How does physical education prove its significance to lessen the number of mortality rate

Journal Article

David Hupin, MD PhD,

*Department of Clinical and Exercise Physiology University Hospital of Saint-Etienne Autonomic Nervous System Laboratory (EA 4607) PRES Lyon, Jean Monnet University Saint-Etienne, France

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  David Hupin, MD PhD, P Edouard, MD, PhD, V Gremeaux, MD, PhD, M Garet, PhD, S Celle, PhD, V Pichot, PhD, D Maudoux, JC Barthélémy, MD, PhD, F Roche, MD, PhD, Physical activity to reduce mortality risk, European Heart Journal, Volume 38, Issue 20, 21 May 2017, Pages 1534–1537, https://doi.org/10.1093/eurheartj/ehx236

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Fifteen minutes daily physical activity may be a new best target for older adults

A thousand and one virtues for physical activity

Studies from Morris et al.1,2 in the 1950s and Paffenbarger et al.3,4 in the 1970s have stimulated a significant interest in understanding the relationship between physical activity (PA) and cardiovascular disease (CVD)-related mortality. Other researchers followed these 2 20th-century visionaries with new cohort studies including a large number of subjects with long follow-up and hard clinical endpoints (beyond CVD).5,6 Consequently, it is currently clearly evidenced that PA has benefited health regardless of age.

This is underlined by the 1001 epidemiological studies identified from PubMed when using the combination of keywords: (‘Motor Activity’[Mesh] OR ‘leisure time’ OR ‘physical activity’) AND ‘Mortality’[Mesh], limited to English articles dealing with older adults (65+ years) before November 2016. However, while regular PA clearly promotes cardiovascular health and prevents all-cause mortality as claimed by scientific societies,7 the evidence appears to remain insignificant or even denied, when trying to broaden the message to the general public.

Fifty shades of physical activity

Undoubtedly, these non-exhaustive epidemiological studies1–6 are a powerful tool for scientific societies to foster PA implementation among older adults. They clarify the type, intensity, duration, and frequency needed to induce health benefits. Based on these studies, the World Health Organization (WHO) 2016 PA guidelines recommend a minimum of 150 min of moderate-intensity or 75 min of vigorous-intensity PA per week, or an equivalent combination of moderate-to-vigorous PA (MVPA).8 The recommendations for older adults duplicate those for middle-aged adults.9

However, for many older adults, moderate intensity as recommended may seem relevant, while 150 weekly minutes PA may be excessive, explaining why only less than half of them achieve this recommended dose of PA.9 Fortunately, an adjustment is suggested when subjects cannot reach the target, stating that they should ‘be as physically active as their abilities and condition allows’.8 This suggests, but with not so much determination, that doing a little is better than doing nothing. In contrast, numerous studies reported significant benefits of vigorous intensity in reducing mortality.10 Others reported an optimal threshold with a long duration of PA.11 Actually, the prescription of PA for older adults needs to be clarified with more relevant and appropriate recommendations, to encourage them to incorporate regular PA into their lifestyle habits.12 From that point of view, we undertook a clarification of the health benefits, including mortality, of a lower level of PA among older adults, from two different cohorts.

How to assess physical activity?

Physical activity was assessed by self-administered questionnaires investigating 5 different types of PA (domestic and work-related activities, transportation, leisure time and sports) during the 7 previous days. Physical activity was measured in metabolic equivalent of task (MET)-minutes, which refers to the amount of energy (calories) expended per minute of PA.13

Based on Ainsworth’s compendium of PA, resting energy expenditure is assumed to be 1 MET. Physical activity of 3-5,9 metabolic units (METs) is defined as moderate, and PA ≥6 METs is considered as vigorous. A combination of 4 MET PA for 15 min and a 6 MET PA for 15 min 5 days a week is equivalent to 750 MET-minutes per week. Total weekly PA between 500 and 1000 MET-minutes produces substantial health benefits.13

We looked at the associated risk of mortality for four categories of weekly PA in MET minutes, defined as inactive (<1 MET-minute per week, reference for comparison), low (1–499 MET-minutes per week), medium (500–999 MET-minutes per week), or high (≥1000 MET-minutes per week).13

Even a low-dose of moderate-to-vigorousPAreduces mortality by 22% in a large American and Asian population cohort from a meta-analysis.13

A meta-analysis was performed in 2015 from cohorts including subjects aged 60 using PubMed and Embase databases, and highlighted 9 relevant Asian and American cohorts.13

We showed from this meta-analysis of 122 417 subjects aged over 60, with a mean follow-up of 9.8 (±2.7) years (Figure 1), that a low dose of MVPA, i.e. 1–499 MET-minute per week), roughly corresponding to 15 min of MVPA per day, was already associated with a striking 22% reduced risk of death in older adults. These results were even more demonstrative for CVD mortality (25%), compared with those who were inactive (Table 1).13

Figure 1

Meta-analysis design.13

Table 1

Dose of MVPA and adjusted all-cause mortality relative risks compared with adjusted cardiovascular disease and all-cancer mortality relative risks13

The low dose appears in bold for the two cohorts.

MVPA, moderate-to-vigorous physical activity; CI, confidence interval; RR, relative risks.

Table 1

Dose of MVPA and adjusted all-cause mortality relative risks compared with adjusted cardiovascular disease and all-cancer mortality relative risks13

The low dose appears in bold for the two cohorts.

MVPA, moderate-to-vigorous physical activity; CI, confidence interval; RR, relative risks.

Even a low-dose of moderate-to-vigorousPAreduces mortality by 22% in a dedicated European (French) cohort: the PROOF cohort.

The PROOF (PROgnostic indicator OF cardiovascular and cerebrovascular events) cohort study was designed to prospectively assess the predictive value of autonomic nervous system (ANS) activity level among a healthy retired French population, regarding cardiovascular events and mortality (all-cause, CVD, and cancers).14

From the 1011 65-year-old subjects initially included, the 15-year follow-up has been currently completed for 688 (68%) subjects, and 89 (9%) deaths were reported (Figure 2). Among the 234 remaining subjects who did not attend the last follow-up, 145 (14%) did not wish to continue the study, 56 (6%) were excluded for loss of autonomy and living in an institution (exclusion criteria) and 33 (3%) were lost to follow-up without obvious cause. In the whole cohort, the relative risk of death (all causes) was also reduced by 22% [relative risks (RR) = 0.78 [95% confidence interval (CI): 0.25–0.90], P < 0.05] as in the meta-analysis, for subjects achieving a low dose of PA (1–499 MET-minutes per week, i.e. the same low dose as considered in the meta-analysis) compared with an inactive lifestyle (<1 MET-minute per week). This relationship was even more marked for CVD mortality (48%, i.e. RR = 0.52 [95% CI: 0.10–0.98], P < 0.05) (Table 2). Furthermore, any interruption of a previous low dose of PA after retirement, exposed older adults to a three-fold increased risk of CVD (RR = 3.4 [95% CI: 3.1–21] P = 0.001).

Figure 2

PROOF cohort study design.

Table 2

Dose of MVPA and adjusted all-cause mortality relative risks compared with adjusted cardiovascular disease and all-cancer mortality relative risks

The low dose appears in bold for the two cohorts.

MVPA, moderate-to-vigorous physical activity; CI, confidence interval; RR, relative risks.

Table 2

Dose of MVPA and adjusted all-cause mortality relative risks compared with adjusted cardiovascular disease and all-cancer mortality relative risks

The low dose appears in bold for the two cohorts.

MVPA, moderate-to-vigorous physical activity; CI, confidence interval; RR, relative risks.

Even a little is good…

We showed from the meta-analysis as well as the PROOF cohort, that a low dose of MVPA, representing half the WHO recommended amount, was already associated with a 22% reduced risk of death in older adults, compared with those who remained inactive. The most significant benefits concerned CVD mortality with 25% and 48% lower risks, respectively, (Figure 3). Interestingly, this level of PA can be achieved by only a 15-min brisk walk each day, an easy target.11

Figure 3

Relationship between the dose of moderate-to-vigorous-intensity physical activity (MVPA) and mortality reduction. The graph represents all-cause mortality, all-cancer and CVD mortality depending on doses of MVPA for the meta-analysis13 (in dotted lines) and for the PROOF cohort (in full line). Mortality reduction was estimated by percentage (±95% CI) in the figure. MET, metabolic equivalent of task. Relative risks for mortality (with 95% CI) are adjusted for confounding variables (such as age, sex, overweight, smoking, elevated blood pressure, type 2 diabetes, plasma cholesterol level, cardiovascular and chronic diseases, cancer, depression, educational level, and self-reported health), depending on the analysed cohort and causes of deaths. Relative risks for mortality (with 95% CI) are adjusted for age and sex.

…obviously more is better!

Mortality was reduced by the greatest extent (40% and 51%, respectively) in those who engaged in the highest dose of MVPA. Although the highest ratio benefit over MET-minutes per week was achieved at the low level of MVPA, reaching the medium and high levels brought further smaller increments of benefit. Also, the more PA performed by older adults, the greater the health benefit and of course, there is no intention to limit PA for these subjects.

Implications for policy and practice

We think that older adults should progressively increase PA in their daily lives rather than dramatically changing their habits to suddenly meet the highest recommendations levels. Indeed, 15 min a day can be a reasonable primary target for older inactive adults. In that view, small increases in PA may enable some older adults to progressively incorporate more moderate activity and thus get closer to the recommended 150 min per week. This could be achieved by associating leisure time PA and daily life activities. Scientific evidence is now emerging to show that there may be health benefits from light intensity activity (1.6–2.9 METs), and from replacing sedentary activities with light intensity activities, when the dose of MVPA is held constant.

Autonomic nervous system might be key for the low dose health benefits

The PROOF cohort study highlighted ANS as a major health marker, allowing to objectively assess the effects of aging.14 Indeed, aging is associated with a decrease of the ANS activity level, as well as alterations in the balance between its sympathetic and parasympathetic components.15 Measurement of this decline in ANS activity may therefore be a predictor of cardiovascular morbidity and mortality.15,16 Physical activity is known to restore the ANS activity and more particularly its parasympathetic component.15,16 Our data from the PROOF cohort suggest that the positive effects of a low dose of MVPA could be, at least partially, explained by its protective impact on ANS activity.14 ANS up-regulation by the low dose of MVPA may thus be key for successful aging.

Key message: if more may be better, even 15 min is already good

Regular PA is an effective strategy for successful aging. Fifteen minutes of MVPA per day could be a reasonable first-line target for older adults previously physically inactive, or chronically ill. This low dose already prevents the physiological decrease of ANS with age and significantly reduces mortality.

The promotion of PA through this pragmatic message: ‘If more may be better, even a little is already good’ could encourage older adults to substitute a sedentary lifestyle by PA, even of short duration or light intensity.

Edouard P (MD, PhD),1,3 Gremeaux V (MD, PhD),4,5 Garet M (PhD),2 Celle S (PhD),1,2 Pichot V (PhD),1,2 Maudoux D,1 Barthélémy JC (MD, PhD),1,2 Roche F (MD, PhD).1,2

1Department of Clinical and Exercise Physiology, University Hospital of Saint-Etienne, Saint-Etienne, France, 2Autonomic Nervous System Laboratory (EA 4607), University of Lyon, Jean Monnet University, Saint-Etienne, France, 3Inter-University Laboratory of Human Movement Science (EA 7424), University of Lyon, Jean Monnet University, Saint-Etienne, France, 4Rehabilitation Department, University Hospital of Dijon, Dijon, France, 5CIC INSERM 1432, Technological Platform, University of Dijon, France

Conflicts of interest: none declared.

References

References are available as supplementary material at European Heart Journal online.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: .

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: .

Supplementary data

Does physical activity reduce mortality?

What are the significance of physical activity in eliminating lifestyle diseases?

What is the relationship between physical activity and all

How does physical fitness help lessen the risk of lifestyle diseases and contribute to the achievement of one's holistic health?