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Physical Activity Guidelines Advisory Committee Report
Part G. Section 1: All-Cause Mortality
List of Figures
List of Tables
Introduction
This chapter examines the relation between physical activity and
all-cause mortality. Two leading causes of mortality, both in the United States
as well as globally, are cardiovascular disease and cancer, with both diseases
estimated to be responsible for 43% of all deaths globally (1). From a biological perspective, the evidence is strongly
persuasive that physical activity reduces the occurrence of these leading
causes of death (discussed in the individual chapters on these diseases); thus,
it is also biologically plausible for physical activity to postpone the
occurrence of all-cause mortality. (Because we all die eventually, when the
phrase "lower risk of all-cause mortality" is used in this chapter, it refers
to lower risk during the period of follow-up in a study; i.e., postponed
mortality.)
Review of the Science
Overview of Questions Addressed
This chapter addresses 5 specific questions:
- Is there an association between physical activity and all-cause
mortality? If so, what is the magnitude of this association?
- What is the minimum amount of physical activity associated with
significantly lower risk of all-cause mortality?
- Is there a dose-response relation between physical activity and
all-cause mortality?
- What is the shape of the dose-response relation between physical
activity and all cause mortality?
- Is the relation between physical activity and all-cause mortality
independent of adiposity?
Data Sources and Process Used to Answer
Questions
To provide evidence-based answers to the above questions, the All-cause
Mortality subcommittee obtained data from a search of the Physical Activity
Guidelines for Americans Scientific Database (see Part F: Scientific Literature Search
Methodology, for a full description of the database). The
Database contains studies published in 1995 and later. The selection criteria
were broad and included searching for studies of all age groups, all study
designs, and all physical activity types that had the outcome of all-cause
mortality. This retrieved 83 publications, of which 7 were excluded for the
following reasons: 3 studies of exercise-related mortality were covered in
another chapter; 2 studies of survival among cancer patients were covered in
another chapter; 1 study provided essentially duplicate results on physical
activity and all-cause mortality as another; and 1 study did not provide
results on the specific association of physical activity with all-cause
mortality. An additional 3 studies of cardiovascular or muscular fitness in
relation to all-cause mortality were excluded because, although they provided
important information, they did not directly inform on the amount of physical
activity associated with decreased risk of premature mortality (additional
discussion of studies on physical fitness and all-cause mortality is provided
later in this chapter). This left 73 studies that provide the evidence based
for the conclusions of this chapter. (Table
G1.A1, summarizes these studies.)
Question 1: Is There an Association Between Physical
Activity and All-Cause Mortality? If So, What Is the Magnitude of This
Association?
Conclusions
The data very strongly support an inverse association between physical
activity and all cause mortality. Active individuals — both men and women
— have approximately a 30% lower risk of dying during follow-up, compared
with inactive individuals. This inverse association has been observed among
persons residing in the United States, as well as in other countries, older
persons (aged 65 years and older), and persons of different race/ethnic groups.
In one study of persons with impaired mobility (unable to walk 2 km and climb 1
flight with no difficulty), physical activity also appeared to be associated
with lower all cause mortality rates.
Rationale
Description of Studies in Evidence Base
Of the 73 studies included in the evidence base (Table G1.A1), 71 were prospective cohort
studies, 1 was a retrospective cohort study, and 1 was a case-control study.
These studies were conducted in many countries in North America, Europe, the
Middle East, Asia, and Australia. Twenty-seven studies, or 37%, were studies in
the United States; the remaining 46 (63%) were conducted in other countries.
The length of follow-up in the studies ranged from 10 months to 28 years, apart
from the one retrospective cohort study of Finnish Olympic athletes, in which
follow-up was 71 years (2). Across all studies, the median
follow-up was 11.7 years.
Population Subgroups
These studies provide a large database that included 312,554
observations in men and 690,671 observations in women, with a total of 140,114
deaths. Because several studies published updated results in the same subjects,
unique observations totaled 254,514 men and 576,574 women, and 113,358 deaths.
Although the total number of women is larger than the total number of men, this
is skewed by 3 large studies of women (3-5); actually,
fewer studies included women (n=51), compared with studies that included men
(n=62).
The youngest subjects included were aged 16 years (6), though most studies (44 of 73 studies, or 60%) included
middle-aged subjects aged 40 years and older. A reasonable body of evidence was
specific to older persons aged 65 years and older, with 15 studies including
such subjects. With regard to race/ethnicity, among the US studies, most
included only small proportions of persons belonging to race/ethnic minority
groups. However, 3 included nationally representative samples of subjects (7-9) and another comprised 48.3% blacks (10). In addition, 2 studies specifically enrolled
Hispanic-American (11) and Japanese-American men (12); 5 studies conducted in Asia enrolled Chinese and
Japanese subjects (4;13-16).
Most of the studies enrolled ostensibly healthy subjects who were free
of cardiovascular disease and cancer. However, several studies did select
patient groups, including patients with coronary artery disease (17;17)) or at high risk (9;18), and patients with diabetes. (7;19-22). In one study, subjects with
impaired mobility were examined separately (23).
Main Findings
The available data strongly support an inverse relation between physical
activity and all cause mortality rates during follow-up, with 67 of the 73
studies reporting a significant, inverse relation for at least one group of
subjects (e.g., men versus women) and/or one domain of activity (e.g., all
activity, exercise activity, or commuting activity).
With regard to the strength of association, the median relative risk
(RR), comparing most with least active subjects was 0.69 across all studies,
indicating a 31% risk reduction with physical activity. This was similar for
men (median RR = 0.71) and women (median RR = 0.67), and for studies where both
sexes were analyzed together (median RR = 0.68). The magnitude of association
in this evidence base, which included studies published in 1995 and later, is
similar to that reported in a 2001 review that included studies published
before 1995 (24).
An inverse association also existed among persons aged 65 years and
older, with a median relative risk of 0.56 when comparing most with least
active persons. No significant interaction was observed with race/ethnic groups
in a study that included nationally representative subjects (i.e., results did
not differ across race/ethnic groups) (7). Inverse
associations also were noted among Puerto Rican men (11),
Japanese-American men (12), and Chinese and Japanese men
and women living in Asia (4;13-16).
Additionally, inverse relations between physical activity and all-cause
mortality were reported among patients with coronary artery disease (17) or at high risk (9;18), and among patients with diabetes (7;19-22). One study examined subjects
with and without impaired mobility separately. Among persons with impaired
mobility, mortality rates also appeared lower among active than inactive
persons (this was not directly tested for statistical significance) (23).
Validity of Findings
Because all of the studies in the evidence base were observational
epidemiologic studies with no randomized controlled trials, the data cannot
prove causality of effect. However, the totality of evidence does support a
cause-and-effect relation between physical activity and lower all-cause
mortality rates for the following reasons. First, as mentioned above, plausible
biological mechanisms — demonstrated in randomized clinical trials
— exist for physical activity to decrease the occurrence of
cardiovascular disease and cancer, the leading causes of mortality worldwide.
Second, bias due to decreased physical activity from ill health (i.e.,
a spurious inverse relation, with ill health causing decreased physical
activity, rather than physical activity causing lower mortality rates) is
unlikely. Many of the studies in Table
G1.A1 included only ostensibly healthy subjects and excluded persons with
cardiovascular disease and cancer. Studies that did include subjects with
chronic diseases typically adjusted for the presence of these conditions, and
continued to observe inverse associations between physical activity and
all-cause mortality rates. Several studies also allowed for a lag period (i.e.,
excluding initial years of follow-up) in analyses to minimize the potential
bias from ill health leading to decreased physical activity (as ill persons are
likely to die early in follow-up); physical activity was significantly related
to lower all-cause mortality rates in these analyses. Finally, if the follow-up
period is long (which was typically the case, with the median follow-up being
11.7 years), the impact of this bias will be diluted, with ill persons dying
early in follow-up.
Third, bias due to systematic misclassification of physical activity is
unlikely. It is true that almost all of the studies collected physical activity
information using self-reports by subjects, and this is likely to be imprecise.
However, because physical activity was assessed prospectively in almost all the
studies, any misclassification is likely to be random (leading to dilution of
results, rather than a systematic bias). Additionally, one study assessed
physical activity using doubly-labeled water, considered a gold standard for
measuring energy expenditure. This study did report an inverse relation between
physical activity and all-cause mortality rates (10).
Fourth, bias resulting from large losses to follow-up is unlikely.
Although many studies did not report follow-up rates, many of these studies
used national systems to ascertain deaths (e.g., National Death Index in the
United States), which tend to be complete. Of the studies that did report
follow-up rates, these tended to be very high.
Finally, physically active persons tend to have other healthy habits as
well, which may confound the association of physical activity with all-cause
mortality rates. This is unlikely to have explained the inverse relation
observed because the association persisted after controlling for several
potential confounders (including age, sex, race, education, smoking, body mass
index [BMI], alcohol, diet, personal and family medical history, and
reproductive variables in women) listed in Table G1.A1.
Physical Fitness and All-Cause Mortality
Studies of physical fitness and all-cause mortality were not reviewed
in the same detail as studies of physical activity because the former studies
do not provide direct information that can be translated to public health
recommendations for physical activity (e.g., How much? What intensity? What
duration? What frequency?). However, physical fitness, which includes
cardiorespiratory fitness, is closely related to physical activity. In
particular, among most individuals and particularly in those who are sedentary,
increases in physical activity result in increases in cardiorespiratory
fitness. Thus, cardiorespiratory fitness is an objective and reproducible
marker of recent physical activity patterns. The findings from studies of
cardiorespiratory fitness mirror those from studies of physical activity in
showing inverse associations with all-cause mortality (see Part G. Section 2: Cardiorespiratory
Health for a detailed discussion of this issue). In fact, the
magnitude of association is stronger for studies of cardiorespiratory fitness,
which may be due in part to the higher precision of measurement, as, most of
these studies use objective measurements of fitness (instead of, typically,
self-reported physical activity). For example, in the Aerobics Center
Longitudinal Study, the relative risks for mortality among the most fit men and
women were 0.49 and 0.37, respectively, while the associations for physical
activity were much weaker (25). In a recent review (26), the median relative risk for all-cause mortality,
comparing most fit with least fit men in 10 studies was 0.55; for women in 6
studies, this also was 0.55. Thus, the findings from studies of physical
fitness support those from studies of physical activity, with regard to an
inverse relation with all-cause mortality.
Question 2: What Is the Minimum Amount of Physical
Activity Associated With Significantly Lower Risk of All-Cause Mortality?
Conclusions
The studies in the evidence base have assessed different domains of
physical activity (including one of more of the following: leisure-time
activity, occupational activity, household activity, and commuting activity),
with most assessing primarily leisure-time physical activity (LTPA), including
walking. Some evidence indicates that it may be the overall
volume of energy expended — regardless of which
activities produce this energy expenditure — that is important to lower
the risk of mortality. The studies also have used different measures or units,
such as kilocalories per week, metabolic equivalent (MET) hours per week, or
hours per week to categorize physical activity levels in analyses. Thus,
combining the findings across studies posed a challenge.
In synthesizing the data across studies and expressing their findings
in a fashion that can be readily translated for public health purposes, the
evidence base is clear in showing that the equivalent of at least 2 to 2.5
hours per week of moderate-intensity physical activity is sufficient to
significantly decrease all-cause mortality rates (see Table
G1.1, below). Several studies investigated walking specifically, and it is
reasonably clear that walking 2 or more hours per week is associated with a
significantly lower risk of all-cause mortality (see Table
G1.2, below). Additionally, faster pace of walking, compared with slower
pace, is associated with lower risk.
Table G1.1. Minimum Amounts of Physical Activity
Associated With Significantly Lower Risks of All-Cause Mortality
The data are presented according to different classifications of
physical activity in the studies reviewed. Within each classification scheme,
studies are ordered according to their findings regarding the minimum amount of
activity observed to be associated with significantly lower risk of all-cause
mortality (lowest to highest).
Studies with subjects classified by energy expended in
physical activity:
Reference |
Men |
Women |
Both Sexes Analyzed
Together |
Yu et al., 2003 (41) |
23.9-2142.9 kcal/day vigorous LTPA (vs. 0-0.6
kcal/day) |
|
|
Lee et al., 1995 (38) |
750-1499 kcal/wk vigorous LTPA (vs. <150
kcal/wk) |
|
|
Tanasescu et al., 2003 (22) |
12.1-21.7 MET-hr/wk LTPA (vs. 0-5.1 MET-hr/wk);
≥16.1 MET-hr/wk walking (vs. 0-1.4) |
|
|
Bucksch 2005 (42) |
|
14-<33.5 kcal/kg/wk LTPA; i.e., ~910-2200 kcal/wk
(65 kg woman) (vs. 0 kcal/kg/wk) |
|
Fried et al., 1998 (36) |
|
|
980-1890 kcal/wk LTPA (vs. ≤67.5 kcal/wk) |
Lee & Paffenbarger 2000 (39) |
1000-1999 kcal/wk LTPA (vs. < 1000 kcal/wk) |
|
|
Janssen & Jolliffe 2006 (17) |
|
|
1000-1999 kcal/wk LTPA (vs. < 500 kcal/wk) |
Lan et al., 2006 (15) |
|
|
1000-1999 kcal/wk LTPA (vs. < sedentary) |
Haapanen et al., 1996 (43) |
>2100 kcal/wk LTPA, household activities, commuting
(vs. <800 kcal/wk) |
|
|
Matthews et al., 2007 (4) |
|
10.0-13.6 MET-hr/day LTPA, work, household,
walking/ cycling commute (vs. ≤9.9 MET-hr/day) |
|
Manini et al., 2006 (10) |
|
|
>770 kcal/day all activities (doubly-labeled water)
(vs. <521 kcal/day) |
Carlsson et al., 2006 (27) |
|
>50 MET-hr/day LTPA, work, household,
walking/cycling (vs. <35 MET-hr/day) |
|
Studies with subjects classified by duration of
physical activity:
Reference |
Men |
Women |
Both Sexes Analyzed
Together |
Bijnen et al.,1999 (44) |
At least 20 min/day, 3 day/wk walking and cycling
(vs. lesser amount) |
|
|
Rockhill et al., 2001 (30) |
|
1-1.9 hr/wk moderate-to vigorous LTPA (vs. <1
hr/wk) |
|
Gregg et al., 2003 (7) |
|
|
≥2 hr/wk walking (vs. none) ≥2 hr/wk
LTPA (vs. none) |
Landi et al., 2004 (45) |
|
|
≥2 hr/wk LTPA and chores (vs. <2 hr/wk) |
Mensink et al., 1996 (46) |
>2 hr/wk sports (vs. none) |
|
|
Leon et al., 1997 (18) |
140 min/day LTPA (vs. 4.9 min/day) |
|
|
Schooling et al., 2006 (16) |
|
|
≤30 min/day LTPA (vs. none) |
Hu et al., 2004a (3) |
|
≥3.5 hr/wk moderate-to vigorous LTPA
(vs. ≤0.5 hr/wk) |
|
Fujita et al., 2004 (13) |
|
≥1 hr/day walking (vs. ≤0.5 hr/day) |
|
Studies with subjects classified by frequency of
physical activity:
Reference |
Men |
Women |
Both Sexes Analyzed
Together |
Sundquist et al., 2004 (31) |
|
|
Occasional LPTA (vs. none) |
Lam et al., 2004 (14) |
1/mo to 1-3/wk LTPA of ≥30 min (vs. <1/mo) |
1/mo to 1-3/wk LTPA of ≥30 min (vs. <1/mo) |
|
Kushi et al., 1997 (47) |
|
Few/mo to 1/wk to moderate LPTA
(vs. never/rarely) |
|
Hillsdon et al., 2004 (48) |
|
|
1/wk vigorous sports/recreation
(vs. <1/mo) |
LTPA, leisure-time physical activity
Table G1.2. Walking and All-Cause Mortality
For each study, the data* presented are for the lowest walking level
significantly associated with decreased relative risk of all-cause mortality.
For studies without significant results, the non significant relative risk
(shown in bold italics) associated with the highest
walking level is given.
Further, the studies are grouped according to different classifications
of walking in the studies reviewed. Within each classification scheme for
walking, studies are ordered from lowest to highest walking level.
Studies with subjects classified by energy expended on
walking:
Reference |
Men |
Women |
Both Sexes Analyzed
Together |
Tanasescu et al., 2003 (22) |
≥16.1 MET-hr/wk (vs. 01.4): RR =
0.60 (0.41-0.88) |
|
|
Matthews et al., 2007 (4) |
|
≥7.1 MET-hr/day (vs. 0.3.4): RR = 0.86
(0.75-1.05) |
|
Studies with subjects classified by time spent
walking:
Reference |
Men |
Women |
Both Sexes Analyzed
Together |
Gregg et al., 2003 (7) |
≥2 hr/wk (vs. 0): RR = 0.61
(0.48-0.78) |
≥2 hr/wk (vs. 0): RR = 0.71
(0.59-0.87) |
|
Stessman et al., 2000 (49) |
|
|
~4 hr/wk (vs. <4 hr/wk): RR = 0.41
(0.19-0.91) |
LaCroix et al., 1996 (50) |
|
|
>4 hr/wk: RR = 0.91
(0.58-1.42) |
Fujita et al., 2004 (13) |
≥1 hr/day (vs. ≤0.5): RR = 0.91
(0.80-1.04) |
≥1 hr/day (vs. ≤0.5): RR = 0.75
(0.62-0.90) |
|
Wannamethee et al., 1998 (35) |
>60 min/day (vs. 0): RR = 0.62
(0.37-1.05) |
|
|
Schnohr et al., 2007 (51) |
>2 hr/day (vs. <0.5): RR = 0.80
(0.59-1.10) |
>2 hr/day (vs. <0.5): RR = 0.89
(0.69-1.14) |
|
Studies with subjects classified by distance
walked:
Reference |
Men |
Women |
Both Sexes Analyzed
Together |
Smith et al., 2007 (21) |
|
|
≥1 mile/day (vs. 0): RR = 0.89 (0.67-1.18),
normoglycemics RR = 0.54 (0.33-0.88), diabetics |
Hakim et al., 1998 (12) |
1.0-2.0 miles/day (vs. <1) RR = 0.68 (no
CI provided) |
|
|
Lee & Paffenbarger 2000 (39) |
≥12.5 miles/wk (vs. <3.1): RR = 0.84
(0.75-0.94) |
|
|
Studies with subjects classified by pace of
walking:
Reference |
Men |
Women |
Both Sexes Analyzed
Together |
Davey Smith et al., 2000; (52) Batty et al., 2002; (19)
Batty et al., 2003 (53) |
P, trend across slower, the same, faster pace
(compared to others) all < 0.01 |
|
|
Schnohr et al., 2007 (51) |
Average walking pace (vs. slow): RR = 0.75
(0.61-0.92) |
Average walking pace (vs. slow): RR = 0.54
(0.45-0.67) |
|
Studies with subjects classified by walking/cycling
combined:
Reference |
Men |
Women |
Both Sexes Analyzed
Together |
Bijnen et al., 1998 (32) |
≥20 min, 3 days/wk: RR = 0.71 (0.58-0.88) |
|
|
Barengo et al., 2004 (54) |
≥30 min/day commute (vs. <15): RR = 1.07
(0.98-1.17) |
≥30 min/day commute (vs. <15): RR = 0.98
(0.88-1.09) |
|
Hu et al., 2004b (20) |
|
|
≥30 min/day commute (vs. 0): RR = 0.88
(0.75-1.04) |
Carlsson et al., 2006 (27) |
|
>1.5 hr/day (vs. almost never): RR = 0.58
(0.45-0.75) |
|
*Data shown are relative risk, RR (95% CI).
It is important to note that this amount — 2 to 2.5 hours per
week of moderate-intensity physical activity — does not represent a
threshold level for risk reduction. Rather, the data consistently support an
inverse dose-response relation for the total volume of energy expended,
supporting a "some is good; more is better" message (see discussion under
Question 3 below).
Rationale
Assessment of Physical Activity
The different studies reviewed in this chapter primarily have used
questionnaires to assess physical activity. These questionnaires were different
across the various studies and assessed one or more domains of physical
activity — leisure-time, household, occupation, and commuting activity
— with most assessing primarily leisure-time physical activity. In
analyses, the studies classified subjects using different classification
schemes, such as by energy expended, duration of activity, and frequency of
activity. Several studies classified subjects by ordinal groupings of physical
activity (e.g., groups denoted as "sedentary," "light," "moderate," and
"heavy"), but the amount of activity attributable to each category was unclear.
Thus, combining the data across studies and translating the findings into a
fashion that could be readily translated for public health purposes was
challenging. Future studies should attempt to collect detailed information on
physical activity, as well as categorize this in ways that make comparison
across studies feasible. One helpful strategy may be to use standardized units,
such as energy expenditure (e.g., MET-hours per week) of duration in activities
of specified intensity (e.g., hours per week of moderate-intensity physical
activity).
Minimum Amount of Physical Activity Needed
Table G1.1 lists the studies with quantifiable
amounts of physical activity, and shows that most of the physical activity
assessments were derived from leisure-time activities. For studies classifying
subjects by energy expended, it appears that some 1,000 kilocalories per week
or 10 to 12 MET-hours per week (approximately equivalent to 2.5 hours per week
of moderate-intensity activity) or more is needed to significantly lower the
risk of all-cause mortality. For studies classifying subjects by the duration
of their physical activity, it appears that some 2 hours per week or more is
needed for significantly lower risks. A few studies classified subjects by the
frequency of physical activity (with or without duration built in). These
sparse data show that even 1 per month to 1 to 3 times per week of physical
activity, lasting at least 30 minutes in duration, is significantly associated
with lower risk. Across all studies, the minimum amount of activity did not
appear to differ for men and women.
Walking
Many studies have included walking in their assessment of physical
activity, although several combined this activity into an overall estimate of
physical activity (e.g., as kilocalorie energy expenditure). In recent years,
however, investigators have been interested in walking as an activity to be
promoted for public health, and several studies have presented data
specifically on walking in relation to all-cause mortality rates.
Table G1.2 summarizes the findings from studies
that have specifically investigated walking. In these studies, investigators
classified walking according to the energy expended on walking, the time spent
walking, the distance walked, the pace of walking, and walking combined with
bicycling, primarily for the purpose of commuting. Only 2 studies examined the
energy expended on walking and all-cause mortality rates; the data are
inconsistent. With regard to the time spent walking, for which most data are
available, the findings are reasonably consistent in showing that walking some
2 or more hours per week is associated with a significantly lower risk. A small
body of data suggests that walking 1 to 2 miles per day is associated with
lower risk. Additionally, faster pace of walking, compared with slower pace, is
consistently associated with lower risk. Few data are available on walking or
cycling as part of active commuting in relation to all-cause mortality, with
investigators typically examining 30 minutes or more per day of active
commuting versus lesser levels. These data are inconsistent and do not indicate
that 30 minutes or more per day of active commuting is associated with lower
risk.
What Activities "Count"?
As mentioned previously, the studies reviewed in this chapter that have
shown an inverse relation between physical activity and all-cause mortality
primarily have assessed leisure-time physical activity, including walking.
However, some evidence indicates that it may be the overall
volume of energy expended — regardless of where this
energy is derived —that is important to lower the risk of mortality.
Studies that have attempted to assess the total amount of energy expended in
leisure-time, occupational, household activity, and commuting activity have
reported significant inverse associations with the overall volume of physical
activity, as well with most of the individual domains analyzed separately
(except for commuting activity). These studies have included the Swedish
Mammography Cohort Study (27) and the Shanghai Women's
Health Study (4). In the Shanghai Women's Health Study (Figure G1.1), as amounts of energy expended on what
investigators termed "nonexercise activities" (i.e., activities other than
leisure-time activity, including household chores, walking and cycling as part
of commuting, and climbing stairs) increased, rates of all-cause mortality
declined steadily.
Within each category of "nonexercise activities," the addition of
"regular exercise" (i.e., regular leisure-time physical activity) further
reduced risk, except at the highest level of nonexercise energy expenditure.
This observation is compatible with the postulated dose-response relation
between physical activity and all-cause mortality, described in detail under
Questions 3 and 4 below. That is, the dose-response is likely curvilinear such
that at higher levels of energy expended, the curve flattens out. So in the
Shanghai Women's Health Study, women at the highest level of nonexercise
activities may have been at the upper end of the dose-response curve, and the
addition of further amounts of energy expended on exercise activities did not
appreciably reduce all-cause mortality rates further.
Figure G1.1. Relative risks of all-cause
mortality according to exercise and nonexercise activities, Shanghai Women's
Health Study
Source: Matthews et al., 2007 (4), with
permission
Values are hazard ratios and 95% confidence intervals.
Adjusted for age (years), marital status (yes, no),
education (elementary school or less, junior high school, high school,
college/post-high school), household income (low, middle, high), smoking (ever,
never), alcohol drinking (ever, never), number of pregnancies, oral
contraceptive use (ever, never), menopausal status (yes, no), and several
chronic medical conditions, such as diabetes (yes, no), hypertension (yes, no),
respiratory disease (yes, no; asthma, chronic bronchitis, or tuberculosis), and
chronic hepatitis (yes, no).
Figure G1.1. Data Points
Non-exercise activities
(MET-hrs/d) |
No
regular exercise Hazard Ratio |
No
regular exercise (95% CI) |
Regular
exercise Hazard Ratio |
Regular
exercise (95% CI) |
09.9 |
1.00 |
|
0.78 |
(0.620.99) |
1013.6 |
0.77 |
(0.620.95) |
0.67 |
(0.540.83) |
13.718.0 |
0.65 |
(0.520.81) |
0.47 |
(0.360.61) |
18.1+ |
0.61 |
(0.490.77) |
0.57 |
(0.440.74) |
Further support for the premise that all activities "count," and that
it is the total amount of energy expended that is relevant for all-cause
mortality, comes from the Health ABC study (10). In this
study, which objectively measured total energy expenditure using doubly-labeled
water, the relative risk for all-cause mortality was significantly lower (0.65)
among men and women who expended more than 770 kilocalories per day in physical
activity, compared with less than 521 kilocalories per day. (The energy
expended in physical activity was estimated as: [total energy expenditure*0.90]
— resting metabolic rate; i.e., assuming the thermic effect of food to be
10%.) Among those expending 521 to 770 kilocalories per day, the relative risk
was 0.64, well below 1.0 but not statistically significant, which is a likely
consequence of reduced power due to the small number of deaths (n=55) in this
study.
Findings from Studies of Physical Fitness That Can Inform on the
Minimum Amount of Physical Activity Needed
As stated previously, studies of cardiorespiratory fitness and all-cause
mortality do not provide direct information on the minimum amount of physical
activity needed. However, these studies can provide indirect information, in
that the physical activity levels of groups of fit subjects, who have lower
mortality rates compared with unfit subjects, can be ascertained. In a large
prospective cohort study where moderate and high levels of cardiorespiratory
fitness were associated with lower rates of all-cause mortality, compared with
low levels of fitness in both men and women, the physical activity levels of
subjects were obtained by questionnaire (28). Men in the
moderate and high cardiorespiratory fitness groups reported an average of 130
and 138 minutes per week of walking, respectively. Among women, the
corresponding amounts were 148 and 167 minutes per week, respectively. Thus,
these data are compatible with data from the overall body of literature on
physical activity and all-cause mortality, which suggest that walking at least
2 hours per week is needed to significantly lower mortality rates.
Question 3: Is There a Dose-Response Relation Between
Physical Activity and All-Cause Mortality?
Conclusions
The dose-response relation can be assessed with respect to specific
dimensions of physical activity, such as the total volume of energy expended,
the intensity of the physical activity carried out, the duration of physical
activity, or the frequency of physical activity. The largest amount of data, as
well as the clearest, pertains to the total volume of energy expended. These
data consistently show an inverse dose-response relation between volume of
energy expended and all-cause mortality. Thus, while the answer to Question 2
above indicates that at least 2 to 2.5 hours per week of moderate-intensity
physical activity is needed to significantly decrease all-cause mortality
rates, this amount does not represent a minimum threshold level for risk
reduction. Rather, the dose-response relation for the total volume of energy
expended supports a "some is good; more is better" message. Some data indicate
that among populations where physical activity levels are likely to be low
(e.g., middle-aged and older women, older men), significantly lower mortality
rates are observed at levels below 2 to 2.5 hours per week of
moderate-intensity physical activity. Taken as a whole, the data support a
target of 2 to 2.5 hours per week of moderate-intensity physical activity for
lowering all-cause mortality rates, yet also encourage any level of activity
below the target for inactive groups of individuals.
Limited data suggest that vigorous-intensity physical activity is
associated with additional risk reduction compared with lower-intensity
activities, beyond its contribution to the total energy expended. There are no
data to clarify dose-response relations for duration and frequency of physical
activity that are independent of their contributions to the total volume of
energy expended. In other words, it is unknown whether multiple, short bouts of
physical activity versus a single, long bout that expends the same energy are
differentially associated with all-cause mortality rates.
Rationale
The concept of "physical activity" is complex, in that it includes many
different aspects, such as the kinds of activities carried out, the intensity
with which they are conducted, and their duration and frequency. In examining
the dose-response relation between physical activity and all-cause mortality,
we can investigate the association with regard to several specific dimensions
of physical activity: the total volume of energy expended, the intensity, the
duration, or the frequency. The dose-response relation for each of these
dimensions is discussed separately below.
Dose-Response Relation for Total Volume of Physical Activity
As Table G1.A1 indicates, the
studies reviewed have used different methods (primarily questionnaires, which
differed across studies) to assess physical activity. However, all of them
possessed a measure that reflected the total volume of energy expended. This is
because any assessment of physical activity, no matter how simple, provides
some indication of the total volume of energy expended. For example, in the
NHANES I Epidemiologic Follow-up Study (29), physical
activity during recreation was assessed by asking, "Do you get much exercise in
things you do for recreation, or hardly any exercise, or in between?" Response
options were: much exercise, moderate exercise, and little or no exercise.
Although it is impossible to equate the different activity categories to actual
kilocalories or MET-hours of energy expended, it is clear that the categories
represent ordered levels representing the total volume of physical
activity.
Of the studies reviewed, 59 of the 73 studies classified subjects
according to at least 3 levels of physical activity, allowing for assessment of
dose-response related to the total volume of energy expended. Among these 59
studies, 33 reported significant, inverse trends between physical activity and
all-cause mortality rates. Another 21 studies showed apparent inverse trends
that were not formally tested for statistical significance. The remaining 5
studies showed a non-significant trend (n=1) or apparent lack of trends that
were not formally tested for significance (n=4).
As discussed above under Question 2, at least 2 to 2.5 hours per week
of moderate-intensity physical activity is needed to significantly decrease
all-cause mortality rates. However, rather than representing a minimum
threshold level for risk reduction, the dose-response relation for the total
volume of energy expended indicates that though this is a desired minimum level
of physical activity, risk reductions already begin to occur below this level,
supporting a message of "some is good; more is better." Additionally, some data
indicate that among populations where physical activity levels are likely to be
low (e.g., middle-aged and older women, older men) significantly lower
mortality rates are observed at levels below 2 to 2.5 hours per week of
moderate-intensity physical activity. In a study of middle aged and older
women, significantly lower rates of mortality were observed among women
engaging in 1 to 1.9 hours per week of moderate-to-vigorous intensity
leisure-time physical activity (30). In another study of
older men and women aged 65 years and older, "occasional" leisure-time physical
activity also was associated with significantly lower mortality rates (31). This association also held true for walking or cycling
for at least 20 minutes, 3 days a week, among men aged 64 to 84 years (32).
Further support for the "some is good; more is better" message comes
from a recent randomized clinical trial of physical activity to increase
cardiorespiratory fitness levels — higher levels of which are associated
with lower all-cause mortality rates — among sedentary, postmenopausal
women (33). In this trial, a dose-response relation was
observed such that graded increased in fitness were observed for 3 groups
exercising at 50%, 100%, and 150% of the Surgeon-General's recommendation (with
100% being equivalent to 150 minutes per week of moderate-intensity physical
activity). Thus, these data support a target of 2 to 2.5 hours per week of
moderate-intensity physical activity for lowering all cause mortality rates,
yet also encouraging any level of activity below the target for inactive groups
of individuals.
Dose-Response Relation for Intensity of Physical Activity
In 11 studies, investigators examined the dose-response relation for
intensity of physical activity. All but one reported significantly reduced
risks for vigorous-intensity activity compared with lesser-intensity physical
activity. However, the interpretation of these findings is not straightforward
because the intensity of physical activity is related to the total volume of
energy expended. That is, when carried out for the same total duration, higher
intensity physical activities expend more total energy than do lower-intensity
physical activities. Thus, if studies do not account for this correlation, it
is unclear whether the significantly reduced risk associated with
vigorous-intensity physical activity can be attributed to the
intensity of the activity, or whether it is merely due to the
increase in the total volume of energy expended (i.e.,
confounding of intensity by volume of energy expended). In other words, for the
same volume of energy expended, does vigorous intensity activity confer
additional benefits compared to moderate- or light-intensity activity?
Of the 11 studies, 4 did attempt to account for confounding by the
volume of energy expended. All 4 reported significant, inverse dose-response
relations with intensity of physical activity. Thus, these limited data suggest
that higher intensities of physical activity are associated with additional
risk reductions for all-cause mortality, beyond their contribution to greater
total volume of energy expended.
Dose-Response Relation for Duration and Frequency of Physical
Activity
Longer duration of physical activity, as well as greater frequency of
physical activity, results in greater total volume of energy expended, compared
with shorter durations or lower frequencies of activity. However, just as with
the dose-response relation to the intensity of physical activity, the relation
between dose and duration or frequency has the potential to be confounded by
the total volume of energy expended. Therefore, the total volume must be taken
into account in order to make conclusions regarding duration and frequency that
are independent of the total volume of energy expended.
Ten studies examined the dose-response relation between duration of
physical activity and all-cause mortality. These studies indicated that longer
durations of activity were associated with lower mortality rates. However,
these studies did not adjust for confounding by volume of physical activity and
so the data on duration may be reflecting the dose-response relation between
the total volume of energy expended and risk of all-cause mortality. These data
cannot provide any conclusion regarding whether multiple, short bouts of
physical activity versus a single, long bout that expends the same energy are
differentially associated with all cause mortality rates.
Three studies examined the dose-response relation for frequency of
physical activity. Again, these studies did not adjust for confounding by
volume of physical activity; thus, the data on frequency may be reflecting
findings for the dose-response of total volume of energy expended and all-cause
mortality rates. These data also cannot clarify the relative benefits of
multiple, short bouts of physical activity versus a single, long bout that
expends the same energy for all-cause mortality rates.
Finally, 1 study examined the association of all-cause mortality and
physical activity carried out 1 to 2 days a week and that generates sufficient
energy expenditure to meet current physical activity recommendations (i.e., the
so-called "weekend warrior" pattern) (34). Overall, the
relative risk for mortality among weekend warriors, compared with sedentary
men, was 0.85 (95% confidence interval [CI], 0.65, 1.11). In stratified
analysis, however, among men without major cardiovascular risk factors, weekend
warriors had a significantly lower risk of dying, compared with sedentary men
(RR = 0.41 [0.21, 0.81]). This was not seen among men with at least 1 major
risk factor (corresponding RR = 1.02 [0.75, 1.38]).
Question 4: What Is the Shape of the Dose-Response
Relation Between Physical Activity and All-Cause Mortality?
Conclusions
The dose-response curve relating different amounts of physical activity
to all-cause mortality rates appears curvilinear. On average across studies,
compared to less than 0.5 hours per week of moderate-to-vigorous physical
activity, engaging in approximately 1.5 hours per week of such activity is
associated with about a 20% reduction in risk. Additional amounts of activity
are associated with additional risk reductions, but at smaller magnitudes, such
that an additional approximately 5.5 hours per week is required to observe a
further 20% in risk (i.e., approximately 7.0 hours per week is associated with
about a 40% reduction in risk, compared with less than 0.5 hour per week).
Rationale
To describe the dose-response curve in detail, studies in which subjects
were classified into at least 5 categories of physical activity were selected.
Eleven studies defined 5 levels of physical activity; one defined 6 levels.
Figure G1.2 shows the dose-response curve for each of the 12 studies. These
categories were defined according to ordinal levels of activity (5;35), the frequency of activity (31), the
time per week spent in physical activity (30), or the
energy expended on physical activity (either as kilocalories per week,
MET-hours per week, or MET-hours per day)(15;17;22;27;36-39). In a first analysis, we did not attempt to quantify
the amount of physical activity, but merely designated these categories as 1 to
6, and plotted the relative risks of all-cause mortality associated with each
of these categories. In general, these studies support a curvilinear shape to
the dose-response curve.
Next, we attempted to synthesize the results across the different
studies to obtain an "average" shape of the dose-response curve. Because the
physical activity categories represented different amounts of physical
activity, we translated them, where possible, into a common measure of hours
per week spent on moderate-to-vigorous physical activity. We excluded from the
analysis the one study that had 6 categories of physical activity because it
used ordinal groupings that did not allow interpretation of the amount of
physical activity. For the remaining studies, we assigned to each of their 5
categories of physical activity the median value of that category, in hours per
week of moderate-to-vigorous physical activity. We plotted the median relative
risk of all-cause mortality against each of these 5 categories of physical
activity.
Figure G1.3 shows that this analysis supports the curvilinear shape
observed for most of the individual studies in Figure G1.2. The largest risk
reduction is seen at the lowest end of the physical activity spectrum, and
additional risk reductions — at smaller magnitudes — are seen at
higher levels of physical activity. On average, it appears that compared to
less than 0.5 hour per week of moderate-to-vigorous physical activity, engaging
in approximately 1.5 hours per week of such activity is associated with about a
20% reduction in risk of all cause mortality. Additional amounts of physical
activity are associated with additional risk reductions, but at smaller
magnitudes, such that an additional approximately 5.5 hours per week are
required to observe a further 20% decline in risk (i.e., approximately 7.0
hours per week is associated with approximately 40% reduction in risk, compared
with less than 0.5 hour per week).
Figure G1.2. Shape of the Dose-Response Curve:
Relative Risks of All-Cause Mortality by Physical Activity Level (Studies With
at Least 5 Levels of Physical Activity)
Figure G1.2. Data Points
Author/Year |
Level 1 |
Level 2 |
Level 3 |
Level 4 |
Level 5 |
Level 6 |
Lee 95 |
1 |
0.88 |
0.92 |
0.87 |
0.87 |
|
Fried 98 |
1 |
0.78 |
0.81 |
0.72 |
0.56 |
|
Kujala 98 |
1 |
0.85 |
0.72 |
0.68 |
0.6 |
|
Wannamethee 98 |
1 |
0.79 |
0.69 |
0.64 |
0.63 |
0.54* |
Lee 00 |
1 |
0.8 |
0.74 |
0.8 |
0.73 |
|
Rockhill 01 |
1 |
0.82 |
0.75 |
0.74 |
0.71 |
|
Tanasescu 03 |
1 |
0.88 |
0.64 |
0.64 |
0.65 |
|
Sundquist 04 |
1 |
0.72 |
0.6 |
0.5 |
0.6 |
|
Trolle-Lagerros 05 |
1 |
0.78 |
0.62 |
0.58 |
0.46 |
|
Carlsson 06 |
1 |
0.49 |
0.43 |
0.41 |
0.39 |
|
Janssen 06 |
1 |
0.87 |
0.77 |
0.54 |
0.63 |
|
Lan 06 |
1 |
0.8 |
0.74 |
0.5 |
0.43 |
|
*Not shown.
Figure G1.3. "Median" Shape of the Dose-Response
Curve
Figure G1.3. Data Points
Hr/wk |
RR |
0.5 |
1 |
1.5 |
0.8 |
3 |
0.73 |
5.5 |
0.64 |
7 |
0.615 |
Question 5: Is the Relation Between Physical Activity
and All Cause Mortality Independent of Adiposity?
Conclusions
The inverse relation between physical activity and all-cause mortality
appears independent of adiposity. Further, this inverse relation appears to
hold regardless of whether subjects are normal weight, overweight, or obese.
Rationale
Debate exists regarding whether adiposity should be adjusted for when
examining the relation between physical activity and all-cause mortality rates.
The argument against adjusting is that adiposity represents one pathway through
which physical activity favorably influences mortality rates; thus, adjustment
for adiposity minimizes the effect of physical activity. Nonetheless, almost
60% of the studies (43 of 73) adjusted their results for BMI or some other
measure of adiposity (e.g., weight or waist-hip ratio). These studies, after
adjustment for adiposity, continued to observe significant, inverse
associations between physical activity and all-cause mortality.
Additionally, a few studies have stratified their findings by BMI, to
examine the relation between physical activity and all-cause mortality among
subjects with different BMI (3;11;39;40). These studies indicate that the
inverse association between physical activity and all-cause mortality holds for
persons who are normal weight, overweight, and obese. For example, among men in
the Harvard Alumni Health Study (39), compared with
inactive and overweight men, those who were active but
overweight had a relative risk of 0.80 (95% CI, 0.71-0.91). Corresponding
results were 0.90 (0.79-1.02) for men who were inactive but of normal
weight, and 0.67 (0.60-0.75) for active and normal weight men. Among
women in the Nurses' Health Study (3), using normal
weight, active women as referent, normal weight women who were
inactive had an elevated relative risk of dying during follow-up, 1.55
(1.42-1.70). Using the same referent, the relative risk for
overweight, active women was 1.28 (1.12-1.46); for overweight,
inactive women, this was 1.64 (1.46-1.83). For obese, active
women, the relative risk was 1.91 (1.60-2.30); for obese and inactive women,
this was 2.42 (2.14-2.73).
Overall Summary and Conclusions
The overall conclusions of this chapter on physical activity and
all-cause mortality may be summarized as the following:
- A large body of scientific evidence, all from observational
epidemiologic studies, exists on the association of physical activity with
all-cause mortality rates.
- The data very consistently show an inverse relation, with the most
active individuals — both men and women — experiencing
approximately a 30% reduction in risk of mortality during follow-up, compared
with the least active.
- The inverse relation extends to older persons, aged 65 years and
older.
- Although this inverse relation has been observed in many countries
throughout the world, the data that are specific to non-white populations are
limited compared to those on white populations. The inverse relation appears to
be similar for both white and non-white populations.
- Studies primarily have assessed leisure-time physical activity,
including walking. There is, however, some evidence to indicate that it may be
the overall volume of energy expended — regardless of
which activities produce this energy expenditure — that is important to
lower the risk of mortality.
- With regard to the minimum amount of physical activity needed, it
appears that at least 2 to 2.5 hours per week of moderate-intensity physical
activity are required to significantly lower all-cause mortality rates. Walking
has been specifically investigated in several studies, and it also appears that
walking at least 2 hours per week is associated with significantly lower
all-cause mortality rates.
- However, this amount — 2 to 2.5 hours per week of
moderate-intensity physical activity — does not represent a minimum
threshold level for risk reduction. The data consistently support an inverse
dose-response relation for the total volume of energy expended, which supports
a "some is good; more is better" message. In particular, the data support a
target of 2 to 2.5 hours per week of moderate-intensity physical activity for
lowering all-cause mortality rates, and encourage any level of activity below
this target for inactive groups of individuals.
- It appears that the shape of the dose-response curve is curvilinear
(see Figure G1.2). On average across studies, compared
to less than 0.5 hour per week of moderate-to-vigorous physical activity,
engaging in approximately 1.5 hours per week of such activity is associated
with about a 20% reduction in risk. Additional amounts of activity are
associated with additional risk reductions, but at smaller magnitudes, such
that another approximately 5.5 hours per week is required to observe a further
20% decline in risk (i.e., approximately 7.0 hours per week is associated with
about a 40% reduction in risk, compared with the risk associated with less than
0.5 hour per week).
- Limited data support vigorous-intensity physical activity being
associated with additional risk reduction, compared with lower intensity
activities, beyond its contribution to the total volume of energy
expended.
- No data are available to inform whether multiple, short bouts of
physical activity versus a single, long bout that expends the same energy are
differentially associated with all-cause mortality rates.
- Finally, the inverse relation between physical activity and
all-cause mortality appears independent of adiposity. Importantly, this inverse
relation appears to hold regardless of whether subjects are normal weight,
overweight, or obese.
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Last revised: June 11, 2008
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