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1. Obesity and Physical Activity Lecture 8 DR. BLEND BAYAR KHALIL M.B.Ch.B - H.D.D Member of ESE Head of NCD 1

2. Lecture Objectives Obesity Physical Activity 2

3. Obesity Definition Obesity is a complex disease involving an excessive amount of body fat. Obesity isn't just a cosmetic concern. It's a medical problem that increases the risk of other diseases and health problems, such as heart disease, diabetes, high blood pressure and certain cancers. 3

4. Definition Overweight: body weight that exceeds some average for stature, perhaps age. Overfat: body fat that exceeds an age- and/or gender appropriate average by some amt. 4

5. Obesity Vs Overweight 5

6. BMI Body mass index (BMI) is a person’s weight in kilograms divided by the square of height in meters. BMI is an inexpensive and easy screening method for weight category underweight, healthy weight, overweight, and obesity. BMI does not measure body fat directly, but BMI is moderately correlated with more direct measures of body fat . Furthermore, BMI appears to be as strongly correlated with various metabolic and disease outcome as are these more direct measures of body fatness 6

7. How is BMI used? BMI can be a screening tool, but it does not diagnose the body fatness or health of an individual. To determine if BMI is a health risk, a healthcare provider performs further assessments. Such assessments include skinfold thickness measurements, evaluations of diet, physical activity, and family history 7

8. BMI chart 8

9. Obesity Epidemiology The worldwide prevalence of obesity nearly tripled between 1975 and 2016. More than 1.4 billion adults were overweight in 2008, and more than half a billion obese In 2016, more than 1.9 billion adults, 18 years and older, were overweight. of these over 650 million were obese. 39% of adults aged 18 years and over were overweight in 2016, and 13% were obese. 9

10. Obesity Epidemiology 10

11. Obesity Epidemiology Most of the world's population live in countries where overweight and obesity kills more people than underweight. Over 340 million children and adolescents aged 5- 19 were overweight or obese in 2016. Overall, about 13% of the world’s adult population (11% of men and 15% of women) were obese in 2016 11

12. Obesity for children Globally, over 40 million preschool children were overweight in 2008 Childhood obesity is one of the most serious public health challenges of the 21st century. Overweight children are likely to become obese adults. They are more likely than non-overweight children to develop diabetes and cardiovascular diseases at a younger age, which in turn are associated with a higher chance of premature death and disability. 12

13. Measurement of obesity BMI Waist hip ratio Skin fold thickness Air displacement Plethysmography Total body electrical conductivity 13

14. Types of Obesity 14 1-Inactivity Obesity 2- Food and Stress Obesity 3- Anxiety Obesity 4- Venous Obesity 5- Gluten Obesity 6- Atherogenic Obesity

15. Types of Obesity Inactivity Obesity It is no secret that a lack of physical activity can cause you to become overweight. In this type of obesity, once-strong parts of the body quickly gain fat and become unhealthy. Food or Stress Obesity If you overeat, and particularly if you overindulge in unhealthy foods, you may suffer from food obesity. Excessive sugar intake can also cause food obesity, which may lead to accumulation of fat around the middle part of the body. 15

16. Types of Obesity Anxiety Obesity Anxiety or depression can often lead to overeating and accumulation of fat in the body, since the body must constantly survive in fight-or-flight mode. To treat this type of obesity, you must control your anxiety. Common treatments include medication, a decrease in caffeine intake. Venous Obesity Venous circulation is one obesity cause that is genetic in nature, rather than habitual in nature. if anyone in your family suffers from venous circulation, you run the risk of the same condition. This type of obesity is particularly common in pregnancy. Exercise is the best solution for this problem. 16

17. Types of Obesity Gluten Obesity You are likely no stranger to the many health problems that gluten can cause. In fact, gluten can actually cause obesity. This type of weight gain is most common in women. It is often spotted during periods of hormonal change, like puberty, pregnancy, and menopause. Atherogenic Obesity People whose fat tends to accumulate in the stomach area often suffer from atherogenic obesity. This is a particularly dangerous condition since it can affect your other organs and lead to breathing problems. It is extremely important to avoid drinking alcohol if you have atherogenic obesity. 17

18. Causes of Obesity Obesity is a long term process. Obesity frequently begins in childhood. Obese parents likely have overweight children. Regardless of final body weight as adults, overweight children exhibit more illnesses as adults than normal kids. 18

19. Causes of Obesity Excessive fatness also develops slowly through adulthood, most weight gain occurring between ages 25 to 44 yrs. Typical American man & woman gain .5 to 1.8 lb /year until 60 19

20. Causes of Obesity Overeating and Other Factors Factors that cause human obesity: genetics, environmental, metabolic, behavioral, social Factors that predispose a person to gain excessive weight gain. Eating patterns Eating environment Food packaging Food availability Body image Physical inactivity Basal body temp Dietary thermogenesis Fidgeting Biochemical differences Quantity & sensitivity to satiety hormones 20

21. Causes of Obesity Characteristics of fast food linked to increased adiposity: Higher energy density Greater saturated fat Reduced complex carbohydrates & fiber Reduced fruits and vegetables. 21

22. Causes of Obesity Genetics plays a role. How much variation in weight gain among individuals can be accounted for by genetic factors? Familial association is not proof of genetic inheritance-families share eating & exercise habits. Largest transmissible variation is cultural . 22

23. Causes of Obesity What is leptin ? A satiety hormone that influences the appetite control in the hypothalamus. A defective gene may cause inadequate leptin production. The brain receives an under assessment of body’s adipose stores & urge to eat. 23

24. Risk factors Several factors are responsible for obesity : Behavioral and lifestyle factors Diseases Mental illness Genetics 24

25. Risk Factors 25

26. Behavioral risk factors Unhealthy dietary patterns Less physical inactivity Medication use Easy availability of fast food Unfavorable physical activity environment Less education and skills Food marketing and promotion 26

27. Health consequences of obesity Obesity affects almost all organ systems and creates adverse health effects. 27 1. Hypertension 2. Dyslipidemia 3. Type 2 diabetes 4. Coronary heart disease 5. Stroke 6. Gallbladder disease 7. Osteoarthritis 8. Sleep apnea, obesity related asthma 9. Endometrial, breast, colon, liver cancers 10. Low quality of life 11. Mental illness 12. Chronic pain

28. Prevention Physical Activity and Exercise Encourage adults and children to engage in regular physical activity and decrease sedentary activity. 28

29. Weight Management Program 29

30. Weight Control One pound of fat contains 3,500 kcal Unbalance the Energy Equation (First Law Thermodynamics) Reduce kcal intake Increase kcal output Reduce intake and increase output 30

31. Altering the Energy Balance Total energy intake (not macronutrient mixture) determines effectiveness of weight loss with diet. Rapid weight loss during first few days comes mainly from body water loss and glycogen depletion. Continued weight reduction occurs at expense of greater fat loss per unit weight loss. 31

32. Fat Cell Size and Number What happens to fat cell size and fat cell number when adults lose weight? Fat cells shrink to a smaller size than adipocytes of nonobese people, number remains same. The large # of relatively small adipocytes may relate to appetite control; person craves food, overeats & gains lost weight. Total number of fat cells increases 3 general periods: Last trimester pregnancy, 1 st year life, adolescence 32

33. Prevention Lifestyle Assessment Related to Obesity Risk Assess BMI at least annually, monitor for increasing BMI. Review dietary and physical activity habits in addition to sleep duration. Review other obesity risk factors such as medical co- morbidities, familial obesity, medication use, and lack of nutrition knowledge and/or skills for food preparation. 33

34. Prevention Counseling and Approaches Discuss weight control interventions for overweight patients to prevent the progression to obesity . Encourage a self-management approach including setting goals for healthy lifestyle habits . 34

35. Maintenance of Goal Weight Selective fat reduction at specific body areas by spot reduction does NOT work. Exercise stimulates fatty acid mobilization through hormones and enzyme action that target fat depots throughout the body. 35

36. 36 Adiponectin Tuesday, August,3 rd ,2004

37. 37 Adipose tissue is an important endocrine organ. Adipocytokines include: Leptin TNF alpha. PAI-1. Adispsin. Resistin. Adiponectin. Diabetes care, Volume 26, # 8, August 2003

38. 38 Journal of Clinical Endocrinology & Metabolism, 89(6):June 2004

39. 39 Adiponectin: Adiponectin = Acrp30 = AdipoQ = GBP28 Adiponectin is an adipocyte-derived adipocytokine . Exclusively synthesized in white adipose tissue. Circulates at relatively high concentrations in the serum ( 2-10 mcg/ ml). Diabetes care, Volume 26, # 8, August 2003

40. 40 Epidemiology: Adiponectin levels are lower in : Obese individuals. Essential Hypertension. Diabetes. CAD. Men. Incidence of Cardiovascualr death is HIGHER in patients with renal failure who have decreeased adiponectin levels. Adiponectin ( Unlike other adipocytokines) is INVERSELY CORRELATED with BMI,Intraabdominal fat and indices of insulin resistance. Diabetes care, Volume 26, # 8, August 2003

41. 41 Decreased adiponectin levels were found to be closely associated to the degree of insulin resistance and hyperinsulinemia in Pima Indians. Negative correlation between circulating adiponectin & Triglyceride levels and Positive correlation between adiponectin and HDL cholesterol in T2DM. Diabetes care, Volume 26, # 8, August 2003

42. 42 Biological Actions of Adiponectin: Insulin-sensitizing. Anti-inflammatory. Antiatherogenic effects. Journal of Clinical Endocrinology & Metabolism, 89(6):June 2004

43. 43 Hypothetical Model for the actions of adiponectin Journal of Clinical Endocrinology & Metabolism, 89(6):June 2004

44. 44 Biological Actions of Adiponectin:

45. 45 Journal of Clinical Endocrinology & Metabolism, 89(6):June 2004

46. 46 Adiponectin & the Metabolic Syndrome: Journal of Clinical Endocrinology & Metabolism, 89(6):June 2004

47. 47 Adiponectin mRNA and protein levels have been found to be reduced in omental fat in comparison with subcutaneous fat. Strong inverse correlation between serum adiponectin levels & Intra-abdominal fat mass. Improvement in insulin sensitivity in obese subjects with gastric bypass surgery increases adionectin levels. Diabetes care, Volume 26, # 8, August 2003

48. 48 Negative correlation of adiponectin levels with body weight and fasting insulin levels and Positive correlation with insulin-stimulated glucose uptake ( a marker of insulin sensitivity). Adipocyte insulin action or signal transduction rather than absolute levels of insulin may regulate adiponectin secretion. Catecholamine-induced insulin resistance. Diabetes care, Volume 26, # 8, August 2003 Diabetes care, Volume 26, # 8, August 2003

49. 49 Adiponectin and Arteriosclerosis: Model illustrating how adiponectin exerts a preventive effect on vascular stenosis in the injured artery. J. Biol. Chem., Vol. 277, Issue 40, 37487-37491, October 4, 2002

50. 50 Adiponectin had effects on monocyte adhesion to endothelium,myeloid differentiation,macrophage cytokine production and phagocytosis. Adiponectin inhibits the action of TNF-alpha. Adiponectin may act as an antiathersclerotic factor through direct effects on the endothelial cells. Strong inverse correlation between CRP,hs-CRP and adiponectin mRNA levels in SC adipose tissue of human subjects with angiographically-demonstrable coronary atherosclerosis. High plasma adiponectin concentrations are associated with lower risk of MI in men. JAMA, April,14 th 2004, Vol 291, # 14

51. 51 Adiponectin & Type 2 DM: Genetic Variation at the adiponectin locus & Risk of T2DM. ( Diabetes, Jan 2004) Plasma adiponectin concentrations in Early pregnancy and subsequent risk of Gestational Diabetes mellitus ( Adiponectin levels were lower in women with gestational DM than in controls). Journal of Clinical Endocrinology& Metabolism, 89(5):2306-2311

52. 52 Adiponectin & Hypertension: Plasma adiponectin concentration was significantly lower in men with hypertension than in normotensive men and was negatively correlated with blood pressure in subjects without hypertension. Hypoadiponectinemia is an independent risk factor for hypertension. There are 4 possible reasons for the negative correlation between hypertension and plasma adiponectin concentration. Hypertension. 43(6):1318-1323, June 2004.

53. 53 Adiponectin & Breast Cancer: An inverse, fairly strong and statistically siginificant association of serum adiponectin with breast cancer in postmenopausal women. Journal of Clinical Endocrinology & Metabolism, 89(3):1102-1107

54. 54 Adiponectin & Endometrial Carcinoma: BMI and adiponectin showed independent effects on the risk of of Endometrial cancer. Journal of Clinical Endocrinology & Metabolism, 89(3):1160-1163

55. 55 Journal of Clinical Endocrinology & Metabolism,Volume 89(8), August 2004: Adiponectin levels in obese children were negatively correlated to age, body fat, and insulin resistance and were decreased in puberty. Significant weight loss led to an increase in adiponectin levels and an improvement of insulin resistance. Serum adiponectin is lowest in the presence of impaired glucose regulation and early diabetes. In the presence of diabetes, serum adiponectin is positively associated with abnormal renal function and diabetes duration. Journal of Clinical Endocrinology & Metabolism, Volume 89(8),August 2004

56. 56 Journal of Clinical Endocrinology & Metabolism,Volume 89(8), August 2004 In contrast to other adipocytokines, adiponectin mRNA is reduced in adipose tissue from obese and diabetic mice and humans but restored to normal levels after weight loss . Plasma adiponectin concentrations are lower in smokers, patients with CAD and women with PCOS.

57. Leptin (Greek leptos meaning thin) is a 16 kDa protein hormone that plays a key role in regulating energy intake and energy expenditure, including appetite and metabolism . It is one of the most important adipose derived hormones . [2] The Ob(Lep) gene (Ob for obese, Lep for leptin) is located on chromosome 7 in humans

58. Human leptin is a protein of 167 amino acids. It is manufactured primarily in the adipocytes of white adipose tissue , and the level of circulating leptin is directly proportional to the total amount of fat in the body. In addition to white adipose tissue—the major source of leptin —it can also be produced by brown adipose tissue , placenta ( syncytiotrophoblasts ), ovaries , skeletal muscle , stomach (lower part of fundic glands), mammary epithelial cells , bone marrow , pituitary and liver . [6] Leptin has also been discovered to be synthesised from gastric chief cells and P/D1 cells in the stomach. [7] Biosynthesis

59. To date, only leptin and insulin are known to act as an adiposity signal. In general, Leptin circulates at levels proportional to body fat . It enters the central nervous system (CNS) in proportion to its plasma concentration. Its receptors are found in brain neurons involved in regulating energy intake and expenditure. It controls food intake and energy expenditure by acting on receptors in the mediobasal hypothalamus Adiposity signal

60. Leptin binds to neuropeptide Y (NPY) neurons in the arcuate nucleus , in such a way that decreases the activity of these neurons. Leptin signals to the brain that the body has had enough to eat, producing a feeling of satiety Satiety

61. The role of leptin / leptin receptors in modulation of T cell activity in immune system was shown in experimentation with mice. It modulates the immune response to atherosclerosis, which is a predisposing factor in patients with obesity. [21] Leptin promotes angiogenesis by increasing vascular endothelial growth factor (VEGF) levels. In some epidemiological studies, hyperleptinemia is considered as a risk factor. However, recently a handful of animal experiments demonstrated that systemic hyperleptinemia produced by infusion or adenoviral gene transfer decreases blood pressure in rats Circulatory system

62. In fetal lung, leptin is induced in the alveolar interstitial fibroblasts ("lipofibroblasts") by the action of PTHrP secreted by formative alveolar epithelium (endoderm) under moderate stretch. The leptin from the mesenchyme, in turn, acts back on the epithelium at the leptin receptor carried in the alveolar type II pneumocytes and induces surfactant expression, which is one of the main functions of these type II pneumocytes. [24] Lung surfactant activity

63. The fact that leptin , a hormone released from fat tissue, can regulate bone mass first came to prominence in 2000. [31] It is now well established that leptin can affect bone metabolism via direct signalling from the brain and that although leptin acts to reduce cancellous bone , it conversely increases cortical bone . A number of theories have been put forward concerning the cortical- cancellous dichotomy including a recent theory suggesting that increased leptin during obesity may represent a mechanism for enlarging bone size and thus bone resistance to cope with increased body weight. [32 Effects on bone

64. Leptin has traditionally been regarded as a link between fat mass, food intake, and energy expenditure. This link originally arose from animal research findings, but its application to describing human systems has since been challenged. [36] In humans, there are many instances where leptin dissociates from the strict role of communicating nutritional status between body and brain and no longer correlates with body fat levels: Leptin levels decrease after short-term fasting (24–72 hours), even when changes in fat mass are not observed. [37] In the obese patients with obstructive sleep apnea (OSA), Leptin is increased, but decreases after administration of a CPAP . [38][39] In non-obese individuals, however, restful sleep (i.e., 8–12 hours of unbroken sleep) can increase leptin within normal ranges. Serum levels of Leptin are reduced by sleep deprivation. [40][41] Increased by perceived emotional stress. [42] Decreased by testosterone and increased by estrogen. [43] Chronically affected by exercise training; it decreases leptin levels Clinical significance

65. Although leptin is a circulating signal that reduces appetite, obese individuals generally exhibit an unusually high circulating concentration of leptin. [56] These people are said to be resistant to the effects of leptin, in much the same way that people with type 2 diabetes are resistant to the effects of insulin . The high sustained concentrations of leptin from the enlarged adipose stores result in leptin desensitization. The pathway of leptin control in obese people might be flawed at some point so the body does not adequately receive the satiety feeling subsequent to eating. Obesity and leptin resistance

66. Some researchers attempted to explain the failure of leptin to prevent obesity in modern humans as a metabolic disorder, possibly caused by a specific nutrient or a combination of nutrients that were not present or were not common in the prehistoric diet. Some proposed "villain" nutrients include lectins [57] and fructose

67. A signal-to-noise ratio theory has been proposed to explain the phenomenon of leptin resistance. [36] In healthy individuals, baseline leptin levels are between 1-5 ng/dl in men and 7-13 ng/dl in women. [36] A large intake of calories triggers a leptin response that reduces hunger, thereby preventing an overload of the inflammatory response induced by caloric intake. It has been theorized that, in obese individuals, the leptin response to caloric intake is blunted due to chronic, low-grade hyperleptinemia depressing the signal-to-noise ratio such that acute leptin responses have less of a physiological effect on the body

68. Although leptin resistance is sometimes described as a metabolic disorder that contributes to obesity, similar to the way insulin resistance is sometimes described as a metabolic disorder that has the potential to progress into the type 2 diabetes, it is not certain that it is true in most cases. The mere fact that leptin resistance is extremely common in obese individuals suggests that it may simply be an adaptation to excess body weight. It has been suggested that the major physiological role of leptin is not as a “satiety signal” to prevent obesity in times of energy excess, but as a “starvation signal” to maintain adequate fat stores for survival during times of energy deficit, [59][60] and that leptin resistance in overweight individuals is the standard feature of mammalian physiology, which possibly confers a survival advantage

69. A different form of leptin resistance (in combination with insulin resistance and weight gain) easily arises in laboratory animals (such as rats), as soon as they are given unlimited (ad libitum ) access to palatable, energy-dense foods, [62] and it is reversed when these animals are put back on low energy-density chow. [63] That, too, may have an evolutionary advantage: "the ability to efficiently store energy during periods of sporadic feast represented a survival advantage in ancestral societies subjected to periods of starvation." [64] The combination of two mechanisms (one, which temporarily suspends leptin action when presented with excess of high-quality food, and the other, which blunts the processes that could drive the body weight back to "normal"), could explain the current obesity epidemic without invoking any metabolic disorders or "villain" nutrients.

70. Health – physical activity Definition Physical activity: Any kind of voluntary body movement that a person does over a given period of time: walking, dancing, stair climbing, etc.), performed by skeletal muscles that spends an additional energy than the required to maintain vital functions (breathing, circulation, etc. 70

71. Health – physical activity Physical exercise: Physical activity that is planned, organized and repeated to improve fitness. Sport: Exercising governed by rules that combines physical activity and other characteristics of the person. Health: State of complete physical, mental and social well-being and not merely the absence of disease or infirmity (WHO). Physical Fitness: The ability to carry out daily tasks with vigor and alertness, without undue fatigue and with ample energy to enjoy leisure-time pursuits and to meet unforeseen emergencies 71

72. Physical activity is defined by its duration, intensity, and frequency Duration is the amount of time spent participating in a physical activity session Intensity is the rate of energy expenditure Frequency is the number of physical activity sessions during a specific time period (e.g. one week). 72

73. Types of Physical Activity The four main types of physical activity are : Aerobic and Anaerobic Muscle-strengthening Bone-strengthening Stretching 73

74. Aerobic and Anaerobic Activity Aerobic activity moves your large muscles, such as those in your arms and legs. Running, swimming, walking, bicycling, dancing, and doing jumping jacks are examples of aerobic activity. Aerobic activity also is called endurance activity. Aerobic activity makes your heart beat faster than usual. You also breathe harder during this type of activity. Over time, regular aerobic activity makes your heart and lungs stronger and able to work better. 74

75. Aerobic and Anaerobic Activities 75

76. Other types of Physical Activity Muscle-strengthening activities improve the strength, power, and endurance of your muscles. Doing pushups and situps , lifting weights, climbing stairs, and digging in the garden are examples of muscle-strengthening activities. With Bone-strengthening activities, your feet, legs, or arms support your body's weight, and your muscles push against your bones. This helps make your bones strong. Running, walking, jumping rope, and lifting weights are examples of bone-strengthening activities. 76

77. Other types of Physical Activity Muscle-strengthening and bone-strengthening activities also can be aerobic, depending on whether they make your heart and lungs work harder than usual. For example, running is both an aerobic activity and a bone-strengthening activity. Stretching helps improve your flexibility and your ability to fully move your joints. Touching your toes, doing side stretches, and doing yoga exercises are examples of stretching. 77

78. Levels of Intensity in Aerobic Activity 78

79. Benefits of Physical Activity 79

80. Benefits of Physical Activity Physical Activity Strengthens Your Heart and Improves Lung Function When done regularly, moderate- and vigorous-intensity physical activity strengthens your heart muscle. This improves your heart's ability to pump blood to your lungs and throughout your body. As a result, more blood flows to your muscles, and oxygen levels in your blood rise. Capillaries, your body's tiny blood vessels, also widen. This allows them to deliver more oxygen to your body and carry away waste products. Physical Activity Reduces Coronary Heart Disease Risk Factors When done regularly, moderate- and vigorous-intensity aerobic activity can lower your risk for CHD. CHD is a condition in which a waxy substance called plaque ( plak ) builds up inside your coronary arteries. These arteries supply your heart muscle with oxygen-rich blood. 80

81. Benefits of Physical Activity Physical Activity Reduces Heart Attack Risk For people who have CHD, aerobic activity done regularly helps the heart work better. It also may reduce the risk of a second heart attack in people who already have had heart attacks. Vigorous aerobic activity may not be safe for people who have CHD. Ask your doctor what types of activity are safe for you. 81

82. Fitness 82 Participating in physical activity is beneficial to people of all ages. Physical activity contributes to fitness, a state in which people’s health characteristics and behaviors enhance the quality of their lives.

83. Psychological Benefits of Exercise With Depression When you exercise, your body releases chemicals called endorphins . These endorphins interact with the receptors in your brain that reduce your perception of pain. Endorphins also trigger a positive feeling in the body, similar to that of morphine. For example, the feeling that follows a run or workout is often described as "euphoric.“ They also act as sedatives. They are manufactured in your brain, spinal cord, and many other parts of your body and are released in response to brain chemicals called neurotransmitters . The neuron receptors endorphins bind to are the same ones that bind some pain medicines . Physical activity also stimulates the release of dopamine, norepinephrine, and serotonin . These brain chemicals play an important part in regulating your mood. 83

84. Releasing Endorphin Hormone 84

85. Benefits of Endorphin Hormone 85

86. Physical Activity Guidelines 86

87. Requirements for a good physical activity 87

88. Why is Proper Hydration Important? Your body is 60-70% water Functions of water in the body : Regulates body temperature Provides nutrients to organs Transports oxygen to cells Removes wastes Protects joints and organs Need to replace fluid lost through perspiration, urination, bowel movements, breathing, etc. 88

89. Hydration When you are physically active, it is even more important to stay hydrated. The best way to stay well- hydrated for exercise is to drink: Before During After 89

90. Which exercises are better for Health 90 Slow – Moderate - Increase

91. Which exercises are better for Health 91

92. Summary Physical Activity is one of the preventions of Obesity . Obesity is one side of the double burden of malnutrition, and today more people are obese than underweight in every region except sub-Saharan Africa and Asia. Once considered a problem only in high-income countries, overweight and obesity are now dramatically on the rise in low- and middle-income countries, particularly in urban settings. Physical activity enhances thinking, learning, and judgment skills . Physical activity ensures healthy growth and development in young people . Physical activity improves overall well-being . 92

93. End Of the Lecture Thanks for Listening 93