LivingLongerThroughPhysicalActivity

Jul 25, 2016 |Catherine Wong, MD; Mary Whooley, MD, FACC
ExpertAnalysis

There is no debate: physically active people live longer than their inactive
counterparts. This relationship has been demonstrated in a variety of populations,
including men and women, middle-aged and older adults, and patients with and
without cardiovascular disease (CVD).1-15 The magnitude of benet is enormous;
moderate exercise has been associated with up to a 40% relative risk reduction in
mortality and a 3-year increase in longevity.5,6 The most recent (2008) Oce of
Disease Prevention and Health Promotion Physical Activity Guidelines Report
recommends 150 minutes per week of moderate aerobic exercise (e.g., brisk
walking or tennis) or 75 minutes per week of vigorous aerobic exercise (e.g.,

jogging or swimming laps).16 However, signicant mortality benet is seen even at

very low levels of physical activity and rises in a dose-dependent manner up to
four times the guideline recommended amount.4-8,17,18 Understanding the
nuances of how physical activity relates to mortality can help clinicians better
translate physical activity recommendations into practice.
No randomized controlled trials have directly looked at the eect of physical
activity on mortality because lifetime follow-up is rarely feasible. However,

signicant evidence suggests that the relationship is causal.19 Numerous high

quality observational studies have demonstrated a strong and consistent

relationship between increased physical activity and decreased mortality.4-8,17,18

Furthermore, studies have demonstrated that the relationship is appropriately
sequenced, with physical inactivity preceding the development of cardiovascular
disease, and that the relationship is dose-dependent, with increasing amounts of
physical activity conferring increasing survival within a certain range. Finally, there
are several biologically plausible mechanisms that can explain the connection.
Thus by the same criteria used to declare a causal relationship between smoking
and cancer, a relationship also lacking the support of RCT data, it can be
concluded with near certainty that physical activity and decreased mortality are
causally related.
Some of the mortality benet seen with physical activity is achieved via a
reduction in traditional cardiovascular risk factors. RCTs have demonstrated that

exercise can reduce obesity, hypertension, dyslipidemia, hyperglycemia, and

smoking.20-26 Unfortunately, the short-term absolute reduction in these risk

factors is modest, even with substantial intervention. For example, after a sixmonth supervised exercise intervention of 90 to 120 minutes of vigorous exercise
per week, Blumenthal et al. demonstrated only a 4 mmHg reduction in systolic

and diastolic blood pressure.24 Stefanick et al. showed that exercise alone did not
signicantly reduce low-density lipoprotein cholesterol (LDL-C) levels, but when
combined with a low-fat diet, exercise led to a mean reduction of 20 mg/dL in
LDL-C.20 The impact of exercise on obesity has been similarly
underwhelming.21,22 In a study by Villareal et al., obese elderly adults who
exercised one to two times the guideline amount achieved no signicant weight
loss.22 A younger overweight cohort was able to achieve some weight loss, but
only after a considerable exercise regimen of running 19km (approximately 12

miles) per week for a year.21 Nonetheless, the modest short-term benets of
exercise may have substantial long-term benets. Moreover, other pathways, in
addition to traditional cardiovascular risk factors, may also mediate the mortality
benet conferred by exercise.
Accordingly, several large-scale observational studies have shown that the
association between physical activity and mortality persists, even after adjusting

for body mass index, smoking, cholesterol, hypertension, and diabetes.3-5

Inammation, currently a hotly debated topic in cardiology, could potentially
explain some of the remaining association. Physical activity has been shown to be
independently associated with lower levels of inammatory markers, such as Creactive protein.27,28 C-reactive protein has, in turn, been shown to be

independently associated with major cardiovascular events.29 Because of the

inherent limitations of observational data, it remains to be denitively shown
whether exercise can decrease inammatory markers and, more importantly,
whether reducing inammation can improve survival. Further research is needed
to clarify the interplay between inammation, exercise, and mortality. Other
subclinical measures of CVD, such as intimal medial thickness, vascular endothelial
function, and vagal tone, also have potential to explain some of the mortality
benet seen with exercise.30,31

Although most of its mortality benet comes from reducing cardiovascular

mortality, physical activity decreases cancer-specic mortality as well. Specically,
exercise has been shown to reduce the risk of developing breast, prostate, and
colon cancer,32-34 possibly via its modulation of sex and metabolic hormones.
Individuals who exercise at or above the guideline recommended amount are 10
to 15% less likely to die from cancer as compared to those who are inactive.4
Furthermore, even after a diagnosis of cancer, physical activity may continue to

slow disease progression and confer survival benet.11 Notably, the benets of
exercise may be comparable to those of breast or colon cancer screening in
reducing the risk of cancer, especially when combined with other modiable
lifestyle interventions.35-37

In summary, exercise signicantly reduces the risk of developing and dying from
CVD and cancer. Although clinicians and patients have long recognized the
importance of physical activity, its adoption remains shockingly low. In the US,
approximately one quarter of adults report no physical activity at all, and nearly

half fail to meet guideline recommended amounts.38,39 An incomplete

appreciation of how physical activity actually brings about health benets may
pose a barrier to the adoption of regular exercise. Clinicians and patients often
overemphasize the importance of surrogate endpoints, such as weight loss and
cholesterol reduction, and overlook the signicant long-term cardiovascular and
cancer-related mortality benets that are achieved even when there is little
immediate reduction in cardiovascular risk factors. Even when the long-term
benets of exercise are appreciated, many patients nd it dicult to sustain
behavioral changes without more proximal rewards and can be discouraged when
surrogate endpoints are slow to attain, as they often are. Instead, clinicians should
emphasize that exercise has substantial long-term benets on mortality and
should encourage patients to nd physical activities that they nd enjoyable. Even
without short-term improvement in traditional risk factors, routine physical activity
at any dose reduces the long-term risk of dying from cancer or CVD.
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Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia,
Prevention, Lipid Metabolism, Nonstatins, Diet, Exercise, Hypertension,
Smoking
Keywords: Adult, Biological Markers, Blood Pressure, Body Mass Index, C-Reactive Protein,
Cardiovascular Diseases, Cholesterol, LDL, Colonic Neoplasms, Diabetes Mellitus, Diet, FatRestricted, Disease Progression, Dyslipidemias, Early Detection of Cancer, Exercise Therapy,
Health Promotion, Hyperglycemia, Hypertension, Inammation, Life Style, Longevity, Obesity,
Overweight, Prostate, Risk Factors, Smoking, Weight Loss

2016 American College of Cardiology Foundation. All rights reserved.