Associations between physical activity and health outcomes in clinical and non-clinical populations: A systematic meta-umbrella review

Nektaria Zagorianakou; Stefanos Mantzoukas; Fotios Tatsis; Evangelia Tsiloni; Spiros Georgakis; Agni Nakou; Mary Gouva; Elena Dragioti

doi:10.12688/f1000research.139857.1

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Systematic Review

Associations between physical activity and health outcomes in clinical and non-clinical populations: A systematic meta-umbrella review

[version 1; peer review: 1 approved with reservations]

Nektaria Zagorianakou¹, Stefanos Mantzoukas², Fotios Tatsis³, [...] Evangelia Tsiloni¹, Spiros Georgakis³, Agni Nakou¹, Mary Gouva¹, Elena Dragioti ^1,4

Nektaria Zagorianakou¹, Stefanos Mantzoukas², [...] Fotios Tatsis³, Evangelia Tsiloni¹, Spiros Georgakis³, Agni Nakou¹, Mary Gouva¹, Elena Dragioti ^1,4

PUBLISHED 14 Sep 2023

Author details Author details

¹ Research Laboratory Psychology of Patients, Families & Health Professionals, Department of Nursing, School of Health Sciences, University of Ioannina, Ioannina, Ipiros Ditiki Makedonia, Greece
² Research Laboratory of Integrated Health, Care and Well-being, Department of Nursing, School of Health Sciences, University of Ioannina, Ioannina, Ipiros Ditiki Makedonia, Greece
³ Faculty of Medicine, School of Health Sciences,, University of Ioannina, Ioannina, Ipiros Ditiki Makedonia, Greece
⁴ Pain and Rehabilitation Centre, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Östergötland County, Sweden

Nektaria Zagorianakou
Roles: Conceptualization, Data Curation, Investigation, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Stefanos Mantzoukas
Roles: Conceptualization, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Fotios Tatsis
Roles: Data Curation, Investigation, Methodology, Writing – Review & Editing

Evangelia Tsiloni
Roles: Data Curation, Investigation, Writing – Review & Editing

Spiros Georgakis
Roles: Data Curation, Investigation, Validation, Writing – Review & Editing

Agni Nakou
Roles: Data Curation, Investigation, Writing – Review & Editing

Mary Gouva
Roles: Conceptualization, Data Curation, Investigation, Methodology, Validation, Writing – Review & Editing

Elena Dragioti
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the HEAL1000 gateway.

Abstract

Background: The beneficial effect of physical activity in various health conditions is recognised, but the consistency and magnitude of its outcomes remain debated. Therefore, we aimed to chart the evidence of the association between physical activity and health outcomes in clinical and non-clinical populations.
Methods: We conducted a meta-umbrella review using a semiquantitative and descriptive analysis. We searched PubMed/MEDLINE, PsycINFO, and CINHAL databases from inception to February 28, 2023, for umbrella reviews that evaluated the relationship between physical activity and health outcomes using validated methods to assess evidence levels. Two reviewers independently screened, extracted data, and assessed quality of the umbrella reviews. The overlap analysis of component meta-analyses within the umbrella reviews was performed using the Corrected Covered Area (CCA) method. To ensure consistency, pooled effect estimates were converted to equivalent odds ratios (eORs).
Results: Sixteen umbrella reviews with a total of 130 statistically significant associations were included. The sole risk-demonstrating association, supported by convincing evidence, was between intensive sports and atrial fibrillation (eOR=1.64, 95%CI=1.10-2.43). The strongest protective associations, supported by convincing and highly suggestive evidence, were between any physical activity and the incidence of Parkinson's disease (eOR=0.66, 95%CI=0.57-0.78), Alzheimer's disease (eOR=0.62, 95%CI=0.52-0.72), cognitive decline (eOR=0.67; 95%CI=0.57-0.78), breast cancer incidence (eOR=0.87, 95%CI=0.84-0.90), endometrial cancer incidence (eOR=0.79, 95%CI=0.74-0.85), and between recreational physical activity and the incidence/mortality of cancer (eOR=0.70, 95%CI=0.60-0.83). The remaining ones demonstrated lower levels of evidence, while 60 (46.2%) of those exhibited multiple levels of evidence, displaying a lack of consistency.
Conclusion: Despite the inconsistent evidence across associations, the contribution of regular physical activity to maintaining both physical and mental health cannot be underestimated, particularly when it comes to cognitive and cancer outcomes. The association between intensive sports and potential risk of atrial fibrillation requires further consideration though.

Keywords

exercise, fitness, physical exercise, mental health, physical health, umbrella review

Corresponding author: Elena Dragioti

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2023 Zagorianakou N et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Zagorianakou N, Mantzoukas S, Tatsis F et al. Associations between physical activity and health outcomes in clinical and non-clinical populations: A systematic meta-umbrella review [version 1; peer review: 1 approved with reservations]. F1000Research 2023, 12:1152 (https://doi.org/10.12688/f1000research.139857.1) First published: 14 Sep 2023, 12:1152 (https://doi.org/10.12688/f1000research.139857.1) Latest published: 14 Sep 2023, 12:1152 (https://doi.org/10.12688/f1000research.139857.1)

Introduction

The gravity of physical activity and its impact on our well-being is widely recognized¹^–⁷ and emphasised on a daily routine level by the World Health Organization (WHO).³^,⁴ At the same time, nearly 70% of the global population is afflicted by the pandemic of physical inactivity,³ which raises public health concerns⁸ and is responsible for a substantial economic burden.⁹

Existing evidence highlight the beneficial effect of physical activity in various health conditions such as non-communicable diseases,⁴^,¹⁰^–¹² including cardiovascular diseases,⁵^,¹³^,¹⁴ like coronary artery disease, stroke, hypertension,¹²^,¹⁴ diabetes,¹²^,¹⁴^–¹⁶ and certain types of cancer.¹²^,¹⁴^,¹⁷ It is also found to be of great aid in musculoskeletal conditions¹⁸^–²¹ and degenerative diseases like osteoporosis and osteoarthritis,⁵^,¹⁴ plays a vital role in in promoting metabolic health²²^,²³ and bear therapeutic effects on mental health disorders, such as depression and anxiety.²⁴^–²⁸

While physical activity is very beneficial, it should not be considered as panacea or an all-rounder for every situation. Potential harms may exist depending on the level of intensity, the population group, and the health condition.⁶ For example, individuals with pre-existing cardiovascular conditions may need to exercise with caution and consult with healthcare professionals to ensure that the exercise intensity is appropriate.²⁹^,³⁰ Similarly, pregnant women should be mindful of their physical activity levels and choose exercises that are safe for them.³¹ In some cases, excessive physical activity can also lead to injuries, overuse syndromes, or exacerbation of existing health conditions.⁶

Hence, the concept of a universal physical activity recommendation seems oversimplified, as factors such as exercise type, intensity, duration, and health condition should be considered.⁶^,³² Such recommendations should be tailored and based on individual needs and capabilities.² Towards this, additional information on the associations between physical activity and different population groups with various health conditions would be of great value.²

Despite numerous umbrella reviews demonstrating the overall positive association between physical activity and health outcomes,³³^–³⁶ the topic is still partially understood due to variations in objectives and methods across these reviews. A comprehensive analysis examining the consistency and magnitude of physical activity effects is still lacking. To address these issues, we conducted a systematic meta-umbrella review (or in other words, an overview of reviews synthesis) on the associations between physical activity and health outcomes in clinical and non-clinical populations, an approach that allows for an overarching charting and comprehensive assessment of the relevant subject based on published umbrella reviews.³⁷^,³⁸

Our aim was to provide an evidence synthesis map on the consistency and magnitude of the health effects of physical activity and its potential protective role across a wide range of physical and mental health outcomes, which, in turn, can contribute to formulating relevant recommendations for further clinical research and practice.

Methods

This meta-umbrella review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines³⁹ and the Preferred Reporting Items for Overviews of Reviews (PRIOR) checklist (see Reporting Guidelines, https://osf.io/bv27t/).⁴⁰ The research question, inclusion criteria, and all methods were determined ad hoc prior to the start of the literature searching. The research question was formulated as follows: How strong is the evidence regarding the effects of physical activity and/or exercise, either as exposure or as interventions on physical or mental health in any populations (clinical and non-clinical) of all ages?

Search strategy

A broad search was performed on three electronic databases (PubMed/MEDLINE, PsycINFO and CINAHL) for umbrella reviews published from inception through February 28, 2023, with no language, age, or setting restrictions. The last update was carried out on April 7th, 2023. The search algorithm included the following search terms: “umbrella review” and (“physical activity” OR “exercise” OR “fitness” OR “physical exercise”). The identified umbrella reviews were first screened based on the title and reading of the abstract. After excluding those records that were not relevant to the subject under investigation, the full texts of the remaining records were further examined for inclusion. References to umbrella reviews included in the final dataset were also checked to identify other eligible articles that may have been missed during electronic searches. Two independent reviewers (MG, NZ) screened titles and full texts in duplicate, with discrepancies to be resolved by a third independent reviewer (ED).

Eligibility criteria

In this study, the unit of analysis was umbrella reviews i.e., a newer form of evidence synthesis from multiple systematic reviews and meta-analyses on a certain question, as previously defined⁴¹^–⁴³ to achieve overall consistency by summarising these reviews together.⁴³^,⁴⁴

Hence our inclusion criteria were: 1) umbrella reviews reporting quantitative data (i.e., with a formal meta-analysis [MA]) from observational individual studies (i.e., case-control, cohort, cross-sectional or ecological studies) and/or randomised controlled trials (RCTs); 2) umbrella reviews reporting data on the association between physical activity and any health outcome in any population of all ages that consider physical activity to be either an etiological factor or an intervention approach; and 3) umbrella reviews using well-known approaches to grading the evidence (e.g., GRADE or similar).⁴¹^,⁴³^,⁴⁵^,⁴⁶

Umbrella reviews were eligible regardless of the physical activity that were examined in terms of type, delivery mode (e.g., supervised or not supervised, in groups etc.), dose (frequency, intensity, and duration), or comparator (e.g., no exercise, other type of physical activity etc.). In the case of two umbrella reviews examining the same association between physical activity type and health outcome (i.e., overlapping umbrella reviews), we retained only the umbrella review with the largest number of included meta-analyses. Any disagreements were resolved through discussion and consensus within the entire review panel.

Our exclusion criteria were: 1) umbrella reviews of network meta-analysis, methodological umbrella reviews or guidelines, policy studies and protocols; 2) umbrella reviews presenting only narrative description of the data; whenever an umbrella review included systematic reviews with and without a formal MA, we retained only the systematic review presenting a formal MA, 3) umbrella reviews not addressing the physical activity as an exposure or an intervention (i.e., physical activity treated as an outcome e.g., adherence to physical activity) or umbrella reviews not addressing physical or mental health outcomes (e.g., academic achievements); and 4) umbrella reviews did not use established approaches to grade the evidence.

Data extraction

Search results were imported into EndNote V.X9 (Clarivate, Philadelphia) where duplicates were removed and then exported into an Excel sheet for evaluation against inclusion criteria and data extraction. Six reviewers (NZ, ED, FT, ET, AN, and SG), in groups of two, performed the data extraction from each eligible umbrella review. We recorded the first author, year of publication, type of physical activity and whether a definition was given, health conditions or population analysed, number of systematic reviews reviewed and number of meta-analysis included, number of primary studies included per systematic review and their study design, total sample size, health outcomes tested, years of evidence reviewed, databases searched, grading method used for the credibility of the evidence, and if funding sources were reported.

We also recorded the dose of physical activity or the comparison group, where reported, the number of studies and cases analysed for each association between physical activity and association-specific estimates (i.e., OR, RR, etc.), as well as the corresponding confidence interval (CI) for each umbrella review. The class of evidence was then recorded as originally reported in the umbrella reviews included, according to our inclusion criteria; all studies must have used an established classification of the robustness of the reported associations. Whenever workable, we recorded the class of evidence from prospective studies as part of a sensitivity analysis.

Outcome measures

Outcomes of interest were any reported health outcome (both physical and mental) assessed using risk ratios (RR), hazards ratio (HR), odds ratio (OR), or standardized mean difference (SMD) metrics of association. Risk difference measures of effect or mean difference or weight mean difference measures of effect were not considered unless they can be converted to either RR or SMD.⁴¹ To provide a robust and clear evidence map, only outcomes with statistically significant associations were assessed in the current study (i.e., outcomes with non-significant associations (p>0.05) were not examined in the current study, regardless of the certainty level reported in the original umbrella reviews).

Quality assessment

The methodological quality of the included umbrella reviews was assessed independently by two reviewers (NZ and ED) employing the AMSTAR 2 checklist (A Measurement Tool to Assess systematic Reviews),⁴⁷ as there are no standard criteria for assessing the quality of umbrella reviews. The AMSTAR 2 method was applied by completing an online checklist (https://amstar.ca/Amstar_Checklist.php) including 16 specific items that automatically calculated the quality as high, moderate, low, and critically low, respectively. The AMSTAR 2 does not generate an overall score.⁴⁷ In cases of discrepancy during the assessment, a third reviewer decided (MG).

Data synthesis

First, we calculated the overlap in component meta-analyses that were included across the eligible umbrella reviews using the Corrected Covered Area (CCA) method⁴⁸ with the following cut-offs: 0%–5%=‘slight overlap’; 6%–10%=‘moderate’; 11%–15%=‘high’ and >15%=‘very high’ overlap. In alignment with prior meta-umbrella review publications,³⁷^,⁴⁹^,⁵⁰ we summarised data that had already undergone meta-analysis and grading (and considered statistically significant at p < .05), instead of re-synthesizing and re-grading them. Hence, the results of the included umbrella reviews are summarised descriptively.³⁷ However, since the primary goal of a meta-umbrella review is to allow comparison of the across different types of pooled effect estimates reported in different umbrella reviews,⁴¹ we converted pooled effect estimates to equivalent odds ratios (eORs), using the formula previously reported.⁴¹^,⁵¹^,⁵² The results with high and moderate evidence were presented using forest plots using STATA 17.0 (STATA Corp., College Station, TX, USA).

Results

Search results

The electronic search identified 240 potentially relevant umbrella reviews. After removing 28 duplicates, 212 umbrella reviews were screened and 131 were further excluded based on title and abstract. No further umbrella review was identified using the hand search method. Eighty umbrella reviews were retrieved in full text and screened against our inclusion criteria (one full text could not be retrieved). Finally, 16 umbrella reviews were deemed eligible and included in the present meta-umbrella study.⁵³^–⁶⁸ Figure 1 depicts the PRISMA flowchart for the study selection process and the Table 1 in Supplementary Material contains the list of full-text articles that were read and excluded along with the specific reasons for exclusion.

Figure 1. PRISMA flow chart for the selection prosses.

Characteristics of included umbrella reviews

The characteristics of the 16 eligible umbrella reviews are described in Table 2 in Supplementary Material. The 16 umbrella reviews corresponded to a total of 462 systematic reviews, with or without meta-analysis but only 103 were meta-analyses and were included here, examining the effects of physical activity, including all types of physical activity and exercise (or mixed types, including combinations aerobic training, strength training, yoga, tai chi, qigong, mind body interventions, etc.), as well as physical leisure activities, occupational physical activity, and sports practice with marked associations mainly in mixed populations not specified (any population). In specific populations, there were associations with five clinical conditions (mild cognitive impairment, dementia and Alzheimer's disease, cancer [any cancer, breast and lung cancer], chronic kidney disease, and type II diabetes mellitus) and four healthy populations (healthy youth, general healthy population, pregnant women and peri or postmenopausal women).

The included umbrella reviews were published between 2015 and 2023 and assessed individual systematic reviews published from 1996 to 2021. The minimum and maximum number of primary studies (i.e., observational studies and randomised controlled trials) included in the meta-analyses were 2 and 514, respectively, while the corresponding figures for the included sample sizes were 53 (minimum) and 3,861,201 (maximum), respectively. As for the grading method employed in eligible umbrella reviews, eight were used the GRADE approach,⁴⁶ seven the Ioannidis Criteria,⁴³ and one the Oxford Centre for Evidence-Based Medicine criteria.⁶⁹

More than 700 associations were identified in total, but only 130 of them were found to be statistically significant and have been evaluated herein. These 130 distinct associations concerned a total of 41 outcomes (e.g., cancer incidence and mortality neurocognitive outcomes, hypertension and cardiovascular outcomes, psychological symptoms, metabolic outcomes, fatigue, quality of life, etc.). Ninety of these 130 associations related to physical health outcomes and 40 to mental health ones. The overlap in component meta-analyses CCA method⁴⁸ indicated a slight overlap (CCA=1.92%; Table 3 in Supplementary Material).

Quality assessment of the included umbrella reviews

Based on AMSTAR 2 evaluation of methodological quality, two umbrella reviews (12.5%) were rated as high quality, six (37.5%) as moderate quality, seven (43.8%) as low quality, and one (6.2%) as critically low quality (Table 1). The items that most often contributed to lower ratings were items 2 and 3 (50 % of umbrella reviews did not include an explicit statement in the article that the review methods were established prior to the conduct of the review and 81.25% did not explain their selection of the study designs for inclusion in the review) and items 7,8 and 10 (75.1% of umbrella reviews did not provide a list of excluded studies and justify the exclusion in the review, 87.5% described partially the included studies in adequate detail, and 93.8 % did report on the sources of funding for the studies included in the review).

Table 1. The quality of the included umbrella reviews according to AMSTAR 2.

References	AMSTAR2 Items*																Overall Rating †
References	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	Overall Rating †
Bellou et al., 2015	Yes	PY	No	No	Yes	Yes	PY	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Low
Bellou et al., 2017	Yes	PY	Yes	No	Yes	Yes	PY	PY	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Low
Cillekens et al., 2020	Yes	PY	No	PY	Yes	Yes	Yes	PY	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Moderate
Demurtas et al., 2020	Yes	Yes	No	PY	Yes	Yes	PY	PY	Yes	No	Yes	Yes	Yes	Yes	No	No	Low
Hou et al., 2023	Yes	Yes	No	PY	Yes	Yes	Yes	PY	Yes	No	No	Yes	Yes	Yes	No	No	Low
Jiang et al., 2020	Yes	PY	No	PY	Yes	Yes	PY	PY	Yes	No	NA	NA	Yes	Yes	Yes	Yes	Moderate
Lesinski et al., 2022	Yes	No	No	PY	Yes	Yes	PY	PY	Yes	No	Yes	Yes	Yes	Yes	No	Yes	Critically low
Markozannes et al., 2015	Yes	PY	No	PY	Yes	Yes	PY	PY	PY	No	Yes	Yes	Yes	Yes	Yes	Yes	Moderate
Martinez-Vizcaino et al., 2022	Yes	Yes	Yes	PY	Yes	Yes	Yes	PY	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	High
Rezende et al., 2017	Yes	PY	Yes	PY	Yes	Yes	PY	PY	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	High
Shepherd-Banigan et al., 2017	Yes	Yes	No	Yes	Yes	Yes	PY	PY	Yes	No	Yes	Yes	Yes	Yes	No	Yes	Low
Singh et al., 2023	Yes	Yes	No	PY	Yes	Yes	Yes	PY	Yes	Yes	NA	NA	Yes	Yes	Yes	Yes	Moderate
Trott et al., 2022	Yes	Yes	No	PY	Yes	Yes	PY	PY	PY	No	Yes	Yes	Yes	Yes	Yes	Yes	Moderate
Valenzuela et al., 2021	Yes	PY	No	PY	Yes	Yes	No	Yes	PY	No	Yes	Yes	Yes	Yes	Yes	Yes	Low
Zhang et al., 2022	Yes	Yes	No	PY	Yes	Yes	PY	PY	Yes	No	Yes	Yes	Yes	Yes	No	Yes	Low
Zhang et al., 2023	Yes	Yes	No	PY	Yes	Yes	PY	PY	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Moderate

* AMSTAR 2 Items are described in Supplementary material.

Summary of evidence for association between physical activity and health outcomes

A total of 130 statistically significant, non-overlapping associations between physical activity and health outcomes were identified for both clinical and non-clinical population categories (Tables 2 and 3). Notably, 129 out of 130 associations were identified as protective against various health outcomes, while only one posed a risk. As shown in Tables 2 and 3, 70 associations (53.8%) had a unique level of evidence while sixty (46. 2%) of them shared multiple levels of evidence, indicating that many statistically significant associations lack consistency. Moreover, only two (1.5%) were supported by convincing/high evidence and 23 (17.7%) by highly suggestive or moderate evidence (Figure 2). The remaining 105 associations were supported by either a suggestive/low (46.2%) or a weak/very low level of evidence (34.6%) (see Table 4-8 in Supplementary Material). Below, we analytically describe the associations with the highest evidence (high and moderate) by population and physical and mental health outcomes.

Table 2. Summary of associations between physical activity and health outcomes in clinical and non-clinical populations with unique level of evidence.

Evidence level	Populations examined	Type of physical activity examined	Decreases	Increases
Convincing/High	Any population (unspecified)	Sports Any physical activity	Parkinson disease	Atrial fibrillation
Highly suggestive/Moderate	Any population (Midlife to Late life (>45 years) Any population (unspecified) Mild cognitive impairment Dementia Breast cancer Peri or post-menopausal women	Any physical activity Occupational physical activity Aerobic exercise intervention Physical activity mixed interventions Yoga	Cognitive decline incidence Colon cancer incidence Depressive symptoms Prostate cancer incidence Psychological distress Psychological symptoms Rectal cancer incidence	Delayed memory
Suggestive/Low	Dementia Mild cognitive impairment Diabetes mellitus type II Any population (unspecified) Peri or post-menopausal women Pregnancy Healthy youth (≤ 18 years) Any non – lung cancer patient	Any physical activity Mind body intervention Occupational physical activity Occupational physical activity Physical activity interventions (home based) Recreational physical activity Total physical activity Traditional resistance training Yoga	Any dementia Coronary artery disease Diabetic retinopathy Distal cancer incidence Oesophageal cancer incidence or mortality Flash severity Gestational diabetes mellitus (GDM) GDM: ADA criteria GDM: First trimester GDM: Obesity and overweight GDM: Other criteria GDM: Supervised intervention GDM: WHO criteria Gestational hypertension and preeclampsia (PE) Gestational hypertension (GH) GH: First trimester GH: Second trimester GH: Supervised intervention Ischaemic stroke Lung cancer incidence PE: First trimester Proximal colon cancer incidence	Activities of daily living Attention Executive function Muscle power (vertical jump) Visuospatial executive function
Weak/Very low	Any non-bladder cancer patient Healthy youth (≤ 18 years) Any population (unspecified) Chronic kidney disease (haemodialysis) Any non-kidney cancer patient Any non-pancreas cancer patient Any population (Midlife to Late life (>45 years)	Any type of resistance training Occupational physical activity Mixed physical activity intervention Any physical activity Recreational physical activity Traditional resistance training Any type of resistance training Occupational physical activity	Bladder cancer incidence Diabetes mellitus type II Diastolic blood pressure Gastric cancer mortality Glioma cancer incidence or mortality Glioma incidence Hodgkin lymphoma incidence or mortality Kidney cancer incidence Meningioma incidence or mortality Multiple sites cancer incidence or mortality Non-Hodgkin lymphoma incidence or mortality Pancreas cancer incidence Prostate cancer incidence or mortality Vascular dementia incidence	Combined motor performance Muscle power (squat jump) Muscle strength (jump) Sleep quality

Table 3. Summary of associations between physical activity and health outcomes in clinical and non-clinical populations with multiple levels of evidence.

Evidence	Population examined	Type of physical activity examined	Decreases	Increases
Convincing/High	None
Highly suggestive/Moderate	Cancer Any population (unspecified) Any female non- endometrial cancer patient Breast cancer Mild cognitive impairment Dementia Chronic kidney disease (peridialysis))	Any physical activity Other physical activity domains Recreational physical activity Occupational physical activity Aerobic; resistance; Yoga Aerobic; resistance; Yoga; Qigong; Pilates Aerobic; strength & flexibility Yoga Mixed physical activity intervention	All types of cancer mortality Alzheimer’s disease incidence Breast cancer incidence Colon cancer incidence or mortality Endometrial cancer incidence Fatigue Risk of falls Systolic blood pressure	Global cognition
Suggestive/Low	Chronic kidney disease (haemodialysis) Any population (unspecified) Any population (Midlife to Late life (>45 years) Any female non- endometrial cancer patient Breast cancer Mild cognitive impairment Dementia Chronic kidney disease (predialysis) Healthy youth (≤ 18 years	Mixed physical activity intervention Recreational physical activity Any physical activity Other physical activity domains (non-occupational) Other physical activity domains (occupational and non-occupational) Occupational physical activity Recreational physical activity Aerobic Aerobic; resistance Aerobic; resistance; aerobic& resistance & stretching. Aerobic; resistance; aerobic & resistance; Yoga; Qigong Aerobic; resistance; stretching. Tai Chi Mind body intervention Resistance training Traditional resistance training Physical activity interventions (home based)	All types of cancer mortality All-cause dementia incidence Breast cancer incidence Colon cancer incidence or mortality Endometrial cancer incidence Fatigue Gastric cancer incidence Risk of falls	Walking capacity Quality of life Muscle power Muscle strength Global cognition Short-term memory
Weak/Very low	Chronic kidney disease (predialysis) Any population (Midlife 45-65 years) Any population (Midlife to Late life (>45 years) Any non-breast cancer patient Any population (unspecified) Chronic kidney disease (haemodialysis) Lung cancer Breast cancer Any non-gastric cancer patient Mild cognitive impairment Alzheimer’s disease Healthy youth (≤ 18 years) Chronic kidney disease (mixed)	Mixed physical activity intervention Any physical activity Occupational physical activity Total physical activity Tai chi Aerobic; resistance; aerobic& resistance Resistance training intervention Aerobic exercise Plyometric training Traditional resistance training	All-cause dementia incidence Alzheimer's disease incidence Breast cancer incidence Colon cancer incidence or mortality Fatigue Gastric cancer incidence Systolic blood pressure	Walking capacity Global cognition Quality of life Muscle power Muscle strength Short-term memory

Figure 2. Forest plots of associations between physical activity and health outcomes supported by convincing and highly suggestive/moderate evidence.

Results by population and health outcomes

Associations between physical activity and physical health outcomes in clinical populations

In total, 14 statistically significant associations were identified in clinical populations including people with chronic kidney disease (n=8), dementia (n=2), any cancer (n=3), and type II diabetes mellitus (n=1) (see Table 4 in Supplementary Material). None of them was found to be at increased risk of physical outcomes due to physical activity. In this population category, the most highly protective associations were identified between all types of cancer mortality and any physical activity (eOR = 0.79, 95%CI=0.75-0.85) and other physical activity (non-occupational; eOR = 0.75, 95%CI= 0.68-0.83), in cancer patients, supported by the highest quality of evidence according to the Ioannides approach (highly suggestive). Two also highly protective associations were found between risk of falls and mixed physical activity (eOR = 0.69, 95%CI=0.55-0.85) in dementia situations and between systolic blood pressure and mixed physical activity (eOR = 0.48, 95%CI= 0.28-0.21) in chronic kidney disease (peridialysis), supported by the highest quality of evidence according to the GRADE approach (moderate; Figure 2).

Associations between physical activity and mental health outcomes in clinical populations

In total, 30 statistically significant associations were identified in clinical populations including people with Alzheimer’s disease (n=1), breast cancer (n=13), chronic kidney disease (n=4), dementia (n=2), lung cancer (n=1), and mild cognitive impairment (n=9) (see Table 5 in Supplementary Material). None of them was found to be at increased risk of mental outcomes from physical activity. In this population category, the most protective associations were found between delayed memory and aerobic exercise (eOR =1.60, 95%CI=1.11-2.30), global cognition and mixed physical activity (eOR =1.72, 95%CI= 1.22-2.43) in mild cognitive impairment, depressive symptoms and mixed physical activity (eOR =0.72, 95%CI= 0.55-0.96) in dementia, psychological distress and yoga (eOR =0.34, 95%CI= 0.24-0.47) and between fatigue and various combinations of physical activity (i.e., aerobic; resistance; yoga; qigong; pilates; strength & flexibility; eOR =0.58, 95%CI= 0.51-0.67;eOR =0.56, 95%CI= 0.43-0.73; eOR =0.46, 95%CI= 0.34-0.62; eOR =0.53, 95%CI= 0.40-0.71; eOR =0.22, 95%CI= 0.09-0.56, respectively) in breast cancer with the highest quality of evidence according to the GRADE approach (moderate; Figure 2).

Associations between physical activity and physical health outcomes in healthy populations

In total, 28 statistically significant associations were identified in healthy populations including pregnant women (n=20), healthy youth (≤ 18 years; n=7), and peri or postmenopausal women (n=1) (see Table 6 in Supplementary Material). None of them was found to be at increased risk of physical outcomes from physical activity. However, as shown in Tables 2 and 3 and Table 6 in Supplementary Material, none of these were supported by the highest level of evidence i.e., high, and moderate according to the GRADE approach. The associations between any physical activity and health outcomes such as gestational diabetes mellitus, gestational hypertension and/or preeclampsia in pregnancy were supported by low evidence according to the GRADE approach. There was also low or very low evidence associating resistance training with health outcomes such as muscular strength and/or strength in healthy adolescents as well as yoga with flash severity peri or postmenopausal women.

Associations between physical activity and mental health outcomes in healthy populations

Only one statistically significant association was identified in healthy populations including peri or postmenopausal women (n=1) (see Table 6 in Supplementary Material). A protective association was found between psychological symptoms and Yoga (eOR =0.56, 95%CI= 0.43-0.74) with the highest quality of evidence according to the GRADE approach (moderate; Figure 2).

Summary of associations between physical activity and physical health outcomes in any population

In total, 48 statistically significant associations were identified in any population mostly including cancer incidence and/or mortality outcomes (n=45) (see Table 7 in Supplementary Material). The highest risk association was found between atrial fibrillation and intensive sports (eOR =1.64, 95%CI= 1.10-2.43), while the most protective associations were found between breast cancer incidence and any physical activity (eOR =0.87,95%CI=0.84-0.90), colon cancer incidence or mortality and recreational physical activity (eOR =0.70,95%CI=0.60-0.83) and between endometrial cancer incidence and any physical activity (eOR =0.79,95%CI=0.74-0.85), supported by the highest quality of evidence according to the Ioannides approach (convincing and highly suggestive; Figure 2). Additionally, four highly protective associations were also identified between colon cancer incidence (eOR =0.74,95%CI=0.67-0.82), endometrial cancer incidence (eOR =0.81,95%CI=0.75-0.87), prostate cancer incidence (eOR =0.86,95%CI=0.78-0.94), and rectal cancer incidence and occupational physical activity (eOR =0.88, 95%CI=0.79-0.98), supported by the highest quality of evidence according to the GRADE approach (moderate; Figure 2).

Associations between physical activity and mental health outcomes in any population

In total, nine statistically significant associations were identified in any population including only neurocognitive health outcomes (see Table 8 in Supplementary Material). None of them was found to be at increased risk of physical outcomes from physical activity. The strongest protective associations were found between Parkinson disease incidence (eOR = 0.66, 95%CI=0.57-0.78), Alzheimer’s disease incidence (eOR = 0.62, 95%CI= 0.52-0.72), cognitive decline incidence (eOR = 0.67; 95%CI= 0.57-0.78) and any physical activity with the highest quality of evidence according to the Ioannides approach (convincing and highly suggestive; Figure 2).

Sensitivity analysis from prospective studies

Only 31 associations were analysed in the umbrella reviews, limited to prospective studies (see Table 9 in Supplementary Material). Most of them remained at the same level as the main analysis. The association between colon cancer incidence or mortality and recreational physical activity was upgraded from highly suggestive to convincing evidence. The association between diabetic retinopathy and total physical activity in people with type II diabetes mellitus was downgraded from suggestive to non-significant evidence. The association between endometrial cancer incidence and any physical activity was downgraded from highly suggestive to suggestive evidence, while the association between oesophageal cancer incidence or mortality and recreational physical activity was downgraded from suggestive to weak evidence.

Discussion

In this comprehensive meta-umbrella review, we examined sixteen umbrella reviews, collectively comprising 130 associations between physical activity and health outcomes that displayed statistical significance. Overall, all but one of these associations exhibited a protective effect. Among the notable findings, the association between atrial fibrillation and intensive sports posed the highest risk. Several other associations showed strong and moderate protective effects, particularly relevant to cognitive outcomes and cancer risk in both clinical and non-clinical populations. However, almost half of the associations displayed varying levels of evidence, indicating a lack of consistency among the statistically significant findings. Our meta-umbrella review represents the pioneering endeavour in its field, being the first of its kind.

At an analytical level, we found strong evidence that intensive sports practice, particularly in athletes, is associated with a potential risk of developing atrial fibrillation. In recent years, participation in very demanding physical activities such as marathon running has become very popular.⁷⁰ Our findings suggest that while physical activity does not have a significant impact on cardiovascular risk, prolonged participation in endurance events does pose a potential risk of atrial fibrillation, which is also consistent with the literature.⁷¹^–⁷³ The mechanisms behind this association are not fully understood, but several factors have been proposed. Factors such as fluid shifts and electrolyte abnormalities, illicit drugs, atrial anatomical adaptations due to chronic volume or pressure overload, alterations in autonomic nervous system, chronic systemic inflammation and atrial fibrosis and enlargement might contribute to the development of atrial fibrillation in high-demanding sport activity.⁷²^,⁷³ Further research is still required to better understand the specific mechanisms and risk factors involved.

Contrarily, the most protective identified associations involved Parkinson's disease, Alzheimer's disease incidence, and cognitive decline; supported by high or highly suggestive evidence. Parkinson's disease is a common neurodegenerative condition⁷⁴ characterised by reduced dopamine and motor symptoms like tremors, bradykinesia, rigidity, and postural instability.⁷⁵ To date, in absence of cure for Parkinson’s disease, existing medications aim solely at controlling the clinical symptoms.⁷⁶ Regular physical activity has a positive impact in health outcomes of the Parkinson’s disease as it can reduce tumour necrosis factor alpha in the skeletal muscle (TNF-alpha),⁷⁷ alleviate neuron loss and enhance nerve regeneration and reduce the accumulation of α-Syn protein which is the main pathogenetic protein of Parkinson's disease.⁷⁸ Alzheimer's disease, furthermore, is a progressive neurodegenerative disorder with no known cure, that most often occurs in people over the age of 65, causing cognitive decline. Clinical symptoms drastically affect the quality of life and include cognitive dysfunction and behavioural disturbances. In line with our findings, a number of studies⁷⁹^–⁸¹ also highlight the protective effects of physical activity and exercise on cognitive and brain health. Although strong evidence does exist, the exact mechanism is not yet specifically identified.⁸² According to Gallaway et al.⁸² some of these mechanisms might be the increased brain blood flow, the improved sleep quality, and the improved metabolic and cardiovascular health in physically active people, who at the same time are at lower risk of developing depression, that is highly associated with dementia.

Consistent with previous reports,¹²^,⁸³^–⁸⁸ we also found highly suggestive and moderate-quality evidence between any physical activity or occupational physical activity and a lower risk for the incidence of several types of cancer including breast, endometrial, colon, prostate incidence, and rectal cancer. Towards the same direction,⁸⁹^,⁹⁰ recreational physical activity was found to have a protective effect against colon cancer incidence/mortality. Physical activity and/or exercise can reduce the risk of cancer occurrence by decreasing markers of systemic inflammation and sex hormone levels, promoting a healthy gut microbiota and improving insulin, leptin, adiponectin levels and function of immune cells.⁹¹ General recommendations by health organisations include at least 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous-intensity exercise each week while strength training is recommended for at least twice a week.⁹²^,⁹³ However, due to lack of data that precludes more specific recommendations,⁹⁰ a need for further research into physical activity specifics for the prevention of some types of cancer arises.⁹¹

Several other associations were supported by moderate levels of evidence, including reduced risk of falls in those with dementia, blood pressure in those with chronic kidney disease (peridialysis), psychological distress and symptoms, and fatigue in women with breast cancer and in postmenopausal women. These findings suggest that participating in various types of physical activities can contribute to reducing falls in individuals with dementia, have a beneficial impact on lowering systolic blood pressure, especially in those receiving peridialysis treatment, and enhance psychological well-being in breast cancer patients and postmenopausal women. According to the literature cardiovascular health is bolstered by regular physical activity,¹³^,¹⁴ which strengthens the heart, enhances blood circulation, and lowers blood pressure.⁹⁴ Additionally, exercise has therapeutic effects on psychological symptoms,²⁴^–²⁸ by promoting the release of endorphins,¹⁴ which contribute to feelings of happiness and well-being.⁶^,²⁷^,³²

Limitations of our study should be considered in the interpretation of the findings. Our meta-umbrella approach relied solely on previously published umbrella reviews, making our results susceptible to any limitations or biases present in those reviews. The decision to include only statistically significant associations may be criticised for potentially limiting the generalizability of our findings. However, we believe that this approach has led to a clearer and more concise understanding of the bigger picture in this area. Moreover, the analysis of the extensive body of evidence encountered various challenges. Methodological differences among the included umbrella reviews posed difficulties, and we excluded several reviews with inadequate reporting methods. The lack of a clear definition for physical activity posed challenges in presenting detailed data, including specific populations, as well as conveying the type, frequency, and intensity of physical activity. This could also be the reason for the inconsistencies in the evidence for half of the associations observed herein. Lastly, it is important to acknowledge that our study may not have captured all relevant studies, as it was confined to the available literature up until the time of the review.

Conclusions

Despite the aforementioned limitations, our findings underscore the significance of physical activity for overall health and well-being. While our review unveiled a potential risk of atrial fibrillation associated with intensive sport activities and most associations were inconclusive, maintaining a regular exercise regimen remains crucial to reducing the risk of various diseases and to alleviate both physical and psychological symptoms. Hence, for optimal health outcomes, it is highly advisable to incorporate physical activity into your daily routine. It's also important to customise recommendations to ensure that they align with personal abilities and goals. However, the lack of data on specific populations and the diverse nature of physical activity make it challenging to provide targeted recommendations based on this study alone. Moreover, physical activity should be balanced with nutrition, rest, and stress management for a healthy lifestyle. Future studies, regardless of their design, should thoroughly investigate the type, intensity, and duration of physical activity as well as personal factors to obtain a comprehensive understanding in terms of both possible benefits and harms. Additionally, there is a great need for a standardised approach in conducting umbrella reviews within this domain.

Data availability

Open Science Framework: Supplementary material meta-UR. “Associations between physical activity and health outcomes in clinical and non-clinical populations: A systematic meta-umbrella review”, DOI: https://doi.org/10.17605/OSF.IO/BV27T.

Reporting guidelines

Open Science Framework: PRISMA and PRIOR checklists for Associations between physical activity and health outcomes in clinical and non-clinical populations: A systematic meta-umbrella review”, DOI: https://doi.org/10.17605/OSF.IO/BV27T.

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

References

1. Bull FC, Al-Ansari SS, Biddle S, et al.: World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br. J. Sports Med. Dec 2020; 54(24): 1451–1462. Publisher Full Text
2. Scatigna M, D'Eugenio S, Cesarini V, et al.: Physical activity as a key issue for promoting human health on a local and global scale: evidences and perspectives. Ann. Ig. Nov-Dec 2019; 31(6): 595–613. PubMed Abstract | Publisher Full Text
3. WHO: Global action plan for the prevention and control of noncommunicable diseases 2013-2020. World Health Organization; 2013.
4. WHO: Global action plan on physical activity 2018-2030: More active people for a healthier world. World Health Organization; 2019.
5. Warburton DE, Nicol CW, Bredin SS: Health benefits of physical activity: the evidence. CMAJ. Mar 14 2006; 174(6): 801–809. PubMed Abstract | Publisher Full Text | Free Full Text
6. Malm C, Jakobsson J, Isaksson A: Physical Activity and Sports-Real Health Benefits: A Review with Insight into the Public Health of Sweden. Sports (Basel). May 23 2019; 7(5). PubMed Abstract | Publisher Full Text | Free Full Text
7. Erickson KI, Hillman C, Stillman CM, et al.: Physical Activity, Cognition, and Brain Outcomes: A Review of the 2018 Physical Activity Guidelines. Med. Sci. Sports Exerc. 2019; 51(6): 1242–1251. PubMed Abstract | Publisher Full Text | Free Full Text
8. Kohl HW 3rd, Craig CL, Lambert EV, et al.: The pandemic of physical inactivity: global action for public health. Lancet. Jul 21 2012; 380(9838): 294–305. PubMed Abstract | Publisher Full Text
9. Ding D, Lawson KD, Kolbe-Alexander TL, et al.: The economic burden of physical inactivity: a global analysis of major non-communicable diseases. Lancet. Sep 24 2016; 388(10051): 1311–1324. Publisher Full Text
10. Saqib ZA, Dai J, Menhas R, et al.: Physical Activity is a Medicine for Non-Communicable Diseases: A Survey Study Regarding the Perception of Physical Activity Impact on Health Wellbeing. Risk Manag Healthc Policy. 2020; 13: 2949–2962. PubMed Abstract | Publisher Full Text | Free Full Text
11. Lee IM, Shiroma EJ, Lobelo F, et al.: Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. Jul 21 2012; 380(9838): 219–229. PubMed Abstract | Publisher Full Text | Free Full Text
12. Kyu HH, Bachman VF, Alexander LT, et al.: Physical activity and risk of breast cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke events: systematic review and dose-response meta-analysis for the Global Burden of Disease Study 2013. BMJ. Aug 9 2016; 354: i3857. PubMed Abstract | Publisher Full Text | Free Full Text
13. Sattelmair J, Pertman J, Ding EL, et al.: Dose response between physical activity and risk of coronary heart disease: a meta-analysis. Circulation. Aug 16 2011; 124(7): 789–795. PubMed Abstract | Publisher Full Text | Free Full Text
14. Miller KR, McClave SA, Jampolis MB, et al.: The Health Benefits of Exercise and Physical Activity. Curr. Nutr. Rep. 2016/09/01, 2016; 5(3): 204–212. Publisher Full Text
15. Hamasaki H: Daily physical activity and type 2 diabetes: A review. World J. Diabetes. Jun 25 2016; 7(12): 243–251. PubMed Abstract | Publisher Full Text | Free Full Text
16. Colberg SR, Sigal RJ, Yardley JE, et al.: Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association. Diabetes Care. 2016; 39(11): 2065–2079. Publisher Full Text
17. Stevens RJ, Roddam AW, Spencer EA, et al.: Factors associated with incident and fatal pancreatic cancer in a cohort of middle-aged women. Int. J. Cancer. May 15 2009; 124(10): 2400–2405. Publisher Full Text
18. Gwinnutt JM, Wieczorek M, Cavalli G, et al.: Effects of physical exercise and body weight on disease-specific outcomes of people with rheumatic and musculoskeletal diseases (RMDs): systematic reviews and meta-analyses informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs. RMD Open. Mar 2022; 8(1): e002168. PubMed Abstract | Publisher Full Text | Free Full Text
19. Faíl LB, Marinho DA, Marques EA, et al.: Benefits of aquatic exercise in adults with and without chronic disease-A systematic review with meta-analysis. Scand. J. Med. Sci. Sports. Mar 2022; 32(3): 465–486. PubMed Abstract | Publisher Full Text
20. Ribas TM, Teodori RM, Mescolotto FF, et al.: Impact of physical activity levels on musculoskeletal symptoms and absenteeism of workers of a metallurgical company. Rev. Bras. Med. Trab. Mar 3 2021; 18(4): 425–433. PubMed Abstract | Publisher Full Text | Free Full Text
21. Rodrigues EV, Gomes AR, Tanhoffer AI, et al.: Effects of exercise on pain of musculoskeletal disorders: a systematic review. Acta. Ortop. Bras. 2014; 22(6): 334–338. PubMed Abstract | Publisher Full Text | Free Full Text
22. Cannata F, Vadalà G, Russo F, et al.: Beneficial Effects of Physical Activity in Diabetic Patients. J. Funct. Morphol. Kinesiol. Sep 4 2020; 5(3). PubMed Abstract | Publisher Full Text | Free Full Text
23. Teich T, Zaharieva DP, Riddell MC: Advances in Exercise, Physical Activity, and Diabetes Mellitus. Diabetes Technol. Ther. Feb 2019; 21(S1): S-112–S-122. Publisher Full Text
24. Kvam S, Kleppe CL, Nordhus IH, et al.: Exercise as a treatment for depression: A meta-analysis. J. Affect. Disord. Sep 15 2016; 202: 67–86. Publisher Full Text
25. Schuch FB, Vancampfort D, Richards J, et al.: Exercise as a treatment for depression: A meta-analysis adjusting for publication bias. J. Psychiatr. Res. Jun 2016; 77: 42–51. PubMed Abstract | Publisher Full Text
26. Cleare A, Pariante CM, Young AH, et al.: Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines. J. Psychopharmacol. May 2015; 29(5): 459–525. PubMed Abstract | Publisher Full Text
27. Anderson E, Shivakumar G: Effects of exercise and physical activity on anxiety. Front. Psych. 2013; 4: 27. PubMed Abstract | Publisher Full Text | Free Full Text
28. Jayakody K, Gunadasa S, Hosker C: Exercise for anxiety disorders: systematic review. Br. J. Sports Med. 2014; 48(3): 187–196. Publisher Full Text
29. Gonçalves C, Raimundo A, Abreu A, et al.: Exercise Intensity in Patients with Cardiovascular Diseases: Systematic Review with Meta-Analysis. Int. J. Environ. Res. Public Health. Mar 30 2021; 18(7). PubMed Abstract | Publisher Full Text | Free Full Text
30. Mytinger M, Nelson RK, Zuhl M: Exercise Prescription Guidelines for Cardiovascular Disease Patients in the Absence of a Baseline Stress Test. J. Cardiovasc. Dev. Dis. Apr 27 2020; 7(2). PubMed Abstract | Publisher Full Text | Free Full Text
31. Evenson KR, Barakat R, Brown WJ, et al.: Guidelines for Physical Activity during Pregnancy: Comparisons From Around the World. Am. J. Lifestyle Med. Mar 2014; 8(2): 102–121. PubMed Abstract | Publisher Full Text | Free Full Text
32. Mahindru A, Patil P, Agrawal V: Role of Physical Activity on Mental Health and Well-Being: A Review. Cureus. Jan 2023; 15(1): e33475. PubMed Abstract | Publisher Full Text | Free Full Text
33. Dipietro L, Evenson KR, Bloodgood B, et al.: Benefits of Physical Activity during Pregnancy and Postpartum: An Umbrella Review. Med. Sci. Sports Exerc. Jun 2019; 51(6): 1292–1302. PubMed Abstract | Publisher Full Text | Free Full Text
34. Dipietro L, Campbell WW, Buchner DM, et al.: Physical Activity, Injurious Falls, and Physical Function in Aging: An Umbrella Review. Med. Sci. Sports Exerc. Jun 2019; 51(6): 1303–1313. PubMed Abstract | Publisher Full Text | Free Full Text
35. Pescatello LS, Buchner DM, Jakicic JM, et al.: Physical Activity to Prevent and Treat Hypertension: A Systematic Review. Med. Sci. Sports Exerc. Jun 2019; 51(6): 1314–1323. Publisher Full Text
36. Zanghì M, Petrigna L, Maugeri G, et al.: The Practice of Physical Activity on Psychological, Mental, Physical, and Social Wellbeing for Breast-Cancer Survivors: An Umbrella Review. Int. J. Environ. Res. Public Health. Aug 20 2022; 19(16). PubMed Abstract | Publisher Full Text | Free Full Text
37. Arango C, Dragioti E, Solmi M, et al.: Risk and protective factors for mental disorders beyond genetics: an evidence-based atlas. World Psychiatry. Oct 2021; 20(3): 417–436. PubMed Abstract | Publisher Full Text | Free Full Text
38. Mentis AA, Dardiotis E, Efthymiou V, et al.: Correction to: Non-genetic risk and protective factors and biomarkers for neurological disorders: a meta-umbrella systematic review of umbrella reviews. BMC Med. Nov 9 2021; 19(1): 297. PubMed Abstract | Publisher Full Text | Free Full Text
39. Page MJ, McKenzie JE, Bossuyt PM, et al.: The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. PLoS Med. Mar 2021; 18(3): e1003583. PubMed Abstract | Publisher Full Text | Free Full Text
40. Gates M, Gates A, Pieper D, et al.: Reporting guideline for overviews of reviews of healthcare interventions: development of the PRIOR statement. BMJ. Aug 9 2022; 378: e070849. PubMed Abstract | Publisher Full Text | Free Full Text
41. Fusar-Poli P, Radua J: Ten simple rules for conducting umbrella reviews. Evid. Based Ment. Health. Aug 2018; 21(3): 95–100. PubMed Abstract | Publisher Full Text
42. Ioannidis JP: Integration of evidence from multiple meta-analyses: a primer on umbrella reviews, treatment networks and multiple treatments meta-analyses. CMAJ. Oct 13 2009; 181(8): 488–493. PubMed Abstract | Publisher Full Text | Free Full Text
43. Janiaud P, Agarwal A, Tzoulaki I, et al.: Validity of observational evidence on putative risk and protective factors: appraisal of 3744 meta-analyses on 57 topics. BMC Med. Jul 6 2021; 19(1): 157. PubMed Abstract | Publisher Full Text | Free Full Text
44. Booth A: EVIDENT Guidance for Reviewing the Evidence: a compendium of methodological literature and websites.2016.
45. Papatheodorou SI, Evangelou E: Umbrella Reviews: What They Are and Why We Need Them. Methods Mol. Biol. 2022; 2345: 135–146. Publisher Full Text
46. Guyatt G, Oxman AD, Akl EA, et al.: GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J. Clin. Epidemiol. Apr 2011; 64(4): 383–394. Publisher Full Text
47. Shea BJ, Reeves BC, Wells G, et al.: AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. Sep 21 2017; 358: j4008. PubMed Abstract | Publisher Full Text | Free Full Text
48. Pieper D, Antoine SL, Mathes T, et al.: Systematic review finds overlapping reviews were not mentioned in every other overview. J. Clin. Epidemiol. Apr 2014; 67(4): 368–375. Publisher Full Text
49. Mentis A-FAD, Efthimios, Efthymiou V, et al.: Non-genetic risk and protective factors and biomarkers for neurological disorders: a meta-umbrella systematic review of umbrella reviews. BMC Med. 2021; 19(1): 6–28. PubMed Abstract | Publisher Full Text | Free Full Text
50. Aromataris E, Fernandez R, Godfrey CM, et al.: Summarizing systematic reviews: methodological development, conduct and reporting of an umbrella review approach. Int. J. Evid. Based Healthc. Sep 2015; 13(3): 132–140. Publisher Full Text
51. Dragioti E, Dimoliatis I, Fountoulakis KN, et al.: A systematic appraisal of allegiance effect in randomized controlled trials of psychotherapy. Ann. General Psychiatry. 2015; 14: 25. PubMed Abstract | Publisher Full Text | Free Full Text
52. Chinn S: A simple method for converting an odds ratio to effect size for use in meta-analysis. Stat. Med. Nov 30 2000; 19(22): 3127–3131. PubMed Abstract | Publisher Full Text
53. Demurtas J, Schoene D, Torbahn G, et al.: Physical Activity and Exercise in Mild Cognitive Impairment and Dementia: An Umbrella Review of Intervention and Observational Studies. J. Am. Med. Dir. Assoc. Oct 2020; 21(10): 1415–1422.e6. PubMed Abstract | Publisher Full Text
54. Rezende LFM, Sá TH, Markozannes G, et al.: Physical activity and cancer: an umbrella review of the literature including 22 major anatomical sites and 770 000 cancer cases. Br. J. Sports Med. Jul 2018; 52(13): 826–833. PubMed Abstract | Publisher Full Text
55. Bellou V, Belbasis L, Tzoulaki I, et al.: Environmental risk factors and Parkinson's disease: An umbrella review of meta-analyses. Parkinsonism Relat. Disord. Feb 2016; 23: 1–9. Publisher Full Text
56. Markozannes G, Tzoulaki I, Karli D, et al.: Diet, body size, physical activity and risk of prostate cancer: An umbrella review of the evidence. Eur. J. Cancer. Dec 2016; 69: 61–69. PubMed Abstract | Publisher Full Text
57. Hou W, Zhai L, Yang Y, et al.: Is physical activity effective against cancer-related fatigue in lung cancer patients? An umbrella review of systematic reviews and meta-analyses. Support Care Cancer. Feb 13 2023; 31(3): 161. PubMed Abstract | Publisher Full Text
58. Cillekens B, Lang M, van Mechelen W , et al.: How does occupational physical activity influence health? An umbrella review of 23 health outcomes across 158 observational studies. Br. J. Sports Med. Dec 2020; 54(24): 1474–1481. PubMed Abstract | Publisher Full Text
59. Valenzuela PL, Santos-Lozano A, Morales JS, et al.: Physical activity, sports and risk of atrial fibrillation: umbrella review of meta-analyses. Eur. J. Prev. Cardiol. Jul 10 2021; 28(7): e11–e16. PubMed Abstract | Publisher Full Text
60. Lesinski M, Herz M, Schmelcher A, et al.: Effects of Resistance Training on Physical Fitness in Healthy Children and Adolescents: An Umbrella Review. Sports Med. Nov 2020; 50(11): 1901–1928. Publisher Full Text
61. Zhang F, Bai Y, Zhao X, et al.: Therapeutic effects of exercise interventions for patients with chronic kidney disease: an umbrella review of systematic reviews and meta-analyses. BMJ Open. Sep 19 2022; 12(9): e054887. PubMed Abstract | Publisher Full Text | Free Full Text
62. Singh B, Olds T, Curtis R, et al.: Effectiveness of physical activity interventions for improving depression, anxiety and distress: an overview of systematic reviews. Br. J. Sports Med. Feb 16 2023; bjsports-2022-106195. PubMed Abstract | Publisher Full Text
63. Shepherd-Banigan M, Goldstein KM, Coeytaux RR, et al.: Improving vasomotor symptoms; psychological symptoms; and health-related quality of life in peri- or post-menopausal women through yoga: An umbrella systematic review and meta-analysis. Complement. Ther. Med. 2017; 34: 156–164. PubMed Abstract | Publisher Full Text | Free Full Text
64. Martínez-Vizcaíno V, Sanabria-Martínez G, Fernández-Rodríguez R, et al.: Exercise during pregnancy for preventing gestational diabetes mellitus and hypertensive disorders: An umbrella review of randomised controlled trials and an updated meta-analysis. BJOG. 2023; 130(3): 264–275. PubMed Abstract | Publisher Full Text | Free Full Text
65. Jiang M, Ma Y, Yun B, et al.: Exercise for fatigue in breast cancer patients: An umbrella review of systematic reviews. Int. J. Nurs. Sci. Apr 10 2020; 7(2): 248–254. PubMed Abstract | Publisher Full Text | Free Full Text
66. Bellou V, Belbasis L, Tzoulaki I, et al.: Systematic evaluation of the associations between environmental risk factors and dementia: An umbrella review of systematic reviews and meta-analyses. Alzheimers Dement. Apr 2017; 13(4): 406–418. PubMed Abstract | Publisher Full Text
67. Trott M, Driscoll R, Pardhan S: Associations between diabetic retinopathy and modifiable risk factors: An umbrella review of meta-analyses. Diabet. Med. Jun 2022; 39(6): e14796. PubMed Abstract | Publisher Full Text
68. Zhang YR, Xu W, Zhang W, et al.: Modifiable risk factors for incident dementia and cognitive impairment: An umbrella review of evidence. J. Affect. Disord. Oct 1 2022; 314: 160–167. Publisher Full Text
69. Oxford Centre for Evidence-based Medicine Levels of Evidence (January 2001).2014.
70. Malchrowicz-Mośko E, Poczta J: Running as a Form of Therapy Socio-Psychological Functions of Mass Running Events for Men and Women. Int. J. Environ. Res. Public Health. Oct 16 2018; 15(10). PubMed Abstract | Publisher Full Text | Free Full Text
71. Cramer GE, Gommans DHF, Dieker HJ, et al.: Exercise and myocardial injury in hypertrophic cardiomyopathy. Heart. Aug 2020; 106(15): 1169–1175. PubMed Abstract | Publisher Full Text | Free Full Text
72. Fragakis N, Vicedomini G, Pappone C: Endurance Sport Activity and Risk of Atrial Fibrillation - Epidemiology, Proposed Mechanisms and Management. Arrhythmia Electrophysiol. Rev. May 2014; 3(1): 15–19. PubMed Abstract | Publisher Full Text | Free Full Text
73. Guasch E, Mont L, Sitges M: Mechanisms of atrial fibrillation in athletes: what we know and what we do not know. Neth. Hear. J. Mar 2018; 26(3): 133–145. PubMed Abstract | Publisher Full Text | Free Full Text
74. Ascherio A, Schwarzschild MA: The epidemiology of Parkinson's disease: risk factors and prevention. Lancet Neurol. Nov 2016; 15(12): 1257–1272. Publisher Full Text
75. Xie A, Gao J, Xu L, et al.: Shared mechanisms of neurodegeneration in Alzheimer's disease and Parkinson's disease. Biomed. Res. Int. 2014; 2014: 648740. PubMed Abstract | Publisher Full Text | Free Full Text
76. Stoker TB, Greenland JC: Parkinson’s Disease: Pathogenesis and Clinical Aspects. Codon Publications Copyright © 2018 Codon Publications; 2018.
77. Greiwe JS, Cheng B, Rubin DC, et al.: Resistance exercise decreases skeletal muscle tumor necrosis factor alpha in frail elderly humans. FASEB J. Feb 2001; 15(2): 475–482. PubMed Abstract | Publisher Full Text
78. Fan B, Jabeen R, Bo B, et al.: What and How Can Physical Activity Prevention Function on Parkinson's Disease? Oxidative Med. Cell. Longev. 2020; 2020: 4293071. PubMed Abstract | Publisher Full Text | Free Full Text
79. Chapman SB, Aslan S, Spence JS, et al.: Shorter term aerobic exercise improves brain, cognition, and cardiovascular fitness in aging. Front. Aging Neurosci. 2013; 5: 75. PubMed Abstract | Publisher Full Text | Free Full Text
80. Farina N, Rusted J, Tabet N: The effect of exercise interventions on cognitive outcome in Alzheimer's disease: a systematic review. Int. Psychogeriatr. Jan 2014; 26(1): 9–18. Publisher Full Text
81. Stephen R, Hongisto K, Solomon A, et al.: Physical Activity and Alzheimer's Disease: A Systematic Review. J. Gerontol. A Biol. Sci. Med. Sci. Jun 1 2017; 72(6): glw251–glw739. Publisher Full Text
82. Gallaway PJ, Miyake H, Buchowski MS, et al.: Physical Activity: A Viable Way to Reduce the Risks of Mild Cognitive Impairment, Alzheimer's Disease, and Vascular Dementia in Older Adults. Brain Sci. Feb 20 2017; 7(2). PubMed Abstract | Publisher Full Text | Free Full Text
83. Courneya KS, Booth CM, Gill S, et al.: The Colon Health and Life-Long Exercise Change trial: a randomized trial of the National Cancer Institute of Canada Clinical Trials Group. Curr. Oncol. Dec 2008; 15(6): 279–285. PubMed Abstract | Publisher Full Text | Free Full Text
84. Kerr J, Anderson C, Lippman SM: Physical activity, sedentary behaviour, diet, and cancer: an update and emerging new evidence. Lancet Oncol. Aug 2017; 18(8): e457–e471. PubMed Abstract | Publisher Full Text
85. Schmid D, Behrens G, Keimling M, et al.: A systematic review and meta-analysis of physical activity and endometrial cancer risk. Eur. J. Epidemiol. May 2015; 30(5): 397–412. PubMed Abstract | Publisher Full Text
86. Wu Y, Zhang D, Kang S: Physical activity and risk of breast cancer: a meta-analysis of prospective studies. Breast Cancer Res. Treat. Feb 2013; 137(3): 869–882. Publisher Full Text
87. Schmid D, Ricci C, Behrens G, et al.: Does smoking influence the physical activity and lung cancer relation? A systematic review and meta-analysis. Eur. J. Epidemiol. Dec 2016; 31(12): 1173–1190. PubMed Abstract | Publisher Full Text
88. Shephard RJ: Physical Activity and Prostate Cancer: An Updated Review. Sports Med. Jun 2017; 47(6): 1055–1073. Publisher Full Text
89. McTiernan A, Friedenreich CM, Katzmarzyk PT, et al.: Physical Activity in Cancer Prevention and Survival: A Systematic Review. Med. Sci. Sports Exerc. Jun 2019; 51(6): 1252–1261. PubMed Abstract | Publisher Full Text | Free Full Text
90. Friedenreich CM, Stone CR, Cheung WY, et al.: Physical Activity and Mortality in Cancer Survivors: A Systematic Review and Meta-Analysis. JNCI Cancer Spectr. Feb 2020; 4(1): pkz080. PubMed Abstract | Publisher Full Text | Free Full Text
91. Jurdana M: Physical activity and cancer risk. Actual knowledge and possible biological mechanisms. Radiol. Oncol. Jan 12 2021; 55(1): 7–17. PubMed Abstract | Publisher Full Text | Free Full Text
92. Coletta AM, Marquez G, Thomas P, et al.: Clinical factors associated with adherence to aerobic and resistance physical activity guidelines among cancer prevention patients and survivors. PLoS One. 2019; 14(8): e0220814. PubMed Abstract | Publisher Full Text | Free Full Text
93. Ainsworth BE, Haskell WL, Whitt MC, et al.: Compendium of physical activities: an update of activity codes and MET intensities. Med. Sci. Sports Exerc. Sep 2000; 32(9 Suppl): S498–S516. Publisher Full Text
94. Nystoriak MA, Bhatnagar A: Cardiovascular Effects and Benefits of Exercise. Front Cardiovasc Med. 2018; 5: 135. Publisher Full Text

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