной нагрузки или числа CD4-клеток у лиц, страдающих ВИЧ-инфекцией. • Имеются недостаточные фактические данные о том, что лица, страдающие ВИЧ-инфекцией, могут одними силовыми тренировками воздействовать на качество жизни, обусловленное состоянием здоровья. 56 57Рекомендации Подтверждающие фактические данные и обоснование Из-за нехватки материалов по отдельным группам населения базой первичных фактических данных для оценки взаимосвязи между малоподвижным образом жизни и показателями здоровья взрослых и пожилых людей, переживших рак, а также взрослых и пожилых людей, страдающих гипертонией, диабетом 2-го типа и ВИЧ-инфицированных, являлась научная литература, которая была подобрана и пересмотрена для взрослых групп населения. Были пересмотрены выводы, сделанные на основе данных о малоподвижном образе жизни по всем группам взрослого населения, включая решение вопроса о том, имеются ли данные, согласно которым соответствующие результаты будут в отношении взрослых и пожилых людей с хроническими патологиями чем-либо отличаться, окажутся для них неприменимыми или будут им противопоказаны. Особо малоподвижный образ жизни взрослых, в том числе лиц, переживших рак, и лиц, страдающих гипертонией и диабетом 2-го типа, а также ВИЧ-инфицированных, ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также росту масштабов распространения сердечно-сосудистых заболеваний, рака и диабета 2-го типа. Лицам, пережившим рак, а также взрослым, страдающим гипертонией, диабетом 2-го типа и ВИЧ-инфицированным рекомендуется следующее. Взрослым и пожилым людям с хроническими патологиями следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, низкая степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии взрослым и пожилым людям с хроническими патологиями следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней и высокой интенсивности. Настоятельная рекомендация, низкая степень достоверности данных Малоподвижный образ жизни не был включен в Глобальные рекомендации ВОЗ по физической активности для здоровья 2010 г. (1). Охват этой новой рекомендации относительно малоподвижного образа жизни распространяется на лиц, переживших рак, и на лиц, страдающих гипертонией, диабетом 2-го типа и ВИЧ-инфекцией. Малоподвижный образ жизни определяется как время, проводимое в состоянии бодрствования в положениях сидя или лежа при низком расходе энергии в профессиональном, образовательном, домашнем и общинном контексте и при передвижении. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО МАЛОПОДВИЖНОГО ОБРАЗА ЖИЗНИ ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) 58 59 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и На основе имеющихся материалов и экспертных заключений эти фактические данные были экстраполированы с целью учета в новых рекомендациях ВОЗ относительно малоподвижного образа жизни для взрослых с хроническими патологиями по единому комплексу важнейших показателей здоровья. Главным основанием для экстраполяции этих данных служит вывод о том, что охват большинства исследований не предусматривал верхнего возрастного предела, включал в себя взрослых старше 65 лет и мог включать взрослых с хроническими патологиями, таких как лица, пережившие рак, и лица, страдающие гипертонией или диабетом 2-го типа. В связи с лицами, страдающими ВИЧ-инфекцией, не было выявлено никаких причин, в силу которых к ним не могли бы применяться данные о воздействии малоподвижного образа жизни на здоровье. Поскольку эти фактические данные имеют косвенное отношение к разработке указанных рекомендаций, уровень их достоверности был понижен. Кроме того, сведения о применимости фактических данных о пользе увеличения объема физически активной деятельности средней и высокой интенсивности для противодействия возможным рискам особо малоподвижного образа жизни были рассмотрены и также экстраполированы с целью учета в рекомендациях для взрослых с хроническими патологиями по единому комплексу важнейших показателей здоровья. Ввиду косвенного характера фактических данных уровень их достоверности был понижен. Выводы ГРР • Фактические данные о малоподвижном образе жизни во всех группах взрослого населения могут экстраполироваться и учитываться при составлении рекомендаций для взрослых и пожилых лиц, переживших рак, а также для взрослых и пожилых лиц, страдающих гипертонией, диабетом 2-го типа и ВИЧ-инфекцией, по единому комплексу важнейших показателей здоровья, но с понижением уровня достоверности этих данных ввиду их косвенного характера. • Фактические данные о пользе увеличения объема физически активной деятельности средней и высокой интенсивности для противодействия возможным рискам особо малоподвижного образа жизни во всех группах взрослого населения могут экстраполироваться и учитываться при составлении рекомендаций для взрослых и пожилых лиц, переживших рак, а также для взрослых и пожилых лиц, страдающих гипертонией, диабетом 2-го типа и ВИЧ-инфекцией, по единому комплексу важнейших показателей здоровья, но с понижением уровня достоверности этих данных ввиду их косвенного характера. • Польза от минимизации объема малоподвижного образа жизни перевешивает риски для лиц, переживших рак, и лиц, страдающих гипертонией, диабетом 2-го типа и ВИЧ-инфекцией. ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) 58 59Рекомендации ДЕТИ И ПОДРОСТКИ (в возрасте 5–17 лет) И ВЗРОСЛЫЕ (в возрасте 18 лет и старше) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ Во многих случаях физическая активность приносит детям и подросткам с ограниченными возможностями такую же пользу для здоровья, которую, как отмечалось в разделе выше, она приносит всем детям и подросткам. Дополнительная польза физической активности в улучшении показателей здоровья людей с ограниченными возможностями также заключается в том, что улучшаются когнитивные способности лиц с заболеваниями и расстройствами, связанными с нарушением когнитивных функций, в том числе лиц с синдромом дефицита внимания/гиперактивности (СДВГ); у детей с ограниченными интеллектуальными возможностями могут улучшаться показатели физического функционирования. В этой связи рекомендуется следующее. Детям и подросткам еженедельно следует посвящать в среднем не менее 60 минут в день занятиям физически активной деятельностью, в основном аэробным нагрузкам средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Физически активной деятельностью с аэробной нагрузкой высокой интенсивности, в том числе направленной на укрепление скелетно-мышечной системы, следует заниматься не реже трех раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных Физическая активность может быть весьма полезна для здоровья детей, подростков и взрослых с ограниченными возможностями. Детям, подросткам и взрослым с ограниченными возможностями следует стараться выполнять эти рекомендации по мере возможности и сообразно своим способностям. Дети, подростки и взрослые с ограниченными возможностями могут заниматься физически активной деятельностью в рамках отдыха и досуга (подвижные игры, занятия спортом или плановые тренировки), физического воспитания, передвижений (использование колесных средств, ходьба и езда на велосипеде) или выполнения домашних обязанностей, то есть в домашнем, образовательном, профессиональном и общинном контексте. Важно обеспечить всем детям, подросткам и взрослым с ограниченными возможностями перспективы и стимулы для участия в физически активной деятельности, которая соответствует их возрасту и способностям, увлекательна и разнообразна. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО ФИЗИЧЕСКОЙ АКТИВНОСТИ П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я • небольшая физическая активность лучше, чем ее полное отсутствие; • если дети и подростки с ограниченными возможностями не выполняют эти рекомендации, любые занятия физически активной деятельностью пойдут на пользу их здоровью; • детям и подросткам с ограниченными возможностями следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • занятия физически активной деятельностью для детей и подростков с ограниченными возможностями не связаны с какими-либо серьезными рисками, если они соответствуют текущему уровню физической подготовки, состоянию здоровья и показателям физического функционирования конкретного ребенка, а полученная в итоге польза для здоровья перевешивает возможные риски; • дети и подростки с ограниченными возможностями могут нуждаться в консультации медицинского работника или другого специалиста по вопросам физической активности и работе с лицами с ограниченными возможностями для определения видов и объема физических нагрузок, которые им подходят. П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я 60 61 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Во многих случаях физическая активность приносит взрослым с ограниченными возможностями такую же пользу для здоровья, которую, как отмечалось в разделе выше, она приносит всем взрослым. Дополнительная польза физической активности в улучшении показателей здоровья людей с ограниченными возможностями также заключается в следующем: у взрослых, страдающих рассеянным склерозом, улучшаются показатели физического функционирования, а также физические, психические и социальные аспекты качества жизни, обусловленного состоянием здоровья; у лиц с повреждениями спинного мозга улучшается функция ходьбы, повышается мышечная сила и улучшается функция верхних конечностей; а также улучшается качество жизни, обусловленное состоянием здоровья; у людей с заболеваниями или расстройствами, связанными с нарушением когнитивных функций, улучшаются показатели физического функционирования и когнитивной деятельности (у лиц с болезнью Паркинсона и лиц, имеющих в анамнезе инсульт); оказывается положительное воздействие на когнитивную деятельность; а также может улучшаться качество жизни (у взрослых, страдающих шизофренией); могут улучшаться показатели физического функционирования (у взрослых с ограниченными интеллектуальными возможностями); и улучшается качество жизни (у взрослых, страдающих большим депрессивным расстройством). В этой связи рекомендуется следующее. Всем взрослым с ограниченными возможностями следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Взрослым с ограниченными возможностями следует не менее 150–300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75–150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Чтобы занятия приносили дополнительную пользу для здоровья, взрослым с ограниченными возможностями также следует выполнять силовые упражнения средней и большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных В ходе еженедельных занятий физически активной деятельностью в целях повышения функциональных возможностей и предотвращения риска падений пожилым людям с ограниченными возможностями следует не реже трех раз в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней и большей интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Взрослые с ограниченными возможностями могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, чтобы занятия приносили дополнительную пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных ДЕТИ И ПОДРОСТКИ (в возрасте 5–17 лет) И ВЗРОСЛЫЕ (в возрасте 18 лет и старше) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я • небольшая физическая активность лучше, чем ее полное отсутствие; • если взрослые с ограниченными возможностями не выполняют эти рекомендации, любые занятия физически активной деятельностью пойдут на пользу их здоровью; • взрослым с ограниченными возможностями следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • занятия физически активной деятельностью для взрослых с ограниченными возможностями не связаны с какими-либо серьезными рисками в том случае, когда они соответствуют текущему уровню физической подготовки, состоянию здоровья и показателям физического функционирования конкретного человека, а полученная в итоге польза для здоровья перевешивает возможные риски; • взрослые с ограниченными возможностями могут нуждаться в консультации медицинского работника или другого специалиста по вопросам физической активности и работе с лицами с ограниченными возможностями для определения видов и объема физических нагрузок, которые им подходят. 60 61Рекомендации ДЕТИ И ПОДРОСТКИ (в возрасте 5–17 лет) И ВЗРОСЛЫЕ (в возрасте 18 лет и старше) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ Подтверждающие фактические данные и обоснование При подготовке настоящих рекомендаций в отношении детей, подростков и взрослых с ограниченными возможностями были использованы и обновлены обобщенные фактические данные, собранные PAGAC (35). Имеются подробные сведения о методах работы, извлечении данных и таблицах обобщенного изложения существующих фактических данных о физической активности и показателях здоровья (35); они были пересмотрены усилиями ГРР в дополнение к результатам обновленного поиска. В ходе процедуры обновления, проведенной при подготовке настоящих рекомендаций, было выявлено 39 обзоров, опубликованных в 2017–2019 гг. Из них 27 соответствовали критериям включения и были использованы при анализе взаимосвязи между физической активностью и показателями здоровья среди детей, подростков и взрослых с ограниченными возможностями. С полной информацией о методах работы, извлечении данных и таблицах обобщенных фактических данных можно ознакомиться в веб-приложении «Профили фактических данных» . Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf В пересмотренном фактическом материале анализировалась взаимосвязь между физической активностью и показателями здоровья у детей, подростков и взрослых с ограниченными возможностями, причиной которых явились следующие состояния здоровья: рассеянный склероз, повреждение спинного мозга, ограниченные интеллектуальные возможности, болезнь Паркинсона, инсульт, большое депрессивное расстройство, шизофрения и синдром дефицита внимания/гиперактивности (СДВГ). К четырем рассмотренным показателям здоровья относились риск сопутствующих заболеваний, физическое функционирование, когнитивные функции и качество жизни, обусловленное состоянием здоровья, хотя по каждому состоянию здоровья были исследованы не все результаты. Воздействие факторов окружающей среды на ограниченные возможности лиц в контексте их физической активности не входило в сферу охвата настоящих рекомендаций и не являлось предметом анализа. Какова взаимосвязь между физической активностью и показателями здоровья у детей и подростков (в возрасте 5–17 лет) и взрослых (старше 18 лет) с ограниченными возможностями? У лиц, страдающих рассеянным склерозом, физическая активность улучшает показатели физического функционирования, функциональной мобильности, скорости и выносливости при ходьбе, кардиореспираторного здоровья, силы и равновесия. Например, интервальные тренировки высокой интенсивности в течение 3–12 недель ведут к улучшению кардиореспираторного здоровья или росту мышечной силы (117), силовые упражнения для нижних конечностей ведут к увеличению силы за средний тренировочный период в 13 недель на 23,1% (95% ДИ: 11,8–34,4) (118), и исследования эффективности танцевальных занятий указывают на улучшение функциональной мобильности и равновесия (119). Имеющиеся фактические данные показывают, что наряду с улучшением физического здоровья физическая активность может благоприятно отражаться на когнитивных способностях лиц, страдающих рассеянным склерозом (35). Согласно результатам более позднего исследования, аэробные упражнения оказывают небольшое, но при этом значительное воздействие на физический, психический и социальный аспекты качества жизни, обусловленного состоянием здоровья (в том числе на симптомы усталости и депрессии) (35, 120). У лиц с повреждениями спинного мозга физическая активность способна укрепить функцию ходьбы, мышечную силу и функционирование верхних конечностей (35). Кроме того, физическая активность может привести к снижению плечевых болей, улучшению функции сосудов и повышению качества жизни, обусловленного состоянием здоровья (35). У лиц, страдающих болезнью Паркинсона, физическая активность может обеспечить улучшение моторных симптомов, функциональной мобильности и работоспособности, выносливости, симптомов «замораживания» при ходьбе и скорости движения вперед и назад (35, 121, 122). Согласно новым данным, у лиц с болезнью Паркинсона физические нагрузки также могут способствовать общему улучшению когнитивных функций (123). У лиц, имеющих в анамнезе инсульт, благодаря физической активности можно добиться улучшения следующих параметров: физического функционирования, особенно функции верхних конечностей, сенсорно-моторной функции нижних конечностей, равновесия, скорости ходьбы, проходимого расстояния, умения и выносливости, кардиореспираторного здоровья, мобильности и активности в повседневной жизни. Имеющиеся данные показывают, что физические нагрузки также способны благотворно влиять на когнитивные способности (35). Применительно к лицам с большим депрессивным расстройством результаты новых обзоров (124, 125) потвердили существующие данные (35) о том, что физическая активность способна улучшить их качество жизни, обусловленное состоянием здоровья (35, 124, 125). У лиц с заболеваниями или расстройствами, связанными с нарушением когнитивных функций, включая шизофрению, физические нагрузки могут оказывать полезное воздействие на когнитивные способности, кратковременную память, социальный когнитивный уровень и внимание/ бдительность (35, 126). В одном обзоре было указано, что физически активная деятельность средней и высокой интенсивности обеспечивает существенное улучшение качества жизни, обусловленного состоянием здоровья, и расширяет ограниченные возможности (35, 124). 62 63 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и ДЕТИ И ПОДРОСТКИ (в возрасте 5–17 лет) И ВЗРОСЛЫЕ (в возрасте 18 лет и старше) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ Было установлено, что у лиц с ограниченными интеллектуальными возможностями физическая активность повышает уровень физического функционирования. Рассмотренные активные мероприятия охватывали в основном упражнения на равновесие и силовые упражнения, выполняемые в течение 6–24 недель; было выявлено значительное улучшение статического равновесия, динамического равновесия и статико- динамического равновесия по сравнению с контрольными группами (35, 127, 128). Фактические данные в отношении детей с синдромом дефицита внимания/гиперактивности, включающие обзор пяти РКИ по проблеме СДВГ (129), указывают на позитивную взаимосвязь между физической нагрузкой и вниманием, управляющей функцией и социальными расстройствами (35, 129). ГРР рассмотрела общие данные по детской, подростковой и взрослой популяции и пришла к выводу, что, поскольку нет никаких оснований полагать, что из-за имеющегося нарушения здоровья воздействие нагрузок на организм будет иным, то занятия физически активной деятельностью принесут здоровью такую же физиологическую пользу. ГРР признала, что лица с ограниченными возможностями фигурируют лишь в немногих исследованиях и что изменение воздействия на эту группу редко является предметом испытаний. Эти фактические данные в сфере ограниченных возможностей, дополненные более обширным материалом по общей популяции, послужили основанием для составления общепопуляционной рекомендации, которая распространяется на лиц с ограниченными возможностями с конкретным упоминанием «всех взрослых», «всех пожилых людей» и «людей с любыми способностями». Выводы ГРР Относительно лиц с повреждениями спинного мозга получены: • фактические данные низкого уровня достоверности о том, что физическая активность снижает плечевую боль, улучшает функцию сосудов в парализованных конечностях и повышает качество жизни, обусловленное состоянием здоровья; и • фактические данные среднего уровня достоверности о том, что физические нагрузки укрепляют функцию ходьбы, мышечную силу и функционирование верхних конечностей. Относительно лиц с заболеваниями или расстройствами, связанными с нарушением когнитивных функций, включая болезнь Паркинсона, получены: • фактические данные высокого уровня достоверности о том, что физическая активность улучшает ряд функциональных показателей, в том числе ходьбу, равновесие, силу и двигательную активность в привязке к конкретному заболеванию; и • фактические данные среднего уровня достоверности о том, что физические нагрузки средней и высокой интенсивности могут оказывать благоприятное воздействие на когнитивные способности. Относительно лиц, имеющих в анамнезе инсульт, получены: • фактические данные среднего уровня достоверности о том, что благодаря подвижной физической активности можно добиться позитивного воздействия на физическое функционирование и когнитивные способности. Относительно лиц с заболеваниями или расстройствами, связанными с нарушением когнитивных функций, включая шизофрению, получены: • фактические данные среднего уровня достоверности о том, что физическая активность повышает качество жизни; и • фактические данные высокого уровня достоверности о том, что физические нагрузки средней и высокой интенсивности могут оказывать полезное воздействие на когнитивные способности, кратковременную память, социальный когнитивный уровень и внимание. Относительно взрослых с большим депрессивным расстройством получены: • фактические данные среднего уровня достоверности о том, что физическая активность повышает качество жизни. Относительно взрослых, страдающих рассеянным склерозом, получены: • фактические данные высокого уровня достоверности о том, что физическая активность, в частности аэробные и силовые упражнения, улучшают показатели физического функционирования, функциональной мобильности, скорости и выносливости при ходьбе, кардиореспираторного здоровья, силы и равновесия; • фактические данные среднего уровня достоверности о том, что физически активная деятельность может благотворно влиять на когнитивные способности; и • фактические данные низкого уровня достоверности о том, что физическая активность улучшает качество жизни, в том числе снижает симптомы усталости и депрессии. Относительно детей и взрослых с ограниченными интеллектуальными возможностями получены: • фактические данные низкого уровня достоверности о том, что физически активная деятельность улучшает физическое функционирование. Относительно детей и подростков с СДВГ получены: • фактические данные среднего уровня достоверности о том, что физические нагрузки средней и высокой интенсивности могут позитивно воздействовать на когнитивные способности, включая внимание, управляющую функцию и социальные расстройства. Далее ГРР пришла к выводу, что собраны достаточные научные подтверждения позитивного воздействия физической активности на целый ряд показателей здоровья в широком спектре функциональных нарушений и что польза от физической активности для лиц с ограниченными возможностями перевешивает ее потенциальные отрицательные аспекты. Ввиду косвенного характера фактических данных для разработки этих рекомендаций уровень их достоверности был понижен. 62 63Рекомендации ДЕТИ И ПОДРОСТКИ (в возрасте 5–17 лет) И ВЗРОСЛЫЕ (в возрасте 18 лет и старше) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ Подтверждающие фактические данные и обоснование Малоподвижный образ жизни не был включен в Глобальные рекомендации ВОЗ по физической активности для здоровья 2010 г. Из-за нехватки материалов по отдельным группам населения базой первичных фактических данных для оценки взаимосвязи между малоподвижным образом жизни и показателями здоровья детей, подростков и взрослых с ограниченными возможностями являлась научная литература, которая была подобрана и пересмотрена для групп населения без ограничения возможностей. Были пересмотрены выводы, сделанные на основе данных о малоподвижном образе жизни в общей популяции, включая решение вопроса о том, имеются ли данные, согласно которым соответствующие результаты в отношении детей, подростков и взрослых с ограниченными возможностями будут чем-либо отличаться, окажутся для них неприменимыми или будут им противопоказаны. Особо малоподвижный образ жизни детей и подростков ведет к следующим негативным последствиям для их здоровья: росту ожирения, ухудшению кардиометаболического и физического здоровья и эмоционального/социально ориентированного поведения; а также к сокращению продолжительности сна. В этой связи рекомендуется следующее. Детям и подросткам с ограниченными возможностями следует сокращать продолжительность периодов пребывания в малоподвижном состоянии, в частности досугового экранного времени. Настоятельная рекомендация, низкая степень достоверности данных Особо малоподвижный образ жизни взрослых ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также росту масштабов распространения сердечно-сосудистых заболеваний, рака и диабета 2-го типа. В этой связи рекомендуется следующее. Взрослым с ограниченными возможностями следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, низкая степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии взрослым с ограниченными возможностями следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней и высокой интенсивности. Настоятельная рекомендация, низкая степень достоверности данных Для детей, подростков и взрослых с ограниченными возможностями малоподвижный образ жизни определяется как время, проведенное в период бодрствования в положении сидя или лежа при низком расходе энергии в образовательном, домашнем и общинном контексте и при передвижении. Есть возможность избегать малоподвижного образа жизни и проявлять физическую активность в сидячем или лежачем положении, занимаясь, например, упражнениями для верхней части тела, инклюзивными и/или специальными для кресла-коляски видами спорта и активной деятельности. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО МАЛОПОДВИЖНОГО ОБРАЗА ЖИЗНИ 64 65 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и ДЕТИ И ПОДРОСТКИ (в возрасте 5–17 лет) И ВЗРОСЛЫЕ (в возрасте 18 лет и старше) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ На основе имеющихся материалов и экспертных заключений эти фактические данные были экстраполированы с целью учета в новых рекомендациях ВОЗ относительно малоподвижного образа жизни для лиц с ограниченными возможностями по единому комплексу важнейших показателей здоровья; при этом признавалось, что представители некоторых групп населения, например пользователи кресел-колясок, неизбежно проводят длительное время в положении сидя и что поэтому сидячее положение может являться нормой. Для этих групп малоподвижный образ жизни следует определять как время, проводимое при низком расходе энергии, например при передвижении в кресле-коляске с электроприводом или сидя в кресле-коляске с ручным приводом, которым управляет другое лицо. Количество исследований о взаимосвязи между малоподвижным образом жизни и показателями здоровья в отношении лиц с ограниченными возможностями является недостаточным, но с учетом экспертного заключения нет никаких оснований полагать, что из-за имеющегося нарушения здоровья воздействие нагрузок на организм будет иным; следовательно, ограничение малоподвижного образа жизни у лиц с ограниченными возможностями принесет их здоровью такую же физиологическую пользу. Ввиду косвенного характера фактических данных для разработки этих рекомендаций уровень их достоверности был понижен. Кроме того, сведения о применимости фактических данных о пользе увеличения взрослыми объема физически активной деятельности средней и высокой интенсивности для противодействия возможным рискам особо малоподвижного образа жизни были рассмотрены и также экстраполированы с целью учета в рекомендациях для взрослых с ограниченными возможностями по единому комплексу важнейших показателей здоровья. Ввиду косвенного характера фактических данных уровень их достоверности был понижен. Выводы ГРР • Фактические данные о малоподвижном образе жизни в детских и юношеских популяциях, как правило, могут экстраполироваться применительно к детям и подросткам с ограниченными возможностями в зависимости от их конкретных способностей. • Фактические данные о малоподвижном образе жизни во всех группах взрослого населения, в том числе о пользе увеличения взрослыми объема физически активной деятельности средней и высокой интенсивности для противодействия возможным рискам особо малоподвижного образа жизни, как правило, могут экстраполироваться применительно к взрослым и пожилым людям с ограниченными возможностями в зависимости от их конкретных способностей. Однако уровень достоверности этих данных был понижен ввиду их косвенного характера. • Польза от минимизации объема малоподвижного образа жизни перевешивает риски для детей, подростков, взрослых и пожилых людей с ограниченными возможностями. 64 65Рекомендации Согласно методике GRADE в основу предлагаемых формулировок обновленных рекомендаций и рейтинга их значимости («настоятельная» или «условная») были заложены такие факторы, как баланс между пользой и вредом; достоверность фактических данных; чувствительность к ценностям и предпочтениям лиц, на которых распространяются данные рекомендации; возможное воздействие на гендерные аспекты; справедливость в социальной и здравоохранительной областях; и приемлемость, целесообразность и ресурсные последствия. Эти факторы были рассмотрены применительно к каждой группе населения, но ввиду схожести обсуждавшихся вопросов и соображений они представлены здесь в объединенном виде. Значимость рекомендации определялась прежде всего на основе оценки баланса между ее пользой и вредом. Рекомендации присваивался статус «настоятельная», если баланс между пользой и вредом был оценен для ее целевой группы как существенный, и статус «условная», если баланс между пользой и вредом был незначительным или если в ее выгодах для целевой группы была возможна высокая степень вариативности. Поиск фактических данных о вреде выполнялся непосредственно путем запроса того или иного нового систематического обзора, однако этот ресурс имел ограниченный характер, поскольку основной массив данных сосредоточен на проблемах травматизма и вреда скорее для атлетов высокого уровня и соревнующихся спортсменов, чем для широких слоев населения. Несмотря на ограниченный характер фактического материала, с учетом экспертного заключения было принято решение о том, что риск не превышает незначительного уровня. Фактические данные обычно указывали на то, что польза от физической активности намного перевешивает вред и что занятие физически активной деятельностью может стать важным фактором содействия устранению какой-либо проблемы со здоровьем, особенно для групп населения, находящихся в неблагоприятном положении. Вопросы справедливости в области здравоохранения, целесообразности и приемлемости также были рассмотрены ГРР и стали предметом обсуждения на открытой онлайновой консультации по проектам рекомендаций, которая проводилась с 31 марта по 17 апреля 2020 г. В материалах обследования для участников этой открытой консультации были поставлены конкретные вопросы о балансе между затратами на выполнение рекомендаций для отдельных лиц и правительств, о потенциальной пользе для здоровья и о том, повысят ли данные рекомендации уровень справедливости в сфере здравоохранения. Кроме того, проекты рекомендаций и формуляры для отзыва были направлены странам, которые недавно выразили заинтересованность в разработке НАУЧНОЕ ОБОСНОВАНИЕ РЕКОМЕНДАЦИЙ Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf национальных рекомендаций относительно физической активности или уже приступили к их составлению. Отзывы были получены в формате более 420 представлений для онлайновой консультации и дополнительной подборки отзывов от Европейского регионального бюро ВОЗ, включающей в себя замечания от сотрудничающих центров ВОЗ и государств- членов. Отзывы по итогам консультации были обобщены, проанализированы ГРР и использованы для дальнейшего рассмотрения вопросов о целесообразности, ресурсных последствиях и справедливости в области здравоохранения в рамках консультации с Руководящей группой и ГРР. Решения были приняты консенсусом по итогам обсуждения. ГРР приходила к консенсусу по каждой рекомендации и по вопросу о значимости рекомендации; ранжирования и голосования при этом не требовалось. ОЦЕНКА ДОСТОВЕРНОСТИ ФАКТИЧЕСКИХ ДАННЫХ ГРР использовала методику GRADE для рассмотрения вопроса о достоверности данных первичного исследования по каждому показателю здоровья, определенному в ГМ/ ВСП, и провела оценку общего уровня достоверности фактических данных, учитывая при этом риск необъективности, непоследовательность, неточность, косвенность данных и искаженность публикации по каждому показателю. Таблицы GRADE с подробным указанием такой информации по каждому набору ГМ/ВСП представлены в веб-приложении «Профили фактических данных» . Оценка достоверности фактических данных проводилась на основе общей оценки всех рассматриваемых показателей здоровья с уделением приоритетного внимания показателям смертности от всех причин и смертности от сердечно-сосудистых заболеваний как наиболее важным величинам, за которыми следовали другие клинические показатели (падения, депрессия, когнитивные способности, качество жизни, обусловленное состоянием здоровья, и т. д.), затем — промежуточные показатели (например, кардиометаболические и другие метаболические маркеры), а также вредные факторы. В случаях, когда отдельный пересмотр фактических данных не производился — например, по малоподвижному образу жизни для подгрупп, — прежде всего из-за нехватки данных по этим группам, выполнялась экстраполяция фактического материала относительно общей популяции с понижением, когда это признавалось целесообразным, уровня достоверности материала ввиду его косвенного характера. ПОЛЬЗА И ВРЕД Процесс разработки рекомендаций предусматривал проведение оценки вредных последствий или рисков. При ограниченности фактических данных решения принимались на основе практического опыта ГРР. В целом 66 67 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и применительно ко всем группам населения был сделан вывод, что польза от физической активности и сокращение времени для малоподвижного образа жизни перевешивают потенциальные вредные факторы. В настоящих рекомендациях, ориентированных на население в целом, не рассматриваются полезные и вредные факторы для спортсменов, практикующих такие виды и объемы активной деятельности, которые необходимы для повышения их физических показателей на соревнованиях. Небольшая физическая активность лучше, чем ее полное отсутствие. Если люди в настоящее время не выполняют эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью. Им следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность. Прохождения предварительного медосмотра перед началом занятий обычно не требуется. Для неактивных людей, которые постепенно повышают физически активную деятельность средней интенсивности, не имеется известных рисков возникновения нежелательных сердечно-сосудистых явлений и присутствует весьма низкий риск травмирования костей, мышц или связок. Лицо, которое регулярно практикует физические нагрузки средней интенсивности, может постепенно повышать их интенсивность до высокого уровня без необходимости консультироваться с врачом. Лицам, у которых при повышении уровня физической активности наблюдается появление новых симптомов, следует обратиться к врачу. Поскольку на выбор соответствующих видов и объемов физической активности могут влиять беременность, хронические патологии и ограниченные возможности, этот выбор нужно делать с учетом своих способностями и при отсутствии противопоказаний. Лица могут получить у специалиста по вопросам физической активности или медицинского работника консультацию относительно видов и объемов физически активной деятельности, которые соответствуют их индивидуальным потребностям, физическим возможностям, функциональным ограничениям/ осложнениям, принимаемым лекарственным средствам и общему плану лечения. Физическая активность низкой и средней интенсивности обычно сопряжена с незначительным риском и рекомендуется для всех. ЦЕННОСТИ И ПРЕДПОЧТЕНИЯ Были рассмотрены ценности и предпочтения лиц, входящих в сферу охвата настоящих рекомендаций (в данном случае это родители, лица для выполнения функций по уходу, дети и подростки, взрослые и пожилые люди, беременные женщины и женщины в послеродовом периоде, лица с хроническими патологиями и/или с ограниченными возможностями). В целом был сделан вывод о незначительности или отсутствии неопределенности по поводу предпочтений в отношении основных показателей, включая смертность вообще и смертность от сердечно-сосудистых заболеваний. Поскольку расчетная потенциальная польза намного перевешивает любой вероятный вред, ГРР в этом смысле сочла, что рекомендации свободны от предпочтений. РЕСУРСНЫЕ ПОСЛЕДСТВИЯ При обсуждении ресурсных последствий выполнения этих рекомендаций в различных условиях учитывались экспертное заключение ГРР и небольшой массив фактических данных о результатах экономического анализа предлагаемых мероприятий и о масштабах экономии средств в системах здравоохранения, которую удастся обеспечить благодаря росту уровней физической активности. Кроме того, по результатам открытой онлайновой консультации более 75% респондентов согласились или твердо согласились с тем, что польза от практического применения рекомендаций перевесит индивидуальные расходы, а 81% опрошенных согласились или твердо согласились с тем, что выгоды от применения рекомендаций на практике будут ощутимее, чем государственные расходы. В имеющихся данных и экспертном заключении признавалось, что существенной пользы для здоровья можно достичь в условиях низкого риска благодаря таким активным занятиям, как ходьба, которая не требует от соответствующего лица ни специальной экипировки, ни каких либо расходов. Далее признавалось, что другие формы физически активной деятельности, например организованные виды спорта, езда на велосипеде и групповые тренировки, могут быть сопряжены с расходами, которые способны стать препятствием для некоторых лиц, особенно для тех, у кого низкий уровень доходов. Осуществление государственной политики и программ по развитию и обеспечению физической активности также требует инвестиций в такие сферы, как людские ресурсы, разработка стратегий, создание инфраструктуры, системы услуг и, возможно, оборудования, часть которых покрывается министерствами здравоохранения, а также в секторы, не связанные с охраной здоровья, такие как спорт, образование, транспорт и городское планирование. Для обеспечения необходимых ресурсов могут потребоваться усилия нескольких уровней власти (национального, субнационального и местного), чтобы создать всем общинам равные условия доступа к занятиям физически активной деятельностью. Эти инвестиции могут обеспечиваться не только с помощью привлечения новых ресурсов, но и путем перераспределения имеющихся бюджетных средств в соответствии с приоритетностью инфраструктур и программ, ориентированных на повышение уровней физической активности населения. Примерами такого бюджетного перераспределения являются направление средств из имеющегося транспортного бюджета на инфраструктуру для ходьбы и езды на велосипеде или из спортивного бюджета — на программу «спорт для всех». В ключевых учреждениях, таких как школы и места работы, проведение малозатратных мероприятий наряду с внесением изменений в обустройство физической среды может стимулировать участие в занятиях физически активной деятельностью, а также способствовать сокращению неравенства возможностей для активного образа жизни, проявляемого в отношении некоторых подгрупп населения. В целом был сделан вывод о том, что, хотя выполнение предлагаемых проектов рекомендаций влечет за собой ресурсные последствия, принятие соответствующих мер является возможным на уровне нынешних структур управления. 66 67Научное обоснование рекомендаций Далее фактические данные подтверждают, что с наращиванием физической активности населения перед системой здравоохранения открываются перспективы существенной экономии средств в сфере медицинского обслуживания. По оценочным данным, в 2013 г. суммарный годовой объем расходов, связанных с недостаточной физической активностью, составил 54 млрд долл. только в части прямых расходов на медицинское обслуживание (130); на национальном уровне расходы в связи с неактивностью оцениваются в 1–3% бюджетов здравоохранения (131). В более широком контексте профилактики неинфекционных заболеваний (НИЗ) дополнительные расходы правительственных и неправительственных организаций в связи с осуществлением рекомендаций можно свести к минимуму, если у отдельных лиц будет возможность без особых затруднений включить рекомендуемый объем физической активности в свою повседневную жизнь, или же, по аналогии, если имеющиеся ресурсы в системе первичной и вторичной медико-санитарной помощи, в школах, на рабочих местах или в транспортном секторе можно будет переориентировать на повышение физической активности населения. Aнализ затрат/выгод, связанных с популяризацией физической активности, указывает на положительную доходность инвестиций за 15 лет в части профилактики НИЗ во многих странах, где были подготовлены обоснования инвестиций (132). Такие мероприятия, как проведение просветительских и пропагандистских кампаний, а также консультирование и ориентация по вопросам физической активности, являются соответственно «наиболее выгодным» и «выгодным» вариантами рекомендуемых мер по борьбе с НИЗ на основе обновленного варианта добавления 3 к Глобальному плану действий по профилактике НИЗ и борьбе с ними на 2013–2020 гг. (133). В целом ГРР пришла к выводу, что польза от выполнения рекомендаций перевешивает сопутствующие затраты. Для осуществления рекомендаций по физической активности в отношении лиц с ограниченными возможностями могут потребоваться инвестиции, например на подготовку специалистов по активному образу жизни, адаптированное оборудование, когда оно необходимо, и на обеспечение доступности объектов инфраструктуры. Благодаря этим инвестициям можно способствовать удовлетворению потребностей целого ряда групп населения. Фактические данные указывают на существенное расхождение в масштабах участия в физически активной деятельности между лицами с ограниченными возможностями и остальными лицами, которое объясняется многочисленными препятствиями в доступе, предлагаемым выбором занятий и отношением со стороны других лиц. Для обеспечения всестороннего и эффективного участия лиц с ограниченными возможностями следует применять принципы универсального дизайна. Действуя согласно новаторским подходам, можно преодолеть многие из этих ресурсных последствий, а внедрение принципов универсального дизайна позволит снижать соответствующие затраты в будущем. СПРАВЕДЛИВОСТЬ, ПРИЕМЛЕМОСТЬ И ЦЕЛЕСООБРАЗНОСТЬ В ходе обновления рекомендаций 2010 г. было решено непосредственно включить в них понятие уязвимых групп населения, таких как лица с хроническими патологиями и/или с ограниченными возможностями. В состав ГРР и Руководящей группы входили представители таких групп. ГРР подробно обсуждала каждую рекомендацию, рассматривая вопрос о том, не приведет ли выполнение этой рекомендации к снижению уровня справедливости в области здравоохранения, а также проблемы, связанные с ее осуществлением, чтобы рекомендации не оказали негативного влияния на аспекты равноправия (например, для обеспечения безопасных объектов и возможностей участия в физической активности, которые доступны для всех, включая лиц с ограниченными возможностями, лиц, находящихся в тяжелом социально-экономическом положении, и других социально отчужденных лиц; для устранения гендерных и иных культурных предрассудков, которые могли бы ограничить доступ и возможность участия в физически активной деятельности, и т. п.). В ходе открытой онлайновой консультации 76% респондентов выразили согласие или твердое согласие с тем, что осуществление настоящих рекомендаций может обеспечить уменьшение несправедливости в здравоохранении путем расширения возможностей для всех вести активный образ жизни и улучшать показатели здоровья. Было отмечено, что благоприятная среда имеет ключевое значение для обеспечения участия в физически активной деятельности. Для устранения барьеров на пути участия в физически активной деятельности уязвимых групп, таких как женщины и девочки, находящиеся в тяжелом социально- экономическом положении, и лица с ограниченными возможностями, потребуется всеобъемлющий подход к вопросам подготовки и проведения политики в различных секторах. Лица с ограниченными возможностями имеют худшие показатели здоровья по сравнению с лицами без ограничения возможностей, хотя польза от физической активности намного перевешивает вред и может стать важным фактором улучшения состояния здоровья. Фактические данные указывают на существенное расхождение в масштабах участия в физически активной деятельности между лицами с ограниченными возможностями и остальными лицами, которое объясняется многочисленными препятствиями в доступе, предлагаемым выбором занятий и отношением со стороны других лиц. Многим лицам с ограниченными возможностями нужно создать условия для занятия различными видами физической активности без необходимости адаптировать оборудование или объекты. Тем не менее в целях создания лицам с ограниченными возможностями условий для участия в физически активной деятельности на основе равенства с другими могут потребоваться приобретение адаптированного оборудования, обеспечение доступности объектов и подготовка специалистов по активному образу жизни. 68 69 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Несмотря на многочисленные данные о значении физической активности и на растущий объем информации о влиянии малоподвижного образа жизни на показатели здоровья на всех этапах жизненного цикла, в ходе дискуссий ГРР выявила существенный пробел в данных, которым нужно уделять приоритетное внимание при подготовке будущих рекомендаций. Пробелы в данных по подгруппам населения включали нехватку информации, которая касается: (1) более точных деталей взаимосвязи «доза- ответ» между физической активностью и/или малоподвижным образом жизни и комплексом изучаемых показателей здоровья; (2) благоприятного воздействия на здоровье физически активной деятельности низкой интенсивности и прерывания малоподвижности какой-либо легкой физической нагрузкой; (3) различий в воздействии на здоровье разных видов и областей физической активности (досуг, работа, передвижение, домашнее хозяйство, обучение) и малоподвижного образа жизни (работа, экранное время, просмотр телевизора); и (4) взаимосвязи между физической активностью и временем пребывания в малоподвижном состоянии и показателями здоровья на протяжении всего жизненного цикла. Было также отмечено, что объем данных, поступающих от стран с низким и средним уровнем дохода, данных об экономически неблагополучных и мало обеспеченных услугами общинах и о лицах с ограниченными возможностями и/или с хроническими заболеваниями по-прежнему недостаточен. План или сфера охвата многих исследований не позволяют тестировать изменение воздействия в зависимости от различных социально-демографических факторов (возраста, пола, расы/этнической принадлежности, социально- экономического статуса), которые способны изменить эффект физической активности для здоровья. Такая информация важна для составления более специфических рекомендаций в области общественного здравоохранения и для сокращения диспропорций в отношении здоровья среди более уязвимых групп населения. С более подробной информацией о пробелах в исследованиях, связанных с этими новыми рекомендациями, можно также ознакомиться в изданных публикациях (134). ПОТРЕБНОСТИ В ИССЛЕДОВАНИЯХ 68 69Потребности в исследованиях Цель настоящих рекомендаций — предоставить директивным органам и лицам, занимающимся разработкой программ мероприятий в областях здравоохранения, образования, трудовых и общинных отношений рекомендации о том, сколько времени детям, подросткам, взрослым и пожилым людям следует ежедневно посвящать физически активной деятельности, а также рекомендации о сокращении времени, проводимого в малоподвижном состоянии. При этом подготовка глобальных рекомендаций не является самоцелью: без их распространения и осуществления не удастся достичь перемен в уровнях физической активности. ПРИНЯТИЕ ВОЗ проводит тщательную и масштабную работу по подготовке рекомендаций глобального масштаба (21), предназначенных для использования всеми странами. В настоящих рекомендациях по вопросам физической активности и малоподвижного образа жизни содержатся научно обоснованные рекомендации относительно воздействия физической активности и малоподвижного образа жизни на здоровье людей, которые могут приниматься и использоваться правительствами стран в рамках их национальной политики. Разработка глобальных рекомендаций на фоне проведения масштабных консультаций должна в основном избавить отдельные страны от необходимости расходования ресурсов на проведение длительных научных изысканий. Обзор и принятие настоящих глобальных рекомендаций по вопросам физической активности и малоподвижного образа жизни дает странам оперативную и экономичную возможность для подготовки рекомендаций, ориентированных на местные условия. Принятие настоящих рекомендаций ВОЗ на региональном или национальном уровне обеспечит страны последовательными рекомендациями о физической активности и малоподвижном образе жизни, которые составлены с учетом самых актуальных и передовых научных данных. Кроме того, согласованность рекомендаций, выполняемых в разных странах, упростит наблюдение на национальном уровне, подготовку глобальных оценочных данных по физической активности и малоподвижному образу жизни и проведение межстрановых сопоставлений. В процессе принятия рекомендаций следует рассмотреть вопрос о целесообразности корректировки их содержания с учетом местных особенностей. Одним из элементов принятия рекомендаций и их включения в соответствующий контекст является их перевод на местный язык. Возможно, при этом потребуется изменить примеры видов физической деятельности с учетом местных особенностей и ПРИНЯТИЕ, РАСПРОСТРАНЕНИЕ, ОСУЩЕСТВЛЕНИЕ И ОЦЕНКА использовать такие средства наглядной информации, которые отражают местные культурные традиции, обычаи и ценности. После проведения ряда региональных семинаров с участием соответствующих заинтересованных сторон в настоящее время разрабатывается поэтапный механизм содействия странам в принятии глобальных рекомендаций. Этот механизм может включать в себя соответствующие национальные данные (например, оценочные данные масштабов распространения физической активности); он также обеспечит ускоренный подход к разработке документа с изложением национальных рекомендаций. Упомянутые вспомогательные ресурсы будут размещены на веб-сайте ВОЗ в 2021 г. При рассмотрении вопроса о принятии настоящих рекомендаций целесообразно выполнить следующую десятиступенчатую процедуру: (1) пропагандировать пересмотр текущих национальных рекомендаций o физической активности и принятие рекомендаций ВОЗ, чтобы добиться разрешения на уровне правительства; (2) привлечь основные заинтересованные стороны как в секторе здравоохранения, так и в других соответствующих секторах, таких как спортивный, образоватeльный и транспортный; привлечь профильные профессиональные ассоциации и ученые круги с необходимым практическим опытом; (3) провести оценку применимости, приемлемости и целесообразности рекомендаций; (4) адаптировать рекомендации к местному контексту, включая язык, примеры и другие культурологические факторы; (5) провести внешний обзор с целевыми пользователями, включая директивные органы, специалистов- практиков и широкую общественность; (6) сформировать бюджет и составить четкий план кампаний по распространению и информированию; (7) опубликовать и популяризировать национальные рекомендации, в идеале —наряду с проведением презентационного мероприятия для обеспечения общественного резонанса и заинтересованности; (8) привлечь соответствующие профессиональные органы или организации и поддержать согласование и/или одобрение проводимой политики; (9) проводить на национальном уровне стратегические и практические мероприятия в поддержку осуществления национальных рекомендаций и поведенческих изменений; (10) согласовать график оценки, пересмотра и обновления рекомендаций. 70 71 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и РАСПРОСТРАНЕНИЕ Национальные рекомендации по вопросам физической активности являются одним из ключевых элементов комплексного подхода органов государственного управления к решению вопроса о повышении уровня физической активности населения. Национальные рекомендации служат основой при разработке и определении первоочередных задач в процессе планирования национальных и субнациональных стратегий и требуют надлежащего распространения точной информации среди соответствующих групп населения. К сожалению, национальные рекомендации слишком часто не получают должного распространения, вследствие чего осведомленность о них как в профессиональных кругах, так и среди широкой общественности остается на весьма низком уровне. Обеспечение специально выделенных ресурсов для содействия широкомасштабному распространению рекомендаций — первый значимый шаг на пути повышения уровня осведомленности и знаний о важности повышения физической активности и сокращения малоподвижного образа жизни. K основным целевым группам для распространения национальных рекомендаций о физической активности и малоподвижном образе жизни относятся: • директивные органы в секторе здравоохранения и за его пределами (в том числе транспорт, планирование, образование, места работы, спорт, парковое хозяйство и досуг) — для наращивания: (a) объема знаний о возможном влиянии роста физической активности и сокращения малоподвижного образа жизни на улучшение состояния не только здоровья, но и ряда разнообразных и при этом актуальных сфер, включая гендерное равенство, правозащитные обязанности и устойчивое развитие; (b) интеграции стратегий и программ, касающихся физической активности и малоподвижного образа жизни, во все соответствующие направления политики; и (c) инвестиций в расширение и координацию национальных и местных мероприятий; • негосударственные субъекты (в том числе неправительственные организации, академические и научно-исследовательские организации, частный сектор, средства массовой информации и учреждения по финансированию научных исследований) — в целях: (a) пропаганды важности роста физической активности и сокращения малоподвижного образа жизни во всех возрастных группах; (b) поощрения и обеспечения согласованности политики; и (c) активизации сотрудничества и инвестиций в сферу проведения политики и местных мероприятий; • специалисты-практики сектора здравоохранения и других секторов (включая спорт, образование, транспорт и планирование) — для повышения: (a) уровня осведомленности и знаний о национальных рекомендациях, касающихся физической активности и малоподвижного образа жизни; (b) уровня знаний, навыков и доверия в связи с популяризацией роста физической активности и сокращения малоподвижного образа жизни; и (c) уровня интеграции аспектов популяризации физической активности в обычную практику, когда это применимо; • широкая общественность и отдельные подгруппы населения — для повышения: (a) уровня осведомленности и знаний о рекомендациях, касающихся физической активности и малоподвижного образа жизни; (b) уровня знаний о том, как выполнять рекомендации относительно физической активности и малоподвижного образа жизни; и (c) уровня намерений и заинтересованности в наращивании физической активности и сокращении малоподвижного образа жизни. ИНФОРМАЦИОННЫЕ КАМПАНИИ Разнообразные материалы принесут пользу различным заинтересованным сторонам; для эффективного доведения рекомендаций до сведения многочисленных целевых групп необходимо учитывать содержание, формат и каналы распространения рекомендаций. При разработке информационной стратегии для популяризации каких-либо рекомендаций проведение формативного исследования может способствовать выявлению основных аудиторий и осмыслению ценностей, потребностей и предпочтений, которые оказывают влияние на уровни физической активности и малоподвижного образа жизни. При этом нужно исследовать препятствия для физической активности или для интеграции физической активности в сферу политики и практики, а также тестировать проекты сообщений и материалов для различных групп. Эти меры будут способствовать подбору основных используемых положений, а также соответствующего формата/ форматов и канала/каналов для распространения информации. Всеобъемлющая информационная стратегия будет включать в себя широкий спектр сообщений, ориентированных на различные аудитории. Возможно, некоторым странам потребуется уделять приоритетное внимание конкретным группам с учетом имеющихся ресурсов (людских и финансовых). Информационные кампании по вопросам физической активности, рассчитанные на широкую общественность или на определенные подгруппы населения, являются затратоэффективными мероприятиями (133) и рекомендуются в Глобальном плане действий ВОЗ по повышению уровня физической активности на 2018–2030 гг. (14). Национальные и субнациональные кампании по вопросам физической 70 71Принятие, распространение, осуществление и оценка активности, как правило, предполагают наличие основного лозунга кампании (например, «Будьте активны» или «Больше двигайтесь») и подготовку дизайновых элементов или знаков, которые могут содержать целевые обращения к различным аудиториям (таким как дети младшего возраста, подростки, взрослые или пожилые люди, менее активные группы, лица с ограниченными возможностями или с хроническими патологиями). Призывы и информационные ресурсы кампании, которые ориентированы на определенные группы населения, наверняка окажут более эффективное воздействие по сравнению с материалами общего характера. При проведении информационных кампаний нужно учитывать охват и эффективность медийных средств — как традиционных (телевидение, радио, рекламные щиты и печатные ресурсы), так и цифровых (веб-сайты, мобильные телефоны и приложения). Не менее полезно предоставлять сведения о национальных рекомендациях в широком спектре форматов. Например, сравнительно новым, но все более распространенным способом популяризации рекомендаций о физической активности является использование инфографики или коротких анимационных видеоклипов. ВОЗ располагает вспомогательными материалами для подготовки и проведения таких информационных кампаний (135). Академические и научно-исследовательские круги наверняка заинтересованы в получении научного доклада с подробным изложением эпидемиологических данных, на которых основаны настоящие рекомендации. При этом специфические детали исследований, легших в основу рекомендаций, вряд ли будут интересны более широкой аудитории. Директивные органы могут предпочесть резюме научных данных или даже какой-либо краткий обобщающий документ. Другие целевые группы, например специалисты сектора здравоохранения и иных секторов, более склонны рассматривать различные виды ресурсов, такие как брошюра или информационный бюллетень о самих рекомендациях или о методах включения аспектов популяризации физической активности в повседневную практику (например, в процедуру приема пациентов в учреждениях здравоохранения или в разработку планов строительства или транспорта для городской среды). Специалисты из разных областей будут заинтересованы в получении ресурсов, которые соответствуют их профилю. В частности, представители медицинских профессий могут воспользоваться подборкой ресурсов, отражающих специфику тех групп населения, с которыми они работают. ОСУЩЕСТВЛЕНИЕ ПОЛИТИКИ И ПРОГРАММ Поскольку сами по себе национальные рекомендации относительно физической активности и малоподвижного образа жизни вряд ли приведут к повышению уровня физической активности населения, их следует рассматривать в качестве одного из элементов политики и концепции планирования. Крайне важно, чтобы национальные рекомендации распространялись среди ключевых аудиторий и опирались на долгосрочную национальную стратегию распространения информации, которая обеспечит рост уровня осведомленности и знаний о многочисленных преимуществах регулярной физической активности и сокращения масштабов малоподвижного образа жизни. Однако для достижения устойчивых перемен в образе жизни эти мероприятия должны подкрепляться мерами политики, создающими благоприятные условия, которые открывают перед людьми возможности и стимулируют их заниматься физически активной деятельностью, наряду с расширением соответствующих местных возможностей для людей участвовать в физически активных мероприятиях. Политика и программы должны учитывать местные особенности и адаптироваться к ним с точки зрения не только системы здравоохранения, но и комплексных многоотраслевых структур, заинтересованных и играющих определенную роль в оказании содействия повышению уровня физической активности. Действовать нужно в рамках общегосударственного подхода, учитывая при этом «систему» мер политики и разнообразных действий, которые могли бы при взаимодействии с широким спектром заинтересованных сторон поддерживать людей на пути к повышению физической активности в самых разных секторах и условиях. Применение такого системного подхода, согласованного с долгосрочной стратегией распространения информации, приводит к тому, что возросший спрос на 72 73 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и физическую активность, стимулируемый эффективным просвещением, удовлетворяется путем создания людям условий и возможностей для физически активной деятельности. В Глобальном плане действий ВОЗ по повышению физической активности на 2018–2030 гг. поставлена цель сократить масштабы распространения недостаточной физической активности на 15% к 2030 г. и предусмотрено 20 мер политики и мероприятий (14). К их числу относится рекомендация для всех стран проводить долгосрочные национальные информационно- просветительские кампании и включить программы консультирования по вопросам физической активности в систему первичной и вторичной медицинской помощи. Другие рекомендации касались формирования благоприятной среды для занятий физически активной деятельностью, включая ходьбу, езду на велосипеде и на других колесных устройствах, для всех групп населения и создание более широких возможностей и программ для развития физической активности в школах, на рабочих местах, в спортивных клубах и на спортивных объектах. Претворение в жизнь всех 20 рекомендаций за короткий срок во всех странах, вероятно, является невыполнимой задачей, и его следует рассматривать в качестве долгосрочной цели. Чтобы наметить комплекс соответствующих и выполнимых мер для непосредственного осуществления, государствам-членам ВОЗ следует провести ситуационный анализ нынешней политики и практики. Проведение такого анализа позволит наладить межсекторальное сотрудничество, будет способствовать выявлению сильных сторон, пробелов и возможностей, а также послужит основой для подготовки и обновления национальных и субнациональных планов. Настоящие новые рекомендации ВОЗ способствуют расширению сферы охвата мероприятий для включения дополнительных групп, таких как лица с ограниченными возможностями или с хроническими патологиями, беременные женщины или женщины в послеродовом периоде. Потребуется проведение политики поддержки осуществления надлежащих программ и практических методов, которые обеспечивают признание потребностей общин и разнообразие групп и условий. В настоящее время разрабатывается ряд пособий по различным секторам, призванных содействовать применению пакета технической документации ACTIVE (135); в этих пособиях каждому сектору будут даны рекомендации о том, как развивать физическую активность, например через школы, через систему первичной медицинской помощи или путем улучшения условий для ходьбы и езды на велосипеде. Целью пакета ACTIVE, как и других региональных и национальных ресурсов ВОЗ, будет являться содействие в выполнении настоящих рекомендаций по вопросам физической активности и малоподвижного образа жизни. НАДЗОР И ОЦЕНКА Глобальные рекомендации ВОЗ по физической активности для здоровья используются в качестве ориентира для мониторинга и надзора за здоровьем населения с 2010 г. Изменения, которые внесены в эти рекомендации в настоящих обновленных рекомендациях, окажут определенное воздействие на эффективность систем надзора и инструментов оценки, используемых в настоящее время для мониторинга национальных уровней физической активности. В связи с опубликованием новых рекомендаций потребуется пересмотр нынешних инструментов и протоколов отчетности для внесения необходимых корректировок и рекомендаций относительно ведения будущей отчетности в соответствии с новыми рекомендациями. Нынешние инструменты, такие как Глобальная анкета физической активности и Глобальное обследование здоровья учащихся, будут пересмотрены, а протоколы ведения отчетности обновлены для их согласования с настоящими новыми рекомендациями; вспомогательные рекомендации будут предоставлены всем странам в 2021 г. Основным инструментом, используемым для мониторинга глобального прогресса в осуществлении политики в области борьбы с НИЗ, является проводимое раз в два года обследование ВОЗ для оценки национального потенциала в отношении НИЗ (ОНП). В ОНП включаются конкретные вопросы, касающиеся системы проведения демографических обзоров для оценки уровня физической активности каждой возрастной группы, охватываемой Рекомендациями ВОЗ по вопросам физической активности и малоподвижного образа жизни, а с 2019 г. — вопросы о наличии национальных рекомендаций по повышению физической активности. Государствам-членам ВОЗ предлагается загружать документацию в обоснование своего ответа. В 2019 г. из 194 государств-членов ВОЗ только 78 (40%) сообщили о наличии у них рекомендаций относительно физической активности (136). Был проведен подробный документальный анализ ответов на вопросы ОНП за 2019 г., который показал, что лишь две трети из этих 78 государств- членов (т. е. 52 из 78) имеют национальные рекомендации с положениями о том, в каких объемах их населению следует заниматься физически активной деятельностью; из них только 42 страны привели свои документы в полное соответствие с Глобальными рекомендациями по физической активности для здоровья 2010 г. (1). Данные, собранные в результате проведения ОНП в 2021 г. и последующих обследований, позволят получить информацию о выполнении этих обновленных рекомендаций. 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Geneva: World Health Organization; 2020. 82 83 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и G lo be b as ed o n io at /S hu tt er st oc k, s ilh ou et te s ha pe s or ig in al ly b as ed o n Sh ut te rs to ck s ou rc es 82 83Библиография 84 85 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Руководящая группа ФАО В состав Руководящей группы входили специалисты по проблемам физической активности, здоровья подростков, старения, ограниченных возможностей, психического здоровья, профилактики травматизма, онкологических заболеваний, беременности и надзора, представляющие как штаб-квартиру, так и региональные бюро. Валентина Балтаг (Департамент по охране здоровья матерей, новорожденных, детей и подростков и проблеме старения — по теме «Здоровье подростков») Морис Букагу (Департамент по охране здоровья матерей, новорожденных, детей и подростков и проблеме старения — по теме «Беременность») Фиона Булл (председатель) (Департамент по вопросам укрепления здоровья — по теме «Физическая активность») Алекс Бутчарт (Департамент социальных детерминантов здоровья — по теме «Профилактика травматизма») Нирджа Чаудхари (Департамент по неинфекционным заболеваниям — по теме «Психическое здоровье/деменция») Регина Гутхольд (Департамент по охране здоровья матерей, новорожденных, детей и подростков и проблеме старения — по теме «Надзор за подростками») Риитта-Майя Хямяляйнен (Региональное бюро для стран Западной части Тихого океана) Андре Илбави (Департамент по неинфекционным заболеваниям — по теме «Онкологические заболевания») Васик Хан (Региональное бюро для стран Восточного Средиземноморья) Линдси Ли (Департамент по неинфекционным заболеваниям — по теме «Ограниченные возможности») Алана Оффисер (по теме «Старение») Лиэнн Райли (Департамент по неинфекционным заболеваниям — по теме «Наблюдение») Гойка Роглич (Департамент по неинфекционным заболеваниям — по теме «Диабет») Хуана Виллумсен (Департамент по вопросам укрепления здоровья – по теме «Физическая активность») Руководящая группа составила проект сферы охвата рекомендаций и подборки ГМ/ВСП. Члены группы провели обзор деклараций интересов, а также занимались подготовкой, пересмотром и окончательной доработкой рекомендаций. Участники процесса разработки рекомендаций ПРИЛОЖЕНИЕ 1. УПРАВЛЕНИЕ ПРОЦЕССОМ РАЗРАБОТКИ РЕКОМЕНДАЦИЙ 84 85Приложение 1 Группа по разработке рекомендаций (ГРР) Группа по разработке рекомендаций включала в себя многочисленных экспертов в данной области, конечных пользователей рекомендаций и лиц, затрагиваемых рекомендациями. В число членов Группы по разработке рекомендаций входили: д-р Салих аль-Ансари (пропаганда здоровья и санитарного просвещения для борьбы с НИЗ посредством физической активности и ходьбы); д-р Стюарт Бидль (физическая активность, малоподвижный образ жизни и поведенческие изменения); д-р Катя Бородулин (физическая активность при беременности и у пожилых людей); д-р Mэтью Буман (сон, малоподвижный образ жизни и физическая активность у лиц с хроническими патологиями); д-р Грит Кардон (физическая активность у детей и подростков); г-жа Кэтрин Карти (физическая активность у лиц с ограниченными возможностями); д-р Жан-Филипп Шапю (сон, малоподвижный образ жизни и физическая активность у детей и подростков); д-р Себастьян Частин (физическая активность, малоподвижный образ жизни и здоровье, объективное измерение объема физической активности и малоподвижного образа жизни); д-р Падди Демпси (физическая активность и малоподвижный образ жизни у взрослых и лиц с хроническими патологиями); д-р Лоретта Дипьетро (физическая активность при беременности и у пожилых людей); д-р Ульф Экелунд (малоподвижный образ жизни и физическая активность, физическая активность у детей и подростков); д-р Джозеф Ферт (физическая активность и психическое здоровье); д-р Кристина Фриденрайх (физическая активность у лиц с хроническими патологиями, физическая активность и риск рака); д-р Леандро Гарсия (физическая активность и здоровье у взрослых); д-р Мутони Гичу (осуществление политики, национальное правительство); д-р Рассел Яго (физическая активность у детей и подростков); д-р Питер Кацмарзик (физическая активность и малоподвижный образ жизни); д-р Эстель В. Ламберт (физическая активность и ожирение); д р Майкл Лейцман (малоподвижный образ жизни и физическая активность у лиц с хроническими патологиями); д-р Карен Мильтон (практическое выполнение рекомендаций); д-р Франсиско Б. Ортега (физическая активность у детей и подростков, психическое здоровье и объективное измерение); д-р Чатуранга Ранасингх (популяризация физической активности и здоровья в общине, на рабочем месте и в школе); д-р Эммануэль Стаматакис (физическая активность, малоподвижный образ жизни и множественные показатели здоровья у взрослых); д-р Анна Тидеман (физическая активность у пожилых людей); д-р Ричард Трояно (разработка политики); д-р Хидде ван дер Плог (физическая активность и малоподвижный образ жизни у взрослых); г-жа Вики Вари (осуществление политики, национальное правительство); д-р Роджер Чоу (Научно-практический центр для стран Северо- Западной части Тихого океана, профессор медицины на кафедрах медицины, медицинской информатики и клинической эпидемиологии Орегонского университета здоровья и науки) принимал участие в работе в качестве методиста GRADE. Дополнительная информация о ГРР содержится в приложении 2. На первом совещании ГРР, состоявшемся 2–4 июля 2019 г., Группа приняла решение относительно вопросов ГМ/ВСП, рассмотрела имеющиеся систематические обзоры и определила необходимые обновления. Далее Группа согласовала процедуру принятия решений по рекомендациям и по уровням достоверности научных данных, которую предстояло применить на втором совещании ГРР. Второе совещание было проведено 11–14 февраля 2020 г.; на нем Группа рассмотрела обновленные данные и согласовала путем консенсуса окончательные рекомендации. 86 87 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Группа внешних рецензентов (ГВР) Из списка кандидатур, предложенных членами ГРР и Руководящей группой, было отобрано семь внешних рецензентов. Они обладали соответствующим практическим опытом, в том числе по реализации программ, и представляли все шесть регионов ВОЗ. ГВР рассмотрела проект рекомендаций и передала Руководящей группе свою рецензию по аспектам их доходчивости и выполнения, которая была надлежащим образом учтена. Внешние рецензенты не вносили изменений в рекомендации. Список внешних рецензентов содержится в приложении 2. Декларации интересов Прежде чем принимать участие в совещаниях ГРР, члены Группы и внешние рецензенты заполнили и представили формуляры декларации интересов ВОЗ и дали подписку о соблюдении конфиденциальности. Руководящая группа рассмотрела и оценила представленные биографические справки и декларации интересов, после чего провела поиск по электронным ресурсам и публикациям на предмет выявления возможных публичных разногласий или интересов, которые могли бы привести к компрометирующим ситуациям. Имена и краткие биографии всех кандидатов в члены ГРР в течение 14 дней размещались на веб-странице ВОЗ «Физическая активность» для публичного ознакомления, но никаких комментариев не поступило. При возникновении потребности в дополнительных инструкциях о регулировании какой-либо декларации или конфликта интересов Руководящая группа обратилась бы за консультацией к коллегам из Бюро по обеспечению соблюдения, управлению рисками и этике. В случае необходимости те лица, у которых выявлен конфликт интересов финансового или нефинансового характера, были бы отстранены от участия в рассмотрении тех тем, по которым они имели конфликт интересов. Вопрос о регулировании конфликтов интересов был рассмотрен в рамках всей процедуры. При необходимости члены ГРР до начала каждого совещания должны были обновить свои декларации интересов, а в начале каждого совещания ГРР им предлагалось сделать устное заявление об интересах. Заявленные интересы членов ГРР и внешних рецензентов обобщены в приложении 3. Ни одного конфликта интересов выявлено не было. Внешнее рецензирование Рассмотрение проекта рекомендаций проводилось семью внешними рецензентами, которые были определены членами ГРР и Руководящей группы. Внешним рецензентам было поручено подготовить комментарии в отношении ясности формулировок, представления фактических данных и выполнения рекомендаций; их комментарии были надлежащим образом учтены. Внешние рецензенты не могли вносить изменения в рекомендации, согласованные членами ГРР. Список внешних рецензентов содержится в приложении 2, а резюме деклараций интересов — в приложении 3. Кроме того, настоятельные просьбы о предоставлении материалов были направлены в региональные бюро ВОЗ. 86 87Приложение 1 Группа по разработке рекомендаций Д-р Салих аль-Ансари Доцент Семейная и общинная медицина Основатель и директор Центра по вопросам укрепления здоровья Эр-Рияд САУДОВСКАЯ АРАВИЯ Д-р Стюарт Бидль Профессор, курс физической активности и здоровья Исследовательская группа по изучению физически активного образа жизни Центр исследований в области здравоохранения Институт по вопросам устойчивости регионов Университет Южного Квинсленда Центральный Спрингфилд AВСТРАЛИЯ Д-р Катя Бородулин Институт по вопросам возраста Хельсинки ФИНЛЯНДИЯ Д-р Мэтью Буман Колледж решений в области здравоохранения Aризонский университет Финикс США Д-р Грит Кардон Кафедра проблем движения и спортивных наук Факультет медицины и наук о здоровье Гентский университет Гент БЕЛЬГИЯ ПРИЛОЖЕНИЕ 2. ГРУППА ПО РАЗРАБОТКЕ РЕКОМЕНДАЦИЙ, ВНЕШНИЕ РЕЦЕНЗЕНТЫ И СОТРУДНИКИ ВОЗ, УЧАСТВОВАВШИЕ В РАБОТЕ НАД НАСТОЯЩИМИ РЕКОМЕНДАЦИЯМИ Г-жа Кэтрин Карти Руководитель проекта кафедры ЮНЕСКО Технологический институт Трали Графство Керри ИРЛАНДИЯ Д-р Жан-Филипп Шапю Старший научный сотрудник Исследовательская группа по проблемам здорового активного образа жизни и ожирения (HALO) Детская больница Восточного Онтарио (CHEO) Научно- исследовательский институт Отделение педиатрии Оттавский университет Oттава, Онтарио КАНАДА Д-р Себастьян Частин Профессор, курс динамики здорового поведения Школа здоровья и наук о жизни Кафедра психологии, социальной работы и смежных медицинских наук Каледонский университет Глазго Глазго СОЕДИНЕННОЕ КОРОЛЕВСТВО Д-р Роджер Чоу (методист GRADE) Кафедры медицины, медицинской информатики и клинической эпидемиологии Орегонский университет здоровья и науки Портленд, Oрегон США Д-р Падди Демпси Совет медицинских исследований, отдел эпидемиологии Школа клинической медицины Кембриджского университета Институт метаболических наук Кембридж СОЕДИНЕННОЕ КОРОЛЕВСТВО 88 89 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Д-р Лоретта Дипьетро Кафедра физических упражнений и наук о питании Школа общественного здравоохранения Института Милкена Университет Джорджа Вашингтона Вашингтон, ОК США Д-р Ульф Экелунд Отделение спортивной медицины Норвежская школа спортивных наук Oсло НОРВЕГИЯ Д-р Джозеф Ферт Ведущий научный сотрудник Школа медицинских наук Maнчестерский университет Maнчестер СОЕДИНЕННОЕ КОРОЛЕВСТВО Д-р Кристина Фриденрайх Научный директор Научно-исследовательский отдел эпидемиологии и профилактики рака Центр Альберты по борьбе с раком Служба здравоохранения Альберты Калгари КАНАДА Д-р Леандро Гарсия Научный сотрудник Центр общественного здравоохранения Университет Квинс в Белфасте Белфаст СОЕДИНЕННОЕ КОРОЛЕВСТВО Д-р Мутони Гичу Начальник отдела гериатрической медицины Департамент неинфекционных заболеваний Mинистерство здравоохранения Найроби KEНИЯ Д-р Рассел Яго Профессор кафедры физической активности детей и общественного здравоохранения Центр по вопросам физических упражнений, питания и наук о здоровье Школа политических исследований Бристольский университет Бристоль СОЕДИНЕННОЕ КОРОЛЕВСТВО Д-р Питер Т. Кацмарзик Заместитель исполнительного директора по делам наук о населении и общественном здравоохранении Профессор и заведующий кафедрой Марии Эданы Коркоран по проблемам детского ожирения и диабета Пеннингтонский центр биомедицинских исследований Батон-Руж США Д-р Эстель В. Ламберт Директор научно-исследовательского центра «Здоровье через физическую активность, образ жизни и спорт» Кептаунский университет Кейптаун ЮЖНАЯ АФРИКА Д-р Майкл Лейцман Профессор эпидемиологии Факультет эпидемиологии и профилактической медицины Регенсбургский университет Регенсбург ГЕРМАНИЯ Д-р Карен Мильтон Доцент кафедры общественного здравоохранения Норвичская медицинская школа Университет Восточной Англии Норвич СОЕДИНЕННОЕ КОРОЛЕВСТВО Д-р Франсиско Б. Ортега Начальник отдела по вопросам популяризации физической активности и здоровья Научно-исследовательский институт спорта и здоровья (iMUDS) Факультет физического воспитания и спорта Университет Гранады Гранада ИСПАНИЯ 88 89Приложение 2 Д-р Чатуранга Ранасингх Руководитель проекта «NIROGI Lanka» Медицинская ассоциация Шри-Ланки Доцент Отделение лечебной физкультуры и спорта Медицинский факультет Университет Коломбо Коломбо ШРИ-ЛАНКА Д-р Эммануэль Стаматакис Центр Чарльза Перкинса Факультет медицины и здравоохранения Школа общественного здравоохранения Сиднейский университет Сидней AВСТРАЛИЯ Д-р Анна Тидеман Доцент Институт здоровья опорно-двигательного аппарата Школа общественного здравоохранения Факультет медицины и здравоохранения Сиднейский университет Сидней AВСТРАЛИЯ Д-р Ричард Трояно Программа исследований в области эпидемиологии и геномики Национальный институт онкологии Национальные институты здравоохранения Роквилл США Д-р Хидде ван дер Плог Доцент Отделение общественного здравоохранения и охраны труда Aмстердамский научно-исследовательский институт общественного здравоохранения Медицинские центры Амстердамского университета Aмстердам НИДЕРЛАНДЫ Г-жа Вики Вари* Pуководитель программы, НИЗ Национальный департамент здравоохранения Порт-Морсби ПАПУА-НОВАЯ ГВИНЕЯ Группа внешних рецензентов Д-р Кингсли Акинрой Нигерийский альянс по борьбе с НИЗ НИГЕРИЯ Д-р Худа Альсияби Директор Департамент общинных инициатив Mинистерство здравоохранения OMAН Д-р Альберто Флорес-Прегонеро Папский Ксаверианский университет КОЛУМБИЯ Д-р Шигеру Иноуэ Факультет профилактической медицины и общественного здравоохранения Tокийский медицинский университет ЯПОНИЯ Д-р Агус Махендра Факультет физического воспитания Университет Пендидикан ИНДОНЕЗИЯ Д-р Дебора Сальво Научно-исследовательский центр профилактики в Сент-Луисе Школа Брауна Университет Вашингтона США Д-р Джаспер Шипперийн Избранный президент Международного общества по физической активности и здоровью на 2020–2022 гг. Факультет спортивных наук и клинической биомеханики Университет Южной Дании ДАНИЯ * не смог принять участие в работе90 91 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и * не смог принять участие в работе Руководящая группа ВОЗ Д-р Валентина Балтаг Начальник отдела по вопросам здоровья подростков и молодых людей Департамент по охране здоровья матерей, новорожденных, детей и подростков и проблеме старения Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ Д-р Морис Букагу Meдицинский сотрудник Охрана здоровья матерей Департамент по охране здоровья матерей, новорожденных, детей и подростков и проблеме старения Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ Д-р Александр Бутчарт Начальник отдела по вопросам предупреждения насилия Департамент социальных детерминантов здоровья Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ Д-р Фиона Булл Начальник отела по вопросам физической активности Департамент по вопросам укрепления здоровья Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ Д-р Регина Гутхольд Научный сотрудник отдела по вопросам здоровья подростков и молодых людей Департамент по охране здоровья матерей, новорожденных, детей и подростков и проблеме старения Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ Д-р Риитта-Майя Хямяляйнен Tехнический сотрудник Отдел по неинфекционным заболеваниям и укреплению здоровья Региональное бюро ВОЗ для стран Западной части Тихого океана Maнила ФИЛИППИНЫ Д-р Андре Илбави Teхнический сотрудник Департамент по неинфекционным заболеваниям Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ Д-р Васик Хан* Региональный советник по вопросам санитарного просвещения и укрепления здоровья Региональное бюро ВОЗ для стран Восточного Средиземноморья Каир EГИПЕТ Г-жа Линдси Ли Teхнический сотрудник по вопросам сенсорных функций, ограниченных возможностей и реабилитации Департамент по неинфекционным заболеваниям Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ Г-жа Алана Оффисер Старший консультант по вопросам здравоохранения Здоровое старение Канцелярия Генерального директора Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ Г-жа Лиэнн Райли Начальник отдела по вопросам надзора Департамент по неинфекционным заболеваниям Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ Д-р Гойка Роглич Meдицинский сотрудник по вопросам ведения неинфекционных заболеваний Департамент по неинфекционным заболеваниям Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ Д-р Хуана Виллумсен Teхнический сотрудник по вопросам физической активности Департамент по вопросам укрепления здоровья Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ 90 91Приложение 2 ПРИЛОЖЕНИЕ 3. РЕЗЮМЕ ДЕКЛАРАЦИЙ ИНТЕРЕСОВ И РЕЗУЛЬТАТЫ ИХ РАССМОТРЕНИЯ Члены Группы по разработке рекомендаций Имя и фамилия Пол Специализация Раскрытие информации об интересах Конфликт интересов и его рассмотрение Д-р Салих аль-Ансари Муж. Специалист по пропаганде здоровья и санитарного просвещения для борьбы с НИЗ посредством физической активности и ходьбы Владелец и директор Центра по вопросам укрепления здоровья Конфликта интересов не выявлено Д-р Стюарт Бидль Муж. Физическая активность у молодежи Исследовательские фонды и платные консультационные услуги Конфликта интересов не выявлено Д-р Катя Бородулин Жен. Физическая активность при беременности Работа в Национальном институте по вопросам здоровья, благополучия и возраста; исследовательские фонды Конфликта интересов не выявлено Д-р Мэтью Буман Муж. Сон и физическая активность у лиц с хроническими патологиями Интересы не декларированы Конфликта интересов не выявлено Д-р Грит Кардон Жен. Физическая активность у молодежи Интересы не декларированы Конфликта интересов не выявлено Г-жа Кэтрин Карти Жен. Физическая активность у лиц с ограниченными возможностями Исследовательские фонды Конфликта интересов не выявлено Д-р Жан-Филипп Шапю Муж. Сон Интересы не декларированы Конфликта интересов не выявлено Д-р Себастьян Частин Муж. Физическая активность и здоровье, oбъективное измерение физической активности Исследовательские фонды Конфликта интересов не выявлено Д-р Падди Демпси Муж. Физическая активность и малоподвижный образ жизни у взрослых и лиц с хроническими патологиями Работа на должности и исследовательские фонды Конфликта интересов не выявлено Д-р Лоретта Дипьетро Жен. Физическая активность у пожилых людей Интересы не декларированы Конфликта интересов не выявлено Д-р Ульф Экелунд Муж. Малоподвижный образ жизни и физическая активность у молодежи Интересы не декларированы Конфликта интересов не выявлено Д-р Джозеф Ферт Муж. Физическая активность и психическое здоровье Интересы не декларированы Конфликта интересов не выявлено Д-р Кристина Фриденрайх Жен. Физическая активность у лиц с хроническими патологиями, физическая активность и риск возникновения рака Интересы не декларированы Конфликта интересов не выявлено Д-р Леандро Гарсия Муж. Физическая активность и психическое здоровье Работа на должности и платные консультационные услуги Конфликта интересов не выявлено Д-р Мутони Гичу Жен. Осуществление политики (национальное правительство) Интересы не декларированы Конфликта интересов не выявлено Д-р Рассел Яго Муж. Физическая активность у молодежи Интересы не декларированы Конфликта интересов не выявлено Д-р Питер Кацмарзик Муж. Физическая активность и малоподвижный образ жизни у молодежи Поддержка в покрытии путевых расходов для содействия комитетам по разработке руководства Конфликта интересов не выявлено 92 93 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Имя и фамилия Пол Специализация Раскрытие информации об интересах Конфликт интересов и его рассмотрение Д-р Эстель В. Ламберт Жен. Физическая активность и ожирение Интересы не декларированы Конфликта интересов не выявлено Д-р Майкл Лейцман Муж. Малоподвижный образ жизни и хронические патологии Интересы не декларированы Конфликта интересов не выявлено Д-р Карен Мильтон Жен. Практическое выполнение рекомендаций Поддержка в покрытии путевых расходов для содействия комитету по разработке руководства Конфликта интересов не выявлено Д-р Франсиско Ортега Муж. Физическая активность у молодежи, психическое здоровье и объективное измерение Интересы не декларированы Конфликта интересов не выявлено Д-р Чатуранга Ранасингх Муж. Популяризация физической активности и здоровья в общине, на рабочем месте и в школе Исследовательские фонды Конфликта интересов не выявлено Д-р Эммануэль Стаматакис Муж. Физическая активность и множественные показатели здоровья у взрослых Грант для технологической компании в целях объективного измерения физической активности Конфликта интересов не выявлено Д-р Анна Тидеман Жен. Физическая активность и показатели здоровья у пожилых людей Интересы не декларированы Конфликта интересов не выявлено Д-р Ричард Трояно Муж. Pазработка политики Интересы не декларированы Конфликта интересов не выявлено Д-р Хидде ван дер Плог Муж. Физическая активность, малоподвижный образ жизни и показатели здоровья у взрослых Поддержка в покрытии путевых расходов для содействия нидерландскому комитету по разработке руководства по физической активности в 2017 г. и исследовательские фонды Конфликта интересов не выявлено Г-жа Вики Вари Жен. Осуществление политики, национальное правительство) Долевое участие (к подготовке руководства не относится) Конфликта интересов не выявлено Внешние рецензенты Имя и фамилия Пол Специализация Раскрытие информации об интересах Конфликт интересов и его рассмотрение Д-р Кингсли Акинрой Муж. Просветительская деятельность, неинфекционные заболевания Интересы не декларированы Конфликта интересов не выявлено Д-р Худа Альсияби Жен. Осуществление политики и программ Интересы не декларированы Конфликта интересов не выявлено Д-р Альберто Флорес-Прегонеро Муж. Измерение и надзор физической активности и малоподвижного образа жизни Интересы не декларированы Конфликта интересов не выявлено Д-р Шигеру Иноуэ Муж. Эпидемиология и популяризация физической активности Интересы не декларированы Конфликта интересов не выявлено Д-р Агус Махендра Муж. Навыки физической активности и движения у детей Интересы не декларированы Конфликта интересов не выявлено Д-р Дебора Сальво Жен. Диспропорции в здравоохранении и социальной сфере с уделением особого внимания профилактике хронических заболеваний Интересы не декларированы Конфликта интересов не выявлено Д-р Джаспер Шипперийн Муж. Физическая активность и антропогенная среда Избранный президент Международного общества по физической активности и здоровью (ISPAH) Конфликта интересов не выявлено 92 93Приложение 3 ISBN 978-92-4-003218-77 0

РЕКОМЕНДАЦИИ ВОЗ ПО ВОПРОСАМ ФИЗИЧЕСКОЙ АКТИВНОСТИ И МАЛОПОДВИЖНОГО ОБРАЗА ЖИЗНИ

РЕКОМЕНДАЦИИ ВОЗ ПО ВОПРОСАМ ФИЗИЧЕСКОЙ АКТИВНОСТИ И МАЛОПОДВИЖНОГО ОБРАЗА ЖИЗНИ Рекомендации ВОЗ по вопросам физической активности и малоподвижного образа жизни [WHO guidelines on physical activity and sedentary behaviour] ISBN 978-92-4-003217-0 (Онлайн-версия) ISBN 978-92-4-003218-7 (Версия для печати) © Всемирная организация здравоохранения, 2021 г. Некоторые права защищены. Настоящая публикация распространяется на условиях лицензии Creative Commons 3.0 IGO «С указанием авторства – Некоммерческая – Распространение на тех же условиях» (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo/deed.ru). Лицензией допускается копирование, распространение и адаптация публикации в некоммерческих целях с указанием библиографической ссылки согласно нижеприведенному образцу. Никакое использование публикации не означает одобрения ВОЗ какой-либо организации, товара или услуги. Использование логотипа ВОЗ не допускается. Распространение адаптированных вариантов публикации допускается на условиях указанной или эквивалентной лицензии Creative Commons. При переводе публикации на другие языки приводится библиографическая ссылка согласно нижеприведенному образцу и следующая оговорка: «Настоящий перевод не был выполнен Всемирной организацией здравоохранения (ВОЗ). ВОЗ не несет ответственности за его содержание и точность. Аутентичным подлинным текстом является оригинальное издание на английском языке». Урегулирование споров, связанных с условиями лицензии, производится в соответствии с согласительным регламентом Всемирной организации интеллектуальной собственности (http://www.wipo.int/amc/en/mediation/rules). Образец библиографической ссылки. Рекомендации ВОЗ по вопросам физической активности и малоподвижного образа жизни [WHO guidelines on physical activity and sedentary behaviour]. Женева: Всемирная организация здравоохранения; 2021 г. Лицензия: CC BY-NC-SA 3.0 IGO. Данные каталогизации перед публикацией (CIP). Данные CIP доступны по ссылке: http://apps.who.int/iris. Приобретение, авторские права и лицензирование. По вопросам приобретения публикаций ВОЗ см. http://apps.who.int/bookorders. По вопросам оформления заявок на коммерческое использование и направления запросов, касающихся права пользования и лицензирования, см. http://www.who.int/about/licensing. Материалы третьих сторон. Пользователь, желающий использовать в своих целях содержащиеся в настоящей публикации материалы, принадлежащие третьим сторонам, например таблицы, рисунки или изображения, должен установить, требуется ли для этого разрешение обладателя авторского права, и при необходимости получить такое разрешение. Ответственность за нарушение прав на содержащиеся в публикации материалы третьих сторон несет пользователь. Оговорки общего характера. Используемые в настоящей публикации обозначения и приводимые в ней материалы не означают выражения мнения ВОЗ относительно правового статуса любой страны, территории, города или района или их органов власти или относительно делимитации границ. Штрихпунктирные линии на картах обозначают приблизительные границы, которые могут быть не полностью согласованы. Упоминание определенных компаний или продукции определенных производителей не означает, что они одобрены или рекомендованы ВОЗ в отличие от аналогичных компаний или продукции, не названных в тексте. Названия патентованных изделий, исключая ошибки и пропуски в тексте, выделяются начальными прописными буквами. ВОЗ приняты все разумные меры для проверки точности информации, содержащейся в настоящей публикации. Однако данные материалы публикуются без каких-либо прямых или косвенных гарантий. Ответственность за интерпретацию и использование материалов несет пользователь. ВОЗ не несет никакой ответственности за ущерб, связанный с использованием материалов. Дизайн: Eddy Hill Design Printed in Switzerland ii iii Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и CОДЕРЖАНИЕ Выражение признательности iv Сокращения и акронимы v Глоссарий терминов vi Резюме 1 Справочная информация 15 Методика 18 Рекомендации 24 Дети и подростки (в возрасте 5–17 лет) 25 Pекомендация относительно физической активности 25 Рекомендация относительно малоподвижного образа жизни 29 Взрослые (в возрасте 18–64 лет) 32 Pекомендация относительно физической активности 32 Рекомендация относительно малоподвижного образа жизни 38 Пожилые люди (в возрасте 65 лет и старше) 43 Pекомендация относительно физической активности 43 Рекомендация относительно малоподвижного образа жизни 46 Беременные женщины и женщины в послеродовом периоде 47 Pекомендация относительно физической активности 47 Рекомендация относительно малоподвижного образа жизни 51 Взрослые и пожилые люди с хроническими патологиями (в возрасте 18 лет и старше) 52 Pекомендация относительно физической активности 52 Рекомендация относительно малоподвижного образа жизни 58 Дети и подростки (в возрасте 5–17 лет) и взрослые (в возрасте 18 лет и старше) с ограниченными возможностями 60 Pекомендация относительно физической активности 60 Рекомендация относительно малоподвижного образа жизни 64 Научное обоснование рекомендаций 66 Оценка достоверности фактических данных 66 Польза и вред 66 Ценности и предпочтения 67 Ресурсные последствия 67 Справедливость, приемлемость и целесообразность 68 Потребности в исследованиях 69 Принятие, распространение, осуществление и оценка 70 Принятие 70 Распространение 71 Информационные кампании 71 Осуществление политики и программ 72 Надзор и оценка 73 Обновление 73 Библиография 75 Приложение 1. Управление процессом разработки руководства 85 Приложение 2. Группа по разработке рекомендаций, внешние рецензенты и сотрудники ВОЗ, участвовавшие в работе над настоящими рекомендациями 88 Приложение 3. Резюме деклараций интересов и результаты их рассмотрения 92 Веб-приложение «Профили фактических данных» https://apps.who.int/iris/bitstream/handle/ 10665/336657/9789240015111-eng.pdf ii iiiCодержание ВЫРАЖЕНИЕ ПРИЗНАТЕЛЬНОСТИ Всемирная организация здравоохранения (ВОЗ) с благодарностью отмечает вклад и поддержку следующих лиц и организаций в разработку настоящих рекомендаций. Фиона Булл и Хуана Виллумсен руководили процессом подготовки данных рекомендаций. Валентина Балтаг, Морис Букагу, Алекс Бутчарт, Неерия Чаудхари, Регина Гутхольд, Риитта-Майя Хямяляйнен, Андре Илбави, Васик Хан, Линдси Ли, Алана Оффисер, Лиэнн Райли и Гойка Роглич являлись членами Руководящей группы ВОЗ, возглавившей процесс подготовки рекомендаций. В состав Группы по разработке рекомендаций (ГРР) вошли Салих Саад аль-Ансари, Стюарт Бидль, Катя Бородулин, Мэтью Буман, Грит Кардон (сопредседатель), Кэтрин Карти, Жан-Филипп Чапут, Себастьян Частин, Падди Демпси, Лоретта ДиПьетро, Ульф Экелунд, Джозеф Ферт, Кристина Фриденрайх, Леандро Гарсия, Мутони Гичу, Русс Яго, Питер Кацмарзик, Эстель В. Ламберт, Майкл Лейцман, Карен Мильтон, Франсиско Б. Ортега, Чатуранга Ранасинге, Эммануэль Стаматакис (сопредседатель), Анна Тидеман, Ричард Трояно, Хидде ван дер Плоег, Вики Вари. Роджер Чоу принимал участие в работе в качестве методиста GRADE. В состав группы внешних рецензентов вошли Кингсли Акинройе, Худа Альсияби, Альберто Флорес-Прегонеро, Шигеру Иноуэ, Агус Махендра, Дебора Сальво и Джаспер Шипперийн. Данные систематических обзоров научной информации, подготовленных к научному докладу Консультативного комитета США по рекомендациям в области физической активности, представленного министру здравоохранения и социальных служб, были обновлены в результате поиска по дополнительным источникам, проведенного Кайлом Спроу (Национальный онкологический институт, Национальный институт здравоохранения, Мэриленд, США). Дополнительную поддержку в целях обзора соответствующих документов оказали Элиф Эроглу (Сиднейский университет), Андреа Хилрайнер (Регенсбургский университет), Бо-Хуэй Хуанг (Сиднейский университет), Кармен Йохем (Регенсбургский университет), Джайро Х. Мигельес (Университет Гранады), Челси Стоун (Университет Калгари) и Леони Уйтдевильиген (УМЦ Амстердама). Резюме научных данных и данные таблиц GRADE были подготовлены Кэрри Патнуод и Мишель Хеннингер (госпитали фонда Кайзера, центр исследований в области здравоохранения, Портленд, Орегон, США). Дополнительные обзоры научных данных провели Н. Фэрхолл, Дж. Оливейра, М. Пиньейру и С. Шеррингтон (Институт здоровья опорно-двигательного аппарата, Школа общественного здравоохранения, Сиднейский университет, Сидней, Австралия) и А. Бауман (Исследовательская группа по сотрудничеству в области профилактики, Школа общественного здравоохранения Сиднейского университета, Сидней, Австралия; и Сотрудничающий центр ВОЗ по вопросам физической активности, питания и избыточного веса); С. Мабвазара, М. Дж. Лагетт, К. Лармут, Ф. Одунитан-Вайяс (Научно-исследовательский центр по вопросам укрепления здоровья в результате повышения физической активности, ведения здорового образа жизни и использования возможностей спортивной медицины, факультет медицинских наук, Кейптаунский университет, Кейптаун, Южная Африка), Л. Лич, С. Онагбие (кафедра наук в области спорта, отдыха и физической культуры, факультет медицинских наук, Кейптаунский университет, Южная Африка), М. Мтетва (Инициатива по борьбе с хроническими заболеваниями в странах Африки, Кейптаунский университет, Кейптаун, Южная Африка), П. Смит (Центр Десмонда Туту по борьбе с ВИЧ, Институт инфекционных заболеваний и молекулярной медицины, факультет медицинских наук, Кейптаунский университет, Кейптаун, Южная Африка) и Ф. Машили (факультет физиологии, Медицинский университет смежных наук Мухимбили, Дар-эс-Салам, Объединенная Республика Танзания); Б. Силлекенс, М. Ланг, В. ван Мехелен, Э. Верхаген, М. Гюисманс, А. ван дер Бик, П. Коенен (кафедра общественного здравоохранения и гигиены труда медицинского центра Амстердамского университета, Амстердам, Нидерланды). Агентство общественного здравоохранения Канады и правительство Норвегии оказали финансовую поддержку, без которой эта работа не могла бы быть завершена. iv v Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и СДВГ синдром дефицита внимания и гиперактивности СОШ скорректированное отношение шансов ИМТ индекс массы тела ДИ доверительный интервал ССЗ сердечно-сосудистое заболевание ДАД диастолическое артериальное давление НОР научное обоснование решений ГРР Группа по разработке руководства GRADE Ранжирование оценки, разработки и экспертизы рекомендаций ОР отношение риска MET метаболический эквивалент нагрузки РСЗ различие средних значений НТСИ непрерывный тренинг средней интенсивности НИЗ неинфекционное заболевание OШ отношение шансов ФА физическая активность PAGAC Консультативный комитет США по Руководящим принципам физической активности НМ/ВСР население, мероприятие/воздействие, сравнение, результат ОАР относительный атрибутивный риск РКИ рандомизированное контролируемое испытание ОТР относительный риск САД систолическое артериальное давление СРС стандартизированная разность средних SPPB краткий набор тестов по оценке физической производительности ТВ телевидение ВАЗ Всемирная ассамблея здравоохранения ВОЗ Всемирная организация здравоохранения СОКРАЩЕНИЯ И АКРОНИМЫ iv vСокращения и акронимы Teрмин Определение Аэробная нагрузка Aктивность, при которой большие мышцы тела совершают ритмичные движения в течение продолжительного времени. Aэробная нагрузка, также называемая тренировкой выносливости, улучшает кардиореспираторное здоровье. К примерам такой нагрузки относятся ходьба, бег, плавание и езда на велосипеде. Анаэробная нагрузка Анаэробная нагрузка заключается в выполнении коротких, но интенсивных тренировочных серий, таких как поднятие тяжестей или спринтерский бег, когда организму требуется больше кислорода, чем он получает. Упражнения на равновесие Статические и динамические упражнения для повышения способности человека выдерживать нагрузки, связанные с осаночными колебаниями или дестабилизирующими воздействиями, которые вызваны самопроизвольными движениями, обстановкой или другими предметами. Индекс массы тела (ИМТ) Отношение веса в килограммах к квадрату роста в метрах. ИМТ-возраст, или ИМТ по Z-показателю ИМТ с корректировкой по возрасту, стандартизированный для детей. Стандартные расчеты отклонения ИМТ производятся путем измерения относительного веса, скорректированного с учетом возраста и пола ребенка. Зная возраст, пол, ИМТ ребенка и соответствующий исходный стандарт, можно вычислить ИМТ по Z-показателю (или эквивалентный ему процентиль ИМТ-возраста). Нагрузка для укрепления костной системы Физическая активность, первоочередная цель которой — обеспечить укрепление определенных участков костей, составляющих скелетную систему. Нагрузки для укрепления костной системы воздействуют на кости или сообщают им усилие натяжения, стимулирующее рост и прочность костной системы. Примерами физической активности для укрепления костной системы являются бег, прыжки через скакалку и поднятие тяжестей. Кардиометаболическое здоровье Совокупное воздействие кровяного давления, липидов крови, глюкозы в крови и инсулина на здоровье человека. Кардиореспираторное здоровье (выносливость) Один из компонентов физического состояния, связанный со здравоохранением. Способность органов кровообращения и дыхания обеспечивать организм кислородом во время продолжительной физической активности. Обычно выражается измеряемым или оцениваемым объемом максимального потребления кислорода (VO2 max). Когнитивные функции Умственная деятельность, т. е. рассудительность, память, внимание и речь, приводящие к усвоению информации и знаний. К этим функциям также можно отнести обучение. Ограниченные возможности здоровья Согласно Международной классификации функционирования, инвалидности и здоровья — обобщающее понятие, которое охватывает нарушения здоровья, ограничения физической активности и факторы, препятствующие полноценному участию в общественной жизни, и указывает на негативные аспекты взаимодействия между индивидуумом (с определенным состоянием здоровья) и его конкретными ситуативными обстоятельствами (экологическими и личными факторами). Области физической активности Уровни физической активности можно оценивать в разных областях, включая одну или несколько следующих областей: досуг, профессиональная деятельность, образование, домашнее хозяйство и/или передвижение. Физические упражнения Подкатегория физической активности, которая является планируемой, структурированной, повторяемой и целенаправленной в том смысле, что ее цель заключается в улучшении или поддержании одного или нескольких компонентов физического состояния. Термины «физические упражнения» и «упражнения» нередко используются как взаимозаменяемые и обычно означают физическую нагрузку, которая выполняется в свободное время и нацелена прежде всего на улучшение или поддержание физического состояния, физической работоспособности или здоровья. Управляющая функция Включает такие компоненты, как кратковременная память, когнитивная гибкость (также называемая гибкостью мышления) и ингибиторный контроль (включающий в себя самоконтроль). Физическое здоровье Один из критериев способности тела к эффективному и результативному функционированию во время работы и досуга, включающий в себя, например, физическое состояние и кардиореспираторное здоровье. Гибкость Компонент физического состояния, связанный со здоровьем и работоспособностью, который отражает возможную амплитуду движений того или иного сустава. Гибкость присуща каждому суставу и зависит от ряда определенных регулирующих факторов, в том числе от плотности конкретных связок и сухожилий. Упражнения для гибкости повышают способность сустава к выполнению полного спектра его движений. Функциональные упражнения Упражнения, которые могут быть включены в комплекс ежедневных задач для укрепления нижней части тела, улучшения равновесия и двигательной активности. К числу таких упражнений относятся тандем и баланс на одной ноге, приседания, вставания со стула, подъемы на носки и перешагивание через препятствия. Физическая активность в домашних условиях Физическая активность, проявляемая дома при выполнении домашних обязанностей (таких как уборка, уход за детьми, садоводство и т. п.). Досуговая физическая активность Физическая активность, проявляемая индивидуумом в условиях, когда она не требуется в качестве одного из основных видов деятельности в повседневной жизни и проявляется по собственному желанию индивидуума. К видам такой активности относятся участие в спортивных мероприятиях, физическая подготовка или тренировка и рекреационные занятия – прогулки, танцы и работа в саду. ГЛОССАРИЙ ТЕРМИНОВ vi vii Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Teрмин Определение Физическая активность низкой интенсивности Физическая активность низкой интенсивности выполняется при расходе энергии от 1,5 до 3 MET, т. е. для нее требуется объем энергии, который менее чем в 3 раза превышает энергозатраты соответствующего лица в состоянии покоя. Примерами упражнений такой интенсивности являются медленная ходьба, купание или другие случайные виды деятельности, не приводящие к значительному увеличению частоты сердечных сокращений или учащению дыхания. Основные группы мышц К основным группам мышц относятся мышцы ног, спины, живота, груди, плеч и рук. Meтаболический эквивалент нагрузки (MET) Meтаболический эквивалент нагрузки, или просто метаболический эквивалент, является физиологической мерой интенсивности различных видов физической активности. Один MET – это эквивалент энергии, расходуемой индивидуумом в сидячем положении в состоянии покоя. Физическая активность средней интенсивности По абсолютной шкале средняя интенсивность соответствует физической активности, интенсивность которой выше интенсивности в состоянии покоя от 3 до менее 6 раз. Если рассматривать шкалу личного потенциала индивидуума, то физическая активность средней интенсивности обычно составляет 5–6 по шкале от 0 до 10. Силовые упражнения Вид физической активности и нагрузки, обеспечивающий наращивание силы, мощности, выносливости и массы скелетных мышц (например, отягощения, тренировки на сопротивление или упражнения на развитие силы и выносливости мышц). Комплексные физические упражнения Для пожилых людей комплексные физические упражнения важны с точки зрения улучшения показателей физического функционирования и снижения риска падений и связанного с падениями травматизма. Такие упражнения могут выполняться дома или в составе организованной группы. Согласно целому ряду научно обоснованных систем, одна тренировка объединяет в себе все виды упражнений (аэробные, силовые и на равновесие), и такой опыт показал свою эффективность. Примерная программа комплексных физических упражнений может включать в себя ходьбу (aэробные упражнение), подъем тяжестей (силовое упражение) и упражнения на равновесие. К упражнениям на равновесие могут относиться ходьба задом наперед, ходьба боком или стояние на одной ноге с одновременным выполнением верхней частью тела упражнений на развитие силы, например подъема на бицепсы. Танцы также сочетают в себе аэробные и балансовые компоненты. Физическая активность в профессиональной среде См. «Физическая активность на работе». Физическая активность Любое движение тела, которое производится скелетными мышцами и требует расхода энергии. Недостаточная физическая активность Физическая активность, уровень которой недостаточен для выполнения настоящих рекомендаций в отношении физической активности. Психосоциальное здоровье Включает в себя психический, эмоциональный и социальный аспекты здоровья. Экранное время досуга Время, проводимое перед экраном (телевизора, компьютера или мобильных устройств) в целях, отличных от целей образования/обучения или работы. Экранное время при малоподвижном образе жизни Время, проводимое за просмотром развлекательного контента на экране (ТВ, компьютера или мобильных устройств). Не включает в себя активные экранные игры, требующие физической наргузки или движения. Малоподвижный образ жизни Любая нагрузка в состоянии бодрствования, которая характеризуется расходом энергии не более 1,5 MET в положениях сидя, лежа или полулежа. Примерами малоподвижного образа жизни являются основная часть сидячей офисной работы, вождение автомобиля и просмотр телевизора; такой образ жизни также ведут лица, которые не способны находиться в стоячем положении, например пользователи кресел-колясок. Вводимое в настоящих рекомендациях определение термина «малоподвижный образ жизни» охватывает самостоятельно оцениваемое малоподвижное сидение (во время досуга, на работе и в целом), пребывание у телевизора (просмотр ТВ или экранное время, а также низкие уровни движения, измеряемые устройствами для оценки движения или позы). Спорт Спорт включает в себя ряд видов деятельности, которые регулируются комплексом правил и выполняются в рамках досуга или соревнования. Спортивные занятия предполагают физическую активность, осуществляемую в составе команды или индивидуально, которая может курироваться официальным учреждением, например спортивным клубом. Физическая активность при передвижении Физическая активность, осуществляемая для передвижения в какие-либо пункты и обратно, которая связана с ходьбой, ездой на велосипеде и на других колесных устройствах (немоторизованных колесных средствах передвижения, таких как самокаты, роликовые коньки, кресла-коляски с ручным приводом и т. п.). Физическая активность высокой интенсивности По абсолютной шкале высокая интенсивность соответствует физической активности, выполняемой при 6 МЕТ или выше. Если рассматривать шкалу личного потенциала индивидуума, то физическая активность высокой интенсивности обычно составляет 7 или 8 по шкале от 0 до 10. Физическая активность на работе Физическая активность во время оплачиваемой или волонтерской работы. vi viiГлоссарий терминов Рекомендации ВОЗ по вопросам физической активности и малоподвижного образа жизни содержит научно обоснованные рекомендации в области общественного здравоохранения для детей, подростков, взрослых и пожилых людей в отношении объема физической активности (регулярности, интенсивности и продолжительности), необходимого для того, чтобы обеспечить значительное улучшение состояния здоровья и снизить соответствующие риски. В нем впервые даются рекомендации по вопросам, касающимся взаимосвязи между малоподвижным образом жизни и показателями здоровья, а также рекомендации для отдельных подгрупп населения, таких как беременные женщины, женщины в послеродовом периоде и лица с хроническими патологиями или ограниченными возможностями. Рекомендации предназначены для директивных органов в странах с высоким, средним и низким уровнем дохода, входящих в структуру министерств здравоохранения, образования, по делам молодежи, спорта и/или социального обеспечения и защиты семьи; для государственных должностных лиц, отвечающих за разработку национальных, субрегиональных или муниципальных планов по повышению физической активности и сокращению масштабов малоподвижного образа жизни в отдельных группах населения и за подготовку соответствующей методической документации; для сотрудников неправительственных организаций, работников сектора образования, частного сектора и сектора научных исследований, а также для работников здравоохранения. Рекомендации были подготовлены в соответствии с положениями Пособия ВОЗ по разработке рекомендаций. Проводились систематические обзоры информации о состоянии важнейших и важных показателей здоровья и дискуссии по вопросам, касающимся пользы и вреда, ценностей и предпочтений, целесообразности и приемлемости, а также последствий с точки зрения обеспечения равенства и использования ресурсов, по итогам которых были составлены рекомендации. Окончательные рекомендации в области общественного здравоохранения, содержащиеся в настоящем документе, предназначены для всех групп населения и возрастных групп от 5 до 65 лет и старше вне зависимости от пола, культурной принадлежности или социально-экономического статуса и актуальны для людей с любым уровнем способностей. Лицам с хроническими патологиями и/или ограниченными возможностями, а также беременным женщинам и женщинам в послеродовом периоде, следует стараться выполнять эти рекомендации по мере возможности и сообразно своим способностям. В процессе подготовки настоящих рекомендаций составлен свод научно обоснованных рекомендаций, которые могут включаться правительствами в разрабатываемые ими механизмы национальной политики, направленной на содействие внедрению всеобъемлющих подходов к повышению уровней физической активности населения. При включении рекомендаций следует рассмотреть вопрос о целесообразности корректировки содержания рекомендаций с учетом конкретных условий. Практические инструменты для содействия проведению кампаний по принятию, распространению, популяризации и осуществлению рекомендаций станут для правительств и заинтересованных сторон подспорьем в налаживании взаимодействия в целях повышения физической активности и сокращения малоподвижности на протяжении всего жизненного цикла. Эти вспомогательные ресурсы будут размещены на веб-сайте ВОЗ после опубликования настоящих рекомендаций. Несмотря на многочисленные данные, подтверждающие значение физической активности, и возрастающий объем информации о влиянии малоподвижного образа жизни на показатели здоровья на всех этапах жизненного цикла, в соответствующем фактическом материале сохраняются значительные пробелы. В частности, меньше данных поступает от стран с низким и средним уровнем дохода и экономически неблагополучных и недостаточно обеспеченных услугами общин; кроме того, налицо нехватка информации о различных подгруппах населения, в том числе о лицах с ограниченными возможностями. Необходимы инвестиции в расширение исследований для получения научных данных именно по указанным областям. С другой стороны, изменения, внесенные в эти рекомендации, окажут определенное влияние на системы надзора и инструменты оценки, которые используются в настоящее время для мониторинга национальных уровней физической активности. Следует пересмотреть существующие глобальные и национальные инструменты и обновить протоколы отчетности, чтобы обеспечить ведение будущей отчетности в соответствии с новыми рекомендациями. В Глобальном плане действий ВОЗ по повышению уровня физической активности на 2018–2030 гг. предусмотрена цель — сократить масштабы малоподвижного образа жизни на 15% к 2030 г. — и сформулированы 20 рекомендуемых мер политики и практических мероприятий. Настоящие рекомендации содействуют всем странам в применении рекомендаций ГПДПУФА в сочетании с пакетом технической документации «ACTIVE», где содержатся рекомендации о том, как способствовать поддержанию физической активности на всех этапах жизненного цикла в самых разных условиях. РЕЗЮМЕ viii 1 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) В связи с этим рекомендуется следующее. Детям и подросткам следует еженедельно посвящать в среднем не менее 60 минут в день занятиям физически активной деятельностью средней или высокой интенсивности, в основном с аэробной нагрузкой. Настоятельная рекомендация, средняя степень достоверности данных Физически активной деятельностью высокой интенсивности с аэробной нагрузкой, в том числе направленной на укрепление скелетно- мышечной системы, следует заниматься не реже трех раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных • небольшая физическая активность лучше, чем ее полное отсутствие; • если дети и подростки не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • детям и подросткам следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • важно предоставить всем детям и подросткам безопасные и равные возможности, а также поощрять их к участию в различных занятиях физически активной деятельностью, которые доставляли бы удовольствие, были бы разнообразными и соответствовали бы их возрасту и способностям.П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я Физическая активность детей и подростков благоприятно отражается на следующих показателях, связанных со здоровьем: состоянии физического здоровья (кардиореспираторный и мышечный тонус), состоянии кардиометаболического здоровья (артериальное давление, дислипидемия, содержание глюкозы и инсулинорезистентность), состоянии костной системы, развитии когнитивных способностей (академическая успеваемость, способность к целенаправленной деятельности), состоянии психического здоровья (уменьшение симптомов депрессии); и снижении степени ожирения. Особо малоподвижный образ жизни детей и подростков ведет к следующим негативным последствиям для их здоровья: повышению степени ожирения; ухудшению состояния кардиометаболического здоровья, физического здоровья и эмоционального/социально ориентированного поведения; а также сокращению продолжительности сна. В связи с этим рекомендуется следующее. Детям и подросткам следует сокращать продолжительность малоподвижных периодов, особенно время досуга у экрана телевизора, компьютера или другого устройства. Настоятельная рекомендация, низкая степень достоверности данных 1 GRADE - Ранжирование оценки, разработки и экспертизы рекомендаций. Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ВВЕДЕНИЕ Регулярная физическая активность является одним из ключевых защитных факторов при профилактике и лечении неинфекционных заболеваний (НИЗ), таких как сердечно-сосудистые заболевания, сахарный диабет 2-го типа и ряда онкологических заболеваний. Физическая активность также благотворно влияет на психическое здоровье, включая профилактику снижения когнитивных функций и предупреждение симптомов депрессии и тревоги; и может способствовать поддержанию оптимального веса и общего самочувствия. Глобальные оценки свидетельствуют о том, что 27,5% взрослых (1) и 81% подростков (2) не выполняют рекомендации ВОЗ 2010 г. в отношении физической активности (3), при этом в последнее десятилетие практически не наблюдалось каких-либо улучшений. Сохраняются также заметные диспропорции: данные свидетельствуют о том, что в большинстве стран девочки и женщины проявляют меньшую физическую активность, чем мальчики и мужчины, и что существуют значительные различия в уровнях физической активности между группами населения с более высоким и более низким социально-экономическим статусом, а также между странами и регионами. СФЕРА ОХВАТА Рекомендации ВОЗ по вопросам физической активности и малоподвижного образа жизни представляют собой научно обоснованные рекомендации в области общественного здравоохранения для детей, подростков, взрослых и пожилых людей в отношении уровня физической активности (регулярности, интенсивности и продолжительности), необходимого для того, чтобы обеспечить значительное улучшение состояния здоровья и снизить соответствующие риски. Впервые даются рекомендации по вопросам, касающимся взаимосвязи между малоподвижным образом жизни и показателями здоровья, а также в отношении отдельных подгрупп населения, таких как беременные женщины, женщины в послеродовом периоде и лица с хроническими патологиями и ограниченными возможностями. ЦЕЛЕВАЯ АУДИТОРИЯ Рекомендации предназначены для лиц, ответственных за разработку политики в странах с высоким, средним и низким уровнем дохода и действующих в рамках министерств здравоохранения, образования, по делам молодежи, спорта и/или социального обеспечения и защиты семьи; государственных должностных лиц, отвечающих за разработку национальных, субрегиональных и муниципальных планов по повышению физической активности и снижению распространенности малоподвижного образа жизни в отдельных группах населения и подготовку соответствующей методической документации; сотрудников неправительственных организаций, работников сектора образования, частного сектора и сектора научных исследований; а также работников здравоохранения. ПРОЦЕСС РАЗРАБОТКИ РЕКОМЕНДАЦИЙ Рекомендации были подготовлены в соответствии с положениями Пособия ВОЗ по разработке рекомендаций (4). В 2019 г. была создана группа по разработке рекомендаций (ГРР), в состав которой вошли технические эксперты и соответствующие заинтересованные стороны из всех шести регионов ВОЗ. В июле 2019 г. группа провела совещание в целях формулирования ключевых вопросов, проведения обзора баз научных данных и согласования методов, используемых при обновлении материалов и в случае необходимости при проведении дополнительных новых обзоров. В феврале 2020 г. ГРР вновь провела совещание в целях обзора информации о важнейших и значимых итоговых результатах и обсуждения вопросов, касающихся пользы и вреда, ценностей, предпочтений, осуществимости и приемлемости, а также последствий с точки зрения обеспечения равенства и использования ресурсов. Рекомендации были разработаны на основе достигнутого консенсуса и размещены в интернете для открытого обсуждения. Обновленные рекомендации в окончательном виде обобщены ниже. Таблицы GRADE 1 и профили фактических данных доступны в виде веб- приложения . Практический инструментарий по оказанию содействия принятию, распространению и выполнению рекомендаций и проведению информационных кампаний поможет правительствам и заинтересованным сторонам в их совместной работе по повышению физической активности населения и снижению распространенности малоподвижного образа жизни на всех этапах жизненного цикла. РЕКОМЕНДАЦИИ Рекомендации в области общественного здравоохранения, представленные в Рекомендациях ВОЗ по вопросам физической активности и малоподвижному образу жизни, предназначены для всех групп населения и возрастных групп от 5 до 65 лет и старше, независимо от пола, культурной принадлежности или социально- экономического статуса, и актуальны для людей с любыми способностями. Лицам с хроническими патологиями и/ или ограниченными возможностями, а также беременным женщинам и женщинам в послеродовом периоде следует по мере возможности и в силу своих способностей стараться выполнять эти рекомендации. 60 следует посвящать занятиям физически активной деятельностью средней или высокой интенсивности, в основном с аэробной нагрузкой. минут в день Не менее 3 следует заниматься физически активной деятельностью высокой интенсивности с аэробной нагрузкой, в том числе направленной на укрепление скелетно- мышечной системы. Не реже дней в неделю СЛЕДУЕТ СОКРАТИТЬ продолжительность малоподвижных периодов, особенно время досуга у экрана телевизора, компьютера или другого устройства. 2 3 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации viii 1Резюме В связи с этим рекомендуется следующее. Взрослым следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, средняя степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии взрослым следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней или высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных В связи с этим рекомендуется следующее. Всем взрослым следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Взрослым следует не менее 150-300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75-150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили дополнительную пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных ВЗРОСЛЫЕ (в возрасте 18-64 лет) ВЗРОСЛЫЕ (в возрасте 18-64 лет) 2 К раку отдельных локализаций относятся рак мочевого пузыря, молочной железы, толстой кишки, эндометрия, аденокарцинома пищевода, рак желудка и почек. • небольшая физическая активность лучше, чем ее полное отсутствие; • если взрослые не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • взрослым следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность. П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я Особо малоподвижный образ жизни взрослых ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению распространенности сердечно- сосудистых заболеваний, рака и диабета 2-го типа. Физическая активность взрослых благоприятно отражается на следующих показателях, связанных со здоровьем: снижается смертность от всех причин, в том числе от сердечно-сосудистых заболеваний, снижается заболеваемость гипертонией, раком отдельных локализаций 2, диабетом 2-го типа, улучшается психическое здоровье (снижаются симптомы тревоги и депрессии); улучшаются когнитивное здоровье и сон; также может снижаться степень ожирения. Взрослые могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных Для того, чтобы занятия приносили дополнительную пользу для здоровья, взрослым также следует выполнять силовые упражнения средней и большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных СЛЕДУЕТ СОКРАТИТЬ ЗАМЕНИТЬ НА продолжительность малоподвижных периодов занятия физически более активной деятельностью любой интенсивности (в том числе низкой интенсивности) 150 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут или не менееНе менее 75 - - Дополнительная польза для здоровья: силовые упражнения средней или большей интенсивности на все основные группы мышц. 2 Не реже дней в неделю 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут болееБолее Дополнительная польза для здоровья: или 4 5 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 1 1 2 3 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и В связи с этим рекомендуется следующее. Взрослым следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, средняя степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии взрослым следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней или высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных В связи с этим рекомендуется следующее. Всем взрослым следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Взрослым следует не менее 150-300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75-150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили дополнительную пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных ВЗРОСЛЫЕ (в возрасте 18-64 лет) ВЗРОСЛЫЕ (в возрасте 18-64 лет) 2 К раку отдельных локализаций относятся рак мочевого пузыря, молочной железы, толстой кишки, эндометрия, аденокарцинома пищевода, рак желудка и почек. • небольшая физическая активность лучше, чем ее полное отсутствие; • если взрослые не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • взрослым следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность. П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я Особо малоподвижный образ жизни взрослых ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению распространенности сердечно- сосудистых заболеваний, рака и диабета 2-го типа. Физическая активность взрослых благоприятно отражается на следующих показателях, связанных со здоровьем: снижается смертность от всех причин, в том числе от сердечно-сосудистых заболеваний, снижается заболеваемость гипертонией, раком отдельных локализаций 2, диабетом 2-го типа, улучшается психическое здоровье (снижаются симптомы тревоги и депрессии); улучшаются когнитивное здоровье и сон; также может снижаться степень ожирения. Взрослые могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных Для того, чтобы занятия приносили дополнительную пользу для здоровья, взрослым также следует выполнять силовые упражнения средней и большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных СЛЕДУЕТ СОКРАТИТЬ ЗАМЕНИТЬ НА продолжительность малоподвижных периодов занятия физически более активной деятельностью любой интенсивности (в том числе низкой интенсивности) 150 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут или не менееНе менее 75 - - Дополнительная польза для здоровья: силовые упражнения средней или большей интенсивности на все основные группы мышц. 2 Не реже дней в неделю 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут болееБолее Дополнительная польза для здоровья: или 4 5 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 2 3Резюме В связи с этим рекомендуется следующее. Всем пожилым людям следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Пожилым людям следует не менее 150-300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75-150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили ощутимую пользу для здоровья, уделять в течение недели время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных ПОЖИЛЫЕ ЛЮДИ (в возрасте 65 лет и старше) ПОЖИЛЫЕ ЛЮДИ (в возрасте 65 лет и старше) • небольшая физическая активность лучше, чем ее полное отсутствие; • если пожилые люди не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • пожилым людям следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • пожилым людям следует оставаться настолько физически активными, насколько позволяют их функциональные возможности, и соразмерять интенсивность занятий физически активной деятельностью с уровнем своего физического здоровья.П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я Особо малоподвижный образ жизни пожилых людей ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению распространенности сердечно-сосудистых заболеваний, рака и диабета 2-го типа. В связи с этим рекомендуется следующее. Пожилым людям следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, средняя степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии пожилым людям следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней или высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Физическая активность пожилых людей благоприятно отражается на следующих показателях, связанных со здоровьем: снижается смертность от всех причин, в том числе от сердечно-сосудистых заболеваний, снижается заболеваемость гипертонией, раком отдельных локализаций, диабетом 2-го типа, улучшается психическое здоровье (снижаются симптомы тревоги и депрессии), улучшаются когнитивное здоровье и сон; также может снижаться степень ожирения. У пожилых людей занятия физически активной деятельностью помогают предотвращать падения и связанный с падениями травматизм, а также препятствуют ухудшению состояния костной системы и ее функциональных возможностей. Пожилые люди могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных Для того, чтобы занятия приносили дополнительную пользу для здоровья, пожилым людям также следует выполнять силовые упражнения средней и большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных В ходе еженедельных занятий физически активной деятельностью в целях повышения функциональных возможностей и предотвращения риска падений пожилым людям следует не реже трех раз в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней и большей интенсивности. Настоятельная рекомендация, средняя степень достоверности данных 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут болееБолее Дополнительная польза для здоровья: или 150 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут не менееНе менее 75или - - силовые упражнения средней или большей интенсивности на все основные группы мышц. Дополнительная польза для здоровья: 2 Не реже дней в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней или большей интенсивности. 3 Не реже дней в неделю СЛЕДУЕТ СОКРАТИТЬ ЗАМЕНИТЬ НА продолжительность малоподвижных периодов занятия физически более активной деятельностью любой интенсивности (в том числе низкой интенсивности) 6 7 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 4 5 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и В связи с этим рекомендуется следующее. Всем пожилым людям следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Пожилым людям следует не менее 150-300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75-150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили ощутимую пользу для здоровья, уделять в течение недели время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных ПОЖИЛЫЕ ЛЮДИ (в возрасте 65 лет и старше) ПОЖИЛЫЕ ЛЮДИ (в возрасте 65 лет и старше) • небольшая физическая активность лучше, чем ее полное отсутствие; • если пожилые люди не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • пожилым людям следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • пожилым людям следует оставаться настолько физически активными, насколько позволяют их функциональные возможности, и соразмерять интенсивность занятий физически активной деятельностью с уровнем своего физического здоровья.П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я Особо малоподвижный образ жизни пожилых людей ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению распространенности сердечно-сосудистых заболеваний, рака и диабета 2-го типа. В связи с этим рекомендуется следующее. Пожилым людям следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, средняя степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии пожилым людям следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней или высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Физическая активность пожилых людей благоприятно отражается на следующих показателях, связанных со здоровьем: снижается смертность от всех причин, в том числе от сердечно-сосудистых заболеваний, снижается заболеваемость гипертонией, раком отдельных локализаций, диабетом 2-го типа, улучшается психическое здоровье (снижаются симптомы тревоги и депрессии), улучшаются когнитивное здоровье и сон; также может снижаться степень ожирения. У пожилых людей занятия физически активной деятельностью помогают предотвращать падения и связанный с падениями травматизм, а также препятствуют ухудшению состояния костной системы и ее функциональных возможностей. Пожилые люди могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных Для того, чтобы занятия приносили дополнительную пользу для здоровья, пожилым людям также следует выполнять силовые упражнения средней и большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных В ходе еженедельных занятий физически активной деятельностью в целях повышения функциональных возможностей и предотвращения риска падений пожилым людям следует не реже трех раз в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней и большей интенсивности. Настоятельная рекомендация, средняя степень достоверности данных 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут болееБолее Дополнительная польза для здоровья: или 150 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут не менееНе менее 75или - - силовые упражнения средней или большей интенсивности на все основные группы мышц. Дополнительная польза для здоровья: 2 Не реже дней в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней или большей интенсивности. 3 Не реже дней в неделю СЛЕДУЕТ СОКРАТИТЬ ЗАМЕНИТЬ НА продолжительность малоподвижных периодов занятия физически более активной деятельностью любой интенсивности (в том числе низкой интенсивности) 6 7 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 4 5Резюме Физическая активность беременных женщин и женщин в послеродовом периоде благоприятно отражается на следующих показателях, связанных со здоровьем матери и плода: снижаются риски преэклампсии, гестационной гипертензии, гестационного диабета, чрезмерного гестационного увеличения массы тела, осложнений при родах и послеродовой депрессии, а также уменьшается количество осложнений у новорожденных, исключаются негативные факторы, влияющие на вес ребенка при рождении; и также исключается повышение риска мертворождения. Всем беременным женщинам и женщинам в послеродовом периоде при отсутствии противопоказаний рекомендуется следующее. Следует регулярно заниматься физически активной деятельностью во время беременности и в послеродовой период. Настоятельная рекомендация, средняя степень достоверности данных Кроме того, женщины, которые до наступления беременности регулярно выполняли аэробные физические упражнения высокой интенсивности или занимались физически активной деятельностью, могут продолжать эту практику во время беременности и в послеродовой период. Настоятельная рекомендация, средняя степень достоверности данных Для того, чтобы физическая активность приносила ощутимую пользу для здоровья, следует уделять не менее 150 минут в неделю занятиям физически активной деятельностью средней и высокой интенсивности с аэробной нагрузкой. Настоятельная рекомендация, средняя степень достоверности данных Рекомендуется использовать различные виды аэробных и силовых физических упражнений. Также могут быть полезными дополнительные легкие упражнения на растяжку. Настоятельная рекомендация, средняя степень достоверности данных БЕРЕМЕННЫЕ ЖЕНЩИНЫ И ЖЕНЩИНЫ В ПОСЛЕРОДОВОМ ПЕРИОДЕ БЕРЕМЕННЫЕ ЖЕНЩИНЫ И ЖЕНЩИНЫ В ПОСЛЕРОДОВОМ ПЕРИОДЕ П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я • небольшая физическая активность лучше, чем ее полное отсутствие; • если беременные женщины и женщины в послеродовом периоде не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • беременным женщинам и женщинам в послеродовом периоде следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • в целях снижения риска недержания мочи можно ежедневно делать упражнения для укрепления мышц тазового дна. • Избегайте занятий физически активной деятельностью во время чрезмерной жары, особенно в условиях высокой влажности. • Не допускайте обезвоживания организма и пейте воду до, во время и после физических нагрузок. • Избегайте занятий теми видами деятельности, которые предполагают физические контакты с другими людьми; повышают риск падений; или могут ограничивать насыщение организма кислородом (например, занятия физически активной деятельностью в условиях больших высот над уровнем моря, если они не являются условиями вашей обычной жизнедеятельности). • Избегайте физических нагрузок в положении лежа на спине после первого триместра беременности. • При принятии решений относительно участия в спортивных соревнованиях или выполнения упражнений, значительно превышающих по своим нагрузкам рекомендуемые уровни, беременным женщинам следует обращаться за консультацией к врачу-специалисту. • Беременным женщинам следует проконсультироваться у своего лечащего врача по вопросу об опасных симптомах, свидетельствующих о необходимости приостановить или ограничить занятия физически активной деятельностью, и немедленно проконсультироваться с квалифицированным врачом-специалистом в случае возникновения таких симптомов. • Возвращение к активной физической деятельности после родов следует осуществлять постепенно, а также по согласованию лечащим врачом в случае родов путем кесарева сечения. К дополнительным рекомендациям относительно мер предосторожности, которые необходимо соблюдать беременным женщинам при занятии физически активной деятельностью, относятся следующие. Особо малоподвижный образ жизни беременных женщин и женщин в послеродовом периоде, как и всех взрослых, ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению распространенности сердечно- сосудистых заболеваний, рака и диабета 2-го типа. В связи с этим рекомендуется следующее. Беременным женщинам и женщинам в послеродовом периоде следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, низкая степень достоверности данных Небольшая физическая активность лучше, чем ее полное отсутствие. СЛЕДУЕТ СОКРАТИТЬ ЗАМЕНИТЬ НА продолжительность малоподвижных периодов занятия физически более активной деятельностью любой интенсивности (в том числе низкой интенсивности) 150 занятия физически активной деятельностью средней интенсивности с аэробной нагрузкой Не менее минут в неделю 8 9 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 6 7 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Физическая активность беременных женщин и женщин в послеродовом периоде благоприятно отражается на следующих показателях, связанных со здоровьем матери и плода: снижаются риски преэклампсии, гестационной гипертензии, гестационного диабета, чрезмерного гестационного увеличения массы тела, осложнений при родах и послеродовой депрессии, а также уменьшается количество осложнений у новорожденных, исключаются негативные факторы, влияющие на вес ребенка при рождении; и также исключается повышение риска мертворождения. Всем беременным женщинам и женщинам в послеродовом периоде при отсутствии противопоказаний рекомендуется следующее. Следует регулярно заниматься физически активной деятельностью во время беременности и в послеродовой период. Настоятельная рекомендация, средняя степень достоверности данных Кроме того, женщины, которые до наступления беременности регулярно выполняли аэробные физические упражнения высокой интенсивности или занимались физически активной деятельностью, могут продолжать эту практику во время беременности и в послеродовой период. Настоятельная рекомендация, средняя степень достоверности данных Для того, чтобы физическая активность приносила ощутимую пользу для здоровья, следует уделять не менее 150 минут в неделю занятиям физически активной деятельностью средней и высокой интенсивности с аэробной нагрузкой. Настоятельная рекомендация, средняя степень достоверности данных Рекомендуется использовать различные виды аэробных и силовых физических упражнений. Также могут быть полезными дополнительные легкие упражнения на растяжку. Настоятельная рекомендация, средняя степень достоверности данных БЕРЕМЕННЫЕ ЖЕНЩИНЫ И ЖЕНЩИНЫ В ПОСЛЕРОДОВОМ ПЕРИОДЕ БЕРЕМЕННЫЕ ЖЕНЩИНЫ И ЖЕНЩИНЫ В ПОСЛЕРОДОВОМ ПЕРИОДЕ П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я • небольшая физическая активность лучше, чем ее полное отсутствие; • если беременные женщины и женщины в послеродовом периоде не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • беременным женщинам и женщинам в послеродовом периоде следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • в целях снижения риска недержания мочи можно ежедневно делать упражнения для укрепления мышц тазового дна. • Избегайте занятий физически активной деятельностью во время чрезмерной жары, особенно в условиях высокой влажности. • Не допускайте обезвоживания организма и пейте воду до, во время и после физических нагрузок. • Избегайте занятий теми видами деятельности, которые предполагают физические контакты с другими людьми; повышают риск падений; или могут ограничивать насыщение организма кислородом (например, занятия физически активной деятельностью в условиях больших высот над уровнем моря, если они не являются условиями вашей обычной жизнедеятельности). • Избегайте физических нагрузок в положении лежа на спине после первого триместра беременности. • При принятии решений относительно участия в спортивных соревнованиях или выполнения упражнений, значительно превышающих по своим нагрузкам рекомендуемые уровни, беременным женщинам следует обращаться за консультацией к врачу-специалисту. • Беременным женщинам следует проконсультироваться у своего лечащего врача по вопросу об опасных симптомах, свидетельствующих о необходимости приостановить или ограничить занятия физически активной деятельностью, и немедленно проконсультироваться с квалифицированным врачом-специалистом в случае возникновения таких симптомов. • Возвращение к активной физической деятельности после родов следует осуществлять постепенно, а также по согласованию лечащим врачом в случае родов путем кесарева сечения. К дополнительным рекомендациям относительно мер предосторожности, которые необходимо соблюдать беременным женщинам при занятии физически активной деятельностью, относятся следующие. Особо малоподвижный образ жизни беременных женщин и женщин в послеродовом периоде, как и всех взрослых, ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению распространенности сердечно- сосудистых заболеваний, рака и диабета 2-го типа. В связи с этим рекомендуется следующее. Беременным женщинам и женщинам в послеродовом периоде следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, низкая степень достоверности данных Небольшая физическая активность лучше, чем ее полное отсутствие. СЛЕДУЕТ СОКРАТИТЬ ЗАМЕНИТЬ НА продолжительность малоподвижных периодов занятия физически более активной деятельностью любой интенсивности (в том числе низкой интенсивности) 150 занятия физически активной деятельностью средней интенсивности с аэробной нагрузкой Не менее минут в неделю 8 9 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 6 7Резюме Взрослым и пожилым людям с хроническими патологиями следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, низкая степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии взрослым и пожилым людям с хроническими патологиями следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней или высокой интенсивности. Настоятельная рекомендация, низкая степень достоверности данных Лицам, пережившим онкологические заболевания, а также взрослым, страдающим гипертонией и диабетом 2-го типа, и ВИЧ-инфицированным рекомендуется следующее. В связи с этим рекомендуется следующее. Всем взрослым и пожилым людям с вышеуказанными хроническими патологиями следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Взрослым и пожилым людям с этими хроническими патологиями следует не менее 150-300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75-150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных При отсутствии противопоказаний взрослые и пожилые люди, страдающие этими хроническими патологиями, могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили дополнительную пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных В ходе еженедельных занятий физически активной деятельностью в целях повышения функциональных возможностей и предотвращения риска падений пожилым людям с этими хроническими патологиями следует не реже трех раз в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней и большей интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Для того, чтобы занятия приносили дополнительную пользу для здоровья, взрослым и пожилым людям с этими хроническими патологиями также следует выполнять силовые упражнения средней и большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) Физическая активность может благоприятно отражаться на здоровье взрослых и пожилых людей со следующими хроническими патологиями: благодаря поддержанию физической активности у лиц, переживших онкологические заболевания, снижаются показатели смертности от всех причин и конкретных онкологических заболеваний, а также риск рецидива или второго первичного рака; у лиц, страдающих артериальной гипертонией, благодаря поддержанию физической активности снижаются показатели смертности от сердечно-сосудистых заболеваний, замедляется прогрессирование заболевания, улучшаются показатели физического функционирования, а также повышается качество жизни, обусловленное состоянием здоровья; у лиц, страдающих сахарным диабетом 2-го типа, благодаря поддержанию физической активности снижаются показатели смертности от сердечно-сосудистых заболеваний и замедляется прогрессирование заболевания; лицам с ВИЧ-инфекцией поддержание физической активности может помочь улучшить физическое и психическое здоровье (снизить симптомы тревоги и депрессии), не оказывая при этом негативного воздействия на прогрессирование болезни (на число CD4-клеток и вирусную нагрузку) или состав тканей организма. П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я • если взрослые с этими хроническими патологиями не в состоянии выполнять вышеперечисленные рекомендации, им следует стремиться к тому, чтобы заниматься физически активной деятельностью в соответствии со своими физическими возможностями; • взрослым с этими хроническими патологиями следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • взрослые с этими хроническими патологиями могут получить консультацию у специалиста по вопросам физической активности или медицинского работника относительно видов и объемов физически активной деятельности, соответствующих их индивидуальным потребностям, физическим возможностям, функциональным ограничениям/ осложнениями, принимаемым лекарственным средствам и общему плану лечения; • как правило, для лиц, не имеющих противопоказаний, нет необходимости в прохождении предварительного медосмотра перед началом занятий физически активной деятельностью низкой и средней интенсивности, не требующих физической подготовки дополнительно к той, которая необходима для энергичной ходьбы или в повседневной жизни. Особо малоподвижный образ жизни взрослых, в том числе переживших онкологические заболевания, страдающих артериальной гипертонией и диабетом 2-го типа, а также ВИЧ-инфицированных, ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению распространенности сердечно- сосудистых заболеваний, рака и диабета 2-го типа. выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней или большей интенсивности. 3 Не реже дней в неделю силовые упражнения средней или большей интенсивности на все основные группы мышц. Дополнительная польза для здоровья: 2 Не реже дней в неделю 150 300 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут не менееНе менее 75 150 или - - 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут болееБолее Дополнительная польза для здоровья: или СЛЕДУЕТ СОКРАТИТЬ ЗАМЕНИТЬ НА продолжительность малоподвижных периодов занятия физически более активной деятельностью любой интенсивности (в том числе низкой интенсивности) 10 11 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 8 9 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Взрослым и пожилым людям с хроническими патологиями следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, низкая степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии взрослым и пожилым людям с хроническими патологиями следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней или высокой интенсивности. Настоятельная рекомендация, низкая степень достоверности данных Лицам, пережившим онкологические заболевания, а также взрослым, страдающим гипертонией и диабетом 2-го типа, и ВИЧ-инфицированным рекомендуется следующее. В связи с этим рекомендуется следующее. Всем взрослым и пожилым людям с вышеуказанными хроническими патологиями следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Взрослым и пожилым людям с этими хроническими патологиями следует не менее 150-300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75-150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных При отсутствии противопоказаний взрослые и пожилые люди, страдающие этими хроническими патологиями, могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили дополнительную пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных В ходе еженедельных занятий физически активной деятельностью в целях повышения функциональных возможностей и предотвращения риска падений пожилым людям с этими хроническими патологиями следует не реже трех раз в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней и большей интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Для того, чтобы занятия приносили дополнительную пользу для здоровья, взрослым и пожилым людям с этими хроническими патологиями также следует выполнять силовые упражнения средней и большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) Физическая активность может благоприятно отражаться на здоровье взрослых и пожилых людей со следующими хроническими патологиями: благодаря поддержанию физической активности у лиц, переживших онкологические заболевания, снижаются показатели смертности от всех причин и конкретных онкологических заболеваний, а также риск рецидива или второго первичного рака; у лиц, страдающих артериальной гипертонией, благодаря поддержанию физической активности снижаются показатели смертности от сердечно-сосудистых заболеваний, замедляется прогрессирование заболевания, улучшаются показатели физического функционирования, а также повышается качество жизни, обусловленное состоянием здоровья; у лиц, страдающих сахарным диабетом 2-го типа, благодаря поддержанию физической активности снижаются показатели смертности от сердечно-сосудистых заболеваний и замедляется прогрессирование заболевания; лицам с ВИЧ-инфекцией поддержание физической активности может помочь улучшить физическое и психическое здоровье (снизить симптомы тревоги и депрессии), не оказывая при этом негативного воздействия на прогрессирование болезни (на число CD4-клеток и вирусную нагрузку) или состав тканей организма. П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я • если взрослые с этими хроническими патологиями не в состоянии выполнять вышеперечисленные рекомендации, им следует стремиться к тому, чтобы заниматься физически активной деятельностью в соответствии со своими физическими возможностями; • взрослым с этими хроническими патологиями следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • взрослые с этими хроническими патологиями могут получить консультацию у специалиста по вопросам физической активности или медицинского работника относительно видов и объемов физически активной деятельности, соответствующих их индивидуальным потребностям, физическим возможностям, функциональным ограничениям/ осложнениями, принимаемым лекарственным средствам и общему плану лечения; • как правило, для лиц, не имеющих противопоказаний, нет необходимости в прохождении предварительного медосмотра перед началом занятий физически активной деятельностью низкой и средней интенсивности, не требующих физической подготовки дополнительно к той, которая необходима для энергичной ходьбы или в повседневной жизни. Особо малоподвижный образ жизни взрослых, в том числе переживших онкологические заболевания, страдающих артериальной гипертонией и диабетом 2-го типа, а также ВИЧ-инфицированных, ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению распространенности сердечно- сосудистых заболеваний, рака и диабета 2-го типа. выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней или большей интенсивности. 3 Не реже дней в неделю силовые упражнения средней или большей интенсивности на все основные группы мышц. Дополнительная польза для здоровья: 2 Не реже дней в неделю 150 300 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут не менееНе менее 75 150 или - - 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут болееБолее Дополнительная польза для здоровья: или СЛЕДУЕТ СОКРАТИТЬ ЗАМЕНИТЬ НА продолжительность малоподвижных периодов занятия физически более активной деятельностью любой интенсивности (в том числе низкой интенсивности) 10 11 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 8 9Резюме ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ Во многих случаях физическая активность приносит детям и подросткам с ограниченными возможностями такую же пользу для здоровья, которую, как отмечалось в разделе выше, она приносит всем детям и подросткам. Дополнительная польза физической активности в улучшении показателей здоровья людей с ограниченными возможностями также заключается в том, что улучшаются когнитивные способности лиц с заболеваниями и расстройствами, связанными с нарушением когнитивных функций, в том числе лиц с синдромом дефицита внимания/гиперактивности (СДВГ); у детей с ограниченными интеллектуальными возможностями могут улучшаться показатели физического функционирования. • небольшая физическая активность лучше, чем ее полное отсутствие; • если дети и подростки с ограниченными возможностями не соблюдают эти рекомендации, любые занятия физически активной деятельностью пойдут на пользу их здоровью; • детям и подросткам с ограниченными возможностями следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • занятия физически активной деятельностью для детей и подростков с ограниченными возможностями не связаны с какими-либо серьезными рисками в том случае, когда они соответствуют текущему уровню физической подготовки, состоянию здоровья и показателям физического функционирования конкретного ребенка; при этом полученная в итоге польза для здоровья перевешивает возможные риски; • дети и подростки с ограниченными возможностями могут нуждаться в консультации медицинского работника или другого специалиста по вопросам физической активности и работе с лицами с ограниченными возможностями для определения видов и объема физических нагрузок, которые им подходят. П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я Особо малоподвижный образ жизни детей и подростков ведет к следующим негативным последствиям для их здоровья: повышению степени ожирения; ухудшению состояния кардиометаболического здоровья, физического здоровья и эмоционального/социально ориентированного поведения; а также сокращению продолжительности сна. В связи с этим рекомендуется следующее. Детям и подросткам с ограниченными возможностями следует сокращать продолжительность малоподвижных периодов, особенно время досуга у экрана телевизора, компьютера или другого устройства. Настоятельная рекомендация, низкая степень достоверности данных В связи с этим рекомендуется следующее. Детям и подросткам еженедельно следует посвящать в среднем не менее 60 минут в день занятиям физически активной деятельностью, в основном аэробного типа, средней или высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Физически активной деятельностью с аэробной нагрузкой высокой интенсивности, в том числе направленной на укрепление скелетно-мышечной системы, следует заниматься не реже трех раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных Следует начинать с небольших физических нагрузок. Небольшая физическая активность лучше, чем ее полное отсутствие. 3 следует заниматься физически активной деятельностью высокой интенсивности с аэробной нагрузкой, в том числе направленной на укрепление скелетно- мышечной системы. Не реже дней в неделю 60 следует посвящать занятиям физически активной деятельностью средней или высокой интенсивности, в основном с аэробной нагрузкой. Не менее минут в день СЛЕДУЕТ СОКРАТИТЬ продолжительность малоподвижных периодов, особенно время досуга у экрана телевизора, компьютера или другого устройства. 12 13 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 0 1 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ Во многих случаях физическая активность приносит детям и подросткам с ограниченными возможностями такую же пользу для здоровья, которую, как отмечалось в разделе выше, она приносит всем детям и подросткам. Дополнительная польза физической активности в улучшении показателей здоровья людей с ограниченными возможностями также заключается в том, что улучшаются когнитивные способности лиц с заболеваниями и расстройствами, связанными с нарушением когнитивных функций, в том числе лиц с синдромом дефицита внимания/гиперактивности (СДВГ); у детей с ограниченными интеллектуальными возможностями могут улучшаться показатели физического функционирования. • небольшая физическая активность лучше, чем ее полное отсутствие; • если дети и подростки с ограниченными возможностями не соблюдают эти рекомендации, любые занятия физически активной деятельностью пойдут на пользу их здоровью; • детям и подросткам с ограниченными возможностями следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • занятия физически активной деятельностью для детей и подростков с ограниченными возможностями не связаны с какими-либо серьезными рисками в том случае, когда они соответствуют текущему уровню физической подготовки, состоянию здоровья и показателям физического функционирования конкретного ребенка; при этом полученная в итоге польза для здоровья перевешивает возможные риски; • дети и подростки с ограниченными возможностями могут нуждаться в консультации медицинского работника или другого специалиста по вопросам физической активности и работе с лицами с ограниченными возможностями для определения видов и объема физических нагрузок, которые им подходят. П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я Особо малоподвижный образ жизни детей и подростков ведет к следующим негативным последствиям для их здоровья: повышению степени ожирения; ухудшению состояния кардиометаболического здоровья, физического здоровья и эмоционального/социально ориентированного поведения; а также сокращению продолжительности сна. В связи с этим рекомендуется следующее. Детям и подросткам с ограниченными возможностями следует сокращать продолжительность малоподвижных периодов, особенно время досуга у экрана телевизора, компьютера или другого устройства. Настоятельная рекомендация, низкая степень достоверности данных В связи с этим рекомендуется следующее. Детям и подросткам еженедельно следует посвящать в среднем не менее 60 минут в день занятиям физически активной деятельностью, в основном аэробного типа, средней или высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Физически активной деятельностью с аэробной нагрузкой высокой интенсивности, в том числе направленной на укрепление скелетно-мышечной системы, следует заниматься не реже трех раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных Следует начинать с небольших физических нагрузок. Небольшая физическая активность лучше, чем ее полное отсутствие. 3 следует заниматься физически активной деятельностью высокой интенсивности с аэробной нагрузкой, в том числе направленной на укрепление скелетно- мышечной системы. Не реже дней в неделю 60 следует посвящать занятиям физически активной деятельностью средней или высокой интенсивности, в основном с аэробной нагрузкой. Не менее минут в день СЛЕДУЕТ СОКРАТИТЬ продолжительность малоподвижных периодов, особенно время досуга у экрана телевизора, компьютера или другого устройства. 12 13 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 0 1Резюме В связи с этим рекомендуется следующее. Взрослым с ограниченными возможностями следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, низкая степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии взрослым с ограниченными возможностями следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней и высокой интенсивности. Настоятельная рекомендация, низкая степень достоверности данных В связи с этим рекомендуется следующее. Всем взрослым с ограниченными возможностями следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Взрослым с ограниченными возможностями следует не менее 150-300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75-150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Для того, чтобы занятия приносили дополнительную пользу для здоровья, взрослым с ограниченными возможностями также следует выполнять силовые упражнения средней и большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных ВЗРОСЛЫЕ (в возрасте 18 лет и старше) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ ВЗРОСЛЫЕ (в возрасте 18 лет и старше) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ Во многих случаях физическая активность приносит взрослым с ограниченными возможностями такую же пользу для здоровья, которую, как отмечалось в разделе выше, она приносит всем взрослым. Дополнительная польза физической активности в улучшении показателей здоровья людей с ограниченными возможностями также заключается в следующем: у взрослых, страдающих рассеянным склерозом, улучшаются показатели физического функционирования, а также физические, психологические и социальные аспекты качества жизни, обусловленного состоянием здоровья; у лиц с повреждениями спинного мозга улучшается функция ходьбы, повышается мышечная сила и улучшается функция верхних конечностей; а также улучшается качество жизни, обусловленное состоянием здоровья; у людей с заболеваниями или расстройствами, связанными с нарушением когнитивных функций, улучшаются показатели физического функционирования и когнитивной деятельности (у лиц с болезнью Паркинсона и лиц, имеющих в анамнезе инсульт); оказывается положительное воздействие на когнитивную деятельность; а также может улучшаться качество жизни (у взрослых, страдающих шизофренией); могут улучшаться показатели физического функционирования (у взрослых с ограниченными интеллектуальными возможностями); и улучшается качество жизни (у взрослых, страдающих большим депрессивным расстройством). Особо малоподвижный образ жизни взрослых ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению распространенности сердечно-сосудистых заболеваний, рака и диабета 2-го типа. Взрослые с ограниченными возможностями могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили дополнительную пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных В ходе еженедельных занятий физически активной деятельностью в целях повышения функциональных возможностей и предотвращения риска падений пожилым людям с ограниченными возможностями следует не реже трех раз в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней и большей интенсивности. Настоятельная рекомендация, средняя степень достоверности данных П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я • небольшая физическая активность лучше, чем ее полное отсутствие; • если взрослые с ограниченными возможностями не соблюдают эти рекомендации, любые занятия физически активной деятельностью пойдут на пользу их здоровью; • взрослым с ограниченными возможностями следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • занятия физически активной деятельностью для взрослых с ограниченными возможностями не связаны с какими-либо серьезными рисками в том случае, когда они соответствуют текущему уровню физической подготовки, состоянию здоровья и показателям физического функционирования конкретного человека; при этом полученная в итоге польза для здоровья перевешивает возможные риски; • взрослые с ограниченными возможностями могут нуждаться в консультации медицинского работника или другого специалиста по вопросам физической активности и работе с лицами с ограниченными возможностями для определения видов и объема физических нагрузок, которые им подходят. 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут болееБолее физически активной деятельности высокой интенсивности с аэробной нагрузкой Дополнительная польза для здоровья: или выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней или большей интенсивности. 3 Не реже дней в неделю СЛЕДУЕТ СОКРАТИТЬ ЗАМЕНИТЬ НА продолжительность малоподвижных периодов занятия физически более активной деятельностью любой интенсивности (в том числе низкой интенсивности) силовые упражнения средней или большей интенсивности на все основные группы мышц. Дополнительная польза для здоровья: 2 Не реже дней в неделю 150 300 150 минут - физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут не менееНе менее 75или - 14 15 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 2 3 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и В связи с этим рекомендуется следующее. Взрослым с ограниченными возможностями следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, низкая степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии взрослым с ограниченными возможностями следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней и высокой интенсивности. Настоятельная рекомендация, низкая степень достоверности данных В связи с этим рекомендуется следующее. Всем взрослым с ограниченными возможностями следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Взрослым с ограниченными возможностями следует не менее 150-300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75-150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Для того, чтобы занятия приносили дополнительную пользу для здоровья, взрослым с ограниченными возможностями также следует выполнять силовые упражнения средней и большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных ВЗРОСЛЫЕ (в возрасте 18 лет и старше) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ ВЗРОСЛЫЕ (в возрасте 18 лет и старше) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ Во многих случаях физическая активность приносит взрослым с ограниченными возможностями такую же пользу для здоровья, которую, как отмечалось в разделе выше, она приносит всем взрослым. Дополнительная польза физической активности в улучшении показателей здоровья людей с ограниченными возможностями также заключается в следующем: у взрослых, страдающих рассеянным склерозом, улучшаются показатели физического функционирования, а также физические, психологические и социальные аспекты качества жизни, обусловленного состоянием здоровья; у лиц с повреждениями спинного мозга улучшается функция ходьбы, повышается мышечная сила и улучшается функция верхних конечностей; а также улучшается качество жизни, обусловленное состоянием здоровья; у людей с заболеваниями или расстройствами, связанными с нарушением когнитивных функций, улучшаются показатели физического функционирования и когнитивной деятельности (у лиц с болезнью Паркинсона и лиц, имеющих в анамнезе инсульт); оказывается положительное воздействие на когнитивную деятельность; а также может улучшаться качество жизни (у взрослых, страдающих шизофренией); могут улучшаться показатели физического функционирования (у взрослых с ограниченными интеллектуальными возможностями); и улучшается качество жизни (у взрослых, страдающих большим депрессивным расстройством). Особо малоподвижный образ жизни взрослых ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению распространенности сердечно-сосудистых заболеваний, рака и диабета 2-го типа. Взрослые с ограниченными возможностями могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, для того чтобы занятия приносили дополнительную пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных В ходе еженедельных занятий физически активной деятельностью в целях повышения функциональных возможностей и предотвращения риска падений пожилым людям с ограниченными возможностями следует не реже трех раз в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней и большей интенсивности. Настоятельная рекомендация, средняя степень достоверности данных П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я • небольшая физическая активность лучше, чем ее полное отсутствие; • если взрослые с ограниченными возможностями не соблюдают эти рекомендации, любые занятия физически активной деятельностью пойдут на пользу их здоровью; • взрослым с ограниченными возможностями следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • занятия физически активной деятельностью для взрослых с ограниченными возможностями не связаны с какими-либо серьезными рисками в том случае, когда они соответствуют текущему уровню физической подготовки, состоянию здоровья и показателям физического функционирования конкретного человека; при этом полученная в итоге польза для здоровья перевешивает возможные риски; • взрослые с ограниченными возможностями могут нуждаться в консультации медицинского работника или другого специалиста по вопросам физической активности и работе с лицами с ограниченными возможностями для определения видов и объема физических нагрузок, которые им подходят. 300 150 минут физически активной деятельности средней интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут болееБолее физически активной деятельности высокой интенсивности с аэробной нагрузкой Дополнительная польза для здоровья: или выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней или большей интенсивности. 3 Не реже дней в неделю СЛЕДУЕТ СОКРАТИТЬ ЗАМЕНИТЬ НА продолжительность малоподвижных периодов занятия физически более активной деятельностью любой интенсивности (в том числе низкой интенсивности) силовые упражнения средней или большей интенсивности на все основные группы мышц. Дополнительная польза для здоровья: 2 Не реже дней в неделю 150 300 150 минут - физически активной деятельности средней интенсивности с аэробной нагрузкой физически активной деятельности высокой интенсивности с аэробной нагрузкой или аналогичное по нагрузке сочетание физической активности в течение недели минут не менееНе менее 75или - 14 15 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и : к р ат ки й о б зо р Рекомендации 2 3Резюме 14 15 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Регулярная физическая активность является общепризнанным защитным фактором при профилактике и лечении неинфекционных заболеваний, таких как сердечно-сосудистые заболевания, диабет 2-го типа, рак молочной железы и толстой кишки (1–3). Физическая активность также благотворно влияет на психическое здоровье (4), задерживает начало развития деменции (5), может способствовать поддержанию оптимального веса (1) и общего самочувствия (6). Согласно определению, физическая активность есть любое движение тела, производимое скелетными мышцами, которое требует затрат энергии (1) и может осуществляться с разной степенью интенсивности как часть работы, выполнения домашних обязанностей или передвижения, досуга, а также при занятиях спортом или участии в спортивных мероприятиях. Малоподвижный образ жизни, соответствующий нижней границе шкалы интенсивности, определяется как любая нагрузка во время бодрствования в положении сидя, лежа или полулежа, связанная с низким расходом энергии (7). Появляющиеся новые данные свидетельствуют о том, что высокая распространенность малоподвижного образа жизни приводит к возникновению сердечно- сосудистых заболеваний и диабета 2-го типа, а также к росту смертности от сердечно-сосудистых, онкологических и других заболеваний (8–10). Недостаточная физическая активность определяется как не соответствующая Глобальным рекомендациям по физической активности для здоровья 2010 г. (1) и относится к числу основных факторов, вызывающих глобальную смертность. Согласно оценкам, если бы мировое население вело более активный образ жизни, это позволило бы ежегодно предотвращать 4–5 миллионов случаев смерти (2, 11). Глобальные оценочные данные о масштабах недостаточной физической активности показывают, что в 2016 г. образ жизни 27,5% взрослых (12) и 81% подростков (13) не соответствовал рекомендациям ВОЗ 2010 г. (1), а данные о динамике свидетельствуют об ограниченном характере глобальных улучшений, достигнутых за истекшее десятилетие. Из имеющихся данных также видно, что в большинстве стран образ жизни у женщин менее активен, чем у мужчин, и что как внутри отдельных стран и регионов, так и между ними наблюдаются значительные различия в уровнях физической активности. Эти различия объясняются неравным доступом к возможностям проявления СПРАВОЧНАЯ ИНФОРМАЦИЯ 1 WHA71.6 Глобальный план действий ВОЗ по повышению уровня физической активности на 2018–2030 гг.. физической активности, что еще более усугубляет неравенство в сфере здравоохранения. В настоящее время не имеется глобальных оценочных данных о распространенности малоподвижного образа жизни, но технологические инновации и переход к более статичным видам работы и отдыха наряду с ростом масштабов использования личных автотранспортных средств способствуют изменению моделей физической активности и распространению малоподвижного образа жизни во всем мире. В Глобальном плане действий ВОЗ по повышению уровня физической активности на 2018–2030 гг. (14) предусмотрены четыре стратегические цели и 20 мер политики для достижения относительного сокращения на 15% общей распространенности недостаточной физической активности среди взрослых и подростков к 2030 г. В 2010 г. ВОЗ опубликовала Глобальные рекомендации по физической активности для здоровья (1) — первые популяционные рекомендации по общественному здравоохранению для детей, подростков, взрослых и пожилых людей. В 2018 г. Всемирная ассамблея здравоохранения в своей резолюции WHA71.61 призвала ВОЗ обновить рекомендации 2010 г. В 2019 г. ВОЗ опубликовала Руководство «Физическая активность, малоподвижный образ жизни и сон у детей в возрасте до 5 лет» (15). Цель этого руководства, составленного по инициативе Комиссии по ликвидации детского ожирения (рекомендация 4.12) (16), — восполнить пробел в связи с этой младшей возрастной группой, которая была обойдена вниманием в Глобальных рекомендациях по физической активности для здоровья 2010 г. (1). В основу Рекомендаций ВОЗ по вопросам физической активности и малоподвижного образа жизни 2020 г., заменяющего рекомендации 2010 г., заложены наиболее поздние фактологические наработки по рассматриваемым поведенческим моделям и связанным с ними последствиям для здоровья. Новые рекомендации станут составной частью свода глобальных рекомендаций в отношении физической активности и малоподвижного образа жизни. 14 15Справочная информация ДРУГИЕ КЛЮЧЕВЫЕ РЕКОМЕНДАЦИИ ВОЗ Важность физической активности для здоровья человека признана и в других рекомендациях ВОЗ. Так, в публикации «Пакет основных мероприятий ВОЗ по оказанию первичной медико-санитарной помощи в отношении неинфекционных заболеваний в условиях ограниченных ресурсов» (17), содержащей протокол клинического ведения артериальной гипертонии, диабета 2-го типа, повышенного сердечно-сосудистого риска, астмы и хронического обструктивного легочного заболевания, рекомендуется постепенно увеличивать физическую нагрузку до средних уровней (такую как энергичная ходьба) и практиковать ее как минимум 150 минут в неделю в соответствии с Глобальными рекомендациями 2010 г. Недавнее Руководство ВОЗ по снижению риска развития когнитивных расстройств и деменции (18) гласит, что для уменьшения риска снижения когнитивных способностей физически активную деятельность следует рекомендовать взрослым с нормальными когнитивными функциями (настоятельная рекомендация) и взрослым с умеренным когнитивным нарушением (условная рекомендация). В публикации ВОЗ «Интегрированный уход за пожилыми людьми: руководство по оказанию помощи на уровне местных сообществ по предотвращению снижения физических и умственных возможностей» (19) рекомендуются комплексные упражнения для предотвращения риска падений и упражнения для пожилых людей со снижающейся мобильностью. В Рекомендациях ВОЗ по оказанию дородовой помощи для формирования положительного опыта беременности (20) предлагается проконсультироваться по вопросам здорового питания и физической активности, которые позволяют поддержать хорошее самочувствие и избежать чрезмерной прибавки в весе, но при этом не стремиться во время беременности и в послеродовой период к достижению более значимого оздоровительного эффекта от физической активности. Существующие рекомендации ВОЗ в сочетании с настоящими обновленными рекомендациями составляют более широкоохватный комплекс глобальных выводов о влиянии физической активности и малоподвижного образа жизни на профилактику и ведение основных заболеваний и на улучшение здоровья и благополучия на протяжении всего жизненного цикла. ОБОСНОВАНИЕ И ЦЕЛЬ За последние 10 лет был отмечен значительный прирост фактического материала о влиянии на здоровье человека различных видов, объемов и периодов физической активности, а также о последствиях малоподвижного образа жизни и его взаимосвязи с уровнями физической активности и здоровья. Кроме того, составленная база фактических данных о физической активности в отдельных подгруппах населения, таких как беременные женщины и лица с хроническими заболеваниями и/или с ограниченными возможностями, теперь позволяет рассмотреть взаимосвязь между физической активностью и показателями здоровья в этих подгруппах. Мера 4.1 Глобального плана действий ВОЗ по повышению уровня физической активности на 2018–2030 гг. (14) предусматривает, чтобы ВОЗ разработала и распространила глобальные рекомендации по повышению уровня физической активности и снижению распространенности малоподвижного образа жизни среди детей в возрасте до 5 лет, молодых людей, взрослых, пожилых людей и определенных групп населения, таких как беременные женщины и лица с хроническими заболеваниями или ограниченными возможностями. Процесс обновления и расширения охвата рекомендаций, проводимый согласно поручению Всемирной ассамблеи здравоохранения, обеспечивает включение отдельных рекомендаций о физической активности для тех групп населения, которые не были охвачены рекомендациями 2010 г. Это согласуется с основными принципами и целями Глобального плана действий по повышению уровня физической активности, а именно со стремлением сократить неравенство и ежедневно содействовать всем группам населения в повышении уровня их физической активности. 16 17 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Главная цель настоящего документа — предоставить научно обоснованные рекомендации в области общественного здравоохранения, посвященные тому, какие объемы и виды физической активности следует практиковать детям и подросткам, взрослым, пожилым людям и таким подгруппам, как беременные женщины и лица с хроническими заболеваниями или ограниченными возможностями, чтобы обеспечить значительное улучшение состояния здоровья и снизить соответствующие риски. В нем также даются научно обоснованные рекомендации, касающиеся взаимосвязей между малоподвижным образом жизни и показателями здоровья. Настоящие рекомендации касаются детей и подростков (в возрасте 5–17 лет), взрослых (в возрасте 18–64 лет), пожилых людей (в возрасте 65 лет и старше) и впервые включают в себя отдельные рекомендации по физической активности для подгрупп населения, таких как беременные женщины и лица с хроническими заболеваниями или ограниченными возможностями. Рекомендации даются для каждой отдельной возрастной группы и подгруппы населения, чтобы обеспечить лицам, работающим с определенными общинами, прямой доступ к соответствующей информации. Составление отдельных рекомендаций для подгрупп населения, особенно для лиц с хроническими заболеваниями или ограниченными возможностями, свидетельствует о важности включения этих подгрупп в процесс выработки политики и мероприятий, касающихся физической активности и малоподвижного образа жизни. В настоящих рекомендациях сон не рассматривается в качестве образа жизни. Сон — важный аспект здоровья и новая тема в области науки о здоровье населения, но все же было решено, что включение сна в обновленные рекомендации выходит за рамки предусмотренного мандата. Тем не менее значение сна является общепризнанным, и он был включен в число важных показателей здоровья при рассмотрении вопроса о воздействии физической активности и малоподвижного образа жизни. ЦЕЛЕВАЯ АУДИТОРИЯ В настоящих рекомендациях представлена процедура разработки рекомендаций и обобщена база фактических данных, рассмотренных в ходе их разработки. Первоочередными целевыми аудиториями рекомендаций являются: (1) директивные органы министерств здравоохранения, образования, по делам молодежи, спорта и/или социального обеспечения и защиты семьи в странах с высоким, а также низким и средним уровнем дохода, занимающиеся разработкой страновых инструкций и подготовкой программ действий по вопросам здравоохранения, образования, условий труда, жилища или общин на протяжении всего жизненного цикла; (2) государственные должностные лица, отвечающие за разработку национальных, субрегиональных и муниципальных планов по повышению физической активности и сокращению масштабов малоподвижного образа жизни в отдельных группах населения с помощью методической документации; (3) сотрудники неправительственных организаций, работников сектора образования, профессиональных организаций и сектора научных исследований; (4) лица, занятые в медицинских учреждениях и лица, предоставляющие консультации и рекомендации, такие как общинные представители, члены семьи, медперсонал и врачи как первичной, так и специализированной помощи или представители смежных с медициной профессий, занятые вне сектора здравоохранения. Они могут опираться на настоящий документ при подготовке своих рекомендаций по указанным темам при отсутствии национальных руководящих материалов. Рекомендации в отношении физической активности и малоподвижного образа жизни, изложенные в документе, следует включать в материалы курсов дослужебной подготовки и повышения квалификации медицинских работников, специалистов по вопросам физической активности и работников образования. Налицо необходимость в производных продуктах данных рекомендаций, предназначенных для инструктирования определенных групп пользователей, заинтересованных сторон в секторах за пределами сферы здравоохранения и широкой общественности, которые пользуются адаптированными материалами для удовлетворения специфических потребностей каждой аудитории. 16 17Справочная информация Настоящие рекомендации были составлены в соответствии с Пособием ВОЗ по разработке руководящих принципов (второе издание) (21). Была учреждена Руководящая группа ВОЗ, возглавляемая Департаментом по вопросам укрепления здоровья, в которую вошли представители региональных бюро ВОЗ и соответствующих департаментов ВОЗ. Была также создана Группа по разработке рекомендаций (ГРР) в составе 27 экспертов и заинтересованных сторон; при ее формировании учитывались принципы гендерного равновесия и географического разнообразия. Проект рекомендаций был рассмотрен семью независимыми внешними рецензентами, которые представили свое заключение о качестве научных данных, их толковании и содержании. Кроме того, состоялось онлайновое публичное обсуждение проекта рекомендаций, после чего более 400 участников дискуссии направили свои отзывы. Эти материалы, полученные от ученых, специалистов-практиков и широкой общественности, были обработаны и использованы членами ГРР при окончательной доработке рекомендаций. Подробные сведения о координации процесса работы над рекомендациями содержатся в приложении 1. СФЕРА ОХВАТА РЕКОМЕНДАЦИЙ И РАССМАТРИВАЕМЫЕ ВОПРОСЫ ГРР рассмотрела вопрос о сфере охвата рекомендаций и на своем первом совещании согласовала наиболее актуальные аспекты, обозначенные как ГМ/ВСП (Группа населения, Мероприятие/Воздействие, Coпоставление, Показатель здоровья). Ключевые вопросы, рассмотренные по каждой подгруппе населения, обобщены следующим образом: По физической активности: a. Какова взаимосвязь между физической активностью (ФА) и показателями здоровья? b. Имеет ли место взаимосвязь «доза-реакция» (объем, продолжительность, регулярность, интенсивность)? c. Варьируется ли эта взаимосвязь в зависимости от типа или области физической активности? По малоподвижному образу жизни: a. Какова взаимосвязь между малоподвижным образом жизни (МОЖ) и показателями здоровья? b. Имеет ли место взаимосвязь «доза- реакция» (общий объем, регулярность, продолжительность и интенсивность перерывов)? c. Варьируется ли эта взаимосвязь в зависимости от типа или области малоподвижного образа жизни? d. Только для взрослых: изменяет ли физическая активность влияние малоподвижного образа жизни на смертность? Для каждой группы населения (Г) в качестве воздействия (В) на нее рассматривалось увеличение объема, продолжительности, регулярности или интенсивности физической нагрузки в сопоставлении (С) с отсутствием физической нагрузки или с физической нагрузкой меньшего объема и меньшей регулярности, интенсивности или продолжительности. Важнейшие и важные показатели здоровья для каждой группы населения обобщены в таблице 1, а подробная информация по каждому вопросу комплекса ГМ/ВСП содержится в соответствующем разделе веб-приложения «Профили фактических данных» . METОДИКА Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 18 19 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Taблица 1: Обобщение важнейших и важных* показателей здоровья по группам населения Показатели (в английском алфавитном порядке) Дети и подростки в возрасте 5–17 лет: ФА и МОЖ Взрослые в возрасте 18–64 лет: ФA Взрослые старше 18 лет: МОЖ Взрослые старше 65 лет: ФA a Беременность и послеродовой период Хронические патологии b Дети и взрослые с ограничен-ными возмож-ностями c Ожирение (набор веса, изменение веса, контроль веса, стабильность веса, статус веса и поддержание веса) Важнейший Важнейший Важнейший Важнейшийa Важнейший Важнейший – ВИЧ – Нежелательные явления Важнейший Важнейший – Важнейшийa Важнейший (исходы для плода) – – Смертность от всех причин и от конкретных причин – Важнейший (особенно онкологические заболевания и ССЗ) Важнейший Важнейшийa – Важнейший – Здоровье костной системы Важнейший – Важный – – – – Кардиометаболическое здоровье Важнейший – – – – – – Когнитивные способности Важнейший Важнейший Важный Важнейшийa – – Важнейший – MС, БП, ЛПИ, ШФ, СДВГ Осложнения при родах – – – – Важный – – Прогрессирование заболевания – – – – – Важнейший – ГT, Д2, ВИЧ, Важнейший – рецидив рака – Падения и связанный с падениями травматизм – – – Важнейший – – – Исходы для плода (вес при рождении, преждевременные роды) – – – – Важнейший – – Функциональная способность – – – Важнейший – – – Гестационный сахарный диабет – – – – Важнейший – – Гестационная гипертония/ преэклампсия – – – – Важнейший – – Качество жизни, обусловленное состоянием здоровья – Важный Важный Важный a – Важнейший – ГT, Д2, ВИЧ Важнейший – MС, ПСМ, ОИВ, БДР, ШФ Заболеваемость раком – Важнейший Важнейший Важнейшийa – – – Заболеваемость ССЗ – Важнейший Важнейший Важнейшийa – – – Заболеваемость гипертонией – Важный – Важный a – – – Заболеваемость диабетом 2-го типа – Важнейший Важнейший Важнейший a – – – Психическое здоровье (симптомы тревоги и депрессии) Важнейший Важнейший Важный Важнейший a Важнейший – – Остеопороз – – – Важнейший – – – Физическое состояние Важнейший – Важный – – – – Физическое функционирование – – Важный – – Важнейший – ГT, Д2, ВИЧ Важнейший – MС, ПСМ, ОИВ, БП, ЛПИ Просоциальное поведение Важный – – – – – – Психосоциальные показатели – – – Важный – – – Риск сопутствующих заболеваний – – – – – Важнейший – ГT, Д2, ВИЧ Важнейший – MС, ПСМ, ОИВ Сон Важный Важный Важный Важныйa – – – * Важнейший показатель здоровья: показатель, имеющий критическое значение для принятия решений; важный показатель здоровья: показатель, который важен, но не является критическим для принятия решений. a Важнейшие и важные показатели здоровья рассматриваются для взрослого населения, включая пожилых людей. b Показатели состояния здоровья по подгруппам: онкологические заболевания – лица, пережившие рак; ГT — гипертония; Д2 — диабет 2-го типа; ВИЧ. c Показатели состояния здоровья по подгруппам: MС – мышечный склероз; ПСМ – повреждение спинного мозга; ОИВ — ограниченные интеллектуальные возможности; БП — болезнь Паркинсона; ЛПИ — лица, пережившие инсульт; ШФ — шизофрения; СДВГ — синдром дефицита внимания/гиперактивности; БДР — большое депрессивное расстройство. Важнейшие и важные показатели здоровья по возрастным группам были рассмотрены и экстраполированы. 18 19Методика ФАКТИЧЕСКИЕ ДАННЫЕ В процессе пересмотра рекомендаций ВОЗ по физической активности 2010 г. были выявлены, а затем обновлены наиболее поздние из соответствующих общих обзоров, относящихся к сфере охвата настоящих рекомендаций. Применение такого подхода объяснялось наличием широкого спектра недавних систематических обзоров, проведенных для информирования органов, которые занимались разработкой ряда национальных рекомендацией в отношении физической активности. В ходе дополнительного обновления принимались меры к тому, чтобы в новых рекомендациях ВОЗ были отражены самые последние данные, которые имеются в быстро эволюционирующей сфере общественного здравоохранения. Общие обзоры отбирались по трем следующим критериям: (i) если обзоры фактических данных были проведены в соответствии со стандартными, официально оформленными систематическими процедурами; (ii) если для оценки достоверности фактических данных применялся метод ранжирования оценки, разработки и экспертизы рекомендаций (GRADE) или какая-либо эквивалентная, подробно описанная и задокументированная методика; и (iii) если обзоры фактических данных были посвящены группам населения, представляющим интерес для авторов рекомендаций, и при этом не ограничивались какими-либо странами или уровнем дохода стран. Вопросы комплекса ГМ/ВСП наряду с важнейшими и важными показателями здоровья проецировались на имеющиеся обзоры фактических данных, после чего при необходимости запрашивалось проведение новых, дополнительных обзоров для восполнения обнаруженных пробелов. ГРР поручила обновить обзоры фактических данных, используя те же поисковые запросы, те же языки поиска и базы данных, которые были задействованы в первоначальных обзорах. Следующие обзоры фактических данных были признаны соответствующими трем вышеупомянутым критериям и отобраны за их новизну и всеохватность: • Poitras et al. (2016) Систематический обзор публикаций о взаимосвязи между физической активностью и показателями здоровья среди детей и молодежи школьного возраста (22), проведенный в рамках процесса разработки Канадой рекомендаций относительно подвижности на 24-часовой период для детей и молодежи (23). В этом обзоре рассматривались лишь те исследования, в которых были использованы объективные измерения параметров физической активности. Обзор в целом охватывал 162 исследования, представлявших 204 171 участника из 31 страны. • Carson et al. (2016) Систематический обзор публикаций о взаимосвязи между малоподвижным образом жизни и показателями здоровья среди детей школьного возраста (24), проведенный в рамках процесса разработки Канадой рекомендаций относительно подвижности на 24-часовой период для детей и молодежи (23). Обзор в целом охватывал 235 исследований (194 отдельных выборки), представлявших 1 657 064 участника из 71 cтраны. • Okely et al. (2019) (25) Систематический обзор, проведенный с целью обновления публикаций Poitras et al. (2016) (22) и Carson et al. (2018) (24) в рамках разработки Австралией рекомендаций относительно подвижности на 24-часовой период для детей и молодежи (в возрасте 5–17 лет) 2019 г. (26). В этом докладе было рассмотрено 42 дополнительных исследования о физической активности и 32 — о малоподвижном образе жизни, опубликованных за период до июля 2018 г. (25). Tаблицы, составленные по методу GRADE в ходе исследования Okely et al., были использованы в качестве основы для порученного обновления, проведенного усилиями ВОЗ. Таблицы GRADE вместе с профилями фактических данных представлены в веб-приложении «Профили фактических данных» . • Двенадцать систематических обзоров, проведенных и обобщенных в рамках процесса разработки Канадой рекомендаций относительно физической активности в период беременности 2019 г. (27). В этих 12 обзорах оценено более 25 000 соответствующих исследований на английском, испанском и французском языках по вопросу о физической активности будущих матерей в период беременности, в которых сообщались данные о материнской, внутриутробной или неонатальной заболеваемости или внутриутробной смертности. В семи из упомянутых систематических обзоров рассматривались показатели здоровья, которые ГРР признала важнейшими и важными (28–34). Таблицы GRADE, включенные в эти обзоры фактических данных, были приняты за основу для поиска публикаций, который был проведен в целях обновления данных и передачи информации для разработки рекомендаций ВОЗ. Обновленные профили фактических данных представлены в веб приложении «Профили фактических данных» . • Научный доклад Консультативной группы по руководящим принципам физической активности (PAGAC) (35), в котором проведено систематическое обновление фактических данных о физической активности и малоподвижном образе жизни и показателей здоровья, опубликованных в 2008–2016 гг. в рамках разработки Рекомендаций относительно физической активности для американцев (второе издание) (36). В обобщенном фактическом материале было рассмотрено в общей сложности 38 основных исследовательских вопросов и 104 подвопроса, отобранных в связи с их актуальностью для общественного здравоохранения. Представленный материал включал в себя результаты систематических обзоров, охватывавших в целом 1130 статей, причем из каждой статьи были взяты выдержки для ответов на 38 упомянутых исследовательских вопросов (35). В протоколах была использована модифицированная версия измерительного инструмента для оценки систематических обзоров (AMSTARExBP), с помощью которого оценивалось методологическое качество систематических обзоров и метаанализов. По каждому первоначальному исследованию была проведена оценка риска необъективности, или процедура внутреннего подтверждения, для которой использовалась адаптированная версия инструмента для оценки необъективности USDA NEL (BAT) (37). Новый фактический материал, собранный в результате проведения обновленных поисков для настоящих рекомендаций ВОЗ, представлен в профилях фактических данных в веб-приложении «Профили фактических данных» ; даются ссылки на доклад и на дополнительные материалы PAGAC (35). Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf20 21 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Meтоды обновления фактического материала и извлечение данных Предметом поиска систематических обзоров и сводных анализов когортных исследований являлись исследования, опубликованные с даты последних поисков каждого из отобранных обзоров (перечисленных выше) до сентября 2019 г.; были разработаны и применены стандартизированные протоколы извлечения данных. Для обновления материалов, представленных в публикациях Poitras et al. (2016) (22), Carson et al. (2016) (24) и Okely et al. (2019) (25), были проведены поиски по базам данных MEDLINE, EMBASE, PsycINFO и SportDiscus на предмет выявления рецензированных обзоров на английском или французском языках. Для обновления результатов поиска, проведенного PAGAC (35), были обследованы базы данных PubMed, CINAHL и Cochrane на предмет выявления рецензированных обзоров на английском языке. Новый поиск по важным показателям здоровья в случаях, когда соответствующие данные не фигурировали в материалах PAGAC (35), из-за ограниченности ресурсов провести не удалось. Поиски проводились без ограничений по странам или уровню дохода стран и охватывали обзоры, в которых рассматривались те или иные субъективные или объективные измерения параметров физической активности или малоподвижного образа жизни. Было решено не проводить поисков на других языках, кроме языков первоначальных исследований, учитывая ресурсные ограничения и предшествующий опыт в этой области, согласно которому поиски такого рода весьма редко приводят к выявлению дополнительных обзоров. Принимались во внимание обзоры, в которых была рассмотрена взаимосвязь между физической активностью или малоподвижным образом жизни и показателями здоровья (исходя из уровней, находящихся выше или ниже какой-либо пороговой величины физической активности или малоподвижного образа жизни), a также обзоры, где исследовалась взаимосвязь «доза реакция» между активностью/ малоподвижностью и параметрами состояния здоровья. Для ранжирования степени достоверности рассматриваемых систематических обзоров на предмет их включения в выборку внешняя исследовательская группа использовала инструмент AMSTAR 2 (Оценка множественных систематических обзоров) (38). Инструмент AMSTAR 2 включает в себя 16 критериев, касающихся планирования и проведения обзора. Общее доверие к результатам каждого обзора ранжировалось согласно опубликованной инструкции: «высокий» рейтинг доверия означает, что в обзоре имеется не более одного некритичного недостатка; рейтинг «средний» указывает, что анализ выявил в обзоре более одного некритичного недостатка; рейтинг «низкий» свидетельствует о том, что в обзоре была обнаружена одна серьезная ошибка наряду с некритичными недостатками или без таковых, либо несколько некритичных недостатков; наконец, рейтинг «крайне низкий» означает, что в обзоре выявлено более одной серьезной ошибки. Один из исследователей провел с помощью инструмента AMSTAR 2 оценку всех обзоров, которые были ранее включены в выборку. Обзоры, оцененные одним исследователем как «крайне низкие», были повторно рассмотрены вторым исследователем с помощью того же инструмента. В результате обзоры, получившие «крайне низкий» рейтинг, были изъяты из выборки как признанные слишком ненадежными для предоставления точного и всеобъемлющего обобщения имеющихся фактических данных, за исключением случаев, когда такой обзор был единственным имеющимся источником по какому-либо конкретному показателю. В этот массив фактических данных были также включены сводные когортные исследования. Для оценки качества исследований внешняя исследовательская группа использовала шкалу Ньюкасла-Оттавы (39). Каждому исследованию была присвоена качественная оценка «хорошо», «удовлетворительно» или «неудовлетворительно». Как правило, качественное исследование соответствовало всем критериям шкалы Ньюкасла-Оттавы. Исследование удовлетворительного качества не соответствовало или неявно соответствовало хотя бы одному критерию этой шкалы, а также не имело известных существенных ограничений, которые могли бы обесценить его результаты. Исследование неудовлетворительного качества содержало одну критическую ошибку или несколько существенных ограничений; такие исследования были исключены из выборки. Кроме того, была проведена оценка на дублирование, поскольку не исключалась возможность совпадения исследований в рамках многочисленных обзоров. Обзоры, в которых содержались излишние комплексы фактических данных, краткие описания обзоров и некоторые из сводных когортных исследований исключались из выборки в случаях, когда обнаруживались другие, более полные и/или свежие обзоры. Meтоды проведения новых обзоров При обнаружении пробелов в имеющихся фактических данных назначались новые общие обзоры для рассмотрения: (1) взаимосвязи между профессиональной (т. е. связанной с работой) физической активностью и показателями здоровья (40); и (2) взаимосвязи между досуговой физической активностью и негативными показателями здоровья (41); (По пунктам 1 и 2 выше поиски проводились с использованием PubMed, SportDiscus и EMBASE в отношении обзоров, опубликованных с 2009 г. по декабрь 2019 г.) (3) взаимосвязи между физической активностью и профилактикой падений; при этом были использованы материалы публикации Sherrington et al. «Систематический обзор Кокрейновского сотрудичества» 2019 г. (42), обновленные путем включения данных, опубликованных с даты последнего поиска в этом первоначальном обзоре до ноября 2019 г.; (4) взаимосвязи между физической активностью и остеопорозом и саркопенией; в процессе поиска существующих систематических обзоров по проблемам остеопороза и саркопении, проведенного по базе PubMed среди обзоров, опубликованных с 2008 г. по ноябрь 2019 г., новых обзоров выявлено не было, но при этом удалось обнаружить восемь новых первичных исследований; 20 21Методика (5) фактических данных о взаимосвязи между физической активностью и показателями здоровья лиц с ВИЧ-инфекцией. Обзорный анализ подтвердил наличие фактических данных о физической активности и показателях здоровья среди лиц с ВИЧ-инфекцией и послужил основанием для проведения общего обзора, который охватывал фактические данные, опубликованные до октября 2019 г., без ограничения по исходной дате; поиск осуществлялся по базам PubMed, CINAHL и Web of Science. Резюме характеристик фактических данных и методов оценки физической активности и малоподвижного образа жизни До недавнего времени первичной методикой измерения параметров физической активности и малоподвижного образа жизни среди взрослых являлся анализ данных самооценки респондентов (т. е. обследований), а среди детей — либо их самооценки, либо сведений от родителей. Хотя эти методы пользуются общепризнанным авторитетом, им свойственны ограничения, к числу которых относятся возможная необъективность информации и погрешность измерения (43). В последние годы, отмеченные активным внедрением цифровой технологии в эту сферу, наблюдается рост масштабов использования аппаратных средств оценки физической активности и малоподвижного времяпровождения и их взаимосвязи с показателями здоровья. При этом, однако, остаются проблемы, связанные с сопоставлением результатов исследований, обусловленные различиями между техническими аспектами и размещением разнообразных устройств (акселерометров), a также различиями в процедурах анализа и представления данных. Так, при измерении времени пребывания в малоподвижном состоянии с помощью аппаратных средств возможны ошибки в расчетах, поскольку многие устройства пока не умеют различать положения тела (например, дифференцировать положения лежа, сидя и стоя неподвижно). Трудности встречаются и при сопоставлении выводов исследований, проведенных с применением аппаратных средств, с результатами исследований, основанных на собственных сообщениях респондентов. Инструменты самооценки различаются по своему содержанию, по примерам физической активности, вариантам ответов и охватываемым сферам. До недавнего времени исследования были прежде всего сосредоточены исключительно на оценке либо общей физической активности, либо досуговой/ рекреационной физической активности; теперь же они все чаще охватывают другие области, такие как физическая активность при передвижении (например, ходьба или езда на велосипеде), на работе или дома. Большинство фактических данных касается взаимосвязи между аэробной нагрузкой и показателями здоровья, однако нынешние исследования посвящены оценке благотворного влияния силовых упражнений, а также сочетаниям различных видов нагрузок и другим областям. Результаты исследований о взаимосвязи между уровнями физической активности и показателями здоровья публикуются и сопоставляются в различных странах. Во многих исследованиях даются сравнения между квартилями или квинтилями физической активности; другие исследования посвящены сопоставлению показателей лиц, «выполняющих» и «не выполняющих» национальные рекомендации. Когда сообщаются данные расчета общей физической активности, они обычно выражены в MET-часах в неделю, и в некоторых исследованиях сравниваются «высшие» и «низшие» показатели, хотя соответствующие категории также варьируются в зависимости от исследований. В публикациях нередко сообщаются результаты анализов с применением величин пограничных значений, основанных на какой-либо существующей рекомендации, на нынешних Глобальных рекомендациях ВОЗ или на количественных показателях из предыдущего поиска (например, на пограничных значениях, составляющих 60 минут в день из поиска данных о молодом населении, или на регулярности в 2–3 раза в неделю для силовых тренировок). Когда такие пограничные значения становятся обычной практикой, процесс получения фактических данных o взаимосвязи между влиянием более высоких или более низких уровней физической активности на показатели здоровья может быть ограничен. Основная часть фактических данных об оценке взаимосвязи между малоподвижным образом жизни и показателями здоровья для детей и подростков носит межсекторальный характер, а большинство исследований опирается на данные самооценки или сообщения родителей об измерении времени пребывания в малоподвижном состоянии, которые могут страдать от погрешностей в измерениях и ошибок памяти. Приоритетное внимание уделялось результатам продольных наблюдательных исследований и экспериментальных разработок, а обзоры, где в исключительном или первоочередном порядке были обобщены межсекторальные фактические данные, во внимание не принимались. Повышенный интерес вызывали данные из обзоров, которым был присвоен уровень достоверности от среднего и выше, а также из обзоров, содержащих данные исследований, проведенных с применением аппаратных измерений воздействия. Ранжирование фактических данных Метод ранжирования оценки, разработки и экспертизы рекомендаций (GRADE) был использован для квалификации уровня достоверности фактических данных по каждому аспекту ГМ/ВСП (44) исходя из тех материалов, которые были заложены в основу обзоров. За отправную точку оценки каждого обзора принимались таблицы GRADE «Профили фактических данных» или «Резюме выводов», когда таковые фигурировали в обзоре. В случаях, когда таблицы в существующих систематических обзорах отсутствовали, для каждой группы населения и каждого показателя здоровья, представляющих интерес, были составлены таблицы «Профиль фактических данных». Метод GRADE применялся для ранжирования достоверности фактических данных по каждому аспекту ГМ/ВСП (44) с учетом следующих критериев: плана исследования; риска необъективности; последовательного 22 23 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и характера эффекта; косвенности; точности эффекта; и других ограничений, включая искаженность публикации и факторы повышения рейтинга эмпирических данных (масштабы последствий, «доза-ответ» и влияние неопределенностей). Рейтинг эмпирических данных из успешно проведенных продольных исследований также был повышен, чтобы более адекватно отражать возросший уровень достоверности сформулированных в этих исследованиях выводов о взаимосвязи между физической активностью или малоподвижным образом жизни и показателями здоровья. Результаты исследований, в которых оценивались непосредственные/косвенные показатели здоровья, не всегда понижались в рейтинге, т. к. эти показатели (в том числе промежуточные) являлись предметом приоритетного внимания ГРР; метод ранжирования GRADE отражает достоверность факторов воздействия на эти показатели здоровья. В ряде случаев рейтинги существующих обзоров, присвоенные по методу GRADE, были изменены для обеспечения последовательности в применении методики GRADE. Достоверность фактических данных по каждому показателю здоровья определялась согласно следующей рекомендации (45): Высокая Очень высокая степень доверия к тому, что реальные последствия близки к оценочным данным об этих последствиях. Средняя Средняя степень доверия к оценкам последствий: вероятно, реальные последствия близки к оценочным данным об этих последствиях, но не исключены и существенные отличия. Низкая Доверие к оценке последствий носит ограниченный характер: реальные последствия могут существенно отличаться от оценочных данных об этих последствиях. Очень низкая Весьма незначительное доверие к оценке последствий: вероятно, реальные последствия существенно отличаются от оценочных данных об этих последствиях. От фактических данных к рекомендациям Для разработки рекомендаций по конкретным вопросам ГРР применила механизм GRADE «Обоснование для решений» (ОДР). Механизм ОДР обеспечивает систематический, структурированный и транспарентный подход к принятию решений. В нем используются эксплицитные критерии формулирования рекомендаций для настоящего документа с учетом фактических исследовательских данных, достоверности данных и при необходимости — экспертных заключений и тематических знаний с точки зрения целевой аудитории. Эти критерии позволяют делать осознанные выводы о балансе между наблюдаемыми свидетельствами желательных и нежелательных результатов, общей достоверности фактических данных, относительной значимости желательных и нежелательных результатов для пациентов, в соответствующих случаях – о расходе ресурсов (стоимостных факторах), потенциальном воздействии на проявления неравенства в здравоохранении, приемлемости и целесообразности рекомендаций. ГРР полностью рассмотрела фактические данные для каждой рекомендации по всем важнейшим показателям здоровья и по всем имеющимся важным показателям здоровья. По отдельным случаям связи между воздействием/мероприятием и результатом исследования значительно различались в части, касающейся конкретного оцениваемого воздействия/мероприятия, оцениваемых результатов, плана исследования и методов анализа, что приводило к разнородности получаемых свидетельств. Поэтому было невозможно применять классический подход GRADE к каждому конкретному случаю связи между воздействием/мероприятием и результатом; вместо этого методика GRADE была применена к общему своду фактических данных по каждому случаю связи между воздействием/мероприятием и результатом, по всем типам и вариантам планов исследования измерений и анализов воздействия/мероприятия. Когда эти факторы вызывали беспокойство по поводу согласованности фактических данных (т. е. о том, что данные о связи определенного случая воздействия/мероприятия с результатом при их рассмотрении разными способами не совпадают), Группа понижала рейтинг достоверности таких данных (21). При рассмотрении последствий физической активности и малоподвижного образа жизни ГРР уделяла приоритетное внимание таким параметрам здравоохранения, как снижение показателей смертности от всех причин и смертности от конкретных причин (сердечно- сосудистых и онкологических заболеваний); сокращение масштабов распространения сердечно-сосудистых заболеваний; онкологические заболевания (отдельных локализаций); диабет 2-го типа; улучшение физического состояния (например, кардиореспираторных функций, моторного развития и мышечного тонуса); улучшение кардиометаболического здоровья (например, таких показателей, как артериальное давление, дислипидемия, уровень глюкозы, инсулинорезистентность); здоровье костной системы; психическое здоровье (например, уменьшение симптомов депрессии, чувство собственного достоинства, симптомы тревоги, СДВГ); улучшение когнитивных способностей (например, академической успеваемости, управляющей функции); и снижение ожирения. При этом были рассмотрены и отрицательные последствия (например, травмы и причинение вреда). Дополнительные факторы При рассмотрении каждой группы населения и всех вопросов, связанных с ГМ/ВСП, ГРР также принимала во внимание ценностные ориентиры и предпочтения лиц, охватываемых настоящими рекомендациями; ресурсные потребности для выполнения предлагаемых рекомендаций; последствия с точки зрения справедливости в области здравоохранения; и приемлемость и целесообразность рекомендаций. Учитывая значительную степень дублирования указанных факторов и оценок ГРР, для каждой группы населения в раздел «Обоснование рекомендаций» включено резюме дискуссий, посвященных оценкам этих элементов. 22 23Методика Рекомендации в области общественного здравоохранения, представленные в Рекомендациях ВОЗ по вопросам физической активности и малоподвижного образа жизни, предназначены для всех групп населения и возрастных групп от 5 до 65 лет и старше, независимо от пола, культурной принадлежности или социально-экономического статуса, и актуальны для лиц с ограниченными возможностями. Новые рекомендации структурированы по возрастным группам и образу жизни (физическая активность и малоподвижность). Каждому комплексу рекомендаций предшествует вступление, где обобщаются показатели здоровья, сопряженные соответственно с физической активностью и с малоподвижным образом жизни, после чего следуют сами рекомендации. Далее представлен ряд практических наблюдений для более углубленного пояснения о том, как представители целевой группы населения могут безопасно следовать данным рекомендациям. Эти практические наблюдения не являются «ступенчатыми рекомендациями» per se; они составлены на основе научных данных и практических соображений, пересмотренных и рекомендованных ГРР. Каждый комплекс рекомендаций сопровождается кратким изложением обосновывающих его научных данных, которые распределены по трем вопросам ГМ/ВСП; сначала приводятся данные о связях с важнейшими показателями здоровья, за которыми следует резюме данных о взаимосвязи «доза-ответ». В конце дается резюме данных o взаимосвязи между различными видами или областями воздействия и показателями здоровья, если такая взаимосвязь существует. РЕКОМЕНДАЦИИ П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я 24 25 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Подтверждающие фактические данные и обоснование При подготовке настоящих рекомендаций в отношении детей и подростков были использованы систематические обзоры (22, 25, 35), обновленные материалами 16 новых обзоров, которые были признаны соответствующими критериям включения. С полной информацией о методах, извлечении данных и профилях фактических данных можно ознакомиться в веб-приложении «Профили фактических данных» . Физическая активность детей и подростков благоприятно отражается на следующих показателях здоровья: состоянии физического здоровья (кардиореспираторный и мышечный тонус), кардиометаболическом здоровье (артериальное давление, дислипидемия, содержание глюкозы и инсулинорезистентность), состоянии костной системы, развитии когнитивных способностей (академическая успеваемость, управляющая функция), состоянии психического здоровья (уменьшение симптомов депрессии); и снижении степени ожирения. В этой связи рекомендуется следующее. Детям и подросткам следует еженедельно посвящать в среднем не менее 60 минут в день занятиям физически активной деятельностью средней и высокой интенсивности, в основном с аэробной нагрузкой. Настоятельная рекомендация, средняя степень достоверности данных Физически активной деятельностью высокой интенсивности с аэробной нагрузкой, в том числе направленной на укрепление скелетно-мышечной системы, следует заниматься не реже трех раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Дети и подростки могут заниматься физически активной деятельностью в рамках отдыха и досуга (подвижные игры, занятия спортом или плановые тренировки), физического воспитания, передвижений (использование колесных средств, ходьба и езда на велосипеде) или выполнения домашних обязанностей, то есть в образовательном, домашнем и общинном контексте. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО ФИЗИЧЕСКОЙ АКТИВНОСТИ ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) • небольшая физическая активность лучше, чем ее полное отсутствие; • если дети и подростки не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • детям и подросткам следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • важно предоставить всем детям и подросткам безопасные и равные возможности, а также поощрять их к участию в различных занятиях физически активной деятельностью, которые доставляли бы удовольствие, были бы разнообразными и соответствовали бы их возрасту и способностям.П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я 24 25Рекомендации Какова взаимосвязь между физической активностью и показателями здоровья у детей и подростков (в возрасте 5–17 лет)? Ранее в обширных фактических материалах было установлено, что увеличение объема и повышение интенсивности физических нагрузок приводят к многочисленным улучшениям показателей здоровья у детей и подростков (1). Недавно полученные данные подтверждают, что увеличение физической активности у детей и подростков приводит к улучшению кардиореспираторного здоровья и состояния скелетно-мышечной системы (22, 35). Например, позитивные результаты приносят занятия физически активной деятельностью средней и высокой интенсивности продолжительностью 30–60 минут не реже трех раз в неделю (22, 35). Регулярные, в основном аэробные физические нагрузки у детей и подростков благоприятно отражаются на показателях кардиометаболического здоровья, включая улучшение артериального давления, липидного спектра, содержания глюкозы и инсулинорезистентности (35). В недавно проведенных обзорах была рассмотрена эффективность школьных программ физической активности (46), интервальных тренировок высокой интенсивности (47) и тренировок сопротивления (48) в сравнении с отсутствием мероприятий по поддержанию кардиометаболического здоровья. Во всех трех обзорах были представлены последовательные фактические данные о том, что такие мероприятия приводили к улучшению кардиометаболических показателей, хотя полученные данные варьировались по уровню их эффективности, а ряд индивидуальных исследований показал статистически значимую пользу физической активности для всех кардиометаболических показателей. Согласно одному обзору по 19 РКИ (n= 11 988) (46), школьные программы физической активности приводили к статистически значимым улучшениям показателей диастолического артериального давления (КС= 0,21 [95% ДИ: 0,42 – 0,01]; p= 0,04) и уровня инсулина натощак (КС= 0,12 [95% ДИ: 0,42 – 0,04]; p= 0,03) по сравнению с отсутствием физически активных мероприятий. Сообщалось, что физически активная деятельность благоприятно воздействует на ожирение и что повышение уровней такой деятельности может обеспечивать поддержание нормального веса у детей и подростков (22, 35). Если наиболее высокие результаты обычно свойственны поперечным исследованиям, то результаты проспективных обсервационных исследований более неоднозначны; это ограничивает возможность осмысления направленности сообщаемых взаимосвязей. В более поздних обзорах испытаний, связанных с мероприятиями в сфере физической активности (лабораторные интервальные ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) тренировки высокой интенсивности [ИТВИ], активное классное обучение, тренировки на сопротивление), были представлены результаты, которые не соответствовали большинству исследований, включенных в обзоры, где не сообщалось о каком-либо эффекте (47, 49, 50). При этом в одном обзоре продольных и поперечных исследований было отмечено наличие негативной взаимосвязи между физической нагрузкой, измеренной с помощью шагомера, и замерами ожирения, ИМТ или охвата талии (51). В целом же полученные фактические данные о том, что физическая активность способствует поддержанию нормального веса, имеют низкую достоверность, и для выявления направленности и прочности такой взаимосвязи необходимы дополнительные исследования. Меньший объем фактических данных получен об анализе взаимосвязи между физической активностью и развитием моторики у детей и подростков; при этом в нынешних обзорах показываются нулевые результаты (22). Для подготовки последующих рекомендаций необходимы дополнительные исследования по моторному развитию как показателю здоровья. Физически активной деятельностью для укрепления костной системы дети и подростки могут заниматься во время подвижных игр, бега, вращений или прыжков. Физическая активность позитивно влияет на прирост костной массы и/или костную структуру; недавние фактические материалы свидетельствуют о том, что дети и подростки, которые физически активнее своих сверстников, имеют более значительную костную массу, более высокие показатели содержания костных минералов или плотности костной ткани, а также более высокую прочность кости (35). Maксимальное укрепление здоровья костной системы в детском и подростковом возрасте может способствовать защите от остеопороза и сопутствующих переломов в более поздние периоды жизни. Развитие и поддержание когнитивных функций остается крайне важным на протяжении всей жизни. У детей и подростков физическая активность благотворно сказывается на их когнитивных функциях и академической успеваемости (например, на результатах школьного обучения, памяти и управляющей функции) (22, 35). Как показал один недавний обзор (19 РКИ; n= 5038), спортивные тренировки несколько раз в неделю в течение шести или более недель обеспечивают более заметный прогресс в показателях когнитивных функций, таких как ингибиторный контроль (СРС 0,26 [95% ДИ: 0,08–0,45], p= < 0,01); кратковременная память (СРС 0,10 [95% ДИ: -0,05–0,25], p= < 0,02) и когнитивная гибкость (СРС 0,14 [95% ДИ: -0,03–0,31], p= < 0,04), по сравнению с отсутствием тренировок (52). Кроме того, физическая активность не только снижает риск наступления депрессии и появления депрессивных симптомов у детей и подростков с последующей глубокой депрессией или без таковой (35), но и по своей эффективности в снижении симптомов 26 27 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и она может быть сопоставима с психологической или лекарственной терапией. Хотя любые физические нагрузки сопряжены с определенным риском причинения вреда (53), имеются весьма ограниченные сведения о причинении вреда от физически активной деятельности на уровнях, рекомендуемых для улучшения состояния здоровья (35). На основе имеющихся фактических данных и экспертного заключения был сделан вывод о том, что потенциальные риски в связи с объемами и видами физической активности, рекомендуемыми для детей и подростков, являются незначительными (35) и могут сокращаться при постепенном повышении уровня и интенсивности нагрузки, особенно для неактивных детей и подростков. Известно, что занятие некоторыми видами спорта, как и повышение интенсивности тренировок, увеличивают травмоопасность (53). Для укрепления научной базы в этой области необходимы дополнительные исследования. Выводы ГРР • Получены фактические данные среднего уровня достоверности о том, что увеличение объема физической активности средней и высокой интенсивности у детей и подростков способствует улучшению кардиореспираторного здоровья и мышечного тонуса, кардиометаболического здоровья и состояния костной системы. • Получены фактические данные среднего уровня достоверности о том, что кратко- и долгосрочная физическая активность средней и высокой интенсивности позитивно влияет на когнитивные функции, академическую успеваемость и психическое здоровье. • Получены фактические данные низкого уровня достоверности о том, что физическая активность благотворно влияет на поддержание нормального веса у детей и подростков. • Получены фактические данные низкого уровня достоверности о том, что риски, связанные с объемами и видами физической активности, рекомендуемыми для детей и подростков, являются незначительными и перевешиваются ее позитивными эффектами. Имеется ли взаимосвязь «доза-ответ» (объем, продолжительность, регулярность, интенсивность)? Хотя массив данных, указывающих на наличие позитивной взаимосвязи между физической активностью и показателями здоровья у детей и подростков, является значительным, исследования о рассмотрении взаимосвязи «доза-ответ» весьма немногочисленны. Поэтому вопрос о точной конфигурации кривой «доза-ответ» и/или наличии ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) пороговых величин физической активности (позволяющих дифференцировать низкий и высокий риски) и конкретных показателей здоровья в случае детей и подростков не столь ясен, как для взрослых групп населения. Тем не менее обширный фактический материал показывает, что большинство выгод для здоровья приобретается при ежедневной физической активности продолжительностью 60 минут (22, 35), и при отсутствии свидетельств противного был сделан вывод о том, что обновленные фактические данные подтверждают нынешнюю рекомендацию ВОЗ о целесообразности занятий физически активной деятельностью средней и высокой интенсивности ежедневно в течение 60 минут (1). Однако рассмотрение всех фактических данных, включая результаты недавних исследований, проведенных с помощью аппаратных измерений физической активности, не позволило подтвердить уточнение о «минимальной» 60-минутной ежедневной пороговой величине продолжительности средней и высокой интенсивности физических нагрузок для улучшения здоровья, поскольку в исследованиях для оценки благотворного влияния физической активности на показатели здоровья широко использовалась «средняя» 60-минутная ежедневная пороговая величина, а не минимальный ежедневный порог, составляющий 60 минут. В итоге обзор показал, что формулировку новой рекомендации следует изменить, чтобы она точнее отражала эти фактические данные. Полезное влияние регулярной высокоинтенсивной деятельности на показатели кардиометаболического здоровья уже было установлено в предшествующий период (1), а недавние обзоры позволили получить дополнительные подтверждающие данные (35). Так, один из недавних обзоров (54) показал, что интервальные тренировки высокой интенсивности в сравнении с продолжительными тренировками средней интенсивности оказывают умеренное позитивное воздействие на кардиореспираторное здоровье (СРС= 0,51 [95% ДИ: 0,33– 0,69], p= < 0,01; I2= 0%). Не было получено данных о том, что продолжительность активности, методика тренировок, соотношение «упражнение/отдых» и общее число серий изменяют воздействие на кардиореспираторное здоровье. Эти результаты в целом соответствуют материалам других недавних обзоров (22, 35, 47) и дают основания подтвердить рекомендацию о том, что молодежи и подросткам следует регулярно заниматься физически активной деятельностью высокой интенсивности для улучшения состояния кардиореспираторного здоровья. Выводы ГРР • Фактические данные подтверждают предыдущую рекомендацию ВОЗ о том, что физически активной деятельностью средней и высокой интенсивности следует заниматься 60 минут в день. 26 27Рекомендации • Имеющиеся данные указывают на необходимость замены предыдущего уточнения о «минимальной» 60-минутной ежедневной пороговой величине продолжительности физической активности на еженедельную «среднюю» пороговую величину, составляющую 60 минут в день, что точнее отражает полученный фактический материал. • Получены фактические данные среднего уровня достоверности о том, что увеличение объема физической активности высокой интенсивности способствует улучшению кардиореспираторного здоровья. Варьируется ли эта взаимосвязь в зависимости от вида или области физической активности? У детей и подростков физическая активность включает в себя развлечения и подвижные игры, спорт, передвижения, досуг, физическое воспитание или плановые тренировки в рамках их деятельности в семейной, школьной и общинной среде. Однако, поскольку прямое сопоставление различных видов или областей физической активности детей и подростков проводилось лишь в немногих исследованиях, не удалось получить достаточные фактические данные, с помощью которых можно было бы определить, варьируется ли взаимосвязь между физической активностью и показателями здоровья в зависимости от вида физической активности (например, аэробные упражнения в сравнении с силовыми) или от области такой активности (например, активное передвижение (ходьба и велосипед) в сравнении с физическим воспитанием и спортом/досугом). ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) Получены фактические данные о том, что увеличение объема аэробной физической активности средней и высокой интенсивности приводит к улучшению кардиореспираторного здоровья детей и подростков и что увеличение силовых нагрузок повышает их мышечный тонус. Эти данные были приняты во внимание при подготовке Глобальных рекомендаций ВОЗ по физической активности для здоровья 2010 г. (1), в которых предлагалось заниматься деятельностью, укрепляющей костно-мышечную систему, не реже трех раз в неделю. Обновленные данные подтвердили, что регулярное выполнение силовых упражнений три раза в неделю приводит к эффективному улучшению показателей мышечного тонуса; при этом не удалось получить достаточный фактический материал, позволяющий конкретно указать продолжительность и интенсивность тренировки, что объясняется прежде всего разнородностью нагрузок, которые оценивались в публикациях (22, 35). Меньше фактических данных имеется о защитном воздействии тренировок сопротивления на кардиометаболическое здоровье. Учитывая отсутствие новой информации о характеристиках, помимо регулярности силовых тренировок для детей и подростков, например о продолжительности нагрузки, невозможно уточнить какие-либо дополнительные детали. Дальнейшее исследование следует посвятить оздоровительному воздействию конкретных видов и областей физической активности, чтобы придать этому компоненту рекомендаций более специфический характер. Вывод ГРР • Получены фактические данные среднего уровня достоверности о том, что силовые упражнения следует выполнять не реже трех раз в неделю. 28 29 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Подтверждающие фактические данные и обоснование Малоподвижный образ жизни не был включен в Рекомендации ВОЗ 2010 г., однако в течение прошлого десятилетия наблюдался рост числа исследований, в которых рассматривались показатели здоровья, обусловленные различными мерами и видами малоподвижного образа жизни. Развитие технологий и цифровых средств коммуникации повлияло на работу, учебу, путешествия и досуговое времяпровождение людей. В большинстве стран дети и подростки теперь посвящают больше времени малоподвижному образу жизни, особенно во время досуга, например экранным развлечениям (телевидению и компьютерам) и цифровым средствам коммуникации, таким как мобильные телефоны. При подготовке настоящих рекомендаций в отношении детей и подростков были использованы систематические обзоры (24, 25), обновленные материалами семи новых обзоров, которые были признаны соответствующими критериям включения. С полной информацией о методах, извлечении данных и профилях фактических данных можно ознакомиться в веб-приложении «Профили фактических данных» . Особо малоподвижный образ жизни детей и подростков ведет к следующим негативным последствиям для их здоровья: повышению степени ожирения; ухудшению состояния кардиометаболического здоровья, физического здоровья и эмоционального/социально ориентированного поведения; а также к сокращению продолжительности сна. В этой связи рекомендуется следующее. Детям и подросткам следует сокращать продолжительность малоподвижных периодов, особенно экранное время досуга. Настоятельная рекомендация, низкая степень достоверности данных Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Малоподвижный образ жизни определяется как время, проводимое в состоянии бодрствования в положениях сидя или лежа при низком расходе энергии в учебных, домашних и общинных условиях, а также при передвижении. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО МАЛОПОДВИЖНОГО ОБРАЗА ЖИЗНИ ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) 28 29Рекомендации Какова взаимосвязь между малоподвижным образом жизни и показателями здоровья у детей и подростков (в возрасте 5–17 лет)? Фактические данные показывают, что увеличение времени, посвящаемого малоподвижному образу жизни, особенно экранного времени досуга, приводит к ухудшению показателей здоровья (24 35). Например, увеличение продолжительности экранного времени (включая просмотр телевизора) влечет за собой ухудшение состояния физического здоровья и кардиометаболического здоровья (24, 25) детей и подростков. Фактические материалы исследований, посвященных аппаратной оценке взаимосвязи между малоподвижным образом жизни и активными мероприятиями, дали скромные результаты; при этом более значимый результат был показан в отношении лиц, уже имеющих избыточный вес (55). Получены ограниченные данные, согласно которым малоподвижный образ жизни детей и подростков не имеет отношения к здоровью их костной системы. Несмотря на еще более неоднозначные результаты, фактические данные также показывают, что малоподвижный образ жизни может быть связан с неблагоприятным воздействием ожирения (24, 25). Согласно выводам одного обзора, посвященного в основном поперечным исследованиям, ежедневное малоподвижное состояние (измеряемое как общий объем экранного времени) в течение более двух часов имеет несомненную связь с избыточным весом/ ожирением у детей по сравнению с меньшими уровнями (< 2 часов в день) (56). При этом другой обзор 20 поперечных исследований (57) не выявил статистически значимой взаимосвязи между малоподвижными видеоиграми и индексом массы тела у детей или подростков. Объемный анализ 29 систематических обзоров позволил сделать вывод, что результаты многих исследований указывают на наличие неблагоприятной взаимосвязи между малоподвижным образом жизни и маркерами жировой ткани у молодежи, когда самооценка ее поведения выявляет ту или иную форму экранного времени (55). Однако в анализе отмечалось, что масштаб такой взаимосвязи незначителен, а в исследованиях, проведенных с применением аппаратной оценки малоподвижного времяпровождения, во многих случаях он и вовсе признан нулевым (55). Исследования мероприятий выявили скромный эффект, который, однако, был более значительным в случае лиц, уже имеющих избыточный вес (55). Для установления взаимосвязи между малоподвижным образом жизни и показателями ожирения требуется дополнительное исследование. Хотя эта область исследований все еще нова, некоторые фактические данные уже указывают на возможное наличие негативной взаимосвязи между малоподвижностью детей и подростков и их благополучием и качеством жизни, а также ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) неблагоприятной взаимосвязи между появлением у них депрессии и проведением досуга у экранов (58, 59). Например, особо малоподвижный образ жизни, оцениваемый как объем экранного времени, и некоторые аспекты пользования компьютером могут вызывать ухудшение психического здоровья (24). Согласно еще одному недавнему обзору, в пяти из восьми исследований была обнаружена взаимосвязь между малоподвижным образом жизни и появлением симптомов тревоги, хотя результаты этих исследований различались в зависимости от применяемых измерений малоподвижного образа жизни (60). Другие фактические данные показывают, что особо длительные периоды просмотра телевизора и занятия видеоиграми в значительной степени связаны с неблагоприятными показателями эмоционального/ социально ориентированного поведения (24); и что повышенный объем экранного времени и просмотра телевизора связан с сокращением времени сна, хотя взаимосвязь между использованием компьютера/видеоиграми и продолжительностью сна при этом не обнаружена (61). Исследование взаимосвязи между малоподвижным образом жизни и психическим здоровьем – это динамично развивающее направление с целым рядом неизвестных аспектов, и обратная зависимость здесь, скорее всего, является очевидной. Для установления направленности и прочности этой взаимосвязи необходимо дополнительное исследование. Выводы ГРР • Получены фактические данные низкого уровня достоверности о том, что особо малоподвижный образ жизни (экранное время) является существенной причиной ухудшения физического состояния и кардиометаболического здоровья у детей и подростков. • Получены фактические данные с уровнями достоверности от очень низкого до среднего о том, что особо малоподвижный образ жизни (экранное время, просмотр телевизора и видеоигры) является существенной причиной неблагоприятных показателей психического здоровья и эмоционального/социально ориентированного поведения у детей и подростков. • Получены фактические данные низкого уровня достоверности о том, что увеличение малоподвижных периодов (экранное время и просмотр телевизора) оказывает вредное воздействие на продолжительность сна у детей и подростков. • Позитивный эффект от сокращения малоподвижных периодов у детей и подростков перевешивает негативные аспекты. Имеется ли взаимосвязь «доза-ответ» (общий объем, продолжительность, регулярность, интенсивность прерывания)? Достаточных фактических данных, позволяющих определить, существует ли взаимосвязь «доза-ответ» между временем пребывания детей и подростков в малоподвижном состоянии (включая экранное время досуга) и показателями здоровья, пока не имеется. Данные об оценке взаимосвязи между малоподвижным образом жизни детей и подростков и их показателями здоровья носят в основном поперечный характер 30 31 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и и имеют низкую степень достоверности по рейтингу GRADE; при этом большинство исследований основано на самооценочных или представленных родителями данных о количестве времени пребывания в малоподвижном состоянии, в которых возможны погрешности измерения и ошибки памяти. Однако имеются данные о том, что сокращение времени пребывания в малоподвижном состоянии, по-видимому, позитивно влияет на показатели здоровья, а взаимосвязь между малоподвижным образом жизни и негативными показателями здоровья обычно оказывается прочнее для малоподвижного образа жизни в случаях, когда оно оценивается как время просмотра телевизора или экранное время досуга в качестве переменной величины воздействия, а не как общий объем времени, проведенного в малоподвижном состоянии. При этом фактические данные были признаны в целом недостаточными для указания конкретных ограничений такого времени. Получение фактических данных о том, что малоподвижный образ жизни связан с ухудшением показателей здоровья, может являться результатом либо прямого эффекта малоподвижного образа жизни, либо переключения времяпровождения на более активные виды деятельности, либо обоих этих факторов. Хотя некоторые исследования указывают на наличие взаимосвязи между экранным временем детей и подростков и негативными показателями их здоровья, общее время пребывания в малоподвижном состоянии (оцененное в ходе исследований с применением аппаратного измерения малоподвижного образа жизни) постоянно не увязывается с состоянием показателей здоровья, если при этом учитывать время, затраченное ими на физически активную деятельность средней и высокой интенсивности (62). Верно и обратное: фактические данные, указывающие на связь физической активности средней и высокой интенсивности с позитивными показателями здоровья, убедительны и подробно описаны в различных контекстах; замена части времени пребывания в малоподвижном состоянии на физическую активность (особенно на физически активную деятельность средней и высокой интенсивности) может привести к улучшению показателей здоровья. Исследования по изучению связи и взаимодействия между малоподвижным образом жизни, физической активностью и показателями здоровья динамично развиваются, и результаты аппаратных измерений малоподвижного образа жизни и состояния кардиометаболического здоровья указывают на ослабление этой связи в случаях, когда учитывается физическая активность средней и высокой интенсивности (т. е. при статистической корректировке) (62–64). Таким образом, для получения дополнительных данных об этой взаимосвязи и их учета в будущих рекомендациях необходимы дальнейшие проспективные исследования с проведением аппаратных измерений воздействия. ДЕТИ И ПОДРОСТКИ (в возрасте 5-17 лет) Выводы ГРР • Получены фактические данные низкого уровня достоверности о том, что особо длительный малоподвижный образ жизни приводит к ухудшению показателей здоровья. • Достаточных данных для уточнения ограничений времени, проводимого в малоподвижном состоянии, не имеется. • Замена времени, проводимого в малоподвижном состоянии, на физическую активность средней и высокой интенсивности может привести к улучшению показателей здоровья. Варьируется ли эта взаимосвязь в зависимости от вида или области малоподвижного образа жизни? Изучение влияния малоподвижного образа жизни на здоровье человека является сравнительно новым исследовательским направлением. Выводы, по сути, делаются на основе результатов исследований, проводимых с применением различных инструментов и измерений воздействия. Часто используются такие понятия, как воздействие, оцениваемое как «общее время, проведенное в малоподвижном состоянии», и время пребывания в малоподвижном состоянии за «экранами» или «просмотром телевизора». Имеющиеся фактические данные показывают, что взаимосвязь между малоподвижным образом жизни и негативными показателями здоровья, как правило, более очевидна применительно к просмотру телевизора или экранному времени досуга, чем к общему времени пребывания в малоподвижном состоянии (24, 35). Возросшее применение аппаратной оценки малоподвижного образа жизни при проведении более поздних исследований позволяет наращивать объем знаний и в сочетании со стандартизированной отчетностью будет содействовать подготовке будущих рекомендаций. Общепризнано, что не все виды малоподвижного образа жизни дают негативный результат. Фактические данные показывают, что некоторые из них, например чтение и выполнение домашних заданий вне школы, способствуют повышению академической успеваемости, т. е. результаты деятельности различаются в зависимости от ее вида (24, 25). Малоподвижный образ жизни может включать в себя время, расходуемое на образовательные занятия/учебу, на спокойные игры или на социальное общение без использования электронных средств. Tакие занятия (например, чтение, складывание головоломок, рисование, рукоделие, пение, музицирование) важны для развития ребенка и обеспечивают когнитивный и иной позитивный эффект. ГРР признала следующее. • Некоторые малоподвижные виды деятельности детей и подростков благоприятно отражаются на их когнитивных функциях и социальном взаимодействии. • Объем данных о вредном воздействии малоподвижного образа жизни на здоровье, как правило, более значителен в части просмотра телевизора или экранного времени досуга, чем общего времени пребывания в малоподвижном состоянии. 30 31Рекомендации Физическая активность взрослых благоприятно отражается на следующих показателях здоровья: снижается смертность от всех причин, в том числе от сердечно-сосудистых заболеваний, снижается заболеваемость гипертонией, раком отдельных локализаций 1 и диабетом 2-го типа, улучшается психическое здоровье (снижаются симптомы тревоги и депрессии); улучшаются когнитивное здоровье и сон; также может снижаться степень ожирения. В этой связи рекомендуется следующее. Всем взрослым следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Взрослым следует не менее 150–300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75–150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, чтобы занятия приносили дополнительную пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Чтобы занятия приносили дополнительную пользу для здоровья, взрослым также следует выполнять силовые упражнения средней или большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных Взрослые могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных Взрослые могут заниматься физически активной деятельностью в рамках отдыха и досуга (подвижные игры, занятия спортом или плановые тренировки), передвижений (использование колесных средств, ходьба и езда на велосипеде), работы или выполнения домашних обязанностей, то есть в повседневном профессиональном, образовательном, домашнем и общинном контексте. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО ФИЗИЧЕСКОЙ АКТИВНОСТИ 1 К раку отдельных локализаций относятся рак мочевого пузыря, молочной железы, толстой кишки, эндометрия, аденокарцинома пищевода, рак желудка и почек. ВЗРОСЛЫЕ (в возрасте 18-64 лет) • небольшая физическая активность лучше, чем ее полное отсутствие; • если взрослые не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • взрослым следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность. П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я 32 33 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Подтверждающие фактические данные и обоснование При подготовке настоящих рекомендаций были использованы и обновлены обобщенные фактические данные, собранные Консультативным комитетом Соединенных Штатов по руководящим принципам физической активности (PAGAC) (35). ГРР рассмотрела весь массив фактических данных, включая как выводы самого PAGAC, так и материалы 28 обзоров и трех сводных когортных исследований, опубликованные за период с 2017 по ноябрь 2019 г., которые соответствовали критериям включения и расширяли объем информации о взаимосвязи между физической активностью и показателями здоровья у взрослых. Кроме того, были назначены два общих обзора для восполнения пробелов в фактических данных и рассмотрения (i) взаимосвязи между профессиональной (т. е. связанной с работой) физической активностью и показателями здоровья (40); и (ii) взаимосвязи между досуговой физической активностью и негативными показателями здоровья (41). В ходе этих общих обзоров было выявлено соответственно 36 и 15 систематических обзоров. Приоритетное внимание уделялось результатам продольных наблюдательных исследований и экспериментальных разработок, а обзоры, где в исключительном или первоочередном порядке были обобщены межсекторальные фактические данные, во внимание не принимались. Повышенный интерес вызывали данные из обзоров, которым был присвоен уровень достоверности от среднего и выше, а также из обзоров, содержащих данные исследований, которые были проведены с применением аппаратных измерений воздействия. С полной информацией о методах, извлечении данных и профилях фактических данных можно ознакомиться в веб-приложении «Профили фактических данных» . Какова взаимосвязь между физической активностью и показателями здоровья у взрослых (в возрасте 18–64 лет)? Взаимосвязь между физической активностью и смертностью от всех причин/смертностью от сердечно-сосудистых заболеваний у взрослых уже широко известна (1). Выводы недавних обзоров подтвердили, что в сравнении с самыми низкими уровнями физической активности более высокие уровни нагрузки способствуют снижению риска смертности. Новые данные исследований, проведенных с применением аппаратных измерений физической активности, подтвердили и расширили доказательства того, что в сравнении с самыми низкими уровнями физической активности любой уровень и все степени интенсивности (включая легкую интенсивность) физической активности способствуют снижению риска смертности (65). Например, в сравнении с наименьшей активностью (при эталонном значении 1,00) скорректированный показатель ОР для квартилей общей физической активности снижался по квартилям физической активности следующим образом: 2-й квартиль (0,48 [95% ДИ: 0,43–0,54]); 3-й квартиль (0,34 [95% ДИ: 0,26–0,45]); и 4-й квартиль (0,27 [95% ДИ: 0,23–0,32]) (65). Новые фактические данные также подтвердили широко известную (1) обратную взаимосвязь между физической активностью и смертностью от сердечно-сосудистых заболеваний (66). Полезное воздействие физической активности на снижение заболеваемости сердечно-сосудистыми болезнями и гипертонией тщательно задокументировано (1). Физическая активность стимулирует целый ряд физиологических реакций, способствующих позитивным кратко- и долгосрочным автономным и гемодинамическим адаптациям, что приводит к уменьшению риска гипертонии — одного из ключевых факторов, вызывающих сердечно-сосудистые заболевания. Фактические данные подтвердили наличие обратной взаимосвязи между физической активностью и ВЗРОСЛЫЕ (в возрасте 18-64 лет) заболеваемостью гипертонией среди взрослых с нормальным артериальным давлением и тот факт, что физическая активность способствует снижению артериального давления у взрослых с прегипертонией и нормальным артериальным давлением (35). Широко известно наличие обратной взаимосвязи между физической активностью взрослых и развитием у них диабета 2-го типа (1). Недавно полученные фактические данные подтвердили наличие обратной криволинейной взаимосвязи между большими объемами физической активности и заболеваемостью диабетом 2-го типа (35), с наблюдаемым снижением кривой при росте уровней физической нагрузки. Один из новых обзоров показал, что данный эффект последовательно наблюдается у лиц различного происхождения с пониженным риском развития диабета 2-го типа при «самом высоком» уровне физической активности в сравнении с «самым низким» уровнем среди: неиспаноязычных белых (КР= 0,71 [95% ДИ: 0,60–0,85]); азиатов (КР= 0,76 [95% ДИ: 0,67–0,85]); испаноязычных (КР= 0,74 [95% ДИ: 0,64–0,84]); и американских индейцев (КР= 0,73 [95% ДИ: 0,60–0,88]), хотя эффект среди неиспаноязычных чернокожих был незначительным (КР= 0,91 [95% ДИ: 0,76–1,08]) (67). Данные показывают, что эффект не изменяется в зависимости от веса и что обратная взаимосвязь между ростом физической активности и снижением заболеваемостью диабетом 2-го типа наблюдается у лиц с нормальным весом, избыточным весом или ожирением (35). Широко известна взаимосвязь между высоким уровнем физической активности и снижением рисков рака толстой кишки и рака молочной железы (1). В предыдущих обзорах фактических данных было установлено, что более высокие уровни физической активности способствуют снижению риска развития рака молочной железы и рака толстой кишки (1). После масштабного роста физической активности и проведения онкологических исследований получены новые данные, которые показывают, что более высокие уровни физической активности содействуют еще и уменьшению риска развития рака мочевого пузыря, эндометрии, аденокарциномы пищевода, рака желудка и почек, а также подтверждают, 32 33Рекомендации что физические нагрузки защищают от рака молочной железы и рака толстой кишки (35). Более высокие уровни физической активности приводят к снижению рисков приблизительно на 10–20% (35). Например, в одном обзоре сообщалось о наличии обратной взаимосвязи с риском рака печени при сопоставлении высоких уровней физической активности с ее низкими уровнями (ОР= 0,75 [95% ДИ: 0,63–0,89]) (68). Пока не получено достаточных подтверждений взаимосвязи между ростом физической активности и снижением рисков гемобластоза, рака головы и шеи, яичников, поджелудочной железы, простаты, щитовидной железы, прямой кишки и мозга (35). Хотя фактические данные указывают на снижение риска рака легких при сопоставлении самых высоких уровней физической активности с самыми низкими, такие выводы можно спутать с последствиями употребления табака; поэтому было решено, что имеющихся данных в целом недостаточно для подтверждения такой связи. Взаимосвязь между физической активностью и ожирением во взрослых группах населения подтверждена менее явно, несмотря на наличие крупного, хотя и разнородного массива данных об оценке этой взаимосвязи на основе различных показателей результата (увеличение массы тела, изменение веса, контроль веса, стабильность веса, состояние массы тела и поддержание веса) (35, 69, 70). Фактические материалы в целом показывают, что повышение уровня физической активности может оказывать более благоприятное воздействие на ожирение и замедление увеличение массы тела у взрослых (35). Для получения последовательных результатов и подтверждения установленных взаимосвязей необходимо дополнительное исследование. Объем исследований, посвященных физической активности и психическому здоровью, когнитивным способностям и сну, существенно возрос после составления Глобальных рекомендаций ВОЗ по физической активности для здоровья 2010 г. (1). На тот момент имелись достаточные данные только для вывода о том, что физическая активность может приводить к уменьшению риска депрессии или ослабления когнитивных функций во взрослых группах населения. Новые фактические материалы, пересмотренные в ходе подготовки настоящих рекомендаций, показали, что у взрослых, занимающихся физически активной деятельностью более высокого уровня по сравнению с более низким уровнем, снижается риск развития тревоги и депрессии. Например, у взрослых с высокими уровнями физической активности по сравнению с низкими уровнями наблюдалось снижение шансов развития симптомов тревоги (ССШ= 0,81 [95% ДИ: 0,69–0,95]) (71) или депрессии (ССШ= 0,78 [95% ДИ: 0,70–0,87) (72). Повышенные объемы физических нагрузок средней и высокой интенсивности приводят к улучшению когнитивных способностей (например, скорости обработки информации, памяти и управляющей функции) (35), функций и структуры мозга и к снижению риска развития когнитивных нарушений, в том числе болезни Альцгеймера (73–76). Фактические данные охватывали несколько групп взрослого населения, представляющих спектр состояний от нормального до нарушенного когнитивного здоровья, и позитивные эффекты физической активности наблюдались по целому ряду видов, включая аэробную нагрузку, ходьбу, силовые упражнения и йогу (74). Имеются фактические данные о том, что как интенсивные тренировочные серии, так и регулярная физическая активность улучшают у взрослых показатели сна и качества жизни, обусловленного состоянием здоровья (35). Данные исследований взаимосвязи между физической активностью и симптомами депрессии, симптомами тревоги и развитием тревоги и депрессии показали, что физическая активность приводит к сокращению симптомов тревоги (77, 78) и сокращению симптомов депрессии (77, 79). Все виды физической активности связаны с определенным риском. Фактические данные назначенного обзора, посвященного негативным эффектам, травмам и вреду в связи с досуговой физической активностью у взрослых (41), указывают на наличие неблагоприятной взаимосвязи между уровнями досуговой физической активности и травмами скелетно- мышечной системы, а также на наличие благоприятной взаимосвязи между досуговой физической активностью и риском перелома и началом коленного или бедренного остеоартрита. Дополнительные имеющиеся данные (35) свидетельствуют о том, что внезапные нежелательные сердечно-сосудистые явления носят редкий характер и связаны с активными тренировочными сеансами довольно высокой интенсивности. В целом же риски нежелательных явлений крайне невелики, когда физические нагрузки имеют среднюю интенсивность и когда рост регулярности, интенсивности и продолжительности нагрузок происходит постепенно (35). Выводы ГРР • Получены фактические данные высокого уровня достоверности о том, что физически активная деятельность любого уровня и любой интенсивности способствует снижению риска смертности от всех причин и смертности от сердечно-сосудистых заболеваний, заболеваемости гипертонией, сердечно-сосудистыми заболеваниями и диабетом 2-го типа. • Получены фактические данные от среднего до высокого уровня достоверности о наличии взаимосвязи между ростом уровней физической активности и снижением риска рака отдельных локализаций. • Получены фактические данные среднего уровня достоверности, подтверждающие взаимосвязь между физической активностью и улучшением показателей психического здоровья, когнитивного здоровья и сна. • Получены фактические данные о взаимосвязи между ростом уровней физической активности и более благоприятным воздействием на ожирение и замедлением увеличения массы тела у взрослых. • Получены фактические данные низкого уровня достоверности о том, что физическая активность, рекомендуемая для взрослых, не окажет вредного воздействия и что польза такой активности для здоровья перевешивает риски. ВЗРОСЛЫЕ (в возрасте 18-64 лет) 34 35 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Имеется ли взаимосвязь «доза-ответ» (объем, продолжительность, регулярность, интенсивность)? Общие фактические данные, касающиеся показателей сердечно-сосудистого и метаболического здоровья, демонстрируют наличие последовательной криволинейной обратной взаимосвязи «доза-ответ» между физической активностью и основными конечными результатами, такими как смертность от всех причин, смертность от сердечно-сосудистых заболеваний, заболеваемость диабетом 2-го типа (67) и раком отдельных локализаций у взрослых. Как видно на рисунке 1, форма кривой «доза-ответ» указывает на отсутствие нижнего порога для полезного воздействия, а наибольшая польза просматривается на нижнем конце кривой «доза- ответ» (65). Данные о наличии такой криволинейной обратной взаимосвязи последовательно указываются в исследованиях, проводимых с применением различных измерений физической активности. Важный новый материал был представлен в метаанализе восьми проспективных когортных исследований со средним сроком последующего наблюдения 5,8 года (диапазон 3–14,5 года) (65); в нем были указаны значения относительного риска (ОР) для квартилей oбщей физической активности с использованием аппаратных измерений воздействия и смертности от всех причин. Результаты показали наличие взаимосвязи «доза-ответ» при росте объема физической активности и пользе от более высоких уровней нагрузки при любой интенсивности в сопоставлении с наименьшей активностью (при эталоне 1,00): 2-й квартиль (ОР= 0,48 [95% ДИ: 0,43–0,54]); 3-й квартиль (ОР= 0,34 [95% ДИ: 0,26–0,45]); и 4-й квартиль (ОР= 0.27 [95% ДИ: 0,23–0,32]). Maксимальное снижение рисков в условиях физически активной деятельности средней и высокой интенсивности наблюдалось при нагрузке продолжительностью 24 минуты в день (или 168 минут в неделю), что почти соответствует рекомендуемой продолжительности, составляющей 150 минут в неделю, и обеспечивает новые данные аппаратных измерений, подтверждающие нынешнюю общую установку для взрослых о занятии физически активной деятельностью в течение 150–300 минут в неделю (65). Эти выводы созвучны фактическим материалам, полученным как из имеющихся обзоров (35), так и из новых выявленных обзоров (66). В верхней части кривой более высокие уровни физической активности продолжают оказывать благоприятное воздействие на снижение риска смертности при отсутствии возрастания риска вреда. Например, результаты нового обзора с выводами метаанализа индивидуальных данных, полученных путем аппаратных измерений воздействия (65), показывают, что, хотя сниженный риск смертности наблюдается вплоть до 750 минут еженедельной физической нагрузки средней и высокой интенсивности, относительный риск смертности стабилизируется за пределами 300 минут в неделю. Эти результаты согласуются с предыдущими фактическими данными, которые последовательно указывали, что увеличение физической активности приносит дополнительные выгоды здоровью, хотя на более высоких уровнях нагрузки относительная польза сокращается (35, 80, 81). Однако для точного определения уровня физической активности взрослых, при котором начинается снижение полезного эффекта для здоровья, этих данных недостаточно. Фактические данные также подтвердили наличие широко известной обратной взаимосвязи между физической активностью и смертностью от сердечно- сосудистых заболеваний, обеспечив дополнительные доказательства соотношения «доза-ответ» в значениях, намного превышающих нынешние рекомендуемые объемы физической активности. Метаанализ 48 проспективных исследований оценки физической активности (общий объем, Рисунок 1. Кривая взаимосвязи «доза-реакция» ВЗРОСЛЫЕ (в возрасте 18-64 лет) Еженедельная физическая активность (в минутах) РИ СК И И ВР ЕД ПО ЛЬ ЗА П ол ьз а д л я зд ор ов ья и ф и зи че ск ог о со ст оя н и я Малоподвижный образ жизни Рекомендуемый диапазон 150 300 34 35Рекомендации досуговая и профессиональная активность) позволил получить дополнительные сведения о взаимосвязи «доза-ответ» (66) со значительным превышением объемов физической активности, рекомендуемых в настоящее время. По сравнению с рекомендуемым уровнем, составляющим 750 MET-минут в неделю, участие в физически активной деятельности на уровне 5000 MET минут в неделю (1000 минут активной деятельности средней интенсивности) приводило к значительному снижению риска смертности от сердечно-сосудистых заболеваний (ОР= 0,73 [95% ДИ: 0,56–0,95]) (66). Согласно предыдущей рекомендации ВОЗ (1), аэробную нагрузку следует выполнять сериями продолжительностью не менее 10 минут. Однако новые данные, полученные с помощью аппаратных оценок, показывают, что физическая активность любой продолжительности, без минимальной пороговой величины, приводит к улучшению показателей здоровья, включая смертность от всех причин (65, 82). Например, новые фактические материалы, полученные в результате обзоров исследований, посвященных оценке физической активности методом акселерометрии, подтверждают наличие аналогичных взаимосвязей между всеми показателями физической активности и уровнем смертности от всех причин с относительным риском 0,27 от общей физической активности, 0,28 для 5-минутных серий и 0,35 для 10-минутных серий при сопоставлении высших и низших квартилей (83). Эти результаты, подтвержденные выводами нового обзора Ekelund et al. 2019 (65), свидетельствуют о том, что физическая нагрузка, выполняемая в течение серии любой продолжительности, обеспечивает улучшение показателей здоровья, включая уровень смертности от всех причин (82). На основании новых фактических данных рекомендация о нагрузке сериями по 10 минут была отменена. Хотя было признано, что фактические данные, указывающие на наличие взаимосвязи между ростом уровней физической активности и снижением риска рака отдельных локализаций, в целом согласуются между собой, достаточные доказательства для определения конкретных уровней физической активности, которым соответствуют сообщаемые показатели снижения риска, получить не удалось, поскольку оценки и классификации воздействия в различных исследованиях были весьма неоднородны. В то же время нет фактических данных, позволяющих предположить, что существует какой- либо минимальный порог, ниже которого физическая активность не приносит никакой очевидной пользы; это означает, что физическая нагрузка любого уровня может способствовать снижению риска рака отдельных локализаций. Для подготовки будущих рекомендаций необходимо дополнительное исследование, посвященное оценке характера связи «доза-ответ» и проводимое с использованием более согласованных процедур измерения и отчетности. Несмотря на наличие объемных фактических материалов о взаимосвязи между физической активностью и различной степенью ожирения, увеличением массы тела и удержанием нормального веса (35), в настоящее время не имеется достаточных данных для более конкретного описания взаимосвязи «доза-ответ» или определения порога наступления эффекта. Для подготовки будущих рекомендаций необходимо дополнительное исследование. Рост объемов физически активной деятельности средней и высокой интенсивности приводит к улучшению когнитивных способностей (например, скорости обработки информации, памяти и управляющей функции) (35), функций и структуры мозга и к снижению риска развития когнитивных нарушений, включая болезнь Альцгеймера (73–76). Получены фактические данные о том, что физическая нагрузка у взрослых, осуществляемая как активными сериями, так и на регулярной основе, улучшает показатели сна и качества жизни, обусловленного состоянием здоровья (35). При этом не имеется достаточных материалов для более конкретного описания взаимосвязи «доза-ответ» между физической активностью и индивидуальными показателями психического и когнитивного здоровья. Аналогичным образом необходимы дополнительные данные для дальнейшего описания взаимосвязи «доза-ответ» между объемом и/или интенсивностью аэробной нагрузки и силовых тренировок и отдельными показателями здоровья. Такая информация очень важна для определения минимальных эффективных доз и максимальных порогов безопасности физически активной деятельности для различных подгрупп населения. Выводы ГРР • Получены фактические данные о том, что повышение физической активности приводит к большему эффекту для показателей здоровья, хотя на более высоких уровнях физической активности относительная польза стабилизируется. Достаточных данных для точного определения уровня, на котором начинается снижение пользы для здоровья, не имеется. • Получены фактические данные высокого уровня достоверности о том, что рост физической активности способствует снижению риска смертности от всех причин, смертности от сердечно- сосудистых заболеваний, смертности от рака, заболеваемости сердечно-сосудистых заболеваниями, гипертонией и диабетом 2-го типа при остутствии роста риска причинения вреда. • Получены фактические данные среднего уровня достоверности о том, что физическая активность любой продолжительности приводит к улучшению показателей здоровья, вследствие чего предыдущее уточнение о том, что аэробные нагрузки рекомендуется выполнять сериями продолжительностью не менее 10 минут, следует исключить. • Получены фактические данные о том, что увеличение объемов физической активности может оказывать более благоприятное воздействие на степень ожирения и замедление роста массы тела у взрослых и что риск того, что физические нагрузки будут вредны для поддержания нормального веса у взрослых, является незначительным. • Получены фактические данные среднего уровня достоверности о том, что еженедельная аэробная нагрузка средней интенсивности или эквивалентная ей нагрузка продолжительностью 150–300 минут снижает риск по целому ряду показателей здоровья и что снижение риска продолжается, но при продолжительности свыше 300 минут в неделю начинает стабилизироваться. ВЗРОСЛЫЕ (в возрасте 18-64 лет) 36 37 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Варьируется ли эта взаимосвязь в зависимости от вида или области физической активности? Фактические данные показывают, что различные виды физически активной деятельности и физические нагрузки в различных областях (т. е. на работе, при передвижении и на досуге) могут благотворно сказываться на показателях здоровья. Что касается смертности от всех причин и смертности от сердечно-сосудистых заболеваний, то выполнение аэробной нагрузки отдельно или в сочетании с силовыми упражнениями дает позитивный эффект, хотя в обоих случаях оптимальный режим обеспечивается соблюдением рекомендуемых уровней (84). Согласно более поздним фактическим данным среднего уровня достоверности, силовые упражнения, выполняемые независимо от аэробной нагрузки, также снижают риск смертности от всех причин. Приведенные в публикации Stamatakis et al. (2018) результаты сводного анализа 11 когортных исследований, посвященных изучению рекомендации о выполнении силовых упражнений дважды в неделю в сопоставлении с уровнями смертности от всех причин, показали, что выполнение как аэробных, так и силовых упражнений на рекомендуемых уровнях (1) в сравнении с несоблюдением какой-либо из рекомендаций (скорректированный ОР= 0,71 [95% ДИ: 0,57–0,87]), а также выполнение только рекомендации о силовых упражнениях в сравнении с ее невыполнением (ОР= 0,80 [95% ДИ: 0,70–0,91]), обеспечивает существенное снижение риска смертности от всех причин (84). Эти данные свидетельствуют о том, что польза для здоровья, обеспечиваемая силовыми упражнениями, не зависит от аэробной нагрузки, а также подтверждают рекомендацию о выполнении силовых упражнений дважды в неделю. Другие выводы, изложенные у Dinu et al. (2019), стали подтверждением вывода о том, что занятия физически активной деятельностью в областях, помимо досуга (или отдыха), могут быть полезны, и непосредственно показали, что виды активного перемещения (т. е. ходьба и велосипед для поездок) способны значительно снижать риск смертности от всех причин (КР= 0,92 [95% ДИ: 0,85–0,98]) (85). В недавнем исследовании приведены фактические данные о том, что для лиц, практикующих активное перемещение (т. е. ходьбу или велосипед для поездок), риск сердечно- сосудистых заболеваний (ишемической болезни сердца, инсульта и сердечной недостаточности) ниже, чем для лиц, не участвующих в активном перемещении (КР= 0,91 [95% ДИ: 0,83–0,99]) (85); и что исходя из этих показателей здоровья имеются достаточные подтверждения, позволяющие сделать вывод, что деятельность в разных областях может быть полезна. При этом нет достаточных фактических данных, позволяющих дифференцировать влияние разных областей физической активности на каждый показатель здоровья. Например, не имеется достаточных данных для решения вопроса о том, варьируется ли взаимосвязь между физической активностью и риском возникновения рака или диабета 2-го типа в зависимости от вида или области физической активности. В отношении показателей психического здоровья фактические данные (35) показывают, что широкий спектр видов физической активности, включая аэробные нагрузки, ходьбу, силовые упражнения и йогу, может благотворно влиять на уменьшение симптомов депрессии и на развитие тревоги (74, 79, 86). Например, в двух обзорах недавно были представлены фактические данные о благотворном воздействии упражнений для тренировки сопротивления на психическое здоровье; в них сообщалось о довольно значительном снижении симптомов депрессии (77) и о небольшом уменьшении симптомов тревоги (78) по сравнению с контролируемыми условиями. По данным одного нового исследования, высокие уровни физической активности в профессиональной среде способствуют снижению риска возникновения многих онкологических заболеваний, ишемической болезни сердца и диабета 2-го типа (40). При этом высокие уровни профессиональной физической активности могут также быть связаны с повышением риска остеоартрита, снижения качества сна и смертности от всех причин среди мужского населения (в отличие от женщин). Нет достаточных фактических данных, позволяющих определить взаимосвязь между физической активностью в профессиональной среде и ожирением, профилактикой увеличения массы тела, психическим здоровьем и качеством жизни, обусловленным состоянием здоровья (40). Также не имеется достаточных данных для решения вопроса о том, варьируется ли взаимосвязь между физической активностью и риском возникновения рака в зависимости от типа и области физической активности. Из-за незначительного объема данных о взаимосвязи между разными областями физической активности было трудно дифференцировать влияние тех или иных областей физических нагрузок на различные показатели здоровья. Выводы ГРР • Получены фактические данные среднего уровня достоверности о том, что выполнение силовых упражнений не реже двух раз в неделю приносит дополнительную пользу для здоровья, но достаточных данных для указания конкретной продолжительности сеанса для достижения оптимального полезного эффекта не имеется. • Получены фактические данные среднего уровня достоверности о том, что физически активная деятельность, осуществляемая в различных областях (т. е. на досуге, при передвижении, на работе), может приносить пользу здоровью, хотя пока нет возможности дифференцировать влияние разных областей физической активности на различные показатели здоровья. • Хотя повышение уровней физической активности в профессиональной среде может быть связано с ростом риска возникновения остеоартрита, снижения качества сна и смертности от всех причин среди мужского населения (в отличие от женщин), общие фактические данные среднего уровня достоверности указывают на то, что профессиональная физическая активность может быть полезна для здоровья. ВЗРОСЛЫЕ (в возрасте 18-64 лет) 36 37Рекомендации Подтверждающие фактические данные и обоснование При подготовке настоящих рекомендаций были использованы и обновлены обобщенные фактические данные, собранные PAGAC (35). ГРР рассмотрела весь комплекс фактических данных, включая как выводы самого PAGAC, так и материалы 13 новых обзоров, которые соответствовали критериям включения и расширяли объем информации о взаимосвязи между малоподвижным образом жизни и показателями здоровья у взрослых. Изучение взаимосвязи между малоподвижным образом жизни и показателями здоровья человека является сравнительно новым направлением общественного здравоохранения по сравнению с последствиями недостаточной физической активности, хотя в истекшем десятилетии оно динамично развивалось. Как правило, целью исследований являлось измерение параметров малоподвижного образа жизни на основе либо (i) вопросников для самооценки, содержащих вопросы об «общем объеме времени», проводимом в малоподвижном состоянии, или о времени, уделяемом определенным занятиям, таким как просмотр телевизора, пользование компьютером/экранными устройствами и пребывание в положении сидя; либо (ii) аппаратных оценок. Поскольку стандартизированных методов измерения или протоколов анализа для малоподвижного образа жизни не существует, сообщаемые результаты носят разнородный характер. К числу недавних методологических подвижек относится применение аппаратной оценки времени, проводимого в малоподвижном состоянии, которая позволит уменьшить погрешность измерений и другие отклонения, свойственные данным самооценки, приводимым по памяти. При рассмотрении всего комплекса фактических данных ГРР уделяла особое внимание материалам с уровнем достоверности не ниже среднего, взятым из обзоров о результатах исследований, в которых содержались данные измерений общего времени, проводимого в малоподвижном состоянии или в положении сидя, или данные аппаратных измерений малоподвижного образа жизни. С полной информацией о методах, извлечении данных и профилях фактических данных можно ознакомиться в веб- приложении «Профили фактических данных» . В течение последнего десятилетия активно развивались исследования, посвященные потенциальному вредному воздействию малоподвижного образа жизни на здоровье человека. К числу заметных наработок более поздних исследований относятся увеличение объема фактических данных о взаимосвязи «доза- ответ» между малоподвижностью и несколькими показателями здоровья, а также о взаимодействии между малоподвижным образом жизни и физической активностью. Особо малоподвижный образ жизни взрослых ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также к повышению распространенности сердечно-сосудистых заболеваний, рака и диабета 2-го типа. В этой связи рекомендуется следующее. Взрослым следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, средняя степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии взрослым следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Малоподвижный образ жизни у взрослых определяется как время, проведенное в период бодрствования в положении сидя или лежа при низком расходе энергии в профессиональном, образовательном, домашнем и общинном контексте и при передвижении. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО МАЛОПОДВИЖНОГО ОБРАЗА ЖИЗНИ ВЗРОСЛЫЕ (в возрасте 18-64 лет) 38 39 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Какова взаимосвязь между малоподвижным образом жизни и показателями здоровья у взрослых (старше 18 лет)? В целом имеются фактические данные о взаимосвязи между увеличением продолжительности малоподвижного состояния (полученные главным образом в виде результатов самооценки или аппаратных оценок времени, проводимого в положении сидя или за просмотром телевизора) и ростом смертности от всех причин, в том числе от сердечно-сосудистых заболеваний, а также ростом масштабов распространения сердечно-сосудистых заболеваний и диабета 2-го типа (8, 35, 65, 87). Например, подтверждающие данные включают в себя результаты недавно проведенного крупного метаанализа (n= 36 383; средний возраст —62,6 года; 72,8% — женщины), который предусматривал акселерометрическую оценку общего времени пребывания в малоподвижном состоянии и уровня смертности от всех причин (65) и который показал, что увеличение продолжительности малоподвижного состояния является существенным фактором смертности от всех причин. Аналогичные выводы были изложены в метаанализе, который охватывал более 1 миллиона респондентов (87) и после коррекции по фактору физической активности показал наличие взаимосвязи между общим временем, проводимым в малоподвижном состоянии, и смертностью от всех причин, в том числе смертностью от сердечно- сосудистых заболеваний (87); однако в этом же исследовании данные о взаимосвязи со смертностью от рака после их коррекции по фактору физической активности не оказались статистически значимыми (87). Еще один недавний метаанализ (8) выявил значительную взаимосвязь между малоподвижным образом жизни (оцениваемым как пребывание в положении сидя) и сердечно-сосудистыми заболеваниями и смертностью от рака; его результаты показали, что при повышении уровня малоподвижного образа жизни, измеряемого как время сидения в самом физически «неактивном», нижнем квартиле (~ 5 минут в день), риск смертности от сердечно-сосудистых заболеваний возрастает на 9–32% (p тренда < 0,001). В этом исследовании сообщалось, что взрослым, проявляющим низкую активность (сидящим) более 8 часов в день, грозит повышенный риск смертности от сердечно- сосудистых заболеваний, за исключением случаев, когда речь идет о «наиболее активных» (т. е. > 35,5 MET- часа в неделю, или ~ 60–75 минут в день) и когда такая зависимость сглаживается. Показатели взаимосвязи между малоподвижным образом жизни и смертностью от рака обычно оказывались ниже, хотя при более длительном времени сидения (особенно > 8 часов в день) наблюдался рост дозозависимого риска на 6–21%, но только для лиц, относящихся к нижнему квартилю физической активности (< 2,5 MET-часа в неделю) (8). Фактические данные подтверждают взаимосвязь между малоподвижным образом жизни (измеряемым как общее время сидения) и ростом возникновения сердечно- ВЗРОСЛЫЕ (в возрасте 18-64 лет) сосудистых заболеваний (ОР= 1,29 [95% ДИ: 1,27–1,30]), который снижался после корректировки с учетом потенциальных ковариантов, включая уровень физической активности (ОР= 1,14 [95% ДИ: 1,04–1,23]) (88). В результате обзора исследований населения Юго-Восточной Азии были получены фактические данные низкого уровня достоверности о том, что увеличение продолжительности времени пребывания в малоподвижном состоянии приводит к росту вероятности ухудшения кардиометаболических показателей (включая диабет 2-го типа, повышение ИМТ и артериального давления) (89). Материалы двух недавних обзоров указывают на взаимосвязь между общей продолжительностью дневного времени, проводимого в положении сидя (88), общего малоподвижного образа жизни и просмотра телевизора (87) с возникновением диабета 2-го типа. Согласно обоим этим исследованиям, повышение уровня малоподвижного образа жизни приводит к росту риска диабета 2-го типа. Например, после коррекции по фактору физической активности линейная связь с диабетом 2-го типа наблюдалась при любом малоподвижном образе жизни (КР= 1,01 [95% ДИ: 1,00–1,01] p= < 0,001) и просмотре телевизора (КР= 1,09 [95% ДИ: 1,07–1,12] p= < 0,001) (87). Кроме того, получены фактические данные, подтверждающие значительную взаимосвязь между малоподвижным образом жизни (измеряемым как время просмотра телевизора) и смертностью от рака (35, 87). Несколько более поздних обзоров низкого и очень низкого уровня достоверности содержат материалы, подтверждающие наличие взаимосвязи между малоподвижным образом жизни и колоректальным раком (90); при этом нет данных о связи с возникновением рака простаты, молочной железы или прямой кишки (90–93). В дополнительных данных (35) сообщалось о существенной взаимосвязи между увеличением времени пребывания в малоподвижном состоянии и ростом риска развития рака тела матки, толстой кишки и легких (35). Получены фактические данные низкого уровня достоверности о том, что между временем пребывания в малоподвижном состоянии и ожирением и другими показателями веса существует неблагоприятная взаимосвязь, и о том, варьируется ли взаимосвязь между малоподвижным образом жизни и весом в зависимости от объема физической нагрузки средней и высокой интенсивности. В целом был сделан вывод об отсутствии достаточных данных для подготовки этих рекомендаций/ этого документа и о необходимости проведения дальнейшего исследования. Имеются ограниченные фактические данные об оценке вредных последствий сокращения времени, проводимого в малоподвижном состоянии. На основе экспертного заключения был сделан вывод о том, что сокращение времени, проводимого в малоподвижном состоянии, вряд ли приведет к росту риска травматизма, особенно если это время использовать для физически активной деятельности низкой интенсивности. 38 39Рекомендации Выводы ГРР • Получены в целом достаточные фактические данные для подготовки новой рекомендации ВОЗ об ограничении малоподвижного образа жизни в целях снижения рисков для здоровья. • Получены фактические данные среднего уровня достоверности о наличии взаимосвязи между увеличением времени, проводимого в малоподвижном состоянии, и повышением смертности от всех причин, в том числе от сердечно- сосудистых и онкологических заболеваний, а также ростом масштабов распространения сердечно- сосудистых заболеваний и диабета 2-го типа. • Получены фактические данные от низкого до среднего уровня достоверности о наличии взаимосвязи между увеличением времени, проводимого в малоподвижном состоянии, и ростом риска развития рака тела матки, толстой кишки и легких. • Достаточных данных, подтверждающих взаимосвязь между малоподвижным образом жизни и степенью ожирения, не имеется; необходимо дальнейшее исследование. • Польза от ограничения времени, проводимого в малоподвижном состоянии, перевешивает любые потенциальные риски. Имеется ли взаимосвязь «доза-ответ» (общий объем, регулярность, продолжительность, интенсивность прерывания)? В целом фактические данные среднего уровня достоверности указывают на наличие нелинейной взаимосвязи «доза-ответ» между временем пребывания в малоподвижном состоянии (время, проводимое в положении сидя или за просмотром телевизора, которое определено путем самооценок или аппаратных оценок) и смертностью от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, и возникновением сердечно-сосудистых заболеваний (8, 35, 87). Недавний метаанализ позволил получить данные высокого уровня достоверности о наличии взаимосвязи «доза-ответ» между измерением общего времени пребывания в малоподвижном состоянии, проведенным методом акселерометрии, и смертностью от всех причин (65); в нем сообщалось, что увеличение времени, проводимого в малоподвижном состоянии, является существенным фактором смертности от всех причин. После коррекции по возможным искажающим факторам, включая время занятия физически активной деятельностью средней и высокой интенсивности, коэффициенты риска для квартилей с растущим временем пребывания в малоподвижном состоянии были равны 1,00 (эталон; наименьшая малоподвижность); 1,28 (1,09–1,51); 1,71 (1,36–2,15) и 2,63 (1,94–3,56) (65). В результате такого анализа взаимосвязи «доза-ответ» между временем малоподвижности и смертностью был выявлен ВЗРОСЛЫЕ (в возрасте 18-64 лет) постепенный рост риска, который начинался примерно от 7,5–9 часов и становился более отчетливым после 9,5 часа. Ежедневное пребывание в малоподвижном состоянии в течение 10 часов и 12 часов было связано с ростом риска смерти, составляющим соответственно 1,48 (1,22–1,79) и 2,92 (2,24–3,83) (65). Еще один недавний метаанализ оценки взаимосвязи «доза-ответ» выявил наличие линейной зависимости между общим временем пребывания в малоподвижном состоянии и смертностью от всех причин (КР на 1 час в день = 1,01 (1,00–1,01) для воздействия ≤ 8 часов в день; и 1,04 (1,03–1,05) для > 8 часов в день); а также смертностью от сердечно-сосудистых заболеваний (КР= 1,01 (0,99–1,02) для ≤ 6 часов в день; и КР= 1,04 (1,03–1,04) для > 6 часов в день) после коррекции по фактору физической активности (87). В результатах этого же исследования наблюдалась незначительная линейная взаимосвязь «доза-ответ» с диабетом 2-го типа применительно к общему объему малоподвижного образа жизни (1,01 (1,00–1,01)) после коррекции по факторам физической активности и просмотра телевизора (1,09 (1,07–1,12)) (87). Фактические данные в целом подтверждают, что увеличение времени пребывания в малоподвижном состоянии приводит к ухудшению показателей здоровья; поэтому был сделан вывод о наличии достаточных данных в поддержку минимизации времени пребывания в малоподвижном состоянии для снижения рисков, грозящих здоровью. Тем не менее с учетом высокой степени вариативности методов оценки малоподвижного образа жизни в различных обзорах (путем самооценки времени, проводимого в положении сидя и за просмотром телевизора, или путем аппаратных (акселерометр) оценок) и вероятности того, что пороговые величины времени пребывания в малоподвижном состоянии могут различаться в зависимости от показателей здоровья, от уровней физической нагрузки средней и высокой интенсивности и от подгруппы населения, был сделан вывод об отсутствии достаточных фактических данных для подготовки рекомендации относительно объема времени (с его количественными показателями). Помимо общего объема времени, проводимого в малоподвижном состоянии, были рассмотрены данные о схемах увеличения времени пребывания в малоподвижном состоянии. Однако достаточного объема материалов для подготовки рекомендаций о частотности и/или продолжительности перерывов в малоподвижном образе жизни собрать не удалось. Выводы ГРР • Достаточных фактических данных для подготовки количественных рекомендаций (касающихся объема времени) в отношении малоподвижного образа жизни не имеется. • Достаточных фактических данных для подготовки рекомендаций о частотности и/или продолжительности перерывов в малоподвижном образе жизни не имеется. 40 41 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Варьируется ли эта взаимосвязь в зависимости от вида и области малоподвижного образа жизни? Одни области или виды малоподвижного образа жизни могут причинять больше вреда, чем другие — по причине как их прямых взаимосвязей, так и их потенциала по оттягиванию на себя времени от занятия физически активной деятельностью, более полезной для здоровья. Хотя работа по исследованию малоподвижного образа жизни продвигается вперед быстрыми темпами, имеющихся фактических данных недостаточно для проведения прямого сопоставления взаимосвязи между различными видами малоподвижного образа жизни и всевозможными показателями здоровья. Например, некоторые исследования приводят к более высоким результатам при измерении малоподвижного образа жизни как времени просмотра телевизора в сравнении с общим временем пребывания в положении сидя (87). Возможно, это объясняется дифференциальной погрешностью измерения или остаточным искажением, которое связано с показателями самооценки и применяемым инструментами. В настоящее время не имеется достаточных фактических данных для определения различных взаимосвязей с разнообразными показателями здоровья и для прояснения вопроса о том, как они могут варьироваться в зависимости от подгруппы населения. Растет число исследований, в которых применяются аппаратные измерения физической активности и времени пребывания в малоподвижном состоянии по отношению к показателям здоровья. Однако при аппаратных измерениях времени пребывания в малоподвижном состоянии возможны некоторые классификационные искажения, поскольку многие из размещаемых устройств (например, на запястье или на талии) пока не умеют различать положения тела (например, лежа, сидя и стоя на месте). Будущее исследование с применением согласованного порядка отчетности и методики, позволяющей различать положения, поможет расширить знания о схемах малоподвижного образа жизни. Вывод ГРР • Достаточных фактических данных для составления рекомендаций о различных типах или областях малоподвижного образа жизни не имеется. Приводит ли уровень физической активности к изменению влияния малоподвижного образа жизни на показатели смертности? Возросший интерес к воздействию малоподвижного образа жизни на показатели здоровья послужил стимулом для исследования потенциального взаимодействия между разными уровнями физической активности и уровнями малоподвижности. На основе имеющихся результатов исследований получены фактические данные среднего уровня достоверности о том, что взаимосвязь между малоподвижным образом жизни и смертностью от всех причин, в том числе от сердечно-сосудистых заболеваний и от рака, варьируется в зависимости от объема физических нагрузок средней и высокой интенсивности (8, 9, 35). Общие выводы показывают, что воздействие малоподвижного образа жизни ощутимее для лиц, занимающихся физически активной деятельностью средней и высокой интенсивности в небольших объемах; иначе говоря, более значительные объемы физической нагрузки средней и высокой интенсивности способны сглаживать ухудшение показателей здоровья, вызванное более высокими уровнями малоподвижного образа жизни. Было установлено, что уровень риска, связанного с временем пребывания в малоподвижном состоянии и смертностью от всех причин, является более высоким на низких уровнях физической активности по сравнению с ее высокими уровнями (35). В последовательном метаанализе Ekelund et al. были рассмотрены совокупные и стратифицированные факторы влияния малоподвижного образа жизни и физической активности на смертность от всех причин у более 1 миллиона мужчин и женщин; анализ показал, что эта взаимосвязь дифференцируется в зависимости от уровня физической активности (9). В ходе анализа использовались квартили малоподвижности (сидячий образ жизни) и квартили с физической активностью средней и высокой интенсивности; было установлено, что в сравнении с эталоном (< 4 часов пребывания в сидячем положении в день и верхний квартиль с нагрузкой средней и высокой интенсивности [> 35,5 MET- часа в неделю]) при последующем наблюдении не отмечалось повышенного риска смерти среди лиц, которые проводили сидя более 8 часов в день, но при этом сообщали о занятиях физически активной деятельностью более 35,5 MET-часа в неделю (ОР= 1,04 [95% ДИ: 0,99–1,10]). Напротив, в случае лиц, которые проводили сидя наименьший объем времени (< 4 часов в день) и относились к нижнему (< 2,5 MET-часа в неделю) квартилю физической активности, при последующем наблюдении отмечался значительно возросший риск смерти (ОР= 1,27 [95% ДИ: 1,22–1,31]). Авторы исследования пришли к выводу, что физическая нагрузка средней и высокой ВЗРОСЛЫЕ (в возрасте 18-64 лет) 40 41Рекомендации интенсивности, выполняемая в течение примерно 60–75 минут в день (верхний квартиль), может сглаживать и даже устранять пагубную взаимосвязь между малоподвижным образом жизни и ухудшением показателей здоровья (9). Взаимосвязь между уровнями малоподвижного образа жизни и физической активностью средней и высокой интенсивности была обобщена в систематическом обзоре PAGAC (35), как показано на рисунке 2. Еще одно недавнее исследование обеспечило новые фактические данные о рассмотрении аналогичных связей с показателями смертности от конкретных причин и привело к аналогичным выводам (8). Результаты масштабного последовательного метаанализа (9 исследований, n= 850 000, смертность от ССЗ; 8 исследований, n= 777 000, смертность от рака) показали, что более высокие уровни физической активности средней и высокой интенсивности сглаживают риск смертности от сердечно- сосудистых заболеваний, возрастающий при высоких уровнях малоподвижного образа жизни, измеряемого как время, проводимое сидя, или как время, проводимое за просмотром телевизора (8). Как видно из результатов исследования, в случае лиц, находящихся в положении сидя более 8 часов в день, наблюдается связь с повышенным риском смерти, за исключением верхнего квартиля, где такая связь сглаживается. В более конкретном выражении риск смерти от сердечно-сосудистых заболеваний для лиц, ежедневное время сидения которых превышает 8 часов, на 32% выше по сравнению с референтной группой (< 4 часов в день) (p тренда < 0,001). Рисунок 2. Взаимосвязь между степенью малоподвижного образа жизни и уровнем физической активности Адаптированный график из доклада PAGAC ВЗРОСЛЫЕ (в возрасте 18-64 лет) Менее явные, но все же значительные в сопоставлении с референтной группой результаты были получены по другим квартилям физической активности (2-й квартиль, ОР= 1,11 [95% ДИ: 1,03–1,20]; 3-й квартиль, ОР= 1,14 [95% ДИ: 1,03–1,26]). Аналогичная взаимосвязь наблюдалось между продолжительностью времени просмотра телевизора и смертностью от сердечно-сосудистых заболеваний среди всех групп с физической активностью средней и высокой интенсивности (8). Наличие связи со смертностью от рака было не столь однозначным, хотя исследование в целом показало, что более высокие уровни физической активности снижают вредное воздействие малоподвижного образа жизни, когда он оценивается как общее время сидения. На основе этих фактических данных был сделан вывод, что более высокие уровни физически активной деятельности средней и высокой интенсивности следует рекомендовать лицам, ведущим весьма малоподвижный образ жизни, и что польза от такой деятельности перевесит риски. Выводы ГРР • Получены фактические данные среднего уровня достоверности о том, что взаимосвязь между малоподвижным образом жизни и смертностью от всех причин, в том числе от сердечно-сосудистых заболеваний и от рака, варьируется в зависимости от объема физически активной деятельности средней и высокой интенсивности. • Повышенные объемы физической нагрузки средней и высокой интенсивности могут сглаживать вредную взаимосвязь между малоподвижным образом жизни и показателями здоровья. П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я Больше физической активности Б ол ее м ал оп од ви ж н ы й о б р аз ж и зн и ВЫСОКИЙ РИСК НИЗКИЙ РИСК М енее малоподвижный образ жизни Увеличение физической акти вн ости У м ен ьш ен и е степени м алоподвижного образа жизни и больш е физической активности 42 43 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Пожилые люди могут заниматься физически активной деятельностью в рамках отдыха и досуга (подвижные игры, занятия спортом или плановые тренировки), передвижений (использование колесных средств, ходьба и езда на велосипеде), работы или выполнения домашних обязанностей, то есть в повседневном профессиональном, образовательном, домашнем или общинном контексте. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО ФИЗИЧЕСКОЙ АКТИВНОСТИ ПОЖИЛЫЕ ЛЮДИ (в возрасте 65 лет и старше) • небольшая физическая активность лучше, чем ее полное отсутствие; • если пожилые люди не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • пожилым людям следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • пожилым людям следует оставаться настолько физически активными, насколько позволяют их функциональные возможности, и соразмерять интенсивность занятий физически активной деятельностью с уровнем своего физического здоровья.П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я Физическая активность пожилых людей благоприятно отражается на следующих показателях здоровья: снижается смертность от всех причин, том числе от сердечно- сосудистых заболеваний, снижается заболеваемость гипертонией, раком отдельных локализаций, диабетом 2-го типа, улучшается психическое здоровье (снижаются симптомы тревоги и депрессии), улучшаются когнитивное здоровье и сон; также может снижаться степень ожирения. У пожилых людей занятия физически активной деятельностью помогают предотвращать падения и связанный с падениями травматизм, а также препятствуют ухудшению состояния костной системы и ее функциональных возможностей. В этой связи рекомендуется следующее. Всем пожилым людям следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Пожилым людям следует не менее 150–300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75–150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, чтобы занятия приносили ощутимую пользу для здоровья, уделять в течении недели время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Чтобы занятия приносили дополнительную пользу для здоровья, пожилым людям также следует выполнять силовые упражнения средней или большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных В ходе еженедельных занятий физически активной деятельностью в целях повышения функциональных возможностей и предотвращения риска падений пожилым людям следует не реже трех раз в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней или большей интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Пожилые люди могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных 42 43Рекомендации Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Подтверждающие фактические данные и обоснование При подготовке настоящих рекомендаций в отношении пожилых людей были использованы и обновлены всеобъемлющие обобщенные фактические данные, собранные PAGAC (35); 15 обзоров соответствовали критериям включения и расширяли объем информации о взаимосвязи между физической активностью и специфическими показателями здоровья пожилых людей (профилактика падений, связанный с падениями травматизм, физическое функционирование, дряхлость и остеопороз). При подготовке фактических данных по профилактике падений были использованы и обновлены материалы «Систематический обзор Кокрейновского сотрудничества» 2019 г., содержащийся в публикации Sherrington et al. (42); в нем были опубликованы данные за период с даты последнего поиска в этом первоначальном обзоре до ноября 2019 г. (девять новых исследований). В процессе поиска существующих систематических обзоров по проблемам остеопороза и саркопении, проведенного по базе PubMed среди обзоров, опубликованных с 2008 по ноябрь 2019 г., новых обзоров выявлено не было, но при этом удалось обнаружить восемь новых исследований. С полной информацией о методах, извлечении данных и профилях фактических данных можно ознакомиться в веб-приложении «Профили фактических данных» . Какова взаимосвязь между малоподвижным образом жизни и показателями здоровья у пожилых людей (в возрасте 65 лет и старше)? Базой первичных фактических данных для оценки взаимосвязи между физической активностью и показателями здоровья пожилого населения, такими как смертность от всех причин и от конкретных причин, масштабы распространения сердечно-сосудистых заболеваний, диабета 2-го типа и онкологических заболеваний, ожирение, психическое здоровье и когнитивные способности, являлась та же научная литература, которая была подобрана и пересмотрена для взрослых групп населения. Этот же массив данных был одобрен и экстраполирован для пожилых людей, поскольку охват большинства исследований не предусматривал верхнего возрастного предела и, следовательно, включал в себя взрослых старше 65 лет. Последующий обзор фактического материала был нацелен на рассмотрение и более подробное изучение взаимосвязи между физической активностью и специфическими показателями здоровья пожилых людей, включая профилактику падений, связанный с падениями травматизм, физическое функционирование, дряхлость и остеопороз. Ослабление физических возможностей у пожилых людей нередко проявляется в падениях и в связанном с падениями травматизме, что может повлечь серьезные последствия. Случайные падения происходят под действием совокупности внешних (связанных с окружающей средой) и внутренних (например, обусловленных нарушениями скелетно-мышечной или нервной систем, влияющими на постуральный контроль) факторов. Фактические данные показывают, что физическая активность у пожилых людей — особенно программы комплексных физических упражнений, включающие в себя различные комбинации упражнений на равновесие, развитие силы, выносливости, походки и физического функционирования, — приводит к снижению вероятности падений и риска ПОЖИЛЫЕ ЛЮДИ (в возрасте 65 лет и старше) травмирования при падениях. Недавно полученные данные свидетельствуют о том, что выполнение пожилыми людьми комплекса упражнений может снизить вероятность падений на 23% (совокупный относительный риск (СОР) 0,77 [95% ДИ: 0,71–0,83]), что существенно уменьшит травмирование при падениях, включая тяжелые случаи падений, приводящие к переломам, травмам головы, открытым ранам, повреждениям мягких тканей или другим травмам, требующим медицинской помощи или госпитализации (42). Эти данные соответствовали выводам других обзоров и подтверждали их (35). После достижения пика старшего юношеского возраста мышечная и костная масса с годами начинает уменьшаться (т. е. появляются саркопения и остеопения/ остеопороз), что может привести к ослаблению силы и физического функционирования. Имеющиеся данные показывают, что регулярная физическая активность способствует улучшению физического функционирования и снижению риска возрастного ослабления физических функций у пожилых людей. Полученные выводы свидетельствуют о благотворном воздействии на динамическое равновесие (СМД= 1,10 [95% ДИ: 0,29–1,90]); мышечная сила (СМД= 1,13 [95% ДИ: 0,30–1,96]); гибкость (СМД= 1,22 [95% ДИ: 0,39–2,04]) и кардиореспираторное здоровье (СМД= 1,48 [95% ДИ: 0,42–2,54]) (94). Данные также показывают, что повышенные уровни физической активности могут улучшать здоровье костной системы и тем самым обеспечивать профилактику остеопороза у пожилых людей (сводный стандартизированный размер эффекта 0,21 [95% ДИ: 0,06–0,36]) (95). Физически активная деятельность может приводить к повышению минеральной плотности костной ткани поясничного отдела позвоночника и шейки бедра (тазобедренного сустава). 44 45 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Выводы ГРР • Получены фактические данные среднего уровня достоверности о том, что физические нагрузки улучшают физическое функционирование и снижают риск возрастного ослабления физических функций у стареющих групп населения в целом. • Получены фактические данные низкого уровня достоверности о том, что риски, связанные с объемами и видами физической активности, рекомендуемыми пожилым людям, являются незначительными и перевешиваются приносимой пользой. Имеется ли взаимосвязь «доза-ответ» (объем, продолжительность, регулярность, интенсивность)? Фактические данные указывают на обратную взаимосвязь между объемом физической активности у пожилых людей и риском ограничений физического функционирования. Вообще, повышенная физическая активность (регулярность, продолжительность и/или объем) приносит больше пользы (35). По имеющимся данным, с точки зрения общего повышения функциональных возможностей быстроскоростная тренировка на сопротивление может быть эффективнее среднескоростной (СМД= 0,41 [95% ДИ: 0,18–0,65]; и SPPB (СМД= 0,52 [95% ДИ: 0,10–0,94])) (96). Имеются ограниченные данные о взаимосвязи «доза- ответ» между физической активностью и профилактикой падений; при этом в большинстве исследований, содержащих подтверждающие данные, рассматривается тестовая программа, рассчитанная на тренировки три раза в неделю. Вывод ГРР • Получены фактические данные высокого уровня достоверности о наличии обратной взаимосвязи «доза-ответ» между объемом аэробной нагрузки и риском снижения физического функционирования в группах пожилого населения в целом. ПОЖИЛЫЕ ЛЮДИ (в возрасте 65 лет и старше) Варьируется ли эта взаимосвязь в зависимости от вида или области физической активности? Программы физической активности для пожилых людей, включающие в себя сочетание упражнений на развитие силы, выносливости, походки и физического функционирования, приводят к снижению вероятности падений и риска получения травм в результате падений. Результаты обзора 11 РКИ показали, что пожилые люди, практикующие различные виды физической активности (как правило, упражнения на равновесие и функциональные упражнения наряду с упражнениями для тренировки сопротивления), могут добиться снижения вероятности падений на 28% (СОР= 0,72 [95% ДИ: 0,56–0,93]) (42). Вывод об эффекте от упражнений для тренировки сопротивления остался неопределенным из-за ограниченности полученных данных (КР= 0,97 [95% ДИ: 0,14–6,49]; одно исследование; n= 73) (42). Имеющиеся данные также показывают, что программы, состоящие из упражнений различных видов, оказывают значительное позитивное воздействие на здоровье костной системы (стандартизированный размер эффекта 0,45 [95% ДИ: 0,20–0,71]; p= 0,001) по сравнению с однообразными программами (95). Выводы ГРР • Получены фактические данные высокого уровня достоверности о том, что высокие уровни физически активной деятельности у пожилых людей, сочетающие в себе упражнения на укрепление равновесия, силы, походки и физического функционирования (например, комплексные физические упражнения), приводят к снижению вероятности падений и риска получения травм в результате падений. • Получены фактические данные среднего уровня достоверности о том, что программы, состоящие из упражнений различных видов, могут оказывать значительное позитивное воздействие на здоровье костной системы и предупреждать остеопороз. 44 45Рекомендации Подтверждающие фактические данные и обоснование Малоподвижный образ жизни не был включен в Глобальные рекомендации ВОЗ по физической активности для здоровья 2010 г. (1). Из-за нехватки материалов по отдельным группам населения базой первичных фактических данных для оценки взаимосвязи между малоподвижным образом жизни и показателями здоровья пожилых людей являлась та же научная литература, которая была подобрана и пересмотрена для взрослых групп населения, поскольку охват большинства исследований не предусматривал верхнего возрастного предела и, следовательно, включал в себя взрослых старше 65 лет. Были пересмотрены выводы, сделанные на основе данных о малоподвижном образе жизни по всем группам взрослого населения, включая решение вопроса о том, имеются ли данные, согласно которым соответствующие результаты будут в отношении пожилых людей чем-либо отличаться, окажутся для них неприменимыми или будут им противопоказаны. Кроме того, сведения относительно применимости фактических данных о пользе увеличения объема физически активной деятельности средней и высокой интенсивности для противодействия возможным рискам особо малоподвижного образа жизни были рассмотрены и также экстраполированы с целью учета в рекомендациях для пожилых людей по единому комплексу важнейших показателей здоровья. В последние десятилетия жизни могут возникать трудности при попытках сократить время малоподвижности из-за ухудшения физического функционирования, хотя общеизвестно, что замена пребывания в малоподвижном состоянии физически активной деятельностью (даже низкой интенсивности) по-прежнему полезна для здоровья. С полной информацией о методах, извлечении данных и профилях фактических данных можно ознакомиться в веб- приложении «Профили фактических данных» . Выводы ГРР • Фактические данные о малоподвижном образе жизни во всех группах взрослого населения, в том числе о пользе увеличения объема физически активной деятельности средней и высокой интенсивности для противодействия возможным рискам особо малоподвижного образа жизни, могут экстраполироваться и учитываться при составлении рекомендаций для пожилых людей по единому комплексу важнейших показателей здоровья. • Польза от минимизации объема малоподвижного образа жизни перевешивает риски для пожилых людей. Особо малоподвижный образ жизни пожилых людей ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также повышению масштабов распространения сердечно-сосудистых заболеваний, рака и диабета 2-го типа. В этой связи рекомендуется следующее. Пожилым людям следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, средняя степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии пожилым людям следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Для пожилых людей малоподвижный образ жизни определяется как время, проводимое в состоянии бодрствования в положениях сидя или лежа при низком расходе энергии в профессиональном, образовательном, домашнем и общинном контексте и при передвижении. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО МАЛОПОДВИЖНОГО ОБРАЗА ЖИЗНИ Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ПОЖИЛЫЕ ЛЮДИ (в возрасте 65 лет и старше) 46 47 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и PREGNANT AND POSTPARTUM WOMEN РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО ФИЗИЧЕСКОЙ АКТИВНОСТИ Беременные женщины и женщины в послеродовом периоде могут заниматься физически активной деятельностью в рамках отдыха и досуга (подвижные игры, занятия спортом или плановые тренировки), передвижений (использование колесных средств, ходьба и езда на велосипеде), работы или выполнения домашних обязанностей, то есть в повседневном профессиональном, образовательном, домашнем и общинном контексте. В настоящих рекомендациях рассматриваются физическая активность и показатели здоровья матери и плода во время беременности и в послеродовой период. Рекомендации адресованы всем беременным женщинам и женщинам в послеродовом периоде независимо от их возраста, культурного уровня или социально- экономического статуса. Поскольку беременность и послеродовой период — важные этапы в жизни женщины, благотворное влияние физической активности на протяжении всего периода зрелости организма подробно описано в рекомендациях, предоставляемых взрослым. Беременным женщинам и женщинам в послеродовом периоде следует получать квалифицированную антенатальную и постнатальную помощь врача-специалиста, который может консультировать по специфическим вопросам, учитывая их медицинский анамнез и любые противопоказания для занятия физически активной деятельностью во время беременности или в послеродовой период. Настоящие рекомендации основаны на принципах общественного здравоохранения и носят общепопуляционный характер. Для женщин с осложнениями в связи с беременностью или родами следует запрашивать клинические консультации. Беременным женщинам и женщинам в послеродовом периоде во всех возможных случаях нужно пытаться следовать этим рекомендациям в соответствии со своими способностями и при отсутствии противопоказаний. Физическая активность беременных женщин и женщин в послеродовом периоде благоприятно отражается на следующих показателях здоровья матери и плода: снижаются риски преэклампсии, гестационной гипертонии, гестационного диабета, чрезмерного гестационного увеличения массы тела, осложнений при родах и послеродовой депрессии, а также уменьшается количество осложнений у новорожденных, исключаются негативные факторы, влияющие на вес ребенка при рождении; и также исключается повышение риска мертворождения. Всем беременным женщинам и женщинам в послеродовом периоде при отсутствии противопоказаний рекомендуется следующее. Следует регулярно заниматься физически активной деятельностью во время беременности и в послеродовой период. Настоятельная рекомендация, средняя степень достоверности данных Чтобы физическая активность приносила ощутимую пользу для здоровья, следует уделять не менее 150 минут в неделю занятиям физически активной деятельностью средней и высокой интенсивности с аэробной нагрузкой. Настоятельная рекомендация, средняя степень достоверности данных Рекомендуется использовать различные виды аэробных и силовых физических упражнений. Также могут быть полезны дополнительные легкие упражнения на растяжку. Настоятельная рекомендация, средняя степень достоверности данных Кроме того, женщины, которые до наступления беременности регулярно выполняли аэробные физические упражнения высокой интенсивности или занимались физически активной деятельностью, могут продолжать эту практику во время беременности и в послеродовой период. Настоятельная рекомендация, средняя степень достоверности данных БЕРЕМЕННЫЕ ЖЕНЩИНЫ И ЖЕНЩИНЫ В ПОСЛЕРОДОВОМ ПЕРИОДЕ 46 47Рекомендации Подтверждающие фактические данные и обоснование При подготовке настоящих Рекомендаций по вопросам физической активности и малоподвижного образа жизни (2020 г.) в отношении беременных женщин и женщин в послеродовом периоде были использованы и обновлены обобщенные фактические данные из семи систематических обзоров, в которых рассматривались важнейшие и важные показатели здоровья (28–34). Четыре обзора из семи соответствовали критериям включения. С полной информацией о методах, извлечении данных и профилях фактических данных можно ознакомиться в веб-приложении «Профили фактических данных» . Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf Какова взаимосвязь между физической активностью и показателями здоровья у беременных женщин и женщин в послеродовом периоде? Физическая активность до и во время беременности может способствовать снижению риска наиболее частых осложнений беременности. Занятия физически активной деятельностью в период беременности эффективно сокращают гестационное увеличение массы тела (разница= 1,14 кг [95% ДИ: 1,67 – 0,62]) (97) и снижает риск гестационного диабета (КР= 0,71 [95% ДИ: 0,57–0,89]) (97), как и физическая активность до беременности (OШ= 0,70 [95% ДИ: 0,57–0,85]) (31, 34, 97), в том числе среди женщин с избыточным весом или ожирением (97). Как представляется, физическая активность в период беременности не приводит к росту масштабов гестационной гипертонии или преэклампсии (31). Согласно фактическим данным, среди беременных женщин с избыточным весом или ожирением не наблюдается заметных различий в распространенности гестационной гипертонии (КР= 0,63 [95% ДИ: 0,38–1,05]) БЕРЕМЕННЫЕ ЖЕНЩИНЫ И ЖЕНЩИНЫ В ПОСЛЕРОДОВОМ ПЕРИОДЕ П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я • небольшая физическая активность лучше, чем ее полное отсутствие; • если беременные женщины и женщины в послеродовом периоде не соблюдают эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью; • беременным женщинам и женщинам в послеродовом периоде следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • в целях снижения риска недержания мочи можно ежедневно делать упражнения для укрепления мышц тазового дна. • Избегайте занятий физически активной деятельностью во время чрезмерной жары, особенно в условиях высокой влажности. • Не допускайте обезвоживания организма и пейте воду до, во время и после физических нагрузок. • Избегайте занятий теми видами деятельности, которые предполагают физические контакты с другими людьми; повышают риск падений; или могут ограничивать насыщение организма кислородом (например, занятия физически активной деятельностью в условиях больших высот над уровнем моря, если они не являются условиями вашей обычной жизнедеятельности). • Избегайте физических нагрузок в положении лежа на спине после первого триместра беременности. • При принятии решений относительно участия в спортивных соревнованиях или выполнения упражнений, значительно превышающих по своим нагрузкам рекомендуемые уровни, беременным женщинам следует обращаться за консультацией к врачу-специалисту. • Беременным женщинам следует проконсультироваться у своего лечащего врача по вопросу об опасных симптомах, свидетельствующих о необходимости приостановить или ограничить занятия физически активной деятельностью, и немедленно проконсультироваться с квалифицированным врачом-специалистом в случае возникновения таких симптомов. • Возвращение к активной физической деятельности после родов следует осуществлять постепенно, а также по согласованию лечащим врачом в случае родов путем кесарева сечения. К дополнительным рекомендациям относительно мер предосторожности, которые необходимо соблюдать беременным женщинам при занятии физически активной деятельностью, относятся следующие. или преэклампсии (КР= 1,39 [95% ДИ: 0,66–2,93]), если сравнивать физически активные группы с группами, получающими стандартный дородовой уход (97). Существует давняя озабоченность в связи с потенциальным вредным воздействием физической активности матери на развитие плода и родоразрешение. Однако, как показывают недавно полученные данные, физическая активность не приводит к росту риска выкидыша, мертворождения или осложнений при родах (32). Согласно фактическим материалам, нет никаких различий в частотности применения кесарева сечения среди беременных женщин с избыточным весом или ожирением, если сравнивать физически активные группы с группами, получающими стандартный дородовой уход (97). Физическая активность во время беременности не связана с ростом риска вредного воздействия на вес при рождении (98) или риска преждевременных родов (32); напротив, она может выполнять защитную функцию, снижая уровень общего рискa (98) даже среди беременных женщин с избыточным весом или ожирением (КР= 1,02 [95% ДИ: 0,54–1,92]) или риска 48 49 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и рождения крупных для гестационного возраста младенцев (КР= 0,90 [95% ДИ: 0,65–1,25]), если сравнивать физически активные группы с группами, получающими стандартный дородовой уход (97). В послеродовой период матери могут переживать широкий спектр физических и эмоциональных изменений. Из фактических данных видно, что физическая активность во время беременности может иметь обратную взаимосвязь с послеродовой депрессией (29). Результаты метаанализа шести испытаний и 11 обсервационных исследований физической активности в ходе беременности (99) показали явную обратную взаимосвязь между физической активностью в период беременности и послеродовой депрессией (СМД= 0,58 [95% ДИ: 1,09 – 0,08]). Этот эффект проявлялся еще более отчетливо при ограничении результатов пятью исследованиями групп, занимавшихся физически активной деятельностью как минимум средней интенсивности (СМД= 0,70 [95% ДИ: 1,19 – 0,22]) (99). Выводы ГРР • Получены фактические данные высокого уровня достоверности о том, что физическая активность в период беременности может сокращать гестационное увеличение массы тела и снижать риск гестационного сахарного диабета. • Получены фактические данные от среднего до высокого уровня достоверности о том, что физическая активность не приводит к росту масштабов гестационной гипертонии. • Получены фактические данные среднего уровня достоверности о том, что физическая активность не приводит к росту риска выкидыша, мертворождения или осложнений при родах; и данные среднего уровня достоверности о снижении риска преждевременных родов для матерей, занимающихся физически активной деятельностью высокой интенсивности. • Получены фактические данные от низкого до среднего уровня достоверности о том, что физическая активность не вызывает рост риска низкого веса при рождении или риска рождения маленьких или крупных для гестационного возраста младенцев. • Получены фактические данные низкого уровня достоверности о том, что физическая активность во время беременности приводит к снижению симптомов послеродовой депрессии. • Риски, связанные с объемами и видами физической активности, рекомендуемой беременным женщинам и женщинам в послеродовом периоде, являются незначительными и перевешиваются приносимой пользой. БЕРЕМЕННЫЕ ЖЕНЩИНЫ И ЖЕНЩИНЫ В ПОСЛЕРОДОВОМ ПЕРИОДЕ Имеется ли взаимосвязь «доза-ответ» (объем, продолжительность, регулярность, интенсивность)? Aнализ фактического материала о физической активности во время беременности и в послеродовой период показывает, что проводимые мероприятия варьируются по объему (т. е. дозе) физической активности в части как ее продолжительности в минутах, так и количества занятий в неделю. В целом же имеющиеся данные отражали регулярность аэробной нагрузки, составляющую не реже трех дней в неделю с типичной продолжительностью 30–60 минут. Эти данные заимствованы из исследований, посвященных влиянию на здоровье какой-либо дозы физической нагрузки, в основном соответствующей объему активности, рекомендуемому для всех групп взрослого населения — 150 минут еженедельной физически активной деятельности средней интенсивности. Хотя обычно считается, что увеличение физической активности (регулярности, продолжительности и/или объема) приводит к большему позитивному эффекту, для более детального осмысления взаимосвязи «доза- ответ» необходимо дальнейшее исследование. Занятие в предбеременный период досуговой физически активной деятельностью большего объема по сравнению с меньшим обеспечивает значительное снижение риска гестационного диабета (OШ= 0,54 [95% ДИ: 0,34–0,87]) (100). Имеются также данные о небольшом, но заметном уменьшении риска преждевременных родов у матерей, практиковавших физические нагрузки высокой интенсивности (КР= 0,20 [95% ДИ: 0,36 – 0,03]) (98). При этом не было обнаружено каких-либо данных о безопасности или дополнительной пользе тренировок на уровнях, существенно превышающих рекомендуемые. Выводы ГРР • Достаточных фактических данных для определения взаимосвязи «доза-ответ» между физической активностью и конкретными важнейшими показателями здоровья во время беременности и в послеродовой период не имеется. • Фактические данные в целом свидетельствуют о благотворном влиянии на важнейшие показатели здоровья, которое достигается благодаря занятиям, в целом соответствующим объему физической активности, рекомендуемому для всех групп взрослого населения — 150 минут еженедельной физически активной деятельности средней интенсивности. • Нет оснований изменять объем или регулярность рекомендуемой физической активности средней интенсивности для беременных женщин и женщин в послеродовом периоде по сравнению с остальными группами взрослого населения. • Получены фактические данные среднего уровня достоверности о снижении риска преждевременных родов у матерей, занимающихся физически активной деятельностью высокой интенсивности. 48 49Рекомендации Варьируется ли эта взаимосвязь в зависимости от вида, области или периода (предбеременный, дородовой или послеродовой) физической активности? Фактические данные взяты из исследований, сосредоточенных на оценке досуговой области физической активности; этот вид активности является в основном аэробным (например, ходьба или плавание), хотя, согласно некоторым результатам оценочных исследований, нагрузки этого вида активности также включают в себя силовые упражнения (например, круговой тренинг) или сочетания аэробных и силовых упражнений. Однако в целом не имеется достаточных данных, позволяющих определить, варьируется ли взаимосвязь между физической активностью и показателями здоровья в зависимости от вида, области или периода (предбеременный, дородовой или послеродовой) физической активности. Вывод ГРР • Получены фактические данные среднего уровня достоверности о том, что беременным женщинам и женщинам в послеродовом периоде следует выполнять различные виды аэробных и силовых физических упражнений. Также могут быть полезны дополнительные легкие упражнения на растяжку. БЕРЕМЕННЫЕ ЖЕНЩИНЫ И ЖЕНЩИНЫ В ПОСЛЕРОДОВОМ ПЕРИОДЕ 50 51 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Особо малоподвижный образ жизни беременных женщин и женщин в послеродовом периоде, как и у всех взрослых, ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также росту масштабов распространения сердечно- сосудистых заболеваний, рака и диабета 2-го типа. В этой связи рекомендуется следующее. Беременным женщинам и женщинам в послеродовом периоде следует сокращать продолжительность пребывания в малоподвижном состоянии. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, низкая степень достоверности данных Для беременных женщин и женщин в послеродовом периоде малоподвижный образ жизни определяется как время, проводимое в состоянии бодрствования в положениях сидя или лежа при низком расходе энергии в профессиональном, образовательном, домашнем и общинном контексте и при передвижении. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО МАЛОПОДВИЖНОГО ОБРАЗА ЖИЗНИ Подтверждающие фактические данные и обоснование Малоподвижный образ жизни не был включен в Глобальные рекомендации ВОЗ по физической активности для здоровья 2010 г. (1). Из-за нехватки материалов по отдельным группам населения базой первичных фактических данных для оценки взаимосвязи между малоподвижным образом жизни и показателями здоровья беременных женщин и женщин в послеродовом периоде являлась научная литература, которая была подобрана и пересмотрена для взрослых групп населения. Были пересмотрены выводы, сделанные на основе данных о малоподвижном образе жизни по всем группам взрослого населения, включая решение вопроса о том, имеются ли данные, согласно которым соответствующие результаты будут в отношении беременных женщин и женщин в послеродовом периоде чем-либо отличаться, окажутся для них неприменимыми или будут им противопоказаны. На основе имеющихся материалов и экспертных заключений эти фактические данные были экстраполированы с целью учета в новых рекомендациях ВОЗ относительно малоподвижного образа жизни для беременных женщин и женщин в послеродовом периоде по единому комплексу важнейших показателей здоровья. Ввиду косвенного характера фактических данных уровень их достоверности был понижен. Учитывая нехватку данных по данной группе населения и тот факт, что беременные женщины были исключены из охвата исследований, рекомендация относительно повышения уровня физической активности сверх ее рекомендуемых объемов с целью сглаживания вредного воздействия особо малоподвижного образа жизни не была экстраполирована для женщин во время беременности и в послеродовой период. Выводы ГРР • Фактические данные о малоподвижном образе жизни во всех группах взрослого населения могут экстраполироваться и учитываться при составлении рекомендаций для беременных женщин и женщин в послеродовом периоде по единому комплексу важнейших показателей здоровья. • Польза от минимизации объема малоподвижного образа жизни перевешивает риски для беременных женщин и женщин в послеродовом периоде. • Ввиду косвенного характера фактических данных уровень их достоверности следует понизить. БЕРЕМЕННЫЕ ЖЕНЩИНЫ И ЖЕНЩИНЫ В ПОСЛЕРОДОВОМ ПЕРИОДЕ 50 51Рекомендации На сегодняшний день большинство рекомендаций о физической активности для лиц с хроническими патологиями ограничено рекомендациями клинического или терапевтического характера. Например, имеются рекомендации и ресурсы по клинической практике, разработанные профессиональными медицинскими ассоциациями для онкологических заболеваний (101), диабета 2-го типа (102), гипертонии (103) и других хронических болезней (104). ВОЗ также подготовила руководство по клинической практике, включающее рекомендации относительно физической активности для пациентов с хроническими заболеваниями (17). В настоящих рекомендациях изложены первые популяционные рекомендации ВОЗ, касающиеся физической активности лиц с хроническими патологиями, особенно лиц с онкологическими заболеваниями (далее именуемых лицами, пережившими рак), гипертонией, диабетом 2-го типа и ВИЧ-инфекцией. Учитывая прогресс в деле эффективной и широкодоступной антиретровирусной терапии для ВИЧ, эта патология теперь также считается хронической. При ведении пациентов, которые проходят интенсивное лечение (например, химиотерапию) или еще не стабилизировались после непрерывного приема лекарств, врачам также следует пользоваться рекомендациями по клинической практике, относящимися к каждой хронической патологии. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО ФИЗИЧЕСКОЙ АКТИВНОСТИ Взрослые с хроническими патологиями могут заниматься физически активной деятельностью в рамках отдыха и досуга (подвижные игры, занятия спортом или плановые тренировки), передвижений (использование колесных средств, ходьба и езда на велосипеде), работы или выполнения домашних обязанностей, то есть в повседневном профессиональном, образовательном, домашнем и общинном контексте. Всем взрослым, пережившим рак, а также взрослым, страдающим гипертонией, диабетом 2-го типа и ВИЧ-инфекцией, нужно пытаться следовать этим рекомендациям по мере возможности, сообразно своим способностям и при отсутствии противопоказаний. Физическая активность может благоприятно отражаться на здоровье взрослых и пожилых людей со следующими хроническими патологиями: благодаря поддержанию физической активности у лиц, переживших рак, снижаются показатели смертности от всех причин и от конкретных онкологических заболеваний, а также риск рецидива или второго первичного рака; у лиц, страдающих артериальной гипертонией, благодаря поддержанию физической активности снижаются показатели смертности от сердечно-сосудистых заболеваний, замедляется прогрессирование заболевания, улучшаются показатели физического функционирования, а также повышается качество жизни, обусловленное состоянием здоровья; у лиц, страдающих диабетом 2-го типа, благодаря поддержанию физической активности снижаются показатели смертности от сердечно-сосудистых заболеваний и замедляется прогрессирование заболевания; лицам, страдающим ВИЧ-инфекцией, поддержание физической активности может помочь улучшить физическое и психическое здоровье (снизить симптомы тревоги и депрессии), не оказывая при этом негативного воздействия на прогрессирование болезни (на число CD4-клеток и вирусную нагрузку) или на состав тканей организма. В этой связи рекомендуется следующее. Всем взрослым и пожилым людям с вышеуказанными хроническими патологиями следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Взрослым и пожилым людям с этими хроническими патологиями следует не менее 150–300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75–150 минут в неделю физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я 52 53 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Чтобы занятия приносили дополнительную пользу для здоровья, взрослым и пожилым людям с этими хроническими патологиями также следует выполнять силовые упражнения средней и большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных В ходе еженедельных занятий физически активной деятельностью в целях повышения функциональных возможностей и предотвращения риска падений пожилым людям с этими хроническими патологиями следует не реже трех раз в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней и большей интенсивности. Настоятельная рекомендация, средняя степень достоверности данных При отсутствии противопоказаний взрослые и пожилые люди, страдающие этими хроническими патологиями, могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, чтобы занятия приносили дополнительную пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных Подтверждающие фактические данные и обоснование Охват настоящих рекомендаций включал в себя оценку взаимосвязи между физической активностью и следующими показателями здоровья: для лиц, переживших рак — смертность от всех причин и от конкретных онкологических заболеваний, а также риск рецидива или второго первичного рака; для лиц, страдающих артериальной гипертонией — смертность от сердечно-сосудистых заболеваний, риск сопутствующих заболеваний, физическое функционирование, качество жизни, обусловленное состоянием здоровья, и прогрессирование заболевания (здесь определено как реакция артериального давления на физическую активность); для лиц, страдающих диабетом 2-го типа — смертность от сердечно-сосудистых заболеваний, риск сопутствующих заболеваний, физическое функционирование, качество жизни, обусловленное состоянием здоровья, и прогрессирование заболевания; и для лиц, страдающих ВИЧ-инфекцией — физическое функционирование (физическое состояние, переносимость нагрузки и сила), качество жизни, обусловленное состоянием здоровья, психическое здоровье (симптомы тревоги и депрессии), кардиометаболические показатели риска заболевания (липиды крови, глюкоза в крови и состав тканей организма) и негативное воздействие на прогрессирование болезни (на число CD4-клеток и вирусную нагрузку). При подготовке настоящих рекомендаций были использованы и обновлены фактические данные из доклада PAGAC (35); были также выявлены 16 новых обзоров за период 2017–2019 гг. по онкологическим заболеваниям (n= 1), гипертонии (n= 2) и диабету 2-го типа (n= 13). Кроме того, из запрошенного общего обзора, посвященного физической активности и показателям здоровья у лиц, страдающих ВИЧ-инфекцией, были взяты данные по 19 признанным приемлемыми обзорам, опубликованным в 2002–2018 гг. С полной информацией о методах, извлечении данных и профилях фактических данных можно ознакомиться в веб-приложении «Профили фактических данных» . Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я • если взрослые с этими хроническими патологиями не в состоянии выполнять вышеперечисленные рекомендации, им следует стремиться к тому, чтобы заниматься физически активной деятельностью в соответствии со своими физическими возможностями; • взрослым с этими хроническими патологиями следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • взрослые с этими хроническими патологиями могут получить консультацию у специалиста по вопросам физической активности или медицинского работника относительно видов и объемов физически активной деятельности, соответствующих их индивидуальным потребностям, физическим возможностям, функциональным ограничениям/ осложнениями, принимаемым лекарственным средствам и общему плану лечения; • как правило, для лиц, не имеющих противопоказаний, нет необходимости в прохождении предварительного медосмотра перед началом занятий физически активной деятельностью низкой и средней интенсивности, не требующих физической подготовки дополнительно к той, которая необходима для энергичной ходьбы или в повседневной жизни. 52 53Рекомендации Какова взаимосвязь между физической активностью и показателями здоровья у взрослых и пожилых людей (в возрасте 18 лет и старше), страдающих онкологическими заболеваниями (лиц, переживших рак), гипертонией, диабетом 2-го типа или ВИЧ-инфекцией? Физическая активность стимулирует в метаболических, гормональных и воспалительных путях благотворные кратко- и долгосрочные изменения, которые считаются факторами защиты от возникновения рака и выживания после него (35). Фактические данные показывают, что повышение уровней физической активности после диагностики рака обеспечивало защиту от смертности от всех причин после рака молочной железы (ОР= 0,58 [95% ДИ: 0,52–0,65], 17 исследований); колоректального рака (ОР= 0,63 [95% ДИ: 0,50–0,78], 10 исследований), рака женской репродуктивной системы (ОР= 0,66 [95% ДИ: 0,49–0,88], 4 исследования); глиомы (ОР= 0,64 [95% ДИ: 0,46–0,91], 1 исследование); гемобластоза (ОР= 0,60 [95% ДИ: 0,51–0,69], 2 исследования); рака почки (ОР= 0,60 [95% ДИ: 0,38–0,95], 1 исследование); рака легких (ОР= 0,76 [95% ДИ: 0,60–0,97], 2 исследования); рака простаты (ОР= 0,60 [95% ДИ: 0,46–0,79], 5 исследований); и рака желудка (ОР= 0,75 [95% ДИ: 0,61–0,93], 1 исследование) (105). Повышенные объемы физической активности после диагностики рака также приводят к снижению риска смертности от конкретных причин у лиц, переживших рак молочной железы, колоректальный рак и рак простаты. Результаты метаанализа показали снижение рисков смерти для лиц верхней группы общей постдиагностической активности в сравнении с нижней группой по всем онкологическим заболеваниям (ОР= 0,63 [95% ДИ: 0,53–0,75], 4 исследования); раку молочной железы (ОР= 0,63 [95% ДИ: 0,50–0,78], 13 исследований); колоректальному раку (ОР= 0,62 [95% ДИ: 0,44–0,86], 6 исследований); и раку простаты (ОР= 0,70 [95% ДИ: 0,55–0,90], 4 исследования) (105). Однако фактические данные оказались недостаточными для решения вопроса о том, существует ли взаимосвязь между физической активностью и рецидивом рака или вторым первичным раком. Физическая активность имеет большое значение как для первичной профилактики гипертонии, так и для ее лечения: фактические данные показывают, что физические нагрузки обеспечивают улучшение физического функционирования, замедляют прогрессирование сердечно-сосудистых заболеваний (т. е. реакцию артериального давления на физическую активность) и снижают смертность от сердечно- сосудистых заболеваний среди лиц, страдающих гипертонией (35). Например, по сравнению с неактивными контрольными группами физически активные лица с гипертонией могут снижать систолическое артериальное давление примерно на 12 мм ртутного столба, а диастолическое артериальное давление – примерно на 6 мм ртутного столба (САР МД= 12,26 мм рт. ст. [95% ДИ: 15,17–9,34], p= < 0,05; ДАР МД= 6,12 мм рт. ст. [95% ДИ: 7,76–4,48], p= < 0,05) (106). Новые фактические материалы свидетельствуют о том, что лица с гипертонией, занимающиеся физически активной деятельностью, способны значительно улучшить свое качество жизни, обусловленное состоянием здоровья, по сравнению со страдающими гипертонией неактивными лицами (54). Физическая активность, включая аэробные нагрузки, силовые упражнения и сочетание аэробных и силовых упражнений, способствует улучшению вторичных показателей риска прогрессирования (HbA1c, артериального давления, ИМТ и липидов) у взрослых, страдающих диабетом 2-го типа (35). Например, недавнее исследование показало, что упражнения на сопротивление помогают активнее снижать HbA1c в сравнении с контрольными группами и что тренировки на сопротивление высокой интенсивности оказывают большое позитивное воздействие на уровень инсулина натощак (107). При этом не имеется достаточных фактических данных для оценки влияния физической активности на качество жизни, обусловленное состоянием здоровья, и на физическое функционирование у взрослых, страдающих диабетом 2-го типа. Физическая активность лиц, страдающих ВИЧ-инфекцией, улучшает их кардиореспираторное здоровье. Рассмотренные мероприятия включали в себя либо аэробные нагрузки, либо тренировки в сочетании с постепенным добавлением силовых упражнений в течение как минимум 30 минут три раза в неделю (108, 109). Имеются также данные о том, что занятия физически активной деятельностью могут улучшить показатели маркеров кардиометаболического риска (например, липидов), хотя полученные результаты неоднозначны; не был установлен факт воздействия на концентрацию инсулина, но при этом содержание глюкозы после аэробной нагрузки снижалось (110). Физическая активность лиц, страдающих ВИЧ-инфекцией, — как аэробная, так и комбинируемая с силовыми упражнениями — имеет несомненную связь с их качеством жизни, обусловленным состоянием здоровья (111), и со снижением симптомов депрессии и тревоги (112). Метаанализ проблем депрессии (9 исследований) показал величину СМД = 0,84 (95% ДИ: 1,57–0,11), благоприятную для физически активных групп (p= 0,02). Показатель СМД для снижения симптомов тревоги (5 исследований) также был статистически значимым и подтверждал целесообразность активности ( 1.23 [95% ДИ: 2,42–0.04], p= 0,04) (112). Кроме того, физическая активность приводит к заметному увеличению разности стандартизированных средних показателей сухой мышечной массы (1,75 кг) и значительному снижению доли телесного жира (на 1,12%) у участников физически активных контрольных групп, а также к росту периферийных мышц ног и рук в сравнении с участниками неактивных контрольных групп (111); при этом она не влечет изменений ИМТ или окружности талии у лиц, страдающих ВИЧ-инфекцией (111). Физическая активность не оказывает вредного воздействия ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) 54 55 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и на маркеры прогрессирования ВИЧ-инфекции, такие как число CD4-клеток (клеток на 1 мм3) или вирусная нагрузка (111). Важно отметить, что, согласно этим данным, физическая активность не будет способствовать подавлению ВИЧ как хронического заболевания. Выводы ГРР • Получены фактические данные среднего уровня достоверности о том, что увеличение объема физической активности после диагностики рака приводит к снижению рисков смертности от всех причин, от конкретных причин и от определенных онкологических заболеваний среди лиц, переживших рак. • Получены фактические данные высокого уровня достоверности о том, что физическая активность снижает риск прогрессирования сердечно- сосудистых заболеваний у взрослых, страдающих гипертонией. • Получены фактические данные среднего уровня достоверности о том, что физическая активность улучшает у взрослых, страдающих гипертонией, показатели физического функционирования и качества жизни, обусловленного состоянием здоровья. • Получены фактические данные высокого уровня достоверности о том, что физическая активность улучшает показатели маркеров прогрессирования заболевания (HbA1c, артериального давления, ИМТ и липидов) у взрослых, страдающих диабетом 2-го типа. • Получены фактические данные среднего уровня достоверности о наличии взаимосвязи между физической активностью и улучшением физического здоровья (максимального потребления кислорода, переносимости нагрузки) и мышечной силы у лиц, страдающих ВИЧ-инфекцией, и о наличии благоприятной взаимосвязи между физической активностью и составом тканей организма, качеством жизни, обусловленным состоянием здоровья, сокращением симптомов депрессии и тревоги и отсутствием изменений в вирусной нагрузке или числе CD4-клеток у лиц, страдающих ВИЧ-инфекцией. • Польза от занятий регулярной физически активной деятельностью для лиц, переживших рак, и лиц, страдающих гипертонией, диабетом 2-го типа и ВИЧ-инфекцией, в части улучшения конкретных показателей здоровья перевешивает смежные риски. Имеется ли взаимосвязь «доза-ответ» (объем, продолжительность, регулярность, интенсивность)? Повышение объема физической активности после диагностики рака приводит к снижению рисков смертности от всех причин и от онкологических заболеваний. Фактические данные указывают на наличие нелинейной взаимосвязи между увеличением постдиагностической физической активности и показателями смертности от рака молочной железы ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) и от всех причин до 10–15 MET-часов в неделю (что согласуется с физической нагрузкой средней и высокой интенсивности продолжительностью 150 минут в неделю) без подтверждения причинения вреда на более высоких уровнях активности (105). Предполагается наличие аналогичной взаимосвязи «доза-ответ» при других локализациях рака, однако немногочисленность состоявшихся исследований не позволяет провести формальный метаанализ. Для выявления степени прочности этой взаимосвязи необходимо дальнейшее исследование. Налицо явная взаимосвязь «доза-ответ» между физической активностью и смертностью от сердечно-сосудистых заболеваний среди лиц, страдающих гипертонией (35). Выводы показывают, что по мере роста систолического артериального давления в гипертонических диапазонах возрастает риск смертности от сердечно-сосудистых заболеваний, однако с наращиванием физической активности этот возросший риск ослабевает (35). По аналогии с рекомендациями для общей популяции основу большинства традиционных мероприятий составляет аэробная нагрузка средней интенсивности продолжительностью 30–60 минут три раза в неделю и/или 2–3 еженедельные тренировки на сопротивление. Получены существенные фактические данные о наличии обратной криволинейной взаимосвязи между объемом физической активности и риском смертности от сердечно- сосудистых заболеваний у взрослых, страдающих диабетом 2-го типа (113–115). Более значительные объемы физической активности (которые ниже, равны или выше рекомендованных 150 минут активной нагрузки средней интенсивности в неделю) постепенно снижают этот риск. Например, в сравнении с полным отсутствием активности занятие той или иной активной деятельностью приводило к снижению риска смертности от сердечно-сосудистых заболеваний на 32% (ОР= 0,68 [95% ДИ: 0,51–0,92]), а занятие физически активной деятельностью в объеме, который соответствует рекомендациям по физической активности или превышает их, обеспечивало снижение риска смертности от сердечно-сосудистых заболеваний на 40% (ОР= 0,60 [95% ДИ: 0,44–0,82]) (115). Основу большинства мероприятий составляет аэробная нагрузка средней интенсивности продолжительностью 150–300 минут или нагрузка высокой интенсивности продолжительностью 75 минут и/или 2–3 тренировки на сопротивление в неделю. По некоторым показателям (например, HBA1c и артериальному давлению) у взрослых, страдающих диабетом 2-го типа, имеются фактические данные о более заметном эффекте большего объема аэробной нагрузки (т. е. более чем 150 минут в неделю в сравнении с менее чем 150 минут в неделю), но при этом данные по интенсивности нагрузки носят ограниченный характер (35). В отношении лиц, страдающих ВИЧ-инфекцией, не было получено достаточных фактических данных для установления взаимосвязи «доза-ответ» между физической активностью и составом тканей организма или косвенными маркерами кардиометаболических заболеваний (такими как липидные профили крови, инсулинорезистентность, 54 55Рекомендации содержание глюкозы в крови натощак или артериальное давление). В большинстве исследований, послуживших источником данных, рассматривались мероприятия по физической активности, которые проводились не реже трех раз в неделю в течение 12–48 недель и представляли собой только аэробную нагрузку средней и высокой интенсивности не менее 30 минут или сочетание аэробной нагрузки с постепенными тренировками на сопротивление. В этом случае также нет достаточных фактических данных для более точного установления взаимосвязи «доза-ответ» между физической нагрузкой и показателями психического здоровья и качества жизни, обусловленного состоянием здоровья. Имеющиеся данные взяты из исследований, которые, как правило, посвящены оценке мероприятий по физической активности, проводимых не реже трех раз в неделю. В целом были получены фактические данные от среднего до высокого уровня достоверности, которые подтверждают рекомендацию о физической активности средней интенсивности (или ее эквивалента) продолжительностью 150–300 минут для определенных групп населения, страдающих хроническими заболеваниями, и конкретного комплекса показателей здоровья. В фактических материалах относительно лиц, страдающих гипертонией и диабетом 2-го типа, и лиц, переживших рак, имелись более конкретные данные о том, что повышенные уровни физической активности приносят больше пользы. Была отмечена вариативность в уровнях достоверности и прямоты данных в зависимости от рассматриваемой конкретной хронической патологии и определенных показателей здоровья. В случаях, когда имеющиеся данные указывали на позитивный эффект силовых упражнений, регулярность нагрузок составляла 2–3 тренировки на сопротивление в неделю. Выводы ГРР • Получены фактические данные среднего уровня достоверности о наличии взаимосвязи «доза-ответ» между физической активностью и снижением смертности от всех причин и смертности от онкологических заболеваний у лиц, переживших рак. • Получены фактические данные высокого уровня достоверности о наличии взаимосвязи «доза-ответ» между физической активностью и смертностью от сердечно-сосудистых заболеваний у взрослых, страдающих гипертонией. • Получены фактические данные о наличии обратной криволинейной взаимосвязи «доза-ответ» между объемом активной деятельности и риском смертности от сердечно-сосудистых заболеваний среди взрослых, страдающих диабетом 2-го типа. • Не имеется достаточных фактических данных о наличии взаимосвязи «доза-ответ» между физической активностью и косвенными маркерами кардиометаболических заболеваний, составом тканей организма и качеством жизни, обусловленным ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) состоянием здоровья, симптомами тревоги и депрессии у лиц, страдающих ВИЧ-инфекцией. • Аэробная физическая активность средней интенсивности (или ее эквивалент) в течение 150–300 минут обеспечивает благоприятные показатели здоровья; были также отмечены позитивные эффекты силовых упражнений при еженедельном проведении 2-3 тренировок на сопротивление. Варьируется ли эта взаимосвязь в зависимости от вида или области физической активности? Имеющиеся фактические данные подтверждают, что различные виды и области физической активности оказывают благоприятное воздействие на показатели здоровья. Лица, пережившие рак, которые соблюдают рекомендуемые уровни аэробной и силовой нагрузки, в сравнении с не соблюдающими никаких рекомендаций лицами значительно снижают риск смертности от рака (ОР= 0,70 [95% ДИ: 0,50–0,98]) (84). Данные показывают, что выполнение одной лишь рекомендации в отношении силовой физической активности в сравнении с невыполнением рекомендаций также приводит к снижению показателей смертности от рака (ОР= 0,66 [95% ДИ: 0,48–0,92]) (84). В результатах одного из метаанализов также сообщалось о наличии таких взаимосвязей в разбивке по областям физической активности; в нем были отмечены наиболее существенные снижения смертности от всех онкологических заболеваний, рака молочной железы и колоректального рака, достигнутые благодаря рекреационной физической активности (105). В отношении взрослых, страдающих от гипертонии, фактические данные подтверждают, что аэробная активность, силовые упражнения и сочетание этих двух видов нагрузки способствуют замедлению прогрессирования сердечно-сосудистых заболеваний. Что касается понижающего воздействия на артериальное давление, обеспечиваемого двумя традиционными видами физической активности (т. е. аэробной активностью и тренировками на сопротивление), то оно, как представляется, не показывает заметной вариативности среди лиц, страдающих гипертонией (35); эти данные, однако, не являются следствием прямого сопоставления двух указанных видов нагрузки. Кроме того, появляются данные, подтверждающие благотворное влияние других видов упражнений для лиц, страдающих гипертоний (например, тайцзи, йога, цигун), однако для изучения этих особых видов активности и определения прочности взаимосвязи необходимо дальнейшее исследование. Aэробная нагрузка, силовые упражнения или их сочетание приводят к улучшению вторичных показателей риска прогрессирования заболевания (HbA1c, артериального давления, ИМТ и липидов) среди взрослых, страдающих диабетом 2-го типа (35, 107). В обзоре материалов 24 РКИ (n= 962) сообщалось, что тренировки на сопротивление позволяют активнее снижать показатель HbA1c по сравнению с контрольными группами (РС= 0,45 [95% ДИ: 0,65–0,25], 20 испытаний; n= 824). При упражнениях на сопротивление высокой интенсивности в сравнении с контрольными группами были обнаружено статистически значимое воздействие на уровень инсулина натощак (РС= 4,60 56 57 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и [95% ДИ: 7,53–1,67], 5 испытаний; n= 174) (107). Еще один обзор, охватывавший 7 РКИ (n= 189), показал, что интервальные тренировки (2–5 раз в неделю, с интервалами 1–4 минуты и общей продолжительностью 20–60 минут) позволяют добиться статистически значимых снижений HbA1c на 0,26% (95% ДИ: 0,46–0,07%, 5 РКИ) по сравнению с группами средней активности и на 0,83% (95% ДИ: 1,39%–0.27%, 4 РКИ) — с неактивными контрольными группами (116). По аналогии с рекомендациями для общей популяции основу большинства этих мероприятий составляют аэробная физическая активность, соответствующая рекомендации относительно аэробной нагрузки средней интенсивности продолжительностью 150–300 минут (или 75 минут высокой интенсивности), и силовые упражнения в виде 2–3 тренировок в неделю. Имеются фактические данные о росте воздействия на некоторые показатели (например, HBA1c и артериальное давление) при увеличении аэробной нагрузки (т. е. более 150 минут в неделю по сравнению с нагрузкой менее 150 минут в неделю), однако сведения об интенсивности носят ограниченный характер. Результаты более поздних исследований показывают, что традиционная китайская гимнастика, например тайцзи, может способствовать снижению уровня глюкозы в крови, однако эти данные имеют средний и вариативный уровень достоверности (т. е. подвержены риску необъективности или непоследовательности). Для определения этих взаимосвязей необходимо дальнейшее исследование. Было доказано, что различные виды физической активности лиц, страдающих ВИЧ-инфекцией, в частности аэробная нагрузка и упражнения на сопротивление, позитивно воздействуют на качество жизни, обусловленное состоянием здоровья (111). Результаты недавнего исследования изменений качества жизни, обусловленного состоянием здоровья, которые были достигнуты благодаря аэробным нагрузкам, постепенному включению упражнений на сопротивление или обоих этих видов нагрузки, указывают на существенные улучшения общего состояния здоровья и психического здоровья. Имеются также фактические данные о том, что как аэробная, так и многокомпонентная физическая активность влияют на снижение симптомов депрессии и тревоги у лиц, страдающих ВИЧ-инфекцией (112). Данные о воздействии физической активности на показатели психического здоровья касались применения только аэробной нагрузки или сочетания аэробной нагрузки ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) с постепенными силовыми упражнениями или йогой. Полученные материалы также показывают, что аэробная нагрузка — отдельно или в сочетании с упражнениями на сопротивление — не вызывает значительных изменений вирусной нагрузки или числа CD4-клеток у лиц, страдающих ВИЧ-инфекцией (111). Непосредственные фактические данные, взятые как из имеющихся, так и из обновленных публикаций, подтверждают целесообразность включения рекомендаций для лиц, страдающих диабетом 2-го типа и гипертонией, согласно которым им следует заниматься аэробной и силовой физически активной деятельностью. Несмотря на нехватку опубликованных данных, налицо биологическое правдоподобие благотворного влияния аэробных и силовых нагрузок на состояние взрослых, страдающих ВИЧ- инфекцией, и лиц, переживших рак. С другой стороны, как отметила ГРР, общепринятые международные рекомендации по клинической практике предписывают этим группам населения занятие аэробной и силовой физически активной деятельностью (например, рекомендации ACSM «Moving Through Cancer» (101), составленные на основе систематического обзора фактических данных (3)). С учетом предварительного характера этих данных уровень их достоверности был понижен. Выводы ГРР • Получены фактические данные среднего уровня достоверности о совокупном или аддитивном воздействии аэробных или силовых упражнений на снижение смертности от рака, а также на улучшение артериального давления у лиц, страдающих гипертонией. • Получены фактические данные высокого уровня достоверности о том, что аэробная нагрузка, силовые упражнения, а также сочетание аэробных и силовых упражнений улучшают состояние маркеров прогрессирования заболевания (HbA1C, артериального давления, ИМТ и липидов) у взрослых, страдающих диабетом 2-го типа. • Получены фактические данные среднего уровня достоверности о том, что регулярные занятия аэробной физически активной деятельностью отдельно или в сочетании с упражнениями на сопротивление не вызывают значительных изменений вирусной нагрузки или числа CD4-клеток у лиц, страдающих ВИЧ-инфекцией. • Имеются недостаточные фактические данные о том, что лица, страдающие ВИЧ-инфекцией, могут одними силовыми тренировками воздействовать на качество жизни, обусловленное состоянием здоровья. 56 57Рекомендации Подтверждающие фактические данные и обоснование Из-за нехватки материалов по отдельным группам населения базой первичных фактических данных для оценки взаимосвязи между малоподвижным образом жизни и показателями здоровья взрослых и пожилых людей, переживших рак, а также взрослых и пожилых людей, страдающих гипертонией, диабетом 2-го типа и ВИЧ-инфицированных, являлась научная литература, которая была подобрана и пересмотрена для взрослых групп населения. Были пересмотрены выводы, сделанные на основе данных о малоподвижном образе жизни по всем группам взрослого населения, включая решение вопроса о том, имеются ли данные, согласно которым соответствующие результаты будут в отношении взрослых и пожилых людей с хроническими патологиями чем-либо отличаться, окажутся для них неприменимыми или будут им противопоказаны. Особо малоподвижный образ жизни взрослых, в том числе лиц, переживших рак, и лиц, страдающих гипертонией и диабетом 2-го типа, а также ВИЧ-инфицированных, ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также росту масштабов распространения сердечно-сосудистых заболеваний, рака и диабета 2-го типа. Лицам, пережившим рак, а также взрослым, страдающим гипертонией, диабетом 2-го типа и ВИЧ-инфицированным рекомендуется следующее. Взрослым и пожилым людям с хроническими патологиями следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, низкая степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии взрослым и пожилым людям с хроническими патологиями следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней и высокой интенсивности. Настоятельная рекомендация, низкая степень достоверности данных Малоподвижный образ жизни не был включен в Глобальные рекомендации ВОЗ по физической активности для здоровья 2010 г. (1). Охват этой новой рекомендации относительно малоподвижного образа жизни распространяется на лиц, переживших рак, и на лиц, страдающих гипертонией, диабетом 2-го типа и ВИЧ-инфекцией. Малоподвижный образ жизни определяется как время, проводимое в состоянии бодрствования в положениях сидя или лежа при низком расходе энергии в профессиональном, образовательном, домашнем и общинном контексте и при передвижении. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО МАЛОПОДВИЖНОГО ОБРАЗА ЖИЗНИ ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) 58 59 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и На основе имеющихся материалов и экспертных заключений эти фактические данные были экстраполированы с целью учета в новых рекомендациях ВОЗ относительно малоподвижного образа жизни для взрослых с хроническими патологиями по единому комплексу важнейших показателей здоровья. Главным основанием для экстраполяции этих данных служит вывод о том, что охват большинства исследований не предусматривал верхнего возрастного предела, включал в себя взрослых старше 65 лет и мог включать взрослых с хроническими патологиями, таких как лица, пережившие рак, и лица, страдающие гипертонией или диабетом 2-го типа. В связи с лицами, страдающими ВИЧ-инфекцией, не было выявлено никаких причин, в силу которых к ним не могли бы применяться данные о воздействии малоподвижного образа жизни на здоровье. Поскольку эти фактические данные имеют косвенное отношение к разработке указанных рекомендаций, уровень их достоверности был понижен. Кроме того, сведения о применимости фактических данных о пользе увеличения объема физически активной деятельности средней и высокой интенсивности для противодействия возможным рискам особо малоподвижного образа жизни были рассмотрены и также экстраполированы с целью учета в рекомендациях для взрослых с хроническими патологиями по единому комплексу важнейших показателей здоровья. Ввиду косвенного характера фактических данных уровень их достоверности был понижен. Выводы ГРР • Фактические данные о малоподвижном образе жизни во всех группах взрослого населения могут экстраполироваться и учитываться при составлении рекомендаций для взрослых и пожилых лиц, переживших рак, а также для взрослых и пожилых лиц, страдающих гипертонией, диабетом 2-го типа и ВИЧ-инфекцией, по единому комплексу важнейших показателей здоровья, но с понижением уровня достоверности этих данных ввиду их косвенного характера. • Фактические данные о пользе увеличения объема физически активной деятельности средней и высокой интенсивности для противодействия возможным рискам особо малоподвижного образа жизни во всех группах взрослого населения могут экстраполироваться и учитываться при составлении рекомендаций для взрослых и пожилых лиц, переживших рак, а также для взрослых и пожилых лиц, страдающих гипертонией, диабетом 2-го типа и ВИЧ-инфекцией, по единому комплексу важнейших показателей здоровья, но с понижением уровня достоверности этих данных ввиду их косвенного характера. • Польза от минимизации объема малоподвижного образа жизни перевешивает риски для лиц, переживших рак, и лиц, страдающих гипертонией, диабетом 2-го типа и ВИЧ-инфекцией. ВЗРОСЛЫЕ И ПОЖИЛЫЕ ЛЮДИ С ХРОНИЧЕСКИМИ ПАТОЛОГИЯМИ (в возрасте 18 лет и старше) 58 59Рекомендации ДЕТИ И ПОДРОСТКИ (в возрасте 5–17 лет) И ВЗРОСЛЫЕ (в возрасте 18 лет и старше) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ Во многих случаях физическая активность приносит детям и подросткам с ограниченными возможностями такую же пользу для здоровья, которую, как отмечалось в разделе выше, она приносит всем детям и подросткам. Дополнительная польза физической активности в улучшении показателей здоровья людей с ограниченными возможностями также заключается в том, что улучшаются когнитивные способности лиц с заболеваниями и расстройствами, связанными с нарушением когнитивных функций, в том числе лиц с синдромом дефицита внимания/гиперактивности (СДВГ); у детей с ограниченными интеллектуальными возможностями могут улучшаться показатели физического функционирования. В этой связи рекомендуется следующее. Детям и подросткам еженедельно следует посвящать в среднем не менее 60 минут в день занятиям физически активной деятельностью, в основном аэробным нагрузкам средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Физически активной деятельностью с аэробной нагрузкой высокой интенсивности, в том числе направленной на укрепление скелетно-мышечной системы, следует заниматься не реже трех раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных Физическая активность может быть весьма полезна для здоровья детей, подростков и взрослых с ограниченными возможностями. Детям, подросткам и взрослым с ограниченными возможностями следует стараться выполнять эти рекомендации по мере возможности и сообразно своим способностям. Дети, подростки и взрослые с ограниченными возможностями могут заниматься физически активной деятельностью в рамках отдыха и досуга (подвижные игры, занятия спортом или плановые тренировки), физического воспитания, передвижений (использование колесных средств, ходьба и езда на велосипеде) или выполнения домашних обязанностей, то есть в домашнем, образовательном, профессиональном и общинном контексте. Важно обеспечить всем детям, подросткам и взрослым с ограниченными возможностями перспективы и стимулы для участия в физически активной деятельности, которая соответствует их возрасту и способностям, увлекательна и разнообразна. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО ФИЗИЧЕСКОЙ АКТИВНОСТИ П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я • небольшая физическая активность лучше, чем ее полное отсутствие; • если дети и подростки с ограниченными возможностями не выполняют эти рекомендации, любые занятия физически активной деятельностью пойдут на пользу их здоровью; • детям и подросткам с ограниченными возможностями следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • занятия физически активной деятельностью для детей и подростков с ограниченными возможностями не связаны с какими-либо серьезными рисками, если они соответствуют текущему уровню физической подготовки, состоянию здоровья и показателям физического функционирования конкретного ребенка, а полученная в итоге польза для здоровья перевешивает возможные риски; • дети и подростки с ограниченными возможностями могут нуждаться в консультации медицинского работника или другого специалиста по вопросам физической активности и работе с лицами с ограниченными возможностями для определения видов и объема физических нагрузок, которые им подходят. П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я 60 61 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Во многих случаях физическая активность приносит взрослым с ограниченными возможностями такую же пользу для здоровья, которую, как отмечалось в разделе выше, она приносит всем взрослым. Дополнительная польза физической активности в улучшении показателей здоровья людей с ограниченными возможностями также заключается в следующем: у взрослых, страдающих рассеянным склерозом, улучшаются показатели физического функционирования, а также физические, психические и социальные аспекты качества жизни, обусловленного состоянием здоровья; у лиц с повреждениями спинного мозга улучшается функция ходьбы, повышается мышечная сила и улучшается функция верхних конечностей; а также улучшается качество жизни, обусловленное состоянием здоровья; у людей с заболеваниями или расстройствами, связанными с нарушением когнитивных функций, улучшаются показатели физического функционирования и когнитивной деятельности (у лиц с болезнью Паркинсона и лиц, имеющих в анамнезе инсульт); оказывается положительное воздействие на когнитивную деятельность; а также может улучшаться качество жизни (у взрослых, страдающих шизофренией); могут улучшаться показатели физического функционирования (у взрослых с ограниченными интеллектуальными возможностями); и улучшается качество жизни (у взрослых, страдающих большим депрессивным расстройством). В этой связи рекомендуется следующее. Всем взрослым с ограниченными возможностями следует регулярно заниматься физически активной деятельностью. Настоятельная рекомендация, средняя степень достоверности данных Взрослым с ограниченными возможностями следует не менее 150–300 минут в неделю заниматься физически активной деятельностью средней интенсивности с аэробной нагрузкой; или не менее 75–150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, чтобы занятия приносили ощутимую пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Чтобы занятия приносили дополнительную пользу для здоровья, взрослым с ограниченными возможностями также следует выполнять силовые упражнения средней и большей интенсивности на все основные группы мышц не реже двух раз в неделю. Настоятельная рекомендация, средняя степень достоверности данных В ходе еженедельных занятий физически активной деятельностью в целях повышения функциональных возможностей и предотвращения риска падений пожилым людям с ограниченными возможностями следует не реже трех раз в неделю выполнять различные комплексные физические упражнения, в которых особое внимание уделяется упражнениям на равновесие и силовым упражнениям средней и большей интенсивности. Настоятельная рекомендация, средняя степень достоверности данных Взрослые с ограниченными возможностями могут увеличивать продолжительность еженедельных занятий и заниматься более 300 минут физически активной деятельностью средней интенсивности с аэробной нагрузкой; или заниматься более 150 минут физически активной деятельностью высокой интенсивности с аэробной нагрузкой; или, чтобы занятия приносили дополнительную пользу для здоровья, еженедельно уделять время аналогичному по нагрузке сочетанию физической активности средней и высокой интенсивности. Условная рекомендация, средняя степень достоверности данных ДЕТИ И ПОДРОСТКИ (в возрасте 5–17 лет) И ВЗРОСЛЫЕ (в возрасте 18 лет и старше) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ П Р А К ТИ Ч ЕС К И Е Н А Б Л Ю Д Е Н И Я • небольшая физическая активность лучше, чем ее полное отсутствие; • если взрослые с ограниченными возможностями не выполняют эти рекомендации, любые занятия физически активной деятельностью пойдут на пользу их здоровью; • взрослым с ограниченными возможностями следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность; • занятия физически активной деятельностью для взрослых с ограниченными возможностями не связаны с какими-либо серьезными рисками в том случае, когда они соответствуют текущему уровню физической подготовки, состоянию здоровья и показателям физического функционирования конкретного человека, а полученная в итоге польза для здоровья перевешивает возможные риски; • взрослые с ограниченными возможностями могут нуждаться в консультации медицинского работника или другого специалиста по вопросам физической активности и работе с лицами с ограниченными возможностями для определения видов и объема физических нагрузок, которые им подходят. 60 61Рекомендации ДЕТИ И ПОДРОСТКИ (в возрасте 5–17 лет) И ВЗРОСЛЫЕ (в возрасте 18 лет и старше) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ Подтверждающие фактические данные и обоснование При подготовке настоящих рекомендаций в отношении детей, подростков и взрослых с ограниченными возможностями были использованы и обновлены обобщенные фактические данные, собранные PAGAC (35). Имеются подробные сведения о методах работы, извлечении данных и таблицах обобщенного изложения существующих фактических данных о физической активности и показателях здоровья (35); они были пересмотрены усилиями ГРР в дополнение к результатам обновленного поиска. В ходе процедуры обновления, проведенной при подготовке настоящих рекомендаций, было выявлено 39 обзоров, опубликованных в 2017–2019 гг. Из них 27 соответствовали критериям включения и были использованы при анализе взаимосвязи между физической активностью и показателями здоровья среди детей, подростков и взрослых с ограниченными возможностями. С полной информацией о методах работы, извлечении данных и таблицах обобщенных фактических данных можно ознакомиться в веб-приложении «Профили фактических данных» . Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf В пересмотренном фактическом материале анализировалась взаимосвязь между физической активностью и показателями здоровья у детей, подростков и взрослых с ограниченными возможностями, причиной которых явились следующие состояния здоровья: рассеянный склероз, повреждение спинного мозга, ограниченные интеллектуальные возможности, болезнь Паркинсона, инсульт, большое депрессивное расстройство, шизофрения и синдром дефицита внимания/гиперактивности (СДВГ). К четырем рассмотренным показателям здоровья относились риск сопутствующих заболеваний, физическое функционирование, когнитивные функции и качество жизни, обусловленное состоянием здоровья, хотя по каждому состоянию здоровья были исследованы не все результаты. Воздействие факторов окружающей среды на ограниченные возможности лиц в контексте их физической активности не входило в сферу охвата настоящих рекомендаций и не являлось предметом анализа. Какова взаимосвязь между физической активностью и показателями здоровья у детей и подростков (в возрасте 5–17 лет) и взрослых (старше 18 лет) с ограниченными возможностями? У лиц, страдающих рассеянным склерозом, физическая активность улучшает показатели физического функционирования, функциональной мобильности, скорости и выносливости при ходьбе, кардиореспираторного здоровья, силы и равновесия. Например, интервальные тренировки высокой интенсивности в течение 3–12 недель ведут к улучшению кардиореспираторного здоровья или росту мышечной силы (117), силовые упражнения для нижних конечностей ведут к увеличению силы за средний тренировочный период в 13 недель на 23,1% (95% ДИ: 11,8–34,4) (118), и исследования эффективности танцевальных занятий указывают на улучшение функциональной мобильности и равновесия (119). Имеющиеся фактические данные показывают, что наряду с улучшением физического здоровья физическая активность может благоприятно отражаться на когнитивных способностях лиц, страдающих рассеянным склерозом (35). Согласно результатам более позднего исследования, аэробные упражнения оказывают небольшое, но при этом значительное воздействие на физический, психический и социальный аспекты качества жизни, обусловленного состоянием здоровья (в том числе на симптомы усталости и депрессии) (35, 120). У лиц с повреждениями спинного мозга физическая активность способна укрепить функцию ходьбы, мышечную силу и функционирование верхних конечностей (35). Кроме того, физическая активность может привести к снижению плечевых болей, улучшению функции сосудов и повышению качества жизни, обусловленного состоянием здоровья (35). У лиц, страдающих болезнью Паркинсона, физическая активность может обеспечить улучшение моторных симптомов, функциональной мобильности и работоспособности, выносливости, симптомов «замораживания» при ходьбе и скорости движения вперед и назад (35, 121, 122). Согласно новым данным, у лиц с болезнью Паркинсона физические нагрузки также могут способствовать общему улучшению когнитивных функций (123). У лиц, имеющих в анамнезе инсульт, благодаря физической активности можно добиться улучшения следующих параметров: физического функционирования, особенно функции верхних конечностей, сенсорно-моторной функции нижних конечностей, равновесия, скорости ходьбы, проходимого расстояния, умения и выносливости, кардиореспираторного здоровья, мобильности и активности в повседневной жизни. Имеющиеся данные показывают, что физические нагрузки также способны благотворно влиять на когнитивные способности (35). Применительно к лицам с большим депрессивным расстройством результаты новых обзоров (124, 125) потвердили существующие данные (35) о том, что физическая активность способна улучшить их качество жизни, обусловленное состоянием здоровья (35, 124, 125). У лиц с заболеваниями или расстройствами, связанными с нарушением когнитивных функций, включая шизофрению, физические нагрузки могут оказывать полезное воздействие на когнитивные способности, кратковременную память, социальный когнитивный уровень и внимание/ бдительность (35, 126). В одном обзоре было указано, что физически активная деятельность средней и высокой интенсивности обеспечивает существенное улучшение качества жизни, обусловленного состоянием здоровья, и расширяет ограниченные возможности (35, 124). 62 63 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и ДЕТИ И ПОДРОСТКИ (в возрасте 5–17 лет) И ВЗРОСЛЫЕ (в возрасте 18 лет и старше) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ Было установлено, что у лиц с ограниченными интеллектуальными возможностями физическая активность повышает уровень физического функционирования. Рассмотренные активные мероприятия охватывали в основном упражнения на равновесие и силовые упражнения, выполняемые в течение 6–24 недель; было выявлено значительное улучшение статического равновесия, динамического равновесия и статико- динамического равновесия по сравнению с контрольными группами (35, 127, 128). Фактические данные в отношении детей с синдромом дефицита внимания/гиперактивности, включающие обзор пяти РКИ по проблеме СДВГ (129), указывают на позитивную взаимосвязь между физической нагрузкой и вниманием, управляющей функцией и социальными расстройствами (35, 129). ГРР рассмотрела общие данные по детской, подростковой и взрослой популяции и пришла к выводу, что, поскольку нет никаких оснований полагать, что из-за имеющегося нарушения здоровья воздействие нагрузок на организм будет иным, то занятия физически активной деятельностью принесут здоровью такую же физиологическую пользу. ГРР признала, что лица с ограниченными возможностями фигурируют лишь в немногих исследованиях и что изменение воздействия на эту группу редко является предметом испытаний. Эти фактические данные в сфере ограниченных возможностей, дополненные более обширным материалом по общей популяции, послужили основанием для составления общепопуляционной рекомендации, которая распространяется на лиц с ограниченными возможностями с конкретным упоминанием «всех взрослых», «всех пожилых людей» и «людей с любыми способностями». Выводы ГРР Относительно лиц с повреждениями спинного мозга получены: • фактические данные низкого уровня достоверности о том, что физическая активность снижает плечевую боль, улучшает функцию сосудов в парализованных конечностях и повышает качество жизни, обусловленное состоянием здоровья; и • фактические данные среднего уровня достоверности о том, что физические нагрузки укрепляют функцию ходьбы, мышечную силу и функционирование верхних конечностей. Относительно лиц с заболеваниями или расстройствами, связанными с нарушением когнитивных функций, включая болезнь Паркинсона, получены: • фактические данные высокого уровня достоверности о том, что физическая активность улучшает ряд функциональных показателей, в том числе ходьбу, равновесие, силу и двигательную активность в привязке к конкретному заболеванию; и • фактические данные среднего уровня достоверности о том, что физические нагрузки средней и высокой интенсивности могут оказывать благоприятное воздействие на когнитивные способности. Относительно лиц, имеющих в анамнезе инсульт, получены: • фактические данные среднего уровня достоверности о том, что благодаря подвижной физической активности можно добиться позитивного воздействия на физическое функционирование и когнитивные способности. Относительно лиц с заболеваниями или расстройствами, связанными с нарушением когнитивных функций, включая шизофрению, получены: • фактические данные среднего уровня достоверности о том, что физическая активность повышает качество жизни; и • фактические данные высокого уровня достоверности о том, что физические нагрузки средней и высокой интенсивности могут оказывать полезное воздействие на когнитивные способности, кратковременную память, социальный когнитивный уровень и внимание. Относительно взрослых с большим депрессивным расстройством получены: • фактические данные среднего уровня достоверности о том, что физическая активность повышает качество жизни. Относительно взрослых, страдающих рассеянным склерозом, получены: • фактические данные высокого уровня достоверности о том, что физическая активность, в частности аэробные и силовые упражнения, улучшают показатели физического функционирования, функциональной мобильности, скорости и выносливости при ходьбе, кардиореспираторного здоровья, силы и равновесия; • фактические данные среднего уровня достоверности о том, что физически активная деятельность может благотворно влиять на когнитивные способности; и • фактические данные низкого уровня достоверности о том, что физическая активность улучшает качество жизни, в том числе снижает симптомы усталости и депрессии. Относительно детей и взрослых с ограниченными интеллектуальными возможностями получены: • фактические данные низкого уровня достоверности о том, что физически активная деятельность улучшает физическое функционирование. Относительно детей и подростков с СДВГ получены: • фактические данные среднего уровня достоверности о том, что физические нагрузки средней и высокой интенсивности могут позитивно воздействовать на когнитивные способности, включая внимание, управляющую функцию и социальные расстройства. Далее ГРР пришла к выводу, что собраны достаточные научные подтверждения позитивного воздействия физической активности на целый ряд показателей здоровья в широком спектре функциональных нарушений и что польза от физической активности для лиц с ограниченными возможностями перевешивает ее потенциальные отрицательные аспекты. Ввиду косвенного характера фактических данных для разработки этих рекомендаций уровень их достоверности был понижен. 62 63Рекомендации ДЕТИ И ПОДРОСТКИ (в возрасте 5–17 лет) И ВЗРОСЛЫЕ (в возрасте 18 лет и старше) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ Подтверждающие фактические данные и обоснование Малоподвижный образ жизни не был включен в Глобальные рекомендации ВОЗ по физической активности для здоровья 2010 г. Из-за нехватки материалов по отдельным группам населения базой первичных фактических данных для оценки взаимосвязи между малоподвижным образом жизни и показателями здоровья детей, подростков и взрослых с ограниченными возможностями являлась научная литература, которая была подобрана и пересмотрена для групп населения без ограничения возможностей. Были пересмотрены выводы, сделанные на основе данных о малоподвижном образе жизни в общей популяции, включая решение вопроса о том, имеются ли данные, согласно которым соответствующие результаты в отношении детей, подростков и взрослых с ограниченными возможностями будут чем-либо отличаться, окажутся для них неприменимыми или будут им противопоказаны. Особо малоподвижный образ жизни детей и подростков ведет к следующим негативным последствиям для их здоровья: росту ожирения, ухудшению кардиометаболического и физического здоровья и эмоционального/социально ориентированного поведения; а также к сокращению продолжительности сна. В этой связи рекомендуется следующее. Детям и подросткам с ограниченными возможностями следует сокращать продолжительность периодов пребывания в малоподвижном состоянии, в частности досугового экранного времени. Настоятельная рекомендация, низкая степень достоверности данных Особо малоподвижный образ жизни взрослых ведет к следующим негативным последствиям для их здоровья: повышению смертности от всех причин, в том числе от сердечно-сосудистых и онкологических заболеваний, а также росту масштабов распространения сердечно-сосудистых заболеваний, рака и диабета 2-го типа. В этой связи рекомендуется следующее. Взрослым с ограниченными возможностями следует сокращать продолжительность малоподвижных периодов. Занятия физически активной деятельностью любой интенсивности (в том числе низкой интенсивности) вместо проведения времени в малоподвижном состоянии также приносят пользу для здоровья. Настоятельная рекомендация, низкая степень достоверности данных В целях уменьшения вредного воздействия на здоровье длительного пребывания в малоподвижном состоянии взрослым с ограниченными возможностями следует стремиться к тому, чтобы превысить рекомендуемые уровни физической активности средней и высокой интенсивности. Настоятельная рекомендация, низкая степень достоверности данных Для детей, подростков и взрослых с ограниченными возможностями малоподвижный образ жизни определяется как время, проведенное в период бодрствования в положении сидя или лежа при низком расходе энергии в образовательном, домашнем и общинном контексте и при передвижении. Есть возможность избегать малоподвижного образа жизни и проявлять физическую активность в сидячем или лежачем положении, занимаясь, например, упражнениями для верхней части тела, инклюзивными и/или специальными для кресла-коляски видами спорта и активной деятельности. РЕКОМЕНДАЦИЯ ОТНОСИТЕЛЬНО МАЛОПОДВИЖНОГО ОБРАЗА ЖИЗНИ 64 65 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и ДЕТИ И ПОДРОСТКИ (в возрасте 5–17 лет) И ВЗРОСЛЫЕ (в возрасте 18 лет и старше) С ОГРАНИЧЕННЫМИ ВОЗМОЖНОСТЯМИ На основе имеющихся материалов и экспертных заключений эти фактические данные были экстраполированы с целью учета в новых рекомендациях ВОЗ относительно малоподвижного образа жизни для лиц с ограниченными возможностями по единому комплексу важнейших показателей здоровья; при этом признавалось, что представители некоторых групп населения, например пользователи кресел-колясок, неизбежно проводят длительное время в положении сидя и что поэтому сидячее положение может являться нормой. Для этих групп малоподвижный образ жизни следует определять как время, проводимое при низком расходе энергии, например при передвижении в кресле-коляске с электроприводом или сидя в кресле-коляске с ручным приводом, которым управляет другое лицо. Количество исследований о взаимосвязи между малоподвижным образом жизни и показателями здоровья в отношении лиц с ограниченными возможностями является недостаточным, но с учетом экспертного заключения нет никаких оснований полагать, что из-за имеющегося нарушения здоровья воздействие нагрузок на организм будет иным; следовательно, ограничение малоподвижного образа жизни у лиц с ограниченными возможностями принесет их здоровью такую же физиологическую пользу. Ввиду косвенного характера фактических данных для разработки этих рекомендаций уровень их достоверности был понижен. Кроме того, сведения о применимости фактических данных о пользе увеличения взрослыми объема физически активной деятельности средней и высокой интенсивности для противодействия возможным рискам особо малоподвижного образа жизни были рассмотрены и также экстраполированы с целью учета в рекомендациях для взрослых с ограниченными возможностями по единому комплексу важнейших показателей здоровья. Ввиду косвенного характера фактических данных уровень их достоверности был понижен. Выводы ГРР • Фактические данные о малоподвижном образе жизни в детских и юношеских популяциях, как правило, могут экстраполироваться применительно к детям и подросткам с ограниченными возможностями в зависимости от их конкретных способностей. • Фактические данные о малоподвижном образе жизни во всех группах взрослого населения, в том числе о пользе увеличения взрослыми объема физически активной деятельности средней и высокой интенсивности для противодействия возможным рискам особо малоподвижного образа жизни, как правило, могут экстраполироваться применительно к взрослым и пожилым людям с ограниченными возможностями в зависимости от их конкретных способностей. Однако уровень достоверности этих данных был понижен ввиду их косвенного характера. • Польза от минимизации объема малоподвижного образа жизни перевешивает риски для детей, подростков, взрослых и пожилых людей с ограниченными возможностями. 64 65Рекомендации Согласно методике GRADE в основу предлагаемых формулировок обновленных рекомендаций и рейтинга их значимости («настоятельная» или «условная») были заложены такие факторы, как баланс между пользой и вредом; достоверность фактических данных; чувствительность к ценностям и предпочтениям лиц, на которых распространяются данные рекомендации; возможное воздействие на гендерные аспекты; справедливость в социальной и здравоохранительной областях; и приемлемость, целесообразность и ресурсные последствия. Эти факторы были рассмотрены применительно к каждой группе населения, но ввиду схожести обсуждавшихся вопросов и соображений они представлены здесь в объединенном виде. Значимость рекомендации определялась прежде всего на основе оценки баланса между ее пользой и вредом. Рекомендации присваивался статус «настоятельная», если баланс между пользой и вредом был оценен для ее целевой группы как существенный, и статус «условная», если баланс между пользой и вредом был незначительным или если в ее выгодах для целевой группы была возможна высокая степень вариативности. Поиск фактических данных о вреде выполнялся непосредственно путем запроса того или иного нового систематического обзора, однако этот ресурс имел ограниченный характер, поскольку основной массив данных сосредоточен на проблемах травматизма и вреда скорее для атлетов высокого уровня и соревнующихся спортсменов, чем для широких слоев населения. Несмотря на ограниченный характер фактического материала, с учетом экспертного заключения было принято решение о том, что риск не превышает незначительного уровня. Фактические данные обычно указывали на то, что польза от физической активности намного перевешивает вред и что занятие физически активной деятельностью может стать важным фактором содействия устранению какой-либо проблемы со здоровьем, особенно для групп населения, находящихся в неблагоприятном положении. Вопросы справедливости в области здравоохранения, целесообразности и приемлемости также были рассмотрены ГРР и стали предметом обсуждения на открытой онлайновой консультации по проектам рекомендаций, которая проводилась с 31 марта по 17 апреля 2020 г. В материалах обследования для участников этой открытой консультации были поставлены конкретные вопросы о балансе между затратами на выполнение рекомендаций для отдельных лиц и правительств, о потенциальной пользе для здоровья и о том, повысят ли данные рекомендации уровень справедливости в сфере здравоохранения. Кроме того, проекты рекомендаций и формуляры для отзыва были направлены странам, которые недавно выразили заинтересованность в разработке НАУЧНОЕ ОБОСНОВАНИЕ РЕКОМЕНДАЦИЙ Размещено по адресу https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf национальных рекомендаций относительно физической активности или уже приступили к их составлению. Отзывы были получены в формате более 420 представлений для онлайновой консультации и дополнительной подборки отзывов от Европейского регионального бюро ВОЗ, включающей в себя замечания от сотрудничающих центров ВОЗ и государств- членов. Отзывы по итогам консультации были обобщены, проанализированы ГРР и использованы для дальнейшего рассмотрения вопросов о целесообразности, ресурсных последствиях и справедливости в области здравоохранения в рамках консультации с Руководящей группой и ГРР. Решения были приняты консенсусом по итогам обсуждения. ГРР приходила к консенсусу по каждой рекомендации и по вопросу о значимости рекомендации; ранжирования и голосования при этом не требовалось. ОЦЕНКА ДОСТОВЕРНОСТИ ФАКТИЧЕСКИХ ДАННЫХ ГРР использовала методику GRADE для рассмотрения вопроса о достоверности данных первичного исследования по каждому показателю здоровья, определенному в ГМ/ ВСП, и провела оценку общего уровня достоверности фактических данных, учитывая при этом риск необъективности, непоследовательность, неточность, косвенность данных и искаженность публикации по каждому показателю. Таблицы GRADE с подробным указанием такой информации по каждому набору ГМ/ВСП представлены в веб-приложении «Профили фактических данных» . Оценка достоверности фактических данных проводилась на основе общей оценки всех рассматриваемых показателей здоровья с уделением приоритетного внимания показателям смертности от всех причин и смертности от сердечно-сосудистых заболеваний как наиболее важным величинам, за которыми следовали другие клинические показатели (падения, депрессия, когнитивные способности, качество жизни, обусловленное состоянием здоровья, и т. д.), затем — промежуточные показатели (например, кардиометаболические и другие метаболические маркеры), а также вредные факторы. В случаях, когда отдельный пересмотр фактических данных не производился — например, по малоподвижному образу жизни для подгрупп, — прежде всего из-за нехватки данных по этим группам, выполнялась экстраполяция фактического материала относительно общей популяции с понижением, когда это признавалось целесообразным, уровня достоверности материала ввиду его косвенного характера. ПОЛЬЗА И ВРЕД Процесс разработки рекомендаций предусматривал проведение оценки вредных последствий или рисков. При ограниченности фактических данных решения принимались на основе практического опыта ГРР. В целом 66 67 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и применительно ко всем группам населения был сделан вывод, что польза от физической активности и сокращение времени для малоподвижного образа жизни перевешивают потенциальные вредные факторы. В настоящих рекомендациях, ориентированных на население в целом, не рассматриваются полезные и вредные факторы для спортсменов, практикующих такие виды и объемы активной деятельности, которые необходимы для повышения их физических показателей на соревнованиях. Небольшая физическая активность лучше, чем ее полное отсутствие. Если люди в настоящее время не выполняют эти рекомендации, небольшая физическая активность пойдет на пользу их здоровью. Им следует начинать с небольших физических нагрузок и со временем постепенно повышать их регулярность, интенсивность и продолжительность. Прохождения предварительного медосмотра перед началом занятий обычно не требуется. Для неактивных людей, которые постепенно повышают физически активную деятельность средней интенсивности, не имеется известных рисков возникновения нежелательных сердечно-сосудистых явлений и присутствует весьма низкий риск травмирования костей, мышц или связок. Лицо, которое регулярно практикует физические нагрузки средней интенсивности, может постепенно повышать их интенсивность до высокого уровня без необходимости консультироваться с врачом. Лицам, у которых при повышении уровня физической активности наблюдается появление новых симптомов, следует обратиться к врачу. Поскольку на выбор соответствующих видов и объемов физической активности могут влиять беременность, хронические патологии и ограниченные возможности, этот выбор нужно делать с учетом своих способностями и при отсутствии противопоказаний. Лица могут получить у специалиста по вопросам физической активности или медицинского работника консультацию относительно видов и объемов физически активной деятельности, которые соответствуют их индивидуальным потребностям, физическим возможностям, функциональным ограничениям/ осложнениям, принимаемым лекарственным средствам и общему плану лечения. Физическая активность низкой и средней интенсивности обычно сопряжена с незначительным риском и рекомендуется для всех. ЦЕННОСТИ И ПРЕДПОЧТЕНИЯ Были рассмотрены ценности и предпочтения лиц, входящих в сферу охвата настоящих рекомендаций (в данном случае это родители, лица для выполнения функций по уходу, дети и подростки, взрослые и пожилые люди, беременные женщины и женщины в послеродовом периоде, лица с хроническими патологиями и/или с ограниченными возможностями). В целом был сделан вывод о незначительности или отсутствии неопределенности по поводу предпочтений в отношении основных показателей, включая смертность вообще и смертность от сердечно-сосудистых заболеваний. Поскольку расчетная потенциальная польза намного перевешивает любой вероятный вред, ГРР в этом смысле сочла, что рекомендации свободны от предпочтений. РЕСУРСНЫЕ ПОСЛЕДСТВИЯ При обсуждении ресурсных последствий выполнения этих рекомендаций в различных условиях учитывались экспертное заключение ГРР и небольшой массив фактических данных о результатах экономического анализа предлагаемых мероприятий и о масштабах экономии средств в системах здравоохранения, которую удастся обеспечить благодаря росту уровней физической активности. Кроме того, по результатам открытой онлайновой консультации более 75% респондентов согласились или твердо согласились с тем, что польза от практического применения рекомендаций перевесит индивидуальные расходы, а 81% опрошенных согласились или твердо согласились с тем, что выгоды от применения рекомендаций на практике будут ощутимее, чем государственные расходы. В имеющихся данных и экспертном заключении признавалось, что существенной пользы для здоровья можно достичь в условиях низкого риска благодаря таким активным занятиям, как ходьба, которая не требует от соответствующего лица ни специальной экипировки, ни каких либо расходов. Далее признавалось, что другие формы физически активной деятельности, например организованные виды спорта, езда на велосипеде и групповые тренировки, могут быть сопряжены с расходами, которые способны стать препятствием для некоторых лиц, особенно для тех, у кого низкий уровень доходов. Осуществление государственной политики и программ по развитию и обеспечению физической активности также требует инвестиций в такие сферы, как людские ресурсы, разработка стратегий, создание инфраструктуры, системы услуг и, возможно, оборудования, часть которых покрывается министерствами здравоохранения, а также в секторы, не связанные с охраной здоровья, такие как спорт, образование, транспорт и городское планирование. Для обеспечения необходимых ресурсов могут потребоваться усилия нескольких уровней власти (национального, субнационального и местного), чтобы создать всем общинам равные условия доступа к занятиям физически активной деятельностью. Эти инвестиции могут обеспечиваться не только с помощью привлечения новых ресурсов, но и путем перераспределения имеющихся бюджетных средств в соответствии с приоритетностью инфраструктур и программ, ориентированных на повышение уровней физической активности населения. Примерами такого бюджетного перераспределения являются направление средств из имеющегося транспортного бюджета на инфраструктуру для ходьбы и езды на велосипеде или из спортивного бюджета — на программу «спорт для всех». В ключевых учреждениях, таких как школы и места работы, проведение малозатратных мероприятий наряду с внесением изменений в обустройство физической среды может стимулировать участие в занятиях физически активной деятельностью, а также способствовать сокращению неравенства возможностей для активного образа жизни, проявляемого в отношении некоторых подгрупп населения. В целом был сделан вывод о том, что, хотя выполнение предлагаемых проектов рекомендаций влечет за собой ресурсные последствия, принятие соответствующих мер является возможным на уровне нынешних структур управления. 66 67Научное обоснование рекомендаций Далее фактические данные подтверждают, что с наращиванием физической активности населения перед системой здравоохранения открываются перспективы существенной экономии средств в сфере медицинского обслуживания. По оценочным данным, в 2013 г. суммарный годовой объем расходов, связанных с недостаточной физической активностью, составил 54 млрд долл. только в части прямых расходов на медицинское обслуживание (130); на национальном уровне расходы в связи с неактивностью оцениваются в 1–3% бюджетов здравоохранения (131). В более широком контексте профилактики неинфекционных заболеваний (НИЗ) дополнительные расходы правительственных и неправительственных организаций в связи с осуществлением рекомендаций можно свести к минимуму, если у отдельных лиц будет возможность без особых затруднений включить рекомендуемый объем физической активности в свою повседневную жизнь, или же, по аналогии, если имеющиеся ресурсы в системе первичной и вторичной медико-санитарной помощи, в школах, на рабочих местах или в транспортном секторе можно будет переориентировать на повышение физической активности населения. Aнализ затрат/выгод, связанных с популяризацией физической активности, указывает на положительную доходность инвестиций за 15 лет в части профилактики НИЗ во многих странах, где были подготовлены обоснования инвестиций (132). Такие мероприятия, как проведение просветительских и пропагандистских кампаний, а также консультирование и ориентация по вопросам физической активности, являются соответственно «наиболее выгодным» и «выгодным» вариантами рекомендуемых мер по борьбе с НИЗ на основе обновленного варианта добавления 3 к Глобальному плану действий по профилактике НИЗ и борьбе с ними на 2013–2020 гг. (133). В целом ГРР пришла к выводу, что польза от выполнения рекомендаций перевешивает сопутствующие затраты. Для осуществления рекомендаций по физической активности в отношении лиц с ограниченными возможностями могут потребоваться инвестиции, например на подготовку специалистов по активному образу жизни, адаптированное оборудование, когда оно необходимо, и на обеспечение доступности объектов инфраструктуры. Благодаря этим инвестициям можно способствовать удовлетворению потребностей целого ряда групп населения. Фактические данные указывают на существенное расхождение в масштабах участия в физически активной деятельности между лицами с ограниченными возможностями и остальными лицами, которое объясняется многочисленными препятствиями в доступе, предлагаемым выбором занятий и отношением со стороны других лиц. Для обеспечения всестороннего и эффективного участия лиц с ограниченными возможностями следует применять принципы универсального дизайна. Действуя согласно новаторским подходам, можно преодолеть многие из этих ресурсных последствий, а внедрение принципов универсального дизайна позволит снижать соответствующие затраты в будущем. СПРАВЕДЛИВОСТЬ, ПРИЕМЛЕМОСТЬ И ЦЕЛЕСООБРАЗНОСТЬ В ходе обновления рекомендаций 2010 г. было решено непосредственно включить в них понятие уязвимых групп населения, таких как лица с хроническими патологиями и/или с ограниченными возможностями. В состав ГРР и Руководящей группы входили представители таких групп. ГРР подробно обсуждала каждую рекомендацию, рассматривая вопрос о том, не приведет ли выполнение этой рекомендации к снижению уровня справедливости в области здравоохранения, а также проблемы, связанные с ее осуществлением, чтобы рекомендации не оказали негативного влияния на аспекты равноправия (например, для обеспечения безопасных объектов и возможностей участия в физической активности, которые доступны для всех, включая лиц с ограниченными возможностями, лиц, находящихся в тяжелом социально-экономическом положении, и других социально отчужденных лиц; для устранения гендерных и иных культурных предрассудков, которые могли бы ограничить доступ и возможность участия в физически активной деятельности, и т. п.). В ходе открытой онлайновой консультации 76% респондентов выразили согласие или твердое согласие с тем, что осуществление настоящих рекомендаций может обеспечить уменьшение несправедливости в здравоохранении путем расширения возможностей для всех вести активный образ жизни и улучшать показатели здоровья. Было отмечено, что благоприятная среда имеет ключевое значение для обеспечения участия в физически активной деятельности. Для устранения барьеров на пути участия в физически активной деятельности уязвимых групп, таких как женщины и девочки, находящиеся в тяжелом социально- экономическом положении, и лица с ограниченными возможностями, потребуется всеобъемлющий подход к вопросам подготовки и проведения политики в различных секторах. Лица с ограниченными возможностями имеют худшие показатели здоровья по сравнению с лицами без ограничения возможностей, хотя польза от физической активности намного перевешивает вред и может стать важным фактором улучшения состояния здоровья. Фактические данные указывают на существенное расхождение в масштабах участия в физически активной деятельности между лицами с ограниченными возможностями и остальными лицами, которое объясняется многочисленными препятствиями в доступе, предлагаемым выбором занятий и отношением со стороны других лиц. Многим лицам с ограниченными возможностями нужно создать условия для занятия различными видами физической активности без необходимости адаптировать оборудование или объекты. Тем не менее в целях создания лицам с ограниченными возможностями условий для участия в физически активной деятельности на основе равенства с другими могут потребоваться приобретение адаптированного оборудования, обеспечение доступности объектов и подготовка специалистов по активному образу жизни. 68 69 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Несмотря на многочисленные данные о значении физической активности и на растущий объем информации о влиянии малоподвижного образа жизни на показатели здоровья на всех этапах жизненного цикла, в ходе дискуссий ГРР выявила существенный пробел в данных, которым нужно уделять приоритетное внимание при подготовке будущих рекомендаций. Пробелы в данных по подгруппам населения включали нехватку информации, которая касается: (1) более точных деталей взаимосвязи «доза- ответ» между физической активностью и/или малоподвижным образом жизни и комплексом изучаемых показателей здоровья; (2) благоприятного воздействия на здоровье физически активной деятельности низкой интенсивности и прерывания малоподвижности какой-либо легкой физической нагрузкой; (3) различий в воздействии на здоровье разных видов и областей физической активности (досуг, работа, передвижение, домашнее хозяйство, обучение) и малоподвижного образа жизни (работа, экранное время, просмотр телевизора); и (4) взаимосвязи между физической активностью и временем пребывания в малоподвижном состоянии и показателями здоровья на протяжении всего жизненного цикла. Было также отмечено, что объем данных, поступающих от стран с низким и средним уровнем дохода, данных об экономически неблагополучных и мало обеспеченных услугами общинах и о лицах с ограниченными возможностями и/или с хроническими заболеваниями по-прежнему недостаточен. План или сфера охвата многих исследований не позволяют тестировать изменение воздействия в зависимости от различных социально-демографических факторов (возраста, пола, расы/этнической принадлежности, социально- экономического статуса), которые способны изменить эффект физической активности для здоровья. Такая информация важна для составления более специфических рекомендаций в области общественного здравоохранения и для сокращения диспропорций в отношении здоровья среди более уязвимых групп населения. С более подробной информацией о пробелах в исследованиях, связанных с этими новыми рекомендациями, можно также ознакомиться в изданных публикациях (134). ПОТРЕБНОСТИ В ИССЛЕДОВАНИЯХ 68 69Потребности в исследованиях Цель настоящих рекомендаций — предоставить директивным органам и лицам, занимающимся разработкой программ мероприятий в областях здравоохранения, образования, трудовых и общинных отношений рекомендации о том, сколько времени детям, подросткам, взрослым и пожилым людям следует ежедневно посвящать физически активной деятельности, а также рекомендации о сокращении времени, проводимого в малоподвижном состоянии. При этом подготовка глобальных рекомендаций не является самоцелью: без их распространения и осуществления не удастся достичь перемен в уровнях физической активности. ПРИНЯТИЕ ВОЗ проводит тщательную и масштабную работу по подготовке рекомендаций глобального масштаба (21), предназначенных для использования всеми странами. В настоящих рекомендациях по вопросам физической активности и малоподвижного образа жизни содержатся научно обоснованные рекомендации относительно воздействия физической активности и малоподвижного образа жизни на здоровье людей, которые могут приниматься и использоваться правительствами стран в рамках их национальной политики. Разработка глобальных рекомендаций на фоне проведения масштабных консультаций должна в основном избавить отдельные страны от необходимости расходования ресурсов на проведение длительных научных изысканий. Обзор и принятие настоящих глобальных рекомендаций по вопросам физической активности и малоподвижного образа жизни дает странам оперативную и экономичную возможность для подготовки рекомендаций, ориентированных на местные условия. Принятие настоящих рекомендаций ВОЗ на региональном или национальном уровне обеспечит страны последовательными рекомендациями о физической активности и малоподвижном образе жизни, которые составлены с учетом самых актуальных и передовых научных данных. Кроме того, согласованность рекомендаций, выполняемых в разных странах, упростит наблюдение на национальном уровне, подготовку глобальных оценочных данных по физической активности и малоподвижному образу жизни и проведение межстрановых сопоставлений. В процессе принятия рекомендаций следует рассмотреть вопрос о целесообразности корректировки их содержания с учетом местных особенностей. Одним из элементов принятия рекомендаций и их включения в соответствующий контекст является их перевод на местный язык. Возможно, при этом потребуется изменить примеры видов физической деятельности с учетом местных особенностей и ПРИНЯТИЕ, РАСПРОСТРАНЕНИЕ, ОСУЩЕСТВЛЕНИЕ И ОЦЕНКА использовать такие средства наглядной информации, которые отражают местные культурные традиции, обычаи и ценности. После проведения ряда региональных семинаров с участием соответствующих заинтересованных сторон в настоящее время разрабатывается поэтапный механизм содействия странам в принятии глобальных рекомендаций. Этот механизм может включать в себя соответствующие национальные данные (например, оценочные данные масштабов распространения физической активности); он также обеспечит ускоренный подход к разработке документа с изложением национальных рекомендаций. Упомянутые вспомогательные ресурсы будут размещены на веб-сайте ВОЗ в 2021 г. При рассмотрении вопроса о принятии настоящих рекомендаций целесообразно выполнить следующую десятиступенчатую процедуру: (1) пропагандировать пересмотр текущих национальных рекомендаций o физической активности и принятие рекомендаций ВОЗ, чтобы добиться разрешения на уровне правительства; (2) привлечь основные заинтересованные стороны как в секторе здравоохранения, так и в других соответствующих секторах, таких как спортивный, образоватeльный и транспортный; привлечь профильные профессиональные ассоциации и ученые круги с необходимым практическим опытом; (3) провести оценку применимости, приемлемости и целесообразности рекомендаций; (4) адаптировать рекомендации к местному контексту, включая язык, примеры и другие культурологические факторы; (5) провести внешний обзор с целевыми пользователями, включая директивные органы, специалистов- практиков и широкую общественность; (6) сформировать бюджет и составить четкий план кампаний по распространению и информированию; (7) опубликовать и популяризировать национальные рекомендации, в идеале —наряду с проведением презентационного мероприятия для обеспечения общественного резонанса и заинтересованности; (8) привлечь соответствующие профессиональные органы или организации и поддержать согласование и/или одобрение проводимой политики; (9) проводить на национальном уровне стратегические и практические мероприятия в поддержку осуществления национальных рекомендаций и поведенческих изменений; (10) согласовать график оценки, пересмотра и обновления рекомендаций. 70 71 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и РАСПРОСТРАНЕНИЕ Национальные рекомендации по вопросам физической активности являются одним из ключевых элементов комплексного подхода органов государственного управления к решению вопроса о повышении уровня физической активности населения. Национальные рекомендации служат основой при разработке и определении первоочередных задач в процессе планирования национальных и субнациональных стратегий и требуют надлежащего распространения точной информации среди соответствующих групп населения. К сожалению, национальные рекомендации слишком часто не получают должного распространения, вследствие чего осведомленность о них как в профессиональных кругах, так и среди широкой общественности остается на весьма низком уровне. Обеспечение специально выделенных ресурсов для содействия широкомасштабному распространению рекомендаций — первый значимый шаг на пути повышения уровня осведомленности и знаний о важности повышения физической активности и сокращения малоподвижного образа жизни. K основным целевым группам для распространения национальных рекомендаций о физической активности и малоподвижном образе жизни относятся: • директивные органы в секторе здравоохранения и за его пределами (в том числе транспорт, планирование, образование, места работы, спорт, парковое хозяйство и досуг) — для наращивания: (a) объема знаний о возможном влиянии роста физической активности и сокращения малоподвижного образа жизни на улучшение состояния не только здоровья, но и ряда разнообразных и при этом актуальных сфер, включая гендерное равенство, правозащитные обязанности и устойчивое развитие; (b) интеграции стратегий и программ, касающихся физической активности и малоподвижного образа жизни, во все соответствующие направления политики; и (c) инвестиций в расширение и координацию национальных и местных мероприятий; • негосударственные субъекты (в том числе неправительственные организации, академические и научно-исследовательские организации, частный сектор, средства массовой информации и учреждения по финансированию научных исследований) — в целях: (a) пропаганды важности роста физической активности и сокращения малоподвижного образа жизни во всех возрастных группах; (b) поощрения и обеспечения согласованности политики; и (c) активизации сотрудничества и инвестиций в сферу проведения политики и местных мероприятий; • специалисты-практики сектора здравоохранения и других секторов (включая спорт, образование, транспорт и планирование) — для повышения: (a) уровня осведомленности и знаний о национальных рекомендациях, касающихся физической активности и малоподвижного образа жизни; (b) уровня знаний, навыков и доверия в связи с популяризацией роста физической активности и сокращения малоподвижного образа жизни; и (c) уровня интеграции аспектов популяризации физической активности в обычную практику, когда это применимо; • широкая общественность и отдельные подгруппы населения — для повышения: (a) уровня осведомленности и знаний о рекомендациях, касающихся физической активности и малоподвижного образа жизни; (b) уровня знаний о том, как выполнять рекомендации относительно физической активности и малоподвижного образа жизни; и (c) уровня намерений и заинтересованности в наращивании физической активности и сокращении малоподвижного образа жизни. ИНФОРМАЦИОННЫЕ КАМПАНИИ Разнообразные материалы принесут пользу различным заинтересованным сторонам; для эффективного доведения рекомендаций до сведения многочисленных целевых групп необходимо учитывать содержание, формат и каналы распространения рекомендаций. При разработке информационной стратегии для популяризации каких-либо рекомендаций проведение формативного исследования может способствовать выявлению основных аудиторий и осмыслению ценностей, потребностей и предпочтений, которые оказывают влияние на уровни физической активности и малоподвижного образа жизни. При этом нужно исследовать препятствия для физической активности или для интеграции физической активности в сферу политики и практики, а также тестировать проекты сообщений и материалов для различных групп. Эти меры будут способствовать подбору основных используемых положений, а также соответствующего формата/ форматов и канала/каналов для распространения информации. Всеобъемлющая информационная стратегия будет включать в себя широкий спектр сообщений, ориентированных на различные аудитории. Возможно, некоторым странам потребуется уделять приоритетное внимание конкретным группам с учетом имеющихся ресурсов (людских и финансовых). Информационные кампании по вопросам физической активности, рассчитанные на широкую общественность или на определенные подгруппы населения, являются затратоэффективными мероприятиями (133) и рекомендуются в Глобальном плане действий ВОЗ по повышению уровня физической активности на 2018–2030 гг. (14). Национальные и субнациональные кампании по вопросам физической 70 71Принятие, распространение, осуществление и оценка активности, как правило, предполагают наличие основного лозунга кампании (например, «Будьте активны» или «Больше двигайтесь») и подготовку дизайновых элементов или знаков, которые могут содержать целевые обращения к различным аудиториям (таким как дети младшего возраста, подростки, взрослые или пожилые люди, менее активные группы, лица с ограниченными возможностями или с хроническими патологиями). Призывы и информационные ресурсы кампании, которые ориентированы на определенные группы населения, наверняка окажут более эффективное воздействие по сравнению с материалами общего характера. При проведении информационных кампаний нужно учитывать охват и эффективность медийных средств — как традиционных (телевидение, радио, рекламные щиты и печатные ресурсы), так и цифровых (веб-сайты, мобильные телефоны и приложения). Не менее полезно предоставлять сведения о национальных рекомендациях в широком спектре форматов. Например, сравнительно новым, но все более распространенным способом популяризации рекомендаций о физической активности является использование инфографики или коротких анимационных видеоклипов. ВОЗ располагает вспомогательными материалами для подготовки и проведения таких информационных кампаний (135). Академические и научно-исследовательские круги наверняка заинтересованы в получении научного доклада с подробным изложением эпидемиологических данных, на которых основаны настоящие рекомендации. При этом специфические детали исследований, легших в основу рекомендаций, вряд ли будут интересны более широкой аудитории. Директивные органы могут предпочесть резюме научных данных или даже какой-либо краткий обобщающий документ. Другие целевые группы, например специалисты сектора здравоохранения и иных секторов, более склонны рассматривать различные виды ресурсов, такие как брошюра или информационный бюллетень о самих рекомендациях или о методах включения аспектов популяризации физической активности в повседневную практику (например, в процедуру приема пациентов в учреждениях здравоохранения или в разработку планов строительства или транспорта для городской среды). Специалисты из разных областей будут заинтересованы в получении ресурсов, которые соответствуют их профилю. В частности, представители медицинских профессий могут воспользоваться подборкой ресурсов, отражающих специфику тех групп населения, с которыми они работают. ОСУЩЕСТВЛЕНИЕ ПОЛИТИКИ И ПРОГРАММ Поскольку сами по себе национальные рекомендации относительно физической активности и малоподвижного образа жизни вряд ли приведут к повышению уровня физической активности населения, их следует рассматривать в качестве одного из элементов политики и концепции планирования. Крайне важно, чтобы национальные рекомендации распространялись среди ключевых аудиторий и опирались на долгосрочную национальную стратегию распространения информации, которая обеспечит рост уровня осведомленности и знаний о многочисленных преимуществах регулярной физической активности и сокращения масштабов малоподвижного образа жизни. Однако для достижения устойчивых перемен в образе жизни эти мероприятия должны подкрепляться мерами политики, создающими благоприятные условия, которые открывают перед людьми возможности и стимулируют их заниматься физически активной деятельностью, наряду с расширением соответствующих местных возможностей для людей участвовать в физически активных мероприятиях. Политика и программы должны учитывать местные особенности и адаптироваться к ним с точки зрения не только системы здравоохранения, но и комплексных многоотраслевых структур, заинтересованных и играющих определенную роль в оказании содействия повышению уровня физической активности. Действовать нужно в рамках общегосударственного подхода, учитывая при этом «систему» мер политики и разнообразных действий, которые могли бы при взаимодействии с широким спектром заинтересованных сторон поддерживать людей на пути к повышению физической активности в самых разных секторах и условиях. Применение такого системного подхода, согласованного с долгосрочной стратегией распространения информации, приводит к тому, что возросший спрос на 72 73 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и физическую активность, стимулируемый эффективным просвещением, удовлетворяется путем создания людям условий и возможностей для физически активной деятельности. В Глобальном плане действий ВОЗ по повышению физической активности на 2018–2030 гг. поставлена цель сократить масштабы распространения недостаточной физической активности на 15% к 2030 г. и предусмотрено 20 мер политики и мероприятий (14). К их числу относится рекомендация для всех стран проводить долгосрочные национальные информационно- просветительские кампании и включить программы консультирования по вопросам физической активности в систему первичной и вторичной медицинской помощи. Другие рекомендации касались формирования благоприятной среды для занятий физически активной деятельностью, включая ходьбу, езду на велосипеде и на других колесных устройствах, для всех групп населения и создание более широких возможностей и программ для развития физической активности в школах, на рабочих местах, в спортивных клубах и на спортивных объектах. Претворение в жизнь всех 20 рекомендаций за короткий срок во всех странах, вероятно, является невыполнимой задачей, и его следует рассматривать в качестве долгосрочной цели. Чтобы наметить комплекс соответствующих и выполнимых мер для непосредственного осуществления, государствам-членам ВОЗ следует провести ситуационный анализ нынешней политики и практики. Проведение такого анализа позволит наладить межсекторальное сотрудничество, будет способствовать выявлению сильных сторон, пробелов и возможностей, а также послужит основой для подготовки и обновления национальных и субнациональных планов. Настоящие новые рекомендации ВОЗ способствуют расширению сферы охвата мероприятий для включения дополнительных групп, таких как лица с ограниченными возможностями или с хроническими патологиями, беременные женщины или женщины в послеродовом периоде. Потребуется проведение политики поддержки осуществления надлежащих программ и практических методов, которые обеспечивают признание потребностей общин и разнообразие групп и условий. В настоящее время разрабатывается ряд пособий по различным секторам, призванных содействовать применению пакета технической документации ACTIVE (135); в этих пособиях каждому сектору будут даны рекомендации о том, как развивать физическую активность, например через школы, через систему первичной медицинской помощи или путем улучшения условий для ходьбы и езды на велосипеде. Целью пакета ACTIVE, как и других региональных и национальных ресурсов ВОЗ, будет являться содействие в выполнении настоящих рекомендаций по вопросам физической активности и малоподвижного образа жизни. НАДЗОР И ОЦЕНКА Глобальные рекомендации ВОЗ по физической активности для здоровья используются в качестве ориентира для мониторинга и надзора за здоровьем населения с 2010 г. Изменения, которые внесены в эти рекомендации в настоящих обновленных рекомендациях, окажут определенное воздействие на эффективность систем надзора и инструментов оценки, используемых в настоящее время для мониторинга национальных уровней физической активности. В связи с опубликованием новых рекомендаций потребуется пересмотр нынешних инструментов и протоколов отчетности для внесения необходимых корректировок и рекомендаций относительно ведения будущей отчетности в соответствии с новыми рекомендациями. Нынешние инструменты, такие как Глобальная анкета физической активности и Глобальное обследование здоровья учащихся, будут пересмотрены, а протоколы ведения отчетности обновлены для их согласования с настоящими новыми рекомендациями; вспомогательные рекомендации будут предоставлены всем странам в 2021 г. Основным инструментом, используемым для мониторинга глобального прогресса в осуществлении политики в области борьбы с НИЗ, является проводимое раз в два года обследование ВОЗ для оценки национального потенциала в отношении НИЗ (ОНП). В ОНП включаются конкретные вопросы, касающиеся системы проведения демографических обзоров для оценки уровня физической активности каждой возрастной группы, охватываемой Рекомендациями ВОЗ по вопросам физической активности и малоподвижного образа жизни, а с 2019 г. — вопросы о наличии национальных рекомендаций по повышению физической активности. Государствам-членам ВОЗ предлагается загружать документацию в обоснование своего ответа. В 2019 г. из 194 государств-членов ВОЗ только 78 (40%) сообщили о наличии у них рекомендаций относительно физической активности (136). Был проведен подробный документальный анализ ответов на вопросы ОНП за 2019 г., который показал, что лишь две трети из этих 78 государств- членов (т. е. 52 из 78) имеют национальные рекомендации с положениями о том, в каких объемах их населению следует заниматься физически активной деятельностью; из них только 42 страны привели свои документы в полное соответствие с Глобальными рекомендациями по физической активности для здоровья 2010 г. (1). Данные, собранные в результате проведения ОНП в 2021 г. и последующих обследований, позволят получить информацию о выполнении этих обновленных рекомендаций. 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Geneva: World Health Organization; 2020. 82 83 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и G lo be b as ed o n io at /S hu tt er st oc k, s ilh ou et te s ha pe s or ig in al ly b as ed o n Sh ut te rs to ck s ou rc es 82 83Библиография 84 85 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Руководящая группа ФАО В состав Руководящей группы входили специалисты по проблемам физической активности, здоровья подростков, старения, ограниченных возможностей, психического здоровья, профилактики травматизма, онкологических заболеваний, беременности и надзора, представляющие как штаб-квартиру, так и региональные бюро. Валентина Балтаг (Департамент по охране здоровья матерей, новорожденных, детей и подростков и проблеме старения — по теме «Здоровье подростков») Морис Букагу (Департамент по охране здоровья матерей, новорожденных, детей и подростков и проблеме старения — по теме «Беременность») Фиона Булл (председатель) (Департамент по вопросам укрепления здоровья — по теме «Физическая активность») Алекс Бутчарт (Департамент социальных детерминантов здоровья — по теме «Профилактика травматизма») Нирджа Чаудхари (Департамент по неинфекционным заболеваниям — по теме «Психическое здоровье/деменция») Регина Гутхольд (Департамент по охране здоровья матерей, новорожденных, детей и подростков и проблеме старения — по теме «Надзор за подростками») Риитта-Майя Хямяляйнен (Региональное бюро для стран Западной части Тихого океана) Андре Илбави (Департамент по неинфекционным заболеваниям — по теме «Онкологические заболевания») Васик Хан (Региональное бюро для стран Восточного Средиземноморья) Линдси Ли (Департамент по неинфекционным заболеваниям — по теме «Ограниченные возможности») Алана Оффисер (по теме «Старение») Лиэнн Райли (Департамент по неинфекционным заболеваниям — по теме «Наблюдение») Гойка Роглич (Департамент по неинфекционным заболеваниям — по теме «Диабет») Хуана Виллумсен (Департамент по вопросам укрепления здоровья – по теме «Физическая активность») Руководящая группа составила проект сферы охвата рекомендаций и подборки ГМ/ВСП. Члены группы провели обзор деклараций интересов, а также занимались подготовкой, пересмотром и окончательной доработкой рекомендаций. Участники процесса разработки рекомендаций ПРИЛОЖЕНИЕ 1. УПРАВЛЕНИЕ ПРОЦЕССОМ РАЗРАБОТКИ РЕКОМЕНДАЦИЙ 84 85Приложение 1 Группа по разработке рекомендаций (ГРР) Группа по разработке рекомендаций включала в себя многочисленных экспертов в данной области, конечных пользователей рекомендаций и лиц, затрагиваемых рекомендациями. В число членов Группы по разработке рекомендаций входили: д-р Салих аль-Ансари (пропаганда здоровья и санитарного просвещения для борьбы с НИЗ посредством физической активности и ходьбы); д-р Стюарт Бидль (физическая активность, малоподвижный образ жизни и поведенческие изменения); д-р Катя Бородулин (физическая активность при беременности и у пожилых людей); д-р Mэтью Буман (сон, малоподвижный образ жизни и физическая активность у лиц с хроническими патологиями); д-р Грит Кардон (физическая активность у детей и подростков); г-жа Кэтрин Карти (физическая активность у лиц с ограниченными возможностями); д-р Жан-Филипп Шапю (сон, малоподвижный образ жизни и физическая активность у детей и подростков); д-р Себастьян Частин (физическая активность, малоподвижный образ жизни и здоровье, объективное измерение объема физической активности и малоподвижного образа жизни); д-р Падди Демпси (физическая активность и малоподвижный образ жизни у взрослых и лиц с хроническими патологиями); д-р Лоретта Дипьетро (физическая активность при беременности и у пожилых людей); д-р Ульф Экелунд (малоподвижный образ жизни и физическая активность, физическая активность у детей и подростков); д-р Джозеф Ферт (физическая активность и психическое здоровье); д-р Кристина Фриденрайх (физическая активность у лиц с хроническими патологиями, физическая активность и риск рака); д-р Леандро Гарсия (физическая активность и здоровье у взрослых); д-р Мутони Гичу (осуществление политики, национальное правительство); д-р Рассел Яго (физическая активность у детей и подростков); д-р Питер Кацмарзик (физическая активность и малоподвижный образ жизни); д-р Эстель В. Ламберт (физическая активность и ожирение); д р Майкл Лейцман (малоподвижный образ жизни и физическая активность у лиц с хроническими патологиями); д-р Карен Мильтон (практическое выполнение рекомендаций); д-р Франсиско Б. Ортега (физическая активность у детей и подростков, психическое здоровье и объективное измерение); д-р Чатуранга Ранасингх (популяризация физической активности и здоровья в общине, на рабочем месте и в школе); д-р Эммануэль Стаматакис (физическая активность, малоподвижный образ жизни и множественные показатели здоровья у взрослых); д-р Анна Тидеман (физическая активность у пожилых людей); д-р Ричард Трояно (разработка политики); д-р Хидде ван дер Плог (физическая активность и малоподвижный образ жизни у взрослых); г-жа Вики Вари (осуществление политики, национальное правительство); д-р Роджер Чоу (Научно-практический центр для стран Северо- Западной части Тихого океана, профессор медицины на кафедрах медицины, медицинской информатики и клинической эпидемиологии Орегонского университета здоровья и науки) принимал участие в работе в качестве методиста GRADE. Дополнительная информация о ГРР содержится в приложении 2. На первом совещании ГРР, состоявшемся 2–4 июля 2019 г., Группа приняла решение относительно вопросов ГМ/ВСП, рассмотрела имеющиеся систематические обзоры и определила необходимые обновления. Далее Группа согласовала процедуру принятия решений по рекомендациям и по уровням достоверности научных данных, которую предстояло применить на втором совещании ГРР. Второе совещание было проведено 11–14 февраля 2020 г.; на нем Группа рассмотрела обновленные данные и согласовала путем консенсуса окончательные рекомендации. 86 87 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Группа внешних рецензентов (ГВР) Из списка кандидатур, предложенных членами ГРР и Руководящей группой, было отобрано семь внешних рецензентов. Они обладали соответствующим практическим опытом, в том числе по реализации программ, и представляли все шесть регионов ВОЗ. ГВР рассмотрела проект рекомендаций и передала Руководящей группе свою рецензию по аспектам их доходчивости и выполнения, которая была надлежащим образом учтена. Внешние рецензенты не вносили изменений в рекомендации. Список внешних рецензентов содержится в приложении 2. Декларации интересов Прежде чем принимать участие в совещаниях ГРР, члены Группы и внешние рецензенты заполнили и представили формуляры декларации интересов ВОЗ и дали подписку о соблюдении конфиденциальности. Руководящая группа рассмотрела и оценила представленные биографические справки и декларации интересов, после чего провела поиск по электронным ресурсам и публикациям на предмет выявления возможных публичных разногласий или интересов, которые могли бы привести к компрометирующим ситуациям. Имена и краткие биографии всех кандидатов в члены ГРР в течение 14 дней размещались на веб-странице ВОЗ «Физическая активность» для публичного ознакомления, но никаких комментариев не поступило. При возникновении потребности в дополнительных инструкциях о регулировании какой-либо декларации или конфликта интересов Руководящая группа обратилась бы за консультацией к коллегам из Бюро по обеспечению соблюдения, управлению рисками и этике. В случае необходимости те лица, у которых выявлен конфликт интересов финансового или нефинансового характера, были бы отстранены от участия в рассмотрении тех тем, по которым они имели конфликт интересов. Вопрос о регулировании конфликтов интересов был рассмотрен в рамках всей процедуры. При необходимости члены ГРР до начала каждого совещания должны были обновить свои декларации интересов, а в начале каждого совещания ГРР им предлагалось сделать устное заявление об интересах. Заявленные интересы членов ГРР и внешних рецензентов обобщены в приложении 3. Ни одного конфликта интересов выявлено не было. Внешнее рецензирование Рассмотрение проекта рекомендаций проводилось семью внешними рецензентами, которые были определены членами ГРР и Руководящей группы. Внешним рецензентам было поручено подготовить комментарии в отношении ясности формулировок, представления фактических данных и выполнения рекомендаций; их комментарии были надлежащим образом учтены. Внешние рецензенты не могли вносить изменения в рекомендации, согласованные членами ГРР. Список внешних рецензентов содержится в приложении 2, а резюме деклараций интересов — в приложении 3. Кроме того, настоятельные просьбы о предоставлении материалов были направлены в региональные бюро ВОЗ. 86 87Приложение 1 Группа по разработке рекомендаций Д-р Салих аль-Ансари Доцент Семейная и общинная медицина Основатель и директор Центра по вопросам укрепления здоровья Эр-Рияд САУДОВСКАЯ АРАВИЯ Д-р Стюарт Бидль Профессор, курс физической активности и здоровья Исследовательская группа по изучению физически активного образа жизни Центр исследований в области здравоохранения Институт по вопросам устойчивости регионов Университет Южного Квинсленда Центральный Спрингфилд AВСТРАЛИЯ Д-р Катя Бородулин Институт по вопросам возраста Хельсинки ФИНЛЯНДИЯ Д-р Мэтью Буман Колледж решений в области здравоохранения Aризонский университет Финикс США Д-р Грит Кардон Кафедра проблем движения и спортивных наук Факультет медицины и наук о здоровье Гентский университет Гент БЕЛЬГИЯ ПРИЛОЖЕНИЕ 2. ГРУППА ПО РАЗРАБОТКЕ РЕКОМЕНДАЦИЙ, ВНЕШНИЕ РЕЦЕНЗЕНТЫ И СОТРУДНИКИ ВОЗ, УЧАСТВОВАВШИЕ В РАБОТЕ НАД НАСТОЯЩИМИ РЕКОМЕНДАЦИЯМИ Г-жа Кэтрин Карти Руководитель проекта кафедры ЮНЕСКО Технологический институт Трали Графство Керри ИРЛАНДИЯ Д-р Жан-Филипп Шапю Старший научный сотрудник Исследовательская группа по проблемам здорового активного образа жизни и ожирения (HALO) Детская больница Восточного Онтарио (CHEO) Научно- исследовательский институт Отделение педиатрии Оттавский университет Oттава, Онтарио КАНАДА Д-р Себастьян Частин Профессор, курс динамики здорового поведения Школа здоровья и наук о жизни Кафедра психологии, социальной работы и смежных медицинских наук Каледонский университет Глазго Глазго СОЕДИНЕННОЕ КОРОЛЕВСТВО Д-р Роджер Чоу (методист GRADE) Кафедры медицины, медицинской информатики и клинической эпидемиологии Орегонский университет здоровья и науки Портленд, Oрегон США Д-р Падди Демпси Совет медицинских исследований, отдел эпидемиологии Школа клинической медицины Кембриджского университета Институт метаболических наук Кембридж СОЕДИНЕННОЕ КОРОЛЕВСТВО 88 89 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Д-р Лоретта Дипьетро Кафедра физических упражнений и наук о питании Школа общественного здравоохранения Института Милкена Университет Джорджа Вашингтона Вашингтон, ОК США Д-р Ульф Экелунд Отделение спортивной медицины Норвежская школа спортивных наук Oсло НОРВЕГИЯ Д-р Джозеф Ферт Ведущий научный сотрудник Школа медицинских наук Maнчестерский университет Maнчестер СОЕДИНЕННОЕ КОРОЛЕВСТВО Д-р Кристина Фриденрайх Научный директор Научно-исследовательский отдел эпидемиологии и профилактики рака Центр Альберты по борьбе с раком Служба здравоохранения Альберты Калгари КАНАДА Д-р Леандро Гарсия Научный сотрудник Центр общественного здравоохранения Университет Квинс в Белфасте Белфаст СОЕДИНЕННОЕ КОРОЛЕВСТВО Д-р Мутони Гичу Начальник отдела гериатрической медицины Департамент неинфекционных заболеваний Mинистерство здравоохранения Найроби KEНИЯ Д-р Рассел Яго Профессор кафедры физической активности детей и общественного здравоохранения Центр по вопросам физических упражнений, питания и наук о здоровье Школа политических исследований Бристольский университет Бристоль СОЕДИНЕННОЕ КОРОЛЕВСТВО Д-р Питер Т. Кацмарзик Заместитель исполнительного директора по делам наук о населении и общественном здравоохранении Профессор и заведующий кафедрой Марии Эданы Коркоран по проблемам детского ожирения и диабета Пеннингтонский центр биомедицинских исследований Батон-Руж США Д-р Эстель В. Ламберт Директор научно-исследовательского центра «Здоровье через физическую активность, образ жизни и спорт» Кептаунский университет Кейптаун ЮЖНАЯ АФРИКА Д-р Майкл Лейцман Профессор эпидемиологии Факультет эпидемиологии и профилактической медицины Регенсбургский университет Регенсбург ГЕРМАНИЯ Д-р Карен Мильтон Доцент кафедры общественного здравоохранения Норвичская медицинская школа Университет Восточной Англии Норвич СОЕДИНЕННОЕ КОРОЛЕВСТВО Д-р Франсиско Б. Ортега Начальник отдела по вопросам популяризации физической активности и здоровья Научно-исследовательский институт спорта и здоровья (iMUDS) Факультет физического воспитания и спорта Университет Гранады Гранада ИСПАНИЯ 88 89Приложение 2 Д-р Чатуранга Ранасингх Руководитель проекта «NIROGI Lanka» Медицинская ассоциация Шри-Ланки Доцент Отделение лечебной физкультуры и спорта Медицинский факультет Университет Коломбо Коломбо ШРИ-ЛАНКА Д-р Эммануэль Стаматакис Центр Чарльза Перкинса Факультет медицины и здравоохранения Школа общественного здравоохранения Сиднейский университет Сидней AВСТРАЛИЯ Д-р Анна Тидеман Доцент Институт здоровья опорно-двигательного аппарата Школа общественного здравоохранения Факультет медицины и здравоохранения Сиднейский университет Сидней AВСТРАЛИЯ Д-р Ричард Трояно Программа исследований в области эпидемиологии и геномики Национальный институт онкологии Национальные институты здравоохранения Роквилл США Д-р Хидде ван дер Плог Доцент Отделение общественного здравоохранения и охраны труда Aмстердамский научно-исследовательский институт общественного здравоохранения Медицинские центры Амстердамского университета Aмстердам НИДЕРЛАНДЫ Г-жа Вики Вари* Pуководитель программы, НИЗ Национальный департамент здравоохранения Порт-Морсби ПАПУА-НОВАЯ ГВИНЕЯ Группа внешних рецензентов Д-р Кингсли Акинрой Нигерийский альянс по борьбе с НИЗ НИГЕРИЯ Д-р Худа Альсияби Директор Департамент общинных инициатив Mинистерство здравоохранения OMAН Д-р Альберто Флорес-Прегонеро Папский Ксаверианский университет КОЛУМБИЯ Д-р Шигеру Иноуэ Факультет профилактической медицины и общественного здравоохранения Tокийский медицинский университет ЯПОНИЯ Д-р Агус Махендра Факультет физического воспитания Университет Пендидикан ИНДОНЕЗИЯ Д-р Дебора Сальво Научно-исследовательский центр профилактики в Сент-Луисе Школа Брауна Университет Вашингтона США Д-р Джаспер Шипперийн Избранный президент Международного общества по физической активности и здоровью на 2020–2022 гг. Факультет спортивных наук и клинической биомеханики Университет Южной Дании ДАНИЯ * не смог принять участие в работе90 91 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и * не смог принять участие в работе Руководящая группа ВОЗ Д-р Валентина Балтаг Начальник отдела по вопросам здоровья подростков и молодых людей Департамент по охране здоровья матерей, новорожденных, детей и подростков и проблеме старения Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ Д-р Морис Букагу Meдицинский сотрудник Охрана здоровья матерей Департамент по охране здоровья матерей, новорожденных, детей и подростков и проблеме старения Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ Д-р Александр Бутчарт Начальник отдела по вопросам предупреждения насилия Департамент социальных детерминантов здоровья Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ Д-р Фиона Булл Начальник отела по вопросам физической активности Департамент по вопросам укрепления здоровья Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ Д-р Регина Гутхольд Научный сотрудник отдела по вопросам здоровья подростков и молодых людей Департамент по охране здоровья матерей, новорожденных, детей и подростков и проблеме старения Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ Д-р Риитта-Майя Хямяляйнен Tехнический сотрудник Отдел по неинфекционным заболеваниям и укреплению здоровья Региональное бюро ВОЗ для стран Западной части Тихого океана Maнила ФИЛИППИНЫ Д-р Андре Илбави Teхнический сотрудник Департамент по неинфекционным заболеваниям Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ Д-р Васик Хан* Региональный советник по вопросам санитарного просвещения и укрепления здоровья Региональное бюро ВОЗ для стран Восточного Средиземноморья Каир EГИПЕТ Г-жа Линдси Ли Teхнический сотрудник по вопросам сенсорных функций, ограниченных возможностей и реабилитации Департамент по неинфекционным заболеваниям Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ Г-жа Алана Оффисер Старший консультант по вопросам здравоохранения Здоровое старение Канцелярия Генерального директора Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ Г-жа Лиэнн Райли Начальник отдела по вопросам надзора Департамент по неинфекционным заболеваниям Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ Д-р Гойка Роглич Meдицинский сотрудник по вопросам ведения неинфекционных заболеваний Департамент по неинфекционным заболеваниям Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ Д-р Хуана Виллумсен Teхнический сотрудник по вопросам физической активности Департамент по вопросам укрепления здоровья Штаб-квартира ВОЗ Женева ШВЕЙЦАРИЯ 90 91Приложение 2 ПРИЛОЖЕНИЕ 3. РЕЗЮМЕ ДЕКЛАРАЦИЙ ИНТЕРЕСОВ И РЕЗУЛЬТАТЫ ИХ РАССМОТРЕНИЯ Члены Группы по разработке рекомендаций Имя и фамилия Пол Специализация Раскрытие информации об интересах Конфликт интересов и его рассмотрение Д-р Салих аль-Ансари Муж. Специалист по пропаганде здоровья и санитарного просвещения для борьбы с НИЗ посредством физической активности и ходьбы Владелец и директор Центра по вопросам укрепления здоровья Конфликта интересов не выявлено Д-р Стюарт Бидль Муж. Физическая активность у молодежи Исследовательские фонды и платные консультационные услуги Конфликта интересов не выявлено Д-р Катя Бородулин Жен. Физическая активность при беременности Работа в Национальном институте по вопросам здоровья, благополучия и возраста; исследовательские фонды Конфликта интересов не выявлено Д-р Мэтью Буман Муж. Сон и физическая активность у лиц с хроническими патологиями Интересы не декларированы Конфликта интересов не выявлено Д-р Грит Кардон Жен. Физическая активность у молодежи Интересы не декларированы Конфликта интересов не выявлено Г-жа Кэтрин Карти Жен. Физическая активность у лиц с ограниченными возможностями Исследовательские фонды Конфликта интересов не выявлено Д-р Жан-Филипп Шапю Муж. Сон Интересы не декларированы Конфликта интересов не выявлено Д-р Себастьян Частин Муж. Физическая активность и здоровье, oбъективное измерение физической активности Исследовательские фонды Конфликта интересов не выявлено Д-р Падди Демпси Муж. Физическая активность и малоподвижный образ жизни у взрослых и лиц с хроническими патологиями Работа на должности и исследовательские фонды Конфликта интересов не выявлено Д-р Лоретта Дипьетро Жен. Физическая активность у пожилых людей Интересы не декларированы Конфликта интересов не выявлено Д-р Ульф Экелунд Муж. Малоподвижный образ жизни и физическая активность у молодежи Интересы не декларированы Конфликта интересов не выявлено Д-р Джозеф Ферт Муж. Физическая активность и психическое здоровье Интересы не декларированы Конфликта интересов не выявлено Д-р Кристина Фриденрайх Жен. Физическая активность у лиц с хроническими патологиями, физическая активность и риск возникновения рака Интересы не декларированы Конфликта интересов не выявлено Д-р Леандро Гарсия Муж. Физическая активность и психическое здоровье Работа на должности и платные консультационные услуги Конфликта интересов не выявлено Д-р Мутони Гичу Жен. Осуществление политики (национальное правительство) Интересы не декларированы Конфликта интересов не выявлено Д-р Рассел Яго Муж. Физическая активность у молодежи Интересы не декларированы Конфликта интересов не выявлено Д-р Питер Кацмарзик Муж. Физическая активность и малоподвижный образ жизни у молодежи Поддержка в покрытии путевых расходов для содействия комитетам по разработке руководства Конфликта интересов не выявлено 92 93 Р ек ом ен д ац и и В О З п о во п р ос ам ф и зи че ск ой а кт и вн ос ти и м ал оп од ви ж н ог о об р аз а ж и зн и Имя и фамилия Пол Специализация Раскрытие информации об интересах Конфликт интересов и его рассмотрение Д-р Эстель В. Ламберт Жен. Физическая активность и ожирение Интересы не декларированы Конфликта интересов не выявлено Д-р Майкл Лейцман Муж. Малоподвижный образ жизни и хронические патологии Интересы не декларированы Конфликта интересов не выявлено Д-р Карен Мильтон Жен. Практическое выполнение рекомендаций Поддержка в покрытии путевых расходов для содействия комитету по разработке руководства Конфликта интересов не выявлено Д-р Франсиско Ортега Муж. Физическая активность у молодежи, психическое здоровье и объективное измерение Интересы не декларированы Конфликта интересов не выявлено Д-р Чатуранга Ранасингх Муж. Популяризация физической активности и здоровья в общине, на рабочем месте и в школе Исследовательские фонды Конфликта интересов не выявлено Д-р Эммануэль Стаматакис Муж. Физическая активность и множественные показатели здоровья у взрослых Грант для технологической компании в целях объективного измерения физической активности Конфликта интересов не выявлено Д-р Анна Тидеман Жен. Физическая активность и показатели здоровья у пожилых людей Интересы не декларированы Конфликта интересов не выявлено Д-р Ричард Трояно Муж. Pазработка политики Интересы не декларированы Конфликта интересов не выявлено Д-р Хидде ван дер Плог Муж. Физическая активность, малоподвижный образ жизни и показатели здоровья у взрослых Поддержка в покрытии путевых расходов для содействия нидерландскому комитету по разработке руководства по физической активности в 2017 г. и исследовательские фонды Конфликта интересов не выявлено Г-жа Вики Вари Жен. Осуществление политики, национальное правительство) Долевое участие (к подготовке руководства не относится) Конфликта интересов не выявлено Внешние рецензенты Имя и фамилия Пол Специализация Раскрытие информации об интересах Конфликт интересов и его рассмотрение Д-р Кингсли Акинрой Муж. Просветительская деятельность, неинфекционные заболевания Интересы не декларированы Конфликта интересов не выявлено Д-р Худа Альсияби Жен. Осуществление политики и программ Интересы не декларированы Конфликта интересов не выявлено Д-р Альберто Флорес-Прегонеро Муж. Измерение и надзор физической активности и малоподвижного образа жизни Интересы не декларированы Конфликта интересов не выявлено Д-р Шигеру Иноуэ Муж. Эпидемиология и популяризация физической активности Интересы не декларированы Конфликта интересов не выявлено Д-р Агус Махендра Муж. Навыки физической активности и движения у детей Интересы не декларированы Конфликта интересов не выявлено Д-р Дебора Сальво Жен. Диспропорции в здравоохранении и социальной сфере с уделением особого внимания профилактике хронических заболеваний Интересы не декларированы Конфликта интересов не выявлено Д-р Джаспер Шипперийн Муж. Физическая активность и антропогенная среда Избранный президент Международного общества по физической активности и здоровью (ISPAH) Конфликта интересов не выявлено 92 93Приложение 3 ISBN 978-92-4-003218-77 0

WHO 身体活動および座位行動に関する ガイドライン This translation was not created by the World Health Organization（WHO）. WHO is not responsible for the content or accuracy of this translation. The original English edition “WHO guidelines on physical activity and sedentary behaviour”. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO shall be the binding and authentic edition. この翻訳は世界保健機関（WHO）によって作成されたものではありません。WHOは本翻訳の内容または正確性につ いて責任を負いません。原本の英語版「WHO guidelines on physical activity and sedentary behaviour」（ジュ ネーブ：世界保健機関；2020. ライセンス：CC BY-NC-SA 3.0 IGO）が正式版です。 翻訳者 宮地元彦 早稲田大学　スポーツ科学学術院 国立研究開発法人医薬基盤・健康栄養研究所　身体活動研究部 翻訳協力・査読者 澤田　亨　早稲田大学 小熊祐子　慶應義塾大学 井上　茂、天笠志保　東京医科大学 岡浩一朗　日本運動疫学会　早稲田大学 協力者 山口美輪、西　信雄　国立研究開発法人医薬基盤・健康・栄養研究所 WHO 身体活動および座位行動に関する ガイドライン 目次 謝辞 省略形と頭字語 ⅴ 用語集 ⅵ エグゼクティブサマリー 1 背景 15 方法 18 推奨事項 24 　＞子どもおよび青少年（５～17歳） 25 　　身体活動の推奨事項 25 　　座位行動の推奨事項 29 　＞成人（18～64歳） 32 　　身体活動の推奨事項 32 　　座位行動の推奨事項 38 　＞高齢者（65歳以上） 43 　　身体活動の推奨事項 43 　　座位行動の推奨事項 46 　＞妊娠中および産後の女性 47 　　身体活動の推奨事項 47 　　座位行動の推奨事項 51 　＞慢性疾患を有する成人および 　　高齢者（18歳以上） 52 　　身体活動の推奨事項 52 　　座位行動の推奨事項 58 　＞障害を有する子ども 　　および青少年（５～17歳）および 　　成人（18歳以上） 60 　　身体活動の推奨事項 60 　　座位行動の推奨事項 64 エビデンスから推奨事項へ 66 エビデンスの確実性の評価 66 利益と害 67 価値観および好み 67 リソースの影響 67 公平性、許容可能性、および実現可能性 68 リサーチのニーズ 69 採択、普及、履行、および評価 70 採択 70 普及 71 周知のキャンペーン 71 政策およびプログラムの履行 72 調査および評価 73 更新 73 参考文献 75 付録１：ガイドラインの管理 策定のプロセス 85 付録２：ガイドライン策定グループ、 外部ピアレビュー担当者、および本ガイドライン策定 担当スタッフ 88 付録３：利益相反の概要 および管理方法 92 ウェブ付録：エビデンスプロファイル https://apps.who.int/iris/bitstream/handle/ 10665/336657/9789240015111-eng.pdf Contents iii W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 謝辞 世界保健機関（WHO）は、これらのガイドラインの作成における以下の個人および組織の貢献と支援に感謝の意を 表する：Fiona Bull and Juana Willumsen は、これらのガイドラインを作成するプロセスを主導した。 Valentina Baltag, Maurice Bucagu, Alex Butchart, Neerja Chowdhary, Regina Guthold, Riitta-Maija Hämäläinen, Andre Ilbawi, Wasiq Khan, Lindsay Lee, Alana Officer, Leanne Riley and Gojka Roglicは、 ガイドライン作成過程を管理したWHO運営グループのメンバーであった。 ガイドライン開発グループ（GDG）のメンバーには、Salih Saad Al-Ansari, Stuart Biddle, Katja Borodulin, Matthew Buman, Greet Cardon（co-chair）, Catherine Carty, Jean-Philippe Chaput, Sebastien Chastin, Paddy Dempsey, Loretta DiPietro, Ulf Ekelund, Joseph Firth, Christine Friedenreich, Leandro Garcia, Muthoni Gichu, Russ Jago, Peter Katzmarzyk, Estelle V. Lambert, Michael Leitzmann, Karen Milton, Francisco B. Ortega, Chathuranga Ranasinghe, Emmanuel Stamatakis（co-chair）, Anne Tiedemann, Richard Troiano, Hidde van der Ploeg, Vicky Wari. が含まれた。 Roger ChouがGRADEの方法論者を務めた。外部レビューグループには、Kingsley Akinroye, Huda Alsiyabi, Alberto Flórez-Pregonero, Shigeru Inoue, Agus Mahendra, Deborah Salvo and Jasper Schipperijnが含 まれた。 Kyle Sprow（National Cancer Institutes, National Institutes of Health, Maryland, USA）が実施した追加の 文献検索のおかげで、2018年の米国身体活動ガイドライン諮問委員会の保健福祉長官への科学的報告のために準備 されたエビデンスの系統的レビューが更新された。 特定された論文をレビューするための追加サポートは、Elif Eroglu（University of Sydney）, Andrea Hillreiner （University of Regensburg）, Bo-Huei Huang（University of Sydney）, Carmen Jochem（University of Regensburg）, Jairo H. Migueles（University of Granada）, Chelsea Stone（University of Calgary）and Léonie Uijtdewilligen（Amsterdam UMC）によって提供された。 エビデンスの要約とGRADEテーブルは、Carrie Patnode and Michelle Henninger（The Kaiser Foundation Hospitals, Center for Health Research, Portland, Oregon, USA）によって作成された。 エ ビ デ ン ス の 追 加 レ ビ ュ ー は、N Fairhall, J Oliveira, M Pinheiro, and C Sherrington（Institute for Musculoskeletal Health, School of Public Health, The University of Sydney, Sydney, Australia）and A Bauman（Prevention Research Collaboration, School of Public Health, The University of Sydney, Sydney, Australia; and WHO Collaborating Centre for Physical Activity, Nutrition and Obesity）；S Mabweazara, M-J Laguette, K Larmuth, F Odunitan-Wayas（Research Centre for Health through Physical Activity, Lifestyle and Sports Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa）, L Leach, S Onagbiye（Department of Sport, Recreation and Exercise Science, Faculty of Health Sciences, University of the Western Cape, Cape Town, South Africa）, M Mthethwa（Chronic Disease Initiative for Africa, University of Cape Town, Cape Town, South Africa）, P Smith（The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa）and F Mashili （Department of Physiology, Muhimbili University of Allied Sciences, Dar Es Salaam, United Republic of Tanzania）；B Cillekens, M Lang, W van Mechelen, E Verhagen, M Huysmans, A van der Beek, P Coenen（Department of Public and Occupational Health at Amsterdam University Medical Centre, Amsterdam, Netherlands）により実施された。 カナダ公衆衛生庁とノルウェー政府が財政支援を提供したが、それなしではこの作業を完了することはできなかった。 iv 省略形と頭字語 ADHD attention deficit hyperactive disorder（注意欠陥多動性障害） AOR adjusted odds ratio（調整オッズ比） BMI body mass index（ボディマスインデックス） CI confidence interval（信頼区間） CVD cardiovascular disease（心血管疾患） DBP diastolic blood pressure（拡張期血圧） EtD Evidence to Decisions（エビデンスから決定へ） GDG Guideline Development Group（ガイドライン策定グループ） GRADE Grading of Recommendations Assessment, Development and Evaluation （推奨事項の査定、策定、および評価の格付け） HR hazards ratio（ハザード比） MET Metabolic Equivalent of Task（代謝当量：メッツ） MD mean difference（平均差） MICT moderate intensity continuous training（中強度の継続的トレーニング） NCD noncommunicable disease（非感染性疾患） OR odds ratio（オッズ比） PA physical activity（身体活動） PAGAC United States Physical Activity Guidelines Advisory Committee （米国人に対する身体活動のガイドライン諮問委員会） PI/ECO Population, Intervention/Exposure, Comparison, Outcome （対象集団、介入／曝露、対照、アウトカム） RaR Relative attributable risk（相対的寄与危険度） RCT randomized control trial（ランダム化比較試験） RR relative risk（相対危険度） SBP systolic blood pressure（収縮期血圧） SMD standardized mean difference（標準化平均差） SPPB short physical performance battery（簡易身体能力組テスト） TV television（テレビ） WHA World Health Assembly（世界保健総会） WHO World Health Organization（世界保健機関） vAbbreviations and acronyms W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 用語集 用語 定義 有酸素性の 身体活動 体の大きな筋肉が持続した期間中に周期的な方法で移動する活動。有酸素性の活動−持久力アク ティビティとも呼ばれ、心肺体力を改善する。 例：ウォーキング、ランニング、水泳、サイクリング 無酸素性の 身体活動 無酸素性の身体活動は、重量挙げや短距離競走などの短い時間に大きな力を発揮するもので、酸素 需要量が酸素供給量を凌ぐ。 バランス トレーニング 体位の動揺から、または自発運動、環境またはその他の物体に起因する不安定化させる刺激からの 課題に耐えるため、本人の能力が向上する用にデザインされた静的および動的な運動。 ボディマスイン デックス（BMI） 体重（kg）／身長（m）2。 年齢階級別BMI または BMI zスコア値 年齢で調整されたBMI。子ども用に標準化されたもの。 BMIの標準偏差スコアは、子どもの年齢と性別で調整された相対的な体重の尺度である。子どもの 年齢、性別、BMI、および適切な参考基準を考慮し、BMI のｚスコア（またはこれに相当する年齢 階級別BMIのパーセンタイル）を測定できる。 身体活動は主に、骨格系を作る骨の特定の部位の強度を増加させるように設計されている。 骨強化活動 骨強化活動は、骨に対する衝撃または緊張力を発生させ、骨の成長を促し強度を高める。ランニン グ、繩跳び、重量挙げは、骨強化活動の例である。 心血管代謝の健康 健康に関する血圧、血中脂質、血糖、インスリンの相互作用。 心肺体力 （全身持久力） 体力の健康関連の構成要素。身体活動を持続的に行っているときに酸素を供給する循環器系および 呼吸器系の能力。 通常、測定または推定された最大酸素摂取量（VO2 max）として表される。 認知機能 脳の活性、すなわち推論、記憶、注意、情報と知識の獲得につながる言語。これには学習も含まれ ることがある。 障害 国際生活機能分類から生まれた、機能不全、活動の限界、参加の制約を指す包括的な用語で、個人 （健康状態）と個人の背景因子（環境および個人因子）との相互作用の負の局面を意味する。 身体活動の場面 身体活動のレベルは、余暇、仕事、学校、家庭および/または移動のうち１つを含む、さまざまな 場面で評価される。 運動 計画的に構成され、意図をもって繰り返し行われる身体活動のサブカテゴリ。体力の１つ以上の構 成要素の改善または維持を目的とする。「運動」および「運動トレーニング」は、しばしば取り換 えて使用されることもあるが、一般的には身体活動を指し、体力、行動体力または健康を増進する か、維持することを主目的に、余暇に行われる。 実行機能 作業記憶、認知的柔軟性（柔軟思考とも呼ばれる）、抑制制御（自己制御を含む）などが含まれる。 体力 仕事やレジャーの活動で効果的かつ効率的に機能する身体の能力の尺度で、たとえば、体力や心肺 体力などがある。 柔軟性 健康関連の構成要素と機能関連の構成要素で、可能な限りの関節の可動域。柔軟性は各関節に特異 的で、特定の靭帯と腱の緊張を含むがこれに限らず多くの特異的な変数に依存する。柔軟運動は、 関節可動域を完全にすることを通して、移動する関節の能力を強化する。 機能向上運動 下半身の強度、バランス、運動能力を改善するために日常的なタスクに組み込める運動。 例： 継ぎ足で歩く、一本足で立つ、スクワットをする、つま先立ちをする、障害物の上を踏む。 家庭場面の 身体活動 家事（掃除、子どものお世話、ガーデニングなど）のために家庭で行われる身体活動。 余暇場面の 身体活動 身体活動は個人で行われ、基本的な日常生活動作として必要なものではなく、個人の裁量で実行す るもの。このような活動にはスポーツへの参加、運動処方、またはトレーニングなどがあり、たと えば、ウォーキングやダンス、ガーデニングなどのレクリエーション活動が該当する。 vi 用語 定義 低強度の身体活動 低強度の身体活動は、1.5～３METs（すなわち本人の安静時のエネルギー消費量の３倍より少な いエネルギーでの活動）である。 これには、ゆっくりと歩くウォーキング、入浴、またはその他の付随的な活動で心拍数または呼吸 スピードの実質的な上昇にはつながらないものが該当する。 主要筋肉群 主要筋肉群には、脚、背部、腹部、胸、肩、腕が含まれる。 代謝当量（メッツ） 作業の代謝当量または単に代謝当量は、身体活動の強度を表す生理的尺度である。１METは、安 静時の着席した状態で、本人が消費したエネルギー等価物である。 中強度の身体活動 絶対目盛で、中強度とは、安静の強度が３倍から６倍未満の間に行われる。 身体活動を指す。本人のキャパシティに比例するスケールで、中強度の身体活動は通常０～10の スケールのうち５または６である。 筋力向上活動 骨格筋の筋力、パワー、持久力、大きさを増加させる身体活動や運動 （例：筋力トレーニング、レジスタンストレーニング、筋持久力運動）。 マルチコンポーネ ントの身体活動 高齢者の場合、マルチコンポーネントの身体活動は、身体機能を向上させ、転倒または転倒から生 じる負傷のリスクを低下させるために重要である。これらの活動は、自宅でも、または構造化され た集団の場でもできる。研究対象の多くの介入は、全種類の運動（有酸素性、筋力向上、バランス トレーニング）を一回に併合すると効果的であることが示された。マルチコンポーネントの身体活 動プログラムの例として、ウォーキング（有酸素性の活動）、重量挙げ（筋力向上）、およびその他 のバランストレーニングを組み込むことができる。バランストレーニングの例は、上体の筋力向上 活動（例：二頭筋カール）をしている間に後ろ向きや横向きで歩いたり、１フィート分高いところ に立ったりすることも含まれる。ダンスは、有酸素性の要素とバランスの要素が併用されたもので ある。 労働場面の 身体活動 仕事の場面の身体活動を参照。 身体活動 エネルギー消費を必要とする骨格筋によって生成される何らかの身体的移動。 身体活動不足 現在の身体活動の推奨事項を満たすには足りない身体活動のレベル。 心理・社会的健康 健康の精神的、感情的および社会的側面を含む。 余暇時間の スクリーンタイム 教育／研究または仕事に関連のあること以外の目的でスクリーン（テレビ、コンピュータ、モバイ ル機器）を見て過ごす時間。 座位の スクリーンタイム スクリーン系の娯楽（TV、コンピュータ、モバイル機器）の視聴に費やした時間。身体活動また は運動が必要とされる活発なスクリーン系のゲームは含まない。 座位行動 座っている、もたれている、横になっている状態で、1.5METs以下のエネルギー消費が特徴的な 覚醒時の行動。事務の仕事でほとんど座って過ごす、車を運転する、テレビを視聴するなどは座位 行動の例であり、立っていることができない人（例：車椅子使用者）にも当てはまる。本ガイドラ インでの座位行動の定義には、自己申告制でほとんど動かず座ったままの行動（余暇時間、職業、 全体）、テレビ（テレビの視聴またはスクリーンタイム、動きまたは姿勢を評価するデバイスで測 定した低レベルの動き）を含めた。 スポーツ スポーツは、一連の規則の範囲内で行われ、レジャーまたは競争の一部として行われる。 スポーツ活動にはチームまたは個人で実行する身体活動があり、スポーツエージェンシーなどの組 織的なフレームワークによって支援される可能性がある。 移動場面の 身体活動 ある場所から別の場所に移る目的で実行される身体活動で、ウォーキング、サイクリング、ホイーリ ング（スクーター、ローラーブレード、手動車椅子など、車輪付きの非自動移動手段）を指す。 高強度の 身体活動 絶対目盛で、高強度は、6.0MET以上で行われる身体活動を指す。本人のキャパシティに比例する スケールで、高強度の身体活動は通常０～10のスケールのうち７または８である。 仕事場面の 身体活動 有償または無償の仕事中に行われる身体活動。 viiGlossary of terms W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r エグゼクティブサマリー 「WHO 身体活動および座位行動に関するガイドライン」 （WHO Guidelines on physical activity and sedentary behaviour）は、子ども、青少年、成人、高齢者に対して 健康上の有意な利益をもたらすとともに健康リスクを緩和 するために必要な身体活動量（頻度、強度、期間）について、 エビデンスに基づく公衆衛生の推奨事項を示すものである。 座位行動と健康アウトカムとの関係に関する推奨事項は今 回初めて示され、妊娠中や産後の女性、慢性的な疾患もし くは障害を抱えている人たちについても言及されている。 本ガイドラインの対象は、高所得国、中所得国、低所得国 の健康、教育、青少年期、スポーツおよび／または社会福 祉もしくは家族福祉に関する省庁の政策立案者、ガイダン ス文書を通して、特定階層の人々の身体活動を増やし座位 行動を減らすための国や地方自治体の計画の策定を担う政 府高官、非政府機関職員、教育部門、民間部門、研究分野 の職員、医療従事者である。 本ガイドラインは、「ガイドライン策定のためのWHOハン ドブック（WHO handbook for guideline development） に準じて作成された。極めて重要なアウトカムに対しては エビデンスの系統的レビューを行い、利益と害、意義、優 先事項、実現可能性、許容可能性のほか、エクイティなら びにリソースの影響を検討したうえで、推奨事項を策定し た。 発表された公衆衛生の最終的な推奨事項の対象は、全人種 の５歳から65歳以上の年齢層で、性別、文化的背景、また は社会経済的地位にかかわりなく、障害の有無を問わずす べての人に該当する。慢性疾患を有する人も、障害のある 人も、妊娠中および産後の女性も、この推奨事項を極力守 るよう努めるべきである。 今回策定されたガイドラインは、一連のエビデンスに基づ いた推奨事項を示すものであり、各政府は国を挙げての政 策的な枠組みの一環としてこれを採択し、身体活動レベル を特定集団ごとに高める包括的なアプローチの裏づけとす ることができる。採択のプロセスにおいては、必ず各地の 現状を踏まえて本ガイドラインを活用することを考慮に入 れる必要がある。今後は本ガイドラインの採択、普及、周 知キャンペーンと履行をサポートする実用的なツールがあ ると、政府と関係者が一丸となってライフコース全体での 身体活動の増進と座位行動の低減に取り組むうえで役立つ。 そのような補助的なリソースは、本ガイドラインの公表後 にWHOウェブサイトを通して入手できるようになる予定で ある。 各年齢層で健康アウトカムと身体活動、さらには座位行動 との関連を支持するデータは大量にあるにもかかわらず、 重大なエビデンスギャップは解消されないままである。特 に、低・中所得国をはじめ、経済的に恵まれない、あるい は公共サービスが不十分な地域社会では比較的エビデンス が少なく、障害のある人を含む亜集団からのエビデンスが 不足している。特にそのようなエリアでエビデンスを構築 するため、より多くの研究に投資する必要がある。また、 これらの推奨事項に今後変更が加えられる場合には、身体 活動の国ごとのレベルのモニタリングに現在使用されてい る調査システムや評価手法にも何らかの影響がある。既存 のグローバルレベルおよび国家レベルでの手法を精査する ことは必須であり、また報告手順を最新化することも、新 たなガイドラインに備えて今後の報告に反映させるために 必要である。 Global action plan on physical activity 2018-2030 （GAPPA：身体活動に関する世界行動計画2018-2030） では、身体活動不足を2030年までに15%低下させること を目標に掲げ、政策的措置や介入への推奨事項として20項 目がまとめられている。このガイドラインは、各国が GAPPAの推奨内容を履行するうえで、またライフコース全 体やさまざまな場面を通して身体活動を促す方法に関する 指 針 を 示 す ツ ー ル キ ッ ト の 専 門 的 パ ッ ケ ー ジ で あ る “ACTIVE”（アクティブ）を実施するうえで裏付けとなる。 viii 子どもおよび青少年 （５〜17歳） 子どもおよび青少年の身体活動は、体力（心肺体力および筋力）、 心血管代謝の健康（血圧、脂質異常症、血糖値、インスリン抵抗 性）、骨の健康、認知アウトカム（学業成績、実行機能）、メンタ ルヘルス（うつの症状の軽減）の向上と、肥満の減少などの健康 効果に利益がある。 子どもおよび青少年の場合、座りすぎは、肥満の増加、心血管代謝の悪化、体力、行動／向社会的 行動、睡眠時間の減少などの悪影響を及ぼす。 推奨事項： ＞子どもおよび青少年は、中強度から高強度の主に有 酸素性の身体活動を週全体で１日につき平均60分以 上行うこと。 強い推奨、エビデンスの確実性は中 推奨事項： ＞子どもおよび青少年は、座位のまま過ごす時間、特 に余暇時間でスクリーンタイムの時間を減らす必要 がある。 強い推奨、エビデンスの確実性は低 ＞高強度の有酸素性の活動とともに、筋肉および 骨を強化する活動を週に３日以上組み込むこと。 強い推奨、エビデンスの確実性は中 少なくとも１日 60 分 少なくとも週に 3 日 減らそう 週全体で中高強度の身体活動。この場 合の身体活動はほとんどが有酸素性の 身体活動であること。 高強度の有酸素性の身体活動ととも に、筋肉および骨を強化する身体活動 を週に３日以上組み込むこと。 座位のまま過ごす時間、特 に余暇時間でスクリーンタ イムを減らす 優れた実践 ・身体活動を一切しないよりは少しでもした方がよい。 ・ 上記の推奨量を満たしていない子どもおよび青少年は、ある程度の身体活動を行うことで健康上の利益が 得られる。 ・ 子どもおよび青少年の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時間を増やして いくべきである。 ・ すべての子どもおよび青少年に対し、楽しめる内容で、多様な、年齢や能力に適した身体活動に参加する 安全かつ公平な機会を設け奨励することが重要である。 1Executive Summary W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 成人 （18〜64歳） 成人の身体活動は、総死亡率、循環器疾患死亡率の低下、高血 圧の発症、部位別のがんの発症１、２型糖尿病の発症の予防、 メンタルヘルス（不安およびうつの症状の軽減）の改善、認知 的健康、および睡眠などの健康効果に利益があり、肥満も改善 される可能性がある。 推奨事項： ＞すべての成人は定期的な身体活動を行うべきである。 強い推奨、エビデンスの確実性は中 ＞なお、成人は、主要筋肉群すべて が関係する中強度以上の筋力向上 活動も週に２日以上行うこと。そ れにより、さらに健康上の利益が 得られる。 強い推奨、エビデンスの確実性は中 ＞成人の場合、有酸素性の身体活動を 少なくとも週に150～300分、また は高強度の有酸素性の身体活動を少 なくとも75～100分を行うか、また は週全体で中強度の活動と高強度の 活動の組み合わせによる同等の量を 行うと、実質的な健康上の利益が得 られる。 　相当する活動を行うこと。 強い推奨、エビデンスの確実性は中 少なくとも週に 150 〜300 分 少なくとも週に 75 〜150 分 少なくとも週に 2 日 中強度の有酸素性の 身体活動 または中強度と高強度の身体活動の組み合わせによる同等の量 高強度の有酸素性の 身体活動 主要筋肉群すべてが関係する 中強度以上の強度で筋力向上 活動を行う さらなる健康増進のために： １ 部位別のがんとは、膀胱がん、乳がん、大腸がん、子宮内膜がん、食道腺がん、 胃がん、腎がんである。 または 2 ＞300 分 ＞ 150 分 中強度の有酸素性 の身体活動 または中強度と高強度の身体活動の組み合わせによる同等の量 高強度の有酸素性の 身体活動 または （18〜64歳） さらに健康上の利益を得るには ＞成人の場合、さらに健康上の利益を得るた め、中強度の有酸素性の身体活動を300分 超に増やしても、あるいは150分超の高強 度の有酸素性の身体活動を行っても、また は週全体で中強度の活動と高強度の活動の 組み合わせによる同等の量を行ってもよい。 条件つきの推奨、エビデンスの確実性は中 優れた実践 ・身体活動を一切しないよりは少しでもした方がよい。 ・ 上記の推奨量を満たしていない成人は、ある程度の身体活動を行うことで健康効果が得られる。 ・成人の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時間を増やしていく。 成人の場合、座りすぎは、総死亡率、心血管疾患死亡率、がん死亡率、心血管疾患、がん、および ２型糖尿病の発生などといった悪影響を及ぼす。 推奨事項： ＞成人は座りっぱなしの時間が短くなるよう に制限をかけること。座位時間をいずれか の強度の身体活動の時間に替えると健康効 果が得られる。 強い推奨、エビデンスの確実性は中 ＞長時間の座りすぎが健康に及ぼす悪影響を 軽減するため、成人は、中高強度という推 奨レベルを上回る身体活動を行うよう心が けること。 強い推奨、エビデンスの確実性は中 減らそう 置き換える 座りっぱなしで過ごす時間を どんな強度（低強度を含む） でも良いので、身体活動を 増やす 3Executive Summary W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 高齢者の身体活動は、総死亡率、心血管疾患死亡率、高血圧の 発症、部位別のがんの発症、２型糖尿病の発症、メンタルヘル ス（不安およびうつの症状の軽減）、認知的健康、および睡眠 などの健康アウトカムに利益があり、肥満も改善される可能性 がある。高齢者の場合、身体活動は転倒や転倒関連の傷害、ま た骨の健康の減退や機能的能力の低下の予防に役立つ。 高齢者 （65歳以上） 推奨事項： ＞すべての高齢者は定期的な身体活動を行うこと。 強い推奨、エビデンスの確実性は中 ＞高齢者の場合、中強度の有酸素性の 身体活動を少なくとも150～300 分、または高強度の有酸素性の身体 活動を少なくとも週に75～150分 行うか、または週全体で中強度の活 動と高強度の活動の組み合わせによ る同等の量を行うと、実質的な健康 上の利益が得られる。 強い推奨、エビデンスの確実性は中 少なくとも週に 150 〜300 分 少なくとも週に 75 〜150 分 中強度の有酸素性の 身体活動 または中強度と高強度の身体活動の組み合わせによる同等の量 高強度の有酸素性の 身体活動 または 少なくとも週に 2 日 少なくとも週に 3 日 さらに健康上の利益を得るには 主要筋肉群すべてが 関係する中強度以上 の筋力向上活動。 中強度以上の、バラ ンス機能を高めるよ うにマルチコンポー ネントの身体活動と 筋力トレーニング。 ＞なお、高齢者は、主要筋肉群すべてが関 係する中強度以上の筋力向上活動も週 に２日以上行うこと。それにより、さら に健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 ＞高齢者は、毎週の身体活動の一環とし て、バランス機能を高めるようにマルチ コンポーネントの身体活動と筋力ト レーニングを中強度以上のレベルで週 に３日以上行って機能的な能力を強化 し、転倒を予防すること。 強い推奨、エビデンスの確実性は中 4 高齢者（65歳以上） ＞ 300 分 ＞ 150 分 中強度の有酸素性 の身体活動 または中強度と高強度の身体活動の組み合わせによる同等の量 高強度の有酸素性の 身体活動 または さらに健康上の利益を得るには ＞高齢者の場合、さらに健康上の利益を 得るため、中強度の有酸素性の身体活 動を300分超に増やしても、あるいは 150分超の高強度の有酸素性の身体活 動を行っても、または週全体で中強度 の活動と高強度の活動の組み合わせに よる同等の身体活動を行ってもよい。 条件つきの推奨、エビデンスの確実性は中 優れた実践・身体活動を一切しないよりは少しでもした方がよい。 ・ 上記の推奨量を満たしていない高齢者は、ある程度の身体活動を行うことで健康効果が得られる。 ・高齢者の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時間を増やしていく。 ・ 高齢者は各自の機能的能力が許す範囲で身体的に活発に動き、身体活動の運動レベルが体力のレベルに見 合ったものになるように調整すること。 高齢成人の場合、座りすぎは、総死亡率、心血管疾患死亡率、がん死亡率、心血管疾患、がん、 および２型糖尿病の発生率などの健康アウトカムが不良であることと関連している。 推奨事項： ＞高齢者は座位のまま過ごす時間が短くなる ように制限をかけること。座位で過ごす時 間をいずれかの強度の身体活動の時間に替 えると健康上の利益がある。 強い推奨、エビデンスの確実性は中 ＞長時間の座りすぎが健康に与える有害な影 響を抑えるため、高齢者は、中高強度とい う推奨レベルを上回る身体活動を行うよう 心がけること。 強い推奨、エビデンスの確実性は中 減らそう 置き換える 座りっぱなしで過ごす時間を どんな強度（低強度を含む） でも良いので、身体活動を 増やす 5Executive Summary W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 妊娠中および産後の女性 妊娠中および産後の女性の妊娠中と後の身体活動は、妊娠腎症、 妊娠高血圧症、妊娠糖尿病、妊娠期の過度の体重増加、分娩合 併症、ならびに後のうつのリスク低下、および新生児合併症の リスクの低下といった母体と胎児の健康上の利益があり、出生 体重への悪影響はなく、死産のリスクが増大することはない。 禁忌事項のない妊娠中および産後のすべての女性への推奨事項： ＞妊娠から産後までの期間を通して、定期的な身体活動を行う。 強い推奨、エビデンスの確実性は中 中強度の有酸素性の 身体活動 少なくとも週に 150 分 さらに： ＞妊娠前に高強度の有酸素性の活動を習慣的に行っていた女性または 身体的に活動的な女性は、妊娠中や産後の期間に、これらの活動を 続行できる。 強い推奨、エビデンスの確実性は中 ＞中強度の有酸素性の身体活動を１週間に少な くとも150分行うと、実質的な健康上の利益 が得られる。 強い推奨、エビデンスの確実性は中 ＞さまざまな有酸素性の筋力向上活動を組み込 む。軽いストレッチを加えることも効果的で ある。 強い推奨、エビデンスの確実性は中 6 妊娠中および産後の女性 優れた実践 ・ 身体活動を一切しないよりは少 しでもした方がよい。 ・ 上記の推奨量を満たしていない 妊娠中および産後の女性は、あ る程度の身体活動を行うことで 健康効果が得られる。 ・ 妊娠中および産後の女性の場合、 身体活動を少し行うことから始 め、徐々に頻度、強度、持続時 間を増やしていく。 ・ 骨盤底筋のトレーニングは、尿 失禁のリスクを低下させるため に毎日行ってよい。 妊婦が身体活動を行う場合に考慮すべき安全上の注意事項： ・ 過度に暑い時期、特に湿度が高いときには、運動を避ける。 ・ 身体活動の前中後に、水を飲んで水分を補給する。 ・ 身体的接触を伴う、転倒のリスクが高い、あるいは酸素供給を制限 するおそれがある（高地に普段居住していない場合の高地での活動 など）といった活動への参加を避ける。 ・ 妊娠中期を過ぎてからは、仰臥位で活動するものを避ける。 ・ 妊娠中の女性が運動競技、または推奨ガイドラインを大幅に上回る 運動を行う場合は、専門の医療従事者による管理指導を仰ぐこと。 ・ 医療従事者は、身体活動を中止すべきあるいは制限すべき危険な兆 候について妊婦に情報提供すべきである。また、そのような兆候が 現れた場合には妊婦は直ちに医療従事者に相談すべきである。 ・ 産後は徐々に身体活動を再開し、帝王切開による分娩であった場合 には、医療従事者に相談する。 妊娠中および出産後の女性の場合、座りすぎは、総死亡率、心血管疾患死亡率、がん死亡率、心血 管疾患、がん、および２型糖尿病の増加といった悪影響が生じる。 減らそう 置き換える 座りっぱなしで過ごす時間を どんな強度（低強度を含む） でも良いので、身体活動を 増やす 推奨事項： ＞妊娠中および産後の女性は座りっぱなしの時間 を減らすべきである。 　座位時間をいずれかの強度の身体活動の時間に 替えると健康上の利益がある。 強い推奨、エビデンスの確実性は低 身体活動を 一切しないよりは 少しでも した方がよい。 7Executive Summary W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 慢性疾患を有する成人および高齢者 （18歳以上） 身体活動は、以下の慢性疾患を抱える成人および高齢者に健康 効果をもたらす。 がんサバイバーの場合―身体活動により、総死亡率、がん特異 的死亡率、がん再発または二次発がんのリスクが改善される。 高血圧患者の場合―身体活動により、心血管疾患死亡率、疾病の進行、 身体機能、健康関連の生活の質が改善される。 ２型糖尿病患者の場合―身体活動により、心血管疾患による死亡率と疾病進行の指標の値が低下する。 HIV患者の場合―身体活動により、体力が向上し、精神的健康が改善される可能性があり（不安 および抑うつの症状の軽減）、病気の進行（CD4リンパ球数およびHIVウイルス量）または体組 成に悪影響を与えられることはない。 推奨事項： ＞上記の慢性疾患を有するすべての成人および高齢者は、定期的な身体活動を行うこと。 強い推奨、エビデンスの確実性は中 少なくとも週に 150 〜300 分 少なくとも週に 75 〜150 分 中強度の有酸素性の 身体活動 または中強度と高強度の身体活動の組み合わせによる同等の量 高強度の有酸素性の 身体活動 または ＞これらの慢性疾患を有する成人および高 齢者の場合、中強度の有酸素性の身体活 動を少なくとも150～300分、または高 強度の有酸素性の身体活動を少なくとも 75～150分行うか、または週全体で中 強度の活動と高強度の活動の組み合わせ による同等の量を行うべきである。 強い推奨、エビデンスの確実性は中 ＞これらの慢性疾患を有する成人および高齢者は、 主要筋肉群すべてが関係する中強度以上の筋力 向上活動も週に２日以上行うこと。それにより、 さらに健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 少なくとも週に 2 日 さらに健康上の利益を得るには 主要筋肉群すべてが 関係する中強度以上 の筋力向上活動。 少なくとも週に 3 日 中程度以上の強度の機能 的バランスと筋力トレー ニングを中心としたさま ざまな種類のマルチコン ポーネントの身体活動 ＞これらの慢性疾患を有する高齢者は、毎週の身体 活動の一環として、バランス機能を高めるように マルチコンポーネントの身体活動と筋力トレーニ ングを中強度以上の強度で週に３日以上行って機 能的な能力を強化し、転倒を予防すること。 強い推奨、エビデンスの確実性は中 8 慢性疾患を有する成人および高齢者（18歳以上） ＞ 300 分／週 以上の ＞ 150 分／週 以上の 中強度の有酸素性 の身体活動 または中強度と高強度の身体活動の組み合わせによる同等の量 高強度の有酸素性の 身体活動 または さらに健康のために ＞これらの慢性疾患を有する成人および 高齢者で、禁忌事項がない場合、さら に健康上の利益を得るため、中強度の 有酸素性の身体活動を300分超に増や しても、あるいは150分超の高強度の 有酸素性の身体活動を行うか、または 週全体で中強度の活動と高強度の活動 の組み合わせによる同等の身体活動を 行ってもよい。 条件つきの推奨、エビデンスの確実性は中 優れた実践 ・ これらの慢性疾患を有する成人で上記の推奨量を満たすことができない場合は、個人の能力に応じて 身体活動を行うことを心がけること。 ・ これらの慢性疾患を有する成人の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時間 を増やしていく。 ・ 成人で、これらの慢性疾患を抱えている場合、個々のニーズ、能力、機能的制限／合併症、薬物療法、全 体的な治療計画に適した活動の種類や量について助言を得たい場合は、身体活動の専門家や医療従事者に 相談することができる。 ・ 運動前の医学的な許可については、禁忌事項がなければ、早歩きや日常生活で必要なレベルを超えない範 囲の低強度または中強度の身体活動を開始する前には概して不要である。 がんサバイバー、高血圧患者、２型糖尿病患者、およびHIV患者などに該当する成人の場合、座り すぎは、総死亡率、心血管疾患死亡率、がん死亡率、心血管疾患、がん、および２型糖尿病の罹患 などの健康アウトカムが不良であることと関連している。 がんサバイバー、高血圧患者、２型糖尿病患者、 およびHIV患者などに該当する成人への推奨事項： ＞慢性疾患を有する成人および高齢者は座位のま ま過ごす時間が短くなるように制限をかけるこ と。座位で過ごす時間をいずれかの強度の身体 活動の時間に替えると健康上の利益がある。 強い推奨、エビデンスの確実性は低 ＞長時間の座位行動が健康に与える有害な影響を 抑えるため、慢性疾患を有する成人および高齢 者は、中高強度という推奨レベルを上回る身体 活動を行うよう心がけること。 強い推奨、エビデンスの確実性は低 減らそう 置き換える 座位のまま過ごす時間 強度を問わず これまで以上の身体活動 （低強度も含む）。 9Executive Summary W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 障害を有する子どもおよび青少年 （５〜17歳） 上記のセクションで述べた、子どもおよび青少年の身体活動の健 康上の利益の多くは、障害を有する子どもおよび青少年に関して も当てはまる。そのほかに障害を有する子どもおよび青少年が得 られる健康アウトカムへの利益としては、注意力欠陥多動性障害 （ADHD）などの認知機能を損なう疾患または障害がある場合に は認知力の改善がある。また、知的障害がある子どもの場合は身 体的な機能が向上する可能性がある。 少なくとも１日 60 分 少なくとも週に 3 日 週全体で中高強度の身体活動。この場合 の身体活動はほとんどが有酸素性である こと。 高強度の有酸素性の身体活動とともに、 筋肉および骨を強化する活動を週に３日 以上組み込むこと。 推奨事項： ＞障害を有する子どもおよび青少年の場合、中高 強度の、多くは有酸素性の身体活動を週全体で １日平均60分以上行うこと。 強い推奨、エビデンスの確実性は中 ＞高強度の有酸素性の活動とともに、筋肉および 骨を強化する活動を少なくとも週に３日は組み 込むこと。 強い推奨、エビデンスの確実性は中 身体活動を 一切しないよりは 少しでも した方がよい。 10 障害を有する子どもおよび青少年（５〜17歳） 身体活動を 少し行うことから 始める。 優れた実践 ・ 身体活動を一切しないよりは少しでもした方がよい。 ・ 障害を有する子どもおよび青少年で上記の推奨事項を満たしていない場合、ある程度の身体活動を行うこ とで健康上の利益が得られる。 ・ 障害を有する子どもおよび青少年の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時 間を増やしていく。 ・ 障害を有する子どもおよび青少年が身体活動を行うことについては、本人の現時点の活動レベル、健康状態、 および身体機能に適した内容であれば、重大なリスクはなく、得られる健康上の利益がリスクを上回る。 ・ 障害を有する子どもおよび青少年は、各自に適した活動のタイプや量を決めるうえで、医療従事者または その他の身体活動および障害の専門家に相談する必要が生じる場合もある。 子どもおよび青少年の場合、座りすぎは、肥満の亢進、心血管代謝の健康度の低下、体力、行動／ 向社会的行動、睡眠期間の減少などの不良な健康アウトカムと関連している。 推奨事項： ＞障害を有する子どもおよび青少年は、座位のま ま過ごす時間、特に余暇時間でスクリーンタイ ムが短くなるように制限をかけること。 強い推奨、エビデンスの確実性は低 減らそう 座位のまま過ごす時間、特に 余暇時間でスクリーンタイム の長さ 11Executive Summary W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 障害を有する成人 （18歳以上） 上記のセクションで述べた、成人の身体活動の健康上の利益の多く は、障害を有する成人に関しても当てはまる。そのほかに、障害を 有する成人の場合には以下の健康アウトカムへの利益がある。 多発性硬化症を有する成人の場合―身体機能の向上と、健康関連の生活 の質の身体的、精神的、社会的場面の向上。 脊髄損傷患者の場合―歩行機能、筋力、上肢の機能の改善、および健康関連の生活の質の向上。 認知機能に障害がある疾患または障害を有する患者の場合―身体機能と認知機能の改善（パーキン ソン病患者およびと脳卒中の既往歴のある者）、認識機能に対する有益な影響、生活の質が改善され る可能性（統合失調症を有する成人の場合）、身体機能が改善される可能性（知的障害者のある成人 の場合）、生活の質の向上（うつ病を有する成人の場合）。 少なくとも週に 150 〜300 分 少なくとも週に 75 〜150 分 中強度の有酸素性の 身体活動 または中強度と高強度の身体活動の組み合わせによる同等の量 高強度の有酸素性の 身体活動 または ＞障害を有する成人の場合、中強度の有酸 素性の身体活動を150～300分以上、 または高強度の有酸素性の身体活動を 75～150分以上行うか、または週全体 で中強度の活動と高強度の活動の組み合 わせによる同等の量を行うと、実質的な 健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 ＞なお、障害を有する成人は、主要筋肉群すべてが 関係する中強度以上の筋力向上活動も週に２日 以上行うこと。それにより、さらに健康上の利益 が得られる。 強い推奨、エビデンスの確実性は中 推奨事項： ＞障害を有する成人は定期的な身体活動を行うこと。 強い推奨、エビデンスの確実性は中 少なくとも週に 2 日 さらに健康上の利益を得るには 主要筋肉群すべてが関係する 中強度以上の筋力向上活動。 12 障害を有する成人（18歳以上） ＞障害を有する成人は、さらに健康上の 利益を得るため、中強度の有酸素性の 身体活動を300分超に増やしても、あ るいは150分超の高強度の有酸素性の 身体活動を行っても、または週全体で 中強度の活動と高強度の活動の組み合 わせによる同等の量を行ってもよい。 条件つきの推奨、エビデンスの確実性は中 少なくとも週に 3 日 中強度以上の、バランス機能 を高めるようにさまざまな要 素で構成された中強度以上の、 バランス機能を高めるように さまざまな要素で構成され た多様な身体活動と筋 力トレーニング。 ＞障害を有する高齢者は、毎週の身体活動の一環と して、バランス機能を高めるようにマルチコン ポーネントの身体活動と筋力トレーニングを中 強度以上のレベルで週に３日以上行って機能的 な能力を強化し、転倒を予防すること。 強い推奨、エビデンスの確実性は中 ＞ 300 分／週 以上の 中強度の有酸素性 の身体活動 または中強度と高強度の身体活動の組み合わせによる同等の量 高強度の有酸素性 の身体活動 または さらに健康上の利益を得るには 優れた実践 ・ 身体活動を一切しないよりは少しでもした方がよい。 ・ 障害を有する成人で上記の奨事項を満たしていない場合、ある程度の身体活動を行うことで健康上の利益 が得られる。 ・ 障害を有する成人の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時間を増やしていく。 ・ 障害を有する成人が身体活動を行うことについては、本人の現時点の活動レベル、健康状態、および身体 機能に適した内容であれば、重大なリスクはなく、得られる健康上の利益がリスクを上回る。 ・ 障害を有する成人は、各自に適した活動のタイプや量を決めるうえで、医療従事者またはその他の身体活 動および障害の専門家に相談する必要が生じる場合もある。 成人の場合、座りすぎは、総死亡率、心血管疾患死亡率、がん死亡率、心血管疾患、がん、および ２型糖尿病の罹患率の上昇といった悪影響を及ぼす。 推奨事項： ＞障害を有する成人は座位のまま過ごす時間が 短くなるように減らすこと。 　座位で過ごす時間をいずれかの強度の身体活 動の時間に替えると健康上の利益がある。 強い推奨、エビデンスの確実性は低 ＞長時間の座位行動が健康に与える有害な影響 を抑えるため、障害を有する成人は、中高強 度という推奨レベルを上回る身体活動を行う よう心がけること。 強い推奨、エビデンスの確実性は低 減らそう 置き換える 座位のまま過ごす時間 強度を問わずこれまで以上 の身体活動（低強度も含む）。 ＞ 150 分／週 以上の 13Executive Summary W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 14 背景 定期的な身体活動は、心血管疾患、２型糖尿病、乳がん、 および大腸がんなどの非感染性の疾患の予防と管理におけ る予防因子として知られている（1−3）。また、身体活動に は、メンタルヘルス上の利益があり（4）、認知症の発症を遅 延させ（5）、健康的な体重維持に役立つ可能性があり（1）、 国民の幸福度（6）にも寄与していることがある。 身体活動は、エネルギー消費を要し（1）、仕事、家事、移動 の一環で、または余暇時間に、もしくは運動やスポーツ活動 に参加する場合に、多様な強度で実行できる、骨格筋によっ て生じる動作として定義される。強度範囲の下限において、 座位行動は、座っている、もたれかかっている、または横た わっている体勢でエネルギー消費が少ないままでの覚醒行動 と定義される（7）。座位行動が多いことは心血管、がん、総 死亡率とともに心血管疾患および２型糖尿病と関連している ことを最新のエビデンスが示している（8−10）。 身 体 活 動 不 足 は、2010 Global recommendations on physical activity for health（2010年健康づくりのため の身体活動に関するグローバルな推奨事項）を満たしてい ないこととして定義され、世界的に死亡の主要な一因であ る。推定では、世界人口が現在よりも活動的であれば、死 亡を年間４～5,000,000例回避可能である（2, 11）。世界 的にみた身体活動不足の推定値は、2016年では成人で 27.5%（12）、 青 少 年 で81%（13）で あ っ た が、 こ れ は 2010年のWHOの推奨事項（1）を満たしておらず、トレン ドデータは世界で過去10年間の改善が乏しいことを示して いる。また、また、ほとんどの国では女性が男性より活動 的ではないこと、また国・地域内での比較や国・地域ごと の比較では身体活動のレベルに有意差があることもデータ が示している。これらの差は、身体を動かす機会をもつこ との不公平によって、ひいては健康における不公平の拡大 によって説明がつく。 現在では、座位行動の世界的な推定値はないが、技術革新や、 座業や座ったままの娯楽が増える傾向のほか、モーター付 きの乗物の使用が増加していることも、世界中の身体活動 の変化のパターンや座位行動の増加に寄与している。 Global action plan on physical activity 2018-2030 （身体活動に関する世界行動計画2018-2030）（14）による と、成人および青少年の身体活動不足の世界的な広がりに 対し、2030年までに15%の相対的減少を達成するための 戦略的な４つの目標と20の政策的措置がある。 2010年にWHOは、初めての子どもおよび青少年、成人、 高齢者の集団ベースの公衆衛生ガイドラインとなるGlobal recommendations on physical activity for health（健 康づくりのための身体活動に関するグローバルな推奨事項） （1）を発表した。2018年の世界保健総会では、決議案 WHA71.61で、2010年の推奨事項を更新するようWHOに 求めた。 2019年には、WHOがGuidelines on physical activity, sedentary behaviour and sleep for children under 5 years of age（５歳未満の子どもの身体活動、座位行動、 睡眠に関するガイドライン）を発表した（15）。このガイド ラインは子ども肥満撲滅委員会（Commission on Ending Childhood Obesity）（勧告4.12）（16）によって求められ ていたもので、これにより、Global recommendations on physical activity for health（健康づくりのための身 体活動に関するグローバルな推奨事項）（1）で省略されてい た若年層が取り上げられた。 本「WHO 身体活動および座位行動に関するガイドライン」 （2020 WHO Guidelines on physical activity and sedentary behaviour）は、この2010年のガイドライン に替わるものであり、特定の行動と付随する健康上の結果 に関するエビデンスの最新版に基づいている。これらは、 身体活動と座位行動に関するグローバルな推奨事項のセッ トの一部を構成するものである。 １ WHA71.6 WHO Global Action Plan on Physical Activity 2018–2030（WHOの身体活動に関するグローバルなアクションプラン）。 15Background W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r その他の重要なWHOガイドライン 健康における身体活動の重要性は、その他のWHOガイドラ インでも指摘されている。WHO Package of essential noncommunicable disease interventions for primary health care in low-resource settings（リソースの少な い現場での一次医療のための基本的な非感染性疾患の介入 のWHOのパッケージ）（17）では、高血圧、２型糖尿病、心 血管リスクの増大、喘息、慢性閉塞性肺疾患に対する臨床 管理の手順が示されるとともに、身体活動を中強度（早歩 きなど）まで徐々に上げていき、2010年のグローバルな推 奨事項に合わせて少なくとも週に150分以上まで増やすた め の 助 言 も 盛 り 込 ま れ て い る。 最 近 のWHOのRisk reduction of cognitive decline and dementia（認知機 能低下および認知症のリスク低下）（18）のガイダンスでは、 認知機能低下のリスクを低下させるために、正常な認知力 をもつ成人（強い推奨）と軽度認知障害を有する成人（条 件つきの推奨）に身体活動を推奨すべきであるとしている。 WHOのIntegrated care for older people：guidelines on community-level interventions to manage declines in intrinsic capacity（内因性の能力低下を管理 するための地域社会レベルの介入に関するガイドライン） （19）では、転倒を予防するための多様な運動と、運動能の 低下がみられる高齢者向けの運動が推奨されている。WHO recommendations on antenatal care for a positive pregnancy experience（ポジティブな妊娠経験のための 出産前ケアに関するWHOの推奨事項）（20）では、妊娠中に 健康に過ごし過度の体重増加を防ぐための健康的な食事と 身体活動に関して指導を受けることが推奨されているが、 妊娠中から産後までの期間の身体活動における健康上の利 益については取り上げられていない。 既存のWHOガイドラインは、これらの最新のガイドライン と併せると、主な疾患の予防と管理に対して、またライフ コース全体での健康とウェルビーイングの促進に対して身 体活動と座位行動の寄与するものに関するグローバルなガ イダンスを一層包括的にまとめたものとなっている。 理論的根拠と目的 身体活動のさまざまなタイプ、量、期間の健康インパクト に関する一連のエビデンスとともに、座位行動の影響と身 体活動のレベルと健康とのその相互関係に関するエビデン スは、ここ10年で内容が大幅に増えている。また、妊娠中 の女性や慢性疾患や障害を有する人たちの身体活動のため の科学的根拠は現在、そのような集団での身体活動と健康 アウトカムとの関連性の検討が可能な状況になっている。 Global action plan on physical activity 2018-2030 （身体活動に関する世界行動計画2018-2030）（14）では、 ACTION 4.1において、５歳未満の子ども、若年者、成人、 高齢者、特定の人たち（妊娠中の女性や慢性の疾患や障害 を有する人など）の身体活動と座位行動に関し、グローバ ルな推奨事項を策定し普及させるようWHOに求めている。 ガイドラインの範囲を更新して広げるのは、2010年の推奨 事項で取り上げられなかった集団の身体活動に関し、具体 的な推奨事項を盛り込むことを求めた世界保健総会の要請 に応じるものである。これは、身体活動に関するグローバ ルな行動計画の鍵となる原則ならびに目標に足並みをそろ えたものであり、つまり不平等を抑えて、すべての人々が 日々の身体活動を増やせるように支援するためのものであ る。 これらのガイドラインのすべてにかかわる目的は、子ども および青少年、成人、高齢者と特定の集団（例えば妊婦と 慢性状態か障害者によるそれらの生活）が有意の健康上の 利益と健康リスクの軽減のために、どのようなタイプの身 体活動をどの程度行うべきであるのかという点について、 科学的根拠に基づいた公衆衛生の推奨事項を示すことにあ る。また、これらのガイドラインは、座位行動と健康アウ トカムとの関連性に関する科学的根拠に基づいた推 奨事項も示している。 16 ガイドラインは子ども子どもおよび青少年（５～17歳）、 成人（18～64歳）、高齢者（65歳以上）を対象に策定され たものであるが、妊娠中の女性や慢性疾患や障害を有する 人などの亜集団の身体活動に関する具体的な推奨事項が初 めて盛り込まれた。推奨事項はそれぞれ特定の年齢層と特 定の集団に向けて策定されており、当該情報を入手しやす い特定のコミュニティに該当する人を示している。特定の 集団ごとに、特に慢性疾患や障害を有する人に向けて推奨 事項を別途示したことで、身体活動と座位行動の介入の政 策と計画に特定の集団を含めることの重要性が際立つ。 これらのガイドラインでは、睡眠を一つの行動としては扱っ ていない。睡眠は、重要な健康関連の問題であり、集団の 健康科学の範疇で新たに登場した論題である。しかしなが ら、今回の最新版の推奨事項で睡眠を取り上げることは、 委託された内容の範囲外に当たるとみなされた。しかしな がら、睡眠の重要性は認識されているため、身体活動と座 位行動の影響を考慮する場合に重要な健康アウトカムとし て盛り込まれた。 想定対象者 本文書は、推奨事項の策定にあたり、プロセスを報告し、 科学的根拠に基づいて精査された内容を要約している。 主な対象者： １． 高所得国ならびに低・中所得国の健康、教育、青少年、 スポーツおよび／または社会福祉もしくは家族福祉を 担当する省庁の政策立案者であり、各国固有のガイド ラインを考案する者、またライフコース全体の健康、 教育、職場、住民もしくは地域社会ベースの介入プロ グラムを立案する者。 ２． ガイダンス文書を通して特定階層の人々の身体活動を 促し座位行動を削減することを目指す、国家、準国家、 または地方自治体の計画を策定する政府高官。 ３． 民間の組織、教育機関、職業団体の職員、もしくは研 究者。 ４． 公共医療の従事者のほか、地域社会、家族、一次医療 もしくは三次医療の看護師、医師、もしくは保健医療 の区分を越えて従事する同様の保健医療および運動の 専門家に助言やガイダンスを行う者。国のガイダンス を利用できない場合は、これらの論題に関する助言の 内容を本ガイドラインで参照できる。 本ガイドラインに記載されている身体活動と座位行動に関 する推奨事項は、医療従事者、身体活動の専門家、教育専 門家に向けて、養成のための研修コースやプロとしての能 力開発のコースの伝達に活用すべきである。 特定のエンドユーザーや、保健医療以外の各部門の関係者、 また幅広いコミュニティに本ガイドラインを伝えるために、 また各対象者の具体的なニーズを満たすよう個別対応のや り取りを行ううえでも、派生的な産物が求められる。 17Background W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 方法 本 ガ イ ド ラ イ ン は、WHO Handbook for guideline development（ガイドライン策定のためのWHOハンドブッ ク第２版）（21）に準じて作成された。健康増進部が率いる WHO運営委員会が設立され、WHOの各地の事務局やWHO の当該部署から代表者が集まって構成された。また、性別 のバランスと地域的に偏りが出ないように考慮したうえで、 専門家や関係者27名から成るガイドライン策定グループ （Guideline Development Group：GDG）が組織された。 ガイドラインの草案を同グループに属さない外部からの評 価者７名が精査し、科学的なエビデンスとその解釈および 内容に関してフィードバックを提示した。また、ガイドラ インの草案についてはオンラインでの公開協議も行い、 400名以上の投稿者からフィードバックが寄せられた。研 究者、診療医、一般市民から得られたこれらの情報をGDG が照合して活用し、ガイドラインを完成させた。ガイドラ インの策定プロセスの管理については、付録１に細部まで すべて記した。 ガイドラインの適用範囲と 懸案のクエスチョン GDGはガイドラインの範囲を精査し、最初の会議では、最 も 重 要 と な るPI/ECO（Population, Intervention/ Exposure, Comparison, Outcome：集団、介入／曝露、 対照、アウトカム）のクエスチョンについて意見が一致し た。各特定集団について取り上げられたクエスチョンを以 下にまとめた。 身体活動について： ａ． 身体活動と健康関連アウトカムとの間にはどのような 関連性があるか？ ｂ． 量反応関係（量、時間、頻度、強度）はあるか？ ｃ． その関連性は身体活動のタイプまたは範囲に応じて変 化するか？ 座位行動について： ａ． 座位行動と健康関連アウトカムとの間にはどのような 関連性があるか？ ｂ． 量反応関係（総量、頻度、時間、中断の強度）はある か？ ｃ． その関連性は座位行動のタイプおよび範囲に応じて変 化するか？ ｄ． 成人のみ：身体活動により、死亡率に対する座位行動 の影響は緩和されるか？ 各集団（population：P）とも、曝露群（exposure：E） は身体活動の量、時間、頻度、または強度の値が高かった が、対照群（comparison：C）では身体活動が一切ないか、 量、頻度、強度または時間が低い値であった。各集団の重 大および重要なアウトカムについて、表１とウェブ付録： エビデンスプロファイルの当該のセクションのPI/ECOの各 クエスチョンの詳細事項にまとめた。 18 表１：集団の群別にみた重大および重要な＊健康アウトカムの概要 アウトカム （アルファベット順） ５～17歳の 子どもおよび 青少年：PA および座位 18～64歳の 成人： PA 18歳以上の 成人：座位 65歳以上の 成人： PAa 妊娠中および 産後 慢性疾患 b 障害を有する 子どもおよび 成人c 肥満（体重増加、体重変 化、体重管理、体重の安 定性、体重の状態、体重 維持） 重大 重大 重大 重大ａ 重大 重大−HIV ― 有害事象 重大 重大 ― 重大ａ 重大（胎児のアウトカム） ― ― 総死亡率および 死因別死亡率 ― 重大 （がんおよび CVD特異的） 重大 重大ａ ― 重大 ― 骨の健康 重大 ― 重要 ― ― ― ― 心血管代謝の健康 重大 ― ― ― ― ― ― 認知機能のアウトカム 重大 重大 重要 重大ａ ― ― 重大−MS、 PD、Stk、 Sch、ADHD 分娩合併症 ― ― ― ― 重要 ― ― 疾病の進行 ― ― ― ― ― 重大−HT、 T2D、HIV、 重大−がんの 再発 ― 転倒および 転倒関連の負傷 ― ― ― 重大 ― ― ― 胎児のアウトカム （出生体重、早産） ― ― ― ― 重大 ― ― 機能的能力 ― ― ― 重大 ― ― ― 妊娠糖尿病 ― ― ― ― 重大 ― ― 妊娠性高血圧／子癇前症 ― ― ― ― 重大 ― ― 健康関連の生活の質 ― 重要 重要 重要ａ ― 重大−HT、T2D、HIV 重大−MS、 PD、Stk、 Sch、ADHD がんの罹患率 ― 重大 重大 重大ａ ― ― ― CVDの罹患率 ― 重大 重大 重大ａ ― ― ― 高血圧の罹患率 ― 重要 重要ａ ― ― ― ２型糖尿病の罹患率 ― 重大 重大 重大ａ ― ― ― メンタルヘルス （不安および抑うつの症状） 重大 重大 重要 重大 ａ 重大 ― ― 骨粗鬆症 ― ― ― 重大 ― ― ― 体力 重大 ― 重要 ― ― ― ― 身体機能 ― ― 重要 ― ― 重大−HT、T2D、HIV 重大−MS、 SCI、ID、 PD、Stk 向社会的行動 重要 ― ― ― ― ― ― 心理・社会的アウトカム ― ― ― 重要 ― ― ― 共存症のリスク ― ― ― ― ― 重大−HT、T2D、HIV 重大−MS、 SCI、ID 睡眠 重要 重要 重要 重要ａ ― ― ― ＊ 重大なアウトカム：意思決定において重大なアウトカム。重要なアウトカム：意思決定において重要ではあるが重大ではないアウトカム。 ａ 高齢者を含む成人集団において重大および重要とみなされたアウトカム。 ｂ 特定集団の病態についてのアウトカムは以下のとおり：がん−がんサバイバー、HT−高血圧、T2D−２型糖尿病、HIV。 ｃ 特定集団の病態についてのアウトカムは以下のとおり：MS−筋硬化症、SCI−脊髄損傷、ID−知的障害、PD−パーキンソン病、Stk−脳卒中サバイバー、Sch−統 合失調症、ADHD−注意欠陥多動性障害。 　 年齢特異的な集団の重大および重要なアウトカムについては、検討し推定されたものである。 19方法 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r エビデンス 身体活動に関する2010年のWHOの推奨事項の改訂は、本 ガイドラインの適用範囲に関連がある最新の当該のアンブ レラレビューを特定したうえで更新することにより行われ た。 このような手法は、複数国の身体活動のガイドラインの策 定を普及させるために行われた最新の系統的レビューの詳 細な内容に基づいて採択された。また、公衆衛生の急速に 発展している分野の最新の利用できるデータがWHOの新た なガイドラインに確実に反映されるようにするため、さら に更新が行われた。 アンブレラレビューは、以下の３つの基準を満たしている ものが選択された。 ⅰ） 文書で十分に裏付けられている標準的な系統的プロセ スに従ってエビデンスレビューが行われている。 ⅱ） エビデンスの確実性の評価には、GRADE（Grading of Recommendations Assessment, Development and Evaluation：推奨の強さのグレーディング）法、 または解説が詳しく文書化されている評価の方法論が 使用されている。 ⅲ） エビデンスのレビューは、国別または国の所得水準に よる制限を設けずに関心対象の集団を取り上げたもの である。 PI/ECOのクエスチョンと、重大および重要な健康アウトカ ムについては、既存のエビデンスのレビューに対してマッ ピングを行い、必要な場合には、格差を取り上げる新たな レビューを委託した。GDGからは、最初のレビューと同じ 検索語、検索言語、およびデータベースを使用してエビデ ンスのレビューを更新するよう依頼した。 以下のエビデンスのレビューは、上記の３つの基準を満た していることを確認したうえで、最新であること、また包 括的であることから選択されたものである。 ・ Canadian 24-hour movement guidelines for children and youth（子どもおよび若年者に対するカナ ダの24時間運動）ガイドライン（23）の策定のプロセス の一環としてPoitras et al.（2016）が行った、学齢に 達した子どもおよび若年者（22）の身体活動と健康指標と の関連性に関する文献の系統的レビュー。このレビュー は、単に身体活動の客観的な測定値を使用した研究のみ に目を向けたものであった。計162件の研究が対象とな り、参加者は31カ国204171名に相当する。 ・ Canadian 24-hour movement guidelines for children and youth（子どもおよび若年者に対するカナ ダの24時間運動）ガイドライン（23）の策定プロセスの 一環としてCarson et al.（2016）が行った、学齢に達 した子どもの座位行動と健康指標との関連性に関する文 献の系統的レビュ （ー24）。（23）. 計235件の研究（194 例の一意のサンプル）が対象となり、参加者は71カ国 1657064名に相当する。 ・ 2019 Australian 24-hour movement guidelines for children and young people（子どもおよび若年者（５ ～17歳）に対する2019年のオーストラリアの24時間運 動）ガイドライン（26）の策定の一環としてOkely et al. （2019） が 実 施 し（25）、Poitras et al.（2016）（22） およびCarson et al.（2018）（24）が更新した系統的レ ビュ （ー24）。この報告では、2019年７月（25）までに 発表された身体活動に関する研究42件と座位行動に関す る研究32件がさらに特定された。 　 Okely et al.が作成したGRADEの表を、WHOのために 委託されて実施した更新版を基にして使用した。この GRADEの表は、エビデンスプロファイルと併せてWeb Annex：Evidence profiles （ウェブ付録：エビデン スプロファイル）に掲載した。 ・ 2019 Canadian guideline for physical activity throughout pregnancy（妊娠の全期間の身体活動に関 する2019年のカナダのガイドライン）の策定の一環とし て実施され、まとめられた12件の系統的レビュ （ー27）。 この12件のレビューは、妊娠の全期間を通しての母体の 身体活動に関する25000件以上の研究を評価したもの で、母体、胎児、または新生児の罹患率または胎児死亡 率のアウトカムについて英語、スペイン語、およびフラ ンス語で報告されている。これらの系統的レビューのう ち７件では、GDGが重大および重要とみなしたアウトカ ムが取り上げられていた（28–34）。これらのエビデンス のレビューから得られたGRADEの表は、策定された WHOの推奨事項を更新し普及させるために実施された文 献検索の基盤として使用された。最新のエビデンスプロ ファイルは、Web Annex： Evidence profiles （ウェ ブ付録：エビデンスプロファイル）に掲載した。 ・ 2018 Physical activity guidelines for Americans （2018年の米国人に対する身体活動のガイドライン）第 ２版（36）の策定の一環として2008～2016年に発表さ れた、身体活動および座位行動ならびに健康アウトカム に関するエビデンスの系統的な更新内容を示すPhysical Activity Guidelines Advisory Group（PAGAC：身体 活動ガイドライン顧問団）の科学的報告書（35）。要約さ れたエビデンスでは、公衆衛生の関連性から選択された 計38件の主なリサーチクエスチョンと計104件のサブク エスチョンが取り上げられていた。このエビデンスを構 成している系統的レビューの結果は、計1130本の論文か Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 20 ら得たもので、38問のリサーチクエスチョンに回答する ためにそれぞれ抽出されたものである（35）。この手順に おいて、系統的レビューとメタアナリシスの方法論的な 質を評価するために系統的レビューを評価する測定ツー ル の“A Measurement Tool to Assess Systematic Reviews”（AMSTARExBP）の修正版を使用した。バ イアスまたは内的妥当性のリスクについては、バイアス 評 価 ツ ー ル のUSDA NEL Bias Assessment Tool （BAT）を適合させたバージョンを使用し、それぞれの当 初の研究について評価を行った（37）。このWHOのガイ ドラインのために実施された検索内容の更新で新たに特 定されたエビデンスをWeb Annex：Evidence profiles （ウェブ付録：エビデンスプロファイル）に掲載した。 リンクはPAGAC（35）の報告書と補足資料に示した。 エビデンスの更新およびデータの抽出方法 コホート研究の系統的レビューとプール解析の検索は、対 象となった各レビュー（リストは上述のとおり）に対して 最後に検索を行った日付から2019年９月までに発表された 研究に対して実施した。データ抽出の手順については、標 準的なものを作成して採用した。 Poitras et al.（2016）（22）, Carson et al.（2016）（24）、 およびOkely et al.（2019）（25）が実施した検索内容を更新 す る た め、 デ ー タ ベ ー ス のMEDLINE、EMBASE、 PsycINFO、およびSportDiscusに検索をかけ、英語または フランス語で執筆された査読済みのレビューを特定した。 PAGAC（35）で実施された検索内容を更新するため、デー タベースのPubMed、CINAHL、およびCochraneに検索を かけ、英語で執筆された査読済みのレビューを特定した。 PAGAC（35）が対象としなかった重要なアウトカムの新規の 検索については、リソースに制約があるため実施しなかった。 検索については、国別または国の所得水準による制限を設 けずに実施し、主観的または客観的に測定された身体活動 または座位行動すべてを取り上げたレビューを対象に含め た。当初の検索で使用された言語以外の言語では検索を行 わないこととした。これは、リソースに制約があるためで あり、また追加のレビューがあった場合に、そのような検 索では得られる結果が極めて少ないものになることを示す 分野でのそれまでの経験から決定された。レビューでは、 身体活動または座位行動と健康関連アウトカムとの関連性 （身体活動または座位行動の閾値の上下のレベルに基づく） を調査し、これらと健康関連アウトカムとの間の量反応関 係を探査して検討した。 外部から集めた評価者のチームは、ツールとしてAMSTAR 2 （Assessment of Multiple Systematic Reviews）を使用 し、組入れ基準の考慮点に従って系統的レビューの信憑性 を評価した（38）。AMSTAR 2ツールには、レビューの計画 と実施に関する16項目が含まれている。各レビューの結果 に対する全体的な信頼性について、公表されているガイダ ンスに従って評価した。具体的には、「高」の評価はレビュー に重大ではない限界点が０または１つあったことを示し、 「中」の評価は重大ではない弱点が複数あると判断されたレ ビューであることを示し、「低」の評価は重大ではない弱点 の有無を問わず重大な欠陥が１つある、または重大ではな い弱さが複数あると判断されたレビューであることを示し、 「極めて低度」は重大な欠陥が複数あったことを示す。 暫定的に含めたすべてのレビューに対し、１名の評価者が AMSTAR 2ツールを使用して評価を行った。１名の評価者 が極めて低いと評価したレビューについては、別の１名の 評価者が同じツールを使用して評価を行った。極めて低い と評価されたレビューは除外した。これは、そのようなレ ビューは信頼性が低すぎるため、特にアウトカムについて 唯一利用できるレビューではない限り、入手したエビデン スの正確かつ包括的なサマリーを示すことはできないもの と判断されたためである。 この総体エビデンスにはプールコホート研究も含まれた。 外部から集めた評価者のチームは、研究の質の評価に、 Newcastle-Ottawaスケール（39）を使用した。各研究の 質を「良好」、「中」、または「不良」で格付けして評価した。 概して、質が高い研究は、Newcastle-Ottawaスケールの すべての基準を満たしていた。質が中程度の研究は、満た していない基準が１つ以上あった、または満たしていたか 否かが不明であったもののその結果を無効とできるほどの 重要な限界もはっきりとは分からなかった。質が低い研究 は、致命的な欠陥が１つあるか、重要な限界が複数あった。 質が低い研究は除外した。 重複について評価したところ、複数のレビューで研究が重 複している可能性が認められた。総体エビデンス、レビュー の概要、および一部のプールコホート研究に重複があるレ ビューは除外し、より包括的な、あるいは最新のレビュー の方を優先した。 新たにレビューを行う方法 既存のエビデンスにおいてギャップが明らかになった場合、 以下について検討するための新たなアンブレラレビューを 委託した。 １． 職業上の（すなわち職業関連の）身体活動と健康関連 アウトカムとの関連性（40）。 ２． 余暇場面の身体活動と有害な健康アウトカムとの関連 性（41）。 （上記のNo. １および２について、2009年から2019年12 月 ま で に 発 表 さ れ た レ ビ ュ ー に 対 し、PubMed、 21方法 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r SportDiscus、およびEMBASEを使用して検索を行った。） ３． 身体活動と転倒予防との関連性。Sherrington et al. （42）による2019年のコクラン共同計画の系統的レ ビューを使用し、2019年11月までの当初のレビュー について最後に検索が行われた日付以降に発表された エビデンスを基に更新した。 ４． 身体活動と骨粗鬆症ならびにサルコペニアとの関連性。 2008年から2019年11月までに発表されたレビュー について、骨粗鬆症とサルコペニアに関する既存の系 統的レビューに関する検索をPubMedの中で実行した ところ、新たなレビューは特定されなかったが、原著 研究が新たに８件特定された。 ５． HIVを有する人における身体活動と健康アウトカムとの 関連性に関するエビデンス。スコーピングレビューで は、PubMed、CINAHL、およびWeb of Scienceを 使用し、開始日の制限を設けず、2019年10月までに 発表されたエビデンスに対して行われたアンブレラレ ビューの実施を裏づけるため、HIVを有する人を対象に した身体活動と健康関連アウトカムに関するエビデン スの有効性を確認した。 身体活動と座位行動のエビデンスの特徴と  評価方法の概要 最近までは、成人を対象に身体活動と座位行動を測定する 場合の主な方法は自己申告式（すなわちアンケート）であ り、子どもを対象とした場合には自己申告か、親や保護者 による思い出し法のいずれかであった。そのような方法は、 これらの方法が安定した強みを有するものの、報告バイア スや測定誤差の傾向があるなどの限界がある（43）。近年、 この分野で急成長しているデジタル技術により、身体活動 と座位時間およびそれらと健康アウトカムとの関連性を評 価する場合にデバイスに基づく尺度の利用が増えている。 しかしながら、結果を複数の研究間で比較することには、 デバイス（加速度計）ごとの技術的な特性や配置の差に起 因する課題や、データの分析や報告の差に起因する課題が 未だに残っている。たとえば、デバイスに基づく尺度で座 位時間を測定する場合、現在のところ、デバイスの多くは 体位（例：横臥位、座位、立位で安静）の違いを識別しな いため、誤算が生じるおそれがある。デバイスを測定のベー スとしている研究から得た所見と、自己申告をベースとし ている研究から得た所見を比較すると、差異が存在する。 内容により、また身体活動の例、回答の選択肢、および対 象とされる場面により、自己申告のツールが異なる。最近 の研究では、トータルでの身体活動か、レジャー／レクリ エーション場面に限っての身体活動のいずれかを評価する ことに主眼が置かれているが、現在は移動時の身体活動 （例：ウォーキングやサイクリング）、職場での身体活動、 家庭内での身体活動など、ほかの場面もますます含まれる ようになっている。大多数のエビデンスは有酸素性の身体 活動と健康アウトカムとの関連性について報告したもので あるが、現在は筋力向上運動の利益をはじめ、さまざまな タイプの活動やほかの場面を組み合わせた場合についても 評価が行われている。 身体活動レベルと健康アウトカムとの関連性に関する結果 は、さまざまな方法で報告され、比較されている。多くの研 究では、身体活動の四分位群または五分位群の比較が報告さ れており、その他の研究では国のガイドラインを「満たして いる」か「満たしていない」かを比較するものもある。 トータルでの身体活動の算出を報告する場合は通常、MET- 時／週で概算を出す。研究によっては身体活動量の「最大」 群と「最小」群の値を比較するものもあるが、カテゴリー も研究ごとに異なる。文献では、既存のガイドラインに基 づくデータカットポイント、または現在のWHOグローバル な推奨事項や先行研究から得た測定基準に基づくデータ カットポイント（例：青少年を対象集団としたある研究で は１日60分のカットポイント、または筋力トレーニングの 介入では週に２～３回など）を適用した分析から得られた 結果がしばしば報告されている。そのようなカットポイン トが珍しいものではなくなってくると、健康アウトカムに おいて、身体活動の曝露レベルが高いか低いかという関連 性に関してエビデンスを構築することに限界が生じる可能 性がある。 子どもおよび青少年の座位行動と健康アウトカムとの関連 性を評価しているエビデンスのほとんどは、事実上横断的 であり、大多数の研究は座位時間の自己申告の尺度か親に よる申告された尺度に依存しており、これらは測定誤差と 思い出しバイアスの影響を受ける。 縦断的な観察研究と介入試験から得たエビデンスを優先し、 横断的なエビデンスを単独で使用したレビュー、または主 として統合したレビューについては考慮に入れなかった。 確実性が中以上に格付けされたレビューにより提供された エビデンスに、またデバイスをベースとした曝露の尺度を 使用した研究からのエビデンスを示すものに重点を置くよ うにした。 一連のエビデンスの格付け GRADE（Grading of Recommendations Assessment, Development and Evaluation：推奨の強さのグレーディ ング）法を使用し、レビューの基盤となるエビデンスに基 づき、各PI/ECO（44）のエビデンスの確実性を評価した。 利用できる場合には、各レビューから得たGRADEの「エビ 22 デンスプロファイル」または「所見の概要」を起点として 使用した。既存の系統的レビューには利用できる表がない 場合には、各集団とアウトカムごとに「エビデンスプロファ イル」表を作成した。 GRADE法を使用して各PI/ECO（44）のエビデンスの確実 性を評価した。その際、基準として、研究デザイン、バイ アスのリスク、効果の一貫性、非直接性、効果の精度、お よびその他に発表バイアスや、観察エビデンス（効果の大 きさ、量反応、および交絡因子の効果）を更新するための 因子を含む限界を考慮した。優れた実施方法による縦断的 研究から得た観察エビデンスについても、そのような研究 から得た身体活動または座位行動とアウトカムとの関連性 に関する所見の確実性の向上をさらに適切に反映するため、 更新を行った。アウトカム（中間のアウトカムを含む）の 優先順位をGDGが付けているため、中程度／非直接的アウ トカムを評価した研究が必ずしもグレードダウンされたわ けではなく、GRADEの格付けは、それらのアウトカムに対 する効果の確実性を反映したものである。場合によっては、 GRADE法の使用における一貫性を確保するために、既存の レビューによるGRADEの格付けを修正した。各アウトカム の総体エビデンスの確実性は、以下のガイダンスに基づい て割り当てた（45）。 エビデンスから推奨事項に向けて GDGは、クエスチョンに特化した推奨事項を作成するため のGRADE Evidence to Decisions（EtD）フレームワー クを採用した。EtDフレームワークは、意思決定への系統的 で構造化された透明性のあるアプローチである。このフレー ムワークでは、リサーチエビデンス、エビデンスの確実性、 また必要な場合には専門家の意見や想定対象者の考えから 得た主題の知識を考慮し、ガイドラインの推奨事項を作成 するため、明確な基準を使用する。これらの基準から、望 ましいアウトカムと望ましくないアウトカムで観察された エビデンス、エビデンスの全体の確実性、望ましいアウト カムと望ましくないアウトカムに関する患者の相対値、該 当する場合はリソースの使用（コスト上の問題）、健康の不 公平への潜在的なインパクト、推奨事項の許容可能性およ び実現可能性のバランスについて、判断が導き出される。 GDGは、すべての重大なアウトカムとすべての利用できる 重要なアウトカムの各推奨事項について、全体的に、総体 エビデンスを検討した。曝露／介入とアウトカムの接点に 関しては、評価対象の具体的な曝露／介入、評価対象のア ウトカム、研究デザイン、および分析的方法において、研 究ごとに大きな差異がみられ、 結 果 的 に 利 用 で き る エ ビ デ ン ス に ば ら つ き （heterogeneity）が生じた。したがって、それぞれの特異 的な曝露／介入とアウトカムの関係に対し、GRADEの古典 的アプローチを適用することはできず、むしろ、曝露／介 入の測定と分析における研究デザインのタイプとバリエー ション全体で、各曝露／介入とアウトカムの関係を取り上 げている全体的な総体エビデンスにGRADEを適用した。こ れらの因子がエビデンスの整合性に関する懸念（すなわち、 異なる視点から注目した場合には、特定の曝露／介入とア ウトカムの関係のエビデンスが一致しなかったこと）につ ながる場合、委員会はエビデンスの確実性をダウングレー ドした（21）。 GDGが身体活動と座位行動の効果を検討するに当たり優先 した健康アウトカムは、総死亡率および死因別死亡率（心 血管疾患およびがん）の低下、心血管疾患の発生率の低下、 がん（部位特異的）、２型糖尿病、体力の向上（例：心肺、 運動技能発達、および筋体力）、心血管代謝系の健康増進 （例：血圧、脂質異常症、グルコース、インスリン抵抗性）、 骨の健康、メンタルヘルス（例：抑うつ症状の減少、自尊 心、不安症状、ADHD）、認知機能のアウトカムの向上 （例：学業成績、遂行機能）、肥満の減少である。有害作用 （例：負傷および損傷）も考慮した。 その他の考慮点 GDGは、各集団とすべてのPI/ECOのクエスションについ ては、ガイドラインで対象とされる者の価値観や好みにつ いても考慮した。具体的には、推奨事項のリソースの影響、 健康の公平性に対するインパクト、および推奨事項の許容 可能性および実現可能性である。これらの考慮点とGDGの 評価には少なからぬ重複があったことから、各集団の群別 にそれらの事柄の評価に関して議論した内容を「エビデン スから推奨事項へ」のセクションにまとめて詳述した。 高 真の効果が効果推定値に近いことに非常に 確信がある。 中 効果推定値に対し中等度の確信がある。真 の効果は効果推定値に近い可能性が高いが、 大幅に異なる可能性もある。 低 効果推定値に対する確信性に限界がある。 真の効果は効果推定値と大幅に異なるかも しれない。 非常に低 効果推定値に対してほぼ確信が持てない。 真の効果は効果推定値と大幅に異なる可能 性が高い。 23方法 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 推奨事項 WHO Guidelines on physical activity and sedentary behaviour （WHO 身体活動および座位行動に関するガイドライン）で 発表される公衆衛生の推奨事項は、性別、文化的背景、ま たは社会経済的地位にかかわらず、全集団と５歳から65歳 以上の範囲の年齢層に向けたものであり、障害の有無を問 わずすべての人に該当する。 新しいガイドラインは、年齢層と行動（身体活動および座 位）別に示されている。それぞれの推奨事項の導入部には、 身体活動と座位行動と関連のある健康アウトカムをまとめ たうえで、推奨事項を記した。優れた実践の部分には、推 奨事項がターゲット集団別に、安全に推奨事項を満たす方 法をより明確に記されている。これらの優れた実践は、そ れ自体で「格付けされた推奨事項」なのではなく、科学的 なエビデンスに由来したものであり、GDGが精査したうえ で推奨する実際的な考慮点から導き出されたものである。 それぞれの推奨事項には、裏付けとなる科学的なエビデン スの概要を示し、３つのPI/ECOのクエスションで構成され ている。１つ目は重大な健康アウトカムとの関係に関する エビデンス、２つ目は量反応に関するエビデンスの概要で あり、最後に、曝露のさまざまなタイプまたは場面と健康 アウトカムとの関連性に関するエビデンス（存在する場合） の概要を示した。 24 子どもおよび青少年 （５〜17歳） 身体活動の推奨事項 子どもおよび青少年の場合、身体活動は、教育現場、家庭、ならびに地域社会の現 場の背景を踏まえて、レクリエーションとレジャー（遊び、ゲーム、スポーツ、ま たは計画的な運動）、体育、移動（車いすでの移動、ウォーキング、サイクリング）、 または家事の一環として行うことができる。 裏付けのエビデンスと理論的根拠 子どもおよび青少年に関して、本ガイドラインでは、系統的レビュー（22, 25, 35）を使用し、組入れ基準を満たし ている新規のレビュー16件が特定され、更新が行われた。方法、データ抽出、およびエビデンスプロファイルにつ いては、Web Annex： Evidence profiles （ウェブ付録：エビデンスプロファイル）に細部まですべて記した。 優れた実践 ・身体活動を一切しないよりは少しでもした方がよい。 ・ 上記の推奨事項を満たしていない子どもおよび青少年は、ある程度の身体活動を行うことで健康上の利益 が得られる。 ・ 子どもおよび青少年の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時間を増やして いく。 ・ すべての子どもおよび青少年に対し、楽しめる内容で、変化に富み、年齢や能力に適した身体活動に参加 する安全かつ公正な機会を設け奨励することが重要である。 子どもおよび青少年の身体活動は、体力（心肺体力および筋力）、心血管代謝の健康（血圧、 脂質異常症、グルコース、インスリン抵抗性）、骨の健康、認知アウトカム（学業成績、実行 機能）、メンタルヘルス（抑うつの症状の軽減）の向上と、肥満の減少などの健康アウトカム に利益がある。 推奨事項： ＞子どもおよび青少年は、中高強度の主に有酸素性の身体活動を週全体で１日につき平均60分 以上行うこと。 強い推奨、エビデンスの確実性は中 ＞高強度の有酸素性の活動とともに、筋肉および骨を強化する活動を週に３日以上組み込むこと。 強い推奨、エビデンスの確実性は中 Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 25推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 子どもおよび青少年（５〜17歳） 子どもおよび青少年（５～17歳）の場合、 身体活動と健康関連アウトカムとの間にはど のような関連性があるか？ 大規模な総体エビデンスによりすでに立証されていること は、子どもおよび青少年の場合、身体活動の量が多く強度 が高いことは、複数の有益な健康アウトカムと関連してい るということである（1）。最近のエビデンスで改めて確認さ れたことは、子どもおよび青少年において、身体活動を増 やすことは、心肺体力および筋力を向上させるということ である（22, 35）。たとえば、週に３日以上の中高強度の身 体活動を30～60分間行うと、好影響が得られる（22, 35）。 子どもおよび青少年の場合、主に有酸素性の定期的な身体 活動は、血圧、脂質プロファイル、グルコース制御、イン スリン抵抗性の改善など、有益な心血管代謝の健康アウト カムと正の相関がある（35）。最近のレビューでは、学校 ベースの身体活動プログラム（46）、高強度のインターバル トレーニング（47）、およびレジスタンストレーニング（48） の有効性について、心血管代謝の健康の尺度を介入なしの 場合と比較して検討が行われた。全３件のレビューの中に、 介入は心血管代謝のアウトカムの向上と関連していたとす る一貫性のあるエビデンスがあったが、効果量の精度には 変動があり、個々の試験ですべての心血管代謝のアウトカ ムに身体活動の統計的に有意な利益を示した試験はほとん どなかった。19件のRCT（ｎ＝11 988）に関する１件の レビュ （ー46）によると、学校ベースの身体活動プログラム は、身体活動の介入がない場合に比べ、拡張期血圧（ES＝ 0.21［95％ CI：0.42～0.01］；ｐ＝0.04）と空腹時イン スリン（ES＝0.12［95％ CI：0.42～0.04］；ｐ=0.03） の統計的に有意な改善と関連があった。 身体活動は肥満との望ましい関連性が報告されており、子 どもおよび青少年の場合、活動レベルが高いことは、健康 的な体重の状態と関連している（22, 35）。結果は概して横 断的研究で最も強いが、前向き観察研究からの混入が多い 結果では、既報の関連性の方向性の理解を制限することに なる。身体活動の介入試験（検査データベースの高強度イ ンターバルトレーニング［HIIT］、教室ベースの能動学習、 レジスタンストレーニング）の最近のレビューでは、効果 の報告がないレビューの対象となった研究の大多数と矛盾 する結果が報告された（47, 49, 50）。しかしながら、縦断 的研究と横断的研究を対象としたあるレビューでは、歩数 計で測定した身体活動と、肥満、BMI、または胴囲の測定 結果との間の負の相関が報告された（51）。全般的にみると、 身体活動は健康的な体重の状態の管理と関連しているとい う確実性の低いエビデンスがあり、関連性の方向性と強度 を判断するには、より多くの研究が必要である。 子どもよび青少年の身体活動と運動技能の発達との関連性 が検討されたエビデンスは少なく、現在のレビューでは所 見が示されていない（22）。今後のガイドラインを普及させ るためのアウトカムとして、運動発達についてさらに研究 する必要がある。 子どもおよび青少年の場合、骨に負荷のかかる活動は、ゲー ムをする、ランニングをする、回転する、あるいはジャン プする動作の一環として可能である。身体活動は骨量増加 分および／または骨構造と正の相関があり、子どもおよび 青少年では、身体活動が多いほど、骨量が多く、骨塩含量 あるいは骨密度が高く、骨強度が高いことを最近得られた エビデンスが裏付けている（35）。子ども期から青少年期に かけて、骨の健康を最大限に高めることは、将来の骨粗鬆 症やそれに伴う骨折を防ぐ一助となる。 認知機能を伸ばして維持することは、生涯にわたり必須で ある。子どもおよび青少年の場合、身体活動は認知機能や 学業上のアウトカム（例：学業成績、記憶力、遂行機能） に正の効果を与える（22, 35）。最近のあるレビュー（19件 のRCT；ｎ＝5038）は、週に複数回の運動介入を６週以 上行うと、運動介入が一切なかった場合に比べ、抑制制御 （SMD 0.26［95％ CI：0.08～0.45］，ｐ ＝＜0.01）、作 業記憶（SMD 0.10［95% CI：−0.05～0.25］，ｐ＝<0.02）、 認 知 的 柔 軟 性（SMD 0.14［95% CI：−0.03～0.31］， ｐ＝<0.04）などの認知機能の値の向上と関連があること を実証した（52）。子どもおよび青少年の身体活動は、大う つ病の有無を問わず、抑うつおよび抑うつ症状を経験する リスクも軽減し（35）、症状緩和という点では心理的治療法 や医薬品による治療法に匹敵しうる。 いずれの身体活動にも有害事象のリスクがつきものである が（53）、健康上の利益があると推奨される身体活動のレベ ルに関連した害のエビデンスの報告例は少ない（35）。利用 できるエビデンスや専門家の意見を基にすると、子どもお よび青少年に推奨される身体活動の量やタイプに関連した 潜在的リスクは低いと考えられ（35）、特に身体活動不足の 子どもおよび青少年の場合、活動性のレベルと強度を徐々 に上げていくとそのリスクは低下する。スポーツによって は、参加すると、運動強度が上昇するにつれて負傷のリス クが増大することは明らかになっている（53）。この分野の 知識の基盤を強化するには、さらに研究が必要である。 GDGが出した結論： ・ 子どもおよび青少年において、中強度や高強度の身体活 動量の増大は心肺体力および筋力の向上、心血管代謝の 健康、骨の健康と関連していることを示す確実性が中程 度のエビデンスがある。 26 子どもおよび青少年（５〜17歳） ・ 短期的および長期的な中高強度の身体活動は、認知機能、 学業上のアウトカムやメンタルヘルスに正の効果がある ことを示す確実性が中程度のエビデンスがある。 ・ 子どもおよび青少年の場合、身体活動が健康的な体重の 状態の管理と望ましい関連を示す確実性が低いエビデン スがある。 ・ 子どもおよび青少年に推奨される身体活動の量とタイプ のリスクは低く、利益が上回ることを示す確実性が低い エビデンスがある。 量反応関係（量、時間、頻度、強度）はある か？ 子どもおよび青少年における身体活動と健康アウトカムの 正の関係を示す実質的な総体エビデンスがあるが、量反応 の問題に取り組んだ研究は極めて少ない。したがって、子 どもおよび青少年の量−反応曲線の正確な形状および／ま たは身体活動や特定の健康アウトカムの閾値（低リスクと 高リスクを識別）の有無については、成人集団に比べてあ まりよくわかっていない。それにもかかわらず、実質的な 総体エビデンスは身体活動を毎日60分行うことで健康上の 利益の多くが得られることを示しており、エビデンスに矛 盾がないことを考えると、最新のエビデンスは１日当たり 60分の中高強度の身体活動を行うという現在のWHOの推 奨事項を再確認するものと結論づけた（1）。 しかしながら、複数の研究が健康アウトカムに関する身体 活動の利益の評価に１日当たり60分という「平均的な」閾 値（60分は１日の最小限の閾値ではない）を幅広く使用し たと想定すると、デバイスを測定のベースとしている研究 から得られた最近の結果を含め、すべてのエビデンスのレ ビューは、健康上の利益のため毎日60分の中高強度の身体 活動という「最小限」の定義の保持を裏付けるものではな かった。レビューでは、新たなガイドラインがこのエビデ ンスを綿密に反映するよう修正されるべきであると結論づ けた。 高強度の定期的な活動が心血管代謝の健康アウトカムに与 える利益はすでに立証されており（1）、最近のレビューによ り、エビデンスはさらに裏づけられている（35）。たとえば、 ある最近のレビュ （ー54）が示すところでは、高強度のイン ターバルトレーニングは、中強度の継続的トレーニングに 比べ、心肺体力に中等度の有益効果がみられた（SMD＝ 0.51［95％ CI：0.33～0.69］，ｐ＝＜0.01；I2＝０％）。介 入期間、運動の種類、運動時と安静時の比率、トータルの まとまった活動（bout）が心肺体力に対する影響を改善し たというエビデンスはなかった。これらの結果は総じて他 の最近のレビューと整合しており、若年および青少年が心 肺体力を改善するためには高強度の定期的な活動を行うべ きという以前からの推奨事項を裏付けている。 GDGが出した結論： ・ エビデンスは、１日当たり60分の中高強度の身体活動と いう以前からのWHOの推奨事項を肯定している。 ・ 60分の身体活動という１日の最小限の閾値という以前の 定義を週当たり１日に平均60分に修正することをエビデ ンスが裏付けている。 ・ 高強度の身体活動量を増やすことが心肺体力の改善と関 連しているという確実性が中程度のエビデンスがある。 その関連性は身体活動のタイプまたは場面に 応じて変化するか？ 子どもおよび青少年の場合、家族や学校ならびに地域社会 の活動という背景での身体活動には、遊び、ゲーム、スポー ツ、移動、レクリエーション、体育、または計画的な運動 が含まれる。しかしながら、身体活動と健康アウトカムと の関連性が活動のタイプ（例：有酸素性運動と筋力向上運 動との比較）または身体活動の場面（例：ウォーキングや サイクリングのような人力による移動と体育との比較、ス ポーツ／レクリエーションとの比較）によって変わるのか 否かを判断するにはエビデンスが不十分である。 子どもおよび青少年の場合、有酸素性の身体活動は、中強 度の場合も高強度の場合も活動量の増大は心肺体力と関連 していること、また筋力向上活動を増やすと筋力が増大す ることを示すエビデンスはある。このエビデンスは、2010 年 のWHOのGlobal recommendations on physical activity for health（健康づくりのための身体活動に関す るグローバルな推奨事項）を普及させ（1）、筋肉と骨を強化 する活動を週に少なくとも３日は組み込むことを推奨して いる。最新のエビデンスからは、週に３回の定期的な筋力 向上活動が筋力の指標の改善に有効であることが再確認さ れた。しかしながら、文献で評価されているものは曝露に ばらつきがあることが大きな原因となり、回数、期間、強 度の具体的な詳細を述べたエビデンスが不十分である（22, 35）。心血管代謝の健康に対し、レジスタンストレーニン グが保護効果を発揮することについては、エビデンスが少 ない。子どもおよび青少年の筋力向上活動について、頻度 以外の特徴（期間など）に関する新たなエビデンスがない ことを考えると、それ以上何か具体的なことを述べること はできなかった。今後の研究では、本ガイドラインのこの 部分についてより詳細な情報を示すため、身体活動の具体 的なタイプや場面からみた健康上の利益を取り上げるべき 27推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r である。 GDGが出した結論： ・ 筋力向上活動は週に少なくとも３日は組み込むべきとい う確実性が中程度のエビデンスがある。 子どもおよび青少年（５〜17歳） 28 子どもおよび青少年 （５〜17歳） 座位行動の推奨事項 座位行動とは、教育、家庭、地域社会の現場や移動時などの状況において、覚醒 しているときに、座ったまままたは横たわったままエネルギー消費が少ない状態 で時間を過ごしていることと定義されている。 裏付けのエビデンスと理論的根拠 座位行動は2010年のWHOの推奨事項に含まれていなかったが、過去10年の間に、座位行動のさまざまな尺度やタ イプと関連のある健康アウトカムを検討した研究が増えてきた。技術やデジタルはこれまでに仕事、勉強、旅行の方 法や余暇の過ごし方に影響を与えてきた。ほとんどの国では、子どもおよび青少年は、特にスクリーンを使用した娯 楽（テレビやコンピュータ）のようなレクリエーションの場合や、携帯電話のようなデジタル通信の場合に、座位行 動で過ごす時間が長い。 子どもおよび青少年に関して、本ガイドラインでは、系統的レビュ （ー24, 25）を使用し、組入れ基準を満たしてい る新規のレビュー７件が特定され、更新が行われた。方法、データ抽出、およびエビデンスプロファイルについては、 Web Annex： Evidence profiles （ウェブ付録：エビデンスプロファイル）に細部まですべて記した。 子どもおよび青少年の場合、座位行動の多さは、肥満の亢進、心血管代謝の健康度の低下、体力、 行動／向社会的行動、睡眠期間の減少などの不良な健康アウトカムと関連している。 推奨事項： ＞子どもおよび青少年は、座位のまま過ごす時間、特に余暇時間でスクリーンタイムが短くなる ように制限をかけること。 強い推奨、エビデンスの確実性は低 Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 29推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 子どもおよび青少年（５〜17歳） 子どもおよび青少年（５～17歳）の場合、 座位行動と健康関連アウトカムとの間にはど のような関連性があるか？ 座位行動が長いと、特に余暇時間のスクリーンタイム（画 面を見ている時間の長さ）が長いほど、不良な健康アウト カムと関連があることをエビデンスが示している（24, 35）。たとえば、子どもおよび青少年では、スクリーンタ イム（テレビ番組の視聴を含む）の時間が長いと、体力や 心血管代謝の健康（24, 25）が不良になることと関連してい る。座位行動との関連性のデバイスに基づく評価や介入試 験から得たエビデンスは中程度の影響を示したが、すでに 肥満を有する対象者の場合は影響がより強いものであった （55）。子どもおよび青少年の座位行動が骨の健康に関連が ないことを示唆しているエビデンスは少ない。 複雑な結果にもかかわらず、座位行動は肥満の望ましくな い測定値と関連している可能性があることもエビデンスは 示唆している（24, 25）。主な横断的研究をレビューしたあ る報告では、１日に２時間を超える座位行動（スクリーン タイムの合計として測定）は、これよりも短時間（＜２時 間／日）の場合に比べ、子ども期の過体重／肥満と明らか に関連していた（56）。ただし、20件の横断的研究をレ ビューした別の報告（57）では、子どもまたは青少年が座 りっきりでビデオゲームを行うこととBMIとの間に統計的 に有意な関連性を見出せなかった。 29件の系統的レビューを扱ったある大規模なレビューで は、座位行動が何らかの形式のスクリーンタイムとして自 己申告させると、若年者の肥満の座位行動とマーカーとの 間の望ましくない関連性を報告した研究が多数あったと結 論づけた。しかしながら、このレビューではそのような関 連性の規模が小さいことに注目しており、座位時間のデバ イスに基づく評価を使用している研究の場合は主にゼロで あるとした（55）。介入試験は中程度の影響を示したが、す でに肥満を有する被験者の場合は影響がより強いもので あった（55）。座位行動と肥満の測定との関連性を普及させ るには、さらに研究が必要である。 子どもおよび青少年においては、研究の新たに登場した分 野でも、いくつかのエビデンスが座位行動と福祉ならびに 生活の質との間の負の関連性を、また抑うつと余暇のスク リーンタイムとの望ましくない関係性を示している（58, 59）。たとえば、スクリーンタイムやコンピュータ使用の 局面をもつものとして評価される座位行動の期間が長いこ とは、メンタルヘルスの不良と関連がありうる（24）。最近 の別のレビューでは、８件の試験中５件で座位行動と不安 症状との間に関連性が認められたが、試験内の座位行動の 測定法が異なっており結果に整合性がなかった（60）。他の エビデンスは、テレビ番組の視聴とテレビゲーム使用の期 間が長いことが行動／向社会的行動（24）の望ましくない測 定値と有意に関連していたことを証明しており、長時間の スクリーンタイムおよびテレビ視聴は睡眠期間の短さと関 連しているが、コンピュータ使用／ゲーム時間と睡眠の長 さとの間には関連性がみられなかった（61）。座位行動とメ ンタルヘルスとの関係性の調査は急速に発展している分野 であるが不明点も多く、エビデンスには逆の因果関係がみ られる可能性が高い。この関連性の方向と強度に関して情 報を出すにはさらに研究が必要である。 GDGが出した結論： ・ 子どもおよび青少年で座位行動（スクリーンタイム）の 期間が長いことは、体力と心血管代謝の健康と有意に関 連しているという確実性が低いエビデンスがある。 ・ 子どもおよび青少年では、座位行動の期間が長いこと（ス クリーンタイム、テレビ番組の視聴、およびテレビゲー ムの使用）はメンタルヘルスや行動／向社会的行動の望 ましくない測定値と有意に関連しているという確実性が 非常に低～中程度のエビデンスがある。 ・ 子どもおよび青少年では、座位行動で長時間過ごすこと （スクリーンタイムおよびテレビ番組の視聴）は睡眠期間 に対する有害な影響と関連している確実性が低いという エビデンスがある。 ・ 子どもおよび青少年において、座位行動の時間を減らす ことの利益は害を上回る。 量反応関係（量、時間、頻度、中断の強度） はあるか？ 子どもおよび青少年において、量反応関係が座位時間（余 暇時間のスクリーンタイムを含む）と健康アウトカムとの 間に存在するか否かを判定するためのエビデンスは十分に 得られていない。子どもおよび青少年の座位行動と健康ア ウトカムとの関連性を評価しているエビデンスのほとんど は、事実上横断的であり、GRADEに従えばエビデンスの確 実性が低く、大多数の研究は座位時間の自己申告の尺度か 親による申告された尺度に依存しており、これらは測定誤 差と思い出しバイアスの影響を受ける。しかしながら、座 位行動で過ごす時間が短いことが健康アウトカムにとって 良いことであるとみられるエビデンスがあり、概して座位 行動と有害な健康アウトカムとの関連は、総座位時間より も、テレビ番組の視聴または余暇時間のスクリーンタイム を曝露変数として評価する場合の座位行動において強く表 れる。ただし、全体的に、制限時間を指定する裏づけとし てはエビデンスが不十分であるとみなされた。 30 子どもおよび青少年（５〜17歳） 座位行動が有害な健康アウトカムに結びつくというエビデ ンスがあるとすれば、座位行動の直接効果の結果となるか、 あるいは身体を活発に動かす行動に置き換えて時間を過ご した結果となるか、またはその両方となる。子どもおよび 青少年のスクリーンタイムと有害な健康アウトカムとの間 の関連性を報告した研究はあるが、中高強度の身体活動の 時間を考慮した場合、総座位時間（座位行動のデバイスに 基づく測定値を使用した試験での評価として）は健康アウ トカムと一貫して関連を示さなかった（62）。これとは逆に、 中高強度の身体活動を有望な健康アウトカムに結びつける エビデンスは、多様な現場で強くみられ、それらは文書で 十分に裏付けられており、一部の座位行動を身体活動（特 に中高強度の身体活動）に置き換えると、健康アウトカム が改善される可能性がある。 座位行動、身体活動、健康アウトカムの間の関連性と相互 作用を調査する研究は急速に増えており、デバイスをベー スとした座位行動の測定値から得たエビデンスと心血管代 謝の健康は、中高強度の身体活動を考慮に入れると（すな わち統計学的に調整すると）、関連性が弱まることを示して いる（62–64）。したがって、これらの関連についての知識 を高めて今後の推奨事項を普及させるには、曝露のデバイ スに基づく尺度を使用したさらなる前向き研究が必要であ る。 GDGが出した結論： ・ 座位行動で長時間過ごすことが不良な健康アウトカムと 関連があるという確実性が低いエビデンスがある。 ・ 座位行動の制限時間を指定するにはエビデンスが不十分 である。 ・ 座位時間を中高強度の身体活動に置き換えると、健康上 の利益が得られる可能性がある。 その関連性は座位行動のタイプまたは場面に 応じて変化するか？ 座位行動の健康影響の試験は、研究の中でも比較的新しい 分野である。よって、所見は、曝露の機器も尺度もさまざ まなものが使用された試験から得られている。「座位行動に 費やされる時間の総数」として評価される曝露が使用され ることが多いが、これは「スクリーン」を使用して過ごす 座位時間、または「テレビ番組の視聴」をして過ごす座位 時間である。 現在利用できるエビデンスからは、座位行動と有害な健康 アウトカムとの関連性は、総座位時間よりも、テレビ番組 の視聴時間または余暇時間のスクリーンタイムにおいて概 して強いことが示唆されている（24, 35）。最近の研究では、 座位行動のデバイスに基づく評価の利用が増えたことで知 識が深まっており、評価法を標準化して併用すると、報告 内容が今後のガイドラインの普及に役立つ。 すべての座位行動が必ずしも有害であるとは限らないこと は認められている。読書する、また学校の外で宿題をする といった特定のタイプの座位行動は学業成績の高さと関連 があることをエビデンスが示唆しており、活動次第でアウ トカムに差異があることを示している（24, 25）。座位行動 に、教育的遊び／勉強または静かな遊びをして過ごす時間、 または電子メディアを使用しない社会的相互作用を含める ことはできる。そのような遊び（例：読書する、パズルを する、絵を描く、工作をする、歌う、音楽を演奏する）は 子どもの発育にとって重要であり、認知面やその他の面で も利益がある。 GDGが認めたこと： ・ 座位の活動の中には、子どもおよび青少年の認知機能や 社会的相互作用に利益があるものもる。 ・ 座位行動の健康への悪影響に関するエビデンスは、総座 位時間よりも、テレビ番組の視聴時間または余暇時間の スクリーンタイムにおいて強く表れる。 31推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 成人 （18〜64歳） 身体活動の推奨事項 成人の場合、身体活動は、教育現場、家庭、および地域社会の現場の背景を踏ま えて、レクリエーションおよびレジャー（遊び、ゲーム、スポーツ、または計画 的な運動）、体育、移動（ホイーリング、ウォーキング、サイクリング）、家事の 一環として行うことができる。 成人の身体活動は、総死亡率、心血管疾患死亡率、高血圧の発症、部位特異固有がんの発症1、 ２型糖尿病の発症、メンタルヘルス（不安および抑うつの症状の軽減）の改善、認知的健康、 および睡眠などの健康アウトカムに利益があり、肥満も改善される可能性がある。 推奨事項： ＞成人は定期的な身体活動を行うこと。 強い推奨、エビデンスの確実性は中 ＞成人の場合、中強度の有酸素性の身体活動を150～300分以上、または高強度の有酸素性の 身体活動を75～150分以上行うか、または週全体で中強度の活動と高強度の活動の組み合わ せによる同等の量を行うと、実質的な健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 ＞成人の場合、さらに健康上の利益を得るため、中強度の有酸素性の身体活動を300分超に増や しても、あるいは150分超の高強度の有酸素性の活動、または週全体で中強度の活動と高強度 の活動の組み合わせによる同等の量を行うと、さらなる健康上の利益が得られる。 条件つきの推奨、エビデンスの確実性は中 ＞なお、成人は、主要筋肉群すべてが関係する中強度以上の筋力向上活動も週に２日以上行う こと。それにより、さらに健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 優れた実践 ・ 身体活動を一切しないよりは少しでもした方がよい。 ・ 上記の推奨事項を満たしていない成人は、ある程度の身体活動を行うことで健康上の利益が得られる。 ・ 成人の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時間を増やしていく。 １ 部位別のがんとは、膀胱がん、乳がん、大腸がん、子宮内膜がん、食道腺がん、胃がん、腎がんである。 32 裏付けのエビデンスと理論的根拠 本ガイドラインでは、United States Physical Activity Guidelines Advisory Committee（PAGAC：米国人に 対する身体活動のガイドライン諮問委員会）（35）がエビデンスをまとめたものを使用して更新した。 GDGは、PAGACが報告した所見と、2017年から2019年11月まで2017年までに発表された28件のレビューと３ 件のコホート研究のプールのいずれも組み入れ基準を満たして成人における身体活動と健康関連アウトカムの関連性 に関するエビデンスを投稿したものを含めた総体エビデンス全体を検討対象とした。 また、２件のアンブレラレビューを委託してエビデンスギャップに対応するとともに、ⅰ）職業上の（すなわち職業 関連の）身体活動と健康関連アウトカムとの関連性（40）の検討と、ⅱ）レジャー場面の身体活動と有害な健康アウ トカムとの関連性（41）の検討を行った。アンブレラレビューでは、それぞれ36件と15件の系統的レビューが特定 された。縦断的な観察研究と介入試験から得たエビデンスを優先し、横断的なエビデンスを単独で使用したレビュー、 または主として統合したレビューについては考慮に入れなかった。確実性が中程度以上に格付けされたレビューによ り提供されたエビデンスに、またデバイスをベースとした曝露の尺度を使用した研究からのエビデンスを示すものに 重点を置くようにした。 方法、データ抽出、およびエビデンスプロファイルについては、Web Annex： Evidence profiles （ウェブ付 録：エビデンスプロファイル）に細部まですべて記した。 成人の場合（18～64歳）、身体活動と健康 関連アウトカムとの間にはどのような関連性 があるか？ 成人における身体活動と総死亡率や心血管疾患死亡率との 間の関連性は、すでに立証されている（1）。最近のレビュー から得た所見では、身体活動のレベルが最低の場合に比べ、 最高の場合は死亡率のリスクの低下と関連していることが 再確認された。デバイスを身体活動の測定のベースとして いる研究から得た新しいエビデンスでは、身体活動のレベ ルが最低の場合に比べ、身体活動のその他のレベルおよび すべての強度（低強度を含む）は死亡率のリスク低下と関 連していることを示すエビデンスが再確認され拡張された （65）。たとえば、身体活動度が最低の場合（参照対象、 1.00）と比較すると、トータルでの身体活動の四分位群に おける補正ハザード比は身体活動の四分位群全体で改善さ れ、 第 ２ 四 分 位 群（0.48［95%CI：0.43～0.54］）、 第 ３四分位群（0.34［95%CI：0.26～0.45］）、第４四分位 群（0.27［95%CI：0.23～0.32］）であった（65）。新た なエビデンスでは、（1）身体活動と心血管疾患死亡率との十 分に立証された逆相関も再確認された（66）。 心血管疾患を抑制し高血圧の発生率を低下させる点で身体 活動がもたらす利益は、十分に裏付けられている（1）。身体 活動は有益な短期と長期の自律神経、そして血行力学の適 応を引き起こす多くの生理反応を促し、心血管疾患の主要 な危険因子である高血圧のリスク低下をもたらす。 エビデンスにより、正常血圧の成人において身体活動と高 血圧の発生との間に逆相関がみられること、また身体活動 は高血圧前症の成人と正常血圧の成人の血圧を低下させる ことが再確認された（35）。 成人における身体活動と２型糖尿病の発生との間の逆相関 は十分に立証されている（1）。最近のエビデンスでは、身体 活動量の多さと２型糖尿病の発生率との間に逆の曲線関係 がみられ（35）、身体活動のレベルが高いところで減少方向 の傾斜が示されることが再確認された。新たなレビューで は、２型糖尿病を呈するリスクの低下について身体活動の レベルが「最高」の群と「最低」の群で比較したところ、 この効果は、非ヒスパニック系白人（RR＝0.71［95%CI： 0.60～0.85］）、 ア ジ ア 人（RR＝0.76［95%CI：0.67～ 0.85］）、ヒスパニック系（RR＝0.74［95%CI：0.64～ 0.84］）、アメリカ原住民（RR＝0.73［95%CI：0.60～ 0.88］）のように背景が異なる被験者でも一貫性があること が明らかになったが、非ヒスパニック系黒人での効果は有 意 で は な か っ た（RR＝0.91［95%CI：0.76～1.08］） （67）。エビデンスは、体重の状態による効果の修飾がない こと、また正常体重、過体重、または肥満を呈する人にお いて身体活動量が多いことと２型糖尿病の発生率が低いこ との間に逆相関が存在することを示唆している（35）。 高レベルの身体活動と大腸がんおよび乳がんのリスク低下 との関連性は十分に立証されている（1）。エビデンスの先行 レビューでは、高レベルの身体活動は、乳がんおよび大腸 がんを呈するリスクの低下と関連していることが明らかに 成人（18〜64歳） Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 33推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r なっている（1）。身体活動とがんの研究が広範に増えた後、 高レベルの身体活動が膀胱がん、子宮内膜がん、食道腺が ん、胃がん、腎がんの発生リスクの低下とも関連があるこ とを示す新たなエビデンスがあり、身体活動が乳がんおよ び大腸がんを予防することが再確認された（35）。高レベル の身体活動は、約10～20%の範囲で変動するリスク低下と 関連がある（35）。たとえば、あるレビューは、低レベルの 身体活動と高レベルの身体活動を比較し、肝がんリスクと の逆相関を報告した（HR＝0.75［95%CI：0.63～0.89］） （68）。身体活動の増加と血液がん、頭頸部がん、卵巣がん、 膵臓がん、前立腺がん、甲状腺がん、直腸がん、および脳 腫瘍のリスク低下との間の関連性に関しては、エビデンス が不十分である（35）。身体活動のレベルが「最高」の群と 「最低」の群で比較すると肺がんのリスク低下を示唆するエ ビデンスがあるが、それらの所見はタバコ使用と交絡して いる可能性があり、全体として関連性を立証するにはエビ デンスが不十分であるという決断に至った。 成人集団の身体活動と肥満との関連はデータが大規模であ るにもかかわらず十分に立証されていないが、アウトカム のさまざまな尺度（体重増加、体重変化、体重管理、体重 安定性、体重の状態、体重維持）全体で、この関係性を評 価する総体エビデンスにばらつきがみられる（35, 69, 70）。全体として、成人では、身体活動が高レベルである ほど肥満の測定値や体重増加の緩和は望ましい結果となる ことをエビデンスが示している（35）。関連性の結果と強度 を立証するにはさらに研究が必要である。 2010年のGlobal recommendations on physical activity for health（健康づくりのための身体活動に関するグローバ ルな推奨事項）（1）の策定以降、身体活動とメンタルヘルス、 認知力、睡眠に関する研究が実質的に増えている（1）。当 時、成人では身体活動が抑うつおよび認知機能低下のリス クを軽減する可能性があることのみを結論づけるのに十分 なエビデンスがあった。本ガイドラインのレビューで得ら れた新たなエビデンスは、身体活動量が多い成人は少ない 成人に比べ、不安と抑うつを呈するリスクが低いことを示 していた。たとえば、身体活動が高レベルの成人は、低レ ベルの成人に比して不安（AOR＝0.81［95%CI：0.69～ 0.95］）（71）や 抑 う つ（AOR＝0.78［95%CI：0.70～ 0.87）を呈するオッズ比が低かった（72）。 中高強度の身体活動量が増えることは認知機能の改善（例： 処理速度、記憶、実行機能）（35）、脳の機能および構造、 アルツハイマー病を含む認知障害を呈するリスクの低下と 関連がある（73–76）。このエビデンスには、認知機能が正 常から認知障害へと傾きを示している成人の複数の集団が 含まれ、有酸素性の活動、ウォーキング、筋力向上活動、 およびヨガを含む種々のタイプの有酸素性の活動の身体活 動の有益な影響が報告された（74）。急激なまとまった活動 （bout）も定期的な身体活動も、成人の睡眠と健康関連の生 活の質のアウトカムを改善するというエビデンスがある （35）。 身体活動と抑うつの症状、不安の症状、不安および抑うつ の発生を検討したエビデンスは、身体活動が不安の症状の 緩和（77, 78）や抑うつ症状の緩和と関連があることを示し た（77, 79）。 身体活動はすべて何らかのリスクを伴う。成人のレジャー としての身体活動と関連のある有害作用、負傷、害に関す るレビューを委託して得たエビデンスは（41）、余暇の身体 活動のレベルと筋骨格の負傷との間の望ましくない関連性 と、余暇の身体活動と骨折のリスクおよび膝または股関節 の変形性関節症の発症との間にみられる望ましい関連性を 示唆している。その他の既存のエビデンス（35）からは、突 然の心臓性の有害事象がまれであること、また相対的に高 強度の身体活動の急激な回数と関連していることが示され ている。通常、中強度の身体活動では有害事象のリスクは 非常に低く、身体活動の頻度を上げても、強度と期間は有 害事象のリスクは緩勾配である（35）。 GDGが出した結論： ・ いずれかのレベルの身体活動をいずれかの強度で行うこ とは、総死亡率、心血管疾患死亡率、高血圧、心血管疾 患、および２型糖尿病の発生率のリスク低下と関連があ るという確実性が高いエビデンスがある。 ・ 高レベルの身体活動と部位別のがんの発生率のリスク低 下との関連性に関しては、確実性が中～高度のエビデン スがある。 ・ 身体活動と、メンタルヘルス、認知機能の健全性、睡眠 アウトカムの改善との間の関連性については、確実性が 中程度のエビデンスがある。 ・ 成人の高レベルの身体活動と肥満の望ましい測定値なら びに体重増加の緩和との間の関連性を示すエビデンスが ある。 ・ 成人に対して推奨される身体活動は有害とならないこと、 またそのような活動から得られる健康上の利益がリスク を上回ることを示す確実性が低いエビデンスがある。 成人（18〜64歳） 34 図１：量反応曲線 １週間の身体活動（分） リス クと 害 利 益 健 康 お よ び 体 力 上 の 利 益 座位 推奨される範囲 150 300 量反応関係（量、時間、頻度、強度）はある か？ 総じて、成人の場合、心血管および代謝性の健康アウトカ ムのエビデンスは、身体活動と、総死亡率、心血管疾患死 亡率、２型糖尿病の発生（67）、部位別のがんの発生などの 主要アウトカムとの間に、整合性のある曲線の逆の量反応 関係を示す。図１に記したとおり、量反応曲線の形状は利 益の下限閾値がないことを示し、最大の利益は量反応曲線 の下端において認められる（65）。曲線の逆相関は、身体活 動のさまざまな尺度を使用している研究で一貫して報告さ れている。 重要な新しいエビデンスは、８件の前向きコホート研究の メタアナリシスで提供され、平均追跡期間は5.8年（範囲３ ～14.5年）で（65）、曝露と総死亡率のデバイスに基づく尺 度を使用したトータルでの身体活動の四分位群の補正ハ ザード比を報告した。その結果示されたものは、身体活動 度が最低の場合（参照対象、1.00）に比べて、身体活動量 を増やすと、いずれの強度の身体活動でも高レベルで行う ことの利益がある量反応と、第２四分位群（補正HR＝0.48 ［95%CI：0.43～0.54］）、第３四分位群（補正HR＝0.34 ［95%CI：0.26～0.45］）、第４四分位群（補正HR＝0.27 ［95%CI：0.23～0.32］）であった。成人では、１日当た り24分（週に168分に相当）の中高強度の身体活動を行う とリスクが最大限に低下することが認められた。これは、 週150分という推奨事項をしっかりと反映したもので、週 当たり150～300分の身体活動という成人の既存のグロー バルなガイダンスを補強する、デバイスに基づくエビデン スを示している（65）。これらの所見は、既存のレビュー （35）やその他の新たに特定されたレビュ （ー66）から得た エビデンスと整合している。 上端は高レベルの身体活動が、害のリスクが増大すること なく、死亡率のリスク低下の点から継続的に利益をもたら していることを示している。たとえば、曝露のデバイスに 基づく尺度から得た個々のデータのメタアナリシスからの 所見を伴う新たなレビューによるエビデンスは（65）、週に 最長750分の中高強度の身体活動を行うと死亡率のリスク 低下が認められるが、週に300分を超えると死亡率の相対 危険度が横ばいになることを示す。相対的な利益は高レベ ルの身体活動で低下するが、これらの結果は、身体活動が 多いほど健康上の利益との関連が示されることを一貫して 示してきた先行するエビデンスと一致する（35, 80, 81）。 しかしながら、成人の場合、健康上の利益が減少に転じ始 める身体活動の厳密なレベルを割り出すには、エビデンス が不十分である。 また、エビデンスでは、身体活動と心血管疾患死亡率との 間で十分に立証された逆相関も再確認され、現在推奨され ている身体活動量を十分に上回る量反応関係のエビデンス も追加された。 身体活動（全体的なもの、余暇的なもの、職業的なもの） を評価した48件の前向き研究のメタアナリシスからは、現 在推奨されている身体活動量を十分に上回る量反応関係の エビデンスが追加された（66）。推奨レベルである週に 成人（18〜64歳） 35推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 750MET分に比べ、週に5000MET分の身体活動を行った 場合（中強度の活動を1000分）、心血管疾患死亡率のリス クが有意に低下する結果となった（HR＝0.73［95%CI： 0.56～0.95］）（66）。以前のWHOの推奨事項（1）では、有 酸素性の活動を少なくとも10分間まとめて行う（boutとい う）べきと結論づけられていた。しかしながら、デバイス （活動量計）を用いて評価した最新のエビデンスによると、 boutの時間を短くしていって最小限の閾値をなくしても、 健康アウトカムの改善（総死亡率を含む）と関連している こと示している（65, 82）。たとえば、加速度計で身体活動 を評価した研究のレビューから得た新たなエビデンスから 再確認されたこととして、身体活動と総死亡率のすべての 指標において同様の関連性が示され、ハザード比はboutを 考えないトータルの身体活動で0.27、５分間以上のまと まった活動（bout）で0.28、10分間以上のまとまった活 動で0.35であり、最も高い四分位群と最も低い四分位群で 比較された（83）。これらの結果は、Ekelund et al. 2019 （65）による新たなレビューの所見により再確認され、長さ を問わずまとまった活動（bout）時間の身体活動は健康ア ウトカムの改善（総死亡率を含む）と関連しているという エビデンスが得られた（82）。新たなエビデンスに基づき、 最低10分間のまとまった活動（bout）に関する推奨事項を 削除した。 高レベルの身体活動と部位別のがんの発生のリスク低下と の関連性を示すエビデンスは全体的に整合していると考え られたが、複数の研究間で曝露の評価と分類に大きなばら つきがあるため、報告されたリスク低下に対応した身体活 動の具体的なレベルを判定するにはエビデンスが不十分で ある。しかしながら、身体活動の有益効果が明らかではな いレベルを下回る下限閾値があることを示唆するエビデン スはなく、よって身体活動をいずれかのレベルで行うと部 位別のがんのリスクを低下させるという点で利益があるこ とを示唆している。 量反応の性質を評価し、より一貫性のある尺度を使用し報 告する今後の研究は、今後のガイドラインを普及させるた めに必要である。 身体活動と、肥満、体重増加、健康的な体重の状態の管理 のさまざまな尺度との間の関連性に関する大規模な総体エ ビデンスがあるが、現在、量反応関係を具体的に詳述し、 効果の閾値を特定するにはエビデンスが不十分である。今 後のガイドラインを普及させるには、さらに研究が必要で ある。 中高強度の身体活動の量が増えることは認知機能の改善 （例：処理速度、記憶、実行機能）（35）、脳の機能および構 造、アルツハイマー病を含む認知障害を呈するリスクの低 下と関連がある（73–76）。急激なまとまった活動（bout） も定期的な身体活動も、成人の睡眠と健康関連の生活の質 のアウトカムを改善するというエビデンスがある（35）。し かしながら、身体活動と、個々の精神および認知機能の健 康アウトカムとの間にある量反応関係を具体的に詳述する にはエビデンスが不十分である。同様に、より多くのエビ デンスは、有酸素性の身体活動や筋力トレーニングの量お よび/または強度と特定の健康アウトカムとの間の量反応関 係を詳しく述べるには、さらに研究が必要である。 そのような情報は、さまざまな集団のサブグループの身体 活動の最小有効量と安全性の最大閾値を立証するために重 要である。 GDGが出した結論： ・ 身体活動が増えるほど、健康アウトカムに対する効果が 大きくなるというエビデンスがあるが、高レベルの身体 活動では相対的な利益は横ばいになる。減少に転じ始め る厳密なレベルを割り出すには、エビデンスが不十分で あった。 ・ 高レベルの身体活動は、害のリスク増大を伴うことなく、 総死亡率、心血管疾患死亡率、がん死亡率、心血管疾患 発生率、高血圧の発生率、２型糖尿病の発生率のリスク 低下と関連しているという確実性が高いエビデンスがあ る。 ・ 身体活動をいずれの時間で行っても健康アウトカムの改 善と関連しているという確実性が中程度のエビデンスを 認めた。有酸素性の活動は少なくとも10分間のまとまっ た活動（bout）で行うべきという以前の定義は削除され なければならない。 ・ 成人では、身体活動を多く行うほど、肥満の望ましい測 定値と体重増加の緩和と関連があるというエビデンスが あり、身体活動が健康的な体重の状態の管理にとって有 害となるというリスクは低い。 ・ 中等度の強度の有酸素性の身体活動を週に150～300分、 またはこれに相当するものを行うと、複数の健康アウト カムのリスクが低下し、リスクの低下は続くものの、週 に300分を超えるとプラトーに達し始めるという確実性 が中程度のエビデンスがある。 成人（18〜64歳） 36 その関連性は身体活動のタイプまたは場面に 応じて変化するか？ エビデンスは、さまざまなタイプの身体活動と、さまざま な場面（すなわち職業、移動、または余暇）で行われる身 体活動が望ましい健康アウトカムを示すことができること を示している。総死亡率と心血管疾患死亡率については、 有酸素性の身体活動のみを行う場合、あるいは筋力を向上 させる運動と併用する場合に利益上の関連性を示すが、両 タイプとも推奨されているレベルで実施することが最適で ある（84）。 最近の確実性が中程度のエビデンスは、有酸素性の身体活 動とは無関係の、筋力を向上させる身体活動が総死亡率の リスク低下と関連していることも示している。Stamatakis et al. が報告した結果（2018）は、総死亡率に対する週２ 日の筋力を向上させる運動の影響を検討した11件のコホー トのプール解析から得られたもので、推奨レベル（1）で有 酸素性の身体活動と筋力を向上させる身体活動をどちらも 行った場合と、推奨事項を満たしていない場合の比較（補 正HR＝0.71［95%CI：0.57～0.87］）と、筋力運動の推 奨レベルを守って行った場合と、守らずに行った場合の比 較（HR＝0.80［95%CI：0.70～0.91］）は、総死亡率の リスクが有意に低下したことと関連があることが明らかに なった（84）。これらのデータは、筋力を向上させる運動と 関連のある健康上の利益が有酸素性の身体活動とは無関係 であることを確認し、また筋力を向上させる運動を週に２ 日行うことを推奨頻度とする裏付けるエビデンスを示す。 Dinu et al.（2019）が報告したその他の所見は、余暇（ま たはレクリエーション）以外の場面で行われる身体活動が 利益をもたらしうることを再確認している裏付けのエビデ ンスを示し、人力による往復移動（すなわち移動のための ウォーキングおよびサイクリング）は具体的に総死亡率の リスクの有意な低下につながることが明らかになった（RR ＝0.92［95%CI：0.85～0.98］）（85）。 活動的な通勤（active commuting）（すなわち移動のため のウォーキングまたはサイクリング）を行う人は、行わな い人に比べ、心血管疾患（冠動脈心疾患、脳卒中、および 心不全）のリスクが低下することを実証するエビデンスを 近 年 の 研 究 が 示 し て い る（RR＝0.91［95%CI 0.83～ 0.99］）（85）。なお、さまざまな場面の身体活動が利益をも たらしうると結論づけるには、これらの健康アウトカムか ら得られるエビデンスは十分にある。しかしながら、身体 活動の異なる場面が各健康アウトカムに与える効果を識別 するにはエビデンスが不十分である。たとえば、身体活動 とがんリスクまたは２型糖尿病発生リスクとの間の関連性 か身体活動のタイプまたは場面に応じて異なるのか否かを 判断するには、エビデンスが不十分である。 メンタルヘルスのアウトカムについては、有酸素性の活動、 ウォーキング、筋力向上活動、ヨガを含むさまざまなタイ プの身体活動が抑うつの症状や不安の発生の軽減に有益な 影響があることをエビデンス（35）が示している（74, 79, 86）。たとえば、レジスタンス運動の介入の有益な影響と メンタルヘルスに関する最近のエビデンスは、対照条件よ りも、抑うつ症状が大きく軽減し（77）、不安症状がわずか に軽減（78）す る と い う 確 実 性 が 中 程 度 の 結 果 を 報 告 した２件のレビューから得られたものである。 新しいレビューから得たエビデンスでは、職業上の高レベ ルの身体活動が多くのがん、冠動脈心疾患、２型糖尿病の リスク低下と関連していることが確認された（40）。しかし ながら、職業上の高レベルの身体活動は、（女性ではなく） 男性では、変形性関節症のリスク増大、質の悪い睡眠、総 死亡率と関連している場合もある。また、職業上の身体活 動と、肥満、体重増加の予防、メンタルヘルス、および健 康関連の生活の質との関係を判断するにはエビデンスが不 十分である（40）。身体活動とがんリスクとの間の関連性が 身体活動のタイプまたは場面に応じて異なるのか否かを判 断するにも、エビデンスが不十分である。身体活動のさま ざまな場面による関連性に関するエビデンスは少ないため、 さまざまな健康アウトカムに対する身体活動のさまざまな 場面の効果を識別することは困難であった。 GDGが出した結論： ・ 週に２日以上に行う筋力向上活動は健康上の利益をさら に加えるが、健康上の利益が最大になる特定の期間を明 記するには、エビデンスが不十分である。 ・ さまざまな場面（すなわち余暇、移動、職業）で行われ る身体活動が健康上の利益を提供することができる確実 性が中程度のエビデンスはあるが、現在、さまざまな健 康アウトカムに対し身体活動のさまざまな場面が与える 影響を識別することはできない。 ・ 職業上の高レベルの身体活動は、男性で（女性ではなく）、 変形性関節症のリスク増大、質の悪い睡眠、総死亡率と 関連している場合あるが、全体として、職業上の身体活 動が健康上の利益をもたらしうるという確実性が中程度 のエビデンスがある。 成人（18〜64歳） 37推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 成人 （18〜64歳） 座位行動の推奨事項 成人の場合、座位行動とは、職業、教育、家庭、地域社会の現場や移動時などの 状況において、覚醒しているときに、座ったまままたは横たわったままエネルギー 消費が少ない状態で時間を過ごしていることと定義されている。 裏付けのエビデンスと理論的根拠 本ガイドラインでは、PAGAC（35）がエビデンスをまとめたものを使用して更新した。GDGは、PAGACが報告し た所見と、組み入れ基準を満たした13件の新たなレビューのどちらも含めた総体エビデンス全体を検討対象とし、 成人の座位行動と健康関連アウトカムの関連性に関するエビデンスを提供した。座位行動と健康アウトカムの間の関 連性を調査することは、身体活動不足との関連性に比べ、公衆衛生の中でも比較的新しい分野であるが、過去10年 に急速に発展してきた。研究では通常、座位行動を測定するが、その時に使用するのは、ⅰ）座位行動で過ごしたお よその「トータルの時間」、すなわちテレビ番組の視聴、コンピュータ／スクリーンの使用、着座中などの具体的な 座位行動で過ごした時間を尋ねる自己申告式の質問票か、またはⅱ）デバイスによる評価である。座位行動のために 標準化された尺度または分析の手順はないため、結果の報告にばらつきがある。 最近の方法論の発展により、座位で過ごした時間をデバイスで評価する方法が使用されているが、これにより測定誤 差や、自己申告制の思い出し法に内在するその他のバイアスを抑制することができる。 総体エビデンス全体を考慮する際に、GDGが重視したのは、中等度以上に格付けされたレビューにより提供された エビデンスか、あるいはトータルの座位または着座時間の測定値を使用した研究から得たエビデンスを提供するレ ビューから得たものか、あるいは入手可能なデバイスをベースとした座位行動の測定値から得たエビデンスであった。 方法、データ抽出、およびエビデンスプロファイルについては、Web Annex：Evidence profiless （ウェブ付 録：エビデンスプロファイル）に細部まですべて記した。 座位行動と関連した潜在的な健康への悪影響の研究は、この10年間のうちに急速に蓄積されてきた。最新の研究で 目覚ましい展開をみせているのは、座位行動と複数の健康アウトカムとの間の量反応関係に関して、また座位行動と 身体活動との間の相互作用に関して報告するエビデンスの増加である。 成人の場合、座位行動の多さは、総死亡率、心血管疾患死亡率、がん死亡率、心血管疾患、がん、 および２型糖尿病の発生率などの健康アウトカムが不良であることと関連している。 推奨事項： ＞成人は座位のまま過ごす時間が短くなるように制限をかけること。座位で過ごす時間をいずれ かの強度の身体活動の時間に替えると健康上の利益がある。 強い推奨、エビデンスの確実性は中 ＞長時間の座位行動が健康に与える有害な影響を抑えるため、成人は、中高強度という推奨レベ ルを上回る身体活動を行うよう心がけること。 強い推奨、エビデンスの確実性は中 Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 38 成人（18〜64歳） 成人（18歳以上）の場合、座位行動と健康 関連アウトカムとの間にはどのような関連性 があるか？ 総じて、座位行動で長時間過ごすこと（ほとんどは着座時 間またはテレビ番組の視聴時間の自己申告式またはデバイ スに基づく評価を介して検討）と、総死亡率、心血管死亡 率、心血管疾患発生率、２型糖尿病発生率が高いこととの 関連性に関するエビデンスがある（8, 35, 65, 87）。 たとえば、エビデンスを裏付けるものには、加速度計で評 価した総座位時間と総死亡率（65）についての最近の大規模 なメタアナリシス（ｎ＝36383；平均年齢62.6歳；女性 72.8％）から得た結果があるが、座位行動で過ごした時間 の増加は総死亡率と有意に関連していることが示された。 100万人を超える参加者で構成されたメタアナリシスから 同様の所見が得られており（87）、そこではトータルの座位 行動と、身体活動で調整後の総死亡率および心血管疾患死 亡率（87）との関連性が示されたが、この研究ではがん死亡 率との関連性は身体活動で調整後に統計的に有意ではな かった（87）。 これとは別の最近のメタアナリシス（8）では、座位行動（着 座として評価）と心血管疾患およびがん死亡率との間の有 意の関連性が報告されており、身体活動の最も低い四分位 群（約５分／日）、「不活動」の着座時間として測定した場 合に座位行動のレベルが高いほど心血管疾患死亡率のリス クが９～32%（トレンド検定：ｐ＜0.001）と高いという 結果が示された。この研究では、１日８時間以上の座位（着 座）をとる成人は心血管疾患死亡率リスクが高くなること が報告された。ただし、関連性が緩和される「最も活動的」 な人を除く（すなわち＞35.5MET−時間／週または約60 ～75分／日）。座位行動とがん死亡率との間の関連性に関 する結果は概して弱いものであったが、着座時間が長い場 合に（特に＞８時間／日）６～21％と高い量関連リスクが 観察されたものの、これは身体活動の最も低い四分位群（＜ 2.5MET−時間／週）の人においてのみ認められた（8）。 エビデンスは座位行動（総着座時間として測定）と心血管 疾患の発生の増加との間の関連性を裏付けているが（HR＝ 1.29［95％ CI：1.27～1.30］）、これは身体活動のレベル を含め、潜在的な共変量で調整後に緩和された（HR＝1.14 ［95％ CI：1.04～1.23］）（88）。東南アジアの集団を対象 とした研究のレビューでは、座位時間が長いほど、望まし くない心血管代謝の指標（２型糖尿病、BMI高値、血圧高 値など）が示される尤度が高くなるという確実性の低いエ ビデンスが示された（89）。 最近の２件のレビューが、１日の総着座時間（88）、トータ ルの座位行動、トータルのテレビ番組の視聴（87）と２型糖 尿病の発生率との関連性について報告している。どちらの 研究も、高レベルの座位行動が２型糖尿病の発生率のリス ク増大と関連していることを明らかにした。たとえば、身 体活動で調整すると、トータルの座位行動（RR＝1.01 ［95％ CI：1.00～1.01］ｐ＝＜0.001）とテレビ番組の視 聴（RR＝1.09［95％ CI：1.07～1.12］ｐ=＜0.001）に おいて２型糖尿病との線形の関連性が認められた（87）。 座位行動（テレビ視聴に費やされる時間として測定した場 合）とがん死亡率との間の有意の関連性を裏付けるエビデ ンスもある（35, 87）。最近のいくつかのレビューで確実性 が低いおよび非常に低いものが、座位行動と大腸がんとの 関連性を裏付けるエビデンスを示しているが（90）、前立腺 がん、乳がん、または直腸がんの発生との関連はみられな かった（90-93）。追加のエビデンス（35）からは、座位行動 で長時間過ごすことと子宮内膜腺がん、大腸がん、肺がん の発生のリスク増大との有意の関連性が報告された（35）。 座位行動で過ごすことと、肥満およびその他の体重の状態 の指標や、座位行動と体重状態との関係が中高強度の身体 活動の量に応じて変化するか否かという点との間には、望 ましくない関係性を示す確実性が低いエビデンスがある。 総じて、これらの推奨事項／ガイドラインを普及させるに はエビデンスが不十分であり、さらなる研究が必要である と結論づけられた。 座位時間を減らすことの有害作用を評価したエビデンスは 少ない。専門家の意見では、座位時間の減少を推奨するこ とで、特に低強度の身体活動に置き換えた場合には、傷害 のリスクを増大させる可能性は低いとの結論であった。 39推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r GDGが出した結論： ・ 総じて、座位行動を制限して健康リスクを抑えるための WHOの新たな推奨事項の策定を裏付けるにはエビデンス が不十分である。 ・ 座位行動で長時間過ごすことと総死亡率、心血管疾患死 亡率、がん死亡率、心血管疾患、および２型糖尿病の発 生率が高いこととの関連性は、確実性が中程度のエビデ ンスがある。 ・ 座位行動で長時間過ごすことと子宮内膜腺がん、大腸が ん、肺がんの発生のリスクが高いこととの関連性は、確 実性が低～中程度のエビデンスがある。 ・ 座位行動と肥満の尺度との間にある関連性に関するエビ デンスは不十分であり、さらなる研究が必要である。 ・ 座位行動を制限することの利益は潜在的なリスクを上回 ると結論された。 量反応関係（量、頻度、期間中断の強度）は あるか？ 総じて、座位時間（自己申告式またはデバイスに基づく評 価による着座時間またはテレビ番組の視聴時間）と総死亡 率、心血管疾患死亡率、がん死亡率、および心血管疾患の 発生との間の非線形量反応関係を確実性が中程度のエビデ ンスが示している（8, 35, 87）。 加速度計で評価した総座位時間と総死亡率の量反応関係に 関し確実性が高いエビデンスを示す最近のメタアナリシス は（65）、座位行動で過ごす時間の増加は総死亡率と有意に 関連していたと報告している。座位時間の四分位群の増加 に関するハザード比は、1.00（参照対象 最短の座位）、 1.28（1.09～1.51）、1.71（1.36～2.15）、 中 高 強 度 の 身体活動で過ごす時間を含む潜在的交絡因子で調整後は 2.63（1.94～3.56）であった（65）。座位時間と死亡率の 量反応関係のこの分析は、約7.5～９時間へと段階的に増え た場合のリスクを示し、9.5時間を超えるとより顕著であっ た。各日10時間および12時間の座位行動と死亡の高リスク との関連性はそれぞれ1.48（1.22～1.79）と2.92（2.24 ～3.83）であった（65）。 量反応を評価した最近の別のメタアナリシスは、総座位時 間と総死亡率との間の非線形関連性を報告した（≦８時間 ／日間の曝露の場合の１時間／日当たりのRR＝1.01（1.00 ～1.01）、＞８時間／日間の曝露の場合は1.04（1.03～ 1.05））、また、心血管疾患死亡率との間では（≦６時間・ 日間の場合のRR＝1.01（0.99～1.02）、身体活動で調整 後は＞６時間／日間のRR＝1.04（1.03～1.04））であっ た（87）。これと同一の研究において、小規模の線形の量反 応関係が２型糖尿病との間に認められ、身体活動で調整後 のトータルの座位行動（1.01（1.00～1.01））と、テレビ 番組の視聴（1.09（1.07-1.12））について報告されていた （87）。 総じて、座位行動が多いことは望ましくない健康アウトカ ムと関連していることをエビデンスが裏付けており、座位 時間を最小限にとどめて健康リスクを抑えることを裏付け るエビデンスは十分にあると結論づけられた。しかしなが ら、座位行動の評価の方法（自己申告による座位時間、テ レビ番組の視聴時間、またはデバイス（加速度計）に基づ く評価による）がレビューによって大幅に変わることや、 座位時間の閾値が健康アウトカム全体において、中高強度 の身体活動のレベルによって、また集団のサブグループの 間で変動する可能性を考慮すると、時間に基づく（定量化 された）推奨事項を設定するには、エビデンスが不十分で ある。 座位行動の全体量のほかに、座位行動が生じるパターンに 関するエビデンスをレビューした。しかしながら、座位行 動の頻度および／または中断の期間に関して推奨事項を作 成するにはエビデンスが少なかった。 GDGが出した結論： ・ 座位行動に関する定量化された（時間に基づく）推奨事 項を設定するにはエビデンスが不十分である。 ・ 座位行動の頻度および／または中断の期間に関して推奨 事項を作成するにはエビデンスが不十分である。 成人（18〜64歳） 40 成人（18〜64歳） その関連性は座位行動のタイプおよび場面に 応じて変化するか？ 座位行動のある場面またはさまざまなタイプは、直接関連 する点からも、また健康的な身体活動で過ごす時間に置き 換える可能性の点からも、ほかに比べて有害な場合がある。 座位行動の研究は急速に発展しているが、さまざまなタイ プの座位行動とさまざまな健康アウトカムとの関連性を直 接比較したエビデンスで利用できるものは限られている。 たとえば、総着座時間よりも、テレビ番組の視聴として測 定される座位行動による結果の方が強力であると報告する 研究もある（87）。これは自己申告法や器具に関連した測定 誤差または残余交絡に起因している可能性がある。現在で は、さまざまな健康アウトカムとのさまざまな関連性や、 それらが亜集団によってどのように変化するのかを判定す るにはエビデンスが不十分である。 ますます多くの研究で、健康アウトカムに関して身体活動 と座位時間のデバイスに基づく尺度が使用されている。し かしながら、多くのこれらのデバイスの配置（例：手首、 腰まわり）は体位（例：横臥位、座位、立位で安静）ごと の違いを識別して決めたものではないため、誤分類が座位 時間のデバイスに基づく尺度から発生する可能性がある。 整合性のある報告方法と体位を識別する方法を使用したさ らなる研究は、座位行動のパターンに関する知識を深める ために役立つ。 GDGが出した結論： ・ 座位行動のさまざまなタイプまたは場面に関して推奨事 項を作成するにはエビデンスが不十分である。 身体活動のレベルは、死亡率に対する座位行 動の影響を修正するか？ 座位行動の健康アウトカムへの影響に対する関心が高まっ ており、身体活動のさまざまなレベルと座位行動のレベル との間の潜在的な相互作用の調査が進むきっかけとなって いる。利用できる研究に基づき、座位行動と、総死亡率、 心血管疾患死亡率、がん死亡率との関係が中高強度の身体 活動の量によって変化するという確実性が中程度のエビデ ンスがある（8, 9, 35）。全体的な所見として、座位行動の 影響は中高強度の身体活動量が少ない人において強く、逆 に言えば、中高強度の身体活動量が多い人ほど、高レベル の座位行動と関連のある望ましくない健康アウトカムを緩 和できる可能性がある。 低レベルの身体活動は、高レベルの身体活動よりも、座位 時間と総死亡率と関連したリスクが顕著に現れることが明 らかになった（35）。整合性のあるメタアナリシスにおいて、 Ekelund et al.は100万人を超える男女を対象に、座位行 動と身体活動を併せて層別化した影響について総死亡率を 用いて調査したところ、関連性は身体活動のレベルに応じ て異なることが明らかになった（9）。分析では、座位行動 （着座）の四分位群と中高強度の身体活動の四分位群が使用 され、参照群（中高強度身体活動［１日当たりの座位が＜ ４時間および中高強度の身体活動の最も高い四分位群［＞ 35.5MET−時間／週）と比較したところ、座位が１日当た り８時間を超えるも身体活動が週に35.5MET−時間を超え る人の追跡調査中に死亡リスクの増大はみられなかった （HR＝1.04［95％ CI：0.99～1.10）。対照的に、座位時 間が最短で（＜４時間／日）、身体活動の最低の四分位群 （＜2.5MET−時間／週）を示した人は、追跡調査中に死亡 のリスクが有意に増加した（HR＝1.27［95％ CI：1.22～ 1.31］）。この研究は、１日当たり約60～75分（最も高い 四分位群）の中高強度の身体活動のレベルが座位行動と健 康アウトカムとの間の有害な関連性を緩和する可能性があ り、それを解消することさえ可能であると結論づけた（9）。 41推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 成人（18〜64歳） 引用元：PAGAC 身体活動が多い 座 位 時 間 が 長 い 高リスク 低リスク 座 位 時 間 が 短 い  ＆ 身 体 活 動 が 多 い 身体 活 動 を 増 や す 座 位 時 間 を 減 らす 図２：座位行動と身体活動のレベルの関係 図２で示すように、座位行動のレベルと中高強度の身体活 動との関係は、PAGAC（35）による系統的レビューに概要 がまとめられている。 別の最近の研究では、死因別死亡率と同様の関連性を調査 して新たなエビデンスを提供し、同様の所見を示した（8）。 高レベルの中高強度の身体活動は、大規模な統合タアナリ シス（９件の研究、ｎ＝850 000、CVD死亡率；８件の研 究、ｎ＝777 000、がん死亡率）の結果から、着座で過ご す時間として測定したか、あるいはテレビ視聴で過ごす時 間として測定したかにかかわらず、高レベルの座位行動に 伴う心血管疾患死亡率のリスク増大を緩和した（8）。この研 究では、１日８時間以上着座している人の場合、死亡のリ スクが高いこととの関連性があることが明らかになった（た だし、この関連性を緩和する最も活動的な四分位群を除く）。 さらに具体的に言えば、心血管疾患死亡率のハザードは、 参照群（＜４時間／日）に比べ、１日に８時間以上着座し ていた人では32％高かった（トレンド検定：ｐ＜0.001）。 結果は顕著ではないが、身体活動のその他の四分位群の参 照群と比較すると依然として有意であった（第２四分位群、 HR＝1.11［95％ CI：1.03～1.20］、第３四分位群、HR ＝1.14［95％ CI：1.03～1.26］）。同様の関連性は中高強 度の身体活動の群全体で、テレビ視聴時間と心血管疾患死 亡率において観察された（8）。がん死亡率の関連性は混在し て曖昧であったが、総着座時間として評価した場合には、 概して高レベルの身体活動が座位行動の有害な影響を緩和 することが示された。 このエビデンスを基にすると、高レベルの座位行動をとる 人に向けて、高レベルの中高強度の身体活動を推奨すべき であること、また利益は害を上回ることで意見が一致した。 GDGが出した結論： ・ 座位行動と総死亡率、心血管疾患、がん死亡率との関係 は中高強度の身体活動の量に応じて変化するという確実 性が中程度のエビデンスがある。 ・ 中高強度の身体活動を多く行うと、座位行動と健康アウ トカムとの間の有害な関連性を緩和することができる。 42 高齢者 （65歳以上） 身体活動の推奨事項 高齢者の場合、身体活動は、教育現場、家庭、または地域社会の現場の背景を踏 まえて、レクリエーションおよびレジャー（遊び、ゲーム、スポーツ、または計 画的な運動）、体育、移動（ホイーリング、ウォーキング、サイクリング）、家事 の一環として行うことができる。 ・ 身体活動を一切しないよりは少しでもした方がよい。 ・ 上記の推奨事項を満たしていない高齢者は、ある程度の身体活動を行うことで健康上の利益が得られる。 ・ 高齢者の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時間を増やしていく。 ・ 高齢者は各自の機能的能力が許す範囲で身体的に活発に動き、身体活動の運動レベルが体力のレベルに見 合ったものになるように調整すること。 高齢者の身体活動は、総死亡率、心血管疾患死亡率、高血圧の発症、部位特異固有がんの発症、 ２型糖尿病の発症、メンタルヘルス（不安および抑うつの症状の軽減）の改善、認知的健康、 および睡眠などの健康アウトカムに利益があり、肥満も改善される可能性がある。高齢者の場合、 身体活動は転倒や転倒関連の負傷、また骨の健康の減退や機能的能力の低下の予防に役立つ。 推奨事項： ＞高齢者は定期的な身体活動を行うこと。 強い推奨、エビデンスの確実性は中 ＞高齢者の場合、中強度の有酸素性の身体活動を150～300分以上、または高強度の有酸素性 の身体活動を75～150分以上行うか、または週全体で中強度の活動と高強度の活動の組み合 わせによる同等の量を行うと、実質的な健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 ＞高齢者は、毎週の身体活動の一環として、バランス機能を高めるようにマルチコンポーネント の身体活動と筋力トレーニングを中強度以上のレベルで週に３日以上行って機能的な能力を強 化し、転倒を予防すること。 強い推奨、エビデンスの確実性は中 ＞高齢者の場合、さらに健康上の利益を得るため、中強度の有酸素性の身体活動を300分超に増 やしても、あるいは150分超の高強度の有酸素性の身体活動を行っても、または週全体で中強 度の活動と高強度の活動の組み合わせによる同等の量を行ってもよい。 条件つきの推奨、エビデンスの確実性は中 ＞なお、高齢者は、主要筋肉群すべてが関係する中強度以上の筋力向上活動も週に２日以上行う こと。それにより、さらに健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 優れた実践 43推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 高齢者（65歳以上） 裏付けのエビデンスと理論的根拠 本ガイドラインでは、高齢者用に、PAGAC（35）がエビデンスを包括的に合成したものを使用して更新した。15件 のレビューは組み入れ基準を満たしており、高齢者に特化した健康関連のアウトカム（転倒予防、転倒関連の負傷、 身体機能、虚弱、骨粗鬆症）と身体活動との関連性の考察を発表した。 転倒予防のエビデンスでは、Sherrington et al.（42）による2019年のコクラン共同計画の系統的レビューを使用し て更新したところ、元のレビューを最後に検索した日付以降2019年11月までに発表されたエビデンス（新しい研究 ９件）があった。2008年から2019年11月までに発表されたレビューについて、骨粗鬆症とサルコペニアに関する 既存の系統的レビューに関する検索をPubMedの中で実行したところ、新たなレビューは特定されなかったが、研究 が新たに８件特定された。 方法、データ抽出、およびエビデンスプロファイルについては、Web Annex： Evidence profiles （ウェブ付 録：エビデンスプロファイル）に細部まですべて記した。 高齢者（65歳以上）の場合、身体活動と健 康関連アウトカムとの間にはどのような関連 性があるか？ 高齢者集団の総死亡率および死因別死亡率、心血管疾患、 ２型糖尿病、がん発生率、肥満、メンタルヘルス、認知機 能のアウトカムなど、身体活動と健康アウトカムの間の関 連性を評価する主要なエビデンスのベースは、成人集団用 に照合しレビューした科学文献と同じであった。大多数の 研究は年齢の上限基準の記載がなかったため、65歳を超え た成人を対象に含めたことから、この同一の総体エビデン スを受け入れ、高齢者に外挿した。 エビデンスのレビューをさらに行い、高齢者に特化した健 康関連のアウトカム（転倒予防、転倒関連の負傷、身体機 能、フレイル、骨粗鬆症など）と身体活動との関連性に関 して検討し発表した。 高齢者の身体能力の低下は、深刻な結果に陥る可能性があ る転倒および転倒関連の負傷としてしばしば現れる。不慮 の転倒は、外因性（環境）および内因的な（例：体位制御 に影響を及ぼす筋骨格または神経系異常）因子の組合せに 起因する。身体活動が―特にマルチコンポーネントの身体 活動のプログラム（バランス、体力、持久力、歩行、およ び身体機能訓練の組合せを含む）において―高齢者の転倒 や転倒を原因とする負傷のリスクと関連していることを、 エビデンスが証明している。最近のエビデンスが実証する ところによると、高齢者の運動は転倒率を23％も低下させ る可能性があり（pooled rate ratio（RaR）0.77［95％ CI：0.71～0.83］）、医療または入院を必要とする骨折、頭 部外傷、開放創、軟部組織損傷、またはその他の何らかの 負傷につながる重度の転倒を含め、転倒を原因とする負傷 のリスクを有意に低下させることができる（42）。このエビ デンスは、ほかのレビューと矛盾するところがなく、また 所見が再確認された（35）。 成人期初期にピークに到達した後は、加齢とともに筋肉と 骨量が低下する傾向があり（すなわちサルコペニアと骨減 少症／骨粗鬆症）、これは体力や身体機能の低下と関連して いる可能性がある。エビデンスでは、高齢者の場合、定期 的な身体活動が身体機能を改善し、加齢による身体機能の 喪失のリスクを低下させることが証明されている。 所見では、動的バランス（SMD＝1.10［95％ CI：0.29～ 1.90］）、 筋 力（SMD＝1.13［95 ％ CI：0.30～1.96］）、 柔軟性（SMD＝1.22［95％ CI：0.39～2.04］）、心肺体 力（SMD＝1.48［95％ CI：0.42～2.54］）に対する有益 な影響が示されている（94）。また、高レベルの身体活動が 骨の健康を改善する可能性があることから、高齢者の骨粗 鬆症を予防する可能性があることもエビデンスは示してい る（プールされた標準化効果量0.21［95％ CI：0.06～ 0.36］）（95）。身体活動の介入が腰椎および大腿骨頸部（股 関節）の骨密度を改善する可能性がある。 GDGが出した結論： ・ 一般的な高齢集団の場合、身体活動が身体機能を改善し、 加齢による身体機能の喪失のリスクを低下させるという 確実性が中程度のエビデンスがある。 ・ 高齢者に推奨される量とタイプの身体活動のリスクは低 く、利益が上回ることを示す確実性が低いエビデンスが ある。 Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf44 高齢者（65歳以上） 量反応関係（量、時間、頻度、強度）はある か？ エビデンスは、高齢者が行う身体活動量と身体機能的制限 のリスクとの間に逆相関を示す。通常は、身体活動が多い ほど（頻度、期間および／または量）、利益の増大を伴う （35）。高速レジスタンストレーニングは一般の機能的な能 力の向上のためには、中速レジスタンストレーニングより も優れている可能性があることをエビデンスが示唆してい る（SMD＝0.41［95％ CI：0.18～0.65］、およびSPPB （SMD＝0.52［95％ CI：0.10～0.94］））（96）。 身体活動と転倒の予防との間の量反応関係を調べているエ ビデンスは少ないが、裏付け的なエビデンスを示す大多数 の研究は、週に３日と一致するプログラムのテストである ことを示している。 GDGが出した結論： ・ 有酸素性の身体活動の量と一般的な高齢者集団の身体機 能的制限のリスクとの間に逆の量反応関係があるという 確実性が高いエビデンスがある。 その関連性は身体活動のタイプまたは場面に 応じて変化するか？ バランス、筋力、持久力、歩行、および身体機能訓練の併 用を含めた身体活動プログラムは、高齢者の転倒率と転倒 を原因とする負傷のリスクの低下と関連している。 種々のさまざまな身体活動の介入（一般的にはバランスお よび機能運動にレジスタンス運動を追加）が行われること で、高齢者の転倒率を最高28％低下させることができるこ とを11件のRCTのレビューから得たエビデンスが示した （RaR＝0.72［95％ CI：0.56～0.93］）（42）。レジスタン ス運動の効果は一定しておらず、限られたデータをベース としている（RR＝0.97［95％ CI：0.14～6.49］；１件の 試験；ｎ＝73）（42）。 エビデンスでは、複数のタイプの運動を含むプログラムは、 含めないプログラムに比べて、しなかったよりも大きな正 の効果を骨の健康にもたらすことも示されている（標準化 効果量0.45［95％ CI：0.20～0.71；ｐ＝0.001）（95）。 GDGが出した結論： ・ 高齢者では、バランス、筋力、歩行、および機能訓練を 併用する高レベルの身体活動（例：マルチコンポーネン トの身体活動）が転倒率と転倒を原因とする負傷のリス クの低下と関連しているという確実性が高いエビデンス がある。 ・ 複数の運動タイプを含めたプログラムは骨の健康と骨粗 鬆症予防に有意の影響を与える可能性があるという確実 性が中程度のエビデンスがある。 45推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 高齢者 （65歳以上） 座位行動の推奨事項 高齢者の場合、座位行動とは、職業、教育、家庭、地域社会の現場や移動時など の状況において、覚醒しているときに、座ったまままたは横たわったままエネル ギー消費が少ない状態で時間を過ごしていることと定義されている。 裏付けのエビデンスと理論的根拠 2010 Global recommendations on physical activity for health（健康づくりのための身体活動に関するグロー バルな推奨事項）（1）には座位行動が取り上げられていなかった。集団に特化したエビデンスがないため、高齢者集 団での座位行動と健康アウトカムとの間の関連性を評価するための主な科学的根拠は、大多数の研究が年齢の上限基 準を述べていなかったため、65歳以上を成人に含めていた事情があり、成人集団用に照合やレビューが行われたも のと同じ学術文献とした。一般的な成人集団の座位行動に関するエビデンスから得た所見については、高齢者の場合 にはアウトカムが異なる、あるいは該当しない、もしくは禁忌となるエビデンスの有無を評価することも含め、レ ビューを行った。 方法、データ抽出、およびエビデンスプロファイルについては、Web Annex：Evidence profiless （ウェブ付 録：エビデンスプロファイル）に細部まですべて記した。 高齢者の場合、座位行動の多さは、総死亡率、心血管疾患死亡率、がん死亡率、心血管疾患、 がん、および２型糖尿病の発生率などの健康アウトカムが不良であることと関連している。 推奨事項： ＞高齢者は座位のまま過ごす時間が短くなるように制限をかけること。 　座位で過ごす時間をいずれかの強度の身体活動の時間に替えると健康上の利益がある。 強い推奨、エビデンスの確実性は中 ＞長時間の座位行動が健康に与える有害な影響を抑えるため、高齢者は、中高強度身体活動の 推奨レベル以上の身体活動を行うことを目標とする。 強い推奨、エビデンスの確実性は中 Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 46 妊娠中および産後の女性 身体活動の推奨事項 妊娠中および産後の女性の場合、身体活動は、教育現場、家庭、または地域社会の現場の背景を踏まえて、レクリ エーションおよびレジャー（遊び、ゲーム、スポーツ、または計画的な運動）、体育、移動（ホイーリング、ウォー キング、サイクリング）、家事の一環として行うことができる。 本ガイドラインでは、妊娠および産後の期間中の身体活動と母体および胎児の 健康アウトカムを取り上げる。年齢、文化的背景、または社会経済的地位にか かわりなく、妊娠中および産後のすべての女性を対象とする。妊娠および産後 の期間は、女性の人生の中の段階であり、成人期全体を通して身体を活動する ことの利益については、成人向けの推奨事項に詳述したとおりである。 妊娠中および産後の女性が妊娠中または産後に身体活動を行うに当たっては、出産前後に専門的な立場から本人の病 歴や禁忌事項を踏まえて助言する医療従事者のケアを受けるべきである。本ガイドラインは公衆衛生と集団をベース としている。妊娠または出産に伴う合併症を有する女性に向けた、臨床的なガイダンスを探究するべきである。 妊娠中および産後の女性は、可能な限り、また禁忌事項に該当しない限りは、これらの推奨事項を満たすよう努める べきである。 妊娠中および産後の女性の妊娠中および産後の身体活動は、母体および胎児にとって、子癇前症、 妊娠性高血圧、妊娠糖尿病、妊娠期の過度の体重増加、分娩合併症、産後の抑うつのリスクが 低下し、数は少ないものの新生児合併症のリスクが低下するという利益があり、出生体重に対 する有害作用はなく、死産のリスクが増大することもない。 禁忌事項のない妊娠中および産後のすべての女性への推奨事項： ＞妊娠から産後までの期間を通して、定期的な身体活動を行う。 強い推奨、エビデンスの確実性は中 さらに： ＞妊娠前に高強度の有酸素性の活動を習慣的に行っていた女性または身体的に活発に動いていた 女性は、妊娠中や産後の期間に、これらの活動を続行できる。 強い推奨、エビデンスの確実性は中 ＞中強度の有酸素性の身体活動を150分以上行うと、実質的な健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 ＞さまざまな有酸素性の筋力向上活動を組み込む。ゆるやかなストレッチを加えることも有益で ある。 強い推奨、エビデンスの確実性は中 47推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 優れた実践 ・ 身体活動を一切しないよりは少 しでもした方がよい。 ・ 上記の推奨事項を満たしていな い妊娠中および産後の女性は、 ある程度の身体活動を行うこと で健康上の利益が得られる。 ・ 妊娠中および産後の女性の場合、 身体活動を少し行うことから始 め、徐々に頻度、強度、持続時 間を増やしていく。 ・ 骨盤底筋のトレーニングは、尿 失禁のリスクを低下させるため に毎日行ってよい。 妊娠中の女性が身体活動を行う場合に加えられる安全上の考慮点： ・ 過度に暑い時期、特に湿度が高いときには、身体活動を避ける。 ・ 身体活動の前中後に、飲料水で水分を補給する。 ・ 身体的接触を伴う、転倒のリスクが高い、あるいは酸素不足のおそ れがある（高地に普段居住していない場合の高地での活動など）と いった活動への参加を避ける。 ・ 妊娠中期を過ぎてからは、仰臥位で活動するものを避ける。 ・ 妊娠中の女性が運動競技、または推奨ガイドラインを大幅に上回る運 動を検討する場合は、専門の医療従事者による管理指導を仰ぐこと。 ・ 妊娠中の女性は、中止のタイミングに関して警告となる危険な徴候 について、あるいはそのような徴候が生じた場合に直ちに身体活動 を制限して、適格な医療従事者の診察を受けること。 ・ 産後は徐々に身体活動を再開する。帝王切開による分娩であった場 合には、医療従事者に相談する。 妊娠中および産後の女性 裏付けのエビデンスと理論的根拠 妊娠中および産後の女性に向けて、本「2020年身体活動および座位行動に関するガイドライン」では、重大および 重要なアウトカム（28-34）を取り上げた７つの系統的レビューから得たエビデンスをまとめたものを使用し、更新し た。７件レビューした中で４件が組入れ基準を満たしていた。 方法、データ抽出、およびエビデンスプロファイルについては、Web Annex： Evidence profiles （ウェブ付 録：エビデンスプロファイル）に細部まですべて記した。 妊娠中および産後の女性の場合、身体活動と 健康関連アウトカムとの間にはどのような関 連性があるか？ 妊娠前および妊娠中の身体活動は、一般的にみられる妊娠 合併症のリスクを低下させるうえで役立つ可能性がある。 過体重または肥満の女性も含め、妊娠中に身体活動を行う ことは、妊娠期の体重増加の抑制（MD＝1.14kg［95％ CI：1.67～0.62］）（97）や、妊娠前から活動的である（OR ＝0.70［95％ CI：0.57～0.85］）（31, 34, 97）のと同様、 妊娠糖尿病のリスクの低下（97）（RR＝0.71［95％ CI： 0.57～0.89］）と有意に関連がある（97）。 妊娠中の身体活動は、妊娠性高血圧または子癇前症の発生 率を上昇させるとは思われない（31）。過体重または肥満が みられる妊婦を対象に、身体活動介入群と標準出産前ケア 群で比較すると、妊娠性高血圧の発生率に（RR＝0.63 ［95％ CI：0.38～1.05］）、または子癇前症に（RR＝1.39 ［95％ CI：0.66～2.93］）有意差はみられないことをエビ デンスが示唆している（97）。 発育中の胎児と分娩に関しては、母体の身体活動の潜在的 有害作用に対する長期の懸念があった。しかしながら、身 体活動が自然流産、死産、または分娩合併症の発生率のリ スク増大と関連していないことを最近のエビデンスが証明 している（32）。過体重または肥満がみられる妊婦を対象に、 身体活動介入群と標準出産前ケア群で比較した場合、帝王 切開分娩の発生率の差を示唆するエビデンスはない（97）。 妊娠中の身体活動は、出生体重（98）または早産（32）に対 する有害作用のリスク増大と関連しておらず、むしろ保護 的に、全体のリスクを軽減している場合さえあり（98）、身 体活動介入群と標準出産前ケア群で比較される過体重また は肥満（RR＝1.02［95％ CI：0.54～1.92］）または在胎 不当過大児（RR＝0.90［95％ CI：0.65～1.25］）がみら れる妊娠女性の場合でも同様である（97）。 Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf48 妊娠中および産後の女性 産後の期間に、母親はさまざまな身体的および感情的変化 を経験する。エビデンスからは、妊娠中の身体活動が産後 の抑うつと逆相関している可能性があることが証明されて いる（29）。妊娠中の身体活動に関する６件の介入研究と 11件の観察研究のメタアナリシスから得られたエビデンス （99）は、妊娠中の身体活動と産後の抑うつとの間に有意の 逆 相 関 を 示 し て い た（SMD＝0.58［95 ％ CI：1.09～ 0.08］）。少なくとも中強度の介入を行う５件の研究に限っ ても、その効果は強力であった（SMD＝0.70［95％ CI： 1.19～0.22］）（99）。 GDGが出した結論： ・ 妊娠中の身体活動は、妊娠期の体重増加を抑制し、妊娠 糖尿病のリスクを低下させる可能性があるという確実性 が高いエビデンスがある。 ・ 身体活動は妊娠性高血圧の発生率を上昇させないという 確実性が中～高度のエビデンスがある。 ・ 身体活動は自然流産、死産、または分娩合併症の発生率 を上昇させないという確実性が中程度のエビデンスが、 また高強度の身体活動を行う母親は早産のリスクが低下 するという確実性が中程度のエビデンスがある。 ・ 身体活動は、低体重児、胎内発育遅延、または在胎不当 過大児のリスクを増大させないという確実性が低～中程 度のエビデンスがある。 ・ 妊娠中の身体活動は低度の産後の抑うつと関連している という確実性が低いエビデンスがある。 ・ 妊娠および産後の女性に推奨される量とタイプの身体活 動のリスクは低く、利益が上回る。 量反応関係（量、時間、頻度、強度）はある か？ 妊娠および産後の期間中の身体活動に関するエビデンス全 体において、介入は身体活動の量（すなわち量）に、分単 位の期間でも週当たりの頻度でも、変化を示した。利用可 能なエビデンスは概して、30～60分間の有酸素性の身体活 動を週に３回以上という典型的な頻度を反映していた。こ のエビデンスは、概して一般の成人集団に推奨されている 活動量（すなわち、週当たり150分の中強度の身体活動） とおおまかに整合する量が健康に与えるインパクトを評価 した研究から得られている。 通常、身体活動が多いほど（頻度、期間および／または量）、 大きな利益と関連していることが明らかになるが、量反応 関係をより詳細に把握するには、さらに研究が必要である。 妊娠前に身体活動を余暇に多く行う場合と少なく行う場合 をみると、妊娠糖尿病の有意に低いリスクと関連がみられ る（OR＝0.54［95％ CI：0.34～0.87］）（100）。小規模 ではあるが、母親が高強度の身体活動を行う場合、早産児 が生まれるリスクが有意に低下するというエビデンスもあ る（RR＝0.20［95 ％ CI：0.36～0.03］）（98）。 推 奨 事 項を有意に越えるレベルで運動した場合の安全性または付 加的な利益に関して確認されたエビデンスはなかった。 GDGが出した結論： ・ 妊娠および産後の期間中の身体活動と特定の重大な健康 アウトカムとの間の量反応関係を判定するには、エビデ ンスが不十分である。 ・ エビデンスは全体的に、重大な健康アウトカムに対する 利益を示しており、また一般の成人集団に推奨されてい る身体活動量（すなわち、週当たり150分の中強度の身 体活動）とおおまかに整合する介入に基づいている。 ・ 一般の成人集団に比べ、妊娠中および産後の女性に推奨 される中強度の身体活動の量または頻度を変更する理由 はなかった。 ・ 高強度の身体活動を行う母親の場合、早産のリスクが低 下するという確実性が中程度のエビデンスがある。 49推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r その関連性は身体活動のタイプまたはタイミ ングの場面（妊娠前、出産前、または産後） に応じて変化するか？ エビデンスは、主に余暇場面の身体活動を評価した研究か ら得られ、活動のタイプはほとんどが有酸素性であったが （ウォーキングまたは水泳など）、筋力トレーニング（例： サーキットトレーニング）も含めた介入または有酸素性運 動と筋力を向上させる運動の併用を評価している研究から 得られたエビデンスもある。しかしながら、全体としては、 身体活動と健康アウトカムとの関連性が身体活動のタイプ または場面もしくはタイミング（妊娠前、出産前、または 産後）によって変化するか否かを判定するにはエビデンス が不十分である。 GDGが出した結論： ・ 妊娠中および産後の女性は種々の有酸素性運動および筋 力向上活動を組み込むべきという確実性が中程度のエビ デンスがある。ゆるやかなストレッチも有益である。 妊娠中および産後の女性 50 妊娠中および産後の女性 座位行動の推奨事項 妊娠中および産後の女性の場合、座位行動とは、職業、教育、家庭、地域社会の現 場や移動時などの状況において、覚醒しているときに、座ったまままたは横たわっ たままエネルギー消費が少ない状態で時間を過ごしていることと定義されている。 妊娠中および産後の女性の場合、座位行動の多さは、総死亡率、心血管疾患死亡率、がん死亡率、 心血管疾患、がん、および２型糖尿病の発生率などの健康アウトカムが不良であることと関連 している。 推奨事項： ＞妊娠中および産後の女性は座位のまま過ごす時間が短くなるように制限をかけること。座位で 過ごす時間をいずれかの強度の身体活動の時間に替えると健康上の利益がある。 強い推奨、エビデンスの確実性は低 裏付けのエビデンスと理論的根拠 2010 Global recommendations on physical activity for health（健康づくりのための身体活動に関するグロー バルな推奨事項）（1）には座位行動が取り上げられていなかった。集団に特化したエビデンスがないため、妊娠中お よび産後の女性での座位行動と健康アウトカムとの関連性を評価するための主な科学的根拠は、成人集団用に照合し レビューした科学文献であった。 一般的な成人集団の座位行動に関するエビデンスから得た所見については、妊娠中および産後の女性の場合にはアウト カムが異なる、あるいは該当しない、もしくは禁忌となるエビデンスの有無を評価することも含め、レビューを行った。 利用できるエビデンスや専門家の意見を基に、エビデンス を外挿し、重大な健康アウトカムの共通項について妊娠中 および産後の女性に対するWHOの新たな推奨事項を伝達さ せた。エビデンスの非直接性から、確実性のレベルをダウ ングレードした。 この集団に特化したエビデンスがないこと、また妊娠女性 は研究対象から外されていたことを考慮し、推奨事項の中 でも、座位行動が多いことの有害な影響に対処する目的か ら推奨レベル以上に身体活動のレベルを上げるための事柄 は、妊娠中および産後の女性に外挿しなかった。 GDGが出した結論： ・ 一般の成人集団の座位行動に関するエビデンスは、重大 な健康アウトカムの共通項について妊娠中および産後の 女性に対する推奨事項を普及させるために外挿されうる。 ・ 座位行動を最小限に減らすことの利益は、妊娠中および 産後の女性にとってのリスクを上回る。 ・ エビデンスの確実性は、非直接性のためダウングレード されなければならない。 51推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 慢性疾患を有する成人および高齢者 （18歳以上） 身体活動の推奨事項 子どもおよび青少年の場合、身体活動は、教育現場、家庭、および地域社会の現場の背景を踏まえて、レクリエー ションおよびレジャー（遊び、ゲーム、スポーツ、または計画的な運動）、体育、移動（ホイーリング、ウォーキン グ、サイクリング）、または家事の一環として行うことができる。 すべての成人のがんサバイバーや高血圧患者、２型糖尿病患者、HIV患者は、可能な限り、また禁忌事項に該当しな い限りは、これらの推奨事項を満たすよう努めるべきである。 現在までのところ、慢性疾患を有する人に向けの身体活動ガイドラインのほと んどは、臨床的または治療的なガイダンスに限られている。たとえば、臨床診 療の推奨事項とリソースは腫瘍学（101）、２型糖尿病（102）、高血圧（103）、 およびその他の慢性疾患（104）を専門とする医学会が開発してきた。WHOに も慢性疾患患者にして身体活動を推奨する内容を含んだ臨床診療ガイダンスが ある（17）。 このガイドラインは、慢性疾患を有する人の、具体的にはがんを有する人（以降は「がんサバイバー」と呼ぶ）、高 血圧患者、２型糖尿病患者、およびHIV患者の身体活動に関する初のWHOの集団ベースのガイドラインである。 HIVに対して有効で広く利用できる抗レトロウイルス治療の進歩を考慮すると、この病態は今では慢性疾患とも考え られる。急性期治療（例：化学療法）を受けている患者、または長期の薬物療法を受けていてまだ安定していない患 者については、医療従事者は各慢性疾患に該当する診療ガイドラインも参照しなければならない。 身体活動は、以下の慢性疾患を抱える成人および高齢者に健康上の利益がある。がんサバイバー の場合―身体活動により、総死亡率、がん特異的死亡率、がん再発または二次原発がんのリス クが改善される。高血圧患者の場合―身体活動により、心血管疾患死亡率、疾病の進行、身体 機能、健康関連の生活の質が改善される。２型糖尿病患者の場合―身体活動により、心血管疾 患による死亡率と疾病の進行の指標の値が低下する。 HIV患者の場合―身体活動により、体力が向上し、メンタルヘルスが改善される可能性があり （不安および抑うつの症状の軽減）、疾病の進行（CD4カウントおよびウイルス負荷）または体 組成に悪影響を与えられることはない。 推奨事項： ＞これらの慢性疾患を有するすべての成人および高齢者は、定期的な身体活動を行うこと。 強い推奨、エビデンスの確実性は中 ＞これらの慢性疾患を有する成人および高齢者の場合、中強度の有酸素性の身体活動を150～ 300分以上、または高強度の有酸素性の身体活動を75～150分以上行うか、または週全体で 中強度の活動と高強度の活動の組み合わせによる同等の量を行うと、実質的な健康上の利益が 得られる。 強い推奨、エビデンスの確実性は中 52 慢性疾患を有する成人および高齢者（18歳以上） ＞これらの慢性疾患を有する成人および高齢者は、主要筋肉群すべてが関係する中強度以上の筋 力向上活動も週に２日以上行うこと。それにより、さらに健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 ＞これらの慢性疾患を有する成人および高齢者で、禁忌事項がない場合、さらに健康上の利益を 得るため、中強度の有酸素性の身体活動を300分超に増やしても、あるいは150分超の高強 度の有酸素性の身体活動を行っても、または週全体で中強度の活動と高強度の活動の組み合わ せによる同等の量を行ってもよい。 条件つきの推奨、エビデンスの確実性は中 ＞これらの慢性疾患を有する高齢者は、毎週の身体活動の一環として、バランス機能を高めるよ うにマルチコンポーネントの身体活動と筋力トレーニングを中強度以上のレベルで週に３日以 上行って機能的な能力を強化し、転倒を予防すること。 強い推奨、エビデンスの確実性は中 ・ これらの慢性疾患を有する成人で上記の推奨事項を満たすことができない場合は、各自の能力に応じ て身体活動を行うことを心がけること。 ・ これらの慢性疾患を有する成人の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時間 を増やしていく。 ・ 成人で、これらの慢性疾患を抱えている場合、各自のニーズ、能力、機能上の限界／合併症、薬物療法、 および治療計画全般に適した活動のタイプと量について、身体活動の専門家や医療従事者に助言を求める ことがある。 ・ 運動前の医学的な許可については、禁忌事項がなければ、早歩きや日常生活で必要なレベルを超えない範 囲の低強度または中強度の身体活動を開始する前には概して不要である。 優れた実践 裏付けのエビデンスと理論的根拠 本ガイドラインの適用範囲として、身体活動と以下の健康アウトカムとの関連性を評価した。がんサバイバーの場合 ―総死亡率、がん特異的死亡率、がん再発または二次原発がんのリスク。高血圧患者の場合―心血管疾患死亡率、共 存症のリスク、身体機能、健康関連の生活の質、疾病の進行（ここでは身体活動への血圧の反応と定義）。２型糖尿 病患者の場合―心血管疾患死亡率、共存症のリスク、身体機能、健康関連生活の質、疾病の進行。HIV患者の場合― 身体機能（体力、運動耐性、筋力）、健康関連の生活の質、メンタルヘルス（不安および抑うつの症状）、心血管代謝 の疾患リスクの指標（血中脂質、血糖、体組成）、疾病の進行への有害作用（すなわち、CD4陽性細胞数、ウイルス 負荷量）。 本ガイドラインを普及させるために十分なエビデンスは、PAGAC（35）の報告にあるとおりで、2017年から2019 年までに特定されたがん（ｎ＝１）、高血圧（ｎ＝２）。２型糖尿病（ｎ＝13）の16件の新しいレビューで更新され た。さらに、HIV患者の身体活動と健康関連のアウトカムに関して委託されたアンブレラレビューでは、2002～ 2018年に発表された適格なレビュー19件から得たエビデンスが提示された。方法、データ抽出、およびエビデンス プロファイルについては、Web Annex：Evidence profiless （ウェブ付録：エビデンスプロファイル）に細部 まですべて記した。 Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 53推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 慢性疾患を有する成人および高齢者（18歳以上） がんを有する成人および高齢者（18歳以上） （がんサバイバー）の場合、身体活動と健康 関連アウトカムとの間にはどのような関連性 があるか？ 身体活動は代謝経路、ホルモン経路、および炎症経路で有 益な短期的かつ長期的変化を促すが、これががんの発生率 と生存率に保護的な作用を発揮すると考えられている （35）。がん診断後の高レベルの身体活動は、乳がん（HR ＝0.58［95％ CI：0.52～0.65］、17件）、大腸がん（HR ＝0.63［95％ CI：0.50～0.78］、10件）、女性の生殖器 がん（HR＝0.66［95％ CI：0.49～0.88］、４件）、神経 膠腫（HR＝0.64［95％ CI：0.46～0.91］、１件）、血液 がん（HR＝0.60［95％ CI：0.51～0.69］、２件）、腎臓 がん（HR＝0.60［95％ CI：0.38～0.95］、１件）、肺が ん（HR＝0.76［95％ CI：0.60～0.97］、２件）、前立腺 がん（HR＝0.60［95％ CI：0.46～0.79］、５件）、胃が ん（HR＝0.75［95％ CI：0.61～0.93］、１件）後の総死 亡率から、保護的な作用を発揮しているものとみられた。 がん診断後の身体活動量が多いことは、乳がん、大腸がん、 前立腺がんのサバイバーの死因別死亡率のリスク低下と関 連している。メタアナリシスでは、診断後の総身体活動量 が最高の例と最低の例で比較して、すべてのがんを合わせ た場合（HR＝0.63［95％ CI：0.53～0.75］、４件）と、 乳がん（HR＝0.63［95％ CI：0.50～0.78］、13件）、大 腸がん（HR＝0.62［95％ CI：0.44～0.86］、６件）、前 立腺がん（HR＝0.70［95％ CI：0.55～0.90］、４件）の 死亡率をみたところ、ハザードの低下が認められた（105）。 ただし、身体活動ががん再発または二次原発がんと関連し ているか否かを判断するには、エビデンスが不十分であっ た。 身体活動は高血圧の主な予防策としても管理方法としても 重要であり、身体活動が高血圧患者の身体機能、心血管疾 患の進行（すなわち身体活動に対する血圧の反応）、および 心血管疾患死亡率を改善することをエビデンスが示してい る（35）。たとえば、身体活動を行わない対照群と比較する と、身体活動を行っている高血圧患者は収縮期血圧を約 12mm Hg下降させ、拡張期血圧を約６mm Hg下降させる （SBP MD＝12.26mm Hg［95％ CI：15.17～9.34］、ｐ= ＜0.05；DBP MD＝6.12mm Hg［95％ CI：7.76～4.48］、 ｐ=＜0.05）（106）。身体活動を行う高血圧患者は、不活動 の高血圧患者に比べて、健康関連の生活の質を有意に改善 できることを新生のエビデンスが証明している（54）。 有酸素性の身体活動、筋力向上活動、および有酸素性身体 の活動プラス筋力向上活動などの身体活動は、２型糖尿病 の成人患者の進行リスクの二次指標（HbA1c、血圧、 BMI、脂質）の改善と関連がある（35）。たとえば、最近の 研究では、レジスタンストレーニングは対照群に比べて HbA1cが大幅に低下したことと関連があること、また高強 度のレジスタンストレーニングが空腹時インスリンに有意 の正の効果を持つことが明らかになった（107）。２型糖尿 病の成人患者の健康関連の生活の質と身体機能に対する身 体活動の効果を評価するには、エビデンスが不十分である。 HIV患者における身体活動は心肺体力を改善する。研究対 象の介入は、有酸素性の運動か、または段階的な筋力を向 上させる運動と併用する運動のいずれかを週３回30分以上 行うというものであった（108, 109）。身体活動介入が心血 管代謝リスクのマーカー（脂質など）を改善するというエ ビデンスもある（結果は様々である）し、血糖は有酸素ト レーニング後に低下するが、インスリン濃度への効果はな いことが確立されているものの、グルコースは有酸素性の トレーニング後に低下した（110）。HIV患者の場合、身体 活動は、有酸素性であるのか、筋力を向上させる運動との 併用であるのかにかかわらず、健康関連の生活の質に正の 相関があり（111）、抑うつおよび不安の症状の軽減と明ら かに関連している（112）。抑うつのメタアナリシス（９件 の 試 験 ） は、0.84のSMDが 示 さ れ（95 ％ CI：1.57～ 0.11）、介入群を支持するものであった（ｐ＝0.02）。不安 の軽減に関するSMD（５件）も統計的に有意で、介入群を 支持するものであった（1.23［95％ CI：2.42～0.04］、 ｐ＝0.04）（112）。身体活動は、運動を行う群の参加者で は、非運動対照群の参加者に比べ、1.75kgの除脂肪体重で 有意の標準化された平均増加や、1.12％の体脂肪率の有意 な減少、また末梢の脚および腕の筋肉の部位の増加とも関 連しているが、HIV患者のBMIまたは腹囲の変化との関連は みられない（111）。身体活動を行うことで、CD4陽性細胞 数（細胞／mm3）またはウイルス負荷量など、HIVの疾患 進行のマーカーに有害な影響が出ることはない（111）。重 要な点として、このエビデンスは、慢性疾患としてのHIVが 身体活動によって悪影響を受けることはないことを示唆し ている。 GDGが出した結論： ・ がんサバイバーの場合、がん診断後に身体活動を多く行 うことは、総死亡率、原因別死亡率、およびがん特異的 死亡率のリスク低下と関連しているという確実性が中程 度のエビデンスがある。 ・ 高血圧の成人患者の場合、身体活動は心血管疾患の進行 のリスクを低下させるという確実性が高いエビデンスが ある。 ・ 高血圧の成人患者では、身体機能と健康関連の生活の質 54 慢性疾患を有する成人および高齢者（18歳以上） のアウトカムを身体活動が改善するという確実性が中程 度のエビデンスがある。 ・ ２型糖尿病の成人患者の場合、身体活動が疾病の進行 （HbA1c、血圧、BMI、および脂質）のマーカーを改善 するという確実性が高いエビデンスがある。 ・ HIV患者の身体活動と、体力（最大酸素消費量、運動耐 性）および筋力の改善との間に関連があり、またHIV患者 の身体活動と、体組成、健康関連の生活の質、抑うつお よび不安の軽減、ウイルス負荷量またはCD4陽性細胞数 の無変化との間に望ましい関連性があるという確実性が 中程度のエビデンスがある。 ・ がんサバイバーと、高血圧患者、２型糖尿病患者、およ びHIV患者の場合、特定の健康アウトカムに関しては、定 期的に身体活動を行うことに付随する利益がリスクを上 回る。 量反応関係（量、時間、頻度、強度）はある か？ がん診断後に身体活動を多く行うことは、総死亡率および がん特異的死亡率のリスク低下と関連している。エビデン スは、診断後の身体活動のレベルを週に最長10～15MET 時間まで（150分／週の中高強度の身体活動に一致）上昇 させることと乳がん特異的死亡率および総死亡率との間に 非線形関係があることを証明しているが、より高いレベル での害についてはエビデンスがない（105）。ほかのがんの 部位について同様の量反応関係を示唆するものはあるが、 正式なメタアナリシスを認めるには研究数が少なすぎる。 関連の強さを判定するにはさらに研究が必要である。 高血圧患者については、身体活動と心血管疾患死亡率との 間に明確な量反応関係がある（35）。所見では、それは高血 圧の範囲内での収縮期血圧上昇として記されており、心血 管疾患死亡率が上昇するリスクではあるが、この程度のリ スクの上昇は高レベルの身体活動で緩和される（35）。一般 集団に対する推奨事項と同様に、従来の介入の大部分は、 週に約30～60分の中強度の有酸素性の活動、週３日および ／または週に２～３回のレジスタンストレーニングを基本 としている。 ２型糖尿病の成人患者には、身体活動のボリュームと、心 血管死亡率のリスクとの間に逆の曲線関係を示す実質的な エビデンスがある（113–115）。身体活動の量が多いことは （中強度の活動を150分／週という推奨レベルを下回る場 合、丁度の場合、上回る場合）、リスクを徐々に低下させる。 たとえば、何らかの活動を行う場合は、活動を一切行わな い場合に比べ、心血管疾患死亡率のリスクが32％低下する が（補正HR＝0.68［95％ CI：0.51～0.92］）、身体活動 ガイドライン以上の基準を満たした量の活動を行うことは、 心血管疾患死亡率のリスクが40％低下したことと関連が あった（補正HR＝0.60［95％ CI：0.44～0.82］）（115）。 ほとんどの介入は、約150～300分の中強度の有酸素性の 活動、または75分の高強度の活動、および／または週に２ ～３回のレジスタンストレーニングをベースとしている。 ２型糖尿病の成人患者の一部のアウトカム（例：HbA1cお よび血圧）の場合、有酸素性の活動が多いと（すなわち 150分／週を超える場合対150分／週未満の場合）より強 い効果が得られるというエビデンスがあるが、強度に関す るエビデンスは少ない（35）。 HIV患者の場合、身体活動と体組成との間に、または心血 管代謝の疾患の中間マーカー（例：血液脂質プロファイル、 インスリン抵抗性、空腹時血糖濃度。または血圧）のため に、量反応関係を立証するにはエビデンスが不十分である。 エビデンスを提供している大多数の研究は、身体活動介入 を実施し、少なくとも12～48週間は週に３回、中高強度の 有酸素運動単独か、または漸増的レジスタンストレーニン グと併用して30分以上行っていた。また、メンタルヘルス と健康関連の生活の質のアウトカムについて、より精度の 高い量反応関係を立証するにはエビデンスが不十分である。 利用できるエビデンスは通常、週３回以上の身体活動介入 を評価している研究から得られる。 総じて、慢性疾患患者の特定の集団と健康アウトカムの特 定のセットには、中強度の身体活動（またはこれに相当す るもの）を150～300分間とする身体活動の推奨事項を裏 付けるための、確実性が中～高度のエビデンスがあった。 高血圧患者、２型糖尿病患者、がんサバイバーを取り上げ たエビデンスでは、活動のレベルが高いことは、利益が大 きいことと関連しているという明確なエビデンスがあった。 特定の慢性疾患と、検討された特定のアウトカムに応じて、 エビデンスの確実性と直接性の変動が認められた。エビデ ンスが筋力トレーニング運動からプラスのアウトカムを示 した場合、活動の頻度は週当たり２～３回のレジスタンス トレーニングであった。 GDGが出した結論： ・ がんサバイバーの場合、身体活動と、総死亡率およびが ん特異的死との間に量反応関係を示す確実性が中程度の エビデンスがある。 ・ 高血圧患者の場合、身体活動と心血管疾患死亡率との間 に量反応関係を示す確実性が高いエビデンスがある。 ・ ２型糖尿病の成人患者の場合、活動のボリュームと、心 55推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 血管死亡率のリスクとの間に逆の曲線関係を示すエビデ ンスがある。 ・ HIV患者の場合、身体活動と、心血管代謝の疾患の中間 マーカー、体組成、健康関連の生活の質、不安および抑 うつ症状との間に量反応関係を示すにはエビデンスが不 十分である。 ・ 望ましい健康アウトカムが得られたのは、150～300分 の範囲での中強度の有酸素性の活動（またはこれに相当 するもの）の介入であり、筋力トレーニングから得られ るプラスのアウトカムに注目すると、週２～３回のレジ スタンストレーニングとなる。 その関連性は身体活動のタイプまたは場面に 応じて変化するか？ 身体活動のさまざまなタイプおよび場面により、望ましい 健康アウトカムが得られるというエビデンスがある。有酸 素性の身体活動や筋力を向上させる身体活動の推奨のレベ ルを満たしているがんサバイバーは、どちらの推奨事項も 満たさないがんサバイバーに比べ、がん死亡率のリスクが 有 意 に 低 い（ 補 正HR＝0.70［95 ％ CI：0.50～0.98］） （84）。筋力を向上させる身体活動の推奨事項のみを遵守し た場合、遵守しなかった場合に比べ、がん死亡率のアウト カムの改善にも有益であることをエビデンスが証明してい る（HR＝0.66［95％ CI：0.48～0.92］）（84）。メタアナ リシスでは、身体活動の場面からこれらの関連性も報告さ れ、レクリエーションの身体活動の場合に、すべてのがん の死亡率、乳がん特異的死亡率、大腸がん特異的死亡率を 一貫して最も低下させることが明らかになった（105）。高 血圧の成人患者については、心血管の疾病の進行を改善す るため、有酸素性の活動と筋力向上活動の２つを併用する ことをエビデンスは支持している。身体活動の従来の方法 （すなわち有酸素性の活動およびレジスタンス系の活動）で の血圧を降下させる作用は、高血圧患者次第で有意に異な るとは思われない（35）。ただし、このエビデンスは、活動 のタイプごとでの直接の比較をベースとしていない。また、 高血圧患者の運動の別の形態（例：太極拳、ヨガ、気功） の有益な影響を裏付ける新たなエビデンスもあるが、関連 性の強度を探索するには、さらに研究が必要である。 有酸素性の活動、筋力向上活動、および有酸素性またはそ れらの併用は、２型糖尿病の成人患者の進行リスクの二次 指標（HbA1c、血圧、BMI、脂質）の改善と関連がある （35, 107）。24件 のRCT（ｎ＝962） に 関 す る あ る レ ビューは、レジスタンストレーニングは、対照群に比べ、 HbA1cの大幅な減少と関連があったことを報告した（MD ＝0.45［95％ CI：0.65～0.25］、20件；n＝824）。対照 群と比較して、高強度のレジスタンストレーニングが空腹 時インスリンに与える影響をみたところ、統計的に有意な 効果がみられた（MD＝4.60［95％ CI：7.53～1.67］、５ 件；ｎ＝174）（107）。７件のRCT（ｎ ＝189）の別のレ ビューでは、インターバルトレーニング（２～５回／週； 間隔１～４分の期間；１回の長さ20～60分）は、MICTに 比べ、HbA1cを統計学的に有意に0.26％（95％ CI：0.46 ～0.07％、５件のRCT）低下させ、一切運動をしない対照 群 に 比 べ0.83 ％（95 ％ CI：1.39 ％ ～0.27 ％（ ４ 件 の RCT）低下させたと報告した（116）。一般集団に対する推 奨事項と同様に、これらの介入の大部分は、推奨されてい る中強度の有酸素性の活動150～300分（または高強度の 活動を75分）と週に２～３回の筋力向上活動と整合する辺 りの有酸素性の活動をベースとしている。一部のアウトカ ム（例：HbA1cおよび血圧）については、有酸素性の活動 （すなわち150分／週を超える場合対150分／週未満の場 合）による強力な効果を示すエビデンスがあるが、強度に 関するエビデンスは少ない。最新の研究は、伝統的な中国 の運動（例：太極拳）は血糖に利益がある可能性があると のエビデンスを出しているが、確実性は中程度で変動しや すいものであった（すなわちバイアスまたは不一致のリス ク）。これらの関連性を判定するにはさらに研究が必要であ る。 有酸素性の活動やレジスタンストレーニングなど、複数の タイプの身体活動は、HIV患者の健康関連の生活の質に正 の効果を持つことが示された（111）。有酸素性運動と、漸 増的レジスタンス運動と、両者の併用に対する反応として の健康関連の生活の質の変化を調べている最近の研究では、 全身の健康とメンタルヘルスの有意な改善が示された。有 酸素性の活動もさまざまな要素で構成された多様な活動も、 HIV患者の抑うつと不安の症状の軽減と関連があるというエ ビデンスもある（112）。メンタルヘルスの症状に対する身 体活動の影響を示すエビデンスには、有酸素性の活動、ま たは漸進性の筋力向上活動と併用する有酸素性の活動、ま たはヨガと併用する場合などがある。エビデンスは、有酸 素性の運動のみの場合、またはレジスタンス運動と併用し た場合に、ウイルス負荷量またはCD4陽性細胞数における 何らかの有意な変化につながることはないことを実証して いる（111）。 既存および最新の文献から得た直接的なエビデンスは、２ 型糖尿病患者と高血圧患者が有酸素性の活動および筋力を 向上させる身体活動を行う場合の推奨事項に含まれる内容 を裏付けている。公表されたエビデンスには欠落があるも のの、HIVの成人患者やがんサバイバー向けの有酸素性の活 動および筋力を向上させる身体活動の利益には生物学的整 合性がある。さらに、GDGが示したとおり、定着している 慢性疾患を有する成人および高齢者（18歳以上） 56 国際的な診療ガイドラインでは、これらの集団に向けた有 酸素性の活動や筋力を向上させる身体活動を推奨している （例：エビデンスの系統的レビュ （ー3）に基づくACSM “Moving Through Cancer” guidelines（101））。このエ ビデンスの基盤となるものは依然として新たに出てくると いう認識から、確実性のレベルはダウングレードされた。 GDGが出した結論： ・ がん死亡率の低下や、高血圧患者の血圧の改善に関する 有酸素性の活動または筋力向上活動の併用効果または付 加的な効果は、確実性が中程度のエビデンスがある。 ・ 有酸素性の活動、筋力向上活動、および有酸素性の活動 プラス筋力向上活動が２型糖尿病の成人患者の疾病の進 行のマーカー（HbA1c、血圧、BMI、および脂質）を改 善するという確実性が高いエビデンスがある。 ・ 定期的な有酸素性の運動のみ、またはレジスタンス運動 と併用した場合に、ウイルス負荷量またはCD4陽性細胞 数における何らかの有意な変化につながることはないと いう、確実性が中程度のエビデンスがある。 ・ HIV患者の健康関連の生活の質に対する筋力トレーニング のみの影響については、エビデンスが不十分である。 慢性疾患を有する成人および高齢者（18歳以上） 57推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 慢性疾患を有する成人および高齢者 （18歳以上） 座位行動の推奨事項 2010 Global recommendations on physical activity for health（健康づ くりのための身体活動に関するグローバルな推奨事項）（1）には座位行動が取り上げ られていなかった。がんサバイバーおよび高血圧患者、２型糖尿病患者、HIV患者の座位 行動に関する今回の新たな推奨事項の適用範囲。 座位行動とは、職業、教育、家庭、地域社会の現場や移動時などの状況において、覚醒しているときに、座ったまま または横たわったままエネルギー消費が少ない状態で時間を過ごしていることと定義されている。 がんサバイバー、高血圧患者、２型糖尿病患者、およびHIV患者などに該当する成人の場合、 座位行動の多さは、総死亡率、心血管疾患死亡率、がん死亡率、心血管疾患、がん、および２ 型糖尿病の発生率などの健康アウトカムが不良であることと関連している。 がんサバイバー、高血圧患者、２型糖尿病患者、およびHIV患者などに該当する成人への推奨事項： ＞慢性疾患を有する成人および高齢者は座位のまま過ごす時間が短くなるように制限をかけるこ と。座位で過ごす時間をいずれかの強度の身体活動の時間に替えると健康上の利益がある。 強い推奨、エビデンスの確実性は低 ＞長時間の座位行動が健康に与える有害な影響を抑えるため、慢性疾患を有する成人および高齢 者は、中高強度という推奨レベルを上回る身体活動を行うよう心がけること。 強い推奨、エビデンスの確実性は低 裏付けのエビデンスと理論的根拠 集団に特化したエビデンスがないため、高血圧、２型糖尿病、HIVを有する成人および高齢者の座位行動と健康アウ トカムとの関連性を評価するための主なエビデンスのベースは、成人集団用に照合しレビューした科学文献であった。 一般的な成人集団の座位行動に関するエビデンスから得た所見については、慢性疾患を有する成人および高齢者の場 合にはアウトカムが異なる、あるいは該当しない、もしくは禁忌となるエビデンスの有無を評価することも含め、レ ビューを行った。 58 慢性疾患を有する成人および高齢者（18歳以上） 利用できるエビデンスや専門家の意見を基に、エビデンス を外挿し、重大な健康アウトカムの共通項について慢性疾 患を有する成人および高齢者に対するWHOの新たな推奨事 項に反映させた。大多数の研究は年齢の上限基準の記載が なかったため、65歳を超えている慢性疾患を有する成人 （例：がんサバイバー、高血圧患者、または２型糖尿病患者） を対象に含めたことの評価から、エビデンスの外挿はしっ かりと裏付けられている。HIV患者について、座位行動の健 康インパクトに関するエビデンスが該当しない理由に関し ては、答えが見つからなかった。これらの推奨事項を策定 するためのエビデンスの非直接性から、確実性のレベルは、 ダウングレードされた。 重大な健康アウトカムの共通項について慢性疾患を有する 成人に推奨事項を普及させるため、高度の座位行動の潜在 的リスクに反対に作用するように中～高強度の身体活動を 多く行う利益に関するエビデンスの適用性も検討のうえ外 挿した。非直接性を考慮し、エビデンスの確実性をダウン グレードした。 GDGが出した結論： ・ 一般の成人集団の座位行動に関するエビデンスは、重大 な健康アウトカムの共通項について、がんサバイバーや 高血圧患者、２型糖尿病患者、HIV患者である成人および 高齢者に向けて推奨事項を普及させるために外挿され、 エビデンスの確実性は非直接性のためダウングレードさ れた。 ・ 高度の座位行動の潜在的リスクに反対に作用するように 中～高強度の身体活動を多く行うことの利益に関するエ ビデンスは、重大な健康アウトカムの共通項について、 がんサバイバーや高血圧患者、２型糖尿病患者、HIV患者 である成人および高齢者に向けて推奨事項を普及させる ために外挿され、エビデンスの確実性は非直接性のため ダウングレードされた。 ・ 座位行動を最小限に減らすことの利益は、がんサバイバー および高血圧患者、２型糖尿病患者、HIV患者にとっての 害を上回る。 59推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 障害を有する子ども・青少年（５〜17歳） および成人（18歳以上） 身体活動の推奨事項 障害を有する子ども、青少年、成人は、身体活動から重要な健康上の利益を得 ることができる。障害を有する子ども、青少年、成人は、これらの推奨事項を極力 守るよう努めるべきである。 障害を有する子ども、青少年、成人の場合、身体活動は、家庭、教育現場、職業および地域社会の現場の背景を踏ま えて、レクリエーションおよびレジャー（遊び、ゲーム、スポーツ、または計画的な運動）、体育、移動（ホイーリ ング、ウォーキング、サイクリング）、または家事の一環として行うことができる。すべての障害を有する子ども、 青少年、成人に対し、楽しめる内容で、変化に富み、年齢や能力に適した身体活動に参加する機会を設け奨励するこ とが重要である。 上記のセクションで述べた、子どもおよび青少年の身体活動の健康上の利益の多くは、障害を 有する子どもや青少年に関しても当てはまる。 障害を有する子どもおよび青少年がさらに得られる健康アウトカムへの利益としては、注意力 欠陥多動性障害（ADHD）などの認知機能を損なう疾患または障害がある場合には、認知力の 改善がある。また、知的障害がある子どもの場合には、身体的な機能が向上する可能性がある。 推奨事項： ＞障害を有する子どもおよび青少年の場合、中高強度の、多くは有酸素性の身体活動を週全体で １日平均60分以上行うこと。 強い推奨、エビデンスの確実性は中 ＞高強度の有酸素性の活動とともに、筋肉および骨を強化する活動を週に３日以上組み込むこと。 強い推奨、エビデンスの確実性は中 優れた実践 ・ 身体活動を一切しないよりは少しでもした方がよい。 ・ 障害を有する子どもおよび青少年でこの推奨事項を満たしていない場合、ある程度の身体活動を行うこと で健康上の利益が得られる。 ・ 障害を有する子どもおよび青少年の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時 間を増やしていく。 ・ 障害を有する子どもおよび青少年が身体活動を行うことについては、本人の現時点の活動レベル、健康状態、 および身体機能に適した内容であれば、重大なリスクはなく、得られる健康上の利益がリスクを上回る。 ・ 障害を有する子どもおよび青少年は、各自に適した活動のタイプや量を決めるうえで、医療従事者または その他の身体活動および障害の専門家に相談する必要が生じる場合もある。 60 障害を有する子ども・青少年（５〜17歳） および成人（18歳以上） 上記のセクションで述べた、成人の身体活動の健康上の利益の多くは、障害を有する成人に関し ても当てはまる。そのほかに、障害を有する成人の場合には以下の健康アウトカムへの利益があ る。多発性硬化症を有する成人の場合―身体機能の向上と、健康関連の生活の質の身体的、精 神的、社会的場面の向上。脊髄損傷患者の場合―歩行機能、筋力、上肢の機能の改善、および 健康関連の生活の質の向上。認知機能を損なう疾患または障害を有する患者の場合―身体機能 と認知機能の改善（パーキンソン病患者およびと脳卒中の既往歴のある者）、認識機能に対する 有益な影響、生活の質が改善される可能性（統合失調症を有する成人の場合）、身体機能が改善 される可能性（知的障害者のある成人の場合）、生活の質の向上（大うつ病を有する成人の場合）。 推奨事項： ＞障害を有する成人は定期的な身体活動を行うこと。 強い推奨、エビデンスの確実性は中 ＞障害を有する成人の場合、中強度の有酸素性の身体活動を150～300分以上、または高強度 の有酸素性の身体活動を75～150分以上行うか、または週全体で中強度の活動と高強度の活 動の組み合わせによる同等の量を行うと、実質的な健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 優れた実践 ・ 身体活動を一切しないよりは少しでもした方がよい。 ・ 障害を有する子どもおよび青少年でこの推奨事項を満たしていない場合、ある程度の身体活動を行うこと で健康上の利益が得られる。 ・ 障害を有する子どもおよび青少年の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時 間を増やしていく。 ・ 障害を有する子どもおよび青少年が身体活動を行うことについては、本人の現時点の活動レベル、健康状態、 および身体機能に適した内容であれば、重大なリスクはなく、得られる健康上の利益がリスクを上回る。 ・ 障害を有する子どもおよび青少年は、各自に適した活動のタイプや量を決めるうえで、医療従事者または その他の身体活動および障害の専門家に相談する必要が生じる場合もある。 ＞障害を有する成人は、主要筋肉群すべてが関係する中強度以上の筋力向上活動を週に２日以上 行うこと。それにより、さらに健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 ＞これらの障害を有する高齢者は、毎週の身体活動の一環として、バランス機能を高めるように マルチコンポーネントの身体活動と筋力トレーニングを中強度以上のレベルで週に３日以上 行って機能的な能力を強化し、転倒を予防すること。 強い推奨、エビデンスの確実性は中 ＞障害を有する成人の場合、中強度の有酸素性の身体活動を300分超に増やしても、あるいは 150分超の高強度の有酸素性の身体活動を行うか、または週全体で中強度の活動と高強度の活 動の組み合わせによる同等の量を行ってもよい。 条件つきの推奨、エビデンスの確実性は中 61推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 障害を有する子ども・青少年（５〜17歳） および成人（18歳以上） Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 裏付けのエビデンスと理論的根拠 本ガイドラインでは、障害を有する子ども、青少年、および成人用に、PAGAC（35）がエビデンスを包括的に合成 したものを使用して更新した。身体活動と健康アウトカムに関する方法、データ抽出、およびこの既存のエビデンス を要約したエビデンス表の詳しい完全版については入手可能になっており（35）、最新版の検索の調査結果に加えて、 GDGのレビュー済みのものを見ることができる。 本ガイドラインの最新版の作成に当たっては、2017年から2019年までに発表された39件のレビューを特定した。 これらのうち、27件は組み入れ基準を満たしており、障害を有する子ども、青少年、および成人における身体活動と 健康関連アウトカムとの関連性の検討内容を伝えるものとなっている。 方法、データ抽出、およびエビデンスプロファイルについては、Web Annex： Evidence profiles （ウェブ付 録：エビデンスプロファイル）に細部まですべて記した。 エビデンスのレビューの際は、多発性硬化症、脊髄損傷、 知的障害者、パーキンソン病、脳卒中、大うつ病、統合失 調症、注意欠陥多動性障害（ADHD）から生じている障害 を有する子ども、青少年、および成人の身体活動と健康関 連アウトカムとの関連性を考慮した。４つの健康関連のア ウトカムで、共存症に付随するリスク、身体機能、認知機 能、および健康関連の生活の質を検討したが、すべてのア ウトカムを病態ごとに探索したわけではない。身体活動の 背景にある障害に対する環境因子の影響は、本ガイドライ ンの範疇から外れるため、除外した。 障害を有する子どもおよび青少年（５～17 歳）および成人の場合（18歳以上）、身体活 動と健康関連アウトカムとの間にはどのよう な関連性があるか？ 多発性硬化症患者の場合、身体活動により、身体機能、機 能的運動能、歩行速度・持久力、心肺体力、筋力、および バランスが改善する。たとえば、３～12週にわたる高強度 のインターバルトレーニングにより、心肺体力または筋力 が向上した（117）。また、下肢の筋力トレーニングにより、 平均13.2週間のトレーニング期間で筋力が23.1％（95％ CI：11.8～34.4）まで増強し、平均13週を超えると筋力 の増大が得られることが明らかになった（118）。なお、ダ ンス介入研究では機能的運動能とバランスの改善が報告さ れた（119）。身体的な健康上の利益と同様に、既存のエビ デンスは、身体活動が多発性硬化症患者の認知機能に有益 となる可能性があることを証明している（35）。比較的新し い研究では、の運動は健康関連の生活の質の身体的、精神 的、および社会的場面（疲労の症状と抑うつ症状を含む） に、小さいながらも有意の影響を与えることが明らかになっ た（35, 120）。 脊髄損傷患者の場合、身体活動はウォーキング機能、筋力、 および上肢機能を改善する可能性がある（35）。身体活動は、 肩痛を緩和するほか、血管機能を改善し、健康関連の生活 の質を向上する可能性がある（35）。 パーキンソン病患者の場合、身体活動は運動症状、機能的 運動能、動作、持久力、すくみ足、前後方向の動きの速度 を改善する可能性がある（35, 121, 122）。新たなエビデン スは、運動がパーキンソン病患者の全般的な認知機能を助 けることもできることを示唆している（123）。 脳卒中の既往歴を有する人の場合、身体活動により、身体 機能、特に上肢機能、下肢の感覚運動機能、バランス、歩 行速度、距離、能力、持久力、心肺体力、運動能、日常生 活動作が改善される可能性がある。既存のエビデンスは、 身体活動が認知に有益な影響を持つ可能性もあることを示 唆している（35）。 大うつ病を有する人の場合、新たなレビュ （ー124, 125） は、身体活動は健康関連の生活の質を改善することができ るという既存のエビデンス（35）を裏付けている（35, 124, 125）。 統合失調症を含め、認知機能を弱める疾患または障害を有 する人の場合、身体活動は、認知力、作業記憶、社会的認 知および注意／覚醒に有益な影響を持つ場合がある（35, 126）。あるレビューでは、中高強度の身体活動により、健 康関連の生活の質や障害の有意な改善が実現することが明 らかになった（35, 124）。 知的障害を有する人の場合、身体活動は身体機能を改善す ることが示された。主にレビュー対象となった介入は、６ ～24週間にわたるバランスと筋力の活動であり、静的バラ 62 障害を有する子ども・青少年（５〜17歳） および成人（18歳以上） ンス、動的バランス、および静的動的バランスの有意な改 善が報告された（35, 127, 128）。 注意欠陥多動障害を有する子どもの場合、エビデンス （ADHD（129）に関わる５件のRCTのうち１件のレビュー を含む）が運動と注意力と、実行機能と社会的障害との間 に正の相関を示している（35, 129）。 GDGは子ども、青少年、および成人の一般集団から得たエ ビデンスを考慮し、機能障害に起因する効果の修飾がある と確信できる理由はなく、同一の健康の生理学的な利益は 身体が活動することにより得られると結論づけた。GDGは、 障害を有する人を対象とした研究がほとんどないこと、ま た効果の修飾があまり検証されていないことを認めた。 障害分野のエビデンスは一般集団の幅広いエビデンスと併 せ、障害を有する人も含めた全般的な集団への推奨事項を 裏づけており、「すべての成人」、「すべての高齢者」、「障害 の有無を問わずすべての人」という言い方をしている点に 注目すべきである。 GDGが出した結論： 脊髄損傷を有する人の場合： ・ 身体活動は麻痺した四肢の血管機能を改善し、健康関連 の生活の質を向上させるという確実性が低いエビデンス ・ 身体活動は歩行機能、筋力、上肢機能を改善するという 確実性が中程度のエビデンス。 パーキンソン病を含む認知機能が損なわれる疾患または障 害を有する人の場合： ・ 身体活動は歩行、バランス、筋力、疾患特異的な運動能 のスコアを含む多くの機能性のアウトカムを改善すると いう確実性が高いエビデンス。 ・ 中高強度の身体活動は認知機能に有益な影響を発揮する 可能性があるという確実性が中程度のエビデンス。 脳卒中の既往歴を有する人の場合： ・ 運動能指向型の身体活動は身体機能と認知機能に有益な 影響を与える可能性があるという確実性が中程度のエビ デンス。 統合失調症を含む認知機能が損なわれる疾患または障害を 有する人の場合： ・ 身体活動が生活の質を改善するという確実性が中程度の エビデンス。 ・ 中高強度の身体活動は認知機能、作業記憶、社会的認知、 および注意力に有益な影響を与える可能性があるという 確実性が高いエビデンス。 大うつ病を有する成人の場合： ・ 身体活動が生活の質を改善するという確実性が中程度の エビデンス。 多発性硬化症を有する成人の場合： ・ 身体活動、特に有酸素性の筋力向上活動は身体機能、機 能的運動能、歩行速度、持久力、心肺体力、筋力、バラ ンスを向上させるという確実性が高いエビデンス。 ・ 身体活動は認知機能に有益な影響を発揮する可能性があ るという確実性が中程度のエビデンス。 ・ 身体活動が疲労の症状および抑うつ症状を含む生活の質 を改善するという確実性が低いエビデンス。 知的障害者を有する子どもおよび成人の場合： ・ 身体活動が身体機能を改善するという確実性が低いエビ デンス。 ADHD者を有する子どもおよび青少年の場合： ・ 中高強度の身体活動は注意力、実行機能、社会的障害を 含む認知機能に有益な影響を与える可能性があるという 確実性が中程度のエビデンス。 さらに、GDGは、機能障害の幅広いエリアで種々の健康ア ウトカムに身体活動が与える好影響に関しては十分な科学 的エビデンスがあること、また身体活動の利益が潜在的な 害を上回ることを結論とした。 これらの推奨事項の策定のためのエビデンスの非直接性か ら、確実性のレベルをダウングレードした。 63推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 障害を有する子ども・青少年（５〜17歳） および成人（18歳以上） 座位行動の推奨事項 障害を有する子ども、青少年、および成人の場合、Sedentary behavior 座位 行動とは、教育、家庭、地域社会の現場や移動時などの状況において、覚醒してい るときに、座ったまままたは横たわったままエネルギー消費が少ない状態で時間を過ごし ていることと定義されている。じっとしていることSedentary behaviorを避け、座位または横臥位のまま身体が活 動的であるようにすることは可能である。たとえば、上体主導の活動、インクルーシブおよび／または車椅子に特化 したスポーツや活動などである。 裏付けのエビデンスと理論的根拠 Global recommendations on physical activity for health（健康づくりのための身体活動に関するグローバルな 推奨事項）（2010）には座位行動が取り上げられていなかった。 集団に特化したエビデンスがないため、障害を有する子ども、青少年、および成人の座位行動と健康アウトカムとの 関連性を評価するための主なエビデンスのベースは、障害を有していない集団用に照合しレビューした科学文献で あった。 一般集団の座位行動に関するエビデンスから得た所見については、障害を有する子ども、青少年、および成人の場合 にはアウトカムが異なる、あるいは該当しない、もしくは禁忌となるエビデンスの有無を評価することも含め、レ ビューを行った。 子どもおよび青少年の場合、座位行動の多さは、肥満の亢進、心血管代謝の健康度の低下、体力、 行動／向社会的行動、睡眠期間の減少などの不良な健康アウトカムと関連している。 推奨事項： ＞障害を有する子どもおよび青少年は、座位のまま過ごす時間、特に余暇時間でスクリーンタイ ムが短くなるように制限をかけること。 強い推奨、エビデンスの確実性は低 成人の場合、座位行動の多さは、総死亡率、心血管疾患死亡率、がん死亡率、心血管疾患、がん、 および２型糖尿病の発生率などの健康アウトカムが不良であることと関連している。 推奨事項： ＞障害を有する成人は座位のまま過ごす時間が短くなるように制限をかけること。座位で過ごす 時間をいずれかの強度の身体活動の時間に替えると健康上の利益がある。 強い推奨、エビデンスの確実性は低 ＞長時間の座位行動が健康に与える有害な影響を抑えるため、障害を有する成人は、中高強度と いう推奨レベルを上回る身体活動を行うよう心がけること。 強い推奨、エビデンスの確実性は低 64 障害を有する子ども・青少年（５〜17歳） および成人（18歳以上） 利用できるエビデンスや専門家の意見を基に、エビデンス を外挿し、重大な健康アウトカムの共通項について障害を 有する人に対する座位行動についてのWHOの新たな推奨事 項を普及させると同時に、車椅子使用者などの特定の集団 群が長期間座位をとることは不可避であるため、座ること が標準となる場合があると認識する。そのような層の場合、 座位行動とは、電動の車椅子に着座して移動するとか、車 椅子を押してもらって移動するなど、エネルギー消費が少 ない状態で時間を過ごしていることと定義される。障害を 有する人の場合、座位行動と健康関連アウトカムとの間に はどのような関連性があるか？しかし、専門家の意見に基 づくと、機能障害に起因する効果の修飾があると確信でき る理由はなく、そのため、同一の健康の生理学的な利益は、 障害を有する人の座位行動を制限することによって得られ る。この推奨事項の策定のためのエビデンスの非直接性か ら、確実性のレベルをダウングレードした。 高度の座位行動の潜在的リスクに反対に作用するように中 ～高強度の身体活動を多く行う成人の利益に関するエビデ ンスの適用性も検討のうえ、外挿し、重大な健康アウトカ ムの共通項について、障害を有する成人に普及させた。非 直接性を考慮し、エビデンスの確実性をダウングレードし た。 GDGが出した結論： ・ 子どもおよび青少年の座位行動に関するエビデンスは全 般的に、具体的な能力に従い、障害を有する子どもおよ び青少年に外挿された。 ・ 高レベルの座位行動の潜在的リスクに反対に作用するよ うに中高強度の身体活動を行う成人にとっての利益を含 め、一般成人集団の座位行動に関するエビデンスは、概 して、その具体的な能力に応じて障害を有する成人およ び高齢者に外挿される。しかしながら、エビデンスの確 実性は、非直接性のためダウングレードされた。 ・ 座位行動を最小限に減らすことの利益は、障害を有する 子ども、青少年、成人、高齢者にとってのリスクを上回 る。 65推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r エビデンスから推奨事項へ GRADEのプロセスに従って提案された最新の推奨事項の言 い回しと強度の評価（「強」または「条件つき」）のベース となった考慮点は、利益と害のバランス、エビデンスの確 実性、ガイドラインで対象とされる者の価値観や好みに対 する感度、性別、社会的公平性、および健康の公平性に対 する潜在的なインパクト、および許容可能性、実現可能性、 およびリソースの影響であった。これらを各集団の群別に 検討したが、問題点と考慮点の類似性を踏まえて、ここで はまとめた形で記す。 推奨事項の強度は、主として利益と害のバランスの評価を 基にした。利益と害のバランスがその推奨事項の標的集団 にとって堅固なものとして評価された場合には「強」と格 付けし、利益と害のバランスがその推奨事項の標的集団に おいてささいなものであるか、または重要な変動が生じる 可能性が高い場合には「条件付き」と格付けた。害に関す るエビデンスは、新しい系統的レビューの委託を通して特 別に求めた。しかしながら、これは限定的なものになった。 理由は、ほとんどのエビデンスでは一般集団ではなくエリー ト選手や競技選手にとっての負傷や害が重視されていたた めである。全体的に、限られたエビデンスではあるが、専 門家の意見から情報を得て、リスクはささいな域を越えな いと結論づけた。エビデンスは概して、身体活動の利益が 害をはるかに上回ること、また身体活動が既存の健康格差 の解消を支える重要な介入となりうることを特に不利な立 場にある集団の場合に示した。 健康の公平性、実現可能性、許容可能性の問題もGDGは検 討し、2020年３月31日から2020年４月17日にかけて開 催された推奨事項の草案に関するオンライン公開協議の一 環として扱われた。公開協議のための調査では、推奨事項 を履行するにあたっての個人と行政の費用のバランスに関 する具体的なクエスチョンについて、またガイドラインが 健康の公平性を改善することになるか否かが問われた。な お、身体活動に関する国内のガイドラインの策定に対する 懸案事項を最近表明した国や、同ガイドラインの草案づく りの工程に入った国には、推奨事項の草案とフィードバッ クフォームを送った。フィードバックは、オンラインでの 協議に対する420本を超える投稿から受け取り、WHO欧州 地域事務局からのフィードバックとの照合も併せて行い、 WHO協力機関やWHO加盟国からのコメントも組み込んだ。 この協議から得られたフィードバックをGDGが照合して精 査し、さらにWHO運営委員会とGDGの協議を通して実現 可能性、リソースの影響、および健康の公平性に関する検 討事項を普及させる際にもこれらのフィードバックを使用 した。 決定は、討議を経てコンセンサスに基づいて下された。 GDGは、各推奨事項と、推奨事項の強度に基づいてコンセ ンサスに達し、評価と投票は不要であった。 エビデンスの確実性の評価 GRADEのフレームワークは、PI/ECOで特定された各アウ トカムに寄与しているプライマリーリサーチの確実性を検 討するためにGDGが使用し、各アウトカムのバイアスのリ スク、不整合、不正確、エビデンスの非直接性、公表バイ アスを考慮に入れているエビデンスの全般的な確実性を評 価した。各PI/ECOのこの情報を詳述したGRADEの表は、 Web Annex：Evidence profiles （ウェブ付録：エビ デンスプロファイル）に掲載した。エビデンスの確実性の 評価は、評価対象のすべてのアウトカムで全般的な評価に 基づいて行われたもので、最も重大なアウトカムとして総 死亡率と心血管死亡率を優先させ、次にその他の臨床上の アウトカム（転倒、抑うつ、認知機能、健康関連の生活の 質など）を、続いて中間のアウトカム（例：心血管代謝の マーカー、その他の代謝性マーカー）と害について取り上 げた。エビデンスが特に精査されていない場合（たとえば 対象となる集団のエビデンスが不足していることを主な理 由として亜集団での座位行動のエビデンスの精査が行われ なかった場合）は、非直接性の観点から、適切であるとみ なされた場合には一般集団のエビデンスが外挿されダウン グレードされた。 Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf66 利益と害 推奨事項の策定には、有害なインパクトまたはリスクの評 価を含めた。エビデンスが限られている場合には、GDGの 専門知識を基に決定を下した。全体として、いずれの集団 でも、身体活動を行い座位行動を制限することの利益は害 を上回ると結論された。 これらのガイドラインは一般集団に関するものであり、競 技に参加するための成績関連の体力の改善に必要なタイプ や量の活動を行うアスリートが経験する利益と害を取り上 げたものではない。 身体活動を一切しないよりは少しでもした方がよい。この 推奨事項を現在満たしていない人の場合、ある程度の身体 活動を行うことで健康上の利益が得られる。そのような人 は、身体活動を少し行うことから始め、徐々に頻度、強度、 持続時間を増やしていく。運動前の医学的な許可は、一般 的には不要である。身体活動を行わなかった人が中強度の 活動を徐々に行うようになった場合の突然の心疾患発症の リスクで既知のものはなく、骨、筋肉、または関節の損傷 のリスクはごくわずかである。中強度の活動を習慣的に行っ ていた人が徐々に高強度へとレベルを上げる際、医療従事 者に相談する必要はない。活動のレベルを上げたときに新 しい症状を呈した場合には、医療従事者に相談すべきであ る。 身体活動の適切なタイプと量の選択は、妊娠中および産後 の女性であるか、慢性の疾患や障害を有する人であるかに よって左右される場合があり、実行可能で禁忌事項がない ものとして選択が行われるべきである。そのような人の場 合、個々のニーズ、能力、機能上の限界／合併症、薬物療 法、および治療計画全般に適した活動のタイプと量につい て、身体活動の専門家や医療従事者に助言を求めることが ある。低強度から中強度の身体活動は通常、リスクが低く、 すべての人に推奨されている。 価値観および好み ガイドラインで対象とされる者の価値観や好み（この場合 は親および介護者、子どもおよび青少年、成人、高齢者、 妊娠中および産後の女性、慢性の疾患や障害を有する人） を検討した。全体的な結論としては、死亡率および心血管 死亡率を含む主要アウトカムに関する好みについての不確 実性はごくわずかであるか、まったくなかった。 推定された潜在的な利益は、いかなる潜在的な害も大きく 上回ったことから、GDGは、推奨事項は好みの影響を受け るものではないとみなした。 リソースの影響 GDGの専門家の意見と、介入や身体活動のレベルを上げる ことによる医療制度の節約についての経済面の分析に関し て報告する小規模の総体エビデンスは、さまざまな設定で の推奨事項のリソースの影響に関する考察を知らせるもの であった。また、オンラインの公開協議から得た結果では、 ガイドラインを履行することは本人にとっての損失を上回 る利益があるという見解には回答者の75%超が同意、また は強く同意したことを示し、行政にとっての損失を上回る 利益があるという見解には回答者の81%が同意、または強 く同意したことを示した。 有効なエビデンスと専門家の意見では、ウォーキングなど の活動は低リスクで実質的な健康上の利益があり、特別な 機器が不要で本人にとっての損失を伴わないと認識されて いる。さらに、その他の形式の身体活動で、たとえばルー ルや指導が必要なスポーツ（structured sports）、サイク リング、運動の教室などの身体活動などは、損失を負う可 能性があり、人によっては、特に低所得者にとってはそれ が障壁となる。身体活動を促し実行できるようにするため の政策や政綱を行政側が履行するには、人的資源、政策開 発、施設やサービスの用意や、また場合によっては設備の 用意などの面で投資も必要となり、中には保健医療の省庁 だけではなく保健医療以外の部門（スポーツ、教育、運輸、 都市計画など）がそれらを負う場合もある。必要とされる リソースは、すべてのコミュニティが身体活動の利用機会 を公平に備えるよう徹底するため、複数の行政レベル（全 国レベル、準全国レベル、および地方レベル）となる。 これらの投資には新しいリソースを伴う場合もあるが、身 体活動の集団のレベルを上げる方向で施設やプログラムの 優先性を反映するよう現在の予算を再割当して対処できる。 予算の再割当の例には、現在の運輸関係の予算からウォー キングやサイクリング用のインフラに当てる例や、スポー ツの予算から「すべての人のためのスポーツ」に当てる例 がある。 学校や職場などの主な現場では、低コストの介入と併せて 物理的環境の修正を行うと、身体活動への参加の支援とな り、また特定集団の一部の人が経験している活動的になる 機会の不公平な格差を軽減することにも役立つ。 全体として、この推奨事項の草案を実現するとリソースの 影響があるが、対策を履行することは、現在のガバナンス 構造内で可能であると評価された。 さらに、身体活動レベルの上昇により、医療制度において 実質的な医療貯蓄が可能であることをエビデンスが裏付け ている。2013年には、身体活動不足のグローバルな年間コ ストについて、直接的な保健医療費のみに起因する推定額 は国際ドルで540億と見積もられ（130）、国家レベルでは 67Evidence to recommendations W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 不活動はヘルスケア予算の１～３％の間で見積もられてい る（131）。 非感染性疾患（noncommunicable disease：NCD）予防 のさまざまな幅広い背景がある中で、推奨される身体活動 が各個人の生活の中に比較的組み込みやすいものであれば、 また身体活動が増した結果として既存のリソースがプライ マリケアやセカンダリケア、職場、または移動にシフトす る場合には、行政機関や民間組織がガイドラインを履行す るうえで負担する追加費用は最小限に抑えられる。 身体活動のプロモーションの損失と利益を分析したところ、 インベストメントケース（投資計画）が実行されている多 くの国では、NCDに関して、15年間にわたりプラスの投資 収益率が示されている（132）。Global action plan for the prevention and control of NCDs 2013–2020 （2013～2020年のNCDの予防と制御のためのグローバル な行動計画）（133）の付録３の最新版に基づくNCDに対処 するための推奨介入のうち、公教育や意識向上キャンペー ン、身体活動のカウンセリングや照会といった介入はそれ ぞれ「最も買得」および「買得」である。全体として、 GDGは、推奨事項の履行の利益は損失を上回ると結論した。 障害を有する人のための身体活動ガイドラインを実現させ るには、身体活動の専門家によるトレーニングを行ったり、 必要に応じて機器を改変したり、利用しやすくするために 必要な設備を用意したりと、投資が必要とされる可能性が ある。この投資により、幅広い層の集団のニーズに応えや すくなる可能性がある。身体活動への参加は、利用機会に 関する複数の障壁や、提供される活動の選択、またその他 の臨み方に起因して、障害のない人とある人の間に有意差 があることをエビデンスが示している。障害を有する人が 完全かつ有効に参加することを確実にするには、ユニバー サルデザインの原則を適用すべきである。これらのリソー スの影響の多くは、技術革新により対処できる。ユニバー サルデザインによるアプローチを採択することで、将来的 にこれらの損失は緩和されるであろう。 公平性、許容可能性、および実現可能性 2010年の推奨事項を更新する際に、慢性疾患や障害を有す る人などの脆弱集団の考慮点を明確に記載する決定が下さ れた。GDGとWHO運営委員会は、そのような層を代表す る人をメンバーに入れた。GDGは、推奨事項の履行が健康 の公平性を減じるのか否かという点や、履行に関連する問 題点を考慮に入れて、各推奨事項をじっくりと検討した。 これは、推奨事項によって公平性の問題が悪化しないこと を保証するためである（たとえば、障害を有する人や、身 体活動を行ううえで社会経済的事情やその他の事情で不利 な立場に置かれている人を含め誰もが利用できる安全な施 設や機会があることを保証し、身体活動への参加方法や機 会の制約となりうる性別やその他の文化的バイアスに対処 する）。ガイドラインを履行することで、すべての人にとっ て活動的になって健康アウトカムを改善する機会が増すこ とにより、健康に対する不公平の緩和が実現するという見 解に対し、オンライン公開協議の回答者の76%が同意、ま たは強く同意した。支援する環境こそが身体活動への参加 を可能にするための重要ポイントである点が注目された。 社会経済的に不利な立場にある女性や女児、また障害のあ る人など、脆弱な層の身体活動に対する障壁に対処するに は、多くの部門に関わる政策の設計や履行に対する包括的 なアプローチが今後必要となる。 障害のある人は障害のない人に比べて健康アウトカムの悪 化を経験しているが、身体活動の利益は害をはるかに上回っ ており、この健康格差を埋める重要な介入となり得る。身 体活動への参加は、利用機会に関する複数の障壁や、提供 される活動の選択、またその他の臨み方に起因して、障害 のない人とある人の間に有意差があることをエビデンスが 示している。機器や設備を調整しなくても、障害のある多 くの人がさまざまな形式の身体活動を行うことができるよ うにすべきである。ただし、障害のある人がほかの人たち と平等な立場で身体活動を行うには、調整済みの機器を用 意し、利用しやすいように施設の設備を整えておく必要が 生じる場合や、身体活動の専門家によるトレーニングが必 要になることがある。 68 リサーチのニーズ 各年齢層で身体活動と、さらには座位行動と、健康アウト カムとを関連付けるデータは大量にあるにもかかわらず、 GDGの議論では重大なエビデンスギャップが明らかになっ た。これは、今後のガイドラインを普及させる際に優先さ れるべきである。集団のサブグループでのエビデンスギャッ プに該当するものは、以下に関する情報の不足であった。 １） 身体活動や座位行動と、研究対象の健康アウトカムの いくつかとの間にある量反応関係に関する、より正確 性の高い詳細 ２） 低強度の身体活動の健康上の利益と、座位時間を低強 度の身体活動で分断することの健康上の利益 ３） さまざまなタイプと場面の身体活動（余暇時間、仕事時 間、移動時間、家事の時間、教育の時間）や座位行動 （仕事時間、スクリーンタイム、テレビ視聴時間）；スク リーン時間；テレビテレビ番組）の健康影響の差異 ４） ライフコース全体で健康アウトカムとあわせて考えた 身体活動と座位時間との関連性 低・中所得国や、経済的に恵まれない、あるいは公共サー ビスが不十分な地域社会からの、また障害や慢性疾患を有 する人のエビデンスは依然として限られたものであること も注目された。 身体活動の健康影響を変える可能性があるさまざまな社会 人口統計学的因子（年齢、性別、人種／民族性、社会経済 的地位）別に効果の修飾（effect modification）を検証す るよう設計された研究や、そのような検証を推進するよう な研究は多くない。そのような情報は、公衆衛生の特殊性 の高い推奨事項を設けるうえでも、また集団の中でも特に 脆弱な場面での健康上の格差を緩和するうえでも重要であ る。 この新しいガイドラインから生じるリサーチギャップに関 する詳細は、すでに発表されている文献の中でも記されて いる（134）。 69Research needs W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 採択、普及、履行、および評価 本ガイドラインは、政策立案者をはじめとし、保健医療、 教育、職場、および地域社会の介入プログラムを考案する 立場にある人に向けて、子ども、青少年、成人、および高 齢者が身体を動かす時間を多くとるための日々の過ごし方 に関する推奨事項や、座位で過ごす時間を制限するための 推奨事項を示すものである。ただし、グローバルなガイド ラインを策定することは本ガイドライン自体の目的ではな い。本ガイドラインの普及と履行なくして、身体の活動性 のレベルの変化が成し遂げられることはない。 採択 WHOは、すべての国が使用するためのグローバルな当該の ガイドライン（21）を策定するための厳密かつ詳細にわたる プロセスを踏んでいる。本「身体活動および座位行動に関 するガイドライン」は、中央政府が採択して国の政策フレー ムワークの一部として利用できる、身体活動と座位行動の 健康インパクトに関する推奨事項を示すものである。グロー バルなガイドラインの策定を行う場合、細部にわたる協議 を経て、各国がリソースを使用して冗長な科学的プロセス を踏まなければならない状況が大幅に削減されるようにす べきである。このグローバルな身体活動および座位行動に 関するガイドラインを精査して採択することで、現地の事 情に合わせて調整されたガイドラインを策定するための迅 速で費用対効果の高い方法を得られる。 地域または国家レベルでWHOガイドラインを採択すると、 各国は身体活動および座位行動に関する一貫性のある推奨 事項を確実に示し、それらを最新かつ最善の有用な科学的 なエビデンスによって補強する。また、複数国で推奨事項 に一貫性があると、全国調査、身体活動と座位行動のグロー バルな推定、クロスカントリーでの比較が容易になる。採 択のプロセス全体において、必ず各地の現状を踏まえて本 ガイドラインを調整して活用することを考慮に入れる必要 がある。現地の言語に翻訳することは、採択とコンテクス ト化（現地事情を踏まえること）の一つである。身体活動 の例は、現地に即したものに変更し、画像の使用に当たっ ては、現地の文化、規範、および価値観を反映するよう調 整したものを使用する必要がある。 当該関係者による一連の地域的なワークショップを行った うえで、グローバルなガイドラインを各国で採択する際に 役立つ段階的なフレームワークを現在開発しているところ である。 このフレームワークでは、当該国のデータ（例：身体活動 に関する有病率の推定値）を読み込むことができる。また、 国内ガイドライン文書を作成する近道となるアプローチを 提供する。これらの補助的なリソース、2021年にWHO ウェブサイトを通して入手できるようになる予定である。 本ガイドラインの採択を検討する場合、以下の10段階のプ ロセスを適用することを推奨する。 １． 身体活動に関する現在の国内ガイドラインの精査と政 府の認可を確保するためのWHOガイドラインの採択を 主唱（advocate）する。 ２． 保健医療部門の中でも、その他のスポーツ、教育、運 輸などの関連部門の中でも、主要なステークホルダー を引き入れるとともに、論題の専門知識を備えた専門 家協会や研究者も採用する。 ３． 推奨事項の適用性、許容可能性、および実現可能性を 査定する。 ４． 言語、例、およびその他の文化的な考慮点など、現地 事情にガイドラインを適合させる。 ５． 政策立案者、実務者、および一般市民を含むターゲッ トユーザーと外部レビューを行う。 ６． 普及や周知のための予算の明確なプランを立てる。 ７． 国内ガイドラインを発表して推進し、パブリシティと 関心が生まれるような開始のイベントを併せると理想 的である。 ８． 関係のある専門家の団体または機関を引き入れ、政策 の整合化や是認をサポートする。 ９． 国内ガイドラインの履行や行動変容を支えるための国 家政策や実践事項を履行する。 10． 本ガイドラインの評価、精査・レビュー、および更新 のスケジュールについて合意を得る。 70 普及 国内の身体活動ガイドラインは、集団ごとの身体活動レベ ルを上げる包括的アプローチを行う上でのガバナンス構造 の中核をなす要素である。国内のガイドラインは、全国お よび準全国の戦略計画を周知させ、適切な方法で当該の層 の人に正しい情報を普及する必要がある。残念ながら、国 内のガイドラインは普及しないことがあまりにも多く、専 門家においても幅広いコミュニティにおいても、推奨事項 に対する意識は依然として非常に低いままである。身体活 動を増やして座位行動を減らすことの重要性についての意 識と知識を変えるには、広範囲な普及に役立つ専用のリソー スを確保することが第一歩として重要である。 身体活動と座位行動に関する国内ガイドラインの普及の主 要な想定対象者を以下に挙げる。 ・ 保健医療部門内外（運輸、都市計画、教育、職場、スポー ツ、公園、レクリエーションなど）の政策立案者。以下 を増やすことが目的。 　ａ． 健康のみならず、幅広く多様な、ただしジェンダー 平等、人権保障義務、および持続可能な発展などの 当該の課題の改善において、身体活動を増やして座 位行動を減らすことが寄与しうることに対する知識 　ｂ． 身体活動および座位行動に関する政策や政綱を関連 あるすべての政策に組み入れること 　ｃ． 拡大され調整された国や現地の対策への投資 ・ 政府以外の部門（非政府組織、学術研究組織、民間セク ター、メディア、研究資金助成機関など）。以下を行うこ とが目標。 　ａ． 全年齢で身体活動を増やして座位行動を減らすこと の重要性に対する意識の向上 　ｂ． 政策の整合化の促進および確保 　ｃ． 政策の履行と現地の対策における共同体制と投資の 強化 ・ 保健医療部門および非保健医療部門（スポーツ、教育、運 輸、都市計画など）の実務者。以下を増やすことが目的。 　ａ． 身体活動と座位行動に関する国内ガイドラインの意 識および知識 　ｂ． 身体活動の増加と座位行動の減少を促すうえでの知 識、スキル、確信 　ｃ． 該当する場合、身体活動推進の日課への組み込み ・ 一般市民と特定の集団のサブグループ。以下を増やすこ とが目的。 　ａ． 身体活動と座位行動に関するガイドラインに対する 意識および知識 　ｂ． 身体活動および座位行動に関するガイドラインの実 現方法に対する知識 　ｃ． 身体活動を増やして座位行動を減らす意向および動 機 周知キャンペーン さまざまな関係者がさまざまな資料から利益を得ることに なるため、複数のオーディエンスにガイドラインを周知す るには、内容やフォーマットのほか、ガイドラインを周知 するための伝達経路を十分考慮する必要がある。ガイドラ インの周知戦略を考案する場合は、形成的研究（formative research）を行うと、主要なオーディエンスを決めやすく なり、また身体活動および座位行動のレベルに影響する価 値観、ニーズ、好みを把握しやすくなる。これには、身体 活動に対する障壁を探ることや、身体活動を政策と実践に 組み込むこと、またさまざまな層で草案のメッセージや資 料をテストすることも含めるものとする。これにより、適 切なフォーマットや周知の経路とともに、使用するキーメッ セージが伝達しやすくなる。包括的な周知戦略には、さま ざまなオーディエンスをターゲットに据えた多様な周知方 法が含まれる。各国とも、利用できるリソース（人材およ び財源）次第で、特定の層を優先させる必要が生じること がある。 一般市民または特定の亜集団を対象とした身体活動に関す る周知キャンペーンは、費用効果的な介入（133）であり、 WHO Global action plan on physical activity 2018- 2030（身体活動に関する世界行動計画2018-2030）（14） で推奨されている。身体活動に関する全国および準全国キャ ンペーンでは通常、キャンペーンの包括的なスローガン （例：「アクティブになろう」あるいは「もっと動こう」）を 決め、デザイン的な要素や特性を考案し、それをさまざま なオーディエンス（例：幼児、青少年、成人または高齢者、 運動不足の人、障害または慢性疾患を有する人）に合わせ たメッセージになるよう手直しをする。特定集団の層に合 わせて手直ししたキャンペーンのメッセージとリソースは、 一般的な資料より効果的になる可能性が高い。周知キャン ペーンについては、従来のメディア（例：テレビ、ラジオ、 広告板、印刷版のリソース）とデジタルメディア（ウェブ サイト、携帯電話、アプリ）の両方のメディアチャンネル が及ぶ範囲と有効性を考慮すべきである。国内ガイドライ ンに関する情報をさまざまなフォーマットで提供すること も有用である。たとえば、比較的新しいものの一般的にな 71採択、普及、履行、および評価 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r りつつある身体活動ガイドラインを周知するためのアプ ローチは、図解を利用したものや、短いアニメーション動 画を使う手法である。 WHOには、そのような周知キャンペーンを展開し履行する ための補助的な資料がある（135）。 学術研究や研究界からは、本ガイドラインの基盤となって いる疫学的エビデンスを詳述した科学的な報告書に関心が 集まる可能性が高い。しかしながら、基盤となる研究の細 部まで具体的に説明したものでは、ほかの一般の読者の関 心を集める可能性は低い。政策立案者には、科学的な内容 をまとめたものが、または短い概要説明書でも好まれる。 医療従事者や非医療従事者など、その他の読者には、ガイ ドラインのパンフレットやファクトシートなどのさまざま なタイプのリソースが、あるいは身体活動の促進を日課に 組み込む方法（たとえば、医療現場では患者の診察時の例、 または都市環境においては建築や輸送のプランを立てる場 合など）が好まれる可能性が高い。専門家の場合も多様で あり、その役職に合わせて調整したリソースが必要になる。 医療専門職の場合は特に、担当する集団の多様な層を反映 したリソースのセットが有利に働く可能性がある。 政策およびプログラムの履行 身体活動と座位行動に関する国内ガイドラインは、それの みで身体活動レベルを集団ごとに高めることにつながる可 能性は低いため、政策やプランニングのフレームワークの 一つとみなすべきである。定期的な身体活動の実施と座位 行動の減少によるさまざまな利益について意識と知識を高 める周知戦略について国を挙げて継続することにより、国 内ガイドラインを主要な読者の間で普及させることは極め て重要である。しかし、持続性のある行動変容を実現する には、これらの対策を人々が実行できるよう奨励するため の支援環境づくりをする政策によって裏付けられている必 要がある。医療制度の観点からも、また身体活動の促進に 関心がある、またはサポートする機会がある複数の部門が 複合された機関の観点からも、政策や政綱は、現地の事情 を考慮して適合させたものにする必要がある。対策は「政 府全体」のアプローチを使用して講じるべきであり、複数 の部門や現場で、広範囲にわたる関係者が携わることによ り、身体活動を行う人々をさらにサポートできるような政 策や複数の対策の「システム」を検討すべきである。持続 的な周知戦略に合わせた「システム」のアプローチを使用 するということは、有効な周知を通して生じた身体活動の 需要増には、身体活動を行う環境や機会を人々に用意する ことで対応するよう徹底するものである。 72 WHO Global action plan on physical activity 2018– 2030（身体活動に関する世界行動計画2018-2030）では、 身体活動不足を2030年までに15%低下させることを目標 に掲げ、政策的措置や介入への推奨事項として20項目がま とめられている（14）。その中で、すべての国に対し、持続 的な国の公教育と意識向上キャンペーンを履行し、一次医 療と二次医療に身体活動のカウンセリングプログラムを組 み込むよう推奨されている。その他推奨事項には、すべて の集団層のためのウォーキング、サイクリング、ホイーリ ングなどの身体活動の適切な環境づくりをすること、また 学校、職場、スポーツクラブ、催事場での身体活動の機会 やプログラムの提供を増やすことなどが盛り込まれた。全 20項の推奨事項の履行は、いずれの国でも短期間で実行で きるわけではないが、長期目標として考察すべきである。 即時に対応することの中から、適切で実行可能なものを特 定するには、WHO加盟国は、現在の政策や実践内容の状況 に応じた分析を行う必要がある。これにより複数の部門が 共同体制を組めるようになり、またギャップや機会ととも に強みのある分野を特定しやすくなり、全国および地域の プランを立てたり更新したりすることの基盤として利用で きる。 これら新しいWHOのガイドラインは、対応範囲を拡大し、 障害または慢性疾患を有する人や妊娠中および分娩後の女 性などの層を追加する際に役立つ。政策は今後、地域社会 のニーズと層や背景事情の多様性を認めた適切な政綱の実 現と実践を支えるものであることが求められる。ACTIVE の専門的パッケージの履行をサポートするための部門に特 化した多くのツールキットが、現在開発中であり（135）、 これは、身体活動を促進する方法に関するガイダンスを各 部門に提供する。 たとえば、学校を通して、一次医療を通して、またはウォー キングやサイクリングの提供を改善して提供する。ACTIVE ツールキットのほか、WHOの地域および国のリソースも、 これらの身体活動と座位行動のガイドラインの履行をサ ポートする。 調査および評価 WHOのGlobal recommendations on physical activity for health（健康づくりのための身体活動に関するグロー バルな推奨事項）では、2010年以降、集団の健康モニタリ ングおよび調査のベンチマークとして利用されてきた。こ の最新のガイドラインの推奨事項に今後加えられる変更は、 身体活動の国ごとのモニタリングに現在使用されている調 査システムや評価手法に何らかの影響を及ぼす。今回の新 たなガイドラインが発表されると、この新しいガイドライ ンに対して将来報告されたことについて調整や推奨事項を 普及させるための現行の手法や報告の手順の精査が必要に なる。たとえば、Global Physical Activity Questionnaire （ グ ロ ー バ ル な 身 体 活 動 の 質 問 票 ） やGlobal Student Health Survey（グローバルな学生健康調査票）などの測 定法を精査し、この新しいガイドラインに合わせて手順も 更新される。2021年にはすべての国に向けたサポートガイ ダンスが提供される予定である。 WHOのNCD Country Capacity Survey（CCS：NCD国 別対応能力調査）は、NCDの政策履行に関して世界の進捗 をモニタリングするために使用される中心的な手段であり、 ２年毎に実施される。CCSには、国内の身体活動ガイドラ インがある場合の、身体活動と座位行動に関するこれらの WHOガイドラインが適用される年齢層ごとの身体活動に関 する集団調査システムに関する具体的なクエスチョンが含 まれている。WHO加盟国は、回答を裏付けるための文書を アップロードするよう依頼される。2019年には、WHO加 盟国194カ国中、78カ国（40%）に身体活動ガイドライン があると報告された（136）。2019年のCCSに対する回答 の詳細なドキュメント分析を実施したところ、国内ガイド ラインをもつ加盟国は78カ国のわずか３分の２の国（52／ 78カ国）で、あることが明らかになった。また、2010年 の WHO の Global recommendations on physical activity for health（健康づくりのための身体活動に関す るグローバルな推奨事項）（1）に完全に併せていた国は、こ れらのうち42カ国のみであった。2021年以降のデータと その後の調査は、これらの最新のガイドラインの取り込み に関する情報を示す。 更新 本ガイドラインの今後の更新は、デバイスに基づく測定法 を使用して身体活動を評価する方法の科学的な進歩や、座 位行動に関する科学の急激な進歩により早期の更新が求め られない限りは、10年後を予定している。 73採択、普及、履行、および評価 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 74 REFERENCES 1. 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Geneva: World Health Organization; 2020. 82 G lo be b as ed o n io at /S hu tt er st oc k, s ilh ou et te s ha pe s or ig in al ly b as ed o n Sh ut te rs to ck s ou rc es 83References W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 84 付録１： ガイドライン開発過程の管理 ガイドライン作成の貢献者 WHO運営グループ 運営グループには、身体活動、青少年期の健康、老化障害、メンタルヘルス、傷害予防、がん、妊娠、およびサーベイランス の分野における本部と地方事務所の両方からの専門家が含まれていた。 ValentinaBaltag Department of Maternal, Newborn, Child and Adolescent Health and Ageing – adolescent health MauriceBucagu Department of Maternal, Newborn, Child and Adolescent Health and Ageing – pregnancy FionaBull Chairperson Department for Health Promotion – physical activity AlexButchart Department of Social Determinants of Health – injury prevention NeerjaChowdhary Department of Noncommunicable Diseases – mental health/dementia ReginaGuthold Department of Maternal, Newborn, Child and Adolescent Health and Ageing – adolescent surveillance Riitta-MaijaHämäläinen Western Pacific Regional Office AndreIlbawi Department of Noncommunicable Diseases – cancer WasiqKhan Eastern Mediterranean Regional Office LindsayLee Department of Noncommunicable Diseases – disability AlanaOfficer Ageing LeanneRiley Department for Noncommunicable Diseases – surveillance GojkaRoglic Department for Noncommunicable Diseases – diabetes JuanaWillumsen Department for Health Promotion – physical activity 運営グループは、ガイドラインの範囲とPI/ECOsを起草しました。彼らは利害宣言を審査し、ガイドラインを起草、検討、 および完成させた。 85Annex 1 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ガイドライン開発グループ（GDG） ガイドライン作成グループは、この分野の関連する専門家、推奨事項のエンドユーザー、および推奨事項の影響を受ける人々 の幅広いグループで構成されていました。ガイドライン開発グループのメンバーは次のとおり： DrSalihSaadAl-Ansari(advocate in health promotion and education to combat NCDs through physical activity and walking); DrStuartBiddle (physical activity and sedentary behaviour, and behaviour change); DrKatjaBorodulin (physical activity in pregnancy and older adults); DrMatthewBuman (sleep, sedentary behaviour, and physical activity in people living with chronic conditions); DrGreetCardon (physical activity in children and adolescents); MsCatherineCarty (physical activity in people living with disability); DrJean-PhilippeChaput (sleep, sedentary behaviour and physical activity in children and adolescents); DrSebastienChastin (physical activity, sedentary behaviour and health, objective measurement of physical activity and sedentary behaviour); DrPaddyDempsey (physical activity and sedentary behaviour in adults and people living with chronic conditions); DrLorettaDiPietro (physical activity in pregnancy and older adults); DrUlfEkelund (sedentary behaviour and physical activity, physical activity in children and adolescents); DrJosephFirth (physical activity and mental health); DrChristineFriedenreich (physical activity in people living with chronic conditions, physical activity and cancer risk); DrLeandroGarcia (physical activity and health in adults); DrMuthoniGichu (policy implementation, national government); DrRussJago (physical activity in children and adolescents); DrPeterKatzmarzyk (physical activity and sedentary behaviour); DrEstelleV.Lambert (physical activity and obesity); DrMichaelLeitzmann (sedentary behaviour and physical activity in people living with chronic conditions); DrKarenMilton (translating recommendations into practice); DrFranciscoB.Ortega (physical activity in children and adolescents, mental health and objective measurement); DrChathurangaRanasinghe (promotion of physical activity and health in the community, workplace and school settings); DrEmmanuelStamatakis (physical activity and sedentary behaviour and multiple health outcomes in adults); DrAnneTiedemann (physical activity in older adults); DrRichardTroiano (policy development); DrHiddevanderPloeg (physical activity and sedentary behaviour in adults); MsVickyWari (policy implementation – national government); DrRogerChou (Pacific Northwest Evidence- based Practice Center and Professor of Medicine, Departments of Medicine, Medical Informatics and Clinical Epidemiology of the Oregon Health and Science University) served as GRADE methodologist. Further details of the GDG are available in Annex 2. 2019年７月２～４日に最初のGDG会議が開催され、GDGはPI/ECOの質問を決定し、既存の系統的レビューを確認し、必要 な改定事項を特定した。グループは、２回目のGDG会議で、適用される推奨事項とエビデンスの強さに関する意思決定の過程 について合意した。２回目の会議は2020年２月11～14日に開催された。更新されたエビデンスがレビューされ、最終的な推 奨事項がコンセンサスに基づき合意された。 86 外部レビューグループ（ERG） GDGと運営グループによって提案された個人のリストから ７人の査読者が選ばれた。彼らは、プログラムの実施を含 む関連する専門知識を提供し、WHOの６つの地域すべてを 代表した。 ERGはガイドライン草案をレビューし、運営グループに対 し、必要に応じて組み込まれた明確性と実施の問題に関す るフィードバックを提供しました。外部の査読者は推奨事 項に変更を加えなかった。外部の査読者が付録２にリスト されている。 利害の宣言 すべてのGDGメンバーと外部の査読者は、GDGの会議に出 席する前に、WHOの利益宣言フォームに記入して提出し、 守秘義務に署名した。運営グループは、提出された履歴書 と利害宣言をレビューおよび評価し、インターネットと出 版物の検索を実行して、妥協的な状況につながる可能性の ある明らかな公の論争または関心を特定した。提案された すべてのGDGメンバーの名前と簡単な経歴は、14日間の公 開協議のためにWHO身体活動のWebページに公開されまし た。コメントはなかった。利益の宣言または相反の管理に 関する追加のガイダンスが必要な場合、運営グループは、 コンプライアンス、リスク管理および倫理に関する担当部 署の同僚と相談した。必要と思われる場合、金銭的または 非金銭的利益相反があることが判明した個人は、利益相反 のあるトピックへの参加から除外される。利益相反の管理 は、過程全体を通じて見直された。GDGメンバーは、必要 に応じて、各会議の前に利害宣言を更新する必要があり、 各GDG会議の開始時に口頭での利害宣言が求められた。 GDGと外部の査読者の宣言された利害は付録３に要約され ている。利益相反は確認されなかった。 査読 ガイドライン草案は、GDGと運営グループによって特定さ れた７人の外部査読者によってレビューされた。外部の査 読者は、明確さ、証拠の提示、および実施の問題について コメントを提供するよう求められた。コメントは必要に応 じて採択された。外部の査読者は、GDGによって決定され た推奨事項を変更することはなかった。外部の査読者は付 録２に記載されています。利害の宣言の要約は付録３に記 載されている。加えて、WHOの地域事務所からも積極的に 意見を求めた。 87Annex 1 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 付録２： ガイドライン開発グループ、外部 の査読者、およびこれらのガイド ラインの開発に関与したスタッフ ガイドライン開発グループ DrSalihAl-Ansari Assistant Professor Family & Community Medicine Founder and CEO Health Promotion Center Riyadh SAUDI ARABIA DrStuartBiddle Professor of Physical Activity & Health Physically Active Lifestyles Research Group Centre for Health Research Institute for Resilient Regions University of Southern Queensland Springfield Central AUSTRALIA DrKatjaBorodulin The Age Institute Helsinki FINLAND DrMatthewBuman College of Health Solutions Arizona State University Phoenix USA DrGreetCardon Department of Movement and Sports Sciences Faculty of Medicine and Health Sciences Ghent University Gent BELGIUM MsCatherineCarty UNESCO Chair Project Manager Institute of Technology Tralee Co Kerry IRELAND DrJean-PhilippeChaput Senior Scientist, Healthy Active Living and Obesity （HALO） Research Group Children’s Hospital of Eastern Ontario （CHEO） Research Institute Department of Pediatrics University of Ottawa Ottawa, Ontario CANADA DrSebastienChastin Professor of Health Behaviour Dynamics School of Health and Life Sciences Department of Psychology, Social Work and Allied Health Sciences Glasgow Caledonian University Glasgow UNITED KINGDOM DrRogerChou（GRADE 方法論学者） Departments of Medicine, and Medical Informatics & Clinical Epidemiology Oregon Health & Science University Portland, Oregon USA DrPaddyDempsey MRC Epidemiology Unit University of Cambridge School of Clinical Medicine Institute of Metabolic Science Cambridge UNITED KINGDOM 88 DrLorettaDiPietro Department of Exercise and Nutrition Sciences Milken Institute School of Public Health The George Washington University Washington, DC USA DrUlfEkelund Department of Sport Medicine Norwegian School of Sport Science Oslo NORWAY DrJosephFirth Presidential Fellow School of Health Sciences University of Manchester Manchester UNITED KINGDOM DrChristineFriedenreich Scientific Director Department of Cancer Epidemiology and Prevention Research Cancer Control Alberta Alberta Health Services Calgary CANADA DrLeandroGarcia Research Associate Centre for Public Health Queen’s University Belfast Belfast UNITED KINGDOM DrMuthoniGichu Head Division of Geriatric Medicine Department of Non-Communicable Diseases Ministry of Health Nairobi KENYA Dr Russell Jago Professor of Paediatric Physical Activity & Public Health Centre for Exercise, Nutrition & Health Sciences School for Policy Studies University of Bristol Bristol UNITED KINGDOM DrPeterT.Katzmarzyk Associate Executive Director for Population and Public Health Sciences Professor and Marie Edana Corcoran Endowed Chair in Pediatric Obesity and Diabetes Pennington Biomedical Research Center Baton Rouge USA DrEstelleV.Lambert Director Research Centre for Health Through Physical Activity, Lifestyle and Sport University of Cape Town Cape Town SOUTH AFRICA DrMichaelLeitzmann Professor of Epidemiology Department of Epidemiology and Preventive Medicine University of Regensburg Regensburg GERMANY DrKarenMilton Associate Professor in Public Health Norwich Medical School University of East Anglia Norwich UNITED KINGDOM DrFranciscoB.Ortega Head Unit of Physical Activity and Health Promotion Research Institute of Sport and Health （iMUDS） Department of Physical Education and Sports University of Granada Granada SPAIN 89Annex 2 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r DrChathurangaRanasinghe Chairperson NIROGI Lanka project Sri Lanka Medical Association Senior lecturer Sports and Exercise Medicine Unit Faculty of Medicine University of Colombo C Colombo SRI LANKA DrEmmanuelStamatakis Charles Perkins Centre Faculty of Medicine and Health School of Public Health University of Sydney Sydney AUSTRALIA DrAnneTiedemann Associate Professor Institute for Musculoskeletal Health School of Public Health Faculty of Medicine and Health University of Sydney Sydney AUSTRALIA DrRichardTroiano Epidemiology and Genomics Research Program National Cancer Institute National Institutes of Health Rockville USA DrHiddevanderPloeg Associate Professor Department of Public and Occupational Health Amsterdam Public Health Research Institute Amsterdam University Medical Centres Amsterdam NETHERLANDS MsVickyWari* Programme Manager, NCD National Department of Health Port Moresby PAPUA NEW GUINEA 外部査読グループ DrKingsleyAkinroye NCD Alliance Nigeria NIGERIA DrHudaAlsiyabi Director Department of Community Based Initiatives Ministry of Health OMAN DrAlbertoFlórez-Pregonero Pontificia Universidad Javeriana COLOMBIA DrShigeruInoue Department of Preventive Medicine and Public Health Tokyo Medical University JAPAN DrAgusMahendra Department of Physical education Universitas Pendidikan INDONESIA DrDeborahSalvo Prevention Research Center in St. Louis Brown School Washington University USA DrJasperSchipperijn President-Elect 2020–2022 International Society of Physical Activity and Health Department of Sports Science and Clinical Biomechanics University of Southern Denmark DENMARK * unable to attend 90 WHO運営グループ DrValentinaBaltag Head Adolescent and Young Adult Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND DrMauriceBucagu Medical Officer Maternal Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND DrAlexanderBuchart Head Violence Prevention Social Determinants of Health Department WHO Headquarters Geneva SWITZERLAND DrFionaBull Head Physical Activity Department of Health Promotion WHO Headquarters Geneva SWITZERLAND DrReginaGuthold Scientist Adolescent and Young Adult Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND DrRiitta-MaijaHämäläinen Technical Officer Noncommunicable Diseases and Health Promotion WHO Regional Office for the Western Pacific Manila PHILIPPINES DrAndreIlbawi Technical Officer Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND DrWasiqKhan* Regional Adviser Health Education and Promotion WHO Regional Office for the Eastern Mediterranean Cairo EGYPT MsLindsayLee Technical Officer Sensory Functions, Disability and Rehabilitation Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND MsAlanaOfficer Senior Health Adviser Healthy Ageing Office of the Director-General WHO Headquarters Geneva SWITZERLAND MsLeanneRiley Head Surveillance Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND DrGojkaRoglic Medical Officer Noncommunicable Diseases Management Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND DrJuanaWillumsen Technical Officer Physical Activity Department of Health Promotion WHO Headquarters Geneva SWITZERLAND * unable to attend 91Annex 2 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 付録３： 利害宣言の要約および管理手順 Name Gender Expertise Disclosureofinterest Conflictofinterest andmanagement DrSalihSaadAl-Ansari Male Advocate in health and education to combat NCDs through physical activity and walking Owner and Chief Executive Officer of the Health Promotion Center No conflict of interest identified DrStuartBiddle Male Physical activity in youth Research funds and paid consultancy No conflict of interest identified DrKatjaBorodulin Female Physical activity in pregnancy Employment at National Institute for Health and Welfare and Age Institute; research funds No conflict of interest identified DrMatthewBuman Male Sleep and physical activity in people living with chronic conditions None declared No conflict of interest identified DrGreetCardon Female Physical activity in youth None declared No conflict of interest identified MsCatherineCarty Female Physical activity in people living with disability None declared No conflict of interest identified DrJean-PhilippeChaput Male Sleep None declared No conflict of interest identified DrSebastienChastin Male Physical activity and health, objective measurement of physical activity Research funds No conflict of interest identified DrPaddyDempsey Male Physical activity and sedentary behaviour in adults and people living with chronic conditions Employment and research funds No conflict of interest identified DrLorettaDiPietro Female Physical activity in older adults None declared No conflict of interest identified DrUlfEkelund Male Physical activity and Employment and paid consultancy No conflict of interest identified DrJosephFirth Male mental health None declared No conflict of interest identified DrChristineFriedenreich Female Physical activity in people living with chronic conditions, physical activity and cancer risk None declared No conflict of interest identified DrLeandroGarcia Male Physical activity and mental health Employment and paid consultancy No conflict of interest identified DrMuthoniGichu Female Policy implementation （national government） None declared No conflict of interest identified DrRussJago Male Physical activity in youth None declared No conflict of interest identified ガイドライン開発グループ 92 外部の査読者 Name Gender Expertise Disclosureofinterest Conflictofinterest andmanagement DrPeterKatzmarzyk Male Physical activity and sedentary behaviour in youth Travel support to assist guideline committees No conflict of interest identified DrEstelleV.Lambert Female Physical activity and obesity None declared No conflict of interest identified DrMichaelLeitzmann Male Sedentary behaviour and chronic conditions None declared No conflict of interest identified DrKarenMilton Female Translating recommendations into practice Travel support to assist guideline committee No conflict of interest identified DrFranciscoOrtega Male Physical activity in youth, mental health and objective measurement None declared No conflict of interest identified DrChathuranga Ranasinghe Male Promotion of physical activity and health in the community, workplace and school settings Research funds No conflict of interest identified DrEmmanuelStamatakis Male Physical activity and multiple health outcomes in adults Grant for technology company for objective measurement of physical activity No conflict of interest identified DrAnneTiedemann Female Physical activity and health outcomes in older adults None declared No conflict of interest identified DrRichardTroiano Male Policy development None declared No conflict of interest identified DrHiddevanderPloeg Male Physical activity, sedentary behaviour and health outcomes in adults Travel support to assist 2017 Dutch Physical Activity Guidelines committee and research funds No conflict of interest identified MsVickyWari Female Policy implementation（national government） Shares（not relevant to guideline） No conflict of interest identified Name Gender Expertise Disclosureofinterest Conflictofinterest andmanagement DrKingsleyAkinroye Male Advocacy, noncommunicable diseases None declared No conflict of interest identified DrHudaAlsiyabi Female Policy and programme implementation None declared No conflict of interest identified DrAlbertoFlórez- Pregonero Male Physical activity and sedentary behaviour measurement and surveillance None declared No conflict of interest identified DrShigeruInoue Male Epidemiology and physical activity promotion None declared No conflict of interest identified DrAgusMahendra Male Physical activity and movement skills in children None declared No conflict of interest identified DrDeborahSalvo Feale Health and social disparities with a particular emphasis on chronic disease prevention None declared No conflict of interest identified DrJasperSchipperijn Male Physical activity and the built environment None declared No conflict of interest identified 93Annex 3

WHO 身体活動および座位行動に関する ガイドライン This translation was not created by the World Health Organization（WHO）. WHO is not responsible for the content or accuracy of this translation. The original English edition “WHO guidelines on physical activity and sedentary behaviour”. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO shall be the binding and authentic edition. この翻訳は世界保健機関（WHO）によって作成されたものではありません。WHOは本翻訳の内容または正確性につ いて責任を負いません。原本の英語版「WHO guidelines on physical activity and sedentary behaviour」（ジュ ネーブ：世界保健機関；2020. ライセンス：CC BY-NC-SA 3.0 IGO）が正式版です。 翻訳者 宮地元彦 早稲田大学　スポーツ科学学術院 国立研究開発法人医薬基盤・健康栄養研究所　身体活動研究部 翻訳協力・査読者 澤田　亨　早稲田大学 小熊祐子　慶應義塾大学 井上　茂、天笠志保　東京医科大学 岡浩一朗　日本運動疫学会　早稲田大学 協力者 山口美輪、西　信雄　国立研究開発法人医薬基盤・健康・栄養研究所 WHO 身体活動および座位行動に関する ガイドライン 目次 謝辞 省略形と頭字語 ⅴ 用語集 ⅵ エグゼクティブサマリー 1 背景 15 方法 18 推奨事項 24 　＞子どもおよび青少年（５～17歳） 25 　　身体活動の推奨事項 25 　　座位行動の推奨事項 29 　＞成人（18～64歳） 32 　　身体活動の推奨事項 32 　　座位行動の推奨事項 38 　＞高齢者（65歳以上） 43 　　身体活動の推奨事項 43 　　座位行動の推奨事項 46 　＞妊娠中および産後の女性 47 　　身体活動の推奨事項 47 　　座位行動の推奨事項 51 　＞慢性疾患を有する成人および 　　高齢者（18歳以上） 52 　　身体活動の推奨事項 52 　　座位行動の推奨事項 58 　＞障害を有する子ども 　　および青少年（５～17歳）および 　　成人（18歳以上） 60 　　身体活動の推奨事項 60 　　座位行動の推奨事項 64 エビデンスから推奨事項へ 66 エビデンスの確実性の評価 66 利益と害 67 価値観および好み 67 リソースの影響 67 公平性、許容可能性、および実現可能性 68 リサーチのニーズ 69 採択、普及、履行、および評価 70 採択 70 普及 71 周知のキャンペーン 71 政策およびプログラムの履行 72 調査および評価 73 更新 73 参考文献 75 付録１：ガイドラインの管理 策定のプロセス 85 付録２：ガイドライン策定グループ、 外部ピアレビュー担当者、および本ガイドライン策定 担当スタッフ 88 付録３：利益相反の概要 および管理方法 92 ウェブ付録：エビデンスプロファイル https://apps.who.int/iris/bitstream/handle/ 10665/336657/9789240015111-eng.pdf Contents iii W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 謝辞 世界保健機関（WHO）は、これらのガイドラインの作成における以下の個人および組織の貢献と支援に感謝の意を 表する：Fiona Bull and Juana Willumsen は、これらのガイドラインを作成するプロセスを主導した。 Valentina Baltag, Maurice Bucagu, Alex Butchart, Neerja Chowdhary, Regina Guthold, Riitta-Maija Hämäläinen, Andre Ilbawi, Wasiq Khan, Lindsay Lee, Alana Officer, Leanne Riley and Gojka Roglicは、 ガイドライン作成過程を管理したWHO運営グループのメンバーであった。 ガイドライン開発グループ（GDG）のメンバーには、Salih Saad Al-Ansari, Stuart Biddle, Katja Borodulin, Matthew Buman, Greet Cardon（co-chair）, Catherine Carty, Jean-Philippe Chaput, Sebastien Chastin, Paddy Dempsey, Loretta DiPietro, Ulf Ekelund, Joseph Firth, Christine Friedenreich, Leandro Garcia, Muthoni Gichu, Russ Jago, Peter Katzmarzyk, Estelle V. Lambert, Michael Leitzmann, Karen Milton, Francisco B. Ortega, Chathuranga Ranasinghe, Emmanuel Stamatakis（co-chair）, Anne Tiedemann, Richard Troiano, Hidde van der Ploeg, Vicky Wari. が含まれた。 Roger ChouがGRADEの方法論者を務めた。外部レビューグループには、Kingsley Akinroye, Huda Alsiyabi, Alberto Flórez-Pregonero, Shigeru Inoue, Agus Mahendra, Deborah Salvo and Jasper Schipperijnが含 まれた。 Kyle Sprow（National Cancer Institutes, National Institutes of Health, Maryland, USA）が実施した追加の 文献検索のおかげで、2018年の米国身体活動ガイドライン諮問委員会の保健福祉長官への科学的報告のために準備 されたエビデンスの系統的レビューが更新された。 特定された論文をレビューするための追加サポートは、Elif Eroglu（University of Sydney）, Andrea Hillreiner （University of Regensburg）, Bo-Huei Huang（University of Sydney）, Carmen Jochem（University of Regensburg）, Jairo H. Migueles（University of Granada）, Chelsea Stone（University of Calgary）and Léonie Uijtdewilligen（Amsterdam UMC）によって提供された。 エビデンスの要約とGRADEテーブルは、Carrie Patnode and Michelle Henninger（The Kaiser Foundation Hospitals, Center for Health Research, Portland, Oregon, USA）によって作成された。 エ ビ デ ン ス の 追 加 レ ビ ュ ー は、N Fairhall, J Oliveira, M Pinheiro, and C Sherrington（Institute for Musculoskeletal Health, School of Public Health, The University of Sydney, Sydney, Australia）and A Bauman（Prevention Research Collaboration, School of Public Health, The University of Sydney, Sydney, Australia; and WHO Collaborating Centre for Physical Activity, Nutrition and Obesity）；S Mabweazara, M-J Laguette, K Larmuth, F Odunitan-Wayas（Research Centre for Health through Physical Activity, Lifestyle and Sports Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa）, L Leach, S Onagbiye（Department of Sport, Recreation and Exercise Science, Faculty of Health Sciences, University of the Western Cape, Cape Town, South Africa）, M Mthethwa（Chronic Disease Initiative for Africa, University of Cape Town, Cape Town, South Africa）, P Smith（The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa）and F Mashili （Department of Physiology, Muhimbili University of Allied Sciences, Dar Es Salaam, United Republic of Tanzania）；B Cillekens, M Lang, W van Mechelen, E Verhagen, M Huysmans, A van der Beek, P Coenen（Department of Public and Occupational Health at Amsterdam University Medical Centre, Amsterdam, Netherlands）により実施された。 カナダ公衆衛生庁とノルウェー政府が財政支援を提供したが、それなしではこの作業を完了することはできなかった。 iv 省略形と頭字語 ADHD attention deficit hyperactive disorder（注意欠陥多動性障害） AOR adjusted odds ratio（調整オッズ比） BMI body mass index（ボディマスインデックス） CI confidence interval（信頼区間） CVD cardiovascular disease（心血管疾患） DBP diastolic blood pressure（拡張期血圧） EtD Evidence to Decisions（エビデンスから決定へ） GDG Guideline Development Group（ガイドライン策定グループ） GRADE Grading of Recommendations Assessment, Development and Evaluation （推奨事項の査定、策定、および評価の格付け） HR hazards ratio（ハザード比） MET Metabolic Equivalent of Task（代謝当量：メッツ） MD mean difference（平均差） MICT moderate intensity continuous training（中強度の継続的トレーニング） NCD noncommunicable disease（非感染性疾患） OR odds ratio（オッズ比） PA physical activity（身体活動） PAGAC United States Physical Activity Guidelines Advisory Committee （米国人に対する身体活動のガイドライン諮問委員会） PI/ECO Population, Intervention/Exposure, Comparison, Outcome （対象集団、介入／曝露、対照、アウトカム） RaR Relative attributable risk（相対的寄与危険度） RCT randomized control trial（ランダム化比較試験） RR relative risk（相対危険度） SBP systolic blood pressure（収縮期血圧） SMD standardized mean difference（標準化平均差） SPPB short physical performance battery（簡易身体能力組テスト） TV television（テレビ） WHA World Health Assembly（世界保健総会） WHO World Health Organization（世界保健機関） vAbbreviations and acronyms W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 用語集 用語 定義 有酸素性の 身体活動 体の大きな筋肉が持続した期間中に周期的な方法で移動する活動。有酸素性の活動−持久力アク ティビティとも呼ばれ、心肺体力を改善する。 例：ウォーキング、ランニング、水泳、サイクリング 無酸素性の 身体活動 無酸素性の身体活動は、重量挙げや短距離競走などの短い時間に大きな力を発揮するもので、酸素 需要量が酸素供給量を凌ぐ。 バランス トレーニング 体位の動揺から、または自発運動、環境またはその他の物体に起因する不安定化させる刺激からの 課題に耐えるため、本人の能力が向上する用にデザインされた静的および動的な運動。 ボディマスイン デックス（BMI） 体重（kg）／身長（m）2。 年齢階級別BMI または BMI zスコア値 年齢で調整されたBMI。子ども用に標準化されたもの。 BMIの標準偏差スコアは、子どもの年齢と性別で調整された相対的な体重の尺度である。子どもの 年齢、性別、BMI、および適切な参考基準を考慮し、BMI のｚスコア（またはこれに相当する年齢 階級別BMIのパーセンタイル）を測定できる。 身体活動は主に、骨格系を作る骨の特定の部位の強度を増加させるように設計されている。 骨強化活動 骨強化活動は、骨に対する衝撃または緊張力を発生させ、骨の成長を促し強度を高める。ランニン グ、繩跳び、重量挙げは、骨強化活動の例である。 心血管代謝の健康 健康に関する血圧、血中脂質、血糖、インスリンの相互作用。 心肺体力 （全身持久力） 体力の健康関連の構成要素。身体活動を持続的に行っているときに酸素を供給する循環器系および 呼吸器系の能力。 通常、測定または推定された最大酸素摂取量（VO2 max）として表される。 認知機能 脳の活性、すなわち推論、記憶、注意、情報と知識の獲得につながる言語。これには学習も含まれ ることがある。 障害 国際生活機能分類から生まれた、機能不全、活動の限界、参加の制約を指す包括的な用語で、個人 （健康状態）と個人の背景因子（環境および個人因子）との相互作用の負の局面を意味する。 身体活動の場面 身体活動のレベルは、余暇、仕事、学校、家庭および/または移動のうち１つを含む、さまざまな 場面で評価される。 運動 計画的に構成され、意図をもって繰り返し行われる身体活動のサブカテゴリ。体力の１つ以上の構 成要素の改善または維持を目的とする。「運動」および「運動トレーニング」は、しばしば取り換 えて使用されることもあるが、一般的には身体活動を指し、体力、行動体力または健康を増進する か、維持することを主目的に、余暇に行われる。 実行機能 作業記憶、認知的柔軟性（柔軟思考とも呼ばれる）、抑制制御（自己制御を含む）などが含まれる。 体力 仕事やレジャーの活動で効果的かつ効率的に機能する身体の能力の尺度で、たとえば、体力や心肺 体力などがある。 柔軟性 健康関連の構成要素と機能関連の構成要素で、可能な限りの関節の可動域。柔軟性は各関節に特異 的で、特定の靭帯と腱の緊張を含むがこれに限らず多くの特異的な変数に依存する。柔軟運動は、 関節可動域を完全にすることを通して、移動する関節の能力を強化する。 機能向上運動 下半身の強度、バランス、運動能力を改善するために日常的なタスクに組み込める運動。 例： 継ぎ足で歩く、一本足で立つ、スクワットをする、つま先立ちをする、障害物の上を踏む。 家庭場面の 身体活動 家事（掃除、子どものお世話、ガーデニングなど）のために家庭で行われる身体活動。 余暇場面の 身体活動 身体活動は個人で行われ、基本的な日常生活動作として必要なものではなく、個人の裁量で実行す るもの。このような活動にはスポーツへの参加、運動処方、またはトレーニングなどがあり、たと えば、ウォーキングやダンス、ガーデニングなどのレクリエーション活動が該当する。 vi 用語 定義 低強度の身体活動 低強度の身体活動は、1.5～３METs（すなわち本人の安静時のエネルギー消費量の３倍より少な いエネルギーでの活動）である。 これには、ゆっくりと歩くウォーキング、入浴、またはその他の付随的な活動で心拍数または呼吸 スピードの実質的な上昇にはつながらないものが該当する。 主要筋肉群 主要筋肉群には、脚、背部、腹部、胸、肩、腕が含まれる。 代謝当量（メッツ） 作業の代謝当量または単に代謝当量は、身体活動の強度を表す生理的尺度である。１METは、安 静時の着席した状態で、本人が消費したエネルギー等価物である。 中強度の身体活動 絶対目盛で、中強度とは、安静の強度が３倍から６倍未満の間に行われる。 身体活動を指す。本人のキャパシティに比例するスケールで、中強度の身体活動は通常０～10の スケールのうち５または６である。 筋力向上活動 骨格筋の筋力、パワー、持久力、大きさを増加させる身体活動や運動 （例：筋力トレーニング、レジスタンストレーニング、筋持久力運動）。 マルチコンポーネ ントの身体活動 高齢者の場合、マルチコンポーネントの身体活動は、身体機能を向上させ、転倒または転倒から生 じる負傷のリスクを低下させるために重要である。これらの活動は、自宅でも、または構造化され た集団の場でもできる。研究対象の多くの介入は、全種類の運動（有酸素性、筋力向上、バランス トレーニング）を一回に併合すると効果的であることが示された。マルチコンポーネントの身体活 動プログラムの例として、ウォーキング（有酸素性の活動）、重量挙げ（筋力向上）、およびその他 のバランストレーニングを組み込むことができる。バランストレーニングの例は、上体の筋力向上 活動（例：二頭筋カール）をしている間に後ろ向きや横向きで歩いたり、１フィート分高いところ に立ったりすることも含まれる。ダンスは、有酸素性の要素とバランスの要素が併用されたもので ある。 労働場面の 身体活動 仕事の場面の身体活動を参照。 身体活動 エネルギー消費を必要とする骨格筋によって生成される何らかの身体的移動。 身体活動不足 現在の身体活動の推奨事項を満たすには足りない身体活動のレベル。 心理・社会的健康 健康の精神的、感情的および社会的側面を含む。 余暇時間の スクリーンタイム 教育／研究または仕事に関連のあること以外の目的でスクリーン（テレビ、コンピュータ、モバイ ル機器）を見て過ごす時間。 座位の スクリーンタイム スクリーン系の娯楽（TV、コンピュータ、モバイル機器）の視聴に費やした時間。身体活動また は運動が必要とされる活発なスクリーン系のゲームは含まない。 座位行動 座っている、もたれている、横になっている状態で、1.5METs以下のエネルギー消費が特徴的な 覚醒時の行動。事務の仕事でほとんど座って過ごす、車を運転する、テレビを視聴するなどは座位 行動の例であり、立っていることができない人（例：車椅子使用者）にも当てはまる。本ガイドラ インでの座位行動の定義には、自己申告制でほとんど動かず座ったままの行動（余暇時間、職業、 全体）、テレビ（テレビの視聴またはスクリーンタイム、動きまたは姿勢を評価するデバイスで測 定した低レベルの動き）を含めた。 スポーツ スポーツは、一連の規則の範囲内で行われ、レジャーまたは競争の一部として行われる。 スポーツ活動にはチームまたは個人で実行する身体活動があり、スポーツエージェンシーなどの組 織的なフレームワークによって支援される可能性がある。 移動場面の 身体活動 ある場所から別の場所に移る目的で実行される身体活動で、ウォーキング、サイクリング、ホイーリ ング（スクーター、ローラーブレード、手動車椅子など、車輪付きの非自動移動手段）を指す。 高強度の 身体活動 絶対目盛で、高強度は、6.0MET以上で行われる身体活動を指す。本人のキャパシティに比例する スケールで、高強度の身体活動は通常０～10のスケールのうち７または８である。 仕事場面の 身体活動 有償または無償の仕事中に行われる身体活動。 viiGlossary of terms W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r エグゼクティブサマリー 「WHO 身体活動および座位行動に関するガイドライン」 （WHO Guidelines on physical activity and sedentary behaviour）は、子ども、青少年、成人、高齢者に対して 健康上の有意な利益をもたらすとともに健康リスクを緩和 するために必要な身体活動量（頻度、強度、期間）について、 エビデンスに基づく公衆衛生の推奨事項を示すものである。 座位行動と健康アウトカムとの関係に関する推奨事項は今 回初めて示され、妊娠中や産後の女性、慢性的な疾患もし くは障害を抱えている人たちについても言及されている。 本ガイドラインの対象は、高所得国、中所得国、低所得国 の健康、教育、青少年期、スポーツおよび／または社会福 祉もしくは家族福祉に関する省庁の政策立案者、ガイダン ス文書を通して、特定階層の人々の身体活動を増やし座位 行動を減らすための国や地方自治体の計画の策定を担う政 府高官、非政府機関職員、教育部門、民間部門、研究分野 の職員、医療従事者である。 本ガイドラインは、「ガイドライン策定のためのWHOハン ドブック（WHO handbook for guideline development） に準じて作成された。極めて重要なアウトカムに対しては エビデンスの系統的レビューを行い、利益と害、意義、優 先事項、実現可能性、許容可能性のほか、エクイティなら びにリソースの影響を検討したうえで、推奨事項を策定し た。 発表された公衆衛生の最終的な推奨事項の対象は、全人種 の５歳から65歳以上の年齢層で、性別、文化的背景、また は社会経済的地位にかかわりなく、障害の有無を問わずす べての人に該当する。慢性疾患を有する人も、障害のある 人も、妊娠中および産後の女性も、この推奨事項を極力守 るよう努めるべきである。 今回策定されたガイドラインは、一連のエビデンスに基づ いた推奨事項を示すものであり、各政府は国を挙げての政 策的な枠組みの一環としてこれを採択し、身体活動レベル を特定集団ごとに高める包括的なアプローチの裏づけとす ることができる。採択のプロセスにおいては、必ず各地の 現状を踏まえて本ガイドラインを活用することを考慮に入 れる必要がある。今後は本ガイドラインの採択、普及、周 知キャンペーンと履行をサポートする実用的なツールがあ ると、政府と関係者が一丸となってライフコース全体での 身体活動の増進と座位行動の低減に取り組むうえで役立つ。 そのような補助的なリソースは、本ガイドラインの公表後 にWHOウェブサイトを通して入手できるようになる予定で ある。 各年齢層で健康アウトカムと身体活動、さらには座位行動 との関連を支持するデータは大量にあるにもかかわらず、 重大なエビデンスギャップは解消されないままである。特 に、低・中所得国をはじめ、経済的に恵まれない、あるい は公共サービスが不十分な地域社会では比較的エビデンス が少なく、障害のある人を含む亜集団からのエビデンスが 不足している。特にそのようなエリアでエビデンスを構築 するため、より多くの研究に投資する必要がある。また、 これらの推奨事項に今後変更が加えられる場合には、身体 活動の国ごとのレベルのモニタリングに現在使用されてい る調査システムや評価手法にも何らかの影響がある。既存 のグローバルレベルおよび国家レベルでの手法を精査する ことは必須であり、また報告手順を最新化することも、新 たなガイドラインに備えて今後の報告に反映させるために 必要である。 Global action plan on physical activity 2018-2030 （GAPPA：身体活動に関する世界行動計画2018-2030） では、身体活動不足を2030年までに15%低下させること を目標に掲げ、政策的措置や介入への推奨事項として20項 目がまとめられている。このガイドラインは、各国が GAPPAの推奨内容を履行するうえで、またライフコース全 体やさまざまな場面を通して身体活動を促す方法に関する 指 針 を 示 す ツ ー ル キ ッ ト の 専 門 的 パ ッ ケ ー ジ で あ る “ACTIVE”（アクティブ）を実施するうえで裏付けとなる。 viii 子どもおよび青少年 （５〜17歳） 子どもおよび青少年の身体活動は、体力（心肺体力および筋力）、 心血管代謝の健康（血圧、脂質異常症、血糖値、インスリン抵抗 性）、骨の健康、認知アウトカム（学業成績、実行機能）、メンタ ルヘルス（うつの症状の軽減）の向上と、肥満の減少などの健康 効果に利益がある。 子どもおよび青少年の場合、座りすぎは、肥満の増加、心血管代謝の悪化、体力、行動／向社会的 行動、睡眠時間の減少などの悪影響を及ぼす。 推奨事項： ＞子どもおよび青少年は、中強度から高強度の主に有 酸素性の身体活動を週全体で１日につき平均60分以 上行うこと。 強い推奨、エビデンスの確実性は中 推奨事項： ＞子どもおよび青少年は、座位のまま過ごす時間、特 に余暇時間でスクリーンタイムの時間を減らす必要 がある。 強い推奨、エビデンスの確実性は低 ＞高強度の有酸素性の活動とともに、筋肉および 骨を強化する活動を週に３日以上組み込むこと。 強い推奨、エビデンスの確実性は中 少なくとも１日 60 分 少なくとも週に 3 日 減らそう 週全体で中高強度の身体活動。この場 合の身体活動はほとんどが有酸素性の 身体活動であること。 高強度の有酸素性の身体活動ととも に、筋肉および骨を強化する身体活動 を週に３日以上組み込むこと。 座位のまま過ごす時間、特 に余暇時間でスクリーンタ イムを減らす 優れた実践 ・身体活動を一切しないよりは少しでもした方がよい。 ・ 上記の推奨量を満たしていない子どもおよび青少年は、ある程度の身体活動を行うことで健康上の利益が 得られる。 ・ 子どもおよび青少年の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時間を増やして いくべきである。 ・ すべての子どもおよび青少年に対し、楽しめる内容で、多様な、年齢や能力に適した身体活動に参加する 安全かつ公平な機会を設け奨励することが重要である。 1Executive Summary W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 成人 （18〜64歳） 成人の身体活動は、総死亡率、循環器疾患死亡率の低下、高血 圧の発症、部位別のがんの発症１、２型糖尿病の発症の予防、 メンタルヘルス（不安およびうつの症状の軽減）の改善、認知 的健康、および睡眠などの健康効果に利益があり、肥満も改善 される可能性がある。 推奨事項： ＞すべての成人は定期的な身体活動を行うべきである。 強い推奨、エビデンスの確実性は中 ＞なお、成人は、主要筋肉群すべて が関係する中強度以上の筋力向上 活動も週に２日以上行うこと。そ れにより、さらに健康上の利益が 得られる。 強い推奨、エビデンスの確実性は中 ＞成人の場合、有酸素性の身体活動を 少なくとも週に150～300分、また は高強度の有酸素性の身体活動を少 なくとも75～100分を行うか、また は週全体で中強度の活動と高強度の 活動の組み合わせによる同等の量を 行うと、実質的な健康上の利益が得 られる。 　相当する活動を行うこと。 強い推奨、エビデンスの確実性は中 少なくとも週に 150 〜300 分 少なくとも週に 75 〜150 分 少なくとも週に 2 日 中強度の有酸素性の 身体活動 または中強度と高強度の身体活動の組み合わせによる同等の量 高強度の有酸素性の 身体活動 主要筋肉群すべてが関係する 中強度以上の強度で筋力向上 活動を行う さらなる健康増進のために： １ 部位別のがんとは、膀胱がん、乳がん、大腸がん、子宮内膜がん、食道腺がん、 胃がん、腎がんである。 または 2 ＞300 分 ＞ 150 分 中強度の有酸素性 の身体活動 または中強度と高強度の身体活動の組み合わせによる同等の量 高強度の有酸素性の 身体活動 または （18〜64歳） さらに健康上の利益を得るには ＞成人の場合、さらに健康上の利益を得るた め、中強度の有酸素性の身体活動を300分 超に増やしても、あるいは150分超の高強 度の有酸素性の身体活動を行っても、また は週全体で中強度の活動と高強度の活動の 組み合わせによる同等の量を行ってもよい。 条件つきの推奨、エビデンスの確実性は中 優れた実践 ・身体活動を一切しないよりは少しでもした方がよい。 ・ 上記の推奨量を満たしていない成人は、ある程度の身体活動を行うことで健康効果が得られる。 ・成人の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時間を増やしていく。 成人の場合、座りすぎは、総死亡率、心血管疾患死亡率、がん死亡率、心血管疾患、がん、および ２型糖尿病の発生などといった悪影響を及ぼす。 推奨事項： ＞成人は座りっぱなしの時間が短くなるよう に制限をかけること。座位時間をいずれか の強度の身体活動の時間に替えると健康効 果が得られる。 強い推奨、エビデンスの確実性は中 ＞長時間の座りすぎが健康に及ぼす悪影響を 軽減するため、成人は、中高強度という推 奨レベルを上回る身体活動を行うよう心が けること。 強い推奨、エビデンスの確実性は中 減らそう 置き換える 座りっぱなしで過ごす時間を どんな強度（低強度を含む） でも良いので、身体活動を 増やす 3Executive Summary W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 高齢者の身体活動は、総死亡率、心血管疾患死亡率、高血圧の 発症、部位別のがんの発症、２型糖尿病の発症、メンタルヘル ス（不安およびうつの症状の軽減）、認知的健康、および睡眠 などの健康アウトカムに利益があり、肥満も改善される可能性 がある。高齢者の場合、身体活動は転倒や転倒関連の傷害、ま た骨の健康の減退や機能的能力の低下の予防に役立つ。 高齢者 （65歳以上） 推奨事項： ＞すべての高齢者は定期的な身体活動を行うこと。 強い推奨、エビデンスの確実性は中 ＞高齢者の場合、中強度の有酸素性の 身体活動を少なくとも150～300 分、または高強度の有酸素性の身体 活動を少なくとも週に75～150分 行うか、または週全体で中強度の活 動と高強度の活動の組み合わせによ る同等の量を行うと、実質的な健康 上の利益が得られる。 強い推奨、エビデンスの確実性は中 少なくとも週に 150 〜300 分 少なくとも週に 75 〜150 分 中強度の有酸素性の 身体活動 または中強度と高強度の身体活動の組み合わせによる同等の量 高強度の有酸素性の 身体活動 または 少なくとも週に 2 日 少なくとも週に 3 日 さらに健康上の利益を得るには 主要筋肉群すべてが 関係する中強度以上 の筋力向上活動。 中強度以上の、バラ ンス機能を高めるよ うにマルチコンポー ネントの身体活動と 筋力トレーニング。 ＞なお、高齢者は、主要筋肉群すべてが関 係する中強度以上の筋力向上活動も週 に２日以上行うこと。それにより、さら に健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 ＞高齢者は、毎週の身体活動の一環とし て、バランス機能を高めるようにマルチ コンポーネントの身体活動と筋力ト レーニングを中強度以上のレベルで週 に３日以上行って機能的な能力を強化 し、転倒を予防すること。 強い推奨、エビデンスの確実性は中 4 高齢者（65歳以上） ＞ 300 分 ＞ 150 分 中強度の有酸素性 の身体活動 または中強度と高強度の身体活動の組み合わせによる同等の量 高強度の有酸素性の 身体活動 または さらに健康上の利益を得るには ＞高齢者の場合、さらに健康上の利益を 得るため、中強度の有酸素性の身体活 動を300分超に増やしても、あるいは 150分超の高強度の有酸素性の身体活 動を行っても、または週全体で中強度 の活動と高強度の活動の組み合わせに よる同等の身体活動を行ってもよい。 条件つきの推奨、エビデンスの確実性は中 優れた実践・身体活動を一切しないよりは少しでもした方がよい。 ・ 上記の推奨量を満たしていない高齢者は、ある程度の身体活動を行うことで健康効果が得られる。 ・高齢者の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時間を増やしていく。 ・ 高齢者は各自の機能的能力が許す範囲で身体的に活発に動き、身体活動の運動レベルが体力のレベルに見 合ったものになるように調整すること。 高齢成人の場合、座りすぎは、総死亡率、心血管疾患死亡率、がん死亡率、心血管疾患、がん、 および２型糖尿病の発生率などの健康アウトカムが不良であることと関連している。 推奨事項： ＞高齢者は座位のまま過ごす時間が短くなる ように制限をかけること。座位で過ごす時 間をいずれかの強度の身体活動の時間に替 えると健康上の利益がある。 強い推奨、エビデンスの確実性は中 ＞長時間の座りすぎが健康に与える有害な影 響を抑えるため、高齢者は、中高強度とい う推奨レベルを上回る身体活動を行うよう 心がけること。 強い推奨、エビデンスの確実性は中 減らそう 置き換える 座りっぱなしで過ごす時間を どんな強度（低強度を含む） でも良いので、身体活動を 増やす 5Executive Summary W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 妊娠中および産後の女性 妊娠中および産後の女性の妊娠中と後の身体活動は、妊娠腎症、 妊娠高血圧症、妊娠糖尿病、妊娠期の過度の体重増加、分娩合 併症、ならびに後のうつのリスク低下、および新生児合併症の リスクの低下といった母体と胎児の健康上の利益があり、出生 体重への悪影響はなく、死産のリスクが増大することはない。 禁忌事項のない妊娠中および産後のすべての女性への推奨事項： ＞妊娠から産後までの期間を通して、定期的な身体活動を行う。 強い推奨、エビデンスの確実性は中 中強度の有酸素性の 身体活動 少なくとも週に 150 分 さらに： ＞妊娠前に高強度の有酸素性の活動を習慣的に行っていた女性または 身体的に活動的な女性は、妊娠中や産後の期間に、これらの活動を 続行できる。 強い推奨、エビデンスの確実性は中 ＞中強度の有酸素性の身体活動を１週間に少な くとも150分行うと、実質的な健康上の利益 が得られる。 強い推奨、エビデンスの確実性は中 ＞さまざまな有酸素性の筋力向上活動を組み込 む。軽いストレッチを加えることも効果的で ある。 強い推奨、エビデンスの確実性は中 6 妊娠中および産後の女性 優れた実践 ・ 身体活動を一切しないよりは少 しでもした方がよい。 ・ 上記の推奨量を満たしていない 妊娠中および産後の女性は、あ る程度の身体活動を行うことで 健康効果が得られる。 ・ 妊娠中および産後の女性の場合、 身体活動を少し行うことから始 め、徐々に頻度、強度、持続時 間を増やしていく。 ・ 骨盤底筋のトレーニングは、尿 失禁のリスクを低下させるため に毎日行ってよい。 妊婦が身体活動を行う場合に考慮すべき安全上の注意事項： ・ 過度に暑い時期、特に湿度が高いときには、運動を避ける。 ・ 身体活動の前中後に、水を飲んで水分を補給する。 ・ 身体的接触を伴う、転倒のリスクが高い、あるいは酸素供給を制限 するおそれがある（高地に普段居住していない場合の高地での活動 など）といった活動への参加を避ける。 ・ 妊娠中期を過ぎてからは、仰臥位で活動するものを避ける。 ・ 妊娠中の女性が運動競技、または推奨ガイドラインを大幅に上回る 運動を行う場合は、専門の医療従事者による管理指導を仰ぐこと。 ・ 医療従事者は、身体活動を中止すべきあるいは制限すべき危険な兆 候について妊婦に情報提供すべきである。また、そのような兆候が 現れた場合には妊婦は直ちに医療従事者に相談すべきである。 ・ 産後は徐々に身体活動を再開し、帝王切開による分娩であった場合 には、医療従事者に相談する。 妊娠中および出産後の女性の場合、座りすぎは、総死亡率、心血管疾患死亡率、がん死亡率、心血 管疾患、がん、および２型糖尿病の増加といった悪影響が生じる。 減らそう 置き換える 座りっぱなしで過ごす時間を どんな強度（低強度を含む） でも良いので、身体活動を 増やす 推奨事項： ＞妊娠中および産後の女性は座りっぱなしの時間 を減らすべきである。 　座位時間をいずれかの強度の身体活動の時間に 替えると健康上の利益がある。 強い推奨、エビデンスの確実性は低 身体活動を 一切しないよりは 少しでも した方がよい。 7Executive Summary W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 慢性疾患を有する成人および高齢者 （18歳以上） 身体活動は、以下の慢性疾患を抱える成人および高齢者に健康 効果をもたらす。 がんサバイバーの場合―身体活動により、総死亡率、がん特異 的死亡率、がん再発または二次発がんのリスクが改善される。 高血圧患者の場合―身体活動により、心血管疾患死亡率、疾病の進行、 身体機能、健康関連の生活の質が改善される。 ２型糖尿病患者の場合―身体活動により、心血管疾患による死亡率と疾病進行の指標の値が低下する。 HIV患者の場合―身体活動により、体力が向上し、精神的健康が改善される可能性があり（不安 および抑うつの症状の軽減）、病気の進行（CD4リンパ球数およびHIVウイルス量）または体組 成に悪影響を与えられることはない。 推奨事項： ＞上記の慢性疾患を有するすべての成人および高齢者は、定期的な身体活動を行うこと。 強い推奨、エビデンスの確実性は中 少なくとも週に 150 〜300 分 少なくとも週に 75 〜150 分 中強度の有酸素性の 身体活動 または中強度と高強度の身体活動の組み合わせによる同等の量 高強度の有酸素性の 身体活動 または ＞これらの慢性疾患を有する成人および高 齢者の場合、中強度の有酸素性の身体活 動を少なくとも150～300分、または高 強度の有酸素性の身体活動を少なくとも 75～150分行うか、または週全体で中 強度の活動と高強度の活動の組み合わせ による同等の量を行うべきである。 強い推奨、エビデンスの確実性は中 ＞これらの慢性疾患を有する成人および高齢者は、 主要筋肉群すべてが関係する中強度以上の筋力 向上活動も週に２日以上行うこと。それにより、 さらに健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 少なくとも週に 2 日 さらに健康上の利益を得るには 主要筋肉群すべてが 関係する中強度以上 の筋力向上活動。 少なくとも週に 3 日 中程度以上の強度の機能 的バランスと筋力トレー ニングを中心としたさま ざまな種類のマルチコン ポーネントの身体活動 ＞これらの慢性疾患を有する高齢者は、毎週の身体 活動の一環として、バランス機能を高めるように マルチコンポーネントの身体活動と筋力トレーニ ングを中強度以上の強度で週に３日以上行って機 能的な能力を強化し、転倒を予防すること。 強い推奨、エビデンスの確実性は中 8 慢性疾患を有する成人および高齢者（18歳以上） ＞ 300 分／週 以上の ＞ 150 分／週 以上の 中強度の有酸素性 の身体活動 または中強度と高強度の身体活動の組み合わせによる同等の量 高強度の有酸素性の 身体活動 または さらに健康のために ＞これらの慢性疾患を有する成人および 高齢者で、禁忌事項がない場合、さら に健康上の利益を得るため、中強度の 有酸素性の身体活動を300分超に増や しても、あるいは150分超の高強度の 有酸素性の身体活動を行うか、または 週全体で中強度の活動と高強度の活動 の組み合わせによる同等の身体活動を 行ってもよい。 条件つきの推奨、エビデンスの確実性は中 優れた実践 ・ これらの慢性疾患を有する成人で上記の推奨量を満たすことができない場合は、個人の能力に応じて 身体活動を行うことを心がけること。 ・ これらの慢性疾患を有する成人の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時間 を増やしていく。 ・ 成人で、これらの慢性疾患を抱えている場合、個々のニーズ、能力、機能的制限／合併症、薬物療法、全 体的な治療計画に適した活動の種類や量について助言を得たい場合は、身体活動の専門家や医療従事者に 相談することができる。 ・ 運動前の医学的な許可については、禁忌事項がなければ、早歩きや日常生活で必要なレベルを超えない範 囲の低強度または中強度の身体活動を開始する前には概して不要である。 がんサバイバー、高血圧患者、２型糖尿病患者、およびHIV患者などに該当する成人の場合、座り すぎは、総死亡率、心血管疾患死亡率、がん死亡率、心血管疾患、がん、および２型糖尿病の罹患 などの健康アウトカムが不良であることと関連している。 がんサバイバー、高血圧患者、２型糖尿病患者、 およびHIV患者などに該当する成人への推奨事項： ＞慢性疾患を有する成人および高齢者は座位のま ま過ごす時間が短くなるように制限をかけるこ と。座位で過ごす時間をいずれかの強度の身体 活動の時間に替えると健康上の利益がある。 強い推奨、エビデンスの確実性は低 ＞長時間の座位行動が健康に与える有害な影響を 抑えるため、慢性疾患を有する成人および高齢 者は、中高強度という推奨レベルを上回る身体 活動を行うよう心がけること。 強い推奨、エビデンスの確実性は低 減らそう 置き換える 座位のまま過ごす時間 強度を問わず これまで以上の身体活動 （低強度も含む）。 9Executive Summary W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 障害を有する子どもおよび青少年 （５〜17歳） 上記のセクションで述べた、子どもおよび青少年の身体活動の健 康上の利益の多くは、障害を有する子どもおよび青少年に関して も当てはまる。そのほかに障害を有する子どもおよび青少年が得 られる健康アウトカムへの利益としては、注意力欠陥多動性障害 （ADHD）などの認知機能を損なう疾患または障害がある場合に は認知力の改善がある。また、知的障害がある子どもの場合は身 体的な機能が向上する可能性がある。 少なくとも１日 60 分 少なくとも週に 3 日 週全体で中高強度の身体活動。この場合 の身体活動はほとんどが有酸素性である こと。 高強度の有酸素性の身体活動とともに、 筋肉および骨を強化する活動を週に３日 以上組み込むこと。 推奨事項： ＞障害を有する子どもおよび青少年の場合、中高 強度の、多くは有酸素性の身体活動を週全体で １日平均60分以上行うこと。 強い推奨、エビデンスの確実性は中 ＞高強度の有酸素性の活動とともに、筋肉および 骨を強化する活動を少なくとも週に３日は組み 込むこと。 強い推奨、エビデンスの確実性は中 身体活動を 一切しないよりは 少しでも した方がよい。 10 障害を有する子どもおよび青少年（５〜17歳） 身体活動を 少し行うことから 始める。 優れた実践 ・ 身体活動を一切しないよりは少しでもした方がよい。 ・ 障害を有する子どもおよび青少年で上記の推奨事項を満たしていない場合、ある程度の身体活動を行うこ とで健康上の利益が得られる。 ・ 障害を有する子どもおよび青少年の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時 間を増やしていく。 ・ 障害を有する子どもおよび青少年が身体活動を行うことについては、本人の現時点の活動レベル、健康状態、 および身体機能に適した内容であれば、重大なリスクはなく、得られる健康上の利益がリスクを上回る。 ・ 障害を有する子どもおよび青少年は、各自に適した活動のタイプや量を決めるうえで、医療従事者または その他の身体活動および障害の専門家に相談する必要が生じる場合もある。 子どもおよび青少年の場合、座りすぎは、肥満の亢進、心血管代謝の健康度の低下、体力、行動／ 向社会的行動、睡眠期間の減少などの不良な健康アウトカムと関連している。 推奨事項： ＞障害を有する子どもおよび青少年は、座位のま ま過ごす時間、特に余暇時間でスクリーンタイ ムが短くなるように制限をかけること。 強い推奨、エビデンスの確実性は低 減らそう 座位のまま過ごす時間、特に 余暇時間でスクリーンタイム の長さ 11Executive Summary W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 障害を有する成人 （18歳以上） 上記のセクションで述べた、成人の身体活動の健康上の利益の多く は、障害を有する成人に関しても当てはまる。そのほかに、障害を 有する成人の場合には以下の健康アウトカムへの利益がある。 多発性硬化症を有する成人の場合―身体機能の向上と、健康関連の生活 の質の身体的、精神的、社会的場面の向上。 脊髄損傷患者の場合―歩行機能、筋力、上肢の機能の改善、および健康関連の生活の質の向上。 認知機能に障害がある疾患または障害を有する患者の場合―身体機能と認知機能の改善（パーキン ソン病患者およびと脳卒中の既往歴のある者）、認識機能に対する有益な影響、生活の質が改善され る可能性（統合失調症を有する成人の場合）、身体機能が改善される可能性（知的障害者のある成人 の場合）、生活の質の向上（うつ病を有する成人の場合）。 少なくとも週に 150 〜300 分 少なくとも週に 75 〜150 分 中強度の有酸素性の 身体活動 または中強度と高強度の身体活動の組み合わせによる同等の量 高強度の有酸素性の 身体活動 または ＞障害を有する成人の場合、中強度の有酸 素性の身体活動を150～300分以上、 または高強度の有酸素性の身体活動を 75～150分以上行うか、または週全体 で中強度の活動と高強度の活動の組み合 わせによる同等の量を行うと、実質的な 健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 ＞なお、障害を有する成人は、主要筋肉群すべてが 関係する中強度以上の筋力向上活動も週に２日 以上行うこと。それにより、さらに健康上の利益 が得られる。 強い推奨、エビデンスの確実性は中 推奨事項： ＞障害を有する成人は定期的な身体活動を行うこと。 強い推奨、エビデンスの確実性は中 少なくとも週に 2 日 さらに健康上の利益を得るには 主要筋肉群すべてが関係する 中強度以上の筋力向上活動。 12 障害を有する成人（18歳以上） ＞障害を有する成人は、さらに健康上の 利益を得るため、中強度の有酸素性の 身体活動を300分超に増やしても、あ るいは150分超の高強度の有酸素性の 身体活動を行っても、または週全体で 中強度の活動と高強度の活動の組み合 わせによる同等の量を行ってもよい。 条件つきの推奨、エビデンスの確実性は中 少なくとも週に 3 日 中強度以上の、バランス機能 を高めるようにさまざまな要 素で構成された中強度以上の、 バランス機能を高めるように さまざまな要素で構成され た多様な身体活動と筋 力トレーニング。 ＞障害を有する高齢者は、毎週の身体活動の一環と して、バランス機能を高めるようにマルチコン ポーネントの身体活動と筋力トレーニングを中 強度以上のレベルで週に３日以上行って機能的 な能力を強化し、転倒を予防すること。 強い推奨、エビデンスの確実性は中 ＞ 300 分／週 以上の 中強度の有酸素性 の身体活動 または中強度と高強度の身体活動の組み合わせによる同等の量 高強度の有酸素性 の身体活動 または さらに健康上の利益を得るには 優れた実践 ・ 身体活動を一切しないよりは少しでもした方がよい。 ・ 障害を有する成人で上記の奨事項を満たしていない場合、ある程度の身体活動を行うことで健康上の利益 が得られる。 ・ 障害を有する成人の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時間を増やしていく。 ・ 障害を有する成人が身体活動を行うことについては、本人の現時点の活動レベル、健康状態、および身体 機能に適した内容であれば、重大なリスクはなく、得られる健康上の利益がリスクを上回る。 ・ 障害を有する成人は、各自に適した活動のタイプや量を決めるうえで、医療従事者またはその他の身体活 動および障害の専門家に相談する必要が生じる場合もある。 成人の場合、座りすぎは、総死亡率、心血管疾患死亡率、がん死亡率、心血管疾患、がん、および ２型糖尿病の罹患率の上昇といった悪影響を及ぼす。 推奨事項： ＞障害を有する成人は座位のまま過ごす時間が 短くなるように減らすこと。 　座位で過ごす時間をいずれかの強度の身体活 動の時間に替えると健康上の利益がある。 強い推奨、エビデンスの確実性は低 ＞長時間の座位行動が健康に与える有害な影響 を抑えるため、障害を有する成人は、中高強 度という推奨レベルを上回る身体活動を行う よう心がけること。 強い推奨、エビデンスの確実性は低 減らそう 置き換える 座位のまま過ごす時間 強度を問わずこれまで以上 の身体活動（低強度も含む）。 ＞ 150 分／週 以上の 13Executive Summary W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 14 背景 定期的な身体活動は、心血管疾患、２型糖尿病、乳がん、 および大腸がんなどの非感染性の疾患の予防と管理におけ る予防因子として知られている（1−3）。また、身体活動に は、メンタルヘルス上の利益があり（4）、認知症の発症を遅 延させ（5）、健康的な体重維持に役立つ可能性があり（1）、 国民の幸福度（6）にも寄与していることがある。 身体活動は、エネルギー消費を要し（1）、仕事、家事、移動 の一環で、または余暇時間に、もしくは運動やスポーツ活動 に参加する場合に、多様な強度で実行できる、骨格筋によっ て生じる動作として定義される。強度範囲の下限において、 座位行動は、座っている、もたれかかっている、または横た わっている体勢でエネルギー消費が少ないままでの覚醒行動 と定義される（7）。座位行動が多いことは心血管、がん、総 死亡率とともに心血管疾患および２型糖尿病と関連している ことを最新のエビデンスが示している（8−10）。 身 体 活 動 不 足 は、2010 Global recommendations on physical activity for health（2010年健康づくりのため の身体活動に関するグローバルな推奨事項）を満たしてい ないこととして定義され、世界的に死亡の主要な一因であ る。推定では、世界人口が現在よりも活動的であれば、死 亡を年間４～5,000,000例回避可能である（2, 11）。世界 的にみた身体活動不足の推定値は、2016年では成人で 27.5%（12）、 青 少 年 で81%（13）で あ っ た が、 こ れ は 2010年のWHOの推奨事項（1）を満たしておらず、トレン ドデータは世界で過去10年間の改善が乏しいことを示して いる。また、また、ほとんどの国では女性が男性より活動 的ではないこと、また国・地域内での比較や国・地域ごと の比較では身体活動のレベルに有意差があることもデータ が示している。これらの差は、身体を動かす機会をもつこ との不公平によって、ひいては健康における不公平の拡大 によって説明がつく。 現在では、座位行動の世界的な推定値はないが、技術革新や、 座業や座ったままの娯楽が増える傾向のほか、モーター付 きの乗物の使用が増加していることも、世界中の身体活動 の変化のパターンや座位行動の増加に寄与している。 Global action plan on physical activity 2018-2030 （身体活動に関する世界行動計画2018-2030）（14）による と、成人および青少年の身体活動不足の世界的な広がりに 対し、2030年までに15%の相対的減少を達成するための 戦略的な４つの目標と20の政策的措置がある。 2010年にWHOは、初めての子どもおよび青少年、成人、 高齢者の集団ベースの公衆衛生ガイドラインとなるGlobal recommendations on physical activity for health（健 康づくりのための身体活動に関するグローバルな推奨事項） （1）を発表した。2018年の世界保健総会では、決議案 WHA71.61で、2010年の推奨事項を更新するようWHOに 求めた。 2019年には、WHOがGuidelines on physical activity, sedentary behaviour and sleep for children under 5 years of age（５歳未満の子どもの身体活動、座位行動、 睡眠に関するガイドライン）を発表した（15）。このガイド ラインは子ども肥満撲滅委員会（Commission on Ending Childhood Obesity）（勧告4.12）（16）によって求められ ていたもので、これにより、Global recommendations on physical activity for health（健康づくりのための身 体活動に関するグローバルな推奨事項）（1）で省略されてい た若年層が取り上げられた。 本「WHO 身体活動および座位行動に関するガイドライン」 （2020 WHO Guidelines on physical activity and sedentary behaviour）は、この2010年のガイドライン に替わるものであり、特定の行動と付随する健康上の結果 に関するエビデンスの最新版に基づいている。これらは、 身体活動と座位行動に関するグローバルな推奨事項のセッ トの一部を構成するものである。 １ WHA71.6 WHO Global Action Plan on Physical Activity 2018–2030（WHOの身体活動に関するグローバルなアクションプラン）。 15Background W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r その他の重要なWHOガイドライン 健康における身体活動の重要性は、その他のWHOガイドラ インでも指摘されている。WHO Package of essential noncommunicable disease interventions for primary health care in low-resource settings（リソースの少な い現場での一次医療のための基本的な非感染性疾患の介入 のWHOのパッケージ）（17）では、高血圧、２型糖尿病、心 血管リスクの増大、喘息、慢性閉塞性肺疾患に対する臨床 管理の手順が示されるとともに、身体活動を中強度（早歩 きなど）まで徐々に上げていき、2010年のグローバルな推 奨事項に合わせて少なくとも週に150分以上まで増やすた め の 助 言 も 盛 り 込 ま れ て い る。 最 近 のWHOのRisk reduction of cognitive decline and dementia（認知機 能低下および認知症のリスク低下）（18）のガイダンスでは、 認知機能低下のリスクを低下させるために、正常な認知力 をもつ成人（強い推奨）と軽度認知障害を有する成人（条 件つきの推奨）に身体活動を推奨すべきであるとしている。 WHOのIntegrated care for older people：guidelines on community-level interventions to manage declines in intrinsic capacity（内因性の能力低下を管理 するための地域社会レベルの介入に関するガイドライン） （19）では、転倒を予防するための多様な運動と、運動能の 低下がみられる高齢者向けの運動が推奨されている。WHO recommendations on antenatal care for a positive pregnancy experience（ポジティブな妊娠経験のための 出産前ケアに関するWHOの推奨事項）（20）では、妊娠中に 健康に過ごし過度の体重増加を防ぐための健康的な食事と 身体活動に関して指導を受けることが推奨されているが、 妊娠中から産後までの期間の身体活動における健康上の利 益については取り上げられていない。 既存のWHOガイドラインは、これらの最新のガイドライン と併せると、主な疾患の予防と管理に対して、またライフ コース全体での健康とウェルビーイングの促進に対して身 体活動と座位行動の寄与するものに関するグローバルなガ イダンスを一層包括的にまとめたものとなっている。 理論的根拠と目的 身体活動のさまざまなタイプ、量、期間の健康インパクト に関する一連のエビデンスとともに、座位行動の影響と身 体活動のレベルと健康とのその相互関係に関するエビデン スは、ここ10年で内容が大幅に増えている。また、妊娠中 の女性や慢性疾患や障害を有する人たちの身体活動のため の科学的根拠は現在、そのような集団での身体活動と健康 アウトカムとの関連性の検討が可能な状況になっている。 Global action plan on physical activity 2018-2030 （身体活動に関する世界行動計画2018-2030）（14）では、 ACTION 4.1において、５歳未満の子ども、若年者、成人、 高齢者、特定の人たち（妊娠中の女性や慢性の疾患や障害 を有する人など）の身体活動と座位行動に関し、グローバ ルな推奨事項を策定し普及させるようWHOに求めている。 ガイドラインの範囲を更新して広げるのは、2010年の推奨 事項で取り上げられなかった集団の身体活動に関し、具体 的な推奨事項を盛り込むことを求めた世界保健総会の要請 に応じるものである。これは、身体活動に関するグローバ ルな行動計画の鍵となる原則ならびに目標に足並みをそろ えたものであり、つまり不平等を抑えて、すべての人々が 日々の身体活動を増やせるように支援するためのものであ る。 これらのガイドラインのすべてにかかわる目的は、子ども および青少年、成人、高齢者と特定の集団（例えば妊婦と 慢性状態か障害者によるそれらの生活）が有意の健康上の 利益と健康リスクの軽減のために、どのようなタイプの身 体活動をどの程度行うべきであるのかという点について、 科学的根拠に基づいた公衆衛生の推奨事項を示すことにあ る。また、これらのガイドラインは、座位行動と健康アウ トカムとの関連性に関する科学的根拠に基づいた推 奨事項も示している。 16 ガイドラインは子ども子どもおよび青少年（５～17歳）、 成人（18～64歳）、高齢者（65歳以上）を対象に策定され たものであるが、妊娠中の女性や慢性疾患や障害を有する 人などの亜集団の身体活動に関する具体的な推奨事項が初 めて盛り込まれた。推奨事項はそれぞれ特定の年齢層と特 定の集団に向けて策定されており、当該情報を入手しやす い特定のコミュニティに該当する人を示している。特定の 集団ごとに、特に慢性疾患や障害を有する人に向けて推奨 事項を別途示したことで、身体活動と座位行動の介入の政 策と計画に特定の集団を含めることの重要性が際立つ。 これらのガイドラインでは、睡眠を一つの行動としては扱っ ていない。睡眠は、重要な健康関連の問題であり、集団の 健康科学の範疇で新たに登場した論題である。しかしなが ら、今回の最新版の推奨事項で睡眠を取り上げることは、 委託された内容の範囲外に当たるとみなされた。しかしな がら、睡眠の重要性は認識されているため、身体活動と座 位行動の影響を考慮する場合に重要な健康アウトカムとし て盛り込まれた。 想定対象者 本文書は、推奨事項の策定にあたり、プロセスを報告し、 科学的根拠に基づいて精査された内容を要約している。 主な対象者： １． 高所得国ならびに低・中所得国の健康、教育、青少年、 スポーツおよび／または社会福祉もしくは家族福祉を 担当する省庁の政策立案者であり、各国固有のガイド ラインを考案する者、またライフコース全体の健康、 教育、職場、住民もしくは地域社会ベースの介入プロ グラムを立案する者。 ２． ガイダンス文書を通して特定階層の人々の身体活動を 促し座位行動を削減することを目指す、国家、準国家、 または地方自治体の計画を策定する政府高官。 ３． 民間の組織、教育機関、職業団体の職員、もしくは研 究者。 ４． 公共医療の従事者のほか、地域社会、家族、一次医療 もしくは三次医療の看護師、医師、もしくは保健医療 の区分を越えて従事する同様の保健医療および運動の 専門家に助言やガイダンスを行う者。国のガイダンス を利用できない場合は、これらの論題に関する助言の 内容を本ガイドラインで参照できる。 本ガイドラインに記載されている身体活動と座位行動に関 する推奨事項は、医療従事者、身体活動の専門家、教育専 門家に向けて、養成のための研修コースやプロとしての能 力開発のコースの伝達に活用すべきである。 特定のエンドユーザーや、保健医療以外の各部門の関係者、 また幅広いコミュニティに本ガイドラインを伝えるために、 また各対象者の具体的なニーズを満たすよう個別対応のや り取りを行ううえでも、派生的な産物が求められる。 17Background W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 方法 本 ガ イ ド ラ イ ン は、WHO Handbook for guideline development（ガイドライン策定のためのWHOハンドブッ ク第２版）（21）に準じて作成された。健康増進部が率いる WHO運営委員会が設立され、WHOの各地の事務局やWHO の当該部署から代表者が集まって構成された。また、性別 のバランスと地域的に偏りが出ないように考慮したうえで、 専門家や関係者27名から成るガイドライン策定グループ （Guideline Development Group：GDG）が組織された。 ガイドラインの草案を同グループに属さない外部からの評 価者７名が精査し、科学的なエビデンスとその解釈および 内容に関してフィードバックを提示した。また、ガイドラ インの草案についてはオンラインでの公開協議も行い、 400名以上の投稿者からフィードバックが寄せられた。研 究者、診療医、一般市民から得られたこれらの情報をGDG が照合して活用し、ガイドラインを完成させた。ガイドラ インの策定プロセスの管理については、付録１に細部まで すべて記した。 ガイドラインの適用範囲と 懸案のクエスチョン GDGはガイドラインの範囲を精査し、最初の会議では、最 も 重 要 と な るPI/ECO（Population, Intervention/ Exposure, Comparison, Outcome：集団、介入／曝露、 対照、アウトカム）のクエスチョンについて意見が一致し た。各特定集団について取り上げられたクエスチョンを以 下にまとめた。 身体活動について： ａ． 身体活動と健康関連アウトカムとの間にはどのような 関連性があるか？ ｂ． 量反応関係（量、時間、頻度、強度）はあるか？ ｃ． その関連性は身体活動のタイプまたは範囲に応じて変 化するか？ 座位行動について： ａ． 座位行動と健康関連アウトカムとの間にはどのような 関連性があるか？ ｂ． 量反応関係（総量、頻度、時間、中断の強度）はある か？ ｃ． その関連性は座位行動のタイプおよび範囲に応じて変 化するか？ ｄ． 成人のみ：身体活動により、死亡率に対する座位行動 の影響は緩和されるか？ 各集団（population：P）とも、曝露群（exposure：E） は身体活動の量、時間、頻度、または強度の値が高かった が、対照群（comparison：C）では身体活動が一切ないか、 量、頻度、強度または時間が低い値であった。各集団の重 大および重要なアウトカムについて、表１とウェブ付録： エビデンスプロファイルの当該のセクションのPI/ECOの各 クエスチョンの詳細事項にまとめた。 18 表１：集団の群別にみた重大および重要な＊健康アウトカムの概要 アウトカム （アルファベット順） ５～17歳の 子どもおよび 青少年：PA および座位 18～64歳の 成人： PA 18歳以上の 成人：座位 65歳以上の 成人： PAa 妊娠中および 産後 慢性疾患 b 障害を有する 子どもおよび 成人c 肥満（体重増加、体重変 化、体重管理、体重の安 定性、体重の状態、体重 維持） 重大 重大 重大 重大ａ 重大 重大−HIV ― 有害事象 重大 重大 ― 重大ａ 重大（胎児のアウトカム） ― ― 総死亡率および 死因別死亡率 ― 重大 （がんおよび CVD特異的） 重大 重大ａ ― 重大 ― 骨の健康 重大 ― 重要 ― ― ― ― 心血管代謝の健康 重大 ― ― ― ― ― ― 認知機能のアウトカム 重大 重大 重要 重大ａ ― ― 重大−MS、 PD、Stk、 Sch、ADHD 分娩合併症 ― ― ― ― 重要 ― ― 疾病の進行 ― ― ― ― ― 重大−HT、 T2D、HIV、 重大−がんの 再発 ― 転倒および 転倒関連の負傷 ― ― ― 重大 ― ― ― 胎児のアウトカム （出生体重、早産） ― ― ― ― 重大 ― ― 機能的能力 ― ― ― 重大 ― ― ― 妊娠糖尿病 ― ― ― ― 重大 ― ― 妊娠性高血圧／子癇前症 ― ― ― ― 重大 ― ― 健康関連の生活の質 ― 重要 重要 重要ａ ― 重大−HT、T2D、HIV 重大−MS、 PD、Stk、 Sch、ADHD がんの罹患率 ― 重大 重大 重大ａ ― ― ― CVDの罹患率 ― 重大 重大 重大ａ ― ― ― 高血圧の罹患率 ― 重要 重要ａ ― ― ― ２型糖尿病の罹患率 ― 重大 重大 重大ａ ― ― ― メンタルヘルス （不安および抑うつの症状） 重大 重大 重要 重大 ａ 重大 ― ― 骨粗鬆症 ― ― ― 重大 ― ― ― 体力 重大 ― 重要 ― ― ― ― 身体機能 ― ― 重要 ― ― 重大−HT、T2D、HIV 重大−MS、 SCI、ID、 PD、Stk 向社会的行動 重要 ― ― ― ― ― ― 心理・社会的アウトカム ― ― ― 重要 ― ― ― 共存症のリスク ― ― ― ― ― 重大−HT、T2D、HIV 重大−MS、 SCI、ID 睡眠 重要 重要 重要 重要ａ ― ― ― ＊ 重大なアウトカム：意思決定において重大なアウトカム。重要なアウトカム：意思決定において重要ではあるが重大ではないアウトカム。 ａ 高齢者を含む成人集団において重大および重要とみなされたアウトカム。 ｂ 特定集団の病態についてのアウトカムは以下のとおり：がん−がんサバイバー、HT−高血圧、T2D−２型糖尿病、HIV。 ｃ 特定集団の病態についてのアウトカムは以下のとおり：MS−筋硬化症、SCI−脊髄損傷、ID−知的障害、PD−パーキンソン病、Stk−脳卒中サバイバー、Sch−統 合失調症、ADHD−注意欠陥多動性障害。 　 年齢特異的な集団の重大および重要なアウトカムについては、検討し推定されたものである。 19方法 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r エビデンス 身体活動に関する2010年のWHOの推奨事項の改訂は、本 ガイドラインの適用範囲に関連がある最新の当該のアンブ レラレビューを特定したうえで更新することにより行われ た。 このような手法は、複数国の身体活動のガイドラインの策 定を普及させるために行われた最新の系統的レビューの詳 細な内容に基づいて採択された。また、公衆衛生の急速に 発展している分野の最新の利用できるデータがWHOの新た なガイドラインに確実に反映されるようにするため、さら に更新が行われた。 アンブレラレビューは、以下の３つの基準を満たしている ものが選択された。 ⅰ） 文書で十分に裏付けられている標準的な系統的プロセ スに従ってエビデンスレビューが行われている。 ⅱ） エビデンスの確実性の評価には、GRADE（Grading of Recommendations Assessment, Development and Evaluation：推奨の強さのグレーディング）法、 または解説が詳しく文書化されている評価の方法論が 使用されている。 ⅲ） エビデンスのレビューは、国別または国の所得水準に よる制限を設けずに関心対象の集団を取り上げたもの である。 PI/ECOのクエスチョンと、重大および重要な健康アウトカ ムについては、既存のエビデンスのレビューに対してマッ ピングを行い、必要な場合には、格差を取り上げる新たな レビューを委託した。GDGからは、最初のレビューと同じ 検索語、検索言語、およびデータベースを使用してエビデ ンスのレビューを更新するよう依頼した。 以下のエビデンスのレビューは、上記の３つの基準を満た していることを確認したうえで、最新であること、また包 括的であることから選択されたものである。 ・ Canadian 24-hour movement guidelines for children and youth（子どもおよび若年者に対するカナ ダの24時間運動）ガイドライン（23）の策定のプロセス の一環としてPoitras et al.（2016）が行った、学齢に 達した子どもおよび若年者（22）の身体活動と健康指標と の関連性に関する文献の系統的レビュー。このレビュー は、単に身体活動の客観的な測定値を使用した研究のみ に目を向けたものであった。計162件の研究が対象とな り、参加者は31カ国204171名に相当する。 ・ Canadian 24-hour movement guidelines for children and youth（子どもおよび若年者に対するカナ ダの24時間運動）ガイドライン（23）の策定プロセスの 一環としてCarson et al.（2016）が行った、学齢に達 した子どもの座位行動と健康指標との関連性に関する文 献の系統的レビュ （ー24）。（23）. 計235件の研究（194 例の一意のサンプル）が対象となり、参加者は71カ国 1657064名に相当する。 ・ 2019 Australian 24-hour movement guidelines for children and young people（子どもおよび若年者（５ ～17歳）に対する2019年のオーストラリアの24時間運 動）ガイドライン（26）の策定の一環としてOkely et al. （2019） が 実 施 し（25）、Poitras et al.（2016）（22） およびCarson et al.（2018）（24）が更新した系統的レ ビュ （ー24）。この報告では、2019年７月（25）までに 発表された身体活動に関する研究42件と座位行動に関す る研究32件がさらに特定された。 　 Okely et al.が作成したGRADEの表を、WHOのために 委託されて実施した更新版を基にして使用した。この GRADEの表は、エビデンスプロファイルと併せてWeb Annex：Evidence profiles （ウェブ付録：エビデン スプロファイル）に掲載した。 ・ 2019 Canadian guideline for physical activity throughout pregnancy（妊娠の全期間の身体活動に関 する2019年のカナダのガイドライン）の策定の一環とし て実施され、まとめられた12件の系統的レビュ （ー27）。 この12件のレビューは、妊娠の全期間を通しての母体の 身体活動に関する25000件以上の研究を評価したもの で、母体、胎児、または新生児の罹患率または胎児死亡 率のアウトカムについて英語、スペイン語、およびフラ ンス語で報告されている。これらの系統的レビューのう ち７件では、GDGが重大および重要とみなしたアウトカ ムが取り上げられていた（28–34）。これらのエビデンス のレビューから得られたGRADEの表は、策定された WHOの推奨事項を更新し普及させるために実施された文 献検索の基盤として使用された。最新のエビデンスプロ ファイルは、Web Annex： Evidence profiles （ウェ ブ付録：エビデンスプロファイル）に掲載した。 ・ 2018 Physical activity guidelines for Americans （2018年の米国人に対する身体活動のガイドライン）第 ２版（36）の策定の一環として2008～2016年に発表さ れた、身体活動および座位行動ならびに健康アウトカム に関するエビデンスの系統的な更新内容を示すPhysical Activity Guidelines Advisory Group（PAGAC：身体 活動ガイドライン顧問団）の科学的報告書（35）。要約さ れたエビデンスでは、公衆衛生の関連性から選択された 計38件の主なリサーチクエスチョンと計104件のサブク エスチョンが取り上げられていた。このエビデンスを構 成している系統的レビューの結果は、計1130本の論文か Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 20 ら得たもので、38問のリサーチクエスチョンに回答する ためにそれぞれ抽出されたものである（35）。この手順に おいて、系統的レビューとメタアナリシスの方法論的な 質を評価するために系統的レビューを評価する測定ツー ル の“A Measurement Tool to Assess Systematic Reviews”（AMSTARExBP）の修正版を使用した。バ イアスまたは内的妥当性のリスクについては、バイアス 評 価 ツ ー ル のUSDA NEL Bias Assessment Tool （BAT）を適合させたバージョンを使用し、それぞれの当 初の研究について評価を行った（37）。このWHOのガイ ドラインのために実施された検索内容の更新で新たに特 定されたエビデンスをWeb Annex：Evidence profiles （ウェブ付録：エビデンスプロファイル）に掲載した。 リンクはPAGAC（35）の報告書と補足資料に示した。 エビデンスの更新およびデータの抽出方法 コホート研究の系統的レビューとプール解析の検索は、対 象となった各レビュー（リストは上述のとおり）に対して 最後に検索を行った日付から2019年９月までに発表された 研究に対して実施した。データ抽出の手順については、標 準的なものを作成して採用した。 Poitras et al.（2016）（22）, Carson et al.（2016）（24）、 およびOkely et al.（2019）（25）が実施した検索内容を更新 す る た め、 デ ー タ ベ ー ス のMEDLINE、EMBASE、 PsycINFO、およびSportDiscusに検索をかけ、英語または フランス語で執筆された査読済みのレビューを特定した。 PAGAC（35）で実施された検索内容を更新するため、デー タベースのPubMed、CINAHL、およびCochraneに検索を かけ、英語で執筆された査読済みのレビューを特定した。 PAGAC（35）が対象としなかった重要なアウトカムの新規の 検索については、リソースに制約があるため実施しなかった。 検索については、国別または国の所得水準による制限を設 けずに実施し、主観的または客観的に測定された身体活動 または座位行動すべてを取り上げたレビューを対象に含め た。当初の検索で使用された言語以外の言語では検索を行 わないこととした。これは、リソースに制約があるためで あり、また追加のレビューがあった場合に、そのような検 索では得られる結果が極めて少ないものになることを示す 分野でのそれまでの経験から決定された。レビューでは、 身体活動または座位行動と健康関連アウトカムとの関連性 （身体活動または座位行動の閾値の上下のレベルに基づく） を調査し、これらと健康関連アウトカムとの間の量反応関 係を探査して検討した。 外部から集めた評価者のチームは、ツールとしてAMSTAR 2 （Assessment of Multiple Systematic Reviews）を使用 し、組入れ基準の考慮点に従って系統的レビューの信憑性 を評価した（38）。AMSTAR 2ツールには、レビューの計画 と実施に関する16項目が含まれている。各レビューの結果 に対する全体的な信頼性について、公表されているガイダ ンスに従って評価した。具体的には、「高」の評価はレビュー に重大ではない限界点が０または１つあったことを示し、 「中」の評価は重大ではない弱点が複数あると判断されたレ ビューであることを示し、「低」の評価は重大ではない弱点 の有無を問わず重大な欠陥が１つある、または重大ではな い弱さが複数あると判断されたレビューであることを示し、 「極めて低度」は重大な欠陥が複数あったことを示す。 暫定的に含めたすべてのレビューに対し、１名の評価者が AMSTAR 2ツールを使用して評価を行った。１名の評価者 が極めて低いと評価したレビューについては、別の１名の 評価者が同じツールを使用して評価を行った。極めて低い と評価されたレビューは除外した。これは、そのようなレ ビューは信頼性が低すぎるため、特にアウトカムについて 唯一利用できるレビューではない限り、入手したエビデン スの正確かつ包括的なサマリーを示すことはできないもの と判断されたためである。 この総体エビデンスにはプールコホート研究も含まれた。 外部から集めた評価者のチームは、研究の質の評価に、 Newcastle-Ottawaスケール（39）を使用した。各研究の 質を「良好」、「中」、または「不良」で格付けして評価した。 概して、質が高い研究は、Newcastle-Ottawaスケールの すべての基準を満たしていた。質が中程度の研究は、満た していない基準が１つ以上あった、または満たしていたか 否かが不明であったもののその結果を無効とできるほどの 重要な限界もはっきりとは分からなかった。質が低い研究 は、致命的な欠陥が１つあるか、重要な限界が複数あった。 質が低い研究は除外した。 重複について評価したところ、複数のレビューで研究が重 複している可能性が認められた。総体エビデンス、レビュー の概要、および一部のプールコホート研究に重複があるレ ビューは除外し、より包括的な、あるいは最新のレビュー の方を優先した。 新たにレビューを行う方法 既存のエビデンスにおいてギャップが明らかになった場合、 以下について検討するための新たなアンブレラレビューを 委託した。 １． 職業上の（すなわち職業関連の）身体活動と健康関連 アウトカムとの関連性（40）。 ２． 余暇場面の身体活動と有害な健康アウトカムとの関連 性（41）。 （上記のNo. １および２について、2009年から2019年12 月 ま で に 発 表 さ れ た レ ビ ュ ー に 対 し、PubMed、 21方法 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r SportDiscus、およびEMBASEを使用して検索を行った。） ３． 身体活動と転倒予防との関連性。Sherrington et al. （42）による2019年のコクラン共同計画の系統的レ ビューを使用し、2019年11月までの当初のレビュー について最後に検索が行われた日付以降に発表された エビデンスを基に更新した。 ４． 身体活動と骨粗鬆症ならびにサルコペニアとの関連性。 2008年から2019年11月までに発表されたレビュー について、骨粗鬆症とサルコペニアに関する既存の系 統的レビューに関する検索をPubMedの中で実行した ところ、新たなレビューは特定されなかったが、原著 研究が新たに８件特定された。 ５． HIVを有する人における身体活動と健康アウトカムとの 関連性に関するエビデンス。スコーピングレビューで は、PubMed、CINAHL、およびWeb of Scienceを 使用し、開始日の制限を設けず、2019年10月までに 発表されたエビデンスに対して行われたアンブレラレ ビューの実施を裏づけるため、HIVを有する人を対象に した身体活動と健康関連アウトカムに関するエビデン スの有効性を確認した。 身体活動と座位行動のエビデンスの特徴と  評価方法の概要 最近までは、成人を対象に身体活動と座位行動を測定する 場合の主な方法は自己申告式（すなわちアンケート）であ り、子どもを対象とした場合には自己申告か、親や保護者 による思い出し法のいずれかであった。そのような方法は、 これらの方法が安定した強みを有するものの、報告バイア スや測定誤差の傾向があるなどの限界がある（43）。近年、 この分野で急成長しているデジタル技術により、身体活動 と座位時間およびそれらと健康アウトカムとの関連性を評 価する場合にデバイスに基づく尺度の利用が増えている。 しかしながら、結果を複数の研究間で比較することには、 デバイス（加速度計）ごとの技術的な特性や配置の差に起 因する課題や、データの分析や報告の差に起因する課題が 未だに残っている。たとえば、デバイスに基づく尺度で座 位時間を測定する場合、現在のところ、デバイスの多くは 体位（例：横臥位、座位、立位で安静）の違いを識別しな いため、誤算が生じるおそれがある。デバイスを測定のベー スとしている研究から得た所見と、自己申告をベースとし ている研究から得た所見を比較すると、差異が存在する。 内容により、また身体活動の例、回答の選択肢、および対 象とされる場面により、自己申告のツールが異なる。最近 の研究では、トータルでの身体活動か、レジャー／レクリ エーション場面に限っての身体活動のいずれかを評価する ことに主眼が置かれているが、現在は移動時の身体活動 （例：ウォーキングやサイクリング）、職場での身体活動、 家庭内での身体活動など、ほかの場面もますます含まれる ようになっている。大多数のエビデンスは有酸素性の身体 活動と健康アウトカムとの関連性について報告したもので あるが、現在は筋力向上運動の利益をはじめ、さまざまな タイプの活動やほかの場面を組み合わせた場合についても 評価が行われている。 身体活動レベルと健康アウトカムとの関連性に関する結果 は、さまざまな方法で報告され、比較されている。多くの研 究では、身体活動の四分位群または五分位群の比較が報告さ れており、その他の研究では国のガイドラインを「満たして いる」か「満たしていない」かを比較するものもある。 トータルでの身体活動の算出を報告する場合は通常、MET- 時／週で概算を出す。研究によっては身体活動量の「最大」 群と「最小」群の値を比較するものもあるが、カテゴリー も研究ごとに異なる。文献では、既存のガイドラインに基 づくデータカットポイント、または現在のWHOグローバル な推奨事項や先行研究から得た測定基準に基づくデータ カットポイント（例：青少年を対象集団としたある研究で は１日60分のカットポイント、または筋力トレーニングの 介入では週に２～３回など）を適用した分析から得られた 結果がしばしば報告されている。そのようなカットポイン トが珍しいものではなくなってくると、健康アウトカムに おいて、身体活動の曝露レベルが高いか低いかという関連 性に関してエビデンスを構築することに限界が生じる可能 性がある。 子どもおよび青少年の座位行動と健康アウトカムとの関連 性を評価しているエビデンスのほとんどは、事実上横断的 であり、大多数の研究は座位時間の自己申告の尺度か親に よる申告された尺度に依存しており、これらは測定誤差と 思い出しバイアスの影響を受ける。 縦断的な観察研究と介入試験から得たエビデンスを優先し、 横断的なエビデンスを単独で使用したレビュー、または主 として統合したレビューについては考慮に入れなかった。 確実性が中以上に格付けされたレビューにより提供された エビデンスに、またデバイスをベースとした曝露の尺度を 使用した研究からのエビデンスを示すものに重点を置くよ うにした。 一連のエビデンスの格付け GRADE（Grading of Recommendations Assessment, Development and Evaluation：推奨の強さのグレーディ ング）法を使用し、レビューの基盤となるエビデンスに基 づき、各PI/ECO（44）のエビデンスの確実性を評価した。 利用できる場合には、各レビューから得たGRADEの「エビ 22 デンスプロファイル」または「所見の概要」を起点として 使用した。既存の系統的レビューには利用できる表がない 場合には、各集団とアウトカムごとに「エビデンスプロファ イル」表を作成した。 GRADE法を使用して各PI/ECO（44）のエビデンスの確実 性を評価した。その際、基準として、研究デザイン、バイ アスのリスク、効果の一貫性、非直接性、効果の精度、お よびその他に発表バイアスや、観察エビデンス（効果の大 きさ、量反応、および交絡因子の効果）を更新するための 因子を含む限界を考慮した。優れた実施方法による縦断的 研究から得た観察エビデンスについても、そのような研究 から得た身体活動または座位行動とアウトカムとの関連性 に関する所見の確実性の向上をさらに適切に反映するため、 更新を行った。アウトカム（中間のアウトカムを含む）の 優先順位をGDGが付けているため、中程度／非直接的アウ トカムを評価した研究が必ずしもグレードダウンされたわ けではなく、GRADEの格付けは、それらのアウトカムに対 する効果の確実性を反映したものである。場合によっては、 GRADE法の使用における一貫性を確保するために、既存の レビューによるGRADEの格付けを修正した。各アウトカム の総体エビデンスの確実性は、以下のガイダンスに基づい て割り当てた（45）。 エビデンスから推奨事項に向けて GDGは、クエスチョンに特化した推奨事項を作成するため のGRADE Evidence to Decisions（EtD）フレームワー クを採用した。EtDフレームワークは、意思決定への系統的 で構造化された透明性のあるアプローチである。このフレー ムワークでは、リサーチエビデンス、エビデンスの確実性、 また必要な場合には専門家の意見や想定対象者の考えから 得た主題の知識を考慮し、ガイドラインの推奨事項を作成 するため、明確な基準を使用する。これらの基準から、望 ましいアウトカムと望ましくないアウトカムで観察された エビデンス、エビデンスの全体の確実性、望ましいアウト カムと望ましくないアウトカムに関する患者の相対値、該 当する場合はリソースの使用（コスト上の問題）、健康の不 公平への潜在的なインパクト、推奨事項の許容可能性およ び実現可能性のバランスについて、判断が導き出される。 GDGは、すべての重大なアウトカムとすべての利用できる 重要なアウトカムの各推奨事項について、全体的に、総体 エビデンスを検討した。曝露／介入とアウトカムの接点に 関しては、評価対象の具体的な曝露／介入、評価対象のア ウトカム、研究デザイン、および分析的方法において、研 究ごとに大きな差異がみられ、 結 果 的 に 利 用 で き る エ ビ デ ン ス に ば ら つ き （heterogeneity）が生じた。したがって、それぞれの特異 的な曝露／介入とアウトカムの関係に対し、GRADEの古典 的アプローチを適用することはできず、むしろ、曝露／介 入の測定と分析における研究デザインのタイプとバリエー ション全体で、各曝露／介入とアウトカムの関係を取り上 げている全体的な総体エビデンスにGRADEを適用した。こ れらの因子がエビデンスの整合性に関する懸念（すなわち、 異なる視点から注目した場合には、特定の曝露／介入とア ウトカムの関係のエビデンスが一致しなかったこと）につ ながる場合、委員会はエビデンスの確実性をダウングレー ドした（21）。 GDGが身体活動と座位行動の効果を検討するに当たり優先 した健康アウトカムは、総死亡率および死因別死亡率（心 血管疾患およびがん）の低下、心血管疾患の発生率の低下、 がん（部位特異的）、２型糖尿病、体力の向上（例：心肺、 運動技能発達、および筋体力）、心血管代謝系の健康増進 （例：血圧、脂質異常症、グルコース、インスリン抵抗性）、 骨の健康、メンタルヘルス（例：抑うつ症状の減少、自尊 心、不安症状、ADHD）、認知機能のアウトカムの向上 （例：学業成績、遂行機能）、肥満の減少である。有害作用 （例：負傷および損傷）も考慮した。 その他の考慮点 GDGは、各集団とすべてのPI/ECOのクエスションについ ては、ガイドラインで対象とされる者の価値観や好みにつ いても考慮した。具体的には、推奨事項のリソースの影響、 健康の公平性に対するインパクト、および推奨事項の許容 可能性および実現可能性である。これらの考慮点とGDGの 評価には少なからぬ重複があったことから、各集団の群別 にそれらの事柄の評価に関して議論した内容を「エビデン スから推奨事項へ」のセクションにまとめて詳述した。 高 真の効果が効果推定値に近いことに非常に 確信がある。 中 効果推定値に対し中等度の確信がある。真 の効果は効果推定値に近い可能性が高いが、 大幅に異なる可能性もある。 低 効果推定値に対する確信性に限界がある。 真の効果は効果推定値と大幅に異なるかも しれない。 非常に低 効果推定値に対してほぼ確信が持てない。 真の効果は効果推定値と大幅に異なる可能 性が高い。 23方法 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 推奨事項 WHO Guidelines on physical activity and sedentary behaviour （WHO 身体活動および座位行動に関するガイドライン）で 発表される公衆衛生の推奨事項は、性別、文化的背景、ま たは社会経済的地位にかかわらず、全集団と５歳から65歳 以上の範囲の年齢層に向けたものであり、障害の有無を問 わずすべての人に該当する。 新しいガイドラインは、年齢層と行動（身体活動および座 位）別に示されている。それぞれの推奨事項の導入部には、 身体活動と座位行動と関連のある健康アウトカムをまとめ たうえで、推奨事項を記した。優れた実践の部分には、推 奨事項がターゲット集団別に、安全に推奨事項を満たす方 法をより明確に記されている。これらの優れた実践は、そ れ自体で「格付けされた推奨事項」なのではなく、科学的 なエビデンスに由来したものであり、GDGが精査したうえ で推奨する実際的な考慮点から導き出されたものである。 それぞれの推奨事項には、裏付けとなる科学的なエビデン スの概要を示し、３つのPI/ECOのクエスションで構成され ている。１つ目は重大な健康アウトカムとの関係に関する エビデンス、２つ目は量反応に関するエビデンスの概要で あり、最後に、曝露のさまざまなタイプまたは場面と健康 アウトカムとの関連性に関するエビデンス（存在する場合） の概要を示した。 24 子どもおよび青少年 （５〜17歳） 身体活動の推奨事項 子どもおよび青少年の場合、身体活動は、教育現場、家庭、ならびに地域社会の現 場の背景を踏まえて、レクリエーションとレジャー（遊び、ゲーム、スポーツ、ま たは計画的な運動）、体育、移動（車いすでの移動、ウォーキング、サイクリング）、 または家事の一環として行うことができる。 裏付けのエビデンスと理論的根拠 子どもおよび青少年に関して、本ガイドラインでは、系統的レビュー（22, 25, 35）を使用し、組入れ基準を満たし ている新規のレビュー16件が特定され、更新が行われた。方法、データ抽出、およびエビデンスプロファイルにつ いては、Web Annex： Evidence profiles （ウェブ付録：エビデンスプロファイル）に細部まですべて記した。 優れた実践 ・身体活動を一切しないよりは少しでもした方がよい。 ・ 上記の推奨事項を満たしていない子どもおよび青少年は、ある程度の身体活動を行うことで健康上の利益 が得られる。 ・ 子どもおよび青少年の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時間を増やして いく。 ・ すべての子どもおよび青少年に対し、楽しめる内容で、変化に富み、年齢や能力に適した身体活動に参加 する安全かつ公正な機会を設け奨励することが重要である。 子どもおよび青少年の身体活動は、体力（心肺体力および筋力）、心血管代謝の健康（血圧、 脂質異常症、グルコース、インスリン抵抗性）、骨の健康、認知アウトカム（学業成績、実行 機能）、メンタルヘルス（抑うつの症状の軽減）の向上と、肥満の減少などの健康アウトカム に利益がある。 推奨事項： ＞子どもおよび青少年は、中高強度の主に有酸素性の身体活動を週全体で１日につき平均60分 以上行うこと。 強い推奨、エビデンスの確実性は中 ＞高強度の有酸素性の活動とともに、筋肉および骨を強化する活動を週に３日以上組み込むこと。 強い推奨、エビデンスの確実性は中 Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 25推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 子どもおよび青少年（５〜17歳） 子どもおよび青少年（５～17歳）の場合、 身体活動と健康関連アウトカムとの間にはど のような関連性があるか？ 大規模な総体エビデンスによりすでに立証されていること は、子どもおよび青少年の場合、身体活動の量が多く強度 が高いことは、複数の有益な健康アウトカムと関連してい るということである（1）。最近のエビデンスで改めて確認さ れたことは、子どもおよび青少年において、身体活動を増 やすことは、心肺体力および筋力を向上させるということ である（22, 35）。たとえば、週に３日以上の中高強度の身 体活動を30～60分間行うと、好影響が得られる（22, 35）。 子どもおよび青少年の場合、主に有酸素性の定期的な身体 活動は、血圧、脂質プロファイル、グルコース制御、イン スリン抵抗性の改善など、有益な心血管代謝の健康アウト カムと正の相関がある（35）。最近のレビューでは、学校 ベースの身体活動プログラム（46）、高強度のインターバル トレーニング（47）、およびレジスタンストレーニング（48） の有効性について、心血管代謝の健康の尺度を介入なしの 場合と比較して検討が行われた。全３件のレビューの中に、 介入は心血管代謝のアウトカムの向上と関連していたとす る一貫性のあるエビデンスがあったが、効果量の精度には 変動があり、個々の試験ですべての心血管代謝のアウトカ ムに身体活動の統計的に有意な利益を示した試験はほとん どなかった。19件のRCT（ｎ＝11 988）に関する１件の レビュ （ー46）によると、学校ベースの身体活動プログラム は、身体活動の介入がない場合に比べ、拡張期血圧（ES＝ 0.21［95％ CI：0.42～0.01］；ｐ＝0.04）と空腹時イン スリン（ES＝0.12［95％ CI：0.42～0.04］；ｐ=0.03） の統計的に有意な改善と関連があった。 身体活動は肥満との望ましい関連性が報告されており、子 どもおよび青少年の場合、活動レベルが高いことは、健康 的な体重の状態と関連している（22, 35）。結果は概して横 断的研究で最も強いが、前向き観察研究からの混入が多い 結果では、既報の関連性の方向性の理解を制限することに なる。身体活動の介入試験（検査データベースの高強度イ ンターバルトレーニング［HIIT］、教室ベースの能動学習、 レジスタンストレーニング）の最近のレビューでは、効果 の報告がないレビューの対象となった研究の大多数と矛盾 する結果が報告された（47, 49, 50）。しかしながら、縦断 的研究と横断的研究を対象としたあるレビューでは、歩数 計で測定した身体活動と、肥満、BMI、または胴囲の測定 結果との間の負の相関が報告された（51）。全般的にみると、 身体活動は健康的な体重の状態の管理と関連しているとい う確実性の低いエビデンスがあり、関連性の方向性と強度 を判断するには、より多くの研究が必要である。 子どもよび青少年の身体活動と運動技能の発達との関連性 が検討されたエビデンスは少なく、現在のレビューでは所 見が示されていない（22）。今後のガイドラインを普及させ るためのアウトカムとして、運動発達についてさらに研究 する必要がある。 子どもおよび青少年の場合、骨に負荷のかかる活動は、ゲー ムをする、ランニングをする、回転する、あるいはジャン プする動作の一環として可能である。身体活動は骨量増加 分および／または骨構造と正の相関があり、子どもおよび 青少年では、身体活動が多いほど、骨量が多く、骨塩含量 あるいは骨密度が高く、骨強度が高いことを最近得られた エビデンスが裏付けている（35）。子ども期から青少年期に かけて、骨の健康を最大限に高めることは、将来の骨粗鬆 症やそれに伴う骨折を防ぐ一助となる。 認知機能を伸ばして維持することは、生涯にわたり必須で ある。子どもおよび青少年の場合、身体活動は認知機能や 学業上のアウトカム（例：学業成績、記憶力、遂行機能） に正の効果を与える（22, 35）。最近のあるレビュー（19件 のRCT；ｎ＝5038）は、週に複数回の運動介入を６週以 上行うと、運動介入が一切なかった場合に比べ、抑制制御 （SMD 0.26［95％ CI：0.08～0.45］，ｐ ＝＜0.01）、作 業記憶（SMD 0.10［95% CI：−0.05～0.25］，ｐ＝<0.02）、 認 知 的 柔 軟 性（SMD 0.14［95% CI：−0.03～0.31］， ｐ＝<0.04）などの認知機能の値の向上と関連があること を実証した（52）。子どもおよび青少年の身体活動は、大う つ病の有無を問わず、抑うつおよび抑うつ症状を経験する リスクも軽減し（35）、症状緩和という点では心理的治療法 や医薬品による治療法に匹敵しうる。 いずれの身体活動にも有害事象のリスクがつきものである が（53）、健康上の利益があると推奨される身体活動のレベ ルに関連した害のエビデンスの報告例は少ない（35）。利用 できるエビデンスや専門家の意見を基にすると、子どもお よび青少年に推奨される身体活動の量やタイプに関連した 潜在的リスクは低いと考えられ（35）、特に身体活動不足の 子どもおよび青少年の場合、活動性のレベルと強度を徐々 に上げていくとそのリスクは低下する。スポーツによって は、参加すると、運動強度が上昇するにつれて負傷のリス クが増大することは明らかになっている（53）。この分野の 知識の基盤を強化するには、さらに研究が必要である。 GDGが出した結論： ・ 子どもおよび青少年において、中強度や高強度の身体活 動量の増大は心肺体力および筋力の向上、心血管代謝の 健康、骨の健康と関連していることを示す確実性が中程 度のエビデンスがある。 26 子どもおよび青少年（５〜17歳） ・ 短期的および長期的な中高強度の身体活動は、認知機能、 学業上のアウトカムやメンタルヘルスに正の効果がある ことを示す確実性が中程度のエビデンスがある。 ・ 子どもおよび青少年の場合、身体活動が健康的な体重の 状態の管理と望ましい関連を示す確実性が低いエビデン スがある。 ・ 子どもおよび青少年に推奨される身体活動の量とタイプ のリスクは低く、利益が上回ることを示す確実性が低い エビデンスがある。 量反応関係（量、時間、頻度、強度）はある か？ 子どもおよび青少年における身体活動と健康アウトカムの 正の関係を示す実質的な総体エビデンスがあるが、量反応 の問題に取り組んだ研究は極めて少ない。したがって、子 どもおよび青少年の量−反応曲線の正確な形状および／ま たは身体活動や特定の健康アウトカムの閾値（低リスクと 高リスクを識別）の有無については、成人集団に比べてあ まりよくわかっていない。それにもかかわらず、実質的な 総体エビデンスは身体活動を毎日60分行うことで健康上の 利益の多くが得られることを示しており、エビデンスに矛 盾がないことを考えると、最新のエビデンスは１日当たり 60分の中高強度の身体活動を行うという現在のWHOの推 奨事項を再確認するものと結論づけた（1）。 しかしながら、複数の研究が健康アウトカムに関する身体 活動の利益の評価に１日当たり60分という「平均的な」閾 値（60分は１日の最小限の閾値ではない）を幅広く使用し たと想定すると、デバイスを測定のベースとしている研究 から得られた最近の結果を含め、すべてのエビデンスのレ ビューは、健康上の利益のため毎日60分の中高強度の身体 活動という「最小限」の定義の保持を裏付けるものではな かった。レビューでは、新たなガイドラインがこのエビデ ンスを綿密に反映するよう修正されるべきであると結論づ けた。 高強度の定期的な活動が心血管代謝の健康アウトカムに与 える利益はすでに立証されており（1）、最近のレビューによ り、エビデンスはさらに裏づけられている（35）。たとえば、 ある最近のレビュ （ー54）が示すところでは、高強度のイン ターバルトレーニングは、中強度の継続的トレーニングに 比べ、心肺体力に中等度の有益効果がみられた（SMD＝ 0.51［95％ CI：0.33～0.69］，ｐ＝＜0.01；I2＝０％）。介 入期間、運動の種類、運動時と安静時の比率、トータルの まとまった活動（bout）が心肺体力に対する影響を改善し たというエビデンスはなかった。これらの結果は総じて他 の最近のレビューと整合しており、若年および青少年が心 肺体力を改善するためには高強度の定期的な活動を行うべ きという以前からの推奨事項を裏付けている。 GDGが出した結論： ・ エビデンスは、１日当たり60分の中高強度の身体活動と いう以前からのWHOの推奨事項を肯定している。 ・ 60分の身体活動という１日の最小限の閾値という以前の 定義を週当たり１日に平均60分に修正することをエビデ ンスが裏付けている。 ・ 高強度の身体活動量を増やすことが心肺体力の改善と関 連しているという確実性が中程度のエビデンスがある。 その関連性は身体活動のタイプまたは場面に 応じて変化するか？ 子どもおよび青少年の場合、家族や学校ならびに地域社会 の活動という背景での身体活動には、遊び、ゲーム、スポー ツ、移動、レクリエーション、体育、または計画的な運動 が含まれる。しかしながら、身体活動と健康アウトカムと の関連性が活動のタイプ（例：有酸素性運動と筋力向上運 動との比較）または身体活動の場面（例：ウォーキングや サイクリングのような人力による移動と体育との比較、ス ポーツ／レクリエーションとの比較）によって変わるのか 否かを判断するにはエビデンスが不十分である。 子どもおよび青少年の場合、有酸素性の身体活動は、中強 度の場合も高強度の場合も活動量の増大は心肺体力と関連 していること、また筋力向上活動を増やすと筋力が増大す ることを示すエビデンスはある。このエビデンスは、2010 年 のWHOのGlobal recommendations on physical activity for health（健康づくりのための身体活動に関す るグローバルな推奨事項）を普及させ（1）、筋肉と骨を強化 する活動を週に少なくとも３日は組み込むことを推奨して いる。最新のエビデンスからは、週に３回の定期的な筋力 向上活動が筋力の指標の改善に有効であることが再確認さ れた。しかしながら、文献で評価されているものは曝露に ばらつきがあることが大きな原因となり、回数、期間、強 度の具体的な詳細を述べたエビデンスが不十分である（22, 35）。心血管代謝の健康に対し、レジスタンストレーニン グが保護効果を発揮することについては、エビデンスが少 ない。子どもおよび青少年の筋力向上活動について、頻度 以外の特徴（期間など）に関する新たなエビデンスがない ことを考えると、それ以上何か具体的なことを述べること はできなかった。今後の研究では、本ガイドラインのこの 部分についてより詳細な情報を示すため、身体活動の具体 的なタイプや場面からみた健康上の利益を取り上げるべき 27推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r である。 GDGが出した結論： ・ 筋力向上活動は週に少なくとも３日は組み込むべきとい う確実性が中程度のエビデンスがある。 子どもおよび青少年（５〜17歳） 28 子どもおよび青少年 （５〜17歳） 座位行動の推奨事項 座位行動とは、教育、家庭、地域社会の現場や移動時などの状況において、覚醒 しているときに、座ったまままたは横たわったままエネルギー消費が少ない状態 で時間を過ごしていることと定義されている。 裏付けのエビデンスと理論的根拠 座位行動は2010年のWHOの推奨事項に含まれていなかったが、過去10年の間に、座位行動のさまざまな尺度やタ イプと関連のある健康アウトカムを検討した研究が増えてきた。技術やデジタルはこれまでに仕事、勉強、旅行の方 法や余暇の過ごし方に影響を与えてきた。ほとんどの国では、子どもおよび青少年は、特にスクリーンを使用した娯 楽（テレビやコンピュータ）のようなレクリエーションの場合や、携帯電話のようなデジタル通信の場合に、座位行 動で過ごす時間が長い。 子どもおよび青少年に関して、本ガイドラインでは、系統的レビュ （ー24, 25）を使用し、組入れ基準を満たしてい る新規のレビュー７件が特定され、更新が行われた。方法、データ抽出、およびエビデンスプロファイルについては、 Web Annex： Evidence profiles （ウェブ付録：エビデンスプロファイル）に細部まですべて記した。 子どもおよび青少年の場合、座位行動の多さは、肥満の亢進、心血管代謝の健康度の低下、体力、 行動／向社会的行動、睡眠期間の減少などの不良な健康アウトカムと関連している。 推奨事項： ＞子どもおよび青少年は、座位のまま過ごす時間、特に余暇時間でスクリーンタイムが短くなる ように制限をかけること。 強い推奨、エビデンスの確実性は低 Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 29推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 子どもおよび青少年（５〜17歳） 子どもおよび青少年（５～17歳）の場合、 座位行動と健康関連アウトカムとの間にはど のような関連性があるか？ 座位行動が長いと、特に余暇時間のスクリーンタイム（画 面を見ている時間の長さ）が長いほど、不良な健康アウト カムと関連があることをエビデンスが示している（24, 35）。たとえば、子どもおよび青少年では、スクリーンタ イム（テレビ番組の視聴を含む）の時間が長いと、体力や 心血管代謝の健康（24, 25）が不良になることと関連してい る。座位行動との関連性のデバイスに基づく評価や介入試 験から得たエビデンスは中程度の影響を示したが、すでに 肥満を有する対象者の場合は影響がより強いものであった （55）。子どもおよび青少年の座位行動が骨の健康に関連が ないことを示唆しているエビデンスは少ない。 複雑な結果にもかかわらず、座位行動は肥満の望ましくな い測定値と関連している可能性があることもエビデンスは 示唆している（24, 25）。主な横断的研究をレビューしたあ る報告では、１日に２時間を超える座位行動（スクリーン タイムの合計として測定）は、これよりも短時間（＜２時 間／日）の場合に比べ、子ども期の過体重／肥満と明らか に関連していた（56）。ただし、20件の横断的研究をレ ビューした別の報告（57）では、子どもまたは青少年が座 りっきりでビデオゲームを行うこととBMIとの間に統計的 に有意な関連性を見出せなかった。 29件の系統的レビューを扱ったある大規模なレビューで は、座位行動が何らかの形式のスクリーンタイムとして自 己申告させると、若年者の肥満の座位行動とマーカーとの 間の望ましくない関連性を報告した研究が多数あったと結 論づけた。しかしながら、このレビューではそのような関 連性の規模が小さいことに注目しており、座位時間のデバ イスに基づく評価を使用している研究の場合は主にゼロで あるとした（55）。介入試験は中程度の影響を示したが、す でに肥満を有する被験者の場合は影響がより強いもので あった（55）。座位行動と肥満の測定との関連性を普及させ るには、さらに研究が必要である。 子どもおよび青少年においては、研究の新たに登場した分 野でも、いくつかのエビデンスが座位行動と福祉ならびに 生活の質との間の負の関連性を、また抑うつと余暇のスク リーンタイムとの望ましくない関係性を示している（58, 59）。たとえば、スクリーンタイムやコンピュータ使用の 局面をもつものとして評価される座位行動の期間が長いこ とは、メンタルヘルスの不良と関連がありうる（24）。最近 の別のレビューでは、８件の試験中５件で座位行動と不安 症状との間に関連性が認められたが、試験内の座位行動の 測定法が異なっており結果に整合性がなかった（60）。他の エビデンスは、テレビ番組の視聴とテレビゲーム使用の期 間が長いことが行動／向社会的行動（24）の望ましくない測 定値と有意に関連していたことを証明しており、長時間の スクリーンタイムおよびテレビ視聴は睡眠期間の短さと関 連しているが、コンピュータ使用／ゲーム時間と睡眠の長 さとの間には関連性がみられなかった（61）。座位行動とメ ンタルヘルスとの関係性の調査は急速に発展している分野 であるが不明点も多く、エビデンスには逆の因果関係がみ られる可能性が高い。この関連性の方向と強度に関して情 報を出すにはさらに研究が必要である。 GDGが出した結論： ・ 子どもおよび青少年で座位行動（スクリーンタイム）の 期間が長いことは、体力と心血管代謝の健康と有意に関 連しているという確実性が低いエビデンスがある。 ・ 子どもおよび青少年では、座位行動の期間が長いこと（ス クリーンタイム、テレビ番組の視聴、およびテレビゲー ムの使用）はメンタルヘルスや行動／向社会的行動の望 ましくない測定値と有意に関連しているという確実性が 非常に低～中程度のエビデンスがある。 ・ 子どもおよび青少年では、座位行動で長時間過ごすこと （スクリーンタイムおよびテレビ番組の視聴）は睡眠期間 に対する有害な影響と関連している確実性が低いという エビデンスがある。 ・ 子どもおよび青少年において、座位行動の時間を減らす ことの利益は害を上回る。 量反応関係（量、時間、頻度、中断の強度） はあるか？ 子どもおよび青少年において、量反応関係が座位時間（余 暇時間のスクリーンタイムを含む）と健康アウトカムとの 間に存在するか否かを判定するためのエビデンスは十分に 得られていない。子どもおよび青少年の座位行動と健康ア ウトカムとの関連性を評価しているエビデンスのほとんど は、事実上横断的であり、GRADEに従えばエビデンスの確 実性が低く、大多数の研究は座位時間の自己申告の尺度か 親による申告された尺度に依存しており、これらは測定誤 差と思い出しバイアスの影響を受ける。しかしながら、座 位行動で過ごす時間が短いことが健康アウトカムにとって 良いことであるとみられるエビデンスがあり、概して座位 行動と有害な健康アウトカムとの関連は、総座位時間より も、テレビ番組の視聴または余暇時間のスクリーンタイム を曝露変数として評価する場合の座位行動において強く表 れる。ただし、全体的に、制限時間を指定する裏づけとし てはエビデンスが不十分であるとみなされた。 30 子どもおよび青少年（５〜17歳） 座位行動が有害な健康アウトカムに結びつくというエビデ ンスがあるとすれば、座位行動の直接効果の結果となるか、 あるいは身体を活発に動かす行動に置き換えて時間を過ご した結果となるか、またはその両方となる。子どもおよび 青少年のスクリーンタイムと有害な健康アウトカムとの間 の関連性を報告した研究はあるが、中高強度の身体活動の 時間を考慮した場合、総座位時間（座位行動のデバイスに 基づく測定値を使用した試験での評価として）は健康アウ トカムと一貫して関連を示さなかった（62）。これとは逆に、 中高強度の身体活動を有望な健康アウトカムに結びつける エビデンスは、多様な現場で強くみられ、それらは文書で 十分に裏付けられており、一部の座位行動を身体活動（特 に中高強度の身体活動）に置き換えると、健康アウトカム が改善される可能性がある。 座位行動、身体活動、健康アウトカムの間の関連性と相互 作用を調査する研究は急速に増えており、デバイスをベー スとした座位行動の測定値から得たエビデンスと心血管代 謝の健康は、中高強度の身体活動を考慮に入れると（すな わち統計学的に調整すると）、関連性が弱まることを示して いる（62–64）。したがって、これらの関連についての知識 を高めて今後の推奨事項を普及させるには、曝露のデバイ スに基づく尺度を使用したさらなる前向き研究が必要であ る。 GDGが出した結論： ・ 座位行動で長時間過ごすことが不良な健康アウトカムと 関連があるという確実性が低いエビデンスがある。 ・ 座位行動の制限時間を指定するにはエビデンスが不十分 である。 ・ 座位時間を中高強度の身体活動に置き換えると、健康上 の利益が得られる可能性がある。 その関連性は座位行動のタイプまたは場面に 応じて変化するか？ 座位行動の健康影響の試験は、研究の中でも比較的新しい 分野である。よって、所見は、曝露の機器も尺度もさまざ まなものが使用された試験から得られている。「座位行動に 費やされる時間の総数」として評価される曝露が使用され ることが多いが、これは「スクリーン」を使用して過ごす 座位時間、または「テレビ番組の視聴」をして過ごす座位 時間である。 現在利用できるエビデンスからは、座位行動と有害な健康 アウトカムとの関連性は、総座位時間よりも、テレビ番組 の視聴時間または余暇時間のスクリーンタイムにおいて概 して強いことが示唆されている（24, 35）。最近の研究では、 座位行動のデバイスに基づく評価の利用が増えたことで知 識が深まっており、評価法を標準化して併用すると、報告 内容が今後のガイドラインの普及に役立つ。 すべての座位行動が必ずしも有害であるとは限らないこと は認められている。読書する、また学校の外で宿題をする といった特定のタイプの座位行動は学業成績の高さと関連 があることをエビデンスが示唆しており、活動次第でアウ トカムに差異があることを示している（24, 25）。座位行動 に、教育的遊び／勉強または静かな遊びをして過ごす時間、 または電子メディアを使用しない社会的相互作用を含める ことはできる。そのような遊び（例：読書する、パズルを する、絵を描く、工作をする、歌う、音楽を演奏する）は 子どもの発育にとって重要であり、認知面やその他の面で も利益がある。 GDGが認めたこと： ・ 座位の活動の中には、子どもおよび青少年の認知機能や 社会的相互作用に利益があるものもる。 ・ 座位行動の健康への悪影響に関するエビデンスは、総座 位時間よりも、テレビ番組の視聴時間または余暇時間の スクリーンタイムにおいて強く表れる。 31推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 成人 （18〜64歳） 身体活動の推奨事項 成人の場合、身体活動は、教育現場、家庭、および地域社会の現場の背景を踏ま えて、レクリエーションおよびレジャー（遊び、ゲーム、スポーツ、または計画 的な運動）、体育、移動（ホイーリング、ウォーキング、サイクリング）、家事の 一環として行うことができる。 成人の身体活動は、総死亡率、心血管疾患死亡率、高血圧の発症、部位特異固有がんの発症1、 ２型糖尿病の発症、メンタルヘルス（不安および抑うつの症状の軽減）の改善、認知的健康、 および睡眠などの健康アウトカムに利益があり、肥満も改善される可能性がある。 推奨事項： ＞成人は定期的な身体活動を行うこと。 強い推奨、エビデンスの確実性は中 ＞成人の場合、中強度の有酸素性の身体活動を150～300分以上、または高強度の有酸素性の 身体活動を75～150分以上行うか、または週全体で中強度の活動と高強度の活動の組み合わ せによる同等の量を行うと、実質的な健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 ＞成人の場合、さらに健康上の利益を得るため、中強度の有酸素性の身体活動を300分超に増や しても、あるいは150分超の高強度の有酸素性の活動、または週全体で中強度の活動と高強度 の活動の組み合わせによる同等の量を行うと、さらなる健康上の利益が得られる。 条件つきの推奨、エビデンスの確実性は中 ＞なお、成人は、主要筋肉群すべてが関係する中強度以上の筋力向上活動も週に２日以上行う こと。それにより、さらに健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 優れた実践 ・ 身体活動を一切しないよりは少しでもした方がよい。 ・ 上記の推奨事項を満たしていない成人は、ある程度の身体活動を行うことで健康上の利益が得られる。 ・ 成人の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時間を増やしていく。 １ 部位別のがんとは、膀胱がん、乳がん、大腸がん、子宮内膜がん、食道腺がん、胃がん、腎がんである。 32 裏付けのエビデンスと理論的根拠 本ガイドラインでは、United States Physical Activity Guidelines Advisory Committee（PAGAC：米国人に 対する身体活動のガイドライン諮問委員会）（35）がエビデンスをまとめたものを使用して更新した。 GDGは、PAGACが報告した所見と、2017年から2019年11月まで2017年までに発表された28件のレビューと３ 件のコホート研究のプールのいずれも組み入れ基準を満たして成人における身体活動と健康関連アウトカムの関連性 に関するエビデンスを投稿したものを含めた総体エビデンス全体を検討対象とした。 また、２件のアンブレラレビューを委託してエビデンスギャップに対応するとともに、ⅰ）職業上の（すなわち職業 関連の）身体活動と健康関連アウトカムとの関連性（40）の検討と、ⅱ）レジャー場面の身体活動と有害な健康アウ トカムとの関連性（41）の検討を行った。アンブレラレビューでは、それぞれ36件と15件の系統的レビューが特定 された。縦断的な観察研究と介入試験から得たエビデンスを優先し、横断的なエビデンスを単独で使用したレビュー、 または主として統合したレビューについては考慮に入れなかった。確実性が中程度以上に格付けされたレビューによ り提供されたエビデンスに、またデバイスをベースとした曝露の尺度を使用した研究からのエビデンスを示すものに 重点を置くようにした。 方法、データ抽出、およびエビデンスプロファイルについては、Web Annex： Evidence profiles （ウェブ付 録：エビデンスプロファイル）に細部まですべて記した。 成人の場合（18～64歳）、身体活動と健康 関連アウトカムとの間にはどのような関連性 があるか？ 成人における身体活動と総死亡率や心血管疾患死亡率との 間の関連性は、すでに立証されている（1）。最近のレビュー から得た所見では、身体活動のレベルが最低の場合に比べ、 最高の場合は死亡率のリスクの低下と関連していることが 再確認された。デバイスを身体活動の測定のベースとして いる研究から得た新しいエビデンスでは、身体活動のレベ ルが最低の場合に比べ、身体活動のその他のレベルおよび すべての強度（低強度を含む）は死亡率のリスク低下と関 連していることを示すエビデンスが再確認され拡張された （65）。たとえば、身体活動度が最低の場合（参照対象、 1.00）と比較すると、トータルでの身体活動の四分位群に おける補正ハザード比は身体活動の四分位群全体で改善さ れ、 第 ２ 四 分 位 群（0.48［95%CI：0.43～0.54］）、 第 ３四分位群（0.34［95%CI：0.26～0.45］）、第４四分位 群（0.27［95%CI：0.23～0.32］）であった（65）。新た なエビデンスでは、（1）身体活動と心血管疾患死亡率との十 分に立証された逆相関も再確認された（66）。 心血管疾患を抑制し高血圧の発生率を低下させる点で身体 活動がもたらす利益は、十分に裏付けられている（1）。身体 活動は有益な短期と長期の自律神経、そして血行力学の適 応を引き起こす多くの生理反応を促し、心血管疾患の主要 な危険因子である高血圧のリスク低下をもたらす。 エビデンスにより、正常血圧の成人において身体活動と高 血圧の発生との間に逆相関がみられること、また身体活動 は高血圧前症の成人と正常血圧の成人の血圧を低下させる ことが再確認された（35）。 成人における身体活動と２型糖尿病の発生との間の逆相関 は十分に立証されている（1）。最近のエビデンスでは、身体 活動量の多さと２型糖尿病の発生率との間に逆の曲線関係 がみられ（35）、身体活動のレベルが高いところで減少方向 の傾斜が示されることが再確認された。新たなレビューで は、２型糖尿病を呈するリスクの低下について身体活動の レベルが「最高」の群と「最低」の群で比較したところ、 この効果は、非ヒスパニック系白人（RR＝0.71［95%CI： 0.60～0.85］）、 ア ジ ア 人（RR＝0.76［95%CI：0.67～ 0.85］）、ヒスパニック系（RR＝0.74［95%CI：0.64～ 0.84］）、アメリカ原住民（RR＝0.73［95%CI：0.60～ 0.88］）のように背景が異なる被験者でも一貫性があること が明らかになったが、非ヒスパニック系黒人での効果は有 意 で は な か っ た（RR＝0.91［95%CI：0.76～1.08］） （67）。エビデンスは、体重の状態による効果の修飾がない こと、また正常体重、過体重、または肥満を呈する人にお いて身体活動量が多いことと２型糖尿病の発生率が低いこ との間に逆相関が存在することを示唆している（35）。 高レベルの身体活動と大腸がんおよび乳がんのリスク低下 との関連性は十分に立証されている（1）。エビデンスの先行 レビューでは、高レベルの身体活動は、乳がんおよび大腸 がんを呈するリスクの低下と関連していることが明らかに 成人（18〜64歳） Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 33推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r なっている（1）。身体活動とがんの研究が広範に増えた後、 高レベルの身体活動が膀胱がん、子宮内膜がん、食道腺が ん、胃がん、腎がんの発生リスクの低下とも関連があるこ とを示す新たなエビデンスがあり、身体活動が乳がんおよ び大腸がんを予防することが再確認された（35）。高レベル の身体活動は、約10～20%の範囲で変動するリスク低下と 関連がある（35）。たとえば、あるレビューは、低レベルの 身体活動と高レベルの身体活動を比較し、肝がんリスクと の逆相関を報告した（HR＝0.75［95%CI：0.63～0.89］） （68）。身体活動の増加と血液がん、頭頸部がん、卵巣がん、 膵臓がん、前立腺がん、甲状腺がん、直腸がん、および脳 腫瘍のリスク低下との間の関連性に関しては、エビデンス が不十分である（35）。身体活動のレベルが「最高」の群と 「最低」の群で比較すると肺がんのリスク低下を示唆するエ ビデンスがあるが、それらの所見はタバコ使用と交絡して いる可能性があり、全体として関連性を立証するにはエビ デンスが不十分であるという決断に至った。 成人集団の身体活動と肥満との関連はデータが大規模であ るにもかかわらず十分に立証されていないが、アウトカム のさまざまな尺度（体重増加、体重変化、体重管理、体重 安定性、体重の状態、体重維持）全体で、この関係性を評 価する総体エビデンスにばらつきがみられる（35, 69, 70）。全体として、成人では、身体活動が高レベルである ほど肥満の測定値や体重増加の緩和は望ましい結果となる ことをエビデンスが示している（35）。関連性の結果と強度 を立証するにはさらに研究が必要である。 2010年のGlobal recommendations on physical activity for health（健康づくりのための身体活動に関するグローバ ルな推奨事項）（1）の策定以降、身体活動とメンタルヘルス、 認知力、睡眠に関する研究が実質的に増えている（1）。当 時、成人では身体活動が抑うつおよび認知機能低下のリス クを軽減する可能性があることのみを結論づけるのに十分 なエビデンスがあった。本ガイドラインのレビューで得ら れた新たなエビデンスは、身体活動量が多い成人は少ない 成人に比べ、不安と抑うつを呈するリスクが低いことを示 していた。たとえば、身体活動が高レベルの成人は、低レ ベルの成人に比して不安（AOR＝0.81［95%CI：0.69～ 0.95］）（71）や 抑 う つ（AOR＝0.78［95%CI：0.70～ 0.87）を呈するオッズ比が低かった（72）。 中高強度の身体活動量が増えることは認知機能の改善（例： 処理速度、記憶、実行機能）（35）、脳の機能および構造、 アルツハイマー病を含む認知障害を呈するリスクの低下と 関連がある（73–76）。このエビデンスには、認知機能が正 常から認知障害へと傾きを示している成人の複数の集団が 含まれ、有酸素性の活動、ウォーキング、筋力向上活動、 およびヨガを含む種々のタイプの有酸素性の活動の身体活 動の有益な影響が報告された（74）。急激なまとまった活動 （bout）も定期的な身体活動も、成人の睡眠と健康関連の生 活の質のアウトカムを改善するというエビデンスがある （35）。 身体活動と抑うつの症状、不安の症状、不安および抑うつ の発生を検討したエビデンスは、身体活動が不安の症状の 緩和（77, 78）や抑うつ症状の緩和と関連があることを示し た（77, 79）。 身体活動はすべて何らかのリスクを伴う。成人のレジャー としての身体活動と関連のある有害作用、負傷、害に関す るレビューを委託して得たエビデンスは（41）、余暇の身体 活動のレベルと筋骨格の負傷との間の望ましくない関連性 と、余暇の身体活動と骨折のリスクおよび膝または股関節 の変形性関節症の発症との間にみられる望ましい関連性を 示唆している。その他の既存のエビデンス（35）からは、突 然の心臓性の有害事象がまれであること、また相対的に高 強度の身体活動の急激な回数と関連していることが示され ている。通常、中強度の身体活動では有害事象のリスクは 非常に低く、身体活動の頻度を上げても、強度と期間は有 害事象のリスクは緩勾配である（35）。 GDGが出した結論： ・ いずれかのレベルの身体活動をいずれかの強度で行うこ とは、総死亡率、心血管疾患死亡率、高血圧、心血管疾 患、および２型糖尿病の発生率のリスク低下と関連があ るという確実性が高いエビデンスがある。 ・ 高レベルの身体活動と部位別のがんの発生率のリスク低 下との関連性に関しては、確実性が中～高度のエビデン スがある。 ・ 身体活動と、メンタルヘルス、認知機能の健全性、睡眠 アウトカムの改善との間の関連性については、確実性が 中程度のエビデンスがある。 ・ 成人の高レベルの身体活動と肥満の望ましい測定値なら びに体重増加の緩和との間の関連性を示すエビデンスが ある。 ・ 成人に対して推奨される身体活動は有害とならないこと、 またそのような活動から得られる健康上の利益がリスク を上回ることを示す確実性が低いエビデンスがある。 成人（18〜64歳） 34 図１：量反応曲線 １週間の身体活動（分） リス クと 害 利 益 健 康 お よ び 体 力 上 の 利 益 座位 推奨される範囲 150 300 量反応関係（量、時間、頻度、強度）はある か？ 総じて、成人の場合、心血管および代謝性の健康アウトカ ムのエビデンスは、身体活動と、総死亡率、心血管疾患死 亡率、２型糖尿病の発生（67）、部位別のがんの発生などの 主要アウトカムとの間に、整合性のある曲線の逆の量反応 関係を示す。図１に記したとおり、量反応曲線の形状は利 益の下限閾値がないことを示し、最大の利益は量反応曲線 の下端において認められる（65）。曲線の逆相関は、身体活 動のさまざまな尺度を使用している研究で一貫して報告さ れている。 重要な新しいエビデンスは、８件の前向きコホート研究の メタアナリシスで提供され、平均追跡期間は5.8年（範囲３ ～14.5年）で（65）、曝露と総死亡率のデバイスに基づく尺 度を使用したトータルでの身体活動の四分位群の補正ハ ザード比を報告した。その結果示されたものは、身体活動 度が最低の場合（参照対象、1.00）に比べて、身体活動量 を増やすと、いずれの強度の身体活動でも高レベルで行う ことの利益がある量反応と、第２四分位群（補正HR＝0.48 ［95%CI：0.43～0.54］）、第３四分位群（補正HR＝0.34 ［95%CI：0.26～0.45］）、第４四分位群（補正HR＝0.27 ［95%CI：0.23～0.32］）であった。成人では、１日当た り24分（週に168分に相当）の中高強度の身体活動を行う とリスクが最大限に低下することが認められた。これは、 週150分という推奨事項をしっかりと反映したもので、週 当たり150～300分の身体活動という成人の既存のグロー バルなガイダンスを補強する、デバイスに基づくエビデン スを示している（65）。これらの所見は、既存のレビュー （35）やその他の新たに特定されたレビュ （ー66）から得た エビデンスと整合している。 上端は高レベルの身体活動が、害のリスクが増大すること なく、死亡率のリスク低下の点から継続的に利益をもたら していることを示している。たとえば、曝露のデバイスに 基づく尺度から得た個々のデータのメタアナリシスからの 所見を伴う新たなレビューによるエビデンスは（65）、週に 最長750分の中高強度の身体活動を行うと死亡率のリスク 低下が認められるが、週に300分を超えると死亡率の相対 危険度が横ばいになることを示す。相対的な利益は高レベ ルの身体活動で低下するが、これらの結果は、身体活動が 多いほど健康上の利益との関連が示されることを一貫して 示してきた先行するエビデンスと一致する（35, 80, 81）。 しかしながら、成人の場合、健康上の利益が減少に転じ始 める身体活動の厳密なレベルを割り出すには、エビデンス が不十分である。 また、エビデンスでは、身体活動と心血管疾患死亡率との 間で十分に立証された逆相関も再確認され、現在推奨され ている身体活動量を十分に上回る量反応関係のエビデンス も追加された。 身体活動（全体的なもの、余暇的なもの、職業的なもの） を評価した48件の前向き研究のメタアナリシスからは、現 在推奨されている身体活動量を十分に上回る量反応関係の エビデンスが追加された（66）。推奨レベルである週に 成人（18〜64歳） 35推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 750MET分に比べ、週に5000MET分の身体活動を行った 場合（中強度の活動を1000分）、心血管疾患死亡率のリス クが有意に低下する結果となった（HR＝0.73［95%CI： 0.56～0.95］）（66）。以前のWHOの推奨事項（1）では、有 酸素性の活動を少なくとも10分間まとめて行う（boutとい う）べきと結論づけられていた。しかしながら、デバイス （活動量計）を用いて評価した最新のエビデンスによると、 boutの時間を短くしていって最小限の閾値をなくしても、 健康アウトカムの改善（総死亡率を含む）と関連している こと示している（65, 82）。たとえば、加速度計で身体活動 を評価した研究のレビューから得た新たなエビデンスから 再確認されたこととして、身体活動と総死亡率のすべての 指標において同様の関連性が示され、ハザード比はboutを 考えないトータルの身体活動で0.27、５分間以上のまと まった活動（bout）で0.28、10分間以上のまとまった活 動で0.35であり、最も高い四分位群と最も低い四分位群で 比較された（83）。これらの結果は、Ekelund et al. 2019 （65）による新たなレビューの所見により再確認され、長さ を問わずまとまった活動（bout）時間の身体活動は健康ア ウトカムの改善（総死亡率を含む）と関連しているという エビデンスが得られた（82）。新たなエビデンスに基づき、 最低10分間のまとまった活動（bout）に関する推奨事項を 削除した。 高レベルの身体活動と部位別のがんの発生のリスク低下と の関連性を示すエビデンスは全体的に整合していると考え られたが、複数の研究間で曝露の評価と分類に大きなばら つきがあるため、報告されたリスク低下に対応した身体活 動の具体的なレベルを判定するにはエビデンスが不十分で ある。しかしながら、身体活動の有益効果が明らかではな いレベルを下回る下限閾値があることを示唆するエビデン スはなく、よって身体活動をいずれかのレベルで行うと部 位別のがんのリスクを低下させるという点で利益があるこ とを示唆している。 量反応の性質を評価し、より一貫性のある尺度を使用し報 告する今後の研究は、今後のガイドラインを普及させるた めに必要である。 身体活動と、肥満、体重増加、健康的な体重の状態の管理 のさまざまな尺度との間の関連性に関する大規模な総体エ ビデンスがあるが、現在、量反応関係を具体的に詳述し、 効果の閾値を特定するにはエビデンスが不十分である。今 後のガイドラインを普及させるには、さらに研究が必要で ある。 中高強度の身体活動の量が増えることは認知機能の改善 （例：処理速度、記憶、実行機能）（35）、脳の機能および構 造、アルツハイマー病を含む認知障害を呈するリスクの低 下と関連がある（73–76）。急激なまとまった活動（bout） も定期的な身体活動も、成人の睡眠と健康関連の生活の質 のアウトカムを改善するというエビデンスがある（35）。し かしながら、身体活動と、個々の精神および認知機能の健 康アウトカムとの間にある量反応関係を具体的に詳述する にはエビデンスが不十分である。同様に、より多くのエビ デンスは、有酸素性の身体活動や筋力トレーニングの量お よび/または強度と特定の健康アウトカムとの間の量反応関 係を詳しく述べるには、さらに研究が必要である。 そのような情報は、さまざまな集団のサブグループの身体 活動の最小有効量と安全性の最大閾値を立証するために重 要である。 GDGが出した結論： ・ 身体活動が増えるほど、健康アウトカムに対する効果が 大きくなるというエビデンスがあるが、高レベルの身体 活動では相対的な利益は横ばいになる。減少に転じ始め る厳密なレベルを割り出すには、エビデンスが不十分で あった。 ・ 高レベルの身体活動は、害のリスク増大を伴うことなく、 総死亡率、心血管疾患死亡率、がん死亡率、心血管疾患 発生率、高血圧の発生率、２型糖尿病の発生率のリスク 低下と関連しているという確実性が高いエビデンスがあ る。 ・ 身体活動をいずれの時間で行っても健康アウトカムの改 善と関連しているという確実性が中程度のエビデンスを 認めた。有酸素性の活動は少なくとも10分間のまとまっ た活動（bout）で行うべきという以前の定義は削除され なければならない。 ・ 成人では、身体活動を多く行うほど、肥満の望ましい測 定値と体重増加の緩和と関連があるというエビデンスが あり、身体活動が健康的な体重の状態の管理にとって有 害となるというリスクは低い。 ・ 中等度の強度の有酸素性の身体活動を週に150～300分、 またはこれに相当するものを行うと、複数の健康アウト カムのリスクが低下し、リスクの低下は続くものの、週 に300分を超えるとプラトーに達し始めるという確実性 が中程度のエビデンスがある。 成人（18〜64歳） 36 その関連性は身体活動のタイプまたは場面に 応じて変化するか？ エビデンスは、さまざまなタイプの身体活動と、さまざま な場面（すなわち職業、移動、または余暇）で行われる身 体活動が望ましい健康アウトカムを示すことができること を示している。総死亡率と心血管疾患死亡率については、 有酸素性の身体活動のみを行う場合、あるいは筋力を向上 させる運動と併用する場合に利益上の関連性を示すが、両 タイプとも推奨されているレベルで実施することが最適で ある（84）。 最近の確実性が中程度のエビデンスは、有酸素性の身体活 動とは無関係の、筋力を向上させる身体活動が総死亡率の リスク低下と関連していることも示している。Stamatakis et al. が報告した結果（2018）は、総死亡率に対する週２ 日の筋力を向上させる運動の影響を検討した11件のコホー トのプール解析から得られたもので、推奨レベル（1）で有 酸素性の身体活動と筋力を向上させる身体活動をどちらも 行った場合と、推奨事項を満たしていない場合の比較（補 正HR＝0.71［95%CI：0.57～0.87］）と、筋力運動の推 奨レベルを守って行った場合と、守らずに行った場合の比 較（HR＝0.80［95%CI：0.70～0.91］）は、総死亡率の リスクが有意に低下したことと関連があることが明らかに なった（84）。これらのデータは、筋力を向上させる運動と 関連のある健康上の利益が有酸素性の身体活動とは無関係 であることを確認し、また筋力を向上させる運動を週に２ 日行うことを推奨頻度とする裏付けるエビデンスを示す。 Dinu et al.（2019）が報告したその他の所見は、余暇（ま たはレクリエーション）以外の場面で行われる身体活動が 利益をもたらしうることを再確認している裏付けのエビデ ンスを示し、人力による往復移動（すなわち移動のための ウォーキングおよびサイクリング）は具体的に総死亡率の リスクの有意な低下につながることが明らかになった（RR ＝0.92［95%CI：0.85～0.98］）（85）。 活動的な通勤（active commuting）（すなわち移動のため のウォーキングまたはサイクリング）を行う人は、行わな い人に比べ、心血管疾患（冠動脈心疾患、脳卒中、および 心不全）のリスクが低下することを実証するエビデンスを 近 年 の 研 究 が 示 し て い る（RR＝0.91［95%CI 0.83～ 0.99］）（85）。なお、さまざまな場面の身体活動が利益をも たらしうると結論づけるには、これらの健康アウトカムか ら得られるエビデンスは十分にある。しかしながら、身体 活動の異なる場面が各健康アウトカムに与える効果を識別 するにはエビデンスが不十分である。たとえば、身体活動 とがんリスクまたは２型糖尿病発生リスクとの間の関連性 か身体活動のタイプまたは場面に応じて異なるのか否かを 判断するには、エビデンスが不十分である。 メンタルヘルスのアウトカムについては、有酸素性の活動、 ウォーキング、筋力向上活動、ヨガを含むさまざまなタイ プの身体活動が抑うつの症状や不安の発生の軽減に有益な 影響があることをエビデンス（35）が示している（74, 79, 86）。たとえば、レジスタンス運動の介入の有益な影響と メンタルヘルスに関する最近のエビデンスは、対照条件よ りも、抑うつ症状が大きく軽減し（77）、不安症状がわずか に軽減（78）す る と い う 確 実 性 が 中 程 度 の 結 果 を 報 告 した２件のレビューから得られたものである。 新しいレビューから得たエビデンスでは、職業上の高レベ ルの身体活動が多くのがん、冠動脈心疾患、２型糖尿病の リスク低下と関連していることが確認された（40）。しかし ながら、職業上の高レベルの身体活動は、（女性ではなく） 男性では、変形性関節症のリスク増大、質の悪い睡眠、総 死亡率と関連している場合もある。また、職業上の身体活 動と、肥満、体重増加の予防、メンタルヘルス、および健 康関連の生活の質との関係を判断するにはエビデンスが不 十分である（40）。身体活動とがんリスクとの間の関連性が 身体活動のタイプまたは場面に応じて異なるのか否かを判 断するにも、エビデンスが不十分である。身体活動のさま ざまな場面による関連性に関するエビデンスは少ないため、 さまざまな健康アウトカムに対する身体活動のさまざまな 場面の効果を識別することは困難であった。 GDGが出した結論： ・ 週に２日以上に行う筋力向上活動は健康上の利益をさら に加えるが、健康上の利益が最大になる特定の期間を明 記するには、エビデンスが不十分である。 ・ さまざまな場面（すなわち余暇、移動、職業）で行われ る身体活動が健康上の利益を提供することができる確実 性が中程度のエビデンスはあるが、現在、さまざまな健 康アウトカムに対し身体活動のさまざまな場面が与える 影響を識別することはできない。 ・ 職業上の高レベルの身体活動は、男性で（女性ではなく）、 変形性関節症のリスク増大、質の悪い睡眠、総死亡率と 関連している場合あるが、全体として、職業上の身体活 動が健康上の利益をもたらしうるという確実性が中程度 のエビデンスがある。 成人（18〜64歳） 37推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 成人 （18〜64歳） 座位行動の推奨事項 成人の場合、座位行動とは、職業、教育、家庭、地域社会の現場や移動時などの 状況において、覚醒しているときに、座ったまままたは横たわったままエネルギー 消費が少ない状態で時間を過ごしていることと定義されている。 裏付けのエビデンスと理論的根拠 本ガイドラインでは、PAGAC（35）がエビデンスをまとめたものを使用して更新した。GDGは、PAGACが報告し た所見と、組み入れ基準を満たした13件の新たなレビューのどちらも含めた総体エビデンス全体を検討対象とし、 成人の座位行動と健康関連アウトカムの関連性に関するエビデンスを提供した。座位行動と健康アウトカムの間の関 連性を調査することは、身体活動不足との関連性に比べ、公衆衛生の中でも比較的新しい分野であるが、過去10年 に急速に発展してきた。研究では通常、座位行動を測定するが、その時に使用するのは、ⅰ）座位行動で過ごしたお よその「トータルの時間」、すなわちテレビ番組の視聴、コンピュータ／スクリーンの使用、着座中などの具体的な 座位行動で過ごした時間を尋ねる自己申告式の質問票か、またはⅱ）デバイスによる評価である。座位行動のために 標準化された尺度または分析の手順はないため、結果の報告にばらつきがある。 最近の方法論の発展により、座位で過ごした時間をデバイスで評価する方法が使用されているが、これにより測定誤 差や、自己申告制の思い出し法に内在するその他のバイアスを抑制することができる。 総体エビデンス全体を考慮する際に、GDGが重視したのは、中等度以上に格付けされたレビューにより提供された エビデンスか、あるいはトータルの座位または着座時間の測定値を使用した研究から得たエビデンスを提供するレ ビューから得たものか、あるいは入手可能なデバイスをベースとした座位行動の測定値から得たエビデンスであった。 方法、データ抽出、およびエビデンスプロファイルについては、Web Annex：Evidence profiless （ウェブ付 録：エビデンスプロファイル）に細部まですべて記した。 座位行動と関連した潜在的な健康への悪影響の研究は、この10年間のうちに急速に蓄積されてきた。最新の研究で 目覚ましい展開をみせているのは、座位行動と複数の健康アウトカムとの間の量反応関係に関して、また座位行動と 身体活動との間の相互作用に関して報告するエビデンスの増加である。 成人の場合、座位行動の多さは、総死亡率、心血管疾患死亡率、がん死亡率、心血管疾患、がん、 および２型糖尿病の発生率などの健康アウトカムが不良であることと関連している。 推奨事項： ＞成人は座位のまま過ごす時間が短くなるように制限をかけること。座位で過ごす時間をいずれ かの強度の身体活動の時間に替えると健康上の利益がある。 強い推奨、エビデンスの確実性は中 ＞長時間の座位行動が健康に与える有害な影響を抑えるため、成人は、中高強度という推奨レベ ルを上回る身体活動を行うよう心がけること。 強い推奨、エビデンスの確実性は中 Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 38 成人（18〜64歳） 成人（18歳以上）の場合、座位行動と健康 関連アウトカムとの間にはどのような関連性 があるか？ 総じて、座位行動で長時間過ごすこと（ほとんどは着座時 間またはテレビ番組の視聴時間の自己申告式またはデバイ スに基づく評価を介して検討）と、総死亡率、心血管死亡 率、心血管疾患発生率、２型糖尿病発生率が高いこととの 関連性に関するエビデンスがある（8, 35, 65, 87）。 たとえば、エビデンスを裏付けるものには、加速度計で評 価した総座位時間と総死亡率（65）についての最近の大規模 なメタアナリシス（ｎ＝36383；平均年齢62.6歳；女性 72.8％）から得た結果があるが、座位行動で過ごした時間 の増加は総死亡率と有意に関連していることが示された。 100万人を超える参加者で構成されたメタアナリシスから 同様の所見が得られており（87）、そこではトータルの座位 行動と、身体活動で調整後の総死亡率および心血管疾患死 亡率（87）との関連性が示されたが、この研究ではがん死亡 率との関連性は身体活動で調整後に統計的に有意ではな かった（87）。 これとは別の最近のメタアナリシス（8）では、座位行動（着 座として評価）と心血管疾患およびがん死亡率との間の有 意の関連性が報告されており、身体活動の最も低い四分位 群（約５分／日）、「不活動」の着座時間として測定した場 合に座位行動のレベルが高いほど心血管疾患死亡率のリス クが９～32%（トレンド検定：ｐ＜0.001）と高いという 結果が示された。この研究では、１日８時間以上の座位（着 座）をとる成人は心血管疾患死亡率リスクが高くなること が報告された。ただし、関連性が緩和される「最も活動的」 な人を除く（すなわち＞35.5MET−時間／週または約60 ～75分／日）。座位行動とがん死亡率との間の関連性に関 する結果は概して弱いものであったが、着座時間が長い場 合に（特に＞８時間／日）６～21％と高い量関連リスクが 観察されたものの、これは身体活動の最も低い四分位群（＜ 2.5MET−時間／週）の人においてのみ認められた（8）。 エビデンスは座位行動（総着座時間として測定）と心血管 疾患の発生の増加との間の関連性を裏付けているが（HR＝ 1.29［95％ CI：1.27～1.30］）、これは身体活動のレベル を含め、潜在的な共変量で調整後に緩和された（HR＝1.14 ［95％ CI：1.04～1.23］）（88）。東南アジアの集団を対象 とした研究のレビューでは、座位時間が長いほど、望まし くない心血管代謝の指標（２型糖尿病、BMI高値、血圧高 値など）が示される尤度が高くなるという確実性の低いエ ビデンスが示された（89）。 最近の２件のレビューが、１日の総着座時間（88）、トータ ルの座位行動、トータルのテレビ番組の視聴（87）と２型糖 尿病の発生率との関連性について報告している。どちらの 研究も、高レベルの座位行動が２型糖尿病の発生率のリス ク増大と関連していることを明らかにした。たとえば、身 体活動で調整すると、トータルの座位行動（RR＝1.01 ［95％ CI：1.00～1.01］ｐ＝＜0.001）とテレビ番組の視 聴（RR＝1.09［95％ CI：1.07～1.12］ｐ=＜0.001）に おいて２型糖尿病との線形の関連性が認められた（87）。 座位行動（テレビ視聴に費やされる時間として測定した場 合）とがん死亡率との間の有意の関連性を裏付けるエビデ ンスもある（35, 87）。最近のいくつかのレビューで確実性 が低いおよび非常に低いものが、座位行動と大腸がんとの 関連性を裏付けるエビデンスを示しているが（90）、前立腺 がん、乳がん、または直腸がんの発生との関連はみられな かった（90-93）。追加のエビデンス（35）からは、座位行動 で長時間過ごすことと子宮内膜腺がん、大腸がん、肺がん の発生のリスク増大との有意の関連性が報告された（35）。 座位行動で過ごすことと、肥満およびその他の体重の状態 の指標や、座位行動と体重状態との関係が中高強度の身体 活動の量に応じて変化するか否かという点との間には、望 ましくない関係性を示す確実性が低いエビデンスがある。 総じて、これらの推奨事項／ガイドラインを普及させるに はエビデンスが不十分であり、さらなる研究が必要である と結論づけられた。 座位時間を減らすことの有害作用を評価したエビデンスは 少ない。専門家の意見では、座位時間の減少を推奨するこ とで、特に低強度の身体活動に置き換えた場合には、傷害 のリスクを増大させる可能性は低いとの結論であった。 39推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r GDGが出した結論： ・ 総じて、座位行動を制限して健康リスクを抑えるための WHOの新たな推奨事項の策定を裏付けるにはエビデンス が不十分である。 ・ 座位行動で長時間過ごすことと総死亡率、心血管疾患死 亡率、がん死亡率、心血管疾患、および２型糖尿病の発 生率が高いこととの関連性は、確実性が中程度のエビデ ンスがある。 ・ 座位行動で長時間過ごすことと子宮内膜腺がん、大腸が ん、肺がんの発生のリスクが高いこととの関連性は、確 実性が低～中程度のエビデンスがある。 ・ 座位行動と肥満の尺度との間にある関連性に関するエビ デンスは不十分であり、さらなる研究が必要である。 ・ 座位行動を制限することの利益は潜在的なリスクを上回 ると結論された。 量反応関係（量、頻度、期間中断の強度）は あるか？ 総じて、座位時間（自己申告式またはデバイスに基づく評 価による着座時間またはテレビ番組の視聴時間）と総死亡 率、心血管疾患死亡率、がん死亡率、および心血管疾患の 発生との間の非線形量反応関係を確実性が中程度のエビデ ンスが示している（8, 35, 87）。 加速度計で評価した総座位時間と総死亡率の量反応関係に 関し確実性が高いエビデンスを示す最近のメタアナリシス は（65）、座位行動で過ごす時間の増加は総死亡率と有意に 関連していたと報告している。座位時間の四分位群の増加 に関するハザード比は、1.00（参照対象 最短の座位）、 1.28（1.09～1.51）、1.71（1.36～2.15）、 中 高 強 度 の 身体活動で過ごす時間を含む潜在的交絡因子で調整後は 2.63（1.94～3.56）であった（65）。座位時間と死亡率の 量反応関係のこの分析は、約7.5～９時間へと段階的に増え た場合のリスクを示し、9.5時間を超えるとより顕著であっ た。各日10時間および12時間の座位行動と死亡の高リスク との関連性はそれぞれ1.48（1.22～1.79）と2.92（2.24 ～3.83）であった（65）。 量反応を評価した最近の別のメタアナリシスは、総座位時 間と総死亡率との間の非線形関連性を報告した（≦８時間 ／日間の曝露の場合の１時間／日当たりのRR＝1.01（1.00 ～1.01）、＞８時間／日間の曝露の場合は1.04（1.03～ 1.05））、また、心血管疾患死亡率との間では（≦６時間・ 日間の場合のRR＝1.01（0.99～1.02）、身体活動で調整 後は＞６時間／日間のRR＝1.04（1.03～1.04））であっ た（87）。これと同一の研究において、小規模の線形の量反 応関係が２型糖尿病との間に認められ、身体活動で調整後 のトータルの座位行動（1.01（1.00～1.01））と、テレビ 番組の視聴（1.09（1.07-1.12））について報告されていた （87）。 総じて、座位行動が多いことは望ましくない健康アウトカ ムと関連していることをエビデンスが裏付けており、座位 時間を最小限にとどめて健康リスクを抑えることを裏付け るエビデンスは十分にあると結論づけられた。しかしなが ら、座位行動の評価の方法（自己申告による座位時間、テ レビ番組の視聴時間、またはデバイス（加速度計）に基づ く評価による）がレビューによって大幅に変わることや、 座位時間の閾値が健康アウトカム全体において、中高強度 の身体活動のレベルによって、また集団のサブグループの 間で変動する可能性を考慮すると、時間に基づく（定量化 された）推奨事項を設定するには、エビデンスが不十分で ある。 座位行動の全体量のほかに、座位行動が生じるパターンに 関するエビデンスをレビューした。しかしながら、座位行 動の頻度および／または中断の期間に関して推奨事項を作 成するにはエビデンスが少なかった。 GDGが出した結論： ・ 座位行動に関する定量化された（時間に基づく）推奨事 項を設定するにはエビデンスが不十分である。 ・ 座位行動の頻度および／または中断の期間に関して推奨 事項を作成するにはエビデンスが不十分である。 成人（18〜64歳） 40 成人（18〜64歳） その関連性は座位行動のタイプおよび場面に 応じて変化するか？ 座位行動のある場面またはさまざまなタイプは、直接関連 する点からも、また健康的な身体活動で過ごす時間に置き 換える可能性の点からも、ほかに比べて有害な場合がある。 座位行動の研究は急速に発展しているが、さまざまなタイ プの座位行動とさまざまな健康アウトカムとの関連性を直 接比較したエビデンスで利用できるものは限られている。 たとえば、総着座時間よりも、テレビ番組の視聴として測 定される座位行動による結果の方が強力であると報告する 研究もある（87）。これは自己申告法や器具に関連した測定 誤差または残余交絡に起因している可能性がある。現在で は、さまざまな健康アウトカムとのさまざまな関連性や、 それらが亜集団によってどのように変化するのかを判定す るにはエビデンスが不十分である。 ますます多くの研究で、健康アウトカムに関して身体活動 と座位時間のデバイスに基づく尺度が使用されている。し かしながら、多くのこれらのデバイスの配置（例：手首、 腰まわり）は体位（例：横臥位、座位、立位で安静）ごと の違いを識別して決めたものではないため、誤分類が座位 時間のデバイスに基づく尺度から発生する可能性がある。 整合性のある報告方法と体位を識別する方法を使用したさ らなる研究は、座位行動のパターンに関する知識を深める ために役立つ。 GDGが出した結論： ・ 座位行動のさまざまなタイプまたは場面に関して推奨事 項を作成するにはエビデンスが不十分である。 身体活動のレベルは、死亡率に対する座位行 動の影響を修正するか？ 座位行動の健康アウトカムへの影響に対する関心が高まっ ており、身体活動のさまざまなレベルと座位行動のレベル との間の潜在的な相互作用の調査が進むきっかけとなって いる。利用できる研究に基づき、座位行動と、総死亡率、 心血管疾患死亡率、がん死亡率との関係が中高強度の身体 活動の量によって変化するという確実性が中程度のエビデ ンスがある（8, 9, 35）。全体的な所見として、座位行動の 影響は中高強度の身体活動量が少ない人において強く、逆 に言えば、中高強度の身体活動量が多い人ほど、高レベル の座位行動と関連のある望ましくない健康アウトカムを緩 和できる可能性がある。 低レベルの身体活動は、高レベルの身体活動よりも、座位 時間と総死亡率と関連したリスクが顕著に現れることが明 らかになった（35）。整合性のあるメタアナリシスにおいて、 Ekelund et al.は100万人を超える男女を対象に、座位行 動と身体活動を併せて層別化した影響について総死亡率を 用いて調査したところ、関連性は身体活動のレベルに応じ て異なることが明らかになった（9）。分析では、座位行動 （着座）の四分位群と中高強度の身体活動の四分位群が使用 され、参照群（中高強度身体活動［１日当たりの座位が＜ ４時間および中高強度の身体活動の最も高い四分位群［＞ 35.5MET−時間／週）と比較したところ、座位が１日当た り８時間を超えるも身体活動が週に35.5MET−時間を超え る人の追跡調査中に死亡リスクの増大はみられなかった （HR＝1.04［95％ CI：0.99～1.10）。対照的に、座位時 間が最短で（＜４時間／日）、身体活動の最低の四分位群 （＜2.5MET−時間／週）を示した人は、追跡調査中に死亡 のリスクが有意に増加した（HR＝1.27［95％ CI：1.22～ 1.31］）。この研究は、１日当たり約60～75分（最も高い 四分位群）の中高強度の身体活動のレベルが座位行動と健 康アウトカムとの間の有害な関連性を緩和する可能性があ り、それを解消することさえ可能であると結論づけた（9）。 41推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 成人（18〜64歳） 引用元：PAGAC 身体活動が多い 座 位 時 間 が 長 い 高リスク 低リスク 座 位 時 間 が 短 い  ＆ 身 体 活 動 が 多 い 身体 活 動 を 増 や す 座 位 時 間 を 減 らす 図２：座位行動と身体活動のレベルの関係 図２で示すように、座位行動のレベルと中高強度の身体活 動との関係は、PAGAC（35）による系統的レビューに概要 がまとめられている。 別の最近の研究では、死因別死亡率と同様の関連性を調査 して新たなエビデンスを提供し、同様の所見を示した（8）。 高レベルの中高強度の身体活動は、大規模な統合タアナリ シス（９件の研究、ｎ＝850 000、CVD死亡率；８件の研 究、ｎ＝777 000、がん死亡率）の結果から、着座で過ご す時間として測定したか、あるいはテレビ視聴で過ごす時 間として測定したかにかかわらず、高レベルの座位行動に 伴う心血管疾患死亡率のリスク増大を緩和した（8）。この研 究では、１日８時間以上着座している人の場合、死亡のリ スクが高いこととの関連性があることが明らかになった（た だし、この関連性を緩和する最も活動的な四分位群を除く）。 さらに具体的に言えば、心血管疾患死亡率のハザードは、 参照群（＜４時間／日）に比べ、１日に８時間以上着座し ていた人では32％高かった（トレンド検定：ｐ＜0.001）。 結果は顕著ではないが、身体活動のその他の四分位群の参 照群と比較すると依然として有意であった（第２四分位群、 HR＝1.11［95％ CI：1.03～1.20］、第３四分位群、HR ＝1.14［95％ CI：1.03～1.26］）。同様の関連性は中高強 度の身体活動の群全体で、テレビ視聴時間と心血管疾患死 亡率において観察された（8）。がん死亡率の関連性は混在し て曖昧であったが、総着座時間として評価した場合には、 概して高レベルの身体活動が座位行動の有害な影響を緩和 することが示された。 このエビデンスを基にすると、高レベルの座位行動をとる 人に向けて、高レベルの中高強度の身体活動を推奨すべき であること、また利益は害を上回ることで意見が一致した。 GDGが出した結論： ・ 座位行動と総死亡率、心血管疾患、がん死亡率との関係 は中高強度の身体活動の量に応じて変化するという確実 性が中程度のエビデンスがある。 ・ 中高強度の身体活動を多く行うと、座位行動と健康アウ トカムとの間の有害な関連性を緩和することができる。 42 高齢者 （65歳以上） 身体活動の推奨事項 高齢者の場合、身体活動は、教育現場、家庭、または地域社会の現場の背景を踏 まえて、レクリエーションおよびレジャー（遊び、ゲーム、スポーツ、または計 画的な運動）、体育、移動（ホイーリング、ウォーキング、サイクリング）、家事 の一環として行うことができる。 ・ 身体活動を一切しないよりは少しでもした方がよい。 ・ 上記の推奨事項を満たしていない高齢者は、ある程度の身体活動を行うことで健康上の利益が得られる。 ・ 高齢者の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時間を増やしていく。 ・ 高齢者は各自の機能的能力が許す範囲で身体的に活発に動き、身体活動の運動レベルが体力のレベルに見 合ったものになるように調整すること。 高齢者の身体活動は、総死亡率、心血管疾患死亡率、高血圧の発症、部位特異固有がんの発症、 ２型糖尿病の発症、メンタルヘルス（不安および抑うつの症状の軽減）の改善、認知的健康、 および睡眠などの健康アウトカムに利益があり、肥満も改善される可能性がある。高齢者の場合、 身体活動は転倒や転倒関連の負傷、また骨の健康の減退や機能的能力の低下の予防に役立つ。 推奨事項： ＞高齢者は定期的な身体活動を行うこと。 強い推奨、エビデンスの確実性は中 ＞高齢者の場合、中強度の有酸素性の身体活動を150～300分以上、または高強度の有酸素性 の身体活動を75～150分以上行うか、または週全体で中強度の活動と高強度の活動の組み合 わせによる同等の量を行うと、実質的な健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 ＞高齢者は、毎週の身体活動の一環として、バランス機能を高めるようにマルチコンポーネント の身体活動と筋力トレーニングを中強度以上のレベルで週に３日以上行って機能的な能力を強 化し、転倒を予防すること。 強い推奨、エビデンスの確実性は中 ＞高齢者の場合、さらに健康上の利益を得るため、中強度の有酸素性の身体活動を300分超に増 やしても、あるいは150分超の高強度の有酸素性の身体活動を行っても、または週全体で中強 度の活動と高強度の活動の組み合わせによる同等の量を行ってもよい。 条件つきの推奨、エビデンスの確実性は中 ＞なお、高齢者は、主要筋肉群すべてが関係する中強度以上の筋力向上活動も週に２日以上行う こと。それにより、さらに健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 優れた実践 43推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 高齢者（65歳以上） 裏付けのエビデンスと理論的根拠 本ガイドラインでは、高齢者用に、PAGAC（35）がエビデンスを包括的に合成したものを使用して更新した。15件 のレビューは組み入れ基準を満たしており、高齢者に特化した健康関連のアウトカム（転倒予防、転倒関連の負傷、 身体機能、虚弱、骨粗鬆症）と身体活動との関連性の考察を発表した。 転倒予防のエビデンスでは、Sherrington et al.（42）による2019年のコクラン共同計画の系統的レビューを使用し て更新したところ、元のレビューを最後に検索した日付以降2019年11月までに発表されたエビデンス（新しい研究 ９件）があった。2008年から2019年11月までに発表されたレビューについて、骨粗鬆症とサルコペニアに関する 既存の系統的レビューに関する検索をPubMedの中で実行したところ、新たなレビューは特定されなかったが、研究 が新たに８件特定された。 方法、データ抽出、およびエビデンスプロファイルについては、Web Annex： Evidence profiles （ウェブ付 録：エビデンスプロファイル）に細部まですべて記した。 高齢者（65歳以上）の場合、身体活動と健 康関連アウトカムとの間にはどのような関連 性があるか？ 高齢者集団の総死亡率および死因別死亡率、心血管疾患、 ２型糖尿病、がん発生率、肥満、メンタルヘルス、認知機 能のアウトカムなど、身体活動と健康アウトカムの間の関 連性を評価する主要なエビデンスのベースは、成人集団用 に照合しレビューした科学文献と同じであった。大多数の 研究は年齢の上限基準の記載がなかったため、65歳を超え た成人を対象に含めたことから、この同一の総体エビデン スを受け入れ、高齢者に外挿した。 エビデンスのレビューをさらに行い、高齢者に特化した健 康関連のアウトカム（転倒予防、転倒関連の負傷、身体機 能、フレイル、骨粗鬆症など）と身体活動との関連性に関 して検討し発表した。 高齢者の身体能力の低下は、深刻な結果に陥る可能性があ る転倒および転倒関連の負傷としてしばしば現れる。不慮 の転倒は、外因性（環境）および内因的な（例：体位制御 に影響を及ぼす筋骨格または神経系異常）因子の組合せに 起因する。身体活動が―特にマルチコンポーネントの身体 活動のプログラム（バランス、体力、持久力、歩行、およ び身体機能訓練の組合せを含む）において―高齢者の転倒 や転倒を原因とする負傷のリスクと関連していることを、 エビデンスが証明している。最近のエビデンスが実証する ところによると、高齢者の運動は転倒率を23％も低下させ る可能性があり（pooled rate ratio（RaR）0.77［95％ CI：0.71～0.83］）、医療または入院を必要とする骨折、頭 部外傷、開放創、軟部組織損傷、またはその他の何らかの 負傷につながる重度の転倒を含め、転倒を原因とする負傷 のリスクを有意に低下させることができる（42）。このエビ デンスは、ほかのレビューと矛盾するところがなく、また 所見が再確認された（35）。 成人期初期にピークに到達した後は、加齢とともに筋肉と 骨量が低下する傾向があり（すなわちサルコペニアと骨減 少症／骨粗鬆症）、これは体力や身体機能の低下と関連して いる可能性がある。エビデンスでは、高齢者の場合、定期 的な身体活動が身体機能を改善し、加齢による身体機能の 喪失のリスクを低下させることが証明されている。 所見では、動的バランス（SMD＝1.10［95％ CI：0.29～ 1.90］）、 筋 力（SMD＝1.13［95 ％ CI：0.30～1.96］）、 柔軟性（SMD＝1.22［95％ CI：0.39～2.04］）、心肺体 力（SMD＝1.48［95％ CI：0.42～2.54］）に対する有益 な影響が示されている（94）。また、高レベルの身体活動が 骨の健康を改善する可能性があることから、高齢者の骨粗 鬆症を予防する可能性があることもエビデンスは示してい る（プールされた標準化効果量0.21［95％ CI：0.06～ 0.36］）（95）。身体活動の介入が腰椎および大腿骨頸部（股 関節）の骨密度を改善する可能性がある。 GDGが出した結論： ・ 一般的な高齢集団の場合、身体活動が身体機能を改善し、 加齢による身体機能の喪失のリスクを低下させるという 確実性が中程度のエビデンスがある。 ・ 高齢者に推奨される量とタイプの身体活動のリスクは低 く、利益が上回ることを示す確実性が低いエビデンスが ある。 Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf44 高齢者（65歳以上） 量反応関係（量、時間、頻度、強度）はある か？ エビデンスは、高齢者が行う身体活動量と身体機能的制限 のリスクとの間に逆相関を示す。通常は、身体活動が多い ほど（頻度、期間および／または量）、利益の増大を伴う （35）。高速レジスタンストレーニングは一般の機能的な能 力の向上のためには、中速レジスタンストレーニングより も優れている可能性があることをエビデンスが示唆してい る（SMD＝0.41［95％ CI：0.18～0.65］、およびSPPB （SMD＝0.52［95％ CI：0.10～0.94］））（96）。 身体活動と転倒の予防との間の量反応関係を調べているエ ビデンスは少ないが、裏付け的なエビデンスを示す大多数 の研究は、週に３日と一致するプログラムのテストである ことを示している。 GDGが出した結論： ・ 有酸素性の身体活動の量と一般的な高齢者集団の身体機 能的制限のリスクとの間に逆の量反応関係があるという 確実性が高いエビデンスがある。 その関連性は身体活動のタイプまたは場面に 応じて変化するか？ バランス、筋力、持久力、歩行、および身体機能訓練の併 用を含めた身体活動プログラムは、高齢者の転倒率と転倒 を原因とする負傷のリスクの低下と関連している。 種々のさまざまな身体活動の介入（一般的にはバランスお よび機能運動にレジスタンス運動を追加）が行われること で、高齢者の転倒率を最高28％低下させることができるこ とを11件のRCTのレビューから得たエビデンスが示した （RaR＝0.72［95％ CI：0.56～0.93］）（42）。レジスタン ス運動の効果は一定しておらず、限られたデータをベース としている（RR＝0.97［95％ CI：0.14～6.49］；１件の 試験；ｎ＝73）（42）。 エビデンスでは、複数のタイプの運動を含むプログラムは、 含めないプログラムに比べて、しなかったよりも大きな正 の効果を骨の健康にもたらすことも示されている（標準化 効果量0.45［95％ CI：0.20～0.71；ｐ＝0.001）（95）。 GDGが出した結論： ・ 高齢者では、バランス、筋力、歩行、および機能訓練を 併用する高レベルの身体活動（例：マルチコンポーネン トの身体活動）が転倒率と転倒を原因とする負傷のリス クの低下と関連しているという確実性が高いエビデンス がある。 ・ 複数の運動タイプを含めたプログラムは骨の健康と骨粗 鬆症予防に有意の影響を与える可能性があるという確実 性が中程度のエビデンスがある。 45推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 高齢者 （65歳以上） 座位行動の推奨事項 高齢者の場合、座位行動とは、職業、教育、家庭、地域社会の現場や移動時など の状況において、覚醒しているときに、座ったまままたは横たわったままエネル ギー消費が少ない状態で時間を過ごしていることと定義されている。 裏付けのエビデンスと理論的根拠 2010 Global recommendations on physical activity for health（健康づくりのための身体活動に関するグロー バルな推奨事項）（1）には座位行動が取り上げられていなかった。集団に特化したエビデンスがないため、高齢者集 団での座位行動と健康アウトカムとの間の関連性を評価するための主な科学的根拠は、大多数の研究が年齢の上限基 準を述べていなかったため、65歳以上を成人に含めていた事情があり、成人集団用に照合やレビューが行われたも のと同じ学術文献とした。一般的な成人集団の座位行動に関するエビデンスから得た所見については、高齢者の場合 にはアウトカムが異なる、あるいは該当しない、もしくは禁忌となるエビデンスの有無を評価することも含め、レ ビューを行った。 方法、データ抽出、およびエビデンスプロファイルについては、Web Annex：Evidence profiless （ウェブ付 録：エビデンスプロファイル）に細部まですべて記した。 高齢者の場合、座位行動の多さは、総死亡率、心血管疾患死亡率、がん死亡率、心血管疾患、 がん、および２型糖尿病の発生率などの健康アウトカムが不良であることと関連している。 推奨事項： ＞高齢者は座位のまま過ごす時間が短くなるように制限をかけること。 　座位で過ごす時間をいずれかの強度の身体活動の時間に替えると健康上の利益がある。 強い推奨、エビデンスの確実性は中 ＞長時間の座位行動が健康に与える有害な影響を抑えるため、高齢者は、中高強度身体活動の 推奨レベル以上の身体活動を行うことを目標とする。 強い推奨、エビデンスの確実性は中 Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 46 妊娠中および産後の女性 身体活動の推奨事項 妊娠中および産後の女性の場合、身体活動は、教育現場、家庭、または地域社会の現場の背景を踏まえて、レクリ エーションおよびレジャー（遊び、ゲーム、スポーツ、または計画的な運動）、体育、移動（ホイーリング、ウォー キング、サイクリング）、家事の一環として行うことができる。 本ガイドラインでは、妊娠および産後の期間中の身体活動と母体および胎児の 健康アウトカムを取り上げる。年齢、文化的背景、または社会経済的地位にか かわりなく、妊娠中および産後のすべての女性を対象とする。妊娠および産後 の期間は、女性の人生の中の段階であり、成人期全体を通して身体を活動する ことの利益については、成人向けの推奨事項に詳述したとおりである。 妊娠中および産後の女性が妊娠中または産後に身体活動を行うに当たっては、出産前後に専門的な立場から本人の病 歴や禁忌事項を踏まえて助言する医療従事者のケアを受けるべきである。本ガイドラインは公衆衛生と集団をベース としている。妊娠または出産に伴う合併症を有する女性に向けた、臨床的なガイダンスを探究するべきである。 妊娠中および産後の女性は、可能な限り、また禁忌事項に該当しない限りは、これらの推奨事項を満たすよう努める べきである。 妊娠中および産後の女性の妊娠中および産後の身体活動は、母体および胎児にとって、子癇前症、 妊娠性高血圧、妊娠糖尿病、妊娠期の過度の体重増加、分娩合併症、産後の抑うつのリスクが 低下し、数は少ないものの新生児合併症のリスクが低下するという利益があり、出生体重に対 する有害作用はなく、死産のリスクが増大することもない。 禁忌事項のない妊娠中および産後のすべての女性への推奨事項： ＞妊娠から産後までの期間を通して、定期的な身体活動を行う。 強い推奨、エビデンスの確実性は中 さらに： ＞妊娠前に高強度の有酸素性の活動を習慣的に行っていた女性または身体的に活発に動いていた 女性は、妊娠中や産後の期間に、これらの活動を続行できる。 強い推奨、エビデンスの確実性は中 ＞中強度の有酸素性の身体活動を150分以上行うと、実質的な健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 ＞さまざまな有酸素性の筋力向上活動を組み込む。ゆるやかなストレッチを加えることも有益で ある。 強い推奨、エビデンスの確実性は中 47推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 優れた実践 ・ 身体活動を一切しないよりは少 しでもした方がよい。 ・ 上記の推奨事項を満たしていな い妊娠中および産後の女性は、 ある程度の身体活動を行うこと で健康上の利益が得られる。 ・ 妊娠中および産後の女性の場合、 身体活動を少し行うことから始 め、徐々に頻度、強度、持続時 間を増やしていく。 ・ 骨盤底筋のトレーニングは、尿 失禁のリスクを低下させるため に毎日行ってよい。 妊娠中の女性が身体活動を行う場合に加えられる安全上の考慮点： ・ 過度に暑い時期、特に湿度が高いときには、身体活動を避ける。 ・ 身体活動の前中後に、飲料水で水分を補給する。 ・ 身体的接触を伴う、転倒のリスクが高い、あるいは酸素不足のおそ れがある（高地に普段居住していない場合の高地での活動など）と いった活動への参加を避ける。 ・ 妊娠中期を過ぎてからは、仰臥位で活動するものを避ける。 ・ 妊娠中の女性が運動競技、または推奨ガイドラインを大幅に上回る運 動を検討する場合は、専門の医療従事者による管理指導を仰ぐこと。 ・ 妊娠中の女性は、中止のタイミングに関して警告となる危険な徴候 について、あるいはそのような徴候が生じた場合に直ちに身体活動 を制限して、適格な医療従事者の診察を受けること。 ・ 産後は徐々に身体活動を再開する。帝王切開による分娩であった場 合には、医療従事者に相談する。 妊娠中および産後の女性 裏付けのエビデンスと理論的根拠 妊娠中および産後の女性に向けて、本「2020年身体活動および座位行動に関するガイドライン」では、重大および 重要なアウトカム（28-34）を取り上げた７つの系統的レビューから得たエビデンスをまとめたものを使用し、更新し た。７件レビューした中で４件が組入れ基準を満たしていた。 方法、データ抽出、およびエビデンスプロファイルについては、Web Annex： Evidence profiles （ウェブ付 録：エビデンスプロファイル）に細部まですべて記した。 妊娠中および産後の女性の場合、身体活動と 健康関連アウトカムとの間にはどのような関 連性があるか？ 妊娠前および妊娠中の身体活動は、一般的にみられる妊娠 合併症のリスクを低下させるうえで役立つ可能性がある。 過体重または肥満の女性も含め、妊娠中に身体活動を行う ことは、妊娠期の体重増加の抑制（MD＝1.14kg［95％ CI：1.67～0.62］）（97）や、妊娠前から活動的である（OR ＝0.70［95％ CI：0.57～0.85］）（31, 34, 97）のと同様、 妊娠糖尿病のリスクの低下（97）（RR＝0.71［95％ CI： 0.57～0.89］）と有意に関連がある（97）。 妊娠中の身体活動は、妊娠性高血圧または子癇前症の発生 率を上昇させるとは思われない（31）。過体重または肥満が みられる妊婦を対象に、身体活動介入群と標準出産前ケア 群で比較すると、妊娠性高血圧の発生率に（RR＝0.63 ［95％ CI：0.38～1.05］）、または子癇前症に（RR＝1.39 ［95％ CI：0.66～2.93］）有意差はみられないことをエビ デンスが示唆している（97）。 発育中の胎児と分娩に関しては、母体の身体活動の潜在的 有害作用に対する長期の懸念があった。しかしながら、身 体活動が自然流産、死産、または分娩合併症の発生率のリ スク増大と関連していないことを最近のエビデンスが証明 している（32）。過体重または肥満がみられる妊婦を対象に、 身体活動介入群と標準出産前ケア群で比較した場合、帝王 切開分娩の発生率の差を示唆するエビデンスはない（97）。 妊娠中の身体活動は、出生体重（98）または早産（32）に対 する有害作用のリスク増大と関連しておらず、むしろ保護 的に、全体のリスクを軽減している場合さえあり（98）、身 体活動介入群と標準出産前ケア群で比較される過体重また は肥満（RR＝1.02［95％ CI：0.54～1.92］）または在胎 不当過大児（RR＝0.90［95％ CI：0.65～1.25］）がみら れる妊娠女性の場合でも同様である（97）。 Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf48 妊娠中および産後の女性 産後の期間に、母親はさまざまな身体的および感情的変化 を経験する。エビデンスからは、妊娠中の身体活動が産後 の抑うつと逆相関している可能性があることが証明されて いる（29）。妊娠中の身体活動に関する６件の介入研究と 11件の観察研究のメタアナリシスから得られたエビデンス （99）は、妊娠中の身体活動と産後の抑うつとの間に有意の 逆 相 関 を 示 し て い た（SMD＝0.58［95 ％ CI：1.09～ 0.08］）。少なくとも中強度の介入を行う５件の研究に限っ ても、その効果は強力であった（SMD＝0.70［95％ CI： 1.19～0.22］）（99）。 GDGが出した結論： ・ 妊娠中の身体活動は、妊娠期の体重増加を抑制し、妊娠 糖尿病のリスクを低下させる可能性があるという確実性 が高いエビデンスがある。 ・ 身体活動は妊娠性高血圧の発生率を上昇させないという 確実性が中～高度のエビデンスがある。 ・ 身体活動は自然流産、死産、または分娩合併症の発生率 を上昇させないという確実性が中程度のエビデンスが、 また高強度の身体活動を行う母親は早産のリスクが低下 するという確実性が中程度のエビデンスがある。 ・ 身体活動は、低体重児、胎内発育遅延、または在胎不当 過大児のリスクを増大させないという確実性が低～中程 度のエビデンスがある。 ・ 妊娠中の身体活動は低度の産後の抑うつと関連している という確実性が低いエビデンスがある。 ・ 妊娠および産後の女性に推奨される量とタイプの身体活 動のリスクは低く、利益が上回る。 量反応関係（量、時間、頻度、強度）はある か？ 妊娠および産後の期間中の身体活動に関するエビデンス全 体において、介入は身体活動の量（すなわち量）に、分単 位の期間でも週当たりの頻度でも、変化を示した。利用可 能なエビデンスは概して、30～60分間の有酸素性の身体活 動を週に３回以上という典型的な頻度を反映していた。こ のエビデンスは、概して一般の成人集団に推奨されている 活動量（すなわち、週当たり150分の中強度の身体活動） とおおまかに整合する量が健康に与えるインパクトを評価 した研究から得られている。 通常、身体活動が多いほど（頻度、期間および／または量）、 大きな利益と関連していることが明らかになるが、量反応 関係をより詳細に把握するには、さらに研究が必要である。 妊娠前に身体活動を余暇に多く行う場合と少なく行う場合 をみると、妊娠糖尿病の有意に低いリスクと関連がみられ る（OR＝0.54［95％ CI：0.34～0.87］）（100）。小規模 ではあるが、母親が高強度の身体活動を行う場合、早産児 が生まれるリスクが有意に低下するというエビデンスもあ る（RR＝0.20［95 ％ CI：0.36～0.03］）（98）。 推 奨 事 項を有意に越えるレベルで運動した場合の安全性または付 加的な利益に関して確認されたエビデンスはなかった。 GDGが出した結論： ・ 妊娠および産後の期間中の身体活動と特定の重大な健康 アウトカムとの間の量反応関係を判定するには、エビデ ンスが不十分である。 ・ エビデンスは全体的に、重大な健康アウトカムに対する 利益を示しており、また一般の成人集団に推奨されてい る身体活動量（すなわち、週当たり150分の中強度の身 体活動）とおおまかに整合する介入に基づいている。 ・ 一般の成人集団に比べ、妊娠中および産後の女性に推奨 される中強度の身体活動の量または頻度を変更する理由 はなかった。 ・ 高強度の身体活動を行う母親の場合、早産のリスクが低 下するという確実性が中程度のエビデンスがある。 49推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r その関連性は身体活動のタイプまたはタイミ ングの場面（妊娠前、出産前、または産後） に応じて変化するか？ エビデンスは、主に余暇場面の身体活動を評価した研究か ら得られ、活動のタイプはほとんどが有酸素性であったが （ウォーキングまたは水泳など）、筋力トレーニング（例： サーキットトレーニング）も含めた介入または有酸素性運 動と筋力を向上させる運動の併用を評価している研究から 得られたエビデンスもある。しかしながら、全体としては、 身体活動と健康アウトカムとの関連性が身体活動のタイプ または場面もしくはタイミング（妊娠前、出産前、または 産後）によって変化するか否かを判定するにはエビデンス が不十分である。 GDGが出した結論： ・ 妊娠中および産後の女性は種々の有酸素性運動および筋 力向上活動を組み込むべきという確実性が中程度のエビ デンスがある。ゆるやかなストレッチも有益である。 妊娠中および産後の女性 50 妊娠中および産後の女性 座位行動の推奨事項 妊娠中および産後の女性の場合、座位行動とは、職業、教育、家庭、地域社会の現 場や移動時などの状況において、覚醒しているときに、座ったまままたは横たわっ たままエネルギー消費が少ない状態で時間を過ごしていることと定義されている。 妊娠中および産後の女性の場合、座位行動の多さは、総死亡率、心血管疾患死亡率、がん死亡率、 心血管疾患、がん、および２型糖尿病の発生率などの健康アウトカムが不良であることと関連 している。 推奨事項： ＞妊娠中および産後の女性は座位のまま過ごす時間が短くなるように制限をかけること。座位で 過ごす時間をいずれかの強度の身体活動の時間に替えると健康上の利益がある。 強い推奨、エビデンスの確実性は低 裏付けのエビデンスと理論的根拠 2010 Global recommendations on physical activity for health（健康づくりのための身体活動に関するグロー バルな推奨事項）（1）には座位行動が取り上げられていなかった。集団に特化したエビデンスがないため、妊娠中お よび産後の女性での座位行動と健康アウトカムとの関連性を評価するための主な科学的根拠は、成人集団用に照合し レビューした科学文献であった。 一般的な成人集団の座位行動に関するエビデンスから得た所見については、妊娠中および産後の女性の場合にはアウト カムが異なる、あるいは該当しない、もしくは禁忌となるエビデンスの有無を評価することも含め、レビューを行った。 利用できるエビデンスや専門家の意見を基に、エビデンス を外挿し、重大な健康アウトカムの共通項について妊娠中 および産後の女性に対するWHOの新たな推奨事項を伝達さ せた。エビデンスの非直接性から、確実性のレベルをダウ ングレードした。 この集団に特化したエビデンスがないこと、また妊娠女性 は研究対象から外されていたことを考慮し、推奨事項の中 でも、座位行動が多いことの有害な影響に対処する目的か ら推奨レベル以上に身体活動のレベルを上げるための事柄 は、妊娠中および産後の女性に外挿しなかった。 GDGが出した結論： ・ 一般の成人集団の座位行動に関するエビデンスは、重大 な健康アウトカムの共通項について妊娠中および産後の 女性に対する推奨事項を普及させるために外挿されうる。 ・ 座位行動を最小限に減らすことの利益は、妊娠中および 産後の女性にとってのリスクを上回る。 ・ エビデンスの確実性は、非直接性のためダウングレード されなければならない。 51推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 慢性疾患を有する成人および高齢者 （18歳以上） 身体活動の推奨事項 子どもおよび青少年の場合、身体活動は、教育現場、家庭、および地域社会の現場の背景を踏まえて、レクリエー ションおよびレジャー（遊び、ゲーム、スポーツ、または計画的な運動）、体育、移動（ホイーリング、ウォーキン グ、サイクリング）、または家事の一環として行うことができる。 すべての成人のがんサバイバーや高血圧患者、２型糖尿病患者、HIV患者は、可能な限り、また禁忌事項に該当しな い限りは、これらの推奨事項を満たすよう努めるべきである。 現在までのところ、慢性疾患を有する人に向けの身体活動ガイドラインのほと んどは、臨床的または治療的なガイダンスに限られている。たとえば、臨床診 療の推奨事項とリソースは腫瘍学（101）、２型糖尿病（102）、高血圧（103）、 およびその他の慢性疾患（104）を専門とする医学会が開発してきた。WHOに も慢性疾患患者にして身体活動を推奨する内容を含んだ臨床診療ガイダンスが ある（17）。 このガイドラインは、慢性疾患を有する人の、具体的にはがんを有する人（以降は「がんサバイバー」と呼ぶ）、高 血圧患者、２型糖尿病患者、およびHIV患者の身体活動に関する初のWHOの集団ベースのガイドラインである。 HIVに対して有効で広く利用できる抗レトロウイルス治療の進歩を考慮すると、この病態は今では慢性疾患とも考え られる。急性期治療（例：化学療法）を受けている患者、または長期の薬物療法を受けていてまだ安定していない患 者については、医療従事者は各慢性疾患に該当する診療ガイドラインも参照しなければならない。 身体活動は、以下の慢性疾患を抱える成人および高齢者に健康上の利益がある。がんサバイバー の場合―身体活動により、総死亡率、がん特異的死亡率、がん再発または二次原発がんのリス クが改善される。高血圧患者の場合―身体活動により、心血管疾患死亡率、疾病の進行、身体 機能、健康関連の生活の質が改善される。２型糖尿病患者の場合―身体活動により、心血管疾 患による死亡率と疾病の進行の指標の値が低下する。 HIV患者の場合―身体活動により、体力が向上し、メンタルヘルスが改善される可能性があり （不安および抑うつの症状の軽減）、疾病の進行（CD4カウントおよびウイルス負荷）または体 組成に悪影響を与えられることはない。 推奨事項： ＞これらの慢性疾患を有するすべての成人および高齢者は、定期的な身体活動を行うこと。 強い推奨、エビデンスの確実性は中 ＞これらの慢性疾患を有する成人および高齢者の場合、中強度の有酸素性の身体活動を150～ 300分以上、または高強度の有酸素性の身体活動を75～150分以上行うか、または週全体で 中強度の活動と高強度の活動の組み合わせによる同等の量を行うと、実質的な健康上の利益が 得られる。 強い推奨、エビデンスの確実性は中 52 慢性疾患を有する成人および高齢者（18歳以上） ＞これらの慢性疾患を有する成人および高齢者は、主要筋肉群すべてが関係する中強度以上の筋 力向上活動も週に２日以上行うこと。それにより、さらに健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 ＞これらの慢性疾患を有する成人および高齢者で、禁忌事項がない場合、さらに健康上の利益を 得るため、中強度の有酸素性の身体活動を300分超に増やしても、あるいは150分超の高強 度の有酸素性の身体活動を行っても、または週全体で中強度の活動と高強度の活動の組み合わ せによる同等の量を行ってもよい。 条件つきの推奨、エビデンスの確実性は中 ＞これらの慢性疾患を有する高齢者は、毎週の身体活動の一環として、バランス機能を高めるよ うにマルチコンポーネントの身体活動と筋力トレーニングを中強度以上のレベルで週に３日以 上行って機能的な能力を強化し、転倒を予防すること。 強い推奨、エビデンスの確実性は中 ・ これらの慢性疾患を有する成人で上記の推奨事項を満たすことができない場合は、各自の能力に応じ て身体活動を行うことを心がけること。 ・ これらの慢性疾患を有する成人の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時間 を増やしていく。 ・ 成人で、これらの慢性疾患を抱えている場合、各自のニーズ、能力、機能上の限界／合併症、薬物療法、 および治療計画全般に適した活動のタイプと量について、身体活動の専門家や医療従事者に助言を求める ことがある。 ・ 運動前の医学的な許可については、禁忌事項がなければ、早歩きや日常生活で必要なレベルを超えない範 囲の低強度または中強度の身体活動を開始する前には概して不要である。 優れた実践 裏付けのエビデンスと理論的根拠 本ガイドラインの適用範囲として、身体活動と以下の健康アウトカムとの関連性を評価した。がんサバイバーの場合 ―総死亡率、がん特異的死亡率、がん再発または二次原発がんのリスク。高血圧患者の場合―心血管疾患死亡率、共 存症のリスク、身体機能、健康関連の生活の質、疾病の進行（ここでは身体活動への血圧の反応と定義）。２型糖尿 病患者の場合―心血管疾患死亡率、共存症のリスク、身体機能、健康関連生活の質、疾病の進行。HIV患者の場合― 身体機能（体力、運動耐性、筋力）、健康関連の生活の質、メンタルヘルス（不安および抑うつの症状）、心血管代謝 の疾患リスクの指標（血中脂質、血糖、体組成）、疾病の進行への有害作用（すなわち、CD4陽性細胞数、ウイルス 負荷量）。 本ガイドラインを普及させるために十分なエビデンスは、PAGAC（35）の報告にあるとおりで、2017年から2019 年までに特定されたがん（ｎ＝１）、高血圧（ｎ＝２）。２型糖尿病（ｎ＝13）の16件の新しいレビューで更新され た。さらに、HIV患者の身体活動と健康関連のアウトカムに関して委託されたアンブレラレビューでは、2002～ 2018年に発表された適格なレビュー19件から得たエビデンスが提示された。方法、データ抽出、およびエビデンス プロファイルについては、Web Annex：Evidence profiless （ウェブ付録：エビデンスプロファイル）に細部 まですべて記した。 Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 53推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 慢性疾患を有する成人および高齢者（18歳以上） がんを有する成人および高齢者（18歳以上） （がんサバイバー）の場合、身体活動と健康 関連アウトカムとの間にはどのような関連性 があるか？ 身体活動は代謝経路、ホルモン経路、および炎症経路で有 益な短期的かつ長期的変化を促すが、これががんの発生率 と生存率に保護的な作用を発揮すると考えられている （35）。がん診断後の高レベルの身体活動は、乳がん（HR ＝0.58［95％ CI：0.52～0.65］、17件）、大腸がん（HR ＝0.63［95％ CI：0.50～0.78］、10件）、女性の生殖器 がん（HR＝0.66［95％ CI：0.49～0.88］、４件）、神経 膠腫（HR＝0.64［95％ CI：0.46～0.91］、１件）、血液 がん（HR＝0.60［95％ CI：0.51～0.69］、２件）、腎臓 がん（HR＝0.60［95％ CI：0.38～0.95］、１件）、肺が ん（HR＝0.76［95％ CI：0.60～0.97］、２件）、前立腺 がん（HR＝0.60［95％ CI：0.46～0.79］、５件）、胃が ん（HR＝0.75［95％ CI：0.61～0.93］、１件）後の総死 亡率から、保護的な作用を発揮しているものとみられた。 がん診断後の身体活動量が多いことは、乳がん、大腸がん、 前立腺がんのサバイバーの死因別死亡率のリスク低下と関 連している。メタアナリシスでは、診断後の総身体活動量 が最高の例と最低の例で比較して、すべてのがんを合わせ た場合（HR＝0.63［95％ CI：0.53～0.75］、４件）と、 乳がん（HR＝0.63［95％ CI：0.50～0.78］、13件）、大 腸がん（HR＝0.62［95％ CI：0.44～0.86］、６件）、前 立腺がん（HR＝0.70［95％ CI：0.55～0.90］、４件）の 死亡率をみたところ、ハザードの低下が認められた（105）。 ただし、身体活動ががん再発または二次原発がんと関連し ているか否かを判断するには、エビデンスが不十分であっ た。 身体活動は高血圧の主な予防策としても管理方法としても 重要であり、身体活動が高血圧患者の身体機能、心血管疾 患の進行（すなわち身体活動に対する血圧の反応）、および 心血管疾患死亡率を改善することをエビデンスが示してい る（35）。たとえば、身体活動を行わない対照群と比較する と、身体活動を行っている高血圧患者は収縮期血圧を約 12mm Hg下降させ、拡張期血圧を約６mm Hg下降させる （SBP MD＝12.26mm Hg［95％ CI：15.17～9.34］、ｐ= ＜0.05；DBP MD＝6.12mm Hg［95％ CI：7.76～4.48］、 ｐ=＜0.05）（106）。身体活動を行う高血圧患者は、不活動 の高血圧患者に比べて、健康関連の生活の質を有意に改善 できることを新生のエビデンスが証明している（54）。 有酸素性の身体活動、筋力向上活動、および有酸素性身体 の活動プラス筋力向上活動などの身体活動は、２型糖尿病 の成人患者の進行リスクの二次指標（HbA1c、血圧、 BMI、脂質）の改善と関連がある（35）。たとえば、最近の 研究では、レジスタンストレーニングは対照群に比べて HbA1cが大幅に低下したことと関連があること、また高強 度のレジスタンストレーニングが空腹時インスリンに有意 の正の効果を持つことが明らかになった（107）。２型糖尿 病の成人患者の健康関連の生活の質と身体機能に対する身 体活動の効果を評価するには、エビデンスが不十分である。 HIV患者における身体活動は心肺体力を改善する。研究対 象の介入は、有酸素性の運動か、または段階的な筋力を向 上させる運動と併用する運動のいずれかを週３回30分以上 行うというものであった（108, 109）。身体活動介入が心血 管代謝リスクのマーカー（脂質など）を改善するというエ ビデンスもある（結果は様々である）し、血糖は有酸素ト レーニング後に低下するが、インスリン濃度への効果はな いことが確立されているものの、グルコースは有酸素性の トレーニング後に低下した（110）。HIV患者の場合、身体 活動は、有酸素性であるのか、筋力を向上させる運動との 併用であるのかにかかわらず、健康関連の生活の質に正の 相関があり（111）、抑うつおよび不安の症状の軽減と明ら かに関連している（112）。抑うつのメタアナリシス（９件 の 試 験 ） は、0.84のSMDが 示 さ れ（95 ％ CI：1.57～ 0.11）、介入群を支持するものであった（ｐ＝0.02）。不安 の軽減に関するSMD（５件）も統計的に有意で、介入群を 支持するものであった（1.23［95％ CI：2.42～0.04］、 ｐ＝0.04）（112）。身体活動は、運動を行う群の参加者で は、非運動対照群の参加者に比べ、1.75kgの除脂肪体重で 有意の標準化された平均増加や、1.12％の体脂肪率の有意 な減少、また末梢の脚および腕の筋肉の部位の増加とも関 連しているが、HIV患者のBMIまたは腹囲の変化との関連は みられない（111）。身体活動を行うことで、CD4陽性細胞 数（細胞／mm3）またはウイルス負荷量など、HIVの疾患 進行のマーカーに有害な影響が出ることはない（111）。重 要な点として、このエビデンスは、慢性疾患としてのHIVが 身体活動によって悪影響を受けることはないことを示唆し ている。 GDGが出した結論： ・ がんサバイバーの場合、がん診断後に身体活動を多く行 うことは、総死亡率、原因別死亡率、およびがん特異的 死亡率のリスク低下と関連しているという確実性が中程 度のエビデンスがある。 ・ 高血圧の成人患者の場合、身体活動は心血管疾患の進行 のリスクを低下させるという確実性が高いエビデンスが ある。 ・ 高血圧の成人患者では、身体機能と健康関連の生活の質 54 慢性疾患を有する成人および高齢者（18歳以上） のアウトカムを身体活動が改善するという確実性が中程 度のエビデンスがある。 ・ ２型糖尿病の成人患者の場合、身体活動が疾病の進行 （HbA1c、血圧、BMI、および脂質）のマーカーを改善 するという確実性が高いエビデンスがある。 ・ HIV患者の身体活動と、体力（最大酸素消費量、運動耐 性）および筋力の改善との間に関連があり、またHIV患者 の身体活動と、体組成、健康関連の生活の質、抑うつお よび不安の軽減、ウイルス負荷量またはCD4陽性細胞数 の無変化との間に望ましい関連性があるという確実性が 中程度のエビデンスがある。 ・ がんサバイバーと、高血圧患者、２型糖尿病患者、およ びHIV患者の場合、特定の健康アウトカムに関しては、定 期的に身体活動を行うことに付随する利益がリスクを上 回る。 量反応関係（量、時間、頻度、強度）はある か？ がん診断後に身体活動を多く行うことは、総死亡率および がん特異的死亡率のリスク低下と関連している。エビデン スは、診断後の身体活動のレベルを週に最長10～15MET 時間まで（150分／週の中高強度の身体活動に一致）上昇 させることと乳がん特異的死亡率および総死亡率との間に 非線形関係があることを証明しているが、より高いレベル での害についてはエビデンスがない（105）。ほかのがんの 部位について同様の量反応関係を示唆するものはあるが、 正式なメタアナリシスを認めるには研究数が少なすぎる。 関連の強さを判定するにはさらに研究が必要である。 高血圧患者については、身体活動と心血管疾患死亡率との 間に明確な量反応関係がある（35）。所見では、それは高血 圧の範囲内での収縮期血圧上昇として記されており、心血 管疾患死亡率が上昇するリスクではあるが、この程度のリ スクの上昇は高レベルの身体活動で緩和される（35）。一般 集団に対する推奨事項と同様に、従来の介入の大部分は、 週に約30～60分の中強度の有酸素性の活動、週３日および ／または週に２～３回のレジスタンストレーニングを基本 としている。 ２型糖尿病の成人患者には、身体活動のボリュームと、心 血管死亡率のリスクとの間に逆の曲線関係を示す実質的な エビデンスがある（113–115）。身体活動の量が多いことは （中強度の活動を150分／週という推奨レベルを下回る場 合、丁度の場合、上回る場合）、リスクを徐々に低下させる。 たとえば、何らかの活動を行う場合は、活動を一切行わな い場合に比べ、心血管疾患死亡率のリスクが32％低下する が（補正HR＝0.68［95％ CI：0.51～0.92］）、身体活動 ガイドライン以上の基準を満たした量の活動を行うことは、 心血管疾患死亡率のリスクが40％低下したことと関連が あった（補正HR＝0.60［95％ CI：0.44～0.82］）（115）。 ほとんどの介入は、約150～300分の中強度の有酸素性の 活動、または75分の高強度の活動、および／または週に２ ～３回のレジスタンストレーニングをベースとしている。 ２型糖尿病の成人患者の一部のアウトカム（例：HbA1cお よび血圧）の場合、有酸素性の活動が多いと（すなわち 150分／週を超える場合対150分／週未満の場合）より強 い効果が得られるというエビデンスがあるが、強度に関す るエビデンスは少ない（35）。 HIV患者の場合、身体活動と体組成との間に、または心血 管代謝の疾患の中間マーカー（例：血液脂質プロファイル、 インスリン抵抗性、空腹時血糖濃度。または血圧）のため に、量反応関係を立証するにはエビデンスが不十分である。 エビデンスを提供している大多数の研究は、身体活動介入 を実施し、少なくとも12～48週間は週に３回、中高強度の 有酸素運動単独か、または漸増的レジスタンストレーニン グと併用して30分以上行っていた。また、メンタルヘルス と健康関連の生活の質のアウトカムについて、より精度の 高い量反応関係を立証するにはエビデンスが不十分である。 利用できるエビデンスは通常、週３回以上の身体活動介入 を評価している研究から得られる。 総じて、慢性疾患患者の特定の集団と健康アウトカムの特 定のセットには、中強度の身体活動（またはこれに相当す るもの）を150～300分間とする身体活動の推奨事項を裏 付けるための、確実性が中～高度のエビデンスがあった。 高血圧患者、２型糖尿病患者、がんサバイバーを取り上げ たエビデンスでは、活動のレベルが高いことは、利益が大 きいことと関連しているという明確なエビデンスがあった。 特定の慢性疾患と、検討された特定のアウトカムに応じて、 エビデンスの確実性と直接性の変動が認められた。エビデ ンスが筋力トレーニング運動からプラスのアウトカムを示 した場合、活動の頻度は週当たり２～３回のレジスタンス トレーニングであった。 GDGが出した結論： ・ がんサバイバーの場合、身体活動と、総死亡率およびが ん特異的死との間に量反応関係を示す確実性が中程度の エビデンスがある。 ・ 高血圧患者の場合、身体活動と心血管疾患死亡率との間 に量反応関係を示す確実性が高いエビデンスがある。 ・ ２型糖尿病の成人患者の場合、活動のボリュームと、心 55推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 血管死亡率のリスクとの間に逆の曲線関係を示すエビデ ンスがある。 ・ HIV患者の場合、身体活動と、心血管代謝の疾患の中間 マーカー、体組成、健康関連の生活の質、不安および抑 うつ症状との間に量反応関係を示すにはエビデンスが不 十分である。 ・ 望ましい健康アウトカムが得られたのは、150～300分 の範囲での中強度の有酸素性の活動（またはこれに相当 するもの）の介入であり、筋力トレーニングから得られ るプラスのアウトカムに注目すると、週２～３回のレジ スタンストレーニングとなる。 その関連性は身体活動のタイプまたは場面に 応じて変化するか？ 身体活動のさまざまなタイプおよび場面により、望ましい 健康アウトカムが得られるというエビデンスがある。有酸 素性の身体活動や筋力を向上させる身体活動の推奨のレベ ルを満たしているがんサバイバーは、どちらの推奨事項も 満たさないがんサバイバーに比べ、がん死亡率のリスクが 有 意 に 低 い（ 補 正HR＝0.70［95 ％ CI：0.50～0.98］） （84）。筋力を向上させる身体活動の推奨事項のみを遵守し た場合、遵守しなかった場合に比べ、がん死亡率のアウト カムの改善にも有益であることをエビデンスが証明してい る（HR＝0.66［95％ CI：0.48～0.92］）（84）。メタアナ リシスでは、身体活動の場面からこれらの関連性も報告さ れ、レクリエーションの身体活動の場合に、すべてのがん の死亡率、乳がん特異的死亡率、大腸がん特異的死亡率を 一貫して最も低下させることが明らかになった（105）。高 血圧の成人患者については、心血管の疾病の進行を改善す るため、有酸素性の活動と筋力向上活動の２つを併用する ことをエビデンスは支持している。身体活動の従来の方法 （すなわち有酸素性の活動およびレジスタンス系の活動）で の血圧を降下させる作用は、高血圧患者次第で有意に異な るとは思われない（35）。ただし、このエビデンスは、活動 のタイプごとでの直接の比較をベースとしていない。また、 高血圧患者の運動の別の形態（例：太極拳、ヨガ、気功） の有益な影響を裏付ける新たなエビデンスもあるが、関連 性の強度を探索するには、さらに研究が必要である。 有酸素性の活動、筋力向上活動、および有酸素性またはそ れらの併用は、２型糖尿病の成人患者の進行リスクの二次 指標（HbA1c、血圧、BMI、脂質）の改善と関連がある （35, 107）。24件 のRCT（ｎ＝962） に 関 す る あ る レ ビューは、レジスタンストレーニングは、対照群に比べ、 HbA1cの大幅な減少と関連があったことを報告した（MD ＝0.45［95％ CI：0.65～0.25］、20件；n＝824）。対照 群と比較して、高強度のレジスタンストレーニングが空腹 時インスリンに与える影響をみたところ、統計的に有意な 効果がみられた（MD＝4.60［95％ CI：7.53～1.67］、５ 件；ｎ＝174）（107）。７件のRCT（ｎ ＝189）の別のレ ビューでは、インターバルトレーニング（２～５回／週； 間隔１～４分の期間；１回の長さ20～60分）は、MICTに 比べ、HbA1cを統計学的に有意に0.26％（95％ CI：0.46 ～0.07％、５件のRCT）低下させ、一切運動をしない対照 群 に 比 べ0.83 ％（95 ％ CI：1.39 ％ ～0.27 ％（ ４ 件 の RCT）低下させたと報告した（116）。一般集団に対する推 奨事項と同様に、これらの介入の大部分は、推奨されてい る中強度の有酸素性の活動150～300分（または高強度の 活動を75分）と週に２～３回の筋力向上活動と整合する辺 りの有酸素性の活動をベースとしている。一部のアウトカ ム（例：HbA1cおよび血圧）については、有酸素性の活動 （すなわち150分／週を超える場合対150分／週未満の場 合）による強力な効果を示すエビデンスがあるが、強度に 関するエビデンスは少ない。最新の研究は、伝統的な中国 の運動（例：太極拳）は血糖に利益がある可能性があると のエビデンスを出しているが、確実性は中程度で変動しや すいものであった（すなわちバイアスまたは不一致のリス ク）。これらの関連性を判定するにはさらに研究が必要であ る。 有酸素性の活動やレジスタンストレーニングなど、複数の タイプの身体活動は、HIV患者の健康関連の生活の質に正 の効果を持つことが示された（111）。有酸素性運動と、漸 増的レジスタンス運動と、両者の併用に対する反応として の健康関連の生活の質の変化を調べている最近の研究では、 全身の健康とメンタルヘルスの有意な改善が示された。有 酸素性の活動もさまざまな要素で構成された多様な活動も、 HIV患者の抑うつと不安の症状の軽減と関連があるというエ ビデンスもある（112）。メンタルヘルスの症状に対する身 体活動の影響を示すエビデンスには、有酸素性の活動、ま たは漸進性の筋力向上活動と併用する有酸素性の活動、ま たはヨガと併用する場合などがある。エビデンスは、有酸 素性の運動のみの場合、またはレジスタンス運動と併用し た場合に、ウイルス負荷量またはCD4陽性細胞数における 何らかの有意な変化につながることはないことを実証して いる（111）。 既存および最新の文献から得た直接的なエビデンスは、２ 型糖尿病患者と高血圧患者が有酸素性の活動および筋力を 向上させる身体活動を行う場合の推奨事項に含まれる内容 を裏付けている。公表されたエビデンスには欠落があるも のの、HIVの成人患者やがんサバイバー向けの有酸素性の活 動および筋力を向上させる身体活動の利益には生物学的整 合性がある。さらに、GDGが示したとおり、定着している 慢性疾患を有する成人および高齢者（18歳以上） 56 国際的な診療ガイドラインでは、これらの集団に向けた有 酸素性の活動や筋力を向上させる身体活動を推奨している （例：エビデンスの系統的レビュ （ー3）に基づくACSM “Moving Through Cancer” guidelines（101））。このエ ビデンスの基盤となるものは依然として新たに出てくると いう認識から、確実性のレベルはダウングレードされた。 GDGが出した結論： ・ がん死亡率の低下や、高血圧患者の血圧の改善に関する 有酸素性の活動または筋力向上活動の併用効果または付 加的な効果は、確実性が中程度のエビデンスがある。 ・ 有酸素性の活動、筋力向上活動、および有酸素性の活動 プラス筋力向上活動が２型糖尿病の成人患者の疾病の進 行のマーカー（HbA1c、血圧、BMI、および脂質）を改 善するという確実性が高いエビデンスがある。 ・ 定期的な有酸素性の運動のみ、またはレジスタンス運動 と併用した場合に、ウイルス負荷量またはCD4陽性細胞 数における何らかの有意な変化につながることはないと いう、確実性が中程度のエビデンスがある。 ・ HIV患者の健康関連の生活の質に対する筋力トレーニング のみの影響については、エビデンスが不十分である。 慢性疾患を有する成人および高齢者（18歳以上） 57推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 慢性疾患を有する成人および高齢者 （18歳以上） 座位行動の推奨事項 2010 Global recommendations on physical activity for health（健康づ くりのための身体活動に関するグローバルな推奨事項）（1）には座位行動が取り上げ られていなかった。がんサバイバーおよび高血圧患者、２型糖尿病患者、HIV患者の座位 行動に関する今回の新たな推奨事項の適用範囲。 座位行動とは、職業、教育、家庭、地域社会の現場や移動時などの状況において、覚醒しているときに、座ったまま または横たわったままエネルギー消費が少ない状態で時間を過ごしていることと定義されている。 がんサバイバー、高血圧患者、２型糖尿病患者、およびHIV患者などに該当する成人の場合、 座位行動の多さは、総死亡率、心血管疾患死亡率、がん死亡率、心血管疾患、がん、および２ 型糖尿病の発生率などの健康アウトカムが不良であることと関連している。 がんサバイバー、高血圧患者、２型糖尿病患者、およびHIV患者などに該当する成人への推奨事項： ＞慢性疾患を有する成人および高齢者は座位のまま過ごす時間が短くなるように制限をかけるこ と。座位で過ごす時間をいずれかの強度の身体活動の時間に替えると健康上の利益がある。 強い推奨、エビデンスの確実性は低 ＞長時間の座位行動が健康に与える有害な影響を抑えるため、慢性疾患を有する成人および高齢 者は、中高強度という推奨レベルを上回る身体活動を行うよう心がけること。 強い推奨、エビデンスの確実性は低 裏付けのエビデンスと理論的根拠 集団に特化したエビデンスがないため、高血圧、２型糖尿病、HIVを有する成人および高齢者の座位行動と健康アウ トカムとの関連性を評価するための主なエビデンスのベースは、成人集団用に照合しレビューした科学文献であった。 一般的な成人集団の座位行動に関するエビデンスから得た所見については、慢性疾患を有する成人および高齢者の場 合にはアウトカムが異なる、あるいは該当しない、もしくは禁忌となるエビデンスの有無を評価することも含め、レ ビューを行った。 58 慢性疾患を有する成人および高齢者（18歳以上） 利用できるエビデンスや専門家の意見を基に、エビデンス を外挿し、重大な健康アウトカムの共通項について慢性疾 患を有する成人および高齢者に対するWHOの新たな推奨事 項に反映させた。大多数の研究は年齢の上限基準の記載が なかったため、65歳を超えている慢性疾患を有する成人 （例：がんサバイバー、高血圧患者、または２型糖尿病患者） を対象に含めたことの評価から、エビデンスの外挿はしっ かりと裏付けられている。HIV患者について、座位行動の健 康インパクトに関するエビデンスが該当しない理由に関し ては、答えが見つからなかった。これらの推奨事項を策定 するためのエビデンスの非直接性から、確実性のレベルは、 ダウングレードされた。 重大な健康アウトカムの共通項について慢性疾患を有する 成人に推奨事項を普及させるため、高度の座位行動の潜在 的リスクに反対に作用するように中～高強度の身体活動を 多く行う利益に関するエビデンスの適用性も検討のうえ外 挿した。非直接性を考慮し、エビデンスの確実性をダウン グレードした。 GDGが出した結論： ・ 一般の成人集団の座位行動に関するエビデンスは、重大 な健康アウトカムの共通項について、がんサバイバーや 高血圧患者、２型糖尿病患者、HIV患者である成人および 高齢者に向けて推奨事項を普及させるために外挿され、 エビデンスの確実性は非直接性のためダウングレードさ れた。 ・ 高度の座位行動の潜在的リスクに反対に作用するように 中～高強度の身体活動を多く行うことの利益に関するエ ビデンスは、重大な健康アウトカムの共通項について、 がんサバイバーや高血圧患者、２型糖尿病患者、HIV患者 である成人および高齢者に向けて推奨事項を普及させる ために外挿され、エビデンスの確実性は非直接性のため ダウングレードされた。 ・ 座位行動を最小限に減らすことの利益は、がんサバイバー および高血圧患者、２型糖尿病患者、HIV患者にとっての 害を上回る。 59推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 障害を有する子ども・青少年（５〜17歳） および成人（18歳以上） 身体活動の推奨事項 障害を有する子ども、青少年、成人は、身体活動から重要な健康上の利益を得 ることができる。障害を有する子ども、青少年、成人は、これらの推奨事項を極力 守るよう努めるべきである。 障害を有する子ども、青少年、成人の場合、身体活動は、家庭、教育現場、職業および地域社会の現場の背景を踏ま えて、レクリエーションおよびレジャー（遊び、ゲーム、スポーツ、または計画的な運動）、体育、移動（ホイーリ ング、ウォーキング、サイクリング）、または家事の一環として行うことができる。すべての障害を有する子ども、 青少年、成人に対し、楽しめる内容で、変化に富み、年齢や能力に適した身体活動に参加する機会を設け奨励するこ とが重要である。 上記のセクションで述べた、子どもおよび青少年の身体活動の健康上の利益の多くは、障害を 有する子どもや青少年に関しても当てはまる。 障害を有する子どもおよび青少年がさらに得られる健康アウトカムへの利益としては、注意力 欠陥多動性障害（ADHD）などの認知機能を損なう疾患または障害がある場合には、認知力の 改善がある。また、知的障害がある子どもの場合には、身体的な機能が向上する可能性がある。 推奨事項： ＞障害を有する子どもおよび青少年の場合、中高強度の、多くは有酸素性の身体活動を週全体で １日平均60分以上行うこと。 強い推奨、エビデンスの確実性は中 ＞高強度の有酸素性の活動とともに、筋肉および骨を強化する活動を週に３日以上組み込むこと。 強い推奨、エビデンスの確実性は中 優れた実践 ・ 身体活動を一切しないよりは少しでもした方がよい。 ・ 障害を有する子どもおよび青少年でこの推奨事項を満たしていない場合、ある程度の身体活動を行うこと で健康上の利益が得られる。 ・ 障害を有する子どもおよび青少年の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時 間を増やしていく。 ・ 障害を有する子どもおよび青少年が身体活動を行うことについては、本人の現時点の活動レベル、健康状態、 および身体機能に適した内容であれば、重大なリスクはなく、得られる健康上の利益がリスクを上回る。 ・ 障害を有する子どもおよび青少年は、各自に適した活動のタイプや量を決めるうえで、医療従事者または その他の身体活動および障害の専門家に相談する必要が生じる場合もある。 60 障害を有する子ども・青少年（５〜17歳） および成人（18歳以上） 上記のセクションで述べた、成人の身体活動の健康上の利益の多くは、障害を有する成人に関し ても当てはまる。そのほかに、障害を有する成人の場合には以下の健康アウトカムへの利益があ る。多発性硬化症を有する成人の場合―身体機能の向上と、健康関連の生活の質の身体的、精 神的、社会的場面の向上。脊髄損傷患者の場合―歩行機能、筋力、上肢の機能の改善、および 健康関連の生活の質の向上。認知機能を損なう疾患または障害を有する患者の場合―身体機能 と認知機能の改善（パーキンソン病患者およびと脳卒中の既往歴のある者）、認識機能に対する 有益な影響、生活の質が改善される可能性（統合失調症を有する成人の場合）、身体機能が改善 される可能性（知的障害者のある成人の場合）、生活の質の向上（大うつ病を有する成人の場合）。 推奨事項： ＞障害を有する成人は定期的な身体活動を行うこと。 強い推奨、エビデンスの確実性は中 ＞障害を有する成人の場合、中強度の有酸素性の身体活動を150～300分以上、または高強度 の有酸素性の身体活動を75～150分以上行うか、または週全体で中強度の活動と高強度の活 動の組み合わせによる同等の量を行うと、実質的な健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 優れた実践 ・ 身体活動を一切しないよりは少しでもした方がよい。 ・ 障害を有する子どもおよび青少年でこの推奨事項を満たしていない場合、ある程度の身体活動を行うこと で健康上の利益が得られる。 ・ 障害を有する子どもおよび青少年の場合、身体活動を少し行うことから始め、徐々に頻度、強度、持続時 間を増やしていく。 ・ 障害を有する子どもおよび青少年が身体活動を行うことについては、本人の現時点の活動レベル、健康状態、 および身体機能に適した内容であれば、重大なリスクはなく、得られる健康上の利益がリスクを上回る。 ・ 障害を有する子どもおよび青少年は、各自に適した活動のタイプや量を決めるうえで、医療従事者または その他の身体活動および障害の専門家に相談する必要が生じる場合もある。 ＞障害を有する成人は、主要筋肉群すべてが関係する中強度以上の筋力向上活動を週に２日以上 行うこと。それにより、さらに健康上の利益が得られる。 強い推奨、エビデンスの確実性は中 ＞これらの障害を有する高齢者は、毎週の身体活動の一環として、バランス機能を高めるように マルチコンポーネントの身体活動と筋力トレーニングを中強度以上のレベルで週に３日以上 行って機能的な能力を強化し、転倒を予防すること。 強い推奨、エビデンスの確実性は中 ＞障害を有する成人の場合、中強度の有酸素性の身体活動を300分超に増やしても、あるいは 150分超の高強度の有酸素性の身体活動を行うか、または週全体で中強度の活動と高強度の活 動の組み合わせによる同等の量を行ってもよい。 条件つきの推奨、エビデンスの確実性は中 61推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 障害を有する子ども・青少年（５〜17歳） および成人（18歳以上） Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf 裏付けのエビデンスと理論的根拠 本ガイドラインでは、障害を有する子ども、青少年、および成人用に、PAGAC（35）がエビデンスを包括的に合成 したものを使用して更新した。身体活動と健康アウトカムに関する方法、データ抽出、およびこの既存のエビデンス を要約したエビデンス表の詳しい完全版については入手可能になっており（35）、最新版の検索の調査結果に加えて、 GDGのレビュー済みのものを見ることができる。 本ガイドラインの最新版の作成に当たっては、2017年から2019年までに発表された39件のレビューを特定した。 これらのうち、27件は組み入れ基準を満たしており、障害を有する子ども、青少年、および成人における身体活動と 健康関連アウトカムとの関連性の検討内容を伝えるものとなっている。 方法、データ抽出、およびエビデンスプロファイルについては、Web Annex： Evidence profiles （ウェブ付 録：エビデンスプロファイル）に細部まですべて記した。 エビデンスのレビューの際は、多発性硬化症、脊髄損傷、 知的障害者、パーキンソン病、脳卒中、大うつ病、統合失 調症、注意欠陥多動性障害（ADHD）から生じている障害 を有する子ども、青少年、および成人の身体活動と健康関 連アウトカムとの関連性を考慮した。４つの健康関連のア ウトカムで、共存症に付随するリスク、身体機能、認知機 能、および健康関連の生活の質を検討したが、すべてのア ウトカムを病態ごとに探索したわけではない。身体活動の 背景にある障害に対する環境因子の影響は、本ガイドライ ンの範疇から外れるため、除外した。 障害を有する子どもおよび青少年（５～17 歳）および成人の場合（18歳以上）、身体活 動と健康関連アウトカムとの間にはどのよう な関連性があるか？ 多発性硬化症患者の場合、身体活動により、身体機能、機 能的運動能、歩行速度・持久力、心肺体力、筋力、および バランスが改善する。たとえば、３～12週にわたる高強度 のインターバルトレーニングにより、心肺体力または筋力 が向上した（117）。また、下肢の筋力トレーニングにより、 平均13.2週間のトレーニング期間で筋力が23.1％（95％ CI：11.8～34.4）まで増強し、平均13週を超えると筋力 の増大が得られることが明らかになった（118）。なお、ダ ンス介入研究では機能的運動能とバランスの改善が報告さ れた（119）。身体的な健康上の利益と同様に、既存のエビ デンスは、身体活動が多発性硬化症患者の認知機能に有益 となる可能性があることを証明している（35）。比較的新し い研究では、の運動は健康関連の生活の質の身体的、精神 的、および社会的場面（疲労の症状と抑うつ症状を含む） に、小さいながらも有意の影響を与えることが明らかになっ た（35, 120）。 脊髄損傷患者の場合、身体活動はウォーキング機能、筋力、 および上肢機能を改善する可能性がある（35）。身体活動は、 肩痛を緩和するほか、血管機能を改善し、健康関連の生活 の質を向上する可能性がある（35）。 パーキンソン病患者の場合、身体活動は運動症状、機能的 運動能、動作、持久力、すくみ足、前後方向の動きの速度 を改善する可能性がある（35, 121, 122）。新たなエビデン スは、運動がパーキンソン病患者の全般的な認知機能を助 けることもできることを示唆している（123）。 脳卒中の既往歴を有する人の場合、身体活動により、身体 機能、特に上肢機能、下肢の感覚運動機能、バランス、歩 行速度、距離、能力、持久力、心肺体力、運動能、日常生 活動作が改善される可能性がある。既存のエビデンスは、 身体活動が認知に有益な影響を持つ可能性もあることを示 唆している（35）。 大うつ病を有する人の場合、新たなレビュ （ー124, 125） は、身体活動は健康関連の生活の質を改善することができ るという既存のエビデンス（35）を裏付けている（35, 124, 125）。 統合失調症を含め、認知機能を弱める疾患または障害を有 する人の場合、身体活動は、認知力、作業記憶、社会的認 知および注意／覚醒に有益な影響を持つ場合がある（35, 126）。あるレビューでは、中高強度の身体活動により、健 康関連の生活の質や障害の有意な改善が実現することが明 らかになった（35, 124）。 知的障害を有する人の場合、身体活動は身体機能を改善す ることが示された。主にレビュー対象となった介入は、６ ～24週間にわたるバランスと筋力の活動であり、静的バラ 62 障害を有する子ども・青少年（５〜17歳） および成人（18歳以上） ンス、動的バランス、および静的動的バランスの有意な改 善が報告された（35, 127, 128）。 注意欠陥多動障害を有する子どもの場合、エビデンス （ADHD（129）に関わる５件のRCTのうち１件のレビュー を含む）が運動と注意力と、実行機能と社会的障害との間 に正の相関を示している（35, 129）。 GDGは子ども、青少年、および成人の一般集団から得たエ ビデンスを考慮し、機能障害に起因する効果の修飾がある と確信できる理由はなく、同一の健康の生理学的な利益は 身体が活動することにより得られると結論づけた。GDGは、 障害を有する人を対象とした研究がほとんどないこと、ま た効果の修飾があまり検証されていないことを認めた。 障害分野のエビデンスは一般集団の幅広いエビデンスと併 せ、障害を有する人も含めた全般的な集団への推奨事項を 裏づけており、「すべての成人」、「すべての高齢者」、「障害 の有無を問わずすべての人」という言い方をしている点に 注目すべきである。 GDGが出した結論： 脊髄損傷を有する人の場合： ・ 身体活動は麻痺した四肢の血管機能を改善し、健康関連 の生活の質を向上させるという確実性が低いエビデンス ・ 身体活動は歩行機能、筋力、上肢機能を改善するという 確実性が中程度のエビデンス。 パーキンソン病を含む認知機能が損なわれる疾患または障 害を有する人の場合： ・ 身体活動は歩行、バランス、筋力、疾患特異的な運動能 のスコアを含む多くの機能性のアウトカムを改善すると いう確実性が高いエビデンス。 ・ 中高強度の身体活動は認知機能に有益な影響を発揮する 可能性があるという確実性が中程度のエビデンス。 脳卒中の既往歴を有する人の場合： ・ 運動能指向型の身体活動は身体機能と認知機能に有益な 影響を与える可能性があるという確実性が中程度のエビ デンス。 統合失調症を含む認知機能が損なわれる疾患または障害を 有する人の場合： ・ 身体活動が生活の質を改善するという確実性が中程度の エビデンス。 ・ 中高強度の身体活動は認知機能、作業記憶、社会的認知、 および注意力に有益な影響を与える可能性があるという 確実性が高いエビデンス。 大うつ病を有する成人の場合： ・ 身体活動が生活の質を改善するという確実性が中程度の エビデンス。 多発性硬化症を有する成人の場合： ・ 身体活動、特に有酸素性の筋力向上活動は身体機能、機 能的運動能、歩行速度、持久力、心肺体力、筋力、バラ ンスを向上させるという確実性が高いエビデンス。 ・ 身体活動は認知機能に有益な影響を発揮する可能性があ るという確実性が中程度のエビデンス。 ・ 身体活動が疲労の症状および抑うつ症状を含む生活の質 を改善するという確実性が低いエビデンス。 知的障害者を有する子どもおよび成人の場合： ・ 身体活動が身体機能を改善するという確実性が低いエビ デンス。 ADHD者を有する子どもおよび青少年の場合： ・ 中高強度の身体活動は注意力、実行機能、社会的障害を 含む認知機能に有益な影響を与える可能性があるという 確実性が中程度のエビデンス。 さらに、GDGは、機能障害の幅広いエリアで種々の健康ア ウトカムに身体活動が与える好影響に関しては十分な科学 的エビデンスがあること、また身体活動の利益が潜在的な 害を上回ることを結論とした。 これらの推奨事項の策定のためのエビデンスの非直接性か ら、確実性のレベルをダウングレードした。 63推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 障害を有する子ども・青少年（５〜17歳） および成人（18歳以上） 座位行動の推奨事項 障害を有する子ども、青少年、および成人の場合、Sedentary behavior 座位 行動とは、教育、家庭、地域社会の現場や移動時などの状況において、覚醒してい るときに、座ったまままたは横たわったままエネルギー消費が少ない状態で時間を過ごし ていることと定義されている。じっとしていることSedentary behaviorを避け、座位または横臥位のまま身体が活 動的であるようにすることは可能である。たとえば、上体主導の活動、インクルーシブおよび／または車椅子に特化 したスポーツや活動などである。 裏付けのエビデンスと理論的根拠 Global recommendations on physical activity for health（健康づくりのための身体活動に関するグローバルな 推奨事項）（2010）には座位行動が取り上げられていなかった。 集団に特化したエビデンスがないため、障害を有する子ども、青少年、および成人の座位行動と健康アウトカムとの 関連性を評価するための主なエビデンスのベースは、障害を有していない集団用に照合しレビューした科学文献で あった。 一般集団の座位行動に関するエビデンスから得た所見については、障害を有する子ども、青少年、および成人の場合 にはアウトカムが異なる、あるいは該当しない、もしくは禁忌となるエビデンスの有無を評価することも含め、レ ビューを行った。 子どもおよび青少年の場合、座位行動の多さは、肥満の亢進、心血管代謝の健康度の低下、体力、 行動／向社会的行動、睡眠期間の減少などの不良な健康アウトカムと関連している。 推奨事項： ＞障害を有する子どもおよび青少年は、座位のまま過ごす時間、特に余暇時間でスクリーンタイ ムが短くなるように制限をかけること。 強い推奨、エビデンスの確実性は低 成人の場合、座位行動の多さは、総死亡率、心血管疾患死亡率、がん死亡率、心血管疾患、がん、 および２型糖尿病の発生率などの健康アウトカムが不良であることと関連している。 推奨事項： ＞障害を有する成人は座位のまま過ごす時間が短くなるように制限をかけること。座位で過ごす 時間をいずれかの強度の身体活動の時間に替えると健康上の利益がある。 強い推奨、エビデンスの確実性は低 ＞長時間の座位行動が健康に与える有害な影響を抑えるため、障害を有する成人は、中高強度と いう推奨レベルを上回る身体活動を行うよう心がけること。 強い推奨、エビデンスの確実性は低 64 障害を有する子ども・青少年（５〜17歳） および成人（18歳以上） 利用できるエビデンスや専門家の意見を基に、エビデンス を外挿し、重大な健康アウトカムの共通項について障害を 有する人に対する座位行動についてのWHOの新たな推奨事 項を普及させると同時に、車椅子使用者などの特定の集団 群が長期間座位をとることは不可避であるため、座ること が標準となる場合があると認識する。そのような層の場合、 座位行動とは、電動の車椅子に着座して移動するとか、車 椅子を押してもらって移動するなど、エネルギー消費が少 ない状態で時間を過ごしていることと定義される。障害を 有する人の場合、座位行動と健康関連アウトカムとの間に はどのような関連性があるか？しかし、専門家の意見に基 づくと、機能障害に起因する効果の修飾があると確信でき る理由はなく、そのため、同一の健康の生理学的な利益は、 障害を有する人の座位行動を制限することによって得られ る。この推奨事項の策定のためのエビデンスの非直接性か ら、確実性のレベルをダウングレードした。 高度の座位行動の潜在的リスクに反対に作用するように中 ～高強度の身体活動を多く行う成人の利益に関するエビデ ンスの適用性も検討のうえ、外挿し、重大な健康アウトカ ムの共通項について、障害を有する成人に普及させた。非 直接性を考慮し、エビデンスの確実性をダウングレードし た。 GDGが出した結論： ・ 子どもおよび青少年の座位行動に関するエビデンスは全 般的に、具体的な能力に従い、障害を有する子どもおよ び青少年に外挿された。 ・ 高レベルの座位行動の潜在的リスクに反対に作用するよ うに中高強度の身体活動を行う成人にとっての利益を含 め、一般成人集団の座位行動に関するエビデンスは、概 して、その具体的な能力に応じて障害を有する成人およ び高齢者に外挿される。しかしながら、エビデンスの確 実性は、非直接性のためダウングレードされた。 ・ 座位行動を最小限に減らすことの利益は、障害を有する 子ども、青少年、成人、高齢者にとってのリスクを上回 る。 65推奨事項 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r エビデンスから推奨事項へ GRADEのプロセスに従って提案された最新の推奨事項の言 い回しと強度の評価（「強」または「条件つき」）のベース となった考慮点は、利益と害のバランス、エビデンスの確 実性、ガイドラインで対象とされる者の価値観や好みに対 する感度、性別、社会的公平性、および健康の公平性に対 する潜在的なインパクト、および許容可能性、実現可能性、 およびリソースの影響であった。これらを各集団の群別に 検討したが、問題点と考慮点の類似性を踏まえて、ここで はまとめた形で記す。 推奨事項の強度は、主として利益と害のバランスの評価を 基にした。利益と害のバランスがその推奨事項の標的集団 にとって堅固なものとして評価された場合には「強」と格 付けし、利益と害のバランスがその推奨事項の標的集団に おいてささいなものであるか、または重要な変動が生じる 可能性が高い場合には「条件付き」と格付けた。害に関す るエビデンスは、新しい系統的レビューの委託を通して特 別に求めた。しかしながら、これは限定的なものになった。 理由は、ほとんどのエビデンスでは一般集団ではなくエリー ト選手や競技選手にとっての負傷や害が重視されていたた めである。全体的に、限られたエビデンスではあるが、専 門家の意見から情報を得て、リスクはささいな域を越えな いと結論づけた。エビデンスは概して、身体活動の利益が 害をはるかに上回ること、また身体活動が既存の健康格差 の解消を支える重要な介入となりうることを特に不利な立 場にある集団の場合に示した。 健康の公平性、実現可能性、許容可能性の問題もGDGは検 討し、2020年３月31日から2020年４月17日にかけて開 催された推奨事項の草案に関するオンライン公開協議の一 環として扱われた。公開協議のための調査では、推奨事項 を履行するにあたっての個人と行政の費用のバランスに関 する具体的なクエスチョンについて、またガイドラインが 健康の公平性を改善することになるか否かが問われた。な お、身体活動に関する国内のガイドラインの策定に対する 懸案事項を最近表明した国や、同ガイドラインの草案づく りの工程に入った国には、推奨事項の草案とフィードバッ クフォームを送った。フィードバックは、オンラインでの 協議に対する420本を超える投稿から受け取り、WHO欧州 地域事務局からのフィードバックとの照合も併せて行い、 WHO協力機関やWHO加盟国からのコメントも組み込んだ。 この協議から得られたフィードバックをGDGが照合して精 査し、さらにWHO運営委員会とGDGの協議を通して実現 可能性、リソースの影響、および健康の公平性に関する検 討事項を普及させる際にもこれらのフィードバックを使用 した。 決定は、討議を経てコンセンサスに基づいて下された。 GDGは、各推奨事項と、推奨事項の強度に基づいてコンセ ンサスに達し、評価と投票は不要であった。 エビデンスの確実性の評価 GRADEのフレームワークは、PI/ECOで特定された各アウ トカムに寄与しているプライマリーリサーチの確実性を検 討するためにGDGが使用し、各アウトカムのバイアスのリ スク、不整合、不正確、エビデンスの非直接性、公表バイ アスを考慮に入れているエビデンスの全般的な確実性を評 価した。各PI/ECOのこの情報を詳述したGRADEの表は、 Web Annex：Evidence profiles （ウェブ付録：エビ デンスプロファイル）に掲載した。エビデンスの確実性の 評価は、評価対象のすべてのアウトカムで全般的な評価に 基づいて行われたもので、最も重大なアウトカムとして総 死亡率と心血管死亡率を優先させ、次にその他の臨床上の アウトカム（転倒、抑うつ、認知機能、健康関連の生活の 質など）を、続いて中間のアウトカム（例：心血管代謝の マーカー、その他の代謝性マーカー）と害について取り上 げた。エビデンスが特に精査されていない場合（たとえば 対象となる集団のエビデンスが不足していることを主な理 由として亜集団での座位行動のエビデンスの精査が行われ なかった場合）は、非直接性の観点から、適切であるとみ なされた場合には一般集団のエビデンスが外挿されダウン グレードされた。 Available online at https://apps.who.int/iris/bitstream/handle/10665/336657/9789240015111-eng.pdf66 利益と害 推奨事項の策定には、有害なインパクトまたはリスクの評 価を含めた。エビデンスが限られている場合には、GDGの 専門知識を基に決定を下した。全体として、いずれの集団 でも、身体活動を行い座位行動を制限することの利益は害 を上回ると結論された。 これらのガイドラインは一般集団に関するものであり、競 技に参加するための成績関連の体力の改善に必要なタイプ や量の活動を行うアスリートが経験する利益と害を取り上 げたものではない。 身体活動を一切しないよりは少しでもした方がよい。この 推奨事項を現在満たしていない人の場合、ある程度の身体 活動を行うことで健康上の利益が得られる。そのような人 は、身体活動を少し行うことから始め、徐々に頻度、強度、 持続時間を増やしていく。運動前の医学的な許可は、一般 的には不要である。身体活動を行わなかった人が中強度の 活動を徐々に行うようになった場合の突然の心疾患発症の リスクで既知のものはなく、骨、筋肉、または関節の損傷 のリスクはごくわずかである。中強度の活動を習慣的に行っ ていた人が徐々に高強度へとレベルを上げる際、医療従事 者に相談する必要はない。活動のレベルを上げたときに新 しい症状を呈した場合には、医療従事者に相談すべきであ る。 身体活動の適切なタイプと量の選択は、妊娠中および産後 の女性であるか、慢性の疾患や障害を有する人であるかに よって左右される場合があり、実行可能で禁忌事項がない ものとして選択が行われるべきである。そのような人の場 合、個々のニーズ、能力、機能上の限界／合併症、薬物療 法、および治療計画全般に適した活動のタイプと量につい て、身体活動の専門家や医療従事者に助言を求めることが ある。低強度から中強度の身体活動は通常、リスクが低く、 すべての人に推奨されている。 価値観および好み ガイドラインで対象とされる者の価値観や好み（この場合 は親および介護者、子どもおよび青少年、成人、高齢者、 妊娠中および産後の女性、慢性の疾患や障害を有する人） を検討した。全体的な結論としては、死亡率および心血管 死亡率を含む主要アウトカムに関する好みについての不確 実性はごくわずかであるか、まったくなかった。 推定された潜在的な利益は、いかなる潜在的な害も大きく 上回ったことから、GDGは、推奨事項は好みの影響を受け るものではないとみなした。 リソースの影響 GDGの専門家の意見と、介入や身体活動のレベルを上げる ことによる医療制度の節約についての経済面の分析に関し て報告する小規模の総体エビデンスは、さまざまな設定で の推奨事項のリソースの影響に関する考察を知らせるもの であった。また、オンラインの公開協議から得た結果では、 ガイドラインを履行することは本人にとっての損失を上回 る利益があるという見解には回答者の75%超が同意、また は強く同意したことを示し、行政にとっての損失を上回る 利益があるという見解には回答者の81%が同意、または強 く同意したことを示した。 有効なエビデンスと専門家の意見では、ウォーキングなど の活動は低リスクで実質的な健康上の利益があり、特別な 機器が不要で本人にとっての損失を伴わないと認識されて いる。さらに、その他の形式の身体活動で、たとえばルー ルや指導が必要なスポーツ（structured sports）、サイク リング、運動の教室などの身体活動などは、損失を負う可 能性があり、人によっては、特に低所得者にとってはそれ が障壁となる。身体活動を促し実行できるようにするため の政策や政綱を行政側が履行するには、人的資源、政策開 発、施設やサービスの用意や、また場合によっては設備の 用意などの面で投資も必要となり、中には保健医療の省庁 だけではなく保健医療以外の部門（スポーツ、教育、運輸、 都市計画など）がそれらを負う場合もある。必要とされる リソースは、すべてのコミュニティが身体活動の利用機会 を公平に備えるよう徹底するため、複数の行政レベル（全 国レベル、準全国レベル、および地方レベル）となる。 これらの投資には新しいリソースを伴う場合もあるが、身 体活動の集団のレベルを上げる方向で施設やプログラムの 優先性を反映するよう現在の予算を再割当して対処できる。 予算の再割当の例には、現在の運輸関係の予算からウォー キングやサイクリング用のインフラに当てる例や、スポー ツの予算から「すべての人のためのスポーツ」に当てる例 がある。 学校や職場などの主な現場では、低コストの介入と併せて 物理的環境の修正を行うと、身体活動への参加の支援とな り、また特定集団の一部の人が経験している活動的になる 機会の不公平な格差を軽減することにも役立つ。 全体として、この推奨事項の草案を実現するとリソースの 影響があるが、対策を履行することは、現在のガバナンス 構造内で可能であると評価された。 さらに、身体活動レベルの上昇により、医療制度において 実質的な医療貯蓄が可能であることをエビデンスが裏付け ている。2013年には、身体活動不足のグローバルな年間コ ストについて、直接的な保健医療費のみに起因する推定額 は国際ドルで540億と見積もられ（130）、国家レベルでは 67Evidence to recommendations W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 不活動はヘルスケア予算の１～３％の間で見積もられてい る（131）。 非感染性疾患（noncommunicable disease：NCD）予防 のさまざまな幅広い背景がある中で、推奨される身体活動 が各個人の生活の中に比較的組み込みやすいものであれば、 また身体活動が増した結果として既存のリソースがプライ マリケアやセカンダリケア、職場、または移動にシフトす る場合には、行政機関や民間組織がガイドラインを履行す るうえで負担する追加費用は最小限に抑えられる。 身体活動のプロモーションの損失と利益を分析したところ、 インベストメントケース（投資計画）が実行されている多 くの国では、NCDに関して、15年間にわたりプラスの投資 収益率が示されている（132）。Global action plan for the prevention and control of NCDs 2013–2020 （2013～2020年のNCDの予防と制御のためのグローバル な行動計画）（133）の付録３の最新版に基づくNCDに対処 するための推奨介入のうち、公教育や意識向上キャンペー ン、身体活動のカウンセリングや照会といった介入はそれ ぞれ「最も買得」および「買得」である。全体として、 GDGは、推奨事項の履行の利益は損失を上回ると結論した。 障害を有する人のための身体活動ガイドラインを実現させ るには、身体活動の専門家によるトレーニングを行ったり、 必要に応じて機器を改変したり、利用しやすくするために 必要な設備を用意したりと、投資が必要とされる可能性が ある。この投資により、幅広い層の集団のニーズに応えや すくなる可能性がある。身体活動への参加は、利用機会に 関する複数の障壁や、提供される活動の選択、またその他 の臨み方に起因して、障害のない人とある人の間に有意差 があることをエビデンスが示している。障害を有する人が 完全かつ有効に参加することを確実にするには、ユニバー サルデザインの原則を適用すべきである。これらのリソー スの影響の多くは、技術革新により対処できる。ユニバー サルデザインによるアプローチを採択することで、将来的 にこれらの損失は緩和されるであろう。 公平性、許容可能性、および実現可能性 2010年の推奨事項を更新する際に、慢性疾患や障害を有す る人などの脆弱集団の考慮点を明確に記載する決定が下さ れた。GDGとWHO運営委員会は、そのような層を代表す る人をメンバーに入れた。GDGは、推奨事項の履行が健康 の公平性を減じるのか否かという点や、履行に関連する問 題点を考慮に入れて、各推奨事項をじっくりと検討した。 これは、推奨事項によって公平性の問題が悪化しないこと を保証するためである（たとえば、障害を有する人や、身 体活動を行ううえで社会経済的事情やその他の事情で不利 な立場に置かれている人を含め誰もが利用できる安全な施 設や機会があることを保証し、身体活動への参加方法や機 会の制約となりうる性別やその他の文化的バイアスに対処 する）。ガイドラインを履行することで、すべての人にとっ て活動的になって健康アウトカムを改善する機会が増すこ とにより、健康に対する不公平の緩和が実現するという見 解に対し、オンライン公開協議の回答者の76%が同意、ま たは強く同意した。支援する環境こそが身体活動への参加 を可能にするための重要ポイントである点が注目された。 社会経済的に不利な立場にある女性や女児、また障害のあ る人など、脆弱な層の身体活動に対する障壁に対処するに は、多くの部門に関わる政策の設計や履行に対する包括的 なアプローチが今後必要となる。 障害のある人は障害のない人に比べて健康アウトカムの悪 化を経験しているが、身体活動の利益は害をはるかに上回っ ており、この健康格差を埋める重要な介入となり得る。身 体活動への参加は、利用機会に関する複数の障壁や、提供 される活動の選択、またその他の臨み方に起因して、障害 のない人とある人の間に有意差があることをエビデンスが 示している。機器や設備を調整しなくても、障害のある多 くの人がさまざまな形式の身体活動を行うことができるよ うにすべきである。ただし、障害のある人がほかの人たち と平等な立場で身体活動を行うには、調整済みの機器を用 意し、利用しやすいように施設の設備を整えておく必要が 生じる場合や、身体活動の専門家によるトレーニングが必 要になることがある。 68 リサーチのニーズ 各年齢層で身体活動と、さらには座位行動と、健康アウト カムとを関連付けるデータは大量にあるにもかかわらず、 GDGの議論では重大なエビデンスギャップが明らかになっ た。これは、今後のガイドラインを普及させる際に優先さ れるべきである。集団のサブグループでのエビデンスギャッ プに該当するものは、以下に関する情報の不足であった。 １） 身体活動や座位行動と、研究対象の健康アウトカムの いくつかとの間にある量反応関係に関する、より正確 性の高い詳細 ２） 低強度の身体活動の健康上の利益と、座位時間を低強 度の身体活動で分断することの健康上の利益 ３） さまざまなタイプと場面の身体活動（余暇時間、仕事時 間、移動時間、家事の時間、教育の時間）や座位行動 （仕事時間、スクリーンタイム、テレビ視聴時間）；スク リーン時間；テレビテレビ番組）の健康影響の差異 ４） ライフコース全体で健康アウトカムとあわせて考えた 身体活動と座位時間との関連性 低・中所得国や、経済的に恵まれない、あるいは公共サー ビスが不十分な地域社会からの、また障害や慢性疾患を有 する人のエビデンスは依然として限られたものであること も注目された。 身体活動の健康影響を変える可能性があるさまざまな社会 人口統計学的因子（年齢、性別、人種／民族性、社会経済 的地位）別に効果の修飾（effect modification）を検証す るよう設計された研究や、そのような検証を推進するよう な研究は多くない。そのような情報は、公衆衛生の特殊性 の高い推奨事項を設けるうえでも、また集団の中でも特に 脆弱な場面での健康上の格差を緩和するうえでも重要であ る。 この新しいガイドラインから生じるリサーチギャップに関 する詳細は、すでに発表されている文献の中でも記されて いる（134）。 69Research needs W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 採択、普及、履行、および評価 本ガイドラインは、政策立案者をはじめとし、保健医療、 教育、職場、および地域社会の介入プログラムを考案する 立場にある人に向けて、子ども、青少年、成人、および高 齢者が身体を動かす時間を多くとるための日々の過ごし方 に関する推奨事項や、座位で過ごす時間を制限するための 推奨事項を示すものである。ただし、グローバルなガイド ラインを策定することは本ガイドライン自体の目的ではな い。本ガイドラインの普及と履行なくして、身体の活動性 のレベルの変化が成し遂げられることはない。 採択 WHOは、すべての国が使用するためのグローバルな当該の ガイドライン（21）を策定するための厳密かつ詳細にわたる プロセスを踏んでいる。本「身体活動および座位行動に関 するガイドライン」は、中央政府が採択して国の政策フレー ムワークの一部として利用できる、身体活動と座位行動の 健康インパクトに関する推奨事項を示すものである。グロー バルなガイドラインの策定を行う場合、細部にわたる協議 を経て、各国がリソースを使用して冗長な科学的プロセス を踏まなければならない状況が大幅に削減されるようにす べきである。このグローバルな身体活動および座位行動に 関するガイドラインを精査して採択することで、現地の事 情に合わせて調整されたガイドラインを策定するための迅 速で費用対効果の高い方法を得られる。 地域または国家レベルでWHOガイドラインを採択すると、 各国は身体活動および座位行動に関する一貫性のある推奨 事項を確実に示し、それらを最新かつ最善の有用な科学的 なエビデンスによって補強する。また、複数国で推奨事項 に一貫性があると、全国調査、身体活動と座位行動のグロー バルな推定、クロスカントリーでの比較が容易になる。採 択のプロセス全体において、必ず各地の現状を踏まえて本 ガイドラインを調整して活用することを考慮に入れる必要 がある。現地の言語に翻訳することは、採択とコンテクス ト化（現地事情を踏まえること）の一つである。身体活動 の例は、現地に即したものに変更し、画像の使用に当たっ ては、現地の文化、規範、および価値観を反映するよう調 整したものを使用する必要がある。 当該関係者による一連の地域的なワークショップを行った うえで、グローバルなガイドラインを各国で採択する際に 役立つ段階的なフレームワークを現在開発しているところ である。 このフレームワークでは、当該国のデータ（例：身体活動 に関する有病率の推定値）を読み込むことができる。また、 国内ガイドライン文書を作成する近道となるアプローチを 提供する。これらの補助的なリソース、2021年にWHO ウェブサイトを通して入手できるようになる予定である。 本ガイドラインの採択を検討する場合、以下の10段階のプ ロセスを適用することを推奨する。 １． 身体活動に関する現在の国内ガイドラインの精査と政 府の認可を確保するためのWHOガイドラインの採択を 主唱（advocate）する。 ２． 保健医療部門の中でも、その他のスポーツ、教育、運 輸などの関連部門の中でも、主要なステークホルダー を引き入れるとともに、論題の専門知識を備えた専門 家協会や研究者も採用する。 ３． 推奨事項の適用性、許容可能性、および実現可能性を 査定する。 ４． 言語、例、およびその他の文化的な考慮点など、現地 事情にガイドラインを適合させる。 ５． 政策立案者、実務者、および一般市民を含むターゲッ トユーザーと外部レビューを行う。 ６． 普及や周知のための予算の明確なプランを立てる。 ７． 国内ガイドラインを発表して推進し、パブリシティと 関心が生まれるような開始のイベントを併せると理想 的である。 ８． 関係のある専門家の団体または機関を引き入れ、政策 の整合化や是認をサポートする。 ９． 国内ガイドラインの履行や行動変容を支えるための国 家政策や実践事項を履行する。 10． 本ガイドラインの評価、精査・レビュー、および更新 のスケジュールについて合意を得る。 70 普及 国内の身体活動ガイドラインは、集団ごとの身体活動レベ ルを上げる包括的アプローチを行う上でのガバナンス構造 の中核をなす要素である。国内のガイドラインは、全国お よび準全国の戦略計画を周知させ、適切な方法で当該の層 の人に正しい情報を普及する必要がある。残念ながら、国 内のガイドラインは普及しないことがあまりにも多く、専 門家においても幅広いコミュニティにおいても、推奨事項 に対する意識は依然として非常に低いままである。身体活 動を増やして座位行動を減らすことの重要性についての意 識と知識を変えるには、広範囲な普及に役立つ専用のリソー スを確保することが第一歩として重要である。 身体活動と座位行動に関する国内ガイドラインの普及の主 要な想定対象者を以下に挙げる。 ・ 保健医療部門内外（運輸、都市計画、教育、職場、スポー ツ、公園、レクリエーションなど）の政策立案者。以下 を増やすことが目的。 　ａ． 健康のみならず、幅広く多様な、ただしジェンダー 平等、人権保障義務、および持続可能な発展などの 当該の課題の改善において、身体活動を増やして座 位行動を減らすことが寄与しうることに対する知識 　ｂ． 身体活動および座位行動に関する政策や政綱を関連 あるすべての政策に組み入れること 　ｃ． 拡大され調整された国や現地の対策への投資 ・ 政府以外の部門（非政府組織、学術研究組織、民間セク ター、メディア、研究資金助成機関など）。以下を行うこ とが目標。 　ａ． 全年齢で身体活動を増やして座位行動を減らすこと の重要性に対する意識の向上 　ｂ． 政策の整合化の促進および確保 　ｃ． 政策の履行と現地の対策における共同体制と投資の 強化 ・ 保健医療部門および非保健医療部門（スポーツ、教育、運 輸、都市計画など）の実務者。以下を増やすことが目的。 　ａ． 身体活動と座位行動に関する国内ガイドラインの意 識および知識 　ｂ． 身体活動の増加と座位行動の減少を促すうえでの知 識、スキル、確信 　ｃ． 該当する場合、身体活動推進の日課への組み込み ・ 一般市民と特定の集団のサブグループ。以下を増やすこ とが目的。 　ａ． 身体活動と座位行動に関するガイドラインに対する 意識および知識 　ｂ． 身体活動および座位行動に関するガイドラインの実 現方法に対する知識 　ｃ． 身体活動を増やして座位行動を減らす意向および動 機 周知キャンペーン さまざまな関係者がさまざまな資料から利益を得ることに なるため、複数のオーディエンスにガイドラインを周知す るには、内容やフォーマットのほか、ガイドラインを周知 するための伝達経路を十分考慮する必要がある。ガイドラ インの周知戦略を考案する場合は、形成的研究（formative research）を行うと、主要なオーディエンスを決めやすく なり、また身体活動および座位行動のレベルに影響する価 値観、ニーズ、好みを把握しやすくなる。これには、身体 活動に対する障壁を探ることや、身体活動を政策と実践に 組み込むこと、またさまざまな層で草案のメッセージや資 料をテストすることも含めるものとする。これにより、適 切なフォーマットや周知の経路とともに、使用するキーメッ セージが伝達しやすくなる。包括的な周知戦略には、さま ざまなオーディエンスをターゲットに据えた多様な周知方 法が含まれる。各国とも、利用できるリソース（人材およ び財源）次第で、特定の層を優先させる必要が生じること がある。 一般市民または特定の亜集団を対象とした身体活動に関す る周知キャンペーンは、費用効果的な介入（133）であり、 WHO Global action plan on physical activity 2018- 2030（身体活動に関する世界行動計画2018-2030）（14） で推奨されている。身体活動に関する全国および準全国キャ ンペーンでは通常、キャンペーンの包括的なスローガン （例：「アクティブになろう」あるいは「もっと動こう」）を 決め、デザイン的な要素や特性を考案し、それをさまざま なオーディエンス（例：幼児、青少年、成人または高齢者、 運動不足の人、障害または慢性疾患を有する人）に合わせ たメッセージになるよう手直しをする。特定集団の層に合 わせて手直ししたキャンペーンのメッセージとリソースは、 一般的な資料より効果的になる可能性が高い。周知キャン ペーンについては、従来のメディア（例：テレビ、ラジオ、 広告板、印刷版のリソース）とデジタルメディア（ウェブ サイト、携帯電話、アプリ）の両方のメディアチャンネル が及ぶ範囲と有効性を考慮すべきである。国内ガイドライ ンに関する情報をさまざまなフォーマットで提供すること も有用である。たとえば、比較的新しいものの一般的にな 71採択、普及、履行、および評価 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r りつつある身体活動ガイドラインを周知するためのアプ ローチは、図解を利用したものや、短いアニメーション動 画を使う手法である。 WHOには、そのような周知キャンペーンを展開し履行する ための補助的な資料がある（135）。 学術研究や研究界からは、本ガイドラインの基盤となって いる疫学的エビデンスを詳述した科学的な報告書に関心が 集まる可能性が高い。しかしながら、基盤となる研究の細 部まで具体的に説明したものでは、ほかの一般の読者の関 心を集める可能性は低い。政策立案者には、科学的な内容 をまとめたものが、または短い概要説明書でも好まれる。 医療従事者や非医療従事者など、その他の読者には、ガイ ドラインのパンフレットやファクトシートなどのさまざま なタイプのリソースが、あるいは身体活動の促進を日課に 組み込む方法（たとえば、医療現場では患者の診察時の例、 または都市環境においては建築や輸送のプランを立てる場 合など）が好まれる可能性が高い。専門家の場合も多様で あり、その役職に合わせて調整したリソースが必要になる。 医療専門職の場合は特に、担当する集団の多様な層を反映 したリソースのセットが有利に働く可能性がある。 政策およびプログラムの履行 身体活動と座位行動に関する国内ガイドラインは、それの みで身体活動レベルを集団ごとに高めることにつながる可 能性は低いため、政策やプランニングのフレームワークの 一つとみなすべきである。定期的な身体活動の実施と座位 行動の減少によるさまざまな利益について意識と知識を高 める周知戦略について国を挙げて継続することにより、国 内ガイドラインを主要な読者の間で普及させることは極め て重要である。しかし、持続性のある行動変容を実現する には、これらの対策を人々が実行できるよう奨励するため の支援環境づくりをする政策によって裏付けられている必 要がある。医療制度の観点からも、また身体活動の促進に 関心がある、またはサポートする機会がある複数の部門が 複合された機関の観点からも、政策や政綱は、現地の事情 を考慮して適合させたものにする必要がある。対策は「政 府全体」のアプローチを使用して講じるべきであり、複数 の部門や現場で、広範囲にわたる関係者が携わることによ り、身体活動を行う人々をさらにサポートできるような政 策や複数の対策の「システム」を検討すべきである。持続 的な周知戦略に合わせた「システム」のアプローチを使用 するということは、有効な周知を通して生じた身体活動の 需要増には、身体活動を行う環境や機会を人々に用意する ことで対応するよう徹底するものである。 72 WHO Global action plan on physical activity 2018– 2030（身体活動に関する世界行動計画2018-2030）では、 身体活動不足を2030年までに15%低下させることを目標 に掲げ、政策的措置や介入への推奨事項として20項目がま とめられている（14）。その中で、すべての国に対し、持続 的な国の公教育と意識向上キャンペーンを履行し、一次医 療と二次医療に身体活動のカウンセリングプログラムを組 み込むよう推奨されている。その他推奨事項には、すべて の集団層のためのウォーキング、サイクリング、ホイーリ ングなどの身体活動の適切な環境づくりをすること、また 学校、職場、スポーツクラブ、催事場での身体活動の機会 やプログラムの提供を増やすことなどが盛り込まれた。全 20項の推奨事項の履行は、いずれの国でも短期間で実行で きるわけではないが、長期目標として考察すべきである。 即時に対応することの中から、適切で実行可能なものを特 定するには、WHO加盟国は、現在の政策や実践内容の状況 に応じた分析を行う必要がある。これにより複数の部門が 共同体制を組めるようになり、またギャップや機会ととも に強みのある分野を特定しやすくなり、全国および地域の プランを立てたり更新したりすることの基盤として利用で きる。 これら新しいWHOのガイドラインは、対応範囲を拡大し、 障害または慢性疾患を有する人や妊娠中および分娩後の女 性などの層を追加する際に役立つ。政策は今後、地域社会 のニーズと層や背景事情の多様性を認めた適切な政綱の実 現と実践を支えるものであることが求められる。ACTIVE の専門的パッケージの履行をサポートするための部門に特 化した多くのツールキットが、現在開発中であり（135）、 これは、身体活動を促進する方法に関するガイダンスを各 部門に提供する。 たとえば、学校を通して、一次医療を通して、またはウォー キングやサイクリングの提供を改善して提供する。ACTIVE ツールキットのほか、WHOの地域および国のリソースも、 これらの身体活動と座位行動のガイドラインの履行をサ ポートする。 調査および評価 WHOのGlobal recommendations on physical activity for health（健康づくりのための身体活動に関するグロー バルな推奨事項）では、2010年以降、集団の健康モニタリ ングおよび調査のベンチマークとして利用されてきた。こ の最新のガイドラインの推奨事項に今後加えられる変更は、 身体活動の国ごとのモニタリングに現在使用されている調 査システムや評価手法に何らかの影響を及ぼす。今回の新 たなガイドラインが発表されると、この新しいガイドライ ンに対して将来報告されたことについて調整や推奨事項を 普及させるための現行の手法や報告の手順の精査が必要に なる。たとえば、Global Physical Activity Questionnaire （ グ ロ ー バ ル な 身 体 活 動 の 質 問 票 ） やGlobal Student Health Survey（グローバルな学生健康調査票）などの測 定法を精査し、この新しいガイドラインに合わせて手順も 更新される。2021年にはすべての国に向けたサポートガイ ダンスが提供される予定である。 WHOのNCD Country Capacity Survey（CCS：NCD国 別対応能力調査）は、NCDの政策履行に関して世界の進捗 をモニタリングするために使用される中心的な手段であり、 ２年毎に実施される。CCSには、国内の身体活動ガイドラ インがある場合の、身体活動と座位行動に関するこれらの WHOガイドラインが適用される年齢層ごとの身体活動に関 する集団調査システムに関する具体的なクエスチョンが含 まれている。WHO加盟国は、回答を裏付けるための文書を アップロードするよう依頼される。2019年には、WHO加 盟国194カ国中、78カ国（40%）に身体活動ガイドライン があると報告された（136）。2019年のCCSに対する回答 の詳細なドキュメント分析を実施したところ、国内ガイド ラインをもつ加盟国は78カ国のわずか３分の２の国（52／ 78カ国）で、あることが明らかになった。また、2010年 の WHO の Global recommendations on physical activity for health（健康づくりのための身体活動に関す るグローバルな推奨事項）（1）に完全に併せていた国は、こ れらのうち42カ国のみであった。2021年以降のデータと その後の調査は、これらの最新のガイドラインの取り込み に関する情報を示す。 更新 本ガイドラインの今後の更新は、デバイスに基づく測定法 を使用して身体活動を評価する方法の科学的な進歩や、座 位行動に関する科学の急激な進歩により早期の更新が求め られない限りは、10年後を予定している。 73採択、普及、履行、および評価 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 74 REFERENCES 1. 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Geneva: World Health Organization; 2020. 82 G lo be b as ed o n io at /S hu tt er st oc k, s ilh ou et te s ha pe s or ig in al ly b as ed o n Sh ut te rs to ck s ou rc es 83References W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 84 付録１： ガイドライン開発過程の管理 ガイドライン作成の貢献者 WHO運営グループ 運営グループには、身体活動、青少年期の健康、老化障害、メンタルヘルス、傷害予防、がん、妊娠、およびサーベイランス の分野における本部と地方事務所の両方からの専門家が含まれていた。 ValentinaBaltag Department of Maternal, Newborn, Child and Adolescent Health and Ageing – adolescent health MauriceBucagu Department of Maternal, Newborn, Child and Adolescent Health and Ageing – pregnancy FionaBull Chairperson Department for Health Promotion – physical activity AlexButchart Department of Social Determinants of Health – injury prevention NeerjaChowdhary Department of Noncommunicable Diseases – mental health/dementia ReginaGuthold Department of Maternal, Newborn, Child and Adolescent Health and Ageing – adolescent surveillance Riitta-MaijaHämäläinen Western Pacific Regional Office AndreIlbawi Department of Noncommunicable Diseases – cancer WasiqKhan Eastern Mediterranean Regional Office LindsayLee Department of Noncommunicable Diseases – disability AlanaOfficer Ageing LeanneRiley Department for Noncommunicable Diseases – surveillance GojkaRoglic Department for Noncommunicable Diseases – diabetes JuanaWillumsen Department for Health Promotion – physical activity 運営グループは、ガイドラインの範囲とPI/ECOsを起草しました。彼らは利害宣言を審査し、ガイドラインを起草、検討、 および完成させた。 85Annex 1 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r ガイドライン開発グループ（GDG） ガイドライン作成グループは、この分野の関連する専門家、推奨事項のエンドユーザー、および推奨事項の影響を受ける人々 の幅広いグループで構成されていました。ガイドライン開発グループのメンバーは次のとおり： DrSalihSaadAl-Ansari(advocate in health promotion and education to combat NCDs through physical activity and walking); DrStuartBiddle (physical activity and sedentary behaviour, and behaviour change); DrKatjaBorodulin (physical activity in pregnancy and older adults); DrMatthewBuman (sleep, sedentary behaviour, and physical activity in people living with chronic conditions); DrGreetCardon (physical activity in children and adolescents); MsCatherineCarty (physical activity in people living with disability); DrJean-PhilippeChaput (sleep, sedentary behaviour and physical activity in children and adolescents); DrSebastienChastin (physical activity, sedentary behaviour and health, objective measurement of physical activity and sedentary behaviour); DrPaddyDempsey (physical activity and sedentary behaviour in adults and people living with chronic conditions); DrLorettaDiPietro (physical activity in pregnancy and older adults); DrUlfEkelund (sedentary behaviour and physical activity, physical activity in children and adolescents); DrJosephFirth (physical activity and mental health); DrChristineFriedenreich (physical activity in people living with chronic conditions, physical activity and cancer risk); DrLeandroGarcia (physical activity and health in adults); DrMuthoniGichu (policy implementation, national government); DrRussJago (physical activity in children and adolescents); DrPeterKatzmarzyk (physical activity and sedentary behaviour); DrEstelleV.Lambert (physical activity and obesity); DrMichaelLeitzmann (sedentary behaviour and physical activity in people living with chronic conditions); DrKarenMilton (translating recommendations into practice); DrFranciscoB.Ortega (physical activity in children and adolescents, mental health and objective measurement); DrChathurangaRanasinghe (promotion of physical activity and health in the community, workplace and school settings); DrEmmanuelStamatakis (physical activity and sedentary behaviour and multiple health outcomes in adults); DrAnneTiedemann (physical activity in older adults); DrRichardTroiano (policy development); DrHiddevanderPloeg (physical activity and sedentary behaviour in adults); MsVickyWari (policy implementation – national government); DrRogerChou (Pacific Northwest Evidence- based Practice Center and Professor of Medicine, Departments of Medicine, Medical Informatics and Clinical Epidemiology of the Oregon Health and Science University) served as GRADE methodologist. Further details of the GDG are available in Annex 2. 2019年７月２～４日に最初のGDG会議が開催され、GDGはPI/ECOの質問を決定し、既存の系統的レビューを確認し、必要 な改定事項を特定した。グループは、２回目のGDG会議で、適用される推奨事項とエビデンスの強さに関する意思決定の過程 について合意した。２回目の会議は2020年２月11～14日に開催された。更新されたエビデンスがレビューされ、最終的な推 奨事項がコンセンサスに基づき合意された。 86 外部レビューグループ（ERG） GDGと運営グループによって提案された個人のリストから ７人の査読者が選ばれた。彼らは、プログラムの実施を含 む関連する専門知識を提供し、WHOの６つの地域すべてを 代表した。 ERGはガイドライン草案をレビューし、運営グループに対 し、必要に応じて組み込まれた明確性と実施の問題に関す るフィードバックを提供しました。外部の査読者は推奨事 項に変更を加えなかった。外部の査読者が付録２にリスト されている。 利害の宣言 すべてのGDGメンバーと外部の査読者は、GDGの会議に出 席する前に、WHOの利益宣言フォームに記入して提出し、 守秘義務に署名した。運営グループは、提出された履歴書 と利害宣言をレビューおよび評価し、インターネットと出 版物の検索を実行して、妥協的な状況につながる可能性の ある明らかな公の論争または関心を特定した。提案された すべてのGDGメンバーの名前と簡単な経歴は、14日間の公 開協議のためにWHO身体活動のWebページに公開されまし た。コメントはなかった。利益の宣言または相反の管理に 関する追加のガイダンスが必要な場合、運営グループは、 コンプライアンス、リスク管理および倫理に関する担当部 署の同僚と相談した。必要と思われる場合、金銭的または 非金銭的利益相反があることが判明した個人は、利益相反 のあるトピックへの参加から除外される。利益相反の管理 は、過程全体を通じて見直された。GDGメンバーは、必要 に応じて、各会議の前に利害宣言を更新する必要があり、 各GDG会議の開始時に口頭での利害宣言が求められた。 GDGと外部の査読者の宣言された利害は付録３に要約され ている。利益相反は確認されなかった。 査読 ガイドライン草案は、GDGと運営グループによって特定さ れた７人の外部査読者によってレビューされた。外部の査 読者は、明確さ、証拠の提示、および実施の問題について コメントを提供するよう求められた。コメントは必要に応 じて採択された。外部の査読者は、GDGによって決定され た推奨事項を変更することはなかった。外部の査読者は付 録２に記載されています。利害の宣言の要約は付録３に記 載されている。加えて、WHOの地域事務所からも積極的に 意見を求めた。 87Annex 1 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 付録２： ガイドライン開発グループ、外部 の査読者、およびこれらのガイド ラインの開発に関与したスタッフ ガイドライン開発グループ DrSalihAl-Ansari Assistant Professor Family & Community Medicine Founder and CEO Health Promotion Center Riyadh SAUDI ARABIA DrStuartBiddle Professor of Physical Activity & Health Physically Active Lifestyles Research Group Centre for Health Research Institute for Resilient Regions University of Southern Queensland Springfield Central AUSTRALIA DrKatjaBorodulin The Age Institute Helsinki FINLAND DrMatthewBuman College of Health Solutions Arizona State University Phoenix USA DrGreetCardon Department of Movement and Sports Sciences Faculty of Medicine and Health Sciences Ghent University Gent BELGIUM MsCatherineCarty UNESCO Chair Project Manager Institute of Technology Tralee Co Kerry IRELAND DrJean-PhilippeChaput Senior Scientist, Healthy Active Living and Obesity （HALO） Research Group Children’s Hospital of Eastern Ontario （CHEO） Research Institute Department of Pediatrics University of Ottawa Ottawa, Ontario CANADA DrSebastienChastin Professor of Health Behaviour Dynamics School of Health and Life Sciences Department of Psychology, Social Work and Allied Health Sciences Glasgow Caledonian University Glasgow UNITED KINGDOM DrRogerChou（GRADE 方法論学者） Departments of Medicine, and Medical Informatics & Clinical Epidemiology Oregon Health & Science University Portland, Oregon USA DrPaddyDempsey MRC Epidemiology Unit University of Cambridge School of Clinical Medicine Institute of Metabolic Science Cambridge UNITED KINGDOM 88 DrLorettaDiPietro Department of Exercise and Nutrition Sciences Milken Institute School of Public Health The George Washington University Washington, DC USA DrUlfEkelund Department of Sport Medicine Norwegian School of Sport Science Oslo NORWAY DrJosephFirth Presidential Fellow School of Health Sciences University of Manchester Manchester UNITED KINGDOM DrChristineFriedenreich Scientific Director Department of Cancer Epidemiology and Prevention Research Cancer Control Alberta Alberta Health Services Calgary CANADA DrLeandroGarcia Research Associate Centre for Public Health Queen’s University Belfast Belfast UNITED KINGDOM DrMuthoniGichu Head Division of Geriatric Medicine Department of Non-Communicable Diseases Ministry of Health Nairobi KENYA Dr Russell Jago Professor of Paediatric Physical Activity & Public Health Centre for Exercise, Nutrition & Health Sciences School for Policy Studies University of Bristol Bristol UNITED KINGDOM DrPeterT.Katzmarzyk Associate Executive Director for Population and Public Health Sciences Professor and Marie Edana Corcoran Endowed Chair in Pediatric Obesity and Diabetes Pennington Biomedical Research Center Baton Rouge USA DrEstelleV.Lambert Director Research Centre for Health Through Physical Activity, Lifestyle and Sport University of Cape Town Cape Town SOUTH AFRICA DrMichaelLeitzmann Professor of Epidemiology Department of Epidemiology and Preventive Medicine University of Regensburg Regensburg GERMANY DrKarenMilton Associate Professor in Public Health Norwich Medical School University of East Anglia Norwich UNITED KINGDOM DrFranciscoB.Ortega Head Unit of Physical Activity and Health Promotion Research Institute of Sport and Health （iMUDS） Department of Physical Education and Sports University of Granada Granada SPAIN 89Annex 2 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r DrChathurangaRanasinghe Chairperson NIROGI Lanka project Sri Lanka Medical Association Senior lecturer Sports and Exercise Medicine Unit Faculty of Medicine University of Colombo C Colombo SRI LANKA DrEmmanuelStamatakis Charles Perkins Centre Faculty of Medicine and Health School of Public Health University of Sydney Sydney AUSTRALIA DrAnneTiedemann Associate Professor Institute for Musculoskeletal Health School of Public Health Faculty of Medicine and Health University of Sydney Sydney AUSTRALIA DrRichardTroiano Epidemiology and Genomics Research Program National Cancer Institute National Institutes of Health Rockville USA DrHiddevanderPloeg Associate Professor Department of Public and Occupational Health Amsterdam Public Health Research Institute Amsterdam University Medical Centres Amsterdam NETHERLANDS MsVickyWari* Programme Manager, NCD National Department of Health Port Moresby PAPUA NEW GUINEA 外部査読グループ DrKingsleyAkinroye NCD Alliance Nigeria NIGERIA DrHudaAlsiyabi Director Department of Community Based Initiatives Ministry of Health OMAN DrAlbertoFlórez-Pregonero Pontificia Universidad Javeriana COLOMBIA DrShigeruInoue Department of Preventive Medicine and Public Health Tokyo Medical University JAPAN DrAgusMahendra Department of Physical education Universitas Pendidikan INDONESIA DrDeborahSalvo Prevention Research Center in St. Louis Brown School Washington University USA DrJasperSchipperijn President-Elect 2020–2022 International Society of Physical Activity and Health Department of Sports Science and Clinical Biomechanics University of Southern Denmark DENMARK * unable to attend 90 WHO運営グループ DrValentinaBaltag Head Adolescent and Young Adult Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND DrMauriceBucagu Medical Officer Maternal Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND DrAlexanderBuchart Head Violence Prevention Social Determinants of Health Department WHO Headquarters Geneva SWITZERLAND DrFionaBull Head Physical Activity Department of Health Promotion WHO Headquarters Geneva SWITZERLAND DrReginaGuthold Scientist Adolescent and Young Adult Health Maternal, Newborn, Child and Adolescent Health and Ageing Department WHO Headquarters Geneva SWITZERLAND DrRiitta-MaijaHämäläinen Technical Officer Noncommunicable Diseases and Health Promotion WHO Regional Office for the Western Pacific Manila PHILIPPINES DrAndreIlbawi Technical Officer Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND DrWasiqKhan* Regional Adviser Health Education and Promotion WHO Regional Office for the Eastern Mediterranean Cairo EGYPT MsLindsayLee Technical Officer Sensory Functions, Disability and Rehabilitation Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND MsAlanaOfficer Senior Health Adviser Healthy Ageing Office of the Director-General WHO Headquarters Geneva SWITZERLAND MsLeanneRiley Head Surveillance Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND DrGojkaRoglic Medical Officer Noncommunicable Diseases Management Department of Noncommunicable Diseases WHO Headquarters Geneva SWITZERLAND DrJuanaWillumsen Technical Officer Physical Activity Department of Health Promotion WHO Headquarters Geneva SWITZERLAND * unable to attend 91Annex 2 W H O g u id el in es o n p h ys ic al a ct iv it y an d s ed en ta ry b eh av io u r 付録３： 利害宣言の要約および管理手順 Name Gender Expertise Disclosureofinterest Conflictofinterest andmanagement DrSalihSaadAl-Ansari Male Advocate in health and education to combat NCDs through physical activity and walking Owner and Chief Executive Officer of the Health Promotion Center No conflict of interest identified DrStuartBiddle Male Physical activity in youth Research funds and paid consultancy No conflict of interest identified DrKatjaBorodulin Female Physical activity in pregnancy Employment at National Institute for Health and Welfare and Age Institute; research funds No conflict of interest identified DrMatthewBuman Male Sleep and physical activity in people living with chronic conditions None declared No conflict of interest identified DrGreetCardon Female Physical activity in youth None declared No conflict of interest identified MsCatherineCarty Female Physical activity in people living with disability None declared No conflict of interest identified DrJean-PhilippeChaput Male Sleep None declared No conflict of interest identified DrSebastienChastin Male Physical activity and health, objective measurement of physical activity Research funds No conflict of interest identified DrPaddyDempsey Male Physical activity and sedentary behaviour in adults and people living with chronic conditions Employment and research funds No conflict of interest identified DrLorettaDiPietro Female Physical activity in older adults None declared No conflict of interest identified DrUlfEkelund Male Physical activity and Employment and paid consultancy No conflict of interest identified DrJosephFirth Male mental health None declared No conflict of interest identified DrChristineFriedenreich Female Physical activity in people living with chronic conditions, physical activity and cancer risk None declared No conflict of interest identified DrLeandroGarcia Male Physical activity and mental health Employment and paid consultancy No conflict of interest identified DrMuthoniGichu Female Policy implementation （national government） None declared No conflict of interest identified DrRussJago Male Physical activity in youth None declared No conflict of interest identified ガイドライン開発グループ 92 外部の査読者 Name Gender Expertise Disclosureofinterest Conflictofinterest andmanagement DrPeterKatzmarzyk Male Physical activity and sedentary behaviour in youth Travel support to assist guideline committees No conflict of interest identified DrEstelleV.Lambert Female Physical activity and obesity None declared No conflict of interest identified DrMichaelLeitzmann Male Sedentary behaviour and chronic conditions None declared No conflict of interest identified DrKarenMilton Female Translating recommendations into practice Travel support to assist guideline committee No conflict of interest identified DrFranciscoOrtega Male Physical activity in youth, mental health and objective measurement None declared No conflict of interest identified DrChathuranga Ranasinghe Male Promotion of physical activity and health in the community, workplace and school settings Research funds No conflict of interest identified DrEmmanuelStamatakis Male Physical activity and multiple health outcomes in adults Grant for technology company for objective measurement of physical activity No conflict of interest identified DrAnneTiedemann Female Physical activity and health outcomes in older adults None declared No conflict of interest identified DrRichardTroiano Male Policy development None declared No conflict of interest identified DrHiddevanderPloeg Male Physical activity, sedentary behaviour and health outcomes in adults Travel support to assist 2017 Dutch Physical Activity Guidelines committee and research funds No conflict of interest identified MsVickyWari Female Policy implementation（national government） Shares（not relevant to guideline） No conflict of interest identified Name Gender Expertise Disclosureofinterest Conflictofinterest andmanagement DrKingsleyAkinroye Male Advocacy, noncommunicable diseases None declared No conflict of interest identified DrHudaAlsiyabi Female Policy and programme implementation None declared No conflict of interest identified DrAlbertoFlórez- Pregonero Male Physical activity and sedentary behaviour measurement and surveillance None declared No conflict of interest identified DrShigeruInoue Male Epidemiology and physical activity promotion None declared No conflict of interest identified DrAgusMahendra Male Physical activity and movement skills in children None declared No conflict of interest identified DrDeborahSalvo Feale Health and social disparities with a particular emphasis on chronic disease prevention None declared No conflict of interest identified DrJasperSchipperijn Male Physical activity and the built environment None declared No conflict of interest identified 93Annex 3