Recommended physical activity and all cause and cause specific mortality in US adults: prospective cohort study
BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m2031 (Published 01 July 2020) Cite this as: BMJ 2020;370:m2031
All rapid responses
We congratulate Zhao et al on their timely study, that very much falls into category of research labelled “the road less travelled”. Positive results promoting a free intervention (exercise); with the potential to prevent disease, reduce mortality and reduce the healthcare costs of Long-Term Conditions (LTC) in patients. The authors comment that only 4 studies have previously reported results on the association between patients meeting physical activity guidelines and all cause mortality. If this is the state of our evidence base, it is no wonder why exercise is so often forgotten and perhaps the most underused intervention available to clinicians today.
If exercise was a pharmaceutical product, with commercial potential it most certainly would be undergoing a re-branding. We propose a three-pronged strategy. Firstly, exercise should not be a binary target, some is better than none and more is better than less. Increases in physical activity even below the recommended guideline amounts is associated with a reduction in all-cause mortality (1,2). Secondly, we need to lead by example, and that includes seamlessly integrating exercise into referral and treatment pathways to prevent and treat LTC’s. Thirdly and finally we can’t do this alone, not without social policies that promote active lifestyle in work and leisure time and that provide funding for research on exercise interventions.
1. Ekelund Ulf, Tarp Jakob, Steene-JohannessenJostein, Hansen Bjørge H, Jefferis Barbara, Fagerland Morten W et al. Dose-response associations between accelerometry measured physical activity and sedentary time and all cause mortality: systematic review and harmonised meta-analysis BMJ 2019; 366 :l4570
2. Leitzmann MF, Park Y, Blair A, et al. Physical Activity Recommendations and Decreased Risk of Mortality. Arch Intern Med. 2007;167(22):2453–2460. doi:10.1001/archinte.167.22.2453
Competing interests: No competing interests
Dear Editor
Good news for the government and the public: exercise really is good for us: data from half a million Americans reports the impact of strength and conditioning exercise: a 40% reduction in the risk of death from cardiac, respiratory or malignant causes[1]. This observational dataset is both statistically and clinically important, suggesting that for close to zero healthcare spending, a substantial societal health gain can be made.
In more good news, NICE guideline 157 published last month may have a similar impact for those whose knees are worn out by their exercise regime[2]. NICE recommends that all eligible patients be offered the choice of partial or unicompartmental knee replacement (UKR), which also offers a 40% reduction in the risk of dying at 10 years (14% mortality following UKR vs 23% following total knee replacement (TKR) according to the Australian National Joint Registry)[3]. The National Joint Registry of England and Wales last published this statistic back in 2012 (8% mortality following UKR vs 18% following TKR at 7 years postop). While UKR isn’t ‘no cost’, last year a large RCT confirmed it to be cheaper and more effective than TKR[4]. It is also now performed routinely in a day case setting[5].
So if lockdown exercise keeps us healthy but wears our knees away, a small safe and effective intervention is available. About half of the 100,000 knee replacements could be done this way[6], saving thousands of lives and perhaps £50m a year.
1. Zhao, M., et al., Recommended physical activity and all cause and cause specific mortality in US adults: prospective cohort study. BMJ, 2020. 370: p. m2031.
2. Joint replacement (primary): hip, knee and shoulder NICE guideline [NG157]. 2020.
3. AOANJRR, Mortality following Hip and Knee Arthroplasty. 2018: Adelaide 2018. p. 8-9.
4. Beard, D.J., et al., The clinical and cost-effectiveness of total versus partial knee replacement in patients with medial compartment osteoarthritis (TOPKAT): 5-year outcomes of a randomised controlled trial. Lancet, 2019.
5. Kort, N.P., Y.F. Bemelmans, and M.G. Schotanus, Outpatient surgery for unicompartmental knee arthroplasty is effective and safe. Knee Surg Sports Traumatol Arthrosc, 2015.
6. Willis-Owen, C.A., et al., Unicondylar knee arthroplasty in the UK National Health Service: An analysis of candidacy, outcome and cost efficacy. Knee, 2009.
Competing interests: No competing interests
Dear Editor,
I congratulate Zhao and colleagues for their very interesting research article about the association of recommended physical activity and all cause and cause specific mortality in the current issue of BMJ [1]. Once again proven: Exercise is and remains the cornerstone of robust good health because it significantly prevents a wide range of diseases, maintains everyday motor skills, and underpins our mental health and sense of well-being.
In this context, it is hardly known that the physician Christoph Schorer (1618-1671) from Memmingen in Germany wrote over 340 years ago one of the first recommendations on physical activity for health in the German language for the general population. He already recommended at that time, for example, a 30 minute walk every morning and regular interruptions to prolonged sitting time [2]. In his "Rules of Health", Schorer advised a moderate lifestyle and balance. In addition to chapters on air, food and drink, he formulated thirteen physical activity recommendations in the chapter 'On Exercise'. In his first rule it says: "Exercise is very necessary for maintaining good health." And in the thirteenth recommendation he wrote, for example [3]: "Those who write a lot and study in a seated position, indeed all those who must have a seat leather, should at least spend half an hour before and after lunch and dinner doing an exercise at least with walking up and down." In the following chapter 'On Rest' Schorer again underlines: "Except in cases of need, sitting or lying down is harmful and causes a lot of illness."
According to Schorer, too, the possibilities of physical activity in today's nervous age, from childhood to old age, urgently need to be cultivated more intensively and robust public infrastructures created for the population-wide desire for movement. In conclusion, the physician wrote in 1677 [3]: "My dear friends, who read this and my health rules, do not mock your physical and mental health, let them be better applied to you, accept with a good mind what I have written from a good heart; and believe that if these rules, when you observe them as much as possible, do not prevent you from death, they will be able to save and protect you from many diseases and pains."
REFERENCES
1. Zhao M, Veeranki SP, Magnussen CG, Xi B. Recommended physical activity and all cause and cause specific mortality in US adults: prospective cohort study BMJ 2020;370:m2031. doi: 10.1136/bmj.m2031.
2. Hofmeister M. Physical activity tips from the 17th Century. Bewegungstherapie und Gesundheitssport 2015;31:205-207. doi: 10.1055/s-0035-1550126. [German].
3. Schorer C. Rules of health, travelers and natives, high and low, scholars and unlearned, useful to read and even more useful to follow. Augsburg, Germany: Göbels; 1677. [German].
Competing interests: No competing interests
Re: Recommended physical activity and all cause and cause specific mortality in US adults: prospective cohort study
Dear Editor,
Further to the article on physical activity, all cause mortality and specific mortality, the research is timely in its conclusion that the largest survival rates in the population surveyed were those who engaged in both aerobic and muscle strengthening activities. (1)
In clinical practice, it is often difficult to go through the specifics of exercise prescription, due to time and comprehension constraints. A simple message often works best. Particularly if this message incorporates the state of the art science which has been provided by this and other informative papers, which recommend 150 minutes or more of moderate intensity exercise a week
The game of golf provides this very prescription. There are different ways to play golf. Walk carrying a bag, pulling a bag, using an electric caddy car or driving in a golf buggy. Each have different energy expenditures and physiology affects. There are known physiological numbers for a variety of activities, called Metabolic Equivalent Units (METs) ( 2 ), which a numerical score of the energy spend of an activity. METs are also used to score an individuals aerobic fitness level or functional capacity. METs are useful when prescribing exercise in different populations.
The average 50-year-old male has an aerobic capacity of 9.2 METs and a female 8.2 MET. (3). Playing golf carrying a golf bag gives you a MET spend of 5.5 METS, pulling a caddy car a metabolic spend of 5METS, whereas an electric caddy car will only utilise 3.5 METs. Assuming average fitness levels, playing golf while carrying a bag or pushing a caddy car will put the 50 year old exerciser into the moderate intensity bracket of 60-85% of functional capacity. This fits neatly into the optimal exercise as described in the paper.
Therefore, playing 9 or 18 holes regularly carrying your golf clubs on your back or pushing a caddy car will give you the required exercise prescription, significantly enhance your wellbeing and survival potential. More physical activity than the minimal recommendation of 150 minutes of moderate intensity activity a week is reported as providing greater health benefits. Thus, extra rounds of golf will have an added wellness enhancement.
In 1948 Mark Twain stated that golf was a good walk spoilt. This research questions Twain`s words Golf is better described as a good walk enhanced, as it add the element of resistance activity with episodes of anaerobic activity, in the golf swing, to the aerobic walk.
Unlike so many things in medicine this is a positive message to give a patient. So often a doctor has to deliver unpleasant news to the patient about their life style and remove something pleasurable from their compendium of life activities. This message is different. Play golf. A few days a week if you can and carry your bag or push the bag if you are able. Simple messaging such as this should yield dividends for the health and wellbeing and survival rates of the population. It could be paraphrased as: “A round a day keeps the doctor away”
1. Zhao, M., et al., Recommended physical activity and all cause and cause specific mortality in US adults: prospective cohort study. BMJ 2020;370:m2031
2 Arena , Myers ,Williams et al Assessment of Functional Capacity in Clinical and Research Settings. A Scientific Statement From the American Heart Association Committee on Exercise, Rehabilitation, and Prevention of the Council on Clinical Cardiology and the Council on Cardiovascular Nursing. Circulation 2007;116:329–343
3 Riebe; Ehrman; Liguori et al . American College of Sports Medicine, guidelines for exercise testing and prescription 10TH Ed, Philadelphia : Wolters Kluwer, [2018]
Competing interests: No competing interests