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For CVD patients, no upper limit to benefits from physical activity — Lifelines Cohort Study

While risk reduction for healthy individuals plateaus at higher levels of physical activity, those with cardiovascular disease (CVD) have no upper limit of physical activity beyond which there is no further benefit, found a study in PLOS Medicine.

The research, by Thijs Eijsvogels at Radboud University Medical Center, The Netherlands, and colleagues, suggests that cardiovascular health status affects the association between physical activity and health outcomes is not well understood. To investigate, researchers used prospectively gathered data from the Lifelines Cohort Study, a population-based cohort of 167,729 individuals living in the Northern Netherlands. They compared the association between physical activity and major adverse cardiovascular events as well as all-cause mortality across healthy individuals, individuals with elevated levels of cardiovascular risk factors, and individuals with cardiovascular disease.

They found that increasing physical activity reduced mortality risk in all groups. However, health benefits appeared to level-off above a certain volume of physical activity in healthy individuals and those with cardiovascular risk factors. In cardiovascular disease patients, the researchers found no evidence of an upper physical activity limit above which there is no further health benefit.

The study was limited in that it relied on self-reported physical activity data from participants, so future research is needed to further validate the findings.

According to the authors, “These findings suggest that cardiovascular disease patients should be encouraged that ‘more is better’ in regard to physical activity. Physical activity recommendations should not follow a ‘one-guideline-fits-all’ approach but underline the need for precision medicine in which physical activity prescription may be dependent on, among other factors, a person’s cardiovascular health status.”

Study details
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 142,493 adults from the Netherlands

Esmée A. Bakker, Duck-chul Lee, Maria T. E. Hopman, Eline J. Oymans, Paula M. Watson, Paul D. Thompson, Dick H. J. Thijssen, Thijs. M. H. Eijsvogels.

Published in PLOS Medicine on 2 December 2021

Abstract

Background
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).

Methods and findings
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 (Q25 5.7; Q75 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.

Conclusions
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.

Author summary

Why was this study done?
• There is debate to whether cardiovascular health status affects the dose–response association between physical activity (PA) and health outcomes.
• Studies among cardiovascular diseases (CVDs) patients found different associations between PA and mortality reductions, which were described as linear, J shaped, or U shaped.
• Recent studies suggested that the cardiovascular health benefits or risk of death of PA may be domain specific as different outcomes were reported for leisure versus occupational PA.

What do these findings mean?
• MVPA is associated with risk reductions in all groups, but, especially, CVD patients should be encouraged that “more is better” regarding PA.
• PA recommendations could be optimised by taking cardiovascular health status and the domain of MVPA into account.

 

PLOS Medicine article – 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 142,493 adults from the Netherlands (Open access)

 

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