Each of these dose–response relations seemed to be linear across the ranges of daily steps and change in daily steps. The linear relationships and effect sizes approximate those observed by Dwyer et al. (11) in a nondiseased population.
Daily step counts, metabolic syndrome, and type 2 diabetes incidence
Using NAVIGATOR data, Huffman et al. (12) observed a relationship of daily steps with metabolic syndrome score: for every incremental of 2000 greater baseline daily steps, there was a 29% reduction in the 6-yr metabolic syndrome score. Ponsonby et al. (13) estimated that for any average daily step count, additional 2000 steps were associated with a 25% reduction in incidence of dysglycemia over the succeeding 5 yr. Similar to the NAVIGATOR studies (12,16), the relationship between daily step count and health outcome seemed linear in Ponsonby et al. (13).
In a study published just after the search date for this article, Kraus et al. (21) reported on the relationship of baseline daily step counts and incident type 2 diabetes in the NAVIGATOR study. Pedometer data were obtained on 7118 participants, and 35% developed diabetes. In an unadjusted analysis, each 2000-step increment in the average number of daily steps up to 10,000 was associated with 5.5% lower risk of progression toward diabetes (hazard ratio, 0.95; 95% confidence interval, 0.92–0.97), with a >6% relative risk reduction after adjustment. This relationship also seems linear.
Demographic factors and weight status
The risk reduction for incident cardiovascular events reported in NAVIGATOR was not affected by weight status, sex, age, geographical region, or level of baseline steps per day (16). Negative associations between daily steps and metabolic syndrome score reported in NAVIGATOR were independent of weight status (12). Ponsonby et al. (13) reported associations that were also independent of weight status when examining daily steps and dysglycemia. Thus, for studies evaluating effect modification by demographic or weight status, none were found. Despite these findings, the evidence on these factors was not sufficient for the Committee to draw a conclusion about any relationship.
The 2018 PAGAC report (4), strengthened by recently published research (11,14,21), supports using daily step count as a viable metric for assessing the association of physical activity with CVD events, type 2 diabetes mellitus onset, and all-cause mortality.
There is a striking contrast between the linear relationship of steps with mortality, CVD, and type 2 diabetes when compared with the rapidly negative curvilinear relationship of moderate-to-vigorous physical activity for these same health outcomes (see an article in this by Kraus et al. (20)). This contrast raises the question as to whether the apparent linear relationship of daily steps with the measured health outcomes is due to the contribution of light-to-moderate habitual daily activities. There are other possible explanations for this contrast between the shapes of the curves for step counts and moderate-to-vigorous physical activity on mortality. For example, measurement error, wear time, and other factors can affect the data gathered by physical activity trackers (3). That said, very low exposures—those with relatively few daily steps—contribute to reduced disease risk, albeit to a lower extent or with less impact than even a small amount of moderate-to-vigorous physical activity. Certainly, light activity contributes to reduction in disease risk (22). These issues will need to be sorted out with more research.
Finally, it remains unclear how many steps provide the optimal health benefit for the general population and for specific health benefits for those with existing disease. The traditional 10,000 step target already is being adopted by some countries (23) as a national public health goal. Is this the right number? Populations around the world are experiencing both increases in sedentary time (24) and decreases in habitual daily physical activity (25). Estimates that current moderate-to-vigorous physical activity guideline targets constitute 3000 to 6000 daily steps (26,27), when added to spontaneous “background activity” of 2500 to 5000 steps, might suggest that one should aim for more than 10,000 steps per day as a public health target to counteract the effects of increasing sedentary time (24,28).
A specific example might be helpful. A sedentary individual finds that she uses 5000 steps per day in normal daily activity. She measures the number of steps in a 10-min brisk (moderate-intensity) walk to be 1000 steps. Therefore, she finds she can meet the US physical activity guidelines for brisk walking of 150 min·wk−1 by adding approximately 2000 brisk walking steps per day to her baseline activities of daily living—or aim for 7000 steps per day, of which 20 min·d−1 is in the form of her daily walk. Pertinently, a 2011 position stand from the American College of Sports Medicine recommends that adults obtain at least 7000 steps per day (29).
However, there is at least one cautionary note. For some populations, 10,000 daily steps might have harmful effects. Limited data suggest a possible progression of osteoarthritis at step count per day greater than 10,000 (see also an article in this issue by Kraus (30)). However, as argued earlier, these step counts per day do not exceed those equivalent to the current physical activity guidelines.
Daily step counts are a readily accessible means by which to monitor and set physical activity goals (see an article on physical activity promotion in this issue (2)). In this review, we point to emerging evidence of a linear inverse dose–response relationship of daily steps with important health outcomes, including all-cause mortality, cardiovascular events, and type 2 diabetes. However, more evidence will be required before these observations can be translated into public health guidelines.
Public health impact
Steps are a basic unit of locomotion and as such provide an easy-to-understand metric of ambulation—an important component of physical activity. Measuring daily step counts can motivate diverse samples of individuals to increase physical activity levels (see the physical activity promotion article in this issue (2)). Increasingly, the self-assessment of steps can be accomplished through objective, readily obtainable technology with physical activity trackers, particularly those worn on the wrist or finger. Unlike the measure of moderate-to-vigorous physical activity in minutes per week or weekly energy expenditure (e.g., MET-minutes), the metric of step counts per day provides a comparable denominator to how dietary energy intake in most dietary guidelines is standardized—per day. As a result, daily steps counts might provide a useful tool for researchers and the public to address a variety of health and physical activity issues. In addition, steps can be at light-, moderate-, and vigorous-intensity levels, providing a range of exertion choice to promote walking at all ages and for all levels of fitness in the context of physical activity monitoring and prescription. For these reasons, measuring of daily step counts has the potential to significantly improve the translation of research findings into public health recommendations, policies, and programs.
Because four of the originally reviewed studies were derived from one study—the NAVIGATOR trial, containing generally older individuals where the generalizability of the findings is suspicious—the Committee originally determined that there was insufficient evidence available to determine whether a relationship exists between steps per day and all-cause and CVD mortality. The grading of the accumulated evidence is available in Supplemental Digital Content 2 (see Table, Supplemental Digital Content 2, evidence statements for conclusions, http://links.lww.com/MSS/B540). However, in the interim, two new articles have come to our attention supporting the relationship between step counts per day and mortality (11,14). The Committee determined that there was limited evidence suggesting that daily step counts are associated with reduced incidence of CVD events and risk of type 2 diabetes. In the interim, one new article has been published supporting the relationship of step counts per day and type 2 diabetes incidence (21); however, this finding was from only one study—the NAVIGATOR trial—and more evidence may be required to change this strength of evidence determination. The Committee determined that there was limited evidence suggesting a dose–response relationship between the measure of steps per day and CVD events and type 2 diabetes risk. However, there are new dose–response data in this report demonstrating a linear relation of step counts per day with all-cause mortality, CVD events, and type 2 diabetes. Finally, the Committee determined that there was insufficient evidence available to determine whether the relationship between the measure of daily step counts and CVD events and type 2 diabetes risk is influenced by age, sex, race/ethnicity, socioeconomic status, or weight status. Thus, although the evidence base supporting the use of daily step counts as a metric for physical activity with respect to its effect on health outcomes is growing, and new evidence supports the previously determined limited evidence, still there is much work to be done before it can be fully adopted.
Needs for future research
Despite a developing literature on the relation of daily step counts and important health outcomes, there remains an insufficient literature to support using this metric as a public health metric for monitoring physical activity exposure. Given this, more research is needed in the following areas.
Advance the understanding of daily step counts and health in research addressing the equivalency of steps per day measured using various devices. Rationale: Peripheral activity monitoring devices include spring-suspended lever arm pedometers, accelerometers converting movement count or gravitational constant data to steps per day, three-dimensional accelerometer-based activity trackers, and smartphone–based mobile applications using internal accelerometers. However, with ever increased interest in personalized health monitoring and more options becoming increasingly available over time, without equivalency research, dose–response understandings will be specific to each device. In addition, newer devices, which more finely parse data, are likely to provide more sensitive metrics for capturing health-related walking behavior—for instance, intensity of steps per day, average stepping rate per day, and stepping cadence. Conversely, advances in daily step count research will inform decisions by product engineers and consumers as to what features are most useful in personalized health monitoring.
Develop more information on the metrics of daily step counts useful for understanding the relationship of steps per day with health outcomes, develop more understanding of the relation of pedometer-measured and accelerometer-measured steps per day, and explore the relationship between stepping cadence and health. This foundational information is critical to understanding how we might use legacy data—such as from National Health and Nutrition Examination Survey, where steps per day data were collected using accelerometers—to develop more detailed information on the relations of daily step counts to health outcomes. Such information will also permit subject-level pooling studies to increase sample sizes by harmonizing pedometer-collected data and accelerometer-collected data. Also requiring more work is the relationship of steps counts measured by pedometer to that of light activity/steps counts measured with accelerometers—not used in this report—and the association of step cadence (measured so far using only accelerometers) with health outcomes (31). Recently, the Consumer Trade Act provided guidelines for all new consumer monitors to meet for quantifying steps per day. This will be useful for getting better consistency between devices and future studies.
Conduct additional longitudinal research in the form of either prospective studies or randomized controlled trials to examine the dose–response relationship between daily step counts and health outcomes. This information is critical for setting target volumes of physical activity using steps per day as a metric for predicting the incidence of future disease outcomes. In this review, only one randomized controlled trial was identified, and it did not include multiple arms to examine the effects of various doses of steps per day on outcomes.
Include measurement methods in prospective and randomized controlled studies examining whether the rate of stepping and bout lengths of continuous stepping influence the relationship between steps per day and disease outcomes. The studies reviewed used simple physical activity trackers providing accumulated steps and could address neither patterns nor intensity of steps. Additional physical activity assessment methods allowing for these data should provide a better target for recommending physical activity volume and effective means for meeting steps per day targets.
Develop more understanding of the relation of individual characteristics—age, sex, infirmity, and disease status—serve as effect modifiers of the relationship of daily step counts and health status. The economy of movement varies by age; walking cadence varies by age; and disease states can influence cadence, energy efficiency, and the safe parameters associated with walking. Therefore, much more information ultimately will be needed before public health and clinical recommendations can be made about the relationships of daily step counts and human health.
The authors gratefully acknowledge the contributions of Anne Brown Rodgers, Health and Human Services (HHS) consultant for technical writing support of the Physical Activity Guidelines Advisory Committee Report, and ICF librarians, abstractors, and additional support staff.
The results of this study are presented clearly, honestly, and without fabrication, falsification, or inappropriate manipulation. The Committee’s work was supported by the US Department of HHS. Committee members were reimbursed for travel and per diem expenses for the five public meetings. Committee members volunteered their time. The authors report no other potential conflicts of interest.
HHS staff provided general administrative support to the Committee and assured that the Committee adhered to the requirements for Federal Advisory Committees. HHS also contracted with ICF, a global consulting services company, to provide technical support for the literature searches conducted by the Committee. HHS and ICF staff collaborated with the Committee in the design and conduct of the searches by assisting with the development of the analytical frameworks, inclusion/exclusion criteria, and search terms for each primary question; using those parameters, ICF performed the literature searches.
This article is being published as an official pronouncement of the American College of Sports Medicine. This pronouncement was reviewed for the American College of Sports Medicine by members-at-large and the Pronouncements Committee.
Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this publication and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations.
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