Skip to content
Spiral Staircase
Buy the book
Menu

Chapter 3 of the book

The Body That Walks

Part One gave the short version. Part Two begins with the oldest signal of all, a body being used: on foot, under load, day after day.

ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.3 things to start with3 popular claims graded101 works cited

How the chapter opens

In the years after the Second World War, a London double-decker bus carried two employees and, without anyone planning it, an experiment. The driver sat at the wheel. The conductor collected the fares, which meant climbing to the top deck and back down, trip after trip, often for decades.

Jeremy Morris ran the Medical Research Council's new social medicine unit in London. His team gathered sick-leave files, doctors' diagnoses and death certificates for tens of thousands of London Transport men, and the double-decker gave them the cleanest comparison possible: two men on the same bus, one sitting, one climbing.

What the chapter covers

The argument, the studies and the stories are in the book. Get the book.

  • ·What Your Body Expects
  • ·What It Gets Instead: The Chair and the Step Count
  • ·What It Gets Instead: The Salt Shaker
  • ·What It Gets Instead: A Back That Rests, a Knee That Waits

Mismatch card

The system

The walking body: leg muscles and joints, heart and blood vessels, lymph, back and feet.

What it expects

Hours on foot most days, rest in squats and on the ground, little salt and plenty of potassium, and use of a sore body while it heals.

What it gets

Nearly eight sedentary hours a day and about 5,100 steps for the average American, about 11 g of salt a day worldwide, and rest, scans and fear after injury.

What happens in the gap

Higher blood sugar within hours of sitting, blood pressure that climbs with age, knee arthritis in American skeletons that has doubled beyond what age and weight explain, and back pain that hardens into disability.

The handrail

Walk toward 7,000 to 8,000 steps, break up sitting, swap to potassium-enriched salt where safe, and keep moving through back pain (ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.)

Strength of evidence

ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials. Trials firmly link movement, salt and potassium to blood sugar, blood pressure and pain, but the step numbers and the fitness link to long life rest on cohorts.

What you've heard

Popular claims this chapter tests, each with the book's verdict and grade.

The protocol

Each action carries the book's evidence grade. How the grades work.

Start here

  1. Walk every day, building toward 7,000 to 8,000 steps from wherever you are

    StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism.for the curveProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.for the exact number

    How: add a walk with a destination, to a shop or a friend's door, and lengthen it over weeks, not days. Under sixty, the gains keep coming up to about 8,000 to 10,000. Some of it should be brisk, about a hundred steps a minute (Chapter 1 gives a fifteen-second check). Why: the steepest drop in risk comes at the bottom, from about 3,000 steps to 5,000, so the least active gain the most.

  2. Break up sitting every half hour

    ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.

    How: stand and walk for two to five minutes, whether a lap of the house, a trip to the water tap or the long way to the bathroom. Set a timer, or tie it to something that already happens, like the end of each call. Why: walking breaks blunt the rise in blood sugar after meals, and walking beats standing.

  3. Swap your table salt for a potassium-enriched salt substitute

    StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism.for blood pressureProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.for strokes and deaths

    How: buy one that lists potassium chloride among its ingredients and use it for cooking and at the table; the big trial used about one part potassium chloride to three parts ordinary salt. Why: it cuts sodium and adds potassium in a single move, and it lowered strokes in the largest trial. Do not use it if you have kidney disease, take potassium-sparing diuretics or potassium supplements, or take any medicine that limits how you clear potassium. If you take any blood-pressure or heart medicine, ask a clinician first. The WHO guideline does not cover pregnancy or children.

Then, pick from this menu

  • **Bank the weekly minutes (StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism.).** Two and a half to five hours a week of anything that makes you breathe harder, including gardening, cycling to work and carrying children, or half that if the effort is vigorous, plus strength work on two or more days (Chapter 4). Brisk walking counts.

  • **Build your fitness ceiling (ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.).** Once walking is easy, add short, hard efforts most days: three or four times a day, a minute or two uphill or fast enough that talking gets awkward (Chapter 1).

  • **Know your blood pressure (StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism.).** Get it checked, measure at home if your clinician advises, and never stop blood-pressure medicine on your own.

  • **Eat for potassium and go easy on salt (StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism. for blood pressure).** Build meals on fruit, vegetables and beans (Chapter 5), and keep total salt under WHO's limit of 5 g a day. Avoid potassium supplements unless a clinician prescribes them. With kidney disease, or on a medicine that affects potassium, ask your clinician what intake is right for you.

  • **For blood pressure, add wall sits or slow breathing (ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.).** Wall sits or handgrip holds a few times a week, on top of walking; the trials varied, so ask a clinician or physical therapist for a tested routine. Or breathe slowly, about six breaths a minute (say, four seconds in and six out), for a few minutes at least three days a week (Chapter 13). If your nose is usually blocked, have it treated; it affects sleep (Chapter 8).

If this is you

Back pain now

stay as active as pain allows, skip the routine scan, and expect most new back pain to settle within weeks (StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism.). Once it has, walking most days helps keep it from coming back (ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials., one large trial). For pain that has lasted months, group cognitive behavioral therapy or a mindfulness course does more than learning about pain alone (StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism.), and pain reprocessing therapy is promising (ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.).24

A sore knee or hip

exercise is the treatment, not the enemy. Walk on flat ground in stable, supportive shoes, which beat flat flexible ones for knee arthritis pain in a trial, add leg strengthening (Chapter 4), and expect some extra ache at first. For pain that stops you walking, the guidelines favor an anti-inflammatory gel rubbed on the knee over pills; ask a pharmacist whether it suits your other medicines. Over forty-five, knee arthritis can be diagnosed without a scan. If you carry extra weight, any loss helps, and a tenth of your weight beats a twentieth. If wall sits hurt your knee, use handgrip holds. If someone offers a knee "clean-out", ask what the evidence shows for degenerative knees.25

Over sixty

add balance and strength work at least three days a week, such as single-leg stands (beside something solid to hold), sit-to-stand and Tai Chi (StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism.). After sixty-five, wear firm, low-heeled shoes at home, not socks or slippers (ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.).26

Perimenopause and after

walking is good for your heart and blood sugar but a weak signal for bone on its own; add the twice-weekly loading in Chapter 4 (ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.).27

Small children, a commute and no spare hour

walk the school run or park at the far end of the lot, walk laps of the field during practice, and take calls on foot. Carrying a child counts as activity.

Starting from nothing, or carrying a lot of weight

begin with the sitting breaks and short, flat walks, and let the step count follow. The first thousand steps you add are worth more than the last.

Night shifts

count the steps your shift already gives you, then add what it lacks: a few brisk minutes before the shift or on a break, and something heavy twice a week (Chapter 4). Light and sleep come first (Chapter 8).

Stiff hips and ankles

rest actively (EmergingEvidence grade: Emerging. Early, small, animal-only, or actively contested.). Sit on the floor, kneel or squat for short spells, holding a doorframe until your hips and ankles allow more. With knee arthritis, avoid long squatting; after a hip replacement, follow your surgeon's advice on deep bending.

Runners or foot trouble

if you want stronger feet, wear flat, flexible shoes for walking, building wear time over months, or do toe curls and arch exercises (ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.). If you have knee arthritis, skip this and follow the knee advice above. Runners: take months, not weeks, and do not change a comfortable heel strike just because it is one.

Long flights or drives

on journeys over about four hours, get up and move your calves (EmergingEvidence grade: Emerging. Early, small, animal-only, or actively contested.). With a past clot or other risk factors, ask a clinician about compression stockings. Skip them with narrowed leg arteries, nerve damage in the legs, fragile skin or very swollen legs unless a clinician advises. A painful, swollen leg or sudden breathlessness after a long journey needs urgent care.28

Tight budget

walking, floor-sitting and wall sits cost nothing, and nothing in this chapter needs a gym, a gadget or a subscription.

Safety

See a clinician before hard exercise if you have chest pain, breathlessness out of proportion to effort, fainting or known heart disease; the risk of vigorous exercise is tiny for most people and lower still in those who do it regularly, so build up gradually. Back pain after a serious accident, or with weakness, tingling or numbness in both legs, numbness around the genitals or anus, bladder or bowel changes, chest pain or fever, needs urgent care. See a doctor for back pain that is worse at night, comes with unexplained weight loss, or lingers beyond a few weeks. With diabetes or numb feet, do not go barefoot or switch to minimal shoes without your clinician, and check your feet daily. Never stop or rapidly cut prescribed opioids on your own; reduce slowly on a plan made with your clinician.29

The skeptic's box

What could overturn this chapter, from the chapter itself.

Almost everything behind this chapter's numbers is observational. People who walk a lot differ from those who walk little in income, illness and a hundred unmeasured ways, and sick people move less, so illness can drive the inactivity. Exercise trials run for months and measure blood pressure or fitness, not decades and deaths; a five-year trial in Norwegians in their seventies found no significant effect on deaths.30 The salt-substitute case for fewer deaths rests largely on one trial in rural China, in older people at high risk. Pain reprocessing therapy rests on one full trial, treated by experts in the method; two of its authors had commercial ties to it. The ancestral figures, such as the Tsimane's steps, show that the old signal was large; they do not show that you need to match it, and no trial has asked.

Go deeper in the reference library

The research this chapter was built from, as longer reference entries: each with its own mismatch card, graded recommendations and the case against it.

See also in the book

Sources behind this page

  1. 30.Stensvold, D., Viken, H., Steinshamn, S.L., Dalen, H., et al. (2020). "Effect of exercise training for five years on all cause mortality in older adults: the Generation 100 study: randomised controlled trial." BMJ, 371, m3485. https://doi.org/10.1136/bmj.m3485 . 1,567 participants aged 70 to 77; the control group was itself fairly active.
  2. 8.Vallance, J.K., Gardiner, P.A., Lynch, B.M., D'Silva, A., et al. (2018). "Evaluating the evidence on sitting, smoking, and health: is sitting really the new smoking?" American Journal of Public Health, 108(11), 1478-1482. https://doi.org/10.2105/AJPH.2018.304649 ; Ekelund, U., Steene-Johannessen, J., Brown, W.J., Fagerland, M.W., et al. (2016). "Does physical activity attenuate, or even eliminate, the detrimental association of sitting time with mortality? A harmonised meta-analysis of data from more than 1 million men and women." The Lancet, 388(10051), 1302-1310. https://doi.org/10.1016/S0140-6736(16)30370-1 ; Saeidifard, F., Medina-Inojosa, J.R., Supervia, M., Olson, T.P., et al. (2018). "Differences of energy expenditure while sitting versus standing: a systematic review and meta-analysis." European Journal of Preventive Cardiology, 25(5), 522-538. https://doi.org/10.1177/2047487317752186 ; Ahmadi, M.N., Coenen, P., Straker, L., and Stamatakis, E. (2024). "Device-measured stationary behaviour and cardiovascular and orthostatic circulatory disease incidence." International Journal of Epidemiology, 53(6), dyae136. https://doi.org/10.1093/ije/dyae136 ; Shrestha, N., Kukkonen-Harjula, K.T., Verbeek, J.H., Ijaz, S., et al. (2018). "Workplace interventions for reducing sitting at work." Cochrane Database of Systematic Reviews, 12, CD010912. https://doi.org/10.1002/14651858.CD010912.pub5 . The smoking and sitting figures are more than 2,000 against about 190 extra deaths per 100,000.
  3. 23.Ridge, S.T., Olsen, M.T., Bruening, D.A., Jurgensmeier, K., et al. (2019). "Walking in minimalist shoes is effective for strengthening foot muscles." Medicine and Science in Sports and Exercise, 51(1), 104-113. https://doi.org/10.1249/MSS.0000000000001751 ; Peters-Dickie, J.L., Detrembleur, C., Guallar-Bouloc, M., Rastelli, M., et al. (2025). "The effects of foot core exercises and minimalist footwear on foot muscle sizes, foot strength, and biomechanics: a systematic review and meta-analysis." Clinical Biomechanics, 122, 106417. https://doi.org/10.1016/j.clinbiomech.2024.106417 ; Relph, N., Greaves, H., Armstrong, R., Prior, T.D., et al. (2022). "Running shoes for preventing lower limb running injuries in adults." Cochrane Database of Systematic Reviews, 8, CD013368. https://doi.org/10.1002/14651858.CD013368.pub2 ; Ridge, S.T., Johnson, A.W., Mitchell, U.H., Hunter, I., et al. (2013). "Foot bone marrow edema after a 10-wk transition to minimalist running shoes." Medicine and Science in Sports and Exercise, 45(7), 1363-1368. https://doi.org/10.1249/MSS.0b013e3182874769 (10 of 19 runners) ; Lieberman, D.E., Venkadesan, M., Werbel, W.A., Daoud, A.I., et al. (2010). "Foot strike patterns and collision forces in habitually barefoot versus shod runners." Nature, 463(7280), 531-535. https://doi.org/10.1038/nature08723 ; Koepsell, T.D., Wolf, M.E., Buchner, D.M., Kukull, W.A., et al. (2004). "Footwear style and risk of falls in older adults." Journal of the American Geriatrics Society, 52(9), 1495-1501. https://doi.org/10.1111/j.1532-5415.2004.52412.x ; Sherrington, C., Fairhall, N.J., Wallbank, G.K., Tiedemann, A., et al. (2019). "Exercise for preventing falls in older people living in the community." Cochrane Database of Systematic Reviews, 1, CD012424. https://doi.org/10.1002/14651858.CD012424.pub2 . Vibram USA helped fund the 2010 Nature study; Koepsell studied people aged 65 and over.
  4. 24.Williams, C.M., Maher, C.G., Latimer, J., McLachlan, A.J., et al. (2014). "Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial." The Lancet, 384(9954), 1586-1596. https://doi.org/10.1016/S0140-6736(14)60805-9 ; Cherkin, D.C., Sherman, K.J., Balderson, B.H., Cook, A.J., et al. (2016). "Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial." JAMA, 315(12), 1240-1249. https://doi.org/10.1001/jama.2016.2323 ; Watson, J.A., Ryan, C.G., Cooper, L., Ellington, D., et al. (2019). "Pain neuroscience education for adults with chronic musculoskeletal pain: a mixed-methods systematic review and meta-analysis." Journal of Pain, 20(10), 1140.e1-1140.e22. https://doi.org/10.1016/j.jpain.2019.02.011 . Median recovery from new back pain was 16-17 days in every arm of the Williams trial.
  5. 25.Paterson, K.L., Bennell, K.L., Campbell, P.K., Metcalf, B.R., et al. (2021). "The effect of flat flexible versus stable supportive shoes on knee osteoarthritis symptoms: a randomized trial." Annals of Internal Medicine, 174(4), 462-471. https://doi.org/10.7326/M20-6321 ; Bannuru, R.R., Osani, M.C., Vaysbrot, E.E., Arden, N.K., et al. (2019). "OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis." Osteoarthritis and Cartilage, 27(11), 1578-1589. https://doi.org/10.1016/j.joca.2019.06.011 ; National Institute for Health and Care Excellence (2022). Osteoarthritis in over 16s: diagnosis and management (NG226). https://www.nice.org.uk/guidance/ng226/chapter/Recommendations . OARSI strongly recommends topical anti-inflammatories (NSAIDs) for knee osteoarthritis; NICE diagnoses it clinically from 45 in people with activity-related joint pain.
  6. 26.Montero-Odasso, M., van der Velde, N., Martin, F.C., Petrovic, M., et al. (2022). "World guidelines for falls prevention and management for older adults: a global initiative." Age and Ageing, 51(9), afac205. https://doi.org/10.1093/ageing/afac205 ; Sherrington, C., Michaleff, Z.A., Fairhall, N., Paul, S.S., et al. (2017). "Exercise to prevent falls in older adults: an updated systematic review and meta-analysis." British Journal of Sports Medicine, 51(24), 1750-1758. https://doi.org/10.1136/bjsports-2016-096547 . Programs that challenged balance for more than three hours a week worked best.
  7. 27.Ma, D., Wu, L., and He, Z. (2013). "Effects of walking on the preservation of bone mineral density in perimenopausal and postmenopausal women: a systematic review and meta-analysis." Menopause, 20(11), 1216-1226. https://doi.org/10.1097/GME.0000000000000100 ; Watson, S.L., Weeks, B.K., Weis, L.J., Harding, A.T., et al. (2018). "High-intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: the LIFTMOR randomized controlled trial." Journal of Bone and Mineral Research, 33(2), 211-220. https://doi.org/10.1002/jbmr.3284
  8. 28.Reyes, N.L., and Abe, K. (2026). "Deep vein thrombosis and pulmonary embolism." CDC Yellow Book 2026. https://www.cdc.gov/yellow-book/hcp/travel-air-sea/deep-vein-thrombosis-and-pulmonary-embolism.html ; Clarke, M.J., Broderick, C., Hopewell, S., Juszczak, E., et al. (2021). "Compression stockings for preventing deep vein thrombosis in airline passengers." Cochrane Database of Systematic Reviews, 4, CD004002. https://doi.org/10.1002/14651858.CD004002.pub4 ; North Tees and Hartlepool NHS Foundation Trust (2026). Anti-embolism stockings (patient leaflet PIL1043, last reviewed 30 March 2026). https://www.nth.nhs.uk/resources/antiembolism-stockings/ . About one symptomatic clot per 4,600 flights longer than four hours.
  9. 29.Albert, C.M., Mittleman, M.A., Chae, C.U., Lee, I.M., et al. (2000). "Triggering of sudden death from cardiac causes by vigorous exertion." New England Journal of Medicine, 343(19), 1355-1361. https://doi.org/10.1056/NEJM200011093431902 ; NHS (2026). Back pain. https://www.nhs.uk/conditions/back-pain/ ; Bus, S.A., Sacco, I.C.N., Monteiro-Soares, M., Raspovic, A., et al. (2024). "Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update)." Diabetes/Metabolism Research and Reviews, 40(3), e3651. https://doi.org/10.1002/dmrr.3651 ; Agnoli, A., Xing, G., Tancredi, D.J., Magnan, E., et al. (2021). "Association of dose tapering with overdose or mental health crisis among patients prescribed long-term opioids." JAMA, 326(5), 411-419. https://doi.org/10.1001/jama.2021.11013 . The absolute risk of sudden death during vigorous exertion is tiny, and lower in habitual exercisers.

Every work this chapter cites

The chapter's 30 notes cite 101 works, listed by note number. Each is also in the full source register.

  1. 1.Morris, J.N (2005). Exercise versus heart attack: history of a hypothesis. Coronary Heart Disease Epidemiology: From Etiology to Public Health. epi.umn.eduRoyal College of Physicians Inspiring Physicians: Jeremy Noah Morris. history.rcp.ac.ukMorris, J.N., Heady, J.A., Raffle, P.A.B., Roberts, C.G., and Parks, J.W (1953). Coronary heart-disease and physical activity of work. The Lancet. 10.1016/S0140-6736(53Blair, S.N., Davey Smith, G., Lee, I-M., et al (2010). A tribute to Professor Jeremiah Morris: the man who invented the field of physical activity epidemiology. Annals of Epidemiology. 10.1016/j.annepidem.2010.06.001University of Minnesota, Heart Attack Prevention, "London Transport Workers Study" (study synopsis), quoting Morris et al (1953). , part 2. epi.umn.eduHeady, J.A., Morris, J.N., and Raffle, P.A.B (1956). Physique of London busmen; epidemiology of uniforms. The Lancet. 10.1016/S0140-6736(56
  2. 2.Morris, J.N (2008). Foreword. 10.1093/acprof:oso/9780195183009.001.0001Lange, K.W (2024). Jeremy Morris as a pioneer of behavioural epidemiology, social medicine and public health. Scandinavian Journal of Public Health. 10.1177/14034948231218313
  3. 3.Bramble, D.M., and Lieberman, D.E (2004). Endurance running and the evolution of Homo. Nature. 10.1038/nature03052Imms, P., Chaudhari, N.N., Cummings, D., Eid Rodriguez, D., et al (2025). Physical activity mediates age differences in cognition among Tsimane forager-horticulturalists. Journals of Gerontology, Series A. 10.1093/gerona/glaf163Shave, R.E., Lieberman, D.E., Drane, A.L., Brown, M.G., et al (2019). Selection of endurance capabilities and the trade-off between pressure and volume in the evolution of the human heart. PNAS. 10.1073/pnas.1906902116Fleg, J.L., Morrell, C.H., Bos, A.G., Brant, L.J., et al (2005). Accelerated longitudinal decline of aerobic capacity in healthy older adults. Circulation. 10.1161/CIRCULATIONAHA.105.545459Shephard, R.J (2009). Maximal oxygen intake and independence in old age. British Journal of Sports Medicine. 10.1136/bjsm.2007.044800
  4. 4.Raichlen, D.A., Pontzer, H., Zderic, T.W., Harris, J.A., et al (2020). Sitting, squatting, and the evolutionary biology of human inactivity. PNAS. 10.1073/pnas.1911868117Raichlen, D.A., Pontzer, H., Harris, J.A., Mabulla, A.Z.P., et al (2017). Physical activity patterns and biomarkers of cardiovascular disease risk in hunter-gatherers. American Journal of Human Biology. 10.1002/ajhb.22919Zhang, Y., Hunter, D.J., Nevitt, M.C., Xu, L., et al (2004). Association of squatting with increased prevalence of radiographic tibiofemoral knee osteoarthritis: the Beijing Osteoarthritis Study. Arthritis and Rheumatism. 10.1002/art.20127
  5. 5.Matthews, C.E., Chen, K.Y., Freedson, P.S., Buchowski, M.S., et al (2008). Amount of time spent in sedentary behaviors in the United States, 2003-2004. American Journal of Epidemiology. 10.1093/aje/kwm390Bassett, D.R., Wyatt, H.R., Thompson, H., Peters, J.C., et al (2010). Pedometer-measured physical activity and health behaviors in U.S. adults. Medicine & Science in Sports & Exercise. 10.1249/MSS.0b013e3181dc2e54Bassett, D.R., Schneider, P.L., and Huntington, G.E (2004). Physical activity in an Old Order Amish community. Medicine and Science in Sports and Exercise. 10.1249/01.MSS.0000106184.71258.32Strain, T., Flaxman, S., Guthold, R., Semenova, E., et al (2024). National, regional, and global trends in insufficient physical activity among adults from 2000 to 2022. The Lancet Global Health. 10.1016/S2214-109X(24
  6. 6.Sylow, L., Kleinert, M., Richter, E.A., and Jensen, T.E (2017). Exercise-stimulated glucose uptake: regulation and implications for glycaemic control. Nature Reviews Endocrinology. 10.1038/nrendo.2016.162Dunstan, D.W., Kingwell, B.A., Larsen, R., Healy, G.N., et al (2012). Breaking up prolonged sitting reduces postprandial glucose and insulin responses. Diabetes Care. 10.2337/dc11-1931Buffey, A.J., Herring, M.P., Langley, C.K., Donnelly, A.E., et al (2022). The acute effects of interrupting prolonged sitting time in adults with standing and light-intensity walking on biomarkers of cardiometabolic health in adults: a systematic review and meta-analysis. Sports Medicine. 10.1007/s40279-022-01649-4Duran, A.T., Friel, C.P., Serafini, M.A., Ensari, I., et al (2023). Breaking up prolonged sitting to improve cardiometabolic risk: dose-response analysis of a randomized crossover trial. Medicine and Science in Sports and Exercise. 10.1249/MSS.0000000000003109
  7. 7.Moore, J.E., and Bertram, C.D (2018). Lymphatic system flows. Annual Review of Fluid Mechanics. 10.1146/annurev-fluid-122316-045259Noddeland, H., and Winkel, J (1988). Effects of leg activity and ambient barometric pressure on foot swelling and lower-limb skin temperature during 8 h of sitting. European Journal of Applied Physiology. 10.1007/BF00417985Kuipers, S., Schreijer, A.J., Cannegieter, S.C., Büller, H.R., et al (2007). Travel and venous thrombosis: a systematic review. Journal of Internal Medicine. 10.1111/j.1365-2796.2007.01867.x
  8. 8.Vallance, J.K., Gardiner, P.A., Lynch, B.M., D'Silva, A., et al (2018). Evaluating the evidence on sitting, smoking, and health: is sitting really the new smoking? American Journal of Public Health. 10.2105/AJPH.2018.304649Tawakol, A., Ishai, A., Takx, R.A., Figueroa, A.L., et al (2017). Relation between resting amygdalar activity and cardiovascular events: a longitudinal and cohort study. The Lancet. 10.1016/S0140-6736(16Saeidifard, F., Medina-Inojosa, J.R., Supervia, M., Olson, T.P., et al (2018). Differences of energy expenditure while sitting versus standing: a systematic review and meta-analysis. European Journal of Preventive Cardiology. 10.1177/2047487317752186Ahmadi, M.N., Coenen, P., Straker, L., and Stamatakis, E (2024). Device-measured stationary behaviour and cardiovascular and orthostatic circulatory disease incidence. International Journal of Epidemiology. 10.1093/ije/dyae136Shrestha, N., Kukkonen-Harjula, K.T., Verbeek, J.H., Ijaz, S., et al (2018). Workplace interventions for reducing sitting at work. Cochrane Database of Systematic Reviews. 10.1002/14651858.CD010912.pub5
  9. 9.Lee, I-M., Shiroma, E.J., Kamada, M., Bassett, D.R., et al (2019). Association of step volume and intensity with all-cause mortality in older women. JAMA Internal Medicine. 10.1001/jamainternmed.2019.0899Paluch, A.E., Bajpai, S., Bassett, D.R., Carnethon, M.R., et al (2022). Daily steps and all-cause mortality: a meta-analysis of 15 international cohorts. The Lancet Public Health. 10.1016/S2468-2667(21
  10. 10.Tudor-Locke, C., Craig, C.L., Brown, W.J., Clemes, S.A., et al (2011). How many steps/day are enough? For adults. International Journal of Behavioral Nutrition and Physical Activity. 10.1186/1479-5868-8-79Tudor-Locke, C., Aguiar, E.J., Han, H., Ducharme, S.W., et al (2019). Walking cadence (steps/min) and intensity in 21-40 year olds: CADENCE-adults. International Journal of Behavioral Nutrition and Physical Activity. 10.1186/s12966-019-0769-6Tudor-Locke, C., Ducharme, S.W., Aguiar, E.J., Schuna, J.M., et al (2020). Walking cadence (steps/min) and intensity in 41 to 60-year-old adults: the CADENCE-adults study. International Journal of Behavioral Nutrition and Physical Activity. 10.1186/s12966-020-01045-zTudor-Locke, C., Mora-Gonzalez, J., Ducharme, S.W., Aguiar, E.J., et al (2021). Walking cadence (steps/min) and intensity in 61-85-year-old adults: the CADENCE-Adults study. International Journal of Behavioral Nutrition and Physical Activity. 10.1186/s12966-021-01199-4Bull, F.C., Al-Ansari, S.S., Biddle, S., Borodulin, K., et al (2020). World Health Organization 2020 guidelines on physical activity and sedentary behaviour. British Journal of Sports Medicine. 10.1136/bjsports-2020-102955
  11. 11.Mandsager, K., Harb, S., Cremer, P., Phelan, D., et al (2018). Association of cardiorespiratory fitness with long-term mortality among adults undergoing exercise treadmill testing. JAMA Network Open. 10.1001/jamanetworkopen.2018.3605
  12. 12.Edwards, J.J., Deenmamode, A.H.P., Griffiths, M., Arnold, O., et al (2023). Exercise training and resting blood pressure: a large-scale pairwise and network meta-analysis of randomised controlled trials. British Journal of Sports Medicine. 10.1136/bjsports-2022-106503Fitzpatrick, M.F., Driver, H.S., Chatha, N., Voduc, N., et al (2003). Partitioning of inhaled ventilation between the nasal and oral routes during sleep in normal subjects. Journal of Applied Physiology. 10.1152/japplphysiol.00658.2002Zwillich, C.W., Pickett, C., Hanson, F.N., and Weil, J.V (1981). Disturbed sleep and prolonged apnea during nasal obstruction in normal men. American Review of Respiratory Disease. pubmed.ncbi.nlm.nih.govChaddha, A., Modaff, D., Hooper-Lane, C., and Feldstein, D.A (2019). Device and non-device-guided slow breathing to reduce blood pressure: a systematic review and meta-analysis. Complementary Therapies in Medicine. 10.1016/j.ctim.2019.03.005
  13. 13.Cipriani, A., Furukawa, T.A., Salanti, G., Chaimani, A., et al (2018). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. The Lancet. 10.1016/S0140-6736(17Gurven, M., Jaeggi, A.V., Kaplan, H., and Cummings, D (2013). Physical activity and modernization among Bolivian Amerindians. PLoS ONE. 10.1371/journal.pone.0055679
  14. 14.Mueller, N.T., Noya-Alarcon, O., Contreras, M., Appel, L.J., and Dominguez-Bello, M.G (2018). Association of age with blood pressure across the lifespan in isolated Yanomami and Yekwana villages. JAMA Cardiology. 10.1001/jamacardio.2018.3676Carvalho, J.J., Baruzzi, R.G., Howard, P.F., Poulter, N., et al (1989). Blood pressure in four remote populations in the INTERSALT Study. Hypertension. 10.1161/01.hyp.14.3.238Denton, D., Weisinger, R., Mundy, N.I., Wickings, E.J., et al (1995). The effect of increased salt intake on blood pressure of chimpanzees. Nature Medicine. 10.1038/nm1095-1009
  15. 15.World Health Organization (2026). Sodium reduction. who.intCogswell, M.E., Zhang, Z., Carriquiry, A.L., Gunn, J.P., et al (2012). Sodium and potassium intakes among US adults: NHANES 2003-2008. American Journal of Clinical Nutrition. 10.3945/ajcn.112.034413
  16. 16.Neal, B., Wu, Y., Feng, X., Zhang, R., et al (2021). Effect of salt substitution on cardiovascular events and death. New England Journal of Medicine. 10.1056/NEJMoa2105675Yuan, Y., Jin, A., Neal, B., Feng, X., et al (2023). Salt substitution and salt-supply restriction for lowering blood pressure in elderly care facilities: a cluster-randomized trial. Nature Medicine. 10.1038/s41591-023-02286-8Lai, H., Nesrallah, G., Guyatt, G.H., Vernooij, R.W.M., et al (2026). Comparative effects of salt substitutes on blood pressure, cardiovascular events and mortality: a systematic review and network meta-analysis. BMC Medicine. 10.1186/s12916-026-04635-zWorld Health Organization (2025). Use of lower-sodium salt substitutes: WHO guideline. ncbi.nlm.nih.gov
  17. 17.Nagano Prefecture Health Longevity Project Research Team (2014). 長野県健康長寿プロジェクト・研究事業 中間報告書. pref.nagano.lg.jpSuzuki, R (2015). Aiming to live long and prosper. Highlighting Japan. gov-online.go.jp
  18. 18.Stieglitz, J., Buoro, Y., Beheim, B., Trumble, B.C., et al (2023). Labour's pain: strenuous subsistence work, mechanical wear-and-tear and musculoskeletal pain in a non-industrialized population. Proceedings of the Royal Society B. 10.1098/rspb.2022.2497
  19. 19.Malmivaara, A., Häkkinen, U., Aro, T., Heinrichs, M.L., et al (1995). The treatment of acute low back pain: bed rest, exercises, or ordinary activity? New England Journal of Medicine. 10.1056/NEJM199502093320602Brinjikji, W., Luetmer, P.H., Comstock, B., Bresnahan, B.W., et al (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology. 10.3174/ajnr.A4173Chou, R., Fu, R., Carrino, J.A., and Deyo, R.A (2009). Imaging strategies for low-back pain: systematic review and meta-analysis. The Lancet. 10.1016/S0140-6736(09Buchbinder, R., Jolley, D., and Wyatt, M (2001). Population based intervention to change back pain beliefs and disability: three part evaluation. BMJ. 10.1136/bmj.322.7301.1516Woolf, C.J (2011). Central sensitization: implications for the diagnosis and treatment of pain. Pain. 10.1016/j.pain.2010.09.030Vlaeyen, J.W.S., and Linton, S.J (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 10.1016/S0304-3959(99
  20. 20.Ashar, Y.K., Gordon, A., Schubiner, H., Uipi, C., et al (2022). Effect of pain reprocessing therapy vs placebo and usual care for patients with chronic back pain: a randomized clinical trial. JAMA Psychiatry. 10.1001/jamapsychiatry.2021.2669Ashar, Y.K., Low, E.L., Knight, K., Schubiner, H., et al (2025). Pain reprocessing therapy vs placebo and usual care for patients with chronic back pain: 5-year follow-up of a randomized clinical trial. JAMA Psychiatry. 10.1001/jamapsychiatry.2025.1844
  21. 21.Hayden, J.A., Ellis, J., Ogilvie, R., Malmivaara, A., and van Tulder, M.W (2021). Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews. 10.1002/14651858.CD009790.pub2Shattock, A.J., Johnson, H.C., Sim, S.Y., Carter, A., et al (2024). Contribution of vaccination to improved survival and health: modelling 50 years of the Expanded Programme on Immunization. The Lancet. 10.1016/S0140-6736(24Krebs, E.E., Gravely, A., Nugent, S., Jensen, A.C., et al (2018). Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA. 10.1001/jama.2018.0899Jones, C.M.P., Day, R.O., Koes, B.W., Latimer, J., et al (2023). Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. The Lancet. 10.1016/S0140-6736(23
  22. 22.Wallace, I.J., Worthington, S., Felson, D.T., Jurmain, R.D., et al (2017). Knee osteoarthritis has doubled in prevalence since the mid-20th century. PNAS. 10.1073/pnas.1703856114Alentorn-Geli, E., Samuelsson, K., Musahl, V., Green, C.L., et al (2017). The association of recreational and competitive running with hip and knee osteoarthritis: a systematic review and meta-analysis. Journal of Orthopaedic and Sports Physical Therapy. 10.2519/jospt.2017.7137Bannuru, R.R., Osani, M.C., Vaysbrot, E.E., Arden, N.K., et al (2019). OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis and Cartilage. 10.1016/j.joca.2019.06.011National Institute for Health and Care Excellence (2022). Osteoarthritis in over 16s: diagnosis and management. nice.org.ukMessier, S.P., Mihalko, S.L., Legault, C., Miller, G.D., et al (2013). Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. JAMA. 10.1001/jama.2013.277669Messier, S.P., Gutekunst, D.J., Davis, C., and DeVita, P (2005). Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis and Rheumatism. 10.1002/art.21139Siemieniuk, R.A.C., Harris, I.A., Agoritsas, T., Poolman, R.W., et al (2017). Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. BMJ. 10.1136/bmj.j1982Kise, N.J., Risberg, M.A., Stensrud, S., Ranstam, J., et al (2016). Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ. 10.1136/bmj.i3740
  23. 23.Ridge, S.T., Olsen, M.T., Bruening, D.A., Jurgensmeier, K., et al (2019). Walking in minimalist shoes is effective for strengthening foot muscles. Medicine and Science in Sports and Exercise. 10.1249/MSS.0000000000001751Peters-Dickie, J.L., Detrembleur, C., Guallar-Bouloc, M., Rastelli, M., et al (2025). The effects of foot core exercises and minimalist footwear on foot muscle sizes, foot strength, and biomechanics: a systematic review and meta-analysis. Clinical Biomechanics. 10.1016/j.clinbiomech.2024.106417Relph, N., Greaves, H., Armstrong, R., Prior, T.D., et al (2022). Running shoes for preventing lower limb running injuries in adults. Cochrane Database of Systematic Reviews. 10.1002/14651858.CD013368.pub2Ridge, S.T., Johnson, A.W., Mitchell, U.H., Hunter, I., et al (2013). Foot bone marrow edema after a 10-wk transition to minimalist running shoes. Medicine and Science in Sports and Exercise. 10.1249/MSS.0b013e3182874769Lieberman, D.E., Venkadesan, M., Werbel, W.A., Daoud, A.I., et al (2010). Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature. 10.1038/nature08723Koepsell, T.D., Wolf, M.E., Buchner, D.M., Kukull, W.A., et al (2004). Footwear style and risk of falls in older adults. Journal of the American Geriatrics Society. 10.1111/j.1532-5415.2004.52412.xSherrington, C., Fairhall, N.J., Wallbank, G.K., Tiedemann, A., et al (2019). Exercise for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews. 10.1002/14651858.CD012424.pub2
  24. 24.Leong, D.P., Teo, K.K., Rangarajan, S., Lopez-Jaramillo, P., et al (2015). Prognostic value of grip strength: findings from the Prospective Urban Rural Epidemiology (PURE) study. The Lancet. 10.1016/S0140-6736(14Cherkin, D.C., Sherman, K.J., Balderson, B.H., Cook, A.J., et al (2016). Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial. JAMA. 10.1001/jama.2016.2323Watson, J.A., Ryan, C.G., Cooper, L., Ellington, D., et al (2019). Pain neuroscience education for adults with chronic musculoskeletal pain: a mixed-methods systematic review and meta-analysis. Journal of Pain. 10.1016/j.jpain.2019.02.011
  25. 25.Paterson, K.L., Bennell, K.L., Campbell, P.K., Metcalf, B.R., et al (2021). The effect of flat flexible versus stable supportive shoes on knee osteoarthritis symptoms: a randomized trial. Annals of Internal Medicine. 10.7326/M20-6321Bannuru, R.R., Osani, M.C., Vaysbrot, E.E., Arden, N.K., et al (2019). OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis and Cartilage. 10.1016/j.joca.2019.06.011National Institute for Health and Care Excellence (2022). Osteoarthritis in over 16s: diagnosis and management. nice.org.uk
  26. 26.Montero-Odasso, M., van der Velde, N., Martin, F.C., Petrovic, M., et al (2022). World guidelines for falls prevention and management for older adults: a global initiative. Age and Ageing. 10.1093/ageing/afac205Sherrington, C., Michaleff, Z.A., Fairhall, N., Paul, S.S., et al (2017). Exercise to prevent falls in older adults: an updated systematic review and meta-analysis. British Journal of Sports Medicine. 10.1136/bjsports-2016-096547
  27. 27.Ma, D., Wu, L., and He, Z (2013). Effects of walking on the preservation of bone mineral density in perimenopausal and postmenopausal women: a systematic review and meta-analysis. Menopause. 10.1097/GME.0000000000000100Watson, S.L., Weeks, B.K., Weis, L.J., Harding, A.T., et al (2018). High-intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: the LIFTMOR randomized controlled trial. Journal of Bone and Mineral Research. 10.1002/jbmr.3284
  28. 28.Reyes, N.L., and Abe, K (2026). Deep vein thrombosis and pulmonary embolism. CDC Yellow Book 2026. cdc.govClarke, M.J., Broderick, C., Hopewell, S., Juszczak, E., and Eisinga, A (2021). Compression stockings for preventing deep vein thrombosis in airline passengers. Cochrane Database of Systematic Reviews. 10.1002/14651858.CD004002.pub4North Tees and Hartlepool NHS Foundation Trust (2026). Anti-embolism stockings. nth.nhs.uk
  29. 29.Albert, C.M., Mittleman, M.A., Chae, C.U., Lee, I.M., et al (2000). Triggering of sudden death from cardiac causes by vigorous exertion. New England Journal of Medicine. 10.1056/NEJM200011093431902NHS (2026). Back pain. nhs.ukBus, S.A., Sacco, I.C.N., Monteiro-Soares, M., Raspovic, A., et al (2024). Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 10.1002/dmrr.3651Agnoli, A., Xing, G., Tancredi, D.J., Magnan, E., et al (2021). Association of dose tapering with overdose or mental health crisis among patients prescribed long-term opioids. JAMA. 10.1001/jama.2021.11013
  30. 30.Stensvold, D., Viken, H., Steinshamn, S.L., Dalen, H., et al (2020). Effect of exercise training for five years on all cause mortality in older adults: the Generation 100 study: randomised controlled trial. BMJ. 10.1136/bmj.m3485

The full source register

This page carries the chapter's apparatus. The chapter itself, and the fifteen others, are in the book.

Get the bookThe 30-day protocolAll sixteen chapters