(C) PLOS One [1]. This unaltered content originally appeared in journals.plosone.org.
Licensed under Creative Commons Attribution (CC BY) license.
url:https://journals.plos.org/plosone/s/licenses-and-copyright

------------



Dose–response association between moderate to vigorous physical activity and incident morbidity and mortality for individuals with a different cardiovascular health status: A cohort study among 142,49

['Esmée A. Bakker', 'Radboud Institute For Health Sciences', 'Department Of Physiology', 'Radboud University Medical Center', 'Nijmegen', 'The Netherlands', 'Research Institute For Sports', 'Exercise Sciences', 'Liverpool John Moores University', 'Liverpool']

Date: 2022-01 

MVPA is beneficial for reducing adverse outcomes, but the shape of the association depends on cardiovascular health status. A curvilinear association was found in healthy and CVRF individuals with a steep risk reduction at low to moderate MVPA volumes and benefits plateauing at high(er) MVPA volumes. CVD patients demonstrated a linear association, suggesting a constant reduction of risk with higher volumes of MVPA. Therefore, individuals with CVDs should be encouraged that “more is better” regarding MVPA. These findings may help to optimize exercise prescription to gain maximal benefits of a physically active lifestyle.

A cohort study was performed in the 3 northern provinces of the Netherlands, in which data were collected between 2006 and 2018, with a median follow-up of 6.8 years (Q 25 5.7; Q 75 7.9). A total of 142,493 participants of the Lifelines Cohort Study were stratified at baseline as (1) healthy; (2) CVRF; or (3) CVD. Individuals were categorized into “inactive” and 4 quartiles of least (Q1) to most (Q4) active based on self-reported MVPA volumes. Primary outcome was a composite of incident MACE and all-cause mortality during follow-up. Cox regression was used to estimate hazard ratios (HRs), 95% confidence intervals (CIs) and P values. The main analyses were stratified on baseline health status and adjusted for age, sex, income, education, alcohol consumption, smoking, protein, fat and carbohydrate intake, kidney function, arrhythmias, hypothyroid, lung disease, osteoarthritis, and rheumatoid arthritis. The event rates were 2.2% in healthy individuals (n = 2,485 of n = 112,018), 7.9% in those with CVRF (n = 2,214 of n = 27,982) and 40.9% in those with CVD (n = 1,019 of n = 2,493). No linear association between MVPA and all-cause mortality or MACE was found for healthy individuals (P = 0.36) and individuals with CVRF (P = 0.86), but a linear association was demonstrated for individuals with CVD (P = 0.04). Adjusted HRs in healthy individuals were 0.81 (95% CI 0.64 to 1.02, P = 0.07), 0.71 (95% CI 0.56 to 0.89, P = 0.004), 0.72 (95% CI 0.57 to 0.91, P = 0.006), and 0.76 (95% CI 0.60 to 0.96, P = 0.02) for MVPA Q1 to Q4, respectively, compared to inactive individuals. In individuals with CVRF, HRs were 0.69 (95% CI 0.57 to 0.82, P < 0.001), 0.66 (95% CI 0.55 to 0.80, P < 0.001), 0.64 (95% CI 0.53 to 0.77, P < 0.001), and 0.69 (95% CI 0.57 to 0.84, P < 0.001) for MVPA Q1 to Q4, respectively, compared to inactive individuals. Finally, HRs for MVPA Q1 to Q4 compared to inactive individuals were 0.80 (95% CI 0.62 to 1.03, P = 0.09), 0.82 (95% CI 0.63 to 1.06, P = 0.13), 0.74 (95% CI 0.57 to 0.95, P = 0.02), and 0.70 (95% CI 0.53 to 0.93, P = 0.01) in CVD patients. Leisure MVPA was associated with the most health benefits, nonleisure MVPA with little health benefits, and occupational MVPA with no health benefits. Study limitations include its observational nature, self-report data about MVPA, and potentially residual confounding despite extensive adjustment for lifestyle risk factors and health-related factors.

Moderate to vigorous physical activity (MVPA) is strongly associated with risk reductions of noncommunicable diseases and mortality. Cardiovascular health status may influence the benefits of MVPA. We compare the association between MVPA and incident major adverse cardiovascular events (MACE) and mortality between healthy individuals, individuals with elevated levels of cardiovascular risk factors (CVRF), and cardiovascular disease (CVD).

Funding: The work of T.M.H.E is supported by the Netherlands Heart Foundation [Senior E-Dekker grant #2017T051]. The Lifelines Biobank initiative received funding from the Dutch Ministry of Health, Welfare and Sport, the Dutch Ministry of Economic Affairs, the University Medical Center Groningen [UMCG], University Groningen and the Northern Provinces of the Netherlands. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data Availability: These third-party data are not freely available. These data cannot be shared publicly because of contractual restriction outlined in the Data Use Agreement for the Lifelines Study and Statistics Netherlands. Researchers seeking to obtain or use data from the Lifelines Study and/or data underlying the results presented in the present study can contact the Lifelines study team ( www.lifelines.nl/researcher/data-and-biobank/all-about-data ) and Statistics Netherlands ( www.cbs.nl/en-gb/onze-diensten/customised-services-microdata/microdata-conducting-your-own-research ).

Copyright: © 2021 Bakker et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

The present study compared the association between the dose of moderate to vigorous (MV) PA and major adverse cardiovascular events (MACE) and all-cause mortality across healthy individuals, individuals with elevated levels of cardiovascular risk factors (CVRF), and individuals with CVD. We also examined the association of the specific domains of accumulating moderate to vigorous physical activity (MVPA), including leisure, nonleisure, and occupational activities on the outcomes, as recent studies suggested that the PA health benefits may differ across the domain in which PA was performed [ 13 ]. We hypothesized that the inverse curvilinear relationship between MVPA volumes and the risk of adverse outcomes, such as typically observed in the general population, will be of lower magnitude in individuals with CVD.

Data from the general population indicate that the benefits of PA on mortality and morbidity follow a curvilinear dose–response relationship [ 1 , 3 – 5 ], indicating that low or moderate volumes of PA yield a large risk reduction, whereas further increases in exercise volumes produce smaller additional benefits. By contrast, studies among cardiovascular disease (CVD) patients show conflicting results. Some studies found a linear association between PA and mortality reductions [ 6 – 8 ], whereas others support the presence of a reverse J-shaped or U-shaped relationship [ 9 – 12 ]. An important limitation of these studies is the inclusion of a single group only, with no study directly comparing the PA dose–response relationship among individuals with different cardiovascular health status.

Regular physical activity (PA) is strongly associated with risk reductions of noncommunicable diseases and mortality [ 1 , 2 ]. The 2020 World Health Organization Physical Activity Guidelines recommend adults to perform at least 150 minutes/week of moderate intensity PA, or 75 minutes/week of vigorous intensity PA, or an equivalent combination of the 2. It also states that individuals with chronic diseases should not follow a “one-size-fits-all” approach and may benefit from alternative exercise prescription. This is especially relevant, given the debate as to whether health status affects the dose–response association between PA and event rate [ 1 , 3 ].

Methods

Study population This study used prospectively gathered data from the Lifelines Cohort Study, a multidisciplinary, population-based cohort of 167,729 individuals living in the northern part of the Netherlands. Lifelines uses a broad range of procedures to assess the biomedical, sociodemographic, behavioral, physical, and psychological factors that contribute to health and disease [14,15]. All inhabitants of the northern Netherlands were eligible for Lifelines except for individuals with (1) severe psychiatric or physical illness (e.g., including individuals with cancer and associated reduced life expectancy); (2) life expectancy <5 years; and (3) lack of fluency in Dutch. Participants ≥18 years old (n = 152,739) were included. Participants were excluded from analyses when (1) no PA data were available (n = 8,666); (2) the participant had an amputated foot or leg (n = 165); or (3) the participant had a disease influencing their ability to be physically active, including multiple sclerosis (n = 347) and Parkinson disease (n = 76) (S1 Fig). We used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline (S1 Table) to report our findings. Participants provided written informed consent as approved by the University Medical Center Groningen Medical Ethical Committee.

Physical examination and questionnaire Participants received a physical examination and completed a baseline questionnaire between 2006 and 2013. The physical examination included anthropometric and blood pressure (BP) measurements. Resting systolic and diastolic BP was based on the average of 10 measurements obtained over 10 minutes using an automated sphygmomanometer (Dynamap, PRO 100V2). Blood samples were obtained after >8 hour of fasting for measurement of total, high-density lipoprotein (HDL), and low-density lipoprotein (LDL) cholesterol, triglycerides, and serum creatinine. Renal function (estimated glomerular filtration rate, eGFR) was estimated [16]. Questionnaires obtained general, lifestyle, and medical data. General information included age, sex, postal code, education level, and income. Income was estimated from Statistics Netherlands [17] using postal codes when not reported. Lifestyle factors included smoking status, alcohol consumption, nutrition intake, and hours of sleep per night. High alcohol consumption was defined as >14 drinks/week or >4 drinks/day for men and >7 drinks/week or >3 drinks/day for women [18]. Smoking status was categorized as currently, previously, and never. Dietary caloric (kcal), protein (g/day), fat (g/day), and carbohydrate (g/day)) intake were assessed using a food frequency questionnaire (FFQ) [19]. Total calories (kcal) and protein, fat, and carbohydrates intake (grams/day) were calculated from the FFQ. The medical history included medication use, presence of CVD, comorbidities, and other illnesses, including cancer, arthritis, multiple sclerosis, and Parkinson disease. Details on the physical examination and questionnaires are described elsewhere [14,15].

Habitual PA volumes Baseline PA was assessed using the Short Questionnaire to Assess Health-enhancing Physical Activity (SQUASH) [20]. SQUASH is divided into transportation, occupation, household, and leisure domains and asks for the duration and intensity of an individual’s typical weekly activities over the past 3 months. Weekly physical activities were converted to the average amount of metabolic equivalent of task (MET) minutes per week based on the compendium of physical activities [21]. MET minutes were calculated by multiplying the MET values of each activity by the duration. Only activities with an MV (≥ 3 MET) intensity were included, since these activities are specified in the PA guidelines [22]. Leisure MVPA contained all activities performed during leisure time. Nonleisure MVPA was defined as PA during transportation, occupation (i.e., intense work activities) and household activities. Subanalyses for occupational MVPA were performed, since previous studies suggest a potential harmful health effect of occupational PA [13]. Total and domain-specific MVPA was used to categorize individuals as inactive individuals (0 MET min/week of MVPA) and into quartiles of MVPA volumes (>0 MET min/week; Q1 to Q4).

Health status Participants were divided at baseline into (1) healthy; (2) CVRF; or (3) CVD. Healthy individuals had CVRF (i.e., BP, cholesterol and glucose) within the normal range and did not have known CVD. Individuals with CVRF had at least 1 of the following at baseline: (1) self-reported hypertension, hypercholesterolemia, or diabetes and used BP-lowering, cholesterol-lowering, or diabetic medications; or (2) had cholesterol levels ≥6.5 mmol/L or glucose levels >6.9 mmol/L fasting or >11.0 mmol/L nonfasting [23,24]; and (3) did not reported CVD. Individuals with CVD reported a history of heart failure, myocardial infarction, or stroke and used cardiovascular medication for these conditions at baseline. The classification of the 3 health status groups was mutually exclusive, meaning the participants were classified into one group.

Clinical outcomes The primary end point was a composite of overall adverse events including MACE and all-cause mortality including CVD mortality. Secondary outcomes were (1) all-cause mortality; and (2) a composite of CVD mortality and MACE. The national death and hospital registry of Statistics Netherlands were used to determine the primary and secondary outcomes. CVD mortality was based on the International Statistical Classification of Disease and Related Health Problems 10th Revision (ICD-10) [25] and included heart, essential hypertension, hypertensive renal, and cerebrovascular diseases deaths (I00 to I78) [25]. MACE was defined as ST-elevated myocardial infarct, non-ST–elevated myocardial infarction, stroke, chronic heart failure, acute heart failure, and major cardiothoracic interventions such as coronary artery bypass grafting, acute and elective percutaneous coronary intervention, and heart transplantation. MACE was classified using the diagnosis treatment codes of the insurance claims from the hospital registry of Statistics Netherlands. When hospital registry data were not available, self-reported MACE during follow-up were used instead. Self-reported MACE was assessed using follow-up questionnaires filled in after a median follow-up of 1.1, 2.1, and 3.8 years. For the date of the self-reported MACE event, we used the date at which the questionnaire was completed. Participants were followed until the first MACE event or death, whichever occurred first. Participants who did not reach the end point were censored at the end of the last assessment.

[END]

[1] Url: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003845

(C) Plos One. "Accelerating the publication of peer-reviewed science."
Licensed under Creative Commons Attribution (CC BY 4.0)
URL: https://creativecommons.org/licenses/by/4.0/


via Magical.Fish Gopher News Feeds:
gopher://magical.fish/1/feeds/news/plosone/