Association Between Domain‐Specific Physical Activity and Novel Inflammatory Biomarkers Among US Adults: Insights From NHANES 2007–2018

Objectives: The novel inflammatory biomarkers, including systemic immune‐inflammation index (SII), systemic inflammation response index (SIRI), and neutrophil‐to‐lymphocyte ratio (NLR), can contribute to predicting the future risk of various diseases. However, the impact of different physical activi...

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Published inMediators of inflammation Vol. 2025; no. 1; p. 1989715
Main Authors Liu, Xin-ying, Yao, Kai
Format Journal Article
LanguageEnglish
Published United States John Wiley & Sons, Inc 01.01.2025
Wiley
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Abstract Objectives: The novel inflammatory biomarkers, including systemic immune‐inflammation index (SII), systemic inflammation response index (SIRI), and neutrophil‐to‐lymphocyte ratio (NLR), can contribute to predicting the future risk of various diseases. However, the impact of different physical activity (PA) domains on systemic inflammation remains unclear. The study aims to investigate the relationship between domain‐specific moderate‐to‐vigorous‐intensity PA (MVPA) and these inflammatory biomarkers among US adults. Methods: Participants from the US National Health and Nutrition Examination Survey (NHANES) (2007–2018) were included in this study. The Global Physical Activity Questionnaire was used to assess self‐reported MVPA. MVPA was categorized into three domains, including occupation‐related MVPA (O‐MVPA), transportation‐related MVPA (T‐MVPA), and leisure‐time‐related MVPA (LT‐MVPA). SII, SIRI, and NLR were derived from the complete blood count results obtained at the NHANES Mobile Examination Centers (MEC). Weighted multivariable linear regression and propensity score matching (PSM) were used to examine the relationship between domain‐specific MVPA and inflammatory biomarkers. Additionally, stratified and mediation analyses were performed to assess potential effect modifications and mediators in this association. Results: The study included a total of 29,072 participants. Following PSM, weighted multivariable linear regression indicated a negative association between LT‐MVPA meeting PA guidelines ( ≥ 150 min/week) and circulating inflammatory biomarkers ( β = −36, 95% confidence interval [CI]: −47 to −25, p < 0.001 for SII; β = −0.09, 95% CI: −0.13 to −0.05, p < 0.001 for SIRI; β = −0.08, 95% CI: −0.11 to −0.05, p < 0.001 for NLR, respectively), adjusting for all potential covariates in model 2. Participants engaging in sufficient T‐MVPA (≥ 150 min/week) also exhibited lower SII and SIRI levels ( β = −17, 95% CI: −32 to −2.4, p = 0.023; β = −0.07, 95% CI: −0.11 to −0.03, p = 0.002). Conversely, O‐MVPA showed no significant correlation with any inflammatory biomarkers (all p > 0.05). No significant effect modification was observed in the association between LT‐MVPA or T‐MVPA and inflammatory biomarkers (SII, SIRI, and NLR). Mediation analysis showed that body mass index (BMI) mediated the relationships between these inflammatory biomarkers and both LT‐MVPA and T‐MVPA. Conclusions: The impact of different PA domains on systemic inflammation varies significantly. Given the well‐established link between chronic inflammation and diseases such as cardiovascular disease (CVD), diabetes, and metabolic disorders, specific recommendations for PA categories should be provided, particularly targeting individuals with high systemic inflammatory responses.
AbstractList The novel inflammatory biomarkers, including systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and neutrophil-to-lymphocyte ratio (NLR), can contribute to predicting the future risk of various diseases. However, the impact of different physical activity (PA) domains on systemic inflammation remains unclear. The study aims to investigate the relationship between domain-specific moderate-to-vigorous-intensity PA (MVPA) and these inflammatory biomarkers among US adults. Participants from the US National Health and Nutrition Examination Survey (NHANES) (2007-2018) were included in this study. The Global Physical Activity Questionnaire was used to assess self-reported MVPA. MVPA was categorized into three domains, including occupation-related MVPA (O-MVPA), transportation-related MVPA (T-MVPA), and leisure-time-related MVPA (LT-MVPA). SII, SIRI, and NLR were derived from the complete blood count results obtained at the NHANES Mobile Examination Centers (MEC). Weighted multivariable linear regression and propensity score matching (PSM) were used to examine the relationship between domain-specific MVPA and inflammatory biomarkers. Additionally, stratified and mediation analyses were performed to assess potential effect modifications and mediators in this association. The study included a total of 29,072 participants. Following PSM, weighted multivariable linear regression indicated a negative association between LT-MVPA meeting PA guidelines ( ≥ 150 min/week) and circulating inflammatory biomarkers (  = -36, 95% confidence interval [CI]: -47 to -25,   < 0.001 for SII;  = -0.09, 95% CI: -0.13 to -0.05,   < 0.001 for SIRI;  = -0.08, 95% CI: -0.11 to -0.05,   < 0.001 for NLR, respectively), adjusting for all potential covariates in model 2. Participants engaging in sufficient T-MVPA (≥ 150 min/week) also exhibited lower SII and SIRI levels (  = -17, 95% CI: -32 to -2.4, =0.023;  = -0.07, 95% CI: -0.11 to -0.03, =0.002). Conversely, O-MVPA showed no significant correlation with any inflammatory biomarkers (all   > 0.05). No significant effect modification was observed in the association between LT-MVPA or T-MVPA and inflammatory biomarkers (SII, SIRI, and NLR). Mediation analysis showed that body mass index (BMI) mediated the relationships between these inflammatory biomarkers and both LT-MVPA and T-MVPA. The impact of different PA domains on systemic inflammation varies significantly. Given the well-established link between chronic inflammation and diseases such as cardiovascular disease (CVD), diabetes, and metabolic disorders, specific recommendations for PA categories should be provided, particularly targeting individuals with high systemic inflammatory responses.
Objectives: The novel inflammatory biomarkers, including systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and neutrophil-to-lymphocyte ratio (NLR), can contribute to predicting the future risk of various diseases. However, the impact of different physical activity (PA) domains on systemic inflammation remains unclear. The study aims to investigate the relationship between domain-specific moderate-to-vigorous-intensity PA (MVPA) and these inflammatory biomarkers among US adults.Methods: Participants from the US National Health and Nutrition Examination Survey (NHANES) (2007–2018) were included in this study. The Global Physical Activity Questionnaire was used to assess self-reported MVPA. MVPA was categorized into three domains, including occupation-related MVPA (O-MVPA), transportation-related MVPA (T-MVPA), and leisure-time-related MVPA (LT-MVPA). SII, SIRI, and NLR were derived from the complete blood count results obtained at the NHANES Mobile Examination Centers (MEC). Weighted multivariable linear regression and propensity score matching (PSM) were used to examine the relationship between domain-specific MVPA and inflammatory biomarkers. Additionally, stratified and mediation analyses were performed to assess potential effect modifications and mediators in this association.Results: The study included a total of 29,072 participants. Following PSM, weighted multivariable linear regression indicated a negative association between LT-MVPA meeting PA guidelines ( ≥ 150 min/week) and circulating inflammatory biomarkers (β = −36, 95% confidence interval [CI]: −47 to −25, p <0.001 for SII; β = −0.09, 95% CI: −0.13 to −0.05, p <0.001 for SIRI; β = −0.08, 95% CI: −0.11 to −0.05, p <0.001 for NLR, respectively), adjusting for all potential covariates in model 2. Participants engaging in sufficient T-MVPA (≥ 150 min/week) also exhibited lower SII and SIRI levels (β = −17, 95% CI: −32 to −2.4, p=0.023; β = −0.07, 95% CI: −0.11 to −0.03, p=0.002). Conversely, O-MVPA showed no significant correlation with any inflammatory biomarkers (all p >0.05). No significant effect modification was observed in the association between LT-MVPA or T-MVPA and inflammatory biomarkers (SII, SIRI, and NLR). Mediation analysis showed that body mass index (BMI) mediated the relationships between these inflammatory biomarkers and both LT-MVPA and T-MVPA.Conclusions: The impact of different PA domains on systemic inflammation varies significantly. Given the well-established link between chronic inflammation and diseases such as cardiovascular disease (CVD), diabetes, and metabolic disorders, specific recommendations for PA categories should be provided, particularly targeting individuals with high systemic inflammatory responses.
Objectives: The novel inflammatory biomarkers, including systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and neutrophil-to-lymphocyte ratio (NLR), can contribute to predicting the future risk of various diseases. However, the impact of different physical activity (PA) domains on systemic inflammation remains unclear. The study aims to investigate the relationship between domain-specific moderate-to-vigorous-intensity PA (MVPA) and these inflammatory biomarkers among US adults. Methods: Participants from the US National Health and Nutrition Examination Survey (NHANES) (2007-2018) were included in this study. The Global Physical Activity Questionnaire was used to assess self-reported MVPA. MVPA was categorized into three domains, including occupation-related MVPA (O-MVPA), transportation-related MVPA (T-MVPA), and leisure-time-related MVPA (LT-MVPA). SII, SIRI, and NLR were derived from the complete blood count results obtained at the NHANES Mobile Examination Centers (MEC). Weighted multivariable linear regression and propensity score matching (PSM) were used to examine the relationship between domain-specific MVPA and inflammatory biomarkers. Additionally, stratified and mediation analyses were performed to assess potential effect modifications and mediators in this association. Results: The study included a total of 29,072 participants. Following PSM, weighted multivariable linear regression indicated a negative association between LT-MVPA meeting PA guidelines (≥150min/week) and circulating inflammatory biomarkers (β =-36, 95% confidence interval [CI]: -47 to -25, p<0.001 for SII; β =-0.09, 95% CI: -0.13 to -0.05, p<0.001 for SIRI; β =-0.08, 95% CI: -0.11 to -0.05, p<0.001 for NLR, respectively), adjusting for all potential covariates in model 2. Participants engaging in sufficient T-MVPA (≥150min/week) also exhibited lower SII and SIRI levels (β =-17, 95% CI: -32 to -2.4, p=0.023; β =-0.07, 95% CI: -0.11 to -0.03, p=0.002). Conversely, O-MVPA showed no significant correlation with any inflammatory biomarkers (all p>0.05). No significant effect modification was observed in the association between LT-MVPA or T-MVPA and inflammatory biomarkers (SII, SIRI, and NLR). Mediation analysis showed that body mass index (BMI) mediated the relationships between these inflammatory biomarkers and both LT-MVPA and T-MVPA. Conclusions: The impact of different PA domains on systemic inflammation varies significantly. Given the well-established link between chronic inflammation and diseases such as cardiovascular disease (CVD), diabetes, and metabolic disorders, specific recommendations for PA categories should be provided, particularly targeting individuals with high systemic inflammatory responses. Keywords: leisure-time-related physical activity, lymphocytes ratio, NHANES, physical activity, systemic immune-inflammation index, systemic inflammation response index
Objectives: The novel inflammatory biomarkers, including systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and neutrophil-to-lymphocyte ratio (NLR), can contribute to predicting the future risk of various diseases. However, the impact of different physical activity (PA) domains on systemic inflammation remains unclear. The study aims to investigate the relationship between domain-specific moderate-to-vigorous-intensity PA (MVPA) and these inflammatory biomarkers among US adults. Methods: Participants from the US National Health and Nutrition Examination Survey (NHANES) (2007–2018) were included in this study. The Global Physical Activity Questionnaire was used to assess self-reported MVPA. MVPA was categorized into three domains, including occupation-related MVPA (O-MVPA), transportation-related MVPA (T-MVPA), and leisure-time-related MVPA (LT-MVPA). SII, SIRI, and NLR were derived from the complete blood count results obtained at the NHANES Mobile Examination Centers (MEC). Weighted multivariable linear regression and propensity score matching (PSM) were used to examine the relationship between domain-specific MVPA and inflammatory biomarkers. Additionally, stratified and mediation analyses were performed to assess potential effect modifications and mediators in this association. Results: The study included a total of 29,072 participants. Following PSM, weighted multivariable linear regression indicated a negative association between LT-MVPA meeting PA guidelines ( ≥ 150 min/week) and circulating inflammatory biomarkers ( β  = −36, 95% confidence interval [CI]: −47 to −25, p   < 0.001 for SII; β  = −0.09, 95% CI: −0.13 to −0.05, p   < 0.001 for SIRI; β  = −0.08, 95% CI: −0.11 to −0.05, p   < 0.001 for NLR, respectively), adjusting for all potential covariates in model 2. Participants engaging in sufficient T-MVPA (≥ 150 min/week) also exhibited lower SII and SIRI levels ( β  = −17, 95% CI: −32 to −2.4, p =0.023; β  = −0.07, 95% CI: −0.11 to −0.03, p =0.002). Conversely, O-MVPA showed no significant correlation with any inflammatory biomarkers (all p   > 0.05). No significant effect modification was observed in the association between LT-MVPA or T-MVPA and inflammatory biomarkers (SII, SIRI, and NLR). Mediation analysis showed that body mass index (BMI) mediated the relationships between these inflammatory biomarkers and both LT-MVPA and T-MVPA. Conclusions: The impact of different PA domains on systemic inflammation varies significantly. Given the well-established link between chronic inflammation and diseases such as cardiovascular disease (CVD), diabetes, and metabolic disorders, specific recommendations for PA categories should be provided, particularly targeting individuals with high systemic inflammatory responses.
Objectives: The novel inflammatory biomarkers, including systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and neutrophil-to-lymphocyte ratio (NLR), can contribute to predicting the future risk of various diseases. However, the impact of different physical activity (PA) domains on systemic inflammation remains unclear. The study aims to investigate the relationship between domain-specific moderate-to-vigorous-intensity PA (MVPA) and these inflammatory biomarkers among US adults. Methods: Participants from the US National Health and Nutrition Examination Survey (NHANES) (2007-2018) were included in this study. The Global Physical Activity Questionnaire was used to assess self-reported MVPA. MVPA was categorized into three domains, including occupation-related MVPA (O-MVPA), transportation-related MVPA (T-MVPA), and leisure-time-related MVPA (LT-MVPA). SII, SIRI, and NLR were derived from the complete blood count results obtained at the NHANES Mobile Examination Centers (MEC). Weighted multivariable linear regression and propensity score matching (PSM) were used to examine the relationship between domain-specific MVPA and inflammatory biomarkers. Additionally, stratified and mediation analyses were performed to assess potential effect modifications and mediators in this association. Results: The study included a total of 29,072 participants. Following PSM, weighted multivariable linear regression indicated a negative association between LT-MVPA meeting PA guidelines ( ≥ 150 min/week) and circulating inflammatory biomarkers (β = -36, 95% confidence interval [CI]: -47 to -25, p  < 0.001 for SII; β = -0.09, 95% CI: -0.13 to -0.05, p  < 0.001 for SIRI; β = -0.08, 95% CI: -0.11 to -0.05, p  < 0.001 for NLR, respectively), adjusting for all potential covariates in model 2. Participants engaging in sufficient T-MVPA (≥ 150 min/week) also exhibited lower SII and SIRI levels (β = -17, 95% CI: -32 to -2.4, p=0.023; β = -0.07, 95% CI: -0.11 to -0.03, p=0.002). Conversely, O-MVPA showed no significant correlation with any inflammatory biomarkers (all p  > 0.05). No significant effect modification was observed in the association between LT-MVPA or T-MVPA and inflammatory biomarkers (SII, SIRI, and NLR). Mediation analysis showed that body mass index (BMI) mediated the relationships between these inflammatory biomarkers and both LT-MVPA and T-MVPA. Conclusions: The impact of different PA domains on systemic inflammation varies significantly. Given the well-established link between chronic inflammation and diseases such as cardiovascular disease (CVD), diabetes, and metabolic disorders, specific recommendations for PA categories should be provided, particularly targeting individuals with high systemic inflammatory responses.Objectives: The novel inflammatory biomarkers, including systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and neutrophil-to-lymphocyte ratio (NLR), can contribute to predicting the future risk of various diseases. However, the impact of different physical activity (PA) domains on systemic inflammation remains unclear. The study aims to investigate the relationship between domain-specific moderate-to-vigorous-intensity PA (MVPA) and these inflammatory biomarkers among US adults. Methods: Participants from the US National Health and Nutrition Examination Survey (NHANES) (2007-2018) were included in this study. The Global Physical Activity Questionnaire was used to assess self-reported MVPA. MVPA was categorized into three domains, including occupation-related MVPA (O-MVPA), transportation-related MVPA (T-MVPA), and leisure-time-related MVPA (LT-MVPA). SII, SIRI, and NLR were derived from the complete blood count results obtained at the NHANES Mobile Examination Centers (MEC). Weighted multivariable linear regression and propensity score matching (PSM) were used to examine the relationship between domain-specific MVPA and inflammatory biomarkers. Additionally, stratified and mediation analyses were performed to assess potential effect modifications and mediators in this association. Results: The study included a total of 29,072 participants. Following PSM, weighted multivariable linear regression indicated a negative association between LT-MVPA meeting PA guidelines ( ≥ 150 min/week) and circulating inflammatory biomarkers (β = -36, 95% confidence interval [CI]: -47 to -25, p  < 0.001 for SII; β = -0.09, 95% CI: -0.13 to -0.05, p  < 0.001 for SIRI; β = -0.08, 95% CI: -0.11 to -0.05, p  < 0.001 for NLR, respectively), adjusting for all potential covariates in model 2. Participants engaging in sufficient T-MVPA (≥ 150 min/week) also exhibited lower SII and SIRI levels (β = -17, 95% CI: -32 to -2.4, p=0.023; β = -0.07, 95% CI: -0.11 to -0.03, p=0.002). Conversely, O-MVPA showed no significant correlation with any inflammatory biomarkers (all p  > 0.05). No significant effect modification was observed in the association between LT-MVPA or T-MVPA and inflammatory biomarkers (SII, SIRI, and NLR). Mediation analysis showed that body mass index (BMI) mediated the relationships between these inflammatory biomarkers and both LT-MVPA and T-MVPA. Conclusions: The impact of different PA domains on systemic inflammation varies significantly. Given the well-established link between chronic inflammation and diseases such as cardiovascular disease (CVD), diabetes, and metabolic disorders, specific recommendations for PA categories should be provided, particularly targeting individuals with high systemic inflammatory responses.
Conclusions: The impact of different PA domains on systemic inflammation varies significantly. Given the well-established link between chronic inflammation and diseases such as cardiovascular disease (CVD), diabetes, and metabolic disorders, specific recommendations for PA categories should be provided, particularly targeting individuals with high systemic inflammatory responses.
Objectives: The novel inflammatory biomarkers, including systemic immune‐inflammation index (SII), systemic inflammation response index (SIRI), and neutrophil‐to‐lymphocyte ratio (NLR), can contribute to predicting the future risk of various diseases. However, the impact of different physical activity (PA) domains on systemic inflammation remains unclear. The study aims to investigate the relationship between domain‐specific moderate‐to‐vigorous‐intensity PA (MVPA) and these inflammatory biomarkers among US adults. Methods: Participants from the US National Health and Nutrition Examination Survey (NHANES) (2007–2018) were included in this study. The Global Physical Activity Questionnaire was used to assess self‐reported MVPA. MVPA was categorized into three domains, including occupation‐related MVPA (O‐MVPA), transportation‐related MVPA (T‐MVPA), and leisure‐time‐related MVPA (LT‐MVPA). SII, SIRI, and NLR were derived from the complete blood count results obtained at the NHANES Mobile Examination Centers (MEC). Weighted multivariable linear regression and propensity score matching (PSM) were used to examine the relationship between domain‐specific MVPA and inflammatory biomarkers. Additionally, stratified and mediation analyses were performed to assess potential effect modifications and mediators in this association. Results: The study included a total of 29,072 participants. Following PSM, weighted multivariable linear regression indicated a negative association between LT‐MVPA meeting PA guidelines ( ≥ 150 min/week) and circulating inflammatory biomarkers ( β = −36, 95% confidence interval [CI]: −47 to −25, p < 0.001 for SII; β = −0.09, 95% CI: −0.13 to −0.05, p < 0.001 for SIRI; β = −0.08, 95% CI: −0.11 to −0.05, p < 0.001 for NLR, respectively), adjusting for all potential covariates in model 2. Participants engaging in sufficient T‐MVPA (≥ 150 min/week) also exhibited lower SII and SIRI levels ( β = −17, 95% CI: −32 to −2.4, p = 0.023; β = −0.07, 95% CI: −0.11 to −0.03, p = 0.002). Conversely, O‐MVPA showed no significant correlation with any inflammatory biomarkers (all p > 0.05). No significant effect modification was observed in the association between LT‐MVPA or T‐MVPA and inflammatory biomarkers (SII, SIRI, and NLR). Mediation analysis showed that body mass index (BMI) mediated the relationships between these inflammatory biomarkers and both LT‐MVPA and T‐MVPA. Conclusions: The impact of different PA domains on systemic inflammation varies significantly. Given the well‐established link between chronic inflammation and diseases such as cardiovascular disease (CVD), diabetes, and metabolic disorders, specific recommendations for PA categories should be provided, particularly targeting individuals with high systemic inflammatory responses.
Audience Academic
Author Yao, Kai
Liu, Xin-ying
AuthorAffiliation 1 Endoscopy Center, Jinshan Hospital, Fudan University, Shanghai 201508, China
2 Department of Neurology, Jinshan Hospital, Fudan University, Shanghai 201508, China
AuthorAffiliation_xml – name: 1 Endoscopy Center, Jinshan Hospital, Fudan University, Shanghai 201508, China
– name: 2 Department of Neurology, Jinshan Hospital, Fudan University, Shanghai 201508, China
Author_xml – sequence: 1
  givenname: Xin-ying
  orcidid: 0009-0004-3876-8514
  surname: Liu
  fullname: Liu, Xin-ying
– sequence: 2
  givenname: Kai
  orcidid: 0000-0001-7772-6991
  surname: Yao
  fullname: Yao, Kai
BackLink https://www.ncbi.nlm.nih.gov/pubmed/40599559$$D View this record in MEDLINE/PubMed
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ContentType Journal Article
Copyright Copyright © 2025 Xin-ying Liu and Kai Yao. Mediators of Inflammation published by John Wiley & Sons Ltd.
COPYRIGHT 2025 John Wiley & Sons, Inc.
Copyright © 2025 Xin-ying Liu and Kai Yao. Mediators of Inflammation published by John Wiley & Sons Ltd. This is an open access article under the terms of the Creative Commons Attribution License (the “License”), which permits use, distribution and reproduction in any medium, provided the original work is properly cited. Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License. https://creativecommons.org/licenses/by/4.0
Copyright © 2025 Xin-ying Liu and Kai Yao. Mediators of Inflammation published by John Wiley & Sons Ltd. 2025
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– notice: Copyright © 2025 Xin-ying Liu and Kai Yao. Mediators of Inflammation published by John Wiley & Sons Ltd. This is an open access article under the terms of the Creative Commons Attribution License (the “License”), which permits use, distribution and reproduction in any medium, provided the original work is properly cited. Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License. https://creativecommons.org/licenses/by/4.0
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Issue 1
Keywords systemic immune-inflammation index
systemic inflammation response index
NHANES
lymphocytes ratio
leisure-time-related physical activity
physical activity
Language English
License Copyright © 2025 Xin-ying Liu and Kai Yao. Mediators of Inflammation published by John Wiley & Sons Ltd.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
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Snippet Objectives: The novel inflammatory biomarkers, including systemic immune‐inflammation index (SII), systemic inflammation response index (SIRI), and...
The novel inflammatory biomarkers, including systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and...
Objectives: The novel inflammatory biomarkers, including systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and...
Objectives: The novel inflammatory biomarkers, including systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and...
Conclusions: The impact of different PA domains on systemic inflammation varies significantly. Given the well-established link between chronic inflammation and...
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SubjectTerms Adult
Adults
Arthritis
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Title Association Between Domain‐Specific Physical Activity and Novel Inflammatory Biomarkers Among US Adults: Insights From NHANES 2007–2018
URI https://www.ncbi.nlm.nih.gov/pubmed/40599559
https://www.proquest.com/docview/3227459693
https://www.proquest.com/docview/3226358650
https://pubmed.ncbi.nlm.nih.gov/PMC12213052
https://doaj.org/article/2f4a4996ba9c44a3b18637c2b5908df4
Volume 2025
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