Physical Activity and Cardiovascular Health

Abstract

Cardiovascular disease (CVD) remains the leading global cause of mortality, with physical activity (PA) and inactivity playing a significant role in its prevalence and outcomes. PA has been shown to substantially reduce cardiovascular and cardiometabolic risk through mechanisms such as favorable cardiac remodeling, improved endothelial function, and enhanced metabolic regulation. This review explores the broad cardiovascular benefits of PA across both general and diabetic populations, highlighting its impact on reducing disease incidence, improving cardiac function, and lowering cardiovascular mortality. Various forms of PA—including aerobic, resistance, and flexibility and balance training—demonstrate differing but complementary roles in promoting cardiovascular health. Despite strong evidence and guideline endorsements, participation rates remain low, with fewer than a quarter of US adults meeting the minimum PA recommendations. Barriers to PA—personal, environmental, and health‐related—remain significant and underaddressed. Enhanced patient education, clinician engagement, and tailored intervention strategies are essential to improve adherence and outcomes. Overall, PA is a critical, evidence‐based strategy for reducing CVD risk.

1. Introduction

Cardiovascular disease (CVD) is the leading cause of death worldwide, accounting for 32% of global mortality in 2022 [1]. Physical activity (PA) can play an important role in both management and prevention of CVD and can improve many cardiovascular (CV) and cardiometabolic risk factors such as blood pressure, dyslipidemia, insulin sensitivity, and endothelial dysfunction [2–4]. PA can also play an important role in both management and prevention of Type 2 diabetes and CVD in diabetic patients [5, 6]. Among patients with Type 2 diabetes, CVD remains the leading cause of morbidity and mortality, affecting about a third [7]. As the prevalence of metabolic syndrome and Type 2 diabetes rises, the need to understand and decrease the associated CVD risks, including PA, has become an important focus in medical research and public health policy making [8, 9]. But despite the known benefits of PA on CV health, less than a quarter of adult Americans meet the recommended minimum PA guidelines per current recommendations [10]. This review focuses on different types of PA, CV benefits of activity in the general population and diabetic population, and barriers to meeting activity goals.

2. Cardiovascular Health

2.1. Mechanism of PA on Improving Cardiovascular Health

CV health is a concept that has become better defined in the last two decades. The American Heart Association (AHA) has established CV health as “Life′s Essential 8” which is a combination of (1) health behaviors including avoiding tobacco use, keeping body mass index (BMI) under 25 kg/m², attaining adequate sleep, eating a heart healthy diet, in addition to engaging in regular PA with the recommendation for 150 min of moderate or 75 min of vigorous PA per week; (2) health risk factors including controlling cholesterol levels, blood pressure, and blood glucose [11, 12].

PA improves CV health primarily through three mechanisms. First, PA encourages beneficial cardiac adaptations through both structural and molecular pathways. Increased CV workload during PA stimulates myocardial hypertrophy and increased chamber volumes that ultimately enhance cardiac output [13]. At a molecular level, PA upregulates ATP‐sensitive potassium channels in cardiomyocytes and favors signaling pathways, such as the insulin‐like growth factor 1/P13K/Akt pathways, that promote cardiac growth, increase contractility, and thwart pathologic remodeling [14, 15].

Second, PA induces vascular development. Increased vascular demand during PA creates shearing stress on endothelial cells, stimulating nitric oxide (NO) production. As a strong vasodilator, NO reduces vascular inflammation and improves endothelial function [16]. On a cellular level, PA also induces mitochondrial biogenesis. Higher mitochondrial density results in improved energy production and decreased oxidative stress, reducing vascular aging [17].

Third, PA favorably shifts metabolic profiles. Participation in PA reduces atherosclerosis risk by encouraging healthier lipid profiles of higher high‐density lipoprotein (HDL), lower low‐density lipoprotein (LDL), and lower triglyceride levels [18]. Additionally, PA enhances insulin sensitivity and improves glucose metabolism, overall lowering risk of Type 2 diabetes [19, 20]. This is driven by processes at the molecular level, particularly when increased glucose influx into muscles promotes phosphorylation of key proteins, including glycogen synthase and TBC1D4 [21].

2.2. Impact of PA on Cardiovascular Outcomes

There is substantial evidence supporting the beneficial impact of PA on CV outcomes [22]. In fact, the multisociety AHA/American College of Cardiology (ACC) guideline on prevention of CVD, management of hypertension, management of chronic coronary disease, and management of heart failure all have PA as a Class 1 recommendation (Table 1) [24–27]. Similar findings have been repeated even in longitudinal studies, such as the Framingham Heart Study, where PA is associated with lower all‐cause and CVD‐attributable death [28].

Table 1.

Summary of recommendations for physical activity on cardiovascular outcomes.

Guideline	Physical activity recommendations to improve CVD	COR	LOE
2019 AHA/ACC Guideline for Primary Prevention of Cardiovascular Disease	Adults should engage in at least 150 min per week of accumulated moderate‐intensity or 75 min per week of vigorous‐intensity aerobic physical activity (or combination) to reduce ASCVD risk.	1	B‐NR
	For adults unable to meet the minimum recommendations activity recommendations, engaging in some moderate‐or‐vigorous‐intensity physical activity, even if less than the recommended amount, can be beneficial to reduce ASCVD risk.	IIa	B‐NR
2017 AHA/ACC Guideline for Management of Patients with Hypertension	Increased physical activity with a structured exercise program is recommended for adults with elevated blood pressure or hypertension.	1	A
2023 AHA/ACC Guideline for Management of Patients with Chronic Coronary Disease	For patients with CCD who do not have contraindications, an exercise regimen is recommended, including ≥ 150 min/week of moderate‐intensity or ≥ 75 min/week of higher intensity aerobic activities to improve functional capacity and QOL and to reduce hospital admission and mortality rates.	1	A
	For patients with CCD who do not have contraindications, resistance training exercises are recommended on ≥ 2 days a week to improve muscle strength, functional capacity, and cardiovascular risk factor control.	1	B‐R
2022 AHA/ACC Guideline for Management of Patients with Heart Failure	In the general population, healthy lifestyle habits such as regular physical activity, maintaining normal weight, healthy diet patterns, and avoiding smoking are helpful to reduce future risk of heart failure.	1	B‐NR

Note: The COR refers to the strength of the recommendation in terms of the certainty of benefit compared to the proportion of risk, while the LOE rates the quality of evidence supporting the recommendation in terms of type, quantity, and consistency of data from research [23].

Abbreviations: ACC American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; CCD, chronic coronary disease; COR, class of recommendation; LOE, level of evidence; QOL, quality of life.

3. PA

3.1. PA and Exercise

PA is any movement by a person that requires any amount of skeletal muscle movement leading to energy expenditure, such as everyday tasks including walking, work activity, leisure activity, cleaning, as well as structured movement such as exercise [29]. PA is quantified using the continuous metric of metabolic equivalent of task (MET) where one MET is defined as the energy used at rest or one′s basal metabolic expenditure, so PA with a MET value of 3 means using three times more energy than being still [30].

Exercise is a subset of PA that is usually planned and structured with the goal to increase or sustain fitness level [31]. Exercise can be grouped into categories—aerobic, resistance, and other (stretching, flexibility, balance) as summarized in Table 2 [5]. Aerobic activity is defined as continuous, rhythmic movements of large muscle groups, usually for at least 10 min at a time [32]. Examples of aerobic PA include walking, running, biking, or swimming—exercises that typically put the most demand on the CV and pulmonary systems [32]. Aerobic activity can be further stratified into light intensity (MET value 1.5–3, such as walking around the house or work setting), moderate intensity (MET value 3–6, such as jogging), or vigorous intensity (MET value > 6, such as running, swimming, or any aerobic activity that leads to an increase in heart rate) [30]. Resistance activities are brief, repetitive motions with weights or resistance (including body weight resistance) to improve muscle mass and endurance [32]. Resistance activities are usually MET value greater than 2 [4]. The last category of exercise includes stretching, flexibility, and balance. These types of exercises typically are a MET value of 2–4 and can improve joint mobility to maintain regular PA levels [19, 30]. Combining different forms of exercise has been shown to be most beneficial for overall cardiometabolic and CV health [33, 34].

Table 2.

Summary of different exercises.

Type of exercise	METs	Examples
Aerobic—light intensity	1.5–3	Walking in the work setting, light housework
Aerobic—moderate intensity	3–6	Fast walking, light jogging, biking slowly
Aerobic—vigorous intensity	≥ 6	Running, swimming, biking
Resistance	≥ 2	Lifting weights, resistance bands
Other	2–4	Stretching, flexibility exercises, balance work

Abbreviation: METs, metabolic equivalent of task.

3.2. Physical Inactivity

Physical inactivity refers to when a person is not meeting their weekly PA recommendations (150 min of moderate or 75 min of vigorous PA per week), usually due to increased stationary activity with minimal energy expenditure such as sitting at a desk, watching television, or lying around while awake [35, 36]. The Sedentary Behavior Research Network defined sedentary behavior as “any waking behavior characterized by an energy expenditure less than 1.5 METs while in a sitting, lying, or reclining position” [36]. Healthcare providers tend to promote PA by prescribing exercise; however, it has been suggested that it may be more beneficial to emphasize not being inactive or sedentary [37]. A meta‐analysis found the largest benefit in terms of CVD risk reduction in diabetic patients to be when moving from total inactivity (0 METs) to some activity (6 MET hours per week), indicating possible “diminishing returns” on increasing PA duration [2]. The AHA guidelines for primary prevention of CVD have a Class IIb recommendation that decreasing sedentary behavior may reduce CVD risk [25]. The US Department of Health PA guidelines state that sedentary behavior is strongly correlated with CV mortality; however, there is not yet sufficient evidence to offer guidelines on exact recommended daily sedentary time [38].

3.3. Sex Differences in Cardiovascular Benefits of PA

Women have been shown to participate in PA less than men from early adolescence and continuing into adulthood [39]. An analysis in The Lancet Global Health from 2018 found that 31.7% of women are inactive compared to 23.4% of men representing a persistent “gender gap” in PA [40]. Prior studies have established differences between men and women in terms of physiologic response and exercise capacity, suggesting there may be sex differences for the CV benefits of PA [41, 42]. A meta‐analysis found a significant association by sex between PA and coronary heart disease, suggesting women had greater benefit of PA compared to men [43]. A recent prospective study from 2024 found that although men and women both achieved peak survival benefit at 300 min of aerobic exercise weekly, women had a significantly greater mortality benefit compared to men for the same amount of exercise (24% vs. 18%; p < 0.001) [42]. In addition, women who engaged in regular resistance training had a significantly increased mortality risk reduction compared to men (11% vs. 19%, p = 0.005) [42]. Interestingly, women derived the greatest mortality benefit with strength training once weekly, compared to men who had greatest benefit with strength training three times weekly [42]. Another study by Qian et al. analyzed what time of day exercise is most beneficial and found that men who exercised in the morning had the highest cardiorespiratory fitness, while women had the highest fitness in the evening group [44]. Sex‐specific risk factors, such as age at menarche, also need to be considered when assessing CVD in women [45]. Current recommendations for PA for the benefit of CV health do not differ by sex [46]; however, future guidelines may benefit from sex‐specific considerations given these emerging data.

3.4. Current Recommendations

There are slightly differing recommendations on optimal PA including type of activity, duration, and intensity; however, there is consensus that any level of PA is better than none, and there are significant CV benefits at essentially every level of PA [47]. Participants in a recent study had the most efficient CVD incidence reduction with 250 min of moderate‐to‐vigorous PA weekly, but significant incidence reduction was noted with even 10–15 min weekly [48].

Most organizational guidelines have adopted a form of the US Department of Health PA Guidelines that recommend everyone get at least 150 min per week of moderate‐intensity aerobic activity and at least 2 days of moderate‐intensity resistance exercises (Table 3) [46]. Unfortunately, only 10% of Americans are aware of PA guidelines, and only 3% know the correct amount of aerobic exercise recommended, highlighting the importance of physician communication and prescription of exercise [50].

Table 3.

How much physical activity is recommended [5, 24, 25, 27, 46, 49].

Guidelines	Physical activity recommendations
US Department of Health Physical Activity Guideline	At least 150 min of moderate‐intensity or 75 min of vigorous‐intensity activity with at least 2 days of muscle‐strengthening activity per week.
AHA/ACC Guideline for Primary Prevention of Cardiovascular Disease	At least 150 min per week of accumulated moderate‐intensity or 75 min per week of vigorous‐intensity aerobic physical activity
AHA/ACC Guideline for Management of Patients with Chronic Coronary Disease	At least 150 min per week of moderate‐intensity aerobic activities or at least 75 min per week of higher‐intensity aerobic activities. Resistance (strength) training exercises are also recommended on at least 2 days per week.
AHA/ACC Guideline for Management of Patients with Hypertension	Either or combination of aerobic exercise (90–150 min per week), dynamic resistance exercise (90–150 min per week), and isometric resistance exercise (three times per week).
American Diabetes Association	At least 150 min or more of moderate‐ to vigorous‐intensity activity weekly, spread over at least 3 days per week, with no more than 2 consecutive days without activity. Shorter durations (minimum 75 min/week) of vigorous‐intensity or interval training may be sufficient for younger and more physically fit individuals.
American College of Sports Medicine	Recommend moderate‐intensity aerobic physical activity for a minimum of 30 min on 5 days per week, or vigorous‐intensity aerobic activity for a minimum of 20 min on 3 days per week. Every adult should perform activities that maintain or increase muscular strength and endurance for a minimum of 2 days per week.

Abbreviations: ACC, American College of Cardiology; AHA, American Heart Association.

4. PA for Persons With Type 2 Diabetes

Type 2 diabetes is defined as hyperglycemia due to insulin resistance. Over 537 million people worldwide in 2021 had Type 2 diabetes, with prevalence expected to increase to 783 million people worldwide by 2045 [51]. CVD is a major complication of diabetes and is associated with increased risk of ischemic heart disease, heart failure, coronary artery disease, and peripheral artery disease [52]. People with Type 2 diabetes have over 50% higher risk of all‐cause mortality and CV mortality compared to people without diabetes [53]. PA improves CV health through three main mechanisms—encouraging beneficial structural and molecular cardiac adaptations, inducing vascular development, and favorably shifting metabolic profiles including improved glucose metabolism—making PA an important aspect of nonpharmacologic prevention and management of Type 2 diabetes [13, 16, 19, 20].

4.1. PA and the Prevention of Type 2 Diabetes

PA, including both aerobic and resistance exercises, is important as it can lead to reducing incidence of Type 2 diabetes and CVD [54]. The Coronary Artery Risk Development in Young Adults (CARDIA) study showed that less fit young adults, measured as lower CRF, were more likely to develop Type 2 diabetes in adulthood [55]. The Diabetes Prevention Study randomly assigned overweight adults to a control group or an intervention group that would focus on diet and exercise with a goal of 30 min a day of PA; they found that the intervention group had a 58% reduction in Type 2 diabetes incidence over the next 4 years compared to the control group [56]. Notably, the effect of PA was greater in the more sedentary population prior to intervention (< 7.5 MET hours per week at baseline) and remained significant when adjusted for weight [57].

Another meta‐analysis showed that just 1 MET increase in activity was associated with an 8% lower risk of Type 2 diabetes incidence [58]. A pooled analysis of prospective observational cohort studies of the general population found inactivity to be associated with a 24% higher risk of CVD and a 42% higher risk of Type 2 diabetes [59]. A sedentary lifestyle significantly affects our cardiometabolic health and increases the risk of type 2 diabetes incidence [35].

4.2. PA and Cardiovascular Outcomes in Diabetes

Prior studies have shown that PA can improve CV outcomes in people with diabetes. A meta‐analysis showed that PA in people with Type 2 diabetes was associated with a 29% lower risk of CV death compared to patients who were inactive [53]. A pooled analysis of 10 population‐based cohort studies showed that people with diabetes (Type 1 and Type 2) who met their PA goals had a 35% lower all‐cause mortality [60]. However, the research on PA for people with Type 1 diabetes compared to Type 2 diabetes is limited and warrants further investigation.

The Look AHEAD clinical trial examined lifestyle intervention on obese patients with Type 2 diabetes and did not find a significant reduction in CV events; however, a post hoc analysis showed patients who lost more than 10% of their body weight did have a significant reduction in CV events [61]. The role of weight loss in the benefits of PA is not as clear. Wahid et al. showed that PA improves CV risk factors but only noted a marginal change in CVD risk when adjusting for body weight, indicating that the CVD benefits of PA may be derived from mechanisms other than weight loss [2].

Cardiac function may also improve with PA in people with Type 2 diabetes. Type 2 diabetes has been shown to be associated with increased incidence of heart failure with subclinical systolic and diastolic dysfunction [62]. A meta‐analysis of six clinical trials found that PA in people with Type 2 diabetes can lead to improvement in early diastolic velocity and systolic function by echocardiography [62].

4.3. PA Recommendations for Persons With Diabetes

The American Diabetes Association and Diabetes Canada both have strong recommendations for PA, recommending at least 150 min or more of moderate‐to‐vigorous‐intensity activity weekly spread over at least 3 days per week, with no more than two consecutive days without activity. Meeting these PA recommendations has been shown to improve glycemic control and CV outcomes in people with diabetes [5, 32]. In fact, some of the most common comorbidities in people with Type 2 diabetes [63] that may increase CVD risk, including obesity, dyslipidemia, hypertension, and chronic kidney disease, all have governing societies that also have strong recommendations for PA (Table 4), further emphasizing the importance of PA for all persons [5, 19, 64–66].

Table 4.

Recommendations for physical activity of common diabetic comorbidities.

Association/society	Recommendations for physical activity	Grade
American Diabetes Association	Adults should engage in 150 min or more of moderate‐ to vigorous‐intensity activity weekly, spread over at least 3 days per week, with no more than 2 consecutive days without activity. Shorter durations (minimum 75 min/week) of vigorous‐intensity or interval training may be sufficient for younger and more physically fit individuals.	A
Diabetes Canada
European Association for the Study of Obesity	Advise an exercise training program based on 150 to 200 min of aerobic exercise at least at moderate intensity.	A
European Society of Cardiology Guidelines for the Management of Dyslipidemia	Recommend 3.5–7‐h moderately vigorous physical activity per week or 30–60 min most days.	A,Ba
Kidney International Guidelines for Management of Chronic Kidney Disease	Advise moderate‐intensity physical activity for a cumulative duration of at least 150 min per week.	1Db

^aGrade A recommendation for improvement in HDL (high‐density lipoprotein) and Class B recommendation for improvement in LDL (low‐density lipoprotein).

^bClass I recommendation, but level of evidence is low (D).

5. Barriers to PA

Many different types of barriers (Figure 1) can affect a person′s PA participation including personal barriers (lack of time, energy, motivation, etc.), environmental barriers (access, cost, weather, etc.), and health‐related barriers (injury, fear of injury, chronic illness). Demographics that are at higher odds of reporting barriers to PA include those who are women, are older, earn a lower income, are married, have acquired higher levels of education, work full‐time jobs, and are smokers [67, 68]. The most prevalent barriers to PA among adults are low mood, lack of time, health issues, and lack of a partner [69]. Overcoming these barriers is vital so that individuals can meet their PA goals, and understanding the barriers is the first step for providers and patients to make individualized PA plans. The Center for Disease Control and Prevention (CDC) [70], the AHA [71], and CardioSmart [72] all provide online resources and recommendations for patients and providers to identify their specific barrier and help them to overcome these common barriers to PA.

Figure 1.

Barriers to physical activity. Figure summary—Different types of barriers can affect a person’s physical activity engagement including personal, environmental, and health‐related barriers. Identifying and understanding barriers to physical activity may improve a person′s adherence with physical activity.

5.1. Personal Barriers

Every individual′s unique personal life can impact PA participation. A person′s beliefs of their health impacts PA participation. People with lower self‐efficacy, lower willpower, or inappropriate goal setting are more likely to have lower levels of PA [68]. Similarly, people not yet in a stage of change mindset prove to be another barrier to PA engagement [68]. Those with more social support, on the contrary, are more likely to participate in PA [73]. Lastly, personal interests in sedentary activities, such as video games and watching television, are also reported barriers to PA [74]. Some suggested approaches to overcome personal barriers include identifying open times in a daily schedule to use for PA, making PA part of a daily routine, and choosing activities that can be done with friends to improve participation [70–72].

5.2. Environmental Barriers

An individual′s environment can heavily impact their ability to engage in PA. Insufficient access to places to exercise or safe neighborhoods to walk is a commonly reported barrier [19, 67]. Poor weather can deter people from PA, particularly outdoors [75]. In patients with Type 2 diabetes and hypertension, a study identified “crowded sidewalks, lack of green spaces, lack of proper lighting in public spaces, and dense traffic” as barriers to PA [76]. Accessibility and the logistics of partaking in PA become even more intricate in patients who have highly morbid conditions. For instance, patients with multiple sclerosis report that they are unable to participate in PA due to inaccessibility and fear of disability stigma in PA spaces [77]. Suggested approaches to overcome environmental barriers include selecting activities that require minimal facilities, are inexpensive and convenient, and can be done regardless of weather [70–72].

5.3. Health‐Related Barriers

Both physical and mental components of health impact an individual′s willingness and ability to participate in PA. Patients in physical discomfort or stress often report that their palpable symptoms are significant barriers to PA [76]. To highlight a few populations, in rheumatic and musculoskeletal disease patients, fatigue and swollen joints are the most commonly reported barriers [78]. In patients with Charcot‐Marie‐Tooth disease, difficulty with balance, pain, and poor muscle strength are frequent barriers [79].

Patients reporting mental health disorders are correlated with higher rates of sedentary behavior on average [80]. However, the relationship between mental health and PA is nuanced and complex. While many patients report symptoms like anxiety as a barrier to engaging in PA, other patients with anxiety were paradoxically more motivated to partake in PA due to its established benefits on mental health outcomes [80]. Suggested approaches to overcome health‐related barriers include talking with a healthcare provider to learn exercises that are appropriate for age, fitness, health, and skill level for the individual and starting slow to gain confidence with those specific exercises [70–72].

6. Future Directions and Conclusion

PA clearly has substantial evidence supporting its benefit in CVD outcomes, including in people with diabetes and other comorbid conditions. Yet, it ironically has remarkably low rates of participation among Americans. It is encouraging that there are several ongoing statements and efforts from multiple societies, ranging from the American Diabetes Association to the American College of Sports Medicine to the Physical Activity Guidelines Advisory Committee, promoting PA. The future direction of improving PA participation includes addressing barriers to PA, improving patient and provider education about the benefits of PA, and endorsing changes in public policy to encourage a more active American lifestyle.

Funding

M.G.: This work was supported by contracts from the National Heart, Lung, and Blood Institute (Nos. N01‐HV‐068161, N01‐HV‐068162, N01‐HV‐068163, N01‐HV‐068164, Grants U01 HL064829, U01 HL649141, U01 HL649241, K23 HL105787, K23 HL125941, K23 HL127262, K23HL151867, T32 HL069751, R01 HL090957, R03 AG032631, R01 HL146158, R01 HL146158‐04S1, R01 HL124649, R01 HL153500, U54 AG065141); General Clinical Research Center grant MO1‐RR00425 from the National Center for Research Resources; the National Center for Advancing Translational Sciences grant UL1TR000124; Department of Defense grant PR161603 (CDMRP‐DoD); grants from the Gustavus and Louis Pfeiffer Research Foundation, Denville, New Jersey; the Women′s Guild of Cedars‐Sinai Medical Center, Los Angeles, California; the Ladies Hospital Aid Society of Western Pennsylvania, Pittsburgh, Pennsylvania; QMED, Inc., Laurence Harbor, New Jersey; the Edythe L. Broad and the Constance Austin Women′s Heart Research Fellowships, Cedars‐Sinai Medical Center, Los Angeles, California; the Barbra Streisand Women′s Cardiovascular Research and Education Program, Cedars‐Sinai Medical Center, Los Angeles, California; the Society for Women’s Health Research, Washington, DC; the Linda Joy Pollin Women′s Heart Health Program; the Erika Glazer Women′s Heart Health Project; the Adelson Family Foundation, Cedars‐Sinai Medical Center, Los Angeles, California; Robert NA. Winn Diversity in Clinical Trials Career Development Award (Winn CDA); and the Anita Dann Friedman Endowment in Women′s Cardiovascular Medicine & Research.

Disclosure

This work is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute, the National Institutes of Health, or the US Department of Health and Human Services. M.G. received consultant fees/honoraria from Medtronic, Novartis, and New Amsterdam.

Conflicts of Interest

The authors declare no conflicts of interest.

Polyak, Alexander , Lee, Alexander , Gulati, Martha , Physical Activity and Cardiovascular Health, Journal of Diabetes Research, 2026, 3341765, 9 pages, 2026. 10.1155/jdr/3341765

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.