Evidence supporting the benefits of physical activity on health has been building for over 60 yr. The foundation was laid by Morris and Raffle (17) when they reported cases of myocardial infarction and death among conductors and drivers of London’s double-decker buses. Compared with the sedentary drivers, the physically active conductors experienced a 26% lower incidence of myocardial infarction and 50% lower mortality during 3 yr of follow-up (17). Forty years later, the United States Department of Health and Human Services released the 1996 Surgeon General’s Report in which they outlined the benefits of physical activity and encouraged all individuals in the United States to be more physically active (28). In 2008, the Department of Health and Human Services released the first US guidelines for physical activity (“2008 guidelines”), in which they described a strong dose–response relationship between physical activity, mortality, and the primary and secondary prevention of several chronic diseases (29).
Worldwide, physical inactivity contributes ∼9% to premature mortality (11) and is considered the fourth leading risk factor for mortality (31). Based on meta-analyses, participation in ≥150 min·wk−1 of moderate-intensity aerobic physical activity is associated with a 14% lower risk for mortality (26) and a 14% lower risk for coronary heart disease (27), relative to individuals who are sedentary. Both estimates are higher in women (26,27). In addition, increasing physical activity levels through structured exercise reduces the risk for death and disability due to many chronic conditions, such as ischemic heart disease (1,19), heart failure (19,23), select cancers (15,16), cerebrovascular disease (19,22), peripheral vascular disease (13,18), chronic lower respiratory disease (14), chronic kidney disease (8), and diabetes (8,19).
Although data that support the benefits of being physically active for secondary prevention of chronic disease continues to grow, there is limited data on the prevalence of individuals diagnosed with chronic disease who meet the 2008 guidelines for aerobic physical activity (i.e., ≥150 min·wk−1 of moderate-intensity activity and/or ≥75 min·wk−1 of vigorous-intensity activity). Using a nationally representative sample of noninstitutionalized civilian adults residing in the United States, the purpose of this cross-sectional study was to describe the association between self-reported chronic diseases and the prevalence of adults who meet the 2008 guidelines for aerobic LTPA.
This analysis used data on adults 18 yr or older who participated in the sample adult questionnaire of the 2014 National Health Interview Survey (NHIS). The NHIS is conducted by the National Center for Health Statistics. Launched in 1957, it is a cross-sectional survey based on a multistage probability sample of households of the civilian, noninstitutionalized population in the United States. To be representative of this population, the sampling design involves stratification, clustering, and oversampling of specific subgroups. The sampling plan is modified every decennial census. Data are collected during an in-home interview conducted by trained surveyors. The survey is conducted continuously each year. One adult 18 yr or older residing in the household is randomly chosen to participate in the sample adult questionnaire portion of the NHIS. A total of 36,697 adults were sampled during the 2014 NHIS. Additional information about the survey is available on the NHIS website (20). This study meets the requirements for institutional review board exemption.
Aerobic physical activity data
Aerobic physical activity was assessed through 2 questions that focus on participation during leisure time:
- 1. How often do you do vigorous leisure-time physical activities for at least 10 min that cause heavy sweating or large increases in breathing or heart rate?
- 2. How often do you do light or moderate leisure-time physical activities for at least 10 min that cause only light sweating or a slight to moderate increase in breathing or heart rate?
Participants were then asked to describe the duration of participation at each intensity category. Data were subsequently recoded within the NHIS database into minutes per session and sessions per week. Using these data and calculations provided by the National Center for Health Statistics (20), total minutes per week spent performing light-to-moderate and vigorous physical activities were determined. In these calculations, time spent performing vigorous physical activity was multiplied by 2 and added to the time spent performing light-to-moderate physical activity (i.e., minutes per week = light-to-moderate time + 2 × vigorous time). The level of LTPA was then categorized for each respondent based on the 2008 guidelines into sufficient aerobic LTPA to achieve substantial health benefits (≥150 min·wk−1) or insufficient aerobic LTPA (<150 min·wk−1) (29).
Demographic and clinical characteristics
All demographic and clinical data were self-reported. Participants who reported a Hispanic or Latino ethnicity were categorized as Hispanic. The remaining participants were categorized as non-Hispanic and white, black, American Native/Alaskan Native, or Asian. The presence of arthritis, cancer, chronic obstructive pulmonary disease (COPD), diabetes (type 1 or type 2), myocardial infarction, and stroke were based on response to the question, “Have you ever been told by a doctor or other health professional that you had…” The survey question on diabetes did not include gestational diabetes. Asthma and hypertension were based on the same “ever been told” question plus a secondary question. For asthma, the secondary question was “Do you still have asthma?” For hypertension the secondary question was “Were you told on two or more different visits that you had hypertension, also called high blood pressure?” Kidney disease was based on respondents reporting that they had been told they had “weak or failing kidneys” in the past 12 months. The actual survey questions for each of these conditions are shown in Supplement Digital Content (see Table, Supplemental Digital Content 1, Survey questions and associated variable names from the 2014 NHIS that were used for each chronic condition, http://links.lww.com/MSS/A627). Obesity was defined as a body mass index (BMI) ≥30 kg·m−2, which was calculated from available height and weight data. Based on the work by Ward and Schiller (30), the sample was categorized by the number of chronic diseases for each respondent (i.e., 0, 1, 2, 3, 4, and ≥5).
Because of the complex sampling design of the NHIS, accurate estimates of the population prevalence require the use of a variance weight that is based on the stratum and primary sampling unit. These weights are provided for each record by the National Center for Health Statistics based on the 2010 US Census Bureau population estimates (20). Missing data were managed with pairwise deletion; however, no respondents were excluded from any analysis because this would affect the population weighting (20). Because we were comparing different populations (e.g., individuals with vs. without chronic disease), estimates derived from general linear modeling were age-adjusted based on the 2000 projected US population using three age categories (18–44 yr, 45–64 yr, and 65 yr or older) (9). Logistic regression was used to compute the odds ratio (OR) and 95% confidence interval (CI) for the dichotomous dependent variable of sufficient volume of aerobic LTPA (≥150 min·wk−1). To compute the OR per decade of age, age was divided by 10 and treated as a continuous variable. SPSS version 21 with the Complex Samples module was used for all analyses. Unless otherwise noted, data are reported as mean estimated prevalence (%) ± SE.
The prevalence estimates for select demographic and clinical characteristics of the US civilian, noninstitutionalized adult population 18 yr or older are shown in Table 1. Overall, the age-adjusted prevalence of individuals who reported sufficient volume of aerobic LTPA (≥150 min·wk−1) was 50.1% ± 0.5%. Men were more likely than women to report sufficient aerobic LTPA (age-adjusted = 53.4% ± 0.6% and 47.1% ± 0.6%, respectively; P < 0.001). The OR associated with sufficient aerobic LTPA per 10 yr of age was 0.82 (95% CI, 0.80–0.84; P < 0.001) among men and 0.83 (95% CI, 0.81–0.85; P < 0.001) among women.
The age-adjusted prevalence estimates of adults who reported sufficient volume of aerobic LTPA by select chronic diseases are shown in Figure 1. Within all chronic disease categories, the prevalence of sufficient aerobic LTPA was lower than the estimate for apparently healthy adults without a chronic condition. The lowest estimates were observed among individuals who reported a history of myocardial infarction, diabetes, kidney disease, stroke, and COPD. The prevalence of sufficient aerobic LTPA was lower among women compared with men within each chronic condition except stroke and COPD (Table 2).
The impact of multiple chronic conditions on the prevalence of sufficient volume of aerobic LTPA is shown in Figure 2. In a multiple logistic regression adjusted for age and sex, each additional chronic disease was associated with an OR of 0.83 (95% CI, 0.81–0.85; P < 0.001) for sufficient aerobic LTPA.
Using a nationally representative sample of noninstitutionalized civilian adults residing in the United States, we estimated the prevalence of adults who meet the 2008 guidelines for aerobic LTPA in the presence of various chronic diseases. Compared with apparently healthy adults, the presence of a chronic disease was associated with a lower prevalence of adults who reported sufficient volume of aerobic LTPA to achieve substantial health benefits as defined in the 2008 guidelines (i.e., ≥150 min·wk−1). Although the highest prevalence of sufficient aerobic LTPA was 54% among apparently healthy adults, the five chronic conditions associated with the lowest prevalence were myocardial infarction (40%), diabetes (36%), kidney disease (31%), stroke (31%), and COPD (26%). Similar patterns were observed for men and women. However, the prevalence of sufficient aerobic LTPA was 2% to 16% lower among women compared to men across all adults and within each chronic condition except stroke and COPD (Table 2). Relative to no chronic disease, each additional chronic disease was associated with 17% lower odds of meeting the 2008 guidelines for aerobic physical activity.
In a related analysis, Crespo et al. (6) reported the prevalence of no LTPA for 11 chronic conditions among adults ages 20 yr or older based on data from the National Health and Nutrition Examination Survey III (conducted 1988 to 1994). In that study, each chronic condition was associated with a higher prevalence of no LTPA. The five conditions associated with the highest prevalence of no LTPA were bronchitis (35%), diabetes (37%), stroke (41%), emphysema (42%), and heart failure (48%). In addition, compared with adults 40 to 59 yr of age, those ≥60 yr were more likely to report no LTPA. Finally, women were more likely than men to report no LTPA across all adults and within each chronic condition except skin cancer (6).
In another related study, Kruger et al. (10) reported the prevalence of no LTPA among adults ages 50 yr or older in relation to five chronic conditions based on data from the 2005 Behavioral Risk Factor Surveillance System. The prevalence of no LTPA was 26% among those without a chronic disease, 34% for arthritis, 39% for myocardial infarction, 40% for obesity, 42% for diabetes, and 45% for stroke. In addition, the prevalence of no LTPA was positively associated with age and was higher among women for all groups except individuals with a BMI < 25 kg·m−2 (10).
There are four categories that are often reported for aerobic LTPA: 1) no LTPA, 2) insufficient LTPA (<150 min·wk−1), 3) sufficient LTPA (≥150 min·wk−1), and 4) highly active (>300 min·wk−1). Although the studies by Crespo et al. (6) and Kruger et al. (10) reported the prevalence of no LTPA, we chose to focus on individuals who reported aerobic LTPA sufficient to achieve substantial health benefits consistent with the 2008 guidelines of ≥150 min·wk−1. By focusing on sufficient LTPA, we hoped to highlight the magnitude of the opportunity to improve public health by increasing aerobic LTPA among individuals who are insufficiently active, including those who are sedentary. Based on the prevalence of sufficient aerobic LTPA reported herein, 51% to 74% of adults in the United States with any one of these chronic diseases are insufficiently active or sedentary and would likely improve their health by increasing time spent performing aerobic LTPA.
The importance of increasing LTPA among individuals who are insufficiently active was highlighted by Carlson et al. (2) Based on US population survey data collected between 2004 and 2011, they reported that 11% of aggregated health care costs were associated with insufficient LTPA (2). Both public health and health care can play roles in increasing physical activity levels. National and international public health organizations have begun this effort with professional statements that highlight the problem (29,31). Unfortunately, based on the data from the NHIS, between 1998 and 2008, little progress has been made in increasing physical activity levels (3).
The importance of physical activity assessment and counseling through the health care system has been recommended (25). Central to this is the physical activity (or exercise) vital sign (25). When included in an electronic medical record and added to the workflow of medical assistants, it resulted in higher rates of physical activity documentation by physicians in progress notes and better outcomes for patients who were overweight or had diabetes (7). In addition, adults who reported a disability secondary to vision, cognition, or mobility were 82% more likely to be active if they had been encouraged to do so by a health care professional in the prior 12 months (4).
A challenge to increasing LTPA is access to professionals who are trained in the acute and chronic responses to exercise in health and disease (25). The role of physical activity and health is not a central cognate in medical school education. In addition, physical activity counseling and advice may not be the best use of physician time. The only professionals with formal training in the health benefits of physical activity are exercise physiologists, clinical exercise physiologists, and physical therapists. However, with the exception of cardiac and pulmonary rehabilitation—both of which require specific diagnoses of overt disease—there are few exercise options for patients with chronic disease that are covered by health insurance. Additional programmatic models that improve patient access to exercise professionals are needed.
New opportunities may be on the horizon through the Affordable Care Act which requires that insurances offered through the Affordable Care Act Marketplace provide preventive services without cost sharing that have received a recommendation grade of “A” or “B” (e.g., high/moderate certainty of benefit) by the US Preventive Services Task Force (5). The US Preventive Services Task Force recently recommended (grade: B) that individuals who are overweight/obese and have additional risk factors for cardiovascular disease should be offered intensive behavioral counseling aimed at promoting a healthy diet and increased physical activity (12). According to Omura et al. (21), 19.9% of adults in the United States meet these criteria and report physical activity below the 2008 guidelines.
The present results are subject to at least three limitations. First, all data were ascertained through self-report. This may have resulted in some misclassification of LTPA habits and chronic diseases due to recall bias. Self-reported physical activity habits tend to be higher than objective measurements (24). It is unknown whether this bias would be different for individuals with chronic disease. If recall bias is similar across subgroups, then there would be minimal effect on the reported results. Second, it is important to note the limitations in the NHIS physical activity questions with light-intensity activity included with moderate-intensity activity and a focus on leisure time activities. The former might overestimate and the latter underestimate the true prevalence of physical activity. However, this error would likely be constant across subgroups with little impact on the disparities noted. Finally, although representative of noninstitutionalized adults living in the United States, it is unknown whether our results can be generalized to institutionalized adults, military personnel, children, and individuals living in other countries.
Although the association between physical activity and health is well known, the prevalence of adults in the United States who perform sufficient volume of aerobic LTPA to achieve substantial health benefits continues to be low. The prevalence of sufficient aerobic LTPA is inversely related to age and is lower among women and those with a chronic disease. Systems to regularly assess physical activity are needed as well as programs to help individuals be more active.
No financial support was received for this study. The results of the present study do not constitute endorsement by ACSM.
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Keywords:© 2016 American College of Sports Medicine
PHYSICAL INACTIVITY; HYPERTENSION; DIABETES; HEART DISEASE; CANCER