A systematic review of the evidence for Canada's Physical Activity Guidelines for Adults

1479-5868-7-391479-5868 Review A systematic review of the evidence for Canada's Physical Activity Guidelines for Adults WarburtonERDarrendarrenwb@interchange.ubc.ca CharlesworthSarahsacjazz@hotmail.com IveyAdamadamivey@interchange.ubc.ca NettlefoldLindsaylindsay.nettlefold@gmail.com BredinSDShannonbredin@interchange.ubc.ca

Cardiovascular Physiology and Rehabilitation Laboratory, University of British Columbia, Vancouver, Canada

Experimental Medicine Program, Faculty of Medicine, University of British Columbia, Vancouver, Canada

Cognitive and Functional Learning Laboratory, University of British Columbia, Vancouver, Canada

International Journal of Behavioral Nutrition and Physical Activity 1479-5868 2010 7 1 39 http://www.ijbnpa.org/content/7/1/39 10.1186/1479-5868-7-3920459783 247200911520101152010 2010Warburton et al; licensee BioMed Central Ltd.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

This systematic review examines critically the scientific basis for Canada's Physical Activity Guide for Healthy Active Living for adults. Particular reference is given to the dose-response relationship between physical activity and premature all-cause mortality and seven chronic diseases (cardiovascular disease, stroke, hypertension, colon cancer, breast cancer, type 2 diabetes (diabetes mellitus) and osteoporosis). The strength of the relationship between physical activity and specific health outcomes is evaluated critically. Literature was obtained through searching electronic databases (e.g., MEDLINE, EMBASE), cross-referencing, and through the authors' knowledge of the area. For inclusion in our systematic review articles must have at least 3 levels of physical activity and the concomitant risk for each chronic disease. The quality of included studies was appraised using a modified Downs and Black tool. Through this search we identified a total of 254 articles that met the eligibility criteria related to premature all-cause mortality (N = 70), cardiovascular disease (N = 49), stroke (N = 25), hypertension (N = 12), colon cancer (N = 33), breast cancer (N = 43), type 2 diabetes (N = 20), and osteoporosis (N = 2). Overall, the current literature supports clearly the dose-response relationship between physical activity and the seven chronic conditions identified. Moreover, higher levels of physical activity reduce the risk for premature all-cause mortality. The current Canadian guidelines appear to be appropriate to reduce the risk for the seven chronic conditions identified above and all-cause mortality.

Evidence Informing Updates to Canada's Physical Activity Guidelines Mark Tremblay

Introduction

There is considerable literature supporting the importance of habitual physical activity in the primary and secondary prevention of varied chronic conditions 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 . Routine physical activity is thought to be of benefit for over 25 chronic conditions 17 . Seven chronic diseases in particular have been associated with a physically inactive lifestyle including coronary artery disease, stroke, hypertension, colon cancer, breast cancer, type 2 diabetes (diabetes mellitus) and osteoporosis 18 19 20 .

Canada has played a leading role in the development of physical activity guidelines for individuals across the lifespan. This includes the development (in 1998) of "Canada's Physical Activity Guide to Healthy Active Living" for adults between the ages of 20 and 55 yr 21 , which was followed by "Canada's Physical Activity Guide to Healthy Active Living for Older Adults" 22 , and "Canada's Physical Activity Guide to Healthy Active Living for Children and Youth" 23 . The adult guidelines (which are now approximately 10 years old) state generally that 20-55 yr adults should accumulate 60 min of daily physical activity or 30 min of moderate to vigorous exercise on at least 4 days a week 18 19 .

We reported recently that Canada's adult guidelines were consistent with other international guidelines and were supported by a compelling body of literature 18 19 . We revealed strong evidence that routine physical activity was effective in the primary prevention of cardiovascular disease, stroke, hypertension, breast cancer, colon cancer, type 2 diabetes and osteoporosis. Moreover, physical activity appears to play an important role in the prevention of obesity and obesity-related co-morbidities. However, implicit in the adult guidelines is the belief that there is a dose-response relationship between physical activity and the associated health benefits. Moreover, a central belief in these guidelines and most international physical activity guidelines is that the dose-response relationship is curvilinear with the greatest health benefits seen in physically inactive individuals who become "more physically active." In fact, a consistent pattern (shown in Figure 1) has been hypothesized, wherein there are marked changes in health status with relatively minor increments in physical activity/fitness in individuals that are the least active/fit. Generally, the health benefits have been thought to level off at the upper end of the physical activity/fitness continuum (Figure 1). However, recent work (such as that provided by Gledhill and Jamnik in the Canadian Physical Activity and Lifestyle Approach) has speculated that there are likely multiple dose-response curves for various endpoints 24 .

Figure 1

Theoretical relationship between the risk for chronic disease and physical activity/fitness

Theoretical relationship between the risk for chronic disease and physical activity/fitness.

The primary purpose of this systematic review was to examine critically the current literature to determine whether or not a dose-response relationship exists between habitual physical activity and chronic disease. In particular, we sought to determine whether the key messaging "Every little bit counts, but more is even better - everyone can do it!" of the adult physical activity guidelines is supported by a strong body of evidence.

Due to the breadth of literature, we have chosen to focus on the relationship between physical activity and all-cause mortality, and the seven chronic conditions that are thought to be reduced greatly with habitual physical activity (i.e., cardiovascular disease (excluding stroke), stroke, hypertension, colon cancer, breast cancer, type 2 diabetes and osteoporosis) (see Table 1). Owing to the nature of the physical activity guidelines, the emphasis of this paper was on primary prevention, despite the clear evidence that routine physical activity is also an effective secondary preventative strategy against many chronic conditions 16 18 19 . Accordingly, our primary objectives were to examine the evidence for a dose-response relationship between: 1) physical activity and all-cause mortality, and 2) physical activity and incidence of the following chronic conditions (cardiovascular disease (except stroke), stroke, hypertension, type 2 diabetes, colon cancer, breast cancer, and osteoporosis.

Table 1

Relative risks (RR) and population attributable risks (PAR%) for physical inactivity in Canada, Australia, and the USA.

Canada

Australia

USA

Disease

PAR%

CHD

1.45

19.4

1.5

2.0

Stroke

1.60

24.3

2.0

Hypertension

1.30

13.8

1.5

Colon Cancer

1.41

18.0

1.5

2.0

Breast Cancer

1.31

14.2

1.1

1.2

Type 2 Diabetes

1.50

21.1

1.3

1.5

Osteoporosis

1.59

24.0

1.4*

18*

2.0

18*

Source: Canadian Data 20; Australian Data 161; US Data: 162. *Evaluated the incidence of falls/fractures.

Methods

Criteria for considering studies for this review

Our research team utilized a rigorous, systematic, and evidence-based approach to examine critically the levels of evidence on physical activity and the risk for premature mortality and chronic disease. Any studies that evaluated the relationship between at least

three

different levels of physical activity and mortality or incidence of chronic disease were eligible for inclusion. Therefore, excluded studies included those that examined only the most active versus least active populations (e.g., sedentary/inactive vs. physically active). Any form of physical activity/exercise measurement (e.g., self-report, pedometer, accelerometer, maximal aerobic power (VO₂max)) was eligible for inclusion. The key outcomes were mortality and incidence of chronic disease. Only published, English language studies examining adults (e.g., 19-65 yr) were included. Participants must have previously been healthy (asymptomatic) adults without established chronic disease. There was no restriction according to study design.

To examine the relative risk reductions associated with physical activity, we calculated the mean and median risk reductions across studies focusing on the highest level versus the lowest level of physical activity/fitness. For each study we also determined whether or not a dose-response relationship was present (i.e., reflecting a progressive decrease in the risk with increasing physical activity/fitness levels).

Search strategy

Literature searches were conducted in the following electronic bibliographical databases:

• MEDLINE (1950-March 2008, OVID Interface);

• EMBASE (1980- March 2008, OVID Interface),

• CINAHL (1982- March 2008, OVID Interface);

• PsycINFO (1840- March 2008, Scholars Portal Interface);

• Cochrane Library (-March 2008),

• SPORTDiscus (-March 2008).

The Medical Subject Headings (MeSH) were kept broad. See tables 2, 3, 4, 5, 6, 7, 8 and 9 for the complete search strategy and keywords used. The electronic search strategies were created and carried out by researchers experienced with systematic reviews of the literature (DW and LN). The citations and applicable electronic versions of the article (where available) were downloaded to an online research management system (RefWorks, Bethesda, Maryland, USA).

Table 2

Results of the MEDLINE literature search regarding all-cause mortality.

Searches (28 Feb 2008)

Results

exp Physical Fitness/

15236

Motor Activity/

49721

exp Physical Endurance/

15383

exp Exercise/

57742

exp Exertion/

88903

exp Sports/

71887

exp exercise therapy/

17231

exp exercise tolerance/

4192

exp health behaviour/

59409

leisure time physical activity.mp

996

occupational physical activity.mp

190

exp Pliability/

2279

exp Muscle Strength/

5717

musc$ power.mp

965

exp Back/

12821

1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15

291635

dose-response.mp

321066

intensity.mp

142881

volume.mp

298471

exp Energy Metabolism/

206808

exp oxygen consumption/

83352

exp time factors/

763712

17 or 18 or 19 or 20 or 21 or 22

1651633

16 and 23

67698

exp Mortality/

190058

all cause mortality.mp

4618

25 or 26

192720

24 and 27

421

limit 28 to (english and humans and "all adult (19 plus years)

279

Table 3

Results of the MEDLINE literature search regarding cardiovascular disease.

Search #

Searches (3 Mar 2008)

Results

exp Physical Fitness/

15244

Motor Activity/

49751

exp Physical Endurance/

15408

exp Exercise/

57806

exp Exertion/

88967

exp Sports/

71931

exp exercise therapy/

17243

exp exercise tolerance/

4205

exp health behaviour/

59467

leisure time physical activity.mp

998

occupational physical activity.mp

191

exp Pliability/

2289

exp Muscle Strength/

5731

musc$ power.mp

965

exp Back/

12822

1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15

291817

dose-response.mp

321198

intensity.mp

142955

volume.mp

298620

exp Energy Metabolism/

206886

exp oxygen consumption/

83387

exp time factors/

764091

17 or 18 or 19 or 20 or 21 or 22

1652372

16 and 23

67760

exp Cardiovascular Diseases/

1411730

exp Heart diseases/

675083

exp Myocardial infarction/

116070

exp Death, Sudden Cardiac/

6772

exp Coronary Artery Disease/

18137

exp Coronary Disease/

144236

exp Vascular Diseases

1018275

25 or 26 or 27 or 28 or 29 or 30 or 31

1411730

24 and 32

9603

limit 33 to (english language and humans and "all adult (19 plus years)")

5544

Table 4

Results of the MEDLINE literature search regarding stroke.

Search #

Searches (29 Feb 2008)

Results

exp Physical Fitness/

15241

Motor Activity/

49744

exp Physical Endurance/

15387

exp Exercise/

57764

exp Exertion/

88921

exp Sports/

71907

exp exercise therapy/

17237

exp exercise tolerance/

4196

exp health behaviour/

59430

leisure time physical activity.mp

996

occupational physical activity.mp

190

exp Pliability/

2288

exp Muscle Strength/

5720

musc$ power.mp

965

exp Back/

12821

1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15

291718

dose-response.mp

321133

intensity.mp

142919

volume.mp

298526

exp Energy Metabolism/

206837

exp oxygen consumption/

83359

exp time factors/

763871

17 or 18 or 19 or 20 or 21 or 22

1651958

16 and 23

67720

exp Stroke/

45243

exp Cerebrovascular Disorders/

196243

exp Brain Ischemia/

58943

exp Brain Infarction/ or exp Cerebral Infarction

21357

exp Infarction, Middle Cerebral Artery/ or exp Intracranial Aneurysm/ or exp Subarachnoid

46725

Hemorrhage/ or exp Cerebral Hemorrhage/exp Ischemic Attack, Transient/

14753

25 or 26 or 27 or 28 or 29 or 30

196243

24 and 31

692

limit 32 to (english language and humans and "all adult (19 plus years)")

291

Table 5

Results of the MEDLINE literature search regarding hypertension.

Search #

Searches (3 Mar 2008)

Results

exp Physical Fitness/

15244

Motor Activity/

49751

exp Physical Endurance/

15408

exp Exercise/

57806

exp Exertion/

88967

exp Sports/

71931

exp exercise therapy/

17243

exp exercise tolerance/

4205

exp health behaviour/

59467

leisure time physical activity.mp

998

occupational physical activity.mp

191

exp Pliability/

2289

exp Muscle Strength/

5731

musc$ power.mp

965

exp Back/

12822

1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15

291817

dose-response.mp

3211987

intensity.mp

142955

volume.mp

298620

exp Energy Metabolism/

206886

exp oxygen consumption/

83387

exp time factors/

764091

17 or 18 or 19 or 20 or 21 or 22

1652372

exp Hypertension/

168466

exp Blood Pressure/

205571

exp Blood Pressure Determination/ or exp Blood Pressure Monitoring, Ambulatory/ or exp Blood

18244

Pressure Monitors/24 or 25 or 26

336025

16 and 23 and 27

5647

limit 28 to (english language and humans and "all adult (19 plus years)")

3642

Table 6

Results of the MEDLINE literature search regarding colon cancer.

Search #

Searches (3 Mar 2008)

Results

exp Physical Fitness/

15244

Motor Activity/

49751

exp Physical Endurance/

15408

exp Exercise/

57806

exp Exertion/

88967

exp Sports/

71931

exp exercise therapy/

17243

exp exercise tolerance/

4205

exp health behaviour/

59467

leisure time physical activity.mp

998

occupational physical activity.mp

191

exp Pliability/

2289

exp Muscle Strength/

5731

musc$ power.mp

965

exp Back/

12822

1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15

291817

dose-response.mp

321198

intensity.mp

142955

volume.mp

298620

exp Energy Metabolism/

206886

exp oxygen consumption/

83387

exp time factors/

764091

17 or 18 or 19 or 20 or 21 or 22

1652372

exp Colonic Neoplams/

51780

exp Rectal Neoplasms/

28011

exp Colorectal Neoplasms/

99982

exp Colorectal Neoplasms/, Hereditary Nonpolyposis/ or exp Intestinal Neoplasms.

117563

24 or 25 or 26 or 27

117563

16 and 23 and 28

108

limit 29 to (53nglish language and humans and "all adult (19 plus years)")

Table 7

Results of the MEDLINE literature search regarding breast cancer.

Search #

Searches (28 Feb 2008)

Results

exp Physical Fitness/

15236

Motor Activity/

49721

exp Physical Endurance/

15383

exp Exercise/

57742

exp Exertion/

88903

exp Sports/

71887

exp exercise therapy/

17231

exp exercise tolerance/

4192

exp health behaviour/

59409

leisure time physical activity.mp

996

occupational physical activity.mp

190

exp Pliability/

2279

exp Muscle Strength/

5717

musc$ power.mp

965

exp Back/

12821

1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15

291635

dose-response.mp

321066

intensity.mp

142881

volume.mp

298471

exp Energy Metabolism/

206808

exp oxygen consumption/

83352

exp time factors/

763712

17 or 18 or 19 or 20 or 21 or 22

1651633

exp Breast Neoplasms/

149817

16 and 23 and 24

296

limit 25 to (54 nglish language and humans and "all adult (19 plus years)"

216

Table 8

Results of the MEDLINE literature search regarding type 2 diabetes.

Search #

Searches (29 Feb 2008)

Results

exp Physical Fitness/

15241

Motor Activity/

49744

exp Physical Endurance/

15387

exp Exercise/

57764

exp Exertion/

88921

exp Sports/

71907

exp exercise therapy/

17237

exp exercise tolerance/

4196

exp health behaviour/

59430

leisure time physical activity.mp

996

occupational physical activity.mp

190

exp Pliability/

2288

exp Muscle Strength/

5720

musc$ power.mp

965

exp Back/

12821

1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15

291718

dose-response.mp

321133

intensity.mp

142919

volume.mp

298526

exp Energy Metabolism/

206837

exp oxygen consumption/

83359

exp time factors/

763871

17 or 18 or 19 or 20 or 21 or 22

1651958

16 and 23

67720

exp Blood Glucose/or exp Diabetes Mellitus, Type 2/

132583

exp Hyperglycemia/

16214

exp Glucose Intolerance/ or exp Glucose Tolerance Test/

24986

exp Hyperinsulinism/

30490

25 or 26 or 27 or 28

165157

29 and 24

3006

Limit 30 to (english language and humans and "all adult (19 plus years)")

1985

Table 9

Results of the MEDLINE literature search regarding osteoporosis.

Search #

Searches (29 feb 2008)

Results

exp Physical Fitness/

15241

Motor Activity/

49744

exp Physical Endurance/

15387

exp Exercise/

57764

exp Exertion/

88921

exp Sports/

71907

exp exercise therapy/

17237

exp exercise tolerance/

4196

exp health behaviour/

59430

leisure time physical activity.mp

996

occupational physical activity.mp

190

exp Pliability/

2288

exp Muscle Strength/

5720

musc$ power.mp

965

exp Back/

12821

1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15

291718

dose-response.mp

321133

intensity.mp

142919

volume.mp

298526

exp Energy Metabolism/

206837

exp oxygen consumption/

83359

exp time factors/

763871

17 or 18 or 19 or 20 or 21 or 22

1651958

exp Osteoporosis, Postmenopausal/ or exp Osteoporosis/

31532

exp Fractures, Bone/ or exp Bone Density/

125269

exp Bone Diseases/ or exp Bone Diseases, Metabolic/

308084

exp "Bone and bones"/

369634

exp Tensile Strength/

12050

exp Compressive Strength

2838

24 or 25 or 26 or 27 or 28 or 29

642158

16 and 23 and 30

2138

limit 31 to (english language and humans and "all adult (19 plus years)")

1193

Screening

Two reviewers (LN and SC) screened independently the title and abstract of the citations to identify potential articles for inclusion. Duplicate citations were removed. The reviewers were not blinded to the authors or journals. Biographies of key studies and reviews in the field were also cross-referenced for further articles. For those articles that appeared relevant, the full text was obtained and data was extracted using a common template. In cases of disagreement, discussion with a third reviewer (DW) was used to achieve consensus. Full (100%) consensus was achieved. All studies that were excluded during the citation and full-article screening processes were recorded along with the reasons for exclusion.

Data Extraction

Two reviewers (LN and SC) completed standardized data extraction forms, which were verified by two other reviewers (DW and SB). We extracted information regarding the study design, the country where the study was conducted, the participant characteristics, the sample size, the objectives of the study, the methodologies employed, the major outcomes (i.e., mortality, incidence of chronic disease, physical activity levels/classifications), and the comments and conclusions made based on the findings of the study. The reviewers were not blinded to the journal or the author names when extracting information from the articles.

Level of Evidence

The approach used to establish the level and grade of evidence was consistent with that used during creation of the "Canadian clinical practice guidelines on the management and prevention of obesity in adults and children" 25 . The level of evidence provides information regarding the strength of the evidence in favour of physical activity/exercise in the primary prevention of premature mortality and the seven chronic diseases of primary interest. This evaluation process is based on a pre-defined and objective criteria (see Table 10).

Table 10

The levels and grade of evidence scaling criteria applied to the articles.

Level of Evidence

Criteria

Level 1

Randomized control trials without important limitations

Level 2

• Randomized control trials with important limitations

• Observational studies (non-randomized clinical trials or cohort studies) with overwhelming evidence

Level 3

Other observational studies (prospective cohort studies, case-control studies, case series)

Level 4

Inadequate or no data in population of interest

Anecdotal evidence or clinical experience

Grade of Evidence

Criteria

Grade A

Strong recommendation (action can apply to most individuals in most circumstances)

• Benefits clearly outweigh risks (or vice-versa)

• Evidence is at Level 1, 2, or 3

Grade B

Weak recommendation (action may differ depending on individual's characteristics or other circumstances)

• Unclear if benefits outweigh risks

• Evidence is at Level 1, 2, or 3

Grade C

Consensus recommendation (alternative actions may be equally reasonable)

• Unclear if benefits outweigh risks

• Evidence is at Level 3 or 4

The grade for each article provides information regarding whether physical activity is effective in the primary prevention of the varied conditions evaluated (Table 10). Where applicable this grade informs the reader about the potential risk of the physical activity. A study that receives the highest grading would indicate that the benefits clearly outweigh the risks and receive a strong recommendation.

Quality Assessment

The quality of each study was also established using the procedures of Gorber et al. 26 . Owing to the fact that only observational study designs were included in our systematic review, we used the Downs and Black 27 scale to assess the quality of non-randomized investigations. Similar to the work of Prince et al. 28 we chose to include the most relevant components of the scoring tool. Therefore, a modified version of the Downs and Black checklist was used with the final checklist consisting of 15 items with a maximum score of 15 points. Higher points reflected a superior quality of investigation.

Results

Physical Inactivity and All-Cause Mortality

A total of 2040 citations were identified during the electronic database search (Figure 2). Of these citations, 288 were identified in MEDLINE, 222 in EMBASE, 496 in Cochrane, and 1034 in the CINAHL/SportDiscus/PsychInfo search. A total of 167 duplicates were found, leaving a total of 1873 unique citations. A total of 1696 articles were excluded after scanning, leaving a total of 177 articles for full review. From these articles 130 were excluded after full review leaving 47 articles for inclusion in the systematic review. An additional 23 articles were added to the review based on the authors' knowledge of the area. The reasons for exclusion included review articles (n = 26), commentary (n = 10), did not report 3 levels of physical activity (n = 24), no objective measure of physical activity (n = 2), report (n = 15), not a formal study (n = 11), not related to all-cause mortality (n = 27), the participants were too young (n = 1), not able to retrieve articles (n = 7), and other (n = 7). Therefore, a total of 70 articles were included in the systematic review of the literature regarding the relationship between physical activity and premature mortality.

Figure 2

Results of the Literature Search for All-Cause Mortality

Results of the Literature Search for All-Cause Mortality.

The majority of the studies included in our systematic review were prospective cohort investigations (Table 11). These studies involved a total of 1,525,377 participants; averaging 21,791 participants per study (range 302-252,925). There were a total of 111,125 reported cases of premature all-cause mortality (ranging per study from 43-10,952). The total length of study follow-up for the prospective cohort studies averaged 11.1 yr (ranging from 0.5-28 yr). The articles were published over a 22 yr period ranging from 1985 to 2007. These studies involved large samples of men and women from regions throughout the world.

Table 11

Studies examining the relationship between physical activity and all-cause mortality.

Publication Country Study Design Quality Score

Objective

Population

Methods

Outcome

Comments and Conclusions

Blair et al 1989 7

To study physical fitness (PF) and risk of all-cause mortality in men and women.

• n = 13,344 (10,224 men; 3,120 women)

Baseline and 8 year follow-up

• 283 deaths

Low levels of PF increase the risk for premature mortality.

• Sex: Men and women

Adjusted risk ratio (RR), 95% confidence interval (CI)

USA

• Age: 20->60 years (yr)

PF assessment: Maximal treadmill exercise test.

Prospective cohort

• Characteristics: Participants were given a preventative Medicine examination including maximal treadmill exercise test

Fitness categorized into quintiles:

Men

D & B score = 12

Q1 = least fit

• Q1 = 3.44 (2.05-5.77)

• Q2 = 1.37 (0.76-2.50)

• Q3 = 1.46 (0.81-2.63)

• Q4 = 1.17 (0.63-2.17)

Q5 = most fit

• Q5 = 1.00 (referent)

Women

• Q1 = 4.65 (2.22-9.75)

• Q2 = 2.42 (1.09-5.37)

• Q3 = 1.43 (0.60-3.44)

• Q4 = 0.76 (0.27-2.11)

• Q5 = 1.00 (referent)

Myers et al 2004 32

To determine the effects of PF and physical activity (PA) on all-cause mortality.

• n = 6,213

Baseline and mean 5.5 ± 2.0 year follow-Up

• 1,256 deaths

Being fit or active is associated with >50% reductions in mortality risk.

• Sex: Men

USA

• Age: Mean 59.0 ± 11.2 yr

PF Level hazard ratio (HR) (95% CI)

• Characteristics: Men referred for exercise testing

PF assessment: Treadmill test to measure VO₂peak

• G1 = 1.00 (referent)

PF predicted mortality more strongly than PA.

Prospective cohort

• G2 = 0.59 (0.52-0.68)

• G3 = 0.46 (0.39-0.55)

• G4 = 0.28 (0.23-0.34)

Increasing PA (by 1000 kcal/wk or 1 MET) confers a mortality benefit of 20%.

D & B score = 12

PA assessment: Self reported PA divided into 4 groups

PA Level HR (95% CI)

G1 = Lowest level

• G1 = 1.00 (referent)

• G2 = 0.63 (0.36-1.10)

• G3 = 0.42 (0.23-0.78)

G4 = Highest level

• G4 = 0.38 (0.19-0.73)

Blair et al 1995 36

To evaluate the relationship between changes in PF and risk of mortality in men.

• n = 9,777

4.9 year mean follow-up

• 223 deaths

Men who maintained or increased adequate PF had a reduced risk for all-cause mortality than individuals who were consistently unfit.

• Sex: Men

• Age: 20-82 yr

RR (95% CI)

USA

• Characteristics: Participants were given a preventative medicine examination including maximal treadmill exercise test

PF assessment: Maximal exercise test at baseline and follow-up

• G1 = 1.00 (referent)

Prospective cohort

• G2 = 0.56 (0.41-0.75)

• G3 = 0.52 (0.38-0.70)

• G4 = 0.33 (0.23-0.47)

D & B score = 13

Groups based on changes in PF

G1 = unfit to unfit

G2 = unfit to fit

G3 = fit to unfit

G4 = fit to fit

Bijnen et al 1999 37

To examine the association of PA at baseline and 5 years

• n = 472

1985 and 1990

• 118 deaths

Recent levels of PA were more important for mortality risk than PA 5 years previously.

• Sex: Men

• Age: >65 yr

PA assessment: Questionnaire, divided into tertiles: Lowest Middle Highest

Multivariate adjusted RR (95% CI)

Netherlands

previously with all- cause mortality risk in a cohort of elderly Dutch men.

• Characteristics: Mostly independently living elders (~95%)

PA in 1985: Lowest tertile = 1.00 (referent) Middle tertile

Retrospective cohort

• Zutphen Elderly Study

• Total activity = 1.25 (0.79- 1.99)

Becoming or remaining sedentary increased the mortality risk.

D & B score = 12

• Walking = 0.97 (0.60-1.57)

• Bike = 0.97 (0.59-1.57)

• Gardening = 0.66 (0.39-1.10)

• Other = 1.08 (0.66-1.78)

• Heavy activity = 0.73 (0.45-1.17)

• Non heavy activity = 0.89 (0.57-1.40)

Highest tertile

• Total activity = 1.25 (0.73-2.12)

• Walking = 0.94 (0.58-1.55)

• Bike = 1.07 (0.61-1.88)

• Gardening = 0.77 (0.42-1.39)

• Other = 1.24 (0.74-2.07)

• Heavy activity = 0.76 (0.44-1.32)

• Non heavy activity = 0.94 (0.58-1.53)

PA in 1990:

Lowest tertile = 1.00 (referent)

Middle tertile

• Total activity = 0.56 (0.35-0.89)

• Walking = 0.82 (0.51-1.32)

• Bike = 0.49 (0.29-0.82)

• Gardening = 1.67 (1.00-2.79)

• Other = 0.93 (0.53-1.65)

• Heavy activity = 1.19 (0.73-1.92)

• Non heavy activity = 0.61 (0.38-0.99)

Highest tertile

• Total activity = 0.44 (0.25-0.80)

• Walking = 1.17 (0.70-1.96)

• Bike = 0.43 (0.23-0.80)

• Gardening = 1.03 (0.55-1.94)

• Other = 0.74 (0.44-1.23)

• Heavy activity = 0.72 (0.40-1.31)

• Non heavy activity = 0.65 (0.40-1.05)

Gregg et al 2003 39

To examine the relationship of changes in PA and mortality among older women.

• n = 9,518

Baseline (1986-1988) and median 10.6 year follow-up (1992-1994)

• 2,218 deaths

Increasing and maintaining PA levels could lengthen life for older women but appears to provide less benefit for women aged at least 75 years and those with poor health status.

• Sex: Women

PA Assessment: Questionnaire, divided into quintiles of PA (kcal/wk)

• Age: ≥ 65 yr

Multivariate adjusted HRR

USA

• Characteristics: White community dwelling participants from 4 US research centres

(95% CI): Quintiles of total

Q1= <163

Prospective cohort

Q2 = 163-503

• Q1 = 1.00 (referent)

Q3 = 504-1045

• Q2 = 0.73 (0.64-0.82)

Q4 = 1046-1906

• Q3 = 0.77 (0.68-0.87)

D & B score = 13

Q5 = ≥ 1907

• Q4 = 0.62 (0.54-0.71)

• Q5 = 0.68 (0.59-0.78)

Walking HRR (95% CI)

• Q1 = 1.00 (referent)

Quintiles of walking(kcal/wk)

• Q2 = 0.91 (0.81-1.02)

Q1 = <70

• Q3 = 0.78 (0.68-0.88)

Q2 = 70-186

• Q4 = 0.71 (0.63-0.82)

Q3 = 187-419

• Q5 = 0.71 (0.62-0.82)

Q4 = 420-897

Q5 = 898

Multivariate adjusted HRR (95% CI)

Change in activity level: Sedentary at baseline

• Staying sedentary = 1.00 (referent)

• Became active = 0.52 (0.40-0.69)

Mod / high active at baseline

• Became sedentary = 0.92 (0.77-1.09)

• Stayed active = 0.68 (0.56-0.82)

Wannamethee et al 1998 40

To study the relationship between heart rate, PA and all- cause mortality.

• n = 5,934

Baseline (1978-1980) and 12-14 year follow-up

• 219 deaths

Maintaining or taking up light or moderate PA reduces mortality in older men.

• Sex: Men

• Age: Mean 63 yr

Multivariate adjusted RR (95% CI),

• Characteristics: Healthy, sedentary(4,311 were considered "healthy" in 1992)

PA assessment: Questionnaire, split into groups

Prospective cohort

• The British Regional Heart Study

• G1 = 1.00 (referent)

• G2 = 0.61 (0.43-0.86)

• G3 = 0.50 (0.31-0.79)

D & B score = 12

PA score

• G4 = 0.65 (0.45-0.94)

G1 =

Inactive/occasional

Regular walking

G2 = Light

• G1 = 1.00 (referent)

G3 = Moderate

• G2 = 1.15 (0.73-1.79)

G4 = Moderately

• G3 = 1.06 (0.75-1.50)

vigorous/Vigorous

• G4 = 0.97 (0.65-1.46)

Regular walking (min/d)

• G5 = 0.62 (0.37-1.05)

G1 = 0

Recreational activity

G2 = <20

• G1 = 1.00 (referent)

G3 = 21-40

• G2 = 0.95 (0.43-1.07)

G4 = 41-60

• G3 = 0.68 (0.43-1.07)

G5 = ≥ 60

• G4 = 0.34 (0.35-1.00)

Recreational activity, 4 groups

Sporting activity

G1 = Inactive/fairly Inactive

• G1 = 1.00 (referent)

G2 = Average 4 hr/weekend

• G2 = 0.50 (0.25-1.03)

G3 = Fairly active >4 h/weekend

• G3 = 0.88 (0.64-1.23)

G4 = Very active

Sporting activity, 3 Groups

G1 = None

G2 = Occasional

G3 = >1 time/month

Paffenbarger et al 1986 63

To examine the PA and life-style characteristics of Harvard alumni for the relationship with all-cause mortality.

• n = 16,936

12-16 year follow-up (1962 to 1978)

• 1,413 deaths

The findings suggest a protective effect of exercise against all-cause mortality.

• Sex: Men

Age adjusted RR (95% CI):

• Age: 35-74

USA

• Characteristics: Harvard alumni

Records of freshman year physical examinations and records of intercollegiate sport

Those who walked

Prospective cohort

• G1 = 1.00 (referent)

• G2 = 0.85

• G3 = 0.79

D & B score = 14

Trend p = 0.0009

PA assessment: Mailed questionnaires surveying post college

Physical Activity Index (95% CI):

• G1 = 1.00 (referent)

• G2 = 0.78

• G3 = 0.73

• G4 = 0.63

Exercise reported: Walking (miles/wk) 3

• G5 = 0.62

groups

• G6 = 0.52

G1 = <3

• G7 = 0.46

G2 = 3-8

• G8 = 0.62

G3 = ≥ 9

Trend p = <0.0001

PA index (kcal/wk) 3 groups:

G1 = <500

G2 = 500-999

G3 = 1000-1499

G4 = 1500-1999

G5 = 2000-2499

G6 = 2500-2999

G7 = 3000-3499

G8 = >3500

Cox proportional hazard models

Schnohr et al 2007 64

To determine the impact of walking duration and intensity on all-cause mortality.

• n = 7,308 (3,204 male; 4,104 female)

Baseline and an average of 12 year

• 1,391 deaths

The findings indicate that the relative intensity and not duration of walking is the most important in relation to all-cause mortality.

Denmark

• Sex: Male and female

follow-up

Multivariate adjusted HR (95% CI):

• Age: 20-93 yr

PA assessment: Questionnaire, 4 durations and 3 intensities

Prospective cohort

• Characteristics: Participants with no history of CHD, stroke or cancer and who had no difficulty in walking

Men

D & B score = 12

• The Copenhagen City Heart Study

• G1 = 1.00 (referent)

• G2 = 0.38 (0.25-0.58)

• G3 = 0.38 (0.18-0.79)

Duration (hours/day)

• G4 = 0.69 (0.44-1.07)

1 = <0.5

• G5 = 0.37 (0.26-0.54)

2 = 0.5-1

• G6 = 0.33 (0.18-0.61)

3 = 1-2

• G7 = 0.78 (0.50-1.23)

4 = >2

• G8 = 0.41 (0.29-0.59)

• G9 = 0.33 (0.20-0.54)

Intensity

• G10 = 0.43 (0.22-0.82)

Slow intensity (SI)

• G11 = 0.42 (0.29-0.60)

Average intensity (AI)

• G12 = 0.28 (0.16-0.48)

Fast intensity (FI)

Women

12 groups

• G1 = 1.00 (referent)

G1 = 1 and SI

• G2 = 0.82 (0.52-1.29)

G2 = 1 and AI

• G3 = 0.78 (0.27-2.21)

G3 = 1 and FI

• G4 = 1.22 (0.82-1.81)

G4 = 2 and SI

• G5 = 0.74 (0.52-1.05)

G5 = 2 and AI

• G6 = 0.56 (0.33-0.96)

G6 = 2 and FI

• G7 = 0.94 (0.60-1.47)

G7 = 3 and SI

• G8 = 0.87 (0.61-1.23)

G8 = 3 and AI

• G9 = 0.48 (0.28-0.83)

G9 = 3 and FI

• G10 = 0.88 (0.40-1.88)

G10 = 4 and SI

• G11 = 0.64 (0.44-0.95)

G11 = 4 and AI

• G12 = 0.38 (0.21-0.69)

G12 = 4 and FI

Kushi et al 1997 65

To evaluate the association between PA and all-cause mortality in postmenopausal women.

• n = 40,417

7 year follow-up

• 2,260 deaths

The results demonstrate a graded inverse association between PA and all-cause mortality in postmenopausal women.

• Sex: Women

• Age: 55-69 yr

PA assessment: Questionnaire for frequency of moderate and vigorous LTPA

Multivariate adjusted Frequency of moderate PA per week RR (95% CI):

USA

• Characteristics: Postmenopausal Iowa women

Prospective cohort

• G1 = 1.00 (referent)

• G2 = 0.71 (0.63-0.79)

D & B score = 13

Divided by frequency/week

• G3 = 0.63 (0.56-0.71)

• G4 = 0.59 (0.51-0.67)

G1 = Rarely/never

Trend p = <0.001

G2 = 1 time/week to a few times/month

Frequency of vigorous PA per week

G3 = 2-4 times/week

G4 = >4 times/week

• G1 = 1.00 (referent)

• G2 = 0.83 (0.69-0.99)

• G3 = 0.74 (0.59-0.93)

Activity index

• G4 = 0.62 (0.42-0.90)

G1 = Low

Trend p = 0.009

G2 = Medium

G3 = High

• G1 = 1.00 (referent)

• G2 = 0.77 (0.69-0.86)

• G3 = 0.68 (0.60-0.77)

Trend p = <0.001

Paffenbarger et al 1993 67

To analyze changes in the lifestyles of Harvard College alumni and the association of these changes with mortality.

• n = 10,269

Baseline (1977) and 8 year follow-up (1985)

• 476 deaths

Beginning moderately vigorous sports activity was associated with lower rates of death from all causes among middle aged and older men.

• Sex: Men

• Age: 45-84 yr (in 1977)

Beginning moderate sports activity was associated with 23% lower risk of death (95% CI 4%-42%, p = 0.015) than those not taking up moderate activity

USA

• Characteristics: Participants with no reported life- threatening disease

PA Assessment: Questionnaire -- blocks walked daily, stairs climbed daily and type, frequency and duration of weekly sports and recreational activities

Prospective cohort

D & B score = 13

Physical activity index (kcal/wk)

Sports and recreational activities

Light <4.5 METs

Moderate >4.5 METs

Weekly lists of deaths were obtained from the Harvard college alumni office

Proportional hazard models with Poisson regression methods

Katzmarzyk and Craig 2002 154

To quantify the relationship between musculoskeletal fitness and all-cause mortality.

• n = 8,116 (3,933 male; 4,183 female)

Baseline (1981) and

• 238 deaths

Some components of musculoskeletal fitness are predictive of mortality.

13 year follow-up

• Sex: Men and women

RR (95% CI) adjusted for age, smoking status, body mass and VO_2max

Canada

Musculoskeletal fitness (sit ups, push ups, grip strength, sit and reach) measures divided into quartiles

• Age: 20-69 yr

Q1 = lowest

Sit ups

Prospective cohort

• Characteristics: Participants who had musculoskeletal fitness measurements taken

Men

• Q1 = 2.72 (1.56-4.64)

Q4 = highest

• Q2 = 1.32 (0.73-2.41)

D & B score = 11

• Q3 = 1.61 (0.90-2.87)

• Q4 = 1.00 (referent)

• Canadian Fitness Survey

Cox proportional hazard ratio model

Women

• Q1 = 2.26 (1.15-4.43)

• Q2 = 2.24 (1.07-4.67)

• Q3 = 1.27 (0.59-2.72)

• Q4 = 1.00 (referent)

Push-ups

Men

• Q1 = 1.25 (0.77-2.05)

• Q2 = 1.17 (0.71-1.90)

• Q3 = 0.94 (0.55-1.62)

• Q4 = 1.00 (referent)

Women

• Q1 = 0.61 (0.32-1.17)

• Q2 = 0.81 (0.45-1.47)

• Q3 = 0.87 (0.48-1.58)

• Q4 = 1.00 (referent)

Grip strength (kg)

Men

• Q1 = 1.49 (0.86-2.59)

• Q2 = 1.42 (0.82-2.45)

• Q3 = 1.59 (0.95-2.68)

• Q4 = 1.00 (referent)

Women

• Q1 = 1.08 (0.58-1.99)

• Q2 = 0.62 (0.44-1.56)

• Q3 = 1.25 (0.70-2.23)

• Q4 = 1.00 (referent)

Sit and reach (cm)

Men

• Q1 = 1.06 (0.64-1.74)

• Q2 = 1.01 (0.61-1.66)

• Q3 = 1.20 (0.74-1.95)

• Q4 = 1.00 (referent)

Women

• Q1 = 1.18 (0.66-2.10)

• Q2 = 1.07 (0.60-1.91)

• Q3 = 0.77 (0.44-1.46)

• Q4 = 1.00 (referent)

Andersen et al 2000 163

To evaluate the relationship between levels of OPA, LTPA, cycling to work and sports participation and all-cause mortality.

• n = 30,640 (17,265 men; 13,375 women)

14.5 year follow-up

• 8,549 deaths

LTPA was inversely associated with all-cause mortality in both men and women in all age groups.

PA assessment: Questionnaire for LTPA, divided into:

Incidence of all-cause mortality and PA

Denmark

• Sex: Men and women

Prospective cohort

• Age: 20-93 years (yr)

Multivariate adjusted RR (95% CI)

G1 = Low

• Characteristics: Participants of the Copenhagen City Heart Study, Glostrup Population Study and Copenhagen Male Study

G2 = Moderate

D & B score = 13

G3 = High

Age 20-44 yr

Men

• G1 = 1.00 (referent)

• G2 = 0.73 (0.56-0.96)

• G3 = 0.74 (0.55-1.01)

Women

• G1 = 1.00 (referent)

• G2 = 0.75 (0.54-1.04)

• G3 = 0.66 (0.42-1.05)

Age 45-64 yr

Men

• G1 = 1.00 (referent)

• G2 = 0.75 (0.67-0.84)

• G3 = 0.75 (0.67-0.85)

Women

• G1 = 1.00 (referent)

• G2 = 0.73 (0.65-0.83)

• G3 = 0.66 (0.56-0.77)

Age >65 yr

Men

• G1 = 1.00 (referent)

• G2 = 0.62 (0.53-0.73)

• G3 = 0.60 (0.50-0.72)

Women

• G1 = 1.00 (referent)

• G2 = 0.52 (0.45-0.61)

• G3 = 0.49 (0.39-0.61)

All age groups

Men

• G1 = 1.00 (referent)

• G2 = 0.72 (0.66-0.78)

• G3 = 0.71 (0.65-0.78)

Women

• G1 = 1.00 (referent)

• G2 = 0.65 (0.60-0.71)

• G3 = 0.59 (0.52-0.67)

Barengo et al 2004 164

To investigate whether moderate or high LTPA are associated with reduced CVD and all-cause mortality, independent of CVD risk factors and other forms of PA in men and women.

• n = 31,677 (15,853 men; 16,824 women)

20 year follow-up

HRR (95% CI)

Moderate and high levels of LTPA and OPA are associated with reduced premature all-cause mortality.

• Sex: Men and women

PA assessment: Questionnaire self administered to measure OPA, LTPA and commuting activity

LTPA

Finland

• Age: 30-59 yr

• 1.00 (referent) = low

• Characteristics: Participants from eastern and south-western Finland

• 0.91 (0.84-0.98) = mod, Men

Prospective cohort

• 0.79 (0.70-0.90) = high, Men

D & B score = 14

• 0.89 (0.81-0.98) = mod, women

• 0.98 (0.83-1.16) = high, women

OPA

• 1.00 (referent) = low

• 0.75 (0.68-0.83) = mod, men

• 0.77 (0.71-0.84) = active, men

• 0.79 (0.70-0.89) = mod, women

• 0.78 (0.70-0.87) = active, women

Bath 2003 165

To examine differences between older men and women on the self-rated health mortality relationship.

• n = 1,042 (406 men; 636 women at baseline)

Baseline, 4 and 12 years post

Number of deaths: At 4 years 242 (106 men; 136 women)

The self-rated health-mortality relationship can be explained by health and related factors among older men and women.

• Sex: Men and women

• At 12 years 665 (287 men; 378 women)

Prospective cohort

• Age: >65 yr

• Characteristics: Community-dwelling Elderly

General physical health

14-item health index (Ebrahin et al 1987) scoring from 0-14 (no health problems -- multiple health problems)

Multivariate adjusted HR (95% CI)

D & B score = 11

• The Nottingham Longitudinal Study of Activity and Ageing

Men after 4 years

• High = 1.00 (referent)

• Med = 1.19 (0.61-2.33)

PA assessment: Self-rated health surveys, divided into 3 levels of PA:

• Low = 1.51 (0.75-3.03)

High

Women after 4 years

Medium

• High = 1.00 (referent)

Low

• Med = 1.03 (0.58-1.82)

• Low = 1.51 (0.86-2.67)

Men after 12 years

Cox proportional hazards regression Models

• High = 1.00 (referent)

• Med = 1.28 (0.94-1.74)

• Low = 1.13 (0.82-1.55)

Women after 12 years

• High = 1.00 (referent)

• Med = 1.20 (0.90-1.61)

• Low = 1.23 (0.93-1.62)

Bijnen et al 1998 166

To describe the association between PA and mortality (CVD, stroke, all-cause) in elderly men.

• n = 802

10 year follow-up

• 373 deaths

PA may protect against all- cause mortality in elderly men

• Sex: Men

• Age: 64-84 yr

PA assessment: Questionnaire, divided into groups:

Multivariate adjusted RR (95% CI)

Netherlands

• Characteristics: Retired Dutch men

• G1 = 1.00 (referent)

Prospective cohort

G1 = Lowest

• G2 = 0.80 (0.63-1.02)

G2 = Middle

• G3 = 0.77 (0.59-1.00)

G3 = Highest

p = 0.04

D & B score = 12

Blair et al 1993 167

To evaluate the relationship of sedentary living habits to all-cause mortality in women.

• n = 3,120

Baseline and 8 year follow-up

• 43 deaths

There is a graded inverse relationship between PF and all-cause mortality in women.

• Sex: Women

• Age: Not available

Age adjusted death rates (per 10,000 person years) by fitness

USA

• Characteristics: Participants were given a preventative medicine examination

PF assessment: PF measured via maximal treadmill exercise test;

Prospective

• Low Fitness = 40

The lack of relationship between PA and death rate was believed to be due to an inadequate assessment of PA.

• Mod Fitness = 16

D & B score = 14

• High Fitness = 7

PA assessment: Questionnaire

No difference between levels of PA

Blair et al 1996 168

To review the association of PF to all-cause and CVD mortality.

• n = 32,421 (25,341 men; 7,080 women)

Baseline and average 8 year follow-up (range 0.1-19.1 years)

• 601 deaths in men

The study observed a steep inverse gradient of death rates across low, moderate and high PF levels. The association was strong and remained after adjustment for potential confounding factors.

• 89 deaths in women

• Sex: Men and women

USA

• Age: 20-80 yr (mean 43 yr)

RR (95% CI) in low PF vs.

PF assessment: Treadmill test; duration was used to assign participants to sex specific groups:

high PF

Prospective cohort

• Characteristics: Participants were excluded if they did not reach 85% of their age predicted maximal heart rate on the maximal exercise treadmill test

Men

• 1.52 (1.28-1.82)

Women

D & B score = 14

• 2.10 (1.36-3.26)

Low (least fit 20%)

Adjusted deaths per 10,000 person years according to PF

Moderate (next 40%)

High (most fit 40%)

Men

• Aerobics Center Longitudinal Study

Proportional hazard modeling

• Low = 49

• Med = 27

• High = 23

Women

• Low = 29

• Med = 13

• High = 14

Boyle et al 2007 169

To examine the association between PA and the risk of incident disability, including impairment in activities of daily living and instrumental activities of daily living in community based older persons free from dementia.

• n = 1,020

2.6 year follow-up

• 156 deaths

The risk of death decreased 11% with each hour of PA/wk.

• Sex: Men and women

• Age: 54-100 yr

PA assessment: Questionnaire, hr/wk of PA Incidence of all-cause mortality

HR for all-cause mortality

USA

• Characteristics: Participants from 40 retirement communities across Chicago

The risk of death was 11% lower for each hr/wk of PA

Prospective cohort

D & B score = 13

• Rush Memory and Aging Project

Bucksch et al 2005 170

To examine the effect of moderately intense PA on all-cause mortality.

• n = 7,187 (3,742 men; 3,445 women)

Baseline (1984-1986) and 12-14 yr follow-up (1998)

• 943 deaths

Participants who achieved recommended amounts of MPA or VPA were at a significantly lower risk of death than their sedentary counterparts.

• Sex: Men and women

RR (95% CI) for achieving recommended PA vs. not achieving recommendation

Germany

• Age: 30-69 yr

Prospective cohort

• Characteristics: Participants were healthy and physically active during leisure time

PA assessment: Questionnaire (Minnesota Leisure Time Physical Activity questionnaire) divided into groups based on: Achieving recommended amount of MPA (30 min, 5 d/wk (≥2.5 h/wk))

Women

• MPA = 0.65 (0.51-0.82)

D & B score = 13

• VPA = 0.78 (0.57-1.08)

• MPA or VPA = 0.60 (0.47-0.75)

Men

• MPA = 0.90 (0.77-1.01)

• VPA = 0.74 (0.61-0.90)

• MPA or VPA = 0.80 (0.68-0.94)

Achieving recommended amount of VPA (20 min, 3 d/wk (≥ 1 h/wk))

RR (95% CI) for volume of lifestyle activities (kcal/kg/wk)

Volume of lifestyle activities (kcal/kg/wk)

Women

G1 = 0

• G1 = 1.00 (referent)

G2 = <14

• G2 = 0.79 (0.57-1.08)

G3 = 14-33.5

• G3 = 0.68 (0.50-0.94)

G4 = ≥ 33.5

• G4 = 0.57 (0.41-0.79)

p < 0.001

Men

• G1 = 1.00 (referent)

• G2 = 0.98 (0.76-1.17)

• G3 = 0.80 (0.63-1.00)

• G4 = 0.91 (0.74-1.13)

p = 0.20

Adjusted for age, other recommendation, social class, smoking, BMI, cardio risk factor index, alcohol intake, chronic disease index and dietary factors

Bucksch and Helmert 2004 171

To examine LTPA and premature death in the general population of former West Germany.

• n = 7,187 (3,742 men; 3,445 women)

Baseline (1984-1986) and 12-14 year follow-up (1998)

• 943 deaths

LTPA is inversely associated with all-cause mortality in men and women.

• Sex: Men and women

RR (95% CI)

• Age: 30-69 yr

Men, LTPA

Germany

• Characteristics: Participants were selected on the basis of the German Cardiovascular Prevention Study

PA assessment: Questionnaire (Minnesota Leisure Time Physical Activity questionnaire) divided into groups based on: LTSA (h/wk)

• G1 = 1.00 (referent)

• G2 = 0.85 (0.78-0.93)

Prospective cohort

• G3 = 0.64 (0.50-0.82)

• G4 = 0.70 (0.54-0.91)

p < 0.001

D & B score = 14

• The National Health Survey of the German Federal Institute of Population Research (1984-1998)

Men, LTPA index

G1 = 0

• G1 = 1.00 (referent)

G2 = <1

• G2 = 0.92 (0.70-1.23)

G3 = 1-2

• G3 = 0.89 (0.69-1.17)

G4 = >2

• G4 = 0.61 (0.44-0.84)

p <0.01

The LTSA-index (kcal/kg/wk)

G1 = 0

Women, LTPA

G2 = 1-10

• G1 = 1.00 (referent)

G3 = 10-25

• G2 = 0.93 (0.82-1.04)

G4 = >25

• G3 = 0.69 (0.48-0.98)

• G4 = 0.57 (0.35-0.94)

Mortality -- Records from the mandatory population registries

p < 0.01

Women, LTPA index

• G1 = 1.00 (referent)

Cox proportional hazard regression model

• G2 = 0.68 (0.45-1.01)

• G3 = 0.79 (0.51-1.21)

• G4 = 0.46 (0.25-0.85)

p < 0.01

Adjusted for age, social class, smoking, BMI, cardio risk factor index, alcohol intake, chronic disease index and dietary factors

Carlsson et al 2006 172

To investigate the association between PA and mortality in post-menopausal women.

• n = 27,734

Baseline (1997) and 2-7 year follow-up (1999-2004)

• 1,232 deaths

The study indicates that even fairly small amounts of activity will reduce mortality in older women.

• Sex: Women

• Age: 51-83 yr

RR (95% CI) adjusted for lifestyle and medical problems

Sweden

• Characteristics: Women who participated in a population based Screening programme in 1987

Prospective cohort

PA assessment: Questionnaires for: METs/day, different PA (walking/biking), LTPA, OPA, household PA, TV watching and reading

PA (METs/day)

• >50 = 1.00 (referent)

D & B score = 12

• 45-50 = 1.05 (0.77-1.42)

• The Swedish Mammography Cohort

• 40-45 s = 1.09 (0.81-1.46)

• 45-40 = 1.26 (0.94-1.70)

• <35 = 2.56 (1.85-3.53)

Mortality -- Records from the National Population Register

Different PA

Walking/biking (min/d)

• > 90 = 1.00 (referent)

• 60-90 = 1.01 (0.76-1.34)

• 40-60 = 0.92 (0.70-1.20)

• 20-40 = 0.96 (0.75-1.23)

• <20 = 1.16 (0.90-1.50)

• Almost never = 1.94 (1.51-2.50)

LTPA (hr/wk)

• >5 = 1.00 (referent)

• 4-5 = 0.95 (0.74-1.22)

• 2-3 = 1.02 (0.83-1.26)

• 1 = 1.09 (0.88-1.36)

• <1 = 1.91 (1.56-2.35)

OPA

• Heavy manual labour = 1.00 (referent)

• Walking/lifting/ a lot carrying = 0.96 (0.55-1.70)

• Walking/lifting/ not a lot carrying = 1.00 (0.60-1.68)

• Mostly standing = 0.91 (0.52-1.61)

• Seated 50% of time = 0.97 (0.58-1.62)

• Mostly sedentary = 1.93 (1.15-3.25)

Household work (hr/d)

• >8 h/d = 1.00 (referent)

• 7-8 = 0.68 (0.49-0.93)

• 5-6 = 0.66 (0.51-0.87)

• 3-4 = 0.83 (0.64-1.06)

• 1-2 = 0.89 (0.69-1.15)

• <1 = 1.73 (1.30-2.32)

Adjusted for age

Crespo et al 2002 173

To study the relationship between PA and obesity with all- cause mortality in Puerto Rican men.

• n = 9,136 (1962-1965)

Baseline and 12 year follow-up

• 1,445 deaths

Some PA is better than none in protecting against all-cause mortality. The benefits are independent of body weight.

Puerto Rico

• Sex: Men

PA assessment: Questionnaire, divided into 4 groups based on METs

Multivariate OR (95% CI) adjusted for age

G1 = low

G4 = high

Prospective cohort

• Age: 35-79 yr

Multivariate logistic function model

• C1 = 1.00 (referent)

D & B score = 12

• Characteristics: Participants with no known coronary heart disease

• C2 = 0.67 (0.57-0.78)

• The Puerto Rico Heart Health Program

• C3 = 0.63 (0.54-0.74)

• C4 = 0.54 (0.46-0.64)

p < 0.0001

Multivariate adjusted OR (95% CI)

• C1 = 1.00 (referent)

• C2 = 0.68 (0.58-0.79)

• C3 = 0.63 (0.54-0.75)

• C4 = 0.55 (0.46-0.65)

p < 0.0001

Davey Smith et al

2000 174

To examine the relationship of PA and various causes of death.

• n = 6,702 (at baseline)

Baseline (1969-1970) and 25 year follow-up

• 926 deaths

In the study, an inverse association of both LTPA and walking pace with mortality from all-causes was seen.

• Sex: Men

PA assessment: Questionnaire with 3 groups for walking pace (Slower, same, faster) and 3 groups for LTPA (inactive, moderately active, active)

Age adjusted RR (95% CI) for walking pace

Prospective cohort

• Age: 40-64 yr

• Slower = 2.47 (2.2-2.8)

D & B score = 13

• Characteristics: Participants from rural northern Japan

• Same = 1.35 (1.2-1.5)

• Whitehall study

• Faster = 1.00 (referent)

p < 0.001

Fully adjusted RR (95% CI) for walking pace

• Slower = 1.87 (1.6-2.1)

• Same = 1.21 (1.1-1.3)

• Faster = 1.00 (referent)

p < 0.001

Age adjusted RR (95% CI) for LTPA

• Inactive = 1.44 (1.3-1.6)

• Mod = 1.13 (1.0-1.2)

• Active = 1.00 (referent)

p < 0.001

Fully adjusted RR (95% CI) for LTPA

• Inactive = 1.20 (1.1-1.3)

• Mod = 1.07 (1.0-1.2)

• Active = 1.00 (referent)

p < 0.001

Eaton et al 1995 175

To determine whether self-reported PA predicts a decreased rate of CHD and all- cause mortality in middle aged men.

• n = 8,463

21 year follow-up

• 2,593 deaths

Baseline levels of self- reported LTPA predicted a decreased rate of CHD and all-cause mortality.

Europe, Israel, mid eastern Asia, Northern Africa

• Sex: Men

PA assessment: Questionnaire for LTPA

Age adjusted RR (95% CI) LTPA

Prospective cohort

• Age: ≥40 yr

G1 = Sedentary

• G1 = 1.00 (referent)

D & B score = 12

• Characteristics: Government employees without known CVD

G2 = Light

• G2 = 0.84 (0.74-0.94)

G3 = Light daily

• G3 = 0.81 (0.73-0.90)

G4 = Heavy

• G4 = 0.84 (0.72-0.98)

OPA

Questionnaire for OPA

• G1 = 1.00 (referent)

G1 = Sitting

• G2 = 0.99 (0.88-1.12)

G2 = Standing

• G3 = 1.09 (0.99-1.20)

G3 = Walking

• G4 = 1.16 (1.03-1.30)

G4 = Physical labour

Fang et al 2005 176

To assess the association of exercise and CVD outcome among persons with different blood pressure status.

• n = 9,791 (3,819 men; 5,972 women)

17 year follow-up

Incidence of all-cause mortality and PA

A significant effect of exercise on mortality in normotensive subjects was not found.

USA

• Sex: Men and women

PA assessment: Questionnaire with 3 groups

Multivariate adjusted HR (95% CI)

Prospective cohort

• Age:25-74 yr

G1 = Least exercise

• G1 = 1.00 (referent)

D & B score = 12

• Characteristics: Non- institutionalized participants

G2 = Moderate exercise

• G2 = 0.75 (0.53-1.05)

G3 = Most exercise

• G3 = 0.71 (0.45-1.12)

Fried et al 1998 177

To determine the disease, functional and personal characteristics that jointly predict mortality.

• n = 5,886

5 year follow-up

• 646 deaths

PA was a predictor of 5-year mortality.

USA

• Sex: Men and women

PA assessment: Self reported exercise (5 groups)

Incidence of all-cause mortality and PA

Prospective cohort

• Age: ≥65 yr

MPA or VPA (kJ/wk)

Multivariate adjusted RR (95% CI)

D & B score = 11

• Characteristics: Community dwelling elders

G1 = ≤282

• G1 = 1.00 (referent)

G2 = 283-1789

• G2 = 0.78 (0.60-1.00)

G3 = 1790-4100

• G3 = 0.81 (0.63-1.05)

G4 = 4101-7908

• G4 = 0.72 (0.55-0.93)

G5 = >7908

• G5 = 0.56 (0.43-0.74)

p < 0.005

Fujita et al 2004 178

To examine the relationship between walking duration and all-cause mortality in a Japanese cohort.

• n = 41,163 (20,004 men; 21,159 women)

Baseline (1990) and 11 year follow-up (2001)

• 1,879 deaths

Time spent walking was associated with a reduced risk for all-cause mortality.

Japan

• Sex: Men and women

PA assessment: Questionnaire Walking, 3 levels:

Age and sex adjusted RR (95% CI) for time spent walking (hr/d)

G1 = ≤30 min

G2 = 30 min to 1 hr

G3 = ≥1 hr

Prospective cohort

• Age: 40-64 yr

Cox proportional hazard model

Whole group

D & B score = 13

• Characteristics: Healthy, sedentary

• G1 = 1.22 (1.09-1.35)

• G2 = 1.09 (0.95-1.22)

• G3 = 1.00 (referent)

p < 0.001

Men only

• G1 = 1.14 (1.00-1.30)

• G2 = 1.03 (0.90-1.19)

• G3 = 1.00 (referent p = 0.061

Women only

• G1 = 1.40 (1.16-1.68)

• G2 = 1.23 (1.01-1.49)

• G3 = 1.00 (referent)

p < 0.001

RR (95% CI) for time spent walking (hr/d) (adjusted for age, education, marital status, past history of diseases, smoking, drinking, BMI and dietary variables)

Whole group

• G1 = 1.17 (1.04-1.31)

• G2 = 1.06 (0.93-1.20)

• G3 = 1.00 (referent)

p = 0.011

Men

• G1 = 1.08 (0.94-1.25)

• G2 = 0.98 (0.84-1.14)

• G3 = 1.00 (referent)

p = 0.318

Women

• G1 = 1.38 (1.12-1.70)

• G2 = 1.24 (1.00-1.54)

• G3 = 1.00 (referent)

p < 0.001

Glass et al 1999 179

To examine any association between social activity, productive activity and PA and mortality in older people.

• n = 2,761 (1,169 men; 1,143 women)

13 year follow-up

Incidence of all-cause mortality by fitness activity quartile

More active elderly people were less likely to die than those who were less active.

USA

• Sex: Men and women

PA assessment: Interview, Amount of activity

13 yr mortality by amount of activity

Prospective cohort

• Age: ≥ 65 yr

G1 = Low

• G1 = 74.0

D & B score = 12

• Characteristics: Healthy elders

G2 = Low-medium

• G2 = 69.8

G3 = Medium-high

• G3 = 62.4

G4 = High

• G4 = 55.2

Gulati et al 2003 180

To determine whether exercise capacity is a predictor for all-cause mortality in asymptomatic women.

• n = 5,721

Baseline (1992) and 8 year follow-up (2000)

• 180 deaths

This study confirmed that exercise capacity is an independent predictor of death in asymptomatic women, greater than what has been previously established among men.

USA

• Sex: Women

PF Assessment: Treadmill stress test Exercise capacity (METs)

G1 = <5

G2 = 5-8

G3 = >8

For every 1 MET increase there was a reduced death risk of 17% (p < 0.001)

Prospective cohort

• Age: Mean 52 ± 11 yr

Age-adjusted RR

D & B score = 11

• Characteristics: Asymptomatic women

• G1 = 2.0 (1.3-3.2)

• St James Women Take Heart Project

• G2 = 1.6 (1.1-2.4)

• G3 = 1.00 (referent)

Adjusted for Framingham

Risk Score

• G1 = 3.1 (2.1-4.8)

• G2 = 1.9 (1.3-2.9)

• G3 = 1.00 (referent)

Haapanen et al 1996 181

To examine the association between LTPA and all-cause mortality.

• n = 1,072

Baseline and a 10 yr

10 month follow-up

• 168 deaths

Low PA is a risk factor for all-cause mortality.

Finland

• Sex: Men

PA assessment: Self-reported LTPA, divided into 4 groups by EE (kJ/wk)

G1 = 0-3349

G2 = 3350-6279

G3 = 6280-8791

G4 = >8791

RR (95% CI) according to EE group

Prospective cohort

• Age: 35-63 yr

Mortality--National

Death Index search

• G1 = 2.74 (1.46-5.14)

D & B score = 14

• Characteristics: Healthy, sedentary

Cox proportional HR

• G2 = 1.10 (0.55-2.21)

• G3 = 1.74 (0.87-3.50)

• G4 = 1.00 (referent)

Hakim et al 1998 182

To examine the association between walking and mortality in retired men.

• n = 707

Baseline and 12 yr follow-up

• 208 deaths

The findings in older physically capable men indicate that regular walking is associated with a lower overall mortality rate.

USA

• Sex: Men

RR (95% CI) according to distance walked

Prospective cohort

• Age: 61-81 yr

Adjusted for age

D & B score = 12

• Characteristics: Retired non-smoking men who were physically capable of participating in low intensity activities on a daily basis

PA assessment: Questionnaire Distance walked (miles/day)

• G1 vs. G3 = 1.9 (1.3-2.9)

G1 = 0.0-0.9

• G1 vs. G3 = 1.6 (1.2-2.2)

G2 = 1.0-2.0

• G2 vs. G3 = 1.2 (0.8-1.7)

G3 = 2.1-8.0

Trend p = 0.002

• Honolulu Heart Program

Adjusted for risk factors

• G1 vs. G3 = 1.8 (1.2-2.7)

• G1 vs. G2 = 1.5 (1.1-2.1)

• G2 vs. G3 = 1.1 (0.8-1.7)

Trend p = 0.01

Hillsdon et al 2004 183

To examine whether VPA is associated with all-cause mortality.

• n = 10,522 (4,929 men; 5,593 women)

>10 year follow-up

• 825 deaths

Questionnaire respondents who reported engaging in VPA less than twice a week experienced a 37% reduced risk of all-cause mortality compared with respondents who reported a lower frequency of VPA.

• Sex: Men and women

PA assessment: Questionnaire for frequency of VPA

Age and sex adjusted RR (95% CI)

• Age: 35-64 yr

G1 = Never, <1 time/month

• Characteristics: Healthy, sedentary

G2 = <2 times/wk

• G1 = 1.00 (referent)

Prospective Cohort

• OXCHECK study

G3 = >2 times/wk

• G2 = 0.57 (0.42-0.79)

• G3 = 0.72 (0.54-0.95)

D & B score = 11

Fully adjusted RR (95% CI)

• G1 = 1.00 (referent)

Mortality -- Recorded from the Office of National Statistics

• G2 = 0.63 (0.45-0.89)

• G3 = 0.81 (0.60-1.09)

Cox proportional HR

Hu et al 2005 184

To examine the association of PA and BMI and their combined effect with the risk of total, CVD and cancer mortality.

• n = 47,212 (22,528 men; 24,684 women)

17.7 year follow-up

• 7,394 deaths

Regular PA is an important indicator for decreased risk of all-cause mortality. PA has a strong independent effect on mortality.

• Sex: Men and women

Finland

• Age:25-64 yr

PA assessment: Questionnaire for PA level, divided into 3 groups

Adjusted HR (95% CI)

• Characteristics: Participants from eastern Finland

Men

Prospective cohort

• G1 = 1.00 (referent)

• G2 = 0.74 (0.68-0.81)

G1 = Low

• G3 = 0.63 (0.58-0.70)

D & B score = 12

G2 = Moderate

Trend p = <0.001

G3 = High

Women

• G1 = 1.00 (referent)

• G2 = 0.64 (0.58-0.70)

• G3 = 0.58 (0.52-0.64)

Trend p = <0.001

Hu et al 2004 185

To examine the association of BMI and PA with death.

• n = 116,564

Baseline (1976) and

• 10,282 deaths

Reduced PA is a strong and independent predictor of death.

• Sex: Women

24 year follow-up

• Age: 30-55 yr

Multivariate RR (95% CI) by PA (hr/wk)

USA

• Characteristics: Females free of known CVD and cancer

PA assessment: Questionnaire for PA level, divided into 3 groups (hr/week)

• G1 = 1.00 (referent)

G1 = ≥ 3.5

• G2 = 1.18 (1.10-1.26)

Prospective cohort

G2 = 1.0-3.4

• G3 = 1.52 (1.41-1.63)

D & B score = 11

G3 = <1.0

Multivariate RR (95% CI) by PA adjusted for BMI

• G1 = 1.00 (referent)

BMI (kg/m²)

• G2 = 1.14 (1.06-1.22)

G1 = <25

• G3 = 1.44 (1.34-1.55)

G2 = 25-29

G3 = 30

Cox proportional HR

Kampert et al 1996 186

To examine PF and PA in relation to all-cause and cancer mortality.

• n = 32,421 (25,341 men; 7,080 women)

Baseline (1970) and ~8 year follow-up (1989)

• 690 deaths

The data support the hypothesis that an active and fit way of life delays death.

• Sex: Men and women

Adjusted RR (95% CI) by quintiles of activity

USA

• Age: 20-88 yr (mean ~43)

Prospective cohort

• Characteristics: Predominantly white and from the middle and upper socioeconomic strata

PA assessment: Questionnaire, divided into quintiles of activity (min/wk)

Men

• Sedentary = 1.00 (referent)

• C1-2 = 0.71 (0.58-0.97)

D & B score = 13

• C3 = 0.83 (0.59-1.16)

Male activity categories

• C4 = 0.57 (0.30-1.08)

• C5 = 0.92 (0.29-2.88)

Sedentary = 855

Trend p = 0.011

C1-2 = 1,072

C3 = 1,292

Women

C4 = 1,453

• Sedentary = 1.00 (referent)

C5 = 1,601

• C1-2 = 0.68 (0.39-1.17)

• C3 = 0.39 (0.09-1.65)

Females activity categories

• C4-5 = 1.14 (0.27-4.80)

Sedentary = 605

Trend p = 0.217

C1-2 = 792

C3 = 979

C4-5 = 1,158

Cox proportional HR

Kaplan et al 1996 187

To assess LTPA and its association with all cause mortality.

• n = 6,131 (3298 men; 2833 women)

28 year follow-up

• 1,226 deaths

The data provide further support for the importance of PA and indicate that the protective effect of PA is a robust one.

• Sex: Men and women

PA assessment: Three questions about PA, with scores 0 (never), 2 (sometimes) or 4 (often).

Incidence of all-cause mortality and PA

USA

• Age: 16-94 yr

• Characteristics: Northern Californian adults

Prospective cohort

Death rates/1000 person years

Men

D & B score = 13

• T1 = 24.68

Tertiles of PA score

• T2 = 11.37

T1 = 0-2

• T3 = 7.59

T2 = 4-6

Women

T3 = 8-12

• T1 = 18.03

• T2 = 7.66

• T3 = 3.88

Khaw et al 2006 188

To examine the relationship between PA patterns over 1 year and total mortality.

• n = 22,191 (9,984 men; 12,207 women)

8 year follow-up

• 1,553 deaths

Even very moderate levels of usual PA are associated with reductions in mortality.

• Sex: Men and women

PA assessment: Questionnaire, divided into 4 groups of PA

Incidence of all-cause mortality and PA

• Age: 45-79 yr

Adjusted RR (95% CI)

• Characteristics: Community living participants

All

Prospective cohort

G1 = Inactive

• G1 = 1.00 (referent)

G2 = Moderately inactive

• G2 = 0.83 (0.73-0.95)

D & B score = 13

• G3 = 0.68 (0.58-0.80)

G3 = Moderately active

• G4 = 0.68 (0.57-0.81)

G4 = Active

Age <65

• G1 = 1.00 (referent)

• G2 = 1.01 (0.78-1.31)

• G3 = 0.81 (0.62-1.07)

• G4 = 0.82 (0.62-1.09)

Age >65

• G1 = 1.00 (referent)

• G2 = 0.77 (0.66-0.91)

• G3 = 0.65 (0.53-0.79)

• G4 = 0.64 (0.50-0.80)

Kohl et al 1996 189

To determine the association of maximal exercise hemodynamic responses with risk of all-cause mortality.

• n = 26,621 (20,387 men; 6,234 women)

Average 8.1 year follow-up

• 348 deaths in men and 66 in women

The results suggest an exaggerated SBP or an attenuated heart rate response to maximal exercise may indicate an elevated risk for mortality.

• Sex: Men and women

USA

• Age: Male mean 42.2 yr; female mean 41.9 Yr

Adjusted RH (95% CI) by maximal exercise test HR

Prospective cohort

Men

• Characteristics: Apparently healthy patients of a preventive medicine centre

PF assessment: Maximal exercise test HR (bpm), divided into 4 Groups:

• Q1 = 1.00 (referent)

G1 = <171

• Q2 = 0.61 (0.44-0.85)

D & B score = 12

G2 = 171-178

• Q3 = 0.69 (0.51-0.93)

G3 = 179-188

• Q4 = 0.60 (0.41-0.87)

G4 = >188

Trend p<0.05

Women

• Q1 = 1.00 (referent)

• Q2 = 1.23 (0.65-2.32)

• Q3 = 0.69 (0.30-1.63)

• Q4 = 0.71 (0.22-2.24)

Trend p>0.05

Kujala et al 1998 190

To investigate LTPA and mortality in a cohort of twins.

• n = 15,902 (7,925 men; 7,977 women)

Baseline 1975 and death outcome from 1977-1994

• 1,253 deaths

LTPA is associated with reduced mortality, even after genetic and other familial factors are taken into account.

• Sex: Men and women

HR (95% CI)

Finland

• Age: 25-64 yr

• Characteristics: Healthy, Finnish same sex twins

PA assessment: Questionnaire, quintiles of fitness in MET hours/day

Adjusted for age and sex

Prospective cohort

• Sedentary = 1.00 (referent)

• OE = 0.71 (0.62-0.81)

• The Finnish Twin Cohort

• CE = 0.57 (0.45-0.74)

D & B score = 13

Q1 = <58

Trend p = 0.001

Q2 = 59-1.29

Q3 = 1.30-2.49

Adjusted for age, sex, smoking

Q4 = 2.50-4.49

Q5 = >4.50

• Sedentary = 1.00 (referent)

• OE = 0.76 (0.67-0.87)

Categorized into:

• CE = 0.68 (0.53-0.88)

-Sedentary

-Occasional exerciser (OE)

Trend p = 0.001

-Conditioning exerciser (CE)

Adjusted for age, sex, smoking, occupational group, alcohol

• Sedentary = 1.00 (referent)

• OE = 0.80 (0.69-0.91)

• CE = 0.76 (0.59-0.98)

Trend p = 0.002

HR (95% CI) among 434 same sex twin pairs compared with sedentary category in 1975

• Sedentary = 1.00 (referent)

• OE = 0.66 (0.46-0.94)

• CE = 0.44 (0.23-0.83)

Trend p = 0.005

Adjusted for smoking

• Sedentary = 1.00 (referent)

• OE = 0.70 (0.48-1.01)

• CE = 0.56 (0.29-1.09)

Trend p = 0.04

Adjusted for smoking, occupational group, alcohol

• Sedentary = 1.00 (referent)

• OE = 0.73 (0.50-1.07)

• CE = 0.56 (0.29-1.11)

Trend p = 0.06

OR (95% CI) in quintiles among 434 same sex twin pairs compared with sedentary category in 1975

• Q1 = 1.00 (referent)

• Q2 = 0.85

• Q3 = 0.72

• Q4 = 0.68

• Q5 = 0.60

LaCroix et al 1996 191

To determine whether walking is associated with a reduced risk of CVD hospitalization and death in older adults.

• n = 1,645 (615 men; 1030 women)

4.2 year follow-up

RR (95% CI) by category of walking

Walking more than 4 hr/wk was associated with a reduced risk of mortality from all-causes.

• Sex: Men and women

PA assessment: Questionnaire for walking h/wk, divided into 3 groups

USA

• Age: ≥65 yr

G1 = <1 hr/week

Men

Characteristics: Participants from a group health co-operative

G2 = 1-4 hr/week

• G1 = 1.00 (referent)

Prospective cohort

G3 = >4 hr/week

• G2 = 0.78 (0.43-1.45)

• G3 = 0.89 (0.49-1.62)

D & B score = 12

Women

• G1 = 1.00 (referent)

• G2 = 0.50 (0.28-0.90)

• G3 = 0.48 (0.25-0.83)

Age 65-74 yr

• G1 = 1.00 (referent)

• G2 = 0.81 (0.40-1.61)

• G3 = 1.13 (0.60-2.15)

Age ≥75 yr

• G1 = 1.00 (referent)

• G2 = 0.63 (0.37-1.08)

• G3 = 0.46 (0.25-0.84)

High functioning

• G1 = 1.00 (referent)

• G2 = 0.73 (0.38-1.41)

• G3 = 0.89 (0.48-1.65)

Limited functioning

• G1 = 1.00 (referent)

• G2 = 0.60 (0.34-1.05)

• G3 = 0.51 (0.28-0.92)

Lam et al 2004 192

To investigate the relationship LTPA and mortality in Hong Kong.

• n = 24,079 cases (13,778 men; 10,301 women);

10 years prior

Multivariate adjusted OR (95% CI) by LTPA

The data confirm and extend previous findings in Caucasian populations on the association between LTPA and longevity.

PA assessment:

Men

Hong Kong

• n = 13,054 controls (3,918 men; 9,136 women)

Questionnaire for LTPA, divided into 3 groups

• G1 = 1.00 (referent)

• G2 = 0.60 (0.54-0.67)

Case-Control

• G3 = 0.66 (0.60-0.73)

• Sex: Men and women

G1 = <1 times per month

D & B score = 12

• Age: ≥35 yr

Women

• Characteristics: All ethnic Chinese

G2 = 1-3 times per month

• G1 = 1.00 (referent)

• G2 = 0.81 (0.74-0.88)

G3 = ≥4 times per month

• G3 = 0.71 (0.66-.077)

Lan et al 2006 193

To investigate the relationship between exercise and all-cause mortality.

• n = 2,113 (1,081 men; 1,032 women)

Baseline and 2 year follow-up

• 197 deaths

Older persons are recommended to expend at least 1000 kcal/wk through regular exercise for mortality reduction.

• Sex: Men and women

HR (95% CI) by LTPA frequency

Taiwan

• Age: ≥65 yr

PA assessment: Questionnaire for LTPA (frequency/wk)

Prospective cohort

• Characteristics: Non-institutionalized elders

Adjusted for age and sex

Protection of exercise against death also increases with the number of activities.

G1 = Sedentary

• G1 = 1.00 (referent)

• Taiwan National Health Interview Survey

G2 = 1 time/wk

• G2 = 0.49 (0.36-0.67)

D & B score = 13

G3 = ≥2 times/wk

• G3 = 0.20 (0.09-0.46)

Trend p = <0.001

Questionnaire for EE (kcal/wk), divided into 5 groups:

Multivariate adjusted

• G1 = 1.00 (referent)

G1 = Sedentary

• G2 = 0.70 (0.50-0.98)

G2 = <500

• G3 = 0.35 (0.15-0.82)

G3 = 500-999

Trend p = 0.014

G4 = 1000-1999

G5 = ≥2000

HR (95% CI) by EE

Adjusted for age and sex

• G1 = 1.00 (referent)

• G2 = 0.64 (0.41-1.01)

• G3 = 0.55 (0.35-0.85)

• G4 = 0.30 (0.17-0.53)

• G5 = 0.24 (0.12-0.48)

Trend p <0.001

Multivariate adjusted

• G1 = 1.00 (referent)

• G2 = 0.80 (0.49-1.30)

• G3 = 0.74 (0.46-1.17)

• G4 = 0.50 (0.27-0.90)

• G5 = 0.43 (0.21-0.87)

Trend p = 0.043

Laukkanen et al 2001 194

To examine the relationship between maximal oxygen uptake and overall mortality.

• n = 1,294

Baseline and 10.7 year follow-up

• 124 deaths

PF has a strong, graded, inverse association with overall mortality.

• Sex: Men

Adjusted RR (95% CI) by quartile

Finland

• Age: 42.0-61.3 yr (mean 52.1)

• Characteristics: Men free from CVD, COPD, and cancer at baseline

PF assessment: Exercise tolerance test, 4 groups by maximal oxygen uptake (ml/kg/min)

Prospective cohort

Maximal oxygen uptake

• G1 = 1.00 (referent)

• G2 = 1.47 (0.71-3.01)

D & B score = 14

• G3 = 2.79 (1.44-5.39)

G1 = >37.1

• G4 = 3.85 (2.02-7.32)

G2 = 32.3-37.1

Linear trend p = <0.001

G3 = 27.6-32.2

G4 = <27.6

Test duration

• G1 = 1.00 (referent)

Test duration (min)

• G2 = 2.22 (1.08-4.55)

G1 = >11.2

• G3 = 2.23 (1.11-4.49)

G2 = 9.6-11.2

• G4 = 3.94 (2.01-7.74)

G3 = 8.2-9.5

Linear trend p<0.001

G4 = <8.2

Lee and Paffenbarger 2000 195

To compare various levels of PA with mortality.

• n = 13,485

Baseline and 15 year follow-up

• 2,539 deaths

The study provides some support for recommendations that emphasize MPA. A benefit of VPA is also evident.

• Sex: Men

• Age: Mean 57.5 yr

RR (95% CI)

• Characteristics: Men who matriculated as undergraduates in 1916-1950

PA assessment:

• G1 = 1.00 (referent)

USA

Questionnaires for LTPA index (including walking, stair climbing, sports and recreational activity),

• G2 = 0.80 (0.72-0.88)

• G3 = 0.74 (0.65-0.83)

Prospective cohort

• G4 = 0.80 (0.69-0.93)

• The Harvard Alumni Health Study

• G5 = 0.73 (0.64-0.84)

Trend p = <0.001

D & B score = 12

5 groups (kJ/wk)

G1 = <4200

G2 = 4200-8399

G3 = 8400-12599

G4 = 12600-16799

G5 = ≥ 16800

Lee et al 1995 196

To examine the independent association of vigorous and non-vigorous PA with longevity.

• n = 17,321

Follow-up 22-26 years

• 3,728 deaths

There is a graded inverse relationship between PA and mortality. Vigorous, but not non-vigorous activities are associated with longevity.

• Sex: Men

• Age: Mean 46 yr

PA assessment: Questionnaires for EE (kJ/wk), quintiles

RR (95% CI) by EE (kJ/wk)

USA

• Characteristics: Harvard University alumni, without self-reported physician diagnosed cardiovascular disease, cancer or chronic obstructive pulmonary disease

Q1= 1.00 (referent)

• Q2 = 0.94 (0.86--1.04)

Prospective cohort

Q1 = ≤ 630

• Q3 = 0.95 (0.86--1.05)

Q2 = 630-1680

• Q4 = 0.91 (0.83 - 1.01)

Q3 = 1680-3150

• Q5 = 0.91 (0.82-1.00)

D & B score = 12

Q4 = 3150-6300

Q5 = >6300

RR (95% CI) by EE (Vigorous activity, kJ/wk)

• Q1 = 1.00 (referent)

• The Harvard Alumni Health Study

• Q2 = 0.88 (0.82-0.96)

• Q3 = 0.92 (0.82-1.02)

• Q4 = 0.87 (0.77-0.99)

• Q5 = 0.87 (0.78-0.97)

Lee et al 2004 197

To investigate the effect of various PA patterns on all-cause mortality.

• n = 8,421

Baseline 1988 and follow-up 1993

• 1,234 deaths

The results suggest that regular PA generating 1000 kcal/wk or more should be recommended for lowering mortality rates. Among those with no major risk factors, even 1-2 episodes per week generating 1000 kcal or more can postpone mortality.

• Sex: Men

• Age: Mean 66 yr

Age adjusted RR (95% CI) by PA pattern

USA

• Characteristics: Participants free of major chronic disease

PA assessment: Questionnaire for PA (kcal/wk), 4 groups

• G1 = 1.00 (referent)

Prospective cohort

• G2 = 0.75 (0.63-0.90)

G1 = <500

• G3 = 0.82 (0.63-1.07)

• The Harvard Alumni Health Study

(Sedentary)

• G4 = 0.61 (0.53-0.69)

D & B score = 11

G2 = 500-999

(Insufficiently active)

Multivariate adjusted

G3 = ≥ 1000

(Weekend warrior)

• G1 = 1.00 (referent)

G4 = Regularly active

• G2 = 0.75 (0.62-0.91)

• G3 = 0.85 (0.65-1.11)

• G4 = 0.64 (0.55-0.73)

Leitzmann et al 2007 198

To examine PA guidelines in relation to mortality.

• n = 252,925 (142,828 male; 110,097 women)

Baseline and 6 month follow-up

• 7,900 deaths

Following PA guidelines is associated with lower risk of death. Mortality benefit may also be achieved by engaging in less than recommended activity levels.

USA

• Sex: Men and women

PA assessment: Questionnaire for MPA and VPA, 5 groups each MPA (h/wk)

Multivariate adjusted RR (95% CI) according to activity

• Age: 50-71 yr

MPA

Prospective cohort

• Characteristics: Participants free of CVD, cancer or emphysema

• G1 = 1.00 (referent)

• The National Institute of Health-American Association of Retired Persons

• G2 = 0.85 (0.79-0.93)

• G3 = 0.79 (0.74-0.85)

D & B score = 13

G1 = sedentary

• G4 = 0.76 (0.71-0.82)

G2 = <1

• G5 = 0.68 (0.63-0.74)

G3 = 1-3

Trend p = <0.001

G4 = 4-7

VPA

G5 = >7

VPA (frequency/wk)

• G1 = 1.00 (referent)

G1 = inactive

• G2 = 0.77(0.71-0.83)

G2 = <1

• G3 = 0.77 (0.72-0.82)

G3 = 1-2

• G4 = 0.68 (0.63-0.73)

G4 = 3-4

• G5 = 0.71 (0.66-0.77)

G5 = ≥ 5

Trend p = <0.001

Cox proportional HR

Leon et al 1997 199

To examine the long-term association of LTPA and risk of death from coronary heart disease and all-causes.

• n = 12,138

16 year follow-up

• 1,904 deaths

The data suggest that a relatively small amount of daily moderate intensity LTPA can reduce premature mortality in middle-aged and older men at high risk for CHD.

• Sex: Men

• Age: 35-57 yr

PA assessment: Minnesota LTPA questionnaire, categorized by frequency/month and average duration, deciles (min/d)

Multivariate adjusted RR (95% CI) by deciles of LTPA

USA

• Characteristics: Men who at entry to the study were free of clinical evidence of CHD or other serious medical problems but were at the upper 10%-15% of a CHD probability score distribution derived from the FHS data

Prospective cohort

• D1 = 1.00 (referent)

• D2-4 = 0.85 (0.73-0.99)

• D5-7 = 0.87 (0.75-1.02)

D & B score = 12

• D8-10 = 0.83 (0.71-0.97)

D1 = 4.9

D2-4 = 22.7

D5-7 = 53.9

D8-10 = 140.4

• Multiple Risk Factor Intervention Trial

Cox proportional HR

Lissner et al 1996 200

To examine the relationship of OPA and LTPA on all-cause mortality in women.

• n = 1,405

Baseline and 20 year follow-up

• 277 deaths

Decreases in PA as well as low initial levels are strong risk factors for mortality.

• Sex: Women

• Age: 38-60 yr

RR (95% CI) by LTPA

Sweden

• Characteristics: Free from major disease at baseline

PA assessment: Questionnaire for OPA and LTPA, 3 groups

20 year follow-up

Prospective cohort

LTPA during age 20-38 years

• The Gothenburg Prospective Study of Women

• Low = 1.00 (referent)

G1 = Low

• Med = 0.66 (0.34-1.26)

D & B score = 10

G2 = Medium

• High = 0.46 (0.21-1.01)

G3 = High

LTPA during age 39-60 years

Proportional hazard regression

• Low = 1.00 (referent)

• Med = 0.56 (0.35-0.90)

• High = 0.44 (0.22-0.91)

LTPA during the past 12 months

• Low = 1.00 (referent)

• Med = 0.56 (0.39-0.82)

• High = 0.45 (0.24-0.86)

20 year follow-up

OPA during age 20-38 years

• Low = 1.00 (referent)

• Med = 0.59 (0.18-1.87)

• High = 0.50 (0.16-1.58)

OPA during age 39-60 years

• Low = 1.00 (referent)

• Med = 0.66 (0.21-2.08)

• High = 0.47 (0.14-1.52)

OPA during the past 12 months

• Low = 1.00 (referent)

• Med = 0.28 (0.17-0.46)

• High = 0.24 (0.14-0.43)

Manini et al 2006 201

To determine whether energy expenditure is associated with all-cause mortality in older adults.

• n = 302 (150 men; 152 women)

Mean follow-up of 6.15 years

• 55 deaths

Free-living activity EE was strongly associated with lower risk of mortality.

• Sex: Men and women

HR (95% CI) by tertiles of PA EE

USA

• Age: 70-82 yr

PA assessment: Questionnaire, divided into tertiles of PA EE (kcal/d)

Prospective cohort

• Characteristics: High-functioning community dwelling elders

Adjusted for age, sex, race and study site

T1 = <521

• T1 = 1.00 (referent)

D & B score = 13

T2 = 521-770

• T2 = 0.63 (0.29-1.18)

T3 = >770

• T3 = 0.37 (0.15-0.76)

Trend p = 0.009

Adjusted for age, sex, race, study site, weight, height, percent body fat and sleep duration

• T1 = 1.00 (referent)

• T2 = 0.57 (0.30-1.09)

• T3 = 0.31 (0.14-0.69)

Trend p = 0.004

Adjusted for age, sex, race, study site, self rated health, education, smoking, CVD, lung disease, diabetes, hip or knee osteoarthritis, osteoporosis, cancer and depression

• T1 = 1.00 (referent)

• T2 = 0.65 (0.33-1.28)

• T3 = 0.33 (0.15-0.74)

Trend p = 0.007

Matthews et al 2007 202

To determine the effects of exercise and non-exercise PA on mortality.

• n = 67,143

Baseline and an average of 5.7 year follow-up

• 1,091 deaths

Overall PA levels are an important determinant of longevity.

• Sex: Women

• Age: 40-70 yr

RR (95% CI)

China

• Characteristics: Women without heart disease, stroke or cancer

PA assessment: Interview to report (MET h/d), 4 groups Overall activity

Multivariate adjustment

Prospective cohort

Overall activity (MET hr/d)

• G1 = 1.00 (referent)

• The Shanghai Women's Health Study

• G2 = 0.81 (0.69-0.96)

D & B score = 12

G1 = ≤ 9.9

• G3 = 0.67 (0.57-0.80)

G2 = 10.0-13.6

• G4 = 0.61 (0.51-0.73)

G3 = 13.7-18.0

Trend p = 0.000

G4 = ≥ 18.1

Adult exercise (MET hr/d)

Adult exercise

• G1 = 1.00 (referent)

G1 = 0

• G2 = 0.84 (0.74-0.96)

G2 = 0.1-3.4

• G3 = 0.77 (0.59-0.99)

G3 = 3.5-7.0

• G4 = 0.64 (0.36-1.14)

G4 = ≥ 7.1

Trend p = 0.008

Cox proportional hazard models

Menotti and Seccareccia 1985 203

To investigate the relationship between OPA and all-cause mortality.

• n = 99,029

Baseline and 5 year follow-up

• 2,661 deaths

The results suggest that PA may play a role in the prediction of fatal events.

• Sex: Men

• Age: 40-59 yr

• Characteristics: Men employed on the Italian railway system

PA assessment: Questionnaire Men at risk classified by 3 levels of PA and 3 levels of job responsibility, combined to create 8 groups of PA-job responsibility

Age adjusted death rates per 1000 over 5 years classified by PA only

Italy

• Sedentary = 26.20

Prospective cohort

• Moderate = 27.05

• Heavy = 27.35

D & B score = 12

Age adjusted death rates per 1,000 over 5 years classified by PA and job responsibility

G1 = sedentary -- low

• G1 = 30.00

G2 = sedentary -- med

• G2 = 25.20

G3 = sedentary -- high

• G3 = 25.80

G4 = moderate -- low

• G4 = 26.30

G5 = moderate -- med

• G5 = 28.50

G6 = moderate -- high

• G6 = 25.80

G7 = heavy -- low

• G7 = 26.90

G8 = heavy -- med

• G8 = 30.80

Mensink et al 1996 204

To compare various indices for PA and their association with cardiovascular risk factors as well as total and CVD mortality.

• n = 15,436 (7,689 men; 7797 women)

5-8 year follow-up

Incidence of all-cause mortality and PA

An inverse relation of PA and total mortality.

Germany

• Sex: Men and women

PA assessment: Questionnaire Total activity, 3 groups

Adjusted RR (95% CI)

• Age: 25-69 yr

Prospective cohort

• Characteristics: Participants from communities in Western Germany

Total activity, men

G1 = Low

• G1 = 1.00 (referent)

G2 = Moderate

• G2 = 0.56 (0.30-1.04)

D & B score = 12

G3 = High

• G3 = 0.78 (0.42-1.44)

Total activity, women

LTPA, 3 groups

• G1 = 1.00 (referent)

G1 = Low

• G2 = 1.24 (0.60-2.58)

G2 = Moderate

• G3 = 1.29 (0.58-2.85)

G3 = High

Conditioning activity, 3 groups

LTPA, men

• G1 = 1.00 (referent)

G1 = No activity

• G2 = 0.61 (0.35-1.05)

G2 = Moderate

• G3 = 0.79 (0.48-1.31)

G3 = High

LTPA, women

• G1 = 1.00 (referent)

Sports activity, 4 groups

• G2 = 0.94 (0.51-1.75)

• G3 = 0.81 (0.44-1.49)

G1 = no sports

G2 = <1 hour

Conditioning activity, men

G3 = 1-2 hours

• G1 = 1.00 (referent)

G4 = >2 hours

• G2 = 0.76 (0.44-1.34)

• G3 = 0.67 (0.36-1.25)

Conditioning activity, women

• G1 = 1.00 (referent)

• G2 = 0.38 (0.13-1.06)

• G3 = 0.80 (0.42-1.54)

Sports Activity, men

• G1 = 1.00 (referent)

• G2 = 0.49 (0.26-0.95)

• G3 = 0.57 (0.30-1.09)

• G4 = 0.36 (0.16-0.79)

Sports activity, women

• G1 = 1.00 (referent)

• G2 = 0.38 (0.12-1.23)

• G3 = 0.52 (0.23-1.17)

• G4 = 0.28 (0.07-1.17)

Morgan and Clarke 1997 205

To assess the value of broadly based customary PA scores in predicting 10-year mortality in elderly people.

• n = 1,042 (407 men; 635 women)

10 year follow-up

Incidence of all-cause mortality and PA

A wide range of customary or habitual PA, can provide indices showing both cross sectional and predictive validity for 10 year mortality.

• Sex: Men and women

PA assessment: Questionnaire for PA, 3 groups

• Age: ≥65 yr

HR (95% CI)

• Characteristics: British elders

Men

Prospective cohort

G1 = Low

• G1 = 1.59 (1.12-2.25)

• Nottingham Longitudinal Study of Activity and Aging

G2 = Intermediate

• G2 = 1.35 (0.96-1.89)

G3 = High

• G3 = 1.00 (referent)

D & B score = 12

Women

• G1 = 2.07 (1.53-2.79)

• G2 = 1.53 (1.12-2.09)

• G3 = 1.00 (referent)

Myers et al 2002 206

To compare PF and PA levels with all-cause mortality.

• n = 6,213

Baseline and mean 6.2 ± 3.7 year follow-up

• 1,256 deaths

Exercise capacity is a more powerful predictor of mortality among men than other established risk factors for CVD.

• Sex: Men

• Age: Mean 59 ± 11 yr

Age adjusted RR (95% CI) by quintile

USA

• Characteristics: Participants with a normal exercise test result (n = 2,534) and participants with an abnormal exercise test or CVD or both (n = 3,679)

PF assessment: Treadmill test for VO₂peak, divided into quintiles (METs)

• Q1 = 4.5 (3.0-6.8)

Prospective cohort

• Q2 = 2.4 (1.5-3.8)

• Q3 = 1.7 (1.1-2.8)

• Q4 = 1.3 (0.7-2.2)

D & B score = 12

Q1 = Lowest level

• Q5 = 1.00 (referent)

1.0-5.9

Q5 = Highest level

≥13.0

Ostbye et al 2002 207

To analyze the effect of smoking and other modifiable risk factors on ill health, defined in a multidimensional fashion.

• n = 12,956

6 year follow-up

• 782 deaths

Quitting smoking and increasing exercise levels are the lifestyle interventions most likely to improve overall health.

• Sex: Men and women

• Age: 50-60 yr

PA assessment: Questionnaire for PA, 4 groups

Incidence of all-cause mortality and PA

USA

• Characteristics: Participants from the Health and Retirement Study (HRS) only

Prospective cohort

G1 = Sedentary

Death rates (95% CI) per 1000 population/yr

G2 = Light

G3 = Moderate

• G1 = 20.6 (17.8-24.0)

D & B score = 13

G4 = Heavy

• G2 = 9.1 (8.1-9.5)

• G3 = 8.3 (7.5-9.2)

• G4 = 4.4 (3.5-5.6)

Paffenbarger et al 1994 208

To study the adoption or maintenance of PA and other optional lifestyle patterns for their influence on mortality rates of Harvard College alumni.

• n = 14,786

Follow-up between

• 2,343 deaths

Adopting a physically active lifeway delays mortality and extends longevity.

• Sex: Men

1977 and 1988

• Age: 45-84 yr (in 1977)

RR (95% CI) of mortality according to PA

USA

PA assessment: Questionnaire for blocks walked daily, stairs climbed daily and type, frequency and duration of weekly sports and recreational activities

Characteristics: Harvard College alumni

Prospective cohort

Physical activity index (kcal/wk)

• G1 = 1.00 (referent)

D & B score = 14

• G2 = 1.13 (1.01-1.26)

• G3 = 0.72 (0.64-0.82)

• G4 = 0.77 (0.69-0.85)

Physical activity index (kcal/wk) Sports and recreational activities were scored according to intensity and duration

Walking (km/wk)